Back Pain Consultation

Patient Name

First

Last

SECTION 1

Individuals suffering from mild to moderate lower back pain.

Preconsutation Assessment

.

Patient Consent

obtained from the patient/carer who does not want to consult with their GP and would prefer to access treatment from the PGD user

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Inclusion Checklist

Individuals from 18-65 years of age
• Individuals with non-specific lower back pain, where no complications are suspected.

Exclusion Checklist

Patients for whom no valid consent has been received.
Hypersensitivity to the active substance(s) or to any of the excipients or trace residuals in the selected naproxen 250mg tablets product. See section 2 and 6.1 of the relevant SPC.
Individuals under 18 years of age or over 65 years of age.
Patients with renal or hepatic impairment.
Known or suspected pregnancy.
Breast-feeding individuals.
Patients who have previously shown hypersensitivity reactions (e.g. asthma, rhinitis, nasal polyps, angioedema or urticaria) in response to ibuprofen, aspirin, or other non-steroidal anti-inflammatory drugs.
Patients with a history of gastrointestinal bleeding or perforation, related to previous NSAIDs therapy.
Patients with a history of, or active, peptic ulceration and active gastrointestinal bleeding (two or more distinct episodes of proven ulceration or bleeding).
Haemorrhoids or predisposition to rectal bleeding.
Patients with uncontrolled, moderate or severe hypertension.
Patients with congestive heart failure, established ischaemic heart disease, peripheral arterial disease, and/or cerebrovascular disease.
Patients with a history of gastrointestinal disease.
Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption.
Patients with coagulation disorders or at high risk of bleeding.
Women who have difficulties conceiving, are undergoing investigation of fertility or are attempting to conceive.
Patients displaying red flag symptoms or signs or serious underlying cause.
Individuals with severe symptoms.
Progressive, persistent, or severe neurological deficit.
Known or suspected intra-abdominal pathology, ankylosing spondylitis, osteoporosis, shingles, sciatica, fracture, cancer, cauda equina syndrome or spinal infection (see pre-treatment management for further information).
Where there is doubt about the patient’s diagnosis.

Tick the one that applies

Patient is INcluded in Treatment
Patient is EXcluded from Treatment

SECTION 2 – Complete this session during consultation

Type of consultation

Video
Telephone
Walk In

Check patient ID presented e,g passport, Drivers License or Photocard

Passport
Drivers License
Photocard
Other

If other please specify

Caution refer to PGD if required

-Lower back pain – non-specific low back pain should be diagnosed. It is important to ensure that specific causes of back pain are excluded, and no red flag symptoms are present

-Undesirable effects – Patients treated with NSAIDs for longer periods should undergo regular medical supervision to monitor for adverse events

-Naproxen decreases platelet aggregation and prolongs bleeding time

-Caution is required when supplying to patient with compromised cardiac function. Patients with risk factors for cardiovascular disease (e.g. hypertension, hyperlipidaemia, diabetes mellitus, smoking) should only be treated with naproxen after careful consideration

-Increasing age – Older patients may have an increased frequency of adverse reactions to NSAIDs especially gastrointestinal bleeding and perforation which may be fatal

-Bronchospasm • Caution is required if administered to patients suffering from, or with a history of, bronchial asthma or allergic disease, since administration of naproxen or other NSAIDs may elicit bronchospasm

-Renal function

-Gastrointestinal (GI) bleeding

-Gastrointestinal disease

-Ocular effects

-Dermatological

Product Interactions

If product is on any medication, check product interaction in BNF or listed in PGD

If patient on any medication, check product interactions

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Action if excluded

Discuss with patient and document the reasons for exclusion from treatment..
• If the patient has consented, refer them to their GP and/or inform their GP.
• Signpost to other services if appropriate.
• Document the reasons for exclusion and any action taken, in the patient’s medication record.
• When treatment is postponed reschedule as appropriate

Action if patient
declines treatment

Ensure patient/carer fully understands the risks of declining the service.
• Advise the patient/carer about the benefits of the service.
• Refer patient to GP if appropriate and explain NHS eligibility for this service where appropriate.
• Document the reasons for declining the service and any action taken, including advice given to the patient.
• Reschedule treatment if appropriate.

Additional Consultation Notes

See PGD for dose, adverse reaction, quantity to supply, advice and treatment

Healthcare Professional Name

First

Last

GPHC Number

Date

SECTION 1

Preconsutation Assessment

SECTION 2 – Complete this session during consultation

Caution refer to PGD if required

Product Interactions

Action if excluded

Action if patient
declines treatment

See PGD for dose, adverse reaction, quantity to supply, advice and treatment

Start Assessment

Complete Patient Details

SECTION 1

Preconsutation Assessment

SECTION 2 – Complete this session during consultation

Caution refer to PGD if required

Product Interactions

Action if excluded

Action if patient declines treatment

See PGD for dose, adverse reaction, quantity to supply, advice and treatment

Start Assessment

Complete Patient Details

Action if patient
declines treatment