Document NLq5dq1BYMVYoD7Xn6x9N73E

"BSNfle DOE WO ncOF MMS9V 1383686 04/23/92 mBimamacm N NN ?mORAMSSCN --r c o pe .mas 12s30 03/31/92 P I ph >s oooe ease HOGRSSM PI TYPE oesrtwBHOXE PRIOR SOURCE HBB*VL SOURCE ac c o en t cestBPnew E*MAYO ET AL wren h me psi; f u s e m) a m> ag g r es s 62305S N MED S R MS s R RA AGE BRIHEWE NON ACCIDENT BRtmJCE REDACTED ' h o n e INOTFY M OSE OF BBtteKY- NJ 07110 es oooe 0716 SS NO RBARCM MIN reuse* CAT 63 07/17/1923 , NEW JERSEY a*j*3t /}^0/Asyw fay/ft' CATHOLIC ET AL S< NO REG *** RETIRED HOME PHONE WJUBER YCFK PHONE HO WIFE RELATION HOME FHONl NUMBBA YCFK PHOTS NO | A0MTTN3 wmoss . "; WIFE "iANEMIA/G. I. BLEEDING IauwMnon|A^msi;M}ANOADonESs r el at on SELF occuram FHune. . ssnol RETIRED FLAN NAME GfiOUPNQ PROVIDENT LIFE= \\ ' \ 15S2C33776i 1. 25 MERCHANT ST.3/100 CINCINNATI OH AARP-PRUDENTIAL 28611907-1 P.O. BCX 13999 PHILADELPHIA CKC0C6 573.9 GUARANTOR'S BAPUXW SHERWIN WILLIAMS CO. :LISTER AVE NEWARK ' NJ 07105 "Q* 201-344-7(g00f ft Vs t t f . Bfcl iar4^n JO 'Mv) . . _____-530.0 .. 0,s\ i ^ " vi %*#*** [REMARKS: AD? NO. T|\Fo REQUESTED 0Xs> djtvw/ kXlEN " NAME: UP'o S : As OQM/BED: If IND: iOP: M. iDDRESS: CCC1 31190A N 07/17/1923 *-#**ADM I S3 i ON'S FORM***^ AGE: 63 ir FI'AT lEMT Nij NED RtC Ni: HU9F' SY _ ' P" TVF'E >' Clt& r <r-\>:. - \ 1 JjME: DRESS: STY: k ATE : UpDNE: $1: _. ILATION: SELF |--NEXT OF KIN INFQ------------- ! 1 '< RELATION: &PKONE: 000-000-0000 MAIDEN NAME: AN'^LlF' I .~'_1*_i---------------------------- 0CCUPA7 ON: VP|_ WANE: EM-'L ADL'R: EX?L CI~Y: Ev-F"_ S~A7: E/EL -'-OLE: ---------- EMERGENCY CON"A-1' NAME: RELA" I ON: -'HOSE: NAME : J.L/GRP NO: IBBSCRIBERs IS CO ADD: 1 PROVIDE!*' " fhis CO PH: I'lAN NAME : PL /GRP NO: SCRIBERt fc:0 ADD: Cl NO INNA! I 0- 425^-6 800-67 ~^-309 il `S; ij u Ph : [RECERT NO: fjiJNCOMPENSATED CARE CHECKLIST .tf NOTIFIED: DSP PAID: INTERVIEW: REF/UNAB: : IP SHOWN: 3RD PARTY: P REQUESTED: GAN DONOR: ST ADN DT: A-T. CODE: N 04/23/92 N IttN DATE: 07/09/92 10:10 3M DR: 795930 ORSINI ET AL FN DR: 795-930 ORSINI ET AL |M DX: SEVERE ANEMIA -MARKS: UCCC PRR COPY " RE--A-. : i I-*: READ/x T LAST DS ACCIDEN ADM PRI ADM SOU REF SOUR L-D HLV PAT CLERK: ADM CLERK*- PB02 10:11 07/09/92 FROM TD13ADNGADFi 0007-SWP-005803089 CONFIDENTIAL ||' Sf. . v: MED REC #: 068834 CLARA I*AASS MEDICAL CLN ! E.R f INICAL RECORD ABSTRACT BILuiNG #: 5383686. NAME' REDACTED ADM DATE: ADM HOUR: ADM CLASS: REF SOURCE: REF HOSP ID: 04/23/92 07:51 K RA DSCH DATE: DSCH STS: DSCH DISC: THN DEST: ICU DAYS: 04/26/92 A HR 000 ATN PRYS: ]-!0$d SVC: C'T Type; FC: TTC;pl |C; DL MAYO t MEEi C; : VS:: '-} I ," /I; fe`. BIR7 HD ATE 07/17/192S B. W. 0 SEX M RACE 1 y c- r - p'-l. tf*****#*****###-*-**-*# 1 AGNOSES7 PROCEDURES> AND CONSULTS* **** * jjf TYPE CODE DESCRIPTION DA - E - V - CIO 042392 ; c* t' i DA ANEMIA NOS 042392 623058 OF ANEMIA NOS 042692 623058 PC 99. 04 PACKED CELL TRANSFUSION 042/92 i*"i**'!***!( PC 92.04 GI SCAN ?< ISOTOPE FVNCT 623058 -v->, iHCPC: DRO NO: 395 TYPE DATE DRO RATE 3360.20 LOS DAYS CERT O'J ! L-1 b-R I ^ k' DAYS TYPE DATE DAYS TYPE DATE DAYS TYPE ' DATE f DAYS l I CERTIFY THAT THE NARRATIVE DESCRIPTIONS)0 DIAGNOSES AND THE MAJOR PROCEDURES HE Si THE BEST OF MY KNOWLEDGE. SIGNATURE: ________________ THE PRINCIPAL AND SECONDARY liRE ACCURATE AND COMPLH JATE: Clj _Jb_______ DATE *v.cr.,\ ,i,i /oo /oo trot-.M rron . md a t t .: 0007-SWP-005803090 CONFIDENTIAL N41657.02 t REDACTED . CLARA NAASS-MEDICAL CENTlL Franklin Avenue Belleville, Hew Jersey FINAL SUMMARY NAME: DATE OF ADMISSION: 4/23/92 MR#: 068834 PHYSICIAN: J. DE MAYO, M.D. DATE OF DISCHARGE:l|c'\ 'L* This 63-year-old white male was admitted to the hospital on 4/23/92 because of severe anemia. The patient has a long history of having had anemia. He has been worked up on numerous occasions and he does have a long history of GI bleeding. He had received several units of blood and his hemoglobin continues to drop down. He had a Billroth II, two times. He has had numerous bouts of GI bleeding and has chronic gastric ulcers. On examination, the patient was markedly pale, weak and complained about abdominal pain. His hemoglobin was low at the office and the patient was advised that he needed admission for blood transfusion. The patient received two units of packed cells, when his hemoglobin was noted to be 5.9. Dr. Orsini and Dr. Scoppetuolo were called in consultation. He had a bone marrow done and this showed a normocellular biopsy. His other tests included a GI bleeding scan with RBC tag. There was a negative GI bleeding scan reported and failed to show any active bleeding area at this time. The patient had other tests done including total iron. The folate acid level was 18.3. His iron binding capacity was 233, which was low. His saturated iron was 94, which was somewhat high. The patient had been taking iron at home. His ferritin was 2,073, which is elevated. His B-12 was 902, which was in the normal range. The patient also had other tests done, including hemoglobin and hematocrit which showed a hemoglobin of 5.8. He had la giant platelet count. His hematocrit was 18.6. , The patient received several units of packed ^BC's and his hemoglobin came up to 8.9, with a hematocrit of 27. platelets were normal. The The patient continued to have some weakness. His abdominal pain seemed to be better. His stool for occult blood was negative. The patient, after being seen by Dr. Scoppetuolo and his group, was discharged home. He will be referred to the Hematology Clinic at the Medical School where he will be worked up for other CONTINUED. .. FINAL SUMMARY 0007-SWP-005803091 CONFIDENTIAL N41657.03 CLARA HAASS MEDICAL CENTER Franklin Avenue Belleville, New Jersey REDACTED FINAL SUMMARY NAME MR#: 068834 PHYSICIAN: J. DE MAYO, M.D. % Page 2 \ possible causes of his anemia which should also include the possibility of a red cell dysplasia which is the most likely diagnosis. The patient is well aware of his diagnosis, also of his further evaluations. He has already had a complete upper GI and lower GI evaluation with no help. The patient requested that he be discharged home so that he could set up an appointment with the Hematology Clinic and get further testing done. Cassette #6380 ly I FINAL SUMMARY 0007-SWP-005803092 CONFIDENTIAL Clara Maass Medical Center BELLEVILLE, N.J. i c Ib b KH C b S J 3 4 I PAST HISTORY: /? / , / '~7~ SOCIAL HISTORY: FAMILY HISTORY: 1 Clara Maass Medical Center BELLEVILLE, N.J. PHYSICAL FINDINGS: Head: Eyes: Ears: Mouth, Throat: Neck: Chest: REDACTED 1 ;^;bib m L-bbo3H / 1 I / 1 S ; G 6 3 M .-f. ? / V 0 L 7 A L r r v *> ' ^ f- ! I V. 1 *' *- l IMPRESSION: l' CONFIDENTIAL CLARA MAASS MEDICAL CENTER Franklin Avenue Belleville, New Jersey Report of Consultation NAME : DATE : 4/23/92 DATE REQUESTED : REPORT REQUESTED REGARDING MR# 06-88-34 ATTENDING PHYSICIAN CONSULTING PHYSICIAN ROOM# DR. J. DE MAYO DR. M. SCOPPETUOLO SIGNATURE OF ATTENDING PHYSICIAN M.D /a The patient is a 63-year-old white male whom we are asked to see in consultation regarding severe anemia. The patient's history dates back to approximately 10-15 years ago when he underwent a Billroth II surgery for peptic ulcer disease. The patient has been stable up until recently when he was found to have severe anemia approximately four to six weeks ago. He was admitted to Clara Maass Medical Center and underwent a bone marrow that was essentially normal with good iron stores. The patient also was transfused at that time and had a workup that included Bl2 and folate levels that showed adequate levels. An upper endoscopy apparently was performed that was negative. He was well and was discharged home in a stable state. He was readmitted back into the hospital at this point when his hemoglobin had dropped down to 7. He was seen as an outpatient, and it was felt that the concern .was that the patient may be having some GI bleeding. He thusly was admitted to the hospital for a bleeding scan. We are asked to see the patient in regard to concurrent care. He denied any vibratory or sensory deficits in the lower extremities and denied any positional or cerebellar complaints at this point. PAST MEDICAL HISTORY was significant for his Billroth II fok peptic ulcer disease. He carries a history of chronic gastric ulcers. MEDICATIONS: Zantac alone REVIEW OF SYSTEMS: As contained in his HPI. ALLERGIES: He denied any allergies to medications. PHYSICAL EXAMINATION: HEENT: Pale conjunctivae. No palpable lymphadenopathy. Lungs: Clear. Heart: Normal SI and S2. Abdomen: Soft. No masses or organomegaly. Neurologic: Intact. All laboratory studies are pending at this time. 0007-S WP-005803095 CONFIDENTIAL N41657.05 ASSESSMENT: Severe anemia, possibly secondary to gastrointestinal bleeding. Also must rule out the possibility of B12 deficiency or early myelodysplastic syndrome or red cell aplasia. PLAN: GI bleeding scan, B12 level, iron levels. The possibility of the need for a colonoscope must be considered or an upper endoscopy if this was not previously done. We will await reports of his blood work before deciding on any need for any transfusion, etc. I' > 0007-SWP-005803096 CONFIDENTIAL NO TRANSPORT: YES: YEAH __ 02 N VENT 1N : N IA EXAMINATION REQUESTED: DIAGNOSIS: GI BLEED ANEMIA/G.I. BLEEDING ROUTIN 07/17/1928 f 383 DE MAYO ET HISTORY AND CLINICAL INFORMATION (PLEASE GIVE BRIEF CLINICAL HISTORY AND IMPORTANT PHYSICAL FINOINGS:) NO REQUEST ACCEPTED WITHOUT CLINICAL INFORMATION BY M O. SEX M % 2N 02620A...... NJ 07110 63 AL -m-- IS PT. PREGNANT? IS PT. NURSING? N -h G.I. BLEEDING RBC TAGGED ORDER NO: REQUESTED BY: REPORT DE MAYO ET AL G. I. BLEEDING , M.D. DATE April 23, 1992--vc. A G. I. Bleeding study was performed today on your above named patient, following the intravenous administration of 21.5 mCi of Tc labeled pertechnetate after the patient had received 6 mgm. of sodium pyrophosphate, containing 1.7 mgm. of stannous chloride with in vivo labelling of the red cells. Serial images were performed every 5 mins, up to 1 hr. as well as a dynamic flow study, which showed an increased hyperemia throughout the spleen, which appeared to be significantly large. Aside from that there was no evidence of extravasation or any unusual vascular markings. The static images failed to show any collection in the abdomen which appeared to be extraluminal, and therefore excluding the possibility of a active bleeding. In the delayed image performed 4 hrs. later, again failed to show any evidence of active bleeding. N IMPRESSION: NEGATIVE G. I. BLEEDING SCANL-fAitiNG-TO-SHOW-ANY--AGTf-VEtBLEEDING AREA. /W DEPARTMENT OF NUCLEAR MEDICINE CLARA MAASS MEDICAL CENTER BELLEVILLE, NEW JERSEY 07109 4 ,. M. D./vc ^. 0007-SWP-005803097 CONFIDENTIAL MBF^REV. 1/92 N41657.06 MED REC #s 068834 CLINICAL RECORD ABSTRACT BILK NG #* 1373075 NAME: REDACTED ADM DATE: ADM HOUR: ADM CLASS: REF SOURCE: F;EF HOSP ID: 03/31/92 12:43 R RA DSCHDATE: *04/06/ 92 DSCH STS: A DSCH DISH: HR TRN DEST: ICU DAYS: 000 ATN PHYS HOSP SVC: PT TYPE: PC*. TISSUE: DE MAYO ET AL MED C' I INSl: I IN32: 0 3L00D: I BIRTHDATE 07/17/1928 B.W. 0 SEX M RACE 1 ZIP 0C'llO RES CODE 0716 *******************DIAGNOSES PROCEDURES AND CTJNSULTS*-***#****#*#*#*'#**#-*'--^-!-'*-? TYPE CODE DESCRIPTION DATE PHYS C01 033192 841916 CIO 040192 795930 DA 535.10 ATROPHIC: GASTRITIS 033192 623058 DF 5:35. 10 ATROPHIC GASTRITIS ~ ' 040692 623058 DF 5:35.40 GASTRITIS NEC 040692 623058 DF 280.0 CHR BLOOD LOSS ANEMIA 040692 6*23058 DF 414.0 CORONARY ATHEROSCLERQSIS 040692 623058 PC 45. 13 SM BOWEL ENDOSCOPY NEC 040392 841 S' 16 PC 41.31 BONE MARROW BIOPSY 040192 795930 PC 99. 04 PACKED CELL TRANSFUSION 040192 623058 HCPC: DRG NO: 182 DRO RATE 3454.21 LOS 6 DAYS CERT 0 OUTLIER 2ND: TYPE DATE DAYS TYPE RE VI EWS*******-*HH*-***# DATE DAYS TYPE DATE DAYS TYPE QATE DAYS 1 I CERTIFY THAT THE NARRATIVE DESCRIPTIONS: DIAGNOSES AND THE MAJOR PROCEDURES P THE BEST OF MY KNOWLEDGE. SIGNATURE: ____________________________ RINGIPAL AND SECONDARY CURATE AND COMPL DATE: 0007-SWP-005803099 CONFIDENTIAL 11: 11 04/10/92 FROM TC:30,MRATT 1 <9 N41657.08 r edac t ed JLARA HISS MEDICAL CENTER Franklin Avenue Belleville, New Jersey FINAL SUMMARY NAME: , MR#: 068834 PHYSICIAN: J. DE MAYO, M.D. DATE OF ADMISSION: Z- DATE OF DISCHARGE: q ^ This 63-year-old white male was admitted as an emergency because of suspected G.I. bleeding. The patient had been at home and having some problem with his blood count. He came to the office appearing quite pale and feeling weak. He had been on iron for over a year and had not been seen in our office for over a year also. The patient has a history, prior to this, of having some G.I. bleeding and anemia. He was treated with iron and had a workup which was not conclusive other than the fact that he had a past history of having had two surgical procedures for bleeding ulcers. Upper G.I. showed that he had a Billroth II which seemed to be functioning and he had no signs of bleeding at that time. It was felt, at this point, that the patient may have some chemical problem which may be causing some bone marrow suppression. The patient had been working Sherman Williams, a paint company and was in contact with Benzine and other chemicals. Because of this, the patient will have a bone marrow before any further testing is done. The patient is also to be seen by Dr. Rizvi, gastroenterologist who worked out the possibility of having some kind of G.I. hemorrhage. The patient, other than his G.I. problems has had no other problem other than his anemia, and having received several blood transfusions, having two surgical procedures for his G.I. bleed. The patient's workup in the hospital, when he was admitted, included blood work and urinalysis. The urine was totally negative. There was no sign of any blood or bleeding in it. He had a stool for occult blood which also came back negative. His hemoglobin, at the time of admission, was 6.1 with a white count of 12.3, platelets 5B7. His differential showed 68 polys, 2 bands, 23 lymphs>1# 1 mono and 4 eosinophils. He had anisocytosis of 3+, poikilocytosis of 2+, polychromia 2+. Toxic granulation of the platelets appeared increased. Basophilic stippling was also present. The patient's subsequent hemoglobins were 6.8 and went down to 5.8. At that point, it was felt that the patient could not wait any longer and he had a blood transfusion. Prior to the transfusion, he had a bone marrow done and his hemoglobin then went up to 9.2 and eventually came down to 8.7 and prior to his discharge, it was at 7.8. The patient's reticulocyte count was CONTINUED___ FINAL SUMMARY 0007-SWP-005803100 CONFIDENTIAL N41657.09 / REDACTED CLARA MAASS MEDICAL CENTER Franklin Avenue Belleville, New Jersey FINAL SUMMARY NA"Ei MR#: 068834 PHYSICIAN: J. DE MAYO, M.D. Page 2 1.2, 1.3. His platelets remained somewhat elevated. Testing revealed that his potassium was slightly elevated and the patient was not on any potassium. Repeat showed that it came down to 5.0. His glucose was 115. His LDH and SGOT were slightly elevated at 257 and 68 respectively. Repeat showed a sodium was normal. Potassium was also normal. His hemoglobin continued to remain at the 8.0 level. His ferritin level was 2,910 which is markedly elevated. His iron binding capacity was 235 which is somewhat low. His iron saturation was 96, which was also high. His vitamin B-12 level was 884. His serum iron was 226, which is also on the high side. The patient had been taking iron. He was also given some Vitamin B-12 injections. The patient had a PSA done which was .2. His endoscopy was not revealing for any bleeding at all. The patient's bone marrow will be reviewed by Dr. Orsini and Dr. Scoppetuolo. His repeat blood work is not back as yet, but the patient was very anxious and would like to go home. Since no further testing is being done at this time, it was decided that the patient could be discharged home, today, 4/6/92, and he will be followed up in the office as an outpatient, on Wednesday, two days from now and he will be given his blood work at that time to re-evaluate, as well as to re-evaluate what is going on with his blood work at this point. The patient is well aware that the diagnosis is not conclusive as of yet and that his blood work is not conclusive and we will be doing further testing as an outpatient. He would prefer that rather than staying in the hospital and doinc^ further studying. FINAL DIAGNOSIS: 1.) Anemia, unknown etiology. 2.) Chronic gastritis. 3.) Rule out any further hematological prob 4.) Status post G.I. bleed. J. DE MAYO, JD/aks SecrePhone DD: 4/6/92 DT: 4/7/92 Cassette #6564 FINAL SUMMARY 0007-SWP-005803101 CONFIDENTIAL Clara Maass Medical Center BELLEVILLE, N.J. DATE OF ADMISSION: ALLERGY: LMP: ! t> REDACTED Lbfc834 i J f! [4 v , - , *' , SOCIAL HISTORY: O^r- ^ FAMILY HISTORY: / -iV"? \ Clara Maass Medical Center BELLEVILLE, N.J. i:qq { qp REDACTED L;bt.ii34 i Breasts: h Cardio-Vascular: r? i Abdomen: Genlro-Urinary: ,,_ y // Skin: faiAsCAL Extremities: Reflexes: Rectal: (if indicated) iPelvic: (if indicated) I fr IMPRESSIONS *6/ J 7 *% <** / L' i w A6tAb 0007-S WP-005803103 CONFIDENTIAL Kf i/A vf' F , M.D. PWV^ICAI FYAMIMATIOW DATE: 0 tfVTT Ak> ?M? H , -tolU^rfL , t-iti' /'O S-^7. <i $ -{jL*u j ^i/j Clara Maass Medical Center 03? 1^2 K cKr/lA<vjv fROM: ATTENDING PHYSICIAN 7/ I" (Ar <</ 7 lP U TO: CONSULTING PHYSICIAN REPORT REQUESTED REGARDING: REDACTED DATE: I ^*1 ' ll-t ^ 0bB83H Vr/Tr/CD H nr h /v'* t? /* l nr i-v c * J M. Pd)2X &i. i if fr.f .f.% CONSULTATION ONLY CONSULTATION AND CONCURRENT CARE TRANSFER TO', ' ULTANT'S CARE AO\ <? A i&sor*- | lr^g?c^_ ^ 3& ai fo V3 a/ ^>g^-oc^k E&ifP /<Q Vh ^ tOvt > Jy ?t V\ -y W. v4*<m'v- 'j;: ' ! . > * -f <? &yb yes? hJelj2~` fC&S-/- <^\<g <5c / ^iASr/AX, H#Xjrz*U. . ^ ]f<^j)(M efor<r<ziK* g <?. C-)<=^ ' 4-\ //4-^ Ar >PU4 ^=> X^i^jyk - ^ -<f <^0 ^ fas**- > /w^- DIAGNOSIS: 7/ RECOMMENDATIONS: /2/y^? ^ Xj u s y l y^5j*/y)o C><^ *=?J c A< sA^bcrsd&S P^CjLL SlAtZs^C-- s\ o rCf -*-*:: '-y/:."--------------'-------------------- -------------- /% /-> / 0007-SWP-005803104 CONFIDENTIAL r>m CD r edac t ed CLARA MAASS MEDICAL CENTER Franklin Avenue Belleville, New Jersey Report of Consultation 7 0 NAME: DATE: 4/1/92 DATE REQUESTED: MR# 06-88-34 ATTENDING PHYSICIAN: CONSULTING PHYSICIAN: ROOM: Dr. J. Orsinx ^ h i is a 63-year-old retired gentleman who I am asked to evaluate because of a severe anemia with a hemoglobin level of approximately 6 ix grams as reported by Dr. De Mayo. > The patient's history dates back several years ago when he had been >; evaluated for an anemia with a complete gastrointestinal evaluation by > Dr. Rizvi that included an upper GI endoscopy and lower endooscopy, / according to the patient. He had been placed on ferrous sulfate since that period of time and has been comfortable up until recently when mevere weakness prompted an investigation and an evaluation had shown he hemoglobin level to be significantly low. I have now been asked to evaluate him for considerations for further evaluation and/or possible therapy. The patient's history also includes a history of anemia with peptic ulcer disease dating back ten years ago, status post surgery, on agamet and Zantac since that period of time, it appears that an ndoscopic evaluation may have been done some time in 1991 and I do believe it was done by Dr. Rizvi but this will have to be clarified. He has been having increasing epigastric discomfort with no nausea, vomiting, diarrhea or constipation being reported. His stools are always black because of the iron. f ki SOCIAL HISTORY: He has worked with a number of chemicals including benzene and asbestos as a laborer in a paint factory for some 40+ years. j FAMILY HISTORY: Noncontributory. MEDICATIONS: As stated above. PHYSICAL EXAMINATION: Finds a chronically ilkl-looking male who appears to be in some distress with vague abdominal discomfort. The temperature is low grade at 99, the blood pressure is normal 110/70. i^^The skin is sallow in color. There is no evidence of petechiae or ii^Pecchymotic lesions. The eyes, mouth and mucous membranes were . v. , ;' r. - v 0007-SWP-005803105 -* CONFIDENTIAL N41657.12 relatively negative. The lungs were clear. The heart was normal sinus rhythm. The breasts were negative. The abdomen was soft, here was no tenderness or organomegaly. His testicular examination ^^as negative. The rectal vault was empty. The prostate was enlarged approximately 1-2+. No nodularities. The reflexes and neurological examination were grossly intact. Checking laboratory tests and x-rays, none of which are available at this time, preliminary labs had indicated the anemia. Further lab tests are pending including foliate, B12, serum ferritin, PSA levels, sed rate and reticulocyte count. I will schedule him for a bone marrow biopsy and aspiration in an attempt to help find the problem. It appears that we are dealing with * some chronic intermittent problem which may be related to the GI tract. : An AV malformation may be a vague consideration and the working V, history also may be a consideration. The differential and CBC will v^jelp to ascertain this. I will complete the workup within the next -f^4-48 hours. Thank you. FINAL DIAGNOSIS: SEVERE AMEMIA, ETIOLOGY TO BE DETERMINED. AMES M ORSINI, M.D d4/l/92 i 4- t4/l/92 df 1 t' II! f. ;3r W 0007-SWP-005803106 : t CONFIDENTIAL y v* 4\i '7} *V\**.*Vv.^.' 1, DIAGNOSIS PROCEDURE 06 88 34 REDACTED s u r g e o n s Dr. Rizvi ANESTHESIOLOGIST FINDINGS GROSS: Premedication: as per anesthesiologist. PREMEOIOTION/DOSAGE ROUTE TIME EFFECT SJCrtsr*CTomO UHS/OTSWOCOTY INDICATIONS FOR PROCEDURE: Severe anemia. History of occult gastrointestinal bleeding PROCEDURE: The patient was placed in the left lateral position. The Olynpus gastroscope was advanced under direct vision to both the loops of the Billroth II anastomosis. Hie anastomosis was patent. No evidence of ulceration was noted but there was bileinduced gastritis in keeping with the diagnosis and also free reflux of bile was noted in the esophagus. The esophagogastric junction was normal. No evidence of esophagitis was seen. IMPRESSION: Patent Billroth II anastomosis. Bile-induced gastritis. Bile reflux. No evidence of ulcer or bleeding noted. The patient tolerated the procedure well and left the endoscopy rocm in good condition. WHAT WAS DONE AND SUTURE MATERIAL USEO: .. ............. ........' - ................................................................................................................................ =..................- .............. " IMMEDIATE POSTOPERATIVE CONDITION: HEMORRHAGE, SHOCK. ETC.: N41657.13 SPECIMEN: . - " ^J^BONE MARROW CYTOLOG' CELL BLOCK r edac t ed AGE SB fY) OPERATING SURGEON HfZ^ Qa A^Aa UJ PRE-OP DIAGNOSIS. l tZ- POST-OP DIAGNOSIS: o Q- Q S/'Cc{ ( *7^-- ----------- y t < CD PAST HISTORY. f7/rdZ+*.--"SU. / t*. A&S J XH 5 -------------- - ' 11 % r/1 t>'1 >- CLINICAL DATA: l iV. T. k . 003 bSn83H 1 Ll ; f" 4 71. L ^` 1t - 19D2 AUUh^.'w^----- - NATURE OF SPECIMEN: 07 |y. fr SPECIAL REQUESTS: /K^V-A^ ^ *: 2 ......... ............ .... . ..... me--* S'jtQ DATE RECEIVED PATH. NO. / -- 0&J.qiJLQJ ---- :------ QD_1QfV3----- The receptacle labeled bone marrow biopsy consists of a core of tissue that measures approximately 3h cm which is received in Bouin's fluid and the specimen is submitted in cassettes labeled A and B. i II - * MICROSCOPIC SLIDES REVEIWED: Multiple sections of the bone marrow biopsy demonstrate areas of dense cellularity with the red blood cells and white cell lines appear normally represented. Throughout there is an adequate number of platlet precursors Throughout the sections there is no evidence of atypical giant cells, granulomata or atypical cells. IMPRESSION: Bone marrow - normocellular Vide sopra. f I 4j;j;^>^PG/ld ;03^April>,-f:y'T992t4^>- -stiEaffy. N. LO CO rank-: PXGradone M.D. 0007-S WP-005803108 CONFIDENTIAL HECK: .. CH/m| itfiifCm!A w al k beo BOATABLE j OB | Oi | IV J X-RAY NO. . | COM l V ! . L l A '* NAME XAMlNATONREaUESTED^^^ y />( ^ ^ZLINPATIENT E.R. TD OUTPATIENT PAT __________________________ 1312016 *, 0b8S3H c ? / r; / s , 3 6 3 k :c cr a l l R a v0 C 7 AL ilSTORY ANO CLINICAL NO REQUEST ACCEPTED WITHOUT ^FORMATION_____________( PERTINENT CLINICAL INFORMATION ) ADDRESS (OP OR E P OLD X-RAY NO .M.P. IRE YOU PREGNANT? Dy e s Dn o ATIENT PREPARED BY PATIENTS WEIGHT REOLJESJEDJY POSSIBLE COMP CASE YES NO FILMS USED 8x10 10x12 11x14 14x17 14x36 REMARKS 2^ t o t al ___ L_^________ L____~ DO NOT WRITE BELOW THIS LINE DATE 92-313641 4-1-92 CHEST X-RAY, PA AND LATERAL ! REDACTED The lung fields are clear of infiltrate or congestive change. Heart and mediastinal structures are unremarkable. Surgical sutures are noted in the anterior aspect of the abdomen on the lateral projection. IMPRESSION: No acute cardiopulmonary pathology is noted. JH/lb 4-1-92 A, ' f' N41657.15 I hereby authorize Clara Maass Memorial Hospital and the physician or physicians in charge of the care of this patient, to carry out -.uch diagnostic procedures, to administer such treatments and administer such onesthetics, transfusions, intravenous medications, and to per<o such operations os may be deemed necessary or advisable in the diagnosis or treatment of this patient, and to exomine and 13 make prof CO __T-- 1^ ------------------------------------------------------------(O to (NEXT OF KIN) iRELATi oHtP ~ 0007-SWP-005 803110 CONFIDENTIAL p'*\ r` CLARA MAASS MEMORIAL HOSPITAL BELLEVILLE, N. J. u i S , 3 , i ^ c 3-5 i 5-.. REDACTED CHECK / if (ladings are normal * '-er avannnstlon. PRESE <4T COMPLAINT Concilia tatsmani of oomplatnta Kilt Hat* i onnt and duration of aeh. Raeocd - otdit of lmportanea. MARK X In appropriate spaos In column at laft If findings .re abnormal on examination, and da sort be la apses belorn P/ >T HISTORY _ Uaaatr . ___Jnfluanaa __ tihoop i Dough ___ Pleurisy __Mumps Tubeiculoota __Cblok .pox ___ Asthma ___Tonsil is Arthritis ___Soarlst rsrsr __Ameblale ___Dlpbth rla ___Luxe ___Rhsum. tie ' ___ Gonorrhea Fever __ Typho 1 Fever_JnJurt a fc_ Malar! ___Operations _ Pnsun ala____.Other b `7/&z-J s$L PA..IILY HISTORY i living, health of, and If ds* o*.assd, c a u s s of death of father, mother, siblings, children. Any familial: ___Cancer ' Heart Disease _Xnberou. .els ___Allergy __ Diabetes ___Arthritis __ Hemophilia Other Kidney Disease _ "\ INVENTORY BY SYSTEMS OENERAL ___Nutrition __Tremor ___ Fever -----Haight Oaln ___Night sweats ___Weight Does __ Falling Hair ___Othar SKIN ___ Eruptions ___Jaundloe ___ Cyanosis ___Other HEAD .. \ * __Hosdshe _8ynoops ___ Traumi. ___Other EYES ___Eye Stisln _J.aoryxaatnn ___Diplopia ___Olaaass ___Photophobia ___Othar (ovar) ATTENDING PHYSICIAN: OF *575 REV. MARCH f7Z HISTORY X 7 / 114).pat*: (1 0007-SWP-005803111 CONFIDENTIAL w N 41657.17 CLAfAMAASS MEMORIAL HOSPITAL E EI.LZVILLE. N. J. PHYSICAL FINDINGS: Scalp: Eyas: jy Ears: \^f-- Mouth, Throat: Neck: tfA ^ P?^V Cl test: Braests: C.trdio-Vascular <^Z) Abdomen: Genitourinary: A / Skint Extremities: Reflexes: Rectal: (If Indicated) Pelvic: (If Indicated) Imprt ssion: ^CTEO 0007-SWP-005803112 CONFIDENTIAL CLARA MAASS MEMORIAL HOSPITAL Bellevil'e, New Jersey .4 -? '** NITIAL PHYSICIAN ADMISSION NOTES .3pji5-r":v . 3 E ,4 Y C * CS REDACTED ANTICIPATED CONSULTATIONS; SPECIAL THERAPY CUAFiMA *SS MEMORIAL HOl .^ITAL * " . BELLEVILLE. N. J. 2! -70-95-0 >500 PATIENT -J- Tl A iMITTCD 050275 DATE 01 -.CKARJSCO / OCCUPAl ON / SHB83SCt o c t o (>23058 $r* J* 23k Htyo HOME PM ON C set r ac e Q330 P H V RELIGION ? oat ATH PLACE *------------- *___ t.zi r, AGE MATAL s er v ic e U6 X as/5 0ATE LAST AOMITTCO SIMTM DATE ''"I YU '< NOTIFY IN EMERGENCY REDACTED _________ ____________________ HEL4T10N5MIP *ESP.PARTY (Oft tNSU<*C0l Vif<t ftitltfttt (SoU) Bawaik, B.J* _ G. I, Bleeding _______________ r* TUE.tr* HMAS. ~ MOTHER'S MAloCgCO^^ t9flmlrmlrm fnrrtlflifl Tlnjri T&3 got 071728 PF LOYR AMO A0ORE S -J \ >Jhan4aJa: liaL galnt Co. Liator Am.a u FINAL (ACKOSISI TO BE COMPLETED BY PHYSICIAN j l ZZ, COD' NO. r. ' * f j '> CV/r y -Ul--..,^ Vl JL-Z SECONt ARY DIAGNOSIS ON CO IPUIC ATIONSI <2-PC or l/c OPERATIONS: /^* -- i-r - t CONSULTATION WITH S: Qp ECOVEHEO tflIMPROVED QuMIMPHOVEO Qn o t t r e a t e d CA'JSE OF DEATH: I HAVE EXAMINED AND APPROVED THircOMPLET^EDIC S d a t e ___________ ", . - '/' ` ' SIGNED. Q SIS ONLY- ; I DIED I hereby authorize Clara Maass Memorial Hospital and the physician or physicians in charge of the care of this patient to earn out such diagnostic procedures, to administer such treatments and administer such anesthetics, transfusions, intravett ms modi cations, and to perform such operations as may be deemed necessary or advisable in the diagnosis or treatment of tie-. patient and to examine and to make proper disposition of all tissue or anatomical parts. 0007-SWP-005803114 CONFIDENTIAL f Ki I...1. I II in MMliIl S w N41657.18 J. . . ' r e d a c t e d CLARA MAASS MEMORIAL HOSPITAL BELLEVILLE. N. J. 2S-70-V5-0* C ? . J . ('M. a y n CHECK V if findings are normal attar examination. PRESENT COMPLAINT ;onciee sta'eraent of complaint* v. n dai# of otieet and duration of e -tu cecord in order of importance* MARK X in appropriate apace in column at l*ft if finding* are abnormal on examination, and describe m apace tmlovt PAST HISTORY . Measles .Jnfhtensa Whoomnic Coug.i . .Pleurisy . ciuckent>t>\ . Tuberculosis . AHilitua . joiiKiitua _ Arthritis . Scarlet Fever . AmeLiaaie . Diphtheria . .. ..Lues .Rheumatic Fever . Gonorrhea . Typhoid Fever _ luiunea . Malana , Operations _ pneumonia . Other FAMILY HISTORY If i ih r , heal ill of. and if do* ceas- v. rau*e of death v*f lather, raori. siblings, children. An' familial: . Ch . er Tu rcuiosix ...Di *i*s ..Hi* -phi La --Ki' *y Di ase _. Heart UixMa.i .. Allersy .. ArUiniia _ Otttai / "? ", // / d ^ ^ c<- -CL j4sa--, (f~ 2- ^>c Y* S&JL-rd? t c a- . -p~*> : ^*^-9 0 /-'C- V IN\ iNTORY BY SYSTEM! GENKRAL _ jV::!rttlOn Tr*m*r _ Kwer _M'*ighi Cain .Nii,,ht$wvau --Weight Lo h s _ Ka'iitiK Hair _ OMM SKIN _ruptmns . Jaundice- Cyanosis .. Orht*i HEAD ^.JIrad.1 dir ^SNncope Trauma _Other EYES . --Ky# Strain . Lai-rymallun -Diplopia . ,, Ui*aba . Phot**phobi .. Other (overt TAKEN BY: .; ATTENDING PHYSICIAN: _ OF 4S7S REV. MARCH 1972 * t> 4C -/ L- , ,......... -- ___ [.yinmi irtthg Hi.iuty) __ x ^ Date:______ --:... NI^TOPY 1__ M.D. Date: 0007-S WP-005803115 CONFIDENTIAL C .ARA MAASS MEMORIAL HOSPITAL BELLEVILLE. N. J. *5 1 7V REDACTED 25-70- :<5-o ' J. ' v ' ro GEN' 1AL CONDITIONS: Temp. B \: a. ----. d. N' 'ItIon. ate.: Height Rasp.: rata PHY' SAL FINDINGS: HEAD: FECK: CF iST: <r ^ CAtDIO-VASCULAR: y----- ABC OMEN: GENITCRIRINARY: ^--\j ' * ^ B JES & JOINTS: GLANDULAR: NEURO-MUSCULAR: ' Wt. n. pf. char. Pulee: rata char. 5 *~x-.-Zu WOF KING DIAGNOSISt (After Physical Examination) EX `MINED BY: AT ENDING PHYSICIAN: OF 4160 325EZ PHYSICAL EXAMINATION0"^-^"6 1 '. 'ty CLARA MAASS MEMORIAL HOSPITAL BELLEVILLE, N. J. > 5L* 75 55-70-va-o REDACTED KAYO *'