SNOMED Curation Portal

Diagnosis: Chronic lymphoid leukaemia, disease Clinic note:Problem Items Addressed This Visit Overview:Incidental finding of lymphocytosis during inpatient admission prompted Peripheral blood immunophenotyping which revealed 40% Clonal B cells with a CLL phenotype

Diagnosis: Squamous cell carcinoma of skin, Lymphocytosis, Chronic lymphoid leukaemia, disease Current Outpatient Medication: atorvastatin calcium carbonate/colecalciferol 1.5 g/400 units per chewable tablet clobetasol propionate 0.05% ointment CODEINE PHOSPHATE (Generic Manuf) Dermol 500 lotion FEXOFENADINE (Generic Manuf) fluticasone 50 microgram nasal spray fluticasone/salmeterol (SIRDUPLA 250) 250micrograms + 25micrograms/actuation evohaler macrogol compound NPF sugar free oral powder omeprazole paracetamol predniSOLone salbutamol (SALAMOL) 100micrograms/puff inhaler Lab Test Results: Component Value HGB 133 WBC 17.9 (H) NEUTROABS 5.7 PLT 195 BILITOT 8 CREATININE 112 (H) ALKPHOS 86 11145642 2/4 SNOMED CT(R) instructions: 10 mg, Oral, Daily 1 tablet, Oral, 2 times daily Topical, Daily, Apply to affected area only. 30-60 mg, Oral, 4 times daily PRN Apply topically to the affected area if required. For dry skin, Use as moisturiser or soap substitute as directed. 180 mg, Oral, Daily 2 sprays, Each Nostril, Every morning 2 puffs, Inhalation, 2 times daily Take ONE sachets to TWO sachets twice a day. 20 mg, Oral, Daily, Do not crush or chew. 1 g, Oral, 4 times daily 5 mg, Oral, Daily, Take one or two a day depending on symptoms 1-2 puffs, Inhalation, 4 times daily PRN Date 23/05/2025 clinical note: I reviewed patient in clinic today. He was admitted to FPH in March with bullous pemphigoid which was managed with corticosteroids. During his admission he was found to have a lymphocytosis and blood film appearances suggestive of CLL. The immunophenotyping has confirmed a diagnosis of chronic lymphocytic leukaemia. We discussed this further today. He has no B symptoms and has not noticed any lumps or bumps.

indications for treatment in his case, and the mainstay of management, will be with active monitoring in clinic with blood tests. We discussed the indications for treatment and some of the therapiesthat are available and used to treat CLL. I suggest he takes the COVID and flu vaccinations and avoids live vaccines such as the yellow fever vaccine or live shingles vaccine (non live version available).He was reviewed by the team as an inpatient and has been provided some written information on CLL which he ha sread. I will arrange a further clinic review in our nurse led CLL clinic with repeat bloods in approximately 8 months time.He knows to contact the team if he has any concerns before his next appointment. For patients on active chemotherapy, please use the 24 hour chemo hotline number on the Haematology CNS contact card. need your NHS number which is on the top of this letter and please leave a message. lf you do not receive an appointment in the timescale you are expecting, please contact our secretaries on the numbers above.

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Diagnosis: Classical Hodgkin lymphoma Clinic note:Problem List Items Addressed This Visit Appointment date: 11/6/2025 Appointment type: Follow Up Consultation Overview Stage 1B with bulky disease — Early unfavourable (Bsx, age) Presenting with cough and weight loss and found to have a mediastinal mass Background: Pre-diabetes, obesity, ex-smoker PS-0 CT PET: FDG avid left thyroid nodule. In addition there is anterior mediastinal lymphadenopathy showing tracer uptake. This is suspicious for either lymphoproliferative disease or, potentially, a thymic mass. There is a nonspecific left lung nodule but no other evidence of disease

Diagnosis SNOMED CT(R) * Mediastinal mass Mediastinal mass * Hepatitis B core antibody positive Hepatitis B core antibody positive * Thyroid nodule Thyroid nodule * Classical Hodgkin lymphoma Classical Hodgkin lymphoma * Swelling of upper limb Swelling of upper limb * Neutropenic sepsis Neutropenic sepsis * Migraine variant with headache Migraine variant with headache plan - ABVDx2 and interim PETCT. If negative aiming for 2 further AVD (with no further Bleo given age) and 30Gy ISRT Hep B Sag -ve Hep B Core Ab positive - On Hep B prophylaxis with Entecavir - Until Jan 2025 Hep E Ab detected, Hep B E Antigen negative Hep C and HIV -ve Interim PETCT - 1) Significant improvement of the thoracic lymphadenopathy, which now demonstrates metabolic activity in between the mediastinal blood pool and background liver in keeping with a complete metabolic response. No new sites of FDG avid disease. Deauville 3. 2) Partial opacification of right maxillary antrum due to a probable obstructive polyp. A dedicated sinus CT is advised for further assessment. AVD x2 and referral for radiotherapy (30Gy in 15 fractions). To cont Hep B PPX and will need end of Rx CT and neck to re-assess thyroid nodule. CT sinus at some point as per PETCT report (likely inflammatory polyp). Completed radiotherapy S- 30Gy in 15 fractions and completed this on 25 August 2023 CT post radiotherapy (to assess thyroid nodule as well): Good response to treatment in ant mediastinal mass. pT2 NO MO left Papillary thyroid cancer - for monitoring vs thyroidectomy. Patient monitoring for lymphoma

Current Outpatient Medication aciclovir co-triMOXAzole (trimethoprim/sulfamethoxazole) 480 mg tablet domPERidone entecavir lansoprazole macrogol 3350 with electrolytes sugar free oral powder mometasone furoate 50 microgram nasal spray nystatin 100,000 units/ml oral liquid ondansetron 4mg tablet paracetamol sodium alginate/calcium carbonate/sodium bicarbonate (PEPTAC/GAVISCON) sugar-free oral suspension Lab Test Results Component Value HGB 136 WBC 6.8 NEUTROABS 43 PLT 295 BILITOT 9 CREATININE 67 ALKPHOS 74 LDH 128 10/6/25 - FBC, LFT's, U+E's normal 11130530 3/5 Hepatitis B surface antigen negative instructions 200 mag, Oral, 3 times daily Take ONE tablet once a day on Mondays, Wednesdays and Fridays. 10 mg, Oral, 3 times daily PRN 0.5 mg, Oral, Daily 30 mg, Oral, Daily, Do not crush or chew. 2 sachet(s), Oral, 2 times daily 2 sprays, Each Nostril, Nightly 1 mL, Oral, 4 times daily Take ONE tablet twice a day 1g, Oral, As needed 10 mL, Oral, 4 times daily (with meals and nightly) Date:20/01/2025 patient is now two years post treatment with chemo/radiotherapy for limited stage Hodgkin lymphoma. She is feeling well and has no B symptoms and has not noticed any recurrent lumps or bumps. She is currently undergoing some investigations under the gynaecology team for post menopausal bleeding.On examination her weight is stable at 97.9kg. There were no palpable nodes or organomegaly.Given that she is in ongoing clinical remission at this timepoint | have discussed discharge back to your care. We discussed the signs and symptoms of recurrence and should you or she have clinical concerns please refer her back to clinic for review.She should have irradiated blood for life in view of the diagnosis of Hodgkin lymphoma.

FHFT haematology For patients on active chemotherapy, please use the 24 hour chemo hotline number on the Haematology CNS contact card.need your NHS number which is on the top of this letter and please leave a message. lf you do not receive an appointment in the timescale you are expecting, please contact our secretaries on the numbers above Blood tests - please book an appointment in advance

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Diagnosis: Recurrent nosebleed Clinic note: i saw patient in the ENT emergency clinic.He woke up yesterday at 04:00AM with bleeding out of both sides of the nose dripping down posteriorly and filling the mouth. It resolved spontaneously at 05:30AM.He denies any preceding trauma, but notes that she has had very high blood pressure readings, quoting a reading of 203/113 before attending A&E. He tried to stop the bleeding with first aid measures but this did not help. He denies any nasal obstruction, crusting, otorrhoea, mid-facial pain, weight loss, or loss of appetite. Past medical history: Papillary thyroid cancer Total thyroidectomy + Right neck dissection 2015 Radio-iodine ablation July 2015 Revision right neck dissection July 2016 Dhx: Losartan, amlodipine, levothyroxine

Plan: 1. QDS naseptin to both nares for 7 days 2. Epistaxis safety netting advice 3. Discharge from ENT clinic Patient was happy with this plan and thanked me for the consultation.

management of their eye condition. A community appointment was undertaken by on 12/06/2025. The outcomes from the appointment are as follows. Pathway: Acute Triage & Treat Clinic (ODTC) Impression: Bilateral blepharitis Bilateral Meibomian gland dysfunction (MGD) secondary dry eyes Care Plan: Px non compliant with lid care: discussed importance of ongoing management and technique Blepharitis/MGD management 1. Heated mask (3-5 mins)/massage once a day or minimum x1-x3 a week 2. Lid hygiene using blephasol bds: morning/night longterm 3. Pres-free drops x4 x6 a day longterm Bleph/MGD leaflet issued.

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Plan: Sometimes people with anxiety and/or depression experience thoughts about harming themselves or ending their lives, this can make day-to-day life a challenge.We want to support you to be able to look after yourself and keep yourself safe so that you can get the most out of your treatment with us. Following our appointment today | wanted toshare the below plan with both you and your GP: My Keeping Well and Safe Plan ° What are the signs that | am feeling worse? (For example: feeling more low or anxious, noticing an increase in self-critical, self-harming or suicidal thoughts, increase in agitation) . ° I would be totally out of control, hysterical not be able to cope. I would be walking around the living room, crying, begging someone to take me to hospital.

problem-solving, looking after physical health, exercise, mindfulness, soothing self-talk, distraction, and stress relievers ° Speak to Samaritans as "I get so much in head and just have to talk". Going out in the garden, enjoy fresh air, listen to the birds, lay down on the grass.

° If needed, a safe place i can go to is? (For example, my bedroom, to an outside space, to a place of worship, community setting, to a friend or relative’s home) ° In a band, playing drums — big outlet for me.

Past medical History: Food allergy(pork ,egg, mutton) Polycytic ovarian syndrome Nasal vestibulitis Menorrhagia Anxiety with depression Acne vulgaris Pollen allergy Asthma Sciatica Available Gl investigations: Faecal PCR 25th April 2022: Negative HLA-B27 21st August 2023: Negative Faecal PCR 3rd July 2024: Negative Ultrasound abdomen and pelvis 9th February 2010: Normal. TTG 26th April 2022: 0.6 (negative, i.e. not coeliac); normal IgA

Plan: 1. Colonoscopy 2. MRE 3. Thyroid function tests You were referred by your GP due to your ongoing symptoms of loose stools and abdominal discomfort for the last3 years.You had been experiencing lower abdominal discomfort mostly cramps, the intensity of which improves withopening the bowels. You open your bowels about 3-4 times a day. Stools have been soft or watery in consistency with occasional bright rectal bleeding of small amount. You do have nocturnal symptoms and you had episodes of incontinence as well in the past. Along with the symptoms you have nausea in the morning. You denied any weight loss. You were previously given amitriptyline for your back pain and were asked to observe a low FODMAP diet. Unfortunately, despite trying both low FODMAP diet and a course of amitriptyline, you still experience persistent symptoms. You take loperamide which also does not seem to improve your symptoms. The symptoms have affected your quality of life and you feel frustrated because of it.Your previous investigations including faecal calprotectin, tissue transglutaminase antibodies and ultrasound abdomen were normal.You do not smoke and rarely drink. You have a desk job. Your sister has been going through the same symptoms.We discussed in detail regarding the possibilities leading to your symptoms. To rule out any organic cause of your symptoms, i have requested a colonoscopy and magnetic resonance enterography (MRE). You will get the appointment for both of them in due course. i have also given you a blood test for thyroid function.We will be writing to you regarding the results of your investigations. Assuming that the results of these investigations are normal, it is likely that your symptoms are likely due to irritable bowel syndrome plus diarrhoea.in that case, we would be discharging you back to your primary care. i would advise you to continue observing low FODMAP diet and to continue taking loperamide for symptom relief.in the meantime, please feel free to contact us if you have any concern.

13 June 2025 Appointment type: New Gastro Consultation 1. Diagnosed in December 2024 following a colonoscopy that showed distal UC in the sigmoid and rectum 2. Commenced on 3 g of Salofalk 3. Calprotectin improved from 4252 in November 2024 to 1031 in April 2025 I reviewed him in clinic who i met for the first time in December for his colonoscopy. He was diagnosed at the time with distal ulcerative colitis and was commenced on Salofalk granules. His symptoms have improved since and he is now opening his bowels three times a day rather than six. There is no blood or mucus in his bowel motion. I note his calprotectin has improved from 4500 to 1000. I have asked for up-to-date blood tests and he knows to contact the IBD nurses if he has a flare. I will see him in 6months time provided he remains well.

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Management Plan: 1. Admit from clinic today I saw patient in pleural clinic this morning. He has been feeling worse over the last 1-2 weeks. He denied pain, but has been a bit more breathless and his exercise tolerance has reduced. He has had a fever on and off for 2-3 days. He reports not sleeping due to a worsening cough and mucus getting stuck. There is some discomfort and he is unable to expectorate. He is not sleeping well. He has noticed both knees have swollen up and he has bilateral leg oedema over the last week. He has been trying to continue to work through all of this as he needs the money but clearly has been struggling. His appetite is reduced.

On examination: BP 101/67 HR 108 bpm Sats 95% T 36.8 Bilateral leg oedema to knee. Bilateral tender ankle joint and knee joints. Knee joints hot. US - thorax - very organised left sided mass within lung. He went on to have a CT thorax which demonstrated a lung abscess with very minimal pleural effusion.We have had a full and frank discussion. I feel that this is a very serious infection and that he should be admitted to hospital. If we leave this - he may die of this infection.He acknowledges this but needs to keep working to earn money, otherwise he will not get paid. He lives alone. His friend nearby but he does not wish to impose on her. He was initially unkeen to proceed with an emergency or planned admission. He feels that his job and finances are key here.After further discussions, he agreed to a emergency admission to hospital. After discussion with microbiology, he will be commenced on 4 times daily Tazocin. We will review his course as an inpatient.

Diagnosis: ypT3 L1 V1 NO (0/33) G2/3, TRG 4, R1 (<1 mm CRM) poorly differentiated adenocarcinoma of the oesophagus. Treated with perioperative FLOT and RAMIO 29th May 2024 (SRP) Adjuvant radiotherapy completed 19th November 2024. New shoulder tip pain for two months. Plan: Surveillance CT R/V in 4 months It was a pleasure to see him in clinic today. He is doing very well following his treatment for oesophageal cancer. He is still struggling with occasional dumping syndrome and we had a long conversation today about his diet reminding him around littleand often high protein high fat diet.He is due to see [PATIENT_NAME] in the near future and i think just to exclude anything sinister with his shoulder tip pain we should bringforward a surveillance CT. His last CT was in February and was reassuring. Otherwise we will catch up with him in four months’time and see how he is getting on.

This is a clinical letter written from one doctor to another and is likely to contain some medical terminology. If you have any questions regarding the content of this letter, please contact your GP. Medical Secretaries are not able to provide patients with results of blood tests, scans or procedures. Results will be discussed at your next appointment unless your Consultant has agreed to write to you separately. However, if you do not receive an expected letter or appointment, please contact the Secretary using the contact details at the top of this letter.Whilst considerable effort is made to ensure correct delivery, if you have received this information in error please notifyus immediately. We try hard to make sure your information is correct, but if any of your details are wrong please contact the secretary using the details at the top of this letter.

Admission date: 13/6/2025 Discharge Date: 13/06/2025 Discharged On Clinical Advice Discharging specialty: Cardiology Or With Clinical Consent Discharge location: FPH CATH LAB Procedure Summary: 77 year old gentleman with previous CABG in 2009 (LIMA to LAD, SVG to OM, D1 and R-PDA). Presented with SOBOE and frequent VEs. CMR showed mild to moderate LVSD with inducible ischaemia in diagonal/Lcx/RCA territory. Symptoms have improved on Bisoprolol. CTCA showed patent LIMA andSVG to RCA but occluded grafts to OM and D1

Recommendations 1. Aspirin lifelong, stop Clopidogrel 2. Continue with Bisoprolol for symptom control. 3. Conservative management of CAD 4. Review 6 months continue taking this medication aspirin 75mg gastro-resistant tablet bisacodyl 5mg gastro-resistant tablet

Last Dose Next Dose bisoprolol 3.75mg tablet Take one tablet once a day. Co-CAReldopa (carbidopa/levodopa) 12.5mg/50mg per tablet empagliflozin 25mg tablet Take one tablet once a day. furosemide 20mg tablet Take one tablet in the morning. LEVEMIR FLEXPEN SUBCUTANEOUS MACROGOL COMPOUND (Generic Manuf) sugar free oral powder Generic drug: macrogol compound NPF metFORmin 850mg tablet Take one tablet twice a day with meals. NAPROXEN (Generic Manuf) 250mg gastro-resistant tablet naproxen NOVORAPID FLEXPEN SUBCUTANEOUS

Last Dose Next Dose RAMipril 2.5mg capsule Take one capsule once a day. rosuvastatin 20mg tablet Take one tablet once a day. STOP taking this medication clopidogrel 75mg tablet

Date completed: 13/6/2025 GP Practice

had bladder neck incision with patient in 2023 LUTS - slow stream IPSS 25/35, Quality of life 4/6 Medications - Nicorandil, Amlodipine, Aspirin, Testogel (Endocrinologist from pituitary damage) Flow today - inadequate Plan: Flexible cystoscopy with patient bladder neck contracture, regrowth of prostate. Then discuss options

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Following the referral, the above client was triaged by Mental Health clinician at Common Point of Entry, and a summary of this contact is attached as follows. (The purpose of Mental health Triage is to determine the urgency, nature and severity of the mental health symptoms presented as well as to ascertain which service response would best meet the needs of the individual. Although it remains a therapeutic contact to support mental health and wellbeing , this is not a full assessment of Mental health)

Routine referral from GP requesting consideration for trauma pathway and for further advice on prescribing as sensitive to SE's from antidepressants and fearful of trying again. Has tried first line SSRI's but unable to tolerate due to nausea becoming anxious and tearful at the thought of re starting, had short term Diazepam and asked for this again but explained risk of addiction and not a long term solution. Has history of anxiety and depression since childhood and previously under CAMHS and MHICS and also did intensive CBT, has had gender identity issues and referred to Tavistock clinic, was assigned as female at birth but identifying as male in early teens, however now identifying as female and more comfortable with this. Diagnosed as Autistic at age 18. Anxiety relates to fear of being attacked and she was attached at age 11 and feels she still has trauma from that. Did not want to go into detail or specify the trauma. Impact of mental health concerns on daily functioning (Mood, relationships, self-care, sleep etc) Had therapy for anxiety before but feels needs to address underlying trauma.Has been using techniques to manage the anxiety such as grounding, breathing but does not help.Reports constantly worried about being attacked or harmed by someone, always worried when leaving the house.When anxious breathing rate increases, palpitations, sweaty, this happens every couple of days. Not able to socialise in large groups, has panic attacks prior to going to family gatherings and needs someone with her. Mood - Gets down when anxiety is stopping her doing things, feels lonely because not able to socialise. Used to suffer from depression but does not feel depressed now. Sleep - Usually good, occasionally wakes up early and feels anxious and panicky. Has long term partner, has own flat down the road from parents.Risk issues identified (current and historical) History: Previous overdose of medication in 2019 and 2023. History of DSH. No recent suicidal ideation, reports 'has got past that now’. No thoughts of DSH. Triage decision and discussion of Rationale: Would like to consider alternative medications to help manage anxiety. Mum is collecting Propranolol today and will try this but would like to consider alternative options for anxiety.

Plan: | will refer to psychology triage to review given prior input from secondary care and extensive history of previous therapy. GP requesting advise of alternative medication options - will refer to psychiatry to review.

Clinic information Summary:This patient has requested an initial outpatient appointment to see doctor. | would appreciate it if you could email me a clinical information summary to ensure that any necessary further treatment can be provided promptly and at the appropriate hospital. Thank you.

13th June 2025 The Berkshire Long COVID Integrated Service (BLIS) Clinic referral outcome.Thank you for kindly completing the The Berkshire Long COVID Integrated Service (BLIS) questionnaire, this has now been reviewed by a member of our specialist team.Based on the information provided, we will be offering you an appointment with our service.This will be with: Multi-disciplinary team, Long Covid Medic and Occupational Therapist. We have provided some information as to what to expect from you appointment.The Berkshire Long COVID Integrated Service (BLIS) Clinic. The clinic provides multi-disciplinary team (MDT) assessments for patients experiencing prolongedsymptoms following SARS-CoV-2 (COVID-19). Who is the service for? This service is for adults and children who are experiencing symptoms for more than 12 weeks following the start of COVID-19 — known as ‘long COVID'. This includes patients treated in hospital for COVID-19 infection and also those treated in the community who did not require hospitalisation.You do not need to have had a positive COVID-19 test to be eligible for the clinic, but there must be signs and symptoms consistent with long COVID. What happens in the BLIS Clinic? You will have an assessment with a member of the multidisciplinary team (MDT) or a combination of the team. This is a team made up of different specialists, including: pain consultant, GP, psychologist, physiotherapists and occupational therapists. The MDT will assess you and set up a management plan to help you with your symptoms. Depending on your individual symptoms, the team may arrange for you to have further physical assessments, such as blood tests, cardiology (heart) investigations or respiratory (breathing) investigations, as appropriate. We can also help you with a management plan for your wellbeing and mental health, if necessary as we understand the impact long COVID may having on your life. The BLIS service is also able refer you on to specialist services and has the potential to offer a plan for further rehabilitation, if you need it.

we also hold clinics at the Bracknell Healthspace. Most of the appointments we offer are in personhowever, we do offer ‘virtual’ consultations either by telephone or video. For more information about BLIS Please find below some resources for further information on Long COVID that you might findhelpful prior to your appointment.

Diagnosis Dose Ca Endometrium 21Gy,3#, 7Gy/# Site Treatment: Endometrium Radical Start Date: 06/06/2025 , Finish Date: 13/06/2025, Total overall intent treatment time :1 week Radiotherapy Side Effects Short term side effects:Skin Redness/irritation/breakdown XX] Vaginal inflammation & discharge x] Diarrhoea, Pelvic pain , Increased urinary frequency , Burning sensation on passing urine, Loss of pubic hair , Tiredness , Irritation of haemorrhoids including bleeding, Difficulty & pain swallowing, Nausea , Vomiting , Pain in treatment area Post treatment instructions (Current medications, referrals made, ongoing care instructions, if chemorad, please state chemo) Please note you may notice the side effects listed above for the next few days and then they should start to settle. Please use dilators as discussed 3-4 weeks after treatment has finished. Follow up instructions: If you do not have a follow up appointment with your Consultant it will be sent by the Oncology Admin team. If you have not received one in 3 months time, please contact the secretary.

problems or questions following radiotherapy please contact the radiotherapy review radiographers ask for the Oncology hotline (24 hours) Date 12/06/2025

Clinical Admin Team for Trauma & Orthopaedics patient was offered spinal surgery but has decided not to go ahead with surgery. We are discharging him back to your care but will be happy to see him again at your request

9th June 2025 I am writing to inform you regarding the ultrasound which was performed on 2nd June to assess your ovaries. This was arranged following suspicious of ovarian cysts following your CT scan which was performed on 22nd January to investigate your urinary tract system. I am pleased to inform you that the ultrasound has shown no evidence of any ovarian cysts and no any gynaecological pathology found. The physiological changes are in keeping with normal menstruation cycle changes. Therefore, no further gynaecological input is required. I am happy to discharge you back to your doctor. Many thanks. PS:The patient has been informed that any medications recommended for prescription in primary careare non-urgent and have been explained, including their potential side effects.

HISTORY:Injured right arm approx 4/52 ago. X-ray completed and advised soft tissue calcification. After a CSCI injection, awaiting both physio and GP follow up. Struggling to sleep. Attended ED as struggling with pain/lack of sleep.Using regular paracetamol 1g QDS but not helping.NSAIDs contra-indicated.Tried codeine previously but untolerated side effect of vomiting PMH CA bilateral breast, NSTEMI, kidney stones, Trifascicular block, Hypertension, hyperlipidaemia. Medicine:Dhx/ Paracetamol, Ezetimibe 10mg OD, Candesartan 2mg ON, ISMN 10mg BD, Lansoprazole 30mg OD,GTN 400mcg [PATIENT_NAME] 75mg OD, Alverine 60mg [PATIENT_NAME] 2.5mg OD, Amlodipine 5mg OD.

IMPRESSION:Shoulder calcification associated pain. PLAN:Advised unfortunately unable to facilitate CSCI within UTC/ED setting. Discussed analgesia options. Can trial amitriptyline as nerve block at night to help with pain. Checked interactions. Advised start low but may need up-titration in 3-5 days by GP. Advised s/e of hypotension, particularly as taking multiple antihypertensive medications, to take care when mobilising, especially ifgetting up overnight. NHS111 for triage if new symptoms/concerns. Date completed: 13/6/2025 GP Practice

Diagnosis Urinary Tract Infection

history of dysuria, for which she was taking trimethoprim and a one day history of fever. Vomiting and poor oral intake. She has no past medical history of UTI's She examined normally. Baseline bloods were done which showed crp of 123 and urine was taken forculture.She was admitted, closely monitored and started on IV ceftriaxone. She is now fit for ambulation and we wish her all th best in her recovery! Discharge Plan: 1. Ambulate on IV ceftriaxone 2. To complete total 7 days antibiotic course- if cultures are negative then to switch to oral co-amox Investigations: Pending at discharge: Pending Labs Order Current Status: Microscopy, urine In process Blood culture paediatric Preliminary result Culture, urine Preliminary result Were there any medication changes during admission? No You have no referrals or appointment requests from this visit. Safety-netting given: Verbally given

Resuscitation patient reflects decisions made during this admission and does not replace documentation in the patient's notes or ReSPECT form. Date completed: 13/6/2025 GP Practice Distribution List:Guardian of patient MEDICAL PRACTICE Future Resources for families, patients and professionals

information on childhood illnesses for families and professionals. This includes advice on warning signsto look out for, where to seek help if required, what you should do to keep your child comfortable, and how long your child’s symptoms are likely to last. Primary Care / GP Clinical Support including directories for Routine and Urgent Advice for clinicians (including ward contact details); all our Same Day Emergency Care Services (SDEC); and for non-urgent clinical queries there is a list of 'Medical secretary/admin support email addresses’ under the ‘Referrals & key contacts’ section.

Clinic note:Routine booking appointment MLC/CLC MLC General Wellbeing Well. Happy to be pregnant.Risk Assessments completed VTE LOW Clinical Screenings: Pre-Eclampsia NAD Pelvic Floor NAD Mental Health NAD GTT Assessment NR

Plan Antenatal care plan discussed and confirmed on conclusion tab, Personalised Care and Support Plannin GP Notified Via communication on Epic Additional Actions Gap & Grow chart generated G50582418 FW8 issued Application Completed Mother's certificate number:10 150 566 006 Exemption ends:10 April 2026 current date :13/6/2025 11:17

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Diagnosis: Bilateral hallux rigidus treated with interpositional arthroplasty (RegJoint). Date of Surgery:31st March 2025. Pain score today 1/10 for both feet. Plan:Review in six weeks in clinic and return to normal shoes. It was a pleasure to see him in clinic today. He is now six weeks down the line from his operation. We removed the K-wires. There is no sign of infection or inflammation. His wounds look fine.He can now start mobilising actively and passively his toes and massaging his wounds with Bio-oil daily for 10 minutes at least three times a day for the next two to three months. I also showed him some exercises to do. He is only feeling some discomfort in both of his toes. Obviously, we are not expecting a full range of movement and he was aware that this operation is not to restore the range of movement of the toes, but to make them pain free and perhaps slightly more mobile than before. The overall orientation of the toes is good. So far so good. He needs to look after the pin sites for a few days and make sure that he is not getting any infection there. We will meet again in six weeks’ time.

| gave him two leaflets to complete the day before he comes to see me again. Patient Foot & Ankle Surgeon Outcome: Six week follow-up - Booked. 30/06/2025

PROBLEMS: Large head circumference with frontal bossing. PLAN:Arrange for MRI under GA. Safety net advice given to the family. It was lovely to meet him with her mother and grandmother in General Paediatric Clinic. he is now 9-month-old baby. She was born at 30 weeks of gestation after a C-section as she was footling breech. No issues in the perinatal or early neonatal period. She was admitted at day 4 of life as she had an episode of going flat and blue. Had bloods and urine screen for sepsis, but everything was negative and then was discharged home. She has been breast feeding well and weaning into solids. She does not have any other symptoms, no vomiting, no signs of irritability. Developmentally, she is as expected for her age. She can sit up, cruise by herself to stand, transfer objects from one hand to the other. She is now babbling. Play peekaboo and wave bye- bye and she is her parents second child. Family history is otherwise unremarkable. On examination in clinic today, she appeared well. There is some frontal bossing notable.Anterior fontanelle was closed. No abnormal or focal neurology noted. Normal power and tone in her limbs. No significant signs of vitamin-D deficiency. Her head circumference was 48. Looking at her red book growth chart, her head circumference have alwaysbeen on the top end of normal. On HC measurement today is appeared to be above the 99.6th centile, which when compared to the last measurement done by the GP which was at the 91st centile, there is an upward trend. We will therefore arrange for an MRI under GA. | have reassured parents in view of her normal development and normal examination, this is all reassuring and not expecting to find any abnormal or concerning findings on the imaging. We will update the family once we get these results. | have given information about the signs and symptoms that would warrant urgent review. In the meantime if you have any concerns, please do not hesitate to contact me.

For urgent medical advice please contact your GP or 111 in the first instance. For medical emergencies you should call 999. All other enquiries to the department will be responded to within 5 working days.This letter/report is confidential and must not be copied to others without the consent of the author, or the young person to whom it relates, or their parents or legally appointed carers.

diagnosis which have been shared with your referring doctor. Diagnosis: Subfertility in clinic - couple 38 yrs Trying to conceive - 3 yrs Cycles /30-35 days LMP - / 26-36 BMI 18 - low PMH

Impression:Appearances in keeping with bilateral tubal patency.

Diagnosis - Unexplained subfertility Options discussed 1. Continue trying naturally for further 3 to 6 months 2. IVF treatment - Will need to self fund treatment, as not eligible for NHS funding under NEHF due to age criteria

diagnosis which have been shared with your referring doctor. Diagnosis: Cyst of ovary Clinic note: Recently seen after TWR with pelvic mass\ CT CAP impression:CT appearances suggest a massive left adnexal cyst. This does not have any malignant features on CT and there is no evidence of nodal metastatic disease. MRI may be useful to characterise this cyst is benign prior to surgicalintervention. date: 30/04/2025:

Conclusion: 1]31.8 cm simple presumed ovarian cyst (O-RADS 2). Residual ovarian tissue is not confidently demonstrated on either side. 2] Coexistent adenomyosis and fibroid formation (predominantly intramural) bloode test: Cai25 66 CEA 7.5 Other markers normal No symptoms at the moment Explained no cancer concern in image but in view of size and CA125 level needs excision Booked as laparoscopy +/- minlaparotomy and BSO as priority 3, xx keen to avoid hysterectomy if not required He is on holiday till 12th July, will be booked for after that Plan: added to WL, see above

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diagnosis whichhave been shared with your referring doctor. Diagnosis: Spina bifida it was a pleasure to see you in the Vascular Clinic today. You had presented with a right ankle ulceration.You are well-known to the Orthopaedic team and you have been under the care of dr previously.Your right leg ulcer developed from a pressure area after using splints in 2023. Your background is of spina bifidaand you are currently using a wheelchair. i note that you have been discussed in the Orthopaedic multidisciplinary team meeting 10 days ago and i am copying in the team so they are aware of this meeting. i believe the origin of this referral was from your GP sometime ago. On examination today you had good pulses in the right lower limb and no evidence of a compromised blood supply. The area of ulceration itself measures approximately 4 x 4 millimetres with a small amount of surrounding erythraemia. You are currently taking antibiotics.

i will discharge you from the Vascular services until patient initiated follow-up as, | believe your care is currentlybeing managed by the Orthopaedic team,however should you require any further vascular input | would be delighted to review you again. Sometimes follow up outpatient appointments can be cancelled or rearranged for a variety of reasons beyond mycontrol. If it is an emergency, then please attend A&E. If you have an aneurysm on surveillance and your appointment is delayed, then please contact us. If your symptoms deteriorate, please contact us. Please Note: This letter has been transcribed using voice recognition software and so may contain typographical errors. date: 12/6/2025

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date : 13 June 2025 We have reviewed your recent chest CT scan June 2025 in our Surveillance meeting on 13/06/25. Your scan shows that the previously noted lung nodule has remained stable, which is reassuring.You will not require any further CT scan surveillance from this lung nodule perspective.Your lung scarring (interstitial lung disease), for which you are having ongoing clinic follow up, also remains stable. Please note: This letter has been transcribed using voice recognition software. While every effort has been made toensure accuracy, minor typographical errors may occur. If you spot any discrepancies, please let me know so they canbe corrected.

If you do not receive an appointment or the results of tests i have arranged within the expected timeframe, kindlycontact my secretary at the number.

diagnosis whichhave been shared with your referring doctor. Diagnosis -bilateral plantar forefoot pain with of cold and hot sensation Previous management -ultrasound-guided injection to both feet in April 2025 (minimal symptoms improvement).Right foot second webspace 8 mm neuroma, third webspace 9 mm neuromaLeft foot second webspace 5 mm neuroma and third webspace 9 mm neuroma Management plan -patient waitlisted for right foot neuroma excision from second webspace and decompression third webspace i review his in my clinic today. She came back to see me today following ultrasound-guided injection to her both feet which gave little symptoms improvement. She wears insole which makes her feel tight in the foot. Her symptoms are more pronounced on the right foot and repeat examination today show focal pain in both 2nd and 3rd webspace but second webspace is slightly more intense. She has palpable dorsalis pedis pulse and foot gets to 10 degrees of dorsiflexion with the knee in full extension. | discussed an option of neuroma excision in second webspace and decompression and third webspace to help with the symptoms. he is keen to go ahead with that and | have entered her name for above procedure. Patient information leaflet regarding the surgery is given to doctor today which explained risks involved with the surgery and postop rehabilitation process.

This letter is voice dictated and autotyped straight from clinic as we try to get information to you and your GP ina timely fashion. You may see some typographical errors that have inadvertently crept in and if so we apologise.

diagnosis whichhave been shared with your referring doctor. Diagnosis: Surgical follow-up Clinic note:it was a pleasure to see this pleasant lady today in the clinic. She contact our Secretary yesterday with someproblem in her wound on the left breast. She had some redness and small gap in the lower aspect of her vertical wound near the inframammary fold. She contacted your GP practice yesterday and started on antibiotic.On examination today there is mild erythema in the lower part of the her vertical mammoplasty scar. There is about 4 mm area of superficial gapping. There are no collections and her scar looks clean.

I have assured herself that this is an minor wound issue and hopefully will settle quickly. I applied some Mepilex dressing today and advised her to finish her course of antibiotic.I will see her back in clinic next week and advised her to contact us sooner in case of any concern. Examination chaperoned by Oncoplastic Breast Fellow Date : 10/6/2025

Diagnosis: Crohn's disease Clinic note: it was a pleasure to speak with patient via telephone today in the IBD review clinic. She reports doing fine, having recently seen her, privately, and due to see doctor next month for her perianal Crohn's disease, and stricturing. She is due an EVA and anal dilatation. She continues on double-dosed subcut infliximab fortnightly, and is due levels in October 2025. I willarrange an IBD CNS follow-up with her results.

Diagnosis: Crohn's disease - Primary Overview Diagnosis and year: 1. Longstanding colonic Crohn's disease maintained on Anti-TNF and Azathioprine 2. lleo-colonic resection 3. Sub-total colectomy and ileo-rectal anastomosis (November 2017) 4. Laparotomy for small bowel obstruction due to internal herniation through mesenteric defect (September 2018) 5. Upstream disease of anastomosis now in remission and ongoing anal stricturing. Current medications: 1. infliximab 5mg/kg started 19/1/2023 had 3 doses next dose 24/4/2023- Switched to 120mg/1ml injections June 2024 then increased to 240mg every 2 weeksstarted 7th May 2025 2. Azathioprine 50mg once a day under SCA Other Meds: Fluoxetine Current Outpatient Medication: * infliximab (REMSIMA) 120mg/1ml injection pre-filled pen, Inject ONE HUNDRED TWENTY mg under the skin every 14 days., Disp: 12 Pre-filled pen, Rfl: 0 Allergen Reactions * Morphine Rash, Vomiting and Itching * Penicillins Unknown Observations: Weight 89 kg Plan: 1. EUA under patient next month 2. Follow-up (PP) 3. Continue CNS review (NHS) - OPA requested after Oct 2025

This letter has been transcribed using voice recognition transcription software. Please excuse anyminor typographical errors that may arise as a consequence. Please let us know if there is anything that needs to be corrected. Date: 13/6/2025

Date: 19/05/25 Primary Eyecare Services are commissioned to provide a direct referral system for primary care optometrists in patient CCG area. This letter is to inform you that a referral for the above captioned person has been undertaken and to provide you with the details of this referral. Information on the type of referral, the provider and the manner in which it was sent are provided above as well details of the treating optometrist. A copy of the referral document is attached to this correspondence for [PATIENT_NAME] information and this will also include full details of the clinical justification for referral. If patient has any questions regarding their referral please ask them to contact their optical practice for further help.

Visual Acuity - Measured with Snellen Test Conditions: Unaided Right Eye: 6/7.5 Left Eye: 6/15 Corrected Right Eye: 6/6 Left Eye: 6/6 Near Right Eye: N5 Left Eye: N5 Binocular: N5 Refraction Right Eye: Sph +0.25 Cyl -0.50 Axis 90 Add +2.75 Left Eye:Distance Sph -0.25 Cyl -1.75 Axis 80Near Add +2.75 Clinical Assessment - Surgery on - Left Eye Unclear Cornea: No Significant Conjunctival Redness Wound red or unusual in any way: No Incision site leakage Active Ant Chamber (>2 cells in 2x2): No Any vitreous activity Posterior Synechiae: No Peaked Pupil Displaced IOL: No CMO Iris Trauma: No Posterior Capsular Thickening Wet AMD: No Dry AMDIntolerable / Unacceptable anisometropia: No Intolerable / unacceptable astigmatism Iris prolapse: No IOP reported Right Eye: 15 Left Eye: 16 Patient reported satisfaction Patient assessment of vision: Better Patient assessment of surgical outcome:Satisfied Refer a patient to Urgent Clinic for assessment no complications seen for LE eye (post cat assessment today) but other eye (1st eye RE) shows mild CMO and despite having follow up with SPA for this 1st eye (prior to LE being listed), there was no mention of CMO - please contact px and review CMO RE (1st eye). VA good RE but has CMO.Thanks

Post Cataract Appointment Outcome Primary Date:2025-05-20 Completing GOC 99-06909 Appointment details if appointed - Target Date: 06-06-2025 Appointment Date if made: 13-06-2025

Post Cataract Transfer Form date: 2028-08-19 Pre existing pathology Consent Details: PES clinicians can access health care records in order to deliver direct care; PES may inform the patient via SMS, email, letter or phone regarding their direct care Operation Date: 09-05-2025 Eyes operated on patient

diagnosis which have been shared with your referring doctor. Diagnosis: Pain of breast Clinic note: it was a pleasure meeting this pleasant lady today in the breast clinic. She complains of left-sided mastalgia for few months. She describes intermittent dull ache mainly on the left side. She does not have any focal breast complaints.She is gravida 4 para 2. She has a half-sister diagnosed with breast cancer at age 55. She is on HRT following bilateral for oophorectomy at 52 .Her breast examination is unremarkable bilaterally with some tenderness in the lower aspect of the breast.

findings today. Her symptoms are benign and likely hormonal related.I given information booklet on breast pain and advised her to use evening primrose for symptom relief. He advised her to remain breast aware and happy to discharge her back to good care.

Trauma & Orthopaedics Date: 13 June 2025 Clinical Details: Ongoing right knee pain with giving way following trauma. Not improving with physio. underlying cause for knee pain patient have any implants or other potential MRI contraindications (see instructions)? No primary purpose of this procedure: Diagnostic when should this scan be booked: Next Available Appointment patient have any of the below that would impact how the imaging exam will be performed: None patient need an overnight bed: No - outpatient provider code:No contact number in case of a critical alert: message on EPIC FINDINGS:The medial and lateral menisci are intact.

plan to see him again in orthopaedics in 4 months time.

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ACTION REQUIRED WITHIN 3 WEEKS Date: 13th Jun 2025 Tesco Pharmacy The patient named below has had their blood pressure and pulse checked under the Community Pharmacy Hypertension Case-Finding Service. They are being referred to you for an appointment within 3 weeks as they fall under one of the following categories: * Blood pressure lower than 90/60mmHg and experience dizziness, nausea or fatigue * High clinic blood pressure of 140/90mmbg or higher, but lower than 180/120mmbHg and have declined/we could not offer Ambulatory Blood Pressure Monitoring Please find the results below: blood pressure reading: Systolic BP 7142mmHg Diastolic BP 78mmHg The patient confirmed they were experiencing the following symptom: Pulse rate : 65 bpm The patient has been advised to make an appointment with the practice within three weeks

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This letter may be generated using voice to text software. Although this is advanced, if there are significant errors in this letter which need to be amended, please call the team on the above number and they can investigate further.

diagnosis which have been shared with your referring doctor. Diagnosis: Injury of superior glenoid labrum of shoulder joint Clinic note: Diagnosis: Right shoulder injury. Management: Discharged to PIFU. i saw this gentleman today as a follow-up for his right shoulder injury that he sustained about 10 days ago when he fell down a scaffold.Reviewing him today, I understand that he has some shoulder pain with mild limitation in the range of motion. Clinically, he is neurovascular intact in all his nerves. Examining his rotator cuff, | am pleased that they all seem intact to me. Although he has some pain with shoulder abduction but he can do it actively and can maintain his arm abducted against pressure, which indicates that his supraspinatus is functioning. The rest of his rotator cuff muscles examination are all normal. I have reassured and have explained to him that | suspect he only sustained a bruise and that is unlikely that he has any rotator cuff injury.

I have reassured him but i have advised him that if he has any concerns he can contact us for further advice. SpR Trauma & Orthopaedics date: 13/6/2025

13 June 2025 Gender: Female We are writing to you as you did not attend your appointment with patient on 13/6/2025 This is the second time you have not attended a clinic appointment with us. As a result, we are now discharging you back to the care of your GP. Unfortunately, we are unable to make any further appointments for you to see us in the specialist asthma clinic without a new request from your GP.

Diagnosis: related liver disease suggestive of advanced fibrosis Gallbladder polyps alcohol intake :70 units/week Metabolic risk factors including BMI: 30, hypertension date: 13 June 2025 Appointment type: Hepatology Follow Up Consultation 1] Fibroscan Sept 2024: Stiffness (kPA): 11.1. IQR/med (%): 7.0. CAP dB/m (Steatosis): 316 2] Bloods Sept 2024: ALT 49, Alb 40, Bili 23, Plts 202, Hb 178, PT ratio 0.93 3] Liver screen Sept 2024: Normal immunoglobulins, negative liver autoantibodies, negative A,B,C,ferritin 238, Tsats 23%, AFP 4, HbA1C 26 4] Ultrasound liver Ganuary 2025): Diffuse liver abnormality most likely due to hepatic steatosis, No concerning liver lesion identified., 4.9 mm gallbladder polyp, Patent portal vein, No ascites.

Medication instructions: candesartan 32mg tablet lansoprazole 30mg gastro-resistant capsule sertraline 50mg tablet thiamine 100mg tablet verapamil 80mg tablet vitamin b compound strong tablet 1 tablet, Oral, Daily Weight: 64.3 kg it was nice to see you with your son for review in the hepatology clinic today. He was able to translate for us in Nepalese. Unfortunately you continue to drink a significant amount of alcohol and do get withdrawal symptoms when you have not had a drink for a while. The alcohol is also affecting your mobility and you have had several falls but thankfully have not caused any serious injury. You otherwise do not describe any symptoms of decompensated liver disease and your last ultrasound looked stable. You have tried to attend New Hope but did not particularly engage and were asked to return once you were. I have made inquiries about whether our alcohol liaison nurses, some of whom speak Nepalese, and run AA meetings might be able to get in touch with you. Otherwise you are aware that you should be cutting down gradually no more than 10% a week to avoid withdrawal symptoms.I have asked you to get some up-to-date blood tests today and you will continue to have 6 monthly ultrasound scans. Given your falls | am also arranging for you to have a baseline DEXA scan to assess your bone health and risk of fractures. We will see you routinely for review.

Date:13/6/2025

diagnosis which have been shared with your referring doctor. Diagnosis: Hyperemesis gravidarum History of genital herpes, not had in the last 10 years. Offered aciclovir prophylaxis from 36/40 if she wishes (she didn’t last pregnancy and had no flare up). Aware vaginal birth still safe either way. Clinic note: G4P1 - EDD 8.11.25 - BMI 20.8 - non-smoker 18+3, FMF. Aware to call MAMAs line from 24/40 if ever worried. 99/66, still awaiting to pass urine. PPROM at 35+5 weeks/ Pre term birth at 36+5/40, No growth on urine culture at the time, HVS showed yeast only. No reason for PPROM documented/known. Generalised anxiety disorder and depression, on Sertraline 50 mg - for baby obs for 24 hours after the birth. See notes by medical professional last clinic appt. Been referred to PMHS re bond with the baby.

indication for cervical length scans. No history of cervical surgery. Advised to continue dalteparin until mobility and fluid intake back to normal which it isn't yet. Aiming for vaginal birth - I am happy supporting this (physio note from 6.1.23 does preclude this). Hoping for epidural. Plan:Growth scans as already requested. See as needed for growth or any other concerns. Can stop dalteparin when hydration and mobility back to normal. Will contact medical professional late September if would like aciclovir

Diagnosis:Raised prostate specific antigen Post-op Diagnosis: Raised prostate specific antigen [R79.8]

Date: 13/6/2025 Procedure(s) (LRB):Perineal Needle Biopsy Of Prostate P2 W1 (N/A) Post-op Instructions: 1]Avoid strenuous activity for 48 hours. 2]Come to the Emergency department if you show signs of infection (fever, sweating, shivering) 3]See CNS for results in 2-4 weeks after PSMA. Actions Required of FHFT: Investigations Pending at Discharge Specimens:Source->Prostate, Type->Tissue, Tests->e HISTOLOGY, TISSUE Description: FUSION TEMPLATE BIOPSIES Requisition Comments: 1] PSA 21 2] Large score 5 lesion within the posterior left mid gland and apical Peripheral zone. This appears organ confined although there is a broad contact with the prostate capsule. A left posterior bladderdiverticulum is noted. 3] Fusion Prostate Biopsies 4] DRE T2c 5] Targeted 6] T1 Left PZ lesion mid to apex 7] Systematic cores : right

You have not been prescribed any medication. Allergies as of 13/6/2025: Not on File Pain Score: None (0/3)

Resuscitation status reflects decisions made during this admission and does not replace documentation in the patient's notes or respect form. Date completed: 13/6/2025 GeneralSurgery -Urology

including directories for Routine and Urgent Advice for clinicians (including ward contact details); all our Same Day Emergency Care Services (SDEC); and for non-urgent clinical queries there is a list of 'Medical secretary/admin support email addresses' under the ‘Referrals & key contacts’ section.

diagnosis which have been shared with your referring doctor. Diagnosis: Parkinson's June 2018, bladder cancer June 2024, non diabetic hyperglycaemia September 2022. Current Medication: Co-beneldopa 12.5 mg / 50 mg x 3 capsules 3x/day at 8 AM, 1 PM and 6 PM, Rotigotine 6 mg transdermal patches daily, Melatonin 2 mg modified release nightly, Midorine 5 mg 3 times a day Carbocisteine 375 mg x 2 capsules 3 times a day, Folic acid 5 mg once daily, Digoxin 125 mcg daily, Apixaban 5 mg twice a day, Lansoprazole 15 mg once daily, Finasteride 5 mg once daily, senna 7.5 mg nightly, Lactulose oral solution 15 mL twice a day when required, Cosmocol daily. it was a pleasure to see you and your wife at your bungalow. You are now more or less housebound. You mobilise well indoors with the Zimmer frame and 1 person with you. You are having carers 4 times a day. You tell me that you sleep well but do experience vivid dreams and hallucinations which are not currently bothering

Problems Identified: 1) Your memory has deteriorated. You forget which buttons you need to press on your recliner chair and you forget how to operate the television control. 2) You have had 2 recent falls due to loss of balance. 3) Intermittent swallowing difficulties. You tell me you have a sensation as if you have something permanently in the back of your throat. 4) Communication difficulties. Both you and your wife are hard of hearing and find it difficult at times to communicate with each other and with other people. 5) Your dexterity is not as good as it was in your having difficulties gripping things. 6) You have had a lot of medical appointments for your bladder cancer and other ailments and you are finding it all a bit much. Plan: 1) You declined a memory test today having made an informed decision, as you did not feel up to it and are not keen to have memory clinic or anyone else involved as you feel you are already having too many appointments at this time. We have left open so that if you change your mind I will be happy to come back and go through a memory test with you.I have explained that this would give us a baseline and possibly help decide on what treatment would be appropriate going forward. You will think about this. 2) You are being very careful when you mobilise now and tend to have someone with you while you use your walking frame. Should you wish to have any balance input from the neuro physiotherapists I would be happy to refer you. 3) You are currently managing to eat and drink and have not had any recent chest infection. I can refer you to the speech and language therapists for an assessment and advice should you wish to do this at some point in the future. 4) The speech and language therapists can also advise regarding communication aids should you wish to pursue this in the future I would be happy to refer you. 5) You may find it helpful to try squeezing a stress ball regularly to exercise the muscles in your hand and see if this helps improve your grip. 6) If in the future an appointment is arranged for me to review your Parkinson's and you feel you are stable and do not want the visit please let the care coordinators know at the Neuro Hub on the number below. It will not upset or offend me. It is completely your choice. I am here to support you and your wife with the Parkinson's and to respect your choices.

A review will be organised in due course. If there are any concerns between appointments the Neuro Hub can be Specialist Date: 13/6/2025

Admission date: 13/6/2025, Reason for admission: Ezetimibe, Admission method: Elective - Waiting List, Length of stay: 0 days , Source of admission: Usual Place of Residence Discharge Summary completed by: Anaesthetist Operative Note: Lumbar screen injection (Bilateral) Updates/current meds:Explained all risks and benefits for procedure

Diagnosis:Bilateral lower back pain Procedure:Bilateral L4/5, L5/S1 medial branches and sacroiliac joints LA +steroids Verbal and written signed consent. The surgical site was appropriately marked. WHO surgical Safety Checklist completed and documented. The patient's identity, site, procedure and informed consent were confirmed. Positioning: (self-positioned and all areas fully padded) PRone Sedation: Sedation provided by Anaesthetist Full asepsis (hat, mask, sterile gloves/gown/drapes); 0.5% chlorhexidine spray x 2 - dried Modality used: Xray Image intensifier - operated by radiographer (digital laterality marker applied by theradiographer at the end of the case in agreement with the clinician) Probe type: 22G, 9 cm Medications used (total): Bupivacaine 0.25% 4 ml - easy to inject, 80mg methyl pred used, Opsite spray dressing Post-operative: Re-positioned on the transfer trolley. All areas intact. Transferred to PACU Plan:Discharge to GP and procedure can be repeated after one year if it did work for her (Patient didnot benefit from radiofrequency before but always benefit benefit from steroids injection)

of any medication we might have proposed today. Available to leave a message on 24/7. Calls arereturned in business hours within 3-4 working days. This isn't a crisis line but is for clinical queries about patients we have seen before. Your medication list-> No intended changes to regular medication unless stated. Only newly started or changed items have been supplied on discharge. Allergies as of 13/6/2025 Aspirin -> Severity:Not Specified , Noted:23/08/2022, Reaction:Upsets stomach BMI (Calculated): 23.5

Resuscitation status reflects decisions made during this admission and does not replacedocumentation in the patient's notes or Respect form. Date completed:13/6/2025 Cross site — Chronic Pain Further Discharge Support Contact Details: including directories for: Routine and Urgent Advice for clinicians (including ward contact details); all our Same Day Emergency Care Services (SDEC); and for non-urgent clinical queries there is a list of 'Medical secretary/admin support email addresses’ under the ‘Referrals & key contacts’ section.

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assessment appointment. We aim for this to take place within the next 3 - 4 weeks (depending on your patient’s availability and requirements).Should you have any further queries regarding your patient, please do contact us on the above number.

Therapies, we hope you found it useful.During patient assessment we discussed the difficulties you have currently been experiencing and discussed options of support both within Talking Therapies and with other local specialist services.Next Steps: At this time, we agreed that patient current needs would be best met by PINC as patient current needs are to be seen in-person.Please be advised that person has made the referral on patient behalf and you have been accepted for an assessment. The wait times are approximately 6-8 months. We would like to remind you that if you feel you need urgent support it is important that you contact GP, who will be able to refer you to the specialist help you need. When GP surgery is closed their answer phone will direct you to the right place, or you can call NHS111

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Here are the details of your telephone appointment. The purpose of this appointment is to give you more information about the SilverCloud programme and guide you through the nextrelevant modules. We look forward to speaking with you. Date: 23rd June 2025 Time: 5:50 pm Location: Telephone What is SilverCloud: SilverCloud is an evidence-based, online programme that will help to teach you techniques based on Cognitive Behavioural Therapy (CBT). It is an interactive programme with many activities to complete to help you to improve your mood. The programme is also very flexible; we can make sure that it fits in well with your lifestyle. What happens next: You will receive an email directly from SilverCloud within the next few days with a link to sign up to the programme. This email may go into your junk folder so please check here.

The tools you will learn are based on Cognitive Behavioural Therapy (CBT). Your treatment about what to expect from your treatment with us. Need to reschedule? Although you can leave messages on SilverCloud, we are unable to see these until the day of your appointment. Monday to Thursday, 8am-8pm, and Fridays, 8am-5pm. Unfortunately, we may need to close your referral if you don’t attend without letting us know first or if you repeatedly give us less than two working days’ notice. Please note we cannot make calls for sessions outside of the UK, so please let your therapist know if you will be abroad at any point so we can work around this. At any point in your treatment journey you can share anonymous feedback with us here .Sometimes it can be common to notice an increase in symptoms, including agitation and distressing thoughts.

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Diagnosis:Psoriatic arthritis Past Medical History:Psoriatic arthritis Medication instructions: * foLlC Acid 5 mg, Oral, As directed, Every day other than methotrexate day « methotrexate 20 mg, Oral, Weekly, To be taken ONCE A WEEK ONLY.

Management plan as discussed with patient 1. He is to stop leflunomide as he is currently not taking it regularly. 2. To switch his oral methotrexate to injection or increase oral methotrexate to 25 mg based on updated patientresults. he is currently not keen on switching to injections, as his planning relocation to Spain. 3. To continue with his medication, but will call the nurses advice once he has had the test done, so appropriate dose of his methotrexate can be put in place. 4. 6 months appointment for next review, but will inform patients’s secretary if he relocates before the appointment is due. Mondays, Wednesdays, and Thursdays from 9 am to 11 am instead of the usual Monday to Friday schedule. This change is to enable us to provide the best patient care in all areas of our service. Please be advised that our services are unavailable on weekends and bank holidays.Kindly leave a voicemail stating your NHS or MRN number and a brief message regarding your rheumatology concern, Without these details, we cannot locate your records and address your concerns. The nurses will do their best to return your call within 24 to 48 hours. You may call the advice patient for: 1] rheumatology flares 2] repeat prescriptions/pateint test forms request for rheumatology medications 3] new/current rheumatology medications 4] biologic appointment. Please note: * Calls not related to rheumatology will not be returned. * For non-rheumatology issues, please contact your GP. * The advice line is not an emergency or urgent care service.

concern please contact the department for correction.

date: 13 June 2025 We have discussed your recent left breast biopsy and imaging in our breast meeting this morning. This has shown benign innocent changes of a fibroadenoma which is reassuring. You will be sent an appointment to be seen and assessed clinically in the breast clinic in the next few weeks. if you wish to discuss any of the above then please contact the breast administration team on practitioner

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past medical history, current medication and performance status. This is important to minimise delays in the patient's pathway.

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diagnosis whichhave been shared with your referring doctor. Clinic note:Patient consented verbally to examination performed by Clinician and chaperoned by a member of staff. Privacy and dignity maintained throughout. Standard IPC precautions taken. No issues or concerns noted.patient was seen in the breast one stop clinic today. She is 9 weeks pregnant and has been feeling well. She noticed 2 small lumps in her left breast 2-3 months ago. They have not changed in this time.No family history of breast or ovarian cancer. No current medication.

Plan:Advised to remain breast aware and report any changes or new concerns to her GP. Reassured and discharged today.

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Diagnosis: 1. Barretts Oesophagus COM2 & HGD 2. Suspected side effect with Famotidine Endoscopy summary: Aug 2024 OGD & HALO90 COM1 Feb 2025 OGD & HALO90 COM1 Jun 2024 OGD COM2. Biopsies columnar lined mucosa with high grade dysplasia Nov 2024 OGD COM1. Biopsies columnar lined mucosa with low grade dysplasia May 2025 OGD COM1 Biopsies - mild reflux changes Current Outpatient Medication and instruction: * alogliptin: 6.25 mg, Oral, Daily * insulin (LANTUS) glargine 100 units/mL vial Subcutaneous * Lansoprazole fast tabs- orodispersible: 30 mg, Oral, 2 times daily, Date: 13 June 2025

plan: OGD and biopsies I am writing to you with the results of your most recent gastroscopy. This shows a very small patch of Barrett's The biopsies showed minor reflux changes only. There was no dysplasia or malignancy.I will arrange a repeat OGD in 6 months.

Diagnosis:Dysplastic naevus of skin,dermatofibroma on left thigh Plan:Skin biopsy histology, tissue Clinic note: Excision dermatofibroma on left thigh. LA 2mm margin and down to fat Other orders: - Appointment request 2 Week Wait; Two Week Wait; Face to Face; No; Specific Clinic and Consultant; HWH PLASTIC SURGERY MINOR OPS GREEN

Procedures: * Excision dermatofibroma on left thigh. LA * 2% ligno with adr * Hemostasis * 2mm margin and down to fat * 4 mono and 4 vicryl * Dressed Post-op: Dressing off 5 days TA patient 6 weeks patient- Plastic Surgery

Date: 13 June 2025 We have received the result of recent echocardiogram which has demonstrated normal left ventricle size and wall thickness with normal ejection fraction of 55-60%. Normal right ventricle size and systolic function. Normal bi-atrialdimensions. Trivial mitral and tricuspid regurgitation. This is a reassuring result.

Date: 13 June 2025 Right sided thyroid swelling for approx 6/12. New right sided sore throat.No other red flag symptoms. U/S initially please Findings The patient is palpating the right side of the thyroid cartilage which appears sonographically normal. The thyroid gland is mildly atrophic in keeping with known chronic hypothyroidism. A 9mm part spongiform part cystic nodule lies in the right lobe of the thyroid (U2). Several other tiny cystic/isoechoic nodules are scattered throughout the thyroid measuring up to 4mm (U2). No suspicious thyroid nodules demonstrated No cervical lymphadenopathy.The major salivary glands appear normal. Conclusion:No significant findings.

Please note that these results from your recent investigation have not shown any suspicious features.i trust that this is reassuring. Date: 13/6/2025

Diagnosis: Ulcerative colitis Clinic note: It was a pleasure to speak to patient via telephone today, in the IBD review clinic. He reports his bowels are stable, opening 1-3 x daily, and he occasionally sees blood and mucus on the tissue paper. I note his recent bloods and faecal calprotectin are essentially normal, and a small bowel ultrasound showed no enteric inflammation. There was a suggestion of needing a flexible sigmoidoscopy, which I will discuss further with patient. his main concern was abdominal bloating and wind, which he gets most evenings, causing a lot of discomfort. He has noticed he is not able to tolerate some foods, such as Rice, Milk and ice cream, and I have advised him to check which foods he finds difficult to tolerate, and avoiding high FODMAP foods. He may find using simeticone (OTC) also helps his symptoms. He will be followed-up later in the year.

Diagnosis: Ulcerative colitis - Primary Overview * Colonoscopy June 2024 - Short segment of severe inflammation of the upper rectum, rectosigmoid and lower sigmoid colon. The inflammation between 16cm to 30 cm from the anal verge. The rest of the colon (including the lower, mid rectum) and terminal ileum are normal * Small bowel ultrasound June 2025 - no enteric inflammation seen Current Outpatient Medication: * PLENVU oral powder, Take 1 dose as directed by your doctor or clinical team for 2 doses., Disp: 3 sachet(s), Rfl: 0 * RAMipril 10mg capsule * Salofalk 3g granules: PO OD Allergen Reactions * Midazolam * Morphine Observations Weight 86 kg Plan 1. Advised Wind-eze for bloating and food amendments 2. Discuss with patient- need for Flexible sigmoidoscopy 3. Follow-up patient 6 months

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PRESENTING COMPLAINT: Colonoscopy performed on 16th January 2025. Iam writing to you on behalf of patient regarding your recent colonoscopy procedure. During the procedure biopsies were taken along with a single polyp found in the transverse colon. The polyp was a singular tubular adenoma and the biopsies showed normal bowel mucosa. Inkeeping with our guidelines there are no concerns regarding these results and no further action is required regarding these. If you have any concerns, please do get in contact.

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Clinic Date: 5th June 2025 I saw patient today in Respiratory Clinic. He was referred during work-up for his well differentiated gastric adenocarcinoma. He was found to have non-granulomatous lymphadenitis on biopsy. At that time he was awaiting treatment for this adenocarcinoma, however, since the referral has been sent he has undergone surgery and is currently ongoing with chemotherapy. He has also had two CTs of thorax in the meantime in February and March of this year. Both of these scans have not shown any evidence of underlying lung disease. There has been no evidence of any pleural effusions, no concerning lung nodules nor infiltrates. From a respiratory point of view, patient feels well in himself. He has said he is not feeling any more breathless than normal, has not had coughs, haemoptysis or night sweats. He tries to walk 10 to 15 minutes each day. He has not noticed any new rashes, any lumps forming or had any eye changes. On examination today, patient does not have any clear respiratory signs. His lungs are clear. There are no extra articular features of other disease such as sarcoidosis. Because of this, we will discharge patient from the Respiratory Clinic. There are no concerning features from this possible non-granulomatous lymphadenitis and no further treatment or further workup is currently required. If anything changes or there are further concerns, please do not hesitate to re-refer to the Respiratory Clinic.

This is a clinical letter written from one doctor to another and is likely to contain some medical terminology. If you have any questions regarding the content of this letter, please contact your GP.Medical Secretaries are not able to provide patients with results of blood tests, scans or procedures. Results will be discussed at your next appointment unless your Consultant has agreed to write to you separately. However, if you do not receive an expected letter or appointment, please contact the Secretary using the contactdetails at the top of this letter.Whilst considerable effort is made to ensure correct delivery, if you have received this information in error please notifyus immediately. We try hard to make sure yourinformation is correct, but if any of your details are wrong please contact the secretary using the details at the top of this letter.

Diagnosis: No diagnosis found. Clinic note: We spoke by telephone today to review your ultrasound guided injection, which was performed in November last year. The ultrasound scan reported some tendinopathy of the supraspinatus tendon and evidence of subacromial bursitis. You tell me that you have had no particular relief following the injection. Unfortunately you have recently had a laparoscopic appendectomy done on the 4th June and are still recovering from this. On discussion with you I have made a referral to the physiotherapy shoulder team at Frimley Park to be assessed to see if you would be suitable to join their shoulder classes. I have also placed you on a patient initiated follow-up for 6 months. If you feel you have not made enough progress with the physiotherapy please contact the MSK admin office on the number below to book an appointment with me.

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Emergency Admission Notification: Accident & Emergency Department Date:13 Jun 2025

CAMHS CPE Telephone Assessment Referral Source: GP, referred due to concerns with anxiety impacting mood,possible deliberate self harm and school attendance. Date: 6th June Current view: A patient called into the CAMHS urgent line on Friday the 6th June due to a deterioration over night in patient's presentation. This seems to have been triggered by a stressful interaction with a teacher in front of her peers.she simply does not cope well with being the "centre" of peoples focus making her incredibly uncomfortable. she self harmed over night and refused to go to school on the Friday. Both of them were extremely distressed during the call, so it was agreed that a triage call would be unsuccessful. CPE agreed to arrange weekend support calls and this would allow for the assessment to happen on Monday 9th.

History: x was able to explain that y has been referred to CAMHS multiple times over the years never really progressing beyond the signposting advice that CAMHS will send to parents/referrers when it is felt that early help services are an appropriate level of support.y has received support via getting help teams in 2023, this was largely focussed around her sleep hygiene which over the course of the intervention seemed to improve. y was also supported via AnDY for her vomit phobia. Speaking with y this is still present for her but as she has matured she is more rational with her phobia.y's early development was a challenge, x explained that y would bevery clingy with her throughout her younger years. y struggled with toileting until around 8 years old, y was still in nappys until that time, she would refuse to use bathrooms anywhere but home and would become very distressed. This is obviously now better, however it is also an indicator of how sensory y was from a young age and how much her feelings of anxiety were present even then. Parents view: x is understandably extremely worried about y and how distressed she becomes. It was hoped that changing schools would help y attendance, this was based on the assumption that y difficulties were the school environment, however, it is clear that y's difficulties are not environmental but her own lack of coping strategies when she is overwhelmed by her feelings of anxiety.x would like guidance and help in how to better support y at times of extreme distress which has often escalated to incidents of self harm. x herself is under investigation due to severe migraine, she in fact had a hospital appointment earlier today for injections into the back of her head. The wider family are aware of this and I'm sure there are shared concerns for x's well being.

assessment of ASC for y. Young persons View: y initially struggled with voicing to assessing clinician what her wishes were in regards to how she feels and copes when she becomes overwhelmed. However, after some gentle prompting importantly y was able to acknowledge that things need to change for her, she cannot simply continue as she is, so y would like to work with services to better understand her emotions, anxiety and how it all affects her so deeply and destructively. y was clearly upset that she had self harmed after such a long period of abstaining, it was estimated that prior to this most recent episode the last incident was July 2024. The cuts during this most recent incident were also deeper than previous times. This is likely due to y cutting with her dominant hand and blade potentially being sharper than she thought. y is not reporting any pain from the injury site and was able to explain that the blade was clean so she is not worried about infection, she is also keeping it clean.y has a very small friendship network that largely keep in touch over social media, y reported that she does not have any peer support for her difficulties and none of them are actually aware of how much she struggles. This also means that y does not have a way to decompress her feelings with peer support and things simply build up. It would also be fair to assume that due to Mums physical tests and worries y isn't wanting to add to x's stress. As mentioned however, y is now ready to engage and to understand what is happening via CAMHS support. Impact: y's functioning is now impacted to a degree that means she isn't able to socialise with her peers, she is very isolative, emotions are building up resulting in concerning outbursts and anger directed back at herself. y is not able to rationalise her anxiety and how it affects her. As a 14 year old young lady y

Through assessment, it is clear that she is a young lady that has struggled for a number of years with anxiety and how being the focus ofanything distresses her. This most recent episode was triggered by an insensitive interaction with a teacher. The school have been contacted by parent to discuss further. The school that y attends currently does not have an attached MHST service that could provide some guidance to the school regarding engaging and supporting pupils with additional emotional needs. However, I understand that the MHST services will be available to this school in the new year. y is also awaiting further assessment of suspected Autism Spectrum Condition, which is clearly going to be a consideration in any review of how y presents

Plan:Refer to patient Anxiety support services for assessment.

We are writing to you as you did not answer your phone when you had your telephone appointment with patient on 13/6/2025 . As a result, we are now discharging you back to the care of your GP. Unfortunately, we are unable to make any further appointments for you to see patient without a new request from your GP. Your fibroid is too small and on the outside of the back of your uterus and therefor won't cause any symptoms.

findings: today to a patient, i explained that i did not remove it as he was not consented for it. It would also be very painful to remove it. He understands that there is a chance that this could harbour something more sinister although it is unlikely.I have rebooked him for an examination under anaesthesia, flexible sigmoidoscopy with an enema on arrival and excision of low rectal lesion. There is a risk of infection, bleeding, pain, recurrence. We will endeavour to get this procedure done in the next couple of weeks.

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history of back problems, he had a back injury about 8 years ago had back surgery with placement of a cement in his lower back and he had occupational back problems. On examination today, both testicles feel normal he has got a palpable left sided varicocele clinically both inguinal regions are normal there is no obvious cough impulse. My impression is that it is likely to have referred pain from his lower back from nerve impingement so I have arranged for him to have an urgent MRI scan of his lumbar and sacral spine and I will do a telephone call with that result. I await the results of the ultrasound scan post embolisation for completeness.

OST Prescription issues: Happy to discuss reduction to current OST buprenorphine 2.4mg daily. Alcohol use: Reports this has increased recently to 3 x bottles 70cl whiskey daily, now drinking more on work days; risks discussed. J still sounds a little ambivalent about completing alcohol detox but adamant he wants to do so; discussed protocol/requirements for alcohol detox to commence, including up to date go summary/ LFT’s/ robust SMART post detox plan; J says he did complete LFT’s so we need these from his gp, who has requested his consent; J is going to give consent to gp to share info with us. Mental health: Denies major concerns; aware of negative impact alcohol is having. Denies current suicidal ideation/intent or self harm. Physical health: Is now bp meds for raised BP. Prescribed medications: Reports bp meds now plus usual; Abasaglar 1 00units/ml solution Thiamme 100mg tablets two tablets to be taken daily Atorvastatin 20mg tablets One To Be Taken daily Ramupril 2.5mg capsules One To Be Taken daily Citalopram 40mg tablets ONE To Be Taken ONCE Daily Ventolin 100micrograms/dose Oneprazole 20mg gastro-resistant capsules One To Be Taken Each

PLAN: OST treatment discussed in line with patient guidelmes and clients experience of OST.We agreed 0.4mg reduction to current OST buprenorphine commencing 9/7/25: 2mg daily, Skylight pharmacy , weekly collection. Continued relapse prevention with Cranstoun keyworker; working towards ambulatory alcohol detox; post detox plan to be completed asap, J will inform us when wanting to ideally commence detox; is planning a week off work for this. To attend medical review every 3 months.

Diagnoses: Flitting joint pain since 12 April 2025 - right shoulder - then right wrist - then left wrist - then left shoulder - then right knee - then DIP joint middle finger, MCPs, PIPs three days in each joint Clinic Date: 10 June 2025 Current symptoms: Morning stiffness 60 minutes Pain worse with activities of daily living Persistently rising acute phase Previous petty mild epilepsy in childhood Pleuritic chest pain 27 March 2025 No improvement in symptoms after IM Depo-Medrone No improvement in symptoms after oral prednisolone 10 mg daily Naproxen helps symptoms, to restart Serology: HLA-B27 negative, rheumatoid factor negative, anti CCP negative, ANA negative

Management: Stop prednisolone 10 mg daily. Previous IM Depo-Medrone 120 mg on 13 May 2025 no improvement in symptoms. Restart naproxen 500 bd. Restart omeprazole 20 mg daily. Start sulfasalazine 500 mg bd for one week then 1g bd and maintain that dose. Follow up: three weeks, repeat blood tests two weeks. Patient returned to see me today at Circle. She reports no improvement after IM Depo- Medrone and no improvement after oral prednisolone 10 mg daily. She tells me her symptoms were better when she was taking naproxen. She tells me she cannot walk upstairs because of pain in her hips and knees, she also has painin her neck, MCP joints of her hands, feet and elbows. She brought with her some photographs on her phone which showed bright redness over the PIP joints of her fingers.She tells me her joint pain is worse in the evening, she does not have real morning stiffness but she does have a pain score of 5/10. She has no shortness of breath, fever, sweats or systemic symptoms.On examination she has no definite synovitis in any of her joints and clinically appears well but she does describe persistent flitting joint pains which are unresponsive to steroids which is unusual.Her inflammatory markers have continued to rise although are low grade. IM Depo-Medrone and oral prednisolone have not helped but naproxen does help. I think we should restart naproxen 500 mg twice daily and stop the oral prednisolone, I have added sulfasalazine 500 mg twice daily to her treatment which Iwould like her to increase in a week to 1 g bd. I will see her back for review in three weeks with blood tests in two weeks to see if we can start to improve her inflammatory response and her symptoms. It is very unusual for inflammatory joint disease not to respond to oral prednisolone.I look forward to seeing her again shortly hopefully the switch to naproxen and sulfasalazine will help.

At the end of the consultation she mentioned that she has had irritable bowel syndrome for years and when on oral prednisolone had some looseness of stools. For that reason | have asked that we check her faecal calprotectin to exclude undiagnosed inflammatory bowel disease which will hopefully improve also with sulfasalazine. I look forward to seeing her again shortly. Overall, she did indicate she was happy with the consultation today and the decisions we have taken together. She understands i will send her a copy of her clinic letter for her information and if she has any further questions or concerns in relation to the consultation or the contents of the letter, she can contact me through my office.

The patient recently received via micro suction at our clinic on 13/06/2025

I know how the results of the E patch of patient falls. date: 13 June 2025 This shows 9 count of pauses. The longest is 2.8 sec's at 22.39 hrs Second-degree AV block -Mobitz type. Atrial fibrillation was not detected during the period of recording. patient does not have any symptoms of faints, collapses loss of consciousness or blackout att this point in time, should he experience any of the symptoms he will need a referral to cardiology.

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DIAGNOSES:Rheumatoid arthritis (seronegative, erosive) MEDICATION: Methotrexate 15 mg once weekly pen device (GP please switch back to tablet option ASAP) Folic acid 15 mg once weekly To commence Hydroxychloroquine 200 mg daily. Supplements: Tumeric Fish oil Glucosamine Vitamin C and D PREVIOUS DMARDS: Hydroxychloroquine Methotrexate subcutaneous pen device possible anaphylaxis. DAS28: 4.92 (SJC 5, TJC 10, Patient global 7, CRP 5). I reviewed this gentleman in the rheumatology clinic today. This gentleman tells me that his joint disease is not too bad at present. However he has not been able to continue with the subcutaneous methotrexate. He tells me that the 1st injection he took okay however after administering the 2nd injection he had a possible anaphylaxis reaction where his tongue swelled up quite significantly which to a degree impacted his breathing. Therefore he was seen by urgent care and was given some steroids which helps settle the situation. This gentleman had previously tolerated oral methotrexate without any significant issues other than some nausea.

impression today is that this gentleman's joint disease is mildly active. Plan 1. GP please can you add hydroxychloroquine 200 mg daily to this patient's repeat prescription list. i have provided this patient with his initial four-week prescription of this medication 2. GP please can you refer this patient for eye screening with regards to commencing hydroxychloroquine. The patient needs to be referred to healthcare Harmony. 3. GP please can you arrange to switch this gentleman back to oral methotrexate tablets, 15mg once weekly. 4. Patient to continue with regular blood test monitoring 5. Routine follow-up.

Please note that reports for non-urgent tests/scans can take up to 8 weeks to be generated. You and your GP will be informed once available. In case of blood results, we will not routinely contact you if these are normal. The administrative team will not be able to tell you your results. All rheumatology patients on disease modifying drugs (DMARDs) in the Berkshire West CCG area are monitored on the DAWN monitoring system in accordance to the agreed prescribing shared care protocol

Date 24/06/2025 Your child will be offered up to 6 appointments then your child’s care will be reviewed to consider the future plan of treatment. Appointments are usually at monthly intervals. It is vitally important that all appointments are attended for your child to gain maximum benefit from the service and course of treatment. Appointments will be offered during our usual clinic times so you may need to take your child out of school. Please allow 30 minutes for all your appointments. Missed appointments may lead to your child being discharged from our service as we will need to prioritise other children on thewaiting list. In order for our care to be most effective at our enuresis clinic, we need you to provide us with some important information before your appointment. One of our nurses will review this in order to offer the best course of treatment for your child and maximise the benefits of our service.Please complete the following attached assessments forms: If you require hard copies of any of these forms contact the school nursing office using details above. 1. Baseline chart. Please fill in daily and scan or photograph and send a copy to us by email on the Friday before your appointment. 2. Drinks chart. Drinking well and getting a good pattern of filling and emptying the bladder is a vital part of the treatment plan for your child, please follow the advice on the drinks chart regarding types of drinks, spacing throughout the day and stopping drinks 1% hours before bedtime.

Bladder capacity measurements. Please follow instructions on the baseline chart for young people and ensure this is completed before returning the form. Families services Please also read through our advice sheets. If you would prefer an online consultation we can offer an appointment via One Consultation, this is a virtual medium which will enable children and young people to fully participate in their appointment alongside their parent/carer. Children and young people will be able to see and speak directly with their clinician, enabling them to be fully involved in decision making regarding the appropriate care pathway and hear the advice being given as they would at a face-to-face appointment. If you would prefer this please contact the office and they will send you a link and instructions on how to access this virtual consultation room, it will be at the same time unless arranged otherwise. Please let us know as soon as possible if you are unable to make any appointment offered as this. If for any reason you no longer require our service, please would you inform us by email or

History: Previous severe LVSD, improved on last TTE Nov 24' LVEF 58% with small localised pericardial effusion, Previous ablation of Atrial flutter 2023. Medications: Bisoprolol, Apixaban Rhythm:Atrial fibrillation with rates seen between 80-110 bpm. Left Ventricle The left ventricle is normal in size. There is normal left ventricular wall thickness. LV systolic function appears preserved in AF with LVEF estimated 55-60% visually. No obvious reginal wall motion abnormalities. Normal LV filling pressure at rest. Right Ventricle The right ventricle is normal size. The right ventricular systolic function is normal. Atria The left atrial size is normal. Right atrial size is normal. There is no Doppler evidence for an atrial septal defect. Mitral Valve The mitral valve is normal in structure and function. There is trace mitral regurgitation. Tricuspid Valve The tricuspid valve is normal in structure and function. There is trace tricuspid regurgitation. Unable to clearly visualise the IVC. Insufficient evidence to assess probability of raised pulmonary artery pressure. Aortic Valve The aortic valve is not well visualized. The aortic valve opens well. No hemodynamically significant valvular aortic stenosis. No aortic regurgitation is present. Pulmonic Valve The pulmonic valve is not well visualized. There is no pulmonic valvular stenosis. Trace pulmonic valvular regurgitation. Great Vessels The aortic root is normal size. Non-dilated proximal ascending aorta. Normal aortic arch appearance with normal descending velocity. Pericardium/Pleural Date: 13/06/2025

There is no pericardial effusion. There is no pleural effusion. Chamber Quantification: IVSd: 0.85 cm EDV(Teich): 61.8 ml Lat E' Vel: 14.3 cm/sec LVIDd: 3.8 cm ESV(Teich): 23.8 ml Lat S Vel: 8.0 cm/sec LVIDs: 2.6 cm EF(Teich): 61.4 % Lat E/E: 4.8 LVPWd: 1.12 cm Sep E' Vel: 6.7 cm/sec LVRWT: 0.25 Sep S Vel: 4.9 cm/sec LV mass(C)d: 114.7 grams Med E/E': 10.2 LV mass(C)dI: 57.9 grams/m? avg Peak E' vel: 10.5 cm/sec avg Peak S Vel: 6.5 cm/sec avg E/E: 7.5 RVDI1 (Base): 3.3 cm LAV (MOD-BP): 54.1 ml RA ESA: 15.2 cm? TAPSE: 1.78 cm LAVi (MOD-BP): 27.3 ml/m? RA ESAi: 7.7 cm?/m? Valves: MV E max vel: 68.6 cm/sec LVOT diam: 1.93 cm PV Vmax: 67.5 cm/sec MV dec slope: 455.5 cm/sec? LVOT area: 2.9 cm? PV max PG: 1.87 mmHg MV dec time: 150.5 msec LVOT Vmax: 64.5 cm/sec LVOT Vmean: 47.5 cm/sec LVOT PGmax: 1.66 mmHg LVOT PGmean: 0.98 mmHg LVOT VTI: 10.9 cm SV(LVOT): 32.0 ml AV Vmax: 84.2 cm/sec AV Vimean: 62.7 cm/sec AV PGmax: 2.8 mmHg AV PGmean: 1.73 mmHg AVVTI: 13.4cm AV VR: 0.76 AV DVI: 0.77 AVA Vmax: 2.25 cm? AVAVTI: 2.38 cm? Other Measurements and Calculations: Ao Sinus Diam: 2.8 cm Ao Sinus Diam indexH (mm/m): 17.3 Ao Prox asc Diam: 3.1 cm Ao Prox asc Diam indexH (mm/m): 19.1 Date: 13/06/2025

Diagnosis: Corneal thinning History : phacoemulsification of cataract with implantation of intraocular lens Clinic note: it was a pleasure to see patient in clinic today. Was referred to cornea team for opinion regarding graft for right corneal opacity- last week however consultant not in - and have requested appointment again in 3 months POH- Post R phaco/CTR - |OL ( HWH - 02/07) has narrow angles and history of Pseudoexfolaition Right T and | for presumed endophthalmitis Also treated for viral keratitis. RE lateral tarsorhhaphy Prev. High pressure RE managed with IV acetazolamide

date: 13/6/2025 medication: Cosopt Pf eye drops Right eye BD Monopost once at night right eye Hycosan presevative free drops PRN both eyes Hylonight at night Celluvisc 1% every 2 hours added today Right eye Was given Acetazolamide a week ago and since IOP normal advised to stop Symptomatology: today right eye not painful however sore and phototphobic Right eye: visual acuity->10/10 Mild Corneal vascularisation 360 degrees periphery Horizontal band of Stromal opacity middle 1/3rd of cornea, thin cornea centrally A/c- quiet Very sensitive eye Left Eye: white and quiet , cataract Kindly seen with patient today.Explained the possibility of graft is there - however - corneal surface is still dry and need to be better and need anterior segment OCT to determine further. Explained detail - guarded visual prognosis as well ,Advised to continue all the drops as prescribed. Review in cornea clinic in a month. Glaucoma clinic in 6 weeks

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management/regular prescription of their anticoagulant medication. Their case notes will be reviewed by one of the haematology consultants who will advise on duration of anticoagulation; they should continue on anticoagulation until at least that time. Please continue to observe warnings and precautions, also to regularly monitor U&E, and LFTs as documented andrecommended by the manufacturer and BNF.

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This is to let you know that patient did not attend their ADHD clinic appointment with us, which was booked for 8th June 2025. Although the patient might have provided a valid reason for not attending, it is our policy that an appointment is considered a non-attendance if it is not cancelled or rescheduled with at least 48 hours notice. We will arrange another appointment, but we are unfortunately not commissioned to offer further appointments if two are missed within one episode of care. Should the patient miss another appointment, they will be discharged back to your care.

Psychiatry UK phone lines are staffed from 8am to 6pm Monday to Friday. You can alsooutside of these hours, you can leave a message on your portal. We endeavour to get backto you within five days; however, there may be delays due to the popularity of our service.

findings revealed a nodule at the caecal pole and it was unclear whether this was scar tissue or residual tumour. There were some post appendicectomy changes in the right iliac fossa but not much else. A right parietal peritonectomy was performed. The gonadal and ureter were dropped back. The right colon wasmobilised. The duodenum was dropped back. The lesser sac was entered. The greater omentum was dissected off the transverse colon. A radical greater omentectomy was performed. Some bleeding from the spleen was controlled with splenic mobilisation and Tachosil. The superior mesenteric vein was dissected out. The ileocolic, the colic vein draining in to the vein of Henley and the right branch of the middle colic were taken flush. Points of resection were chosen on the terminal ileum and the transverse colon and the bowel transected using firings of GIA 80 stapler to complete the en bloc right parietal and radical right hemicolectomy. One hour of hyperthermic intraperitoneal chemotherapy was given with Mitomycin C at 42°C. This was followed by a thorough lavage. An end-to-end hand sewn ileocolic anastomosis was performed using 3/0 PDS interrupted serosubmucosal sutures. The mesenteric window was closed. Two abdo vacs were placed in the abdomen. The midline sheath was closed using no.1 nylon. A Redivac was placed in the subcutaneous space. Skin margins were approximated using staples. patient lost approximately 500mls of blood during his surgery. He did not require any colloid, blood or blood products during the procedure. He was transferred to Intensive Care Unit following his surgery and we will let you know how he fares post operatively.

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Plan: 1. Since you are on a medication for epilepsy and this is known to increase risk of osteoporosis i would recommend your GP arrange a repeat DEXA scan in four years time. i have not booked to speak to you again in clinic.

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Plan: 1. i will refer to the IVAS unit for a three year course of intravenous zoledronic acid. 2. Please could your GP prescribe a regular calcium and vitamin D supplement - eg AdCal D3 1 BD 3. You will need a repeat DEXA scan in three years time to review your fracture risk

Please could your GP recheck your folate levels - this was low as an inpatient and replaced with only a month course of folic acid.i have not booked to speak to you again in clinic. Date: 4/6/2025

Admission date: 13/5/2025 Length of stay: 28 days Admission method: Emergency - A&E, Casualty, or Dental Casualty Department Source of admission: Usual Place of Residence Discharge Date: 11/06/25 Discharge method: Discharged On Clinical Advice Or With Clinical Consent Discharge type: Usual Place of Residence Discharging specialty: Medicine for Older People Patient was discharged on the 11th of June with catheter ,which we assumed was long term. On reviewing notes the following day appears that patient used to self catheterise pre admission but as he was drowsy on admission to FPH and unable to mobilise he had a STC inserted. This has remained in place throughout, and unfortunately he had not been TWOCced prior to discharge. i have spoken to patient over the phone, and after confirming the above, i have apologised for this. He has agreed to attend TWOC Clinic, so that he can resume self-catheterisation after this.i have now done the referral to TWOC Clinic at FPH.

Date: 13/05/25, following a fall at home with reduced GCS. On admission he was reviewed by the stroke team, who advised this was unlikely caused by a cerebrovascular event. Blood tests showed elevated inflammatory markers, CK of 3514 and a troponin of 2301. The raised troponin level was felt to be due to the long lie, and improved with intravenous fluids. A CT head was done which showed no acute intracranial pathology and a CTPA was performed due to worsening confusion which was negative for PE. His ECGs showed new atrial fibrillation, and so he has been commenced on Apixaban and bisoprolol. His blood cultures form grew beta haemolytic group strep B. A transthoracic echo showed a possible vegetation on pacing wire. Consequently, a transoesophageal echo was completed, which showed a tiny mobile mass, but not fitting with device infection. A CT abdomen pelvis was completed, which did not show an intra-abdominal cause for the infection. He was treated with intravenous antibiotics. patient also had peripheral oedema secondary to low albumin levels, and received nutritional supplements. patient also reported ongoing left upper arm and shoulder pain. A shoulder x-ray was taken which showed: Normal left glenohumeral and acromioclavicular alignment. No acute bony injury. No evidence of calcific rotator cuff tendinopathy. He was then transferred to Farnham Hospital for ongoing rehabilitation. Here has remained medically stable throughout, and has engaged well with therapy. He will be referred onto community physio for further support. We wish him all the best! Discharge Plan: You will need a follow up chest x-ray to ensure that your chest infection has resolved. This will be booked as an outpatient - please attend Frimley Park Hospital Radiology Department between 0900-7600 on the week beginning 30 June 2025. Telephone follow up with the results of the above CXR. You will be contacted by haematology to resume your next cycle of chemotherapy. Repeat blood cultures have been taken on day of discharge. If negative - nil to be actioned. You will be contacted otherwise. Medication changes: ° Started on Apixaban 5mg twice daily. ° Started on bisoprolol 2.5mg daily. ° Amiodarone stopped.

Assessment: Clean->Skin intact Cleaned genital area (including under foreskin) Date:10/06/25 Collection Container Other Securement Method Other Reason for Continuing: Urinary Urology/gynaecology/surgery Catheterization past POD 1 Fluid Balance & Device Diagnostics: Catheter Urine Output (mL) 500 mL Bladder Wash N/A Bladder Wash (NaCl only) N/A Has the catheter bag been changed?No Date of next catheter bag 15/06/25 review due (7days from this date) Management plan: District nurse referral for catheter care in the community Weight: 97.4 kg (07/06/25 11:00) Your medication list PAUSE taking these drugs

Pausetaking this medication: furosemide 40mg tablet Take ONE Wait to take this until your doctor or tablet in the other care provider tells you to start morning. again. START taking this medication: apixaban 5mg tablet Take ONE tablet twice a day. bisOProlol 1.25mg tablet Take ONE Start taking on: 12 June 2025 tablet once a day. CONTINUE taking this medication: ACICLOVIR (Generic Manuf) 200mg Take ONE dispersible tablet twice a day. Generic drug: aciclovir carbAMAzepine (TEGRETOL) 100mg Take TWO tablets once a day. Generic drug: carbAMAzepine famotidine 40mg tablet Take ONE tablet at night. FLUCONAZOLE (Generic Manuf) 50mg Take ONE capsule once a day. Generic drug: fluconazole

NITROLINGUAL 400micrograms/dose Place ONE pump sublingual spray to TWO Generic drug: glyceryl trinitrate sprays under the tongue if required for chest pain. paracetamol 500mg tablet Take TWO tablets four times a day as required for pain. STOP taking this medication amiODArone 200mg tablet aspirin 75mg dispersible tablet medications list: * ACICLOVIR (Generic Manuf) 200mg dispersible tablet * apixaban 5mg tablet * bisOProlol 1.25mg tablet * carbAMAzepine (TEGRETOL) 100mg tablet * famotidine 40mg tablet * FLUCONAZOLE (Generic Manuf) 50mg capsule * furosemide 40mg tablet * NITROLINGUAL 400micrograms/dose pump sublingual spray Information about where to get these drugs is not yet available * paracetamol 500mg tablet

Assessments: Resuscitation : For CPR Resuscitation reflects decisions made during this admission and does not replace documentation in the patient's notes or ReSPECT form. Date completed: 13/6/2025

Department Contact Details Further Discharge Support Contact Details: including directories for: Routine and Urgent Advice for clinicians (including ward contact details); all our Same Day Emergency Care Services (SDEC); and for non-urgent clinical queries there is a list of 'Medical secretary/admin support email addresses’ under the ‘Referrals &key contacts’ section.

Date: 13/06/2025 Primary Diagnosis hysteroscopy Description: Hysteroscopy (including biopsy, dilatation, +/- cauterisation, curettage and resection of polyp(s) +/- Mirena coil insertion) Additional Description Hysteroscopy + TCRP + Mirena coil insertion Clinical Summary Eat and drink as tolerated - avoid dehydration Take oral pain relief regularly 48-72 hours, even if not in pain, to avoid the onset of pain Mild bleeding is expected for few days, wear sanitary pads only. No tampons please. Mobilise regularly but have plenty of rest. No heavy lifting or doing any strenuous activities for 1-2 weeks. Shower as normal after 24 hours, no bathing or soaking for 2 weeks. Wear antiembolic stockings until fully mobile. No alcohol intake 48 hours after general anaesthetic and while on opiates to nurse in charge. We can provide: 1 .Telephone advice. 2 .Outpatient Clinic appointment for a face to face review with our resident medical officer. 3. Contact your admitting consultant for advice on how to deal with your concern or potentially book you into outpatient clinic or re-admit you to the Hospital (subject to Covid Restriction).

Arranged Advice Sheet Emergency Details VTE Prophylaxis Full Mobility Full Continence Completed by: /06/2025

| reviewed in clinic on 11/6/2025. Included below are my notes from the clinic visit as well as the patient's medication list. Clinic note: Reason for attendance: Chest Pain Patient symptoms she is a 87 y.o. old lady who was referred in by the Emergency Department (ED) at Frimley following an attendance on 18/5/25 with chest discomfort. Acute coronary syndrome was excluded with a negative troponin (14ng/) initially and then 16ng/I which is on the borders of being positive for a women. ECG showed a sinus tachycardia and right bundle branch (not on old ECGs) block and CXR report does not raise any acute concerns.

Date:18/05/2025 Diagnosis : Asthma HTN Reflux CKD stage 3 Breast lumpectomy Porphyria Cardiac history and investigations CXR result if within 2 months, Narrative Exam: XR Chest Indication: Chets apin this am feeling SOB ? caue ? LRTI Findings: Comparison made to previous radiograph dated 10/08/2024. AP erect radiograph. The lungs appear hyperinflated. No evidence of focal consolidation, pleural effusion or pneumothorax. Allowing for projection, the cardiomediastinal contour appeared to be within normal limits.

History: Lives in annex of son and daughter in laws house Independent with ADLs Mobilises with a stick Medications - did not have list with her, takes 2 tablets a day which she believes to be: Amlodipine Letrizole Inhaler when she remembers Recent course anti biotics (GP connected care.) Connected care also says prochlorperazine Examination findings: Heart sounds |+11+0 - no additional sounds, no murmur Clear breath sounds heard No ankle oedema Right leg feels warm to touch on front of shin, appears a little red., no swelling No chest wall tenderness on palpation ECG Result Clinic letter 2021 documents narrow complex - ECG not viewable

history of premature cardiovascular disease (before the age of 65) - mother had heart problems died aged 83, youngest of 6 Previous cardiovascular disease - no Smoking - Ex smoker - 3 yrs only Alcohol - very little - 4 units if that TYPICALITY OF ANGINAL CHEST PAIN NICE CG95 Constricting discomfort in the front of the chest, or in the neck, shoulder, jaw or arms: yes Precipitated by physical exertion: no Relieved by rest or GTN within about 5 minutes: no Symptoms according to NICE: Non anginal Reference NICE CG95 1.3.3.1 - Assess the typicality of chest pain as follows: Presence of three of the features above is defined as typical angina. Presence of two of the three features above is defined as atypical angina. Presence of one or none of the features above is defined as non-anginal chest pain.

history: smoking, dyslipedaemia, hypertension and diabetes Estimate the Risk Factor-weighted Clinical Likelihood (RF-CL) of obstructive CAD Sympxom score O- 1 pownt 2 pomnts 2 points ¢ Women ¢ Men r Women r Men 4 Women a Men Number of B1R348 O123 45 12-34-58 0-1 2-345 O-12-34-5 0-12-3458 430-39 GDE CLES CLS €4OQ F500 OCG Age 40-49 ES a ws ® CHS 2O@ 4@®@ 6aO Acces0-59 DDS £00 £20 @©00@ 606 266 aces @4@ ©0080 800 @CG6 G66 2682 G86 &@6 agers «6 @G 666 6086 8844 Clinical likelihoed: @ Verylow @Qlow © Moderate @ ESC ESC 2024 Guidance on Chronic coronary syndromes. Estimation of the clinical likelihood of obstructive coronary artery disease Score today 7 - low Summary described an isolated episode of chest pain which was ‘non anginal’ in character. Her risk factors for cardio-vascular disease are advanced age, hypertension and pre diabetes. . patients's clinical examination did not demonstrate any heart murmurs and chest was clear - she does have a tender, red area on the front of the leg and her ECG shows a right bundle branch block and sinus tachycardia. | have discussed her case with , looking at her ECGs, troponin results, negative BNP, observations including sats (95%) and her symptoms which have not recurred apart from some exertional breathlessness which she reports is not new or worsened. assessment and advice: *Not suggestive of an ACS. * No further chest pain suggestive of angina. * No symptomatic indication for any cardiac investigations at this time. * RBBB on ECG noted in 87 yr old with hypertension and normal heart sounds

Plan: Discharge GP recommendations i have advised patient make an appointment with you regarding redness on right leg - front of shin / redness and warm to touch. Calf does not appear swollen. Patient has HR of 95 today and 105 on ECG. Sinus tachycardia. Please consider causes of tachycardia such as infection / thyroid etc

Indication: lron deficiency anaemia PR bleeding - altered blood Findings: One 5 mm sessile Paris Is polyp in the rectum; performed cold forceps biopsy with partial piecemeal removal for sampling; injected 1.5 mL of adrenaline to address bleeding; haemostasis achieved Impression Overall Impression: a polyp just inside anal verge. Biopsy taken .

Await pathology results Staff Role: RN Endo Nurse MD Endoscopist Medications: nitrous oxide/oxygen (ENTONOX) 50%/50% gas - 1 each (Totals for administrations occurring from 15:02 to 16:01 on 08/06/25) Preprocedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered and informed consent obtained. Details of the Procedure: The patient underwent no sedation. The patient's blood pressure, heart rate, level of consciousness, oxygen and respirations were monitored throughout the procedure. A digital rectal exam was performed. A perianal exam was performed. The scope was introduced through the anus and advanced to the caecum. Retroflexion was performed in the rectum. The quality of bowel preparation was evaluated using the Boston Bowel Preparation Scale with scores of: right colon = 2, transverse colon = 2, left colon = 2. The total BBPS score was 6. Bowel prep was adequate. The patient experienced no blood loss. Clinical intention was achieved. The procedure was not difficult. There were no apparent adverse events. CANCER PATHWAY STATUS: Performance status: 0 Evidence of Cancer: No Patient informed: Yes Patient removed from fast track: Yes CNS/MDTC Informed: No. Procedure Events ENDO UPPER GI SCOPE IN TIME 8/6/2025 15:12 ENDO UPPER GI SCOPE OUT TIME 8/6/2025 15:14 ENDO SCOPE IN TIME 8/6/2025 15:20 ENDO CAECUM REACHED 8/6/2025 15:36 ENDO SCOPE OUT TIME 8/6/2025 15:58 Specimens: Type->Rectal bx, Source->Tissue (Histology) Rectum, Tests->HISTOLOGY, TISSUE ,MD , date-> 8/6/2025

Please note that these results from your recent investigation have not shown any suspicious features. i trust that this is reassuring. i am going to organise a flexible sigmoidoscopy to determine how best to remove this polyp.

They have provided their consent for us to communicate with you as their registered GP. If you are aware that any of the information that the patient has provided to us may be inaccurate, or have any concerns about their participation in programme, we would be very grateful if you would contact us on the details above so that we can discuss next steps with them. Please note that we are not asking you to provide any information unless you feel it necessary; the responsibility for treatment remains entirely with us and our prescribers. We have prescribed: Mounjaro KwikPen 5mg/0.6ml solution for injection 2.4ml pre-filled pens (Company Ltd) Quantity: 1 Directions: Once a week for 4 weeks We have given the patient the following information: Thank you for completing your refill information. Blood results: There are no new results to review since your last refill. New dose: Remain on Mounjaro 5mg due to optimal amount of weight loss. Keep up the good work! A further prescription has been issued for you.

Your medication will be delivered by our pharmacy partner who will be in touch with you shortly. Once received, please follow the directions carefully and remember to check in weekly. Wishing you continued success on your weight loss journey! Mounjaro approved. There are a few important things that you should be aware of: Weight reduction varies from patient to patient and is dependent on adhering to a nutritional diet and regular exercise. It is important for everyone to follow healthy eating advice and to try to keep cholesterol to a healthy level. You should aim to eat a healthy, balanced diet low in saturated fat and high in fibre, exercise regularly and visit the NHS Eatwell Guide for dietary tips Keep well hydrated. Mounjaro can make you dehydrated so it is important that you drink plenty of water each day. Make sure that your NHS GP is aware. We will inform your NHS GP that you are taking Mounjaro, but you should also notify them yourself. This information may be important for them when prescribing medications or providing medical care. Administering medication. You should inject your dose of Mounjaro as instructed under the skin in one of the following areas: stomach area, upper leg (thigh) or upper arm. Do not inject into a vein or muscle. Make sure to change (rotate) your injection site within the area you choose with each injection to reduce your risk of getting lumps under the skin. Do not use the same site for each injection. If you are taking other medication: * If you are a woman on oral hormonal contraceptives, you must to ensure you either switch to a non- oral contraceptive or use a barrier contraceptive (eg condoms) for 4 weeks whenever your dose is adjusted. * If you are taking medications that require blood test monitoring, be aware that Mounjaro may affect the levels. Please consult your GP to determine if more frequent blood tests are needed. * If you are using medications (such as anticonvulsants) for symptom management, monitor your symptoms closely and report any changes to your NHS GP or specialist, as you may need a dosage adjustment. When to Stop Taking Mounjaro: You should stop taking Mounjaro and inform us immediately if you: * Become unwell or dehydrated * Become pregnant * Develop pancreatitis, gastroparesis, or diabetic ketoacidosis If you are scheduled for surgery requiring general anaesthesia, you must inform the anaesthetist

problems breathing or swallowing, or severe rash or itching. You should pay attention to any mental health changes, especially sudden changes, in your mood, behaviours, thoughts, or feelings. Contact us right away if you have any mental health changes that are new, worse, Or worry you. General side effects and risks: Whilst the majority of patients tolerate Mounjaro quite well, we understand that it is crucial for you to have an understanding of the potential side effects. Below, we have provided to help you with this. Please read the Patient that comes with Mounjaro as well. Common side effects include nausea, diarrhoea, constipation, vomiting, Injection site reaction (redness), low blood sugar that can cause headache, tiredness, dizziness. You may notice some hair loss, please tell us at your next refill if it is significant. It is usually temporary and many see their hair regrowth even while on Mounjaro. Mounjaro can increase the risk of gallbladder or bile-related issues, such as gallstones. If you have had gallstones before, there is a chance they could flare up again. Mounjaro may cause gastrointestinal side effects, such as nausea or constipation, which could be more pronounced for those with pre-existing bowel conditions. Please let us know if you experience any side effects that are difficult to manage.

plan: This will mean they determine whether you need to increase your dose or stay at your current one based on what's best for you. started on any new medications (prescribed or purchased over the counter) or supplements since your last prescription: No anything changed in your medical history in the last four weeks: Nothing has changed with my medical history currently experiencing any side effects that you suspect may be a result of your medication: No past month, how many hours of sleep did you typically get per night: 7 - 9 hours past month, have you noticed any of the following sleep-related habits: Difficulty staying asleep describe your physical activity level this month: Fairly active: I've been aiming for around 150 minutes of activity each week. you noticed that you have been short of breath in completing of your daily activities over the past month: None of the above How often have you snacked between meals this month: Multiple times a day

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Today we spoke on the telephone. Your symptoms have not significantly worsened since we last spoke, but similarly have not improved either. You are still getting terrible symptoms into your right leg, which are worse with standing and walking. You have no symptoms of cauda equina syndrome at present. You have had some numbness going into the right leg. The power in your legs has not changed. You have no symptoms or features suggestive of infection, and you have inspected the wound since you came home. You have not taken the Gabapentin at present. | have explained you can take this whilst being on Amitriptyline, but you have to monitor for effects of drowsiness and CNS depression. | have encouraged you to try this to see if it would help with your symptoms. Today, we made plans to speak again next Wednesday. If your symptoms change or worsen over the weekend, | would advise you to contact Circle Hospital. You can also send messages to my email address, and these will be passed on. You are aware if you have any concerning symptoms or signs, then you should contact us immediately or present to the emergency department. | have explained today that | feel this is most likely due to swelling and potential bleeding around the surgical site, and you are at an increased risk of this as we have had to put you on Enoxaparin after the operation. | have explained | have seen this before, and it can improve with time. The alternative to waiting is to look to remove the bleeding and swelling from around the surgical site after an MRI scan. If you are not making progress over the next week, we may have to consider this, but we both would like to avoid further surgery at this stage.

This patient received an assessment by our doctors at Asda Online Doctor service on the 13/06/25 for E66.0 Obesity and a prescription for: [1 pre-filled disposable injection Mounjaro KwikPen 7.5 mg]+[6 x Needles for Pre-filled and Reusable Pen injectors 4mm/32] was issued to them. Your patient was prescribed this treatment for weight loss following an online consultation in which we established the suitability for online prescribing. Their current health including medical history, medications, allergies, BMI and previous attempts to lose weight were assessed. Our guidelines for prescribing are rigorous; though we are a private healthcare provider, we use NHS good practise guidance to ensure safe prescribing: - We follow drug SmPCs for inclusion and exclusion criteria. - We ask for photographic evidence of weight and body shape at initiation, and at regular intervals throughout their journey with us. - We ensure initiation only with a BMI 30, or 27 (Mysimba/Saxenda/Wegovy/Mounjaro) or 28 (Orlistat) with weight-related comorbidities, as per SmPC; or a BMI 27.5 if in a high risk ethnic category, as per NICE guidelines. - GP notification is mandatory for every order. We do not prescribe for anyone who does not give us their GP details. - We review the patient at 12 weeks for Orlistat, 16 weeks for Mysimba, and 17 weeks for Saxenda (as long as they have titrated to the maintenance dose of 3mg as per SmPC), to ensure they have achieved their weight loss target. - We request further photographic evidence of weight and eligibility every 3-6 months, or more frequently if they are close to our lower threshold BMI. They have been advised on how to take the medication and on potential side effects as well as health promotion advice on diet, regular exercise and when to seek medical attention. They have been encouraged to contact us should they have any questions or concerns regarding their treatment. We do not require you to take on responsibility for prescribing this treatment. The patient has opted to obtain this privately, and we will continue to assess future requests from them. Please do not hesitate to contact us if you would like further information. We encourage you to contact us should there be any reason you feel this patient should not be taking this medication, e.g. having a normal BMI or a history of an eating disorder. (For airline travel: | would kindly request that the patient named above is permitted to carry this medication in their hand luggage. There is a chance of freezing which can damage some medication if it is kept in the hold. Any other components e.g needles / syringes can be placed in hold luggage). Our online consultations include a medical assessment questionnaire specific to the patient's condition which was designed by our GMC registered Doctors. Our Doctors then review the assessment, discuss further with the patient as appropriate and ensure it is safe to prescribe within GMC and relevant national guidelines before issuing any prescription. The service was found to be Safe, Effective, Caring, Responsible and Well Led following the most recent CQC inspection.

Low Blood Pressure Symptoms of low BP Symptoms experienced considered at risk and requires same day referral:Ambulatory Blood Pressure Monitoring (if consent to ABPM is eligible) Lifestyle Discussion pt after long hot walk - remeasure in 4 week Healthy living advice:Healthy diet Lifestyle advice given:Regular physical activity Signposting & Escalation Signposted to ODS code of organisation Escalated to ODS code of organisation

management as its affecting her daily activities. if you have any further queries or concerns contact the clinic.

Date: 13/06/2025, Letter Date: 12/06/2025 Discharge Notes: received physiotherapy treatment for RT shoulder pain . The patient was discharged from Empire Physiotherapy's care on 12/06/2025 with a pain rating of 2/10 VAS. The patient achieved an overall estimated improvement of 30%. The discharge letter was issued on Thursday, 12 June 2025. attended 3 over a period of 5 weeks. The following interventions were used patient education, soft tissue manipulation, acupuncture, HEP Progress Summary: state the patient's improvement in terms of Goals, ADLs, Range of motion, pain scale PT feels better than before and able to self manage with HEP. Recommendations: It is recormmended that continue to manage with the prescribed home exercise program and physical activity to maintain and improve his/her ability to perform ADLs. It is recommended follows up with his/her primary care provider if he/she experiences any significant changes in his/her pain levels or functional abilities. if you have any further queries or concerns contact the clinic.

Date :10/06/2025 Diagnosis: Depression with psychotic symptoms, currently in Remission, Parkinsonian disorder on the recent DaTscan.

history, and the fact that he may develop suicidality that is difficult to spot, risk remains mild-moderate. His medication remain locked in the safe and administered by his support workers. Peter denied having any thoughts/plans against others. No safeguard issues identified today. he has a driving licence but he does not drive. He does not drink alcohol and he does not use illicit drugs. Increased psychomotor retardation, persecutory/nihilistic delusions with significant impact on his daily function. Alcohol/substance misuse/smoking &vaping he does not drink alcohol currently. He does not smoke and he does not use illicit drugs. Reported Allergies: None recorded on RiO. Review: As per neurology advice: "Although Parkinson's medication may help his speed of movement and his tremor, there may also impact on his cognition making him more muddled, and the relative benefits of the Parkinson's medications need to be carefully considered in the light of his psychiatric condition. If cognitive symptoms develop, they are not thought to be due to his mood or psychiatric medication, he may benefit from an acetylcholinesterase inhibitor such as donepezil or rivastigmine (either tablet form or patches)." 1. Vortioxetine 20mg OM 2. Mirtazapine 45mg ON 3. Aripiprazole 20mg OM 4. Lercanidipine 10mg OD 5. Tamsulosin M/R 400mcg OM 6. Ramipril 10mg OM 7. Finasteride 5mg OM 8. Atorvastatin 20mg ON 9. Lansoprazole 30mg OM Agreed medication changes after review: No changes to his current psychotropic medications. | would be grateful if you could prescribe Zopiclone 7.5mg ON for his insomnia.

he had capacity for therapeutic decisions today. Weagreed to the following plan: 1. he will continue with his current psychotropicmedications without changes. We agreed that he willtry Zopiclone 7.5mg ON for his insomnia. 2. Briege will continue supporting Peter in the community. 3. him to continue engaging with his community activities, including the Parkinson's UK neuro walking football group. 4. | will review him in October (or earlier if required) and | will update you on his progress. 5. |am sure you will continue monitoring his physical health as per protocol for patients on antipsychotics. 6. In the meantime, Peter and his family have psychiatry, CMHT/CRHTT numbers and will use them if required. Physical Health/Investigations Physical health problems include hypertension, prostate hypertrophy, bladder cancer (surgically treated in July 2020 after successfully removing the tumour - no need for chemotherapy). Last recorded BMI (May 2024) was 26.78 kg/m2). Last TSH (May 2024) 1.26 mlU/L. Low 25-OH vitamin D 14nmol/L (he had replacement treatment for this). Has Patient been discharged: No.

assessment and is happy to continue with the current treatment plan. We also agreed to meet again sometime in October and review his progress.

MSE: On mental state examination today, was casually dressed, appropriately for the weather. Clean but not kempt. No abnormal behaviours in the room. Good eye contact. Hypomimia. No resting tremor. He participated well to our discussion. Speech had low volume, reduced quantity but was not depressed. He denied feeling depressed. His affect was euthymic and reactive at times. No evidence of delusions or thought disorder. No night hallucinations reported today. Oriented in time, place and person. His insight was present. We believe mutual respect between our staff and our patients is important. We will always aim to be polite, and kind and we ask that you treat our staff in the same way. Sadly, cases of abuse have been increasing against our staff and we will now take strong action against anyone who is verbally, racially, or physically abusive to them. This may include contacting the police and stopping future appointments.

assessment your patient disclosed she was "binge eating", which could pose a risk to her physical health due to her bariatric surgery. The patient has been advised that we will be updating you with this information and has been encouraged to speak to you directly, with regards to the risk such actions pose to herself.

Here are the details of your telephone appointment. The purpose of this appointment is to give you more information about the SilverCloud programme and guide you through the next relevant modules. We look forward to speaking with you. Date: Tuesday 24th June 2025 Time: 1:00 pm Location: Telephone What is SilverCloud SilverCloud is an evidence-based, online programme that will help to teach you techniques based on Cognitive Behavioural Therapy (CBT). It is an interactive programme with many activities to complete to help you to improve your mood. The programme is also very flexible; we can make sure that it fits in well with your lifestyle. What happens next You will receive an email directly from SilverCloud within the next few days with a link to sign up to the programme. This email may go into your junk folder so please check here. What you can do now @ Sign up and familiarise yourself with SilverCloud before the appointment so that we can answer any questions you have during the session. @ Complete the first two modules so that you’re able to get the most from your appointment. @ Complete your health questionnaires within 1-2 days of your scheduled appointment.

The tools you will learn are based on Cognitive Behavioural Therapy (CBT). Your treatment about what to expect from your treatment with us Although you can leave messages on SilverCloud, we are unable to see these until the day of your appointment. Monday to Thursday, 8am-8pm, and Fridays, 8am-5pm. Unfortunately, we may need to close your referral if you don’t attend without letting us know first or if you repeatedly give us less than two working days’ notice. Please note we cannot make calls for sessions outside of the UK, so please let your therapist know if you will be abroad at any point so we can work around this. At any point in your treatment journey you can share anonymous feedback with us here Get urgent help: Sometimes it can be common to notice an increase in symptoms, including agitation and distressing thoughts.

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Diagnosis: Prostate cancer care review done Clinic note: Background: Known case of low risk prostate cancer 2013 Recent PSA : 9.3 ng/ml June 2025 No recent changes in LUTS No bony pain Plan: Repeat PSA in six months Telephone clinic review with the results | had a telephone consultation with today and my notes and plan are as above.

Date: 13/6/2025, Urology

assessment and treatment. Should you have any questions regarding your discharge or require any further information, please do not hesitateto contact us.

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impression: PFO with no haemodymic impact. No feature of pulmonary hypertension. As advised earlier she needs to work on her weight reduction. There is no long-term Cardiology follow-up needed. |will offer her reassurance from our end.

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Diagnosis: Kidney stone Assessment: BIBA due to Rt lower abdominal pain upon waking up this morning and continues when he came to work today. No rebound tenderness. Had a previous hx of coughing up bloods. MORPHINE MAKES PT. SICK SO BADLY. Requested Actions for GP: Moved to CDU CTKUB report pending Investigations: FBC, Zone, COAG, INR, AMY, CRP, LFT, UE, No Investigations

Date:13/06/2025 Outcome: Admitted Destination: CDU Follow Up: General Practitioner TTA Medication:No relevant medication details Treatments: Verbal advice, Written advice, Medications Administered to the Patient whilst in ED: Medication Dose Route codeine 60 mg oral diclofenac (diclofenac sodium 400 m rectal suppository) g Sodium Chloride 0.9% intravenous infusion 1000 mL IV Results:Laboratory or Other Results This Visit (last charted value for your 13/06/2025 visit) Blood Sciences Anion gap level POC, blood: 5.9 mmol/L Sample type POC, blood: Venous blood Glucose level POC, blood: 5.6 mmol/L -- Normal range between ( 3.9 and 5.8 ) Chloride level POC, blood: 104 mmol/L -- Normal range between ( 95 and 108 ) lonised calcium level POC, blood: 1.19 mmol/L -- Normal range between ( 1.15 and 1.29 ) O2 Saturation level POC, blood: 56.9 % -- Normal range between ( 95.0 and 99.0 ) pCO2 level POC, blood: 6.4 kPa -- Normal range between ( 4.67 and 6.40 ) pO2 level POC, blood: 4.1 kPa -- Normal range between ( 11.1 and 14.4 )

Date: 13/06/2025 Lactate level POC, blood: 1.3 mmol/L -- Normal range between ( 0.5 and 1.6 ) Potassium level POC, blood: 4.8 mmol/L -- Normal rangebetween ( 3.5 and 5.3 ) Sodium level POC, blood: 138 mmol/L -- Normal range between ( 133 and 146 ) FiO2 level POC: 21.0 % pH (POCT) level, blood: 7.388 -- Normal range between ( 7.350 and 7.450 ) Carboxyhaemoglobin level POC, blood: 1.7 % -- Normal rangebetween ( 0.5 and 1.5 ) Oxyhaemoglobin level POC, blood: 55.5 % Bilirubin total level POC, blood: 0 umol/L -- Normal range between ( 0 and 20 ) Deoxyhaemoglobin level POC, blood: 42.1 % Methaemoglobin level POC, blood: 0.7 % -- Normal range between ( 0.0 and 1.5 ) Haemoglobin level POC, blood: 156 g/L -- Normal range between ( 135 and 180 ) Ward Operator ID: 92727 ABL9O FLEX Plus TH ACC Ward Haematocrit level, blood: 47.7 % Patient temp POC, data: 37.0 cBase (Ecf)c level POC, blood: 3.8 mmol/L cHCO3-(P,st)c level POC, blood: 25.8 mmol/L White blood cell count, blood: 6.6 x10“9/L -- Normal range between ( 4.2 and 10.6 ) Alanine aminotransferase level, blood: 22 unit/L -- Normal range between (0 and 45 ) Albumin level, blood: 45 g/L -- Normal range between ( 35 and 50 ) Alk phos level, blood: 91 unit/L -- Normal range between ( 30 and 130 ) Amylase level, blood: 59 unit/L -- Normal range between ( 0 and 100 ) APTT, blood: 32.5 second(s) -- Normal range between ( 23.9 and 35.5 ) Basophil count, blood: 0.1 x10*9/L -- Normal range between ( 0.0 and 0.2 ) Chloride level, blood: 106 mmol/L -- Normal range between ( 95 and 108 ) C-reactive protein level, blood: 2.3 mg/L -- Normal range between ( 0.0 and 5.0 ) Creatinine level, blood: 115 umol/L -- Normal range between ( 64 and 104 ) Eosinophil count, blood: 0.1 x10*9/L -- Normal range between ( 0.0 and 0.5 ) Fibrinogen level, blood: 3.71 g/L -- Normal range between ( 1.90 and 4.30 ) Haematocrit level, blood: 0.440 L/L -- Normal range between ( 0.390 and 0.500 ) Haemoglobin: 148 g/L -- Normal range between ( 130 and 168 ) Lymphocyte count, blood: 1.1 x10*9/L -- Normal range between ( 1.1 and 3.6 ) Mean cell haemoglobin conc, blood: 337 g/L -- Normal range between ( 315 and 350 ) Mean cell haemoglobin level, blood: 29.2 pg -- Normal range between ( 27.5 and 33.1 ) Mean cell volume, blood: 86.7 fL -- Normal range between ( 83.5 and 99.5 ) Mean platelet volume, blood: 9.9 fL -- Normal range between ( 8.0 and 12.0 ) Monocyte count, blood: 0.5 x10“9/L -- Normal range between ( 0.3 and 0.9 ) Neutrophil count, blood: 4.9 x10*9/L -- Normal range between ( 2.0 and 7.1 ) Nucleated red blood cell count, blood: 0.2 x10*9/L -- Normal range between ( 0.0 and 0.1 ) Platelet count, blood: 333 x10‘9/L -- Normal range between ( 130 and 370 ) Potassium level, blood: 4.9 mmol/L -- Normal range between ( 3.5 and 5.3 ) INR, blood: 1.0 ratio

Prothrombin time, blood: 13.8 second(s) -- Normal rangebetween ( 12.8 and 17.4 ) Red blood cell count, blood: 5.07 x10*12/L -- Normal rangebetween ( 4.23 and 5.46 ) Red blood cell distribution width: 12.7 % -- Normal rangebetween ( 10.0 and 16.0 ) Sodium level, blood: 139 mmol/L -- Normal range between ( 133 and 146 ) Total bilirubin level, blood: 11 umol/L -- Normal range between ( 0 and 21 ) Urea level, blood: 6.8 mmol/L -- Normal range between ( 2.5 and 7.8 ) Estimated GFR CKD EPI: 65 ml/min/1.73m2 Final Emergency Department Discharge Summary

Diagnosis SNOMED CT(R) * Epilepsy Epilepsy * Tonic-clonic epilepsy Tonic-clonic epilepsy * Seizure Seizure * Psychologic conversion disorder Psychologic conversion disorder Medication: * Lamotrigine 250mg twice daily to continue. * Perampanel 2mg tablets - 2mg (1 tablet) at night for 2 weeks, then 4mg (2 tablets) at night to continue. * Ethosuxamide 250mg capsules 500mg twice daily to wean over 8 weeks (reduce by 250mg every 2 weeks) once stable on Perampanel. Rescue medication: If has >1 generalised tonic clonic seizure in 24h - Clobazam increased to 7.5mg twice daily for 3 days Midazolam prefilled syringe for prolonged GTCS Please could you provide and her Mother with Clobazam liquid (5mg/5mls)- 7.5mg dose to be used as rescue as above.

Date:11/6/2025 Paediatric Specialist Epilepsy Nurse

diagnosis of EUPD. Routine GP referral requesting medication advise. On mirtazapine 30mg, duloxetine 120mg and quetiapine 50mg AM, 25mg Lunch and 300mg PM. Lots of social stressors, recent divorce and several bereavements. Physical health conditions and high BMI , on complex medication regime.

Active Problems: Depression 28/03/2025 Police domestic incident report received 07/02/2025 Pre-diabetes 06/12/2024 Chronic liver disease 26/06/2024 Chronic liver disease (Decompensated, alcoholic hepatitis) 09/06/2024 Chronic low back pain 11/12/2023 Opioid medication review 02/02/2022 Barrett's oesophagus (GASTROSCOPY RE,PORT Barrett's mucosa) 24/11/2021 Low back pain (Disc degeneration at L4/L5 and L5/S1 levels. Degenerative changes in the upperplate of 51 and mild

assessment (Common Point of Entry Mental Health Services) 04/09/2018 Therapeutic lumbar epidural injection (lumbar epidural in October last year) 11/04/2018 Barrett's oesophagus 13/04/2017 Obstructive sleep apnoea ((Grouped with Obstructive sleep apnoea)) 26/08/2016 Essential hypertension (PRIORITY=1) 08/12/2015 Discharge summary (Mixed overdose PRIORITY=1) 17/08/2015 Discharge summary ((Grouped with Discharge summary)) 17/08/2015 Depressed (- depression - he does not fulfil the criteria for the diagnosis of Bipolar Affective Disorder - reduce Fluoxetine at the rate of 20mg every 2 weeks with a view to discontinue PRIORITY=1) 12/03/2014 Low back pain (numbness around back apssage & reduced anal tone ? cuada equina PRIORITY=1) 31/12/2012 Low back pain ((Grouped with Low back pain)) 31/12/2012 Bipolar psychoses 01/10/2012 Chest pain 30/11/2010 Plantar fasciitis 18/07/2010 Knee pain 08/03/2010 Obesity 08/03/2010 Vasectomy NEC 27/02/2008 Non-alcoholic fatty liver 08/08/2006 Mixed hyperlipidaemia 04/07/2006 Current Repeat Medications: Buprenorphine 10 micrograms / hour transdermal patches Apply One Patch Each Week As

patient will follow up OT report as awaiting for adjustment (Bath) GP kindly review Pregabalin dose, noted reduction of dose impacting on sleep, mobility, pain in feet and mood. Requesting increase to 150mg TDS. Previously on 150mg BD, requires dose in afternoon. Please refer to Podiatrist for foot pain and pain clinic.

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Diagnosis: Hydronephrosis - Bilateral antenatally - resolved on scan on day 3 Exam: US Abdomen and Pelvis indication: BL antenatal renal dilatation in a male baby, needs urgent post natal scan, call extention 139340 when radiology team is ready for baby.

Normal sonographic appearances of both kidneys with no hydronephrosis. The left kidney measures maximaily 5.6 cm in bipolar dimension with a maximal renal pelvic AP dimension of 0.2 cm.The right kidney measures maximally 5.4cm in bipolar dimension, also with a maximal renal pelvic AP dimension of 0.2cm. Normal urinary bladder. MRCS GMC [ID] Visit Vital Signs: BP ()) 106/65 Ht 72.5cm Wt 8.46 kg BMI 16.10 kg/m? BSA 0.41 m? Distressed during BP Notes: he attended clinic today with his Mum. He is now 6 months of age and was found to have antenatal bilateral hydronephrosis at birth. He was scanned within 3 days of birth and this was entirely normal with no evidence of hydronephrosis. Mum reports that he is doing really well and developing normally. There have been no concerns about urinary tract infections and he has a good stream. | have explained to parents that as the subsequent ultrasound scan was normal we would not expect this to recur or redevelop. Likewise as there is now no hydronephrosis he should not be at an increased risk of urinary tract infections. his examination was unremarkable. His blood pressure was a little on the generous side however he was becoming fractious in the clinic prior to this being done. he has been discharged from clinic.

If your child's consultant has requested blood tests within a certain time frame, please ensure you have booked in good time as we are unable to take bookings over the phone and you will be redirected to book online and there will be extended wait time due to capacity. Please note that blood tests are held in the Children's Ambulatory Care & Outpatient Unit (CACOU), Entrance B and is only for children aged 10 years and below; exceptions apply for those children with additional needs. if your child is over 10 years, they will need to attend the blood test clinic near Main Reception. There are a few things to know before bringing a child for a blood test - please read the FAQ's when booking. support healthcare professionals — which means that your child is likely to receive consistently high- quality care, irrespective of which healthcare professional they see.

Record allows parents/guardians with parental responsibility to access the child's records if the child is under 16. This will give them proxy access. Proxy access enables a parent, family member, or carer etc. to act on behalf of the patient when using Record. For more information on how to gain proxy access please follow the link above. Date: 11/6/2025

Date:12 June 2025 A safety plan can help us through difficult times. Whilst staying safe, it is good to plan ahead even if we are feeling fine at the moment. Areas of Focus Warning signs of a crisis(e.g what | have noticed happens before, triggers, and situations that cause me concern) Actions -What i and others will do (use words or pictures/symbols) to keep my environment safe in relation to each area of focus. what works for me or distracts me, how can | make use of social connections (who, what, where, when outside of myself), things | need to remove to keep myself or others safe (e.g. disposing of tablets/sharps)

management when in crisis: Building social engagement. Reduce and discontinue cannabis use. Structure to his day. Engage with Recovery college and Sport in Mind. Has info and will self refer. Gym and walks regularly. My Strengths: Good sense of humour. Wants to change and have a better future. Leo identifies his family, mum, dad and brother as his protective factors. Spending time with my dog

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Diagnosis: B-cell chronic lymphocytic leukaemia Clinic note: Problem List Items Addressed This Visit Overview: CLL - Active monitoring - Bicytopenia Atrial Flutter - treated with successful ablation. impaired LV systolic function — EF 45-50% CT neck chest abdomen and pelvis January 22-lymphadenopathy above and below diaphragm with splenic and liver involvement. Spleen 18 cm. Bone marrow aspirate-> than 80% small lymphocytes Bone marrow immunophenotyping-88% clonal B cells with CLL phenotype

Date: 09/06/2025 plan - Acalabrutinib - Commenced once daily Feb ‘23. Increase to BD March '23. CT Nov '23: Conclusion: There is been a good response to treatment with reduction in size of the previously enlarged lymph nodes above and below the diaphragm, splenomegaly and liver lesion. 19.03.25 ECOG PS 1 Patient Diagnosis * B-cell chronic lymphocytic leukaemia * Chronic mucoid otitis media Current Outpatient Medication * ACICLOVIR (Generic Manuf) 200 mg, Oral, 3 times daily * CALQUENCE 100 mg, Oral, 2 times daily * dapagliflozin 10 mg, Oral * eplerenone 25 mg, Oral, Daily * RAMipril 3.75 mg, Oral, Daily * simvastatin 20 mg, Oral, Nightly Lab Test Results Component: HGB 127 () PLT 158 WBC 6.6 NEUTROABS 4.1 CREATININE 150 (H) EGFR 36 (L) CALCIUM 2.29 PHOS 1.03 K 47 ALKPHOS 60 ALT 23 BILITOT 7 LDH 181 HCT 0.402 it was a pleasure to speak to over the phone today.

He has been doing generally well since we last met reporting no significant issues including infections requiring antibiotics. He denies any B symptoms. He is tolerating acalabrutinib well with no significant side effects and his blood results show good control of the CLL on the current dose. As has 1 month's supply of his medication at home, | will issue another 2 months prescription and schedule a further review over the telephone in August. knows to contact us, should he have any concerns between now and his next review | would be grateful if can use the QR code below to provide any feedback on the pharmacist led haematology clinics. FHFT haematology PLEASE HAVE BLOODS DONE PRIOR TO NEXT APPOINTMENT, IF THIS SHOULD BE WITH THE GP THEN PLEASE CONTACT US FOR THE FORMS. For patients on active chemotherapy, please use the 24 hour chemo hotline number on the Haematology CNS contact card. need your NHS number which is on the top of this letter and please leave a message. if you do not receive an appointment in the timescale you are expecting, please contact our secretaries on the numbers above Blood tests - please book an appointment in advance

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Diagnosis Thrombocytopaenia Platelet count 30-40 x 10 9/I Treatment nalive R90 Panel Heterozygous for c.229C>T, p(Arg77*) nonsense variant TUBB1 Thank you for reviewing the above pleasant 51 yo who is known to us with longstanding thrombocytopaenia.a Her platelet count has been between 30-40 x 10 9/1. It was thought she had Chronic ITP and has never required treatment, bleeding or procedures requiring a higher platelet count. She does travel frequently due to her job. She has no children and her two sisters have a history of thrombocytopaenia during pregnancy. Her younger sister did require platelets during pregnancy. She only takes Tranexamic acid during her periods but she has not had a period for more than 6 months. She does report easy bruising and no bleeding. Find enclosed a copy of the R90 panel result.

Date:10/6/2025 Range & Units Haemoglobin 115-1659/L 136 WBC 4-11 10*9/L 4.1 Platelets 750 - 450 10*9/L 30 (L) RBC 3.5 -5.5 10*12/L 3.97 Hematocrit 0.37 - 0.47 Ratio 0.401 MCV 75-105 fL 101.0 MCH 26 - 35 pg 34.3 MCHC 290-350g/L 340 RDW 11-15% 11.5 MPV 8.2-17.9 FL 15.1 (H) Neutrophils Absolute 2-7510*9/L 24 Lymphocytes Absolute 1-4 10*9/L 1.3 Eosinophils Absolute 0-0410*9/L 0.0 Monocytes Absolute 0.2-0.8 10*9/L 04 Basophils Absolute O- 0.1 10*9/L 0.0 Hypochromia % 0.3

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Management Programme. They have provided their consent for us to communicate with you as their registered GP. If you are aware that any of the information that the patient has provided to us may be inaccurate, or have any concerns about their participation in programme, we would be very grateful if you would contact us on the details above so that we can discuss next steps with them. Please note that we are not asking you to provide any information unless you feel it necessary; the responsibility for treatment remains entirely with us and our prescribers. We have prescribed: *Mounjaro KwikPen 5mg/0.6ml solution for injection 2.4ml pre-filled pens (Company Ltd) Quantity: 1 Directions: Once a week for 4 weeks New dose: Increase to Mounjaro 5mg A further prescription has been issued for you. If you have any questions about your dosing schedule,

Your medication will be delivered by our pharmacy partner who will be in touch with you shortly. Once received, please follow the directions carefully and remember to check in weekly. Wishing you continued success on your weight loss journey! Mounjaro approved. There are a few important things that you should be aware of: Weight reduction varies from patient to patient and is dependent on adhering to a nutritional diet and regular exercise. It is important for everyone to follow healthy eating advice and to try to keep cholesterol to a healthy level. You should aim to eat a healthy, balanced diet low in saturated fat and high in fibre, exercise regularly Keep well hydrated. Mounjaro can make you dehydrated so it is important that you drink plenty of water each day. Make sure that your NHS GP is aware. We will inform your NHS GP that you are taking Mounjaro, but you should also notify them yourself. This information may be important for them when prescribing medications or providing medical care. Administering medication. You should inject your dose of Mounjaro as instructed under the skin in one of the following areas: stomach area, upper leg (thigh) or upper arm. Do not inject into a vein or muscle. Make sure to change (rotate) your injection site within the area you choose with each injection to reduce your risk of getting lumps under the skin. Do not use the same site for each injection. If you are taking other medication: * If you are a woman on oral hormonal contraceptives, you must to ensure you either switch to a non- oral contraceptive or use a barrier contraceptive (eg condoms) for 4 weeks whenever your dose is adjusted. * If you are taking medications that require blood test monitoring, be aware that Mounjaro may affect the levels. Please consult your GP to determine if more frequent blood tests are needed. * If you are using medications (such as anticonvulsants) for symptom management, monitor your symptoms closely and report any changes to your NHS GP or specialist, as you may need a dosage adjustment. When to Stop Taking Mounjaro: You should stop taking Mounjaro and inform us immediately if you: * Become unwell or dehydrated * Become pregnant * Develop pancreatitis, gastroparesis, or diabetic ketoacidosis If you are scheduled for surgery requiring general anaesthesia, you must inform the anaesthetist, as they

problems breathing or swallowing, or severe rash or itching. *You should pay attention to any mental health changes, especially sudden changes, in your mood, behaviours, thoughts, or feelings. Contact us right away if you have any mental health changes that are new, worse, Or worry you. General side effects and risks: Whilst the majority of patients tolerate Mounjaro quite well, we understand that it is crucial for you to have an understanding of the potential side effects. Below, we have provided to help you with this. Please read the Patient that comes with Mounjaro as well. Common side effects include nausea, diarrhoea, constipation, vomiting, Injection site reaction (redness), low blood sugar that can cause headache, tiredness, dizziness. You may notice some hair loss, please tell us at your next refill if it is significant. It is usually temporary and many see their hair regrowth even while on Mounjaro. Mounjaro can increase the risk of gallbladder or bile-related issues, such as gallstones. If you have had gallstones before, there is a chance they could flare up again. Mounjaro may cause gastrointestinal side effects, such as nausea or constipation, which could be more pronounced for those with pre-existing bowel conditions. Please let us know if you experience any side effects that are difficult to manage.

plan: This will mean they determine whether you need to increase your dose or stay at your current one based on what's best for you. Have you started on any new medications (prescribed or purchased over the counter) or supplements since your last prescription: No Has anything changed in your medical history in the last four weeks: Nothing has changed with my medical history Are you currently experiencing any side effects that you suspect may be a result of your medication: No In the past month, how many hours of sleep did you typically get per night: 7 - 9 hours In the past month, have you noticed any of the following sleep-related habits:None of the above How would you describe your physical activity level this month: Just getting started: | haven't done much physical activity, but I'm still working on it. Have you noticed that you have been short of breath in completing of your daily activities over the past month: Bending down (To put on socks or shoes, pick up something off the floor)Carrying objects (Carrying your groceries or laundry) How often have you snacked between meals this month: Once a day

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Admission method: Emergency - A&E, Casualty, or Dental Casualty Department Source of admission: Usual Place of Residence Discharge Date: 13/06/2025 Discharge Time: Early Afternoon Discharge method: Discharged On Clinical Advice Discharging specialty: Paediatrics Or With Clinical Consent Discharge type: Home Discharge location: FPH F01 Discharge Summary completed by:(Foundation Doctor) Discharge from Ward F1

Diagnosis: 1. Suicidal ldeation 2. Low Mood Hospital Course Dear you for your continued care of this patient.He was admitted to Hospital on 12/06/2025 with suicidal ideation and low mood. She examined normally with normal observations. She was noted to have a background of ongoing headaches with no red flag symptoms. She was reviewed by the CAHMs team who have deemed her medically fit for discharge with a safety plan completed and plan in place in the community. We wish her all the best in her recovery! Discharge Plan As per CAHMs plan- rapid response to make contact and to continue with youth line counselling every Saturday Were there any medication changes during admission? No Issues requiring GP action: GP to kindly review headache and consider whether to start propanolol for tension headaches. Patient to also see optician. you! Safety-netting given: verbally given

Assessments: Pain Score: None (0/3) Resuscitation reflects decisions made during this admission and does not replace documentation in the patient's notes or ReSPECT form. Distribution List:Guardian of PRACTICE Date completed: 13/6/2025

Future Resources for families, patients and professionals information on childhood illnesses for families and professionals. This includes advice on warning signs to look out for, where to seek help if required, what you should do to keep your child comfortable, and how long your child’s symptoms are likely to last. Further Discharge Support Contact Details: including directories for: Routine and Urgent Advice for clinicians (including ward contact details); all our Same Day Emergency Care Services (SDEC); and for non-urgent clinical queries there is a list of 'Medical secretary/admin support email addresses’ under the 'Referrals & key contacts’ section.

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assessment because she struggled with the CBT part of her previous DBT sessions. Told me that DBT did not work so she was apprehensive about the CBT offer. She went to Sandhurst counselling as advised but they turned her down because her case was complex. This year she self-referred to avail the previous CBT "exposure type therapy" offer as she wants to live her life "a bit better". Reported that her OCD is ruining her and husband's life, she feels that her "cage is getting smaller" and she does not Know what else to do. She gave me a WORD document (containing her and husband’s views) and consented or this to be shared to the team. Summary Outcome of MDT Review: Refer to CMHPT for CBT offer. (discussed with client and made aware that there is a waiting time) Safety Plan: 1. How will i and others recognise warning signs: becomes anxious/feels chest tightens/ increase heart rate/ tearful/ quiet/ not feeling good which comes out of nowhere 2. Distraction techniques: ocus on breathing so her breathing will be under control/ playing games on phone talking to husband / doing house chores/ TIPP skills 3. How can! make best use of social connections: husband is the only one who sees her currently, she avoids going out as much as possible to avoid contamination of germs that she can pass on to husband. 4. Who can! contact: Will tell husband who can call emergency services. Danica does not want to call ambulance service as she avoids being near to other people. 5. Things | need to remove to keep myself and others safe: Husband purchased a safe to store tablets and has gone around the house to look for hidden medications to take them away. (however, husband can’t stop her getting hold of tablets) 6. Protective factors are: Supportive husband 7. Strengths:

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Diagnosis: Closed fracture of shoulder Clinic note: Fellow (Trauma & Orthopaedics) Verbal consent obtained for discussion and examination Option of chaperone provided to patient Proximal humerus fracture date of injury 22nd June 2024 Outcome: Discharged to patient initiated follow-up

history of having fallen over onto his left shoulder following which he suffered a proximal humerus fracture at the surgical neck. This was managed conservatively and earlier this year a CT scan was undertaken in order to assess the progress of healing. A fresh x-ray has been done at his visit today. On examination, he has range of motion of 120 degrees abduction, 120 degrees of forward flexion. Near complete range of external rotation, and on internal rotation can lay the dorsum of his palm onto T12. There is no evidence of adhesive capsulitis at the moment. He remains neurovascularly intact. in light of the clinical and radiological recovery as detailed in the letter above, we are happy to discharge this patient to patient initiated follow-up for a period of 6 months. In case the patient needs to see us during this time, an appointment can be arranged telephonically by the patient. in case the patient does not require this appointment in the coming 6 months, they may be safely discharged back to the care of their GP practice.

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Type 1 diabetes 1997 Last HbA1c 41 mmol/mol April 2025 DAFNE course attended 2022 FSL2 in use Blood pressure in target range June 2025 Creat 61 eGFR >90 April 2025 Last ACR normal (1.3) in April 2025 Chol 4.6, HDL 1.62, non HDL Chol 3, Chol:HDL 2.8 BDR February 2025 Foot examination normal April 2025 FSL readout last 14 days June 2025: Time in range 86% High 10%, very high 2%, <3.9 2% 6 low glucose events in last 14 days Sensor low alarm is set to 3.9

Plan: Will call us in December 2025 to discuss a switch from Levemir to Toujeo in advance of the discontinuation of Levemir in 2026. Would consider future HCL pump use. Next appointment-12 months.

Diagnosis: Obsessive Compulsive Disorder. Separation Anxiety.

Risk to Self:patient reported no historic or current self-harming behaviours, no suicidal thoughts, intention or plans. Risk to others: patient reported she has not hurt anyone, she sometimes thoughts about hurting others when annoyed but has never acted upon it and has no plans to do so. Risk from others: patient reported she has never felt threatened by anyone, she has not experienced any form of bullying, although reported some occasional misunderstandings within friendships. patient does not use social media at all. No involvement with social care historic or current. Clinical Summary | am writing to let you know that patient has completed her course of Cognitive Behaviour Therapy (CBT), at the Berkshire Child and Adolescent Mental Health Service (CAMHS). | worked with patient for 22 sessions and we had regular review sessions; 30" January; 25" February; 29" April and 10" June 2025. Throughout the therapy we focussed on CBT models for OCD and transdiagnostic anxiety model. patient identified 3 main goals that she wanted to work towards; 1. To boss OCD back a bit (initially 3/10) now 8.5/10 reports getting better at this and feeling proud 2. To know what to do when in fight or flight situation - (initially7.5/10) now 8.5/10 using techniques more, including calming activities like listening to music and drawing. 3. To know how to control OCD and forget about those thoughts - (initially 2.5/10) now 5.5/10 - resisting and delaying compulsions, recognised anxiety and thoughts go over time. Intervention The initial psycho-education session was about the symptoms of anxiety and how it personally affected her thoughts, body responses, feelings and behaviour. she was introduced to the idea that the way she thinks affects the way she feels and that the things that she does affects how she thinks and feels. patient used a step-by-step approach to overcome her fears of situations which caused her anxiety. This involved identifying thoughts, behaviours or situations that caused distress, rating these according to intensity and completing experiments to reduce the level of intensity and provide evidence to challenge negative thinking. patient was able to use a problem-solving technique which she put into practice with some problems she had faced, such as increased anxiety and stress in the morning before school. patient was able to produce numerous solutions to this problem including; using visual prompts for tasks, organising the night before and positive self-talk. patient was also able to learn from her experiences of facing her anxiety to help her think calmer, more balanced thoughts about the problems she faced, such as when riding her bike, and when facing future anxiety- provoking situations.

patient was confident that she would be able to recognise the symptoms in herself if she was beginning to relapse, and understands this is normal, (e.g. increase of physical symptoms of anxiety or avoiding situations) and said she would try to seek support by speaking to Mum or trusted adults in school as well as referring to her Relapse Prevention Plan if she noticed a deterioration.

I have informed the family that is now discharged from CAMHS Anxiety Disorders Treatment Team, but to visit her GP again and ask for a referral to CAMHS if her symptoms should deteriorate again, significantly impacting her daily functioning. has put in a lot of hard work while coming to CAMHS and I hope she is really pleased with the progress that she has made. I wish all the best for the future, and hope she continues to be her amazing creative self.

Diagnosis: Single pregnancy H/O: emergency caesarean section Clinic note: 32yr, P2, 244+5 P2 — LSCS 2021 and 2023. GDM in both pregnancies BMI 25.64 BP 111/71. No urine Last Hb 113

OB History: Gravida 4 Para 2 Preterm 0 Term 2 ss: Miscarriages Outcome: Len/2nd GA :37w 4 Current Weight: 3710g 3 Term 37wOd Date: 20/11/23 PL 1 Live Births: 2 Sex Type: M method: cs Anaestesia : Spinal PTL : Yes status: live birth ,Living

Previous CS details: Emergency Cervical dilation in cm (if applicable): 1st at 6cm for sepsis, 2nd at 3cm Reason(s) for previous CS: Sepsis at 6cm In 2021, then PPROM in 2023 + contracting Complications (eg PPH, wound infection): Pain on BF Other previous abdominal surgery: Has keloid midline Medical conditions relevant to surgery/ anaesthetic: No Any contraindications to labour and vaginal birth: No (If yes to the following, please refer to PMH ANC) Any Tokophobia: No Any trauma / lasting shock or fear about labour/ delivery: No Women Choosing or Considering Caesarean Birth (First Appointment)\ Please refer to appropriate ANC (see pathway below)

Plan for labour before CS discussed: Yes Plan delivery by: 39-40/40 Notes: To attend asap if in labour Coil Insertion at Planned or Emergency CS (For All) An IUS (hormone-containing coil) can be inserted into your womb at the time of Caesarean section. It does not affect your recovery and is is safe for breastfeeding. It provides effective contraception for up to 5 years with a low unplanned pregnancy rate of 2:1000 women. Many women have lighter or no periods. A copper coil (non hormonal can also be inserted if you prefer. After Caesarean section, the risk of coil expulsion (falling out) is < 10% and you would require a check for this 6 weeks after giving birth. Woman wishing for IUS in the even of Caesarean delivery: No Notes: Thinks will go for patch Briefly discussed sterilisation - irreversible, small chance of failure with risk of ectopic pregnancy Further information VBAC - Advantages Quicker recovery Less risk for future pregnancies Shorter hospital stay Fewer breathing problems in babies Chances of Successful VBAC: * Single previous CS, no vaginal birth - 3 out of 4 women (72-75%) *Single previous CS, at least 1 previous vaginal birth - 9 out of 10 women (85-90%) Unsuccessful VBAC more likely if: * Induced labour

problems after birth 2-3 in 100 4-6 in 100 Baby developing hypoxic ischaemic encephalopathy (brain 8 in 10,000 <1 in 10,000 injury) at birth Stillbirth beyond 39 weeks whilst waiting for labour 1 in 1000 N/A Serious issues in future pregnancies eg low lying or invasive N/A Increased risk placenta, surgical complications, stillbirth Induction of Labour in Women with Previous Caesarean Section *The risk of scar rupture is 1 in 200 in VBAC labour which starts spontaneously. If a woman has her labour induced, this risk is increased 2-3 fold, ie 2-3 in 200. *There is a 1.5 fold increased risk of Caesarean delivery in induced labour compared with spontaneous labour.

Aware that if has GDM again, may be booked into DANC Date: 13/6/2025

Date: 13/06/25 Spoke to: mother of Details Checked: yes Date of Injury: 12/06/2025 Mechanism of Injury: Hit right wrist on edge of desk Diagnoses: Right wrist soft tissue injury Current Symptoms: Localised pain and Swelling Symptom Management: Pain relief - paracetamoi ibuprofen, Rest, Ice and Elevation Equipment: Futura splint is this a recurrent injury: No

Patient : Healing Takes 6-12 weeks. Symptoms You may have pain and swelling to your wrist and hand for 3-6 months after your injury. Taking regular pain medication and using ice will help with symptoms. Futuro splint to be worn for comfort. Can remove for washing, dressing and completing exercises. You should stop using your splint as soon as possible. Exercises Commence free range of movement being guided by pain .Return to Activity/Sports No heavy lifting for the first 6 weeks. Info sent: Soft tissue wrist injury care plan by Email Contact Virtual Fracture Clinic if you are struggling to regain movement, are concerned about your symptoms or need further . Follow up: No routine follow up required

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assessment of their needs with the information available to the pharmacist at the time. support or advice provided and any additional information for the general practice is given below: Patient : Patient ethnicity | Not stated Gender | Female Clinical Observations: Patient temperature | 38.5°C Medicines supply information (If supply made) Phenoxymethylpenicillin 250mg/5ml oral solution sugar free Phenomethylpenicillin 100 ml

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Patient: Gender | Female Patient ethnicity | Not stated Clinical Observations: Patient temperature | 0.0°C Medicines supply information (If supply made) Phenomethylpenicillin

pt feels very unwell, been having it for 4 days now, temperature was 34 but pt been feeling hot and cold. very painful even to talk, cant get out of the bed/come down to the pharmacy for throat check. painful to swallow as well.

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assessment to determine if cannabis based prescription medicines (CBPMs) are a suitable therapeutic option for their Movement Disorder. Your patient has undergone an assessment with Mamedica for treatment of their condition specified above, with CBPMs. Based on my assessment today and a thorough review of the patient records, | have determined the patient a suitable candidate for treatment with CBPMs. | have prescribed the following for the patient: 17% THC, <1% CBD Flower - Lavender Cake (10g) () THC 17% : CBD <1% Vape 0.25 g, as Directed 1 (ONE) x 10 g (TEN GRAMS) Container 22% THC, <1% CBD Flower - Wedding Pop Triangle (10g) THC 22% : CBD <1%

1 (ONE) x 10 g (TEN GRAMS) Container Grow by Safricanna 15% THC, <1% CBD Flower - Black Cherry Punch (10g) THC 15% : CBD <1% Vape 0.25 g, as Directed We have had a thorough consultation with pt regarding CBPMs. The patient has read and signed a consent agreement, indicating the patient understands and agrees to the risks involved with receiving CBPMs. We have discussed treatment goals with the patient and explained about the potential adverse effects of this treatment, drug interactions and how the long term effects are still unclear. We have explained how to administer the medication and that the effects of CBPMs in its prescribed form could last up to 8 hours after consumption, and the patient must not drive or operate machinery during that period of time, if they feel impaired. We have also explained that the product must be kept in original packaging and in a secure place out of the reach of children. We informed the patient that they are only permitted to obtain CBPMs from a licensed pharmacy and are allowed to carry only a 28-day supply of their prescribed daily dosage. We have also advised the patient that they must keep their medication in its original prescription bottle or packaging while traveling within the country. This, along with a copy of their prescription, serves as proof of their legal right to possess CBPMs. If the patient is traveling to another country, they have been informed that it is their responsibility to verify whether it is legal to bring their medication into that country. The patient was informed that sharing or selling their CBPMs is prohibited under UK law. The patient understands that they can only be registered with one clinic prescribing CBPMs, must attend regular follow-ups to monitor the effects of the treatment, and that failure to comply with any of these conditions will result in the termination of their access to our services. If you have any concerns regarding your patients being prescribed CBPMs, please do not hesitate to

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Date:13/6/2025 This is to confirm to you that had his procedure on 10/6/2025 We inform all patients to contact us in the first instance for any aftercare related enquiry. Furthermore, the pt has received a comprehensive aftercare pack with a semen sample bottle and instructions.

Date: 12 June 2025 Following your child’s last consultation with , he wishes to review her again in July. me as above for a Weybridge appointment (Tuesdays & Saturdays) if you have not already done so. Pir you are offered a Saturday appointment in Windsor by BMI Bookings, this is an error and please only book a Saturday if you are prepared to come to the Weybridge clinic or are booking a remote appointment. .

history of epilepsy and no clues for any nocturnal seizures. Reports of more normal behaviour when not with parents | was interested to hear that when goes to her grandmother the report is of her behaviour being quite normal. The nursery staff have also repeatedly reported that 's behaviour is normal. However, in the last couple of weeks, they have also started noticing that her behaviour is slightly different, particularly during the episodes of worsening. Birth & pregnancy: was born at 31 weeks by elective caesarean section for maternal indications, a product of normal pregnancy with normal antenatal scans. She was well at birth and had no neonatal problems. Resolved infantile acid reflux She suffered from acid reflux, and our colleague commenced her on omeprazole at 12 weeks of age,

indication of any residual relevant symptoms. Urine Infection presenting with fever with no obvious focus and treatment for possibly sepsis At six months of age, she had a fever with no obvious focus. This really went on for a while and pt had to be seen repeatedly in the local surgery and in A&E before she was admitted and diagnosed with UTI but treated for possible sepsis. She stayed in the hospital for one week. pt however had a renal ultrasound scan, which was normal and was discharged from further follow-up. Rhinitis with allergic features and recurrent cold illnesses pt attends nursery and has had recurrent colds like expected. At times, the family feel that she has constant snuffliness with clear discharge. She is seen to rub her nose and mouth breathe at night but there is no snoring. Her sleep generally is restful. Other History She is up to date with her vaccines. There is no other history of significant illnesses. Physical Examination pt looked quite healthy with plenty of energy certainly but she had some obvious attention-seeking behaviour. She has no dysmorphic features and no skin marks. Her heart sounds were normal. There was no lymphadenopathy or palpable organomegaly and the chest was clear. Neurological examination was not obtained but, overall, from her posture and active movements, there were no obvious neurological deficits. | am told pt is, if anything, advanced in her speech. Her weight was 13.8 kg and her height 88.8 cm. Opinion & Management Plan | asked the family to keep a diary, which they have started already, of pt's behaviour and to comment particularly on the environment, diet, etc., in the days that precede her periods of worsening. | also asked the family to try to bring a report from the nursery staff. | think it will be appropriate to ask my colleague , who has special interest in behavioural paediatrics and ADHD, to see the family and Lily for further assessment and to whom | am copying this letter. The family are keen on obtaining further investigations, including blood testing to explore any underlying causes, including “deficiencies”. Given the abrupt episodic nature if the clinical picture, an EEG may be relevant but | explained we should leave these decisions to . Today, | explained to the family the importance of consistency and firmness and setting limits of what is allowed and what is not. | am going to review Lily in six weeks' time and shall keep you updated.

Diagnosis: Ventricular tachycardia Anaemia Clinic note: Heart Rhythm Clinic Review Ht Readings from Last 1 Encounters: Wt Reacings from Last 1 Encounters: 03/02/25 = 1.79m 06/06/25 118.9 kg

Past Medical History: Diagnosis * Body mass index 30+ - obesity * Chronic kidney disease stage 4 * COPD - Chronic obstructive pulmonary disease * Gout Date: 03/2024 * Ventricular tachycardia * Malignant tumour of colon * Heart failure with reduced ejection fraction Anaemia * Heart failure with reduced ejection fraction * Hyperlipidaemia * Hypertension * Malignant tumour of ascending colon * Myocardial infarction 2014 * Paroxysmal atrial fibrillation * Pneumonia 2019 * Unspecified Diabetes Mellitus Past Surgical History: Procedure * CARDIAC CATHETERISATION 3VD * INSERT / REPLACE / REMOVE PACEMAKER Dual chamber ICD * CORONARY ARTERY BYPASS GRAFT * REPLACEMENT OF CARDIOVERTER DEFIBRILLATOR Generator Change - ICD Dual Chamber performed by , MD at FPH Cath Lab Current Outpatient Medication Medication amiODArone 200 mg, Oral, Daily apixaban 5 mg, Oral, 2 times daily aspirin 75 mg, Oral, Daily atorvastatin 40 mg, Oral, Nightly BISOPROLOL (Generic Manuf) 7.5 mg, Oral, Nightly bisOProlol 5 mg, Oral, Daily CONTIFLO XL 400 micrograms, Oral, Daily with breakfast FERROUS FUMARATE (Generic Manuf) 210 mg, Oral, Every other day FORXIGA 10 mg, Oral, Daily macrogol compound NPF sugar free oral Take TWO sachets once a day.

History Tobacco Use Smoking Status Former « Current packs/day: 0.00 * Types: Cigarettes * Quit date: 2014 * Years since quitting: 11.4 Smokeless Tobacco Not on file Tobacco Comments Stopped 2014 Howard reports current alcohol use of about 9.7 units of alcohol per week. No Known Allergies Investigations Lab Test Results Component Value Date HAEMOGLOBIN 85 (L) 09/06/2025 HAEMOGLOBIN (POCT) 85 (L) 06/06/2025 HAEMOGLOBIN TOTAL (VBG POCT) 86 (L) 06/06/2025 CREATININE 142 (H) 09/06/2025 CREATININE (VBG POCT) 140 (H) 06/06/2025 CREATININE U MG/DL 6.0 19/03/2025 FREE T4 12.4 02/02/2025 TSH 1.92 02/02/2025 PLATELETS (POCT) 250 06/06/2025 PLATELETS AUTO 263 09/06/2025 Transthoracic echo (TTE) complete 24/03/2024 interpretation Summary - Mildly dilated LV cavity size (EDVi of 89ml/m2). Mild septal LVH. Severely impaired visual ejection fraction of 20-25% (see LV report). Grade 1 diastolic dysfunction with normal diastolic filling pressure, Ave E/e of 7.5.

findings: There is emphysema. A 45 mm triangular right middle lobe lung nodule (series 35 image 164) has not altered in size on volumetric comparison in a 9-month period and does not require further surveillance based on its size. Conclusion: There is severe three-vessel native coronary artery disease with four patent coronary artery bypass vein grafts. The patient is thought to have had a previous LIMA graft that has now occluded. There is emphysema. Pacing Checks in the last Year Cardiac Device Check - ICD Dual Chamber 03/02/2025 interpretation Summary Check type: inpatient check on CCU to decrease lower rate limit of ICD to help overdrive slow VT Summary: attempted lower rate limit to 7Obpm but this resulted in further prolongation of P-R interval and hence RV-pacing, in light of known severely impaired LV, | then attempted 60bpm which then allowed intrinsic AV node conduction and no RV-pacing. | spoke with this man and his wife on the phone. The phone line was poor and | will arrange a face to face appointment for next week at Frimley Park. He continues to be very breathiesss with anaemia and heart failure, he is stage 4 in terms of NYHA class. His haemoglobin has improved slightly on the most recent blood tests from the 9th of June though is still below the target of 90. His rhythm appears stable with no further alerts, he should continue on mexiletine, | have issued a further prescription. He will need to pick this up from the hospital pharmacy. We had a discussion about stopping his apxiaban. He and his wife were unaware that the tumour in his bowel might be causing bleeding. He reports ongoing black stool without frank blood. They would like to discuss things face to face so | will bring him in next week.

management of his anaemia and stroke risk. | think in this situation the risk of stroke is lower than that of life threatening blood loss and he should stop his apixaban. He should also stop his aspirin. | will copy my letter to the SDEC team regarding the need for further transfusion in the mean time. He may well require further admission for this.

Date: 13 June, 2025 Past Medical History Heart failure with reduced EF 15-20% LBBB -— not for device COPD Mild to moderate focal disease in the RCA Obstructive Jaundince Diverticular disease Anxiety with depression Medications (including over the counter) Furosemide 40mg OD Ramipril 2.5mg OD Bisoprolol 2.5mg BD Spironolactone 50mg OD Aspirin 75mg OD Dapagliflozin 10mg OD Fluoxetine 20mg OD GTN spray Lansoprazole 15mg OD Paracetamol 1g QDS Salbumtamol 100mcg 2 puffs Anoro Ellipta 55meg + 22mcg OD Blood Results - Sample 25B40165169 (Blood) Collected 09 Apr 2025 13:30 Received 09 Apr 2025 15:12 CREATININE AND ELECTROLYTES, BLOOD Sodium 141 mmol/L 133 - 146 Potassium 4.5 mmol/L 3.5 - 5.3 ns (32 disability cc 100 ee SCharity | BG confident METABAN EMEMPLOYER | (outstanding f)

Management Plan Discharge Stable Advised to contact the HF office in the event of worsening symptoms. A follow-up home visit was conducted today with . She reports feeling generally well and denies any exacerbation of her symptoms. Her legs today look trim with minimal signs of oedema bilaterally although R does look slightly worse, it is significantly better than the last time. Her lung field is clear on auscultation with good bilateral air entry with no added sounds. She does She did not report of any worsening symptoms of breathlessness, chest pain or palpitations. She continues to feel occasionally dizzy but denied any symptoms of presyncope or syncope. As she is stable on optimised medical therapy and as her symptoms remain stable, | arm now discharging her from my care. In accordance with the NICE guidance it is advised that you recall the patient every 6 months for a heart failure review, and we would recommend the following checks: . Blood pressure . Pulse check . Weight . Review of ankles and chest for any fluid . Review of medications Review of symptoms . A blood test to check kidney function and full blood count . flu injection every year However, she still has access to the Heart Failure Service and is aware to contact us if they have any of the following symptoms: . Breathlessness at rest . More breathless when you move around . Ankle swelling . Rapid weight gain . More tired than usual . Dizziness | would currently put them in NYHA class: II Please add to your heart failure register. On examination today: Blood pressure (mmHg) 113/55 mmHg Pulse (bpm) 71 bpm

Weight (kg) Oxygen saturation on air %. Lungs Oedema ECG Chest Pain Orthopnoea Palpitations Dizzy Breathlessness Breathlessness Comments Cough Nocturnal Dyspnoea Fatigue INHS Berkshire Healthcare 54.4 kgs 99% Clear Minimal oedema around the ankles RBBB Nil 3 pillows Nil Occasional Nil Nil Nil Nil Function Nurse

ASSESSMENT LETTER 12of June 2025 Past Medical History Heart failure with reduced EF 30-35% Atrial Fibrillation HTN Depression Frailty Osteoarthritis Psoriasis Medications (including over the counter) Digoxin 62.5mcg OD Losartan 25mg OD Spironolactone 25mg OD Alendronic acid 70mg take one tablet once a week Bisoprolol 5mg BD Calcium Carbonate/calecalciferol 1.5g OD Edoxaban 30mg OD Empagliflozin 10mg OD Furosemide 40mg OD Lansoprazole 30mg OD Levothyroxine 50mcg OD Sertraline 100mg BD Blood Results - Sample 24B41431976 (Blood) Collected 04 Nov 2024 12:00 Received 04 Nov 2024 15:35 CREATININE AND ELECTROLYTES, BLOOD

Management Plan * Stable from a heart failure perspective — 22"¢ of July home visit appointment given. *Heart rate; good rate control 83 bpm AF — reported no more palpitations * Review in 6 weeks * Please follow up in view of her chronic diarrhea- feels weak and fatigued | conducted a home visit today to review , who was recently admitted to hospital due to worsening palpitations and ongoing chronic diarrhoea. At the time of review, appeared clinically well. However, she reported persistent fatigue and intermittent episodes of diarrhoea, which continue to affect her overall well-being. | would appreciate your assistance in further evaluating and managing this gastrointestinal issue. From a cardiac standpoint, she remains stable with no clinical signs suggestive of heart failure decompensation. On examination, her lower limbs were not oedematous, and auscultation of the lungs revealed clear fields with good bilateral air entry. Cardiac auscultation demonstrated dual heart sounds with an irregular rhythm consistent with her known atrial fibrillation; no murmurs audible. A single-lead ECG performed during the visit confirmed atrial fibrillation with adequate rate control, with a heart rate of 83 bpm. Her blood pressure was noted to be on the lower side; however, she did not report any symptoms of dizziness or recent syncopal episodes. mentioned she is scheduled for a blood test under your care. If you can kindly follow up in view of her ongoing intermittent diarrhoea. | would currently put them in NYHA class: II Please add to your heart failure register. On examination today: Blood pressure (mmHg) 94/49 mmHg Pulse (bpm) 83 bpm Weight (kg) Did not weigh Oxygen saturation on air %. 98% Lungs Clear Oedema Mild oedema around the ankles — non pitting ECG Atrial fibrillation — 83 bpm Chest Pain Nil Orthopnoea 2 pillows

Dizzy Nil Nil breathlessness but does get breathless on Breathlessness stairs which she avoids. Lives on the ground floor. Breathlessness Comments Cough Nil Nocturnal Dyspnoea Nil Fatigue Nil Function Nurse

13 June 2025 The Centerra cardiac monitor shows sinus rhythm throughout with heart rate ranging between 44 and 88 bom. Prolonged PR noted. There were infrequent supraventricular and ventricular ectopics seen. No sustained tachycardia seen. These results are very reassuring. We will write back with the results of tilt table test.

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Diagnosis: Anatomic narrow angle glaucoma of right eye Clinic note: Glaucoma clinic Booked from virtual clinic for ?cataract evaluation Current Age: 76 y.o. Diagnosis: R chronic narrow angle Family History of glaucoma: Nil Vision: RE 6/38 ph 6/17 LE :6/7.9 Treatment: Latanoprost BE Ocular Surgery Hx: Bilateral YAG PI patent

history of any ocular inflammation/Uveitis P| patent both eyes. Continue Latanoprost both eyes Listed for R phaco + [OL -mid dilated pupil . Change in Tx:Nil Review in Glaucoma Clinic in 6/12

13 June 2025 i wonder if you could help with seeing in order to help facilitate an NF1 screening genetic test in addition to an R218.1, 223.1 and 223.2 tests. Two clinic letters have been enclosed which provide medical details. | did try and make the referral myself but it was rejected as only certain groups of individuals are allowed to request an NF1 test.

Genetic test request form enc.

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Past medical history includes coccydynia, HLA-B27 negative chronic bilateral sacroiliitis and dermatitis. Current medications include paracetamol and ibuprofen as required. is breastfeeding, so is limited by other medication choices. There are no known drug allergies. lives at home with her husband and daughter who is nearly 2 years old. We took the opportunity in clinic today to do recent imaging. MRI spine and coccyx February 2025 is reported as showing mild multilevel disc degeneration in the coccygeal spine, as well as a type 2 coccygeal configuration. There are no sinister features. On examination, points to pain over the coccyx area. Today in the clinic, we have had a discussion as to the natural progression of coccydynia. has tried a number of appropriate treatments to help with her symptoms, including using a coccyx cushion, physiotherapy, and simple analgesia. We have discussed that could also trya TENS machine. Included with this letter is information on the purchasing and application of the device over the painful area to try and help with symptomatic relief. We have gone on to discuss the possibility of injection therapy, more specifically, we have discussed a sacrococcygeal and coccyx injection. understands that any form of injection therapy is not curative, but is undertaken with an aim to reduce symptoms for a period of time so that long-term management strategies including physiotherapy and exercise can be undertaken. Having discussed the potential benefits and risks, including failure of benefit, feels that she has exhausted other conservative strategies and would like to proceed. We look forward to welcome to the Day Surgery Unit at Ashford Hospital for her injection in due course. In the interim time, | have stressed the importance of continuing with the previous physiotherapy exercises shown.

- If you have a medication query please contact your prescribing GP in the first instance. - If you require urgent assistance please contact your GP, local walk in centre, NHS 111, A&E or the emergency services

INDICATIONS: TENS produces a mild electrical Stimulation that does not Cause any harm. However, if you have a cardiac pace maker, certain skin conditions, have epilepsy or are pregnant you should consult your doctor or nurse Specialist before using TENS. INSTRUCTIONS FOR USE There are many TENS machines on the market most of which include comprehensive operating manuals for use. General advice for standard TENS treatment is: * Place the electrodes where you feel the pain. * Place the electrodes on your skin 2 to 4 fingers apart. ® Adjust the controls so that the stimulation you feel is strong but comfortable. ® Use for 30-60 minutes initially checking for any skin irritation caused by the electrode pads. * Thereafter use for up to 4 hours in one session with a break of 30-60 minutes before using again. * Itis advisable to change the position of the electrodes Slightly each day to prevent your skin becoming sore. SKIN CARE When you first start using the TENS machine it is important to check your skin before and after use for a rash or blisters, as these might indicate that you are allergic to the electrode pads. If this happens, stop using the machine, remove the electrode pads and contact the company you bought your TENS machine from for their advice on electrodes for sensitive skin. IS IT SAFE FOR ME TO DRIVE WHILE USING TENS? We do not advise you to drive or operate machinery while using a TENS machine. Cautions * Do not place electrodes on the front of the throat as spasm of the neck muscles can occur. * Do not place electrodes on the front of the neck as there is a small chance these could affect nerves that pass through this area of the neck and regulate your heart rate. * Electrodes should not be placed over the eyes, in the mouth or internally.

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TENS MACHINES The following list shows just a few of the TENS machine suppliers. It is not exhaustive and not intended as a list of recommendation. You may like to consider the following points when purchasing a TENS unit: * Having a dual channel TENS allows you to use 4 pads and may give you flexibility in treating larger areas or two pain areas at atime * Some TENS machines take rechargeable batteries * The cost of the replacement pads, this can vary from company to company * Some machines switch off automatically after 15-20 minutes, usually TENS is recommended for a minimum of 45 minutes TPN 200 plus Med-Fit 1 —_ _ we Dual channelled TENS machine £16.99-£29.99 Boots Pharmacy www.boots.com Boots advanced TENS pain relief unit £49.99 2 year guarantee TENSCare Touch TENS machine and other inducing above can be found on Amazon. Ranging from £22.50-£55.20

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13 June 2025 patient attended for Day Case Infusion on 13/6/2025. The procedure was uneventful. This is the second dose. First dose was given 06/06/25 1000mg . Total dose 2000mg Administrations As of 13/06/25 15:21 ferric carboxymaltose (FERINJECT) 1,000 mg in sodium chloride 0.9% 270 mL infusion (mL/hr) Tota! dose: 1,000 mg* *From user-documented volume Date/Time Rate/Dose/Volume Action 13/06/25 14:46 1,000 mg - 540 mL/hr (over 30 min) New Bag 15:18 (over 15 min) Stopped

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Reason for referral: Abdominal pain, alternating bowel habits. Consultant: have always suffered with constipation, in the last 6 months have experienced loose stool 4-5 times a day. can experience abdominal discomfort which leads to loose stools. feel look very bloated. If wear tight clothing will experience abdominal pain. deny any rectal bleeding. Your weight is stable. have not experienced upper GI symptoms. live at home with your husband and foster children. PS of 0. have no family history of bowel disease or cancer. do not smoke and drink 0 units of alcohol per week. Past medical history - None of significance Medications- Progesterone micronised 100mg capsules Allergies- No known allergies. Recent bloods-HB138 eGFR83 FIT- negative

Plan- CT Colonography, discharge from FDS pathway and requested as urgent due to negative FIT. Today we have discussed the procedure and all associated risks. | have explained that that the medications that you need to take in anticipation of this scan will be provided by the Radiology department along with instructions on how to take it and a leaflet about the procedure that you are going to have. You have stated that you understand the procedure and feel that you can manage the gastrografin and side effects at home. Should any further procedures be required then | will be back in touch with you in due course to discuss these. | will write to you with the results when they are available to me.

Reason for referral: FIT positive and weight loss. Consultant: deny upper or lower GI symptoms. do note have had weight loss. are unsure of how much but this is over years and due to changing your dietary intake. live at home alone. PS of 2. When leaving the house use a mobility scooter, are not able to walk very far but only small distances indoors. have no family history of bowel disease or cancer. do not smoke (ex smoker) and drink 0 units of alcohol per week. Past medical history - MI 2011 Medications- Atorvastatin 40mg tablets Ramipril 2.5mg capsules Bisoprolol 5mg tablets Aspirin 75mg dispersible tablets Allergies- No known allergies

Plan- You have declined a CT Colonography due to the gastrograffin side effects, you do not feel you can manage this. | have therefore requested a CT of your chest abdomen and pelvis. You are aware this is not as high quality of an investigation. if you have not had your appointments through within two weeks, please contact me or one of the team on

Management Programme. They have provided their consent for us to communicate with you as their registered GP. If you are aware that any of the information that the patient has provided to us may be inaccurate, or have any concerns about their participation in programme, we would be very grateful if you would contact us on the details above so that we can discuss next steps with them. Please note that we are not asking you to provide any information unless you feel it necessary; the responsibility for treatment remains entirely with us and our prescribers. We have prescribed: ¢ Mounjaro KwikPen 5mg/0.6ml solution for injection 2.4ml pre-filled pens (Eli Lilly and Company Ltd) Quantity: 1 Directions: Once a week for 4 weeks We have given the patient the following information: ¢ Thank you for completing your refill information. Blood results: There are no new results to review since your last refill. New dose: Remain on Mounjaro 5mg due to optimal amount of weight loss. Keep up the good work! A further prescription has been issued for you. If you have any questions about your dosing schedule,

Your medication will be delivered by our pharmacy partner who will be in touch with you shortly. Once received, please follow the directions carefully and remember to check in weekly. Wishing you continued success on your weight loss journey! Mounjaro approved. There are a few important things that you should be aware of: Weight reduction varies from patient to patient and is dependent on adhering to a nutritional diet and regular exercise. It is important for everyone to follow healthy eating advice and to try to keep cholesterol to a healthy level. You should aim to eat a healthy, balanced diet low in saturated fat and high in fibre, exercise regularly Keep well hydrated. Mounjaro can make you dehydrated so it is important that you drink plenty of water each day. Make sure that your NHS GP is aware. We will inform your NHS GP that you are taking Mounjaro, but you should also notify them yourself. This information may be important for them when prescribing medications or providing medical care. Administering medication. You should inject your dose of Mounjaro as instructed under the skin in one of the following areas: stomach area, upper leg (thigh) or upper arm. Do not inject into a vein or muscle. Make sure to change (rotate) your injection site within the area you choose with each injection to reduce your risk of getting lumps under the skin. Do not use the same site for each injection. If you are taking other medication: * If you are a woman on oral hormonal contraceptives, you must to ensure you either switch to a non- oral contraceptive or use a barrier contraceptive (eg condoms) for 4 weeks whenever your dose is adjusted. * If you are taking medications that require blood test monitoring, be aware that Mounjaro may affect the levels. Please consult your GP to determine if more frequent blood tests are needed. * If you are using medications (such as anticonvulsants) for symptom management, monitor your symptoms closely and report any changes to your NHS GP or specialist, as you may need a dosage adjustment. When to Stop Taking Mounjaro: You should stop taking Mounjaro and inform us immediately if you: * Become unwell or dehydrated * Become pregnant * Develop pancreatitis, gastroparesis, or diabetic ketoacidosis If you are scheduled for surgery requiring general anaesthesia, you must inform the anaesthetist, as they

problems breathing or swallowing, or severe rash or itching. *You should pay attention to any mental health changes, especially sudden changes, in your mood, behaviours, thoughts, or feelings. Contact us right away if you have any mental health changes that are new, worse, Or worry you. General side effects and risks: Whilst the majority of patients tolerate Mounjaro quite well, we understand that it is crucial for you to have an understanding of the potential side effects. Below, we have provided to help you with this. Please read the Patient that comes with Mounjaro as well. Common side effects include nausea, diarrhoea, constipation, vomiting, Injection site reaction (redness), low blood sugar that can cause headache, tiredness, dizziness. You may notice some hair loss, please tell us at your next refill if it is significant. It is usually temporary and many see their hair regrowth even while on Mounjaro. Mounjaro can increase the risk of gallbladder or bile-related issues, such as gallstones. If you have had gallstones before, there is a chance they could flare up again. Mounjaro may cause gastrointestinal side effects, such as nausea or constipation, which could be more pronounced for those with pre-existing bowel conditions. Please let us know if you experience any side effects that are difficult to manage. Please see below the provided by the patient.

plan. This will mean they determine whether you need to increase your dose or stay at your current one based on what's best for you. Have you started on any new medications (prescribed or purchased over the counter) or supplements since your last prescription? No Follow-up question [No] Please give more details | haven't started any new medication since my last prescription. Has anything changed in your medical history in the last four weeks? Nothing has changed with my medical history Are you currently experiencing any side effects that you suspect may be a result of your medication? Yes What symptoms are you experiencing? Nausea Constipation Please rate the severity of the side effect(s) you are experiencing Moderate Side effects (Somewhat manageable) Have you needed to use any of the medications provided in your complimentary SheMed side effect care package? Yes Which medication have you used? Gaviscon

Did this medication help alleviate your symptoms effectively? Yes In the past month, how many hours of sleep did you typically get per night? 7 - 9 hours In the past month, have you noticed any of the following sleep-related habits? Regular bedtime and wake-up time Difficulty staying asleep How would you describe your physical activity level this month? Fairly active: I've been aiming for around 150 minutes of activity each week. Have you noticed that you have been short of breath in completing of your daily activities over the past month? Walking (walking to from work, mode of transport, climbing stairs at home) How often have you snacked between meals this month? Rarely How would you describe your portion sizes this month? Small How often have you eaten fast food or takeaways this month? Rarely or never How many alcoholic drinks have you consumed per week on average over the past month? 0 Please re-confirm your women's life stage Premenopause Have you experienced any of these symptoms over the past month? Select all that apply None of the above Have you been diagnosed with any of the following conditions over the past month? None of the above Did you have a period in the past month? Yes

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Diagnosis: Breast changes Clinic note: it was a pleasure to see in the breast clinic today. She has been referred to us as she presents with a right breast lump for the last few weeks. She was on Flucloxacillin for one week and the symptoms disappeared. Currently no further lump palpable from patient perspective. Family history of breast cancer Mother 69 years old On examination Cup D, ptosis grade 3 Right breast: no nodules palpable, no lymph nodes palpable Left breast: no nodules palpable, no lymph nodes palpable 11/6/2025 Bilateral mammograms

PLAN Discharge from our care Patient consented verbally to examination performed by Clinician and chaperoned by . Privacy and dignity maintained throughout. Standard IPC precautions taken. No issues or concerns noted.

Date: 13th June 2025 Dear Your patient recently had a medical examination and we've noticed that their blood pressure is raised. A copy is enclosed for your reference. Although we have been able to offer terms of acceptance, we thought it would be best to let you know so that you can see your patient for a review if you feel this is required. first).

2.1) Is the appearance of the applicant ies No consistent with the stated age? | If yes, comment : 2.2) Is the general appearance of the io T Yes applicant abnormal in any way? | If yes, comment: 2.3) Are there any signs of alcohol, drug or tobacco misuse? ho [Yes BASIC MEASUREMENTS | 2.4) | Height 168 on Chest measurement (full inspiration) 89 a Weight 60 kg Chest measurement (full expiration) | 84 am BMI 21.3 Abdominal Girth [ 87 am If over 140/90, please provide 2 further readings at § 2.5) Resting Blood pressure readi Prat minute Intervals retreti P "9 Norco 153 sf T50 | Lowest of 3 readings . ool 85 o| 96 2.6) Pulse Rate i | , : | If no, describe pulse : 2.7) Is the pulse regular? Wes T No [no describe: 2.8) Are the heart sounds normal? (Yes T No If yes, describe timing (systolic/diastolic), ste, intensity, _fadiabon and character ; 2.9) Are there any murmurs? Wo Yes | If yes, is this meld, moderate or severe : 2.10) Does the heart appear to be enlarged? Vo [Yes | If yes, please provide details : 2.11) Are any of the peripheral pulses r weak/absent? Wo © ves

Diagnosis: * Inactive TB Regular Medications: * Adcal D3 two tabs once daily Lansoprazole 30mg once daily Allopurinol 100mg od Atorvastatin 10mg od Eye drops * —Rituximab - 02 December 2024 No Known Drug Allergies Inactive TB treatment: Six months treatment isoniazid 50 mg six tablets once a day Pyridoxine 10 mg once a day

Treatment start date: 11 December 2024 Completion date: 10 June 2025 Repeat ALT - normal range 19 March 2025 Missed doses? No New symptoms (Eg cough, night sweats, weight loss)? No Other issues discussed: Nil Thank you for speaking with me in my telephone clinic today. Chemoprophylaxis has now been completed. you will not require treatment again, even if a tuberculosis test (skin test or IGRA) is positive or reactive. The exception is if you are re-exposed to someone with infectious tuberculosis and a tuberculosis specialist or the UK Health Security Agency decides that re-treatment is indicated. We have discharged you from the TB service.

assessment, you should inform them that you have previously been treated for latent TB. We recommend keeping your treatment completion letter to provide as evidence of this. It is important you still attend for TB assessment and screening investigations. Now | have been treated for latent TB, is it possible for me to be infected again Yes, if you have another exposure to someone with infectious TB it is possible you will be infected again. It is important you attend for assessment and investigations if identified as a close contact. is it possible the treatment might not have worked, and | will still develop active TB in the future? Treatment for latent TB infection is effective in preventing progression to active TB disease if medication has been taken as directed. However, you should remain vigilant for symptoms of active TB and seek medical review immediately if symptoms develop. What are the symptoms of active TB? A cough for 3 weeks or more, weight loss, fever, night sweats, tiredness, loss of appetite. Do not wait for all symptoms to develop. If you have 3 symptoms, contact the TB nurse or GP. . Can | now have a BCG vaccination? No, BCG vaccination is not recommended for individuals with a history of TB infection (active or latent).

Indication: Left shin melanoma 2008. In transit metastases 2018, 2020 and 2024. For high risk surveillance (cannot have MRI) Post IV contrast. Findings: Unremarkable intracranial appearances with no evidence of intra- or extra-axial haemorrhage, mass lesion or large vessel infarct. Normal bony structures, mastoid air cells and visualised paranasal sinuses. Conclusion: Normal study

Diagnosis: skin cancer

Appointment type: Cardiology Follow Up Consultation Dear 1. HFpEF with episode of cardiac decompensation during HER 2 treatment and stabilisation function on medical therapy 2. Bileaflet mitral valve prolapse with moderate mitral regurgitation and mild aortic regurgitation 3. Hypertension Medication Anastrozole, ramipril 10, atorvastatin 40, bisoprolol 1.25 mg, alendronic acid, D3 | caught up with this lady today. She has now completed HER2 cancer treatment and has now been put on zoledronic acid. | could not hear mitral murmur today and echo at the end of cancer treatment shows mitral prolapse with moderate MR and good biventricular systolic function with diastolic dysfunction. She currently has no symptoms or signs of cardiac decompensation and is doing very well. | booked a surveillance echo for 2 years time

Allergies: No Known Allergies errors but do let me know about anything clinically significant which needs to be corrected. Cardiology Administrators: For any appointment queries please contact the following If you do not receive an appointment or receive results of tests which | have organised in the timescale you are expecting, please contact my secretary on the number above.

12 June 2025 Dear | spoke to today and he seems to be stable on Meflynate XL 30mg, he has increased focus and is able to control his emotions more. The family have also noticed a difference in ’s behaviour, and can now have a more meaningful conversation with him as has the patience to properly listen and engage. Today on medication, his BP was 134/77 and HR was 72/min. His latest weight this week is 97.5kg. Now that ’s ADHD medication is stable and predictable, please can you provide ongoing prescriptions in keeping with the attached shared care agreement? (A iN C2 a Natalie Ascher-Heard Senior Specialist ADHD Nurse CFAA ADHD Specialist Service

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DIAGNOSES: Stage IIIA T4 N1 MO non-small cell lung cancer squamous cell carcinoma. Insufficient tissue for PDL1. Lung function tests 10th April 2025 FEV1 1.7L, TLCO 65%. | had a face-to-face consultation with in her third week of radiotherapy. She is tolerating the treatment well, although she has persisting weakness with the voice, which has slightly worsened whilst on radiotherapy. | am hoping this will settle after she completes the radiotherapy. She reports that her appetite is good and she is eating well; however, she has lost 1kg since she started the radiotherapy. She is going to drink and increase the intake of her of milk and dairy products as well. | will review her next week and if things are continuing to go well, | will see her approximately six weeks following completion of the radiotherapy with an aim for a CT shortly after to assess response.

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Below are the results from your recent visit: Recent cardiac monitor shows heart rate ranging between 55--108 bpm with a mean heart of 78 bpm. Predominant sinus rhythm noted with normal PR interval QRS duration. Infrequent ventricular and supraventricular ectopics noted. No sustained tachyarrhythmias seen. Heart rate variation was within normal limits. Essentially the cardiac monitor results are very reassuring and no further cardiac action is required. Thank you sincerely 13/6/2025

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management of patients transferring from Secondary Care to Primary Care Prescribing arrangements for the use of methylphenidate, dexamfetamine, atomoxetine, lisdexamfetamine, guanfacine and unlicensed drugs in children with ADHD (attention deficit hyperactivity disorder) with transition to adult services in hospital

History Version Date Author Reason V 1.0 November 2013 | Kiran Hewitt/ Katie | New document Sims V 2.0 November 2017 | Ozma Tahir Review - Replaces version 1: Prescribing Arrangements for the use of methylphenidate, dexamfetamine, lisdexamfetamine and atomoxetine in child ADHD (attention deficit hyperactivity disorder) with transition to Adult services in Berkshire V2.1 March 2018 Ozma Tahir Update to formulary position in Berkshire East for lisdexamfetamine, atomoxetine and dexamfetamine V2.2 October 2019 Ozma Tahir NICE update September 2019 re requirement before prescribing atomoxetine (and other QT prolonging medicines), subsequently removed. V 3.0 May 2021 Ozma Tahir Review. Inclusion of guanfacine as amber status in line with NICE recommendations. This prescribing guideline remains open to review considering any new evidence. This guideline should only be viewed online and will no longer be valid if printed off or saved locally

Principles of Prescribing Arrangement These prescribing Guidelines are a local policy to enable General Practitioners to accept responsibility for the prescribing and monitoring of medicines, treatments or devices in primary care, in agreement with the initiating specialist service. This guideline provides a framework for the seamless transfer of care for a person from a hospital or specialist service setting to general practice, where this is appropriate and, in the patient’s, best interest. People should never be placed in a position where they are unable to obtain the medicines they need because of a lack of communication between primary and secondary care. It is important to note, in line with the General Medical Council guidance on prescribing, doctors are responsible for prescriptions they sign, and their decisions and actions when they supply and administers medicines and devices; or authorise or instruct others to do so. Transfer of care Transfer of clinical responsibility to primary care should only be considered where the patient’s clinical condition is stable or predictable. Referral to the GP should only take place once the GP has agreed to this in each individual case, and the hospital or specialist will continue to provide prescriptions until a successful transfer of responsibilities. The GP should confirm the agreement and acceptance of the shared care prescribing arrangement and that supply arrangements have been finalised. The secondary care provider must supply an adequate amount of the medication to cover this transition period. The patient should then be informed to obtain further prescriptions from the GP. Clinicians should clearly explain what a shared care arrangement means for the patient and why it might be an option in their case. The patient or their carers should have the opportunity to ask questions and explore other options if they don’t feel confident that shared care will work for them. They should be fully involved in, and in agreement with, the decisions to move to a shared care model for their on-going care. Importantly, patients should never be used as a conduit for informing the GP that the prescribing is to be transferred. Patient consent The best interest, agreement and preferences of the patient should be at the centre of the decision to begin shared care and their wishes followed wherever possible. Patients should be able to decline shared care if, after due consideration of the options, they decide that it is not in their best interests. Involvement of carers may be critical, especially in circumstances when it is not possible for the patients to make a decision e.g. mental capacity; where appropriate they should be included in the discussion about shared care.

diagnosis of ADHD should be made only after a comprehensive assessment by a specialist with expertise in ADHD°. Symptoms include: - Inattention, for example, not listening when spoken to, not following through on instructions given, avoiding tasks which require prolonged mental effort, easily distractable etc. - Hyperactivity and impulsivity e.g. fidgetiness, not being able to remain seated, unable to play quietly, talking excessively, interrupting others etc. To attain ADHD diagnosis, several symptoms should be present before the age of 12 years and that these are present in two or more settings. There are three types of ADHD: e Predominantly inattentive; Some hyperactive-impulsive symptoms may also be present, but these are not clinically significant in relation to the inattentive symptoms. e Predominantly hyperactive-impulsive; Some inattentive symptoms may also be present, but these are not clinically significant in relation to the hyperactive-impulsive symptoms. e Combined; Both inattentive and hyperactive-impulsive symptoms are clinically significant, with neither predominating in the presentation. Appropriate psychological, psychosocial and behavioural interventions should be put in place as well as considering drug treatments. Around 65% of patients with ADHD continue to meet full criteria or have achieved only partial remission by adulthood. It is appropriate to continue treatment started in childhood in adults whose symptoms remain disabling. 87 states that ‘Healthcare providers should ensure continuity of care for people with ADHD’. Also, that after titration and dose stabilisation, prescribing and monitoring of ADHD medication should be carried out under Shared Care Protocol arrangements with primary care. The BHFT CAMH Service is commissioned to provide a service to children aged up to and including 18 years of age.

green, brown or non-formulary drugs in the NHS Berkshire traffic light system. This document sets out these responsibilities from initial referral to the Child and Adolescent Mental Health Service (CAMHS) ADHD Pathway through to on-going treatment maintenance, support and ultimately, referral to Adult ADHD services if necessary. Formulary Status and Prescribing Guidance According to NICE Guidelines*: 1. Offer methylphenidate (either short or long acting) as the first line pharmacological treatment for children aged 5 years and over and young people with ADHD. 2. Consider switching to lisdexamfetamine for children aged 5 years and over and young people who have had a 6-week trial of methylphenidate at an adequate dose and not derived enough benefit in terms of reduced ADHD symptoms and associated impairment. 3. Consider dexamfetamine for children aged 5 years and over and young people whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile. Note that this is an off-label use for some people aged 6 to 17. See NICE's information on prescribing medicines. 4. Offer atomoxetine or guanfacine to children aged 5 years and over and young people if: e they cannot tolerate methylphenidate or lisdexamfetamine or e their symptoms have not responded to separate 6-week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses. Choice of Medicine (with | Place in therapy Formulary status link to SPC) Berkshire West Methylphenidate IR 18 line Amber Modified release options on BHFT Formulary: - Xenidate XL® (equivalent to Concerta XL®) - Equasym XL® - Medikinet XL® Lisdexamfetamine 2"4 line Amber Dexamfetamine 34 line Amber Atomoxetine 34 line Amber Guanfacine 34 line Amber Prescribing Information

history of substance misuse. Patients have been known to increase their dose of stimulant to higher than the maximum licensed doses. Symptoms of chronic intoxication with amfetamines include severe dermatoses, marked insomnia, irritability, hyperactivity, personality changes and even psychosis. If extra prescriptions are requested by the patient or their carer, then the prescriber must inform either the GP or Consultant Psychiatrist (depending on who the request goes to) of this immediately to prevent duplication of requests. If a patient is suspected of misusing stimulants, they should be referred back to their Consultant Psychiatrist, for consideration of alternate treatment. Pregnancy & Lactation The safety of these drugs in pregnancy and lactation cannot be guaranteed. Ifa patient taking any of these drugs reports a pregnancy or is planning a pregnancy, refer to the specialist for guidance and advice. Alternatively, call the Medicines Responsibilities Specialist Team Responsibilities (CAMHs) The service offers medication choice for children aged 6 years and over and young people. Initial Consultation 1. To determine diagnosis of Attention Deficit Hyperactivity Disorder following full assessment 2. Carry out a full pre-drug treatment assessment including: e a full mental health and social assessment e a full history and physical examination, including: . past and present medical and psychiatric disorders or symptoms . Baseline height, weight, blood pressure, heart rate. * documentation of concomitant medicines * assessment for risk of substance misuse and drug diversion

assessment of the rate and rhythm of the pulse. Details of what should be included in the cardiac examination can be found in appendix 2. 3. At the time of diagnosis, clinicians from the ADHD Specialist Care Pathway provide young people and carers with psycho-education and information about the comprehensive management of ADHD _ including non-psychopharmacological interventions and psychopharmacological interventions. A. All medication for ADHD should only be initiated by a healthcare professional with training and expertise in diagnosing and managing ADHD. NICE”) state; ‘An electrocardiogram is not needed before starting stimulants, atomoxetine or guanfacine if cardiovascular history and examination are normal and the person is not on medicine that poses an increased cardiovascular risk’. However, where there are cardiovascular risk factors (including family history), the GP will be requested to provide an ECG. For further information regarding the drug initiation process, see appendix 6: drug initiation protocol. B. Within 4 weeks of initial prescription (and usually within first 2 weeks — this could be in the form of a telephone review): e Review efficacy of medication prescribed, e Monitor for side-effects. Those patients prescribed atomoxetine should be closely monitored for agitation, irritability, suicidal thinking, self-harming behaviour and unusual changes in behaviour, particularly during the initial months of treatment of after a change in dose. Parents or carers should also be warned about the potential for liver damage in rare cases with atomoxetine (usually presenting as abdominal pain, unexplained nausea, malaise, darkening of the urine or jaundice). e Adjust dose if necessary, or switch to alternative if treatment deemed ineffective e Height, weight, blood pressure and pulse check at follow-up appointment.

6. When the patient is stable refer to GP for shared care when both parties consider it is clinically appropriate to do so. 7. Provide support and advice regarding all aspects of medication to the GP. 8. Review progress if requested by GP e.g. change in behaviour; treatment resistance, increased sedation, significant growth delay etc. Notify the GP of the results of any patient reviews, including changes in prescribed dose, and ensure the patient has sufficient medication until the GP has received this information. 9. Receive and respond to feedback from shared care GP as appropriate, e.g. progress/status of the child and in particular noting any dose changes/alterations/discontinuation etc. of treatment under the shared care agreement. 10. Liaise with the child’s; school, residential placements and respite care homes as appropriate and ensure that information on drug treatment is given as appropriate to the patient, carers and teachers. 11. At least annually, review and monitor progress. This would include monitoring of physical parameters/ psychiatric symptoms and inform the GP of the outcome. Ideally timed so that patient is reviewed every 3months, alternating between GP and CAMHs specialist. 12. Because BHFT make recommendations in a cost-effective manner, changes of specified brands should only be initiated by the secondary care specialist to prevent potential adverse effects when switching brands. Different brands of modified release methylphenidate are not interchangeable. Drug Holidays These should be discussed with and initiated by the specialist. If a child or young person's height over time is significantly affected by medication (that is, they have not met the height expected for their age), consider a planned break in treatment over school holidays to allow ‘catch-up' growth. Drug holidays may reduce adverse events without causing a deterioration of ADHD symptoms over time. The effect of missed doses planned dose reductions and brief periods of no treatment should be considered and the preferred pattern of use should also be reviewed. Coexisting conditions should be reviewed, and the child or young person treated or referred if necessary. The need for psychological and social support for the child or young person and for the parents or other carers should be assessed. Drug holidays are not advised for guanfacine in view of discontinuation symptoms. Trial withdrawal There should be a discussion with the patient at annual reviews to consider whether the medication is still needed, especially where treatment has continued for 24 months. If there has not already been a trial off medication, consider withdrawal of medication (except if review by specialist has led to an increase in dose). This should be offered and discussed with the patient and the outcome recorded. Consideration must be given to patient choice.

Methylphenidate, dexamfetamine and lisdexamfetamine can generally be withdrawn by treatment discontinuation but monitor for signs of withdrawal (e.g. extreme tiredness, becoming even more hyperactive, eating more and depression). Atomoxetine withdrawal Reduce the dose at weekly intervals and discontinue over a four-week period. Guanfacine withdrawal Blood pressure and pulse may increase following discontinuation of guanfacine. In post- marketing experience, hypertensive encephalopathy has been very rarely reported upon abrupt discontinuation of treatment. To minimise the risk of an increase in blood pressure upon discontinuation, the total daily dose should be tapered in decrements of no more than 1 mg every 3 to 7 days. Blood pressure and pulse should be monitored when reducing the dose or discontinuing treatment. If two or more doses are omitted unintentionally, then guanfacine should be re-titrated from the start again. If by the age of 17yrs and 6 months, the patient is not stable after trial withdrawal and is foreseen to continue with medication treatment into adulthood, the transition to the adult ADHD service is to be made (see appendix 5). Tertiary Care Specialist Advice and Unlicensed Use of Medicines In children and young people whose ADHD is unresponsive to methylphenidate, lisdexamfetamine, dexamfetamine, atomoxetine and guanfacine, further treatment should follow referral to tertiary services. The use of medication not included in recommendations, or unlicensed for ADHD (such as bupropion, clonidine, modafinil and imipramine) should only be considered in the context of tertiary services. Advice from a tertiary service should be sought for Clonidine for children with ADHD and sleep disturbance, rages or tics, atypical antipsychotics in addition to stimulants for people with ADHD and coexisting pervasive aggression, rages or irritability. Transition to Adult Services e The transition process applies to all CAMHs patients on prescribed ADHD treatment (i.e. methylphenidate, atomoxetine, dexamfetamine, lisdexamfetamine and guanfacine), (see appendix 5; transition protocol). e Transition process to commence at 17yrs 6 months, in preparation for transfer at 18 years. e If the patient has psychiatric co-morbidity requiring on going managed care with CMHT care pathways, transition should be made to CMHT as usual. (Note, the CMHT will not continue the prescription for ADHD treatment, this will be continued by GP)

assessment of on-going need and offer medication monitoring and supervision If GP unable to continue prescribing, drug treatment will stop when discharged from CAMHs Transfer of Prescribing Responsibilities Transfer of clinical responsibility to primary care should only be considered where the person’s clinical condition is stable or predictable. Communicate to the patient’s GP to request a transfer of prescribing responsibilities; detailing the drug, formulation, dose, and frequency to be prescribed, along with details of how to refer to the CAMHS team should the patient develop a problem with their treatment. Disease Monitoring The patient will be reviewed by the Specialist Team when necessary. The time interval will differ depending on the individual patient. Communicate to the GP all necessary monitoring that needs to be carried out in primary care (detailed below). Primary Care Team Responsibilities (General Practitioner) Pre-Referral to secondary care specialist service: Referral from the community to CPE from either health, education, or social care professionals (for example, GPs, paediatricians, educational psychologists, SENCOs, social workers, Primary Mental Health Care Worker). The person making the referral to secondary care must inform the child or young person's GP. Because symptoms of ADHD can be mimicked by a number of physical conditions such as thyrotoxicosis, or side effects of medical treatment for physical conditions (e.g. high dose salbutamol in asthma) or associated with physical conditions such as neurofibromatosis, and tuberosclerosis, the referrer/GP should provide as much medical information as possible at the initial referral including: o details of any diagnosis or history where caution is needed for potential medication treatment, such as history of exercise syncope, undue breathlessness, and other cardiovascular symptoms o past and present medical and psychiatric symptoms including currently prescribed medications and allergies. Records of any previous physical assessments including cardiovascular system examination, weight, blood pressure and heart rate. o Information that suggests risk of substance misuse and drug diversion should be included in the referral.

history of serious cardiac disease such as malignant arrhythmias, a history of sudden death in young family members who are under the age of 40, abnormal findings on previous cardiac examination before medical intervention for ADHD (see appendix 2). Any abnormal findings should be sent to the CAMHS psychiatrist as well as GP. General Practitioner Responsibilities - Maintenance Issue repeat prescriptions after stabilisation. Methylphenidate, Dexamfetamine and Lisdexamfetamine are controlled drugs (CDs). Sustained release methylphenidate preparations need to be prescribed by brand as they are NOT interchangeable due to different release profiles. Changes of specified brands should only be initiated by the secondary care specialist to prevent potential adverse effects when switching brands. Continue any required monitoring as per specialist recommendations (will be dependent on the drug prescribed). To evaluate annually the benefit of treatment, symptom control, adverse effects, and the need to continue. Provide feedback to the specialist as appropriate, as to the progress/status of the child and in particular notifying of intention to discontinue and adverse effects of treatment. Ideally timed so that patient is reviewed every 3 months, alternating between GP and CAMHs specialist. To make urgent arrangements to be seen by the specialist in the event of any of the following. o Failure to thrive/retardation of growth o Persistent sleep disturbance o Persistent problems with poor attention/deterioration in behaviour o Pronounced change in mental state To refer patients for prompt specialist cardiac evaluation if symptoms develop such as palpitations, exertional chest pain, unexplained syncope, dyspnoea, or other symptoms suggestive of heart disease. To be alert for signs of diversion, misuse, or abuse of methylphenidate. Where a change in medication or dose is required, for example if a drug/dose has not been tolerated, the following procedure will be followed: a. GP/Patient to contact Clinical Nurse Specialist who will liaise with Consultant to decide on a suitable alternative dose. b. Clinical Nurse Specialist will send a written request featuring the prescriber’s advice to ask GP, including which prescriber gave the advice, to issue a prescription, detailing individual patient plan including dose titration or the need to discontinue treatment (where applicable). c. Written requests from NMP’s will not require approval from a doctor for requests as stated in 8.b. Report adverse events to the CHM/MHRA. 10. Report adverse events to the consultant sharing the care of the patient.

Results within normal limits Discontinue if neutropenia develops and discuss with appropriate specialist. Atomoxetine may require dose reduction/discontinuation if laboratory or clinical evidence of abnormal hepatic function. Behaviour including self- harming At each appointment Able to cope with daily living If unexpected change in behaviour is noted review is indicated.

Mental state including emergence of psychotic symptoms, irritability, tics, suicidal thinking or anxiety/panic symptoms 3-12 monthly depending on actual presentation (by GP or if specialist has been referred to) Discuss with secondary care specialist as necessary Patient's role (or that of carer) e Ask the specialist or GP for information if he or she does not have a clear understanding of the treatment. e Tell the specialist or GP of any other medication being taken, including over-the-counter products. e Read the patient information leaflet included with your medication and report any side effects or concerns you have to the specialist or GP e Adhere to treatment as advised by the specialist.

Wherever possible, queries regarding medications are best addressed to the patient’s CAMHS consultant or ADHD Practitioner. However, GPs and other clinicians can access urgent medical advice about a young people on ADHD medications or other clinical enquiries requesting to be called back by the on-call CAMHS Consultant.

diagnosis and management. 14 March 2018 Last updated: 13 September 2019 Recommendations | Attention deficit hyperactivity disorder: diagnosis and management | Guidance | NICE Assessment Report. Atomoxetine: a review of the effects on heart rate and blood pressure. May 2012. SPCs (Summary of Product Characteristics) for Equasym XL, MedikiNet XL, Concerta XL, Strattera, Elvanse and Ritalin. ‘Practitioner Review: Current best practice in the management of adverse effects during treatment with ADHD medications in children and adolescents.’ Cortese et al. Journal of Child Psychology and Psychiatry. 54:3 (2013), pp227-246. London Medicines Evaluation Network. Extended-release methylphenidate — a review of the pharmacokinetic profiles available.

Appendix 1: Dosing/ cost information Drug (with Action Dosage (BNF) BNF® Prices links to SPC) Methylphenidate | CNS stimulant. | For Child 5 years 15mg/day = IR Schedule 2 Initially 2.5 mg twice daily, £9.09 controlled increased in steps of 2.5 mg daily Generic drug. if required, at weekly intervals, 100mg/day = methylphenidate | Onset: 20-60 increased if necessary up to £54.60 min 1.4 mg/kg daily in 2-3 divided Duration: 2-4 doses, discontinue if no response hours after 1 month, if effect wears off in evening (with rebound hyperactivity) a dose at bedtime may be appropriate (establish need with trial bedtime dose). Treatment may be started using a modified-release preparation. - For Child 6-17 years Initially 5 mg 1-2 times a day, increased in steps of 5-10 mg daily if required, at weekly intervals, increased if necessary up to 60 mg daily in 2-3 divided doses, increased if necessary up to 2.1 mg/kg daily in 2-3 divided doses, the licensed maximum dose is 60 mg daily in 2-3 doses, higher dose (up to a maximum of 90 mg daily) under the direction of a specialist, discontinue if no response after 1 month, if effect wears off in evening (with rebound hyperactivity) a dose at bedtime may be appropriate (establish need with trial bedtime dose). Treatment may be started using a modified-release preparation. Methylphenidate modified release Dose titration should start at the lowest possible dose. This is achieved by starting patients on immediate release methylphenidate 5mg once or twice daily and increasing dose by 5- 10mg every week before moving to a modified release preparation.

Xenidate XL® CNS stimulant 18mg — 54mg once daily 18mg/day = Schedule 2 Start at 18mg daily. Adjust at £31.19 controlled weekly intervals. 27mg/day = drug. £36.81 Onset: 30min 36mg/day = —2h £42.45 Duration: 54mg/day = 12hours £36.80 IR:22% 108mg/day = ER:78% 18mg Xaggitin XL® = 18mg £73.60 Concerta XL® = 15mg Ritalin® CNS stimulant. | 10mg — 60mg once daily. 20mg/day = Schedule 2 £30.00 controlled Start at 10mg daily. Adjust at 30mg/day = drug. weekly intervals. £35.00 Onset: 20-60 40mg/day = Medikinet XL® | min £57.72 capsules Duration: up to 50mg/day = 8 hours £62.52 IR:50% 60mg/day = ER:50% £67.32 100mg/day = £113.02 CNS stimulant. | 10mg to 60mg once daily 10mg/day = Schedule 2 Start at 10mg daily. Adjust at £25.00 controlled weekly intervals. 20mg/day = drug. £30.00 Onset: 20-60 30mg/day = Eaves | min £35.00 gapsures Duration: 8 60mg/day = hours £70.00 IR:30% 100mg/day = ER:70% £130.00 Lisdexamfetami | CNS stimulant | 30mg once daily (morning), 30mg/day = ne Schedule 2 increased weekly to 50mg then £58.24 controlled drug | 70mg if necessary. 50mg/day = Elvanse® Onset: 3.5 £68.60 hours Can be started at 20mg if consid | 70mg/day = Duration: £83.16 unclear Atomoxetine Selective For Child 6-17 years (body- 60mg/day Noradrenaline | weight up to 70 kg) and less = Strattera® reuptake Initially 500 micrograms/kg daily | £48.20 inhibitor (nota | for 7 days, dose is increased controlled according to response; drug) maintenance 1.2 mg/kg daily,

total daily dose may be given 80- Onset of either as a single dose in the 100mg/day = action: may morning or in 2 divided doses £64.28 take 4-6 weeks | with last dose no later than early evening, high daily doses to be Liquid Can be given | given under the direction of a 4mg/1ml as a single specialist; maximum 1.8 mg/kg (300mls) dose in the per day; maximum 120 mg per £85.00 morning OR day. twice daily — last dose no For Child 6-17 years (body- later than early | weight 70 kg and above) evening. Initially 40 mg daily for 7 days, dose is increased according to response; maintenance 80 mg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening, high daily doses to be given under the direction of a specialist; maximum 120 mg per day. Dexamfetamine | CNS stimulant | Initially 2.5 mg 2-3 times a day, 10mg/day = Schedule 2 increased in steps of 5mg once £49.46 controlled drug | weekly if required. 60mg/day = Onset: 20-60 £238.68 min Usual maximum 1 mg/kg daily, up Duration: 3-6 to 20 mg daily (40 mg daily has Liquid hours been required in some children); | 5mg/5ml (500ml) = maintenance dose to be givenin | £114.49 2-4 divided doses. Guanfacine Selective Start with img daily, then 1mg/day = alpha2A- increase dose weekly by not £60.00 Intuniv® adrenergic more than 1mg increments receptor according to response. 4mg/day = agonist. Non- £81.60 stimulant. The recommended maintenance dose range is 0.05-0.12 mg/kg/day.

assessment, investigation, and referral for cardiology opinion, of paediatric patients with ADHD in whom treatment is being considered. Reference is made to the guidance produced by the National Institute for Health and Clinical Excellence - NICE clinical guideline 87, ‘Attention deficit hyperactivity disorder, Diagnosis and management of ADHD in children, young people and adults, September 2008.’ For those in whom treatment (Methylphenidate, Atomoxetine, Dexamfetamine) is being considered, we suggest: A full history and physical examination, including: e assessment of history of o Symptoms = exercise syncope = undue breathlessness, not obviously due to a respiratory cause = chest pains = palpitations o Past medical and family history = past medical or family history of serious cardiac disease = ahistory of sudden cardiac death in family members aged <40 years e examination of the cardiovascular system, including: o height o weight o heart rate oc blood pressure (plot on a centile chart - An electrocardiogram (ECG) should be performed if there are: © positive features in the history o abnormal findings on cardiac examination (murmur, abnormal pulses, radio-femoral delay, hypertension). o The ECG should be done in a recognised electrophysiology department o if the treatment may affect the QT interval (NICE 2018)

history for cardiovascular symptoms a past medical history of serious cardiac disease or family history of sudden cardiac death in people under 40 years Sustained resting tachycardia, greater than maximum heart rate for age on 2 separate occasions (see table below). BP>95"" percentile Abnormal cardiovascular examination Abnormal ECG blood pressure that is classified as hypertensive for adults (see NICE's guideline on hypertension in adults) shortness of breath on exertion compared with peers Monitoring of treatment and consideration of onward referral Monitor heart rate and blood pressure and record on a centile chart before and after each dose change, and every 3-12 months. Palpitations, arrhythmia, sustained resting tachycardia (see table below), or systolic blood pressure rising to greater than the 95th percentile, measured on two separate occasions, should prompt dose reduction and/or stoppage, but are not necessarily indications for referral to a Paediatrician with a Cardiology Interest. Age — related Heart Rate Ranges! Age Heart Rate Range <1 yr 80 — 180 1-2 yrs 100 — 160 2-4 yrs 80 - 140 4-6 yrs 80 — 120 6-8 yrs 70-115 8-12 yrs 70-110 >12yrs 60 — 110

assessment D1. Before starting medication, people with ADHD should have a full assessment, which should include: * a review to confirm they continue to meet the criteria for ADHD and need treatment * a review of mental health and social circumstances, including: * presence of co-existing mental health and neurodevelopmental conditions * current educational or employment circumstances * risk assessment for substance misuse and drug diversion * care needs * a review of physical health, including: - a medical history, conditions that may be contraindications for specific medicines - current medication - height and weight (measured and recorded against the normal range for age, height and sex) - baseline pulse and blood pressure (measured with an appropriately sized cuff and compared with the normal range for age) - an ECG if the treatment may affect the QT interval (for example, tricyclics and monoamine oxidase inhibitors). D2. Refer for a cardiology opinion before starting medication for ADHD if any of the following apply: * history of congenital heart disease or previous cardiac surgery * history of sudden death in a first-degree relative under 40 years, which could suggest a family history of cardiomyopathy or channelopathy * shortness of breath on exertion compared with peers * fainting on exertion or in response to fright or noise * palpitations that are rapid, regular and start and stop suddenly (fleeting occasional 8 bumps are usually ectopic and do not need investigation) * chest pain suggesting cardiac origin * signs of heart failure * blood pressure consistently above the 95th centile for age and height. Allergies Prior to commencing ADHD medications for drug naive individuals, any food allergies or intolerances should be elicited in order to exclude products that may contain the known allergen. Further enquiries regarding product composition can be obtained via the information help desk at Prospect Park Pharmacy. Example: Gluten intolerance 1) The manufactures of Medikinet can confirm that both the controlled release capsules and immediate release tablets are gluten free and there is no risk of cross contamination during the manufacturing process. 2) The manufactures of Concerta XL cannot specifically state that the product does not contain gluten as they cannot confirm that there is no cross contamination during the manufacturing process. Gluten is not listed in the product ingredients.

3) Novartis confirmed that although the Ritalin does not come into contact with gluten in the process of manufacturing, it does contain wheat starch at less than 100ppn wheat gluten. According to Celiac UK this is classified as a low gluten product. Immediate release (IR) or sustained release, OROS (Osmotic controlled Release Oral System) ? Is there any evidence in terms of efficacy and adverse effects? IR methylphenidate versus OROS methylphenidate * No evidence was identified for all-cause mortality, suicide or suicidal ideation, cardiac mortality, cardiac events, substance misuse, increase in seizures, liver damage, tremor, congenital defects, sexual dysfunction and psychotic symptoms for follow up to 12 weeks. No evidence was identified for follow up over 12 weeks. + At 4 weeks the total number of children reporting any adverse event was not Clinically different between the groups (1 study, low quality). Differences in appetite, insomnia and tics at 3-4 weeks (1 study very low quality) were not clinically important between the 37 groups. Answer: No When to use IR? 1. Titrating in slower steps Ensure that dose titration is slower and monitoring more frequent if any of the following are present in people with ADHD: * neurodevelopmental disorders [for example, autism spectrum disorder, tic disorders, learning disability (intellectual disability)]. * mental health conditions [for example, anxiety disorders (including obsessive— compulsive disorder), schizophrenia or bipolar disorder, depression, personality disorder, eating disorder, post-traumatic stress disorder, substance misuse] * physical health conditions (for example, epilepsy or acquired brain injury). IR: tailoring to need and flexibility; - Addition in the afternoon to 8 h OROS - Co-existing conditions where careful monitoring and slow titration required. 2. Treatment is tailored effectively to the individual needs of the child, young person or adult. - Flexibility around more drug free periods during the day. - Adjunct when effect of OROS wears off. 3. To optimise effect (for example, a modified-release preparation of methylphenidate in the morning and an immediate-release preparation of methylphenidate at another time of the day to extend the duration of effect). When to use OROS or sustained release medications ? 1 Sustained and smoother cover during the day Less variation in blood level concentrations Convenience Fewer times to administer during the day Administration Difficulties swallowing tablets 'ortpoe

problems of storing and administering controlled drugs at school 8. the risk of stimulant misuse and diversion with immediate-release preparations Matched Biphasic Release Methylphenidate Preparations According to the London Medicines Evaluation Network the newer preparations Matoride XL and Xenidate XL have been granted replicate marketing authorisation to Concerta XL on the basis that they have satisfied the criteria for an equivalent release profile for the Concerta XL product. It would seem appropriate for Matoride XL or Xenidate XL to be considered as alternatives to Concerta XL when initiation of Concerta XL is appropriate in an individual patient. As per BNF advice, prescribers should specify the brand when prescribing Matoride XL or Xenidate XL to ensure the correct product is dispensed. Xenidate XL is preferred to Matoride XL because it offers dose increases of Img steps with a 27 mg tablet (18-27-36-45-54). Matoride XL does not provide a 27 mg tablet and thus only offers 18 mg step increases (18-36-54). Cost efficiencies The NHS indicative price for Xenidate XL is almost half as much as Concerta XL (see BNF). Concerta XL 18mg tablets (Janssen-Cilag Ltd) Size Unit NHS indicative price Drug tariff | Drug tariff price . Methylphenidate hydrochloride 18mg 30 tablet (POM) £31.19 Part VIIIA Category C £31.19 Xenidate XL 18mg tablets (Mylan) Active ingredients Size Unit NHS indicative price Drug tariff Drug tariff price . Methylphenidate hydrochloride 18mg 30 tablet (POM) £15.57 Part VIIIA Category C £31.19 Switching stable patients to different biphasic release Methylphenidate Preparations Switching a stable patient from Concerta XL to another matched biphasic release preparation is not recommended. The patient should remain on whichever brand they were initiated on if they are stable. There are many reports in this country and abroad where patients were seriously destabilised after a local switch in brand. Destabilising a patient can have huge financial implications — e.g. repeat appointments, drug costs, education/job losses etc. that could far outweigh any cost- savings from switching. Using SR 5mg Dose Increases When considering dose increases of Medikinet XL in 5 mg steps, a detailed assessment of the effectiveness of drug cover over time is required and

consideration should be taken whether alternative modified-release preparations with different biphasic release profiles are more appropriate to use.

assessment: re-evaluation if they will still meet the criteria for ADHD, offer medication breaks. DIVA is a useful tool to use. 2.Update the initial ADHD assessment report, with the information gathered since e.g. new information regarding family history of cardiac disease may have been documented, update of any medical condition since diagnosis etc. 3. Evaluate the need for concurrent referral to CMHT or other agencies 4. Adult ADHD team members will endeavour to attend the CAMHS ADHD team meeting once a quarter, that complex transition cases could be discussed. B. In the second six months: Initiate the referral to Adult ADHD team: when the YP is around 17 and half years old, referral to ADHD team, using ADHD transition referral form Inform the GP about the transition and request GP for physical checks, as per the shared cared protocol with adult services, so that the physical check results are available for the adult services when YP is seen first time by the adult team Transition groups: Whilst the YP waits for the transition, they will have opportunity to attend the transition group. Aim of the transition group will be to socialise the YP to adult ADHD service, psych education of ADHD in adult and inform the YP about the available resources they can access (in the education services, voluntary sectors etc). (The details for the group is yet to be formalised, we also plan to use Skype for YP who are not able to attend the meeting, and also use Sharon platform) e Once referral is accepted by the Adult ADHD team, YP will be discharged from the CAMHS e First appointment with the Adult ADHD team will be with in the 6 months to one year of the referral

Consultant Child and Adolescent psychiatrist

Diagnosis: Single pregnancy Clinic note: Routine booking appointment MLC/CLC CLC - BMI 37 General Wellbeing Generally well in herself, feeling sensitive to smells Quit smoking when had positive pregnancy test - consented to referral to stop smoking service, does not feel she needs NRT Risk Assessments completed VTE - scores 2 (family hx and BMI) Pre-Eclampsia (aspirin provided as family hx and BMI) Pelvic Floor - referred to pelvic workshop

Assessment - to have at 28 weeks Safeguarding No concerns Referrals to Obstetrics, pelvic workshop, stop smoking service Medications Provided Aspirin - advised to commence from 12 week scan Completed with consent Booking Bloods MSU CO Monitoring - 3 Vaccinations All pregnant women are eligible for the flu (seasonal), pertusis vaccine (whooping cough), RSV and covid vaccines. Please speak to your MW of how to receive these vaccines. Vaccinations in Pregnancy The RSV vaccine will be administered by your MW at 31 weeks of pregnancy A guide to RSV vaccination for pregnant women Foods in pregnancy Exercise and physio advice including pelvic floor Whooping cough and Flu Vaccines Vitamin D and Folic Acid Screening Tests

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management for this patient. The patient does meet the criteria for the and has been accepted for assessment andtreatment. As your surgery has opted not to provide management at this stage, she will be treated by BHFT.

Diagnosis: Closed left finger dislocation Clinic note: Diagnoses: Left index finger PIPJ dislocation + 5th metacarpal fracture - Other orthopaedic injuries: Right distal clavicle fracture, Right 3-7 rib fractures - Other injuries: facial fractures, frontal lobe contusion, extradural haematoma Date of Injury: 15/5/25 Mechanism of Injury: Fell down flight of stairs Background: Pre diabetic, previous mild stroke, lives alone

Management so far: - Open reduction of index finger PIPJ dislocation + K wire fixation 4/6/25 Plan: Remove backslab Thermoplastic splint Fracture clinic next week 20/6/25 for removal of wire. Patient to come at 13:30 Has fracture clinic follow up on 4/7/2025 with in regards to his clavicle fracture | saw a 76 year old gentleman in fracture clinic today alongside . He is 1 week down the line since the above surgery. He is currently an inpatient. On examination today: Backslab removed Wound site and pinsite clean and healthy Minimal tenderness Nil tenderness over MC fracture Nil tenderness over clavicle fracture site. Skin intact We will see him in 1 weeks time for removal of wire. 6 Trauma & Orthopaedics Registrar

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We discussed currently experiencing heightened anxiety, challenges with attending school which has resulted in an additional private psychologist appointment on Monday 16 June to support this current crisis. The EHCP review has not gone ahead and therefore no resolution regarding 's ongoing provision has been finalised. We discussed the CAMHS offer as follows; « will be reviewed and offered individual Cognitive Behavioural Therapy (CBT) weekly, this is psychotherapy with a qualified CBT Therapist, not a psychologist or a psychiatrist. « Alongside this offer, will have access to our Consultant Psychiatrist to review and monitor medication, within the next 4 weeks, | am unable to state how regular these appointments /reviews will be going forward as offered on an individual basis and dependant on the psychiatrist's professional opinion. « Our service offers time-limited therapy, it is reviewed every 6 weeks and is not an indefinite offer, a typical treatment offer is between 12 to 18 sessions. You shared concerns around being able to engage with a new therapist at this time, has spent time building trusting relationships and developing a support network she trusts, and you felt it would not be the right time to withdraw this from at a time she needs consistency. stated that her preference is to continue with current provision in place, having developed positive therapeutic relationships. 3 disability Fear Q speed on te BES confident Fig Outstanding sy LEADER = - NoExcuse Weill be polite and kind and we expect you to treat our staff in the same way. We will take action against ForAbuse = anyone who is verbally, racially, physically or sexually abusive, including stopping access to our services.

As discussed, you have confirmed that it is not the right time for pt to accept the CAMHS treatment offer and feel this would not be in pt's best interests for the reasons stated above and accept that pt will therefore be discharge from our service. | can confirm that pt is now discharged from CAMHS Anxiety Disorders Treatment Team, however, should the situation change within a six-month period, visit her GP again and ask for a re-referral to Berkshire Child and Adolescent Mental Health Service (CAMHS). | wish pt and yourselves all the best for the future and hope that all goes well with the upcoming EHCP review.

HISTORY:General non-specific malaise for 5 days. In last two days, getting dizzy spells, feels needs to sit down, feeling hot/sweaty. Feels eyes are ‘a bit funny’ and vision blurred - episodes last 5-10mins. Then gets headaches and palpitations (feels fast heart rate). Some nausea but no vomiting. 2/7 history. Waking up with headaches. E&D ok. Appetite normal. Passing urine and opening bowels ok. Reports symptoms not similar to previous hypo/hyperthyroidism symptoms. PMHx/ Thyroidectomy

INITIAL PLAN: For ECG and bloods, then review. INVESTIGATION RESULTS (15:40): 12-Lead ECG - Sinus rhythm with single PVC recorded, nil acute findings. Latest 13/06/25 Range & Units Sodium 133 - 146 140 mmol/L Potassium Blood 3.5-5.3 5.1 mmol/L

Urea 2.5-7.8 5.3 mmol/L Creatinine 49 - 90 umol/L 69 eGFR result/1.73m2 (EPI) 90 - 120 87 (L) mL/min CRP O-5 mg/L 6.5 (H) High-Sensitivity Troponin | O- 15 ng/L 19 (H) Haemoglobin 115 - 165 g/L 140 WBC 4-11 10*9/L 7.1 Platelets 150 - 450 273 10*9/L RBC 3.5-5.5 A471 10*12/L Hematocrit 0.37 - 0.47 0.439 Ratio McVv 75 - 105 fL 93.3 MCH 26 - 35 pg 29.7 MCHC 290 - 350 g/L 319 RDW 11-15% 12.8 MPV 8.2 - 11.9 fL 10.6 Neutrophils Absolute 2-75 10*9/L 45 Lymphocytes Absolute 1-4 10*9/L 1.7 Eosinophils Absolute 0 - 0.4 10*9/L 0.2 Monocytes Absolute 0.2 - 0.8 10*9/L 0.6 Basophils Absolute 0 - 0.1 10*9/L 0.1 Hypochromia % 0.4 WBC (POCT) Haemoglobin (POCT) Platelets (POCT) Red Cell Count (POCT) HCT (POCT) MCV (POCT) MCH (POCT) MCHC (POCT) 4-11 10*9/L 6.98 115-165 g/L 136 150 - 450 10*9/L 3.5 -5.5 10*12/L 0.37 - 047 L/L 0.414 75-105fL 90.0 26-35pg 29.7 290 - 350 g/L 330

RDW (POCT) 11-15% 16.5 (H) MPV (POCT) 75-9L 9.5 (H) Neutrophils (POCT) 2-7.5 10*9/L 4.29 Lymphocytes (POCT) 1-410*9/L 1.79 Monocytes (POCT) 0.2 - 0.8 10*9/L 0.66 Eosinophils (POCT) 0-04 10*9/L 0.16 Basophils (POCT) 0 - 0.1 10*9/L 0.06 Large Immature Cells (POCT) 0- 0.1 10*9/L 0.02 D-dimer (POCT) 0-530 ng/mL 264 Wells Score (POCT) Not Provided ECG 12 lead Rpt (P) (L): Data is abnormally low (H): Data is abnormally high (P): Preliminary Rpt: View report in Results Review for more information In light of borderline raised high-sensitivity troponin, d/w medics - not suitable for Medical SDEC. Advised discuss with medical take, bleep 5371. d/w Medical SpR - accepted for medical review - moved to ambulatory ED. Many thanks in advance. Date completed: 13/6/2025 GP Practice

Assessment: PC:11/40 pregnant/. PV bleed 2 hours- 1 pad used/ passes a lot of blood on toilet abdo / back pain / nil tip of shoulder pain Patient emotional and woried about baby Decline analgesia Diagnosis: Threatened miscarriage

Outcome: Treatment complete Destination: Home Follow Up: General Practitioner No relevant medication details Treatments: Verbal advice, Medications Administered to the Patient whilst in ED: Results:_Laboratory or Other Results This Visit (last charted value for your 13/06/2025 visit) No Laboratory or Other Results This Visit Final Emergency Department Discharge Summary

Admission Notification as an EMERGENCY admission into Urology department at TH SAU SDEC Date of Admission: 13 Jun 2025 16:04 .

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Date: 30/05/2025 Clinic Letter: Concerns Autism Spectrum Condition Selective eating Constipation Sleep difficulties Medications Slenyto 2mg Laxido 1-2 sachets per day

Plan to continue to have Slenyto 2mg at bedtime, to follow sleep routine and he could have Melatonin breaks in school holidays. As is selective with his eating, | have requested nutritional bloods to see if he has any nutritional deficiencies. 's mother could go to website and could book the blood tests for hospital | will see face to face in 4 months.

13 June 2025 Recent cardiac monitor shows heart rate ranging between 57 to 97 bpm with a mean heart of 72 bpm. Sinus rhythm was noted throughout the recording with normal heart rate variation. infrequent ectopics seen. There was no evidence of sustained arrhythmias or AV block. Essentially these results are very reassuring. Thank you sincerely 13/6/2025 16:06

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Diagnosis: Seen in preoperative assessment clinic Cataract Clinic note: i had the pleasure of reviewing pt in the eye clinic today. Referred for cataract evaluation. On examination, there was presence of cataracts in both eyes and an epiretinal membrane in right eye. * We have discussed Cataract surgery including the pros and cons. ¢ We discussed the risks which include: infection, inflammation, loss of the capsular bag, further surgery and 1:1000 risk of loss of vision e We have discussed the post-operative target prescription outcome. You would like to aim to improve distance vision only. You may still require glasses for distance to further improve your vision. You understood and accept that you will be reliant on reading glasses to improve near vision activities (reading and computer distances) in this case. * You are happy to proceed with cataract surgery at this stage * The Cataract Leaflet has been given to you today and you have been advised to read it carefully before you attend for surgery.

We have listed for Left phacoemulsification + IOL under local anaesthesia. For right eye as discussed I have requested an opinion from the vitreoretinal team for further management.

Result Value Ref Range Calcium 1.82 mmol/L Comment: Note new calcium reagent formulation and equation for calculation of adjusted calcium in use from 19.05.2025 Adjusted Calcium 1.96 (L) 2.2 - 2.6 mmol/L Phosphate level 1.43 0.8 - 1.5 mmol/L Alkaline phosphatase 72 30 - 130 U/L Albumin 40 35 - 50 9/L Vitamin D level, blood (Collected: 10/6/2025 10:19) Result Value Ref Range 25-OH vitamin D 63 50 - 200 nmol/L Comment: Vitamin D interpretation: < 25 nmol/L uu... Vitamin D deficiency. 25 - 50 nmol/L ...... May be inadequate >50 nmol/L... Sufficient

250 nmol/L ........ Possible vitamin D toxicity. Urea and electrolytes profile, blood (Collected: 10/6/2025 10:19) Result Value Sodium Blood 141 Potassium Blood 3.8 Comment: No specimen time provided. Urea 3.2 Creatinine 66 eGFR result/1.73m2 (EPI) >90 Comment: NICE no longer recommends adjusting eGFR for African-Caribbeans (NG203, updated August 2021). Free T4 level, blood (Collected: 10/6/2025 10:19) Result Value Free T4 17.7 Thyroid stimulating hormone level, blood (Collected: 10/6/2025 10:19) Result Value TSH 2.45 2/2 Ref Range 133 - 146 mmol/L 3.5- 5.3 mmol/L 2.5 - 7.8 mmol/L 49 - 90 umol/L 90 - 120 mL/min Ref Range 9 - 19.1 pmol/L Ref Range 0.35 - 4.94 mlU/L Please increase alphacalcidiol to 0.75 mcg , please arrange to get prescription from your doctor, please continue with other medications the same. , KHULOOD 13/6/2025 16:01

Diagnosis: Type 2 diabetes mellitus Past Medical History: Diagnosis Date » Acute non-ST segment elevation 25/09/2023 myocardial infarction PCI to RCA Asthma Diabetes mellitus IDDM Hypertension Lab Test Results Component Value Date HGBA1C 84 26/09/2023 CHOL 6.7 27/09/2023 HDL 0.93 (L) 27/09/2023

TRIG 3.0 (A) 27/09/2023 CREATININE 95 16/08/2024 EGFR 74 (L) 16/08/2024 ALT 38 28/08/2023 NA 135 16/08/2024 K 5.1 16/08/2024 Vital signs: 13/06/25 13:32 BP: 118/70 BP Location: Right arm Patient : Sitting BP Cuff Size: Adult Pulse: 64 Weight: 91.6 kg Current Outpatient Mecication Medication Instructions * aspirin 75 mg, Oral, Daily * atorvastatin 80 mg, Oral, Nightly * bisOProlol 1.25 mg, Oral, Daily * glyceryl trinitrate 400micrograms/dose pump 1-2 sprays, Sublingual, As needed sublingual spray * insulin (LANTUS SOLOSTAR) glargine 8 Units, Subcutaneous, Every morning * insulin (NOVORAPID FLEXPEN) aspart 2 Units, Subcutaneous, Daily before breakfast * insulin (NOVORAPID FLEXPEN) aspart 2 Units, Subcutaneous, Daily with dinner * insulin (NOVORAPID FLEXPEN) aspart 10 Units, Subcutaneous, Daily with lunch * MONOMIL XL 30 mg, Oral, Every morning * prasugrel 10 mg, Oral, Daily * RAMipril 2.5 mg, Oral, Daily Body mass index is 26.48 kg/m’. External results HbA1C: Hbatc (mmol/mol) - Transcribed from external source for NDA*: 92 mmol/mol mmol Hbaic - Specimen date for external result*: 30/01/25 Total Cholestrol: Total Serum Cholesterol - Transcribed from external source for NDA*: 4.7 Total Serum Cholesterol - Specimen date for external result*: 30/01/25 Urine ACR: reports that he has quit smoking. His smoking use included cigarettes. He has never used smokeless tobacco. Latest Reference 28/09/23 Range & Units 09:27 Glutamic acid decarboxylase Abs 0 - 5 U/mL <5 Tyrosine phosphatase related IA- U/mL <10 2 Abs Glucose (peptide hormone lab) = mmol/L 13.8

it was lovely to meet Geoffrey in our urgent clinic today. During his admission in September 2023, the type of diabetes was uncertain. However, his antibodies have since returned negative, confirming a diagnosis of Type 2 Diabetes Mellitus (T2DM). pt reports that he only takes his Lantus when consuming carbohydrate rich foods. He is inconsistent with his insulin administration, which is reflected in his elevated HbA1c level of 92 mmol/mol. The reason for not injecting Lantus daily is his concern that it will cause his blood glucose to drop too low. | provided education on the importance of taking Lantus regularly and advised him to reduce the dose by 10-20% if glucose levels drop below 4 mmol/L, or to contact us for further advice (contact number provided). We also discussed the potential introduction of Metformin, which may help with insulin resistance and could possibly allow him to reduce or stop insulin in the future. Education was provided on how Metformin works and its potential side effects. pt mentioned he had previously been on oral tablets, which he felt were ineffective. He also reported experiencing thrush while on them and is reluctant to restart oral medication. He has been restricting his carbohydrate intake and is determined to lower his blood glucose levels through diet alone. | explained that with an HbA1c of 92 mmol/mol, dietary changes alone are unlikely to be sufficient, and medication is necessary at this stage. pt reports a recent eye examination that showed signs of retinopathy, and he also experiences numbness in his heels. We discussed that these are signs of diabetes-related complications, and that dietary control alone will not be adequate to manage his condition. While diet plays a significant role in managing T2DM, he also requires medical intervention. pt's father had a leg amputation, and he is very keen to avoid a similar outcome. Following our discussion, pt has agreed to take his insulin regularly. He has a diabetes blood test scheduled for 16th June and would like to discuss initiating oral therapy after receiving the results. He has also agreed to monitor his blood glucose readings over the coming week and to call us to review his results. Screening: Eye screening completed: Routine eye check carried out for this year?*: 01 Stage recorded: Right eye Left eye Follow up appointment frequency Renal Stage: ACR/PCR (mg/mmol) Feet checked: Routine foot check carried out for this year?*: 01 @ Smoking: tobhxp ® Pregnancy current or planned: .obstatus Changes agreed today Continue taking Lantus, reduce dose by 10-20% if noted hypoglycaemia. Call us in the office with week worth of glucose readings. Contact after his diabetes blood test, to discussed initiation of oral diabetes medications.

Requested GP actions: 13/6/2025 e Please ensure has up to date diabetes screening (cholesterol, HbA1C, Urine ACR and serum creatinine). e Podiatry referral to review 's toe. Next appointment: - 3 months time in our general diabetes clinic

Diagnosis: COPD - Chronic obstructive pulmonary disease Ex-smoker - stopped 20 years ago, about 30 pack years. Tuberculosis - Treated as a child and ? again in 2017 Other orders - Appointment request Routine; Face to Face; No; Specialty —- Any Location, Any Consultant; Respiratory Medicine; General - Outpatient referral to Air Team; Future; Expected date: 11/06/2025 - CT Sinuses with Contrast; Future; Expected date: 11/06/2025

Diagnosis Date Noted * Asthma 11/08/2022 * COPD - Chronic obstructive pulmonary disease 11/08/2022 * Sinus bradycardia 31/03/2025 Resolved Outpatient Problems Diagnosis Date Noted * No Resolved Outpatient Problems Past Medical History: Diagnosis Date * Cardiac arrhythmia * Coronary arteriosclerosis 2016 * Hypertension Full lung function tests; 11.6. 2025: FEV1 0.89 (45.5%) FVC 2.39 (102%) ratio 0.37 Transfer factor = 60% predicted. Performance status = 1. | met this 71-year-old lady in the chest clinic today. She is known to have COPD and had TB as a child and was re-treated She stopped smoking 20 years ago with about a 30-pack-year history. Her main complaint is of a productive cough of thick yellow/green sputum, which seems to originate in her throat and is difficult to clear. She also has nasal discharge and uses saline washes for this. From the COPD point of view, she is reasonably well and although does get breathless occasionally, she can easily manage a flight of stairs and kept up with me walking down the corridor. She has had no chest infections over the last year. She also has a significant cardiac history and had 2 stents inserted 10 years ago.

history, | have requested a sputum sample for both TB and M&CS. i have also requested a CT of her sinuses. | have referred her to our AIR Team and requested pulmonary rehabilitation. in the meantime, | have given her a trial of carbocisteine to see if it will help clear her sputum. When we next see her, we will discuss the merits of using a triple inhaler.

Diagnosis Date Noted * Asthma 11/08/2022 * COPD - Chronic obstructive pulmonary disease 11/08/2022 * Sinus bradycardia 31/03/2025 Resolved Outpatient Problems Diagnosis Date Noted * No Resolved Outpatient Problems Past Medical History: Diagnosis Date * Cardiac arrhythmia * Coronary arteriosclerosis 2016 * Hypertension Full lung function tests; 11.6. 2025: FEV1 0.89 (45.5%) FVC 2.39 (102%) ratio 0.37 Transfer factor = 60% predicted. Performance status = 1. i met this 71-year-old lady in the chest clinic today. She is known to have COPD and had TB as a child and was re-treated She stopped smoking 20 years ago with about a 30-pack-year history. Her main complaint is of a productive cough of thick yellow/green sputum, which seems to originate in her throat and is difficult to clear. She also has nasal discharge and uses saline washes for this. From the COPD point of view, she is reasonably well and although does get breathless occasionally, she can easily manage a flight of stairs and kept up with me walking down the corridor. She has had no chest infections over the last year. She also has a significant cardiac history and had 2 stents inserted 10 years ago. Currently she takes Symbicort 400 1 puff in the morning and DuoResp 320/9 1 puff at night. She finds that this

history, | have requested a sputum sample for both TB and M&CS. i have also requested a CT of her sinuses. | have referred her to our AIR Team and requested pulmonary rehabilitation. in the meantime, | have given her a trial of carbocisteine to see if it will help clear her sputum. When we next see her, we will discuss the merits of using a triple inhaler.

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Presented On: 13-Jun-2025 13-Jun-2025 Kidney stone (Presumed)

Safety Alerts: None Medications and Medical Devices No relevant medication details Screened by : Allergies and Adverse Reactions Active: morphine - Sick building syndrome (Allergy) - Recorded: 13-Jun-2025 Assessment Scales

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Diagnosis: Sprain of thumb Clinic note: Diagnoses: Right thumb MCP) volar plate injury + sprain ulnar collateral ligament - US right thumb 31/5/25: The UCL and the flexor tendon of the right thumb are intact. There is no joint effusion demonstrated at the MCPj. No flexor tenosynovitis detected on the right thumb. Date of Injury: 20/4/2025 Mechanism of Injury: Hyperextension of thumb pushing rubbish into bin Background: RHD, cares for her children with special needs, fit and well, smoker, no alcohol, NKDA

Management so far: 1. Thumb spica splint Plan: 1. Referral to hand therapy for strengthening exercises and thermoplastic splint 2. Discharge from clinic with open access follow up i saw a 38 year old woman in fracture clinic today. She is nearly 2months down the line since the above injury. She has had her ultrasound scan which was very reassuring. She tell me her pain anf function have improved considerably, however, she does still get pain down the thenar eminence and down her thumb. On examination today: Nil swelling or bruising Mild tenderness over RCL, previously over UCL. Mild tenderness over volar aspect of MCPJ Able to flex/extend/circumduct the thumb Nil laxity on stressing UCL/RCL in extension and at 30 degrees of flexion. Stiff compared to contralateral side Nil tenderness over scaphoid tubercle Sensation intact Today | have explained the likely cause of her symptoms and that there is no surgery required for her injury. She needs to continue to strengthen the thumb and her symptoms should continue to subside. | am referring her to the hand therapists for strengthening exercises and a splint for comfort. i am discharging her with open access follow up for 6 months. | wish her all the best.

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assessment and treatment. Should you have any questions regarding your discharge or require any further information, please do not hesitate to contact us.

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diagnosis: Likely cellulitis Needing to rule out DVT Hospital Course: attended UTC on 12/6/25 with a rash on his leg and tenderness in the leg. He had a diarrhoeal and vomiting episode on Monday which has happened multiple times since his liver transplant 4 years ago and spent most of his time in bed over the next 3 days.

history of 2 previous DVTs in his R leg which presented similarly to this. He is on apixaban 2.5mg BD. Anthony was seen by the post taking acute internal medicine consultant. He felt that it was appropriate to avoid admission to hospital given Anthony's immunosupression. He felt his presentation was likely in keeping with a cellulitis but that we needed to rule out a DVT. He had 3 x blood cultures taken and was given IV ceftriaxone and discharged. Discharge plan 1. Daily ceftriaxone in medical SDEC for 3 days 2. US doppler to exclude DVT on Monday 16th June at 13:00. 3. Review of bloods and cultures in AECU on Monday to determine further appropriate treatment Medication changes; 1. Apixaban has been increased to 5mg BD (with the first dose starting on the evening of the 13/6). Allergies as of 13/6/2025 No Known Allergies Assessments: Pain Score: Mild (1/3) BMI (Calculated): 35.8

Resuscitation status reflects decisions made during this admission and does not replace documentation in the patient's notes or ReSPECT form. Distribution List: Date completed: 13/6/2025 GP Practice

assessment and treatment. Should you have any questions regarding your discharge or require any further information, please do not hesitate to contact us.

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11th June 2025 | had a telephone consultation telephone conversation with you this afternoon. A recent CT scan you had during your inpatient stay indicated dilated biliary system with no obvious cause. The scan was reviewed at our weekly GI radiology meeting and a further MRI scan was suggested. Reassuringly you have not noticed any jaundice or significant abdominal discomfort. | will arrange an MRI scan of your biliary system & will be in touch following the results of this.

Diagnosis: Blood in urine Clinic note:Non visible haematuria Complaint:No complaint of LUTS Ex-smoker Past Medical History: Olfactory hallucinations Migraines Endometriosis Diverticulosis US Urinary Bladder (03/06/25): No cause for symptoms identified sonographically Right renal angiomyolipomas. Follow up in one year June 2026)

Findings: Urethra: Normal Bladder: Normal UO: Normal Plan: Discharge from haematuria pathway Repeat ultrasound scan in a year's time to review right renal angiomyolipomas

Management Programme. They have provided their consent for us to communicate with you as their registered GP. If you are aware that any of the information that the patient has provided to us may be inaccurate, or have any concerns about their participation in programme, we would be very grateful if you would contact us on the details above so that we can discuss next steps with them. Please note that we are not asking you to provide any information unless you feel it necessary; the responsibility for treatment remains entirely with us and our prescribers. We have prescribed: * Mounjaro KwikPen 5mg/0.6ml solution for injection 2.4ml pre-filled pens (Eli Lilly and Company Ltd) Quantity: 1 Directions: Once a week for 4 weeks We have given the patient the following information: Thank you for completing your refill information. Blood results: There are no new results to review since your last refill. New dose: Increase to Mounjaro 5mg A further prescription has been issued for you. If you have any questions about your dosing schedule, please read our online guide which explains our personalised approach to your plan Your medication will be delivered by our pharmacy partner who will be in touch with you shortly. Once

management, monitor your symptoms closely and report any changes to your NHS GP or specialist, as you may need a dosage adjustment. When to Stop Taking Mounjaro: You should stop taking Mounjaro and inform us immediately if you: * Become unwell or dehydrated * Become pregnant * Develop pancreatitis, gastroparesis, or diabetic ketoacidosis If you are scheduled for surgery requiring general anesthesia, you must inform the anesthetist, as they may advise temporarily stopping Mounjaro. If you experience any of the following serious side effects, stop your medication regime and report to us the following effects or contact 999 or 111 if the symptoms are severe: * Severe pain in your stomach area (abdomen) that will not go away, with or without vomiting. * Fever, yellowing of your skin or eyes (jaundice), or clay-coloured stools. * Shaking, sweating, headache, drowsiness, weakness, dizziness, confusion or irritability. * You feel a swelling in your neck; there is difficulty in swallowing or persistenT hoarseness. * You feel short of breath or if you feel your heart racing or pounding in your chest and it lasts for several minutes. * Nausea, vomiting, or diarrhoea that does not go away, or if you cannot drink liquids by mouth. * Serious allergic reactions such as swelling of your face, lips, tongue, or throat, fainting or feeling dizzy,

problems breathing or swallowing, or severe rash or itching. *You should pay attention to any mental health changes, especially sudden changes, in your mood, behaviours, thoughts, or feelings. Contact us right away if you have any mental health changes that are new, worse, Or worry you. General side effects and risks: Whilst the majority of patients tolerate Mounjaro quite well, we understand that it is crucial for you to have an understanding of the potential side effects. Below, we have provided to help you with this. Please read the Patient that comes with Mounjaro as well. Common side effects include nausea, diarrhoea, constipation, vomiting, Injection site reaction (redness), low blood sugar that can cause headache, tiredness, dizziness. You may notice some hair loss, please tell us at your next refill if it is significant. It is usually temporary and many see their hair regrowth even while on Mounjaro. Mounjaro can increase the risk of gallbladder or bile-related issues, such as gallstones. If you have had gallstones before, there is a chance they could flare up again. Mounjaro may cause gastrointestinal side effects, such as nausea or constipation, which could be more pronounced for those with pre-existing bowel conditions. Please let us know if you experience any side effects that are difficult to manage. Please see below the provided by the patient. Questionnaire Responses In the last four weeks, have you missed any dose of your weight loss medication, excluding injections taken later than prescribed? No Have you been rotating your injection sites? Yes On a scale of 1 to 10, how satisfied are you with the results of your treatment? 8 Our clinicians will assess your progress by considering any side effects you've experienced and your weight loss journey to help tailor your treatment plan. This will mean they determine whether you need to increase your dose or stay at your current one based on what's best for you. Okay Have you started on any new medications (prescribed or purchased over the counter) or supplements since your last prescription? No

history in the last four weeks? Nothing has changed with my medical history Are you currently experiencing any side effects that you suspect may be a result of your medication? No In the past month, how many hours of sleep did you typically get per night? 7 - 9 hours In the past month, have you noticed any of the following sleep-related habits? Regular bedtime and wake-up time How would you describe your physical activity level this month? Fairly active: I've been aiming for around 150 minutes of activity each week. Have you noticed that you have been short of breath in completing of your daily activities over the past month? None of the above How often have you snacked between meals this month? Occasionally How would you describe your portion sizes this month? Moderate How often have you eaten fast food or takeaways this month? Rarely or never How many alcoholic drinks have you consumed per week on average over the past month? 0 Please re-confirm your women's life stage Perimenopause Have you experienced any of these symptoms over the past month? Select all that apply Hot flushes Fatigue Irregular or no periods

Management Programme are provided by hospital, trading as eMed

Diagnosis: Parastomal hernia O/E - stoma Seen by stoma nurse Clinic note: Face to face clinic appointment Reason for appointment: Overdue annual review Stoma Type: End colostomy

Stoma Condition: Pink, warm, moist mucosa. Spout: Flush skin level Stoma situated: LIF. Below the bend line No dips and creases around the stoma Template size: 30mm round Stoma Output: Type 4 BSC Medication required to support stoma output: Nil Eating and drinking: Normal diet Peristomal skin Assessment (DET) Peristomal discolouration No Discolouration - Healthy peristormal skin - 0, no severity score - 0 Peristomal Erosion No erosion - peristomal skin healthy and intact - 0, no severity score - 0 Tissue Overgrowth No tissue overgrowth - 0, no severity score -0 Total DET Score: 0 Body Profile assessment Outward body shape Abdomen is firm and variable Large parastomal hernia noted. Non problematic. Present Supplies, product codes and quantities Using: WAP Salts Adhesive Remover Spray 50ml x4 cans [2824055] Moderma Flex Drainable Pouch with Viewing option, Softflex and Integral Filter, Midi, Beige, 15-55mm x3 boxes

assessment in A&E if experiencing sever abdominal pain which likely would be associated with reduced/ altered stoma output + nausea/ vomiting. Follow up plan: To be seen in 1 year. Aware of contact details for the department. Notes copied from Epic to MiMe 13/6/2025

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Diagnosis: Stomal granuloma O/E - stoma Seen by stoma nurse Clinic note: Face to face clinic appointment Reason for appointment: Planned review Stoma Type: lleostomy

Stoma Condition: Pink with warm mucosa, Large granuloma at 3 o'clock which is painful and bleeds. Spout: Above skin level Stoma situated: RIF. Below bend line No dips and creases around the stoma Template size: 34 mm (w) 24 mm (h) previously cutting 25 mm round Stoma Output: Variable, Type 5-7 BSC Medication required to support stoma output: Loperamide 4mg QDS. Eating and drinking: Normal diet Peristomal skin Assessment (DET) Peristomal discolouration Some peristomal skin discoloured where pouch adheres >25% - 1 Severity is leading to complications - 2 Peristomal Erosion Small amount of erosion noted but affecting <25 of the skin covered by adhesive - 1 Severity is leading to complications - 2 Tissue Overgrowth No tissue overgrowth - 0, no severity score -0 Total DET Score: 6 Treatment plan to reduce DET score: Continue alginate pouch. Cutting template altered top to bottom measurement. Body Profile assessment Regular body shape Abdomen is soft and uniform. No evidence of a parastomal hernia. Present Supplies, product codes and quantities

Using: [BW3] Independence Fusion 1ml applicator [423626] Esteem Body soft convex ileostomy bag standard with window, 7mm depth, 40mm plateau, cut to fit 10mm-35mm [423610] Esteem Body soft convex ileostomy bag standard with window, 3.5mm depth, 40mm plateau, 25mm stoma [UFWAFH33] UltraFrame Flange Extenders [MH2NF413] Welland Aura 2 oval convex flange with Manuka honey 45mm size cut to fit 13mm-40mm [MH2D555] Welland Aura 2 drainable pouch with integral closure soft backing beige split cover Midi 55mm [15704]SenSura soft seal 1-piece open, Midi, soft cover 15-43mm [12070] Brava Elastic Tape [12060] Brava Lubricating Deodorant Sachet 7.5ml 12080] Brava Skin Cleanser (3=3x15 or 45 Device) [12021] Brava Skin Barrier Wipe To trial: [SCA35-4120KV] Oakmed Alginate Soft Convex lleo Pouch, Soft Cover Both Sides, soft touch closure, 20 / 35mm cut to fit Changing the pouch ideally once per day, however more if leaks. [SCA35—4115KVB] cut to fit 15-35mm Obtaining deliveries via Bullen Literature Supplied: Consent gained to send the following via Showpad: N/A Notes: Granuloma treated with silver nitrate stick. Patient advised: 1. Continue to treat the granuloma with silver nitrate daily. Recommended to protect the healthy stomal mucosa and skin with vasoline. 2. Please liaise with GP about a prescription for Loperamide. 3. Discussed how to take Dioralyte/ Oral rehydration sachets when feeling thirsty (double strength 2 sachets in 200mlIs). 4. Discussed dietary measures to improve stoma output. 5. As stoma products are being altered, | shall inform the GP and Bullen separately with new prescription details. GP Actions: « Please prescribe Loperamide oro-dispersible tablets 4mg to be take 4 times a day 30 minutes before food. Follow up plan: To be seen 22/08/2025 @ 14:30

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Diagnosis Possible LRTI Hospital Course presented to FPH on 13/0/25 due to a new cough and confusion.

Assessments: Pain Score: None (0/3) Reaction Type _ Reactions Allergy Rash

Resuscitation status: For CPR Resuscitation status reflects decisions made during this admission and does not replace documentation in the patient's notes or ReSPECT form. Date completed: 13/6/2025

Plan: Review in 8 weeks was admitted under my care as an NHS patient at Hospital. He had hydrocele repair under general anaesthetic as a day case. We performed Jabali's procedure, 200 ml of straw-coloured fluid was drained. Testis was normal. The tunica was everted with 3-0 Vicryl. Dartos muscle was closed with 3-0 Vicryl, the skin was closed with 3-0 Vicryl Rapide. | advised to wear a scrotal support for the next 10 days. | will arrange a follow-up for a wound review in 8 weeks.

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Diagnosis Both eyes: neurofibromatosis type | (NF 1) (30-Jun-2023) Visual Acuity right eye 6/7.5 unaided, left eye 6/7.5 unaided was seen in the Eye Clinic at Hospital on 12th June 2025.

i can confirm that | had a telephone consultation with from our colorectal Surveillance clinic. He came to our clinic following left hemicolectomy in Feb 2024, histology from the surgery was reported as Moderately differentiated adenocarcinoma-sigmoid colon, EMVI - 0/8, RO, TNM(8th edition)-pT1,NO MDT decided to follow him with routine surveillance. doesn't have any recent blood tests on the system, so | have requested to get it done at Hospital as per his preference. , he underwent CT CAP in April | have reassured him report today which is at end of the letter. As part of his colorectal Surveillance plan, he had his colonoscopy in March 2025, which report was given to him same day. In today’s consultation, patient me that he is eating and drinking well and his bowel habits are normal for him. He has no concerns in regards to abdomen pain or tiredness. i have booked mr for investigations for April 2026 including CT CAP and bloods Followed by a Findings: Comparison is made with the previous scan from January 2024.. There are resolving patch of consolidation in the right lung base in the right upper lobe with subsegmental atelectasis. Clear left lung field. Evidence of previous stent insertion. No focal liver lesion or biliary tree dilatation. Large 2 cm gallstone. No acute cholecystitis. The pancreas, spleen, both kidneys and adrenals are unremarkable. There are couple of tiny non-obstructive right lower pole renal stones. A simple 3.3 cm right lower pole cyst and a smaller cyst on the left side noted. No enlarged abdominal pelvic lymph

nodes. No CT evidence of bowel mass. Left-sided stoma noted. No intrinsic bladder wall lesion. No free fluid or localised collection. No destructive bone lesion. 22/5/2025

Admission date: 12/6/2025 Admission time: 19:29 Length of stay: 1 days Admission method: Emergency - A&E, Casualty, or Dental Casualty Department Source of admission: Usual Place of Residence Discharge Date: 13/06/25 Discharge Time: 1400 Discharging consultant: LEE, KIAN Discharging specialty: Paediatrics Discharge location: FPH F01

Diagnosis: Paracetamol Overdose Hospital Course: Dear you for your continued care of this patient. was admitted to Hospital on 12/06/2025 due to Paracetamol Overdose. She has been given one dose on IV NAC as her paracetamol levels are just on the treatment line but slight vagueness about time of overdose. Repeat levels came back within normal limits and she examined normally with normal observations. She was reviewed by the CAHMS team and they have deemed her fit for discharge. We wish her all the best in her recovery! Discharge Plan As per CAHMS team Issues requiring GP action: Nil Outpatient Follow-Up You have no referrals or appointment requests from this visit. Safety-netting given: Other: Verbally given

Pain Score: None (0/3) Resuscitation : No Order Resuscitation reflects decisions made during this admission and does not replace documentation in the patient's notes or ReSPECT form. 13/6/2025

Future Resources for families, patients and professionals information on childhood illnesses for families and professionals. This includes advice on warning signs to look out for, where to seek help if required, what you should do to keep your child comfortable, and how long your child’s symptoms are likely to last. Primary Care / GP Clinical Support Department Contact Details Hospital - . — Friday: 09.00-15.00 Hospital - . Paediatrics — Friday: 09.00-15.00 Further Discharge Support Contact Details: including directories for: Routine and Urgent Advice for clinicians (including ward contact details); all our Same Day Emergency Care Services (SDEC); and for non-urgent clinical queries there is a list of 'Medical secretary/admin support email addresses' under the ‘Referrals & key contacts’ section.

As discussed, your adalimumab levels are slightly on the low side. This raises the possibility that increasing your dose to 40mg every week, and stopping leflunomide, may improve your symptoms. You've agreed to give this a go and | have forwarded your details to our specialist pharmacist to get this started. i would appreciate if your GP could remove leflunomide from your repeat prescription. Although you no longer require leflunomide blood tests, you will need bloods every 5 months for monitoring adalimumab. | will get one of our nurses to provide blood forms separately.

problem in getting your prescription. You may need to pause your long-term arthritis medications if you are unwell from another condition, for example when taking antibiotics for an infection or a virus requiring antiviral drugs. if unsure, please contact us to confirm. After an organ transplant, do not stop any without speaking directly to your transplant team. in general, do not stop your long-term steroids (prednisolone).

Indication: Kidney stone patient - staghorn for PCNL Comparison: CT abdomen and pelvis 31 March 2025

Findings: The staghorn calculus in the right kidney has increased in size since March and measures up to 350 HU. There are a number of simple cysts in the right kidney and an obstructed inferior pole calyx. New right perinephric fat stranding and prominence of the retrocaval lymph nodes noted. The ureters opacify bilateral but more so on the left and the urinary bladder is unremarkable. Partial duplex left kidney enhances normally with several simple cysts. Sigmoid diverticulosis and cholecystectomy while the remaining abdominal and pelvic viscera are unremarkable. A prominent left inguinal lymph node maintains normal architecture and is likely incidental. No significant skeletal findings. Opinion: Increased size of the right staghorn calculus with features of inferior pole caliceal obstruction. if you have any questions or concerns, please don't hesitate to call.

Clinic note: it was a pleasure to see in the breast clinic today. She has been referred to us as she presents with a left breast nipple changes in the last 2 weeks with swelling and redness area. No discharge, no lumps palpable. Family history of breast cancer - No On examination Cup B, ptosis grade 1 Right breast: No palpable nodule, no lymph nodes palpable Left breast: No palpable nodule, no lymph nodes palpable She has small erythema in both nipple. Left side tiny superficial spot with decolouration that patient refers is new. Nothing concerning. PLAN 2 weeks of topic corticoids in both nipple, two times per day. New appointment for reviewing

Patient consented verbally to examination performed by Clinician and chaperoned by . Privacy and dignity maintained throughout. Standard IPC precautions taken. No issues or concerns noted. Torre Breast Oncoplastic Fellow 11/6/2025 N.B. This letter has been transcribed using voice recognition transcription software. Please excuse any minor typographical errors that may arise as a consequence. Please let us know if there is anything that needs to be corrected.

Diagnosis: Attends regular retinal screening Nonexudative age-related macular degeneration Clinic note: | have reviewed your notes and test reports in virtual medical retina clinic For hydroxychloroquine retinopathy screening On hydroxychloroquine 200 mg 3 times a week for rheumatoid arthritis. Examination shows stable visual acuity in both eyes OCT shows features of dry age-related macular degeneration in both eyes which appears stable as previous visit. Review will be arranged for detailed evaluation.

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13 June 2025 We discussed your scans at our team meeting today. The lump isn't visible on MRI but that might be because it's just too small; the way an MRI works, it can sometimes miss small lumps which are clearly visible on other types of scan. The radiologists want to do a repeat ultrasound, with xrays as well, to see if anything has changed since the last scan. They will let me know once they've had a look and | can then take things forward. An appointment will be with you shortly.

Diagnosis Presented for elective cryoablation and renal biopsy. Hospital Course Dear presented for her elective cryoablation under interventional radiology 13/6/25

Assessments: Pain Score: Mild (1/3) BMI (Calculated): 34

Resuscitation status: For CPR Resuscitation status reflects decisions made during this admission and does not replace documentation in the patient's notes or ReSPECT form. Distribution List: Date completed: 13/6/2025

Diagnosis Post-op Diagnosis * Sialoadenitis [K11.2] Procedure Information Procedure date: 13/6/2025

Excision of sublingual gland (Right) Post-op Instructions ENT WOUND CARE ADVICE SHEET Stitches You have had stitches that are soluble (no need for suture removal, the sutures will dissolve over time). Wound Care Advice You may experience some discomfort in the area when the local anaesthetic starts to fade after a few hours. We advise you to take a simple painkiller such as Paracetamol. To minimise the chances of bleeding, do not take any Aspirin or oral anticoagulants for 24 hours after surgery. If bleeding does take place, press on the wound with clean gauze/tissue for 10 minutes. If bleeding should continue, reapply pressure until it stops. Keep the wound as clean as possible. If clothing rubs on the wound, keep it covered with a breathable dressing/dry plaster. If the wound is on the face, use extra pillows at night to sleep more upright. This will reduce swelling and bruising. Ask for medical help if worried that the wound is not settling properly. This can be your GP, practice nurse or the hospital. see the ENT team urgently. In case of severe bleeding that persist for more than 15 minutes despite pressure, please present to the nearest Emergency Department. Further information: Post operative advice Please keep wound clean and dry Complete 7 day course of oral Co-Amoxiclav (antibiotics) ENT follow-up 4 weeks Please start Pregabalin 75mg twice daily Continue to take your regular pain relief as required Actions Required of FHFT Investigations Pending at Discharge Specimens

Description: Right Level 1A Source :Neck Type : Tissue Tests : e HISTOLOGY, TISSUE , MD(Histology) Comment: Right level 1a clearance with lymph nodes Description: Right Neck Level 1 B Comment: Right neck level 1b clearance + lymph nodes Neck Tissue e HISTOLOGY, TISSUE , MD (Histolog y) Description: Sublingual/Submandibular accessory gland Unresulted Labs No unresulted labs Outpatient Follow-up Referrals Provided Procedures 3/5 Collected At Priority 13/6/25 16:13 Urgent « Appointment request Routine; Face to Face; No; Specific Clinic and Consultant; FPH ENT H&N Actions Required of General Practice (GP)

Assessments: Overall MUST Score with calculated weight: 0 Pain Score: None (0/3) BMI (Calculated): 31.6 Resuscitation : No Order Resuscitation reflects decisions made during this admission and does not replace documentation in the patient's notes or ReSPECT form.

Admin Opening time: (Mon-Fri 07:30- Team 16:30) Neck/ENT Nurse Specialist Further Discharge Support Contact Details: including directories for: Routine and Urgent Advice for clinicians (including ward contact details); all our Same Day Emergency Care Services (SDEC); and for non-urgent clinical queries there is a list of 'Medical secretary/admin support email addresses’ under the 'Referrals & key contacts’ section.

Admission date: 13/6/2025 Reason for admission: Admission time: 04:14 Admission method: Maternity - Admitted Antepartum Length of stay: 0 days Source of admission: Usual Place of Residence Discharge Date: 13/6/25 Discharge Time: 1330 Or With Clinical Consent Discharging consultant: Discharge method: Discharged On Clinical Advice Discharging specialty: Obstetrics Discharge address: 7 Waterside Lane Sandhurst

History: Smoking history: Substance misuse: reports that she has never | reports that she has |Social History smoked. She has never used|never smoked. She has smokeless tobacco. She never used smokeless [Substance and Sexual Activity reports that she does not tobacco. Drug Never drink alcohol and does not Use use drugs. Alcohol in pregnancy: Social History Substance and Sexual

Problems in labour: None [0] Date/time membranes ruptured: Amniotic fluid colour: ROM to Delivery Time: 0h 00m Clear [1] [12437185] Delivery Providers Delivering clinician: Provider Role Beverley RIXON-NICHOLLS Delivery Assist Alexandra SHURVINTON, RM Delivery Midwife Date/Time of delivery: Type of delivery: Spontaneous vertex 13/6/2025 11:10 Shoulder dystocia?: Anterior shoulder: No Sex: male Weight:3050 g Resuscitation method: None [1] Suspected anomalies?: no GAP/GROW birth weight centile: 28.1 1 Minute 5 Minute 10 Minute Apgar 9 9 Totals:

Third Stage Placenta delivery method: Controlled cord traction and maternal effort [6] Date/Time placenta delivered: 13/6/2025 12:09 Placenta condition: Complete [4] Membranes: Complete Perineal/vaginal tract: Intact [1] Total measured blood loss: 150 mL Intrapartum & Postnatal: 13/06/25 06:54 - Delivery Admission: 13/06/25 04:14 - Delivery Blood Loss 13/06/25 17:32 Intrapart Delivery um & Admissi Postnata on OB Hospital [ID] 150 mL Measure Encount d Blood er Loss Total 150 mL = 150mL Length of 1st stage: 4 hours 0 mins Length of 2nd stage: O hours 16 mins Length of 3rd stage: O hours 59 mins Total length of labour: 5 hours 15 mins Postnatal

problems?: None Breast problems?: No problems Has the patients passed urine post delivery?: Yes Volume of urine voided: |1st Void 150 2nd Void 150 Normal amount? If no, plan:Yes Any other postnatal problems?: None Hb post delivery: Has Anti D been given during this admission? Not required What medication has been prescribed on discharge?:None Has the mother received any debriefing or discussion following the delivery?: None required Details of support groups given?: No Does the patient have a personalised Care Plan?No Have details about 'My Personal Maternity Care Plan’ phone app been provided?Yes Type of feeding at discharge. Type of feeding at discharge: Breast only Contraception discussed?:\Contraception prescribed at discharge?: No Yes If yes which method/drug: Sterilisation performed?:No Is the baby being discharged with the mother?: Yes If not, why?: N/A What follow up is required? (remember to order if applicable): Community midwifery Which agencies have been informed of the discharge?: None applicable

Resuscitation : No Order Resuscitation reflects decisions made during this admission and does not replace documentation in the patient's notes or ReSPECT form.

Department Contact Details FHFT - Cross Site - Maternity - MAMAS For urgent enquiries please call us on 16 weeks to 28 days postnatal Gynaecology Care Centre (UGCC) 15 weeks+6 days and below Gynaecology Care Centre (UGCC) 15 weeks+6 days and below Further Discharge Support for Primary Care / GP: our primary care clinicians, including a Routine Advice Directory & an Urgent Advice directory (which includes a directory for the wards). There is also a Same Day Emergency Care Services (SDEC) directory, and for non-urgent clinical queries there is a ‘Medical secretary/admin support email addresses’ directory under the ‘Referrals & key contacts’ section.

13/06/2025 Care Information Regarding Patient Dear patient was referred to care innovations for further investigation and of their eye condition by, Triage Outcome Information: - Referralreason: External Eye Disease - Pathway/clinic: 13003 CAB Extermal Eye Disease - Priority: Rapid Access Information: - Referral Date: 13/06/2025 You will find a copy of the referral attached and any other communications relating to this patient we currently hold. Ifthere are any changes to their planned care pathway or they need further onward referral you will be immediately notified.

Referral Received by Evolutio: 13/06/2025 Referred By: at Evolutio Referral Created By: Optometrist Referral sent via GP: NoRequirements Referral Reason: External Eye Disease Bracknell and Ascot CCG Pathway: 13003_CAB_External Eye Disease Visual Fields: none entered x* Cycloplegic refraction % = Dilated fundus examination Prescription: Near VA | Sphere | Cylinder | Axis Aided VA | Add Prism(H) | Base Prism(V) | Base R L Tonometry: ; | Right Left Date Time Instrument Right IOP Av | Left IOP Av_|Pachymetry { 13/06/2025 | 1PM ICare 18 18 A/C Angles [cp Ratio lo3 los [Depth |

Impression notes: 67M Impression:subconjunctival haemorrhage right eye, deep redness and possible scleral inflammtion inferiorly AC cells/flare noted same eye Notes to provider: no known trauma spoken to eye casualty main department px to be seen today with notes in hand Triage Notes: Please assess this eye casualty return, Reader HB

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Exam date: 13/06/2025 Eye: Both QI: 10 DISC | BOTH EYES QI:48 L 3D 6x6 mm 3D 6x6 mm |ONH parameters | Right | Left | Normal | NFL thickness NFL thickness NFL significance 250 Disc Area[mm?] __| 1.84 | 2.00 | | 210 Rim Area [mm2] 1.06 - 2.05 210 | (Cup Area [mm2] 0.00 - 0.90 170 Rim Volume [mm?] 0.16 - 0.55 170 130 Cup Volume [mm] 0.00 - 0.23 130 Mean Cup depth [mm] | 0.09 | 0.15 | 0.00 - 0.29 5 90 Max Cup depth [mm] | 0.25 | 0.38 | 0.00 - 0.59 | 90 | 50 50 1 10 . . 10 a n Cup V/H 72 | 064 | | mn ° 144 O° 105 = R/D minimum | 0.19 | 0.16 | ~ 109 2 123 ore <> _ Rimabsence (J KD sre 70 . 37 87 <n 68 | W <r} 80 67 ‘ 71 a [a a <a sf /\Jun 144 191 80 108 124 103 1, M42 Ring diameter 2.40 mm Ring thickness 0.40 mm Ring diameter 2.40 mm Ring thickness 0.40 mm 300) 300) 300) 2504 2507 2507 200+ 2007 2004 I [NFL parameters | _-Right_ | Left INSTIN average [um] | 96 | 98 PG Inter Eye Symmetry 0.76 200 pm Version: 11.5.0 REVOFC Device SN: 1900374/19 Print date: 13/06/2025 OPTOPOL Technology Sp. z 0.0.

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diagnoses Presenting Complain-RE 2/7 bloodshot, pain. Px pulling down the top lid and that's happens No diagnoses recorded. Patient was paying banbington in the morning. Spoke to Sony Evolutio tl UA -0.10 UA -0.16 Visual Acuity Date:13 June 2025 Eye casualty triage note Prince Charles Eye Unit User(s): medi

Last 3 Consultations ‘been rubbing excessively his eyes 13/06/2025 had a sudden sharp stabbing pain yesterday and then son noticed a while after eye was red no visual disturbance in preceeding days or now has‘some ankle swelling ’ only regular meds are glucosamine/CLO and cetirizine Examination 166/113, 150/102 O/E - blood pressure reading 152/90 mmHg « Heart rate 74 beats/min there is ablood fluid line at base of right eye ball and i Comment suggest book nhs health check , should go to eye clinic to ensure no significant issues bp bd for a week History duty gp came on around 6pm last night felt stabbing pain in his right eye but didn't look in mirror eye is very red now and is spreading is not painful bp normal no visual disturbance had a red eye before

PROBLEM: No HAVE YOU USED ANY MEDICATION OR OTHER TREATMENT FOR YOUR AILMENT?: No DO YOU HAVE ANY SPECIFIC WORRIES OR CONCERNS YOU WOULD LIKE THE PRACTICE TO BE AWARE OF? WHAT ARE YOUR NEEDS AND EXPECTATIONS AS A RESULT OF YOUR ENQUIRY?: | am concerned that this is a symptom of something more serious. | checked my BP this morning and it was 135/85 duty tel appt booked for this morning Values and Investigations (Latest Value) 13-Jun-2025 Heart rate 74 beats/min 13-Jun-2025 O/E - blood pressure reading 152/90 mmHg 16-Apr-2024 Johns Hopkins adjusted clinical groups system 3 Patient need group segmentation - low need adult 02-Feb-2024 BCS: FOB result ; . FOBT Non-Response. Sent when Discharged for non-response to initial Test Kit No response to BCSP invitation 28-Mar-2023 XR CHEST - (AV) - Normal - no action required REPORT Exam: XR Chest Indications: cough not improving Findings:The lungs and pleural spaces are blear. Reported by : C7042636 ; 03-Dec-2021 QRISK2 cardiovascular disease 10 year risk score 15.6 % 03-Dec-2021 Body mass index 29.9 kg/m2 03-Dec-2021 Body weight 100 kg 05-Nov-2021 HBA1C FOR DM DIAGNOSIS - (KTAN1926) - Normal - no action required HbA1c levi - IFCC standardised 37 mmol/mol 20 - 41 mmol/mol | Result does not support diagnosis of T2DM. Not recommended for diagnosis in pregnancy, in acutely unwell patients and when type 1 diabetes mellitus is suspected. See HbAlc in Diagnosis (WHO,2011) for limitations. 05-Nov-2021 ! Urea and electrolytes - (KTAN1926) - Satisfactory -no action required

- Change prescription of Evorel patches 100mcg/24hrs, changed twice weekly to 150mcg/24hrs, changed twice weekly - Arrange monitoring blood tests in 12 weeks Many thanks for your ongoing support with ’s care. We recently had a follow-up TransPlus consultation with and discussed her most recent blood test results and current hormone regimen. The therapeutic range for oestradiol is 350 to 750 pmol/L. Given ’s low oestradiol result (234pmol/L) we have agreed that her oestrogen dose should be increased. We would, therefore, be grateful if you would please change her regime from Evorel patches 100mcg/24hrs, changed twice weekly to: " Evorel patches 150mcg/24hrs, changed twice weekly Monitoring In terms of monitoring, she will need blood tests every twelve weeks until stable. At this point she will only need annual monitoring. Ideally, the blood test should be taken 4 to 6 hours after ingestion of oral oestrogen/4 to 6 hours after application of oestrogen gel/24 hours before the application of a new oestrogen patch. She will need: " Oestradiol - the therapeutic range is 350 to 750 pmol/L = Testosterone = Liver Function — should be largely within normal range "Prolactin ~ should be largely within normal range We will continue to catch up with within our service and we would be grateful if you could continue to forward ’s blood results to the email address in the header. Please do not hesitate to contact me if you have any questions or concerns.

TransPlus On behalf of: in HIV/Sexual Health and Gender Specialist

Date:- 13/06/2025 | have seen your patient in clinic today and due to changes in their stoma care routine | need to make the following changes to their prescription. Please could you discontinue the following items: Company [Product Details Code Number Convatec Esteem Body soft convex ileostomy bag standard with window, 7mm depth, 23626 40mm plateau, cut to fit 10mm-35mm Convatec Esteem Body soft convex ileostomy bag standard with window, 3.5mm depth, 23610 40mm plateau, 25mm stoma elland Welland Aura 2 drainable pouch with integral closure soft backing beige Split jH2D555 cover Midi 55mm MH2NF413 Welland Aura 2 oval convex flange with Manuka honey 45mm size elland cut to fit 13mm-40mm Coloplast|SenSura soft seal 1-piece open, Midi, soft cover 15-43mm 15704 CliniMed |UltraFrame Flange Extenders UFWAFH33: Coloplast|/Brava Skin Barrier Wipe 12021 Please can you make these amendments to their monthly repeat prescription: Code Approx Product Details a orth | See Oakmed Oakmed Alginate Soft Convex Ileo Pouch, Soft Cover Both SCA35- Sides, soft touch closure, 20 / 35mm cut to fit 4120KV SCA35- Oakmed 4115KVBK | | ProSys Coloplast | Brava Elastic Tape 12070 [4 Coloplast | Brava Lubricating Deodorant Sachet 7.5ml 12060 {2 Coloplast | Brava Skin Cleanser (3=3x15 or 45 Device) 12080

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Received: 15/04/25 Test Result Units Reference Range Laboratory Information Sample Type: Venous Blood Biochemistry Hb Alc (mmol/mol) 33 mMol/Mol <42 Comments HbAIC Reference range as per NICE guideline [NG17/PH38/NM148] <42: Non-diabetic 42 -~ 47: Impaired glucose regulation/increased risk of diabetes mellitus >48: Consistent with diabetes mellitus/impaired glucose regulation Calcium ** 2.43 mmol/L 2.20 -~ 2.60 Adjusted Calcium ** 2.38 mmol/L 2.20 - 2.60 Uric Acid H 463 umol/L 200 ~- 430 C Reactive Protein (high sensitivity) H 5.51 mg/L <1.00 Sodium ** 141 mmol/L 133 - 146 Lipid Profile Cholesterol H 6.00 mmol/L <5.00 Triglycerides 1.72 mmol/L <2.30 Comments Fasting: <1.8 mmol/L Please note non-fasting range now given as primary range. HDL Cholesterol 1.16 mmol/L 0.90 - 1.70 LDL Cholesterol H 4.06 mmol/L <3.00 Non HDL Cholesterol H 4.84 mmol/L <4.00 HDL % of Total * L 19 % >20 Thyroid Stim. Hormone 3.880 mIU/L 0.270- 4.200 Free Thyroxine (FT4) 14.1 pmol/L 12.0 - 22.0 Active B12 126.0 pmol/L >37.5- Comments Please note change of reference range 29 Jul 2024. Folate (serum) ** L 6.4 nmol/L >7.0 Comments Please note: A Folate result between 7-13 nmol/L may indicate a possible Folate deficiency.

Received: 15/04/25 Test Result Units Reference Range 25 OH Vitamin D L 45 nmol/L 50 - 250 Comments Total 25(OH) vitamin D < 25 nmol/L is deficient. Total 25(0H)D of 25-50 nmol/L may be inadequate in some people. Total 25(0H)D > 50 nmol/L is sufficient in most individuals. Total Vitamin D level >250 nmol/L - indicates potential for toxicity. Please note change of reference range 23 Oct 2022 Prostate Specific Ag (Total) 1.36 ug/L <3.60 Comments Method: Roche Elecsys Ferritin Comments lease note change of [Transferrin Saturation Please note change in recommendations. Liver Function Test reference range: 9 Dec 2022. 15.5 umol/L 10.0 - 30.0 H 61.3 umol/L 12.0 - 43.0 77 umol/L 45 - 61 L 20 % 25 -~ 45 298 ug/L 30 - 518 ref range for females in line with NIC! Cl Total Protein 73 g/L 60 - 80 Albumin 42 g/L 35 - 50 Globulin 30 g/L 19 ~ 35 Alanine Transferase 40 U/L <45 Alkaline Phosphatase 65 U/L 30 ~ 130 Gamma GT H 68 U/L <55 Bilirubin 7 umol/L <22 Kidney Function Urea 6.6 mmol/L 2.5 - 7.8 Creatinine 106 umol/L 60 - 120 estimated GFR L 72 ml/min/1l.73m2 >90

Specimen 14/04/25 08H40M 15/04/25 09H53M 15/04/25 14H16M Test Result Units Reference Range Haematology Haemoglobin (g/L) * 151 g/L 130 - 180 Red Cell Count * 4.91 10*12/L 4.40 — 6.50 Hot * 0.440 L/L 0.400- 0.520 Cv * 89.7 £L 80.0 - 100.0 CH * 30.7 pg 27.0 - 32.0 CHC (g/L) * 343 g/L 320 —- 360 RDW * 14.5 % 11.5 - 15.0 Platelets * 239 10*9/L 150 -— 450 PV * 10.2 EL, 7.90 - 13.0 White Cell Differential White Ce Count * 5.7 10*9/L 3.0 - 11.0 Neutrophils * 2.6 10*9/L 2.0 - 7.5 Lymphocytes * 2.60 10*9/L 1.50 - 4.50 onocytes * 0.30 10*9/L 0.20 - 0.80 Eosinophils * 0.20 10*9/L 0.00 - 0.40 Basophils * 0.000 10*9/L 0.000- 0.100 Neutrophils % 45.5 % Lymphocytes % 45.6 % onocytes % * 5.6 % Eosinophils % * 3.1 % Basophils % * 0.2 % End of report Key for report symbols:

Admission date: 10/6/2025 Admission time: 18:30 Admission method: Emergency - A&E, Casualty, or DentalCasualty Department Length of stay: 2 days Source of admission: Usual Place of Residence Discharge Date: 13/6/2025 Discharge Time: 18:30 Discharge method: Discharging specialty: General Medicine Discharge type: Discharge location: FPH AMU YELLOW Discharge Summary completed by: AGAMY,HISHAM (Resident Doctor) Discharge Diagnosis Possible seizures

Dear is a 25 year old woman who came to the hospital at 10/06/2025 with complaining of feeling generally unwell and fever over the past 5 days before admission. She also mentioned having an unwitnessed seizure on Friday at work 6/6/25. She also had multiple similar episodes in the past and was under for work up, but was not diagnosed as epileptic and was not put on antiepileptic drugs. She was admitted and blood and urine cultures were taken but came back negative. A seizure chart was made but no further seizures were observed. On 13/06/2025 Neurology consultation was made and treating it as an epileptic seizure and treating it with anti-epileptic medications was recommended: Lamotrigine 25mg OD - to be increased by 25mg every 2 weeks up to 50mg BD is now medically fit for discharge, on Lamotrigine 25mg OD to be followed up by the GP. Pertinent Examination At Time of Discharge Examination Actions Required of FHFT Investigations Pending at Discharge (Hospital to follow-up and action) Unresulted Labs

Outpatient Follow-Up You have no referrals or appointment requests from this visit. Fit Note Issued: No Actions Required of General Practice (GP) Follow up Lamotrigine dose Weight Weight: 75.5 kg (12/06/25 00:29) Your medication list START taking this medication Last Dose Instructions Given lamOTrigine 25mg tablet Take ONE tablet once a day. CHANGE how you take this medication Last Dose Instructions Given betahistine 8mg tablet Take ONE What changed: tablet three * when to take this times a day if * reasons to take this required * Another medication with the same (dizziness).

CONTINUE taking this medication Last Dose Next Dose Instructions Given Due ivabradine 7.5mg tablet Take ONE tablet twice a day. omeprazole 20 mg dispersible tablet Take ONE tablet once a day. Do not crush or chew. pizotifen 1.5mg tablet Take ONE tablet once a day. proCHLORperazine 5mg tablet Take ONE tablet three times a day if required for nausea or vomiting. ZOLMitriptan 2.5mg tablet Take ONE tablet once if required for migraine. May repeat in 2 hours if unresolved. Do not exceed 10 mg in 24hours.

Assessments: Overall MUST Score with calculated weight: 0 Pain Score: Mild (1/3) BMI (Calculated): 27.7 Resuscitation : For CPR 5/6 Resuscitation reflects decisions made during this admission and does not replace documentation in the patient's notes or ReSPECT form. Date completed: 13/6/2025

For Clinical Queries with regards to prescribing or Clinical content of this letter please contact theDischarging Consultant through the Medical Secretary/Admin Support e-mail address availableat nhs website

Diagnosis: Left TMJ clicking with occasional locking. TREATMENT PLAN: Conservative management. | saw on the Maxillofacia Clinic today. He reports over the last six months or so he started to get clicking sound and occasionally sticking from the left jaw joint. He reports the jaw sticks so that he cannot open wide and demonstrates that he can reach around 1cm when his jaw is stuck. It does seem to have more in the evening when he goes to eat. It can cause him pain around the left jaw joint. Seems to loosen itself quite quickly particularly since he was advised by yourself to do some exercises. He does not give a history of any locking open and he denies any parafunctional habits. On examination today, there was no clicks or crepitus from the TM joints. mouth opening is around 31mm and he does have a deep overbite of approximately 5mm. There is no tenderness to the muscles of mastication today and he opens without any deviation. LL3 sits in crossbite. | have explained to and reassured him with regard to the reason for the clicking noises from the joints. This is cartilage disc within the joint, moves back and forwards. It is possible that occasionally rather than clicking back into place straightaway the disc becomes a bit stuck preventing full mouth opening. Most commonly, these things do loosen themselves on their own and simple measures such as heat packs, massage, topical ibuprofen gel, soft foods and some exercises that | have given him some information about can help things. Often the muscles in the area will also spasm up and this can can cause pain when opening the mouth also. This can be made worse during times of stress and with habits such as grinding or clenching. | have reassured that | do not see anything concerning and that for the majority of people the symptoms do not deteriorate any further. | have suggested he carries on with conservative management and at this stage, | am happy to discharge him from the department. He is aware if things significantly deteriorate, he can be re-referred.

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pt 's EEG does show potential for generalised seizure. First seizure presentation of this type occurring in late-20's is unusual but no unheard of. Follow-up is in place and we can discuss next steps.

13th June 2025 Thank you for having your blood tests completed (9th of June) Your INR is 2.7 Your kidney function is stable with a creatinine of 159 (EGFR 36) Your liver enzymes still show an elevated ALP at 640. Your gamma-GT is 56 which suggests the ALP may not be originating from the liver. We have sent off tests for this Your tacrolimus levels are 9.5 which are satisfactory. We will review your progress in 3 weeks' time

Please do not call in to request blood/test results. Due to patient confidentiality the admin team are unable to provide these over the phone. Should results require any further action — we will contact you. With normal results, we will not contact you due to the volume of results we receive each week. Non urgent tests and scans can take up to 8 weeks to be generated. This letter is generated using voice to text software. Although this is very advanced, it can make mistakes and | apologise if any mistakes in syntax have slipped through. All letters are 'sense checked" but not necessarily read through comprehensively. If there are significant errors in this letter which need to be corrected, please let the team know on the above number or

Diagnosis:Cutaneous lipoma of the right buttock, It was my pleasure to review you at Hospital today. | was pleased to see the scar on your right buttock is healing well. The pathology report confirmed the lesion removed was a cutaneous lipoma. There was no evidence of any cancer cells. No further surgical treatment is required. | have attached a copy of the report for your

CLINICAL DETAILS: Excision of lesion right buttock Neurofibroma + lipoma MACROSCOPIC DESCRIPTION: Pot labelled as lipoma right buttock: Lobulated fatty piece of tissue weighing 1.2 g and measuring 27 x 15 x 12 mm. Attached skin ellipse measuring 14 x 10 mm. Cut surfaces are fatty. A1, A2x2 AJE. MICROSCOPIC DESCRIPTION: Skin lesion from right buttock: Sections show skin displaying florid lobules of mature adipose tissue separated by delicate fibrous septae. The overlying dermis and epidermis are unremarkable. The features are suggestive of cutaneous lipoma. No evidence of malignancy. CONCLUSION: Skin lesion from right buttock: Features are suggestive of cutaneous lipoma.