Reviewed triage note:

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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

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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

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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

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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.