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Adult Revolving Fund Pharmacy Prescription Form AMPATH#____patient.medical_record_number Date____encounter.encounter_id 1901Drug Name (tick)1895 Non-ARV Medication Prescription Form Indication (please tick) Sig (Qty per pack) 6042 1896 Analgesic Headache 620Fever 5945Pain 7032 1 TDS 1889 x 3days Ibuprofen 400mg 912 (43) Inflammation (9) Paracetamol 500mg 2 TDS x 3days(18) Headache620Fever5945Pain7032 89 (44) Anti-Infective Amoxicillin 500mg Pneumonia 43 Resp inf 999 Sinusitis 1 TDS x 7days(21) 265 (45) 222 Strep throat 150Other 5622 Erythromycin 400mg Pneumonia Resp inf SinusitisStrep 1 TDS x 7days(21) 272 (46) throatOther GI Infection UTI 55 gonorrhea893 1 BD 1888 x Ciprofloxacin 500mg /chlamydia 6247 5days(10) 740 (47) Typhoid 141 1 BD x 14days(28) Skin infection 79 Pneumonia 43Resp Inf 999Sinusitis 1BD x 7days(14) 222Chlamydia 6247/PID 902→Add Doxycycline 100mg quinolone 95 (48) GI Infection UTI 1 BD x 5days(10) Typhoid 1 BD x 14days(28) Amoxicillin/Clavulanic Pneumonia Resp inf 1 BD x 7 days (14) SinusitisStrep throatOther acid 625mg 450 (57) Coartem (AL) 6282 (67, Malaria123 4 BD x 3 days (24) 68, 69) Mebendazole 100mg Worms199 1 BD x 3 days (6) 244 (49) Albendazole 400mg Worms199 (pregnant patients) 1 OD x 1 (1) 941 (50) Metronidazole 200mg Amoebiasis 124Giardia 2 TDS x 7days (42) 237 (51) 713Anaerobe Trich Apply to affected area Local skin infection Dermoguard cream 2253 # of packs 1 2 3 Anti-inflammatory Asthma 5 Prednisolone 5mg tab 765 (52) PCP with low O2 Sat (<90%) Cardiovascular Medications Enalapril 10mg CCF 1456 HTN 903Kidney Disease 1242 (53) 1886 Diabetes 175 HCTZ 50mg 1243 (54) HTN Gastrointestinal Antacid tab 944 Heartburn 111 GERD 1293 Loperamide 2mg ARV diarrhea Prolonged Diarrhea 429 (55) 5018 Omeprazole 20mg Heartburn GERD 1244 (56) Vitamin Supplementation FerrousSO4 (60mg Fe) Low MCV Anemia 256 (58) Folic acid 257 (70) Multivitamin tab 461 Other 5622 Other 5622 High MCV Anemia Pregnancy 44 Nutritional supplement 1 OD PRN x7days(7) 2 puffs QID PRN(1) 1890 4 BD x 3days(24) 8 BD x 5days, 8 OD x 5 days, then 4 OD x 11days (164) 1-2 prn (6) 1 OD x 7 days (7) 1 TDS x 30 days (90) 1 OD x 30 days (30) 1OD x 30days (30) Ciprofloxacin 500mg Amoxicillin/Clavulanic acid 625mg Coartem (AL) Mebendazole 100mg Albendazole 400mg Metronidazole 200mg Dermoguard cream Non-ARV Medication Prescription Form Indication (please tick) # of packs 1 2 3 Pneumonia Resp inf SinusitisStrep 1 TDS x 7days(21) throatOther Pneumonia Resp inf SinusitisStrep 1 TDS x 7days(21) throatOther GI Infection UTI gonorrhea/chlamydia 1 BD x 5days(10) Typhoid 1 BD x 14days(28) Skin infection Pneumonia Resp Inf 1BD x 7days(14) SinusitisChlamydia/PID→Add quinolone GI Infection UTI 1 BD x 5days(10) Typhoid 1 BD x 14days(28) Pneumonia Resp inf 1 BD x 7 days (14) SinusitisStrep throatOther Malaria 4 BD x 3 days (24) Worms 1 BD x 3 days (6) 1 OD x 1 (1) 2 TDS x 7days (42) Apply to affected area BD Worms (pregnant patients) AmoebiasisGiardiaAnaerobeTrich Local skin infection PCP with low O2 Sat (<90%) Cardiovascular Medications Enalapril 10mg CCFHTNKidney DiseaseDiabetes HCTZ 50mg HTN Gastrointestinal Antacid tab HeartburnGERD Loperamide 2mg ARV diarrhea Prolonged Diarrhea Omeprazole 20mg Heartburn GERD Vitamin Supplementation FerrousSO4(60mg Fe) Low MCV Anemia Folic acid Multivitamin tab Other Other Sig (Qty per pack) HeadacheFeverPainInflammation 1 TDS x 3days (9) HeadacheFeverPain 2 TDS x 3days(18) Antihistamine/Allergy/Asthma/Steroid Chlorpheniramine AllergyItchingRash Folliculitis Salbutamol inh AsthmaDifficulty Breathing Anti-inflammatoryAsthma Prednisolone 5mg tab 2 TDS PRNx5days(30) Doxycycline 100mg ½ OD x 30 days (30) Analgesic Ibuprofen 400mg Paracetamol 500mg Anti-Infective Erythromycin 400mg 1 OD x 30 days (30) Drug Name (tick) Amoxicillin 500mg BD Antihistamine/Allergy/Asthma/Steroid Allergy 142Itching 879Rash Chlorpheniramine 913 512Folliculitis 842 Asthma 5Difficulty Breathing 7225 Salbutamol inh 798 Price (Kshs) Name___________patient.given_name, patient.middle_name, patient.family_name Gender: patient.sex Male Female Prescriber: Clinical Officer Express Care NurseConsultant encounter.provider_id Prescriber Code: _ Prescriber Signature: _______________________ Pharmacy Initials Entered by: _____Dispensed by: ____ High MCV Anemia Pregnancy Nutritional supplement 1 OD PRN x7days(7) 2 puffs QID PRN(1) 4 BD x 3days(24) 8 BD x 5days, 8 OD x 5 days, then 4 OD x 11days (164) 1 OD x 30 days (30) ½ OD x 30 days (30) 2 TDS PRNx5days(30) 1-2 prn (6) 1 OD x 7 days (7) 1 TDS x 30 days (90) 1 OD x 30 days (30) 1OD x 30days (30) Receipt #: ___________________ Adult Revolving Fund Pharmacy Prescription Form AMPATH#____________________________ Date______________ Price (Kshs) Name_____________________________________________________________________________ Gender: Male Female Prescriber: Clinical Officer Express Care NurseConsultant Prescriber Code: ________________ Prescriber Signature: _______________________ Pharmacy Initials Entered by: _____Dispensed by: ____ Receipt #: ___________________