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PATIENT VISIT Patient Name:
Location: Date: / / DOB: / / Age: yrs mos days
CLINICIAN: / / T RR HR BP / O2Sat
Last MD Visit: Last Anti-Helminth Rx: LMP: < 4 wks; > 4wks
Pre Post
No problems No problema Weight: kg Height: cm
Wt for Age (percentile): <3, 3, 15, Median, 85, 97, >97
Reueolle Dolor de cabeza Dolor abdominal Respirar el problema Tos GEN: Ill-appearing Y N
Wheezing Headache Abdominal Pain Breathing Problem Cough HEENT: Normal / Abnormal
RESP: Normal / Abnormal
Llanta Fiebre Dolor de pecho Problema menstrual Cargue la perdida CV: Normal / Abnormal
Crying Fever Chest Pain Menstrual Problems Wt loss SKIN: Normal / Abnormal
Fatiga Diarrea Nariz liquida Dolor de espalda Palidezca/anemia □ Glucose □ UA □ UPT
Fatigue Diarrhea Runny Nose Back Pain Pale/Anemia □ Syphilis □ HIV □ TB
□ Thin/Thick □ Malaria
Picar ojos Sudores Calambres Dolor de hueso Garganta adolorida □ Dengue □ Troponin
Itchy Eyes Sweats Cramps Bone Pain Sore Throat □ H.pylori □ Hgb
Other/Otro:
Assessment/Plan: (See reverse)
HEALTH MAINTAINANCE
□ #180, Adult Multivitamin, 1 daily
□ #180, Pediatric Multivitamin, 1 daily
□ #1, Infant Multviatamin, 1 ml daily
□ #100, Folic Acid 800 mcg, 1 daily
- offer to all females > 17
□ #270, Prenatal Vitamins, 1 daily
- offer pregnancy test if LMP>4wk
- UPT: pos or neg
□ Albendazole 400 mg x 1
- after next period or if neg upt
SCABIES / LICE
□ 0.5 oz, Lice Treatment
□ 2 oz, Scabies treatment
□ 60g, Permithrin cream 5%
Malaria – P. vivax confirm: Y N
Hydroxychloroquine 200 (155 mg base)
□ #10, 4 now, 2 pills in 6 to 8 hours
□ (PEDS) ~10 mg/kg base once then
5mg/kg base in 6 to 8 hours
Has had Primaquine before? Y N
□ Primaquine 15 mg, 2 daily x 14 days
□ Primaquine 15 mg, 3 pills weekly for 8 weeks (if naïve to primaquine)
Ferrous sulfate 325
□ #25, 1 pill daily for anemia
□ #50, 1 pill daily for anemia
DENGUE – test pos or neg
ASTHMA / RAD / COPD
Prednisone 5mg/5ml
□ (<5kg) 60 ml, 2 tsp daily x 5 days
□ (5-7.5kg) 90 ml, 2 tsp daily x 5 days
Prednisone 5mg
□ (7.5-10kg) #15, 3 po daily x 5 days
□ (10-15 kg) #20, 4 po daily x 5 days
□ (>15 kg) #30, 6 po daily x 5 days
□ (COPD) #40, 4 po twice daily x 5d
Albuterol MDI
□ #1 MDI, 2 puffs every 4 to 6 hours
as needed for difficulty breathing
Tiotropium MDI
□ #150 caps, 1 inhalation daily
AOM / Sinusitis / Pneumonia
Amoxicillin 125/5ml suspension:
□ (4.5-9 kg) 160 mls, 1 teasthingy
three times daily for 10 days
Amoxicillin 250 (40-80/kg/day):
□ (>9kg) #20, 1 three times daily x 7d
□ (>9kg) #30, 1 three times daily x 10d
Amoxicillin 500 (40-80/kg/day):
□ (>19kg) #20,1 three times daily x 5d
□ (>19kg)#30,1 three times daily x 10d
□ #60, 2 three times daily x 10 days
Cefdinir 250mg/5ml(14mg/kg/d divq12)
□ (17-35kg) 35 mls, ½ teasthingy
□ (>35kg) 70 mls, 1 teasthingy
- twice daily for 7 days
Cefprozil 125 mg/5 ml (15-30mg/kg/d)
□ 8-16 kg, 50 mls, ½ teasthingy
□ 17-32 kg, 100 mls, 1 teasthingy
- twice daily for 10 days
Cefprozil 250 mg/5 ml (15-30mg/kg/d)
□ (9-17 kg) 50 mls, ½ teasthingy
□ (18-36 kg) 100 mls, 1 teasthingy
- twice daily for 10 days
Cefprozil 500 mg tab
□ #10, 1 tab daily for 10 days
□ #20, 1 tab twice daily for 10 days
SKIN inFECTION/ RASH / TINEA
Cephalexin 250 mg (25-100/kg/d¸q6-8)
□ #15 (8-30kg) 1 three times daily x 5d
□ #20 (>30kg), 1 four times daily x 5d
Cephalexin 500 mg
□ #20(>30kg) 1 four times daily x 5 d
SMX 800 mg+TMP 160 mg
□ #10 halves(>16kg), 1 twice daily x5d
□ #10 (>32 kg), 1 twice daily x 5 days
□ #20, 1 twice daily x 10 days
SMX 200 mg +TMP40 mg / 5ml (>2mos)
□ (5-10kg) 30 mls, ½ teasthingy
□ (>10 kg) 60 mls, 1 teasthingy
- Twice daily for 5 days
- (8-10mg/kg/d TMP div q12)
Triple Antibiotic
□ 0.9 g Packets, apply twice daily
□ 30 g tube, apply twice daily
Clotrimazole 1%
□ 24g tube, apply to rash twice daily
□ 30g tube, apply to rash twice daily
Silver sulfadiazine
□ 50g, apply to wound twice a day
Nystatin/Triamcinalone
□ 15g, Apply to rash twice daily
Terbinafine 250 mg
□ #14, one daily for 14 days
□ #42 halves, one daily for 42 days
□ #42, one daily for 42 days
Arthritis/PAIN/Fever/Gout
Ibuprofen 200
(max 10mg/kg/dose or 600)
□ #15, 1 pill every 6 hours as needed
Acetaminophen 500
(max 15mg/kg/dose or 1000)
□ #10, 1 pill every 6 hours as needed
Acetaminophen 325
(max 15mg/kg/dose or 650)
□ #10, 1 pill every 6 hours as needed
Acetaminophen 80
(max 15mg/kg/dose)
□(>5kg) #10, 1 every 6 hrs as needed
Acetaminophen 80mg/0.8 ml
□ (2.7-5.4kg) 0.4 mls (1st line) every 6 hours as needed for pain or fever
□ (>4kg) 0.8 mls (2nd line) every 6 hours as needed for pain or fever
Allopurinol 100 mg □ One daily (gout)
Eczema / Itching / Insomnia
Hydrocortisone 1%
□ 30g, Apply to rash twice daily
Diphenhydramine 25 mg
□ #20,one every 6 hours as needed
Diphenhydramine 50 mg
□ #20,one every 6 hours as needed
Giardia / Amebiasis
Metronidazole 250
□ #15, 1 pill three times daily x 5d
□ #30, 2 pills three times daily x 5d
□ #42, 2 pill three times daily x 7d
□ Patient instructed to avoid alcohol
URI / Pharyngitis
Penicillin (Pen Vee K) 250
□ #20, 1 pill three times daily
Chlorphenaramine 4 (0.35/kg/d div q6)
□ #10 halves, ½ tablet every four hrs as needed for congestion
Diphenhydramine 25 mg
□ #20, one every 6 hours as needed for congestion
Guaifenesin 100 mg/5 ml
□ 60mls, 1 teasthingy every 4 hours as needed for cough
Pseudoephedrine 30
□ #15, one every 6 hours as needed for congestion
enteritis / Dysentery
ORT – give instructions
□ 1 Liter □ 2 Liters □ 3 Liters
Loperamide 2mg/10ml unit dose
□ (>2yo) #10, 5ml following diarrhea, max 3 doses per day
□ (>6-8yo) #10, 10ml following initial diarrhea then 5 ml as needed, max 3 doses per day
□ (8-11yo) #10,10ml once then 5 ml as needed for diarrhea,max 5 doses a day
Loperamide 2 mg tablet
□ (>12yo) #10, 2 pills then one as needed following diarrhea
Ciprofloxacin 500
□ #10, 1 pill twice daily x 5 days
SMX 200 mg +TMP40 mg / 5ml (>2mos)
□ (5-10kg) 30 mls, ½ teasthingy
□ (>10 kg) 60 mls, 1 teasthingy
- Twice daily for 5 days
SMX-TMP 800-160
□ #10, 1 twice daily x 5 days
Constipation / Dyspepsia
Bisacodyl 5
□ # 10, 1 or 2 pills daily as needed for
constipation
Ranitidine 150 (for indigestion/reflux)
□ #28 halves, ½ once daily as needed
□ # 28, 1 once daily as needed
□ # 40, 1 twice daily as needed
Docusate Sodium 100
□ #25, 1 pill once daily as needed to soften stools
□ #50, 1 pill twce daily as needed to soften stools
Calcium Carbonate 500
□ #20, 1-2 as needed for Indigestion
Vaginitis/urethritis/salpin
Fluconazole 200
□ #1, 1 pill once
□ #3, 1 pill daily x 3 days
Ciprofloxacin 500 mg
□ #1, 1 pill for GC
Amoxicillin 500 mg
□ #20, one three times daily x 7d OR
Doxycycline 100 mg
□#14, one twice dailyx7d for Chlamydia
Metronidazole 250 mg
□ #8, 8 pills x 1 for trichomonas
□ #21, one three times daily x7d for BV
Cystitis / Pyelo
Ciprofloxacin 500
□ #6, 1 pill twice daily x 3 days
□ #14, 1 pill twice daily x 5 days
SMX-TMP800-160 (6-12/kg TMP div q12)
□ #10, 1 pills twice daily x 5 days
HTN / ANGINA / CVA / USA
□ ASA 81, #300, one pill daily
□ HCTZ 25, #300, one pill daily
□ Atenolol 100, #300 halves, one daily
□ Atenolol 100, #300, one daily
□ Enalapril 10, #330, one pill daily
(not in pregnancy)
□ Lasix 20, #20, 1 pill daily as needed
□ Lasix 40, #20, 1 pill daily as needed
□ Trandalopril 2mg/verapamil 240mg
# 350, one daily (not in pregnancy)
□ Bisoprolol 10mg/HCTZ 6.25 mg
□ Isosorbide mononitrate 60 mg, # 250,
one daily
□ Diltiazem 180 mg, #360, one daily
Diabetes
□ Metformin 500, #333, 1 pill daily
□ Metformin 500, #600, one twice daily
□ Metformin 1000,#350,one twice daily
□ Glipizide ER 5, #270, one daily
□ Glipizide ER 5, #600, one twice daily
□ Glipizide ER 10, #250, one daily
DEPRESSION/ANXIET/Seizure
□ Sertraline 50 mg, #360, one daily
□ Paroxetine 10 mg, #360, one daily
□ 12 month’s supply given with help from social support / family
□ Dilantin 100 mg, #300, three daily
H. PYLORI / REFLUX
H. pylori test neg pos
Omeprazole 20mg
□ #28, one daily
□ Quadruple therapy: 14 day course of:
Bismuth 262mg, #112, Two 4 times/d
Metronidazole 250mg,#56,one 4 times/d
Amoxicillin 500 mg, #28, one 2 times/d
Omeprazole 20mg,#28, one twice daily
Osteomyelitis
Dicloxicillin 250 (12.5-25/kg/d¸q6)
□ #200, 1 four times daily x 50 days
Thrush / Candidiasis
Nystatin 100,000U/ml Suspension
□ 1 ml each cheek 4 times daily
Fluconazole 200
□ #10, 1 pill daily x 10 days
□ Consider refer for HIV counseling if risk factors present
Syphilis / HSV / PCP Proph
□ T. pallidum serology pos or neg
□ no evidence of neurosyphylis
Pen G benzathine □ 2.4 M units x 1
Duration > 1yr
Acyclovir 200
□ #25, 2 pills three times daily x 4d
□ , #50, 2 pills five times daily x 5d
SMX-TMP 800-160 □ , #60, one daily
Alabama Honduran Medical Education Network: Jan 27, 2008
PATIENT VISIT Patient Name:
Location: Date: / / DOB: / / Age: yrs mos days
CLINICIAN: / / T RR HR BP / O2Sat
Last MD Visit: Last Anti-Helminth Rx: LMP: < 4 wks; > 4wks
Pre Post
No problems No problema Weight: kg Height: cm
Wt for Age (percentile): <3, 3, 15, Median, 85, 97, >97
Reueolle Dolor de cabeza Dolor abdominal Respirar el problema Tos GEN: Ill-appearing Y N
Wheezing Headache Abdominal Pain Breathing Problem Cough HEENT: Normal / Abnormal
RESP: Normal / Abnormal
Llanta Fiebre Dolor de pecho Problema menstrual Cargue la perdida CV: Normal / Abnormal
Crying Fever Chest Pain Menstrual Problems Wt loss SKIN: Normal / Abnormal
Fatiga Diarrea Nariz liquida Dolor de espalda Palidezca/anemia □ Glucose □ UA □ UPT
Fatigue Diarrhea Runny Nose Back Pain Pale/Anemia □ Syphilis □ HIV □ TB
□ Thin/Thick □ Malaria
Picar ojos Sudores Calambres Dolor de hueso Garganta adolorida □ Dengue □ Troponin
Itchy Eyes Sweats Cramps Bone Pain Sore Throat □ H.pylori □ Hgb
Other/Otro:
Assessment/Plan: (See reverse)
HEALTH MAINTAINANCE
□ #180, Adult Multivitamin, 1 daily
□ #180, Pediatric Multivitamin, 1 daily
□ #1, Infant Multviatamin, 1 ml daily
□ #100, Folic Acid 800 mcg, 1 daily
- offer to all females > 17
□ #270, Prenatal Vitamins, 1 daily
- offer pregnancy test if LMP>4wk
- UPT: pos or neg
□ Albendazole 400 mg x 1
- after next period or if neg upt
SCABIES / LICE
□ 0.5 oz, Lice Treatment
□ 2 oz, Scabies treatment
□ 60g, Permithrin cream 5%
Malaria – P. vivax confirm: Y N
Hydroxychloroquine 200 (155 mg base)
□ #10, 4 now, 2 pills in 6 to 8 hours
□ (PEDS) ~10 mg/kg base once then
5mg/kg base in 6 to 8 hours
Has had Primaquine before? Y N
□ Primaquine 15 mg, 2 daily x 14 days
□ Primaquine 15 mg, 3 pills weekly for 8 weeks (if naïve to primaquine)
Ferrous sulfate 325
□ #25, 1 pill daily for anemia
□ #50, 1 pill daily for anemia
DENGUE – test pos or neg
ASTHMA / RAD / COPD
Prednisone 5mg/5ml
□ (<5kg) 60 ml, 2 tsp daily x 5 days
□ (5-7.5kg) 90 ml, 2 tsp daily x 5 days
Prednisone 5mg
□ (7.5-10kg) #15, 3 po daily x 5 days
□ (10-15 kg) #20, 4 po daily x 5 days
□ (>15 kg) #30, 6 po daily x 5 days
□ (COPD) #40, 4 po twice daily x 5d
Albuterol MDI
□ #1 MDI, 2 puffs every 4 to 6 hours
as needed for difficulty breathing
Tiotropium MDI
□ #150 caps, 1 inhalation daily
AOM / Sinusitis / Pneumonia
Amoxicillin 125/5ml suspension:
□ (4.5-9 kg) 160 mls, 1 teasthingy
three times daily for 10 days
Amoxicillin 250 (40-80/kg/day):
□ (>9kg) #20, 1 three times daily x 7d
□ (>9kg) #30, 1 three times daily x 10d
Amoxicillin 500 (40-80/kg/day):
□ (>19kg) #20,1 three times daily x 5d
□ (>19kg)#30,1 three times daily x 10d
□ #60, 2 three times daily x 10 days
Cefdinir 250mg/5ml(14mg/kg/d divq12)
□ (17-35kg) 35 mls, ½ teasthingy
□ (>35kg) 70 mls, 1 teasthingy
- twice daily for 7 days
Cefprozil 125 mg/5 ml (15-30mg/kg/d)
□ 8-16 kg, 50 mls, ½ teasthingy
□ 17-32 kg, 100 mls, 1 teasthingy
- twice daily for 10 days
Cefprozil 250 mg/5 ml (15-30mg/kg/d)
□ (9-17 kg) 50 mls, ½ teasthingy
□ (18-36 kg) 100 mls, 1 teasthingy
- twice daily for 10 days
Cefprozil 500 mg tab
□ #10, 1 tab daily for 10 days
□ #20, 1 tab twice daily for 10 days
SKIN inFECTION/ RASH / TINEA
Cephalexin 250 mg (25-100/kg/d¸q6-8)
□ #15 (8-30kg) 1 three times daily x 5d
□ #20 (>30kg), 1 four times daily x 5d
Cephalexin 500 mg
□ #20(>30kg) 1 four times daily x 5 d
SMX 800 mg+TMP 160 mg
□ #10 halves(>16kg), 1 twice daily x5d
□ #10 (>32 kg), 1 twice daily x 5 days
□ #20, 1 twice daily x 10 days
SMX 200 mg +TMP40 mg / 5ml (>2mos)
□ (5-10kg) 30 mls, ½ teasthingy
□ (>10 kg) 60 mls, 1 teasthingy
- Twice daily for 5 days
- (8-10mg/kg/d TMP div q12)
Triple Antibiotic
□ 0.9 g Packets, apply twice daily
□ 30 g tube, apply twice daily
Clotrimazole 1%
□ 24g tube, apply to rash twice daily
□ 30g tube, apply to rash twice daily
Silver sulfadiazine
□ 50g, apply to wound twice a day
Nystatin/Triamcinalone
□ 15g, Apply to rash twice daily
Terbinafine 250 mg
□ #14, one daily for 14 days
□ #42 halves, one daily for 42 days
□ #42, one daily for 42 days
Arthritis/PAIN/Fever/Gout
Ibuprofen 200
(max 10mg/kg/dose or 600)
□ #15, 1 pill every 6 hours as needed
Acetaminophen 500
(max 15mg/kg/dose or 1000)
□ #10, 1 pill every 6 hours as needed
Acetaminophen 325
(max 15mg/kg/dose or 650)
□ #10, 1 pill every 6 hours as needed
Acetaminophen 80
(max 15mg/kg/dose)
□(>5kg) #10, 1 every 6 hrs as needed
Acetaminophen 80mg/0.8 ml
□ (2.7-5.4kg) 0.4 mls (1st line) every 6 hours as needed for pain or fever
□ (>4kg) 0.8 mls (2nd line) every 6 hours as needed for pain or fever
Allopurinol 100 mg □ One daily (gout)
Eczema / Itching / Insomnia
Hydrocortisone 1%
□ 30g, Apply to rash twice daily
Diphenhydramine 25 mg
□ #20,one every 6 hours as needed
Diphenhydramine 50 mg
□ #20,one every 6 hours as needed
Giardia / Amebiasis
Metronidazole 250
□ #15, 1 pill three times daily x 5d
□ #30, 2 pills three times daily x 5d
□ #42, 2 pill three times daily x 7d
□ Patient instructed to avoid alcohol
URI / Pharyngitis
Penicillin (Pen Vee K) 250
□ #20, 1 pill three times daily
Chlorphenaramine 4 (0.35/kg/d div q6)
□ #10 halves, ½ tablet every four hrs as needed for congestion
Diphenhydramine 25 mg
□ #20, one every 6 hours as needed for congestion
Guaifenesin 100 mg/5 ml
□ 60mls, 1 teasthingy every 4 hours as needed for cough
Pseudoephedrine 30
□ #15, one every 6 hours as needed for congestion
enteritis / Dysentery
ORT – give instructions
□ 1 Liter □ 2 Liters □ 3 Liters
Loperamide 2mg/10ml unit dose
□ (>2yo) #10, 5ml following diarrhea, max 3 doses per day
□ (>6-8yo) #10, 10ml following initial diarrhea then 5 ml as needed, max 3 doses per day
□ (8-11yo) #10,10ml once then 5 ml as needed for diarrhea,max 5 doses a day
Loperamide 2 mg tablet
□ (>12yo) #10, 2 pills then one as needed following diarrhea
Ciprofloxacin 500
□ #10, 1 pill twice daily x 5 days
SMX 200 mg +TMP40 mg / 5ml (>2mos)
□ (5-10kg) 30 mls, ½ teasthingy
□ (>10 kg) 60 mls, 1 teasthingy
- Twice daily for 5 days
SMX-TMP 800-160
□ #10, 1 twice daily x 5 days
Constipation / Dyspepsia
Bisacodyl 5
□ # 10, 1 or 2 pills daily as needed for
constipation
Ranitidine 150 (for indigestion/reflux)
□ #28 halves, ½ once daily as needed
□ # 28, 1 once daily as needed
□ # 40, 1 twice daily as needed
Docusate Sodium 100
□ #25, 1 pill once daily as needed to soften stools
□ #50, 1 pill twce daily as needed to soften stools
Calcium Carbonate 500
□ #20, 1-2 as needed for Indigestion
Vaginitis/urethritis/salpin
Fluconazole 200
□ #1, 1 pill once
□ #3, 1 pill daily x 3 days
Ciprofloxacin 500 mg
□ #1, 1 pill for GC
Amoxicillin 500 mg
□ #20, one three times daily x 7d OR
Doxycycline 100 mg
□#14, one twice dailyx7d for Chlamydia
Metronidazole 250 mg
□ #8, 8 pills x 1 for trichomonas
□ #21, one three times daily x7d for BV
Cystitis / Pyelo
Ciprofloxacin 500
□ #6, 1 pill twice daily x 3 days
□ #14, 1 pill twice daily x 5 days
SMX-TMP800-160 (6-12/kg TMP div q12)
□ #10, 1 pills twice daily x 5 days
HTN / ANGINA / CVA / USA
□ ASA 81, #300, one pill daily
□ HCTZ 25, #300, one pill daily
□ Atenolol 100, #300 halves, one daily
□ Atenolol 100, #300, one daily
□ Enalapril 10, #330, one pill daily
(not in pregnancy)
□ Lasix 20, #20, 1 pill daily as needed
□ Lasix 40, #20, 1 pill daily as needed
□ Trandalopril 2mg/verapamil 240mg
# 350, one daily (not in pregnancy)
□ Bisoprolol 10mg/HCTZ 6.25 mg
□ Isosorbide mononitrate 60 mg, # 250,
one daily
□ Diltiazem 180 mg, #360, one daily
Diabetes
□ Metformin 500, #333, 1 pill daily
□ Metformin 500, #600, one twice daily
□ Metformin 1000,#350,one twice daily
□ Glipizide ER 5, #270, one daily
□ Glipizide ER 5, #600, one twice daily
□ Glipizide ER 10, #250, one daily
DEPRESSION/ANXIET/Seizure
□ Sertraline 50 mg, #360, one daily
□ Paroxetine 10 mg, #360, one daily
□ 12 month’s supply given with help from social support / family
□ Dilantin 100 mg, #300, three daily
H. PYLORI / REFLUX
H. pylori test neg pos
Omeprazole 20mg
□ #28, one daily
□ Quadruple therapy: 14 day course of:
Bismuth 262mg, #112, Two 4 times/d
Metronidazole 250mg,#56,one 4 times/d
Amoxicillin 500 mg, #28, one 2 times/d
Omeprazole 20mg,#28, one twice daily
Osteomyelitis
Dicloxicillin 250 (12.5-25/kg/d¸q6)
□ #200, 1 four times daily x 50 days
Thrush / Candidiasis
Nystatin 100,000U/ml Suspension
□ 1 ml each cheek 4 times daily
Fluconazole 200
□ #10, 1 pill daily x 10 days
□ Consider refer for HIV counseling if risk factors present
Syphilis / HSV / PCP Proph
□ T. pallidum serology pos or neg
□ no evidence of neurosyphylis
Pen G benzathine □ 2.4 M units x 1
Duration > 1yr
Acyclovir 200
□ #25, 2 pills three times daily x 4d
□ , #50, 2 pills five times daily x 5d
SMX-TMP 800-160 □ , #60, one daily
Alabama Honduran Medical Education Network: Jan 27, 2008