HPI:
presenting after GSW 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 assault was unprovoked.
Patient states that they do not know the assailant.

Denies head trauma. Denies loss of consciousness. No blurry vision.
No stridor, hoarseness.
No SOB.
Denies abdominal pain.

ROS: 10 point ROS review and negative except as otherwise indicated above

Physical 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.

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MDM GSW to Lower Extremity
presenting after GSW that occurred just prior to arrival.

Workup
XR tib/fib
CTA LE

Therapies
Tdap
Ancef 2g IVPB

Social/Other
Patient does not wish to file a police report.