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iMAP for GPs
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I would like to form a study group to share our portflio ideas for iMAP
if any one interested
also please look at critreria one and share what you think with me
miro180Management Plan
Describe a management plan, referenced to a specific written, national or local protocol, which you have used in the management of a patient with a long term condition. Your management plan should clearly illustrate compliance with the guidance.
Management Plan:
Menorrhagia (heavy menstrual bleeding HMB):
NICE define it as: excessive menstrual blood loss which interferes with the woman's physical, emotional, social life. In my routine practice I find some difficulty to have a rigid clinical definition to menorrhagia, it is largely a subjective symptom as what constitutes heavy bleeding to one woman may be quite normal for another. In this particular patient NICE definition was correct as this lady’s symptoms were disturbing her life for the last five months.
I refer to NICE guidelines for management of menorrhagia published 2007, which emphasise that menorrhagia management should be woman-centred care. I am also aware that if a woman does not have the capacity to make decisions about her care, I should follow a code of practice accompanying the Mental Capacity Act published April 2007. I am familiar with the local guidelines for management and referral in HMB. For my prescribing I refer to BNF section 6.4. I also use for a quick reference guide (gpnotebook.com)
Summary of NICE guidelines 2007:
1. History taking, examination and investigations
History should be focusing on impact of the problem on women life.
If the history suggests symptoms of intermenstrual or postcoital bleeding, pelvic pain or pressure symptoms, a physical examination and other investigations (such as ultrasound, endometrial biopsy) should be performed. Pharmaceutical treatment can be started without carrying out a physical examination or other investigations if no suggestion of these symptoms in the history.
2. Examination
A physical examination should be carried out before all:
• LNG-IUS fittings
• Investigations for structural or histological abnormalities.
Women with fibroids that are palpable abdominally or more than 12 cm as measured by U/S should be offered immediate referral to a specialist.
3. Laboratory tests
A full blood count test should be carried out on all women with HMB. This should be done in parallel with any HMB treatment offered.
4. Acceptable, treatments should be considered in the following order
a) Levonorgestrel-releasing intrauterine system (LNG-IUS) provided long-term (at least 12 months) use is anticipated
b) Tranexamic acid or non-steroidal anti-inflammatory drugs (NSAIDs) or combined oral contraceptives (COCs)
c) Norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens.
5. Education and information provision
Patient should be offered information about his condition. And if patient is referred to specialist she should be given information about all the process involved till seen by the specialist.
Please indicate how you used this Management Plan in the management of a particular patient. Please describe with reference to the Management Plan.
The long term condition treated
History
This 41years old lady is well known to me, she came complaining of HMB, she had a past medical history of depression other wise there was nothing in her records which correlate to her current symptoms of menorrhagia.
She was sterilized.
She described flooding most of the days of the cycle which goes some times for seven or ten days which is far from her normal. She described occasional blood clots in the size of big buttons. Periods were regular.
She is a British, white, tall and thin lady; she is non smoker and she works as a hair dresser.
She denied post coital bleeding, or inter-menstrual bleeding, there was no urinary frequency, or back pain.
Her smear test was up to date.
examination
As per NICE algorhythm, I examined her generally and abdominally. Her BP was 120/70, and her pulse was 78/ minute. There were no signs of Thyroid disease. Her abdominal examination was normal. I took a full blood count (FBC) it was normal.
.
The prescribing issue
1. Tranexamic acid 1.5gm three times daily for heavy periods.
2. Mefenamic Acid to take 500mg three times daily for pain.
3. norethisterone 15mg daily for ten days
The rationale used to prescribe
In detailed history menorrhagia symptoms were starting to affect patient’s family life, sex life as well as her work. She was also feeling very low.
I offered her the management options She didn’t anticipate using the LNG-IUS for long time and she opted to try pharmacological treatment. I offered her Tranexamic acid for heavy periods and Mefenamic acid for pain. I had a chat with her about coping strategies with heavy periods and I gave her a patient information leaflet about menorrhagia. I warned her re red flags symptoms to report back. I also asked her to keep menstruation diary and to come for a review after three cycles.
I reviewed her after another four month she reported less bleeding in the first tow cycles only which was less in the amount but not in duration; however in last two cycles she had felt worse. She came feeling much run down and she thought that the heavy periods are bringing back her depression symptoms. That consultation was a lengthy one as this lady felt very low about her HMB symptoms
She reported pelvic pains in last three months which was rather new, as per NICE I needed to examine her internally so I took her verbal consent, I called for a nurse chaperone and recorded the nurse’s name in the consultation. I felt that the uterus is bulky however there were normal adenexae otherwise examination was entirely normal. I arranged for U/S scan and re discussed options of management with my patient, I also put the referral to specialist as one of the options for her to choose from, she wanted to try hormonal treatment.
The U/S results showed a small subserosal fibroid of 8cm size, otherwise normal
She still wanted to try hormonal treatment so I prescribed her norethisterone 15mg daily from day 5 of the cycle to day 26th. Knowing this lady for long time, I needed to warn her about the side effect of norethisterone as it can worsen her depressive symptoms, but she agreed to have it as she linked her low mood symptoms to the excessive periods.
There was no contraindication for this patient to receive Norethisterone.
Monitoring or investigations
Full blood count, pelvic Ultrasound
Menstruation diary
Relevant follow up
. I reviewed her in three month’s time from the second visit. She felt much better, and her periods were back to normal. She didn’t report any side effects to medications, she was much better in mood and work life.
I advised her to continue use the hormonal treatment for anther three cycles and then stop. I gave her red flag symptoms to report back
Reflection:
In review of this case I realized that I didn’t record fully the menstrual cycle diary in follow up visit, I was more concerned with the patient’s emotional and family influence of the disease that I forgot to re mention the other options of management i.e. LNG-IUS,I agree! I would pay a couple bucks for an app. I know they've got a lot going on with the bugs and things but maybe once all that is settled we could encourage them:) I do CC more on my phone than any other way so an app would be awesome.
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