Focused Exam: Alcohol Use Disorder Completed _ Shadow Health 2020

Chief Complaint Established chief complaint and reason for admittance Reports car accident Reports injury Reports passive suicidal ideation History of Present Illness Followed up on details of car accident Reports loss of consciousness Reports being unsure of how the accident happened Reports wearing seatbelt Reports being the driver - no other passengers in car Reports was told she would get a ticket for DUI Followed up on alcohol use just prior to car accident Reports drinking before accident Reports being unsure of how many drinks - "at least 5" Reports was drinking with friends at a party Reports left party to drive home because she was mad at her girlfriend and could not take any more Asked about driving impaired Reports knew she was driving under the influence but did not care Reports have driven in past after drinking, but this time she did not care if she injured herself