Review Charts

Medical Abbreviations Glossary of Terms

Patient ID:

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Date of most recent office visit:

Month: Year:

Are you the primary source of care for this patient's gout? (Check "No" if shared with the patient's primary care provider.)
Yes No
If no, who is the primary source of care for this patient's gout?
Cardiologist Emergency physician Internist / Family Medicine Nephrologist Nurse practitioner Orthopedic surgeon Physician assistant Podiatrist Other:

Patient Demographics
Gender:	Male Female
Year of Birth:	19
Race: (Check ALL that apply)	African American/Black	American Indian/Alaskan Native
	Native Hawaiian/Pacific Islander	Asian, Specify:
	Caucasian/White	Other, Specify:
	No Race Specified

Ethnicity:

Hispanic/Latino

Not Hispanic/Latino

Not Documented

1. Does the patient have a diagnosis of gout?

Yes No

1b. How was the diagnosis made? (select all that apply)

Crystal proven
Elevated uric acid
Appropriate clinical picture

1c. When was the diagnosis established?

Month: Year: Not documented

1d. When did you assume care of this patient?

Month: Year:

1e. Does the patient have: (select all that apply)

Gout attacks twice or more per year
Tophaceous deposits
Xray evidence of gout
History of nephrolithiasis
None of the above

2. Which of the following medications from the list below is the patient currently taking?
**optional search / add by:
Select drug name and press ADD to check appropriate box below

Urate Lowering Drug
Uricosuric Agent
	Probenicid (Benemid®, Probalan®)
	Probenecid and colchicine (ColBenemid®, Col-Probenecid®, Proben-C®)

Xanthine Oxidase Inhibitor
	Allopurinol (Lopurin®, Zyloprim®)
	Oxipurinol
Prophylactic Agent (Use for longer than 30 days, not simply for acute attack)
Colchicine
	Colchicine
Non-selective NSAID
	Diclofenac potassium (Cataflam®)
	Diclofenac sodium (Voltaren®, Voltaren XR®)
	Diclofenac sodium with misoprostol (Arthrotec®)
	Diflunisal (Dolobid®)
	Etodolac (Lodine®, Lodine XL®)
	Fenoprofen calcium (Nalfon®)
	Flurbiprofen (Ansaid®)
	Ibuprofen (Prescription: Motrin®, Non-prescription: Advil®, Motrin IB®, Nuprin®)
	Indomethacin (Indocin®, Indocin SR®)
	Ketoprofen (Prescription: Orudis®, Oruvail®, Non-prescription: Actron®, Orudis KT®)
	Meclofenamate sodium (Meclomen®)
	Mefenamic acid (Ponstel®)
	Meloxicam (Mobic®)
	Nabumetone (Relafen®)
	Naproxen (Naprosyn, Naprolan®)
	Naproxen sodium (Prescription: Anaprox®, Non-prescription: Aleve®)
	Oxaprozin (Daypro®)
	Piroxicam (Feldene®)
	Sulindac (Clinoril®)
	Tolmetin sodium (Tolectin®)
Corticosteroid
	Dexamthasone (Decadron®)
	Methylprednisolone (Medrol®, Depomedrol®)
	Prednisone (Deltasone®)
Proton Pump Inhibitor
	Esomeprazole (Nexium®)
	Lansoprazole (Prevacid®)
	Omeprazole (Prilosec®)
	Pantoprazole (Protonix®)
	Rabeprazole (Aciphex®)
Other Gastroprotective Agent
	Misoprostol (Cytotec®)

Diuretic
	Bumetanide (Bumex®)
	Chlorothiazide (Diuril®)
	Furosemide (Lasix®)
	Hydrocholothiazide (Dyazide®, Hydrodiuril®, Maxzide®, Moduretic®)
	Metolazone (Zaroxolyn®)
	Spironolactone (Aldactone®)
ACE Inhibitor
	Benazepril (Lotensin®)
	Captopril (Capoten®)
	Enalopril (Vasotec®)
	Fosinopril (Monopril®)
	Lisinopril (Prinivil®, Zestril®)
	Moexipril (Aceon®)
	Quinapril (Accupril®)
	Ramipril (Altace®)
	Trandolapril (Mavik®)
ARB
	Losartan (Cozaar®)
Salicylate
	Aspirin, acetylsalicylic acid (Non prescription: Anacin®, Ascriptin®, Bayer®, Bufferin®, Ecotrin®)
	Choline and magnesium salicylate (CMT®, Tricosal®, Trilisate®)
	Choline salicylate, liquid only-(Arthropan®)
	Magnesium salicylate (Prescription: Magan®, Mobidin®, Mobogesi®, Non Prescription: Arthritab®, Bayer Select®, Doan's Pills®)
	Salsalate (Amigesic, Anaflex® 750, Disalcid®, Marthritic®, Mono-Gesic®, Salflex®, Salsitab®)
	Sodium salicylate (Available as generic only)
COX-2 selective NSAID
	Celecoxib (Celebrex)
Narcotic Analgesic
	Codeine (Tylenol® #3, T3 )
	Fentanyl (Duragesic®, E-TRANS® Fentanyl)
	Hydrocodone (Vicodin®)
	Hydromorphone (Dilaudid®)
	Levorphanol (Levodromoran®)
	Meperidine (Demerol®)
	Methadone (Dalophine®)
	Morphine sulfate (MSIR®, MS Contin®, Oromorph®, Roxanol®)
	Oxycodone (Oxycontin, Percocet®, Percodan®, Tylox®)
	Oxymorphone (Opana ®)
Other Analgesic (non-opioid)
	Propoxyphene (Darvocet®)
	Tramadol (Ultram®, Ultram® ER, Ultracet®)
Immunosuppressive Agents
	Azathioprine (Imuran®)
	Cyclosporine (Neoral®, Sandimmune®)
	Tacrolimus (Prograf® )

None of the Above

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