Normal

Constitutional: Pt is oriented to person, place, and time. Pt appears well-developed and well-nourished.
HENT:
Head: Normocephalic and atraumatic.
Mouth/Throat: Oropharynx is clear and moist.
No hematomas or lacerations or abrasions to face or scalp
OP clear, no blood, no malocclusion, dentition intact
Nares clear, no nasal septal hematoma
TMs clear, no hemotympanum
Midface stable
Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to light.
Neck:
C-spine midline nontender, no step-offs
Cardiovascular: Normal rate, regular rhythm and normal heart sounds.
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. He has no wheezes.
CTA bilaterally
Abdominal: Soft. Bowel sounds are normal. Pt exhibits no distension. There is no tenderness.
Musculoskeletal:
No bony tenderness to extremities, no deformities, full ROM extremities
Chest wall stable
Pelvis stable and non-tender
No vertebral TTP and spine without stepoffs
Neurological: Pt is alert and oriented to person, place, and time.
Moving all extremities willfully, able to wiggle all fingers and toes
Alert and oriented x 3
Sensation grossly intact
Skin: Skin is warm and dry.
No abrasions, no lacerations
Psychiatric:
Behavior is appropriate for situation
Nursing note and vitals reviewed.