Download Other Past Medical History

FRACTURED NECK OF FEMUR PROFORMA
SW 03/10
Consultant
Hosp Number
Forename(s
Surname
Date / Time
Date of Birth
SHO/ NOF
coordinator
Next of Kin
Bleep
Ward
Tel
*36 hour breach date/ time:__________________ (MUST be completed for all patients)
History (Please obtain collateral from Relative if present or contact care home where appropriate)
Past Medical History:
Does it include?
(Tick relevant box and indicate when in the adjoining box)
Myocardial infarction
yes
no
Dementia
yes
no
Angina
yes
no
CVA
yes
no
CCF
yes
no
Epilepsy
yes
no
Hypertension
yes
no
Parkinson’s Disease
yes
no
Diabetes Mellitus
yes
no
Rheumatoid Arthritis*
yes
no
COPD*
yes
no
Hiatus Hernia
yes
no
Asthma*
yes
no
Peptic Ulcer
yes
no
Previous #
yes
no
Carcinoma
yes
no
(please indicate site)
If carcinoma, which type? *
Is there a history of previous falls? Yes/ No
Is there a history of osteoporosis? Yes/ No
(if yes, ensure relevant medication is completed in the drug history section)
Any Visual impairment? Yes/ No
Other Past Medical History
Proforma filled in by:
SIGNATURE…………………
Designation…………………
PRINT NAME………………………
Bleep………
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FRACTURED NECK OF FEMUR PROFORMA
SW 03/10
NAME…………………………………………………….
DOB…………………………
Not suitable for theatre without Ortho Geriatric Senior or Medical team review if:
1.
2.
3.
4.
MI or CVA in last 1 month
(If new MI or CVA refer to Medical SpR Immediately)
Poorly controlled angina or CCF
Uncontrolled Arrhythmias eg AF Rate > 100
Severe respiratory problems (Peak Flow less than 150L/min or hypoxic)
* If COPD/Asthma, PEFR essential & consider arterial blood gases ON AIR
* If Pacemaker it should have been checked in the last 1 year
* If Carcinoma SEND Surgical Samples For Histology and X-Ray ALL of the Femur
Social History
Own house
Sheltered
Residential
Meals on Wheels
x wk
Home help
x wk
Nursing home
Other
Carer?
District Nurse
x wk
Day Centre
x wk
Barthel score in week prior to admission
Bowels
Grooming
Toilet
Incontinent
0
Incontinent
0
Unable
0
Unable
0
Occ. accident
1
Occ. accident
1
Help
1
Some help
1
Continent
2
Continent
2
Independent
2
Independent
2
Needs Help
0
Dependent
0
Immobile
0
Unable
0
Independent
1
Independent
1
Wheelchair
1
Major help
1
Dependent
Some help
Independent
0
1
2
Dependent
Some help
Independent
0
1
2
Walks with 1
Independent
2
3
Bladder
Bathing
Dressing
Feeding
Mobility
Stairs
Transfer
2
Minor help
3
Independent
Total Score
/20
Walking Aid & Type?
Smoker (Number/day)
Alcohol (unit/day)
Medication (Dose & Times) All medications MUST BE LISTED in this section and not just on
the drug chart
* IF YES: Give Reason for Anticoagulation & check
INR. See Trust guidelines for Warfarin and hip #.
Anticoagulant *
Allergies
2
SW 03/10
FRACTURED NECK OF FEMUR PROFORMA
NAME…………………………………………………….
DOB…………………………
Leg Shortened and Rotated? YES □ NO
General Appearance (Anaemia; Breasts; lymphadenopathy)
TEMPERATURE
On Examination:
Mild Pain = 1
No Pain = 0
PAIN Score
Moderate Pain = 2
□
Severe Pain = 3
Cardiovascular System
BP
Pulse Rate
Heart Sounds
Other
Pacemaker


MmHg
/minute
Yes
Acceptable Theatre Range Systolic 150-100 / Diastolic 50-100
Rhythm
No
Murmur to neck?
Yes
No
If uncontrolled arrhythmias, aortic/mitral stenosis or evidence of ischaemia, not for theatre until
reviewed by medical team (see ECHO guidelines).
If Pacemaker has not been checked in last 1yr not for theatre until checked.
Respiratory System
Creps, Wheeze,  Breath Sounds
RESPS
02 sats.
%
%
PEFR
On air
If 02 saturation less than
90% on air, not for theatre;
refer for medical review &
consider ABG
on
litres/02
litres/min If PEFR less than 150 l/min,
not for theatre until
reviewed by medical team
Abdomen
o
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SW 03/10
FRACTURED NECK OF FEMUR PROFORMA
NAME…………………………………………………….
DOB…………………………
Central Nervous System
Evidence of CVA?
Yes
No
If evidence of new CVA, Refer to Stroke Nurse/
Medical Team Immediately & not for theatre till
reviewed.
Yes
No
If swallow reflex not OK, keep NBM & refer to
Speech & Language Therapist (x6090)
If yes, describe:
If new CVA, is swallow
reflex OK?
MTS (MANDATORY)
GCS
Age
D.O.B.
Year
Place
Time (To Hour)
Queen
WWI
Recognise 2 people
20 -1 backwards
Recall Address
Total
/10
Eye Opening
Verbal Response
Motor Response
Spontaneous
To Command
To Pain
None
Orientated
Confused
Random
Grunts
None
Obeys
Localises pain
Withdraws
Flexes to Pain
Extends to pain
None
=4
=3
=2
=1
=5
=4
=3
=2
=1
=6
=5
=4
=3
=2
=1
Total
/ 15
MUSCULOSKELETAL SYSTEM
Please document site and nature of any additional injuries identified
Pressure Areas : please indicate if the following areas have any signs of pressure damage:
SACRUM: Y/N
RIGHT HEEL: Y/N
LEFT HEEL: Y/N
4
Other site(specify:
SW 03/10
FRACTURED NECK OF FEMUR PROFORMA
NAME…………………………………………………….
DOB…………………………
Pre-operation Check List. - Not for Theatre Until Completed
Results of investigations (MUST BE COMPLETED BY ADMITTING DOCTOR):
Hip X ray comments (if any)
Type of fracture - please circle on diagram LEFT □
RIGHT □
OR
EXTRA CAPSULAR
INTRA CAPSULAR
Femur proximal,
# trochanteric region
Femur proximal,
# of the neck
Does it look pathological?
Yes
IF YES: Consent for and request biopsy for
histology at operation & X-Ray entire Femur.
No
Bloods: Must be checked in ALL patients and results recorded below by 8am on day of
surgery.
Acceptable Pre-OP values
Result
Result
Acceptable Pre-Op values
Hb
More than 10 g/dl
Na
130 - 145 mmol/l
WBC
Less than 12 x 109 /l
K
3.4 - 5.5 mmol/l
9
Plts
100 - 400 x 10 /l
Urea
Less than 15 mmol/l
MCV
Normal range 82-98
Creat
Less than 200 umol/l
INR
<1.5
CCa
2.15-2.60 mmol/l
Glucose/BM
Less than 15
CRP
0-10
Sickle
If Applicable
Urine DStick
+
If [K ] < 4 Add K+ to IV fluids
Group and Save? YES □ NO □
Chest X-Ray Performed?
YES □ NO □ (MUST Have Pre-Op.)
Results of Chest X ray
LVF
Yes
No
Infection
Yes
No
Other
Findings
ECG Performed?
ECG findings:
YES □ NO □
5
If evidence of LVF or
infection, not for
theatre
until reviewed by
medical team
SW 03/10
FRACTURED NECK OF FEMUR PROFORMA
NAME…………………………………………………….
DOB…………………………
Treatment Plan
PLEASE REFER to A to Z for ELDERLY TRAUMA PATIENTS FOR PRE-OPERATIVE MANAGEMENT GUIDELINES
MUST BE COMPLETED BY ADMITTING DOCTOR
Blood results reviewed and acted on
If on Anti-coagulation and INR>1.5, ensure appropriate action to reverse anticoagulation has been followed (SEE A to Z GUIDANCE NOTES)
Group & Save sent
Thromboprophylaxis risk assessment form completed online
*THIS MUST BE COMPLETED FOR ALL PATIENTS*
Give Clexane 40mg s/c od and TEDS (unless
Clexane & TEDS
contraindicated). Review dose in renal failure (eGFR<30)
prescribed
IFB requested
(SEE PAGE 7)
Analgesia
prescribed
All patients must be referred to anaesthetist for
consideration of IFB
(AVOID NSAIDS AND TRAMADOL in the elderly)
Give Paracetamol 1g IV/ po QDS
Codeine Phosphate and Morphine PRN ONLY
N/ Saline(1L over 8 hr) - consider alternative fluid with
IV fluids
hyper/ hyponatraemia or seek advice if patient has signs of
prescribed
cardiac failure
Prescribe Cyclizine 50mg TDS PRN unless Parkinsons
Anti-emetic
patient ( in PD use Domperidone 10mg TDS PRN)
prescribed
Laxido i sachet BD +/- Senna i-ii tablets nocte prescribed
Prescribe CHO loading drinks and regular Fresubin i BD
CHO loading regimen: 1 drink evening before surgery (all patients) then
1 drink 6am (morning list pts) OR 1 drink 11am (afternoon list pts)
MRSA screen sent and Protocol Prescribed
Test urine (if catheterised send urine for MRSA)
Only Catheterise if clinically indicated e.g acute retention
Dementia screening online assessment and AMTS (MANDATORY)
NO ROUTINE ECHO
If valvular stenosis suspected, use invasive monitoring, meticulous haemo-dynamic control & vasoactive agents
ESM ?Aortic Stenosis
GET OLD NOTES/ ECHO RESULTS
Known Aortic Stenosis
Last ECHO within 1 yr
Documented results
OK
No new symptoms
New ESM
Any of:
New symptoms
SOBOE/ orthopnoea
Angina
Drop attacks
Abnormal ECG (LVH, arrhythmia)
High BP, narrow pulse pressure?
YES
No ECHO required
ECHO required
6
NO
No ECHO required
SW 03/10
FRACTURED NECK OF FEMUR PROFORMA
NAME…………………………………………………….
DOB…………………………
7
SW 03/10
FRACTURED NECK OF FEMUR PROFORMA
Fascia-iliaca blocks (Bleep 504 or 930 to request block)
This section to be completed by clerking doctor
IFB requested:
Yes □
□
No
Date/ Time requested………………………………
Anaesthetist contacted:
504 □
930 □
730 □
(if 504 or 930 are unable to attend, contact obstetric anaesthetist on Bleep 730)
Expected time of attendance…………………………
Yes □
Any delay expected?
No □
Reason for delay…………………………………………………………………………
Alternative analgesia prescribed: Yes □
No □
This section to be completed by anaesthetist
Anaesthetist (name/ designation/ bleep):
Time attended:
(*Name and bleep number of person completing IFB must be documented*)
Consent Obtained: Yes □
Sterile: Yes □
Contraindications………………………………………………….
Time inserted:
)
Single Shot IFB: Yes □ No □
Needle Tuohy
…………..G
Pump started: Yes / No
Pain score- initial
Catheter: Yes □ No □
Catheter……cm
Levobupivicaine 0.25%............ml
Pump prescribed: Yes/ No
/10
Post IFB
/10
Any Complications (please document)
Pre-operative anaesthetic assessment and anaesthetic chart completed: Yes □ No □

Aim for IFB catheter where possible. IFB catheters should be reviewed for removal at 48 hours
post-op.
8
FRACTURED NECK OF FEMUR PROFORMA
SW 03/10
If For theatre – please tick when completed
If For medical review
Obtain consent
If urgent or immediate need, bleep duty medical registrar
Mark limb
Surgery within 36 hours of Admission.
Ensure Anaesthetist Aware of patient.
*If unfit for surgery for Orthogeriatric Review next
day or On call Medical Team
Put on trauma list
Yes / No
Time Fit For surgery
Nil by mouth from
May eat & drink
Please circle appropriate order -Indicate Nil by mouth only if patient is admitted between 12 midnight & 6 am and
due to go to theatre.
Cardiopulmonary Resuscitation Status FOR CPR
or
Not FOR CPR
COMPLETE YELLOW DNAR FORM. See Hospital Guidelines.
*Details of the person completing this proforma MUST be completed*
SIGNATURE…………………
Designation…………………
PRINT NAME………………………
Bleep………
Date……… Time……………
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SW 03/10
FRACTURED NECK OF FEMUR PROFORMA
NAME…………………………………………………….
DOB…………………………
ASA score
Class I
II
III
Completely healthy
Mild systemic disease
Severe systemic disease – not
incapacitating
Incapacitating disease
threatening life
Moribund – unlikely to survive
+/- surgery
IV
V
Score=
NHFS
Age
Sex
Admission HB
Living in a home
No. of
comorbidities
Admission MTS
Malignancy
Variable
66-85
>=86
Male
<10g/L
Yes
>=2
Score
3
4
1
1
1
1
<6/10
Yes
1
1
Score=
Charlson Score
1. Acute MI; CVA; CCF I50; Connective Tissue Disorder; Dementia;
Pulmonary Disease; PVD
2. Diabetes; Diabetes complications; Renal Disease; Paraplegia;
Liver Disease;
>3. Metastatic Ca; Severe Liver Disease; Cancer; HIV
Score=
10
SW 03/10
FRACTURED NECK OF FEMUR PROFORMA
NAME…………………………………………………….
DOB…………………………
Orthogeriatric Review
Orthogeriatrician………………….
Date…………….
Time……………..
Pre- op
□
Post op □
Day(s) post op: 1/ 2/ 3/ 4 (please circle)
Operation performed:
Hemi-arthroplasty
□
DHS □
Cannulated Screws □
IM nail
□
THR □
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SW 03/10
FRACTURED NECK OF FEMUR PROFORMA
NAME…………………………………………………….
DOB…………………………
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SW 03/10
FRACTURED NECK OF FEMUR PROFORMA
Name............................................................................... DOB...............................................
Orthogeriatric falls and bone health assessment checklist:
Bone Protection used (all patients>75yrs)
Bisphosphonate/ Yes
No
If no, why not
Strontium
Calcium &
Vitamin D
Yes
No
Reason
Strontium used
If no, Why not
**NOT FOR STRONTIUM IF HISTORY OF VTE OR IMMOBILE (d/w ortho-geriatric team directly)
Osteoporosis risk factors (all males >50 and females 50-74yrs should be risk assessed)
TICK ALL THAT APPLY
BMI<19
Steroids
EtoH
Previous fragility
fracture
Smoking
Premature
menopause
Sedentary
Rheumatoid
arthritis
Parental History
Coeliac disease
DEXA
Yes/ NO
Inpt/ Outpt
If no, why not
Date:
Osteoporosis screening bloods (Men over 50yrs and females under 75yrs)
Vitamin D
PSA (men)
PTH
Testosterone (men)
Serum electrophoresis
LH/FSH/Prolactin
(if applicable)
Urine electrophoresis
Coeliac screen
Medical Falls Assessment
Medication review
Postural BP
Likely cause of fall
Accidental/mechanical
Unwitnessed
Falls investigations requested
24hr tape
24hr BP monitor
Visual Assessment
Syncope
Other (specify)
ECHO
Other
AMTS (must be completed 72
hours post op)
Score:
Will this patient require OPD
follow-up/ investigation:
Orthopaedics
Multi-factorial
TILT test
/10
Date completed:
Medical
13
SW 03/10
FRACTURED NECK OF FEMUR PROFORMA
NAME…………………………………………………….
DOB…………………………
POST OPERATIVE ORTHOPAEDIC REVIEW
ORTHOPAEDIC CONSULTANT…………………………………..
Date of Operation…………………
Procedure…………………………………………………………………..
DAY 1 post-op review
Date/ time………………………
Findings:
Wound review:
Check X-Ray result:
Weight-bearing status (please circle): NWB/ PWB/ FWB
* If NWB/ PWB, review in …….weeks
Reviewed by (sign & print name)………………………. Designation……….. Bleep……...
DAY 4 post-op review
Date/ time………………………
Findings:
Wound review:
Check X-Ray result:
Weight-bearing status (please circle): NWB/ PWB/ FWB
* If NWB/ PWB, review in …….weeks
Reviewed by (sign & print name)………………………… Designation………… Bleep……...
Ortho happy for ongoing care under orthogeriatricians (please circle): YES/ NO
(Patients will be reviewed at the request of the ortho-geriatric team if concerns arise)
On-going daily orthopaedic input required (please circle):
YES / NO
(e.g. NOF patients with wound infection, peri-prosthetic or re-fracture, revision surgery, other site fractures
requiring ongoing orthopaedic management)
14
SW 03/10
FRACTURED NECK OF FEMUR PROFORMA
15