Consider using meloxicam and diclofenac more often. Meloxicam is once daily.
What if I put a minimum age and pregnancy category on each med?
With or without food?
What is my end goal? Combine the Otitis Media Rx on this page with the Otitis Media MDM and adult and ped PLANs
Otitis Media
- Right AOM ICD-10 Code H66.91 Otitis media, unspecified, right ear
- Left AOM ICD-10 Code H66.92 Otitis media, unspecified, left ear
Amoxicillin 500 mg oral tablet
Take one tab oral three times a day for 7 days
SIG
21 tablets
DISPENSE
Capsules may be subbed for tabs
Pharmacist note
Amoxicillin 500 mg oral tablet
Take one tab oral three times a day for ten days
SIG
30 tablets
DISPENSE
Capsules may be subbed for tabs
Pharmacist note
Notes:
5-7 days for mild-moderate AOM
10 days for severe AOM
Treat perf TM the same, but some people add drops in addition to oral. Weak evidence for that.
See also, and eventually combine this all:
AOM MDM Macro
AOM Adult plan
AOM Peds plan
Sinusitis
- ICD-10 Code J01.00 Acute maxillary sinusitis, unspecified
- ICD-10 Code J01.10 Acute frontal sinusitis, unspecified
- ICD-10 Code J01.90 Acute pansinusitis or Acute sinusitis, unspecified
Amoxicillin-Clavulanate 875/125mg oral tablet
Take one tab oral two times a day for 7 days. May stop after 5 days if symptoms are gone.
SIG
14 tablets
DISPENSE
Amoxicillin-Clavulanate 500/125mg oral tablet
Take one tab oral three times a day for 7 days. May stop after 5 days if symptoms are gone.
SIG
30 tablets
DISPENSE
Add children's weight based dosing.
Notes:
Bacterial Pharyngitis
Augmentin for bacterial pharyngitis
875 mg every 12 hours for 5 to 7 days
Amoxicillin-Clavulanate 875/125mg oral tablet
Take one tab oral two times a day for 7 days. May stop after 5 days if symptoms are gone.
SIG
14 tablets
DISPENSE
Bacterial Vaginosis
Metronidazole 500mg oral tablet
Take one tab oral two times a day for 7 days.
SIG
14 tablets
DISPENSE
- Metronidazole vaginal suppository
0.75% gel: Intravaginal: One applicatorful (5 g containing ~37.5 mg metronidazole) once daily at bedtime for 5 days
Cellulitis (low likely MRSA)
Cephalexin 500 mg 4 times daily for at least 5 days
Caps may be subbed for tabs
Cephalexin 500mg oral tablet
Take one tab oral four times a day for 5 days.
SIG
20 tablets
DISPENSE
Duration should be extended up to 14 days if not resolved/slow response.
Cellulitis (MRSA coverage)
content missing
Streptococcal Pharyngitis
- ICD-10 Code J02.0 Streptococcal pharyngitis
- ICD-10 Code J02.9 Acute Pharyngitis, unspecified
Penicillin V potassium 500 mg oral tablet
Take 1 tab oral on an empty stomach twice a day for ten days
SIG
20 tablets
DISPENSE
Notes:
Hypertension
Initiate an ACE inhibitor or ARB plus a dihydropyridine calcium channel blocker
Losartan + Amlodipine
ARB over ACE-i because ARB lower side effect profile than ACE
I've been prescribing Losartan, but Dr Jordy Cohen prefers Olmesartan because the half life is longer/dosing is less frequent.
See Curbsiders podcast episode #321 Hypertension FAQ: Common Outpatient Cases with Dr. Jordy Cohen
Olmesartan slightly more expensive, but don’t have to dose as often.
Losartan cheaper, but should be twice daily, yet most prescribe it QD.
Valsartan is lower potency.
Losartan:
Initial: 25 to 50 mg once daily; evaluate response after ~2 to 4 weeks and titrate dose (eg, increase the daily dose by doubling) as needed up to 100 mg/day in 1 to 2 divided doses.
losartan 25 mg oral tablet
Take 1 tab oral once a day.
Losartan 25mg oral tablet
Take one tab oral once a day.
SIG
Typically 30, 60, or 90 tablets
DISPENSE
Amlodipine:
2.5 to 5mg QD. Evaluate After 2-4 weeks and titration up to max 10mg /day
amLODIPine 2.5 mg oral tablet
Take 1 tab oral once a day.
Amlodipine 2.5mg oral tablet
Take one tab oral once a day.
SIG
Typically 30, 60, or 90 tablets
DISPENSE
Azor 5/20:
- Available as generic
- Olmesartan 20mg/Amlodipine 5mg
- ce a day.
Azor 5/20 (generic)
Take one tab oral once a day.
SIG
Typically 30, 60, or 90 tablets
DISPENSE
Dr. Cohen’s preferred combination therapy for initial treatment: low-dose calcium channel blocker (ex: 2.5 mg amlodipine) + ARB (ex: 10 mg olmesartan). However, I haven't found it at that dosing, so I wonder if she has them cut a 5/20 in half?
According to 5 Minute Consult: The usual starting dose of Azor/generic Azor is 5/20 mg once daily. The dosage can be increased after 1 to 2 weeks of therapy to a maximum dose of one 10/40 mg tablet once daily as needed to control blood pressure.
MDM:
I feel the patient's symptoms are most consistent with essential hypertension. Given the patient’s history and evaluation here today, I feel that more malignant processes are extremely unlikely.
The patient understands that although his HTN medication may not make him feel better or any different, not keeping his HTN in control can greatly increase the risk for long term cardiovascular events.
CPT codes for out of office BP readings
CPT code 99473 can be used when a patient receives education and training (facilitated by clinical staff) on the set-up and use of a SMBP measurement device validated for clinical accuracy, including device calibration. 99473 can only be reported once per device.
CPT code 99474 can be used for SMBP data collection and interpretation when patients use a BP measurement device validated for clinical accuracy to measure their BP twice daily (two measurements, one minute apart in the morning and evening), with a minimum of 12 readings required each billing period.
UTI
Macrobid 100 bid 5 days
TMP-SMX 1 DS tab twice daily; females for 3 days males for 7 days
Macrobid 100mg oral capsule
Take one cap oral twice a day for 5 days.
SIG
10 capsules
DISPENSE
TMP-SMX 800/160mg oral tablet
Take one tab oral twice a day for 5 days.
SIG
10 tablets
DISPENSE
chart a urinalysis (UA)
Influenza
J09.X2 Influenza A
J10.89 Influenza B
Blepharitis
* H01.001 …… right upper eyelid
* H01.002 …… right lower eyelid
* H01.003 …… right eye, unspecified eyelid
* H01.004 …… left upper eyelid
* H01.005 …… left lower eyelid
* H01.006 …… left eye, unspecified eyelid
Conjunctivitis
H10.30 Unspecified acute conjunctivitis - unspecified eye
H10.31 Unspecified acute conjunctivitis - right eye
H10.32 Unspecified acute conjunctivitis - left eye
H10.33 Unspecified acute conjunctivitis - bilateral
H10.5 Blepharoconjunctivitis
H10.9 Unspecified conjunctivitis
ciprofloxacin 0.3% ophthalmic solution
Drip 1 drop into affected eye(s) every 15 minutes for first 6 hours, then 4-6 times a day for 2 weeks
Drip 1 drop in the affected eye every hour while you are awake for 2 days. Then use 1 drop 4-6 times a day for at least 7 days.
Drip 2 drops in affected eye every 30 minutes on day 1. Drip 2 drops into affected eye every hour on day 2. Drip 2 drops into affected eye every four hours for the remainder of the two weeks.
2.5g?
Please adjust dose to match your in-stock bottle size.
Erythromycin ophthalmic ointment
Instill 1cm ribbon into affected eye 4 times a day for 7 days.
3.5g
Please adjust dispense quantity to match your in-stock tube size.
Chlamydia
Doxycycline monohydrate 100 mg oral capsule
Take one capsule oral two times a day for 7 days
SIG
14 capsules
DISPENSE
tablets may be subbed for capsules and hyclate may be subbed for monohydrate
Pharmacist note
Doxycycline monohydrate v hyclate. Both are equally effective in treating infections, monohydrate is typically better tolerated and significantly cheaper than hyclate.
Alternatives:
Azithromycin (Z-Pak) 250mg tablet
Take two tablets oral at once on day 1, then one tablet per day for the remaining four days.
SIG
6 tablets
DISPENSE
Capsules may be subbed for tablets
Pharmacist note
Notes:
A urine sample only tests for GU chlamydia, and will NOT show positive if the infection is in the throat or rectum.
Throat and rectal swabs may be indicated, depending on sexual practices and symptoms.
Doxycycline is preferred to Azithromycin, especially for rectal infections.
- Use Z-pack for pregnant women and those allergic to doxy.
- Use a one-time, 1g directly observed dose of azithromycin if you suspect the patient will have issues with compliance with the 7-day BID doxy course.
Levo: 500mg bid 7 days is third line
chart a urinalysis (UA)
Gonorrhea
A54.6 G of rectum
For individuals who weigh < 150 kg
Ceftriaxone 500 mg intramuscular (IM) in a single dose
TB Test Injection
Z11.1 Encounter for screening for respiratory tuberculosis
ASSESSMENT:
Pt denies any flu-like symptoms, cough, exposure to TB or recently being out of the country. Pt denies they have ever tested positive for TB skin test. 0.1ml inserted ID into (RIGHT/LEFT) forearm. Pt tolerated well.
PLAN:
Pt to RTC in 48-72h for reading.
TB consent form in docs of chart.
TB Test Read
Z11.1 Encounter for screening for respiratory tuberculosis
ASSESSMENT:
No erythema noted. No induration seen or palpated. Patient negative for TB.
PLAN:
Form completed, scanned, added to documents section, and original given to the patient.
PPD TB test read criteria:
Induration of ≥5 mm is considered positive in:
- People living with HIV
- Recent contacts of people with infectious TB disease
- People who have fibrotic changes on a chest radiograph
- Patients with organ transplants
- Other immunosuppressed patients (e.g., patients on prolonged therapy with corticosteroids ≥15 mg per day of prednisone or those taking TNF-α antagonists)
Induration of ≥10 mm is considered positive in:
- People born in countries where TB disease is common, including Mexico, the Philippines, Vietnam, India, China, Haiti, and Guatemala
- People who misuse drugs and alcohol
- People who live or work in high-risk congregate settings (e.g., nursing homes, homeless shelters, or correctional facilities)*
- Mycobacteriology laboratory workers
- People with certain medical conditions that place them at high risk for TB (e.g.,silicosis, diabetes mellitus, severe kidney disease, certain types of cancer, or certain intestinal conditions)
- Children younger than 5 years of age
- Infants, children, and adolescents exposed to adults in high-risk categories
Induration of ≥15 mm is considered positive in
- People with no known risk factors for TB
* For employees who are otherwise at low risk for TB and who are tested as part of an infection control screening program at the start of employment, a reaction of ≥ 15 mm is considered positive. Some health care workers participating in an infection control screening program may have had an induration > 0 mm that was considered negative at baseline. If these health care workers have an increase in induration size upon subsequent testing, they should be referred for further evaluation.
Herpes HSV-1 and HSV-2
HSV First time
1g twice daily for 7 to 10 days;
HSV breakout
500 mg twice daily for 3 days
HSV daily prophylaxis
500mg daily, reassess annually
500mg twice daily for three days
1g 3 times daily for 7 to 10 days; for slowly improving lesions
Steroids
oral - dosepak, oral poison oak dose
topical - maybe do one moderate intensity and one high intensity? Or consider listing eczema and psoriasis treatments?
MethylPrednisone
Medrol Dosepak 4 mg oral tablet
Take 6 tabs oral at once on day 1. Take 5 tabs at once the next day. Each day take one less pill for a total of 6 days.
21
tabs
Prednisone for Poison Oak
40 mg for five days, 20 mg for five days, 10 mg for five days, and then discontinue.
predniSONE 10 mg oral tablet
take 4 tabs oral once a day for 5 days, then 2 tabs a day for 5 days, then 1 tab a day for 5 days.
20+10+5 = 35 tabs
EKG
Chart an EKG like this:
EKG:
- Rate: 99bpm
- Rhythm: sinus
- Axis: 99 degrees
- P waves: present for every QRS
- PR interval: 999ms
- QRS complex: 99ms
- QT interval: 999ms
- ST-segment: No significant elevation.
- T waves: Present and not excessively large or small.
Gas and Bloating (ABD pain)
Simethicone
OTC - Over the Counter
Simethicone 125 mg oral capsule - Take 1 capsule oral after meals QID for 7 days for gas and bloating
Simethicone is OTC and is in Mylanta and “Tums with gas relief”
Simethicone is an anti foaming agent that reduces bubbles and therefore bloating.
Dicyclomine
Rx - Prescription only
Brand name:
Bentyl
Anti-spasmodic
Dicyclomine 10 mg oral capsule - Take 1 tab oral QID PRN for ABD cramping and spasms
Appendicitis (ABD pain)
oral regimen
Ciprofloxacin 500
Take 1 tab oral twice a day for 14 days. May stop after 10 days if all symptoms gone.
28
Metronidazole 500
TID for 10-14 days
Take 1 tab oral three a day for 14 days. May stop after 10 days if all symptoms gone.
42
Pneumonia diagnosis tools:
At least one of the following abnormal vital signs:
◦ Temperature >37.8 °C
◦ Heart rate >100 beats/minute
◦ Respiratory rate >20 breaths/minute
And at least two of the following clinical findings:
◦ Decreased breath sounds
◦ Crackles
◦ Absence of asthma
UA
UA:
- GLU: Negative
- BIL: Negative
- KET: Negative
- SG: 1.010
- BLO: Negative
- pH: 7.0
- PRO: Negative
- URO: 0.2
- NIT: Negative
- LEU: Negative
link to UTI Rx
Dandruff
Dandruff/Antifungal shampoos include:
Ketoconazole 2%
Zinc Pyrithione 1%
Selenium Sulfide 2.5%
Ciclopirox 1% (prescription)
Gout
- Right AOM ICD-10 Code H66.91 Otitis media, unspecified, right ear
- Left AOM ICD-10 Code H66.92 Otitis media, unspecified, left ear
Gout guidelines don't indicate a clear preference for first line treatment: Steroid vs Colchicine vs NSAID
The EULAR guideline recommends colchicine as the drug of first choice for acute gout attacks.
In contrast, DEGAM recommends using prednisolone.
Unlike in the USA where colchicine is available in 0.6 mg tablets, in Germany, only 0.5 mg are available.
not yet formatted
30 mg prednisolone for 5 days
low-dose colchicine (day 1: 1.5 mg; days 2–5: 1 mg)
1. 40mg prednisone QD until flare resolves
2. Colchicine 1.2mg
Colchicine – On the first day of therapy, 1.2 mg of oral colchicine is followed one hour later by 0.6 mg. On subsequent days, colchicine 0.6 mg twice daily should be administered until 48 hours following the flare.
We use naproxen 500 mg twice daily or indomethacin 50 mg three times daily until a few days after the flare has resolved. NSAIDs should be avoided in older patients and others who are at higher risk of the kidney, cardiovascular, and gastrointestinal side effects of NSAID
Allopurinol is prophylactic. Colchicine can be abortive or prophylactic, but you can't add Colchicine to a flare if they are already on prophylactic Colchicine.
Who needs urate lowering therapy (ULT): Patients with two or more flares in a year (Grade A); tophus or tophi on exam or imaging (Grade A); CKD stage 2 or worse (Grade C); past urolithiasis (Grade C) – [Khanna et al. ACR 2012 Gout Guidelines]
ULT with allopurinol: Start at 100 mg daily (50 mg daily if CKD 4) and titrate up by 100 mg every two weeks up to 300 mg. Monitor serum uric acid level after 4-8 weeks on therapy.
Flare management: Do not stop treatment before 10 days. Otherwise, the patient may have rebound symptoms. Dr Neogi uses prednisone 30 mg po daily and tapers by 5 mg every 2 days (12 days total).
Natural history: Pain peaks in 24 hours and lasts up to 14 days, but untreated gout can progress to a chronic inflammatory arthritis.
Colchicine XXXXXXXXXXX
Take one tab oral three times a day for 7 days
SIG
21 tablets
DISPENSE
Capsules may be subbed for tabs
Pharmacist note
Prednisone XXXXXXXXXXX
Take one tab oral three times a day for ten days
SIG
30 tablets
DISPENSE
Capsules may be subbed for tabs
Pharmacist note
Indomethacin XXXXXXXXXXX
Take one tab oral three times a day for ten days
SIG
30 tablets
DISPENSE
Capsules may be subbed for tabs
Pharmacist note
Get Uric Acid below 6 if possible
Notes:
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Action Urgent Care order rules:
- The provider must have a written order with the medication, dosage, and administration type in the pts chart. MAs are unable to do anything involving medication preparation until this step is complete.
- The MA preparing the medication checks with another MA on-shift to make sure it is being done correctly.
- The provider does a final approval check where the MA verbally states the patient name and room number and then shows the provider the medication, dosage, and administration type. After this approval, the medication may be administered.
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