1.

A/c CHOLECYSTITIS
NPO, BP, TPR Chart
Inj tramadol Phenergan im q8h
Inj. Ciplox 200mg IV Q12h
Inj Metrogyl 500mg IV Q8h
Pantop
P'mol 500mg im
IVF

2.A/C PAROTITIS
TPR, BP, I/O Chart, Oral feeds as tolerated
Inj. Moxiclav 1.2g iv BD
Inj. Metrogyl 500mg IV Q8h
Pantop
Pmol
IVF
Head end Elevated - postop

3.A/C PSYCHOSIS /DELIRIUM

A/C psychosis - orientation to place present
Delirium - not oriented to place

Treatment of A/C psychosis

Inj. Haloperidol 5/10mg IV (don't give more than 2 dose will cause dystonia)
Inj. Phenergan 25/50mg IV

Treatment of Delirium
If due to Alcohol withdrawal = inj Lorazepam 4mg IV/IM
If not due to withdrawal = inj Haloperidol 2.5mg ( don't give Phenergan) if higher dose may
cause dystonia

PSYCHOSIS is due to increase in DA mesolimbic pathway

Mesocortical pathway - Altered behaviour
Mesolimbic pathway
Nigrostriatal pathway - muscle rigidity
Tuberoinfundibular pathway - ⬆️temp⬆️vasodilation, sweating, increase prolactin ⬆️ amenorrhea,
galactorrhea, infertility

D2 receptor blocking agents produce EPS symptoms

DELIRIUM - a/c confusional state

Cause:
Structural - Head injury, CVA, SAH, ICSOL, encephalopathy, abscess
Metabolic - electrolyte imbalance, hepatic/renal failure, vit deficiencies, endocrinopathies.
Hypoperfusion- shock, CHF, Anaemia, arrhythmia
Infection - meningitis, Encephalitis, sepsis, pneumonia
Toxins- alcohol, cannabis, sedatives, narcotics
Post ictal state, alcohol withdrawal

4.A/C TONSILLITIS
Examine r/o quinsy
1. T. Azithromycin 500mg OD or
T. Amoxiclav 625mg TID or
T. Erythromycin 250mg TID or
T. Levofloxacin 500mg OD
2.T. P'mol 500mg TID x 5 days
3. T. Rantac 150mg x 5 days
4. Warm Saline gargle QID
QUINSY (peritonsillar abscess)
Features
Septicaemia like
Fever with rigor and chills (104°)
Generalised malaise, body aches, headache, nausea, vomiting, throat pain- unable to swallow saliva, ear
pain, foul breath

Examination - Bulge of ant. tonsillar pillar & soft palate, shift of uvula, congestion of pharyngeal wall,
tonsillar enlargement, mucus covering the tonsillar region
Cervical lymphadenopathy
Trismus
Torticollis
Pt may be dehydrated
Treatment
Admit
1. IVF
2. IV antibiotics- penicillin, cefuroxime, cefpodoxime, clindamycin treatment for 7-10 days
3. Paracetamol infusion
4. Mouth washes- saline, chlorhexidine
5. Needle aspiration➡pus c/s
6. I&D under LA if abscess
7. Tonsillectomy - hot or interval

Steroids can be added - dexamethasone 1 dose

5.A/C ABDOMINAL PAIN

Suspect UTI? URE?
Abdominal pathology - USG?
Renal colic? URE for RBCs
Pregnancy in females? UPT?
If UTI
1. Inj. Cyclopam 1amp IM stat
Inj. Tramadol 1amp IM stat
Inj. Emeset 1amp IV stat
Inj. Pantop 1amp Iv stat
Inj. Sposmo(Diclofenac + Dicyclomine)
Inj. Buscopan(hyoscine butylbromide) 1 amp IM
(for digestive tract spasm and motility)

2. Catheterise bladder
URE

3. T. Levofloxacin 500mg OD 1 week or

T. Ofloxacin 200mg BDx 1 week or
T. Ciprofloxacin 500mg BD x 1 week
In children
T. Cefixime 8mg/kg/dose OD (adult 200mg)
4mg/kg BD
(syp 100mg/5ml,200mg/5ml)
4. T. Lyser D BD x 1 week
5. T. P'mol 500mg TID x 1 week
6. T. Rantac 150mg BD x 1 week
7. Syp. Citralka 2tsp in 1 glass of water TID x 1week
8. T. Cyclopam 10mg TID x 1 week
T. Pantop 40mg OD
T. Pyridium(phenazopyridine)200mg TID x 2 days
(child 12mg/kg/day)
9. T. Nitrofurantoin 100mg OD x 1 week
(⬆️ 25/50/100mg)
Citralka ( disodium hydrogen citrate)

T. Drotaverine(antispasmodic) 40 mg tds
Inj. Cyclopam 10mg IM stat
Inj. Pantoprazole 40 mg iv stat
Doxycycline 100mg bd 7 days
+
Levoflox 500 od
or
Azithro 500 od
or
CiploX 500 bd
T. Metrogyl 400mg BD x 5 days
Drotaverine uses
Pain In Stomach, Chest Pain, Pain Due To Ulcers Of The Intestine, Gallstones Pain In The
Kidneys, Pain Due To Liver And Gallbladder Diseases, Painful Periods

Children
Syr. Amoxicillin 1 tsp TID
Syr. P'mol 125/5 TID
Syr. Cyclopam 10mg/5ml TID
Syr. Colicaid <6 mon age 5-10 (4)drops QID
>6-12month 10-12(8) drops TID/QID

Colicaid =simethicone+dill oil +fennel oil

ULCER
syp. Sucralfate 15ml TDS
Syp Digene gel 15ml TDS
Syp. Mucaine gel

APPENDICITIS
Pain- periumbilical or RIF, nausea, vomiting, fever, Anorexia, pain on coughing
Fever, tachycardia, RIF tenderness, guarding, rebound tenderness...
ALVARADO SCORE >7 appendicitis
5-6 equivocal need, USG/CT
Migratory RIF pain 1
Anorexia 1
Nausea, vomiting 1
Tenderness in RIF 2
Rebound tenderness 1
Elevated temp 1
Leucocytosis 2
Shift to left 1

Treatment
Npo, TPR, I/O chart
Tramadol /Diclo/pmol
Pantop
IVF 5D,RL,NS
Sx - inj. Cefotaxime 1g IV Q8H ATD
Inj. Metrogyl 500mg Iv Q8H

PERFORATION PERITONITIS
Acid peptic d/s, NSAIDs?
Guarding, Rigidity, Fever, tachycardia, tachypnoea, shock, no movement with respiration

PYELONEPHRITIS
Pyuria, dysuria, ⬆️frequency of urination
URE?

A/C CYSTITIS (E. Coli >80%)

RBCs in urine + UTI features
T. Clotrimazole (septran) 960mg BD x 3d
T. Nitrofurantoin SR 100mg BD x 7 days
T. Ciprofloxacin 500mg BD x 5 days

6.ABORTION
<7 wks T. Mifepristone 200mg PO f/b after 24-48hrs
T. Misoprostol(PGE1) 400mcg orally

7-9Wks T. Mifepristone 200mg PO f/b after 24-r8hr

T. Misoprostol 800mcg PO/Vaginal/buccal
(if no abortion after 4hrs) T. PGE1 400mcg

9-13wks T. Mifepristone 200mg PO f/b after 36-48hr

T. PGE1 800mcg Vaginally
( A maximum of 4 doses of PGE1 400mcg
Vaginally/orally @ 3 hr intervals)

13-24wks T.Mifepristone 200mg PO f/b after 36-48hr

T. PGE1 800mcg Vaginally, then 400mcg
orally/Vaginally 3 hrs apart to a max of 4
doses
(if abortion not occurs, Mifepristone can be repeated 3 hrs after the last dose of PGE1 and 12
hrs after PGE1 may be recommended)

7.AKATHISIA / DYSTONIA
Treatment
1. Inj Phenergan 12.5/25mg IM stat
T. Trihexyphenidyl(Parkin)

2. Benzodiazepines
inj. Lorazepam 4mg IV
Inj. Diazepam iv give very slowly
Inj. Clonazepam iv (long acting)

3. Beta blockers
Arkamin(clonidine) - used to decrease BP
 Propranolol

Pregabalin, vit B6, NAC

Ask for h/o any drug intake

D2 receptor blocking agents produce these symptoms (Antipsychotic drugs)

Differentiate from NMS

Severe muscular rigidity - lead pipe rigidity
Hyperthermia
Diaphoresis- ⬆️sweating
Pallor
Dyspnoea, mutism
Tremor
Incontinence
Shuffling gait
Psychomotor agitation
Altered consciousness Delirium, lethargy, stupor, coma

O/E
Diaphoresis
Sialorrhea
Tachycardia
Tachypnoea
Increased BP
Hypoxemia
Lab- ⬆️CPK

Complications of NMS
Dehydration - poor oral intake
ARF - rhabdomyolysis(⬆️temp, ⬆️Ca)
DVT and pul embolism - due to rigidity and immobilization
Arrhythmia and collapse
Aspiration pneumonia
Resp failure
Seizures
Hepatic failure
DIC

If NMS never give Phenergan (aggravate symptoms)

Treatment
Discontinue all antipsychotics
Dantrolene
Bromocriptine
Amantadine
Lorazepam
ECT

8.ALCOHOL WITHDRAWAL
Tremor, Irritability, Anorexia, nausea
Seizures (Rum Fits)

Alcohol Dependence syndrome(ADS) - 6 features

Craving for alcohol
Lack of control
Pleasure is alcohol(salience-primacy)
Know harmful but drinks
Withdrawal symptoms
Tolerance

. Narrowing of the drinking repertoire

• Priority of drinking over other activities (salience)
• Tolerance of effects of alcohol
• Repeated withdrawal symptoms
• Relief of withdrawal symptoms by further drinking
• Subjective compulsion to drink
• Reinstatement of drinking behaviour after abstinence

12-48 hrs after last intake

1. 20mg of chlordiazepoxide QID

or
Inj. Diazepam 10mg-20mg IM/IV, only after alcohol blood levels is 0.
Inj. Lorazepam 2mg iv stat
2. Inj. Thiamine 200mg IM stat, if Hypoglycemia present Thiamine should be given before
dextrose

3. T. Diazepam 10mg TDS or

T. lorazepam 2mg Q4H, Q6H, Q8H& SOS (depends on symptoms - drowsiness)
4. T. Neurobion forte BC OD
5. T. Pantop 40mg BD, inj. Pantop

ADVICE ON DISCHARGE
1. T. Lorazepam 2mg 1-1-1 & SOS x 2 days
1/2-1/2-1/2 & 1 SOS x2 days
0-0-1 & 1 SOS x 2 days
2. T. Thiamine 100mg OD x 2 weeks
3. T. MVT 1 OD

If need small amount of Haloperidol can be given

Alcoholic hallucinations
Chlorpromazine 100mg TID

Avoid driving
Movement disorder
Can take up to 5 lora tabs
Never take tab and drink
Always keep stomach full
Delay drinking to 1 hr, concentrate on other activities
Lime tea
Think of harmful effects of drinking

DELIRIUM TREMENS- after 72-96hrs

Rx Benzodiazepines
(Delirium + Tremor)
Hallucinations, agitation, confusion, autonomic, hyperactivity

WERNICKE'S ENCEPHALOPATHY
Nystagmus, ophthalmoplegia, confusion, ataxia

Korsakoff's syndrome - irreversible

Short term memory loss, confabulation

Anticraving agents- once he stops drinking, to prevent relapse

Disulfiram 200-400mg OD
Topiramate
Acamprosate 666mg TID

Alcohol withdrawal symptoms can begin as early as two hours after the last drink, persist for
weeks, and range from mild anxiety and shakiness to severe complications, such as seizures
and delirium tremens (DTs).

Severe alcohol withdrawal symptoms are a medical emergency.

Alcohol initially enhances the effect of GABA, the neurotransmitter which produces feelings of
relaxation and calm. But chronic alcohol consumption eventually suppresses GABA activity so
that more and more alcohol is required to produce the desired effects, a phenomenon known as
tolerance.
Chronic alcohol consumption also suppresses the activity of glutamate, the neurotransmitter
which produces feelings of excitability. To maintain equilibrium, the glutamate system responds
by functioning at a far higher level than it does in moderate drinkers and nondrinkers.
When heavy drinkers suddenly stop or significantly reduce their alcohol consumption, the
neurotransmitters previously suppressed by alcohol are no longer suppressed. They rebound,
resulting in a phenomenon known as brain hyperexcitability. So, the effects associated with
alcohol withdrawal -- anxiety, irritability, agitation, tremors, seizures, and DTs -- are the opposite
of those associated with alcohol consumption.
Minor alcohol withdrawal symptoms often appear 6 to 12 hours after a person stops drinking.
Sometimes a person will still have a measurable blood alcohol level when symptoms start.
Symptoms include:
Shaky hands
Sweating
Mild anxiety
Nausea
Vomiting
Headache
Insomnia
Between 12 and 24 hours after they stop drinking- visual, auditory, or tactile hallucinations.
These usually end within 48 hours. Although this condition is called alcoholic hallucinosis, it's
not the same as the hallucinations associated with DTs. Most patients are aware that the
unusual sensations aren't real.

Withdrawal seizures usually first strike between 24 and 48 hours after someone stops drinking,
although they can appear as early as 2 hours after drinking stops.. The risk of seizures is
especially high in patients who previously have undergone multiple detoxifications.

DTs usually begin between 48 and 72 hours after drinking has stopped, Risk factors for DTs
include a history of withdrawal seizures or DTs, acute medical illness, abnormal liver function,
and older age.

Symptoms of DTs, which usually peak at 5 days, include:

Disorientation, confusion, and severe anxiety

Hallucinations (primarily visual) which cannot be distinguished from from reality
Profuse sweating
Seizures
High blood pressure
Racing and irregular heartbeat
Severe tremors
Low-grade fever

9.ALCOHOLIC GASTRITIS
A/c epigastric pain, nausea
1. Inj. Pantop 1amp IV stat
2. 1 ⚀ IV Fluids DNS with polybion
Adv:
1.T. Pantop 20mg OD x 1 week
2. T. Polybion/vit B complex OD x 2 weeks
3. Avoid alcohol

Librium(amitriptyline+chlordiazepoxide) 25mg 2 tab stat

Librium 25 mg bd

Hypoglycemia:
50 ml 25% Dextrose IV STAT +1 amp polybion

10.ALLERGIC RHINITIS
1. Budesonide spray or
Azelastine nasal spray or
Sodium cromoglycate nasal spray
2. T. Cetirizine 10mg HS x 3 days

Azeflo
Mometasone
Fluticasone
Montec

11.ALLERGIES
1) Inj. AVIL(pheniramine maleate) 1amp IV stat
2. Inj. Hydrocortisone 100mg IV stat
(Pediatric dose ➡3-5mg/kg/dose)
Inj. Betamethasone(betnesol) 8mg IV stat

3) T. AVIL 25mg BD/HS x3 days

4) T. CPM(chlorpheniramine maleate)4mg BD/HS x3 days

Avil- ⬆️ 25mg , 50, mg

⬆️ 22.75 mg/ml
CPM - ⬆️ PIRITON 4mg
⬆️ POLARAMINE 2mg, 6mg

Mild - Erythema, urticaria, periorbital edema

Inj. Dexona 1amp IV stat
(Pediatric dose 0.1-0.2mg/kg/dose)
 Inj. AVIL(12.5mg) 1amp IV stat
(Pediatric dose 0.5mg/kg/dose)

Mod - Breathlessness, stridor, wheeze, nausea, vomiting, dizziness, diaphoresis.

Inj. Hydrocortisone 100mg IV stat
If BP⬇ = 1 ⚀ NS & Refer (Dobutamine 2 amp in 1⚀ NS, start with 4 drops;upto 32 drops)

Severe (icu needed)- Hypoxia, hypotension, confusion, LOC

Ini. Adrenaline 0.5ml-1ml 1/1000 IM/SC stat, Can repeat 0.3-0.5ml after 15min
Supine position,
O2 supplementation
IVF - RL/NS
IF BP Falling - inj. Mephendramine(M6) 2cc iv stat

Methylprednisolone 125mg iv
Hydrocortisone 500mg iv

Adv:
1. T. AVIL 25mg BD x 3days (If severe)
2. T. Cetirizine 10mg BD x3 days (moderate)

(Sneezing, itching)
1. T. Cetirizine 10mg HS x 5 days
2. T. Levocetrizine 5mg HS x 5 days
3. T. Montelukast 10mg HS x 5 days
4. T. AVIL 25mg BD/HS x 5 days
5. T. CPM 4mg BD x 5 days
6. T. Sinarest TID x 5 days

Avil overdose give Phenergan

Symptoms
Low BP, Giddiness, nausea, dyspnoea, tachycardia, urticaria

12. ANALGESIC
1) Inj. Voveran 50mg/75mg IM stat ATD
C/I - asthma, COPD, Allergy, gastritis
2) Inj. Tramadol 50mg IM stat
C/I - Head injury
3) Inj. Cyclopam 1amp IM stat
(for colicky abdominal pain)
4) Inj. Paracetamol 2cc IM stat (pain +fever)
5) Inj. Ketanov(ketorolac) 1amp IM stat ATD
6) Inj. Tramadol 50mg +inj. Phenergan 12.5mg
Diclofenac transdermal patch(NU patch)

Tablet ⬆️ (3-5 days)

1) T. Diclofenac 50mg BD
2) T. Aceclofenac 100mg BD
3) T. Indomethacin(MICROCID) 25mg HS
4) T. Ibuprofen 400mg BD
5) T. Tramadol 50mg BD
6) T. Mefenamic acid 500mg BD

ACLOFEN, DOLOWIN, DOLOKIND, HIFENAC (Aceclofenac)

⬆️ 100mg
⬆️ SR(sustained release) - 200mg DOLOKIND, SIGNOFLAM

VOVERAN, DICLOFAM, DICLOMAX(Diclofenac)

⬆️ 50mg
⬆️ 75mg/3ml
VOVERAN-D(dispensable tab), ZOBID-D 50mg
VOVERAN - SR, ZOBID-SR, DICLONAC-SR 100mg

ARTISID(Indomethacin) 25mg. Cap

INDOCID, MICROCID 75mg SR-cap

BRUFEN, IBUGESIC, SUGAFEN(Ibuprofen)

⬆️ 200mg 400mg
IBUGESIC 100mg/5ml suspension

MEFTAL(Mefenamic acid) ⬆️ 250mg, 500mg

MEFTAL-P 100mg kid tab, 100mg/5ml susp.

Fall, sprain, contusion

T. Septid D or T. Lyser D
T. Rantac

Neck pain, sprain

T. Tizan 2mg (aceclofenac+paracetamol+
serratiopeptidase +tizanidine)

LOW BACK PAIN :

T. Diclofenac
T. Rantac
T. Calcium
Cap. Iron OD x 30 days

13.ANEMIA
Hb <11
Koilonychia, platonychia, leg cramps, CCF,palpitation Splenomegaly, giddiness, numbness,
angular stomatitis, dysphagia(plummer vinson)

Oral iron/ parenteral iron = same effect

1)Iron syrup vitcofol 5ml OD

Ferrous Fumarate (100 Mg)
Folic Acid (Vitamin B9) (0.5 Mg)
Cyanocobalamin (5 Mcg)

2)Tonoferon drops/syr. (5ml BD after food)

Iron Hydroxide (25 Mg)
Folic Acid (Vitamin B9) (500 Mcg)
Vitamin B12 (5 Mcg)

Tonoferon paed
2mcg/200mcg/80mg/5ml

Up to 3 months 3 drops
3-6 months 5 drops
6-12month 6-12 drops bd
Therapeutic:double the prophylactic dose

Cap. Vitcofol BD
ferrous fumarate 300 mg, folic acid 0.75 mg, vitamin B12 7.5 mcg, vitamin B6 1.5 mg, zinc
sulphate 7.5 mg.

T. Folic acid 5mg OD

Pediatric
3-6mg/kg/day elemental iron
Iron sucrose 1-3mg/kg IV diluted in 150ml NS over 1hr

After correction continue to 4-6 mon

Anemia in pregnancy:
Symptoms
Fatigue, anorexia, dyspnoea, dizziness, headache, insomnia, palpitations
Signs -pallor, edema, tachycardia, glossitis, stomatitis.
TREATMENT
Oral (<30wks)
1. T. Iron TID x 2 weeks(after correction OD)
1 iron tab = 60mg elemental iron
Have more side effects- so can be given on alternate days

Dimorphic anemia= check S. Folate level

Parenteral (30-36wks)
2. Hb(14) - pt Hb x wt in kg x 2.21 +1000 mg
For each gram below normal give 250mg elemental iron
Inj. Iron dextran or iron sorbitol citrate IM 100mg daily until the full dose (IV has risk of
anaphylaxis - test dose 1ml)

Blood transfusion >36 wks

14.ANTI ANXIETY
1) T. Alprax 0.25/0.5 mg HS
Pediatric - 0.01-0.02mg/kg/dose TID
2) T. Lorazepam 2mg HS
3) T. Amitriptyline 10mg /25mg HS
(Pediatric - 0.3mg/kg/dose x TID)

Buspirone - non benzodiazepine anxiolytic

ALPRAX ALZOLAM RESTYL TRIKA(Alprazolam)

⬆️ - 0.25mg, 0.5mg, 1mg
⬆️ - SR 0.5mg, 1mg, 1.5mg

ATIVAN LARPOSE LORVAN TRAPEX (Lorazepam)

⬆️ - 1, 2mg TID
⬆️- 2mg/ml (loperz)

AMITONE TRYPTOMER TADAMIT(Amitriptyline)

⬆️ - 10mg, 25mg, 75mg

For sleep:
T. Quetiapine 12.5mg
Zolpidem
Clonotril

DIAZEPAM
Severe anxiety - 2mg TID, or inj. 10mg IM/IV
Insomnia - 5-15mg HS
Muscle spasms 2-15mg/day
Preanesthetic medication 5-20mg

TO TAKE CT/MRI IN CHILD

Midazolam

ANXIETY DISORDER:
Etizola plus ½ - 0 - ½ x 2 weeks
Etizolam(0.5mg) + Escitalopram(10mg)

Petril MD(clonazepam 0.25mg) sos

15.ANTIEMETICS
1) Inj. Emeset 4mg(1amp) IV
2) Inj. Perinorm 1amp IV
3) T. Domperidone 10mg BD/TID
4) T. Perinorm 10mg BD/TID
5) T. Pantop- DSR BD(if ssso. gastritis +)
Syp. Mucaine Gel (gastritis)

ZOFAR, ZODAN, EMEST, ONDEM(Ondansetron)

⬆️ - 4mg, 8mg ⬆️ - 2mgm/ml
NAUCID, VOMIKIND ⬆️ - 4mg ⬆️ - 2mg/ml ⬆️ - syr. 2mg/5ml

PERINORM, REGLAN, MAXERAN(metoclopramide)

⬆️ - 5mg,10mg
⬆️- Syr.5mg/5ml
0.2-0.5mg/kg
Adverse effects: sedation
(For drug induced vomiting, migraine)

DOMPERON, DOMSTAL, MOTINORM(Domperidone) ⬆️ - 5mg,10mg, 30mg

⬆️ - DT 5mg, 10mg
1 mg/ml susp
10mg/ml drops

Inj. Emeset 4mg IM stat

Or
Inj. Perinorm(metoclopramide) 1amp IV stat
Inj. Rantac 1amp IV stat

If severe start RL/DNS

Adv:
T. Ondansetron 4mg or 8mg TID x 3days
T. Domperidone 10mg BD
ORS SOS

PEDIATRIC
Domstal 2 drop
Junior lanzol(lansoprazole) 15 mg 1/4 tab
T. Domperidone 0.2-0.5mg/kg/dose x TID
Inj. Emeset 4 mg iv stat

If hypovolemic
1 ⚀ normal saline IV Stat
50 ml 25 D IV stat

16.ANTI THYROID DRUGS

Propylthiouracil 300-400mg
Maintenance dose 100-150

Safe in pregnancy
Carbimazole 15-40mg
5mg,20mg tabs

HYPOTHYROIDISM
Thyroxine
Thyronorm 25mcg, 50, 100

17.ANTIBIOTICS
1)T. Ciplox 500mg 1-0-1x 5/7 days
(for diarrhea, food poison, UTI)
2)C. Amoxicillin 500mg 1-1-1 x 5/7 days
( for URT/LRT, small wound)
3)T. Azithromycin 500mg OD x 5/7 days
4)T. Amoxiclav 375/625mg TID x 5 days
(for ENT infection, deep wounds)
5)T. Ampiclox 500mg zee TID/QIDd
(for ENT, infection, deep wounds)
6)T. Erythromycin 250mg TID x 5 days
(sore throat)
7)T. Norfloxacin 400mg BD x 5/7 days
(UTI)
8) T. Levofloxacin 500mg OD x 7 days
(bact. Sinusitis, c/c bronchitis)
Parenteral
Inj. Cefotaxime 1g IV Q12h/8h ATD
Inj. Amikacin 500 mg IV Q12h ATD
Inj. Ciplox 200mg IV Q12h
Inj. Gentamycin 80mg IV Q12h
Inj. Ampicillin 500 mg IV Q6h
Inj. Metrogyl 500 mg iv Q8h
Inj. Meropenem 1g
Inj. Sulbactam 500mg
Inj. Piperacillin 4g
Inj. Cefoperazone 500mg/1g
Inj. Ceftriaxone 500mg/1g
Inj. Amoxicillin 500mg /1g
Inj. Cloxacillin 500mg IV
Inj. Moxiclav 1.2g IV

Amikacin 250 mg or 500 mg stat

Clindamycin 600 mg stat
Gentamicin 800 mg stat

Cap. Moxiclav 625mg TID x 5 days

Cap. Moxkid 500mg TID

Bacterial infection
Amoxicillin 50mg/kg/day (tid)
Azithromycin
Erythromycin
Cefadroxime 50mg/5ml
Cephalexin
T. Cefpodoxime 200mg
T. Cefixime 200mg (8mg/kg/day, 50mg/5ml)
T. Cefuroxime 500mg
Clavulanate potassium 125mg
Clavulanic acid 125mg

Meningitis
100mg/kg ceftriaxone
200mg/kg cefotaxime
3-4 lakhs/kg penicillin
400mg/kg ampicillin

Taxim 100mg/kg
Gentamycin 50mg/kg
Metrogel 7.5mg/kg
PNEUMONIA
Ceftriaxone
Amikacin
Piptaz
Levofloxacin( gram - ve)

18.APHTHOUS ULCER
1st visit:
Betadine gargle
T. B. Complex OD/BD x 1 week, MVT
T. Riboflavin 10mg TID
T. Pantop 40mg OD x 1 week
T. Vizylac 1 OD
T. Rebagen(rebamipide) 50mg BD
T. Ibuprofen 400mg BD x 3days

2nd visit:
Zytee gel(Choline salicylate) for LA( 5 min before food) + Metrogyl DG gel for LA (after food)
Wash mouth

Ora fast or Dologel CT(lidocaine HCL+Choline salicylate) for LA

Tess ointment (triamcinolone) for LA
Clenora gel for LA
Wysolone(prednisolone) 10mg make powder and apply over ulcer

Tetracycline or doxycycline capsules mouth wash

19.BRONCHIAL ASTHMA
Check whether Breathlessness due to CVS

DANGER SIGNS
Check Spo2 <92%
Silent Chest
Hypotension
Bradycardia
PaO2 <60mmHg

If resp
O2 inhalation
1. Nebulisation with salbutamol 0.5ml in 3ml NS stat
(<12yrs)
(3 times 20 min apart. if not controlled add
ipratropium bromide 0.5mg or budesonide)
2. Inj. Hydrocortisone 100mg IV stat(5mg/kg/dose) (4-6hrly)
3. Inj. Deriphyllin 1amp IV stat (CI in child if PR ▶ 110)
4. Inj. Dexona 1amp IV stat (PD 0.2-0.3mg/kg)
(if controlled change to ⬆️)

Inj. Aminophylline 5mg/kg (25mg) over 20min infusion

Inj. CPM 2mg stat

T. Deriphyllin 100mg BD/TID x 5 days

T. Salbutamol 2mg BD/TID x5days
T. Cetirizine ime 10mg BD x 5 days
T. Montelukast 10mg HS x 5 days
(montekid 5mg HS in children)

Steroid:
T. Omnacortil(prednisolone) 10mg TID x 2 days
BD x 2 days
OD x 1 day

T. Montair LC(montelukast + levocetrizine 10+5)

Asthalin inhaler:
PD 100mcg /puff
Adult 200mcg/puff
Seroflow
Airtec SF (25/125)

Exercise induced asthma prophylaxis

Montelukast 10mg 2hrs before ex

Nebulisation with Asthalin respules

Salbutamol solutions 2.5mg/2.5ml, 5mg/2.5ml
Salbutamol◀ 12yrs 0.5ml
▶ 12 yrs 1ml
Ipravent ◀ 1yr 0.5ml
▶ 1yr 1ml
Budesonide 0.1mg/kg/dose

Adrenaline
Asthma - 0.01mg/kg S/c
Anaphylaxis - 0.01mg/kg IM
Croup - nebulisation with 0.5-2.5ml
IN ICU
Magnesium sulphate 0.1ml/kg (1.2-2g) over 20min
⬇ (if not controlled)
Inj. Terbutaline 0.4mg s/c or IM
Terbutaline infusion

COPD
H/o COPD, Cough, sputum, chest tightness,

Examine for
1. ECG - ACS, AF, MFAT
2. Pneumothorax - breath sounds, VF, VR. X-ray Chest
3. Cor-pulmonale- B/l pedal edema, A/c LVF, BVF
4. Respiratory failure
Type I - hypoxemic
Type II- CO2 retention - high bounding pulse, warm extremities, flapping tremor, palmar
Erythema, disorientation

TREATMENT
1. Neb salbutamol ( C/I - ⬆️PR, CAD)
+ Ipravent
2. Inj. Deriphyllin iv Q8h (C/I - seizures)
3. Inj. Dexona or hydrocortisone iv Q8h
4. Inj. Lasix 40mg iv stat (if cor pulmonale, BP⬆️)
5. Mucolytes - mucinac (NAC) 600mg BD
6. NIV

20.BEE/WASP STING
Management
1. Stabilise vitals
2. Scrap off the sting
3. Locally apply alkaline solution - lime or methylene blue or ammonia
4. Apply ice
5. Tab/Inj. Avil or topical antihistamines
6. Tab/Inj. Hydrocortisone or topical steroids
7. Aminophylline for bronchospasm
8. If anaphylaxis - adrenaline + hydrocortisone

Do RFT if multiple stings

Symptoms
Local - pain, urticaria, itching, erythema
Systemic - anaphylaxis, itching, erythema, hypotension, bronchospasm, abdominal cramps,
convulsions
T. Atarax 25mg tds 3days
T. Deflazacort 6mg bd 3day
Calamine lotion for LA

21.BLEEDING PV
BP, PR, pallor?
Hb, pcv, blood group?
1. Inj. Trapic iv stat
Or
Inj. Ethamsylate iv stat
2. T. Trapic-MF 1-0-1 x 3 days
3. Iv fluid

T. Ethamsylate 250mg/500mg BD

22.BPH
1) T. Tamsulosin 0.4mg 1 HS
2) Dutaz-T 1 HS

CONTIFLO-OD, URIPRO, VELTAM, URIMAX (Tamsulosin) ⬆️ - 0.2mg, 0.4mg

Dutaz-T (dutasteride & tamsulosin)

1. T. Finas(finasteride) 5mg OD x 1 week

2. T. Rantac 150mg BD x 1 week
3. T. Lasik 40mg OD x 1 week ( BPH with urinary retention)

T. Finasteride 5mg od [Finast]

BPH with urinary retention
T. Urimax.F od
(Onset of action 55 min)

23.BREAST ENGORGEMENT
Hot bag fomentation
Manual expression
Inj. Lasix 20mg (reduces venous return)

Do TSH, in postpartum physiological hypothyroidism, Thyroxine empirically can be started

24.BREATHLESSNESS
H/o- sudden or chronic?
Bp, PR, or Basal crep?
1. Cardiac(LVF) - If BP⬆ ➡ lasix
120 ➡20mg iv stat
140➡40mg iv stat
180➡60mg iv stat
If BP ⬇ - first ⬆ BP & then lasix. Gap of
10-15 min, keep on giving

2. Respiratory - salbutamol nebulisation 20min apart

x 3 times
Inj. Hydrocortisone 100mg IV stat
Inj. Deriphyllin 1amp IM stat
Inj. Dexona(dexamethasone) 1amp IV stat

Adv:
T. Asthalin(salbutamol) 2mg TID x 7 days
T. Deriphyllin 100mg TID x 7 days
T. Cetirizine 20mg BD x 7 days
T. Montelukast 10mg BD x 7 days

PULMONARY OEDEMA
Dyspnea, Profuse sweating
Increase BP
Basal crepitation
Previous history of cardiac disease

Propped up position - max ventilation & perfusion occurs

Inj/T. Lasix 40 mg BD
O2 inhalation
Inj. Deriphyllin 1 amp IV stat
Inj. Dexona 1 amp IV stat

25.BURNS
Wash with NS
1. Silverex gel(silver sulphadiazine)
2. T. Ampiclox 500mg BD x 5 days
3. Inj. TT 0.5ml IM stat

If severe refer with IV fluids(RL)

IVF replacement
4ml/%burns/kg/day
First half within 8 hrs, remaining in next 16 hrs
First 24hrs - crystalloids (RL)
After 24hrs - colloids (plasma, dextran)
Antibiotics
Inj. Taxim
Inj gentamicin
Inj. Rantac 50mg IV TID

26.CALF CRAMPS
R/O DM, Hypocalcemia, salt deficiency, dehydration

RBS? SE? Ca²+

Treatment
Inj. Calcium gluconate 10cc slow iv
Inj. Tramadol 500mg + Phenergan 12.5mg IM stat
T. Calcium 500mg OD x 3 weeks
T. Tramadol 50mg
INTERMITTENT CLAUDICATION
T. Pentoxifylline (trendal) 400mg TID
T. Cilostazol(cletus) 100mg BD (½hr b4 fud)

27.CATHETERISED pt ➡ URINE RETENTION, DYSURIA, BLADDER SPASM, URGENCY,

FREQUENCY
1. T. Flavoxate 200mg TDS x 5 days
2.T. Rantac 150mg BD x 5 days
3. T. Ciprofloxacin 500mg BD x 5 days
4. T. Lyser D BD x 5 days

28.CELLULITIS
Expanding infection of the skin and subcutaneous tissue
Painful edema
Erythema

CBC - Leukocytosis
Blood & skin culture
Treatment
Antibiotics
Inj Ampiclox
Inj. Ceftriaxone
Inj. Amikacin
Inj. Metrogyl
29.CHEST PAIN
ECG - MI, Arrhythmia, hyper and hypokalaemia

Troponin - will rise within in 3-4hrs and remain up to 2 weeks

CPK will rise within 3-4hrs and peaks in 24hrs returns to normal in 2-3 days
TREATMENT
Morphine, O2, Nitrates, Aspirin

If BP⬆ ➡1. isordil 5mg sublingual stat (isosorbide dinitrate)

(C/I if BP ◀ 100)
2. T. Ecosprin(aspirin) 300mg stat
T. Clopidogrel 300mg Stat
T. Atorvastatin 80mg stat
3. T. Alprax 0.25mg
4. Inj. Pantop 40mg IV stat (never give Omeprazole)
Inj. Tramadol 50mg IM stat
Refer
Sedatives
Inj lorazepam 2mg IV stat
T. Alprax 0.25mg HS
T. Diazepam 5mg HS

If STEMI (need ICU)

Inj. Streptokinase 1.5 million units in 100ml NS over 1hr
C/I in unstable angina & NSTEMI, post op, pregnancy, stroke
Should be given within in 12hrs of Onsest of pain

In all ACS ( Trop T positive)

Inj. Heparin 4000U IV stat followed by 750U/hr infusion 3-5 days
(60U/kg heparin, 12U/kg maintenance )

MAINTENANCE DOSE
T. Aspirin 75mg 0-1-0
T. Clopidogrel 75mg 0-1-0
T. Atorvastatin 10mg 1-0-0
T. Metoprolol 12.5mg 1-0-1
T. Sorbitrate 5mg s/l sos
T. Enalapril 2.5 mg 1-0-0
T. Pantop 40mg OD

ECG changes ➡ Lead ll, lll, AVF ➡Inf. wall MI

V1-V2- PWMI
V3-V5 - AWMI
 I, AVL - LWMI
V5-V6 - apical MI
V2-V4 - ASMI

A/c ANTERIOR MI
Significant Q waves, ST elevation & T inversion in lead V2,V3, V4
Q waves and T inversion in lead V1
If change only in V1,V2 it is septal MI
ANTERIOR MI:
definition of STEMI officially according to the ACC/AHA guidelines for STEMI is “New ST elevation at
the J point in at least 2 contiguous leads of ≥ 2 mm (0.2 mV) in men or ≥1.5 mm (0.15 mV) in women in
leads V2–V3 and/or of ≥1 mm (0.1 mV) in other contiguous chest leads or the limb leads 1.” So 1 mm in
any 2 contiguous leads EXCEPT leads V2 or V3 where the elevation must be 2 mm in men or 1.5 mm in
women

A/c ANTEROLATERAL MI
Significant Q waves, ST elevation & T inversion in lead I, aVL, V5,V6
Most common MI

A/c INFERIOR WALL MI

Significant Q waves, ST elevation & T inversion in lead II, III, aVF

A/c POSTERIOR WALL MI

Lead V1 shows unusually tall R wave ( its mirror image of deep Q wave)
V1 R/S ▶ 1, DD- RVH
POSTERIOR MI:
ST segment depression (not elevation) in V1 to V4. Think of things backwards. These are the
septal and anterior ECG leads. The MI is posterior (opposite to these leads anatomically), so
there is ST depression instead of elevation. Turn the ECG upside down and it will look like a
STEMI.
The ratio of the R wave to the S wave in leads V1 or V2 is > 1. This represents an upside down
Q wave (similar in reason to the ST depression instead of elevation).
ST elevation in the posterior leads of a posterior ECG (leads V7 to V9). A posterior ECG is done
by simply adding three extra precordial leads wrapping around the left chest wall toward the
back

HYPERKALEMIA
Small or absent P waves
Atrial fibrillation
Wide QRS
Shortened or absent ST segment
Wide, tall and tented T waves

HYPOKALEMIA
Small or absent T waves or inverted T waves
Prominent U waves
T wave is the tent house of K(potassium)

(More K- tall T, less K- flat or inverted T)

ATRIAL FIBRILLATION
PR is irregularly irregular
R-R intervals are very different from beat to beat
Narrow QRS tachycardia
No P waves, instead small fibrillatory 'f' waves seen

ATRIAL FLUTTER
PR is regular or variable
Atrial rate is 300/min
All P waves are not conducted to ventricles
R-R intervals vary depending on the AV conduction ratio
QRS is narrow (◀ 0.12 sec)
The P waves have a saw toothed appearance called 'F' waves

VENTRICULAR TACHYCARDIA
A wide QRS tachycardia is VT until proved otherwise
Features suggesting VT
Evidence of AV dissociation
Independent P waves
Beat to beat variability of the QRS morphology
Very wide complexes (▶ 0.14ms)
The QRS is similar to that in Ventricular ectopics
Concordance (chest leads all positive or negative)

PATHOLOGICAL Q WAVE:
Pathological Q wave of infarction in respective leads is due to the dead muscle
It is deep in amplitude(more than 25% of the succeeding R waves or ▶ 4mm)
Its duration is ▶ 0.04sec or ▶ 1 small box
It is seen in the leads facing the infarcted muscle mass

NORMAL Q WAVES:
Normal Q wave in lead I is due to septal depolarisation
It is small in amplitude (less than 25% of the succeeding R wave or ◀ 3mm)
Its duration is ◀ 0.04sec or ◀ 1 small box
Seen in L1,Sometimes in V5,V6

T WAVE INVERSION:
Deep symmetric inverted T waves in more than 2 chest leads
85% of the patients with T wave inversion had 75% of stenosis of coronary artery
T wave inversion is significantly associated with MI

RIGHT ATRIAL ENLARGEMENT

Always examine lead II, for RAE
Tall peaked P waves, arrowhead P waves
Amplitude is 4mm,(0.4mV) abnormal
Causes:
Pulmonary hypertension, mitral stenosis
Tricuspid stenosis, regurgitation
Pulmonary valvular stenosis,
Pulmonary embolism
ASD with L to R shunt

LEFT ATRIAL ENLARGEMENT

Always examine V1 and lead I for LAE
Biphasic P waves and prolonged T waves
P wave 0.16sec,elevated downward component
Cause
Systemic hypertension, MS, MR, AS, AR
Left ventricular hypertrophy with dysfunction
ASD with R to L shunt

RIGHT VENTRICULAR HYPERTROPHY

Tall R in V1 with R ▶ ▶ S, or R/S ratio ▶ 1
Deep S waves in V4,V5 and V6
DD'S posterior wall MI Dextrocardia
Associated with right axis deviation, RAE
Deep T wave inversion in V1,V2 and V3
Absence of inferior MI

LEFT VENTRICULAR HYPERTROPHY

High QRS voltages in limb leads
R in lead I + S in lead III ▶ 25mm
S in V1 + R in V5 ▶ 35mm
R in aVL ▶ 11mm S in V3+ R in aVL▶ 24 ♐, ▶ 20♀
Deep symmetric T inversion in V4,V5 and V6
QRS duration ▶ 0.09sec
Associated left axis deviation, LAE

COMPLETE RBBB - M pattern

Complete RBBB has a QRS duration ▶ 0.12Sec
R wave in lead V1(usually see RSR complex)
S waves in lead I, aVL, V6. R waves in lead aVR
QRS axis in RBBB is - 30 to 90(normal)
Incomplete RBBB has a duration of 0.10 to 0.12sec with the same QRS features as above

T WAVE
NORMAL
Upright in all leads except aVR and V1
Amplitude < 5mm in limb leads, < 15mm in precordial leads

Peaked T waves:
Tall, narrow, symmetrically peaked T-waves are characteristically seen in hyperkalaemia.

Hyperacute T waves:
Broad, asymmetrically peaked or ‘hyperacute’ T-waves are seen in the early stages of ST-
elevation MI (STEMI) and often precede the appearance of ST elevation and Q waves. They are
also seen with Prinzmetal angina.(diabetic MI )

Loss of precordial T-wave balance occurs when the upright T wave is larger than that in V6.
This is a type of hyperacute T wave.

The normal T wave in V1 is inverted. An upright T wave in V1 is considered abnormal —

especially if it is tall (TTV1), and especially if it is new (NTTV1).
This finding indicates a high likelihood of coronary artery disease, and when new implies acute
ischemia.

INVERTED T WAVES ARE SEEN IN THE FOLLOWING CONDITIONS :

Normal finding in children
Persistent juvenile T wave pattern
Myocardial ischaemia and infarction
Bundle branch block
Ventricular hypertrophy (‘strain’ patterns)
Pulmonary embolism
Hypertrophic cardiomyopathy
Raised intracranial pressure
T wave inversion in lead III is a normal variant. New T-wave inversion (compared with prior
ECGs) is always abnormal. Pathological T wave inversion is usually symmetrical and deep
(>3mm).

Paediatric T waves:
Inverted T-waves in the right precordial leads (V1-3) are a normal finding in children,
representing the dominance of right ventricular forces.

Normal pattern of T-wave inversions in a 2-year old boy

Persistent Juvenile T-wave Pattern
T-wave inversions in the right precordial leads may persist into adulthood and are most
commonly seen in young Afro-Caribbean women. Persistent juvenile T-waves are asymmetric,
shallow (<3mm) and usually limited to leads V1-3.

Persistent juvenile T-waves in an adult

Myocardial Ischaemia and Infarction

T-wave inversions due to myocardial ischaemia or infarction occur in contiguous leads based on
the anatomical location of the area of ischaemia/infarction:
Inferior = II, III, aVF
Lateral = I, aVL, V5-6
Anterior = V2-6

. Dynamic T-wave inversions are seen with acute myocardial ischaemia.

. Fixed T-wave inversions are seen following infarction, usually in association with pathological
Q waves.

. Inferior T wave inversion due to acute ischaemia

. Inferior T wave inversion with Q waves due to prior inferior MI

. T wave inversion in the lateral leads due to acute ischaemia

. Anterior T wave inversion with Q waves due to recent anterior MI

BUNDLE BRANCH BLOCK

Left Bundle Branch Block:
. Left bundle branch block produces T-wave inversion in the lateral leads I, aVL and V5-6.

. Lateral T wave inversion due to LBBB

Right Bundle Branch Block:

. Right bundle branch block produces T-wave inversion in the right precordial leads V1-3.

VENTRICULAR HYPERTROPHY
. Left Ventricular Hypertrophy:
Left ventricular hypertrophy produces T-wave inversion in the lateral leads I, aVL, V5-6 (left
ventricular ‘strain’ pattern), with a similar morphology to that seen in LBBB.
Lateral T wave inversion due to LVH

. Right Ventricular Hypertrophy:

Right ventricular hypertrophy produces T-wave inversion in the right precordial leads V1-3 (right
ventricular ‘strain’ pattern) and also the inferior leads (II, III, aVF).

T wave inversion in the inferior and right precordial leads due to RVH

PULMONARY EMBOLISM:
Acute right heart strain (e.g. secondary to massive pulmonary embolism) produces a similar
pattern to RVH, with T-wave inversions in the right precordial (V1-3) and inferior (II, III, aVF)
leads.

T wave inversion in the inferior and right precordial leads in a patient with bilateral PEs

Deep T wave inversion in V1-3 with RBBB in a patient with massive PE

Pulmonary embolism may also produce T-wave inversion in lead III as part of the SI QIII TIII
pattern (S wave in lead I, Q wave in lead III, T-wave inversion in lead III).
SI QIII TIII pattern in acute PE

HYPERTROPHIC CARDIOMYOPATHY(HOCM):
. HOCM is associated with deep T wave inversions in all the precordial leads.

T wave inversion in V1-6 due to HOCM

RAISED INTRACRANIAL PRESSURE:

. Events causing a sudden rise in ICP (e.g. subarachnoid haemorrhage) produce widespread
deep T-wave inversions with a bizarre morphology.

Widespread deep T wave inversion due to SAH

BIPHASIC T WAVES :
There are two main causes of biphasic T waves:
Myocardial ischaemia
Hypokalaemia

The two waves go in opposite directions:

. Ischaemic T waves go up then down
. Hypokalemic T waves go down then up
Ischaemia

WELLENS SYNDROME:
Wellens’ syndrome is a pattern of inverted or biphasic T waves in V2-3 (in patients presenting
with ischaemic chest pain)

30.CHICKEN POX
1. T. Acyclovir 800mg 5 times x 5-7 days
2. T. Cetirizine 10mg HS x 5 days (for itching)/amitriptyline 10mg BD
3. Plenty of oral fluids
4. Sisomicin cream if eruption

Can be given in pregnancy and lactation too

5 times x 5 days

Pediatric - 20mg/kg/dose 5 times x 7 days, not exceeding 800mg/day

If secondary infection
Ampiclox
Azithromycin

Varicella Vaccination (BIOVAC)

9mon - 12yrs = single dose 0.5ml S/C deltoid
> 13 yrs = 2 doses 6 wks apart 0.5ml S/C deltoid
Vaccine contraindicated in pregnancy

31.C/C LIVER DISEASE

Input/output monitoring
Bowel wash HS
Syp. Lactulose 10ml tid or 30ml HS
T. Rifaximin 550mg BD/Rifagut 400mg TID
Inj Vit K 1amp IV OD
T. MVT 1 OD

Altered sleep - T. Librium 2 HS

Syp looz 30ml HS

T. Folic acid 5mg OD

T. Propol(propranolol) 20mg BD
Inj Thiamine 100mg IV OD

Ascitic tap, FFP

Cirrhosis with PHTN

If altered sensorium - meningeal signs?

Inv
Routine
PT/INR

TREATMENT
Inj cefotaxime 2g IV BD
Inj Vit K 1amp IV OD
Inj Thiamine 100mg IV OD
T. Rifaximin 550mg BD
Inj Analiv 5g in 1 ⚀ NS BD
Inj. Pantop 80mg in 1 ⚀ NS Q8H
Kanzomin sachet 1/2-0-1/2
Bowel wash BD
Syp looz 30ml HS
Ryles tube aspirate
Inj. Perinorm 1amp IV Q8h

T. Propranolol 20mg TID

T. Lasix 40mg 1-1-0

Analiv- L ornithine- L- aspartate, pancreatin

T. Analiv 500mg
Kanzomin - amino acids (valine, isoleucine, leucine)

HEPATIC COCKTAIL PREPARATION

Lemon 2
Tender coconut water 3
Glucose 50mg
Syp. Polybion 15ml

3 tender coconut , 2 lemon.15-20ml syp. polybion. 1 pack glucose powder. Mix dilute to 5-6
litters give over 1 day for hepatic encephalopathy with drowsiness... Reduce glucose in diabetic
s....titrate according to urine output if it is low - caution in Hepatorenal syndrome.. Avoid in
hyperkalemia...
Good cheap substitute for analiv or kanzomin(lola) in other situations
32.C/C KIDNEY DISEASE
Always take as a/c on chronic
1.
Symptoms:
Increased fatigue
Anorexia
Abdominal pain
Persistent vomiting
Edema
Decreased urine output

Nephropathy:
. INTRINSIC-symptoms
Increased BP
Hematuria, proteinuria
Albuminuria, edema
Decreased urine output
. TUBULO-INTERSTITIAL-symptoms
⬇ or normal BP,
Normal output (nocturia), ⬆️thirst
Anaemia - peritubular cell source of EPO
Acidosis

DIABETIC KIDNEY DISEASE

pt with DM, have renal disease but not DKD if
. No retinopathy
. Short duration of diabetes
. Renal artery stenosis

Symptoms
Frothy urination (proteinuria)
Edema (hypoalbuminemia)
Hypertension
suspect DKA

POVD signs- Peripheral pulse? Carotid bruie?

Neuropathy - ⬇ sensation and ⬇ reflexes
Non healing ulcers, osteomyelitis
Diabetic retinopathy - blurred vision, floaters, decrease in visual acuity

Investigation
UKB, RBS, ECG & S. E for hyperkalemia
TREATMENT
Inj. Lasix 20mg iv stat
T. Lopin(amlodipine) 5mg stat
If low k+ ◀ 3.5=2 amp Kcl in 1 ⚀ NS(32 drops/min)
3.5 - 5=2 amp Kcl in 1 ⚀ NS(16 drops/min)
▶ 5=no correction needed
S/c insulin - calculate the total dose needed to correct DKA, 2/3rd of that is needed. Of that 2/3rd plain &
1/3rd NPH

Adv:
T. Arkamin(clonidine) 0.1mg TID x 1 week

33.CONJUNCTIVITIS
Infective - ciplox or ofloxacin eye drops QID x 1w
Allergic - limbal thickening
Redness around limbus
1. Sodium cromoglycate eye drops BD x 1 week
2. Winolap(olopatadine) eye drops BD x 2 weeks

Eye functioning
Zn sulphate astringent eye drops

Ciplox QID 1 wk
Oflox QID 1wk
Children Tobramycin QID x 7 days (<11 yrs)
Moxiflox e/d QID x 1 week
Flurbiprofen(Flur) e/d QID x 1 week

Predmet( prednisolone) QIDx 1 week, then taper TID, BD, OD

HPMC(hydroxypropyl methyl cellulose) e/d QID

34.CONSTIPATION
1. T. Dulcolax 2 tab(5mg/10mg) HS x 5 days
2. T. Domperidone 10mg OD x 5 days
3. Syp. Lactulose 10ml TID or 30ml HS
4. Liquid paraffin(stool softener) 30ml @6 pm

Soap water enema

▶ 2 yrs 5ml BD (syr. Lactulose)

▶ 5 yrs 10ml BD
Syp. Milk of magnesia ( 1tsp with 1 glass of water)
(Syp. Cremaffin plus)

Syp. Trucolax 10ml tds

(liquid paraffin, milk of mg, sod. Picosulphate)

EMETICS
Apomorphine (oral 0.02 - 0.3mg/kg)
Syp. Ipecac 5ml/kg

MODERATE
1) Diet
2) Water intake to be increased
3) Isopgul or Isogel 1 tsp in water or milk daily at night
4) laxative syrup(senolax syrup) 1 tsp daily
5) syp of fig

SEVERE
1)hypertonic saline enema
2)bowel wash with normal saline till all the hard masses are removed

Beans, sweet potato, groundnut, almond, cauliflower, broccoli, maize, cabbage, green leaves,
orange, apples

35. COUGH
If productive cough- T. Azithromycin 500mg OD x
syp. Ascoril 2tsp BD
syp. Bromhexine/Guaiphenesin
2tsp TID x 5 days
Syp. Ambroxol

Non-productive cough- Mit'S Linctus codeine 2tsp

TID x5d or
Codiene Syp 10mg TID or
Syr. Tusq D 2 tsp BD
T. Cetrizine or
T. Salbutamol
Pulmorex D

1.T. Asthalin 2mg TID x 5 days

T. Amoxicillin 500mg TID x 5 days

2. For both cough & cold)

Syp. Tmini (phenylephrine + CPM)
 Syp. Cetin Bro(cetirizine +ambroxol)

COUGH SYP
1. Syp. Piriton 1 tsp TID x 5 days
(wet cough)
2. Syp. Brohist- D 1tsp TID x 5 days
(dry cough)
3. Syp. Brohist-P 1tsp TID x 5 days
(productive cough)
4. Asthalin salvent- salbutamol sulphate
5. Asthalin exp - terbutaline sulphate, bromhexine
HCL, guaiphenesin
6. Ascoril ESBRON - terbutaline sulphate,
bromhexine HCL, guaiphenesin
7. Ascoril LS - levosalbutamol sulphate, ambroxol
HCL, guaiphenesin
8. Bromo - terbutaline sulphate, bromhexine HCL,
guaiphenesin
9. Tusq Dx - dextromethorphan HBr,
chlorpheniramine maleate, phenylephrine HCL
10. Respicure(MUCODIL) - terbutaline sulphate,
ambroxol HCL, guaiphenesin
11. Epixyl LD -terbutaline sulphate, bromhexine HCL, phenylephrine HCL
12. Ventryl
13. Vindopen PD
Ascoril

cough >2 years of age

1. Syp. Asthalin 1 tsp TID
2. Steam inhalation
3. Syp. Amox 125 mg/ 5 ml or 250 mg/ 5 ml
pneumonia refer

Mucorin A
Acetylcysteine 300mg + ambroxol 30mg

36.CUT INJURY
Clean, suture, wound

Prilox cream (lidocaine & prilocaine)

C/I in open wounds, around eyes

1. Inj. TT 0.5ml IM stat

2. T. Ampiclox 500mg QID x 5 days
3. T. Rantac 150mg BD x 5 days
4. T. Lyser D BD x 5 days
5. Remove suture after 5 days

Facial sutures should be removed within 3-5 days if not leads to secondary infection and
scarring.
Face 3-5 days
Neck 7 days
Arm and back of hands 7 days
Scalp 5-7 days
Chest abdomen and back 7-10 days
Legs and top of feet 10 days
Palm, soles, fingers or toes 12-14 days
Overlying a mobile joint 12-14 days

Mucosa - monocryl 5-0

Prolene 5-0
Catgut- best absorbable

Vicryl(Absorbable) for lip

Adrenaline soaked, Gauze

37.DENGUE
3 stages - fever 1-4days, convalescence 4-7 days , recovery >7days

Fever 5 days
Lethargy
Myalgia, Retro orbital pain, back pain
Abdominal pain - cholecystitis, pancreatitis, hepatitis
Persistent vomiting
Rashes, facial redness
Pt looks too sick

Signs of capillary leak - 3rd space leak( seen in 2nd infection, super infection,
immunosuppressed)
Conjunctival edema, chemosis
Ascites
Pleural effusion
Mucosal Bleeding

Postural hypotension, S.BP fall >20, D.BP> 10mmHg

Hepatomegaly >2cm
Rapid ⬆️ in PCV, ⬇ in Platelets
Signs of shock- tachycardia, hypotension

PLT transfusion indication:

Plt < 10000
Bleeding manifestation except petechiae, ecchymosis
CKD, CLD patient

Plt increase will take 2 weeks

Investigation
CBC, Dengue NS1 antigen, Dengue IgM antibody

Treatment
. Complete rest, papaya leaves juice
. IVF - only in febrile phase (avoid fluid overload-pulmonary edema )
. Symptomatic treatment

38.DIABETIC FOOT:
TPR, BP, I/O Chart
Inj. Ampicillin 500mg IV Q6H
Inj. Cloxacillin 500mg IV q6h
Inj. Tramadol +Phenergan im
Pantop
IVF
Insulin

X-ray to r/o osteomyelitis

39.DIARRHOEA
1. Cap. Enuff(Racecadotril or Zedott=antisecretory) 2 tab stat
⬆️ - 10mg, 100mg
Cap. Enuff 100mg BD/TID x 3 days
Cap. Vizylac TDS x 5 days (vit-thiamine & riboflavin, lactobacillus, pyridoxine )
(Syp. Vizylac)

2.T. Ciplox 500mg BD x 5 days Or

T. Metrogyl 400mgTID
3. ORS

If severe : lnj. Cipro 200mg IV ATD Q12H or

Inj. Gentamycin 80mg IV Q8H or
Inj. Metronidazole 500mg IV ATD Q8H
 IVF - RL
4. T. Loperamide 4mg stat, 2mg after each stool
5. C. Neutralin B (MVT +lactic acid bacillus) OD
6.T. Bifilac(lactobacillus) BD x 5 days
C. Ginvus gold OD
(lycopene, chromium, lactic acid bacillus, vit, min)

T. Albendazole 400mg single dose

MUCOUS DIARRHOEA
T. Ornidazole 500mg BD x 5 days
T. Tinidazole 500mg BD (after food)
Syp. Digene gel (to ⬆️metallic taste)

DYSENTERY:
1. One pint RL/NS
2. T. Ciprofloxacin(ciplox) 500mg BD x 5 days
Child - cefixime
3. T. Rantac 150mg BD x 5 days
4. T. Paracetamol 500mg TDS/SOS
5. ORS x 5 days

Loperamide(antimotility) Pediatric dose 1mg TID or 2mg BD

(C/I in children)

ORS
1. Ringer lactate
Racecadotril[acetorphan or zedot ] 100mg TDS
Ciplox TZ BD 5DAYS
T. cyclopam 10 mg if needed
T. lactospore TDS
Inj. Metrogyl 100 ml iv

Padiatrics
No drugs needed
IV Fluids, isolyte p
Syr vizylac 1 tsp BD
Syr Zincovit 1 tsp BD
ORS
Infants : syp. Zinc 20mg/5ml (7-14days)
<6 mon of age 10mg OD
>6 mon of age 20mg
40.FOOD POISON
T. Ciplox 500mg 1-0-1x 5 days
T. Rantac 150mg BD x 5 days

IN pregnancy:
IVF - RL or NS (K+ supplement if needed)
Loperamide
Bismuth subsalicylate
Ciprofloxacin 500mg TID x5 days

C. Sanflora(prebiotic & probiotic)

41.DIABETIC KETOACIDOSIS
DM with infection, stress, trauma develop DKA
DM pt with abdominal pain, vomiting, sweating, tremor, blurred vision & disorientation

Alcohol, pregnancy - euglycemic DKA, GRBS<300

Signs - Pt looks too sick, dehydration, Hypotension, cold extremities, peripheral cyanosis, tachycardia,
kussmaul breathing, smell of acetone, hypothermia, confusion and coma.
Hyponatremia, hyperkalemia, azotemia

ECG - For electrolyte imbalance

Inv - GRBS, UKB, SE, RFT,
Check BP If systolic <90, 2 ⚀ Ns

2 IV cannulas, large bore(18G)

Start fluids (3L NS, 3L DNS) NS to replace ECF, DNS to replace ICF
Check SE, if K+ >3.3 start insulin infusion
If K+<3.3 inj. KCL 1amp in 1 ⚀ NS over 4hrly

If GRBS above 250, do UKB & ABG (<7.35)

1.50U plain insulin in 1 ⚀ NS (16 drops/min=1ml/min=0.1U/kg/hr)

2. Another iv for hydration ( 2 ⚁ NS in 30min, next 2 ⚁ NS in 1hr, next 2 ⚁ NS in 2hr, next 2 ⚁ NS in 2-
4hr & when GRBS <270 give 5D 1L 8-hourly)
3. GRBS hourly (if decreasing 50-100/hr mx good, if not increase the drops of insulin by 4-8 drops/min.
GRBS <250 ➡ 8 drops/min, <180 ➡4-6 drops/min & then stop if no acidosis. Stop insulin infusion &
change to S/C insulin)

4. Bicarbonates- for coma, shock, acidosis, severe hyperkalaemia, acidosis induced resp/Cardiac failure
Sodium bicarbonate 50-100mEq in 1L 0.45% NS over ½—1hr

Calculate the dose of insulin, 2/3 PI and 1/3 NPH

Check hourly GRBS, 4th hourly SE, SpO2, Bp

0.1U/kg weight (6 - 8 U) IV or IM or S/C glucose should fall 55-110mg/dl/hr

(if Hypoglycemia may lead to cerebral edema)

Complications of DKA
(ACIDITI)
ARDS
Cerebral edema
Infections
Dilatation (gastric dilatation, gastritis)
Insulin resistance
Thrombosis
Infarction (MI)
Hypoglycemia,hyperkalaemia- initial stage
Hypokalaemia - once Rx starts

42.DOG BITE/CAT BITE

1. Wash the site with soap and water for 15 min
2. Inj. TT 0.5ml IM stat
3. IDRV 0.5ml on days 0 3 7 & 28 (2-2-2-2)
4. ERIG, calculate the total dose (0.133 x wt in kg) in
and around the wound, rest in buttock(not more
than 5ml)
5. C. Ampiclox 500mg QID x 3 days

I Touch or lick on intact skin No Rx

II Minor scratches, aberrations IDRV
III Blood oozing IDRV + ERIG

Pre-exposure 0 7 28(1 site)

Re-exposure 0 3(1 site)
IMRV 0 3 7 14 28 90

IMRV indications: Sites

Immunosuppressive patients .Deltoid
Pts on drugs like Steroids. . Ant lat part of thigh
Uncontrolled DM
43. DYSMENORRHEA
1. T. Meftal spas 500mg TID x 3 days
2.T. Omeprazole 40mg BD x 2 days

Inj. Meftal spas 1amp im

Inj. Tramadol 50 - 100mg
Inj. Cyclopam
OCP's - To convert anovulatory cycles to ovulatory

Primary - in young adolescent, due to contractions of uterus, normal

Secondary - due to some gynecological pathology

Fibroids
Adenomyosis, Endometriosis
STD, PID
Ovarian tumor
Intra Uterine device

44.EAR BLEED
If active bleed ear pack by tillis forceps
Cause - trauma, fb ear
Ruptured eardrum- trauma,fb,sounds, pressure variation
Skull fracture - base of skull fracture
Viral hemorrhagic fever (ebola)
Otic polyp
Malignant otitis externa
DIC

Look for facial nerve /csf rhinorrhoea

Never do syringing

PINNA LACERATION
1. Thorough cleaning with H2O2 & betadine ⬇ LA
2. Suture with 3-0 silk, without injuring cartilage
If cartilage injury ➡ need admission (risk of perichondritis)
Inj. Ciplox
T. Ciplox
Mupirocin Ointment for LA

45.EAR PAIN
Children: Adult:
A/c otitis media, ASOM Otitis externa
Otitis externa CSOM, mastoiditis
Ear picking Trauma,TM joint arthritis
Foreign body ASOM, wax,
Wax Malignant otitis externa
referred pain throat

AOM/ASOM
h/o ear pain more at night,
h/o URTI few days ago
No ear discharge (if discharge & pain - ASOM)

Always look for complications - mastoid tenderness, meningitis, sepsis, facial palsy

1. Syp/T. Amoxicillin x 10 days (Avoid ciplox for children)

2. Syp/T. Cetirizine 10mg HS x 5 day(avoid <2yrs)
3. Syp or T. P'mol /meftal
4. Nasal drops - NS or oxymetazoline or xylometazoline(otrivin) x 1 week
Avoid ear drops / nose blowing

Earache,Ear discharge
Otogesic ear drops 2-2-2 *Ear drops
Otogesic (benzocaine, phenylephrine, antipyrine)
Chloragesic(lignocaine + chloramphenicol)
Syp. Ibugesic 0.5 tsp x 3 days

AOM (give antibiotics minimum of 10 days)

Amoxicillin
Ampicillin
Co-amoxiclav
Erythromycin
Cefixime
Cefpodoxime
Co-trimoxazole

Maggots in ear :
Symptoms : severe pain, blood stained watery discharge
Rx: instill chloroform water/4%xylocaine
Syringing is contraindicated

Living organisms in ear :

Instill oil
Spirit
Chloroform water
4% xylocaine
Syringing
Oral nasal decongestant
Pseudoephedrine(sudafed) 30mg BD

CSOM:
Always look for complications
1. T. Ciplox 500mg TID x 1 week
2. T. Rantac 150mg BD x 1 week
3. Ciplox D ear drops 2° TID x 1 week
4. T. Cetrizine 10mg HS x 1 week
5. Saline/ oxymet N/D x 1 week

Ear Drops
Neomycin
Polymyxin
Chloromycetin
Gentamycin

OTITIS EXTERNA
H/o ear picking, cleaning, trauma
H/o diabetes ➡to r/o malignant otitis externa
Look for FB, TM status
Adv:
1. Steroid (betamethasone) +antibiotic(sofra/genta) ear pack, remove after 48hrs
2. Moxiclav 625mg/ cloxacillin
3. P'mol/meftal
4. Bestopic N Ointment/ Neosporin H/ Burg(G, T, bact)

46.EAR WAX
Symptoms:
Diminished hearing
Tinnitus
Giddiness
Reflex cough(due to wax impaction on tympanic membrane)

EAR DROPS
1. Otorex
2. Waxolve
3. Soliwax
4. Dewax(ceronil) 1 drop TID x 1 week then do syringing
(Carbamide peroxide)
(paradichlorobenzene+turpentine oil+chlorobutanol+lignocaine)

Sodium bicarbonate drops with glycerine x 1w then syringing

47.ELECTROCUTION
ECG
CBC
RFT - myoglobinuria
X-ray for fractures, spine
URE
Spo2

LOOK FOR:
. Severe burns- Entry & Exit wound
. Confusion
. Difficulty breathing
. Heart rhythm problems (arrhythmias)
. Cardiac arrest
. Muscle pain and contractions
. Seizures
. Loss of consciousness

Treatment
. Inj. TT 0.5ml IM stat
. IVF - RL
. Minor wounds - dressing
. Large wounds - need sx consultation, expect acidosis, myoglobinuria
. Monitor urine output (fluid shift) - catheterise
. CPR

Bicarbonate - For acidosis

Mannitol

48.EPISTAXIS
Cause
CHILDREN ADULT
URTI URTI
Foreign body Hypertension
Trauma Alcoholism
Bleeding disorder use of antiplatelets
Nose picking Bleeding disorder
Malignancy- mass
Rhinosporidiosis

1. Check vitals - BP, PR

2. Nose pinching & ice pack application
3. Start IV infusion, sit forward
4. Inj. Tranostat 500mg IV stat/sos
 Or
T. Tranostat 500mg TID
4. Inj. Ampicillin 500mg IV Stat, ATD
5. Inj. Pantop 40mg IV stat
6. Oxymetazoline/Saline Nasal drops 2° stat & QID
7. T. Levocetrizine 5mg HS/cetrizine 10mg stat
8. T. Amlodipine 5mg stat (if HTN)
9. T. Alprax 0.5mg SOS

Nasal packing - with soframycin Ointment

Avoid nose blowing

Examine for post nasal bleeding in throat

In case of trauma - surgery consultation

X-ray nasal bone lateral view

49.NASAL BONE #
X-ray Nasal bone lateral view
Any external deformity /crepitus of nasal bone
Septal hematoma - pinkish fusiform swelling
CSF rhinorrhoea - clear fluid rich in sugar on bending forward (Target sign in white kerchief)
If asso. # of other facial bones need CT scan

PNS - sinus tenderness

Adv
1. Antibiotics
2. Analgesics
3. Septid D
4. T. Cetirizine 10mg HS
5. Oxymetazoline Nasal drops
6. Avoid nose blow

Displaced # - Reduction immediately or after 5-7 days (inflammation subsides)

Look for septal hematoma/CSF rhinorrhoea

50.FEBRILE SEIZURES
1. History
TYPICAL ATYPICAL
Single episode Recurrent
Onset within 24hr Anytime
Less than 10mts More than 15mts
 Generalised Focal
No postictal confusion +
Epilepsy in future (-) +

Rule out bacterial Meningitis

2. Left lat. Position, o2 inhalation, throat suction and maintain airway

3. Vitals
4. Check GRBS(if lasts >5 min, LOC.. 5ml/kg of 10% dextrose ) , Electrolytes, SGPT, TC, DC, BUN
5. Tepid sponging
6. Paracetamol 15mg/kg x TID, tepid sponge
7. If seizures present at examination inj. lorazepam
0.1mg/kg over 1min(max 4mg)(slow IV) 1st dose
⬇ (not controlled)
Inj. Lorazepam 0.05mg/kg
Or
IV diazepam 0.3mg/kg/dose over 2min (max 5mg/kg)
Rectal diazepam 0.3-0.5mg/kg/dose(max 10mg)

1. Inj Diazepam 0.3mg/kg IV (should not be diluted)

If no IV access rectal Diazepam
Repeat after 20 mnts
2. Inj. Midazolam 0.15mg/kg. Buccal midaz 0.5mg/kg, (max 10mg)
3. Inj. Lorazepam 0.1mg/kg, a repeat dose of 0.05mg/kg may be given over 10 min

If convulsions doesn't subside or if recurs start

Phenytoin sodium IV 15-20mg/kg (diluted 1:1 in in saline or distilled water) at a rate of 1mg/kg/min

If seizures persist, phenobarbitone 10mg/kg IV. Can be repeated once.

Diazepam drip 20mg in 500ml RL (0.04mg/ml) at a rate of 7ml/kg/hr

If K/C/O febrile seizures - prophylaxis

Tab. Clobazam(frisium 0.3-1.0mg/kg) 5mg hs.. Max 10mg x 3 days
<30Kg =5mg OD
Onfi (Clobazam) oral suspension 2.5mg/ml

51.FEVER
36.6 - 37.2°C
Hyperpyrexia >107°F
Fever with joint pain, rash - Dengue, chikunguniya

1. P'mol ⬆️ 125mg, 250mg, 500mg, 625mg

Pediatric (10 - 15mg/kg)
 If temp ⬆ 100= inj. P'mol 1amp IM stat
Observe, if Allergy ➡inj Avil/dexona

Do BRE, URE, Peripheral smear

Lepto- ⬇ urine output, body ache
Dengu- ⬇ platelets
Malaria - PS for parasites
2. Amoxicillin 500mg TID
Or
Levofloxacin 500mg BD
Or
Taxim 200mg BD
3. If along with body ache
Meftal-P(mefenamic acid+paracetamol)TID x5days

FEVER + HEADACHE
1. Jonac(diclofenac) suppository(if severe
headache)
2. Piroxicam 2 tab sos
3. Meftal-P TID x 5 days
4. Antibiotics if necessary
5. T. AC para(aceclofenac +paracetamol
100+500mg ) 1 tab sos
6. T. Sibelium(flunarizine) 10mg OD x 2 weeks

Inj. p'mol 1 amp IM stat (if ▶ 100F)

Adult -T. pmol 500 mg TDS x 3 dy

Children -T. pmol 250 TID x3dy
5-9 yrs -syp. pmol 250 1 tsp TDS x 3dy
<5 yrs -Syp. pmol 125 1tsp TDS x 3dy

Infants Acetaminophen drops 3 drops x 3dy

P'mol suppository (Anamol) 8 mg/kg wt stat

Moxkid DT(amoxicillin) 125 OR 250 mg

P'mol suppository 80mg, 125mg,175mg

SHORT FEBRILE ILLNESS

1. Q4H Temp/BP chart
2. Inj. C. Penicillin 1.5million units IV Q6h ATD
3. T. Doxycycline 100mg BD
4. T. Pantop 40mg OD
5. T. P'mol 500mg SOS

52.FOREIGN BODY EYE

Look under torch light,check visual acuity
Eye wash with NS
Try to remove with cotton bud after applying proparacaine
Ciplox or ofloxacin eye drops BD x 1 week
Pad and bandage

53.FOREIGN BODY NOSE AND ORAL CAVITY

Nose:
If anteriorly placed - can use tilley forceps
Slippery, rounded objects - remove by eustachian catheter

Position of the child very important

Oral Cavity:
Look for respiratory distress - if severe Heimlich maneuver

Look for FB in oral Cavity

IDL examination
If no FB seen- x-ray soft tissue neck- AP & LAT
Look for wheeze- chest x-ray PA View

ADVICE - Refer
NPO
Inj. Pantop
IV antibiotics - ampicillin 500mg Q6H ATD
IVF
Inj. Diclofenac 1amp IM ATD
In. Dexona 8mg IV stat

CT scan- if several days back

If remove ⬆️GA/LA
Inj. TT

Type of FB, time of insertion, time of last food intake, complaints, point of distress

54.GASTRITIS
1) Inj. Rantac 50mg IV
2)Inj. Pantop 40mg IV
3) syr. Mucaine gel TID (anaesthetic gel)
4) T. Rantac 150mg BD
5)T. Pantop 40mg OD
6) T. Omeprazole 20mg OD/BD
7)T. Rabeprazole 20mg OD/BD
8)T. Lansoprazole 15/30mg

55.GIDDINESS /VERTIGO
first differentiate between syncope & vertigo
If syncope - transient loss of consciousness
Vertigo - surrounding spins
Symptoms increases during exercise of UL- subclavian steal syndrome- Check B/l radial pulse

Look for anemia, ⬆ ⬆️BP, GRBS, ECG

Romberg’s test? ⬆️ Vit B12 deficit
Rule out cerebellar function: (post. Cerebral circulation stroke)
Finger nose, heel knee,straight line walking
Dysdiadochokinesia, nystagmus, rebound phenomenon
Visual complaints

VERTIGO
1)Inj. Stemetil(prochlorperazine (12.5mg) 1amp IM
stat
2)T. Vertin(Betahistine) 8mg(TDS) or 16mg (BD)x 3 days (C/I in children)
3)T. Cinnarizine 25mg BD/TDS x 3days
If not subsided ENT consultation
4)T. Stemetil 5mg BD x 5 days ( have extrapyramidal
side effects, giv inj. Phenergan 12.5mg IM stat)
5)T. vertigon(cinnarizine + domperidone) 25 mg
6)T. stugeron(cinnarizine + domperidone) 25 mg
TDS

T/inj. Promethazine theoclate(avomine) 25mg

Diazepam 5-10mg IV
Inj. Atropine 0.4mg sc

BPPV? - vertigo for min

Meniere's? - min - hours
Viral labyrinthitis, Drugs- sedatives, ototoxic? > 24hrs

56.HAEMATEMESIS
Erosion, ulcers, alcoholism, esophagitis, bleeding disorders, CA stomach, NSAIDs
Post.nasal pathology

Always check postural BP

Look BP, PR
Keep NPO
1. Check BP if below 100
2. Put 2 IV cannula, supine, head end down
3. Start 2 pint NS fastly( colloids better RL)
4. Inj. Pantop 1amp Iv stat Or Inj emeset 4mg IV
Or (REFER)
Inj. Pantop 120mg in 1 ⚀ 5D over 12th hourly
Inj. Pantop 80mg IV in 1 ⚀ NS Q8H x 3days
5. Ryles tube➡look for fresh blood
Give cold saline wash
6. Monitor BP, PR
7. Inj. Vit K 1amp(10mg) IV OD
Inj. Ethamsylate 1amp(250mg) IV stat & Q8H
Inj. Octreotide 50-100mcg IV stat & 250mcg in 1 ⚀ NS infusion in 5hrs(25-50mcg/hr)
8. Inj. Terlipressin 2mg IV stat, and 1mg Q6h
9. Inj. Cefotaxime 1g IV Q8H

Syp. Lactulose 10ml TID

T. Rifaximin 550mg BD

Hb? Arrange blood? RFT, LFT, SE, PT/INR

57.ALOPECIA /HAIR FALL

1. Betnovate scalp solution
2. Evion capsules puncture and locally apply on scalp
3. Tab evion 400 mg od
High protein diet . cold hair bath. don't comb wet hair. protein shampoo twice weekly.

Tab. Biotin OD

dandruff, seborrheic dermatitis

Flucort lotion BD then maintenance tacrolimus lotion

Look for Anemia hypothyroidism.

Vit D And Biotin is good supplement
If patient can afford, vit D assay and D3 sachet can be prescribed

If the hairloss s circumscribed alopecia areata - give topisal 6% or clobetasol cream plus biotin
and minoxidil
If it is diffuse and local cause like seborrhea present treat it with kz shampoo twice weekly

If it is telogen effluvium ( following stress ) - give supportive treatment

58.HAND FOOT MOUTH DISEASE

Usually occurs in children, viral etiology
No specific antiviral
Disease is self limiting within a week (7-10 days)
Spread through body fluids

SYMPTOMS:
. Fever, sore throat, Irritability
. Skin Rash over foot and hand, buttock⬆️ may turn into blisters
. Painful blisters in mouth,
. Headache, loss of appetite

TREATMENT:
. Supportive
. Plenty of oral fluids, avoid spicy foods
. Ice creams and cold drinks
. Paracetamol
. Cetirizine

If blisters - give ointment (emollient)

Emoderm

59.HEAD INJURY
OBSERVATION
GCS
Pupillary reaction
Limb movements
RR, PR, BP, Temperature, SpO2

MANAGEMENT of EDH
Npo/ Neuro observation /Head injury chart
IVF 1500ml NS
Inj. Taxim 1g IV Q8H ATD
Inj. Gentamycin
Inj. Rantac 50mg IV BD /pantop 40mg IV OD
Inj. Paracetamol 2cc IM TID
Inj. Eptoin 600mg in 200ml NS over 20 mins & 100mg Q8H
Inj. Thiamine 100mg IV OD (for alcoholics)
Refer to neurosurgery

SDH
Inj. Mannitol 100ml IV Q8H
Inj. Vit K IV OD
Inj. Phenytoin 1g IV infusion & 100mg TID
Inj. Pantop 40mg IV OD

GCS (Normal 15, Abnormal 3-14)

Eye Opening
Spontaneous (4 points)
To speech(3 points)
To pain (2 points)
None (1 point)

Best Motor Response

Obeys verbal command (6 points)
Localizes pain (5 points)
Withdraws from painful stimuli(4 points)
Abnormal flexion to pain[decorticate] (3 points)
Extensor response [Decerebrate] (2 points)
None (1 point)

Best Vocal Response

Oriented conversation (5 points)
Confused (4 points)
Inappropriate words (3 points)
Incomprehensible sounds (2 points)
None (1 point)

INDICATIONS FOR CT SCAN

GCS ◀ 13, any time after injury
GCS =13 or 14, 2 hrs after injury
GCS 14/15 with
Suspected open or depressed fracture
Any sign of basal skull fracture
Hemotympanum
Panda eyes
CSF otorrhoea
Battle's sign
More than one episode of vomiting
Age greater than or equal to 65, loss of
consciousness, or amnesia
Post traumatic seizures
Coagulopathy- on warfarin/Aspirin/Clopidogrel
Focal neurological deficit
Amnesia of events 30min before the event
High velocity RTA
Fall from significant height

INDICATIONS FOR ADMISSION

All patients with GCS ◀ 14
Pt's with new, clinically significant abnormalities on imaging
Evidence of recent intracranial bleeding/contusion/pneumocephalus

Pt's who have not returned to GCS equal to 15 after 24hrs of observation, regardless the
imaging results

If for CT scan
Persistent vomiting, severe headaches

Drug or alcohol intoxication

Shock
Meningism
CSF leak

OBSERVATION (at least for 6 hrs)

GCS half hourly until GCS=15
Pupillary reaction
Limb movements
RR, PR, BP, Temperature, SpO2

60.HEADACHES
Examine for
Fever, rash, purpura - meningism
Thunder clap- SAH
Gait, temporal region- Thickening of sup. Temporal artery
Sinus tenderness
Red eyes? Palate? Glaucoma?
Pain during movement of neck, cough, sneezing?
Diminished vision
Change in cognition
Aura, nausea, vomiting

TREATMENT
T. paracetamol
Inj. Ketanov ATD
Inj. Tramadol + Phenergan
SUNCT/SUNA
2-3 min headache, DD- Trigeminal Neuralgia
Rx- A/c - iv lidocaine
Prophylaxis - lamotrigine, topiramate, Gabapentin

TEMPORAL ARTERITIS
Elderly >50yrs,females. Inflammation of the vessel - narrowing
Headache, jaw claudication, polymyalgia rheumatica, fever, weight loss
If untreated =loss of vision (ophthalmic artery involved due to narrowing by inflammation )
Temporal artery - thick, (biopsy)
Rx- prednisolone

TENSION HEADACHE
Most common headache
No associated symptoms
Increased with movement, emotions
Rx- low dose amitriptyline
T. Amitriptyline 10-25mg HS
T. Diazepam 2mg
T. P'mol 500mg or, ibuprofen 400mg

Primary sexual headache - Rx Indomethacin

R/o SAH( Thunder clap)

MIGRANE
Inj. Ketonov/other Analgesics im stat ATD
If nausea - inj. Emeset
Inj. Fortwin(pentazocine) 30mg in 1ml IM stat

1. T. Meftal 500mg TID

2. T. Flunarizine 5/10mg HS x 2 weeks (have extrapyramidal side effects)
3. T. P'mol 500mg TID
4. T. Domperidone 10mg TID/emeset 4mg
5. T. Stemetil 5mg BD /sos

Tab. Vasograin 1 sos

(ergometrine, pmol, caffeine, prochlorperazine maleate)

MIGRANE PROPHYLAXIS (if 3-4 episodes lasting for >48hrs/month)

1. T. Propranolol 20mg OD/BD x 1 month
2. T. Pregabalin 75mg HS x 2 weeks
3. T. Amitriptyline 25mg HS x 1 week (best)
T. Imipramine 25mg TID
Gabapentin
Pizotifen

If severe (a/c)
T. Sumatriptan 25mg(50-100mg) orally Q2H
(max 300mg/day)
Inj. Sumatriptan(6mg) 0.5ml SC

Sumatriptan + naproxen[Best]
Naproxen(NSAIDs) 500mg BD

Lie down in dark room, ice packs over head

T. Ergotamine 1-2mg stat, then 1mg ½hrly till relief
(max 5mg/day, C/I in pregnancy & elderly)
T. Fortwin 25mg QID
+ p'mol(Fortagesic) TID

Symptoms :
Common in females, usually lateralized
With(classical) or without aura(common)
Numbness, photophobia, phonophobia, vomiting
Visual field defects
OCP's can precipitate so avoid if taking
Previous similar history

Rule out other causes of headaches - HTN, head injury, sinusitis, referred pain

CLASSICAL MIGRAINE - with aura

Rx - Valproate, Topiramate

COMMON MIGRAINE
Rx - Propranolol

MIGRAINE SINE MIGRAINE

Only blurring of vision (aura) for 10-20min without headache
Precipitating factors = TV, sweets, hypo

Treatment - beta blockers

CLUSTER HEADACHE /PAROXYSMAL HEMICRANIA

Both same features
Migraine features, males, begins @ Same time
½-1hr duration (5-8 episodes/d)
Cluster Rx-
A/c sumatriptan inj or 100% O2
Prophylaxis =verapamil, lithium, methysergide

Hemicrania Rx - Indomethacin 2-3wks

61.HEPATITIS A
Loss of appetite,
Nausea, vomiting
Abdominal pain
Fever

IgM HAV, HBsAg, HCV,.. PT/INR, LFT

IVF - 2 ⚁ DNS with polybion over 8 hours

T. Udiliv(ursodeoxycholic acid) 300mg/150 1-0-1
5mg/kg BD (⬇ LDL)in treatment of gallstones
T. Limarin(silymarin) 70/140mg BD/TID (in Liver d/s)
T. Pantop 40mg BD
Inj. Emeset 8mg IV Q8H
Inj perinorm 10mg IV BD

PT>OT, GGT⬆️- alcoholic

In a/c hepatitis albumin normal
In c/c hepatitis albumin decreased

children- silymarin 5mg/kg/day in BD/TID

Hep A vaccine 1-18yrs 0.5ml IM 2 doses 6mon apart

>19yrs 1ml IM 2 doses 6 mon apart

HEPATITIS B
Needle prick injury from HepB pt
HepB Ab titer >10 mIU/mL (normal)
<10mLU/mL is negative
give HBIG + HBV

HepB vaccine <10 yrs 0.5ml IM arm

>10 yrs 1ml IM arm
Dose- 0,1,6 mon
62.HICCUPS
1. Inj. Perinorm 1amp (10mg) IV stat
Inj. Phenergan 12.5mg IM stat (for extrapyramidal
symptoms)
2. Inj. Pantop 40mg IV stat
3.T. Pantop 40mg BD x 3days
4.T. Baclofen 5mg/10mg BD x 3days
Syp. Mucaine gel 2tsp stat

RFT

inf wall MI
uraemic encephalopathy
Sub diaphragmatic abscess

Breathing in and out in plastic bag, hold breath as long as possible

Drink ice water

63.HYPERCALCAEMIA
ECG CHANGES
shortening of the QT interval
In severe hypercalcaemia, Osborn waves (J waves) may be seen
Ventricular irritability and VF arrest has been reported with extreme hypercalcaemia

Bizarre-looking QRS complexes

Very short QT interval
J waves = notching of the terminal QRS, best seen in lead V1
Cause
Hyperparathyroidism (primary and tertiary)
Myeloma
Bony metastases
Paraneoplastic syndromes
Milk-alkali syndrome
Sarcoidosis
Excess vitamin D (e.g. iatrogenic)

64.HYPEREMESIS GRAVIDARUM
Stop oral feeds (if severe)
1. Inj. Phenergan 12.5mg IM stat (IV)
2. T. Doxinate[doxylamine+pyridoxine(vit B6)] 10mg +10-30mg BD or metoclopramide 10mg tid
3. IV Fluids RL or NS
4. Intermittent IV 25% dextrose 100ml bolus

5%DNS is much of no use

If prolonged vomiting Thiamine 100mg IV can be given to prevent wernicke's encephalopathy

MILD
B6+ doxylamine or
Diphenhydramine or
Dimenhydrinate

MODERATE
Promethazine
Prochlorperazine
Chlorpromazine
Metoclopramide or
Odansetron

SEVERE
IVF + Thiamine
IV metoclopramide
Promethazine
Odansetron

65.HYPERGLYCEMIA
FBS >126mg/dl
PPBS > 200mg/dl

Symptoms of DM + RBS >200

Hba1c >6.5%

Symptoms
Increased nocturnal urination
Increased thirst
Blurred vision, headache

Keto Acidosis features

Nausea, vomiting, abdominal pain
Fruity smelling breath
Dry mouth,
Confusion, coma

GRBS above 230

If 200 - 300 = T. Metformin(glyciphage) 500mg stat
300 - 350 = T. Glimi-M2(Glimepiride +metformin) 1g
stat
Above 400 = Inj. Plain insulin iv stat(6 units) & then 50U insulin in 1 ⚀ NS(6 drops/min).
Assess GRBS hourly, stop if below 250

Inj. PI 6U IM stat, if K+ > 3

If <3 insulin infusion 50U in 1 ⚀ NS 16°/min with 1 amp kcl in 1 ⚀ NS. Monitor hourly GRBS,

1. T. Metride(Glimepiride +metformin) 1mg OD

2. T. Tribet(Glimepiride +metformin +pioglitazone)
3. Glibenclamide(Daonil) - 2.5mg BD or 5mg OD
4. Pioglitazone - 15-45mg OD
5. Voglibose - 0.2-0.3mg (pt having only postprandial hyperglycemia, give with each meal )
6. Glimepiride 1-8mg OD (rbs▶ 300)
7. Glipizide 2.5-30mg OD/BD
8. Metformin 500mg OD

Metformin 500mg start twice daily and can increase up to 1g TID. (METFORMIN SR OD/BD)

OHA(Antiglycemics)
1)T. Metformin(Glyciphage) 500mg OD to start with
(especially if obese)
2)T. Glibenclamide 1.5mg OD to start with then
2.5mg BD, 5mg BD
3)T. Glimepiride 1mg OD to start with
4)T. Glipizide 5mg OD to start with

66.HYPERKALAEMIA
Even if symptom is not present, treatment is needed

Drugs(spironolactone, ACEI, AKI/CKD, Dietary intake

>5.5mEq/L

clinical features:
Cardiac arrhythmia, palpitation, muscular weakness
➡ flaccid paralysis and respiratory distress
Bradycardia

Unexplained ecg finding consider hyperkalaemia

S. E, RFT, ECG
ECG
Tall, peaked T waves
Prolongation of PR interval
Prolongation of QRS complex
Reduced or absence of P wave
Sine wave pattern

TREATMENT
1. 10ml of 10% calcium gluconate over 2-3min q8h
2. Nebu with 10-20mg of salbutamol in 5ml NS over 10 minutes, Q8H can be repeated every 2-6 hrs
3. 50ml of 50% glucose + 10 U Plain insulin IV bolus
Or
500ml of 20% glucose + 10 U plain insulin iv infusion over 6-12 hrs
Or
100ml 25%D with 10U PI q8h

Cation exchange resins (oral or rectally)

1. Sodium polystyrene sulfonate 25-50g mixed with 100ml of 20% sorbitol orally.
Or
Sodium polystyrene sulfonate 50g + 50ml of 70% sorbitol mixed in 150ml of water as enema
2. Calcium Resonium(15 mg)
3. K bind resin 1/2 sachet in 30ml sorbiline Q8H along with food (not on empty stomach), plenty of oral
fluids

If acidosis present
50-100 ml of 8.4% sodium bicarbonate IV
Inj. NaCo3 2amp IV Stat

If residual renal function present

Furosemide and normal saline IV

If these measures fails

Haemodialysis

67.HYPERTENSION
Can present as
Headache, SAH, IC Bleed, CVA, MI, LVF, nausea, vomiting, giddiness, palpitation, dyspnoea,
blurred vision

ANTIHYPERTENSIVES
1) T. Atenolol 25mg/50mg/100mg to start with
2) T. Amlodipine 5mg OD to start with
3) T. Enalapril 2.5mg OD to start with
4) T. Metoprolol 25mg/50mg OD to start with
5) T. Losartan initial dose 50 mg, maintenance dose
25-100mg OD
6) T. Telmisartan intial dose 40mg OD, maintenance
dose 20-80mg OD
Hydrochlorothiazides 25-100mg OD

68.HYPOCALCEMIA
Ionized Ca+ normal 8.8-10.4mg

SYMPTOMS
Severe symptoms of calcium deficiency disease include:

confusion or memory loss

muscle spasms
numbness and tingling in the hands, feet, and face
depression
hallucinations
muscle cramps
weak and brittle nails
easy fracturing of the bones
Seizures
Neuromuscular excitability
Carpopedal spasm
Tetany
Chvostek’s sign
Trousseau’s sign

ECG changes:
Hypocalcaemia causes QTc prolongation primarily by prolonging the ST segment.
The T wave is typically left unchanged.
Dysrhythmias are uncommon, although atrial fibrillation has been reported.
Torsades de pointes may occur, but is much less common than with hypokalaemia or
hypomagnesaemia.

Treatment
Inj. Calcium gluconate 10cc slow iv
T. Calcium 500mg OD
T. Vit d3

69.HYPOGLYCEMIA
If GRBS▶ 100 normal
◀ 80 5%DNS if BP normal
If low BP + vomiting
25%DNS 100ml stat
IVF - RL/NS + polybion 1⚀ if BP 90/60

Pt feeling dizzy & head spin

GRBS
IF 60 - 80 = 25ml 25% dextrose push stat
40 - 60 = 50ml 25% dextrose push stat

Symptoms
Tremor
Nervousness /anxiety
Sweating, chills and calmminess
Irritability, impatience
Confusion, Delirium
Lightheadedness, dizziness
Nausea, hunger,
Blurred /impaired vision
Tingling or Numbness of lips and tongue
Weakness, fatigue
Sadness, stubbornness
Lack of coordination
Seizures, unconsciousness
Tachycardia

70.HYPOKALEMIA
Even symptom is not present, treat it

ECG changes:
Small or absent T waves or inverted T waves
Prominent U waves (in precordial leads)
ST depression
Apparent QT Prolongation (due to fusion of TU waves)
T wave is the tent house of K(potassium)

(More K- tall T, less K- flat or inverted T)

Treatment
Syp. Potklor 10ml in 1 glass water
Tender coconut water, bananas, orange, tomatoes
Inj. KCL 1amp IV

SYMPTOMS
. Muscle cramps
. Weakness, tiredness, or cramping in arm or leg muscles, sometimes severe enough to cause
inability to move arms or legs due to weakness (much like a paralysis)
. Tingling or numbness
. Nausea or vomiting
. Abdominal cramping, bloating
. Constipation
. Palpitations (feeling your heart beat irregularly)
. Passing large amounts of urine or feeling thirsty most of the time
. Fainting due to low blood pressure
. Abnormal psychological behavior: depression, psychosis, delirium, confusion, or
hallucinations.

Complications
Frequent supraventricular and ventricular ectopics
Supraventricular tachyarrhythmias: AF, atrial flutter, atrial tachycardia
Potential to develop life-threatening ventricular arrhythmias, e.g. VT, VF and Torsades de
Pointes

Hypokalaemia is often associated with hypomagnesaemia, which increases the risk of

malignant ventricular arrhythmias
Check potassium and magnesium in any patient with an arrhythmia

71.HYPOTENSION
1. 2 ⚀ NS, refer if not better
2. 2 amp noradrenaline in 1 ⚀ NS, start 6°/min
3. 2 amp Dobutamine in 1 ⚀ NS & start with 4°/min (max 32 drops)
Need ICU setup

Bp around 60mmhg ➡10ml NS IV push + iv fluids fast

Bp 90mmhg ➡no iv push, only IVF

Bp+palpitation ➡T. Amlodac-AT (T. Aten 25mg)

If diabetic 1 ⚀ NS
If non diabetic 1 ⚀ 5%DNS

Inj. Vasopressin 1 amp in 250ml NS over 4°/min

Symptoms
Dizziness or lightheadedness
Fainting
Dehydration and unusual thirst
Lack of concentration
Blurred vision
Cold, clammy and pale skin
Rapid and shallow breathing
Fatigue and depression
72.HYPOTHYROIDISM
Do Free T3, Free T4, TSH

TREATMENT
T. Thyroxine 25/50/100 mcg early morning on empty stomach

psychosis
Constipation
Metabolic encephalopathy
Myxedema coma- ⬇ BP, ⬇ temp, ⬇ RR, unresponsive,
coma

Fatigue
Weight gain
Constipation
Dry skin
Hoarseness of voice
Increased sensitivity to cold
Muscle weakness
Elevated cholesterol levels
Muscle aches, stiffness, swelling of joints, pain
Thinning of hair
Bradycardia
Oligomenorrhea
Depression, impaired memory
Hyporeflexia, decreased muscle tone

In INFANTS
Jaundice
Frequent choking
Large and protruded tongue
Constipation, decreased muscle tone
Puffy face
Fail to grow - short
Excessive sleepiness
Mental and physical retardation
Delayed puberty
Delay in eruption of permanent teeth

73.IMMUNISATION
At Birth:
Hep B - within 24hrs, 0.5ml IM, Ant.lat.Thigh(almt)
BCG - Within 1 year, 0.1ml(0.05ml within 1mon), ID, Left upper arm
OPV 0 - Within 15 days, 2 drops, Oral
6, 10, 14 weeks:
Pentavalent - 0.5ml IM ALMT(upto 1 yr of age)
(DPT, Hep B, HiB)
OPV - 1st 2nd 3rd doses 2 drops oral
Or
IPV - 0.1ml ID right arm @ 6 & 14 weeks

9-12 months:
Measles - 0.5ml, s/c, right arm
(Give upto 5 yrs if not received at 9-12mon)
Vit A - 1ml (1lakh IU) oral

1 3/4 yrs (15 months) :

MMR - 0.5ml s/c right arm

1. 5-2 yrs(18-24 months):

DPT Booster¹ - 0.5ml IM ALMT
OPV Booster¹ - 2 drops oral
Vit A (2nd dose) - 2ml(2 lakh) oral

Every 6 months Vit A - 2ml, oral, upto 5 yrs

2 years :
Vit A 3rd dose 2ml oral
2.5 years:
Vit A 4th dose 2ml oral
3 years
Vit A 5th dose 2ml oral
3.5 years:
Vit A 6th dose 2ml oral
4 years:
Vit A 7th dose 2ml oral
4.5 years:
Vit A 8th dose 2ml oral

5-6 years:
DPT Booster² - 0.5ml IM upper arm
Vit A 9th dose 2ml oral

10 years:
TT - 0.5ml IM upper arm

16 years:
TT - 0.5ml IM upper arm

1-7 yrs(if Pentavalent not taken)

DPT

>7 years(if Pentavalent not taken)

DT single dose 0.5ml IM arm

Varicella vaccine (don't give if <1yr of age)

<15yrs 1 dose 0.5ml IM
>15yrs 2 doses 0.5ml 1 month apart

HepB <10 yrs 0.5ml IM arm

>10 yrs 1ml IM arm
0,1,6 mon

3.5yrs not immunized

Give BCG, DPT¹, OPV¹, Measles, Vit A

HPV vaccine
9 - 25 yrs(ideally before the Onsest of sexual life 11-12 Yrs)
Bivalent [cervarix] 16,18 0.5ml IM (dose 0,1,6) - only for females
Quadrivalent[Gardasil] 6,11,16,18 0.5ml IM (dose 0,2,6) - Males and females
9 valent HPV[Gardasil 9]- both males and females 0.5ml IM

PREGNANCY SAFE VACCINES

TT
Hep A & B
Rabies vaccine (ARV

74.INCESSANT CRY
Thorough history and examination ; ask for appetite and stool passage( if good - minor
problems)
1. Nasal discharge/stiffness
Saline Nasal drops 1 drop QID x 1 week

2. Abdominal pain - less than 6 mon = Breast milk

3. Fever - r/o meningitis
4. Intusucception- h/o weaning, coliky pain, red
current jelly stools.
Breast feed - Look whether cry is consolable or not
Unconsolable - r/o meningitis
5. ASOM - high fever
6. Osteomyelitis - Look for any immovable limbs
7. Pinworm - pruritus ani (look around anus)

Rx
1. Syrup Pedicloryl(triclofos sodium) 500mg/5ml
(for sleeping)
1/2 of body wt in ml
2. Syr. Colicaid ◀ 6 mon age 5-10 (4)drops QID
▶ 6-12month 10-12(8) drops TID/QID

75.INTERTRIGO
Occurs in any skin folds
Erythema, crusting, fissuring, vesicles & pustules in later stages

Treatment
Keep the folds dry
Compress with burrow solution 1:40
Clotrimazole ointment
Castellani paint (carbol fuchsin)

76.IC BLEED
Mannitol infusion
Lasix: T. Furosemide 40mg or inj. Furosemide 10/20mg
Dulcolax 5mg 2 tab HS x 5 days
Gelusil Al(OH)3 500mg

Refer to neurosurgery

77.INTUBATION
ETT size
males 8-8.5
Females 7-7.5

Children <6 age/3 +3.5

>6 age/4 +4.5

Insertion depth
Children age/2 +12
Males 20-22 at incisor level
Females 18-20

78.IRREGULAR MENSES
Young girl
1. T. Fe OD x 3 weeks
2. T. Mala D/Mala N OD x 21 days (start on 5th day)
3. T. Deviry OD x 10 days (for withdrawal bleeding)
4. T. Metformin 500mg OD x 2 weeks / BD 3
months
Investigate for PCOD

79.POISON (ABRUS PRECATORIUS)

Symptoms
Haemorrhagic gastritis
CVS manifestation - arrhythmia, convulsions, cerebral edema

TREATMENT
Decontamination ( stomach wash, activated charcoal)
Supportive measures

80.LEPTOSPIROSIS
High fever, rigor and chills, headache, myalgia, vomiting, diarrhea, jaundice, red eyes,
abdominal pain, rash(purpura petechiae, epistaxis)
BRE

T. Doxycycline 100mg TID x 3days or BD x 7 days

C/I in pregnancy & children, for them amox 500mg

81.MEASLES
Viral fever, usually in unimmunised child

Highly contagious, fever, sore throat, running nose, myalgia, whole body rash, cough, red eyes,
koplik's spots- inside mouth

Treatment
1. No specific antiviral treatment
2. Plenty of oral fluids
3. Complete bed rest, avoid contact with others at least for 4 days after the appearance of rash
4. T. Paracetamol
5. Vaccination of unimmunised child within 3 days of exposure
6. Vit A can be given
7. If secondary infection present - antibiotics

Complications:
Otitis media
Croup
Diarrhea
Pneumonia
Encephalitis

82.MENORRHAGIA
1. T. Trapic-MF TID x 3 days
(tranexamic acid + mefenamic acid)
2. T. Fe OD x 3 weeks
3. T. Deviry(medroxyprogesterone) TID x 3 days

83.MOTION SICKNESS
T. Phenergan 10 mg 1 hs before travel
Inj. Phenergan 25 or 12.5mg
T. Chlorpromazine 25 mg TDS x 3 DAYS

Avomine(promethazine) 25mg
Hyoscine 0.2mg before travel most effective
300mcg 30 min before travel, (Q4h if needed)

84.MUMPS
Fever, myalgia,
Any h/o abdominal pain
Male pt- always check for orchitis

Treatment:
-Plenty of oral fluids
-T. Paracetamol
-Complete rest, reduce personal contact
-Mouth wash after each food

If orchitis
-Scrotal support
-Analgesics NSAIDs
Or T. Prednisolone 60mg OD x 3 days, then taper over 4 days

Complications:
. Orchitis
. Pancreatitis
. Meningitis
. Encephalitis
. Oophoritis, mastitis - after puberty
. Hearing loss
. Abortions
85.NUMBNESS
(peripheral neuropathy, numbness)
1. T. Pregabalin 75mg HS x 5 days
2. T. Gabapentin 100mg TID x 3 days

T. Amitriptyline 25mg HS x 1 week

T. Nurokind (B12)
T. Nurokind G(B12+Gabapentin)
T. Nurokind Lc(B12+FA+L-carnitine)
C. Renerve

Renerve
Alpha Lipoic Acid, Chromium Picolinate, Folic Acid, Inositol, Mecobalamin, and Selenium as
active ingredients.

Renerve plus
+ zinc

Renerve G
Gabapentin 300mg + B12 500mcg

Renerve D
+ pyridoxine + vit D3

Inj. Vit C IM/IV/SC

20ml in 50ml ns iv

86.NIPPLE CRACK
Nip care ointment for LA BD x 1 week
Apply after each feed

Lanolin - emollient

87.NIPPLE DISCHARGE
Milky discharge - Check local cause - infection
S. Prolactin levels?
H/o thyroid disease?

GALACTORRHOEA
T. Bromocriptine(Dopamine agonist) 0.8/2.5/5mg OD x 2 weeks
88.OPHTHALMOLOGY
Check vision

Proparacaine e/d ( anesthetic)

Moxiflox eye drops/ eye Ointment
Tobramycin e/d
Flurbiprofen e/d
Chloromycetin applicaps
T. Ciplox 500mg BD
T. Rantac 150mg
T. Mefenamic acid 500mg
C. Sporidex(cephalexin) 250mg TID
LUBRICANTS
Hpmc(hypromellose) e/d
Cmc(carboxymethyl cellulose) e/d

UVEITIS
Predmet e/d
Cycloplegic atropine - action 2 wks
Homatropine- 2 days
Cyclopentolate 24 hrs
Tropicamide + phenylephrine 6 hrs

GLAUCOMA
never give Cycloplegic
Always check digital tonometry

CHEMICAL INJURY
Eye wash 3-4 unit NS
Antibiotic drops
Lubricant
Steroid drops

WELDING - flash of light

Pain at night
Rx- eye padding with antibiotics for at least 24hrs

CORNEAL ULCER
No padding

DACRYOCYSTITIS
A/C, C/C
A/C= warm Compress
T. Ciplox, moxiflox eye drops
 Massaging
T. Mefenamic acid
Abscess - I&D

89.ORAL CANDIDIASIS
T. Fluconazole 150mg once a week x 4 weeks
Candid mouth paint

90.PEDIATRIC DOSE
Weight calculation
◀ 1 yr x+9/2
1-6 yr 2x+8
▶ 7 yrs 7x-5/2 or 3x

Blood transfusion - 10-15ml/kg

Feed-150ml/kg Q2H after PND7

Fluid replacement per day

0-10kg = 100ml/kg
10-20kg = 1000ml for the first 10kg + 50ml/kg for
each kg beyond 10
▶ 20kg = 1500ml+20ml/kg for each kg beyond 20

1. T. Paracetamol - 10-15mg/kg/dose x TID/QID

Syp. P'mol 125mg/5ml
250mg/5ml
Suspension - 100mg/ml
⬆️ - 125mg, 300mg, 500mg, 650mg
(Pain, fever)
Suppository 1-2yrs 80mg
2-4yrs 170mg
4-6 yrs 250mg
For 0-2 yrs paracetamol drops (calpol 100ml/ml)
3-5kg 0.5ml(8 drops )
5-8kg 0.8ml
8-11kg 1.2ml
11-13kg 1.7ml
13-15kg 2ml

2. C. AMOXICILLIN - 10/kg/dose x TID

Syp. Amoxicillin 125mg/5ml, 250mg/5ml
⬆️ - 125mg, 250mg
 (ENT & URTI infection)

3. T. Salbutamol - 0.1mg/kg/dose x BD/TID

Syp. Salbutamol 2mg/5ml
Nebulisation 0.5mg in NS
⬆️ - 2mg, 4mg

4. T. Azithromycin - 10mg/kg/dose x OD
Syp. Azithromycin 100mg/5ml, 200mg/5ml
⬆️ - 250mg, 500mg
DT- 100mg
Inj. 500mg
(pneumonia, pertussis)

5. T. Diazepam - 0.1-0.3mg/kg/dose x TID

⬆️ - 2mg, 5mg, 10mg
⬆️ - 5mg/ml
Syp. - 2mg/5ml
(anxiety, panic disorder, convulsions, muscle relaxation, extrapyramidal symptoms)

6. T. Albendazole(zentel) 2 doses 2 weeks apart

◀ 2 years 200mg stat(Rx whole family)
▶ 2 years 400mg stat
(don't give if below 1 year)
Syp. 200mg/5ml
T. Banocide(Diethylcarbamazine)
(for filariasis,Tropical eosinophilia)
⬆️ 50mg, 100mg
Syp. 50mg/5ml

7. T. Cyclopam - 0.5mg/kg/dose x TID

Syp. Cyclopam 10mg/5ml
⬆️ - 10-20mg im
⬆️ 10mg, 20mg
(don't give below 6 months)

8. Metoclopramide(perinorm)
0.1mg/kg/dose xTID
Syp - 5mg/5ml; ⬆️ - 10mg ;⬆️ 5mg/ml
9. Ondansetron(emeset) - 0.1mg/kg/dose x TID
Syp - 2mg/5ml ; ⬆️ - 4mg, 8mg
⬆️ ◀ 5 yrs 2mg IV stat
▶ 5 yrs 2-4mg IV stat

10. Domperidone(domstal)-0.3mg/kg/dose TID

⬆️ 5mg,10mg
Susp. 1mg/ml
(hav extra pyramidal side effects)

11. Anal excoriation - Siladerm gel for LA BD x 1

week

12. Ranitidine (Rantac)

2mg/kg/dose BD
IV 1-2mg/kg/dose
⬆️ 150mg, 300mg
Syp 75mg/5ml
⬆️ 2ml amp(25mg/ml)
Carmicide(sodium citrate + citric acid) 5ml BD

13. Mefenamic acid - 8mg/kg/dose x TID

100mg tab

MEFTAL-P Syp MEFTAL-P Tab

6 months - 2 years 2.5 ml ½ tablet
2 - 5 years 5 ml 1tablet
5 - 9 years 7.5 ml 1 ½ tablet
9 - 12 years 10 ml 2 tablets

14. Paraffin (laxative)

1ml/kg OD upto 5 years r
Above 5 yr, 5-10ml/dose

15. Pantoprazole 0.5-1mg/kg/dose OD

⬆️ - 20mg, 40m
( duodenal/gastric ulcer, reflux esophagitis)

16. Acyclovir
⬆️ - 200mg, 400mg & 800mg
⬆️ - 250mg
Suspension - 200mg/5ml, 400mg/5ml
 Ointments
Chicken pox- 16mg/kg/dose x 5 times x 7 days
Adults - 800mg 5 times x 7 days
Herpes simplex- 10mg/kg/dose x TID/QID x7days

17.T. Ambroxol 30mg

Syp 15mg/5ml
(for cough with expectoration)

18. Amikacin 7.5mg/kg/dose BD/TID IV/IM

(for septicaemia)

19. Co-Amoxiclav(Rx pneumonia)

15-30mg/kg/dose x BD
⬆️ 375mg,625mg
Syp. 228.5mg, 457mg

20. C. Ampicillin (for both gram +ve&-ve inf)

12.5-25mg/kg/dose QID IM/IV ATD
⬆️ - 250mg, 500mg
DT-125,250mg
Syp. 125mg or 250mg/5ml

Ampiclox 15mg/kg/dose x TID

Syr. 125+125/5ml

Syrup Pedicloryl(triclofos sodium) 500mg/5ml

(for sleeping)
0.5mg/kg/dose
1/2 of body wt in ml

Syrup Colfin 2mg/5ml

(for URTI)
0.1mg/kg

Syr. Atarax(hydroxyzine) 2mg/kg/dose x BD

(10mg/5ml)
Antihistamine, (for Allergy, sedation, anxiety)
T. Hydroxyzine 10mg,25mg,50mg TID

Syr. Colicaid ◀ 6 mon age 5-10 (4)drops QID

▶ 6-12month 10-12(8) drops TID/QID
Colicaid =simethicone+dill oil +fennel oil
(for abdominal pain)

T. Iron 3-6mg/kg/day x 3 months

T. Clobazam(frisium) 0.5mg/kg (benzodiazepine)

(for seizures)

Syr. Smuth (magnesium hydroxide)

For ulcers, heartburn, indigestion

Syr. Sodium valproate

Syr. Taxim (50mg/5ml)

Syr. Cefixime 100/5, 200/5, 500/5

(4mg/kg BD)

Diaper rash
Happynap cream
Siladerm cream

ANTACID( Gelusil)
Infants =1-2ml/kg/dose QID
Children =5-15ml/kg/dose QID

ASPIRIN (for rheumatic fever)

75-100mg/kg/day in 4 divided dose
Analgesia- 10mg/kg/dose QID
Antiplate-5mg/kg/day OD

ACYCLOVIR
(for Herpes simplex encephalitis, cutaneous and genital HSV, Varicella, chickenpox)
10mg/kg/dose TID/QID x 1 week
⬆️ 200mg, 400mg, 800mg
Susp. 400mg/5ml, 200mg/5ml
Inj. Vial 250mg
Topical ointments

ADRENALINE
1ml amp of 1:1000 solution (1mg/1ml)
(for bronchospasm, anaphylaxis, restoration of cardiac rhythm in cardiac arrest (C/I ventricular
fibrillation), nebulisation in croup and bronchiolitis)
0.01ml/kg/dose slow s/c(not ▶ 0.5ml/dose) may repeat after 5 min
1-5ml for nebulisation

AMBROXOL
⬆️ 30mg
Syp. 15mg/5ml

AMIKACIN
(for neonatal sepsis)
7.5mg/kg/dose BD/TID IM /IV
◀ 7 days neonates BD
▶ 7 days neonates TID

AMPICILLIN
⬆️ 250mg, 500mg
Syp 125mg/5ml, 250mg/5ml
50-100mg/kg/day ➗into 4 doses
◀ 7 days age 50mg/kg/dose BD/TID
▶ 7 days age 50mg/kg/dose TID/QID

ANTI HAEMOPHILIC FACTOR

25U/kg/dose every 12-24hrs

BETAMETHASONE
0.2mg/kg/day in 2-3 ➗ dose
(for anaphylactic reactions, asthma, Allergic dermatitis, Allergic conjunctivitis, uveitis)
⬆️ 0.5 mg
⬆️ 4mg/ml
0.1% ear/eye drops,
skin cream 0.025% x OD - TID

BISACODYL(DULCOLAX)
◀ 2yrs 5mg suppository
▶ 2yrs 10mg suppository
▶ 6 yrs 5mg HS
⬆️ 5mg
Suppository 5mg, 10mg

BROMHEXINE
(mucolytic)
4mg/dose x TID/QID

CARBAMAZEPINE
5-10mg/kg BD
Antiepileptic(for seizures, neuropathic pain, trigeminal neuralgia)
Syr. Tegretol 100mg/5ml

CEPHALEXIN
50-100mg/kg/day in 3-4 ➗ dose
Cap 250mg
DT 125mg, 250mg
Syp 125or250mg/5ml
(for UTI, skin and soft tissue infect, pharyngitis, bone & joint infection, tonsillitis)

CETIRIZINE
◀ 1yr 2.5mg OD HS
1-6yrs 2.5mg OD/BD HS
⬆️5, 10mg (0.2mg/kg/day)
Syp 5mg/5ml

CHLORAMPHENICOL
50-100mg/kg/day in 4 ➗dose
(for meningitis, typhoid, pneumonia)

CPM
0.1mg/kg/dose x TID
Upto 6 yrs 1mg QID
▶ 6 yrs 2mg QID
⬆️ 2mg, 4mg
Syp 2mg/5ml

CIMETIDINE
10-20mg/kg/day in 4 ➗dose
⬆️ 200mg, 400mg
(gastric and duodenal ulcer)

CINNARIZINE
0.3-0.5mg/kg/dose x TID
⬆️ 25mg
(for vertigo)

CIPROFLOXACIN
10-15mg/kg/dose x BD
10mg/kg/dose x BD IV
⬆️ 250mg, 500mg, 750mg
CISAPRIDE
(for non ulcer dyspepsia, reflux esophagitis)
0.15-0.3mg/kg/dose x TID/QID
Syp 1mg/ml
⬆️ 10mg

CLOXACILLIN
100-200mg/kg/day PO, IM, IV
⬆️ 250mg, 500mg
Syp 125mg/5ml
⬆️ 250mg, 500mg

CO-TRIMOXAZOLE(trimethoprim[TPM] +sulfamethoxazole)
(for UTI, pneumonia, bacterial diarrhea)
6-10mg/kg/day(tpm) in 2 ➗ dose
⬆️ (80mg tpm+400mg sulpha)
⬆️ Pediatric T(20+100)
Syp (40+200)

DERIPYLLINE
(for asthma)
5mg/kg/dose x TID
C/I in seizures
⬆️ 100mg
Syp 50mg/5ml
⬆️ 110mg/ml

DEXCHLORPHENIRAMINE MALEATE
0.1mg/kg/day
⬆️ 2mg
Syp 2mg/5ml

DEXTROMETHORPHAN
Antitussive(for cough) use carefully in asthma and productive cough, because it suppress the
elimination of sputum
1mg/kg/day in 3-4 ➗dose
Adult = 10-30mg x TID/QID
DIAZEPAM
0.1-0.3mg/kg/day 3 ➗dose
In status epilepticus 0.3mg/kg/dose slow IV, repeat if needed
Has respiratory depressant effect, give sternal pressure or ambu bag support
Rectal dose 0.5 mg/kg then 0.25mg/kg after 10 min if needed (rectal acts faster than IM)

(for anxiety, Epilepsy)

Adult, anxiety - 2-10mg BD/TID/QID

DICLOFENAC (ATD- 0.1ml test dose, watch for 15min before giving IM)
1mg/kg/dose x BD/TID
⬆️ 50mg
SR ⬆️ 75mg, 100mg
Ophthalmic drops
⬆️ 3ml vials with 25mg/ml

DICYCLOMINE(cyclopam)
(for abdominal pain, renal colic, spasmodic dysmenorrhoea)
C/I ◀ 6mon, urinary retention
0.5mg/kg/dose x 3 (don't give below 6 mon of age)
Child 10mg/dose x BD /TID
Adult 20-40mg/dose

DIMENHYDRINATE(dramamine)
(for vertigo, motion sickness)
5mg/kg/day in 3-4 ➗dose
2-5yrs = 12.5mg/dose
▶ 5yrs = 25mg/dose
Adult 50mg/dose

DIPHENHYDRAMINE(benadryl)
(for allergies, extrapyramidal symptoms)
5mg/kg/day in 3-4 ➗dose
⬆️ 1mg/kg/dose
Adult 25-50mg QID

DOXYCYCLINE (don't give below 8yrs)

(for cholera, mycoplasma, chlamydia)
5mg/kg/day OD
Adult 100-200mg/day in 1-2 ➗dose

ERGOTAMINE
(for migraine headache)
 ⬆️ 1mg

ERYTHROMYCIN
(for atypical pneumonia, pertussis, pharyngitis)
⬆️ 250mg, 500mg
Susp 125mg/5ml
10mg/kg/dose
Infants 10mg/kg/dose BD
▶ 7days age 10mg/kg/dose TID

ETHAMSYLATE
(for epistaxis, haematemesis, haemoptysis)
10mg/kg
Adult 250-500mg QID

FLUCONAZOLE (C/I in liver disease)

(for systemic candidiasis)
6-12mg/kg/day in 1-2 ➗dose 1-4 weeks
⬆️ 50mg, 150mg, 200mg
Adult :Oropharyngeal candidiasis = 200mg on day1
then 100mg for 14 days
Vaginal candidiasis 150mg single dose

FRUSEMIDE
1-2mg/kg/dose x TID/QID
0.5-1mg/kg/dose IM TID/QID
⬆️ 40mg
⬆️ 20mg/2ml
(for pulmonary edema, cardiac edema, hepatic edema)
Adult 20-80mg/dose x TID/QID

FURAZOLIDONE
(for enteritis, protozoal diarrhoea)
⬆️ 100mg
Susp 25mg/5ml
6mg/kg/day in 3 ➗ dose orally
C/I ◀ 1 month of age

FUSIDIC ACID
Antibiotic for LA

GAMMA BENZENE HEXACHLORIDE(scaboma)

(for pediculosis capitis, P. Pubis, scabies)
1% lotion, 1% cream once in a week
GENTAMYCIN
(for infection in newborn, septicaemia, UTI)
5-7.5mg/kg/day in 2-3 ➗dose IM/IV
C/I un renal failure

GRISEOFULVIN
(for Tinea of skin, hair, nail and scalp)
5mg/kg/dose x BD
⬆️ 125mg, 250mg, 500mg
C/I in liver disease

HYDROCHLOROTHIAZIDE
(for edema, hypertension )
Edema: ◀ 6 mon age= 1-1.5mg/kg/dose x BD
▶ 6 mon age= 1mg/kg/dose x BD
Adult = 25-100mg/kg/day in 1-2 ➗dose
HTN: 1mg/kg/day OD (children)
Adult 12.5-50mg OD

HYDROCORTISONE(as succinate)
(for anaphylaxis,,status asthmaticus, shock, addison's disease)
5mg/kg/dose
⬆️ 20mg
⬆️ 100mg IV
HYDROCORTISONE(as acetate)
Inj. 25mg (for osteoarthritis, keloid give only intralesionally) don't give IM/IV

IBUPROFEN
(for dental pain, aphthous ulcer)
⬆️ 200mg, 400mg
Susp 100mg/5ml
8-10mg/kg/dose x TID/QID
Adult 400-800mg/dose x TID/QID
Syp. Ibugesic

Syp. Metronidazole 100mg/5ml.. 5mg/kg

Midazolam 0.05mg/kg IV

Activated charcoal , in syp. Sorbitol 100ml

<6 mon 1-2g/kg
>6 mon 50-100g

Muscle spasm
C. Myoril(thiocolchicoside) 2/4/8mg BD x 5 days
C. Myoril plus
Myospaz(chlorzoxazone) BD
Myospaz forte
Inj. Myoril 1amp IM ATD

WALRI
Prednisolone 1-2mg/kg/day in 2 ÷ dose
Syp. Prednisolone 5/5, 10/5, 15/5,20/5, 25/5
⬆️ - 5mg

Dulcolax suppository 5mg/10mg (>6yrs)

Oral thrush
Candid(clotrimazole) mouth paint
>4 mon old, clean tongue by kerchief
Silicon baby brush

91.PARONYCHIA
A/c & c/c
A/c - due to trauma
C/c - fungal infections

Look for floating nail- if present remove

Treatment
Drain pus
Ampiclox
Analgesics

92. PULP SPACE INFECTIONS

TREATMENT
Vertical oblique incision
Ampiclox
Analgesics

93.HEMORRHOIDS
1 Cap. Smuth HS x 1 week
2 Ointment smuth for LA
3 Sitz bath- sit in saline for 20-30min 2-3 times/day
4 T. Dulcolax 2 tab hs or syr. Lactulose 10ml tid
5 Fiber diet, plenty of water
6 Antibiotics if needed

Smuth = calcium dobesilate(500mg) +Docusate sodium (100mg)

BLEEDING PER RECTUM

T. Ethamsylate 500mg TID
T. Trapic 500mg OD
T. Cadisper C 1 daily
T. Rantac

94.PILONIDAL SINUS
More near sacral region just above coccyx, males
Primary lesion in the fissure
Secondary on adjacent sides

Symptoms
Pain, discharge, swelling
Tuft of hair in opening sinuses

TREATMENT
T. Ciplox tz bd
Metrogyl ointment la x 1 week
Drainage of abscess
Sx - Excision with Z plasty

95.ANAL FISSURE
An ulcer of the anal canal, common in males, posteriorly

Cause- constipation, hard stools, std

A/C - Severe sphincter spasm, pain, constipation, without edema & inflammation
C/C - inflamed, indurated, sentinel pile,
Less pain, bleeding, discharge

Treatment
Sitz bath ,adequate fluid intake
Diltigesic(Diltiazem 2%) ointment LA (dilate BV)
Syp. Lactulose
Lignocaine ointment 5%
0.2% nifedipine ointment (relax sphincter pressure)
Nitroglycerin ointment (dilate BV)
Stretching anal canal
Sx- fissurectomy, sphincterotomy
96.PNEUMONIA
Symptoms
High grade fever, rigor and chills, fast breathing, Breathlessness, Leucocytosis

ATYPICAL
Abdominal pain, mild fever, cough, diarrhea

If staph Aureus
Rapidly progressing pneumonia, pneumatocele, emphysema,

<2 months
Inj. Ampicillin 50mg/kg/dose q6h ATD
Inj. Gentamicin 5mg/kg/dose Q12h ATD
If chlamydia suspected
Inj. Azithromycin 10mg/kg/dose OD

Indications for hospitalization:

• Infants less than 3 months
• Severe malnutrition
• More than two risk factors
• Comorbidities
• Associated complications
• Respiratory rate more than 70/min in infants and more than 50/min in older children
• Respiratory distress – grunting, alae nasi flare, ICR or SCR
• Cyanosis or SpO2 less than 92% in room air
• Poor oral intake/dehydration
• Inappropriate observation or supervision at home

97.POISON KEROSENE
1. Chest x-ray - To r/o pneumonia
2. Don't do ryles tube wash
3. Check Spo2
4. Monitor hourly RR

Inj. Pantop 1amp IV stat

O2 if needed
Inj. Corticosteroids

CLINICAL FEATURES
Respiratory problems may develop within 6hrs

Acute exposure to kerosene by inhalation can result in headache, dizziness, drowsiness,

euphoria, restlessness, ataxia, convulsions, coma and death. It can also provoke signs of
pulmonary irritation like coughing and shortness of breath due to aspiration leading to aspiration
pneumonia.

Throat swelling, Eyes, ears, nose, and throat Pain, Abdominal pain, Bloody stools, vomiting,
possibly with blood, Heart and blood Collapse, Low blood pressure -- develops rapidly.

The defatting action (chemical dissolving of dermal lipids from the skin) of kerosene on the skin
can result in local irritation as well as drying and cracking of skin. There may be transient pain
with redness, blistering and superficial burns.

Kerosene poisoning in the eyes may result in irritation causing an immediate stinging and
burning sensation with excessive tear production.

Intentional ingestion of kerosene can cause nausea, vomiting and occasionally diarrhoea.

PATHOGENESIS
• Pathogenesis is mainly due to aspiration either during ingestion.
• Systemic absorption is very small.
• Most children ingest less than 30ml.
• CNS symptoms are due to hypoxia and acidosis. These results from damage to the lungs.
• Respiratory problems are mainly due to development of atelectasis and pneumonitis.

Changes in the Lungs

Atelectasis develops due to damage to surfactant, which increases surface tension.

Bronchospasm, atelectasis, emphysema and signs of inflammation such as edema, hyperemia
and infiltration of polymorphs, vascular thrombosis, hemorrhagic necrosis of
bronchial,bronchiolar and alveolar tissue may develop.
Superseded secondary infection is rarely seen.
GIT Changes- ulceration of stomach.
Liver- fatty infiltration is seen.
Heart- myocardial degeneration is present.
Kidney- renal tubular lesions.
Blood- intravascular haemolysis is due to damage to RBC membrane.

DIAGNOSIS
It is based on the history of ingestion, radiological investigation in addition to above clinical
features.

INVESTIGATIONS
X-ray chest- Initially fine, punctate, mottled densities appear in the perihilar area and mid lung
fields. Ill defined, patchy densities develop subsequently. These commonly coalesce to form
larger areas of consolidation.
Pneumonitis typically is bilateral and generally involves multiple lobes, most severely the lower
lobes.
Localised areas of atelectasis and obstructive emphysema are often present.
Pleural effusion, pneumatoceles, pneumothorax, pneumomediastinum and subcutaneous
emphysema are infrequently noted.
Varying degrees of hypoxia and hypercarbia are present.

. Leucocytosis with shift to the left

. ketonuria and glycosuria may occur.
. Haemolytic anemia (unusual finding.)

TREATMENT
Dermal exposure
• Remove patient from exposure.
• Remove all soiled clothing.
• Wash the contaminated area thoroughly with soap and water.
• Treat symptomatically.

Ocular exposure
• Remove patient from exposure.
• Immediately irrigate the affected eye thoroughly with water or 0.9% saline for at least 10-15
minutes.

Inhalation
• Remove patient from exposure and give oxygen.
• Maintain a clear airway and adequate ventilation.
• Apply other measures as indicated by the patient’s clinical condition.

Ingestion
• Gastric lavage should not be undertaken. Consider gastric aspiration within 1 hour of
ingestion, if very large amounts have been taken or there

98.NAPHTHALENE INGESTION
Fatal dose 2-5g
Hemotoxic - cause hemolysis
Symptoms
Vomiting, abdominal pain, diarrhea, fever, convulsions
Pallor, weakness, jaundice, cyanosis, dark urination

Inv
CBC, PS,

TREATMENT
Stomach wash
Inj emeset 4mg IV stat
Treat hemolysis by Blood transfusion
[3/28, 3:31 PM] Ramki Janarthanan: POISON OP
stomach wash with activated charcoal & refer

If organophosphate
Symptoms - all sphincter relaxation
MUSCARINIC
Profuse sweating, diarrhea, urination, vomiting, lacrimation, salivation, drowsy, bronchorrhea-
check chest (SpO2), pupil constrict
Brady/tachycardia
NICOTINIC
Weakness, cramps, muscle fasciculations, hypotension, resp paralysis.

Delirium, coma, resp arrest, seizures

Examine
Vitals
Chest - basal creps? Aspiration?
ECG- QT Prolongation
Chest x-ray
CBC, GRBS, SE, ABG,

Management
2 IV cannulation
1. Stomach wash- Ryles tube aspirate(only if within 1 hr of ingestion)
Activated charcoal 50g stat
MgSo4 sachet 2-2-2
2. Catheterization (urination)
3. Atropinization until the symptoms reverse - drying up of mouth
(Inj. Atropine 50-100mg(100ml) iv stat) followed by 50 ml 8 hourly then taper, [maintenance -
total dose x⅓ in 1 ⚀ NS Q8H x 3d
(paed- atropine 0.05mg/kg,repeat every 10-15 min)
4. SpO2 - O2 support / intubation
5. Bp- IV Fluids
6. Pralidoxime 1g IV Stat after Atropinization, can be repeated if needed TID/QID.
(25mg/kg/dose slow iv infusion in NS) (children - 20-40mg/kg)
( not needed for carbamate poisons)
7. Inj pantop 40mg IV OD

Atropine adv. Effects

Atropine psychosis - self limiting
Tachycardia, Arrhythmia
Intermediate syndrome - no treatment
Give support - intubation, IVF

OP poison - malathion, parathion, Tic 20

Carbamate - furadan, baygon, sevin

Complications:
Aspiration pneumonia
Pulmonary edema
Pneumonitis
ARDS

99.PARACETAMOL POISON
If taken > 6 tabs 650mg @ a time or 15 tab 500mg
150mg/kg in a single dose

LFT, PT INR, urine output monitoring

NPO for 12 hrs

Ryles tube aspirate
Activated charcoal 50g (1g/kg)stat
MgSo4 sachet 2-2-2 x 1 day

. Inj. N Acetyl cystine 7.5g (150mg/kg)in 1 ⚀ 5 DNS over 1 hr, then 2.5g(50mg/kg) in 1 ⚀ 5 DNS
over 4 hrs, then 5g(100mg/kg) in 1 ⚀ 5 DNS over 16 hrs.
. IVF
. Inj. Pantop 1amp
. Antiemetics if needed

NAC
(200mg/ml, 2ml amp)
Oral- 5% solution (140mg/kg) in water
½ dose q4h x 17 doses

Clinical stages
I. 1st 24 hr - vomiting, abdominal discomfort, Anorexia, non specific symptoms
II. 24-48hr - Hepatic derangement, abdominal pain, oliguria, PT⬆️, LFT⬆️
III. 72-96hrs- encephalopathy, cardiomyopathy, RF
IV. >4 days - resolution of hepatic damage
[3/28, 3:31 PM] Ramki Janarthanan: POISON RAT

SYMPTOMS
Epigastric pain, vomiting, intense thirst, arrhythmia, hypotension, resp distress, epistaxis,
hematemesis, Hematuria, IC bleed.

RFT, LFT, PT INR, APTT

TREATMENT
1. Gastric lavage
Saline ⬆️ KMnO4 1:10000 ⬆️ 1% NaHCo3
2. Inj. Pantop /Rantac
3. Inj. Vit K 1 amp
FFP, PRBC transfusion

100.TURPENTINE POISON
NPO for 12 hrs
Inj pantop 40mg IV BD
Syp sucralfate
IVF- ⚀ DNS /6 hrs

Symptoms
Blood in urine
Kidney failure (no urine produced)
Loss of vision
Severe pain in the throat
Severe pain or burning in the nose, eyes, ears, lips, or throat
Blood in the stool
Burns of the food pipe (esophagus)
Severe abdominal pain
Vomiting
Vomiting blood

Collapse
Low blood pressure that develops rapidly

Breathing difficulty (from breathing in poison)

Severe cough or choking
Throat swelling (which may also cause breathing difficulty)

Bluish skin color

Burns
Irritation

Treatment
If the chemical is on the skin or in the eyes, flush with lots of water for at least 15 minutes
If the person breathed in the poison, immediately move him or her to fresh air.

101.POSTPONE MENSES
T. Norethisterone(primolut N) 5mg/10 BD, 3-5 days before expected date of menses to till the
date she wants to postpone.

Avoid if h/o allergies to Norethisterone

102.POVD
1. T. Trental 400mg TID (pentoxifylline) decrease blood viscosity
2. T. Stiloz(cilostazol) 50/100mg BD (½ hr b4 food)
3. Diclofenac
4. Rantac

103.PRE-ECLAMPSIA
Gestational hypertension + proteinuria
Eclampsia= pre-eclampsia +seizures

>140 systolic, >90 diastolic, 2 values 6hrs apart

>160sys, >100dias = needs Rx

. Proteinuria >300mg in 24hr urine

Severe proteinuria >5g in 24hrs
. Edema - edema in non dependent area or generalized edema

SEVERE PRE-ECLAMPSIA :
>160sys or >110 dia
Proteinuria >5g
Headache, visual disturbance, epigastric pain
Oliguria, <500mL in 24hrs
Thrombocytopenia <1lakh
Increased liver enzymes (>50IU/L)( >70sig, >150)
Increased serum creatinine
IUGR
Pulmonary edema = Rx Diuretics

IMPENDING SIGNS
Headache, flashes of light
Nausea, vomiting
Epigastric pain
Brisk deep tendon reflexes, ankle clonus

Investigation
RFT =⬆️S. UA, ⬆️B. Urea, ⬆️S. Cr
LFT= ⬆️SGOT, SGPT, ⬆️Bilirubin >1.2
⬆️LDH >600U/L
CBC =⬆️PCV, ⬆️Plt
⬆️PT, APTT
PS= Hemolysis

PROPHYLAXIS
. Low dose aspirin 75mg(only for high risk pts, start @ 12 wks - 34-36wks)

TREATMENT
MILD
Bed rest in left lat position

. Labetalol 200-400mg/day in 2 doses PO or

. IV Alpha methyl dopa 1000-2000mg/day in 3-4 doses
. Nifedipine 20-40mg/day in 2-4 doses PO or IV
. Hydralazine 50-300mg/day in 2-3 doses

Hydralazine 5mg IV stat for severe hypotension

S/L nifedipine may cause sudden BP fall it should be avoided..

Treatment
If BP>160/100 + symptoms
Inj. Labetalol 20mg iv stat, and can be doubled in every 10mts upto 300mg/24hr
⬆️ or
Inj. Hydralazine 5mg iv stat, every 20mts
⬆️ or
Nifedipine 5mg s/l or 10 mg oral
⬆️
Mgso4 for seizures prophylaxis

104.PULMONARY EDEMA
Dyspnoea, anxiety, restlessness, cough, pink frothy sputum, cyanosis, fatigue, dizziness,
syncope, basal creps

TREATMENT
1. Propped up position
2. O2 inhalation by mask
3. Inj lasix 20-80mg (1mg/kg/dose) IV Q8H only if BP >100mmHg. (max 200mg)
(If Bp < 100mmHg inj. NA 2 amp in 250ml NS @ 4°/min then 8°⬆️ 16°⬆️ 20°)

Nebu- ipravent
If high BP + pul. Edema = inj NTG 2amp in 1 ⚀ NS @ 8°/min⬆️16°⬆️20°
⬇
Non invasive ventilation
⬇
Ventilator with high PEEP

CAUSE
1. A/C LVF
2. MI, AF, AR, MR
3. Pulmonary embolism
4. A/c myocarditis, cardiomyopathy

A/c LVF TREATMENT

1. Lasix
2. Nitro glycerine - Glycerine trinitrate 10-200mcg/min or S/L isordil 5mg every 10 min till
improvement/ BP <110mmHg
3. Inj. Morphine sulphate 4mg (2-5mg) IV over 15 mins can be repeated after 20min
4. Inj. Dobutamine

105.RAPD
Relative Afferent Pupillary Defect

Implies - Optic nerve damage

Inj. Methylprednisolone 500mg IV infusion in 250ml NS over 20 mins BD x 3days

106.RAYNAUD'S PHENOMENON
Vasospasm - cold, emotions, vibrations, collagen vascular d/s, drugs, vascular occlusions
Triphasic color - white(spasm), blue(capillaries & veins dilate) Red(warmth/Rx)

Treatment
Avoid cold
Ca channel blockers(vasodilation)
1. Nifedipine and diltiazem
2. Nicardipine
3. Amlodipine

107.RENAL COLIC
Inj. Voveran 1amp IM stat ATD (C/I in children)
T. Lyser D BD/T. Cyclopam 10mg TID
T. P'mol 500mg TID/T. Meftal spas x5d
T. Rantac 150mg BDx5d/T. Ac para sos
Inj. Buscopan 1amp IV stat
Inj. Pantop 1amp Iv stat

Jonnac suppository - for all pain

Diclofenac best drug to relieve pain
Ureteric colic
Tamsulosin can be given
Nifedipine

Diuretics shouldn't be given in a/c pain, give after the pain subsides

108.RHEUMATOID ARTHRITIS
DIP joint involvement( usually spared)
Raised ESR, CRP
Positive RA factor
Anti- CCP antibody
X-ray changes
Ophthalmology cx to check eye? - keratoconjunctivitis sicca

Treatment
Rest, physiotherapy
T. Deflazacort 6mg 2-0-0 x 7 days (3-4 months)
1-0-0 x 7 days
T. HCQ 200mg BD
NSAIDs - aspirin
Rantac
Methotrexate 7.5-10mg/wk
Folic acid 5mg/week, A following MTX

FEATURES:
Females, > 40-50 years
Symmetrical involvement
Deformity of hands and wrist, foot, other joints
Splenomegaly
Constitutional symptoms
Tender swelling
Restriction of movement
GOUT
Most common in men
Big toe, foot, ankle, knee commonly involved
Pain, burning, swelling, tenderness more at night time

Febuxostat 40mg OD

Treatment:
Rest the affected joint(s).
Use ice to reduce swelling
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Colchicine
Oral corticosteroids

109.CHEST INJURY /RIB #

Check vitals, dyspnoea?
Check air entry, sometimes Spo2 will be normal.
? Pneumothorax ? Hemothorax
USG Abdomen(must) to r/o blunt trauma abdomen

Check Hb?
Chest x-ray

If Pneumothorax - ICD tube

Diclofenac patch (Nu patch)

RTA
ABC maintained?
Pulse? Tachycardia
Bp - hypo
Spo2

IVF, Cross matching, Hb?

1000ml RL, 20ml/kg in children (bolus)

Monitor vitals
Urine output
Mental status
If no response, give 2nd bolus

After 2nd bolus if no response, Blood transfusion needed

110.SCORPION BITE
Presents with severe pain and sweating
(No specific antidote)

Check vitals- make stable➡IVF

1. Inj. Pethidine 100mg IM/IV stat
Or inj. Fortwin 1cc IM/IV (SOS)
2. Inj. Local xylocaine 2% around the wound
3. T. Prazosin 1 mg stat or Propranolol 40mg stat
 In children Prazosin ¼-½ tab, propranolol 10mg
4. Inj. TT 0.5ml IM stat
Antibiotics
Analgesics
Anti-inflammatory
Anti-anxiety➡to make calm, decrease HR,

If there is Systemic symptoms:

Profuse sweating, cold extremities, priapism, hypersalivation, vomiting, Hypertension, tachycardia,
pulmonary edema.

1. Check vitals every 10min

2. T. Prazosin 1mg stat, ½ tab after 4 hrs and ½ tab every 6 hrs until the Systemic symptoms subsides
Or
T. Propranolol 40mg stat, 1 tab after 4 hrs, 1 tab every 6 hrs
3. Ini. Fortwin 1cc IM/IV SOS
4. If hypotension - IVF (RL or NS)
5. If Bp > 150/100 T. Nifedipine 5mg sublingual, repeat after ½-1 hr, SOS
6. If Tachycardia Inj. Diazepam 2cc IM/Slow IV

If there is pulmonary edema

Breathlessness, Basal creps
Manage accordingly

Immobilise
Muscle relaxants
Intubation if needed
Cardiac - hyperdynamic state - alpha+beta blockers
Hypertension - nitrates

Investigation
BT, CT, PT/INR, Peripheral smear ➡hemotoxic, hemolysis
RFT, LFT, SE, ABG, URE➡myoglobinuria
SpO2
Chest x-ray ➡pul. Edema
ECG- MI / Echocardiography ➡cardiotoxic
S. Amylase, lipase ➡pancreatitis

111.SEIZURES
H/o any skip of doses
Differentiate from syncope, pseudoseizures
Never mistake VT/VF for seizures in cardiac pt

GCS, Pupils, fundus, FND, neck stiffness,

Check for distended bladder - catheterize

Left lateral position

O2 inhalation
IV cannulation
Avoid injuring environment

Check GRBS, vitals, SE, S. Ca, S. Mg, LFT,RFT(in CKD suspect)

CBC(inf-meningitis, encephalitis)

If Hypoglycemia(<90) - inj. Thiamine 100mg IV stat, followed by 25%D

1. Inj. Lorazepam(0.1mg/kg) 4mg IV stat(max dose)

(Can repeat once 10 min apart)
OR
Inj. Diazepam(0.15 -0.2mg/kg) 10mg IV over 15 mnts(max dose)
⬇ (if not controlled after 10 mim)
Repeat the dose
⬇ (not controlled)
Refer
Caution in head injury, elderly with COPD

If IV access not available

Inj. Midazolam 10mg IM (>40kg), 5mg(<40kg)

After 20 - 40min
2. Inj. Phenytoin(15-20mg/kg) 800mg in 100/250ml NS IV over 20 mins (give slowly)
⬇ (not controlled)
Inj. Phenytoin 400mg infusion
Watch for cardiac arrhythmias & hypotension, thrombophlebitis

( inj. Fosphenytoin 15mg/kg infusion over 10min)

3. If still continues (>30-1hr)

A) inj. Sod. Valproate 30mg/kg (max 3g/dose)

1g in 500ml NS over 1hr IV
B) inj. Levetiracetam 60mg/kg (max 4.5g/dose)
1g in 500ml NS over 30min
C) Inj. Phenobarbitone 15mg/kg
500-1000mg in 100ml NS over 30min
⬆️(if not controlled)
Intubation, Ventilation
Midazolam drip
Give GA with propofol or thiopental

If controlled
Sod. Valproate 800-2000mg/day 500mg tab
Phenytoin 300mg/day OD or 100mg 1-0-2
Carbamazepine 400-1200mg/day

Levetiracetam 500mg

Phenytoin adverse effects

Cardiac arrhythmia, hypotension, thrombophlebitis
Cerebellar signs

SEIZURES SYNCOPE
. Aura .Presyncope- lightheadedness
. Automatism darkening of vision, nausea
. Cyanosis . Pale
. Tonic clonic movts+ . Movements +
. Any positions . Usually in standing
. Tongue biting . Less severe
. Urine incontinence . May present
. Post ictal state . No post confusion
Paralysis
Hyperventilation (Neurocardiogenic
Muscle cramps Cardiogenic)

Pediatric dose - diazepam 0.3mg/kg/dose slow IV

Children 0.2-0.3mg rectal diazepam

Monitor PR, BP, RR, diazepam may cause respiratory depression,

If resp depression, give painful stimulus or ambu bag

Rectal dose 0.5mg/kg (acts faster than IM)

Lorazepam
Adult & children inj 4mg IV stat
⬆️ 2mg TID
(if not controlled repeat the dose after 10-20min)

If any seizures >5min

Inf- cerebral Malaria, Encephalitis, rickettsiae

In postpartum - cerebral venous thrombosis

POST ICTAL STATE

Confusion
Drowsy
Hyperventilation
Hypertension
Hyperreflexia
Pupils dilated and reacting
BL plantar extensor
Post ictal headache, muscle pain

MRI is best /contrast CT

112.SKIN INFECTIONS
1. T. Corporis - clotrimazole cream for LA BD x 2
weeks
(if extensive add T. Fluconazole 150mg once a
week x 3 weeks)
2. Keep area, dry
3. Avoid contacts, use separate soap, towels, can spread by pets
(Red raised border and clear center, ringworm
Itchy, on arms, face, legs, and other wet areas..)
Miconazole, ketoconazole, terbinafine ointments also used

2. URTICARIA - Cetirizine + calamine lotion for LA BD

x 5 days

3. Acne - clindamycin(clindac A gel 1%) morning +

Retino AC night for LA x 2 weeks
(avoid exposure to sunlight)
(if asso. pustules add T. Doxycycline 100mg OD x 5 days OR T. Azithromycin 500mg OD x 5
days)
To remove scar of acne ADALENE NANO GEL for LA BD x 2 weeks or NO MARKS CREAM
10-30mg/kg/day ➗3-4 PO
10mg/kg/dose x TID/QID IV/IM
Adult 150-450mg/dose TID/QID
⬆️ cap 150mg, 300mg
⬆️ 150mg/ml

AZIDERM 2%(azelaic acid) - Hyperpigmentation

MELACARE - hyperpigmentation below eye
NO MARKS CREAM - for chicken pox scar

4. Scabies - 5% permethrin cream (@ night then bath

morning) use 1 full tube @ a time
5% permethrin cream
25% benzyl benzoate lotion
10% sulfur ointment
10% crotamiton cream
1% lindane lotion
Ivermectin pills single dose for extensive lesion with crusts
(pimples with burrow lesion(S shaped) , itching more @ night)

5. Seborrheic dermatitis (Dandruff)

- Ketoconazole 2% - twice weekly for 2-4 weeks
Nizral 2%
- Seleen 2.5% shampoo
-ketofast
- Af K shampoo(ketoconazole)
- 8x

6. Oozing from skin

- Saline compress
- powdered or systemic antibiotics
(Hairy area- ointments/lotions)
(Non-hairy- creams)

7. Wart
Topical salicylic acid/cautery/cryo
Wartrol Ointment for LA

8. Molluscum - a viral infection

Self limiting
Ethyl alcohol/Griseofulvin/cautery/cryotherapy
(Looks like acne)
10% KOH & Refer
Retino A 0.025 cream
Fusidic acid Ointment for LA
Trichloroacetic acid ointment for LA

. very small, shiny, and smooth in appearance

flesh-colored, white, or pink
. firm and shaped like a dome with a dent or dimple in the middle
. filled with a central core of waxy material
between 2 to 5 millimeters in diameter, or between the size of the head of a pin and the size of
an eraser on the top of a pencil
. present anywhere except on the palms of your hands or the soles of your feet
. present on the face, abdomen, torso, arms, and legs
present on the inner thigh, genitals, or abdomen in adults

9. Verp/choodu kuru/Prickly heat/heat rash/miliaria

Calamine lotion, frequent bath
Betamethasone cream

10. Skin thickening

Topical Salicylic acid + steroid combination

11. Pediculosis
Permethrin 1% lotion, wash after 10mts, comb to
remove mites

12. Pimples
Mild - moderate Clindamycin ointment
Azithromycin 200mg
Doxycycline 100mg
13. T. Versicolor
Miconazole or clotrimazole 2%

SKIN CREAM
Soframycin(ophthalmic)
Fucidin(futop) - for impetigo, folliculitis, paronychia, infected eczema, infected wound
Mupirocin - for impetigo

Non-specific
1. Calamine lotion
2. T. AVIL 25mg BD x 3 days
3. Betamethasone ointment
4. Candid ointment

T. Erythromycin 20 mg/kg/day
250mg 3 or 4 dose
Cap. Cloxacillin 50mg/kg/day
250mg or 500mg 3 or 4 dose
Co-trimoxazole 8 mg/kg/day 2 dose
TOPICAL
1]Framycetin skin cream(soframycin)
2]fusidic acid cream (futop,fucidin)
3]mupirocin cream [T. bact,bactroban]

CLOBEN-G[clotrimazole+beclomethasone+dipropionate+neomycin]
Fungal infections of armpit and skin fold, vagina, penis, groin, vulva, toes
Fungal infections of nappy rash
Wheezing
Shortness of breath
Hepatic coma
Wounds
Ulcers
External ear infections
Eye infections
Diarrhea
Dysentery

Fluconazole/Ketoconazole powder
Clotrimoxazole ointment

PIMPLES TREATMENT
Clinface (Lincomycin 2%) HS for LA
1. Clindac A gel for LA morning
2. If cystic - antibiotics either doxycycline or Lymecycline for up to 10days
3. Deriva BP ointment HS

FOOT CRACKS
Clobetasol+salicylic acid cream (soltop S)
White soft paraffin
Petroleum jelly
Vaseline
Logi feel
Fusidic acid
Coconut oil

ORAL HERPES
Acyclovir tab/ointment 400mg TID x 7 days
Paracetamol
Fucidin cream for LA

INTERTRIGO
Candid cream for LA
Keep dry

113.SNAKE BITE
1. Inj. TT 0.5ml IM stat
2. Antibiotics - ampicillin 500mg TID Or
amoxiclav 625mg TID
3. Inflammation - Lyser D(Diclofenac 50mg + serratiopeptidase 10mg) or GM dressing
4. ASV 10 vials iv infusion in 1 ⚀ NS in 1hr, repeat 10-15 vials after 1-2hrs,check vitals (if
anaphylaxis -stop ASV, give adrenaline +hydrocortisone + avil, then restart ASV )
5. Symptomatic Rx pantop, emeset, FFP
If severe pain - p'mol infusion 100mg IV stat

(1 vial in 100ml NS, slow IV look for anaphylaxis if no rest of 9 vials in same 100ml NS)

Max of 25 vials can be given

Signs & symptoms

Fang marks
Pain, spreading edema, paresthesia
Numbness, bleeding manifestations, ptosis,
Hematuria, oliguria, hypotension
Circumoral paresthesia, aphonia/dysarthria
Diplopia, resp arrest
Enlarged tender lymph node involving the bitten limb

Do BT, CT(20min whole blood CT) , if abnormal

Loose tourniquet
Refer to higher center

Keep in observation and do 4th hourly BT, CT

Monitor vitals- hourly =shock (tachycardia, low BP, cold periphery, mental status, capillary refill,
urine output, bulbar muscle weakness )
Single breath count >20 normal
CBC- thrombocytopenia, Leucocytosis
Peripheral smear - hemolysis
PT/INR, APTT
ABG- acid base imbalance
RFT - renal failure
SE
Urine routine - myoglobin
Chest x-ray to r/o pul. Edema
ECG
Management
Restrict mobility
IVF
Oxygen
Antivenom
Surgery - compartment syndrome

snakebite protocol should be followed even if snake is nonpoisonous.. keep under observation
for 24 hrs.. initially BT, CT at 1 hr interval and later from 4th onwards BT, CT at 3 hr interval...
after 12 hrs look BT CT at 6 hr interval on 24 complete hrs if normal pt can b discharged, during
IP keep limb elevated and look for edema or redness locally if it crosses one joint or if it causes
bubo be little more cautious increase frequency of BT CT, give a empirical dose of Ampicillin
and gentamycin 2 dose 12 hr apart, on discharge even if no signs of fever give 5 days course of
ampiclox and a nsaid if local pain persist, non poisonous snake if deep bite there is 60to70%
chance of cellulitis or local infections , ask them not to panic if bubo is present in the groin in 2
days,

Snake bite new protocol

National Snakebite Management Protocol, 2009

It is now recommended to adopt what has been called the ‘Do it R.I.G.H.T.’ approach, stressing
the need for Reassurance, Immobilisation as per a fractured limb, Getting to Hospital without
delay and Telling the doctor of any symptoms that develop.

20 Minute Whole Blood Clotting Test (20WBCT) in the diagnosis and management of viperine
bite- 10ml blood of victim in plain vial is checked for clotting after 20min.
If not clotted- suggest viper.

Pain management - never give NSAIDs- causes more bleeding. Never give morphine- can
cause respiratory failure.

ASV Administration Criteria-ASV should be administered if there is significant envenomation i.e.

incoagulable blood shown by the 20WBCT or significant limb swelling for viperine bite,
neurological signs for cobra & krait bite.

ASV Dosage & Repeat Dosage-The recommended initial dose of ASV is 8-10 vials
administered over 1 hour.

Mode of administration of ASV is IV only.

Dose of ASV is same in children, pregnant or elderly, because venom injected is of same
amount, so ASV required is of same dose.

Repeat doses for haemotoxic viperine snakes is based on the 6 hour rule.
Repeat doses for neurotoxic snakes is based on the 1-2 hour rule.

The maximum recommended dose for haemotoxic bites in 30 vials of ASV.

The maximum recommended dose for neurotoxic bites is 20 vials of ASV.

ASV Reactions- No ASV Test Doses are to be administered.

At the first sign of an adverse reaction the ASV is halted-0.5mg Adrenaline is given IM- ASV
remaining dose should be given- Avil & Efcorlin can be given to prevent ASV anaphylaxis.

Neurotoxic Bite -neostigmine test-Despite the fact that the neostigmine test (Neostigmine
0.5mg IM with atropine 0.6mg IV) was actually an Indian discovery, it is still poorly used in India.
Neostigmine works in cobra bite as cobra venom acts on postsynaptic neurons.

Hemotoxic bites with correct signs of envenomation can be treated with 8-10 vials of ASV,
stabilised if any ASV reaction occurs with adrenaline and then transferred to a higher centre
with the ability to carry out the required blood tests to identify occult bleeding or renal
impairment.

Heparin has no role in curing DIC of snakebite, and can increase bleeding, so contraindicated in
viperine bites.

Botropase should not be used as coagulant in controlling viperine bite bleeding, as it causes
consumptive coagulopathy.

Neurotoxic bites with correct signs of envenomation can be treated with 8-10 vials of ASV,
stabilised if any ASV reaction occurs with adrenaline and administered the neostigmine test.

If there is no evidence of impending respiratory failure, determined by patient ability to perform

a neck lift the patient can be treated locally.

If the patient is unable to perform a neck lift then they will be transferred to a higher centre with
mechanical ventilatory capability.

The rational application of ASV and repeat doses has resulted in patients being discharged
earlier.

114.STRIDOR
Propped up position
O2 stat
Inj. Hydrocortisone 200mg IV stat
Inj. Deriphyllin 100mg IV stat/ TID
Strict bed rest - never walk, talk

Refer - emergency tracheostomy may be needed

Check vitals
Temp
Chest - air entry? Wheeze? Creps?
SpO2
H/o Previous Malignancy? FB?

115.EYE DISCHARGE
1. Tobramycin e/d TID x 1 week ( below 11 yrs)
2. Tobramycin ointment

Above 11 yrs moxiflox e/d

Moxiflox e/o hs

116.SUPRAVENTRICULAR TACHYARRHYTHMIAS
Need 2 persons, ICU setup, Needs continuous Cardiac monitoring
1. Carotid massage, after checking for carotid bruie
2. Valsalva can be tried
3. 3 way cannula
6mg adenosine in one way, and 20ml NS in other way, immediately rise that limb above head,
(Adenosine run off)
⬆️(if tachycardia not subsiding)
With 12mg adenosine repeat the same procedure
⬆️( if tachycardia not subsiding)
DC Shock

Adv.
1. T. Verapamil 1 stat, followed by TDS

117.SYNCOPE
Prodromal symptoms (nausea, vomiting, blurring of vision, lightheadedness, tinnitus)
⬆️
Anoxic phase (LOC, pallor, sweating, bradycardia, tachypnoea)
⬆️
Recovery phase (Horizontal position)
⬆️
After effects (confusion, amnesia, drowsy)

Cause
Simple faint - emotional, fear, venesection,hypoxia orthostatic hypotension, Hypoglycemia,
Cardiogenic - HOCM, valvular lesion (AS)
Neurocardiogenic - cough, straining

Treatment
Rest and salted drinks

PRE SYNCOPE (a pre- or near-syncope episode) - this is when the person can remember
events during the loss of consciousness, such as dizziness, blurred vision, muscle weakness,
as well as the fall before hitting their head and losing consciousness.

SYNCOPE (a synoptic episode) - this is when the individual may remember the feelings of
dizziness and loss of vision, but not the fall.

Symptoms
A feeling of heaviness in the legs
Blurred vision
Confusion
Feeling warm or hot
Lightheadedness, dizziness, a floating feeling
Nausea
Sweating
Vomiting

Signs
Low BP, hypoxia, pale

Cause
Neurocardiogenic syncope (also known as reflex syncope, vasovagal episode, vasovagal
response, vasovagal attack, vasovagal syncope) - occurs when something causes a short-term
malfunction of the ANS.

. Suddenly seeing something that is unpleasant or shocking, such as blood

. Exposed to a horrible/frightening experience
. Emotionally upset- hearing about the death
. Standing still for long Periods.
Being in a hot and stuffy place for a long time.

Occupational syncope - type of neurocardiogenic syncope, but the link is physical rather than
emotional, mental or abstract. Examples
. Coughing
. Defecating
. Lifting a heavy weight
. Sneezing
. Urinating.
ORTHOSTATIC HYPOTENSION
caused by:
. Severe dehydration
. Untreated diabetes - the patient urinates much more frequently and becomes dehydrated. If
blood glucose levels go to high there may be damage to some nerves, especially those that
regulate blood pressure.
. Drugs - diuretics, beta-blockers and antihypertensive drugs may cause orthostatic hypotension
. Alcohol
. Neurological conditions - Parkinson's disease
. Carotid sinus syndrome - temporary unconsciousness resulting from pressure on the pressure
sensors (carotid sinus) in the carotid artery, when the individual turns his head to one side,
wears a tight collar or tie, or presses over the carotid sinus while shaving.
. Cardiac syncope
- Arrhythmias
- Stenosis of valves
- Hypertension
- MI

118.TINGLING LIMBS
1. Inj. Neurobion 2cc im x 5-10 days
2. Inj. Meconerv 500mg im OD x 10 days
T. Neurobion forte
T. Calcium 500mg OD
T. Iron
C. Methylcobalamin 2/3/35mg BD

If no relief
Inj calcium gluconate 10ml slow iv

If burning sensation
Calcium pantothenate 50mg BD x 1 month

119.TOOTH ACHE
Lignocaine in cotton as LA
T. Ibuprofen 400mg BD x 3days
Inj. Ketanov 1amp IM stat ATD

Ibuprofen 10mg/kg/dose TID/QID

Paracetamol

120.TRAUMATIC TM PERFORATION
Confirm with otoscope
Keep ear dry
Do tunning fork tests
Pure tone audiometry

Antibiotics
T. Cetirizine
Nasal drops

121.TYPHOID FEVER
SYMPTOMS
Fever, abdominal pain, rash
Abdominal tenderness
Bloody stools
Chills
Agitation, confusion, delirium, seeing or hearing things that are not there (hallucinations)
Difficulty paying attention (attention deficit)
Mood swings
Nosebleeds
Severe fatigue
Slow, sluggish, weak feeling

WEEK ONE:
Gradual rise in temperature, typically worse through the day, over the first 2-3 days, typically
reaches 40°C (104°F).
Dry cough.
Relative bradycardia (Faget's sign): - the pulse is slower than would be expected from the
degree of temperature.
Malaise.
Headache.
Epistaxis in around a third.
Abdominal pain.
Leukopenia with relative lymphocytosis.
Blood cultures are positive for S. typhi (or S. paratyphi).

Widal's test is usually negative.

In this bacteremic phase it is possible to find bacteria in the reticuloendothelial tissues of the
liver, spleen, bone marrow, and gallbladder and Peyer's patches in the terminal ileum. The
gallbladder is infected via the liver and infected bile gives positive stool cultures and re-infects
the bowel. Gallstones predispose to chronic biliary infection and long-term faecal carriage.

WEEK TWO:
During the second week the patient has a toxic appearance with apathy and sustained pyrexia.
High fever around 40°C (104°F), often swinging.
Malaise and weakness.
Relative bradycardia, with dicrotic pulse wave.
Confusional state, which gave typhoid the name of 'nervous fever'.
Rose spots on the lower chest and abdomen - seen in around one third of Caucasian patients;
difficult to see in darker skin. Rose spots are caused by bacterial emboli. They are crops of
macules 2-4 mm in diameter that blanch on pressure.
Lung base rhonchi.
Abdominal distension with right lower quadrant tenderness and increased borborygmi.
Diarrhoea, typically green, with a characteristic foul smell, often compared to pea soup.
Constipation may also occur.
Hepatosplenomegaly is common.
Elevated liver transaminases.
Positive Widal's test.

WEEK THREE:
By the third week there is considerable weight loss.
Pyrexia persists and a toxic confusional state may occur.
Marked abdominal distension develops and liquid, foul, green-yellow diarrhoea is common.
The patient is weak with a weak pulse and raised respiratory rate.
Crackles may develop over the lung bases.
Death can occur at this stage from overwhelming toxaemia, myocarditis, intestinal
haemorrhage, or perforation of the gut, usually at Peyer's patches.
Complications which are most likely to develop at this stage include:
Intestinal haemorrhage due to bleeding from congested Peyer's patches.
Perforation of the distal ileum, frequently fatal. There may be little warning, and peritonitis is a
common complication.
Encephalitis.
Neuropsychiatric symptoms: muttering, picking at clothes, confusion.
Metastatic abscesses.
Cholecystitis.
Endocarditis.
Osteitis.
Dehydration is a significant risk.
One third develop a macular truncal rash.
Thrombocytopenia with risk of bleeding.
Eye complications may occur (usually only with associated systemic illness) including corneal
ulcers, uveitis, abscesses (eyelid or orbit), vitreous or retinal haemorrhage, retinal detachment,
optic neuritis, extraocular muscle palsies, and orbital thromboses.

WEEK FOUR:
In the untreated patient the fourth week sees the fever, mental state and abdominal distension
slowly improve over a few days, but intestinal complications may still occur. Convalescence is
prolonged, and most relapses occur at this stage
INVESTIGATIONS
CBC - plt⬆️
S. Typhi H >1/200, O>1/100
Blood culture - 1st week of fever
Urine
Stool culture

TREATMENT:
IVF
Ciprofloxacin
Ceftriaxone
Azithromycin

Complications:
Intestinal hemorrhage (severe GI bleeding)
Intestinal perforation
Kidney failure
Peritonitis

123.MANAGEMENT OF UNCONSCIOUS PATIENT

Alcoholic - always do a CT head

BP➡ HYPERTENSION
1. T. Leptin(amlodipine) 5mg if moderate
2. T. Amlodac-AT(amlodipine & atenolol) (if
severe) + palpitation

T. Nifedipine- 10mg, 20mg

T. Telmisartan - 40mg
T. Enalapril - 2.5mg, 5mg
T. Aten - 25mg, 50mg
T. Losartan - 50mg

HYPOTENSION
1. 1 ⚀ NS refer if not better
2. 2amp noradrenaline in 1 ⚀ NS start with 6 drops
3. 2 amp Dobutamine in 1 ⚀ NS & start with 4 drops (max 32 drops)
Need ICU setup

Bp around 60mmhg ➡10ml NS IV push + iv fluids fast

Bp 90mmhg ➡no iv push, only IVF

Bp+palpitation ➡T. Amlodac-AT (T. Aten 25mg)

2. PR - if no pulse/weak pulse
Start ivf fast
Give CPR & defibrillator if necessary

3. Spo2➡if less than 92% ➡ give o2

CAUSE
METABOLIC
1. DKA
2. Hypoxic encephalopathy
3. Head trauma
4. Hypoglycemia
5. Hypo/hypernatremia
6. Hypertensive encephalopathy
7. Liver failure, renal failure, sepsis
8. Post ictal state

STRUCTURAL
Subdural hematoma
Hemorrhage
Stroke
Tumor
Abscesses
Hydrocephalus

INVESTIGATE
Bp, Spo2, CBC, RFT, LFT, SE, URE, S. Mg+, S. Ca+, GRBS

Examination
Gcs
Respiratory pattern
Pupillary reaction, anisocoria?
Doll's eye movement (only if no cervical spine injury)

If Herniation identified
1. Endotracheal Intubation and maintain PCo2 @ 25-30mmHg
2. Inj. Mannitol (100ml) 1-2g/kg IV over 20min
3. Inj. Dexona 10mg IV stat followed by 4mg IV Q6h
(reduce brain edema around tumor/abscess)

124.URTI
Headache, sinusitis, nose block, fever, cough, throat pain
1. Steam inhalation - give karvol decongestant
capsules to put in 500ml water and inhale
Saline gargle
2. T. Azithromycin 500mg OD x 5 days (1hr b4 fud r
2hr after fud, CI ◀ 6 month age)
Or
T. Amoxicillin 500mg TID x 5 days
3. T. Sinarest/ T. Rhinostat TID x 5 days
T. Wikoryl TID x 5 days (p'mol combinations)
4. T. Meftal-P TID x 5 days
5. Syp. Ascoril/Syp. Tusq D 2 tsp TID x 5 days

If severe throat pain

T. Moxiclav 625mg BD /TID x 5 days
6.T. Reactine plus(diclofenac +paracetamol)
7.T. Atarax(hydroxyzine) 10mg
8. Montekid 5mg HS
Nasal drops
X-ray PNS - OMV

125.UTI in PREGNANCY
Cefixime
Amoxicillin 500mg TID x 3d
Ampicillin 250mg QID x 3d
Cephalosporin 250mg QID x 3d
Nitrofurantoin 100mg BD x 3d (with caution in G6pD deficit)
Cotrimoxazole 160/800mg BD x 3d

126.VAGINAL DISCHARGE
1. Whitish discharge + pruritus = candidiasis
T. Fluconazole 150mg stat
T. Fluconazole
Cansoft CL vaginal tab HS x 3 days
(clotrimazole + clindamycin)
Candid V3 200mg pessary HS x 3 days

2. Foul smelling discharge

? PID
T. DOXYCYCLINE + T. Metronidazole x 1 week

127.VITAMIN TABLETS
T. Neurobion forte- vit B complex with B12
T. Polybion
T. Livogen Z - Ferrous fumarate, Folic acid & ZnSo4
Zincovit - vit + minerals Zn nutritional food
supplements
Tonoferon
Evion(vitamin E capsules) - 200mg, 400mg
Evion LC(Vit E Acetate & levocarnitine tab)
Hemsi(Fe)

CALCIUM
T. Vitocalz
T. Calcium 500mg TID
T. Calvus fresh plus

Signs of vitamin B12 deficit

Fatigue,
Tingling and Numbness
Joint pain
Palpitations and breathlessness
Jaundice and swollen tongue

Inj. Nurokind plus IM/IV

(Mecobalamin, pyridoxine, nicotinamide)

T. Zincovit
Zincovit Tablet contains Biotin, Carbohydrate, Chromium, Copper, Folic Acid, Iodine,
Magnesium, Manganese, Molybdenum, Niacinamide, Selenium, Vitamin A, Vitamin B1, Vitamin
B12, Vitamin B2, Vitamin B5, Vitamin B6, Vitamin C, Vitamin D3, Vitamin E, and Zinc as active
ingredients.

Calvus fresh plus

Calcium citrate, Mgso4, ZnSo4, vit D3 10mcg, B12

128.BED WETTING
1. T. Imipramine 25mg HS 1 hour before bed
2. ▶ 6 yrs old T. Amitriptyline 5mg @ bed
(0.5mg/kg HS)

URINARY INCONTINENCE, NOCTURNAL ENURESIS

1. Oxybutynin 5mg BD (above 5yr)
0.2mg/kg/dose x 2-4 doses/day
⬆️ - 2.5mg, 5mg
Syp. 5mg/5ml

129.FACIAL PALSY
RX
Prednisolone 1mg/kg/day x 10 days and taper next 5 days
Acyclovir 400mg 5 times x 7 days
Care for the eyes

130.HYPONATREMIA
Sodium level < 135 mEq/L
Mild 130-134 mEq/L
Moderate 125-129 mEq/L
Severe < 125 mEq/L
Ccf, renal failure, liver failure, pneumonia may be associated.

Check vitals
Symptoms
Nausea, vomiting, malaise, lethargy, loss of consciousness, headache, seizures, coma
If < 115mEq/L ➡ brain edema

Inv - S. Electrolytes, and urine sodium, urine osmolality

Check - GRBS, hyperglycemia may cause hyponatremia

Management :
Correct if only symptomatic
Salted diet
3%NS slowly over 6 hrs only if < 120mEq/L
If above 120mEq/L NS slowly
(fast correction may cause demyelination)
If low BP ➡ NS
Normal BP and asymptomatic ➡fluid restriction
High Bp➡ salt, fluid restriction, and loop diuretics( frusemide), vassopressin antagonist

T. Natrise
T. Hyponat

131.IV FLUIDS
5%D
CONTRAINDICATIONS
Head injury, a/c ischaemic stroke
Hypovolumic shock
Hyponatremia
Uncontrolled DM

NS- ⬆️interstitial and intracellular fluid

CONTRAINDICATIONS
Pre Eclampsia
CHF, renal disease and Cirrhosis
Dehydration with hypokalaemia - deficit of IC K+

DNS
CONTRAINDICATIONS
Anasarca-cardiac, hepatic, renal
Severe hypovolemic shock(osmotic diuresis)

RINGER LACTATE
CONTRAINDICATIONS
Liver disease, severe hypoxia and shock
Severe CHF, lactic acidosis takes place
Addison's disease
Vomiting or NGT aspiration induced alkalosis
Simultaneous infusion of blood and RL

Colloids - ⬆️ fluid in intravascular compartment

132.KELOID
Intralesional injection of Steroids (Triamcinolone Acetate)

133.NORMAL DELIVERY
C. Amoxicillin 500mg TID x 5 days
T. Paracetamol 500mg TID x 5 days
T. Fe 1 OD x 6 weeks
T. Calcium 500mg 1 OD x 6 weeks

134.NORMAL VALUES
Temperature
98.2± 0.7, fever if> 98.9 morning, >99.9 evening

CBC
Hb - ♐14-18, ♀ - 11.5-16.5, pregnancy ▶ 11
WBC - 4-11000, P50-70, L20-40, E1-4, M2-8
RBC ♐4.5-6.5, ♀ - 3.8-5.8
PLT 1.5-4
MCV 80-100 fL
MCH 27-32pg
MCHC 32-36g/dl
ESR ♐0-10, ♀ 3-15
PCV ♐47, ♀ 42
RDW 11.5-14.5
Reticulocyte 0.5-1%

S. Electrolytes
Na+ 135-145 mmol/L
K+ 3.6-5.1
Cl- 95-107
HC03- 21-29
H+ 37-45
Mg 1.5-2
Ca+ 8.5-10.5
P 3-4.5
Zn 11-22mmol/L, 72-144 Meq/L
Fe 10-32mmol/L, 56-178Meq/L

RFT
S. Urea 15-40mg/dl, 2.5-6.5mmol/L
S. Creatinine 0.68-1.36
S. Uric acid 2-8mg/dL

LFT
S. Bilirubin Total 0.2-0.8
Direct 0.1-0.3
Total protein 6-8
Albumin 3.5-5 (⬆️in c/c liver disease)
SGOT or AST 10-35 U/L(⬆️in heart, sk muscle, RBC)
SGPT or ALT 10-40 U/L(more specific to liver)
ALP 40-125 U/L AST>ALP=Cirrhosis
Globulin 1.5-3 ALP>AST=CLD
Fibrinogen 0.3g/dL AST:ALT>2 Alcoholic LD
A/G ratio 1.7-2
LDH 208-460 U/L
Ammonia 15-45 mg/dl
ALP - Marker of cholestasis(obstruction)
(⬆️in Bone, liver, placenta, intestine pathology)
⬆️ALP + ⬆️GGT or 5’ neucleotidase = alcoholic liver disease

PaC02 34-45mmHg 4.5-6 kpa

PaO2 90-110mmHg 12-15 kpa
O2 saturation ▶ 97%

TFT
TSH 0.5-5 mU/L
T4 9-21 pmol/L
T3 0.9-2.4 nmol/L
PTH 1-6.5 pmol/L, 10-65 pg/ml

Lipid profile
S. Cholesterol 160-200, mild 200-250
Moderate 250-300
Severe ▶ 300
HDL ♐50-110, ♀ 45-100
LDL ◀ 100
VLDL ◀ 30
Triglycerides 53-150 mg/dl

Glucose level
FBS 70-110
PPBS 80-160
2hr post prandial ◀ 140
Impaired glucose tolerance =2hr OGT 140-200
Impaired fasting glucose ▶ 100 ◀ 125
DM if RBS ▶ 200
FBS ▶ 126
2hr OGT▶ 200
HbA1c ▶ 6.5%

PT 10.3-13.5 sec
APTT 26-30 sec
PT INR 0.9-1.2
BT
CT

CSF
Cells ◀ 5/mm3
Protein 140-450 mg/dl
Glucose 41-81 mg/dl

135.OBSTETRICS CASE HISTORY

G2P1L0A0
LMP-
EDC- (9mon+7days)
Gestational Age-

HOPI
T¹
. Pregnancy confirmed when? UPT? - ve after 15 days of missed period & +ve 1 month after
. Excessive vomiting, bleeding PV, fever with rash, UTI, radiation exposure, drug intake
. USG? 10-14wks
. FA 5mg tabs can start preconceptionally
. ANC - Monthly once?

T²
. ANC- monthly once upto 28 wks?
. Quickening - 16 - 18 wks
. 2 doses of inj. TT 16-24wks(4 wks apart)
. GCT 24-28wks? GTT? USG? 18-20wks
. H/O HTN, GDM, UTI, Bleeding PV, fever
.FA, FeSo4 100mg&Calcium 1g continue to 3mon postpartum - from 13th week

T³
. ANC- every 2wks upto 36wks then weekly ?
. Fetal movements?
. USG?
. H/O HTN, GDM, Bleeding or leaking PV, pedal edema, fever, abdominal pain
. Tabs

Menstrual history?
Marital history?
Past obs history?
. Normal or operative?
. Intra or postpartum Complications?
. Baby wt? CSAB? Breast fed?
Past medical/surgical illness?

Examination :
INSPECTION
. Abdomen distended longitudinally?
. Umbilicus?
. Stria gravida? Albicans?
. Any scar? Dilated veins? Pulsations?

PALPITATION
. Local rise of temp, tenderness?
. Fundal height? Corresponding week?
. Symphysiofundal height? @14-36wks=GA
. Abdominal girth? @ 24-36wks in inch=GA
FUNDAL GRIP
UMBILICAL GRIP
1st PELVIC GRIP
2nd PELVIC GRIP
AUSCULTATION
FHR- 110-160bpm
EFW
SFH - 12x 155 (unengaged)
SFH - 11x 155 (engaged)

WARNING SIGNS
Bleeding PV
Headache, blurring of vision, epigastric pain, oliguria
Pedal edema-not subsiding, facial edema
Decreased fetal movement
Abdominal pain
UTI, leaking PV

136.PAIN & INFLAMMATION MANAGEMENT

Inj. Voveran 1amp IM stat ATD + inj. Pantop 1amp Iv stat
Lyser D TID x 5 days
Pantop 20mg BD x 5 days

If muscle spasm
Inj. Pyroxicam 1amp IM (10mg, 20mg oral)
T. Metaxalane
T. Dalowin MR/Dalostat MR

137.OP POISON - MANAGEMENT

stomach wash with activated charcoal & refer

If organophosphate
Symptoms - all sphincter relaxation
MUSCARANIC
Profuse sweating, diarrhea, urination, vomiting, lacrimation, salivation, drowsy, bronchorrhoea-
check chest (SpO2), pupil constrict
Brady/tachycardia
NICOTINIC
Weakness, cramps, muscle fasciculations, hypotension, resp paralysis.

Delirium, coma, resp arrest, seizures

Examine
Vitals
Chest - basal creps? Aspiration?
ECG- QT Prolongation
Chest x-ray
CBC, GRBS, SE, ABG,

Management
2 IV cannulation
1. Stomach wash- Ryles tube aspirate(only if with in 1 hr of ingestion)
Activated charcoal 50g stat
MgSo4 sachet 2-2-2
2. Catheterization (urination)
3. Atropinisation until the symptoms reverse - drying up of mouth
(Inj. Atropine 50-100mg(100ml) iv stat) followed by 50 ml 8 hourly then taper, [maintenance -
total dose x⅓ in 1 ⚀ NS Q8H x 3d
(paed- atropine 0.05mg/kg,repeat every 10-15 min)
4. SpO2 - O2 support / intubation
5. Bp- IV Fluids
6. Pralidoxime 1g IV Stat after Atropinisation, can be repeated if needed TID/QID.
(25mg/kg/dose slow iv infusion in NS) (children - 20-40mg/kg)
( not needed for carbamate poisons)
7. Inj pantop 40mg IV OD

Atropine adv. Effects

Atropine psychosis - self limiting
Tachycardia, Arrhythmia

Intermediate syndrome - no treatment

Give support - intubation, IVF

OP poison - malathion, parathion, Tic 20

Carbamate - furidan, baygon, sevin

Complications:
Aspiration pneumonia
Pulmonary edema
Pneumonitis
ARDS

138.RAT POISON MANAGEMENT

SYMPTOMS
Epigastric pain, vomiting, intense thirst, arrhythmia, hypotension, resp distress, epistaxis,
hemetemesis, Hematuria, IC bleed.
RFT, LFT, PT INR, APTT

TREATMENT
1. Gastric lavage
Saline ⬆️ KMnO4 1:10000 ⬆️ 1% NaHCo3
2. Inj. Pantop /Rantac
3. Inj. Vit K 1 amp
FFP, PRBC transfusion

140.DRUGS SAFE IN PREGNANCY /LACTATION

1. Amoxicillin, Ampicillin - URTI, UTI
2. Moxiclav - sinusitis, UTI
3. Azithromycin, clarithromycin, erythromycin - LRTI
metronidazole, clindamycin - Bacterial vaginismus
Amikacin, gentamycin - pyelonephritis
4. Paracetamol, Mefenamic acid (meftal)
5. Diclofenac (voveran) if extremely necessary (only
in T1)- excreted in breast milk
6. Phenergan IV or IM (vomiting), Perinorm
7. Cyclopam
8. Tramadol- excreted in breast milk
9. Acyclovir - herpes, Varicella
10. Oxymetazoline drops
11. Codeine, dextromethorphan- cough
12. All Anti asthma medications safe, inhaled Steroids beclomethasone, Fluticasone safe

Nitrofurantoin can be used but can induce hemolytic anemia in G6pD pts

Quinolones should be avoided

For HTN
. alpha methyl dopa
. Nifedipine
. Labetolol

For Epilepsy - has risk for fetus

Avoid valproate use lamotrigne
Phenytoin
Sodium valproate
IV diazepam
Carbamazepine

VACCINES SAFE
. TT
. Anti Rabies vaccine
. Hep A&B

All live vaccines are contraindicated like MMR, BCG, Varicella

Perinorm for milk secretion

LABOUR ANALGESIC
Morphine
Pethidine
Pentazocin(Fortwin)
Tramadol
Promethazine(phenergan)

Lung maturity
Inj. Betamethasone 12mg IM 24hrs apart 2 doses

141.SEDATIVES
T. Alprax 0.25 mg, 5mg
Valium 2mg, 5mg
Tryptomer 10mg, 25mg
Clobazam 5mg

142.SEPTIC SHOCK MANAGEMENT

1. Fluid resuscitation
2. Inj. Hydrocortisone iv (10mg/kg/dose) QID
3. Systemic antibiotics

143.SPRAIN TREATMENT
X-ray to r/o #
Rest
Ice
Compression
Elevation

Ibuprofen
Diclo
Rantac
Crepe bandage
144.STOP SMOKING
Nicotine chewing gum(nicotex) 2mg/4mg
>25 cigarettes/day 4mg

Nicotine withdrawal
Treatment Bupropion, varenicline, nortriptyline, clonidine, rimonabant

145.STROKE MANAGEMENT
Golden hour, 4.5hrs of Onsest. Thrombolysis (rtPA)
If CT=No h'ge
Embolic - source of embolus (cardiac)

Thrombus - early morning

Hemorrhagic - while working, hypertensive, features of raised ICT

Headache
Vomiting
Blurring of vision (papilledema)
Loc, confusion
Hypertension
Bradycardia
Resp. Depression

146.TINNITUS
Local examination of the ear, wax? FB?
T. Neurobion 1BD x 1 month
T. Complamina Retard 1 BD
T. Restyl 0.25mg HS

147.URINARY INCONTINENCE
STRESS
During cough, sneezing, laughing, just before mensus

URGE
Leaking at unexpected times @ sleep, can't withhold
Anxiety, hyperthyroidism, Uncontrolled DM
Spinal cord injury, MS, Parkinson

OVERACTIVE BLADDER
Abnormal nerve signals to bladder
Urinate frequently >7 times @ day, >2 times @ night
Nocturia, incontinence, urgency
FUNCTIONAL
Disabled, bed ridden
Parkinson, alzheimers

OVERFLOW
Uncontrolled DM
Bladder stones obstruction
Incomplete voidence

TRANSIENT INCONTINENCE
UTI, constipation, cold.