Page 1482 - 6. 2016 Diary 1st half New 26-05-21 No Table

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The Doctor’s Folder / pub Book Issue: 5!
Stage 5
Folder 5
Originator Details: 18 Aug 2016
Last Amended by Details: 18 Aug 2016
Jack Mumford
Page Numbers:56
Originator Details: 18 Aug 2016 11:34
Jack Mumford Medical
Originally Entered by Details: 18 Aug 2016 11:54
Jack Mumford Last Amended by Details: 18 Aug 2016 11:54
Jack Mumford Validated by Details: 18 Aug 2016 11:54
Jack Mumford Significant: No Added to Risk
History: No
Contains Third Party Info: No Conceal
From Client: Not Concealed
Offered a Simon bloods, physical and ECG, Simon consented. Bloods were taken aseptically
and sent to NMUH
ECG showed Normal sinus rhythm
Examination: pulse 76bpm, warm and well perfused, cap refill <2 secs.
No signs of anaemia, no central or peripheral cyanosis.
Heart sounds normal, no added sounds.
Chest clear.
Abdo soft non-tender
No calf swelling or tenderness.
Neurology not formally assessed but grossly intact.
On 5th finger of right-hand patient has a small laceration, appears clean, no erythema or pus,
probably a couple of days old, unsure how he did it. Patient concerned that he has cut through
his tendons, i have reassured the patient that the cut does not appear deep enough for this to
of happened and that his range of movement if limited only by pain.
On the 5th finger of his right hand, Simon has swelling over his DIP a black appearance
around the cutical which looks like dry blood. The joint is not hot to touch and there is no
obvious erythema. Range of movement is slightly limited by pain during active movement
however it is only mildly tender to palpate and range of movement if full during passive
movement.
Reviewed by Dr Rudra - agrees with assessment. Simon reports falling on finger yesterday
and has been swollen and painful since. Poor ROM (active and passive). Currently on section
and new to ward, agreed to remain on ward so that mental state can be monitored. Currently
not for A & E as not emergency. However, have neighbour strapped finger and consider
sending for XR with section 17 leave if no improvement next week. Simon was happy with
this and agreed to plan.
Imp: Likely bruised DIP Plan:
1. Chase bloods
2. Paracetamol PRN
3. Neighbour strap swollen finger
Review in 5 days, if no improvement consider: x-ray of the left 5th finger

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The Doctor’s Folder / pub Book Issue: 5!