This table cannot be relied upon in the absence of: PA Medical Directive #8 - Gastroenterology
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1 Title and Number f Directive: Order Table PA-8: Gastrenterlgy This table cannt be relied upn in the absence f: PA Medical Directive #8 - Gastrenterlgy 1. OVERALL CONDITIONS - The PA may evaluate and prvide care fr patients presenting with the fllwing new r nging cnditins: Infectius Acute gastrenteritis Helicbacter pylri infectin Traveller s diarrhea Clstridium difficile infectin Diseases f esphagus: Gastresphgeal reflux disease (GERD) Esphageal dysmtility Diseases f stmach: Gastritis Dudenitis Delayed gastric emptying Peptic ulcer disease Diseases f small intestine and cln: Diarrhea Cnstipatin Malabsrptin Small bwel bstructin Crhn s disease Ulcerative clitis Irritable bwel syndrme Diverticular disease Clnic plyps Diseases f rectum and anus: Anrectal abscess Anal fissure Hemrrhids 1
2 Diseases f appendix and pancreas: Appendicitis Pancreatitis Diseases f biliary tract: Chlecystitis Chlelithiasis Miscellaneus cnditins: Hernias Lactse intlerance Celiac disease Nenatal jaundice GI symptms: Diarrhea, cnstipatin, abdminal pain, abdminal blating, flatulence, belching, nausea, vmiting, dysphagia. - Directives fr Peridic Health Exam apply, with adaptatins as identified in this rder table. - PA will discuss patient status and care with the physician n an nging basis as identified in the Practice Outline, and as necessary. Guidelines: - Anti-infective Guidelines fr Cmmunity-acquired Infectins, 2012 editin. - Canadian Assciatin f Gastrenterlgy Clinical Practice Guidelines, - Cmpendium f Pharmaceuticals and Specialties, Orders Indicatins and Cntraindicatins. 2. HISTORY AND PHYSICAL EXAMINATION - The PA may cmplete a fcused histry based n presenting cnditin. Histry f present illness. Pertinent past medical histry. - Fcused physical exam may include: Vital signs. Grwth in children. 2
3 ENT. Respiratry system. Cardivascular system. Abdminal exam. 3. COUNSELING - Dietary cunseling where indicated. - Lifestyle mdificatin as apprpriate. - Smking cessatin if applicable. - Envirnmental factrs if cntributry. - Supprtive therapy as apprpriate. - Educatin regarding cnditin. 4. LABS AND INVESTIGATIONS - The PA may rder any f the fllwing labs as necessary: CBC. TSH. Electrlytes. Renal functin (creatinine, BUN, A:Cr). Liver functin tests (AST, ALT, alk phs, GGTT, bilirubin). Pancreatic enzymes (lipase, amylase). Lactic acid. Serum albumin. ESR, hs-crp. PT, PTT, fibringen. H pylri serlgy. Hepatitis viral serlgy. Alchl/drug screen. 3
4 Stl culture Indicatins: - Bldy diarrhea. - Fever. - Tenesmus. - Severe r persistent symptms. - Recent travel t a third wrld cuntry. - Knwn expsure t a bacterial agent. - Presence f fecal leukcytes. Fecal ccult bld Indicatins: - Detectin f gastrintestinal bleeding. - Screening test fr bwel cancer. Fecal leukcytes Indicatins: - Assist in the differential f diarrhea disease. - Fecal leukcytes may indicate the fllwing: Bacteria that invade the clnic mucsa. Ulcerative clitis. Antibitic clitis. Pseudmembranus clitis. Stl sample fr va & parasites Indicatins: - Establish the diagnsis f intestinal parasitic infestatin r infectin. Clstridium difficile txins Indicatins: - Determine presence f txins prduced by C diff. 4
5 Upper gastrintestinal series Indicatins: - Evaluatin f the gastrintestinal tract fr the fllwing: Presence f neplasms. Inflammatry diseases. Ulcers. Diverticula. Obstructin. Freign bdy. Hiatal hernia. Gastresphageal reflux. Abdminal x-ray series Indicatins: - Assessment f intestinal bstructin. - Lcatin f freign bdies, free peritneal r retrperitneal air. - Displacement f the gastric air bubble. - Elevatin f diaphragm. - Displacement f the lateral and pelvic fat lines. - Disturbance f nrmal bwel patterns and renal shadw. Abdminal ultrasund Indicatins: - Presence f neplasms, cystic lesins, enlarged lymph ndes, bile ducts, abdminal abscesses, pancreatic mass r pseudcysts, gallbladder calculi, r any malignancies. Abdminal CT scan - In cnsultatin with supervising physician. Indicatins: - Diagnsing abdminal disease. - Investigating acute abdmen. 5
6 5. IMMUNIZATIONS - In accrdance with PA Medical Directive #1 Peridic Health Exam. Guidelines: - Canadian Immunizatin Guide Seventh Editin THERAPEUTICS Antibitics - The PA may prescribe the fllwing antibitics: Amxicillin. Azithrmycin. Ciprflxacin. Clarithrmycin. Levflxacin. Metrnidazle. Nrflxacin. Oflxacin. Indicatins: - Infectius gastrenteritis.* - Helicbacter pylri infectin.* - Traveller s diarrhea.* - Clstridium difficile.* * Nt all antibitics apply t all cnditins, apprpriate guidelines shall be utilized. Cntraindicatins: - As per individual medicatin guidelines in CPS. Histamine H2 antagnist - The PA may prescribe the fllwing histamine H2 antagnists: Cimetadine. Famtidine. Ranitidine. Indicatins: - Shrt-term treatment f active ulcers. - Dudenal ulcer prphylaxis - Gastric hypersecretry cnditins - GERD - Peptide ulcer disease. Cntraindicatins: - As per individual medicatin guidelines in CPS. 6
7 Prtn pump inhibitrs - The PA may prescribe the fllwing prtn pump inhibitrs: Esmeprazle. Lansprazle. Omeprazle. Pantprazle. Rabeprazle. Indicatins: - Ersive esphagitis. - Nnersive reflux disease. - Symptmatic GERD. - Helicbacter pylri eradicatin. - Preventin/treatment f NSAID-induced ulcers. - Dudenal ulcers. - Gastric ulcers. - Hypersecretry cnditins. Cntraindicatins: - As per individual medicatin guidelines in CPS. Tpical crticsterids - The PA may prescribe the fllwing tpical crticsterids: Hydrcrtisne cream. Indicatins: - Hemrrhids. - Anal itching. Cntraindicatins: - As per individual medicatin guidelines in CPS. Antidiarrheal agents - The PA may prescribe the fllwing antidiarrheal agents: Bismuth Lperamide. Indicatins: - Acute diarrhea. - Chrnic diarrhea. - Traveler s diarrhea. - Helicbacter pylri eradicatin (bismuth nly). Cntraindicatins: - Avid lperamide as primary therapy in patients with the fllwing: Acute dysentery. Acute ulcerative clitis. 7
8 Bacterial enterclitis. Pseudmembranus clitis assciated with brad-spectrum antibitic use. Cntraindicatins: - As per individual medicatin guidelines in CPS. Laxatives - The PA may prescribe the fllwing laxatives: Bwel evacuant: Plyethylene glycl-electrlyte slutin and bisacdyl. Sdium phsphates. Bulk-prducing laxatives (fiber supplements): Methylcellulse. Plycarbphil. Psyllium. Wheat dextrin. Lubricant laxatives: Mineral il. Osmtic laxatives: Glycerin. Lactulse. Plyethylene glycle Srbitl. Saline laxatives: Magnesium citrate. Stimulant laxatives: Bisacdyl. Dcusate and senna. Senna. Miscellaneus: Indicatins: - Cnstipatin. - Bwel preparatin befre clnscpy (plyethylene glycl and sdium phsphates nly). Cntraindicatins: - As per individual medicatin guidelines in CPS. 8
9 Castr il. Magnesium hydrxide. Stl sfteners - The PA may prescribe the fllwing stl sfteners: Dcusate. Dcusate and senna. Indicatins: - Stl sftener. Cntraindicatins: - As per individual medicatin guidelines in CPS. Antispasmdic: - The PA may prescribe the fllwing antistpasmdics: Scplamine butylbrmide. Indicatins: - Gastrintestinal spasm. Cntraindicatins: - As per individual medicatin guidelines in CPS. 7. REFERRALS - The PA may make a referral t the Family Health Team as apprpriate. - The PA may make a referral fr endscpy in cnsultatin with supervising physician. - The PA may make referrals t gastrenterlgy specialists in cnsultatin with supervising physician. 9
10 9. ABSENTEE NOTES The PA may write absentee ntes as apprpriate. 10
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