Trauma/General Surgery Consult / H&P
The patient was seen in the [] at the request of [].
Assessment: This is a [].
Injuries/comorbidities: -[].
Plan: []. DVT prophylaxis[]. GI prophylaxis[]. ______________________________________ CC: []. HPI: [].
Past medical history: -[].
Past surgical history: -[].
Allergies: -[].
Social history: -[]smoking, alcohol, drugs.
Family history: -[]bleeding problems, problems with anesthesia.
Medications: -[].
Review of systems: As above; otherwise, negative to include neurologic, eyes, ENT, CV, respiratory, GI, musculoskeletal, GU, skin, psychiatric, hematologic, and allergy.
______________________________________ Physical Exam
Constitutional: Patient appears awake, alert, no acute distress, HR, BP, Saturation reviewed in records. [] Eyes: pupils equal, round, reactive to light, no icterus. HENT: normal cephalic, atraumatic, no facial tenderness or crepitus, normal external inspection of ears/nose, no septal hematoma. Neck: trachea midline, no crepitus, thyroid without mass CV: regular rate, rhythm, bilateral radial pulses 2+, no cyanosis, no edema, no pulsatile abdominal mass. Respiratory: lungs clear bilaterally, no tenderness to palpation, normal inspection of chest. Abdomen: soft, non-tender, no masses, no hernia noted GU: normal external genitalia, pelvis stable Lymph nodes: no cervical or supraclavicular masses noted. Musculoskeletal: -bilateral upper extremity without focal tenderness, without deformity, with ROM intact -bilateral lower extremity without focal tenderness, without deformity, with ROM intact -no cervical spine tenderness with full ROM -no thoracic/lumbar spine tenderness or step-off. Skin: no lacerations or abrasions noted, skin warm to palpation. Psychiatric: normal mood and affect, memory intact. Neurologic: bilateral upper and lower extremity sensation intact.
______________________________________ [] Labs and images also reviewed personally.
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