CDM Dispensary 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:
*
Visit Type:
*
...
First dispensary visit after screening
Second dispensary visit after screening
Return dispensary visit
Referred from clinic
Walk-in
Status of patient
Patient being followed up for:
HTN
DM
Other
Specify other follow up:
*
Hypertension status
...
New HTN Patient
Known HTN Patient
Year of Diagnosis [Hypertension]:
*
Diabetes status
...
New DM Patient
Known DM Patient
Year of Diagnosis [Diabetes]:
*
Do fasting blood sugar
Vital Signs
Systolic Blood Pressure (mmHg):
*
Diastolic Blood Pressure (mmHg):
*
Pulse Rate (per minute):
Temperature (centigrade):
Weight (KG):
Height (CM):
BMI:
Confirmed underweight
Confirmed overweight
Educate on weight reduction.
How long ago was the first day of your menstrual period?
*
Consider pregnancy test
Lab tests
Urinalysis
URINALYSIS
Urinalysis Result:
*
...
Normal
Abnormal
Not Done
Protein:
*
Nil
+
++
+++
Leucocytes:
*
Nil
+
++
+++
Ketones:
*
Nil
+
++
+++
Glucose:
*
Nil
+
++
+++
Nitrites:
*
Nil
+
++
+++
Pus Cells:
*
Nil
+
++
+++
Urinalysis Date Collected:
*
Blood Test
Fasting Blood Sugar:
Date Collected [FBS]
A1c:
Date Collected [A1c]
Random Blood Sugar:
Date Collected [RBS]
RBS is >= 7.8
Request patient to come for fasting blood sugar
Creatinine:
Date Collected [Creatinine]
Haemoglobin:
Date Collected [Haemoglobin]
Urine Pregnancy Test
Urine pregnancy test results:
*
...
Positive
Negative
Indeterminate
Test Not Done
Date Collected
Pregnancy confirmed
Do not dispense
Refer to high risk ANC
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:
Patient on enalapril and has recurrent cough
Change Enalapril to Losartan and rule out TB
Possible Amlodipine or Nifedipine side effects
Stop Nifedipine or Amlodipine
Refer to CO
Possible Metformin side effects
Refer to CO OR Reduce Metformin dose
Possible Hypoglycemia
Reduce OR STOP dose of Glibenclamide
Possible CVS complication
Consult on phone 0718980323
Possible CNS complication
Consult on phone 0718980323
Consider Angioedema side effects due to ACEI/ARB
Stop all ACEI/ARB medications
Level of skin rash:
*
...
Mild
Moderate
Severe
other
Specify Other level of skin rash:
*
Consider referral to CO
History
Do you smoke cigarettes?
*
...
Yes
No
Stopped
Do you sometimes drink alcohol?
*
...
Yes
No
Stopped
How long ago?
*
Duration stopped Alcohol:
*
...
Weeks
Months
Years
Weeks:
*
Months:
*
Years:
*
What kind do (did) you usually drink? (tick all that apply)
*
Beer
Spirits / Liquor
Wine
Chang'aa
Busaa
How often did you have a drink containing alcohol in the last year?
*
...
Never
Monthly or less
2 to 4 times a month
2 to 3 times a week
4 to 5 times a week
6 or more times a week
How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?
*
...
0 drinks
1 to 2 drinks
3 to 4 drinks
5 to 6 drinks
7 to 9 drinks
10 or more drinks
How often did you have six or more drinks on one occasion in the past year?
*
...
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Current medication
Are you currently taking any medication?
*
...
Yes
No
Which medications are you currently taking?
Anti-diabetic drugs
Metformin
Metformin
Dosage:
*
...
500mg
750mg
850mg
1g
Frequency per day:
*
...
Once Daily
Twice Daily
Possible Metformin side effects
Refer to CO OR Reduce Metformin dose
Glibenclamide
Glibenclamide
Frequency and Dosage:
*
...
2.5mg Once Daily
5mg Once Daily
5mg AM, 2.5mg PM
10mg AM, 5mg PM
Possible Hypoglycemia
Reduce OR STOP dose of Glibenclamide
Gliclazide
Gliclazide
Dosage:
*
...
40mg
80mg
160mg
Gliclazide frequency per day:
*
...
Once Daily
Twice Daily
Glimepiride
Glimepiride
Dosage:
*
...
1mg
2mg
3mg
4mg
Glimepiride frequency per day:
*
...
Once Daily
Insulin
70% NPH Insulin with 30% Regular Insulin
AM Units:
*
PM Units:
*
Wrong combination of anti-diabetic medications
SET: Insulin, Glimepiride, Gliclazide, Glibenclamide
Patient can only be on one at any given time
Anti-hypertensive agents
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
Possible Amlodipine or Nifedipine side effects
Stop Nifedipine or Amlodipine
Refer to CO
Amlodipine
Amlodipine
Dosage:
*
...
2.5mg
5mg
10mg
Amlodipine frequency per day:
*
...
Once Daily
Possible Amlodipine or Nifedipine side effects
Stop Nifedipine or Amlodipine
Refer to CO
Felodipine
Felodipine
Dosage:
*
...
2.5mg
5mg
10mg
Felodipine frequency per day:
*
...
Once Daily
Wrong combination of drugs, all ACEI/ARBs
SET: Lisinopril, Losartan, Enalapril
Patient can only be on one at any given time
Wrong combination of drugs, all CCBs
SET: Nifedipine, Amlodipine, Felodipine
Patient can only be on one at any given time
Consider Angioedema side effects due to ACEI/ARB
Stop all ACEI/ARB medications
Other
Other Medication
Medication Name:
Dose in Milligrams (mg):
Dose in Milliliters (ml):
Frequency per day:
...
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
Care plan for this visit
Life style modification care plan:
*
Salt reduction
Exercise
Reduce alcohol
Smoking cessation
Weight reduction
General diet education
Medications dispensed
Anti-diabetic drugs
Metformin
Metformin
Dosage:
*
...
500mg
750mg
850mg
1g
Frequency per day:
*
...
Once Daily
Twice Daily
Glibenclamide
Wrong combination of anti-diabetic medications
SET: Insulin, Glimepiride, Gliclazide, Glibenclamide
Patient can only be on one at any given time
Glibenclamide
Frequency and Dosage:
*
...
2.5mg Once Daily
5mg Once Daily
5mg AM, 2.5mg PM
10mg AM, 5mg PM
Anti-hypertensive agents
Enalapril
Wrong combination of drugs, all ACEI/ARBs
SET: Lisinopril, Losartan, Enalapril
Patient can only be on one at any given time
Enalapril
Dosage:
*
...
5mg
10mg
20mg
Enalapril frequency per day:
*
...
Once Daily
Twice Daily
Confirm Creatinine is normal.
If no creatinine available, do not start enalapril or losartan
Lisinopril
Wrong combination of drugs, all ACEI/ARBs
SET: Lisinopril, Losartan, Enalapril
Patient can only be on one at any given time
Lisinopril
Dosage:
*
...
5mg
10mg
20mg
Lisinopril frequency per day:
*
...
Once Daily
Twice Daily
Lisinopril/HCTZ
Wrong combination of drugs, all ACEI/ARBs
SET: Lisinopril, Losartan, Enalapril
Patient can only be on one at any given time
Wrong combination of drugs
SET1: Lisinopril, combined Lisinopril/HCTZ
SET2: HCTZ, combined Lisinopril/HCTZ
Patient can only be on one at any given time
Lisinopril/HCTZ
Dosage:
*
...
5mg
10mg
20mg
Lisinopril/HCTZ frequency per day:
*
...
Once Daily
Twice Daily
HCTZ
Wrong combination of drugs
SET1: Lisinopril, combined Lisinopril/HCTZ
SET2: HCTZ, combined Lisinopril/HCTZ
Patient can only be on one at any given time
HCTZ
Dosage:
*
...
12.5mg
25mg
HCTZ frequency per day:
*
...
Once Daily
Losartan
Wrong combination of drugs, all ACEI/ARBs
SET: Lisinopril, Losartan, Enalapril
Patient can only be on one at any given time
Losartan
Dosage:
*
...
25mg
50mg
100mg
Losartan frequency per day:
*
...
Once Daily
Confirm Creatinine is normal.
If no creatinine available, do not start enalapril or losartan
Nifedipine
Wrong combination of drugs, all CCBs
SET: Nifedipine, Amlodipine, Felodipine
Patient can only be on one at any given time
Nifedipine
Dosage:
*
...
20mg
Nifedipine frequency per day:
*
...
Twice Daily
Amlodipine
Wrong combination of drugs, all CCBs
SET: Nifedipine, Amlodipine, Felodipine
Patient can only be on one at any given time
Amlodipine
Dosage:
*
...
2.5mg
5mg
10mg
Amlodipine frequency per day:
*
...
Once Daily
Felodipine
Wrong combination of drugs, all CCBs
SET: Nifedipine, Amlodipine, Felodipine
Patient can only be on one at any given time
Felodipine
Dosage:
*
...
2.5mg
5mg
10mg
Felodipine frequency per day:
*
...
Once Daily
If patient has been on
Enalapril
for over a year
Check creatinine and potasium
If patient has been on
Losartan
for over a year
Check creatinine and potasium
Other Medications
Other Medication
Medication Name:
Dose in Milligrams (mg):
Dose in Milliliters (ml):
Frequency per day:
...
Every Morning
Every Evening
Once Daily
Twice Daily
Tests Ordered
None
Urinalysis
HbA1c
Microalbumin
Creatinine
Potassium
ECG
Lipid Profile
Other
Specify other test ordered:
Transfer Status
Transfer care to other center?
*
...
Yes
No
Specify:
*
...
AMPATH
Non AMPATH
Referrals
Referrals Ordered:
...
Group care
COE
Health Centre
Name of the care group:
*
Name of COE:
...
MTRH
Kitale
Webuye
Teso
Name of the Health Centre :
*
Date referred:
Date referred:
Date referred:
Return Date to Dispensary:
Educate on prevention
Weight reduction if BMI >25
Exercise
Smoking cessation (if applicable)
Alcohol reduction (if applicable)
DISCHARGE HOME
Pt under 35 with elevated BP
Refer to CO/Health Center
Hypertension in Pregnancy
.
REFER TO C.O/ High Risk ANC.
Advise on
Salt reduction
Weight reduction if BMI > 25
Exercise
Smoking cessation (if applicable)
Alcohol reduction (if applicable)
Review in a month
Stage II Hypertension
Refer to CO
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 OD or Felodipine 5mg OD or Nifedipine 20mg BD
Advise on
Salt reduction
Weight reduction if BMI > 30
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 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 or Felodipine 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
Continue HCTZ 25mg Once daily
Continue Amlodipine 5mg Once daily
Review in 3 months
UNCONTROLLED HYPERTENSION
REFER TO CO
Advise on
Salt reduction
Weight reduction if BMI > 25
Exercise
Smoking cessation (if applicable)
Alcohol reduction (if applicable)
Possible side effects of CCB
Reduce dose or change prescription
Patient does not have diabetes
Educate on prevention and discharge or followup after a year as needed
Patient with pre-diabetes
Educate on lifestyle modification
Repeat FBS after 6 months
Pregnant patient with Diabetes
Please Refer to High Risk ANC Clinic
Patient blood sugar is very high
REFER TO CO
Educate on lifestyle modification
DM CONFIRMED
Start on Metformin 500mg OD
To be seen in two (2) weeks
Possible Metformin side effects
Refer to CO, or reduce Metformin dose
Patient controlled CT Metformin 500mg Once Daily (OD)
Check HbA1C annually
Blood sugar not optimally controlled on metformin 500 mg OD
Increase Metformin up to 500mg twice daily (BD)
Follow up with patient after 2 weeks
Educate patient on lifestyle modification
Patient controlled CT Metformin 500mg Twice Daily (BD)
Check HbA1C annually
Blood sugar not optimally controlled on metformin 500 mg BD
Titrate Metformin to 750mg twice daily
Follow up with patient after 2 weeks
Educate patient on lifestyle modification
Patient controlled CT Metformin 750mg Twice Daily (BD)
Check HbA1C annually
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
Patient controlled CT Metformin 1000mg Twice Daily (BD)
Check HbA1C annually
Patient Uncontrolled
REFER TO CO
Patient with severely elevated blood sugar and with current concern for complications
Refer to CO
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.
If HbA1c observation date is more than 5 months, please advice patient to plan for upcoming HbA1c test in a month.
Patient with possible DM complications
Refer to Center of Excellence (COE)
Patient with Hypertension in Diabetes
REFER TO CO
Advice on salt reduction
Hypoglycemia symptoms
Patient has hypoglycemia symptoms
Possible kidney complications
Patient has significant proteinuria
Refer to CO
Order for Creatinine