H&P / Consult APSO template
Trauma/General Surgery Consult / H&P
The patient was seen in the [] at the request of [].
Assessment:
This is a [].
Injuries:
-[].
Comorbidities:
-[].
Plan:
[].
Lines: []
Activity: []
DVT prophylaxis: SCD [].
GI prophylaxis: []
Bowel regimen: []
Pneumonia prevention: IS []
Dispo: []
Surrogate decision maker: [].
______________________________________
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.
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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.
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[]
Labs and images also reviewed personally.