All records regarding this patient's ED course of examination, treatment, and findings - in addition to his brief in-hospital stay - were originally obtained with permission of the receiving hospital. All identifying references to the actual patient have been deleted, to preserve patient confidentiality.
IN-HOSPITAL RECORD:
The patient was admitted to the "Short Stay" ward (less than 48 hours hospitalization anticipated). The ED nursing notes indicated that the patient was sent to the "intensive care unit" from the ED, at 0700 hours on 08/23/98. Unless he went there briefly, and THEN was sent to Short Stay, that note was in error. The patient was removed from the ventilator and extubated soon after his arrival in Short Stay, demonstrating an adequate pulse-ox on room air.
Apparently the "mushroom" usage ("other" on the TOX screen) was identified while in Short Stay. I surmise that the patient volunteered information regarding this use. The patient's past medical history was obtained. He had diminished hearing in his left ear, secondary to a bout of meningitis when 5 years old. He had no other history of medical, traumatic, or psychiatric difficulties. He took no medications.
Continued observation and further lab tests were performed while the patient was in Short Stay, with no indications of any developing complications, injury or illness. A Psychiatry consult was obtained and the patient was referred for out-patient substance abuse treatment.
The patient was discharged "to his Sister" on 08/24/98 (I don't have a note of what time), without medications, without disabilities, and with instructions to return to the ED in 3-5 days for right eye suture removal.
Reportedly, on 08/26/98 the patient returned to the ED, presenting with a complaint of "severe headache." Examinations were negative. The patient was discharged from the ED with a diagnosis of "post-concussion syndrome."
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