(With punches to head)
presenting after an assault that occurred [just prior to arrival].
Patient complains of pain in the ___
Patient states that the injury occurred at ___
Pain is described as moderate in nature and worse with movement.
Patient states that they ___ know the assailant.

Physical Violence Context:
Patient was punched.
Patient was not kicked.
Patient was not choked.
Patient was not bitten.

Sexual Violence Context:
Patient states there was not anal or genital penetration.

Associated symptoms:
Endorses head trauma.
Denies loss of consciousness.

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Exam:

General: well developed patient in [moderate] distress.
Head: [no head trauma].
Eyes:  [PERL, EOMI, no entrapment].
ENT: [oropharynx normal, no dental injury, no septal hematoma].
Neck: [NEXUS negative, normal inspection].
Back: [no vertebral tenderness, normal inspection].
Cardiovascular: regular rate and rhythm; no rubs, murmur, gallops.
Respiratory: [chest non tender, no crepitus, clear to auscultation bilaterally, normal respiratory effort].
Abdominal exam: [soft non-tender, no peritoneal signs, normal inspection, no seat belt sign].
Neurological: [alert and oriented, Glascow Coma Scale 15].
Skin: [warm, well perfused, no rashes, normal capillary refill].
Psych: normal.
Extremities: [no evidence of trauma, normal range of motion, no tenderness, normal distal pulses].
Genitourinary: [no injuries noted].