Physical exam
Mike Simpson
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
Mike appears comfortable with no increased work of breathing at rest.
Vital signs
HR 84 bpm, regular
RR 18/min
BP 150/85 mmHg
Temperature: 36.8 °C
SatsO2 95% on RA
Regional exam
Neck examination: Jugular venous pressure is mildly elevated. Carotid pulses strong, regular. Carotid bruit on left carotid artery.
Cardiovascular palpation: Apex beat palpable and laterally displaced. Leg examination: Pitting oedema to mid shins bilaterally.
Cardiovascular auscultation: Heart sounds dual, with no murmurs.
Respiratory exam: Equal air entry bilaterally, inspiratory bi-basal crackles.
Abdominal examination: Abdomen moderately distended due to central adiposity. Symmetrical, soft, non-tender. Appreciable hepatomegaly. Positive hepatojugular reflux
All other examinations normal.
