H&P / Consult APSO template


 Trauma/General Surgery Consult / H&P

 

The patient was seen in the [] at the request of [].

 

Assessment:

This is a [].

 

Injuries/comorbidities:

-[].

 

Plan:

[].

DVT prophylaxis[].

GI prophylaxis[]. 

______________________________________

CC: [].

HPI: [].

 

Past medical history:

-[].

 

Past surgical history:

-[].

 

Allergies:

-[].

 

Social history:

-[]smoking, alcohol, drugs.

 

Family history:

-[]bleeding problems, problems with anesthesia.

 

Medications:

-[].

 

Review of systems:

As above; otherwise, negative to include neurologic, eyes, ENT, CV, respiratory, GI, musculoskeletal, GU, skin, psychiatric, hematologic, and allergy.

 

______________________________________ 

Physical Exam

 

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.

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 also reviewed personally.



 

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