General: Alert, no acute distress.
Glasgow coma scale: Eye response: 4 /4, verbal response: 5 /5, motor response: 6 /6.
Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit observed.
Skin: Warm, dry, abrasions noted across anterior chest.
Head: Normocephalic, atraumatic.
Neck: Supple, trachea midline, no step offs, full ROM, Tenderness: Bilateral, moderate, posterior,
bilateral posterior paraspinal tenderness noted.
Eye: Pupils are equal, round, and reactive to light, extraocular movements are intact.
Ears, nose, mouth, and throat: Oral mucosa moist.
Cardiovascular: Regular rate and rhythm, No murmur.
Respiratory: Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal,
Symmetrical chest wall expansion.
Chest wall: No deformity, On exam Anterior, moderate, tenderness, abrasions, no ecchymosis,
no rash, no crepitus, no subcutaneous emphysema, no deformity.
Back: Lumbar: Midline, diffuse, moderate, tenderness, no swelling, no ecchymosis, no step-off.
Musculoskeletal: Proximal upper extremity: Left, shoulder, clavicle, tenderness, Lower extremity:
Left, knee, tenderness, Ankle/foot:
Gastrointestinal: Soft, Nontender, Non distended, Normal bowel sounds, Guarding: Negative,
Rebound: Negative.
Psychiatric: Cooperative, Appropriate mood and affect.
Review of Systems
Constitutional symptoms: No fever, no chills.
Skin symptoms: Abrasions.
Eye symptoms: Vision unchanged.
ENVIT symptoms: Negative except as documented in HA.
Respiratory symptoms: No shortness of breath, no orthopnea.
Cardiovascular symptoms: Chest pain, diffuse, anterior, acute, moderate pain, achy,
no palpitations, no tachycardia, no syncope.
Gastrointestinal symptoms: No abdominal pain, no nausea, no vomiting.
Genitourinary symptoms: Negative except as documented in HA.
Musculoskeletal symptoms: Back pain, Joint pain, Reports: Left, shoulder, foot,
knee, acute, pain.
Neurologic symptoms: No headache, no dizziness, no numbness, no tingling, no weakness.
Psychiatric symptoms: Negative except as documented in HA.
Endocrine symptoms: Negative except as documented in HA.
Hematologic/Lymphatic symptoms: Negative except as documented in HA.
Allergy/immunologic symptoms: Negative except as documented in HA.
Additional review of systems information: All other systems reviewed and otherwise negative.