NAC OSCE A Comprehensive ReviewNAC OSCE A Comprehensive Review First Edition ConadaPrep)Copyright @ 2011, Canadaprep. ‘All rights reserved. No pact of this publication may be reproduced or transmitted in any form o: by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher, Reproducing passages from this book without such written permission is an inftingement of copyright law. Care has been taken to confirm the accuracy of the information presented and to describe generally aceepted practices. Howeves, the authors, editors, and publishers are not sesponsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the contents of the publication,’The authors, editors, and publishers have exerted every effort accordance with the current to ensure that drug selection and dosage set forth in this text oF recommendations and practices at the time of publication. However in view of ongoing research, changes in ‘government regulations, and the constant flow of information relating to drug therapy and drug reactions, ‘the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. This publication has not been authored, reviewed or supported by the Medical Council of Canada, nor is it endorsed by the Medical Council as a review material for the NAC OSCE.PREFACE ‘This book was written due to the lack of preparation material available for the National Assessment Collaboration (NAC) Objective Structured Clinical Examination (OSCE). As an International Medical Graduate (IMG) preparing for clinical and written exams in Canada, there is no comprehensive review textbook available for the NAC OSCE. Due to the lack of resource materials, many students are forced to study ftom sources that are not relevant to the NAC OSCE. This eventually hampers the candidate's score in the examination. ‘This book aims to guide you through the steps of the NAC OSCE and ensures that you are well prepared and a step ahead of the competition. A great effort has been put into collecting and organizing relevant content for both the clinical OSCE stations and the written therapeutic exam, ‘Written by medical graduates who are oriented to the NAC OSCE, this comprehensive review can be used as a framework, complementing your clinical skills and therapeutic knowledge as you prepare for the examination, This book is dedicated to all the IMGs preparing for the medical licensing examinations in Canada. “And most important, have the courage to follow your Beart and intuition. They somehow already know what yet truly want to Become. Everything else is secondary.” ~ Steve JobsTABLE OF CONTENTS Introduction to NAC OSCE General Information sa. Registration for NAC OSC Fees Examination station NAC OSCE scoring Saumple of Therapeutic written test. : Sample clinical case station ...... "3 5 ‘Therapeutic Guidelines Maticine Cardioto, Dermatolo Endocrinolog - Gastroenterology Hematology .. Infectious Diseases Neurology’. Qrolarmgciogy Pulmonol Rheumatol Nephrology/Ucclogy Emergency Medicine sss Counseling (smoking/alcohoi) Obstetrics & Gynecology Sexually transmitted infections . Usinary tract infection Vulvovaginitis Pelvic inflammatory disease Dysfunctional uterine bleeding. Dysmenorthea ‘ + oe " 40 Endometriosis pe = 40 Hormone replacement therapy Emergency contraception .. Group B Streptococcus in pregnancy Pregnancy induced hypertension Ectopic pregnancy .. Hypezemesis gravidarum Drugs contraindicated in pregnancy Pediatrics ‘Acute bronchiolitis. a : Acute otitis media. : 2 : Asthma| we it ve Bacterial tracheitis Bacterial pneumonia 46 Croup (Laryngotrachcobronchitis) 148 Ebae 48 Seemed plants (Group A Saepincocas) 48 ‘Whooping cough (Pertussis) A Bacterial mieningitis Febrile seizures Urinary tract infection .. Dose of tylenol. Immunization scheduleTABLE OF CONTENTS Psychiat Ustedon Mania Panic disorde Social phobia wn General anxiety disorder Obsessive compulsive disorder. Post traumatic stress disorder... Dementia _ Depression. Paychosis . ‘Mood stabiliz ‘Medications causing sexual dysfunction .. Substance abuse... Clinical Examination Abdominal... Cardiovascular Peripheral vascular » Respiratory examina Central nervous system Upper limb neurological 7 Lower limb neurological « Musculo-skeletal system : Spine/Back . HID saincussisotonmnt reat Knee Breast examination ~ ral State Examination Clinical cases Protocol for history taking... Medicine Cerebrovascular attack... Digoxin toxicity... Infectious mononucleosis (sore throat) ‘Migraine (Headache) . Myocardial Infaretion(Chest pain) Pneumonia Post exposure prophylaxis for HIV Pulmonary eubolisth Seizure disorder ‘Temporal arteritis onmren di hee stetrics and Gynecology Abortion ‘Antenatal vis Ectopie pregnancyTABLE OF CONTENTS. Infertility. OCP counseling... Pelvic inflammatory disease Placenta previa. Pre eclampsia vacsnesnn Pediatrics Failure to thrive Febrile seizure... Measles " % Neonatal jaundice . Primary nocturnal enuresis, Pylorie steno Speech delay.. Bulimia. Delirium . Dementia... Depression Mania Panic attack Schizophrenia Suicide cree Surgery Back Pain . Basal cell carcinoma Benign prostatic hyperplasi Carpal Tunnel Syndrome Deep Vein Thrombosis Diabetic foot Difficulty Hematemesi Neck swelling Pain abdomen Peripheral vascular disease .. Post operative fever .. Solitary lung nodule ‘Thyroid mass Trauma. Counseling Breast feeding... 2 2 159 Child abuse Domestie violence wn. Hormone replacement therapy. ‘Mammogram Immunizz Obesity . SmokingIntroduction to NAC OSCE | General Info 1 Introduction to NAC OSCE General Information ‘The National Assessment Collaboration, or NAC OSCE, was established to provide a system that streamlines the assessment of IMG medical knowledge and clinical stills throughout Canada. Many international medical graduates (IMGs) find that the path to obtaining 1 medical license in Canada challenging and difficult to navigate. Different provinces and territories have their own system for assessing IMG medical knowledge and clinical skills. Comprised of a number of federal and provincial assessment and educational stakeholders, the NAC OSCE aims to streamline the evaluation process through which an IMG must navigate to obtain a license to practice medicine in Canada. Through such a system, an IMG's path to licensure would be the same, regardless of the jurisdiction in which he or she is being assessed. The NAC OSCE has replaced CEHPEA’ Clinical ‘Examination 1 (CE1), which was unique to Ontario, Registration for NAC OSCE Registration for the NAC OSCE in Ontario starts in Novernber, with the deadline in January the next year. Candidates are advised to complete their registration within this time-frame, Once the deadline is over, the candidate will not be able to register for the NAC OSCE for the entire year. The exams are scheduled for ‘March, June, August and September. Visit www.mee.ca and www.cchpea.ca for updated information. Fees Application Fee: $200 which is non-refundable, NAC OSCE Fee in Ontario: $1850 and Exam Date Change Fee: $100 All fees are in (CAD) Canadian Dollars, Examination station “The format for the National Assessment Collaboration (NAC) Objcctive Structured Clinical Examination (OSCE) consists of 12 stations based on presentations of clinical scenarios. For a given administration, each candidate rotates through the same series of stations. Each station is 10 minutes in length with two minutes berween stations. At each station, a brief written statement introduces a clinical problem and outlines the candidate's tasks (c.g take a history, do a physical examination, ctc.).In each station, there is atleast one standardized patient and a physician examiner. Standardized patients have been trained to consistently portray a patient problem, Candidates should interact with standardized patients as they would with their own patients. The physician examiner observes the patient encounter, For most stations, the candidate will be asked to respond to a series of standardized oral questions posed by the physician examiner after seven minutes with the standardized patient. There are no rest stations. Orientation videos hetp://www:mce.ca/en/video/QEIL-Orientation/index html2 NAC OSCE | A Comprehensive Review ‘The examination includes a separate written test of candidates’ therapeutic knowledge. This component lasts 45 minutes and consists of 24 short-answer questions testing the candidates’ knowledge of therapeutics for patients across the age spectrum and related to pharmacotherapy, adverse effects, disease prevention and health promotion, NAC OSCE scoring ‘The candidate’s total examination score will be determined by combining the scares on the OSCE component with the scores on the therapeutics component. The OSCE score contributes 75 per cent of the total score and the therapeutics score contributes 25 per cent of the total score, For reporting purposes, the NAC total ‘examination scores are reported on a scale with a distribution ranging from 0 1 100 with a fixed passing mark of 65. Number of times candidates can take the examination Starting in 2011, the NAC OSCE can be attempted once per Canadian Resident Matching Service (CaRMS) cycle. If you pass the examination, you can register for the examination a maximum of two additional times if your eligibility is maintained. Regardless of whether you pass or fail, you can only take the examination three times. Ifyou take the examination more than once, the most recent zesult will be the only valid result, Sample of Therapeutic written test Question: An otherwise healthy 65 year old woman presents with a 3 week history of aching and morning stiffness in both shoulders with difficulty dressing. She has no temporal artery tenderness, headache, jaw pain or visual disturbance. Her ESR (Exythrocyte sedimentation rate) is 100 and you have made the diagnosis of POLYMYALGIA RHEUMATICA (PMP). ‘What would you choose as the drug of first choice for initial medical therapy? (Drug, dose, route of administration and duration are required.) Answer: —— Answer key the marker receives: PREDNISONE 7.5 20 mg PO od for 2-4 weeks following resolution of symptoms Question: An otherwise healthy 55 year old male with a history of childhood “chickenpox” presents with a 2 day history of painful unilateral vesicular eruption in a restricted dermatomal distribution. You make a diagnosis of HERPES ZOSTER (shingles). ‘What would you choose as the drug of first choice to promote healing and lessen the neuropathic pain? (Drug, dose, route of administration and duration are required.) Answer: Answer key the marker receives: VALACYCLOVIR (VALTREX ®) 1000 mg PO tid X 7 days OR FAMCICLOVIR (FAMVIR ®) S00 - 750 mg PO tid X 7 days OR ACYCLOVIR (ZORIVAX ®) 800 mg PO 5X / day X 7 days)Introduction to NAC OSCE | General Info ‘Sample Clinical Case Station Example instruction written outside the station David Thompson, 59 years old, presents to your office complaining of jaundice, Tn the next 7 minutes, obtain a focused and relevant history After the 7 minutes, you will be asked to answer questions about this patient, Example of post encounter questions (QU. The abdominal examination of David Thompson revealed no organ enlargement, no masses and no tenderness. What radiologic investigation would you first order to help discriminate the cause of the jaundice? Q2. Ifthe investigations revealed that this patient ikely had a post-hepatie obstruction, what are the two principal diagnostic considerations? QB. What madiologie procedure would you consider to elucidate the level and nature of the obstruction?Therapeutic Guidelines | Medicine Therapeutic Guidelines Medicine 1. Cardiology Acute Myocardial Infarction : Immediate management in ER 1. Beta blockers: Inj Metoprolol 2.5-5 mg rapid IV q2-5 min, upto ARTE MUTREATMENT 15 mg over 10-15 minutes, then 15 minutes after reeciving 15 mg IV. B: Beta Blockers 2, Then 50 mg PO q6h x 48 hours, then 50-100 mg PO BID. M::Morphine Sulphate 3. Inj Morphine Sulfate IV 2-5 mg every 3-30 min pn Cou A (If pain not relieved with 3 Sublingual Nitroglycerins) a pee " 4, Oxygen by nasal cannula at 4 liters per minute 5. Sublingual Nitroglycerin 0.3-0.6 mg, q5min up to 3 times. 6, Non-enteric coated Aspirin 325 mg PO. 7. Cardiology Consultation Post MI drugs Drugs Benefits Side effects Contraindication ACE Inhibitors 4 mortality Hypotension/dizziness | lateral renal artery Ramipril - 10mg hs Prevents ventricular remodelling | Hyperkalemia stenosis Lsinopril - 10mg od + proteinuria Angioedema Hof angioedema Enalapril — 20mg od Renal insufficiency Pregnancy Captopril 50mg tid ‘Cough, taste changes ARB 4 mortality Angicedema Valsartan ~ 160mg bid | proteinuria |Cough, taste changes Candesartan - 32mg od Beta Blocker + mortality Decreases BP&HR | Severe/poorly Metoprolol ~ 100mg bid 4 sudden death, reinfarction & | Dizziness fatigue controlled asthma Atenolol ~ 100mg od archythmias Sexual dysfunction _|2/ird degree heart Carvedilel - 25mg bid Cardioselective :preferredfor | May mask hypoglycemia | Dlock Propranolol — 60-80 tid mild asthma and diabetes eaentr HR<50, SEP<90 rdiogenic shock | Cocaine use Statins + mortality in post MI patients | Gl upset, muscle aches, | Active liver disease, Atorvastatin - 10mg od with high cholesterol myopathy, rhabdomyo- | alcoholics, pregnancy Simvastatin - 20-40mg od iysssimpotence Anti-platelets 4 vascular events Recent/active ASA ~ 80-162mg od bleeding Clopidogrel ~ 75mg od Glintolerance or ASA Warfarin ~ 1-10mg od allergy8 NAC OSCE | A Comprehensive Review Atrial Fibrillation 1. To control rate: + Inj Metoprolol 5 mg bolus 1V, followed by infusion at 0.05 mg/kg/min, increasing as needed 10.0.2 mg/kg/min. + Inj Diltiazem 20 mg bolus. Maintenance infusion of 5-15 mg/h. + Inj Verapamil 5-10 mg IV over 2-3 min, repeated once after 30 mins. + Tab Amiodarone (in case of heart failuze + Loading dose: 800 ~ 1600 mg P mg/day divided bid-tid. + Maintenance: 200 mg PO od. 2. To prevent thromboembolism: Assess with CHADS 2 score + No risk: Tab Aspirin 81-325 mg PO od. +L moderate risk: Tab Aspirin 81-325 mg PO od or Tab Warfarin 2-15 mg PO od to maintain INR23. + > I moderate risk or very high risk: Tab Warfarin 2-15 mg PO od to maintain INR 2-3. 3. To control chythm: + Tab Flecsinide 300-400 mg PO bolus dose, maintenance: 50-150 mg PO bid. (First choice) + Tab Sotalol 80-160 mg PO bid. ( Second choice) + Tab Amiodarone (in case of heart failuse + Loading dose: 800 ~ 1600 mg PC mg/day divided bid-tid. + Maintenance: 200 mg PO od. + Electrical Cardioversion: 100-360 joules. divided doses until response; till max 1000 divided doves until response; till max 1000 Congestive Cardiac Failure : Immediate management in the ER CAR-TREATMENT MNEMONIC Litasix + Oxygen by nasal cannula at 4 Titers per minute. M:: Morphine Sulphate + Inj Furosemide (Lasix) 10 mg IV stat. Me eacenn + Inj Moxphine sulfate IV 2-5 mg every 5-30 min pn. Bae rieageee + Sublingual Nitroglyccrin 0.3-0.6 mg qSmin up to 3 ti Position > 45 degrees + Position of patient > 45 degrees. D: Dopamine (indicated in cardiogenic shock and hypotension) Non pharmacological management of Heart Failure + Brercise : Regular physical activity + Salt restriction : symptomatic HF ~ 2-3g salt/day (14 tsp/day) no added salt in diet. HE with fluid retention : 1-2g salt/day (% tsp/day) + Fluid intake : 1.5/2L per day in patients with fluid retention or HF not controlled by diuretics. + Daily weight measurement, + Education, + Aggressive risk reduetion (BP, glucose, lipids) + Lifestyle modifications, influenza vaccination.Therapeutic Guidelines | Medicine Dyslipidemia 1. HMG CoA Inhibitors: + Atorvastatin : Tab Lipitor 10-80 mg qhs + Rosuvastatin :Tab Crestor 10-40mg ghs + S/E: GI symptoms, rash, pruritus, inereased liver enzymes, myositis. + CALs active liver disease, muscle disease, pregnancy. ibrates: increased TG (triglycerides) + Fenofibrate : Tab Lipidil 67-200 mg/d 3. Bile acid sequestrants : increased LDL. + Tab Colestipol 5-30g/day 4, Cholesterol absorption inhibitors: + Tab Ezetimibe 10mg /day. Lo af Total cholesterol/HDL_ HIGH (10yr CAD > 20%) Target LDL - <2.0 Target <4 MODERATE (0y¢CAD > 10-19%) _| Treat fLDL- >3.5 Treat it>5 LOW (1oye CAD <10%) ‘Treat if LDL- =5 Treat re ~~ High Risk : All with CAD, CVD, most diabetes cases & chronic renal disease, Hypertension Non pharmacological treatment : + Smoking cessation: smoking aggravates hypertension and remains the major contributor to cardiovascular disease in people under 65 years. + Weight reduction : Maintain BM1<27, particularly in patients with glucose intolerance + Alcohol restriction, + Sodium restziction <150mmol/day: Blood pressure risk factors Consider treatment if BP BP target Noviskfactors > 160/100 «140/90 Isolated systolichypertension _SBP>160 seP<140 Moderate-High riskpatient — >140/90 oo Diabetes or Renal disease = 130/80 <130/8010 NAC OSCE | AComprehensive Review Commonly used anti-hypertensive drugs : a - a . - Drug c ‘indication Side Effect Diuretics Uncomplicated HTN, Diabetes | Rash, allergic rxn, pancreatitis, sexual Hydrochlorothiazide HCT ~ 12.5-25mg od with normal albuminuria, LH | dysfunction. HCT contraindicated in Spironolactone ~ 25-50mg od and isolated systolic HTN gout, Beta Blockers Stable angina, Ml, LVH, Fatigue, insomnia, 4 HR, impotence, Metoprolol ~ 50mg bid or 100mg SR od uncomplicated HTN <60 years, | dizziness. C/ ~ asthma/COPD, 2/3" Propranolol ~ 80mg bid degree heart block, uncompensated HF Atenolol ~ 50-100mg od severe PAD ACE Inhibitors Heart failure, diabetes, post Ml, | Cough, loss of taste, rash, angioedema, Ramiprit ~ 10mg hs uncomplicated HTN, LVH, prior | renal failure, | BP Te a 7 ree CVAITIA, renal disease, all C/A ~ b/lrenal artery stenosis, Hx of ‘peed ona regnanc) Captopril- 25-50™mg bid coronary artery disease pts angioedema, pregnancy ‘Angiotensin Il Receptor Blockers Diabetes, uncomplicated HTN, Fatigue, headache, rash, angioedema, Losartan- 25-50mg od ‘solated systolic HTN, LVH, 4 BP, K+, pancreatitis. Valsartan ~ 80-160mg od patients unable to tolerate ACEI. C/I ~ b/l renal artery stenosis, Hx of Candesartan - 8-16mg od angioedema, pregnancy Calcium Channel Blockers Uncomplicated HTN, LVH, Angina, | Dizziness, headache, rash, edema, ‘Amlodipine ~ 2.5-10mg od Isolated systolic HTN, diabetes | gingival hypertrophy, worsen HF Nefidipine- 10mg tid without nephropathy CA ~ hypotension, recent Mi with Verapamil- 40-80mg tid pulmonary edema, sick sinus, Dittiazem ~ 30-60mg tid syndrome, 2"/3rd AV block Methyldopa ~ 125mg bid to 500mg qid First-line for hypertension in _| Sedation, dry mouth, hepatotoxic, pregnancy lupus like symptoms. Infective Endocarditis Prophylaxis + Inj Ampicillin 2g 1V q4h x dweeks. + Inj Gentamicin Img/kg LV q8h x4 weeks + Prophylaxis: Dental/respiratory/esophageal procedure: Tab Amoxicillin 2g PO. 30-60 min prior; ‘Tab Clindamycin 600mg PO, if allergic to penicillin, Rheumatic Heart Disease (RHD) + Tab Erythromycin 500 mg tid PO x 10days, * Tab Penicillin VK 500 mg PO bid x 10 days.Therapeutic Guidelines | Medicine u 2. Dermatology Acne Mild : <20 comedones (whiteheads/blackhcads) or <15 inflammatory papules, or a lesion count <30 Moderate : 15-50 papules and pustules with comedones, cysts are sare, lesion count ranges from 30-125 Severe : Primarily nodules and cysts,also present are comedones, papules and pustules, scarring is present, lesion count >125 1 Benzoyl Peroxide (Antibacterial/Keratolytic) Indication: 1" tine _S/E scontact dermatitis, 2 | Dose: apply to entire afected area ghs or bid medication for mild- dryness, erythema, burning He moderate acne. &pruritis {Tretinoin (Retinoid) Tline treatment for mild- | S/E erythema, dryness, L | Dose: qhs, apply 30-45 minutes after wash moderate comedones acne. _ burning, photosensitivity | Oral antibiotics Indicated for moderate-_S/E: Gl upset, nausea, Tetracycline - initial 500mg bid then 250-500mg od | severe acne. vomiting, candidiasis. Doxycycline - 100mg od ‘Acne on chest, back & (CAsliver disease Erythromycin - initial 500mg bid then 250-500mg od _| shoulders $ Combined Oral Contraceptive Females with moderate- C/I: Smoking, migraine with J Diane 35/Yasmin/Alesse: od x21 days, 7 days severe acne + seborrhea + aura, seizures 1 offfeycle hirsutism, late onset acne tsotretinoin Severe nodulocysticacne, | Teratogenicity : ocular 1 Accutane :0.5-1mg/ka/day x 16-20 weeks acne with scarting, failure to effects ~ conjunctivitis, © | important : Tests for pregnancy 30 days prior to respond to other treatments | night vision, premature starting Accutane, before each refill. Patient has to epiphyseal closure, 1 LFTs, sign an informed consent. pseudomotor cerebri, ‘mucocutaneous effects, myalgias. Photosensitivty. 1 of ABCs , consider the need for early intubation if airway is compromised. + Humidified 02 if any suspicion for inhalational injury. + Oxygen 100% if known carbon monoxide exposure of fire in an enclosed space. (Half life of hemoglobin will drop from 330 to 90 mins). + Establish IV access. + Fluid resuscitation : Parkland formula 4ml g/l + Nasogustrie tube drainage for ileus, + Bladder catheterization to monitor urinary output, minimum ImL/kg/he. axis : 0.5 ml. tetanus toxoid IM in previously immunized and 250 units‘T1G IM if burn, % over 8 hours and rest over 16 hours + Tetanus prophy d, unimmuniz12 NAC OSCE | A Comprehensive Review Psoriasis ‘Topical Preparations : 1. Topical Corticosteroids + High Potency’Topical Steroids (Usually indicated) + Very high potency: e.g, Clobetasol (Temovate) + High potency: e.g, Fluocinonide (Lidex) + Low Potency Topical Steroids (Alclometasone dipropionate) usually indicated in + Genitals + Maintenance’Therapy 2, Vitamin D based topicals + Caleipotriene (Dovonex) + Used in combination with Topical Corticosteroids 3. Retinoid based topicals = + Tazarotene (Tazorac) ‘More irritating than Caleipotriene 4, Immunosuppressant based topicals : * Tacrolimus 0.1% or Pimecrolimus 0.1% ercams Effective in facial and intertriginous Psoriasis 5. Adjunctive agents in combination with above : + Topical Salicylic Acid (Keratolytic Agent) 6. Poorly tolerated topicals (use Calcipotriene instead) . + Historically used with UVB light exposure + Anthralin (Anthra-Derm) + Cou Tar (eg. Zetar) Ultraviolet light + Risk of non-Melanoma skin cancer + Protocols + Ultraviolet B exposure alone + Ultraviolet A exposure with psoralen (PUVA) Increased risk of non-Melanoma skin cancer Systemic agents (most are for higher risk) + Immunosuppressants + Etretinate + Cyclosporine + Methotrexate (unclear efficacy)‘Therapeutic Guidelines | Medicine B + Biological agents + Tumor necrosis factor (TNF) receptor blockers Etanercept (Enbrel) Infliximab (Remicade) + Other mechanisms Alefacept (Amevive) izumab (Raptiva) + Thiazolidinedione (Avandia, Actos) ~ experimental + Appears effective in Psoriasis even in non-diabeties + Only small trials support to date Cellulitis + Cause: B Hemolytic Streptococeus , Staphylococcus + ‘Treatment: ‘Tab Cloxacillin 500mg PO qid x 10-14 days If patient is allergic to penicillin : Tab Cephalexin 500mg PO qid 10-14 days OR “Tab Clindamycin 300mg PO gid x 10-14 days Pediculosis + Permethrin 11% - wash hair with regular shampoo, then apply permethrin and leave for 10 mins then rinse + Pyrethrins with piperonyl butoxide + Lindane 1% C/L in neonates, young children and pregnant women, causes neurotoxicity + Wash all clothes and linen in hot water, then machine dry. + Permethrin 5% ~ massage into all skin areas, from the top of the head to the soles of the feet, leave for ‘8-14 hours then wash off. * — Crotamiton 10% + Scabene (aerosol spray) + Lindane : used only if allergic to permethrin, + Treat family and contacts. + Wash all clothes and linen in hot water, then machine dry. Tinea Cruris/Pedis (Jock itch/Athlete’s foot) + Clotrimazole 1% cream apply bid + Ketoconazole 2% cream apply bid14 NAC OSCE | A Comprehensive Review 3. Endocrinology ‘Diabetes Mellitus Blood glucose target |AIC q3-6 months Normal range<6 Target 4-7mmol/t Normal range 4-6mmol/L Fasting plasma glucose Post prandial blood glucose 2h Target 5-10mmoV/L Normal range 5-8mmoV/L Approach to management of diabetes mellitus 1. Lifestyle modification & patient education 2. Oral hypoglycemic monotherapy + Biguanides (Metformin) ~ 250-500mg PO bid-tid (if obese or overweight) + Sulfonylureas (Glyburide) ~ 80mg PO bid + Thiazolidinecione (Pioglitazone) ~ 15img PO od; Rosi + Alpha glucosidase inhibitors (Acarbose) - 50mg PO tid 3. Oral combination therapy (2 agents often needed; after 3 years 50%, after 9 years 75%) 4, Tasulin therapy +/- oral hypoglycemics rvone— 4mg PO od + Fluid replacement + Initial : Give 1 liter NS bolus over fist 45 minutes, repeat fluid bolus until shock corrected. + Next : Replace first 50% volume deficit in first 8 hours, use Normal Saline or Lactated Ringers. Replace remaining 50% deficit over next 16 hours, use DS 1/2 NS at 150-250 ml per hour. + Insulin (Hypokalemia must be corrected prior to Insulin) » Initial i. Give IV bolus of 0.15 units/kg ii, Start 0.1 units/kg/hour Insulin Drip + Maintenance i. Anticipate Serum Glucose drop of 50-70 mg/dV/hour + Tfinadequate drop, then increase drip @) Tnerease Insulin Infusion rate by 50-10% b) Continue at increased rate until adequate ii, When Serum Glucose <200-250 mg/dl a) Keep Serum Glucose at 150 t0 200 mg/dl b) Decrease rate by 30% (t0 0.05 units/kg) or 9 ontinue Insulin Drip and start SC dosingTherapeutic Guidelines | Medicine 15 + Potassium Do not administer Insulin until potassium >3.3, + Give KC1 40 mE/hour IV un + Serum Potassium 3.3 to 5.0 mEq/L. i. Standard replacement: 20-30 mEq per liter + Serum Potassium >5.0 mEq/L. i. Do not administer any potassium i, Monitor every 2 hours until <5.0 corrects ications ABG pl < 6.9 t0 7.0 after initial hour of hydration ii, Other contributing factors + Shock or Coma : + Severe Hyperkalemia | Bipperthyroidiom + Tab Propylthiouracil(PTU) 100 mg PO tid, to max 150 mg 6-8 hours, + Tab Methimazole 10-30 mg PO od. + Medications associated with Hyperthyroidism: intake cess Thyroid horm Dietary lodine Amiodarone Hypothysoidiem + ‘Tab L-Thyroxine 0.05-0.2 mg/day + Medications associated with Hypothyroidism: i. Inorganic iodine ii, Iodide iii, Amiodarone iv. Lithium Hyperprolactinemia + Tab Bromocriptine 1,25-2.5 mg PO od, increase by 2.5 mg/day q3-7days to max 15 mg/day. + Tab Cabergoline 0.25 mg PO twice weekly, may increase by 0.25 mg q4weeks up to max Img twice weekly.16 NAC OSCE | A Comprehensive Review Medications causing hyperprolactinemia ) ») 9 @ 2 f) 2 n) i ? » » m) n) °) P) Benzodiazepines Buspirone MAOT SSRI TCA Valproie acid Methyldopa Verapamil Atenolol Danazol Estrogen Depo-Provera OCPs Metoclopromide Amphetamines Cannabis Impotence "Tab Sildenafil 25-100mg per dose, to take half an hour to 4 hours prior to intercourse. S/E: flushing, headache, indigestion C/T: don't take with Nitrates: 4. Gastroenterology Acute Gastroenteritis Perioperative for 24hrs Inj Ampicillin 1-2¢ IV q4-6h. Inj Flagyl 500mg IV bid. Inj Gentamicin 3-Smy/kg/day q8h (monitor creatinine levels). NPO ‘Tab Flagyl 500 mg PO bid 5 days. E.Coli (Traveler's diarrhea) ‘Tab Ciprofloxacin 500 mg PO bid x 3 days. an “Tab Norfloxacin 400 mg PO bid x3 days. Cayptespaidium Oral rehydration solution | Giardia lambliaTherapeutic Guidelines | Medicine v7 + NPO + Inj Flagyl 400 mg TV gh + Inj Meperidine 75-100mg IV q2-3h + IVE + NG tube + Replace calcium ‘Crohn's s Discase 1, Mild to moderate + Tab Mesalamine 800 mg PO tid. Maintenance dose 3.2 ~4g per day: + Tab Sulfasalazine 250 mg per day and increase up to 2 g per day, Maintenance dose is 500- 1000 mg PO gid with food. 2. Moderate to severe: + Tab Prednisone 40 mg PO gid x 8-12 weeks and taper gradually. + Tab Azathioprine 2-2.5 mg/kg/day. Used for maintenance while tapering corticosteroids, Diverticulitis, + Inj Flagyl 500mg IV bid + Inj Ciprofloxacin SOOmg IV bid. Helicobacter Pylori 1. HP-PAC (7 blister pack) 7-14 days + Tab Lansoprazole 30mg PO bid + + Tab Clarithromycin 500mg PO bid + + Tab Amoxicillin 1g bid LINE Quadruple : 14 days + Tab Lansoprazole 30mg PO bid + Tab Flagyl 500mg PO bid + Tab Tetracycline 500mg bid * Tab Bismuth 525mg PO qid18 NAC OSCE | A Comprehensive Review HepB ps xpe oe 1. Known HBsAg Positive Source: i. Unvaccinated exposed patient: + Hepatitis B Immunoglobulin (HBIG) 0.06 ml/kg and + Hepatitis B Vaccine 0,1and 6 months. ii, Exposed patient with known response to vacel + No teatment. iii, Exposed patient with known failed response to vaccine: + Patient has not yet completed second 3-dose series: + Hepatitis B Immunoglobulin (HBIG) 0.06 ml/kg and + Hepatitis B Vaccine (complete second 3-dose series) + Patient has completed two prior 3-dose series: + Hepatitis B Immunoglobulin (HBIG) 0.06 mi/kg + Second Hepatitis B Immunoglobulin dose. iv. Exposed patient with unknown response to vaccine: + Test for Antibody to HBsAg + Adequate Antibody (HBsAg Positive): No treatment + Inadequate Antibody (HBsAg Negative) + Hepatitis B Immunoglobulin (HBIG) 0.06 mV/kg and + Hepatitis B Vaccine booster dose: 2. Known HBsAg Negative Source: i, Administer Hepatitis B Va ii, No treatment otherwise needed. 3. Unknown HBsAg Source Status: i. Unvaecinated exposed patient + Hepatitis B Vaccine Series ji, Exposed patient with known response to vaccine + No treatment iil, Exposed patient with known failed response to vaceine + Treat source as HBsAg positive if high risk iv. Exposed patient with unknown response to vaccine + Test for Antibody to HBsAg + Adequate Antibody (HBsAg Positive): No treatment + Inadequate Antibody (HBsAg Negative) ‘+ Hepatitis B Vaccine initial and booster dose + Recheck titer in 1 to 2 months 4. Infant with ITBsAg Positive Mother: j i. Hepatitis B Immunoglobulin (HBIG) 0.5 ml within 12 hours of birth. i ii, Hepatitis B vaccine: Dose 1 within 12 hours of birth, Dose 2 at age 1 months, Dose 3 at age Series if unvaccinated 6 months, iii, Repeat HBsAg and HbsAb at 9 months & 15 months,Therapeutic Guidelines | Medicine 19 Reptic ulcer disease + Tah Omeprazole 20mg PO od. + Tab Ranitidine 150 mg PO bid. ‘Dleerative Colitis + ‘Tab Sulfasalazine 250 mg per day and increase up to 2 g per day. Maintenance dose is 500-1000 mg PO gid with food. + Tab Mesalamine 800 mg PO tid, Maintenance dose 3.2 ~ 4g per day. + Rectal suppositories preferred for proctitis. ‘Acute Cholecystitis (Perioperative) + Inj Cefaolin 0.5-1.5mg IV q6h + NPO + IVE + NG Tube 5. Hematology Anemia + Toon Deficiency Anemia : Tab Ferrous fumarate(Palafer) 300 mg PO gd OR ‘Tab Ferrous Sulfate 325 mg PO qd “Tab Ferrous Fumarate 300mg PO gd + Tab F 6. Infectious Diseases Prophylaxis for opportunistic infections in HIV patients + Pneumocystis cariniis CD4 counte 200 cells/mm” or oral candidiasis. ‘Tab TMP/SMZ DS PO OD till CD4 counts + Toxoplasma gondii: IgG antibody positive and CD4 count < 100 cells/mm? th, TMP/SMZ DS PO OD till CD4 counts rises. + Mycobacterium tuberculosis: Mantoux > 5 mm in immunocompromised or contact with active TB. ~ Tab Isoniazid 300 mg PO OD x 9 months along with ~ Tab Pyridoxine 50 mg PO OD. + Mycobacterium avium complex: CD4 counts < 50 cells/mm’. - Tab Azithromycin 1200 mg PO once a week. ~ Tab Clarithromycin 500 mg PO once a week. + Varicella zoster virus: Recent exposure to chicken pax or shingles ~ Varicella zoster immune globulin within < 96 hours of exposure.20 NAC OSCE | A Comprehensive Review ‘HIV post exposure prophylaxis + Start within hours of exposure (under 24 to 48 hours). + Triple Therapy for 4 weeks: 1, Fisst two medications: AZT and 3TC (or Combivir) i. Tab Zidovudine (AZT) 300 mg PO bid and ii. Tab Lamivudine (3TC) 150 mg PO bid. 2. Third medication (choose one): i. Tab Indinavir (IDV) 800 mg PO tid or ii, Tab Nelfinavir (Viracept) 750 mg PO tid or iii, Tab Efavirenz 600 mg PO qhs. + Obtain baseline labs to monitor for adverse reaction: 1. Pregnancy Test Complete Blood Count with differential and platelets Urinalysis Renal Function ‘Tests Liver Function Tests weer Malaria 1, Treatment for active infection: i, Tab Chloroquine 1 g PO stat, then 500 mg PO 6-8 hours later, then 500 mg PO at 24 hours (& 48 hours after initial dose. ji, Tab Mefloguine 1250 mg stat dose. iii, ‘Tab Primaquine 15 mg base PO od x 14 days. 2. Chemoprophylaxis: i. Tab Chloroquine 500 mg PO once a week ii, ‘Tab Mefloquine 250 mg PO once a week. Pulmonary tuberculosis 1, Initiation Phase: Tab Rifampin 600 mg +’Tab Isoniazid 300 mg + Tab Py 2 months. . Continuation Phase: Tab Isoniazid 300 mg + Tab Rifampin 600 mg for 4 months. 3. Add Tab Pyridoxine (Vit B,) 50 mg PO OD. inamide 2 g for Rabies a er Wash wound with soap and water. + Human Rabies Immunoglobulin 20 TU/kg IM stat and half dose into the wound. + Rabies vaccine 1 ml IM on days 0, 3,7, 14,28. + Inform Public Health. + Capture animal & observe x 10 days, then examine brain for negri bodies.‘Therapeutic Guidelines | Medicine 21 ‘Tetanus Prophylaxis: Based upon Tetanus immunization stacas ~ ae Clean, minorwounds | _Allother History of tetanus immunization oe SSeS Td orTdap* 0.5mi | Tig** 250U | Td or Tdap* | Tig ‘@ecerain or <3 doses ofan immunization Yes Yes | > 3dosesreceived in animmunization Not No ™ adult-type combined tetanus and diphtheria toxoids or a combined preparation of diphtheria, tetanus and acellular pertussis. Ifthe patient is <7 years old, a tetanus toxoid-containing vaccine Is given as part ofthe routine childhood emunization. * Tetanus immune globulin, given at a separate site from Td (ot Tap) ¥es,if> 10 years since last booster. 5 Yes if > 5 years since last booster, More frequent boosters not required and can be associated with increased adverse cerents. The bivalent toxoid, Td, snot considered to be significantly more reactogenic than Talone and Is recommended ‘© Use in this circumstance. The patient should be infornied that Td (or Tdap) has been given, 7. Neurology ‘Seizures 1. Acute Management: © Inj Diazepam 5-10mg IV q2-3mins till seizure stops. + Inj Phenytoin 20mg/kg IV at 50mg per min, * Inj Phenobarbital 20mg/kg IV at 50-7Smg/min + Ifall fails then rapid sequence intubation. ieee 2. Primary Generalized & Partial seizures: ee + Tab Phenytoin: Loading 300mg PO q4h x 3 doses, | 0:Osteomalacia then 300mg PO qhs. ' peer ci folic =a + Tab Valproate: Loading 15mg/ky/day, increments by NiNewopatues vertgo, 1Omg/kg/day qweeldy, tll seizures are controlled. ataxia, headache * Tab Carbamazepine: Start 100-200mg PO od-bid, ‘ increments by 200mg/per q2d, if needed till max : = 800mg-1200mg per day. 3, Absence Seizures: + Tab Ethosuximide 500mg PO daily in divided doses, increments by 250mg/day q4-7d prn till max 1500mg per day. Meningitis * — Investigations : CT then L + Empirical adule antibiot Inj Ceftriaxone 2g 1V q12h Inj Dexamethasone 10mg qh IV x 4 days for pneumococcal meningitis Meningococcal: give contacts Tab Rifampin 600mg PO ql2h x 4 doses CSF analysis, blood C&S, neurology consult 3" generation cephalosporins + vancomycin + ampicillin22 NAC OSCE | A Comprehensive Review CSF Findings : Normal or mildly increased Normal Turbid Gear 018-045 | 1 <1 2535 <22 ___ Normal Normal 60-50% Postive Normal 06 oa 206 <3 -_>500 <1000 90% PMIN Monocytes 10% have >90% PMN, 30% have >50% PMN Fibrin web 0-05 1625 a <04 100-500 Monocytes + ‘Tab'Tripran and ‘Tab Prednisone at the beginning of the cycle and prophylactic treatment with Tab Lithium(300-600mg daily initially chen monitor serum levels) + Dihydroergotamine nasal spray 4mg per 1 ml. One spray each nostril and repeat q15mins. Migraine 1. Mild ~ Moderate + NSAIDS + Tab Ibuprofen 200mg tid + Tab Aspirin 600mg PO 4h 2. Moderate ~ Severe + TRIPTANS + Tab Sumatriptan 25mg PO & repeat q 2hrs prn + Tab Mecoclopramide 10mg PO stat 3. Prophylaxis: + Tab Propranotol 60mg PO daily + Tab Amitriptyline 10-25mg PO qhs. “TecateTherapeutic Guidelines | Medicine 23 Myasthenia Gravis 1. Anticholinesterase (Cholinergic) + Tab Mestinon (Neostigmine and Pyridostign 2. Immunosuppressive therapy + Tab Prednisone: Start at 20 mg qd, increase gradually by 5 mg every 3 days to 60mg, Continue for 3 months or until clinical improvement stops or declines. Taper gradually to every other day . + Tab Azathioprine (Imuran) 2 mg/kg/clay. Effective when given with Prednisone. Effect not seen for 6 months or more, Monitor CBC and LF'TS 3. Plasmapheresis (Plasma Exchange) and IV Ig: Indicated for emergent worscning/crisis. Response rate: 70%. + Tab Carbidopa/L evodopa 25/100 mg PO bi + Tab Bromocriptine 1.25 mg PO bid. + ‘Tab Pergolide 0.05 mg PO od, titrate q2-3 days to the desired effect. Maintenance dose is 3-6 mg/day in divided doses. ‘Tab Premipexole 0.125 mg PO tid, increase to 1.5 - 4.5 mg/day in divided doses. + Tab Ropinirole 0.25 mg PO tid, increase weekly to max dose 24 g/day. Amantadine 100 mg PO od to max 100 mg PO gid. Tab Selegiline 5 my PO bid. fab Benztropine 0.5-6 mg/day PO in divided doses. ‘Tab Entacapone 200 mg given concurrently with Carbidopa/Levodopa. : 60-120 mg q3-4h. «id, inerease as needed to max 200/2000me/day. 8. Otolaryngology Acute Sinusitis + Tab Amoxicillin 500mg tid PO x 10 days, + Decongestant: Tab Sudafed 60mg PO qoh + Nasal saline. Acute Pharyngitis + Group A Hemolytic Strep: Tab Penicillin V 300mg PO tid x 10days + Penicillin allergie:'Tab ythromyein 500mg tid x 10 days24 NAC OSCE | A Comprehensive Review 9. Pulmonology Asthma 1. Intermittent Asthma: Short acting beta-agonist ~ Salbutamol (Ventolin) Inhaler 1-2 puffs q4-6h pn. 2. Mild Intermittent Asthma: + Long acting beta agonist ~ Salmeterol Inhaler 1-2 puffs bid. + Inhaled steroids: i, Fluticasone (Flovent) 2-4 puffs bid. ii, Budesonide (Pulmicort) 2 putts bid. iii, Beclomethasone (Vanceril) 1-4 pufis (40ug) bid or 1-2 puffs (80pg) bid. 3. Moderate Persistent Asthma: + Inhaled steroids: Fluticasone (Flovent) 2-4 puts bid. Budesonide (Pulmicort) 2 puis bid. iii, Beclomethasone (Vanceril) 1-4 pulls (40pg) bid or 1-2 pufls (80yx) bid. + Long acting beta agonist ~ Salmeterol Inhaler 1-2 puffs bid. + Leukotriene Receptor Antagonist: + ‘Tab Montelukast 10 mg PO qhs. + Tab Zileuton 600 mg PO gid. 4. Severe Persistent Asthma: + High dose Inhaled steroids. + Long acting beta agonist. + Leukotriene Receptor Antagonist. + Systemic Steroids: i, Tab Prednisone 2 mg/kg/day PO (max 60 mg/day). ii, Inj Methylprednisolone (Depo-medrol) 2mg/kg IV, then 0.5 mg/kg qéh x Sdays. Acui ition of COPD + Admit with nasal O,.Keep saturation between 88-92% . If silent chest/GCS < 8 or decreased LOC then intubate. + Elevated bed > 43 degrees. + WE + MDI: 8 puffs of Ventolin (Salbutamol) alternate with 8 putts of Atrovent (Ipratropium) back to back every 20 mins 3 times. + Nebulizer : 2ce Ventolin + Ice Atrovent in 3ce NS q20 inins x 3 mes. + Inj Hydrocortisone 125mg, IV stat, if severe. “eftriaxone 1-2 g IV q24h along with ‘wobactam 3.375 g IV q6h. + Inj Methylprednisolone 2mg/kg IV, then 0.5 mg/kg. qoh x 5 days.Therapeutic Guidelines | Medicine 25 Community Acquired Pneumonia 1. Outpatient management: + Tab Doxyeycline 100 mg PO bid x 7-10 days. + Tab Erythromycin 250 ~ $00 mg bid x 7-10 days, + Tab Azithromycin 500 mg PO od x 5 days. + Tab Levofloxacin $00 mg PO od x 7-10 days, ‘Tab Augmentin 500 mg/ 125 mg PO gh x Sdays. 2. Inpatient management: + Inj Ceftriaxone 1-2 IV bid along with + Inj Levofloxacin 500 mg IV od x 7-10 days. + Inj Azithromycin 50 mg IV over 1 hour od x 1-2 days. Pulmonary Embolism 1. Investigations + V/Qscan, spiral CT or D-dimer (if unlikely Wells’ seore < 4) + CBC, INR, PTT, BUN, creatinine, ALT, AST. 2. Management: Initiation + Start Warfarin (Coumadin) concurrent with Heparin. + Contraindicated in pregnancy. (If contraindicated may put IVC filter) + Start Tab Warfarin at 5 mg PO daily on Day 1-2 and Heparin 5000 U TV bolus followed by continuous infusion 20 U/kg/hour, titrate to INR 2-3 then stop heparin within 24 hours, + Check INR in 3-5 days, + ‘Therapeutic INR: 2.0 10 3.0 1U, + Osygen, and if pain give morphine or NSAID. 3. Management: Duration of Anticoagulation © Very low risk: 6-12 weeks + Symptomatic isolated calf vein thrombosis. + Low risk patient: 3-6 months Reversible thromboembolism risk (transie + Upper extremity Deep Vein Thrombosis. + Moderate risk patient: 6-12 months + First idiopathic DVT or PE. + High risk patient: 12 months or lifetime Anticoagulation + Recurrent DVT or PE or'Thrombophila risk such as post-operative PE).26 NAC OSCE | A Comprehensive Review 10. Rheumatology Osteoporosis Tab Calcium (1500mg/day) and Tab Vitamin D (800 TU/day) intake in diet or as supplements. + Bisphosphonates: Alendronate, Risedronate or Raloxifene. + Hormone Replacement Therapy + Calcitonin + Recombinant Parathyroid Hormone + Lifestyle modifications: Weight bearing exercises, smoking and alcohol cessation. Osteoarthritis + Tab'Tylenol 500 mg PO tid + Tab Ibuprofen 200-600 mg PO tid. + Tab Naproxen 125-500 mg PO bid. + Tab Celecoxib 200 mg PO od. + Other treatment: + Tab Acetaminophen +"Tab Codeine, + Tntra-articular corticosteroid injection. + Ingr-articular hyaluron injection. + Topical NSAIDs. + Capsaicin cream, + Glucosamine sulfate, Rheumatoid Arthritis 1. First Choice: + Tab Naproxen 500 mg PO bid. + Tab Ibuprofen 300-800 mg PO qid. + Tab Indomethacin 25-50 mg PO bid or id, 2. Analgesies: Tib Acetaminophen 500 mg PO tid pen, 3. Corticosteroids: given intra-articular i, Small Joints: + Inj Hydrocortisone 8-20 mg + Inj Methylprednisolone 2-5 mg, + Inj Betamethasone 0.8 - 1.0 mg, ii, Large Joints: + Inj Hydrocortisone 40, 100 mg. + Inj Methylprednisolone 10 - 25 mg. + Inj Betamethasone 2 - 4 mg.Therapeutic Guidelines | Medicine 27 4, Disease Modifying Anticheumatic Drugs (DMARDs): Start within 3 months of diagnosis to reduce discase progression. i, Mild disease: + Tab Hydroxychloroquine 200 mg PO bid. * Tab Sulfasalazine 500 mg PO bid to tid, ii, Moderate disease: + Tab Methotrexate 10-15 mg PO once weekly, then increase to 20 mg PO once weekly. + Combination therapy: + Methotrexate + Sulfasalazine + Hydroxychloroquine. + Methotrexate + Cyclosporine, + Methotrexate + Etanercept (biological DMARD), iii, Biological DMARDs: used in persistent disease: + Etanereept $C, + Infliximab IV. + Anakinra SC. + Adalimumab SC. + Abatacept IV, + Rituximab IV. + If Corticosteroids are used for> 3 months, do baseline DEXA and start bisphosphonate therapy. + SE of Corticosteroids: Osteoporosis, cataracts, glaucoma, peptic ulcer disease, avascular necrosis, hypertension, increased infection rate, hypokalemia, hyperglycemia, hyperlipidemia, * C/I to Corticosteroids: Active infection, hypertension, diabetes mellitus, gastric ulcer, osteoporosis. 1. Acute Gout: SAIDs:’Tab Indomethacin 25-50 mg PO tid x 10-14 days. ‘Tab Naproxen 500 mg PO bid x 4-10 days. ‘Tab Colchicine 0.6 mg PO q1h till pain relief (max 4-6 doses), then bid x 3-5 days, iv. Systemic Steroids: (rule out Septic Arthritis) + Inj Methylprednisolone 40 mg IV single dose + Inj Depo-Medrol 80-120 mg IM single dose. + Oral: Tab Prednisone 40 mg PO od x Sdays, then gradually taper the dose, v. _Intra-Articular Corticosteroid: used in lange single joints & refractory cases. + Inj Betamethasone 7 mg or Inj ACTH 40-80 IU. 2, Recurrent Gout: «ut for 3-6 months. i. Over producers: Tab Allopurinol 100-300 mg/day PO. ii, Under-excreters: Tab Probenecid 250 mg PO bid (max:1500 mg bid) or Tab Sulfapyrizine 50 mg PO bid (max: 1000 mg bid). iii, Concurrently start with Tab Colchicine 0.6 mg PO bid x 3-6 months.28 NAC OSCE | A Comprehensive Review ‘Temporal arteritis + Start high dose Tab Prednisone 60 mg PO od until symptoms subside and ESR normal + Then 40 mg PO od for 4-6 weeks + Then taper to 5-10 mg PO od for 2 years (relapses occur in 50%) if treatment is terminated before 2 years). Treatment does not alter biopsy results if the sample is taken within 2 weeks. + “Monitor ESR regularly. + If visual symptoms are present, or develop during treatment, the patient is admitted and given Inj Prednisolone 1000 mg IV q12h for lays. Polymyalgia Rheumatica Management 1, General measures * Consider concurrent Temporal Arteritis (See above) + NSAIDs 2. Prednisone (key to management) + See Corticosteroid Associated Osteoporosis + Efficacy: 90% response Dramatic improvement in first 48 hours If no response to steroids ~ reconsider diagnosis Reconsider diagnosis Consider Methotrexate + Polymyalgia alone Dose: 15-20 mg PO qd + Polymyalgia with Temporal Arteritis Dose: 40-60 mg PO qd Symptoms and signs remit within 1 month Decrease dose by 10% each week after improvement + Course + Initial: Maintain starting dose for 1 month + First steroid taper (depends on clinical response) ‘Taper by 2.5 mg per month down to 10 mg/day then Taper 1 mg per 4-6 weeks down to 5 to 7.5 mg/day + Final steroid taper Indicated when symptom five for 6-12 months Do not taper until sedimentation rate normalizes ‘Taper by 1 mg every 6-8 weeks until done + Anticipate 2-6 year Relapse common in first 18 months of steroid use Patients off steroids at 2 years: 25% e of steroidsTherapeutic Guidelines | Medicine 29 Fibromyalgia 1. ANTIDE! SAI * Assists with loe: + Does not affect ‘Tender Points 2. Tricyclic Antidepressants + Amitriptyline (Wlavil) i, First week: 10 mg PO qhs ii, Next three weeks: 25 mg PO ghs iii, Later: $0 mg PO ghs + Nortriptyline (Pamelor) 3. Novel Antidepressants + Venlafaxine (Effexor) + Duloxetine (Cymbalta) 4, Selective Serotonin Renptake Inhibitors (SSRI) + Combination: Fluoxetine and Amitriptyline Benefits pain, stiffness and sleep Scones + Gonococcal: Inj Ceftriaxone 1g TV q24h x 2-4 days, then switch to Tab Ciprofloxacin 500 mg PO bid x 7 days + Non-Gonococeal: Inj Naficillin 2g IV q4h x 2 weeks, then switch to Tab Ciprofloxacin 500 mg PO bid x 2-4weeks. 11. Urology/Nephrology Urinary tract infection (UTI) 1, Acute uncomplicated UTI; outpatient + Tab Bactrim DS PO bid x 3 days. * Tab Nitrofurantoin (Macrobid) 100 mg PO bid x S days. UTE: outpatient Ciprofloxacin 500 mg bid x 3 days. Norfloxacin 400 mg PO bid x 3 days. + Tab Ofloxacin 200 mg PO bid x 3 days. 3. Acute complicated UTL: inpatient * Inj Ampicillin 1-2 g IV q4-Gh and Inj Gentamicin 2mg/kg IV loading dose followed by 1.7 mg /kg q8h IV OD + Inj Ciprofloxacin 400 mg IV bid. * Switch to oral antibiotics upon improvement for a total course of 14-21 days. 2, Drug resi30 NAC OSCE | A Comprehensive Review ‘Acute Pyelonephritis 1. Ourpatient management: For acute uncomplicated cases + Tab Ciprofloxacin 500 mg PO bid x 10 days. + Tab Gatifloxacin 400 mg PO daily x 10 days. + Tab Moxifloxacin 400 mg PO daily x 10 days. + Tab Levofloxacin 250 mg PO daily x 10 days. + Tab Augmentin bid x 14 days. + Tab Bactrim bid x 14 days. 2. Inpatient management: [V for 48-72 hours, then switch to oral agents. Total duration of treatment for 14 days. + Inj Ceftriaxone (Rocephin) 1-2 grams 1V 424 hours. + Taj Cofotaxime (Claforan) 1 gram LV q12 hours + Inj Ampicillin 2 x IV qoh with Inj Gentamicin 2mg/kg IV loading dose , then 1.7mg/kg sh. * Inj Piperacillin 3.375g LV q6h. 12. Emergency Medicine/Poisoning Acetaminophen Intoxication + Toxic level dose is more than 7.5 + Iavestigations : Monitor drug level stat and then q4h (Acetaminophen nomogram), LFT, INR, PTT, BUN, Creatinine, ABG, Glucose + Rx: Charcoal/Gastric lavage as per presentation ‘N-acetyl cysteine 140mg/kg PO, then 7Omg/kg q4h for 18 doses Alcohol withdrawal + Treatment: Inj Diazepam 10-20mg 1V Inj Thiamine 100mg IM then 50-100mg/day Fluid resuscitation with DSW 1-2mL/kg IV Allergic Revetion 1. Severe: Inj Epinephrine 0.3-0.5 mg SC/IM stat 2, Mild: Tab Benadryl 25-50mg PO q6hx 3d 3. Tab Prednisone 60mg PO od x 3d Abaphylnds + Epinephrine autoinjector (HpiPen) if available + Epinephrine 1V or ETT : Iml of 1:10,000 in adults + Inj Diphenhydrumine (Benadryl) 50mg IV or IM q4-6 bh + Inj Methylprednisone 50-100mg IV according to severity + Te wheezing or spasm present : Salbutamol via nebulizer.Therapeutic Guidelines | Medicine 31 Asrhythmias Arrhythmias duc to 2° degree and 3" degree heart block : Inj Atropine 0.5mg TV while waiting for transcutaneous pacing, ‘Transcutaneous pacing first (give Inj Midazolam 2mg for sedation) Admit for transvenous pacing Unstable patients (hypotensive systolic BP < 90, chest pain, SOB, altered mental status or “ARDIOVERT! unconscious) Stable patient Atrial fibrillation : either chemical cardioversion (Amiodarone) or electrical (Synchronized DC cardioversion) Ventricular tachycardia : DC cardioversion or Inj Lidocaine/Amiodarone 150mg IV over 10 mins, Ventricular fibrillation : Always defibrillate! Synchronized cardioversion not useful because there is no QRS complex to synchronize with PSVT : Valsalva or carotid massage (after checking for bruit), Inj Adenosine 6mg rapid IV push. Ifno response then Metaprolol, Dild ASA Intoxication Investigations : Drug levels, electrolytes, ABG, BUN, Creatinine Rx: Gastric lavage/Charcoal Alkalinize urine with DSW, KCl and NaHCO, ‘Aim : urine pH > 7.5 Diabetic ketoacidosis Estimated daily basal glucose requirement is 0.5U/kg, Investigations: Blood glucose, electrolytes, ABG, serum ketones, osmolar gap, anion gap, BUN, creatinine. Look of the cause : Urinalysis, blood C&S, chest x-ray, ECG. Monitor : Urine output, extra-cellular fluid volume, electrolytes, ABG, creatinine, capillary blood glucose and level of consciousness every 1-2 hours Management: Rehydration : NS 11/h in first 2 hours followed by 0.45% NS 500cc/h then switch to maintain blood glucose 13.9-16.6mmol/L to avoid rapid decrease of osmolality, K+ replacement : As acidosis is corrected, hypokalemia may develop. If K+ is 3.3-5.0 mmol/L, add KCI 20-30 mEq/L to keep it within this range. Correct acidosis : If pH < 7,0/hypotension/coma then give 3 amp NaHCO, (150mEq/L) Reduce blood glucose : Start Insulin therapy with 0,15U/kg bolus and maintain 0.1U/kg/h until acidosis and blood glucose resolve. “Treat underlying precipitant.32 NAC OSCE | A Comprehensive Review Digoxin Intoxication + Investigations : Plasma digoxin/digitoxin levels, ECG, electrolytes, BUN, Cr ( levels > 2.6 indicate intoxication) + Rx: Treat arrhythmias (common with digoxin intoxication; vfib, vtach, conduction blocks) Gastric lavage / Charcoal (1g/kg) for ingestion NaHCO3 or glucose and insulin Ventricular tachycardia : Digibind 10-20 vials if dose unknown, Chronic toxicity : then Digibind 3-6 vials IV over 30 mins. Follow ECG, K” Mg’, Digoxin levels every 6 hours, + Systolic BP > 180mmflg and Diastolic BP » 120mmHg (with signs of acute organ damage) + Investigations : CBC, electrolytes, BUN, Creatinine, ABG, Urinalysis, CXR, ECG, BP in all four limbs, Fundoscopy, Cardiology consult. + 1st Line: Inj Sodium nitroprusside 0.3 meg/kg/min IV OR Inj Labetalol 20mg 1V bolus q 10 mins. + Aortic dissection : Sodium nitroprusside + Beta blocker (esmolol) + Catecholamine excess : Inj Phentolamine $-15mg TV q 5-15 mins + Mi/Pulmonary edema : Inj Nitroglycerin 5-20meg/min TV, increase by Smeg/min every 5 min dill symptoms improve. Hypoglycemia + Investigations: Baseline blood glucose, insulin and C-peptide, check glucose q15 mins until » Smmol/L, tient can eat/drink : give 15g carbohydrate if BG < 4mmol/L. (15g glucose tabs or % caps of juice or 3 spoons of sugar in water.) NPO : give 25g carbohydrate if BG < 4mmol/I. ( D50W 50cc IV push 1 amp OR DIOW 500ce TV OR glucagon 1-2mg IM/SC ) + Rx: If Methanol/Ethylene glycol intoxication + Investigations; CBC, electrolytes, glucose, methanol level. = Re: Ethanol 10mg/kg over 30 mins OR Inj Fomepizole 15mg/kg 1V over 30 mins.Therapeutic Guidelines | Medicine 33 Opioid Intoxication + Mental status effects includ sedation, decreased anxiety, a sense of tranquility and indifference to pain produced by mild-to-moderate intoxication. Severe intoxication ean lead to delirium and coma + Physiological effects include the following: Respiratory depression (may occur while the patient maintains consciousness) Alterations in temperature regulations Hypovolemia (truc as well as relative), leading to hypotension Miosis Soft tissue infection Increase sphincter tone (can lead to urinary retention) + Treatment IV glucose : 50% Dextrose 50ml Inj Nalaxone 0.4mg upto 2mg IV for reversal of opioid intoxication, Inj Thiamine 100mg IM stat & OD x 3days 02, intubation & mechanical ventillation Shock (Curdiogenie/Neurogenic) + Dopamine : 1-3mey/ky/smin is the renal dose; 4-10meg/ky/min is the inotropic dose + Dobucamine : 2.5-Smey/kg/min Sprain (Ankle) RICE + Rest + Ice: using bag of ice, apply during the day for $-20 mins every 2 hours. + Compression : Tensor bandage or special supports. + Elevation : Elevate the ankde as much as possible + Analgesics as needed. + Crutches if too painful to bear weight. + Investigations; CBC, clectrolytes, BUN, glucose, creatinine, INR/PTT if suspecting TIA, ABG, Non contrast urgent CT scan. + Treatments: NPO, Foley catheter, DVT prophylaxis, Neurology consult, Rule out contraindications for thrombolytic treatment. Urgent neurology consult. ‘Thrombolysis : TPA within 3 hours of symptoms Anti-coagulation : Low dose Heparin 5000 U bid, start Warfarin within 3 days, monitor INR/PTT Tfunable to thrombolyse or anti-coagulate then :'Tab ASA 50-325mg od or Tab Clopidogrel 75mg od BP control : decrease slowly, IV Labetalol (First line treatment) Bed rest, analgesics, mild sedation and laxatives, avoid hyperglycemia. , carotid doppler34 NAC OSCE | A Comprehensive Review + Patients who present to the ED following psychotropic drug overdose with GCS <8 should undergo intubation at the earliest opportunity to prevent hypoventilation and aspiration pacumonia, tions : Drug levels, ECG, ABG, electrolytes, LFTs, RFTs. + Re: Activated charcoal 1gm/kg via NG Diazepam for seizures Wide ORS/Seizures : NaHCO, (1-2 mg/kg bolus dose and then 100-150 mEq in 11, 15/0.45% NaCl infused 100-200 mi/h IV) + Invest Upper GI Bleed ent with IVF, cross & type, 2 large bore IV cannulas. + Investigations : CBC, platelets, INR, BUN, creatinine, PT'T, electrolytes, LFTs * Management: NG tube, NPO, blood transfusion if needed, upper GI endoscopy Inj Octreotide SOmeg loading and 30meg per hour (for varices) SC/IV Inj Pantoprazole 50mg LV stat and SOmg q8h (gastric ulcer) Lower GI Bleed + Stabilize patient with IVE, eross & type, 2 large bore IV cannulas. + Investigations: CBC, platelets, INR/PTT, BUN, creatinine, electrolytes. + Management: NG tube, NPO, blood transfusion if needed, sigmoidoscopy, colonoscopy, angiogram (for angjodyspl: ‘Warfarin Intoxication + Treatment according to INR levels INR < 5: Stop warfarin, observation, sesial INR/PTT. INR 5-9: Ifno risk factors for bleeding, hold warfarin x 1-2 days & reduce maintenance dose. OR Vitamin K 1-2 mg PO, if patient at increased risk or FFP for active bleeding. top warfarin, Vitamin K 2-4 mg PO, serial INR/PTT then additional Vitamin K if needed or FFP for active bleeding. INR > 20: FFP 10-15ml/kg, Inj Vitamin K 10mg LV over 10 min, increase dose of Vitamin K (qh) if needed. INR 9-20:Therapeutic Guidelines | Medicine 35 13. Counselling Smoking cessation 1. Nicotine gums: 2mg if < 25 cig/day, dmg i> 25cig/day * 1 piece qt-2h for 1-3mths 2. Nicotine patch: + 21mg per day for 4 weeks + 14mg per day for 2 weeks + 7g per day for 2 weeks Nicotine inhaler: 6-16 cartridges per day upto 12 weeks 4. Bupropion(Zyban): + 150mg GAM x days, then 150mg bid for 7-12 weeks + Maintenance 150mg bid for upto 6 months. * General Stop smoking during second week of medication Stop Bupropion if unable to quit by 7 weeks Minimum of & hours between doses More is not better Swallow pills whole (not crushed, divided or chewed). Alcohol cessation Protocol: Aleohol Dependence CAGE Question ee + Lab markers C :Have you ever fet the need Serum Gamma glutamyl transferase or Je CUT downs your Carbohydrate deficient Transferrin es ae fe ANNOYED at criticism of Initial Management yourdrinking? * Tab Thiamine 100 mg PO qd G pha 2 oo tH nen «Tab Folate 1 my your drinking? re ae ie Relat E; Have you ever hada drink © Multivitamin gd first thing inthe morning + Treat Hypomagnesemia if present | (EYEOPENER)? + Seizure precautions | 2.Long-Term Abstinence Programs + Alcoholics Anonymous + Detoxification centers + Halfway House36 NAC OSCE | A Comprehensive Review, 3. Adjunctive Medications for abstinence 1LFirst line (consider Naltrexone with Campral) + Tab Naltrexone Blocks Opioid receptors Decreases pleasure from Alcohol Dosing: 50 mg orally daily Eficetive in short-term, but not in long-term + Tab Campral (Acamprosate) Balances GABA and glutamate neurotransmitters Reduces ansiety from abstinence Dosing: 2 tabs PO tid 2.Second line agents to consider + Selective Serotonin Reuptake Inhibitors (SSRI) Consider especially if comorbid depression Provac often used, but other SSRIs effective © "Tbpitwisane Tepans) Decreases Alcohol use severity and binge drinking Improves well being, quality of life in Aleoholies 3.Agents to avoid + Antabuse “Taken 250 to 500 mg orally daily Not recommended due to risk and uncertain benefit + Delirium ’Tremens General Protocol (Requites ICU observation) + Tab Diazepam (Valium) Dose: 10-25 mg PO qh pm while awake Endpoint: until adequate sedation + Inj Lorazepam (Ativan) Dose: 1-2 my IV qh pr while awake for 3-5 days Endpoint: until adequate sedation + Librium (Chlordiazepoxide) Dose: 50 to 100 mg PO/IM/IY qth (max: 300 mg/day) Endpoint: until adequate sedationNOTES38 NAC OSCE | AComprehensive Review Obstetrics & Gynecology 1, Semually Transmitted Infection a. Chlamydia Tab Azithromycin 1g PO stat or Tab Doxycycline 100mg PO bid x 7 days If pregnant: Tab Erythromycin 500mg PO tid x 7 days. Treat partner, Reportable disease. b. Gonorrhea: Inj Ceftriaxone 125mg IM stat + Tab Doxycycline 100mg bid x 7 days. If pregnant : Inj Spectinomycin 2y¢ IM stat ‘Treat partner, Reportable disease. . Syphilis: Primary, Secondary, Latent Syphilis (duration less 1 year ): Inj Benzathine Penicillin G 2.4 MU IM for 1 dose ‘Treat partnes, Reportable disease. If allergic to Penicillin: Tab Doxycycline 100 mg PO bid for 14 days. Late latent, Cardiovascular (duration over 1 year) Inj Benzathine Penicillin G 2.4 MU IM once a week for 3 weeks If Penicillin allergic : Tab Tetracycline 500 mg PO gid for 4 weeks or ‘Tab Doxycycline 100 mg PO bid for 4 weeks Neurosyphilis : Inj Aqueous Penicillin G 3-4 MU IM every 4 hours for 10-14 days. d. Genital herpes: First episode: ‘Tab Acyclovir 400mg PO tid x 10 days or ‘Tab Famciclovir 250 mg tid x 10 days or ‘Tab Valacyclovir 1 g bid x 10 days Recurrent: ‘Tab Acyclovir 400mg PO tid x 5 days or “Tab Famciclovie 120 mg bid x 5 days or “Tab Valacyclovir 500 mg bid x 5 days Suppression: if more than 6 episodes per year ib Acyclovir 400mg PO bid x 12 months Severe episode: Inj Acyclovir 5-10 mg/kg qBh x 5-7 days ¢. Genital warts (HPV): Local treatment with LIQUID NITROGEN repeat every 1-2 weeks Podophyllotoxin 0.5% gel bid x 3days,then 4 days off — to be repeated for 4 weeks. Prophylaxis for HPV (for Cervieul CA & warts) ~ Inj Gardasil IM 0,2 and 6 months.Therapeutic Guidelines | Obstetrics & Gynecology 39 GENERAL INSTRUCTIONS for all sexually transmitted infections: © Treat all parmers © Avoid sexual intercourse tll treatment completion. © Barrier contraception/ educate about sa © Rescreening in 3 months. sex practices, * DOXYCYCLINE: Drug induced PHOTOSENSITIVITY, use sun sercen ACYCLOVIR: headache, GI upset, impaired renal function, tremors, agitation, lethargy, confusion, coma 2. Urinary Tract Infection Uncomplicated: Tab Bactrim DS PO bid x3 days or ‘Tab Nitrofurantoin 100mg PO gid x Sdays. (with food) In pregnancy: Treat asymptomatic UTI ‘Tab Amoxicillin 250mg PO tid or "Tab Macrobid 100mg PO hid x 10 days. Pyclonephritis: Acute Uncomplicated: "Tab Ciprofloxacin 500mg PO bid x 10 days or ‘Tab Augmentin 625mg PO bid x 14 days. Inpatient: Inj Ceftriaxone 1g TV bid for 48 hours then switch to oral drugs + Inj Gentamicin 50mg IV q8h for 24 hours. 3. Vulvovaginitis a. Candidiasis: ib Miconazole 200mg PV qhs x3 days or ‘Tab Nystatin (100,00 unit) vaginal tah PV qhs x 14 days or ‘Tab Fluconazole 150mg PO stat dose. Prophylaxis: 4 or more infection per year ~"Tab Fluconazole 150mg PO every 3days for 3 doses. Maintenance:'Tab Fluconazole 150mg PO each week. Monitor liver enzymes every 1-2 months, b. Bacterial vaginosis: “Tab Flagyl S00mg PO bid x 7days.(with food) ©. Trichomonas vaginalis: b Flagyl 2g PO for 1 dose. or ‘Tab Flagyl 500mg PO bid x Zdays.(with food), treat partner. d. Atrophic vaginitis: ‘Topical Estrogen eream 0,5 to 2g daily to be applied locally.40 NAC OSCE | A Comprehensive Review 4, Pelvic Inflammatory Disease (PID) a. Outpatient: Inj Ceftriaxone 250mg IM stat dose + Tub Doxycycline 100mg PO bid x 14days. b. Inpatient: Inj Cefoxitin 2g IV qh + Inj Doxycycline 100mg IV q12h. Continue IV for 48 hrs & then tab Doxycycline 100mg PO bid x 14 days. Reportable disease, treat partners, rescreening after 4-6 weeks incase of documented infection. 5. Dysfunctional Uterine Bleeding (DUB) a. Mild DUB: + NSATDs—Tab Mefenamie acid 500mg PO tid x 5 days, + Anitfibrinolytics ~Tranexamic acid 500mg PO tid x 5 days, Combined OCPS + Mirena / Provera + Tab Progestin one tab OD in first 10-14days, . Severe DUB: + Inj Premarin 25mg IV q4h +'Tab Gravol 50mg PO 4h, + With Tab Ovral PO tid till bleeding stops (24hrs), THEN bid for 2 days, THEN od for Says. + Continue conventional OCPs if pregnancy not desired 6.Dysmenorthea “Tab Ibuprofen 400mg PO gid from 1st day of menstrual cycle. + Oral Contraceptive Pills, + Important to rule ont secondary causes of dysmenorrhea. 7. Endometriosis a) NSAIDs : Tab Ibuprofen 400 ng PO gid till symptoms last. b) Oral Contraceptive pills ©) Tab Provera 10-20 mg PO OD. Tab Danazol 600-800 mg PO OD for 6 months. ©) GnRH Agonist: Inj Leuprolide 3.75 mg IM once a month for 6 months. Inj Goserelin 3.6 mg SC every 28 days for 6 months. Use GnRH Agonist along with Estrogen/Progesterone add back therapy. (To reduce the side cffcets of bone Loss.)‘Therapeutic Guidelines | Obstetrics & Gynecology 41 8. Hormone Replacement Therapy (HRT) 2) Only Estrogen - Tab Premarin 0.625mg PO OD ( only estrogen) b) Cyelie Dose -Tab Premarin 0.625mg PO OD and Tab Provera 510mg PO OD from days 1-14. ©) Standard dose - Tab Prempro (premarin 0.625mg and provera 2.5mg) combination pill PO OD. 4) Pulsatile ~Tab Premarin 0.625mg PO OD and Low dose Tab Provera 15 mg PO OD. Given as 3 days on and 3 days off. ¢) Transdermal : Estradiol transdermal patch twice daily and Tab Provera 2.5 mg PO OD. 9. Emergency contraception OTC no prescription needed. Take within 72 hours of unprotected intercourse. Tab Ovral 2 tabs PO qi2h x 2 doses (has Levonorgestrel 0.Smy/dose + estrogen 0.1mg/dose) + Tab Benadryl 10mg 1 hr before dose (emesis induced by Estrogen). Plan B (Tab Levonorgestzel 0.7Smg/tab) one tab q12hes x 2 doses. 10. Group B Streptococcus (GBS) in pregnancy + Inj Penicillin G 5 MU IV then 2.5 MU IV q4h till delivery. + Penicillin allergic: Inj Cefazolin 2.g IV then 1g q8h or Inj Clindamycin 900 mg IV q8h or Inj Erythromycin 500 mg TV q6h. 11. Pregnancy Induced Hypertension (PIH) a Initial: To maintain DBP<100 . abetalol 20mg IV bolus every 10-20 mins pen. (C/I asthma,CHF) + Tab Nifedipine XL 10mg PO very 20-30 mins prn Inj Hydralazine Smg or 10mg IM every 20 mins prn, then 5 or 10mg every 3 hrs pen (S/W: fetal tachycardia, maternal headache, palpitations) b. Maintenan + Tab Methyldopa 250-500mg PO bid — qid. ‘Tub Metoprolol 25-100mg PO bid. + Tab Labetalol 100-400my PO qid. Anticonvulsant therapy: Inj Magnesium sulfate 4g IV bolus over 20 min, followed by maintenance of 2-4 g/hout. Monitor signs of Magnesium toxicity ~ depressed deep tendon seflexes, decreased respiratory reflex, anutic, hypotonic, CNS or cardiac depressio Antagonist to Magnesium sulfate: Calcium gluconate(10%) 10 ml TV over 2 minutes. 4. Avoid these antihypertensives: + ACE(-) & ARBs— neonatal renal failure, teratogenic, IUGR. + Atenolol -TUGR + Thiazide diuretics ~ maternal fluid depletion,42 NAC OSCE | A Comprehensive Review 12. Ectopic Pregnancy a) Inj Methotrexate 50mg/m’ BSA IM stat dose. b) Repeat beta hCG levels weekly till <1. ©) Contraception till beta heg returns to SmIU/ml or less. d) Do CBC, LETS 15. Hyperemesis Gravidarum ‘Tab Diclectin (10 mg Doxylamine with 10 mg Pyridoxin) started as 1 tab GAM + 1 tab qPM + 2 tabs qhs. Maximum 8 tabs per day. 14, Drugs contraindicated in pregnancy + Chloramphenicol: Gray baby syndrome + Erythromycin: Maternal liver damage (used only if allergic to penicillin) + Fluoroquinolone: Cartilage damage. + Metronidaz: + Sulfa drugs: Miscarriage in 1© trimester and kernicterus in 3" trimester Anti-metabolite, high risk in 1° trimester and breast feeding. Can lead to miscarriage. +” Tetracyclines: Staining of teeth in children. + ACE inhibitors: IUGR, oligohydranminos, fetal renal defects. * Anticonvulsants: ’) Phenytoin: Fetal hydantoin syndrome ~ IUGR, facial dysmorphogenesis, cardiovascular defects, congenital anomalies of hand & foot, umbilical hernia and congenital anomalies, ii) Valproic acid: Lumbosacral spina bifida with meningomyelocele or meningocele, often accompanied by midfacial hypoplasia, deficient orbital ridge, prominent forehead, congenital heart disease, and decreased postnatal growth. iii) Carbamazepine: Unique facial appearance and underdevelopment of the fingers, toes, and nails; developmental delay. iv) Phenobarbital: Cleft palate/lip, congenital heart disease, intra-cranial hemorrhage. aginal adenosis, adenocarcinoma, uterine malformations in female fetuses. ’s cardiac anomaly, goiter, hyponatremia. Congenital facial paralysis with or without limb defects (Mobius syndrome) and Neural tube defects + Retinoids: Deformities of the cranium, ears, face, imbs, and liver, hydrocephalus, microcephaly, heart defects, cognitive defects, craniofacial alteration, cleft palate, neural tube defects, cardiovascular malformations and kidney alterations.Therapeutic Guidelines | Obstetrics & Gynecology 43 Warfarin: High risk of spontaneous abortion, stillbirehs, IUGR. Fetal Warfarin Syndrome: Deformities of the axial and appendicular skeleton, hypoplastic nose, optic atrophy, mental retardation, brachydactyly, scoliosis, mental retardation, intra~ cranial hemorrhage. Alcohol: High incidence of abortion and still births, IUGR. Fetal Alcohol Syndrome: Decreased muscle tone and coordination, cognitive impairmen ASD/VSD, narrow small eyes with large epicanthal folds, small head, small mid-face, indistinct philtrum, thin upper lip. igarette smoking: IUGR, placental abruptio/ prev Cocaine: IUGR, microcephaly, prematurity, mental retardation, . spontaneous abortionTherapeutic Guidelines | Pediatrics 45 Pediatrics 1 Acute Bronehi a. Mild distress: oral/IV hydration, antipyretics for fever, humidified O,, VENTOLIN 0.03ce in 3m! NS by face mask q20min and then qlhr. b. Moderate to severe distress: all the above + Ribavirin in high risk groups like congenital lung cliscase, congenital heart disease, bronchopulmonary dysplasia, immunodeticient patients. Antibiotics, ipratropium, systemic corticosteroids have no use. 2. Acute Oni Media (AOM) a) First line: Tab Amoxicillin 80-90mg/ky/day PO divided qh for 10d. If allergic ~’Tab Azithsomycin 10mg/kg/day OD for 3 days.’To be given if child > 6months old. b) Second line: Tab Augmentin 90mg/kg/day divided q12h for 10 days or Tab Cefuroxime 30mg/kp/day divided bid for 10 days, Avoid FLUQROQUINOLONES under 16 years age. 3. Asthma + Classification (NIH recommendations) a) Intermittent Asthma- Occasional exacerbations (Less than twice per week). b) Mild Persistent Asthma- Frequent exacerbations (>twice weekly, but not daily). ©) Moderate Persistent Asthma- Daily symptoms ly Beta Agonist use d) Severe Persistent Asthma~ Continuous Symptoms and frequent exacerbations. + Acute Management i. O, (to maintain O, saturation > 9006). fi, Fluids, if dchydrated. fii, B, Agonist : Salbutamol (Ventolin)- 0.03 ce/kg in 3ce NS every 20 minutes for 3 doses then 0.15-0.3 mg/kg (not to exceed 10 mg) every 1-4 hours as needed or 0.5 mg/kg/hour by continuous nebulization. un bromide (Atrovent) 1ce added to each of first 3 salbutamol masks. one 2mg/kg in ER, then Img/kg PO OD x 4d. svere— Ipratroy vy. Steroids: Inj Predni 4, Bacterial Tracheitis * Airway management, keep child calm. + Humidified 0, + Nebulized racemic epinephrine(1:1000 solution) in 3ml NS, 1-3 doses, ql-2h. + Inj Ceftriaxone 75-100mg/kg/day q24hrs + Inj Vancomycin 40mg/ke/day in divided doses every 6-8h.46 NAC OSCE | A Comprehensive Review 5. Bacterial Pneumonia Newborn (under 3 weeks old) 1, Admit all newborns with Pneumonia, 2. Antibiotic regimen (Use 2-3 antibiotics combined) a) Antibiotic 1: Ampicillin i. Age <7 days + Weight <2 kg: 50-100 mg/kg divided q12h. + Weight >2 kg: 75-150 mg/kg divided q8b. ii, Age >7 days + Weight <1.2 kg: 50-100 mg/kg divided q12h + Weight 1.2-2 kg: 75-150 mg/kg divided qBh. + Weight >2 kg: 100-200 mg/kg divided qoh. Gentamicin (dosing below if >37 weeks old) + Age <7 days: 2.5 mg/kg repeated qi2b. + Age >7 days: 2.5 mg/kg repeated qBh. 3: Cefirtaxime (optional) + Age <7 days: 100 mg/kg divided q12h. + Age >7 days: 150 mg/kg divided q8h. 3. Organisms requiring additional antibiotic coverage i. Methicillin Resistant Staphylococcus Aureus (MRSA}-Vancomycin a) Age <7 days © Weight < 1.2 kg: 15 mg/kg IV OD. + Weight 1.2—2 ky : 10-15 my/kg IV q12-18h, + Weight > 2 kg 10-15 mg/kg IV q8-12h. b) Age > Zdays , weight > 2 kg : 45-60 mg/kg/day in divided IV qh. ii, Chlamydia trachomatis-Exythromycin 30-50 mg/kg/d PO divided q8h. b) Antibiotic ©) Antibion Management: Age 3 weeks to 3 months 1, Outpatient (if afebrile without respiratory distress) i. Azithromycin 10 mg/kg day 1, 5 mg/kg days 2-5 PO. ii, Erythromycin 30-40 mg/kg/day PO divided qoh x1 0days. 2, Inpatient {if febrile or hypoxic) i, Laj Erythromycin 40 mg/kg/day IV divided q6h and ii, One of the following antibiotics if febrile: + Inj Ceforaxime 200 mg/kg/day TV divided qh. + Inj Cefuroxime 150 me/ky/day IV divided qh. 3. Critically il i, Inj Cefotaxime as above and Inj Cloxacillin or ii, Inj Cefuroxime alone as aboveTherapeutic Guidelines | Pediatrics 47 Management: Age 3 months to 5 years 1. Outpatient (if afebrile without respiratory distress) a) Co nitial parenteral antibiotic at diagnosis: + Inj Ceftriaxone 50 mg/kg/day up to 1 gram IM x1 dose. + Start oral antibiotics concurrently as below. b) First-line oral agents: + Amoxicillin 90 mg/kg/day PO divided qh x7-10d. ¢) Alternative oral agents: + Amoxicillin-Clavulanie Acid (Augmentin) . + Erythromycin. + Clarithromycin. Azithromycin. 2. Inpatient (af febrile or hypoxic): a) Inj Cefotaxime 150 mg/kg/day IV divided qoh. b) Inj Cefuroxime 150 mg/kg/day IV divided qh. ©) Ifeonfirmed Pneumococcal Pneumonia: + Inj Ampicillin alone 200 mg/kg/day LV divided qh. 3. Critically il: a) Option 1 + Inj Cefotaxime 150 mg/kg/day IV divided q6h and + Inj Erythromycin 40 mg/kg/day IV divided qoh. b) Option 2 + Inj Cefuroxime 150 mg/kg/day IV divided 8h and + Inj Cloxacillin 150-200 mg/kg/day IV divided gob, Management: Age 5 to 18 years 1. Outpatient: a) First-line oral agents: i. Erythromycin 40 mg/kg/day PO divided qoh x 7-104. ii, Clarithromycin 15 mg/kg/day PO divided q12h x 7-10d. iii, Azithromycin + Day 1:10 mg/kg day 1 PO (maximum 500 mg). + Days 2-5: 5 mg/kg/day PO (maximum 250 mg). b) Preumococeal Pneumonia confirmed: i, Amoxicillin 90 mg/kg/day PO divided qh x 7-104. 2. Inpatient: a) First line and in critical illness: i. Inj Cefuroxime 150 mg/kg/day IV divided q8b and ii, Inj Erythromycin 40 mg/kg/day IV divided géh. b) Paeumococeal Pneumonia confirmed: i, Inj Ampicillin 200 mg/ky/day IV divided gh.48 NAC OSCE | A Comprehensive Review 6. Croup (Laryngotracheobronchitis) 2) Humidified O, b) _ Nebulized racemic epinephrine(1:1000 solution) in 3m NS, 1-3 doses, ql-2h : + Child < 6mths: 0.25inl + Child > mths: 0.5m + Adolescent: 0.75ml ©) Dexamethasone 0.6mg/kg IM/IV/PO, max dose 10mg, given as a single dose. 7. Bpiglottitis + Suspect epiglotttis if child has fever, ill looking, dyspnea, dysphonia, loss of voice, stridor, sudden in onset. + Investigations: Pharyngeal swab and culture Blood culture Lateral X-ray neck (Thumbprint sign) ABG,CBC Endoscopy in ER + Treatment: Intubation IV fluid IV Cefuroxime 8. Streptococcal Pharyngitis (Group A Streptococcus) Melsaate Criteria ~ no cough, tender anterior cervical lymph nodes, erythematous tonsils with exudate, fever > 38°C, age 3-14 years. a) If 1 symptom only — no culture or antibiotics needed. b)_ If> 1 symptom, culture positive ~ treat with antibiotics: Penicillin V 40 mg/kg/day PO divided bid x 10 days. Erythromycin 40mg/kg/day PO divided tid x 10 days. ‘Acetaminophen for fever or pain. ©) Invasive GAS: needs admission — Inj Clindamycin 40 mg/kg divided into 3-4 doses and Inj Penicillin 250 000 ~ 400 000 Ukg/day divided into 6 doses x 10 days. 9. Whooping Cough (Pertussis) a) Exythromycin 40-5Omg/kg/day PO divided gid x 10d. b) Azithromycin 10mg/ky/PO OD day! Smg/ky PO OD day2 to days. (preferred) ©) Isolate for 5 days of treatment, d) Erythromycin to all the houschold members.Therapeutic Guidelines | Pediatrics 49 10. Bacterial Meningitis (Reportable disease) a) Inj Dexamethasone 0.6 mg/kg/day IV in 4 divided doses. Start within 1 hour of 1° antibiotic dose. b) Ampicillin: i, Agee 1 month ~ 50 mg/kg IV q8-12h. ii, Age>1 month ~ 50 mg/kg IV qoh. ©) Ceftaxime: i. Age < L month ~ 50 mg/kg TV g8-12h i, Age>1 month ~ 200 mg/kg/day IV divided q6-8h. d) Ceftriaxone: i, Ages 1 month — 50-75 mg/kg IV divided q12-24h Age> 1 month 100 mg/kg/d IV divided q12h ©) Gentamycin: 2-2.5 mg/kg TV qBh. f) Vancomyein: 15 mg/kg qéh 1V x 7-14 days. g) Prophylaxis for contacts i. He Influenzae: Rifampin 20 mg/kg/day up to 4 days. ii, N. Meningitides : + Rifunpin + Children: 10 mg/kg PO q12h x 2 days (max 600 mg), + Adults: 600 mg PO q12h x2 days. + Ciprofloxacin (adults) 500mg PO for one dose. + Ceftriaxone : + Age<15 years: 125 mg IM for one dose. + Ages 15 years: 250 mg IM for one dose. 11. Febrile Seizures In ER :Tnj Diazepam 0.2 —0.5mg/kg TV glSmins till b) Home : Diazepam rectal suppository. ©) Investigate & teat the cause of fever 12, Urinary Tract Infection (UTD) Oral Treatment- for 7-14 days. i, Cofixime (Suprax) 8 mg/kg PO divided bid or ii, Cefpodoxime (Vantin) 10 mg/kg PO divided bid or iii, Cefprozil (Cefzil) 30 mg/kg PO divided bid or ix. Cephalexin (Keflex) 50-100 mg/kg PO divided qi. 2. IV antibiotics Inj Cefotaxime 50-150mg/ke/day divided q4-6h or ‘75me/kg/day divided q12-24h. Tnj Ceftriaxone 3. UTI Prophylaxis i, Bactrim (mg TMP/10mg SMZ per kg) at bedtime qhs.50 NAC OSCE | A Comprehensive Review aa a) General Measures: i. ABC management. ii, Oxygen. iii, IVE iy, Nebulised beta-agonist (Albuterol). bb) Anaphylaxis with airway compromise: Epinephrine (1:1000 solution) 0.01ml/ky SC/TM(upto 0.3m) ©) Urticaria, Pruritus of Flashing: Inj Diphenhydramine 25-50mg IM/V every 6hrs prn. Orally same dose qéh x 3days. @) Prevention: i, Medical alert bracelet. ii, Strict avoidance of allergen. i. BpiPen. iv, Allergy testing and desensitization therapy. 14, Anemia in + 6mg/kg/day elemental iron bid-tid. + Investigate the cause of anemia, 15. Dose of Tylenol in children 4) 40-60 mg/kg/day PO divided qéhr prn (not to exceed 5 doses/24 hours). b) Neonates: 10-15 mg/kg PO q6-8hr pn, 16, Immunization Schedule for Infants and Children in Canada52 NAC OSCE | A Comprehensive Review Psychiatry 1. Agitation & Aggression Agitation can be defined as excessive verbal and/or motor behavior. It can readily escalate to aggression, which can be cither verbal (vicious cursing and threats) or physical (toward objeets or people). Goals of treatment (Nonpharmacological treatment) Create a safe environment for treatment Decrease stimulation Permit patient to ventilate his or her feelings, but this may need to be cut short if the degree of agitation is escalating and there is clear danger to self and others. Behavioral approaches include never turning your back to an agitated patient, talking softly rather than shouting, and inquiring about what specific needs the patient may have Prevent further episodes of agitation or aggression ‘Delirium, First-generation Antipsychotics (FGA) Haloperidol ; 0.5-2.5 mg POM bid ANTIPSYCHOTICS S/E S Delirium or acute confusional state is a common and severe neuropsychiatric syndrome with core features of acute onset and fluctuating course, attentional deficits and generalized severe disorganization of behavior. Treatment of delirium requires treatment of the underlying causes. Antipsychoties are first-line treatment. Haloperidol is the most effective medication for decreasing agitation in delirious patients. First generation antipsychotic Loxapine and second generation (atypical) antipsychotics such as Olanzapine,Risperidone and Quetiapine can also be used. Benzodiazepines should be reserved for cases of alcohol withdrawal. + Loxapine : 12.5-50 mg/day PO soa Parcreond | Second generation (atypical) antipsychotics (SGA) reameiptaa ee: 4 + Olanzapine : 5-10 mg/day PO, 2.5-10 mg TM (repeat 2h and 6h prn | Syndrome (NMS) to max of 30 mg/24 h) Sedation + Risperidone : 0.5-2 mg/day PO port st elaeaall + Quetiapine : 25-100 mg/day PO Hypefprolactinemia and Benzodiazepines I dysfunction. + Lorazepam : 0.5-1 mg POM q6-8h i Oxazepam : 10-15 mg PO tidTherapeutic Guidelines | Psychiatry 53 Mania + Mania is a state of abnormally elevated or irritable mood, arousal, and/ or energy levels. Treatment of ‘mania involves both acute control of severe agitation by a mood stabilizer and long term mood stabilizers, Initially atypical antipeychoties such as Risperidone, Olanzapine or Quetiapine are effective, First-generation Antipsychotics + Haloperidol : 5-10 mg/day POM. Atypical antipsychotics + Risperidos mg/day PO + Olanzapine : 5-20 mg/day PO, 2.5-10 mg IM (repeat 2h and 6h prn to max of 30 mg/24 h) + Quetiapine : start with 100 mg/day PO; increase by 100 mg/clay as necded to 300-600 mg/day ided BID 2. Anxiety Disorders + Ansivty disorders are a group of conditions with exaggerated ansiousness and worry about a number of concerns persists for an extended period of time. Goals of treatment (Nonpharmacologic treatment) + Stress reduction and relaxation techniques such as meditation and low impact yoga is often helpful. + Cognitive behavioral therapy (CBT) + Reduction of consumption of caffeine and other stimulants. + Minimize use of alcohol Panic disorder + Panic attack or panic disorder involves sudden anxiety that occurs without warning, Symptoms can include chest pain, heart palpitations, sweating, shortness of breath, feeling of unreality, trembling, dizziness, nausea, hot flashes or chills, a feeling of losing contol, or a fear of dying, Panic attacks are extremely common - 10% to 2046 of the population experience a panic attack at some point in theit life. Some people start to avoid situations that might trigger a panic attack; this is called panic attack with agoraphobia. Panic disorder refers to recurring feelings of terror and eas, which come on unpredictably without any clear trigger. + SSRIs and SNRIs are the first choice in the treatment of panic disorders, Sclective serotonin reuptake inhibitors (SSRIs) ike Citalopram, Escitalopram, Fluoxetine, Paroxetine and Sertraline are all effective in reducing punie attacks, Serotonin norepinephrine reuptake inhibitor (SNRIs) eg. Venlafaxine is also used in panie disorder. + ‘There is a delay in the onset of response to these drugs which may be accompanied by initial agitation. Combining SSRI or SNRI with a brief course of low dose benzodiazepine ean increase adherence to medication and produce rapid response. + Other medication include Tricyclic antidepressants (TCAs) cg. Imipramine, Desipramine and Clomipramine and Monoamine oxidase inhibitors (MAOIs) eg. Phenelzine, 'Tranyleypromine.54 NAC OSCE | A Comprehensive Review Selective serotonin reuptake inhibitors (SSRIs) + Paroxetine : 20-60 mg/day PO SEROTONIN SYN + Fluoxetine : 20-80 mg/day PO oO Nr: + Sertraline : 50-200 mg/day PO inus tachycardia, HTN, + Citalopram : 20-60 mg/day PO at at tyres: + Escitalopram : 10-20 mg/day PO flewa, muscle rigidity, Seats 5 taxi, ncoordnation, Serotonin norepinephrine seuptake inhibitor (SNRIs) PTI berapd ober + Venlafaxine :37.5-22.5 mg/day Ca eae ‘Tricyclic antidepressants (TCAs) Metiioeroide Feperolol + Clomipramine : 75-225 mg/day : + Desipramine : 75-300 mg/day ia eee + Imipramine : 75-300 mg/day Benzodiazepines * Alprazolam : 0.25 mg tid-qid, up to 1 mg PO qid + Clonazepam : 0.25-0.5 mg PO bid Monoamine oxidase inhibitors (MAOIs) + Phenelzine : 45-90 mg/day + Tranyleypromine : 20-60 mg/day Social Phobia involves excessive anxiety in social situations where people ‘ocial anxiety inelude small group anxiety include jons that eanse + Social anxiety, also known as social phobi fear being embarrassed or made fin of. Situations that can trigge discussions, dating, going to a party, and playing sports. Common symptoms of socia blushing, sweating, and dry mouth. People with social phobia often avoid social situ: anxiety. + SSRI and SNRI are mainstay drugs for the treatment for social phobia. Escitalopram, Fluvoxamine, Paroxetine, Sertraline and Venlafaxine may be used for milder cases, + Simple stage fright or fear of public speaking may respond to low dose Propranolol 10mg taken 30 minutes before the event. General Anxiety Disorder + Generalized anxiety disorder (GAD) is associated with continual excessive anxiety and worry about & number of things (c.g., work, money, children, and health). There is no specific source of fear. Symptoms can include muscle tension, trembling, shortness of breath, fast heartbeat, dizziness, dry mouth, nausea, sleeping problems, and poor concentration, CBT is the most effective psychosocial treatment but often takes 20 or mor sions to be effective. + SSRIs and SNRIs have become established as first line treatments for GAD. Bupropion and. Pregabalin are further choices, Law dose benzodiazepines can be used but dependence is « problem: Buspizone has « low abuse potential and is less sedating than benzodiazepines. + Buspirone : Sing hid-tid, up to 60 mg/dayTherapeutic Guidelines | Psychiatry 55 + Pregabalin : Initial 150 mg/day in 2-3 divided doses, may be increased to 150 mg bid after 1 week if necessary Bupropion (Wellbutrin, Zyban): Use : Smoking cessation, second line Antidepressant. Antidepressant: Start 100 mg bid x 4 days > 100 m g tid. Obsessive-compulsive disorder (OCD) OCD involves recurring unpleasant thoughts (obsessions) and/or repetitive behaviours (compulsions). ‘The thoughts may be connected to the repetitive behaviours, For example, people who fear getting an infection may constantly wash their hands. Ac times, however, therc’s no connection at all between the thoughts and the behaviours. + CBT is the psychotherapy of choi SSRIs : Fluoxetine, Fluvoxamine, Paroxetine and Sertraline, in the usual antidepressant dosing range are the drugs of choice in Canada. It may take 6-8 weeks for symptoms to improve. Second line drugs include Clomipramine, Venlafaxine, Citalopram and Mirtazapine. Post-traumatic stress disorder (PTSD) + PTSD is associated with extreme anxiety that appears after a traumatic experience. Symptoms usually start within 3 months of the traumatic event but may take years to start, PTSD can be associated with sleep problems, nightmares, irritability, and anger. Feelings of guilt and unworthiness are common with PTSD. Traumatic experiences that can trigger PTSD include wars, plane crashes, natural disasters (cg. hurricane, carthquake), and violent crimes (e.g., rape, abuse), + SSRI and SNRI antidepressants have been shown to be effective in reducing the symptoms of PTSD. Fluoxetine, Paroxetine, Sertraline and Venlafuxine are first line options. 3. Dementia Dementia is a serious loss of cognitive ability in a previously unimpaired Zope person, beyond what might be expected from normal aging. Dementia is | ADAMADL Dressing | nota single disease, but rather a non-specific illness syndrome in which Eating affected areas of cognition may be memory, attention, language, and ‘Ambulation problem solving, It is normally required to be present for at least 6 months pene to be diagnosed, + The most common causes of dementia are Alzheimer's disease and vasculir | shopping dementia, It afiects about 1% of people aged 60-64 years and as many as | Housekeeping. 30-50% of people older than 85 years, ‘Accounting + Benzodiazepines must be used cautiously in the elderly patients due to | Food Making increase risk of falls and impaired cognition. [ieeporeaesy56 NAC OSCE | A Comprehensive Review 4, Depression Nonpharmacological treatment + Cognitive behavioral and interpersonal psychotherapy are as effective as antidepressants in mild to moderate depression. Pharmacological treatment + Take medication daily, antidepressant must be taken for 2 to 4 weeks for effect to be noticeable. Medication must he taken even if patient is feeling better. SSRI + Paroxetine (Paxil): Start 20 mg ghs, increase 10mg every 2wks, max 60mg per day. + Bhuoxetine (Prozac): Start 20mg PO qd, avoid increasing more often than monthly, max 80mg PO per day + Sertraline (Zoloft): Start SOmg PO qAM, increase 50mg every 2 weeks, max 200mg per day + Fluvoxamine (Luvox): Start 25mg PO ghs x 3 days -> 50mg PO ghs x 7 days -> titrate 150-250 mg daily divided doses bid. + Citalopram (Celexa): Start 20mg PO gd, max 60mg, + Escitalopram (Lexapro): Start 10mg PO gd Monoamine Oxidase Inhibitor (MAO inhibitor): Use in Atypical depression, Refractory depression, + Isocarboxazid (Marplan) ~ 10 mg PO bid, max 60 mg per day: + Phenelzine (Nardil) ~ 15 mg PO tid, max 90 mg per day. + Tranyleypromine (Parnate) ~ 10-40 mg per day in divided doses, max 60 mg per day. Complication: Hypertensive crisis, Serotonin syndrome, Interaction with tyramine containing foods to bbe avoided strietly. Serotonin Norepinephrine Reuptake Inhibitors(SNRI) not used these days + Tricyclic Antidepressants: Amitriptyline 25 mg qhs, Nortriptyline (Pamelor) S/E: Anti-cholinergic ~ dry mouth, constipation, blurred vision, Anti-histaminergic — sedation, weight gain; Scrotonengie ~ sexual dysfunction; Orthostatic hypotension; Sinus tachycardia, SVT, Ventricular tachycardia, Prolonged QT interval, heart block; Withdrawal symptoms. Other : Venlafaxine (Effexor) 37.5 mg PO od 6. Psychosis In acutely psychotic individuals, short-acting parenteral antipsychotics either alone or in combination with a parenteral benzodiazepine may be recommended. Liquid formulations of atypical antipsychotics may be used as an alternative to intramuscular injections, Risperidone and Olanzapine are examples. Atypical anipaychotics: Clozapine ~ 12.5 mg PO qd or bid, titrate slowly upwards in increments of 25-50 mg/day “Target dose 1300 ~ 450 mg/day, max 900 mg/day. S/E: Agranulocytosis, Diabetes mellitus, hypertriglyceridemia, NOT 1” LINE Anti-psychotic, Order weekly blood counts for1 month and then q2 weeks,Therapeutic Guidelines | Psychiatry 57 + Olanzapine (Zyprexa) ~ Start 5-10 mg PO qd, inezease in 5 mg increments weekly as tolerated, max 20 mg/day. ld sedation, insomnia, dizziness, early AST & ALT Life- threatening neurological coe peers with misde elevation, restlessness, weight yain, increased risk of diabetes jidity, fi mic mellitus and hyperlipides tabby, delta. + Quetiapine (Seroquel) ~ Start 25 mg PO bid tid, increase in 25- Elevated creatine 50 mg/day increments, target 300-400 mg/day divided doses bid EPCSPHOMInase tid, max 750 mg/day, | S/E: Headache, sedation, dizziness, constipation + Risperidone (Risperdal) ~ Start 1 mg PO bid, slow titration 2-4 mg PO daily or divided doses bid, max 16 mg/day. S/R: Insomnia, agitation, EPS, headache, ansiety, hyperprolactenemia, postural hypotension, constipation, dizziness, weight gain, ‘Typical antipsychotics: + Haloperidot (Haldol)- 5-10 mg PO, IM, IV. May repeat q30-60mins, max 300 mg per day. + Fluphenazine (prolixin) ~ 2.5 mg PO bid, max 40 mg per day. f - EXTRA PYRAMIDAL SIDE EFFECTS: Akinesia treat with Benztropine mg PO /IM/IV OD Dystonic reaction — treat with Lorazepam or benztropine. Dyskinesia Akathesia ~ creat with Lorazepam, Propranolol or Diphenhydramine. Perioral tremor Neuroleptic malignant Syndrome — Muscle rigidity, tremor, delirium, high fever, diaphoresis, hypertension, Discontinue drug. Give symptomatic treatment and supportive care.”Treatment with Dantrolene or bromocriptine. Tardive dyskinesia — Blinking, lip smacking, sucking, chewing, grimaces, choreoathetoid movements, tonic contractions of neck / back. ‘Treatment — Clozapine. 7. Mood stabilizers : Used in Bipolar disorder. + Lithium bicarbonate ~ Start 300 mg PO bid, then ine Serum levels — 0.6 — 1.2 mEq/l, monitor RF'Ts, TF TS. S/E: tremor, polydipsia, hypothyroidism, weight gain, nausea/voniting, diarrhea, ataxia, slurred speech, lack of coordination ‘Treatment of Lithium toxicity: Discontinue lithium. Check serum lithium levels, BUN, electrolytes, IV fluids ~ Normal saline. Hemodialysis in case Li > 2 mmol/L, coma, shock, severe dehydration, deterioration, unresponsive to treatment. 40 900 ~ 1800 mg per day divided doses.