HISTORY:
for
Last drink: ago
Typical consumption: per day,
Attempts to reduce or stop:
Severity of symptoms:
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Eyes: -R: , -L: ,
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Extremities: , , cap refill , pulses ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , , ,
- ECG
- Psychoeducation about alcohol withdrawal
- Encourage abstinence from alcohol
-
-
-
-
-
- Referral to addiction services
- Referral to social worker
- Referral to psychologist
- Follow-up in
- Return if symptoms worsen or if new symptoms develop
- Go to ER if seizures, severe tremors, hallucinations, or confusio