Part 86, page 39

Transcript

The scan is the source; the transcript is machine-generated from it.

SUMMARY SHEET A:NO S:YES

NORTHERN VIRGINIA DOCTORS HOSPITAL

NAME: COFFELT, JACK - TELEPHONE: 521-4665 PREVIOUS ADMISS. TO NVDH: YES [X] NO [ ] TIME OF ADMISSION: 2:15pm ADMISSION DATE: 7/19/73

ADDRESS: 4208 S. 12th RD. ARL. VA. 22204 AGE: 48 SEX: M [X] F [ ] RACE: W [X] C [ ] MARITAL STATUS: S [X] M [ ] W [ ] DIV. [ ] SEP. [ ]

DATE OF BIRTH: 2/20/25 BIRTH PLACE: MISSOURI RELIGION: PROT. OCCUPATION: PHYSICIST ACCOMODATION: PRIV. [ ] SEMI PRIV. [X] CARDIAC [ ] ROOM NO.: 348 ROOM RATE: 66.00

ADMITTING DIAGNOSIS: THROMBOPHLEBITIS

NOTIFY IN EMERGENCY: [blank] RELATIONSHIP: [blank] OFF. PHONE: [blank] HOME PHONE: [blank] DEPOSIT: [blank] ADM. BY: [blank]

INSURANCE: GHI CONTRACT NO: 159-1727 CODE NO: 1110-B EFF: 6/1/72

INSURED THROUGH: SELF EMPLOYER: IBM CORP. (UNABLE TO GIVE PHONE#) BUS. PHONE: b6 b7C

CAUSE FOR ADMISSION: Thrombophlebit[is] [handwritten, partially illegible]

PHYSICAL FINDINGS: [handwritten, partially illegible] got [illegible] order left leg [illegible]

LABORATORY FINDINGS: [handwritten] By CBC K UA

OPERATIVE PROCEDURES AND DATES: [blank] CODE: [blank]

OPERATIVE FINDINGS: [blank]

SUMMARY OF HOSPITAL COURSE: [handwritten, partially illegible] [guess: Treated with] [guess: bedrest] [illegible] x [illegible] [handwritten] [guess: cleared] as [guess: pt off] [guess: Hep] 7/[guess: 31]/73

FINAL DIAGNOSIS: Thrombophlebit - left [guess: saphen] - [guess: thigh] CODE: 451.0

COMPLICATIONS: 0 CONSULTATION WITH: 0 DISCHARGE DATE: 7-31-73

CONDITION ON DISCHARGE: RECOVERED [ ] IMPROVED [X] SAVED [ ] NOT TREATED [ ] D X. ONLY [ ] AUTOPSY [ ] COPY TO PHYSICIAN -- YES [X] NO [ ]

M.D.: b6 b7C

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DB Cooper-37883

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79883