ReEval

  • [3] [b]Re-evaluation:[/b]
    • [01] __
      • [01] __
    • Unchanged on re-evaluation. 
    • Improved on re-evaluation.
      • [01] On thorough re-evaluation, after patient was observed on telemetric monitoring, patient remains hemodynamically stable, normal vital signs, with clear sensorium, repeat cardio-pulmonary-abdominal exam benign, is ambulatory, has no new development of pain, pain is well-controlled and is amenable to discharge after observation period in the ED.
      • Normal neurologically evaluation,   
        • [01] Patient has normal speech, clear sensorium, exhibits linear thinking, able to articulate plan for aftercare, and exhibits normal fine motor skills.
        • [01] Abdominal Benign. Repeat abdominal exam  did not reveal any tenderness in any of the four quadrants. No rebound their guarding. patient  tolerated PO fluids and food to the emergency department without any recurrence of abdominal pain or vomiting.
        • __
      • Respiratory status, 
        • [01] No signs of respiratory distress on exam, able to speak in full sentences without dyspnea. Respiratory related vital signs reassuring and suggestive of improvement. Improved respiratory exam compared to prior.
        • Unchanged respiratory status compared to prior.
        • Worsening respiratory status compared to prior.
        • __
      • Clinically Sober.
        • [01] Patient demonstrates clinical sobriety.
          • [01] speak non-slurred speech
          • [01] is alert and oriented
          • [01] ambulatory with steady gate
          • [01] has fine motor intact
          • [01] able to articulate plan for safe aftercare upon discharge from ED.
          • __
        • [01] Re-evaluation after sobriety did not reveal any new symptoms/signs. Unlikely initially unappreciated pathology on initial eval given patient has no new complaints and re-examination does not reveal any new abnormalities suggestive of previously undetected pathology.
        • [01] Instructed patient to exercise cautions after discharge
          • [01 Expressed the importance to the patient not drive for remainder of day and to exercise extreme caution while around stairs, areas for potential falls, and to avoid areas with potential for being hit by car (street crossing, etc). Patient advised not to drink/use substances which alter mental status/cause sedation/impair judgement or reflexes (alcohol, illicit substances, prescription medications) if driving in general and advised to refrain from those substances in general. Patient advised to seek treatment for substance abuse.
        • [01] Patient requests discharge, will oblige demonstration of capacity, sobriety, and no unevaluated pathology.
        • __
    • On re-evaluation, remains intoxicated. Hemodynamically stable. Will continue observation.
    • [2] __

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