MDM //
Patient presented with altered mental status, smelling of alcohol with documented history of alcohol dependence. They arrived afebrile, with stable vital signs. Bedside glucose check without evidence of severe derangement. No signs of trauma or other etiology of altered mental status on initial exam. Patient was monitored with serial exams for several hours while they cleared their alcohol and altered mental status. Repeat exam benign. Patient then demonstrated ability to ambulate safely, tolerated oral intake, and articulated a safe discharge plan. Discharged to self-care, with return precautions for any new or concerning symptoms.
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