Document ypkpwyBLj83J9DYgDbNox6q3V

Baystate Medical Cente Springfield, Massachusetts Adra: 6/1/37 g Name WARREN, JOHN K. Guaraieri, M.D. Dijc; 6/13/87 # 03542S2EE HISTORY OF PRESENT ILLNESS: dizziness. Chief complaint was unsteadiness anc This 63 year old, white male with a 20 years hisuory cf Meniere's Disease presents complaining1 of a two day history cf dizziness and significant headache. The patient states that he had been in his usual state of good health until 5/30/87 when shortly after awaken ing he developed some nausea. Shortly after his nausea began he developed a headache which began initially in his right eye and subsequently migrated across his forehead, down the crown cf his head, and down to the occiput. Ha stated that the headache was right sided only. The headache and nausea ware accompanied by dizziness, trouble focusing, and some dry heaves, although the patient's wife states he had vomited up some brownish material. He did not go to work that day because of his nausea and light headedness. He had anorexia for the rest of 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 headedness in that arm. Throughout the rest of that day, 5/31/S7, he reportedly began to feel somewhat better. This a.m. 5/31/37, the patient stares that his nausea and vomiting had resolved and he was able to keep solid feeds down. He stared that he was still dizzy, unsteady, and his right arm still is somewhat unsteady. He reports that he -ypicaily 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, excere that he was a litrle mere unsteady trap, usual. Also arypical is that he dees not have arm Typically he does not have a headache associated with his Meniere's attacks. PAST MEDICAL HISTORY: 1} Status FCst head trauma with 13 sutures on the occiput on 11/19/35. 2) History of arrhythmias 11/35 to 12/35 on Procan, subsequently discontinued by Cardiologist. Follow-up Holters and tread mill stress 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 I also had a CVA. An 84 year old sister alive and well, status post ' hip replacement. Springfieid-Wesson Women\ Unit n W c:*scr. Memorial UCC 086031 t ! Hi-aory arid Physical Operative Note I :{ D'vcharee Stimtnarv I i Otter PRIVILEGED AND CONFIDENTIAL MATERIAL" SUBJECT TO PROTECTIVE ORDER" WARREN, JOHN, K. Guarnieri, M.D Pace 2 SOCIAL HISTORY: Patient is married, lives with his wife in Springfield, has children. Denies any history of cigarette smoking or alcohol use; -Works-as a -tank farm operator at Monsanto., Reports exposure to and MEDICATIONS: Dramamime prn. dizziness. Allergies; none. SYSTEM REVIEW: Poor dentition by history. History of some dizziness times many years. Fatty tumor the right"upper extremity. PHYSICAL EXPO-1: Generally well developed, well nourished, white male in no acute distress. Alert and oriented times four. Tenc. 93.9, pulse 72, E? 124/64 lying, pulse 76, B? 130/70 sitting posi tion, respirations 16. EZZNT; NCAT, scar on the occiput. PERL. ECMI. Strabizmus ncued of the right eye. Patient with horizontal nystagmus of eyes on right gaze, greater than left gaze. Fundi- poorly visualized. TMs clear without erythema. Nose and throat clear. Mouth with poor dentition. Neck; supple, full range of metier, without JVD, without lympnadsncpathy, without thyromegaly, without bruits. Heart; RR normal, normal Si, S2, with a 1/6 systolic murmur at the left sternal border without S3 or S4. Lungs; clear to auscultation. Coarse bilateral breath sounds. Abdomen; soft, contender, positive bowel sounds, without masses or organo megaly. Ixuremities; without clubbing, cyanosis, or edema. Cranial names 2 through 12 crossly intact. Cerebellar was intact. Motion was 5/5 in the upper and lower extremities bilaterallv. Sensory exam was grossly ir.uact to light touch and pin prick. Rectal; heme negarive wirhout masses. * LABORATORY: Upon admission revealed a hemoglobin 11.9, hematocri'i < UJ > j t; .8, a W3C count 8.7. Patient had a differential of 3 bands. 25 c :iys, 1.lymph, 1 memo, sodium 139, potassium 4.3, chloride QC t-- O HI o ICS*, 24, glucose 70, BUN.19, creatinine 1.1, calcium z Im 111 9.0. 2<H **5 0 = Q j Ct HOSPITAL COURSE: Patient was admitted with the diagnosis of in 2 a. uj Meniere's Disease versus a cerebral vascular accident. Patient Ul t- 2 0 _l Z *- o 5 ul t- underwent accident. a CAT scan of the head to rule out cerebral vascular CT scan of the head revealed multiple lesions sugges g Q o tive of metastases. As a result radiation therapy was consulted a. E U->l :o begin radiation therapy to the patient's head. Patient under O 5 went a bronchoscopy to attempt to assess possible pulmonary source 9 'or his metastases. Bronchoscopy showed-inflammatory disease of nknown etiology, however, without any evidence of a ..letastatic 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 biopsy revealed necrotic tissue without clear evidence or either vrim.ar'f cancer or metastasis to the liver. Patient was placec on UCC 086032 WARREN, JOHN K. Guamisri, M.D Pace 3 IV Decadxon to try to reduce some of his cerebral edema and radiation to his brain was continued. However, again no clear cut primary source was evident. Further work-up of the patient's brain lesions included IV? and CT scan of the pelvis which were again ncndiacncstic of primary lesion. He continued to have daily radiation therapy as well as Decsdron. However, as no primary .lesion was discovered from the patient's canc.er and he was feeling somewhat better after receiving radiation .therapy and Decadron, patient was discharged to home in stable condition on 6/13/37 with regular diet and activity ad. lib. dedications on discharge were Decadron 4 me. p.o. c.i.d. for three days and 2 mg. p.c. c.i.d. for two days. Patient was to see Dr. Arthur McGuire at his office one week after discharge for continuing of the tapering schedule. Patient was placed on Reglan 10 mg. p.o. one rac and c. hs., Carafate 1 cm. p.o. one rac and c. hs. FINAL DIAGNOSIS: 1. METASTATIC BRAIN CANCER WITH UNDETERMINED PRIMARY. 2. QUESTION OF A LUNG CARCINOMA. 3. RADIATION . THERAPY TO THE -PAIN. 4. STATUS POST BRONCHOSCOPY. 5. STATUS _PC.SC COMPUTED TOMOGRAPHY DIRECTED BIOPSY OF THE LIVER WHICH REVEALED MENINGIOMA. 6. MENIERE'S DISEASE. The patient will be followed by Dr. Arthur McGuire for furthe: wcrk-uo as well as for KG: bsa= 23 D-.1Q/5/87 T: 10/10/37 cc: Dr. K. Gua: PRIVILEGED AND "CONFIDENTIAL MATERIAL SUBJECT TO PROTECTIVE ORDER" UCC 086033 Baystate Medical Center Springfield, Massachusetts Adm: i/i/88 expired 231633 Name WARREN, JOHN H.Dr. FlatowDisc: 1/29/85 # 056629646 g f-- o p O tz Cs t CL Ui oQ I-- o UJ 0Q =) This 64-year-old white male with hemangiosarcoma of the liver widely metastatic was admitted through the Emergency Room with persistent vomiting of coffeeground material, progressive weakness. The pa tier, was discharged home 36 hours prior to this admission following reins tution of whole brain radiation for central nervous system metastase He had a long history of Meniere's disease with tinnitus and vertigo but was admitted in June of 1987 with exacerbation of symptoms. Stu -at that time showed multiple brain metastases and following biopsy c - -pleural and pulmonary metastases the diagnosis of hemangiosarcoma wa made. The patient gave a long history of exposure to vinyl chloride at .his place of employment. In J.une he was treated with whole brain radiation plus Decadron with improvement and then received chemother with DTIC, Adriamycin followed by Methotrexate plus Citrovorum reset without any improvement. There was progression of multiple pulmer.ar nodules, intermittent hemoptysis, intermittent hematuria, progressiv anemia with positive stool guaiacs requiring multiple transfusions. On his recent admission for severe weakness and ataxia repeat CT sea of the brain showed recurrence of the CNS metastases particularly in the posterior fossa. On 12/31/87 radiation to the whole brain for 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 t 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 medicatic at home included Dilantin 400 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. KEENT: total alopecia no scleral icterus, pupils were equal,.extraocular movements normal, nose and pharynx.unremarkable. -Necki.no venous distension. Lungs: clear to percussion, inspiratory rales present lower left lung field Heart: sinus tachycardia, grade 2/6 systolic murmur-left sternal bor 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. No rectal masses. Extremities: no focal weakness, no dependent edema, deep tendon reflexes 3+ and symm trical. . LABORATORY DATA: Hemoglobin 8.1, hematocrit 24.5, white count 15,30 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. SpringficldAVesson Women's Unit I I Wesson Memorial HMory and Physical Operative Note continued UCC 086034 m Discharge Summary j ! Other WARREN, JOHN H. continued.... Dr. Flatow - -- Calcium 7.8,. total protein 3.7 with' albumin 1.9, alkaline phosphate: 316, LDH 04, 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 IV^fluids and continued on his Lanoxin and Dilantin. Decadror was switched to 4 mgs intravenously every 6 hours. Compazine was given IM for nausea. Carafate and Zantac were added for possible upper GI bleeding. The patient was continued by Dr. Stark on his whole brain radiation with treatments through 1/12/88 to a total of 4 60.0 rads with 14 0 0 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 pro 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 wioh cutaneous metastatic lesions. Great difficulty was had in maintaining peripheral IV sites. Toward the end of his course additional discussions were field 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 care ..was 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 undersigned present.' Permission for postmortem examination was not obtained. FINAL DIAGNOSIS: 1. HEMANGIOSARCOMA OF THE LIVER. 2. RECURRENT ; METASTATIC DISEASE TO THE BRAIN. 3. MULTIPLE PULMONARY METASTASEST 4. PERSISTENT GASTROINTESTINAL BLEEDING WITH SUSPECTED GASTRO INTESTINAL METASTASES. 5. INTERMITTENT HEMATURIA WITH SUSPECTEDURINARY TRACT METASTASES. 6. MULTIPLE CUTANEOUS METASTASES. 7. PAST HISTORY OF CARDIAC ARRHYTHMIAS. Om 2 CO FF/bss23 D: 2/16/88 T: 2/18/88 cc: Dr. Flatow F. Flatow, M.D. ucc 086035 PRIVILEGED AND `CONFIDENTIAL MATERIAL SUBJECT TO PROTECTIVE ORDER" .Jl O^a00t0e^T^i-m"e" Prooiem | #1 l^L wcj^/zyv pLJZdOJpjcLpntf71-, S?Z<CJ& cLj. C /C L?^ nr?/.on. 6_JC?r/>n ( P 0 DC^rC/ forPOT^bord '-------------1/9 (^~rPJr)?L- /co n C,P^c,oo. ^JZcocl^ Y' C/U.CJL C Qp J>rl ^nC/PoP^t. ahn&^sJer-nn h&A c n JzlCLsCJnls 1 /.ny-?C.^7CP~ rtl-n.O^- -A La_> jod<5 o ' d/Q>A . c^JZjLnrs-P - . [Mi,o? u~?ruz^CGLe,^_ aMsW^ci^lAjL lLq . ' if: irhj>-i> `jhA'fYC. , a&j 'h/Jecbru dkPntnco \\ ! C/7rrnes "-----------:---------------' Loi_ lA'St'l^i l<T i f CCCIL-: Cl ! 9r.\\ ,'r-\' >Lu 0t x, .V0J - ' -o/>'-U'f/ _ y* rf I T c.`ii^.L.>u"'"v.' _ --r. -o_j_ . f?. 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L^S. a.'Ta_-v-oLu ibshs .' rTV^ ^._Wa_3 7L> - ' iQ (T{ , + Af>C-<T t'0l . -H -> " --- - Q A n 0\3-.!> C 1 QT C~ ll ^ b- fit-. U'A HusL. ^'V^.lLSvJ ^7-./VL^ao^- . ^><\.'kU^.OPI ~hvj!_<s',^ YiOl-0 r.cth../U-. >S-U/.^r< aVp . r;V*vr-/A_. p r iv il e g a n dM CONFIDENTIAL MATERIAL Jii~IF\ LU 1 o LU H o= oc a: a. uj Og P '. ^..0 jgcA y /OC/3 / ~ -` <g /m? ,aj <fvi <L<rtit.j.a_ , ^p^<uA~^dL ^ oi&JLs CU--k^ A S-/ 3 <v 5 ;o D: pi .<n ,< WCbCs pc if M ^ y?5S ; ^/ f w f^ui' ^ ph^p rt VI Ot W>.pp r) ft 1 pol rL^~ M sfciv\ r vLiX^yi t U-:V- /ft: nh-P4./ UCC 086039 ; ^U-a <PTP nr^pf t/ y?M,m1$- *>tu rd\Q <JyM> o Ul -J CO D w Date Time Problem # & <g> ^ 8-- Am. A* u a_:,,. ? __A, 'b-dL. r -r 4 ^ ? (\ I- ' ^ *___iA. , V ^ ^-V - j Q *<, 'jaA \-f& y P____ v p . -if i 4\*' g(. ri_ \ j*i f s\ /VA xG>,. U -W--^ -.a P,. 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