.
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Standard Fo
Rev. August 19:
Prom
ted
~
3
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.
—
1
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By Buresa of the Budget
Circular A—i2
CLINICAL RECORD
CONSULTATION SHEET
REQUEST
"Nellis AFB
; FROM: (Requesting ward, unit, or actinity)
Hospital
DATE
| Mercury Dispensary
_OF REQUEST
October 1958
REASON FOR REQUEST Complaintsand findinga)
The patient struck his head in an unknown manner late this morning
wnile getting out of a truck. There were no witnesses and the patient
cannot remember what happened.
Since that time, he has been quite
drowsy and is disoriented as to time, place, and pearson. Neurological .
exam. is unremarkable at present.
I believe this patient has suffered
cerebral concussion and merits hospitalization for observation. Thank
you very much,
PROVISIONAL DIAGNOSIS
Cerebral concussion. .
i
f°
PLACE OF CONSULTATION
C) aepsive
® emencency
CON cae
(D routine
CONSULTATION REPORT
‘This leyear old male was admitted to Nellis AFB Hospital on 18 October 1958 with histery
that he is a bacteriologist with the Public Health Service assigned to the Nevada Test
Site and that on the morning of admission it was stated that he became disoriented while
working. Patient was unable to tell the admitting physician what had happened but believed
that he heard someone say that he had fallen off a running board shortly before. There
apparently were no witnesses at the time to confirm this and because of his disoriented
state he was referred to this facility.
At the time of admission patient was well oriented
with entirely clear sensorium except for an expression of surprise at his discovery of the
time of day, insofar as approximately four hours of time had elapsed for which patient
had no memory.
Physical examination was entirely normal as was neurological examination.
Clinical Course: Patient was afebrile on admission and remained so throughout his hospital
stay. Routine laboratory workup including CBC, urinalysis and fasting blood sugar were
all normal. Skull X-rays showed no evidence of pathology, and in general the patientts
condition was satisfactory. Over the next two days the patient had no complaints except
for a slight occipital headache which was not incapacitating and it should be noted that
the patient was at all times completely rational and oriented with a clear sengorium.
Patient was obagpét ont} the. morning of 21 October 1958 at which time he was dismissed
in apparent gougases
PRIVACY AGT MATERIAL REMOVED
Ry
W MILLS, Capt, USAF (MC)
(Continued on reverse side)
DATE
IDENTIFICATION NO.
21 Oct 58 PHS 10610
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—iast, frat,
middie: drade; date; hoeprtal or medical facility)
ORGANIZATION
PublisHealth Service
REGISTER NO.
WARD NO.
3
CONSULTATION SHEET
.
NeLLts
US. coreEDag
“a NEVE
4, 308652
16—sall0-5f
Standart? Form 513