Professional Documents
Culture Documents
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
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
Comments
To room 15BHE
Huehnergarth, Gretchen A, RN assigned as
Registered Nurse
McIntyre, Daniel, MD assigned as Attending
Page 1
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
07/10/15 1946
CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015
YARNISH, THERESA M
YARNISH, THERESA M
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
--
Phone
717-544-4978
Pager
Page 2
CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015
Discharge Orders
None
Page 3
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
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:
Paranoid Schizophrenia
Page 4
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
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:
Page 5
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.
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
CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015
ED Notes (continued)
Page 7
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
Page 8
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)
Page 9
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
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
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 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
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
:
Version 1 of 1
Author Type: Registered Nurse
Status: Signed
Version 1 of 1
Author Type: Registered Nurse
Status: Signed
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
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
MCINTYRE, DANIEL
MCINTYRE, DANIEL
Source
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
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
CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015
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
BUN/Creatinine
Ratio
Osmolality
Calculation
(serum)
Calcium
20
10 - 20 Ratio
275
275 - 300
mOsm/Kg
9.7
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
Source
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
Flag
Comment
Lab
LG
LAB
Page 14
CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015
Source
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
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
LG
LAB
LG
LAB
Page 15
CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015
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
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
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
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
Page 17
CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015
1817
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
Page 18
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
Page 19
CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015
Name
Groff, Barbara A
Huehnergarth, Gretchen A, RN
Yarnish, Theresa M, RN
Status
Final result
Ordering Provider
MCINTYRE, DANIEL
Final result
MCINTYRE, DANIEL
Final result
MCINTYRE, DANIEL
Final result
MCINTYRE, DANIEL
MCINTYRE, DANIEL
MCINTYRE, DANIEL
Page 20
CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015
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
CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015
Scanned Information
Encounter-Level Documents - 07/10/2015:
Scan on 7/11/2015 8:21 PM (below)
Page 22
CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015
Page 23
CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015
Order-Level Documents:
There are no order-level documents.
Code Documentation
No data selected in time range
Page 24
CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015