Any Handwriting Detectives about for A&E Dr's report?

[TrailingPearls]

Was in A&E with a buggered ankle in 2010 and just trying to decipher what the Dr wrote in this report. I remember an X-ray and pain relief but cannot for the life of me remember the diagnosis! Just that it wasn't broken and I couldn't walk on it for 2 weeks It was weak for months.

What the hell does it say?! I've got as far as the date and time and possibly spotted the word 'today' so still no major clues . I'm guessing the L circled was my left ankle, which is weird, as I would have put money on it being the right one Memory eh.

PS. No alcohol involved, I'm just hypermobile.

That isn’t transactional analysis. It’s tenoachillies intact, TA tick.

Just like the previous poster is wrong about nausea and vomiting. NV tick in this case is neurovascularly intact.

Medical notes are precisely that, notes often in shorthand for the use of the individual who wrote them, and occasionally others who speak the same language and understand the medical shorthand. Offering them up to the lay community to attempt translation is at best likely to be misleading.

If you simply want a diagnosis your best bet may be to request the xrays and report.

I'd say NV is Neurovascular

Next to NV, l think that looks like FRM = full range of movement

Oops. Thanks Asdf12345. Love the term 'neurovascularly intact'.

Yes I understand what you're saying about asking laypeople to look at my records. And yes my x-rays & MRI images are on order. Unfortunately in the absence of appropriate medical care over the years, deteriorating health & becoming registered disabled (& constantly misdiagnosed ) then I have to gather clues & evidence in whatever way I can.

With children, I also have a responsibility to ensure they don't get fobbed off like I have.

Thank you PonderingPanda

@Asdf12345 I think there is a very real danger to patients if notes are not clear and easy to read. They are absolutely not just notes for the single clinician, those notes have to provide a clear and accurate picture of assessments and diagnoses as well as care plans for other professionals. There is no point in only one person being able to decipher medical notes. Acronyms, again, they’re just a source of confusion, if you write in a letter to me that this woman has had an IUD then as a midwife I’m picturing one thing and yet a gynae nurse is seeing something totally different. Notes must be clear and unambiguous for the safety of all patients - and the medical professionals who follow on.

Wrongdissection I've seen so many reports on MN re: the confusion around medical acronyms between different departments. You're right, they can mean totally different things dependent on which area the HCP works in.

That's why I added A&E to my post title to hopefully minimise confusion.

After the 3 lines ( after xray comment) I think it's the management plan. So
RICE - rest, ice, compression, elevation ( standard advice for sprained ankle)
ORA - could it be Oral Analgesia?
Word after the third line could be "advice "

After the bottom bit where it's says 'no definite bony injury' his plan is RICE (rest, ice, compression, elevation), over the counter analgesia and advice.

Xpost! I think it's OTCA - over the counter analgesia

Xpost yes makes sense!

Thecurtainsofdestiny DrFoxtrot

I really appreciate your input. The day itself was a complete blur tbh so posting here has been really useful. Thank you.

Brilliant Team Effort all round

25/5/2010 15.50 (or 15.45)
37 year-old female, no known drug allergies
Injury left ankle today
complaining of pain laterally
on examination left ankle
TA = Tibialis anterior, …. ?, nv = neurovascularly intact, …. ?, ?wb = weight bearing
No (def) deformity, swelling (…. laterally …. …
No ….
x-ray left ankle, no (def) deformity (BI) bony injury
1st arrow (R.I.C.E) rest, ice, compression, elevation
2nd arrow ?
3rd arrow (d) discharge advice - arrow from here ?

Initials of health care professional

Rosebud21 cheers! I have a wealth of information from all this input yesterday. Not just a vague sheet.