Physical exam
Olive Greene
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
Olive appears of stated age, with no increased work of breathing. Her body habitus is overweight.
Vital signs
HR 85 bpm
RR: 20/min
BP: 145/85 mmHg
Temperature: 37.9 °C
SatsO2: 95% on room air
Regional exam
Hands: mild tar staining between first and second finger of right hand. Good perfusion. No clubbing, no muscle wasting, no wrist tenderness.
Eyes: dark circles under eyes. No conjunctival pallor. Pupils round, equal, reactive to light and accommodation.
Mouth: cracked lips. Good dentition. No visible inflammation of oropharynx or tonsils.
Neck: trachea midline. Normal carotid pulses, no carotid bruit. JVP not elevated. No lymphadenopathy.
Chest: normal shape. Symmetrical expansion.
Cardiac exam: heart sounds dual, no murmurs. Loud S2.
Respiratory exam: Adequate air entry on all fields, except in right middle zone. Prominent added crackles in the same zone. Fine end-expiratory wheezes in lower zones.
All other examinations normal.
