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FOLLOW-UP visit _1 Drug x ___________months

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FOLLOW-UP visit _1 Drug x ___________months Powered By Docstoc
					MALE/fNCBP ISOTRETINOIN progress tracker VERSION 4/2009 Today’s Date:____________________ pt. name ________________________
START Age: __________ Weight __________lbs = ________kg Course # _______ Sex:_______ [F: JUSTIFICATION FOR NCBP:                                                                                                                ]
                    ADVISED:                                                                   Physical Exam                                                                     CONSENT
                                                    The patient appears generally healthy, with normal mood and affect: _____YES _____NO
  Patient was counseled and advised of the                                                                                                    ______Treatment options, including doing nothing, were discussed at length with
  following possible adverse effects, appropriate   Examined: __Face __Scalp __Neck __Shoulders __Back __Chest __arms __legs
                                                    Comedonal acne:                 __none         __few      __scattered      __numerous
                                                                                                                                              the patient and parent. They voiced understanding of all risks associated with
  care, and monitoring: (check only those done):
                                                    Inflammatory papules:           __none         __few      __scattered      __numerous     Isotretinoin. Patient agreed to be compliant with therapy and blood tests. Informed
  _____ dry eyes/skin/nose/lips care                                                                                                          consent was completed and signed. At least 25 minutes was spent counseling the
                                                    Nodules or cysts:               __none         __few      __scattered      __numerous
  _____ headaches, visual changes                   skin:                           __dry __oily __red __scarred __rash __normal              patient and parent concerning diagnosis, prognosis, treatment options, contraception,
  _____ D/C vit. A, other acne Tx.                  lips:                           __cracked __ peeling __crusted __normal                   pregnancy, birth defects, inflammatory bowel disease, permanent skeletal & eye
  _____ iPLEDGE program, forms                      corners of mouth:               __cracked __ peeling __crusted __normal                   problems, depression, suicide, iPLEDGE requirements, labs, risks, adverse effects.
  _____ sun and cold wind protection                Painful inflamed cyst(s) persisting > 2weeks: Location(s)_______________________
  _____ depression, suicide                          Dx: V58.69, &         ___Hidradenitis ___Grovers ___Rosacea ___Nodular, cystic Acne, severe and/or resistant to oral antibiotics and topical retinoids
  _____ labs/tests required
  _____ take with fatty meals                        Plan: Rx:         ___brand name only  ___ generic isotretinoin ______mg, disp.#______, take _____/ week
  _____ pseudotumor cerebri                                    Rx: ___fasting Triglycerides, Tot.al Cholesterol, and Hepatic panel
  _____ LASIK, skin fragility                        ______ Trident Dermatology Consent form completed
  _____ sore muscles/joint pain                      ______ Pt registered and confirmed online
  _____ Inflammatory Bowel Disease                   _______ROV in 31+ days                                       The patient was interviewed, examined, and treated by:

Other Dx/Tx:



1 mo.        Date:___________________ pt. STARTED taking isotretinoin: ____/______/_______ , _____MG, #______per week, for ______weeks
                                                                       ___
LABS: TC____________ Triglycerides__________ Hepatic Panel: ____WNL ___abnormal        ___Labs not done   ___Waiting for results
History: Acne is: __no change __better __worse;               __joint/muscle pain __mood disorders __headache __vision change __diarrhea
         other Hx:
Physical Exam
The patient appears generally healthy, with normal mood and affect______________                               Plan: Rx: __ Accutane __generic ______mg, disp. #______, take ________/ week
Examined: __Face __Scalp __Neck __Shoulders __Back __Chest __forearms __arms __legs                            ______Rx Trigl, Tot.Chol., Hepatic panel, HCG
Comedonal acne:         __none      __few    __scattered    __numerous                                         ______ iPLEDGE counseling documented online, pt reminded of program requirements
Inflammatory papules: __none        __few    __scattered    __numerous                                         _____Pt counseled re: serious adverse effects of Isotretinoin, including birth defects, pseudotumor cerebri.
Nodules or cysts:       __none      __few    __scattered    __numerous                                         ____Dx: angular cheilitis. Tx: Rx mupirocin oint. 1 tube, apply tid RFx1
skin:                   __dry __oily __red __scarred __rash __normal                                           ____Dx: dyslipidemia. Tx: pt given type 4 diet, counseled, rx exercise, repeat labs
lips:                   __bleeding __cracked __ peeling __red __crusted __normal                               ____Dx: Gilbert’s dz., R/O hemolysis; PLAN: ordered retic. count, CBC, direct and total bilirubin
corners of mouth:       __bleeding __cracked __ peeling __red __crusted __normal                               ____Dx: dermatitis medicamentosa (“Accutane rash”, arms).
Painful inflamed cyst(s) persisting > 2weeks: Location(s)_______________________                                          PLAN: Rx: triamcinolone cream, 60g, apply to arms BID, 1 refill
Dx:           V58.69, Nodulocystic acne __Hidradenitis __Grovers __rosacea                                     ____Dx:acne cyst. PLAN: IL injection(11900) of 2.5% Kenalog, 0.1cc, 30G syringe
Other Dx/Tx:                                                                                                   _____Counseling confirmed online, pt Qualified to receive Rx, advised of 6-day limit.
                                                                                                               _____ROV in 31+ days




2 mo.                Date:__________________________________                                    Current Dose: 40 mg, #______ per week                                          On isotretinoin for            ______mo.
LABS:          TC____________ Triglycerides___________                   Hepatic Panel: ____WNL ___abnormal                      Labs not done_____               Waiting for results___
History: Acne is: __no change __better                              __worse;       __arthritis ___muscle pain                 __mood disorders               __headache __vision change                       __diarrhea
               :_____________________________________________________________
Physical Exam
The patient appears generally healthy, with normal mood and affect______________                               Plan: Rx: __ Accutane __generic ______mg, disp. #______, take ________/ week
Examined: __Face __Scalp __Neck __Shoulders __Back __Chest __forearms __arms __legs                            ______ Rx Trigl, Tot.Chol., Hepatic panel, HCG
Comedonal acne:           __none     __few     __scattered  __numerous
Inflammatory papules:     __none    __few      __scattered  __numerous
                                                                                                               ______ iPLEDGE counseling documented online, pt reminded of program requirements
Nodules or cysts:         __none     __few     __scattered  __numerous                                         _____Pt counseled re: serious adverse effects of Isotretinoin, including birth defects, pseudotumor cerebri.
skin:                       __dry __oily __red __scarred __rash __normal                                       ____Dx: angular cheilitis. Tx: Rx mupirocin oint. 1 tube, apply tid RFx1
lips:          __bleeding __cracked __ peeling __red __crusted __normal                                        ____Dx: dyslipidemia. Tx: pt given type 4 diet, counseled, rx exercise, repeat labs
corners of mouth:         __bleeding __ fissured __red __crusted __normal                                      ____Dx: Gilbert’s dz., R/O hemolysis; PLAN: ordered retic. count, CBC, direct and total bilirubin
Painful inflamed cyst(s) persisting > 2weeks: Location(s)_______________________                               ____Dx: dermatitis medicamentosa (“Accutane rash”, arms).
Dx:           V58.69, Nodulocystic acne __Hidradenitis __Grovers __rosacea                                                   PLAN: Rx: triamcinolone cream, 60g, apply to arms BID, 1 refill
                                                                                                               ____Dx:acne cyst. PLAN: IL injection(11900) of 2.5% Kenalog, 0.1cc, 30G syringe
Other Dx/Tx:
                                                                                                               _____Counseling confirmed online, pt Qualified to receive Rx, advised of 6-day limit.
                                                                                                               _____ROV in 31+ days



3 mo.                Date:__________________________________                                    Current Dose: 40 mg, #______ per week                                          On isotretinoin for            ______mo.
LABS:          TC____________ Triglycerides___________                   Hepatic Panel: ____WNL ___abnormal                   Labs not done_____                Waiting for results___
History: Acne is: __no change __better                              __worse;       __arthritis ___muscle pain                 __mood disorders              __headache __vision change                        __diarrhea
       Other Hx:
Physical Exam: Patient appears generally well, with normal mood and affect____
Examined: __Face __Scalp __Neck __Shoulders __Back __Chest __forearms __arms __legs                            Plan: Rx: __ Accutane __generic ______mg, disp. #______, take ________/ week
Comedonal acne:           __none     __few     __scattered  __numerous
                                                                                                               ______ Rx Trigl, Tot.Chol., Hepatic panel, HCG
Inflammatory papules:     __none    __few      __scattered  __numerous
Nodules or cysts:         __none     __few     __scattered  __numerous                                         ______ iPLEDGE counseling documented online, pt reminded of program requirements
skin:                       __dry __oily __red __scarred __rash __normal                                       _____Pt counseled re: serious adverse effects of Isotretinoin, including birth defects, pseudotumor cerebri.
lips:          __bleeding __cracked __ peeling __red __crusted __normal                                        ____Dx: angular cheilitis. Tx: Rx mupirocin oint. 1 tube, apply tid RFx1
corners of mouth:         __bleeding __ fissured __red __crusted __normal                                      ____Dx: dyslipidemia. Tx: pt given type 4 diet, counseled, rx exercise, repeat labs
Painful inflamed cyst(s) persisting > 2weeks: Location(s)_______________________                               ____Dx: Gilbert’s dz., R/O hemolysis; PLAN: ordered retic. count, CBC, direct and total bilirubin
Dx:           V58.69, Nodulocystic acne __Hidradenitis __Grovers __rosacea                                     ____Dx: dermatitis medicamentosa (“Accutane rash”, arms).
                                                                                                                             PLAN: Rx: triamcinolone cream, 60g, apply to arms BID, 1 refill
Other Dx/Tx:
                                                                                                               ____Dx:acne cyst. PLAN: IL injection(11900) of 2.5% Kenalog, 0.1cc, 30G syringe
                                                                                                               _____Counseling confirmed online, pt Qualified to receive Rx, advised of 6-day limit.
                                                                                                               _____ROV in 31+ days
4 mo.                                                           Started isotretinoin:
    today’s Date:_________________                                                                        Currently taking: 40 mg, #______ per week, for                                                  ________mo.
LABS:          TC____________ Triglycerides___________ Hepatic Panel: ____WNL ___abnormal           Labs not done_____         Waiting for results___
History:       Acne is: __no change __better __worse;         __joint/muscle pain __mood disorders __headache __vision change __diarrhea
               other Hx:
 Physical Exam
The patient appears generally healthy, with normal mood and affect______________                           Plan: Rx: __ Accutane __generic ______mg, disp. #______, take ________/ week
Examined: __Face __Scalp __Neck __Shoulders __Back __Chest __forearms __arms __legs                        ______Rx Trigl, Tot.Chol., Hepatic panel, HCG
Comedonal acne:         __none      __few    __scattered    __numerous                                     ______ iPLEDGE counseling documented online, pt reminded of program requirements
Inflammatory papules: __none        __few    __scattered    __numerous                                     _____Pt counseled re: serious adverse effects of Isotretinoin, including birth defects, pseudotumor
Nodules or cysts:       __none      __few    __scattered    __numerous                                     cerebri.
skin:                   __dry __oily __red __scarred __rash __normal                                       ____Dx: angular cheilitis. Tx: Rx mupirocin oint. 1 tube, apply tid RFx1
lips:        __bleeding __cracked __ peeling __red __crusted __normal                                      ____Dx: dyslipidemia. Tx: pt given type 4 diet, counseled, rx exercise, repeat labs
corners of mouth:       __bleeding __ fissured __red __crusted __normal                                    ____Dx: dermatitis medicamentosa (“Accutane rash”, arms).
Painful inflamed cyst(s) persisting > 2weeks: Location(s)_______________________                                     PLAN: Rx: triamcinolone cream, 60g, apply to arms BID, 1 refill
Dx:            V58.69, Nodulocystic acne __Hidradenitis __Grovers __rosacea                                ____Dx:acne cyst. PLAN: IL injection(11900) of 2.5% Kenalog, 0.1cc, 30G syringe
Other Dx/Tx:                                                                                               _____Counseling confirmed online, pt Qualified to receive Rx, advised of 6-day limit.
                                                                                                           _____ROV in 31+ days



5 mo.                    today’s Date:_________________                                                              Currently taking:       40 mg, #______ per week, for ________mo.
LABS:          TC____________ Triglycerides___________ Hepatic Panel: ____WNL ___abnormal          Labs not done_____        Waiting for results___
History:       Acne is: __no change __better __worse;         __joint/muscle pain __mood disorders __headache __vision change __diarrhea
               other Hx:
 Physical Exam
The patient appears generally healthy, with normal mood and affect______________                           Plan: Rx: __ Accutane __generic ______mg, disp. #______, take ________/ week
Examined: __Face __Scalp __Neck __Shoulders __Back __Chest __forearms __arms __legs                        ______Rx Trigl, Tot.Chol., Hepatic panel, HCG
Comedonal acne:         __none      __few    __scattered    __numerous                                     ______ iPLEDGE counseling documented online, pt reminded of program requirements
Inflammatory papules: __none        __few    __scattered    __numerous                                     _____Pt counseled re: serious adverse effects of Isotretinoin, including birth defects, pseudotumor
Nodules or cysts:       __none      __few    __scattered    __numerous                                     cerebri.
skin:                   __dry __oily __red __scarred __rash __normal                                       ____Dx: angular cheilitis. Tx: Rx mupirocin oint. 1 tube, apply tid RFx1
lips:        __bleeding __cracked __ peeling __red __crusted __normal                                      ____Dx: dyslipidemia. Tx: pt given type 4 diet, counseled, rx exercise, repeat labs
corners of mouth:       __bleeding __ fissured __red __crusted __normal                                    ____Dx: dermatitis medicamentosa (“Accutane rash”, arms).
Painful inflamed cyst(s) persisting > 2weeks: Location(s)_______________________                                     PLAN: Rx: triamcinolone cream, 60g, apply to arms BID, 1 refill
Dx:            V58.69, Nodulocystic acne __Hidradenitis __Grovers __rosacea                                ____Dx:acne cyst. PLAN: IL injection(11900) of 2.5% Kenalog, 0.1cc, 30G syringe
Other Dx/Tx:                                                                                               _____Counseling confirmed online, pt Qualified to receive Rx, advised of 6-day limit.
                                                                                                           _____ROV in 31+ days




6      mo.              today’s Date:_________________                                                                Currently taking:       40 mg, #______ per week, for ________mo.
LABS:          TC____________ Triglycerides___________ Hepatic Panel: ____WNL ___abnormal           Labs not done_____       Waiting for results___
History:       Acne is: __no change __better __worse;         __joint/muscle pain __mood disorders __headache __vision change __diarrhea
               other Hx:
 Physical Exam
The patient appears generally healthy, with normal mood and affect______________                           Plan: Rx: __ Accutane __generic ______mg, disp. #______, take ________/ week
Examined: __Face __Scalp __Neck __Shoulders __Back __Chest __forearms __arms __legs                        ______Rx Trigl, Tot.Chol., Hepatic panel, HCG
Comedonal acne:         __none      __few    __scattered    __numerous                                     ______ iPLEDGE counseling documented online, pt reminded of program requirements
Inflammatory papules: __none        __few    __scattered    __numerous                                     _____Pt counseled re: serious adverse effects of Isotretinoin, including birth defects, pseudotumor
Nodules or cysts:       __none      __few    __scattered    __numerous                                     cerebri.
skin:                   __dry __oily __red __scarred __rash __normal                                       ____Dx: angular cheilitis. Tx: Rx mupirocin oint. 1 tube, apply tid RFx1
lips:        __bleeding __cracked __ peeling __red __crusted __normal                                      ____Dx: dyslipidemia. Tx: pt given type 4 diet, counseled, rx exercise, repeat labs
corners of mouth:       __bleeding __ fissured __red __crusted __normal                                    ____Dx: dermatitis medicamentosa (“Accutane rash”, arms).
Painful inflamed cyst(s) persisting > 2weeks: Location(s)_______________________                                     PLAN: Rx: triamcinolone cream, 60g, apply to arms BID, 1 refill
Dx:            V58.69, Nodulocystic acne __Hidradenitis __Grovers __rosacea                                ____Dx:acne cyst. PLAN: IL injection(11900) of 2.5% Kenalog, 0.1cc, 30G syringe
Other Dx/Tx:                                                                                               _____Counseling confirmed online, pt Qualified to receive Rx, advised of 6-day limit.
                                                                                                           _____ROV in 31+ days



7 mo. Today’s Date:____________________                                                                             Currently taking: 40 mg, #__________ per week.                On isotretinoin for ______mo.
History:    Acne is: __no change __better __worse;       ROS:    _____joint/muscle pain __mood disorders __headache __vision change __diarrhea
other ROS/Hx negative except:___________________________________________________________________________________________________________________________________________________
Physical Exam:                                                                          Dx: V58.69,& ___Nodulocystic acne              __Hidradenitis __Grovers __rosacea ______________
The patient appears:   ____ generally healthy ____normal mood and affect                        PPlan: Rx: __ Accutane __generic ______mg, disp. #______, take ________/ week
Areas Examined: __Face __Scalp __Neck __Shoulders __Back __Chest __arms __legs
Comedonal acne:                   __none     __few     __scattered  __numerous                  ______Rx Trigl, Tot.Chol., Hepatic panel, HCG
Inflammatory papules: __none        __few     __scattered   __numerous                          ______ iPLEDGE counseling documented online, pt reminded of program requirements
Nodules or cysts:                 __none     __few     __scattered  __numerous                  _____Pt counseled re: serious adverse effects of Isotretinoin, including birth defects, pseudotumor cerebri.
skin:                             __dry __oily __red __scarred __rash __normal                  ____Dx: angular cheilitis. Tx: Rx mupirocin oint. 1 tube, apply tid RFx1
lips:                             __cracked __ peeling __red __crusted __normal                 ____Dx: dyslipidemia. Tx: pt given type 4 diet, counseled, rx exercise, repeat labs
corners of mouth:                 __cracked __ peeling __red __crusted __normal                 ____Dx: dermatitis medicamentosa (“Accutane rash”, arms).
Painful inflamed cyst(s) persisting > 2weeks: Location(s)_______________________
                                                                                                           PLAN: Rx: triamcinolone cream, 60g, apply to arms BID, 1 refill
Other Dx/Tx:                                                                                    ____Dx:acne cyst. PLAN: IL injection(11900) of 2.5% Kenalog, 0.1cc, 30G syringe
                                                                                                    ______Counseling conf. on internet                         _______ROV in 31+ days

____STOP isotretinoin ___COMPLETED COURSE ___NO Rx GIVEN for isotretinoin
____Pt advised not to get pregnant for the next 2 months;     _____ NO Rx given _____ Rx Differin 0.1% Cream, 45g, apply to face Qhs, R4; ____iPLEDGE updated
____Pt reminded no elective surgery (including LASIK) for 6 months                   _____ pt reminded to avoid sun exposure. ____ROV 1 month, 6 months, & PRN

				
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posted:10/16/2011
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