| Patient’s understanding of migraine | Patient to have a clear understanding of migraine and the patient’s role in managing the condition | Patient education | GP |
| Diagnosis of migraine | Patient to undergo clinical assessment | Diagnostic criteria for migraine with and without aura Awareness of differential diagnosis Exclusion of serious differential diagnoses | GP / other specialist |
| Assessment of risk for differential diagnosis of migraine | Patient to undergo appropriate clinical assessment and tests to exclude serious differential diagnoses of migraine c | Patient to undergo as appropriate the following: Clinical history and examination Blood tests Brain neuro-imaging Referral to specialist | GP / other specialist |
| Nutrition Awareness of dietary triggers for migraine in sensitive individuals | Healthy eating pattern, low fat diet Avoidance of dietary triggers for sensitive migraineurs | Patient education OR As per Lifescripts action plan Balanced dietary advice incorporating avoidance of triggers | GP to monitor Patient to implementDietician to advise |
| Physical Activity Awareness of the beneficial effects of exercise on migraine prophylaxis Development of an exercise programme to meet both healthy lifestyle and migraine prophylaxis requirements | Your target:At least 30 minutes walking or equivalent 5 or more days per week | Patient exercise routine | Patient to implementGP to monitor Physiotherapist to advise |
| Alcohol Awareness that alcohol can trigger a migraine in sensitive individuals | Your target:≤ standard drinks per dayIdeal:≤ 2 standard drinks per day (men)≤ 1 standard drinks per day (women) Avoidance of alcohol trigger | Reduce alcohol intakeAvoidance of alcohol triggersPatient education | Patient to manageDietician to adviseGP to monitor |
| Patient’s understanding of hayfever | Patient to have a clear understanding of hayfever and the patient’s role in managing the condition | Patient education | GP |
| Diagnosis of hayfever | Patient to undergo clinical assessment | Symptoms SneezingItching: Nose, eyes, ears, palateRhinorrhoeaPostnasal dripCongestionAnosmiaHeadacheEaracheTearingRed eyesEye swellingFatigueDrowsinessMalaiseSnoringFrequent sore throatsConstant clearing of the throat, cough Signs Pale nasal turbinates, Clear nasal dischargeNasal crease Deviation or perforation of the nasal septum Retraction and abnormal flexibility of the tympanic membrane Injection and swelling of the palpebral conjunctivae, with excess tear production. Dennie-Morgan lines: prominent creases below the inferior eyelidAllergic shiners: dark circles around the eyes. Oropharyngeal “Cobblestoning: streaks of lymphoid tissue on the posterior pharynx Tonsillar hypertrophyMalocclusion (overbite)High-arched palate | GP / other specialist |
| Testing in hay fever | Patient to undergo appropriate clinical testing | Total serum IgE Total blood eosinophil count Skin prick testing: immediate hypersensitivity testing.False negatives with concurrent administration of antihistaminesRisk of anaphylaxis Allergen specific immunoglobulin CT scan paranasal sinuses: evaluating acute or chronic sinusitis | GP / other specialist |
| Assessment of red flags for hay fever | Patient to undergo appropriate clinical assessment to exclude serious differential diagnoses of hay fever | Red flags Unilateral nasal symptoms Bloody nasal dischargeNosebleeds Pain and nasal blockage Crusting Nasal deformity due to perforated septum | GP / other specialist |
| Complications | Assessment of complications of hay fever | Acute or chronic sinusitisOtitis mediaSleep disturbance or apnoeaDental problems (overbite): Caused by excessive breathing through the mouthPalatal abnormalitiesEustachian tube dysfunctionPoor sleepPsychological problems including anxiety and depressionReduced performance at school or work | GPOther specialistPsychologist |
| Control of allergens | Minimisation of symptoms by the control of exposure of patients to allergens identified as triggers for symptoms | Provision of information relevant to control of allergen exposure. | GP Other specialist |
| 3. Medication | |||
| Medication review | Correct use of medications, minimise side effects Ensuring patient awareness and understanding of first and second line therapies used in the management of hayfever: their indications, contra-indications and side effects. First line therapiesAntihistaminesDecongestantsNasal spraysEye drops SteroidsMast cell stabilisersDecongestants Second line therapiesOral leukotriene inhibitors Third line therapiesImmunotherapy | Patient educationReview medications | GP and pharmacist to review and provide education |
| Antihistamines | Second generation non-sedative antihistamines Fexofenadine (Telfast)Loratadine ( Claratyne)Cetirizine (Zyrtec) First generation sedative antihistamines Dexchlorpheniramine (Polaramine) Promethazine (Phenergan) | Patient education Review medications | GP and pharmacist to review and provide education Gp to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Decongestants | Nasal decongestantsOxymetazoline Chemist’s Own DecongestantDimetapp 12 Hour Nasal spray Phenylephrine Nyal Decongestant Nasal Spray Sodium chloride Dimetapp Infant Nasal reliefFESS | Patient education Review medicationsBeware risk of rhinitis medicamentosa | GP and pharmacist to review and provide education GP to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Eye drops – | Mast cell stabilisersCromoglycate Cromolux eye drops Opticrom Lomide eye drops (Lodoxamide) Antihistamine eye drops Eyezep (Azelastine) | Patient education Review medications | GP and pharmacist to review and provide education GP to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Nasal Therapies | Nasal steroids FluticasoneAvamysBeconase 24 HourFlixonase Flixonase nasules BeclomethasoneBeconase 12 Hour MometasoneNasonex aqueous nasal spray BudesonideRhinocort Nasal cromoglycateRynacrom Metered Dose Nasal Spray Nasal antihistaminesAzelastineAzep Nasal Spray | Patient education Review medications | GP and pharmacist to review and provide education GP to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Second line therapies | Cysteinyl Leukotriene receptor antagonists Compete with cysteinyl luekotrienes at CysLT1 receptors Montelukast | Patient education Review medications | GP and pharmacist to review and provide education Gp to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Third line therapy | Immunotherapy for symptoms related to an identified allergen despite first and second line therapies and despite use of allergen control measures.Small risk of anaphylaxisOnsite resuscitation equipment needed | Patient education Review medications | GP / Allergen SpecialistPharmacist |
| Pharmacist role in TCA | Pharmacist to be aware of underlying disease process which merits pharmacological intervention | Pharmacist to review the indications for therapy, assess the side effects of therapy and monitor compliance with therapy GP and Pharmacy to reconcile prescribing and dispensing records | Pharmacist to monitor the progress of symptoms and or complications and provide appropriate advice to patient which may include advice to return to see the prescribing clinician and or general practitioner |
| Patient’s understanding of heart failure | Patient to have a clear understanding of heart failure and the patient’s role in managing the condition | Patient educationCompliance with medicationCompliance with dietary adviceCompliance with exercise adviceAvoidance of smoking and alcohol | GP/ dietician/ physiotherapist/ exercise physiologist |
| Diagnosis of heart failure | Patient to undergo appropriate clinical examination and tests | Symptoms OrthopnoeaParoxysmal dyspneaCough sobReduced exercise tolerance Clinical examination findings Third heart sound, sinus tachycardia pulmonary rales elevated JVP hepatomegaly pedal or dependent oedema Ancillary testsCXRECGEchocardiography | GP / other specialist |
| Assessment of risk factors for heart failure | Patient to undergo appropriate tests to exclude causes of secondary heart failure which include but are not limited to the following: ischaemic heart disease, valvular disease and hyperthyroidism, anaemia | Patient to undergo as appropriate the following: angiography, echocardiographyThyroid function tests Full blood count | GP / other specialist |
| 2. Lifestyle | |||
| Nutrition specific for heart failure | Minimise symptoms of heart failure by appropriate nutritional intervention | Low salt dietAbstinence from alcohol | Patient to implementGP to monitor Dietician to advise |
| Physical Activity | Minimization of symptoms of heart failure by appropriate exercise rehabilitation Awareness of the effects of heart failure on cardiac output and exercise tolerance Understanding of the role that exercise rehabilitation plays in the optimal management of hart failure | Patient exercise routine Your target:At least 30 minutes walking or equivalent 5 or more days per week | Patient to implementGP to monitorPhysiotherapist and exercise physiologist to advise |
| Alcohol in heart failure | Prevention of worsening of heart failure in patients with alcohol related heart failure | If heart failure developed as a result of alcohol then target should be complete abstinence | Patient to implementGP to advise and monitorDietician to advise |
| Standard medication regime | All patients should be on standard treatment regime (unless contra-indicated) | First lineACE-inhibitor + cardioselective beta blocker Second lineAbove + Aldosterone antagonist + ivabradine (if indicated) | GP /other specialist |
| Beta blockade | Understand the role that beta blockers play in heart failure Understand the indications, contra-indications and side effects of these medications. Monitor compliance, indications, contraindications and side effects of these medications | Patient education and monitoring | GP to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| ACE – Inhibitors (Or sartans licensed for the management of heart failure) | Understand the role that ACE – Inhibitors play in heart failure Understand the indications, contra-indications and side effects of these medications. Monitor compliance, indications, contraindications and side effects of these medications | Patient education and monitoring | GP to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Digoxin | Understand the role that digoxin plays in heart failure Understand the indications, contra-indications and side effects of these medications. Monitor compliance, indications, contraindications and side effects of these medications | Patient education and monitoring | GP to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Diuretics Including loops, thiazides and aldosterone antagonists | Understand the role that diuretics plays in heart failure Understand the indications, contra-indications and side effects of these medications. Monitor compliance, indications, contraindications and side effects of these medications | Patient education and monitoring | GP to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Ivabradine | Understand the role that ivabradine plays in heart failure Understand the indications, contra-indications and side effects of these medications. Monitor compliance, indications, contraindications and side effects of these medications | Patient education and monitoring | GP to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Monitoring | Early identification of impending worsening of heart failure or complications of treatment | Patient to weight regularly and to have regular blood tests especially to test for electrolytes. | GP / other specialist |
| Pharmacist role in TCA | Pharmacist to be aware of underlying disease process which merits pharmacological intervention | Pharmacist to review the indications for therapy, assess the side effects of therapy and monitor compliance with therapy GP and Pharmacy to reconcile prescribing and dispensing records | Pharmacist to monitor the progress of symptoms and or complications and provide appropriate advice to patient which may include advice to return to see the prescribing clinician and or general practitioner |
| 4. Psychosocial | |||
| Depression in heart failure | Awareness that patients with heart failure are at high risk of developing depression. Manage depression | Early identification and appropriate management of depression in patients with heart failure.Appropriate interventions to include Medication or cognitive behaviour therapy | GP to assess and initiate managementPsychologist to provide talking therapies |
| Patient’s understanding of cerebrovascular disease | Patient to have a clear understanding of cerebrovascular disease and the patient’s role in managing the condition | Patient education | GP |
Stroke action plan if relevant | Understand the symptoms of the onset of stroke. Understand the FAST test Develop action plan | GP and patient agree on FAST test use and action plan including the use of emergency ambulance service | GPPatient Pharmacist |
| 2. Lifestyle | |||
| Improved diet for patients with history of cerebrovascular disease | Secondary prevention and minimizing risks | Healthy eating pattern, low fat (especially saturated fat) diet, low in sodium, high in fruit and vegetables Patient education | GP o monitor Patient to implementDietitian to advise |
| Physical Activity as part of strategy to improve post stroke functioning and to reduce secondary risk | Increase regular exercise | Patient exercise routine Target:At least 30 minutes walking or equivalent 5 or more days per week | Patient to implementGP to monitor Physiotherapist / exercise physiologist to advise |
| 2. Biomedical | |||
| Cholesterol and stroke | Secondary prevention | Patients with a history of stroke and high cholesterol should be referred to dietician for further counseling and nutritional review | Patient to manageGP to monitor / adviseDietician to advise |
| Blood pressure | Reduction in blood pressure as part of secondary prevention of stroke Even in normotensive patients with stroke reduction in blood pressure confers benefits in terms of secondary prevention | Check every 6 months Target:< 135/85If diabetic target may be lower | GP |
| Diabetes screen | Exclude diabetes as a risk factor in cerebrovascular disease | Annual check | GP |
| If diabetic | Ensure HBA1C < 7.5 | Check every 6 months Consider medication to achieve this glycaemic target | GP |
| 3. Medication | |||
| Anti-hypertensive medication in stroke | Secondary prevention of stroke Medical optimization for stroke Use of ACE-inhibitors with diuretics as first line therapies | Patient education and monitoring Understand the role that antihypertensive medications play in reducing blood pressure and understand the need for optimal blood pressure control in stroke. Use of ACE-inhibitors with diureticsHas the most direct evidence Understand the indications, contra-indications and side effects of these medications. Monitor compliance, indications, contraindications and side effects of these medications | GP to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Anti-platelet medication | Secondary prevention and medical optimization for stroke TIA – dipyridamole for 2 years with aspirin lifelong Ischaemic stroke – Plavix lifelong | Patient education and monitoring Understand the role that anti-platelet medications play in preventing cerebrovascular disease Understand the indications, contra-indications and side effects of these medications. Monitor compliance, indications, contraindications and side effects of these medications | GP to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Cholesterol lowering agents | Secondary prevention and medical optimization for stroke All patients with TIA and ischaemic stroke should be on statins unless contra-indicated | Patient education and monitoring Understand the role that cholesterol lowering medications play in preventing cerebrovascular disease Understand the indications, contra-indications and side effects of these medications. Monitor compliance, indications, contraindications and side effects of these medications | GP to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| 4. Psychosocial | |||
| Depression | Understand the risk of developing depression and or anxiety disorders in any chronic disease in general and in cerebrovascular disease in particular Understand the role of screening for mood disorder and anxiety disorder Assess and provide management for any mood or anxiety disorder: management may include talking therapies and or medications. | Assessment. Management with either Medication or talking therapies. Referral to psychologist / psychiatrist as appropriate | GP to assess and initiate management Psychologist / psychiatrist |
| Patient’s understanding of polycystic ovarian syndrome | Patient to have a clear understanding of polycystic ovarian syndrome and the patient’s role in managing the condition | Patient education | GP | |||
| Diagnosis of polycystic ovarian syndrome | Patient to undergo clinical assessment Positive diagnosis made | Demonstration of the following Key features according to the Rotterdam consensus. 2/3 of oligomenorrhoea or amenorrhoea features of PCOS on uss examination > 12 follicles 3-12 mm ovarian volume > 10 cm *3echogenic ovarian stroma evidence of androgenic effects clinical evidence of androgenic effects includes acne hirsuitism male pattern baldness biochemical evidence of androgenic effects includesraised testosterone (free / total) raised androstenedione and reduced sex hormone binding globulin(note cocp raises shbg) additional clinical evidence supportive of PCOS obesity BMI > 30 hypertension additional biochemical evidence of PCOS Raised LHLH > 12 or three times fsh Hyperlipidaemia | GP / other specialist | |||
| Exclusion of differential diagnoses of (secondary) oligomenorrhoea | Patient to undergo appropriate clinical assessment and if appropriate subsequent imaging | Diagnoses to exclude Hypothalamic failure Exercise > 2 hours per day Work > 10 hours per dayDepressionAnorexia Kallman’s syndrome with loss of smell Pituitary causes Prolactin elevation –prolactinoma or dopamine antagonists Pituitary failure – SOL / sheehan’s syndromeLow TSH Thyroid diseaseHypothyroidism and hyperthyroidism can both cause amenorrhoea Adrenal disease Congenital adrenal hyperplasia ( 17 hydroxyprogesterone) Testosterone sectreting tunmour – > testosterone twice the upper limit of normal Ovarian causes Premature ovarian failure FSH > 20 Outflow tract causesAsherman’s syndrome – history of surgery or instrumentation of outflow tract Haematocolpos or haematometria | GP / other specialist | |||
| Awareness of complications | Patient to undergo appropriate clinical assessment and if appropriate subsequent imaging | Obesity Impaired glucose tolerance diabetes and gestational diabetes (especially in patients with a positive family history of diabetes and patients with central obesity) Adverse cardiovascular profile; hypertension hyperlipidaemia myocardial infarction and sleep apnoeaIncreased risk of first trimester fetal loss Increased risk of amenorrhoea and endometrial cancer | GP / other specialist | |||
| 2. lifestyle | ||||||
| Nutrition | low calorie low GI diet suited to PCOS and metabolic syndrome | Patient education | GPPatient to implementDietitian to advise | |||
| Weight | Weight loss of 5kg improves menstrual irregularities fertility and acne | MonitorReview 6 monthly | Patient to implementGP to monitorPhysio / dietician to advise | |||
| Physical Activity awareness of the positive benefits of physical activity in PCOS | Target of 45 minutes of exercise 5 times per week, with two thirds of exercise being aerobic and one third of exercise being resistance exercise | Patient exercise routine | Patient to implementGP to monitorPhysiotherapist to advise | |||
| 2. Biomedical | ||||||
| Vitamin D | Regular monitoring of Vitamin D levels – 50% of women with obesity are at risk of Vitamin D deficiency | 6 monthly check supplementation if neededDietary intervention if needed | Gp to diagnose and monitorDietician to advise re dietary interventions | |||
| 3./ A Medication | ||||||
| Insulin sensitisers | MetforminInitial dose 500mg bd Can increase to 850 mg bd Improves OvulationConceptionMiscarriage rate Acne Hirsuitism Facilitates weight loss | Patient education Review medications | GP and pharmacist to review and provide education Gp to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. | |||
| Anti-androgens | Improve acne hirsuitism and male pattern baldness spironolactone 50 mg bd cyproterone 50 mg daily flutamide 125 mg daily (half tablet 250)beware breast cancer inasteride – 5-alpha-reductase inhibitor 5 mg dailybeware breast cancer | Patient education Review medications | GP and pharmacist to review and provide education Gp to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. | |||
| Contraception in PCOS | Advantages Controlled monthly bleedingPrevention of endometrial carcinomaIncreased levels of shbg thereby reducing androgen exposure Disadvantages Cocp increases insulin resistance and the risk of diabetes Pop increases risk of conversion of gestational diabetes to frank diabetets. Options include use of anti-androgenic cocp e.g. use of cyproterone acetate or drospirenone Otherwise use lowest dose oestrogen possible e.g. loette / microgynon 20 Oral flucose tolerance tests prior to initiating oral contraception and every six months during oral contraceptive use. | Patient education Review medications | GP and pharmacist to review and provide education Gp to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. | |||
| Patient’s understanding of dysmenorrhoea | Patient to have a clear understanding of dysmenorrhoea and the patient’s role in managing the condition | Patient education | GP |
| Diagnosis of dysmenorrhoea | Patient to undergo clinical assessment and investigations as appropriate Investigations can include STD screenUSS pelvis(Indications for USS pelvis:Abnormal pelvic examinationRefusal of pelvic examinationPoor response to first line treatment) | Identification of risk factors: SmokingObesity Young ageFamily history Menorrhagia | GP / other specialist |
| Assessment of risk factors for secondary dysmenorrhoea | Patient to undergo appropriate tests to exclude serious differential diagnoses of secondary dysmenorrhoea | Exclusion of causes of secondary dysmenorrhoeaEndometriosisFibroidsPelvic inflammatory diseaseOvarian cystsEndometrial polypsCervical stenosisImperforate hymenCongenital Mullerian abnormalities | GP / other specialist |
| 2. Lifestyle / conservative management | |||
| Dietetic intervention in primary dysmenorrhoea | Minimisation of symptoms | Low fat Vegetarian diet | GP to monitor Patient to implementDietician to advise |
| Physical Activity Awareness of the benefits of exercise on dysmenorrhoea | The provision of advice and exercise therapy Minimisation of symptoms of dysmenorrhoea | Patient exercise routine Your target:At least 30 minutes walking or equivalent 5 or more days per week | Patient to implementGP to monitor Physiotherapist and exercise physiologist to advise and monitor |
| 2. Biomedical | |||
| 3. Medication | |||
| Medication review | Correct use of medications, minimise side effects Ensuring patient awareness and understanding of first and second line therapies used in the management of dysmenorrhoea: their indications, contra-indications and side effects. | Patient educationReview medications | GP and pharmacist to review and provide education |
| First line therapies | Regular oral paracetamolOral NSAIDS | Patient education Review medications | GP and pharmacist to review and provide education Gp to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Second line therapies | Combined oral contraceptive PillMirena system | Patient education Review medications | GP and pharmacist to review and provide education Gp to review at 6 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Patient’s understanding of hyperlipidemia and potential macrovascular complications including peripheral vascular disease, coronary heart disease and cerebrovascular disease | Patient to have a clear understanding of hyperlipidemia and the patient’s role in managing the condition | Patient education | GP |
| 2. Lifestyle | |||
| Nutrition | Optimize health normalize lipid profile by dietary intervention | Healthy eating pattern, low fat diet Patient education T LEAST five portions, and ideally 7-9 portions, of a variety of fruit and vegetables per day. THE BULK OF MOST MEALS should be starch-based foods (such as cereals, wholegrain bread, potatoes, rice, pasta), plus fruit and vegetables. NOT MUCH fatty food such as fatty meats, cheeses, full-cream milk, fried food, butter, etc. Use low- fat, mono-unsaturated or polyunsaturated spreads. INCLUDE 2-3 portions of fish per week, at least one of which should be oily (but, if you are pregnant, you should not have more than two portions of oily fish a week). LIMIT SALT to no more than 6 g a day (and less for children). If you eat red meat, it is best to EAT LEAN RED MEAT, or eat poultry such as chicken. If you do fry, choose a VEGETABLE OIL such as sunflower, rapeseed or olive. OR As per Lifescripts action plan | GP to monitorPatient to implementDietitian to advise |
| Weight | Achieve and maintain a normal weight to optimize health status in patients with hyperlipidemia | Your target:BMI ≤ 25Men waist ≤ 94 cmWomen waist ≤ 80 cm MonitorReview 6 monthly | Patient to implementGP to monitorDietician to advise |
| Physical Activity | Improved functional status and optimized health in patients with hyperlipidemia | Patient exercise routine Your target:At least 30 minutes walking or equivalent 5 or more days per week | Patient to implementGP to monitorPhysiotherapist / exercise physiologist to advise |
| 2. Biomedical | |||
| Cholesterol / Lipids | Optimal lipid profile to minimise health risks of hyperlipidemia | Annual checkYour target:Cholesterol ≤ 4.0 mmols/LTriglycerides ≤ 2.0 mmol/LLDL-C ≤ 2.5 mmol/LHDL-C ≥ 1.0 mmol/L The use of appropriate medication to achieve above targets | GP |
| Patient’s understanding of osteoarthritis | Patient to have a clear understanding of osteoarthritis and the patient’s role in managing the condition | Patient education | GP |
| Diagnosis of osteoarthritis | Patient to undergo clinical assessment | Activity related joint pain without significant morning stiffness with or without confirmatory x-rays | GP / other specialist |
| Assessment of risk factors for osteoarthritis | Patient to undergo appropriate tests to exclude serious differential diagnoses of osteoarthritis which include but are not limited to the following: Inflammatory arthropathyCrystal arthropathyTraumaCancerSepsis | Patient to undergo as appropriate the following: blood tests FbcEsrCrpRheumatoid factorANA / DsDNA / ENAX-raysFurther imaging as necessaryJoint aspiration as appropriate | GP / other specialist |
| Gout | prevent attacks | Learn avoidance of trigger foods and alcohol | GPPatient |
| Confirm presence of chronic hepatitis C | Check for active infection | Check hepatitis C PCR | GP |
| Education about hepatitis C | Good understanding of chronic hepatitis C | Patient education re- disease prognosis- potential transmission- treatment options- avoidance of alcohol | GPEducator |
| Determine genotype / viral load | Determine likelihood of response to treatment | Hepatitis C genotypeHepatitis C genotype | GP |
| Perform baseline examinations and tests | Detect signs of advanced liver disease or cirrhosis | Physical examinationInvestigations: FBC, coagulation, UEC, LFTAbdominal ultrasoundSpecialist referral if symptoms / signs of cirrhosis | GP Specialist |
| Detect other causes of liver disease | Need to optimise liver health | Check Hep A, Hep B, HIV serologyMetabolic liver disease: Iron studies, serum copper Exclude autoimmune hepatitis: ANA (antinuclear antibody), SMA (smooth muscle antibody) and LKMA (liver kidney microsomal antibody)Review alcohol intake, weight | GP Specialist |
| Detect and manage conditions that are contra-indications to interferon / ribavirin | Need to detect health problems prior to treatment | Check for: Uncontrolled depression, psychosisAutoimmune diseasesPregnant women or couples unwilling to comply with adequate contraceptionSevere concurrent medical disease: epilepsy, cardiovascular, poorly controlled diabetes, renal failure Decompensated cirrhosis | GP Specialist |
| Detect and manage conditions that are relative contra-indications to interferon / ribavirin | Need to optimise health prior to treatment | Check for:Haemoglobin <130 for men <120 for women, neutrophil count <1500/mm3platelet count <90,000/mm3 Raised creatinine Significant coronary heart disease: consider ECGUntreated thyroid diseases: check TSH | GP Specialist |
| Review medication if prescribed | Correct use of medications, minimise side effects, good adherence | Patient educationReview medications | GP to review and provide education, possible shared -care |
| HCC screening | Early detection of HCC | 6 monthly screening if cirrhosis- upper abdominal ultrasound- alpha-foetoprotein (AFP) | GP Specialist |
| Iron deficiency | alleviate deficiency, minimise impact of | Investigate, advise re; diet and supplementation. Address primary cause of iron deficiency | GP, Dietician |
| Digoxin therapy | manage, prevent side effects | monitor, educate re: toxicity | GP, Pharmacist |
| Incontinence | manage | refer and follow up to incontinence services; consider physiotherapy | GP. Physiotherapist |
| Constipation, chronic | manage | Investigate, self-management: rotate remedies, fibre and fluids. | GP |
| Blood pressure. | Aim for blood pressure 130/75. | Monitor, review medications, patient education. | GP, Health Promotion Officer |
| Chronic pain issues | manage, pain free | review pain self-management, ongoing physiotherapy | GP, Physiotherapist |
| Overweight. | Increase patient’s understanding of causes of being overweight, risks associated with going on some “diets”, realistic approach to safe weight reduction. | Patient education – lifestyle. | GP, Health Promotion Officer, dietician, Physiotherapist. |
| Glaucoma | minimize end organ damage | regular eye assessment and adjustment of specific therapymonitor as per specialist advice | Ophthalmologist |
| Mental Health Needs/ Problems | Goal | Planned Actions/ Tasks | Service Provider Responsible |
| Mental health problem. | Increase patient’s understanding of Mental condition. | Patient education. | GP |
| Maintain general health. | Prevention and health promotion | Review patient’s health risk’s as per Red Book and medication.e.g. Measure weight, height, BMI, blood pressure. Test total cholesterol profile. | GPHow often? once every 6-12 months. |
| Risk of acute hospital admission risks. | reduce risk of hospital admission | assessment, treatment, referral to psychiatrist if needed, education on self-monitoring. | GP |
| Need for healthy diet. | To maintain a healthy weight & healthy diet. | Increase understanding of healthy eating. Review diet. | GP |
| Need for physical activity. | To exercise for at least 30 minutes, most days of the week. | To establish a regular exercise routine. Reinforce activity. | An exercise program of patient’s choice. Reinforced by GP. |
| Psychiatric emergency. | Patient/ carers know what to do. | assess possible emergency, work out simple step by step plan | GP |
| Social burden of chronic disease. | prevent any social impact of chronic disease on patient’s life | assessment, support, education, referral to SOCIAL WORKER if needed | GP. |
| Anti-hypertensive medication | Understand the role that antihypertensive medications play in reducing blood pressure and understand the need for optimal blood pressure control in cardiovascular disease.Understand the indications, contra-indications and side effects of these medications. Monitor compliance, indications, contraindications and side effects of these medications | Patient education and monitoring | Gp to review at 6 monthly intervals or more frequently if indicatedpharmacist to review opportunistically at each dispensing.Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Patient’s understanding of cerebrovascular disease including peripheral vascular disease, coronary heart disease and cerebrovascular disease | Patient to have a clear understanding of cardiovascular disease and the patient’s role in managing the condition | Patient education | GP |
| Emergency action plans as relevant Chest pain action plan if relevant | Understand cardiac chest pain e.g pain associated with exercise, relieved by rest crushing retrosternal pain radiation to neck chin or left arm.Understanding associated symptoms of cardiac chest pain or angina e.g. acute nausea, vomiting, sweating , diarrhoea Develop action plan | GP and patient agree on written action plan on use of anti-anginals and when to ring the ambulance – especially when chest pain persists > 10 minutes after use of anti-anginal medication. | GPPatientpharmacist |
| Stroke action plan if relevant | Understand the symptoms of the onset of stroke.Understand the FAST test | GP and patient agree on FAST test use and action plan including the use of emergency ambulance service | GP, Patient |
| Peripheral arterial disease action plan if relevant | Understand the symptoms of chronic limb ischaemia and acute limb ischaemia. | GP and patient to agree on management plan for both acute and chronic limb ischaemia including appropriate use of emergency ambulance service | GP, Patient |
| Osteoporosis. Relevant history – consider risk factors for osteoporotic fractures ☞ | Limit effects of co-existing conditions and medications on bone loss | Monitor bone loss closely | GP |
| Patient’s understanding of osteoporosis | Patient to have a clear understanding of osteoporosis and the patient’s role in self management | Patient education | -GP-Patient |
| Pain management | Optimal pain management | Development of pain management program suitable to needs of patientOptions: analgesia, counselling, physiotherapy, occupational therapy | -GP-Physiotherapist-Patient |
| Nutrition | Maintain healthy diet. | -Assess dietary calcium & vitamin D intake.-Provide patient education re adequate intake & sources of calcium & vitamin D, including adequate sun exposure ☞-Consider calcium and vitamin D supplements if intake inadequate ☞ | -GP/Dietitian-Patient |
| Bone density | Maintain or increase bone mass density | DEXA scan ☞ | GP to advise |
| MobilityRecurrent falls | Optimise mobility Reduce risk of falls | Targeted & multi-faceted falls prevention programs ☞ | -Occupational therapist-Podiatrist-Physiotherapist-GP referral to falls exercise program/clinic-Patient |
| Migraine | prevent attacks | Learn avoidance of trigger foods and alcoholPreventive therapy and cervical mobilization to prevent risk of CIA | GPDietitian |
| Family history of bowel cancer | prevention | Educate about risk factors, importance of monitoring | GP |
| Asthma | ||||
| Patient’s understanding of asthma | Patient to have a clear understanding of asthma and the patient’s role in self management.. | Patient education (using patient education checklist).Ongoing asthma education by GP during regular reviews. | GPAsthma educatorPatient | |
| Minimise symptoms | Absent or minimal symptomsNo nocturnal or early morning symptoms.No exertional cough or wheeze.Absent or minimal reliever medication use (less than 3 times a week). | GP to assess asthma severity when patient is stable (asthma history checklist may help) and individualise treatment.Patient to keep symptom diary or PEFR diary.Patient to adhere to preventer medication routine.Patient to take continuing responsibility for their asthma and attend for regular review. | GPPatient | |
| Asthma action plan | Patient is in control of their asthma and not vice versa Patient is able to detect any deterioration in asthma and respond appropriately. Patient knows when to and how to obtain prompt medical attention | GP to formulate and provide a written asthma action plan and discuss with patient. Patient to use asthma action plan and have it reviewed regularly | GPPatient | |
| 2. Lifestyle | ||||
| Physical Activity | Your target:At least 30 minutes walking or equivalent 5 or more days per week | Patient exercise routine | Patient to implement | |
| 3. Biomedical | ||||
| Achieve best lung function | Achieve best quality of life Best lung function on spirometry Best PEFR | GP – intensive asthma therapy until best lung function achieved Patient to continue with intensive asthma therapy until best lung function achieved Patient to have regular spirometry to monitor lung function | GP Patient GP/AEPatient | |
| Maintain best lung function | Reduce the frequency and severity of asthma attacks Prevent the permanent development of abnormal lung function | GP help patient identify trigger factors Patient to avoid trigger factors if possible Patient to use preventers regularly | GP/Allergist Patient Patient | |
| 4. Medication | ||||
| Optimize medication program | Minimum medication used to maintain good symptom control No side effects or minimum side effects from medications | GP to supervise step down of medication after effective control in place for 6-12 weeks.GP/AE to organize regular spirometry Patient agree to return for planned review even when feeling ‘well’ | GP GP/AE Patient | |
| COAD. Understanding condition | Patient has a clear understanding of condition and their role in self management | Initial and ongoing COAD education | GP / Nurse/ AE |
| Optimize lung function | Minimize cough and breathlessness | Patient and doctor to assess and monitorConsider referral to physio / Pulmonary rehab program | Physio / Pulmonary rehab |
| Identify triggers | Avoid / Treat triggers, including infections;allergens; temperature change; dust; smoke. | GP to help patient to build awareness of COAD triggers and importance of prompt management of flare-ups | GP/ AE |
| Treatment plan for exacerbations | Patient is able to detect any deterioration in a condition and respond as per plan at first sign of worsening symptoms. Patient knows when to and how to obtain prompt medical attention. | Plan may include antibiotics, steroids, physio. Plan to be regularly reviewed by patient and GPConsider written action plan. | GP |
| Physical activity | Exercise >30 minutes walking or equivalent 5+ days per week | Take medication as prescribed before undertaking moderate or vigorous exercise | GP, Physio |
| Smoking | Complete cessation | Consider referral to Quit (QUITLINE 131848) / medication | GP |
| Maintain best lung function | Aim for best lung function on spirometry and best PEFR | Consider peak flow meter for home monitoring. Consider spirometry to monitor lung function | GP/ AE |
| Correct use of Medications | Optimal medication delivery & minimal side effects for good symptom control. | Use Spacer for inhalers. Patient to see GP for regular review. | GP/ AE/ Pharmacist |
| Vaccination | Flu / Pneumovax | Annually in AprilPneumovax 5 yearly (x 2) | GP |
| Chest infections | Treat appropriately | Make an appointment to see doctor if chest infection develops | GP |
| Heart failure | Optimal heart function. | GP to treat and manage appropriately | GP |
| Recent chest Xray | GP to consider if chest Xray needed | GP |
| Patient problems / needs / relevant conditions | Goals – changes to be achieved (if possible) | Required treatments and services including patient actions | Arrangements for treatments/services (when, who, and contact details) |
| 1. General | |||
| Patient’s understanding of premenstrual syndrome | Patient to have a clear understanding of premenstrual syndrome: its diagnosis, differential diagnosis and management | Patient educationUse of Patient education leaflet | GP PsychologistDieticianPhysiotherapist |
| Correct diagnosis of premenstrual syndrome | Positive diagnosis of PMS with identification of symptoms limited to luteal phase of cycle, with resolution of symptoms at or soon after menses. Symptoms can be both psychological and physical. Symptoms must adversely impact upon function | Completion of prospective symptom diary “Daily record of Severity of Symptoms” | GPPatient |
| 2. Lifestyle | |||
| Nutrition | Healthy eating pattern, low fat dietRegular, frequent (2–3 hourly), small balanced meals rich in complex carbohydrates.Understanding how diet can positively impact upon symptoms of PMS | Patient education | GPPatient to implementDietitian |
| Weight | Your target:BMI ≤ 25Men waist ≤ 94 cmWomen waist ≤ 80 cm | MonitorReview 6 monthly | Patient to monitorGPDietician |
| Physical Activity | Your target:At least 30 minutes walking or equivalent 5 or more days per week Understanding the role exercise specifically plays in the management if PMS | Patient exercise routine | Patient to implementGPPhysiotherapist |
| Smoking | Complete cessation | Smoking cessation strategy:Consider:- Quit- Medication | Patient to manageGPSmoking cessation advisor |
| Alcohol | Your target:≤ standard drinks per dayIdeal:≤ 2 standard drinks per day (men)≤ 1 standard drinks per day (women) | Reduce alcohol intakePatient education | Patient to manageGP to monitor |
| 2. Biomedical | |||
| Magnesium | Understand the role that Magnesium plays in the management of PMS Your target Magnesium within the normal range 0.75 – 1.2 mmol/l | Initial screen and annual checkAdvice about nutritional supplements (see below) | GPPharmacist |
| Calcium | Understand the role that Calcium plays in the management of PMS Your target Corrected calcium within the normal range 2.25 – 2.5 mmol/l | Initial screen and annual checkAdvice about nutritional supplements (see below) | GPPharmacist |
| Vitamin D | Achieve and maintain a healthy level of Vitamin D > 70 ng /ml | Initial screen and annual checkAdvice about nutritional supplements (see below) | GP Pharmacist |
| Cholesterol / Lipids | Your target:Cholesterol ≤ 4.0 mmol/LTriglycerides ≤ 2.0 mmol/LLDL-C ≤ 2.5 mmol/LHDL-C ≥ 1.0 mmol/L | Annual check | GP |
| Blood pressure | Your target:< 140/90If diabetic target may be lower | Check every 6 monthsDiscuss with GP | GP |
| Diabetes screen | Exclude diabetes as a risk factor in cardiovascular disease | Annual check | GP |
| If diabetic | Ensure HBA1C < 7.5 | Check every 6 months Consider medication to achieve this glycaemic target | GP |
| 3. Medication | |||
| Medication review | Correct use of medications, minimise side effects | Patient educationReview medications | GP and pharmacist to review and provide education |
| Simple analgesics Paracetamol and NSAIDS | Understand the role that simple analgesics play in the management of PMS when characterized by pain. Understand correct use and dosage regimesUnderstand the indications, contra-indications and side effects of simple analgesics Monitor compliance, indications, contraindications and side effects of simple analgesics | Patient education and monitoring | GPPharmacist GP to review at 3 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Over the counter remedies including nutritional supplements and herbal remedies MagnesiumCalcium / vitamin DAgnus castus Ginko Biloba | Understanding the role that nutritional supplements play in the management and amelioration of PMS Understand the indications, contra-indications and side effects of these nutritional supplements Monitor compliance, indications, contraindications and side effects of these nutritional supplements | Patient education and monitoring | GPPharmacist GP to review at 3 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Selective serotonin reuptake inhibitors(SSRIs) or serotonin noradrenaline reuptake inhibitors (SNRIs)- either luteal phase only or continuous. | Understand the role that SSRIs and SNRIs play in the management of PMS. Understand that the use of SSRIs and SNRIs in the management of PMS is not a licensed indication. Understand that the decision to use SSRIs or SNRIs in the management of PMS is made on the basis of greater likelihood of benefit compared to the lesser likelihood of harm Understand the indications, contra-indications and side effects of these medications. Monitor compliance, indications, contraindications and side effects of these medications | Patient education and monitoring | GP to review at 3 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Suicide risk | Awareness of the elevated risk of suicide in young people treated with antidepressants including SSRIs and SNRIs. | Patient education and monitoring | GP to review at 3 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| Suppression of ovulation by the use of late generation combined oral contraceptive pills containing either Drospirenone Desogestrel Gestodene Norgestimate | Understand the role that ovulation suppression plays in the management of PMS. Understand that the use of ovulation suppression in the management of PMS is not a licensed indication. Understand that the decision to use ovulation suppression in the management of PMS is made on the basis of greater likelihood of benefit compared to the lesser likelihood of harm. Understand that ovulation suppression renders a patient infertile for the duration of use and is not appropriate for those women who are trying to start a family. Understand the indications, contra-indications and side effects of these medications. Monitor compliance, indications, contraindications and side effects of these medications | Patient education and monitoring | GP Pharmacist GP to review at 3 monthly intervals or more frequently if indicated Pharmacist to review opportunistically at each dispensing. Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising. |
| 4. Psychosocial | |||
| Psychological treatments for PMS CBT | Understand the role that CBT plays in the management of PMS, especially in terms of reducing symptoms of anxiety, depression, and in terms of improving behavior and daily activities Understand the risk of developing depression and or anxiety disorders in any chronic disease in general and in cardiovascular disease in particular Understand the role of screening for mood disorder and anxiety disorder Assess and provide management for any mood or anxiety disorder: management may include talking therapies and or medications. | Assessment of mental state and the use of cognitive behavioral therapy Referral to psychologist / psychiatrist as appropriate | GP to assess and initiate management Psychologist / psychiatrist |
| Social isolation | Reduce social isolation | Provide CBT Improve social support E.g. referral to support group | GP / psychologist to advise and monitor |
| Poor dental health + chronic infection affecting general health and management of other chronic conditions | preventive activities, treatment, patient education | ongoing dental care | Dentist |
| B12 deficiency | alleviate deficiency, minimise impact of deficiency | Investigate, advise re; diet and supplementation. Address primary cause of deficiency | GP, Dietician |
| Cholesterol / Lipids | Your target:Cholesterol ≤ 4.0 mmols/LTriglycerides ≤ 2.0 mmol/LLDL-C ≤ 2.5 mmol/LHDL-C ≥ 1.0 mmol/L | Annual check, education re: risks of CVD | GP |
| Hypertension | BP within normal range (around 130/60) | Patient education, lower salt intake, regular check up, review medications | GP |
| Medication review | Safe use of medications, minimise side effects | Patient educationReview medications | GP to review and provide education, accredited pharmacist |
| Recurrent UTI | manage, prevent reoccurrence | Education about self-management: fluids intake, complimentary medicine. | GP |
| Age related issues | prevent any age related problems | Annual health assessment 75+ | GP |
| Hay fever, sinusitis, wheeze | manage | self-management – trigger avoidance; explore wheeze, seasonal asthma | chronic recurrent, anatomical background- educate, non specific allergy: trial of sinus rinse |
| Renal Impairment | manage | follow up specialist care, education re; diet for kidney health | GP, dietician |
| Vit D deficiency | alleviate, prevent complications | monitor, educate re: safe exposure to sun and supplementation | GP |
| Insomnia | manage | Assess, provide sleep hygiene education, refer to specialist if needed | GP |
| Warfarin (or similar) therapy | manage, correct dosing, prevent adverse events | monitor, educate re: diet and self-management | GP, Pharmacist, dietitian |
| Sleep apnoea | manage, prevent complications | follow up specialist care, education, support and re-assurance, re-enforce self-management | GP, Respiratory physician |
| Need for podiatry care, chronic foot pain, reduced mobility, foot problem affects posture. | Restore mobility, pain free | Assessment, podiatry care, consider specialist care | GP, Podiatrist |
| Alcohol consumption – above recommended level | Recommendations:Males: no more than 4 standard drinks per dayFemales: no more than 2 standard drinks per dayBetter – none | Reduce excessive alcohol intakePatient education: ongoing counselling, discuss referral to specialist | -GP to monitor-Counselling-Patient |
| Diabetes. | Increase patient’s understanding of Diabetes. | Patient education – lifestyle. | GP |
| Blood sugar level control | BSL in normal range < 6 fasting; <11 random. (at list aim to) | assess patient’s way of self-monitoring: support, educate. Monitor | GP |
| Blood pressure control. | Aim for blood pressure 130/75. | Monitor, review medications, patient education. | GP |
| Lipids | LDL-C <2.5 mmol/LTC < 3.5 mmol/LHDL-C > 1.1 mmol/LTryglyceride < 2.0 mmol/L | Monitor, review medications, patient education. | GP, Health Promotion Officer |
| Future complications. | To prevent/minimise the long-term effects of Diabetes on body. To manage medication. | Annual complication assessment & review. Adjustment of medication. | Consultant physician |
| Vestibular disorder | manage, reduce risk of falls, minimise debilitating impact on everyday life | Monitor, assist in managing the disorder, motivate patient to commence and continue prescribed exercise therapy, psychological support | GP |
| Diverticular disease | manage, prevent complications | Monitor, education re: diet for diverticular disease, regulation of dietary fibre. | GP, Dietitian |
| Reflux (GORD) | manage, minimise symptoms | Monitor, review medications / possible side effects, educate re: triggers of reflux / self-management | GP |
| Abnormal eating pattern | Manage | Obtain weight history, including initial motivation for weight loss or food restrictionsOpenly discuss and have an understanding of the complex food and weight-related behaviors of the patient so that appropriate supports can be integrated into the treatment plan. | GP, Dietitian |
| Eating pattern | Manage | Conduct a nutritional assessment: It is critical that the health care provider openly discuss and have an understanding of the complex food and weight-related behaviors of the patient so that appropriate supports can be integrated into the treatment plan. · Assess the patient’s beliefs and fears about food and weight gain Excessive focus on food and weight can be a maladaptive method of coping with stress. · Knowledge about nutrition and sources of information This information provides the basis for an individualized teaching plan about maintaining adequate nutritional intake. · Behaviors used to reduce calorie intake (dieting), to increase energy output (exercising), and generally to lose weight (vomiting, purging, and laxative abuse) | GP, Dietitian |
| Hypothyroid monitoring. | Monitoring of end organ damage inc systemic complications | Review patient’s status.Measure weight, height, BMI, blood pressure.Test total cholesterol profile.renal functionTFTseye health | GPHow often?once every 6-12 months. |
| Patient’s understanding of falls and falls risk | Patient to have a clear understanding of risk of falls and the patient’s role in diagnosing and managing the condition | Patient education | GP |
| Identification of high risk of falls | Patient to undergo clinical assessment after a fall or if identified as being at high risk of falls | Screening for risk factors for high risk of falls Risks for falls include Previous falls Medications: sedatives, hypnotics, antidepressants, anti-Parkinson’s drugs diuretics, antihypertensive drugs Cognitive state Abbreviated mental test score < 8 Psychological factorsAnxiety depression Reduced insight regarding mobility Age > 65 | GP / other specialist |
| Multifactorial risk assessment | Patient to undergo appropriate multifactorial assessment | Patient to undergo as appropriate the following: Identification of falls history Assessment of gait, balance mobility, and muscle weakness Assessment of osteoporosis risk Assessment of the older person’s perceived functional ability and fear relating to falling Assessment of visual impairment Assessment of cognitive impairment Assessment of urinary incontinence Cardiovascular examination Neurological examination Medication review | GP / other specialist |
| 2. Lifestyle | |||
| Nutrition | Healthy eating pattern, low fat diet | Patient education OR As per Lifescripts action plan Balanced dietary advice incorporating avoidance of triggers | GP to monitor Patient to implementDietician to advise |
| Intervention specific physical activity to reduce the risk of falls Strength and balance training | Patient to undergo Strength and balance training Those most likely to benefit are older people living in the community with a history of recurrent falls and/or balance and gait deficit. | Strength and balance training is recommended. Exercise programs to reduce falls should have a high balance challengeComponent This should be individually prescribed and monitored by anappropriately trained professional. | Patient to implement GP to monitorPhysiotherapist or exercise physiologist to advise |
| 2. Biomedical | |||
| Vitamin D | Target > 75 nmol / l | There is evidencethat vitamin D deficiency and insufficiency are common among older people and that, when present, they impair muscle strength and possibly neuromuscular function, via CNS-mediated pathways The use of combined calcium and vitamin D3 supplementation has been found to reduce fracture rates in older people Correction of vitamin D deficiency or insufficiency may reduce the propensity for falling | GP / Dietician / pharmacist |
| 3. Medication | |||
| Medication review in patients with high risk of falls | Minimisation of risk of falls by appropriate cessation of medication contributing to that risk | Older people on psychotropic medications should have their medication reviewed, with specialist input if appropriate, and discontinued if possible toreduce their risk of falling | GP Pharmacist Specialist |
| 4. Psychosocial | |||
| Cognitive impairment | Identification of cognitive impairment as a risk factor for falls and as a special consideration in the provision of exercise therapy for falls | Use of appropriate clinical assessment for the identification and diagnosis of cognitive impairment Abbreviated mental test Mini-mental state examination ACE-R | GPPsychologist Social worker |
| Patient’s understanding of chronic tension headache | Patient to have a clear understanding of chronic tension headache and the patient’s role in managing the condition | Patient education | GP |
| Diagnosis of chronic tension headache | Patient to undergo clinical assessment Positive diagnosis made | Demonstration of the following Key features Recurrent featureless headache which does not interfere with activity Headache Constant (not throbbing or pulsating) Bilateral No sensitivity to noise light smell or movement Able to work through headache. Activity does not worsen headache | GP / other specialist |
| Exclusion of red flag factors in the diagnosis of primary headache syndrome | Patient to undergo appropriate clinical assessment and if appropriate subsequent neuro-imaging | Red flags to excluderedflags pressure symptoms vomiting positional change acute vertigosharp pain on coughing sneezing straining or laughing or stooping headache worst ever / sudden onsetmaximum intensity within 5 minutes of onset new onset / unusual unilateral migraine that never occurs on the other side past history malignancy head trauma in the last 3 months immunosuppression HIV triggers exercise coughing /sneezing posture systemic features weight loss fever diarrhoea skin rashes malaise vomiting without known cause associated features neck stiffness local tenderness focal neurology higher cortical dysfunction change in personality impaired consciousness | GP / other specialist |
| 2. Lifestyle | |||
| Nutrition | Healthy eating pattern, low fat diet | Patient education OR As per Lifescripts action plan | GPPatient to implementDietitian |
| Weight | Your target:BMI ≤ 25Men waist ≤ 94 cmWomen waist ≤ 80 cm | MonitorReview 6 monthly | Patient to implementGP to monitorPhysio / dietician to advise |
| Physical Activity awareness of the positive benefits of physical activity on stress in general and secondarily on tension headaches | Your target:At least 30 minutes walking or equivalent 5 or more days per week | Patient exercise routine | Patient to implementGP to monitorPhysiotherapist to advise |
| Patient’s understanding of men’s health and erectile dysfunction | Patient to have a clear understanding of men’s health and erectile dysfunction | Patient education | GP/ specialist / psychologist / pharmacist |
| Patient’s understanding of atrial fibrillation | Patient to have a clear understanding of atrial fibrillation and the patient’s role in managing the condition | Patient education | GP |
| Diagnosis of atrial fibrillation | Patient to undergo ecg | Demonstration of absence of P waves with irregularly irregular QRS complexes | GP / other specialist |
| Assessment of risk factors for atrial fibrillation | Patient to undergo appropriate tests to exlude causes of secondary atrial fibrillation which include but are not limited to the following : ischaemic heart disease, mitral valve disease and hyperthroidism | Patient to undergo as appropraite the following: angiography, echocardiographythyroid function tests | GP / other specialist |
| Patient’s understanding of lumbago | Patient to have a clear understanding of lumbago and the patient’s role in managing the condition | Patient education | GP |
| Diagnosis of lumbago | Patient to undergo clinical assessment | Mechanical low back pain without radicular symptoms and without red flag symptoms | GP / physiotherapist / other specialist |
| Assessment of risk factors for lumbago | Patient to undergo appropriate clinical assessment to exclude serious differential diagnoses of lumbago | Red flag symptoms suggestive of alternative diagnosis Bilateral sciaticaSaddle anaesthesiaSphincter disturbanceFoot dropPain when lying flat Pain at night Weight lossFeverAcute kyphosis or scoliosisTrauma with osteoporosisAge of onset < 20 > 50Thoracic painConstant and progressive painMorning stiffness Exclusion of important differential diagnoses Including but not limited to the following: Inflammatory arthropathyCrystal arthropathyTraumaCancerSepsis The use of appropriate tests to exclude the above | GP / other specialist |
| Clozapine Patient’s understanding of Clozapine therapy and importance of compliance | Patient to have a clear understanding of therapy and its role in managing the condition | Patient education | GP, Clozapine Co-ordinator |
| Regular monitoring – blood count | monitor, prevent adverse events | Blood count done every 28 days | GPClozapine Co-ordinator |
| Regular metabolic screening – 6 monthly | monitor, prevent adverse events | Regular 6 monthly monitoring of: Height, Weight, WC, BMI, Lipids, Fasting glucose, U & E, LFT, Lipids | GP |
| Electrocardiogram | prevent adverse events | annual ECG | GP |
| Assessment performed on each visit or 28 days | prevent adverse events | General Health Check inc. Blood Pressure & Weight; Examine mouth & throat for signs of infection; Check temperature, heart sounds & pulse rate; Assess for any adverse side effect from Clozapine; | GP |
| GP absence management | maintain integrity of therapeutic monitoring | Discuss with Clozapine Co-ordinator, maintain current contact details | GP |
| CCF | Manage, achieve optimal cardiac function, prevent complications | Follow up attendances by cardiologist, discuss self-management: salt / fluid intake, lifestyle.Develop Action plan | GP, Cardiologist |
| HIV infection | manage | 1. Monitor, follow up specialist care and management, re-enforce education about condition.2. Discuss and re-enforce regularly what needs to be done in terms of self-monitoring and safety.3. Address impact of the condition on mental health and well-being. Ongoing counselling, support, discuss need for referral to psychologist. | GP, Specialist |
| Ischaemic Heart Disease | under control | Monitor, follow up specialist care, review medications, heart action plan | GP |
| Pacemaker | manage, prevent any adverse events | Follow up specialist’s care, emergency action plan | GP |
| Epilepsy | Manage | Increase patient’s understanding of epilepsy. Review and monitor management of epilepsy.Provide education re: self-management.Follow up specialist’s care.Carer’s education (if appropriate) | GP |
| Pharmacist role in TCA | pharmacist to be aware of underlying disease process which merits pharmacological intervention | pharmacist to review the indications for therapy , assess the side effects of therapy and monitor compliance with therapy GP and Pharmacy to reconcile prescribing and dispensing records | pharmacist to monitor the progress of symptoms and or complications and provide appropriate advice to patient which may include advice to return to see the prescribing clinician and or general practitioner |
| Smoking | Complete cessation | Smoking cessation strategy:Consider:- Quit- Medication | Patient to manageGP |
| Patient’s understanding of dermatitis | Patient to have a clear understanding of dermatitis and the patient’s role in managing the condition | Patient education | GP |
| Testing in dermatitis | Patient to undergo appropriate clinical testing | Serum IgE levels – elevated secondary to loss of suppressor lymphocyte activity Skin prick tests – positive to common allergens Skin prick testing: immediate hypersensitivity testing.False negatives with concurrent administration of antihistaminesRisk of anaphylaxis Radioallergosorbent testing (RAST) / allergen specific immunoglobulin- suggest that IgE is synthesised against the specific antigens of the house dust mite, pollens, cat and dog hair, food allergens Skin biopsy reveals chronic inflammation involving lymphocytes, mast cells, histiocytes, eosinophil degranulation White dermographism – rubbing skin elicits a simple white linear streak along the site of pressure with no erythema | GP / other specialist |
| Assessment of red flags for dermatitis | Patient to undergo appropriate clinical assessment to exclude serious differential diagnoses of dermatitis | Red flags Acute Superimposed bacterial infectionSuperimposed herpes simplex infection – eczema herpeticum Chronic Differentials includeMycosis fungoidesBCCSCC | GP / other specialist |
| Complications | Assessment of complications of dermatitis | Sleep disturbance Psychological problems including anxiety and depressionReduced performance at school or work | GPOther specialistPsychologist |
| Control of allergens | Minimisation of symptoms by the control of exposure of patients to allergens identified as triggers for symptoms | Provision of information relevant to control of allergen exposure. | GP Other specialist |
| Avoidance of triggers | Minimisation of symptoms by the control of exposure of patients to allergens identified as triggers for symptoms | Provision of information relevant to control of triggersE.g. Avoidance of irritantsPersonal protective equipmentGloves / Non-latex glovesPowder free gloves Avoidance of skin dehydrationCentral heating – dry heat Frequent washing Use of soaps and detergents | GP / other specialist |
| Confirm presence of chronic hepatitis C | Check for active infection | Check hepatitis C PCR | GP |
| Education about hepatitis C | Good understanding of chronic hepatitis C | Patient education re- disease prognosis- potential transmission- treatment options- avoidance of alcohol | GPEducator |
| Determine genotype / viral load | Determine likelihood of response to treatment | Hepatitis C genotypeHepatitis C genotype | GP |
| Perform baseline examinations and tests | Detect signs of advanced liver disease or cirrhosis | Physical examinationInvestigations: FBC, coagulation, UEC, LFTAbdominal ultrasoundSpecialist referral if symptoms / signs of cirrhosis | GP Specialist |
| Detect other causes of liver disease | Need to optimise liver health | Check Hep A, Hep B, HIV serologyMetabolic liver disease: Iron studies, serum copper Exclude autoimmune hepatitis: ANA (antinuclear antibody), SMA (smooth muscle antibody) and LKMA (liver kidney microsomal antibody)Review alcohol intake, weight | GP Specialist |
| Detect and manage conditions that are contra-indications to interferon / ribavirin | Need to detect health problems prior to treatment | Check for: Uncontrolled depression, psychosisAutoimmune diseasesPregnant women or couples unwilling to comply with adequate contraceptionSevere concurrent medical disease: epilepsy, cardiovascular, poorly controlled diabetes, renal failure Decompensated cirrhosis | GP Specialist |
| Detect and manage conditions that are relative contra-indications to interferon / ribavirin | Need to optimise health prior to treatment | Check for:Haemoglobin <130 for men <120 for women, neutrophil count <1500/mm3platelet count <90,000/mm3 Raised creatinine Significant coronary heart disease: consider ECGUntreated thyroid diseases: check TSH | GP Specialist |
| Review medication if prescribed | Correct use of medications, minimise side effects, good adherence | Patient educationReview medications | GP to review and provide education, possible shared -care |
| HCC screening | Early detection of HCC | 6 monthly screening if cirrhosis- upper abdominal ultrasound- alpha-foetoprotein (AFP) | GP Specialist |
| Irritable Bowel Syndrome | Increase patient’s understanding of condition. | Patient education. Support. | GP |
| Self-management | Develop self-management routine. | Assess patient’s way of self-monitoring: support, educate. Establish and maintain trigger avoidance routine. | GP |
| Dietary management | establish and maintain dietary regimen for best management of IBS | Work together with dietitian in order to establish and maintain dietary regimen for best management of IBS. | GP, Dietitian |
| Psychological management | Manage impact and psychological aspects of IBS | Assess the need of the patient for psychological services. If needed, involve psychologist under GP MHP awareness and discussion of the psycho-social factors that impact upon IBS symptoms awareness and discussion of the role of talking therapies to reduce symptoms of IBS awareness and discussion of the relationship between anxiety / depression and IBS symptoms | GP, psychologist |
| “Red Flags” | Exclude dangerous / underlying conditions | Investigate any “red flags”. Explain all the possibilities to the patient. awareness of the possible differential diagnoses of IBS including inflammatory bowel disease, coeliac disease, and in women ovarian cancer the arrangement of appropriate investigations relevant to the exclusion of serious differential diagnoses | GP |
| Medications | Medications management | a. Assess need for medications. Support and explanation.b. Review medications in order to identify potential triggers of IBS symptoms discussion and awareness of the indications and side effects of drugs relevant to the pharmacological management of IBS which include but are not limited to antispasmodics Mintec Mebeverine digestible fibre therapy Fybogel Pain management therapy tricyclic antidepressants second line agents selective serotonin receptor blockers | GP, Pharmacist |
| Chronic fatigue syndrome | Increase patient’s understanding of CFS. | Patient education. | GP |
| Impact of CFS on everyday life | Minimise symptoms | Monitor progress, introduce step up exercise routine if appropriate, dietary intervention conductive of maintaining maximum achievable life style | GP, Physio, Dietitian |
| Impact of CFS on mental health and well-being | Manage | Supportive therapy, assess need for GP MHP and a referral to psychologist | GP |
| STD concerns | Increase patient’s understanding and awareness of STD risk . | Patient education – lifestyle. | GP / patient |
| Minimisation of STD risk | prevention of STD | GP: education and counselling on safe sex practices patient: follow advice given | GP / patient |
| Investigation of STD risk | diagnosis of STD | Arrange appropriate tests which may include urine NAAT / swabs / serology | GP |
| Psychological aspects related to main problem | address any psychological co-morbidity whether related or not to STD risk | Assess psychological state and cognition supportive therapy \Referral to psychologist if needed | GP |
| Alcohol | Your target:≤ standard drinks per dayIdeal:≤ 2 standard drinks per day (men)≤ 1 standard drinks per day (women) | Reduce alcohol intakePatient education.Role of alcohol as psychosocial co-morbidity | Patient to manageGP to monitor |
| Illicit substances | prevent misuse | Assessment and harm reduction advice | GP |
| Smoking | Complete cessation | Smoking cessation strategy:Consider:- Quit- Medication | Patient to manageGP |
| General health monitoring | Maintain general health | Assess the risks and conduct preventive measures as per preventive health guidelines by RACGP | GP |
| Age over 30 years (over 50 years most at risk) – skin cancer risk | Address the risk | Monitor:Annual review- skin checkEducate re: self check | GP, Patient |
| Skin condition | Increase patient’s understanding of skin condition. | Patient education. Support. | GP |
| Self-management | Develop self-management routine | assess patient’s way of self-monitoring: support, educate.Use of cleansers and moisturizersIdentifying and avoiding triggers | GP |
| Coeliac Disease | Increase patient’s understanding of Chronic condition. | Patient education.In people with coeliac disease the immune system reacts abnormally to gluten (a protein found in wheat, rye, barley and oats), causing small bowel damage. The tiny, finger-like projections which line the bowel (villi) become inflamed and flattened. This is referred to as villous atrophy. Villous atrophy reduces the surface area of the bowel available for nutrient absorption, which can lead to various gastrointestinal and malabsorptive symptoms. Symptoms can also be caused by inflammation in other parts of the body.A number of serious health consequences can result if the condition is not diagnosed and treated properly | GP |
| Diagnosis and monitoring | Diagnose and appropriately monitor | assessment, monitoring – determine if gluten is avoided, patient education. | GP |
| General health monitoring. | Monitoring of general health | Review patient’s status.Measure weight, height, BMI, blood pressure.Test total cholesterol profile.Deficiencies due to malabsorption | GPHow often?once every 6-12 months. |
| Deficiencies due to malabsorbption | Manage, monitor | Monitor as above, assess possible symptoms, manage | GP, Dietitian, Specialist if needed |
| Medications. There are no medications for Coeliac disease, however, medications for other conditions may be required. | Correct use of medication, with minimal side-effects. | Education about medications. Home medicine review if needed. | Pharmacist |
| Future complications. Coeliac disease may affect all body systems. | To prevent/minimise the long-term effects of Coeliac disease on body and everyday life. To manage medication. | Annual complication assessment & review. Adjustment of medication. | GP, Consultant physician if required |