Referral form to the Bristol Children’s Epilepsy Surgery Service
(Brief version)
Ward 38, Level 5, Bristol Children’s Hospital, Upper Maudlin Street, Bristol BS2 8AE
Telephone: 0117342 8665 – Fax: 01173428527 - Email:
Please complete either this brief form or the more detailed form in the appendix and forward to us using the above contact methods. We will aim to respond within 24-48 hours of being contacted, but if you need urgent advice then please phone 0117 927 6998 and ask to speak to the Paediatric Neurologist on call.
You may find the guidance provided in the detailed referral form helpful when completing the briefer version. Boxes may be expanded as required.
Date of referral:Name of child: / DOB: / Sex:
Home address: / Telephone:
Name of referring consultant: / Telephone:
Address / Email:
Summary of medical diagnoses problems:
Current problems:
Seizures: Please provide detailed information as indicated in appendix:
Past medical & surgical history:
Development & behaviour:
List medications and dose:
1.
2.
3
4
5 / 6.
7.
8.
9.
10.
Family history:
Examination:
Neuroimaging: (Type of imaging, and when and where performed. Please provide on disk if outside SW region, or alternatively if possible using web based technology send to Bristol Children’s Hospital Neuro-radiology Department for the attention of Dr Marcus Likeman.)
Neurophysiology: (Forward neurophysiology technical report and conclusion. If possible forward relevant pages of EEG.)
Other relevant investigations/information:
End of brief version of form
Appendix:
Referral form to the Bristol Children’s Epilepsy Surgery Service
(Detailed version with guidance)
Ward 38, Level 5, Bristol Children’s Hospital, Upper Maudlin Street, Bristol BS2 8AE
Telephone: 0117342 8665 – Fax: 0117342 8527 - Email:
Please complete and forward to us using the above contact methods. We will aim to respond within 24-48 hours of being contacted, but if you need urgent advice then please phone 0117 927 6998 and ask to speak to the Paediatric Neurologist on call.
Date of referral:Name of child:
First name:
Middle Name:
Surname: / DOB: / NHS number:
Sex:
Home address: / Home telephone:
Mobile telephone:
Name of mother: / Name of father:
Name of GP: / Telephone:
GP address: / Email (if known):
Name of referring consultant: / Telephone:
Address / Email:
School: / School address:
School telephone:
Named Epilepsy Nurse / Epilepsy Nurse address :
Epilepsy Nurse contact number: / Email address:
SUMMARY OF MEDICAL DIAGNOSES /PROBLEMS (Detailed referral form)
Current problems:Seizures:
Onset: age, context – was child unwell or have fever or other problems, time of day, awake or from sleep, clustering, duration of seizure, if awareness retained during seizure, description of attack (in slow motion): any warning, motor features, sensory features, autonomic features, psychic features, part of body affected, evolution of attack, if speech affected, any memory of event by child, automatisms, any effects on speech during or after attack, any paralysis following attack – for how long, how long before child recovered, if needed hospital care, if needed intubation and ventilation to terminate attack, if cause of seizure identified, clustering of seizures, any dangerous ictal or post-ictal concerns or effects on behaviour
Subsequent seizures - if different types of seizures – order of appearance, frequency, description events, precipitants
Current seizures – description of events, frequency, duration, precipitants, response to rescue medication
Have family seen a local epilepsy nurse?
Are they aware of the Epilepsy Action Website?
Has SUDEP been discussed?
Past medical and surgical history:
Pregnancy: any complications such as pv bleeding, fevers, infections, rashes, reduced fetal movements, poly or oligohydramnios, preterm labour, prolonged rupture of membranes, loss of twin, maternal medication
Labour: presentation, foetal distress, method delivery
Delivery : birth weight, need for resuscitation, Apgar scores at 1, 5, 10 minutes
Newborn period: feeding problems, seizures, hypoglycaemia, jaundice needing treatment, respiratory distress, need for ventilation
Head injuries:
Serious illnesses:
Other diagnoses:
Development & behaviour:
Gross motor, fine motor, vision, hearing, speech, language, social, behaviour, academic. Any concerns? Educational Psychology involvement/ Developmental assessment/ Educational Statement
Any regression? Neuropsychology assessment: when, where
Any concerns about psychological or psychiatric well-being: Asperger, autism, ADHD, depression, OCD, self-harm, suicidal ideation/attempt. CAMHS involved?
Medication:
Current medications: how long on each drug, when started, last change in dose, side effects, efficacy, rescue medication
Previous medications: how long on each, how long ago, why discontinued, side effects
Tried ketogenic diet: what age, which type, for how long, did it help, what level of ketosis, why stopped
Allergies:
Medication and non-medication related
Immunisations:
Up to date or otherwise
Family history:
Parental country of origin, if related (e.g. first cousins), occupation, any inherited illnesses, any neurological problems, age and sex of children
Expectations:
Will parents/guardian be able to come to Bristol for clinic appointments, prolonged investigations (usually 5 days in the first instance),may need drug reduction/withdrawal to precipitate seizures during monitoring, appreciate that child being assessed for possible surgery, that success cannot be guaranteed and there are risks associated with neurosurgery, and following assessment that we may need further investigations such as invasive monitoring, and even after all that we may not proceed to surgery if there is no clear target or risks of operating considered too high?
Examination:
Well/unwell
Height
Weight
Head circumference
Right or left handed or ambidextrous
Dysmorphic features
Neurocutaneous stigmata
Cardiovascular- pacemaker, prosthetic valves
Respiratory
Abdominal - gastrostomy
Nervous system especially:
Visual fields
Eye movements
Fundoscopy
Facial weakness
Neck movements
Speech
Limbs: tone, power, co-ordination, DTR, plantars, ataxia. If weakness description of independent finger movements, degree of hand function, if handedness has changed with time
Gait – if problems describe gait, how far can child walk, degree of support needed
Investigations:
CT – when and where
MRI – when and where, epilepsy protocol?, findings
EEG – when and where, interictal awake and asleep, ictal
CSF – paired fasting glucose with blood, protein, cells, other
Genetic studies, array CGH, Ring 20 – if specifically requested, SCN1A, other
ECG
SPECT – ictal, subtraction
PET – ligand
fMRI – motor, language – paradigm used
MEG
Wada
Formal visual fields assessment
Other
Referral forms for Bristol Children’s Epilepsy Surgery Service Oct 2014