ANTIBIOTIC MICROBIAL CHECKLIST

PATIENT ID.: DRUG ALLERGY: YES / NO

IF YES, PLEASE MENTION:
DIAGNOSIS:

ANTIBIOTIC INDICATED ACCORDING TO NAG: YES / NO

IF NO, PLEASE MENTION REASON (C&S REPORT ETC.):
HISTORY TAKING YES NO
VITAL SIGNS YES NO
PHYSICAL EXAMINATION YES NO
RELEVANT INVESTIGATION YES NO
PHARYNGITIS: STREP SCORE (SCORE >3, ANTIBIOTIC INDICATED)
CHARACTERISTIC SCORE TOTAL SCORE
TEMPERATURE >38oC +1
ABSENCE OF COUGH +1
TENDER ANTERIOR CERVICAL LYMPHADENOPAHTY +1
TONSILLAR EXUDATES OR SWELLING +1
<15 YEARS OLD +1
PATIENT’S AGE
>45 YEARS OLD -1
RHINOSINUSITIS (>3 CAN START ANTIBIOTIC)
NASAL OBSTRUCTION OR PURULENT/ GREENISH NASAL DISCHARGE YES NO
FACIAL PAIN/ HEADACHE/ SMELL DISTUBANCES (AT LEAST 1) YES NO
VAS (PAIN SCORE) 8-10 YES NO
DURATION OF SYMPTOM >5 DAYS YES NO
OTITIS MEDIA PNEUMONIA/ BRONCHITIS
OTALGIA YES NO ACUTE COUGH + SPUTUM YES NO
FEVER >39oC YES NO ABNORMAL VITAL SIGNS YES NO
DURATION >48H YES NO +CREPITATIONS, PLEURAL EFFUSION YES NO
PERFORATED TM (ADULT) YES NO YES NO
ABNORMAL CXR
NOT DONE

URINARY TRACT INFECTION (UTI)

PREGNANT (ASYMPTOMATIC BACTERIURIA) YES NO
URINARY SYMPTOMS >3 YES NO
NITRATE POSITIVE YES NO
UFEME
LEUCOCYTE POSITIVE YES NO
YES NO
URINE C&S IF YES, RESULT:

COMPLICATED UTI YES NO

SKIN & SOFT TISSUE INFECTION

ABSCESS YES NO
IMPETIGO YES NO
CELLULITIS YES NO
OTHER DIAGNOSIS:

YES NO
PUS C&S IF YES, RESULT:

NOTES:

Signature MO: Signature Pharmacist: