NEUROSURGERY PRE-ASSESSMENT CLINIC PROFORMA



[pic]Neurosurgery Pre-Assessment Clinic Proforma

[pic]

Patient details (use addressograph sticker) Assessment date:

Name: ...................................................................... Reassessment date:

Address: ................................................................... (Use a different colour pen)

Unit number: ....................... DoB: ..........................

Consultant: PvH PM GT NP SR PC AT JT ST DP

Diagnosis:

Proposed Operation:

Current Symptoms:

Past Medical History: (If as per nursing assessment tick here ()

Add any additional comments...

Drug & Allergy History: (If as per nursing assessment tick here ()

Add any additional comments...

Is the patient taking aspirin/warfarin/clopidogrel? Yes No

If yes, give details and action required ...........................................................................

Social History: (If as per nursing assessment tick here ()

Add any additional comments...

Occupation:

Hand Dominance:

Overall Appearence:

Cardiovascular System:

Respiratory System:

Gastrointestinal System:

Neurological Examination:

|Cranial Nerves: | | | |

| | |Right |Left |

| | | | |

|I |Olfactory | |

|II |Fundi | | |

| |Visual acuity | | |

| | | | |

| |Visual fields | | |

| | | | |

| | | | |

|III IV VI |Pupil size | | |

| |Direct | | |

| |Consensual | | |

| |Accommodation | | |

| |Eye movements | | |

| | | | |

|V |Motor | | |

| |Sensory | | |

| |Corneal reflex | | |

| |Always test corneal reflexes in ‘trigeminal’ patients |

| | | | |

|VII |Motor | | |

|VIII |Hearing | | |

| | | | |

|IX X |Gag reflex | |

|XI |Shoulder shrug | | |

|XII |Tongue | | |

Neck movements:

Upper Limbs:

| | |Right |Left |

| | | | |

|Inspection | | | |

|Tone | | | |

|Power |Shoulder abduction | | |

| |Shoulder adduction | | |

| |Elbow flexion | | |

| |Elbow extension | | |

| |Wrist flexion | | |

| |Wrist extension | | |

| |Finger absuction | | |

| |Finger adduction | | |

|Reflexes |Triceps | | |

| |Biceps | | |

| |Supinator | | |

|Co-Ordination | | | |

|Hoffman’s | | | |

Lower Limbs:

| | |Right |Left |

| | | | |

|Inspection | | | |

|Tone | | | |

|Power |Hip flexion | | |

| |Hip extension | | |

| |Knee flexion | | |

| |Knee extension | | |

| |Ankle dorsiflexion | | |

| |Ankle plantarflexion | | |

| |EHL | | |

| |FHL | | |

|Reflexes |Knee | | |

| |Ankle | | |

| |Plantars | | |

|Co-Ordination | | | |

|Straight Leg Raise | | | |

Gait:

Sensation: Fully intact (

Some abnormal findings (document overleaf) (

Investigations: (please tick)

|FBC |( |Chest X-ray | |

Anaesthetic Review:

Is not required (

Is required (state reason/question to be answered below) (

Results:

|Hb | |Na | |T3 | |

|WCC | |K | |T4 | |

|Plts | |Creat | |TSH | |

|INR | |Urea | |Prolactin | |

|PT | |Glucose | |IGF-1 | |

|APTT | |Cortisol | |LH | |

| |Serum HBG | |FSH | |

| |Testost | |

| |ACTH | |

ECG

CXR

MRSA Screening Result

MRSA Prophylaxis Chart Completed? Yes ( Not Required (

Final Checklist:

• Drug chart? Yes (

• MRSA prophylaxis (if appropriate)? Yes ( N/A (

• ‘Results’ section completed? Yes (

• Patient fit for surgery? Yes ( No (

Pre-assessment performed by: Date:

Results checked by: Date:

Re-assessment performed by: Date:

Repeat results checked by: Date:

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