{"text":"Clelland, Agnes M, CHI: 0809555328, 11-Sep-2008, Trauma and Orthopaedic Surgery Page 2 of 5 \nS \nCLINICAL INFORMATION \nHistory of presenting complaint \/ qxamination findings \/ investigation results \nPresenting complaint ' \nSevere arm pain, paraesthesia, history of trauma back in December, definite bone abnormality just distal to \nelbow. \nComment: Dear Doctor, \nDescription: \nThe above lady fell and did attend Casualty in December and no obvious fracture was picked up, but the lady \ndefinitely has a very hard, firm swelling just distal to her elbow joint and since that date has been getting \nsevere pain and now what sounds like some nerve trapping also, paraesthesia in her hand, very severe pain \nright down her elbow to her hand and also up from her shoulder joint also. This is stopping the lady sleep and \ncausing her to really struggle to try to function at work. I would very much value your assessment of her as \nsoon as possible, as the lady really does seem at her wits end with regard to the amount of pain she is in. \nMany thanks. \nYours sincerely, \nAlice McSherry GP \nt _) Lifesty\ufb01e Risks and Alerts \/ Examinations and Investigations \nDescription\/Question - Result\/Comment Date \nNever smoked tobacco: 27-Aug-2003 \nNever smoked tobacco: - . - 20-Aug-2002 \nNever smoked tobacco: 15-Apr-2008 \nNever smoked tobacco: 27-ul-2007 \nNever smoked tobacco: . 20-Mar-2007 \nNever smoked tobacco: ' 07-Mar-2006 \nNever smoked tobacco: 01-Dec-2005 \nLight drinker - 1-2u\/day: 27-Aug-2003 \nTrivial drinker - <1lu\/day: . . 20-Aug-2002 \nLight drinker - 1-2u\/day: \" 22-Aug-1994 \nAlcohol intake within recommended sensible limits: 27-3ul-2007 \nAlcoho! intake within recommended sensible limits: 20-Mar-2007 ; \nAlcohol intake within recommended sensible limits: 07-Mar-2006 \nAlcoho! intake within recommended sensible limits: 01-Dec-2005 \n. Alcohol intake within recommended sensible limits: 13-Aug-2004 \nU Enjoys light exercise: 20-Aug-2002 \nAvoids even trivial exercise: 22-Aug-1994 \nEnjoys light exercise: . 27-1ul-2007 \nEnjoys light exercise: 20-Mar-2007 \nEnjoys light exercise: . ' 07-Mar-2006 \nEnjoys light exercise: \u2018 . 01-Dec-2005 \nEnjoys light exercise: 13-Aug-2004 \nReason for referral \nCare type requested: Out Patient \nExpected outcome: Not Specified \nPast medical history . \nPre-existing conditions (High & medium priority - all) \nDescription . E:Ttoer ded Modifier Extension %gtof \nBody mass index 30+ - obesity - \u2018 - - . 15-Apr-2008 \nO\/E - right foot pulses present ) - ' -, - - 20-Mar-2007 \nOJE - Vibration sense of right foot normal - - - 20-Mar-2007 \ne dboos = o Ml rws b mamme ok wadan walefeeral N eaa Anon o Tt oo e \n11 NN 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