Hepatitis Checklist and Referral Form

Transcription

1 Contact details: Hepatitis Checklist and Referral Form GSTT KCH Other Address Westminster Bridge Rd London, SE1 7EH Denmark Hill London, SE5 9RS Phone Fax Referral Date ~[Today...] Patient Name ~[Forename] ~[Surname] Referring Clinician ~[Free Text: Referring DOB ~[Date Of Birth] Clinician?] Practice Details ~[Surgery Address Line Patient Address ~[Patient Address Block] 1] ~[Surgery Address Line 2] ~[Surgery Address Line 3] ~[Surgery Address Line 4] ~[Surgery Address Line 5] ~[Surgery Tel No.] Patient Tel ~[Telephone Number] Mobile ~[Mobile]~[Mobile Number] NHS Number ~[NHS Number] Hospital Number ~[Hospital Number] History How long has this patient been registered at your practice? Date exposure took place (if known)? How was the patient exposed/method of transmission (if known)? Has this patient been treated for hepatitis B or C in the past? Which centre? Have contacts/family members been informed? Advice given to patient regarding safe sex? Alcohol history (units/week): FAST questionnaire score: Smoking history: Final January 2015

2 Please complete hepatitis B+C serology for all patients and document results fully below Decision Matrix for Hep B (NICE) Hepatitis (Please tick) HBV REFER / INFORM SPECIALIST SERVICES IF: Surface antigen test positive* All individuals with HBV SAg +ve should be referred (the term carrier is misleading) eantigen positive PRIOR TO REFERRAL, PLEASE COMPLETE AND DOCUMENT/ATTACH Liver function tests, including AST and GGT DNA titre AFP HIV test Ultrasound *Individuals with HBV s Ag ve & cab +ve alone have cleared HBV spontaneously, repeat test to exclude false positive Final January 2015

3 HCV REFER / INFORM SPECIALIST SERVICES IF: HCV RNA positive** include level: PRIOR TO REFERRAL, PLEASE COMPLETE AND DOCUMENT BELOW Genotype Liver function tests, including AST and GGT AFP HIV test Ultrasound **15-20% of patients will clear HCV (HCV RNA negative) these individuals do not have chronic HCV and so do not need referral PLEASE perform HIV testing for all patients prior to referral. If not possible please DISCUSS need for HIV test Have patient s family members and close contacts been screened and vaccinated? ( YES/NO/NOT TESTED)] GP comments (including any other relevant information): ~[Free Text:Any other Comments including Relevant History?] Diabetes (year of diagnosis and recent HbA1c) Weight / BMI ~[ReadCode:22A~1Y~~R~Date Free Text~1]/~[ReadCode:22K~1Y~~R~Date Free Text~1] Blood pressure ~[Blood Pressure:1] Medications ~[Medication] Allergies ~[Allergies] Final January 2015

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5 Flow Chart for Management of Non Alcoholic Fatty Liver Disease (NAFLD) Figure for diagnosis and management of NAFLD in primary care. Adapted from BMJ article: Anstee Q, McPherson S BMJ 2011;343:d3897 Abnormal liver function tests and obesity +/- diabetes Liver screen and ultrasound scan Screen positive, for example hep B +ve Alternative Diagnosis, refer appropriately Screen negative and fat on ultrasound (likely NAFLD) Calculate fib 4 score Screen negative and no fat on USS Go through liver screen again, especially alcohol. IF still no clear diagnosis, refer to secondary care <1.3 low risk >1.3 high risk Mild NAFLD Refer to secondary care using form Life style advice (weight loss and attention to all CVS risk factors) Repeat LFTs and FIB 4 annually January 2015 approved at IAB meeting

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7 CHECK LIST AND REFERRAL FORM FOR ABNORMAL LFTs (INCLUDES LIVER SCREEN ) Contact details: GSTT KCH Other Address Westminster Bridge Rd London, SE1 7EH Denmark Hill London, SE5 9RS Phone Fax Referral Date ~[Today...] Patient Name ~[Forename] ~[Surname] Referring Clinician ~[Free Text: Referring DOB ~[Date Of Birth] Clinician?] Practice Details ~[Surgery Address Line Patient Address ~[Patient Address Block] 1] ~[Surgery Address Line 2] ~[Surgery Address Line 3] ~[Surgery Address Line 4] ~[Surgery Address Line 5] ~[Surgery Tel No.] Patient Tel ~[Telephone Number] Mobile ~[Mobile]~[Mobile Number] NHS Number ~[NHS Number] Hospital Number ~[Hospital Number] This form is not appropriate for decompensated liver failure. Please seek urgent advice from gastroenterology/hepatology for patients with abnormal LFTs in the following groups: 1. abnormal INR/abnormal albumin 2. symptomatic/ jaundiced/clinically unwell Patients with a significant alcohol history, and moderately abnormal LFTs (<1.5xnormal) should be given lifestyle advice and the test repeated at a 3 month interval in the first instance. Remember to consider and exclude drug induced causes of hepatitis. Take appropriate action following guidance from the BNF or the drug summary of product characteristics ( Remember Lambeth has a high prevalence of undiagnosed hepatitis B+C, have a low threshold for screening all patients. Please fill in the boxes below or attach all relevant results. Final version approved January 2015

8 HISTORY Alcohol consumption (units/week) FAST questionnaire score Smoking history Medications Diabetes? Include year of diagnosis, treatment and recent HbA1c. Clinical Values Date BP Weight and BMI Blood Results Date Date (Please show trend where possible) FBC U&E Lipid profile HbA1c ALT AST ALP GGT Final version approved January 2015

9 Bilirubin (isolated raised bilirubin in an asymptomatic patient is likely gilberts, a benign condition,please do not refer) INR (document warfarin therapy) Albumin Further investigations( Liver screen ) Date Hepatitis Serology A, B and C (if positive refer to hepatitis clinic using appropriate form) HIV Liver auto antibodies/ Coeliac Screen Iron studies (include ferritin) Ultrasound Do you suspect non-alcoholic fatty liver disease (fat on USS and centrally obese/diabetic patient)? Y/N Please see attached flow chart for management of NAFLD by GPs FIB 4 score = Please explain below Why are you referring this patient now? What action/investigations/advice you have given already? Any further information you feel relevant? Final version approved January 2015

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11 Upper GI patient pathway Discuss and counsel re: lifestyle factors Alcohol/Smoking/Weight loss Raise head of bed Timing of evening meal Medications (NSAID/Aspirin/Prednisolone/Bisphonates) Educational leaflet Patient presenting with symptoms (dyspepsia, epigastric pain, acid regurgitation) GP takes full history and clinical examination Consider cardiac and biliary disease Exclude red flags: Dysphagia Weight loss Upper abdominal mass Obstructive Jaundice Persistent Vomiting Iron deficiency anaemia Age>55 with unexplained and persistent recent-onset dyspepsia Refer NO by 2WW pathway Previous endoscopy and no new alarm symptoms First Diagnosis of Dyspepsia (no investigations) History of acute gastrointestinal bleeding (haematemesis/melaena) Immediate referral to on-call gastroenterology Consider continuing management according to previous findings and recommendations Good response initially and then symptoms return negative Offer empirical full dose PPI treatment** for 4 weeks H.Pylori test* Inadequate Response positive Treat H.pyloriFor treatment regimes, including 2 nd line and penicillin allergy refer to: (page 16) Step down PPI therapy to the lowest dose needed to control symptoms Discuss using treatment on an asneeded basis Long term management of dyspepsia: Annual review Encourage attempt to step down/stop PPI Advise return to self treatment with antacid/alginate if appropriate * 2 week wash out of all acid suppressant medications prior to h.pylori test **PPI Full dose Low Dose Offer H2 receptor antagonist High dose Lansoprazole 30mg OD 15mg OD 30mg BD Omeprazole 20mg OD 10mg OD 40mg OD Inadequate Response Second-line treatment failure Refer to secondary care

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13 REFERRAL FORM FOR UPPER GI SYMPTOMS Contact Details (indicate appropriate trust) GSTT KCH Address Westminster Bridge Rd London, SE1 7EH Denmark Hill London, SE5 9RS Telephone Patient Details: Name DOB Address Telephone number Referring clinician name Date of referral Practice Details (stamp/sticker) Describe patient s symptoms: Have you considered the 2 week wait criteria? Details of all treatments to date: H.pylori results and eradication regimes: (with dates)

14 Blood Results Hb Ferritin Coeliac Screen Renal Profile LFTs (please consider to exclude biliary disease) Result and Date Is this a referral for direct access endoscopy? Yes No Note: Patients need to be withdrawn from PPI 2 weeks prior to endoscopy

15 IRRITABLE BOWEL SYNDROME PATHWAY Patient presenting with lower gastrointestinal symptoms for at least 6 months suggestive of irritable bowel syndrome (IBS) WITHOUT ALARM SYMPTOMS: Abdominal pain (relieved by defecation, made worse by eating) (IBS-A) Bloating (IBS-B) Constipation (IBS-C) altered bowel frequency or stool form Diarrhoea (IBS-D) is common; overlap exists (IBS-M mixed) Rectal and Abdominal Examination Bloods: FCALP <60 FBC and ESR TFT (if appropriate) Coeliac screening (IgA ttga) Faecal calprotectin (FCALP) (if diarrhoea is predominant symptom) Stool MCS (if diarrhoea is predominant symptom, travel history, etc) FCALP Repeat in 4-6 weeks and consider IBS advice 150 >150 FCALP >150 Diagnose IBS and give information Abnormal blood tests and examination Anaemia Abdominal masses Rectal masses Inflammatory markers ESR Refer as new Inflammatory Bowel Disease via RMBS ALARM symptoms Unintentional weight loss Rectal bleeding A family history of bowel or ovarian cancer > 60 years of age, a change in bowel habit lasting more than 6 weeks with looser and/more frequent stools Symptoms suggestive of ovarian cancer Women (especially if 50yrs) who reports having any of the following symptoms on a persistent or frequent basis particularly more than 12 times per month: persistent abdominal distension (women often refer to this as 'bloating') feeling full (early satiety) and/or loss of appetite pelvic or abdominal pain increased urinary urgency and/or frequency Refer to Gynaecology Resources on DXS Secondary care Diet and Physical Activity Offer verbal and written lifestyle and physical activity advice IBS-B IBS-D IBS-M Refer to Dietitian for low FODMAP diet Consider IAPT referral Response to psychological therapy +/- TCAs (additional benefit over pain) IBS-C does not respond to low FODMAP diet, follow constipation management 1 st line pharmacological treatment Choice of single or combination of medications is determined by predominant symptoms. Recommend regular dosing and review treatment after 4-6 weeks initially then consider PRN for symptom control If IBS-A consider antispasmodic agent: Mebeverine 135mg tablets 1-2 three times a day If IBS-C consider laxative: Ispagel orange 1 sachet in water 1 3 times daily, preferably after If IBS-D consider antimotility agent: Loperamide 2mg capsules 2-4 caps twice a day max. 2 nd line pharmacological treatment (unlicensed ut recommended by NICE CG ) Refer to Gastroenterologist if all treatment fails If pain and IBS-D consider TCA: Amitriptyline 10mg-30mg at night Nortriptyline 2.5mg-10mg at night If pain and IBS-C consider SSRI Paroxetine 20mg once a day Fluoxetine 20mg once a day TCAs may be increased every 2 weeks if tolerated; if no or partial response; no more than 6-8 weeks trial 3 rd line pharmacological treatment If pain and IBS-C consider guanylate cyclase-c receptor agonist Linaclotide 290 micrograms once daily for 4 weeks If symptomatic even after a trial of 2 laxatives from 2 different groups for at least 6 months consider Prucalopride 2mg once daily for 4 weeks (Women only) Lubiprostone 24micrograms twice daily for 2 weeks Treatment discontinued if ineffective after indicated period Date reviewed: June 2014 Next review date : June

16 Diet and Lifestyle Advice (Ref: NICE CG61 Feb 2008) Have regular meals and take time to eat. Avoid missing meals or leaving long gaps between eating. Drink at least eight cups of fluid per day, especially water or other non-caffeinated drinks, for example herbal teas. Restrict tea and coffee to three cups per day. Reduce intake of alcohol and fizzy drinks. It may be helpful to limit intake of high-fibre food (such as wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice); REDUCE INSOLUBLE FIBRE. Reduce intake of 'resistant starch' (starch that resists digestion in the small intestine and reaches the colon intact), which is often found in processed or re-cooked foods. Limit fresh fruit to three portions per day (a portion should be approximately 80 g). People with diarrhoea should avoid sorbitol, an artificial sweetener found in sugar-free sweets (including chewing gum) and drinks, and in some diabetic and slimming products. People with wind and bloating may find it helpful to eat oats (such as oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day); INCREASE SOLUBLE FIBRE. Some people find taking probiotics regularly helps relieve the symptoms of IBS. However, there is no scientific evidence to prove that probiotics work and have beneficial health effects. If you decide to try probiotics, make sure you follow the manufacturer's instructions and recommendations regarding dosage, you should continue for at least 4 weeks to notice any difference. This is not available on prescription. Some people claim therapies such as acupuncture and reflexology can help people with IBS. Physical Activity (Ref: NICE CG61 Feb 2008) Aim for 30 minutes of moderate activity on 5 days of the week or more. South East London Area Prescribing Committee. A partnership between NHS organisations in South East London: Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark Clinical Commissioning Groups (CCGs) and GSTFT/KCH /SLAM/ & Oxleas NHS Foundation Trusts/Lewisham & Greenwich NHS Trust Date reviewed: June 2014 Next review date : June

17 ireferral FORM FOR SUSPECTED IRRITABLE BOWEL SYNDROME Contact Details (indicate appropriate trust) Address GSTT KCH Westminster Bridge Rd Denmark Hill London, SE1 7EH London, SE5 9RS Telephone Patient Details: Name DOB Address Telephone number Referring clinician name Date of referral Practice Details (stamp/sticker) Describe patient s main symptoms Details of all treatments to date Blood Results Result and Date

18 Hb Ferritin ESR Calcium (IBS-C) TSH Coeliac Screen Faecal Calprotectin and stool culture (IBS-D) Please explain below why you are referring this patient at this moment in time: What is the desired outcome of this referral, for the GP and for the patient:

19 PR Bleeding Referral Form Note to GPs: This form is specifically to refer patients under age 40 that you believe have HAEMORRHOIDS OR ANAL FISSURE to a nurse led clinic for confirmation of diagnosis and treatment. Contact details: GSTT KCH Other Address Westminster Bridge Rd London, SE1 7EH Denmark Hill London, SE5 9RS Phone Fax Referral Date ~[Today...] Patient Name ~[Forename] ~[Surname] Referring Clinician ~[Free Text: Referring DOB ~[Date Of Birth] Clinician?] Practice Details ~[Surgery Address Line Patient Address ~[Patient Address Block] 1] ~[Surgery Address Line 2] ~[Surgery Address Lin3 3] ~[Surgery Tel No.] Patient Tel ~[Telephone Number] Mobile ~[Mobile]~[Mobile Number] NHS Number ~[NHS Number] Hospital Number ~[Hospital Number] Referral Checklist 1. Have you considered 2 week wait criteria Yes No 2. Please indicate treatments used? E.g. Laxatives, topical therapies (local anaesthetics /astringents/topical steroids)/ GTN ointment- for anal fissures only 3. Date of first onset of symptoms: 4. Previous episode? (When/ How long?) 5. PR Bleeding Bright Red A Altered (Please tick box) Mixed with stool Coating the stool On the tissue In the pan 6. Pain Yes No Character 7. Mucous Yes No 8. Pruritus Ani Yes No

20 History of presenting complaint Please comment on presence of; Constipation, weight loss, change in bowel habit Include here what you consider to be the likely cause of bleeding Past Medical history Relevant Medications Including over the counter laxatives/ suppositories Allergies Family History Examination findings Digital Rectal Examination Essential prior to referral Further Investigations Including previous Proctoscopy or colonoscopy Notes Patients with first onset of symptoms after age 40 should be referred to the main colorectal clinics and have U&Es checked and documents for quicker consideration of CTE/ colonoscopy at the clinic Please use appropriate treatments for an adequate duration, for example GTN ointment for a maximum of 8 weeks for anal fissures only. Please kindly fill all sections of the form completely to avoid unnecessary delays