Reviewed triage note:
”
“__________________________
HPI (on my evaluation of patient):
Patient has no medical complaints.
not on a hold placed by pre-hospital personal
positive 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
—————————-
Review Of Systems:
Constitutional: no recent fever
Integument: no rashes
Eye: no acute vision changes
ENT: no current rhinorrhea/sore throat
CV: no chest pain, no syncope
Resp: no SOB, no new productive cough
GI: no abd pain, no vomiting, blood/tarry stool
GU: no dysuria
MSK: no recent trauma/fall to any extremitity
Neuro: no focal weakness
Psych: no confusion
Physical Exam:
Constitutional: Vitals signs as above, NAD
Skin: No rash, warm, dry
Eye: PEERL, EOM intact
CV: RRR, No r/m/g
Resp: Lungs CBTA, respirations non-labored
GI: Abd soft, non-tender
LEs:No LE swelling, palpable pulses
MSK: No deformitites, normal ROM
Neuro: Alert and oriented, no focal motor/sensory deficit
————————————————————————————————————
Psychiatric examination:
Gen: appears stated age, in no apparent distress, no agitation, well-groomed
Speech: Normal rate, normal content
Thought process: Linear, non-tangential
Thought content: no Suicidal ideation, no plan, denies homicidal ideation
Mood: Soft
Affect: depressed
____________________
ED COURSE/MDM/A/P:
Diagnostically:
POC glucose (eval for hypoglycemia)
EKG (eval for cardiac conduction abnormalities which can reveal occult ingestion)
Utox (to be followed by pysch ED)
_upreg
MDM:
Medically cleared for psychiatric evaluation.
No acute medical emergency requiring medical intervention prior to psychiatric evaluation.
Placed on 1-1 sitter
RNs removed objects that could be used for self harm.
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
DISPOSITION: psych ED
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).
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