Physical Exam //

TRAUMA EXAM Vital signs GENERAL: On backboard with C-collar in place. SKIN: Warm and well perfused. No rashes, bruises, discolorations or abrasions. HEAD: Atraumatic, normocephalic without edema, discoloration or evidence of trauma. Facial bones without deformities or tenderness. EYES: PERRL. No scleral icterus or conjunctival injection. Extraocular muscles intact without nystagmus or diplopia. No proptosis or enophthalmos. EARS: Normal appearing pinnae. No hemotympanum. NOSE: No discharge, tenderness, laxity. No nasal septal hematoma. MOUTH: No malocclusion or trismus. Moist mucus membranes without blood. Posterior pharynx without erythema or exudate. NECK: Trachea midline. No discolorations or edema. Neck immobilized in cervical collar. CV: Regular rate and rhythm, Normal s1 and s2. No murmurs, rubs, or gallops. PV: Radial pulses 2+ bilaterally and symmetric. Dorsalis pedis pulses 2+ bilaterally and symmetric. 2+ capillary refill. No extremity edema. CHEST: No abrasions or ecchymosis. Chest symmetric with respirations. No chest wall tenderness. No crepitus. No step offs. Lungs are clear to auscultation bilaterally. No rales, rhonchi, wheezing or stridor. ABDOMEN: No ecchymosis or abrasions. Soft, nondistended, nontender. Bowel tones normoactive. No masses or organomegaly. BACK: No abrasions, skin openings, or ecchymosis. Spine without bony tenderness, no step offs. PELVIC: Pelvis stable, nontender to lateral compression and palpation of symphysis pubis. RECTAL: Normal tone. Stool without gross blood. GU: Normal external genitalia without blood at meatus. No ecchymosis or edema. MSK: No gross deformities or discolorations or lesions. Tolerates full range of motion of extremities without tenderness. NEURO: Alert and oriented to person, place, and time. GCS 15. CN II-XII intact. Sensation grossly intact. Strength 5/5 in bilateral UE and LE. Finger to nose intact bilaterally.



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