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PRIVILEGED and SUBJECT m,AL MATERIAL SUBJECT TO PROTECTIVE ORDER" Baystate Medical Center Springfield, Massachusetts Adm: 6/1/37 cr J Name W-^RR^N, JOHN K. Guamieri, M.D. Disc; g^ 3/g? # G5542S2S HISTORY OF PRESENT ILLNESS: Chief complaint was unsteadiness ar.c dizziness. This 63 year old, white male with a 20 years hisuory cf Meniere's Disease presents complaining of a two cay history cf dizziness and significant headache. The patient snares than he.had teen n his usual state of good health unzil 5/30/87 when shcrtlv afner awakaninc he developed seme nausea, Shcrtlv afner his nausea becan he developed a headache which began initial!*/ in his richt evs and subsequently migrated across his forehead, down the crown cf his head, and down to the occiput. He stated that the headache was right sided only. The headache and nausea were accompanied by dizziness, trouble focusing, and some dry heaves, although the patient's wife states he had vomited up seme brownish material. He did not go to work that day because of his nausea and light heacedness. He had anorexia for the rest cf that day, but stated his headache began to resolve. On Sunday, he stated his headache was gone, but his nausea, dry heaves, and dizziness persisted. He also noted that his right arm was somewhat unsteady and it felt as if he had light heacedness in that am. Throughout the rest of that day, 5/31/87, he reportedly began to feel somewhat better. This a.m. 5/31/37, the patient states that his nausea and vomiting had resolved and he was able to keen solid feeds down. He stated that ha was snill dizzy, unsteady, and his right arm still is somewhat unsneady. He reports that he typically has an attack of his Meniere's Disease every four to five years, but it was felt that this particular episode was similar to his previous attacks, excepu that., he was a little mere unsteady than usual. Also aoypical is that he does not have arm Typically he does non have a headache associated with his Meniere's artacks. PAST MEDICAL HISTORY: - 1) Status pest head trauma with 13 sutures on the occiput on 11/19/35. 2) History .of arrhythmias 11/35 to 12/85 on Procan, subsequently discontinued by Cardiologist. Follow-up Holters and tread mill snress tests within normal limits. 3) History of fibula/tibia fracture right leg in 1934. 4) Status, post right eye surgery secondary to strabismus. 5) History of Meniere's Disease. 6) History of asthma. 7) History of bronchitis, 5/19/87. FAMILY HISTORY: Father died of an M.I. in 1985. Mother died at age 80 secondary to carcinoma of the uterus and ovaries. He's got a brother at the age of 67 who had a CVA, a 66 year old brother also had a CVA. An 84 year old sister alive and well, status post hip replacement. Springfield-Wesson W omen s Unit ! ! Wesson Memorial I I HiMorv and Physical Operative Note UCC 081374 Discharge Summary Other WARP.IN, JOHN K Guarnieri , M.D Pace 2 SOCIAL EISTORY: ' Patient is married, lives with his wire in Springfield, has children. Denies any history of cigarette smoking or alcohol use; -Works'as a--tank farm operator at Monsanto.. Parents exoosurs to and . midic; 11' * , is; none. S'm P_tvT.=.W: Poor dentition by history. History of some dizziness times mar.v veers. Fatrv tumor the richt urrer extremitv. < U>J 04 H Q LU O 35 III i* W CD d < Q. UJ UJ H g i a: == O UJ "5 Om ow AL il';-!; Generally well developed, well nourished, whine w. = 2 r no* "I a^ cu^ 4t*e-- ci2stm,nrtrne* nss. Alert and oriented times four. Tern: 93.9, pulse 72, 5? 124/64 lying, pulse 76, 5? 130/70 sitting posi tion, respirations 16. HUNT; NCAT, scar cr. the occiput. FIRL. ICMI. Strabizmus ncred of the right eye. Patient with horizontal nystagmus of eyes on right gaze, greater than left gaze. Fundi pccrly visualized. TMs clear without erythema. Nose and throat clear. Mouth with poor dentition. Neck; supple, full range of metier, without. JVD, without lynphadenepathy, without thyrcmegaly, without bruits. Hearn; HP. normal, normal SI, S2, with a 1/6 sysuoiic murmur at the left sternal border without S3 cr S4. Lungs; clear to auscultation. Coarse bilateral breath sounds. Abdomen; soft, ncr.tender, positive bowel sounds, without masses cr organo megaly. lxnremities; without clubbing, cyanosis, or edema. Cranial nerves 2 through 12 grossly intact. Cerebellar was intact. Motion was 5/5 in the upper and lower extremities bilaterally. Sensory exam was grossly iroact to light touch and pin prick. Rectal; heme negative wiuheut masses. LA3C'HACO?-Y: Upon admission rSvealed a hemoglobin 11.9, hematocrit 34.8, a W3C count 8.7. Patient had a differential of 3 bancs, 25 polys, 1_.lymph, 1 mono, sodium 139, potassium 4.3, chloride 103, bicarb. 24, clucose 70, 5UN.19, creatinine 1.1, calcium 9.0. HOSPITAL COURS: Patient was admi with the diagnosis of Meniere's Disease versus a cerebral vascular accident. Patient underwent a CAT scan of the head to rule out cerebral vascular accident. CT scan of the head revealed multiple lesions sugges tive of metastases. As a result radiation therapy was consulted to begin radiation therapy to the patient's head. Patient under went a bronchoscopy to attempt to assess possible pulmonary source for his metastases. Bronchoscopy showed-inflammatory disease of unknown etiology, however, without any evidence of a metastatic or gross primary lesion. Patient underwent a CT scan of the chest on 6/4/87 which revealed multiple nodular densities on lungs with scarring and fibrosis at both lower lobes. CT scan of the abdomen showed a large liver mass, however, no clear primary was again elicited. A CT directed needle biopsy of the liver mass was scheduled to attempt to determine if that was the etiology of the patient's liver biopsy. CT scan with liver. biepsv revealed necrotic tissue without clear evidence of either primary cancer or metastasis to the liver. Patient was placed on UCC 081375 WARREN, JOHN K. Guarnieri, M.D. Pace 3 XV Decadcrcn -to -try -to reduce some of his cerebral edema and radiation -to his brain was continued. However, again no clear brain lesions included IV? and CO scan of the pelvis which were again ncndiagncstic of primary lesion.. He continued to have daily radiation therapy as well as Deoadror*. However, as no primary -lesion was discovered from the pendent's cancer and he was feeling -sunewhat better afner receiving radiation therapy and Deoadror., pauier.t was discharged to heme in stable condition on 6/13/S7 wit", regular dien and acnivitv ad. lib. Medicanicns on discharge were Cecadrcn 4 mg. p.o. q.i.d. for three days and 2 mg. p.c. -q.i.d. for two days. Patient was to see Dr. Arthur McGuire at his office one we eh afner discharge for continuing of the tapering schedule. Patienn was placed on Regian .10 mg. p.c. one rac and c. hs., Carafane 1 gm. p.o. one rac and c. hs. FINAL DIAGNOSIS: 1. METASTATIC BRAIN CANCHR WITH UNDETERMINED PRIMARY. 2. QUESTION OF A LUNG CARCINOMA. 3. RADIATION -.TTEERAPY TO THE BRAIN. 4. STATUS POST BRONCHOSCOPY. 5. STATUS POST COMPUTED TOMOGRAPHY DIRECTED BIOPSY CF THE-LIVER WHICH REVEALED MENINGIOMA. 6. MENIERE'S DISEASE. The natient will be followed bv Dr. A.rniur McGuire for further EC-:t sr=2S D-.10/5/87 T:10/10/S7 co: Dr. X, Guamieri PRIVILEGED AND "CONFIDENTIAL MATERIAL SUBJECT TO PROTECTIVE ORDER" UCC 081316 PRIVILEGED AND "CONFIDENTIAL MATERIAL SUBJECT TO PROTECTIVE ORDER" Name WARREN, JOHN H. Dr. Flatow Bavstate Medical Center Springfield, Massachusetts Adm:1/1/88 expired 231633 Disc: 1/2 9/8 8 # 056629646 This 64-year-old white male with hemangiosarcoma of the liver widely metastatic was admitted through the Emergency Room with persistent vomiting of coffeegrouna material, progressive weakness. The patient' was discharged home 36 hours prior to this admission following reinsti but was admitted in June of 1987 with exacerbation of symptoms. Study *at that time showed multiple brain metastases and following biopsy of "'pleural and pulmonary metastases the diagnosis of hemangiosarcoma was made. The patient .gave a long history of exposure to vinyl chloride .at .his place of employment. In June he was treated with whole brain .radiation .plus .Decadron with improvement and then -received chemotherapy with DTIC, Adriamycin followed by Methotrexate plus Citrovorum rescue without any improvement. There was progression of multiple pulmonary -nodules,-intermittent hemoptysis, intermittent hematuria, progressive anemia with positive stool guaiacs requiring multiple transfusions. On his`recent admission for severe weakness and ataxia repeat CT scan of the brain showed recurrence of the CNS metastases particularly in the posterior fossa. On 12/31/87 radiation to the whole brain dor a second course was begun-by Dr. Stark and he was discharged home over the long holiday-weekend. On 1/1/88 he began- to vomit, was unable to maintain his medications, complained of headache on the right side radiating to the occipital area.- He was treated with Torecan and oral Decadron, neither of these modalities helped and he was brought "to the.Emergency Room with his persistent vomiting. Other medications . :at home included Dilantin 4,00 mgs daily, Digoxin .25 mgs daily for arrhythmias, folic acid and iron for his anemia and Decadron. --PHYSICAL EXAM: Revealed a, chronically .--ill, pale "white male. Blood pressure 150/80, pulse 120, temperature ,99.1- -.HEENT: total alopecia, no scleral icterus, pupils were equal,, extraocular movements normal, nose .and.pharynx.unremarkable. --Neck:.no venous distension. Lungs: clear to percussion, inspiratory rales present lower left lung field. Heart: sinus .tachycardia,,grade 2/6 systolic murmur-left sternal borde Abdomen: soft, no palpable liver, no focal tenderness. Genitalia: normal male. Rectal exam: copious soft, dark stool guaiac positive. Vomitus brought in by the family also tested at this time and guaiac positive, no frank blood seen. Mo rectal masses. Extremities: no focal weakness, no dependent edema, deep tendon reflexes 3+ and symme trical. - LABORATORY DATA: Hemoglobin 8.1, hematocrit 24.5, white count 15,300, platelet count 577,000. Reticulocyte count 3.5%. Sodium 133, potas sium 4.5, chloride 102, C02 23, glucose 157, BUN 17, creatinine 0.3. _ . Springfield-Wesson Women's Unit Wesson Memorial continued........... History and Physical Operative Note 0 Discharge Summary 0 Other UCC 081377 WARREN, JOHN H continued.... Dr. Flatow Calcium 7.8, total protein 3.7 with albumin 1.9, alkaline phosphates .316, LDH.804, SGOT 59. Dilantin level 4.6, Digoxin level 0.6.' No .-additional x-ray studies were done. HOSPITAL -COURSE: The patient was continued on full fluid diet, given XV .-fluids and continued on his Lanoxin and Dilantin. Decadron was switched to 4 mgs intravenously every 6 hours. Compazine was given IM for nausea. Carafate arid Zantac were added for possible upper GI bleeding. The patient was continued by Dr. Stark on his whole brain radiation with treatments through 1/12/83 to a tonal of 4600 rads with 1400 in "this-most recent course. Because of his -poor clinical condition it was elected to discontinue the whole brain radiation. Unfortunately the family remained very optimistic throughout this course of treatment and failed to accept the prc-gressive deterioration in Mr. Warren's condition. They continued _to -describe excellent oral intake due to their feeding efforts in the hospital but total oral..intake/day was measured in teaspoons of food. Mr. Warren became progressively weak, -had continued blood loss anemia and at the family's insistence required numerous transfusions of packed cells to maintain satisfactory hemoglobin. Multiple nodules developed progressively on the skin consistent wich cutaneous metastatic lesions. Great difficulty was had in maintaining peripheral IV sites. Toward the end of his course additional discussions were held with the family who still spoke of surgical consultations to remove all metastatic lesions from the brain, the lungs, skin, the liver, the gastrointestinal and genitourinary tracts. They were discouraged from this approach and finally after extensive review of the problem concluded that additional supportive carerwas of.no long term benefit. When no more peripheral IV.sites were obtainable it was elected not to prepare a central line and not to continue with blood transfusions. At this point the patient's status was very poor and he slipped further over subsequent days to expire at 2:35 PM 1/29/88 with, the family and undersignedpresent. Permission for postmortem examination was not obtained. FINAL DIAGNOSIS: 1. HEMANGI0SARC0MA OF THE LIVER. 2. RECURRENT ; i METASTATIC DISEASE TO THE BRAIN. 3. MULTIPLE PULMONARY METASTASES;" 4. PERSISTENT GASTROINTESTINAL BLEEDING WITH SUSPECTED GASTRO INTESTINAL "METASTASES. . 5. INTERMITTENT-HEMATURIA WITH SUSPECTED URINARY TRACT METASTASES. 6. MULTIPLE CUTANEOUS METASTASES. 7. PAST HISTORY OF CARDIAC ARRHYTHMIAS. FF/bss23 D: 2/16/88 T: 2/18/88 cc: Dr. Flatow F. Flatow, M.D. f\ n\ PRIVILEGED AND "CONFIDENTIAL MATERIAL SUBJECT TO PROTECTIVE ORDER" UCC 081378 .L. r** ^ I- rL 1 W* P- -*1 * r*l __ _ A FLAT C ,* r r U'j ! > Li!J,,, r^r u, ia*s*/; o,>~-^-r - *ruv--*J; ~` EAVSTATE MEDICAL CENTER 3orincfieid. MA 0115S Divisicn cf Nursing (ADDRESSOGHAPH IMFRINT) Cate^' | Prooiem Time i n PATIENT PROGRESS NOTE ; /r/r ' Pi.. rydd'-f.-'J // - (S< Y~1 'U^-Al (Li s'tAW' l': : -r ^ .Tl i /' )i- (b' ft.\syrU . "~fj -;1 f J(L( u /tl . Lu.^P*ha-/V Z I p-h TWI.-^v.6a /t-"U-1 iC: { iv;-o - 3-41CV A I^PvaL-, YrA A P- C,r/,-'<n. ^ /C f^U r AidrT . /VIZ P^j.1 .\M _____ ^ w (V /- ?_<^ i I,-. -' -1 -?' f - if ` ! ^. ^it-i . /T~--v' -/.a / - '? ' yl , ,/ dSL. ^ / jL P*. /o -`V 15^ i/' - "*' - . _i*'-. ; -r< '/? 'P f"/-'7'-' V-- , ) rs$od A? / / _y^. 1. X/'D;y_ ^f> >*? - ( I-7 g?- ptfsjc a j r ,2 3 *(?*< /** s' / PRIVILEGED AND " CONFIDENTIAL MATERIAL SUBJECT TO PROTECTIVE te-rhs.-S-' sn d C -V--' --7"?.- pr^^O--~r /\>yd\dri'iLS- hkt \ 1<- O- ^ P`j/ 0 / < ?p rf--*,:/b, n/_ig mriJ~d/. /It'^~CS-r-Ci\A i^-T (S'l'-S ? ! a>'1VY rfk Jj U'*.;. V I ' ^ is,-*. A.il^y\ tviy// /_; / V- /-j*A o; uj P ~ dtLr'A-'- -- i ^ // !_b fi <> . < - / ' A'J'CAS'^ L`>-C,riT-rliUr>ar_^ /--*- ft* * * s\ r jt \ o jIMVsj-Vz-j/ / / 0' dAJp'f'/r.'vA/ s~d'v,,.'S, , a /p.s Ssr^toCcCp'* ._____ i/^S- c/ ^ y....... 7 - y--- rr^* - -- 1-- $S/A /r> s /sri 3, / T A - Sr P~ y "v / />. /,, ss~ AS____ i._______________^__ )__y_7__^__f_^_S___ ___"_-_L_____ -- /W-fS' C-Zd s^UC^L^rf* Cs/CO.'l^, ! -r> / K/ <^211',*^u^ /<. s? sd1>> -y -> A J^L ZlSsSL&^l___ ZT;O.Lj' J' s. 'iZdsy' ZaJ^-aZ A- ) ___{a* ,T <~zp,` . d"-' ^L' ' TZ'ftZZ S' c/^, ,-r>A^ -7- ,,___________________^--------__________-r 'r,____________________________________________________________________________________________ X?.S~ f S'A1t j /-^y_f>/;t-``cZd / `bL'' (S'* dZL f-) --T ) 4-/ ^Z2u^'/<yiJ fitJ.S~ r / \*ls ->7. - - - - - - - - - - - - - - - - - ^- - - - - - - - - - - - - - - - i ~5- 'STL/, 0l\^ ------------- -------- / --'1 f? / // -i-------- ------------ 1/D - v/5^ L,i!'r^G&7z- . j, ,t/ cZltAdon o hIj^4A>,vrt<3L6^ C-- -----j-f---c--u-- :i- cs "Z?--zr,/o\/--v--rr-~--A.-(-,, ----+--y^s/",rr lLA^Lt'pi i-J^TzT/ri^/DrrLob T^tZ-- -J i C_ toni'// /^- Z. j/-1 . Z/> j , y?-Q- ^J-?r:ZZ_/ s_/>"sOs^ C* -- \tw^r.~ a:^--r*c **r? / P^T.TNT ?" UCC 081379 UCC 081380 Locc: i: \i: n;,"! r > c// fUTOU, F,U3 r L. A 7 G\i, i 020 o :vu/:: E "'STATE MEDICAL CENTER ipringfieid, MA 011S9 Division of Nursing (ADDRE3SGGRAPH IMPRINT) Date Proolem ^-'''Tiine * a aox :o '~7r- ' tP/.A-A d'ZZ.C__ ot-g -zd tf? - /-?'? / / /,.U-.i-r.-- . / C X nc ( d<J/rrs/" V 6^ "X*/ )CiQ PATIENT PROGRESS NOTE 4 ^*' s', , ^ -* ^ i///'(-L^~,---- ,) . ~Cr 'J ,r^ ^ f~ V'3 clc*^7 -Jrcil'i'- Z" reJ^xexi C/^ d^e;/-^. if n<ixfc.-f*3`r2 mnt, ~^S.K i n r Sllwid i Oj.i! 0 * pCnT' T-^erd ~ SC^ ^ c/i? h-e^Jz^Lr aob^y...a.-1-r rw!,cV '/Viarg `aie/~ -f^So -TO: c ^ 5. I 3 ft a., 5". tf 0 yj'u. t ^ ,'-'C Vv^-O IWA0\\ ~W *vL\^ Va/iVt ? 1 T UfVf C ImLc-1 Pa /'//m-t L? //"4 9. -1V$! > At) I Ox <cVt. V\ I! A-L- A.O, 5V.. ,A 5~V\.\ VP VV <2 o; p ouj0 | Q E2 = uj -j a; a; O < Q. 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O <5 kjyO 1 /] tL L - f- HA .Ml)0,P 0 <' Ah A m..fylGV\ f/yj-er-oi'L/j ^o-lrcfrd L'*A r -- l4l/J (id-At Pt. id), bfet well, caiin<oPfu!11 0 -died iaj^U tL'^en -fcA . ^ a:'It) (niTiofy Ar/inin<3 n^ar ucilc<J (jyi n-f - TTxin f- reap on mf. 7U pa-tent infusing sdiffiruftr./ <#c/b <offcro<3cP to e^diafron Th^r q&g 61^ m &_(vrcn-hm^ R3 -fMs au/en---------- fa Pt. fynina nili cA mxxih/szrm ^QllaJihci mif-chs 3 *r?ini 3:0 t-- <ZL Q : Pb in hcr(x dm.ifc crL> {J SS . hexAgjo oafk^. ..^7 / ^r ,1 /t- A(r\ n 4s t n,tni -p vr ^/?/X; H^AmaO/ -A r mh.Lti pU UCC 081381 Date Time i ProDlem len11 r\i4sc# . nr\ dies If? Pa f (6j) (- f K> of , I'yC^hcA I jw 1 Hr A-^> P' ;nO/y_ _______ 0 v^J__________ . AV ^/A i i/i ~ ^ yQ/v-t i /) IfOfi > L-.w-T/Q h-fT'J ~ I'llfj\'k (Ji. ;/.)5 1V^ 1^ "0: (j -- /$ /V O ;^7 /4Q V .i?~OK Q- .tV Wyjn-aimr, m? /(,<;) If, /c/ t'Ti Ifxrnrri nr\ri fprr^'Wrwi r>rl . rtjidp ini\ <? r/ r< , njr_ c^n r^-x j-nneev/ n.\oa^i <r if\ OflAtucu/^ ..-h^vA^p^^ n 1 ft". (-- /? 'Q.l- .71 44in \V\Ur c J 'p< ao Jbi^OOP^i cr j/la/55 hPr A-~'. (Vfifiv/AAlndfTAOrt . F ffifWftJL^.'--r'foA A'yUs ---- ; :1 ." ="-=1 TT-! I / ; 4v,o, << 1-- o> I nc. 'C f < ? <? 7 rr^rTv^DCtC- ^=rDi..-7 cT^ 'W^'JO / j Q <5^? '-^tn 9o O_a0tn~ *Ls_ ` - ------ zT^nLAj^i / \ -/^\l V- */? * ' *^ 1 _ _ _ 1 0 ~ .J^&2r sr//CSZ%- . C , ^/CS J5~,' r* y/ feiOL, J <z*& , .1 ^ #/?**/. " 4c* ! ( K!4 ?<! M^!4!^LijU.aXjJL ^^4 M44.I-iofo\r. 3-' kL\o,,tdioCi.u 1 Ouc^fVfci^H -YC, vil/' OAjLtO' - ------------ f\V .Kl ^U-O l * i~J_---- T . ?%*<_? ''Holt' V '^?9-4-_ ^^ . />_s i -1*4-5s 1 1 OP '' CU`dO1 'c^- r'_ 0J.C4U TKi.T '-'X.f rt-L-l t> -t -=.VL^^"- ^ n n^A. f! V--* ^ _ f ,-- _ _ ' .*>>,% no /*, .- r Y'Llr -v f C /*,. + JH_t. ' P rl * * \L o>Xc^-P. 1 ^ -j--\ LlCc-', -(,-j o o \ . A (^S. \^~r. -h_jJ!--i i^:^. S-M*' ,* O ^ r P- --- ^ --4- ,\_` - '_. -/ - .-t ---- '-- - 40 O. 4-' f &0 44?.? I f2fl* 15 - Pi fks. lw Li'L. j*r'/'/rh'.uy.a ?? C..isuh t^A j'U oi.-,<Si . 1 r) :'PtoM'<L . *n iLatafc, (J ^r..'bu,izA __ J Tiud.* _.; P; (^0 ben.. /Oc, ~ / J 1 ' ^(> a_' 01 liritui. '0\_,ftn_ , ^Sil-i'-L<U^/-Lf)'JL ft's (Sku.s*jL /Z'P ^ 3- 5:0 P: p-.3 n 6e^ * . !1 cm 6t w.pnrl p&4 w a- 1 K<s , t-n/ rn (!lui i^I r* or( U */ \ po4- 04 M Stcv\. rute^yi i'^ 4 : \^\Qis\ aYjP^i_ 4_ oVl__ i { ]/ yP rUL n a/y( - rO\A 0 C1 i/4/1,__ 1n { UvuirAQA ~-------^ ------- J)A'^A7(L/A. Q-WJKfH J Ccin/J o Oz _ mM O mz <r- h m m o >r- Om * o Is omo H 33 < m > UCC 081382 PRIVILEGED AND CONFIDENTIAL MATERIAL >U E ^C T TO PROTECTIVE W ORDER" /A S n - - uViW Sr"? Z/ ff*l *`* 1 iW2 7!,-Li r,tKi t ^_wn, -> -'r ^ i. A** 7i. -~ *** r _ 1 !/! :/i- f o,< * -r s ^-i ii - 'r\ `d ^ v *J 4'^ {ADDRE3SCGRAFH IMPRINT) E/' 'STATE MEDICAL CENTER Springfield. MA 01199 Division of Nursing PATIENT PROGRESS NOTE Oate^^ ; Tirr.e Prcclem a 1 1 ' 1 1 /-// -r r-i ALr2S }7kZ.&: 1 yy y ' / 1 S'A-t'i^~PT /r) - /L-j ,>--? i/' /r-tiy-fL^^r yp-i: ______ / X2^CyJ<yy^i--^ >- ' P. yp 6 s - ^*^1 >CL^-?~c~'--r<-y 1 `hm^s ^ --r. 1 ^ '," )Xl>:L^ Pn i.vT u (/ ''j O' f?t~.,(/T'pj/( . Ifrft /y','U',\J',CT ?0] US-.L\M-J , ^kXi,t^yr.-^ L^y rp.J.u y s Qj-C`A P-yAP i.v\Vi ^ lOi'-fb-, fLZ,ys-ftc4-U'Ai^s 11 ! A7 CtCt. y_rt r i^\wJ.tr''^{~Jh C-rZw i/yndc^,\uZ<. \ P`, Ace AJCP ^ / ^ P' y.sy'j 'dicuh HAA /> ^6' nJTtXc-^n f>U dk*a.`*&gJL-. -CSz^ ri_-J iZA'J;yys 0 fbj.A CY\ PsnCauJ,. , }^u,v p PipylA1 y ,-; ft? o' /> ,,' ' v dr-' ^ ^ *f S? /f (j ' y' Af"s , /J >-K JTf ' 6~S S /A 0. -- I ^1 t .t y-ft^.'/^~> A - s J si?.-- '?2 1 /p (T^ f>T,1 f t A - <XZP A pyy-^ %4- /^T spPLjlA/ -- PA s:T~ . fo% rL~r~. ^ tP S- ^ Sy. ss* _y> p h i// , P*y>.*-u s-f. Syy> Pi. - ^ --- y (s. ^--------------------s^. XOs - ," .1 tj^-P<P /^\CU*z_jL r~ <-L s/s/cf b fi y'Lltsu_- S p /' /^ ,* St jO* y1 f - J' / -*--i * ' L / jr /PP. /y,-^v /S/sy /?!_/} ./i^^ J S /.'y^^O^P^y.P/b f/ / ^J^C./rs '? ///l / '/) AltAsnftAxPZyxt AftAj/y /'xy^A^A/AsAl'A.. iP/iT /j/pA/CssyiLSZy*/ ~S1 . > ~/ it 'A- "iU 1*^-4 ' PLt . h ft* D n/r/ PA --/suvs;jyJi -- - ^ SfLPUysl-J .AjCZlL \ `f . J 'fUu% \o. p/ /'.^y1*^*):, ?,, ^yQxyOf IAts lysS s? yysyjpyH S^Sl^L / / ____ Jo'lh/A JsuAm .AAprrpL ^4- fjAusyJ) y' A /? /.-v^ /? ftfv*, J snsf ft r~r~ cUS-CL 0 pc^> oiaj. /)r A ,<S vT) " __________ . dU> ~,rs^z^s/ a/,,,, ^/V>-^iV-' -." fShl^tr' -_- , T /) / ^ ^ Ai6(?i/. ^.~../ A "'-/ np i C1 PJ ------ - .AiL 4^ ___ _______ iC /,/ ; . s /' UCC 081383 SDate TimetI PrODlem 0 S-- j A. 7 .`Vj [ -- ^^ LLJJ.,__ .A_^. ` ^V 1 l ''' /*_* -y^ <-is -27J,-mghotrzanhlSrm|i a (\ l , r- t \ \ ,- -- ' '-1-MJ`-j--I-------a-L_-r {1 V * - *Vj" - -_ - m5pm _1_____ !________IisP , -_________ q_*___ V ' '' v> n , P J-M t/d3 1 ffctL/QJ jJhriAi^r^)n^ PZa-'yr- S L^nJ^y7!^ ^ os?/ SX^ji'igOHk3>? moH hm 2 ' IQ: /VA\^ D'H'CqjO*) usY7Aj.jS>/sr>Q *d<Occ/Aj , <m >r O^o- <-* cL)J\ a/J, yLD on lj./yUjjy'jty^yy?. -- AuO L.> HcLd,'?7i?A > CJ' 1 tSuijilQj)Jsr> S) -sr-j/xr-! sjU P`- -*j_ _^rsL/rULc&-/v 7 , ..-r1- r? ft s\ p 2 JL o/v sO'isy^z: vidiOoi ^ cX n n J p>- '7ltj/S/f\ T&oWj 0- AjjJ. lr2Jb I l 1^1 I A/ I U^fK\ TVO 'V\`r'M -fil \^ - p-Ur^L :- j !" . lS-at- 0 ,v "> t>. ir-..inj .lv-v --ii y -- \rbt LJjy^.i r`'f~ ( / ~0? WA/WW - 0 ? -e-V-ArL-t J^ tC 11 f\\ P*V ft t~-A _ \t?u. avrA \Sr-co%&niL> -A '(3>~ MtVl*?/)) tr/jrr/^urz^ uOOruiZl, a'77ZJt: ?Sfc.//?L> OfZ% <L- &PJS/TV ; Jzj^/yiorJ J VtO Ja&Pj>s>7 . ftj)'jar> oOrJ^o j A jQ&Sjj'.t&r'o & \A ^fatL/fQO QX-`*k-' ? CjyriX^tC) lAtiVL r i/rTjxrvt ~&Jt/n fb^.AAOy^ctr^j. GXZt&p2,7Z fJZA Qy ^ .^?xyy^/ / LtfLD fs.rsy-i. \Stcony ^\j2jx^A^zq?^-- H' " ,/ L/2/>U^cl2/7Z^y7{jJ^ \P?nr,c//7Zfzzll -- cy Win 03uf sS^ /?^3 ^^7 ,^r77 ^'4rztt4b(hJ&2k-& rUPU^) Cj ^ I 'AO .o-^gT^U <k X | Ag.L? rH TC^, WtOCQ JL \.Pv^cXL- lln'M IQnn AO ^ \0^Li^TqJL< \d_ ft. m^<if_^_.i-jjd..r hn^tTrk kG^ vKo <LA.KJ^A^ r pL^KP luXi 1 ^~fh~ SJZ. f): /5S nrdhitm t/riori Hid iTurnr, Plon 1 jj Hoiiy. n/um.i xOmfrrrrtt^o/ni t/mrvi .n4r)t JyJar'p iWcv n - htrm? C?> Wfi.//D 00A / /hi,nyrn X^hhrnurl ^ h\) Crr\ liinv.vl lr)r> tHnfasr.n.ur^ moT^ri\0YJmtnairnct <TrLiUj.ci.Jfif isn (D It P. Phi jTiWfhr, AlPf'in j'vfrnJTt AfiJ! llfr P rtr'pr. OCP- i .,.f__________________________________ _____________ H W/r.i*> Hv.iClrtt^lfn (/ ^ Jw Q -'.c'i j/V\ (Arv\ P\,v\ 1 taT f/ i,\ k, *i/\ ; __~S!.}C\,A j <? fp^ UCC 081384 6 cwOz -- m g5OHHz rm* mu>2 70 70 ^TM sos~ mH >qz qma rj ZJ m< > r~ ! !__ __ t* L* M-J *l-l * 3, J- - ^? C / > ^^ ^W -- * w inn , jch;; h f L . 70i; # r73 i -- ._^ -.A / 4 ' / "> H G 2 j ' ^ * -> - > ; '' - ' " * ^P ' 'J - 'f (ADDRE3S0GRAPH IMPRINT) Date^'' j PrODlem ... #.. 1|TO7 ..Lf.A'.v?.-..' -- ^ !1 ^ 'Ulra\ HAr .C- /0 ^ r* - 7-- . fcx.& r i\'-`n,-.l\ >* i1 ` U-,\'yu.:A;? r t-- 1 / * V , 1 EAVS7A7E MEDICAL CEMTcn Springfield, MA 011SS Division of Nursing PATIENT PROGRESS NOTE .^- . cL ^ ---y U--_' 7^ . O^-j . )________ __-- ^nXxiL ^/7,. 'TPlPm i !(' ,f)U^l,r.v^-T' V P - 0.^' AJC;0 1 "l fa -- Ho CV'Za-<Ls r`i\-tr\L-.L^ 4 P-<Ld t-P_/'D jyckffl 11^ ind- (jJ&1 lci.P l~Tb 'p-P , Krf^-1 I PI f- I <P7 >he\j?c( in 1 TV Pl.cbhvo1 o f/H ' C_<L itoffi /rfi/rl -S: 0 6iU -pry^. ji1 9 i^jL7L7- Ob \ \n-VS$kh^nn onthfir, irn-tn?} (i)ni.r,irrin ohan X 1 liJulimn iiAirne lOfnr Orm n/rnt iPncj? AkYi-htmiP) V$1 \'AJfejun PCiti mfty.ri .Ui)nr-,srl Q J Dnrwf/rrnirJ.)o y I (y,OPirr, onion /ftr^jri LpPi/nr.u/'j'rm a CidiLCiufu I im (PPrr./rr, fi toacIPa bfnP/Pn inn nmPlh P\r Xfcr 1 F) fi~>r Y)vt im fihi>T) 7rrPhnsttu / I u -T- ' (J U 1 P:fir; nir, /f )CP * i I I P i-db-W g ~p -me. % baCkL azuM- l-~7-it S* \s- KM*r,imt J-hucUTTKOJ JPPcJA a rv <r^ /21 v 0 - fp\ . trr b-l { ! 'Zizz-rp'^ ^ j>-) . PiKcZ' Jj ,~7~jC, (sr.ld 'U lAV-tyy'JS' A / It ,, a-r^-'yLu'^ , A-rAL-r'jS cJ-^ P - A-JCP 35. / . , j/ ^ 1 ^ 0- 0 ihZ/fc -4^2H*h* 7) ,-H Pri\ ll ^^______ v^'<11 f lL r rriA, rTTT '^.j!^ f\^t t l\.Z 6 T7(;, n^. 0 1 r li __________ of >1- Litrel> < ? 'J/ - /srt> ?L,iM <^i.' <-'Pt *1 A ^ st'i+i CU-if* i^*'t 9 x- jOiTT^-lrJ .X 3 Tr^.g/Sn-h! Y -t- X y1 / ^ V , I ''`--fZ ~i' njrH cs'(1-rX :.- . / i!>^A f'i` ,/ : n -j tie 'uLO. .f'-L^ > Sr-r' I,-s-j, 7e 1^ / Pr y-l-?Jev, /'j-'. C.W i ^ C'CJ i /* Jr&n&J tli/A.l 6V-/' /;; ;fj jf '. I*t --- J)Jm~ yA/nn&~' UCC 081385 Dale ^00** \ PrcDiem Time; * v-\.v. ^ m r^L"-- LV-.1 j' * _*. ^ i. V A-l Ip^^t-cvx /' , f'f\ <j**v i : i K ; (j / ^ " -S/1 . o -a 'i.v~j J r^' \/ ypLi_i..\ v -rrr^.Cv TJ ''"V f jJ V f,, . ,' C( - f / j?*_ 1 t?X' ' j!^!^! ! In.nn fi)IV-PC * r/-Ml'0 {Nn-&l Ki*.ari-hc I 1 >1 Cf)*-IQ nh.^p;H -/h Mi. fb^; 'HvirUfrcer- (s-t i ipTi Si., ifrr u' i i rrr t n~r('* ' /} D/ >, ':i0-'V1 P l fl T.( / n*:T . 1 i Pi'THY'' yjih hd.Vri nrpJfJ N'fS . ir, r,rnpt t ^ (H7 (' V tH l i rf'rl Fniw1 ft\ r . rrnJA - p,\ an f? r~>A .v* !n a,pi ; r, ffVTi 1 / tsi 1 ;---------------~-~!-- ' !-:-------------------------;-------- ------------------ - ( ,v rimiv--l ^P~ru--Pjir--i--M II UCC 081386