🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2026-09-30 13:48:07
Transcript
Doctor: Patient's in mid-admission. Patient has a currently in medical observation, vomiting. Patient's laying down. Cell is open. Patient was sat up. Patient declined to have a conversation. Patient's hunched over with his eyes closed, unable to obtain history. Previous history, he has a history of substance abuse disorder, possibly psychosis in the past. He's previously been on olanzapine and trazodone. He's currently on Suboxone. No infantinol use issues in the past, but no documented alcohol abuse in the past. We'll keep the patient on medical observation. He's currently on Suboxone 12. He'll be increased to 20 given his withdrawal symptoms. There's vomit on the floor of the cell. We'll also start him on Clonidine 0.2 BID for three days. Then we'll do 0.1 BID for three additional days. He'll get some Gravol. And continue to manage his withdrawal symptoms with close monitoring and possibly escalating medical care if needed.
Clinical Notes
SOAP Clinical Note
Subjective
The patient is currently in medical observation due to vomiting. The patient is laying down and declined to have a conversation. The patient is hunched over with eyes closed, making it difficult to obtain a full history.
Objective
The patient has a history of substance abuse disorder and possibly psychosis. Previously prescribed medications include olanzapine and trazodone. The patient is currently on Suboxone. There is no documented history of alcohol abuse.
Assessment
The patient is experiencing withdrawal symptoms, as evidenced by vomiting and the need for increased medication dosage.
Plan
- Increase Suboxone dosage from 12 to 20.
- Start Clonidine 0.2 mg BID for three days, then reduce to 0.1 mg BID for three additional days.
- Administer Gravol for nausea.
- Continue close monitoring of withdrawal symptoms and escalate medical care if necessary.