Patient is oriented to person only , disoriented to place and time. Coarse bilateral hand tremor present at rest. Patient is agitated and restless, difficulty following multi-step commands. Reports sensation of "bugs crawling under my skin." Hyperreflexia noted bilaterally on assessment. No focal neurological deficits. Pupils equal and reactive 3mm bilaterally.

Heart sounds S1/S2 present. Rate irregular. No murmurs or extra sounds auscultated. Peripheral pulses 2+ bilateral upper and lower extremities. No peripheral edema noted. Capillary refill less than 2 seconds. Patient denies chest pain or palpitations.

Lungs clear to auscultation in all fields. Respirations unlabored, no accessory muscle use. No cough. No adventitious breath sounds. SpO₂ within acceptable limits on room air.

Patient reports nausea , no vomiting at this time. Abdomen soft with mild diffuse tenderness on palpation. Bowel sounds present all four quadrants. Last bowel movement yesterday , normal consistency. Urine output adequate , clear, yellow. No urinary complaints.

Diaphoretic , skin cool and clammy to touch. Mucous membranes dry. No rashes, wounds, or skin breakdown noted. Reports severe anxiety , "my anxiety is through the roof." No IV site redness, swelling, or signs of infiltration. PIV patent.