LGH Medical File From 302 by Detective Bearinger of Lancaster City Police of July 10, 2015un

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
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

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
07/10/15 1801
07/10/15 1824
User
HUEHNERGARTH,
GRETCHEN A
07/10/15 1946
Transfer 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

GROFF, BARBARA A
INTERFACE, INCOMING
RAD RESULTS
HUEHNERGARTH,
GRETCHEN A
ECHEVARRIA, MARIAN E
R
R
R
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

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

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

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

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

ED Record
CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015
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
RN
Filed: 7/10/2015 8:31 PM
Note Time: 7/10/2015 8:31 PM
Version 1 of 1
Status: Signed
Patient medical history and current status reviewed. Active medical problems: stable
Version 2 of 2
RN
Filed: 7/10/2015 10:05 PM
Note Time: 7/10/2015 8:32 PM
Status: Addendum
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

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

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

ED Record
CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015
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
Version 1 of 2
RN
Filed: 7/10/2015 8:52 PM
Note Time: 7/10/2015 8:32 PM
Status: Signed
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

ED Record
CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015
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:
Use of other substances: no
Type/Route:
Amount/Frequency:
Last use:
Printed on 7/28/2015 11:44 AM
Page 10

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

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
Printed on 7/28/2015 11:44 AM
Version 1 of 1
Page 11

ED Record
CATERBONE,STANLEY J
MRN: 0542297
DOB: 7/15/1958, Sex: M
Adm: 7/10/2015, D/C: 7/11/2015
RN
Filed: 7/10/2015 10:28 PM
Note Time: 7/10/2015 10:26 PM
Version 1 of 1
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
:

RN
Filed: 7/10/2015 10:33 PM
Note Time: 7/10/2015 10:33 PM
Version 1 of 1
Status: Signed
Patient requested and was given copy of 302

RN
Filed: 7/10/2015 10:37 PM
Note Time: 7/10/2015 10:37 PM
Version 1 of 1
Status: Signed
Patient declined any anxiolytic or antipsychotic

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

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]

(Abnormal)
result
LABORATORY
Specimen Collection
Type
Source
Collected On
07/10/15 1948
Printed on 7/28/2015 11:44 AM
Page 13

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.

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]

Specimen Collection
Type
Source

result
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

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

Alcohol, Serum [110835908]
Concentrations above 400 mg/dL may be fatal.
Toxic Screen, Urine, No Confirmation [110835906]

Specimen Collection
Type
Source

result

result
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

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

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

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]
Performed:
07/10/15 1810 - 07/10/15 1810
Narrative:
Two-view right shoulder

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

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

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

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

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

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

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
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

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

ED Record
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
Printed on 7/28/2015 11:44 AM
Page 24

ED Record

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

LGH Medical File From 302 by Detective Bearinger of Lancaster City Police of July 10, 2015un

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LGH Medical File From 302 by Detective Bearinger of Lancaster City Police of July 10, 2015un

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LANCASTER GENERAL HOSPITAL

Health Information Management

Printed on 7/28/2015 11:44 AM

XR SHOULDER RIGHT MIN 2 VW

LANCASTER GENERAL HOSPITAL

ED Disposition set to Transfer

MCINTYRE MD, DANIEL P

(Final result) XR SHOULDER RIGHT MIN 2

ED Disposition set to Transfer

(Final result) CBC

XR SHOULDER RIGHT MIN 2 VW

Printed on 7/28/2015 11:44 AM

LANCASTER GENERAL HOSPITAL

Printed on 7/28/2015 11:44 AM

LANCASTER GENERAL HOSPITAL

Patient on 302 for psychosis and paranoia directed at a Lancaster Detective

Current Every Day Smoker -- 1.00 packs/day

Continues to smoke daily

Printed on 7/28/2015 11:44 AM

LANCASTER GENERAL HOSPITAL

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

OXYGEN SATURATION INTERPRETATION:

Printed on 7/28/2015 11:44 AM

LANCASTER GENERAL HOSPITAL

The patients condition at the time of Disposition is Unchanged.

LANCASTER GENERAL HOSPITAL

History of Present Illness:

General Appearance and Behavior:

Thought Processing and Cognitive Evaluation:

LANCASTER GENERAL HOSPITAL

Social, Family and Developmental History:

Printed on 7/28/2015 11:44 AM

LANCASTER GENERAL HOSPITAL

History of Present Illness:

LANCASTER GENERAL HOSPITAL

General Appearance and Behavior:

Thought Processing and Cognitive Evaluation:

LANCASTER GENERAL HOSPITAL

History of withdrawal symptoms:

Social, Family and Developmental History:

LANCASTER GENERAL HOSPITAL

Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 10:28 PM

Patient requested and was given copy of 302

Patient declined any anxiolytic or antipsychotic

LANCASTER GENERAL HOSPITAL

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

Last MAR action:

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

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

Comment: For Transfers Only.

14.0 - 18.0 g/dL

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

LANCASTER GENERAL HOSPITAL

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

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

0.7 - 1.2 mg/dL

8.6 - 10.3 mg/dL

Notes for GFR:

Alcohol, Serum [110835908]

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

Printed on 7/28/2015 11:44 AM

LANCASTER GENERAL HOSPITAL

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

Toxic Screen, Urine, No Confirmation [110835906]