EAMC DFCM OPD Charting Guidelines March 2022 PDF

EAMC DFCM OPD Charting Guidelines as of March 2022 DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline. There are 4 Clerks/ Interns posts: 1. Triage 2. Vital Signs 3. Consults 4. Census Patient Car...

EAMC DFCM OPD Charting Guidelines as of March 2022 DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline. There are 4 Clerks/ Interns posts: 1. Triage 2. Vital Signs 3. Consults 4. Census Patient Care Flow Chart Triage Vital Signs Team Consultation Team Census Encoding Brief HPI Vital Signs and Anthropometrics History and Physical Exam Checking of chart completion Triaging of patients to different Referring of patients with abnormal Referring of patients to Residents on Encoding of Patient Charts on the departments. vital signs and red flag symptoms. Duty Computer ER referrals Logging and charting of time Checking of chart completion Checking of accuracy of orders: recieved and time interviewed Takes note the Time referred to the spelling errors, correct prescriptions. resident. Logging of time referred and time Takes note the time discharged (time discharged. when the resident is finished checking the patient and the chart. Carrying out Corrected Resident's Orders (prescription, Lab requests, Clinical abstracts or medical certificates) Checking of completion and correct chart orders (prescription, Lab requests, Clinical abstracts or medical certificates). Discussing Patient discharge instructions to the patient. Checking of chart completion prior to encoding. Checks completeness of time stamps. (time recieved, time interviewed, time referred, time discharged.) CENSUS ASSISTANTS RESPONSIBILITIES Assistant 1 1. Checks the completeness of the Daily census every after OPD hours. (with the encoder of the day) 2. Uploads the Census file on the Google drive link. 3. Checks and corrects spelling errors, dosages, and other encoding errors. 4. Every Tuesday, Converts OPD Daily Census Document files to DOH CENSUS Format. See DOH Census Editing Guidelines. Assistant 2 1. Compiles Daily Morbidity Tally Sheets and encodes it to the Morbidity Census Excel file. 2. Copies Daily Census Summary information to Daily Census Summary File. 3. Every Tuesday, copies all the census on the Daily OPD census to the Master Monthly Census. 4. On the last day of the rotation, copies the Master monthly Census to the Master Annual Census. Files to be submitted at the End of the rotation. Soft copy of OPD Daily Census Summary. Soft and Hard Copies of OPD Daily Morbidity Tally Summary. FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY EAMC DFCM OPD Charting Guidelines as of March 2022 DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline. HISTORY OF PRESENT ILLNESS PRIMARY SYMPTOM Associated symptoms Pertinent negatives Medications/consults Timing: Associated with: List your differentials Medical Consults if any Previous episodes, Include RELEVANT symptoms only. Then pertinent negatives. Ex. Sought consult at Frequency, the Review of Systems. No dysuria, frequency, urgency, fever, Diagnosed with Duration chills, flank or suprapubic pain. Diagnostics done were Location Gynecologic Prescribed with Quality or Character No vaginal discharge, vaginal pruritus, Self-medicated with Severity dyspareunia With relief/no relief of symptoms. Radiation FOR PATIENTS SEEN AT THE ER, Relieving factors ALWAYS START THE HISTORY Precipitating factors PRIOR TO THE ER CONSULT. Progression Interim history: Progression, if episodic, frequency, Timing of symptoms, relieving and aggravating factors, Reason for consult: persistence, progression, severity, of symptoms prompted consult. Minimum “Normal” Physical Exam findings Neuro PE (Normal) I Not assessed General Conscious, coherent, not in cardiorespiratory distress II PERRLA Survey III, IV, VI EOM- able to perform cardinal Eye ROM V clenches teeth symmetrically, intact facial sensation Skin Skin is brown moist with good skin turgor, no visible mass or VII Symmetrical facie lesions. VIII Intact audition HEENT Normocephalic, Pink palpebral Conjunctiva, anicteric sclera, IX, X Uvula in midline, (+) gag reflex (Inspection, No Nasal nor aural discharge, no tonsillopharyngeal XI Shrugs both shoulders symmetrically Palpation) congestion, Neck is supple with no CLAD and no JVD XII Tongue protrudes in midline, no fasc. Chest/Lungs No mass or lesions, Symmetrical chest expansion, no (Insp, Palp, retractions, no chest lagging, vesicular breath sounds. Perc, Ausc) Heart Adynamic Precordium, PMI at 5th ICS Left Midclavicular line, (Inspe, Normal Rate, Regular Rhythm, distinct S1 and S2, No Ausc) murmurs Abdomen Globular, no visible mass or lesions, normoactive bowel (Insp, Aus, sounds , soft, non-tender, no CVA tenderness, Negative Palp, Perc) Murphy sign, tympanitic Extremities No gross deformities, full and equal pulses, capillary refill time 45 years old Blood-sugar monitoring 3. Non-Pharmacologic management Prostate Cancer Screening 4. Referrals Males, 50 years old and above Do Digital Rectal Exam 5. Follow up Prostate Cancer: 55-69 years old PSA every 2 years Colorectal Cancer Screening DIAGNOSTICS All >50 years old Endoscopy Laboratory/Imaging Request should be clustered in to: 1. PRIORITY LAB WORKUP: Labs that are relevant to the diagnosis >40 years old Oral cavity inspection For any patients >40 years old and above with Abdominal or Chest pain do STAT 12L Colorectal Cancer: 50-75 years old FOBT or FIT yearly ECG to Rule out Ischemic Heart Disease, if the patient came back with Normal ECG Colonoscopy every 10 years given results, Write Stat12 L ECG – DONE negative initial colonoscopy If refused for any reason, fill up the “release of responsibility form” and indicate the Flexible sigmoidoscopy every 5-10 years primary reason for refusing, then write STAT 12 L ECG – Refused, waiver signed. Lung Cancer Screening LIST PRIORITY WORKUP FIRST BEFORE ROUTINE WORKUP. Smoking history (>10 pack years) Chest X-ray PAL 2. ROUTINE LAB WORKUP: All 55-80 years old with history of Annual screening with Low Dose CT Scan 12 L ECG, FBS, Lipid Profile, Blood Uric Acid, CBC with pc, UA, Na, K, Cl, BUN, smoking 30 pack years and currently Creatinine, SGPT SGOT smoking or have quit within 15 years Indications for routine workup 1. Obese at any age Preventive Medicines 2. 40 years old and above 1. Statins – 40-75 years old; >10% ASCVD Risk (Hypertension, Diabetes 3. Underweight at any age Mellitus, Dyslipidemia, Smoking) For patients qualifying 1 and 2 Write “For Wellness: 12 L ECG, FBS, Lipid Profile, 2. Aspirin – 50-59 years old; CVD and Colorectal Ca Blood Uric Acid, CBC with pc, UA, Na, K, Cl, BUN, Creatinine, SGPT SGOT 3. Immunizations a. Anyone >55, Recommend PCV and influenza vaccine FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY EAMC DFCM OPD Charting Guidelines as of March 2022 DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline. Adults 21-45 years old: accumulate 30-60 minutes of daily physical activity consisting Pre-Employment Workup. of any one or a combination of the following activities. For fitness purposes, adults Routine: students, office, sales, etc.: CBC with PC, UA, Chest Xray PA-L should work towards 20-30 minutes continuous physical activity for a minimum of three Food handlers: CBC with PC, UA, Chest Xray PA-L, FA, Anti-HAV days per week For strenuous jobs: CBC with PC, UA, Chest Xray PA-L, 12-L ECG Employees above 35 years old: 12 Lead ECG Activities of Daily Living Active travel - Walking Exercise Prescription: - Cycling Formula: - Stair climbing HRmax = 220-age Active daily tasks Resting HR - average heart rate upon waking up on three consecutive mornings - Scrubbing/mopping floors Target Heart Rate = [(HRmax – resting HR) x % intensity desired] + resting HR - Cleaning rooms Level of fitness Intensity - General carpentry Light 50-60% - Fetching water in a pail Moderate 60-70% - Raking leaves Vigorous 75-95% - Bathing dog - Cleaning the car Per age: - Rearranging household Children 5-12 years old: at least 60 minutes of daily physical activity consisting of any furniture one or a combination of the following activities: Exercise, Dance, and Recreational - Brisk walking Activities - Dancing Active Daily Task Active travel Goal: Moderate intensity aerobic - Cycling - Walking physical activity resulting in a - Swimming - Cycling noticeable increase in heart rate and - Stair climbing breathing continuously for a minimum Active daily task (household and school of 30 minutes OR accumulated bouts chores) of 10 minutes or longer - scrubbing/ mopping floor For more active people with no risk - Jogging - fetching water in a pail factors, vigorous activity resulting in fast - Vigorous dancing - raking leaves breathing and substantial increase in - Ballgames - bathing dog heart rate - cleaning the car Goal: done continuously and done at - rearranging household least three times a week with a future furniture goal of being able to do it 5-6 times Muscle Strengthening and Flexibility - Calisthenics Exercise, Dance or Sports Sports Activities - Stair Climbing Goal: 20-30 minutes programmed Active games Goal: done at least thrice a week, non- - Weight training physical activity consecutive days High Impact Play (Unstructured - Running Activities in the Workplace - Walking Spontaneous Play) - Jumping Goal: two-minute physical activities for - Stair climbing - Hopping every hour of sitting - Stretching - Skipping - Luksong tinik Older Adults 46-59 years old: accumulate at least 30 minutes daily physical activity - Patintero consisting of any one or a combination of the following activities - Tumbang preso - Agawan base Activities for Daily Living Active Travel - Stair climbing - Walking - Playground activities - Cycling - Stair climbing Adolescents to Young Adults 13-20 years old: at least 60 minutes of daily physical Active Daily Task (household cholres activity consisting of any one or a combination of the following activities: Exercise, Dance, and Recreational - Brisk or race walking Activities - Dancing Active Daily Task Active travel Goal: Moderate intensity aerobic - Cycling - Walking physical activity resulting in a - Rowing - Cycling noticeable increased heart rate and - Swimming - Stair climbing breathing. Activities done continuously Active daily task (household and school for a minimum of 30 minutes OR chores) accumulated bouts of 10 minutes or - scrubbing/ mopping floor longer - fetching water in a pail For more active people with no risk - Jogging - raking leaves factors, vigorous activity resulting in fast - Vigorous dancing - bathing dog breathing and substantial increase in - Ball games - cleaning the car heart rate - rearranging household Goal: done continuously and done at furniture least three times a week with a future goal of being able to do it 5-6 times Exercise, Dance or Sports (at least 40 Fitness-related Muscle Strengthening and Flexibility - Weight bearing calisthenics minutes programmed physical activities) Rhythmic activities Activities - Stair climbing Goal: continuous 20-30 minutes Sports activities Goal: done at least thrice a week, - Weight training minimum for at least 3-5 times a week non-consecutive days High Impact Play (Unstructured - Brisk walking Balance and Coordination - Walking Spontaneous Play) - Jogging Goal: 2-4days/week - Gentle yoga Goal: at least 20 minutes of sustained - Indigenous games - Tai-chi moderate to vigorous physical activities - Dancing - Dance resulting in rapid breathing - Aquatic activities Activities in the Workplace - Walking Goal: two-minute physical activities for - Stair climbing every hour of sitting - Stretching FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY EAMC DFCM OPD Charting Guidelines as of March 2022 DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline. Young Old 60-69 years old: at least 30 minutes daily physical activity consisting of any Vintage Old 80 years old and above one or a combination of the different types of physical activities for the following: Activities for Daily Living Active Travel Activities for Daily Living Active Travel - Assisted walking and stair - Walking climbing - Cycling - Mild, easy daily tasks - Stair climbing o Mild garden or yard Active Daily Task (household chores work and yard work) o Dusting furniture Exercise, Dance, and Recreational - Moderate to brisk walking o Folding clothes Activities - Dancing o Sweeping inside the Goal: Moderate intensity aerobic - Cycling house physical activity resulting in a - Calisthenics Exercise, Dance, and Recreational - Leisure walk around noticeable increased heart rate and - Rowing Activities neighborhood, yard, living breathing. Activities done continuously - Swimming Goal: Total of 20 minutes area for a minimum of 30 minutes OR - Stair climbing continuously, three times weekly OR - Stationary biking accumulated bouts of 10 minutes or accumulated bouts of 10 minutes or - Calisthenics longer longer - Swimming For more active people with no risk - Jogging, brisk or race Muscle Strengthening and Flexibility - Mild calisthenics factors, low to moderate intensity walking Activities - Light weight training activity resulting in fast breathing and - Vigorous dancing Goal: done at least twice a week, on - Elastic band exercises substantial increase in heart rate - Step-aerobics non-consecutive days Goal: done continuously for a - Swimming Balance and Coordination - Walking minimum of 30 minutes, and done 3- Goal: at least three days per week - Gentle yoga 5x/week - Tai-chi Muscle Strengthening and Flexibility - Body weight bearing - Slow Dancing Activities calisthenics - Mild aquatic activities Goal: done at least twice a week, non- - Stair climbing consecutive days - Weight training WELL ADULT CHARTING: Well-balanced diet Balance and Coordination - Walking Adequate/Increase oral fluid intake Goal: 2-4days/week - Gentle yoga Adequate rest and sleep - Tai-chi Moderate intensity exercise 4-5x/week for 30 minutes - Dance Follow-up schedule - Aquatic activities Advised Activities in the Workplace - Walking Goal: two-minute physical activities for - Stair climbing PHARMACOLOGIC MANAGEMENT every hour of sitting - Stretching Use standard format: Generic name, stock dose, dosing, frequency, duration*. Middle Old 70-79 years old USE OD, q8h for TID, q12h for BID, q6h for QID. NEVER USE, BID, TID, QID, E.g. Co-amoxiclav 1 g/tab, 1tab q12 for 7 days Activities for Daily Living Active Travel *No duration for maintenance medications o Walking o Assisted Stair climbing Mild, easy daily Task (household NON-PHARMACOLOGIC MANAGEMENT chores) SEE SAMPLE PLANS for other nonpharmacologic management o Mild garden or yard work Smoker: Smoking cessation advised, patient in pre-contemplation stage, advised o Dusting furniture patient that he can come back anytime if decided to quit. o Folding clothes Fluid intake: o Sweeping inside the house For well adults: Increase oral fluid intake. Exercise, Dance, and Recreational - Leisurely walk around For CKD, CHF patients. Limit fluid intake to 1L/ day instead. Activities neighborhood, parks, and Activity: Moderate intensity physical activity 30 mins/day 5x per week as tolerated. (for Goal: Total of 30 minutes malls healthy patients who you think can tolerate exercise) continuously, three times weekly OR, - Stationary biking DIET PLAN (compute for all Obese, DM and Hypertensive patients) accumulated bouts of 10 minutes or - Calisthenics longer - Swimming HOW TO COMPUTE FOR THE DIET PRESCRIPTION For more active people with no risk - Walking 1. Ideal body weight using Tanhauser method. factors, low to moderate intensity of - No impact aerobic dancing (Height in cms – 100) X 0.9 = aerobic activity resulting in slight - Social dancing Eg. (169 – 100) = 69 X 0.9 = 62.1 kgs elevation of breathing rate and heart - Swimming 2. Total Caloric Requirement = IBW X Activity factor rate Activity factor Goal: done continuously and done at 25 for bedridden, 30 for sedentary, 35 for moderate activity, 40 for strenuous. least 30 minutes, and done three 3. Distribution: days per week, on non-consecutive CHO: TC x 0.6, CHON: TC x 0.15, Fat: TC x 0.25 days Muscle Strengthening and Flexibility - Mild calisthenics Sample Diet plan Order Activities - Light weight training Refer to Nutrition Clinic for a diet plan Goal: done at least thrice a week, on - Elastic band exercises Diet: E.g. Low Salt, Low Fat, and/or DM Diet (specific) non-consecutive days TC: 1539, CHO: 923, CHON: 231, Fat: 385 Balance and Coordination - Walking If the patient already had a diet plan from nutrition clinic write: Goal: 2-4days/week - Gentle yoga “Continue diet plan C/O Nutrition Clinic” - Tai-chi If the patient has previous diet prescription but still unable to go to Nutrition clinic write: - Dance “Still for Nutrition clinic referral” - Aquatic activities REFERRALS Refer to for further evaluation and co-management. NEVER write refer to for Clinical abstract. Refer to Ophthalmology for officia fundoscopy (all New DM and Hypertensive patients) FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY EAMC DFCM OPD Charting Guidelines as of March 2022 DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline. Refer to Ophthalmology for annual fundoscopy (for previously screened old patients) Follow up ASAP with For follow up laboratories Refer to HACT for counselling and testing (all urethritis and other STI’s) results Refer to GI for possible colonoscopy Refer to Nutrition Clinic for Diet Plan: Write type of Diet (DM, DASH, Low purine, low Follow up after 2 For Viral Exanthem T/C Varicella, Herpes zoster salt, low fat, low calorie etc) and for Obese or underweight compute diet prescription weeks once lesions HACT means HIV-AIDS Core Team. But writing “HIV” or “AIDS” on patient’s charts or have DRIED requests is taboo so we use HACT instead. Follow up once seen For patients referred to other departments by - Hypertensive Urgency SBP > 180mmHg or DBP >120mmHg refractory despite rest and giving maintenance medications, ask the patient to rest and take BP after NEVER WRITE ON THE CHART “FF UP ONCE WITH RESULTS” or “To come 15 minutes, if still elevated, give long-acting oral anti-hypertensives(ARBS or back” ACEis) then re-check after 15 minutes, if still elevated, give CCBs then recheck, NEVER FORGET TO GIVE A PATIENT A FOLLOW UP CARD. is still elevated, ask assistance to Resident for coordination to ER (if not available, Ask the patient to always bring the follow up card and his/her Hospital ID ”green” ask patient’s relative to buy Irbesartan 150mg/tablet or Telmisartan 40mg/tablet at Card. the Pharmacy; if no companion, ask for assistance of a resident) IF IN DOUBT, USE 3 DAYS FOLLOW UP - Hypertension with signs of end-organ damage (vascular and hemorrhagic stroke, ADVISED (always end your charting with it.) retinopathy, myocardial infarction, heart failure, proteinuria and renal failure) - Congestive Heart Failure NYHA III or IV with unstable vital signs and has overt AT THE END OF EVERY PLAN DO NOT FORGET THE FOLLOWING: signs of congestion (anasarca, rales, distended neck veins, difficulty of breathing) YOUR FULL NAME AND SIGNATURE - Community-Acquired Pneumonia, Moderate Risk and High Risk TIME RECEIVED - Dengue with Warning Signs (No urine output for the past 6 hours, active bleeding, TIME INTERVIEWED hypotension) TIME REFERRED TO THE RESIDENT - Leptospirosis moderate-severe (acute febrile illness, unstable vital signs, icteric TIME DISCHARGED: TIME THE RESIDENT WAS FINISHED SEEING THE PATIENT. sclera or jaundice, abdominal pain, nausea, vomiting and diarrhea, EXCLUDE THE TIME YOU USED TO CORRECT AND CARRY OUT CORRECTED oliguria/anuria, meningeal irritation, sepsis/septic shock, altered mental status, PATIENT PLANS. difficulty of breathing, hemoptysis) - COVID-19, Suspect, Severe or Critical (with unstable vital signs, same signs and symptoms with CAP-MR, difficulty of breathing) PATIENT FOLLOW UPS - Bronchial Asthma in Acute Exacerbation refractory despite given three Always review previous charting. nebulizations and chest physiotherapy SOAP format - Symptomatic Anemia (anemia with laboratory evidence with symptoms of pallor, dyspnea, easy fatigability, lightheadedness); Anemia with evidence (CBC Subjective: 24 hours 60 mmHg as needed for colds. with or without the following symptoms: - triggered by exercise, laughter, - Temp >36C or 37.8 -Older than 35 years old with significant May gargle with Chlorhexidine oral smoking history at bedtime for 5 days solution 3x a day after meals. -Alpha-antitrypsin deficiency Butamirate 50mg/tab, 1 tab every 8 Cold soft diet -History of Significant exposure to indoor hours for 5 days Increase oral fluid intake or outdoor air pollution, occupational N-Acetylcysteine 600mg/sachet, Refer to ENT-OHNS for further Cetirizine 10 mg/tab, 1-tab once a day at dusts, or chemicals dissolve 1 sachet in 1/2 glass water evaluation and management (If with bedtime for 1 week or -Smoking history of >40 pack years and drink for 5 days Hypertrophic tonsils) Loratadine 10 mg/tab 1-tab once a day Spirometry with Bronchoprovocative test Well-balanced diet Follow up after 3 days for 1 week (Metacholine Test) Advised Increase oral fluid intake to 2.5L/day Hypoallergenic diet Salbutamol + Ipratropium bromide Adequate rest and sleep Increase oral fluid intake Allergen Identification and avoidance. nebules, nebulize with 1 nebule up to Moderate intensity exercise 5x a week, Avoid exposure to cigarette smoke, pets, 3 doses 15 minutes apart as needed 30 minutes a day and known allergens for shortness of breath then Q8 for 3- Home isolation for 7 days (Inquire about Recommended pneumococcal and 5 days COVID immunization status) influenza vaccines (age dependent) Start Indacaterol + Glycopyrronium Habilin form issued Follow up after 3 days 110/50 mcg/actuation, 1-2 puffs once a day Refer to LGU/BHERT for monitoring of Advised Identify potential allergens, allergen symptoms during isolation period avoidance, hypoallergenic diet, proper COVID-19 minimum infection protocols: cough etiquette, droplet precaution, droplet precaution, proper cough increase oral fluid intake etiquette, wear mask at all times, Recommended pneumococcal and practice social distancing, regular hand influenza vaccines (age dependent) Procedure done: Demo use of hygiene metered dose inhaler / rotahaler / Recommend influenza and asthma device pneumococcal immunization once Follow up after 3 days current infection is resolved Advised WOF: Difficulty of breathing, O2 FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY EAMC DFCM OPD Charting Guidelines as of March 2022 DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline. saturation 40 YRS. OLD WITH CHEST PAIN, Chest Xray PAL if indicated DO NOT COMPLETE THE CHART YET AND REFER Irbesartan 150 or 300 mg/tab, 1-tab once a day THE PATIENT RIGHT AWAY TO THE RESIDENT ON Telmisartan 40 or 80 mg/tab 1-tab once a day DUTY. DO HEART SCORE USING MDCALC AND Losartan 50 or 100 mg/tab, 1-tab once a day or q12 THE ROD WILL DECIDE IF PATIENT IS FOR STAT 12 Amlodipine 5 or 10 mg/tab, 1-tab once a day (watch L ECG OR IMMEDIATE ER REFERRAL. out for signs of edema) If patient came back with 12 L ECG strip photocopy Strict compliance with medications within the day, write STAT 12 L ECG done. Daily BP monitoring and record If patient refuses due to any circumstance, have the Advised smoking cessation (if present) 12 L ECG, FBS, LP, BUA, CBC with PC, UA, Na, K, Cl, patient signed Release of Responsibility Form and Moderate to vigorous activity 3-4days/week averaging iCa, BUN, Crea, SGPT SGOT indicate the reason for refusal. Then write, 40 minutes per session 2D echo with doppler studies STAT 12 L ECG/ ER referral refused; waiver signed. (If newly diagnosed HTN), Patient education on Chest Xray PAL For FBS, LP, BUA, CBC with PC, UA, Na, K, Cl, BUN, hypertension, risk factors, compliance to medications, BNP, TSH Crea, SGPT SGOT complications ARBS 2D echo with doppler studies (If normal BMI) Maintenance of normal BMI Losartan 50 or 100 mg/tab, 1-tab once a day, q12 Chest Xray PAL Encourage participation of patient and family members Irbesartan 150 or 300 mg/tab, 1-tab once a day Isosorbide Mononitrate 30 mg/tab 1-tab once a day to community intervention programs Telmisartan 40 or 80 mg/tab 1-tab once a day Isosorbide Dinitrate 5 mg/ tab 1-tab sublingual as Refer to Nutrition Clinic for a diet plan Betablocker needed for chest pain, may repeat up to 3 doses 15 Diet: Low Salt, Low Fat Diet, DASH (Dietary Carvedilol 6.25 mg/ tab half tab q12 minutes apart. Approaches to Stop Hypertension) For asthmatics: Clopidogrel 75 mg/tab 1-tab once a day Habilin Form Given Metoprolol Succinate 100 mg/tab 1 -tab once a day Atorvastatin 40 mg/tab 1-tab once a day at bedtime TC: 1539, CHO: 923, CHON: 231, Fat: 385 Bisoprolol 5 mg/tab 1-tab once a day Watch out for chest pain not relieve by ISDN, advised to Refer to Ophthalmology for official fundoscopy Atenolol 50 mg/tab 1-tab once a day go to ER if unrelieved after 30 minutes. Follow up after 1 week If indicated: Watch out for severe headache may be a side effect of Advised Atorvastatin 40mg/tab 1-tab once a day at bedtime nitrates. Follow up ASAP if with headache. Hypertension suspect (single episode of BP >140/90 Antiplatelets Daily BP monitoring and record mmHg in patients 50 years old if 40 years old and above ALWAYS if 40 years old and above ALWAYS - Family History of upper GI malignancy Rule out ACS if the setting of symptoms is acute Rule out ACS if the setting of symptoms is acute - Unintended weight loss (days) warrants immediate ER referral (days) warrants immediate ER referral - GI bleeding or Iron deficiency Anemia Rule out IHD if the setting of symptoms is Rule out IHD if the setting of symptoms is chronic - Progressive Trouble Swallowing chronic (weeks to months) (weeks to months) - Pain in swallowing ABDOMINAL PAIN PROTOCOL ABDOMINAL PAIN PROTOCOL - Persistent vomiting FOR PATIENTS >40 YRS. OLD WITH FOR PATIENTS >40 YRS. OLD WITH ABDOMINAL - Palpable mass or lymphadenopathy ABDOMINAL PAIN, DO NOT COMPLETE THE PAIN, DO NOT COMPLETE THE CHART YET AND - Jaundice CHART YET AND REFER THE PATIENT RIGHT REFER THE PATIENT RIGHT AWAY TO THE Still follows ABDOMINAL PAIN PROTOCOL AWAY TO THE RESIDENT ON DUTY. THE ROD RESIDENT ON DUTY. THE ROD WILL DECIDE IF ABDOMINAL PAIN PROTOCOL WILL DECIDE IF PATIENT IS FOR STAT 12 L PATIENT IS FOR STAT 12 L ECG OR IMMEDIATE ER FOR PATIENTS >40 YRS. OLD WITH ABDOMINAL ECG OR IMMEDIATE ER REFERRAL. REFERRAL. PAIN, DO NOT COMPLETE THE CHART YET AND If patient came back with 12 L ECG strip If patient came back with 12 L ECG strip photocopy REFER THE PATIENT RIGHT AWAY TO THE RESIDENT photocopy within the day, write STAT 12 L ECG within the day, write STAT 12 L ECG done. ON DUTY. THE ROD WILL DECIDE IF PATIENT IS FOR done. If patient refuses due to any circumstance, have the STAT 12 L ECG OR IMMEDIATE ER REFERRAL. If patient refuses due to any circumstance, have patient signed Release of Responsibility Form and If patient came back with 12 L ECG strip photocopy the patient signed Release of Responsibility indicate the reason for refusal. Then write within the day, write STAT 12 L ECG done. Form and indicate the reason for refusal. Then STAT 12 L ECG/ ER referral refused; waiver signed. If patient refuses due to any circumstance, have the write FBS, LP, BUA, CBC with pc, UA, Na, K, Cl, BUN, patient signed Release of Responsibility Form and STAT 12 L ECG/ ER referral refused; waiver Crea, SGPT SGOT indicate the reason for refusal. Then write signed. Omeprazole 40 mg/cap, 1 cap once a day 30 minutes CBC with PC, Fecal Immunochemical Test c/o Gastro, FBS, LP, BUA, CBC with pc, UA, Na, K, Cl, BUN, before breakfast for 8 weeks T, H. pylori stool antigen test. Crea, SGPT SGOT Avoid spicy, acidic, fatty, and caffeinated food and Omeprazole 40 mg/cap, 1 cap once a day 30 beverages, Small frequent meals, avoid skipping of Omeprazole 40 mg/cap, 1 cap once a day 30 minutes minutes before breakfast for 2-4 weeks meals. before breakfast for 4 weeks Avoid spicy, acidic, fatty, caffeinated food and Maintain upright position 2-3 hours after meals. Dysmotility-like dyspepsia: Domperidone 10 mg/tab 1 tab q beverages Follow up after 3 days 8 as needed for abdominal pain Small frequent meals, avoid skipping of meals Advised FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY EAMC DFCM OPD Charting Guidelines as of March 2022 DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline. Avoid spicy, acidic, fatty, and caffeinated food and Follow up after 3 days beverages, small frequent meals, avoid skipping of meals. Advised Refer to IM-Gastro for possible endoscopy Follow up after 3 days Advised Hemorrhoids (Internal or External) only Internal Acute Gastroenteritis without signs of Biliary cholic to consider Cholelithiasis Hemorrhoids have grading system dehydration For Hepatobiliary Tree ultrasound, - Always inspect to rule out thrombosed which For Fecalysis (if indicated: hematochezia) hemorrhoids which may warrant urgent consult Racecadotril 100 mg/tab 1-tab q8 until 2 consecutive Start Domperidone 10 mg/tab 1 tab q 8 as needed for Diagnostics: none formed stools abdominal pain Pharmacologic: ORS sachet dissolve in 200 ml of clean water and or Hyoscine n-butylbromide 10 mg q8 as needed for 1. Diosmin/Hesperidin 500mg/tablet 2 tablets drink 1 sachet for every bout of loose stool pain. three times a day for 4 days, 2 tablets twice a Proper handwashing, proper food preparation. Avoid fatty food. day for 3 days, 2 tablets once a day for 7 days WOF weakness, drowsiness, persistent vomiting, Watch out for fever, right upper quadrant pain. for a total of 14 days decreased urination. Small frequent meals. Nonpharmacologic: Follow up after 3 days. Follow up after 3 days 1. Warm sitz bath three times a day or as needed Advised for 15 minutes 2. Soft, high fiber diet 3. Avoid straining 4. Increase oral fluid intake Refer to General Surgery for further evaluation and co- management Follow-up once seen by General Surgery Advised Functional Constipation/ Primary Constipation R/O H. pylori infection Intra-abdominal Mass to consider or rule out Large bowel Obstruction. - appropriate for patients with dyspepsia and low risk malignancy Types: gastric cancer (younger than 55, no alarm symptoms - History and PE pointing to malignancy 1. Normal Transit constipation such as weight loss, progressive dysphagia, - PE findings of palpable mass anywhere in 2. Slow transit constipation odynophagia, recurrent vomiting, family history of GI the GI area 3. Disorders of defecation cancer, overt GI bleed, abdominal mass or IDA, or - Strong family history 2 or more for over 3 months: jaundice) - Identify risk factors 1. Fewer than three spontaneous bowel movements per week Diagnostics: 2. Straining during at least 25% of defecations - Endoscopy for >55 or who have alarm 3. Lumpy or hard stools in at least 25% of symptoms defecations PPI should be stopped for 2 weeks prior to: 4. Sensations of incomplete evacuation for at - H. pylori stool antigen test (c/o GI) least 25% of defecations attempts - Urea breath test 5. Sensation of anorectal obstruction or blockage Pharmacologic: for at least 25% of defecation attempts First Line: 6. Manual maneuvering required to defecate of r 1. PPI + Amoxicillin 1g + Clarithromycin at least 25% of defecation attempts twice a day for 7-14 days Imaging: Scout Film of the Abdomen, FIT or FOBT 2. PPI + Clarithromycin 500mg + Metronidazole 500mg twice a day for Pharmacologic: Choose one and remember the MOA and 10-14 days apply in accordance to patient needs 3. PPI + Amoxicillin 1g twice a day for 5 1. Polyethylene Glycol 17 g/ sachet dissolve in days then followed by PPI + 120 ml of water and drink once a day. Clarithromycin 500mg + Tinidazole 2. Psyllium powder 1 tsp or 1 packet once to 500mg or Metronidazole 500mg twice thrice a day a day for another 5 days for a total of 3. Lactulose 15-30mg/day) 10 days 4. Magnesium hydroxide suspension 30-60ml/day 5. Docusate 100mg/tablet 1 tab twice a day 6. Bisacodyl 5-15mg/day 7. Senna tablet 15mg/tablet per day Nonpharmacologic: - Schedule toileting after meals - Exercise - Increase oral fluid intake (20-35g/day) - Increase fiber intake Follow up after 3 days. Advised FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY EAMC DFCM OPD Charting Guidelines as of March 2022 DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline. Genitourinary/ Nephrology Disorders Acute Uncomplicated Cystitis Complicated Urinary Tract Infection Urinary Tract Infection in Male Urethritis/Gonococcal Vaginitis (pre-menopausal women, no prior history Acute pyelonephritis High risk sexual behavior [Z72.5] of UTI within 2x in 6 mos, or 3 in 1 year) UA, Urine GSCS UA, Urine GSCS - Unprotected intercourse No need for Urinalysis - Intercourse under influence Start one Start one of substances Ideally for Nitrofurantoin as 1st line Ciprofloxacin 500 mg/tab 1-tab q12 for Ciprofloxacin 500 mg/tab 1-tab q12 for - Multiple sexual partners treatment but patient opted for cheaper 7-10 days* 7-10 days - Intercourse with persons drug Levofloxacin 250 mg/tab 1-tab once a Levofloxacin 250 mg/tab 1-tab once a with injecting drug use Start one day for 7-10 days day for 7-10 days - Early age of initiation of Cefuroxime 500 mg/tab 1-tab q 12 for Ofloxacin 400 mg/tab 1-tab once a day Ofloxacin 400 mg/tab 1-tab once a day intercourse (WHO before 15 7 days* for 5 days for 5 days years old) Cefaclor 500 mg/tab 1-tab q8 for 7 Cefixime 400 mg/tab 1-tab once a day Cefixime 400 mg/tab 1-tab once a day - Engaging in unnatural and days for 14 days for 14 days unprotected sex Cefixime 200 mg/tab 1-tab q12 for 7 Increase oral fluid intake 2-2.5 L/day, Increase oral fluid intake greater than 2- - Intercourse with female sex days proper perineal hygiene (for women 2.5 L/day workers/ paid sex/ casual Ofloxacin 200 mg/tab 1-tab q12 for 3 only), avoid delays in voiding Avoid delays in voiding sex days Follow up after 3 days Follow up after 3 days Ciprofloxacin 250 mg/tab 1-tab q12 for Advised Advised Urethral Discharge GS/CS, UA, HBSAG, 3 days RPR, HACT Levofloxacin 250 mg/tab 1-tab q12 for Recurrent UTI Ceftriaxone 250 mg TIM as a single 3 days -healthy non-pregnant woman with no known urinary tract abnormalities dose ANST (-) Co-Amoxiclav 625 mg/tab 1-tab q12 -has 3 or more episodes of acute uncomplicated cystitis documented by urine culture PLUS for 7 days during a 12-month period OR 2 or more episodes in a 6-month period. Doxycycline 100mg/tab 1-tab q12 for 7 Well-balanced diet days Avoid prolong sun exposure during Increase oral fluid intake 2-2.5 L/day Urine GSCS prior to initiation of empiric antibiotics doxycycline treatment Avoid delays in voiding OR Follow up after 3 days Any of the antibiotics for acute uncomplicated cystitis may be used in the treatment of Azithromycin 500 mg/tab 2 tabs as a Advised individual episodes of UTI in women with recurrent UTI. single dose (for better compliance) Breakthrough infections during prophylaxis should be treated empirically with any of Alternative: the antibiotics recommended for uncomplicated cystitis other than the antibiotic being Cefixime 400mg/tab PO single dose + given for prophylaxis. Request for a urine culture and modify the treatment Azithromycin 1g PO single dose accordingly. Allergy to Cephalosporins: Gemfloxacin 320mg/tablet PO single dose + Azithromycin 1g PO single dose OR Gentamicin 240mg IM single dose + Azithromycin 1g PO single dose Avoid delays in voiding. Increase oral fluid intake greater than 2.5 L/day, Counselling done: increased patient ‘s awareness on high risk activities, sexual abstinence during treatment, encourage sexual partner screening, and use protective contraception (condoms) Refer to HACT for further counselling Increase oral fluid intake 2-2.5 L/day, proper perineal hygiene (for women only), avoid and testing delays in voiding Follow up after 3 days Follow up after 3 days Advised Advised Benign Prostatic Enlargement with End-Stage Renal Disease secondary Nephrolithiasis (confirmed by UTZ) To consider CKD Stage III -V (Mild/Moderate/Severe Lower urinary to Chronic Glomerulonephritis or For UA (EGFR less than 60 mL/min/1.73m2) tract Symptoms. Hypertensive Kidney Disease or Medical Expulsion therapy: Repeat Creatinine, Use IPSS scoring Diabetic Kidney Disease Tamsulosin 0.4 (400mcg) mg/tab 1-tab Spot Urine Protein/Creatinine Ratio or For KUBP Ultrasound, PSA Continue Hemodialysis (frequency)/ once a day 24-hour urine protein week Sambong tablet 1-tab q8h for 1 month Na, K, Cl, Ca, Mg, Ph, Start Tamsulosin 0.4 (400mcg) mg/tab 1- Continue Medications: K citrate 1080 mg/tab 1-tab Q8 for 1 KUB Ultrasound with Doppler studies tab once a day month Refer to Nutrition Clinic for a diet plan Or Tamsulosin + Finasteride 0.4/5 Renal diet Increase oral fluid intake Diet: Low Salt mg/tab 1-tab once a day (for Prostate Limit fluid intake to less than 1L/day Low salt diet TC: 1539, CHO: 923, CHON: 231, Fat: greater than or equal to 40g in Strict compliance with medications Refer to Urology for further evaluation 385 ultrasound) Daily BP monitoring and record and management (for stones greater For possible referral to IM and Decrease oral fluid intake at bedtime. Refer to Nutrition Clinic for a diet plan than 5 mm) Nephrology once with conclusive Avoid delays in voiding Diet: Low Salt, Low Fat Diet Follow up after 1 month or anytime if with results. Procedure done: Digital rectal TC: 1539, CHO: 923, CHON: 231, Fat: problems Follow up ASAP with results. examination and prostate examination 385 Advised Plan to refer to Urology for further Clinical abstract given and patient evaluation once with results. referred to Social Services Follow up after 1 week Refer to IM-Nephro for further Advised evaluation and co-management. Referral form given! or Arthritic Gouty arthritis in flare Osteoarthritis, Group of Diseases (AGD) to consider Osteoarthritis Limitation of activities due to disability [Z73.6] For severe symptoms add Colchicine 500 mcg/tab 1-tab q8 until 6 days or NON HYPERTENSIVE, LESS THAN 40 YRS OLD Limitation of activities due to disability [Z73.6] relief of symptoms or diarrhea occurs Lumbar MRI if with radiculopathy symptoms >40 YRS OLD, HYPERTENSIVES, DIABETICS, CKD UNLESS THERE IS CONTRAINDICATION: Scoliosis series if with scoliosis Lumbar MRI if with radiculopathy symptoms Uncontrolled hypertension, history of chest pain, MI, Lumbosacral Xray APL if with visible spine deformity or Scoliosis series if with scoliosis stroke, Gastric or duodenal ulcers crepitus Lumbosacral Xray APL if with visible spine deformity or Select one if without any contraindication. Avoid imaging if symptoms are 6 certification. weeks) Follow up after 3 days Referral to LGU for possible psychosocial disability certification. Follow up after 3 days Infectious Diseases Viral Exanthem to consider Varicella Zoster / Herpes Dengue Fever Syndrome w/o warning signs Zoster (Shingles)/ Herpes Zoster ophthalmicus For CBC with PC Fever for 3 days- Dengue NS If within 48 hours from the onset of rash or vesicles. Fever for >3 days- Dengue IgG, IgM Start Acyclovir 800 mg/tab 1-tab q4 hours (8 am, 12 nn, Paracetamol 500 mg/tab 1-tab q4 for fever >37.8 C 4 pm, 8 pm, 12 mn) for 7 days, ORS sachet dissolve in 200 ml of clean water and drink Pregabalin 75mg/tab 1-tab q12 every 3-4 hours as tolerated Keep lesions dry, proper handwashing, avoid scratching Avoid dark-colored foods affected areas. WOF: Urination less than 4-6x per day, Abdominal pain Isolate from household members, or tenderness, Persistent vomiting, Mucosal bleed contact and droplet precaution. (gums, urine, vomitus) For patients with Herpes Zoster ophthalmicus Follow up today with results or at the ER if OPD is Refer to Ophthalmology for further evaluation and already closed. management Advised. Follow up after 2 weeks or once all lesions have DRIED. Have the patient sign on the chart that he/she will come Advised back today with results or at the ER if OPD is closed Example “Ako ay babalik sa OPD or sa ER dala-dala ang resulta ngayong araw na ito” Viral Exanthem to consider Rubeola Leptospirosis, Mild (Moderate- Severe, send to ER) CBC with pc, Measles IgM, IgG c/o Public Health Unit CBC PC, UA, BUN, Crea, SGPT, SGOT, Lepto-MAT Cetirizine 10 mg/tab 1-tab once a day at bedtimefor 2 Doxycycline 100 mg/tab 1-tab q12 for 7 days weeks for pruritus Paracetamol 500 mg/tab 1-tab q4 for fever >37.8 C Loratadine 10mg/tab 1-tab once a day for 2 weeks for ORS sachet dissolve in 200 ml of clean water and drink pruritus every 3-4 hours as tolerated Proper body hygiene, proper handwashing, Keep Increase oral fluid intake lesions clean and dry. Avoid scratching affected areas. WOF: Urination less than 4-6x per day, tea colored Airborne precaution: Isolate from household members, urine, Abdominal pain or tenderness, Persistent wear mask if necessary. vomiting, or yellowing of the skin Watch out for progressive cough, fever, difficulty of Follow up today with results or at the ER if OPD is breathing or shortness of breath. closed. Refer to PHU for surveillance and testing. Advised. Follow up after 1 week. Have the patient sign on the chart that he/she will come Advised back today with results or at the ER if OPD is closed Example “Ako ay babalik sa OPD or sa ER dala-dala ang resulta ngayong araw na ito” Routine Patients ESSENTIALLY WELL ADULT AT THE TIME OF CONSULT (pre-employment) Follow ups from ER (treat as NEW patient) For pre-employment work-up: Chest X-ray PAL, CBC w/ PC, UA, Take note of the history of present Illness before the ER consult. (for food handlers) add FA, Anti-HAV Then: Sought consult at (for strenuous occupation) add 12 L ECG Diagnosed with Well balanced diet Diagnostics done were FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY EAMC DFCM OPD Charting Guidelines as of March 2022 DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline. Adequate oral fluid intake Results were as follows Moderate intensity physical activity 30 mins/day 5x per week as tolerated. (for healthy Prescribed with patients who you think can tolerate exercise) Self-medicated with Follow up ASAP with result With Relief/no relief of symptoms Advised Patient came in today as follow up per ED instructions. Endocrine / Metabolic/ Hematology Disorders Anterior Neck Mass to consider Multinodular Anterior Neck Mass to consider Hypothyroidism sec Diabetes Mellitus Type 2 Toxic/Non-Toxic Goiter, Hyperthyroidism, to (RAI/ Hashimoto Thyroiditis/ Multinodular Non- Diabetes Mellitus Type 2 suspect Toxic Goiter/ Total Thyroidectomy) Diabetes Mellitus Type 2, insulin-requiring If mass is small, do Thyroid Ultrasound Priority labs: FBS, HBA1C (if known DM prior to consult) If mass is large or with CLAD, do Neck Ultrasound FBS only (if for DM suspect) LP, BUN, Crea, UA, 12 L TSH, Free T4, Free T3, Calcium (if S/P total ECG. Thyroidectomy), BUA, CBC with pc, Na, K, Cl, SGPT SGOT Hypothyroid medications: Chest X-ray PAL if indicated Less than 65 yrs old: Initial Low dose: Levothyroxine 50 mcg/tab 1-tab once a Or Start Metformin 500mg/tab 1-tab q8h day Gliclazide 80 mg/tab 1-tab once a day/Q12 Full-dose Levothyroxine (1.6 to 1.7 mcg per kg) For CKD patients (EGFR less than 60) 65 years and older or who have ischemic heart Glimepiride 2 mg/tab 1-tab once a day/q12 For PATIENTS IN IMPENDING STORM: Compute disease, start with: Levothyroxine 25 to 50 mcg per day Sitagliptin 50 or 100 mg/tab 1-tab once a day using the Burch-Wartofsky Scoring Avoid goitrogenic food such as brussel sprouts, For HBA1C >10 %: Insulin Glargine (0.1 to 0.2 IU/Kg) If mass is small, do Thyroid Ultrasound radishes, cabbage, and cauliflower, iodine rich foods. or 10 IU SQ ODHS If mass is large or with CLAD, do Neck Ultrasound Watch out for lack of energy, sleepiness, weight gain, or Atorvastatin 20 mg/ tab 1-tab once a day at bedtime TSH, Free T4, Free T3, Calcium), lethargy (ALWAYS START FOR PTS WITH DM) Prioritize TSH, FT4 For possible referral to ENT-OHNS once with results Strict compliance with medications CBC with PC, SGPT, SGOT. Follow up ASAP with results. Daily foot care, proper foot gear Advised Procedure done: Comprehensive foot exam for DM Antithyroid medications: patient Methimazole 5mg/tab 1-tab q8h (then adjust accordingly Procedure done: Insulin therapy demonstration at increments of 5mg) Refer to Nutrition Clinic for a diet plan Propranolol 10/tab 1-tab once a day for palpitations, Diet: DM diet tachycardia. TC: 1539, CHO: 923, CHON: 231, Fat: 385 Avoid goitrogenic food such as Brussel sprouts, Refer to Ophthalmology for official fundoscopy radishes, cabbage, and cauliflower. Recommended pneumococcal and influenza vaccines Watch out for fever, sore throat, generalized body (age dependent) malaise, chest pain, severe palpitations, nervousness, Follow up after 1 week fatigue. Advised For possible referral to ENT-OHNS once with results Follow up ASAP with results. Advised Monitoring Dyslipidemia Asymptomatic Hyperuricemia Every visit: Feet inspection When to start? Repeat BUA after 2 months Annual: 1. All diabetics, Stroke (CVA), TIA or MI patients should Urinary albumin, EGFR, Spot Albumin/Crea ratio be started on a HIGH INTENSITY STATIN. WHEN TO START URICOSURIC AGENTS? 10g monofilament testing 2. !"#$%&'()$*+$',&$-./01$)2*(&$34567 If with history of gout or uric acid Nephrolithiasis Every 1-2 years: Comprehensive diabetic eye exam 7 mg/dl (416 umol/L) in men 3. !$"6$%&'()$89:;$