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.
tion to remedy this. He has
applied for disability income and then rejected and is in the process of
an appeal based on physical and psychiatric claims.
He has had some recent episodes of drinking but was sober when he
impulsively took an overdose of medications which he says was to allow
Baystate Wing Hospital Inpatient Psychiatry
40 Wright Street
Palmer, MA 01069-
Patient Name: STEBBINS, RICHARD
MRN: M168269
Account Number: V49810013
Discharge Date: 12/24/2015
Patient Type: Disch I P
Admission/History and Physical
him to get some sleep but was in the context of his wife's infidelities
according to him. This resulted in treatment for an overdose at Mary
Lane Hospital and referral here for inpatient psychiatric evaluation
which was originally thought to be voluntary but required a Section 12B
later superseded by him signing a CV.
PAST MEDICAL HISTORY: The patient has had surgery for rotator cuff
injuries, knee injuries and ankle injuries. He has had a tonsillectomy.
He has low testosterone for unclear reasons according to him.
Otherwise, there is no history of surgery, accidents or serious illness.
He has had self-harming incidences related to alcohol use but denies
that that was the case in his current situation. H e reports no adverse
drug reactions or allergies.
FAMILY AND SOCIAL HISTORY: The patient is the oldest of three children
of parents who divorced in his early adulthood. H e describes a cared
for unmolested childhood. H e had hyperactivity and perhaps learning
disability for which h e took Ritalin without good results and he says h e
14:00 EST
NAME: STEBBINS, RICHARD
HOSP#: V49810013
CHART LOC:
DOB: 10/08/78
MR#: M168269
PCP:
DICTATING: FRANKLIN GERALD S MD
PSYCHIATRIC ADMISSION NOTE CONTINUED:
outgrew his attentional problem. H e graduated from high school, had
some college and has had a variety of employments. Currently works for
a contractor for Stop and Shop. He has been married twice and has three
children with whom he is estranged. He has been with his current wife
for several years and he feels that they are working on their
relationship.
MENTAL STATUS EXAMINATION: The patient was alert, fluent and
cooperative. His affect was congruent with his mood which was neutral.
His thinking was superficially logical, relevant and realistic. H e
tended to project blame for his failure to have continuity of care
psychiatrically. He denied suicidality. Agreed to cooperate with the
safety plan while on the unit and afterwards. He expressed displeasure
with being hospitalized and requested discharge after agreeing to sign a
Conditional Voluntary application and a release for us to talk with his
DIAGNOSES:
AXIS I: Adjustment disorder with mixed disturbance of mood and conduct.
Baystate Wing Hospital Inpatient Psychiatry
4 0 Wright Street
Palmer, MA 01069-
Patient Name: STEBBINS, RICHARD
MRN: M168269
Account Number: V49810013
Discharge Date: 12/24/2015
Patient Type: Disch IP
Admission/History and Physical
14:00 EST
Rule out major affective disorder.
AXIS II: Cluster B personality disorder.
AXIS III: N o diagnosis.
AXIS IV: Marital discord.
AXIS V: Global Assessment of Functioning 35, best in the past year
TREATMENT PLAN: colatera contacto coin treat mart give s an plysial exork, plan, aftercare plan and observe.
927 T: sn DD: 20151223 TD: 1029 DT: 20151223 TT: 1052 JOB: 08-04044476
safety
FRANG/STE
D: 12/23/15
T: 12/23/15
FRANKLIN GERALD S MD
ESigned by:
Date: 12/24/15 Time: 0652
NOT FOR REDISCLOSURE WITHOUT PATIENT'S INFORMED CONSENT
Baystate Wing Hospital Inpatient Psychiatry
40 Wright Street
Palmer, MA 01069-
Patient Name: STEBBINS, RICHARD
MRN: M168269
Account Number: V49810013
Discharge Date: 12/24/2015
Patient Type: Disch I P
14:00 EST
Document Type:
Event Date:
Result Status:
Signed By:
Discharge/Transfer Note Hospital HIM
Discharge/Transfer Note Hospital
12/24/2015 14:06 EST
Auth (Verified)
Franklin MD, Gerald S (12/24/2015 14:06 EST)
Discharge/Transfer Note Hospital
BAYSTATE WING
HOSPITAL
Palmer, Massachusetts
PSYCHIATRIC DISCHARGE SUMMARY
NAME:
STEBBINS, RICHARD
DOB:
10/08/78
ACCT#:
V49810013
MR#:
M168269
PCP:
ADMITTED:
12/22/15
DISCHARGED:
Psych Discharge Summary
Present Psychiatric History
ID/HPI
DATE OF ADMISSION: 12/22/15
DATE OF SERVICE: 12/23/15
CHIEF COMPLAINT: This 37-year-old man was admitted to Parker North at
Baystate Wing Hospital on 12/22/15 on a Conditional Voluntary
application because of an overdose.
HISTORY OF PRESENT ILLNESS: The patient states that he has been
hospitalized three times previously for self-harming behavior, twice at
Baystate Medical Center and once at Noble Hospital two months prior to
Baystate Wing Hospital Inpatient Psychiatry
4 0 Wright Street
Palmer, MA 01069-
Patient Name: STEBBINS, RICHARD
MRN: M168269
Account Number: V49810013
Discharge Date: 12/24/2015
Patient Type: Disch IP
14:00 EST
Discharge/Transfer Note Hospital HIM
admission. Each time he was self-harming and was given incomplete
treatment according to him which was not useful and discharged without
appropriate aftercare. H e has a history of prescriptions for lorazepam,
gabapentin, trazodone, Haldol and Cogentin, and he reports that h e 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. H e has also had exposure to psychotherapy which has been
ineffective. In recent days he has felt lethargic and emotionally
unresponsive compared to his usual state of being which he attributes to
low testosterone levels that have been discovered medically. He is in
the process of pursuing an endocrine evaluation to remedy this.
applied for disability income and then rejected and is in the process of
an appeal based on physical and psychiatric claims.
He has had some recent episodes of drinking but was sober when he
impulsively took an overdose of medications which he says was to allow
him to get some sleep but was in the context of his wife's infidelities
according to him This resulted in treatment for an overdose at Mary
Lane Hospital and referral here for inpatient psychiatric evaluation
which was originally thought to be voluntary but required a Section 12B
superseded by him signing a CV.
PAST MEDICAL HISTORY: The patient has had surgery for rotator cuff
injuries, knee injuries and ankle injuries. H e has had a tonsillectomy.
H e has low testosterone for unclear reasons according to him.
Otherwise, there is no history of surgery, accidents or serious illness.
He has had self-harming incidences related to alcohol use but denies
that that was the case in his current situation. He reports no adverse
drug reactions or allergies.
FAMILY AND SOCIAL HISTORY: The patient is the oldest of three children
of parents who divorced in his early adulthood. H e describes a cared
for unmolested childhood. He had hyperactivity and perhaps learning
disability for which he took Ritalin without good results and he says he
outgrew his attentional problem. He graduated from high school, had
some college and has had a variety of employments. Currently works for
a contractor for Stop and Shop. H e has been married twice and has three
children with whom he is estranged. He has been with his current wife
for several years and he feels that they are working on their
relationship.
MENTAL STATUS EXAMINATION: The patient was alert, fluent and
cooperative. His affect was congruent with his mood which was neutral.
His thinking was superficially logical, relevant and realistic.
tended to project blame for his failure to have continuity of care
psychiatrically. He denied suicidality. Agreed to cooperate with the
safety plan while on the unit and afterwards. He expressed displeasure
with being hospitalized and requested discharge after agreeing to sign a
Conditional Voluntary application and a release for us to talk with his
Baystate Wing Hospital Inpatient Psychiatry
40 Wright Street
Palmer, MA 01069-
Patient Name:
STEBBINS, RICHARD
MRN:
M168269 V49810013
Account Number:
Discharge Date:
Patient Type:
12/24/2015
Disch I P
Discharge/Transfer Note Hospital HIM
14:00 EST
wife.
Allergies
Coded Allergies:
N o Known Allergies (12/22/15)
Past History
Social History Occasional alcohol
Current medical problems
1 . Suicide attempt by multiple drug overdose
2. Major depressive disorder with psychotic features
3 . GAD (generalized anxiety disorder)
4. Tobacco abuse
Hospital Course
Patient was admitted to Parker North. H e declared himself safe shortly after
admission and requested discharge. His safety agreement was endorsed as
credible by his family. He was uninterested in medication changes. H e planned
to continue in the outpatient care of his medical needs. He was discharged on
12/24/15 in improved condition, free of harmful impulses and aware of crisis
Mental Exam
Sensorium and orientation
Clear and intact
Mood/affect euthymic
Anxieties calm
Thought content/processes
Baseline
Cognition
Intact
Insight/judgement
Limited insight
Adequate judgment
Risk of lethality
Minimal
Laboratory Findings
Lab Results
Laboratory Tests
Test
Chemistry
Sodium (135 - 145 mmol/L)
Potassium (3.6 - 5.0 mmol/L)
chloride (97 - 110 mmo] / L)
Carbon Dioxide (21 - 3 2 mmol/L)
Result Date Time
138 12/22 1730
4.0 12/22 1730
106 12/22 1730
25 12/22 1730
Baystate Wing Hospital Inpatient Psychiatry
Patient Name: STEBBINS, RICHARD
MRN: M168269
40 Wright Street
Palmer, MA 01069-
Account Number: V49810013
Discharge Date: 12/24/2015
Patient Type: Disch I P
Discharge/Transfer Note Hospital HIM
BUN (5 - 2 5 mg/dL)
Creatinine (0.6 - 1.3 mg/dl)
Estimated GFR ( MDRD) (> or = 60)
Glucose (70 - 99 mg/dL)
Calcium (8.5 - 10.6 mg/dL)
Total Bilirubin (0.2 - 1.25 mg/dL)
Direct Bilirubin ( 0.0 - 0.2 mg/dL)
AST (10 - 42 U/L)
ALT (10 - 6 0 U/L)
Alkaline Phosphatase (42 - 121 U/L)
Total Protein (6.0 - 8.0 gm/dL)
Albumin (3.2 - 5.5 gm/dL)
TSH 3rd Generation (0.34 - 4.6 uIU/ml)
Hematology
WBC (4.5 - 10.8 k/MM3)
RBC (4.5 - 5.7 M/mm3)
Hgb (14.0 - 18.0g/dL)
H c t ( 4 2 . 0 - 5 4 . 0 % )
MCV (80 - 94 fL)
MCH (27 - 32 pg)
MCHC (32 - 3 6 g/dl)
RDW (11.5 - 14.5 % )
Plt Count (140 - 440 k/mm3)
MPV (6.2 - 10.1 fl)
14 12/22 1730
1.01 12/22 1730
> 60 12/22 1730
9 4 12/22 1730
9.5 12/22 1730
0.70 12/22 1730
0.1 12/22 1730
10 12/22 1730
1 3 12/22 1730
61 12/22 1730
6.8
0.69 12/2 12/22 1730
4.4
12/22 1730
12/22 1730
6.3
5.42
17.0
50. 6
93
31.4
34
13.3
224
8.7
12/22 1730
12/22 1730
12/22 1730
12/22 1730
12/22 1730
12/22 1730
12/22 1730
12/22 1730
12/22 1730
12/22 1730
14:00 EST
Time of Elaboration
Total time w/pt (minutes) 45
Time counsel/coord (minutes) 10
Discharge Plan
DSM-5 / ICD-10 Diagnoses:
DIAGNOSES:
AXIS I: Adiustment disorder with mixed disturbance of mood and conduct.
Rule out major affective disorder.
AXIS II: Cluster B personality disorder.
AXIS III: No diagnosis.
AXIS IV: Marital discord.
AXIS V: Global Assessment of Functioning 35, best in the past year
unknown
Prescriptions
Prescriptions
Continue taking these medications:
Buprenorphine/Naloxone Film* (Suboxone Film*) 8 MG/2 MG FI
1 EACH Sublingual Three times daily
Start taking the following new medications:
Baystate Wing Hospital Inpatient Psychiatry
40 Wright Street
Palmer, MA 01069-
Patient Name: STEBBINS, RICHARD
M168269
Account Number: V49810013
Discharge Date: 12/24/2015
Disch I P
14:00 EST
Discharge/Transfer Note Hospital HIM
Gabapentin* (Neurontin*) 300 MG CAP
300 MILLIGRAM Oral Iwice daily
Days = 3 0
No Refills
Olanzapine* (Zyprexa*) 5 MG TAB
5 MILLIGRAM Oral Twice daily as needed as needed for anxiety
N o Refills
ESigned by:
FRANKLIN GERALD S MD
Date: 12/24/15 Time: 1420
/
NOT FOR REDISCLOSURE WITHOUT PATIENT'S INFORMED CONSENT
Patient Name: STEBBINS, RICHARD
Baystate lin Health
Baystate Mary Lane Hospital
8 5 South Street
Ware, MA 01082-
Male
13:43 EST
16:05 EST
Print Date and Time: 2/28/2025 15:43 EST
Document Type:
Event Date:
Result Status:
Signed By:
Admission/History and Physical
History and Physical Hospital
12/20/2015 10:12 EST
Auth (Verified)
Kochar MD,Jinesh (12/20/2015 10:29 EST)
Medical H & P
Patient: STEBBINS, RICHARD MRN: 210389
Age: 37 years Sex: Male DOB: 10/8/1978
Associated Diagnoses: None
Author: Kochar MD, Jinesh
FIN: 148415630
Visit Information
Chief Complaint:
Intentional drug overdose.
Admission Information
Attending Physician Certification o f Inpatient Medical Necessity
Validation o f Inpatient Order.
History of Present Illness
Mr. Stebbins is a 37-year-old male with history o f prior suicidal attempts, depression, psychosis, who presents t o 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 m e
that she found multiple empty bottles o f Haldol, trazodone, Cogentin, Ativan. The patient remembers taking 3 0 pills
o f Ativan. Because of when necessary use, the wife is not able to tell me how many pills o f other medications were
ingested. Patient reports that he took i t because he was frustrated and down. I t 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, M A 01082-
Patient Name: STEBBINS, RICHARD
MRN: 210389
Account Number:
148415630
Discharge Date: 12/22/2015
Patient Type: Disch Obv
Admission/History and Physical
16:05 EST
Ordered
0.9% NaCI 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, B y 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 i s n o history of recent alcohol use. Patient does report smoking.
Family History
Unable to obtain from the patient
Review of Systems
Significant
Other neg except a s above and in the HPI.
Physical Examination
Vital Signs
Vitals: VITAL SIGNS SECTION
12/20/2015 4:01 Temperature
Temperature Route
Pulse Rate
Respiratory Rate
Systolic Blood Pressure
Diastolic Blood Pressure
Blood pressure sites
Oxygen Saturation
Mode of Delivery (Oxygen)
97.7 DegF
Temporal 7 1 bpm
15 br/min
127 mm Hg
76 mm Hg
Arm, left
Room air.
General
Appearance: N o 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-
Patient Name: STEBBINS, RICHARI
MRN: 210389
Account Number: 148415630
Discharge Date: 12/22/2015
Patient Type: Disch Obv
Admission/History and Physical
Soft non-tender.
GU/Rectal
GU/Rectal: n o CVAT.
Skin: No rash.
Neurologic
Neuro Exam: C N 2-12 normal, No acute dystonic reaction is noted..
Motor Exam: Coordination (heel t o 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: 1 5
ML/MIN/1. 73 M2
WBC 4.6 k/mm3
Hgb 15. 7 Gm/dL
Het 4 4 . 9 응
Platelet Count 206 k/ mm3
RBC
4.96 m/mm3
MCV 90.5 femtoliters
MCH 31.7 pg
MCHO 3 5 . 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
N e u t 응 6 0 . 2 응
Lymph § 2 2 . 7 %
M o n O 용 1 1 . 7 용
Eos 8
4 . 1 응
Baso 8 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 1 4
BUN 12 mg/dL
Creatinine-Blood 1.1 mg/dL
Estimated GFR, Non African American
Estimated GFR, African American
ML/ M I N/1. 73 M2
16:05 EST
>60
>60
Baystate Mary Lane Hospital
85 South Street
Ware, M A 01082-
Patient NaRN: 2TEBINS, RICHARD
210389
Account Number:
Discharge Date: 12/22/2015
Patient Type: Disch Obv
16:05 EST
Admission/History and Physical
Calcium
Phosphorus
Magnesium
Alkaline Phosphatase
AST ( SGOT)
ALT ( SGPT)
Bilirubin, Total
8.8 mg/ dL
4.2 mg/dL
1.7 mEg/L
5 9 units/L
11 units/L
14 units/L
0.7 mg/dL
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 b y 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 t o 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 i s no evidence of acute dystonic/other extrapyramidal effects. The patient's recall of past events i s
however inaccurate. If this progresses, neurology consultation might b e considered. Patient will need inpatient
psychiatric admission after medical observation for this problem is complete.
CODE STATUS: Full code.
Due t o prophylaxis: With sequential compression device
Baystate Mary Lane Hospital
8 5 South Street
Ware, M A 01082-
Patient Name: STEBBINS, RICHARD
MRN: 210389
Account Number: 148415630
Discharge Date: 12/22/2015
Patient Type: Disch Obv
16:05 EST
Document Type:
Event Date:
Result Status:
Signed By:
Discharge/Transfer Note Hospital HIM
Discharge/Transfer Note Hospital
12/22/2015 14:47 EST
Auth (Verified)
(12/22/2015 15:01 EST)
Hospitalist Discharge Summary
Patient: STEBBINS, RICHARD MRN: 210389
Age: 37 years Sex: Male DOB: 10/8/1978
Associated Diagnoses: None
Author: Thippanna MD, Ramakrishna
FIN: 148415630
Discharge Information
Admission Date: 12/19/2015
Principal Discharge Diagnosis
Drug overdose with suicidal intention
Medications
(Selected)
Hospital Course
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 a t
least 30 minutes o f lorazepam. The shins speech was very slurred and main source o f history is his wife. She
told me that she found multiple empty bottles of Haldol, trazodone, Cogentin, Ativan. The patient remembers
taking 3 0 pills of Ativan. Because o f when necessary use, the wife is not able t o tell me how many pills o f other
medications were ingested. Patient reports that he took it because h e 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.
Hospital Course
Physical examination at the time of discharge
Vitals
Temperature 98.2, pulse 77, respiration 80, blood pressure 124/79, 02 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
Baystate Mary Lane Hospital
85 South Street
Ware, M A 01082-
Patient Name: STEBBINS, RICHARD
210389
Account Number: 148415630
Discharge Date: 12/22/2015
Patient Type: Disch Obv
Discharge/Transfer Note Hospital HIM
16:05 EST
No pedal edema or asterixis
Hospital Course
Mr. Stebbins is a 37-year-old male with history o f 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
i s n o evidence o f acute dystonic/other extrapyramidal effects. Patient is well oriented. Patient i s seen
by behavioral health network and is section 12 all for inpatient psych placement. Patient i s accepted by
inpatient psychiatric facility in wing Memorial. Patient is being discharged to inpatient psych today at 4
PM
QTa prolonged due to OD
Is normalized, discontinued telemetry.
CODE STATUS: Full code.
Due t o prophylaxis: With sequential compression device
Results
Laboratory: LABORATORY
12/22/2015 6 : 20
HOURS.
ML/ M I N/1. 73 M2
ML/MIN/1.73 M2
12/20/2015 6:15
Hold Lav
SPECIMEN DISCARDED AFTER 2 4
sodium 142 mmol/L
Potassium 1.5 mmo 1/L
Bicaridhate Level 105 mmol/L
23 mmol/L
Anion Gap
1 4
Glucose Level
85 mg/dL
BUN 11 mg/dI
Creatinine-Blood 1.0 mg/dI
Estimated GER, Non African American
Estimated GFR, African American
Calcium
WBC
Hgb
Hct
Platelet Count
RBC
MCV
9.1 mg/dL
4.6 k / mm3
15.7 Gm/ dL
MCH
MCHC
4 4 . 9 응
206 k/ mm3
4.96 m/mm3
90.5 femtoliters
31.7 pg
35.0%
>60
>60
Baystate Mary Lane Hospital
8 5 South Street
Ware, M A 01082-
ML/ MIN/1. 73 M2
ML/MI N/1.73 M2
12/19/2015 16:36
Patient Name: STEBBINS, RICHARD
MRN:
Account Number: 148415630
Discharge Date: 12/22/2015
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
N e u t 응 6 0 . 2 %
Lymph 22.7 8
M o n o 용 11.7 8 H
Eos 8 4 . 1 %
B a s o %
1 . 3 %
RDW-SD 40.8 fentoliters
Sodium 141 mmol/I
Potassium 4.4 mmol/I
Chloride 104 mmol/I
Bicarbonate Level 2 3 mmol/I
Anion Gap 14
BUN 12 mg/dI
Creatinine-Blood 1.1 mg/dL
Estimated GFR, Non African American
Estimated GFR, • African American
Calcium
Phosphorus
Magnesium
Alkaline Phosphatase
AST (SGOT)
8.8 mg/dL
4.2 mg/dI
1.7 mEg/L
59 units/I
11 units/I
14 units/I
Barbiturate Screen, Urine NONE DETECTED
Cannabinoid Screen, Urine POSITIVE
Cocaine Metabolite Screen, Urine
16:05 EST
>60
>60
DETECTED
NONE
POSITIVE
Benzodiazepine Screen, Urine
Amphetamine Screen, Urine NONE DETECTED
Opiate Screen, 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 NEGATI VE
Hemoglobin, Urine
NEGATIVE
Nitrite, Urine NEGATIVE
Leukocyte, Urine NEGATI VE
Urobilinogen
NORMAL mg/dI
Baystate Mary Lane Hospital
8 5 South Street
Ware, MA 01082-
12/19/2015 14:49
12/19/2015 14:48
ML/MI N/1. 73 M2
ML/MI N/1.73 M2
Patient Name: S103BNS, RICHARD
210389
Account Number: 148415630
Discharge Date:
12/22/2015
Patient Type: Disch Obv
Discharge/Transfer Note Hospital HIM
Troponin I Quant <0.01 ng/mL.
WBC 5.6 k/ mm3
Hgb 17.3 Gm/dL
Hct 4 8 . 4 %
Platelet Count 220 k/mm3
RBC 5.44 m/mm3
MCV 89. 0 femtoliters
MCH 31.8 pg
MCHC 3 5 . 7 응
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
N e u t 응 6 8 . 0 %
Lymph 8 1 8 . 5 용
M o n o 용 9 . 2 용
Eos 8 3 . 6 %
B a s o 응 0 . 7 용
RDW-SD 41.8 femtoliters
INR 1.1
Protime (PT) 11.3 seconds
APTT 27.3 seconds
Sodium 139 mmo1/L
Potassium 4 . 5 mmol/L
Chloride 102 mmol/I
Bicarbonate Level 23 mmol/L
Anion Gap
1 4
Glucose Level 89 mg/dL
BUN 15 mg/ dL
Creatinine-Blood 1.2 mg/ d L
Estimated GER,
Non African American
>60
Estimated GFR, African American >60
Calcium
Magnesium
Protein, Total
Albumin
Alkaline Phosphatase
AST (SGOT)
ALT ( SGPT)
Bilirubin, Total
Bilirubin, Direct
Bilirubin, Indirect
C-Reactive Protein
CK, Total
Ethanol, Serum
9.3 mg/dI 1.8 mEg/I
6.9 Gm/ dL
4.5 Gm/ dL
69 units/L
11 units/I
1 7 units/I
0.7 mg/dL
0.2 mg/dL
0.5 mg/dL
<0.1 mg/dI
54 units/L
NONE DETECTED mg/dI
16:05 EST
Baystate Mary Lane Hospital
85 South Street
Ware, MA 01082-
Patient NaRN: 2103BNS, RICHARD
210389
Account Number: 148415630
Discharge Date: 12/22/2015
Patient Type: Disch Obv
Discharge/Transfer Note Hospital HIM
Salicylate Level
Acetaminophen Level
Hold Red Tube
<0.3 mg/aL
<15 mg/L
SPECIMEN DISCARDED AFTER 1
16:05 EST
WEEK •
Result type:
Result date:
ECG 12-Lead
22 December 2015 8:19
* Final Report *
EK00201
Ventricular Rate: 7 9 BPM
Atrial Rate: 79 BPM
P-R Interval: 176 ms
QRS Duration: 9 2 ms
Q-T Interval: 400 ms
QTC Calculation( Bezet): 458 ms
P Axis: 72 degrees
R Axis: 4 6 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 I wave abnormality no longer evident in Inferior leads
Nonspecific I wave abnormality no longer evident in Anterolateral leads
OT 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 t o Quit Smoking, Staying Smoke-Free, The Benefits of Living
Smoke Free, Tips for Quitting Smoking (Cardiovascular), Why D o You Smoke?, Diet-Regular (CUSTOM),
Activity-Increase a s Tolerated (CUSTOM).
Discharge Disposition
Discharge: Inpatient psychiatric
Code Status: Full Code.
Discharge Condition: good, compared t o admission improved.
Less than 30 minutes spent on discharge
Baystate Mary Lane Hospital
35 South Street
Nare, MA 01082
Patient Name: STEBBINS, RICHARD
MRN: 210389
Account Number: 148415630
Discharge Date: 12/22/2015
Patient Type: Disch Obv
16:05 EST
Document Type:
Event Date:
Result Status:
Signed By:
Discharge/Transfer Note Hospital HIM
Discharge/Transfer Note Hospital
12/22/2015 15:11 EST
Auth (Verified)
Potts, Susan (12/22/2015 15:11 EST)
Medical formed on: 1262015 151 by 222015 15:13
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, Ramakrıshna
Medical Necessity for Transportation: Other patient condition
Patient Condition at Time o f Transport: Other: Section 12-transferring for Inpatient Psych.
Explanation o f Medical Necessity: Inpatient Psych-section 12
Interfacility Transfer Reason: Psych admission/transfer
medically necessary for this transport.
Medical Necessity Verified by: Potts, Susan
Credentials: RN
Potts, Susan - 12/22/2015 15:11
Patient Name: STEBBINS, RICHARD
Baystate Mary Lane Hospital
5 South Stree
Vare, MA 01082
Account Number: 148415630
Discharge Date: 12/22/2015
Patient Type: Disch Obv
16:05 EST
Document Type:
Event Date:
Result Status:
Signed By:
Discharge/Transfer Note Hospital HIM
Discharge/Transfer Note Hospital
12/22/2015 16:05 EST
Modified
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 b y Potts, Susan
Nursing Discharge Note 2
Discharge Time: 16:05
Discharge Level o f Care at Discharge: Psychiatric Facility/Unit (ATZ)
Patient Left Unit Via: Ambulance
Patient Accompanied Off Unit with : Ambulance/Chair Van Personnel
Handover Given t o 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 a t B . Wing. Report called to Shaka, a t Wing.
Potts, Susan - 12/22/2015 16:41
Did Pi have Specially Bed or Wound Pace: Noth at B. Wing) previously charted by Potts, Susan at 12/2/2015 16:38):
Potts, Susan - 12/22/2015 16:38
Baystate Mary Lane Hospital
8 5 South Street
Ware, MA 01082-
Patient Name: STEBBINS, RICHARD
210389
Account Number:
Discharge Date: 148415630 12/22/2015
Disch Obv
16:05 EST
Document Type
vent Date:
Result Status:
Signed By:
Emergency Medicine Notes
Emergency Medicine Note
12/19/2015 14:12 EST
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
Intentional drug overdose
Patient: STEBBINS, RICHARD MRN: 210389 FIN: 148415630
Age: 3 7 years Sex: Male DOB: 10/8/1978
Associated Diagnoses: Polysubstance overdose; Prolonged QT interval
Author: Cannizzaro PA, Christopher J
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, a m being Supervised b y 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 p m the patient took unknown quantities o f Ativan, Haldol, Trazadone,
Gabapentin and Cogentin. H e 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 h e had slurred speech and poor fine motor function.
Currently he denies any complaints..
Review of Systems
Constitutional symptoms: Negative except a s documented i n HPI.
Skin symptoms: Negative except a s documented i n HPI.
Eye symptoms: Negative except a s documented i n HPI.
ENMT symptoms: Negative except as documented in HPI.
Respiratory symptoms: Negative except as documented i n HPI.
Cardiovascular symptoms: Negative except as documented i n HPI.
Gastrointestinal symptoms: Negative except as documented in HPI.
Genitourinary symptoms: Negative except as documented in HPI.
Baystate Mary Lane Hospital
8 5 South Street
Ware, MA 01082-
Patient Name: STEBBINS, RICHARD
MRN:
210389
Account Number: 148415630
Discharge Date: 12/22/2015
Patient Type: Disch Obv
16:05 EST
Emergency Medicine Notes
Musculoskeletal symptoms: Negative except as documented i n HPI.
Neurologic symptoms: Negative except as documented in HPI.
Hematologic/Lymphatic symptoms: Negative except a s documented i n HPI.
Health Status
Allergies:
Allergic Reactions (Selected)
NKA.
Medications: Per nurse's notes.
Past Medical/ Family/ Social History
Medical history: Depression, psychosis, Sl..
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
98.4 DegE
Temperature
Temperature Route
Temporal 116 bpm H
16 br/min
Respiratory Rate
Systolic Blood Pressure
104 mm Hg
Diastolic Blood Pressure 62mm H g
Blood pressure sites Arm, right
Mean Arterial Pressure
76 m m Hg
Oxygen Saturation
100 g
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, N o 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, t o
situation, Cranial nerves I! - XII: Intact, Motor strength: Equal bilaterally, Motor function: Active tremor,
Coordination: Fingers) to nose abnormal, heel(s) o f foot to opposite shin abnormal, Speech: Dysarthric,
slurred, Gait: Ataxic.
Baystate Mary Lane Hospital
85 South Street
Ware, MA 01082-
Patient Name: STEBBINS, RICHARD
210389
148415630
Account Number:
Discharge Date:
12/22/2015 Disch Obv
Patient Type:
Emergency Medicine Notes
16:05 EST
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
IV PRN Angio (ED Only) (Order): Document IV Site (Q4H Pediatrics; Q8H Adults), 12/19/2015 14:31
Pharmacy:
NaCI 0.9% Bolus 1000 mL (Order): 1,000 mL, Infusion, IV Infusion, Once, Routine, 12/19/2015 14:31
Cardiology:
ECG 1 2 Lead (Order): Stat, Reason: Other: Drug overdose., 12/19/2015 14:31.
Results review: Lab results : Results
12/19/2015 14:49
Troponin I Quant
<0.01 ng/mL
12/19/2015 14:48
WBC
5.6 k / mm3
Hgb
17.3 Gm/dL
Hct
Platelet Count
RBC
MCV
MCH
MCHC
MPV
Abs. Neut
Abs. Lymph
Abs. Mono
Abs. E o
Abs. Baso
N e u t g
Lymph 8
4 8 . 4 %
220 k/mm3
5.44 m/mm3
89.0 femtoliters
31.8 p g
3 5 . 7 %
10.6 femtoliters
3.8 k/ mm3
1.0 k/mm3
0.5 k/mm3
0.2 k/mm3
0.0 k/mm3
6 8 . 0 %
1 8 . 5 응
Baystate Mary Lane Hospital
8 5 South Street
Ware, MA 01082.
ML/MI N/1.73 M2
ML/MI N/1.73 M2
Patient Name: S103BBINS, RICHARD
210389
Account Number: 148415630
Discharge Date:
12/22/2015
Patient Type: Disch Obv
16:05 EST
Emergency Medicine Notes
Mono 8
9 . 2 %
Eos 8 3 . 6 %
Baso 8 0 . 7 응
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/I
Anion Gap 14
Glucose Level 89 mg/dL
BUN 15 mg/ dL
Creatinine-Blood 1.2 mg/dI
Estimated GFR, Non African American
>60
Estimated GFR, African American >60
Calcium
Magnesium
Protein, Total
Al bumi n
Alkaline Phosphatase
AST ( SGOT)
ALT (SGPT)
Bilirubin, Total
Bilirubin, Direct
Bilirubin, Indirect
C-Reactive Protein
Ethanol, Serum
Salicylate Level
Acetaminophen Level
Hold Red Tube
9.3 mg/dI
1.8 mEg/L
6.9 Gm/dL
4.5 Gm/dL
69 units/L
1 1 units/l
17 units/L
0.7 mg/dL
0.2 mg/dL
0.5 mg/ dL
<0.1 mg/dL
NONE DETECTED mg/dL
<0. 3 mg/dI
<15 mg/L
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
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