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Contents

Resp ....................................................................................................................................................... 3
Asthma .............................................................................................................................................. 7
COAD .................................................................................................................................................. 8
Suspected bronchiectasis .............................................................................................................. 8
Bronchopneumonia ........................................................................................................................ 8
Pulmonary Embolism ..................................................................................................................... 9
Drugs.................................................................................................................................................. 9
Cardiology ............................................................................................................................................... 3
Stable Angina ................................................................................................................................... 3
AMI ..................................................................................................................................................... 4
APO..................................................................................................................................................... 4
Arrhythmia ....................................................................................................................................... 4
New Onset AF ............................................................................................................................... 4
SVT ................................................................................................................................................. 4
Infective Endocarditis .................................................................................................................... 5
CCF...................................................................................................................................................... 5
Uncontrolled Hypertension .......................................................................................................... 5
Hypertension ................................................................................................................................... 5
CRHD- tooth extraction .................................................................................................................. 5
Drugs.................................................................................................................................................. 3
Renal .................................................................................................................................................... 10
Acute Renal Failure....................................................................................................................... 10
Chronic Renal Failure ................................................................................................................... 11
Nephrotic Syndrome..................................................................................................................... 11
Electrolyte Disturbances ............................................................................................................. 11
Hypokalaemia ............................................................................................................................ 11
Hyperkalemia ............................................................................................................................ 11
Na.................................................................................................................................................. 12
Hypocalcemia ............................................................................................................................. 12
Infectious Ds.......................................................................................................................................... 12
Suspected Dengue ............................................................................................................................ 12
TB ...................................................................................................................................................... 15

Neuro .................................................................................................................................................... 15
Stroke ................................................................................................................................................ 15
Fits ..................................................................................................................................................... 15
Status Epilepticus .............................................................................................................................. 16
Acute psychosis ................................................................................................................................. 17
Endrocrine ............................................................................................................................................. 17
Hypoglycemia .................................................................................................................................... 17
Diabetes ............................................................................................................................................ 17
DKA................................................................................................................................................ 18
HONK ............................................................................................................................................. 18
Thyroid .............................................................................................................................................. 19
Hyperthyroid ................................................................................................................................. 19
Thyroid Storm ............................................................................................................................... 19
Hypothyroid ...................................................................................................................................... 19
Myxoedematous Coma ................................................................................................................. 19
Hypothyroidism................................................................................................................................. 19
Serious Metabolic Acidosis: pH<7.1, HCO3<10 mmol/L ....................................................................... 19
Hematology ........................................................................................................................................... 20
Warfarin Overdose............................................................................................................................ 20
Drug & blood reaction .......................................................................................................................... 20
Anaphylaxis ....................................................................................................................................... 20
Hypersensitivity ................................................................................................................................ 20
Ix ............................................................................................................................................................ 21
Drugs ..................................................................................................................................................... 22
ABx .................................................................................................................................................... 22
Sxmatic Relief .................................................................................................................................... 23
Procedures ............................................................................................................................................ 24
PD ..................................................................................................................................................... 24
CVP ........................................................................................................................................................ 24
Documentation ..................................................................................................................................... 24
Pronouncing Death ........................................................................................................................... 24

Cardiology

MAP= 1/3 SBP + 2/3 DBP


If pt on aspirin develop epigastric pain, change to cardiprin. !UGIB

Entry criteria:UA or NSTEMII c as ischemic pain at rest within past 24H, with evidence of CAD (ST segment
deviation or +marker)

UA
Normal CE
Clexane X3/7, BD. OD if Creat
clearance<30
OR Fundaparinox X3/7
2.5mg OD
Aspirin 300 mg stat, 150mg OD
EST
Refer cardio

NSTEMI
STEMI
Incr CE
STE
Clexane X5/7 OR Fundaparinox X5/7
Plavix (clopidogrel) 300 mg stat, 75 mg OD
Aspirin 300 mg stat, 150mg OD

Streptokinase (first 12 H)
1.5 Mu in 100cc NS in 1 H
T/O CRU

IV heparin if poor renal function


IV GTN if persistent chest pain: 10 mg in 50cc NS, run @ 3cc/H. !CI by low BP

Stable Angina
Dx: CE normal, no ECG changes, CP w high risk factors
1.
2.
3.
4.

Ix: CE X3, Serial ECG X3, ECG stat if CP


T. aspirin 150 mg OD
T. Isordil 10mg TDS
T. Ticlid 250mg BD

Unstable Angina:
1.
2.
3.
4.
5.
6.
7.
8.

T.Aspirin 300 mg stat & 150 mg OD. T.cardiprin 100 mg OD if got gastritis.
S/C clexane 0.1mg/10 kg BD X3/7. S/C Funda 2.5 mg OD
liq paraffin 15 mls TDS
T. alprazolam 0.25 mg ON
T. Lovastatin 20 mg ON
3L NP O2
CRIB
KIV ACE inhibitor( if BUSE normal) or beta blocker (target HR 50-60, bisoprolol or metaprolol
50mg BD)
9. IX
a. Serial ECG + CE (X3)
b. Daily PT/INR/APTT
c. FBC, RP/LFT,CE, RBS, Coags. FBS, FSL
d. UFEME
e. Echo, CXR

AMI

Aspirin 300 mg stat & 150 mg OD


T. Plavix 300 mg stat & 75 mg ON
T. alprazolam 0.25 mg ON
GTN: S/L GTN 1/1PRN
IV morphine 2.5 mg stat & PRN
IV Maxalon 10 mg stat
IV ranitidine 50 mg TDS
Face mask 5L O2
T. Lovastatin 20 mg ON
With cardiogenic shock:
o IV Dobutamine 500mg in 50cc NS run 3cc/H IV dopamine IV dobutamine
o NBM w IVD 2 pint NS

APO
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

CXR-cardiomegaly, kerly A&B


Serial ECG/CE X3
ABG
IV Lasix 40mg stat & OD/BD/TDS
Strict I/O: CBD,CVP (can use condom catheter)
Fluid restriction 1L/day
(if creps present) Neb Combivent stat, 1/2Hly X2, 2Hly X2, 4Hly
Prop up
O2 5-10L/min
T.aspirin 150mg OD
T. Ticlid
KIV ACE inhibitor (if RP normal)

Arrhythmia
New Onset AF
Acute Mx

IV amiodarone 300mg in 50cc NS over 1H, followed by 500mg in 1 pint D5% run over
23H WITH cardiac miotoring
IV Digoxin 0.25 mg in 50cc ND over 1H
Digoxin PO 0.5mg BD, 0.125-0.25mg OD.
Keep K>4.0

SVT
? carotid massage
IV adenosine 6mg

IV adenosine 12 mg X2 (2 min interval)

IV verapamil 5-10mg over 2 min (if not on B blocker)


OR IV atenolol 2.5mg (@ 1mg/min)
SVT, AF- 50-100J synchronize
VT w pulse: IV lignocaine 20% 50-100mg
VT pulseless (hemodynamically unstable): 360J CPR
Torsades de pointes: IV Ca Gluconate

Infective Endocarditis

Cardinal signs: fever, hematuria, splenomegaly, murmur


Mx

IV C-pen 4 Mu X4/52
IV Gentamicin 80mg TDS X2/52, 240mg OD

CCF

1.
2.
3.
4.
5.
6.
7.
8.

Causes: MADHATEN- MI, Anemia, Drug noncompliance, HPT, Antithyroid, Thyrotoxic,


Ethanol, Right Heart Failure.
IV Lasix 40mg stat then OD/BD
Prop up pt
Fluid restriction 800cc /day or 500cc/day
Strict I/O
O2 if needed
Chest physio
Neb Combivent if SOB
+ACE inhibitor, digoxin, spironolactone

Uncontrolled Hypertension

IV GTN (50mg in 50 cc NS @ 3cc per hour)


CRIB
VS 2 Hly
Strict IO
Antihypertensive: T.Captopril
KIV for aspirin/ticlid
Allow orally, low salt diet
BP Hly

Hypertension

Exclude urgency, emergency


If not compliant, use old medications
Rpt BP in 1H: If still high: IV GTN 10 mg in 50cc NS at 3cc/H
BP 2 Hly and titrate accordingly

CRHD- tooth extraction


1.
2.
3.
4.
5.

Withold warfarin
IV Heparin 25000 u in 50 cc NS, run @ 2cc/H
IV Unasyn 1.5g (1H pre and 6H post etraction)
Withold IV Heparin 2H prior to extraction
Restart T warfarin/Heparin 6H post extraction if no bleeding

6. TCA 2/12
7. Ref warfarin to 1.5mg post tooth extraction
8. T Lasix 20mg OD

Drugs
ACE inhibitor

perindropril (Coversyl)

T. 2/4/ 8mg OD

Enalapril
Captopril

2.5/5/10 mg BD
6.25mg TDS
12.5 mg BD/TDS
18.75mg TDS
25mg BD/TDS
50mg TDS
2.5mg BD
10 mg OD
1/10 mg BD
Max 6mg TDS

Ranipril
Alpha blocker

ARB

Beta blocker

Prazosin

Doxazosin
Irbesartan
Losartan
(Cozaar/Hzaar)
Telmisartan (micardis)
Valsartan (diovan)
Metoprolol (betaloc)
Propanolol

1/16 mg OD
150/300 mg OD
50mg OD
100 mg OD
20/40/80 mg OD
30/50/80/160 mg OD
50/100 mg BD
200mg OD
20/40/80 320 mg/
BD

bisoprolol

Beta and alpha2 blocker

Atenolol
Carvedilol (cardioselective)
Betaprolol
Labetolol
Carvedilol

CCB

Amlodipine
Nifedipine
Diltiazem
Filodipine

Centrally acting

Methyldopa

Diuretics

HCTZ
Lasix

CI: Renal artery


stenosis
AR:Gi disorder,
dizziness, headache

CHF due to
mechanical
obstruction

cardioselective

Not absolutely CI in
COPD
50/100 mg OD
3.125/6.25mg BD
10/40 mg OD
100mg BD
800 mg TDS
12.5 mg OD
50mg OD
5/10 mg OD
10/30mg TDS
30/60 mg TDS
T. 5mg BD
T. 10mg OD
125/250 mg BD/TDS
Max 1g TDS
T. 25mg OD
Max 200mg OD
T. 20/40 mg OD/BD

hepatotoxic

Spiranolactone
Lovastatin
Simvastatin
Atorvastatin
Pravastatin
Gemfibrozil (brand
name- Lopid)

Lipid lowering

T. 25mg OD
T. 20/40 mg ON
T. 20/40 mg ON
T. 20/40 mg ON
T. 20/40 mg ON
T. 300mg

Active liver disease

Inotropes
Dopamine

20 mcg/kg/min
Single strength: 200 mg in 50 cc NS
400mg in 50cc NS at 72cc/H

Dobutamine

250 mg in 50cc
500 mg in 500cc run 3cc/H
Initial: 0.5-1.0 mcg/kg/min
Maintenance 2.5-20 mcg/kg/min
Max 40 mcg/kg/min, up to 20cc/H
4mg in 50cc
8mg in 50CC
0.005-0.5 mcg/kg/min, up to 20 cc/H

Noradrenaline

Indication: non hypovolemic


shock
CI: tachyarrhythmia, VF,
pheochromocytoma
Indication: hypotension, heart
failure
Cardiogenic shock

Indication: septic shock where


peripheral vascular resistance is
low

Resp

PEFR children (ht in cm-100) X5, then +100


PEFR Men [( htX5.48+ 1.58) - (ageX0.041)] X60
PEFR women [(htX3.72 +0.24) (age X 0.03)] X60
NP 3L

VM 28 35 50%

HFM 10 15 L/min

Intubation
*if CO2 retention- max VM 28%

Asthma
1. Ix: FBC, RP, Coags, ABG, GM, RBS, Sputum C&S, CXR, ECG if >40,
a. CXR: hyperinflated lung when R>5th rib, L> 6th rib. Sulcus widened, flattened
diaphragm
2. Prop up pt
3. Neb combivent 4Hly
4. Neb Pulmicort 1mg BD/TDS

5.
6.
7.
8.
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10.
11.
12.
13.
14.
15.

IV Hydrocortisone 100mg QID X1/7 then T.Prednisolone 30mg OD X5/7


MDI Budesonide 400mg BD
MDI Berodual 2/2 TDS
O2 3L NP
PEFR chart BD
V/S 4Hly, keep SpO2>95%
Check inhaler technique
Chest physio
T.Bisolvent 8mg TDS
Pneumonia: Augmentin/EES
If not improving: IV Aminophylline or T.Neulin 2/2 or 1/1 TDS

COAD
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Ix: FBC/BUSE/Coags/RBS, ABG, Sputum C&S, CXR


Neb combivent 4Hly
Neb ventolin 2 Hly if severe (alternate w neb combivent)
IV hydrocortisone 100mg QIDX1/7
Neb Pulmicort 1mg BD/TDS
O2 3L NP
MDI Budesonide 400 mg BD
MDI Berodual 2/2 TDS
Check inhaler technique
PEFR chart
If no improvement, (d/w MO) KIV for IV Aminophylline 250mg/500mg in 50 cc NS over 24H
AND T. Neulin

Suspected bronchiectasis

1.
2.
3.
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6.
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9.
10.

Persistent cough, copious purulent sputum, intermittent hemoptysis


Signs: clubbing, coarse insp cresp, wheeze
Ix: FBC, BUSE, LFT, ESR, ABG, ECG, Mantoux, Sputum AFBX3, Sputum C&S
IV Unasyn 1.5g TDS
T. EES 800mg BD
O2 3L NP
CRIB
Neb A:V:N 2:1:2 if worsening (atrovent, ventolin, NS)
MDI Combivent 2 puff TDS
Postural drainage later
Chest physio

Bronchopneumonia

A/B options:
o IV Unasyn 1.5g TDS+ T.EES 820 mg QID
o IV Augmentin 1.2g TDS + T.EES 820 mg QID
o HCAP: IV Tazosin 4.5mg stat & TDS, or renal dose 2.25 mg TDS
T.PCM 1g TDS
Tepid sponging

Decongestant:
o T. Piriton 4mg TDS
CAP: strep pneumonia, moxarella
HAP: G-ve, Klebsiella, Enterobacter, Pseudomonas, ACBC ESBL. 3rd-4th line: cefipime, tienam,
imipenem
A/B choice
o 1st line: Augmentin w EES
o 2nd line: Unasyn, cefuroxime, augmentin
o 3rd line: fortum, cefobid

Pulmonary Embolism

Ix
o ABG: hypoxia, hypocapnia
o ECG: SI, Q III, T III. Sinus tachycardia, RBBB, R ventricular strain, RAD
o D dimer
o CXR
o Spiral CT
O2 supplement
Prop up pt
Heparin infusion

Drugs
Anticholinergic

Atrovent (Ipatropium)

Short acting B
agonist

Ventolin
Respolin (salbutamol)

2 puff PRN

Long acting B
agonist

Serevent (salmeterol)

2 puff TDS

Long acting
anticholinergic
steroid
Combo

Spiriva (Tiotropium)
Budesonide (inflammide)
Combivent (Ipatropium
+albuterol)
Seretide (salmaterol &
fluticasone)

2 puff TDS/PRN

Renal
Creatinine clearance Cockcroft-Gault formula

0.88 if male
Normal F95, M120

Acute Renal Failure


Dx: rapidly rising Urea and creat, oliguria (U/O <400mLs/day or <30 mLs/H)
Urinary profile in prerenal/renal failure

Sediment
Specific Gravity
Na
Fractional excretion of Na
U:P Urea
U:P Creatinine
U:P osmolality
Osmolality

Mx

Prerenal
N
>1.020
<20 mmol/L
<1%
>20
>40
>1.2
>500

Renal
Tubular cell/cast/granular cell
1.010-1.012
>40
>1%
<10
<20
<1.2
<400

Ix:
o FBC, RP, Ca/Alb/PO4, FBS
o ABG (acidosis)
o UFEME, Urine C&S, Urinary profile
o ECG (hyperK)
o USG KUB
o CXR TRO Pedema
Fluid restriction 800cc/day (oliguric ARF). In prerenal cause- fluid replacement
Strict IO
KIV PD if urea increase
Tx hyperkalemia
Dietary advice: low protein and postassium diet
Fluid challenge: 250 cc NS over 15 mins. If BP not improved or CVP does not increase by 2
cm, rpt fluid challenge (up to 500-1000cc)
Keep CVP 5-10 cm
Scenario
o Good BP and U/O: fluid for maintenance
o Volume restored, low BP= inotrope
o Volume restored, BP good, U/O poor- IV frusemide. If not improving w frusemide
and inotropes, fluid restriction 500cc /d

Chronic Renal Failure

Indications for dialysis


o Urea>30, Creat >300
o K>6
o HCO3<10, Severe metabolic acidosis-pH<7.1
o Volume overload, pulmonary edema unresponsive to diuretics
o Uremic sx:
Uremic encephalopathy: asterixis, neuromuscular irritability, somnolence,
sleepiness, drowsiness, coma, seizure
GI: N&V, Hrage,
Stages:
o Mild: GFR 30-50, moderate 10-29, severe <10, ESRF <5

Nephrotic Syndrome

Ix:
o
o
o
Plan
o
o
o
o
o
o
o
o
o

FBC, RP, LFT, ESR


UFEME, 24H urine protein & Creatinine clearance
Screening: CT Screen (C3, C4, ASOT, ANA, anti dsDNA, Rh factor, ANF). Throat swab
Nephrotic chart
Daily urine albumin, daily UFEME
BP monitoring- 4Hly V/S
Thymol Gargle (if sore throat)
Prop up pt
ROF 1L/d
T. Lasix 40 mg OD
For USG KUB later
High protein diet

Electrolyte Disturbances
Hypokalaemia
Fast correction
o 1g KCL in 100cc NS over 1 H
o Max 1.5g KCl in 100cc over 1H
o Repeat BUSE 1H post correction
BEWARE fast correct in ESRF pt!!
Hyperkalemia

Dx
1. Sx rare: muscle weakness, abd distension, diarrhea
2. ECG: tall T wave flatten P wave widened QRS sine wave VF/Asystole
3. Cause
a. Renal failure: dialysis
b. Drug induced: ACE inhibitor,
c. Acute adrenal insuff: long term prednisolone + stress. IV NS +IV hydrocortisone
100mg 6 Hly

d. Acidosis: tx cause of acidosis, consider IV NaHCO3 1mmol/g over 5 mins

Mx
1. 5-6: oral kalimate 5/10/15 g TDS. Stop when K<5.0
2. If K>7 OR K>6 AND QRS widening, give cocktail
3. Cocktail:
a. IV 50cc D50% (bolus, over 5min) +IV Actrapid 10 u
b. 10cc IV Ca Gluconate 10% (1-2 amp) over 5-10 mins w ECG monitoring
c. Repeat ABG, KIV resonium A
4. (If expected persistent hyperK-RF, crush injury), Resonium A 15g TDS
5. IV NaHCO3 1mmol/kg over 5 min (caution: fluid overload)
6. Perform dialysis
Na
Requirement: 1-2mmol/kg/d
Na maintenance= (2XBW)/ 177
Na deficit = (140-Na) X 0.6 (young) or 0.5 (old) X BW, divide by 17.7
1 pint= 150 mmol/L
Mist NaCl= 1g/5ml, 1ml=3.5 mmol
Correct < 12 mmol/24H
00
Hypocalcemia
Fast correct
o IV 20cc 20% Ca gluconate over 20 min
o IV 10cc 10% Ca gluconate over 10 mins
ECG: Prolonged QT, corrected QT =QT/square root of RR. Normal 0.38-0.42

Infectious Ds
Suspected Dengue

DF

Warning signs: incr Hct/decr PC, fluid accumulation(PEffusion/ascites), abdominal pain,


persistent vomiting, tender hepatomegaly, mucosal bleeding, restlessness/lethargy,
WHO definition: ALL of
o Continuous high grade fever 2-7 days
o Hragic diathesis OR +ve tourniquet test OR shock
o PC<100
o Hct (>20% to baseline) OR evidence of plasma leakage
Course: incubation 4-7D, febrile D1-3, critical D4-5, recovery D6-10
Hct: F>40%, M>46%
Hess test: BP cuff between SBP & DBP 5 mins, >20 petechiae/2.5cm2 area
Thrombocytopenia + leukopenia
+warning signs

DHF
DHF w compensated shock
DHF w decompensated shock

Thrombocytopenia + Hct
+ warning sign
Normal BP
Systolic hypotension

WHO grading

DF: Hct normal, thrombocytopneia


DHF: thrombocytopenia, Hct
Grade 1: positive Hess test
Grade 2: spontaneous bleeding
Grade 3: compensated shock (rapid weak pulse, pulse pressure<20mmHg)
Grade 4: uncompensated shock (hypotension)

1.
2.
3.
4.
5.

FBC OD if PC>100, BD if 60-100, TDS if 50-60, QID if 30-50,


Tx Platelet if <20
BUSE/ LFT/CE, Coags, PR/INR/APTT, UFEME (hematuria), GSH
Dengue serology, PCR, virus protein
CXR if SOB

Muar Med sign: fundoscopy-retinal hrage, bleeding (epistaxis, petchechiae, rash), jaundice,
arthralgia/myalgia, headache, retro-orbital pain.

Complete Dx: DHF grade x, Day x of illness, x phase, x hours of defeversence with/without
warning signs or organ impairment, with (compensated) shock

1.
2.
3.
4.
5.
6.

Enc fluid intake


Inform if bleeding tendencies, PC< 20, BP<90/60
Notify case
VS 4Hly
If menses: T.provera 10mg OD
!! DO NOT GIVE RANITIDINE OR MAXOLON- mask sx

Fluid mx

Ix

Mx


Dengue CME question
1. Severe Dengue, D4 illness, compensated shock, with warning signs, critical phase
2. How to manage Ht 153.4 kg Wt 68 kg
a. Ideal body weight
b. Run fluid bolus 5-10cc/kg NS over 1H
c. Refer GA
d. Dengue serology
3. Why the above regime
a. Fluid resuscitation for compensated shock
4. How soon to repeat FBC
a. Right after finishing bolus
b. To decide if require further fluid resuscitation
5. HR 118 BP 100/86Hct 47
a. Inadequate fluid resuscitation
b. Repeat bolus 5-10cc/kg NS over 1H
6. Hct 38 BP 92/76. Imp and mx
a. Decompensated shock
b. Suspect bleeding tendencies
c. Blood transfusion: WB or PC
d. Further fluid bolus
7. Warning sign

8. Hct

TB

If started tx: sputum Ogawa, sputum Bactec


Notify PHI
Fill in TB form
TB counselling
Eye assessment
Hemoptysis chart
3L NPO2
Contact tracing
TB w/up

Anti TB regime

Isoniazide
Rifampicin
Pyrazinamide
Ethambutol
Streptomycin

Daily dose
Mg/kg
5-8, recom 5
10-15recom 10
20-40, recom 25
15-25, recom 20
15-20

Max (mg)
300
600
1500
1200
1000

Biweekly dose
Mg/kg
15-20
15-20
50
50
15-20

Max (mg)
1200
600
3000
2000
1000

Pyroxidine 10 mg OD

Neuro
Stroke

1.
2.
3.
4.
5.
6.
7.
8.

Ix: FBC, RP RBS, FSL, Ca/Mg/PO4/Alb, Coags, ESR, ECG, Echo (if have ht problem), KIV CT
brain, CXR (TRO aspiration pneumonia).
Withhold all antiplatelet until CTBrain
BP: keep MAP<130
NBM (depends on gag reflex), with IV ranitidine 50 mg TDS
RT (if no gag reflex)
IVD 3 pint NS/24 H
Limb/chest physio
KIV IV GTN
GCS Chart 2-4 Hly, inform if GSC drop, for urgent CT brain
4 Hly positioning
Ripple mattress (if bed bound)

Fits
Breakthrough Seizures

Causes:
o Missed dose, incorrectly timed dose, incorrect dosage
o Switching meds
o Sleep deprivation
o Stress
o Alcohol/drug use
o Menses
o Acute illness: esp vomit/diarrhea decreases drug absorption

Mx
1. IV Phenytoin loading dose: 750 mg in 100cc NS over 1H, maintenance 100mg TDS, then T.
Phenytoini 300 mg ON
2. IV Diazepam 5mg PRN
3. Fit chart
4. NBM
5. GCS chart
6. (If Focal)- KIV CT brain
7. T. Folate 5mg OD

Status Epilepticus
Dx
1. Seizures lasting >15 mins OR multiple seizure episode without regaining full consciousness in
between
Mx
1. RBS/GM, FBC, RP/LFT, Ca, Mg, Alb, ABG. KIV toxicology/drug level
2. Emergency Mx:
a. Protect airway: roll pt to lateral position.
b. Take V/S & GM, tx hypotension/arrhythmia/hyperthermia
c. IV Diazepam 5-10 mg stat, repeat every 5 min (MAX bolus 40 mg)
3. (If required): IV Diazepam infusion- 30 mg Diazepam in 500 NS or D5% run over 8H (MAX 100
mg /day)
4. IV Phenytoin loading dose 750 mg/100cc NS over 1H Followed by IV Phenytoin 100mg bolus
every 6-8H
a. (15-18 mg/kg eg. 750-1000 mg in 100cc NS over H
b. under ECG & BP monitoring: wo arrhythmia
5. If seizure persist w phenytoin loading dose,
a. IV phenobarbitone 10mg/kg eg. 600mg over 10min
b. If persist: IM Paraldehyde 5100mL OR IV Lignocaine 50 mg KIV followed by 50100mg in 250cc D5% over 1H
c. If persist: refer GA

6. KIV ventilation if spont resp inadequate (pO2 <80 mmHg, CO2 retention)
7. Find cause
a. Electrolyte, acid base imbalance
b. Hypoglycemia- IV D50% 50cc
c. Cerebral hypoxia: O2, CPR, ventilation
d. Uremic encephalopathy- dialysis
e. Hypertermia:
f. Hypertensive encephalopathy- IV Nitroprusside/labetolol/hydralazine
g. Drug overdose
h. Infection-meningitis
8.
9.
10. l

Acute psychosis

IM Clopixel Acuphase 100mg Stat,


o Repeat again 100mg on D2 (if pt still psychotic), D3 (if not psychotic)
o KIV repeat again 50-100mg 2 day after last dose
+ Diazepam for sedation

Endrocrine
Hypoglycemia

GM<2.8
50cc D50 bolus, GM 1H post dose, then 4Hly GM
IVD 2 pint D10%, adjust accordingly
Search for cause
o OFF insulin & OHA
o If no cause- do RBS
If GM high 1H post bolus
o Gh GM before cutting downDO NOT give IV actrapid
o If on IVD- cut down.
o If not on IVD- rpt GM in 1H. Allow 2-3X

Diabetes

Dx Criteria
Normal
<5.6
<6.1

Asx pt
FPG

Target:

>5.6
6.1-6.9 OGTT
> 7.0 FPG

o
o
o
o
o
Drugs

FBS
HbA1c
TG
HDL
LDL

Biguanide

: 4.4-6.1
: <6.5
: <1.7
: >1.1
: <2.6

Acarbose: 50 mg OD
MTF 500 mg OD-TDS, max 1000 mg BD

sulphonylurea

Diamicron (Gliclazide): 40-80 mg OD, max


160 mg BD
Diamicron MR: 120 mg OD
Daonil (Glibenclamide): 2.5/5 mg OD
Max 15mg OD
Sitagliptin: max 100mg OD
Thiazolidinedione Insulin Sensitizer
(TZD)
Rosiglitazone: 4mg OD, max 4mg BD
MTF+ Gliben
Glucovance: 1/1 OD, max 4 tabs OD

CI: Creat>150, creal clr<30,


recent MI, liver cirrhosis, CCF,
chronic resp ds
SE: lactic acidosis w renal
impairment, Vit B12
difficiency (in liver cirrhosis,
CCF), GI disturbance
SE: GI disturbance, headache,
sensitivity

SE: hypoglycemia

DKA
Dx criteria: ketonuria, ketoacidosis(pH<7.3, HCO3<15), high GM. Usually Type I young pt

1.
2.
3.
4.
5.
6.
7.

Kussmaul breathing, ketone breath, polydipsia, polyuria, dehydration, vomiting, abdominal


pain
Ix: Septic w/up, BUSE, ABG stat & 4Hly, GM stat & 4Hly, urine for ketone stat &daily
Sliding Scale
2 pint NS over H, then 2 pint NS over 1 H, 2 pint over 2H, then 6 pint NS over 24 H+ 1.5 g
KCL each pint
O2 3L NP
CVP, CBD (can use condom cathter)
Strict I/O
R/T if pt drowsy- free flow and 4Hly aspirate
DKA chart

HONK
BUSE stat, RBS
Plasma osmolality= 2 (Na + K) + urea + glucose

Thyroid
Hyperthyroid
Carbimazole
PTU
Propanolol

Initial 4-6wk
30-40 mg OD
300-450 mg OD

Maintenance
5-10 mg OD
Max 60mg OD
50-100 mg OD
30-60mg OD

Thyroid Storm
Cardinal sx: severe tachycardia, hyperthermia, GI sx (vomit, diarrhea, abdo cramp, jaundice),
delirium
Precipitating factors: stress, surgery, radio-iodine therapy in poorly prepared pt, MI
Mx

FBC, BUSE, septic wup, TFT


Rehydrate
T. propranolol T. 40-50mg TDS (except in CCF). IV propranolol 2mg TDS/QID.
IV Dexamethasone 2mg QID, IV hydrocortisone 200mg QID (block T4T3)
PTU 150-200mg QID
Carbimazole 15-20mg QID

Hypothyroid
L-thyroxine

50-100 mcg OD

Maintenance
100 mcg OD

Myxoedematous Coma
Ix
o ABG: hypercapnia
o FBC, BUSE, GM, TFT
o ECG: short Q wave
L-thyroxine

Hypothyroidism

<3.0
Sx: tremor, palpitation, weakness, headache
50cc D50 bolus, then flush w NS 5mL. Rpt GM after 5 mins
Then D10% maintenance, or if GM>15 D5%

Serious Metabolic Acidosis: pH<7.1, HCO3<10 mmol/L


Causes: Sepsis, hypoxia, renal failure
1. 50 cc 8.4% NaHCO3 in 1pint NS over 1H
2. HCO3 if pH < 7.2,

a. 1/3 (BE-5) (wt) =x, give x/2


b. 0.5 x BW x (24-HCO3)
c. 1 mL 8.4% NaHCO3=1 mmol NaHCO3.

Hematology
Warfarin Overdose

Plan
o
o
o

Daily Coags,
Wo for bleeding tendencies
If bleeding:
Withhold warfarin
Vit K/FFP (d/w MO first)
Avoid green vegetables: cabbage(bunga kubis), spinach(bayam), mustard (sawi),
soya bean, peanuts, alcohol

Drug & blood reaction


Anaphylaxis

Swelling>itchy
o IM prednisolone 40 mg stat
o IV Hydrocortisone 100 mg stat
o T. piriton 4 mg TDS
Itchy>swelling
o IM piriton 10-20 mg stat
o T. prednisolone 5 mg OD

Hypersensitivity

IV Hydrocortisone 100mg QID


IV piriton 1amp TDS (slow)
IVD 2 pint
Neb combivent if SOB
Insect bite: IV cloxacillin 500mg QID

Ix
Anemic W/up

Connective Tissue ds w/up

Lumbar Puncture

Multiple myeloma w/u

Pleural fluid- ABC

Renal w/up

Septic w/up

Stool w/up
TB w/up

TIBC, serum iron (green)


Serum Ferritin (gel)
PBF
FBC
+ Hb Electrophoresis (GSH bottle)
LE cells X3
ANA, BNF
Anti ds DNA
C3,C4
ASOT
RF
RBS, serum protein
AFB
Biochemistry (protein, glucose)
Cell count/FEME/ Gram stain
C&S
India ink
Latex agglutination)
Viral Study (HSV/Enterovirus)
Ca PO4 albumin
Skeletal survey
Urine for Bence Jones proteins
ESR
PBF
Serum protein electrophoresis (gel tube)
GM stat or RBS!!
AFB
Biochemistry (pH, LDH, glucose, protein)
FEME (cell count)
C&S
Cytology
RP, Ca, PO4, Alb
HIV, HEP B/c, VDRL
USG KUB
24 H urine protein
24H urine Creatinine clearance
Blood, urine, sputum C&S
WWF (gel bottle)
BFMP X3 (blood film malarial parasite)
UFEME
FBC, GSH
+ ESR, CRP
Stool C&S, ova & cyst, FEME
CXR
ESR
Sputum & Blood C&S
RP/LFT
Sputum AFBX3
Mantoux test

HV/Hep B/Hep C

Drugs
ABx
Amoxycillin
Augmentin (Amoxycillin +
Clavulanic acid)
Azithromycin (macrolide)
Bactrim (trimethoprim&
sulfamethoxazole)
Bacampicillin (prodrug of
ampicillin)
Benzylpenicillin

C-penicillin
Cefuroxime (2nd gen)
Cefobid (Cefoperazone, 3rd gen)
Ciprobay (ciprofloxacin)
Claforan (Cefotaxime, 3rd gen)

Clarithromycin (macrolide)
Clindaymycin
Cloxacillin
Doxyxycline
EES (erythromycin
ethylsuccinate)
Flagyl (Metronidazole)
Fortum (Ceftazidine, 3rd
gen+antipseudomonal)
Imipenem
Meropenem
Rocephine (Ceftriaxone)
Sulfaperazone (Cefoperazone
+sulfabactam)
Tazosin (tazobactam
+piperacillin)
Tienam (imipenem +cilastatin)

T. 1g BD
IV 1.2g TDS
T 625mg BD, 625mg TDS for
pneumonia
IV 500mg /1g OD
T. 500 mg OD
2/2 BD
T 400 mg BD
IM 1.2/2.3 megaunit weekly in
syphilis
IV slow infusion 7.2g daily in 6
divided dose
IV 2-4 megaunit QID
IV 3.5g QID
T 125 mg QID
IV 1.5g stat, 750mg BD
T. 250mg BD
IV 500mg/1g BD
T. 200 mg BD
IV 400-800mg OD
IV 1g QID normally change
to T.Zinnat
T. 1g BD (max 12g/d)
T 500mg OD/BD/TDS
T. 400 /600 mg QID
IV 1g QID
T. 500mg QID
T. 100 mg BD
T. 800mg BD/ 400mg QID
(max 4g/d)
IV 500 mg TDS
T. 400mg BD
IV 1g TDS 2g BD 2gTDS
IV 500mg TDS/QID
IV 500 mg OD 1g TDS
IV 2g stat, 1g OD
IV 1-2g BD
IV 4.5mg TDS
IV 1g BD

Unasyn
(ampicillin+sulfabactam)
Vancomycin
Zinacef (cefuroxime)
Zinnat

IV 1.5-3 g TDS (max 12g/d)


T 375mg BD
IV 1g OD
750mg TDS
T. 500mg BD

H pylori eradication
o C.lansoprazole 20 mg BD, T. Amoxycillin 1 g BD, T. Clarithromycin 500 mg BD 2/52
o THEN C. lansoprazole 30 mg OD 6/52

Meningitis
Prophylaxis of meningococcal
meningitis
Pneumonia (partially tx)

IV Rocephin 2g stat & BD


IV Acyclovir 500mg stat & TDS
IM ciprobay 2g stat
T. Ciprobay 500mg stat
T.Ampicillin 600mg 2 days
IV cefotaxime 1g QID
T. Clarithromycin 500mg BD

Sxmatic Relief
Actifed

Decongestant
DONT give <2yo

Buscopan (hycosine)

1/1 TDS
(triprolidine 2.5mg,
pseudoephedrine 60mg)
T. 10mg TDS

Motilium (domperidone)

T. 10 mg TDS

N&V, dyspepsia, GORD

Piriton (Clorpheniramine)

T. 4 mg TDS/QID/4 Hly

Stemetil (Prochlorperazine)
Stugeron

5/10 mg BD/TDS
T. 25mg TDS (vestibular
disorder)
50-75mg TDS (PVD)

GI spasm

N&V, vertigo

Procedures
PD
Indication
1.
2.
3.
4.

Creat>300,
Metabolic acidosis
HperK >6
Uremic encphalopathy

Documentation
PD done aseptic technique under the supervision of Dr.. Consent taken
SpO2 maintained >95% throughout procedure
Good inflow & outflow observed, no immediate complications noted. Clear PD fluid
Plan:

PF for 60 cycles
Isotonic solution in/out first 6 cycles
a. In 5-10 mins
b. Out 10-20 mins
c. No retention
Then for the 7th cycle onwards: in 10 mins, retain 20 mins, out 15 mins
Inform if PD poor flow/blood stained/ leaking/ ssx of peritonitis

Others:
(IF TURBID)Add IV Genta 8mg in each PD bag until clear
Wo for ssx peritonitis
IV Dormicum 2.5mg during PD (If pt resist, add 2.5mg)-monitor SpO2

CVP

Normal 8-12
Tip of CVP: 2nd ICS. If too deep- low reading, too peripheral- high reading.

IJVC
Placement in R atrium

Documentation
Pronouncing Death

Informed by SN
Pt put on VS monitoring & Cardiac monitor

Active bagging & CPR commenced


1 amp of atrophine/adrenaline given via PERIPHERAL LINE
However
o Serial BP measurement and pulse checking done
o BP & SpO2 unrecordable, pulse absent,
o Asystole on cardiac monitor
o No spontaneous breathing, no heart sound
o Pupils fixed and dialted
Pronounce death at
Cause of death