ࡱ>  bjbjSS *11cjj8@, wZ((4)))** *$у̀9*B**">+,j+̀jj))6///+j)j8)/*//XpLw)Џ\UTb..sZ;<wsq.$qww2q~Z~**/*****̀̀/***w****q********* 0: Scenario Title: Weight loss and amenorrhea in a 17year-old female Scenario Author: Dr Lisa Page and Dr Isabel McMullen Updated (2017): Dr Carol Kan and Professor Janet Treasure a) Learning objectives. Please describe the learning objectives for this scenario under the following headings. Please add or remove sub-headings and add additional details as required. Please note not all of the Main Headings will be required for all scenarios so please delete if you do not wish to use. Main HeadingSub-HeadingDetails (please list any further headings under this sub-heading)1. Basic Science & Pathology Normal and abnormal structure and function relevant to this scenarioAnatomyHistopathologyImmunologyMicrobiologyPhysiologySecondary amenorrhea, other systemic changes secondary to weight loss GeneticsHeritability of psychiatric disorderBiochemistryBiochemical changes due to malnutritionOther2. Clinical Science: Physical and Psychological Clinical features of this scenario and related conditions to be covered hereSymptomsWeight loss, cessation of periods, social withdrawal, cold intoleranceSignsMental state examination & general physical examinationInvestigationsWeight & calculation of body mass index (BMI) Full blood count Biochemistry (including Calcium, phosphate) Thyroid function tests Inflammatory markers Further history from schoolManagementInitial management in primary care Weight monitoring Dietician Involvement of family and school Clear plan for referral to specialist services if no improvement Specialist psychological therapiesPrognosis and outcomePrognosis of anorexia nervosaOtherEngaging a reluctant patient3. Population Sciences & Health Care Public health issues related to this scenario in the UK or elsewhere. For instance: why does this patient have this problem in this society? What is our response to it?Public health and clinical epidemiology (including statistics)Prevalence Prognosis Sex differencesIssues of access to health careThe patient may not present selfComplementary medicineHealth care systemsClose multidisciplinary workingResource managementReferral for specialist treatmentHealth educationEducating the patient, family and schoolEnvironmental, economic, political influences (both local and global) on the evolution of this condition This condition in other societiesOther4. Skills Practical and communication skills related to this scenarioCommunicationEngaging patient, family and schoolAspects of history takingImportance of history taking from those other than the patientAspects of clinical examinationMental state examinationTeam working Liaising with dietician and other professionals with clear planOther 5. Professional Development & Practice Responsibilities, ethical and legal issues, self and professional management issuesResponsibilities and boundaries of a doctorBalancing confidentiality with involvement of family and schoolValues, impact of personal values on behaviourDieting and concern about body image are common in Western society, disordered eating behaviours can gradually become compulsive and slip into anorexia nervosa. The Mental Health Act is sometimes need to be considered in patients with a severe, treatment-resistant form of anorexia nervosa. There have been legal cases where repeated inpatient care under the Mental Health Act was challenged. Other ethical issuesDifficulties of engaging a patient who would rather not be treatedLegal issuesAwareness that rarely the Mental Health Act is used to enforce treatment in Anorexia Nervosa Clinical governanceOther6. The Individual in Society The effect on the individual and on society of this scenario at this timeNormal development and ageingEffect on school attendance and workWhat does this condition mean for this patient and her/his family?Frustration and stress for rest of familyCoping with illness and treatmentThis is usually a chronic conditionLifestyle, behaviour and healthOther b) Reading list Please add any recommended reading and textbooks that you feel are relevant to this current scenario and the issues that it addresses. Treasure, J., A.M. Claudino, and N. Zucker, Eating disorders. Lancet, 2010. 375(9714): p. 583-93.Treasure, J. Anorexia Nervosa: A Survival Guide for Families, Friends and Sufferers, 1997. Psychology Press; 1 edition.Eating disorders: recognition and treatment. NICE guideline [NG69] Published date: May 2017 https://www.nice.org.uk/guidance/ng69 c) Useful links Please indicate below any useful general links and references that you feel are relevant to the issues that are covered in this scenario. These can be links to government reports and guidelines, national and international policies, GMC recommendations etc (NB. These are not intended to be web links covering specific learning resources and topics as these will be covered during the scenario development). If you can please include the web address if available. www.b-eat.co.uk http://tabithafarrar.com/ www.nedc.com.au www.freedfromed.co.uk mengetedstoo.co.uk dwed.org.uk www.youngminds.org.uk/whatsworryingyou www.mentalhealth.org.uk/a-to-z/e/eating-disorders https://www.kcl.ac.uk/ioppn/depts/pm/research/eatingdisorders/about-us.aspx Section 1. Scenario introduction Please give a brief introduction to the scenario (bearing in mind that most patients present initially to a General Practitioner) that should include the initial complaints of the presenting patient, a brief indication of any previous treatment and history. Gemma is a 17-year-old A-level student who is brought to your GP clinic by her mother in late August. Her mother is concerned because the family have noticed that Gemma has lost a lot of weight over the past 6 to 9 months and she has not had a menstrual period for 6 months. Her mother is also worried because Gemma has become much more withdrawn and quiet over the same period and no longer sees her friends outside of school. Gemma is silent during the consultation unless you ask her a question directly. As far as you can tell from the GP records, Gemma has been a healthy child and adolescent until now. She started her periods at the age of 12. From the description please add up to three questions for the student to answer based on the information they have been given above. At this stage the student will enter their own answers to the three questions. Only after they have completed this task will they be allowed to progress to see what they should have written and view the explanations and links to associated learning resources. One question might ask the student to list likely diagnoses based on their interpretation of the information they have been given at this stage. e.g. Give three likely diagnoses that you should consider at this stage and please add your question and three model answers (with explanations and indicate what areas in basic science, pathology and clinical science should be taken into account and explored further) below: Q1. What types of disorders should you consider at this stage in a 17-year-old female?1. An eating disorder2. Depression3. An organic disorder such as thyroid disease Another question might encourage the student to think about the major areas that they should be considering based on the information and symptoms that have been given so far. (questions could possibly cover severity, onset and pattern of symptoms if relevant) e.g. Give three important questions that you should explore about her symptoms and please add your questions and appropriate answers below: Q2. Give three areas of the history that you would like to clarify with the patient (and her mother) initially. Weight loss Clarify how much weight Gemma has lost over the last 9 months. It is useful to record her current weight and her lowest and highest ever weight. Patients attitude to weight loss Who is worried about your weight loss? Are they right to be worried? What might they have noticed? Are you concerned about your current weight? How about the amount of weight that you have lost? Do you have an ideal weight? Have your eating habits changed in the last year? If so, how? Physical and other symptoms of starvation Have you noticed any change to your body? For example, have you been feeling more dizzy/more tired/more weak/ more sensitive to the cold recently? Sometimes people find it hard to focus at school/work, have you noticed any change in your concentration? Also, it can be hard to find the energy to see friends and family, have things changed in any way? The SCOFF questionnaire (Morgan, Reid, Lacey et al., 1999) is a simple screening instrument developed for detecting eating disorders in the community. It is designed to raise suspicion of a likely case rather than to diagnose eating disorder. It should not be used as the sole method to determine whether or not a patient has an eating disorder. Do you make yourself Sick because you feel uncomfortably full? Do you worry you have lost Control over how much you eat? Have you recently lost more than One stone in a 3 month period? Do you believe yourself to be Fat when others say you are too thin? Would you say that Food dominates your life? *One point for every  yes ; a score of e"2 indicates a likely case of anorexia nervosa or bulimia It can, however, be difficult to approach a patient about their eating disorders. Morgan John F, Reid Fiona, Lacey J Hubert. The SCOFF questionnaire: assessment of a new screening tool for eating disorders BMJ 1999; 319 :1467 A third question might ask the student to consider the underlying causes (basic science, pathology etc) of the main symptoms that the patient is presenting with and/or examine the likely causes. e.g. What is the physiological explanation for the symptom of... Q3. What other factors in the history would you be interested in obtaining during this initial interview?  Long explanation: Attempts to lose weight Once you have enquired about the patients attitude to weight loss, it is important to clarify whether she is attempting to use any of the following means to lose weight [compensatory behaviours]: Restriction of food or calorie intake Excessive exercising (Self induced) vomiting Use of laxatives or diuretics Depression Weight loss can be associated with depression. The patients mother has also told you that she has become socially withdrawn in the past few months why is this? It is important to determine if she has other significant symptoms of depression (such as low mood, anhedonia [loss of pleasure in daily activities] and anergia). In any case, it would be advisable to establish whether she feels life is worth living if her answer is ambivalent or she tells you that her life is not worth living then a fuller assessment of suicidal risk is required. See Out of Sorts module for further details on assessment of depression. Social factors In any female adolescent with secondary amenorrhea it is important to ensure she is not pregnant. This will need to be enquired about tactfully and you may wish to ask the mother to leave for this part of the interview1. This could also be an opportunity to ask about difficulties with relationships, problems at school (social or academic) and problems within the family. 1There are no firm rules about whether you should ask the mother to leave in order to cover these more sensitive questions. In general, it is useful to minimise the potential for there to be secrets between family members, but this will be balanced by your judgement as to whether you will get truthful answers to questions about sexual activity etc with the mother present. You will be informed by your knowledge of the family.  Section 2: Further history This section will provide the student with a further history of the patient based on an interview. Please indicate below the relevant areas of the patient history that you feel the student should need in order to carry on. You can provide a simple bulleted list of relevant findings from the history or if you prefer present the history in the form of a very short interview (no more that 1 1.5 sides of A4 paper). See Appendix 1 for an example. This transcript might then be converted into a video interview that the students will subsequently have to watch before they are presented with the correct points from the interview that they should have picked up. Please enter the relevant information to be obtained from the patient history below: Amount of weight loss The patient has lost 11kg over 9 months (weight 9 months ago and highest ever weight = 58kg; current weight = 47kg). This loss started gradually but has increased in rate over the past 2 months. She weighs herself at least daily using her mothers scales. Attitude towards weight loss The patient does not see her weight loss as problematic. In fact, she currently considers herself to be considerably heavier than she would like. Attempts to lose weight [compensatory behaviours] She says that she is watching what she eats to control her weight, but denies that this constitutes dieting. Her mother, however, tells you that the patient routinely misses breakfast and now insists on preparing her own evening meal which she eats alone (rather than joining the rest of the family). It is not clear whether she eats at school. She does not binge eat. In addition to deliberately restricting her food intake, the patient admits that she is exercising to lose weight but denies using other methods of weight loss. She is jogging most days before school and her mother suspects that she is exercising in her room in the evenings. This interest in exercise started about 3 or 4 months ago. Physical symptoms The patient admits that her periods have stopped, but she is unconcerned by this. She has never been sexually active and therefore denies that she could be pregnant. Other physical symptoms include general tiredness and an intolerance of cold (she uses a hot water bottle most of the time at home), but she denies other specific physical symptoms. Her mother expresses surprise that her daughter says she is tired because the family have noticed that she seems to be unusually active around the home (for example they have noticed her jogging on the spot whilst watching TV) and Gemma is usually awake and busy well before the rest of the family. Depression You ask about other depressive symptoms. The patient tells you that she is feeling a bit low in mood and lacking in energy. She is also sleeping rather less than previously and is usually waking at about 6am (in order to go jogging). She denies deliberately avoiding her friends, saying that she still gets on with them but would rather spend her time on school work and with her family. It seems clear that her mood has only lowered in the past couple of months and prior to that was fine. She still feels that life is worth living and has no thoughts of harming herself. Social factors You decide to keep the mother in the room whilst you enquire about other social factors. The patient denies any problems at school and points out that she performed extremely well in her recent summer exams. She is about to apply to university and is hoping to train as a vet. When you enquire about family problems, the patient denies that there are any. However, after a pause the mother admits that there have been difficulties between the mother and Gemmas father. It seems that about a year ago, Gemmas father left the family home after it came to light that he had been having an affair. About 9 months ago he returned to live with the family, but Gemmas mother is worried that he may still be having an affair. It is clear that she has discussed this possibility at length with Gemma. There are frequent arguments between the parents. Family history When you ask about family history, the mother says that she is aware that Gemmas (paternal) grandmother had a chronic unexplained wasting disease throughout her 20s and 30s (which started after she gave birth to Gemmas father). The grandmother apparently saw a series of doctors at the time who were unable to explain why she could not put on weight. She eventually improved spontaneously in her early 40s but died before she was 50. After this interview your main differential diagnosis is of an Eating Disorder (namely Anorexia Nervosa). However, you wish to exclude thyroid disease, particularly hyperthyroidism (although symptoms such as cold intolerance do not fit with this). Other endocrine or gastrointestinal diseases seem unlikely.  Point to note at this point if you include them: ask for key extra questions on the history ask for a differential diagnosis what will be the key elements you require on examination to refine your differential? You will also need to provide information on: key questions and answers differential diagnosis including links learning resources on each of the differentials Section 3. Patient examination The next stage that the students will progress to is the patient examination, they will not be required to choose which examination to do but will be presented with all the examination results relevant to this scenario. We have divided the examinations into 10 areas. If you have any examinations that do not fit into these categories please include it under Other In the list below please fill in the relevant examination findings for each system. If you do not feel that examination of a particular system is relevant to this scenario please indicate by putting Not Necessary beside the appropriate examination. Please see the example scenario for information on the style of data that is required. ExaminationExamination results1. General examinationWeight 47.2kg Height 1.68m Pale and underweight, wearing 3 layers of warm clothes Well-hydrated Apyrexial Lanugo hair on face Tooth enamel appears intact Hands are cold and mildly cyanosed at fingertips, but no calluses (ie. Russells sign for self-induced vomiting is absent). Nose is also mildly cyanosed No central cyanosis and no lymphadenopathy2. Cardiovascular systemPulse 60 Blood pressure 90/60 (standing) BP 85/57 (lying) No other abnormalities3. Gastrointestinal systemNo organomegaly No other abnormalities4. Genitourinary systemSecondary sexual characteristics present Not examined further5. Mental/psychiatric examAppearance and behaviour: Appears reluctant to participate in assessment, but is co-operative with direct questioning. Eyes cast downwards during much of consultation. Not obviously agitated. Speech Quiet but normal in form and content, Mood Subjectively and objectively low. Admits to tiredness but activity/energy levels are high. No anhedonia. Few symptoms of anxiety. Sleep disturbed no initial insomnia but sleeping poorly at night and awakening at 6am (without alarm). Appetite diminished. No evidence of suicidal ideation Thoughts Overvalued idea that she is overweight and needs to lose weight. Preoccupied with her weight. No persecutory or grandiose thoughts and no delusions. Abnormal Perceptions None Cognitive state Not specifically tested, but no concern noted during assessment.6. Musculoskeletal systemNo evidence of significant proximal muscle weakness7. Nervous systemNormal8. Respiratory systemNormal9. Reticuloendothelial systemNormal10. UrinalysisNormal11. OtherNo other examinations performed The students are usually asked to consider their answers to the questions introduced so far as individuals. They then come together as the group of 8 students to discuss their own views on the interpretation of the examination finding, the diagnosis and the investigations to be done. They are joined by the tutor who reviews their initial ideas on differential diagnosis, helps them with this discussion on examination findings and plans for investigations, and then gives them the results of the investigations as set out below. Explanation of the examination findings. Please indicate the meaning of the relevant findings and how they relate to this case. Indicate where suitable links to learning resources occur. Examination Findings: Body mass index (BMI) It is essential that you weigh the patient on your scales and record your findings. You must also establish the patients height in metres as this allows you to calculate her BMI. The BMI is important as it tells you how underweight / overweight an individual is for their height. The BMI can be calculated as follows: BMI = Weight in kilograms (Height in metres)2 For Gemma, BMI = 47.2/1.682 = 16.7kg/m2 (link to PDF_resource_1) The diagnostic criteria for Anorexia Nervosa in International Classification of Diseases - 10th Edition (ICD-10) state that the patient should have a BMI of less than 17.5kg/m2. BMI can be less reliable as a marker in Anorexia Nervosa: if rapid change in weight at extremes of height if bulimic features if fluid restriction if physical comorbidity, such as type 1 diabetes Children have a BMI range which changes developmentally. The cut off for BMI to make the diagnosis is a weight and height below the second centile of BMI (Growth chart:  HYPERLINK "https://www.cdc.gov/growthcharts/clinical_charts.htm)" https://www.cdc.gov/growthcharts/clinical_charts.htm) In addition, weight loss at a rate of 1kg/week is of concern. General examination Significant weight loss can lead to the growth of pale, downy hair on the face this is known as lanugo hair. A patient with Anorexia Nervosa usually feels the cold more than others. Gemma is noted to be wearing layers of warm clothing and yet still her peripheries are cold to touch. A patient who chronically self-induced vomiting may have eroded her tooth enamel. Another characteristic sign is the formation of a callus on the back of the proximal inter-phalangeal joint due to repeated use of that finger to cause vomiting (Russells sign). It is relatively rare in clinical practice. In this case, Gemma does not use vomiting to control her weight and therefore lacks these clinical signs. In addition, patients who are severely malnourished, can have a low core body temperature. Cardiovascular system In severe Anorexia Nervosa the patient can become bradycardic or develop (postural) hypotension. Mental/psychiatric examination It is common for a patient with Anorexia Nervosa to be very reluctant to accept that she has a problem. In this case the patient has been brought to you by her mother her reluctance to see you is manifest in her behaviour during the interview. She has some symptoms consistent with depression, such as low mood and early morning wakening. However, on taking a careful history, it is clear that the weight loss preceded the depressive symptoms and the depression is likely to be secondary to this. It is extremely common to experience worsening depressive and anxiety symptoms as weight decreases. A patient with Anorexia Nervosa will usually, but not always, tell you that they are fearful of gaining weight and becoming fat in the UK psychiatrists call this an overvalued idea which is said to be less intense and fixed than a delusion1. Musculoskeletal system A sign of severe Anorexia Nervosa is the development of a proximal muscle weakness. This can be quickly assessed by asking the patient to stand up from squatting without using their arms to support them. 1The fear of fatness may be absent in patients with Anorexia Nervosa who are from non-Western cultures. Section 4. Investigations & Results The students are next required to decide what are the most relevant patient investigations that need to be carried out immediately and the most appropriate investigations to be carried out later. Students will not be allowed to progress through the scenario unless they have selected the correct investigations to perform at this stage. When they select the correct investigation the student will be given additional information about the investigation they have selected and its relevance to this scenario. The students are asked: What n investigations would you do now, to have results available within the next two hours (choose from the list)? 2. What would you consider the n most important investigations on the list to be sent off at this stage? The list of investigations has been divided into 11 categories with each of these containing further containing specific investigations. If the investigation does not fit into any of these categories please include it under Other Please select a set number of the most appropriate investigations to do immediately and later from the list below. Please tick the appropriate options from the column labelled Immediate investigation and those from the column Later investigation. Could you please provide brief explanations behind each investigation chosen. You may insert red herrings if you wish but again please also explain why these are not appropriate investigations at this time. Immediate investigation (Y)Later investigation (Y)1) HaematologyFull blood countYESRCoagulation studiesCross-matchBlood FilmImmediate investigation (Y)Later investigation (Y)2) Clinical biochemistryElectrolytes, urea, creatinineYLiver function testsYCalcium, phosphate, alkaline phosphataseYC reactive proteinYCreatine kinaseYTroponinD-dimersThyroid function testsArterial blood gasesOxygen saturationAlpha1-antitrypsin concentrationGlucoseLipid ProfileGlycated haemoglobin, HbA1cYImmediate investigation (Y)Later investigation (Y)3) MicrobiologySputum cultureBlood culturemid stream urineHIV testPneumococcal antigen in urineSputum for acid fast bacilliCSF: culture and sensitivity, polymerase chain reactionCSF: Gram stainCMV PCRThroat swab: culture and sensitivitySerological testing for hepatitis A, B and C virusesStool CultureImmediate investigation (Y)Later investigation (Y)4) HistopathologyCytologyHistologyImmediate investigation (Y)Later investigation (Y)5) ImmunologyMycoplasma, legionella, chlamydia antibody titresAutoantibodiesAnti-nuclear factorAnti-neutrophil cytoplasmic antibodyAnti glomerular basement membrane antibodyImmediate investigation (Y)Later investigation (Y)6) Drug monitoringPhenytoin levelAntibiotic levelsTheophylline levelParacetamol & salicylate levelsDigoxin levelLaxative screenYImmediate investigation (Y)Later investigation (Y)7) ImagingChest X-rayOther plain X-rays by siteContrast studies (barium meal, enema, IVU)CT chestCT by anatomical siteCT chest (high resolution)CT chest (spiral)MRI by anatomical siteUltrasound by anatomical sitePET scanVentilation/perfusion lung scanThyroid scanBone scanImmediate investigation (Y)Later investigation (Y)8) Cardiology investigationsEchocardiogram24 hour ECGECGYTreadmill exercise testImmediate investigation (Y)Later investigation (Y)9) EndoscopyGastroscopyColonoscopySigmoidoscopyBronchoscopyCystoscopyImmediate investigation (Y)Later investigation (Y)10) Psychiatric investigationsInformant history/old case notesRisk AssessmentCollateral historyAdditional History from SchoolYImmediate investigation (Y)Later investigation (Y)11) Other testsRespiratory function testsElectroencephalogramElectromyogramDMSA renogramSensory nerve conduction studiesMotor nerve conduction studiesLumbar PunctureOral glucose tolerance test Please now provide the clinical reasoning for each of the investigations you selected and indicate where relevant possible links to additional learning resources and areas of study: a) Immediate investigations Investigation 1Investigation categoryClinical BiochemistryInvestigation titleUrea, electrolytes and creatinineExplanationElectrolytes may be dangerously disturbed in eating disorders. The main concern is inadequate fluid intake in combination with poor eating. Dehydration may occur causing an elevated urea. In addition, if the patient is using laxatives, diuretics or vomiting as methods to control their weights, in which case potassium can be dangerously low - predisposing to cardiac arrhythmias. (see guide to medical risk assessment for eating disorders - PDF_resource_2). Results & explanation Result Normal Range Na 136 mmol/L 137-145 K 3.6 mmol/L 3.5-4.9 Urea 6.8 mmol/L 2.5-7.5 Investigation 2Investigation categoryClinical BiochemistryInvestigation titleThyroid function testsExplanationAlthough this patient is unlikely to have either hypothyroidism or thyrotoxicosis, it is worth excluding in cases of new onset weight change particularly when accompanied by changes in heat tolerance and/or mood. Results & explanation Result Normal Range Thyroid stimulating hormone 1.43 mU/L 0.30-5.00 Free T4 10.8 pmol/L 10.3-21.0 Investigation 3Investigation categoryInsert category hereInvestigation titleInsert investigation name hereExplanationInsert brief explanation of the investigation hereResults & explanationInvestigation 4Investigation categoryInsert category hereInvestigation titleInsert investigation name hereExplanationInsert brief explanation of the investigation hereResults & explanation b) Later investigations Investigation 1Investigation categoryHaematologyInvestigation titleFull Blood CountExplanationHaemoglobin may be slightly low, reflecting a normocytic, normochromic anaemia. If weight loss is severe then white cell count and platelets may diminish, leading to patients being at risk of infection. Results & explanation Result Normal Range Hb 11.2 g/dL 11.5-16.5 White Blood Cell 3.6 x 109/L 4-11 Neutrophil 1.1 x 109/L 1.5-7 Lymphocyte 2.2 x 109/L 1.5-4 Eosinophil Mean cell vol. Platelets 0.3 x 109/L 96.8 fl 208 x 109/L 0.04-4 82-99 150-400  Investigation 2Investigation categoryClinical BiochemistryInvestigation titleCRPExplanationCRP is usually normal in Anorexia Nervosa, but it is important to rule out a potential cause of weight loss such as inflammatory bowel disease (which would elevate CRP), particularly if there are symptoms such as diarrhoea.Results & explanation Result Normal Range CRP 4 mg/dL <10 Investigation 3Investigation categoryClinical BiochemistryInvestigation titleLiver function testsExplanationLiver enzymes can be elevated in Anorexia Nervosa and in extreme cases albumin can be low due to nutritional deficiency. In severe cases hypoalbuminaemia can lead to peripheral oedema. Results & explanation Result Normal Range Alk Phosp 88 U/L 45-105 Alanine am. trans. 29 U/L 1-31 Bilirubin 18 mol/L 1-22 GGT Albu Total Prot. 33 U/L 35 g/L 70 g/L 4-35 37-49 61-76 Investigation 4Investigation categoryClinical BiochemistryInvestigation titleHbA1cExplanationHbA1c refers to glycated haemoglobin which identifies average plasma glucose concentration over 8-12 weeks, providing a useful longer-term gauge of blood glucose control. This allows us to rule out both type 1 and type 2 diabetes. Results & explanation Result Normal Range Hba1c 40 mmol/mol <48 Investigation 5Investigation categoryClinical BiochemistryInvestigation titleCalcium, phosphate & cortisol. Creatinine kinaseExplanationBaseline calcium and phosphate may be useful. In severe Anorexia Nervosa, hypophosphataemia can become a problem and lethal during refeeding as can hypocalcaemia. They are consequences of carbohydrate metabolism. A raised creatinine kinase shows that malnourishment is sufficiently severe to cause breakdown of muscle. Results & explanation Result Normal Range Ca 2.7 mmol/L 2.5-3.2 Phosphate 0.98 mmol/L 0.87-1.45 Creatinine Kinase 135 IU/L 30-145 Investigation 6Investigation categoryDrug MonitoringInvestigation titleLaxative screenExplanationResults & explanationThe urine laxative screen is negative. Investigation 7Investigation categoryAdditional investigationsInvestigation titleAdditional history from schoolExplanationAdditional or collateral history is often required in order to make a full assessment. In Gemmas case the GP is confident of the diagnosis before speaking to the school, but sometimes a diagnosis can only be arrived at after additional history has been gained. However, it is necessary to gain the patients consent before approaching any third party. In Gemmas case, it would be useful to find out how much she was eating as school and if they had concerns about her exercise or her academic work. Results & explanationGemma gives you consent to speak to her form teacher, Miss Carrington. Miss Carrington tells you that several teachers have expressed concern over Gemmas recent weight loss and withdrawal from group activities in class. About 3 weeks ago the physical education staff mentioned that they had noticed Gemma exercising alone in the gymnasium during break periods and asked her not to do this. Miss Carrington is unaware of Gemmas eating habits during school hours but says she will attempt to monitor this and let you know. Miss Carrington indicates that she would like to be involved in any management plan for tackling Gemmas eating problems.  Section 5. Diagnosis The student will normally have sufficient information to make an informed diagnosis. Students will not be allowed to continue in the case until they have made the appropriate next step. The student will select a diagnosis from a list of possible options. Please give a list of options below and if required provide an explanation for each one. Diagnosis option 1Anorexia NervosaExplanationThe patient has a BMI of <17.5kg/m2 which has been achieved by food restriction and excessive exercise. She has the overvalued idea that she needs to lose more weight and lacks insight that her weight is dangerously low. She has developed amenorrhoea as a result of her weight loss. Her depressive symptoms are secondary to her weight loss. At present her illness status would not be classed as severe or critical, but there are some subtle abnormalities of her investigation that indicate that she is becoming chronically malnourished. (See Word_resource_3 for ICD-10 diagnostic criteria for Anorexia Nervosa). Correct (Y/N)Y Diagnosis option 2Bulimia NervosaExplanationThe patient is not engaging in binge eating behaviours that are characteristic of Bulimia Nervosa. In addition, her BMI is low (<17.5kg/m2) and thus, even if she was bingeing, she would be classed as suffering from Anorexia Nervosa (binge-purge subtype). Correct (Y/N)N Diagnosis option 3DepressionExplanationHer history over time is important here. She currently has some depressive symptoms but these have developed after her weight loss was underway and are secondary to severe weight loss.Correct (Y/N)N Diagnosis option 4ThyrotoxicosisExplanationInsert explanation here if required Diagnosis option 1N Diagnosis option 5Inflammatory bowel diseaseExplanationInsert explanation here if required Correct (Y/N)N Section 6. Patient Management Please fill in the box below the working diagnosis and explain what happens to the patient next (admitted/discharged). Include the treatment rgime that the patient has been given including drugs, doses and other advice. The working diagnosis is Anorexia Nervosa. The patients BMI is currently 16.7kg/m2 which indicates that treatment can be carried out in the community (rather than as an in-patient). The GP is in an ideal position to initiate management and co-ordinate with other services. An explicit plan needs to be made with Gemma, her mother and the school which includes the following: Psychoeducation Gemma and her family about Anorexia Nervosa is an important first step. A non-blaming position is adopted by the GP with an emphasis on regaining normal eating practices and halting exercise whilst Gemmas weight is so low. Information on books and online resources are given to the family. Motivational Interviewing The GP is aware of the need to establish a therapeutic relationship with Gemma, as she is clearly reluctant to accept the need for treatment for her eating disorder. An empathic but firm attitude is adopted by the GP who also draws on communication skills known as motivational interviewing to encourage Gemma to move towards changing her eating habits. Physical health checks Gemma needs to be weighed on a regular basis by a health professional and this weight is to be recorded. The GP asks Gemma to return once a week on the same day/time in order to see the GP and be weighed. The potential for deliberate falsification of weight needs to be kept in mind by the GP. For example, water-loading or filling pockets with weights. Ideally, a weight gain of around 0.5kg per week is achieved and sustained in the community. A chart needs to be maintained of Gemmas progress with weight gain (see PDF chart 2). In addition, physical parameters such as blood pressure, pulse and temperature are useful markers for medical risks associated with Anorexia Nervosa. Dietary plan A dietary plan is made with Gemma and her mother. This includes clear guidelines about regular eating, such as three meals a day and preferably in the company of family members (when at home) and either a member of staff/friend when at school. Having snacks between meals can be a useful additional to her eating behaviours. Advice is given on a balanced, healthy diet, while patients are encouraged to slowly reintroduce foods that are currently avoided or viewed as forbidden. The GP has access to a community dietician to whom she refers Gemma urgently. The GP and dietician need to work closely together to monitor Gemmas condition. Compensatory behaviours An agreement is made that Gemma will cease exercising until she reaches a healthy weight. The GP emphasises that Gemma is putting herself at risk by exercising at her current low weight. Family The family is explicitly involved in the plan to help Gemma reverse her weight loss. It is important that they feel confident and well equipped to deal with the inevitable difficulties that this will entail. Parents need to be firm, consistent and empathic during this time. Involvement of family is particularly important with a young patient who is still living at home. School Gemmas form teacher, Miss Carrington, is involved in the plan and asked to give feedback on how Gemma does. Miss Carrington will attempt to ensure that Gemma does not exercise whilst at school. They agree with Gemma that her friends will spend time with her at lunch time and inform Miss Carrington if for any reason Gemma and her friends do not lunch together and Miss Carrington will then meet with Gemma to discuss this further. Future planning The GP explains to Gemma and her family that since an eating disorder is suspected, she will be referred immediately to a community-based, age-appropriate Eating Disorder service for further assessment or treatment. To discuss with clinical tutor and as a group: What do you think is the most difficult part of the management plan (as outlined above) for the GP to put in place and why? Have you ever heard of any other conditions that motivational interviewing is used for? What if Gemma had not given her consent for the GP to involve her form teacher? Is there a place for anti-depressant medication? Non-exhaustive answers: Patient engagement Engaging a resistant patient is difficult. Most patients attend their doctor because they want to receive treatment but this is not the case here. Motivational interviewing was originally developed by clinicians working within addictions. However, the principles can be applied to a wide number of clinical scenarios such as eating disorders (See http://www.motivationalinterviewing.org/ for more details). If students are interested, then the Prochaska and DiClemente model of behavioural change could be discussed as an additional theoretical model for treating an eating disorder patient over time (see PDF_resource_4 for brief overview). Multidisciplinary approach Working at the centre of a multidisciplinary team (in this case dietician, family, school, GP) can be challenging, especially if you retain overall clinical responsibility for a patient but are expecting others to implement some of the management plan. Third party If the patient refused to give her consent for the GP to contact the school, it would be difficult to argue that the GP should overrule this. However, it would be worth the GP exploring Gemmas resistance to this over a period of time and ensuring that Gemma was aware of why the GP felt this was important. Pharmacological therapy There is evidence that anti-depressants are not particularly helpful in Anorexia Nervosa. Depressive symptoms will probably respond best to weight gain and there is no evidence that the core features of Anorexia Nervosa are helped by antidepressants. Occasionally however antidepressants are used when there is a severe co-morbid depressive syndrome or very pronounced obsessive-compulsive symptoms (which are common at lower weights in Anorexia Nervosa). There is, however, evidence that antidepressants (SSRIs in particular) are helpful in combination with cognitive behavioural therapy in the treatment of Bulimia Nervosa. Second-generation antipsychotic drugs, such as Olanzapine, are increasingly administered in people with Anorexia nervosa for its benefits on mood and support weight gain in Anorexia Nervosa. The evidences for its use in Anorexia Nervosa remain limited at present.  Section 7. Scenario review This is an opportunity to look over the scenario and ask the student to summarise the position that has been reached or to do a task such as write out the drug chart, send a discharge letter, speak to the relatives etc. Gemma agrees to the management plan as outlined above. As the GP, you want to refer Gemma to the community Eating Disorder service as soon as possible, so you decide to dictate a referral letter immediately and you ask your secretary to fax it across to the Eating Disorder service urgently. Elements to be contained in the letter: Name, address, date of birth, NHS number of patient Living arrangement Degree of weight loss with current BMI Other core features of Anorexia Nervosa present: Dietary restriction, excessive exercise, fear of fatness, lack of insight into current low weight, absence of bingeing/additional methods of weight loss Positive findings on physical examination, including lanugo hair, cold extremities, low/normal blood pressure and mental state findings Investigations performed to date and results Diagnosis and management plan now in place Need for dietetics input and urgency specified Plan to refer to specialist Eating Disorder service if no improvement or deterioration Request to contact GP with response to referral/plan Section 8. Scenario development At this point there is the opportunity to develop the scenario, to add some twists or to discuss the natural history of the condition. It may be the time to bring in factors relevant to social, legal or ethical issues, public health matters or the natural history of the condition. Over the next 8 weeks the GP sees Gemma on a weekly basis for physical health checks and general review while waiting for a review with the eating disorder team. The GP also tries to elicit feedback on a regular basis from the family, school and dietician to inform her assessment of Gemmas progress. The GP tracks Gemmas weight on the progress chart (see JPEG_resource_5). Initially, Gemmas weight stabilises. All the feedback that Gemma is working hard to manage her eating difficulties and is engaging well with the management plan. However as can be seen on the chart from week 4 onwards, there is a gradual decline in Gemmas weight. This continues over the next 4 weeks. Week 4 coincided with the beginning of the school holidays. At weeks 5 and 6, Gemmas mother phones you in tears as Gemma is once again exercising in her room at night and refusing to eat with the family. She wants to know what to she should do. It also transpires that the tension between Gemmas parents has escalated. Gemmas father has decided that everyone is being too soft with Gemma and she needs to be handled more firmly. By week 8, Gemmas BMI is 15.5kg/m2. The dietician tells you that there is little more that she can do to help. During your appointment with Gemma and her mother on week 8, you take Gemmas blood pressure and find that her standing blood pressure is 90/60 whilst her lying blood pressure is 80/55. Q1. Why has Gemma developed a postural drop? What do you think should happen now? Answer: All the evidence suggests that Gemmas clinical situation is deteriorating. Her BMI is steadily falling, she is unable to engage with the management plan and her physical state is becoming more compromised. Furthermore, the situation at home has deteriorated and Gemmas parents are not acting coherently in their management strategies. At this point, an assessment at the specialist Eating Disorder service was arranged. The local Eating Disorders team starts to see Gemma and her family regularly, allowing the GP to step back. The Eating Disorders team still elects to treat Gemma as an outpatient at this weight, but supplements the management plan with the following: Family therapy The sessions are aimed at ensuring that a coherent strategy is being implemented by Gemmas parents and to tackle any ongoing difficulties within the family. It becomes clear during these sessions that major parental discord remains, leading to an inconsistent approach to Gemmas management. It is noted that Gemmas mother tends to use Gemma as a confidante about her marital problems, whilst her father views Gemmas difficulties in very black and white terms and advocates a rather punitive approach. The family therapist suggests that the parents access relationship counselling to work through their marital difficulties away from the family therapy sessions. Individual therapy Gemma starts regular cognitive-behavioural therapy sessions with an Eating Disorders therapist. She attends these sessions weekly and the therapy encourages Gemma to identify her thoughts, emotions and behaviours. They also explore how they are linked. Gemma is able to identify that controlling her weight makes her feel safe and in control but, although she realises that her health is suffering, she finds it difficult to put any strategies for gaining weight into practice. Q2. Look at the NICE guidelines for management of Anorexia Nervosa (see PDF_resource_6). What other psychological treatments are recommended for the treatment of Anorexia Nervosa? Do you think that the GP should have referred Gemma earlier for psychological treatment, if so, who might a GP be able to refer such a patient to other than the Eating Disorders service? What might be the problems with such a referral? A2. In children and adolescent, family therapy should be first considered. It usually involves working with a therapist and exploring how anorexia nervosa has affected patient and his/her family, while identifying ways for family members to support patient on their recovery journey. It usually involves 18-20 sessions a year. If family therapy was deemed unacceptable, contraindicated or ineffective, individual eating-disorder-focused cognitive behavioural therapy or adolescent-focused psychotherapy for anorexia nervosa could be considered. For family members, it can be useful be given carer guides to equip them with skills in managing Anorexia Nervosa. The recent NICE guidelines state that for adults with anorexia nervosa, consider one of: Individual eating-disorder-focused cognitive behavioural therapy Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) Specialist supportive clinical management Eating Disorder centres vary in which treatment they offer and it is usually dependent on local expertise and patient preference. Ideally Gemma should be seen soon by the Eating Disorders service when the GP first diagnosed Anorexia Nervosa, however in reality this can be difficult to arrange. Over the next 4 months Gemma continues to receive treatment as an outpatient. During this time Gemma suspends her studies at school to concentrate on getting well. Unfortunately, her weight fails to improve and continues to fall, albeit at a lower rate (see JPEG_resource_7). It is agreed by Gemma and her family that she will be admitted to the regional Eating Disorders inpatient unit if her BMI falls below 14.5kg/m2, which it eventually does. Although Gemma is reluctant to be admitted to the unit, she accepts that she is struggling with outpatient treatment and agrees to be admitted voluntarily. Q3. What options are available to the clinical team if they feel that someone should be admitted as an in-patient and they refuse? A3. The Mental Health Act (1983) can be used to enforce admission and treatment in a non-consenting patient with Anorexia Nervosa. In practice this is uncommon and is usually reserved for non-consenting patients with BMI in the critical range or below. Gemma is admitted informally to the Eating Disorders in-patient unit and has a 16-week admission. During the admission she gains an average of 1kg per week and is discharged at a BMI of 19kg/m2. She continues with her individual psychological therapy during this time and this is supplemented by a number of other interventions. Meanwhile, Gemmas parents decide to separate after participating in relationship counselling and her father moves out of the family home. Gemma returns home with the aim of re-starting school the following academic year and continuing with her individual therapy as an out-patient. The GP is invited to attend the discharge planning meeting on the ward and asks about Gemmas prognosis. The GP is also curious to know how common the condition is and whether she is likely to encounter it again in her clinical career. Q4. What is the prevalence and prognosis in Anorexia Nervosa? A4. Epidemiology The prevalence of Anorexia Nervosa is approximately 3-7 per 1000 in adolescent females. A GP will have, on average, 1-2 cases of Anorexia Nervosa amongst their caseload at any one time, although they can be unidentified. It is unclear whether Anorexia Nervosa is increasing in prevalence in Western cultures some in the field argue that the prevalence remains stable over time and between cultures, but its recognition and cultural interpretation will vary. Anorexia Nervosa is approximately 10 times more common in females than males. The average age of onset is 15 years. Prognosis Anorexia Nervosa is a serious psychiatric condition. The mortality is highest in Anorexia Nervosa than any other psychiatric condition (including schizophrenia) with 10-20% of patients eventually dying due to complications of the illness/suicide. Anorexia Nervosa is usually a chronic disorder, with an average duration of illness of 6 years. Relapse is common. A study examining long-term recovery in America found a recovery rate of 31.4% for Anorexia Nervosa and 68.2% for Bulimia Nervosa at 9-year follow up and 62.8% for Anorexia Nervosa and 68.2% for Bulimia Nervosa at 22 years follow-up (Eddy et al., 2017). About 50% of patients with Anorexia Nervosa who have not recovered by 9 years progress to recovery at 22 years. Recovery from Anorexia Nervosa may therefore occur later but is continued over the long term, arguing for clinicians to remain hopeful for this complex patient group. There is some fluidity between the different categories of eating disorder. A study reported that one third of patients with Anorexia Nervosa cross over to Bulimia Nervosa but were likely to relapse into Anorexia Nervosa over a 7 years period (Eddy et al., 2008). Those with Bulimia Nervosa were much less likely to cross over to Anorexia Nervosa. J Clin Psychiatry. 2017 Feb;78(2):184-189. doi: 10.4088/JCP.15m10393. Recovery From Anorexia Nervosa and Bulimia Nervosa at 22-Year Follow-Up. Eddy KT1,2,3, Tabri N2,3, Thomas JJ2,3, Murray HB2, Keshaviah A2, Hastings E2, Edkins K2, Krishna M2, Herzog DB3, Keel PK4, Franko DL2,5. Am J Psychiatry. 2008 Feb;165(2):245-50. doi: 10.1176/appi.ajp.2007.07060951. Epub 2008 Jan 15. Diagnostic crossover in anorexia nervosa and bulimia nervosa: implications for DSM-V. Eddy KT1, Dorer DJ, Franko DL, Tahilani K, Thompson-Brenner H, Herzog DB.      PAGE  PAGE 1  TIME \@ "dddd, dd MMMM yyyy" Tuesday, 25 September 2018 Fai-Lam, I want to swap TFT and FBC and follow the chart earlier for the immediate and later investigation. Example: TFT can be done later, but FBC should be done earlier. If I copy and paste the tables, it starts to affect the formatting, so I have left it. Hb reporting has been changed across board. I presume that you will be changing it for the module. I have left it for now. Also the order of the investigation does not match the table in the earlier section, but I dont know if that matters. Fai-Lam I cannot create a new box. We need ECG: Many patients with anorexia nervosa demonstrate bradycardia. Pulse rate <50 beats/minute is a concern and if it is <40 beats/minute, hospital admission needs to be considered. The ECG may demonstrate heart block or prolonged QTc. CSVbiyz}p пЮxjYYIhJVhH 5CJ\^JaJ hJVh!CJOJQJ^JaJhe>CJOJQJ^JaJ#he>he>5CJOJQJ^JaJ#he>h5CJOJQJ^JaJ#he>h!5CJOJQJ^JaJ hJVhCJOJQJ^JaJ hJVhH CJOJQJ^JaJ hJVhCJOJQJ^JaJ#hJVhH 5CJOJQJ^JaJhJVhH CJ^JaJCDz  D $7$8$H$If^gduz $Ifgduz $7$8$H$IfgduzgdH gdH gdH  E a (  6 7 d EY­­www­i­YhJVhH 6CJaJmH sH hJVhH 6CJ^JaJ hJVh!CJOJQJ^JaJ hJVhH CJOJQJ^JaJ&hJVhH 6CJOJQJ]^JaJ)hJVhH B*CJOJQJ^JaJph,hJVhH 5B*CJOJQJ^JaJph%hJVhH B*CJaJmH phsH &hJVhH 5CJOJQJ\^JaJ"D E UG $7$8$H$Ifgduzkd$$IfF ],% e  t%0    4 ap k$ $7$8$H$Ifa$gduz $7$8$H$Ifgduzqkd$$If4,%J%  t% 04 af4p  zl[l$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd$$IfF ,%J ! t%0    4 a zlWl$ $7$8$H$Ifa$gduz $7$8$H$Ifgduzkdg$$IfF ,%J ! t%0    4 a zl[l$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd4$$IfF ,%J ! t%0    4 a 7 zl[l$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd$$IfF ,%J ! t%0    4 a7 8 9 B g zl[[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd$$IfF ,%J ! t%0    4 ag h i v zl[l$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd$$IfF ,%J ! t%0    4 a zl[[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd$$IfF ,%J ! t%0    4 a zll[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd_$$IfF ,%J ! t%0    4 a ) zl $7$8$H$Ifgduzkd:$$IfF ,%J ! t%0    4 a) * + 4 { o$$7$8$H$Ifa$gduz $7$8$H$Ifgduzqkd $$If4,%J%  t% 04 af4p { | } zl[l$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd $$IfF ,%J ! t%0    4 a 7 N d zl[llllll$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd $$IfF ,%J ! t%0    4 a .Qzl[llllll$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd[ $$IfF ,%J ! t%0    4 a QRSizl[l$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd( $$IfF ,%J ! t%0    4 azl[[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd $$IfF ,%J ! t%0    4 azll[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd $$IfF ,%J ! t%0    4 azl $7$8$H$Ifgduzkd$$IfF ,%J ! t%0    4 ao$$7$8$H$Ifa$gduz $7$8$H$Ifgduzqkd$$If4,%J%  t% 04 af4p )zl[l$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd2$$IfF ,%J ! t%0    4 a)*+BCzl[l$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd$$IfF ,%J ! t%0    4 aCDEYyzl`l $$Ifa$gduz $7$8$H$Ifgduzkd$$IfF ,%J ! t%0    4 ayz{zl[[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd$$IfF ,%J ! t%0    4 azl[[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkdf$$IfF ,%J ! t%0    4 aXZzl[[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd3$$IfF ,%J ! t%0    4 aZ[\~zl[[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd$$IfF ,%J ! t%0    4 azl[[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd$$IfF ,%J ! t%0    4 azll[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd$$IfF ,%J ! t%0    4 azl $7$8$H$Ifgduzkd$$IfF ,%J ! t%0    4 atc$$7$8$H$Ifa$gduz $$Ifa$gduz $7$8$H$Ifgduzqkd^$$If4,%J%  t% 04 af4p  #bzl[[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd $$IfF ,%J ! t%0    4 abcdzl[l$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd$$IfF ,%J ! t%0    4 azl[l$ 9r $Ifa$gduz $7$8$H$Ifgduzkd$$IfF ,%J ! t%0    4 azl[[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkdq$$IfF ,%J ! t%0    4 azllll[$$7$8$H$Ifa$gduz $7$8$H$IfgduzkdL$$IfF ,%J ! t%0    4 axzl $7$8$H$Ifgduzkd'$$IfF ,%J ! t%0    4 a$wx@GYwx|v_v_N77-HhYGh`hKCJOJQJ^JaJ h`hnCJOJQJ^JaJ-HhYGh`hKCJOJQJ^JaJ-HhYGh`hKCJOJQJ^JaJ h`h)CJOJQJ^JaJ hJVh!CJOJQJ^JaJ hJVhH CJOJQJ^JaJ&hJVhH 6CJOJQJ]^JaJ)hJVhH B*CJOJQJ^JaJph,hJVhH 5B*CJOJQJ^JaJphxyzo$$7$8$H$Ifa$gduz $7$8$H$Ifgduzqkd$$If4,%J%  t% 04 af4p zl[JA8 $Ifgd` $Ifgd^s$$7$8$H$Ifa$gdK$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd$$IfF ,%J ! t%0    4 a+<F׵zfzfzfzfzO,hJVhH 5B*CJOJQJ^JaJph&hJVhH 6CJOJQJ]^JaJ hJVhH CJOJQJ^JaJ h`h`hKh`CJOJQJ^JaJ h`h)CJOJQJ^JaJ h`h`CJOJQJ^JaJ h`hH CJOJQJ^JaJ h`h^sCJOJQJ^JaJ-HhYGh`hKCJOJQJ^JaJqcRR$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd{$$IfF ,%J ! t%0    4 a $Ifgd` jzl[[$$7$8$H$Ifa$gduz $7$8$H$IfgduzkdH $$IfF ,%J ! t%0    4 ajklzl[[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd!$$IfF ,%J ! t%0    4 azl[[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd!$$IfF ,%J ! t%0    4 azll[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd"$$IfF ,%J ! t%0    4 azll[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd#$$IfF ,%J ! t%0    4 azl $7$8$H$Ifgduzkde$$$IfF ,%J ! t%0    4 a!"%5  !0ŵţŒn^PDhJVhe5CJaJhJVhe0J"5CJaJhJVhe5CJaJmH sH #hJVh]CJOJQJ\^JaJ#hJVh]CJOJQJ]^JaJ hJVh]CJOJQJ^JaJ#hJVhH 5CJOJQJ^JaJhJVhH 6CJaJmH sH  hJVhH CJOJQJ^JaJ&hJVhH 6CJOJQJ]^JaJ)hJVhH B*CJOJQJ^JaJph?tc$$7$8$H$Ifa$gduz $$Ifa$gduz $7$8$H$Ifgduzqkd$%$$If4,%J%  t% 04 af4p ?@Azl[l$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd%$$IfF ,%J ! t%0    4 azl[[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd&$$IfF ,%J ! t%0    4 azl[[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkdj'$$IfF ,%J ! t%0    4 a!"zl[[$$7$8$H$Ifa$gduz $7$8$H$Ifgduzkd7($$IfF ,%J ! t%0    4 a"#$56 zrrmmmd $IfgduzgdH $a$gdH kd)$$IfF ,%J ! t%0    4 a !8/ $Ifgd`^kdJ*$$Ifl%%04 lal $Ifgde^kd)$$Ifl%%04 lal !"3-.=MX7AY!ޢޑraPޢP? hJVhMCJOJQJ^JaJ hJVhwzCJOJQJ^JaJ hJVh`CJOJQJ^JaJ h`h`CJOJQJ^JaJhCJOJQJ^JaJ hJVhCJOJQJ^JaJ#hJVhH 5CJOJQJ^JaJhJVhH 5CJaJh`h`5CJaJ#h`h`CJOJQJ\^JaJ hJVhH CJOJQJ^JaJhJVhH 5CJaJmH sH !"#3.>Tht $IfgdgdH ^kd*$$Ifl%%04 lal $Ifgd`=>@AB gdH ^kd<+$$Ifl%%04 lal $Ifgduz ]"^"":#;#$$^$|wwn $IfgduzgdH h^hgdH  & FgdH  9r gdH gdH ckd+$$IflP%%0%4 lalyt Y!]"^"""":#;#$$J$U$^$_$u$v$$$$%K&&&&&&&ܽw`I``I`I`-hJVhwz0JB* CJOJQJ^JaJph3f-hJVhH 0JB* CJOJQJ^JaJph3fhJVhH 0JCJ^JaJhJVhH 0J5CJ^JaJ$hJVhH 0JCJOJQJ^JaJ'hJVhH 0J5CJOJQJ^JaJ#hJVhH 5CJOJQJ^JaJhJVhH CJ^JaJ hJVhH CJOJQJ^JaJ#hJVhH 6CJOJQJ^JaJ^$_$u$v$$BYkd,$$Ifl;%#04 la $IfgduzYkd8,$$Ifl;%#04 la$$$$$$=88gdH ^kd-$$Ifl;%#04 laytJV $IfgduzYkd*-$$Ifl;%#04 la$% & &J&K&&&&&naT & F $Ifgd $If^gd}wakd&.$$Ifl%#0#4 layt>$If^>`gduz  9r gdH  9r h^hgdH  & FgdH &&&&&&&&'''':'E'Y'['|'}''ïs_K3.HhYGh40J5CJOJQJ^JaJ'hJVh0J>*CJOJQJ^JaJ'hJVh{0J5CJOJQJ^JaJ'hJVhSk0J5CJOJQJ^JaJ'hJVh|S0J5CJOJQJ^JaJ'hJVhwz0J5CJOJQJ^JaJ'hJVhH 0J5CJOJQJ^JaJ'hJVh0J5CJOJQJ^JaJ'hJVhH 0J>*CJOJQJ^JaJ'hJVh}w0J5CJOJQJ^JaJ&Z'['}'(((/*0*+++ ,,-n-p-.m.n.. & F$Ifgd $Ifgd $If^gde> & F $Ifgd` & F $Ifgd $Ifgd|S $If^gd'''((((((((;)N)`)®kWC(C4HhYGhe>h40J5CJOJQJ^JaJ'he>h0J5CJOJQJ^JaJ'he>he>0J5CJOJQJ^JaJ4HhYGhe>h40J>*CJOJQJ^JaJ'he>he>0J>*CJOJQJ^JaJ'he>h`0J>*CJOJQJ^JaJ'he>h0J>*CJOJQJ^JaJ'hJVh0J5CJOJQJ^JaJ.HhYGh40J5CJOJQJ^JaJ!h`0J5CJOJQJ^JaJ `).*/*0*%++++++++N,P,,,:-<-m.n....//0 0 0òòòyfyfVHVhJVhH 5CJ^JaJhJVhH 0J5CJ^JaJ$hJVhH 0JCJOJQJ^JaJ'hJVhH 0J5CJOJQJ^JaJ&hJVh5CJOJQJ\^JaJ hJVhCJOJQJ^JaJ hJVhCJOJQJ^JaJ'hJVh0J5CJOJQJ^JaJ'he>h0J5CJOJQJ^JaJ'he>h`0J5CJOJQJ^JaJ../// 0 0u0yh>$If^>`gduz^gdgdH  & FgdH gdH  9r gdH akd.$$Ifl%#0#4 layt 0u0v0w000000L1f1g1h1111ծr^J6'hJVh(_V0J>*CJOJQJ^JaJ'hJVhH 0J>*CJOJQJ^JaJ'hJVh0J5CJOJQJ^JaJ'hJVh0J5CJOJQJ^JaJ'hJVhH 0J5CJOJQJ^JaJ'hJVh}w0J>*CJOJQJ^JaJ'hJVh0J>*CJOJQJ^JaJ$hJVh}w0JCJOJQJ^JaJ$hJVhH 0JCJOJQJ^JaJ-hJVhH 0JB* CJOJQJ^JaJph3fu0v0w0000h11111tgggZ & F $Ifgd(_V & F $Ifgduz $If^gd}w & F$Ifgduz $Ifgd $Ifgduz^kd$/$$Ifl%#0#4 la 111Z4[4j45577777xsnsgdH gdH ckd/$$Ifl%#0#4 layt $Ifgduz & F$Ifgd}w $If^gd}w 112 3Y4Z4[4i4j4E5F555d6l67777ذ؆؆r_NAhJVhH CJ^JaJ hJVhH CJOJQJ^JaJ$hJVhH 0JCJOJQJ^JaJ'hJVh|S0J5CJOJQJ^JaJ*hJVhH 0J5CJH*OJQJ^JaJ'hJVh}w0J>*CJOJQJ^JaJ'hJVh}w0J5CJOJQJ^JaJ'hJVhW0J5CJOJQJ^JaJ'hJVhH 0J5CJOJQJ^JaJ&hJVh}w5>*CJOJQJ^JaJ77::;;;o<<<<<>j?k?|?}?~?BB BBVDeDGGGݸɸ}ݸݤiݸU}&hJVh5>*CJOJQJ^JaJ'hJVh0J5CJOJQJ^JaJ hJVh|SCJOJQJ^JaJ*hJVh0J5>*CJOJQJ^JaJ'hJVh0J>*CJOJQJ^JaJ hJVhCJOJQJ^JaJ&hJVh5>*CJOJQJ^JaJ hJVhH CJOJQJ^JaJ!hJVhH B* CJ^JaJph3f7L:M::::;;;n<o<<>>j?k?}?B BBUDVDeDG $If^gd $If^gd & F$Ifgd}w $IfgduzgdH GGGGIIIJJJJJwrrmgdH gdH [kd 0$$IflZ %%04 lal $If^gd) & F$Ifgd}w $Ifgduz $Ifgd|S GGIIIIJJ9L:LXLYLZL5M7MMO=O>OUOcOpOܼܼvcOc9+hJVhH 5B*CJ\aJmH phsH &hJVhH 5CJOJQJ\^JaJ%hJVhH B*CJaJmH phsH hJVh(_V5CJaJmH sH hJVhH 5CJaJmH sH %hJVhH B* CJaJmH ph3fsH %hJVhH B* CJaJmH phsH hJVhH CJaJmH sH  hJVh|SCJOJQJ^JaJ hJVhH CJOJQJ^JaJ#hJVh)5CJOJQJ^JaJJ KAKKKKK L9LYLZLMMO)O=O $IfgduzgdH gdH h^hgdH  & F gdH =O>OUOcOpOOOOOullcZQQH $Ifgd $Ifgd|S $Ifgd $Ifgduz $Ifgduzkd0$$Ifl00 E&0   t%0E&4 lalppOOOOOEP_PiPjPkPpPwPPPPPPdzǥ}l[K;hJVh|S5CJaJmH sH hJVhH 5CJaJmH sH  hJVh^CJOJQJ^JaJ hJVh`CJOJQJ^JaJ'HhYGh^CJOJQJ^JaJ'HhYGhH CJOJQJ^JaJh`CJOJQJ^JaJ&hJVhH 5CJOJQJ\^JaJ hJVhH CJOJQJ^JaJ hJVh|SCJOJQJ^JaJ+hJVh|S5B*CJ\aJmH phsH OOkPPPPPne $Ifgduzkd_1$$Ifl00 E&0   t% 0E&4 lalp $Ifgd A; $IfgduzPPPPPPPPPQQ Q Q Q!Q"Q#Q$Q?QOQgQhQiQQQQQQQQQ±   gO.hJVhH 5>*B*CJ\aJmH phsH .hJVh A;5>*B*CJ\aJmH phsH hJVhH 5CJaJmH sH  hJVhq:CJOJQJ^JaJ hJVhH CJOJQJ^JaJ hJVh|SCJOJQJ^JaJ+hJVhH 5B*CJ\aJmH phsH &hJVhH 5CJOJQJ\^JaJ%hJVhH B*CJaJmH phsH PPPP Q!Q $Ifgduz $Ifgduz_kd2$$Ifl4E&E& t%0E&4 lalf4!Q"Q#Qw $Ifgduzkd2$$Ifl00 E&0   t% 0E&4 lalp #Q$Q?QOQfQ $Ifgduz $Ifgduz_kdf3$$Ifl4E&E& t%0E&4 lalf4fQgQhQw $Ifgduzkd3$$Ifl00 E&0   t% 0E&4 lalp hQiQQQQ $Ifgduz $Ifgduz_kd4$$Ifl4E&E& t%0E&4 lalf4QQQw $IfgduzkdF5$$Ifl00 E&0   t% 0E&4 lalp QQQQRRRRRRSSSTTTT $Ifgduz $Ifgduz_kd6$$Ifl4E&E& t%0E&4 lalf4QQQ R&RRRRRRRRRSSSTTTTTTTTTUU髙wfVfwC%hJVhH B*CJaJmH phsH hJVhH >*CJaJmH sH  hJVh A;CJOJQJ^JaJ hJVh|SCJOJQJ^JaJ hJVhH CJOJQJ^JaJ#hJVh A;>*CJOJQJ^JaJ#hJVhH >*CJOJQJ^JaJ+hJVh|S5B*CJ\aJmH phsH +hJVh A;5B*CJ\aJmH phsH +hJVhH 5B*CJ\aJmH phsH TTTTUUnkd6$$Ifl00 E&0   t% 0E&4 lalp $Ifgd|S $IfgduzUUUPU $Ifgduz_kdM7$$Ifl4E&E& t%0E&4 lalf4UUU+U7UOUPUQURUSUeUkUlUmUnUoUUUUUUUUUUUUUUUUUUUUUUUUWXɹɣɣɣɣɣɣɅs"hJVhH 5CJ\aJmH sH hJVhH CJ^JaJ hJVhH CJOJQJ^JaJ+hJVhH 5B*CJ\aJmH phsH hJVh|S5CJaJmH sH hJVhH 5CJaJmH sH %hJVhH B*CJaJmH phsH &hJVhH 5CJOJQJ\^JaJ(PUQURU{r $Ifgduzkd7$$Ifl00 E&0   t% 0E&4 lalp ytRUSUeUlU $Ifgduz_kd8$$Ifl4E&E& t%0E&4 lalf4lUmUnUw $Ifgduzkd79$$Ifl00 E&0   t% 0E&4 lalp nUoUUU $Ifgduz_kd9$$Ifl4E&E& t%0E&4 lalf4UUUw $Ifgduzkd:$$Ifl00 E&0   t% 0E&4 lalp UUUU $Ifgduz_kd>;$$Ifl4E&E& t%0E&4 lalf4UUUw $Ifgduzkd;$$Ifl00 E&0   t% 0E&4 lalp UUUU $Ifgduz_kd<$$Ifl4E&E& t%0E&4 lalf4UUUw $Ifgduzkd=$$Ifl00 E&0   t% 0E&4 lalp UUUU $Ifgduz_kd=$$Ifl4E&E& t%0E&4 lalf4UUUUWXX;XXXX{vqvvvvhh $IfgduzgdH gdH gdH kdk>$$Ifl00 E&0   t% 0E&4 lalp X;XXXXXXXXYYY*CJOJQJ^JaJ hJVh|SCJOJQJ^JaJ hJVhCJOJQJ^JaJ hJVh}wCJOJQJ^JaJ&hJVh5>*CJOJQJ^JaJ&hJVh A;5>*CJOJQJ^JaJ hJVhH CJOJQJ^JaJhJVh}wCJaJmH sH hJVhH 5CJaJmH sH hJVhH CJaJmH sH XXX[?[@[A[C[E[W[[[[[[\\ ]޻ުޙު慎ުޙr](hJVh CJOJQJ^JaJnH tH (hJVh(_VCJOJQJ^JaJnH tH #hJVhq:CJH*OJQJ^JaJ hJVh(_VCJOJQJ^JaJ hJVhq:CJOJQJ^JaJ hJVhCJOJQJ^JaJ#hJVhH CJH*OJQJ^JaJ hJVhH CJOJQJ^JaJ hJVh A;CJOJQJ^JaJ ] ]P]Q]]]]]]]]^__ _&_'_Q_\_j____` `A`I```ٵ٤nnnnnnnZ'hJVh}w0J>*CJOJQJ^JaJ hJVhq:CJOJQJ^JaJ hJVh}wCJOJQJ^JaJ&hJVh5>*CJOJQJ^JaJ hJVhH CJOJQJ^JaJ hJVhCJOJQJ^JaJ$hJVh 0JCJOJQJ^JaJ hJVh CJOJQJ^JaJ)jhJVh CJOJQJU^JaJb\]]]]]__```aawaxaabbddeee $If^gd}w & F%$Ifgd(_V $Ifgduz $If^gd & F&$Ifgd ``aaSavawaxaabbbccccccddddeeeee*CJOJQJ^JaJ hJVh}wCJOJQJ^JaJ hJVhH CJOJQJ^JaJ&hJVh}w5>*CJOJQJ^JaJ*hJVh}w0J5>*CJOJQJ^JaJ'hJVh}w0J5CJOJQJ^JaJe;f22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd@$$If4\U"`an  04 af4p plqlrllllSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdA$$If4\U" an  04 af4p llllllSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd\B$$If4\U" an  04 af4p llllllSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd?C$$If4\U" an  04 af4p lllSG $$Ifa$gduzkd"D$$If4\U" an  04 af4p llllllll $$Ifa$gduzckdE$$If4U"s"04 af4lllmmmPGG;; $$Ifa$gduz $IfgduzkdE$$If4F{U"ln 0    4 af4plmm2m5m`mcmxmymzm{mmmmmmmmmmmmmmmnn#n%n5n7nUnVnWnXn[nnϵσq#hJVhH CJOJQJ^JaJh2hJVh5B*CJOJQJ\^JaJhph/hJVhH B*CJH*OJQJ^JaJhph2hJVhW5B*CJOJQJ\^JaJhph2hJVhH 5B*CJOJQJ\^JaJhph,hJVhH B*CJOJQJ^JaJhph$mmm2m3m5mSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdF$$If4\U"`an  04 af4p 5m6m7m`mbmcmSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdG$$If4\U" an  04 af4p cmdmemxmym{mSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdjH$$If4\U" an  04 af4p {m|m}mmmmSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd?I$$If4\U" an  04 af4p mmmmmmSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdJ$$If4\U" an  04 af4p mmmmmmSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdJ$$If4\U" an  04 af4p mmmmmmSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdK$$If4\U" an  04 af4p mmmmmmSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdL$$If4\U" an  04 af4p mmmmmmSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdhM$$If4\U" an  04 af4p mmmnnnSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd=N$$If4\U" an  04 af4p nnn#n$n%nSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdO$$If4\U" an  04 af4p %n&n'n5n6n7nSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdO$$If4\U" an  04 af4p 7n8n9nUnVnXnSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdP$$If4\U" an  04 af4p XnYnZnSG $$Ifa$gduzkdQ$$If4\U" an  04 af4p Zn[n\nfnxn~nnn $$Ifa$gduzckdR$$If4U"s"04 af4nnnnnnPGG;; $$Ifa$gduz $Ifgduzkd3S$$If4F{U"ln 0    4 af4pnnnnnnnnnnoo'o)ocoeowoyoooooooooo2pCpMpOp[p]p`pppppppqq*q,qYq[q\qqqqqqqqqr rrr.r1r4rjrtrrжжжжжжжжжжжжФжжФжжжжжФжжжжжжФ#hJVhH CJOJQJ^JaJh2hJVhH 5B*CJOJQJ\^JaJhph,hJVhH B*CJOJQJ^JaJhph/hJVhH 5B*CJOJQJ^JaJhph@nnnnnnSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdYT$$If4\U"`an  04 af4p nnnnnnSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd.U$$If4\U" an  04 af4p nnnnnnSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdV$$If4\U" an  04 af4p nnnoooSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdV$$If4\U" an  04 af4p o o o'o(o)oSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdW$$If4\U" an  04 af4p )o*o+ocodoeoSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdX$$If4\U" an  04 af4p eofogowoxoyoSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdeY$$If4\U" an  04 af4p yozo{ooooSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdHZ$$If4\U" an  04 af4p ooooooSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd+[$$If4\U" an  04 af4p ooooooSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd\$$If4\U" an  04 af4p ooooooSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd\$$If4\U" an  04 af4p oooSG $$Ifa$gduzkd]$$If4\U" an  04 af4p oooppp-p1p $$Ifa$gduzckd^$$If4U"s"04 af41p2pDpMpNpOpPGG;; $$Ifa$gduz $IfgduzkdL_$$If4F{U"ln 0    4 af4pOpPpQp[p\p]pSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdr`$$If4\U"`an  04 af4p ]p^p_pSG $$Ifa$gduzkdGa$$If4\U" an  04 af4p _p`papkp}pppp $$Ifa$gduzckd*b$$If4U"s"04 af4ppppppPGG;; $$Ifa$gduz $Ifgduzkdb$$If4F{U"ln 0    4 af4pppppppSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdc$$If4\U"`an  04 af4p pppqqqSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdd$$If4\U" an  04 af4p qqq*q+q,qSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkde$$If4\U" an  04 af4p ,q-q.qYqZq[qSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkddf$$If4\U" an  04 af4p [q\q]qSG $$Ifa$gduzkd9g$$If4\U" an  04 af4p ]q^q_qiq{qqqq $$Ifa$gduzckdh$$If4U"s"04 af4qqqqqqPGG;; $$Ifa$gduz $Ifgduzkdh$$If4F{U"ln 0    4 af4pqqqqqqSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdi$$If4\U"`an  04 af4p qqqqqqSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdj$$If4\U" an  04 af4p qqqr r rSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdsk$$If4\U" an  04 af4p  r r rrrrSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdHl$$If4\U" an  04 af4p rrr.r/r1rSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd+m$$If4\U" an  04 af4p 1r2r3rSG $$Ifa$gduzkdn$$If4\U" an  04 af4p 3r4r5r?rQrWrerir $$Ifa$gduzckdn$$If4U"s"04 af4irjrurrrrPGG;; $$Ifa$gduz $Ifgduzkdo$$If4F{U"ln 0    4 af4prrrrrrrrrrss+s-sFsHshsjsuswssssssssssttt!t/t1t7t8t9t:tTtVtYtttttϽsϽ2hJVh5B*CJOJQJ\^JaJhph/hJVh5B*CJOJQJ^JaJhph/hJVhH 5B*CJOJQJ^JaJhph#hJVhH CJOJQJ^JaJh,hJVhH B*CJOJQJ^JaJhph2hJVhH 5B*CJOJQJ\^JaJhph-rrrrrrSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdp$$If4\U"`an  04 af4p rrrrrrSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdq$$If4\U" an  04 af4p rrrrrrSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdVr$$If4\U" an  04 af4p rrrrrrSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd+s$$If4\U" an  04 af4p rrrsssSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdt$$If4\U" an  04 af4p sss+s,s-sSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdt$$If4\U" an  04 af4p -s.s/sFsGsHsSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdu$$If4\U" an  04 af4p HsIsJshsisjsSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdv$$If4\U" an  04 af4p jskslsusvswsSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdTw$$If4\U" an  04 af4p wsxsyssssSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd)x$$If4\U" an  04 af4p ssssssSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdx$$If4\U" an  04 af4p ssssssSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdy$$If4\U" an  04 af4p sssSG $$Ifa$gduzkdz$$If4\U" an  04 af4p ssssssss $$Ifa$gduzckd{$$If4U"s"04 af4sstt t!tPG>22 $$Ifa$gduz $Ifgduz $Ifgdkd |$$If4F{U"ln 0    4 af4p!t"t#t/t0t1tSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdF}$$If4\U"`an  04 af4p 1t2t3t7t8t:tSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd~$$If4\U" an  04 af4p :t;t22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd~$$If4\U" an  04 af4p VtWtXtSG $$Ifa$gduzkd$$If4\U" an  04 af4p XtYtZtdtvt|ttt $$Ifa$gduzckd$$If4U"s"04 af4ttttttPGG;; $$Ifa$gduz $Ifgduzkd=$$If4F{U"ln 0    4 af4pttttttSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdc$$If4\U"`an  04 af4p tttttttttt%uCueuguhuiuyu{u|u}uuuuuuuuuuvv3v5vFvHvXvZv}vvvvvvvvvvv齥齥锅hJVhH CJaJmH sH  hJVhH CJOJQJ^JaJ/hJVhH 5B*CJOJQJ^JaJhph#hJVhH CJOJQJ^JaJh2hJVhH 5B*CJOJQJ\^JaJhph,hJVhH B*CJOJQJ^JaJhph/ttttttSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd8$$If4\U" an  04 af4p ttttttSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd $$If4\U" an  04 af4p ttttttSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd$$If4\U" an  04 af4p tttSG $$Ifa$gduzkd$$If4\U" an  04 af4p tttt uu u$u $$Ifa$gduzckd$$If4U"s"04 af4$u%uDueufuguPGG;; $$Ifa$gduz $Ifgduzkd!$$If4F{U"ln 0    4 af4pguhuiuyuzu{uSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdU$$If4\U"`an  04 af4p {u|u}uuuuSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd8$$If4\U" an  04 af4p uuuuuuSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd$$If4\U" an  04 af4p uuuSG $$Ifa$gduzkd$$If4\U" an  04 af4p uuuuuuuu $$Ifa$gduzckd$$If4U"s"04 af4uuuvvvPGG;; $$Ifa$gduz $Ifgduzkd$$If4F{U"ln 0    4 af4pvvv3v4v5vSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd$$If4\U"`an  04 af4p 5v6v7vFvGvHvSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd$$If4\U" an  04 af4p HvIvJvXvYvZvSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdT$$If4\U" an  04 af4p Zv[v\v}v~vvSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd)$$If4\U" an  04 af4p vvvvvvSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd$$If4\U" an  04 af4p vvvvvvSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkdӑ$$If4\U" an  04 af4p vvvvvvSG>22 $$Ifa$gduz $Ifgduz $$Ifa$gduzkd$$If4\U" an  04 af4p vvvvvwwwSNNIINNgdH gdH kd}$$If4\U" an  04 af4p vwwwwwwwwwwxx#x$x%x1xqxx"yXyyyǰ|n|]K|:]] hJVhaCJOJQJ^JaJ#hJVhH CJOJQJ]^JaJ hJVhCJOJQJ^JaJhJVhH 6CJ^JaJ#hJVhH 5CJOJQJ^JaJ#hJVhH 6CJOJQJ^JaJhJVhH 6CJ]^JaJ,hJVhH 5B* CJOJQJ^JaJph hJVhH CJOJQJ^JaJ,hJVhH 5B*CJOJQJ^JaJphhJVhH 5CJaJmH sH wwwwwwl|kdR$$Ifl0 % !  0%4 lalp $Ifgduz  9r $Ifgduzwwx$xzz $Ifgduz|kd$$Ifl0 % !  0%4 lalp $x%x1xxxzzzqqhq $Ifgda $Ifgd $Ifgduz|kd$$Ifl0 % !  0%4 lalp yyyzzz/z0z3z>zFzGzIzTz\z]zbzmzuzzzzzzznW@W-jhJVh0JCJOJQJU^JaJ,hJVhH 5B* CJOJQJ^JaJph#hJVhH 6CJOJQJ^JaJ hJVhCJOJQJ^JaJ#hJVhH CJOJQJ\^JaJ&hJVhH 5CJOJQJ\^JaJ)hJVhH 5CJOJQJ\]^JaJ#hJVhaCJOJQJ]^JaJ hJVhaCJOJQJ^JaJ hJVhH CJOJQJ^JaJzzzz"z/zzooo $IfgduzK$ $Ifgduz|kdR$$Ifl0 % !  0%4 lalp /z0z3z>zFzTIII $IfgduzK$kd$IfK$L$l    Fw+  t0        44 lapyt]FzGzIzTz\zTIII $IfgduzK$kd$IfK$L$l    Fw+  t0        44 lapyt]\z]zbzmzuzTIII $IfgduzK$kdd$IfK$L$l    Fw+  t0        44 lapyt]uzvzzTK $Ifgduzkd$IfK$L$l    Fw+  t0        44 lapyt]zzzzz\kdv$$Ifl4%%0%4 lalf4 $Ifgd|kd™$$Ifl0 % !  0%4 lalp zzzzzzl|kd$$Ifl0 % !  0%4 lalp $Ifgduz  9r $Ifgduzzzzzzzzzzz{{{{{|||#|'|(|3|4|ͻͻߕ~iߕVO=#hJVhH CJOJQJ\^JaJ hJVhH $hJVhJV0J!CJOJQJ^JaJ)hJVhH 5CJOJQJ\]^JaJ,hJVhH 5B* CJOJQJ^JaJph&hJVhH 5CJOJQJ\^JaJ#hJVhaCJOJQJ]^JaJ#hJVhH CJOJQJ]^JaJ#hJVhH 5CJOJQJ^JaJ hJVhH CJOJQJ^JaJhJVhH 6CJ]^JaJzzzzzz $Ifgduz|kdś$$Ifl0 % !  0%4 lalp zzz{{zzz $Ifgduz|kdk$$Ifl0 % !  0%4 lalp {{{{{|ujjj $IfgduzK$  9r $Ifgduz|kd$$Ifl0 % !  0%4 lalp |||(|3|RG<1 $IfgdJK$ $IfgdJVK$ $IfgduzK$kd$IfK$L$l    Fw+  t0        44 lapytJV3|4|<|J|U|TII> $IfgdJK$ $IfgdeK$kdx$IfK$L$l    Fw+  t0        44 lapyt]4|:|;|<|U|V|||||||||||||| }=}>}ŴjXXFXF#hJVhH CJOJQJ]^JaJ#hJVhH 5CJOJQJ^JaJ,hJVhH 5B* CJOJQJ^JaJphhJVhH 6CJ]^JaJ#hJVhH 6CJOJQJ^JaJ hJVhH CJOJQJ^JaJ hJVhCJOJQJ^JaJ#hJVhCJOJQJ\^JaJ)hJVh5CJH*OJQJ\^JaJ&hJVh5CJOJQJ\^JaJU|V||RI $Ifgduzkd'$IfK$L$l    Fw+  t0        44 lapytJ||||z\kd$$Ifl4%%0%4 lalf4 $Ifgduz|kdڟ$$Ifl0 % !  0%4 lalp ||||||l|kd$$Ifl0 % !  0%4 lalp $Ifgduz  9r $Ifgduz||||zz $Ifgduz|kdݡ$$Ifl0 % !  0%4 lalp || }=}zz $Ifgduz|kd$$Ifl0 % !  0%4 lalp =}>}T}U}zz $Ifgduz|kd)$$Ifl0 % !  0%4 lalp >}S}T}U}V}W}X}h}i}j}}}}}}} ~ ~!~"~$~%~&~>~M~۲ېېۀmZG$hJVhH 5B* CJ^JaJph%hJVhH B*CJaJmH phsH %hJVhB*CJaJmH phsH hJVhH 5CJaJmH sH #hJVhH 5CJOJQJ^JaJhJVhH 6CJ]^JaJ,hJVhH 5B* CJOJQJ^JaJph#hJVhH CJOJQJ]^JaJ hJVhH CJOJQJ^JaJ&hJVhH 5CJOJQJ\^JaJU}V}W}X}z\kd$$Ifl4%%0%4 lalf4 $Ifgduz|kdϣ$$Ifl0 % !  0%4 lalp X}h}i}j}}}l|kd$$Ifl0 % !  0%4 lalp $Ifgduz  9r $Ifgduz}}}}zz $Ifgduz|kdҥ$$Ifl0 % !  0%4 lalp }}} ~zz $Ifgduz|kdx$$Ifl0 % !  0%4 lalp  ~ ~!~"~ul $Ifgduz  9r $Ifgduz|kd$$Ifl0 % !  0%4 lalp "~#~$~%~>~N~O~~yypg $Ifgduz $IfgduzgdH gdH |kdħ$$Ifl0 % !  0%4 lalp M~N~O~P~g~r~s~t~~~~~!"qst~jSA#hJVhH CJOJQJ\^JaJ-jhJVha0JCJOJQJU^JaJ&hJVhH 5CJOJQJ\^JaJ)hJVhH 5CJOJQJ\]^JaJhJVh 6CJ^JaJ hJVhH CJOJQJ^JaJhJVhH 6CJ^JaJhJVh6CJ^JaJ#hJVhH 6CJOJQJ^JaJhJVhH CJ^JaJ$hJVhH 5B*CJ^JaJphO~P~g~s~{ $Ifgduz $Ifgduzqkdj$$Ifl0 % !0%4 lals~t~~~{ $Ifgduz $Ifgduzqkd$$Ifl0 % !0%4 lal~~~s{ $Ifgduz $Ifgduzqkd$$Ifl0 % !0%4 lalstyyy $IfgduzK$ $Ifgduzqkd)$$Ifl0 % !0%4 lalTIII $IfgduzK$kd$IfK$L$l    Fw+  t0        44 lapyt]TIII $IfgduzK$kd{$IfK$L$l    Fw+  t0        44 lapyt]&@HI]^yij{ij{ijiUiUi&hJVhCJH*OJQJ\^JaJ#hJVhCJOJQJ\^JaJ&hJVh|p5CJOJQJ\^JaJ#hJVhH CJOJQJ\^JaJ#hJVhH CJH*OJQJ^JaJ hJVhH CJOJQJ^JaJ&hJVhH 5CJOJQJ\^JaJ&hJVh,-5CJOJQJ\^JaJ&hJVh5CJOJQJ\^JaJTIII $IfgduzK$kd*$IfK$L$l    Fw+  t0        44 lapyt]TIII $IfgduzK$kd٬$IfK$L$l    Fw+  t0        44 lapyt]&6@LUTKB7BB $IfgdeK$ $Ifgde $Ifgd,-kd$IfK$L$l    Fw+  t0        44 lapyt]Udkqyz|@7 $Ifgduzkd7$IfK$L$l    Fw+  t0        44 lapyt] $Ifgde $IfgdeK$yz}~Հ؀ـڀā̺ޣހrހaހaPaP?P hJVhOCJOJQJ^JaJ hJVhMCJOJQJ^JaJ hJVh CJOJQJ^JaJhJVhH 6CJ^JaJ$hJVhH 5B*CJ^JaJphhJVhH 6CJ]^JaJ,hJVhH 5B* CJOJQJ^JaJph#hJVhCJOJQJ]^JaJ#hJVhH CJOJQJ]^JaJ hJVhH CJOJQJ^JaJ hJVhCJOJQJ^JaJ|}~ $Ifgduzvkd$$Ifl0 % !0%4 lalyt $Ifgduz  9r $Ifgduzakd$$Ifl4%%0%4 lalf4~ul $Ifgduz $Ifgduzkd$$Ifl0 % !  0%4 lalp Հـypg $Ifgd $Ifgduzkd԰$$Ifl0 % !  0%4 lalp yt ـڀƁ~ul $Ifgd $Ifgduzkd$$Ifl0 % !  0%4 lalp āŁƁǁ݁ށWXYiʳvdRdR;,hJVhH 5B* CJOJQJ^JaJph#hJVhH CJOJQJ\^JaJ#hJVhJCJOJQJ\^JaJ&hJVhH 5CJOJQJ\^JaJ&hJVh 5CJOJQJ\^JaJ)hJVhH 5CJOJQJ\]^JaJ,hJVhH 56CJOJQJ\]^JaJ$hJVhH 5B*CJ^JaJph#hJVhH CJOJQJ]^JaJ hJVhH CJOJQJ^JaJƁǁ݁ށ~ujjj $IfgduzK$ $Ifgduzkd*$$Ifl0 % !  0%4 lalp RGG< $IfgdJK$ $IfgduzK$kdв$IfK$L$l    FU  t0    F    44 lapytJVRI $Ifgduzkd$IfK$L$l    FU  t0    F    44 lapytJVWX~u $IfgduzkdR$$Ifl0 % !  0%4 lalp XYij $Ifgduz  9r $Ifgduzakd$$Ifl4%%0%4 lalf4ijk‚Âςă˃̬҃̾ߚ̃nZH#hJVhaCJOJQJ\^JaJ&hJVhH 5CJOJQJ\^JaJ)hJVhH 5CJOJQJ\]^JaJ,hJVhH 56CJOJQJ\]^JaJ#hJVhJCJOJQJ]^JaJ#hJVhH CJOJQJ]^JaJhJVhH 6CJ^JaJ$hJVhH 5B*CJ^JaJph hJVhH CJOJQJ^JaJhJVhH 6CJ]^JaJjk~ul $Ifgduz $Ifgduzkd$$Ifl0 % !  0%4 lalp ‚~ul $Ifgduz $IfgduzkdU$$Ifl0 % !  0%4 lalp ‚Âς~ull $Ifgduz $Ifgduzkd$$Ifl0 % !  0%4 lalp ~ujjj $IfgduzK$ $Ifgduzkd$$Ifl0 % !  0%4 lalp ă˃ӃTIII $IfgduzK$kdG$IfK$L$l    Fw+  t0        44 lapyt]҃Ӄԃ '?DEKLORSZ[\lܷܣn\E,hJVhH 5B* CJOJQJ^JaJph#hJVhH CJOJQJ]^JaJ hJVhWCJOJQJ^JaJ#hJVhaCJOJQJ\^JaJ#hJVhWCJOJQJ\^JaJ&hJVhW5CJOJQJ\^JaJ hJVhaCJOJQJ^JaJ&hJVhH 5CJOJQJ\^JaJ hJVhH CJOJQJ^JaJ#hJVhH CJOJQJ\^JaJӃԃTIII $IfgduzK$kd$IfK$L$l    Fw+  t0        44 lapyt] TIII $IfgduzK$kd$IfK$L$l    Fw+  t0        44 lapyt]'.6?RII>II> $IfgdeK$ $Ifgdekdb$IfK$L$l    Fw+  t0        44 lapyta?ELRSY@7 $Ifgduzkd$IfK$L$l    Fw+  t0        44 lapyt] $IfgdeK$ $IfgdeYZ[~u $IfgduzkdĻ$$Ifl0 % !  0%4 lalp [\lm $Ifgduz  9r $Ifgduzakdx$$Ifl4%%0%4 lalf4lmnÄɄ…Åڅ̾̚t]H4&hJVhq& 5CJOJQJ\^JaJ)hJVhq& 5CJOJQJ\]^JaJ,hJVhq& 56CJOJQJ\]^JaJ&hJVhq& CJOJQJ\]^JaJ#hJVhH CJOJQJ]^JaJ#hJVhq& CJOJQJ]^JaJ#hJVhH 5CJOJQJ^JaJhJVhH 6CJ^JaJ$hJVhH 5B*CJ^JaJph hJVhH CJOJQJ^JaJhJVhH 6CJ]^JaJmn~ul $Ifgduz $Ifgduzkd$$Ifl0 % !  0%4 lalp ~ul $Ifgdq& $Ifgduzkd$$Ifl0 % !  0%4 lalp Ä~ulc $Ifgduz $Ifgdq& $Ifgduzkd$$Ifl0 % !  0%4 lalp …Å̅م~ujjj $IfgdeK$ $IfgduzkdK$$Ifl0 % !  0%4 lalp مڅTI>I $Ifgdq& K$ $IfgdeK$kd$IfK$L$l    Fw+  t0        44 lapyte 67K}҆ӆaˇ͇·ʹʢuddddQ$hJVhH 5B*CJ^JaJph hJVh}r CJOJQJ^JaJhJVhH 6CJ^JaJ#hJVhH 5CJOJQJ^JaJhJVhH CJ^JaJ,hJVhH 5B* CJOJQJ^JaJph hJVhH CJOJQJ^JaJ#hJVhH 6CJOJQJ^JaJ hJVhq& CJOJQJ^JaJ#hJVhq& CJOJQJ\^JaJTK $Ifgduzkd$IfK$L$l    Fw+  t0        44 lapyte~u $Ifgduzkdk$$Ifl0 % !  0%4 lalp  $Ifgduz  9r $Ifgduz^kd$$Ifl%%0%4 lal 6v $Ifgduz  9r $Ifgduzqkd$$Ifl0 % !0%4 lal67K| $Ifgduzqkde$$Ifl0 % !0%4 lal|}ˇ͇{{ $Ifgd}r $Ifgduzqkd$$Ifl0 % !0%4 lal͇· {ppp $IfgdeK$ $Ifgduz $Ifgduzqkd$$Ifl0 % !0%4 lal$'.1:;\]fhyzDzyhVDyhVDyhVD#hJVhq& CJOJQJ\^JaJ#hJVh}r CJOJQJ\^JaJ hJVhq& CJOJQJ^JaJ hJVh}r CJOJQJ^JaJ&hJVhq& 5CJOJQJ\^JaJ&hJVh}r 5CJOJQJ\^JaJ)hJVhq& 5CJOJQJ\]^JaJ,hJVhq& 56CJOJQJ\]^JaJ hJVhH CJOJQJ^JaJ hJVh"iCJOJQJ^JaJ'0TIII $IfgdeK$kd$IfK$L$l    Fw+  t0        44 lapyte01;]gTIII $IfgdeK$kd$IfK$L$l    Fw+  t0        44 lapyteghzTIII $IfgdeK$kd$IfK$L$l    Fw+  t0        44 lapyteRI $Ifgduzkd1$IfK$L$l    Fw+  t0        44 lapyte׈ 2LNdŸܦqZܦG6 hJVh"iCJOJQJ^JaJ$hJVhH 5B*CJ^JaJph,hJVhH B*CJOJQJ^JaJhph#hJVhH 6CJOJQJ^JaJ(jhJVh0J6CJU^JaJhJVhH 6CJ^JaJ#hJVhH 5CJOJQJ^JaJhJVhH CJ^JaJ,hJVhH 5B* CJOJQJ^JaJph hJVhH CJOJQJ^JaJ#hJVhq& CJOJQJ]^JaJ%^kdy$$Ifl%%0%4 lal $Ifgduzqkd$$Ifl0 % !0%4 lal׈vqkd$$Ifl0 % !0%4 lal $Ifgduz  9r $Ifgduz  $Ifgduzvkd$$Ifl0 % !0%4 lalyt  $Ifgduzqkd^$$Ifl0 % !0%4 lal2e{ $Ifgduz $Ifgduzqkd$$Ifl0 % !0%4 lalefgh%^kd$$Ifl%%0%4 lal $Ifgduzqkdz$$Ifl0 % !0%4 laldfghxyz(A^g^_ϸϦϦχvχvχcThJVhH CJaJmH sH $hJVhH 5B*CJ^JaJph hJVh}r CJOJQJ^JaJ hJVhCJOJQJ^JaJhJVhH 6CJ^JaJ#hJVhH 5CJOJQJ^JaJ,hJVhH 5B* CJOJQJ^JaJph hJVhH CJOJQJ^JaJhJVhH CJ^JaJ#hJVhH CJOJQJ]^JaJhxyzvqkd$$Ifl0 % !0%4 lal $Ifgduz  9r $Ifgduz߉ $Ifgduzqkd9$$Ifl0 % !0%4 lal߉{{ $Ifgd}r $Ifgduzqkd$$Ifl0 % !0%4 lal{ $Ifgduz $IfgduzqkdG$$Ifl0 % !0%4 lalYZ zq $Ifgduz  9r $IfgduzgdH qkd$$Ifl0 % !0%4 lal *HLMiy~Ǒϑ ͻ{i{{XXFF#hJVhH CJOJQJ]^JaJ hJVh|pCJOJQJ^JaJ#hJVhCJH*OJQJ^JaJ hJVhCJOJQJ^JaJ hJVhH CJOJQJ^JaJhJVhH 6CJ]^JaJhJVhH 6CJ^JaJ#hJVhH 5CJOJQJ^JaJhJVhH 5CJaJmH sH hJVhH CJaJmH sH %hJVhH B* CJaJmH phsH *zzz $Ifgduz|kdU$$Ifl0 % !  0%4 lalp zz $Ifgduz|kd$$Ifl0 % !  0%4 lalp zq $Ifgduz $Ifgduz|kd$$Ifl0 % !  0%4 lalp ͒ $Ifgduz  9r $Ifgduz\kdU$$Ifl4%%0%4 lalf4̒͒Βڒ3OV[`deq}ٓۓܓ ԔՔ֔ ?@SUVXYlϾ퉾Ͼ퉾Ͼ퉾퉾Ͼ#hJVhH CJOJQJ]^JaJ#hJVhfCJH*OJQJ^JaJ hJVhfCJOJQJ^JaJ hJVhH CJOJQJ^JaJhJVhH 6CJ]^JaJhJVhH 6CJ^JaJ#hJVhH 5CJOJQJ^JaJ6͒Βڒړۓzzz $Ifgduz|kd$$Ifl0 % !  0%4 lalp ۓܓzz $Ifgduz|kd$$Ifl0 % !  0%4 lalp zz $Ifgduz|kd.$$Ifl0 % !  0%4 lalp  $Ifgduz  9r $Ifgduz\kd$$Ifl4%%0%4 lalf4Քzz $Ifgduz|kdo$$Ifl0 % !  0%4 lalp Ք֔zz $Ifgduz|kd$$Ifl0 % !  0%4 lalp zz $Ifgduz|kd$$Ifl0 % !  0%4 lalp  $Ifgduz  9r $Ifgduz\kdo$$Ifl4%%0%4 lalf4 =>?zzzz $Ifgduz|kd$$Ifl0 % !  0%4 lalp ?@SUul $Ifgduz  9r $Ifgduz|kd$$Ifl0 % !  0%4 lalp UVWXzz $Ifgduz|kdH$$Ifl0 % !  0%4 lalp XYl $Ifgduz  9r $Ifgduz\kd$$Ifl4%%0%4 lalf4zzzz $Ifgduz|kd$$Ifl0 % !  0%4 lalp ɕ˕̕ΕѕҕЖ"#$%JN]^ʺʇuaO;&hJVh15>*CJOJQJ^JaJ#hJVhf5CJOJQJ^JaJ&hJVhf5>*CJOJQJ^JaJ#hJVhH CJH*OJQJ^JaJ hJVhfCJOJQJ^JaJ%hJVhH B* CJaJmH phsH hJVhH CJaJmH sH hJVhH 5CJaJmH sH  hJVhH CJOJQJ^JaJ#hJVhH CJOJQJ]^JaJ#hJVhH 5CJOJQJ^JaJɕ˕zz $Ifgduz|kd/$$Ifl0 % !  0%4 lalp ˕͕̕ΕϕѕhiϖЖі~~yyyyyyyy~gdH gdH |kd$$Ifl0 % !  0%4 lalp іMN^89ѝҝߝ()cd|89@ $If^gd1 $If^gdf & F'$Ifgdf $Ifgduz*T[acޜ8ѝҝߝ7?Ee՞)Itv}d|נ9@޼޼ʙ hJVh,CJOJQJ^JaJ#hJVh15CJOJQJ^JaJ hJVh`CJOJQJ^JaJh`CJOJQJ^JaJ&hJVh15>*CJOJQJ^JaJ hJVh1CJOJQJ^JaJ hJVhH CJOJQJ^JaJ3tu^_ e & F$Ifgduz & F$Ifgduz $If^gd55 $Ifgduz $If^gd1 & F'$Ifgdfޣiqu\_ U޹ިޖނިqq]&hJVh35>*CJOJQJ^JaJ hJVh3CJOJQJ^JaJ&hJVh555>*CJOJQJ^JaJ#hJVhH 5CJOJQJ^JaJ hJVh55CJOJQJ^JaJ&hJVh~5>*CJOJQJ^JaJ hJVh,CJOJQJ^JaJ hJVhH CJOJQJ^JaJ hJVhCJOJQJ^JaJ s[kd{$$Ifl%%04 lal $Ifgd3 $If^gd55 & F$Ifgduz $If^gd3 Ue֭qryzݮ;Aͼމxxx͉iVi%hJVhH B* CJaJmH phsH hJVhH CJaJmH sH  hJVhQ)CJOJQJ^JaJ hJVh3CJOJQJ^JaJ hJVhGCJOJQJ^JaJ hJVhpq CJOJQJ^JaJ hJVhJCJOJQJ^JaJ hJVh}CJOJQJ^JaJ hJVhH CJOJQJ^JaJ hJVhdMCJOJQJ^JaJޱ&Mͳ'~ӴԴ & Fgdn & FgdH gdH gdH ѰҰ߰%&/LM~ֲ-6b̳ͳ&'}~ĴĤĤĴĴĴĴĴĴhJVhnCJaJmH sH hJVhJVCJaJhJVhn5CJaJmH sH hJVhH 5CJaJmH sH hJVhH CJaJmH sH  hJVhH CJOJQJ^JaJ5jhJVhn0JCJOJQJU^JaJnH tH /ҴԴ.EWqlԷ)JU}ӸǹWYw{|CQ˺˨˙˨˨x˨˨˨˨˨˨˨eUhJVhn5CJaJmH sH %hJVhn5CJH*\aJmH sH "hJVhJV5CJ\aJmH sH h`5CJ\aJmH sH hJV5CJ\aJmH sH "hJVhn5CJ\aJmH sH  hJVhH CJOJQJ^JaJ"hJVhH 5CJ\aJmH sH hJVhH CJaJmH sH %hJVhH B* CJaJmH phsH  klXYۻܻ9:M01^gd & F(gdH gdH gdH &$d%d&d'dNOPQgdH QlzۻܻVf F]`xͺ͊xfWxWͺC&hJVhn5>*CJOJQJ^JaJhJV5CJ\aJmH sH "hJVh" 5CJ\aJmH sH "hJVhn5CJ\aJmH sH hJVhH CJ\aJmH sH hJVhH CJaJmH sH  hJVhH CJOJQJ^JaJ%hJVhH 56CJ\aJmH sH "hJVhH 5CJ\aJmH sH hJVhn5CJaJmH sH hJVhH 5CJaJmH sH (h9:LM "#M/01ܺܺ˦~k[>8jhJVh0J5B*CJU\aJmH phsH hJVhH CJ]aJmH sH %hJVhH 56CJ\aJmH sH &hJVhH 5CJOJQJ\^JaJ&hJVh5CJOJQJ\^JaJ&hJVh5>*CJOJQJ^JaJ hJVh<CJOJQJ^JaJ hJVhCJOJQJ^JaJ hJVhH CJOJQJ^JaJ#hJVhn5CJOJQJ^JaJ 1<[kvʷ~~l~YL<h)5CJ\]aJmH sH h&CJ]aJmH sH %h&h&5CJ\]aJmH sH "h~ h&5CJ]aJnH tH h&5CJ]aJh&h&5CJ]aJhO\5CJ\]aJmH sH h`5CJ\]aJmH sH %h~ h~ 5CJ\]aJmH sH %h~ h5CJ\]aJmH sH "h~ hH 5CJ]aJmH sH hJVhH CJ]aJmH sH rsFqrgdH gdH gd& & F)gdQgd`gd&gd9oqrsw~ FGpqϿn\M\n\>h`5CJ]aJnH tH h&5CJ]aJnH tH "h&h5CJ]aJnH tH "h&hO\5CJ]aJnH tH "h~ h5CJ]aJnH tH %h~ h5CJ\]aJmH sH %h~ hH 5CJ\]aJmH sH  h`h`h`5CJ\]aJmH sH hO\5CJ\]aJmH sH hFQ5CJ\]aJmH sH hz: 5CJ\]aJmH sH qr 7EeBP=AB˸ޥޥޒnn[nJ7%hJVhH 56CJ\aJmH sH  h~ hH CJOJQJ^JaJ%h~ h~ 5CJH*\aJmH sH "h~ h~ 5CJ\aJmH sH "h~ hH 5CJ\aJmH sH %h~ hH 56CJ\aJmH sH %h~ h~ 5CJ\]aJmH sH %h~ h5CJ\]aJmH sH %h~ hNJ5CJ\]aJmH sH %h~ hH 5CJ\]aJmH sH h&h&mH nH sH tH  CDEhv;tdOdddd> hJVhH CJOJQJ^JaJ(h~ h~ 5CJH*\]aJmH sH h~ 5CJ\]aJmH sH %h~ h~ 5CJ\]aJmH sH %h~ hH 5CJ\]aJmH sH "h~ hH 5CJ\aJmH sH "hJVhH 5CJ\aJmH sH h~ 5CJ\aJmH sH hJVhH CJaJmH sH %hJVhH 56CJ\aJmH sH hJVhH CJ]aJmH sH +_a %BGoqz{"'Mj̸ڧڧ̸q`qO hhCJOJQJ^JaJ hh<CJOJQJ^JaJ hh~ CJOJQJ^JaJ hhH CJOJQJ^JaJ&hh~ 5>*CJOJQJ^JaJ hJVhGCJOJQJ^JaJ&h~ h~ 5>*CJOJQJ^JaJh~ CJOJQJ^JaJ hJVhH CJOJQJ^JaJ(hJVhH 56CJ\]aJmH sH +pq{`ab{|2|}~gd1^gdgd^gd & F*gdH ^gd~  & F*gd~ gdH  05Y- `~ܹxg_[_[_[_[G&jhCJOJQJUmHnHuh jh U hh3|CJOJQJ^JaJ h1h1CJOJQJ^JaJh1CJOJQJ^JaJ hh2CJOJQJ^JaJ hhCJOJQJ^JaJ hhH CJOJQJ^JaJhhCJOJQJ^JaJ hhCJOJQJ^JaJ$hh0J$CJOJQJ^JaJQf$dN]h]h&`#$$a$]^wϭ~zpppdpbp[ hhUhCJOJQJaJjh0JUh "hB*OJQJmHnHphuhB*OJQJph jhB*OJQJUph&h0JB*OJQJmHnHphuh0JB*OJQJph$jh0JB*OJQJUph h0Jjh0JUhhCJOJQJ#]wgd Not sure what happens with the formatting here. Is it still a e-module or workshop basis? This will need updating: https://www.nice.org.uk/guidance/ng69 PHASE 3 SCENARIO TEMPLATE  hh3|CJOJQJ^JaJh h(. A!"#$% $$If!vh#v #ve#v :V   t%05 5e5 44 p$$If!vh#vJ%:V 4  t% 05J%44 f4p $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/  / /  / 44 $$If!vh#vJ%:V 4  t% 05J%44 f4p $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/  / /  / 44 $$If!vh#vJ%:V 4  t% 05J%44 f4p $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/  / /  / 44 $$If!vh#vJ%:V 4  t% 05J%44 f4p $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/  / /  / 44 $$If!vh#vJ%:V 4  t% 05J%44 f4p $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/  / 44 $$If!vh#vJ%:V 4  t% 05J%44 f4p $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 $$If!vh#v#vJ #v!:V  t%055J 5!/ / / 44 w$$Ifl!vh#v%:V l05%4alw$$Ifl!vh#v%:V l05%4alw$$Ifl!vh#v%:V l05%4alw$$Ifl!vh#v%:V l05%4al$$Ifl!vh#v%:V lP0%5%4alytw$$If!vh#v#:V l05#4aw$$If!vh#v#:V l05#4aw$$If!vh#v#:V l05#4a$$If!vh#v#:V l05#4aytJV}$$If!vh#v#:V l0#5#4ayt}$$If!vh#v#:V l0#5#4aytw$$If!vh#v#:V l0#5#4a$$If!vh#v#:V l0#5#4ayt{$$Ifl!vh#v%:V lZ 05%4al$$Ifl!vh#v0 #v:V l  t%0E&50 54alp$$Ifl!vh#v0 #v:V l  t% 0E&50 5/ 4alp $$Ifl!vh#vE&:V l4 t%0E&5E&/  4alf4$$Ifl!vh#v0 #v:V l  t% 0E&50 5/ 4alp $$Ifl!vh#vE&:V l4 t%0E&5E&/  4alf4$$Ifl!vh#v0 #v:V l  t% 0E&50 5/ 4alp $$Ifl!vh#vE&:V l4 t%0E&5E&/  4alf4$$Ifl!vh#v0 #v:V l  t% 0E&50 5/ 4alp $$Ifl!vh#vE&:V l4 t%0E&5E&/  4alf4$$Ifl!vh#v0 #v:V l  t% 0E&50 5/ 4alp $$Ifl!vh#vE&:V l4 t%0E&5E&/  4alf4$$Ifl!vh#v0 #v:V l  t% 0E&50 5/ 4alp yt$$Ifl!vh#vE&:V l4 t%0E&5E&/  4alf4$$Ifl!vh#v0 #v:V l  t% 0E&50 5/ 4alp $$Ifl!vh#vE&:V l4 t%0E&5E&/  4alf4$$Ifl!vh#v0 #v:V l  t% 0E&50 5/ 4alp $$Ifl!vh#vE&:V l4 t%0E&5E&/  4alf4$$Ifl!vh#v0 #v:V l  t% 0E&50 5/ 4alp $$Ifl!vh#vE&:V l4 t%0E&5E&/  4alf4$$Ifl!vh#v0 #v:V l  t% 0E&50 5/ 4alp $$Ifl!vh#vE&:V l4 t%0E&5E&/  4alf4$$Ifl!vh#v0 #v:V l  t% 0E&50 54alp $$Ifl!vh#v%:V l 05%4alyt $$If!vh#v#vl#vn:V 4 055l5n/ / / 44 f4p$$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#vs":V 405s"/ 44 f4$$$If!vh#v#vl#vn:V 4 055l5n/ / / / 44 f4p$$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#vs":V 405s"/ 44 f4$$$If!vh#v#vl#vn:V 4 055l5n/ / / / 44 f4p$$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#vs":V 405s"/ 44 f4$$$If!vh#v#vl#vn:V 4 055l5n/ / / / 44 f4p$$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#vs":V 405s"/ 44 f4$$$If!vh#v#vl#vn:V 4 055l5n/ / / / 44 f4p$$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#vs":V 405s"/ 44 f4$$If!vh#v#vl#vn:V 4 055l5n/ / / 44 f4p$$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#vs":V 405s"/ 44 f4$$$If!vh#v#vl#vn:V 4 055l5n/ / / / 44 f4p$$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#vs":V 405s"/ 44 f4$$$If!vh#v#vl#vn:V 4 055l5n/ / / / 44 f4p$$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#vs":V 405s"/ 44 f4$$$If!vh#v#vl#vn:V 4 055l5n/ / / / 44 f4p$$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#vs":V 405s"/ 44 f42$$If!vh#v#vl#vn:V 4 055l5n/ /  / / / 44 f4p$$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n/ 44 f4p $$If!vh#vs":V 405s"/ / 44 f4$$$If!vh#v#vl#vn:V 4 055l5n/ / / / 44 f4p$$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$If!vh#v#v#va#vn:V 4  0+555a5n44 f4p $$Ifl!vh#v #v!:V l  0%5 5!/  4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $IfK$L${!vh#v:V l  t0    5/ pyt]$IfK$L${!vh#v:V l  t0    5pyt]$IfK$L${!vh#v:V l  t0    5pyt]$IfK$L${!vh#v:V l  t0    5pyt]$$Ifl!vh#v #v!:V l  0%5 5!/ 4alp $$Ifl!vh#v%:V l40%5%/ 4alf4$$Ifl!vh#v #v!:V l  0%5 5!/ /  4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $IfK$L${!vh#v:V l  t0    5/ pytJV$IfK$L${!vh#v:V l  t0    5pyt]$IfK$L${!vh#v:V l  t0    5pytJ$$Ifl!vh#v #v!:V l  0%5 5!/ 4alp $$Ifl!vh#v%:V l40%5%/ 4alf4$$Ifl!vh#v #v!:V l  0%5 5!/ /  4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!/ 4alp $$Ifl!vh#v%:V l40%5%/ 4alf4$$Ifl!vh#v #v!:V l  0%5 5!/ /  4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l0%5 5!/ 4al$$Ifl!vh#v #v!:V l0%5 5!/ 4al$$Ifl!vh#v #v!:V l0%5 5!/ 4al$$Ifl!vh#v #v!:V l0%5 5!/ 4al$IfK$L${!vh#v:V l  t0    5/ pyt]$IfK$L${!vh#v:V l  t0    5pyt]$IfK$L${!vh#v:V l  t0    5pyt]$IfK$L${!vh#v:V l  t0    5pyt]$IfK$L${!vh#v:V l  t0    5pyt]$IfK$L${!vh#v:V l  t0    5pyt]$$Ifl!vh#v #v!:V l0%5 5!/ 4alyt$$Ifl!vh#v%:V l40%5%/ 4alf4$$Ifl!vh#v #v!:V l  0%5 5!/ /  4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp yt $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $IfK$L${!vh#v:V l  t0    F5/ pytJ$IfK$L${!vh#v:V l  t0    F5/ pytJ$$Ifl!vh#v #v!:V l  0%5 5!/ 4alp $$Ifl!vh#v%:V l40%5%/ 4alf4$$Ifl!vh#v #v!:V l  0%5 5!/ /  4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $IfK$L${!vh#v:V l  t0    5/ pyt]$IfK$L${!vh#v:V l  t0    5pyt]$IfK$L${!vh#v:V l  t0    5pyt]$IfK$L${!vh#v:V l  t0    5pyta$IfK$L${!vh#v:V l  t0    5pyt]$$Ifl!vh#v #v!:V l  0%5 5!/ 4alp $$Ifl!vh#v%:V l40%5%/ 4alf4$$Ifl!vh#v #v!:V l  0%5 5!/ / / /  / 4alp $$Ifl!vh#v #v!:V l  0%5 5!/ 4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!/ 4alp $IfK$L${!vh#v:V l  t0    5/ pyte$IfK$L${!vh#v:V l  t0    5pyte$$Ifl!vh#v #v!:V l  0%5 5!/ 4alp $$Ifl!vh#v%:V l0%5%/ 4al$$Ifl!vh#v #v!:V l0%5 5!/ / /  / 4al$$Ifl!vh#v #v!:V l0%5 5!/ 4al$$Ifl!vh#v #v!:V l0%5 5!4al$$Ifl!vh#v #v!:V l0%5 5!/ 4al$IfK$L${!vh#v:V l  t0    5/ pyte$IfK$L${!vh#v:V l  t0    5pyte$IfK$L${!vh#v:V l  t0    5pyte$IfK$L${!vh#v:V l  t0    5pyte$$Ifl!vh#v #v!:V l0%5 5!/ 4al$$Ifl!vh#v%:V l0%5%/ 4al$$Ifl!vh#v #v!:V l0%5 5!/ / /  / 4al$$Ifl!vh#v #v!:V l0%5 5!/ 4alyt$$Ifl!vh#v #v!:V l0%5 5!4al$$Ifl!vh#v #v!:V l0%5 5!/ 4al$$Ifl!vh#v #v!:V l0%5 5!/ 4al$$Ifl!vh#v%:V l0%5%/ 4al$$Ifl!vh#v #v!:V l0%5 5!/ / 4al$$Ifl!vh#v #v!:V l0%5 5!4al$$Ifl!vh#v #v!:V l0%5 5!4al$$Ifl!vh#v #v!:V l0%5 5!4al$$Ifl!vh#v #v!:V l0%5 5!4al$$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!/ 4alp $$Ifl!vh#v%:V l40%5%/  4alf4$$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!/ 4alp $$Ifl!vh#v%:V l40%5%/  4alf4$$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!/ 4alp $$Ifl!vh#v%:V l40%5%/  4alf4$$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!/ 4alp $$Ifl!vh#v%:V l40%5%/  4alf4$$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp $$Ifl!vh#v #v!:V l  0%5 5!4alp {$$Ifl!vh#v%:V l05%4al^% 06866666666866666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@Phx_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH b@b H Heading 1$7$8$@&H$#5B*OJQJ\^JmH phsH D@D H Heading 2$@&5CJOJQJV@V H Heading 3$$@&a$56B* CJOJQJph@@@ H Heading 4$@& 6OJQJ^@^ H Heading 5$7$8$@&H$ 6B*OJQJ^JmH phsH D@D H Heading 6$@&5CJOJQJB@B H Heading 7 <@&CJaJDA`D Default Paragraph FontRi@R  Table Normal4 l4a (k (No List 4@4 H Header  9r 4 @4 H Footer  9r :B@: H Body Text CJOJQJ.)@!. H Page Number(W`1( H Strong5>P@B> H Body Text 2 5OJQJLC@RL H Body Text Indent h^hOJQJ6U`a6 H Hyperlink >*B*phFV`qF H FollowedHyperlink >*B* ph`}@` H Table Columns 5:V0    j jjj#j#4VB*`Jph B*`Jph5\5\5\56\]H@H  Balloon TextCJOJQJ^JaJ,, pq searchwordB'`B [FComment ReferenceCJaJ<@< [F Comment TextCJaJFoF [FComment Text Char CJaJtH Hj@H [FComment Subject5CJ\aJRoR [FComment Subject Char5CJ\aJtH \`\a90Medium List 2 - Accent 2 _HmH sH tH  o J_tgc0o!0 e a-size-largeB^2B O\0 Normal (Web)#dd[$\$*oA*  highlightPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]  Kan, CarolqvKCkKCkKCkKCXkKCkYGYGӛYGYGYGu bbbe Y!&'`) 017GpOPQUXxZ ]`=flnrtvyz4|>}M~yāi҃ldUQqoq5JNV\cjqv|D 7 g ) { Q)CyZbxj?"  ^$$$&.u017GJ=OOP!Q#QfQhQQQTUPURUlUnUUUUUUUUXb\e=kDlhlpllllllm5mcm{mmmmmmmn%n7nXnZnnnnnno)oeoyoooooo1pOp]p_ppppq,q[q]qqqqq rr1r3rirrrrrrs-sHsjswssssss!t1t:tVtXtttttttt$ugu{uuuuuv5vHvZvvvvvww$xz/zFz\zuzzzzz{|3|U|||||=}U}X}}} ~"~O~s~~sU|ـƁVXj‚Ӄ?Y[mم6|͇0g eh߉͒ۓՔ ?UX˕іprstuvwxyz{|}~      !"#$%&'()*+,-./012346789:;<=>?@ABCDEFGHIKLMOPQRSTUWXYZ[]^_`abdefghiklmnoprstuwxyz{}~ TPTTX!#%D_e!! @ @ (  n  S ))?#" ? 0(  B S  ? e)>%u OLE_LINK1:CYC kkkXkkqv}qv/2d&g&(($*+*A.D.FF2G4GBHNH>_B_}ddee.h=hOmWm7q;qMqQqfqjq#s%sAsEsvvvvQwSwxyYzizzzzz{{{{||||}} $@Ddh%.@F<AQY~~MM YY `~y>I*|[ } ~{NPݨ1BZ@-UfxQnJG{ H*m t`'jW[hX#@L RE< 9r&#O-̴cr!1BM.1rl7D9D)D9D<XH nAI  Nk.ZQjyWHy_ bBu`z7a  %c-yf:uh'q&6kX2qZZIjyrvXa@t Y.{‰` d|rUx77| q/~ ^`.^`.^`.^`. ^`OJQJo( ^`OJQJo( ^`OJQJo( ^`OJQJo(hh^h`. hh^h`OJQJo(h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^h`o(. 8^8`hH. L^`LhH.  ^ `hH.  ^ `hH. xL^x`LhH. H^H`hH. ^`hH. L^`LhH.h ^`o(hH) ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH.^`OJQJo(hH^`OJQJ^Jo(hHop^p`OJQJo(hH@ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoP^P`OJQJo(hHh ^`o(hH)h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hH^`o() ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH.h ^`o(hH)h^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hH ^`OJQJo("  ^`OJQJo("  pp^p`OJQJo("  @ @ ^@ `OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  PP^P`OJQJo(" ^`CJOJQJo(^`CJOJQJo(opp^p`CJOJQJo(@ @ ^@ `CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(PP^P`CJOJQJo(h ^`o(hH) 8^8`hH. L^`LhH.  ^ `hH.  ^ `hH. xL^x`LhH. H^H`hH. ^`hH. L^`LhH.h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh ^`o(hH) 8^8`hH. L^`LhH.  ^ `hH.  ^ `hH. xL^x`LhH. H^H`hH. ^`hH. L^`LhH.h ^`o(hH) hh^h`OJQJo(h ^`hH)h ^`hH.h pL^p`LhH.h @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PL^P`LhH.h ^`o(hH) ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH.^`o() ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH. hh^h`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo( hh^h`OJQJo(^`o(. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.^`o(. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.^`o() ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH.h ^`o(hH) ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH.h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo( hh^h`OJQJo(h^`.hpp^p`.h@ L@ ^@ `L.h^`.h^`.hL^`L.h^`.hPP^P`.h L ^ `L.88^8`B*OJQJo(ph ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( hh^h`OJQJo(h ^`o(hH)*7anAI_@t<XH7|bBu`jyrX2qY.{)<RE~}|yf %cO-{ d|yW*m r!1.ZQ NuhqR;>`'l7W[hq/~@L.19r&**                                                               *d6yP׸.| V3F>ؠl֗                                                                                                                              u|"        ss9Cz_cAuSe=2:f{LEn#`jY#~Mey2Z6 41&Q Q z_cP z_c3 |a |a  yEn#`8z_cA j-olz_c%^|a  jbz_c`]sz_c}S{|a TA|a S[5!S~xv |a Zp" j-T_" j-$A&po'ct)|a >bP+\^^+K),En#`rx- j-GU-En#` j-41 1 W2pt3$4a+5S^7|a [85Nw9z_cEq:_f= j-W,)@z_cCl@tA|a +YHSpI j-VbDJ4*KA&kM#~MzN>fOBwzQSCQ|a LvRz_cRE"Sz_c3S|a ZTVWp (Y j-2ZQ0]&]|a %]S~ ^ j-d^ j-N_a j-arcb41 b|a z_cUcHXdz_c.fA&:fC if|a `hg#~M(gS(g{)mjpt3pjJ;kEn#`9JMkz_cI%ukK x:fGy|a 5/y{|a mlaWQ)Wq& z: ~ 1|Sbn@,Kpq }r O%,J/O/Y/55}6q: A;E<j+@GJJdMFQwS(_V X ZO\]r`"i>k^s}wuzwz3|!4,-$Q`a)e>M<JV^ Skf134a9[F)]M#a o;)2~H }nONJcyy" <&|pG)e{@4$%@,\@p@UnknownTreasure, Janet G*Ax Times New Roman5Symbol3. *Cx Arials BureauGrotesqueThreeSevenCourier New;. *Cx Helvetica5. .[`)Tahoma?= *Cx Courier New;WingdingsA$BCambria Math"1h`iG`iGRFD;k|D;k|!'4 2qHP ?J/2!xx BScenario Title: Weight loss and amenorrhea in a 17 year-old femaleDEBAdminSin Fai Lam, Chun Chiang*                           ! " # $ % & ' ( ) Oh+'0 ( H T ` lxDScenario Title: Weight loss and amenorrhea in a 17year-old female DEBAdminNormalSin Fai Lam, Chun Chiang2Microsoft Office Word@@J>]b@N:T@N:TD;՜.+,D՜.+,|8 hp  Kings College|k CScenario Title: Weight loss and amenorrhea in a 17year-old female Title 8@ _PID_HLINKSAUw6https://www.cdc.gov/growthcharts/clinical_charts.htm)  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry F S]UTData 1TableM%WordDocument*SummaryInformation(DocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q