Physical Exam - Psychiatric Mental Status Exam

The patient’s mood [how the patient tells you they’re feeling-is described as anxious/depressed/crawling out of their skin/etc.].  The patient’s affect [what you observe-appears anxious/depressed/flattened/blunted/restricted/exaggerated] which is [congruent/incongruent] with their reported mood.  Patient noted to be [making good/poor eye contact/frequently looking down/away].  Patient [was/was not] noted to be attending to internal stimuli [specify/with patient noted to be conversing in an empty room/etc.].  The patient’s thought process is noted to be [organized/disorganized with/without delusions/obsessions].  The patient’s speech [is noted to be unremarkable/notable for pressured speech/inappropriately loud/soft given size of the room and distance apart/tangential speech/etc.].  The patient was noted to be [well kempt and groomed/disheveled/encrusted with urine and feces].  

The patient was noted to be expressing [suicidal thoughts with/without reported plan/no suicidal or homicidal thoughts or plan at this time].  The patient [reported/denied] hallucinations [described as auditory/visual].

https://www.hippoed.com/em/ercast/episode/march2017/examiningmental

Physical Exam - Orthopedic Hand Exam

[Right/Left] hand notable for [abrasion/laceration/swelling] of the [dorsal/palmar aspect of the index/middle/ring/pinky/thumb].  [Full/Limited] active range of motion of the [right/left index/middle/ring/pinky/thumb] at the [distal interphalangeal (DIP)/proximal interphalangeal (PIP)/metacarpophalangeal (MCP) joint] [motion limited to ##°].  [Full/Limited] passive range of motion of the [right/left index/middle/ring/pinky/thumb] at the [distal interphalangeal (DIP)/proximal interphalangeal (PIP)/metacarpophalangeal (MCP) joint] [motion limited to ##°]. 

[Normal/Abnormal] Allen's test (normal reperfusion from the ulnar artery after temporary occlusion of the radial and ulnar arteries, suggesting good collateral flow) of the [right/left] hand. 

[Remainder of extremity exam unremarkable.]

Physical Exam - Orthopedic Knee Exam

[No/Minimal/Moderate] isolated tenderness to palpation over the patella of the [right/left] knee.  [No/Minimal/Moderate] tenderness to palpation at the head of the [right/left] fibula.  [Limited/full] active range of motion of the [right/left] knee to [90/##]°.  [Limited/full] passive range of motion of the [right/left] knee to [90/##]°.  Patient [not able/able] to ambulate 4 steps in the ED [despite pain/due to pain]. 

[No/Mild/Moderate] instability on valgus (medial) stress of the [right/left] knee.  [No/Mild/Moderate] instability on varus (lateral) stress of the [right/left] knee.  [Negative/Positive] Lachman's test (instability with anterior stress on the knee in 15-30° flexion).  [Negative/Positive] anterior drawer test (instability with anterior stress on the knee in 90° flexion).  [Negative/Positive] posterior drawer test (instability with posterior stress on the knee in 90° flexion).  [Negative/Positive] McMurray's test of lateral meniscus (pain when knee is brought from full to 90° flexion while leg is externally rotated with compression over the medial joint line).  [Negative/Positive] McMurray's test of medial meniscus (pain when knee is brought from full to 90° flexion while leg is internally rotated with compression over the lateral joint line). 

[Remainder of extremity exam unremarkable.]

https://www.orthobullets.com/recon/12755/knee-physical-exam--adult

Physical Exam - Orthopedic Shoulder Exam

[No abnormal appearance/Squared-off appearance] of the [right/left] shoulder when exposed and compared to the [right/left] shoulder.  [Limited/full] active range of motion of the [right/left] shoulder [in abduction/adduction/flexion/extension] [motion limited to ##°].  [Limited/full] passive range of motion of the [right/left] shoulder [in abduction/adduction/flexion/extension] [motion limited to ##°].  [Intact/Diminished] sensation to light touch [throughout/distribution] of the [right/left] arm.  [No/Palpable] deformity of the [distal/middle/proximal] aspect of the [right/left] clavicle.  [No deformity or elevation] of the [right/left] acromioclavicular (AC) joint. 

[Positive/Negative] Adson's test (no decrease in pulse or loss of sensation with the arm abducted to 180°).  [Positive/Negative] apprehension test (with patient supine and arm positioned in 90° abduction and external rotation, additional external rotation is applied while watching patient for evidence of apprehension suggestive of instability in the glenohumeral joint).  [Positive/Negative] Hawkin's test (with the arm in 90° front flexion and with the elbow flexed to 90, the arm is brought into further internal rotation, and considered positive if pain is reported in the superior and lateral aspect of the shoulder, suggestive of shoulder impingement).  [Positive/Negative] empty can test (arm in 90° front flexion with forearms in pronation, as if emptying cans, suggestive of supraspinatus injury).  [Positive/Negative] Yergason's test (starting with the arm adducted to the body with the elbow flexed at 90° and the forearm in full pronation, the patient flexes at the elbow while supinating the forearm as the examiner palpates over the bicipital groove in the shoulder for pain suggestive of bicep tendon pathology). 

[Remainder of extremity exam unremarkable.]

https://www.orthobullets.com/shoulder-and-elbow/3037/shoulder-exam

Physical Exam - Orthopedic Ankle Exam

[No/Minimal/Moderate] tenderness to palpation along the posterior edge of the distal 6 cm of the [right/left] fibula.  [No/Minimal/Moderate] tenderness to palpation along the posterior edge of the distal 6 cm of the [right/left] tibia.  [No/Minimal/Moderate] swelling to the [medial/lateral] [right/left] ankle [with/without] palpable bony deformity.  [No/Minimal/Moderate] ecchymosis to the [medial/lateral ankle/sole of the foot]. 

[Negative/Positive] anterior drawer test of the [right/left ankle].  [Negative/Positive] inversion (supination) test of the [right/left ankle].  [Negative/Positive] eversion (pronation) test of the [right/left ankle].

[Remainder of extremity exam unremarkable.]

https://www.orthobullets.com/foot-and-ankle/7005/ankle-ligaments