HISTORY:
Presents for a
Event: , ago
Impact: at around
Patient: , ,
Able to exit on their own:
Medications: ,
Allergies:
Past medical history:
Last meal: hours ago
Tetanus vaccination:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head:
Eyes: -R: , -L: ,
Ears: -R: , -L:
Nose:
Throat:
Neck:
Heart: ,
Lungs: ,
Chest: on
Abdomen: , , ,
Pelvic: vulva , vagina , cervix , uterus , adnexa ,
Genital: , testicles , penis
Skin:
Extremities: , , cap refill , pulses ,
Cervical spine: on , range of motion
Shoulder: : on , range of motion
Elbow: : on , range of motion
Wrist: : on , range of motion
Hand: : on , range of motion
Lumbar spine: on , range of motion
Hip: : on , range of motion
Knee: : on , range of motion
Ankle: : on , range of motion
Foot: : on , range of motion
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
ASSESSMENT:
DDx:
PLAN:
- X-ray: , ,
- CT scan: , , , ,
-
-
-
- Physical therapy
- for
- Referral to orthopedic surgeon
- Referral to neurologist
- Referral to trauma surgeon
- Follow-up in
- Return if pain worsens, if new symptoms develop, or if symptoms do not improve with treatment