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1 (#"""(+*#"(#*(#"4#' (Med 01) PILOT Patient Details (attach Addressograph): #!! " $ $ %& '( % $ ) * +# *# ##!! %#!! *!!!! HCV status: HBV status: HAV status PCR: Genotype: HbsAg (surface antigen) HbcAb (core antibody) Any known co-infection: Suspected mode of transmission & Year Any existing risk factors: If IVDU current usage : YES / NO Comments:, # # $%! " &$' % ()(* # -! # - - *- -.//31 2.//01 2

2 OVERVIEW OF HEPATITIS C TREATMENT PATHWAY. DISCHARGE / REFERRED TO HEPATOLOGY CLINIC SUSTAINED VIROLOGICAL RESPONSE POST TREATMENT BLOOD TESTING MONITORING DURING TREASTMENT START TREATMENT PRE TREATMENT ASSESSMENT ARRANGE LIVER BIOPSY/ GENOTYPE 1 /CLINICAL INDICATION PATIENT DECLINED OR NOT SUITABLE FOR TREATMENT CONTINUED TO BE MONITORED CONFIRM DIAGNOSIS & EDUCATION, USS. STAGE OUT PATIENT APPOINTMENTS FIRST APPOINTMENT 2 ND APPOINTMENT 3 RD ASPPOINTMENT 4 TH APPOINTMANE FOURTNIGHTLY APPOINTMENTS FOR 8 WEEKS MONTHLY APPOINTMENTS THERAFTER ( total 24 weeks genotype 2,3,4 + L.V.L.1 +R.V.R., 48 weeks genotype,5,6+h.v.l.l.+c.e.v.r.; or 72 weeks genotype 1 2 WEEKS POST TREATMENT COMPLETION 6 MONTHS POST TREATMENT BLOOD TESTING OUTCOME Education and nurse specialist contact outside of clinic appointments NB. All patients referred receive education, counselling and Ultra Sound Scan on confirmation of diagnosis (Red Star). Patients are then individually assessed if not suitable for treatment they are monitored and continually reassessed (green stars). Blue stars indicate a route through a treatment programme. Patients on the green pathway may enter the start of the blue path if deemed suitable during monitoring. It is possible not all patients will be cured and discharged. Those who do not have a negative Sustained Virological Response will continue monitoring.

3 GUIDELINES FOR TREATING PATIENTS WITH HEPATITIS C. Patient details. Ensure patient details are correct. Request patient contact number. Enter details into data base. Record patients wishes regarding treatment options. Ensure addressograph used on every page. Identify any key workers or shared care input from external agencies i.e. CDAT. If 1 st.dna without notice, letter to patient, check address with referral agency and place back on waiting list. If 2 nd DNA without notice, Discharge from service, complete data base and letter to referral source. Education & Support. Provide full verbal education, regarding disease progression, transmission, symptoms, transmission, precautions, pregnancy, assessments, monitoring, treatment, side-effects and efficacy. Provide patient information leaflet. Provide contact details and telephone number of Nurse Specialist. Ensure details entered into data base. If Blood transfusion < 1991 provides information re: Skipton Fund. Assess patient support mechanisms at home. Letter to referral source. Stage 1 first appointment. Discuss with consultant any concerns or at case conference as required. Arrange next out patient appointment when results are available. Patient details. Ensure patient details and contact number remain unchanged. Enter all new information from appointment into data base. Record patient s wishes regarding treatment options. Ensure addressograph used on every page. Identify any key workers or shared care input from external agencies i.e. CDAT. If 1 st.dna without notice, letter to patient, check address with referral agency and place back on waiting list. If 2 nd DNA without notice, Discharge from service, complete data base and letter to referral source. Education & Support. Assess patient support mechanisms at home. Explain results of previous investigations. Explain Liver Biopsy procedure if necessary. Letter to referral source. Assessment. Complete medical history. Assess possible co-infection. Assess suspected route of transmission. Assess any ongoing recreational drug use. Record medication and drug allergies. Assess / discuss contraception. Assess alcohol and cannabis use. Assess any ongoing Health problems which may impact on treatment i.e. weight loss. Complete general, respiratory and abdominal examinations, record findings. If femoral stab indicated arrange same. Investigations. Ensure patient understands and consents to Investigations. Arrange all base line blood tests, FBC, Co-agulation screen, RBL, Thyroid function tests, Glucose, GGT, Urate & AFP. Arrange any blood test outstanding of Hepatitis Screen, HAV, HBV, HCV-PCR and Genotype, EDTA if genotype 1, 4, 5 or 6. Arrange Ultra Sound Scan of Liver and Abdomen. Ensure all blood forms are identified as high risk. ECG if patient >45yrs of age ( see protocol) Refer cardiology if previous angina/m.i/cva. Refer ophthalmology if known glaucoma / family history. ( see cautions re: treatment) Urine drug testing with consent if necessary. Stage 2 second appointment. Assessment. Assess any ongoing recreational drug use, advise regarding direct / indirect sharing as appropriate. Assess alcohol and cannabis use. Assess current medication. Chose continuing care option, 1 patient for treatment, or 2 on going monitoring, Option 1 (for treatment) Assess suitability for Liver biopsy.( see protocol, platelet count >150, INR <1.5, no current drug use) If patient suitable for treatment but is not for Liver Biopsy (see N.I.C.E guidance No.14) arrange OPD when available. Investigations. Ensure patient understands and consents to Investigations Ensure all blood forms are identified as high risk. Urine drug testing with consent if necessary. Arrange repeat co-agulation screen, FBC and LFT. If option 1 arrange Liver Biopsy if indicated above or option 2 OPD 6months. Discuss with consultant any concerns or at case conference as required Arrange next out patient appointment option 1- when results are available or option 2 6 monthly review. Option 1 (for treatment) Explain biopsy results. Ensure appropriate contraception Re-educate re treatment, side-effects and efficacy. Ensure patient aware of importance of attending OPD. Ensure patient has Specialist Nurse contact details. Letter to referral source. Stage 3 third appointment. Assessment & Investigations Option 1 (for treatment) Ensure no on going recreational drug use. Random urine drug screen if necessary. Present patient to consultant for review for treatment if yes continue, if no return to ongoing monitoring.. Ensure adequate funding available (refer high cost drug budget) Arrange OPD s for treatment ( 24 weeks genotype 2/3, 48 weeks genotype 1,4,5 & 6) Arrange medication availability with pharmacy. Arrange base line blood tests, FBC, INR, LFT

4 Patient details (option 1 & 2) Ensure patient details and contact number remain unchanged. Enter all new information from appointment into data base. Record patients wishes regarding treatment options. Ensure addressograph used on every page. Identify any key workers or shared care input from external agencies i.e. CDAT. If 1 st.dna without notice, letter to patient, check address with referral agency and place back on waiting list. If 2 nd DNA without notice, Discharge from service, complete data base and letter to referral source Education and Support. Starting treatment (option 1) education and support. Ensure appropriate contraception Re-educate re treatment, side-effects and efficacy. Ensure patient aware of importance of attending OPD. Ensure patient has Specialist Nurse contact details. Educate re safe disposal of sharps and provide bin. Demonstrate method of subcutaneous administration of medication. Advise patient take paracetamol at home. Advise patient injection site may become pink. Patient details (option 1 & 2) Ensure patient details and contact number remain unchanged. Enter all new information from appointment into data base. Record patients wishes regarding treatment options. Ensure addressograph used on every page. Identify any key workers or shared care input from external agencies i.e. CDAT. If 1 st.dna without notice, letter to patient, check address with referral agency and place back on waiting list. If 2 nd DNA without notice, Discharge from service, complete data base and letter to referral source. Option 2 (ongoing monitoring) Assess any ongoing recreational drug use advise regarding direct / indirect sharing as appropriate. Assess alcohol and cannabis use. Assess current medication. Assess general health, symptoms. Reassess suitability for Liver biopsy / consultant review for treatment if Yes return to stage 2 assessment. If no arrange OPD 6 months. Discuss with consultant any concerns or at case conference as required Arrange next out patient appointment for 6 monthly review. Stage 4- fourth appointment Assessment and treatment. (option 1) Ensure blood results indicate suitable for treatment (see cautions) Assess and discuss contraception. Arrange doctor to complete prescription. Arrange collection of prescription from pharmacy. Arrange home-visit or appointment to supervise next dose. Provide patient with blood form for FBC and LFT 10days post dose. OPD as per plan. Letter to referral source. Option 2 (ongoing monitoring) Assess any ongoing recreational drug use, advise regarding direct / indirect sharing as appropriate. Assess alcohol and cannabis use. Assess current medication. Assess general health, symptoms. Reassess suitability for Liver biopsy / consultant review for treatment if Yes return to stage 2 assessment. If no arrange OPD 6 months. Discuss with consultant any concerns or at case conference as required Arrange next out patient appointment for 6 monthly review. Stage 5 fifth and subsequent appointments. Option 1 (during treatment) Patients will continue to be reviewed every two weeks for the first 8 weeks of their treatment programme then on a monthly basis providing blood results allow. The duration of treatment is indicated according to genotype. education and support. Ensure appropriate contraception. Ensure patient has Specialist Nurse contact details. Provide information regarding any specific side-effects. Letter to referral source. Assessment and treatment. Ensure blood results indicate suitable for treatment (see cautions) adjust dose of treatment as per protocol. Assess and discuss contraception. Arrange doctor to complete prescription. Arrange collection of prescription from pharmacy. Assess weight loss (expected) Assess appetite, nausea, vomiting. Check injection sites. Assess mood. Assess sleep pattern. Arrange blood test as per plan prior to next appointment. Assess any other side-effects. If HB< 9 consider use of EPO, If neutrophils <1.5 despite dose reduction consider G-CSF> Week 12, genotype 1,4,5 & 6 only blood for EDTA. (early Virological response rate) if >/= 2 log deficit continue if not consultant review re discontinuation of treatment. Random urine drug screen if appropriate. OPD as per plan. Patient details (option 1 & 2) Ensure patient details and contact number remain unchanged. Enter all new information from appointment into data base. Record patients wishes regarding treatment options. Ensure addressograph used on every page. Identify any key workers or shared care input from external agencies i.e. CDAT. Option 2 (ongoing monitoring) Assess any ongoing recreational drug use, advise regarding direct / indirect sharing as appropriate. Assess alcohol and cannabis use. Assess current medication. Assess general health, symptoms. Reassess suitability for Liver biopsy / consultant review for treatment if Yes return to stage 2 assessment. If no arrange OPD 6 months.

5 If 1st.DNA without notice, letter to patient, check address with referral agency and place back on waiting list. If 2nd DNA without notice, Discharge from service, complete data base and letter to referral source. Patient details Ensure patient details and contact number remain unchanged. Enter all new information from appointment into data base. Ensure addressograph used on every page. Identify any key workers or shared care input from external agencies i.e. CDAT. Request return of sharps bin for disposal as per hospital policy. If 1 st.dna without notice, letter to patient, check address with referral agency and place back on waiting list. If 2 nd DNA without notice, Discharge from service, complete data base and letter to referral source. Patient details. Ensure patient details and contact number remain unchanged. Enter all new information from appointment into data base. Ensure addressograph used on every page. Identify any key workers or shared care input from external agencies i.e. CDAT. Request return of sharps bin for disposal as per hospital policy. If 1 st.dna without notice, letter to patient, check address with referral agency and place back on waiting list. If 2 nd DNA without notice, Discharge from service, complete data base and letter to referral source. Letter to referral source. Patient details. Enter all new information from appointment into data base Ensure addressograph used on every page. If 1 st.dna without notice, letter to patient, check address with referral agency and place back on waiting list. If 2 nd DNA without notice, Discharge from service, complete data base and letter to referral source. Letter to referral source. Discuss with consultant any concerns or at case conference as required Arrange next out patient appointment for 6 monthly review. Stage 6-2 weeks post treatment (option 2 continue as above) Investigations & Education. Arrange PCR blood test 2 weeks post treatment completion. Ensure appropriate contraception continues, female patients - 6months, male patients -7 months. Ensure patient has Specialist Nurse contact details. Advise patient of continued future protection against possible re-infection and need for repeat PCR in 6 months. Discuss with consultant any concerns or at case conference as required Arrange OPD when results available and explain result, If negative see stage 7 if positive arrange continued monitoring and support from nurse specialist. Letter to referral source. Stage 7 24 weeks post treatment (option 2 continue as above) Stage 8 discharge. Investigations & Education. Arrange PCR blood test for sustained Virological response (SVR). Ensure appropriate contraception continues, female patients 6months, male patients 7 months post treatment. Ensure patient has Specialist Nurse contact details. Advise patient of need for continued future protection against possible re-infection Discuss with consultant any concerns or at case conference as required Arrange OPD when results available and explain result, if positive arrange continued monitoring and support from nurse specialist, if negative see stage 8. Education. Inform referral source of outcome of treatment +/- GP as per patient instruction. Advise patient of need for continued future protection against possible re-infection. Advice future testing will show antibody positive PCR negative. Discuss with consultant any concerns or at case conference as required Discharge patient from service.

6 HPC: Any previous jaundice: Immunisations: Treatment Abroad: Significant Travel: Previous Blood Transfusions: Skipton fund discussed Other Risk Factors: Yes / No PMHx: Gynae. Hx: Contraception: Drug Hx: Allergies:

7 Social History: Alcohol consumption: Smoker: Yes / No Systems review: Cardiac: Respiratory: Abdominal: C.N.S: Bowel Habits: Current weight/loss/gain: Vomiting: Weight: ON EXAMINATION BP: Pulse: O/E

8 INFORMATION/PATIENT EDUCATION DATE: SEEN BY: VISIT 1 TOPICS DISCUSSED/INFORMATION GIVEN What is Hepatitis? Disease Progression Symptoms Transmission routes Precautions Implications of Alcohol and cannabis use Assessment Process Blood Tests USS Treatment and It s Effects Information Leaflet Supplied Specialist Nurse Contact Number Opportunity for Patients Questions Comments/Concerns: INITIAL INVESTIGATIONS ARRANGED Blood Sampling: FBC, LFT, U&E, HCV, PCR, HCV, GENOTYPE, CLOTTING SCREEN, AFP Arrange USS Abdomen OPD When Results are Available Other: YES/NO COMMENTS: Signature:..

9 DATE: SEEN BY: VISIT 2 INFORMATION GIVEN Explain Results of Investigations Establish if current drug usage Discuss Urine Testing Does Patient Want Treatment? Is Liver Biopsy indicated? If NO Discuss Follow Up Patients Concerns/Questions Answered INITIAL YES/NO YES/NO INVESTIGATIONS ARRANGED Arrange Liver Biopsy, Medical Day Unit if indicated Repeat Clotting Screen Next appointment arranged /52 Or OPD following investigations INITIAL COMMENTS: Signature:..

10 DATE: SEEN BY: VISIT 3 INFORMATION GIVEN Biopsy / investigation Results Explained If For Treatment Recap of Education as on Visit 1 Contraception Method: Side-Effects of Treatment Need for OPD Attendance Follow up appointment for./52 Base line bloods arranged including viral load if required Patients Questions Answered INITIAL COMMENTS: Signature:.. CONSULTANT REVIEW: For Treatment: YES / NO Signature

11 DATE: SEEN BY: VISIT 4 STARTING TREATMENT INFORMATION GIVEN Treatment Schedule Contraception Discussed Sharps Disposal Discussed & Bin supplied Treatment & Side Effects Revisited Patient to Collect Prescription During OPD Demonstrate First Does Administration Instruct Patient to Take Paracetamol at Home Advised to Observe Injection Site Arrange to Supervise Next Dose Ensure Patient has Specialist Nurse Contact Number Patient Questions/Concerns Discussed INITIAL INVESTIGATIONS REQUIRED FBC, LFT & INR Form for 10 Days Time supplied INITIAL COMMENTS: Signature:..

12 APPOINTMENTS DURING TREATMENT DATE : SEEN BY: WEEK: Assess Mood Evidence of Sleep Disturbances Weight Appetite Check Injection Sites Check for Other Side-Effects Repeat Prescription Investigations as per Chart ASSESSMENT Y / N COMMENTS: Signature:..

13 APPOINTMENTS DURING TREATMENT DATE : SEEN BY: WEEK: Assess Mood Evidence of Sleep Disturbances Weight Appetite Check Injection Sites Check for Other Side-Effects Repeat Prescription Investigations as per Chart ASSESSMENT Y / N COMMENTS: Signature:..

14 Genotype 1(L.V.L.) 3, 2, 4 Royal Glamorgan Trust Hospital Ynysmaerdy Llantrisant Rhondda Cynon Taff CF72 8XR Reference: The following appointments have been made for you. If you are unable to attend at any time, then please contact either Miss Vickie Price, secretary on ext 4849 ;Angela Andrew or Pam Hams on (01443) ext 4946 or mobile number: (Angela) (Pam) WEEK DATE TIME START WEEK 2 WEEK 4 WEEK 6 WEEK 8 WEEK 12 WEEK 16 WEEK 20 WEEK 26 WEEK 30 WEEK 48 To be arranged WEEK 52 To be arranged Many Thanks Mrs A Andrew, Nurse Specialist Mrs P Hams, Nurse Specialist For Dr R Alcolado, Consultant Physician Royal Glamorgan Trust Hospital Ynysmaerdy Llantrisant Rhondda Cynon Taff

15 Genotype 1(H.V.L.), 5,6 CF72 8XR Reference: The following appointments have been made for you. If you are unable to attend at any time, then please contact either Miss Vickie Price, secretary on ext 4849 ;Angela Andrew or Pam Hams on (01443) ext 4946 or mobile number: (Angela) (Pam) WEEK DATE TIME START WEEK 2 WEEK 4 WEEK 6 WEEK 8 WEEK 12 WEEK 16 WEEK 20 WEEK 24 WEEK 28 WEEK 32 WEEK 36 WEEK 40 WEEK 44 WEEK 50 WEEK 54 WEEK 74 To be arranged WEEK 78 To be arranged Many Thanks Mrs A Andrew, Nurse Specialist Mrs P Hams, Nurse Specialist For Dr R Alcolado, Consultant Physician

16 PONTYPRIDD & RHONDDA NHS TRUST GASTROENTEROLOGY HEPATITIS C TREATMENT MONITORING DATE HCV PCR AFP SIGNATURE COMMENTS LIVER BIOPSY RESULT DATE PERFORMED STAGE GRADE COMMENTS

17 WEEK DATE WEIGHT Hb WBC Neu Plt ALT AST BIL GGT TSH URATE T4 SIG COMMENTS ADDITIONAL INFORMATION/COMMENTS

18 TABLE OF INVESTIGATIONS REQUIRED DURING HEPATITIS C TREATMENT PROGRAMME Genotype 3, 2 4, L.V.L.1 DATE WEEK HCV PCR GENOTYPE HBC HAC AFP CLOTTING SCREEN FBC U & E LFT T4 URATE GLUCOSE OTHER 1 ST VISIT X X X X X X X X X X X X 2 ND VISIT X 3 RD VISIT TX COM X X WEEK 2 X X WEEK 4 X X X RVR(LVL 1 WEEK 6 X X WEEK 8 X X X X X X WEEK 12 X X X X X WEEK 16 X X X X WEEK 20 X X X X X WEEK 26 X X X X WEEK 48 X COMMENTS:

19 TABLE OF INVESTIGATIONS REQUIRED DURING HEPATITIS C TREATMENT PROGRAMME Genotype 1, 4, 5 DATE WEEK HCV PCR GENOTYPE HBC HAC AFP CLOTTING SCREEN FBC U & E LFT T4 URATE GLUCOSE OTHER 1 ST VISIT X X X X X X X X X X X X 2 ND VISIT X 3 RD VISIT TX COM X X WEEK 2 X X WEEK 4 x X X X WEEK 6 X X WEEK 8 X X X X X X WEEK 12 X X X X X WEEK 16 X X X X WEEK 20 X X X X X WEEK 24 x X X X X WEEK 28 X X X WEEK 32 X X X X X X WEEK 36 X X X WEEK 40 X X X X WEEK 44 X X X X X WEEK 48 X X X X WEEK 50 X X X X WEEK 74 X COMMENTS:

20 AUDIT OF ALL PHASES OF HEPATITIS C TREATMENT PROGRAMME FOR GASTROENTEROLOGY NURSING SERVICES, PONTYPRIDD AND RHONDDA NHS TRUST HOSPITAL:. AUDIT PERIOD: V I S I T No of X s Patient details complete Contact Number available GP details complete Source of referral evident HCV genotype known HBV status known HAV status known Issue of co-infection addressed Suspected transmission details complete Existing risk factors addressed History take documentation complete Diagnosis explained Disease progression explained Signs and symptoms explained Modes of transmission explained Necessary precautions explained Alcohol abstention explained Assessment process explained Treatment and side effects explained USS explained Patient information booklet supplied CNS contact number provided Section signed and dated V I S I T 2 Blood results explained USS results explained Any current drug usage addressed Evidence of patient consent to treatment Liver biopsy explained Section signed and dated V I S I T 3 Biopsy results explained Evidence of education update Contraception discussed Treatment discussed Side effects discussed OPD attendance discussed Treatment start date set Treatment appointment schedule arranged Section signed and dated V I S I T 4 Sharps disposal discussed

21 Treatment and side-effects information given First dose administration given Injection site care information given Second dose under supervision Section signed and dated V I S I T S D U R I N G T R E A T M E N T Mood assessed Sleep pattern assessed Patient weight record Appetite addressed Other side-effects if experience addressed Investigations as per plan Visits signed and dated R E S U L T S M O N I T O R I N G Patient details complete Investigations conducted as per table Results table completed for every visit Entries signed and dated Number of ticks: Row A Total = Number of ticks: Row B Total = For each column, count all the actual ticks and the total are entered into Row A. The total number of all potential (not including any N/A s) is entered into Row B. These numbers are then totalled and transferred to the calculation at the end.

22 V I S I T No of X s Patient details complete Contact Number available GP details complete Source of referral evident HCV genotype known HBV status known HAV status known Issue of co-infection addressed Suspected transmission details complete Existing risk factors addressed History take documentation complete Diagnosis explained Disease progression explained Signs and symptoms explained Modes of transmission explained Necessary precautions explained Alcohol abstention explained Assessment process explained Treatment and side effects explained USS explained Patient information booklet supplied CNS contact number provided Section signed and dated V I S I T 2 Blood results explained USS results explained Any current drug usage addressed Evidence of patient consent to treatment Liver biopsy explained Section signed and dated V I S I T 3 Biopsy results explained Evidence of education update Contraception discussed Treatment discussed Side effects discussed OPD attendance discussed Treatment start date set Treatment appointment schedule arranged Section signed and dated V I S I T 4 Sharps disposal discussed Treatment and side-effects information given First dose administration given Injection site care information given Second dose under supervision Section signed and dated

23 V I S I T S D U R I N G T R E A T M E N T Mood assessed Sleep pattern assessed Patient weight record Appetite addressed Other side-effects if experience addressed Investigations as per plan Visits signed and dated R E S U L T S M O N I T O R I N G Patient details complete Investigations conducted as per table Results table completed for every visit Entries signed and dated Number of ticks: Row C Total = Number of ticks: Row D Total = Columns C & D are calculated as for A & B. Data for A, B, C & D are entered into The equation below. The total then demonstrates percentage of compliance to Hepatitis C treatment programme based on a sample of 20 patients receiving the service. % compliance = (A + C) / (B + D) x 100 therefore A+C = x 100 = % B+D Whereby an X has been entered into a section this will provide direction to areas of The service, which will be revisited and assessed for possible improvement.

24 AUTHORS Angela Andrew, Specialist Nurse Gastroenterology. Pam Hams, Specialist Nurse Gastroenterology, Dr Ruth Alcolado, Consultant Physician. Victoria Price, Secretary Gastroenterology. Jayne Gibbs Administration Support REFERENCES The National Institute for Health and Clinical Excellence (2000), Guidance On The Use Of Interferon Alpha for Hepatitis C. Technology appraisal Guidance - No. 14. NICE. London. ABBREVIATIONS USED IN PATHWAY. AFP Alpha-fetoprotein ALT Alanaline Transaminase AST Aspartate amino transferase BIL Total Bilirubin BP Blood Pressure. CDAT-Community Drug and Alcohol Team. CNS Central Nervous System CVA Cerebral Vascular Accident. DHx Drug History ( prescribed and recreational) DNA Did Not Attend. ECG Electrocardiograph. EDTA Quantatative PCR. FBC Full Blood Count. GGT Gamma-glutamyl transpeptidase. GP General Practitioner HAV Hepatitis A HB Haemoglobin HBV Hepatitis B HCV Hepatitis C HPC History of Presenting Complaint Hx History. INR International Normalised Ratio. IVDU - Intravenous Drug Use LFT Liver Function Tests MI Myocardial Infarction. NEU Neutrophils. OPD Out Patient Department appointment. PCR Polymease Chain Reaction. PLT Platelets. PMH Past Medical History SIG Signature. T4- Thyroxine TSH Thyriod-stimulating hormone. U&E Urea and Electrolyte. USS Ultra Sound Scan. WBC Wight Blood Cell Count.