Part 86, page 41

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NORTHERN VIRGINIA DOCTORS HOSPITAL HISTORY

COFFELT JACK 7 [?] 79895

INFORMANT [REDACTED] DATE 7/7/73

CHIEF COMPLAINT: "I have pain in my L leg"

PRESENT ILLNESS: This is [the] first NVDH admission for this 48 y.o. W.M. former employee who complains of acute self-[guess: treatment] in L leg. He has had [guess: soreness/min.] for 3-4 yrs BTA and was once hospitalized for 1 wk. for edema 2° to [guess: thine] varicosities. 4-5 days BTA pt [guess: moved] lifted heavy object and felt burning sensation in lower medial L leg - a local swelling developed at this time (this became tender, exquisitely so at 10 A.M. today 7/6/73 when pt stood and noticed hot, flaming [guess: sensation] this very localized region below the knee. 11 [guess: hrs], this sensitive to standing, less [guess: under] [guess: this time]. [guess: Erosion] [?] hurt to walk but is very [guess: susceptible] to [guess: edematous] [guess: signs/standing]. [guess: Mentions] no muscle cramps

PAST MEDICAL ILLNESS: Allergies - 0. Surgery - 3x for inguinal hernia. R ear, nasal bone replaced - 3 yrs. BTA. Food general health otherwise.

FAMILY HISTORY: NC - orphan.

SOCIAL HISTORY: Smoking Hx - 1-2 packs/day x 30 yrs. ETOH - heavy - calls self "borderline alcoholic".

REVIEW OF SYSTEMS: N.C.

Signed [REDACTED]

N.V.D.H. Form No. 23 REV 4 66