management plan


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management plan

; MP proposed and written course of short-term and long-term treatment regimes linking the patient examination and diagnosis to resolution of patient's presenting condition; should be agreed by both practitioner and patient, and include an outline of all treatments likely to be included, estimates of treatment success rates, likelihood of recurrence of condition and/or need for further or ongoing treatments, and the frequency of those treatments; it should also note any items of (written) information or verbal advice given to the patient, specify any discipline to whom patient should be referred, and also detail any treatment area to be undertaken by the patient him- or herself; therapies indicated in the MP plan should be supported by evidence-based medicine, local protocols, treatment algorithms and similar; MP is retained in patient notes, copied to referring practitioner, reviewed regularly (e.g. after specified number of visits) and a list of the range of other possible options recorded if initial interventions are unsuccessful or problem recurs (e.g. referral to another specific discipline for a named form of therapy/advice) (Table 1)
Table 1: Example of a management plan for a child with nail pain
FeatureDetail/explanation
Main presenting complaint9-year-old girl presents with 3-week history consisting of pain in the medial (tibial) sulcus of the left hallux since 'picking' nail
Otherwise fit (i.e. no other significant medical history; no regular medications)
Advised to contact you by GP
ExaminationLocal tenderness, inflammation and swelling at medial area of left hallux; no signs of obvious infection; medial side of nail plate very ragged as a result of onychotillomania
Vascular examination: normal
Neurological examination: normal
Dermatological examination: mild hyperhidrosis in both feet
Biomechanical assessment: fully compensated rearfoot varus; no joint pathologies
Social assessment: dance and gymnastics twice a week
Footwear assessment: trainers (one size too small); laces not tied
Diagnostic testsNone indicated
Management plan Short-term plan
Explanation of likely cause of current problem (picking nails, hyperhidrotic skin, short, unlaced shoes, excess pronation)
1. Immediate treatment: exploration of both sides of both first toenails, and reduction of ragged edges with Black's file + LA is necessary, with patient/parental consent. Advise regime of daily warm saline foot baths and demonstration to mother on how to pack affected sulcus with cotton wool. Review in 7 days (or SOS)
2. Advice
Exercise advice: no gym/sport/dance before next appointment
Shoe advice (give leaflet) - needs a larger trainer, and needs to tie laces so that rearfoot is retained in the heel cup of the shoe
Skin care advice (treatment/avoidance of hyperhidrosis) - give leaflet
3. Temporary insole with medial felt (cobra) pad to minimize hallux trauma due to excess compensatory pronation/foot lengthening on weight-bearing
4. Letter to GP informing of action to date (copy to notes)
Long-term plan
Explanation of details of other treatments that may be necessary after next visit
1. Further clearance of medial side of first nail or removal of spike of nail under LA or removal of medial section of first nail under LA and phenolization of exposed pocket of nail matrix + dressings (94% cure rate) + details of aftercare regimes for this range of options
2. Biomechanical and gait evaluation, with provision of bespoke antipronatory orthoses
3. Review patient every 4 months to monitor biomechanical, skin and nail function

LA, local anaesthetic.

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