Diagnose & Rx with Confidence

TREATMENT GUIDE
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DR ASIF ALI KHAN
YANGTZE UNIVERSITY CHINA

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 •- • .
. · --· .•
DEDICATION
••
• • • • •• • ••
I dedicated my work to my loving parents (my immunity) who always walk in when
others walk out. To my siblings Shujat ali (BSN), Tariq ali (pharmacist), Junaid ali,
Toheed ali & my sister.

TO MY UNCLE NEUROSURGEON DR. SHAMSHER ALI KHAN FOR HIS

UNCONDITIONAL LOVE AND SUPPORT

DIDICATED TO MY MEDICAL SCHOOL

YANGTZE UNIVERSITY JINGZHOU HUBEi CHINA
I WOULD LIKE TO EXPRESS MY SPECIAL THANKS AND GRATITUDE TO
INTERNATIONAL STUDENT AFFAIRS OFFICE OF YANGTZE UNIVERSITY

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FOR THEIR FEEDBACK & SUPPORT.
 • • • ••• •
SPECIAL THANKS TO MY MENTORS ••
•
• • • • •• • ••
Thank you for sharing your life experiences with me, you have always given me the
motivation I need. My success is due to your support, encouragement, and guidance.
I will remain forever grateful.

JINNAH POST GRADUATE MEDICAL CENTRE (JPMC) KARACID

Ci!" PROF. DR LAL REHMAN (HOD NEUROSURGERY WARD 16-18)

" PROF. DR. M. IQBAL AFRIDI (EX-HOD PSYCHIATRY WARD-21)

er PROF. DR M. SHAMIM QURESI-11 (EX-HOD SURGERY WARD-2)
r:r PROF. SHAHBAZ HAIDER (HOD MEDICINE WARD-5)
r:r PROF DR. CHOONI LAL (HOD PSYCHIATRY WARD-21)
r:r ASS PROF. DR M. NAEEM KHAN (SURGERY WARD-2)
qr ASS PROF. DR JAWED AKBER DARS (PSYCHIATRY WARD-21)

w DR. KASHIF MEHMOOD (HOD ORTHOPEDIC WARD 14)

r:r DR. M. INAM KHAN (CONSULTANT PHYSICIAN MEDICINE WARD-5)
r:r DR. FARRUKH JAVED (CONSULTANT NEUROSURGEON WARD I 6- I 8)
w DR. TANWEER AHMED (CONSULTANT NEUROSURGEON WARD 16-18)
qr DR. RABAIL AKBER (CONSULTANT NEUROSURGEON WARD 16-18)

r:r DR. RAJA MUSAB AF AQ (RESIDENT ORTHOPEDIC WARD 14)

r:ir DR. BAKHT MUHAMMAD KAKAR (RESIDENT PSYCHIATRIST WARD 20)
r:r DR. SHARIF JAN (RESIDENT PSYCHIATRIST WARD-21)
r:r DR. FAZAL MEHMOOD (RESIDENT MEDICINE WARD-4)
r:il" DR. KASHIF SARFARAZ (RESIDENT NEUROSURGEON WARD 16-18)

c:r DR. MANISHA ASWAN! (SURGERY WARD-2)

r:r DR. HASSAN AHMAD (SURGERY WARD-2)
C'ir DR. UMAIR AHMED (UMDC)

C'ir DR. AGHA SOHAlB KHAN (LNMC)

DOCTORS' INSTITTE OF MEDICAL SCIENCES (DIMS) LAHORE

w DR. AI-I.MAD MURTAZA
r:r DR. ABBAS (DIMS)

DOCTORS & PROFESSIONALS INN KARACHI

-
qr DR. ASAD TAHA

qr SIR SYED NAJMI

 • • • ••• •
••
•
YANZGTE UNIVERSITY JINGZHOU HUBEi CHINA
•
<:ir Dr Seidu A. Richard (PHD Neurosurgery)
• • • •• • • •
<:ir Dr Rabindra Yadav (MS orthopedics)
w Dr Urooj Ahmad (Biochemistry)
<:ir Dr Siddique Ur Rehman (Histology and Anatomy)

<:ir Dr Parkash Shahu (Medical Ethics, Interpersonal communication & Psychology)

<:ir Dr Deepak Malla (Consultant Cardiologist)

<:ir Dr Saroj Suwal (Medical literature)

<:ir Dr Rajeev Bhandari

<:ir Dr Sunil Mishra

<:ir Dr Nipun Shresta (Paediatrics)

rr Dr Mala Shresta (Regional Anatomy)

rr Dr Sagar Khatiwada
rr Dr Parkash Shresta (MS Internal Medicine)
<:ir Dr Shradha Shresta (MS Gynaecology & obstetrics)

c1r Dr Sudarshan Subedi (MS Internal Medicine)

rr Dr Sudhir (MS ENT)
c1r Dr Shamshad Ahmed (MS General surgery)
w Dr Rajiv Jaiswal (MS Orthopaedics)
<:ir Dr Kabita Shah (MS Gynaecology & obstetrics)

c1r Dr Sushil Bhandari

<:ir Dr Barjnew Yadav (MS ENT)

c1r Dr Anup
<:ir Dr Sijan

c:r Dr Farhao Khan

c1r Dr Umesh Guargain (MS Internal Medicine)
c1r Dr Devanand Yadav (MS General surgery)
c:r Dr Ujwal Thakur (MS Radiology)
<:ir Dr Faran Khan

c1r Dr. Qian Feng (PHD Physiology)

<:ir Dr Liu Rong (PHD Immunology)

r:r Liu Weirong (PHD Pathology)

<:ir Dr Peng Xiaochun (PHD Path-physiology)

c1r Dr Hu ya (PHD Pharmacology)

c1r Dr. Xiao rou (PHD Ophthalmology)
<:ir Dr. Luo guocai (PHD Neurosurgery)

c1r Dr Lu Hongzhu (PHD Paediatrics)

c:r Dr Pan Fengman (PHD Traditional Chinese medicine)
<1r Dr Huang Jingbo (PHD Medical Imaging)
c1r Dr Wang Xianwang ((Molecular biology
<:ir Dr Luo man (Preventive and social medicine)

<:ir Dr Xiang Ying (Genetics)

c1r Dr Caofen (Rehabilitation medicine)

c1r Miss Sessi (Basic Chinese)
<:ir Miss Amanda (Intermediate Chinese)

c1r Miss Wang Xiao Tian (Basic Chinese)

rr Miss Dai Chenxi (Medical Chinese)
 • ·- • ---· • . .•
•••
ACKNOWLEDGMENT
• • • • • • •
My sincere SPECIAL THANKS to all FMGS/LMGS students/Doctors, present and past, for their
tremendous feedback and support. I am grateful to all my seniors, juniors, friends and colleagues
of past and present of VANGZTE UINVERSITV for their moral support. Thanks to ALL my dearest
(Colleagues/friends/teachers) for their feedback & strong support.
er DR. JAVED AFZAL ar DR. M. ISMAIL SAADAT
,:JI" DR. KHALID KHAN (COUSIN) ,:JI" DR. NISAR AHMAD (COUSIN)
ar DR. ABDUL ZAHIR SAHAR ar DR. IMRAN AHMAD (COUSIN)
ar DR. M. ZEESHAN NOOR MALIK ,:JI" DR. WAQAR KHAN
Qr DR. AHMAD MEHMOOD Qr DR. FATIMA IZHAR
"' DR. ABBAS AKHTAR "' DR. SHAISTA LODHI
Qr DR. AYAZ ALI MORIO <7' DR. DR. FILZA RAHAT KHAN
,:JI" DR. ANAM BASHARAT <Ir DR. SHADAB KAMAL
er DR. USMAN SHAH <Ir DR. FAISAL NIAZI (YANGTZE)
qr DR FATIMA GUL <r DR. NOOR UL AIN
<r DR. RIDA KHAN qr DR. ANWAAR HUSSAIN
er DR. AAMINA SADAF qr DR. IJAZULHAQ (YICHUN UNIVERSITY)
<7 DR. AFSAH ASAD <7 DR. M ANEES ARAIN
qr DR M AMMAR YOUNUS r::;r DR. SANA JAMALI
er DR. SAMRA AGHA er DR. KIRAN SHAHZAD
er DR. MADIHA NAZ QURESHI Qr DR. SHAISTA
Qr DR. SHAHEER SHAH <r DR. SAJID MEHMOOD
<Ir DR KHADIM KHAN <Ir DR. WASIF KHAN
qr DR. LUQMAN KHAN qr DR. INAM ULLAH (MANIJAN)
<r DR. NIMRA AFZAL <r DR. ABDUL BASIT
C1r DR. SALMAN JAVAID RATERYA "' DR. IKRAM UL HAQ
<Ir DR. ABDULLAH ABID (SENOIR) er DR ZUHAIB GUL (R PSYCHIATRIST LRH)
Qr DR. TAI MOOR YASIN er DR. M NAJAM CHAUDHRY
<Ir DR. UROOSA RIND Qr DR. ZAHOORA RAJPER
<r DR. SYED AFTAB ALAM Qr DR. ABDUL SAQIB QURESHI
<7 DR. KAI NAT (52 JPMC) qr DR. M ASLAT ANJUM
er DR. SANJANA KARERA (JPMC) er DR. AMIR ZAMAN KAKAR
<7 DR NEELAM LAKHWANI (JPMC) <7 DR. DAWOOD SHAH KAKAR
<:r DR. RAM AREJA (JPMC) er DR. M. OWAIS HAQYAR
er DR. DANIYAL ABRO (JPMC) er DR. KAMRAN KHAN
<Jr DR. NAWAZ AFRIDI er DR. MARYAM AWAN
<7 DR. SAAD ULLAH Qr DR. NIDA ZEHRA
<Ir DR. ABIID ARAIN er DR. RABIYA QAISAR
Qr DR. SAMINA LAILA NAQVI (KANEEZ-E-ZEHRA) <sr DR ANOOD GHULAM RASOOL
<r DR. FIZAH INAM CHAUDHRY <sr DR TUBA ZAHID
a,- DR. WASEEM IMTIAZ "' DR. YAMNA NOOR

-
<sr DR. ARSHAD ALI KHAN Qr DR. MEHBOOB ALI KHAN
<:r DR. ADNAN TUNIO er DR. TUBA ZAHID
<sr DR. MUHAMMAD ABRAR SHAIKH Qr DR. FAIZA BUTT
Qr DR HASSAN JAVED <:r DR. PRIYA SINGH
 Cir DR. RAMSHA JUTT <ii' DR. SIMRA RAFFAT
Cir DR RABIA AZIZ NIAZI Cir DR SUMBUL MURTAZA
Cir DR. SHAISTA ALI BALOCH Cir DR ZIA AMAN KHAN
r:ir DR. REENA BHATTI (if" DR. AZIZ UR REHMAN
r:ir DR. KHADIJA NASIM r:ir DR. MALIK MUHAMMAD ADIL
(if>
DR. SYEDA RAMSHA AKHLAQ <ii' DR. BILAL ASHRAF
Cir DR. TASLEEM UL HAQ (if" DR. ALI MURTAZA RAJPER
r:ir DR. MALIK NADAR Cir DR. SHAFAQAT ALI
r:r DR. ABID AZIZ KOLACHI r:r DR. M. MUBASHIR MOGHAL
r:r DR. M ABRAR HAFEEZ qr DR. QADEER SHABIR

r:r DR. ALI KHAN qr DR. HAMMAD ZAHID

r:ir DR ALI SHAH (YANGTZE) <:Jr DR. RAFIULLAH (YANGTZE)

r:r DR. AQSA SADAF r:r DR. RABAIL TAJ
(if> DR. AHMAD ULLAH (if> DR. M ASIF NAWAZ
(if" DR. FAHAD RASHID QAZI Cir DR. HAFIZ MAJID
Cir DR. IRFAN ALI JATOI Cir DR. TABISH MAQSOOD AHMAD
Cir DR. YASMEEN HASHMI Cir DR. KAINAT FATIMA
Cir DR. KANWAL TAHIR Cir DR. ZEESHAN ABDULLAH
r:ir DR. JAM FEROZ KHAN SAMOO r:ir DR. MAHWASH FAROOQ
(ii"' DR. MUHABBAT KHAN (ii"' DR. NOMAN HAIDER
(ii"'
DR. MUHAMMAD KHALID Cir DR. FAISAL KHAN SALEEM
(ii"' DR. ANEELA ASGHAR Cir DR SAMEENA BHAN
(ii"' DR. KIRAN PERVAIZ Cir DR HAZRAT ALI
r:r DR. ASIM ARAIN Cir DR. SHAHNEELA QAZI
(ii"' DR ABID HUSSAIN Cir DR. ZIAULLAH (YANGTZE)
(ii"' DR. MISHAL BAIG Cir DR. AGHA KHAN
r:r DR. SHOAIB ZULFIQAR MIRZA qr DR. UZMA SHAHZADI
r:ir DR. KABEER AHMED BALOCH Cir DR. HUSNAIN BUKHARI
(ii"' DR. NAYAB ABDULLAH (ii"' DR. SYED PERVAIZ SHAH
(ii"' DR. HAFIZ MUHAMMAD ABUBAKAR <:Jr DR. KALSOOM MUSTAFA
(ii"' DR. TAHIR SHAH <:Jr DR. ASAD MANDOKHAIL
Cir DR.HYDRI RAZA <:Jr DR. AHMAD HANIF
<:Jr DR. SHAH FAISAL Qr> DR SAEED AHMAD UNAR
(ii"' DR. ARSHAD HUSSAIN DETHO Cir DR MUHAMMAD SIKANADAR
(ii"' DR ABDUL RASOOL SOLANGI Cir DR KHWAJA ADNAN AHMAD
(if" DR HAMMAD SAJJAD Cir DR MUHAMMAD WASIQ
(ii"' DR MUHAMMAD BILAL Cir DR PRIH ASMA RAHUJO
(ii"' DR. ARSALAN AHMAD Cir DR SUNIL KUMAR
(if> DR WASEEM AHMAD MEMON r:ir DR MOAZZAM ALI
(if> DR. NIMRA CHAUDHRY r:ir DR NOAMAN KHAN MEMON
DR. SABA ZAFAR DR MUDASSAR

-
(ii"' r:ir

(ii"' DR. HIDAYAT ULLAH r:ir DR UMAR BASIT

r:ir DR MUHAMMAD SHOAIB <:Jr DR AZWAR ANJUM
Cir DR USMAN RASHID <JI" DR AQIB RASHEED
(ii"' DR HASSAN MUSTAFA Cir DR JEHANGIR TALPUR
 • • • • • • •
•
••
•
SECTION CONTRIBUTORS
• • • •• • • •
The author expresses his appreciation to the contributors for
ensuring the accuracy of 2 nd Edition DOD Treatment Guide.

DR. HANIF KHAN TARAKAI

Medical Officer, MTI-Bacha Khan Medical Complex
Has been awarded,
"Excellent International Graduate"
"The Chinese Government Outstanding International Student
Scholarship"
"Hubei Provincial Excellent International Student Scholarship"
"Yangtze University Excellent International Student
Scholarship"

DR MUHAMMAD ADNAN SAMI

MBBS Khyber Medical University
FCPS, MRCS-A
Post Graduate Trainee Orthopaedic
Khyber Teaching Hospital Peshawar

DR UMM E FARWA TAHIR

MBBS "Hunan Normal University"
Ex House physician and Surgeon at AIMTH
Medical Officer at "Doctors Hospital in Gynae and OBS"
Awarded with "Hunan Chinese Government Scholarship"
Awarded with "Hunan Normal University Scholarship"
Certified with "Outstanding International Student of Hunan
Normal University"
Distinction in Gynaecology, Surgery, Medicine, Paediatrics and

-
14 other Subjects of MBBS)
 •- • .
. · --· .•
•••
PREFACE
• • • • • • •

I am thankful to Almighty Allah who gave me the courage to write the 2nd edition of
DOCTOR ON DUTY HOUSEJOB TREATMENT GUIDE with great support from my family,
teachers and friends. This book has been designed to fill a unique niche for the house
officers, internees, trainees, new medical officers and physicians interested in OPD and
emergency medicine.
In the DOCTOR ON DUTY TREATMENT GUIDE BOOK, we have concentrated on presenting
the material in short, concise paragraphs, and using tables to emphasize the most
important topics.

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 . ·- • --· • . .•
• ••
DISCLAIMER
• • • • •• • •

Any set of guidelines can provide only general suggestions for clinical practice and
practitioners must use their own clinical judgment in treating and addressing the
needs of each individual patient, taking into account patient's unique clinical
situation. There is no representation of the appropriateness or validity of these
guideline recommendations for any given patient. This manual does not intend to be
either restrictive or prescriptive. Treatment guidelines are provided in good faith.
Contributors and editors cannot be held responsible for errors, individual response
to drugs and other consequences.

I welcome comments, suggestions, and constructive criticism of this notes, which may
be emailed at idocasifali@gmail.com

YOU CAN ALSO FOLLOW US ON INST AGRAM

& FACEBOOK PAGE: dodtreatmentguide
FACEBOOK: drasifkhann

SOME BEAUTIFUL MOTIVATIONAL QUOTES

Whatever you do, do with determination. You have one life to live; do your work with passion and give
your best. �:;��!;!:J..?.�..��!��-�.?.��-�-�-.���t��.?.!�f:.!.��E:..?.�:.�.!:1::?!.���:..�.P.���2�.���t-�.!�.. [:.�.!!��- best result.
Whenever a doctor cannot do good, he must be kept from doing harm.
The natural healing force within each of us is the greatest force in getting well.
.......... .............................................•..................................................•..........•..........................................
A wise man should consider that health is the greatest of human blessings. and learn how by his own
thought to derive benefit
................ ............................................................ fr om his illnesses.
........·-··-············································"·······················
"The chapter you are learning today is going to save someone's life tomorrow. Pay attention."
"Wherever the art of medicine is loved, there is also a love for humanity."
..............................................................................................................................................................
"Behind every successful doctor, there is always a great nurse."
************
Facebook page: drasifkhann Instagram: dodtreatmentguide
 •- • .
. · --· .•
CONTENTS
••
• • • • • • ••
CHAPTER-1-HISTORY TAKING AND EXAMINATION 1

CHAPTER-2 SYMPTOMS AND QUESTIONARY 9

CHAPTER-3 PROCEDURES AND WARD SKILLS

1. Passing IV line (IV cannulation) 13
2. Setting up a drip 14
3. Venepuncture/phlebotomy 15
4. Vacutainer Tube Guide - Draw tubes 17
5. Blood cultures 18
6. Blood transfusion 19
7. Guidelines for blood transfusion 21
8. Arterial Blood Gas (ABGs) Sampling 25
9. Intramuscular, subcutaneous, and intradermal drug injection 27
10. Nasogastric intubation 29
11. Male catheterization 30
12. Female catheterization 31
13. Endotracheal intubation 33
14. Joint Aspiration (Arthrocentesis) 35
15. Lumber puncture 36
16. Paracentesis Abdominis (Ascitic tapping) 38
17. Paracentesis Thoracis (Pleural fluid tapping OR Thoracentesis) 40
18. Bedside Blood Glucose Measurement 42
19. Scrubbing up for theatre 43
20. Simple suturing 45

CHAPTER-4 PRESCRIBING, ADMINISTRATIVE AND

COMMUNICATION SKILLS
1. Explaining Skills 47
2. Endoscopies Explanation 48
3. Obtaining Consent so
4. Breaking Bad news 51
5. Requesting investigations for histopathology of specimen after procedure 52
6. Call to other department/consultation form 53
7. Discharge planning and negotiation 54

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8. Taking Consent for LAMA/DAMA 56
9. Death confirmation and death certification 57
 DOCTOR ON DUTY TREATMENT GUIDE

CHAPTER-5 INFECTIOUS DISEASES

1. Fever of unknown origin (FUO) 58
2. Fever with chills and rigors 60
3. Sepsis 61
4. Enteric fever (Typhoid fever) 63
5. Malaria fever (Falciparum fever) 64
6. Brucellosis 65
7. Weil's Disease (Leptospirosis) 66
8. Schistosomiasis 67
9. Tick typhus/scrub typhus 68
10. Epidemic typhus 68
11. Endemic typhus 69
12. Rocky mountain spotted fever 69
13. Syphilis 70
14. Coxiella Burnetii (Q-Fever) = Questionable Fever 71
15. Shigellosis 72

CHAPTER-6 PULMONOLOGY
1. Fever with Dry cough 73
2. Fever With Productive Cough 73
3. Community-Acquired Pneumonia (CAP) Outpatient (OPD) 74
4. Community-Acquired Pneumonia (CAP) Inpatient (ward/ER) 76
5. Nosocomial Pneumonia/Hospital-Acquired Pneumonia (HAP) 77
6. Ventilator-Associated Pneumonia (VAP) 78
7. Chlamydia Psittaci Pneumonia 79
8. Mycoplasma Pneumonia 80
9. Legionnaires Disease (Legionellosis/Legionella Pneumonia) 81
10. Staphylococcal Pneumonia 82
11. Pneumococcal Pneumonia 82
12. Lung Abscess 83
13. Pulmonary Tuberculosis 84
14. Bronchial Asthma 87
15. Chronic Obstructive Pulmonary Disease (COPD) 90
16. Severe cough in a Patient With history of Asthma 93
17. Pleural Effusion 94
18. Bronchiectasis 96

CHAPTER-7 CARDIOLOGY
1. Evaluation to the Management of Hypertension 98
2. Hypertension - Medication Prescription 101
3. Anti-Hypertensive Treatment Based on Comorbidities 103

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4. Hypertension long-term management & follow-up 104
5. Acute Myocardial Infarction With ST-Segment Elevation 105
6. Stable Angina Pectoris (Chronic) 108
 CONTENTS

7. Un-Stable Angina 110

8. Congestive Cardiac Failure (CHF) 111
9. Approach to the Diagnosis of Heart Failure 113
10. Medical Treatment of heart Failure according to stages 114
11. General measure and Approach to the management of Heart Failure 115
12. Evidence-Based Treatment of Heart Failure 116
13. Acute Heart Failure & Pulmonary Edema 118
14. Infective Endocarditis 119
15. Rheumatic Heart Disease 122

CHAPTER-8 GASTROENTEROLOGY & HEPATOLOGY

1. Approach to the management Nausea & Vomiting 123
2. Life-Threatening causes of Nausea & Vomiting 124
3. Oral Ulcer (Aphthous Ulcer, Stomatitis) 125
4. Gastro-Esophageal Reflex Disease (GERO) 126
5. Gastric Ulcer (Peptic ulcer) 127
6. Duodenal Ulcer (Peptic ulcer) 128
7. Helicobacter Pylori Infection 129
8. Functional Dyspepsia 133
9. Hiccups (Singultus) 134
10. Irritable Bowel syndrome (IBS) 136
11. Ulcerative Colitis 137
12. Adults Constipation 138
13. Non-Alcoholic Fatty Liver Disease (NAFLD) Or "Fatty Liver/Hapatic Steatosis 139
14. Amoebic Liver Abscess (Hepatic Abscess) 140
15. Chronic Hepatitis-B viral Infection 141
16. Chronic Hepatitis-C viral Infection 142
17. Decompensated Chronic Liver Disease (DCLD) = Liver Cirrhosis+ Ascites 143
18. Ascites 144
CHAPTER-9 ENDOCRINOLOGY
1. Diabetes Mallitus 146
2. Injectable Anti-Diabetic/ Hypoglycemic Drug Brands 147
3. Insulin Regimens 148
4. Principles of Insulin Adjustment 149
5. Sliding-Scale Insulin Regimen 149
6. Insulin Regimens for Glucocorticoid-lnduced Hyperglycemia 149
7. Characteristics of Insulin Therapy 150
8. Diagnosis Of Diabetes Mellitus 150
9. Type-1 Diabetes Mallitus (DM Type-I) 151
10. Type-2 Diabetes Mallitus (DM Type-II) 153

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11. Diabetic Nephropathy 156
12. Diabetic Neuropathy 157
DOCTOR ON DUTY TREATMENT GUIDE

13. Diabetic Retinopathy 158

14. Diabetic Ketoacidosis (OKA) 159
15. Hyperosmolar Hyperglycemic State (HHS) 161
16. Hypothyroidism 163
17. Hyperthyroidism & Thyrotoxicosis 164
18. Pheochromocytoma 165
19. Hyperprolactinemia 167

CHAPTER-10 NEPHROLOGY & UROLOGY

1. Fever with Burning Micturition 168
2. Urinary Tract infection (UTI) in Adults 169
3. Acute Pyelonephritis 170
4. Tiny Renal Stones (Nephrolithiasis) Conservative Rx 172
5. Benign Prostatic Hyperplasia (BPH) 173
6. International Prostate Symptom Score (IPSS) 174
7. Urinary Incontinence 175
8. Urge Incontinence 176
9. Stress Incontinence 177
10. Overactive Bladder (OAB) 178
11. Male Sexual Dysfunction & Erectile Dysfunction 179
12. Painful Bladder Syndrome (Interstitial Cystitis) 181
13. Nephritic Syndrome 182
14. Nephrotic Syndrome 183
15. Acute Renal Injury (AKI) 184
16. Diagnosis of AKI 186
17. Treatment for the Underlying Cause of AKI 187
18. Acute Renal Injury (AKI) Ward/ER Rx 188

CHAPTER-11 HAEMATOLOGY
1. Iron Deficiency Anemia (IDA) 189
2. Megaloblastic Anemia (Vitamin B12 & Folic Acid Anemia) 191
3. Diagnosis of Megaloblastic Anemia 192
4. Treatment of Megaloblastic Anemia 194
5. Acute Leukemia 195
6. Thrombotic Thrombocytopenic Purpura (TTP) 196
7. Immune Thrombocytopenic Purpura (ITP) 197
8. Aplastic Anemia 198

CHAPTER-12 NEUROLOGY & PSYCHIATRY

1. Migraine Headache 199
2. Cluster Headache 201
3. Tension Headache 202
4. Transient lschaemic Attacks (TIA) 203
5. Cerebrovascular Accident (lschemic Stroke) 204
 CONTENTS

6. Postherpetic Neuralgia 205

7. Trigeminal Neuralgia 206
8. Bell's Palsy (Facial Palsy/7th CN Paralysis) 207
9. Parkinson's Disease 208
10. Resting Tremors 210
11. Essential Tremor 211
12. Alzheimer's Disease 212
13. Guilin-Barre Syndrome (GBS) 213
14. Cerebral Palsy (CP) 215
15. Semen leakage after urination (Dhat Syndrome) 216
16. Premature ejaculation (Rapid/Early ejaculation) 217
17. Insomnia Disorder 218
18. Acute Stress Disorder 219
19. Panic Attack 220
20. Panic Disorder 220
21. Generalized Anxiety Disorder (GAD) 221
22. Bipolar Affective Disorder (BIPAD) 222
23. Schizophrenia 224
24. Opioid Withdrawal Syndrome (Symptomatic) 225

CHAPTER-13 RHEUMATOLOGY & ORTHOPADIC

1. Osteoporosis 226
2. Post-menopausal Osteoporosis 227
3. Arthritis 228
4. Post Chikungunya Arthritis 229
5. Osteoarthritis conservative Rx 230
6. Rheumatoid Arthritis 232
7. Gouty Arthritis 234
8. Plantar Fasciitis 235
9. Polymyalgia Rheumatica 236
10. Fibromyalgia Syndrome 237

CHAPTER-14 ENT
1. Acute Tonsillitis 239
2. Acute Pharyngitis 240
3. Acute Sinusitis (Acute Sinus Infection) 241
4. Chronic Sinusitis 242
5. Acute Rhinitis 243
6. Chronic Simple Rhinitis 244
7. Hypertrophic Rhinitis (Chronic) 244
8. Allergic Rhinitis 245

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9. Deviated Nasal Septum (DNS) 246
10. Septal Haematoma 247
 DOCTOR ON DUTY TREATMENT GUIDE

11. Septal Abscess 247

12. Adult with Ear Discharge/Infection 248
13. Acute Supporative Otitis Media (ASOM) 249
14. Chronic Suppurative Otitis Media (CSOM) 250
15. Tinnitus 252
16. Vertigo 253
17. Benign Paroxysmal Positional Vertigo (BPPV) 254
18. Ear, Nose and Throat Drug Brands in Pakistan. 256

CHAPTER-15 EYE
1. Hordeolum (Stye) 259
2. Chalazion (Meibomian Gland Lipogranuloma) 259
3. lritis (Anterior Uveitis) 260
4. Acute Mucopurulent Conjunctivitis 260
5. Chlamydia! Conjunctivitis 261
6. Allergic Conjunctivitis 261
7. Viral Conjunctivitis (Adenovirus Conjunctivitis) 262
8. Herpes Simplex Keratitis 263
9. Blepharitis (Blepharitis Squamosa) 264
10. Corneal Abrasion 265
11. Sub-Conjunctiva! Hemorrhage 265
12. Ocular Chemical Burns Injuries (Non-Mechanical) 266
13. Corneal Foreign Bodies (Mechanical) 267
14. Acute Angle Closure Glaucoma (AACG) 268
15. Eye/Ophthalmic Drug Brands In Pakistan 270

CHAPTER-16 DERMATOLOGY
1. Scabies 273
2. Acne vulgaris 274
3. Psoriasis 276
4. Seborrheic Dermatitis (Seborrheic eczema) 277
5. Tinea pedis/(Athlete's foot)/and Tinea manuum) 278
6. Tinea Corporis (Ring worm) 279
7. Tinea varsicolor (Pityriasis Varsicolor) 280
8. Tinea cruris (Jock itch) 281
9. Melasma 282
10. Vitiligo 283
11. Herpes-Zoster (Shingles) 285
12. Atopic Dermatitis/Atopic Eczema 286
13. Allergic Contact Dermatitis 287
14. Napkin Dermatitis (Pamper Rashes) 288

-
15. Pompholyx (Dyshidrotic Eczema) 289
16. Hyperhidrosis 290
17. Hirsutism 291
18. Commonly used Dermatological/Skin 292
 CONTENTS

CHAPTER-17 EMERGENCY MEDICNE & POISONING

20. The primary and secondary surveys 297
21. FAST (Focused Assessment with Sonography for Trauma) 298
22. Pain management Approaches 299
23. Oral Opioid and Non-Opioid Analgesics 301
24. Foreign Body Aspiration 303
25. Management of Un-Responsive Patient 306
26. Evaluation and Management of Coma 307
27. Hypertensive Emergency Management 312
28. Approach to Diarrhea 314
29. Gastroenteritis of Infectious origin 315
30. Evaluation of Gastroenteritis 316
31. Acute Gastroenteritis/Food poisoning in adults 318
32. Typhoid Fever (Enteric Fever) 319
33. Severe Falciparum Malaria 320
34. Status Epilepticus (Seizures/Fits) 321
35. Epistaxis (Bleeding through Nose) ER Rx 322
36. Acute Viral Hepatitis (Hepatitis-A/Jaundice) 323
37. Upper Gastrointestinal bleeding 324
38. Upper Gastrointestinal bleeding Secondary to CLO 325
39. Hepatic Encephalopathy 326
40. Amoebic Liver Abscess 327
41. Pyogenic Liver Abscess 328
42. Acute Blood loss (Hemorrhagic shock) 329
43. Acute Haemolytic Transfusion Reaction 330
44. Dengue Fever with Severe/Progressive thrombocytopenia 331
45. Iron Deficiency Anemia (IDA) 333
46. Megaloblastic Anemia 335
47. Acute Asthma 336
48. Status Asthmaticus 337
49. Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) 338
50. Acute Renal Colic/pain (2° Nephrolithiasis) 339
51. Acute Pyelonephritis 340
52. Acute Chest Pain/Acute Coronary syndrome 341
53. Cardiac Arrest 342
54. Pulmonary Edema 343
55. Acute Myocardial Infarction 344
56. Pulmonary Embolism 345
57. Fever with ALOC 347
58. Approach to Meningitis (complete detail) 348

-
59. Bacterial Meningitis 351
60. Viral Meningitis 352
 DOCTOR ON DUTY TREATMENT GUIDE

61. HSV Encephalitis 353

62. lntracerebral hemorrhage (Hemorrhagic stroke) 354
63. lschaemic Stroke 355
64. Anaphylaxis 356
65. Organophosphate Poisoning 357
66. Benzodiazepines poisoning 358
67. Opiates/Opioid Poisoning 359
68. Acids/Caustic Ingestion 360
69. Kerosene Poisoning 361
70. Paraphenylene Diamine (PPD) Poisoning (Kala-Pathar) 362
71. Human Bites 363
72. Dog Bites (Rabies Virus) 364
73. Unknown Insect Bites/Sting Bites 365
74. Snake Bites 366
75. Hypokalemia 368
76. Hyperkalemia 369
77. Hypoglycemia 370
CHAPTER-18 COVID-19 (Coronavirus Disease 2019)* 372

CHAPTER-19 GENERAL SURGERY

1. Approach to Management of Acute Abdomen 384
2. Differential Diagnosis and Causes of Acute Abdomen 390
3. Diagnostic approach of Acute Abdomen 391
4. Radiological Approach of Acute Abdomen 392
5. Stepwise management of Acute Abdomen 393
6. Acute Appendicitis 394
7. Acute Cholecystitis 395
8. Cholelithiasis 397
9. Choledocolithisis 398
10. Acute Cholangitis 399
11. Acute Anal fissure conservative Rx 401
12. Hemorrhoids conservative Rx 402
13. Ano-Rectal Abscess 403
14. Pilonidal Sinus 403
15. Acute Pancreatitis 404
16. Intestinal Obstruction 407
17. Spontaneous Bacterial Peritonitis 408
18. Secondary Bacterial Peritonitis 409
19. Pressure ulcer (Bed sore) 410
20. Diabetic foot ulcer 411

-
21. Hypertrophic scar 412
22. Keloid scar 413
 CONTENTS

CHAPTER-20 NEUROSURGERY
1. Degenerative Disk Disease 414
2. Brachialgia (Cervical Radiculopathy/Pinched nerve) 415
3. Conservative treatment of Lower Back Pain 416
4. Sciatica Pain 419
5. Epidural Hematoma/Extradural hematoma (EDH) 420
6. Subdural Hematoma (SDH) 423
7. Brain Abscess 427
8. Traumatic Brain Injury (Head Trauma) 429
9. Pneumocephalus 430
10. Subarachnoid Hemorrhage 431

CHAPTER-21 GYNAECOLOGY & OBSTETRICS

1. Fever with Dry Cough in Pregnancy 432
2. Fever with Productive Cough in Pregnancy 432
3. Typhoid Fever (Enteric Fever) in Pregnancy 433
4. Malaria Fever (Falciparum malaria) in Pregnancy 434
5. UTI (Urinary tract infection) in Pregnancy 435
6. Nephrolithiasis (Renal Stones) in Pregnancy - conservative Rx 436
7. Community-Acquired Pneumonia (CAP) Outpatient (OPD) in Pregnancy 437
8. Community-Acquired Pneumonia (CAP) Inpatient (WARD) in Pregnancy 439
9. Vaginal Yeast Infection (Vulva-Vaginal Candidiasis) 440
10. Chlamydia! Infection 440
11. Leucorrhea 441
12. Pelvic Inflammatory Diseases (PID) 442
13. Trichomoniasis 443
14. Atrophic Vaginitis 444
15. Primary Dysmenorrhea (Menstrual Pain) 444
16. Secondary Dysmenorrhea 445
17. Premenstrual syndrome (PMS) 446
18. Mittleshmerz 447
19. Menorrhagia 447
20. Oligomenorrhea 447
21. Endometriosis 448
22. Uterine Leiomyomas (Fibroids) 449
23. Female Infertility 450
24. Polycystic ovary syndrome (PCOS) 452
25. Benign Ovarian Cyst 455
26. Post-Partum Hemorrhage (PPH) 456
27. Nausea And Vomiting Of Pregnancy (Uncomplicated) 458
28. Hyperemesis Gravidum 458
29. Chronic Hypertension in Pregnancy 459
30. Pre-Eclampsia 460
DOCTOR ON DUTY TREATMENT GUIDE

31. Eclampsia 462

32. Migraine Headache in Pregnancy 463
33. Gastroesophageal Reflux Disease (GERO) in Pregnancy 463
34. Peptic Ulcer Disease in Pregnancy 464
35. Helicobacter Pylori in Pregnancy 464
36. Constipation in Pregnancy 465
37. Hemorrhoids Conservative in Pregnancy 465
38. Anemia of pregnancy 466
39. Iron Deficiency Anemia (IDA) in Pregnancy 467
40. Megaloblastic Anemia (MBA) in Pregnancy 468
41. Gestational Diabetes Mellitus (GDM) 469
42. Hypoglycemia in Pregnancy 470
43. Diabetic Ketoacidosis (DKA) in Pregnancy 471
44. Hyperthyroidism in Pregnancy 472
45. Hypothyroidism in Pregnancy 472
46. Normal Pregnancy 473
47. Pregnancy- Pre-conception Counselling 474
48. Diagnosis of Pregnancy 476
49. Physiological Changes During Pregnancy 477
50. Nutrition During Pregnancy 479
51. Physical Activity During Pregnancy 480
52. Safe and Unsafe Sports During Pregnancy 480
53. High-Risk Pregnancy 480
54. Ectopic Pregnancy 481
55. Pregnancy Loss and its types 484
56. Spontaneous Abortion 485
57. Recurrent or Habitual Miscarriage 486
58. Anti-Phospholipid Syndrome (APS) 488
59. Pueperal sepsis 489
60. Postpartum Endometritis 490
61. Emergency Contraception "Postcoital Contraception" 491
62. Overview of Different Types of Hormonal Contraceptives 492
63. Gynaecological Drug Brands in Pakistan 493
64. U.S. Food and Drug Administration Pregnancy Drug Categories, 1979 496
65. Drugs used in pregnancy with known adverse effects in human pregnancy 496
66. Safe medicines in Pregnancy 497
67. World Health Organization General Cautions for Drugs and Breastfeeding 500
68. 2015 U.S. Food and Drug Administration Pregnancy and Lactation Labeling Rule 500
Required Information on Package Insert for Every Medication
69. Fetal Radiation Effects & Characteristics 501
 CONTENTS

CHAPTER-22 PAEDIATRICS & NEONATOLOGY

1. The Newborn Infant 502
2. Apgar Score 502
3. Neonatal Resuscitation 503
4. Assessment of the newborn 504
5. Fluid Management in Newborn 505
6. Dehydration & Treatment Plan 506
7. Neonatal Hypothermia 507
8. Vitamin-K deficiency bleeding of the newborn 508
9. Neonatal Polycythemia 508
10. Neonatal Hypocalcemia 509
11. Neonatal Hypoglycemia 510
12. Neonatal Respiratory Distress Syndrome (NRDS) 512
13. Surfactant Replacement Therapy (Guidelines) 513
14. Less Invasive Surfactant Administration (LISA) 514
15. Neonatal jaundice 515
16. Guidelines For Phototherapy & Exchange Transfusion 516
17. Neonatal Seizures 517
18. Neonatal Sepsis 518
19. Acute Tonsillitis 519
20. Acute Epiglottitis 520
21. Laryngotracheobronchitis (CROUP) 521
22. Bronchiolitis 523
23. Lower Respiratory Tract Infections (LRTls) 524
24. Community Acquired Pneumonia 525
25. Paediatric Pneumonia (CAP) in Patient (Ward) 526
26. Acute Asthma Attack ER Rx 527
27. Status Asthmaticus ER Rx 528
28. Fever with Burning Micturition 529
29. Urinary Tract infection (UTI) in Children's 530
30. Allergic Rhinitis 531
31. Food Allergy 532
32. Child with cold & flue 533
33. Child with Dental Infection/Pain 533
34. Child with Ear Pain 534
35. Child with Ear Discharge/Infection 534
36. Acute Supporative Otitis Media (ASOM) 535
37. Management of Fever 536
38. Enteric Fever (Typhoid Fever) 538
39. Enteric Fever/Typhoid Fever (Severe/Complicated) 539
40. Malaria Fever (Falciparum Fever) 540
41. Severe complicated Malaria 541

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42. Pulmonary Tuberculosis 542
43. Chickenpox (Varicella) 543
 DOCTOR ON DUTY TREATMENT GUIDE
44. Mumps (Epidemic Parotitis) 544
45. Measles (Rubeola) 545
46. H.Pylori infection 546
47. Iron Deficiency anemia(IDA) 547
48. PICA Eating Syndrome 547
49. Infantile colic 548
50. Constipation 549
51. Vitamin-D Deficiency 551
52. Hypocalcaemia 551
53. Oral Ulcer (Aphthous Ulcer) 552
54. Assessment of Degree of Dehydration in Diarrhea 553
55. Treatment of Dehydration Based on Severity 553
56. Mild To Moderate Gastroenteritis/Acute Diarrhea 554
57. Severe dehydration/severe diarrhea 555
58. Lactose intolerance/Diarrhea due to Formula milk 556
59. Status Epilepticus 557
60. Febrile seizures 558
61. Bacterial meningitis 560
62. Tetanus 562
63. Scabies 563
64. Hypothyroidism (Congenital & Acquired) 564
65. Hypothyroidism 565
66. Immunization Schedule in children's 566

CHAPTER-23 PAEDIATRICS DRUG DOSAGES 567

BLANK PAGE 615

CHAPTER-24 COMMON DRUG BRANDS IN PAKISTAN

1. Commonly used NSAIDs, Analgesic, Antipyretics, opioids analgesics 617
2. Commonly used Antibiotics drug brands 619
3. Cardiovascular (CVS) drug brands 624
4. Commonly used Oral hypoglycemic drug brands 627
5. Commonly used Anti-depressants 629
6. Commonly used Benzodiazepines, anxiolytic drug brands 631
7. Commonly used Anti-Epileptics drug brands 632
8. Commonly used Anti-Psychotics drug brands 634
9. Commonly used Anti-Allergic/antihistamine drug brands 635
10. Commonly used anti-tussive cough suppressant 636
11. Commonly used Anti-Emetic/Anti-Vertigo 637
12. Commonly used Anti-Peptic Ulcer 638
13. Commonly used Muscle Relaxant 639

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14. Commonly used Multivitamins/Iron & Supplementation 640
15. Commonly used laxative (constipation) drug brand 642
16. Commonly used Anti-Viral drug brands 643
17. Antacids, Anti-Flatulence and Anti-Spasmodic drug brands 644
 • • • ••• •
••
•
CH History Taking and Examination
•
• • • • •• • •

Principles for Good Clinical Diagnosis

► There are three main steps to making a correct diagnosis:
1. Comprehensive history taking of the patient
2. Good and complete examination of patient
3. Laboratory investigation

Importance of History Taking:

► Obtaining an accurate history is the critical first step in determining the etiology of a patient's
problem.
► It enables doctors to make accurate provisional diagnosis.

General Approach
1. Introduce yourself: give your name and your job (e.g. Dr. Asif, Medicine dept. etc... )
2. Identity: confirm you're speaking to the correct patient (name and date of bi1th)
3. Treat patient appropriately in a friendly relaxed way.
4. Permission: confirm the reason for seeing the patient ("I'm going to ask you some questions
about yow- cough, is that OK?")
5. Confidentiality & respect patient privacy.
6. Try to see things from patient point of view.
7. Understand patient underneath mental status, anxiety, irritation or depression.
8. Positioning: patient sitting in chair approximately a meter away from you. Ensure you are sitting
at the same level as them and ideally not behind a desk, Always exhibit neutral position.
9. Listening.
10. Questioning: simple/clear/avoid medical terms/open, leading, inten-upting, direct questions &
summarizing.

Components of History Taking

1. Personal _Details:.
Name: Yd lp rU I.;� l.½1
Age: Y0�JA&,�";-11
Gender: .I.! d� Jt � � �J _,s �...}A
Address: - J 4S
\'. U# t:t. ' '.I1
Occupation YU# �.;S lp rlS i.i1
Religion --
Marital status yU# 0 J.i.1 c.S JW:. '.I1 lp
Date of Admission Y� c·1 ci_, U..S �. , '-11, / Yc' i u.i�- . , '-11.
•- 1-1.S JU-M.11.1
Mode of Admission Y<.»A �JA:!I l:! � d1 <.»A c.S 3 �_,, i.ii
 2. �"1.��Js�mP.,�m.t{G!.�J;.
1. This is why the patient is here, in the emergency room or OPD
✓ What brings you here?\'<..l:¾t �l J��1...., c-5(�) � U.S '-:,ll tr.
✓ How can I help you?
✓ What seems to be the problem?
2. This must be put in a short statement in the patient's own word.
3. If there are more than one complaint, list them in order of severity or duration.
4. Include the duration of the chief compliant.
5. Each complaint should be written in one line.

► Example:
Chief Complaint (Symptoms) Duration
• Fever 4 days
• Cough 3 days
• Expectoration 2 days
• Presence of blood in sputum 1 day
N.B: It should be recorded in patient own words

3. History
1) History of present illness:
► This is the detailed reason why the patient is here. It is the why, when and where, etc ...
► Use the OD-PARA approach/SOCRATES Approach can help develop your differential
diagnosis and to cover all aspects of information
1. Onset: When did the chief complaint occur (gradual, rapid or sudden, intermittent or
constant
2. Duration: When do the symptoms occur? At night, all the time, in the mornings, etc...
3. Progression: Is this problem getting worse or better Is there anything that the patient
does that makes it better or worse
•'- Aggravating factor: Increase with food or anything
5. Relieving factor: Relief with food, Position ...
6. Associated symptoms: any other info about the chief complaint that has not already
been covered Ask if there is anything else that the patient has to tell about the chief
complaint. (nausea, Vomiting)
Example in Urdu:
O-Onset: \'I.Jt e,Jy!. c'4 .J� .JS �i er-'
D-Duration: \'d c""' � .J� .JS "ti
P-Progression: �·ct La,.J �c-4w
• -
I w.a.i�
Y .J • •
. �
c-'t tJ->'-"
A-Aggravating factor: \'-'t l:i\+ AJ:I .J� c""' ,-+J �
\' -'t ut.:i.. -'t r5 .Jw• c""' ,'+J �

-
R- Relieving factor
A- Associated features: \'d l:.iS <Jo"� u+:' ,..a...... .JJ1 �.JS c-1 "tl �t.... � .J�
\'d l:.iS <Jo"� u+,:i � .JJI �.JS c-1 "ti l:.iS o.ffe, � .J�
·a •t,.1 LJ:!A csii+t 'd � 'd c.r"-'¥ :<.J"l:!JA
 OR
❖ A useful mnemonic "SOCRATES"
l. Site: where exactly is the pain?
2. Onset and progression: when did the pain start and how has it changed or evolved?
3. Character: what type of pain is it ( e.g. dull, sharp, or crushing)?
4. Radiation: does the pain move anywhere (e.g. into the jaw, arm, or back)?
5. Associated symptoms and signs: ask specifically about sweating, nausea and vomiting,
shortness of breath, cough, haemoptysis, dizziness, and palpitations
6. Timing and duration: does the pain occur at particular times of the day? How long
does each episode last?
7. Exacerbating and alleviating factors: does anything make the pain better or worse
( e.g. exercise, movement, deep breathing, coughing, cold air, large or spicy meals,
alcohol, rest, GTN, sitting up in bed)?
8. Severity: "How would you rate the pain on a scale of 1 to 10, with 1 being no pain at
all and 10 being the worst pain you have ever experienced?"

2) Past medical history

• Ask the patient about all previous medical problems.
• They may know these medical problems very well or they may forget some. Top ensure
none are missed ask about these important conditions specifically
(Mnemonic: "MJTHREADS Ca")
cjf" Myocardial infarction Cit" Jaundice
qr Tuberculosis (if" Hypertension

r::r Rheumatic fever r::r Epilepsy

r::r Asthma r::r Diabetes
cjf" Stroke Cit" Cancer (and treatment if so)

3) Drug History
• All medications that they take for each medication ask them to specify:
• Dose, frequency, route and compliance (i.e. whether they regularly take these medication).
• If they take medication weekly ask what day of the week they take it.
• If they take a medication with a variable dosing (e.g. Warfarin) ask what their cunent
dosing regimen is
• Recreational drugs
• Intravenous drug use (current or previous)
• Over the counter (OTC) medications

4) Allergies History
• Does the patient have any allergies?
• If allergic to medications, clarify the type of medication and the exact reaction to that
medication.
• Medication reaction: Sulfa drugs - rash, Cipro - rash, Benadryl - causes mild dystonic
reaction
 • Specifically ask about whether there's been a history of anaphylaxis e.g. "throat swelling,
trouble breathing or puffy face"
5) Family History
• Ask the patient about any family diseases relevant to the presenting complaints (e.g. if the
patient has presented with chest pain, ask about family nistory of heart attacks).
• Enquire about the patient's parents and sibling and, if they were deceased below 65, the
cause of death
• If relevant and a pattern has emerged from previous history sketch a short family tree

6) Social history:
• Occupation/Employment history: Particularly relevant with exposure to certain
pathogens e.g. asbestos, where you need to ask whether they have ever been exposed to
any dusts
• Marriage status:
• Tobacco use---how much and for how long
• Quantify the number of pack years (number of packs of 20 cigarettes smoked per day
multiplied by the number of years smoking)
• Alcohol use: Work out the number of unjts per week
• Illicit drug use
• Immunization status: recent immunizations
• Home situation:
• House or bungalow
• Any carers
• Activities of daily living (ability to wash, dress and cook)
• Mobility, and inunobility aids
• Social/family support
• Do they think they're managing?
• Travel history
• Further social history may be required depending on the type of presenting complaint
for example:
• Respiratory presenting complaint
• Ask about pets, dust exposure, asbestos, exposure to the farms, exposure to birds or if
there are any hobbies
• Infectious to disease related: STDs
• Ask for a full travel history including all occasion's exposure to water, exposw·e to
foreign food, tuberculosis risk factors, and HIV risk factors.

4. Gesture of_Patient:Particular gestures useful in analyzing specific pain symptoms

I. A squeezing gesture to describe cardiac pain

-
11. Hand position to describe renal colic
...
111. Rubbing the sternum to describe heartburn
IV. Rubbing the buttock and thigh to describe sciatica
V. Arms clenched around the abdomen to describe mid-gut colic
5. Specific_information:
• Patient may have ignored the feature of disease thinking it as unimportant
• A doctor should put the questions regarding main presenting feature of systemic review
(Systemic Disease) i.e. disease of Respiratory system, CVS, CNS, Urinary system etc...

6. Features .of System.Review:

❖ Run through a full list of symptoms from major systems:
1) General:
)) Appetite )) Weight
» Sleep » Fever
» Energy » Edema
» Odour » Posture

2) Respiratory system
)) Cough » Expectoration (Sputum)
» Color of sputum » Ilemoptysis
» Breathlessness » Chest pain/Discomfort
» Wheezing

3) Cardiovascular system
» Chest pain/ Discomfort ))Breathlessness
)) Palpitation » Oedema feet/ Ankle swelling
» Pain in lower leg when walking » Syncope/ Dizziness

4) Central nerv ous system

)) Orientation: To place ,time, person )) Headache
)) Dizziness )) Syncope
)) Vertigo )) Fits/ Faints
>> Weakness of any part of body )) Insomnia
» LeveJ of Consciousness: confused, » Paresthesia
Alert, Restless, lethargic, comatose
» Numbness/ Tingling sensations » Visual disturbance

5) Alimentary system/Gastrointestinal system

» Dental/ gums problems » Tongue problems
» Heart burn/ indigestion/ Flatulence » Nausea/ Vomiting
» Abdominal pain/ Tenderness Abdominal spasm
))

» Change in bowel habit:i.e. Dianhea/ Hematemesis

))

Constipation

-
» Melena )) Hematechezia
)) Jaundice )) Dysphagia
» Anorexia » Color of stool
6) Gcnitoudnary system
Women Men
)) Painful urination )) Painful urination
)) Blood in urine )) Blood in urine
)) Sexually transmitted infections )) Sexually transmitted infections
)) Onset of menstruation )) Burning micturition
)) Last menstrual period )) Pain in flanks
)) Timing and regularity of )) Incontinence
periods
)) Length of periods )) Hesitancy passing urine
)) Type of flow )) Frequency of micturition
)) Vaginal discharge )) Urethral discharge
)) Burning micturition )) Change in libido
)) Pain in flanks )) Erectile dysfunction
)) Incontinence )) Passage of stone in urine
)) Pain during sexual intercomse )) Hydrocele
)) Polyuria / oligurfa )) Polyuria I oliguria
)) Difficulty in urination: )) Difficulty in urination:
i.e. stoppage, dribbling i.e. stoppage, dribbling

7) Musculoskelctal system/ Locomotor· system

)) Weakness/ Paralysis/Contracture
)) Pain I Stiffness in joints
)) Pain/ stiffness of back
)) Muscle are bone pain
» Swelling of joints
» Loss of joint function
)) Fracture/ Multiple bone fracture
)) Difficulty in movements:
I.e. walking, sitting, standing, turning of head, bending etc...
» Curv ature of Spine: Lordosis, kyphosis, scoliosis

8) Ear Nose and Throat ( ENT):

Often incorporated into the Respiratory system review
» Ear pain (Earache) » Ear Discharge
» Hearing loss » Noises in the Ears
» Tinnitus » Nasal discharge
» Allergy » Common Cold
» Hay Fever » Sinusitis
» Sore Throat » Throat pain
» Nasal congestion » Nasal obstruction
 9) Eye:
)) Visual changes » Redness
)) Weeping » Itching/ irritation
)) Discharge )) Bulging

10) Endocrine system:

Excessive thrust
)) » Tiredness
Cold/Heat intolerance
)) » Hair distribution
Sweating
)) » Weight gain/loss
Appetite
)) » Hairsutism
Change in appearance of eye
))

11) Integumentary (Skin):

Rashes
))

Lumps
))

Itching
))

Bruising
))

General pallor of patient, e.g. pale, flushed, cyanotic, jaundiced

))

7. Physical. Examination_ of the_paticnt

► Vital signs:
• Vital signs include the measurement of:Temperature, Respiratory rate, Pulse rate,
Blood pressure and Sp02
• These numbers provide critical information (hence the name "vital") about a patient's state
of health. ln particular, they:
1. Can identify the existence of an acute medical problem.
2. Are a means of rapidly quantifying the magnitude of an illness and how well the
body is coping with the resultant physiologic stress? The more deranged the vitals,
the sicker the patient.
3. Are a marker of chronic disease states (e.g. hypertension is defined as chronically
elevated blood pressure)?

-
 ► General physical examination
t. The patient should be approached from right side.
2. GPE starts as soon as the physician looks at the patient.
3. General appearance: No Apparent Distress (NAO), sitting up in bed, well groomed.
4. Facial features, expression, mood and attitude
5. Eyes - Pupils equal, round, and reactive to light and accommodation (PERRLA), Extra-
ocular motion intact (EOM intact)
6. ENT - Normal tongue, cheek, breath and odor
7. Neck - No noticeable or palpable swelling, redness or rash around throat or on face
8. Lymph Nodes - No lymphadenopathy
9. Hands and arms
10. Oedema and Jaundice
1 t. Extremities: No edema, cyanosis or clubbing
12. Skin: No rashes, skin warm and dry, no erythematous areas
13. Psychiatry : No anxiety, depression and stress

8. Give _a _differential diagnosis

9. Pcrtincnt.Diag_nostic Tcsts:ExpJain a brief investigation

LAB INVESTIGATION
QI CBC (Complete blood count)
er BUN (Blood urea nitrogen), Urinalysis
er Culture: Blood/urine/stool/sputum/pus
qr Serum Urea, Creatinine & Electrolyte test (serum U/C/E)

{If Blood Glucose/Blood sugar (Fasting/Random)

{d UPT (Urine pregnancy test)

r:r TFTs (Thyroid function test)
(JI' LFTs (Liver function test)

Cir FLP (Fasting Lipid profile)

er RFTs (Renal function test)

Cl' Inflammatory marker: ESR, CRP, fibrinogen, ferritin, procaJcitoninand IL-6

c::;r Marker of hemolysis: LOH, Heptoglobin, reticulocytes, unconjugated bilirubin

Radiology
c:Jr X-Ray and Specific Ultrasound (US whole abdomen, KUB, Pelvis, Prostate)

er CT scan (Computed Tomography)

c:r MRI scan (Magnetic resonance Imagining)
(if" ECG (Electrocardiography)

Qr Echocardiography&Angiography

-
10. Provisional Diagnose

1 t. Mana_gement Plan
 • • • • •• •
••
•
Procedures and Ward Skills
•
• • • • •• • •

PASSING IV LINE (IV CANNULATION)

"" Equipment:Gather the equipment in a clean tray.
» A pair of non-sterile gloves, a tourniquet, Alcohol sterets or prepackaged chlorhexidine and
alcohol sponge
» An rv cannula of appropriate size. Size is primarily determined by the viscosity of the fluid to
be infused (e.g. blood requires pink or larger) and the required rate of infusion
» A pre-filled 5 ml syringe containing saline flush
» A11 adhesive plaster/transparent film dressing
,;;- lntroduction:lntroduce yourself to the patient and confirm name and age of the patient.
or Consent:Explain the procedure and obtain his consent. For example, "l would like to insert a thin
plastic tube into one of the veins on your arm. The tube will enable you to receive IV fluids and
prevent you from becoming dehydrated. You may feel a sharp scratch when the needle is inserted,
but only the plastic tube will remain in the vein. Do you have any questions?"
r:s1· Ask him on which arm he would prefer to have the cannula and ask him to expose this arm.

r:r Wash your hands.

er Position the patient so that his arm is fully extended. Ensure that he is comfortable.
r:r /\pply the tourniquet proximal to the venepuncture site.
ar Select.a vein.by pa�pation: the bigger and straighter the better. Try to avoid the dorsum of the
hand and the antecubital Cossa if possible (may be uncomfortable on flexion).
r:r Don a pair of non-sterile gloves.
c.r Clean the skin with an alcohol steret and let it dry.
r:r Remove the cannula from its packaging and remove its needle cap.
r:s,• Anchor the vein by stretching the skin and insert the cannula at an angle of approximately 30
degrees.
r:r Once a flashback is seen, advance the whole cannula and needle by about 2 mm.
r:r Pull back slightly on the needle and continue to hold the needle while advancing only the cannula
into the vein.
r:r Release the tourniquet.
r:r Occlude the vein by pressing on the vein over the tip of the cannula.
r:;3 Remove the needle completely, and inm1ediately put it into the sharps box.
r:'ir Cap the cannula with the same cap that was on the end of the needle or heplock
w Fix the cannula by applying an adhesive plaster (tegaderm) or transparent film dressing
r:r Flush the cannula with 5 ml normal saline to prevent blood from occluding it.
cyr Dispose of clinical waste in a clinical waste bin.
r:r Ensure that the patient is comfortable and inform him of possible complications (e.g. pain,
erythema).
r:r Thank the patient.
 Q11'AllmtftJIIGtJJDI-Dm, .............

Haemoguard
Stopper Tube content Determination

•
Prothrombin Time (PT) FDPs
BLUE TUBE APIT Coagulation Screen
SODIUM CITRATE fNR Thrombophilia Screen
D-Dimers Lupus Anticoagulant
Screen
CBC/FBC Direct comb test
Blood smear G6PD

•
Retjculocyte count Malaria Parasites
PURPLE TUBE EDTA TUBE ESR Monospot test (EBY)
HbA l C Antibody Screening
Parathyroid hormone (PTH) Cord Blood Samples

•
Red cells folate level
GREEN TUBE Insulin
HEPARJN Ammonia
Renin and aldosterone
LFTs (Direct and indirect Complement
bilirubin, ALT. AST, ALP. Auto-antibody screen
GGT, Total protein & Hepatitis A & E
albumin, TPAGR antibodies
RFTs 1-IBsAg
YELLOW Urea and creatinine AntiHCV
GEL TUBE - SST Electrolytes Dengue NSl
(serum separating CRP serum LOH
tube) serum magnesium Vitamin 812
serum calcium Iron studies
serum phosphate Ferritin
HIV Lipid profile
Amylase and Lipase TFTs (freeTJ, T4 &
CPK TSH)
RA factor Thyroid antibodies
Blood glucose (FBS/RBS) Cortisol
Uric acid Testosterone
indirect coomb test CaJcitorun
Osmotic fragility test Growth hormone
Toxicology IGF-1

•
I mmunoglobul in Beta HCG
Bone profile Troporun

-
GREY SODIUM Glucose
FLUORIDE Lactate
r:.· Introduce yourself to the patient and confirm name and age of the patient.
(j/" Explain the procedure and obtain his consent.
t'i1" Position the patient on a bed with the joint, e.g. knee, well supported
(if" Gather the equipment
r;;;• Wash and dry your hands.
(j/" Put on sterile gloves.
(j/" For the knee, use a lateral approach
(if" Draw a line on the lateral edge of the patella between the upper and middle thirds.
r:r Then aim for 1-2 cm below this point
r:r Clean with chlorhexidine solution from the centre outwards and allow to dry
r:il' Apply refrigerant alcohol spray at the point you have marked for needle insertion
r:.· Use a green needle, and advance it at 90° to the skin, heading between the patella and femoral
condyle, and aspirating as you go until joint flujd is aspirated
w Collect as much as required for analysis or, for symptomatic reHef, until dryness is achieved
r:'I" The needle can be left in situ and the syringe changed if an injection is required, e.g. steroids
(if' Cover the wound with a small sterile dressing
(ii• Record the procedure and the amount, colour and consistency of fluid aspirated
r:r Ensure that the patient is comfortable.
r:JT> Thank the patient.
(j/" Discard any rubbish.
 • •

• • • • • ••
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 CONSULTATION SHEET (SAMPLE)
Date: C.R/MR No:
Patient full Name:
At?e : I
Sex: Ward No: I
Bed No:
Date of admission: Time of admission:
Consulting department: Requesting department:
Surgery Oncall ward Oncology ward# I 0

Date and Time Date and Time

Reason for I Patient has severe abdominal pain and absolute constipation from 2 days, we
Consultation: are susoecting intestinal obstruction
Clinical detail of Patient:
We have a 44 y/o female patient with K/C/O Ovarian CA. came to us via ER with
)) Lower abdominal pain
)) Weight loss
)) Urgent urination
)) Constipation

On Examination:
)) CVS: GCS (E4VsM6), Pupil: BERL (BIL Equally reactive to light). Planters, Power intact
)) CNS: SI +S2+0
)) Respiratory: B/L NVS (Normal vesicular Breath)
)) Abdomen: Soft, Distended, Tender . Gut Sounds - audible

Vitals Monitoring
)) B.P: 100/70 mmHg
)) P.R: 86 bmp
)) R.R: 16/minute
)) Temp: A/F (As Follow)
)) SpO2: 96%
)) RBS: I 06 mg/dL

Treatment notes:

Doctor on duty:

Signature:
Remarks:
 G CONSENT mR DAMA/LAMA
AMA: Against medical advice
DAMA: Discharge against medical advice
LAMA: Leave against medical advice.

WRrTEN CONSENT

I am leaving the hospital Ward/ER against medical advice. Doctor explained me about my disease
condition and ill effects of discharge against medical advice and I understand those risks.

Doctors and any hospital staffs will not be responsible for any ill effects happening after my leaving
from the medicine ward 5 JPMC Karachi".

l. Name of responsible person:

2. Relation:
3. CNIC No:
4. Signature:
5. Date:
6. Time:

Name and sign of doctor on dutv:

WRITEN CONSENT

This is to certify that I, _________________,a patient at

__________________(fill in nameof your hospital and ward), am refusing
at my own insistence and without the authorityof and against the advice of my attending
physician(s) _________________, request to leave againstmedical advice.

The medical risks/benefits have been explained to me by a member of themedical staff and I
understand those risks.

I hereby release the medical center, its administration, personnel, and myattending and/or resident
physician(s) from any responsibility for allconsequences, which may result by my leaving under these
circumstances.
J. Name of responsible person:
2. Relation:
3. CNIC No:
4. Signature:
5. Date:
6. Time:

Name and sign of doctor on duty:

 • • • • • •
••
·•
Infectious Disease
•
• • • • •• •
FEVER OF UNKNOWN ORIGIN (FUO) Rx
Definition: Fever of unknown origin (FUO) ls defined as a temperature of> 38.3°C (100.9.F) lasting for> 3 weeks
with no clear etiology despite appropriate diagnostics. Infections, malignancy, and inflammatory or rheumatic
conditions are the most frequent etiologies of FUO.
The differential includes the following:
er Infectious: TB, infective endocarditis, brucellosis, occult abscess, osteomyelitis, Q fever, complicated UTI,
catheter infections, typhoid fever, Viral infection (e.g., EBV, CMV, HIV)
"" in HIV patients, consider MAC, histoplasmosis, CMV, or lymphoma.
r:r Neoplastic: Lymphomas (HL, NHL), leukemias, melanoma, hepatic and renal cell carcinomas,
r:r Autoimmune: Still's disease, SLE, cryoglobulinemia, polyarterltis nodosa, connective tissue disease,
granulomatous disease (including sarcoidosis).
r:r Miscellaneous: Pulmonary emboli, alcoholic hepatitis, cirrhosis, drug fever, familial Mediterranean fever,
factitious fever, Subacute thyroiditis, Inflammatory bowel disease, Sarcoidosis, Post-Ml syndrome
,,. Undiagnosed (10-1S%).

Diagnosis
The initial diagnostic approach to FUO should focus on a comprehensive history (Confirm the presence of fever and
take a detailed history, including family, social, sexual, occupational, dietary, exposures (pets/animals), and travel)
and physical examination with minimal initial diagnostics to identify diagnostic clues that can guide targeted
diagnostics. If the diagnosis remains unknown, additional laboratory studies (e.g., serology, electrophoresis) and
advanced diagnostics (e.g., PET-CT, tissue biopsy) should be considered.
Labs:
,,. Obtain a CBC with differential
Clues to infective causes where unclear
» t Lymphocytes (Lymphocytosis): viral infection, rubella, infectious mononucleosis, mumps), pertussis,
brucellosis, and Chronic infections (Tuberculosis, syphilis, toxoplasmosis), HL, NHL and CLL.
» � Lymphocytes (Lymphocytopenia): Infections (sepsis, measles, miliary TB, HIV}, Legioneila, steroids.
» t White blood cells (Leukocytosis): Infections, Sepsis, Leukemia ➔ leads to increased release of premature
leukocytes into the blood (AML, ALL, CLL, CML) and Drugs (lithium)
» � White blood cells (Leukopenia): Typhoid fever, Typhus, Chikungunya infection, Zika fever, Acute HIV
infection, aplastic anemia, SLE, rheumatoid arthritis and Viral hemorrhagic fevers such as Dengue fever,
Lassa fever, Ebola fever, Crimean-Congo hemorrhagic fever, Hanta fever, Yellow fever.
» t Neutrophils (Neutrophilia): Bacterial infection (especially pyogenic, due to S. aureus, S. pneumoniae)
» � Neutrophils (Neutropenia): sepsis, viral, brucella, typhoid fever, kala-azar, TB, aplastic anemia, hepatitis
t Eosinophils (Eosinophilia): Parasites (Strongyloidiasis, Schistosomiasis, Trichinellosis), drugs (macrolides,
allopurinol), polyarteritis nodosa, Aspergillus infection, CML and Hodgkins disease
» � Eosinophils (Eosinopenia): Infections (typhoid fever, paratyphoid fever, sepsis)
» � Platelets (Thrombocytopenia): Malaria (parasites on film indicative), CML, EBV
r:r LFTs: hepatitis, cholangitis, alcoholic liver disease.
r:r Acute phase reactants: erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
r:r Urinalysis and urine culture
r:r Blood culture (three sets) if bacteremia is suspected
r:r Thyroid function test and thyroid antibodies
<r Lumbar puncture: if any suggestion of CNS infection - headache, delirium.
r:r serum protein electrophoresis
<r Sputum Gram stain and culture
<»- Tuberculosis suspected: culture urine, sputum, stool, CSF and morning gastric aspirates and PPD
<»- Specific tests (ANA, RF, CK, dsDNA, ANCA, anti-CCP, viral cultures, and viral serologies/antigen tests) can be
obtained if an infectious or autoimmune etiology is suspected.
<»- Imaging: Obtain a CXR. CT of the chest, abdomen, and pelvis should be done early in the workup of a true FUO.
Invasive testing (marrow/liver biopsy) is generally low yield. Laparoscopy and colonoscopy are higher yield as
second-line tests (after CT).

Name:
Temperature:
f::::. Enteric fever
C/C:
» Fever low then gradually
increases to 104.9 F
» Headache
» vomiting
» Weakness and fatigue
» Muscle aches
» Relative bradycardia
» Loss of appetite
» Abdominal pain
» Rash (Rose spot)
» Diarrhea
» Hepatosplenomegaly
Incubation period: 5-30 days
(most commonly 7-14 days)
Treatment duration: 7- 14 days
For severe infection, 1/V
Ceftriaxone (Titan, Rocephin)
Dose: 50-60mg/kg
Rx for Carrier: (CMDT2020)
Ciprofloxacin, 750mg PO x BO
for 4 weeks. Cholecystectomy
may also achieve this goal.
Di_unosis: Mnemonic 'BASU'
1st week: Blood culture
2nd week: Antigen test/Wida!
3rd week: Stool culture
4th week: Urine culture
Blood culture is the most
important diagnostic test at
disease onset, as stool cultures
are often negative despite
active infection.
Gold standard test is Bone
Marrow culture
Complete Blood Count {CBC)
» Anemia
» Leukopenia or leukocytosis
- Absolute eosinopenia
- Relative lymphocytosis
LFTs: maybe Abnormal
USG whole abdomen:
Hepatosplenomegaly
FIVEltflNITRIC.
Age: Sex: Date:
B.P: Pulse: Resp. Rate:
1. Tab. Ciprofloxacin 250mg, 500mg (Novidate, Ciproxen, Ciplet)
I - I - I (TDS), I - 0 - I (BO) - [Dose: 20-25mg/kg]
OR Tab. Levofloxacin 500mg x OD
Duration: 5-7 days for uncomplicated and for 10-14 days for severe
enteric infection. (Ref: CMDT 2022)
OR Cap Cefixime 400mg (Cefspan, Cefiget, Cefim)
Q-0-1 (OD), I-0-I (BO)-(Dose: C:efixime 20mg/kg]
2. Tab Paracetamol 500mg (Calpol, Febrol, Panadol)
1-1-1 (TDS)
3. Syp Lysovit OR Syp Leaderplex
2-O-2 (2tsp. two times a day)
If Epigastric upset
4. cap Omeprazole 40mg (Zoltar, Risek)
0-0-1 (OD)
�.:.;..3oc-'di.s
If Nausea/vomiting then add
5. Syp/Tab Domperidone (Motilium Syp lmg/ml, Tab 10mg) x TDS
---½ -:a.. 30 ,-, ,...;i.s
1. Tab Azithromycin 500mg (Zetro, Bectizith, Azomax)
0-0-I (OD) -(Dose: 10/kg/day x 7 days]
250mg (Ponstan, Mefnac, Dollar)
2. Tab Mefenamic acid 500mg (Ponstan fort, Mefnac OS, Dollar OS)
1-1-1 (TDS)
3. Syp Trimetable OR Syp Tresorix forte
2 - 0 - 2 (2tsp. two times a day)
� .:.;.. 30 c di.s
If Epigastric upset
4. cap Esomeprazole 40mg (Esso, Nexum)
0-0-1 (OD)
c1ri .:.;.. 30 c-' di.s
If Nausea/vomiting then add
5. Syp/Tab Domperidone (Motilium Syp lmg/ml, Tab 10mg) x TDS
-
c1ri .:.;.. 30 c-' ,::-ii+$
Prevention: Salmonella infection is best prevented by protecting the water
supply, preventing fecal contamination during food production, cooking and
refrigerating foods, pasteurizing milk and milk products, and handwashing
before preparing foods.
 SYPHIJSllx
Name: Age: Sex: Date:
Temperature: B.P: Pulse: Resp. Rate:
Pathogen: Treponema pallidum: gram-negative, spiral-shaped bacteria belonging to the spirochete family
Transmission: Sexual contact (via small mucocutaneous lesions), Vertical (Placenta from mother to fetus)
er Primary syphilis
» Painless LN + painless indurated genital ulcer (hard chancre)
» Most common site of ulcer is genitalia > mouth, nipple
» VDRL negative - Antibodies take 2-3 months to develop
cr Secondary syphilis: highly infectious stage
» Constitutional symptoms:
• Generalized painless inguinal lymphadenopathy
• Fever, fatigue, myalgia, headache
» Diffuse, maculopapular rash that involves the palms and soles
» Condyloma lata at mucocutaneous junction
» Additional lesions: Patchy alopecia (moth-eaten alopecia), Sore throat (acute syphilitic tonsillitis)
» All the serological tests are 100% positive
er Tertiary/Latent syphilis: No clinical symptoms, diagnosis by serology only.
er Quaternary syphilis:
» CVS: aortic aneurysm, aortic regurgitation
» Neuro-syphilis: Cerebrospinal fluid examination (CSF) evaluation recommended in all patients
1. Meningovascular: Stroke, neuropathies
2. General paresis of insane: Dementia, Psychosis
3. Argyll Robertson pupil: pupil constricts with accommodation but is not reactive to light
4. Tabes Dorsalis: Numbness, Muscular weakness
Diagnostics
er Serological test - VDRL & RPR test become positive 4-6 weeks after infection or 1-3 weeks after the
appearance of a primary lesion- maybe used for secondary, tertiary and quaternary syphilis
er Investigation of choice for Primary early syphilis: Dark field Microscopy (up to 90% sensitivity)
er Late diseases: TPA ➔ Detection, Alternative T.Pallidum polymerase chain reaction (PCR)

Primary, secondary. or early latent syphilis (<1 year}

cr lnJ. Benzathine penicillin G 2.4 million units (Benzibiotic) x Intramuscularly (IM) x once only
Alternative:
» Cap. Doxycycline 100mg (Vibramycin, Doxyn) x I - 0 - I (BO) x for 14 days
(+/-) Tab. Metronidazole 400mg (Klint, Flagyl) x TDS
» Or lnj. Ceftriaxone lg (Titan) x IM/IV x daily for 8-10 days

Late latent or uncertain duration (or >1 year}/ Tertiary without neur osyphllis

cr lnj. Benzathine penicillin G 2.4 million units (Benzibiotic) x IM x once weekly for 3 weeks
Alternative
» Cap. Doxycycline 100mg (Vibramycin, Doxyn) x I - 0 -1 (BO) x for 28 days
» (+/-) Tab. Metronidazole 400mg (Klint, Flagyl) x TDS

Symptomatic or asymptomatic neurosyphilis

cr lnj. Aqueous penicillin-G 18-24MU x IV x given every 4 hourly or as continuous infusion for 10-14 days
Alternative
» Procaine penicillin, 2.4 million units. x IM x daily
Plus Tab. Probenacid 500mg orally four times daily for 11r14 days
» Or lnj. Ceftriaxone 2g (Titan) x IM/IV infusion x daily for 10-14 days
 • •
•
• • •• •
••
• •
Pulmonology
• • • • •• • •

Name: Age: Sex: Date:

Temperatu(e: B.P: Pulse: Resp. Rate:

6_ Upper RTI
C/C:
» Cough (dry) 1. Tab. Co-Amoxiclave 625mg, lg (Augmentin, Calamox)
» Sore throat I - I - I, I - 0- I (625mg = TDS, lg= BD)
» Runny nose Or Tab. Azithromycin 500mg (Macrobac, Azomax, Zetro)
» Nasal congestion Or Tab. Levofloxaein 500mg (Leflox, Levoxin)
» Headache 0-0-1 (OD)
» Low-grade fever
» Facial pressure 2. Syp. Cough suppressants (Hydrillin OM, Reltus DM, Corex-0)
» sneezing 2 Teaspoonful x TDS

Investigation: 3. Tab. Loratidine 10mg (Softin, Lorin NSA, Loril)

» CBC
» Chest X-ray (CXR) P.A view
» Rule out COVID-19 if suspected
send Covid protocol test
Or Tab. Fexofenadine 60mg or 120mg (Fexet, Telfast, Fexo)
0-0-1 (OD)
4. Tab. Paracetamol (Panadol, Calpol, Febrol)
I - I - I, if high fever than 2 - 2 - 2 (1-2 Tablets x TD$)

Name: Age: Sex: Date:

Tern erature: B .P: Pulse: Res . Rate:

6. LowerRTI
C/C:
» Fever 1. Tab. Co-Amoxiclave 625mg, lg (Augmentin, Calamox)
» Cough with Sputum production I - 1-1, I -0-1 (625mg = TDS, lg= BO)
» Post nasal drip Or Tab. Clarithromycin 500mg (Claritek, Klaricid)
» Rapid breathing or difficulty 1-0-1 (BO)
breathing. Or Tab. Azithromycin 500mg (Macrobac, Azomax, Zetro)
» Wheezing Or Tab. Levofloxacin 500mg (Leflox, Levoxin)
» Skin turning a blue color due to Or Cap. Cefi><ime 400mg (Cefim, Cefspan, Cefiget)
lack of oxygen. 0-0-1 (OD)
» Chest pain or tightness
2. Syp. Cough suppressants (Hydrillin, Corex-0, Cofrest)
Investigation: 2 Teaspoonful x TDS
» CBC
» Urea, creatinine and electrolytes 3. Tab. Loratidine 10mg (Softin, Lorin NSA, Loril)
» ESR Or Tab. Fexofenadine 60mg or 120mg (Fexet, Telfast, Fexo)

-
» Chest X-ray (CXR) P.A view 0-0- I (OD)
» Sputum culture Fexofenadine should.be .used with.caution.along_ with Azithromycin
» Rule out COVID-19 if suspected because combination.will.increased_ the.risk.ofQ..T prolong_ation
send Covid protocol test
4. Tab. Paracetamol (Panadol, Calpol, Febrol)
I - I - I, if high fever than 2 - 2 - 2 (1-2 Tablets x TDS)
 COMMUNITY-ACQUIRED PNEUMONIA (CAP) OUTPATIENT (OPD) Rx
Name:
Temperature:
D,.CAP
C/C:
Typical pneumonia: It is characterized by a
sudden onset of symptoms caused by lobar
infiltration.
)) Severe malaise
)) High fever and chills
)) Productive cough with purulent sputum
(yellow-greenish)
Crackles and bronchial breath
sounds on auscultation
- Decreased breath sounds
- Enhanced bronchophony,
egophony, and tactile fremitus
» Dullness on percussion
» Tachypnea and dyspnea (nasal flaring,
thoracic retractions)
» Pleuritic chest pain when breathing,
often accompanying pleural effusion
» Pain that radiates to the abdomen and
epigastric region (particularly in children).
Atypical pneumonia: typically has an
indolent course (slow onset) and commonly
manifests with extrapulmonary symptoms.
)) Nonproductive, dry cough
)) Dyspnea
)) Auscultation often unremarkable
)) Common extrapulmonary features
include fatigue, headaches, sore throat,
myalgias, and malaise
....... ·- -·
Diagnosis
Pneumonia is a clinical diagnosis based on
history, physical examination, laboratory
findings, and CXR findings. Consider
microbiological studies and advanced
diagnostics based on patient history,
comorbidities, severity, and entity of
pneumonia.
Laboratory findings:
» CBC: Leukocytosis
» Inflammatory markers: 1' CRP, 1' ESR
» 1' Serum procalcitonin (PCT): PCT is an
acute phase reactant that can help to
Age: Sex: Date:
8.P: Pulse: Resp. Rate:
Criteria for hospitalization
, Every patient should be assessed individually and clinical judgment
"
is the most important factor.
The pneumonia severity index (PSI) and the CURB-65 score are
tools that can help to determine whether to admit a patient.
CURB-65 score
)) Confusion (disorientation, impaired consciousness) 1
)) Serum Urea> 7 mmol/L (20 mg/dl) 1
)) Respiratory rate �30/min 1
)) Blood pressure: systolic BP s 90 mmHg or diastolic BP s 1
60 mmHg
)) Age� 65 years 1
Interpretation: Each finding is assigned 1 point.
» CURB-65 score O or 1: The patient may be treated as an outpatient.
» CURB-65 score�2: Hospitalization is indicated.
» CURB-65 score� 3: Consider ICU level of care.
,. Pneumonia severity index (PSI/PORT score)
)) Patients are assigned to one of five risk classes based on a
more complex point system than in CURB-6.
)) Points are distributed based on patient age, comorbidities, and
lab results.
Criteria for ICU admission
r
The decision of whether to admit a patient to the ICU should be based on
clinical Judgment.
-,- The IDSA/ATS criteria for severe CAP can be used to help triage patients
with CAP and guide empiric antibiotic treatment decisions.
IDSA/ATS criteria for severe CAP
•Th• lnf..,..IN,< ni..-• c-,_, of America (ln<:.&I & .... A-• •., Thnr.arir c-•-• tATSl
"""
Major criteria ) Septic shock/need for vasopressors
) Mechanical ventilation
Minor criteria ) Confusion
) Body temperature< 36° C
) Hypotension requiring fluid resuscitation
) Respiratory rate� 30/min
) PaO2/FiO2 S 250
) Leukopenia (WBC< 4,000/mm3)
) Thrombocytopenia (platelet count< 100,000/mm3)
) BUN � 20 mg/dl
) Multilobar infiltrates
Interpretation
Severe CAP: one major criterion or� 3 minor criteria
 diagnose bacterial lower respiratory tract
infection.
» ABGs: -.!-Pa02 , deranged LFTs & Urea,
creatinine & electrolytes.
Chest x-ray (PA & lateral view)
Indications: all patients suspected of having
pneumonia
Findings
» Lobar pneumonia
- Opacity of 1 or more pulmonary lobes
- Presence of air bronchograms:
appearance of translucent bronchi inside
opaque areas of alveolar consolidation
» Bronchopneumonia
- Poorly defined patchy infiltrates
scattered throughout the lungs
- Presence of air bronchograms
» Atypical or interstitial pneumonia
- Diffuse reticular opacity
- Absent (or minimal) consolidation
» Parapneumonic effusion
Chest CT (usually without contrast)
Adv antages: more reliable evaluation of
circumscribed opacities, pleural empyema,
or sites of consolidation
Indications
» Inconclusive chest x-ray
» Recurrent pneumonia
» Poor response to treatment
.,,. Duration of treatment: 5 to 7 days of
therapy is usually sufficient.
COMMUNITY-ACQUIRED PNEUMONIA (CAP)
Previously healthy patients without comorbidities or risk factors for
resistant pathogens
Cap. Amoxicillin 500mg x 2 (Amoxil) lg x Three time daily (TDS)
Or cap. Doxycycline 100mg (Vibramycin, Doxyn) x two time daily
Or Tab. Azithromycin 500mg (Azomax) x 500mg on day-1,
followed by 250mg once daily for 4 days or 500mg OD for 3 days.
Or Tab. Clarithromycin 500mg (Claritek, Klaricid) x two time daily.
Patients with comorbidities or risk factors for resistant pathogens
Single therapy (Monotherapy): with a Resp. fluoroquinolone
» Tab. Levofloxacin 750mg (Leflox) x once daily
» Or Tab. Moxifloxacin 400mg (Avelox, Moxiget} x once daily
» Or Tab. Gemifloxacin 320mg (Grat, Gemi) x once daily
Combination therapy
» Tab. Amoxicillin/clavulanic acid lg (Augmentin) x 8D
» Or cap. Cefuroxime 250mg (Zinacef, Zecef) x 500mg x BD
» Or Tab. Cefpodoxime 200mg (Prelox, Orelox) x 8D
PLUS one of the following:
» Or Cap. Doxycycline 100mg (Vibramycin) x two time daily
» Or Tab. Azithromycin 500mg (Azomax) x 500mg on day-1,
followed by 250mg OD for 4 days or 500mg OD for 3 days.
» Or Tab. Clarithromycin 500mg (Claritek, Klaricid) x 8D
r Supportive treatment
» Supportive c are: Adequate hydration, nutrition, and rest
» Anti-tussive: Syp. Corex-D or Syp. Pulmonol or Syp. Hydrillin
» Fever: Tab. Paracetamol 500mg (Panadol) x 1-2 x TDS
» Calcium/vitamins supplement: Abocal or CAC-1000 x: daily
» Antihistamine: Tab. Fexofenadine 120mg x OD

Left upper lobe pneumonia

Right lung opacity Right upper lobe pneumonia Chest x-ray (PA view): A large,
homogeneous opacification (green
X-ray chest (PA view): Chest x-ray (PA view): overlay) can be seen over the left

An ill-defined area of opacification in
the lower right lung extends inferiorly
to obscure part of the margin of the
right hemidiaphragm.
Source: © IMPP
There is heterogeneous right upper
lobe consolidation with air
bronchograms.
Source: © IMPP
-
upper lobe. It is also obscuring the left
heart border and left pulmonary
vessels.
This appearance is typical of airspace
consolidation due to left upper lobe
pneumonia.
 LUNG ABSass Rx
Name: Age: Sex: Date:
Temperature: B.P: Pulse: Resp. Rate:
Definition: Suppurative inflammation of lung tissue within normal parenchyma ➔ result of autodigestion of tissue by
inflammatory cells
Etiology
1. Most often a result of Risk factors
» Aspiration of oropharyngeal material
1. Poor oral hygiene
» Bronchial obstruction. e.g. cancer
,, sequela of bacterial pneumonia 2. Impaired swallowing
2. Common pathogens include Bacteroides, Peptostreptococcus, 3. lmmunosuppression
Fusobacterium 4. Altered consciousness includes
3. Less commonly: monomicrobial fung abscess caused bys. aureus, » Seizures
K.pneumoniae, Strept.pyogenes, Strept.anginosus » Dementia
4. More often seen in the right lung than the left ➔ result of wider and » Alcoholism
straighter right mainstem bronchos
5. if multiple foci present the cause is most likely hematogen.ous spreading

L
C/C:
Indolent presentation with <7r Admit the patient and start immediate empiric antibiotic therapy
symptoms that evolve over weeks (after obtaining samples for culture).
to months er Consider th@ following consults as appropriate: Pulmonary,
» Fever, Malaise Infectious disease and cardiothoracic surgery or interventional
» Cough with production of foul- radiology for patients with large abscesses.
smelling sputum Ci/" Identify and treat the underlying cause.

» Anorexia, weight loss
» Night sweats
» Hemoptysis
Diagnostics
Chest X-ray or CT): irregular
rounded cavity with an air-fluid
level that is dependent on body
position (most commonly in the
right lung)
» Upright position: right lower
lobe
» Recumbent position: right
upper or middle lobe
CBC: WBC ( 1' 1' 1')
Gram stain
Sputum culture and sensitivity
c:,, Empiric antibiotic therapy for bacterial lung abscess
► No risk factors for MRSA infection
Any one of the following:
» lnj. Ceftriaxone lg (Rocephin, Titan) x IV x BD
PLUS lnj. Metronidazole 500mg/100ml (Flagyl) x IV x TDS
» Or lnj. Ampicillin-sulbactam l.Sg to 3g (Ambac) x IV x TDS
» Or lnj. Moxifloxacin 400mg/250ml (Moxiget, Mofest) x OD
» Or lnj, Ertapenem lg (lnvanz, Ernem) x IV x OD
» Or lnj. Clindamycin 600mg x IV x 8hourly then 300mg x PO x
8 hourly (be cautious for C. difficile infection)
► Suspected MRSA Infection
Any one of the following:
» lnj. linezolid 600mg/300ml (Nezkil, Ecasil) x IV x BO
» Or lnj. Vancomycin 500mg x IV x TDS
,,,. lnterventional therapy
► Indications
» Large abscess
» Significant hemoptysis
» Inadequate response despite appropriate antibiotic therapy,
characterized by:
» Persisting fever and/or purulent sputum
» Inadequate signs of resolution on imaging
► Options
» First line: bronchoscopic drainage or image-guided
percutaneous drainage
» Rarely: surgical resection (segmentectomy, lobectomy,
pneumonectomy)
 • • • • •• •
•
•

CHAPTER- 7

• • • • •• •

EVALUATION TO THE MANAGEMENT OF HYPERTENSION RX

1. Definition: Hypertension, defined as a Systolic Blood Pressure greater than 120mmHg or a Diastolic Pressure
greater than 80mmHg, occurs in 20% to 40% of the population. The.2017 American. College of Cardiology
!,ACCI/American.Heart Association. {AHA)_guidelines define guidelines define it as a blood pressure of 2:
13 0/80 mm Hg and by .�!ghth.J2im..�..,,t[9_r:,_.,_1,�gmm.in�.�--UN�:.�U.c;rJ.ti:. l.,. as 2:140/90 mmHg.
. �
2. Types of Hypertension:
)) Primary (Essential) hypertension: ~90% of cases of hypertension & has no detectable cause (idiopathic)
)) Secondary hypertension occurs secondary to another disease process (e.g., Renal, endocrine disorder
and vascular diseases) in approximately 5% to 10% of patients.
3. Clinically, hypertension is usually asymptomatic until organ damage occurs, which commonly affects the
brain, heart, kidneys, and/or eyes (e.g., retinopathy, myocardial infarction, stroke). If present, early
symptoms of hypertension may include headache, dizziness, tinnitus, and chest discomfort.

AHA/ACC 2017 B.P Categories

B.P Category Systolic Blood Pressure (mm Hg) Diastolic Blood Pressure (mm Hg)
Normal blood pressure <120 <80
Elevated 120-129 < 80
Stage 1 hypertension 130-139 80-89
Stage 2 hypertension 2: 140 2:90

JNC-8 B.P categories

BP Category Systolic Blood Pressure (mm Hg) Diastolic Blood Pressure (mm Hg)
Normal blood pressure <120 <80
Pre-Hypertension 120-139 80-89
Stage 1 hypertension 140-159 90-99
Stage 2 hypertension 2: 160 2:100
GENERAL APPROACH
<Ir' Screen patients using in-office blood pressure measurement.
�- Confirm elevated values with ABPM or HBPM.
Qr Perform a thorough physical examination and obtain initial laboratory studies.
)) Stratify patients by cardiovascular risk (using the ASCVD risk estimator tool).
)) Evaluate for target organ damage.
or Consider diagnostic workup for secondary causes of hypertension in patients with:
)) Abnormalities identified during evaluation for newly diagnosed hypertension
)) Signs suggestive of secondary hypertension

SCREENING FOR HYPERTENSION

QI"' Indications
)) Annual screening
• Individuals> 40 years of age
• Adults of any age with risk factors for primary hypertension
)) Screening Every 3-S years: individuals 18-39 years of age with previously normal blood pressure (<
13 0/85 mm Hg) and no risk factors
<Ir Method: in-office blood pressure measurement
 » Urine analysis: Proteinuria, hematuria (signs of glomerular injury)
» If Diabetic: FBS, RBS, HBAlC, Fasting Lipid profile and Urine for micro-albumin
» ECG: LVH, signs of cardiac ischemia (e.g., ST depressions or elevations)
» Echocardiography: LVH
» Chest x-ray: to rule out cardiomegaly, pulmonary edema
» Consider CT Brain - if neurological symptoms are present.

OUTPATIENT APPROACH TO THE MANAGEMENT OF HYPERTENSION

Indications for Anti-Hypertensive treatment: The thresholds for pharmacological treatment are controversial.
The following recommendations are based on the 2017 ACC/AHA guidelines.
cr Adults with Systolic BP�130mmHg or Diastolic BP� S0mmHg and� 1 of the following:
� Clinical Atherosclerotic Cardiovascular Disease(ASCVD): lschemic heart disease, peripheral artery
disease, or previous stroke
� Congestive heart failure (CHF)
� 10-year ASCVD risk�10%; (based on the ACC/AHA Pooled Cohort Equations; includes age� 65 years and
diabetes mellitus)
r.11" All adults with Systolic BP� 140 mmHg or Diastolic BP �90 mm Hg

Choice of initial medication should be based on the following:

<r Patient's initial blood pressure:
» Systolic BP 130-139mmHg or Diastolic BP 80-89mmHg (Stage-1 Hypertension): Consider initial
monotherapy ➔ Begin therapy with one primary antihypertensive.
» Systolic BP� 140 mmHg or Diastolic BP� 90mmHg AND an average blood pressure > 20/10 mm Hg above
target (>160/100 mmHg) ➔ Begin therapy with two primary antihypertensives.
,,,. Life style modifications for all patients with SBP >120mmHg or DBP > 80mmHg

CHOICE OF ANTI-HYPERTENSIVE MEDICATION

ALL OTHER PATIENT AGE< 55 YEARS:
1. First-line treatment: ACE inhibitor (Lisinopril, Captopril, Enalapril) or ARB (Valsartan, Telmisartan,
Losartan) or CCB (Amlodipine, Nifedipine) or Diuretic (Thiazide type)
2. Second-line treatment: Vasodilating Beta blockers (Carvedilol, Labetolol, Nebivolol)
er ALL OTHERS PATIENT AGE> 55 YEARS:
1. First-line treatment: CCB (Amlodipine) or Diuretic
2. Second-line: ACE inhibitor or ARB or vasodilating beta-blocker (Carvedilol, Labetolol, Nebivolol)
er If BP not respond to single therapy advice combine drugs: ACEI or ARB+ CCB or Diuretics (Thiazide)
» Amlodipine + Valsartan (Exforge, Newday, Dioplus)
» Amlodipine + Perindopril (Amlod-P, Coversam)
er If not controlled with Combine two drugs (ACEI/ARB+ CCB), add Diuretics (Thiazidel
- Amlodipine + Valsartan + Hydrochlorothiazide (Exforge-HCT, Avsar Plus, Co-Extor)
cr For Resistant hypertension: Uncontrolled Hypertension with three classes of anti-hypertensive drugs and
the drug should include 'Thiazides',
» For example PATIENT ON ACEI/ARB + CCB + THIAZIDES and BP still not controlled then ADD ALPHA­
BLOCKER OR VASODILATING BETA BLOCKER

cr In adults with Chronic Kidney Disease (CKD): Initial (or Add-On) treatment should include an ACE inhibitors
or ARBs to improve kidney outcome.
11> Do not combine an ACE inhibitor with an ARB to treat hypertension (NICE-2019)
 ALL OTHERS PATIENT, AGE <55 YEARS

1. Life style modifications for managing hypertension

<1r A diet rich in fruits, vegetables, and low-fat dairy foods and low in saturated and total fats (DASH diet)
has been shown to lower blood pressure. Increased dietary fiber lowers blood pressure
CJf Decrease dietary sodium: Daily salt intake <1500 mg
<I' 1- Dietary Potassium: Daily potassium intake 3.S-5g (preferably by increasing fruit & vegetable intake)
<1r Decrease alcohol Intake, provide counseling on alcohol use disorder, if necessary.
� Dally Regular Exercise: 20-25 minutes per day or 150 minutes per week
..,. Weight loss: Target BMI 18.5-24.9
er Smoking cessation should be advised in all patients to reduce ASCVD risk.

2. Choice of Anti-Hypertensive Agent:

� First-line treatment: ACE inhibitor or ARB or CCB or diuretic
� Second-line treatment: Vasodilating Beta blockers

ACEls_Based Treatment ARBs Based Treatment

,.,, Tab. Lisinopril 5mg or 10mg (Zestril) " Tab. Valsartan 80mg, 160mg, 320mg (Exforge, Diovan)
» Initial oral dose 5mg upto 10mg x once daily » Initial oral dose 80mg x once daily
» Dosage Range: 5-40 mg once daily » Dosage Range: 80-320mg once daily
vr Or Tab. Enalapril 5mg or 10mg (Renitec, Cortec) s Or Tab. Telmisartan 20mg, 40mg (Telsarta, Tasmi)
» Initial oral dose 5mg x once daily » Initial oral dose 40mg x once daily
» Dosage Range: 5-40mg in 1 or 2 doses » Dosage Range: 40-80mg once daily
,,. Or Tab. Captopril 25mg or 50mg (Capoten, Capril) ,. Or Tab. Losartan 50mg or 100mg (Eziday, Cozaar)
» Initial oral dose 25mg x twice daily » Initial oral dose 50mg x once daily
» Dosage Range: S0-450mg in 2 or 3 doses » Dosage Range: 50mg up to 100mg once daily

ALL OTHERS PATIENT, AGE> 55 YEARS

1. Life style modifications for managing hypertension (Mention Above)

2. Choice of Anti-Hypertensive Agent

� First line: CCB or Diuretic
� Second line: ACE inhibitors or ARB or vasodilating Beta-Blocker

<r Tab. Amlodipine 5mg or 10mg (Norvasc, Sofvasc)

» Initial dose 2.5mg x once daily
» Dosage range: 2.5 upto 10 mg once daily
er Or Tab. Nifedipine 30mg (Adalat LA)
» Initial dose 30mg once daily
» Dosage range: 30-90mg ER once daily
 • • • ••• •
••
•
CH GIT & Liver •
• • • • •• • •

APPROAOI TO MANAGEMENT NAUSEA& VOMff:ING Rx

Name: Age: Sex: Date:
Temperature: 8.P: Pulse: Resp. Rate:

6_ Nausea/vomiting Inpatient Treatment

C/C:
Red flags for nausea and vomiting <r ABCD&E survey
� Abdominal ar Maintain intravenous line (IV cannula)
» Persistent vomiting - Keep patient NPO and Consider NPO diet.
» Hematemesis ar A nasogastric suction tube for gastric or mechanical small bowel
» Feculent vomiting obstruction improves patient comfort and permits monitoring of
» Melena
fluid loss.
» Hematochezia er Perform screening examination and targeted diagnostics to rule out
» Acute and/or severe abdominal
pain life-threatening & other causes (see below table).
er Once life-threatening causes have been ruled out:
» Progressive dysphagia
» Unintentional weight loss » Conduct a detailed patient history and clinical examination.
<r Neurologic » Consider further diagnostic testing.
» Altered mental status ar Identify and treat hypovolemia: lnj. 0.9% Normal saline
» Focal neurological deficit <r Identify and treat electrolyte imbalance: IV 0.45% NS with 20 mEq/L
» Meningeal signs of potassium chloride is given in most cases to maintain hydration.
<r Pulmonary/cardiovascular <r Identify and treat acid-base disorders.

» Dyspnea ar Identify and treat the underlying cause.

» Chest tightness <r Minimize or discontinue any contributing medications.

» Feeling of impending doom or Administer antiemetic therapy.

» lnj. Metoclopramide 10mg/2ml (Metaclon) x IV/IM x
Immediately life-threatening causes stat/every 6-8 hourly.
� Hemorrhagic stroke » Or lnj. Dimenhydrinate 50mg/1ml (Gravinate) x IV/IM x
� CNS infection: meningitis, encephalitis stat/every 6-8 hourly. (Maximum 400mg/day)
� Myocardial infarction » If not controlled/severe/Postoperative/chemotherapy induced
� Acute pancreatitis vomiting, consider:
� Bowel obstruction lnj. Ondansetron 8mg/4ml (Onset, Onseron) x dilute in 100ml
� Bowel perforation 0.9% N/S x IV x Stat
� Diabetic ketoacidosis » Consider lnj. Dexamethasone 4mg/ml (4-8mg) x IV x stat
� Adrenal crisis
� Drug overdose/withdrawal
� Poisoning (ingestion of toxins) Outpatient Treatment

Investigation:
» Routine Investigation: CBC, ESR, Serum
glucose, Urea, creatine & electrolytes,
LFTs, Beta HCG urine test.
» In patients with severe and sustained
vomiting: ABGs and Urine ketones.
» Specific Ultrasound & X-Ray according
to localization of symptoms
» Further diagnostic testing to consider
based on localization of symptoms
r:r General measure: Most causes of acute vomiting are mild, self­
limited, and require no specific treatment. Patients should ingest
clear liquids (broths, tea, soups, carbonated beverages) and
small quantities of dry foods (soda crackers). Ginger may be an
effective non-pharmacologic treatment.
Pharmacological Treatment
a- Tab. Dimenhydrinate 50mg (Gravinate)
Or Tab. Metoclopramide 10mg (Metaclon, Maxolon)
Or Tab. Prochlorperazine 10mg (Stemetil)
Or Tab. Domperidone 10mg (Motilium, Domel)
1-1-1 (TDS)
If not controlled/severe/Postoperative/chemotherapy induced
vomiting, consider:
<It> Tab. Ondansetron 4mg (Onset, Onseron) x 4-8mg twice daily
Name:
Temperature:
GERO
C/C:
Typical symptoms
» Retrosternal burning pain (heartburn) that
worsen while lying down (at night/after eating)
» Regurgitation
» Dysphagia, odynophagia
» Water brash: symptom of excessive salivation
triggered by refluxing of stomach acid
Atypical symptoms
» Pressure sensation in the chest/non-cardiac
chest pain
» Belching, bloating
» Dyspepsia, epigastric pain
» Nausea, Halitosis
Extra-esophageal symptoms
» Chronic non-productive cough and nighttime
cough
>) Hoarseness
» Dental erosions
Aggravating factors
» Lying down shortly after meals
» Certain foods/beverages
Treatment Duration: 6-8 weeks
Investigation:
1. Upper endoscopy: UGO ➔ Age .:60 years,
atypical symptoms, or alarm features (Anemia
dysphagia, odynophagia , Barret esophagus)
2. 24 hour Esophageal pH monitoring
3. Esophageal manometry
Treatment with PPls:
Standard dose of PPI for 8 weeks.
» Continuous management (based on the
clinical response after 8 weeks)
- Good.response and no.complications:
Discontinue PPL
- Good.response in patients with
complications: Continue PPI at
maintenance dose.
- Partial response: Increase dose (to twice
daily therapy), adjust timing, or switch to a
different PPL
- Recurrence of symptoms after
discontinuation of PPI or during weaning:
Consider confirming the diagnosis (e.g .,
with ambulatory esophageal pH
monitoring) prior to continuing
maintenance therapy
- No response: further diagnostic evaluation
» There is controversy surrounding the risks of
long-term PPI therapy
Age: Sex: Date:
B.P: Pulse: Res . Rate:
1st line Rx with/without Metoclopramide
1. Life-style modification: There is conflicting evidence as to
which lifestyle modifications confer a significant benefit. The
following recommendations are commonly mentioned in the
literature but should be approached on a case-by-case basis, as
they may offer relief only for some patients.
<I"" Dietary recommendations
» Small portions
» Avoid eating at least 3 hours before bedtime.
» Avoid foods/beverages that appear to trigger symptoms
<r Physical recommendations
» Weight loss in patients with obesity
» Elevate the head of the bed (10-20 cm) for patients
with nighttime symptoms.
r Reduce or avoid triggering substances
)> Nicotine, alcohol, caffeine if the patient experiences a
correlation with symptoms
)> Drugs that may worsen symptoms: E.g., CCBs, diazepam
2. Cap. Esomeprazole 20mg, 40mg (Nexum, Esso)
Or Cap. Dexlansoprazole 30mg, 60mg (Razodex, Desktop)
1-0-1 (BO), 0-0-1 (OD)
c1tt�30�.24S
3. Tab. Metoclopramide 10mg (Metoclon, Maxolon)
1-1-1 (TDS)
c1tt�30��
4. Syp. Antacids (Hilgas, Gaviscon Advance, Mucain)
2 teaspoonful at bed time x HS or BO
2nd line Rx PPls, consider adjunctive prokinetic
1. life-style modification
2. Tab. Pantoprazole 20mg, 40mg (Zopent, Protium)
Tab. Vonoprazan 10mg, 20mg (Vonozan, Voniza)
I -0- I {BD), 0-0- I (OD)
1..�30 �C":4S
c-r;
3. Tab. ltopride 50mg (Ganaton, Nogerd)
Or Tab. Levosulpride 25mg or 50mg (Levopra id, Sci pride)
Two times a day {BO)
c1tt� 30� C"4S
+/- {Rx mostly in psychogenic dyspepsia/Depression)
4. Cap. Fluoxetine 20mg (Flux, Depex)
Or Tab. Escitalopram 5mg or 10mg ( Estar, Citanew)
�· c::-c""
< • •.u C·
...,_,. -rY
I 't ...5..,\
-
One tab after breakfast (OD)
Temperature:
L OPD management
C/C:
» Abdominal pain/spasm
» Inability to defecate for days or
weeks
» Normal bowel sounds
» Distended, tympanitic abdomen
Digital Rectal Examination: hard,
impacted stools distending the
rectum
US whole abdomen & Pelvis
Abdominal x-ray erect & supine (to
rule out bowel perforation)
Findings:
» Dilated bowel loops
» Fecal shadows in the colon and
rectum
» Air-fluid levels may be visible.
Investigation:
» CBC
» Urea, creatinine & electrolytes
Dosage/Warnings of Enema
» Using more than one enema in
24 hours can be harmful.
» Not for more than 3 days
» Use in caution: kidney disease
and heart diseases, > 55 years
Contraindication of enema
1. Rectal bleeding/piles/fissure
2. Gastric/intestinal bleeding
3. Acute inflammation and
ulcerous in the colon or anus
4. Pregnancy
5. Rectal cancer
6. Intestinal perforation
Indication of enema
» Treat constipation.
» Treat impacted bowels.
» Clean the bowel.
» Prep for surgery.
» Prep for x-rays.
» Prep for endoscopy.
Pulse: Resp. Rate:
� Identify and treat any underlying conditions
" Lifestyle changes:
» High-fiber diet
» Increased water intake: 8-10 glass per day
» Regular Exercise on daily basis
1. Syp Lactulose (Lilac, Duphalac)
15ml to 60ml 4-6hourly then 30ml x PO x OD
OR sodium Picosulphate (Tab/Syp. Laxoberon, Tab/drops
Conspic)
If Diabetic Tab Laxoberon OR Drops/Tab. Skilex
2. Tab. Drotaverine 80mg (Nospa forte, Relispa forte)
3. Psyllium husk (lsphaghol)
0-0-1 (HS)
If epigastric discomfort/pain
4. Cap. Omeprazole 40mg (Risek, Zoltar)
0-0-1 (OD)
c3tt.:.....3oc�4S
ER management of Constipation
1. Admit in ER
2. Pass IV cannula
3. Send initial investigation: US whole abdomen, X-ray abdomen
erect and supine, CBC and Urea, creatinine & electrolytes (UCE).
4. lnj. Drotaverine 40mg (Nospa) diluted in 100ml 0.9% NS x IV
5. lnj. Ketorolac 30mg (Toradol) dilute in 4 ml 0.9% NS x IV slow
If not respond or severe pain than
lnj. Tramadol 100mg/2ml (Tramol) PLUS inj. Dimenhydrinate
50mg/1ml (Gravinate) dilute in 100ml 0.9 Normal Saline x IV
6. Correction of electrolytes imbalance
7. Rule out intestinal/rectal pathology first
8. Enema of Sodium Biphosphate 19.2g + Sodium Phosphate 7.2g
(Kleen Enema, Fleet Enema) ➔ works by increasing water in the
intestine to hydrate and soften the stool and help produce a
bowel movement without pain or spasm.
» Apply Fleet or Kleen Enema solution rectally while lying
down on your left side position or in a knee-chest position.
» Applicator tips for Kleen Enema are lubricated with
petroleum jelly for ease of insertion into the rectum.
» Attempt to hold the enema solution until the urge to
evacuate is strong, but no longer than 10 minutes.
Do not force the enema tip into rectum as this can cause injury
 • • • ••• •
••
•
Endocrinology •
• • • • • • •

TYPE-1 DIABETES MALLmJS (OM TYPE-I) Rx

INSULIN & DIABETES MELLJTUS

" Oral hypoglycemic drugs should be avoided in Type-I DM patients and should not be used during pregnancy
and breast-feeding.
,,. Insulin is always indicated in a patient who has been in ketoacidosis (Regular insulin only), and in most
young patients who usually have Type-I DM.
� Insulin is also indicated in older or Type-2 DM patients when oral anti-diabetic drugs cease to be effective.
ar Insulin is always safe in pregnancy as well in breast feeding.
""" The starting dose of any long-term treatment for diabetes must initially be low. with increments in the dose
over several days or weeks according to results of blood glucose testing
,.,,. Hypoglycemia is a potential side-elTect with all oral anti-diabetic drugs (except Metformin) and Insulin
rr Insulin therapy should usually begin with teaching the patient the correct technique for subcutaneous
injections, as self- injections are to be strongly encouraged.
.
,.,, Patients should be made aware of the different appearance of dilTerent kinds of insulin (soluble/regular which
is fast-acting= gin clear; NPH or Lente which arc intermediate-acting= cloudy: pre-mixed insulin
preparations containing both soluble and NPH insulin = cloudy)
er Cloudy Insulin's (Intermediate-acting OR Pre-mixed) can only be given subcutaneously and SHOULD NOT
be injected IM OR IV. Only soluble/regular insulin ma> be given by the IM OR IV route during emergency
treatment.
� NPII doses should be administered in addition to usual basal insulin in patients who arc already receiving
insulin.
r:r Patients should be made aware of the strengths of insulin and the kind of syringes to be used. To avoid
confusion, I 00 Units/ml insulin must be administered ONLY wilh 0.3 ml, 0.5 ml or I ml Units-I 00 syringes
(Insulin Syringe) calibrated for this strength of insulin.
""" Do not share needles, insulin pens, or syringes with others. Do NOT reuse needles.
QI'"
Before starting Lantus, tell your doctor about all your medical conditions, including if you have Iivcr or
kidney problems, if you are pregnant or planning to become pregnant or if you are breast-feeding or planning
to breast-feed.
<#' Change (rotate) your injection sites within the area you chose with each dose to reduce your risk of getting
pitted or thickened skin (lipodystrophy) and skin with lumps (localized cutaneous amyloidosis) at the
injection sites. Do not use the same spot for each injection or inject where the skin is pitted, thickened, lumpy,
tender, bruised, scaly, hard, scarred or damaged.
e1r Insulin's currently available in PAKISTAN are preferably injected 15-30 minutes before a meal.
<Tr Two injections daily (before breakfast and dinner) of an intermediate-acting or pre-mixed
QI•
Insulin give better blood glucose control than once daily injections. Older patients and those with kidney
disease may sometimes manage adequately on a single daily injection.
Two-thirds of the total daily insulin requirement is given before breakfast, and the remainder before the

-'------------------'
C1r
evening meal.
a,- Insulin requirements vary from patient to patient irrespective of age and body weight.
 CHARACTERISTCS OF INSULIN THERAPY
ONSET OF PEAK EFFECTIVE FREQUENCY OF CONTROLLING SUGAR
TYPES OF INSULIN ACTION ACTION ACTION INSULIN INTAKE LEVEL TYPE
Ultra Short Acting Insulin
.,,.Lispro insulin 5 to 15 Control sugar level
"" Aspart insulin minutes 1 to 1.5 2 to 4 hours TD5with meal after each meal
.,,.
Glulisine insulin hour (insulin should be
Short Acting Insulin 30 to 60 given before 15-30
or Regular Insulin minutes 2 hour 6 to 8 hours TDS with meal minutes)
Intermediate Acting Insulin After lunch sugar and
or NPH insulin (Neutral 2 to 4 hours 6 to 7 10 to 20 hours Two times a day after dinner to control
protamine Hagedorn) hours (BO) Fasting blood sugar
Long Acting Insulin
qr Glargine_insulin 0.5 to 1.hour ~24 hours
er Detemir insulin 0.5 to 1 hour Flat 17 hours Once a day All sugar level
,,. Degludec insulin 0.5 to 1.5 hour >42 hours

DIAGNOSIS OF DIABETES MELLITUSjDMl

DIAGNOSTIC CRITERIA
1. Sign and symptoms of DM + Fasting blood sugar {FBS} >126 mg/di.
2. Sign and symptoms of DM + Random blood sugar (RBS} >200 mg/di .
3. FBS >126 mg/di in 2 separate time/occasion
4. RBS >200 mg/di in 2 separate time/occasion
5. If FBS = 126mg/dl + 2 hour Oral glucose tolerance test {OGTT} �200 mg/dl.

ORAL GLUCOSE TOLERANCE TEST (DIAGNOSTIC TEST}

,,. 2-hour glucose value after oral glucose tolerance test (OGTT} in mg/dl (mmol/L)
» Normal value:< 140 (< 7.8) in healthy person
» Impaired glucose tolerance: 140-199 (7.8-11.0)
,,. Capillary blood sugar level should not be used in the diagnosis of OM
qr Venous blood sugar level should be used in the diagnosis of OM.

HEMOGLOBIN-Ale (HbAlc)
,,. Normal value: < 5.7
.,. Prediabetes: 5.7-6.4, Patients are at an increased risk of developing OM (Insulin resistance).
or Diabetes mellitus: � 6.5
or Indicates glucose levels from the previous 8-12 weeks.
or Should not be used for diagnosis of DM, Should be used for monitoring of OM
or Half-life of RSC is_2-3_months that's.why HbAlc should be.monitor every 3-4.months

SPECIFIC AUTOANTIBODIES FOR DIABETES MELLITUS TYPE 1

<1r Anti-GAD antibodies
qr Anti-tyrosine phosphatase-related islet antigen (IA-2)
qr Islet cell surface antibody (ICSA; against ganglioside)
C-PEPTIDE
<1r Decrease C-peptide levels indicate an absolute insulin deficiency ➔ type 1 diabetes
er Increase C-peptide levels may indicate insulin resistance and hyperinsulinemia ➔ type 2 diabetes

URINE ANALYSIS
c,,Microalbuminuria: an early sign of diabetic nephropathy
r-rGlucosuria: Testing urine for glucose does not suffice to establish the diagnosis of diabetes mellitus.
"' Ketone bodies (usually accompanied by glucosuria}: positive in diabetic ketoacidosis (OKA)
 TYPE-1 DIABITTS MALLITUS (DM TYPE-I) Rx
Name: Age: Sex: Date:
Temperature: B.P: Pulse: Resp. Rate:

� DMTYPE-I
C/C:
Onset: General Principles
» Often sudden <1r Main goal: Blood glucose control, tailored to glycemic targets and

» Diabetic ketoacidosis (DKA) is the regularly monitored

first manifestation in approx. one­ <Y" Comprehensive diabetes care (all patients)
third of cases. » Continuous patient education
» Alternatively, children may present » Life-style Modification
with acute illness and classic • Weight reduction and Smoking cessation
symptoms. • Balanced diet and nutrition: Avoidance of sugars,
Clinical features concentrated sweets and foods high in saturated fats and
» Classic symptoms of cholesterol, advice a high-fiber diet & eating nonstarchy
hyperglycemia vegetables, whole foods & grains
• Polyuria, which can lead to • Regular exercise: Daily 20-25 minutes of moderate
secondary enuresis and nocturia intensity physical activity, such as brisk walking, biking, or
in children swimming, and muscle-strengthening exercises two or
• Polydipsia three times per week.
• Polyphagia
<1r Monitor patient's glycemic control annually: HbAlc of <6.5%
» Nonspecific symptoms
• Unexplained weight loss (<48mmol/mol) is ideal.
• Visual disturbances, e.g., blurred <:r Starting dose calculation in type-1 OM
vision >> Exogenous insulin requirements will depend on the residual
• Fatigue insulin production of the pancreas.
• Pruritus » Total daily dose (TDD) of insulin is usually~ 0.4-1.0 units/kg
• Poor wound healing per day, divided into 50% basal and 50% prandial insulin.
• Increased susceptibility to » Consider initiating treatment with 0.5 units/kg per day.
infections (if" Dose titration
• Calf cramps » After beginning insulin treatment, there is often a temporary
» A thin appearance is typical for reduction in exogenous insulin demand.
patients with TlDM » Dosage should be adjusted according to glycemic monitoring.

er Treatment with insulin (Rx-1)

Patients should followed up for (lnsuget R, Humulin-R, Actrapid)
» Diabetic Retinopathy � Regular human (rDNA origin) insulin injection
» Diabetic neuropathy 100 units/ml subcutaneous use (SC) x BD
» Diabetic Nephropathy 6-8 units before breakfast (morning) &
» Diabetic foot 4-6 units before dinner (Evening)
» Hypertension
» Lipoatrophy (Observe Injection (lnsuget-N, Humulin-N) N=NPH
sites) � Human insulin rDNA origin + Insulin lsophane injection
100 units/ml subcutaneous use (SC) x BD
8-12 units before breakfast & 4-6 units before dinner
(Insulin can be given 15-30 minutes before every meal, dose

IIDIII
should be titrated & adjust according to blood sugar level)
 DIABETIC KETOACIDOSIS (OKA) ER/Ward Rx
Name: Age: Sex: Date:
Temperature: B.P: Pulse: Resp. Rate:

CLINICAL PRESENTATION OF OKA:

(if" Rapid onset (<24hr) in contrast to HHS (Insidious/days)

1(1' Classic features of OM: Polydipsia, polyphagia, Polyuria ➔ dehydration (loss of fluid 6L)

c:,;- Sign of volume depletion (Dry mucous membranes, decreases skin turgor), hypotension, and shock.

Qr Hyperventilation: long, deep breaths/Kussmaul respirations ➔ nail foolish remover smell in the breath or

fruity odor on the breath (from exhale acetone).

<1r Recent weight loss

"' Hyperviscosity Syndrome:

i:,- Central nervous system features: ALOC, Lethargy, Drowsiness, Coma, Convulsions and CVA.

c:r Eyes features: Blurring of vision

r:ir Cardiovascular features: Angina, Myocardial infarction, lschaemic heart disease (IHD)

<1r Gastrointestinal tract features: Epigastric pain, mesenteric ischaemia ➔ acute abdominal pain (according to
the area of vessel involvement, abdominal tenderness, Nausea and vomiting.

DIAGNOSTIC APPROACH
" Check Blood sugar level (BSL): < 600 mg/dl (< 33.3 mmol/L) or maybe seen in >200 mg/di BSL ➔ About 10%
of patients with OKA will be euglycemic (e.g., glucoses 250 mg/dl)
er Check serum bicarbonate {HC03), serum urea, creatinine and electrolytes.
er Check Anion gap = (Na•+ K•) - (Cl + HC03·) or Na• - (Cl + HC0 3·)
» Normal value 10-12 mmol/L, Anion gap will be high in DKA
<7' Check for the presence of ketones in urine (ketonuria) ➔ test urinalysis.

� Serum beta-hydroxybutyrate (8-hydroxybutyrate most common ketone produced in DKA. Serum

measurement is more sensitive than urine ketone)
er Check ABGs: high anion gap metabolic acidosis (pHs 7.30)
er Diagnostic workup to evaluate the underlying cause: HbAlc, CBC, ECG, infectious workup, serum LDH, LFTs,
serum amylase/lipase, serum procalcitonin, blood/urine culture.
rr CT abdomen, CXR and ECG.

DIAGNOSTIC CRITERIA
Qr Blood glucose > 250 mg/dl

w Moderate-large - Urine ketones

""' Acidosis with pH < 7.3
<:if" Serum bicarbonate < 18 mmol/L

DKA VS HHS
QI> OKA: hyperglycemia, high anion gap metabolic acidosis, ketonuria/ketonemia

or Hyperosmolar hyperglycemic state (HHS): Hyperglycemia, hyperosmolality, and dehydration without

ketonuria, Also known as Hyperosmolar Non-ketotic coma (HONK)
8
Formula for Hyperosmolarity = 2 (Na+ K) + :RN + �: Average serum osmolarity: 275-295mosmol/L
L

-
SEVERITY OF OKA
Grade Arterial pH Serum bicarbonate Anion gap Mental status
Qr Mild > 7.24 15-18 mEq/L > 10 mEq/L Alert
Qr Moderate 7.!r7.24 l!rlS mEq/L > 12 mEq/L Alert or drowsy
Qr severe < 7.0 < 10 mEq/L > 12 mEq/L Stuporous
 Diabetic Ketoacidosis (OKA)
1. Airway: Ensure patient is maintaining own airway, Sit patient up to prevent acidosis
2. Breathing: Check Sp02 & correct hypoxia with supplementary 02, watch for Kussmaul breathing, which
may be present to compensate for metabolic acidosis
3. Circulation:
» Vitals Monitor: BP, PR, RR, Temperature, Sp02 x 4hourly
» Maintain 2 Large bore intravenous line ,c (20 gauge)
» Monitor labs: Blood sugar level x lhourly, ABGs x 4hourly, Input/output record x 1-4hourly,
electrolytes 4hourly
» Insulin therapy: Pak.*Brands (Humulin-R/Actrapid/lnsuget-R)
1. lnj Regular Insulin x 5-lOunits x IV (0.14mg/kg) + 5-lOunits x Subcutaneous (0.4mg/kg) x stat
2. Insulin Infusion: 60 units of Regular insulin injection with 100ml 0.9% N/S is prepared in 100ml IV
chamber x IV x 10 mic drops/minute start if K0 >3.5
3. Not to start IV Insulin if K+-+ level is <3.3, Maintain serum potassium between 4-5 mEq/L.
4. Continous IV insulin infusion until the anion gap is normal
5. Once anion Gap is normal then shift the Patient to S/C (Subcutaneous) insulin
» Fluid replacement therapy: Extracellular fluid loss is replaced by 0.9% N/S (isotonic solution),
Intracellular fluid loss is replaced by Dextrose 5% OR 10%. (Fluid of choice is 0.9% N/S or 0.45% N/S)
<>' First hour: 0.9% N/S 1000-lSOOmL (or 1-2L) bolus fluid at 15-20 ml/kg/hour
Next 24-48 hours: Adiust Intravenous fluid rate and composition accoJdiQ& to CVPL urine Qut_PJJt,
blood glucose,_and corrected sodium levels .
.,. Than ll of 0.9% N/S in 2hours
t:11' Than ll of 0.9% N/S in 4hours

vr Than ll of 0.9% N/S in 6 hours

vr Than ll of 0.9% N/S in 8hours.
Change to 5% dextrose once blood glucose <200-250 mg/dl
MOST HOSPITAL WARD/ER PROTOCOL AS FOLLOW:
1) First 1-2L 0.9% N/S is given fast in 1 hour.
2) Then 3rd drip of ll 0.9% N/S is given at the rate of 125drops/minute
Add 20ml (20-40mEg/Ll of KCL to each Liter of 0.9% of N/S once K is <5.5
3) Then 4th drip of ll 0.9% N/S + KCL 20ml is given at the rate of 88 drops/minute
4) Then 5th drip of ll 0.9% N/S + KCL 20ml is given at the rate of 33 drops/minute
S) Then 6th drip of ll 0.9% N/S + KCL 20ml is given at the rate of 22 drops/ minute
» If pH=7.0 or <7.0 despite adequate IV fluid resuscitation: administer IV lnj Sodium Bicarbonate x 2vial
(SOml/cc) in 500ml 0.45% N/S x over 1 hours.
» Acidosis usually resolves with fluids and insulin therapy, the use of bicarbonate is usually not necessary
Current stud)t':_Sodium Bicarbonate. should be. avoided ➔ .Oxford textbook of medicine
» Start 5% Dextrose if RBS value is <200-250 mg/dl at the rate 125ml IV/hour
» If RBS value is >250mg/dl changed dextrose into 0.9% N/S
4. Disability & Exposure {Secondary Survey)
» Consider early HOU/ICU Admission
» NPO status in patients with high anion gap metabolic acidosis on insulin infusion
» Pass Nasogastric tube and folly's catheter
» Monitor pupillary reflexes and GCS level
» lnj Calcium gluconate in 100ml 0.9% N/S over lSminutes if indicated (SOS)
» Antibiotics cover: lnj Ceftriaxone 2g (Rocephin) Or lnj Moxifloxacin 400mg (Moxiget) x IV x OD
» PPls: llnj Omeprazole 40mg x IV x OD
» Give appropriate analgesic if pain and anti-emetic if nausea/vomiting
 HYPERTHYROIDISM & THYROTOXICOSIS RX
Name: Age:
Temperature: B.P:
D,. Hyperthyroidism
C/C:
r:1r General
» Heat intolerance
» Excessive sweating because of increased
cutaneous blood flow
» Weight loss despite increased appetite
» Frequent bowel movements (because of
intestinal hypermotility)
» Weaknes:s, fatigue
» Onycholysis
» Infiltrative dermopathy, especially in the
pretibial area (pretibial myxedema)
r:,,- Eyes
» Lid lag: caused by adrenergic overactivity
» Lid retraction: "staring look"
» Graves ophthalmopathy (exophthalmos,
edema of the periorbital tissue)
r.r Goiter: Diffuse, smooth, nontender goiter; often
audible bruit at the superior poles. Also seen in
subacute thyroiditis, toxic adenoma, and toxic
Multi Nodular Goiter
r:r Cardiovascullar
» Tachycardia, Palpitations, irregular pulse (due
to Atrial Fibrillation/Ectopic beats)
» Hypertension with widened pulse pressure
» Cardiac failure: elderly patients often present
with features of cardiac failure (e.g., pedal
edema, exertional dyspnea).
» Abnorma I heart rhythms, including atrial
fibrillation
» Chest pain
r:1r Musculoskeletal
» Fine tremor of the outstretched fingers
» Hyperthyroid myopathy
» Osteopathy: Osteoporosis due to the direct
effect of T3 on osteoclastic bone resorption,
fractures (in the elderly)
r:Jr Endocrinological
» Female: oligo/amenorrhoea, anovulatory
infertility, dysfunctional uterine bleeding
» Male: gynecomastia, decreased libido,
infertility, erectile dysfunction
» Glucose intolerance
<r Neuropsychiatric system:
» Anxiety, Emotional instability
» Depression, Restlessness, Insomnia,
» Tremoulousness (results from the
hyperadrenergic state)
» Hyperreflexia
Sex: Date:
Pulse: Resp. Rate:
Thyroid function tests:
Initial screening test: TSH level - low/undetectable; a normal
TSH level usually rules out hyperthyroidism.
Interpretation of thyroid function test
» ,J,rsH, 1' Free T4: Primery Thyrotoxicosis
» -.1,TSH, Normal Free T4 and total T3: Mild or subclinical
thyrotoxicosis
» ,J,rsH, Normal Free T4, 1' total T3: T3 thyrotoxicosis
» Normal or 1' TSH, 1' Free T4 and 1' total T3: Thyrotropic
adenoma (TSH-secreting pituitary adenoma)
Baseline Investigation
)) CBC: leukocytosis and/or mild anemia
)) LFTs: mildly elevated AST, ALT, ALP and bilirubin
)) Fasting lipid profile: ,J, total cholesterol, LDL, and HDL
Blood sugar level: Hyperglycemia
)) Serum Calcium level: Mild hypercalcemia
)) ESR: typically 1' (> 100 mm/hour) in subacute thyroiditis
)) TSH Receptor Antibody (TRAb): if Graves' disease is
suspected but classic clinical features are absent
)) ECG: Tachycardia, Atrial fibrillation, LBBB and ECG signs of
LVH in patients with dilated cardiomyopathy
)) Nuclear medicine thyroid scan and Radioactive iodine
uptake measurement: First-line test for most patients
with uncertain etiology of thyrotoxicosis after Initial
evaluation
» Thyroid ultrasound with Doppler: Palpable abnormality,
e.g., goiter or nodules
» Ultrasound-guided FNAC
» Chest X-ray
1. Tab. Propranolol 40mg (lnderal, Cardinal)
½ - ½ - ½ (Half tablet x TDS), than I -1- I (TDS)
Dosage: started as 20 to 40mg every 8 hours and
then titrated every three days to a maximal daily
dose of 240 mg as needed to control symptoms
2. Tab. Carbimazole 5mg (Neomarcazole)
2 _ 2 _ 2, (2 1abltU x TOS) 3 _ 3 _ 3, (3 x TOS) 4 _ 4 _ 4 (4 x TOS)
» Initial dose: 3 0-60 mg orally x TDS per oral until
normal function, than start maintenance therapy.
» Lower dose of 10-20 mg for very mild symptoms
» Maintenance dose: 5 to lSmg/day x OD or BO
» Duration of therapy: 12-18 months.
» The starting dose of antithyroid drugs can be
gradually reduced (titration regimen) as
thyrotoxicosis improves.
Propylthiouracil (PTU) 50mg (Procarbizole)
Dosage: 100-200 mg orally daily in 3-4 divided doses
 • • • • •• •
••
•

•
C Nephrology & Urology •
• • • • •• • •

FEVER WITH BURNING MICTURATION Rx

Name: Age: Sex: Date:

Temperature: B.P: Pulse: Resp. Rate:

6- Fever with burning Micturition

C/C:
1. Fever
2. Lower abdominal pain 1. Tab. Norfloxacin 400mg (Noroxin, Utinor)
3. Burning micturition Or Tab. Ciprofloxacin 500mg (Ciplet, Novidate)
4. Dysuria Or Tab. Levofloxacin 250mg (Leflox, Levoxin)
5. Hematuria 1-0-1 {BO)

250mg (Ponstan, Mefnac, Dollar)

Investigation: 2. Tab. Mefenamic acid 500mg {Ponstan fort, Mefnac OS, Dollar OS)
» Urine O/R Or Tab. Paracetamol SOOmg {Panadol, Calpol, Febrol)
» CBC 1-1-1 (TDS)
» Urine C/S
3. Syp. Sodium Acid Citrate {Citralka, Fedralka)
If H/O stone or suspected stone than 2-3 Teaspoonful BD/TDS in a glass water
advice
» Urea, creatinine and electrolytes
» US KUB

1. Cap. Cephalexin 250mg, 500mg (Ceporex, Keflex)

1-1-1 (TDS), I -0-1 (BO)
Or cap. Cefixime 400mg (Cefspan, Cefiget)
0-0-1 {OD)

2. Tab. Diclofenac sodium 50mg, 100mg (Voren, Voltral)

1-0-1 {BO)
Or Tab. Mefenamic acid 500mg {Ponstan fort, Mefnac OS, Dollar OS)
1-1-1 (TDS)

3. Syp. Sodium Acid Citrate {Citralka, Fedralka)

2-3 teaspoonful BD/TDS in a glass water

If Nausea/vomiting then add

4. Tab. Domperidone 10mg (Motilium, Dome!)
1-1-1
c1HGi..30cc¥

.rm
 TINY RENAL STONES {NEPHROLITHIASIS} CONSERVATIVE Rx
Name: Age: Sex: Date:
Temperature: B.P: Pulse: Resp. Rate:

� Nephrolithiasis
C/C: ��
)) Tiny real stone <8-lOmm in size
Antibiotics indicated in case of concomitant UTI
)) Sudden onset of severe U/L and colicky
1. Tab. Norfloxacin 400mg (Noroxin, Uretic, Utinor)
flank pain (renal colic)
Or Tab. Ciprofloxacin 500mg (Ciplet, Novidate)
)) Radiates anteriorly to the lower
1-0-1 (BO)
abdomen, groin, labia, testicles, or
Or Cap. Cefixime 400mg (Cefspan, Cefiget)
perineum
0-0-1 (OD)
)) Nausea vomiting
)) Hematuria 2. Tab. Diclofenac sodium 50mg, 100mg (Voren, Voltral)
)) Dysuria, frequency, and urgency Or Tab. Tramadol + Paracetamol (Pentra plus, Distalgesic)
)) Passage of gravel or a stone 1-0 -I (BO)

Investigation For spasm/colicky pain

)) CBC -WBCs . increases 3. Tab. Phenazopyridine 100mg (Urilef, Uropin) x BO
)) Serum Urea, creatinine & Electrolyte Or Tab. Drotaverine 80mg (Relispa forte, Nospa forte) x BO
)) Uric acid, Calcium, & phosphorus level Expulsive therapy can reduce ureteral spasm and increase
)) Urine 0/R & C/S
spontaneous passage rates by about 50%.
)) X-ray KUB & U/S KUB 4. Cap. Tamsulosin 0.4mg (Tamsolin, Maxflow, Prostreat) x OD
)) CT KUB (Best) Or Tab. Terazosin 2mg, 5mg (Hytrin) x 2-Smg PO daily x BD/00
Intravenous [!J'.elogram (IVP)
Or Tab. Doxazosin 2mg, 4mg (Cardura) x 4mg PO daily x 80/00
))

...................,............,........................................
INDICATION OF POTASSIUM CITRATE (K-STONE) Or Cap. Silodosin 4mg (Silorap, Sildat, Sildoso) x OD
Indicated for management of )) Note: Silodosin is more effective than tamsulosin for
1. Renal tubular acidosis (RTA) with calcium stones promotlns the passage of distal ureteral stones
2. Hypocitraturlc calcium oxalate nephrolithiasis of
S. Other Rx: Tab. Potassium citrate (K-stone) x 80/TDS
any etiology
3. Uric acid lithiasis with or without calcium stones 6. Adequate Oral Hydration: Increase oral fluid intake
Medical Expulslve Therapy: Kidney stones 5 mm or smaller have about a 70% probability of passing spontaneously, whereas
stones between 5 and 7 mm have a 60% chance, stones 7 to 9 mm have a 48% chance, and stones 9 mm or larger have a 25%
chance of passing spontaneously. Stones located more distally in the ureter are more likely to pass spontaneously. Medical
expulsive therapy may be cautiously attempted with ureteral stones smaller than 10 mm diameter for 4 to 6 weeks if pain is
controlled, kidney function is normal, and there is no evidence of urinary tract infection or significant obstruction. The patient
must be followed closely, generally with repeat ultrasound examinations every week or 2 weeks.
Overview - Types Of Stone PREVENTION
Stone Type Incidence Etiology 1. Sufficient fluid intake (2: 2.5 L/day)
Calcium ~75% )) Hypercalciuria 2. For calcium stones:
Oxalate )) Hyperoxaluria )) Reduced consumption of salt and animal protein
)) Hypocitraturia )) Reduced consumption of oxalate-rich foods andl
)) -.1, Urine pH supplemental vitamin C: for oxalate stones
Uric acid ~10% )) ,,I, Urine pH )) Ttiiazide diuretics for recurrent calcium-containing
)) Hyperuricemia/Gout stones with idiopathic hypercalciuria (i .e., no
)) Hyperuricosuria hypercalcemia)
Struvite ~5-10% )) UTI with urease-producing 3. For uric acid stones or high urinary uric acid levels in, those
bacteria with calcium stones: Allopurinol
Calcium <5% )) Hyperparathyroidism 4. Depending on urinary pH and stone composition: urine
phosphate )) Type-I RTA (R....tArto,yStonosls) alkalinization or acidification
Cysteine <5% )) Cystinuria 5. Low calcium diets increase the risk of calcium-containing
stone formation because they increase oxalate reabsorption!
 MALE SEXUAL DYSFUNCTION & ERECTILE DYSFUNCTION Rx
Name: Age: Sex: Date:
Temperature: B.P: Pulse: Resp. Rate:
Definition: Erectile dysfunction can be defined as a man's inability to obtain rigidity sufficient to permit coitus of
adequate duration to satisfy himself and his partner.
Epidemiology: Current estimates suggest that 10 to 15% of all American men suffer from erectile dysfunction, with the
incidence progressively increased as men become older. Data from the Massachusetts Aging Study report that 52% of
men 40 to 70 years of age experience some degree of erectile dysfunction. The prevalence of erectile dysfunction is even
higher in men with type 2 diabetes mellitus and after radical prostatectomy for prostate cancer.
ETIOLOGY
<r Primary erectile dysfunction with normal <r Secondary erectile dysfunction with an abnormally functioning penis
functioning penis » Vascular disease: atherosclerosis causing ..I, blood flow to the
» Psychogenic: organ
• Fear of intimacy, depression, » Obesity
stress, anxiety, or guilt » Diabetes mellitus
• Performance anxiety » Hypertension
• Common post-myocardial » Medications: �-blockers, antidepressants, and antipsychotics
infarction secondary to anxiety » Substance use, Alcohol
» w Testosterone » Penile disorders
» w Libido » Neurologic: stroke, seizures, multiple sclerosis
» w Desire » Endocrine: hypogonadism, hyperprolactinemia
» Thyroid disease » Chronic prostatitis, prostate cancer, Peyronie disease
» Cushing's syndrome ,, Pelvic trauma, surgery, or irradiation increase chances

� ED Investigation for ED (RACGP Guidelines)

C/C:
Symptoms
» Presence or absence of morning or
nighttime erections ➔ if present, this may
suggest psychogenic etiology
,, Difficulty with arousal
,, Difficulty with orgasms
Physical Examination:
» During the physical exam, vital signs, body
habitus (obesity), and secondary sexual
characteristics should be assessed.
,, Basic cardiovascular and neurologic
examinations should be performed.
» The genitalia should be examined, noting the Alter modifiable risk factors
stretched length of the penis, fibrosis of the ,,. Lifestyle changes
penile shaft, and any abnormalities in size or
consistency of either testicle.
or Erectile dysfunction should be
distinguished from problems with penile
deformity, libido, orgasm, ejaculation, and
� Compliance with diabetes and cardiovascular drugs
penile deformity.
""" The severity, intermittency, and timing of
erectile dysfunction should be noted.
r Complete blood count (CBC)
r Liver function test (LFTs)
.,. Serum Electrolytes
� Serum urea and creatinine
,,. Fasting Lipid profile
rr Blood Glucose
t;1 Thyroid function test
r Serum Testosterone level, Luteinizing hormone (LH) and
progesterone level (hypogonadism)
r1r Serum Ferritin (Hemochromatosis may cause hypogonadism
in Anglo-Celtic patients)
First line treatment
,, smoking and drug cessation
» reduced alcohol
» improved diet and exercise
» stress reduction
» Offending drugs such as estrogens, morphine,
sedatives, and neuroleptics should be discontinued
,, Modify medication regimen
» Address psychosocial issues
» Discuss sexual misinformation
» Manage androgen deficiency: Give Testosterone
 First line treatment for Erectile Dysfunction
�.t
r:1 If patient has Irritative symptoms, low post-void residual volume and BPH
» Cap. Tamsulosin 0.4mg (Tamsolin, Maxflow, Prostreat)
» Or Tab. Solifenacin 5mg or 10mg (Solif, Solifen, Urgecin)
0 - 0 - I (Once per orally daily)

r:r Patients with mild to moderate Erectile Dysfunction:

» Tab. Slldenafil 50mg, 100mg (Viagra)
► Dosage: initially starting dose of sildenafil is 50 mg, increasing in 25-mg increments up to 100 mg.
► Should be taken 25 to 60 minutes before intercourse. Duration of effect is approximately 4 hours

» Or Tab. Vardenafil 10mg, 20mg (Levitra)

► Dosage: initially starting dose of Vardenafil is 10mg, increasing in 10mg, Increments up to 20mg.
► Should be taken 20 to 60 minutes before intercourse. Vardenafil has a relatively longer duration of
action (4 to 6 hours)

» Or Tab. Tadalafil 5mg, 10mg 20mg (Cialis)

► Dosage: initially starting dose of Tadalafil is 5mg, increasing in 10mg, Increments up to 20 mg.
► Should be taken 25 to 60 minutes before intercourse. Tadalafil has a faster onset of action and longer
duration (36 hours)

Or Tab. Avanafil 50mg, 100mg, 200mg (Stendra)

► Dosage: initially starting dose of Avanafil is 100mg
► Maintenance dose: 50 to 200 mg orally as needed adjusted according to response to 50-200 mg
► Should be taken 25 to 60 minutes before intercourse. Avanafil has relatively longer duration (6 hours)

er Patients with severe Erectile Dysfunction without increasing side effects ➔ Combination theraphy
» Long acting: Tab. Tadalafil (Cialis) at dose 2.5mg to 5mg
Plus
» Short acting: Tab. Sildenafil (Viagra) 50mg
► Should be taken 25 to 60 minutes before intercourse.

PRECAUTIONS
<JI• Warn patients about potential side effects
» Color vision changes
» Headache, dyspepsia, facial flushing
» Sudden blindness from non-ischemic anterior optic neuropathy (case reports)
r:r Avoid in patients on nitrates (may induce hypotension) & those with recent or unstable coronary artery disease
r:;,, Fatty food Reduced absorption of Sildenafil, Vardenafil and Avanafil.
r:r All PDE-5 inhibitors are metabolized by cytochrome P450 isozyme 3A4 (CYP3A4); doses should be reduced when

IIIEm
combined with inhibitors of CYP3A4 (erythromycin, ketoconazole, protease inhibitors, and grapefruit juice)
 • • • • • ••
••
•
Haematology
CHA
•
• • • • •• • •

IRON DEFIQENCY ANEMIA (IDA) RM

Name: Age: Sex: Date:
Temperature: B.P: Pulse: Reso. Rate:
Introduction:
- Iron deficiency anemia is the most common hematological/ nutritional disorder worldwide.
- IDA most common in female 15-45 years of reproductive age
» 30% developing countries
» 14% developed countries
or Iron deficiency anemia (IDA) is due to deficiency of iron causing defective heme synthesis.

CAUSES OF IRON DEFIOENCY ANEMIA (IDA) -'

Decrease intake Impaired absorption Increased requirement Chronic blood loss
• Steatorrhea • Gastrointestinal Tract
• Dietary lack • Celiac Sprue • Growing infants Peptic ulcer
•
))

Tropical sprue and children )) Gastric cancer

• Poverty • Whipples disease )) Hemorrhoids
• Crohn disease • Pregnant females )) Ankylostoma Duodenal
• Infants • TB intestine (Hookworm)
• Chronic diarrhea • Premenopausal • Urinary tract
• Elderly • Gastroectomy women • Genital tract
• Duodenal surgery • Respiratory tract
• Duodenal resection
"
PATHOGENESIS OF IRON DEFICIENCY ANEMIA (IDA)
Iron Deficiency Anemia due to decreased synthesis of heme and can be divided into 3 stages.
"'"" Stage 1 (Iron depletion): Iron adequate to maintain normal Hb level and only serum ferritin decreased.
er Stage 2 (Iron deficient erythropoiesis): Lowering of serum iron and transferrin saturation levels without
anemia (Hb, MCV and MCH within normal range). Bone marrow shows iron deficient erythropoiesis.
c;,• Stage 3 (Iron deficiency anemia): Low serum iron, serum ferritin and transferrin saturation. Impaired
hemoglobin production. Morphologically, first reduction in the size

CLINICAL FEATURES OF IRON DEFICIENCY ANEMIA {IDA)

Nonspecific and related to both severity and the cause of the anemia (e.g. gastrointestinal disease)

7
-
=
<1r Onset: Insidious.
Factors Enhancing Iron Absorption
Nonspecific symptoms: » Haem iron, proteins fermentation
» Chest pain and dyspnea on exertion products, meat, fishmeat, fish
» Fatigue, palpitations, breathlessness, weakness a111d irritability. » Ascorbic acid, citric acid, Tartaric acid,
gaStric acidity.
» Pharyngeal/esophageal webs formed cause dysphagia.
» Increased erythropoiesis (high
.,,. Patterson-Kelly or Plummer-Vinson syndrome: altitude, haemolysis, bleeding)
» Microcytic hypochromic anemia
» Atrophic glossitis Factors Inhibiting Iron Absorption
» Tea, coffee, milk, egg, Zinc

I ))
» Esophageal webs
Phosphate, Antacids, Herbal drinks
c;,• Congestive heart failure in severe anemia. )) Calcium & Calcium rich foods
.,,. Central nervous system:
» Pica-unusual craving for substances with no nutritional value like clay or chalk.
» Craving for ice (pagophagia) specific to iron deficiency.
» Pica may be the cause rather than effect of IDA
c:r Physical Findings
Diminished tissue enzymes cause characteristic epithelial changes of iron deficiency anemia.
» Angular stomatitis and glossitis
» Chronic atrophic gastritis
» Koilonychia (spoon nails).
'------'--'-'----'----------------------' - : I
 DIAGNOSIS OF IRON DEFICIENCY ANEMIA (IDA)
11
<1,> 1 Step:
» Confirmation of anemia
• Hemoglobin (Hb): '1,'1,'1, Investigation
• Hematocrit/Packed cell volume (PCV): '1,'1,'1, » Complete blood count (CBC)
<:r 2nd Step: » Peripheral smear
» Check MCV co,unt: <76 femtoliters ('1,'1,'1,) » Iron studies: Ferritin level
» Peripheral smear: » Ultrasound abdomen
• Microcytic (small) and hypochromic (pale) RBCs
• Severe anemia shows ring/pessary cells.
• Moderate anemia anisocytosis and poikilocytosis pencil/cigar-shaped cells.
• WBCs: Normal; eosinophilia in hookworm infestation.
• Platelets: Normal
rd
<:r
3 Step:
» Serum iron pr,ofile (iron studies)
• Reduced: Serum iron, Ferritin, % transferrin receptor saturation.
• Increased: TIBC, TFR and red cell protoporphyrin

Treatment of IDA-1

1. Increase consumption of iron-rich diet (meats, iron-fortified food, fresh green leafy vegetables)
2. Treat the underlying disease: Antihelminthics for hookworrm, OCPs for menorrhagia
3. Tab. Ferrous (Iron) Sulphate 200mg (Ferrous sulphate)
» Dosage: 60mg to 200mg elemental iron daily
4. Tab. Methyl-Folate 400mcg (Myfol, Adfol, Maxfol, M-Folate)
0-0-1(00}

Treatment of IDA-2

1. Tab. Ferrous sulphate 150mg + Folic acid+ 8-Complex (Fefol, FefolVit, Fervit)
Or Cap. Ferrous (Iron) Sulphate 250mg + 8-Complex (Singobion)
Or Tab. Elemental Iron 105mg + Folic acid 800mcg + 8-Complex (lberet-Folic)
Or Tab. Iron Polymaltose 100mg + Folic Acid 0.35mg (Malttofer-Fol, Ferosoft-FA, Malcifer-F, Polymalt-F)
1-0-1 (BO)
Or Syp. Iron Polymaltose 100mg + Folic Acid 0.35mg (Maltofer-Fol, Ferosoft-FA, Malcifer-F, Polymalt-F)
2-0-2 (BO)

Treatment of IDA-3

(if• Maintain intravenous {IV) access

o:r If Hb<7: Cross matching with Arrange 2 units of PCVs
<:r lnj. Iron (Ferric) sucrose (Venofer, Besleri-S, Ferosoft-S) 100 to 200mg after diluted in 100ml 0.9% Sodium
Chloride (Normal saline) regularly for 3 days or on alternative days (Total 3 doses).
Or lnj. Ferric carboxymaltose 500mg/10ml (Ferinject, FCM) after dilution in 100ml 0.9% Sodium Chloride
(Normal saline) infuse immediately (using a volumetric infusion pump) over 15 minutes.
» First Maximum dose per infusion is 20 mg/kg up to 1000 mg (use ideal body weight if overweight)
» After Ferric carboxymaltose injection➔ flush IV line with 50 ml sodium chloride 0.9%.
» Second dose should be administer at least 1 week later, Remainder of total body iron deficit not
exceeding 20 mg/kg up to 1000mg given �1 week later
» After Ferric carboxymaltose injection➔ flush IV line with 50 ml sodium chloride 0.9%.

- <:r lnj. Vitamin Bl+ 82 + 86 (Neurobion, Neuro-Bedoxine) x IV x stat on Alternative day x 10 doses
 • • • • •• •
••
•

Neurology & Psychiatry

•
• • • • •• • • •
MIGRAINE HEADACHE Rx
Name: Age: Sex: Date:
Temperature: B.P: Pulse: Resp. Rate:

6. Migraine Headache
C/C:
» Pain: Crescendo pattern
Pulsating/throbbing Moderate to
severe pain
» Patient retreats to dark, quiet room
» Sensitivity to light (Photophobia)
» Sensitivity to sound (Phonophobia)
» Nausea & vomiting
» ± aura (visual, speech, or motor
deficits)
» Duration: 4-72 hr
Potential triggers
» Stress
» Change in sleep pattern
» (too much or too little)
» Hormonal changes
» Variations in caffeine intake
» Foods: chocolate, hard
» cheese, MSG, nitrates,
» tyramines
Diagnostic Crjteria without Aura
At least five attacks fulfilling the
following criteria: untreated headache
lasting 4 to 72 hours
Group A {.2 of 4):
1. Unilateral headache
2. Throbbing or pulsating pain
3. Moderate to severe pain that inhibits
ability to function
4. Pain aggravated by routine physical
activity
�x2�P..!tU.2f.i);
1. Presence of nausea or vomiting
2. Presence of photophobia and
Phonophobia
Underlying disorders that may cause
secondary headaches
ER.Rx for Acute Attack:
r:, lnj. Ketorolac 30mg (Toradol)+ Metoclopramide 10mg
(Metaclon)x IV slow x Stat (dilute in 2ml N/S)- no data
suggest dilution
Or
lnj. Diclofenac sodium 75mg (Voren)x IM/IG PLUS lnj
Metoclopramide 10mg (Metaclon)x IM/IV x stat
Note: Decreased gastric motility may limit effectiveness,
Dopamine antagonist (metoclopramide:1' GI motility and may
help as antiemetic and maybe used as monotherapy for
treatment by IV route)- J.Q.b.D.�.!"!9.P.�in�.Jm... M.�.<;IJ_c;in�.�-t-�-�-c;IJ
Home Rx for.Acute.Attack:
� Tab Sumatriptan 2.5mg + Naproxen sodium 550mg (Sumoxen
plus)
OR Zolmitriptan 2.5mg nasal Spray (Zolmipine)X intranasal
OR Tab Sumatriptan
Serotonin 5-HT receptor agonists ("triptans")- Drugs of choice
for moderate or severe migraines or if no response to
analgesics
Mild to Moderate Migrain
�X
er Behavioral modification
» Avoid "triggers" (e.g., foods, alcohol, caffeine, nicotine,
nitrates)
» Regular sleeping patterns
» Minimize stress
<1r Tab. Paracetamol 500mg (Panadol, Calpol)x TDS
Or
Tab. Mefenamic acid 500mg (Ponstan forte, Mefnac OS)x TDS
Or
Tab. Naproxen sodium 250mg, 500mg (Neoprox, Flexin)x BO
must be ruled out
,<'x For Prophylaxis Rx 1:

Recommendations for use of prophylactic 1. Cap. Flunarizine 5mg (Sibelium, Lunar)

migraine medication 2 Caps. at night x OD
er Start with low dose and titrate slowly
er Decrease in headache frequency may 2. Tab. Naproxen 250mg, 500mg(Flexin, Synflex, Neoprox)
be imperceptible the 1st month 1-0-1(BO}
» For first month, 10% decrease in
frequency is considered successful Long term NSAIDs causes gastritis so add on
» Improvement is cumulative, may 3. Cap. Omeprazole 40mg (Risek, Ruling)
take 6 months to reach efficacy 0-0-1(OD)
» Success= 50% reduction in c1rl.:...3oc"�
headache frequency
+/-
r:,r After a 6-month period of headache
4. Tab. Propranolol lOmg (lnderal, Cardinal)
stability, periodically evaluate. I-0-I(10mg x BD), 2 - 0- 2(20mg x BD)
MIGRAINE HEADACHE PREVENTIVE DRUGS For Prophylaxis Rx 2:
f:l -Blockers: Metoprolol, propranolol, and �X
Timolol have established efficacy. Atenolol 1. Tab. Divalproex sodium 500mg (Epival CR)
and Nadolol probably effective. 0+0+ I(OD)
ACEls(Usinopril) & ARBs(candesartan}
probably effective 2. Tab. Diclofenac potassium 50mg(Caflam, Dyclo-P)
Calcium channel blockers: conflicting I+ 0+I(BO)
evidence regarding efficacy despite their
historical use Long term NSAIDs causes gastritis so add on
Valproate and Divalproex sodium 3. Cap. Esomeprazole 40mg (Esso, Nexum)
(teratogenic), Established efficacy. As 0+0+1(0D)
effective as �-blockers. c1rl w1.. 30 c"�
�!9.�:�ff.�ft[�.W.�.!&.�. t&.c!!!'!:
Topiramate(may cause weight loss}: +/-
Established efficacy. Consider side-effect 4. Tab Propranolol 10mg(lnderal, Cardinal)
of weight loss for obese patients. 1-0-1(10mg x BD), 2-0-2(20mg x BD)
Tricyclic's(amitriptyline}: probably
effective; unrelated to antidepressant
For Pro_phylaxis Rx 3:
activity �X
Selective serotonin reuptake inhibitors:
venlafaxine, probably effective 1. Tab. Topiramate 25mg, 50mg
NSAIDs: use to prophylaxis known triggers 0-0-1 {OD)
(e.g., start before menses for menstrual 2. Tab. Diclofenac potassium 50mg(Caflam, Dyclo-P)
migraine) I+ 0 + I (BD}
Riboflavin {Vitamin 82}: Small studies
suggest effectiveness. Long term NSAIDs causes gastritis so add on
Pizotifen is effective 3. Cap. Esomeprazole 40mg (Esso, Nexum)
0-0-1(OD)
c1rl .:... 30 c" ,24-S
+/-
4. Tab Propranolol 10mg(lnderal, Cardinal}
I-0-I(10mg x BO), 2-0-2(20mg x BD)
- Name:
CEREBROVASCULAR ACCIDENT (ISCHEMIC STROKE) Rx
Age: Sex: Date:
(..,:)
. .. . B.P: Pulse: Res . Rate:
z
6. CVA (lschemic Stroke)
C/C:
I.I.I
ci:: » Sudden onset of focal neurologic
deficits 1. Tab. Lisinopril 5mg or 10mg (Zestril) {see hypertension}
>
I­ • Weakness » Initial oral dose 5mg upto 10mg x once daily
:) • Paralysis Or Tab. Losartan 50mg or 100mg (Eziday, Cozaar)
0
• Paresthesia » Initial oral dose 50mg x once daily
z • Aphasia (Avsar or Dioplus 5/80mg)
0
ci:: • Dysarthria Or Tab. Amlodipine + Valsartan (Avsar or Dioplus 10/160mg)
» Nonspecific symptoms: 0- 0-I (Once daily) (Avsar or Dioplus 5/160mg)
u • Impaired consciousness
0 • Nausea 2. Tab. Atorvastatin 20mg or 40mg (Lipitor, Lipiget) x OD
0 • Vomiting Dosage: 40 up to 80mg daily
• Headache Or Tab. Rosuvastatin 10mg or 20mg (X-Plended, Rovista) x OD
• seizures Dosage: 20mg up to 40mg daily
» Symptoms depend on the
location of the stroke (see stroke 3. Tab. Aspirin 75mg, 150mg (Loprin, Ascard)
symptoms by affected vessels 0- 0-I (Once daily)
and stroke symptoms by affected Dosage: 75mg up to 150mg (81-325mg) x once daily
region) Patients who cannot tolerate aspirin or have aspirin insensitivity
Or serious adverse effects ➔ Clopidogrel
Mostly Pt. get depressed and panic Tab. Clopidogrel 75mg (Lowplat, Clopid, Noclot)
due to brain damage so 0- 0-1 (Once daily)
1. Tab. Sertraline 50mg, 100mg Or Tab. Ticagrelor 90mg (Anplag) x Loading dose 180mg (2-
(Sert, Reline) Tablets) x stat on day-1, then 80mg x twice daily.
� d�li � v,J� �I
One tab after breakfast x OD 4. Tab. Pantoprazole 40mg (Zopent)
0-0-1 (OD)
If sleep pattern disturb
�.:,.;... 30 c:--' c::::4S
2. Tab. Lorazepam 1mg or 2mg
(Ativan)
0- 0-l xHS
 RESTING TREMOR Rx
Name: Age: Sex: Date:
Temperature: B.P: Pulse: Resp. Rate:
., Definition: Resting tremor occurs when a body part is at complete rest against gravity.Tremor amplitude
decreases or disappears with onset of movements (voluntary activity), but once partial stability is attained
in a new position, the tremors returns.
<Jr Age of onset: ~ 60 years
qr Etiology
)) Parkinson disease
)) Drug induced parkinsonism (neuroleptics, metoclopramide)
)) Progressive supranuclear palsy
qr Pathophysiology: caused by a dysfunction of the basal ganglia, especially substantia nigra
TREATMENT ARE SAME AS PARKINSONS DISEASE
6 Resting tremor
C/C:
)) Typically, asymmetric resting tremor
�x Patients the age > 65 or multimorbid patients of any age

of the extremities (especially 1. Tab. Carbidopa PLUS Levodopa (Sinemet, Neudopa)

apparent in the hands); at a low ½ - ½ - ½ (Rx should start from gradualllr'. low dose to high}
Levodopa Is best taken between meals (e.g., 30 minutes before a meal)
frequency (4-6 Hz, rarely up to 9 Hz)
2. Tab. Procyclidine 5mg (Kamadrin, Kampro)
)) "Pill-rolling" of hands that subsides ½-0- ½, (2.5mg = Half x BD), than I -0-I (BD)
with voluntary movements.
)) Reduced with target-directed lfTremors not controlled & still tremors then add on
3. Tab. Amantadine 100mg (PK Merz, Amanta)
movement
Initially 100mg x OD, than 100mg x 2-3 time per day
)) In early Parkinson disease, unilateral
tremors are common.
Worsens with emotional stress Patients under the age of 65 with no significant
))
� comorbidities
)) Often associated with rigidity,
1. Tab Ropinirole 0.25mg, 1mg, 2mg (Ronirol, Requip, Ropinol)
bradykinesia, and postural instability Week Ascending Dosage Total Daily Dose
(also see "Parkinson disease") 1 0.25 mg xTDS 0.75 mg
........................................................... ..........
, ,
2 0.5 mg xTDS 1.5 mg
Diagnostics 3 0.75 mg xTDS 2.25 mg
4 1 mg xTDS 3 mg
Typically a clinical diagnosis
))
)) After Week 4, if necessary, the daily dose may be increased by
MRI for atypical presentations
))
1.Smg/day on a weekly basis up to a dose of 9mg/day, and then
))The history and examination of the by up to 3mg/day weekly up to a maximum recommended daily
patient with tremor should focus on 3 dose of 24mg/day (8 mg three times daily).
practical questions: )) Ropinirole should be discontinued gradually over a 7-day period
1. Is the movement disorder in patients with Parkinson's disease.
actually tremor?
)) The frequency of administration should be reduced from three
times daily to twice daily for 4 days. For the remaining 3 days,
2. Is the tremor isolated, or are the frequency should be reduced to once daily pri,or to
there accompanying neurologic complete withdrawal of Ropinirole
abnormalities?
Give ropinirole single drug if not respond PLUS add on
3. What are the phenomenologic
2. Tab. Carbidopa + Levodopa (Sinemet, Neudopa)
features of the tremor?
½ - ½ - ½ (Rx should start from gradualllr'. low dose to high}
3. Tab. Procyclidine 5mg (Kamadrin, Kampro)
½ -0- ½, (2.5mg = Half x BO), than I -0-1 (BO)
 • •
•
• • •• •
••
• •
CHA Ophthalmology
• • • • •• • •

I
HORDEOLUM (STYE) RX
r:r Common acute inflammation of the tear gland or eyelash follicles (Zeis or meibomian glands)
<lr" Etiology
)) Mainly Staphylococcus aureus, rarely Streptococcus
)) Increased occurrence in individuals with acne vulgaris and diabetes mellitus
r:r Classification
)) E><ternal hordeolum: inflammation of Moll's or the Zeis gland at the lid margin
)) Internal hordeolum: inflammation of the meibomian gland; usually visible at the palpebral conjunctiva (less
common)

� HORDEOLUM (STYE)
C/C: �x
» Painful 1. Most are self-limiting and resolve spontaneous l y after 1-2 weeks.
» Erythematous 2. Warm compress and massage
» Tender pus-filled nodule 3. Eyelid margin hygiene
» Spontaneous perforation and 4. Topical antibiotics
purulent discharge after a
few days In the case of non-response to medical therapy or severe symptoms:
..................................... incision and curettage, with systemic antibiotics (e.g., cephalexin)

CHALAZION (MEIBOMIAN GLAND LIPOGRANULOMA) RX

,, Chalazion is an acute or chronic inflammation of the eyelid secondary to blockage of one of the meibomian or Zeis oil
glands in the tarsal plate
er Etiology
» Poor eyelid hygiene, stress , or immunodeficiency
» Systemic conditions: tuberculosis, rosacea, seborrheic dermatitis
» Local anatomical abnormalities: complications of chronic blepharitis, malignancy, eyelid trauma, or post-surnery

� HORDEOLUM (STYE)
C/C:
» Chronic (s l ow-growing) 1. Conservative:
» Firm, rubbery nodule on the eye l id <»- Wait and watch
» Heaviness of the eyelid <:I' warm compresses
» Can cause visua l disturbances, if rJ1> Eyelid hygiene
l arge enough
2. In secondary infection: local antibiotics, e.g., tetracyc l ine,
doxycyc l ine, minocycline, or metronidazo l e
Usua lly a clinica l diagnosis➔ Everting
the eye l id may a llow for better er Chronic or recurrent chalazia may require
visualization of the lesion. » Incision and curettage/drainage depending on the size
Biopsy: for a persistent or recurrent » lntralesional steroids - injection of corticosteroids into the
chalazion, may be a sign of a sebaceous l esion or incision
carcinoma (a carcinoma of the
meibomian gland). Chalazion may also er Refer to an ophthalmo l ogist in 1 to 2 weeks.
� _ _l�
cl_in_ica _m
l y�re_s e _ _ b_le_ a_ _ b_as _ _a�-------------------
_ a_ l_ _ce_ll_ c_ a_r c_ _in_om ------ � -
 CORNEAL ABRASION RX
QI Definition: scrape or scratch injury (mechanical or chemical disruption) on the corneal epithelium
<Jr Epidemiology: most common eye injury among children's, and probably the most common eye injury in
general population.
c:r Lesion heal very quickly (24-48); time to healing depends on how deeply the cornea was involve.
or Typical causes:
» Direct injury: finger nails, mascara brushes, branches, chemical injuries (i.e. mace)
» Foreign matter stuck under the eyelid, Blowing dust or debris
» Prolonged contact lens wear or improperly fitted lenses
» Other causes: Iatrogenic (during procedure), Entropion, UV light (i.e., UV keratitis), Thermal burns
(e.g., cigarettes, matches), Trachoma and Ory eyes (e.g., Sjogren syndrome)
6. Corneal abrasion
C/C;
» Foreign body sensation in the eye er Removal of any retained foreign object.
» Eye pain
er If pain Analgesia: oral NSAIDs, topical NSAIDs (Diclofenac,
» Epiphora
ketorolac), or narcotics, depending on pain severity.
er Infection prophylaxis ➔ antibiotic eye drops.
» Blurred vision
» Photophobia
» Conjunctiva! injection
1. Ciprofloxacin 0.3% eye drops (Ciloxan, Ethiflox, Rocip)
1 drops in affected eye 4-5 times a day.
Diagnosis:
Or Moxifloxacin 0.5% eye drops (Moxiral, Moxigan, Megamox)
» History: injury
1 drop 3 times a day in affected eye
» Sensation: Pain, Photophobia
Duration: 5-7 days
» Vision: Decreased if central
» Discharge: tearing
If eye pain than advice oral tablets/topical eye drops
» Pupillary Right Reflex (PLR): Brisk or Ketorolac 0.5% e·ye drops (Ketrosan, Ketro)
» Conjunctiva! injection: Diffuse
cr Tab Diclofenac sodium 50mg, 100mg (Voren, Voftral) x BD
» Corneal appearance: stains with
fluorescein
» lntraocular Pressure (IOP):
Normal

SUBCONJUNCTIVAL HEMORRHAGE RX
er injury to the eye leading to hemorrhage beneath the conjunctiva

6. Subconjunctival Hemorrhage
C/C:
Diagnosis:
» History: trauma, hypertension, <1r Reassurance - it's a benign and self­
incidental, diabetes, coagulopathy limiting condition.
» Sensation: none, mild irritation
or Prognosis: clears within 1-2 weeks.
» Vision: Normal
» Discharge: None er If recurrent
» Pupillary Right Reflex (PLR): Brisk » Coagulation profile
» Conjunctiva! injection: localised, » Bed side sugar level, HBAlC
bright red » Check blood pressure, if high Rx accordingly
» Corneal appearance: clear <I" Otherwise no treatment required
» lntraocular Pressure (IOP): Normal

CHA
Name:
Temperature:
6 Scabies
C/C:
» Incubation period: approx. 3-6
weeks following infestation.
» Intense pruritus that increases
at night
» Burning sensation
» Skin lesions
• Elongated, erythematous
papules
• Burrows of 2-10 mm in
length
• Scattered vesicles filled
with clear or cloudy fluid
• Excoriations, pustules, and
secondary infection
» Predilection sites
• Wrists (flexor surface)
• Medial aspect of fingers
• lnterdigital folds (hands
and feet)
• Male genitalia (e.g.,
scrotum, penis)
• All other intertriginous
areas of the skin (anterior
axillary fold, buttocks)
• Periumbilical area or waist
• Additionally in children,
elderly persons, and
immunosuppressed
patients: scalp, face, neck,
under the nail, palms of
hands, and soles of feet
Pregnancy
» Permethrin is safe (category B)
'--------------'------------
• • • • •• •
••
•
• •
Dermatology
• • • • •• • •
SCABIES Rx
Age: Sex: Date:
B.P: Pulse: Resp. Rate:
ar Treat all house hold contacts whether symptomatic or
asymptomatic, Can provide family members with prescriptions for
treatment based on physician's comfort
er Wash all bed linens/clothing/towels with hot water and hot drying
cycles
1. Permethrin 5% Cream, Lotion (Lotrix, Mitonil)
» Day-1 take bath, dry your skin with separate towel and apply
permethrin 5% cream/lotion below collar line (face spared)
from behind the ears down to the toes including creases and
web spaces and leave on overnight
» Day-2 Apply permethrin 5% cream/lotion only, without bath
» Day-3 No application of permethrin 5%, take only bath with
warm soapy water
2. Tab Loratidine 10mg (Softin, Loril)
Or Tab Levocetrizine 5mg (Belair, Xyzal)
Twice daily (BD)
Post-scabetic pruritus
» Consider topical steroids
» Can give concurrently with treatment
» Duration of pruritus can persist for up to 4 weeks post-treatment
Tab. lvermectin (lvermite) especially indicated in large outbreaks or
severe forms of scabies. Best to only use if crusted scabies or repeat
exposure
.:,,· Dosage: 200 mcg/kg
er Can retreat in 2 weeks
� Not for use if less than 5 years old or less than 15 kg
<I' Norwegian crusted scabies
» Combination 5% permethrin with oral lvermectin 200 mcg/kg
» Permethrin to full body daily for 7 days, then twice weekly until
resolved
» Oral lvermectin given on days 1, 2, 8, 9, 15, 22, 29
 VITILIGO Rx
Name: Age: Sex: Date:
Temperature: B.P: Pulse: Resp. Rate:
<lf' Vitiligo Is a common skin condition in which a patchy loss of epidermal melanocytes results in depigmentation.
<11 This loss is hypothesized to be a result of autoimmune destruction, oxidative stress, and/or intrinsic melanocyte
defects in genetically predisposed individuals, and is commonly associated with other autoimmune diseases.
.,. The clinical course is highly variable, with unilateral or bilateral distribution of well-demarcated, depigmented
macules, which may progress during the course of the disease.
er These lesions have a predilection for facial, acral, extensor, and sun-exposed areas of the body. Vitiligo is often a
clinical diagnosis, but Wood lamp examination, dermoscopy, and/or skin biopsy are useful in ambiguous cases.
Classification according to location
Generalized (most common): widespread distribution of localized: isolated area affected (e.g., dermatomal)
lesions, frequently with mucosa! involvement 1. Focal: one or more lesion in one area (commonly
1. Acrofacial: lesions mainly on the hands and face trigeminal nerve distribution)
2. Vulgaris: patches that are widely distributed 2. Segmental: unilateral, asymmetric lesions that follow
3. Mixed: a combination of segmental and non- dermatomal patterns; a common variant in children
segmental vitiligo 3. Mucosa!: only the oral and genital mucosa affected
4. Universal: almost the entire body affected
Classification according to clinical course and prognosis
Segmental: Non-segmental:
» It is also called unilateral vitiligo, happens on one » It is also called bilateral or generalized vitiligo
part of the body. » It may appear on all body parts, especially areas that are
» early onset, rapidly spreading; depigmented lesions bumped or rubbed frequently.
may remain unchanged for life » These patches often extend slowly over time if left
» It often starts at a young age and usually stops untreated.
spreading after a year. » A family history and progression of disease are common.
D, Vitiligo Limited disease Rx 1
C/C:
» Irregular, well-demarcated,
General measures
depigmented (white) macules or .,. Sunscreen (to Prevent Burns): Always apply a sunscreen, ideally with
patches, surrounded by normal skin a sun protection factor (SPF) of 30 or above, to protect your skin
» Unilateral or bilateral distribution, with from sunburn and long-term damage.
stable or slowly progressive lesions. " Temporary makeup to color skin
» Commonly on the face (e.g., perioral <>- Skin camouflage creams: it can be applied to the white patches of
and periocular regions), neck, scalp, skin. The creams are made to match your natural skin colour. The
acral surfaces (e.g., hands), extensor cream helps to blend the white patches with the rest of your skin, so
surfaces, or genitalia. they are not as noticeable.
» leukotrichia: depigmented hair; an er Oral antioxidant and Vitamin-0 supplementation
indicator of poor prognosis.
er Topical corticosteroids (If <10% body area are involved)
» Coexisting Autoimmune Diseases ,> Betamethasone Cream or ointment (Betnovate, Provate)
( ~ 20% of patients) ,> Or Fluticasone Cream or ointment (Cutivate, Ticovate)
• Most Common: Hashimoto ,> Or Mometasone Cream (Hivate, Santomet)
thyroiditis and Graves' disease Topical application twice daily on affected site x Every 2 weeks
• Other disorders: type 1 diabetes, for 4-6 months. (On sensitive areas like face, neck or groin it
psoriasis, inflammatory bowel should be used once daily).
disease, alopecia areata, pernicious
er Topical Calcineurin Inhibitors are alternative to topical
anemia, Addison disease
corticosteroids and to minimize the risk of skin atrophy due to
» Depigmentation of the retina may also
steroid use. For spots on an adult's face, eyelids, genitals, breasts or
occur. underarms a less irritating ointment tacrolimus 0.1% is preferable
1> Tacrolimus 0.1% Ointment (Crolimus, Eczemus)
Topical application twice daily on affected site
Diagnostics
» Usually a clinical diagnosis
» If diagnosis is uncertain:
■ Wood lamp examination: The vitiligo
lesions appear as well-defined blue­
white areas.
■ Dermoscopy: Vitiligo lesions have a
characteristic perilesional
hyperpigmentation & telangiectasia.
• Skin biopsy and histology:
Melanocytes are absent, perilesional
lymphocytes may be seen
» Serological markers of autoimmune
disease (e.g., thyroid function tests and
antithyroid antibodies) once vitiligo is
confirmed
Follow-up: After 1 month
Surgical Options include
» Split-skin grafts
» Mini/punch graft
Surgical procedures aim to replace the
melanocytes with ones from a normally
pigmented autologous donor site. Several
melanocyte transplantation techniques can
be performed under local anaesthesia in an
outpatient facility, However, transplantation
for extensive areas may require general
anaesthesia. All methods require strict
sterile conditions.
Limited disease Rx 2
11· If a patient does not respond to the previous option, then high­
potency topical corticosteroids
er A pulse treatment with 0.1% clobetasol, alternating with 0.1%
tacrolimus ointment in a one week on/one week off regimen is often
reported to provide good repigmentation.
» Clobetasol Cream or ointment (Clobevate, Dermovate, Clobeta)
Topical application twice daily on affected site x for 6-8 months.
(On sensitive areas like face, neck or groin it should be used
once daily).
» Tacrolimus 0.1% Ointment (Crolimus, Eczemus)
Topical application twice daily on affected site
» Consider Oral corticosteroids if not respond (Mention below)
For Progressive or refractory disease
Second line therapy: primarily focus on improving skin appearance with
a combination of topical, systemic and UVB phototherapy treatments.
Such treatment duration varies from 8 to 24 months of two- to thrice­
weekly treatments, with an average 65-75% success rate.
r Phototherapy
» Narrowband ultraviolet-B (NB-UVB) phototherapy
, It is the treatment of choice for non-segmental, generalized
vitiligo.
, NB-UVB produces better repigmentation than PUVA, with
better color match and fewer side effects.
► NB·UVB therapy is also better tolerated, and could be used
on expecting or nursing women, and children.
, Combination interventions.are superior to .monotherapies,
like NB-UVB. with 0.1% tacrolimus.ointment.
» Psoralen with ultraviolet-A phototherapy
» PUVA phototherapy
If a patient has rapidly expanding vitiligo, with new spots appearing
every week or existing ones getting bigger, then advice
Oral Corticosteroids
» Tab . Prednisolone 5mg (Deltacotril, Rapicort)
» Or Tab. Betamethasone 0.5mg (Betnelan, Betnesol)
Two days a week for 16 weeks
er lmmunosuppressants drugs:
» Tab. Azathioprine 50mg (lmuron, Amorin) x half tab daily
Dosage: 0.6 to 0.75 mg/kg, under monitoring with CBC
 • • • • • •
••
•
C Emergency Medicine & Poisoning
•
• • • • •• • •

THE PRIMARY SECONDARY AND TERTIARY SURVEYS

In this station, you are going to be asked to assess a patient with a medical emergency or who has suffered severe
trauma (e.g. from a road traffic accident).
What follows is a general outline of the areas that you are going to need to cover.

PRIMARY SURVEY
► The quick look
• Inspect the patient.
• lntroduce yourself to him. Is he responsive? Try to elicit a response by shouting out his name.

>- Airway anti cervical spine

• Assess the airway for obslniction.
• If necessary. clear and secure the airway.
• If there is suspicion of a cervical spine injury, use the jaw-thrust technique.
• If there is suspicion of cervical spine injury, immobilize the cervical spine in a stiff collar.
• Place sandbags on either side of the head and tape them across the forehead.

>- Brenthing
• Assess breathing: look, listen, feel.
• Expose the chest.
• Note the rate and depth of respiration.
• Look for asymmetries of chest expansion.
• Look for chest injuries.
• Palpate for tracheal deviation. Palpate, percuss, and auscultate the chest. Try to exclude flail segments,
pneumothorax, or haemothorax.
• Attach a pulse oximctcr.
• If appropriate, ventilate using a bag, mask. and oropharyngcal airway or cndotrachcal tube.

► Circulation and haemorrhage control

• Control any visible hacmon·hage by direct pressure.
• Look for clinical signs of shock: assess the pulse. skin colour, capillary refill time, JVP, heart sounds, and
blood pressure. Try to exclude cardiac tamponade.
• Attach an ECG monitor.
• Place two large-bore (grey) cannulas into large peripheral veins.
• Take a sample of blood for group and cross-match.
• Start fluid replacement.

► Disability (neurological assessment)

• Assess neurological function on the AVPU scale:
A Ale11
V Voice elicits a response
P Pain elicits a response
U Unresponsive
• Assess the pupils for size and reactivity.
• Check that all limb extremities can be moved.

► Exposure and environmental control

• Remove the patient's remaining clothing and inspect both his front and back. Log-roll him (with the help
of others) so that his spine remains immobilized.
• Cover him with a blanket.
 Severe Falciparum Malaria ER Rx
Name: Age: Sex: Date:
Temperature: B.P: Pulse: Resp. Rate:

6.
C/C: �x
Symptoms 1. Airway:
)) Fever with chill and rigor )) Ensure patient is maintaining own airway
)) Headache/Body ache )) Assess and secure stable airway
)) Sweats, Fatigue, general
2. Breathing: Check Sp02 & Give high flow 02 as appropriate
malaise
Nausea, vomiting and 3. Circulation:
Diarrhea )) Maintain intravenous line (IV cannula)
)) General malaise )) Vitals monitoring: Check BP, PR, RR, Temperature, Sp02
)) Cough, Oyspnea )) Send labs: CBC, U/C/E, LFTs, Blood sugar, ABGs.
)) Muscle or back pain )) lnj Dextrose 5% ll x IV x OD
)) Loss of appetite )) lnj Artemisinin 30mg, 60mg or 120mg (Gen-M) x IV/IM
Signs
Dosage: 2.4mg/Kg at 0, 12 and 24 hours then 2.4mg/Kg daily for
)) Increase temperature
)) Sweating upto 7 days.
)) Pallor Reconstitution/Dilution Method
)) Jaundice ► Step 1: First Add Sodium Bicarbonate lnj. 5% in vial & mix
)) Respiratory distress well until clear solution.
)) Splenomegaly ► Step 2: For I.V use: Add 2.5ml Sodium Chloride lnj. 0.9% in
..................................... vial (Step 1) & mix well & use by slow I.V route over 2-3
minutes (Do not put solution in I.V drip).
Investigation
,,
Refl!!!?.l)�J?.:.�.t.tP.i://M.r!ll!Ph�rroJl•.�.Qro/!ros/.GM_fy1.J(ljl!i.tJ9.'l:�i:ti:\�.r!�ll!,P.�f
)) Microscopy of thick and ...
thin blood films (gold For I.M use: Add 1ml Sodium Chloride lnj. 0.9% in vial (Step
standard test) 1) & mix again & use by I.M route
)) Malaria parasite (MP) ICT )) IV fluid: lnj R/L or lnj 0.9% N/S x ll x IV x 00/80
)) Routine test: CBC, LFTs, )) Correct electrolytes imbalance
RBS, BUN, RFT, )) Fever: lnj. Paracetamol lg/lOOml (Provas) x IV x BD/TDS/SOS
Sfelectrolytes, serum
Lactate and ABGs
)) Consider antibiotics according culture: lnj. Ceftriaxone 2g
)) Urine D/R (Rocephin, Titan) x IV x OD, dilute in 100ml 0.9%NS
)) Blood/Urine C/S )) lnj. Omeprazole 40mg (Risek) x IV x OD
)) Ultrasound whole abdomen 4. Disability & Exposure
)) Consider early HOU/ICU Admission
)) Pass Nasogastric tube and folly's catheter
)) Monitor pupillary reflexes and GCS level
)) Encourage oral feeding
)) Correct underlying cause
)) Radiology: CXR, USG (Splenomegaly)
 KEROSENE POISONING Rx
Name: Age:
Temperature: B.P:
� Kerosene Poisoning
C/C:
Mostly patient are asymptomatic with
history of exposure.
Symptoms soon after ingestion ➔ typically
progress to respiratory failure.
» Characteristic odour
» Respiratory system: symptoms usually
occur within 30 minutes of exposure.
Immediate signs are coughing, choking,
gagging. Signs of pulmonary injury are
dyspnea, cyanosis wheezing, rales, nasal
flaring, grunting and fever. Fever >48
hours indicates bacterial superinfection.
» CVS: Dysrhythmias, hypotension, and
shock.
» CNS: Headache, LOC, dizziness, ataxia,
seizures, tremors and coma
» GIT: Burning sensation, nausea, vomiting,
hematemesis & abdominal pain
» Skin and mucous membrane: mucosal
irritation and chemical burns
Diagnosis:
» Petroleum distillate odor may emanate
from the mouth/cloths
» Arterial Blood Gas (ABG) will show
hypoxemia and hypercarbia.
» Bedside pulse oximetry: '1, SpO2 (Hypoxia)
» CBC may reveal raised WBCs
» Chest X-ray: may be normal up to 6-
12hours post aspiration following which
pneumonitis maybe seen.
» ECG may reveal arrhythmia if the
poisoning is severe.
cr Observe patient in ER for 6-8 hours
<iT' Do not induce vomiting
c:,- Do not attempt gastric lavage
r:r Risk of aspiration outweighs any benefit
from removal of substance
r:r There is no role for steroids
<iT' Pneumatoceles usually resolve
spontaneously
Sex: Date:
Pulse: Resp. Rate:
NO GASTRIC LAVAGE (CONTRA-INDICATED)
Treatment is.mainly su_p_portive.,_ as .there. is no
specific _anti-dote
1. Airway:
» Ensure patient is maintaining own airway
» Assess and secure stable airway
2. Breathing:
» Check SpO2 & Give high flow 02 as appropriate
» Keep patient NPO
3. Circulation:
» Maintain intravenous line (IV cannula)
» Vitals monitoring: Check BP, PR, RR, Temperature, SpO2
» Send labs: CBC, U/C/E, LFTs, Blood sugar, ABGs.
» IV hydration: lnj. Ringer Lactate 1L x IV x Stat
» IV Antibiotics: lnj. Ceftriaxone 1-2g, diluted in 100ml
0.9% NS x IV x stat
Indication of antibiotics: Fever more than 48 hours,
increasing infiltrates on chest x-ray, Sputum/tracheal
aspirate yield culture positive
» If vomiting: lnj. Dimenhydrinate
» If seizures: Give lnj. Diazepam 10mg/2ml (Valium) x
diluted in 8ml 0.9% NS or Dextrose 5% x (2mg upto
10mg) x IV slow over 5 minutes.
If recurrent seizures: lnj. Levetiracetam 500mg - lg in
100ml 0.9% N/S x IV slow over 15-20 minutes
4. Disability & Exposure
» Cutaneous decontamination: Remove contaminated
clothing. Irrigate affected skin, eyes and hair. Wash with
soap and water.
» Gastric decontamination is not recommended. The risk
of aspiration due to emesis and gastric lavage outweigh
the benefits. Activated charcoal does not bind well to
hydrocarbons while it increases the risk of spontaneous
vomiting and further aspiration.
» Monitor pupillary reflexes and GCS level
» Consider early HDU/ICU Admission
» Correct underlying cause

Name:
Temperature:
� Dog bite
C/C:
Prodromal symptoms
Flu-like symptoms (e.g., fever,
malaise/fatigue)
Locally: pain, paresthesia, and
pruritus near the bite site
Encephalitic rabies {most
common type)
Hydrophobia + CNS symptoms
(Anxiety, agitation, Confusion,
hallucinations, Photophobia
Fasciculations, Seizures, increase
Muscle tone and nuchal rigidity
Autonomic symptoms: e.g.,
hypersalivation, hyperhidrosis
Coma and death
Paralytic rabies(< 20% of cases)
Flaccid paralysis, paraplegia and
loss of sphincter tone,
Respiratory failure and death
Investigation
Non-immunized patient: rabies
antibodies
Immunized patient: rising serum
antibodies over a few days
CSF: findings characteristic of
encephalitis
Skin: biopsy from the back of the
neck for RT-PCR and
immunofluorescence staining
Saliva: RT-PCR for viral RNA, viral
culture
Postmortem brain tissue
autopsy: Negri bodies
CATEGAORY
1 Touching/Feeding of animals, Licks on intact skin
Nibling of uncoverd skin
2 Minor scatches/Abrasions with out bleeding
Single/Multiple transdermal bites Or scratches
IIIDI
3 Licks on broken skin.
Contamination of mucous membrane with saliva from licks
DOG BITE (RABIES VIRUS) ER/Ward Rx
Age: Sex: Date:
B.P: Pulse: Resp. Rate:
1. Airway:
» Ensure patient is maintaining own airway
» Assess and secure stable airway
2. Breathing: Check Sp02 & Give high flow 02 as appropriate
3. Circulation:
)) Pass IV line (IV cannula)
)) Vitals monitoring: Check BP, PR, RR, Temperature, Sp02
)) Send labs: CBC, U/C/E, LFTs, PT, APTT & INR
)) IV Fluid: R/L OR 0.9% N/S x ll x IV x stat (Hypotensive Pt.)
)) lnj lmatet 0.5ml x IM x stat, repeat after 4 weeks
)) Give lnj hydrocortisone 100-200mg (Solu-cortif) + Pheniramine
maleate 25mg/2ml (Avil) x IV x Stat
)) Analgesia: lnj Diclofenac 75mg x IM Or Toradol 30mg X IV/IM
)) lnj Co-Amoxiclave 1.2g (Augmentin) x IV x stat
)) Nonimmunized patient:
, Passiv-e immunization: Rabies immunoglobulin EQUIRAB is
given into the site of the wound by injection
OOSEGE:
Equine Rabies lmmunoglobulin and Human Rabies lg
ERIG: 20 IU/kg (0.133 ml/kg)
✓ 50kg Patient x 20 IU = 1000 IU
✓ 1000 + 150 IU/ml = 6.7ml
HRIG: 40 IU/kg (0.200 ml/kg)
✓ 50kg Patient x 40 IU = 2000 IU
✓ 2000 + 200 IU/ml = 10ml
PLUS
► Active immunization: inactivated rabies vaccine INDIRAB
0.5ml is given IM/ID on days 0, 3, 7, 14, and 28
» Prior immunization: Even patients who have been vaccinated
against rabies should be treated after exposure!
Rabies vaccine IM on days O and 3.
4. Disability & Exposure
,, Cleaning and debridement, as with all bite wounds
>> Extensive irrigation and debridement in OR with Antibiotics
>> Counsel the patient and discharge on
- Tab Co-Amoxiclave (Augmentin) 625mg x TDS, lg x BO
- Tab Danzen OS/ Tab Danzen forte x PO x BD/TDS
- Tab Paracetamol (Panadol/Calpol) x PO x TDS
TYPE OF CONTACT PROPHYLAXIS
NONE
Rabies vaccine only
Wond management
Rabies vaccine and
immunoglobalins
Wound management
 • • • • •• •
COVID - 19 ••
•
C
•
• • • • •• • •

COVI0-19 (coronavirus disease 2019)

► Introduction COVID-19: COVID-19 is an acute infectious respiratory disease caused by
infection with the new coronavirus subtype SARS-Co V-2. first detected a cluster of cases of 'viral
pneumonia' in Wuhan, People's Republic of China, in 31 December 2019. COVID- I 9 usually
presents with fever and upper respiratory symptoms, especially dry cough and often dyspnea;
asymptomatic courses and certain other symptoms can also occur.
► Incidence and prevalence
» The disease is currently spreading worldwide
» It is cu1Tently spreading worldwide and is considered a pandemic disease.

,- Transmission: mainly person-to-person

» Primarily via respiratory droplets: can be emitted during sneezing and coughing as well as
load speech
» Via aerosols: infectious concentrations of viral particles were detected in aerosols for a
duration of 3 hours and could last even longer
» Direct contact transmission: especially hand-to-face contact
» Fomite (surface) transmission: viral particles remain infectious on surfaces outside a host
for up to a few days depending on the material
• Latex, aluminum, copper: 8 hours
• Cardboard: 24 hours
• Countcrtops, plastic, stainless steel: 1-3 days
• Wood, glass: 5 days
» Fecal-oral transmission: Evidence that both SARS-CoV and MERS-CoV arc excreted
fecally suggests that fecal-oral transmission is possible
► Zoonotic Disease: especially from civet cats, camels Bats
► Incubation pe.-iod: 2-14 days (average 5 days)
► Range from: Common cold to middle cast respiratory syndrome
► Clinical features range from: Clinical courses range from: very mild to developing into severe
with pneumonia and even critical with life-threatening complications such as ARDS, shock, and
organ dysfunction.
► Duration of infectiousness:
» It is estimated that infected individuals:
• Become infectious 2.5 days before the onset of symptoms
• Cease to be infectious 8 days after the onset of symptoms.
» The period of greatest infectiousness is at the beginning of symptoms.
» Viral RNA has been found in respiratory samples long after initial infection, but the presence
of detectable viral RNA does not mean that the individual is still infectious.
, Immunity and reinfection:
» There is evidence of immune responses to SARS-Co V-2 following an initial infection or
exposure to viral components.
» But the duration of immunity and its efficacy on the prevention of reinfection is still
uncertain.
» Some studies suggest that the magnitude of the immune response might be dependent on the

IIIJD
severity of the disease.
» Cases of possible reinfection have been reported
► COVID19 Management of hospitalized patients
1. Maintain ABCD&E
2. Administer 02 therapy via nasal canula: 1-6 L O2/min if SpO2 <94%
��.t:�f.':I.L}�!t�..P.�t��-�tt}��,.�.�Qr9.: SpO2 of 90-94% is appropriate
3. Regular monitoring: BP, Pulse, Respiration, SpO2. Temperature and lab investigations
4. Supportive care: Adequate hydration. nutrition, and rest
5. Fever management: lnj Paracetamol 1g/100ml x IV x TDS/SOS
6. JV fluid: lnj 0.9% N/S and Ringer Lactate IL x BDfrDS (Fluid-sparing resuscitation and
electrolyte balance as needed)
7. Empiric antibiotic therapy: Antibiotics do not work against viruses; they only work on
bacterial infections secondary to COVJD.
lnj Azithromycin 500mg (Azitma) x IV infusion in 250-300ml 0.9% N/S x OD over 3hours
Jnj Piperacillin + Tazobactam 4.Sg (Tanzo, Tazocin) x JV infusion in I 00ml of 0.9% N/S
over 30-40 minutes x TDS
8. Anticoagulation: NIH _COVID-19 Treatment Guidelines (See) - Hospitalized patients should
be treated with prophylactic dose anticoagulation (e.g., with LMWH or fondaparinux).
Inj Enoxaparin sodium 40mg, 60mg, 80mg (Clexane) x 100 JU/kg ( l .5mg/kg) x SC x OD
Alternative: lnj Fondaparinux (Arixtra) 5-10mg x SC x OD
9. Co1·ticostcroids (CS): Dexamethasone is a corticosteroid that can help reduce the length of
time on a ventilator and save lives of patients with severe and critical illness. Corticosteroids
believed to reduce the severity of cytokine storm. Based on results of a large randomized UK
study in which dexamethasone resulted in lower mortality for patients on ventilators (reduced
by 33%) and those requiring oxygen (reduced by 20%), the NJI I COVID-19 Treatment
Guidelines Panel recommends using dexamethasone in patients with COVID-19, adults doses
of Corticosteroids are:
cr lnj Dexamethasone 4mg/J ml (Decadron): 6 mg PO/JV once daily for 7-10 days
er lnj Hydrocortisone 100mg (Solu-cortif): 50 mg JV every 8hr. for 7-10 days
er lnj Methylprednisolonc (Solu-Medrol): 32mg/day (0.5-1 mg/kg/day) x IV given in 1-2
divided doses for 7-10 days
JO. To date, there is no specific medicine recommended to prevent or treat the new Coronavirus.
11. PRONE POSITrONING: prone positioning increased lung recruitment and improved
oxygenation, it improves breathing comfort and oxygenation and is extremely beneficial for
COVID-19 patients with compromised breathing. prone position keep alveolar units open and
makes breathing easier
r:r Patients were asked to alternate every 2 hours between a prone and supine position during
the day and sleep in a prone position at night, as tolerated.
r:r A physician provider supervised the first episode of proning. Patients were asked to self­
prone, and nursing staff reminded patients.
er While proned. the patient is made to lie on his/her belly using pillows. One can also lie on
their right side (right lateral), left side (left lateral) or sit at a 60-90 degree angle in the
'fowler position'.
r:r It is suggest that a patient remain prone for a minimum of 30 minutes to a maximum of2
hours. "This helps improve ventilation to the lungs and hence oxygen levels start
improving," 11111111
 COVID19 (ASYMPTOMATIC OR MILD TO MODERATE) RX

�
C/C: .a
Cir Most common symptoms: .,.. Minimize �Jead of infection:
f�y_��
)) )) Stay in a designated "sick room" away from other
f2tl&l.!�
)) people.
P.rlfQ!:!gl}
)) )) Home Isolation: Use a separate bathroom if possible.
)) Do not leave home except to get medical care.
er Other symptoms that are less common )) If going out is necessary, avoid public places, public
and may affect some patients include: transportation, ridesharing, and taxis.
)) Loss of taste or smell, Nasal )) Wear a facemask.
congestion, Conjunctivitis (also )) Follow general protective measures as described above.
known as red eyes) )) Avoid sharing personal household items and wash any
))Sore throat and Headache, used items thoroughly.
)) Muscle or joint pain, )) Clean "high-touch" surfaces daily.
)) Different types of skin rash,
)) Nausea or vomiting,
tr Suppurative care and symptomatic treatment: Increase
)) Diarrhea, intake of Oral fluid, fresh juices, vegetables and fruits
)) Sputum production 1. Fever and body pain:
..................................... Tab Paracetamol 500mg (Panadol/Calpol)
1-2 tablets 6 hourly
2. Cough suppressant:
Productive cough: Syp. Hydrillin/Syp. Seroline
Ory Cough: Syp. Corex-D/Syp. Hydrillin DM
2 -2-2 x TDS (2teaspoonfull 3times a day)
3. Decrease ��etite.,_ ene!K.'£.and immunity:
Syp. Tresorix forte OR Syp. Trimetabol
2-0-2 (BD) 2teaspoonful before meal
Tab CAC 1000 OR Abocal 1000 x OD in a glass water
Tab. Revital multi Or Tab Surbex-z x PO x OD
Tab Cecon x PO x OD (chewable tablets)
4. Tab Azithromycin 500mg (Zetro, Azomax)
0-0-1 (OD) x 7-10days

s. Tab Prednisolone 5mg (Deltacortril): 40 mg/day PO

given in 1-2 divided doses for 7-10 days may be given
according to patient comorbidities
� Monitor symptoms carefully: Individuals should seek
medical care immediately if symptoms worsen or any
emergency warning signs develop, including:
» NOT MAINTINING 02 SITURATION
» Difficulty breathing/SOB
» Persistent pain or pressure in the chest
» Change in mental status (e.g., confused,
nonresponsive)
» Signs of cyanosis (e.g., bluish lips)
 • • • • •• •
••
•
C General Surgery •
• • • • •• • •

APPROACH TO THE MANAGEMENT OF ACUTE ABDOMEN

► Start with IPrcscnting complaint and history of presenting complaint

Make your approach in a case of acute abdomen as following:
I. Ons1.:t: When did the chief complaint occur (gradual. rapid or sudden. intermittent or constant
2. Durntion: When do the symptoms occur? At night, all the time, in the mornings, etc ..
3. Progression: Is this problem gelting worse or better Is there anything that the patient does that
makes it better or worse
-t. Aggravating factor:
S. Radiation: Do tJ,e symptoms radiate to anywhere in the body, and ifso, where? Pain in left
chest radiating to left arm is which suggestive of ischemic heart disease. Pain in flanks
radiating to groins is feature ofureteric (stone) pain
6. Rdic, ing factors: Relief with food. Position ...
7. Scale: On a scale of I to 10, how bad are the symptoms
8. Site: Anatomical location, or region
9. Associated symptoms: any other info about the chiefcomplaint that has not already been
covered Ask ifthere is anything else that the patient has to tell about the cruefcomplaint.
(Nausea, Vomiting); Vomiting: It can occur in acute abdominal but remains persistent in
upper intestinal obstruction)

Ask about:
» Systemic signs and symptoms: fever. jaundice. loss of weight or anorexia, effect on everyday
life.
» Upper GI signs and symptoms: dysphagia. indigestion (heartburn), nausea, vomiting,
haematemesis.
» Lower GI signs and symptoms: diarrhoea or constipation, melaena or rectal bleeding,
Steatorrhoea.
» Genitourinary signs and symptoms: frequency, dysuria, haematuria.
» Gynaecological signs and symptoms: length of menstrual period, amount of bleeding, pain,
Intramcnstrual bleeding. last menstrual period.

Complete detail about Past medical history, Drug history, Family history, social history
. ?
Wh at 1s the charactcr of oam.
Pain can be of following character
)) Burning )) Stabbing or crushing
)) Gripping heaviness )) Pricking
)) Dull )) Colicky
)) Throbbing ))

► Start GPE and whole abdomen examination.

❖ Gesture of Patient: Particular estures useful in anal

» As describe cardiac

» Rubbin the buttock and thi0 h to describe sciatica

» Arms clenched around the abdomen to describe mid- t colic
 ACUTE CHOLECYSTITIS Rx
6. Acute Cholecystitis
C/C:
Risk Factors: Fat, Female, Forty
Flatulent, Fertile
Right hypochondriac (RHC) pain due
to local irritation of peritoneum
» Typically more severe and prolonged
(> 6 hours) than in biliary colic
» Postprandial
» Radiation to the right shoulder {due
to referred pain from dermatome/
phrenic nerve irritation)
Guarding
Fever, malaise, loss of appetite
Nausea and vomiting
On Physical Examination:
» 1' Pulse rate(+/-)
» 1' Temperature(+/-)
» RHC tenderness to palpation
» Murphy sign +ve: sudden pausing
during inspiration upon deep
palpation of the RHC due to pain,
Murphy sign may be falsely
negative in patients > 60 years.
» Boas sign: hyperesthesia to light
touch in RUQ or infrascapular area
» Peritoneal signs may indicate
perforation
» Sometime a ball like structure is
palpable by examiner hand due to
swollen gall bladder.
» Always look for jaundice
Investigation findings:
» CBC: WBC 1'1'
» LFTs: 1'/Normal
» CRP: 1'1'
» Serum amylase: exclude acute
pancreatitis, {S/lipase most specific)
» U/S whole abdomen(for gallstone)
» X-ray erect abdomen(Shows
Mercedes sign+ exclude enteric
perforation "gas under diaphragm")
» CT abdomen with contrast and
HIDA scan
Note: Avoid Ceftriaxone because according to literature patient receiving ceftriaxone can develop acute
cholecystitis: ceftriaxone-associated sludge can trigger existing gallstones to become symptomatic, ceftriaxone
pseudolithiasis can transform into ceftriaxone gallstones, or the patient can become symptomatic from
preexisting cholecystolithiasis unrelated to ceftriaxone therapy.
1. Maintain ABCO&E
2. Pass two large bore Intravenous cannulation
3. Vitals monitoring: BP, PR, RR, Temperature, Sp02
4. No feeding by mouth (NPO-Bowel rest) - 2-3 days
S. Perform a focused history and physical examination.
6. Send labs: CBC, Urea, Creatinine, electrolyte(U/C/E), LFTs, PT APTT
& INR, serum amylase, Anti HCV, HBsAg, RBS & CRP
7. Pass Nasogastric (NG) tube➔ Aspiration through NG Tube:
Aspiration of HCI decreases the stimulus to the secretion of bile.
Spasm of gall bladder may come down. After 2-3 days, pain comes
down, signs(tenderness) disappear and abdomen becomes soft.
NG tube is removed, clear oral fluid is given for 2-3 days followed
by soft diet. After 6 weeks, the patient is advised to undergo
elective cholecystectomy.
8. Foley's catheterization for urine output record
9. Bowel care: if constipation give Syp. Lactulose/Skilex drop
10. Start IV fluid therapy: R/L x 80, 0.9% N/S or Dextrose 5% x IV x OD
11. Correction of electrolytes imbalance
12. Start IV fluid: R/L x 80, 0.9% N/S OR Dextrose 5% x IV x OD
13. Consider IV empirical antibiotics therapy
� lnj Metronidazole 500mg/100ml(Flagyl) x IV x TDS
PLUS
� lnj Cefuroxime 750mg (Zinacef) x IV x 8D
� or lnj. Ceftazidime lg (Fortum, Fortazim) x IV x BO
� or Inf. Ciprofloxacin 400mg/100ml (Novidate) x IV x 80
14. lnj Omeprazole 40mg/vial (Risek, Ruling) x IV x OD
15. IV Analgesia for Pain: lnj. Ketorolac 30mg/ml(Toradol) dilute in
4ml 0.9% N/S x IV x TDS, If not controlled give lnj. Buprenorphine
0.3mg/ml(Buepron, Norpin), OR lnj Nalbuphine lOmg/ml(Kinz)
PLUS with lnj dimenhydrinate 50mg(Gravinate) dilute in 8ml 0.9%
N/S or Dextrose 5% x give slow IV x 80
16. IV Spasmolytics: consider as adjuvant therapy with analgesics in
patients with severe pain
� lnj. Phloroglucinol+Trimethylphloroglucinol 40+0.04mg/4ml
(Spasrid, Spasfon) in 100ml Dextrose 5% x IV BD/TDS
EDII
 ANAL FISSURE CONSERVATIVE Rx
Name:
Temperature:
--------+- Age:
B. P:
Sex:
Pulse:

6_ Anal Fissure
C/C:
» Severe pain on defaecation.
General measures for anal fissure
» Constipation
er Adequate fluid intake (6-8 glasses of liquids)
» Perianal pain & itching
"" Avoid constipation
» Perianal irritation
"" Advise fiber rich diet to prevent constipation i.e vegetables,
» Bleeding is usually small (Bright
fruits, brown rice.
red blood) and occurs as a streak e1r· Bulk forming agents (psyllium husk, bran)
by the side of stools. cr Sitz bath - sitting in a tub containing lukewarm water provide
» relief from spasm and pain or containing warm antiseptic
On examination, a longitudinal
lotion
ulcer is seen in the midline
" Once recovers, regular anal dilatation
posteriorly that maybe covered
by a skin tag. There is local Pharmacotherapy
inflammation and induration
1. Tab Metronidazole 400mg {Flagyl/Metrozine)
I+I+I (TDS)
Consider antibiotics if soft tissue infection:
2. Cap Cephalexin 250mg, 500mg {Ceporex, Keflex) x TDS/BD
OR Cap Cefixime 400mg (Cefiget) x OD

3. Cap Esomeprazole 40mg (Esso/Nexum)

0+0+I
� .!.u..o 30 � ci..�

4. Glyceryl tri nitrate 2% ointment (GTN)

l+0+I
,,. Topical nitroglycerine 0.2% is also used to relax the
sphincter. It causes severe headache.
5. Lidocalne 2% jelly (Xyloaid/Lignocaine)
I+0+I
6. Syp Lactulose 30ml (Duphalac/Lilac)
Medicated Disposable Sitz Bath 0+0+I

SITZ BATH
Sitz bath is used after perinea! surgeries like for
piles, fissure, and fistula.
Patient sits in warm water bath with perineum dipped in the water.
Often small quantity of antiseptics or KMNO4 is added.
Duration of setting: 15-20 minutes
Warm water is used, Warm water is a vasodilator, which means
that it causes blood vessels to open and muscles to relax. By
loosening the tightened and swollen piles, it eases the pain and the
swollen portion may even shrink.

Name:
Temperature:
�
C/C:
» Colicky abdominal pain
» Obstipation/Constipation
» vomiting &/or nausea
» Abdominal distention
» Increased high-pitched bowel
sounds (early) or the absence of any
bowel sounds (late) Diffuse
abdominal tenderness
» Collapsed, empty rectum on digital
rectal examination (complete bowel
obstruction); or impacted feces
» History of abdominal surgery
Workup before operation
Send.labs: CBC, Urea, creatlnine &
electrolytes, LFTs, PT & INR, Viral
marker (Anti HCV, HBsAg)
RadlolQ&lcal Imaging:
Abdominal ultrasound: Multiple fluid­
filled dilated bowel loops> 2.5 cm in
diameter adjacent to collapsed bowel
loops, Thickened bowel wall, and
Prominent pllcae circulares of dilated
small bowel loops (referred to as the
keyboard sign)
X-ray Chest PA view: Air under the
diaphragm is an Indicator of bowel
perforation
X-ray abdomen Erect & supine view:
Dilated bowel loops proximal to the
obstruction, Rectal air shadow absent,
Multiple air-fluid levels.
CT abdomen with IV and oral contrast:
Similar findings as on x-ray, Transition
point at site of obstruction
» If Cardiac patient: ECG, and
echocardiography
Indications of Immediate Surgery in
Intestinal Obstruction:
» Complicated bowel obstruction:
- Signs of ischemia
- Colonic perforation
- Clinical deterioration
» Obstructed or strangulated hernia
» Operative decompression needed
(in Toxic megacolon)
» Volvulus of gut
» Acute obstruction
» Entero-llthotomy for gallstone lieus
INTESTINAL OBSTRUCTION Rx
Age: -�· Date:
t
B.P: !Pulse. Resp. Rate:
1. Maintain ABCO&E
2. Admit the patient in surgical unit
3. No feeding by mouth (NPO-Bowel rest)
4. Vitals monitoring: Check BP, PR, RR, Temperature, Sp02.
5. Pass Nasogastric tube with continuous suction (in patients with
persistent vomiting, significant upper GI distension, complete bowel
obstruction, or volvulus) & Foley's catheterization for urine output
6. IV fluid therapy: Initial fluid resuscitation with 0.9% N/S, R/L, or
Dextrose 5% followed by maintenance fluid therapy x IV x TDS
7. Correction of electrolytes imbalance
8. Consider IV empiric antibiotic therapy for intra-abdominal infection
in complicated bowel obstruction.
» lnj. Metronidazole 500mg/100ml (Flagyl) x IV x TOS
n PLUS one of the following:
• lnj. Ceftriaxone lg (TTtan, Rocephin) x IV x BO
• or lnj. Cefuroxime 750mg (Zinacef, Zecef) x BD/TDS
• or lnj. Ciprofloxacln 400mg/100ml (Novidate, Ciplet) x BO
If sey_e_r_e i nfectioo_or Hieh Ris.k .P.atien.t
• or lnj. lmlpenem-cilastatin SOOmg-lg (Cilapen, Tienam) x TDS
• or lnj. Meropenem lg (Meronem, Meroget) x TDS
• or lnj. Piperacillin-tazobactam 4.Sg (Tanzo, Tazocin EF) x TDS
9. lnj. Omeprazole 40mg (Risek) diluted in 10ml 0.9% N/S x IV x OD
10. IV analgesic for Abdominal Pain:
» lnj. Drotaverine Nospa 40mg/1ml x IV stat in 100ml 0.9% NS
» If pain not controlled give lnj. Ketorolac 30mg (Toradol) in 4ml 0.9%
N/S x IV. If the pain is more severe give lnj. Tramadol 100mg/2ml
(Tramol) or lnj. Nalbuphine 10mg/1ml (Kinz)
PLUS with lnj. dimenhydrinate 50mg/1ml (Gravinate) dilute in 8ml
0.9% N/S or 0/W x give slow IV (or dilute in 100ml 0.9% NS)
Note: Opioids.should_be_avoided.in.suspected paralytic ileus and
acute colonic pseudo-obstruction.
11. IV antiemetics for vomiting as needed:
» lnj Dimenhydrinate 50mg/1ml {Gravinate) x IV x TDS
Or lnj. Metoclopramide 10mg/2ml (Maxolon) x TDS (Risk of EPS)
» If not response/severe vomiting than lnj. Ondensetron 8mg/4ml
(Onset) - diluted in 50-100 ml 0.9% N/S over 15-20 minutes.
After complete workup transfer the patient to the operating room
Procedure: exploratory laparotomy
rr Management of the obstruction (Adhesiolysis, hernia reduction,
cecopexy, tumor resection)
rr Resection of gangrenous bowel with restoration of intestinal transit or
creation of a stoma.
 KELOID Rx
Name: Age: Sex: Date:
Temperature: B.P: Pulse: Resp. Rate:
,:;,- Definition: skin lesions caused by high fibroblast proliferation and collagen production as excessive tissue
response to, typically small, skin injuries
er Etiology: Unknown; imbalance in wound healing processes due to local factors, Genetic predisposition,
more common in blacks
,:;,- Pathophysiology: increased synthesis and unorganized deposition of collagen types I and Ill and fibroblast
proliferation
r:-,- Associated with: Elevated levels of growth factors; deeply pigmented skin
{'if" Common in certain areas of body: Above clavicle, upper extremities, on the trunk, face (Especially seen in

triangle whose boundaries are xiphisternum and each shoulder tip)

er Histology
» Excess collagen & hypervascularity; Contain disorganized type I & Ill collagen
» Thicker colla en bundles form acellular node like structures

�
C/C:
» Brownish-red scar tissue of
varying consistency (soft or
hard) with claw-like appearance
that grows beyond the
boundaries of the original lesion
» Pruritus
» Pain
QI· Treatment option same as Hypertrophic scar
,:;,- Keloids rarely regress with time, often refractory to medical and
surgical intervention
er First line treatment: Silicones in combination with pressure therapy
and intralesional corticosteroid injection
Qr Refractory cases (after 12 months of therapy): Excision+ Post-op

» Localization: earlobes, face radiotherapy (external beam or brachytherapy)

(especially cheeks), upper
extremities, chest, and neck
Diagnosis: based on clinical
appearance of lesion and patient
history of trauma or surgery
er New treatment modalities: Internal cryotherapy & 5% lmiquimod
Prognosis
» Does not regress spontaneously
» Frequent recurrences after resection
 • • • • • •
••
•
C Gynaecology & Obstetrics
•
• • • • •• • •

FEVER WITH DRY COUGH IN PREGNANCY Rx

Name: Age: Sex: Date:
Temperature: B.P: Pulse: Resp. Rate:

6_ Upper RTI
C/C:
» Cough (Dry)
» Sore throat
1. Tab. Co-Amoxiclave 625mg, lg (Augmentin, Calamox)
» Runny nose
1-1-1, 1-0-1 (625mg=TDS, lg=BO)
» Nasal congestion
Or Tab. Azithromycin 500mg (Macrobac, Azomax, Zetro)
» Headache
0-0-1 (OD)
» Low-grade fever
» Facial pressure
2. Syp. Oiphenhydramine (Benadryl)
» sneezing
2 Teaspoonful x TDS

Investigation:
3. Tab. Paracetamol (Panadol, Calpol, Febrol)
» CBC
1-1-1
» Chest X-ray (CXR) P.A view
» Rule out COVID-19 if suspected
send Covid protocol test

FEVER WITH PRODUCTIVE COUGH IN PREGNANCY Rx

Name: Age: Sex: Date:
Temperature: B.P: Pulse: Resp. Rate:

6, Lower RTI �x
C/C:
)) Fever 1. Tab. Co-Amoxiclave 625mg, lg (Augmentin, Calamox)
)) Cough with Sputum production I - I - I, I - 0- I (625mg=TDS, lg=BO)
)) Post nasal drip Or Tab. Azithromycin 500mg (Macrobac, Azomax, Zetro)
)) Rapid breathing or difficulty Or cap. Cefixime 400mg (Cefim, Cefspan, Cefiget)
breathing. 0-0-1 (OD)
)) Wheezing
)) Skin turning a blue color due to 2. Tab. Loratidine 10mg (Softin, Lorin NSA, Loril)
lack of oxygen. 0-0-1 (OD)
)) Chest pain or tightness
Investigation: 3. Tab. Paracetamol (Panadol, Calpol, Febrol)
)) CBC 1-1-1
)) Urea, creatinine and electrolytes
)) ESR 4. Syp. Koflet (Cough suppressants)
)) Chest X-ray (CXR) P.A view 2 teaspoonful x TDS Better to avoid in 1st trimester)
)) Sputum culture Or Syp. Diphenhydramine (Benadryl)
)) Rule out COVID-19 if suspected
send Covid protocol test
 TYPHOID FEVER (ENETRIC FEVER} IN PREGNANCY Rx
Name:
Temperature:
f::::. Enteric fever
C/C:
» Fever low then gradually
increases to 104.9 F
» Headache
» vomiting
» Weakness and fatigue
» Muscle aches
» Relative bradycardia
» Loss of appetite
» Abdominal pain
» Rash (Rose spot)
» Diarrhea
» Hepatosplenomegaly
Incubation period: 5- 30 days
(most commonly 7-14 days)
Treatment duration: 7- 14 days
Diagnosis: Mnemonic 'BASU'
1st week: Blood culture
2nd week: Antigen test/Widal
3rd week: Stool culture
4th week: Urine culture
Blood culture is the most important
diagnostic test at disease onset, as
stool cultures are often negative
despite active infection.
Gold standard test is Bone Marrow
culture
» Complete Blood Count (CBC)
• Anemia
• Leukopenia or leukocytosis
- Absolute eosinopenia
- Relative lymphocytosis
» LFTs: maybe Abnormal
» Ultrasound whole abdomen:
Hepatosplenomegaly
Age: Sex: Date:
B.P: Pulse: Resp. Rate:
1. Cap Cefixime 400mg (Cefspan, Cefiget, Cefim)
0- 0- I (OD), I-0- I (BD) - [Dose: Cefixime 20mg/kg)
Or Tab Azithromycin 500mg (Zetro, Bectizith, Azomax)
0-0- I (OD)- [Dose: 10/kg/day x 7 days]
2. Tab Paracetamol 500mg (Calpol, Febrol, Panadol)
1-1-1 (TDS)
3. Syp. Lysovit or Syp. Leaderplex
2 - 0 - 2 (2tsp. two times a day)
If Epigastric upset
4. Tab. Pantoprazole 40mg (Zopent)
0-0-1 (OD)
�.:......3ocd4-S
If Nausea/vomiting then add
5. Tab. Metoclopramide 10mg (Metaclon, Maxolon)
I- 1-1 (TDS)
Or Tab. Ondansetron 4mg (Onset, Onseron) x BD/TDS
I- 0- I (BD) or I- I - I (TDS)
� .:.,.... 30 c ,24-S
�f For severe Enteric infection
ar lnj. Ceftriaxone 2g (Titan, Rocephin, Oxidil) x IV x OD/BD
» Dose: 5 0-60mg/kg
» Diltution: Diluted in 100ml 0.9% N/S
� If Fever: lnj. Paracetamol lg/l00ml (Provas) x 8 hourly Or SOS
w If vomiting: lnj. Metoclopramide 10mg/2ml (Metaclon) x IV x TDS
ar Correct dehydration and electrolytes imbalance
Prevention:
Salmonella infection is best prevented by protecting the water
supply, preventing fecal contamination during food production,
cooking and refrigerating foods, pasteurizing milk and milk
products, and handwashing before preparing foods.
 MITTLESHMERZ RX
Name: Age: Sex: Date:
Temperature: B.P: Pulse: Resp. Rate:
er Definition of Mittleshmerz
» Physiological preovulatory pain in female individuals of reproductive age
» Also referred to as ovulatory or midcycle pain
<r Epidemiology: occurs in approx. 40% of female individuals of reproductive age
r:r Etiology: Enlargement and rupture of the follicular cyst and contraction of Fallopian tubes during midcycle
ovulation lead to transient peritoneal irritation from follicular fluid
� Mittleshmerz
C/C:
» Recurrent unilateral lower abdominal pain
(Anafortan Plus, Spasfon, Spasrid)
(can mimic appendicitis)
• Pain occurs during midcycle in 1. Tab. Phloroglucinol and Trimethylphloroglucinol
individuals with regular menses.
• Dull and achy pain which can become Consider NSAIDs if severe or not respond
cramp-like 2. Tab Mefenamic acid 500 mg (Mefnac DS, Ponstan Fort)
• Can last up to 3 days 1-1-1 (TDS)
» Physical examination: lower abdominal pain Or Tab. Naproxen sodium 500mg (Flexin, Synflex)
on palpation 1-0-1, Initially 500mg 8D day 1-3, then 250mg x 8D

MENORRHAGIA RX
Name: Age: Sex: Date:
Temperature: B.P: Pulse: Resp. Rate:

Treat underlying cause (see etiology of secondary dysmenorrhea)

1. Tab Mefenamic acid 500 mg (Mefnac DS, Ponstan Fort) x TDS

Or Tab. Naproxen sodium 500mg (Flexin, Synflex) x Initially 500mg 8D day 1-3, then 250mg x 8D
2. Consider to stop acute bleeding: Cap. Tranexamic acid 500mg (Transamine) x BD/TDS
3. Other medications
» COCP (Tab. Vaz, Tab. Diane-35, Tab. Progyluton) x once daily for 21 days than 7 days break x 3 months
» Norethisterone 5mg (Tab. Primolut-N, Tab. Noregyn) x TDS
Norethisterone Guidelines: 1 tablet x TDS (15 mg) for 10 days. After stop taking the tablets patient will usually
have bleeding like a period. To stop periods causing problems again, Doctor may tell to patient to take
Norethisterone Tablets for a few days after your next two periods. Advice to take 1 tablet twice a day (10 mg)
for 8 days. Patient will need to start taking these tablets 19 days after your last period began.

OLIGOMENORRHEA RX
Name: Age: Sex: Date:
Temperature: B.P: Pulse: Resp. Rate:
<r Definition: Influent menstrual periods
<Jr Causes: PCOS, Cushing syndrome, Prolactinoma, PID, Asherman syndrome, hyperthyroidism, CAH.

� Oligomenorrhea
C/C:
» Menstrual period at interval of> 35 days.
» Usually light menstrual flow Treat underlying cause
» Irregular menstrual periods with unpredictable flow First line drug if no underlying pathology
» Fever than 6 to 8 periods over year

Investigations: CBC, HBAlC, TSH, T3, T4, LH, FSH, Serum » Tab. Dydrogesterone 10mg (Duphaston)
prolactin, testosterone level and USG pelvis 1-0-1 (BO)
 NAUSEA AND VOMITING OF PREGNANCY (UNCOMPLICATED) RX

� Nausea and vomiting of

pregnancy
�x
C/C: <r Rehydration (oral hydration is usually sufficient)
Clinical diagnosis <Jr Adapt diet and avoid triggers.
,,
))

)) Nausea Advice Ginger tea, if patient unable to take anti-emetics

and/or vr Replace iron-containing supplements with folate-containing prenatal vitamins.
vomiting (Cap. Iberet folic, Cap. Fefolvit or Tab. Maltofer Fol)
)) Normal vital signs, <:I" Antiemetic therapy for nausea and vomiting of pregnancy: If the response to

lab findings, and normal an antiemetic from one class is inadequate, add an antiemetic from another
physical examination class in a stepwise manner, as shown below.
.................................... 1. Tab. Doxylamine 10mg + Vitamin-86 l0mg (Envepe, Femiroz) x TDS/8D
Or Tab. Meclizine 25mg + Vitamin-86 50mg (Navidoxine) x 8D
2. For refractory symptoms despite combination therapy above, add one of
the following:
)) Tab. Dimenhydrinate 50mg (Gravinate) x TDS
)) Or Tab. Metoclopramide 10mg {Maxolon, Metoclon) x TDS
))Or Tab. Ondansetron 8mg (Onset, Onseron) x 4-8mg x TDS
Reference )) Or Tab. Prochlorperazine 5mg {Stemetil) x TDS
RCOG guideline )) Or Tab. Promethazine 25mg (Avomine) x TDS
AMBOSS
NICE )) Consider also: Change oral Dimenhydrinate (Gravinte) to IV.
3. Last resort: Add methylprednisolone (see Hyperernesis Gravidum)

HYPEREMESIS GRAVIDUM (HG) RX

� Hyperemesis Gravidum
C/C:
Clinical diagnosis
�x
➔
))
<r Admit the patient (Inpatient admission) Consult O8/GYN
)) Characterised by severe,
protracted nausea & vomiting v,- IV fluid resuscitation/replacement: Start IV fluids containing Dextrose 5%,
associated with Weight loss Ringer lactate or Normal saline to replete volume and reverse ketonuria.
more than S % from before .,. IV Electrolyte repletion: if -l- K++ add 25ml KCL in 1L NS or calculate deficit
pregnancy weight, dehydration er IV Thiamine repletion {lnj. Neurobion), consider in patient with severe
and electrolyte imbalances. recurrent vomiting, better add in Ringer Lacate.
,,, .................................. er IV Antiemetic Therapy
Laboratory analysis )) lnj. Dimenhydrinate 50mg (Gravinate) x IV x TDS
>> Electrolyte disturbances Or lnj. Metoclopramide 10mg {Metaclon) x IV x TDS
(hypokalemia & hypochloremic )) If fail: lnj. Ondansetron 8mg x IV over 10-15 min. x BD/TDS
metabolic alkalosis) )) If fail: lnj. Hydrocartisone 100mg x IV x 8D Or lnj. methylprednisolone
>> Signs of dehydration
16mg x IV x TDS for 3 days/once improvement occurs, than convert it
( 1' hematocrit)
to Tab. Prednisolone 5mg (Deltacotril) x 4O-S0mg daily PO, with the
» Ketonuria (urine ketone 2++)
dose gradually tappered down until the lowest maintainance dose that
» Urea increase
controls the symptoms is reached.
Reference qr Consider enteral tube feeding (nasogastric/nasoduodenal) or TPN.
RCOG guideline
r:r Closely monitor vitals and urine output.
AMBOSS
NICE qr Monitor urine ketones, Urea, creatinine & electrolytes, and BMI.

cr Check other co-morbidities that causes severe nausea/vomiting

 SAFE MEDICINES IN PREGNENCY - CATEGORY 'B' DRUGS (CATEGORY 'C' ARE HIGHLITED)
See section drug brands for brahd names available in Pakistan

r Metoclopramide (Metaclon)
r:r ANTI-EMETICS r:r Doxylamine
cr Dicyclomine
�- Meclizine

Cir Promethazine (Category-Cl

r:r DRUG FOR PEPTIC ULCER
er Ondansetron (Onset)
cr Dimenhydrinate (Gravinate)
r:r Famotidine
r:r Omeprazole (Risek) (Category-()
er Pantoprazole (Zopent)
r:r Esomeprazole (Nexum)
er Sucralfate (Ulsanic)
er Aluminum hydroxide

r:r ANTACIDS r:r magnesium hydroxide

r:r Calcium carbonate (Category-()
er Simethicone (Category-Cl

"'
.r Dietary fibre

LAXATIVES <r lsphaghol

\I" Lactulose

� Glycerine suppositories
cr Paracetamol

rr NSAIDS: Associated with oligohydramnios, premature closure of the

r:r ANALGESICS
r:r ANTI-SPASMODIC
fetal ductus arteriosus with subsequent persistent pulmonary
hypertension of the newborn, fetal nephrotoxicity, and
periventricular hemorrhage.
)) Ibuprofen (Use with caution; avoid in third trimester)
)) Naproxen (Use with caution; avoid in third trimester)
Better to avoid, Paracetamol/acetaminophen is safe
(ir Drotaverine

r:,r Phloroglucinol

cr Penicillin group

)) Penicillin-G
)) Ampicillin (Penbritin)
)) Amoxicillin (Amoxil)
)) Cloxacillin
)) Piperacillin
)) Co-Amoxiclav (Augmentin)
Cir Cephalosporins (almost all are safe)

)) Cephalexin (Keflex)
)) Cephadroxil (Cedrox)
 )) Cephradine (Velocef)
» Cefaclor (Ceclor)
)) Cefuroxime
)) Ceftriaxone
<r ANTIBIOTICS )) Cefixime
<It Macrolides
)) Azithromycin (Azomax)
)) Erythromycin (Erythrocin)
)) Clarithromycin (Category-C)
This drug should not be used during pregnancy unless there are
no alternatives and the benefit outweighs the risk to the fetus.

<If' Clindamycin (Delacin-C)

er Vaneomycin

-
er Nitrofurantoin (Fetus-Hemolytic anemia -Reported in some cases)
<I Meropenem

Aztreonam
<JI Fosfomycin
c:,- lmipenem-cilastatin

., lsoniazid
<1t ANTI-TUBERCULOUS " Rifampicin
<JI Ethambutol

I Pyrazinamide

" Chlorpheneramine malate

Cl" 0i_phenhvdramine

<It Loratidine
c:r ANTI-ALLERGIC ,:;r Cetirizine

Cl Levocetirizine

Above Antihistamine are not recommended in the 1st trimester can

lead to fatal defects
Consider Meclizine and Cyclizine
er Saline nasal spray
,.,. OKymethazoline
<:I' Xylometazoline

<:I' Diloxanide furate

<ii"' ANTI-AMOEBIC <r Paramomycin

er Nitazoxanide
7 Metronidazole (should be avoid in 1st Trimester)

Use in First trimester: Fetus- Low birth weight babies, spontaneous

abortions, and carcinogenic possibilities
er Chloroquine
r:r Mefloquine
,:;r ANTI-MALARIAL <1r' Quinine

<1r' Proguanil

For first trimester

r:r Piperazine
 • •
•
• • • •
••
·•
C Peadiatrics
•
• • • • •• •
� THE NEWBORN INFANT
NEWBORN TERMINOLOGY

...
GENERAL
Infant: A child under 1 year of age
I

....,.
rr Newborn (Neonate):
Perinatal period:
Postpartum period:
or Live birth:
TIMING OF BIRTH
,,. Term birth:
)) Early term infant: Live birth between 37 0/7 weeks and 38 6/7 weeks of aestation
)) Full term infant:
)) Late term infant:
<I" Preterm infant:
A child under 28 days of age
The period from the 22nd week of gestation to the 7th day after birth
First 6-8 weeks after birth
Postnatal presence of vital signs (e.g., respiration, pulse, umbilical cord pulse)
Umbrella term for live births between 37 and 42 weeks of gestation
Live birth between 39 0/7 weeks and 40 6/7 weeks of aestation
Live birth between 41 0/7 weeks and 41 6/7 weeks of gestation
Live Birth Between 20 0/7 Weeks And 36 6/7 Weeks Of Gestation

-
<Jr Postterm infant: Live Birth After The 42nd Week Of Gestation
EVALUATION OF BIRTH WEIGHT
Aooropriate-for-gestational-a11e Infant (AGA): Birth Weiaht 10th-90th Percentile For Gestational Age
Birth Weiaht< 10th Percentile For Gestational Aile

...
<Jr Small-for.gestatlonal-aae infant (SGAl:
<r Large-for-gestational-age infant (LGA): Birth Weight> 90th Percentile For Gestational Aile
Low birth weight
" Birth weight<2,500 g regardless of the gestational age
" Occurs in early term infants and Infants with Intrauterine growth restriction
)) Associated with Increased mortality, particularly due to sudden infant death syndrome
)) Very low birth weight: birth weight between 1,000-1,499 g regardless of the gestational age
)) Extremelv low birth weight:birth weight< 1,000 g reaardless of the gestational age
PREGNENCY LOSS
<r' Miscarriage (spontaneous abortion) <r Stillbirth (fetal death)
)) Absence of vital signs )) Absence of vital signs
)) Pregnancy loss before the 20th week of )) Most US states report fetal death if pregnancy loss occurs
gestation during or after the 20th week of gestation
)) Fetal weight less than 500 g )) Fetal weight more than 500 g
,.
IMMEDIATE CARE & APGAR SCORE -
Immediate Care Of The Newborn
<r' Wipe the newborn's mouth and nose to clear airway secretions, use suction only If necessary.
er Dry and stimulate the newborn.
Qr Provide warmth.
rr Skin-to-skin contact with mother and Initiation of breastfeeding

...
rr Clamp and cut the umbilical cord.
Apgar score assessment at 1 and 5 minutes after birth
,-,- Begin resuscitation if onset of respirations has not yet occurred within 30-60 seconds
Apgar score
Apgar score:Appearance, Pulse, Grimace, Activity, Respirations
,-,- Used for standardized clinical assessment of newborns at 1 and 5 minutes after birth
)) Five components: skin color, heart rate, reflex irritability to tactile stimulation, muscle tone, respiratory effort
)) Each component is given 0-2 points, depending on the status of the newborn.
)) The total Apgar score is the sum of all five components.
o:r Assessing the need for and beginning neonatal resuscitation should be done independently of and before the Apgar

.,,.
score is determined
Assessment of the Apgar score at 5 minutes:infants with scores <7 may require further intervention
)) Reassuring: 7-10
)) Moderately abnormal: 4-6

.,,.
)) Low:0-3
In infants with a score below 7, the Apgar assessment is performed at 5-minute intervals for an additional 20 minute
(Jr Persistently low Apgar scores are associated with long-term neurologic seciuelae.
 DEHYDRATIO & TREATMENT PLA

ASSESSMENT OF DEHYDRATION
MODERATE
FEATURES MILD DEHYDRATION DEHYDRATION SEVERE DEHYDRATION
Condition Normal/awake Restless, Irritable Lethargic/Unconscious
Eyes Normal Sunken Very Sunken & dry
Tears Present Absent Absent
Mouth & Tongue Moist, Wet Dry Very dry
Thirst Drinks normally, not thirsty Thirsty, drink eagerly Drinks poorly/not able to drink
Skin pinch Goes back quickly Goes back slowly Goes back very slowly
Very fast, weak, or you cannot
Pulse Normal Faster than normal feel it
Decide TI1e patient has no signs of lfthe patient has two or more If the patient has two or more
dehydration signs. including at least one signs, including at least one sign,
sign , moderate dehydration severe dehydration
Treatment Use treatment PLAN A Weight the patient and Weight the patient and
treatment PLAN B urgently treatment PLAN C

TREATMENT OF DEHYDRATION ACCORDING WHO & IMNCI GUIDLINES

vr Mother educated to use increased amounts of home available tluids

PLAN-A vr ORS packets or prepared solution (Pedialyte or Pedicare solution) is advice for use at home
'-I' Breast feeding should be continued

" Rehydration therapy

PLAN-B )) Correction of existing water and electrolyte deficit

qr
75 ml /kg ORS iujirst 4 hours
Maintenance therapy
I
)) Replacement ofongoing losses due to continue diarrhea
)) Start when signs of dehydrations disappear usually in first 4 hours
10-20 ml /kg ORS/or eaclt liquid stool
I
'7 Start IV fluid immediately
qr Best recommended Intravenous fluid solution is Ringer's lactate (Hartmann's solution)
PLAN-C qr Normal saline can be used
qr Dextrose is not effective.
qr lOOml/kg of fluid is to be given as shown below:
Age First, give 30ml/kg in: Then, give 70ml/kg in:
< 12 months old 1 hour 5 hours
2:12 months to 5 years 30 minutes 2, 1/2 hours
er Repeat once if the radial pulses is still very weak or not detectable
cr Reassess the child every 1-2 hours. If hydration status is not improving, give the intravenous
drip more rapidly.
qr Also give ORS (about 5 ml/kg/hour) as soon as the child can drink; usually after 3-4 hours

.... (Infants) or 1-2 hours (children).

Reasses:. an infant after 6 hour:. and a child after 3 hours. Clc1s:.ify dehydration than choose

-.m the appropriate plan (A, B, or C) to continue the treatment.

- ACUTE TONSILLITIS RX
• Tonsillitis
C/C:
Most commonly seen in school
going children
Most common cause-viral
infections: Tonsilitis initially starts
with viral infection followed by
secondary bacterial infection.
The leading symptoms tend to be
mild and non-specific, and include:
)) Fever, malaise, headache
)) Sore throat (acute phase)
» Runny nose, Dry Cough in 1/3
)) Nasal obstruction
)) Headache
)) Low-grade fever
Cough (dry) in 1/3
))
Particularly in very young
))
children, feeding may be
affected
Signs
)) lnflammed tonsils, pillars, soft
palate, uvula
)) Bilateral jugulodigastric lymph
nodes are enlarged and tender.
.....................................
» Most of the infections are due
to Streptococcus and penicillin
is the DOC.
» Patients allergic to penicillin can
be treated with Macrolides:
Erythromycin OR Clarithromycin.
» Other: Cephalexin, Cefadroxil
» Improvement can be expected
within 3-4 days.
» Antibiotics should be continued
for 5-7days (10 days)
» Azithromycin only for 5 days
�x
er Self-limited; Antibiotic therapy for acute Group 'A' Strept pharyngitis
"'
recommended to prevent rheumatic fever
Patient are kept on bed rest
er Encourage good oral hydration and food intake
"' Steam inhalation may be benefited
156.25mg/5ml (Augmentin, Calamox)
1. Syp. Co-Amoxiclave 312.50mg/5ml (Augmentin OS, Calamox DS)
Dosage: 25-40mg/kg/day x divided every 8-12 hourly.
TDS/BD (1 Teaspoonful= 5ml)
OR Syp Cefadroxil 125mg/5ml, 250mg/5ml (Cedrox, Duricef)
Dosage: 30mg/kg/day divided every 12 hourly PO (Max: 2g/day).
BD (1 Teaspoonful= 5ml)
l<;�!P.R!.§PJ.l}.�, P.�n i:!g9.[.(9.�-� =250mg/5ml)
2. Syp. Paracetamol (�.c!!P.9.! =120mg/5ml, P.�n!:!gQ[.=160mg/5 ml)
TDS/QID (1 Teaspoonful = 5ml)
Dosage: 10·15mg/kg/Dose
If symptoms of allergy, hay fever, cough & common cold.
3. Syp. Dextromethorphan + Chlorpheniramine Maleate (Babynol)
1-2 teaspoonful TDS
�x
1. Syp. Azithromycin 200mg/5ml (Azomax, Zetro, Azitma)
Dosage: lOmg/kg on day 1 (Max: 500 mg/day) followed by 5mg/kg/day
once daily for 5 days (Max: 250 mg/day).
OD (1 Teaspoonful= 5ml)
Or Syp. Clarithromycin 125mg/5ml, 250mg/5ml (Claritek, Klaricid)
Dosage: 15mg/kg/day x BO (Maximum dose lg/Day)
BO (1 Teaspoonful= 5ml)
2. Syp. Ibuprofen (Brufen= 100mg/5ml, Brufen OS= 200mg/5ml)
Dosage: lOmg/kg/dose x 6-8 hourly (max daily dose:40mg/kg/day)
TDS/QID (1 Teaspoonful = 5ml)
If symptoms of allergy, hay fever, cough & common cold.
3. Syp. Dextromethorphan + Chlorpheniramine + Ephedrine (Corex-0)
1-2 teaspoonful x TDS
 LOWER REPIRATORY TRACT INFECTION (CHEST INFECTION) Rx
Name:
Temperature:
f::. LRTI (Chest infection)
C/C:
» Fever
» Cough and Irritability
» Poor feeding
» Vomiting
» Tachypnoea at rest
(most useful sign)
- <2 months:>60/min
- 2-11 months:>SO/min
- 1-5 year:>40/min
» Bronchial breathing
» lnspiratory crackles
» Recession
» Abdominal pain (referred
pleural pain)
Investigation:
» CBC
» Blood culture
» Chest-X-ray PA view
Admit children with sats
<92%, RR>70, t t HR, t
CRT or apnoea/grunting
Ill CHILD if ANY of the
following:
ar Poor perfusion
" Altered level of
consciousness
er Respiratory failure:
Hypoxia, Hypercapnia and
Acidosis
Admit to hospital
ar Resuscitate
ar Start IV antibiotics &
antipyretic
ar Discuss case with PICU
Age: Sex: Date:
B.P: Pulse: Resp. Rate:
156.25mg/5ml (Augmentin, Calamox)
1. Syp. Co-Amoxiclave 312.50mg/5ml (Augmentin OS, Calamox OS)
Dosage: 25-40mg/kg/day x TDS/BD (1 Teaspoonful= 5ml)
Or Syp. Cefuroxime 125mg/5ml (Zecef, Kefrox, Evorox)
Dosage: 20-30mg/kg/dose (Max: 500 mg/dose) x BO
Or Syp. Cefixime 100mg, 200mg (Cefspan, Cefiget)
Dosage: 8-l0mg/kg/day x BO
1-0-1 (OD)
L<;�)P.Q!.§P.l.1,1.�• .P.�n�gQ[.fQIT.� =250mg/Sml)
2. Syp. Paracetamol L<;.<!)P.Q!=120mg/Sml, .P.�n�g9.!= . l60mg/S ml)
TDS/QID (1 Teaspoonful= 5ml)
Dosage: 10-lSmg/kg/Oose
3. Syp. Anti-tussive {Cough suppressants) (Hydrillin, Babynol, Corex-D)
1-2 Teaspoonful x TDS
1. Syp. Azithromycin 200mg/5ml (Azitma, Zetro, Azomax)
Dosage: lOmg/kg/day x once daily
0-0-1 (OD)
Or Syp. Clarithromycin 125mg, 250mg (Klaricid, Claritek)
Dosage: 15 mg/kg/day x BO (1 Teaspoonful = 5ml)
1-0-1 (OD)
( �.i!)P.Q!.§PJ.9.�, .P..1m�g9.[.fQIT.� =250mg/Sml)
2. Syp. Paracetamol L<;.<!)P.Q!=120mg/Sml, .P.lm�g9.!_=l60mg/S ml)
TDS/QID (1 Teaspoonful= 5ml)
Dosage: 10-lSmg/kg/Dose
3. Syp. Anti-tussive (Cough suppressants) (Hydrillin, Cofrest, Corex-D)
1-2 Teaspoonful x TDS
Neonate/infant prescription
(Augmentin, Calamox, Amclav infant drops)
1. Co-Amoxiclave 62.Smg/ml Infant drops
Dosage: 30mg/kg/day x TDS
Or Syp. Cefaclor S0mg/ml infant drops (Ceclor, Cefalor, Hiclor)
Dosage: 30-40mg/kg/dose x BD/TDS
Or Syp. Cefixime 100mg (Cefspan, Cefiget)
Dosage: 8-lOmg/kg/day x BO
(_Panadol (80mg/0. 8ml) infant drops)
2. Paracetamol (Tempol lOOmg/ml infant drops)
Dosage: 10-lSmg/kg/Dose
3. Anti-tussive/cough suppressants infant drops: (Coferb, Cofif, Hylixia)
Dosage - Children 6 months to 1 year: 12-14 drops 3 times a day
 ACUTE SUPPORATIVE OTITIS MEDIA (ASOM) Rx I

7 Acute inflammation of middle ear cleft <3 weeks, infective in origin.

'if'" One of the most common infectious disease seen in children Stages of ASOM
'ii'" Peak incidence - first 2 years of life 1. Stage of tubal occlusion
,,-. Most common route of infection is through Eustachian tube 2. Stage of pre-suppuration
-r Organism 3. Stage of suppuration
» Bacterial: Streptococcus pneumoniae (Most common), 4. Stage of resolution
H. influenzae (2nd most common), Moraxella catarrhalis 5. Stage of complication
» Viral: Synctial virus, Influenza virus, Rhino and adeno virus
6_ASOM
C/C:
» Ear Pain: Older children will most
1. Syp. Amoxicillin 125mg/5ml, 250mg/5ml (Amoxil, Zeemox)
frequently report ear pain; in
Dosage: 40mg/kg/day in three divided doses
infants and nonverbal children
TDS (1 Teaspoonful = 5ml)
symptoms can be nonspecific, and
may be easily confused with other 312.50mg/5ml (Augmentin DS, Calamox DS)
conditions. Or Syp. Co-Amoxiclave 156.25mg/5ml (Augmentin, Calamox)
» General symptoms Dosage: 25-40mg/kg/day x divided every 8-12 hourly.
- Otalgia/Earache, commonly TDS/BD (1 Teaspoonful = 5ml)
described as throbbing pain. (�.<!!P.9.!.�P.l.l:l.�. P..!!!1�9.9.l.t9.rt�. =250mg/Sml)
- Hearing loss in the affected ear 2. Syp. Paracetamol LC.<!! P.9.!=120mg/Sml, P..!!!1�9.9.l=160mg/S ml)
- Fever TDS/QIO (1 Teaspoonful = 5ml)
- Otorrhea (Ear Discharge) in the Dosage: 10-15mg/kg/Oose
case of a ruptured tympanic Or Syp. Ibuprofen (Brufen=lOOmg/Sml, Brufen DS=200mg/Sml),
membrane. Dosage: lOmg/kg/dose x 6-8 hourly
Maximum daily dose: 40mg/kg/day
Examination findings
TDS/QID (1 Teaspoonful= 5ml)
Otoscopy
» Bulging tympanic membrane (TM) 3. Polymyxin + Lidocaine Ear drops (Otocain)
with loss of landmarks Or Ciprofloxacin + Lidocaine Ear drops (Cipocain)
» Opacification and loss of light 2-3-drops 3-4 time a day
reflex
» Retracted and hypomobile TM
» Purulent/serosa nguinous
discharge in the external auditory 1. Syp. Cefaclor 125mg/5ml, 250mg/5ml (Ceclor, Cefalor)
canal or visible perforation Dosage: 20mg/kg/day 2-3 times a day
» Distinct erythema of the TM BD/TOS (1 Teaspoonful = 5ml)
» Additional findings that may be
(Cefspan DS, Cefiget OS = 200mg/5ml)
present: Yellow spot on the TM,
Or Syp. Cefixime (Cefspan, Cefiget = 100mg/5ml)
Cartwheel TM, Blisters/bullae on
Dosage: 16mg/kg/day every 12 hourly on day 1, then 8
the Tympanic membrane (TM)
mg/kg/day for 13 days.
Tuning fork test: hearing loss BO (1 Teaspoonful= 5ml)
secondary to an effusion. (Ponstan DS 100mg/5ml, Dollar DS 100mg/5ml)
CBC: Leukocytosis maybe present 2. Syp. Mefenamic acid (Ponstan 50mg/5ml, Dollar 50mg/5ml)
Dosage: 3mg/kg/dose OR in some Books >6 months 6.5-25
Gram stain and culture of middle ear mg/kg daily 3-4 times daily for not longer than 7 days.
fluid - if patient not responded to Rx TDS (1 Teaspoonful = 5ml)
Blood cultures: indicated only in
3. Tobramycin + Dexamethasone Ear drops (Dexatob)
severe infection
Or Ciprofloxacin+Dexamethasone Ear drops (Cipotec-D)
Duration of antibiotics: 7-10 days 2-3-drops 3-4 time a day
 MALARIA FEVER (FALCIFARUM MALARIA) Rx
Name: Age: Sex: Date:
Temperature: B.P: Pulse: Resp. Rate:

� Malaria fever
C/C: �x
)) Fever with chill and rigor
)) Headache/Body ache (Artheget junior 15+90mg/Sml)
)) Sweats 1. Syp Artemether 15mg + Lumefantrine 90mg (Artem 15+90mg/Sml)
)) Abdominal pain
)) Nausea and vomiting. OD/BO (See standard dosage below)
)) General malaise & Fatigue Available brands: Syp. Artem/Artheget junior/Gen-M 15+90mg/Sml
)) Loss of appetite
)) Jaundice in preparation of 30ml and 60ml bottle
)) Splenomegaly
·····································
Kc!)P.Q!. §P.1.1.l.�, P.f!!1f!9.9.!.f9.!l�. =250mg/Sml)
Investigation:
2. Syp. Paracetamol ($;f!)P.Q! =120mg/Sml, P.f!f!i!9.9.L=160mg/5 ml)
)) CBC
» Malaria Parasite: If malaria TDS/QID (1 Teaspoonful= 5ml)
is diagnosed on blood film,
Dosage: lSmg/kg/Dose
but type unclear, treat as
falciparum malaria OR Syp. Ibuprofen (Brufen= 100mg/5ml, Brufen OS= 200mg/5ml)
)) MP ICT Rapid test
Dosage: l0mg/kg/dose x 6-8 hourly
)) Do not treat unless ICT or
blood film positive Maximum daily dose: 40mg/kg/day)
)) If negative and clinical TOS/QID (1 Teaspoonful= 5ml)
suspicion of malaria, send a
repeat after 12-24hr and
third after further 24hr 3 Syp Multivitamins/Appetite stimulant (Lysovit, Tresorix forte)
....................................
Treat malaria as falciparum until 1-2 Teaspoonful BD/OD
proven other wise

DOSAGE AND ADMINISTRATION OF ARTEMETHER lSMG + LUMEFANTRINE 90MG ORAL SUSPENSION

Body Weight (Kg) 1st Day 2nd Day 3rd Day
5-7.4 Kg 7ml 7ml 7ml
7.5-9.9 Kg 10 ml 10 ml 10 ml
10-12.4 Kg 14ml 14ml 14ml
12.5-14.9 Kg 17ml 17ml 17ml
15-17.4 Kg 20 ml 20 ml 20 ml
17.5-19.9 24ml 24ml 24ml
19.9-25 Kg 26 ml 26 ml 26 ml

Qr Daily dosage for 3 days x OD/BD, should be taken with food or milk.
Qr Patients who vomit within 1 hour of taking the medication should repeat the dose.
 MEASELS (RUBEOLA) Rx
Name: Age:
Temperature: B.P:
6 Measles (Rubeola)
C/C:
Incubation period: 10-14 days
Prodromal/catarrhal stage: 4-7 days
» Coryza, cough, and conjunctivitis
» Fever
» Koplik spots: .P.iHh.C?&n.C?m.C?n!c.'!!JJ.�n.t�. .'!!.m.9J
-��-�.QJ.!C�.�!. m��9.�i! ➔ Tiny white or bluish­
gray spots on an irregular erythematous
background that resemble grains of sand
Exanthem stage: Duration is 7 days
(develops 1-2 days after enanthem)
» High fever, malaise
» Generalized lymphadenopathy
» Erythematous maculopapular, blanching,
partially confluent exanthem
• Begins behind the ears along the
hairline
• Disseminates to the rest of the body
towards the feet (palm and sole
involvement is rare)
• Fades after ~5 days of onset, leaving a
brown discoloration and desquamation
in severely affected areas
Recovery stage: The cough may persist for
another week and may be the last remaining
symptom.
CBC: I leukocytes, I platelets
Serology is Gold standard: detection of
Measles-specific rgM antibodies.
Administration of vitamin A has been reported
to reduce seroconversion in vaccinees and
should therefore be avoided at or after
Immunization.
The efficacy of ribavirin administration in
__,_____TT--:=;;;71-....---r-._--,r--,
severe measles is un roven.
Sex: Date:
Pulse: Resp. Rate:
� Rx is supportive therapy, such as Antipyretics, vitamin-A
supplementation, and cough suppressants.
-r Bacterial superinfection should be promptly treated with
appropriate antimicrobials, but PfQPhvlactic antibiotics to
prevent superinfection are of no known value.and are
therefore.not. recommended.
7 �upplementation with Vitamin A, 200,000 IU
administered orally to children once daily for 2 days, has
been reported to decrease the severity of measles,
especially in those with vitamin A deficiency
" < 6 months old should receive 50,000 JU for 2 days.
" Children 6 months to 1 year x 100,000 JU for 2 days.
1. Syp. Azithromycin 200mg/5ml (Azomax, Zetro)
Dosage: lOmg/kg on day 1 (Max: 500 mg/day) followed
by Smg/kg/day once daily for 5 days
Maximum daily dose: 250 mg/day.
0- 0- 5ml OD (1 Teaspoonful= 5ml)
L<;.c!!P.R!.�P.1.Y.�, P.i!!li!9.9.U9.rtf!! =250mg/Sml)
(�i!!P.R! =120mg/Sml, P.!!!li!9.9.!.=160mg/5 ml)
2. Syp Paracetamol
Dosage: 10-lSmg/kg/Dose
TDS/QID (1 Teaspoonful= 5ml)
(Brufen OS OR Bludol OS = 200mg/Smll)
3. Syp. Ibuprofen (Brufen OR Bludoi = 100mg/5ml)
Dosage: lOmg/kg/dose x 6-8 hourly (max daily
dose:40mg/kg/day)
TDS/QID (1 Teaspoonful= 5ml)
If symptoms of allergy, hay fever, cough & common cold.,
4. Syp Dextromethorphan + Chlorpheniramine +
Ephedrine (Corex-D, Cofrest) x TDS
5. Vitamin-A supplementation (A-MAX Drops)
i
HYPERTHYROIDISM Rx
Name: Age:
Temperature: B.P:
,6,.
Hyperthyroidism
C/C:
> Hyperthyroidism is more common in females
than males. In children, it most frequently
occurs during adolescence.
> The course of hyperthyroidism tends to be
cyclic, with spontaneous remissions and
exacerbations. Symptoms include poor
concentration, hyperactivity, fatigue, emotional
labiality, personality disturbance/unmasking of
underlying psychosis, insomnia, weight loss
(despite increased appetite), palpitations, heat er Antithyroid agents (methimazole/Carbimazole):
intolerance, increased perspiration, increased
stool frequency, polyuria, and irregular menses.
> Signs include tachycardia, systolic hypertension,
increased pulse pressure, tremor, proximal
muscle weakness, and moist, warm, skin.
Accelerated growth and development may
occur.
> Thyroid storm is a rare condition characterized
by fever, cardiac failure, emesis, and delirium
that can result in coma or death.
> Most cases of Graves' disease are associated
with a diffuse firm goiter.
> A thyroid bruit and thrill may be present.
> Many cases are associated with exophthalmos
Laboratory Findings
> Decrease TSH, T4, Free T4, 13, and free T3 (FT3)
are elevated except in rare cases in which only
the serum T3 is elevated (T3 thyrotoxicosis).
> The presence of thyroid-stimulating
immunoglobulin (TSI) or thyroid eye disease
confirms the diagnosis of Graves' disease.
> TSH receptor-binding antibodies (TRAb) are
usually elevated.
Treatment guidelines
» Clinical response in 2 -3 weeks
» Adequate control in 1 -3 months
» Durations: 5 years
Sex: Date:
Pulse: Resp. Rate:
.,. Strenuous physical activity should be avoided in
untreated hyperthyroidism.
,,. Beta-Adrenergic blockers: These are adjuncts to
therapy. They can rapidly ameliorate symptoms and
are indicated in severe disease with tachycardia and
hypertension. Bl-Specific agents such as atenolol are
preferred because they are more cardioselective.
Propranolol also decreases conversion of T4
Antithyroid agents are frequently used in the initial
treatment of childhood hyperthyroidism. These drugs
interfere with thyroid hormone synthesis, and usually
take a few weeks to produce a clinical response.
Adequate control is usually achieved within a few
months. If medical therapy is unsuccessful, more
definitive therapy, such as radioablation of the
thyroid or thyroidectomy, should be considered.
Propylthiouracll lPTU) is rarely utilized because of
reports of severe hepatotoxicity.
1. Tab. Propranolol lOmg (lnderal, Cardinal) x 80/TDS
Dosage: 0.5mg to 2mg per kg per day
2. Tab. Carbimazole 5mg (Neomarcazole) x 00/80
» Dose per kg body weight: Dose typically used is
0.2mg -O.Smg/kg per day (or 0.1mg to
1.0mg/kg per day)
» Fixed doses:
• Infants: 1.2Smg/day
• 1-5 years: 2.5 to 5.0mg per day
• 5 -10 years: 5.0mg to 10mg per day
• 10-18 years: 10 -20mg per day
» With severe clinical or biochemical
hyperthyroidism, doses that are 50%-100%
higher than the above can be used.
 • •
•
• ••• •
••
•
Pediatric & Neonatal Drug Dosage with
CH
National & International Drugs Brand Names •
• • • • •• • •

(;cncric N:tnu·: PanU.'l'tamol

► Brand ame with Drug Concentration:
» Syp Panadol (160mg/5ml), Syp Panadol Fort (250mg/5m I)
» Syp Tempol (120mg/5ml), Syp Tempo! 6plus (250mg/5ml)
» Syp Calpol, Syp Calpol 6 plus
» Peadiatric Drops: Panadol Drops (60mg/20ml). Tempol 6plus drops ( I 00mg,/20ml)
» IV Infusion: lnj Provas 1g/100ml, lnj Bofalgan l g/l 00ml
» IM Joj. Provas 300mg/2ml
» PR: Napa Suppository 125mg, 250mg, 500mg
► Route: Per Orally (PO), Intravenous (JV), Per Rectal (PR). Intramuscular (IM)
► Dosage: Recommended dose l O- I 5mg/kg/dose (4-6llourly)

Neonatal Dose Peudiatric Dose

Intravenous loading dose: 20 mg/kg/dose Intravenous:

Intravenous Maintenance dose: Children < 2 years: I 0-15 mg/kg,ldosc

every 6 hours
PMA 28-32 weeks: IO mg/kg/dose every 12 hours
Maximum daily dose: 22.5 mg/kg/day Maximum daily dose: 60 mg/kg/day

PMA 33-36 week9: IO mg/kg,ldose every 8 hours

Maximum daily dose: 40 mg/kg/day Children 2-12 years: 15 mg/kg every 6
hours or 12.5 mg/kg every 4 hours
PMA ;::37 weeks: IO mg/kg/dose every 6 hours
Maximum daily dose: 40 mg,lkg/day Maximum single dose: 15 mg/kg

Per Oral: Maximum daily dose: 75 mg/kg/day

GA 28-32 weeks: I 0-12 mg/kg/dose every 8 hours Per Oral: I 0-15 mg/kg/dose every 4-6
Maximum daily dose: 40mg/kg/day hours as needed: do not exceed 6 doses
in 24
GA 33-37 weeks <lO days: 10-15 mg/kg/dose hours
every 6 hours
Maximum daily dose: 60 mg/kg/day

Term neonates ?:10 days: 12-15 mg/kg/dose

every 6 hours
Maximum daily dose: 90 mg/kg/day

IV Administration: Give undiluted or dilute to a concentration of l mg/mL in Dextrose 5%

water (05%W) or 0.9% Normal Saline (0.9% N/S). Use within I hour of dilution.

❖ Overdoses of Paracetamol can be treated with Acetylcysteine.

 Generic Name: As >irin (Acctylsnlin lie Acid)

► Brand Name with Drug Concentration:

» Tab Disprin 300mg, Tab Disprin CV I 00mg
» Tab Loprin 75mg, 150mg
» Tab Ascard 75mg, 150mg

► Route: PO

► Dosage:
» Analgesic and antipyretic (children): 10-15 mg/kg/dose every 4-6 hrs.
» Anti-inflammatory: 60-90 mg/kg/day in divided doses.
» Antiplatelct: 1-5 mg/kg/day to 5-10 mg/kg/day given as a single daily dose (doses are rounded to
convenient amount e.g.. ½ of 80 mg tablet).
» Kawasaki disease: 80-100 mg/kg/day divided every 6hr
» Rheumatic fever: 60-100 mg/kg/day divided every 6hr

Generic l\amc: l\1cfcmnnic Acid

► .Brand Name with Drug Concentration:

» Syp Ponstan (50mg/5ml), Syp Ponstan fort (100mg/5ml)
» Syp Dollar (50mg/5ml). Syp Dollar OS (100mg/5ml)

► Route: Per Orally (PO)

► Dosage: Recommended dose 3mg/kg/dose OR in some books >6 moths 6.5-25 mg/kg daily 3-4 times
daily for not longer than 7 days.

Dose (May be prescribed up to 3 limes d:1ily)

» 6 months - J year » One 5 ml spoonful
» 2 years - 4 years » Two 5 ml spoonfuls
» 5 years - 8 years » Three 5 mJ spoonfuls
» 9 years - 12 years » Four 5 ml spoonfuls

Generic Numc: Dcxibu rofcn

► Brand Name with Drug Concentration:

» Syp Tercica (100mg/5ml)
» Syp Dexibu (I 00mg/5ml)

► Route: Per Orally (PO)

► Dosage: Recommended dose 10-15mg/kg in 2-3 divided doses

-
 Generic Name: Dom leridonc

► Brand Name with Drug Concentration:

» Syp Motilium (5mg/5ml)
» Syp Dome! (5mg/5ml)
► Route: PO
► Dosage: usually 0.3 mg/kg/dose every 6-8 hr.
» Gastro-oesophageal reflux disease, gastro-intestinal stasis (Off label use) in neonate by mouth 0.1-0.3
mg/kg 4-<> times daily before feeds
» For nausea and vomiting:
Child over 1 month and bodyweight up to 35 kg: 0.25-0.5 mg/kg 3-4 times daily
Maximum dose: 2.4 mg/kg in 24 hours
Body-weight 35 kg and over: I 0-20 mg 3-4 times daily
Maximum dose 80 mg daily
» Gastro-oesophageal reflux disease, gastro-intestinal stasis:
Child J month-12 years: 0.2-0.4 mg/kg (max. 20 mg) 3-4 times daily before food
Child 12-18 years: 10-20 mg, 3-4 times daily before food

Generic Name: Ondansetron

► Brand Name with Drug Concentration:
» lnj Zofran 4mg/2ml, Inj Zofran 8mg/4ml
» lnj Onset 8mg/4ml
» lnj Onseron 4mg/2ml, Syp Onseron 4mg, Tab Onseron 8mg
► Route: IM, IV, PO
► Indications: Prevention of Postoperative vomiting, chemotherapy induced vomiting, Radiation induced
vomiting, uncontrolled/severe vomiting
► Dosage for>6mooths: Safety and efficacy not established in infants< 6 months
» JV: 0.05 mg/kg (Range from 0.05-0.15 mg/kg per dose over 15 minutes is given by IV infusion
diluted in 25 to 30 ml of 0.9% /S Or 5% Dextrose
» PO: 2-4 mg 8 hourly , 4-8mg 12 hourly

Generic Name: Granisetron

► Brand Name with Drug Concentration:
» Inj Graniset (3mg/3ml) - CCL Pharma
» Tab Graniset I mg
► Route: TM, IV, PO
► Dosage for>6months:
» IV: Children> 2 year: I 0-20 mcg/kg half an hour before chemotherapy; 2-3 doses may be given.
(PO is given in adults: I mg BD or 2 mg OD I hour before chemotherapy)
-
 • •• • • •• •
••
•

• •
CHA Commonly Prescribe Drug Brands in Pakistan

• • • • •• • •

Non-Steroidal Anti-inflammatory Dru�s ( SAIDS)/Analgesic/Antipyretics/Opioids analgesics

Generic Brand & stren th Dosa e

» Tab Panadol 500mg, Tab Calpol 500mg

Paracetamol » Syp Panadol l60mg.15rnl, Syp Calpol 120mg./5ml
(Acetaminophen) » Syp Panadol Forte 250mg/5ml, Syp Calpol 6plus TDS/QID
250mg./5ml
» Infant drops: Panadol drop. Tempo! plus drop
» IV Infusion: Provas I g./100ml, Bofalgan
lg/1001111
» Na a su 125mg, 250m2, and 500m

Paracetamol + Caffeine » Tab Panadol Extra. Tab Cal ol lus TDS/ ID

Paracetamol + Pseucloephedrine + » Tab Panadol CF' TDS

Chlor >henirnmine mal eate » Tab Reltus CF

» Tab Bnifcn 200mg, 400mg, 600mg TDS

Ibuprofen » Syp Brufen, Syp Brufen DS
» lnj Xalcvc 400mg./4ml (Dilute in I 00ml N/S = IV)
» lnbufin 400mg/l 00ml IV infusion
» Brufcn cream

Oexibuprofen » Tab Tercica 200mg. 300mg. and 400mg TDS

» S' Tercica 100111 5ml

lbu rofen + codeine >hos hate » Tab Bnifen Plus 8O/T'DS

Meferrnmic acid » Tab Ponstan, Tab Ponstan forte TOS

» Tab Oollor, Tab Oollor DS
» S Oollor OS
Codeine phosphate+ Paracetamol +
Caffeine » Tab Na adoc TOS
» Tab Voltral 25mg, 50mg, I 00mg (SR)
Oiclofcnac sodium » Tab Voren 25mg, 50mg. I 00mg (SR)
» lnj Voren 75mg/5ml. lnj Voltral 75mg/5ml BO
» Voltral Emul el. Dicloran el

0iclolenac ota!isium » Tab Caflam 50mg, Tab Maxit 50m 0, 75m 0 BO

lndomcthacin » Cap Indobid 25mg

» In· Liometacen 50m •

Naproxen Sodium » Tab Neoprox 250mg, 500mg BD

» Tab Flexin 250mg, 500mg
» Tab S flex 550mo

Aceclofenac » Tab Acenac I 00mg BD

» Cap Acenac SR 200mg
» lnj Acenac 15mg x IM
» Acenac Gel
Aspirin )) Tab Disprin 300mg, Tab Disprin CY I 00mg
)) Tab Loorin 75ml?., Tab Loorin I S0ml?.

Flul'biprofen )) Tab Ansaid I 00mg. Tab synalgo I 00mg BO

)) Tab Froben 50mg, I 00mg
)) Cap Froben SR(200ml!.), Froben gel

Nimcsulide )) Tab Unix 100mg, Tab Nims 100mg BO

Pil'oxicam )) Cap Feldine 20mg, Tab Feldine 20mg BO

Meloxicam )) Tab Melfix 7.5mg, Tab Melfix 15mg BO

)) Tab Mobix 7.5 mg, Tab Mobix 15mg

Lornoxicam )) Tab Atcam 8mg. Tab Xikaraoid 8mg BO

Pil'oxicam + Beta Cvclodextl'in )) Tab Brexin 20ml?., Tab Briax 20mg BO

Paracetamol+ Orphenadrine citrate )) Tab Neubrol, Tab Neubrol forte aorros

)) Tab. Sinaxamol. Tab. Sinaxamol forte

Parncetamol + Thioridazine + caffeine )) Tab Diagcsic-P TDS

)) Cap Celbexx I 00mg, Cap Cclbexx 200mg
Celecoxib )) Cap Seleco I 00mg, Cap Seleco 200mg BO
)) Cao Nuzib I O0mi:i.. Cao Nuzib 200mg
)) Tab Flexia 60mg
Etol'icoxib )) Tab Etoxib 60mg BO
)) Tab Starcox 60msi.

Paracetamol 325m2 + Tramadol 37.Sme )) Tab Tramol plus, Tab Distalgesic, Tab Tonoflex-P BO/TDS

Paracetamol 650mf:?. + Tramadol 80me )) Tab Tonoflcx-P forte OD/BO

Ibuprofen+ Pseudoephedrine )) Tab Arinac. Tab Arinac forte TDS

)) Syp Arinac

Diacel'cin S0m2 )) Cap Diaroxx 50mg, Cap Diora 50mg BD

Tramadol )) Cap. Tramol 50mg, Tab Tramol SR I 00mg BD/0D

)) lnj Tramol I 00mg/2ml

Tapentadol 75111!! )) Tab Tapento IR 75mg 80/00

Morohine sulphate )) Cao. Mae.nus MR 101111?.. Cao Magnus MR 30mg Borros

Ketorolac )) lni. Toradol J0mwl ml. lni. Ketor J0mg/1 ml Borros

Buprenorphine )) lnj. Buepron 0.Jmg/1 ml, lnj Norpin 0.Jmg/1ml

)) Tab. Bunorfin, Tab Zonor

Pentazocine )) Inj. Pentazogon 30mg/1ml, Tnj Sosegon 30mg/1ml

)) Tab. Sosel!.on 25mg

Nalbuphine )) lnj. Kinz 10mg/1ml

)) lnj. Kinz 20mg/l ml
 COMMONLY USED A Tl-DEPRESSANT DR GBRAN0 I PAKISTAN

USUAL MAXIMUM
GENERIC BRA D DAILY DOSE
DOSAGE

)) Cap Prozac 20mg, Cap Flux 20mg

Fluoxctinc )) Cap Rize 20mg, Syp Rize 20mg 5-40 Mg 80 Mg
)) Cap Depricap 20mg, Syp Depricap 20mg
)) Cap Floxac 20m.e,, Tab Floxac 20mg

Citalopr-am )) Tab Ciprarn 20mg

)) Tab Celesta 20mg 20-40 mg 40 mg
)) Tab Cipramil 20mg
)) Tab Citalo 20mg

)) Tab Cipralex I 0mg, 20mg

Escitalopram )) Tab Estar 5mg, I 0mg, 20mg
)) Tab Pexnew 5mg. I 0mg, 20mg 10-20 mg 20 mg
)) Tab Citanew 5mg, 10mg, 20mg
)) Drops: Citanew I Omg/ml. Prolexa I Omg/ml

Fluvoxaminc )) Tab Flaverin 50mg, I 00mg 100-300 mg 300 mg

)) Tab Voxamine 50mg, 100mg

)) Tab Seroxat 20mg, Tab Seroxate 25mg

Paroxctine )) Tab Seroxat CR 12.5mg
20-30 mg 50 mg
)) Tab Paraxyl 20mg
)) Tab Paraxyl CR 12.SrnJI., 25mg and 37.5mg

Sertralinc )) Tab Zolofi 50mg

)) Tab Sestrin 50mg and I 00mg 50-150 mg 200 mg
)) Tab Sert 50mg and I 00mg
)) Tab Preloft 50mg and I 00mg

Venlafaxine )) Tab Enpress 37.5mg and 75mg

Cap Enpress XR 75mg
)) Tab Vendep 50mg, Tab Vendep XR 75mg 150-225 mg 225 mg
)) Cap Efexor XR 75mg and 150mg
Tab Efexor 37.5mg

Desvenlafaxine )) Tab Lafaxine ER 50mg

)) Tab Depistiq XR 50mg 50 mg 100 mg
)) Tab Venadex ER 50mg

Duloxetine )) Cap Dulan 20mg. 30mg and 60mg

)) Cap Lyta 20mg, 30mg and 60mg 30-60 mg 120 mg
)) Cap Zenbar 20mg, 30mg and 60mg

lmipramine )) Tab Tofranil 25mg 150-300 mg 300 mg

» Tab lmiuol 25mg

Clomioramine )) Tab Clomfranil I 0mg and 25mg 100 mg 250 mg

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