3. Physical examination
Emphasise signs relevant to both the patient's presenting and chronic problems and to differential diagnoses where applicable.
Note signs of long-term psychotropic drug use.
Also attempt to identify signs that indicate the presence/absence of conditions that may present with psychiatric complications (i.e. neurological and endocrine disorders, substance abuse).
On general inspection, Lucy appeared to be tired. She showed a prominent sign of proptosis. She also had a few bruises on her left arm, due to frequent cannulation and blood test, and a scar from her recent biopsy on the right side of her forehead.
On cardiovascular, respiratory and abdominal examinations, no significant signs were detected. Blood pressure was normal, 130/82. Pulse rate was 80 beats per minute and respiratory rate was 14 beats per minute.
On neurological examination, there were no signs of muscle wasting, abnormal movements or tremor. The upper limbs showed full range of active and passive movements. On flexion and extension of the right arm, however, pain was detected. The patient had normal tone, power, coordination and sensation in both arms. Reflexes, however, were increased in both arms.
Examination of the lower limb showed normal tone, power, coordination and sensations. Plantar reflexes in both legs, however, were decreased. There were no signs of abnormal gaits. Trendelenburg test, Pull test, and Romberg's test all showed negative results.
You may use the simple past tense to describe the patient's state at the time of the Physical Examination, as in Example 12. This emphasises that the exam findings are specific to the time of conducting the Physical Examination, but suggests that they are probably subject to change if repeated.
Alternatively, you may use the simple present tense to report the findings of the Physical Examination. This would contribute toward a consistent reference point for the report by placing the activity of the Physical Examination at the same time as the interview, the findings of which are forming the basis of this report.
It would also grant the Physical Examination findings more immediate perspective.Both approaches to reporting the findings of the Physical Examination are acceptable. It is important to be consistent, though, in the approach you adopt.