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: