Family Health Care Clinic, Inc.
Clinical Guidelines
Approved 08 /09
FAMILY HEALTH CARE CLINIC, INC.
CLINICAL GUIDELINES
Services that would be appropriate to treat in a primary care clinic:
 Localized infections
 Medication administration or refills
 Musculoskeletal pains not associated with recent trauma
 Needle sticks or puncture wounds
 Otitis media unless associated with a temperature over 104° or ear
drainage
 Paronychia
 Sinusitis
 Sore throat
 Stye
 Sublungual hematoma
 Suture removal
 Toothache without facial swelling or lymphadenopathy
 Urinary burning, frequency
Notwithstanding the above, the emergency room is the appropriate level of service for the following
conditions:








Abnormal or unstable vital signs
Abnormal motor, sensory,, <w tendon functions of recent onset
Eye pain or redness in the presence of contact lenses, foreign body, or trauma
Inability to be transferred into a wheelchair for transport
Laceration of eyelids, vermillion border of the hp or other complex facial laceration
Nose bleeding unable to be controlled by conservative measures
Psychiatric loss of control, intoxication, significant confusion or disorientation, or if mere
is a high probability of a need for security
Vaginal bleeding or pain in pregnancy or in any woman with a late or missed period
Diabetes Mellitus
The Primary Care Provider Recommended Guidelines:
Metabolic diseases characterized by hyperglycemia from defects in insulin, secretion, insulin action, or both.
I.
Coordinate Care and Anticipate Needs = Risk Factors
II.
Pathogenesis and etiologic classification of DM
A.
B.
Type I usually results in absolute insulin deficiency
1.
Occurs in 10% of diagnosed diabetics
2.
Acute onset of polydipsia, polyphagia, polyuria, weight loss, blurred vision, frequent infections
3.
Can occur at any age, but usually highest incidence in childhood and adolescence.
a.
Morbidity and mortality greatest in infants
b.
Fatigue, weakness, and listlessness
c.
Nocturnal enuresis
d.
More infections and sick days
e.
Ketoacidosis may occur
Type II characterized by resistance to the action of insulin and a relative or predominant impairment of
insulin secretion
1.
Occurs mainly in adults ≥ 30 years of age
2.
Obesity and increased abdominal fat
3.
Gradual onset with slow progression of symptoms
4.
Fatigue
5.
50% of patients will eventually need insulin
6.
Ketoacidosis rarely occurs
7.
Hyperglycemic hyperosmolar nonketotic coma predominant
a.
Blood glucose ≥ 600 mg/dl
b.
Often precipitated by drugs such as steroids and diuretics, therapeutic procedures,
chronic disease, and acute stress
8.
At risk for cardiovascular disease
9.
Type 2 diabetes in children
a.
Obesity
C.
b.
Family history
c.
Acanthosis nigricans in 90% of children, velvety hyperpigmented patches in
intertriginous area
d.
Polycystic ovarian syndrome
e.
Hypertension and dyslipidemia may occur
Other specific types of diabetes
1.
Genetic defects
2.
Exocrine pancreas
3.
Endocrinopathies
4.
Drug or chemical induced
5.
Infections
6.
Immune-mediated diabetes
7.
Other genetic disorders
D.
Gestational DM
E.
Impaired glucose tolerance
F.
1.
Asymptomatic, at risk for developing DM and cardiovascular disease
2.
Associated with insulin resistance syndrome
Macrovascular and microvascular complications
1.
2.
3.
Retinopathy
a.
Prevalence is related to duration and type of DM
b.
Occurs in most Type 1 patients after 20 years and in ≥ 60% of type 2 DM
Nephropathy
a.
Develops in 35 – 45% of type 1 DM and 20% in type 2 DM
b.
Diabetes in most common cause of ESRD in US
Neuropathy
a.
Peripheral, symmetric sensorimotor neuropathy which is usually only minimally
uncomfortable
b.
May have lancinating or burning pain
c.
Cardiovascular disease
d.
III.
Care in office or rapid treatment site – Diagnostic Criteria
A.
Family history of diabetes, hypertension, cardiovascular impairment, and renal manifestations
1.
2.
3.
4.
5.
B.
C.
Polydipsia, polyuria, and weight loss
Fasting plasma glucose of ≥ 126/mg/dl
2 hour plasma glucose of ≥ 200/mg/dl during an oral glucose tolerance test
Fatigue
Infections
Physical Examination
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
D.
Hx of gestational DM
Prior of previous pharmacological, nutritional, and self-management treatment plans
Dietary habits
History of smoking, hypertension, and obesity
Psychological, sociological and economic factors that may impact DM management
Symptoms of DM
1.
2.
3.
4.
5.
Compare height and weight with norms
Vital Signs
Examine skin
Ophthalmoscopic examination
Mouth and dental exam
Thyroid
Cardiovascular
Abdomen
Extremities including feet
Neurological
Diagnostic Tests
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
IV.
Increased prevalence of infections, cognitive impairment, and contracture of digits
(hammer toes and stiff fingers)
Screening
Random plasma glucose measurement
Fasting plasma glucose measurement
HbA1C
Diabetic retinopathy
Fasting lipid profile
Annual serum creatinine
Urinalysis
Microalbuminuria
Diabetic ketoacidosis
Educate patient, family, and caregiver about:
A.
Underlying pathologies and management plan
1.
2.
3.
4.
5.
6.
7.
Explain long-term complications
Patient to wear Medic-Alert tags
If applicable, discuss contraception and importance of glucose control before conception and
during pregnancy
Nutritional recommendations
Physical activity
Medication regimen
Insulin therapy, if applicable
B.
C.
How to recognize signs and symptoms of complications, and when to report to health care
professional, including:
1.
Hyperglycemia
2.
Hypoglycemia
3.
Skin breaks including diabetic foot ulcers
4.
Change in Blood pressure.
5.
Change in Weight
6.
Proteinuria
7.
Cerebral or visual disturbances.
Assess psychosocial factors, including:
1.
2.
3.
V.
Anxiety and depression.
Changes in lifestyle.
Changes in social roles.
D.
Coordinate development of treatment goals and plans with multiple caregivers
F.
Ensure timely referral to appropriate community resources and applications for public funding.
G.
Ensure that follow-up appointment is made and transportation is available.
Home health care may be suitable for patients who require skilled assessment and management of care
A.
To minimize out-of-home appointments for patients
B.
Blood pressure.
C.
Weight
D.
Proteinuria
E.
Cerebral or visual disturbances
F.
Medication management in home environment utilizing glucose monitoring
G.
Signs and symptoms of edema, including pulmonary edema.
H.
Patient is safe at home, with adequate caregiver available as needed
Hypertension
The Primary Care Provider Recommended Guidelines:
I.
II.
Coordinate Care and Anticipate Needs = Risk Factors
A.
B.
C.
D.
Family history of hypertension or vascular disease.
Personal history of cardiovascular or hypertensive disease
Personal history of tobacco use.
Diabetes
E
Renal infections
F.
Circulatory involvement
Care in office or rapid treatment site
A.
Hypertensive disorders are the most common medical complication
B.
Medically assess and stabilize preexisting blood pressure or renal disease:
1.
2.
3.
4.
5.
III.
Educate patient, family, and caregiver about:
A..
B.
Underlying pathologies and management plan
How to recognize signs and symptoms of complications, and when to report to health care professional,
including:
1.
2.
IV.
Assess blood pressure
Obtain urinalysis for protein urea.
Obtain blood sample for blood urea nitrogen, creatinine, uric acid, platelets and hemoglobin.
Assess edema.
Assess reflexes.
Blood pressure elevation >30 systolic or > 15 diastolic from baseline.
Assess home safety, needs, and capabilities
Routine Patient Visit Care
A..
Monitor progress:
1.
2.
3.
4.
5.
6.
7.
B.
Blood pressure.
Weight
Proteinuria
Intake and output
Cerebral or visual disturbances.
Signs and symptoms of edema, including pulmonary edema.
Nail beds, observing for cyanosis.
Assess psychosocial factors, including:
C.
4.
Anxiety and depression.
5.
Changes in lifestyle.
6.
Changes in social roles.
7.
Coordinate development of treatment goals and plans with multiple caregivers
D.
Ensure timely referral to appropriate community resources and applications for public funding.
G.
V.
VI.
VII.
Ensure that follow-up appointment is made and transportation is available.
Home healthcare may be suitable for patients who require skilled assessment and management of care, including:
A.
To minimize out-of-home appointments
B.
Blood pressure.
C.
Weight
D.
Proteinuria
E.
Intake and output.
F.
Cerebral or visual disturbances
G.
Signs and symptoms of edema, including pulmonary edema.
IH
Nail beds, observing for cyanosis.
I.
Patient is safe at home, with adequate caregiver available as needed
Educate patient, family, and caregiver about care requirements.
Clinical Indications for Inpatient Admission
A.
Uncontrolled hypertension (systolic >=160 mm Hg or diastolic >=010 mm Hg) with (any one of the
following):
1.
2.
3.
4.
5.
6.
7.
8.
Proteinuria > 100 mg/L on urine dipstick or > 1 g/24 hours
Rapid increase in serum creatinine to > 1.2 mg/dL
Platelet count <100,000/mm3
Evidence of microangiopathic hemolytic anemia
Elevated hepatic enzymes (alanine aminotransferase or aspartate aminotransferase)
Epigastric pain
Significant edema
Evidence of acute and progressing target organ disease (any one of the following):
a.
Hypertensive encephalopathy
b.
Cerebral infarction
c.
Intracerebral hemorrhage
d.
Myocardial ischemia, myocardial infarction
e.
Acute pulmonary edema
f.
Aortic dissection
g.
Seizures
h.
Acute renal insufficiency
i.
Papilledema
j.
Optimal Recovery Course
9.
Day 1: Admit patient for blood pressure out-of-control, hypertensive symptoms, or failure to
respond to outpatient antihypertensives. Bed rest. Frepuent vital signs. Urinalysis, CBC, platelet
count, chemistry panel (including creatinine and transaminases). Oral or parenteral
antihypertensives. Discharge planning
10.
Day 2: Blood pressure normal or adequately controlled. Laboratory values normal or resolved to
near normal. Up ad lib. Oral medication. Discharge
B.
Goal Length of Stay: Ambulatory to 1 day
Note: Goal length of stay assumes optimal recovery, decision-making, and care. Patients may be discharged
to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical
status and care needs.
C
Extended stay beyond goal length of stay may be needed for:
1.
2.
VIII.
Other hypertension-associated conditions (e.g., hemolysis, low platelets) - may require ongoing
inpatient care. Expect moderate to prolonged stay extension.
Uncontrolled hypertension or target organ damage (e.g., cerebral infarction).
Home Care
A.
Restriction of activity
B.
Home blood pressure monitoring
C.
Discourage use of alcohol and tobacco
D.
Pharmacologic treatment for diastolic blood pressure greater than 100 mm Hg
IMMUNIZATIONS
Recommended childhood and adolescent immunization schedule- The guideline recommendations were approved by the Advisory
Committee on Immunization Practices, the American Academy of Family Physicians, and the American Academy of
Pediatrics.
Primary Care Provider Recommendations:
I.
Ensure that the recommended childhood and adolescent immunization schedule is current with changes in
manufacturers' vaccine formulations
II.
Provide Vaccine Information Statements to parents or guardian - The National Childhood Vaccine Injury Act requires
that all health-care providers give parents or patients copies of Vaccine Information Statements before administering
each dose of the vaccines listed in the schedule.
III.
Verify the status of child’s immunization by reviewing Form 121 for MSBH Immunization Registry.
IV.
Ensure entries are made to MSBH Immunization Registry when immunizations are given. If FHCC EMR records
show immunizations were given and recorded in registry, ensure corrections are made.
V.
Advise parents or guardian of recommended immunization schedule if not current and/or when next immunizations
are due according to the attached schedule.
Papanicolaou (Pap) Smear
The Primary Care Provider Recommended Guidelines:
Cervical cytology is primarily a screening test that can link human papillomavirus (HPV) with cervical cancer and its precursors.
Females patients ages 21 to 64 should be evaluated at least every two (2) years utilizing cervical cytology.
I.
Cervical cytology is primarily a screening test that in some instances may serve as a medical consultation by providing
an interpretation that contributes to a diagnosis.
A.
Approximately 13,000 women in the US develop cervical cancer each year, and about 4,500 women die of
the disease. Most women who develop cervical cancer have never had a Pap smear or have not had one in
the past 5 years.
B.
Of the more than 50 million women who undergo Pap testing in the US each year, approximately 3.5 million
(7%) are diagnosed with a cytological abnormality requiring additional follow-up or evaluation.
II.
Diagnosis/Evaluation/Plan/Management
A.
Pathogenesis
1.
Oncogenic strains of HPV are present in more than 80% of cervical cancers. However, infection
with an oncogenic strain does not mean that a woman will inevitably develop intraepithelial
lesions.
2.
Incidence of infection with HPV is directly related to sexual activity; the greater the number of
partners, the greater the risk of HPV infection
3.
Other cofactors that have a role in development of cervical neoplasia include smoking, sexual
behavior (early onset and multiple partners), and immunological status of the woman
B.
Specimen Type:
1.
2.
C.
General Categorization
1.
2.
3.
D.
G.
Trichomonas vaginalis
Fungal organisms morphologically consistent with Candida spp
Shift in flora suggestive of bacterial vaginosis
Bacteria morphologically consistent with Actinomyces spp
Cellular changes consistent with Herpes simplex virus
Other Non-Neoplastic Findings
1.
2.
3.
4.
5.
F.
Negative for Intraepithelial Lesion or Malignancy
Epithelial Cell Abnormality
Other
Organisms
1.
2.
3.
4.
5.
E.
Conventional Smear
Liquid-based
Reactive cellular changes associated with inflammation (includes typical repair)
Radiation
Intrauterine contraceptive device (IUD)
Glandular cells status post hysterectomy
Atrophy
Epithelial Cell Abnormalities
1.
Squamous Cell
2.
Glandular Cell
Other malignant neoplasms
III.
Identification of endometrial cells if not associated with menses or after menopause may indicate risk for an
endometrial abnormality, although most often this is a benign finding. Note: Cervical cytology, primarily a screening
test for squamous epithelial lesions and squamous cancer, is unreliable for detection of endometrial lesions and should
not be used to evaluate suspected endometrial abnormalities
IV.
Categories of women in need of paps smears
A.
B.
C.
D.
E.
Postmenopausal women
Immunosuppressed women
Pregnant women
Adolescents
Young women of reproductive age
V.
Refer for colposcopic evaluation and biopsy of lesions suspicious for high-grade disease or cancer
VI.
Educate patient concerning need for paps smear screening on a regular basis throughout her life time.
Prenatal Care (1st Trimester)/ New Born Higher Birth Weight
The primary Care Provider Recommended Guidelines:
I.
Be aware that the current 11 % rate of preterm birth has not changed significantly in the past 20 years despite
increased
rate of interventions, including bed rest, hydration, and enhanced prenatal care
II.
Educate pregnant women that risk factors are present in 50% of women with preterm labor: Risk factors include:
A.
Demographic risks:
1.
2.
3.
4.
5.
B.
Medical risks predating current pregnancy
1.
2.
3.
4.
5.
6.
7.
C.
Multiple gestation.
Infection, including: bacterial vaginitis and urinary tract infection
Incompetent cervix
Short interval between pregnancies
Bleeding in first trimester
Placenta previa or abruptio placentae
Fetal anomalies
Premature rupture of membranes
Behavioral and environmental risks:
1.
2.
3.
4.
5.
6.
III.
History of previous preterm birth
Multiple abortions, spontaneous or elective.
Uterine anomalies
Low pregnancy weight for height.
Parity (0 or >4)
Diabetes
Hypertension
Medical risks in current pregnancy
1.
2.
3.
4.
5.
6.
7.
8.
D.
African-American.
Below 17 or above 24 years of age
Lower socioeconomic status
Unmarried
Lower level of education.
Diethylstilbestrol exposure
Smoking
Poor nutrition
Alcohol or other substance use, especially cocaine
Late or lack of prenatal care.
High stress
Prenatal in Office Site
A.
B.
C.
Medically assess and stabilize comorbid medical conditions, including diabetes and hypertension
Identify women at risk for preterm labor and tailor interventions to specific needs and resource availability.
Most interventions designed to prevent preterm birth do not work
Interventions may include
1.
Toxocolytic agents, including:
2.
3.
4.
IV.
IV.
a..
Beta agonists, e.g., ritodrine and terbutaline
b.
Prostaglandhn inhibitors, e.g., indomethacin.
c.
Calcium channel blockers, e.g., nifedipine.
d.
Oxytocin antagonists
e.
Magnesium sulfate
Special programs targeted to high-risk conditions, including drug use
Relaxation therapy
Antibiotic treatment of urinary tract infections and bacterial vaginitis
Educate patient, family, and caregiver about:
A.
How to recognize signs and symptoms of preterm labor.
B.
How to recognize signs and symptoms of complications, and when to report to health care professional
If hospitalized, monitor daily progress:
A.
Ensure that patients with premature rupture of the membranes who test positive for group B Streptococcus
receive antibiotic therapy
B.
Assess psychosocial factors, including:
C.
Fear for outcome, anxiety and depression.
1.
2.
3.
Changes in lifestyle
Changes in social roles.
Provide support and referral, as needed.
D.
Corticosteroid therapy may promote fetal maturation
E
Facilitate decision about home care. Home healthcare may be suitable for patients with cervical dilatation of
3 cm or less, and fewer than 4 to 6 contractions per hour
F
Coordinate development of treatment goals and plans with multiple caregivers
G.
Facilitate transition to next level of care
H.
Regularly communicate with professional staff, patient, family, and caregiver
I
Ensure that follow-up appointment is made
J
Hospital Admission may be indicated for (any one of the following)
1.
2.
3.
4.
5.
6.
7.
Preterm rupture of membranes
IV tocolytics (beta-adrenergic agonists) required
Administration of IV magnesium as a tocolytic
Suspected amnionitis
Significant vaginal bleeding
Maternal infection (e.g., pyelonephritis, pneumonia)
Severe maternal disease trigger or comorbidity including:
8.
9.
10.
L.
Day 1
a.
Uncontrolled diabetes
b.
Diabetic ketoacidosis
c.
Severe dehydration
d.
Preeclampsia
e.
Severe hypertension
Delivery
Fetal demise
Condition requiring premature delivery (preeclampsia or presumed fetal growth restriction)
Admit patient with significant contractions before term. Bed rest. Parenteral hydration, parenteral
tocolytic therapy, and corticosteroids[A1 (if indicated for fetal maturation). Eliminate infectious or
other medical causes. Usual diet. Discharge planning. Possible discharge, if contractions cease and
parenteral medication not in use.
Day 2:
M.
Contractions ceased. Activity as tolerated. Discharge. Goal Length of Stay: Ambulatory to 1 day
Extended stay beyond goal length of stay may be needed for:
1.
2.
3.
Significant infection - anticipate parenteral antibiotics, observation until contractions ceased;
transition to home healthcare for continued parenteral antibiotics. Expect brief stay
extension.
Continued uterine contractions - anticipate continued parenteral tocolytics; for progression to
delivery expect brief stay extension; if contractions controlled, continued IV tocolytics may or may
not be necessary. Expect brief to prolonged stay extension.
Fetal demise - anticipate progression to delivery and possible induction of delivery (near term); if
contractions cease and delivery not elected, anticipate discharge while awaiting spontaneous
delivery. Possible brief stay extension.
Continued vaginal bleeding - anticipate rapid evaluation of placenta previa or abruption, may
require surgical control, delivery, or both. Expect brief to moderate stay extension.
5.
Other condition (e.g., severe maternal disease, premature delivery) requiring continued inpatient
care. Expect brief to moderate stay extension.
Alternatives to hospitalization
4.
V.
A.
Outpatient care in labor and delivery unit
B.
1.
Observation, fetal and maternal monitoring
2.
Tocolytic trial
3.
Discharge if contractions ceased
Home care
1.
2.
3.
4.
Decreased activity
Possible parenteral hydration
Possible tocolytic therapy
Corticosterohds[A] (if indicated for fetal maturation)
Tobacco Use and Smoking Cessation
The Primary Care Provider Recommended Guidelines:
I.
II.
III.
IV.
Destructive health behavior involving use of tobacco (cigarettes, chewing tobacco, and snuff)
A.
Tobacco use is the leading preventive cause of death in US. One of every 5 deaths is the result of
tobacco use.
B.
23.5% of US adults smoked cigarettes in 2003.
C.
Tobacco smoke contains numerous substances which are toxic, mutagenic, or carcinogenic
D.
Tobacco smoke contains carbon monoxide, nicotine, and tars.
E.
Results to delicate pulmonary tissues are devasting.
Assess effect of tobacco dependence on patient.
A.
Physiological factors
B.
Psychological factors
C.
Social/behavioral factors
Psychological barriers to quitting include:
A.
Withdrawal syndrome with symptoms such as anxiety, irritability, anger, impatience, restlessness,
difficulty concentrating, sleep disturbances, increased appetite, and depressed mood.
B.
Symptoms begin a few hours after last cigarette smoked.
C.
Frequently use tobacco to handle stress and negative emotions such as anger and anxiety.
Diagnosis/Evaluation
A.
B.
\
History
1.
Number of years smoked and how many packs per day
2.
How soon after arising 1st cigarette is smoked.
3.
Past attempts at quitting.
4.
Cough, sputum production, shortness of breath, recurring respiratory infections.
Physical Examination
1.
Monitor vital signs
2.
Examine ears, nose, mouth, pharynx, mouth for inflammation
3.
Complete exam of lungs
4.
Complete exam of heart and peripheral vascular system.
C.
V.
Diagnostic Tests
1.
Consider spirometry
2.
Screen for lipid disorders.
Plan/Management
A.
Major intervention
1.
Brief clinical intervention
2.
Intensive clinical intervention
3.
Systems interventions
B.
Identify all tobacco users at every visit –
C.
Advise all smokers to stop
1.
Be clear.
2.
Speak strongly.
3.
Personalize advice.
4.
Assess willingness to make a quit attempt.
5.
Assist patient who is willing to quit
6.
a.
Counseling
b.
Pharmacotherapy
Follow up