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HomeMy WebLinkAbout01-04-07 .. ,j Joseph A. Ricci, Esq. Pa. ID 49803 Lavery, Faherty, Young & Patterson, P.C. 225 Market Street Suite 304 Harrisburg, PA 17101 (717) 233.6633 Counsel for Carlisle Regional Medical Center o ~o --::0 .~!? -0 -.,...!IO -:,) ::t:>r- ?;2;9j "c"_ (f) x ~J,.} ~-) 00 :::) c .." . ::0 ::0 --1 ]> ,...." = = -..t <- )> 2: I +:- -0 :x Co.) +:- co : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY PENNSYLVANIA IN RE: John Brennman : DOCKET NUMBER: : EMERGENCY GUARDIANSHIP EMERGENCY PETITION FOR PLENARY GUARDIANSHIP OF THE PERSON AND ESTATE AND NOW comes, Carlisle Regional Medical Center, by and through its counsel, Lavery, Faherty, Young & Patterson, P.C. by Joseph A. Ricci, Esquire, and requests that this Honorable Court enter an Order granting an emergency plenary guardianship of the person and estate of Mr. John Brenneman for the following reasons: 1. The alleged incapacitated person is Mr. John Brenneman, an adult male aged 80. 2. M,.. Brenneman is currently a patient in the Intensive Care Unit at the Carlisle Regional Medical Center. 3. Prior to his hospitalization, Mr. Brenneman was receiving care at the Forrest Park Health Center, 700 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania. ,i ,I 4. Mr. Brenneman has no known relatives. 5. Currently Mr. Brenneman is receiving medical services at the Carlisle Regional Medical Center, 45 Sprint Drive, Carlisle, PA 17013. 6. Prior to his admission to the hospital, Mr. Brenneman was receiving medical care at the Forrest Park Health Center. 7. Prior to his admission to the Forrest Park Health Center, Mr. Brenneman was a residing at 17 Shirley Lane, Boiling Springs, Cumberland County, Pennyslvania. 8. The Petitioner requests that this Honorable Court appoint Mr. Richard A. Hess, 15 Shirley Lane, Boiling Springs, Cumberland County, Pennsylvania as temporary guardian of the person and estate of Mr. Brenneman. 9. Mr. Richard A. Hess is the long time next door neighbor of Mr. Brenneman and has been his closest friend for 19 years. 10. Mr. Richard Hess has been providing financial assistance to Mr. Brenneman since his hospitalizations. 11. Mr. Richard Hess has been authorized by Mr. Brenneman to receive Privileged Healthcare Information. See Affidavit of Dr. Donald Kovacs attached hereto as Exhibit "A." 12. Mr. Richard Hess does not have any interest that is adverse to the interests of Mr. Brenneman, the alleged incapacitated person. 13. Mr. Richard Hess has agreed to accept appointment as Guardian of the Person and Estate of Mr. John Brenneman, the alleged incapacitated person. See Affidavit of Richard A. Hess attached hereto as Exhibit "B." ,1 ,l 14. The emergency plenary guardianship of the person and estate of Mr. John Brenneman is necessary for the following reasons: a) Mr. Brenneman is an elderly gentleman who is currently a patient in the Intensive Care Unit of the Carlisle Regional Medical Center who is in an unconscious state and is unlikely to recover the ability to act on his own behalf. See Affidavit of Dr. T. Alex Boshnakov attached hereto as Exhibit "C." b) Mr. Brenneman has no known family members. c) The Forrest Park Health Center has relinquished responsibility for the care of Mr. Brenneman upon his admission to the Carlisle Regional Medical Center. d) At this time, there is no other reasonable alternative to effect the proper care of Mr. Brenneman besides the appointment of a plenary guardian of the person and estate. e) Mr. Brenneman suffers from an acute metabolic hypoxic encephalopathy following a cardiac arrest which occurred at the Forrest Park Health Center. As a result of the hypoxic encephalopathy, Mr. Brenneman will potentially suffer from numerous medical complications, which will require an ability to understand the nature of the complications and how they will be treated. The treatments necessary will include the need to provide informed consent to permit the medical treatments. Moreover, the medical condition of Mr. Brenneman is one in which he may desire to withhold medical care since the ;a " likelihood of recovery is extremely remote absent a medical miracle. See Selected medical records attached hereto has Exhibit "D." f) Mr. Brenneman is unable to speak due to his comatose condition; therefore, he is unable to participate in medical decision making on his own behalf. See Affidavit of Dr. T. Alex Boshnakov attached hereto as Exhibit "C." g) Mr. Brenneman has previously indicated, on numerous occasions, to his primary care physician a desire to refuse care suggested for purposes of diagnosing and treating potentially life threatening illnesses such as prostate cancer, colon cancer, and chronic illnesses such high cholesterol. h) Mr. Brenneman has indicated to his friend and neighbor, Richard Hess that he would not desire to receive medical treatment that would merely prolong his death and not effect a cure. See Affidavit of Richard A. Hess attached hereto as Exhibit "R" i) Without the appointment of a guardian, the medical staff of the Carlisle Regional Medical Center is unable to properly effectuate the wishes of Mr. Brenneman and provide reasonable and necessary medical treatments to properly care for Mr. Brenneman, since the patient is unable to provide the necessary consents for his continued care. 11. A plenary guardianship will permit the appropriate decision-making to take place in the short term and allow for the wishes of Mr. Brenneman to be carried out. WHEREFORE it is respectfully requested that this Honorable Court issue an Order appointing Richard A. Hess, Boiling Springs, Cumberland County, Pennsylvania as fa ..1 guardian of the person and estate of John Brenneman for the purpose of providing medical decision-making authority. Lavery, Faherty, Young & Patterson, P.C. Date: ~ ~I 07 .. AFFIDAVIT OF DONALD J. KOVACS. M.D. AND NOW this ~day of January 2007, I, Donald J. Kovacs, M.D., do hereby swear and affirm: 1. I am a physician licensed to practice medicine in the Commonwealth of Pennsylvania. 2. My medical practice IS limited to the specialty of Family Practice and Geriatrics. 3. I am the primary care physician for Carlisle Regional Medical Center patient John Brenneman and have served in that capacity since 1989. 4. Mr. Brenneman became a patient of the Carlisle Regional Medical Center on December 28, 2007. 5. Mr. Brenneman is a patient suffering from severe hypoxic encephalopathy as a result of cardiopulmonary arrest which occurred at the Forrest Park Health Center. 6. Mr. Brenneman is currently comatose and requires mechanical life support including ventilatory support. 7. Mr. Brenneman has indicated on numerous occasions that he did not wish to receive care which would prolong his dying and not effect a cure. 8. Mr. Brenneman has, on numerous occasions, refused diagnostic tests to identify preventable and treatable illnesses such as prostate cancer, colon cancer, and chronic illnesses such as high cholesterol. 9. Mr. Brenneman's refusal of care is rationally based upon his realization that he has no family to support, that such illnesses if treated could result in prolonged survival with a poor quality of life which would be hampered by potentially serious disability. , 10. Mr. Brenneman has no family. He is widowed. He has no children. He was an only child and has no siblings. Both of his parents are deceased. 11. Mr. Brenneman has indicated that he has a close friend by the name of Richard Hess who has been permitted to receive Private Healthcare Information. 12. Mr. Brenneman has indicated that Mr. Hess is a neighbor who has been providing assistance with financial matters when he has been unable to handle those matters himself. 13. I had occasion to meet Mr. Hess while Mr. Brenneman was hospitalized in early December 2006 and found Mr. Hess to be a responsible individual to who expressed a desire to provide what ever assistance was required for the benefit of Mr. Brenneman. 14. Mr. Brenneman's current medical condition prevents him from being able to provide his informed consent to any medical care which he may require. 15. Mr. Brenneman's inability to communicate prevents the medical staff at the Carlisle Regional Medical Center from effectuating the wishes of Mr. Brenneman. Respectfully submitted, Date: Jl Lf 10] ~ J l~ MO Donald J. Kovacs, M.D. Sworn to r:.:nd !f~rtbecl of 2~. ~ '" t1-t'" ;U\ '.) ,,-(i_" ;.. brl" H{11. .., ,... ."'.H~ ~c,-t" . '<,~ ~jj'_d r: );, ., '" l> ;t. ..!.,..t.01f'....r :~!_,.,\J_ i .~~.~r:'~\:i:'~~'i',;:t_i~~.. (:- __=4:.} ; ", ,~1,~~ ", ii,..... \.>,.,:1,;/,\1.:, ,l"iJ < \ . ~ 1 . ;,~ ..' "-:~: t'>' A:' q':' il" ~' ,I )1. .. . AFFIDAVIT OF RICHARD A. HESS AND NOW this ~ day of January 2007, I, Richard A. Hess., do hereby swear and affirm: 1. I am adult individual who resides at 15 Shirley Lane, Boiling Springs, Cumberland County, Pennsylvania. 2. I am the next door neighbor of John Brenneman, currently a patient in the Intensive Care Unit of the Carlisle Regional Medical Center. 3. I have known Mr. Brenneman for 19 years. 4. Mr. Brenneman is a widow who has no children, no siblings and no known extended family. 5. Mr. Brenneman has authorized me to receive Private Healthcare Information from his primary care physician, Dr. Donald Kovacs. 6. Since Mr. Brenneman became ill in December of 2006 I have been authorized to assist Mr. Brenneman with his financial matters and have reviewed his mail, deposited checks and assisted with the payment of bills. 7. Since Mr. Brenneman became ill and was a resident at the Forrest Park Health Center I was instructed to contact his attorney, Hamilton Davis, Esq. in the event it was necessary to obtain a copy of Mr. Brenneman's will. 8. I have been advised that representatives of the Carlisle Regional Medical Center have been told by Attorney Davis that the entirety of Mr. Brenneman's Estate is to be left in trust for the University attended by Mr. Brenneman's deceased wife. 9. I have no financial interests in the Estate of Mr. Brenneman. l . 10. As Mr. Brenneman's closest friend, I am in the best position to be able to respond to inquiries about Mr. Brenneman's medical care. 11. As Mr. Brenneman's closet friend, I am in the best position to see that Mr. Brenneman's wishes are carried out. 12. Mr. Brenneman has on numerous occasions had conversations with me in which he expressed his wishes that he not receive medical treatments which would only prolong his dying and not effect a cure. 13. I am willing to accept an appointment from the Court of Common Pleas of Cumberland County as Guardian of the Person and Estate of Mr. Brenneman. Respectfully Submitted, Date: ~VOJ~ ~ ,2;JOl ~J~a,~ . chard A. Hess ,'~l ".' . ?Vi'~~ ...~,.\';,\I r't"';"~.,.),) '.1;..1'. :.~ ~'~ll':': J'> .).' ~\'d:i''t' ..,. :\(,l. It: .,,',;" !'_._ 'j.'."! tr;-""A" IV." ,,' "_(i~. .1 ';'\11~, .... ,d,."'" ;;,tJ ',,'i../,~.t t... ',~ i ,'~:' ;,_. t') , ~: ..." ' ....,.' (fl";, ," ,..1.,.!~, ''''i ~,f' l AFFIDAVIT OF T. ALEX BOSHNAKOV. M.D. AND NOW this ~ day of January 2007, I, T. Alex Boshuakov, M.D., do hereby swear and affirm: 1. I am a physician licensed to practice medicine in the Commonwealth of Pennsylvania. 2. My medical practice is limited to the specialty of Internal Medicine. 3. I am one of the attending physicians for Carlisle Regional Medical Center patient John Brenneman. 4. Mr. Brenneman became a patient of the Carlisle Regional Medical Center on December 28, 2007. 5. Mr. Brenneman is a patient suffering from severe hypoxic encephalopathy as a result of cardiopulmonary arrest which occurred at the Forrest Park Health Center. This condition renders Mr. Brenneman severely disabled with significant and irreversible damage to the brain. 6. Mr; Brenneman is currently comatose and requires mechanical life support including ventilatory support. 7. Mr. Brenneman is unable to communicate and therefore cannot meaningfully participate in decisions about his medical care. 8. Mr. Brenneman currently requires breathing support with a ventilator; accordingly, he is currently in need of the use of an endotracheal tube. 9. The long-term use of an endotracheal tube will cause the patient to suffer painful pressure ulcerations of the throat and lips. .# t . 10. Painful pressure ulcers caused by an endotracheal tube can be avoided if the patient undergoes a surgical procedure known as a tracheostomy. 11. A tracheostomy involves the surgical entry into the trachea to allow the placement of a breathing tube. 12. A tracheostomy is a surgical procedure which requires a patient's informed consent. 13. Mr. Brenneman's medical condition prevents him from being able to provide his informed consent to any medical care which he may require. 12. Failure to obtain the necessary consents for surgical intervention will subject Mr. Brenneman to painful and unnecessary pressure ulcers of the throat and lips. 13. Mr. Brenneman is unable to obtain adequate nutrition without the surgical insertion of a feeding tube. 14. Insertion of a feeding tube IS a surgical procedure which requires the patient's informed consent. 15. Given Mr. Brenneman's current medical condition, the prognosis is grim and further interventional care will not result in a cure of the patient's condition but will only prolong his dying. 16. Information provided to the hospital by Mr. Brenneman's pnmary care physician, Donald Kovacs. M.D. suggests that Mr. Brenneman would not consent to further interventional care. 17. Without proper authority the Carlisle Regional Medical Center is required to continue to provide care that the patient may not desire and for which the patient may not have provided his consent. , ' 18. Mr. Brenneman has no family. He is widowed. He has no children. He was an only child and has no siblings. Both of his parents are deceased. 19. Mr. Brenneman's current medical condition prevents him from being able to provide his informed consent to any medical care which he may require. 20. Mr. Brenneman's inability to communicate prevents the medical staff at the Carlisle Regional Medical Center from effectuating the wishes of Mr. Brenneman. Respectfully submitted, Date: \ ~ 0 . . 71796033r"'.':.'" "~I . ... ../ CARLISLE CE 014pm. 12-1 3/29 BRENNEMAN. JOHN MS2 0205 W CHIEF COMPLAINT: Dysphagia. HISTORY OF PRESENT ILLNESS: This 80-year-old white male presents to the emergency room with progressively worsening dysphagia, nasal congestion, shortness of breath, progressive worsening hoarseness, poor appetite, and weight loss. He was recently in the hospital where biopsy of the nasopharyngeal mass was obtained at that time. Biopsy report was apparently negatiVe but etiology of the mass was not clear at this time. He was sent home from this admission and has persisting and worsening symptoms at this time. PAST MEDICAL HISTORY: Past Medical History is positive for polio at the age of 20. He also carries the diagnosis of hypertension, benign Prostatic hypertrophy and peripheral vascular disease. PAST SURGICAl HISTORY: Past Surgical History is positive for left Inguinal hernia and repair and TURP. He also had biopsy of his throat done. MEDICATIONS: Aspirin, Augmentin, and Chlorthalidone. AlLERGIES: No known drug allergle.. 951466 SOCIAL HISTORY: He is a nonsmoker, nondrinker, lives alone. FAMILY HISTORY: FomBy Hisloly Is not slgni-'L His father had mlOCallllallnlaralon at lI1e age of 52. REVIEW OF SYSTEMS: He thinks that he has a right Inguinal hernia noted. He also has significant bruising of his lower abdomen after admission from before and he states that he has had foot pain bilaterally for awhile and this has progressively Worsened. He denies any chest pain or shortness of broall1. Denies any COUgh Of whoe2lng. Ha denies any paJpilatJons. Ha -. any na__ _ilfng, constipation. or diarrhea, heartburn, indigestion, black or blOOdy bowel movements. Denies dYSUria, frequency, or urgency since the surgery to his prostate. GENERAl- His exam reveals him to be alert and oriented x3 in no apparent distress. VITAL SIGNS - Blood P......... is 143/71, I8OplraIo,y rata 18. W8/ght 185 POUnds, lamp _ 95.8F, _ 84. PtfYSICAL EXAM-NATION HEENT - Head was normocephalic. Eyes - PERRlA, EOMI. Ears _ no injection or bulging of the tympanic mombtanos, canaIa ora patent. - - MlIdIy boggy turblnafos. Throat _ wlIhcut slgnillcant injection. Mouth was without leSions. Dentition was stable. NECK - Supple aIIhough Ihor. was some dacreasad range of motion of hb neck bilalarally. No neck vain distention, no bruits or thyromegaly noted. CHEST - Clear to auscultation. BACK - Was Positive for somewhat significant kyphosis. .' HEART - Regular rate and rhythm with ectopy at times, no murmurs or gallops. Page 1 of2 THIS DOCUMENT IS NOT A LEGAL COpy UNLESS SIGNED. CARLISLE REGIONAl MEDICAl CENTER HISTORY & PHYSICAl EXAMINATION 9356223 BRENNEMAN, JOHN MS2 0205 W 951466 12/10/2006 09/10/1926 KOVACS, DONALD J , '" 71 CARLISLE MED~CE 4/29 028pm 12-1 . BRENNEMAN, JOHN MS2 0205 W 951466 ABDOMEN - Abdomen was ncntender, no masses no hepatosPlenomegaly. Bowel sounds were heart Ihrough"", Lower abdomen ~ a lefI inguinal hernia repair scar and right Inguinal hernia. He has a significant amount of bruising across his lower abdomen. EXTREMITIES - 10_ extremJlies reveal full range of mollon of his joints. There _ -._ pU'ses ot the do....ts pedla and PllSIeIior Ubia/ puis.. with significant edema of both lower Oldremllies, right worse than the left, significant onychomycosis and on the right there were erythematous cold toes, on the left there were warm erythematous toes noted. Both were mildly tender. SKIN - Without rashes, lesIons and breakdown. NEURQ - Cranial ...... II through XII were _. No focal neuroJoglc signs were noted. No weakness or decreaSed sensation of the upper extremities. There was generalized weakness of both lower extremities bllaterany. ASSESSMENT: 1. N_i)'ngeaJ m... with aSSOCiated d)'Sphagia, hoarseness. nasal oon_. WOVlt 1000. 2. H_Ia. etloIogy ie uncerlain. Could this be asSOCIated with the m.... We... goi1g 10 gel a CT of the chest, CT of the head. 3. Ilysphagla. PossIbly there ts dysPhagia bejond the n~I mass. th.......... we will consult gastroenterology and also go ahead with barium swallow. 4. He has the hIsIoIy ofhypertensJon, benign Proslatlc ~y, signlflcar,1 P8!fphera,VllSQJ/ar - WIth ""YChom~.. of the - exlramllies is noted. At this polnt we will go ehead with his workup as ordered and replace his sodium and watch him closely. JAP/nw 0: 12/1012006 16:38:35 T: 12/1112006 06:51:19 C: Joseph A. Pion, D.O. Joseph A. Pion, 0.0. Page 2 of 2 THIS DOCUMENT IS NOT A LEGAL Copy UNLESS SIGNED. CARLISLE REGIONAL. MED'CAL. CENTER HISTORY & PHYSICAL EXAM'NATlOlif 9356223 BRENNEMAN, JOHN MS2 0205 W 951466 12/1012006 09/10/1926 KOVACS, DONALD J 717960339~.......~....W.\ . J ... (: ,':i~;~>; ,<,jill CARLISLE 120 pm 12-14'20~ \iJII 8/29 BRENNEMAN, JOHN MS2 0205 W CONSULTATION TO: ATTENDING PHYSICIAN: DATE: TYPE OF CONSULTATION: Gregory l. lewis, M.D. KOVACS. DONALD J 12/1012006 GASTROENTEROLOGY 951466 HISTORY OF PREsENT ILLNESS: This pleasant 80-year-old ll8n1leman was admilled to the Carllsla Regional Medical Canter tonight by Dr. Pion because the pallenl has had a prog-lve .....throellOld difficulty -1Iowing, -g and h__. Apparently th~ _ "-' many _ ago bol was inleonillenl and has become m.... conslenl and _ in the IlI8lBeVetel -.. The_1lI1S lhet he had polio in 1947 and since then he he. had Inleonittent hoersaness encI """"lng. He had a '-1t admission one _k ego. He was admllled by Dr. Koliacs end seen by Dr. Ferrero. lnnlelty Dr. Ferrero fell the _t had a mass at lhe bese at h~ longue bola biopsy was -1Ir1d felt lhel he jusl has a 8InInge/y sI1Sjled uYUIe. He felt h~ fcceJ """" __ llOITIlal but he did feellhere was muc:h erythema in lhe beck of h~ throat. He _1Iy lIrI10lged fer a video SWSlIowlng .tudy, Ihe resuHs of which .... not known -- lhe - was p/eced on a _ diet by Ihe ._lhenIpIst. The patient. '-r. lest night "-' to choke and had trouble breelhing IIr1d came to lhe OInBrgency room today for his admission. PAST MEDICAl.. HISTORY: Hi. pesl medical hlsby includes aloft inguineJ hem/a rape" by Dr. FrIk:hIey In 2001. He had alrensurelhrel_1US8Ction In 2000. The _ been Ieklng ~ 25 mg deIy for hypertension, baby aspirin daily. ALLERGIES: He has no known drug allergies. SOCIAL ffI8TORy: SOCIal h~tory ....... lhet he ~ .._ from lhe Air -.. He ~ a wfd-.- who"'" in Boiling Springs. FAMII. Y HISTORY: Family history .-.-~ lhet his father had a _ieI infardlcn at age 52, REVIEW OF SYSTEMs: On - at _so the _I has _Ie dyspnea. related to """"Ing. He hes no heattbum. no abdominal pain. nonneJ bowai Iunction. He has had a redUCed _ and weight loss recenlly. He also has some eppe..., dlscomfort 0',,, his right Ingu/neJ .... _ he has a hem~ and is scheduled to see Dr. Hardesty for right inguinal hernia repair. PHYSiCAl EXAMINATION: GENERAL - On physical """"'Inetion. the _t ~ In no scula distress. He I. -... VITAL SIGNS - His 1em_1e ~ 97 ~ FeIvenheIt, ptJiso 87 per m"ute. ...pi'etory... 18 per m_. blood -.. 146/83. HEENT - Pupils. -.1llUnd encI end _ to light There Is no cervlcel~. Toogue is moist CHEsT - Chest """'" Is cIeer. HEART _ HIlSlt """'" Is regular _I a muonur. ABDOMEN - Abdomlnef exam .....,. .ome -.ym.... in Ihe right inQtdnej ..... of uncerlaln eti%uy. He - to ba"" a right Inguinal hamIe. Howe.er. ft ~ nonlandor. There ~ no <>rgan~ty. EXTREMITIES - Exlremity exam r_. no ademe or phlebltis. NEUROlOGIC _ He ~ oriented 10 person, place, and time. DIAGNOSTIc STUDtEs: Delabese inclUde. hypona_ with a sodilJm 123 encl. chloride at 88 at uncertain etiology. Liver functtons .... 1lClnneI. Albumin Is .Iightly low at 3.1. /iemogJobjn 13.8. whJte cell count 10,100. Page 1 of2 THIS DOCUMENT IS NOT A lEGAL COpy UNLESS SIGNED. CARUSLE REGIONAL MEDICAL CENTER CONSUL TATIO~ ASSESSMENT AND PlAN, I canad Dr. Fe..", who felt this _'. Problem .... not Predomlnantly_, nose and throel. He did not h"", a m_. therefore. ... Petienl~ hoarsan_ end cho/dng may be POSI 9356223 BRENNEMAN, JOHN MS2 0205 W951466 12/10/2006 09/10/1926 KOVACS, DONALD J 717960339~~ ' ~... ~;"".;.~.;}i~ CARLISLE MEOrlfE \'.. _ "" .,~ ',,;0 138 pm 12-14-20~.....{'t.' ~~ 9/29 BRENNEMAN. JOHN MS2 0205 W POlio syndroma which is a syndrome where the pallent. distanUy 18Brs slier 8l<posure 10 IlOIlo. may dllVe/op Progressive SW"OWIng diffICUIU... I cannollotal/y rule oula stricture of his esophagus and as part of his video swallowing stUdy there may be images of his esophagus but' am uncertain. I s_ reccnsultng lI1a speech lherapistlo get her OPinion. Tha paUont may need 10 have his esophegeeJ anatomy and function Sludled further. I feel a neurolcgy -ueUon may also be holpM In confirming postpollo syndrome. He has hyponatremia. One wonders -lI1is is refatecflo _ diuretics or diet or even syndrome of Inepproprlata AOH. I ..1 take the liberty of ordering some urine e/ectrotytes and a U""'lyols 10 look for SPecific gravity. He may need a nephrOlogy consult. Thank you. GLUsap 0: 12/1012006 19:57:34 T: 12/11/2006 06:30:25 951466 C: Gregory l. Lewis, M.D. KOVACS, DONAlD J Gregory L. Lewis, M.D. Page 2 of 2 THIS DOCUMENT IS NOT A LEGAL COpy UNLESS SIGNED. CARLISLE REGIONAl MEDICAl CENTER OONSUl TATION 9356223 BRENNEMAN, JOHN MS2 0205 W951466 12/1012006 09/10/1926 KOVACS, DONAlD J 71796033 CARLISLE MEe)L CE ~ ,~ 1039 pm 12-14- 5/29 i ,~ ", BRENNEMAN, JOHN CONSULTATION TO: ATTENDING PHYSICIAN: DATE: TYPE OF CONSULTATION: MS2 0205 W REASON FOR CONSULTATION: Dysphagia. Mohammad K. Ismail, M.D. Donald J. Kovacs, M.D. 12/11/2006 NEUROLOGIC EVALUATION 951466 HISTORY OF PRESeNT ILLNESS: Mr. B""'neman is an 80-year-old vary _ant genlleman for whom I was con.ulted by Dr. KOVllCs for avaJuation for his dysphagia. The _ is a good hialorian 8l1d _rts that he has dllllaAty with ~ ..... the age at 19 when he had polio that aIfoc:Ied his neck 8l1d ahouIder m_. He recalled that he .... In th. Army and al that..... h. always had 11I1 issue With SWallowing III1j/hlng blggeo-Ihan 88p1lfn l8b1et. He IIfoo llCknOWleciged W he was eick IhIs -. is a_. He..ports that for the....1 "'" years his _is 98lOOg low and he cannot _loudly. He has had mora dllllaAty with _ng and _ for the P8SI few months. The patienl_ seen by Dr. Fa""", a few months ago llI1d at that .....th.... .... tha _fb/fIty of some masstha, .... 0llJl/0rad In tha n~...... He has been OIled out for any """"'. He is _ -Ilted 10 the hOlpl/al for evaluation of WOrsening dYSPhagia. The - denies W he has double vision. He danles W he has droopy ayes or ex_ 8I1IOunt of fallgu.. He has no numbo... or -,- or any other"..., of the body. He he. some dlfflc:ulty With urination lII1d _ut.. this 10 - PmbIams. The _, danles any signiflcantlOO/ght Ioas or nigh' sweats. PAST MEDICAL HISTORY: Past Medical History is significant: 1. for polio at the age of 19. 2. history of hypertension, 3. history of benign prostatic hypertrophy, and 4. history of peripheral vascular disease. PAST SURGICAL HISTORY: Past Surgical History is significant for 1. left Inguinal hemla repair and 2. transurethral resection of prostate. 3. He recently had a biopsy of his throat and was reportedly negative. ALLERGIES: None. MEDICATIONS: Aspirin, Augmentin and Chlorthalldone. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient lives alone. He was in the Army. HABITS: He does not smoke, drink or use illicit drugs at the moment. REVIEW OF SYSTEMS: Roo"-ry: The patient_ som. COUgh and shorin... of br.ath. He deoles any Ches' pain 01 dyspnea. Neurological: The padeo, raports some diffICUlty "'th his light ann due 10 his chron~ 'houIder-... due to polio. He has swallowing and speech prOblems as described above. Constltution.,: Danles fa...., chms. night ........ _ gain or lOSs in f8CentP8S1. Page 1 of 3 THIS DOCUMENT IS NOT A LEGAL COpy UNLESS SIGNED. CARLISLE REGIONAL MEDICAL CENTER CONSUL TATIO~ 9356223 BRENNEMAN. JOHN MS2 0205 W951466 12/10/2006 09/10/1926 KOVACS. DONALD J " 4'" . BRENNEMAN, JOHN ICU 0005 0 951466 CHIEF COMPLAINT: Cardiac arrest. HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old gentleman followed by Dr. Kovacs. He just recently moved into a nursing home. He has had progressive dysphagia, weight loss and weakness. He is felt to have a post pOlio syndrome. In reviewing the nursing home records, over the past week, he has gone from doing his ADLs independently to needing assist of two. This morning, he apparently was found unresponsive. When paramedics arrived, he was in PEA with a pUlse of about 10. He was resuscitated to atrial fibrillation at a controlled rate. He was profoundly hypotensive requiring dopamine. In the emergency department, the patient is completely unresponsive on a ventilator. To the best of my knowledge, the patient has not had any recent complaints of chest pain or respiratory problems. He is on Protonix for some recent diagnosis of esophagitis and had his esophagus dilated as well. He apparently also had a mass in the back of his throat, which was biopsied and was negative. PAST MEDICAL HISTORY: As above. He also has benign prostatic hypertrophy, peripheral vascular disease and hypertension. PAST SURGICAL HISTORY: Transurethral resection of the prostate and left inguinal hernia repair. CURRENT MEDICATIONS: Protonix 40 milligrams twice a day, chlorthalidone 25 milligrams daily and p.r.n.'s ALLERGIES: None. SOCIAL HISTORY: He moved into a nursing home a couple weeks ago. He is a nonsmoker, nondrinker. He is widowed and has no children. REVIEW OF SYSTEMS: Obviously unavailable since the patient is intubated. On reviewing the nursing home notes, again, he has gotten weaker and more fatigued, had significant dysphasia and decreased p.o. intake and weight loss. PHYSICAL EXAMINATION GENERAL: The patient is not responsive even to deep pain. He seems to be posturing in at decerebrate manner. HEENT: Pupils were equally round; they were sluggish to react. Oropharynx reveals an ET tube in place. NECK: Neck is supple. He does have external JVD when lying flat. LUNGS: Lungs reveal loose rhonchi anteriorly bilaterally. There was no wheezing, no crackles noted. HEART: Heart exam reveals irregularly irregular rhythm. There was no murmur auscultated. He has a concave sternum. PMI was not laterally displaced. ABDOMEN: Abdomen is soft. He has no reaction to palpation to suggest tenderness. Normal active bowel sounds. No masses. . \. EXTREMITIES: Extremities were mottled and cold. He has onychomycosis of all of his ten toenails. Page 1 of 2 THIS DOCUMENT IS NOT A LEGAL COpy UNLESS SIGNED. CARLISLE REGIONAL MEDICAL CENTER HISTORY & PHYSICAL EXAMINATION 9357702 BRENNEMAN, JOHN ICU 0005 0 951466 12/28/2006 09/10/1926 KOVACS, DONALD J 1 " BRENNEMAN, JOHN ICU 0005 0 951466 NEUROLOGICAL EXAM: No response to painful stimuli. Decerebrate posturing at times. Toes are downgoing bilaterally. SKIN: Skin is cold and mottled. LABORATORY STUDIES: BUN 22, creatinine 1.3, sodium 119, glucose 112, bicarbonate 28. Chest x-ray does not show an acute infiltrate. pH 7.31, C02 57, 02109. White count 15.7, hemoglobin 13.3. Electrocardiogram shows atrial fibrillation. CPKs are pending. ASSESSMENT: 1. Pulseless electrical activity cardiac arrest. 2. History of progressive decline with weight loss, weakness and dysphasia. 3. Hyponatremia of unclear etiology. 4. Atrial fibrillation. PLAN: At this point in time, we will support the patient on a ventilator, continue dopamine drip and aggressive IV fluid rehydration. Because he was becoming less ambulatory over the past week and had a PEA arrest I do want to rule out PE, especially in the setting of atrial fibrillation. I will see if radiology will do a CT angio, but because his BUN is 22, I think he may not qualify. Therefore, I will order lower extremity Dopplers instead. If his CAT scan of his brain is negative, I will place him empirically on subcutaneous Lovenox twice a day. The patient is normally followed by Dr. Kovacs and he requested that while the patient is in the ICU, he remain on our service and then get transferred back to Dr. Kovacs' service when he is out of the ICU. I attempted to reach the patient's only contact, which is a friend, and did leave a message on his phone, that is Mr. Richard Hess, phone number 580-7814. CC/jn 0: 12/28/2006 16:06:32 T: 12/28/2006 19:29:40 C: Christina Collins, M.D. Page 2 of 2 THIS DOCUMENT IS NOT A LEGAL COpy UNLESS SIGNED. CARLISLE REGIONAL MEDICAL CENTER HISTORY & PHYSICAL EXAMINATION 9357702 BRENNEMAN, JOHN ICU 0005 0 951466 12/28/2006 09/10/1926 KOVACS, DONALD J . 4' I. ~ BRENNEMAN, JOHN ICU 0005 0 951466 CONSULTATION TO: ATTENDING PHYSICIAN: DATE: TYPE OF CONSULTATION: Mohammad K. Ismail, M.D. KOVACS, DONALD J 12/29/2006 NEUROLOGY REASON FOR CONSULTATION: Decreased mental status. HISTORY OF PRESENT ILLNESS: Mr. Breneman is an 80-year-old gentleman followed by Dr. Kovacs and was recently admitted to the hospital for the evaluation of dysphagia. The patient has a history of post-polio syndrome and no significant intervention was recommended. The patient was in a nursing home and in the morning was found unresponsive. The paramedics were called to the scene and they found him in PEA with a pulse of about 10. The patient was resuscitated through ALS and intubated. He was brought to the emergency room where he was noted to have a pulse of 110 and blood pressure was 66/46. He was noted to have atrial fibrillation. His temperature was 96.3. The patient was unresponsive at that time and he was admitted to the Intensive Care Unit for further management. Since his admission, the patient has not made significant recovery in his mental status. He is not able to wake up and communicate. The patient has remained unresponsive although his vital signs have been stable. In reviewing the nursing home chart, it was noted the patient did not complain of any chest pain, shortness of breath, on the night prior to this incident. In fact, he was making good recovery since his discharge from the hospital and he was doing his ADLs fairly independently. PAST MEDICAL HISTORY: Significant for: 1. Hypertension. 2. History of peripheral vascular disease. 3. History of prostatic hypertrophy. 4. History of post-polio syndrome. PAST SURGICAL HISTORY: Significant for transurethral resection of the prostate and left inguinal hernia repair in the past. MEDICATIONS: Protonix 40 milligrams twice a day, Chlorthalidone 25 milligrams daily. ALLERGIES: None. SOCIAL HISTORY: The patient moved to a nursing home a few weeks ago. He is retired. Habits - He does not smoke, drink or use illicit drugs. REVIEW OF SYSTEMS: Not obtainable. The patient is unresponsive. PHYSICAL EXAMINATION: General: This is an 80-year-old gentleman laying on a bed, intubated and unresponsive. Vitals: EYES: Blood pressure: 104/70. Pulse: 101 and regular. He was afebrile. Pupils were 3.5 mm and nonreactive to light. Extraocular movements could not be checked and Doll's eye test was negative. Corneal reflex was minimally present bilaterally. Examination of the fundi was difficult but no apparent hemorrhage or bleed was noted. Page 1 of 2 THIS DOCUMENT IS NOT A LEGAL COPY UNLESS SIGNED. CARLISLE REGIONAL MEDICAL CENTER CONSULTATION 9357702 BRENNEMAN, JOHN ICU 0005 D 951466 12/28/2006 09/10/1926 KOVACS, DONALD J fo ~. ~ BRENNEMAN, JOHN ICU 0005 0 951466 Cardiovascular: Heartbeat is regular in rate and rhythm. Auscultation reveals no murmurs, gallops, or abnormal sounds. Pedal pulses are palpable, both dorsalis pedis and posterior tibial. Carotid artery exam reveals no bruits and full and equal pulse. Extremities have no edema or varicosities. Respiratory: The patient was on a ventilator with respiratory rate of 14. Breath sounds were present bilaterally. Musculoskeletal: Inspection, palpation: of spine and both upper and lower extremities, unless stated otherwise, showed no misalignment, deformity, asymmetry, tenderness, mass, or swelling. ROMs were assessed in spine and upper body and lower extremities and found to be normal. Muscle tone was slightly increased in all four extremities. The patient was having a few spontaneous projecting type of movements in the upper and lower extremities. However, he is not showing any sort of response on stimulation from sternal rub and suborbital pressure. Neurological: Mental Status: Patient was unresponsive. Not showing any sign of grimace or movement with deep sternal rub. Language: Not examined. Cranial Nerves: Limited. Pupils are fixed and corneal reflex is minimally present. There was no apparent facial droop. Reflexes: The patient has absent ankle jerks and knee jerks bilaterally. Reflexes in the upper extremities are also diminished. Babinski was negative. LABORATORY AND X-RAY: CT of the head was ordered yesterday and showed no intracranial bleed. He also has CT of the chest and thorax that showed extensive mucous plugging within the airways of both lower lobes. EKG done showed that he has sinus arrhythmia with a heart rate of 117 when he presented to the emergency room. White count 15.7, hemoglobin 13.3, platelet count 268, BUN 22, sodium 119, potassium 3.3, blood sugar 112. CPK level 2,105. MB fraction was 28.1. Troponin-11.15. IMPRESSION: This is an 80-year-old gentleman who has a history of hypertension, peripheral vascular disease and now presents to the hospital with the sudden onset of loss of consciousness and was noted to be in a cardiac arrest. Most likely the cause for the decreased mental status is anoxic encephalopathy. His neurological examination showed that he has fixed pupils and minimal reaction even 12 hours after the accident. I believe the overall prognosis is poor. Other differentials that need to be considered is nonconvulsive status epilepticus or infection to the CNS, overdosage of some sedative medications. PLAN: At this time, I will order an EEG. I would also like to explore other causes for his decreased mental status as described above. I will continue to follow this patient with you. MKllle 0: 12/29/200614:49:18 T: 12/29/200621 :06:45 Mohammad K. Ismail, M.D. C: Mohammad K. Ismail, M.D. KOVACS, DONALD J 9357702 BRENNEMAN, JOHN ICU 00050951466 12/28/2006 09/10/1926 KOVACS, DONALD J Page 2 of 2 THIS DOCUMENT IS NOT A LEGAL COpy UNLESS SIGNED. CARLISLE REGIONAL MEDICAL CENTER CONSULTATION .~Bi40 1/03/07 15:28:52 CARLISLE REGIONAL MEDICAL CTR Heart Coid: Page: 858 1 Report status: TRANSCRIBED Pat.Type: 11 16:48 350424 K Admit...: 12/28/2006 16:00 Discharg: Location: ICU ,0005,D Trnsc.: 12/31/2006 11:42 Pat Nbr: 9357702 BRENNEMAN, Req By: 4510 KOVACS, DONALD Med. Rec: 0000951466 Type: M~D Dict.: 12/30/2006 Physician: ISMAIL, MOHAMMAD JOHN J ------------------------------------------------------------------------------- BRENNEMAN, JOHN ELECTROENCEPHALOGRAM 12/30/2006 CLINICAL HISTORY: This is an 80-year-old gentleman who had a cardiac arrest and was brought to the hospital with decreased mental status. The patient has been unresponsive since then. This EEG was ordered to evaluate further prognosis and rule out nonconvulsive status epilepticus. The patient is not on any sedative medication. TECHNICAL SUMMARY: This is a 17-lead, 10-20, bipolar and referential, digital EEG recording done on a patient who was unresponsive and on the ventilator. The record opened with the patient unresponsive and with his eyes closed. No well-defined background alpha rhythm was noted. There was diffuse depression, and slowing was noted in the theta to delta range. At the time, the rhythm was 3 to 4 Hz, 10 to 30 microvolts, but generally symmetrical. Unfortunately this EEG was contaminated with a lot of artifacts related to the intensive care unit and electrical activity that made it somewhat difficult to interpret this record. There was poor reactivity in this EEG record. There was no frank epileptiform discharge noted. Photic stimulation was done at several frequencies, and eyes were opened manually. No response was noted in the occipital leads. Overall there was minimal variability in this EEG record. Single-lead EKG monitoring throughout the record showed some artifacts and irregularly irregular rhythm. IMPRESSION: This is a severely abnormal electroencephalographic record due to: 1. Lack of well-defined background alpha rhythm. 2. Lack of variability and reactivity in this electroencephalographic record. 3. Diffuse depression and slowing throughout this electroencephalographic record. COMMENT: This EEG pattern is compatible with the diagnosis of severe metabolic or hypoxic encephalopathy. No apparent epileptiform discharge was noted to explain the patient's decreased mental status. MKI/am D: 12/30/2006 16:48:11 T: 12/31/2006 11:31:21 C: Donald J. Kovacs, M.D. Juliusz C. Nitecki, M.D. Mohammad K. Ismail, M.D. Dictated by 1141 - ISMAIL, MOHAMMAD K . . "" .. cr~ 361 Alexander Spring Road. Carlisle, PA 17015-9129. (717) 249-1212 COLLABORATIVE CARE WORKSHEET BRENNEMAN, JOHN Patient #: 9357702 12/28/2006 Time: 16:00:00 KOVACS, DONALD J Med Rec #: 0000951466 0005/D 09/10/1926 Sex: M Age: 080 Patient Name: Admit Date: Att Phys: Room/Bed: DOB: DISCHARGE ASSESSMENT/SOCIAL SERVICE Assessment Date/Time: 12/29/2006 15:40:00 Discharge needs are unclear, will follow Mental Status: Unresponse Living Arrange: In nursing home Activities: Total dependent Agency Support and DMB already in home: BQUIPMBNT COMMBNTS Referral Services: FACILITY SBRVICB RBFBRRAL ACCBPTED Discharge Plan: 12/29-per review, pt is from Forest Park. Recently admitted there on 12/15. pt is widowed with no children. will check with Darlene B. @ Forest Park rei bed status. Ijk Last Updated: 12/29/2006 15:42:11 LKEEN USBR DISCHARGE ASSESSMENT/SOCIAL SERVICE Assessment Date/Time: 01/02/2007 09:18:00 Care Conference: 01/01/2007 00:00:00 0830: Discussed current medical status w/Dr Boshnakov,Hospitalist and nurs ing staff at ICU unit. This writer will tic attorney: Hamilton Davis & neighbor, exploring whether or not there is a POA or family member avail able to make end of life decisions regarding pt. 0930: T/C Hamilton Davis,Esquire: spoke with receptionist. Introduced self & role related to pt. Per receptionist, Rick Hess,neighbor called Hamilt on Davis last week,Mr Davis was unsure if he was pt's attorney or not, possibly being other attorney in the office is pt's attorney. This writer requested that Mr Davis be consulted to determine if he is pt's attorney or not, notifying this writer. Receptionist said OK. Return phone number provided. T/C Darlene @ Forest Park NH: Discussed above information. She reports that when pt was admitted to their facility,pt did not have a Living Will nor POA. No additional information obtained. T/C Rick Hess,Neighbor @ 258-6023 1ft message requesting return tic. T/C Rick Hess @ 580-7814: discussed at length pt's current status. Mr Hess reports that he would write pt's checks out,pt would then sign them. To his knowledge, there is no living relative. pt always told him if somethi ng happened to him to contact Hamilton Davis,Esquire. Mr Hess did contact Mr Davis last week,but to date, has not received a return tic by him. Per pt,the bank was his POA,but Mr Hess is not sure whom to contact at the bank, this writer requested that he check the bank statements & obtain an ad dress/phone number for this writer to contact. He will return tic with r. \, 111M 1111 III IMII III 11111 III 1111 III 111111.1 mmIII 1IIIIIIIIgMII 8995210 9357702 .... ~ cz~ 361 Alexander Spring Road. Carlisle, PA 170H5-9129. (717) 249-1212 COLLABORATIVE CARE WORKSHEBT Patient Name: BRENNEMAN, JOHN Patient #: 9357702 DISCHARGE ASSESSMENT/SOCIAL SERVICE Care Conference: this information as soon as possible. This writer provided my return tic number. 0950: Received return tic Sarah @ Hamilton Davis,Esquire's office: she repo rts that Mr Davis drew up pt's will in 1983,but has not had any contact w/pt since 1991. Sarah reports the will does not provide any living will or POA information. This writer requested that the will be checked for any relative information. Sarah will check and return tic. 1010: T/C Office of Aging: 1ft message requesting information ref: no POA available & assistance needed. T/C Coroner's Office: spoke w/Mr Norris. He reports that unless there is a named family member in the will, the hosital will need to seek guardian ship of pt. 1200: Recd tic Jennifer Mann @ Office of Aging: she reports that unless pt received current services via OOA, the hospital will need to seek guardi anship of pt. If pt was currently receiving OOA services, they may be able to assist. 1430: Spoke w/Bill Ziesmer,CFO/Admin on Call for hospital. Status update provided regarding need for guardianship of pt. Joe Ricci: 233-6633 is hospital attorney. T/C Joe Ricci: status update provided regarding need for hospital to seek guardianship of pt. Mr Ricci request that this writer tic pt's attorney & request copy of will, name of funeral home that pt's mother was buried at. He will meet w/hospitalist tomorrow 1/03/2007. This writer will tic neighbor: Rick Hess & advise of hospital's plan of care. 1630: T/C Hamilton Davis: 717-532-5713 : 1ft VM for Sarah - requested retur n t/c,notified that Joe Ricci,CRMC Atty pursuing guardianship & request ing copy of pt's will along w/name of funeral home for pt's mother. T/C Rick Hess,pt's neighbor: 1ft VM w residence notifying that hospital atty: Joe Ricci will be contacting him due to seeking guardianship of pt along w/need for neighbor to report what pt always told him regarding end of life issues. Notified Dr Boshnakov that hospital attorney will be coming to hospital to discuss guardianship with him 1/03/2007. Said OK. Last Updated: 01/02/2007 09:31:41 SWASTLER DISCHARGE ASSESSMENT/SOCIAL SERVICE Assessment Date/Time: 01/03/2007 09:46:50 Care Conference: 00/00/0000 00:00:00 0930: Recd VM Rick Hess - he reports that he found some information,pt used M&T Bank in Boiling Springs,PA. Additionally,he does have a safety depos it box at that bank. Perhaps there is some documentation as to his wish es in this situation there. 0950: Per Dr Boshnakov,Hospitalist. He has spoken with Dr Kovacs,pt's fami ly physician. Dr Kovac is to review his chart at the office & obtain any documentation regarding pt's end of life wishes. 1010: T/C M&T Bank,Boiling Springs,PA: spoke with Branch Manager: Rebecca Dorwart. Status update provided regarding current situation and need for POA/Living Will or pt's wishes to be provided. Notified that possibl y pt had safety deposit box at their branch, and M&T was trust holder.Per 1IIIII1 Ila IMIIIIIM ~.IIIIIIIII1I.11111 IIIIII 111111 ~IIIII.IIIII 111111 8995210 9357702 ,? . .. L ~ cz~ 361 Alexander Spring Road. Carlisle, PA 1701 ~129 . (717) 249-1212 COLLABORATIVE CARE WORKSHEET Patient Name: BRENNEMAN, JOHN Patient #: 9357702 DISCHARGE ASSESSMENT/SOCIAL SERVICE Care Conference: Rebecca Dorwart,she reports that per their file,pt is a individual hold er,M&T is not POA. She does see where they are listed as a possibly hold er at another location,she will t/c that location & return t/c with this writer. 1100:Recd return t/c Rebecca Dorwart,Branch Mgr @ M&T,she reports that pt did not have a safety deposit box @ M&T,nor at any of the branches in Car lisle,PA - she checked prior to returning t/c with this writer. 1130: T/C Rick Hess @ 580-7814 w/status update regarding above information. He reports that the other bank pt dealt w/was F&M in Boiling Spring,per haps they have something in his safety deposit box there. 1140: T/C F&M Bank,Boiling Springs,PA: requested to speak w/Branch Mgr - sp oke w/Kevin Stoner.Status update provided regarding need for POA/Living Will,etc. Mr Stoner will check & return t/c with this writer. Per his req uest,telephone # provided to Rick Hess,Neighbor. 1200: Reed t/c Kevin Stoner,F&M Bank,reports that following investigation at their bank,pt did not have any safety deposit box at their bank. 1300: Per Dr Boshnakov,per Dr Kovacs,pt would not accept any preventive care or treatment,always stating "r am too old and dying",refusing various types of life sustaining tx. 1500: Dr Boshnakov,this writer,Mr Ricci,Esq met to discuss current status. Last Updated: 01/03/2007 09:46:50 SWASTLER ~ 1 11111 11111 lUll III 11111 11111111 1111 1111 Ilia 1111111 ml 11111 III 11111 II III 8995210 9357702