Trauma / Acute Care Surgery Progress Note
Assessment: [].
Problems: [].
Plan: [].
Tertiary Survey: []
Activity: []
Lines: []
Diet: []
Pulmonary Toilet: IS, Vap prevention bundle
GI prophylaxis: []
Bowel regimen: []
VTE prophylaxis: []
Dispo: []
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Chief Complaint: [].
Subjective: [].
Objective: [].
Exam:
Constitutional: Patient appears [], no acute distress, HR, BP reviewed in records. []
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 non-labored, no tenderness to palpation, normal inspection of chest.
Abdomen: soft, non-tender, no masses, no hernia 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 reviewed: [].
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