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| wy 92-657 Standard Form S02 Rav. Aunuil 1954 ” Bureey of the Sudget hd Cirevler A 22 { 5) CLUUCAL RECORD NARRATIVE SUMMARY : DATE OF ADMISSION DATE OF DIBCHARGE see 3/29/65 | 4/2/65 : (Sten ond dete at end of narrative) o2- was physiologic with no masses or vinccrocegaly apparent, Bilateral flank scars were noted, There was no CVA tenderncss on examination of the back. Genitalia examination was normal, Extremitics revealed good radial and dor- . salis pedis pulecs bilaterally. Posterior tibial pulees were fir bilaterally, . There was no pretibial edena, clubbing, or varicosities present, Neurologic ‘ czanination was physiologic, except for som decrease in vibratory sensation ! over both lower extremities, LAB AND X-RAY EXAMINATIONS: Hematocrit 47, WBC 10,900, sedimentation , rate 11, Serum electrolytes included a CO2 of 34.5 meq/L. Chlorides 95, sodium 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 301k cant. Liver function studies were essentially normal, Chest x-ray was un- changed from previous admission, EKG was essentially unchanged from previous tracing taken at this hospital on 2/7/64, The present EKG showed evidence of a right 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 . episodes of angina, requiring approximately 10-20 nitroglycerin tablets per day. At no time during the hospitalization did he appear to be in acute distreas, The patient did state on one occasion experiencing moderate anginal pain shortly after cnother patient on the ward had euffered from an acute myocardial infarce tion with cardiac arrest, During that episode, patient was present while the other patient was having external cardiac massage and resuscitation attempted. All the other patients, including Mr, Ganbino, were asked to leave the ward at that tine, It vas only later in the day that the patient stated be had experienc precordial chest pain during the cpisode, It was felt that the petient had reached ucxium evaluation @ thie tine and was fit for discharge, FINAL DIAGNOSES: 1, Arteriosclerotic heart disease, 2. Anginal syndrom, secondary to #1. 3. Diabetes mellitus, 4, Chronic congestive heart failure, nsated, (On additional sheets of this form (Standard Form $02) lf more space ts required) ZATION BIGNATURE OF PHYSICIAN © IDENTIFICATION NO. | ORG. REGISTER NO. 82389 | PATIENT'S IDENTIFICATION (For typed or written entries give: Nemo—lan, first, middle; grede; hate; horplal or medical facility); Doe GABDIO, Carlo 6 CLR be USPHS Hospital, Staten Island 4, ‘ York AAT Bea] toe sen