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TRAUMA EXAM

- GENERAL: Conversant and cooperative. In no acute distress.
- VITALS: Triage note and vitals reviewed.
- HEAD: Normocephalic. Atraumatic.
- EYES: Clear. No Discharge. No Photophbia
- ENT: No stridor, drooling, hoarse voice, swelling or trismus.
- NECK: No tracheal deviation. Not Tender. No Bruising.
- CARDIAC: Normal rate. Regular rhythm. Normal heart sounds.
- LUNGS: Effort normal. No Respiratory distress. No Splinting. No Wheezing. No Rales.
- CHEST: No tenderness
- ABDOMEN: Soft. No guarding. No rebound. Not Tender. No Bruising.
- EXTREMITIES: No Edema. No Tenderness. No deformity.
- NEURO: Alert and oriented. Non-focal. Normal speech.
- SKIN: Warm and dry. No erythema. No Abrasions
- PSYCHIATRIC: Normal mood and affect.

from emresource.org

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