Physical exam
Ashley Monroe
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
Ashley appears pale and thin. If measured, her BMI is 17.
Vital signs
HR 72 bpm
RR: 20/min
BP: 120/85 mmHg
Temperature: 36.4 °C
SatsO2: 99% on room air
Regional exam
Eyes: Conjunctival pallor
Mouth: Good hydration, good dentition. No ulcerations, no signs of glossitis, angular stomatitis, blue-grey freckles.
Hands: Palmar pallor
Abdomen: Abdomen slightly distended. Soft and non-tender on superficial palpation. No palpable masses on deep palpation. No hepatomegaly or splenomegaly. Bowel sounds present, active.
Digital rectal examination declined by patient.
Lymphatic system: no lymphadenopathy
All other examinations normal.
