PRINT BLANK FORM RESET FORM PRINT COMPLETED FORM AND RESET 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 1 of 2 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 PRINT COMPLETED FORM AND RESET AM/PM