. ~S Standard Fo Rev. August 19: Prom ted ~ 3 % . — 1 . 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