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LANCASTER GENERAL HOSPITAL

Health Information Management


555 North Duke Street
Lancaster PA 17604-3555
ED Record
Patient Demographics
Name
Caterbone, Stanley J

Patient ID
0542297

Address
Phone
1250 FREMONT STREET 717-826-5354 (H)
LANCASTER PA 17603717-669-2163 (M)
9543

SSN
xxx-xx-0959

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015

Sex
Male

EMail

Birth Date
07/15/58 (57 yrs)
Employer

County
LANCASTER

Race
White

Reg Status
Verified

PCP
Sullivan, Brian P, MD717-291-5991

Marital Status
Single

Religion
-

Alias
CATERBONE,STANLEY

Language
ENGLISH

Emergency Contact 1
Refused
ED Arrival Information
Expected
-

Arrival
7/10/2015
17:46
Arrival Complaint
psych eval

Acuity
2=Emergent

Means of
Arrival
Police

Escorted By
-

Service
Emergency
Medicine

Admission
Type
Emergency

Chief Complaint
Psych Evaluation [160478]
Diagnosis
Acute psychosis
ED Events
Date/Time
07/10/15 1746
07/10/15 1747
07/10/15 1747
07/10/15 1747
07/10/15 1747
07/10/15 1748
07/10/15 1748
07/10/15 1749
07/10/15 1749
07/10/15 1749

Event
Patient arrived in ED

User
RODRIGUEZ-SOTO,
MELISSA
RODRIGUEZ-SOTO,
MELISSA
RODRIGUEZ-SOTO,
MELISSA
Patient roomed in ED RODRIGUEZ-SOTO,
MELISSA
Assign Nurse
HUEHNERGARTH,
GRETCHEN A
Assign Attending
HUEHNERGARTH,
GRETCHEN A
Assign Doctor/Pt. eval HUEHNERGARTH,
begins
GRETCHEN A
Triage Started
HUEHNERGARTH,
GRETCHEN A
XR Ordered
MCINTYRE MD, DANIEL P
Imaging Exam
MCINTYRE MD, DANIEL P
Ordered

Printed on 7/28/2015 11:44 AM

Comments

To room 15BHE
Huehnergarth, Gretchen A, RN assigned as
Registered Nurse
McIntyre, Daniel, MD assigned as Attending

XR SHOULDER RIGHT MIN 2 VW

Page 1

LANCASTER GENERAL HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record
ED Events
Date/Time
07/10/15 1750
07/10/15 1801
07/10/15 1801

Event
Vitals Assessment

07/10/15 1829

Charting Complete
Transfer Disposition
Selected
Disposition Selected
Registration
Completed
Xray Final Result

07/10/15 1938

Lab Ordered

07/10/15 1946

Admit Disposition
Selected
Disposition Selected

07/10/15 1801
07/10/15 1824

User
HUEHNERGARTH,
GRETCHEN A
MCINTYRE MD, DANIEL P
MCINTYRE MD, DANIEL P

07/10/15 1946

Transfer Disposition
Selected
Disposition Selected

07/10/15 2010

Lab Resulted

07/10/15 2034

Lab Resulted

07/10/15 2323

Assign Nurse

07/10/15 2323

Remove Nurse

YARNISH, THERESA M

07/10/15 2333
07/11/15 0000
07/11/15 0040
07/11/15 0040

Triage Completed
ED Census
Patient discharged
Patient departed from
ED

YARNISH, THERESA M

07/11/15 0114
07/11/15 0114
07/11/15 0114
07/11/15 0114
07/11/15 0119
07/21/15 1520

YARNISH, THERESA M
YARNISH, THERESA M
YARNISH, THERESA M
YARNISH, THERESA M
Charting Complete
YARNISH, THERESA M
Charting Complete
HUEHNERGARTH,
GRETCHEN A
Imaging Exam Started MESKEY, ELIZABETH M
Imaging Exam Ended MESKEY, ELIZABETH M

07/10/15 1946

07/10/15 1810
07/10/15 1812

ED Treatment Team
Provider
McIntyre, Daniel, MD
Huehnergarth,
Gretchen A, RN
Yarnish, Theresa M,
RN

Comments

ED Disposition set to Transfer

MCINTYRE MD, DANIEL P


GROFF, BARBARA A
INTERFACE, INCOMING
RAD RESULTS
HUEHNERGARTH,
GRETCHEN A
ECHEVARRIA, MARIAN E
R
ECHEVARRIA, MARIAN E
R
ECHEVARRIA, MARIAN E
R
ECHEVARRIA, MARIAN E
R
INTERFACE, INCOMING
LAB RESULTS
INTERFACE, INCOMING
LAB RESULTS
YARNISH, THERESA M

07/10/15 1946

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015

(Final result) XR SHOULDER RIGHT MIN 2


VW
CBC, POCT URINE PREGNANCY
ED Disposition set to Admit

ED Disposition set to Transfer

(Final result) CBC


(Final result) BASIC METABOLIC PANEL
(BMP)
Yarnish, Theresa M, RN assigned as
Registered Nurse
Huehnergarth, Gretchen A, RN removed as
Registered Nurse

YARNISH, THERESA M
YARNISH, THERESA M

XR SHOULDER RIGHT MIN 2 VW


XR SHOULDER RIGHT MIN 2 VW

Role
Attending Provider
Registered Nurse

From
07/10/15 1748
07/10/15 1747

To
07/11/15 0040
07/10/15 2323

Registered Nurse

07/10/15 2323

--

Printed on 7/28/2015 11:44 AM

Phone
717-544-4978

Pager

Page 2

LANCASTER GENERAL HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015

Discharge Orders
None

Printed on 7/28/2015 11:44 AM

Page 3

LANCASTER GENERAL HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015

ED Notes
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 5:49 PM
Author: Huehnergarth, Gretchen A, Service: (none)
RN
Filed: 7/10/2015 5:50 PM
Note Time: 7/10/2015 5:49 PM
Editor: Huehnergarth, Gretchen A, RN (Registered Nurse)

Version 1 of 1
Author Type: Registered Nurse
Status: Signed

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
Author: McIntyre, Daniel, MD
Service: Emergency Medicine
Filed: 7/10/2015 6:01 PM
Note Time: 7/10/2015 5:58 PM
Editor: McIntyre, Daniel, MD (Physician)

Version 1 of 1
Author Type: Physician
Status: Signed

HISTORY:
Chief Complaint
Patient presents with

Psych Evaluation

HPI
56-year-old male with a long psychiatric history presents to the emergency room in police custody on a 302
petition. Apparently the patient has been contacting a detective and making threats of packing into police
computers. The patient has been off of his medication for some time. The patient appears paranoid. He is
complaining of right shoulder pain. He states that he was arrested while cutting his lawn today. He thinks that
his right arm was twisted in his shoulders been uncomfortable since. The patient denied any other injuries. He
denies any homicidal or suicidal thoughts.
No past medical history on file.
No past surgical history on file.
No family history on file.
Not significant
Social History
Substance Use Topics

Smoking status:

Types:
Smokeless tobacco:
Alcohol Use:

Current Every Day Smoker -- 1.00 packs/day


Cigarettes
Not on file
Yes

Continues to smoke daily


Problem List
Diagnosis

Paranoid Schizophrenia

Printed on 7/28/2015 11:44 AM

Page 4

LANCASTER GENERAL HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015

ED Notes (continued)
Review of Systems
I 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 been
thoroughly documented in the HPI (above in the chart) and all other systems are negative.
PHYSICAL EXAM:
Vital Signs
Temperature
Pulse/Heart Rate
Respiration
BP
MAP
SpO2
O2 Device
O2 Therapy Flow

132/74 mmHg (07/10/15 1750)


93 MM HG (07/10/15 1750)

Physical Exam
Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. No
distress.
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 normal
muscle 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 and
delusional. 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 HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015

ED Notes (continued)
LAB INTERPRETATION:

RADIOLOGY INTERPRETATION:

ED COURSE:
Procedures
MDM
Patient has been evaluated by myself and the mental health liason. Mental health liason has discussed the
case with the psychiatrist on call. We feel patient would benefit from inpatient psychiatric admission. Mental
health liason is arranging transfer to an inpatient bed.

The patients condition at the time of Disposition is Unchanged.

McIntyre, Daniel, MD
07/10/15 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
Author: Huehnergarth, Gretchen A, Service: (none)
RN
Filed: 7/10/2015 8:31 PM
Note Time: 7/10/2015 8:31 PM
Editor: Huehnergarth, Gretchen A, RN (Registered Nurse)

Version 1 of 1
Author Type: Registered Nurse
Status: Signed

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 2
Author: Huehnergarth, Gretchen A, Service: (none)
Author Type: Registered Nurse
RN
Filed: 7/10/2015 10:05 PM
Note Time: 7/10/2015 8:32 PM
Status: Addendum
Editor: 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 HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 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 ina
series of paranoid delusions regarding the government and FBI
Patients petitioner is a local Detective who states that patient has sent him over 100 emails since mid
June 2015, and to other police. He states the emails are more antagonistic One of them stating "Why
are you trying to kill me" the petitioner states that patients behavior is becoming alarming and that he
fears patient will reach the paranoid state of 2010 when he stated cops should be beaten and killed
To this writers knowledge patient has never been violent
Patient told this writer a lengthy statement of his making a legal petition in the case of Michelle
Lambert (convicted Lancaster murderer from 1990's), patient states he met with the attorney general
recently 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 she
was a liar. He stated he would sue the hospital "back to the courts" and demanded this writer write
down the number of the court case he had against LGH from the past.
Patient believes the police and FBI are hacking his computer
Patient lives with his brother and doesn't drink alcohol or use drugs
He denies he has been hospitalized since 2010 at Fairmount. He is requesting to return to Fairmount

General Appearance and Behavior:


Appearance/Behavior: Agitated
Eye Contact: Good
Appetite: no change from normal
Sleep: no change

Thought Processing and Cognitive Evaluation:


Orientation: Time, Place, Person, Name and Situation
Attention & Concentration: WNL
Mood: Hostile
Affect: Appropriate
Speech: Rate: normal Volume: normal Coherence: good
Thought Process: Logical:no
Thought Association: Tangential
Abnormal Thought Content:
Suicidal thoughts: no
Homicidal thoughts: no
Hallucinations: no
Delusions: yes
Printed on 7/28/2015 11:44 AM

Page 7

LANCASTER GENERAL HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015

ED Notes (continued)

Insight: poor
Judgment: 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: yes
Outpatient services: no
Psychiatrist:
Therapist:
Case Management:
Other Services:
Medication and treatment compliance: n/a
History of Suicide Attempts: no
Family history of suicide: no
Acts of Self Harm: no
Acts of Violence: no

Social, Family and Developmental History:


Current relationships/support system: brother
Living situation: with brother
Education:
Employment: no
Legal history and current charges, probation/parole: no
Custody status/Child Service Involvement: no
Abuse/Trauma: no

Printed on 7/28/2015 11:44 AM

Page 8

LANCASTER GENERAL HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015

ED Notes (continued)

Functional Status:
Independent for ambulation: yes
Independent in performing ADLs: yes
Special equipment/environmental needs: no
Language and Cultural Needs: no

Clinical Impression:
psychosis
Plan for Disposition:
Commitment Status: 302
Physician 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 2
Author: Huehnergarth, Gretchen A, Service: (none)
Author Type: Registered Nurse
RN
Filed: 7/10/2015 8:52 PM
Note Time: 7/10/2015 8:32 PM
Status: Signed
Editor: 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 ina
series of paranoid delusions regarding the government and FBI
Patients petitioner is a local Detective who states that patient has sent him over 100 emails since mid
June 2015, and to other police. He states the emails are more antagonistic One of them stating "Why
are you trying to kill me" the petitioner states that patients behavior is becoming alarming and that he
fears patient will reach the paranoid state of 201 when he stateded cops should be beaten and killed
To this writers knowledge patient has never been violent
Patient told this writer a lengthy statement of his making a legal petition in the case of Michelle
Lambert (convicted Lancaster murderer from 1990's), patient states he met with the attorney general
recently 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 she
was a liar. He stated he would sue the hospital "back to the courts" and demanded this writer write
down 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 HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015

ED Notes (continued)

Patient believes the police and FBI are hacking his computer
Patient lives with his brother and doesn't drink alcohol or use drugs
He denies he has been hospitalized since 2010 at Fairmount. He is requesting to return to Fairmount

General Appearance and Behavior:


Appearance/Behavior: Agitated
Eye Contact: Good
Appetite: no change from normal
Sleep: no change

Thought Processing and Cognitive Evaluation:


Orientation: Time, Place, Person, Name and Situation
Attention & Concentration: WNL
Mood: Hostile
Affect: Appropriate
Speech: Rate: normal Volume: normal Coherence: good
Thought Process: Logical:no
Thought Association: Tangential
Abnormal Thought Content:
Suicidal thoughts: no
Homicidal thoughts: no
Hallucinations: no
Delusions: yes
Insight: poor
Judgment: 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 HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 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: yes
Outpatient services: no
Psychiatrist:
Therapist:
Case Management:
Other Services:
Medication and treatment compliance: n/a
History of Suicide Attempts: no
Family history of suicide: no
Acts of Self Harm: no
Acts of Violence: no

Social, Family and Developmental History:


Current relationships/support system: brother
Living situation: with brother
Education:
Employment: no
Legal history and current charges, probation/parole: no
Custody status/Child Service Involvement: no
Abuse/Trauma: no

Functional Status:
Independent for ambulation: yes
Independent in performing ADLs: yes
Special equipment/environmental needs: no
Language and Cultural Needs: no

Clinical Impression:
psychosis
Plan for Disposition:
Commitment Status: 302
Physician 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
Printed on 7/28/2015 11:44 AM

Version 1 of 1
Page 11

LANCASTER GENERAL HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 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
Author: Huehnergarth, Gretchen A, Service: (none)
RN
Filed: 7/10/2015 10:28 PM
Note Time: 7/10/2015 10:26 PM
Editor: Huehnergarth, Gretchen A, RN (Registered Nurse)

Version 1 of 1
Author Type: Registered Nurse
Status: Signed

Insurance
Insurance Company :humana
MH Managed by
: lifesync
Phone Number
:8665500027
Staff talked with
:heather H
Authorization #
:none
Dates Authorized
:7/10-7/13 review 7/13
Other 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
Author: Huehnergarth, Gretchen A, Service: (none)
RN
Filed: 7/10/2015 10:33 PM
Note Time: 7/10/2015 10:33 PM
Editor: Huehnergarth, Gretchen A, RN (Registered Nurse)

Version 1 of 1
Author Type: Registered Nurse
Status: Signed

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
Author: Huehnergarth, Gretchen A, Service: (none)
RN
Filed: 7/10/2015 10:37 PM
Note Time: 7/10/2015 10:37 PM
Editor: Huehnergarth, Gretchen A, RN (Registered Nurse)

Version 1 of 1
Author Type: Registered Nurse
Status: Signed

Patient declined any anxiolytic or antipsychotic


Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 10:37 PM

ED Orders
Start
07/10/15 Toxic Screen, Urine, No Confirmation ONE TIME
1939
07/10/15 Alcohol, Serum ONE TIME
1939
Printed on 7/28/2015 11:44 AM

Status
Final result

Ordering Provider
MCINTYRE, DANIEL

Final result

MCINTYRE, DANIEL

Page 12

LANCASTER GENERAL HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record
ED Orders
Start
07/10/15 Basic Metabolic Panel (BMP) (For Transfers Only)
1939 ONE TIME
Comments: For Transfers Only.
07/10/15 CBC (For Transfers Only) ONE TIME
1939 Comments: For Transfers Only.
07/10/15 ibuprofen (ADVIL,MOTRIN) tablet 600 mg ONCE
1830

07/10/15 XR SHOULDER RIGHT MIN 2 VW ONE TIME


1750

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015

Status
Final result

Ordering Provider
MCINTYRE, DANIEL

Final result

MCINTYRE, DANIEL

Last MAR action:


Given - by
HUEHNERGARTH,
GRETCHEN A on
07/10/15 at 1954
Final result

MCINTYRE, DANIEL

MCINTYRE, DANIEL

Lab Results (07/10/15 - 07/10/15)


CBC (For Transfers Only) [110835910] (Abnormal)
Ordering provider: McIntyre, Daniel, MD 07/10/15 1938
Specimen Collection
Type

Source

Resulted: 07/10/15 2010, Result Status: Final


result
Resulting Lab: LANCASTER GENERAL
LABORATORY
Collected On
07/10/15 1948

Comment: For Transfers Only.


Components
WBC Count

Value
11.4

Ref Range
4.8 - 10.8 K

Flag
H

Comment
-

RBC Count

5.12

4.60 - 6.20 M

Hgb

14.7

14.0 - 18.0 g/dL

Hct

42.5

42.0 - 52.0 %

MCV

83.0

80.0 - 100.0 fL

MCH

28.7

27.0 - 33.0 pg

MCHC

34.6

32.0 - 36.0 %

Platelet Count

203

150 - 450 K

RDW

14.4

12.2 - 14.6 %

Lab
LG
LAB
LG
LAB
LG
LAB
LG
LAB
LG
LAB
LG
LAB
LG
LAB
LG
LAB
LG
LAB

Basic Metabolic Panel (BMP) (For Transfers Only) [110835909]


Resulted: 07/10/15 2034, Result Status: Final
(Abnormal)
result
Ordering provider: McIntyre, Daniel, MD 07/10/15 1938
Resulting Lab: LANCASTER GENERAL
LABORATORY
Specimen Collection
Type
Source
Collected On
07/10/15 1948
Printed on 7/28/2015 11:44 AM
Page 13

LANCASTER GENERAL HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 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)
Comment: For Transfers Only.

Resulted: 07/10/15 2034, Result Status: Final


result

Components
Value
95

Ref Range
65 - 100 mg/dL

Blood Urea
Nitrogen
Sodium

16

8 - 22 mg/dL

137

Potassium

4.1

135 - 145
mmol/L
3.4 - 5.3 mmol/L

Chloride

105

98 - 107 mmol/L

CO2 Venous

28.0

Anion Gap

21.0 - 31.0
mmol/L
5 - 15 mmol/L

Creatinine

0.8

0.7 - 1.2 mg/dL

BUN/Creatinine
Ratio
Osmolality
Calculation
(serum)
Calcium

20

10 - 20 Ratio

275

275 - 300
mOsm/Kg

9.7

8.6 - 10.3 mg/dL

GFR

>60

mL/min/1.73
sqm

Glucose (serum)

Comment:

Flag

Comment
-

Lab
LG
LAB
LG
LAB
LG
LAB
LG
LAB
LG
LAB
LG
LAB
LG
LAB
LG
LAB
LG
LAB
LG
LAB
LG
LAB
LG
LAB

Notes for GFR:


1. Multiply result by 1.21 if patient is black/African
American.
2. Chronic kidney disease: <60 mL/min/1.73 sq.m.
Renal Failure: <15 mL/min/1.73 sq.m.

Alcohol, Serum [110835908]


Ordering provider: McIntyre, Daniel, MD 07/10/15 1938
Specimen Collection
Type

Source

Resulted: 07/10/15 2037, Result Status: Final


result
Resulting Lab: LANCASTER GENERAL
LABORATORY
Collected On
07/10/15 1948

Components
Alcohol (serum)
Comment:

Value
NONE DETECTED

Ref Range
None Detected
mg/dL
Intoxication Symptoms: 50-100 mg/dL
Comatose Level: 350-500 mg/dL

Printed on 7/28/2015 11:44 AM

Flag

Comment

Lab
LG
LAB

Page 14

LANCASTER GENERAL HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015

Lab Results (07/10/15 - 07/10/15) (continued)


Alcohol, Serum [110835908]
Concentrations above 400 mg/dL may be fatal.

Toxic Screen, Urine, No Confirmation [110835906]


Ordering provider: McIntyre, Daniel, MD 07/10/15 1938
Specimen Collection
Type

Source

Resulted: 07/10/15 2037, Result Status: Final


result

Resulted: 07/10/15 2301, Result Status: Final


result
Resulting Lab: LANCASTER GENERAL
LABORATORY
Collected On
07/10/15 2149

Components
Urine
Amphetamine
Screen
Urine Barbiturate
Screen
Urine
Benzodiazepine
Screen
Urine Cocaine
Metabolite Screen
Urine Marijuana
Screen
Urine Opiate
Screen
Comment:

Value
NONE DETECTED

Ref Range
None Detected

NONE DETECTED

Flag

Comment
-

Lab
LG
LAB

None Detected

NONE DETECTED

None Detected

LG
LAB
LG
LAB

NONE DETECTED

None Detected

NONE DETECTED

None Detected

See Below

None Detected

LG
LAB
LG
LAB
LG
LAB

NONE DETECTED Hydrocodone and Methadone are not routinely


detected by the LGH Urine Toxic Screen. These drugs
must be ordered specifically.

UR Oxycodone
NONE DETECTED
None Detected
Screen
Urine
NONE DETECTED
None Detected
PCP(Phencyclidin
e) Screen
Comment:
Unconfirmed screening results MUST NOT be used for
non-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

Printed on 7/28/2015 11:44 AM

LG
LAB
LG
LAB

Page 15

LANCASTER GENERAL HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015

Lab Results (07/10/15 - 07/10/15) (continued)


Toxic Screen, Urine, No Confirmation [110835906]
Testing Performed By
Lab - Abbreviation
Name
Director
6 - LG LAB
LANCASTER
Bruce King, M.D.,
GENERAL
Director
LABORATORY

Resulted: 07/10/15 2301, Result Status: Final


result
Address
555 N. Duke St.
Lancaster PA 176022250

Valid Date Range


10/10/13 1035 - Present

Radiology Results (07/10/15 - 07/10/15)


XR SHOULDER RIGHT MIN 2 VW [110832753]
Ordering provider: McIntyre, Daniel, MD 07/10/15 1749
Performed:
07/10/15 1810 - 07/10/15 1810
Narrative:
Two-view right shoulder

Resulted: 07/10/15 1825, Result Status: Final


result
Resulted by:
Smigocki, Gene C, MD
Resulting Lab: LANCASTER GENERAL RADIOLOGY

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 the
acromioclavicular joint. Joint spaces and soft tissues are otherwise normal.
Impression:
No evidence of fracture

Dictating Workstation: HMINWKS2


Specimen Collection
Type

Testing Performed By
Lab - Abbreviation
7 - LG RADIOLOGY

Source

Name
LANCASTER
GENERAL
RADIOLOGY

Collected On
07/10/15 1810

Director
Robert
Latshaw,MD

Address
555 N. Duke St.
Lancaster PA 176043555

Valid Date Range


08/08/12 1438 - Present

EKG Results
None
All Administrations of ibuprofen (ADVIL,MOTRIN) tablet 600 mg
Action
Recorded
Dose/Rat
User(s)
Time
Time
e
Route
Huehnergarth,
07/10/15
07/10/15
600 mg
Oral
Gretchen A, RN
1954
1955
Printed on 7/28/2015 11:44 AM

Site

Comment

Action
Given

Reas
on

Page 16

LANCASTER GENERAL HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record
All Administrations of ibuprofen (ADVIL,MOTRIN) tablet 600 mg
ED Current OP Medications
Medication
NAPROXEN 500 MG ORAL TABS

Sig
1 TABLET
TWICE DAILY
as needed for
pain
VICODIN ES 7.5-750 MG ORAL
1/2 to 1 tablet
TABS
every 6 hours
as needed for
pain
Medications not reviewed this encounter

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015

Dispense
60

Start Date
9/23/2009

30 tablet

5/10/2010

End Date

Doc. Provider
Sullivan, Brian P,
MD

Sullivan, Brian P,
MD

Medication Comments
** No Medication Comments Found **
Allergies (verified on: 05/25/10)
Agent
NO KNOWN ALLERGIES

Severity

Comments

Follow-up Information
None
Vitals from to

Date and Time


07/10/15 1750

BP
132/7
4
mmH
g

Positio
n
Pulse
-82

Resp
20

Temp
98 F
(36.7
C)

Temp
src
Oral

SpO2
--

Oxyge
n
Thera
py
Doppl
Flow
er/Fet
(L/min Weigh oscop
)
t
e Rate
----

POCT
Carbo
xyhem
oglobi Wh
n
o
-GA
H

Flowsheets (all recorded)


Transfer Charting - Sat July 11, 2015
0043
Transport Request
Ambulance
Yes -TMYARNIS
Arrived
Transfer Checklist - Sat July 11, 2015
0043
Transfer Checklist
Report to
Yes -TMYARNIS
Transfer Team

Printed on 7/28/2015 11:44 AM

Page 17

LANCASTER GENERAL HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015

Flowsheets (all recorded)


MAR MINI-FLOWSHEET DATA - Fri July 10, 2015
1954
1817
Number Scale
*Pain Rating
4 -GAHUEHNE
7 -GAHUEHNE
Custom Formula Data - Fri July 10, 2015
1750
OTHER
Mean Arterial
93 MM HG GAHUEHNE
Pressure
Triage Plan - Fri July 10, 2015
2333
Triage Acuity Calculator
Is
No -TMYARNIS
RESUSCITATI
ON required?
Is this an
Yes (2) -TMYARNIS
EMERGENT(Hi
gh Risk,
Altered LOC,
Severe Pain)
situation?
Patient Acuity
2 -TMYARNIS
ED Destination Behavioral Health
-TMYARNIS

Vital Signs - Fri July 10, 2015


1954
Vital Signs
BP

1817

132/74 mmHg GAHUEHNE


82 -GAHUEHNE

Pulse
Resp
Temp
Temp src
Pain
Assessment
Number Scale
*Pain Rating
*Pain Location

1750

20 -GAHUEHNE
98 F (36.7 C) GAHUEHNE
Oral -GAHUEHNE

0-10 -GAHUEHNE

4 -GAHUEHNE

Pain
Description Quality
*Factors that
Aggravate Pain
*Factors that
Relieve Pain

7 -GAHUEHNE
shoulder GAHUEHNE
aching -GAHUEHNE

activity -GAHUEHNE
repositioning GAHUEHNE

Transfer Charting - Fri July 10, 2015


2216
Printed on 7/28/2015 11:44 AM

Page 18

LANCASTER GENERAL HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015

Transport Request
Dispatcher
Yes -GAHUEHNE
Called
Name of
jaimie -GAHUEHNE
Dispatcher
ETA of
2330 -GAHUEHNE
Ambulance
Ambulance
Yes -GAHUEHNE
Arrived
Transfer Mode Gurney GAHUEHNE

Type of
Transfer

BLS/ALS/CCT
Ambulance GAHUEHNE

Accompanied
By

EMS Personnel GAHUEHNE

Transfer Checklist - Fri July 10, 2015


2216
Transfer Checklist
Reason for
Patient Request GAHUEHNE
Transfer
Accepting
fairmount GAHUEHNE
Hospital
Accepting
bridget bautista GAHUEHNE
Physician
Sending
mcintyre GAHUEHNE
Physician
Report to
Yes -GAHUEHNE
Transfer Team
Report to
Yes -GAHUEHNE
Receiving
Facility
Spoke with
tyree -GAHUEHNE
Transfer
Yes -GAHUEHNE
Consent
Signed
Copy of
Yes -GAHUEHNE
Records and DI
Obtained
Faxed Records Yes -GAHUEHNE
to Receiving
Facility
Travel Screening - Fri July 10, 2015
1824
Travel Screening
Has the patient No -BG017
traveled to
Africa OR had
contact with
someone who
has traveled to
Africa in the
last 21 days?
Printed on 7/28/2015 11:44 AM

Page 19

LANCASTER GENERAL HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015

Arrival Documentation - Fri July 10, 2015


1749
Triage Start
Triage Start
Start -GAHUEHNE
Prehospital Treatment
Prehospital
No -GAHUEHNE
Treatment
Vitals Reassessment - Fri July 10, 2015
1750
Vitals Assessment
Automatic
YES -GAHUEHNE
restart vitals
timer
User Key
User ID
BG017
GAHUEHNE
TMYARNIS

Name
Groff, Barbara A
Huehnergarth, Gretchen A, RN
Yarnish, Theresa M, RN

(r) = User Recd, (t) = User Taken, (c) = User


Cosigned
Effective Dates
03/23/11 03/23/11 -

ED After Visit Summary


Diagnoses this visit
Your diagnosis was ACUTE PSYCHOSIS.
You were seen by
You were seen by McIntyre, Daniel, MD.
ED Prescriptions
None
Orders Completed During Your ED Visit
Start
07/10/15 Toxic Screen, Urine, No Confirmation ONE TIME
1939
07/10/15 Alcohol, Serum ONE TIME
1939
07/10/15 Basic Metabolic Panel (BMP) (For Transfers Only)
1939 ONE TIME
07/10/15 CBC (For Transfers Only) ONE TIME
1939
07/10/15 ibuprofen (ADVIL,MOTRIN) tablet 600 mg ONCE
1830
07/10/15 XR SHOULDER RIGHT MIN 2 VW ONE TIME
1750

Status
Final result

Ordering Provider
MCINTYRE, DANIEL

Final result

MCINTYRE, DANIEL

Final result

MCINTYRE, DANIEL

Final result

MCINTYRE, DANIEL

Last MAR action:


Given
Final result

MCINTYRE, DANIEL
MCINTYRE, DANIEL

Suture Information from to


None

Printed on 7/28/2015 11:44 AM

Page 20

LANCASTER GENERAL HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015

ED After Visit Summary (continued)


Information regarding the care you received at the
Lancaster 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 an
emergency basis only, and are not intended to be a substitute for or an effort to provide complete medical
care. Your primary care physician may request a copy of your records and all test results. It is important that
you let him/her check you again, and that you report any new or remaining problems.
XRAYS/EKGS
The 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 the
cardiologist and/or radiologist.

MEDICATIONS/PRESCRIPTIONS
Take 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 call
the Physician Referral Line at 1-888-LGH-INFO (1-888-544-4636) and you will be assisted in locating a
Primary Care Physician.
REFERRAL TO SPECIALIST
If you are being referred to any doctor/specialist other than your own Primary Care Physician: Please contact
your doctor for a referral and any paperwork or referral forms that may be required. If you have any
questions about whether you need such forms, contact your insurance company or doctor's office as soon as
possible.
The staff of the Lancaster General Hospital Emergency Department and Trauma Services strives to ensure
quality care and customer service during your visit.
Your Current Condition does not require hospitalization. Your condition can, however, change. If there are
any concerns regarding your condition, you may return to the Emergency Department or contact your
Primary Physician.
The Emergency Physicians of Lancaster Emergency Associates (LEA) are the exclusive providers of
Emergency Medical care at Lancaster General Hospital. We appreciate any comments or feedback you may
have on your experience with us in the Emergency Department and invite you to visit us at
www.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 HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 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
717 544-5125
Penne Marino, RN, Days Assistant Nurse Manager
717 544-4582
Amy Sechrist, RN Evenings Assistant Nurse Manager 717 544-7055
Lisa Williams, RN Nights Assistant Nurse Manager
717 544-1776
Lancaster General Hospital Convenience Pharmacy 717 544-5929
Hours of Operation: Monday through Friday 7am- 6pm
Saturday 9am- 3pm
Sunday Closed
Procedures and tests performed during your visit
Alcohol, Serum
Basic Metabolic Panel (BMP) (For Transfers Only)
CBC (For Transfers Only)
Toxic Screen, Urine, No Confirmation
XR 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 HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 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 HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 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 HOSPITAL


Health Information Management
555 North Duke Street
Lancaster PA 17604-3555
ED Record

Scanned Information (continued)


Sedation Documentation
No data selected in time range

CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015