Physical exam
Lucy Potts
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
Lucy appears unwell, with sunken eyes and thin body habitus. She is drowsy and confused when spoken to.
Vital signs
HR 140bpm, regular (normal: 65-120/bpm)
RR 45/min, rapid (normal: 15-30/min)
BP 110/70 mmHg (normal: 95-115/55-75 mmHg)
Temperature 36.9 °C
SatsO2 98%
Regional exam
Hydration: signs of dehydration. Abnormal skin turgor, dry mucous membranes.
Hands: capillary refill time 4 seconds
Cardiovascular exam: NAD
Respiratory exam: laboured breathing noted. On oral inspection, fruity-smelling breath. Scarcely collaborative, not following commands.
Abdominal exam: abdomen soft, non-tender, not distended. Bowel sounds normal/diminished. Scarcely collaborative.
Neurological exam: drowsy, listless, irritable, not following commands. Reflexes present.
All other examinations normal.
