Neurosurgery Pre-Assessment Clinic Proforma

Patient details (use addressograph sticker) Assessment date:

Name: ...... Reassessment date:

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

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

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

Diagnosis:

Proposed Operation:

Current Symptoms:

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

Add any additional comments...

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

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 ð)

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 ð

Some abnormal findings (document overleaf) ð

Anaesthetic Review:

Is not required ð

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

Final Checklist:

·  Drug chart? Yes ð

·  MRSA prophylaxis (if appropriate)? Yes ð N/A ð

·  ‘Results’ section completed? Yes ð

·  Patient fit for surgery? Yes ð No ð

Pre-assessment performed by: Date:

Re-assessment performed by: Date:



Investigations: (please tick)

FBC / Ö / Chest X-ray / Pituitary Function bloods / TFTs (inc T3)
U&E / Ö / ECG (everyone over 50) / Prolactin
LFTs / ECHO / IGF-1
Bone Profile / Spirometry / LH
Clotting screen / Ö / Pulmonary fuction / FSH
Group & save / Ö / C-Spine X-rays / Testosterone
Sickle cell / T-Spine X-rays / ACTH
Glucose / L-Spine X-rays / Cortisol
Others (please state) / Serum HBG

Anaesthetic Review:

Is not required ð

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

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 ð Not Required ð

Final Checklist:

Drug chart? Yes ð

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

‘Results’ section completed? Yes ð

Patient fit for surgery? Yes ð No ð

Pre-assessment performed by: Date:

Results checked by: Date:

Re-assessment performed by: Date:

Repeat results checked by: Date:

Neurosurgery Pre-Assessment Proforma. I Anderson, H Chance & S Thomson. JuneJuly 2012 Update2December 2009