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Abbreviation: 2tfp-plan-msk-lbp-nonspec-initialDescription: v1.0

Recommendations/education provided:Pt educated on the following items: Pt given education handout and instructed that most LBP episodes resolve in 4 weeks or less, avoid bed rest/bending/twisting, return to normal activities as soon as possible. Pt can use short term superficial heat and medication to relieve symptoms. Pt instructed to follow up in 4 weeks or if symptoms worsen.-Patient verbalizes understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-msk-lbp-nonspec-initialDescription: v1.0

CDS LBP Nonspecific Initial VisitSidebar B: Interventions (source: VA/DoD CPG 2017)

Category Intervention

Low Back Pain DurationAcute

<4 Weeks

Subacute or Chronic

>4 Weeks

Self-careAdvice to remain active X XBooks, handout X XApplication of superficial heat X

Non-pharmacologic therapy

Spinal manipulation XClinician-guided exercise XAcupuncture XCBT and/or mindfulness-based stress reduction XExercise which may include Pilates, tai chi, and/or yoga X

Pharmacologic therapy

NSAIDs X XNon-benzodiazepine skeletal muscle relaxants X Antidepressants (duloxetine) X

Other therapies Intensive interdisciplinary rehabilitation X

Abbreviations: CBT: cognitive behavioral therapy; NSAIDs: nonsteroidal anti-inflammatory drugs

Medication: -If an NSAID is required in a patient with GI risk, naproxen with a proton pump inhibitor may be a viable option. (VA/DoD CPG)-VA/DoD CPG suggests the use of relatively COX-2 selective NSAIDs over non-selective NSAIDs based on patient risk factors, primarily gastrointestinal (GI) toxicity.Med Comments Dose Max

Dose

per dayibuprofen 1st line 400 mg q 4-6

h 3200 mgnaproxen 1st line 250mg BID 1500 mgmeloxicam 1st line for those at higher risk of GI bleed 7.5 mg QD 15 mgcyclobenzaprine optional 5 mg TID 30mg

esomeprazole optional, if on NSAID and GI risk, may not be on formulary 20mg QD 40 mg

omeprazole optional, if on NSAID and GI risk, no FDA indication for this use 20mg QD 40 mg

Imaging/labs: NOT recommendedNonpharmaceutical treatments: superficial heatReferrals: NOT recommendedPatient education: https://familydoctor.org/condition/low-back-pain/ https://www.acponline.org/system/files/documents/patients_families/products/health_tips/back_en.pdfReferences: https://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId=109#4

Abbreviation: 2tfp-plan-msk-lbp-nonspec-fu Description: v1.0

Functional Impairment: Pt does not have a significant functional impairment Pt has a significant functional impairment and will be referred for multidisciplinary rehabilitation or specialty care:

Recommendations/education provided:-Patient educated on the following items: Pt given education handout and instructed to avoid bed rest/bending/twisting, return to normal activities as soon as possible. Pt instructed that exercise which may include Pilates, tai chi, and/or yoga can improve chronic back pain. Pt instructed to follow up in 4 weeks or if symptoms worsen.-Patient verbalizes understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-msk-lbp-nonspec-fuDescription: v1.0

CDS LBP Nonspecific Follow-upSidebar B: Interventions (source: VA/DoD CPG 2017)

Category Intervention

Low Back Pain DurationAcute

<4 Weeks

Subacute or Chronic

>4 Weeks

Self-careAdvice to remain active X XBooks, handout X XApplication of superficial heat X

Non-pharmacologic therapy

Spinal manipulation XClinician-guided exercise XAcupuncture X

https://www.acponline.org/system/files/documents/patients_families/products/health_tips/back_en.pdf

https://familydoctor.org/condition/low-back-pain/

CBT and/or mindfulness-based stress reduction XExercise which may include Pilates, tai chi, and/or yoga X

Pharmacologic therapyNSAIDs X XNon-benzodiazepine skeletal muscle relaxants X Antidepressants (duloxetine) X

Other therapies Intensive interdisciplinary rehabilitation X

Abbreviations: CBT: cognitive behavioral therapy; NSAIDs: nonsteroidal anti-inflammatory drugs

Medication: CONSIDER LONG TERM RISKS OF NSAIDs-If an NSAID is required in a patient with GI risk, naproxen with a proton pump inhibitor may be a viable option.- VA/DoD CPG suggests the use of relatively COX-2 selective NSAIDs over non-selective NSAIDs based on patient risk factors, primarily gastrointestinal (GI) toxicity.

Med comments DoseMax Dose per day

ibuprofen 1st line 400 mg q 4-6 h 3200 mg

naproxen 1st line 250 mg BID 1500 mgmeloxicam 1st line for those at higher risk of GI bleed 7.5 mg QD 15 mgduloxitine optional 30 mg QD 60 mgesomeprazole

optional, if on NSAID and GI risk, may not be on formulary 20 mg QD 40 mg

omeprazole optional, if on NSAID and GI risk, no FDA indication for this use 20 mg QD 40 mg

Imaging: Diagnostic imaging is recommended only for patients when neurologic deficits are serious or progressive or when red flag symptoms are present.Labs: Appropriate laboratory testing is indicated only when red flag symptoms are present.Referrals: as per chart aboveFollow up: 4 weeks or if symptoms worsen

Abbreviation: 2tfp-plan-msk-lbp-redflagDescription: v1.0

Patient’s LBP is identified as or suspected as “red flag” condition and will be referred for further diagnostic testing and evaluation.Recommendations/education provided:-Patient educated on the possible etiology of their LBP and next steps in management. -Patient verbalizes understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-msk-lbp-redflagsDescription: v1.0

CDS LBP Red FlagsSidebar A: Diagnostic Work-up (source: VA/DoD CPG 2017)

Possible causes or conditions

Red flags or risk factors on history or physical examination

Suggested diagnostic imaging

CancerHistory of cancer with new onset of LBPUnexplained weight lossFailure of LBP to improve after 1 monthAge > 50 yearsMultiple risk factors present

Lumbosacral plain radiography

For inconclusive results, advanced imaging such as MRI with contrast* as appropriate

InfectionFeverIntravenous drug useRecent infectionImmunosuppression

MRI with contrast*ESR (electron spin resonance)

Fracture

History of osteoporosisChronic use of corticosteroidsOlder age (≥75 years old)Recent traumaYounger patients with overuse at risk for

stress fracture

Lumbosacral plain radiography

For inconclusive results, advanced imaging such as MRI Ϯ, CT, or SPECT as appropriate

Ankylosing spondylitis

Morning stiffnessImprovement with exerciseAlternating buttock painAwakening due to low back pain back pain

during the second part of the night (early morning awakening)

Younger age

Anterior-posterior pelvis plain radiography

Herniated disc

Radicular back pain (e.g., sciatica)Lower extremity dysesthesia and/or

paraesthesiaPositive straight-leg-raise test or crossed

straight-leg-raise test

None

Severe/progressive lower extremity neurologic deficits

Symptoms present > 1 monthMRI Ϯ

Spinal stenosis

Radicular back pain (e.g., sciatica)Lower extremity dysesthesia and/or paraesthesiaNeurogenic claudicationOlder age

None

Severe/progressive lower extremity neurologic deficits

Symptoms present > 1 monthMRI Ϯ

Cauda equina or conus medullaris syndrome

Urinary retentionUrinary or fecal incontinenceSaddle anesthesiaChanges in rectal toneSevere/progressive lower extremity

neurologic deficits

Emergent MRI Ϯ

Abbreviations: CT: computed tomography; ESR: electron spin resonance; LBP: low back pain; MRI: magnetic resonance imaging; SPECT: single-photon emission computed tomography *MRI with contrast, except where contraindicated (e.g., renal insufficiency), otherwise MRI without contrastϮMRI, except where contraindicated, (e.g., patients with pacemakers), otherwise CT or CT myelogram

Abbreviation: 2tfp-plan-msk-knee-initial-conservmgmtDescription: v1.0Patient diagnosed with soft tissue injury of the knee. Recommendations/education provided:Patient educated on conservative treatment: -Relative rest: crutches not indicated indicated until able to bear weight with normal gait. -Knee immobilizer hinged brace not indicated indicated. -Short term medication as prescribed, as needed for pain. -Range of motion exercises as soon as can be tolerated, along with progressive weight-bearing and exercise. Yes No: Plain radiographs ordered based on Pittsburgh Ottawa knee rules. Yes No: Referral to Physical therapy for guidance on ROM and strength training.Follow up in 3-5 days 1-2 weeks as needed .Patient instructed to follow up immediately for severe or worsening pain, skin discoloration distal to the injury, or new or worsening numbness.Yes No: Medical profile, duty/activity restriction provided. -Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviations: 2tfp-plan-msk-knee-initial-referDescription: v1.0

Patient diagnosed with knee injury requiring specialist evaluation: _Recommendations/education provided:Interim management: - Yes No: Crutches for no weight bearing limited weight bearing. - Yes No: Knee immobilizer hinged brace. - Yes No: Plain radiographs ordered based on Pittsburgh Ottawa knee rules. -Yes No: Referral to Physical therapy for guidance on ROM and strength training.Follow up in 3-5 days 1-2 weeks as needed .Patient instructed to follow up immediately for severe or worsening pain, skin discoloration distal to the injury, or new or worsening numbness.Yes No: Medical profile, duty/activity restriction provided. -Patient verbalized understanding of diagnosis, instructions, and treatment plan.

Abbreviations: 2tfp-plan-msk-knee-fu-conservmgmtDescription: v1.0

Patient diagnosed with soft tissue injury of the knee, responding to conservative management. -Continue Discontinue relative rest (brace, crutches, weight bearing as tolerated, ROM and strength exercises). -Continue Discontinue knee brace. -Continue Discontinue crutches. -Continue Discontinue short term medication as prescribed, as needed for pain. -Range of motion exercises and strengthening exercises. Yes No: Referral to Physical therapy for guidance on ROM and strength training.Follow up in 3-5 days 1-2 weeks as needed .

James Neville, 12/03/18,

I created these abbreviations, feel free to change them.

Patient instructed to follow up immediately for severe or worsening pain, skin discoloration distal to the injury, or new or worsening numbness.Yes No: Medical profile, duty/activity restriction provided. -Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: 2tfp-plan-msk-knee-fu-referDescription: v1.0

Patient diagnosed with soft tissue injury of the knee, not responding to conservative treatment. -Continue Discontinue relative rest (brace, crutches, weight bearing as tolerated, ROM and strength exercises). -Continue Discontinue Initiate knee immobilizer hinged brace. -Continue Discontinue short term medication as prescribed, as needed for pain.Yes No: MRI ordered. Yes No: Referral to Physical therapy for guidance on ROM and strength training.Yes No: Referral to Orthopedics for management.Follow up in 3-5 days 1-2 weeks as needed .Patient instructed to follow up immediately for severe or worsening pain, skin discoloration distal to the injury, or new or worsening numbness. -Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: 2tfp-plan-msk-knee-osteoarthritisDescription: v1.0

Patient diagnosed with osteoarthritis of the knee.Discussed management strategies including appropriate physical activity, medication risks and benefits, physical therapy options, weight loss. Yes No: short term medication as needed for pain.Yes No: plain radiographs, weight-bearing. Yes No: Referral to Physical therapy for guidance on ROM and strength training.Yes No: Referral to Orthopedics for management.Follow up in 2-3 months or as needed.-Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-msk-knee-traumaDescription: v1.0CDS Generalized Knee Trauma

DX ACL PCL Osteochondral injuryMeds NSAIDs for short term pain controlMedical Equipment

-Hinged knee brace-Crutches prn for pain

-Hinged knee brace for grade 3-4 injury-Crutches prn for pain

-Crutches prn for pain

Plain films Pittsburg knee rules Pittsburg rules but may not show on plain film

MRI For DX and grading If DX is suspected -required for DXReferrals -PT for strength &

ROM-Ortho to discuss treatment options

- PT for strength & ROM-Ortho for grade 3-4 injuries

-Ortho for eval and management

CDS Anterior Knee TraumaDX Patellar Dislocation Patellar or Quad tendon tear

Meds NSAIDs for short term pain controlMedical Equipment

-Knee immobilizer for 6 weeks-Crutches

-Knee immobilizer brace, for non-operative tears up to 6 weeks of immobilization, data inconclusive on optimal length-Crutches

Plain films Mandatory Pittsburg knee rulesMRI If osteochondral fracture on x-

rays or if there is hemarthrosisnone

Referrals -Physical therapy for injuries without displaced osteochondral fragment-Ortho for surgery if displaced osteochondral fragment present

-Physical therapy-Ortho Complete tear should be referred promptly to ortho, or for partial tears that do not respond to conservative therapy

CDS Posterior Knee TraumaDX Posterior Capsule

TearPCL Knee Dislocation


-Hinged knee brace for grade 3-4 injury-Crutches prn for pain

Plain films Pittsburg knee rulesMRI For DX and grading If DX is suspectedReferrals -Physical therapy

-Ortho for grade 3 injury

- Physical therapy- Ortho for grade 3-4 injuries

-Prompt Ortho referral for reduction

CDS Lateral Knee TraumaDX LCL Injury Meniscus Injury


-Brace locked in full extension for 2 weeks-Crutches

Plain films Pittsburg knee rules Pittsburg knee rulesMRI If osteochondral fracture on x-

rays or if there is hemarthrosisIf suspected meniscal injury

Referrals -Physical therapy - Ortho if Grade 3 for surgery or continued instability/pain after conservative therapy

-Physical therapy-Ortho for large complex tears, locked knee or persistent symptoms despite conservative therapy for 3-6 weeks

CDS Medial Knee TraumaDX MCL Injury Meniscus Injury


-Hinged brace if needed for stability and pain -Crutches if needed for pain

Plain films Pittsburg knee rules Pittsburg knee rulesMRI Not required If suspected meniscal injuryReferrals -Physical therapy

-Ortho if posterior ligament injury or continued instability/pain after conservative therapy

-Physical therapy-Ortho for large complex tears, locked knee or persistent symptoms despite conservative therapy for 3-6 weeks

Abbreviation: cds-msk-knee-notrauma-noeffusion-genDescription: v1.0

Generalized Pain: No Trauma, No EffusionDX Osteoarthritis

Meds -Acetaminophen-NSAIDs -Add capsaicin-add duloxetine or tramadol

Other therapies

-Steroid injections-Weight loss program if BMI>25

Plain films If needed to confirm DXReferrals -Physical therapy early in treatment to maintain ROM and strength

-Ortho for surgical consult is fifth line TX option

Anterior Knee Pain: No Trauma, No EffusionDX Patellofemoral

PainPatellar Subluxation Patellar/Quad

TendinopathyTreatments Ice, NSAIDs for short term pain controlRadiology none Plain films US if needed for DXReferrals -Physical therapy for

education, exercise program and bracing if necessary

-Physical therapy for strength and ROM-Ortho for management

-Physical therapy for strength and ROM

DX Pre/infra Patellar Bursitis

Osgood-Schlatter Disease

Hoffa’s Fat Pad Syndrome

Treatments Ice, NSAIDs for short term pain control Relative rest, Ice, NSAIDs for short term pain control

Radiology US if needed for DX none noneReferrals none -Physical therapy for

strength, pain reduction and ROM

-Physical therapy for strength and ROM

DX Osteoarthritis Chondromalacia PatellaMeds -Acetaminophen

-NSAIDs -Add capsaicin-add duloxetine or tramadol

NSAIDs for short term pain control

Other therapies


Plain films If needed to confirm DX noneReferrals -Physical therapy early in

treatment to maintain ROM and strength-Ortho for surgical consult is fifth line TX option

-Physical therapy: pt education, exercise program and bracing if necessary

Medial Knee Pain: No Trauma, No EffusionDX Degenerative

Meniscal InjuryPes Anserine

BursitisOsteoarthritis

Meds NSAIDs for short term pain control

-weight reduction-if persistent consider steroid injection

-Acetaminophen-NSAIDs -Add capsaicin

-add duloxetine or tramadol-Steroid injections-Weight loss program if BMI>25

Radiology MRI if suspected none If needed to confirm DXReferrals -Physical therapy

-Ortho for large complex tears, locked knee or persistent symptoms despite conservative therapy for 3-6 weeks

-Physical therapy for quadriceps strengthening

-Physical therapy early in treatment to maintain ROM and strength-Ortho for surgical consult is fifth line TX option

Lateral Knee Pain: No Trauma, No EffusionDX Degenerative

Meniscal InjuryIliotibial Band

SyndromeOsteoarthritis

Meds NSAIDs for short term pain control

-NSAIDs for short term pain control-Relative Rest-Ice-If persistent pain consider steroid injection (sources disagree on when to consider)

-Acetaminophen-NSAIDs -Add capsaicin-add duloxetine or tramadol-Steroid injections-Weight loss program if BMI>25

Radiology MRI if suspected None If needed to confirm DXReferrals -Physical therapy


-Physical therapy to maintain strength and mobility


Posterior Knee Pain: No Trauma, No EffusionDX Popliteal (Baker’s) Cyst Other, more rare, causes

Meds None -Popliteus tendinopathy-Popliteal artery aneurysm-Popliteal artery entrapment

Other therapies

-Arthrocentesis with steroid injection if symptomatic

Radiology If uncertain Dx, plain films and US

Referrals Ortho if refractory to steroids

Abbreviation: cds-msk-knee-notrauma-effusion-genDescription: v1.0Generalized Knee Pain: No Trauma, + Effusion

DX Osteoarthritis Osteochondral InjuryMeds -Acetaminophen



Other therapies


-Crutches prn for pain-Ice

Radiology Plain films needed to confirm DX -MRI if suspected- Pittsburg rules but may not show on plain film

Referrals -Physical therapy early in treatment to maintain ROM and strength-Ortho for surgical consult is fifth line TX option

-Ortho for evaluation and management

Other Causes-Septic Joint (emergency ortho referral)-Crystal arthropathy-Rheumatic diseaseIf any of the above are considered, then perform synovial fluid analysis and treat accordingly

Anterior Knee Pain: No Trauma, + EffusionDX Osteoarthritis Osteochondral Injury



Other therapies






Medial Knee Pain: No Trauma, + EffusionDX Osteoarthritis Osteochondral Injury Degenerative

Meniscal InjuryMeds -Acetaminophen




Other therapies



Radiology Plain films needed to confirm DX

-MRI if suspected- Pittsburg rules but may not show on plain film

MRI if suspected



-Physical therapy -Ortho for large complex tears, locked knee or persistent symptoms despite conservative therapy for 3-6 weeks

Lateral Knee Pain: No Trauma, + EffusionDX Degenerative Meniscal

InjuryOsteoarthritis

Treatments NSAIDs for short term pain control

-Acetaminophen-NSAIDs -Add capsaicin-add duloxetine or tramadol-Steroid injections-Weight loss program if BMI>25

Radiology MRI if suspected If needed to confirm DXReferrals -Physical therapy



Posterior Knee Pain: No Trauma, + EffusionDX Osteoarthritis Osteochondral Injury



Other therapies






Abbreviation: 2tfp-plan-msk-shldr-rotcuffDescription: v1.0

Recommendations/education provided:-Patient diagnosed with partial full thickness acute/symptomatic thickness rotator cuff tear. CDS if acute/symptomatic full thickness tear, refer to ortho and DELETE free text below!-Patient instructed on home exercises-Physical Therapy consult to decrease pain, restore ROM, and regain strength-Short term medication as needed for pain-Follow up in 3-5 days 1-2 weeks as needed

Abbreviation: cds-msk-shldr-rotcuffDescription: v1.0

CDS Rotator CuffImaging -Ultrasound or MRI for DX

-Plain films if needed to rule out associated pathology or if trauma, but not necessary for DX of non-traumatic rotator cuff pathology

Acute/symptomatic tears

Refer to surgery for acute, symptomatic full thickness tears (caused by trauma or acute on chronic)

Other types of tears

-Home exercises-Short term meds for pain relief 1st line Acetaminophen, 2nd line

NSAIDS-Physical therapy referral to decrease pain, restore ROM, and regain strength-Steroid injections: may be beneficial, but effect may be small and not well-maintained

Abbreviation: 2tfp-plan-msk-shldr-arthritisDescription: v1.0

Recommendations/education provided:- Patient educated on activity modification, intermittent ice as needed, and short-term medication for pain control.- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-msk-shldr-arthritisDescription: v1.0CDS Shoulder ArthritisImaging If needed to confirm DX: Plain films: anteroposterior, Y-outlet, and axillary

viewsRest Activity modificationIce Intermittent application PRNOral Meds 1st line Acetaminophen, 2nd line oral NSAIDsInjections -Steroid injection

-viscous-supplementationReferrals -PT to decrease pain, restore ROM, and regain strength

-Ortho: failure to improve or maintain function with course of conservative therapy

**The American Academy of Orthopedic Surgeons was unable to recommend for or against PT/Meds/Steroid injections**

Abbreviation: 2tfp-plan-msk-shldr-adcapDescription: v1.0

Recommendations/education provided:-Patient diagnosed with adhesive capsulitis and educated short term medication for pain control.- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-msk-shldr-adcapDescription: v1.0CDS Adhesive CapusilitisImaging (plain films and MRI are not diagnostic), plain films if needed to rule out

other causesLabs consider fasting glucose in patients not diagnosed with diabetesOral Meds 1st line Acetaminophen, 2nd line oral NSAIDs, 3rd line short course oral

steroids

Injections -Steroid injectionReferrals -PT to decrease pain, restore ROM, and regain strength

-Ortho: for severe cases after 6-12 weeks of conservative therapy

Abbreviation: 2tfp-plan-msk-shldr-ac-sprainDescription: v1.0

Recommendations/education provided:Patient diagnosed with Grade 1-2 Grade 3-6 AC joint injury/sprain.-Patient educated on use of sling for 1-3 weeks and then may return to normal activities when pain subsides, intermittent ice as needed, and short-term medication for pain control.-Patient referred to ortho.- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-msk-shldr-ac-sprainDescription: v1.0

CDS Acromioclavicular SprainImaging Plain films: Zanca, anteroposterior, lateral, axial; potentially Skyler notch

viewGrade 1-2

Rest Sling for 1-3 weeksIce Intermittent application PRNOral Meds 1st line Acetaminophen, 2nd line oral NSAIDsInjections -Steroid injection

-viscous-supplementationReferrals -PT to decrease pain, restore ROM, and regain strength

Grade 3-6Referrals Ortho: refer all grade 3-6 sprains

Abbreviation: 2tfp-plan-msk-shldr-dislocationDescription: v1.0

Recommendations/education provided:- Patient educated on sling use for 4 weeks and need to repeat films 2 weeks after acute dislocation.- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-msk-shldr-dislocationDescription: v1.0CDS Shoulder DislocationImaging -Plain films: Anteroposterior, scapular Y, and

axillary or Velpeau views to evaluate for associated fractures

-Repeat films in 2 weeks after acute dislocationActivity Sling for 4 weeks for acute dislocationReferrals -PT to decrease pain, restore ROM, and regain

strength-Ortho: for young athletes, recurrent dislocations, irreducible dislocations and fractures

Abbreviation: 2tfp-plan-msk-shldr-bictendonitisDescription: v1.0

Recommendations/education provided:- Patient educated on activity modification, intermittent ice as needed, and short-term medication for pain control.- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-msk-shldr-bictendonitisDescription: v1.0CDS Bicep TendinitisImaging (not needed for diagnosis or to begin conservative treatment)

-US-Plain films: Anteroposterior, scapular Y, and axillary

Rest Activity modificationIce Intermittent application PRNOral Meds 1st line Acetaminophen, 2nd line oral NSAIDsInjections -Steroid injectionReferrals -PT to decrease pain, restore ROM, and regain strength

-Ortho: for refractory symptoms after 3 months of conservative therapy, or if significant damage to the tendon

Abbreviation: 2tfp-plan-msk-shldr-clavfxDescription: v1.0

Recommendations/education provided:- Patient diagnosed with clavicular fracture and will be placed in sling for 2-6 weeks and referred to PT. placed in sling and referred to orthopedics.- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-msk-shldr-clavfxDescription: v1.0CDS Clavical FxImaging Plain films: Anteroposterior, serendipity viewsConservative treatment: Non-displaced Group I (middle third) and all Group III

(medial third)Rest Sling for 2-6 weeksReferrals -PT to decrease pain, restore ROM, and regain strength

Refer to Orthopedic Surgery: displaced Group I (middle third) and all Group II (lateral third), also open fractures and fractures showing tenting of the skin or

causing neurovascular compromiseReferrals Ortho

Abbreviation: 2tfp-plan-msk-shldr-proxhumfxDescription: v1.0

Recommendations/education provided:- Patient diagnosed with proximal humerus fracture and will be placed in sling for 6-8 weeks and referred to PT. placed in sling and referred to orthopedics.- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-msk-shldr-proxhumfxDescription: v1.0

CDS Prox Humerus FxImaging Plain films: Anteroposterior, serendipity views

Conservative treatment for minimally displaced proximal fractures: Rest Sling for 6-8 weeksReferrals -PT to decrease pain, restore ROM, and regain strengthRefer: Orthopedic Surgery for young and active adults with two, three, or four-part fracturesReferrals Ortho

Abbreviation: 2tfp-plan-msk-ank-sprDescription: v1.0

Recommendations/education provided:- Pt diagnosed with Grade 1 2 3 ankle sprain. -Radiographs not indicated indicated based on Ottawa ankle rules. -Pt educated on conservative treatment: Relative rest: Crutches not indicated indicated until able to bear weight with normal gaitIce: 3-7 days, either (10 min on-10 min off-10min on) or (20 min on) every 2 hours while awakeCompression/bracing: Air stirrup brace with elastic compression wrap or lace-up brace. Short term casting (10 days).Elevation: Above level of heart-Short term medication as needed for pain-Range of motion exercises as soon as can be tolerated, along with progressive weight-bearing and exercise, and non-weight-bearing Achilles stretches.-Follow up in 3-5 days 1-2 weeks as needed -Pt instructed to follow up immediately for severe or worsening pain, skin discoloration distal to the injury, or new or worsening numbness. Pt also instructed that to prevent further injury during high risk activities: Lace-up, air stirrup braces or taping; rehabilitating ankle sprains appears to prevent subsequent sprains.- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-msk-ank-sprDescription: v1.0

CDS Ankle SprainGrades of Ankle Sprain Am Fam Physician. 2006 Nov 15;74(10):1714-1720SIGN/SYMPTOM GRADE I GRADE II GRADE IIILigament tear None Partial CompleteLoss of functional ability Minimal Some GreatPain Minimal Moderate SevereSwelling Minimal Moderate SevereEcchymosis Usually not Common YesDifficulty bearing weight None Usual Almost always

Ottawa Rule: An ankle radiographic series is only required if there is: Any pain in the malleolar zone AND any of these findings: a. Bone tenderness at posterior edge or tip of lateral malleolus b. Bone tenderness at posterior edge or tip of medial malleolus c. Inability to bear weight both immediately and in the emergency department

Films http://ohri.ca/emerg/cdr/docs/cdr_ankle_card.pdfProtection -Grade I-II: Air stirrup brace

-Grade III: short term casting (10 days) or standard bracingRest crutches until able to bear weight with normal gaitIce for the first 48 hours or until swelling has improved, either (10 min on-10

min off-10min on) or (20 min on) every 2 hours while awakeCompression -Grade I-II: Air stirrup brace with elastic compression wrap or lace-up

brace-Grade III: short term casting (10 days) has comparable outcomes to standard bracing with elastic compression wrap, either treatment appropriate based on patient preference or compliance

Elevation above level of heart, aim for 2 hours per dayActivity Weight bearing and ankle exercises as soon as pain permitsMeds 1st line Acetaminophen, 2nd line topical NSAIDS, 3rd line oral NSAIDsReferrals -PT: Proprioception, strengthening and plyometrics

-Ortho: For chronic ankle instability that does not respond to rehabilitation

Follow up: 3-5 days if pain and swelling inhibit exam; Follow up immediately for severe or worsening pain, skin discoloration distal to the injury, or new or worsening numbness.

Abbreviation: 2tfp-plan-msk-ank-highsprDescription: v1.0

Recommendations/education provided:- Pt diagnosed with Grade 1 2 3 high ankle sprain. - Pt educated on conservative treatment: Rest: Grade 1 Non-weight bearing crutches for 1-3 weeks, followed by weight bearing as tolerated, gradual return to activity Grade 2-3 Non-weight bearingIce: 2 days, either (10 min on-10 min off-10min on) or (20 min on) every 2 hours while awake

Compression/bracing: Posterior leg splint with compressive elastic bandage; ankle device that limits external rotationElevation: above level of heart-Short term medication as needed for pain-Follow up in: 3-5 days 1-2 weeksFollow up immediately for severe or worsening pain, skin discoloration distal to the injury, or new or worsening numbness.- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-msk-ank-highsprDescription: v1.0

CDS High Ankle SprainFilms Ottawa rule or if suspected high ankle sprain. Required for grading and

dispositionProtection Posterior leg splint or ankle device that limits external rotationRest -Grade 1 Non-weight bearing crutches for 1-3 weeks

-Grade 2-3 Non-weight bearingIce 2 days, either (10 min on-10 min off-10min on) or (20 min on) every 2

hours while awakeCompression

Compressive elastic bandage for posterior leg splint

Elevation above level of heartActivity Grade 1: after 1-3 weeks, weight bearing as tolerated, gradual return to

activityGrade 2-3: as per ortho

Meds 1st line Acetaminophen, 2nd line topical NSAIDS, 3rd line oral NSAIDsReferrals -Ortho (within 5-7 days): Grade 2-3: Patients with instability on stress

testing or gross diastasis of the syndesmosis, if deltoid ligament disruption or complete diastasis of syndesmosis, associated fracture (particularly fibular fracture if > 2 inches above ankle joint), widening of ankle mortise > 2 mm or joint incongruity on standard or stress radiographs

Follow up: 3-5 days if pain and swelling inhibit exam; Follow up immediately for severe or worsening pain, skin discoloration distal to the injury, or new or worsening numbness.

Ottawa Rule: An ankle radiographic series is only required if there is: Any pain in the malleolar zone AND any of these findings: a. Bone tenderness at posterior edge or tip of lateral malleolus b. Bone tenderness at posterior edge or tip of medial malleolus c. Inability to bear weight both immediately and in the emergency department

Abbreviation: 2tfp-plan-msk-ank-fxDescription: v1.0

Recommendations/education provided:-Pt referred to ortho for fracture management-Pt educated on interim conservative treatment: Rest: Crutches, non-weight bearingIce: 2 days, either (10 min on-10 min off-10min on) or (20 min on) every 2 hours while awake

Compression/bracing: splint pending referralElevation: above level of heart-Short term medication as needed for pain- Patient verbalized understanding of diagnosis, instructions and treatment plan.-Follow up in:

Abbreviation: cds-msk-ank-fxDescription: v1.0

Films http://ohri.ca/emerg/cdr/docs/cdr_ankle_card.pdfProtection splint pending referralRest Non-weight bearingIce 2 days, either (10 min on-10 min off-10min on) or (20 min on) every 2

hours while awakeCompression

elastic wrap with splint

Elevation above level of heartActivity Non-weight bearingMeds 1st line Acetaminophen, 2nd line topical NSAIDS, 3rd line oral NSAIDsReferrals -Ortho:

Respiratory

Abbreviation: 2tfp-plan-resp-ARDescription: v1.0

Recommendations/education provided:Diagnosis of Allergic Rhinitis discussed with the patient. Advised patient that the mainstay of treatment is allergy avoidance. In addition, taking anti-allergy medications prior to exposure to known allergens is the best way to prevent symptoms. Nasal saline irrigation is beneficial for symptom management as well. Other measures include frequent hand washing as well as showering before bed to wash off any allergens from skin and hair. Patient advised to take medications as prescribed and instructed to return to clinic if symptoms are unrelieved by treatment.

Abbreviation: cds-resp-ARDescription: v1.0

Allergic Rhinitis Eval CDS:Diagnosis of Allergic Rhinitis (AR) should be made when patient presents with:One or more of the following symptoms: nasal congestion, runny nose, itchy nose, sneezing.And physical findings consistent with an allergic cause such as: clear rhinorrhea, pale discoloration of nasal mucosa, red and watery eyes.

IgE testing (blood or skin) should be performed for patients with a clinical diagnosis of AR who; do not respond to empiric treatment, when the diagnosis is uncertain, or when determination of specific target allergen is needed.Radiologic imaging is not recommended for patients with symptoms consistent with AR.

Targeted immunotherapy is the only treatment that changes the natural course of AR.

Allergic Rhinitis Treatment: 1st line action Allergen Avoidance and patient education1st line Meds Intranasal steroids alone

are the initial treatment for patients whose symptoms affect quality of life;

Beclomethasone, Budesonide, Ciclesonide, Fluticasone propionate, Momentasone, Triamcinolone acetonide;( all above-2 sprays in each nostril qd) Flunisolide; 2 sprays in each nostril bid.

2nd Line Meds Oral second generation antihistamines for patients whose primary complaint is sneezing and itching;

Cetirazine (Zyrtec) 10 mg q dDesloratadine (Clarinex) 5 mg qdFexofenadine (Allegra) 180 mg qdLoratadine (Claritin) 10 mg qd

3rd line Intranasal antihistamines, Combinations of intranasal steroid + antihistamines are most effective.

Azelatine (Astetin)—antihistamine alone.Azelatine + Fluticasone (Dymista) –combination (both: 1 spray in each nostril Bid)

3rd line other Intranasal cromolyn Cromolyn; 1 spray in each nostril q4-6 hours

Intranasal anticholinergic Ipratropium (Atrovent); 2 sprays in each nostril QID

Oral decongestants PseudoephedrineLeukotriene receptor blocker

Montelukast (Singulair) 10mg qd

Immunotherapy Immunotherapy should be considered for moderate or severe persistent allergic rhinitis unresponsive to usual treatments, those who cannot tolerate or who want to avoid long-term medication use, and in patients with allergic asthma.

Patient education: https://familydoctor.org/condition/allergic-rhinitis/References: https://www.aafp.org/afp/2015/1201/p985.html Clinical Practice Guideline: https://www.aafp.org/patient-care/clinical-recommendations/all/allergic-rhinitis.html

Abbreviation: cds-resp-copdDescription: v1.0

Chronic Obstructive Pulmonary Disease (COPD) CDS:Recommended non-pharmacologic COPD interventions include: (1) smoking cessation, (2) reduction of other risk factors (e.g., exposure to open cooking fires), (3) vaccinations, (4) active education and with a written COPD action plan, (5) pulmonary rehabilitation and oxygen therapy as required.Inhaled glucocorticoids should NOT be used as sole therapy for COPD (i.e. without long-acting bronchodilators).First-line therapy for COPD management is a long-acting inhaled bronchodilator (beta-agonist or anticholinergic).

https://www.aafp.org/patient-care/clinical-recommendations/all/allergic-rhinitis.html

https://www.aafp.org/patient-care/clinical-recommendations/all/allergic-rhinitis.html

https://www.aafp.org/afp/2015/1201/p985.html

https://familydoctor.org/condition/allergic-rhinitis/

The addition of short course antibiotics and short course glucocorticoids at the time of acute exacerbation decreases rate of hospitalizations. Referral: Pulmonology: For patients not reaching treatment goals on maximal therapy, for patients considering travelling with hypoxia.Immunizations: PCV13 (before administration of PPSV23), PPSV23, Influenza annually.Imaging: CXR PA/LATLabs: Theophylline level

Abbreviation: cds-resp-influenzaDescription: v1.0

CDS Influenza:Antiviral Treatment: recommended for the following:

1. Pt is at higher risk for influenza complications 2. Pt has severe, complicated, or progressive illness 3. Previously healthy, symptomatic outpatient not at high risk with confirmed or suspected

influenza on the basis of clinical judgment, if treatment can be initiated within 48 hours of illness onset

Antiviral medications: (oseltamivir, zanamivir, or peramivir) other:Supportive treatment: analgesics, antipyretics, rest, adequate (but not excessive) hydration.Follow-up: If symptoms worsen

Abbreviation: cds-resp-pharyngitisDescription: v1.0

CDS Phyaryngitis:Diagnosis: Centor score 0-1: No ABX or RADT 2-3: Perform RADT or throat CX (may perform if score is 1 and clinical suspicion is high), Treat with ABX if positive 4 or>: Treat empirically with ABXCan consider throat culture in children with negative RADT

ABX Treatment: 1st Line: Penicillin PCN Allergy: Azithromycin

Abbreviation: cds-resp-otitismediaDescription: v1.0

CDS Otitis Media:ABX Indications: -2yrs and less with Bilateral AOM -6 mo. and older with severe AOM (i.e., moderate or severe otalgia or otalgia for at least 48 hours, or temperature 39°C [102.2°F] or higher) -2yrs and less without severe AOM: can offer observation with close follow up or ABX

ABX Treatment:

https://www.uptodate.com/contents/peramivir-pediatric-drug-information?source=see_link

https://www.uptodate.com/contents/zanamivir-pediatric-drug-information?source=see_link

https://www.uptodate.com/contents/oseltamivir-pediatric-drug-information?source=see_link

1st Line: Amoxicillin 80-90 mg/kg divided BID for 7 days PCN Allergy: Azithromycin

Abbreviation: 2tfp-plan-resp-cold-pedsDescription: v1.0

Recommendations/education provided:Parent education: Colds are self-limited, usually lasting up to 10 days; therefore, management is directed at symptom relief rather than treating the infection. There is no single treatment that produces significant improvements in symptoms of the common cold. Over-the-counter cough and cold medications for children younger than six years are ineffective and are associated with overdose and toxicity. Extra fluid intake in children is not advised because of potential harm.

Abbreviation: cds-resp-cold-pedsDescription: v1.0

CDS Adult Common Cold:Symptomatic treatment options with potential benefit:

<1 y/o: acetaminophen (fever) 1-5 y/o: honey (cough), acetaminophen (fever/pain) 6-11 y/o honey (cough), acetaminophen (fever/pain), ipratropium nasal spray (nasal discharge),

nasal irrigation (nasal congestion) 12-18 y/o honey (cough), acetaminophen (fever/pain), ipratropium nasal spray (nasal discharge),

oral or topical decongestants (nasal congestion)

Abbreviation: cds-resp-cold-adultDescription: v1.0

CDS Adult Common Cold:Symptomatic treatment options with potential benefit:ipratropium nasal spray (nasal discharge) honey (cough) oral or topical decongestants (nasal congestion) dextromethorphan (cough)

Abbreviation: 2tfp-plan-resp-cold-adultDescription: v1.0

Recommendations/education provided:Patient was educated as follows: Colds are self-limited, usually lasting up to 10 days; therefore, management is directed at symptom relief rather than treating the infection. There is no single treatment that produces significant improvements in symptoms of the common cold.

Abbreviation: cds-resp-bron-pedsDescription: v1.0

CDS Pediatric Bronchitis:1. Referring to bronchitis as a “chest cold” increases patients’ acceptance of not receiving antibiotics 2. NOT indicated: CXR/bronchodilators/ABX

Symptomatic treatment options with potential benefit:-dextromethorphan-guaifenesin-honey for cough

Abbreviation: 2tfp-plan-resp-bron-pedsDescription: v1.0

Recommendations/education provided:Parent education: “Chest Colds” are self-limited, usually lasting up to 10 days; therefore, management is directed at symptom relief rather than treating the infection. Over-the-counter cough and cold medications for children younger than six years are ineffective and are associated with overdose and toxicity.

Abbreviation: cds-resp-bron-adultDescription: v1.0

CDS Adult Bronchitis:1. Referring to bronchitis as a “chest cold” increases patients’ acceptance of not receiving antibiotics 2. NOT indicated: bronchodilators/ABX 3. Indications for CXR: pulse >100/minute, respiratory rate >24 breaths/minute, temperature >38°C

[100.4°F], or oxygen saturation <95 percent

Symptomatic treatment options with potential benefit:-dextromethorphan-guaifenesin-honey for cough

Abbreviation: 2tfp-plan-resp-bron-adultDescription: v1.0

Recommendations/education provided:Patient education: “Chest Colds” are self-limited, usually lasting up to 10 days; therefore, management is directed at symptom relief rather than treating the infection. Multiple studies show no benefit from decongestants, antihistamines, codeine, beta agonists or ABX for treatment of acute bronchitis.

Abbreviation: cds-resp-sinusitis-acute-peds

Description: v1.0

CDS Pediatric Acute Sinusitis:ABX indicated due to: 1. persistent illness (nasal discharge [of any quality] or daytime cough or both lasting more than 10 days without improvement) 2. a worsening course (worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement) 3. severe onset (concurrent fever [temperature ≥39°C/102.2°F] and purulent nasal discharge for at least 3 consecutive days.Imaging:

-None in uncomplicated case of sinusitis -Contrast-enhanced computed tomography scan of the paranasal sinuses ordered if the child is

suspected of having orbital or central nervous system complications other:Antibiotics (10-day course):

1st line: Amoxicillin with clavulanate 45 or 90 mg/kg per day in 2 divided doses -Ceftriaxone single 50-mg/kg given either intravenously or intramuscularly (for children who are

vomiting, unable to tolerate oral medication, or unlikely to be adherent to the initial doses of antibiotic) -PCN Allergy Type 1: a combination of clindamycin and cefixime or linezolid -PCN Allergy NON-Type 1: Cefpodoxime 10 mg/kg per day orally divided every 12 hours (maximum

daily dose 400 mg) or Cefdinir 14 mg/kg per day orally divided every 12 or 24 hours (maximum daily dose 600 mg)

Follow up: If there is either a caregiver report of worsening (progression of initial signs/symptoms or appearance of new signs/symptoms) or failure to improve within 72 hours of initial management.

Abbreviation: cds-resp-sinusitis-acute-adultDescription: v1.0

CDS Adult Acute Sinusitis:ABX indicated if:

1. Persistent symptoms >10 days 2. Onset of severe symptoms 3. Signs of high fever (>39°C) and purulent nasal discharge facial pain lasting for at least 3

consecutive days 4. Onset of worsening symptoms following a typical viral illness lasting 5 days that was initially

improvingImaging:

1. Not required in uncomplicated cases of sinusitis 2. A contrast-enhanced computed tomography scan of the paranasal sinuses is indicated in

recurrent sinusitis in spite of maximal medical therapy Antibiotics (5-10-day course):

1st line: Amoxicillin with clavulanate 500mg/125/mg TID (PCN Allergy/2nd line): doxycycline 200mg daily (PCN Allergy/2nd line): a combination of clindamycin 300mg TID plus cefpodoxime 200mg BID

Symptomatic treatment: Decongestants Intranasal steroids OTC analgesics Saline nasal irrigation

Abbreviation: cds-resp-sinusitis-chronicDescription: v1.0

CDS Adult Chronic Sinusitis:Diagnosis: should be confirmed by symptoms and objective physical findings such as

a. non-contrast-enhanced CT b. anterior rhinoscopy c. endoscopy

Symptomatic Treatment: -Saline nasal irrigation -Intranasal steroids

Acute Flare Treatment: -May consider up to 3-week course of ABX (Augmentin or high-dose clarithromycin (500 mg twice

daily for 7 days then 250 mg daily for 7 days)-Patients with polyps: oral steroids (less than 3 weeks)

Abbreviation: cds-resp-pneu-adultDescription: v1.0

CDS Adult Pneumonia:Labs: testing for specific pathogens should be ordered only when it would alter standard empiric therapy Radiology: chest radiography or lung ultrasonography recommendedDisposition: Pts can be managed as outpatient if CRB-65 score <2 CRB-65 (add some of responses below, If “Yes” assign score of 1)0=No 1=Yes :New onset confusion0=No 1=Yes :RR>29 breaths per minute0=No 1=Yes :SBP < 90, or DBP < 600=No 1=Yes :Age 65 or older

ABX Treatment: 1st Line: azithromycin 500mg day one and followed by 4 days of 250mg a day 2ndLine: doxycycline 100mg bid 5-7 days

Abbreviation: cds-resp-pneu-pedsDescription: v1.0

CDS Pediatric Pneumonia:Imaging: CXR is not recommended in children with mild uncomplicated acute lower respiratory tract infectionsABX Treatment:

1. ABX not prescribed due to viral pathogens being responsible for great majority of clinical disease in preschool-aged children

2. Suspected typical bacterial etiology: amoxicillin 90mg/kg bid 7 days 3. Suspected atypical bacterial etiology: azithromycin 10mg/kg day one and followed by 4 days of

5mg/kg a day 4. Alternative agents: levofloxacin and doxycycline

Follow up: within 48hrs of diagnosis

GI

Abbreviation: 2tfp-plan-gi-gerdDescription: v1.0

Recommendations/education provided:Home care instructions given to patient and discussed how lifestyle changes are first-line intervention such as: Elevate head of bed, avoid meals 2 to 3 hours before bedtime, weight loss, tobacco cessation, alcohol avoidance, and limiting the consumption of patient-specific food triggers.

Abbreviation: cds-gi-gerdDescription: v1.0

CDS GERD:1st line lifestyle and diet modifications, antacids plus H2 blockers or PPIs2nd line Maximize PPI and H2 therapyNon-responders

Refer for endoscopy

Indications for endoscopy: -Alarm symptoms: dysphagia, bleeding, anemia, weight loss, recurrent vomiting-Persistent typical GERD symptoms despite treatment with twice-daily PPI for 4 to 8 weeks-Men >50 years with chronic GERD (>5 years) and other risk factors: hiatal hernia, high BMI, tobacco use, high abdominal fat distribution-History of severe erosive esophagitis (Assess healing and check for UGI pathology including Barrett esophagus.)-Surveillance (history of Barrett esophagus)Labs: none, There is insufficient evidence to routinely test for Helicobacter pylori References: https://www.aafp.org/afp/2003/1001/p1311.htmlhttps://www.aafp.org/afp/2015/0515/p692.html

Patient Information: https://www.aafp.org/afp/2015/0515/p692-s1.html

Abbreviation: 2tfp-plan-gi-gerd-pediatric-initialDescription: v1.0

Initial GERD A/P:A: Pediatric GERDRecommendations/education provided:P: Home care instructions, education and reassurance given to caregiver patient and discussed: Small, frequent infant feedings along with burping, possible thickening feeding to decrease the volume regurgitated and keeping patient upright after feedings, prone positioning was not recommended head elevation in bed recommended. Finally, reassured parents that infant GER/GERD is not associated with SIDS. prone positioning not recommended

Medication instruction not given given for:__ Referral not given given for:__ Labs not ordered ordered for: __Verbalizes understanding of instructions and treatment plan and instructed to F/U if symptoms persist or worsen. Patient Education-Infant: https://5minuteconsult.com/collectioncontent/3-197353/patient-handouts/acid-reflux-gastroesophageal-reflux-disease-discharge-instructions-infant

https://5minuteconsult.com/collectioncontent/3-197353/patient-handouts/acid-reflux-gastroesophageal-reflux-disease-discharge-instructions-infant



Patient Education-Child: https://5minuteconsult.com/collectioncontent/3-196912/patient-handouts/acid-reflux-gastroesophageal-reflux-disease-discharge-instructions-childPatient Education Adolescent: https://5minuteconsult.com/collectioncontent/3-197352/patient-handouts/acid-reflux-gastroesophageal-reflux-disease-discharge-instructions-adolescent

Abbreviation: 2tfp-plan-gi-gerd-peds-fu-responsiveDescription: v1.0

A: GERD responsive to treatment Recommendations/education provided:P: Instructed to continue with treatment plan, and verbalizes understanding of instructions and treatment plan. Instructed to follow up in clinic if symptoms persist or worsen.

Abbreviation: 2tfp-plan-gi-gerd-peds-fu-unresponsiveDescription: v1.0

Recommendations/education provided:A: GERD not responsive to treatmentP: Home care instructions given. Medication instruction not given given for: __ Referral not given given for:__Testing not ordered ordered for: __ . Verbalizes understanding of instructions and treatment plan instructed to follow up in clinic in: __ or sooner if symptoms worsen.

Patient Education Infant: https://5minuteconsult.com/collectioncontent/3-197353/patient-handouts/acid-reflux-gastroesophageal-reflux-disease-discharge-instructions-infantPatient Education Child Hand-out:https://5minuteconsult.com/collectioncontent/3-196912/patient-handouts/acid-reflux-gastroesophageal-reflux-disease-discharge-instructions-childPatient Education Adolescent Hand-out:https://5minuteconsult.com/collectioncontent/3-197352/patient-handouts/acid-reflux-gastroesophageal-reflux-disease-discharge-instructions-adolescent

Abbreviation: cds-gi-gerd-pediatricDescription: v1.0

CDS Infant GERD Assessment: Diagnosis of GERD is frequently made clinically. Many common conditions in infancy such as physiologic GER, infant colic, milk protein allergy, or multifactorial feeding difficulties/aversion can present with symptoms that can be difficult to distinguish from GERD and history should also assess for these conditions. Pay attention to feeding volume and frequency in addition to weight gain, failure to thrive, and irritability in association with regurgitation events. Identify episodes of pneumonia, obstructive apnea, chronic cough, stridor, wheezing. Identify additional signs/symptoms that suggest food protein allergy (hematochezia, rash, diarrhea, irritability, failure to thrive). Evaluate for evidence of bowel obstruction (forceful emesis, polyhydramnios during pregnancy). If vomiting is atypical or associated with other signs/symptoms, rule out infection, metabolic disease, anatomic abnormality, or neurologic disease.Special questions:-Presence of polyhydramnios or bilious emesis?

https://5minuteconsult.com/collectioncontent/3-197352/patient-handouts/acid-reflux-gastroesophageal-reflux-disease-discharge-instructions-adolescent


https://5minuteconsult.com/collectioncontent/3-196912/patient-handouts/acid-reflux-gastroesophageal-reflux-disease-discharge-instructions-child








-Family history of metabolic disease?-Family history of allergies/atopy?-Perinatal asphyxia (and other neurologic disorders)?-History of prematurity?

CDS older child assessment: Identify typical adult GERD complaints (chest pain, heartburn, regurgitation, dysphagia), but recognize that children describe discomfort poorly (often isolated abdominal pain). Identify episodes of pneumonia, choking, chronic cough, laryngitis, stridor, and wheezing (may need to assess swallowing function). Assess for solid food dysphagia (more common with eosinophilic esophagitis).Evaluate for presence of nocturnal GERD symptoms.Special questions:-Family history of GERD?-Family history of allergies/atopy?-Family history of eosinophilic esophagitis or other chronic GI disease such as celiac disease or inflammatory bowel disease?

Abbreviation: cds-gi-gastroenteritis-pedsDescription: v1.0

Treatment: -oral rehydration first line, IV if needed -ondansetron oral dose 0.15 mg/kg (maximum dose of 8 mg) -? ProbioticsRehydration should be administered orally with an over-the-counter oral rehydration solution.Children should receive rapid oral rehydration (within three to four hours of symptom onset).In infants who are breastfed, breastfeeding should continue.In infants who are formula-fed, diluting the formula is not recommended, and special formulas usually are not needed.As soon as the dehydration is corrected, a regular diet should resume.Ongoing diarrhea losses should be replaced with additional doses of an oral rehydration solution.

Derm

Abbreviation: 2tfp-plan-derm-eczDescription: v1.0

Recommendations/education provided:Patient instructed that best symptom management is through the use of skin moisturizers every day. Other actions advised include; avoidance of hot baths or showers, gently patting skin dry, and application of moisturizer within 3 minutes of bathing. Home humidification may be helpful as well as supplementation with fish oil, and vitamin D plus vitamin E. Patient advised to follow up in 4 weeks if not improving.

Abbreviation: cds-derm-eczDescription: v1.0

CDS Eczema1st line Emollients (moisturizers)2nd line (mild) Low potency (and for eczema on face and neck,) consider desonide

(Desonate) 0.05% gel, cream or ointment, or foam; or fluocinolone (generic) 0.01% cream twice daily

2nd line (mod/sev)

consider betamethasone valerate (Beta-Val) 0.1% cream or lotion; or fluticasone propionate (Cutivate) 0.05% cream twice daily for moderate sx

3rd line (mod) -Crisaborole (Eucrisa) topically twice daily may also be effective for patients aged ≥ 2 years with mild-to-moderate sx-Topical calcineurin inhibitors (such as tacrolimus 0.1% or pimecrolimus 1% twice daily) are indicated for lesions; recalcitrance to steroids, on sensitive areas (face, anogenital, skin folds), for steroid-induced atrophy, and to break long-term uninterrupted topical steroid use

Recurrent flares use topical steroids once or twice weekly at sites of prior dermatitis for proactive, maintenance therapy

Sleep/allergy issues

Sedating antihistamines are indicated for the treatment of atopic dermatitis when patients have sleep disturbances and concomitant allergic conditions.

Oral ABX Do not use oral antibiotics for atopic dermatitis unless there is clinical evidence of infection

Nonpharmacologic

Dietary supplements with some evidence of benefit for atopic eczema include fish oil, and vitamin D plus vitamin E

Referral : to dermatology when attempts at management have not controlled symptoms or facial involvement not responding to treatment.

Patient education: https://www.aafp.org/afp/2012/0701/p35-s1.html References: Atopic Dermatitis: An Overview; https://www.aafp.org/afp/2012/0701/p35.html Treatment Options for Atopic Dermatitis; https://www.aafp.org/afp/2007/0215/p523.html

Abbreviation: 2tfp-plan-derm-tincapDescription: v1.0

Recommendations/education provided:

Tinea Capitus: Patient instructed that this is the most common fungal infection in children and that topicals do not penetrate hair follicles so oral medication must be used to successfully treat it. However, use of an antifungal shampoo for the first two weeks of treatment decreases risk of transmission. Return to school is permissible once treatment has been started. Report for labs if ordered and take oral medications as prescribed.

Abbreviation: cds-derm-tincapDescription: v1.0

CDS Tinea Capitus:Standard treatment is with oral terbinafine (Lamisil), itraconazole (Sporanox), fluconazole (Diflucan), or griseofulvin. These agents must be used because topicals do not penetrate the hair follicles. They have similar efficacy rates and potential adverse effects, but griseofulvin requires a longer treatment course. 1st line Microsize griseofulvin (Grifulvin V),



https://www.aafp.org/afp/2012/0701/p35-s1.html

-children is 15-20mg/kg (maximum 1 g) once daily or in divided doses-adults it is 500 mg once daily. Give after a high-fat meal

2nd line (mild) Ultramicrosize griseofulvin (Gris-PEG)-children is 5-10mg/kg (maximum 750 mg) once daily or in divided doses-adults it is 375 mg once daily or in divided doses

3rd line oral terbinafine (Lamisil), itraconazole (Sporanox), fluconazole (Diflucan)

Transmission decreased

Transmission is decreased by the use of selenium sulfide containing shampoo daily for the first two weeks.

Labs: Most systemic antifungals require baseline ALT, AST, CBC, and creatinine measurement, then repeat at 6-8 weeks. References: Diagnosis and Management of Tinea Infections; https://www.aafp.org/afp/2014/1115/p702.html Common Tinea Infections in Children; https://www.aafp.org/afp/2008/0515/p1415.html

Abbreviation: 2tfp-plan-derm-tineaDescription: v1.0

Recommendations/education provided:Advised to use antifungal cream as prescribed and to keep affected areas as dry as possible to include drying thoroughly after bathing. Patient to follow up if no resolution after 2 weeks.

Abbreviation: cds-derm-tineaDescription: v1.0

CDS Tinea cruris/corporis/pedis: Adults/adolescents:

-terbinafine (Lamisil) 1% cream twice daily or solution once daily for ≥ 1 week-butenafine 1% cream twice daily for 2 weeks-ketoconazole 2% cream once daily for 2 weeks

Pediatrics -oxiconazole 1% (Oxistat) cream or lotion 1-2 times daily for 2 weeks-clotrimazole 1%(Lotrimin) cream, lotion, or solution twice daily for 2weeks

Severe case Consider oral antifungal for severe disease of concomitant onychomycosis

Don’t use steroids

Topical antifungals are first line, combos with steroids are not recommended

Labs: none unless using oral antifungals, then AST, ALT, CBC, Creatinine at baseline and at 6-8 weeksPatient education: https://familydoctor.org/condition/ringworm/ References: Diagnosis and Management of Tinea Infections; https://www.aafp.org/afp/2014/1115/p702.html Common Tinea Infections in Children; https://www.aafp.org/afp/2008/0515/p1415.html

Abbreviation: 2tfp-plan-derm-onychDescription: v1.0



https://familydoctor.org/condition/ringworm/



Recommendations/education provided:Diagnosis of Onychomycosis discussed with the patient. Long treatment course, high treatment failure rates, as well as high recurrence rates discussed. The need to monitor liver and kidney function as well as complete blood counts depending upon the medication chosen was also discussed. The patient has elected not to treat their fungal nail infection at this time. The patient has elected to treat their fungal nail infection with the medication ordered. Required labs discussed with the patient and ordered. Follow up in 12 weeks.

Abbreviation: cds-derm-onychDescription: v1.0

O nychomycosis CDS: Treatment recommendations:For confirmation, if feasible, perform the KOH preparation during the patient visit; or substitute a test that involves less physician time, such as a culture or a PAS stain of nail clippings.Don’t prescribe oral antifungal therapy for suspected nail fungus without confirmation of fungal infection (potassium hydroxide preparation or culture). --American Academy of Dermatology Treatment courses for onychomycosis are long (three to six months), treatment success rates are low (35-75%), and recurrences are common (up to 50%).

Adjust doses for liver or kidney diseaseTopicals for limited disease:

-efinaconazole 10% solution (Jublia) once daily-tavaborole 5% solution(Kerydin) applied once daily-ciclopirox 8% lacquer(Penlac) applied once daily for up to 48 weeks

Systemic treatment for greater disease or unresponsive Tx: 1st line

-terbinafine (Lamisal)250 mg (62.5 mg if the patient is < 20 kg [44.1 lbs], 125 mg if the patient is 20-40 kg [44.1-88.2 lbs]) orally once daily for 12 weeks (6 weeks for fingernails).-Labs: Baseline AST/ALT and a CBC. Repeat at 6 weeks for courses greater than 6 weeks

2nd line-systemic -itraconazole (Sporonox)200 mg orally once daily for 12 weeks (6 weeks for fingernails) or pulse dosing with 200 mg orally twice daily for 1 week per month (5 mg/kg/day for 1 week/month in children) for 3 pulses (2 pulses for fingernails-Labs: Baseline AST/ALT

Systemic alternate

Fluconazole (Diflucan)-(has been used but not FDA approved); adults 150mg to 300mg once weekly for 6 months for toenails, 3 months for fingernails-Labs; baseline ALT, AST, Alk phos, creatinine and CBC.

References: Diagnosis and Management of Tinea Infections; https://www.aafp.org/afp/2014/1115/p702.html

Abbreviation: 2tfp-plan-derm-versicolorDescription: v1.0

Recommendations/education provided: Discussed diagnosis of Tinea Versicolor with the patient. Treatment prescribed as ordered. Patient instructed that infection will be cured prior to pigmentation returning to normal tone. Patient to follow up if no resolution after 4 weeks.


Abbreviation: cds-derm-versicolorDescription: v1.0

Tinea Versicolor (Pityriasis versicolor) CDS: Woods light is a simple and easy technique reported in some studies to confirm diagnosis of TV in up to 62% of the patients. TV lesions have a pale yellow to white florescence.Treatment options

-zinc pyrithione 1% shampoo applied for 5-10 minutes then rinsed, use daily for 2 weeks-selenium sulfide 2.5% shampoo applied for 5-10 minutes then rinsed, use daily for 1 week-ketoconazole shampoo applied for 5-10 minutes then rinsed, daily for 1-4weeks-sulfur salicylic acid shampoo for 1 week-topical azole creams, terbinafine cream, as for tinea corporis

Reference : Essential Evidence Plus; Tinea versicolor; http://www.essentialevidenceplus.com/content/eee/772

Abbreviation: 2tfp-plan-derm-impetigoDescription: v1.0

Recommendations/education provided:Discussed diagnosis of Impetigo. Advised that although self-limited, treatment is still recommended because it often gets worse before it gets better and treatment helps prevent spread to others. Use medication as ordered for 7-day course. Advised on need for frequent hand washing, avoiding touching others and not sharing towels. Follow if rash worsens or does not resolve.

Abbreviation: cds-derm-impetigoDescription: v1.0

CDS: ImpetigoTreatment: Topical antibiotics: first line for localized infection. Topical antibiotics have the advantage of being applied only where needed, minimizing antibiotic resistance and systemic side effects.Oral antibiotic therapy can be used for impetigo with large bullae or when topical therapy is impractical. Treatment is for a 7-day course.Medication Adult dose Children’s dose1st line options:Topical

-mupirocin (Bactroban) 2% ointment 3 times daily for 7 days-retapamulin (Altabax) 1% ointment twice daily for 5 days

2nd line: oral, any of the following:Amox/clavulanate (Augmentin)

875/125 mg q 12 hours

Based on mg/kg day of amoxicillin, in divided doses every 12 hours. <3 months: 30 mg/kg/day. Three months or older: 25 to 45 mg per kg per day for those weighing less than 40 kg (88 lb); 875/125 mg every 12 hours for those weighing 40 kg or more.

Cephalexin (Keflex)

250 mg every six hours or 500 mg

25 to 50 mg per kg per day in divided doses every six or 12

http://www.essentialevidenceplus.com/content/eee/772

every 12 hours hoursDicloxacillin 250 mg every six

hours12.5 to 25 mg per kg per day in divided doses every six hours

Trimethoprim/ sulfamethoxazole

160/800 mg every 12 hours

8 to 10 mg per kg per day based on the trimethoprim component in divided doses every 12 hours

Patient education: https://www.aafp.org/afp/2014/0815/p229-s1.html References: https://www.aafp.org/afp/2014/0815/p229.html Common Skin Rashes in Children: https://www.aafp.org/afp/2015/0801/p211.html

Abbreviation: 2tfp-plan-derm-urticariaDescription: v1.0

Recommendations/education provided:Diagnosis of urticaria discussed with the patient. The patient has no symptoms of anaphylaxis. The patient has symptoms of anaphylaxis and has been instructed on the use of epi-pens and need to seek immediate medical attention for symptoms of anaphylaxis. Patient instructed to avoid all triggers of hives, avoid tight clothing, wash hands frequently and to avoid stress, fatigue and extreme temperature changes. Patient advised that alcohol, tobacco, and exercise may exacerbate hives. Patient instructed to use non-sedating antihistamines as ordered. Patient to follow up in 6 weeks for re-evaluation, sooner as needed.

Abbreviation: cds-derm-urticariaDescription: v1.0

Urticaria CDS: Do not routinely do diagnostic testing in patients with chronic urticaria. The mainstay of treatment is avoidance of identified triggers. It is also recommended that patients avoid using aspirin, alcohol, and NSAIDs, as well as avoid wearing tight clothing because these may worsen symptoms.1st line options: - Zyrtec (cetirizine)

-Claritin (loratadine)-Allegra(fexofenadine) -Seldane (terfenadine)

2nd line: try a different 2nd gen H1 antihistamine to control symptoms of urticaria, second-generation H1 antihistamines can be titrated to two to four times the normal dose

3rd line H2 antihistamines and leukotriene receptor antagonists may be added if neededSevere symptoms or 4th line

consider the addition of a short course (< 2 weeks) of oral corticosteroids (for example, prednisone 20-40 mg/day)

Patient education: Hives (urticaria) https://familydoctor.org/condition/hives-urticaria/ Reference: Acute and Chronic Urticaria: Evaluation and Treatment; https://www.aafp.org/afp/2017/0601/p717.html

Abbreviation: 2tfp-plan-derm-diaperDescription: v1.0

Recommendations/education provided:


https://familydoctor.org/condition/hives-urticaria/




Diagnosis of diaper dermatitis discussed with parent. Parent instructed to change diapers frequently to avoid skin exposure to wetness. Clean with warm water and very mild soap rather than baby wipes which may sting the involved areas. Allow air-drying of skin (including diaper-free time) to allow affected areas to dry completely. Use topical barrier protection with zinc oxide (e.g. desitin), lanolin, or petrolatum. Do not use powders. Use other topical meds as ordered. Follow up as needed if rash does not resolve.

Abbreviation: cds-derm-diaperDescription: v1.0

CDS: Diaper Dermatitis1st line options: Topical barrier preparations should be applied with each diaper change. They

include; zinc oxide, lanolin , petrolatum, creams with vitamin A (such as A&D ointment).

If evidence of superinfection with tinea

-1st choice Nystatin-other effective ones include: clotrimazole, econazole, ketoconazole, and miconazole.

Patient education: https://familydoctor.org/condition/diaper-rash/ Reference: https://www.uptodate.com/contents/diaper-dermatitis?search=diaper%20rash&source=search_result&selectedTitle=1~106&usage_type=default&display_rank=1

Abbreviation: 2tfp-plan-derm-liceDescription: v1.0

Recommendations/education provided:Patient advised that Lice is caused by small insects that live on the skin and cause itching. Patient instructed to be sure to wash clothing, bed sheets, and pillows in very hot water. Items that are unable to be machine washed (e.g. stuffed animals) should be put in a sealed plastic bag for two weeks to kill the lice and lice eggs. Also, vacuum your house thoroughly. Patient advised that medication must be used as prescribed to eliminate the infection. Topical therapies must be repeated in 7-10 days to fully eliminate lice. Patient also instructed that itching may continue for 2 weeks after infection.

Abbreviation: cds-derm-liceDescription: v1.0

Lice CDS:Decontaminate clothing and bedding (including stuffed animals) with machine wash at 60 degrees C (140 degrees F) and hot dryer. Body Lice: Firstline- Permethrin 1% lotion or shampoo (Nix) is first-line treatment for pediculosis, except in places with known permethrin resistance. Topical permethrin for patient and to all household/close contacts ≥ 2 months old (even if they are asymptomatic). For scalp lice follow package instructions. For body lice permethrin should be applied to all skin surfaces from the neck to toes for 8-14 hours and then washed off. For body or scalp involvement treatment should be repeated in 7-10 days as permethrin is not ovicidal.Patient education: Lice and Scabies; https://www.aafp.org/afp/2012/0915/p535-s1.htmlReferences: Pediculosis and Scabies: A Treatment Update; https://www.aafp.org/afp/2012/0915/p535.html



https://www.uptodate.com/contents/diaper-dermatitis?search=diaper%20rash&source=search_result&selectedTitle=1~106&usage_type=default&display_rank=1

https://www.uptodate.com/contents/diaper-dermatitis?search=diaper%20rash&source=search_result&selectedTitle=1~106&usage_type=default&display_rank=1

https://familydoctor.org/condition/diaper-rash/

Abbreviation: 2tfp-plan-derm-scabiesDescription: v1.0

Recommendations/education provided:Patient advised that the condition is caused by small insects that live on the skin and cause itching. Patient instructed to be sure to wash clothing, bed sheets, and pillows in very hot water. Items that are unable to be machine washed (e.g. stuffed animals) should be put in a sealed plastic bag for 72 hours to kill the insects. Patient advised that medication must be used as prescribed to eliminate the infection. Patient also instructed that itching may continue for 2 weeks after infection.

Abbreviation: cds-derm-scabiesDescription: v1.0

CDS Scabies: Scabies treatment: Permethrin 5% cream for classic scabies is the first-line treatment, permethrin cream should be applied to all areas of the body from the neck down, kept on overnight or for eight to 14 hours, washed off, and reapplied in one week. Patients should be educated that they may continue to have itching for up to two weeks, even after appropriate and effective treatment.B. Topical crotamiton 10% cream or lotion can be used in infants and is applied from the neck down for 2 consecutive nights and then washed off 48 hours after the second application.C. Oral ivermectin 200mcg/kg (with a repeat dose at 2 weeks) for patients > 5 years old(> 15 kg [33 lbs]) who are not pregnant or lactatingD. Treat pruritus and dermatitis with emollients, antihistamines, and topical steroids as needed.Patient education: Lice and Scabies; https://www.aafp.org/afp/2012/0915/p535-s1.htmlReferences: Pediculosis and Scabies: A Treatment Update; https://www.aafp.org/afp/2012/0915/p535.html

Abbreviation: 2tfp-plan-derm-barbaeDescription: v1.0

Recommendations/education provided:Patient advised to avoid a close shave, leaving hair at a length of 0.5 to 3 mm. Use clippers, a single-blade razor, or depilatories. Shave in the direction of hair growth and do not pull the skin taut while shaving. Loosen embedded hairs before shaving by brushing the neck, applying warm compresses, or gently rubbing with a towel. Patient advised to avoid plucking hairs as well. Patient advised to use topical meds as prescribed and that resolution may take months.

Abbreviation: cds-derm-barbaeDescription: v1.0

Pseudofolliculitis CDS:Treatment: For pseudofolliculitis barbae, consider other methods of hair removal, including depilatory or laser hair removal.



For supportive and empiric treatment of suspected infectious folliculitis; decrease exposures, such as shaving, contaminated water, occupational chemicals.1st line options: Adjunct therapy to changes in shaving habits include;

topical steroids, benzoyl peroxide, topical retinoids, and topical antibiotics

Suspected bacterial causes

Consider topical anti-bacterials such as mupirocin ointment (3 times per day for 3 to 5 days) or benzoyl peroxide washes

Suspected fungal Treat orally as tinea capitusPatient education: Common Conditions in Skin of Color; https://www.aafp.org/afp/2013/0615/p850-s1.html References: Dermatologic Conditions in Skin of Color: Part II. Disorders Occurring Predominantly in Skin of Color; https://www.aafp.org/afp/2013/0615/p859.html

Abbreviation: 2tfp-plan-derm-psoriasisDescription: v1.0

Recommendations/education provided:The diagnosis of psoriasis was discussed with the patient and that the primary goal of treatment is control of the disease. Patient advised that symptom management is benefitted through the use of skin moisturizers every day. Other patient actions to improve psoriasis include regular exercise, plenty of rest, a healthy diet, and reducing stress. Alcohol and tobacco use can make psoriasis worse. Spending some time in the sun (about 30 minutes per day) tends to help. Patient instructed to use all medications as ordered and advised that adherence to the medication regimen is essential to improvement. Patient advised to follow up in [_] weeks.

Abbreviation: cds-derm-psoriasisDescription: v1.0

Psoriasis CDS:1st line Topical corticosteroids (first-line treatment for limited disease): Same

progression (weak to strong) as for atopic derm, up to Clobetasol (apply thin layer TOPICALLY to affected area twice daily; MAX 50 g/week (21 capfuls); MAX duration of 2 consecutive weeks

Alternative -calcipotriene (calcipotriol) 0.005% cream/ointment, or scalp solution twice daily with maximum dose of100 grams/week-calcitriol ointment applied twice daily with maximum dose of 200 grams/week dithranol(anthralin), and coal tar

2nd line -combination calcipotriene plus betamethasone appears more effective for psoriasis than either monotherapy-combination of topical salicylic acid and topical corticosteroid (mometasone furoate 0.1% plus salicylic acid 5%) applied twice a day, appears more effective than topical corticosteroid alone-consider topical targeted phototherapy (laser therapy) for adults and children with mild, moderate, or severe psoriasis with < 10% body surface area (BSA) involvement

Topical medications are first-line for limited disease. Advise emollients for all patients to restore cutaneous barrier function (as per Atopic dermatitis). Moderate to severe psoriasis is typically defined as involvement of more than 5 to 10 percent of the BSA. Patients with more than 5 percent BSA affected are generally candidates for phototherapy or systemic therapy, since application of topical agents to a large area is not usually practical.


Referral: to a dermatologist should be considered in the following settings; confirmation of the diagnosis is needed. The response to treatment is inadequate as measured by the clinician, the patient, or both, and in cases of widespread severe disease.Patient adherence to topical therapy may be the biggest barrier to successful treatment. Early follow up (1-2 weeks) may improve adherence.Prevalence of depression is as high as 60 percent for patients with psoriasis.Patient education: https://www.aafp.org/afp/2013/0501/p626-s1.htmlReference: https://www.aafp.org/afp/2013/0501/p626.html

Abbreviation: 2tfp-plan-derm-pityroseaDescription: v1.0

Recommendations/education provided:Diagnosis of pityriasis rosea and temporary nature of condition discussed. Advised symptomatic treatment to address itching and to expect symptoms to last 2 to 12 weeks. Follow up as needed.

Abbreviation: cds-derm-pityroseaDescription: v1.0

CDS Pityriasis Rosea:1st line Topical agents for itching have been suggested

including topical steroids, zinc oxide, or calamine lotion.pruritis Oral antihistamines commonly used to reduce pruritusSevere symptoms

-Acyclovir has been shown to improve pruritis and resolution: 800 mg orally 5 times daily for 7 days (20 mg/kg orally 4 times daily for children) appears to increase lesion regression or 400 mg orally 5 times daily for 7 days may reduce erythema and scaling.

Patient education: https://www.aafp.org/afp/2018/0101/p38-s1.html Reference: https://www.aafp.org/afp/2018/0101/p38.html

Abbreviation: 2tfp-plan-derm-rosaceaDescription: v1.0

Recommendations/education provided: Patient advised to use sunscreen with sun protection factor (SPF) > 30, avoid potential triggers (hot or cold weather, hot beverages, alcohol) and adhere to a skin care regimen including only gentle cleansers. Use topical medication as ordered. Follow up in 6-8 weeks or prn.

Abbreviation: cds-derm-rosaceaDescription: v1.0

Rosacea CDS:



http://www.dynamed.com/topics/dmp~AN~T116841



Topical meds for rosacea:Medication Strength/dosage indicationMetronidazole 0.75% gel cream or lotion

apply bid, 1% gel apply q dPapules, pustules, erythema

Azelaic acid 15% gel qd or bid Papules, pustules, erythemaSulfacetamide 5% or 10 % cream or other

prepApply qd or bid

Papules, pustules, erythema

Brimonidine .33% gel apply once q day ErythemaIvermectin 1% cream once q day Papules, pustulesPermethrin 5% cream once q day Papules, erythemaBenzoyl peroxide 5% gel apply qd or bid Papules, pustules, erythemaClindamycin 1% gel apply bid Papules, pustulesErythromycin 2% gel apply bid Papules, pustulesTretinoin cream .025%, .05%, .1% cream or

0.01%, 0.025% gel; qHSPapules, pustules, erythema, telangiectasia

-For moderate-to-severe low-dose oral doxycycline (40 mg once per day or 20 mg twice per day) reduces inflammatory lesionsPatient education: https://www.aafp.org/afp/2015/0801/p187-s1.html References: https://www.aafp.org/afp/2015/0801/p187.html

Abbreviation: 2tfp-plan-derm-acneDescription: v1.0

Recommendations/education provided: This patient has been diagnosed with mild moderate severe acne. Patient instructed to wash face gently twice a day with a mild non-medicated cleanser and follow with any topical treatments prescribed. Patient encouraged to avoid oil-based cosmetics or other products which may occlude pores. Patient instructed there is no current evidence to support dietary changes or supplements in the treatment of acne. Patient advised not to expect visible improvement for at least 1 month after changes in treatment and that accurate measure of full response cannot be performed until 8-12 weeks of treatment. Patient advised to follow up within 8-12 weeks or sooner as needed.

Abbreviation: cds-derm-acneDescription: v1.0

Acne CDSMild 1st line Monotherapy with topical retinoid (preferred if comedonal acne) or topical

benzoyl peroxideMild 2nd line Combination therapy, with benzoyl peroxide plus topical retinoid, or benzoyl

peroxide plus topical clindamycin is more effective than single therapy, particularly if the patient has mixed inflammatory and noninflammatory lesions

Mild 3rd line May offer triple topical therapy with topical retinoid, clindamycin, and benzoyl peroxide if 2-drug combination is not completely effective

Moderate or unresponsive to topical

in nonpregnant patients aged > 8 years, add oral antibiotic to topical combination therapy of topical retinoid plus benzoyl peroxide. Consider doxycycline with dosing for acne for adults and children aged> 8 years and > 100 pounds, at 50-100 mg once or twice daily.

Moderate or unresponsive

Replace oral doxycycline with Bactrim or erythromycin; note that antibiotic course is not recommended for more than 3 months.



to topicals + DoxySevere acne, or acne resistant to 3 months of oral antibiotic plus topical therapy

-For women, consider adding combined oral contraceptives. Ortho-Tricyclen, Yaz, Ortho-cyclen, Ocella, and Yazmin (and others) have all been demonstrated to improve acne.-For men or women, oral isotretinoin with conventional dosing or low-dose, and prevention against the possibility of pregnancy while taking isotretinoin, including monthly pregnancy testing for women. Physicians, distributors, pharmacies, and patients must register in the iPLEDGE program (http://www.ipledgeprogram.com (http://www.ipledgeprogram.com)) before using isotretinoin.◦Check baseline liver function tests, serum cholesterol and triglycerides and consider monitoring for depression, anxiety, liver function tests, serum cholesterol, and triglycerides while on isotretinoin.

Patient education: https://www.aafp.org/afp/2012/1015/p734-s1.html References: Diagnosis and Treatment of Acne. Am Fam Physician. 2012 Oct 15;86(8):734-740.Acne Vulgaris: Treatment Guidelines from the AAD. Am Fam Physician. 2017 Jun 1;95(11):740-741.

Metabolic

Abbreviation: 2tfp-plan-met-obesityDescription: v1.0

Recommendations/education provided:Discussed the patient’s weight with the patient and their BMI which currently classifies them as being overweight obese. Discussed obesity related conditions and how excess weight contributes to these conditions. Patient advised that weight loss through comprehensive lifestyle interventions (including dietary modification, physical activity and behavioral components) improves obesity related conditions and may prevent cardiovascular events such as heart attack and stroke. Discussed appropriate interventions based upon their BMI. Referral not to Nutritionist to IBHC for Bariatric Surgery evaluation provided. Patient instructed to take medications as prescribed.

Abbreviation: cds-met-obesityDescription: v1.0

Obesity CDS:Comprehensive lifestyle interventions are the first line approach. Near term (e.g. within 2 weeks) and frequent follow up help maintain adherence. The USPSTF recommends that patients who are obese be referred to intensive, multicomponent behavioral interventions with 12 to 26 sessions per year.Patients with a BMI of 40 kg/m2 or greater, or 30 kg/m2 or greater with obesity-related comorbidities should be offered referral for consideration of bariatric surgery.Referrals: -Nutritionist for dietary evaluation and counseling for weight loss. -IBHC for multicomponent behavioral intervention for weight loss and health improvement-Bariatric surgery referral for individuals with BMI>40 or those with obesity associated conditions and BMI>30. Meds: Pharmacologic treatment may be offered to overweight patients with comorbidities and to obese patients who are unable to lose weight with comprehensive lifestyle modification alone.Medication for Obesity Tx

Dosage Addressed by VA DoD CPG

phentermine/ 7.5/46 mg po qd


topiramate extended-release

15/92 mg po qd Yes

Orlistat 60 or 120 mg po TID YesLorcaserin 10 mg po BID YesNaltrexone/bupropion Two 8/90mg tabs po

BID No

Patient education: Weight Loss: Practical Tips, https://www.aafp.org/afp/2016/0901/p361-s1.html Weight Loss Surgery; https://www.aafp.org/afp/2016/0101/p31-s1.html Weight-control Information Network: http://www.win.niddk.nih.gov/publications/index.htm References: VA/DoD CLINICAL PRACTICE GUIDELINE; Screening and management of overweight and obesity 2014; https://www.healthquality.va.gov/guidelines/CD/obesity/CPGManagementOfOverweightAndObesityFINAL041315.pdf Update on Office-Based Strategies for the Management of Obesity; https://www.aafp.org/afp/2016/0901/p361.html Treatment of Adult Obesity with Bariatric Surgery; https://www.aafp.org/afp/2016/0101/p31.html

Abbreviation: 2tfp-plan-met-dm2Description: v1.0

Recommendations/education provided:The patient’s diagnosis of type 2 diabetes was discussed with the patient. HgbA1c level is presently at near above target. Goal level HgbA1c of 6-7 7-8 8-9 <10 discussed. Dietary, lifestyle, exercise, and self-management recommendations reviewed with patient. Patient education provided. Current medication will be adjusted remain unchanged as per medication module and orders.Signs and symptoms of hypo and hyperglycemia discussed. The patient has been given instructions to follow up in 3 6 12 1 2 month(s).

Abbreviation: cds-met-dm2Description: v1.0

CDS: DM Type 2: Treatment:Life Style modification, diet, exercise, and diabetic education are the first non-pharmacologic treatment for diabetes and should be initiated immediately upon diagnosis.

HbA1c Goal:7% to 8% in most adults because targets of 7% or less do not appear to result in

reduced risk of mortality or macrovascular events6% to 7 % DoD CPG suggests this goal if no comorbidities and safely achievable7% to 9% Older adults goal depending on number of comorbidities.

Glycemic Control:1st line Metformin 500mg po with evening meal, 500mg po BID with meal,

850mg Bid, 500 TID, 1000 Bid (escalate dose to reach Hgb A1C goal)2nd line options (add to metformin)

-Glipizide (Glucotrol) start at 5mg po q d 30 minutes before meal. Divided doses as increase max single dose 15mg.-Glipizide XL –start at 5mg qd (or match immediate release dose) increase to up to 20mg q d-Pioglitizone (Actos) 15 mg, 30mg, up to 45mg q d-Empagliflozin (jardiance) 10mg q d advance to 25 mg q d as



https://www.healthquality.va.gov/guidelines/CD/obesity/CPGManagementOfOverweightAndObesityFINAL041315.pdf

https://www.healthquality.va.gov/guidelines/CD/obesity/CPGManagementOfOverweightAndObesityFINAL041315.pdf

http://www.win.niddk.nih.gov/publications/index.htm



needed/tolerated.-Alogliptan (Nesina) :6.25, 12.5, or 25mg. all q d, most common dose is 25mg q d

3rd line Add another of the options above4th line Injectable therapy

Cardiovascular Risk Reduction:Aspirin Patients with known cardiovascular disease or those >50 y.o. with least 1

other cardiac risk factor should receive aspirin (75–162mg/day) or Clopidogrel 75mg if ASA allergy

Lipids Low to mod dose statins (Atorvastatin 20–40 mg) for those without ASCVD, high dose statin (Atorvastatin 40–80 mg) for those with ASCVD

Blood pressure

Goal below 140/90 if low risk, <130/80 for high risk patients if able. ACE or ARB are first line, then add Chlorthalidone start at 25 mg po qd up to max dose of 100mg qd

Hypoglycemia: Glucagon should be prescribed for all individuals at increased risk of clinically significant hypoglycemia, defined as blood glucose 54 mg/dL (3.0 mmol/L).Labs: Hgb A1c q 3 months if not at goal, q 6 months if at goal, creatinine (Chem7 annually). Microalbumin creatinine UA (urinary albumin to creatinine ratio) and GFR. ADA-at least once a year, assess urinary albumin (e.g., spot urinary albumin–to–creatinine ratio) and estimated glomerular filtration rateLipids assessed at diagnosis and annually if abnormal. If normal assess q 5 years.Immunizations:ADA aligns with CDC recommendations for all diabetics: “The CDC Advisory Committee on Immunization Practices (ACIP) recommends influenza, pneumococcal, and hepatitis vaccinations specifically for people with diabetes.” Influenza –annuallyPPSV23 – once for ages 2-64, and at 65 or older regardless of previous statusHep B – 3 dose series for ages 19-59, also consider for unvaccinated who are 60 or older

Referrals: 1. Nutritionist for medical nutrition therapy at time of diagnosis and as needed2. Diabetes self-management education (DSME) and at time of diagnosis and as needed3. Ophthalmologist or optometrist for retinal exam at the time of the diabetes diagnosis. Every 1-2 years thereafter.4. Podiatry for diabetic foot or for those at high risk5. Cardiology for CVD complications6. Nephrology- consider referral if evidence of diabetic kidney disease7. Endocrinologist- consider referral for uncontrolled diabetes and or concomitant diabetes and other endocrine diagnoses

Patient education: https://www.aafp.org/afp/2009/0101/p42.html (Lifestyle Changes to Manage Type 2 Diabetes)

Abbreviation: 2tfp-plan-cv-htnDescription: v1.0

Recommendations/education provided:Reviewed non-pharmacologic interventions: Diet, Exercise, and Weight Control. Recommended Sodium RestrictionCurrent Treatment plan has not reached goal been effective. Current plan will be adjusted remain unchanged as per medication module and orders. Potential side effects of Medications were discussed with the patient.The patient has been given instructions to follow up in 3 6 12 1 2 month(s).


Abbreviation: cds-met-htnDescription: v1.0

CDS Hypertension:Patient Type Medication comments

No specific indication-BP goal: <140/90

1st line: chlorthalidone 12.5-25mg2nd line: amlodipine 2.5-10mg + max dose of chlorthalidone3rd line: lisinopril 10-40mg + max doses of chlorthalidone and amlodipine4th line: add fourth med or refer

-max out dose before adding another med-If SBP >20 or DBP >10 over goal, start with 2 meds (2nd line option)- if not tolerant of ACEI, then replace with losartan 25-100mg

Non-black with CKD or DMBP goal ≤ 130/80

1st line: lisinopril 10-40mg2nd line: chlorthalidone 12.5-25mg + max dose of lisinopril3rd line: amlodipine 2.5-10mg + max doses of chlorthalidone and lisinopril4th line: add fourth med or refer

-max out dose before adding another med-If SBP >20 or DBP >10 over goal, start with 2 meds (2nd line option)- if not tolerant of ACEI, then replace with losartan 25-100mg

Black with CKD or DM?BP goal ≤ 130/80

1st line: lisinopril 10-40mg + chlorthalidone 12.5-25mg2nd line: amlodipine 2.5-10mg + max doses of chlorthalidone and lisinopril3rd line: add fourth med or refer

-max out dose before adding another med- if not tolerant of ACEI, then replace with losartan 25-100mg

CAD 1st line: carvedilol 25-50mg or atenolol 25-100mg

High CAD risk 1st line: chlorthalidone 12.5-25mg2nd line: carvedilol 25-50mg or atenolol 25-100mg + max dose of chlorthalidone3rd line: lisinopril 10-40mg + max doses of chlorthalidone and carvedilol/atenolol4th line: add fourth med or refer

-max out dose before adding another med- if not tolerant of ACEI, then replace with losartan 25-100mg

Labs:UA, BMP, lipid panel, fasting glucose

mandatory as baseline, then as clinically indicated

hematocrit and calcium optional at baseline, then as clinically indicatedOther tests:

12-lead electrocardiogram mandatory as baseline, then as clinically indicatedNon-pharmacologic interventions:

Overweight or obese hypertensive patients should reduce their body mass index to below 25.Aerobic exercise of 30 to 45 minutes per session, at least four times per weekSelf-monitoring device (e.g., pedometer, mobile apps, etc.) to increase adherence to physical activityFor patients interested in complementary and alternative medicine, consider mind-body therapies such as transcendental meditation or yogaDietitian-led Dietary Approaches to Stop Hypertension (DASH) Diet for the treatment

and/or prevention of hypertension for patients with hypertension and/or interested patients with prehypertension and other cardiovascular risk factorsSmoking cessation

Diagnosis and Management of Hypertension in Primary Care Setting: https://www.healthquality.va.gov/guidelines/CD/htn/HTNSUM3FIA20151209.pdfBlood Pressure Targets in Patients with Hypertension and Cardiovascular Disease https://www.aafp.org/afp/2018/0901/p276.htmlHypertension: https://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId=12Clinical Practice Guidelines: Management of High Blood Pressure in Adults: https://www.aafp.org/patient-care/clinical-recommendations/all/highbloodpressure.html

Abbreviation: 2tfp-plan-met-hlpDescription: v1.0

Recommendations/education provided:Reviewed Diet, Exercise, and Weight Control.Pt compliant with medication therapy, no side effects, continue current treatment.The patient has been given instructions to follow up in 3 6 12 1 2 month(s).

Abbreviation: cds-met-hlpDescription: v1.0

Perform Risk Stratification: http://www.cvriskcalculator.com/ -Follow instructions on website

HIGH INTENSITY STATIN TREATMENT:-Atorvastatin 40mg to 80 mg

MODERATE INTENSITY TREATMENT:-Atorvastatin 10-20 mg-Simvastatin 20-40 mg

Labs:-Repeat lipid panel can be performed to monitor compliance, not mandatory- VA/DoD CPG suggests establishing baseline liver function tests (LFTs) and creatinine kinase (CK) before initiation of drug therapy (weak evidence)-VA/DoD CPG suggests measuring LFTs 4-12 weeks after the initiation of high-dose statin. (weak evidence)-Follow up CK /LFT’s only if clinical signs of side effects emerge (weak evidence)

BH

Abbreviation: cds-bh-adhd

http://www.cvriskcalculator.com/

Description: v1.0

Treatment: -<6 y/o Behavioral therapy first line: -Parent Training, Classroom management, peer intervention -6-11 y/o first line is stimulant then Atomoxitine, guanfacine or catapress -Concerta, methylphenidate ER, Adderall XR, -12-18 stimulants first line can add behavioral therapy (APA recommends both together, 2011).Follow-up: titrate every 2 weeks to effective dose or side effects, once stable on meds f/u every 3 months for 1 year, then can go to 6 months between appointments.

Endocrine

Abbreviation: 2tfp-plan-end-thy-hypoDescription: v1.0

Recommendations/education provided:TSH level is presently at not at target. Current medication will remain unchanged be adjusted as per medication module and orders. The patient has been informed not to use dietary supplements or other over-the-counter products for treatment of hypothyroidism as they are unproven and may be dangerous.The patient has been given instructions to follow up in 1 2 3 6 12 month(s).

Abbreviation: cds-end-hypothyDescription: v1.0

Hypothyroidism: CDSTests: Serum TSH alone is the gold standard. Do not order other tests. If TSH is abnormal confirm diagnosis with free thyroxine (T4) and repeat TSH. Thyroid antibody titers (TPO ab, Tg ab) are only indicated after confirmation of hypothyroidism to determine etiology.Diagnosis: 1. Primary Hypothyroidism: TSH > 10.0 mU/L and low T4. (AACE recommends repeat TSH to confirm diagnosis.)2. Subclinical Hypothyroidism: TSH >5.5 and normal T4.3. Central Hypothyroidism: Low TSH and Low T4 (refer to endocrinology)Treatment:1. Primary Hypothyroidism: Levothyroxine alone is the Gold standard treatment. For adults <50 without ASCVD: start at 1.6mcg per kg per day, take with water 30-60 minutes before breakfast. Repeat TSH at 4-8 weeks. If normal TSH maintain current dose and repeat TSH at 6 months. If TSH >5.0 increase levothyroxine by 12.5-25 mcg/day. If TSH <0.35 decrease dose 25 mcg/day. Once TSH is normal for 6 months may follow level annually. Target TSH is 2.0-3.0 mU/L.For adults >50 or with ASCVD; start at 25-50 mcg levothyroxine per day and increase by 25mcg/day every 3-4 weeks until normal TSH level is reached.Patients should be started and maintained on either brand-name or generic levothyroxine preparations, and not switched back and forth between the two. Patients who do switch products should undergo repeat TSH and free T4 testing in six weeks to ensure normal range levels.Poor adherence to levothyroxine therapy is the most common cause of persistently elevated TSH levels in patients on adequate doses of thyroid hormone.

Target TSH is 2.0-3.0 mU/LInitial Dosing - Adults <50 without ASCVD: Levothyroxine 1.6mcg per kg per day

- Adults >50 or with ASCVD: start at 25-50 mcg levothyroxine per day and increase by 25mcg/day every 3-4 weeks-Repeat TSH at 4-8 weeks-If normal TSH maintain current dose and repeat TSH at 6 months.

TSH >5.0 on follow up testing

-increase levothyroxine by 12.5-25 mcg/day

TSH <0.35 on follow up testing

- decrease dose 25 mcg/day

TSH 2-3 on follow up testing

- Once TSH is normal for 6 months may follow level annually

Nonmedical management:American Association of Clinical Endocrinologists/American Thyroid Association (AACE/ATA) recommends against use of dietary supplements, nutraceuticals, or other over-the-counter products for treatment of hypothyroidism.

Abbreviation: 2tfp-plan-end-subclin-hypothyDescription: v1.0

Subclinical Hypothyroidism: PlanDiagnosis of subclinical hypothyroidism discussed with the patient. Reviewed the specific circumstances when treatment of subclinical hypothyroidism is required. This patient does not require treatment at this time requires levothyroxine as prescribed. The patient has been informed not to use dietary supplements or other over-the-counter products for treatment of hypothyroidism as they are unproven and may be dangerous.The patient has been given instructions to follow up in 1 2 3 6 12 month(s).

Abbreviation: cds-end-subclin-hypothyDescription: v1.0

Subclinical Hypothyroidism: CDSTests: Serum TSH alone is the gold standard. Do not order other tests. If TSH is abnormal confirm diagnosis with free thyroxine (T4) and repeat TSH. Thyroid antibody titers (TPO ab, Tg ab) are only indicated after confirmation of hypothyroidism to determine etiology.Diagnoses: 1. Primary Hypothyroidism: TSH > 10.0 mU/L and low T4. (AACE recommends repeat TSH to confirm diagnosis.)2. Subclinical Hypothyroidism: TSH >5.5 and normal T4.3. Central Hypothyroidism: Low TSH and Low T4 (refer to endocrinology)Imaging: NO imaging is indicated if physical exam of thyroid is normal. If goiter or nodules are present a thyroid ultrasound is recommended.Treatment Subclinical Hypothyroidism: Levothyroxine therapy is only recommended for the following groups: patients who have symptoms of hypothyroidism, patients desiring pregnancy, patients with increased thyroid antibody titers. Dosing: Start Levothyroxine at 50mcg per day, increase at 6 week interval by 25mcg/day until normal TSH is reached. May discontinue if no symptomatic benefit is achieved and monitor as below.Patients without symptoms or other indication may be monitored for primary hypothyroidism with TSH every 6-12 months.

For suspected Central or Secondary Hypothyroidism an endocrinology consultation is recommendedTarget TSH is 2.0-3.0 mU/L

Levothyroxine therapy is only recommended for subclinical hypothyroidism in the following groups

-patients who have symptoms of hypothyroidism - Adults >50 or with ASCVD: -Patients desiring pregnancy- Patients with increased thyroid antibody titers

Initial Dosing -levothyroxine 50mcg per day-Repeat TSH at 4-8 weeks

Follow up -increase at 6-week interval by 25mcg/day until normal TSH is reachedPatients without symptoms or other indication

- TSH testing q6-12 months

Nonmedical management:American Association of Clinical Endocrinologists/American Thyroid Association (AACE/ATA) recommends against use of dietary supplements, nutraceuticals, or other over-the-counter products for treatment of hypothyroidism.References:1. AFP: https://www.aafp.org/afp/2012/0801/p244.html 2. DynaMed Plus: http://www.dynamed.com/topics/dmp~AN~T115914/Hypothyroidism-in-adults 3. Essential Evidence Plus: http://www.dynamed.com/topics/dmp~AN~T115914/Hypothyroidism-in-adults 4. Choosing wisely: http://www.choosingwisely.org/clinician-lists/american-society-clinical-pathology-suspected-thyroid-disease-evaluation/

ICD 10 Codes:Hypothyroidism, unspecified: E03.9Other specified hypothyroidism: E03.8

STI

Abbreviation: 2tfp-plan-sti-hsv-initialDescription: v1.0

Recommendations/education provided:- Patient diagnosed with first episode of genital herpes simplex virus (HSV) based on history contact exposure and congruent symptomatology laboratory result.- Patient counseled regarding the natural history of genital herpes, sexual and perinatal transmission, methods to reduce transmission, and treatment with medication, including limitations of medication therapy and suppression therapy.Patient counseled on the need to avoid transmission risk to sexual partners. Follow-up: Referral: to public health/preventive medicine for education and contact tracing as needed- Patient verbalized understanding of diagnosis, instructions and treatment plan.

http://www.choosingwisely.org/clinician-lists/american-society-clinical-pathology-suspected-thyroid-disease-evaluation/

http://www.choosingwisely.org/clinician-lists/american-society-clinical-pathology-suspected-thyroid-disease-evaluation/

http://www.dynamed.com/topics/dmp~AN~T115914/Hypothyroidism-in-adults




Abbreviation: cds-sti-hsv-initialDescription: v1.0

CDS Genital Herpes Simplex Virus - first episode:Differential Diagnosis of Genital UlcersInfectious Chancroid (classically a deep, undermined, purulent ulcer that may be associated with painful inguinal

lymphadenitis.) Fungal infection Genital herpes simplex (classically multiple, shallow, tender ulcers that may be vesicular; in addition, only

herpes simplex virus (HSV) is associated with recurrent disease Granuloma inguinale Lymphogranuloma venereum Secondary bacterial infection Syphilis (classically a painless, indurated, clean-based ulcer, called a chancre)Noninfectious Aphthous ulcers Behçet syndrome Fixed drug eruption Neoplasms Psoriasis Sexual trauma

Med, 1st line options, choose one

Acyclovir 400mg TID for 7-10 days

(may be extended if healing is incomplete after 10 days of therapy)

Valacyclovir 1 g orally twice a day for 7–10 days

(may not be on formulary) (may be extended if healing is incomplete after 10 days of therapy)

Famciclovir 250 mg orally three times a day for 7–10 days

Famciclovir (may not be on formulary) (may be extended if healing is incomplete after 10 days of therapy)

Lab HIV Ag/Ab Combo ½ Screen

Lab HSV PCR or cell culture

LabPoint of care serology testing, e.g. HerpeSelect HSV-2 Elisa

if available

Abbreviation: 2tfp-plan-sti-hsv-recurrentDescription: v1.0

Recommendations/education provided:Patient diagnosed with recurrent genital herpes simplex virus (HSV) based on history. history and laboratory result. Patient counseled regarding the natural history of genital herpes, sexual and perinatal transmission, methods to reduce transmission, and treatment options including intermittent medication to treat outbreaks versus daily medication to suppress outbreaks. Neither treatment eliminates outbreaks or transmission. Patient selected suppressive therapy.Patient counseled on the need to avoid transmission risk to sexual partners. Follow-up: 6 months to review efficacy of suppressive therapy, earlier as needed

Referral: to public health/preventive medicine for education and contact tracing as neededPatient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-sti-hsv-recurrentDescription: v1.0

CDS Genital Herpes Simplex Virus - Recurrent: “Frequent recurrence” of HSV warranting daily suppressive therapy is often considered to be 6 or more occurrences per year.Factors to consider when deciding between daily suppression vs. episodic therapy include patient preference, frequency of outbreaks, likely adherence, toxicity, risk of transmission to uninfected partner, and psychosocial considerations.Valacyclovir 500 mg once a day might be less effective than other valacyclovir or acyclovir dosing regimens in persons who have very frequent recurrences (i.e., ≥10 episodes per year).

Med, 1st line options, choose one

Acyclovir 400mg BID #180/1Valacyclovir (may not be on formulary) 500mg daily #90/1Valacyclovir (may not be on formulary) 1 g daily #90/1

Famciclovir (may not be on formulary) 250 mg twice a day #180/1

Abbreviation: 2tfp-plan-sti-syphillisDescription: v1.0

Recommendations/education provided:- Patient diagnosed with primary secondary early latent late latent syphilis based on laboratory result. - Patient counseled regarding the natural history of syphilis, sexual and perinatal transmission, methods to reduce transmission, and treatment options. - Patient counseled on the need to avoid transmission risk to sexual partners. Follow-up: at 6 and 12 months for clinical and serologic evaluationReferral: to public health/preventive medicine for education and contact tracing as needed- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-sti-syphilisDescription: v1.0

CDS Syphlilis: Recommend accessing more detailed references regarding syphilis diagnosis and management such as the CDC’s 2015 STD Treatment Guidelines at https://www.cdc.gov/std/tg2015/default.htm .-Primary syphilis infection: ulcers or chancre at the infection site-Secondary syphilis: manifestations include, but are not limited to, skin rash, mucocutaneouslesions, and lymphadenopathy-Tertiary syphilis: (cardiac involvement, gummatous lesions, tabes dorsalis, and general paresis).-Latent infections (i.e., those lacking clinical manifestations) are detected by serologic testing. -- Early latent syphilis: acquired within the preceding year. -- Late latent syphilis: all other cases of latent syphilis.

https://www.cdc.gov/std/tg2015/default.htm

Lab testing: Patients with a positive RPR or VDRL test should undergo specific treponemal testing, such as the fluorescent treponemal antibody absorption assay or the T. pallidum particle agglutination test to confirm infection with T. pallidum. Patients with a negative VDRL or RPR test and strong clinical indicators of primary syphilis should have repeat nontreponemal serology in two weeks.Clinical and serologic evaluation should be performed at 6 and 12 months after treatment.

Lab “Syphilis screen”, RPR, or VDRLLab FTA (fluorescent treponemal antibody) for

confirmation after positive screening testLab HIV AG/AB combo 1/2 screen

Med Primary, secondary, and early latent syphilis: Benzathine penicillin G

2.4 million units IM in a single dose

Med Primary or Secondary if PCN Allergic: Doxycycline

100 mg po BID for 14 days

MedLate Latent Syphilis or Latent Syphilis of Unknown DurationBenzathine penicillin G

7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervals

Referral: allergy/immunology for persons with penicillin allergy

Abbreviation: 2tfp-plan-sti-urethritisDescription: v1.0

Recommendations/education provided:- Patient diagnosed with nongonococcal urethritis based on symptoms and laboratory result. - Patient counseled regarding the diagnosis and natural history of NGU and treatment options. - Patient counseled on the need to avoid transmission risk to sexual partners. Follow-up: at 3 months for clinical and evaluation including retesting, earlier if symptoms recur or do not abateReferral: public health/preventive medicine for contact tracing- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-sti-urethritisDescription: v1.0

CDS Urethritis:-NGU is confirmed in symptomatic men when staining of urethral secretions indicates inflammationwithout Gram negative or purple diplococci. -All men who have confirmed NGU should be tested for chlamydia and gonorrhea even if point-of-care tests are negative for evidence of GC.-Testing for T. vaginalis should be considered in areas or populations of high prevalence.- Providers should be alert to the possible diagnosis of chronic prostatitis/chronic pelvic pain syndromein men experiencing persistent perineal, penile, or pelvic pain or discomfort, voiding symptoms, pain during or after ejaculation, or new-onset premature ejaculation lasting for >3 months.- All sex partners of men with NGU within the preceding 60 days should be referred for evaluation, testing, and presumptive treatment with a drug regimen effective against chlamydia.

Lab gram stain

Lab NAAT for GC and chlamydia

Lab HIV AG/AB combo 1/2 screen

Lab syphilis serology

Med1st line options, choose one

Azithromycin1 gram single dose

may be associated with higher compliance

Med Doxycycline100mg BID for 7 days

Med2nd line options, choose one

erythromycin base 500mg QID for 7 days

Mederythromycin ethylsuccinate

800mg QID for 7 days

Med levofloxacin500mg daily for 7 days

Med ofloxacin300mg BID for 7 days

Med

1st line; see comment moxifloxacin

400mg BID for 7 days

for persistent or recurrent NGU after azithromycin failure

Med 1st line metronidazole2 grams single dose

for trichomonas infection

Abbreviation: 2tfp-plan-sti-cervicitisDescription: v1.0

Recommendations/education provided:Patient diagnosed with cervicitis based on symptoms and physical exam; laboratory results are available pending. Patient counseled regarding the diagnosis and natural history of cervicitis and treatment options, including presumptive treatment pending receipt of lab results. Patient counseled on the need to avoid transmission risk to sexual partners, to abstain from sexual intercourse until they and their partner(s) have been adequately treated. Follow-up: 2 weeks to evaluate clinical response, earlier if symptoms recur or do not abateReferral: public health/preventive medicine for contact tracingPatient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-sti-cervicitisDescription: v1.0

CDS Cervicitis:-Cervicitis: 1) a purulent or mucopurulent endocervical exudate visible in the endocervical canal or on an endocervical swab specimen and 2) sustained endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os.- Women with a new episode of cervicitis should be assessed for signs of PID, tested for chlamydia and GC with NAAT using vaginal, cervical, or urine samples.-Also evaluate for BV and trichomoniasis, treat if detected.-Presumptive treatment for GC and chlamydia should be provided for women at increased risk (e.g., those aged <25 years and those with a new sex partner, a sex partner with concurrent partners, or a sex partner who has a STI), especially if follow-up cannot be ensured or if testing with NAAT is not possible. For women at lower risk of STDs, deferring treatment until results of diagnostic tests are available is an option.

- To minimize transmission and reinfection, women treated for cervicitis should be instructed to abstain from sexual intercourse until they and their partner(s) have been adequately treated (i.e., for 7 days after single-dose therapy or until completion of a 7-day regimen) and symptoms have resolved.-Women who receive a diagnosis of cervicitis should be tested for HIV and syphilis.


vaginal, cervical, or urine sample

Lab wet prep for bacterial vaginosis and trichomoniasis

Lab CBC For consideration of PIDLab ESR (sed rate) For consideration of PIDLab C-reactive protein For consideration of PID

Lab HIV AG/AB combo 1/2 screen

Lab syphilis serology


Azithromycin1 gram single dose

presumptive treatment for women at increased risk

Med Doxycycline100mg BID for 7 days

presumptive treatment for women at increased risk; Don't use if pregnant

Abbreviation: 2tfp-plan-sti-chlamydiaDescription: v1.0

Recommendations/education provided:- Patient diagnosed with chlamydial infection based on laboratory result confirmed contact notification. - Patient counseled regarding the diagnosis and natural history of chlamydia infections and treatment options. - Patient counseled on the need to avoid transmission risk to sexual partners, to abstain from sexual intercourse until they and their partner(s) have been adequately treated. Follow-up: if symptoms recur or do not abate.Referral: public health/preventive medicine for education and contact tracing as needed- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-sti-chlamydiaDescription: v1.0

CDS Chlamydia: -Persons who receive a diagnosis of chlamydia should be tested for HIV, GC, and syphilis.

Lab NAAT for GC vaginal, cervical, or urine sample

Lab

HIV AG/AB combo 1/2 screen

Lab

“Syphilis screen”, RPR, or VDRL


Azithromycin 1 gram single dose

presumptive treatment for women at increased risk

Med Doxycycline 100mg BID for 7 days

presumptive treatment for women at increased risk; Don't use if pregnant

Abbreviation: 2tfp-plan-sti-gonococcalDescription: v1.0

Recommendations/education provided:- Patient diagnosed with gonococcal infection based on laboratory result confirmed contact notification. - Patient counseled regarding the diagnosis and natural history of gonococcal infections and treatment options. - Patient counseled on the need to avoid transmission risk to sexual partners, to abstain from sexual intercourse until they and their partner(s) have been adequately treated. Follow-up: if symptoms recur or do not abate.Referral: public health/preventive medicine for education and contact tracing as needed- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-sti-gonococcalDescription: v1.0

CDS Gonococcal Infections:

Lab GC culture endocervical or urethral specimen


endocervical swabs, vaginal swabs, urethral swabs (men), and urine (from both men and women

Lab gram stain Male urethra, not other sources

Lab


Lab


Med 1st line

Ceftriaxone AND

250 mg IM in a single dose

Uncomplicated Gonococcal Infections of theCervix, Urethra, Rectum, Pharynx, and Conjunctiva

Azithromycin 1g orally in a single dose

Med

alternative

Cefixime AND400 mg orally in a single dose

Azithromycin 1 g orally in a single dose

Abbreviation: 2tfp-plan-sti-vaginosisDescription: v1.0

Recommendations/education provided:- Patient diagnosed with bacterial vaginosis based on symptoms and test results. - Patient counseled regarding the diagnosis and natural history including possibility of sexual transmission. - Patient counseled on the possibility of sexual transmission, to abstain from sexual intercourse until completion of treatment. Follow-up: if symptoms recur or do not abate.Referral: public health/preventive medicine for education and contact tracing: yes no.- Patient verbalized understanding of diagnosis, instructions, and treatment plan.

Abbreviation: cds-sti-vaginosisDescription: v1.0

CDS Bacterial Vaginosis:- “All women with BV should be tested for HIV and other STDs.” (CDC, 2015)- “BV is associated with having multiple male or female partners, a new sex partner, douching, lack of condom use, and lack of vaginal lactobacilli; women who have never been sexually active are rarely affected. The cause of the microbial alteration that precipitates BV is not fully understood…” (CDC 2015)- Clinical criteria require three of the following symptoms or signs:• homogeneous, thin, white discharge that smoothly coats the vaginal walls;• clue cells (e.g., vaginal epithelial cells studded with adherent coccobacilli) on microscopic examination;• pH of vaginal fluid >4.5; or• a fishy odor of vaginal discharge before or after addition of 10% KOH (i.e., the whiff test).

Lab gram stain vaginal fluidLab wet prep, KOH vaginal fluid

Lab Vaginitis/vaginosis DNA probe vaginal fluid



Lab “Syphilis screen”, RPR, or VDRL

Lab HIV serology Med

1st line options, choose

one

metronidazole OR 500mg BID for 7 days avoid alcohol

Med

metronidazole 0.75% gel OR

1 full applicator (5g) intravaginally once a day for 5 d avoid alcohol

Med Clindamycin cream 2%

2 full applicator (5g) intravaginally at bedtime for 5 d

Med

Alternative options,

choose one

Tinidazole OR 2 g orally once daily for 2 d avoid alcoholMed Tinidazole OR 1 g orally once daily for 5 d avoid alcoholMed

Clindamycin OR 300 mg orally twice daily for 7 d

Med Clindamycin ovules OR

100 mg intravaginally once at bedtime for 3 days

Abbreviation: 2tfp-plan-sti-trichomoniasisDescription: v1.0

Recommendations/education provided:Patient diagnosed with trichomoniasis based on symptoms and test results. Patient counseled regarding the diagnosis and natural history and treatment options. Patient counseled on the need to avoid transmission risk to sexual partners, to abstain from sexual intercourse until they and their partner(s) have been adequately treated. Follow-up: in 2 weeks to 3 months for retesting, earlier if symptoms recur or do not abate.Referral: public health/preventive medicine for education and contact tracing.- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-sti-trichomoniasisDescription: v1.0

CDS Trichomoniasis:- Most infected persons (70%–85%) have minimal or no symptoms, and untreated infections might last for months to years. (CDC, 2015)- The use of highly sensitive and specific tests is recommended for detecting T. vaginalis.Lab wet prep, KOH vaginal fluid

Lab Vaginitis/vaginosis DNA probe vaginal fluid

Lab NAAT for trichomonas vaginal swab or urine



Lab “Syphilis screen”, RPR, or VDRL

Lab HIV serology Med 1st line

options, choose one

metronidazole OR 2 grams single dose avoid alcoholMed Tinidazole

2 g orally once daily for 2 days avoid alcohol

Med Alternative metronidazole

500mg BID for 7 days avoid alcohol

Abbreviation: 2tfp-plan-sti-pidDescription: v1.0

Recommendations/education provided:- Patient diagnosed with Pelvic inflammatory disease (PID) based on clinical findings.

- Patient counseled regarding the diagnosis, natural history, and treatment options including the choice between parenteral and intramuscular/oral treatment regimes.Pending identification of a causative organism, patient counseled on the need to abstain from sexual intercourse until they and their partner(s) have been adequately treated. Referred to ED Follow-up within 72 hours, earlier if symptoms recur or do not abate.Referral: public health/preventive medicine for education and contact tracing as needed- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-sti-pidDescription: v1.0

CDS Pelvic Inflammatory Disease:The decision of whether hospitalization is necessary should be based on provider judgment and whetherthe woman meets any of the following suggested criteria:• surgical emergencies (e.g., appendicitis, ectopic pregnancy) cannot be excluded;• tubo-ovarian abscess;• pregnancy;• severe illness, nausea and vomiting, or high fever;• unable to follow or tolerate an outpatient oral regimen; or• no clinical response to oral antimicrobial therapy.-Intramuscular/oral therapy can be considered for women with mild-to-moderately severe acute PID, because the clinical outcomes among women treated with these regimens are similar to those treated with intravenous therapy. (CDC, 2015)Lab wet prep Lab gram stain Lab C-reactive protein Lab ESR

Lab NAAT for GC/chlamydia

Lab CBC

Med

1st line

option

Ceftriaxone PLUS 250 mg IM in a single doseDoxycycline 100 mg orally twice a day for 14 dayswith or without Metronidazole 500 mg orally twice a day for 14 days

OR

Med

1st line

option

Cefoxitin AND 2 g IM in a single dose

Probenecid PLUS1 g orally administered concurrently in a single dose

Doxycycline 100 mg orally twice a day for 14 dayswith or without Metronidazole 500 mg orally twice a day for 14 days

OR

Med

1st line

option

Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) Doxycycline 100 mg orally twice a day for 14 dayswith or without Metronidazole 500 mg orally twice a day for 14 days

Abbreviation: 2tfp-plan-sti-pediculosispubisDescription: v1.0

Recommendations/education provided:- Patient diagnosed with pediculosis pubis based on symptoms and presence of pubic lice/nits. - Patient counseled regarding the diagnosis and natural history and treatment options. - Patient counseled on the need to avoid transmission risk to sexual partners, to abstain from sexual intercourse until they and their partner(s) have been adequately treated. - Patient counseled to decontaminate bedding and clothing.Follow-up: 1 week for re-evaluation, then as needed if symptoms recur.Referral: public health/preventive medicine for education and contact tracing.- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-sti-pediculosispubisDescription: v1.0

CDS Pediculosis Pubis:Bedding and clothing should be decontaminated (i.e., machine-washed and dried using the heat cycle or dry cleaned) or removed from body contact for at least 72 hours. Fumigation of living areas is not necessary.Persons with pediculosis pubis should be evaluated for other STDs, including HIV.

Med 1st line Permethrin 1% cream rinse applied to affected areas and washed off after 10 minutes

Med2nd line option Malathion 0.5% lotion

applied to affected areas and washed off after 8–12 hours

Med2nd line option Ivermectin

250 μg/kg orally, repeated in 2 weeks

LabHIV AG/AB combo 1/2 screen

Lab“Syphilis screen”, RPR, or VDRL

LabNAAT for GC and chlamydia

Abbreviation: 2tfp-plan-sti-scabiesDescription: v1.0

Recommendations/education provided:- Patient diagnosed with scabies based on clinical presentation. - Patient counseled regarding the diagnosis and natural history and treatment options. - Patient counseled on the need to avoid transmission risk to sexual partners, to abstain from sexual intercourse until they and their partner(s) have been adequately treated. - Patient counseled to decontaminate bedding and clothing and keep fingernails closely trimmed.- Patient advised to have sexual, close personal, or household contacts within the month preceding scabies infestation examined.Follow-up: 1 week for re-evaluation, then as needed if symptoms recur.

Referral: public health/preventive medicine for education and contact tracing.- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-sti-scabiesDescription: v1.0

CDS Scabies:Scabies in adults frequently is sexually acquired, although scabies in children usually is not. (CDC, 2015)

Med

1st line options, choose

one

Permethrin 5% cream OR

applied to all areas of the body from the neck down and washed off after 8–14 hours

Infants and young children should be treated with permethrin

Med Ivermectin

200ug/kg orally, repeated in 2 weeks†

Infants and young children aged <10 years should not be treated with lindane.

Med Alternative

s, choose one

Lindane (1%) 1 oz of lotion OR

applied in a thin layer to all areas of the body from the neck down and thoroughly washed off after 8 hours


Med

Lindane (1%) 30 g of cream

applied in a thin layer to all areas of the body from the neck down and thoroughly washed off after 8 hours


Lab


Lab


LabNAAT for GC and chlamydia

**Other conditions in CDC’s 2015 Guide, but no Plan/CDS built. Let me know if they are needed.Vulvovaginal candidiasis (not an STI so Plan and CDS not done, but can be made if desired)Vaginal Discharge (I could make an abbreviated Plan and CDS for this combining BV, trich, and yeast, but

I’m not sure how exactly they manage it, e.g. is the DNA probe result quick enough to manage the specific condition in the same visit? I think it is, then they would go to the specific diagnosis CDS.)

EpididymitisHPV infectionAnogenital wartsProctitis, proctocolitis, and enteritisSexual assault and abuse and STDs

Abbreviation: 2tfp-plan-sti-anogenitalwartsDescription: v1.0

Recommendations/education provided:- Patient diagnosed with genital anogenital warts based on clinical presentation.

- Patient counseled regarding the diagnosis, natural history, and treatment options including provider or patient administered treatments. Patient counseled on the need to avoid transmission risk to sexual partners, to abstain from sexual intercourse until they and their partner(s) have been adequately treated. Follow-up: 3-4 months for re-evaluation, earlier as needed.Referral: public health/preventive medicine for education and contact tracing.- Patient verbalized understanding of diagnosis, instructions and treatment plan.

Abbreviation: cds-sti-anogenitalwartsDescription: v1.0

CDS Anogenital Warts:Diagnosis of anogenital warts is usually made by visual inspection. -can be confirmed by biopsy, indicated if lesions are --atypical (e.g., pigmented, indurated, affixed to underlying tissue, bleeding, or ulcerated lesions). --the diagnosis is uncertain --lesions do not respond to standard therapy --disease worsens during therapy. HPV testing is not recommended for anogenital wart diagnosis, because test results are not confirmatory and do not guide genital wart management.-No definitive evidence suggests that any one recommended treatment is superior to another, and no single treatment is ideal for all patients or all warts.- Management of cervical and intra-anal warts should include consultation with a specialist.

Patient-Applied:

Med

1st line options,

choose one

Imiquimod 5% creamapplied once at bedtime, three times a week for up to 16 weeks

Med Imiquimod 3.75% creamapplied once at bedtime nightly for up to 16 weeks

MedPodofilox 0.5% solution or gel

applied to anogenital warts twice a day for 3 days, followed by 4 days of no therapy; cycle can be repeated, as necessary, for up to four cycles.

MedSinecatechins 15% ointment

applied three times daily (0.5 cm strand of ointment to each wart) using a finger to ensure coverage with a thin layer of ointment until complete clearance of warts is achieved. This product should not be continued for longer than 16 weeks.

Provider–Administered:

Chemical treatment

1st line options,

choose one

Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80%–90% solution

ProcedureCryotherapy with liquid nitrogen or cryoprobe

Procedure

Surgical removal either by tangential scissor excision, tangential shave excision, curettage, laser, or electrosurgery

Neuro

Abbreviation: cds-neuro-headacheDescription: v.1.0

Headache Eval CDS:Signs and symptoms

Tension-type Migraine Cluster

Location Bilateral Unilateral in 60 to 70%, bifrontal or global in 30%. bilateral in kids

Always unilateral, usually begins around the eye or temple

Characteristics

Pressure and tightness, waxes and wanes

Gradual in onset, crescendo pattern; pulsating; moderate or severe intensity; aggravated by routine physical activity

Pain begins quickly, reaches a crescendo within minutes; pain is deep, continuous, excruciating, and explosive in quality

Patient Appearance

may remain active

prefers rest in quiet dark place

remains active, agitated

Duration 30 min-7 days 4-72 hours 30 minutes to 3 hoursAssociated symptoms

None Nausea, vomiting, photophobia, phonophobia; may have aura (usually visual, but can involve other senses or cause speech or motor deficits)

Ipsilateral lacrimation and redness of the eye; stuffy nose; rhinorrhea; pallor; sweating; Horner syndrome; restlessness or agitation; focal neurologic symptoms rare; sensitivity to alcohol, tobacco

Red Flag Signs and Symptoms in the Evaluation of Acute HeadacheDanger sign or symptom Possible diagnoses TestsFirst or worst headache of the patient’s life

Central nervous system infection, intracranial hemorrhage

Neuroimaging

Focal neurologic signs (not typical aura)

Arteriovenous malformation, collagen vascular disease, intracranial mass lesion

Blood tests, neuroimaging

Headache triggered by cough or exertion, or while engaged in sexual intercourse

Mass lesion, subarachnoid hemorrhage

Lumbar puncture, neuroimaging

Headache with change in personality, mental status, level of consciousness

Central nervous system infection, intracerebral bleed, mass lesion

Blood tests, lumbar puncture,neuroimaging

Neck stiffness or meningismus Meningitis Lumbar punctureNew onset of severe headache inpregnancy or postpartum

Cortical vein/cranial sinus thrombosis, carotid artery dissection, pituitary apoplexy

Neuroimaging

Older than 50 years Mass lesion, temporal arteritis Erythrocyte sedimentation rate, neuroimaging

Papilledema Encephalitis, mass lesion, meningitis, pseudotumor


Rapid onset with strenuous exercise Carotid artery dissection, intracranial bleed

Neuroimaging

Sudden onset (maximal intensity occurs within seconds to minutes, thunderclap headache)

Bleeding into a mass or arteriovenous malformation, mass lesion (especially posterior fossa), subarachnoid hemorrhage


Systemic illness with headache (fever, rash)

Arteritis, collagen vascular disease, encephalitis, meningitis

Blood tests, lumbar puncture, neuroimaging, skin biopsy

Tenderness over temporal artery Polymyalgia rheumatica, temporal arteritis

Erythrocyte sedimentation rate,temporal artery biopsy

Worsening pattern History of medication overuse, mass lesion, subdural hematoma

Neuroimaging

New headache type in a patient with:

Cancer Metastasis Lumbar puncture, neuroimaging

Human immunodeficiency virus infection

Opportunistic infection, tumor Lumbar puncture, neuroimaging

Lyme disease Meningoencephalitis Lumbar puncture, neuroimaging

Criteria for Low-Risk HeadachesAge younger than 30 yearsFeatures typical of primary headachesHistory of similar headacheNo abnormal neurologic findingsNo concerning change in usual headache patternNo high-risk comorbid conditions (e.g., human immunodeficiency virus infection)No new, concerning historical or physical examination findings

Abbreviation: 2tfp-plan-neuro-headache-migraineDescription: v1.0

Recommendations/education provided:Treatment options and plan discussed. Patient informed of value of keeping a headache log to record frequency of headaches as well as aggravating and alleviating factors. Patient informed that the National

Headache Foundation (www.headaches.org) is an excellent resource for headache information. Patient instructed to return to clinic or emergency room if headaches worsen.

Abbreviation: cds-neuro-headache-migraineDescription: v1.0

CDS Acute Migraine Treatment: “Do not use opioids or butalbital for migraine except as a last resort.” -American Academy of NeurologyMild to Moderate ASA, NSAIDs (alternatives: Indomethacin or Tylenol)Severe Triptans are first line (Review cardiovascular and neurologic

contraindications to triptans before use), Combining NSAIDS with triptans is more effective than either alone.Combining metoclopramide (10-20 mg) with other migraine drugs improves their absorption. Patient should be warned of tardive dyskinesia symptoms and review of patient meds should be conducted due to multiple drug interactions.

Nonpharmacologic: Rest in a calm, quiet, dark environment is recommended.

Imaging: Neuroimaging should be reserved only for patients with red flag symptoms or abnormal findings on neurologic exam.

Migraine Prophylaxis:General indication for: >4 Headaches/month, Headaches lasting >12 hours, Failed acute treatment and menstrual migraines. Specifically indicated to reduce risk of neurologic damage in uncommon migraines conditions (e.g. hemiplegic migraine, brainstem aura, or prolonged aura).a. Equal efficacy with: Amitriptyline, one of the beta blockers (metoprolol, propranolol, or timolol), or topiramate. i. Choose based on other symptoms or contraindications (e.g. for patient with HTN use propranolol, for patient with insomnia or depressed mood use amitriptyline). ii. Start prophylaxis drug at lowest possible dose then increase gradually until therapeutic benefit or intolerable SEs.Patient education: Migraines: https://www.aafp.org/afp/2002/1201/p2140.html#National Headache Foundation (www.headaches.org)

Abbreviation: 2tfp-plan-neuro-headache-clusterDescription: v1.0

Recommendations/education provided:Cluster Headaches (Trigeminal autonomic cephalgias)Treatment options discussed. Patient informed of value of managing or avoiding triggers, with an emphasis on smoking cessation, alcohol avoidance, and proper sleep hygiene. Patient informed that the National Headache Foundation (www.headaches.org) is an excellent resource for headache information. Patient instructed to return to clinic or emergency room if headaches worsen.

Abbreviation: cds-neuro-headache-clusterDescription: v1.0

Cluster Headaches CDS:

http://www.headaches.org/


Acute (in office) 100% inhaled O2 if available: nonrebreathing facial mask with a flow rate of at least 12 L/min x 15 min

Acute (home) 1st line: Sumatriptan 6mg SQ (may have slight advantage over other triptans and admin forms)2 nd Line : Intranasal Sumatriptan or Zolmitriptan to CONTRALATERAL side of HA, or Zolmitriptan; 5 mg orally; maximum of 10 mg per day3 rd line: oral ergotamine

Prophylaxis Verapamil at low dose slowly titrated up until at least 240mg/day,Interim (brief) prednisone may be used when starting verapamil to decrease HA frequency during titration. Interim Prednisone dose: 60-100mg daily x 5 days then taper by 10 mg/day until complete.

Imaging: Imaging studies are not routinely recommended and are not helpful diagnostically in the absence of red flags for serious intracranial pathology.Patient education: Cluster Headaches: https://www.aafp.org/afp/2013/0715/p122-s1.html

National Headache Foundation (www.headaches.org)

Abbreviation: 2tfp-plan-neuro-headache-tensionDescription: v1.0

Recommendations/education provided:Treatment options discussed. Patient informed of the value of keeping a headache log to record frequency of headaches as well as managing or avoiding triggers. Proper sleep hygiene advised. Patient informed to limit use of pain relievers to only when necessary as these can cause rebound headaches. Patient instructed that the National Headache Foundation (www.headaches.org) is an excellent resource for headache information. Patient instructed to return to clinic or emergency room if headaches worsen.

Abbreviation: cds-neuro-headache-tensionDescription: v1.0

CDS Tension HeadacheDO NOT use Butalbital or Opioids for Tension Type Headaches

Acute 1st line: NSAIDS (Ibuprofen, ASA, or Naprosyn) at standard doses or Acetaminophen 1000mg are recommended.2 nd line: ASA/Acetaminophen/caffeine preparations

Prophylaxis Amitriptyline; start at lowest possible dose (10-12.5 mg nightly) gradually increase until benefit or intolerable SEs.

Imaging: is not recommended for TTH.Patient education: https://www.aafp.org/afp/2002/0901/p805.html# Rebound headaches: https://www.aafp.org/afp/2004/1215/p2313.html#




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