Date post: | 05-Sep-2015 |
Category: |
Documents |
Upload: | stan-j-caterbone |
View: | 12 times |
Download: | 4 times |
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Patient Demographics
ED Arrival Information
Expected Arrival AcuityMeans ofArrival Escorted By Service
AdmissionType
- 7/10/201517:46
2=Emergent Police - EmergencyMedicine
Emergency
Arrival Complaintpsych eval
Chief ComplaintPsych Evaluation [160478]
DiagnosisAcute psychosis
ED EventsDate/Time Event User Comments07/10/15 1746 Patient arrived in ED RODRIGUEZ-SOTO,
MELISSA07/10/15 1747 RODRIGUEZ-SOTO,
MELISSA07/10/15 1747 RODRIGUEZ-SOTO,
MELISSA07/10/15 1747 Patient roomed in ED RODRIGUEZ-SOTO,
MELISSATo room 15BHE
07/10/15 1747 Assign Nurse HUEHNERGARTH,GRETCHEN A
Huehnergarth, Gretchen A, RN assigned asRegistered Nurse
07/10/15 1748 Assign Attending HUEHNERGARTH,GRETCHEN A
McIntyre, Daniel, MD assigned as Attending
07/10/15 1748 Assign Doctor/Pt. evalbegins
HUEHNERGARTH,GRETCHEN A
07/10/15 1749 Triage Started HUEHNERGARTH,GRETCHEN A
07/10/15 1749 XR Ordered MCINTYRE MD, DANIEL P XR SHOULDER RIGHT MIN 2 VW07/10/15 1749 Imaging Exam
OrderedMCINTYRE MD, DANIEL P
Printed on 7/28/2015 11:44 AM Page 1
CATERBONE,STANLEY ENGLISH
Emergency Contact 1Refused
Name Patient ID SSN
Address Phone EMail Employer1250 FREMONT STREETLANCASTER PA 17603-9543
717-826-5354 (H)717-669-2163 (M)
Sex Birth Date
County RaceLANCASTER White
Caterbone, Stanley J 0542297 xxx-xx-0959
Reg Status PCPVerified Sullivan, Brian P, MD717-291-5991
Male 07/15/58 (57 yrs)
Marital Status Religion Alias LanguageSingle -
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED EventsDate/Time Event User Comments07/10/15 1750 Vitals Assessment HUEHNERGARTH,
GRETCHEN A07/10/15 1801 Charting Complete MCINTYRE MD, DANIEL P07/10/15 1801 Transfer Disposition
SelectedMCINTYRE MD, DANIEL P ED Disposition set to Transfer
07/10/15 1801 Disposition Selected MCINTYRE MD, DANIEL P07/10/15 1824 Registration
CompletedGROFF, BARBARA A
07/10/15 1829 Xray Final Result INTERFACE, INCOMINGRAD RESULTS
(Final result) XR SHOULDER RIGHT MIN 2VW
07/10/15 1938 Lab Ordered HUEHNERGARTH,GRETCHEN A
CBC, POCT URINE PREGNANCY
07/10/15 1946 Admit DispositionSelected
ECHEVARRIA, MARIAN ER
ED Disposition set to Admit
07/10/15 1946 Disposition Selected ECHEVARRIA, MARIAN ER
07/10/15 1946 Transfer DispositionSelected
ECHEVARRIA, MARIAN ER
ED Disposition set to Transfer
07/10/15 1946 Disposition Selected ECHEVARRIA, MARIAN ER
07/10/15 2010 Lab Resulted INTERFACE, INCOMINGLAB RESULTS
(Final result) CBC
07/10/15 2034 Lab Resulted INTERFACE, INCOMINGLAB RESULTS
(Final result) BASIC METABOLIC PANEL(BMP)
07/10/15 2323 Assign Nurse YARNISH, THERESA M Yarnish, Theresa M, RN assigned asRegistered Nurse
07/10/15 2323 Remove Nurse YARNISH, THERESA M Huehnergarth, Gretchen A, RN removed asRegistered Nurse
07/10/15 2333 Triage Completed YARNISH, THERESA M07/11/15 0000 ED Census07/11/15 0040 Patient discharged YARNISH, THERESA M07/11/15 0040 Patient departed from
EDYARNISH, THERESA M
07/11/15 0114 YARNISH, THERESA M07/11/15 0114 YARNISH, THERESA M07/11/15 0114 YARNISH, THERESA M07/11/15 0114 YARNISH, THERESA M07/11/15 0119 Charting Complete YARNISH, THERESA M07/21/15 1520 Charting Complete HUEHNERGARTH,
GRETCHEN A07/10/15 1810 Imaging Exam Started MESKEY, ELIZABETH M XR SHOULDER RIGHT MIN 2 VW07/10/15 1812 Imaging Exam Ended MESKEY, ELIZABETH M XR SHOULDER RIGHT MIN 2 VW
ED Treatment TeamProvider Role From To Phone PagerMcIntyre, Daniel, MD Attending Provider 07/10/15 1748 07/11/15 0040 717-544-4978Huehnergarth,Gretchen A, RN
Registered Nurse 07/10/15 1747 07/10/15 2323
Yarnish, Theresa M,RN
Registered Nurse 07/10/15 2323 --
Printed on 7/28/2015 11:44 AM Page 2
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Discharge OrdersNone
Printed on 7/28/2015 11:44 AM Page 3
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 5:49 PM Version 1 of 1Author: Huehnergarth, Gretchen A,RN
Service: (none) Author Type: Registered Nurse
Filed: 7/10/2015 5:50 PM Note Time: 7/10/2015 5:49 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)
Patient on 302 for psychosis and paranoia directed at a Lancaster Detective
Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 5:50 PM
ED Provider Notes by McIntyre, Daniel, MD at 7/10/2015 5:58 PM Version 1 of 1Author: McIntyre, Daniel, MD Service: Emergency Medicine Author Type: PhysicianFiled: 7/10/2015 6:01 PM Note Time: 7/10/2015 5:58 PM Status: SignedEditor: McIntyre, Daniel, MD (Physician)
HISTORY:
Chief ComplaintPatient presents with
Psych Evaluation
HPI56-year-old male with a long psychiatric history presents to the emergency room in police custody on a 302petition. Apparently the patient has been contacting a detective and making threats of packing into policecomputers. The patient has been off of his medication for some time. The patient appears paranoid. He iscomplaining of right shoulder pain. He states that he was arrested while cutting his lawn today. He thinks thathis right arm was twisted in his shoulders been uncomfortable since. The patient denied any other injuries. Hedenies any homicidal or suicidal thoughts. No past medical history on file.
No past surgical history on file.
No family history on file.Not significantSocial HistorySubstance Use Topics
Smoking status: Current Every Day Smoker -- 1.00 packs/dayTypes: CigarettesSmokeless tobacco: Not on fileAlcohol Use: Yes
Continues to smoke dailyProblem List
DiagnosisParanoid Schizophrenia
Printed on 7/28/2015 11:44 AM Page 4
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes (continued)
Review of SystemsI have reviewed and agree with the nursing notes as well as the social history.
Review of Systems both pertinent positive and negative findings of the review of systems, has beenthoroughly documented in the HPI (above in the chart) and all other systems are negative.
PHYSICAL EXAM:Vital SignsTemperaturePulse/Heart RateRespirationBP 132/74 mmHg (07/10/15 1750)MAP 93 MM HG (07/10/15 1750)SpO2O2 DeviceO2 Therapy Flow
Physical ExamConstitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. Nodistress.HENT:Head: Normocephalic and atraumatic.Eyes: Conjunctivae are normal. Pupils are equal, round, and reactive to light.Neck: Normal range of motion. Neck supple.Cardiovascular: Normal rate, regular rhythm and normal heart sounds.Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. He has no wheezes.Abdominal: Soft. There is no tenderness.Musculoskeletal: Normal range of motion. He exhibits no edema.Neurological: He is alert and oriented to person, place, and time. No cranial nerve deficit. He exhibits normalmuscle tone.Skin: Skin is warm and dry. He is not diaphoretic.Psychiatric: His mood appears anxious. His speech is rapid and/or pressured. Thought content is paranoid anddelusional. He expresses no homicidal and no suicidal ideation.
EKG RHYTHM:
EKG INTERPRETATION:
OXYGEN SATURATION INTERPRETATION:
Printed on 7/28/2015 11:44 AM Page 5
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes (continued)
LAB INTERPRETATION:
RADIOLOGY INTERPRETATION:
ED COURSE:Procedures
MDMPatient has been evaluated by myself and the mental health liason. Mental health liason has discussed thecase with the psychiatrist on call. We feel patient would benefit from inpatient psychiatric admission. Mentalhealth liason is arranging transfer to an inpatient bed.
The patients condition at the time of Disposition is Unchanged.
McIntyre, Daniel, MD07/10/15 1801
Signed by McIntyre, Daniel, MD on 7/10/2015 6:01 PM
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 8:31 PM Version 1 of 1Author: Huehnergarth, Gretchen A,RN
Service: (none) Author Type: Registered Nurse
Filed: 7/10/2015 8:31 PM Note Time: 7/10/2015 8:31 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)
Patient medical history and current status reviewed. Active medical problems: stable
Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 8:31 PM
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 8:32 PM Version 2 of 2Author: Huehnergarth, Gretchen A,RN
Service: (none) Author Type: Registered Nurse
Filed: 7/10/2015 10:05 PM Note Time: 7/10/2015 8:32 PM Status: AddendumEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)Related Notes: Original Note by Huehnergarth, Gretchen A, RN (Registered Nurse) filed at 7/10/2015 8:52 PM
Arrival Status:Police on 302 petitioned by Lancaster Detective
Chief Complaint:Patient was sending paranoid and harrassing emails to local detective(enclosed copies in 302)Printed on 7/28/2015 11:44 AM Page 6
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes (continued)
History of Present Illness:Patient denies he is suicidal or homicidal or psychotic. He denies he is paranoid and is invested inaseries of paranoid delusions regarding the government and FBIPatients petitioner is a local Detective who states that patient has sent him over 100 emails since midJune 2015, and to other police. He states the emails are more antagonistic One of them stating "Whyare you trying to kill me" the petitioner states that patients behavior is becoming alarming and that hefears patient will reach the paranoid state of 2010 when he stated cops should be beaten and killedTo this writers knowledge patient has never been violentPatient told this writer a lengthy statement of his making a legal petition in the case of MichelleLambert (convicted Lancaster murderer from 1990's), patient states he met with the attorney generalrecently about this case and that he also drove to the office of Mike Sturla in Harrisburg.Patient became very paranoid of nurse and said she had purposely given him a cold room, that shewas a liar. He stated he would sue the hospital "back to the courts" and demanded this writer writedown the number of the court case he had against LGH from the past.Patient believes the police and FBI are hacking his computerPatient lives with his brother and doesn't drink alcohol or use drugsHe denies he has been hospitalized since 2010 at Fairmount. He is requesting to return to Fairmount
General Appearance and Behavior:Appearance/Behavior: AgitatedEye Contact: GoodAppetite: no change from normalSleep: no change
Thought Processing and Cognitive Evaluation:Orientation: Time, Place, Person, Name and SituationAttention & Concentration: WNLMood: HostileAffect: AppropriateSpeech: Rate: normal Volume: normal Coherence: goodThought Process: Logical:noThought Association: Tangential
Abnormal Thought Content:Suicidal thoughts: noHomicidal thoughts: noHallucinations: noDelusions: yes
Printed on 7/28/2015 11:44 AM Page 7
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes (continued)
Insight: poorJudgment: poor
Substance Use:Alcohol use: no Type: Amount/Frequency: Last use: History of withdrawal symptoms:
Use of other substances: no Type/Route: Amount/Frequency: Last use: History of withdrawal symptoms:
History of Treatment for Substance Use: no
Past Psychiatric History and Current Treatment:Inpatient history: yesOutpatient services: no Psychiatrist: Therapist: Case Management: Other Services:Medication and treatment compliance: n/aHistory of Suicide Attempts: noFamily history of suicide: noActs of Self Harm: noActs of Violence: no
Social, Family and Developmental History:Current relationships/support system: brotherLiving situation: with brotherEducation:Employment: noLegal history and current charges, probation/parole: noCustody status/Child Service Involvement: noAbuse/Trauma: no
Printed on 7/28/2015 11:44 AM Page 8
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes (continued)
Functional Status:Independent for ambulation: yesIndependent in performing ADLs: yesSpecial equipment/environmental needs: noLanguage and Cultural Needs: no
Clinical Impression:psychosis
Plan for Disposition:Commitment Status: 302Physician recommendation: admit Psychiatrist is okay with patient request to transfer to Fairmount
Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 10:05 PM
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 8:32 PM Version 1 of 2Author: Huehnergarth, Gretchen A,RN
Service: (none) Author Type: Registered Nurse
Filed: 7/10/2015 8:52 PM Note Time: 7/10/2015 8:32 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)Related Notes: Addendum by Huehnergarth, Gretchen A, RN (Registered Nurse) filed at 7/10/2015 10:05 PM
Arrival Status:Police on 302 petitioned by Lancaster Detective
Chief Complaint:Patient was sending paranoid and harrassing emails to local detective(enclosed copies in 302)
History of Present Illness:Patient denies he is suicidal or homicidal or psychotic. He denies he is paranoid and is invested inaseries of paranoid delusions regarding the government and FBIPatients petitioner is a local Detective who states that patient has sent him over 100 emails since midJune 2015, and to other police. He states the emails are more antagonistic One of them stating "Whyare you trying to kill me" the petitioner states that patients behavior is becoming alarming and that hefears patient will reach the paranoid state of 201 when he stateded cops should be beaten and killedTo this writers knowledge patient has never been violentPatient told this writer a lengthy statement of his making a legal petition in the case of MichelleLambert (convicted Lancaster murderer from 1990's), patient states he met with the attorney generalrecently about this case and that he also drove to the office of Mike Sturla in Harrisburg.Patient became very paranoid of nurse and said she had purposely given him a cold room, that shewas a liar. He stated he would sue the hospital "back to the courts" and demanded this writer writedown the number of the court case he had against LGH from the past.
Printed on 7/28/2015 11:44 AM Page 9
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes (continued)
Patient believes the police and FBI are hacking his computerPatient lives with his brother and doesn't drink alcohol or use drugsHe denies he has been hospitalized since 2010 at Fairmount. He is requesting to return to Fairmount
General Appearance and Behavior:Appearance/Behavior: AgitatedEye Contact: GoodAppetite: no change from normalSleep: no change
Thought Processing and Cognitive Evaluation:Orientation: Time, Place, Person, Name and SituationAttention & Concentration: WNLMood: HostileAffect: AppropriateSpeech: Rate: normal Volume: normal Coherence: goodThought Process: Logical:noThought Association: Tangential
Abnormal Thought Content:Suicidal thoughts: noHomicidal thoughts: noHallucinations: noDelusions: yes
Insight: poorJudgment: poor
Substance Use:Alcohol use: no Type: Amount/Frequency: Last use: History of withdrawal symptoms:
Use of other substances: no Type/Route: Amount/Frequency: Last use:
Printed on 7/28/2015 11:44 AM Page 10
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes (continued)
History of withdrawal symptoms:
History of Treatment for Substance Use: no
Past Psychiatric History and Current Treatment:Inpatient history: yesOutpatient services: no Psychiatrist: Therapist: Case Management: Other Services:Medication and treatment compliance: n/aHistory of Suicide Attempts: noFamily history of suicide: noActs of Self Harm: noActs of Violence: no
Social, Family and Developmental History:Current relationships/support system: brotherLiving situation: with brotherEducation:Employment: noLegal history and current charges, probation/parole: noCustody status/Child Service Involvement: noAbuse/Trauma: no
Functional Status:Independent for ambulation: yesIndependent in performing ADLs: yesSpecial equipment/environmental needs: noLanguage and Cultural Needs: no
Clinical Impression:psychosis
Plan for Disposition:Commitment Status: 302Physician recommendation: admit Psychiatrist is okay with patient request to transfer to Fairmount
Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 8:52 PM
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:26 PM Version 1 of 1
Printed on 7/28/2015 11:44 AM Page 11
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes (continued)
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:26 PM Version 1 of 1Author: Huehnergarth, Gretchen A,RN
Service: (none) Author Type: Registered Nurse
Filed: 7/10/2015 10:28 PM Note Time: 7/10/2015 10:26 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)
Insurance
Insurance Company :humanaMH Managed by : lifesyncPhone Number :8665500027Staff talked with :heather HAuthorization # :noneDates Authorized :7/10-7/13 review 7/13Other Information :
Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 10:28 PM
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:33 PM Version 1 of 1Author: Huehnergarth, Gretchen A,RN
Service: (none) Author Type: Registered Nurse
Filed: 7/10/2015 10:33 PM Note Time: 7/10/2015 10:33 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)
Patient requested and was given copy of 302
Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 10:33 PM
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:37 PM Version 1 of 1Author: Huehnergarth, Gretchen A,RN
Service: (none) Author Type: Registered Nurse
Filed: 7/10/2015 10:37 PM Note Time: 7/10/2015 10:37 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)
Patient declined any anxiolytic or antipsychotic
Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 10:37 PM
ED Orders
Start Status Ordering Provider07/10/15
1939Final result MCINTYRE, DANIEL
07/10/151939
Final result MCINTYRE, DANIEL
Printed on 7/28/2015 11:44 AM Page 12
Toxic Screen, Urine, No Confirmation ONE TIME
Alcohol, Serum ONE TIME
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Orders
Start Status Ordering Provider07/10/15
1939Final result MCINTYRE, DANIEL
07/10/151939
Final result MCINTYRE, DANIEL
07/10/151830
Last MAR action:Given - byHUEHNERGARTH,GRETCHEN A on07/10/15 at 1954
MCINTYRE, DANIEL
07/10/151750
Final result MCINTYRE, DANIEL
Lab Results (07/10/15 - 07/10/15)
CBC (For Transfers Only) [110835910] (Abnormal)Resulted: 07/10/15 2010, Result Status: Final
resultOrdering provider: McIntyre, Daniel, MD 07/10/15 1938 Resulting Lab: LANCASTER GENERAL
LABORATORY
Basic Metabolic Panel (BMP) (For Transfers Only) [110835909](Abnormal)
Resulted: 07/10/15 2034, Result Status: Finalresult
Ordering provider: McIntyre, Daniel, MD 07/10/15 1938 Resulting Lab: LANCASTER GENERALLABORATORY
Printed on 7/28/2015 11:44 AM Page 13
07/10/15 1948Comment: For Transfers Only.
XR SHOULDER RIGHT MIN 2 VW ONE TIME
Components
Value Ref Range Flag Comment LabWBC Count 11.4 4.8 - 10.8 K H - LG
LABRBC Count 5.12 4.60 - 6.20 M - LG
LABHgb 14.7 14.0 - 18.0 g/dL - LG
LABHct 42.5 42.0 - 52.0 % - LG
LABMCV 83.0 80.0 - 100.0 fL - LG
LABMCH 28.7 27.0 - 33.0 pg - LG
LABMCHC 34.6 32.0 - 36.0 % - LG
LABPlatelet Count 203 150 - 450 K - LG
LABRDW 14.4 12.2 - 14.6 % - LG
LAB
Basic Metabolic Panel (BMP) (For Transfers Only)ONE TIME
CBC (For Transfers Only) ONE TIME
ibuprofen (ADVIL,MOTRIN) tablet 600 mg ONCE
Comments: For Transfers Only.
Comments: For Transfers Only.
Specimen Collection
Specimen CollectionType Source Collected On
07/10/15 1948
Type Source Collected On
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Lab Results (07/10/15 - 07/10/15) (continued)
Basic Metabolic Panel (BMP) (For Transfers Only) [110835909](Abnormal)
Resulted: 07/10/15 2034, Result Status: Finalresult
Alcohol, Serum [110835908]Resulted: 07/10/15 2037, Result Status: Final
resultOrdering provider: McIntyre, Daniel, MD 07/10/15 1938 Resulting Lab: LANCASTER GENERAL
LABORATORY
Printed on 7/28/2015 11:44 AM Page 14
16 8 - 22 mg/dL - LGLAB
Sodium 137 135 - 145mmol/L
- LGLAB
Potassium 4.1 3.4 - 5.3 mmol/L - LGLAB
Chloride 105 98 - 107 mmol/L - LGLAB
CO2 Venous 28.0 21.0 - 31.0mmol/L
- LGLAB
Anion Gap 4 5 - 15 mmol/L L - LGLAB
Creatinine 0.8 0.7 - 1.2 mg/dL - LGLAB
BUN/CreatinineRatio
20 10 - 20 Ratio - LGLAB
OsmolalityCalculation(serum)
275 275 - 300mOsm/Kg
- LGLAB
Calcium 9.7 8.6 - 10.3 mg/dL - LGLAB
GFR >60 mL/min/1.73sqm
LGLAB
Comment: Notes for GFR:1. Multiply result by 1.21 if patient is black/African American.2. Chronic kidney disease:
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Lab Results (07/10/15 - 07/10/15) (continued)
Alcohol, Serum [110835908]Resulted: 07/10/15 2037, Result Status: Final
result
Toxic Screen, Urine, No Confirmation [110835906]Resulted: 07/10/15 2301, Result Status: Final
resultOrdering provider: McIntyre, Daniel, MD 07/10/15 1938 Resulting Lab: LANCASTER GENERAL
LABORATORY
Printed on 7/28/2015 11:44 AM Page 15
Collected On07/10/15 2149
Components
Value Ref Range Flag Comment LabUrineAmphetamineScreen
NONE DETECTED None Detected - LGLAB
Urine BarbiturateScreen
NONE DETECTED None Detected - LGLAB
UrineBenzodiazepineScreen
NONE DETECTED None Detected - LGLAB
Urine CocaineMetabolite Screen
NONE DETECTED None Detected - LGLAB
Urine MarijuanaScreen
NONE DETECTED None Detected - LGLAB
Urine OpiateScreen
See Below None Detected LGLAB
Comment: NONE DETECTED -Hydrocodone and Methadone are not routinelydetected by the LGH Urine Toxic Screen. These drugsmust be ordered specifically.
UR OxycodoneScreen
NONE DETECTED None Detected - LGLAB
UrinePCP(Phencyclidine) Screen
NONE DETECTED None Detected LGLAB
Comment: Unconfirmed screening results MUST NOT be used fornon-medical purposes: (eg. employment testing, legal testing) CUT OFF CONCENTRATION FOR POSITIVE RESULTS: Amphetamines = 1000 ng/mL Barbiturates = 200 ng/mL Benzodiazepine = 200 ng/mL Cocaine = 300 ng/mL Opiates = 300 ng/mL Oxycodone = 100 ng/mL Phencyclidine = 25 ng/mL THC = 50 ng/mL
Concentrations above 400 mg/dL may be fatal.
Specimen CollectionType Source
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Lab Results (07/10/15 - 07/10/15) (continued)
Toxic Screen, Urine, No Confirmation [110835906]Resulted: 07/10/15 2301, Result Status: Final
result
Testing Performed ByLab - Abbreviation Name Director Address Valid Date Range6 - LG LAB LANCASTER
GENERALLABORATORY
Bruce King, M.D.,Director
555 N. Duke St.Lancaster PA 17602-2250
10/10/13 1035 - Present
Radiology Results (07/10/15 - 07/10/15)
XR SHOULDER RIGHT MIN 2 VW [110832753]Resulted: 07/10/15 1825, Result Status: Final
resultOrdering provider: McIntyre, Daniel, MD 07/10/15 1749 Resulted by: Smigocki, Gene C, MDPerformed: 07/10/15 1810 - 07/10/15 1810 Resulting Lab: LANCASTER GENERAL RADIOLOGYNarrative: Two-view right shoulder
History: Pain following injury
Comparison: None
Technique: Internal and external views were obtained
Findings:
No osseous abnormality is present. Minor degenerative changes are present in theacromioclavicular joint. Joint spaces and soft tissues are otherwise normal.
Impression:
No evidence of fracture
Dictating Workstation: HMINWKS2
Testing Performed ByLab - Abbreviation Name Director Address Valid Date Range7 - LG RADIOLOGY LANCASTER
GENERALRADIOLOGY
RobertLatshaw,MD
555 N. Duke St.Lancaster PA 17604-3555
08/08/12 1438 - Present
EKG ResultsNone
All Administrations of ibuprofen (ADVIL,MOTRIN) tablet 600 mg
User(s)ActionTime
RecordedTime
Dose/Rate Route Site Comment Action
Reason
Huehnergarth,Gretchen A, RN
07/10/151954
07/10/151955
600 mg Oral Given
Printed on 7/28/2015 11:44 AM Page 16
Specimen CollectionType Source Collected On
07/10/15 1810
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
All Administrations of ibuprofen (ADVIL,MOTRIN) tablet 600 mg
ED Current OP MedicationsMedication Sig Dispense Start Date End Date Doc. ProviderNAPROXEN 500 MG ORAL TABS 1 TABLET
TWICE DAILYas needed forpain
60 9/23/2009 Sullivan, Brian P,MD
VICODIN ES 7.5-750 MG ORALTABS
1/2 to 1 tabletevery 6 hoursas needed forpain
30 tablet 5/10/2010 Sullivan, Brian P,MD
Medications not reviewed this encounter
Medication Comments** No Medication Comments Found **
Allergies (verified on: 05/25/10)Agent Severity CommentsNO KNOWN ALLERGIES
Follow-up InformationNone
Vitals from to
Date and Time BPPosition Pulse Resp Temp
Tempsrc SpO2
OxygenTherapyFlow(L/min)
Weight
Doppler/Fetoscope Rate
POCTCarboxyhemoglobin
Who
07/10/15 1750 132/74mmHg
-- 82 20 98 F(36.7C)
Oral -- -- -- -- -- GAH
Flowsheets (all recorded)
Printed on 7/28/2015 11:44 AM Page 17
AmbulanceArrived
Yes -TMYARNIS
Transfer Charting - Sat July 11, 2015
Transfer Checklist - Sat July 11, 2015
0043Transfer ChecklistReport toTransfer Team
Yes -TMYARNIS
0043Transport Request
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Flowsheets (all recorded)
Printed on 7/28/2015 11:44 AM Page 18
MAR MINI-FLOWSHEET DATA - Fri July 10, 2015
Custom Formula Data - Fri July 10, 2015
1750OTHERMean ArterialPressure
93 MM HG -GAHUEHNE
1954 1817
Triage Plan - Fri July 10, 2015
2333Triage Acuity CalculatorIsRESUSCITATION required?
No -TMYARNIS
Is this anEMERGENT(High Risk,Altered LOC,Severe Pain)situation?
Yes (2) -TMYARNIS
Patient Acuity 2 -TMYARNISED Destination Behavioral Health
-TMYARNIS
Vital Signs - Fri July 10, 2015
1954 1817 1750Vital SignsBP 132/74 mmHg -
GAHUEHNE
Pulse 82 -GAHUEHNEResp 20 -GAHUEHNETemp 98 F (36.7 C) -
GAHUEHNE
Temp src Oral -GAHUEHNEPainAssessment
0-10 -GAHUEHNE
Number Scale*Pain Rating 4 -GAHUEHNE 7 -GAHUEHNE*Pain Location shoulder -
GAHUEHNE
PainDescription -Quality
aching -GAHUEHNE
*Factors thatAggravate Pain
activity -GAHUEHNE
*Factors thatRelieve Pain
repositioning -GAHUEHNE
Number Scale
Transfer Charting - Fri July 10, 2015
2216
*Pain Rating 4 -GAHUEHNE 7 -GAHUEHNE
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Printed on 7/28/2015 11:44 AM Page 19
ETA ofAmbulance
2330 -GAHUEHNE
AmbulanceArrived
Yes -GAHUEHNE
Transfer Mode Gurney -GAHUEHNE
Type ofTransfer
BLS/ALS/CCTAmbulance -GAHUEHNE
AccompaniedBy
EMS Personnel -GAHUEHNE
Transport Request
Transfer Checklist - Fri July 10, 2015
2216Transfer ChecklistReason forTransfer
Patient Request -GAHUEHNE
AcceptingHospital
fairmount -GAHUEHNE
AcceptingPhysician
bridget bautista -GAHUEHNE
SendingPhysician
mcintyre -GAHUEHNE
Report toTransfer Team
Yes -GAHUEHNE
Report toReceivingFacility
Yes -GAHUEHNE
Spoke with tyree -GAHUEHNETransferConsentSigned
Yes -GAHUEHNE
Copy ofRecords and DIObtained
Yes -GAHUEHNE
Faxed Recordsto ReceivingFacility
Yes -GAHUEHNE
DispatcherCalled
Yes -GAHUEHNE
Travel Screening - Fri July 10, 2015
1824Travel ScreeningHas the patienttraveled toAfrica OR hadcontact withsomeone whohas traveled toAfrica in thelast 21 days?
No -BG017
Name ofDispatcher
jaimie -GAHUEHNE
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED After Visit Summary
Diagnoses this visitYour diagnosis was ACUTE PSYCHOSIS.
You were seen byYou were seen by McIntyre, Daniel, MD.
ED PrescriptionsNone
Orders Completed During Your ED Visit
Start Status Ordering Provider07/10/15
1939Final result MCINTYRE, DANIEL
07/10/151939
Final result MCINTYRE, DANIEL
07/10/151939
Final result MCINTYRE, DANIEL
07/10/151939
Final result MCINTYRE, DANIEL
07/10/151830
Last MAR action:Given
MCINTYRE, DANIEL
07/10/151750
Final result MCINTYRE, DANIEL
Suture Information from toNone
Printed on 7/28/2015 11:44 AM Page 20
Automaticrestart vitalstimer
YES -GAHUEHNE
Arrival Documentation - Fri July 10, 2015
User Key(r) = User Recd, (t) = User Taken, (c) = User
Cosigned
Toxic Screen, Urine, No Confirmation ONE TIME
User ID Name Effective DatesBG017
Alcohol, Serum ONE TIME
Groff, Barbara A -GAHUEHNE Huehnergarth, Gretchen A, RN 03/23/11 -
Basic Metabolic Panel (BMP) (For Transfers Only)ONE TIME
TMYARNIS Yarnish, Theresa M, RN 03/23/11 -
CBC (For Transfers Only) ONE TIME
1749
ibuprofen (ADVIL,MOTRIN) tablet 600 mg ONCE
Triage StartTriage Start
XR SHOULDER RIGHT MIN 2 VW ONE TIME
Start -GAHUEHNEPrehospital TreatmentPrehospitalTreatment
No -GAHUEHNE
Vitals Reassessment - Fri July 10, 2015
1750Vitals Assessment
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED After Visit Summary (continued)
Information regarding the care you received at theLancaster General Hospital Emergency Department
You may receive a survey about your emergency department visit.Our goal is for our patients to receive very good care during their ED visit.Please take a moment to complete a survey if you receive one so we may continue to improve.
The examination and treatment you have received in the Emergency Department have been rendered on anemergency basis only, and are not intended to be a substitute for or an effort to provide complete medicalcare. Your primary care physician may request a copy of your records and all test results. It is important thatyou let him/her check you again, and that you report any new or remaining problems.
XRAYS/EKGSThe interpretation of EKG'S and/or x-rays at the time of the emergency visit may only be a preliminary report.You will be notified by telephone if there is a change in the interpretation when the tests are reviewed by thecardiologist and/or radiologist.
MEDICATIONS/PRESCRIPTIONSTake all medication as prescribed by the physician.
FAMILY PHYSICIAN If you are being referred to your own Primary Care Physician for follow up and do not have one, please callthe Physician Referral Line at 1-888-LGH-INFO (1-888-544-4636) and you will be assisted in locating aPrimary Care Physician.
REFERRAL TO SPECIALISTIf you are being referred to any doctor/specialist other than your own Primary Care Physician: Please contactyour doctor for a referral and any paperwork or referral forms that may be required. If you have anyquestions about whether you need such forms, contact your insurance company or doctor's office as soon aspossible.
The staff of the Lancaster General Hospital Emergency Department and Trauma Services strives to ensurequality care and customer service during your visit.Your Current Condition does not require hospitalization. Your condition can, however, change. If there areany concerns regarding your condition, you may return to the Emergency Department or contact yourPrimary Physician.
The Emergency Physicians of Lancaster Emergency Associates (LEA) are the exclusive providers ofEmergency Medical care at Lancaster General Hospital. We appreciate any comments or feedback you mayhave on your experience with us in the Emergency Department and invite you to visit us atwww.LancasterEmergencyAssociates.com
We constantly are looking for ways to improve your Emergency Department Experience.If you have any suggestions or concerns, please let us know.
Printed on 7/28/2015 11:44 AM Page 21
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED After Visit Summary (continued)
You may call any of the following ED Management Team:Jolyne Barnett, RN ED Nurse Manager 717 544-5125Penne Marino, RN, Days Assistant Nurse Manager 717 544-4582Amy Sechrist, RN Evenings Assistant Nurse Manager 717 544-7055Lisa Williams, RN Nights Assistant Nurse Manager 717 544-1776
Lancaster General Hospital Convenience Pharmacy 717 544-5929Hours of Operation: Monday through Friday 7am- 6pmSaturday 9am- 3pmSunday Closed
Procedures and tests performed during your visitAlcohol, SerumBasic Metabolic Panel (BMP) (For Transfers Only)CBC (For Transfers Only)Toxic Screen, Urine, No ConfirmationXR SHOULDER RIGHT MIN 2 VW
Scanned Information
Encounter-Level Documents - 07/10/2015:
Scan on 7/11/2015 8:21 PM (below)
Printed on 7/28/2015 11:44 AM Page 22
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Scanned Information (continued)
Scan on 7/11/2015 5:38 PM (below)
Printed on 7/28/2015 11:44 AM Page 23
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Scanned Information (continued)
Order-Level Documents:There are no order-level documents.
Code Documentation
No data selected in time range
Printed on 7/28/2015 11:44 AM Page 24
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Scanned Information (continued)
Sedation Documentation
No data selected in time range
Hospital Encounter on 7/10/2015ED Arrival InformationChief ComplaintTreatment TeamDischarge OrdersED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 5:49 PMED Provider Notes by McIntyre, Daniel, MD at 7/10/2015 5:58 PMED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 8:31 PMED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 8:32 PMVersion 1
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:26 PMED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:33 PMED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:37 PMCBC (For Transfers Only) - Final resultBasic Metabolic Panel (BMP) (For Transfers Only) - Final resultAlcohol, Serum - Final resultToxic Screen, Urine, No Confirmation - Final resultXR SHOULDER RIGHT MIN 2 VW - Final resultAllergiesFollow-up InformationAll Flowsheets07/11/15Transfer ChartingTransfer Checklist
07/10/15MAR MINI-FLOWSHEET DATACustom Formula DataTriage PlanVital SignsTransfer ChartingTransfer ChecklistTravel ScreeningArrival DocumentationVitals Reassessment
User Key
PrescriptionsEncounter-Level Documents:Scan on 7/11/2015 8:21 PMScan on 7/11/2015 5:38 PM
Order-Level Documents: