Preview
FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019
2"
DEC 2015
Dear Siror Madam,
We are enclosing a copy of the Information requested.
The materials subrnitted are coniidential and are not to be released to any other parties.
An requests for certifieddupAcate copies of billsshould be forwarded to the business office. Ifyou
require further information or have any question regarding a bill,please contact them at 631-7194767.
AN requests for x-ray lilmsshouki be forwarded to x-rays departrnent, ifyou require further information
please contact thena at 631 968-3193.
Ifthis patientis a Medicare beneficiary please be advised that according to CMS's MSP Manual Pub. 100,
Chapter 3, section 10.4 a copy of thisrequest if from an attorney or an insurance company has been
provided to:
MEDICARE - COB
MSP Claims investigation Pmject
P.O. Bon 5041
New York, NY 10274-5041
We are pleased to be of service, and ifthere is anything Iurther we can do please letus know.
very trulyyours,
susan Hawldns
Medical infonnation
Medical Records Department
FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019
34450 : Southside Hospital 123438 : Gary Priesday
...........-................... .................
...........
................................-............................ ..... .
...................................
... ...........
Log ID: 89924946 Associates: 34450 Locatiom
Hospital
Requester Information
Law O&es Of
Phone: 516-741-3900 Name: Mitchell J Angel P L L Type: Attomey
170 Old state*
Country
Address: City: Mineola NY -11501
Road Suite 210 zip:
Patient Information
neceived Date: 11/21/20 13
Fiewt Nanne: xxxxxx Last Name: xxxxxxxx DOB:
SSN: Med Rec Mo: Claim #:
Gart Location: Perm File Date of senice: 8/19-8/23/07a
Complete Date: Enter Date:
11/21/2013 @
Pending
10:14G6:am
HIPAA reportable DeEvery
Page Count: Mail
disclosure: Mdhod:
Attention of :
Forms Sent:
comments:
Entered by: 34450-Shawkins-Member
Awaiting Dictation : Awaiting
signature :
Pushed froun AnadaPrm N/A
Update Record [ Close This Window
Delete Recofd
Correspondence History New Comesporpdence Le9em
I INDEX NO. 026910/2012
FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM
NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019
SOUTHSIDE HOSPITAL INPATIENT RECORD
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FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019
SOUTHSIDE HOSPITAL
Bay Shore, NY 11706
Inpatient Attestation
womNam ra am. as weome mer
5CHAI.LER, xxxxxx Female 33
men owmpom us
08/19/07 01:42 AM 08/23/07 05:30 PM 4 Routine Discharge
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29 6 20 Magor depressive affecdve disorder, single episode. onspecified
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29630 Major depresolve affective disorder, recurrent episode, unspeciGod
DX Code S¾nddty,Qiagnots Text '. ; .
40390 Anthms, vrtspeoHledtype,unspedf Red
3051 Yetzsceo use disorder
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FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019
SOUT1tSIDE HOSP1TAL
301 East Main Street
Bay Shore, NY 11766
631-968.3000
DISCHARGE SUMMARY
xxxxxxxx, xxxxxx
KENNETH GARCIA, M.D.
ADMITTED: 08/19/2007
DISCHARGED: 08/23/2007
HISTORY: Please refer to the intake evaluation for
details regarding the patient's past medical and psychiatric histories as well as a
description of the events which led to the patient's current hospitalization. In summary,
the patient is a 33 year old Caucasian female with a history of depression who was
brought to the 2 North Psychiatric Unit following stabilization for her intention drug
overdose of 33 tablets of Benadryl with an additional quantity of atoohol which raised her
blood alcohol level to 223. The patient admitted that this was a suicide attempt.
According to the patient and her husband, they have three children and have been atost
recently attempting to have another. However, most recently, the patient had experienced
her tierd miscarriage and was yery distraught over these events. The patient suffers from
depression and, only one month prior to this current hospitalization, had taken an
overdose of Xanax also in an attempt at suicide.
The patient emphasized that she has a
history of verbal and physical abuse in childhood and this had attributed to difficulties
with that had followed in her late adolescence, Just prior to graduating high
coping
school, the patient had been involved in a physically abusive relationship with a
boyfriend just before she met her current busband. They had met and they went through
a successf W courtship and both parties feltthat, in general, their marriage had gone on
quite well,
What was additionally disconcerting to the
couple was the fact that Pameta's Benadryl overdose was taken while xxxxxx was the
only adult at home and her children had just been put to bed, placing them in a vulnerable
situation should anything have happened following xxxxxx's demise and before another
responsible adult was present. Child Services had already been notified and were
investigating the case.
During my initialevaluation, the patient
immediately was asking to be discharged, stating that her husband was having problems
taking care of the children. According to the patient, there had been some ongoing
marital issues forwhich they had been receiving counseling for the past two years, In
addition, the patientherself is under a psychiatrist's and psychologist's care and had
reported feeling good on the dose of $0 mg of Zoloft per day. The patient had becorne so
determined to have a child that one attempt at becondng pregnant was quickly followed
by another attempt to become pregnant. One miscarriage was followed immediately by
TNlS IS A CONFIDENTIAL DISCHAROB SUMMARY
PRIVILHOED COMMUNICATION Page ) of3
FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019
xxxxxxxx, xxxxxx
new efforts to become pregnant The patient was surprisingly dismissive about potential
•
changes her children faced because there were no other adults in the home ifthey had
awskened to discover their mother incapacitated,
PAST PSYCHIATRIC HISTORY: The patient had taken a previous overdose of
Xanax one month previously. There was no violence towards others.
ALLERGIES: No known allergies to medications. .
PAST MEDICAL HISTORY: Obesity and three other miscarriages.
SUBSTANCE ABUSE HISTORY: None.
FAMILY HISTORY: When asked regarding her family and their
psychiatric history, the patient could only respond that the family was dysfunctional and
physically and verbally abusive towards her when she was growing up. The patient
preferred not to discuss anything further than that.
LABORATORY DATA: During the patient's intake examination, she
received a comprehensive laboraton evaluation in the Emergency Room which was
signiticant for being very normal with no significant laboratory abnormalities whatsoever
including electrolytes, liver function tests,complete blood count, and blood serum
toxicol.ogy screens.
MENTAL STATUS EXAMINATION: On admission: Disheveled, yet cooperative
and calm Caucasian female who appeared inappropriately appropriate. In other words,
the patient appeared to be and upbeat and not what one would expect of sorneone
friendly
who had recently attempted suicide, The patients speech was normat. The patients
mood was reported to be normal. Thought processes wereIntact. The patient denied
hallucinations and delusions, The patient was denying suicida!ity or homicidality. The
patient w as alert and oriented x three. Memory and concentration were intact. Abstract
thinking was intact, Intelligence was average. Insight and Judgment were poor,
HOSPITAL COURSBr The patient was admitted. The patient's
hospital course was significant for the lack of substantial investment on the patient's part
with mgards to confronting difficult issues. The patient recognized that inany of her
problems wem in the behavioral realm and attributed that to ber abusive childhood. The
patient expressed serious intent to obtain the proper suppon on an outpatient basis.
However, the patient was very anxious to be discharged from our service. I had two
meetinga with her and her husband to discuss issues regarding their marriage as well as
making sure that steps were10 place to protect the children from the patient's absence did
that occur again.
At discharge, the patient was alert and
oriented x three, The patient was in no acute distress. There was no psychomotor
retardation or agitation. The patient's eye costact was good, The patient denied any
THIS IS A CONFIDENTIAL DISCHA103 SUMMAILY
PRIVELEGED COMMUNICATION Page 2 of3
FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019
SCHALIER, xxxxxx
discomfort whatsoever. The patient believed that she had made an oversight that she
•
could not possibly repeat. The patient feltshe would do well on an outpatient basis with
a therapist and a psychiatrist that she already had in place. Child Protective Services had
investigated this situation at home and had discerned that what was needed was there to
be further oversight of the home situation and were satisfied so long as the couple
followed through with their outpatient therapy. The patient's mood was positive and
upbeat. The patient's af Tectwas full range and congruent, The patient d enied suicidality
or homicidality, The patient admitted to atedety at times. However, the patient denied
phobias, panic attacks, or obsessive/compulsive behavior. Insight and judgment were
poor. Knowledge base and intellect were average.
We increased the patient'sZoloft to 100 mg
per day which she appeared to be tolerating with no untoward symptoms.
CONDITION ON DISCHARGE: Stable,
FOI1OW-UP: As an outpatient.
FINAL DIAGNOSIS: AXIS I: ADJUSTMENT DISORDER
WITH DBPRESSED MOOD, RULE OUT
MAJOR DEPRESSIVE DISORDER
AXiS II: BORDERLDIE PERSONALITY
. DISORDER
AXIS III: OBESITY; BENADRYL
OVERDOSB
AXIS IV: FAMILIAL AND SOCIAL
ISSUES; CHRONIC PERSONALITY
VULNERABILITIES AND MBNTAL
ILLNESS
AXIS V: CURRENT GAF 30
KE M.D.
KG/se
D: 09/14/2007 03:18 PM
T: 09/17/2007 12:28 PM
Job No: 09589
THIS IS A CONFIDENTIAL DISCHARGE SUMMARY
PRIVILEGED COMMUNICATION Page3 of3
FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019
Southside Hospital
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FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019
Southside Hospital
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ADMISSION / DISCHARGE MEDICATION P II0
HISTORY
ALLERGIES and DRUG REACTIONS (checle -
reaeffort .D > Q No
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KNOWN AURRGlES
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CURRENT MEDICAT
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FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
NYSCEF
! DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019
SOUTHSIDE HOSPZTAL BNERGENCY D5PT. RECORD BAYSHORB, NY
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FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019
511118558111155 liftllRIll11555
SOUTHSIDE HOSPITAL
PHYSICIAN HIGHLIGHTS RECORD
VITAL SIGNS
BP-
VITAL SIGNS (Sun Aug 19 2007 01:34 MEA); 147/99, Pulse: 96, Resp: 20, Temp:.100.7, Pain: 0, 02
set 99 on RA
(10:40 BAS): BP: 12W85, Pulae: 75, Reep: 20, Temg 98.1, O2 sat 100 on ra,
(15:58 PT3): BP: 123/84, Pulse: 72, Resp: 18,Temp; 98.1, Pain: 0, O2 sat 98 on ra,Time: 1856.
(Mon Aug 20 2007 00:46 LDS): BP: 11547, Pulse: 74, Resp: 1.6, Temp: 90.4, Pain: 0,O2 sat: 98 on ra,
(Mon Aug 20 2007 04:62 ALP): BP: 120/S0, Pulse: 80, Resp: 20, Temp; 98.8, O2 sat: 90% on RA.
(Mon Aug 20 2007 16:17 CMM): BP: 124/84, Pulse: 82, Resp: 18, Temp: 96.7, Pain: 0, Og set 99 on ra,
KNOWN ALLERGIES
Nkda, No known drug allergies (nkda).
CURRENT MEDICATIONS (01:S4 MEA)
Advalr Diskus:
Rofoft: . . . .
PI OVERDOSE
CHitiF COMPt.AINT (02:43 MJC): Patient presents for theevaluation of aulcide attempt overdose,
depression, Amount ingested 33 tabB.
HISTORIAN (02:43 MJC): History obtained from pellent, History obtained Irom spouse.
TIME COURSE (D2;43 MJC): Onaet of symptoms reported he gradual, Symptoms are Jmproved,
Complaint 18 resolved,
ASSOCIATED WITH (0233 MJC): Depression.
EXACERBATED BY (02:43 MJC): Patients condition exacerbated by personet problems. history of
previous episodes.
NOTES (02:43 MJC): feeling stressed, around someone pregnant (she had a miscarriage in June)HAS 3 amall
chporen.took as tabs 26 mg Bendadpyl taba,,
(07:55 MJC): complain of dry mouth.
PAST MEDICAL HISTORY
MEDICAL HISTORY (Sun Aug 19 2007 01:34 MEA): History of pulmonary disease, htcluding astinna..
SUMGlCAL HISTORY (Sun Aug 19 2007 01:34 MEA): D and C K3..
PSYCHIATRIC HISTORY (Sun Aug 19 2007 01:84 MEA): History of depresqlon,,
SOCIAL HISTORY (Sun Aug 19 2007 01:84 MEA): Patient emokes tobacco, Denice consumption of atoohol,
Lives at homme with family..
NOTES (Sun Aug 19 2007 0t34 MEA): Nursing records reviewed..
MEDICAL HISTORY (02:44 MJC): History of pulmonary disepae. Inotuding asthma.
PSYCHIATRIC HISTORY (02:44 MJC): No history ofdepression, homfoidal ideation, schizophrenia,
History of suicidat idention, History of suicide attempta,
SOCIAL HISTORY (02:44 MJC): Denies alcohot abuse, drug abuse, Petlest emakes tobacco.
NOTES (02:44 MJC): Nursing records reviewed, Agree w(th nursing records.
PHYSICAL EXAM (O2:47 MJC)
Prepueæ w Aea so toot e aw cwee e &ckwe N. Page 1at +
FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019
EllRI111551111115 HIIIIIIIIIIHIIIII
SOUTHSIDE HOSPITAL
PHYSICIAN HIGHLIGHTS RECORD
CONSTITUTIONAL; Patient Vflal
fe afetnile, q(gns reviewed, Patient has normal pulse, Patient has normal
blood pressure. Patient has normal respitc|ply rele, Welf appearing, Patient appears comfortable, Alertand
oriented X 3,
HEAD: Atraumallo, Normooephah
EYES: Sciere are normal, Conjunctiva are normal.
NECK: Normal ROM, No jugglar venous distent¾ No meningeal signs, Cervical spine nontender.
RESPIRATORY CHEST: Chest isnon-tender, Breath sounds nonnel, No respiratory distress.
CARDIOVASCOLAR: MRR, No murmur, No rub,No gallop.
ABDOMEN: Abdomen is nontender, No masses, Bowel sounds normal
BACK: There isno tenderness to palpation, Normal Inspection.
NGURO: GCS is 15, No focal motor deficite,No focal sensory deficits,Cranial nerves Intact,No cerebe ar
deficits,Nomial DTRs, Horizontal nystagmus presesit in the left eye,Horizontet nys tagmus present in
the right eye,
SKIN: Sldn iswarm, Skinlsdry, Sidn is normal color.
PSYCHIATRIC: Oriented X 3, Nor mal affool,hgement and Insightnormal, No complaint of suicidalideation,
No complaint ofhomicidal ideation, able tosimile and laugh, during evaluation.
ESULTS
LABORATORY pt18 MJG):
R Auq19 200
weo ae rHoustouM 4M0,a
RED CELLS 4A7 MWCM 4AWRO .
HEMOGLOBIN 18E GWDL . . 12.0-10E
MEMATOGRIT 40 % 37·S-47-0
Preview
FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019 2" DEC 2015 Dear Siror Madam, We are enclosing a copy of the Information requested. The materials subrnitted are coniidential and are not to be released to any other parties. An requests for certifieddupAcate copies of billsshould be forwarded to the business office. Ifyou require further information or have any question regarding a bill,please contact them at 631-7194767. AN requests for x-ray lilmsshouki be forwarded to x-rays departrnent, ifyou require further information please contact thena at 631 968-3193. Ifthis patientis a Medicare beneficiary please be advised that according to CMS's MSP Manual Pub. 100, Chapter 3, section 10.4 a copy of thisrequest if from an attorney or an insurance company has been provided to: MEDICARE - COB MSP Claims investigation Pmject P.O. Bon 5041 New York, NY 10274-5041 We are pleased to be of service, and ifthere is anything Iurther we can do please letus know. very trulyyours, susan Hawldns Medical infonnation Medical Records Department FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019 34450 : Southside Hospital 123438 : Gary Priesday ...........-................... ................. ........... ................................-............................ ..... . ................................... ... ........... Log ID: 89924946 Associates: 34450 Locatiom Hospital Requester Information Law O&es Of Phone: 516-741-3900 Name: Mitchell J Angel P L L Type: Attomey 170 Old state* Country Address: City: Mineola NY -11501 Road Suite 210 zip: Patient Information neceived Date: 11/21/20 13 Fiewt Nanne: xxxxxx Last Name: xxxxxxxx DOB: SSN: Med Rec Mo: Claim #: Gart Location: Perm File Date of senice: 8/19-8/23/07a Complete Date: Enter Date: 11/21/2013 @ Pending 10:14G6:am HIPAA reportable DeEvery Page Count: Mail disclosure: Mdhod: Attention of : Forms Sent: comments: Entered by: 34450-Shawkins-Member Awaiting Dictation : Awaiting signature : Pushed froun AnadaPrm N/A Update Record [ Close This Window Delete Recofd Correspondence History New Comesporpdence Le9em I INDEX NO. 026910/2012 FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019 SOUTHSIDE HOSPITAL INPATIENT RECORD W accr Mo pATs Ann Tax amu a noon asts suptcar. 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PNcent m6, cuxar unstan steenas 631-96e-3632 MAJOR tEPRESSION FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019 SOUTHSIDE HOSPITAL Bay Shore, NY 11706 Inpatient Attestation womNam ra am. as weome mer 5CHAI.LER, xxxxxx Female 33 men owmpom us 08/19/07 01:42 AM 08/23/07 05:30 PM 4 Routine Discharge stattam Commercial Insurance weenvenm . car MASIAR, STEPHEN JONES.CORF,EN aca± um:wn 019 MENT AL DISEASES S DISORDERS acom onov-a 430 PsYCliOSEE aswas arneaum amasseamiar swanardhm 1,5934 19.0000 556.64 Adntit p Addit biognosis Text 29 6 20 Magor depressive affecdve disorder, single episode. onspecified - . 1 a h 29630 Major depresolve affective disorder, recurrent episode, unspeciGod DX Code S¾nddty,Qiagnots Text '. ; . 40390 Anthms, vrtspeoHledtype,unspedf Red 3051 Yetzsceo use disorder ÑX Code •Prpcedù Ten LRath . Stergeort Date Prlmed;asl25tol FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019 SOUT1tSIDE HOSP1TAL 301 East Main Street Bay Shore, NY 11766 631-968.3000 DISCHARGE SUMMARY xxxxxxxx, xxxxxx KENNETH GARCIA, M.D. ADMITTED: 08/19/2007 DISCHARGED: 08/23/2007 HISTORY: Please refer to the intake evaluation for details regarding the patient's past medical and psychiatric histories as well as a description of the events which led to the patient's current hospitalization. In summary, the patient is a 33 year old Caucasian female with a history of depression who was brought to the 2 North Psychiatric Unit following stabilization for her intention drug overdose of 33 tablets of Benadryl with an additional quantity of atoohol which raised her blood alcohol level to 223. The patient admitted that this was a suicide attempt. According to the patient and her husband, they have three children and have been atost recently attempting to have another. However, most recently, the patient had experienced her tierd miscarriage and was yery distraught over these events. The patient suffers from depression and, only one month prior to this current hospitalization, had taken an overdose of Xanax also in an attempt at suicide. The patient emphasized that she has a history of verbal and physical abuse in childhood and this had attributed to difficulties with that had followed in her late adolescence, Just prior to graduating high coping school, the patient had been involved in a physically abusive relationship with a boyfriend just before she met her current busband. They had met and they went through a successf W courtship and both parties feltthat, in general, their marriage had gone on quite well, What was additionally disconcerting to the couple was the fact that Pameta's Benadryl overdose was taken while xxxxxx was the only adult at home and her children had just been put to bed, placing them in a vulnerable situation should anything have happened following xxxxxx's demise and before another responsible adult was present. Child Services had already been notified and were investigating the case. During my initialevaluation, the patient immediately was asking to be discharged, stating that her husband was having problems taking care of the children. According to the patient, there had been some ongoing marital issues forwhich they had been receiving counseling for the past two years, In addition, the patientherself is under a psychiatrist's and psychologist's care and had reported feeling good on the dose of $0 mg of Zoloft per day. The patient had becorne so determined to have a child that one attempt at becondng pregnant was quickly followed by another attempt to become pregnant. One miscarriage was followed immediately by TNlS IS A CONFIDENTIAL DISCHAROB SUMMARY PRIVILHOED COMMUNICATION Page ) of3 FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019 xxxxxxxx, xxxxxx new efforts to become pregnant The patient was surprisingly dismissive about potential • changes her children faced because there were no other adults in the home ifthey had awskened to discover their mother incapacitated, PAST PSYCHIATRIC HISTORY: The patient had taken a previous overdose of Xanax one month previously. There was no violence towards others. ALLERGIES: No known allergies to medications. . PAST MEDICAL HISTORY: Obesity and three other miscarriages. SUBSTANCE ABUSE HISTORY: None. FAMILY HISTORY: When asked regarding her family and their psychiatric history, the patient could only respond that the family was dysfunctional and physically and verbally abusive towards her when she was growing up. The patient preferred not to discuss anything further than that. LABORATORY DATA: During the patient's intake examination, she received a comprehensive laboraton evaluation in the Emergency Room which was signiticant for being very normal with no significant laboratory abnormalities whatsoever including electrolytes, liver function tests,complete blood count, and blood serum toxicol.ogy screens. MENTAL STATUS EXAMINATION: On admission: Disheveled, yet cooperative and calm Caucasian female who appeared inappropriately appropriate. In other words, the patient appeared to be and upbeat and not what one would expect of sorneone friendly who had recently attempted suicide, The patients speech was normat. The patients mood was reported to be normal. Thought processes wereIntact. The patient denied hallucinations and delusions, The patient was denying suicida!ity or homicidality. The patient w as alert and oriented x three. Memory and concentration were intact. Abstract thinking was intact, Intelligence was average. Insight and Judgment were poor, HOSPITAL COURSBr The patient was admitted. The patient's hospital course was significant for the lack of substantial investment on the patient's part with mgards to confronting difficult issues. The patient recognized that inany of her problems wem in the behavioral realm and attributed that to ber abusive childhood. The patient expressed serious intent to obtain the proper suppon on an outpatient basis. However, the patient was very anxious to be discharged from our service. I had two meetinga with her and her husband to discuss issues regarding their marriage as well as making sure that steps were10 place to protect the children from the patient's absence did that occur again. At discharge, the patient was alert and oriented x three, The patient was in no acute distress. There was no psychomotor retardation or agitation. The patient's eye costact was good, The patient denied any THIS IS A CONFIDENTIAL DISCHA103 SUMMAILY PRIVELEGED COMMUNICATION Page 2 of3 FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019 SCHALIER, xxxxxx discomfort whatsoever. The patient believed that she had made an oversight that she • could not possibly repeat. The patient feltshe would do well on an outpatient basis with a therapist and a psychiatrist that she already had in place. Child Protective Services had investigated this situation at home and had discerned that what was needed was there to be further oversight of the home situation and were satisfied so long as the couple followed through with their outpatient therapy. The patient's mood was positive and upbeat. The patient's af Tectwas full range and congruent, The patient d enied suicidality or homicidality, The patient admitted to atedety at times. However, the patient denied phobias, panic attacks, or obsessive/compulsive behavior. Insight and judgment were poor. Knowledge base and intellect were average. We increased the patient'sZoloft to 100 mg per day which she appeared to be tolerating with no untoward symptoms. CONDITION ON DISCHARGE: Stable, FOI1OW-UP: As an outpatient. FINAL DIAGNOSIS: AXIS I: ADJUSTMENT DISORDER WITH DBPRESSED MOOD, RULE OUT MAJOR DEPRESSIVE DISORDER AXiS II: BORDERLDIE PERSONALITY . DISORDER AXIS III: OBESITY; BENADRYL OVERDOSB AXIS IV: FAMILIAL AND SOCIAL ISSUES; CHRONIC PERSONALITY VULNERABILITIES AND MBNTAL ILLNESS AXIS V: CURRENT GAF 30 KE M.D. KG/se D: 09/14/2007 03:18 PM T: 09/17/2007 12:28 PM Job No: 09589 THIS IS A CONFIDENTIAL DISCHARGE SUMMARY PRIVILEGED COMMUNICATION Page3 of3 FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019 Southside Hospital e-w e=••== c at n to F P n •PSYCHIATRIC SERVICES P 0115 (3 aa Cischarge 3 5 AR S TE InterdiscIpanary instructione · |SoclAC WORK l Aftercate mental. alth ohttmen • ' . --~, AA ilFA) ATkàW tr ‰ co ..k) .. Gb ThursdoL( prn . . 431- 90 - 7 60 Case Uanagement (If sodioable): .. Home Care liff±t-ONew ORestored OHome Care Agencv: . Phone Support Group: Discharged tor amily DSelf GAdult Home OSober House OSNF Q Comrnunity Residenne ORehab OOther: Individual(s)notified of Ofacharget.....-... . a. .. O - Address: .. .. Plme; Will reside . Name Relationship: Address: n34 A (/1r, ,. .lrWI (3hp ef Trartsportation: QTa RBus rivateVeNcle Social Worter Signa pata fifyou should need to contact Soola Worlt olease call 6311966-34241 NURSING Medical aftercare accolnt ent: T , .w , aw / ) Instructic s/0ther N2Re- b Prescript ona GNem DietL. .../ Activity: S ...__ Accompanied tw: s if EifOther: Name &M Re ationship edf b 4 NRðcit Î4c{q Ftë$finf rLE 8,D5ý supp C UVes L.lNo d nderstand these discharge.Instructlons Patient Signatu Û QA Date: RN $ignature: . Date- 1 b onits' W,you shotdd need to contact the psychiatry 2North @ (631) 960-S144or 4Brackett 0 (631)968-0312 300a30000 awledenood FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019 Southside Hospital l) s:Mun .P4ngu ADMISSION / DISCHARGE MEDICATION P II0 HISTORY ALLERGIES and DRUG REACTIONS (checle - reaeffort .D > Q No ALLERGY ' KNOWN AURRGlES Hath HIves , 00Â1 8enon SheMsh Q YES Latex Q yes SOURCE OF MEDICATIOA NISTORY WOSEN'S HEALTH Q PATIENT WRITYGN LIST O MEDICAL RECORD LMP: PATgwr / FAMILY ReCALL • Q ND PREGNANT ES • Wads: n . . Q NO LACTATING YES CURRENT MEDICAT • ONS ToKEN AT IOME MEDICATION UST Prescribed, Over-the-caunter, ierbals, VIamins 11econoife With Prescriber · CIRCLE C 10 05tWIM 04 O MEDICATIONS NO MEDICATlQNg m am mEm . LAST C//tRE O/C R DGCOVONUE MEDSAT O ,. (F D/C Q ) C O C D/C c D/C O NJ O C 9/c C D/c O O C DS C D/C O O C D/C C 0/C O O C DS C D/C O O C D/C C 0/C O O C D/C C D/c O O C D/c C D/C O O C II/C C D/C O O C D/C C DS O O C D/C C D/C O O C D/C C D/C O O C D/C C D/C O O C DM C D C O FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF ! DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019 SOUTHSIDE HOSPZTAL BNERGENCY D5PT. RECORD BAYSHORB, NY PAMERA CNETs 47 itant, 1734 $PUR DR 8 psym isLID gotarrre FAT. k90NB PAT. NAED5tr )U0DE AGE s3K REL MS· CIIIACCQNPARXED BY PM$/PCP 631 B59-9539 BLAIR 33Y F agZ M W SELF NBKT OF EXW NaW3 K éd A$D P50NE SQiAQ.SR ,tcNY 1734 SPOR DR E ISIstP , NY 11751 631 859-9539 RETATION: $ _... 825 EA$ VO PO BOX DP 1001 GARDEN CTY , NY 11530 POLXCE HOLDER NAME iota: # SOc,isse. 45¯¯uum st,ht it SCEA1LER ,10NY I32 pvty- OF ps m 97 sus 1872R cnzun anShTB PATIOUE/W5AK2585 GufG2r MBmtra B2MATUAZA F43QqRNCE MOCTURIA 35FE4/ APvBTtTs Loss/ewot warsay ross/eats vaqzuAL assemnaos 2t,rsp2N0 IHectrftsmucs 2YE/BAR/TEROAT/RECE PAEW BTE/WaR/WASAL MS/9ACii 001NT BERRT PA23/8Nsr43NG/BEONRSS/8TXPPRESS DZ8CBARGB AEAMRBD V2310N/BRARDr@,BTB/ CLADDICATION NU901,5 PAZN/ATjt0Mrg/N8&RNR$8 san xterms onomeanark scorous PArs ascs; TINg1tUS VERTzGo 3P5894215 erASSES/CONTACTS IkIf RAHE LEATONA PRURIT18 PETEUH2At B2023226 cAarad osmours goaksasses prefunera orseenses ascusrTz 4849 ExanfteraL/as8TING BTSUNEA PRCOUCTzVM/DRT NBURC EEAnhcgg trushBAS ALTBRED . .e9nan unanam mpopTests BP3BC%/fISION/ anneurom exxzona sounotaøcs Tamson Aenxra PRESSURR SURNZnG)PLEURETEC CP 4 MCOPg DX251stas VRRT200 ev ozAPaommers smo oarnoonsa noma vswes nonassrow/usern rusomera AutzsTr ascerns at 42N E103B VON2 190R5274 20iD0 POE3D P T c0HSTXPATICA pf WBL$RA H502 EtRS QBRMC ADWOpht F2ME SSE!F Sy Np. JiTBTORY + PRY2 CAL TINE TIMB TX I ADDITIONAL R-CORDBs OrL08 OTeama ¤vararsp asranevzars wo. Co8'T Ocons (nmm toasrana . . .... d2acLt Lavan or cans rzman . . nzAdHoexa 1 2 3 4 5 %TBs Tang ' nzacmass gutpzanD . L(t45 OrMOBS j_jI202 LIANA ponzcas ennaspsa µnumsp ea, onsT, saws or ranwarap exam, PAczarTr FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019 511118558111155 liftllRIll11555 SOUTHSIDE HOSPITAL PHYSICIAN HIGHLIGHTS RECORD VITAL SIGNS BP- VITAL SIGNS (Sun Aug 19 2007 01:34 MEA); 147/99, Pulse: 96, Resp: 20, Temp:.100.7, Pain: 0, 02 set 99 on RA (10:40 BAS): BP: 12W85, Pulae: 75, Reep: 20, Temg 98.1, O2 sat 100 on ra, (15:58 PT3): BP: 123/84, Pulse: 72, Resp: 18,Temp; 98.1, Pain: 0, O2 sat 98 on ra,Time: 1856. (Mon Aug 20 2007 00:46 LDS): BP: 11547, Pulse: 74, Resp: 1.6, Temp: 90.4, Pain: 0,O2 sat: 98 on ra, (Mon Aug 20 2007 04:62 ALP): BP: 120/S0, Pulse: 80, Resp: 20, Temp; 98.8, O2 sat: 90% on RA. (Mon Aug 20 2007 16:17 CMM): BP: 124/84, Pulse: 82, Resp: 18, Temp: 96.7, Pain: 0, Og set 99 on ra, KNOWN ALLERGIES Nkda, No known drug allergies (nkda). CURRENT MEDICATIONS (01:S4 MEA) Advalr Diskus: Rofoft: . . . . PI OVERDOSE CHitiF COMPt.AINT (02:43 MJC): Patient presents for theevaluation of aulcide attempt overdose, depression, Amount ingested 33 tabB. HISTORIAN (02:43 MJC): History obtained from pellent, History obtained Irom spouse. TIME COURSE (D2;43 MJC): Onaet of symptoms reported he gradual, Symptoms are Jmproved, Complaint 18 resolved, ASSOCIATED WITH (0233 MJC): Depression. EXACERBATED BY (02:43 MJC): Patients condition exacerbated by personet problems. history of previous episodes. NOTES (02:43 MJC): feeling stressed, around someone pregnant (she had a miscarriage in June)HAS 3 amall chporen.took as tabs 26 mg Bendadpyl taba,, (07:55 MJC): complain of dry mouth. PAST MEDICAL HISTORY MEDICAL HISTORY (Sun Aug 19 2007 01:34 MEA): History of pulmonary disease, htcluding astinna.. SUMGlCAL HISTORY (Sun Aug 19 2007 01:34 MEA): D and C K3.. PSYCHIATRIC HISTORY (Sun Aug 19 2007 01:84 MEA): History of depresqlon,, SOCIAL HISTORY (Sun Aug 19 2007 01:84 MEA): Patient emokes tobacco, Denice consumption of atoohol, Lives at homme with family.. NOTES (Sun Aug 19 2007 0t34 MEA): Nursing records reviewed.. MEDICAL HISTORY (02:44 MJC): History of pulmonary disepae. Inotuding asthma. PSYCHIATRIC HISTORY (02:44 MJC): No history ofdepression, homfoidal ideation, schizophrenia, History of suicidat idention, History of suicide attempta, SOCIAL HISTORY (02:44 MJC): Denies alcohot abuse, drug abuse, Petlest emakes tobacco. NOTES (02:44 MJC): Nursing records reviewed, Agree w(th nursing records. PHYSICAL EXAM (O2:47 MJC) Prepueæ w Aea so toot e aw cwee e &ckwe N. Page 1at + FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 86 RECEIVED NYSCEF: 01/10/2019 EllRI111551111115 HIIIIIIIIIIHIIIII SOUTHSIDE HOSPITAL PHYSICIAN HIGHLIGHTS RECORD CONSTITUTIONAL; Patient Vflal fe afetnile, q(gns reviewed, Patient has normal pulse, Patient has normal blood pressure. Patient has normal respitc|ply rele, Welf appearing, Patient appears comfortable, Alertand oriented X 3, HEAD: Atraumallo, Normooephah EYES: Sciere are normal, Conjunctiva are normal. NECK: Normal ROM, No jugglar venous distent¾ No meningeal signs, Cervical spine nontender. RESPIRATORY CHEST: Chest isnon-tender, Breath sounds nonnel, No respiratory distress. CARDIOVASCOLAR: MRR, No murmur, No rub,No gallop. ABDOMEN: Abdomen is nontender, No masses, Bowel sounds normal BACK: There isno tenderness to palpation, Normal Inspection. NGURO: GCS is 15, No focal motor deficite,No focal sensory deficits,Cranial nerves Intact,No cerebe ar deficits,Nomial DTRs, Horizontal nystagmus presesit in the left eye,Horizontet nys tagmus present in the right eye, SKIN: Sldn iswarm, Skinlsdry, Sidn is normal color. PSYCHIATRIC: Oriented X 3, Nor mal affool,hgement and Insightnormal, No complaint of suicidalideation, No complaint ofhomicidal ideation, able tosimile and laugh, during evaluation. ESULTS LABORATORY pt18 MJG): R Auq19 200 weo ae rHoustouM 4M0,a RED CELLS 4A7 MWCM 4AWRO . HEMOGLOBIN 18E GWDL . . 12.0-10E MEMATOGRIT 40 % 37·S-47-0