Document 6428560

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Pediatric Initial Neurosurgery Evaluation
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Form Origination Date: 7/06
Version: 2
Patient Name
MRN
PATIENT IDENTIFICATION LABEL
Version Date: 11/07
Date:
Neurosurgery H&P
Requesting MD/Service:
History Obtained From:
Patient
Chief Complaint:
HPI (4):
Neurosurgery Consult
Mother
Father
Sister
Location of consult:
Brother
Grandmother
ER
(
Grandfather
) ICU
Other:
Floor (
)
Other:
(Location, duration, timing, severity, quality, context, things that relieve or exacerbate, associated symptoms)
Medical allergies:
Medications:
Immunization Status:
UTD
Delayed:
ROS (NAT = Not able to test)
Neuro
Neg
NAT
Neg
NAT
General
Hematologic
Neg
NAT
ENT
Neg
NAT
Cardio/Vasc
Neg
NAT
Respiratory
Neg
NAT
Eyes
Neg
NAT
PMH, PSH, Development
NL
ABN
Pregnancy, Labor and Delivery:
Family Hx:
Social Hx: Who lives at home with patient:
Educational Hx: Grade level
PE: Temp
Tmax
FOC
General Appearance:
Nutrition:
NPO
Tube Feeds
PN
NE = Not examined
Neck
WNL
NE
Head/Face
WNL
NE
Heart
WNL
NE
Lungs
WNL
NE
Abdomen
WNL
NE
GU
WNL
NE
Rectal
WNL
NE
Fontanelle
Open
Closed
Abnormal reactions:
Endocrine
GI
GU
Musculoskeletal
Skin
Psych
Other
Major Illnesses, Injuries or Operations:
Patient
Mother
Performance:
(%)
Pulse
Fluids
Solids
Father
None
Sister
Brother
Academic assistance:
B/P
Bottle
Neg
Neg
Neg
Neg
Neg
Neg
Neg
NAT
NAT
NAT
NAT
NAT
NAT
NAT
Development:
Gross motor
Fine motor
Language / social
Grandmother
NL
Grandfather
ABN
Other:
Resp
Breast-fed
Suck / root
Moro
Tonic neck
Head control
Infants
Ventilated:
Weight:
Activity:
Bedrest
In chair
Appears
Disappears
Birth
3-4 months
NL
ABN
Birth
4-5 months
NL
ABN
2-3 weeks 4-6 months
NL
ABN
5 months Persists
NL
ABN
Rolls over
Y
N
Sits
Y
N
Crawls
Y
N
Walks
Y
N
kg (% =
Ambulating
Resident/MLP Signature
Pager ID
Date
Time
AM/PM
Attending Signature
neurospedsinitialeval
Pager ID
Date
Time
OTE 900398 Rev. 11/07
AM/PM
)
This form may be completed on line. Tab or move
cursor to text field and type in text.
For HIPAA Compliance reasons, this form
IS NOT TO BE SAVED with patient information.
Selecting the PRINT button will clear all information
Pediatric Initial Neurosurgery Evaluation
from the note.
Page 2 of 2
Form Origination Date: 7/06
Version: 2
Patient Name
MRN
PATIENT IDENTIFICATION LABEL
Version Date: 11/07
Date:
Neurosurgery H&P
Neurosurgery Consult
Neuro Exam
Minimal or no medical sedation
Heavily sedated
Sedated and pharmacologically paralyzed
Spontaneously
To command (6)
Localizes (5)
Withdrawals (4)
ABN flexion (3)
Neuro: Best Motor Exam:
Normal
Oriented (5)
Confused (4)
Inappropriate (3)
Incomprehensible (2)
Best Verbal Exam:
Spontaneous (4)
To speech (3)
To pain (2)
None (1)
GCS
Best Eye Opening:
Alert
Drowsy but arousable
Lethargic, difficult to arouse
Confused / delirious
=
Alertness:
Orientation:
NAT
Oriented to time, place, person
Oriented only to:
Time
Place
Person
NAT
Appears WNL
3/3 objects at 5 min Other:
Memory:
NAT
Appears WNL
3/3 objects at 5 min Other:
Knowledge:
CN 2
V fields / acuity
CN 7
Facial movements
NAT
Normal fields
Normal acuity
Discs
Not seen well
NAT
No papilledema
CN 8
Hearing
CN 9, 10 Soft palate
CN 3, 4, 6 Pupils
NAT
PERRL Right pupil
mm
RRL
Other:
Left pupil
mm
RRL
Other:
EOM
NAT
EOM full
CN 11
Sternocleidomastoid
& Trapezius
CN 12
Tongue
CN 5
Facial sensations
NAT
Facial sensation normal
Rt corneal
Present
Absent
Lt corneal
Present
Absent
Strength
NAT
All Normal Right ARM
Normal
Left ARM
Normal
Normal
Left LEG
Normal
Right LEG
Right:
Left:
Hemiparesis:
IP
Quad Ham
DF
EHL
PF
Motor
NAT
Del
Bic
Tri
WE
Grip
HI
Other:
Group
Right
Specific
Left
Sensation
NAT
All Normal Right ARM
Normal
Left ARM:
Normal
Normal
Left LEG:
Normal
Right LEG
Other:
Sensory Level:
Gait
Babinski
ABN extension (2)
None (1)
None (1)
Unresponsive
None Other:
NAT
Normal facial symmetry
NAT
NAT
Normal hearing bilaterally
Rises symmetrically
NAT
NAT
NL Sternocleidomastoid
& Trapezius
Midline, normal
Other:
ABG:
O2:
Vent:
/
/
NAT
NAT
Normal
Radiology:
Right
Absent
Present
Left
Absent
Present
Coor
NAT
Normal Rt FN
Abnl
PT/PTT=
Normal Rt FN
Abnl
INR=
Tone
NAT
WNL
Phenytoin=
Pulses
NAT
Carotid WNL
Abbreviations: EVD=External ventricular drain; NAT=Not able to test; Del=Deltoids; Bic=Biceps; WE=Wrist extensors; HI=Hand intrinsics; IP=Iliopsoas; Quad=Quadriceps; Ham=Hamstring;
EHL=Extensor hallucis longus; PF=Plantar flexors; DF=Dorsi flexors
A/P: I have discussed the patient with the attending, Dr.
, and he/she agrees with the plan of treatment.
Resident/MLP Signature
I,
More than 50% of this visit (
Attending Signature
neurospedsinitialeval
Pager ID
Date
Time
AM/PM
saw and evaluated the patient. Discussed with residents and/or MLP and agree with their findings and plan as documented in the note.
min total) was spent on education and counseling.
Pager ID
Date
Time
OTE 900398 Rev. 11/07
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AM/PM