upstairsfromreality

Patient Name: Hatherly, Victor Ignatius
DOB 1/17/1998 Age 25 Y Sex:M
Preferred Pronouns: He/Him
Chief Complaint: traumatic amputation of left thumb

Patient presented to A and E accompanied by an employee of the London Underground. Underground employee left at start of consultation.

Tachy at 120 bpm. BP 90/54, O2 98%, resps 25, temp 36.8,

Pale and diaphoretic.

Saline IV started upon arrival.


Patient stated that his left thumb had been cut off at work in a deliberate attack by a client. He state LOC for an undetermined time following the attack. Thumb did not arrive with patient.

Upon examination, left hand distal and proximal phalanges of the first digit were missing, with a single, full depth laceration through the joint. No fracture observed, confirmation by plain film x-ray required. Tourniquet applied to wrist in the field, replaced in the A&E.

Sterile dressing placed.

Orders:
Imagining: x-ray left hand, three views
Labs: CBC, chem-7
Orthopedic consult to determine immediate vs urgent surgery.


John Watson.