6. Clinical findings
What to write
Describe the relevant physical examination (PE) findings.
Explanation
Report relevant data from the PE and other significant clinical findings identified at the onset of care in the clinical findings section, along with an explanation of the examination methods, if necessary. These can be listed in the text and may include deidentified photographs. In some subspecialties, the notation used to describe the physical examination (e.g., ophthalmology) is unique, and the description of the examination may require additional explanation. If the physical findings are extensive, they may be organized as a summary table or figure. Record relevant findings that occurred during the course of care, with dates, in the “Follow-Up and Outcomes” section.
Example
“At age 2 years 10 months, this previously healthy North American Indian girl presented with a 3-week history of left knee swelling and morning stiffness without associated symptoms. There were no infectious contacts reported at the first presentation. On the initial physical examination, the left knee was moderately swollen and warm with signs of both intra-articular fluid and synovial hypertrophy. Flexion and extension were limited by 10°. The child was afebrile and appeared otherwise healthy. There were no abnormal pulmonary signs and no peripheral lymphadenopathy. The remainder of the examination was normal.”
From Mycobacterium tuberculosis monoarthritis in a child1.
Training
The UK EQUATOR Centre runs training on how to write using reporting guidelines.
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