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NY 97-657 . Standard Form 502 Rev. August 1954 : ° Bureeu of the Svdget ; ‘ * . Tirevlar A 2 : f ») “4 ed CLINICAL RECORD | - NARRATIVE SUMMARY | 7 GATE OF ADMISSION DATE OF DISCHARGE MUMBER OF DAYS HOSPITALIZED 3/29/65 4/2/65 (Sign end dais at end of narrative) : e2a was physiologic with no masses or vinccromecpaly apparent, Bilateral flank scare were noted, There was no CVA tenderncss on examination of the back. Genitalia examination was normal, Extremities revealed good radial and dor- salis pedis pulecs bilaterally. Posterior tibial pulees were fir bilaterally, - There was no pretibial edema, clubbing, or varicosities present, Neurologic | czanination was physiologic, except for som decrease in vibratory sensation over both lover extremities, LAB AND K-RAY EXAMINATIONS ; Hematocrit 47, WBC 10,900, sedimentation rate 11. Serum electrolytes included a CO2 of 34.5 meq/L. Chlorides 95, sodiun 140, potassium 3,8, calcium 10.2, phosphorus 2,9, and uric acid 6.7. Urinalysis . was unremarkable, Serology was non-reactive. Serum cholesterol] was reported as 301 ctmt. Liver function studies were essentially normal. Chest x-ray was une chanced from previous admission, EKG was essentially unchanged from previous tracing taken et this hospital on 2/7/64, The present EKG showed evidence of a tight bundle branch block with,old anterior myocardial infarction. In addi- tion, a first degree AV block was present, Non-specific ST and T wave changes — of ischemia and/or digitalis effect were also apparent. — COURSE IN HOSPITAL: The patient continued to have recurring isodes of angina, réquiriag approximately 10-20 nitroglycerin tablets per day. At no time during the hospitalization did he appear to be in acute distress, Tha patient did state on one occasion experiencing moderate anginal pain shortly after cnother patient on the ward had suffered from en acute myocardial infarce tion with cardiac arrest, During that episode, patient was present while the other patient was having external cardioc massage and resuscitation attempted. "All the other patients, including Mr, Gacbino, were asked to leave the ward at that tine. It was only later in the day that the patient stated be had experienc precordial chest pain during the episode, It was felt that the pe tient hed reached moxiug evaluation & this tine and was fit for discharge, FINAL DIAGNOSES: 1. Arteriosclerotic heart disease, on 2. Anginal syndrom, secondary to #1, 3. Diabetes mellitus. i 4, Chronic congestive heart fallure, sieProm (Use qdditional sherts of this form (Stand ard Form $02) if more space ts required) SIGNATURE OF FHYSICIAN GATE [OENTIFICATION NO. | ORGANIZATION cole PATIENT 6 IDENTIFICATION (For typed oF writien entries givet Neme—lan, first, middle; grade; date; hosplial or medical facility) Do Do {- GASTRO, Carlo op ree ATIVE SUMMAR USPHS Hogpital, Staten Island 4 Yew York re SE wee endard Form $0 te . wa. ite nm ar qerbo toe on . . ny + ec ty . “PF teow s . yam . a tee ty ~ ‘ ‘ * 5 . ‘ . aot