• On reevaluation:
    • Neurologically Intact.  Patient has normal speech, clear sensorium, exhibits linear thinking, able to articulate plan for aftercare, and exhibits normal fine motor skills.
    • 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
      • 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.
      • Patient demonstrates clinical sobriety.
        • speak non-slurred speech
        • is alert and oriented
        • ambulatory with steady gate
        • has fine motor intact
        • able to articulate plan for safe aftercare upon discharge from ED.
      • 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.
      • Employed importance that 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.
      • Patient requests discharge, will oblige demonstration of capacity, sobriety, and no unevaluated pathology.
    • Reviewed and interpreted diagnostics by me.
      • Laboratory Analysis Reviewed/Interpreted.
        • Preg test neg
        •  CBC:
          • Non contributory to patient’s condition.
        • BMP:
          • No significant pathologic electrolyte derangements.
        • Trop
          • undetectable
          • <99th percentile
          • >99th percentile but under cut off for positive
          • positive
          •  
        • Delta trop
          • undetectable
          • <99th percentile
          • >99th percentile but under cut off for positive
          • positive (>3)
        •  LFTs/lipase:
          • No laboratory evidence of hepato-biliary-pancreatic pathology (appreciated limited sensitivity) and therefore correlated clinically.
        •  UA:
          • contributory to patient’s condition.
          • No hematuria.
          • No consistent with infection.
          • Equivocal for infection
            • Empirically treated.
            • UCx sent with f/u mechanism in place
        • CK
        • ESR
        • EtOH level
        • Ingestion labs (ASA, Tylenol)
          • neg
      • EKG Interpretation:
        • Normal EKG in eval for blunt cardiac injury):
          • EKG: NSR, regular rate, normal axis, normal intervals, no abnormal TWI, no ST elevation/depression.
          • Interpretation: No clear evidence of active ischemia on EKG
        • Normal EKG in eval for arrhythmia/syncope:
          • EKG: Normal Sinus Rhythm. No arrythmia (no PACs, no PVCs), no brugada wave, no prolonged QTc, no delta wave/no shortened PR, no episilon wave, no evidence of ischemia.
          • Interpretation: No cardiogenic etiology for syncope obvious on EKG.
        • Abnormal EKG
          • Sinus tachycardia, no abnormal TWI, no significant ST. No EKG e/o ischemia suggestive no EKG evidence of blunt cardiac injury.  elevation/depression.
          • Non-specific repolarization abnormalities. No ST elevation/depression. No EKG e/o ischemia suggestive no EKG evidence of blunt cardiac injury.
          • ST morphology concerning for blunt myocardial ischemia/infarct.
            • troponin sent
          • Potential arrhythmogenic etiology elucidated on EKG.
            • Would benefit from syncope work up, telemetric monitoring given possible non-mechanical cause to truama.
            • Hx not c/w syncope/arrhythmia and given pt is symptomatic, advised for prompt f/u with PMD.
      • XRs reviewed.
        • Neg. No evidence of fracture, dislocation, or foreign body. (Reviewed and interpreted by me with overread in place for radiology overreads).
      • CTs reviewed.
        • Neg for any acute emergent pathology on rad read
        •  Neg for any acute emergent pathology on ED prelim read (with formal overread mechanism for critical findings in place).
    • Dispo:
      • Discharge from ED given above diagnostic findings in conjunction with the patient’s evaluation, the patient is at sufficiently low risk and does not meet criteria for admission.
    • Diagnosis:
    • COUNSELING: Patient/family educated on diagnostics, assessment, treatment plan. Patient/family amendable and in agreement with plan. All questions and concerns answered and addressed.