Ricky Medical File: 2015-2016 Bay State Medical records- Include December and January Psych ward stays

These Bay State health notes are a mess I know that I'll have to go through and read them 1 by 1 or decide what to do with them but they're here for now. Ai will need to use ocr readers for all of these at the moment.

Baystate Health

Baystate Wing Hospital Inpatient Psychiatry

40 Wright Street

Palmer, MA 01069-

STEBBINS, RICHARD

210389

148195992

Attending Physician: Velazquez MD, Louis Angel

Patient Location: Parker North

Date of Birth and Sex: 10/8/1978 Male

Admit Date and Time: 1/19/2016 01:18 EST

Discharge Date: 1/25/2016 12:40 EST

Patient Type: Disch IP

Print Date and Time: 2/28/2025 15:43 EST

Request ID: 263443414

Admission/History and Physical

Document Type: History and Physical Hospital

Event Date: 1/19/2016 17:25 EST

Result Status: Auth (Verified)

Signed By: Umanzor MD, Rene Alberto (1/19/2016 17:25 EST)

History and Physical Hospital

BAYSTATE WING

HOSPITAL

Palmer, Massachusetts

PSYCHIATRIC HISTORY ASSESS EXAM

NAME: STEBBINS, RICHARD

DOB: 10/08/1978

ACCT#: 148195992

MR#: 210389

PCP:

ADMITTED: 12/19/2015

DATE OF SERVICE: 01/19/16

HPI

Hosp Psych H P

Chief Complaint

Suicidal ideation

History of Present Illness

37-year-old male who was admitted on December 28 with a suicidal attempt. He was seen at Mary Ln., Hospital and then transferred to this facility. He had taken benztropine trazodone, Ativan, and Haldol.

He was brought into the emergency room by his wife as the patient appeared to be very depressed At the emergency room patient was found to be agitated and depressed. He initially denied suicidal ideation, but then I read in the note that he was found to with rat poison and water. The patient and wife eloped from the emergency room. But Warren police found them and brought them back. He has been admitted to the psychiatric unit for further ventilation and treatment. This happened on January 18

Then on January 19 the patient got very agitated as he was denied Ativan and put a towel around his neck. For details please see Dr. Frieda has evaluation from earlier this morning.

Currently patient is sleepy. He has been through a lot this morning. And is difficult to gather history from him. He denies being on any kind of discomfort.

History - Hosp Psych H P

Past Medical/Surgical History

Past Med/Surg History

Suicide attempt by multiple drug overdose

Tobacco abuse

GAD (generalized anxiety disorder)

Major depressive disorder with psychotic features

Myopathy

Additional Med/Surg History

Patient states that he recently had a muscle biopsy at Mercy Hospital and he was found to have myopathy. The biopsy was from his right forearm. Patient states that this was a suicide in a lot of muscle cramps.

Patient also states that he's had multiple surgeries including ankle, knee, wrist, elbow

Allergies

Coded Allergies:

No Known Allergies (12/22/15)

Reported Medications

Active Scripts

Gabapentin* (Neurontin*) 300 MG PO BID

30 Days

Baystate Wing Hospital Inpatient Psychiatry

40 Wright Street

Palmer, MA 01069-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 12:40 EST

Patient Type: Disch IP

Admission/History and Physical

Prov: 12/24/15

Olanzapine* (Zyprexa*) 5 MG PO PRNBID PRN anxiety

14 Days

Prov: 12/24/15

Discontinued Reported Medications

Buprenorphine/Naloxone Film* (Suboxone Film*) 1 EACH SL TID

Family History

Additional Family History

Patient was unable to give me a lot of history. He states that both mother and father alive and well

Social History

Social History Married, Employed (stocks shelves at grocery Stor), Current smoker (also smokes marijuana), Occasional alcohol

ROS Hosp Psych H P

Review of Systems

Patient denies of any headache, chest pain, abdominal pain, diarrhea The rest of the 14 review of systems have been reviewed and are negative or as per the history of present illness. There is nothing clinically relevant to add.

Phys Exam Hosp Psych H P

Physical Exam

Vitals/I O

Vital Signs

Result

Date

Time

Pulse Ox

01/19

1718

B/P

102/63

01/19

1718

O2 Flow Rate

01/19

1718

Temp

98.9

01/19

1718

Pulse

01/19

1718

Resp

01/19

1718

Intake Output

Intake

01/19 0700

01/18 2300

01/18 1500

Intake Total

Output Total

Balance

Patient 191 lb

Weight

Weight Portable Scale

Measurement

Baystate Wing Hospital Inpatient Psychiatry

40 Wright Street

Palmer, MA 01069-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 12:40 EST

Patient Type: Disch IP

Admission/History and Physical

Method

Physical exam

General.: Well nourished, well hydrated. Alert and oriented x3 pleasant patient in no acute distress.

HEENT: Normocephalic, atraumatic, extra ocular muscles intact, no jaundice, oral mucosa was moist. Hearing was intact.

Neck was supple, there was no rigidity, no increased thyroid, no cervical adenopathies.

CVS: Heart was regular rate and rhythm, S1 plus S2. No S3, no S4.

Pulmonary: Clear to auscultation bilaterally. There are no crackles. No wheezing. No use of accessory respiratory muscles.

Abdomen: Soft. Nontender. Nondistended. No hepatosplenomegaly. Bowel sounds are normal throughout

Extremities: No cyanosis, no clubbing. No edema

Musculoskeletal: No acute arthritis. There is no evidence of chronic degenerative joint disease.

Skin: Moist and warm with no rashes and no lesions.

CNS: Alert and oriented x3, no focal weakness, cranial nerves are normal

Results

Laboratory Tests

01/18

2019

Chemistry

TSH 3rd Generation (0.34 - 4.6 uIU/ml) 0.31

Toxicology

Salicylates (100 - 300 mg/L)

< 25

Urine Opiates Screen (NEGATIVE)

NEGATIVE

Acetaminophen (10 - 30 ug/mL)

< 10

Ur Barbiturates Screen (NEGATIVE)

NEGATIVE

Ur Phencyclidine Scrn (NEGATIVE)

NEGATIVE

Ur Amphetamine Screen (NEGATIVE)

NEGATIVE

U Benzodiazepines Scrn (NEGATIVE)

NEGATIVE

U Cocaine Metab Screen (NEGATIVE)

NEGATIVE

U Cannabinoids Screen (NEGATIVE)

POSITIVE

Ethyl Alcohol (None Detected mg/dl)

< 10

Allied Health

Allied Health notes reviewed Nursing

A/P Hosp Psych H P

Assessment and Plan

Baystate Wing Hospital Inpatient Psychiatry

40 Wright Street

Palmer, MA 01069-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 12:40 EST

Patient Type: Disch IP

Admission/History and Physical

Problem List

Major depressive disorder with psychotic features

Plan to address prob

Patient is being admitted for treatment of his depression and psychotic features. He also attempted to draw attention this morning by putting a towel around his neck. He is medically cleared to be admitted to the psychiatric unit

Myopathy

Plan to address prob

He states that he has been diagnosed with some sort of myopathy from the right forearm and is scheduled to see an endocrinologist. We will ask to get those records. Apparently this was done at Mercy Hospital

Subclinical hyperthyroidism

Plan to address prob

Patient has no known history of thyroid disease. Back in December his TSH was 0.7. Yesterday it was checked and it was 0.3. We'll go ahead and recheck in a.m. and add antibodies, free T4, free T3.

DVT Prophylaxis Documentation

None S patient is ambulatory

Contraindication to Pharmacologic Prophylaxis+ DRUG TX NOT INDICATED

Reason Mechanical Device not Applied+ TX NOT INDICATED

Code Status

Full code

Care Level

Complexity of Care

N99222 Comprehensive history, comprehensive examination, medical decision making of moderate complexity, at least 50 minutes at the bedside, patient's floor/unit.

ESigned by:

UMANZOR, RENE MD

Date:

Time: 1741

NOT FOR REDISCLOSURE WITHOUT PATIENT'S INFORMED CONSENT

Baystate Wing Hospital Inpatient Psychiatry

40 Wright Street

Palmer, MA 01069-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 12:40 EST

Patient Type: Disch IP

Admission/History and Physical

Admit Notes

Document Type: Admit Notes

Event Date: 1/19/2016 00:00 EST

Result Status: Auth (Verified)

Signed By: Franklin MD, Gerald S (1/19/2016 00:00 EST)

PSYCHIATRIC ADMISSION NOTE

NAME: STEBBINS, RICHARD

HOSPITAL #: 148195992

CHART LOC:

BAYSTATE WING

HOSPITAL

Palmer, Massachusetts

DOB: 10/08/1978

MR #: 210389

PCP:

DICTATING: FRANKLIN GERALD S MD

The patient was admitted on January 19, 2016.

HISTORY OF PRESENT ILLNESS:

This 37-year-old man was admitted to Parker North at Baystate Wing Hospital on January 19, 2016 on a conditional voluntary application because of suicidal ideation.

The patient presented to Crisis Services at Baystate Wing Hospital reporting that he had a mixture of rat poison and water in a bottle and that he was going to drink it but had not done so. He stated that he was chronically suicidal, always wanting to hurt himself and that he was again struggling with suicidal impulses. He was discharged from this unit December 23, 2015 after a one day stay with a diagnosis of adjustment disorder with mixed disturbance of mood and conduct, rule out major affective disorder, cluster B personality disorder. He continued to feel intermittently suicidal and was noncompliant with aftercare arrangements.

PAST MEDICAL HISTORY:

He has a past history of prior admissions to Baystate Medical Center, here and Noble Hospital. Each time, he was self-harming and given incomplete treatment according to him which was not useful and discharged without appropriate aftercare according to him. He has a history of prescriptions for Lorazepam, Gabapentin, Trazodone, Haldol and Cogentin and he reports that he has had exposure to lithium and Depakote in the past, but he is unclear about what his diagnoses were, and is only certain that these treatments were ineffective. He also had exposure to psychotherapy which has been ineffective. In recent days, he has been feeling nonresponsive emotionally and lethargic which he has attributed to low testosterone levels in the past and feels that he should continue pursuing this line of explanation for aftercare.

Baystate Wing Hospital Inpatient Psychiatry

40 Wright Street

Palmer, MA 01069-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 12:40 EST

Patient Type: Disch IP

Admission/History and Physical

The patient has had surgery for rotator cuff injuries, knee injuries and ankle injuries. He has had a tonsillectomy. He has had low testosterone for unclear reasons according to him. He has self-harming incidences related to alcohol use but denies that was the case in his current situation. He reports no adverse drug reactions or allergies.

SOCIAL AND FAMILY HISTORY:

The patient is the oldest of three children of parents who divorced in his early adulthood. He describes a cared-for unmolested childhood. He had hyperactivity and perhaps a learning disability for which he took ritalin without good results and says he outgrew his attentional problem. He graduated from high school. He has had some college and has had a variety of employments. Most recently, he was working as a contractor for Stop Shop. He has been married twice and has three children from whom he is estranged. He has been with his current wife for several years and feels they are working on their relationship.

PSYCHIATRIC ADMISSION NOTE CONTINUED:

NAME: STEBBINS, RICHARD

HOSP#: 148195992

CHART LOC:

DOB: 10/08/1978

MR#: 210389

PCP:

DICTATING: FRANKLIN GERALD S MD

MENTAL STATUS EXAMINATION:

The patient barricaded himself in a room and attempted asphyxiating himself with something around his neck requiring a security code and is now resting after an injection of Zyprexa 10 mg IM, having complained that he was unable to sleep for several days prior to his suicide gesture.

Details of his current mental status are unavailable because he is sedated.

DIAGNOSIS:

Axis I. Adjustment disorder with mixed disturbance of mood and conduct. Rule out major affective disorder, cluster B personality disorder.

Axis IV. Interpersonal conflict.

Axis V. GAF 35, best in the past year unknown.

TREATMENT PLAN:

Maintenance of outpatient medications, physical exam, collateral contact with community, caregivers and social network, safety plan, aftercare plan and observe.

FRANG/AR

ESigned by:

FRANKLIN GERALD S MD

Date: Time: 0644

NOT FOR REDISCLOSURE WITHOUT PATIENT'S INFORMED CONSENT

Baystate Wing Hospital Inpatient Psychiatry

40 Wright Street

Palmer, MA 01069-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 12:40 EST

Patient Type: Disch IP

Discharge/Transfer Note Hospital HIM

Document Type: Discharge/Transfer Note Hospital

Event Date: 1/25/2016 10:19 EST

Result Status: Auth (Verified)

Signed By: Franklin MD, Gerald S (1/25/2016 10:19 EST)

PSYCHIATRIC DISCHARGE SUMMARY

BAYSTATE WING

HOSPITAL

Palmer, Massachusetts

NAME: STEBBINS, RICHARD

DOB: 10/08/1978

ACCT#: 148195992

MR#: 210389

PCP:

ADMITTED: 12/19/2015

DISCHARGED:

Psych Discharge Summary

Present Psychiatric History

ID/HPI

The patient was admitted on January 19, 2016.

HISTORY OF PRESENT ILLNESS:

This 37-year-old man was admitted to Parker North at Baystate Wing Hospital on January 19, 2016 on a conditional voluntary application because of suicidal ideation.

Baystate Wing Hospital Inpatient Psychiatry

40 Wright Street

Palmer, MA 01069-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 12:40 EST

Patient Type: Disch IP

Discharge/Transfer Note Hospital HIM

PAST MEDICAL HISTORY:

SOCIAL AND FAMILY HISTORY:

MENTAL STATUS EXAMINATION:

Details of his current mental status are unavailable because he is sedated.

Allergies

Coded Allergies:

No Known Allergies (12/22/15)

Past History

Social History Married, Employed (stocks shelves at grocery Stor), Current smoker (also smokes marijuana), Occasional alcohol

Current medical problems

Major depressive disorder with psychotic features

Myopathy

Subclinical hyperthyroidism

Hospital Course

Patient was admitted to Parker North. He remained on constant observations throughout his stay. He objected to his confinement throughout and was supported in his position by his significant other who requested a transfer to a similar locked unit, but none could be found who would accept him in transfer. After a risk/benefit discussion he agreed to a trial of lithium for its protective effect in preventing completed suicides. Ultimately he declared himself safe and requested discharge. He was optimistic about couples therapy as an outpatient. He was discharge on 1/25/16 in improved condition, free of harmful impulses and aware of crisis services. He was referred to appropriate aftercare providers.

Mental Exam

Sensorium and orientation Clear and intact

Mood/affect euthymic

Anxieties calm

Thought content/processes Baseline

Cognition Intact

Insight/judgement Poor

Risk of lethality Minimal

Appearance Casual

Speech/language Within normal limits

Hallucinations Denied

Laboratory Findings

Lab Results

Laboratory Tests

Test

Chemistry

Result

Date

Time

Free T4 (0.61 - 1.12 ng/dL)

1.16

01/20

0500

Free T3 pg/mL ((2.3 - 5.0) PG/ML)

2.9

01/20

0500

TSH 3rd Generation (0.34 - 4.6 uIU/ml)

0.18

01/20

0500

Immunology

Thyroglobulin Antibody

Pending

01/20

0500

Baystate Wing Hospital Inpatient Psychiatry

40 Wright Street

Palmer, MA 01069-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 12:40 EST

Patient Type: Disch IP

Discharge/Transfer Note Hospital HIM

Thyroid Peroxidase Ab

Pending

01/20

0500

Toxicology

Salicylates (100 - 300 mg/L)

< 25

01/18

2019

Urine Opiates Screen (NEGATIVE)

NEGATIVE

01/18

2019

Acetaminophen (10 - 30 ug/mL)

< 10

01/18

2019

Ur Barbiturates Screen (NEGATIVE)

NEGATIVE

01/18

2019

Ur Phencyclidine Scrn (NEGATIVE)

NEGATIVE

01/18

2019

Ur Amphetamine Screen (NEGATIVE)

NEGATIVE

01/18

2019

U Benzodiazepines Scrn (NEGATIVE)

NEGATIVE

01/18

2019

Lithium (0.6 - 1.2 mmol/L)

0.2

01/23

0753

U Cocaine Metab Screen (NEGATIVE)

NEGATIVE

01/18

2019

U Cannabinoids Screen (NEGATIVE)

POSITIVE

01/18

2019

Ethyl Alcohol (None Detected mg/dl)

< 10

01/18

2019

Time of Elaboration

Total time w/pt (minutes) 45

Time counsel/coord (minutes) 10

Discharge Plan

DSM-5 / ICD-10 Diagnoses:

Axis I. Adjustment disorder with mixed disturbance of mood and conduct. Rule out major affective disorder, cluster B personality disorder.

Axis II: Cluster B personality disorder

Axis III: Endocrine abnomalities

Axis IV. Interpersonal conflict.

Axis V. GAF 35, best in the past year unknown.

Prescriptions

Stop taking the following medications:

Gabapentin* (Neurontin*) 300 MG CAP Oral Twice daily Days = 30

Continue taking these medications:

Olanzapine* (Zyprexa*) 5 MG TAB

5 MILLIGRAM Oral Twice daily as needed as needed for anxiety

Days = 14

Start taking the following new medications:

Trazodone* (Desyrel*) 50 MG TAB

50 MILLIGRAM Oral At bedtime as needed as needed for Insomnia

Days = 30

No Refills

Baystate Wing Hospital Inpatient Psychiatry

40 Wright Street

Palmer, MA 01069-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 12:40 EST

Patient Type: Disch IP

Discharge/Transfer Note Hospital HIM

Olanzapine (Olanzapine Odt) 5 MG TAB

5 MILLIGRAM Sublingual Twice daily as needed as needed for agitation

Days = 10

No Refills

Lithium Carbonate* (Lithonate*) 300 MG TAB

450 MILLIGRAM Oral Twice daily

Days = 30

No Refills

ESigned by:

FRANKLIN GERALD S MD

Date:

Time: 1040

NOT FOR REDISCLOSURE WITHOUT PATIENT'S INFORMED CONSENT

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Attending Physician: Kochar MD, Jinesh

Patient Location: DW

Date of Birth and Sex: 10/8/1978 Male

Admit Date and Time: 12/19/2015 13:43 EST

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Print Date and Time: 2/28/2025 15:43 EST

Request ID: 263443416

Admission/History and Physical

Document Type: History and Physical Hospital

Event Date: 12/20/2015 10:12 EST

Result Status: Auth (Verified)

Signed By: Kochar MD, Jinesh (12/20/2015 10:29 EST)

Medical H & P

Patient: STEBBINS, RICHARD

Age: 37 years Sex: Male DOB: 10/08/1978

Associated Diagnoses: None

Author: Kochar MD, Jinesh

MRN: 210389

FIN: 148415630

Visit Information

Chief Complaint:

Intentional drug overdose.

Admission Information

Attending Physician Certification of Inpatient Medical Necessity

Validation of Inpatient Order.

History of Present Illness

Mr. Stebbins is a 37-year-old male with history of prior suicidal attempts, depression, psychosis, who presents to the emergency room after ingesting numerous sedative/hypnotics-antipsychotics. The patient remembers taking at least 30 minutes of lorazepam. The shins speech was very slurred and main source of history is his wife. She told me that she found multiple empty bottles of Haldol, trazodone, Cogentin, Ativan. The patient remembers taking 30 pills of Ativan. Because of when necessary use, the wife is not able to tell me how many pills of other medications were ingested. Patient reports that he took it because he was frustrated and down. It appears that there is a recent inpatient psychiatric admission for suicidal attempt a few months ago. The patient denies any chest pain, dyspnea, palpitations or acute dystonic reactions.

Past Medical History

Problem list

All Problems

Depression / Confirmed

Epicondylitis / 122185010 / Confirmed

Allergies

Allergic Reactions (Selected)

NKA

Current medications (Selected)

Inpatient Medications

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Admission/History and Physical

Ordered

0.9% NaCl 1000 mL: 1,000 mL, Infusion, IV Infusion, 1,000 mL, 125 mL/hr, Infuse over 8 hr, Continue until D/C'd, Routine, 12/19/15 16:37:00

Pneumococcal 23-Valent Vaccine: 0.5 mL, Injection, Intramuscular, Once, Routine, 12/20/15 8:00:00, Stop date 12/20/15 8:00:00

influenza virus vaccine, inactivated: 0.5 mL, Injection, Intramuscular, Once, Routine, 12/20/15 8:00:00, Stop date 12/20/15 8:00:00

Documented Medications

Documented

Benztropine Tablet: unknown, By Mouth, Daily, Maintenance, 12/19/15 14:01:31

Gabapentin: = 300 mg, By Mouth, 2 times a day, 0 Refills, Maintenance, 12/19/15 14:01:01

Haldol Tablet: 5 mg, By Mouth, 2 times a day, Maintenance, 12/19/15 14:00:34

Lorazepam: = 0.5 mg, By Mouth, 2 times a day, 0 Refills, Maintenance, 12/19/15 13:59:18

Trazodone: = 50 mg, By Mouth, Daily at bedtime, 1-2 tablets, 0 Refills, Maintenance, 12/19/15 13:59:52

Social History

There is no history of recent alcohol use. Patient does report smoking.

Family History

Unable to obtain from the patient

Review of Systems

Significant

Other neg except as above and in the HPI.

Physical Examination

Vital Signs

Vitals: VITAL SIGNS SECTION

12/20/2015 4:01

Temperature

97.7

DegF

Temperature Route

Temporal

Pulse Rate

bpm

Respiratory Rate

br/min L

Systolic Blood Pressure

127

mm Hg

Diastolic Blood Pressure

mm Hg

Blood pressure sites

Arm, left

Oxygen Saturation

Mode of Delivery (Oxygen)

Room air

General

Appearance: No apparent distress.

HEENT

Eyes: EOMI, PERRL.

Neck: Supple.

Cardiovascular

Cardiac: PMI Non displaced, RRR.

Respiratory

Respiratory: CTA.

Abdomen/GI

Non-distended.

Normal bowel sounds.

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Admission/History and Physical

Soft non-tender.

GU/Rectal

GU/Rectal: no CVAT.

Derm

Skin: No rash.

Neurologic

Neuro Exam: CN 2-12 normal, No acute dystonic reaction is noted..

Motor Exam: Coordination (heel to shin, rapid alternating movements), Motor strength WNL.

Reflex Exam: Babinski absent.

Psychiatric

Orientation to time.

Orientation to person.

Orientation to place.

Patient's slurred speech has improved.

Results Review

7 day results Labs & Documents

Laboratory: LABORATORY

12/20/2015 6:15

WBC

4.6

k/mm3

Hgb

15.7

Gm/dL

Hct

44.9

Platelet Count

206

k/mm3

RBC

4.96

m/mm3

MCV

90.5

femtoliters

MCH

31.7

MCHC

35.0

MPV

10.8

femtoliters

Abs. Neut

2.8

k/mm3

Abs. Lymph

1.1

k/mm3

Abs. Mono

0.5

k/mm3

Abs. Eo

0.2

k/mm3

Abs. Baso

0.1

k/mm3

Neut %

60.2

Lymph %

22.7

Mono %

11.7

% H

Eos %

4.1

Baso %

1.3

RDW-SD

40.8

femtoliters

Sodium

141

mmol/L

Potassium

4.4

mmol/L

Chloride

104

mmol/L

Bicarbonate Level

mmol/L

Anion Gap

BUN

mg/dL

Creatinine-Blood

1.1

mg/dL

Estimated GFR, Non African American ML/MIN/1.73 M2

Estimated GFR, African American ML/MIN/1.73 M2

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Admission/History and Physical

EKG Results

Normal sinus rhythm

Impression and Plan

Advanced Directive

Status

Full

Comprehensive Assessment Plan as follows

Mr. Stebbins is a 37-year-old male with history of depression, polysubstance abuse, who presents to the emergency room with suicidal attempt with multiple scratch and drugs.

Intentional drug overdose: Patient admitted to doing self-harm by overdosing himself with prescription medications. He took at least 30 tablets of lorazepam 0.5 mg tablets, trazodone, benztropine, Haldol. During my initial assessment, patient's speech was much slurred, which appears to be clearing at this time. QTC is slightly prolonged but below 500 ms. At this time, we'll continue with supportive treatment, including intravenous fluids and observe the patient. Monitor on telemetry. His serum electrolytes including magnesium are within normal limits. There is no evidence of acute dystonic/other extrapyramidal effects. The patient's recall of past events is however inaccurate. If this progresses, neurology consultation might be considered. Patient will need inpatient psychiatric admission after medical observation for this problem is complete.

CODE STATUS: Full code.

Due to prophylaxis: With sequential compression device

Calcium

8.8

mg/dL

Phosphorus

4.2

mg/dL

Magnesium

1.7

mEq/L

Alkaline Phosphatase

units/L

AST (SGOT)

units/L

ALT (SGPT)

units/L

Bilirubin, Total

0.7

mg/dL

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Discharge/Transfer Note Hospital HIM

Document Type: Discharge/Transfer Note Hospital

Event Date: 12/22/2015 14:47 EST

Result Status: Auth (Verified)

Signed By: (12/22/2015 15:01 EST)

Hospitalist Discharge Summary

Patient: STEBBINS, RICHARD

Age: 37 years Sex: Male DOB: 10/08/1978

Associated Diagnoses: None

Author: Thippanna MD, Ramakrishna

MRN: 210389

FIN: 148415630

Discharge Information

Admission Date: 12/19/2015

Principal Discharge Diagnosis

Drug overdose with suicidal intention

Medications

(Selected)

Hospital Course

HPI

Physical examination at the time of discharge

Vitals

Temperature 98.2, pulse 77, respiration 80, blood pressure 124/79, O2 sat 97% on room air

Gen. examination

No pallor, no icterus, no cyanosis, no clubbing or lymphadenopathy

HEENT

Normocephalic/atraumatic, extraocular movements are intact, pupils are equal and reacting to light, no JVD

Cardiovascular system

S1 and S2 heard, no murmur or rub or gallop

Respiratory system

Lungs are clear to auscultation no headed sounds

GI system

Abdomen soft nontender no hepatosplenomegaly

Nervous system

Conscious, well oriented no focal neurological deficit

Extremities

No pedal edema or asterixis

Hospital Course

Mr. Stebbins is a 37-year-old male with history of depression, polysubstance abuse, who presents to the emergency room with suicidal attempt with multiple scratch and drugs.

Intentional drug overdose: Patient admitted to doing self-harm by overdosing himself with prescription medications. He took at least 30 tablets of lorazepam 0.5 mg tablets, trazodone, benztropine, Haldol. During my initial assessment, patient's speech was much slurred, which appears to be clearing at this time. QTC is normalized. His serum electrolytes including magnesium are within normal limits. There is no evidence of acute dystonic/other extrapyramidal effects. Patient is well oriented. Patient is seen by behavioral health network and is section 12 all for inpatient psych placement. Patient is accepted by inpatient psychiatric facility in wing Memorial. Patient is being discharged to inpatient psych today at 4 PM

QTc prolonged due to OD

Is normalized, discontinued telemetry.

CODE STATUS: Full code.

Due to prophylaxis: With sequential compression device

Results

Laboratory: LABORATORY

12/22/2015 6:20

HOURS.

Hold Lav

Sodium

142 mmol/L

Potassium

4.5 mmol/L

Chloride

105 mmol/L

Bicarbonate Level

23 mmol/L

Anion Gap

Glucose Level

85 mg/dL

BUN

11 mg/dL

Creatinine-Blood

1.0 mg/dL

Estimated GFR, Non African American ML/MIN/1.73 M2

Estimated GFR, African American ML/MIN/1.73 M2

SPECIMEN DISCARDED AFTER 24

12/20/2015 6:15

Calcium

9.1 mg/dL

WBC

4.6 k/mm3

Hgb

15.7 Gm/dL

Hct

44.9 %

Platelet Count

206 k/mm3

RBC

4.96 m/mm3

MCV

90.5 femtoliters

MCH

31.7 pg

MCHC

35.0 %

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Discharge/Transfer Note Hospital HIM

MPV

10.8 femtoliters

Abs. Neut

2.8 k/mm3

Abs. Lymph

1.1 k/mm3

Abs. Mono

0.5 k/mm3

Abs. Eo

0.2 k/mm3

Abs. Baso

0.1 k/mm3

Neut %

60.2 %

Lymph %

22.7 %

Mono %

11.7 % H

Eos %

4.1 %

Baso %

1.3 %

RDW-SD

40.8 femtoliters

Sodium

141 mmol/L

Potassium

4.4 mmol/L

Chloride

104 mmol/L

Bicarbonate Level

23 mmol/L

Anion Gap

BUN

12 mg/dL

Creatinine-Blood

1.1 mg/dL

Estimated GFR, Non African American ML/MIN/1.73 M2

Estimated GFR, African American ML/MIN/1.73 M2

12/19/2015 16:36

Calcium

8.8 mg/dL

Phosphorus

4.2 mg/dL

Magnesium

1.7 mEq/L

Alkaline Phosphatase

59 units/L

AST (SGOT)

11 units/L

ALT (SGPT)

14 units/L

Bilirubin, Total

0.7 mg/dL

DETECTED

Barbiturate Screen, Urine

NONE DETECTED

Cannabinoid Screen, Urine

POSITIVE

Cocaine Metabolite Screen, Urine

NONE

Benzodiazepine Screen, Urine

POSITIVE

Amphetamine Screen, Urine

NONE DETECTED

Opiate Screen, Urine

NONE DETECTED

PCP Screen, Urine

NONE DETECTED

Appear/Color, Urine

AMBER

Specific Gravity, Urine

1.015

pH, Urine

6.0

Albumin, Urine

NEGATIVE

Glucose, Urine

NEGATIVE

Ketones, Urine

NEGATIVE

Bilirubin, Urine

NEGATIVE

Hemoglobin, Urine

NEGATIVE

Nitrite, Urine

NEGATIVE

Leukocyte, Urine

NEGATIVE

Urobilinogen

NORMAL mg/dL

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Discharge/Transfer Note Hospital HIM

12/19/2015 14:49 Troponin T Quant <0.01 ng/mL

12/19/2015 14:48

WBC

5.6 k/mm3

Hgb

17.3 Gm/dL

Hct

48.4 %

Platelet Count

220 k/mm3

RBC

5.44 m/mm3

MCV

89.0 femtoliters

MCH

31.8 pg

MCHC

35.7 %

MPV

10.6 femtoliters

Abs. Neut

3.8 k/mm3

Abs. Lymph

1.0 k/mm3

Abs. Mono

0.5 k/mm3

Abs. Eo

0.2 k/mm3

Abs. Baso

0.0 k/mm3

Neut %

68.0 %

Lymph %

18.5 %

Mono %

9.2 %

Eos %

3.6 %

Baso %

0.7 %

RDW-SD

41.8 femtoliters

INR

1.1

Protime (PT)

11.3 seconds

APTT

27.3 seconds

Sodium

139 mmol/L

Potassium

4.5 mmol/L

Chloride

102 mmol/L

Bicarbonate Level

23 mmol/L

Anion Gap

Glucose Level

89 mg/dL

BUN

15 mg/dL

Creatinine-Blood

1.2 mg/dL

Estimated GFR, Non African American ML/MIN/1.73 M2

Estimated GFR, African American ML/MIN/1.73 M2

Calcium

9.3 mg/dL

Magnesium

1.8 mEq/L

Protein, Total

6.9 Gm/dL

Albumin

4.5 Gm/dL

Alkaline Phosphatase

69 units/L

AST (SGOT)

11 units/L

ALT (SGPT)

17 units/L

Bilirubin, Total

0.7 mg/dL

Bilirubin, Direct

0.2 mg/dL

Bilirubin, Indirect

0.5 mg/dL

C-Reactive Protein

<0.1 mg/dL

CK, Total

54 units/L

Ethanol, Serum

NONE DETECTED mg/dL

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Discharge/Transfer Note Hospital HIM

WEEK

Salicylate Level

<0.3 mg/dL

Acetaminophen Level

<15 mg/L

Hold Red Tube

SPECIMEN DISCARDED AFTER 1

Result type: ECG 12-Lead

Result date: 22 December 2015 8:19

* Final Report *

EK00201

Ventricular Rate: 79 BPM

Atrial Rate: 79 BPM

P-R Interval: 176 ms

QRS Duration: 92 ms

Q-T Interval: 400 ms

QTC Calculation( Bezet): 458 ms

P Axis: 72 degrees

R Axis: 46 degrees

T Axis: 39 degrees

Normal sinus rhythm with sinus arrhythmia

Possible Left atrial enlargement

Borderline ECG

When compared with ECG of 21-DEC-2015 10:05,

Nonspecific T wave abnormality no longer evident in Inferior leads

Nonspecific T wave abnormality no longer evident in Anterolateral leads

QT has shortened

Confirmed by SANGHVI MD, H. (301) on 12/22/2015 12:41:40 PM

Reader: SANGHVI MD, H.

Discharge Plan

Diet/Activity/Patient Education/Follow Up

Patient was given the following educational materials: Coping with Smoking Withdrawal, Getting Support for Quitting Smoking, Health Effects of Smoking, Planning to Quit Smoking, Staying Smoke-Free, The Benefits of Living Smoke Free, Tips for Quitting Smoking (Cardiovascular), Why Do You Smoke?, Diet-Regular (CUSTOM), Activity-Increase as Tolerated (CUSTOM).

Discharge Disposition

Discharge: Inpatient psychiatric

Code Status: Full Code.

Discharge Condition: good, compared to admission improved.

Less than 30 minutes spent on discharge

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Discharge/Transfer Note Hospital HIM

Medical Necessity for Ambulance Entered On: 12/22/2015 15:13

Performed On: 12/22/2015 15:11 by Potts, Susan

Medical Necessity for Ambulance

Transport Date: 12/22/2015

Transportation From: Baystate Mary Lane Hospital

Transport To: Parker North at Baystate Wing Memorial Hospital

Attending Physician: Thippanna MD, Ramakrishna

Medical Necessity for Transportation: Other patient condition

Patient Condition at Time of Transport: Other: Section 12-transferring for Inpatient Psych.

Explanation of Medical Necessity: Inpatient Psych-section 12

Interfacility Transfer Reason: Psych admission/transfer

Medical Necessity Attestation: By completing this form, I certify the information provided is based upon evaluation of the patient's condition and is true to the best of my knowledge and training. I have determined ambulance transportation is medically necessary for this transport.

Medical Necessity Verified by: Potts, Susan

Credentials: RN

Potts, Susan - 12/22/2015 15:11

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Discharge/Transfer Note Hospital HIM

Document Type: Discharge/Transfer Note Hospital

Event Date: 12/22/2015 16:05 EST

Result Status: Modified

Signed By: Potts, Susan (12/22/2015 16:41 EST); Potts, Susan (12/22/2015 16:38 EST)

Nursing Discharge Note Entered On: 12/22/2015 16:41

Performed On: 12/22/2015 16:05 by Potts, Susan

Nursing Discharge Note 2

Discharge Time: 16:05

Discharge Level of Care at Discharge: Psychiatric Facility/Unit (ATZ)

Patient Left Unit Via: Ambulance

Patient Accompanied Off Unit with: Ambulance/Chair Van Personnel

Handover Given to Transport Personnel: Yes

DC Instructions Provided & Signed by Pt: Yes

Patient Understands D/C Instructions: Yes

Patient Instructions Discharge Signed: No

Instructions for Discharge Comments: pt. transferring to inpt. psych

Potts, Susan - 12/22/2015 16:38

Discharge Comments: Parker North at B. Wing. Report called to Shaka, at Wing.

Potts, Susan - 12/22/2015 16:41

{[Parker North at B. Wing.] previously charted by Potts, Susan at 12/22/2015 16:38};

Did Pt have Specialty Bed or Wound Vac: Yes

Potts, Susan - 12/22/2015 16:38

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Emergency Medicine Notes

Document Type: Emergency Medicine Note

Event Date: 12/19/2015 14:12 EST

Result Status: Modified

Signed By: Simmons MD, Charles M (12/19/2015 17:39 EST); Simmons MD, Charles M (12/19/2015 17:32 EST); Cannizzaro PA, Christopher J (12/19/2015 16:20 EST); Cannizzaro PA, Christopher J (12/19/2015 16:19 EST); Cannizzaro PA, Christopher J (12/19/2015 14:32 EST)

Intentional drug overdose

Patient: STEBBINS, RICHARD

Age: 37 years Sex: Male DOB: 10/08/1978

Associated Diagnoses: Polysubstance overdose; Prolonged QT interval

Author: Cannizzaro PA, Christopher J

MRN: 210389

FIN: 148415630

Basic Information

Time seen: Date & time 12/19/2015 14:04:00,

*** This PA/NP Note is considered Preliminary until an Attending attestation has been added ***

I, Chris Cannizzaro, am being Supervised by the Attending Physician, Dr. Simmons.

History source: Patient.

Arrival mode: Private vehicle.

History limitation: None.

History of Present Illness

The patient presents with intentional overdose. The substance ingested was benzodiazepine. The onset was 15 hours ago. Associated symptoms: denies nausea, denies vomiting, denies chest pain, denies shortness of breath, denies abdominal pain, denies confusion, denies headache, denies fever, denies chills and denies dizziness. Patient brought in by his wife for drug overdose. Last night around 11 pm the patient took unknown quantities of Ativan, Haldol, Trazadone, Gabapentin and Cogentin. He states that he just wanted to sleep. Wife states that he snored loudly last night and then she had trouble arousing him this morning. Upon awakening he had slurred speech and poor fine motor function. Currently he denies any complaints..

Review of Systems

Constitutional symptoms: Negative except as documented in HPI.

Skin symptoms: Negative except as documented in HPI.

Eye symptoms: Negative except as documented in HPI.

ENMT symptoms: Negative except as documented in HPI.

Respiratory symptoms: Negative except as documented in HPI.

Cardiovascular symptoms: Negative except as documented in HPI.

Gastrointestinal symptoms: Negative except as documented in HPI.

Genitourinary symptoms: Negative except as documented in HPI.

Musculoskeletal symptoms: Negative except as documented in HPI.

Neurologic symptoms: Negative except as documented in HPI.

Hematologic/Lymphatic symptoms: Negative except as documented in HPI.

Health Status

Allergies:

Allergic Reactions (Selected)

NKA.

Medications: Per nurse's notes.

Past Medical/ Family/ Social History

Medical history: Depression, psychosis, SI. .

Social history: Alcohol use: Denies, Tobacco use: Regularly, Family/social situation: Married.

Problem list:

Active Problems (2)

Depression

Epicondylitis

Physical Examination

Vital Signs

VITAL SIGNS SECTION

12/19/2015 13:49

Temperature

98.4

DegF

Temperature Route

Temporal

Pulse Rate

116

bpm H

Respiratory Rate

br/min

Systolic Blood Pressure

104

mm Hg

Diastolic Blood Pressure

mm Hg

Blood pressure sites

Arm, right

Mean Arterial Pressure

mm Hg

Oxygen Saturation

100

Mode of Delivery (Oxygen)

Room air

General: Alert, no acute distress.

Skin: Warm, dry, pink, intact.

Head: Normocephalic, atraumatic.

Neck: Supple, no tenderness.

Eye: Normal conjunctiva.

Ears, nose, mouth and throat: Oral mucosa moist.

Cardiovascular: Regular rate and rhythm, No murmur, Normal peripheral perfusion.

Respiratory: Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal, Symmetrical chest wall expansion.

Neurological: Level of consciousness: Slow, Cognitive function: Oriented x 4, to person, to place, to time, to situation, Cranial nerves II - XII: Intact, Motor strength: Equal bilaterally, Motor function: Active tremor, Coordination: Finger(s) to nose abnormal, heel(s) of foot to opposite shin abnormal, Speech: Dysarthric, slurred, Gait: Ataxic.

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Emergency Medicine Notes

Medical Decision Making

Differential Diagnosis: Intentional overdose, accidental overdose.

Orders Launch Orders

Laboratory:

ASA Level (Order): Stat, 12/19/2015 14:31

Acetaminophen Level (Order): Stat, 12/19/2015 14:31

Ethanol Level (Order): Stat, 12/19/2015 14:31

CRP (Order): Stat, 12/19/2015 14:31

Calcium Level (Order): Stat, 12/19/2015 14:31

Creatinine (Order): Stat, 12/19/2015 14:31

BUN (Order): Stat, 12/19/2015 14:31

CBC w/ Differential (Order): Stat, 12/19/2015 14:31

Electrolytes (Order): Stat, 12/19/2015 14:31

Glucose Level (Order): Stat, 12/19/2015 14:31

Urinalysis (Order): Stat, Urine, 12/19/2015 14:31

Troponin T Quant (Order): Stat, 12/19/2015 14:31

PT (INR) (Order): Stat, 12/19/2015 14:31

PTT (Order): Stat, 12/19/2015 14:31

Magnesium Level (Order): Stat, 12/19/2015 14:31

Total Protein (Order): Stat, 12/19/2015 14:31

Bilirubin Total + Direct (Order): Stat, 12/19/2015 14:31

AST (Order): Stat, 12/19/2015 14:31

ALT (Order): Stat, 12/19/2015 14:31

Alk Phos (Order): Stat, 12/19/2015 14:31

Albumin Level (Order): Stat, 12/19/2015 14:31

Patient Care:

IV PRN Angio (ED Only) (Order): Document IV Site (Q4H Pediatrics; Q8H Adults), 12/19/2015 14:31

Pharmacy:

NaCl 0.9% Bolus 1000 mL (Order): 1,000 mL, Infusion, IV Infusion, Once, Routine, 12/19/2015 14:31

Cardiology:

ECG 12 Lead (Order): Stat, Reason: Other: Drug overdose., 12/19/2015 14:31.

Results review: Lab results: Results

12/19/2015 14:49

12/19/2015 14:48

Troponin T Quant

<0.01 ng/mL

WBC

5.6 k/mm3

Hgb

17.3 Gm/dL

Hct

48.4 %

Platelet Count

220 k/mm3

RBC

5.44 m/mm3

MCV

89.0 femtoliters

MCH

31.8 pg

MCHC

35.7 %

MPV

10.6 femtoliters

Abs. Neut

3.8 k/mm3

Abs. Lymph

1.0 k/mm3

Abs. Mono

0.5 k/mm3

Abs. Eo

0.2 k/mm3

Abs. Baso

0.0 k/mm3

Neut %

68.0 %

Lymph %

18.5 %

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Emergency Medicine Notes

Mono %

9.2 %

Eos %

3.6 %

Baso %

0.7 %

RDW-SD

41.8 femtoliters

INR

1.1

Protime (PT)

11.3 seconds

APTT

27.3 seconds

Sodium

139 mmol/L

Potassium

4.5 mmol/L

Chloride

102 mmol/L

Bicarbonate Level

23 mmol/L

Anion Gap

Glucose Level

89 mg/dL

BUN

15 mg/dL

Creatinine-Blood

1.2 mg/dL

Estimated GFR, Non African American ML/MIN/1.73 M2

Estimated GFR, African American ML/MIN/1.73 M2

Calcium

9.3 mg/dL

Magnesium

1.8 mEq/L

Protein, Total

6.9 Gm/dL

Albumin

4.5 Gm/dL

Alkaline Phosphatase

69 units/L

AST (SGOT)

11 units/L

ALT (SGPT)

17 units/L

Bilirubin, Total

0.7 mg/dL

Bilirubin, Direct

0.2 mg/dL

Bilirubin, Indirect

0.5 mg/dL

C-Reactive Protein

<0.1 mg/dL

Ethanol, Serum

NONE DETECTED mg/dL

Salicylate Level

<0.3 mg/dL

Acetaminophen Level

<15 mg/L

Hold Red Tube

SPECIMEN DISCARDED AFTER 1 WEEK

Notes: Patient with some CNS symptoms as well as tachycardia and QTC elongation following polysubstance overdose. I spoke with poison controla nd they recommend cardiac monitoring, repeat ECGs every 4 hours until the QTc normalized, magnesium supplementation to a mg over 2.0, Ativan as needed for agitation, and IVF supplementation. They also recommend admission because he will need to be monitored for at least the next 12 hours and until symptoms are improving. Spoke with Dr. Kochar who accepted the patient..

Impression and Plan

Diagnosis

Polysubstance overdose

Prolonged QT interval

Plan

Condition: Improved, Stable.

Disposition: Admit time 12/19/2015 16:19:00, Kochar MD, Jinesh.

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Emergency Medicine Notes

Prescriptions:

Launch prescriptions

Patient Care:

Admit Request (ED Only) (Order): 12/19/2015 16:19

Admit/Transfer/Discharge:

Observation Patient Status (Order): 12/19/2015 16:19

Addendum

Teaching-Supervisory Addendum-Brief

I participated in the following activities of this patients care: I, Dr. Simmons, have reviewed the care and documentation of this patient and agree with the PA unless otherwise noted..

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Emergency Medicine Notes

Emergency Dept Discharge Instructions

Document Type: Emergency Dept Discharge Instructions

Event Date: 12/19/2015 19:50 EST

Result Status: Auth (Verified)

Signed By: Snow, Nancy (12/19/2015 19:50 EST)

ED Patient Instructions

Baystate Mary Lane Hospital

85 South Street Ware MA, 01082

(413) 967-2275

Name: STEBBINS, RICHARD

Visit Date: 12/19/2015 13:43:00

DOB: 10/08/1978

MRN: 210389

Address: PO BOX 579 SPRINGFIELD MA 01119

Phone: (413)949-1925

Current Date: 12/19/2015 19:50:53

FIN: 148415630

Primary Care Provider:

Name: Skalski MD, Mark S, Reference Physician

Phone: (413) 733-4101

Baystate Mary Lane Hospital would like to thank you for allowing us to assist you with your healthcare needs. The following includes patient education materials and information regarding your injury/illness. Our entire staff strives to provide an excellent experience for our patients and their families. PLEASE REMEMBER you have been evaluated and treated today on an Emergency Care basis, PLEASE ENSURE YOU FOLLOW-UP PER THE INSTRUCTIONS BELOW!

If further treatment with your primary care physician or another doctor is recommended, it is important for you to keep the appointment. Call your primary care physician or return to the Emergency Department immediately if your condition worsens, fails to improve, or new symptoms develop. If you need to find a doctor, you can call Baystate Health Link for a referral at 413-967-2488.

You have a right to receive a written discharge plan and meet with Emergency Department physicians and nurse/discharge planner if you disagree with the written discharge plan. If you have any questions regarding these instructions after you leave, please call us at 413-967-2275 and we will be happy to assist you.

X-ray readings are preliminary. A radiology specialist will review your films. If you need copies of your x-rays, please call the Film Library at 413-967-6211.

Patient Visit Summary:

Follow-Up Instructions

No follow up information was provided.

Patient Education Materials

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Emergency Medicine Notes

REASON FOR VISIT:

When you arrived to the emergency department, you were initially evaluated for the following reason(s):

Intentional drug overdose; POLYSUBSTANCE OVERDOSE

PRESCRIPTIONS:

Home Meds

Display

Benztropine (Benztropine Tablet)

unknown, By Mouth, Daily, Maintenance, 12/19/15 14:01:31

Gabapentin

= 300 mg, By Mouth, 2 times a day, 0 Refills, Maintenance, 12/19/15 14:01:01

Haloperidol (Haldol Tablet)

5 mg, By Mouth, 2 times a day, Maintenance, 12/19/15 14:00:34

Lorazepam

= 0.5 mg, By Mouth, 2 times a day, 0 Refills, Maintenance, 12/19/15 13:59:18

Trazodone

= 50 mg, By Mouth, Daily at bedtime, 1-2 tablets, 0 Refills, Maintenance, 12/19/15 13:59:52

MEDICATIONS GIVEN:

If you received medications in the Emergency Department, below is the list of those medications. It is important that you review your medications with your primary care provider and that you carry an updated list of your medications with you at all times in case of an emergency.

Medication

Dose

Route

Performed By

Sodium Chloride 0.9%

1000 mL Initial Volume 1000 mL/hr

IV Infusion Forearm, Right

Snow, Nancy

Magnesium Sulfate

1 Gm

IVPB

Snow, Nancy

Sodium Chloride 0.9%

1000 mL Initial Volume 125 mL/hr

IV Infusion Peripheral IV

Weeks, Elizabeth A

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Emergency Medicine Notes

EMERGENCY DEPARTMENT PHYSICAN:

Simmons MD, Charles M

BMLH ED DISCHARGE INSTRUCTIONS SIGNATURE PAGE

Name STEBBINS, RICHARD

DOB 10/08/1978 12:00 AM

MRN 210389

Acct# 148195992

Diagnosis:

I STEBBINS, RICHARD , have received the above patient education materials/instructions and have verbalized understanding. If ambulance or transport services are being used I further acknowledge being given a choice of service.

If you need to contact me, please call me at this number:

Patient Signature

Instructions given to patient or representative

and witnessed by

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Emergency Medicine Notes

ED Clinical Summary

Document Type: ED Clinical Summary

Event Date: 12/19/2015 19:50 EST

Result Status: Auth (Verified)

Signed By: Snow, Nancy (12/19/2015 19:50 EST)

Baystate Mary Lane Hospital ED Clinical Summary

Person Information

Name: STEBBINS, RICHARD

Age: 37 Years

Sex: Male

DOB: 10/08/1978 12:00 AM

Visit Reason: Intentional drug overdose; POLYSUBSTANCE OVERDOSE

MRN: 210389

Acct#: 148195992

Acuity: 2

Arrival Mode: Wheelchair

Admit Source: Self Referral

Diagnosis:

Provider Roles:

Provider

Role

Assigned

Unassigned

Cannizzaro PA, Christopher J

ED Provider

12/19/2015 1:56 PM

Leibowitz MD, Morris B

ED Attending

12/19/2015 1:56 PM

12/19/2015 3:10 PM

Snow, Nancy

ED RN

12/19/2015 2:26 PM

Simmons MD, Charles M

ED Attending

12/19/2015 3:10 PM

Arrival: 12/19/2015 1:43 PM

Encounter Type: Observation

Medication Information:

Medications Given:

Medication

Dose

Route

Performed By

Sodium Chloride 0.9%

1000 mL Initial Volume 1000 mL/hr

IV Infusion Forearm, Right

Snow, Nancy

Magnesium Sulfate

1 Gm

IVPB

Snow, Nancy

Sodium Chloride 0.9%

1000 mL Initial Volume 125 mL/hr

IV Infusion Peripheral IV

Weeks, Elizabeth A

Prescriptions:

Home Meds

Display

Benztropine (Benztropine Tablet)

unknown, By Mouth, Daily, Maintenance, 12/19/15 14:01:31

Gabapentin

= 300 mg, By Mouth, 2 times a day, 0 Refills, Maintenance, 12/19/15 14:01:01

Haloperidol (Haldol Tablet)

5 mg, By Mouth, 2 times a day, Maintenance, 12/19/15 14:00:34

Lorazepam

= 0.5 mg, By Mouth, 2 times a day, 0 Refills, Maintenance, 12/19/15 13:59:18

Trazodone

= 50 mg, By Mouth, Daily at bedtime, 1-2 tablets, 0 Refills, Maintenance, 12/19/15 13:59:52

Orders Placed:

Start Time

Order

Type

Status

Stop Time

Provider

12/19/2015 2:31 PM

Glucose Level

Laboratory

Completed

12/19/2015 3:24 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

Electrolytes

Laboratory

Completed

12/19/2015 3:24 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

CBC w/ Differential

Laboratory

Completed

12/19/2015 2:55 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

BUN

Laboratory

Completed

12/19/2015 3:24 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

Creatinine

Laboratory

Completed

12/19/2015 3:24 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

Calcium Level

Laboratory

Completed

12/19/2015 3:24 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

C Reactive Protein

Laboratory

Completed

12/19/2015 3:29 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

Ethanol Level

Laboratory

Completed

12/19/2015 3:24 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

Acetaminophen Level

Laboratory

Completed

12/19/2015 3:24 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

Salicylate Level

Laboratory

Completed

12/19/2015 3:24 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

ECG 12 Lead

Cardiology

InProcess

12/19/2015 2:31 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

IV PRN Angio (ED Only)

Patient Care

Ordered

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

Sodium Chloride 0.9% 1,000 mL

Pharmacy

Completed

12/19/2015 5:07 PM

Cannizzaro PA, Christopher J

12/19/2015 10:00 PM

IV Site Assessment

Patient Care

Ordered

12/19/2015 10:00 PM

SYSTEM

12/20/2015 6:00 AM

IV Site Assessment

Patient Care

Ordered

12/20/2015 6:00 AM

SYSTEM

12/19/2015 7:45 PM

ECG 12 Lead

Cardiology

Ordered

12/19/2015 7:45 PM

Cannizzaro PA, Christopher J

12/19/2015 5:00 PM

Magnesium Sulfate

Pharmacy

Completed

12/19/2015 5:20 PM

Cannizzaro PA, Christopher J

12/19/2015 2:48 PM

Hold Red Top Tube

Laboratory

Completed

12/19/2015 2:50 PM

Cannizzaro PA, Christopher J

12/19/2015 4:08 PM

ED - Laboratory

Patient Care

Ordered

12/19/2015 4:08 PM

Cannizzaro PA, Christopher J

12/19/2015 4:08 PM

Emerg Drugs of Abuse Screen Urine (ED Only)

Laboratory

Ordered

12/19/2015 4:08 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

Albumin Level

Laboratory

Completed

12/19/2015 3:24 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

Alk Phos

Laboratory

Completed

12/19/2015 3:24 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

ALT

Laboratory

Completed

12/19/2015 3:24 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

AST

Laboratory

Completed

12/19/2015 3:24 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

Bilirubin Total + Direct

Laboratory

Completed

12/19/2015 3:24 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

Total Protein

Laboratory

Completed

12/19/2015 3:24 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

Magnesium Level

Laboratory

Completed

12/19/2015 3:24 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

PTT

Laboratory

Completed

12/19/2015 3:06 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

INR

Laboratory

Completed

12/19/2015 3:06 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

Troponin T Quant

Laboratory

Completed

12/19/2015 3:14 PM

Cannizzaro PA, Christopher J

12/19/2015 2:31 PM

Urinalysis

Laboratory

Completed

12/19/2015 4:49 PM

Cannizzaro PA, Christopher J

12/19/2015 5:00 PM

Lorazepam

Pharmacy

Ordered

12/19/2015 5:00 PM

Cannizzaro PA, Christopher J

12/19/2015 4:19 PM

Admit Request (ED Only)

Patient Care

Canceled

12/19/2015 5:11 PM

SYSTEM

12/19/2015 9:00 PM

Pain Evaluation

Patient Care

Ordered

12/19/2015 9:00 PM

SYSTEM

12/19/2015 9:00 PM

Patient/Family Education Record

Patient Care

Ordered

12/19/2015 9:00 PM

SYSTEM

12/19/2015 4:19 PM

Status Observation

Admit/Transfer /Discharge

Ordered

12/19/2015 4:19 PM

Cannizzaro PA, Christopher J

12/19/2015 2:48 PM

CPK Total Only

Laboratory

Completed

12/19/2015 5:04 PM

Cannizzaro PA, Christopher J

12/19/2015 5:45 PM

Catheter Foley

Patient Care

Ordered

Kochar MD, Jinesh

12/20/2015 9:00 AM

Safety Data

Patient Care

Ordered

12/20/2015 9:00 AM

SYSTEM

12/20/2015 9:00 AM

Braden Assessment

Patient Care

Ordered

12/20/2015 9:00 AM

SYSTEM

12/20/2015 9:00 AM

Patient/Family Education Record

Patient Care

Ordered

12/20/2015 9:00 AM

SYSTEM

12/20/2015 9:00 AM

Pain Evaluation

Patient Care

Ordered

12/20/2015 9:00 AM

SYSTEM

12/20/2015 9:00 AM

Falls Risk Assessment

Patient Care

Ordered

12/20/2015 9:00 AM

SYSTEM

12/19/2015 9:00 PM

Safety Data

Patient Care

Ordered

12/19/2015 9:00 PM

SYSTEM

12/19/2015 9:00 PM

Falls Risk Assessment

Patient Care

Ordered

12/19/2015 9:00 PM

SYSTEM

12/19/2015 5:11 PM

Assessment on Patient Care

Ordered

12/19/2015 5:11 PM

SYSTEM

12/19/2015 5:11 PM

Admit

Patient Care

Ordered

12/19/2015 5:11 PM

SYSTEM

12/19/2015 5:11 PM

Complete Valuables and Belongings Form

Patient Care

Ordered

12/19/2015 5:11 PM

SYSTEM

12/19/2015 5:11 PM

Admission Assessment

Patient Care

Ordered

12/19/2015 5:11 PM

SYSTEM

12/19/2015 5:11 PM

Pain Evaluation

Patient Care

Ordered

12/19/2015 5:11 PM

SYSTEM

12/19/2015 5:11 PM

Preparation for Discharge

Patient Care

Ordered

12/19/2015 5:11 PM

SYSTEM

12/19/2015 5:11 PM

Safety Data

Patient Care

Ordered

SYSTEM

12/20/2015 8:00 AM

Braden Assessment

Patient Care

Ordered

SYSTEM

12/19/2015 5:11 PM

Braden Assessment on Patient Care

Ordered

12/19/2015 5:11 PM

SYSTEM

12/19/2015 5:11 PM

Admit Case Management

Patient Care

Ordered

12/19/2015 5:11 PM

SYSTEM

12/19/2015 5:11 PM

ED FN ESHLD Event (ED Only)

Discern Rule Order

Ordered

12/19/2015 5:11 PM

SYSTEM

12/19/2015 5:11 PM

Falls Risk Assessment

Patient Care

Ordered

SYSTEM

12/19/2015 5:11 PM

Patient/Family Education Record

Patient Care

Ordered

SYSTEM

12/19/2015 5:43 PM

Neuro Checks

Patient Care

Ordered

12/19/2015 5:43 PM

Kochar MD, Jinesh

12/20/2015 8:00 AM

Foley Catheter Evaluation

Patient Care

Ordered

12/20/2015 8:00 AM

SYSTEM

12/19/2015 5:24 PM

IV Site Assessment

Patient Care

Ordered

SYSTEM

12/19/2015 4:37 PM

Admit - Medicine (CPG's)

Patient Care

Ordered

12/19/2015 4:37 PM

Kochar MD, Jinesh

12/19/2015 4:37 PM

DVT Prophylaxis Risk Assessment

Patient Care

Ordered

12/19/2015 4:37 PM

Kochar MD, Jinesh

12/19/2015 4:36 PM

Pneumatic Compression Boots

Patient Care

Ordered

12/19/2015 4:36 PM

Kochar MD, Jinesh

12/19/2015 4:09 PM

Add On Lab Order

Laboratory

Ordered

12/19/2015 4:09 PM

Cannizzaro PA, Christopher J

12/19/2015 4:35 PM

Condition

Admit/Transfer /Discharge

Ordered

12/19/2015 4:35 PM

Kochar MD, Jinesh

12/19/2015 4:35 PM

Full Resuscitation

Patient Care

Ordered

12/19/2015 4:35 PM

Kochar MD, Jinesh

12/19/2015 4:35 PM

Vital Signs per Unit Standard

Patient Care

Ordered

Kochar MD, Jinesh

12/19/2015 4:35 PM

Cardiac Monitor

Patient Care

Ordered

12/19/2015 4:35 PM

Kochar MD, Jinesh

12/19/2015 4:36 PM

Activity

Patient Care

Ordered

Kochar MD, Jinesh

12/19/2015 4:36 PM

Call MD

Patient Care

Ordered

12/19/2015 4:36 PM

Kochar MD, Jinesh

12/19/2015 4:36 PM

Call MD

Patient Care

Ordered

12/19/2015 4:36 PM

Kochar MD, Jinesh

12/19/2015 4:36 PM

Call MD

Patient Care

Ordered

12/19/2015 4:36 PM

Kochar MD, Jinesh

12/19/2015 4:36 PM

Provide Smoking Cessation Information

Patient Care

Ordered

12/19/2015 4:36 PM

Kochar MD, Jinesh

12/20/2015 7:00 AM

BUN

Laboratory

Ordered

12/20/2015 7:00 AM

Kochar MD, Jinesh

12/20/2015 7:00 AM

Creatinine

Laboratory

Ordered

12/20/2015 7:00 AM

Kochar MD, Jinesh

12/20/2015 7:00 AM

Electrolytes

Laboratory

Ordered

12/20/2015 7:00 AM

Kochar MD, Jinesh

12/20/2015 7:00 AM

Calcium Level

Laboratory

Ordered

12/20/2015 7:00 AM

Kochar MD, Jinesh

12/20/2015 7:00 AM

Magnesium Level

Laboratory

Ordered

12/20/2015 7:00 AM

Kochar MD, Jinesh

12/20/2015 7:00 AM

Phosphorus Level

Laboratory

Ordered

12/20/2015 7:00 AM

Kochar MD, Jinesh

12/20/2015 7:00 AM

CBC w/ Differential

Laboratory

Ordered

12/20/2015 7:00 AM

Kochar MD, Jinesh

12/20/2015 7:00 AM

AST

Laboratory

Ordered

12/20/2015 7:00 AM

Kochar MD, Jinesh

12/20/2015 7:00 AM

ALT

Laboratory

Ordered

12/20/2015 7:00 AM

Kochar MD, Jinesh

12/20/2015 7:00 AM

Alk Phos

Laboratory

Ordered

12/20/2015 7:00 AM

Kochar MD, Jinesh

12/20/2015 7:00 AM

Bilirubin Total

Laboratory

Ordered

12/20/2015 7:00 AM

Kochar MD, Jinesh

12/19/2015 4:36 PM

ECG 12 Lead PRN

Patient Care

Ordered

12/19/2015 4:36 PM

Kochar MD, Jinesh

12/19/2015 4:37 PM

Sodium Chloride 0.9% 1000 mL

Pharmacy

Ordered

1/18/2016 4:36 PM

Kochar MD, Jinesh

12/19/2015 2:02 PM

ED FN High Fall Risk (ED Only)

Discern Rule Order

Ordered

12/19/2015 2:02 PM

SYSTEM

12/19/2015 2:28 PM

ED FN EMS HandOver Event (ED Only)

Discern Rule Order

Ordered

12/19/2015 2:28 PM

SYSTEM

Referred By:

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Emergency Medicine Notes

ED Triage Form - MLH

Entered On: 12/19/2015 13:49

Performed On: 12/19/2015 13:47 by Weeks, Elizabeth A

Ebola Triage Screening

Travel from W. Africa in past 21 days: No

Weeks, Elizabeth A - 12/19/2015 13:47

Triage - MLH

Stated Complaint: Took to much medication

Arrived by Ambulance: No

Communication Barriers: None

Language Spoken v001: English

Weeks, Elizabeth A - 12/19/2015 13:47

DCP GENERIC CODE

ED Tracking Acuity: TOO MUCH MEDICATION

ED Tracking Acuity: 12/19/2015 13:47

ED Tracking Acuity: 2

Tracking Group: BMLH ED Tracking Group

Weeks, Elizabeth A - 12/19/2015 13:47

ABC Stable: Yes

Weeks, Elizabeth A - 12/19/2015 13:47

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Emergency Medicine Notes

ED SBAR (Nursing) - BHS v.2

Entered On: 12/19/2015 19:01

Performed On: 12/19/2015 19:30 by Snow, Nancy

Situation

Stated Complaint: Took to much medication

ED Reason For Admission: overdose

History of Present Illness: Pt took more medication than prescribed last night at approx 11PM. Pt took multiple doses of Ativan, gabapentin, trazodone, haldol and benztropine, unknown quantities in an attempt to sleep. Spouse became aware this AM when pt was drowsy, speech garbled.

Call with Questions (ED): Snow, Nancy

Admitting Physician: Kochar MD, Jinesh

Language spoken: English

Snow, Nancy - 12/19/2015 18:52

Background

PMH: Depression/Anxiety, Smoking, Other: infection RT shoulder s/p rotator cuff surg. 11/2014, muscle myopathy, SI attempts, multiple ortho surgeries.

ED Course Of Events: Pt took trazodone, ativan, benzotropine and haldol about 2300 last night. Wife noticed he was very sleepy this am and couldn't walk and that is when she discovered all his med bottles were empty. States pt is very good at hiding his emotions and depression. told her he was trying to sleep without taking his meds lately and seemed OK. Pt is antsy, and restless but happy. Pt 's wife has been with him keeping from pulling wires and IV's. Security has been monitoring. pt was evaluated in ED and we have to call BHN after he is medically cleared because he willneed to be a section 12 and Psychiatrically admitted. Discharged frm wing in October after cutting arm with scapel.. 1000cc NS, 1 GM Magnesium IV in Ed. answers questions but speach still garbled. Can stand and walk but very ataxic. Seeing flowers etc. -Hallucinating but very happy and cooperative

Snow, Nancy - 12/19/2015 18:52

Assessment

Alert/Oriented: Yes

ED Precautions: None

Fall Risk Level: High Risk

Field IVI: No

Foley catheter inserted: No

Cardiac Monitoring in ED: Yes

Cardiac Rhythm: Normal sinus rhythm

Snow, Nancy - 12/19/2015 18:52

Recommendations

INPT Nurse Review (ED): Other: face to face report received from Nancy Snow, Rn

Clark RN, Laura - 12/19/2015 20:41

Additional Recommendations Comment: 1950 Report to Laura Clark RN. Transport to DW on Monitor

Snow, Nancy - 12/19/2015 19:48

Baystate Wing Hospital Inpatient Psychiatry

40 Wright Street

Palmer, MA 01069-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 14:00 EST

Patient Type: Disch IP

Wing Laboratory

CHEMISTRY WING

Collected Date 12/22/2015

Collected Time 17:30 EST

Procedure

Units

Reference Range

Glucose Level Wing

mg/dL

[70-99]

Albumin Wing

Gm/dL

[3.2-5.5]

4.4

Alkaline Phosphatase Wing

u/L

[42-121]

BUN Wing

mg/dL

[5-25]

Calcium Wing

mg/dL

[8.5-10.6]

9.5

Chloride Wing

mmol/L

[97-110]

106

CO2 Wing

mmol/L

[21-32]

Creatinine Wing

mg/dL

[0.6-1.3]

1.01

Bilirubin, D Wing

mg/dL

[0.0-0.2]

0.1

Estimated GFR Wing

[> or = 60]

Potassium Wing

mmol/L

[3.6-5.0]

4.0

Sodium Wing

mmol/L

[135-145]

138

SGOT/AST Wing

u/L

[10-42]

SGPT/ALT Wing

u/L

[10-60]

Bilirubin, T Wing

mg/dL

[0.2-1.25]

0.70

Total Protein Wing

Gm/dL

[6.0-8.0]

6.8

Thyroid Stimulating Hormone Wing

UIU/ML

[0.34-4.6]

0.69

Result Comments

F1: Estimated GFR Wing

Units = mL/min/1.73 m2

Chronic Kidney Disease: Estimated GFR <60 mL/min/1.73 m2

Severe Kidney Disease: Estimated GFR <15 mL/min/1.73 m2

Note: The result for African American individuals must be multiplied by 1.210.

Glomerular Filtration Rate (GFR) is estimated based on the MDRD equation as recommended by the National Kidney Disease Education Program.

HEMATOLOGY WING

Collected Date 12/22/2015

Collected Time 17:30 EST

Procedure

Units

Reference Range

White Blood Count Wing

k/mm3

[4.5-10.8]

6.3

Red Blood Count Wing

m/mm3

[4.5-5.7]

5.42

Hemoglobin Wing

g/dl

[14.0-18.0]

17.0

Hematocrit Wing

[42.0-54.0]

50.6

Mean Cell Volume Wing

[80-94]

Mean Corpuscular Hgb Wing

[27-32]

31.4

Mean Corpuscular Hgb Conc Wing

g/dl

[32-36]

Red Cell Distri Width Wing

[11.5-14.5]

13.3

Platelet Count Wing

k/mm3

[140-440]

224

Mean Platelet Volume Wing

[6.2-10.1]

8.7

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Urine Studies

Collected Date 12/19/2015

Collected Time 16:36 EST

Procedure

Units

Reference Range

Appear/Color, Urine

AMBER F12

Specific Gravity, Urine

[1.002-1.030]

1.015

pH, Urine

[4.0-8.0]

6.0

Albumin, Urine

[NEG]

NEGATIVE

Glucose, Urine

[NEG]

NEGATIVE

Ketones, Urine

[NEG]

NEGATIVE

Bilirubin, Urine

[NEG]

NEGATIVE

Hemoglobin, Urine

[NEG]

NEGATIVE

Nitrite, Urine

[NEG]

NEGATIVE

Leukocyte, Urine

[NEG]

NEGATIVE

Urobilinogen

mg/dL

[NORM]

NORMAL

Result Comments

F12: Appear/Color, Urine

CLEAR

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Cardiovascular

EK00201

Vent. rate 78 BPM

PR interval 162 ms

QRS duration 90 ms

QT/QTCB 428/487 ms

P-R-T axes 57 56 34

Technician: RICHARD ROMAN

Test ind: Other:

BAYSTATE HEALTH-MLH EW ROUTINE RETRIEVAL

Abnormal ECG

When compared with ECG of 14-SEP-2013 22:12,

No significant change was found

Confirmed by SANGHVI MD, H. (301) on 12/21/2015 9:09:31 AM

Referred by: Ramakrishna Thippanna

Confirmed By: H. SANGHVI MD

25mm/s 10mm/mV 100Hz 10.2.3 12SL 241 CID: 2

SID: 0M0210389 EID: 301 EDT: 09:09 21-Dec-2015 ORDER: 011581947 ACCOUNT: 0148415630-0210389

Page 1 of 1

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Cardiovascular

Document Type: ECG 12-Lead

Event Date: 12/19/2015 14:41 EST

Result Status: Auth (Verified)

Signed By:

MUSEWebURL

http://BSMUSE01:9081/musescripts/museweb.dll?RetrieveTestByDateTime?PatientID=000339334&Date=19-12-2015&Time=14%3a41%3a30%3a255&TestType=ECG&Site=1&OutputType=PDF&Ext=PDF HNAM URL

EK00201

Ventricular Rate: 78 BPM

Atrial Rate: 78 BPM

P-R Interval: 162 ms

QRS Duration: 90 ms

Q-T Interval: 428 ms

QTC Calculation(Bezet): 487 ms

P Axis: 57 degrees

R Axis: 56 degrees

T Axis: 34 degrees

Normal sinus rhythm

Prolonged QT

Abnormal ECG

When compared with ECG of 14-SEP-2013 22:12,

No significant change was found

Confirmed by SANGHVI MD, H. (301) on 12/21/2015 9:09:31 AM

Reader: SANGHVI MD, H.

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Cardiovascular

EK00201

Vent. rate 68 BPM

PR interval 182 ms

QRS duration 94 ms

QT/QTCB 440/467 ms

P-R-T axes 54 55 27

Technician: GABRIEL SUAREZ

Test ind: Other:

BAYSTATE HEALTH-MLHDW ROUTINE RETRIEVAL

Normal sinus rhythm

Possible Left atrial enlargement

Borderline ECG

When compared with ECG of 19-DEC-2015 14:41,

No significant change was found

Confirmed by SANGHVI MD, H. (301) on 12/21/2015 9:09:51 AM

Referred by: Ramakrishna Thippanna

Confirmed By: H. SANGHVI MD

25mm/s 10mm/mV 100Hz 10.2.3 12SL 241 CID: 3

SID: 0M0210389 EID: 301 EDT: 09:09 21-Dec-2015 ORDER: 011715601 ACCOUNT: 0148415630-0210389

Page 1 of 1

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Cardiovascular

Document Type: ECG 12-Lead

Event Date: 12/19/2015 20:12 EST

Result Status: Auth (Verified)

Signed By:

MUSEWebURL

http://BSMUSE01:9081/musescripts/museweb.dll?RetrieveTestByDateTime?PatientID=000339334&Date=19-12-2015&Time=20%3a12%3a07%3a255&TestType=ECG&Site=1&OutputType=PDF&Ext=PDF HNAM URL

EK00201

Ventricular Rate: 68 BPM

Atrial Rate: 68 BPM

P-R Interval: 182 ms

QRS Duration: 94 ms

Q-T Interval: 440 ms

QTC Calculation(Bezet): 467 ms

P Axis: 54 degrees

R Axis: 55 degrees

T Axis: 27 degrees

Normal sinus rhythm

Possible Left atrial enlargement

Borderline ECG

When compared with ECG of 19-DEC-2015 14:41,

No significant change was found

Confirmed by SANGHVI MD, H. (301) on 12/21/2015 9:09:51 AM

Reader: SANGHVI MD, H.

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Cardiovascular

EK00201

Vent. rate 71 BPM

PR interval 180 ms

QRS duration 94 ms

QT/QTCB 442/480 ms

P-R-T axes 59 59 33

Technician: GABRIEL SUAREZ

Test ind: Other:

BAYSTATE HEALTH-MLHDW ROUTINE RETRIEVAL

Possible Left atrial enlargement

Incomplete right bundle branch block

Prolonged QT

Abnormal ECG

When compared with ECG of 19-DEC-2015 20:12,

No significant change was found

Confirmed by SANGHVI MD, H. (301) on 12/21/2015 9:10:45 AM

Referred by: Ramakrishna Thippanna

Confirmed By: H. SANGHVI MD

25mm/s 10mm/mV 100Hz 10.2.3 12SL 241 CID: 3

SID: 0M0210389 EID: 301 EDT: 09:10 21-Dec-2015 ORDER: 011781539 ACCOUNT: 0148415630-0210389

Page 1 of 1

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Cardiovascular

Document Type: ECG 12-Lead

Event Date: 12/20/2015 00:16 EST

Result Status: Auth (Verified)

Signed By:

MUSEWebURL

http://BSMUSE01:9081/musescripts/museweb.dll?RetrieveTestByDateTime?PatientID=000339334&Date=20-12-2015&Time=00%3a16%3a31%3a255&TestType=ECG&Site=1&OutputType=PDF&Ext=PDF HNAM URL

EK00201

Ventricular Rate: 71 BPM

Atrial Rate: 71 BPM

P-R Interval: 180 ms

QRS Duration: 94 ms

Q-T Interval: 442 ms

QTC Calculation(Bezet): 480 ms

P Axis: 59 degrees

R Axis: 59 degrees

T Axis: 33 degrees

Normal sinus rhythm

Possible Left atrial enlargement

Incomplete right bundle branch block

Prolonged QT

Abnormal ECG

When compared with ECG of 19-DEC-2015 20:12,

No significant change was found

Confirmed by SANGHVI MD, H. (301) on 12/21/2015 9:10:45 AM

Reader: SANGHVI MD, H.

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Cardiovascular

EK00201

Vent. rate 76 BPM

PR interval 170 ms

QRS duration 92 ms

QT/QTCB 422/474 ms

P-R-T axes 56 58 35

Technician: GABRIEL SUAREZ

Test ind: Other:

BAYSTATE HEALTH-MLHDW ROUTINE RETRIEVAL

Incomplete right bundle branch block

Borderline ECG

When compared with ECG of 20-DEC-2015 00:16,

No significant change was found

Confirmed by SANGHVI MD, H. (301) on 12/21/2015 9:10:58 AM

Referred by: Ramakrishna Thippanna

Confirmed By: H. SANGHVI MD

25mm/s 10mm/mV 100Hz 10.2.3 12SL 241 CID: 3

SID: 0M0210389 EID: 301 EDT: 09:10 21-Dec-2015 ORDER: 011842375 ACCOUNT: 0148415630-0210389

Page 1 of 1

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Cardiovascular

Document Type: ECG 12-Lead

Event Date: 12/20/2015 03:58 EST

Result Status: Auth (Verified)

Signed By:

MUSEWebURL

http://BSMUSE01:9081/musescripts/museweb.dll?RetrieveTestByDateTime?PatientID=000339334&Date=20-12-2015&Time=03%3a58%3a53%3a255&TestType=ECG&Site=1&OutputType=PDF&Ext=PDF HNAM URL

EK00201

Ventricular Rate: 76 BPM

Atrial Rate: 76 BPM

P-R Interval: 170 ms

QRS Duration: 92 ms

Q-T Interval: 422 ms

QTC Calculation(Bezet): 474 ms

P Axis: 56 degrees

R Axis: 58 degrees

T Axis: 35 degrees

Normal sinus rhythm

Possible Left atrial enlargement

Incomplete right bundle branch block

Borderline ECG

When compared with ECG of 20-DEC-2015 00:16,

No significant change was found

Confirmed by SANGHVI MD, H. (301) on 12/21/2015 9:10:58 AM

Reader: SANGHVI MD, H.

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Cardiovascular

EK00201

Vent. rate 104 BPM

PR interval 158 ms

QRS duration 90 ms

QT/QTCB 388/510 ms

P-R-T axes 64 55 31

Technician: KEIR DARCEY

Test ind: Other:

BAYSTATE HEALTH-MLHDW ROUTINE RETRIEVAL

Sinus tachycardia

Possible Left atrial enlargement

Nonspecific T wave abnormality

Abnormal ECG

When compared with ECG of 20-DEC-2015 03:58,

Nonspecific T wave abnormality, worse in Inferior leads

Nonspecific T wave abnormality now evident in Lateral leads

Confirmed by SANGHVI MD, H. (301) on 12/21/2015 5:56:28 PM

Referred by: CHARLES M SIMMONS

Confirmed By: H. SANGHVI MD

25mm/s 10mm/mV 100Hz 10.2.3 12SL 241 CID: 3

SID: 0M0210389 EID: 301 EDT: 17:56 21-Dec-2015 ORDER: 012388199 ACCOUNT: 0148415630-0210389

Page 1 of 1

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Cardiovascular

Document Type: ECG 12-Lead

Event Date: 12/21/2015 10:05 EST

Result Status: Auth (Verified)

Signed By:

MUSEWebURL

http://BSMUSE01:9081/musescripts/museweb.dll?RetrieveTestByDateTime?PatientID=000339334&Date=21-12-2015&Time=10%3a05%3a06%3a255&TestType=ECG&Site=1&OutputType=PDF&Ext=PDF HNAM URL

EK00201

Ventricular Rate: 104 BPM

Atrial Rate: 104 BPM

P-R Interval: 158 ms

QRS Duration: 90 ms

Q-T Interval: 388 ms

QTC Calculation(Bezet): 510 ms

P Axis: 64 degrees

R Axis: 55 degrees

T Axis: 31 degrees

Sinus tachycardia

Possible Left atrial enlargement

Nonspecific T wave abnormality

Abnormal ECG

When compared with ECG of 20-DEC-2015 03:58,

Nonspecific T wave abnormality, worse in Inferior leads

Nonspecific T wave abnormality now evident in Lateral leads

Confirmed by SANGHVI MD, H. (301) on 12/21/2015 5:56:28 PM

Reader: SANGHVI MD, H.

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Cardiovascular

EK00201

Vent. rate 79 BPM

PR interval 176 ms

QRS duration 92 ms

QT/QTCB 400/458 ms

P-R-T axes 72 46 39

Technician: KEIR DARCEY

Test ind: Other:

BAYSTATE HEALTH-MLHDW ROUTINE RETRIEVAL

Normal sinus rhythm with sinus arrhythmia

Possible Left atrial enlargement

Borderline ECG

When compared with ECG of 21-DEC-2015 10:05,

Nonspecific T wave abnormality no longer evident in Inferior leads

Nonspecific T wave abnormality no longer evident in Anterolateral leads

QT has shortened

Confirmed by SANGHVI MD, H. (301) on 12/22/2015 12:41:40 PM

Referred by: Ramakrishna Thippanna

Confirmed By: H. SANGHVI MD

25mm/s 10mm/mV 100Hz 10.2.3 12SL 241 CID: 3

SID: 0M0210389 EID: 301 EDT: 12:41 22-Dec-2015 ORDER: 013294352 ACCOUNT: 0148415630-0210389

Page 1 of 1

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Discharge Date: 12/22/2015 16:05 EST

Patient Type: Disch Obv

Cardiovascular

Document Type: ECG 12-Lead

Event Date: 12/22/2015 08:19 EST

Result Status: Auth (Verified)

Signed By:

MUSEWebURL

http://BSMUSE01:9081/musescripts/museweb.dll?RetrieveTestByDateTime?PatientID=000339334&Date=22-12-2015&Time=08%3a19%3a04%3a255&TestType=ECG&Site=1&OutputType=PDF&Ext=PDF HNAM URL

EK00201

Ventricular Rate: 79 BPM

Atrial Rate: 79 BPM

P-R Interval: 176 ms

QRS Duration: 92 ms

Q-T Interval: 400 ms

QTC Calculation(Bezet): 458 ms

P Axis: 72 degrees

R Axis: 46 degrees

T Axis: 39 degrees

Normal sinus rhythm with sinus arrhythmia

Possible Left atrial enlargement

Borderline ECG

When compared with ECG of 21-DEC-2015 10:05,

Nonspecific T wave abnormality no longer evident in Inferior leads

Nonspecific T wave abnormality no longer evident in Anterolateral leads

QT has shortened

Confirmed by SANGHVI MD, H. (301) on 12/22/2015 12:41:40 PM

Reader: SANGHVI MD, H.

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Attending Physician: Friedman MD, Emanuel

Patient Location: Out Pt

Date of Birth and Sex: 10/8/1978 Male

Admit Date and Time: 8/6/2015 09:38 EDT

Discharge Date: 8/6/2015 23:59 EDT

Patient Type: One Time OP

Print Date and Time: 2/28/2025 15:43 EST

Request ID: 263443419

Chemistry

Collected Date 8/6/2015

Collected Time 09:43 EDT

Procedure

Units

Reference Range

Testosterone Total, LC/MS

ng/dL

[280-800]

268 L F1

Result Comments

F1: Testosterone Total, LC/MS

TEST PERFORMED AT BAYSTATE MEDICAL CENTER, 759 CHESTNUT STREET,

SPRINGFIELD MA 01199

Baystate Mary Lane Hospital

85 South Street

Ware, MA 01082-

STEBBINS, RICHARD

210389

148195992

Attending Physician: Sivak MD, Joseph J

Patient Location: Out Pt

Date of Birth and Sex: 10/8/1978 Male

Admit Date and Time: 6/30/2015 09:50 EDT

Discharge Date: 6/30/2015 23:59 EDT

Patient Type: One Time OP

Print Date and Time: 2/28/2025 15:43 EST

Request ID: 263443420

Chemistry

Collected Date 6/30/2015

Collected Time 09:50 EDT

Procedure

Units

Reference Range

Sodium

mmol/L

[133-145]

139

Potassium

mmol/L

[3.6-5.2]

4.6

Chloride

mmol/L

[98-107]

103

Bicarbonate Level

mmol/L

[22-29]

Anion Gap

[4-17]

Glucose Level

mg/dL

[70-99]

99 F1

BUN

mg/dL

[6-20]

Creatinine-Blood

mg/dL

[0.7-1.2]

1.3 H

Estimated GFR Creatinine

ML/MIN/1.73 M2

Estimated GFR, African American

ML/MIN/1.73 M2

Calcium

mg/dL

[8.6-10.5]

9.4

Protein, Total

Gm/dL

[6.2-8.2]

7.1

Albumin

Gm/dL

[3.4-4.8]

4.5

AG Ratio

1.7

Alkaline Phosphatase

units/L

[40-129]

AST (SGOT)

units/L

[0-38]

ALT (SGPT)

units/L

[0-41]

Bilirubin, Total

mg/dL

[0-1.2]

0.7

Bilirubin, Direct

mg/dL

[0-0.3]

0.1

Bilirubin, Indirect

mg/dL

[0.0-0.7]

0.6

TSH

mIU/mL

[0.40-4.00]

1.53 F3

Free T4

ng/dL

[0.70-1.80]

1.17 F3

Lithium Level

mmol/L

[0.6-1.2]

0.9 F3

Result Comments

F1: Glucose Level

FASTING

F2: Estimated GFR, African American, Estimated GFR Creatinine

THE MDRD STUDY'S ESTIMATED GFR EQUATION HAS NOT BEEN VALIDATED IN CHILDREN (<18 YRS), PREGNANT WOMEN, THE ELDERLY (AGE >70 YRS), RACIAL OR ETHNIC SUBGROUPS OTHER THAN CAUCASIANS AND AFRICAN AMERICANS.

F3: Free T4, Lithium Level, TSH

TEST PERFORMED AT BAYSTATE MEDICAL CENTER, 759 CHESTNUT STREET, SPRINGFIELD MA 01199