Carlson Records — USA v. Jittaphol (Dkt. 34-2, D. Mass.)

Record facts

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Case 1:21-cr-10270-MLW Document 34-2 Filed 01/28/22 Page 1 of 15
From:
01/20/2022 15:14 #871 P.004/019
CARLSON RECOVERY CENTER
January 14, 2022
Helping individuals, families and communities improve the quality of lives
for those with behavioral health and developmental challenges.
bhn
CARLSON RECOVERY CENTER
471 Chestnut Street
Springfield, MA 01107
Voice: 413-733-1431
Facsimile: 413-272-1960
www.bhninc.org
Aticha Jittaphol
DOB: [redacted]
[Stamp, printed reversed: CONFIDENTIAL]
To Keith Halpern:
Per your request, I am writing this letter regarding Aticha's Federally mandated
admission on 12.06.2021. She formulated treatment goals including taking better care of her
health and mind by refraining from methamphetamine use, stopping methamphetamine use as
it interfered with her work and personal life and discharging to Hope Center CSS even though
she would rather not but she wanted to cooperate with her mandate.
She attended psychoeducational groups once she felt better and noted how moved she
was by the life stories her peers shared. Aticha was polite, cooperative and participatory as
reflected through her verbiage and demeanor. She successfully discharged to The Hope Center
CSS on 12.13.21.
Sincerely,
[signature, followed by handwritten "MSLADC[illegible]"]
Debi Dennis MS LADC1, Clinical Supervisor
Carlson Recovery Center
471 Chestnut Street
Springfield, Ma 01104
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Carlson Recovery Center - Detox
Discharge Nursing
Session Information
Client: Jittaphol , Aticha (260293) [redacted]
Staff: Epps, Tashonda (010063)
Document Date: 12/13/2021
Client Program: (Not Set)
Detox Discharge Summary--Nursing
Admission Date: 12/0[illegible]/2021
Discharge Date: 12/13/2021
Did person receive methadone? [ ] Yes [x] No
Condition on Admission: cows=0
Medications Person being discharged with: spironolactone 100mg
Type of Discharge: Routine
Administrative Review needed for future Admission to Detox? [ ] Yes [x] No
Details on Administrative Review:
Condition at Discharge: client denies withdrawal symptoms
Other Notes/Comments:
Goals Addressed
No goal(s) addressed were chosen
Goals Addressed: nursing goals addressed
Signatures
Signature #1: Tashonda Epps (No Primary Credential) - 12/13/2021 2:38 PM
Signature #2: Alison TellierFox (Registered Nurse) - 1/4/2022 5:02 AM
Signature History
Action | Date | Staff
Document Signed | 12/13/2021 | Tashonda Epps (No Primary Credential)
Document Signed | 1/4/2022 | Alison TellierFox (Registered Nurse)
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Carlson Recovery Center - Detox
Nursing Assessment
Session Information
Client: Jittaphol , Aticha (260293) [redacted]
Staff: Schulz, Ronald (007144)
Document Date: 12/6/2021
Client Program: (Not Set)
Detox Nursing Admission Information
Date/Time : 12/06/2021 04:30 PM
Chief Concern: withdrawal
Degree of Intoxication on Admission: Mild
Previous Admission: [ ] Yes [x] No
Medical Information
Seizures: [ ] Yes [x] No
Chronic Illness: [ ] Yes [x] No
Diabetes: [ ] Yes [x] No
Allergies: NKDA
Injury/Illness: denies
HCG Test? [ ] negative [ ] positive
Last Menstrual Period:
Past Medical History: On hormone replacement therapy for transitioning male to female
Medication, Dosage, Route and Times per day: spironolactone 100mg PO BID
Social History
Domiciled: [ ] Yes [x] No
Employed: [ ] Yes [x] No
Tobacco: [ ] Yes [x] No
Psychiatric History
Psychiatric History:
Mental Status
Appearance: [x] Alert [ ] Disheveled [ ] Lethargic [ ] Makes Eye Contact [ ] Older Than Stated Age [ ] Poor Hygiene
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Carlson Recovery Center - Detox
Nursing Assessment
[ ] Stuporous [ ] Well Groomed [ ] Younger Than Stated Age
Speech: [x] Clear [ ] Delayed [ ] Excessive [ ] Incoherent [ ] Loud [ ] Pressured [ ] Slurred [ ] Soft
Oriented to Person, Place and Time/Date: [x] Yes [ ] No
Observed Affect:
Are the patient's thought processes intact? [x] Yes [ ] No
Comments:
Toxicology Screen
Opiates: [x] Negative [ ] Positive
Oxy's: [x] Negative [ ] Positive
Methadone: [x] Negative [ ] Positive
Benzodiazepines: [x] Negative [ ] Positive
Suboxone: [x] Negative [ ] Positive
Cocaine: [x] Negative [ ] Positive
Comments: + methamphetamine
Substance Use/Addictive Behavior History
Does person report a history of, or current, substance use or other addictive behavior concerns? [ ] No [x] Yes
Substance Use/Addictive Behavior History Addendum
Have you ever used | Age of First Use | Date of Last Use | Frequency | Amount | Method
Amphetamines/Stimulants | 24 | 12/5 | Daily/Multiple times/day | 1 gram | [ ] Oral [x] Smoked [ ] Inhaled [ ] Injected [ ] Other
Substance Use/Addictive Behavior Service History
[x] None Reported
Toxicology Screen Completed: [ ] No [x] Yes
+ methamphetamine
Other Addictive Behaviors: [x] None Reported [ ] Gambling [ ] Tobacco [ ] Other
Longest period of abstinence:
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Carlson Recovery Center - Detox
Nursing Assessment
American Society of Addiction Medicine (ASAM) Degree of Severity at Admission for the Following Dimensions
[ ] NA
Intoxication/Withdrawal Potential | Biomedical Conditions/Complications | Emotional/Behavioral/Cognitive | Readiness to Change | Relapse/Continued Use Potential | Recovery Environment | Family Functioning (Youth Only)
For Persons considering an Opiate Treatment Program complete this box
[x] Not Applicable
Detox Physical Health Assessment
EENT: [x] No problems reported [ ] Abnormal Pupils [ ] Blurred Vision [ ] Double Vision [ ] Cataracts [ ] Contacts [ ] Glasses [ ] Glaucoma [ ] Vision Impairment [ ] Dizziness [ ] Ear Infection [ ] Hearing Aid [ ] Hearing Impairment [ ] Tinnitis [ ] Nasal Discharge [ ] Other
Comments:
Cardiovascular: [x] No Problems Reported [ ] Anemic [ ] Arrhythmia [ ] Congestive heart failure [ ] Coronary Artery Disease [ ] Heart Murmur [ ] History of Edema [ ] History of chest pain [ ] History of heart attack [ ] Hx of Heart Surgery [ ] Hypertension [ ] Myocardial Infarction [ ] Other [ ] Pacemaker [ ] Peripheral Artery Disease [ ] Related Meds
Comments:
Respiratory: [x] No Problems Reported [ ] Asthma [ ] Bi-pap machine [ ] Bronchitis [ ] C pap machine [ ] COPD [ ] Emphysema [x] History of Smoking [ ] Inhalant use [ ] Other [ ] Pneumonia [ ] Shortness of breath with minimal effort [ ] Smoker--Current [ ] Steroid dependent [ ] Tuberculosis [ ] URI [ ] Wheezing
Comments: smoking methamphetamine
Gastrointestinal: [x] No Problems Reported [ ] Constipation Bowel Pattern [ ] Diarrhea [ ] Diverticulitis [ ] Duodenal Ulcer [ ] Gas
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Carlson Recovery Center - Detox
Nursing Assessment
[ ] Nausea [ ] Other [ ] Pain [ ] Peptic Ulcer [ ] Vomiting
Comments:
Hepatic: [x] No Problems Reported [ ] Cirrhosis [ ] Hepatitis A [ ] Hepatitis B [ ] Hepatitis C [ ] Other
Comments:
Genito-Urinary: [x] Deferred
Comments:
Musculoskeletal: [x] No Problems Reported [ ] Abnormal Gait/Coordination [ ] Arthritis [ ] Back Injury/Surgery [ ] Cramping [ ] Hx of Fractures [ ] Muscle Aches [ ] Other [ ] Spinal Deformity [ ] Stiffness [ ] Weakness
Comments:
Skin: [ ] No Problems Reported [ ] Acne [ ] Burns [ ] Color [ ] Eczema [ ] Fungal Infection [ ] Infection at Injection Site [ ] Injection Site [ ] Lesions [ ] Moist [ ] Other [ ] Piercings [ ] Psoriasis [ ] Rash [x] Tattoos [ ] Temp [ ] Wounds
Comments:
Neurological: [x] No Problems Reported [ ] Alzheimer's [ ] Decreased sensitivity [ ] Delirium Tremens [ ] Dementia [ ] Distractible [ ] Dizziness [ ] Epilepsy [ ] Headaches [ ] History of Head Trauma [ ] History of Stroke/ TIA [ ] History of loss of consciousness [ ] Migraines [ ] Other [ ] Paralysis [ ] Syncope [ ] Tremors [ ] Weakness
Comments:
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Carlson Recovery Center - Detox
Nursing Assessment
Endocrine: [ ] No Problems Reported [x] Hormone Therapy [ ] Hyperthyroid [ ] Hypothyroid [ ] Other [ ] Type I Diabetes [ ] Type II Diabetes
Insulin Dependent? [ ] Yes [ ] No
Comments: Male to female transition
Nutrition: [x] No Problems Reported [ ] Appetite Decreased [ ] Appetite Increased [ ] Dietary Needs [ ] Food Allergies [ ] Other [ ] Supplements Taken [ ] Weight Gain [ ] Weight Loss
Comments:
Sleep: [ ] No Problems Reported [ ] Daytime Napping [ ] Difficulty falling/staying asleep [x] Insomnia [ ] Other [ ] PRN/OTC Meds Used [ ] Restless [ ] Reverse Sleep Cycle
Comments:
Detox Risk Assessment
What are your plans after detox? work with probation
How would you describe your mood now? okay
Are you currently suicidal? denies
Have you recently had suicidal ideation or self-harming behaviors? [ ] Yes [x] No
Do you feel safe now? yes
Have you recently tried to kill yourself? : [ ] Yes [x] No
In the past have you ever tried to kill yourself? [ ] Yes [x] No
Are you currently hearing voices that are telling you to hurt yourself or others? denies
Is there anything going on on the outside that could make you feel suicidal? denies
Have you had problems controlling your anger around other people? [ ] Yes [x] No
Have you ever engaged in violent behavior, or hurt others physically? denies
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Carlson Recovery Center - Detox
Nursing Assessment
Have you ever been discharged from a program like this one due to your behavior? : [ ] Yes [ ] No
Recommendations:
Based on the information gathered, the patient will be: [ ] Recommended for an EATS bed [x] Recommended for straight detox [ ] Sent to ED for further evaluation
If patient is not safe for admission, was patient sent to ED? [ ] Yes [ ] No
Other Information:
Client DSM Diagnosis as of 12/6/2021 04:57 PM
Client: Jittaphol , Aticha (260293) [redacted; the last characters are not legible]
Effective Date/Time: 12/6/2021 04:57 PM
External Diagnosis: No
Diagnosed By: Schulz, Ronald (007144)
Comments:
Diagnosis
DSM-5 | Severity/Specifier | ICD-10 | SNOMED | Comments
F15.20 - Stimulant Use Disorder, Severe, Amphetamine-type substance | | F15.20 - Other stimulant dependence, uncomplicated | 442406005 |
The Diagnoses above display in priority order.
Psychosocial and Contextual Factors
ICD-10 Code - Description | Comments
Z64.4 - Discord With Social Service Provider, Including Probation Officer, Case Manager, or Social Services Worker |
Diagnostic Formulation
No records found.
Signatures
Signature #1: Ronald Schulz (Registered Nurse) - 12/6/2021 5:06 PM
Signature History
Action | Date | Staff
Document Signed | 12/6/2021 | Ronald Schulz (Registered Nurse)
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Carlson Recovery Center - Detox
Nursing Progress Note
Session Information
Client: Jittaphol , Aticha (260293) [redacted]
Staff: Schulz, Ronald (007144)
Document Date: 12/6/2021
Client Program: (Not Set)
Detox Nursing Progress Note
Date/Time: 12/06/2021 05:00 PM
Details: 32 year old female admitted for detox from methamphetamine from federal probation
Utox positive methamphetamine only
Med hx Hepatitis B
psych hx - anxiety
Client is on spironolactone 100mg PO BID (client brought) and estrogen patch (client did not bring)
MassPAT - nothing
Client currently on no protocol as they are here for methamphetamine only-RSRN
Signatures
Signature #1: Ronald Schulz (Registered Nurse) - 12/6/2021 5:12 PM
Signature History
Action | Date | Staff
Document Signed | 12/6/2021 | Ronald Schulz (Registered Nurse)
Jittaphol , Aticha (260293)    1 of 1    Date Printed: 1/20/2022 12:39 PM
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Carlson Recovery Center - Detox
Nursing Progress Note
Session Information
Client: Jittaphol , Aticha (260293) [redacted]
Staff: Owusu, Sonia (010062)
Document Date: 12/7/2021
Client Program: (Not Set)
Detox Nursing Progress Note
Date/Time: 12/07/2021 04:59 AM
Details: Signs of life check completed. Sleeping during rounds. will continue to monitor
Signatures
Signature #1: Sonia Owusu (No Primary Credential) - 12/7/2021 4:59 AM
Signature History
Action | Date | Staff
Document Signed | 12/7/2021 | Sonia Owusu (No Primary Credential)
Jittaphol , Aticha (260293)    1 of 1    Date Printed: 1/20/2022 [rest of the line cut off at the bottom edge of the page]
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Carlson Recovery Center - Detox
Nursing Progress Note
Session Information
Client: Jittaphol , Aticha (260293) [redacted]
Staff: Bernazki, Sandra (003436)
Document Date: 12/8/2021
Client Program: (Not Set)
Detox Nursing Progress Note
Date/Time: 12/08/2021 03:28 AM
Details: Signs of life checks being completed. Assessed for wd sx throughout the night. Offers n/c. Observed resting in bed. Will continue to moniter.
Signatures
Signature #1: Sandra Be[illegible]azki (LPN) - 12/8/2021 3:28 AM
Signature History
Action | Date | Staff
Document Signed | 12/8/2021 | Sandra Be[illegible]azki (LPN)
Jittaphol , Aticha (260293)    1 of 1    Date Printed: 1/20/2022 12:39 PM
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Carlson Recovery Center - Detox
Nursing Progress Note
Session Information
Client: Jittaphol , Aticha (260293) [redacted]
Staff: Be[illegible]azki, Sandra (003436)
Document Date: 12/9/2021
Client Program: (Not Set)
Detox Nursing Progress Note
Date/Time: 12/09/2021 01:48 AM
Details: Signs of life checks being completed. Assessed for wd sx throughout the night. Offers n/c. Observed resting in bed. Will continue to moniter.
Signatures
Signature #1: Sandra Bernazki (LPN) - 12/9/2021 1:49 AM
Signature History
Action | Date | Staff
Document Signed | 12/[illegible]/2021 | Sandra Bernazki (LPN)
Jittaphol , Aticha (260293)    1 of 1    Date Printed: 1/20/2022 12:39 PM
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Carlson Recovery Center - Detox
Nursing Progress Note
Session Information
Client: Jittaphol , Aticha (260293) [redacted]
Staff: Be[illegible]azki, Sandra (003436)
Document Date: 12/10/2021
Client Program: (Not Set)
Detox Nursing Progress Note
Date/Time: 12/10/2021 02:25 AM
Details: Signs of life checks being completed. Assessed for wd sx throughout the night. Offers n/c. Observed resting in bed. Will continue to moniter.
Signatures
Signature #1: Sandra Be[illegible]azki (LPN) - 12/10/2021 2:27 AM
Signature History
Action | Date | Staff
Document Signed | 12/10/2021 | Sandra Bernazki (LPN)
Jittaphol , Aticha (260293)    1 of 1    Date Printed: 1/20/2022 12:39 PM
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Carlson Recovery Center - Detox
Nursing Progress Note
Session Information
Client: Jittaphol , Aticha (260293) [redacted]
Staff: Owusu, Sonia (010062)
Document Date: 12/11/2021
Client Program: (Not Set)
Detox Nursing Progress Note
Date/Time: 12/11/2021 04:16 AM
Details: Signs of life check completed. Sleeping during rounds. will continue to monitor
Signatures
Signature #1: Sonia Owusu (No Primary Credential) - 12/11/2021 4:1[illegible] AM
Signature History
Action | Date | Staff
Document Signed | 12/11/2021 | Sonia Owusu (No Primary Credential)
Jittaphol , Aticha (260293)    1 of 1    Date Printed: 1/20/2022 12:39 PM
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Carlson Recovery Center - Detox
Nursing Progress Note
Session Information
Client: Jittaphol , Aticha (260293) [redacted]
Staff: Jackson, Bethany (008786)
Document Date: 12/12/2021
Client Program: (Not Set)
Detox Nursing Progress Note
Date/Time: 12/12/2021 04:16 AM
Details: Client in for crystal meth, client resting in room, safety checks completed, will continue to observe
Signatures
Signature #1: Bethany Jackson (LPN) - 12/12/2021 4:17 AM
Signature History
Action | Date | Staff
Document Signed | 12/12/2021 | Bethany Jackson (LPN)
Jittaphol , Aticha (260293)    1 of 1    Date Printed: 1/20/2022 12:39 PM


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