Chronic Standard Plans.

Standard Care Plans (Azzolini)

UC - Respiratory


*** Cough

Standard Recs:
> reviewed: rest/hydration, humidifier/mask/scarf use, nasal saline +/- bulb suction, hand washing to reduce transmission.
> OTC PRN tylenol/ibuprofen as tolerated. if >18 yo, may try nyquil/dayquil
> precautions given; notably if sx worsen or change, RTC or go to ER.
> RTC if sx worsen or fail to improve in the next 1 week.



DM Flowsheet
Diabetes: – Diabetes control: _***__; Blood sugars: _***_
– Complications: _***_ retinopathy, _***_ LE neuropathy; _***_ ulcers; _***_ CKD; _***_microalbuminuria; – ASCVD RFs / hx: CAD hx _***__, CVA hx_***__ – Other rx: ACEi/ARB _***__; statin _***__; ASA 81 _***__ – Lifestyle: _***_ ADA diet, _***_ nutritionist; – Last ophtho exam: *** – Last DM foot exam: *** – vaccinations: PNA vaccine _***__; flu vaccine _***_ – Current Regimen: *** reviewed in EMR.
– Note: ***
PE:
DM Foot exam: b/l no rash or lesions, warm & dry, dorsalis pedis 3+, monofilament testing sensation intact throughout
DM BG log: *** prepare a print out
AP
#. Diabetes
- A1C goal

> Lifestyle: rec low carb & sugar diet / regular moderate intensity exercise
> c/w current rx:
> labs today

> check BG daily as directed; BG goals fasting <120, post-prandial <180

- DM foot exam: click on the procedure code, monofilament testing


-
DM Foot exam: b/l no rash or lesions, warm & dry, dorsalis pedis 3+, monofilament testing sensation intact throughout
- ACEi/ARB; metformin
- BG Log -
printout
-
Youtube video; DietDoctor.com, fasting for DM
- DM Diet for Latinos ;
print out
- DM diet; “Healthy eating for Diabetes


Screen Shot 2017-06-08 at 11.28.45 AM



Obesity:
Weight Management

- Since last visit, ***

- Current diet:
- Current physical activity:

- Notes:

Goals
=> Wt: *** => Function: *** => Other: ***

- Start Date: *** Wt: *** ; ***
- Date: *** Wt: *** ; ***
- Date: *** Wt: *** ; ***

Max weight: *** ; Start wt: *** and BMI: ***
Co-morbidities: MSK _***_; CV _***_; Psych _***_; Endocrine _***_; Other _***_
Previous wt loss efforts: ***

- Secondary evaluations:
=> Insulin resistance : *** => OSA: ***
=> Thyroid function : *** => Anemia: ***
=> NAFLD / NASH: *** => Lipid panel: ***
=> Other: *** PCOS

=> Psych: ***
=> Social support: ***
=> Rx review: ***
=> Rx risk review: ***
=> Bariatric candidate: ***


HPI Template:
- Current Rx:
- Diet:
- Exercise:
- Medical Context: (PCOS, HLD, CAD, OSA, thyroid, rx induced)
- Co-morbidities:
- Social support:
- History of stimulant use / risk:
- Bariatric candidate:
- Initial BMI__; Wt__ on date: __


- Wt: ; BMI: ; goal BMI = <30
- consider metabolic syndrome; PCOS; OSA; TSH; evaluate for ASCVD RFs
> rec slow carb diet / kcal restriction 1500 daily.
> rec cardio exercise 3x/wk x20-30min
> journal daily; develop daily habits of diet/exercise and social support for changes.
> wt goal:
> lipid panel; A1C; CMP/LFTs; TSH
> PHQ9
> RTC 1-2 mo


Hepatitis B
Chronic Hepatitis Since last visit, *** Sx: _***_ abdominal pain, _***_ skin changes, _***_ anorexia Current Rx: _***_ HBeAg status: _***_ ; Cirrhosis presence: _***_ Other viral infections: Hep D _***_; Hep C _***_; HIV _***_ Vacc: HAV vacc _***_, Hep B vacc _***_
Date: _***_   Labs/imaging: _***_ Date: _***_   Labs/imaging: _***_
AP: #. Chronic Hepatitis B: - *** doing well, *** suppressed and stable. - routine monitoring ==> Abdo US, AFP, LFTs, HBV DNA. - Avoid etoh and hepatotoxic rx. Avoid transmission risks (Hep B vacc for family / close contacts, safe sex practices, avoid blood exposure risk) - RTC for Hep B monitoring next in 6 months.
 
========
- if on tx  ==>  CBC, BMP - if AFP high or US abnl ==> CT or MRI abdo - ? cirrhosis screening - ? indications for referral



HA:
- Px: , no trauma/injury, no red flags (_____)
- DDx: likely tension vs migraine, dehydration, MSK
> HA log; include foods, exercise, occupational exposure
> lifestyle changes: decrease screen time, inc daily hydration, inc posture, improve sleep
>
> RTC / ER if sx worsen or if weakness, vision changes.
> RTC 2-4 weeks re-evaluation.

Migraine : > sumatriptan 25-50 mg q2 hr PRN (max 200mg/d) , excedrin, zofran 4-8mg q6 PRN n/v
Migraine ppx: propranolol, duloxetine
Tension : >
Cluster:
Withdrawal HA:
Sx control: zofran

Migraine
acuterxprotocol



Asthma:
***

Depression:
- Px: , no SI/HI, no etoh / drug abuse
- Stressors :
- PHQ9 ; GAD7:
> citalopram 10mg/d; (precautions given; if any SI/HI in next few weeks, dc SSRI and call back)
> daily journal, engage in local activities
> refer to psych / counseling
> RTC/ER if sx worsen or develop Si/HI

- other anti-depressant indications ?

Low back pain
- Px: ; no injury/trauma, no red flags (saddle anesthesia, weakness, f/c)
- etio: likely muscular spasm vs sciatica vs spinal stenosis vs pririformis syndrome
> naproxen BID x5d; cyclobenzaprine x3d (precautions given to avoid if driving, etoh use, or operating heavy machinery)
> gradual return to normal activity; walking program.
> RTC 2 weeks; anticipate improvement within 1-2 weeks; if not sig improvement by 4-6 weeks, will consider MRI
> RTC / ER if sx worsen or weakness, incontinence, f/c.


CKD
- CKD stage
- 2/2: DM2, HTN
- Rx: ACEi; reviewed rx.
- reduce RFs; including DM2, HTN, HLD
> BMP, CBC
> avoid NSAIDs, other nephrotoxic agents
> adequate hydration daily

- follow K



HTN:

- BPs: ; goal: <140/<90
- Cx: renal / cardiac / neuro
- Rx:
- No red flags; given precautions for ED: CP, vision changes, HA, worsening sx.
- Lifestyle: improve sleep, decrease stress, low Na diet.

- W/u: CBC (anemia/polycythemia), CMP (AKI/CKD), lipid panel, TSH
>

- R/o secondary etio: CXR (coarctation aorta), BUN/Cr (renal), renal US (renal AA stenosis), CBC (polycythemia vera, anemia), TSH,
- complications: nephropathy
- Rx induced: OCPs, AKI/CKD

CAD:
- RFs: smoking; HLD; obesity; DM
- Current Rx:
- Cardiac hx: MI / stent / CABG
- sx at baseline, no acute CP.
- Lifestyle: counseled on smoking cessation, inc exercise

- ASA 81mg/d; BB; statin; ACEi

CHF Flowsheet
- Systolic/Diastolic; ischemic / nonischemic; echo on LVEF
- NYHA Stage:
- Current Rx: coreg, ACEi, ßB, aldactone
- Cardiologist:
- no acute complaints, sx at baseline today.
> regular wt checks, salt restricted diet.
> precautions to RTC/ER: SOB, difficulty breathing, worsening swelling LE

NYHA-heart-failure-classification


Asthma Flowsheet
> Stage :
> Control:
> Current Regimen
> Asthma Action Plan :
> Spirometry:

COPD:
- GOLD Stage / Group:
- Cx: O2 use.
- RFs: tobacco use, allergy management, GERD
- Spirometry:
- Current Rx: albuterol PRN
- Vaccines: pneumonia, flu vac.
- sx at baseline today, no acute change
> c/w regimen.
> avoid smoke & tobacco / allergens. regular hand washing
> Pulm rehab:
> RTC 3-6 mo re-evaluation
> RTC / ER if sx worsen, especially severe SOB/wheezing/CP.

• Treatment by groups : high risk = >2 exac/yr.
Group A
low risk/low sx
Group B
low risk/high sx
Group C
high risk/low sx
Group D
high risk/high sx
1. SABA q6 PRN or SA-AC q6 PRN
2nd line: LABA or LA-AC or  combination SABA/LAAC
1. LABA or LA-AC
2. LABA + LA-AC
1. (LABA or LA-AC) + resp CS. 
2. (LABA+LA-AC)
1. (LABA or LA-AC) + resp CS
2. LSBA + LA-AC + resp CS; plus PDE-4 inhibitor
LABA: salmeterol (serevent discus) BID; formoterol (brovana) 15 mcv BID
SABA: albuterol 2puffs q6 PRN
LA-AC: tiotropium (spiriva) qday. 
SA-AC: ipratropium bromide (atrovent) 2-3 puffs aid or 500 ug vial neb qid. 
inhaled CS: flovent 
Combination rx: combivent (ipratropium + albuterol); symbicort (budesonide + formoterol)



Spirometry Reading:

Restrictive disease: think of the lung as being a smaller box. FVC is low because it is compressed. The outlet efflux straw is normal, so no problem getting air out (% of volume out in 1 second is normal = FEV1/FVC normal >70%, meaning most of the volume that is there is blown out easily and quickly). The absolute volume out in 1 second can be normal or lower (lower because since the FVC / total volume is lower anyways, the absolute volume out in 1 sec may also be lower!).

Obstructive disease, there is no box. The straw is being squeeze though. FVC (should be mostly normal) is not the major thing affected, but it may be low (why low? because the measure of the FVC requires total volume that the lung can blow out. in obstructive disease, some of the air can just be stuck and can’t get out whatsoever). The FEV1 is the main thing affected, is low, can’t get it through the squeezed straw. FEV1/FVC <70% = This is the key point, volume is ok, but the 1 second out is just so low so the % of the FVC out is at least <70%.

0ce90331f3b12c0ff85efa183e943165

HLD Flowsheet
- Lipid profile: ;ASCVD Risk 10yr:
> Current rx:
> Lifestyle: low fat diet, inc exercise, wt loss.

- statin indicated if hx CAD/CVA or DM2 (CAD equivalent)


Smoking
- pack years; current
- cx: COPD, cough
- stage (pre/contemplative/preparation/action/maintenance)
- vacc: flu, pneumovax
> reviewed risks of smoking; including heart disease, stroke, lung CA, COPD.
> cessation counseling; gradual weaning
> RTC 2-4 weeks
> goal by next visit:

- AAA screen; LDCT;

#. Eczema
- care = atopic dermatitis
- px: young age px w/ pruritis, (acute/chronic), atopy, flexural regions.
- cx: (impetigo/cellulitis), lichen simplex
- emollient standard; CS for flare-ups; anti-histamine for pruritis (=placebo), allergies
- aquaphor / eucerin / vaseline TID
- CS topical: PRN x3-14d; hydrocortisone 1%; triamcinolone 0.1%
- 2nd line: tacrolimus (calcineurin-inhib) topical.
- CS only low-potency in face, groin, axillae
- RTC 1 wk.




=============================

#. Chronic Pain

> progress towards functional goals; red flag behaviors; presence of uncontrolled psych / other medical issues
> UDS, AZSCMP
#. chronic pain
- etio: 
- goal: functional
- risk profile: ORT, CAGE, PHQ9
- regimen: 
- pain contract
- UDS, AZSCMP
- RTC 1 mo.  s

#. Hepatitis C
. Hep C screening indicated in: all 45-65 yo. High RFs: jail/prison, tattoos, sex
. R/o concurrent infections: Hep A (Ab), Hep B (sAg, sAb), HIV screen
. Vaccinate for Hep B : immunity = Hep B surface Ab; Vaccinate for Hep A / pneumovax / influenz
. R/o cirrhosis – RUQ US (MC evaluation), biopsy.
. rx: avoid etoh, NSAIDs, Tylenol ok. If adv disease – may DC statins (not evidence for DC though).

. Tx goal: eradication of HCV = SVR (sustained virologic response = 3 mo neg) = 97-100% HCV RNA neg long-term
. Candidates for Hep C tx: basically everyone w/ Hep C; 95% chance of SVR achievement. Even in advanced cirrhosis.


#. ASA Primary Prevention
When to use ASA 81mg qday?

NEW 2016 updates: USPSTF: ASA 81mg/d for primary prevention CVD, colorectal CA in 50-60 yo (>10% CVD risk, no inc risk bleeding, life expectancy >10 years)
> make assessment of high risk vs low risk groups: fhx, PMHx CVD/CVA/DM/smoker/etc.

• Men 45-80 yo – primary prevention ACS/MI
• Women 55-80 yo – primary prevention CVA
• Secondary prevention: ACS/CAD, CVA
• ? Cancer prevention: primarily colorectal cancer. Also decrease mortality in cancer cases.
 
So:
1000 patients >60 yo at average risk CAD (10-20% over 10 yrs) and average malignancy risk (12%) over 10 year period taking ASA 81mg:
• 6 fewer deaths
• 17 fewer non-fatal MI
• 6 fewer cancers
• 16 more major bleeding events (ICH, GI requiring hospitalization /transfusion). Note that if bleed, typically in early tx. 

INR
• Warfarin / INR Protocol: