Document eve8qVdExOy3exNaorvZwJ6py
:
Levinson (1934-1988) Al/eed A. Levinson Richard J. Levinson Robert Jay Axelrod 'David T Wheaton `Ronald B Grayzel
__ .. Patrick K-Ciuifkld Managing Partner
Workers' Compensation-
fcvii^nAxelrocl^Mieaton
\ V K () h h s -{-<) N A I, e.()-K.<M),`R A T I'O- N *
March 29, 1989
* .
^ - Jt
Elaine Brennan * Stewart-Husid William D. Levinson Robert E. Bennett * * `Richard Marcolus
John $. Sawicki `Gaiy EiynoJames J. Dunn George H. Conover, Jr.
Of Counsel
Robert L. Hollingshead, Esq., 163 Madison Avenue, Morristown, N.J. 07960-1945
D ar Mr. Hollingsheadr ;R`e.:. Paterson ,v^ Union Carbide-
VU?dC.P
I wish to supplement answers to interrogatories as follows.
Mr. Peterson was treated by Dr. I.J. Fine at the Perth Amboy General Hospital on October 10, 1978 and May 15, 1979 and last saw him on July 31, 1984. You are in receipt of his report and I am attempting to obtain his bill.
Mr. Peterson was treated and operated on by Dr. Hugh Biller on February 24, 1984 at Mt. Sinai and his bill is $4,855. He last saw Dr. Biller in November of 1988 and will see him again in six months. Enclosed find copy of bill.
Mr. Peterson was hospitalized on the following dates:
Perth Amboy General Hospital, 10/9/78 to 10/11/78 -Lesion of
left vocal
cord - I am enclosing a copy of this report.
I am
attempting to obtain a copy of this bill.
Perth Amboy General Hospital, 5/15/79 - Lesion of left vocal cord - I am enclosing a copy of this report and bill in the sum of $228.
Mt. Sinai Hospital - pre-admission test - 1/20/84 - enclosed find copy of bill in the sum of $445.
Mt. Sinai Hospital -1/24/84 - biopsy - enclosed is a copy of this report - I am attempting to obtain the bill.
Mt. Sinai Hospital - 2/23/84 to 3/8/84 - left homilaryngectomy by Dr. Biller - enclosed is a copy of this report and bill in the sum of $8,080.34.
UCC 088752
Cnwflrt o*tf TUI Aooncr 'Ado Hutu Ntv Yort tn
Lincoln Plaza, 2 Lincoln Highway, P.O. Box 2905, Edison, NJ 08818-2905 (201)494*2727 Fax (201) 494-2712 Plaza One Building, Route* 202 4 31, Fletnington, NJ 08822 (201) 782-6766 Fax (201) 782-6325 /w# Repty To Bauon 1015 Park Avenue, Plainfield, NJ (201) 757*2727
Dr. Patel, Anesthesia $588 (bill enclosed) -Mt. Sinai Hospital - 4/8/85 to 4/10/85 - Laryngoscopy with left vocal cord teflon injection - this report was submitted to you - enclosed find copy of his bill in the sum of $1,901.80 Anesthesia Department $336 (bill enclosed) I will further call upon the following fact witnesses to testify on behalf of the plaintiff at the time of trial.
..." George Kushner, 549 Hartford StPerth Amboy. . .
Eva Erickson, 531Hartford St., Perth Amboy Katherine Notaro, 542 Hartford St., Perth Amboy Geneviene Pajak, 548 Hartford St., Perth Amboy These witnesses lived in the area of the terminal and will testify about the nature and magnitude of the chemical emissions from this plant. I will call upon the following expert witnesses to testify on behalf of the plaintiff herein at the time of trial. Dr. Samuel Epstein; Professor Burton Davidson; Dr. Fred Cohen; Dr. I.J, Fine and Dr. Hugh Biller. Unless I hear from you to the contrary, I shall assume that this letter will serve in lieu of more formal answers herein.
UCC 088753
HWIIMIIlIf Ifttpl HUQMI UH* tflMIUHIMII JVMt w*VW4a*w vmhm ........
pint th* iMriofut infomutnn rvquMttd on ihi form. , Thi* ciotomMI contains all tha Information doctor it required to supply. It it not necessary tor this office to fill out the Inturenoe company i form.
ATTENDING PHYSICIAN'S STATEMENT
tONOSIS
OFESSIONAL SERVICES LI Comprehensive Oftlce Visit (OV) isequent OI rice visit (OV) t qiterative Visit (OV) imitation (C) r, Note A Throat > read A Neck .'nd Opinion
FEE
Report to Referring Phyt. n:
dress: .__ . __________ _____ loohonei______ ._________ ___ ____ OCEDURES
crolaryneotcopy tnovil Impacted Cerumen uterliatlon of Nasal Septum nirol of Natal Hemorrhage Cauterisation Packing l ral Irrigation D Unilateral Bilateral r bln alas. Cauterisation
<
rrlngolomy R L Insertion w/tribe OR L sal Fracture (Closed Reduction) >d*yi site___________________________________
AUDIOGRAMS (AU)
Pure Tone Air A Bone
With Speech Testing
Pure Tone Air A Bone Only
Speech Reception Threshold
Speech Discrimination
Impedance Testing
Acoustic Reflexes
TOII\fr Tests .
/
vestibulaAte
Caloric Test
'
Vestibular Teitgw/E.N.Q,.
Other Tests
_ . >_______
OTHrt SERVICES (O) .
n
FEE
Date of Service
PLACE OF SERVICE
name
TTx^r
O OFFICE HOSPITAL
HOSPITAL SE RVICES performed at
Ml. Sinai Hospital. New Vork, N. Y. 10029
Initial Hospital Consultation (IHC)
Code
FEE
Follow-up Visit() (HFV)
Dates
... . . .. ... ,, .
90260
____
<nnoF(v {)
fo 1 Do
D1 Do Not
[ Accept Assignment
PHYSICIANS SIGNATURE
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Dale
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HUGH K BILLER. M.D.
MEAD * NECK IUROCRV tt lA^TMTH BTNEET SUITE SAB
NEW YORK, N. V. INII
(Sit) I7MI1I
LISP 111713
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PRIVILEGED AND "CONFIDENTIAL MATERIAL SUBJECT TO PROTECTIVE
ORDER"
UcC 088755
C.One East One Hundredth Street Physicians.' P.
METZGER PAVILION - MAIN FLOOR - ROOM 19
<2121 650-7481 7482 7483
100TH STREET AND 5TH AVE. NEWYORK. N,. Y. 10029
ACCflUNT
M 13f
0ATE Of SE*
2- 24-84 TO
John Pettersen
694 Brace Avenue
Perth Amboy, N.J. 08861
FOR PRIVATE PROFESSIONAL SERVICES ADMINISTRATION OF ANESTHESIA
Dr. N. Patel $588.00.
l.D. TAX NO. 1 3-2694308
WE REQUEST REMITTANCE TO BE LEFT WITH HOSPITAL CASHIER OR
AT OUR BUSINESS OFFICE - HOURS 8:30 AM to 4 PM
PLEASE MAKE CHECK PAYABLE TO One East One Hundredth Street Physicians. P. C.
Pi Ait INDICA1F ACCOUNT NUMBER ON FACE OF CHECK
"CONF?nc/LEGED AND
ORDER"
Cc 088756
/- statement
HUGH F. BlLLCft. M.D,
9* CAST *ITM ItMCT SUITS Ml
NCWVOAN.I.T lm
(til) t#*44Xt
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PLEASE PAY LAST AMOUNT IN THIS COLUMN
AU-Movim
C--Contuitatlon HPV--M<JOltl FollOwUO Vltlt iMC-imtm Hotoitti Cooiuimion O--Omar Sarvicat
Ov-Offlca vltlt A---Procaduraa AOA-AkiI<m on Account S-Suroary VT--VaatlOutar Tattt
tv r is a copy or rout tocouvr u rr amm on *w.- uoGtt ca*o
PRIVILEGED AND "CONFIDENTIAL MATERIAL SUBJECT TO PROTECTIVE
ORDER"
UCC 088757
PRIVILEGED AND "CONFIDENTIAL MATERIAL SUBJECT TO PROTECTIVE
ORDER"
UCC 088758
YUAit StrCK iU
THIS NUMBER IN . lALL CORRESPONDENCE
" PATIENT NO.
. 041907
tUNIT NO1394158 TIENT: PETERSON,
JOHN
ittb MUUiN i OliNAi nU&niAL
.. ONE GUJTA.VE L.LEVY PLACENEW YORK, NEW YORK 10029. (212) 650-8885
FEDERAL I.D. NO: 13-1624096
STATEMENT
statement date
4-20-85
ADMISSION DATE
4-08-85
STATEMENT TYPE
DISCHARGE
DISCHARGE date
4-10-85
3 A G E **.
i
Days n hc.
n:,G
U A
BILL
PETERSON, JOHN
R A
TO
694 BRACE AVENUE
n [SS-L PL 280
INSURANCE CO
1 BC NJ 330024
2
3
GROUP NO
policy :.a.m
1610282 92
N
T
j^PERTH AMBOY
NJ 08861j
O
AMOUNT ENCLOSED S.
R
PLEASE MAKE CHECK PAYABLE TO THE MOUNT SINAI HOSPITAL AND RETURN THIS PORTION WITH YOUR PAYMENT TO
Ntw -ok oo.j
DSTING DATE
CODE
DESCRIPTION OF SERVICE OR CHARGE
408rl679 S RM/BRD
2 3 70.00
4IOfi 1510113BLOOO-SMA 6
4)08 1510114BL000--SHA 12
4j08 1420182COULTBI C0UNT-C8C
4108 142Q184BLQ0D--DIFFERENT IAL|
4k) 8 1210002ECG
408(1310311CHEST-1 FILM
410917760202CPERATING RC0M
40917760212RECOVERY ROCM
4|09 143003CBL000 TYPING 4091142 0004ISP. GRAVITY
4)1V 720008DAILY TELEPHONE LC
420 TOTALS
1,901.80
HOSPITAL SERVICES
WT 11
! 6800 ; 124tO0 I 4<j0(| : isoa ! 85iod
\
\
1)1i11i i
\
i 8^0d
11
155700
.1 i
14200
i i
i 2do<J
i
i 70 P | 7180
;
1190180
>1
1i
* ESTIMATED INSURANCE COVERAGE
11111 "
1 B/C 74000 6800
11111I1
1240d 44;od
11 8500
2
3
))11 1
\
a^od 557j0Cl
14200
1 29!0d
1i ^0C|
i ii
i ii
i
i i
89400
DUE FRG PaTIEN
7|
i
7e
420 992 9521INSUR PAYMENT ADJ
7146 8CRI
/h./. t/r/f/z&czj-
-
PRIVILEGED AND "CONFIDENTIAL MATERIAL SUBJECT TO PROTECTIVE
ORDER"
A! .
i UCC 0887 59
420 balance DUE
l*l?q*a
ATIENIT NO:
8041907 '
atient namE: PETERSON, JOHN AM to'tv IO PANEm -uPAMt 'N AtL CGMfUONOt*4Ct
THE MOUNT SINAI HOSPITAL ONE GUSTAVE L LEVY PLACE
nvw vOP2Ht 21nAswo-avaQasMk 10029
_____ 1____ i___ !___ ___ '
... 1
1179(32 ! ;
::
i
------ ?--
THIS BILL CONTAINS CHARGES FOR HOSPITAL SERVICES ONLY PLEASE PAY
t
CHARGES FOR PROFESSIONAL and OTHER SERVICES MAY BE BILLED
T--------- 1
INDEPENDENTLY
THIS AMOUNT
* THE INSURER'S ANO PATIENT'S PORTION OF THE CHARGES INCURREO HAVE SEEN COMPUTED ON THE BASIS Of PRELIMINARY INFORMATION FURN'SHED TO uS Final DETERMINATION OF YOUR BENEFITS BY THE CLAIM DEPARTMENT of 1-OUR INSURANCE COMPANY MAY CHANCE THESE AMOUNTS THE SETTLEMENT OF THIS ACCOUNT IS YOUR RESPONSIBILITY
THE MOUNT SINAI MEDICAL CENTER
ONE GUSTAVE L. LEVY PLACE NEW YORK, N. Y, 10029
R. JOHN PETERSEN
MAY.3,
M........................................................................................................................................................ ..................19..
694 BRACE AVENUE
.
ATTN: SPECIAL ACCOUNTS
................................................................................
19 EAST 98thst.rm.8B
PERTH AMBOY, NEW JERSEY 08861 2 .........................................................................................
PHONE:650-6333
PAT-OR
PHASE DETACH TOP PORTION - RETURN WITH YOUR REMITTANCE TO ACCOUNTING DEPARTMENT.
1^-84
ieieitie PRE-ADMISSION TESTING
TOTAL BLUE CROSS OF N.J. PAID
BALANCE DUE
BLUE CROSS OF NEW JERSEY ONLY PARTIALLY PAID FOR THIS ACCOUNT AND STATED THE FOLLOWING: PATIENT REACHED LABORTORY MAXIMUM. PLEASE REVIEW AND PAY,
445. 00
445. 00 104. 00 341. 00
UNPAID ACCOUNTS MAY BE SENT TO A COLLECTION AGENCY.
PUASE MAKE CHECKS PAYABLE TO "THE MOUNT SINAI HOSPITAL*' t
PRIVILEGED AND "CONFIDENTIAL MATERIAL SUBJECT TO PROTECTIVE
ORDER"
UCC 088760
It-tls NUMtttK IN
ALL CORRESPONDENCE
PATIENT NO.
7547 0601
UMT NO:
1394158
IENT:
PETERSEN,
JOHN
ONE GUSTAVE L. LEVY PLACE NEW YORK, NEW YORK 10029. (212) 650-8885
FEDERAL i.D. NO: 13-1624096
STATEMENT
STATEMENT DATE
3-19-84
ADMISSION DATE'
2-23-84
STATEMENT TYPE
DISCHARGE
DISCHARGE DATE
3--08--84
PAGE N
1
DAYS IN HC
G
U A
^PETERSEN, JOHN BILL
R A
TO
694 BRACE AVENUE
I
CO PL
INSURANCE CO.
20a 1 > BC NJ 330024
2
3
GROUP NO.
POLICY/CLAIM 16102829k
N
T
j^PERTH AMBOYU
NJ 08861^
O
AMOUNT ENCLOSED $_
R
PLEASE MAKE CHECK PAYABLE TO THE MOUNT SINAI HOSPITAL AND RETURN THIS PORTION WITH YOUR PAYMENT TO:
Jo*, niw to* ioou
DSTING
date
CODE
DESCRIPTION OF SERVICE OR CHARGE
HOSPITAL SERVICES
* ESTIMATED INSURANCE COVERAGE
1
B/C
2
3
DUE FRO PATIENT
2pH 681 W RM/BRD
2 355.OC
wim
2{25H 674 W RM/BRD
12 355-OC
4126000
4260(001
223(1510113BL00D-SMA 6 2(231510114 BLOOD-SMA 12
2231310311CHEST--1 FILM &3131085OhiET READING
&50Q
419^)0(
790a
i3j00
6500 jxi9|oa|
791001
13!00j
2$231210002ECG
81;O0
8100
2247770212REC0VERY ROOM 2S247770204k)PERATING ROOM
13600 8000Q
136100! isociod
2j24 7770712TRACHE0ST0MY TUBE 224(15300OaSURG. PATH .FRO. 8906|
28oq
83149
2551
2qoq 10900
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6500
65iO0j
'51O114|BL0OD--SMA 12
1190Q
inqoq
14201! :0ULTER COUNT--CBC
4200
4200
14201 i|BL 000--DIFFERENT lAIJ
niocl
uiod
43003! JL03D TYPING
2800
28oq
Jl 43005 OB LOGO COMPAT TEST J1420004SP. GRAVITY
2200 7|00i
2200
tool
^2 61420182CQUL TER COUNT-CBC
4210 0
42)001
227 1 530002SURG PATH.R0U.84241
628 ll
1919
82100
2)2 7182 OOOaMA SK , CANN UL A NE BU.
42jOO|
42joaj
22S18400041.V. SOLUTIONS
600
6(oq
22918400041.V. SOLUTIONS 3j011510U3BL00D-SMA 6 3O1151011418LDO0-SMA 12
1450
6504
11900
1450 65(0C| 11900
3011420182tOULTER COUNT-CBC
4200
4200
3)011 8400041. V. SOLUTIONS
itjSOl
ltsoj
301184000411. V. SOLUTIONS 3011840004I.V. SOLUTIONS
1400 17i50i
1400 17150
3(0211840 00411. V. SOLUTIONS
3f00i
3oc|
30 2jl 8400041. V. SOLUTIONS 302182OOOoMASKfCANNULA,NEBU 3041 82 0008MA SK , C ANNUL A ,NE BU 3041 820008IMASK, CANNULA ,NE3U.
305jl84000QlDRUGS 3O6I1510113BLQ00-SMA 6
1900 16800 12600
12600
4700! 6500
i9oq 16800
il26i00i
12600 471001 6*00
PRIVILEGED AND "CONFIDENTIAL MATERIAL SUBJECT TO PROTECTIVE
ORDER"
3Q^iL51 Oil 4iB LOOP--SMA 12
3kM84 000c1dRUGS
x BALANCE DUE
\TIENT NO: \TENT NAME:
NP( FQ P*INI NUMtft AU COrtJK>KHF<e
119.00
119j5d
X
11900 iii950|
UCC 088761
xn
ii ii 1
THIS BILL CONTAINS CHARGES FOR HOSPITAL SERVICES ONLY. PLEASE PAY
CHARGES FOR PROFESSIONAL AND OTHER SERVICES MAY BE BILLED _ . . . _ * .. i , . i -r-
INDEPENDENTLY.
THIS AMOUNT
THE MOUNT SINAI HOSPITAL
ONE GUSTAVE L. LEVY PLACE Niw ron. new to* loan (212) 6S0-8885
* THE INSURER'S AND PATIENTS PORTION OP THE CHARGES INCURRED HAVE BEEN COMPUTED ON THE BASIS OP PRELIMINARY INFORMATION FURNISHED TO US. FINAL DETERMINATION OF YOUR BENEFITS BY THE CLAIM DEPARTMENT OF YOUR INSURANCE COMPANY MAY CHANGE THESE AMOUNTS. THE SETTLEMENT OF THIS ACCOUNT IS YOUR RESPONSIBILITY
THIS NUMBER IN
all correspondence
"PATIENT NO.
7547060
UNIT NO:
1394158
riENT:
PETERSEN*
JOHN
1 A. - Av M.
^ X
> i"\l i X W kJl X X
ONE GUSTAVE L LEVY PLACE NEW YORK, NEW YORK 10029. (212) 650-8885
FEDERAL I.D. NO: 13-1624096
STATEMENT
STATEMENT DATE
3--19-84
ADMISSION DATE"
2-23-84
STATEMENT TYPE
DISCHARGE
DISCHARGE DATE
3-08--84
PAGE N
2
DAYS IN HC
G U A
Petersen* john BILL
R TO 6$4 BRACE AVENUE
A
n CO PL
INSURANCE CO.
isp 1 1 iC N4 330024
--* -- 2
3
GROUP NO.
POLICY/CLAIM
161028292
N
T
jPERTH AMBOYU
NJ 08861j
O
AMOUNT ENCLOSED $_
R PLEASE MAKECHECK PAYABLE TO THE MOUNT SINAI HOSPITAL AND RETURN THIS PORTION WITH YOUR PAYMENT TO: "w Jok, niw yok ioo*j
DSTING DATE
CODE
DESCRIPTION OF SERVICE OR CHARGE
840004 UV. SOLUTIONS L420182 :0ULTER C0UNT-C8C 82 0008 4ASK CANNUL A*NEBU 840020TAKE HOME DRUGS >7200085AILY TELEPHONE LO >720008 JAILY TELEPHONE LO L 840000 5RUGS L8400041.V. SOLUTIONS
L 8400041* V* SOLUTIONS
HOSPITAL SERVICES
1300 4200 4200!
404j 600! 3600; 130Oj 13 DO! 500!
319 TOTALS
8*125.04
8080 34
44?0i
3AW92 952 NSUR PAYMENT AOJ
* ESTIMATED INSURANCE COVERAGE
1 B/C 2
3-
130
4200
42001
1300 1300!
500! II I
807900 Il tI
10 34j920R
DUE FRO PATtEN'
40 60 360
460
PRIVILEGED AND "CONFIDENTIAL MATERIAL SUBJECT TO PROTECTIVE
ORDER"
uec S762
319
balance due --
"6*790.12
' TIENT NO:
---------------- P>47U60
'nENTNAME: PtrEftSEN, JOHN
J mu a YAfKNr mjutu in au coihvonocnce
THE MOUNT SINAI HOSPITAL ONE GUSTAVE L. LEVY PLACE
NEW rOK. Niw row 10029 12131 650-888S
X J___ L
PLEASE PAYTHIS BILL CONTAINS CHARGES FOR HOSPITAL SERVICES ONLY.
CHARGES FOR PROFESSIONAL AND OTHER SERVICES MAY BE BILLED - ,, . .
. . __
INDEPENDENTLY.
THIS AMOUNT
"55jC
* THE INSURER'S ANO PATIENTS PORTION OF THE CHARGES INCURRED HAVE BEEN COMPUTED ON THE BASIS
OF PRELIMINARY INFORMATION FURNISHED TO US. FINAL DETERMINATION OF YOUR BENEFITS BY THE CLAIM
DEPARTMENT OF YOUR INSURANCE COMPANY MAY CHANGE THESE AMOUNTS.
TU8 CtmcUEUT
TUIC i/'P'ftllMf 1C VAIIB
l*W
PERTH AMBO.Y GENERAL HO-iri i At.
*`
Thi* is t certify that I o my own will am releasing myself or my n
10/24/78 PETERSEN
1# DAYS CODE 231
MB'
03it
JOHN (08861)
ELECT, natoer no. i 227512.1
A
694 BRACE AVENUE PERTH AMBOY NE WJERSEY 1216^49484^
444422 11334411
PPRR E
l*?
' -t
; 49
* .5r
^ wif>`V
4/29/29_____!___ MM/1___ W
to* t#*:|
from the Perth Amboy G neral pitol against the advice of the afi ing Physician.
noPH____--S-- 5SW
511-01 $12Q___ td
SHIRLEY
*033R3
-SAME
WIFE
OOCTO*
SAHE
2
jltTMCwC
143.8
DR. I..J.
iri-lTT^O HiMM
LESION OF LEFT VOCAL CORD
FINE
(w'fin? a-
L. SAME.
I release the hospital, it, employee officers, and my attending physician all liability for any adverse results c by myself or my minor leaving the ht
OCCtAtrO*
.
prematurely.
HAIWT. SUPRV, I__________AMBOY TERM INAL ING CO.
, o went
vn
PERTH
NONE EC/ D
AMBOY
N.J.
*V\ta* / 9rtC
1 -l/i
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N.J. PLAN # 1610 28 2929
COvf4*6
CODE 655
J
F
,1 lYRS
IT
WA.
GROUP# 00 R5326--EE.DT, 3/1/78 o*curroe ho PAT RSSP/ SUB THRU ABOVE
0*t*
FiNAl DIAGNOSIS (STANDARD NOMENCLATURE)
A Qa-S'h
1-
"COnSLEGED and
ASSOCIATED DISEASE
ORDER"
CODE
OPERATION
CONSULTATION WITH.
CONDITION ON
.--,,
_
_ __
DISCHARGE:
U RECOyfRES-J IMFRQVEI^LJ UNimF-RCVED _j NOT TREATED EXPIRED AUTOPSY
REMARKS.-
CAUSE OF DEATH; APPROVED 8r RECORD COMMITTEE
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UCC 088763 .
SfCNAfUtf OF ATTfNPlNO PMTSCUN
P*rlfc JUborGmardl Hospitml
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PRIVILEGED AND "CONFIDENTIAL MATERIAL SUBJECT TO PROTECTIVE
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UCC 088765
RARITAN BAY HEALTH SERVICES CORP.
y PtflTH AMBOY GENERAL HOSPiT-'-L ' ..D BB'jCO pt. CAC'iAL HOSP'T-'L
NAME PETERSETT
KXgRSXlM JOHN
FULt ADDRESS
FIRST
(06861 )
ELEC PAT
HISTORY NO.
38 0063-8 049484 >
TELEPHONE
RELIGION '
ACE
DATE OF
H
SEX jLiAbS
442 1341
PRO
50 4/29/29
MM-1! W
DATE ADMITTED
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[FLOOR
ROOM
5/15/79
Y&5/
7*,,
S_____1 SOS____
NOTIFY in emergency
rt.Fi*iONe
RATE
MARITAL
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RELATION
SHIRLEY
address
SAME
WIFE
SAME
SERVICE
|ATTENDING HYSIC AN
|REFtRSED BY
INI___P_ 1 143-8 DR. 1.J.FINE-
ADMITTING .DIAGNOSIS
I SAME
LESION VOCAL CORD LEFT SIDE;
OCCUPATION
EMPLOYER
,MA.jJiT-r- SUPER.V
ADR$5VSipfPt^' M'APtMCv?f`6Y,Nj
amboy terminal co.
TEie^HONC
YRS EMPLOYED
PREVt^)U^ ^ygSlONS
F/C- d---------
DA/S SrAY
..........1 DISC
.
DIED ! ' 'A
-7/
'NO PHONERESPONSIBLE PARTY OR ;nS.?an.;E COVERAGE
13YRS
`
_____NJ PLAN LDENT# F. 1 fil Q 23 2Q2Q Qrf A55
This is to certify that I of my own free will am releasing myself or my minor
Nome of Potient
Relotion&hip from the Perth Amboy General Hos pital against the advice of the attend ing Physician.
DOCTOR
I release the hospital, its employees, and officers, and my attending physicians from all liability for any adverse results caused by myself or my minor leaving the hospital prematurely.
Signed
Witn*
ADDRESS
ERTiFlCATE NO. ^INSURANCE
5E.D. 9/1/78---------GR 00 85326 THRU.----- -- Date
--ABOVE SUB.--------SUB. PT. ANU"F'TTKES'PTF/TT
FINAL DIAGNOSIS (STANDARD NOMENCLATURE)
L^~L-,____ An-i--
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CODE NO. /i- /
ASSOCIATED DISEASE
privileged and
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OPERATION / /
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CONDITION ON
'_
DISCHARGE:
G- RECOVERED V'pRCVED U UNIMPROVED NOT TREATED
REMARKS:
EXPIRED
AUTOPSY
.AUSE OF DEATH:
UCC 088766
APPROVED BY RECORD COMMITTEE
DAY SURGERY CENTER FACE. SHEET #2
i,. , , PETEPSEN JOHN
/' /
3SQ062-S
4 ) 4-i. -20
142--fine
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PEFTH AMPCY .K-1C
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FINAL DIAGNOSIS (STANDARD NOMENCLATURE)
ASSOCIATED DISEASE: COMPLICATIONS: A OPERATION: A
--yit-
CODE NC
PRIVILEGED and `^^NT'AL MATERIAL SUBJECT TO PROTECTIVE
ORDER"
DESCRIPTION OF OPERATlftN: What was done. Incision, Normal and Pathologic; What was removed, Drained, C lOSure, *c. --
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UCC 088767
CONDITION ON DISCHARGE:O Ambulatory CD No Pain ^?WSTeedirig MEDICATION:
nMMiiAN BAY HbALl'H SERVICES CORPORATION Perth Amboy, New Jersey
DAY SURGERY CENTER
ate
Chief Complaint/History of Present Illness: ___
PETEPSE'I JOHN
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Senses
Past Medical History (If yes, explain below)
NO
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Parity
SUBJECTt?AL MATERWL SUBJECT TO PROTECT/VE
ORDER"
VES
NO Vft
m DIABETES
Q
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E COUGH
D SMOKE
Q
TBC
0 NEUROLOGICDISEASE
NO
B HEART DISEASE B JAUNDICE ffi LUNG DISEASE KIONEY DISEASE A Gl DISEASE 5 CONTACT LENS
T
Previous Anesthesia
Explanation or other
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Previous Surgical Complications
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PHYSICAL EXAMINATION: AGE
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UCC 088772
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DICAL RcCC.SOS
THU it * coNriutwriAi and fHiviutcsn communicatio*
THE MOUNT SINAI MEDICAL CENTER
nsw runs
PRIVILEGED AND
"CONFIDENTIAL MATERIAL SUBJECT TO PROTECTIVE
ORDER"
SUMMARY
Dictatorjutd Dwtalov'i.No.:
l>t* of Dictation: At tending NtyjrcunService:
Dr. Klar3fuj.d #4403 7-3-84
Dr. 3illor
ENT
Paiienl: Peterson, John Unit No/. X394-X58 Admitted: 2-23-84
Uncharged. J-8-84
DISCHARGE DIAGNOSIS
Well differentiated squamcus cell carcinoma of the true vocal cord with infiltration of the lamina propria.
OPERATIONS *,JF ANY)
Left hcmilaryngestony by Dr. 3i_Ier on 2-24-84.
HISTORY The patient is a 54 year old male admitted with a left vocal ccru squamous cell CA. The patient has a history of vocal cord stripping 5 year3 ace, at P'rth invcy with a moat recent 5 month history of progressive hoarseness without dysphagia or odonephagia. No neck masses or weight loss are noted. Recently scoped with positive squamous cell CA.
PHYSICAL EXAM Exam was remarkable for no nook nodes, no masses, trachea was midlir.o There was a left vocal core lesion located to the. anterior commissure but did not cross the c emirsssu're. The vocal cord lesion was locettf on the true vocal cords. Epiglottis was normal, and periform sinuses werenoted to be normal.
PATT HISTORY Past medical historv was otherwise unremarkable.
HOSPITAL COURSE The patient underwent a direct laryngoscopy, trachnostomv, prelaryngeal node hiops^, and left hemilaryngectcmy on 2-24-84. Surgeons were" Drs. Biller; Ettlestoi n, Gidfried, and Servidio. The patient tolerat-d the procedure well. ? crtooerusively the patient initially had a low grade isvor to 101 , with some crackles in both chest fields and wa3 congest.a. The pa tie.nt was placed on chest PT and frequent suctioning i . < rdsr to f .cixitate the brrathing. s ^:*nept tor. otb-v, incident the .ntient d iu very well postoperatively and was disc.', ml or. 1-3-34, hi:j i::ch s i*-e alncst completely closed, and to be foils . by Dr. 3iller s -'fries
LAE DATA - inax path report b-'t./ed fat 'p.d lymph nc .^3 nngativ- for tumor. :-i ; had a left honilaryngectcmy ..uc:.,n * t, v. .11 differentiated varucaeqmamous cell carcinoma of the true cord vith superficial infiltratisu
UCC 088774
PaiiMic Paterson/ John twt 1394-158 of the lamina propria and moderate dysplasia extending into the posterior margin. Laboratory values remained within normal limits while in the hospital. JK/dmt/RR EnveloDG #13 7-14-34
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UCC 088775