CDM Health Centre HTN-DM Encounter Form V0.01
Demographics
AMRS ID Number:
Family Name:
Given Name:
Middle Name:
Gender:
...
Male
Female
Date Of Birth:
Encounter Details
Name of Dispensary:
*
Provider Name:
*
Provider system-id:
*
Encounter Date:
*
Current Visit:
*
...
Initial Visit
Return Visit
Status of patient
Diabetes
...
New DM Patient
Known DM Patient
Year of Diagnosis [Diabetes]:
*
Hypertension
...
New HTN Patient
Known HTN Patient
Year of Diagnosis [Diabetes]:
*
HIV Status
...
Negative
Positive
Unknown
Enrolled to care
...
Yes
No
Referral
Is patient a referral?
*
...
Yes
No
Specify referring facility
*
...
Dispensary
COE
Group care
Other
Complaints
Does patient report any complaint?
*
...
Yes
No
Does patient have any of the following?
*
Shortness of breath on activity
Palpitations (heart racing)
Recurrent dizziness
Fainting
Leg swelling
Loss of consciousness
Blurring of vision
Focal weakness
Foot complaints
Nausea
Vomiting
Abdominal discomfort/diarrhea
Persistent constipation
Recurrent cough
Mouth swelling
Neck swelling
Persistent headache
Excess Hunger
Tremors
Sweating
Reduced urine output
Weakness in one part of the body
Nightmares
Skin rash
Other
Specify Other complaint:
Level of skin rash:
*
...
Mild
Moderate
Severe
other
Specify Other level of skin rash:
*
Possible Metformin side effects
Reduce Metformin dose
Patient has hypoglycemia symptoms.
Patient with hypoglycemia
Review drug dosing and nutrition
Possible CVS complication
Consult on phone 0718980323
Possible CNS complication
Consult on phone 0718980323
Drug Use
Do you smoke cigarettes?
...
Yes
No
stopped
Do you sometimes drink alcohol?
...
Yes
No
stopped
Current medication
Are you currently taking any medication?
*
...
Yes
No
Which medications are you currently taking?
Metformin
Metformin
Dosage:
*
...
500mg
750mg
850mg
1g
Frequency per day:
*
...
Once Daily
Twice Daily
Possible Metformin side effects
Reduce Metformin dose
Glibenclamide
Glibenclamide
Frequency and Dosage:
*
...
2.5mg Once Daily
5mg Once Daily
5mg AM, 2.5mg PM
10mg AM, 5mg PM
Patient has hypoglycemia symptoms.
Patient with hypoglycemia
Review drug dosing and nutrition
Enalapril
Enalapril
Dosage:
*
...
5mg
10mg
20mg
Enalapril frequency per day:
*
...
Once Daily
Twice Daily
If patient on Enalapril or Losatarn for >=12 months
Check creatinine and potassium
Patient on enalapril and has recurrent cough
Change Enalapril to Losartan and rule out TB
Lisinopril
Lisinopril
Dosage:
*
...
5mg
10mg
20mg
Lisinopril frequency per day:
*
...
Once Daily
Twice Daily
Lisinopril/HCTZ
Lisinopril/HCTZ
Dosage:
*
...
5mg
10mg
20mg
Lisinopril/HCTZ frequency per day:
*
...
Once Daily
Twice Daily
HCTZ
HCTZ
Dosage:
*
...
12.5mg
25mg
HCTZ frequency per day:
*
...
Once Daily
Losartan
Losartan
Dosage:
*
...
25mg
50mg
100mg
Losartan frequency per day:
*
...
Once Daily
If patient on Enalapril or Losatarn for >=12 months
Check creatinine and potassium
Nifedipine
Nifedipine
Dosage:
*
...
20mg
Nifedipine frequency per day:
*
...
Twice Daily
Amlodipine
Amlodipine
Dosage:
*
...
2.5mg
5mg
10mg
Amlodipine frequency per day:
*
...
Once Daily
Felodipine
Felodipine
Dosage:
*
...
2.5mg
5mg
10mg
Felodipine frequency per day:
*
...
Once Daily
Gliclazide
Gliclazide
Dosage:
*
...
40mg
80mg
160mg
Gliclazide frequency per day:
*
...
Once Daily
Twice Daily
Patient has hypoglycemia symptoms.
Patient with hypoglycemia
Review drug dosing and nutrition
Glimepiride
Glimepiride
Dosage:
*
...
1mg
2mg
3mg
4mg
Glimepiride frequency per day:
*
...
Once Daily
Patient with hypoglycemia
Review drug dosing and nutrition
Patient has hypoglycemia symptoms.
Insulin
Insulin 70/30
AM Units:
*
PM Units:
*
Patient with hypoglycemia
Review drug dosing and nutrition
Patient has hypoglycemia symptoms.
NPH
NPH
AM Units:
*
PM Units:
*
Humalog
Humalog
AM Units:
*
Lunch Units:
*
PM Units:
*
Other
Other Current Medication
Medication Name:
*
Dose in Milligrams (mg):
Dose in Milliliters (ml):
Frequency:
*
...
Every Morning
Every Evening
Once Daily
Twice Daily
Adherence:
For the drugs you are currently taking, did you miss any doses in the last one week?
*
...
Yes
No
Specify the number of missed doses:
*
...
Few
Half
Most
All
Specify reason for non compliance:
*
...
Missed Appointment
Healed by faith
Forgot to take medicine
Medicine not useful
Side effects
Time for a break
Medicine not dispensed
Medication ran out
Dypnoeic
Is the patient dyspnoeic?
*
...
Yes
No
Specify NYHA functional class:
*
...
1
2
3
4
Vital Signs
Temperature (centigrade):
Blood Pressure:
1
st
Reading
Systolic(mmHg):
*
Diastolic (mmHg):
*
2
nd
Reading
Systolic (mmHg):
*
Diastolic (mmHg):
*
Pulse Rate (per minute):
Waist Circumference (CM):
Weight (KG):
Height (CM):
Body Mass Index:
Confirmed overweight
Educate on weight reduction.
How long ago was the first day of your menstrual period?
Controlled Hypertension
Continue on HCTZ 25mg OD
Review in 3 months
Controlled Hypertension
Continue on HCTZ 25mg Once daily
Continue on Amlodipine 2.5mg Once daily
Review in 3 months
General Exam
General physical exam findings
*
Pallor
Jaundice
Cyanosis
Oedema
Other
Systemic Exam
CVS
CVS
Normal
Abnormal
Specify:
*
Cardiac murmur
Gallop
Elevated Jugular venous pressure
Evidence of cardiac enlargement
Other
RS
RS
Findings noted on examination of the chest
*
Normal
Abnormal
Specify:
*
Crepitations
Diminished breath sounds
Wheeze
Other
P/A
P/A
Findings noted on examination of the abdomen
*
Normal
Abnormal
Specify:
*
Ascites
Hepatomegaly
Splenomegaly
Mass,Abdominal
Other
CNS
CNS
Findings noted on examination of the abdomen
*
Normal
Abnormal
Specify:
*
Altered mental status
Focal weakness
Cranial nerve abnormalitites
Seizure
Other
Extremities
Extremities
Findings noted on examination of the extremities:
*
Normal
Abnormal
Specify:
*
ulcers
Callousness
Hardened Nails
Fungus
Cellulitis
Edema
Dry
Monofilament test
Right Foot:
*
Left Foot:
*
Investigations/Labs
Urinalysis
URINALYSIS
Urinalysis Result:
*
...
Normal
Abnormal
Not Done
Protein:
*
Nil
+
++
+++
Date Collected [Protein]
Leucocytes:
*
Nil
+
++
+++
Date Collected [Leucocytes]:
Ketones:
*
Nil
+
++
+++
Date Collected [Ketones]:
Glucose:
*
Nil
+
++
+++
Date Collected [Glucose]:
Nitrites:
Nil
+
++
+++
Date Collected [Nitrites]:
Pus Cells:
*
Nil
+
++
+++
Date Collected [Pus cells]:
If:
Repeat urinalysis has Protein of +, ++ or +++
And/or Creatinine is > 106mmol/l
Confirm Diabetes kidney disease, and consult.
PDT
PDT:
*
...
Positive
Negative
Indeterminate
Test Not Done
Date Collected [PDT]
ECG
ECG:
...
Normal
Abnormal
Date Collected [ECG]
CXR
CXR:
...
Normal
Abnormal
Date Collected [CXR]
RBS
RBS:
Date Collected [RBS]
Patient with hypoglycemia
Review drug dosing and nutrition
FBS
FBS:
Date Collected [FBS]
Patient with hypoglycemia
Review drug dosing and nutrition
HbA1c
Hb A1c:
Date Collected [Hb A1c]
Creatinine
Creatinine:
Date Collected [Creatinine]
If:
Repeat urinalysis has Protein of +, ++ or +++
And/or Creatinine is > 106mmol/l
Confirm Diabetes kidney disease, and consult.
Haemoglobin
Haemoglobin:
Date Collected [Haemoglobin]
LDL
LDL:
Date Collected [LDL]
HDL
HDL:
Date Collected [HDL]
TG
TG:
Date Collected [TG]
Cholesterol
Cholesterol:
Date Collected [Cholesterol]
Problem list / Complications
Stroke:
Stroke
Add
Ongoing
Remove
Heart failure
Add
Ongoing
Remove
Kidney failure
Add
Ongoing
Remove
Peripheral Neuropathy
Add
Ongoing
Remove
Visual Impairment
Add
Ongoing
Remove
Erectile Dysfunction
Add
Ongoing
Remove
Gastropathy
Add
Ongoing
Remove
Arthritis
Add
Ongoing
Remove
PUD
Add
Ongoing
Remove
Psychiatric
Add
Ongoing
Remove
Other Problems added:
Diabetes
Hypertension
HIV
Care plan for this visit
Life style modification care plan:
*
Salt reduction
Exercise
Reduce alcohol
Smoking cessation
Weight reduction
General diet education
Treatment
Anti diabetic drugs/OHA
Anti diabetic drugs/OHA
Metformin
Metformin
Plan:
*
...
Start
Continue
Change
Stop
Dose:
*
...
500 mg
850 mg
1000 mg
Frequency:
*
...
Once Daily
Twice Daily
Glibenclamide
Glibenclamide
Plan:
*
...
Start
Continue
Change
Stop
Dose:
*
...
2.5 mg
5.0 mg
7.5 mg
10 mg
Frequency:
*
...
Am
Pm
Gliclazide
Gliclazide
Plan:
*
...
Start
Continue
Change
Stop
Dose:
*
...
40 mg
80 mg
160 mg
Frequency:
*
...
Once Daily
Twice Daily
Glimepiride
Glimepiride
Plan:
*
...
Start
Continue
Change
Stop
Dose:
*
...
1 mg
2 mg
3 mg
4 mg
Frequency:
*
...
Once Daily
Insulin 70/30
Insulin 70/30
Plan:
*
...
Start
Continue
Change
Stop
AM Units:
*
PM Units:
*
NPH
NPH
Plan:
*
...
Start
Continue
Change
Stop
AM Units:
*
PM Units:
*
Humalog
Humalog
Plan:
*
...
Start
Continue
Change
Stop
AM Units:
*
Noon Units:
*
PM Units:
*
Anti-hypertensive agents
Anti-hypertensive agents
Enalapril
Enalapril
Plan:
*
...
Start
Continue
Change
Stop
Dose:
*
...
2.5 mg
5 mg
10 mg
15 mg
20 mg
Frequency:
*
...
Once Daily
Twice Daily
Confirm Creatinine is normal.
If no creatinine available, do not start enalapril or losartan
Lisinopril
Lisinopril
Plan:
*
...
Start
Continue
Change
Stop
Dose:
*
...
10 mg
15 mg
20 mg
Frequency:
*
...
Once Daily
Twice Daily
HCTZ
HCTZ
Plan:
*
...
Start
Continue
Change
Stop
Dose:
*
...
12.5 mg
25 mg
Frequency:
*
...
Once Daily
Losartan
Losartan
Plan:
*
...
Start
Continue
Change
Stop
Dose:
*
...
25 mg
50 mg
100 mg
Frequency:
*
...
Once Daily
Confirm Creatinine is normal.
If no creatinine available, do not start enalapril or losartan
Nifedipine
Nifedipine
Plan:
*
...
Start
Continue
Change
Stop
Dose:
*
...
20 mg
40 mg
Frequency:
*
...
Twice Daily
Atenolol
Atenolol
Plan:
*
...
Start
Continue
Change
Stop
Dose:
*
...
25 mg
50 mg
100 mg
Frequency:
*
...
Once Daily
Lisinopril/HCTZ
Lisinopril/HCTZ
Plan:
*
...
Start
Continue
Change
Stop
Dose:
*
...
20mg / 12.5mg
Frequency:
*
...
Once Daily
Twice Daily
Amlodipine
Amlodipine
Plan:
*
...
Start
Continue
Change
Stop
Dose:
*
...
2.5mg
5mg
10mg
Frequency:
*
...
Once Daily
Felodipine
Felodipine
Plan:
*
...
Start
Continue
Change
Stop
Dose:
*
...
2.5mg
5mg
10mg
Frequency:
*
...
Once Daily
J.ASA
J.ASA
Plan:
*
...
Start
Continue
Change
Stop
Dose:
*
...
75mg
Frequency:
*
...
Once Daily
Atorvastatin
Atorvastatin
Plan:
*
...
Start
Continue
Change
Stop
Dose:
*
...
10mg
20mg
40mg
80mg
Frequency:
*
...
Once Daily
Peripheral neuropathy drugs
Peripheral neuropathy drugs
Amitriptylline
Amitriptylline
Plan:
*
...
Start
Continue
Change
Stop
Dose:
*
...
25mg
50mg
Frequency:
*
...
Nocte
Carbamazepine
Carbamazepine
Plan:
*
...
Start
Continue
Change
Stop
Dose:
*
...
100mg
200mg
Frequency:
*
...
Once Daily
Twice Daily
Tests Ordered
None
Urinalysis
HbA1c
Microalbumin
Creatinine
Potassium
ECG
Lipid Profile
Other
Specify other test ordered:
*
Discharge Status
Discharged Home?
*
...
Yes
No
Date discharged:
*
Follow up plan
Referrals Ordered:
...
Continue care in clinic
Transfer to dispensary
Group care
COE
Name of the care group:
*
Name of COE:
...
MTRH
Kitale
Webuye
Teso
Reason for referral to COE:
Further management of DM
Further management of HTN
Eye Review
Surgical review
Renal review
CVD review
Nutrition
Physiotherapy
Other
Name of the Dispensary :
*
Return date:
Return date:
Return date:
Return date:
Patient with unconfirmed hypertension
Advise on
Salt reduction
Weight reduction if BMI > 25
Exercise
Smoking cessation (if applicable)
Alcohol reduction (if applicable)
Review in a month
Start HTN treatment
START HCTZ 25mg Once daily
Give instructions on salt reduction
Review in a month
Confirmed Hypertension
Start HCTZ 25mg Once daily
Advise on
Salt reduction
Weight reduction if BMI > 25
Exercise
Smoking cessation (if applicable)
Alcohol reduction (if applicable)
Review in 3 months
Controlled Hypertension
Continue on HCTZ 25mg OD
Review in 3 months
Continue HCTZ 25mg a day
Add Amlodipine 2.5mg Once daily
Advise on
Salt reduction
Weight reduction if BMI > 25
Exercise
Smoking cessation (if applicable)
Alcohol reduction (if applicable)
Review in 3 months
Refer to CO if this is third dispensary
Controlled Hypertension
Continue on HCTZ 25mg Once daily
Continue on Amlodipine 2.5mg Once daily
Review in 3 months
Titrate medication
Continue HCTZ 25mg Once daily
Increase Amlodipine to 5mg Once daily
Advise on
Salt reduction
Weight reduction if BMI > 25
Exercise
Smoking cessation (if applicable)
Alcohol reduction (if applicable)
Review in a MONTH
Refer to CO if this is third dispensary visit on this drug regimen
Controlled Hypertension
Continue HCTZ 25mg Once daily
Continue Amlodipine 5mg Once daily
Review in 3 months
UNCONTROLLED HYPERTENSION
Titrate Amlodipine or Felodipine dose to 10mg OD
Advise on
Salt reduction
Weight reduction if BMI > 30
Exercise
Smoking cessation (if applicable)
Alcohol reduction (if applicable)
UNCONTROLLED HYPERTENSION
Advise on
Salt reduction
Adherence
Weight reduction if BMI > 30
Exercise
Smoking cessation (if applicable)
Alcohol reduction (if applicable)
Check U/E/Cr levels and consult
Possible side effects of CCB
Reduce dose or change prescription
Possible angioedema from ACEi/ARB
Stop these class of drugs immediately and consult
DM CONFIRMED
Start on Metformin 500mg OD
To be seen in two (2) weeks
If HbA1c observation date is more than 5 months, please advice patient to plan for upcoming HbA1c test in a month.
If difference between last HbA1c date and current visit date is more than 6 months, Please ALERT patient of a missed HbA1c test to be done immediately.
Patient with possible DM complications
Refer to Center of Excellence (COE)
Blood sugar not optimally controlled on metformin 500 mg twice daily
Increase Metformin up to 750mg twice daily (BD)
Follow up with patient after 2 weeks
Educate patient on lifestyle modification
Blood sugar not optimally controlled on metformin 500 mg twice daily
Increase Metformin up to 750mg twice daily (BD)
Follow up with patient after 2 weeks
Educate patient on lifestyle modification
Blood sugar not optimally controlled on metformin 750 mg twice daily
Titrate Metformin to 1000mg twice daily
Follow up with patient after 2 weeks
Educate patient on lifestyle modification
Diabetes not controlled with metformin 1000 mg twice daily
Refer client to Clinical Officer
Patient with severely elevated blood sugar and with current concern for complications
Refer to Clinical Officer
Patient with Hypertension in Diabetes
REFER TO CO
Advice on salt reduction