HISTORY:
Chest wall injury sustained ago
Event:
Location::
Radiation:
Severity: , / 10
Type:
Pattern:
Worsening factors:
Treatments tried: ,
Occupation:
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Chest: on
Breasts: -R: , -L:
Abdomen: , , ,
Skin:
Extremities: , , cap refill , pulses ,
ASSESSMENT:
DDx:
PLAN:
- Chest X-ray
- ECG
- Troponin
-
-
-
- Activity as tolerated
- Respiratory exercises
- Referral to ER
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as shortness of breath