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The original documents are located in Box 37, folder "Ford, Gerald - Physical Examination -
1972" of the Betty Ford White House Papers, 1973-1977 at the Gerald R. Ford
Presidential Library.
Copyright Notice
The copyright law of the United States (Title 17, United States Code) governs the making of
photocopies or other reproductions of copyrighted material. Betty Ford donated to the United States
of America her copyrights in all of her unpublished writings in National Archives collections.
Works prepared by U.S. Government employees as part of their official duties are in the public
domain. The copyrights to materials written by other individuals or organizations are presumed to
remain with them. If you think any of the information displayed in the PDF is subject to a valid
copyright claim, please contact the Gerald R. Ford Presidential Library.
THE ATTENDING PHYSICIAN
CONGRESS OF THE UNITED STATES
R.J. PEARSON, M.D.
F.A.C.P., F.A.C.C.
FORD, Gerald R.
CONGRESSMAN/MICHIGAN
PHYSICAL EXAMINATION Part-I
February 18, 1972
This is Mr. Ford's first routine annual physical examination
since January 1970, and there has been no specific complaint
in the past several months. Mr. Ford feels that he is quite
healthy, able to live a vigorous life without symptoms.
Since his last annual physical examination he has had a number
of orthopedic problems but generally has had no incurrent
illnesses.
SYSTEMS REVIEW
Eyes: He has always been nearsighted since early high
school, but recently in the early morning he has noticed
that newsprint is not clear. He has difficulty reading
the batting averages, stock market and other fine prints.
The nearsightedness that he has always had may have gotten
worse in recent years.
ENT: He has no trouble hearing. He is not bothered by any
ringing in his ears, dizziness, vertigo, or unsteadiness.
He states that he has always had a congenital draining from
one of his sinuses, on the right, which in turn causes a
need for clearing the throat and a cough. He can feel the
accumulation of the postnasal dripping, which is a rather
frequent cause for clearing the throat and coughing. He has
never coughed up any blood.
Lungs: The cough mentioned above is associated with a post-
nasal dripping. Since he was 27 years old he has smoked a
pipe, 6-7 pipefulls per day, more when he is not active and
less when he is skiing or on vacation. He does not inhale.
He has never had any pleuritic pain, nor shortness of breath.
He has recently come from a skiing vacation where he skied
vigorously at the altitude of 10,000 to 12,000 feet. He is
also able to swim vigorously 10 minutes, twice daily, without
any cardiovascular symptoms.
Cardiovascular: No chest discomfort, pressure, tightness,
indigestion. No palpitations, skipped beats, tachycardia,
faintness, etc. No leg pain with exertion. No transient
numbness, disuse , etc.
Gastrointestinal: He has a good appetite, is able to eat
everything except sourkraut, which causes him to have diarrhea.
FORD
Stuaro
I OF IV
THE ATTENDING PHYSICIAN
CONGRESS OF THE UNITED STATES
R.J. PEARSON, M.D.
F.A.C.P., F.A.C.C.
FORD, Gerald R.
CONGRESSMAN/MICHIGAN
PHYSICAL EXAMINATION Part-I (Con't) February 18, 1972
He states that several years ago on gastrointestinal series
they thought they saw an ulcer scar, but he has never had
any ulcer symptoms. Occasionally he has hemorrhoids, assoc-
iated with constipation or exertional activities and has
superficial bleeding on the stool and on the toilet tissue.
Genitourinary: He has nocturia regularly, 1 time per night,
occasionally twice if he has had a lot to drink. Occasion-
ally under stressful circumstances he has hesitancy in
starting his stream but he has no bleeding, burning, frequency,
dribbling, etc.
Musculoskeletal: In 1958 he had the sudden onset of severe
back pain where he could not get up or down and he had to be
hospitalized at Bethesda. This was thought to be a muscle
spasm. He has chronic knee problems from old football injuries,
particularly on the right, which has fluid occasionally if he
has a lot of trauma to the knee, such as skiing or walking.
He injured his right shoulder while skiing early this year and
he has had physical therapy to it. The pain is in the region
of the insertion of the bicipital tendon. He has had some
skin lesions on his nose and face, which have been looked at
periodically by the dermatologists.
PHYSICAL EXAMINATION
Temperature: 98°.
Pulse: 60 and regular.
Blood Pressure: 110/70, both arms.
Respirations: 14 per minute.
Chest: 41" unexpanded. 43 1/2" expanded.
Eyes: Normal extraocular movements. Pupils are round,
regular and react to light and accommodation. Ocular
fundi show no vascular changes. Visual fields are normal
by confrontation.
Ears: Ear canals are relatively clear bilaterally. The
right TM appears normal. The left drum appears slightly
thickened and slightly inflammed. Weber and Rinne are normal.
Nose & Throat: There are tobacco stained teeth but there are
no oral lesions of smoking injury, no thickening of the mucous
membranes or redness. The tongue appears to be normal, as
does the pharynx. The nose shows the septum to be deviated to
the right but otherwise is normal.
FORD
BEMALU
LIBRARY
II OF IV
THE ATTENDING PHYSICIAN
CONGRESS OF THE UNITED STATES
R.J. PEARSON, M.D.
F.A.C.P., F.A.C.C.
FORD, Gerald R.
CONGRESSMAN/MICHIGAN
PHYSICAL EXAMINATION Part-I (Con't) February 18, 1972
Neck: Supple. Carotid artery pulsations are equal
bilaterally without any murmur. Thyroid is not felt.
There are no lymph nodes palpable.
Skin: There are several benign, non-pigmented nevi on
the face, and some prominent blackheads on the tip of the
nose.
Lymphatic: No palpable lymph glands in the supraclavicular
or infraclavicular areas, axillary areas, or groin.
Chest: Normal expansion of the lungs. Breath sounds are
clear and resonant. Percussion note is normal.
Cardiovascular: Heart is normal size to percussion. To
palpation the apical impulse is well within the midclavicular
line in the 5th left interspace. 1st sound is slightly
greater than 2nd sound at the apex. A-2 is greater than P-2
and splitting is normal at the 2nd left interspace. There
are no murmurs nor gallops.
Abdomen: Soft. Neither liver, kidney nor spleen is palpable.
The abdominal aorta is palpable and does not appear to be
enlarged. There is an old right lower quadrant scar which
is about 2 1/2 to 3 cm wide and about 12 cm in length, from
an appendectomy when he was four years old.
Genitalia: Normal external genitalia with circumcision.
Testicles are normal. No hernia.
Rectal: Prostate is 1 - 2+ symmetrically enlarged, soft,
without any nodularity. No stool is present in the rectum.
There are large, external, hemorrhoidal tags,
Peripheral Vascular: All pulses are palpable and equal.
Neurological: Deep tendon reflexes are brisk and equal
bilaterally. Babinski downward. Skin sensation normal
all over.
Congressman Ford has a new problem which was picked up on
his routine x-ray and will be called PROBLEM #9.
Abnormal x-ray finding on the chest-x-ray, nodular
area in the left 1st interspace, peripherally, which was
present on the 1970 film but not on the 1967 film. The
radiologist (Dr. Turner) has suggested that the patient
have laminography to try to determine the nature of this
FORD
lesion.
4
As far as PROBLEM #7 is concerned, Mr. Ford has
BEHALD
LIBRARY
previously had high cholesterol and high triglycerides,
and because of recent evidence of effectiveness of
III OF IV
THE ATTENDING PHYSICIAN
CONGRESS OF THE UNITED STATES
R.J. PEARSON, M.D.
F.A.C.P., F.A.C.C.
FORD, Gerald R.
CONGRESSMAN/MICHIGAN
PHYSICAL EXAMINATION Part-I (Con't) February 18, 1972
Clofibrate in reducing the instance of heart attack, in
addition to lowering these variables, he agreed to take
Clofibrate, 500mgm q.i.d.
Other active problems remain:
#1. Chronic arthritis, traumatic, both knees.
#2. Nasal septal deviation.
#4. Chronic sinusitis.
PLAN
1. Consultations regarding his change in visual
acuity with the eye department; orthopedic department
regarding the chronic arthritis in his knees and his
shoulder discomfort; urology for prostate; gastroenterology
for routine sigmoidoscopy. It is planned at the present
time to have these consultations at the Naval Hospital on
February 25, 1972. ALSO LAMINOGRAPHY 2/25/72
treem N Gany
FREEMAN H. CARY, M.D.
rlm
BERALD . 1375917 FORD
IV OF IV
THE ATTENDING PHYSICIAN
CONGRESS OF THE UNITED STATES
R.J. PEARSON, M.D.
F.A.C.P., F.A.C.C.
FORD, Gerald D.
Congressman, Michigan
PHYSICAL EXAMINATION - PART II
April 24, 1972
Regarding Problem #1 - Chronic Arthritis, both knees - he
was seen in orthopedic consultation by the Orthopedic
Department, Bethesda Naval Hospital and there opinion was
that he had a tear of the right lateral meniscus of the
knee and recommended that he have knee suregry at his
convenience and that he continue his physical therapy to
strengthen the quadriceps.
Regarding Problem #7 - Hypercholesterolemia - he was placed
on Atromid-S, 500mgms. q.i.d.
The new problem, Problem #9 - Abnormal Density on X-ray,
Chest - turned out to be pleural capping on laminography.
His shoulder discomfort turned out to be bursitis.
The remainder of his consultations and work-up, revealed
know significant abnormality.
F. H. CARY, M.D.
wfw
GURRLO FORD LIBRARY
-
R
L
F
V1
V2
V3
V4
V5
V6
ELECTROCARDIOGRAPH REQUEST
PREV. ECG YES
NO
AMB.
BED.
EMERG.
DIG.
QUIN.
AGE 58 SEXM B.P. 120/80 DATE 2-1
CLIN. DIAG.: ROUTINE
ORDERED BY
Wt. 208 1/27
Ht. 6'
ELECTROCARDIOGRAPH REPORT
RHYTHM: SINUS
X
OTHER:
RATES: 54-62
INTERVALS:
AXIS:
SINUS BRADYCARDIA-ARRHYTHMIA WITH
ATR.
VENTR.
P-R 0 ,16qrs .08 QTc 40
+15 0
DADE PVC
DESCRIPTION:
LIMB LEADS
PRECORDIAL LEADS
P
NOTCHED IN II, V2, thru V4
T Axis =(
FORD
QRS
TRANSITIONAL V2.
.
S-T
T.U
INTERPRETATION, SERIAL CHANGES, IMPLICATIONS:
BEBALD
LIBRARY
(1) OCCASIONAL PVC,
(2) WITHIN NORMAL LIMITS.
(3) NO SIGNIFICANT CHANGE SINCE 1-5-70.
PATIENT'S IDENTIFICATION
INTERPRETED BY
FORD, GERALD R. (CONGRESSMAN: MICHIGAN)
FREEMAN H CARY
R. J. PEARSON, M. D.
ECG NO.
WARD
R A
ATTENDING PHYSICIAN
DATE
U. S. CAPITOL
(SEE OVER)
WASHINGTON, D. C.
Cong g Ford 2-16-72
LIBRARY
GENALO
DAVA
"Te 708
the MILH NI PRINTED
20-P5
I
If
RECORDING CHARTS GRAPHIC CONTROLS CORPORATION BUFFALO, NEW YC
1
III
June, 1973
now on file.
admission for Congressman Ford. Please substitute for the copy
This is a corrected copy of Narrative Summary on the July, 1972,
Patient Affairs,
Naval Hospital,
Bethesda, Md.
+ FORD
Standard Form 502
Rev. August 1954
Bureau of the Budget
6-11-73 pk
Circular A...32
CLINICAL RECORD
NARRATIVE SUMMARY
DATE OF ADMISSION
DATE OF DISCHARGE
NUMBER OF DAYS HOSPITALIZED
7-9-72
7-22-72
(Sign and date at end of narrative)
FINAL DIAGNOSIS:
INTERNAL DERRANGMENT RIGHT KNEE. POST OPERATIVE HEMATOMA, RIGHT KNEE.
KERATOTIC NEVI, LEFT LOWER EYELID AND RIGHT CHEEK.
SUMMARY:
This 59 year old Congressman from Michigan has a history of trauma to the right
knee in 1929 while playing football. He had pain and effusion and following this,
he had some persistent difficulty with pain and use of the knee. He was able to
use the knee despite the somewhat limited motion and pain on use, but during the
last six to nine months, he had noted recurrent effusion with a catching sensation
in the lateral aspect of the joint. This usually followed some sport such as
skiing and he had relief of the effusion and pain with rest. Due to the persistence
of pain and effusion on activity, he was referred here for evaluation.
Physical examination is normal with the exception of the lower extermities. There
is a well healed scar on the left lateral aspect of the left knee. On the right
knee, he has some synovial thickening with pain and clicking on McMurray's
test laterally. The remainder of the examination is normal.
Hospital course: The patient was admitted for surgery to the right knee. During
his pre-operative evaluation, he was noted to have abrasion over the left tibia
and he was therefore observed for several days. The abrasion did not have any
drainage and appeared to be healing well and without difficulty, so he was operated
upon on 12 July 1972 and a right lateral meniscectomy was performed.
Following this procedure, a keratitic
lesion from the left lower eyelid and a nevus from the right cheek were excised
under local anesthesia and closed with 6-0 nylon sutures. A dressing was applied
to the right cheek area. The popliteal tendon had to be released from the
posterior part of the meniscus and was repaired at the time of closure. The
post-operative course was benign. He did have an episode of erythema over the
wound three days post-operatively and a hematoma was removed. The wound was
opened slightly at its posterior margin to allow the hematoma to be removed, but
he had no other difficulty. The patient was therefore discharged on 21 July 1972
to be followed at the Capitol for physical therapy and rehabilitated.
FORD
GERALD
LIBRAR
J. F. LOVEJOY UR
APPROVED:
LCDR MC USNR
D. 0. WILSON, CAPT MC USN. CHIEF OF ORTHOPEDICS
(Use additional sheets of this form (Standard Form 502) if more space is required)
He
SIGNATURE OF PHYSICIAN
DATE
IDENTIFICATION NO.
ORGANIZATION
372 28 6532
PATIENT'S IDENTIFICATION (For typed or written entries give: Name--last, first,
REGISTER NO.
WARD NO.
middle: grade; date: hospital or medical facility)
I-7202819
NARRATIVE SUMMARY
Standard Form 502
FORD, GERALD R., CONGRESSMAN, MICHIGAN
502.108
NAVAL HOSPITAL, BETHESDA, MARYLAND
THE ATTENDING PHYSICIAN
UNITED STATES CAPITOL
WASHINGTON, D.C.
Vice President of U.S.
CONSOLIDATED LABORATORY REPORT
Page 1
NAME: LAST Ford, Gerald FIRST
(mich) O. Pod.
1972
MIDDLE
BLOOD TYPE/RH
DATE
DATE:
1/28/74/28/74
Color
Y/chear
Specific Gravity
1.015
Ph
acid
Albumin
0
the
Sugar
0
0
-URINALYSIS
Occult Blood
0
MICROSCOPIC:
White Blood Cells
Rare
Red Blood Cells
Epithelial Cells
Bacteria
Crystals
Casts
Mucous
acc.
Ketones
Normals-Bench
Hemoglobin
14-17
17.7
Hematocrit
42-47
50
White Blood Count
5-10
5.8
DIFF: Neutrophils
50-70
55
HEMATOLOGY-
Bands
0-3
Lymphocytes
20-40
38
Eosinophils
0-3
7
Basophils
0-1
Monocytes
2-8
Sed Rate (Male)
0-9MM/1 Hr.
4
(Female)
0-20MM/1 Hr.
Sickle Cell
Glucose (Fasting)
60-110
101
(1 Hour)
196
(Random)
BUN
8-20 mgm.
17
Creatinine
.6-1.6
.8
Uric Acid
3.5-7.5
7.8
Sodium
133-145
144
Potassium
3.5-5
4.1
GENERAL CHEMISTRY-
Chloride
95-108
105
Carbon Dioxide
20-30
27
Phosphate
2-3.5
4.3
Total Protein
6-8.4
6.7
Albumin
4-6
Globulin CALCIUM
10.1
Alkaline Phos
15-60
60
FORD
Acid Phos
0-2
1.8
#
SGOT
0-35
29
SGPT
5-24
20
LDH
40-150
147
CERALO
1898911
0-100
Billubin, Total
0-1.5
.9
BSP
0.5%/45 min. ret
Cholesterol
150-250
251
Tryglycerides
35-150
O
ATTENDING PHYSICIAN
Ford, Gerald
U. S. CAPITOL, WASHINGTON, D.C.
CONSOLIDATED LABORATORY REPORT
O- Pas 7-8-72
ME:
Last
First
Middle
Blood Group/Rh
Date
1/18/72
2/28/12
DATE
7/8/72
4/8/71
Color
y-cled
yellow
inllaw
Clear
Hazy
Specific Gravity
1.016
1.020
1.012
Ph
5
5
5
Albumin
0
0
the
0
Sugar
0
0
0
0
URINALYSIS
Occult Blood
0
0
0
MICROSCOPIC:
White Blood Cells
0-2
2-3
2-3
Red Blood Cells
Epithelia
Few
Bacteria
Crystals
Casts
Mucous
on.
mod.
NORMALS-BENCH
Hemoglobin
14-17
15.6
15.8
16.6
Hematocrit
42-47
47
48
49
White Blood Count
5-10
6.1
5.4
6.4
DIFF: Neurtrophils
50-70
54
59
69
Bands
0-3
HEMATOLOGY
Lymphocytes
20-40
44
36
24
Eosinophils
0-3
3
/
Basophils
0-1
Monocytes
2-8
2
2
6
Sed Rate (Male)
0-9MM/1 hr.
M
6/7
2
(Female)
0-20MM/1 hr.
Cholesterol
150-250
270
295
290
PO4
2.3-5
2.8
4.0
2.9
Uric Acid
3.5-7.5
9.9
7.0
7.8
Creatinine
.6-1.6
1.0
0.95
1.0
Sodium
133-145
139
139
139
Potassium
3.5-5
4.1
4.4
4.6
Chloride
95-108
Carbon Dioxide
20-30
Total Protein
6-8.4
Albumin
4-6
GENERAL CHEMISTRY
Calcium
8.9-11
9.8
10.2
10.2
Acid Phos
(IU)0.13.0.54 0-2 0.13.0.54
0.7
0.18
0.18
Alkaline Phos
9-35(IU)
23
23
22
FORD
SGOT
8-35
10
25
SGPT
0-35
LDH
24-78(IU)
CPK
30-60
SEHALD
LIBRARY
BUN
10-24
15
17
15
Bilirubin, Total
.1-1
0.9
0.6
0.5
Bilirubin, Direct
.05-.31
cose, Fasting
65-110
95
98
cose, 1 hour
135
Glucose, 2 hour
75
Orthotoludine Method
(3br.)
GPO : 1970 0 51-622 (No. 1)
CONSOLIDATED LABORATORY REPORT (Page 2)
DATE:
2/18/72
BACTERIOLOGY:
Throat Culture
Urine Culture
Sputum Culture
Stool Culture
Stool, Ova & Parasites
Stool, Occult Blood
VDRL
hig
MISCELLANEOUS TESTS
DATE:
2/18/72
Normals-Bench
Amylase
33-161
Lipase
0-1.1
PBI
3.6-7.7
Total Lipids
Tryglycerides
35-135
218
BSP
0-5%/45min ret.
Iron
40-150
TIBC
220-430
T-3
.81-1.17
T-4
5.1-11.1
FORD
$
BEHALD
MBRARV
GPO : 1970 0 - 51-622 (No.2)
SUMMARY SHEET
FORD, GERALD R.
25APR72
CONGRESSMAN, MICHIGAN
ACTIVE PROBLEMS
INACTIVE PROBLEMS
1. MUSCULOSKELETAL
A), CHRONIC ARTHRITIS KNEES,
WITH MEDIAL MENISCUS TEAR.
SURG REGINA KNEE 7/72
B).
BURSITIS (R) & (L) SHOULDERS,
C),
(R) MEDIAL EPICONDYLITIS.
D),
FRACTURED (R) CLAVICLE - AGE 14.
2.
NASAL SEPTAL DEVIATION.
3.
EXTERNAL HEMORRHOIDS
4. CHRONIC SINUSITIS/RHINITIS.
5.
CRYPTITIS,
6.
MILD OBESITY.
7, HYPERCHOLESTEROLEMIA/HYPERTRIGLYCERIDEMIA
(?TYPE II ABNORMALITY).
8. HYPERURICEMIA/GOUT.
9.
APPENDECTOMY - CHILDHOOD.
MEDICATIONS AND MANAGEMENT
1.
A), ORTHOPEDIC CONSULTANT RECOMMENDS SURGERY.
2.
3.
4. SUDAFED.
5.
6.
7, DIET, ATROMID-S
8.
9.
FAMILY HISTORY
MOTHER DIED AT AGE 71, ACUTE MYOCARDIAL INFARCTION, WAS DIABETIC.
FATHER DIED AGE 72, FROM A FALL.
THREE HALF BROTHERS, ONE IS ASTHMATIC
P.E.
2/18/72
D.O.B. 7/14/13
1080 LIGHARY .
TELEPHONE: OFFICE - 225-3831
HOME - 751-0177
Standard Form 513
Rev. August 1954
Bureau of the Budget
Circular A--32
S/N 0109-201-2602
CLINICAL RECORD
CONSULTATION SHEET
REQUEST
TO:
FROM: (Requesting ward, unit, or activity)
DATE OF REQUEST
CAPITOL PHYSICIAN
ORTHOPEDIC CLINN
13 DEC 72
REASON FOR REQUEST (Complaints and findings)
USNH, BETH., MD.
Followup appointment
PROVISIONAL DIAGNOSIS
DOCTOR'S SIGNATURE
APPROVED
PLACE OF CONSULTATION
EMERGENCY
11
BEDSIDE
ON CALL
X
ROUTINE
CONSULTATION REPORT
ORTHOPAEDIC
CLINIC
13 DECEMBER 72
Congressman Ford had difficulty with his right knee and had a lateral menis-
cectomy in July 1972. Post-operatively, his knee was rehabilitated with
little difficulty.
ON EXAM TODAY: There is no effusion. There is some mild^thickening of the
synovium and he has þain on compression of the patella. Medial, lateral
and collateral ligaments appear to be stable. His drawer sign is negative.
There is some mild tenderness on full flexion of the knee, postero-lateral
aspect of the knee at the surgical incision. The remainder of the exam
was WNL.
IMPRESSION: The patient has done very well in his post-operative rehabili-
tation program, and it is expected he should have little difficulty with
his future. We plan to see him PRN and he should return to full activity
as tolerated.
FORD
GERALO
LIBRARY
ntc
(Continued on reverse side)
SIGNATURE AND TITLE
DATE
IDENTIFICATION NO.
ORGANIZATION
JOHN F. LOVEJOY, JR., LCDR MC USNR 12/13/72 ASST. CHIEF, ORTHOPAEDICS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name-Iast, first,
REGISTER NO.
WARD NO.
middle; grade; date; hospital or medical facility)
CLINIC
pec
FORD, GERALD CONGRESSMAN, MICHIGAN
CONSULTATION SHEET
OPD #1-05-38
Standard Form 513
513-104-02
Standard Form 513
Rev. August 1954
Bureau of the Budget
Circular A-32
CLINICAL RECORD
CONSULTATION SHEET
REQUEST
TO:
FROM: (Requesting ward, unit, or activity)
DATE OF REQUEST
PT. (Capatol)
Orthopedic Clinic
REASON FOR REQUES (Complaints and findings) main Naual Disp
Ki
/
2
Please Daily begin isotonic PRE to
guad DC I hom. womenty on NK dable
M
PROVISIONAL DIAGNOSIS
Remain on 30-50% WB on erables
Post lateral APPROVED memoratory PLACE OF CONSULTATION
DOCTOR'S SIGNATURE
EMERGENCY
BEDSIDE
ON CALL
ROUTINE
CONSULTATION REPORT
FORD
a
BERALD
LIBRARY
(Continued on reverse side)
SIGNATURE AND TITLE
DATE
IDENTIFICATION NO.
ORGANIZATION
PATIENT'S IDENTIFICATION (For typed or written entries give: Name-last, first,
REGISTER NO.
WARD NO.
middle; grade; date; hospital or medical facility)
Ford, Gerald
CONSULTATION SHEET
Standard Form 513
513-104-02
Cong /meh
HEALTH RECORD
CHRONOLOGICAL RECORD L MEDICAL CARE
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
Ortho
2 weeks per lateral nonesastary MD
7/25/72
Exam: Modenately Lense effenso
wome bealed. Flyes 90°
of looks 10.15° sor.
(Lifting 10# unwtris)
Ree:
1
Sectimes renared - would health
2
Tostant isotoms PRE
on NK table to grass thems
3
Dencere on 30-50% WB
on enotates
4
RTC 2weeles - may there
broke to go on care.
Agual
HHC
ace
FORD
&
BERALD
LIBRARY
PATIENT'S IDENTIFICATION (Use this Space
for Mechanical Imprint)
PATIENT'S NAME (Last, First Middle initial)
SEX
Ford Grold
YEAR OF BIRTH
RELATIONSHIP TO SPONSOR
COMPONENT OR STATUS
DEPARTMENT OR SERVICE
U.S. -
SPONSOR'S NAME
Congruss RANK/GRADE
SVC OR IDENTIFICATION NO.
ORGANIZATION
S/N 0109-201-6901
CHRONOLOGICAL RECORD OF MEDICAL CARE
Standard Form 600
February 1969
General Services Administration and
Interagency Comm. on Medical Records
FPMR 101-11.809-3
600-103
INV
Standard Form 513
.
2325-92
Rev. August 1954
Bureau of the Budget
Circular A-32
0900
CLINICAL RECORD
CONSULTATION SHEET
REQUEST
TO:
FROM: (Requesting ward unit or activity).
DATE OF REQUEST
ORTH
AT PHYSICIAN S OFFICE
U. S. CAPITOL
18 Feb 72.
REASON FOR REQUEST (Complaints and findings)
EVALUATION OF RT. SHOULDER 85Kg
Topo E' 75° PCDB WC пгив
INJURY + OLD RT, KNEE PROBLEM S.
FORD
DOIVERS
LIBRARY
PROVISIONAL DIAGNOSIS TO pla 31 pre
LOSSK Aan NOW unce TOL asug: ASIA
ROSTINE ANNUAL
MS
DOCTOR'S
SIGNATURE
KD65
APPROVED
00
anegos
PLACE
OR
CONSULTATION
EMERGENCY
R.
J.PEARSON,
IR.
этао
CO
ET
BEDSIDE
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to
ON CALL
ROUTINE
REDS MC US#1 MO byso CONSULTATION REPORT p6
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116
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THE
Ta
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CHIEF COMPLAINT: Evaluation of right shoulder nain and first
35 FEB1972
current effusion and instability in the right knee.
the Present Illness: This 58 y.o. gentleman developed shoulder pain,
in 0855 right, approx. 1 JAN 72 He had had no difficulty before a
($) skiing trip, and after several weeks of skiing, he noted some
DOBILIAG stiffness in his shoulder There was no specific accident. The
SU sug pt noted that sleeping on the stomach with his shoulder ABDucted
I! RUNGHTS fo and his head on the hand which was the normal way he slept,
T8
gre magros caused pain in the shoulder He also noted he had to change his 01
on ароль fije sleeping habit due to the pain and on arising in the morning. ther
was stiffness and limited ABDuction of the right shoulder.
He was seen by Dr Pearson following the skiing trip and treated with oral medi-
cation injection and PT with some gradual improvement TO миг" OU 6XSW-
The pt is having some difficulty with his right knee, which he dates to a football
injury occurring in 1929 At that time he injured both knees had subsequent
difficulty of the deft knee and requiring an operation in 1933 which was probably
a lateral meniscectomy He,has had no significant difficulty with this knee
following surgery, However his right knee has given him problems lowing
exercised This: consisted of effusion, provoked by exercise and relieved with rest
With this fall, he developed a new symptom, which was instability of the knee.
He noted after walki and external rotating the foot, there was a grinding
sensation in the lateral aspect of the leg ro He noted lying in bed in a relaxed
position, some movement caused (Continued discomfort on reverse side) in this area.nT Also after making a
SIGNATURE AND TITLESSION any 23 EDUDATED 446 INDENTIFICATION NO.
ORGANIZATION
all
absecu oz essuqioR' H6 молта Snoto дте LTSPE KOGG 98 ps MONTH USAG a
R
PATIENT'S IDENTIFICATION (For typed or written entries give: Name-last, first,
REGISTER NO.
WARD NO.
middle; grade; date; hospital or medical facility)
B
CONSUMPATION SHEET
RETURN
Standard Form 513
76/2
513-104-02
FORD, GEPAID 9. MTCH.
RETURN TO ATTENDING
ATTENDING PHYSICIAN
NHY ICIAN U. CAPITOL
DOB 07-14-13
ROOM H-166
U.S. CAPITOL
BOOW H-ree
2
СУЫШОГ
VILLENDING
BEINB
effectives
213
BUREL
angan as megroof
БУЛЕЙЛЕ Daug Esse year'
ио:
AND vor
speech or standing, he would guard his right knee as he would have a
eleigradi ng sensation and a feeling the knee was going to way He has
balone physical therapy far the knee and had no difficul ty with effusione
2 diallowing his skiing this year but due: to the persistent instabi FYEXT
Hwas meferred here Past hx is non contributor toof* g
fute ts p6 делегобед g UGM MBE
PHYSICAL EXAM: The pt is in good physical condition Exam of the
upper shoulder shows pain on palpation of the tendon and
5 the dong head of the biceps in the picepital groove of the humerus There
girs amormal ROM of the cervical spine wi the no on motion, and a neg
Spunl ingls test. There is Limited ABDuction external and internal rotation
I/Of the ght shoulder, with pai on extremes of thes mot The
exam of both upper extremities and the neurological exam is WNL. On exam-
Heining the right knee there is mild effusion. There is some loss of quadri-
ceps tone with a measurable decrease in the size of the quadricers of 1.11
9" above the tibial tubercle. There is no pain on compression of the patella,
of the medial and lateral lateral ligaments, as well as the anterior/posterio
I
ligaments to be intact. External rotation. extension of the knee there is
an audible and palpable click over the lateral meniscus. He also has Your
positive Appley's grinding test for a lateral meniscus injury security I/6
(1) sug MOEKS of 110 upgeq 20116
IMPRESSION: Bursitis of the right shoulder, resolving with present therapy.
(2) Tear of the right lateral meniscus of the knee Date
SPEERIALS
CALLENT gua IL CUG LIEUI K066*
DISPOSITION: Recommended he continue his therapy to the right shoulder and
ПЗИН in addition to PT, do a home program of ROM exercises. The pt was presented
to Capt Wilson and his findings were the same on the knee. It is our
feeling that he should have a lateral meniscectomy of the knee, and it was
recommended, We plan to do this at his convenience, which will probably be
in July 72. We would also like him to continue his PT in the interim, to
protect the knee from further quadriceps atrophy and effusion.
Thank you very much for sending us this very interesting patient. We will
certainly be glad to do his surgery at his convenience.
Respectfully,
P
ODD
5
EAHTONLION
John F. Lovejoy, Jr., LCDR MC USNR
at
151.
Orthopaedic Service
FORD
КЕУЗОЙ 603 BEDGERS (combrate inquire
B СУБТЬСТ
OKIH
ORRICE
10
MEODEDA
OFINICATION SECOND
payment perful
BAN
0.8.00
272
1-25-72
Standard Form 513
Rev. August 1954
1038
Bureau of the Budget
Circular A-32
CLINICAL RECORD
CONSULTATION SHEET
REQUEST
TO:
FROM (Requesting ward, unit or activity)
DATE OF REQUEST
GI
ITENDING PHYSICIAN S OFFICE
U. S. CAPITOL
18 Feb 72.
REASON FOR REQUEST (Complaints and findings)
HEMORRHOIDS c OCC BRIGHT
RED RECTAL BLEEDING = RONSTIPATION
&
DCC DIARRHEA c SAVER- KRAUT INVESTION
PROVISIONAL DIAGNOSIS
ROUTINE ANNUAL PE
DOCTOR'S SIGNATURE
APPROVED
PLACE OF CONSULTATION
EMERGENCY
R. J. PEARSON, JR.
BEDSIDE
ON CALL
ROUTINE
RADM MC USN
CONSULTATION REPORT
2/25/72 History is above.
Exa Inspection: Extemal heronhoide lags.
Digits. Sord splainter to Protto WNL.
No horse home
Prats to 22cm revals none cobene
huncon throghout. No active firme you
Imp: External heronhoid,
Advine: Ba Even to exclude proxime FORD
ltrolg, to bleedy
4
SERALD
LIBRARY
(Continued on reverse side)
He
SIGNATURE AND TITLE
DATE
IDENTIFICATION NO.
ORGANIZATION
2/25/72
12
PATIENT'S IDENTIFICATION (For typed or written entries give: Name-last, first,
REGISTER NO.
WARD NO.
middle; grade; date; hospital or medical facility)
B
f
RETURN SHEET
Form 513
519-104-02
FORD, CERALD Re MICH.
ATTENDING PHYSICIAN
TO ATTENDING
PMV ICIAN 01 CABITOL
DOB 07-14-13
ROOM H-166
U.S. CAPITOL
2-25-72.
Standard Form 513
Rev. August 1954
0800
Bureau of the Budget
Circular A-32
CLINICAL RECORD
CONSULTATION SHEET
REQUEST
TO:
AT
ROM (Revines) CubliNot STICE
DATE OF REQUEST
EYE
0. S. CAPITOL
18 Feb 1972.
REASON FOR REQUEST (Complaints and findings)
ALWAYS NEAR SIGHTED Now DIFFICULT
MORNING VISION 10 NEWS PRINT. NEEDS
TONO TONOMETRY
PROVISIONAL DIAGNOSIS
ANNUAC PE
DOCTOR'S SIGNATURE
APPROVED
PLACE OF CONSULTATION
EMERGENCY
R. PEARSON, JK. K.Y
BEDSIDE
ON CALL
ROUTINE
RADM AC US#
CONSULTATION REPORT
20/20- TJ, kas J, )-75-75-75
14
20/15 -25-1.00x85
a
20/20
05-15-75x105
20/15
-1.00-25x105
14
pupil= = reactin, version full
sk., cornea, AC + line clear
Juneh : disa sharp 0.3 cup vessus x marula noned
periphing che
BERALD & FORD
(Continued on reverse side)
SIGNATURE AND TITLE
DATE
IDENTIFICATION NO.
ORGANIZATION
LCDRM 23 Ford
PATIENT'S IDENTIFICATION (For typed or written entries give: Name-last, first,
REGISTER NO.
WARD NO. p
middle; grade; date; hospital or medical facility)
Mc
CONSULTATION SHEET
RETURN TO:- 513-104-02 Form
513
FORD. GERALD (итси.)
RETURN 70 ATTENDING
ATTENDING PHYSICIAN
PHY ICIAN If CA ITOL
07-14-13
ROOM H-166 U.S. CAPITOL
Standard Form 519
Rev. August 1954
Bureau of the
Budget Circular A-32
U.S. GOVERNMENT PRINTING OFFICE 1964 0-718-468
CLINICAL RECORD
RADIOGRAPHIC REPORTS
ATTACH SD REPORT ALONG HERE ^ AND SUCCEEDING ONES ON ABOVE LINES
ATTACH 2D REPORT WITH TOP AT THIS LINE
2-18-72
500
400
300
200
150
140
130
120
110
50
ATTACHING MARGIN
MEFR
©
......
e
Cong 10 ....... 90 g 70 0 . Ford 0 . @ 09 a 0 S @
.
50
0
0
45
4
40
35
LITERS AND TENTHS OF LITERS
3
F.U.C 492- 103 % Promal 30
/sec. 3.6L - 26904 Total
25
2
2sec 4.25L 90% of Total
a
20
15
1
10 $ FORD LIGHORY
MEFR.
SECONDS AND TENTHS OF SECONDS
McKESSON VITALOR
CHART NO. VC-26
MFD. BY McKESSON APPLIANCE CO., TOLEDO, OHIO
PATIENT'S IDENTIFIC
O.
grade; date; bospital or medical facility)
RADIOGRAPHIC REPORTS
Standard Form 519
519-106
2-25-72
Standard Form 513
Rev. August 1954
Bureau of the Budget
0930
Circular A-32
CLINICAL RECORD
CONSULTATION SHEET
REQUEST
TO:
AT SUPPLICE
DATE OF REQUEST
G.U.
U. S. CAPITOL
18-7ab-1972
REASON FOR REQUEST (Complaints and findings)
NOCTURIA 1*2X, OCC HESITARCY,
PROSTATE 1+ ENLARGED
PROVISIONAL DIAGNOSIS
ROUTINE ANNUAL PE
DOCTOR'S SIGNATURE
JJC R. VEARSON, JR
APPROVED
PLACE OF CONSULTATION
EMERGENCY
Y
BEDSIDE
ON CALL
ROUTINE
RADM MC USN
CONSULTATION REPORT
OROLOGY CLINIC
BETEESDA
no significant GU ob tructive
O25FEB1972 symptoms. nortune probably
related to fluid. intake.
PE: Prostate is small, symmetical
and benign
Inps no significant Gll abnormations FORD
4
Plan RR T gear
SERALD
LIBRARI
(Continued on reverse side)
He
SIGNATURE AND TITLE
1/25/72
DATE
IDENTIFICATION NO.
ORGANIZATION
My
PATIENT'S IDENTIFICATION (For typed or written entries give: Name-last, first,
REGISTER NO.
WARD NO.
middle; grade; date: hospital or medical facility)
CONSULTATION SHEET
JB
RETURN
Standard Form 513
513-104-02
FORD, GERALD (MICH)
RETURN TO ATTENDING
ATTENDING PHYSICIAN
ICIANCY CAPITOL
DOB 07-14-13
ROOM H-166
U.S. CAPITOL
DATE
PROGRESS NOTES
9/21/71
lun Small then Unned from help - 10pm present 10 drugs of
7JAN72
Minor Problem. Pain in right shoulder.
Subjective: Mr. Ford was skiing over the holidays and suffered
no overt trauma to his right shoulder but has noticed a mild
anterior right shoulder pain, particularly on elevation.
Physical examination was unrevealing, as were the x-rays.
Plan: (1) Rx - a. Brief course of Butazolidin. b. Heat
and rest for three days, then resume exercise. C. If no
improvement to see orthopedists. (2)Dx- a. X-RAYS NORMAL
BRIAN SHEEDY, M.D.
rlm
20JAN72
Since he was given the Butazolidin, the shoulder did improve
but then with the excessive hand shaking the last few days,
there has been a recurrence of the pain just about over the
insertion of the bicipital tendon. The pain is aggravated
when he puts his hand over his head or in marked external ro-
tation and abduction. We injected the point with Lidocaine
and Celestone and suggested that he continue to get heat for
the next 2-3 days.
R. J. PEARSON, M.D.
wfw
7FEB72
Telecon with Captain Turner, Radiologist, NH, Bethesda,
says that he has discovered a lesion just below the first
rib, far-out laterally, on the left that looks as though it
is pleura based. In retrospect he can see the same small
lesion in last year's film, but it was not present in 1967.
He feels this deserves laminograms.
R. J. PEARSON, MD.
wfw
25FEB72
Dr. Miller of the Radiology Department at Bethesda Naval Hosp.
called regarding Congressman Ford's laminogram. He states
that in his opinion and also that of Dr. Armstrong, the lamino-
gram shows apical pleural scarring, which is present also to
some degree on the right side. He felt that this had been
present for some time and was no cause for alarm. Did not
recommend any acceleration in the routine x-rays that we have
been getting.
HEM H. CARY M.D.
rlm
0801 Lighent + 8079335
GPO 1968 0-94-871
OFFICE OF ATTENDING PHYSICIAN
UNITED STATES CAPITOL
WASHINGTON, D.C.
DATE
PROGRESS NOTES
25FEB72
ADDENDUM TO PREVIOUS ENTRY OF THIS DATE:
Telephone conversation with Congressman Ford. Mr. Ford was
given the information regarding his laminogram showing apical
pleural scarring,and he stated that Dr. Lovejoy of the ortho-
pedic department suggested that he have his right knee operated
on to remove some cartilage. The consultation has not yet
returned from Bethesda. Mr. Ford states that he does not have
the time this year to have it done but he would early next year.
As soon as the consultation is back, or I have talked with Dr.
Lovejoy, I will have more information about the urgency of the
knee operation.
May F. H. CARY, M.D.
rlm
12JUL72
Telephone conversation with Dr. Lovejoy, Bethesda Naval Hospital
orthopedic department. Surgery on the right knee just
completed, which was very difficult because of the severely
torn-up meniscus, necessitating taking down part of the
popliteus tendon to complete the repair. Estimation of
recovery time is unchanged and he should be able to be on
the House Floor on Monday, July 17th for business.
F HV CARY, M.D.
rlm
17JUL72
Telephone conversation with Dr. Lovejoy, Bethesda Naval Hospital
Dr. Lovejoy opened the knee incision on Saturday because of the
fever and some joint effusion and expressed some blood from the
knee joint, which he felt was the cause of the irritation of the
knee and also the fever. Apparently the fever subsided after he
did this. He will plan to keep him overnight for several more
days until he is certain that there is no infection in the knee
joint.
F. JHC H. CARY, M.D.
rlm
FORD
ULRALD
Name:
FORD, Gerald R.
CONGRESSMAN/MICHIGAN
(Last)
(First)
(State)
(Allergies)
DATE
PROGRESS NOTES
26JUL72
Problem: Post operative knee.
SUBJECTIVE: Congressman Ford thinks that his knee is a little
bit swollen today compared to yesterday. It is not particularl
painful. He has not had any physiotherapy or heat to his knee
yet today.
OBJECTIVE: The knee is swollen. There is moderate joint ef-
fusion. Inferior to the "hockey Stick" scar there is a 2 to 3
centimeter border of erythema which is warm and over the super-
ior part of the scar, extending up to the patella is an area of
erythema which is warm.
ASSESSMENT: I described these findings to Dr. Wilson, who saw
Mr. Ford yesterday and removed the suture from his knee. He
feels that the findings are different, but perhaps related to
being up and about and perhaps EXTRAVASA some of the
fluid in his knee joint into the soft tissue. He would be
happy to see Mr. Ford this evening or tomorrow morning, should
Mr. Ford desire to have his knee examined. This message was
given to Mr. Ford and he decided to see how his knee progressed
during the night before he decides to go out.
F. H. CARY, M.D.
wfw
27JUL72
Problem: Post operative knee.
O: The knee remains swollen today, with effusion. The erythema
and warmth has subsided considerably since yesterday. He is
planning to go to St. Louis this afternoon, will return this
evening and will have it checked again tomorrow. There is
decided improvement.
F.VH. CARY, M.D.
rlm
28JUL72
PROBLEM: Post operative knee.
Seen in his office. The right knee perhaps is slighlty more
effused than it was yesterday. He had a long difficult day yes-
terday, going to St. Louis and coming back and being on his
knee a great deal of the time and giving a 45 minute speech.
There was some pain medially, but not great. After talking
to Dr. Lovejoy it was felt that the best course of treatment
was to stay off the knee as much as possible over the week-
end, to take two aspirins four times a day and keep his
feet elevated. We will reevaluate him on Monday, July 31.
F. H. CARY, M.D.
WfW
FORD
GERALDE
Lishary
GPO 1968 0-94-871
OFFICE OF ATTENDING PHYSICIAN
UNITED STATES CAPITOL
WASHINGTON, D.C.
DATE
PROGRESS NOTES
31JUL72
Problem - follow-up postoperative knee.
S: Since last seen, on 28 July, the right knee has remained
swollen, warm and erythemic. He states that he was not able
to stay off his knee as much as what he would have liked for
the past several days. He does state that to him the knee looks
somewhat better this morning and the incision is not as red.
O: Exam of the right knee still shows considerable amount of
effusion. There is some erythema to the lateral portion of the
incision of the right knee. No active drainage.
A: He is to follow-up with Dr. Wilson in the morning for further
evaluation of knee and possible aspiration,
Pecollums
R. E. COLLINS, II, M.D.
rlm
15AUG72
Telephone conversation with Dr. Lovejoy.
Continued improvement. Mr. Ford has now been graduated to a
walking cane.
John F. H. CARY, M.D.
rlm
17AUG72
Follow-up post-operative right knee.
S: Mr. Ford seen today in PT for reevaluation of right knee.
He has improved over the past several days. He was seen by
Dr. Lovejoy on Tuesday (2 days ago) and it was suggested at
that time if the effusion does not improve, he should return
before attending the convention for possible tap.
O: Exam of the right knee shows some resolution of the effusion
The incision is well healed without erythema. Mr. Ford is
tolerating 15 pounds of flexion-extension exercises. In
telephone consultation with Dr. Lovejoy today, he suggested to
defer any tap and to continue as directed.
A: Postop right knee with resolving effusion.
P: Continue as directed. To return in Dr. Lovejoy on Sep. 12,
for follow-up.
Recollus
R. E. COLLINS, M.D.
FORD
rlm
&
SERALD.
Name:
FORD, Gerlad R.
Congressman, Michigan
(Last)
(First)
(State)
(Allergies)
DATE
PROGRESS NOTES
3OCT72
Problem - avulsion left shin.
S: Yesterday he scraped his left shin with his briefcase while
walking from the plane. The avulsion is in the same area of his
accident in June en route to China and he was concerned about it
because of the infection that he had subsequent to that injury.
O: A 1.2 X 0.8 cm. superficial avulsion of the midshin with
no surrounding erythema. Just above it there is a small bruise
of about Icm.
P: Clean with pHisoHex and use Bacitracin Ointment covering
with bandaid. Wil I check again tomorrow.
F. H. CARY / M.D.
rlm
30CT72
Post-op. right knee surgery.
Now doing the PRE's up to 42.5 pounds on the right knee, 50
pounds on the left. Beginning to do some running in pláce,
walks virtually normal except climbing stairs he has some
difficulty.
A: Remarkable progress since July 12, 1972.
F. H. CARY, M.D.
rlm
6OCT72
Problem skinned left shin.
0: No evidence of infection. I believe the bandaid is probably
more irritating than the good that they are doing and suggest
that we just omit them. Continue to use Bacitracin.
F. JNCONY H. CARY, M.D.
rlm
FORD
4
BERALOH
LIDRARY
GPO 1968 0-94-871
OFFICE OF ATTENDING PHYSICIAN
UNITED STATES CAPITOL
WASHINGTON, D.C.
DATE
PROGRESS NOTES
2/11/71
sl. tenderness R clateral foot x3wk
1600k
Rx Local heat
10 reduess swelling heat
1430
Consider tray Sylvestec
16fsB.71
FOOT IMPANKS
X-RAN X-RAY NEG VEG
CONT wuing PHYSIO.
4/8/71
awoke c Swollen L 3/yrd pipjount
1030h
area Theat 0 redness. Otherwise
asymptomatic o H/O trauma
KR meg
Blood battery U/A
Rx Butazoadin alka 100mg aid è
hylanta dosage decreasing
Sylvester
4/9/71
Report of lob. But of 4/8/71 jun to
pt. AA wa telen
P, SYLVESTER
1800
28JUNEZ
STOPPED ON SOMETHING SNARPIN HIS 4ARD 9957 PAIN
INBAW9 @F007 SMALL grass FORD SPUINTER
REMOVED FONCEPS,
&
LIDRAR
Name: Ford Gerald
lincli
Johnny
(Last)
(First)
(State)
Mone
(Allergies)
Standard Form 513
Rev. August 1954
Bureau of the Budget
Circular A-32
S/N 0109-201-2602
CLINICAL RECORD
CONSULTATION SHEET
REQUEST
TO:
FROM: (Requesting ward. unit, or activity)
DATE OF REQUEST
CAPITOL PHYSICIAN
ORTHOPEDIC CLINIC
13 DEC 72
REASON FOR REQUEST (Complaints and findings)
USNH, BETH., MD.
Followup appointment
PROVISIONAL DIAGNOSIS
DOCTOR'S SIGNATURE
APPROVED
PLACE OF CONSULTATION
EMERGENCY
"
BEDSIDE
ON CALL
ROUTINE
CONSULTATION REPORT
ORTHOPAEDIC
CLINIC
13 DECEMBER 72
Congressman Ford had difficulty with his right knee and had a lateral menis-
cectomy in July 1972. Post-operatively, his knee was rehabilitated with
little difficulty.
ON EXAM TODAY: There is no effusion. There is some mild thickening of the
synpvium and he has "pain on compression of the patella. Medial, lateral
and collateral ligaments appear to be stable. His drawer sign is negative.
There is some mild tenderness on full flexion of the knee, postero-lateral
aspect of the knee at the surgical incision. The remainder of the exam
was WNL.
IMPRESSION: The patient has done very well in his post-operative rehabili-
tation program, and it is expected he should have little difficulty with
his future. We plan to see him PRN and he should return to full activity
as tolerated.
FORD
BERALUA
(Continued on reverse side)
SIGNATURE AND TITLE
DATE
IDENTIFICATION NO.
ORGANIZATION
JOHN F. LOVEJOY. JR. LCDR MC USNR 12/13/72 ASST. CHIEF, ORTHOPAEDICS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name-last, first,
REGISTER NO.
WARD NO.
middle; grade; date; hospital or medical facility)
CLINIC
FORD, GERALD CONGRESSMAN, MICHIGAN
CONSULTATION SHEET
OPD #1-05-38
Standard Form 513
513-104-02
Standard Form 513
Rev. August 1954
Bureau of the Budget
Circular A-32
0900
CLINICAL RECORD
CONSULTATION SHEET
REQUEST
TO:
FROM: (Requesting ward, unit, on activity)
DATE OF REQUEST
ORTH
CAPITOL S. =
18 Feb 72.
REASON FOR REQUEST (Complaints and findings)
EVALUATION OF KT. SHOUL SER S.KV
INJURY t OLD RT. KNEE PROBLEMS.
PROVISIONAL DIAGNOSIS
ROUTINE MONUAL
PE
DOCTOR'S SIGNATURE
APPROVED
PLACE OF CONSULTATION
EMERGENCY
my
BEDSIDE
ON CALL
ROUTINE
KANK 250 YESN
CONSULTATION REPORT
RTHO OPD
SNH BETHESDA
Rn It Lovejoy
CHIEF COMPLAINT: Evaluation of right shoulder pain and re-
25FEB1972
current effusion and instability in the right knee.
Present Illness: This 58 y.o. gentleman developed shoulder pain,
in0855
right, approx. 1 JAN 72. He had had no difficulty before a
skiing trip, and after several weeks of skiing, he noted some
stiffness in his shoulder. There was no specific accident. The
pt noted that sleeping on the stomach with his shoulder ABDucted
and his head on the hand, which was the normal way he slept,
caused pain in the shoulder. He also noted he had to change his
sleeping habit due to the pain and on arising in the morning, ther
was stiffness and limited ABDuction of the right shoulder.
He was seen by Dr. Pearson following the skiing trip and treated with oral medi-
cation, injection and PT with some gradual improvement.
The pt is having some difficulty with his right knee, which he dates to a football
injury occurring in 1929. At that time, he injured both knees, had subsequent
difficulty of the left knee and requiring an operation in 1933 which was probably
a lateral meniscectomy. He has had no significant difficulty with this knee
following surgery. However, his right knee has given him problems following
exercise. This consisted of effusion, provoked by exercise and relieved with rest
With this fall, he developed a new symptom, which was instability di the knee.
He noted after walking and externally rotating the foot, there was a grinding
sensation in the lateral aspect of the leg. He noted lying in bed, in a relaxed
position, some movement caused discomfort in this area. Also after making a
(Continued/on reverse side)
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DATE
IDENTIFICATION NO.
ORGANIZATION
PATIENT'S IDENTIFICATION (For typed or written entries give: Name-last, first,
REGISTER NO.
WARD NO.
middle; grade; date; hospital or medical facility)
FORD
CONSULTATION SHEET
&
FORD, GERALD R. MICH.
Lionaur
Standard Form 513
513-104-02
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BERALD
PHYSICIAN US CAPITOL
DOB 07-14-13
speech or standing, he would guard his right knee as he would have a
grading sensation and a feeling the knee was going to give way. He has
done physical therapy for the knee and had no difficulty with effusion
following his skiing this year, but due to the persistent instability
was referred here. Past hx is non-contributory.
PHYSICAL EXAM: The pt is in good physical condition. Exam of the right
upper shoulder shows pain on palpation of the supraspinatous tendon and
the long head of the biceps in the bicepital groove of the humerus. There
is a normal ROM of the cervical spine with no pain on motion, and a neg.
Spurling's test. There is limited ABDuction, external and internal rotation
of the right shoulder, with pain on extremes of these motions. The motor
exam of both upper extremities and the neurological exam is WNL. On exam-
ining the right knee, there is mild effusion. There is some loss of quadri-
ceps tone with a measurable decrease in the size of the quadriceps of 1/1/2" -
9" above the tibial tubercle. There is no pain on compression of the patella,
of the medial and lateral collateral ligaments, as well as the anterior/posterio
ligaments to be intact. External rotation, extension of the knee - there is
an audible and palpable click over the lateral meniscus. He also has a
positive Appley's grinding test for a lateral meniscus injury.
(I)
IMPRESSION: Bursitis of the right shoulder, resolving with present therapy.
(2) Tear of the right lateral meniscus of the knee.
DISPOSITION: Recommended he continue his therapy to the right shoulder and
in addition to PT, do a home program of ROM exercises. The pt was presented
to Capt Wilson and his findings were the same on the knee. It is our
feeling that he should have a lateral meniscectomy of the knee, and it was
recommended. We plan to do this at his convenience, which will probably be
in July 72. We would also like him to continue his PT in the interim, to
protect the knee from further quadriceps atrophy and effusion.
Thank you very much for sending us this very interesting patient. We will
certainly be glad to do his surgery at his convenience.
Respectfully,
t
OFD'
BL
KneF
EAYFANDON
John F. Lovejoy, Jr LCDR MC USNR
Orthopaedic Service
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Standard Form 513
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Rev. August 1954
Bureau of the Budget
0930
Circular A-32
CLINICAL RECORD
CONSULTATION SHEET
REQUEST
ETO:
GU
ATTENDING PAYSICIAN or activity)
DATE OF REQUEST
OFFICE
U. S. CAPITOL
18 Feb 1972
REASON FOR REQUEST (Complaints and findings)
NOCTURIA 1*2* / DCC HESTIAGY
PROSTATE 1+ ENLARGED
PROVISIONAL DIAGNOSIS
ROUTINE ANNUAL PE
JH
APPROVED
PLACE OF CONSULTATION
EMERGENCY
JR
BEDSIDE
ON CALL
ROUTINE
RADM MC USN
CONSULTATION REPORT
CHINIC
BETHESDA
no significant Fu obstructive
25FEB1972
related to fluid intake.
symptoms. nortuna probably
PE: Prostate is small, symmetecal
and benign
Plan ( AR T gear
Injp: no significant GU abnormation 8 FORD VIDERET
GENALD
(Continued on reverse side)
DATE
IDENTIFICATION NO.
ORGANIZATION
SIGNATURE Amadeo AND TITLE
2/15/72
PATIENT'S IDENTIFICATION (For typed or written entries give: Name-last, first,
REGISTER NO.
WARD NO.
middle; grade; date; hospital or medical facility)
CONSULTATION SHEET
Standard Form 513
513-104-02
FORD, GERALD R. (MICH)
RETURN TO ATTENDING
PHYSICIAN UC CARITOL
DOB 07-14-13
cp.t
Standard Form 513
Rev. August 1954
Bureau of the Budget
0800
Circular A-32
CLINICAL RECORD
CONSULTATION SHEET
REQUEST
TO:
TEROM: (Requesting ward (unit) activity DATE OF REQUEST
EYE
U. S. CAPITOL
18 Feb 1972
REASON FOR REQUEST (Complaints and findings)
ALWAYS NEAR SIGHTED New DIFFICULT
MORNING VISION = NEWS PRINT NEEDS
TONOMETRY
PROVISIONAL DIAGNOSIS
ANNUAC PE
DOCTOR'S SIGNATURE
APPROVED
PLACE OF CONSULTATION
EMERGENCY
R. J PEAHSON JR.
my
BEDSIDE
ON CALL
ROUTINE
RADE MC USN
CONSULTATION REPORT
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(Continued on reverse side)
SIGNATURE AND TITLE
DATE
IDENTIFICATION NO.
ORGANIZATION
Jamel LCDKM
233612
PATIENT'S IDENTIFICATION (For typed or written entries give: Name-last, first,
REGISTER NO.
WARD NO.
middle; grade; date; hospital or medical facility)
CONSULTATION SHEET
Standard Form 513
513-104-02
FORD, GERALD R. (MICH.)
RETURN TO ATTENDING
PHYSICIAN US CARITOL
DOB 07-14-13
Rev. August 1954
Bureau of the Budget
1030
Circular A-32
CLINICAL RECORD
CONSULTATION SHEET
REQUEST
TO:
FROM: (Requesting ward. unit, or activity)
DATE OF REQUEST
GI
AT TENDING PHYSICIAN S OFFICE
D. S. CARITOL
18 Feb 72.
REASON FOR REQUEST (Complaints and findings)
HEMORAHOIDS i Dic BRIGHT
RED RENTAL BILEEDING = OONSTIPATION
DCC DIARRHEA. c SAVER PRAUT INVESTION
PROVISIONAL DIAGNOSIS
ROUTINE ANNUAL PE
DOCTOR'S SIGNATURE
APPROVED
PLACE OF CONSULTATION
EMERGENCY
R. J. PEARSON JR.
BEDSIDE
ON CALL
ROUTINE
RADM MC USN
CONSULTATION REPORT
2/25/72 History is above.
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No home
Prato to 22 can revals none colone
huncoss throughout. No artice firme yes
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Advice: Ba Even to exchade proxing
strolgy to bludy
(Continued on reverse side)
SIGNATURE AND TITLE
DATE
IDENTIFICATION NO.
ORGANIZATION
2/25/72
PATIENT'S IDENTIFICATION (For typed or written entries give: Name-last, first,
REGISTER NO.
WARD NO.
middle; grade; date; hospital or medical facility)
FORO
CONSULTATION SHEET
Standard Form 513
513-104-02
FORD, GERALD R. MICH.
RETURN TO ATTENDING
PHYSICIAN US CAPITOL
DOB 07-14-13