ABD Reassessment
Serial abdominal exam without increased tenderness; no peritoneal signs. Patient well appearing, tolerating PO. Hemodynamically stable.
AMA
After extensive discussion of R/B/A per routine with patient, patient electing to leave against medical advice. As prior, risks explained to patient with understanding and full capacity. Patient encouraged to return to ED if patient decided to change mind regarding care or if any new concerning symptoms arise.
Discharge
Pt well appearing, nontoxic, af, HDS. Patient advised of exam and study findings Patient understands and agrees with the plan of discharge. Return precautions discussed. Patient verbalized full understanding. Patient comfortable going home.
EKG Normal
EKG: normal sinus rhythm, no TWI/ST changes, normal intervals, ***normal axis.
EKG syncope
EKG reviewed, no TWI/ST changes. No dysrhythmias. Low suspicion for WPW, long QT, HOCM, Brugada.
ETOH reassess/discharge
Serial abdominal exam without increased tenderness; no peritoneal signs. Patient with increased lucidity, tolerating PO, interactive with staff. Hemodynamically stable.
Trialed gait after several hours of observation in the ED with improvement in mental status to baseline and with stable gait. Cautious return precautions discussed w/ full understanding.
FAST Neg
FAST negative: Cardiac motion present. No pericardial fluid . No free fluid RUQ, LUQ or in pelvis.
Headache
Patient headache has improved after medication. No focal neurological deficits.
Reassess
Patient reassessed and re-examined. No additional findings on exam or complaints. Pt well-appearing.
Signout
Patient Signed out to Dr.
Pending items
Likely dispo
Signout
Patient Signed out to Dr.
Pending items
Likely dispo
