Medical Clearance

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):

Declaration

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: