HPI (on my evaluation of patient):
Patient has no medical complaints.
not on a hold placed by pre-hospital personal
_ SI
hx of suicide/self harm in past
denies active attempt on this presentation (ingestion/physical self harm)
no HI
hx of psych disorder
denies illicit drug use
denies etoh use
denies recent head trauma
Agitation pertinent exam:
     no signs of head trauma
    no meningismus
     Toxicologic Exam:
    _ HR
     _ LOC
     _ pupils
     _ skin
     _ stigmata of IVDU
     _ n/v/d
     _ palpable bladder suggestive urinary distention
POC glucose (eval for hypoglycemia)
EKG (eval for cardiac conduction abnormalities which can reveal occult ingestion)
Utox (to be followed by pysch ED)

Medically cleared for psychiatric evaluation.
No acute medical emergency requiring medical intervention prior to psychiatric evaluation.
The brief medical screening evaluation (history and physical) did not reveal any clear medical conditions which are thought to be more likely as causative to the patient’s psychiatric complaints than primarily psychiatric pathology. Given the most likely etiology for the patient’s symptoms at this time would require an emergent psych evaluation and the risks of delayed psychiatric evaluation outweigh the benefit of further medical evaluation at this time, the patient is to be evaluated by psychiatry. This emergency medical screening examination does exclude all underlying medical conditions which may be contributory or exacerbating the patient’s psychiatric complaints (as this is not feasible to be done in an medical screening exam). Additionally, the patient may have additional comorbidities/medical need which will need to be addressed on an non-emergent basis.
DIAGNOSIS: psychiatric disorder NOS
COUNSELLING: Patient informed of treatment plan.
*This information is intended for educational purposes only and not intended for use in patient care (which requires a trained credentialed attending physician and individualization of the medical care plan to the specific patient).

Leave a Comment