1.

Respiratory

It was a pleasure to see this lady today in the Drug Allergy Clinic.
She reports developing severe facial angio-oedema after taking both
Aspirin and Codeine. In addition, historically, she has undergone skin
testing to range of antibiotics in Pakistan and has been told that she is
allergic to all of them apart from Cefaclor.

Today, she proceeded to a Codeine challenge and received a

cumultative dose of 31 mg and did not develop any evidence of
utricaria or angio-oedema. NSAIDs such as Aspirin are far more
likely the cause of angio-oedema and utricaria and therefore
presently, she should avoid Aspirin although in due curse we may
consider a challenge to Celecoxib.

Skin prick testing in the absence of challenging is not of allegation

mean the diagnosing allergy to Penicillin. My understanding is she
underwent no _____ challenge and it is unclear why skin prick testing
was performed. At that time based on her description, it sounds like
she was demographic. We will therefore aim to bring her back in due
course to the Drug Allergy Clinic for oral Amoxicillin challenge. If
this is negative there should be no hesitation about prescribing her
beta-lactum. In the absence of reacting to any other antibiotic group,
it would be reasonable to also prescribe these for her.

Thanking you for your help with her ongoing care.

2. Neurology

Thank you for asking me to see this lady, who suffered a fall when in
a bus she standing was stopped unexpectedly last year. She hit her
heard on the hard surface and was discovered later to have suffered a
traumatic subdural. From what I understand, this was managed
conservatively.

After discharge, she went to the St. John’s Therapy Centre and was
given exercises. Since returning home, she has become more
dependant, but has reliable son and daughter, who visits her on most
days and help her with most of the things if she needs help with. She
does not suffer from any vestibular symptoms and is able to mobilise
independently. I note, however, that her blood pressure today was
105/57 mmHg suggesting that it might be worthwhile making some
adjustment to her antihypertensive regime, which I see is quiet
intensive at present.

I do not think, however, that she requires further neurological input at

this stage as she is very still potential to recover functionally from her
recent traumatic brain injury.

3. Urology

Diagnosis:
Sterile pyuria

Patient has been a bit of mystery. She has little in the wake of
symptoms since her first episode. She is not diabetic. She does not
suffer from constipation, but she does have a sterile pyuria. It then
became apparent that she was doing self catheterisation that has been
since around about January. There has been no positive cultures and
her symptoms are variable, but the main problem is that she cannot
empty her bladder when she comes to hospital as she is intermediated
by the toilet and she always has 365 ml in her bladder. In lite of all
this, I have asked her to stop self catheterising for the movement. In
the next time, if she thinks she has one of these episodes, she will let
us know and do a blood test and MFU. As I dictate this, she then
showed me a number of residual volumes, but it is not clear whether
she measured before weeing or after weeing. In light of this, we will
stuck to the plan, but she will do three post-void residual was using
her catheter sometime in the next week or so and then we will await
events, I will see her in six week’s time if nothing has happened.

4. Gastroenterology

Forgive me if I am writing to you unnecessarily because I have

feeling I have already dictated at least once on this patient to you.
However, my secretaries said you have not had no communication
from us following her consultation with me in the Gastroenterology
Clinic at Hammersmith Hospital on 26th February 2018. Patient
attended that consultation with her carer and both of them were
adamant that all of her symptoms have gone away and that her
digestive system is back to normal. Indeed Patient told me she felt
the best she had done in ages! I therefore simply arranged for blood
screen and a faecal calprotectin assay. I enclosed copies of the blood
results from 26th February 2018, which are highly reassuring. I also
enclosed the blood tests somebody else have requested for 20th April
2018, which also showed normal CEA125. The faecal calprotectin
assay is modestly elevated at 173 and therefore taking that forward
would depend on weather she has become significantly symptomatic
again. In the first instant, I would simply repeat the blood screen and
a faecal calprotectin assay. If the calprotectin remains significantly
alleviated, i.e. over 120 mg/g _____ (1:59) of faeces, then it would
not be unreasonable for her to have endoscopic investigation. Do let
me note how she is getting on.

Kind regards

5. Dermatology

Patient was referred to us to out Mole Mapping Service. She has

Crohn’s disease and is on Azathioprine 100mg daily. She works in
nursery and travels frequently to _____. She has used sunbeds about
three years ago. She use SPF 50 sun ____ protection daily. She has
had no previous excisions. Her mum did had a BCC removed.
Clinically, her skin burns easily, but _____ tan easily. Clinically, she
has more than 50 moles. I performed a full body check for her and
there were no suspicious lessons. However, in view of her
immunosuppressive therapy and the increased number of moles, I am
referring her to our Mole Mapping Service. I have given advise about
sun protection and use of sunscreen with high SPF. I have also
advised her that if in future she notices any new moles or any changes
in her current moles, she should contract us straight away.

Kind regards

6. Rheumatology

Diagnoses:
1. Osteoarthritis, left hand
2. Hypothyroidism

Medication:
Thyroxine.

Patient is seen today in General Arthritis Clinic. She has been

complaining of left wrist and knuckle pain on and of since reactive
arthritis 12 years ago. Feels her hand grip has gone week and
difficulty to fully bend her fingers. She was also complaining of
swelling of her MCP joints, which are specifically on the palmar
surface of her and specifically second and fourth MTP joint, which
was two months ago. She does complain of morning stiffness during
the acute episodes. No other joints are involved. She does not seem
to have any history of skin rash, GI, genitourinary, back or tendinitis.
The pain does seem to restrict her ability to work as a caretaker.
Physical examination reveals tender second and fifth fingers, but there
is no joint swelling or tenderness. Her blood tests are normal for
inflammatory markers and was negative for rheumatoid factor.
Ultrasound scan of her hand was done to look for any tenosynovitis,
which showed there is no active inflammation or tenosynovitis.
Degenerative changes are noted to the palmer aspect of second MCP
joint with osteophyte at the volar aspect. There is a small ganglion
fist at the dorsal aspect of the wrist.

Plan:
We are discharging her back to the GP as there is no case for her
inflammatory arthritis, cause for her pain. I have advised her
meloxicam 15 mg once a day for the pain in her wrist that could be
secondary to the cyst. GP to please refer patient to hand surgeon in
case her symptoms get more worse.
Thank you.

7. Gynaecology

I saw your patient in clinic today. As you are aware, the patient was
found to have a complex looking ovarian mass and underwent surgery
under my care. She had a 20-cm pelvic mass involving both ovaries
that was adherent to the _____ in the pelvis over the bladder, over the
bowel and over the pelvic side walls and was also adherent to the
uterus and the external lilac vessels. She underwent removal of this
mass and this was sent for frozen section. She subsequently
underwent staging as the mass was identified as a ovarian
malignancy.

Her surgery is complicated by small cystectomy that was repaired at

the time. Patient is making good recovery following surgery having
been discharged just under a weak ago. She is eating and drinking
normally and passing urine and opening her bowls regularly. She
does have a great appetite and has been encouraged to eat more.

On examination, her midline wound was healing, but was gapping

slightly at the lower end. We have re-dressed the area and asked her
to come see the practice nurse alternative days for this to be
monitored.

I have explained to patient that the histology has revealed evidence of

stage 1 endometrioid carcinoma of the ovary. The patient would
benefit from adjuvant chemotherapy and so the patient at some point
to meet our Medical Oncology team today.
With kind regards.

8. Cardiology

We received your letter in addition to patients’ _____ concern

regarding her use of Ticagrelor. You stated in your letter that it
appears no application to HSC was made for her Ticagrelor and she is
having difficulty getting this on a GMS as a result. Confirmation of
HSC approval is not necessarily for community sourcing of this drug
and is not applied provided the commencing prescribing doctors as a
standard. Ticagelor is not a direct oral anticoagulant therapy. It does
necessitate HSC approval for sourcing of this drug. Therefore, she
should be able to receive this too much as in the community. As
regards direct oral anticoagulant therapy, we are always happy to gain
HSC approval for these medications.

Any another queries, we are happy to answer.

Kind regards.

9. Endocrinology

Diagnoses:
Recent admission with acute kidney injury, deep venous thrombosis,
Heparin-induced thrombocytopaenia, which required IT admission.
Adrenal haemorrhage.
Negative TB-ELISpot
Liver lobe activity on CT breath on 29th September and reduction in
size of adrenal masses.

Current Medications:
Prednisolone 20 mg reducing course.
Warfarin.
Irbesartran 75 mg bd.
Clotrimazole.
Lansoparzole.

Results:
Pending.

It has been a pressure meeting this gentleman in Endocrine Clinic

today. He has made an excellent recovery following his prolonged
admission first at Northwick Park Hospital and then at Hammersmith
Hospital. A renal biopsy taken at the time of his admission to
Hammersmith Hospital showed minimum change disease and is
currently on a reducing course off Prednisolone. He is being followed
up at Northwick Park by Dr. Duncan, Consultant Nephrologist.

His recent PET-CT showed low level activity in both adrenal glands
and reduction in size of the adrenal masses suggestive of haemorrhage
rather than lymphoma or TB. His TB-ELISpot was negative.

His blood pressure today was 190/100 mmHg lying and 150/80
mmHg standing. The blood test including plasma renin activity and
will be seen in Northwick Park in the Renal Clinic next week. I
advised him not to reduce his steroids to less than 5 mg of
Prednisolone daily. We will need to carry out adrenal testing and if it
is likely that he will need to stay on lifelong steroid replacement.
Episodes are likely that he will require Fludrocortisone. I look
forward to reviewing him again in two months time, by which time he
maybe in a much lower dose of Prednisolone. He is aware that he
must not stop his steroids and need to attend hospital for steroid
injection in the event of vomiting or any illness when he is unable to
take oral tablets.

10. ENT

Diagnosis:
No nasal fracture amenable to MUA.

Management:
Discharged to care of GP.

Patient was seen eight days following a cycling accident where he

landed flat on his face. He was seen in _____ here, at the time _____
referred him for nasal fracture evaluation a week later. He has been
very well in himself and the bruising over his nose denies to come
down significantly. There are no breathing problems and no problems
with blood.

On examination today, his nose was straight. The septum was

unremarkable and there is nothing else to be found. Patient was
discharged to the care of his GP.
11. Orthopaedics

This peasant lady returned to clinic today. Her nerve conduction

studies of her ulnar nerve was very reassuring and showed a
_____nerve. However, she still got quiet of bit of pain in her elbow
and I wonder if this is just an extreme to this elbow. Certainly, she is
very painful on palpitation of common extensor origin. So I think
before we embark on anything _____, we will get an ultrasound-
guided injection to see if this improves the situation, also enabling us
to have an ultrasound examination of the elbow _____. We will
review her in three months' time to see how she ______.

12. Ophthalmology:

Visual acuity is 6/5, 6/6 right and left respectfully.

Patient was reviewed in the clinic today, who has been followed for
possible low-tension glaucoma. His corrected interocular pressures
are 22 mmHg and 23 mmHg today with a disc capping of 0.6 and
0.75, although he has retinal nerve fibre layer within normal limits,
but he has got ____ disc asymmetry with thinning of neuroretinal rim
in the left inferior and temporal aspect. I am going to repeat the
visual field in six months' time to access if there is any definite
evidence of glaucoma or suggest variation of normal.

Many thanks.