THE WAY OF THE PRIMARY CARE PHYSICIAN
ICU notes are usually written based on organ system. The concept is that physicians try not to miss any issues which need to be addressed by reviewing all the body system. This method can also be applicable to outpatient visit summary. Using this system may increase a chance to remind physicians to follow up important medical issues and treatment goals in the primary care setting.
Outpatient Visit Summary
This is a __ year-old ____ male / female who has been followed up since ___
[Past Medical History]
[Surgical History]
[Medications]
・・・
< Medications prescribed by others >
Aspirin 81mg po daily, ・・・ by cardiology
Oxycodone 5mg po q6h prn, ・・・ by orthopedic surgery
Citalopram 20mg po once daily, ・・・ by psychiatric
< Change of major medications >
Dosage:
Metoprolol increased from 25mg/day to 50mg/day due to tachycardia ( / / )
Discontinuation:
Lisinopril due to cough ( / / )
Clopidogrel one year after DES placement due to GI bleeding ( / / )
Spironolactone due to hyperkalemia ( / / )
Warfarin due to recurrent PE in the setting of unstable INR ( / / )
Initiation:
Losartan 50mg po once daily (since / / )
Apixaban 5mg po BID (since / / )
Adherent / nonadherent -> Intervention：
Person who manages medications: patient /____
[Allergy / Side Effect]
Penicillin: itchiness (patient tolerated ceftriaxone and meropenem)
Atorvastain: muscle ache / elevated CPK
NSAIDs： upper GI bleeding resulted in blood transfusion
Lisinopril: cough
Spironolactone: hyperkalemia
[Social History]
Visiting nurse (－/＋) __ times/wk, Type of cares:
Home physical therapy (－/＋) __ times/wk, Type of therapy:
Home aid service (－/＋) __ times/wk, grocery shopping / cooking / cleaning / washing
Day care center (－/＋) __ times/wk, Type of care:
Living situation: single family home / apartment / elderly home / nursing home / acute rehab facility / long-term acute care facility
Lives on ___ floor, Elevator (－/＋) Stairs (－/＋) Number of steps:
Financial status:
Family (－/＋) close / estranged, live in ____
Contact person： Relationship: usually see __ times/mo, TEL:
Lives alone / lives with others:
Activity level
Ambulation: able / unable
Supportive device: none / cane / walker / wheel chair
Bedridden (－/＋)
Urination / defecation:
Dietary intake: independent / partial assist / full assist / tube feeding
Exercise capacity: above / below 4METS
(climb up a flight of stairs, walk up hill, perform heavy work around house)
Occupation:
Interest / hobby:
Exercise: Type: __ hours/one time, __ times/wk
Smoking (－/＋) current / former smoker, __ pack-year, quit in ___
Alcohol: none / occasional / often, Type of alcohol: Amount per day: __ times/wk
Recreational drug: (－/＋) Type: IV/orally/nasally/ , h/o detox program use:
[Family history]
ORGAN SYSTEM BASE
[Neurology]
Orientation: person / place /day / month / year / president ( / / )
Communication: good / some difficulty / only yes-no question / non-verbal
Cranial nerve ( / / )
Extraocular movement: direct pupillary light reflex:
Facial sensation: jaw opening: bite strength:
Eyebrow raise: eyelid close: smile: frown: pucker:
Palate elevation: lateral head rotation: shoulder shrug: Tongue protrusion:
Muscle strength (R/L out of 5)
Shoulder abduction / elbow flexion / elbow extension / wrist extension / wrist flexion /
Hip flexion / hip adduction / knee extension / knee flexion / foot dorsiflexion / foot plantar flexion /
Sensation (to soft touch: R/L)
Shoulder (C4) / Lateral arm (C5) / thumb (C6) / middle finger (C7) / small finger (C8) / medial arm (T1) / nipple (T4) / umbilicus (T10) /
Below inguinal ligament (L1) / middle thigh (L2) / lower thigh (L3) / medial foot (L4) / dorsal foot (L5) / lateral foot (S1) /
Gait:
Head CT(－/＋)( / / )
Brain MRI(－/＋)( / / )
Head MRA(－/＋)( / / )
Neck MRA(－/＋)( / / )
Carotid artery US(－/＋)( / / )
＜Ischemic Stroke＞
Date of Dx ( / / )
Type: Embolic / Large-vessel thrombosis / Small vessel thrombosis
Residual Sx:
Anti-coagulation Tx (－/＋): mg , Reason not to be on: high risk for fall
Anti-platelet Tx (－/＋): mg , Reason not to be on: h/o significant GI bleeding
(clopidogrel 75mg daily or ASA 25mg+dipyridamole 200mg BID or ASA 81-325mg daily,
Efficacy: clopidogrel ≒ ASA+dipyridamol > ASA,
Cost: ASA+dipyridamol > clopidogrel > ASA)
Baseline blood pressure / mmHg
Target blood pressure 140/90 or 130/ (recent lucunar stroke)
Current anti-hypertensive meds: mg po +
(ACEI / ARB (first choice) ± long-acting dihydropyridine CCB or diuretic
(AHA/ASA recommends adding diuretic to ACEI/ARB as needed))
Current statin Tx: mg po daily
Target LDL: N/A
(high intensity statin Tx: atorvastatin 40-80mg, rosuvastatin 20-40mg or low-moderate intensity statin Tx if not tolerate high intensity Tx)
＜Seizure Disorder＞
Primary / Secondary：
History of seizure: initial occurrence / / times/year, the last seizure / /
Seizure free interval:
EEG ( / / ):
History of treatment: meds started after second Sx, meds once discontinued on , Sx recurred on then meds restarted since
Current meds: (since / / )
Adherence good / nonadherent
Serum level ( / / )
Major side effect:
phenytoin (dizziness, D), carbamazepine (aplastic anemia, leukopenia, D), valproic acid (elevated NH3, hepatotoxicity, D), ethosuximide (bone marrow supression, D), gabapentin (GI, D), lamotrigine (headache, tremor), leviteracitam (GI, D), oxcarbazepine (hypoNa, D), topiramate (mood problem, kidney stone), zonisamide (kidney stone)
(D: drowsiness)
Driving restriction (＋/－)
Occupation:
Folic acid supplementation: 0.8mg po daily (4mg/day if on valproate / carbamazepine) for childbaering age
Neurologist ________
＜Parkinson Disease＞
Date of onset ( / / )
Date of diagnosis ( / / )
Brain MRI ( / / )
Ruling out causative medications:
History of treatment:
Current meds: mg (since / / )
Side effect:
Speech: no impairment / mild / moderate / severe
Dysphagia: none / mild / moderate / severe
Tremor: none / mild / mod-severe
Bradykinesia: none / mild / mod-severe
Rigidity: none / mild / mod-severe
Gait: no impairment / mild / moderate / severe
Fall: none / occasionally / frequently
Non-motor Sx: cognitive impairment (－/＋) psychosis (－/＋) mood disorder(－/＋)
Autonomic dysfunction: orthostatic hypotension (－/＋) constipation(－/＋) difficulty urinating (－/＋)
Neurologist ________
＜Dementia＞
Mini-mental state exam /30 ( / / )
(cut-off <24 advanced (<17) severe (<10))
Evaluation for reversible / treatable cause:
VitB12, ESR, TSH, RPR, Head CT/MRI, eval for ETOH abuse, screen for depression
For selected patient:
ANA, ANCA, CSF(TB, cryptococcus, cytology, ..), HIV, paraneoplastic Ab, heavy metal screen, ..
Diagnosis: vascular dementia
Current meds: mg (since / / )
Side effect:
Decision making capacity evaluation: ( / / )
Intervention: live alone, no healthcare proxy, cooking, driving, financial management, lost
＜Migraine＞
Frequency: times/month
Disability: mild / moderate / severe
Neurological symptoms: (－/＋):
Brain CT/MRI (－/＋):
Usual medications for acute setting: mg Effectiveness:
Life-style modification: sleep / regular meal / avoid triggers
Prophylaxis: (since / / )
Indication for prophylaxis Tx: >4 times/month, last longer than 12h,
failure / side effect / contraindication to acute therapy, menstrual migraine, ..
(metoprolol, amitriptyline (for insomnia,depression), valproate (for seizure), topiramate (for obesity))
[Cardiovascular]
Heart murmur (－/＋： at ) Chronic leg edema (－/＋)
Baseline BP Baseline HR
Baseline rhythm SR / Afib / pacer
ECG ( / / ) rhythm HR axis PR QRS QTc ST-T
Echocardiography ( / / ) LVEF diastolic Fx valve Pulmonary artery systolic pressure RV Fx
Pacemaker (－/＋) placement ( / / ) Type: Reason:
ICD (－/＋) placement ( / / ) Primary prevention／Secondary prevention
Cardiac stress test ( / / ) Type: Result:
Coronary angiography: ( / / ) Result:
Coronary intervention：CABG ( / / ) DES ( / / ) BMS ( / / )
Valvular intervention: (－/＋) ( / / ) Valve: Type of intervention: Type of valve:
Ankle-brachial index ( / / ): (0.9-1.3:normal, 0.4-0.9:a/w claudication, <0.4: multilevel disease)
Cardiovascular Risk: (Framingham 10 year risk) % ( / / )
Abdominal US ( / / ) (Screening for AAA x 1 for 65-75 yo male with h/o smoking)
＜Hypertension＞
Baseline BP Patient’s target BP (manual)
Current meds: (since / / ) (since / / ) (since / / )
Target BP
＜125-130/90＞ similar to SPRINT study population
(non-nursing home resident 50 yo or older patients without h/o DM / stroke / symptomatic HF with at least one following risk factor: 75yo or older / CAD / PAD / ABI<0.9 / CA calcification / LVH / GFR 20-59 / 10 year CV risk > 15%)
＜130/80＞ proteinuric CKD / DM
＜140/90＞ stroke / Others
＜150/ ＞ 80 yo or older if 140/ not achievable
(Diastolic blood pressure no less than 70mmHg or at least 65mmHg for elderly patient -> increase CV risk)
Initial monotherapy (less than 20/10mmHg above Target BP)
ACEI/ARB (young) or long-acting dihydropyridine CCB (elderly) or thiazide (for osteoporosis, without gout / hyponatremia)
(switch to different type of meds if moderate dose doesn’t achieve target BP instead of increasing to maximum dose)
Combination therapy (more than 20/10mmHg above Target BP)
ACEI/ARB + long-acting dihydropyridine CCB
(add other meds as needed if not achieve target BP)
Screening for secondary hypertension
Indication: younger than 30 yo, refractory HTN, Sx indicative, abrupt elevation of blood pressure,
Evaluation (as needed): adherence, home blood pressure, technique of measuring, diet, causative medications, polysomnography, duplex doppler US, plasma renin activity / plasma renin concentration, dexamethasone suppression test, 24h urine fractionated CA/metanephrine
＜Heart Failure＞
HFrEF
TTE( / / ) LVEF ％ diastolic Fx RV function
Underlying heart disease:
NYHA: (I: no limit, II: climb more than 1 flight of stairs, not jog, III: climb only 1 flight, IV:Sx at rest)
Frequency of hospitalization for acute exacerbation times/year
Current body weight kg( / / ) Targer BW kg
Baseline proBNP:
Current meds: ( / / ) ( / / ) ( / / )
Life-style modification: sodium restriction 2-3g/day, fluid restriction 1.5-2L/day (if hyponatremia), daily weight, medication adherence
Diuretic: mg
Furosemide 20-40mg (max single dose: 160-200 (max 600mg/day)), Torsemide 5-10mg (max single dose: 100mg (max 200mg/day)), Bumetanide 0.5-1.0mg (max single dose 5mg (max 10mg/day))
BB: mg
Carvedilol 3.125mg BID titrate to 25mg BID, Metoprolol 12.5mg/day titrate to 200mg/day
ACEI/ARB: mg
Lisinopril 5mg/day, titrate to 20mg/day, Valsartan 20mg BID titrate to 160mg BID
Mineralcorticoid receptor antagonist: mg
EF<30%+NYHAII or EF<35% +NYHAIII/IV -> Spironolactone 12.5 - 25mg/day, titrate to 50mg/day
Hydralazine + Nitrate: mg + mg
African-american (or any ethnicity) with EF<40% and persistent NYHAIII/IV with meds above
Hydralazine 25mg TID + Isosorbide dinitrate 20mg TID, titrate to Hydralazine 75mg x 3 + Isosorbide dinitrate 40mg x 3 (or Isosorbide mononitrate 40mg->100mg/day)
Digoxin: mg
NYHAII-IV despite appropriate Tx, Digoxin 0.125mg/day, target serum level 0.5-0.8ng/ml
ICD placement
Secondary prevention or
EF<35% and NYHAII-III, ischemic cardiomyopathy with EF<30% and NYHAI
(Biventricular pacinng with ICD: EF<35% and NYHAIII-IV and QRS>120)
Cardiac resynchronization Tx:
SR and EF<35% and QRS>150 and non-LBBB or LBBB and NYHAIII/IV despite optimal Tx
HFprEF
Diastolic dysfunction: mild／moderate／severe
Tx: control HTN, volume control, maintenance of sinus rhythm, coronary revascularization as needed
＜Atrial Fibrillation＞
Chronic / Paroxysmal
Symptoms: asymptomatic / mild / moderate to severe
Baseline HR
Target HR 80 (symptomatic) / 110 (asymptomatic)
Rate control med: mg ( / / )
Algorithm: BB or CCB or digoxin (for HFrEF)ー＞BB or/+ CCB + digoxin ー＞ablation or amiodarone
(BB: atenolol 25-100mg/day, metoprolol 50-200mg/day, CCB: verapamil 120-360mg/day, diltiazem 120-360mg/day, digoxin 0.125-0.25mg/day)
CHA2DS2-VASc:
Anti-coagulation: mg / Reason not to be on:
History of cardioversion:
History of ablation:
＜Coronary Heart Disease＞
Date of Dx: ( / / )
Stress test: ( / / ):
CAG / intervention: ( / / ):
Exertional angina / dyspnea (－/＋) stable / worsening
Current medications: mg
Antiplatelet Tx: Aspirin: 81-325mg/day or clopidogrel 75mg (allegic to ASA)
Anti-anginal Tx: BB (or/+ CCB) ± long-acting nitrate -> revascularization
(BB: atenolol, metoprolol, CCB: amlodipine, felodipine, Nitrate: isosorbide dinitrate / mononitrate, transderm NTG)
ACEI/ARB: (HTN / DM / CKD / EF<40%)
Statin:
At least moderate intensity Tx: lovastatin / pravastatin / simvastatin 40mg, atorvastatin 10-20mg, rosuvastatin 5-10mg
High risk: high-intensity Tx: atorvastatin 40-80mg, rosuvastatin 20-40mg
Management: weight loss, smoking cessation, DM, HTN, HL, anemia, hypoxia, hyperthyroidism, stress
＜Peripheral Artery Disease＞
Symptoms: asymptomatic / claudication / pain at rest / non-healing ulcer / gangrene
Physical exam: color / pulse / ulcer / sensation / motor
Wave doppler: femoral / popliteal / anterior tibial / posterior tibial /
ABI: ( / / )
CTA / angiography ( / / ):
Risk management: antiplatelet (aspirin 81mg or clopidogrel 75mg), smoking cessation, DM, HTN, HL
Revascularization: ( / / )
Vascular surgeon _____
[Respiratory]
Chronically wheezing (－/＋) Chronically distant lung sound (－/＋)
Chest X-ray ( / / ):
Pulmonary function test ( / / ):
Chest CT ( / / ):
ABG on RA／ L:
Smoking: pack-year quit since___ / current smoker interested in cessation yes / no , Attempt with / without meds:
＜COPD＞
%Predicted FEV1 FEV1 L
GOLD stage (%PreFEV1 1: >80, 2: 50-80, 3: 30-50, 4: <30)
Baseline CO2
Smoking
Frequency of acute exacerbation times/year, hospitalization times/year
Current meds: ( / / ) ( / / ) ( / / )
Short-acting bronchodilator (for all patients)
Albuterol 90mcg 2 puff q4-6h prn or Ipratropium 2 puff q4h prn
Long-acting bronchodilator (initiate with either of themー＞both)
LA anticholinergic: Tiotropium 18mcg inhale once daily
LABA: Salmeterol 1 inhale BID, Formoterol 12mcg inhale BID
Inhaled glucocorticoid (add on LA bronchodilator, stage 3/4)
Fluticasone 100/250/500mcg inhale BID, Budesonide 100/200/400mcg BID
[Refractory to Tx]
Theophylline 300-600mg/day
PDE4 inhibitor: Roflumilast 500mcg once dialy (decrease inflammation -> potentially reduce exacerbation)
Management: supplemental O2, smoking cessation, vaccine, rehabilitation, surgery, terminal care
Home oxygen Tx (since / / ) L/min at rest, L/min on ambulation
(Lung volume reduction surgery: benefit for upper lobe emphysema and low exercise capacity)
＜Bronchial Asthma＞
Symptom: intermittent (＜2/week) ／ mild persistent (＞2/week) ／moderate persistent (daily) ／ severe persistent (all day)
Frequency of acute exacerbation times/year
History of hospitalization / intubation:
PFT ( / / )
Peak flow (personal best)
Current meds: ( / / ) ( / / )
Short-acting bronchodilator (for all patients)
Albuterol 90mcg 2 puff q4-6h prn
Inhaled glucocorticoid
Fluticasone 100/250/500mcg BID, budesonide 100/200/400mcg BID
Long-acting bronchodilator
LABA: Salmeterol 1 inhale BID, Formoterol 12mcg BID
[Adjusting controller Tx] (refractory to LABA + high dose IG)
Leukotriene receptor antagonist: Montelukast 10mg once daily
Theophylline 300-600mg/day
Anticholinergic bronchodilator: Tiotropium 18mcg inhale once daily
Anti-IgE Tx (IgE 30-700IU/ml, positive allergen test)
Systemic steroid: (uncontrolled despite other meds -> lowest dose and shortest course as possible)
Control trigger: allergen (pet, dust, pollen, ・・), smoking, rhinitis, GERD, meds
＜Venous Thromboembolism＞
PE / DVT times ( / / ) ( / / )
Provoked (－/＋):
Anticoagulation (－/＋): mg Duration of Tx:
Pulmonary HTN (－/＋)
Hypercoagulable state work-up: indication (－/＋) Result:
IVC Filter: placed ( / / ) removal ( / / )
Reassessment for continuation of anticoagulation: fall risk, bleeding risk, malignancy, quality of life, patient’s wish
＜Obstructive Sleep Apnea＞
Polysomnography ( / / )
Baseline SpO2 minimum SpO2 Total AHI (obstructive AHI central AHI )
Apnea Hypopnea Index： mild (5-15) moderate (15-30) severe (>30)
Modification： weight loss, avoidance of alcohol・sedative med, non-spine position
CPAP／BPAP setting:
Adherence: good / nonadherent Intervention:
Control Sx: sleepiness(＋/－) poor concentration(＋/－) fatigue (＋/－) headahce(＋/－)
Pulmonologist _____
[Gastroenterology]
EGD ( / / ):
Colonoscopy ( / / ):
Abdominal US ( / / ):
Abdominal CT ( / / ):
Upper GI bleeding (－/＋) ( / / ) cause:
Lower GI bleeding (－/＋) ( / / ) cause:
＜GERD＞
Symptoms: Frequency: ＜ 2/week, ＞2/week, Severity: mild / severe
Current meds: mg (since / / )
Sx: mild / less frequent: famotidine 10mg BIDー＞20mg BID (at least 2weeks)ー＞pantoprazole 20mg/dayー＞pantoprazole 40mg/day (step up Tx if Sx not controlled)
Sx: severe / frequent: pantoprazole 40mg/day
Discontinue meds if Sx resolves (Tx continued for 8 weeks)
Indication for maintenance PPI Tx: Barret esophagus / severe erosive esophagitis (standard dose or higher), recurrent GERD after discontinuation of Tx (lowest effective dose)
EGD ( / / ):
Indication for EGD: refractory to PPI standard dose x 4-8 weeks, alarm feature (dysphagia, odynophagia, GI bleeding, anemia, weight loss, recurrent vomiting), screen for Barrett esophagus (chronic GERD, hiatal hernia, older than 50 yo, male, obesity)
＜Peptic Ulcer Disease＞
H.pylori-positive ulcer / NSAIDs-induced ulcer / Non-H.pylori-Non-NSAIDs ulcer
EGD ( / / ):
Follow-up EGD (－/＋) ( / / ):
History of treatment:
Duration of PPI Tx (pantoprazole 20-40mg/day)
- H.pylori positive ulcer:
Uncomplicated duodenal ulcer: 2 weeks
Complicated duodenal ulcer: 4-8 weeks
Gastric ulcer: 8-12 weeks
- NSAIDs-induced ulcer: at least 8 weeks
- Non-H.pylori/Non-NSAIDs ulcer: long-term
Maintenance PPI Tx: pantoprazole 20-40mg/day
Indication for maintenance Tx (for high risk group): ulcer > 2cm + older than 50 yo, non-H.pylori/non-NSAIDs ulcer, refractory / frequent ulcer, failure to Tx of H.pylori, continued NSAIDs)
H.pylori eradication Tx: (－/＋)
H.pylori eradication confirmation: ( / / )
＜Cirrhosis＞
Cause:
Child-Pugh MELD score ( / / )
Management: vaccine (HAV/HBV), adjustment of meds, avoid alcohol, follow-up complications
[Varices] (－/＋)
EGD ( / / ):
History of treatment:
Endoscopic screening:
No varices: every 2-3 years, Small varices: every 1-2 years, decompensated cirrhosis: every year
Beta blocker: nadolol 40mg, titrate to achieve resting HR of 55-60/min
(BB used for both primary and secondary prevention for both compensated and decompensated cirrhosis, but with low threshold of discontinuing for side effect, especially for pt with decompensated cirrhosis)
[Ascites] (－/＋)
2 gram sodium diet, fluid restriction (if Na<125)
Diuretic: spironolactone 100-400mg + furosemide 40-160mg/day
Paracentesis ± Albumin administration ( iv 6-8 gram / L of fluid removal when more than 5L removed)
Monitor: renal function, mental status
[Recurrent hepatic encephalopathy] (－/＋)
Lactulose 30ml 3-4 times/day ー＞ keep BM 2-3 times/day
Rifaximin 550mg PO BID (add on lactulose as needed)
Oral branched-chain amino acid (when refractory to lactulose / rifaximin or protein-intolerant)
[Hepatocellular carcinoma] (－/＋)
Screening (all patients with cirrhosis regardless of the cause): abdominal US every 6 months: The last US ( / / ):
Diagnosis ( / / )
History of Tx:
[Nephrology / Urology]
Baseline Cre ( / / )
UA ( / / ) protein (－/ ＋) occult blood (－/ ＋) RBC Cast
Urine protein (albumin) (mg/dl) - Urine creatinine (mg/dl) ratio (≒ g/day)( / / )
(Proteinuria: >150mg/day, moderately increased albuminuria: 30-300mg/day, severely increased albuminuria: >300mg/day)
Renal US ( / / ):
Urinary catheter （－/＋：Type: reason: The day cath was lastly changed ( / / )
＜Chronic Kidney Disease＞
Stage (GFR: 1:>90, 2: 60-89, 3: 30-59, 4: 15-29, 5: <15)
Cause: proteinuria(－/＋) DM(－/＋)
[Blood pressure control]
Baseline BP / mmHg
Current meds： mg
Diabetic nephrophathy or proteinuric CKD: Target BP: 130/80
(1) ACEI or ARB ± (2) loop diuretic ± (3) nondihydropyridine CCB or dihydropyridine CCB (if already on BB)
Nondiabetic and nonproteinuric CKD: Target BP 140/90 or 125/-130/90 (older than 50 yo＋high CVD risk)
-> loop diuretic (if edema) ± ACEI or ARB ± CCB
[Glycemic control]
HbA1c ( / / )
Target HbA1c: 7 or 8 (elderly)
[Metabolic acidosis]
HCO3 ( / / )
Goal: HCO3>23 sodium bicarbonate 0.5-1.0mEq/kg/day
[Fluid volume]
Edema (＋/－) refractory HTN (＋/－)
Clinical volume overload or subclinical overload (refractory HTN) ー＞loop diuretic
[Hyperkalemia]
K ( / / )
Dietary restriction, discontinue causative meds, diuretic ー＞ decrease the dose of ACEI/ARBー＞ discontinue ACEI/ARB (if K>5.5)
[Anemia]
Hb ( / / )
Target Hb 10.0 - 11.5 (For predialysis patient)
Rule out other causes： yes / no
Transferin saturation % Ferritin ( / / )
Iron supplement: ferrous sulfate 325mg TID or IV (when transferin saturation<30%, ferritin<500)
Erythropoiesis stimulating agent：initially 10000 units SC weekly (Indication: Hb<10, iron deficiency corrected, no h/o stroke or active malignancy)
[Bone metabolism]
Intact PTH: corrected Ca: phos: 25(OH) D ( / / )
Target: intact PTH / Ca / phos in normal range
(1) dietary phosphate restriction ＜900mg/day ->
(2) phosphate binder：calcium gluconate 1000mg/day (when hypocalecemic) or sevelamer 800mg TID (when hypercalcemic) ＋ ergocalciferol 50000u weekly if 25(OH)D < 30 ->
(3) active oral vitamin D derivative (calcitriol, alfacalcidol, doxercalciferol, paricalcitol) (only if corrected Ca<9.5 and phos not elevated, then discontinue ergocalciferol) ->
(4) cinacalcet 30mg/day
[dyslipidemia] statin (＋/－)
＜ESRD＞
Preparation for renal replacement therapy
Referral to nephrologist (when GFR<30), Discussion, access placement (AV fistula / AV graft / tunneled catheter / peritoneal dialysis catheter), transplantation, vaccine (HBV, pneumococcus)
Access placement: AV fistula ( / / ) AV graft ( / / ) tunneled catheter ( / / ) peritoneal dialysis catheter ( / / )
Date of initiation: Hemodialysis / peritoneal dialysis (since / / )
Dialysis schedule: Mo / We / Fr
Facility: TEL
Nephrologist ______
Dry weight kg
[Infectious Disease]
Culture in the past： MRSA(－/＋)： pseudomonas(－/＋)： ESBL(－/＋)： Other:
Healthcare-associated：on HD, IV chemotherapy, nursing home/long-term care facility residence
＜HIV＞
Screening for all patients 13-75 yo ( / / ) positive / negative
Date of diagnosis ( / / )
Route of infection:
HIV-RNA / viral load ( / / )
CD4 ( / / )
History of ART：
Since when ( / / )
Adherence: adherent / non-adherent
Side effect:
Prophylaxis for opportunistic infection：TMP-SMX / azithromycin /
Monitoring
ROS / Physical Exam (infection, skin, eye, oral, neuro/cognitive Fx, GI, CV, lung, renal/urology, malignancy, metabolic , ..)
Cancer: anal pap smear (every year) (with age-appropriate other cancer screening) ( / / )
Infection
Syphilis serology, chlamydia/gonorrhea PCR, trichomonas: every year (when sexually active) ( / / )
TB, HAV, HBV: at baseline ( / / )
HCV: at baseline + every year (if IV drug abuse, MSM) ( / / )
Ophtahlmology evaluation: CD4 < 50, every 6-12 months ( / / )
Medication toxicity
Labs: CBC, BUN, Cre, AST, ALT, T-bil, UA: every 6 months ( / / )
Vaccine: generally the same recommendation with immunocompetent except for when CD4 < 200, live vaccine is not recommended at that time
ID physician _________
＜Hepatitis B＞
HBs-Ag (－/＋) HBs-Ab (－/＋) ( / / )
Screening: all Asian (+ other), sexual contact to HBsAg positive patient, IV drug abuse, MSM, chronically elevated AST/ALT, HCV/HIV patients, on HD, pregnant female, initiation of immunosuppression Tx
Work-up: CBC, INR, LFT, HBsAg/Ab, HBeAg/Ab, HBV-DNA, HIV, HCV, HAV-IgG ( / / )
HBeAg (＋/－) HBV-DNA int unit/ml ALT
Liver biopsy: no / mild / moderate / advanced fibrosis
History of treatment:
(treatment: typically indicated for evidence of fibrosis (even decompensated cirrhosis) ± high HBV-DNA>2000 / ALT>2xULN)
Current meds: (since / / )
Duration of Tx: usually longer than 4-5 years (at least one year after seroconversion, life-long Tx for cirrhosis)
Hepatocellular carcinoma screening: abdominal US every 6 months ( / / )
(indication for screening: cirrhosis／cirrhotic hepatitis／HB carrier with risk (Asian male>40 yo, Asian female>50 yo, family h/o HCC, African-american))
ID physician or gastroenterologist ________
＜Hepatitis C＞
HCV-Ab (－/＋) ( / / )
Screening: sexual contact to HCV positive patients, IV drug abuse, child born to HCV mother, chronically elevated ALT, HBV/HIV patients, on HD, blood product transfusion (clotting factor before 1987, blood before 1992)
Work-up: CBC, INR, LFT, HBsAg/Ab, HIV-Ab, HAV-IgG, HCV-RNA ( / / )
Risk management: alcohol, smoking, obesity, marijuana (all promote fibrosis)
(Coffee > 2cups/day reduced risk of hospitalization and mortality)
Fatigue: ondansetron 4mg BID (long-term use -> risk for constipation, arrhythmia)
History of treatment:
Treatment: (considered for all patients including decompensated cirrhosis)
Evaluation prior to treatment: HCV genotype, Fibrosis stage (AST to Platelet ratio / direct maker of fibrosis / abdominal US), h/o Tx
Duration of Tx: usually 12-24 weeks
Hepatocellular carcinoma screening: abdominal US every 6 months (for cirrhosis)
ID physician or gastroenterologist __________
＜vaccination＞
Tetanus / diphtheria (every 10 years) last time ( / / ) next ( / / )
Pneumococcus (x 1 or 2 times) (older than 65 yo, 19-64 yo with risk factor: chronic heart / lung / liver / kidney disease, smoking, alcoholism, DM, immunocompromised,.) ( / / )
(Booster x 1 required for people who received before 65 yo (at least 5 year interval)
HPV ( x 1: 9-26 yo female, 9-21yo male (up to 26 yo with MSM)) (＋/－)
Influenza (every year) ( / / )
HBV (on HD, IV drug user, healthcare worker, chronic liver disease, DM < 60 yo, ..) (＋/－)
Zoster ( x 1: older than 60 yo) (＋/－)
[Endocrinology / Metabolism]
＜Diabetic Mellitus＞
Type 1 / Type 2
Date of diagnosis ( / / )
HbA1c ( / / ) (every 3-6 months)
Patient’s target HbA1c
Target HbA1c: 7 (most patients), 8 (elderly), 6 (T1DM, pregnancy)
Urinary Albumin-to-Creatinine ratio (mg/dl／g/dl) (≒mg/day) ( / / ) (every year)
(Moderately increased albuminuria: 30-300mg/day, Severely increased albuminuria: >300mg/day)
Initiation of ACEI: when albuminuria > 30mg/day × 2 (regardless of blood pressure (data limited for normotensive patients))
Blood pressure
Baseline BP: / mmHg
Target BP 130/80
(1) ACEI/ARB ± (2) long-acting dihydropyridine CCB ± loop diuretic (for renal faiure) ± carvedilol (if BB given)
Statin
LDL ( / / )
Target LDL N/A (less than 100(no overt CVD) / less than 70(overt CVD))
Indication of statin: all diabetic patients older than 40 yo (regardless of LDL or risk factor) -> moderate or high intensity statin Tx
Or younger than 40 yo patients with CVD or CVD risk factors (LDL>100, HTN, obesity)
Aspirin: ASA 81mg/day
Indication for ASA: Secondary prevention／Primary prevention: cardiovascular risk 10 year risk > 10% (male or female older than 50 yo with at least following one risk factors: smoking, HTN, obesity, albuminuria, HL, family history of CHD)
Foot examination / neuropathy ( / / ) (every year)
Ophthalmology evaluation ( / / ) (every year)
ECG (at baseline, older than 50 yo)
Vaccine: HBV, pneumococcus (one more after 65 yo (5 year interval)), influenza
Management: smoking cessation, exercise, weight loss, nutritious education
Childbearing female: check hCG if miss menstruation -> discontinue statin/ACEI/ARB if positive
Current meds:
Insulin regimen:
Oral hypoglycemic agents:
Adherence: adherent / non-adherent
Hypoglycemic episodes:
Medication therapy (for T2DM)
Initiate medications when diagnosis (with lifestyle intervention)
Initiate Metformin 500mg BID (first choice) (titrate up to 2000-2500mg/day over 1-2 months)
(consider early introduction of insulin Tx when glucose>300-350, HbA1c>10 (with /without additional Tx) )
if not achieve target HbA1c after 3 months ->
Dual agent therapy
Metformin + SU or TZD or DPP4 or GLP1RA or SGLT2I or Basal insulin
if not achieve target HbA1c after 3 months ->
Triple agent therapy or insulin therapy
Metformin + 2 agents (following agents are usually not used together: SU and insulin / GLP1RA and DDP4 / GLP1RA and SGLT2. Otherwise any other combination possible (usually metformin + SU + one) )
if not achieve target HbA1c ->
Switch to Insulin therapy (SU, DPP4, GLP1RA are usually discontinued, other oral agents are continued)
SU: glipizide 5mg once daily (Efficiency: high, hypoglycemic risk: moderate, cost: low, side effect: hypoglycemia)
TZD: pioglitazone 15mg once daily (Efficiency: high, hypoglycemic risk: low, cost: low, side effect: heart failure)
DDP4: sitagliptin 100mg once daily (Efficiency: moderate, hypoglycemic risk: low, cost: high, side effect: rare)
SGLT2I: canagliflozin 100mg once daily (Efficiency: moderate, hypoglycemic risk: low, cost: high, side effect: GU)
GLP1RA: exenatide 5mcg BID (Efficiency: high, hypoglycemic risk: low, cost: high, side effect: GI)
(Meglitinide (repaglinide): may be used instead of SU in patient with irregular meal or late postprandial hypoglycemia)
(Alfa-glucosidase I, pramlintide, bromocriptine: may be tried in specific situations, but generally not favored due to modest efficacy, frequency of administration, or side effect)
T1DM: follow up with endocrinologist ________
＜Dyslipidemia＞
TG T-chol LDL HDL ( / / )
Current meds: (primary / secondary prevention)
[Secondary prevention] (known coronary heart disease or other cardiovascular disease)
Acute coronary syndrome: -> atorvastatin 80mg once daily
High risk group: (CHD or equivalent: MI, angina, stroke, TIA, PAD, 10y CVD risk>20%, GFR<45)
-> high-intensity Tx: (atorvastatin 40-80mg, rosuvastatin 20-40mg)
Very high risk group (CHD + multiple risk factor (especially DM) or severe and poor controlled risk factor (especially current smoker) or (TG>200 + LDL>130 + HDL<40) or ACS
-> maximize statin ± second LDL-lowering agent
(Second LDL-lowering agent: niacin or ezetimibe)
[Primary prevention] (without cardiovascular disease)
Framingham 10 year risk of cardiovascular disease %
(statin reduces relative risk by 20-30%-> Absolute risk reduction %)
If make a decision to start primary prevention based on absolute risk reduction -> moderate intensity Tx:
(lovastatin / pravastatin / simvastatin 40mg, atorvastatin 10-20mg, rosuvastatin 5-10mg)
(not give other type of anti-hyperlipidemia meds for primary prevention if patient doesn’t tolerate statin -> life-style modification ± ASA)
(ACC/AHA 2013 guideline redommends statin Tx as primary prevention for those: LDL > 190 or diabetic Pt > 40 yo or 10 years risk > 7.5%)
(fibrate Tx would be appropriate when TG > 500 to prevent pancreatitis)
＜Hypothyroidism＞
Screening: indicative symptoms/signs, abnormal labs (anemia, hyponatremia, CPK, dyslipidemia,..), thyroid injury, autoimmune thyroiditis, central hypothyroidism
Cause:
TSH FT4 T3 ( / / )
Target TSH: normal range (lower half of normal range if still symptomatic)
Check TSH once a year (6 weeks after change of dose)
Current meds: (since / / )
Levothyroxin initial dose: 50mcg / 25mcg (elderly)
Subclinical hypothyroidism
Indication for treatment: TSH>10, TSH 4.5-10 and symptomatic or positive TPO-Ab, pregnancy)
Symptom control: fatigue (＋/－) constipation(＋/－) cold intolerance(＋/－) dry skin(＋/－) edema(＋/－) depressive mode(＋/－)
＜Osteoporosis＞
Risk factor: h/o fracture, glucocorticoid Tx, low body weight, current smoker, excessive alcohol intake(>3 drinks/day), rheumatoid arthritis, malabsorption condition (pancreatic disease, celiac disease, IBD, gastric bypass surgery)
Screening: all female older than 65 yo, postmenopausal female younger than 65 yo with risk factors, male with risk factors (low bone mass, h/o fracture, hyperparathyroidism, androgen deprivation Tx, ..)
Timing of DXA: hip/(spine)
T: - 2 to - 2.5 or ongoing risk: every 2 years
T: - 1.5 to - 2 without risk: every 5 years
T: - 1 to - 1.5 without risk: follow up in 10-15 years
2 years after initiation of Tx
DXA: ( / / ) T score: hip spine next ( / / )
Current meds: ( / / )
Indication for bisphosphonate: postmenopaussal female or male > 50 yo who have either h/o hip or vertebral Fx or T score < -2.5 or patients with osteopenia (T score -1.0 to -2.5) with 10 y osteoporotic fracture risk > 20%
Risk factors for Osteonecrosis of the jaw: IV bisphosphonate, cancer, anti-cancer Tx, compromised immune system, DM, smoking, glucocorticoid, dental extraction, dental implant, poorly fitting denture, preexisting dental disease
＜Vitamin D Deficiency＞
Risk factor: inadequate sun exposure, gastrectomy, pancreatic insufficiency, cirrhosis, anticonvulsants, nephrotic syndrome, renal failure, hypoparathyroidism
Risk: high / low,
Serum 25(OH) D: ( / / )
Treatment：
＜Gout＞
Attack: times/year
Severity: mild / moderate-severe
Tophaceous deposit (＋/－)
Life modification: weight loss, vitamin C 500mg/day, limit alcohol, anti-HTN med (switch from thiazide diuretic to losartan), ASA (keep low-dose if possible)
Indication for urate-lowering Tx: attack more than 2 times/year or severe symptoms, tophaceous deposit, recurrent uric acid nephrolithiasis
Current meds ( / / ) Prophylaxis (＋/－)(colchicine 0.6mg daily less than 6 months)
Uric acid ( / / )
Target uric acid： < 6 or < 5 (if tophaceous deposit)
Measurement of urinary uric acid excretion: mg/day ( / / )
(indication for measurement: attack at young male < 25 yo, premenopausal female, considering uricosuric agent (:probenecid))
＜Adrenal Incidentaloma＞ (＞1cm)
Evaluation of hormonal secretion:
Dexamethasone suppression ( / / )
24h urinary fractionated metanephrine/catecholamine ( / / )
Plasma aldosterone-to-plasma renin activity ratio / plasma potassium ( / / )
Evaluation for malignancy:
Abdominal CT ( / / )
Size： Unilateral / bilateral
Attenuation: high / low
Primary malignancy elsewhere (＋/－)
Follow-up CT abdomen at 3-6 mo / 12 mo / 24 mo (if benign appearance)
Adrenalectomy ( / / ) (suspicious, large, biochemically documented pheochromocytoma, increase in size by >1cm during follow-up)
[Hematology]
WBC Hb Hct MCV PLT ( / / )
Baseline Hb: Baseline PLT:
History of transfusion: ( / / )
Reason:
Bone marrow aspiration / biopsy (－/＋) ( / / )
Reason: Result:
Lab evaluation: Reticulocyte production index iron ferritin TIBC transferrin saturation VitB12 folate TSH ( / / )
＜Iron Deficiency Anemia＞
Date of diagnosis: ( / / )
Hb on Dx: Latest Hb ( / / )
Presumed cause:
(etiology: menstruation, gastrectomy, inflammatory bowel disease, malignancy, GI bleed, myeloproliferative disease, ..)
History of work-up:
Current treatment: (since / / )
Indication for Tx: all patients without contraindication to iron Tx (regardless of symptoms, even without anemia)
Ferrous sulfate 325mg (iron: 65mg/Tab) (recommended dose: iron 150-200mg/day)
When intolerant to iron Tx: decrease the dose, or switch to liquid, or switch to IV
Follow up Hb / reticulocyte 2 weeks after initiation of Tx (Hb usually increases by 2g/dl in 3 weeks)
When lack of response: check adherence, rule out GI bleed -> evaluation for H.pylori infection / Celiac disease
Duration of Tx: until transferrin saturation normalizes (anemia improve in 6-8 weeks, replete iron store in 6 months)
＜Thrombocytopenia＞
Baseline PLT
Stable / worsening
History of work-up: (causative meds, blood smear, LFT, HIV-Ab, HBs-Ag/Ab, HCV-Ab, VitB12, folate, abdominal US, ANA, LDH,..)
Referral to hematologist : (－/＋)
Bone marrow aspiration / biopsy (－/＋) ( / / )
Cause: unknown / ________
(DDx: ITP, liver disease, Myelodysplastic syndrome, HIV, medication, malignancy, vitamin B12/folate deficiency,…)
Reassess requirement of antiplatelet /NSAIDs
Activity restriction: PLT<50000 -> extreme athletics (boxing, rugby,..)
[Oncology]
Family history： at age of
Smoking: pack-year, current smoker / quit in ____
Occupational exposure: (－/＋):
＜Cancer Screening＞
[Breast cancer]
Risk factor: BRCA1/BRCA2, family history (mother / sister), estrogen Tx, alcohol, menarche < 12 yo、menopause > 55 yo
Discussion regarding risk and benefit of screening:
Patient desires screening: yes / no
Mammography (40 or 50 yo to 10y prior to life-expectancy, every 2 years)
Result ( / / )
Next ( / / )
[Cervical cancer]
Pap smear ( 21 – 64 yo, every 3 years, also 65 – 75 yo or longer for people with risk (abnormal pap smear, smoking, HPV-disease, new partner) or not adequately screened)
Result ( / / )
Next ( / / )
[Colorectal cancer]
Family history (－/＋) at age of
50 – 75 yo, colonoscopy every 10 years or sigmoidscopy every 5 years with FOBT every 3 years
Result ( / / )
Next ( / / )
[Lung cancer]
Low-density helical CT (55 – 74 yo with > 30 pack-year, every year)
Result ( / / )
Next ( / / )
[Prostate cancer]
Risk factor: family history (especially younger than 65 yo), African-American, gene
Discussion regarding risk and benefit
Patient desires screening: yes / no
PSA/(DRE) (50 yo to 10 y prior to life-expectancy, every 2-4 years)
PSA: ( / / )
Next ( / / )
＜Lung Nodule＞
Risk stratification
Family history of lung cancer (＋/－) emphysema (＋/－) in upper lobe (＋/－) spiculation (＋/－)
Attenuation： solid／subsolid／part-solid
Size： mm, number of nodule:
Risk： high／intermediate／low
Chest CT ( / / ):
Management:
(Discontinue follow-up / follow-up CT in ____ / PET / sampling / resection)
＜Thyroid Nodule＞
Non-functional / Functional (TSH, radionuclide scan)
US: cm
Echoic feature: hyper / hypo,
regularity: vascularity: calcification:
FNA (－/＋) ( / / ) Result:
Management:
(follow up US in 12-24mo, repeat FNA, thyroidectomy)
[Allergy / Autoimmune Disease]
＜Allergic Rhinitis＞
Symptoms:
Frequency: < 4 times/week / > 4 times/week
Severity: mild / moderate to severe (impairment of daily activity)
Hypersensitivity skin test: (－/＋)( / / )
(Indication for skin test: unclear diagnosis, refractory to Tx, coexisting persistent asthma and/or recurrent sinusitis/otitis,…)
Allergen avoidance (pollen, pet, dust, mites, mold, minimize reservoirs (carpets, and uncovered pillows or bedding)
Current meds: (since / / )
Medical treatment
Glucocorticoid nasal spray: (first choice)
fluticasone propionate (50mcg/spray) 2 sprays into each nostril once daily
(initiate at maximal dose-> taper to lowest effective dose)
Alternative or add-on
Anti-histamine nasal spray: olopatadine 2 sprays into each nostril BID
Second generation oral anti-histamine: cetirizine 10mg daily, loratadine 10mg daily
cromolyn nasal spray: 1 spray into each nostril 3-4 times a day (safe for children, less effective)
montelukast 10mg daily (concomitant asthma or nasal polyp)
Refractory to treatment
Subcutaneous immunotherapy / referral to allergy specialist
Indication: Sx upon natural exposure to the allergen ＋ specific IgE (serum or skin) ＋ uncontrolled / side effect of med / cost burden associated with chronic medication use
Duration of Tx: 3-5 years
＜Rheumatoid Arthritis＞
Date of diagnosis ( / / )
History of treatment:
Current medications: ( / / ) ( / / )
Disease activity:
Joint tenderness (shoulder / elbow / wrist / MCP1 / 2 / 3 / 4 / 5 / PIP2 / 3 / 4 / 5 / IP / knee / )
Joint swelling (shoulder / elbow / wrist / MCP1 / 2 / 3 / 4 / 5 / PIP2 / 3 / 4 / 5 / IP / knee / )
ESR CRP ( / / )
Functional capacity: (I) complete / (II) adequate for normal activities / (III) limited / (IV) Bedridden / wheelchair bound
Rehabilitation
Medication toxicity monitoring
HBs-Ag/Ab, HCV-Ab, TB, ophthalmology evaluation: at baseline
ROS: SOB, edema, tarry stool, hematuria, visual change
Labs: CBC, Cre, LFT every 8-12 weeks (initiation or dose increase: every 2 weeks for 3 months), HbA1c
Prophylaxis for osteoporosis
Vitamin D 800 units daily ＋ Ca supplement (require total 1200mg daily (diet + supplement)) (for all patients on any dose of glucocorticoid with an anticipated duration of ≥3 months)
BisphosphonateTx
Indication:
Postmenopausal female with T score -1.0 to -2.5 or high risk male older than 50 yo (low bone mass, h/o fracture, hyperparathyroidism, androgen deprivation Tx, ..) (upon initiation of glucocorticoid regardless of dose or duration)
Postmenopausal female or male older than 50 yo who take prednisone 7.5mg or equivalent more than 3 months
Rheumatologist ______
[Nutrition]
BMI ( / / )
Swallow evaluation ( / / )
Target daily nutrition: kcal protein Na K phosphate
Nutrition teaching ( / / )
Diet modification: diet: liquid:
Supplemental nutrition
Fluid restriction:
Tube feeding: Type: kcal/day, water bolus ml x times/day, Total fluid L/day
[Code Status]
Resuscitation: okay / do not
Intubation: okay / do not
Non-invasive ventilation: okay / do not
Hemodialysis: okay / do not
Tube feeding: okay / do not
IV hydration: okay / do not
Blood transfusion: okay / do not
Transfer to hospital: okay / do not
Healthcare proxy (－/＋): Relationship TEL
[Referral]
(1) Aspirin and extended-release dipyridamole versus clopidogrel for recurrent stroke.
Sacco RL, N Engl J Med. 2008;359(12):1238.
(2) A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet. 1996;348(9038):1329.
(3) Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
Kernan WN, Stroke. 2014;45(7):2160
(4) A Randomized Trial of Intensive versus Standard Blood-Pressure Control.
SPRINT Research Group, N Engl J Med. 2015;373(22):2103.
(5) 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.
Yancy CW, Circulation. 2013;128(16):1810.
(6) A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema.
Fishman A, N Engl J Med. 2003;348(21):2059.
(7) Management of varices and variceal hemorrhage in cirrhosis.
Garcia-Tsao G, Bosch J N Engl J Med. 2010;362(9):823.
(8) STANDARDS OF MEDICAL CARE IN DIABETES 2016 (American Diabetes Association)
(9) W.H.O. cooperative trial on primary prevention of ischaemic heart disease using clofibrate to lower serum cholesterol: mortality follow-up. Report of the Committee of Principal Investigators. Lancet. 1980;2(8191):379.
(10) Fifteen year mortality in Coronary Drug Project patients: long-term benefit with niacin.
Canner PL, J Am Coll Cardiol. 1986;8(6):1245.
(11) Effects of long-term fenofibrate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus (the FIELD study): randomised controlled trial.
Keech A, Lancet. 2005;366(9500):1849.
