NATIONAL NEUROLOGY REGISTRY Stroke Notification Form

Transcription

1 TIOL NEUROLOGY REGISTRY Stroke tification Form Instruction Where check boxes are provided, check ( ) one or more boxes Where radio buttons are provided, check ( ) one box only For Office Use only ID Centre Centre Code Or Reporting centre name Date of tification (ddmmyyyy) SECTION 1 PATIENT DETAILS & DEMOGRAPHICS 1 Name (Please print in capital letters) 2 RN 3 NRIC MyKad - - Old IC Other ID document Specify document type (if others) Passport Armed Force ID Work Permit # Drivers Licence Police ID Card Others 4 Address Postcode Town City 5 Contact number 12 Occupation State Johor Darul Takzim Kedah Darul Aman Kelantan Darul Naim Melaka Negeri Sembilan Darul Khusus Pahang Darul Makmur Perak Darul Ridzuan Perlis Indera Kayangan Pulau Pinang Sabah 6 Date of Birth Estimated presumed year (ddmmyyyy) (autofill if MyKad is available) 8 Gender Home If the exact date is not known, please enter 0107yyyy & check the estimatedpresumed year box Male Female Sarawak Selangor Darul Ehsan Terengganu Darul Iman Wilayah Persekutuan Kuala Lumpur - Handphone - 7 Age (autocalculate) Wilayah Persekutuan Labuan, Sabah Wilayah Persekutuan Putrajaya t applicable - Foreign 9 Ethnic group Malay Orang Asli Murut Iban Other Malaysian, specify Foreigner, specify country Chinese Kadazan Dusun Bajau Orang Ulu Indian Melanau Bidayuh 10 Education level Primary Secondary Tertiary Nil 11 Marital status Single Married Widowed Divorced Legislator senior officals, managers Technicians, associate professionals Service workers, shop and market sales workers Craft and related trades workers Elementary occupations Professionals Clerical workers Skilled agricultural, fishery workers Plant and machine operators and assemblers Housewife specify Unemployed Retired SECTION 2 DIAGNOSIS 1 Diagnosis Epilepsy Stroke SECTION 3 SOURCE OF REFERRAL AND MODE OF ARRIVAL 1 Source of referral GP OPD Klinik Kesihatan, specify state Johor Darul Takzim Kedah Darul Aman Kelantan Darul Naim Melaka Negeri Sembilan Darul Khusus Neurology clinic Ward Pahang Darul Makmur Perak Darul Ridzuan Perlis Indera Kayangan Pulau Pinang Sabah Self walk in Other hospitals Sarawak Selangor Darul Ehsan Terengganu Darul Iman Wilayah Persekutuan Kuala Lumpur Wilayah Persekutuan Labuan, Sabah Wilayah Persekutuan Putrajaya 2 Mode of arrival Ambulance Own transport FinalizedVersion13 last updated on Mandatory Fields Page 1 of 7

2 TIOL NEUROLOGY REGISTRY Stroke tification Form Instruction Where check boxes are provided, check ( ) one or more boxes Where radio buttons are provided, check ( ) one box only I Patient Name and NRIC Number For Office Use only ID Centre II Name of reporting centre III Centre Code SECTION 4 VITAL SIGN AT EMERGENCY DEPARTMENT (ED) 1 Height (cm) 2 Weight (kg) 4 BP a Systolic Diastolic (mmhg) 6 Oxygen saturation (%) 7 Glasgow Coma Scale 8 Glucometer reading a Eye opening b Verbal response c Motor response d Total score (Autocalculate but editable) (mmoll) t available 3 BMI 5 Pulse rate (beatsmin) 4-Spontaneous--open with blinking at baseline 3-To verbal stimuli, command, speech 2-To pain only (not applied to face) 1- response 5-Oriented 4-Confused conversation, but able to answer questions 3-Inappropriate words 2-Incomprehensible sound 1- response (kg m 2 ) (Autocalculate) 6-Obeys commands for movement 5-Purposeful movement to painful stimulus 4-Withdraws in response to pain 3-Flexion in response to pain (decorticate posturing) 2-Extension response in response to pain (decerebrate posturing) 1- response Severe Moderate Mild (autofill) > T-intubated t available 9 Handedness Right Left 10 Stroke event First 11a Date of symptoms onset 12a Date of arrival to Emergency Department 13a Date MedicalNeurology team consulted 14a Date SurgicalNeurosurgical team consulted 14c Duration (time of onset to time of arrival to ED) 14d Arrival within 3 hours 15 Date of Admission SECTION 5 RISK FACTORS Recurrent Hours (autofill based on the calculated hours in 14 c) Ambidextrous a Number of previous stroketia Mins (autocalculate) 11b Time of symptoms onset 12b Time of arrival to Emergency Department 13b Time MedicalNeurology team consulted 14b Time SurgicalNeurosurgical team consulted Ignorance Geographical location Traffic jam caregiver transport specify 15b Time of admission 1 Risk factors ne Hypertension <1 year 1-5 years 6-10 years >10 years Diabetes <1 year 1-5 years 6-10 years >10 years Smoker Never Fomer Current Hyperlipidemia IHD Heart disease Atrial fibrillation Alcohol Hyperuricaemia Peripheral arterial disease Family history of stroke Sedentary lifestyle OCP a Year(s) <5 years 5 years b Number of stick(s) per day <10 sticks sticks >20 sticks FinalizedVersion13 last updated on Mandatory Fields Page 2 of 7

3 TIOL NEUROLOGY REGISTRY Stroke tification Form Instruction Where check boxes are provided, check ( ) one or more boxes Where radio buttons are provided, check ( ) one box only I Patient Name and NRIC Number For Office Use only ID Centre II Name of reporting centre III Centre Code SECTION 6 CLINICAL MANIFESTATIONS APPARENT AT THE START OF THE EVENT 1 Headache 2 Nausea or vomiting SECTION 7 PHYSICAL EXAMITIONS 3 Vertigo Giddiness 4 Altered sensorium 5 Visual alteration 6 Speech disturbances 7 Hemiparesis 8 Tetraparesis 9 Monoparesis 1 Physical examination Done t Done 2 NIH Stroke NIH Stroke Scale Scale 1A Consciousness 0=Alert 1=Sleepiness 2=Stupor 3=Coma 1B Questions 0=Answers to both questions 2=Answers neither questions 1=Answers to only one question 1C Commands 0=Performs both tasks 2=Performs neither tasks 1=Performs only one task 2 Gaze 0=rmal 2=Forced deviation, or total gaze paresis 1=Partial gaze palsy 3 Visual field 0= visual loss 2=Complete hemianopsia 1=Partial hemianopsia 3=Bilateral hemianopsia 4 Facial palsy 0=rmal 2=Partial facial paralysis 1=Minor facial paralysis 3=Complete facial paralysis 5 Arm Left 0= drift 3= effort against gravity strength 1=Drifts down before 10 seconds 4= movement 2=Some effort against gravity UN=Limb amputated 6 Leg strength Right Left Right 0= drift 1=Drifts down before 10 seconds 2=Some effort against gravity 0= drift 1=Drifts down before 5 seconds 2=Some effort against gravity 0= drift 1=Drifts down before 5 seconds 2=Some effort against gravity 3= effort against gravity 4= movement UN=Limb amputated 3= effort against gravity 4= movement UN=Limb amputated 3= effort against gravity 4= movement UN=Limb amputated 7 Ataxia 0=Absent 2=Ataxia in two limbs 1=Ataxia in only one limb UN=Limb amputated 8 Sensory 0=rmal 2=Severe or complete sensory loss 1=Mild to moderate sensory loss 9 Language 0= aphasia 2=Severe aphasia 1=Mild to moderate aphasia 3=Mute or global aphasia 10 Dysarthria 0=rmal 2=Severe dysarthria or anarthria 1=Mild to moderate dysarthria UN=Intubation 11 Inattention 0= abnormality 2=Severe inattention 1=Mild inattention Total (Autocalculated but editable) Score (autofill) 0 = Stroke 1-4 = Minor stroke 5-15 = Moderate stroke = Moderate Severe stroke = Severe Stroke SECTION 8 STROKE CLASSIFICATIONS 1 WHO Ischaemic ICH 2 OCSP TACI PACI 3 TOAST Large vessel Lacunar 4 Location Right hemisphere Left hemisphere SAH TIA LACI POCI Cardioembolic Undetermined Brainstem Multiple bilateral hemisphere Unclassified Unclassified t applicable Determined t applicable Uncertain (Autofill if WHO = ICH or SAH) (Autofill if WHO = ICH or SAH) FinalizedVersion13 last updated on Mandatory Fields Page 3 of 7

4 TIOL NEUROLOGY REGISTRY Stroke tification Form Instruction Where check boxes are provided, check ( ) one or more boxes Where radio buttons are provided, check ( ) one box only I Patient Name and NRIC Number For Office Use only ID Centre II Name of reporting centre III Centre Code SECTION 9 TREATMENT TYPE 1 Prior medications Aspirin Ticlopidine Clopidogrel Dipyridamole Heparin LMWH Warfarin Insulin Gemfibrozil Complementary traditional medicine 75 mg OD 100 mg OD 150 mg OD 300 mg OD n-compliance ACE inhibitors ARB CCB Beta Alpha Diuretics Statins Oral antidiabetics Supplementary medicine Perindopril Enalapril Captopril Losartan Irbersartan Amlodipine Felodipine Metoprolol Atenolol Propanolol Prazosin Ramipril Frusemide Moduretic Chlorothiazide Indapamide Hydrochlorothiazide Lovastatin Simvastatin Gliclazide Metformin Glibenclamide Lecithin Omega 3 Valsartan Telmisartan Nifedipine Bisoprolol Carvedilol Terazocin Atorvastatin Pravastatin Glimepiride Rosiglitazione Acarbose Rosuvastatin specify Morisky Scale 1 Do you ever forget to take your medicine? 1= 0= Score 2 Are you careless at times about taking your medicine? (Do you sometimes miss a dose?) 3 When you feel better do you sometimes stop taking your medicine? 4 Sometimes if you feel worse when you take your medicine, do you stop taking it? 1= 1= 1= 0= 0= 0= Score Score Score Score (autofill) 4= ncompliant 3= Poor 2= Average 1= Satisfactory 0= Compliant a How long defaulted treatment b Reason Months Years Attitude (fed upignorance) Poverty (no transport, poor support from caregiver) Previous dominant stroke FinalizedVersion13 last updated on Mandatory Fields Page 4 of 7

5 TIOL NEUROLOGY REGISTRY Stroke tification Form Instruction Where check boxes are provided, check ( ) one or more boxes Where radio buttons are provided, check ( ) one box only I Patient Name and NRIC Number For Office Use only ID Centre II Name of reporting centre III Centre Code SECTION 9 TREATMENT TYPE (cont) 2a) Treatment medications Aspirin Ticlopidine Clopidogrel Dipyridamole Heparin LMWH Warfarin Mannitol Insulin Gemfibrozil 75 mg OD 100 mg OD 150 mg OD 300 mg OD n-compliance ACE inhibitors ARB CCB Beta Alpha Diuretics Statins Oral antidiabetics Perindopril Enalapril Captopril Losartan Irbersartan Amlodipine Felodipine Metoprolol Atenolol Propanolol Prazosin Ramipril Frusemide Moduretic Chlorothiazide Indapamide Hydrochlorothiazide Lovastatin Simvastatin Gliclazide Metformin Glibenclamide Valsartan Telmisartan Nifedipine Bisoprolol Carvedilol Terazocin Atorvastatin Pravastatin Glimepiride Rosiglitazione Acarbose Rosuvastatin specify IV Labetalol IV Nitroglycerine IV Nimodipine IV Nicardipine IV Nitroprusside IV Isosobide mononitrate (isoket) 2b) Anti- platelet within 48 hrs Was patients given antiplatelet within 48 hours? 2c) Dysphagia screening Was patient screened for dysphagia prior to oral intake? 2d) DVT prophylaxis Were patients given DVT prophylaxis? Reason Contraindicated Refusal specify 2e) Stroke Education Did patients or carers receive stroke education regarding -Risk factors for stroke -Stroke warning symptoms -Medication -Rehabilitation -Follow -up? 2f) Rehabilitation Is there any documentation in patient s file that specific plans for rehabilitation were made(during in-patient and upon discharge)? FinalizedVersion13 last updated on Mandatory Fields Page 5 of 7

6 TIOL NEUROLOGY REGISTRY Stroke tification Form Instruction Where check boxes are provided, check ( ) one or more boxes Where radio buttons are provided, check ( ) one box only I Patient Name and NRIC Number For Office Use only ID Centre II Name of reporting centre III Centre Code SECTION 9 TREATMENT TYPE (cont) 3 Medications at discharge Aspirin Ticlopidine Clopidogrel Dipyridamole Heparin LMWH Warfarin Insulin Gemfibrozil 75 mg OD 100 mg OD 150 mg OD 300 mg OD n-compliance ACE inhibitors ARB CCB Beta Alpha Diuretics Statins Oral antidiabetics specify Perindopril Enalapril Captopril Losartan Irbersartan Amlodipine Felodipine Metoprolol Atenolol Propanolol Prazosin Ramipril Frusemide Moduretic Chlorothiazide Indapamide Hydrochlorothiazide Lovastatin Simvastatin Gliclazide Metformin Glibenclamide Valsartan Telmisartan Nifedipine Bisoprolol Carvedilol Terazocin Atorvastatin Pravastatin Glimepiride Rosiglitazione Acarbose Rosuvastatin 4 Acute stage procedures a Acute stage procedures b Location of admission c Thrombolysis d Other procedures Neuro ICU General ICU HDW Ward specify Date Intra-arterial thrombolysis Mechanical thrombectomy Time (24hours) Date Date Time (24hours) Time (24hours) e Surgical intervention Craniectomy VP shunt f Intubation Clot evacuation g In hospital transferred out Neuro ICU General ICU HDW Ward specify SECTION 10 1st HEMATOLOGY & OTHER LABORATORY RESULTS I 1st hematology and other laboratory results available? Hematology & other laboratory Value Tick if t Done Hematology & other laboratory Value Tick if t Done 1 Hemoglobin (gdl) 6 HDL (mmoll) 2 Glucose 3 Creatinine 4 Uric acid (mmoll) ( moll) ( moll) Fasting n-fasting 7 LDL (mmoll) 8 Triglycerides (mmoll) 9 INR 5 Total cholesterol (mmoll) 10 HbAIc 11 Platelets (%) (x10 9L) FinalizedVersion13 last updated on Mandatory Fields Page 6 of 7

7 TIOL NEUROLOGY REGISTRY Stroke tification Form Instruction Where check boxes are provided, check ( ) one or more boxes Where radio buttons are provided, check ( ) one box only I Patient Name and NRIC Number For Office Use only ID Centre II Name of reporting centre III Centre Code SECTION 11 INVESTIGATIONS 1 CT Scan 2 First ECG upon admission 3 Imaging and Other Investigations a Date of first scan c Duration Admission ED to CT Scan c ECG findings SECTION 12 OUTCOME 1 Stroke complications during hospitalization 2 Modified Rankin scale 3 Date of discharge 5 Discharge destination a Date of ECG MRI Carotid Doppler TCD Cerebral Angiography Angio MR Angio CT ECHO Holter Hours b Time of first scan d Neuroimaging findings rmal Atrial fibrillation Left ventricular hypertrophy ne Decubitus ulcer Stroke associated pneumonia Cardiac arrthymia Gastrointestinal bleed 0= symptoms at all 6=Death Mins (autocalculate) b Time Sepsis, DVT 4 Length of stay 1= significant disability despite symptoms; able to carry out all usual duties and activities (days) rmal Others Urinary Tract Infection (UTI) Upper Respiratory Tract Infection (URTI) specify 2=Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance 3=Moderate disability; requiring some help, but able to walk without assistance 4=Moderately severe disability Unable to attend to own bodily needs without assistance, and unable to walk unassisted 5=Severe disability; bed ridden, incontinent and requiring constant nursing and attention (Autocalculate) Home Old folks home (charity) Nursing home Others 6 Outcome Alive a Follow up Neurology Stroke clinic MOPD Estimated date of the next follow up GP Private AOR Klinik Kesihatan specify Death a Date of death (autofill as date of discharge but editable) b Cause of death Massive infarct Massive bleed Cardiac cause Other causes Sepsis due to aspiration pneumonia Sepsis due to other foci GIT bleed Metabolic cause egrenal failure FinalizedVersion13 last updated on Mandatory Fields Page 7 of 7

8 TIOL NEUROLOGY REGISTRY STROKE FOLLOW UP FORM Instruction Where check boxes are provided, check ( ) one or more boxes Where radio buttons are provided, check ( ) one box only For Office Use only ID Centre I Patient Name III Reporting centre name II NRIC Number SECTION 1 DATE OF ASSESSMENT FOLLOW UP OUTCOME IV Centre Code A Date of Assessment t applicable B Follow Up Month Month 3 Month 12 Others months SECTION 2 PATIENT STATUS 1 Patient status Alive Death a Date of death b Primary cause of death a Neurologic cause b Another cause Recurrent stroke Cardiovascular related death Sepsis specify Transfer to a new centre a Date of transfer b Name of centre Lost to follow up 2 Modified Rankin scale 0= symptoms at all 1= significant disability despite symptoms; able to carry out all usual duties and activities 2=Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance 3=Moderate disability; requiring some help, but able to walk without assistance 4=Moderately severe disability Unable to attend to own bodily needs without assistance, and unable to walk unassisted 5=Severe disability; bed ridden, incontinent and requiring constant nursing and attention 6=Death (Autofill as 6 - Death if Patient status is Death) 3 BP a Systolic Diastolic (mmhg) 4 Glucometer reading (mmoll) t available > 5 Complications Cardiac arrhythmia Seizure Spasticity Decubitus ulcer Pneumonia ne (Autofill as ne if Patient status is Death) 6 Readmission Acute stroke ADD tification Stroke related complications n-stroke related complications (Autofill as if Patient status is Death) FinalizedVersion13 last updated on Mandatory Fields Page 1