| Presenting Complaint |
Observations
Temp |
Pulse |
Resp |
BP |
Oximetry |
BSL |
Verbal Response |
Eyes Open |
Motor Response |
GCS Total |
||||
| 6 | Obeys commands | ||||||
| 5 | Orientated | 5 | Localises pain | V |
|||
| 4 | Confused | 4 | Spontaneous | 4 | Withdraws | E |
|
| 3 | Inappropriate | 3 | To Speech | 3 | Abnormal flexion | M |
|
| 2 | Incomprehensible sounds | 2 | To Pain | 2 | Extension | ||
| 1 | None | 1 | None | 1 | None | Total | |
| Pupils | Left | Right |
| Size | ||
| Reaction |
| Urinalysis | Leucocytes | Nitrates | Protein | Blood | Ketones | Glucose |
Clinical Findings
| Nystagmus Absent | |
| Normal extra-ocular movements | |
| Normal tone, reflexes symmetrical and brisk | |
| No ataxia - normal finger-nose and heel-toe | |
| No neck stiffness | |
| Oriented | |
| Short term memory | |
| Long term memory | |
| Serial 7's or 'world' backwards | |
| Mini-mental examination performed (see separate sheet) | |
| Normal chest examination | |
| Normal abdominal examination |
Further Investigations Performed
| FBC | Biochem | ABG | ECG | BAL |
| Other (please specify): | ||||
Having examined this patient, I declare him/her to be medically fit for further psychiatric investigation and treatment including transfer to a specialised mental care facility if necessary.
Signature:
Name:
Position:
Date: