Daily Progress Note

Trauma / Acute Care Surgery Progress Note


Assessment: [].


Problems: [].


Plan: [].


______________________________________


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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