Clacton Minor Injuries Unit

Clacton Hospital

Tower Road

Clacton

Essex

CO15 1LH

Tel : 01255 201594

Fax: 01255 201583

14 Sep 2012

Ranworth Surgery

103 Pier Avenue

Clacton-on-Sea

CO15 1NJ

Dear Dr Saima Qurban

Re: Mr Colin Kerr NHS Number: 624 191 1090 Date Of Birth: 29 Nov 1979

Mr Kerr attended Clacton Minor Injuries Unit on 14 Sep 2012 11:25 presenting with the following complaint - VOMITING.

The source of admission was - Self.

Clinical Entry at MIU

14 Sep 2012 11:34: 246A. 2469. O/E - Diastolic BP reading

C: vomiting

H: onset 1700 yesterday, afternoon, has started to feel better over past hour.

pt is alchohol dependent, and drug user.

pt takes 2.4 mgs subbutex, 1.2mgs valium. has not taken todays meds.

lives in night shelter. has rehab placement within next 6 weeks. attends with friend Gary Wheeler.

nkda

has not seen gp claims he felt too unwell to attend earlier

is very anxious.

is managing alchohol withdrawal due to vomiting, with bacardi breezers.

E: T 35.7

BP 128 / 90 mmHg

Sp02 97%

p111

does not appear intoxicated.

looks well but anxious, no diarrhoea, no vomiting over past hour. started to feel a bit better so came to miu. no abdo pain, reports his stomach is tender because of the vomiting. no chest pain, does not appear dehydrated.

CRT2<secs, alert and coherent.

IMP vomiting.

I: None

D: Gastrointestinal conditions - other Site: Abdomen Laterality:Not applicable

T: Observation/electrocardiogram/ pulse oximetry/head injury/trendsGuidance/advice only -verbal advised we are nurse led miu and pt needs gp rv, appt obtained for 1520 today. advised if concerns then needs to contact surgery again, if deterioration or sos then 999 to a+e. pt and friend happy with plan.

Done By: Valerie Winter (Community Practitioner) - Location: Minor Injuries Unit

Medication was prescribed as follows -

Drug name

Dose

Start date

The patient's discharge status was -

If you have any concerns or queries about this attendance please contact the department on 01255 201594.