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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