I went in to see Isobel just before three o'clock. She was asleep but woke up when I manipulated her right arm and wrist. There is less swelling in the arm but the second finger is even more swollen than usual. She said that she did not feel uncomfortable. Once again she was not very talkative. I fed her a few grapes.

The doctor came soon after three o'clock. She believes that the swelling is entirely due to immobility. The doctor and the nurses agree that the swelling of both arm and neck has reduced over the past few days, although we all agreed that at times there had seemed to be a random fluctuation in the amount of swelling of the right arm. We all agreed that the amount of Isobel's speech had dramatically decreased. The nurses had already discussed with the doctor the problems with feeding and giving Isobel drinks. They also find that she is forgetting to swallow unless reminded. They also have problems with drinks escaping from the side of the mouth when Isobel does not swallow. The doctor is arranging for a speech and language therapist to check the functioning of Isobel's swallowing. The doctor agreed that the elevation of the right arm should continue and that the manipulation helps. After discussion we agreed that tomorrow Isobel's bed would be rotated through ninety degrees so that she has reasons to look to her right, in order to encourage movement of the head.

After the doctor had gone, I fed Isobel a few more grapes while reading to her from her book. Isobel finished a half drunk beaker of squash and ate a banana with her beaker of afternoon tea. The was no great difficulty with the drinks apart from the need to remind Isobel to swallow. I helped Isobel order her food for tomorrow - liver and bacon for lunch and sandwiches for tea. I stopped reading to Isobel at ten past four as she was starting to appear tired. She fell asleep within a couple of minutes and slept until I woke her at twenty to five in order to prepare for tea.

Tea arrived a couple of minutes later before Isobel was properly awake (there is a lot of variation in tea times, because a lot of residents need to be helped with their food). Possibly because she was not fully awake, feeding her corned beef and chips turned into a saga lasting half an hour, by the time she finished the chips were stone cold. The problem again was that Isobel did not swallow. Many times she opened her mouth for another fork load of food, but had not swallowed the previous one. I was relieved when the eating of mandarin orange flan proved much easier and took only five minutes or so; her mug of tea was drunk without problems.

I fed Isobel a few more grapes while I read to her. After six o'clock Isobel again seemed tired and by about a quarter past six I stopped reading and spent a few minutes manipulating her fingers. The second finger was again straightened, much easier than last time so maybe that is more evidence that manipulation has a lasting effect. Isobel was asleep within a few minutes after I finished. The carers came in at about twenty to seven to change her (sometimes this happens before the night shift take over at seven, but often it is afterwards). I was keen to get Isobel to drink some more, and I helped her to drink a large beaker of squash. This proved much slower and more difficult than the previous drinks and some drink was lost out of both sides of Isobel's mouth, however about 95% was drunk. Isobel was still very tired and I left at about 7.10pm.

Although I had come in earlier specifically to see the doctor, I don't think Isobel can be expected to stay awake throughout long visits. Whenever Isobel is woken up it takes ten to fifteen minutes to wake her up properly and if she has only been asleep for a short time she does not seem to properly wake up at all. Long visits during which she has short periods (about half an hour) of sleep do not seem to be very helpful. It may be better to cram important activities such as eating and finger manipulation into a single shorter period of say an hour and a half and then let her fall asleep naturally while being read to.