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Microsoft word - hip fracture primary operation form1.doc

Q2. Patient
// -
Year, month, day and 4 digit security number fracture
Q7. Sex  1= Male 2= Female.

Q14. Type
 (see figure on the back of this form) 1=Undisplaced cervical fracture 2=Displaced cervical fracture 3= Basocervical fracture 4= Trochanteric two fragments fracture 5= Trohcanteric fracture multi fragments 6=Subtrochanteric fracture Fracture
Q374. Time of fracture .
(if it is not known use day of admission) 24 hours clock admission
Q139. Time of admission .

Q140 Time of first pain relief .
Q141. Time of Xray .
Q9. Admitted
1 Own home 2=Sheltered housing 3= Institutional care 6=Rehabilitation unit 7= Acute hospital 8=Other
Q10. Living
1=Yes 2=No 3=Institutional care (category 3-7 above).
Q11. Walking
1= Walked alone out of doors 2= Walked out of doors only if accompanied 3= Walked alone indoors but not out of doors 4= Walked indoors only if accompanied 5= Unable to walk
Q12. Walking aids
1 – Can walk without aids 2= One aid (stick, crutch, tripod or hemiwalker) 3 = Two aids 4=Frame/Rollator 5=Wheelchair/bedbound Pathological

Q16. Date
Q142. Time .

Q17. Primary
1 Single screw, pin or nail 2= Two screws, pins or nails 3= Three or more screws, pins or nails 4= Single screw, pin or nail with side plate 5= Intramedullary nail 6= Hemiarthroplasty 7= Total hip arthroplasty 8= Conservative 9= Other (for more detailed se back on this form) Q18. Date of Discharge or death from admission ward // Year/ Month/ Day
Q19. Discharged
1 Own home 2=Sheltered housing 3= Institutional care 6=Rehabilitation unit 7= Acute hospital 8=Other 9=Deceased At admission During hospital At discharge
Occurrence of pressure ulcers on buttock or sacrum Q144. Q120. Q163.
Occurrence of pressure ulcer on heel

Q145. Q121. Q164.
Occurrence of pressure ulcerany other area Q146. Q122. Q165.
Q166 Is a validated risk assessment scale used?
 1=Yes 2= No
At admission
Q153. On Warfarin

Q154. Kognitive status
 1= Normal mental functioning 2= Suspect dementia/delirium 3=Dementia diagnose Q147. Kognitive screening SPMSQ  (see on the back of this form)
During hospitalization
Q127. Superficial woid infection
1=Yes 2=No
Q378. Length ………….cm
Q128. Deep wound infection 1=Yes 2=No
Q 379. Weight ………….kg
Q 380 .BMI ,
Own Questions (only analyzed by the own clinic)
 Q149.  Q150.  Q151.  Q152.  Q375.  Q376.  Q377. 
// (Year/ Month/ Day) Q159. // (Year/ Month/ Day)
// (Year/ Month/ Day) Q162. // (Year/ Month/ Day)
. (24 hours clock)

Codes for ASA classification

1. A Completely fit and healthy person who is on no medication and has no medical illness (other than the hip fracture). They obviously may have had medical problems in the past but these are now resolved. 2. The patient has some illness but this has no effect on normal daily activity and the patient has no symptoms related to this condition. Examples of this are things such as hypertension on treatment. 3. These are patients who suffer from conditions such as diabetes mellitus, asthma, angina, respiratory diseases. Providing however these conditions can be described as mild to moderate and only result in minimal symptoms with little restriction on the patients lifestyle. 4. This is more symptomatic illness causing everyday and severe restriction on the patients’ life style. Examples of such conditions are severe chronic bronchitis, unstable diabetes, frequent angina. 5. Moribund. The patient is in such a poor physical state that he/she is not expected to live more than a few days. Additional codes for Primary operation
Two Cancellous threaded screws (e.g. AO, Asnis) Sliding hip screw with trochanteric side plate Sliding hip screw with Medoff side plate Long intramedullary nail (type unspecified) Unipolar hemiarthroplasty (type unspecified) Bipolar hemiarthroplasty (type unspecified) Total hip replacement (type unspecified) Conservative treatment (indication or method not specified)
Codes for Pressure ulcer classification
0= None
Partial thickness skin loss. The skin surface is broken resulting in an abrasion or crater. Full thickness skin loss and extension into subcutaneous fat but not through underlying fascia. Extensive destruction involving damage to muscle, bone or tendon. Pfeiffer test Short portable mental status questionnaire (SPMSQ)
Scores below 7 (max = 10) are generally considered to be indicative of impaired mental function. This test should be administered to the patient on admission to the acute orthopaedic ward, if possible prior to operative procedure. Who is the prime minister in Sweden now? Who was the prime minister before him/her Count backwards 20-1, (score 1 if no mistakes or subject corrects themselves spontaneously).


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Elissa D. Viarengo, L.Ac BioFeedback Practitioner New Patient Intake Form Name:____________________________________________________ If a minor, Name of Parents / Guardian: ___________________________ Address: __________________________________________________ City: ____________________ State: _________ Zip Code: __________ Home Telephone (with area code): ________________________

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One Year Post-Exclusivity Adverse Event Review: Imiquimod Pediatric Advisory Committee Meeting November 18, 2008 Amy M. Taylor, MD, MHS, FAAP Medical Officer Pediatric and Maternal Health Staff Office of New Drugs Food and Drug Administration Background Drug Information • Drug: AldaraTM (Imiquimod) Topical Cream • Therapeutic Category: immune response modifier

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