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taba05
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5
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Appendicitis
Intestinal obstruction ) : (
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. O.V.
until proved otherwise
:
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Shocked .Hemagel
47
. ....
Arrested
Vital signs Hisory
Data DD of Hematemsis from
epistaxis & Heamoptysis Well
known Hepatic P.U.
Upper
G.I.T Endoscpoy
-2 Bronchial Asthma
cardiac Asthma Acute pul. Edema
History Chest
Cardiac
-3 HPN )
( ) (
Cerebreal Hge.
Stroke -4
: Hge. Infarction
Rapid History
Vital Signs Stroke
-5 Coma
DKA ) Acute Myocardial Infarction ( AMI
Stroke Psychic
Toxicity Cardiac arrest
Absent Breath sound & Heart Sound
) CPR ( Cardio Pulmonary Resuscetation
Endotracheal Tube
.
-6 Acute Abdomen DKA Inferior MI
Mild
-7 Hepatic Encephalopathy )
(
48
)
(
... History
Signs data
-8 Toxicology
** :
** % 50 % 50 )
( History
)
(
.
.
-9 Mild
)
( :
** Tonsilitis & Sore thoat
** Common cold & headache
** Gastritis & Heart burn History Inferior M.I.
** Vomiting & Abdominal Pain History
Appendicitis
** Diarrhea & colic
** Constipation History Intestinal obstruction
** Dizzines or syncope
** Chest infection & Fever
** Bone ache & Myositis
- 1 Polytrauma
) ) RTA ( Road Traffic Accident
(
) (
Shocked Resuscetation
49
. )
"
" (
Internal organ
contusion
- 2 ) Single trauma ( Direct truama
) :
(
- 3 Stitches
Simple Interrupted suture
. Matress
.
....
Ischemia
. ))
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-4 Renal colic History
Acute Abdomen
.
50
Renal colic & urine retention
Epistaxis
) (
51
)
(
52
-:
* Nitrate
* Anti HPN
) Neubelizer (
: ) ( ) ( 0 1 ) ( 0 2 )
( 0 3 ) ( 0 4
)
( ) (0 5 ) (0 6
) (
-1 History Examination
-2 )
(
-3 ABG )
(
-4 ) (
-5 ) (
-6 ) (
.1 )
(
.2 ABG )
(
.3 ) Nasogastric tube ( ryle tube
.4 ) :
53
Virgin
(
.5
.6
.7
.8 ) (
.9 CPR
.10
-1
-2 ) (
-3
-:
: = .
.. =
: : 0 2
-4 ) : ( )
( Intestinal
obstruction -:
54
-7
....
.
-8
-9 ... )
(
* :
* 12 1
*
* ) (
*
55
*
) (
*
*
*
) (
) (
*
.
...
56
57
Bronchial Asthma
Presentation
Patient said he is asthmatic
.. Complain of chest allergy
..Dyspnea and chest wheeze
By examination.. Bilateral diffuse sibilant ronchi
Management
250
NB cardiac patient
ventolin
bisolvon, avil
.
nebulizer 6 :
)farcolin (salbutamol
2 saline
anti muscrinic
Atrovent to relive bronchial spasm in vials inhalation solutions
58
(dexamethasone) solucortef
Renal colic
* history Stone
buscopan
visceralgine glucolynamine
spasmofen .
:
loin pain
burning haematuria
Management
250 ) ( stone
Crystals:
* urates urosolvin eff.
Zyloric (200-800) tab Or No-uric (100-300) mg
*oxalate
epimag eff
59
.
* phosphate
vitacid c tab
pus :
* HPF
* 5 30
Uvamine retard cap 12
) Macrofuran(50-100 6
* 30 50 Quinolones UTI
) Ciprofar 250 or ciprofloxacin or bactiflox (250-500 12
)Kiroll or tarivan(ofloxacin200
12 .
*
Coliurinal or proximol Antiseptic eff.
3
Rowatinex cap Analgesic 8
50
vomiting
*You should at first exclude that:
Appendicitis
Acute abdomen
Insecticides
DKA
60
* :
cortigen B6 amp
MOTILIUM tab 3
urine retention
*
Epistaxis
* hypertension
:
Nasal trauma,dryness of nasal mucosa , bleeding disorders
*bleeding come mainly from kisselbach's plexus at anterior
nasal septum.
First aid
-venous pressure
-Hand compress nostrils for 10 minutes
-Leaning forward
61
-May use cold compresses on nasal septum and not inside nose
-Add amp epinephrine to nasal pack for local use
-Afrin adult spray 0.05%
4
Management
* nasal pack pressure
Vaseline gauze
(full flexed to avoid
)aspiration
* haemostatic haemostop
.Local
(ethmasylate)dicynone 250.
* :
Ruta-C tablets 1X3 ,heamostop tablets 1X3 or dicynone
Antihaemorrhagic and capillary
protective
*
Pt=prothrombin time=10-15 sec
PTT=partial thromboplastin time=35-45 sec
Bleeding time=2-7 min
Platelet count =150,000 - 400,000
*
c
*
recurrent epistaxis
hemorrhagic telangectasia=HHT
62
Hereditary
Wounds
:
fucidin dressing
10 ) ( velosef 500 8 brufen 400 tab
*
.....
) (
* ....
.
* 6 .
*
* .
Hepatic coma
diuretics
Fluid replacement
63
500 % 5 12 500 24
2ry hyperaldosteronism with salt and water retention
) (coma
def.: loss of consciousness
Causes
64
*intracranial as:
head trauma & inrta cranial. Hge. (cerebrovascular stroke) with
increased B.P
brain abscess, encephalitis ,meningitis, massive infarction
,hypertensive encephalopathy, brain tumor. All intra cranial
causes may &may not come with lateralization signs which
are :
* unequal pupil,*facial asymmetry,*unilateral hyper or
hypotonia
*unilateral Babiniski, asymmetrical deep reflexes
*extra cranial causes:
toxic as co poisoning
-(D.M)may be: 1- hypoglycemic treated with 100 cm glucose
25% 2- DKA
-uraemic (CRF)
-AMI
-hepatic (Encephalopathy)
-resp. failure
Diagnosis:
history + complete physical exam. + Investigations like
*ABG
*renal function tests
*complete urine analysis
*urea & creatinine
*random blood sugar (R.B.S)
* glucose & acetone in urine
* liver functions tests (L.F.T)
*billirubin direct, indirect & total
*SGOT & SGPT
*Prothrombin activity
*ECG
*Abdominal U/S
*Brain CT
TTT:
1- maintain adequate oxygenation
65
.
2-ttt of shock if present
*By insertion of nasogastric tube and feeding the patient with 2
liters of fluid
. 2 *Insertion of Foley's catheter and estimation of urine in 24h
. 24 12 1 3-hospitalization &recording vital signs at regular intervals.
onset coma *
neurological cases and hypoglycemic coma sudden onset
metabolic coma gradual onset
hyperglycemic coma& DKA
Intracranial Heamorrhage
One of cerebrovascular stroke (C.V.S)
Patient clinically presents with History of hypertension, Right or
lift hemiplegia, hemiparesis, facial deviation, Coma, Slurred
speech.
Investigations needed
*For hypertension
- Na, K
-
-Cholesterol & TG in blood
-Urea &createnine
-Complete urine analysis
*For other causes
-Random blood glucose
66
-ECG
-Urgent CT brain
Treatment:
*Dehydrating measures and antihypertensives
-mannitol 20 % 250 cc IV
12
-lasix 40 mg amp.
70\100 12
-fortacortine amp. IV
24 12
*Cerebral Stimulants :
oxybral ampoule IM improve cerebral and memory
-condition
-Nootropil ampoule IV
8 2
*Measures to prevent stress ulcer
-zantac amp.
150 12
-motilium syp
3
*Intubation
-Ryle catheter ordinary fluid and cannula and give 1.5 liter
-Foley's catheter
24
*Care of comatozed patient
*Specific measures to stop hge.
-dicynone amp IV 8 2
-konakion amp 8 2
-cyclokapron amp 8
*if vomiting give primperan *abimol *flumox 500 mg
Management
250
tagamet(cimetidine) zantac(ranitidine)
*
zantac 150 or 300 mg tab
3 mucogel susp or epicogel
proton pump inhibitor
or omez or omepack losec
:
anti-inflammatory drugs
as piroxicam
Alternatives:
Zantac (tab&) ,Ranitidine(tab&) ,Histac(tab&) Aciloc
(tab) ,Ranitak(tab)
Fluid therapy
= Fluid assessment
hypovolemia
hypervolemia
B. pressure
Systolic 100 or low
High
Pulse rate & Tachycardia & small Normal & big volume
volume
volume
Central venous
zero
high
pressure
tongue
Skin elasticity
dry
Loss of it
haematocrit
increased
68
wet
Normal or peripheral
edema
decreased
little
normal
*Fluid replacement:
*Glucose 5% given
To replace water loss not associated with electrolyte disturbance
As solvent for many IV drugs
*Dextrose ,Glucose (20,25,40,50%) given in
As nutrient to give calories when GIT feeding isn't accessible as
in deep coma
Strong hypertonic as in case of sever hypoglycemic coma
**25,40,50% are in bottles and amp. Amp=25 ml
*Saline (Nacl 0.9%) used in
Water loss with electrolyte loss
*Sodium bicarbonate
In cases of sever metabolic acidosis
0,5&4,2 % bottles
8,4% in amp.
Ringer solution 500 ml
Contain NaCl , CaCl , KCl
*Plasma expanders
*To maintain normal blood volume as in shock and hemorrhage
*Crystalloids
* As saline & ringer give transient effect
Fate: escape to interstitial space
*Glucose 5% fate is intracellular space
*Colloids
Mannitol, dextran, gelatin, albumin
Fate: intravascular space
Hypertension
More than 150/90 plus headache with or without epistaxis
*
Investigations
69
24
Management
* lasix 3
8 epilat 10mg 12
. cerebral
edema capoten 25 mg
8
Tritac tab 5 mg once daily
aldomet 250
atenolol 50
Combination.
*
:
Drug choice
young adult First line is diuretics & b-blockers
2nd is ACE inhibitors as capoten or Ca channel blockers as
Epilat
In old age 1st line is Ca channel blocker with or without
diuretics
In H. failure Lasix capoten
Nefidipine & B.Blockers
R. failure Lasix-nefidipine(epilat)-aldomet
) thiazide diuretics & capoten (ACE inhibitors
*Alternatives:
*Ca channel blockers
& -Epilat , adalat 10 mg soft capsule (nifedipine) in HPN
)unstable angina(coronary & peripheral V.D
70
Appendicitis
Presentation
1- Symptoms
* , fever
* periumblical localized in
R.iliac fossa
* anorexia
* nausea vomiting
2- Signs
*
macburny point
* tenderness and rebound tenderness rigidity
* cross tenderness
* cough tenderness
*
.
Management
* %25
: analgesic not mask the
diagnosis
*
renal colic
* W. Blood cells
71
11
pelvis*
. history Mid-cyclic pain
*
appendectomy
laparoscopy or laparotomy
peritonitis,
septicemia and septic shock
( typical) *
.
acute abdomen analgesic
mask diagnosis
HCL gastritis
Management
* myolgen cap or norgesic tab or myolax ,myorelax ,myofen
cap. (sk.ms.relaxant&analgesic) or dimra or mark-fast( new)
*cataflam 50 or ketofan 50 or antiflam 50, adwiflam 50,
rheumaren 50, rheumafen 50, voltaren 50(anti inflammatory &
anti rheumatic)
* Felden gel or olfen gel
*Neurovit amp or neuroton or tri B(vitamin B complex)
.
Toxicology Cases
organophosphate poisoning
72
Presentation
pin point pupil, bradycardia, hypotension
salivation, secretion
sweating, diarrhea
Management:
*for a case of acute intoxication 4 broad lines should be done.
1-first aid or supportive care
-which is life saving to maintain patent air way and removing
secretions and insertion of oropharyngeal tube.
2-prvention of further absorption of poison here by
- removing contaminated clothes and washing skin Also by
insertion of ryle tube 16 and performing stomach wash
500 :
clear
300 ( 10 charcoal tab)
ryle
3-methods to increase elimination of poison
4- Use antidote
- Atropine 2 ampoule in one injection every 15 min
pupil fully dilated or pulse 15 *
reaches120
secretion
dry tongue
73
spasmodigestin tab
gastrofate(sucralfate)mucosal protective
food poisoning
Common cold
+
Management:
flumox cap 500
5
abimol extra tab
bradoral lozeng
3
vitacid -c tab
(antihistaminic 3 Flurest tab
& decongestant)
Alternatives
*Flumox, famox 500, flucamox (cap- vials) ampiclox (cap-vials
5oo-syr),
hi-flucil, miclox(250-500),amoclox(500)
*abimol,cetal,paracetamol,pyral,paramol,temporal,panadol
*flurest,sine-up,flustop,congestal,conta-flu tab,coldex cap,
clarinase tab
Cough
Management
3 coflin syr
mucophyline syr
phenadone syr
3 ( antihistaminic corticosteroid )
74
Farcolin(salbutamol) tab
Alternatives
* Coflin contain(cough suppressant ,decongestant ,anti
allergic),codilar, tussilar,neo pulmolar, selgon, siloma
* Mucophyline, neominophyline, mucosin, mucovent,
farcosolvin, trisolvin, ambroxol, Koffex, Actifed, solvex
*Phenadone, vendexine, apidone syp
*Farcolin, ventolin, bronchovent, salbovent tab
gastroenteritis
* vomiting, diarrhea, abdominal pain with or without fever
Management
avil + +
adolor
dehydrated
Home TTT
8 antennal cap or diax*
3 spasmocin tab or no-spasm or visceralgine*
) 3 flagyl 500 tab or amrizole*
(
Motilium tab or domperidone or motinorm or gastromotil*
Streptokine tab or entocid*
chronic *
ciprofloxacin500 tab(quinolones)
12
*
uncontrolled DM
Headache ,malaise ,blurring of vision history of DM or patient
on anti DM ttt
75
pin prick the finger tip ,put a blood drop on the tape mark ,put
the tape in the device, wait and read the resulting number ,if
random blood sugar is:
-250 - 200
300 - 250
300 - 350
350- 400
400 25
25 500 20
500
12
3
150
neuritis
presentation
random blood glucose more than 400
, low potassium level acetone on urine
polyurea ,acetotic breathing rapid deep breathing, tender
abdomen ,vomiting
Management
500 + kcl
500 +
500 +
500 +
? How to begin
76
iv fluid replacement
1 1
1 1 8
lowering blood glucose by insulin
25 100
250 250 ) % 5 (
200
200 250
250 300
300 350
350 400
400 25
correction of potassium
potassium chloride two ampoule on 500 cc ringer
correction of acidosis
12 250
prophylactic of DVT
500
Blood glucose level
motilium,zantac,tri-B,prempran
hypoglycemic coma
77
intestinal obstruction
abdominal distension and colic ,vomiting ,absolute constipation
x ray show multiple air fluid level
Management
12 fortacorten
kenacort vial
Or claritine ) allergex tab avil
(or tavegyl
Topical corticosteroid betaderm
heamatemesis
78
-first or recurrent attack
-amount of blood
-history of liver disease, DM, hypertension,
analgesic abuse
-do general and local examination, comment on neck vein, LL
oedema hepatosplenomegaly, ascitis ,vital sign pulse BP temp,
consciousness
Management
Nothing P.O. (per ...............
)oral
500 %5
cyclokapron
)(tranexamic acid antifibrinolytic
haemostop
antihaemorrhagic and capillary protective
ranitidine
amri-k or konakion or haemokion
) (10-9-7-2
Hyperkalemia
3.5 5
* asystole
*
100 10
* direct iv
.
Acidosis
phHCO3 deficit
79
* 100 %25 5 10
VI Intracelluar shift of K ion
*
* beta agonist
tachycardia cardiac
*
.
-1
-2
-3 & ACEI :
Beta blockers & spironolactone
-4
Acidosis-5
-6
.
Other prescriptions
Impotence
pregnyl 5000 10 /
proctan cap /
Anderiol cap / 12
vasotal tab 400 12 /
......................................... .................................................. .
.
)pregnyl 5000 I.U ( Human chorionic gonadotrophin
5000profasi ) (
: 10
80
Premature ejaculation
Prozac disp or anfranil 25 or 75 mg cap
)Antidepressent (delay ejaculation
Common mistakes
* :
:
: 40
: -
81
Rx
Ciprofar 500(-Ciprofloxacin-) tab
)Alternatives:(cipromax- Ciprobay -bactiflox 250,500,750
Diprofos- (betamethasone) amp
Alternatives: (decadron,dexamethason,solu cortef, kenacort
)A
Colostop-( piperment+anise oil) caps
)Alternatives: (epicogel,magsilon,sedo-mag
Answer
* "
""ciprofloxacin
* " " Mucogel " "antacid
*
.
*
interaction ciprofloxacin
.
* interaction ciprofloxacin Ca
Fe ... -
- - -
82
multivitamins
-
- - ciprofloxacin
ciprofloxacin
quinolones (macrolids) azithromycin
Rx
* Zithromax 250 -azithromycin- caps(azalide
cap250,500,susp200)azrolid 500
* Xithrone-zisrocin zithrokan
250 3
500 3
Susp 200 single dose 3
*Mineravit- multivitamins- caps
* betamethsone amp :
...
...
) (.
:
....
:
quinolones
Macrolides
Penicellins rifampicin
83
-
-
* "
"
Cephalosporons cephalexin
* 12 8
12 .
www.allteb.com
/
84
bronchial asthma
)(
wheezes
)(
""""""""""""""""""""""""""""""""""""""""""
"""" """"
""""""""""""""""""""""""""""""""""""""""""
"""" "
dysponeic /cyanosed/ sweaty
cardiac
/respiratory/cardiorespiratory failure
-1 : history
85
-2 chest auscultation
bronchial<<<wheezes
crepitations>>>cardiac
cardiac asthma
wheezy
) (
hypoxia
signs of right side heart failure
lower limb oedema/congested neck
veins/enlarrged tender liver
long standing B.A
PULMONARY HYPERTENSION
right side heart failure
)
(
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::::::::::::::::::::::::
cardiac asthma
DS3
VASODILATORS AS : ACEI
86
DIURETICS
DIGITALIS
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::::::::::::::::::::::::
:
FEV
mild to moderate-1
life thereatening-3
)
( ventilator
-2
severe B.A
BOLUS OF +
STEROID
5-4 ) (
200
DRUG
INTER ACTION
87
)(
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::::::::::::::::::::::::
1
2
3
: history -1
acute abdomen
absolute constipation , repeated
vomiting
: abdominal examination -2
traid of abdominal : tenderness/rigidity / :
distension
shock -/+
ryle
analgesic/spasmolytic
<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<
<<<<< << <<<<<<<<<<<<<<<<<<
:causes of acute abdomen
surgical causes:
perforated viscuc
intestinal obstruction
mesentric vascular occlusive disease
ectopic pregnancy
peritonitis
pancreatitis
::::::::::::::::::::::::::::::::::::::::::::::::::
:::::::::::::::::::::::::::::::::::
89
perforated viscuc
cxr
air under diaphragm
""""""""""""""""""
intestinal obstruction
abdominal x
ray erect & supine
erect :for air/ fluid level >>>> more than
3& step ladder appearance
supine : for site of obstruction
""""""""""""""""""""""""""""
90
12
24
92
Loss of conciousness
abc
A:airway secretions
aspiration
B:breathing
arrested
C:circulation shocked
..................................................
.. ..................................................
)
(
shock
shocked 80/120
70/90 shocked
shock
Shock tissue hypoperfusion to vital
organs
93
neurological
examination
Pupil: unequal = brain stem lesion
Mouth :deviated to one side sign of
lateralization
Upper & lower limb weakness : sign of
lateralization
Urine incontinence . sign of
lateralization
Babinisky sign sign of lateralization
:
Meningitis : rigid stiff
neck/fever/photophopia/repeated vomiting
Vertibrobasilar insufficiency : nystagmus
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::
abc
signs of system failure
Heart failure/ respiratory failure/renal
failure/liver cell failure
endocrine causes of
coma
95
)
systematic (
Or thyroid dysfunction comas
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::
hysterical coma
Blinking & escaping eye ball
::::::::::::::::::::::::::::::::::::::::::::::::::
:::::::::::::::::::::::::::
poisoning
organophosphorus
history
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::
Septic coma
::::::::::::::::::::::::::::::::::::::::::::::::::
:::::::::::::::::::::::::::::::::
96
:::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::::
Diabetic emergencies
diabetic comas
hypoglycemic coma -1
hyper glycemic comas -2
DKA/ LA/HONK
cerebrovascular stroke -3
97
GLIBENCLAMIDE
GLIBENCLAMIDE 2
PEAKES OF HYPOGLYCEMIA
ATTACK
ATTACKS2
:
irreversible brain damage due to -1
prolonged hypoglycemia
resistant hypoglycemia as insulinoma -2
stroke-3
end stage renal disease -4
99
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::
Hyper glycemic comas
(diabetic keto acidosis (dka -1
lactic acidosis -2
(hyper osmolar non ketotic (honk -3
: c/p
Diabetic patient . with repeated
vomiting/abd pain/
oliguria/dehydrated/precoma/or comatosed
Random blood sugar (rbs) = >300
acidosis
:
Hyper glycemia
20
dehydration
metabolic acidosis
ph<7.1
200 4
100
hyperkalemia
diastole
systole
antihyperkalemic measures
-1 100
20-2 200 %25
4 -3 200
hyper glycemic comas
Allteb.1aim.net
101
Haematemsis & melena.
1st aid measures :1-Vital data : pulse .. ... Bl.pr.
2-Canula & give : ((haematemsis cocktail )) ...............>
Dicynon"hemostatic" , Konakion "vit.k ", Cyclokabron "
antifibrinolytic" ,and Zantac
" H2 blocker"
3-Ryle --------------- Never before canula
*Values : -Ensure no bleeding
-To wash by cold water with or without adrenaline to cause
local VC.
*Continue wash till it become clear to prepare pt. For endoscopy
.
N.B.: Pt. Fit for endoscope means :- Ryle wash becomes clear .
- Pt. is not shocked.
- Pt is not in encephalopathy.
4- 3 blood samples ((obtained from the canula before giving
cocktail ))
- One for CBC ----- baseline Hbe
-----Plat. ((decrease in HCV +ve pt. ))
- One for metabolic profile ----Routine ..
- One for blood preparation.
5- ECG ....to exclude ISHD.
** If bleeding severe or pt not fit for endoscope or not available
endoscope
** We may use Sangstakin ---inflate gastric ballon with 250-300
cc saline
** sangstakin should not be left more than 48 hours to prevent
necrosis .
102
** Also in case of severe bleeding we can give :-Somatostatin:- [Octeriotide = antigrowth hormone] 25-50
ug\h..."one
ampoule contain 100 ug"
+ 4 - 400 saline or Ringer
Value : VC.
- Glypressin "One ampoule contain 1mg "
6 1 2
$$. Take care :
It cause coronary VC, so give nitroderm patches if blood
pr. Allows.
Glypressin is # in IHD, old age..
Blood is given if pt. chocked.
Plasma is given if pt INR >1.5
Plat. Is given if pt plat. >50,000
Till blood --give Colloid which last in intravascular space more
than crystalloids. E.g. : Dextran,haemgel.
If Colloid not available ----- give crystalloids E.g.: Saline,
Ringer.
TTT OF PU
a)1st aid measures
b)Upper GIT endoscopy for D.D.- if active bleeding injection
with adrenaline
c) Losec ( Omeprazole) vial + 200 cc Ringer over 2 hours.
d) If anteral gastritis or Du Tripple therapy to eradicate h.pylori
It includes :- PPI e.g. : Gastrazole 1*2*15 days
- Clarithromycin 2*2*15 days
- Amoxicilin 2*2*15 days.
Discharge Pt. when :Melena stopped
Hb = 8 or more.
Avoid spicy food , smoking , NSAID
NB: If pt. with PU with severe haematemsis consult Surgery.
104
6-Tapping:
105
N.B.:
106
TTT: - Antipyretic.
- Antibiotic3rd generation cephalosporin E.g. : cefotaxime "claforan"
1 gm \ 8 h for 5 days unless there is renal failure ((dose adjustment)) Anticoma measures ( previousely mentioned ) - Albumin.
Hepatic encephalopathy :It's neuropsychiatric complex in pts with acute or chronic LCF or
portosystemic shunting(i.e.: disorderd conciousness, abnormal
behavior)
Ask about ppt factors in Ch. Liver disease pts :
-Diuretics
- High dietary prot.
- Haematemsis, melena
- Fever (infection)
- SBP
- Severe vomiting or diarrhea, excess tapping of ascitis.
- Hepatotoxicity ( alcohol ,drugs e.g. : sedative, opiod)
Management :
1-Vital data ((fever. Haematemsis ))2-Canula sample for metabolic
profile. ( Na, K, Creat, RBS)3-Ryle &wash to exclude haematemsis.4Chest x ray ( chest infection. . Rt sided P.effustion.5-ECG
107
TTT:
1- To avoid prot. In diet. 2- Eradicate bact. Flora by: - Neomycin 500
mg 2*4*5
Flagyl 250 mg 1*3*7 - Lactulose 30 ml \8 h. (osmotic purgative ) Enema \4h
3- Hepamerz"L-Arnithine L-aspanate (2 amp +200cc glucose 10% \12
h.)
if creat > 3
4-Aminolesan 500ml\12h (AA infusion
5-TTT of the cause :
E.g. : Haematemsis Dicynon ,konakion, cyclokapron ,zantac.
Infection TTT
SBP Antipyretic, Antibiotic, Anticoma, Albumin
Fever
Management:
if u dont find a cause for fever & fever is prolonged > 2 wks >>>>>>
FUO
UTI:
C/O: dysuria, frequency, urgency, hematuria. Ask for urine analysis: if
pus cells > 100 / hpf (N=0 /hpf) >>>> ask for urine culture ttt: Give the best
antibiotics which is sulfa or Quinolones e.g. -Sutrim tab. 2*2*5-Chemotrim fort
1*2*5-Septrin 1*2*5 ORQuinolones if there is hypersensitivity to sulfa or
resistance to it-Tarivid 200mg (ofloxacin) 1*2*5-Oflicin 200mg (ofloxacin)
1*2*5if pylonephritis: IV AB is required (hospital admission)
Tonsillitis or oropharingitis:
TTT: 1- Antibiotics for 1 wk:
the best is penicillin e.g. Ampiclox 1*4 - 1st generation cephalosporins e.g.
Velosef or Duricef - Sulfa e.g. Sutrim2- Antipyretic 3- mouth wash
Otitis Media:
As above + nasal decongestant e.g. Afrin drops 1*3*7
Bronchitis:
As above + expectorants & mucolytics e.g. Mucosol syrup 1*3
Mucophylline Bronchophene Bisolvon 1*3 Trisolven
Gastroentritis:
Bronchial asthma
During attacks:
109
N.B.:
* In case of cocktail if the pt is diabetic give saline & if the pt is
hypertensive gives glucose. *If the pt has HF or CRF give minimal
fluids 100cc or 200cc
Home ttt:
R/- ttt of ppt factor e.g. infection - Spray e.g. Clenil (salbutamol+
Beclomethasone)
6
Coma
(disturbed level of conscious)
Signs of lateralization:
deviation of the angle of the mouth.
Deviation of the tongue.
.Weakness on one side with withdrawal on painful stimulus
Change in the tone on one side.
Eye deviation
Babiniski (extensor planter response)
Causes:
A-With lateralizing signs: ( need CT
110
Management:
Rapid history
111
112
113
Management of DKA:
Hemotest
Urine sugar & acetone
ABG & ECG
MP (glu >250mg/dl, +++ urine sugar &acetone
ABG shows PH < 7.3 or HCO3 low)
We have 4 problems
1Hyperglycemia:
- Give insulin 10 IU IM/hr + urine sugar & acetone & hemotest/ hr
- if the pt is markedly dehydrated start by 10 IU IV
- once Glu is < 250 mg/dl give Glu. 5% to improve cellular
dehydration
2Acidosis:
- HCO3 is not given unless PH < 7.1 or deficit is > -10
3Dehydration:
- 4- 6 L in the 1st 24 hrs
- 500cc/ hr for 2hrs
- 500cc/ 2hr for 4hrs
- 500cc/ 4hrs
with follow up by fluid chart
N.B. diabetic pt with Chr renal failure >>> fluids will lead to
pulmonary
Edema, so central line is fixed & measure CVP & if low
compensate
by oral route
114
4Hypokalemia:
-if K > 6 dont give
- 4.5 -6 give 1 amp.
- 3.4 5 give 2 amp.
- < 3 give 3amp.
5Correction of PPT factors e.g. chest infection >>>>give AB.
N.B.:- In hyperosmolor non ketotic coma, heparin is given for
prophylaxis as
hyperosmolarity >>>> hyperviscosity >>>> infarction.
- AGAIN: if the pt with hyperosmoler coma is not improved, do
CT
exclude infarction.
Allteb.1aim.net
115
Non specific skills:
1- Accurate measuring of blood pressure, pulse and temperature.
2- Withdrew many venous samples and insert many canulae.
3- Withdrew arterial samples and know WRERE to analyze and
learn reading.
4- Inserting male and female urinary catheters.
5- Dealing with central lines (see insertion, how to give through,
withdrew from and how to measure CVP).
6- When, what type, why and how to prepare blood transfusion
and other blood components.
7- How to communicate with residents, staff, nurses and patients
(how to tell bad news, death, cancer, risky operation and strict
follow up?
8- How to write requests for consultation and referral? And stay
beside every consultant and see how they examine and take
decision.
9- Try to read every X ray, C.T., ECG, MRI, ERCP, .. You
meet.
10- Don't go to any request unless you know its value and every
thing about the patient.
Specific skills:
Surgical dressings
1- How to do proper dressing for clean, septic, open and closed
wounds.
2- What is the frequency of dressings?
3- When to use saline, alcohol, betadine, iroxol, EUSOL,
paraffin oil, glycerin, tincture benzoic and others?
116
117
Preoperative preparation:
1. How to write and take surgical consent?
2. How to do colonic lavage, ask for shaving, fasting, resuscitate
and give preoperative analgesics and antibiotic?
Operations:
1. Sterilization and toweling for the patient.
2. Sterilization of you and how to wear gown and gloves?
3. Watch induction and termination of anesthesia try to do
endotracheal intubation.
4. Assist in some operations and do closure of: thyroidectomy,
hernial repair, appendectomy and mastectomy.
5. Watch other major operations to take an idea e.g. Whipple's,
colectomy and others.
6. Interested personal can do appendectomy, abscess drainage
and removal of cysts and swellings.
7. How to use surgical instruments and why every one?
8. How to write operative details?
Postoperative management:
1. What is the treatment given to every case?
2. When to do postoperative dressing?
3. When and how to start oral feeding and what are the fluids
given to nothing per os N.P.O. patients?
4. What Total Parentral Nutrition TPN and when to start?
Conference :
1. Try to learn how senior staff take decision and think of
surgical cases e.g. obstructive jaundice, breast lump, bleeding
per rectum etc.
2. Ask about any thing you don't understand. Don't be ashamed
it's your last chance to learn surgery.
CONCLUSION:
Try to learn and do what junior resident surgeons know and do.
N.B.
5 Days in burn unit:
1. Try to know and see surgical dressings of burns.
118
119