Physical exam
James Nguyen
Facilitator notes
Facilitator, please ask the student/team what examination they want to perform, and provide ONLY the finding of the examination they request, i.e. only one line at a time. Ask the student/team to be specific!
Example vignette
Team – “Measure vital signs.”
Facilitator – “What vital signs would you like?”
Team – “Heart rate.”
General inspection
James appears of stated age. He is tall and lean. You note accessory respiratory muscle use.
Vital signs
HR 123 bpm, regular
RR 28/min
BP 124/96 mmHg
Temperature 37.4 °C
SatsO2 95%
Regional exam
Hands examination: long fingers, no discolorations, capillary refill <3 seconds.
Face examination: no conjunctival pallor, no cyanosis, high arched palate.
Neck examination: JVP not elevated, normal waveform; carotid pulses present and regular, no bruit on auscultation.
Cardiovascular examination: heart apex palpable at fifth intercostal space, left midclavicular line. No palpable heaves or thrills. Heart sounds dual, no murmurs.
Respiratory examination: markedly diminished breath sounds and vocal resonance on the left lung fields, good air entry and vocal resonance on the right. No added sounds. Percussion note hyperresonant on the left fields compared to the right.
Abdominal examination: abdomen soft, non tender, no organomegaly.
All other examinations normal.
