The patient registered with the Ixworth Surgery. A new patient questionnaire was completed, noting a height of 1.75m, weight of 82.555 Kg (13 st), BMI of 26.96 Kg/m², an alcohol intake of 6 units/week, and a history as an ex-smoker who stopped in April 2007. The patient's previous GP was Dr. S Gankerseer. His previous address was 175 Station Road, Burgess Hill.
A GP consultation notes the patient is "new to area - moved from Sussex" and had "recent domestic probs" with his wife, who had postnatal depression. The patient reported his wife had tried to assault him while he was holding their baby, but she then called the police, accusing him of assault. He was arrested but not charged. He was sleeping on a mattress at a nightly basis. The GP recorded a history of sleep apnoea, lumbar disc problems, and asthma, and that the patient needed medication.
The patient was seen by a GP and noted as "more depressed". He had split up with his wife and was living in rented accommodation in Newmarket. He wanted to restart fluoxetine, which he had stopped abruptly in October 2008 after 5 years. The GP diagnosed a depressive disorder and prescribed Fluoxetine 20mg capsules.
A telephone encounter with Burnett Barker Solicitors revealed that a court case was starting on Monday, January 25th, and a report was needed. The GP faxed the letter to the solicitors.
The patient's annual asthma review was conducted, noting he was a smoker of 15 cigarettes/day. A letter was sent to an outside agency to support a rehousing application because his current housing was affecting his asthma and sleep apnoea. The patient was informed he could collect the letter at no charge.
A GP sent a general letter to a solicitor, but the specifics are not detailed. An entry also notes a letter to Dr. Theodore Bailey.
The patient first rang, expressing he felt suicidal and would do something violent, but that his parrot was the only thing stopping him. The GP referred him to the crisis team. The crisis team rang back, but the patient hung up on them. They noted he was "focussed on housing and finances and he did not want to discuss mood".
A GP entry notes a letter to support the patient, and an appointment was suggested with a Mental Health link worker to discuss the best course of action to respond to a letter from a presiding judge in a custody case.
A nurse noted a face-to-face consultation with the patient at the request of a GP, following court recommendations for clinical psychological input. The patient "felt he might have 'rubbed the psychologist up the wrong way'," referring to a previous court-ordered assessment. The patient denied any suicidal ideation, stating "I've always got something to live for," and described himself as a "thinker of 'eclectic thoughts'". The nurse could not elicit any current concerning psychiatric illness and supported the view that the patient did not meet the criteria for assessment by the Community Mental Health Team.
The patient told a GP that he had stopped taking his fluoxetine, weaning himself off it over three months and had been two months drug-free. He experienced some withdrawal effects like tremors, but they had subsided. The GP noted he "looks well, animated, loud pressurred speech with flight of ideas, no delusions or abnormal thoughts" and diagnosed a "? manic episode with no psychosis". The GP advised him to call 999 or the surgery if he developed thoughts of harming himself or others.
The patient called to report that he was no longer taking antidepressants and had been off them for four months. He requested an assessment on headed paper from an appointment with Kevin Rowland, which the GP agreed to provide for court use.
The patient was newly registered with a GP and dissented from the disclosure of his personal identifiable data to both the secondary use GP patient identifiable data and the HSCIC. This consent change was noted as a "Major" event.
The patient was seen and was "very tearful". He wanted to restart his fluoxetine, which he had stopped the previous year, following a recent breakdown of a relationship. The GP noted he was "not from around the area, no friends" and was not actively suicidal. The GP started him back on Fluoxetine and made a mental health referral.
The patient reported he had two recent RTAs, resulting in his car being written off. He went to A&E the next day and was advised to see his GP. He reported some anxiety and felt he needed something to help him sleep and for "prn anxiety". He was given a short course of Diazepam.
The patient attended with a parrot on his shoulder, complaining of a reaction to buprenorphine patches. He stated that after 2-3 days, he gets a headache and his skin looks red where the patch was applied. He was worried about low blood sugar and also had "troubles with DWP". He was informed that the lowest dose of fentanyl was much stronger than his current dose of Buprenorphine, and his request for Diazepam was declined.
A GP noted the patient had "anxiety re assault last week" and was having flashbacks related to PTSD. He was given Diazepam 5mg tablets.
The patient saw a GP and discussed that he had stopped using Reletrans (a type of buprenorphine) due to blistering but had managed to decrease his Tramadol dose. The GP requested an x-ray of his pelvis and hips and blood tests for HbA1c and cholesterol.
The patient attended with a parrot on his shoulder. He stated he had a lot of issues with ongoing pain and had stopped taking his morphine due to concerns about addiction, not because of an improvement in pain. He requested a letter for benefits regarding this. The GP agreed to refer him to MSK for pain and provide a "TWIMC letter".
The patient had a fall from a tree the previous day while trying to rescue his parrot, resulting in a wrenched and painful left shoulder. He also requested more Diazepam, stating he only uses it occasionally when he can't sleep due to his post-traumatic stress disorder. The GP noted that the patient cannot have NSAIDs and agreed to prescribe Beclometasone nasal spray for hay fever.
The patient explained that a friend who was staying had attacked him a week ago. He said the friend, a prostitute who was also a drug addict, bit him on the side of his abdomen and also punched him and stamped on his foot. He was worried that he should get checked out for the human bite.
A GP entry notes the patient had abdominal pain after a human bite four months prior and was worried about an infection. The patient "insists he is not allergic to penicillin" and the penicillin allergy alerts were removed. He was prescribed Flucloxacillin.
A note was added to the patient's record stating his preference for only core items to be included in his Summary Care Record was overridden so that additional items would be included, under COPI Regulations.
A GP consultation notes the patient has "probs with pete sharples housing assoc" and has booked a consultation with a medical cannabis clinic (project 2021). An attempt to send an email to his hotmail address failed due to a "permission or security issue," but after a phone call, the correct email address was used and the email was sent.
A GP consultation notes the patient is "using cannabis from project 21" and is off fluoxetine. He had an appearance at Ipswich Magistrates' Court the following week with an anti-social behavior clerk from Flagship. The patient states he "feels well now as in ct".
A GP consultation notes the patient has "probs to do with Mr Sharples anti social behaviour officer". The patient "uses these threats as a tool" and a mental health team referral was discussed and accepted. The GP recorded that the patient had lost weight due to stress and was not eating well.
A GP noted an email and letter to the mental health team and that the patient was happy to be re-referred. Referrals to the mental health team were then emailed to Suffolk Access and Assessment.
An entry notes an "Adult safeguarding concern". A letter was sent to a clinic in relation to this. This concern was discussed at a Safeguarding Meeting and reviewed by a Safeguarding Lead. The entry notes that the GP had referred the patient to Mental Health and that the case was to stay on the list.
A GP consultation notes that the patient had a cut on his arm and finger and had tried penicillin, which was ok with him. The GP then noted they would "send letter to dr zapata from medical cannabis clinic". A copy of the cannabis clinic letter was then sent to Dr. Zapata.
A GP consultation notes the patient was "spoken post discharge feeling well now". The patient stated he "doesn't cannabis related to his problems section 2 recinded on 3/6 2021 by dr michael no information here only assessment when detained".
A GP entry notes "threats to kill himself on email, urgent referral to CMHT". The referral form for the mental health counsellor was documented.
A referral was made to the Suffolk MASH Unit for a Suffolk Safeguarding Adults enquiry. The record was accessed under the MASH Information Sharing Agreement and Caldecott Guidelines, meeting the criteria for "the protection of vulnerable members of the community".
A GP consultation notes the patient had a fungal toenail infection and was prescribed Terbinafine 250mg tablets.
A GP consultation notes the patient "breathed in cloud of dust 4/7 ago" after visiting a neighbor who was sweeping a yard. The patient had a streaming nose and cough and suspected sinusitis. He was prescribed Amoxicillin and a nasal spray.