COMMUNITY HEALTH CENTRE POLICIES AND PROCEDURES

Transcription

1 COMMUNITY HEALTH CENTRE POLICIES AND PROCEDURES PRIMARY HEALTH CARE Medical Directive Title: DELEGATION AND MEDICAL DIRECTIVES FOR PAs Apprved By: Senir Leadership Team Number: PHC Created/Last Reviewed: September 2, 2009 / New Page: 1 f 100 Wrking Grup prviding input fr medical directive prttype: Principal Cntributrs (Supervising Physicians) Grup Members (Supervising Physicians) (Physician Assistants) Cnsultants Facilitating Develpment 1 Delegatin and Medical Directives Tlkit fr CHCs, December 2008

2 Page: 2 f 100 NOTES The term patient is used in this directive fr ease f reference, hwever; it is recgnized that in many CHC settings, the term client is used. THIS DOCUMENT IS A REVISION OF A PROTOTYPE. THE PROTOTYPE WAS DEVELOPED AS PART OF THE ONTARIO PHYSICIAN ASSISTANT PRIMARY CARE DEMONSTRATION PROJECT. THE DELEGATION AND MEDICAL DIRECTIVES TOOLKIT FOR CHCS IS AVAILABLE FROM THE ASSOCIATION OF ONTARIO HEALTH CENTRES WEBSITE AT Fr additinal infrmatin n delegatin and directives, see An Interprfessinal Guide n the Use f Orders, Directives and Delegatin available frm the Federatin f Health Regulatry Clleges f Ontari s website at Delegatin and Medical Directives Tlkit fr CHCs, December 2008

3 Page: 3 f 100 TABLE OF CONTENTS Order Tables Peridic Health Exams, Preventative Care 1a - Adult Female 10 1b - Adult Male 15 1c Prenatal Care 18 1d - Baby r Yunger Child 21 1e - Older Child r Adlescent 23 1f - Newly Arrived Canadian Adult r Child 25 Chrnic Disease Management Fllw-up 2a - Asthma, COPD 27 2b - Type 2 Diabetes 30 2c - Hypertensin 33 2d - Dyslipidemia 36 2e - Depressin 39 2f - INH Prphylaxis, Latent Tuberculsis 41 2g - Obesity 43 2h - Tbacc Dependence 45 2i - Hypthyridism 49

4 Page: 4 f 100 2j Osteprsis 51 2k - Ostearthritis 54 2l - Hepatitis C 57 2m Chrnic pain management 59 Acute Cmplaint Presentatins in Well Patient 3a - Acute Cmplaint Exam 61 3b - Urinary Tract Infectin Symptms in Female Patient 62 3c - Eye Inflammatin - Cnjunctiva 65 3d - Ear Discmfrt 67 3e - Upper Respiratry Tract Infectin (URTI) Symptms - Sinus 71 3f - URTI Symptms Thrat 74 3g - Vmiting r Diarrhea 77 3h - MSK Pain 80 3j Dermatitis 83 3k Vulvvaginitis 85 3l Allergic Rhinitis 87 Acute Cmplaint Fllw-up in Well Patient 4a - Verrucae Vulgaris (Wart) treatment 89

5 Page: 5 f 100 4b Pneumnia 91

6 Page: 6 f 100 CHC PA MEDICAL DIRECTIVES Title: CHC PA Medical Directive Number: PA MedDir-01 PHC Effective Date: May 1, 2009 Review due by: May 1, 2010 Spnsring/Cntact Persn(s) (Supervising Physicians) Orders: Appendix Attached: Yes NTitle: Order Tables The physician assistant may perfrm a histry, physical exam and diagnstics and therapeutics in accrdance with the rders and cnditins identified in this directive, including thse identified in the appended Order Tables: Peridic Health Exams, Preventative Care 1a - Adult Female 1b - Adult Male 1c - Prenatal 1d - Baby r Yunger Child 1e - Older Child r Adlescent 1f - Newly Arrived Canadian Adult r Child Chrnic Disease Management Fllw-up 2a - Asthma, COPD 2b - Type 2 Diabetes 2c - Hypertensin 2d - Dyslipidemia 2e - Depressin 2f - INH Prphylaxis, Latent Tuberculsis 2g - Obesity 2h - Tbacc Dependence

7 Page: 7 f 100 2i - Hypthyridism 2j - Osteprsis 2k - Ostearthritis 2l - Hepatitis C 2m Chrnic pain management Acute Cmplaint Presentatins in Well Patients 3a - Acute Cmplaint Exam 3b - UTI Symptms in Female Patient 3c - Eye Inflammatin - Cnjunctiva 3d - Ear Discmfrt 3e - Upper Respiratry Tract Infectin (URTI) Symptms - Sinus 3f - URTI Symptms - Thrat 3g - Vmiting r Diarrhea 3h MSK pain 3j Dermatitis 3k Vulvvaginitis 3k Allergic rhinitis Acute Cmplaint Fllw-up 4a - Verrucae Vulgaris (Wart) treatment 4b - Pneumnia. Recipient Patients: Appendix Attached: Yes N Title: Patients wh: Are registered t an attending physician wh has apprved this directive, and Meet the cnditins identified in this directive, including the Order Tables Authrized Implementers: PA(s) wh have: Appendix Attached: Yes N Title: A cmpleted Practice Outline, including successful cmpletin f the Level 1 Assessment Authrizatin frm the supervising attending physician t see the physician s patients using this directive Indicatins: Appendix Attached: Yes NTitle: Order Tables The PA is authrized t see patients prir t physician cntact at the time fr:

8 Page: 8 f 100 Peridic Health Exams, Preventative Care in accrdance with the cnditins identified in Order Tables 1a-f Acute Cmplaint Presentatins, if patients are well, in accrdance with the cnditins identified in Order Tables 3a-h. Well patients are defined as thse wh d nt have a cncurrent medical cnditin fr which they are receiving regular medicatin r medical treatment The PA is authrized t see patients diagnsed and assigned t the PA by the physician fr: Chrnic Disease Management Fllw-up r Acute Cmplaint Fllw-up in accrdance with the cnditins identified in Order Tables 2a-l and 4a-b respectively Cntraindicatins: See appended Order Tables. Cnsent: Appendix Attached: Yes N Title: The PA will btain cnsent t implement the physician s rders fr assessments, diagnstics and therapeutics under this directive in accrdance with any relevant CHC plicies and prcedures. If a patient r legal substitute decisin maker is unable t prvide cnsent, r if btaining prper infrmed cnsent exceeds PA cmpetencies, the PA will cntact the supervising physician prir t implementing any rders. PA will infrm patient f any cst that will be incurred prir t administratin f therapeutics that are nt cvered by MOHTLC. Guidelines fr Implementing the Order / Prcedure: Appendix Attached: Yes NTitle: Order Tables The PA will cnduct assessments accrding t Bates' Guide t Physical Examinatin. Bickley, L.S. 9th ed. Lippinctt; Philadelphia The PA will discuss the assessment and plans fr each patient with the attending supervising physician and relevant thers, in accrdance with the Practice Outline and this directive, unless the physician assigns therwise n a case by case basis Fr additinal guidelines, see appended Order Tables DOCUMENTATION AND COMMUNICATION: Appendix Attached: Yes N Title: The PA will dcument the histry, physical examinatin, diagnstics and therapeutics in the prgress ntes r n the relevant frm r sectin f the recrd in accrdance with CHC recrdkeeping plicies. S/he will ensure cntrlled acts are dcumented when perfrmed. The PA will dcument discussins regarding care between the PA and physician, including any direct rders btained frm the physician, in the relevant sectin f the recrd. When transcribing a medical directive rder, the PA will include the fllwing infrmatin in his r her sign-ff: Name and number f this directive, Name f the attending physician, and PA s printed name and signature. (Physicians may c-sign direct rders r medical directives transcribed by the PA at their discretin.)

9 Page: 9 f 100 Review and Quality Mnitring Guidelines: Appendix Attached: Yes N Title: Staff identifying any untward r unintended utcmes arising frm implementatin f rders under this directive, r any issues identified with it will reprt these t supervising physician and/r the Directr f Health Services as sn as pssible fr apprpriate dispsitin. This des nt include untward r unintended utcmes r issues that are pssible clinical sequelae regardless f whether a direct rder r directive is used. Administrative Apprvals: Appendix Attached: Yes N Identify the relevant apprval cmmittees and staff members, fr example: Administrative Staff and Cmmittees, C-implementer representatives etc.; and ensure a signed cpy f apprvals is maintained either in this sectin r as part f the Medical Directive recrd. See the prttype Administrative Apprval Frm fr a pssible template fr btaining apprval signatures. See Practice Outline Sectin 11 fr cnsideratins f wh ught t sign. Title: Apprving Physician(s)/Authrizer(s): Appendix Attached: Yes N Identify the primary supervising and supervising physicians and ensure a signed cpy f apprvals is maintained either in this sectin r as part f the Medical Directive recrd. Title: References Appendix Attached: Yes N Title: As identified in each Order Table

10 Page: 10 f 100 Order Table 1a Peridic Health Exam Preventative Care Adult Female This table cannt be relied upn in the absence f: CHC PA Medical Directive PA MedDir 01 Fr each patient, the PA will cmplete the full Preventative Care Checklist Frm assessment, unless the physician assigns therwise. The Assessment and Plans sectin will be discussed with the attending physician, unless the attending physician assigns therwise. Any abnrmal sign r symptm must be discussed by the PA with the supervising physician within 24 hurs f its determinatin. 1. Physical Exam Orders The PA may put an instrument*, hand, r finger: a. Beynd the anal verge. b. Beynd the labia majra. T perfrm a physical exam and t swab fr culture and sensitivity and t btain samples. Cntraindicatins: Recent surgery r trauma Pain, discmfrt r resistance n insertin Indicatins, Cntraindicatins and Guidelines If the cntraindicatins exist, the PA will nt prceed with the physical exam and will cnsult with the attending supervising physician. * The term instrument will nly refer t the fllwing: swabs fr culture and sensitivity, nasal speculum, vaginal speculum and cytlgy brush 2. Labs and Investigatins Indicatins: yrs Indicatins: 65 yrs Screening Mammgraphy See current CCPG fr High, Mderate and Lw Risk definitins. Ref: Canadian Task Frce n Preventive yrs q 1 yr (if mderate r high risk.) q 2 yrs (lw risk) < 50 yrs if high r medium risk fr hereditary breast cancer as per CCPG until age 69 q 1 yr (if mderate r high risk.) q 2 yrs (lw risk)

11 Page: 11 f 100 Health Hemccult multiphase Ref: Canadian Task Frce n Preventive Health 50 yrs q 1-2 yr If mderate r high risk as per CCPG - discuss case finding with MD 65 q 1-2 yr Cervical Cytlgy Screening Audimetry Indicatins If ever sexually active, until age 70 Cervical cytlgy screening shuld be initiated at 21 years f age fr wmen wh are r have ever been sexually active. If screening is nrmal, screening shuld be dne every 3 years. The absence f a T zne is nt a reasn t repeat a Pap test earlier than the recmmended interval. Screening may be discntinued after the age f 70 if there is an adequate negative screening histry in the previus 10 years (3-4 negative) Indicatins Fr anyne with a sensry r cnductive hearing lss either n exam r reprted fr mre than 1 mnth Psitive Weber r Rinne test. Cntraindicatins D nt perfrm and cnsult physician if: Patient has had a hysterectmy Hx f cervical / vaginal /vulvar carcinma. Recent Hx f irregular vaginal bleeding r sptting. Abnrmal cervix n speculum examinatin. Immunsuppressed patient Guidelines/Reference Current Ontari Cervical Screening Practice Guidelines Cntraindicatins Acute expsure t lud nise in the past 48 hrs. Cerumen visibly bstructing ear canal Recent Bartrauma. Guidelines Clinical Guidelines in Family Practice 3 rd ED

12 Page: 12 f 100 Gnrrhea /Trichmnas Screen Chlamydia Screen Fasting lipid prfile Fasting Bld Glucse Bne Mineral Density Varicella immunity Rubella immunity Indicatins Vaginal discharge, dysuria, abnrmal vaginal bleeding, pelvic pain r dyspareunia High risk patients (yuth 15-24, new r mre than 2 sexual partners in past year, multiple partners, past Hx f STI, vulnerable ppulatins) Mucpurulent discharge frm the endcervix, adnexal r uterine tenderness, cervical friability, cervical mtin tenderness 50, r pstmenpausal r sner if at risk as/preventative Care Checklist Frm Reference Q 3 yrs if 40 r sner and mre frequently if at risk as/preventative Care Checklist Frm Reference Indicatin yrs.: If at risk as/preventative Care Checklist Frm Reference Indicatin: Females f child-bearing age with unprven immunity (Hearing lss) Guidelines 2. Immunizatins yrs 65 yrs Influenza Vaccine Current Canadian Clinical Practice Guidelines Indicatins >/= 65 years: if n previus BMD in past 3 years If previus results nrmal, q 3 yrs If previus results abnrmal, discuss with physician If results shw n immunity, see immunizatin sectin belw fr rubella and varicella vaccine See Current Canadian Immunizatin Guide fr dsing and cntraindicatins q 1 yr, n patient request r if patient at high risk as/preventative Care Checklist Frm Reference, r capable f transmitting influenza t thse at high risk Annually

13 Page: 13 f 100 Tetanus/diptheria Vaccine. May be replaced with a 1 dse bster f dtap if nne previusly recrded in immunizatin recrd Rubella Vaccine (MMR) Varicella Vaccine (2 dses Pneumcccal Vaccine (plysaccharide) q 10 yrs Immunize if unsure f last tetanus immunizatin If patient unsure r n recrd f previus immunizatin If nil demnstrated rubella immunity n serlgical testing, with child-bearing ptential Indicatins: yrs Fr discussin in wmen f child-bearing age if NO histry f varicella infectin and/r n demnstrated immunity n serlgical testing High risk: immuncmprmised/chrnic disease (kidney, heart, diabetes, lung: asthma / COPD/chrnic brnchitis), Asplenia Institutinalized Same as yrs Nt required Indicatins: 65 yrs Discuss with physician if patient requests Resident f nursing hme Hmes fr aged and chrnic care facilities r wards. 65 yrs f age and lder regardless f medical cnditin. Meningcccal Vaccine Indicatins: yrs Given nly after discussin with supervising physician Indicatins: 65 yrs Given nly after discussin with supervising physician Tuberculsis Mantux Indicatins as per Canadian tuberculsis Standards guidelines, Public Health Agency f Canada and the Lung Assciatin High risk: immuncmprmised/chrnic disease (kidney, heart, diabetes, lung: asthma / COPD/chrnic brnchitis) Travel t endemic area Same as yrs

14 Page: 14 f 100 Immigrants and visitrs frm cuntries f high TB incidence within 2 years f arrival in Canada Recent cntact with active TB Students r emplyees wh require prf as part f a screening prcessstudents r emplyees wh require prf as part f a screening prcess Zster Vaccine T be discussed and ffered t anyne >60. T be discussed and ffered t anyne >60. HPV vaccine T be discussed and ffered t females age Only publicly funded fr females in grade 8

15 Page: 15 f 100 Order Table 1b Peridic Health Exam Preventative Care Adult Male This table cannt be relied upn in the absence f: CHC PA Medical Directive -PA MedDir 01 Fr each patient, the PA will cmplete the full Preventative Care Checklist Frm assessment, unless the physician assigns therwise. The Assessment and Plans sectin will be discussed with the attending physician, unless the attending physician assigns therwise. Any abnrmal sign r symptm must be discussed with the supervising physician within 24 hurs f its determinatin. 1. Physical Exam Orders The PA may put an instrument*, hand, r finger: c. Beynd the anal verge. T ffer a rutine digital rectal exam fr all men >50 years f age Cntraindicatins: Recent surgery, trauma Pain, discmfrt r resistance n insertin Indicatins, Cntraindicatins and Guidelines If the cntraindicatins exist, the PA will nt prceed with the physical exam and will cnsult with the attending supervising physician. * The term instrument will nly refer t the fllwing: swabs fr culture and sensitivity, nasal speculum 2. Labs and Investigatins yrs 65 yrs Hemccult multiphase Screening Audimetry 50 yrs q 1-2 yr If mderate r high risk as per CCPG Guidelines, discuss ther testing with MD Indicatins Fr anyne with a sensry r cnductive hearing lss either n exam r reprted fr mre than 1 mnth 65 q 1 2 yr Cntraindicatin Acute expsure t lud nise in the past 48 hrs.

16 Page: 16 f 100 Gnrrhea /Trichmnas Screen Chlamydia Screen Fasting lipid prfile Fasting Bld Glucse Bne Mineral Density Psitive Weber r Rinne test. Indicatins Discharge frm urethra, dysuria, bleeding High risk patients (yuth 15-24, new r mre than 2 sexual partners in past year, multiple partners, past Hx f STI, vulnerable ppulatins) 40, r sner if at risk as/preventative Care Checklist Frm Reference, repeat every 1-3 years Q 3 yrs if 40 r sner and mre frequently if at risk as/preventative Care Checklist Frm Reference If at risk as/preventative Care Checklist Frm Reference Cerumen visibly bstructing ear canal Recent Bartrauma. Guidelines Clinical Guidelines in Family Practice 3 rd ED (Hearing lss) Guidelines As per current Canadian Clinical Practice Guidelines Initiate at 65 years f age 3. Immunizatins Indicatins: yrs Indicatins: 65 yrs Influenza Vaccine Tetanus/diptheria Vaccine. May be replaced with a 1 dse bster f dtap if nne previusly recrded in immunizatin recrd See Canadian Immunizatin Guide Seventh Editin 2006 fr dsing and cntraindicatins q 1 yr, n patient request r if patient at high risk as/preventative Care Checklist Frm Reference r capable f transmitting influenza t thse at high risk q 10 yrs Immunize if unsure f last tetanus immunizatin Annually Same as 21-64

17 Page: 17 f 100 MMR (Measles, mumps, rubella) Vaccine If unsure, r n recrd f vaccinatin Nt required Varicella Vaccine (2 dses) yrs 65 yrs Fr discussin at patient request if NO histry f varicella infectin Discuss with physician at patient request Zster Vaccine T be discussed and ffered t anyne >60. T be discussed and ffered t anyne >60. Pneumcccal Vaccine (plysaccharide) Meningcccal Vaccine High risk as per Canadian Immunizatin Guide 2006 eg Immuncmprmised/chrnic disease (kidney, heart, diabetes, lung: asthma / COPD/chrnic brnchitis), Asplenia Institutinalized Given nly after discussin with supervising physician HPV vaccine T be discussed with males ages Nt publicly funded Resident f nursing hme Hmes fr aged and chrnic care facilities r wards. 65 yrs f age and lder regardless f medical cnditin. Given nly after discussin with supervising physician Tuberculsis Mantux Indicatins as per Canadian tuberculsis Standards guidelines, Public Health Agency f Canada and the Lung Assciatin High risk: immuncmprmised/chrnic disease (kidney, heart, diabetes, lung: asthma / COPD/chrnic brnchitis) Travel t endemic area Immigrants and visitrs frm cuntries f high TB incidence within 2 years f arrival in Canada Recent cntact with active TB Students r emplyees wh require prf as part f a screening prcess Same as yrs

18 Page: 18 f 100 Order Table 1c Peridic Health Exam, Preventative Care Prenatal Care This table cannt be relied upn in the absence f: CHC PA Medical Directive -PA MedDir 01 Fr each patient, the PA will discuss the assessment and plans with the attending physician, unless the attending physician assigns therwise..any abnrmal sign r symptm must be discussed with the supervising physician within 24 hurs f its determinatin. Orders 1. Histry and Physical Exam At the first prenatal visit, after a pregnancy has been cnfirmed, a cmplete physical exam, as indicated n the OMA/MOHLTC Antenatal Recrd 1 Cmplete the Antenatal Recrd Medical Histry in full Subsequent Antenatal visits shuld ccur every 4 weeks until 28 weeks, then every 2 weeks until 36 weeks and then weekly after that until delivery Every antenatal visit will begin with an assessment f gestatinal age, weight in kg, bld pressure, and urine dip fr prtein At each antenatal visit, measure the SFH, auscultate the fetal heart rate and use Lepld s maneuvres if able t determine fetal presentatin Frm 28 weeks gestatin, lwer limbs shuld be examined fr edema Any unique medical cmplaint shuld be assessed eg. back pain, haemrrhid, See OMA/MOHLTC Antenatal Recrds 1 and 2 See OMA/MOHLTC Antenatal Recrds 1 and 2 Indicatins, Cntraindicatins and Guidelines Pregnant patients shuld be referred t an accucheur (midwife, family dctr practising bstetrics r an bstetrician) with a cmplete cpy f the antenatal recrds and lab results if there is n such prvider available t prvide nging care at the Clinic An examinatin requiring a rectal exam r a pelvic exam shuld be discussed with the supervising physician prir t its initiatin

19 Page: 19 f 100 vaginal discharge, dysuria 2. Labs and Investigatins At the first antenatal visit, the Initial Labratry Investigatins n the Antenatal Recrd 1 shuld be rdered, and IPS testing discussed. Varicella immunity shuld als be determined at this time The IPS with bld wrk and US t measure nuchal translucency shuld be ffered and rdered t be perfrmed at a recgnized cmmunity r hspital clinic between 11 and 14 weeks f pregnancy, with infrmed cnsent After 14 weeks f pregnancy the patient wh missed the IPS shuld be ffered the MSS between 15 and 20+6 weeks An ultrasund shuld be rdered at weeks rutinely fr mrphlgy Repeat bldwrk shuld be rdered at weeks as per Additinal Lab Investigatins n the Antenatal Recrd 2. Patients wh are Rh negative shuld have bldwrk repeated at 28 weeks fr antibdies and then receive RhIg (Rhgam) A third trimester US may be rdered, in cnsultatin with the supervising physician, if the measured SFH r fetal psitin is nt within expected nrms. The PA may refer any pregnant patient directly t the hspital fr immediate assessment if the presentatin is beynd the scpe f the PA/supervising physician team, after cnsultatin with the supervising physician Wmen wh will be greater than 40 years f age at delivery shuld be ffered a referral t genetic cunseling befre 12 weeks gestatinal age fr cnsideratin f amnicentesis If a Pap test has been cmpleted within the last 6 mnths and all previus Pap tests have been nrmal, it may be deferred t the pstpartum visit If the IPS is declined, and the first day f the last menstrual perid is uncertain, a dating bstetrical US shuld be rdered as sn as pssible Screening fr gestatinal diabetes is cntrversial in healthy yung wmen wh are nt verweight. This rutine investigatin can be deferred with the agreement f the supervising physician and the patient

20 Page: 20 f 100 Vaginal-rectal swab fr Grup B strep shuld be dne fr all pregnant wmen between weeks gestatin US shuld be rdered fr the verdue pregnancy at 41 weeks, rdered at the 40 week visit 3. Immunizatins Influenza vaccine shuld be ffered t all pregnant wmen during influenza seasn 4. Medicatins (Renewals and Adjustments) Flic acid 5 mg may be rdered fr high risk patients wh have drug benefits t cver the cst in the first trimester Ferrus glucnate 300 mg OD with juice may be rdered fr irn-deficiency anemia Diclectin 2 tabs q hs fllwed by 1 tab BID prn may be rdered fr thse with symptms f hyperemesis graviderum Salbutaml HFA and inhaled crticsterids may be renewed fr patients with a cnfirmed diagnsis f asthma, previusly prescribed and regularly used Any ther medicatin requiring renewal during pregnancy must be discussed with the attending physician Dates may vary slightly due t weekends and hlidays, but US shuld be bked at a slightly earlier rather than later date if necessary Cntraindicatins as per the current Canadian Immunizatin Guide Cntraindicatins as per the current CPS

21 Page: 21 f 100 Order Table 1d Peridic Health Exam, Preventative Care - Baby r Yunger Child This table cannt be relied upn in the absence f: CHC PA Medical Directive -PA MedDir 01 Fr each patient, the PA will discuss the assessment and plans with the attending physician, unless the attending physician assigns therwise. Any abnrmal sign r symptm must be discussed with the supervising physician within 24 hurs f its determinatin. 1. Physical Exam Orders Indicatins, Cntraindicatins and Guidelines 0-5 yrs ld by fllwing evidence-based infant/child health maintenance guide Measure weight, height, head circumference and plt percentiles n the apprpriate grwth recrd fr bth bys and girls Visual acuity as per Snellen Chart when able t cmprehend therwise visin screening including crneal light reflex test and cver-uncver test fr strabismus BP nce between 2-3 years, nce at 4-5 years Injury preventin strategies reviewed at every visit and cunselling prvided as needed 2. Labs and Investigatins As/Rurke Baby Recrd As/ Grwth Recrds, Rurke Baby Recrd r WHO Grwth Recrds As/Rurke Baby Recrd As/Rurke Baby Recrd As/Rurke Baby Recrd Only in cnsultatin with physician 3. Immunizatins

22 Page: 22 f 100 Fllw Rurke baby recrd as per MOHLTC As/Rurke Baby Recrd and the current Canadian Immunizatin Guide and current Schedule f Publicly funded immunizatins in Ontari. May discuss alternative self-pay schedule fr newbrns with 3-4 dses meningcccal vaccine 4. Medicatins (Renewals and Adjustments) Only in cnsultatin with physician 5. Referrals Dentist/ptmetrist as indicated if has nt been seen within last year

23 Page: 23 f 100 Order Table 1e Peridic Health Exam, Preventative Care Older Child r Adlescent This table cannt be relied upn in the absence f: CHC PA Medical Directive -PA MedDir 01 Fr each patient, the PA will discuss the assessment and plans with the attending physician, unless the attending physician assigns therwise. Any abnrmal sign r symptm must be discussed with the supervising physician within 24 hurs f its determinatin. Orders 1. Histry and Physical Exam Indicatins, Cntraindicatins and Guidelines Histry including physical activity, diet, schl and hme, televisin, dental, drugs and alchl Cmplete physical exam as per Bates including measure bld pressure, weight, height, BMI and plt percentiles n the apprpriate grwth recrd fr bth bys and girls Visual acuity as per Snellen Chart Injury preventin strategies reviewed at every visit and cunselling prvided as needed 2. Labs and Investigatins As per the Greig Health Recrd N labratry investigatins are t be requested withut cnsultatin with physician. 3. Immunizatins

24 Page: 24 f 100 Adacel (dtap) Meningcccus HPV (Gardasil) Hepatitis B Varicella 4. Medicatins (Renewals and Adjustments) N medicatins may be prescribed withut cnsultatin with the physician 5. Referrals Dentist/ptmetrist as indicated if has nt been seen within last year Fr all children wh have received their primary series, between ages years Fr children ages years r years and high risk persns, usually received in schl Fr males and females age >9 years, nly publicly funded fr girls in grade 8 and usually received in schl Fr all children nt vaccinated previusly at age years, usually received in schl One bster dse if nt received and previusly immunized and in discussin with family and physician fr children nt previusly vaccinated and never having been infected with chickenpx

25 Page: 25 f 100 Table 1f Peridic Health Exam, Preventive Care - Newly Arrived Canadians Adult r Child This table cannt be relied upn in the absence f: CHC PA Medical Directive -PA MedDir 01 This Order Table applies t adults and children. Fr each patient, the PA will discuss the assessment and plans with the attending physician prir t the end f the visit, unless the attending physician assigns therwise. Any abnrmal sign r symptm must be discussed with the supervising physician within 24 hurs f its determinatin. Orders 1. Histry and Physical Exam Indicatins, Cntraindicatins and Guidelines Full histry including: Date f arrival in Canada, Place f rigin, Displacement/migratin histry, Stress f mving Past r present dmestic vilence/abuse Trauma histry Husing Past and Current Educatin/Occupatin Cmmunity supprt Immunizatin status, if knwn Full physical exam as per PHE See Evidence-based clinical guidelines fr immigrants and refugees, Kevin Pttie et al 2011 Cmplete histry and physical may ccur ver the curse f 2 visits within 2 weeks 2. Cunseling Settlement cunselling 3. Labs and Investigatins CBC with differential - Ferritin Children and Females nly Hep A(Ab), Hep B(Ab/Ag), Hep C

26 Page: 26 f 100 Varicella titre VDRL- patients >/= 15 yrs HIV with infrmed cnsent TSH Lead Children nly Stl O&P X 3 Urinalysis Fasting Glucse - >/= 40 yrs Hbg electrphresis - patient with previus diagnsis f anemia Fasting lipids if > 50 yrs ld TB testing. If psitive, ntify physician immediately and rder chest x-ray Pap test fr all wmen ever sexually active 4. Immunizatins In accrdance with the Current Canadian Immunizatin Guide, Part 3 Immunizatin f Persns New t Canada and Immunizatin f Children and Adults with Inadequate Immunizatin Recrds Only written dcumentatin f vaccinatin given at ages and intervals cmparable with the Canadian schedule shuld be cnsidered valid. All children and adults lacking written dcumentatin f immunizatin are started n a primary immunizatin schedule as apprpriate fr their age. 5. Medicatins (Renewals and Adjustments) Only in cnsultatin with physician, fllwing the Preventive Care Guide fr Immigrants/ Migrants frm Develping Cuntries

27 Page: 27 f 100 Order Table 2a Chrnic Disease Management Fllw-up Asthma, COPD This table cannt be relied upn in the absence f: CHC PA Medical Directive -PA MedDir 01 Orders 1. Overall Cnditins Indicatins, Cntraindicatins and Guidelines Patient diagnsed and referred by physician t PA, with medicatins started by physician prir t referral Directive fr Peridic Health Exam, Preventative Care applies, with adaptatins as identified in this rder table Visit schedule identified by physician n referral, then in cnsultatin depending n severity, stability f disease and medicatin requirements in accrdance with current Canadian Clinical Practice Guidelines and current Canadian Thracic Sciety Recmmendatins ( PA cnsults with the attending physician if patient s parameters change frm thse n referral, and will discuss patient status and care with the physician n an nging basis as identified in the Practice Outline, r n referral Histry and Physical Exam Cmplete a fcused histry asking specifically abut need fr rescue medicatin (puffers), amunt f puffer use, shrtness f breath, triggers, cugh, wheeze, sputum prductin, and tbacc use Review the asthma/copd actin plan if cmpleted Cnduct a full respiratry, ENT exam Ntify physician f any untward changes r side effects f medicatins as per the current CPS, Current Canadian Clinical Practice Guidelines Current Canadian Thracic Sciety Recmmendatins ( 3. Cunseling

28 Page: 28 f 100 Asthma/COPD actin plan Smking cessatin if applicable Envirnmental cntrls eg. Pets, dust, smke, carpets 4. Labs and Investigatins Measurements f lung functin, including PFT and Spirmetry/Canadian Clinical Practice Guidelines CXR in patients with acute exacerbatin f COPD, in cnsultatin with physician. 5. Immunizatins Pneumcccal plysaccharide vaccine At least nce with diagnsis and then with any reprted change in respiratry status As per current Canadian Clinical Practice Guidelines Current Canadian Thracic Sciety Recmmendatins ( Current Canadian Clinical Practice Guidelines Current Canadian Thracic Sciety Recmmendatins ( COPD patients receive pneumcccal vaccine at least nce in a lifetime and, if required, bsters as per current Canadian Immunizatin Guide. Asthmatic patients receive pneumcccal vaccine in cnsultatin with physician. As per current Canadian Clinical Practice Guidelines Current Canadian Thracic Sciety Recmmendatins ( Cntraindicatins as per Current Canadian Immunizatin Guidelines Influenza Vaccine Bth Asthmatics and COPD patients receive Influenza vaccine annually, in accrdance with Peridic Health Exam, Preventive Care 6. Medicatins (Renewals r Adjustments)

29 Page: 29 f 100 Any adjustments - nly in cnsultatin with physician. May renew any regular shrt acting and regular lng acting brnchdilatrs if the patient is stable, until the next visit. Cnsult with physician if there is a pattern f increasing use. May renew any regular inhaled crticsterids with instructins t rinse the muth after use May renew any regular regime f shrt acting and lng acting antichlinergics 7. Referrals Lung Health Assessment if available Smking cessatin cunsellr if available Pulmnary rehab fr COPD patients in cnsultatin with physician Unless suspect an adverse reactin as/ Current CPS r a new nset arrhythmia. Unless suspect an adverse reactin as/ Current CPS, r severe steprsis, a recent bne fracture r patient is diabetic with uncntrlled sugars r is hypertensive and/r BP is nt well cntrlled, r has had an acute psychtic episde, in which case, cnsultatin with the supervising physician is required Unless suspect an allergy Refer fr Lung Health Assessment n patient request, r if patient may benefit frm educatin and additinal supprt Refer t smking cessatin cunselr n patient request r if patient is still using tbacc prducts

30 Page: 30 f 100 Order Table 2b Chrnic Disease Management Fllw-up Type 2 Diabetes This table cannt be relied upn in the absence f: PA Medical Directive -PA MedDir 01 Orders 1. Overall Cnditins Indicatins, Cntraindicatins and Guidelines Patient diagnsed and referred by physician t PA, with medicatins started by physician prir t referral Directive fr Peridic Health Exam, Preventative Care applies, with adaptatins as identified in this rder table Visit schedule identified by physician n referral, generally apprximately every three mnths in accrdance with physician practice and Canadian Clinical Practice Guidelines, then in cnsultatin with physician, depending n severity, stability f disease and medicatin requirements PA cnsults with the attending physician if patient s parameters change frm thse n referral, and will discuss patient status and care with the physician n an nging basis as identified in the Practice Outline, r n referral 2. Histry and Physical Exam Fcused Histry including: Medicatin use and cmpliance, Self mnitring f bld glucse levels, hypglycemic episdes, Smking status, Alchl cnsumptin, Exercise, and diet Ntify physician f any untward changes r side effects f medicatins as per Current CPS, prir t end f visit See - Current Canadian Clinical Practice Guidelines,

31 Page: 31 f 100 Fcused physical, including BP, weight, and BMI every visit, Ft exam testing fr lss f sensatin with a 10g mnfilament annually, Sensry examinatin annually, CVS exam annually Ensure fundscpy cmpleted by an phthalmlgist r ptmetrist. 3. Cunseling Medicatin use and cmpliance, Self mnitring f bld glucse levels, Management f hypglycemia, Smking cessatin, Alchl cnsumptin, Exercise, and diet 4. Labs and Investigatins HbA1c ECG Screen fr adequate cntrl f serum lipids especially LDL <2.0, Screen fr nephrpathy: Serum creatinine, Every ne t tw years, as identified by physician Current Canadian Clinical Practice Guidelines Canadian Diabetes Assciatin Clinical Practice Guidelines Preventin and Management f Diabetes in Canada - Canadian Clinical Practice Guidelines Current Canadian Diabetes Assciatin Clinical Practice Guidelines Preventin and Management f Diabetes in Canada Every three six mnths Current Canadian Clinical Practice Guidelines In cnsultatin with physician Annually, if previus results were nrmal r at target. Every 3 mnths if nt at target Current Canadian Clinical Practice Guidelines Annually if egfr.60 ml/min and previus ACR nrmal, Cnsult physician if egfr<60 ml/min

32 Page: 32 f 100 egfr and randm urine test fr albumin t Creatinine rati 5. Immunizatins Pneumcccal plysaccharide vaccine Influenza 6. Medicatins (Renewals & Adjustments) Adjust r start any new diabetic medicatins in cnsultatin with physician Renew insulin sensitizers, insulin secretaggues, insulin r alpha-glucsidase inhibitrs, biguanides, DPP-4 inhibitrs Adjust basal insulin dses n a sliding scale by 2 units every 3 days until fasting plasma glucse is <7 7. Referrals Ophthalmlgist/ptmetrist. Diabetes teaching, Dietitian Chirpdist Nephrlgists, endcrinlgist, Diabetes Clinic, and cardilgist in cnsultatin with physician and/r persisting micralbuminuria In accrdance with Peridic Health Exam, Preventative Care See Current Canadian Immunizatin Guide Indicatin: HbA1C<0.80 and n episdes f hypglycemia See Current Canadian Clinical Practice Guidelines Unless suspect adverse reactin as/ Current CPS, uncntrlled r unstable bld sugars, r it is greater than fur mnths since last fasting bld wrk including HbA1c See Current Canadian Clinical Practice Guidelines In cnsultatin with physician Unless suspect adverse reactin as/ Current CPS, uncntrlled r unstable bld sugars, r it is greater than fur mnths since last fasting bld wrk including HbA1c Ophthalmlgist/ptmetrist - newly diagnsed diabetic patients r n eye care r 2 years r mre Diabetes teaching, dietician n patient request r if patient may benefit frm additinal supprt and health teaching Chirpdist fr assistance with ftcare, fr health teaching, r n patient request Current Canadian Clinical Practice Guidelines

33 Page: 33 f 100 Order Table 2c Chrnic Disease Management Fllw-up Hypertensin This table cannt be relied upn in the absence f: PA Medical Directive PA MedDir 01 Orders 1. Overall Cnditins Indicatins, Cntraindicatins and Guidelines Patient diagnsed and referred by physician t PA, with medicatins started by physician Directive fr Peridic Health Exam, Preventative Care applies, with adaptatins as identified in this rder table Visit schedule Patients with adequately cntrlled HTN with n cncurrent cnditins fllwed every12 mnths Patients with HTN and any f impaired fasting, glucse intlerance, smking, family Hx f premature CAD, dyslipidemia, sedentary lifestyle fllwed up at three t six mnth intervals as identified by physician n referral Current Canadian Hypertensin Educatin Prgram Recmmendatin: PA cnsults with the attending physician if patient s parameters change frm thse n referral, and will discuss patient status and care with the physician n an nging basis as identified in the Practice Outline, r n referral 2. Histry and Physical Exam Fcused histry t include: Medicatin cmpliance/side effects, Headaches, visin changes, Urinary changes, Chest pain, shrtness f breath, Diet, exercise rutine Fcused physical exam including CVS, Respiratry, PVS, BMI, and Ntify physician f any untward changes r side effects f medicatins as per current CPS prir t end f visit.

34 Page: 34 f 100 BP ( 3 readings averaged with electrnic BP machine after resting 5 mins) BP targets accrding t the Current guidelines in Canadian Hypertensin Educatin Prgram Recmmendatin 3. Cunseling Identify mdifiable/nn-mdifiable cardivascular risk factrs and cunsel lifestyle mdificatins as apprpriate Medicatin cmpliance cunselling 4. Labs and Investigatins CR, egfr BUN, Lytes, CBC Urinalysis ECG <140/ 90 in ffice Islated SBP < 140 DM <130/80, but with nephrpathy < 125 / 75 Chrnic Kidney Disease < 130/80 Cnsult with physician prir t end f visit if BP utside targets Current Canadian Hypertensin Educatin Prgram Recmmendatin: Annually In cnsultatin with physician fr case-finding fr silent ischemia Current Canadian Hypertensin Educatin Prgram Recmmendatin: Fasting Lipid Prfile Annually if lipids at target, every 3 mnths if nt at target Current Canadian Hypertensin Educatin Prgram Recmmendatin: Any ther Lab investigatins in cnsultatin with physician i.e. urine fr metanephrines, VMAs, crtisl Creatinine Clearance, CXR, 5. Immunizatins Current Canadian Hypertensin Educatin Prgram Recmmendatin:

35 Page: 35 f 100 In accrdance with Peridic Health Exam, Preventative Care 6. Medicatins (Renewals and Adjustments) After reviewing lab wrk that is less than ne year ld (CR, egfr BUN, Lytes, CBC Urinalysis) and it is within patient s parameters n referral r as identified by physician May renew any diuretics, beta- blckers, ACE Inhibitrs, ARB, and CCB until next visit. Any adjustments r new anti-hypertensives in cnsultatin with physician. 7. Referrals Dietician Exercise cunsellr, if available Smking cessatin cunsellr, if available Unless suspect allergy/sensitivity as per current CPS, uncntrlled/nt at target BP, a change in CR, egfr r CR Clearance, r a new arrhythmia cnsult physician Current Canadian Hypertensin Educatin Prgram Recmmendatin: Current Canadian Hypertensin Educatin Prgram Recmmendatin: Patient request r patients wh may benefit frm assistance with lw-salt diet r weight lss On patient request Fr smkers cntemplating quitting

36 Page: 36 f 100 Order Table 2d Chrnic Disease Management Fllw-up - Dyslipidemia This table cannt be relied upn in the absence f: CHC PA Medical Directive PA MedDir 01 Orders 1. Overall Cnditins Indicatins, Cntraindicatins and Guidelines Patient diagnsed and referred by physician t PA, with medicatins started by physician prir t referral Directive fr Peridic Health Exam, Preventative Care applies, with adaptatins as identified in this rder table Visit schedule identified by physician n referral PA cnsults with the attending physician if patient s parameters change frm thse n referral, and will discuss patient status and care with the physician n an nging basis as identified in the Practice Outline, r n referral 2. Histry and Physical Exam Fcused histry, including medicatin cmpliance and side-effects, exercise and diet, muscle pain, skin clur changes, abdminal pain, smking, chest pain and exertinal dyspnea Physical including cardivascular exam BP, BMI, waist circumference Cmplete a Framingham risk assessment and establish lipid targets. 3. Cunselling Identify mdifiable risk factrs (diet, exercise, besity, and smking) and discuss lifestyle changes Ntify physician f any untward changes r adverse reactins t medicatin as per current CPS prir t end f visit See Current Canadian Cardivascular Sciety psitin statement- Recmmendatins fr the diagnsis and treatment f dyslipidemia and preventin f cardivascular disease See Current Canadian Cardivascular Sciety psitin statement- Recmmendatins fr the diagnsis and treatment f dyslipidemia and preventin f cardivascular disease

37 Page: 37 f Labs and Investigatins Rutine fasting lipid prfile at least annually r as set by physician (ttal chlesterl, triglycerides, HDL-C, LDL-C, TC/HDL rati), fasting bld glucse annually Baseline LFT (AST, ALT),CK, hscrp (if indicated) prir t initiating pharmactherapy and repeat ALT between ne t three mnths f initiating therapy. Mnitr LFT annually thereafter Any ther lab investigatin requires an rder frm the physician, i.e. ap-lipprtein A&B, HbA1c (Des PA require and rder, cannt it just be as per the guidelines) An assessment f exercise capacity by graded exercise stress testing requires an rder frm the physician. Nn-invasive assessment f athersclersis such as determinatin f ankle-brachial index (ABI) and cartid imaging requires an rder frm physician. 5. Immunizatins In accrdance with Peridic Health Exam, Preventative Care 6. Medicatins (Renewals and Adjustments) Any new medicatins r adjustments require an rder frm the physician. May renew any regular statin, bile acid and/r chlesterl absrptin inhibitrs, See Current Canadian Cardivascular Sciety psitin statement- Recmmendatins fr the diagnsis and treatment f dyslipidemia and preventin f cardivascular disease See Current Canadian Cardivascular Sciety psitin statement- Recmmendatins fr the diagnsis and treatment f dyslipidemia and preventin f cardivascular disease See Current Canadian Cardivascular Sciety psitin statement- Recmmendatins fr the diagnsis and treatment f dyslipidemia and preventin f cardivascular disease See Current Canadian Cardivascular Sciety psitin statement- Recmmendatins fr the diagnsis and treatment f dyslipidemia and preventin f cardivascular disease See Current Canadian Cardivascular Sciety psitin statement- Recmmendatins fr the diagnsis and treatment f dyslipidemia and preventin f cardivascular disease If chlesterl prfile taken within the past 6 mnths and lipids at target, nrmal LFT and CK and patient reprts n adverse effect t medicatin as per current CPS.

38 Page: 38 f 100 fibrates, and niacin until the next visit 7. Referrals Dietitian Fitness cunsellr, if available Smking cessatin cunsellr D nt renew and cnsult with attending physician if any f the fllwing: Myalgia, abnrmal liver enzymes, r renal dysfunctin with fibrates On patient request, r if patient wuld benefit and is interested On patient request, r if patient wuld benefit and is interested On patient request, r if patient wuld benefit and is interested

39 Page: 39 f 100 Table 2e Chrnic Disease Management Fllw-up - Depressin This table cannt be relied upn in the absence f: CHC PA Medical Directive PA MedDir 01 Orders 1. Overall Cnditins Indicatins, Cntraindicatins and Guidelines Patient diagnsed and referred by attending physician t PA, with medicatins started by physician prir t referral Directive fr Peridic Health Exam, Preventative Care applies, with adaptatins as identified in this rder table Visit schedule identified by physician n referral PA cnsults with the attending physician if patient s parameters change frm thse n referral, and will discuss patient status and care with the physician n an nging basis as identified in the Practice Outline, r n referral 2. Histry and Physical Exam Cnduct a thrugh Mental Status examinatin, including medicatin cmpliance, scial circumstances, and drug and alchl intake Administer the PHQ-9 t determine treatment benefits 3. Cunseling Supprtive cunselling Ntify physician f any untward changes r adverse reactins t medicatin as per current CPS, prir t end f visit If any f the fllwing are present, ntify physician at the time f visit: Hmicidal r suicidal ideatin, hallucinatins, agitatin, delusins, disrientatin, wrsening md, affect r depressive symptmlgy Drug r alchl use If requested by physician. See Current Canadian Clinical practice Guidelines Include: Management strategies fr dealing with depressive symptms Review f crisis management plan that has been put int place

40 Page: 40 f 100 Medicatin cmpliance 4. Labs and Investigatins CBC, glucse, creatinine, electrlytes, lipase, TSH 5. Immunizatins As per Peridic Health Exam, Preventive Care 6. Medicatins (Renewals and Adjustments) May renew existing antidepressants until the next visit as lng as patient is stable, i.e. imprvement r n change in PHQ-9 r cmparable assessment Any adjustments r new prescriptins require an rder frm the attending MD. 7. Referrals Fitness cunsellr, if available Cmmunity supprt grups if available Cunsellr/psychlgist/scial wrker Addictins cunsellr, if available Psychiatrist If medicatin respnse is pr and symptms have nt imprved after 6 weeks f therapeutic dse and tests have nt been dne within previus 12 mnths, requisitin lab wrk and cnsult attending physician Mnitr antidepressant effect, ntify physician at time f visit f any changes in PHQ-9 cmparable assessment r any untward effects as per current CPS/CANMET Guidelines Patient request r if patient may benefit frm additinal assistance with exercise r supprt Fr clients interested in shrt-term cunseling Fr clients living with addictin and interested in cunseling In cnsultatin with physician fr refractry depressin and/r c-mrbid psychiatric illness

41 Page: 41 f 100 Order Table 2f Chrnic Disease Management INH Prphylaxis, Latent Tuberculsis This table cannt be relied upn in the absence f: CHC PA Medical Directive PA MedDir 01 Orders 1. Overall Cnditins Indicatins, Cntraindicatins and Guidelines Patient diagnsed and referred by physician t PA, with medicatins started by physician prir t referral, i.e. all patients with a psitive Mantux test, and a nrmal CXR wh meet the criteria fr treatment as per the current Canadian Tuberculsis Standards: Directive fr Peridic Health Exam, Preventative Care applies, with adaptatins as identified in this rder table Visit schedule mnthly clinical assessment required unless therwise specified by referring physician PA cnsults with the attending physician if patient s parameters change frm thse n referral, and will discuss patient status and care with the physician n an nging basis as identified in the Practice Outline, r n referral. Patients t be reviewed with physician at least n a mnthly basis References fr this table See current Canadian Tuberculsis Standards: 2. Histry and Physical Exam Fcused histry including: Side effects f medicatin paying particular attentin t anrexia, nausea, vmiting, fatigue, fever, numbness r tingling f the hands r feet and/r abdminal discmfrt/jaundice, pruritis Medicatin cmpliance Fcused physical exam including CVS, Respiratry, and Abdminal Exam 3. Cunseling Nncmpliance with medicatins must be discussed with attending physician prir t discharge

42 Page: 42 f 100 Preventative Maintenance Medicatin cmpliance, prper diet, rest 4. Labs and Investigatins Baseline liver functin tests (ALT and AST) Repeat AST and ALT ne mnth later 5. Immunizatins As per Peridic Health Exam, Preventative Care 6. Medicatins (Renewals & Adjustments) May renew: INH (isniazid) fr adults - 5mg/kg (maximum 300 mg/day) x 9 mnths, 12 mnths fr HIV psitive patients Pyridxine 25 mg p OD x 9 mnths, 12 mnths fr HIV +ve patients 7. Referrals Referral t TB clinic/respirlgist in cnsultatin with physician Reprt t Dept. f Public Health In high risk grups fr hepattxicity as per current Canadian Tuberculsis Standards INH and pyridxine can be renewed n a mnthly basis by the PA if the patient is cmpliant with treatment and tlerating the medicatin well Cntraindicatins fr INH include active tuberculsis, previus histry f adverse reactin t INH. And/r acute liver disease (NB. HBsAg and hep C psitivity are nt cntraindicatins unless assciated with chrnic active hepatitis cnsult physician Mandatry fr all patients receiving treatment

43 Page: 43 f 100 Order Table 2g Chrnic Disease Management Fllw-up Obesity This table cannt be relied upn in the absence f: CHC PA Medical Directive PA MedDir 01 Orders 1. Overall Cnditins Indicatins, Cntraindicatins and Guidelines Patient diagnsed and referred by physician t PA Directive fr Peridic Health Exam, Preventative Care applies, with adaptatins as identified in this rder table Visit schedule identified by physician n referral PA cnsults with the attending physician if patient s parameters change frm thse n referral, and will discuss patient status and care with the physician n an nging basis as identified in the Practice Outline, r n referral 2. Histry and Physical Exam Risk f Assciated Disease Accrding t BMI and Waist Size PA will assess and ask abut c-mrbidities and risk factrs; CVD, CAD, HTN, smking, lipid prfile, diabetes, sleep apnea, gallstnes, emtinal stresses, psych issues Assess patient s mtivatin fr weight lss including past attempts, supprt frm family / friends, bstacles, gals. Waist circumference (cm) Vital signs Histry and physical will include Framingham study including metablic syndrme BMI Waist less than r equal t 102 cm. (men) r 88 cm (wmen) Waist greater than 102 cm (men) r 88 cm (wmen) 18.5 r less Underweight -- N/A Nrmal n Increase risk -- N/A Overweight Lw High