Inpatient Referral Toperi-Prosthetic Joint Infection Group

inpatient Referral toperi-Prosthetic Joint infection group

Demographics(please complete shaded areas, using drop down menus as required)

Hospital Number:

Patient Name:

Age:years

Gender: FemaleMale

Date of referral://

Ward:373634Other (please specify):

Consultant:Mr AdedapoMr Al-MaiyahMr BakerMr BonnerMr EardleyMr GrayMr HollandMr HopcroftMr HuiMr JamesonMr LiowMr MackenneyMr McMurtryMr McVieMr PortProf RanganCol StewartMrs TateMr Van NiekerkMr Van VuurenMr WallaceMr WebbMr WhiteMr Ya'ishOther (please specify):

Joint

Problem joint:RightLeftPrimary hipHip hemiarthroplastyRevision hipPrimary kneeRevision knee

Date implanted/ last op:// Cons: Mr BakerMr GrayMr HopcroftMr HuiMr JamesonMr McMurtryMr PortMr Van VuurenMr WallaceMr WebbMr WhiteMr Ya'ishOther (please specify):

Wound now:DryOpenAntibiotic therapy:NoneYes (please specify):

Symptoms:Pain NoYesSwelling NoYesSepsis NoYes

Free text history:

Investigations and management

CRP:ESR: WCC: Renal function: NormalAKICKD

Aspiration:NoYes (specifiy results below)(whilst receiving not receiving antibiotics)Date://

Washout/DAIR:NoYes (specifiy results below)Date://

Gram stain:NegativeGram + cocciGram - cocciGram + rodGram - rodFungiOther (please specify):WC count: Cell diff: %

Free text comments:

Medical History and medications

Hypertension:NoYesDetails:

Thyroid disease: NoHypothroidismOtherDetails:

IHD:NoYesDetails:

CVA (incl TIA):NoYesDetails:

MI: NoYesDetails:

CABG:NoYesDetails:

AF:NoYesDetails:

COPD:NoYesDetails:

Asthma:NoYesDetails:

Chronic Liver Dis:NoYesDetails:

CKD:NoYesDetails:

Rheum arthritis:NoYesDetails:

Other joint inflam:NoYesDetails:

DM:NoInsulin dependentNon-insulin dependent

Steroids:NoYesDetails:

DMARDs:NoYesDetails:

Anticoags:NoYesDetails:

Smoker:NoYesNumber/wk:

Alcohol xs:NoYesUnits/wk:

BMI: kg/m2

Once completed please save as this document using [hospital number] as file name, then email as an attachment to the Periprosthetic Joint Infection group (‘South Tees NHS Trust’ – ‘Group emails’ under the Global Address book on the Trust email, then type in the search ‘Peri' - it will come up as the first option. Click ‘To->’ in order to email the group and cc the referring consultant’s secretary.

Northern Periprosthetic Joint Infection Unit August 2016