JORHAT MEDICAL COLLEGE AND HOSPITAL

CASE RECORDS FOR NEURO TRAUMA

INSTRUCTIONS: While filling in details of history and examination, first tick the box adjoining the
features which are present and then use the adjacent space to write in detail ONLY about the
features which are PRESENT)
(Tick)
1. Name:
Team: NS-I NS-II
2. Age : Gender: M F
OPD: TUE FRI
3. Referred From:

4. Date and Time of Examination:__________ at ____ ______ AM/PM

5. Informant’s Name : Eyewitness Hearsay
6. Date and Time of Injury: _____/ _____/ ______ at ______ ______ AM/PM
7. Place of Injury : ______________________________________________________________
8. History of Injury in Detail :

RTA Fall Driver Passenger Helmet Alcohol Intake

Assault Other Pedestrian Yes No Yes No

9. History following trauma : (describe each event including duration, frequency, etc)

Loss of consciousness

Lucid Interval
Seizures
Vomiting
Amnesia
Bleeding from ear /nose
EXAMINATION

Vital signs on arrival:

10. Airway on arrival Clear Requires Intubation

11. Spontaneous Respiration Normal Tachypnoeic Gasping
12. Pulse Rate / minute
13. Carotid Pulsations Right Left
14. Blood Pressure on arrival mmHg
15. BP after ½ Hour mmHg (fill if initial BP<20mmHg systolic
16. Details of systemic examination including: (tick if present)

CSF rhinorrhoea /Otorrhea /Both

Active peripheral bleeding
Fractures
Peripheral pulses
(If long bone fracture is present)
Chest Injury
Abdominal Injury
Wounds
 JORHAT MEDICAL COLLEGE AND HOSPITAL
CASE RECORDS FOR NEURO TRAUMA

17. Details of Spine Examination:

Spinal Tenderness
Spinal Deformity

Neurological Examination:
18. Details of sensorium initially and after primary resuscitation (write appropriate score)

Glasgow Coma Scale

Adults Children Infants (Toddlers < 3yrs)
Eyes opening score
Initial After Resuscitation
4-Spontaneously Spontaneously
3- To verbal command To
2- To pain To pain
1- No response No response
Motor response Score
Initial After Resuscitation 6- Obeys Spontaneous movement
5-Localise pain Localise pain
4-Flexion withdrawal Flexion withdrawal
3-Decorticate Decorticate
2-Decerebrate Decerebrate
1-No response No response
Vertical response Score
Initial After Resuscitation 5-Oriented (appropriate words) Smiles (coos appropriately)
4-Disoriented (inappropriate words) Cries and consolable
3-Inappro Words (Persistent cries) Cries and inconsolable
2-Incomprehensible sounds (cries) Grunts (moans)
1-No response No response
TOTAL TOTAL
19. Horizontal oculocephalic reflex:
Right- Present Absent Not Tested Left Present Absent Not Tested
20. Pupillary light reflex
Right _________mm Reaction: Normal Sluggish Absent Cannot assess
Left __________ mm Reaction: Normal Sluggish Absent Cannot assess
21. Motor System Examination:
Right Left

Upper Limb: Tone:

Power:

Lower Limb: Tone:

Power:
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CASE RECORDS FOR NEURO TRAUMA

22. Any other neurological deficits like cranial nerve or limb palsies sensory loss and bowel and
bladder involvement

Clinical Impression:

23. Any change in GCS/neurological examination noted during observation:

Yes No

24. C.T. Scan Head done_______________ hours after injury showed:

Fracture
Contusion
EDH/SDH/ICH/IVH/SAH
Pneumocephalus
Changes in cortical sulci/Midline shift/Basal
cisterns/Ventricles
Diffuse Axional Injury
Brainstem Contusion

25. Other relevant investigations (X-rays/MRI): ____________________________________

26. Management Plan (in hospital):

27. Course in the Hospital (including repeat CT Scan done, if any) :

 JORHAT MEDICAL COLLEGE AND HOSPITAL
CASE RECORDS FOR NEURO TRAUMA

28. Condition at Discharge:

Final Management Plan: -

1. Referred to a General Hospital for further management and observation
2. Patient should be referred back in case of any neurological deterioration
3. Follow up in neurosurgery OPD on Tues day/Friday at 10 am after 1 week

TREATMENT AND ADVICES AT DISCHARGE:

Signature: _____________________________

Name of the Resident:

(in Capitals)
DATE
TIME