Lower limbs

{Lower limbs}

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment
      
PRESENTING COMPLAINTS OR ISSUES
Reasons for visit:
[-] new problem/issue
[-] review/follow-up

Presenting symptoms:
[+] 
[-]

History of presenting complaint:
-

Management to date:
-

Diagnostic investigation results:
[+] 
[~] 
[-] 
[?]

History since last contact:
-

PHYSICAL EXAMINATION
Normal ranges are in {braces}.

General findings: {abnormalities}
[-] resting posture 
[-] lacerations, abrasions 
[-] ecchymoses 
[-] amputation 
[-] scars 
[-] peripheral pulses 
[-] skin colour and texture 
[-] shoe wear pattern - abnormal and/or asymmetrical

Leg lengths, measured between the ASIS and medial malleolus (cm): 
  Right: 
  Left:

Limb circumferences (cm):
  Right thigh: 
  Left thigh: 
  Right calf: 
  Left calf:

Neurological examination: {abnormalities}
[-] right leg
[-] left

Right hip: {abnormalities}

[-] deformity 
[-] tenderness

Active ranges of motion (degrees): 
    Flexion {>100}: 
    Extension {>19}: 
    Internal rotation {>20}: 
    External rotation {>30}: 
    Abduction {>25}: 
    Adduction {>15}:

Left hip: {abnormalities}

[-] deformity 
[-] tenderness

Active ranges of motion (degrees): 
    Flexion {>100}: 
    Extension {>19}: 
    Internal rotation {>20}: 
    External rotation {>30}: 
    Abduction {>25}: 
    Adduction {>15}:

Right knee: {abnormalities}

[-] alignment 
[-] effusion 
[-] heat 
[-] ligaments 
[-] crepitus 
[-] McMurray sign

Active ranges of motion (degrees):
    Flexion {>110}: 
    Extension {0}:

Left knee: {abnormalities}

[-] alignment 
[-] effusion 
[-] heat 
[-] ligaments 
[-] crepitus 
[-] McMurray sign

Active ranges of motion (degrees):
    Flexion {>110}: 
    Extension {0}:

Right ankle and hind foot: {abnormalities}

[-] deformity 
[-] swelling 
[-] bruising 
[-] ligaments 
[-] crepitus

Active ranges of motion (degrees):
    Plantar flexion {>20}: 
    Extension {>10}: 
    Inversion {>20}: 
    Eversion {>10}:

Left ankle and hind foot: {abnormalities}

[-] deformity 
[-] swelling 
[-] bruising 
[-] ligaments 
[-] crepitus

Active ranges of motion (degrees):
    Plantar flexion {>20}: 
    Extension {>10}: 
    Inversion {>20}: 
    Eversion {>10}:

ASSESSMENT
Clinical summary:
[+] 
[~] 
[-]

Diagnosis/es:
1. 
2.

Differential diagnosis:
-

MANAGEMENT PLAN
Procedures performed:
-

Diagnostic investigations requested:
-

Referrals:
-

patient information and advice:
-

Medication:
-

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

Lower limbs

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