Below is a sample write-up of a patient without any significant physical exam findings.
Please pretend as though you saw one of disease cases from the handout given in class &
replace the physical exam findings below with those listed in the case. If no information
was given in the case, assume a normal finding (i.e. such as a finding from your lab
partner).(4 pt)
Date: Physical exam on 2 January 2007, 10:15 am
ID: Name, age, date-of-birth, profession
CC: chief complaint and duration
Vital signs
Temp: 98 °F
Pulse: 60, regular rate and rhythm
Resp: 12
BP: 125/75 (sitting, right arm)
Pain: 0/10
2nd BP: 148/84 (seated, right arm)
Height: 5’ 3” (by pt. report)
Weight: 132# (by pt. report)
BMI: please calculate (kg/m2)
Inspection: Chest is symmetric, no scars. No cardiac heaves or lifts. Symmetrical
expansion with respiration, no other wall motions.
Palpation: No thrills appreciated. Point of maximal impulse (PMI) (apical
impulse) noted at midclavicular line, in fifth intercostal space.
Auscultation: Normal S1 and S2, with regular rate and rhythm. S2 > S1 at the
base, S1 > S2 at apex. No splitting of the heart sounds heard. No murmur. No
S3 or S4, no friction rub.
Maneuvers: No murmur is heard while squatting or upon release of valsalva, standing or
during valsalva strain.
Draw timing diagram:
Inspection: No jugular venous distention or pulsations.
Auscultation: No carotid bruits, or transmitted murmur. Carotid pulses 2/4
Peripheral vascular:
Inspection: No rashes, swelling, color change, or cyanosis in arms or legs. No signs
of venous stasis or arterial insufficiency in legs, with normal hair distribution, and no
pigmentation around ankles. No spider veins on legs and thighs bilaterally. No
clubbing in fingernails. Capillary refill is brink (<1 sec).
Palpation: Hands warm and pink. Feet are a bit cool to the touch and pale, but equal
bilaterally. No pitting or non-pitting edema in feet.
Palpation of Pulses:
Carotid: 2/4 bilaterally (can mention here or in “Neck” section)
Radial: 2/4 bilaterally
Brachial: 2/4 bilaterally
Femoral: right 2/4, left 2/4
Popliteal: right 2/4, left 2/4
Posterior tibial: right 1/4, left 1/4
Dorsalis pedis: right 2/4, left 2/4
Maneuvers: Allen test indicates collateral circulation in hands bilaterally, with reflushing within 5 seconds.
Please include your suspected diagnosis for both cases given in the class handout, as
well as a brief (1 – 3 sentences) justification for your diagnosis.(1 pt)