Trauma/General Surgery Consult / H&P
The patient was seen in the  at the request of .
This is a .
Past medical history:
Past surgical history:
-smoking, alcohol, drugs.
-bleeding problems, problems with anesthesia.
Review of systems:
As above; otherwise, negative to include neurologic, eyes, ENT, CV, respiratory, GI, musculoskeletal, GU, skin, psychiatric, hematologic, and allergy.
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.
-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 also reviewed personally.