Case Paper Formats

Poisoning
___yrs old Male / Female patient • No H/o Salivation Lacrimation
b/b relatives to CPRH casualty Urination Fasciculation
Today At ___ with c/o • No Dilated pupils
____ ml ___________ • No jaundice
Consumption on __/__/____ at
__:__ pm • No oligouria Hematuria
• No Hematemesis
Gramaxone Poisoning
• Inform Seriousness • Iv 2° DNS & 2° D5X 24 hrly
• Written Concent • Inj Cyclophosphamide 500mg in 1
NS 1-0-0
• Do MLC
• Inj Mesna 600mg in 1 NS 1-0-0
• Do RT give Multani mitti Wash
till clear fluid comes • Inj MPS 500mg in 100ml NS 1-0-0
• Do Foley’s • Inj Monocef 1gm 1-0-1
• Urgent Hemodialysis (if • Inj Pan 40 1-0-1
consumption is <6hrs ) • Inj Vit C 1gm in 100ml NS 1-0-1
• Cap Vit E 1-0-1
TPR/BP/ SpO2 Monitoring
I/O Charting
OP Poisoning • Iv 2° DNS & 2° D5X 24 hrly
(×DM)
• Inform Seriousness
• Inj Atropine 5cc in 1 NS – TDS
• Written Concent
• Inj PAM 1gm in 100ml NS – TDS
• Do MLC
• Inj Augmentin 1.2gm – BD
• Do RT give KMnO4 Wash till
clear fluid comes • Inj Rantac 50mg – BD
• Do Foley’s
If P < 90/min Inj Atropine 2cc stat
• Inj Atropine 5cc stat If T > 102°F Hold Atropine
• Inj PAM 2gm iv stat Cold Sponging
TPR/BP/ SpO2 Monitoring
I/O Charting
Phenyl Poisoning
• Inform Seriousness • Iv 2° DNS & 2° D5X 24 hrly
• Written Concent • Inj Rantac 50mg – BD
• Do MLC
• No RT
TPR/BP/ SpO2 Monitoring
I/O Charting
Rat Kill Poisoning
• Inform Seriousness • Iv 2° DNS & 2° D5X 24 hrly
• Written Concent • Inj Pause 1 amp Stat & 1-1-1
• Do MLC • Inj sylate 1 amp Stat & 1-1-1
• Do RT give NS Wash till clear • Inj Vit K 30mg Stat & 1-0-0
fluid comes • Inj Pan 40mg OD
• Do Foley’s

TPR/BP/ SpO2 Monitoring

I/O Charting
 Snake Bites
___yrs old Male / Female patient No Ptosis
b/b relatives to CPRH casualty No Breathlessness
Today At ___ with c/o
No Difficulty in Swallowing
No S/O Int or Ext Bleeding
Snake Bite on ____________ at
__:__ AM/PM on __/__/____
• Bite Mark
• Local Swelling
• Local Temperature
Non Poisonous Snake Bites / Unknown Bites
• Inform Seriousness • Inj ASV 60U in 1 ° NS Stat (if
• Written Concent swelling)
• Do MLC • Inj Tramadol 1 amp in 100ml NS
(if pain)
• GM Dressing locally (if swelling)
• Tab Rantac 150mg BD
• Limb elevation (if swelling)
• Inj Emset 8mg (SOS)
• Tab Chymerol forte BD

• Inj ASV Test Dose stat

Deal Symptomatically
• Inj TT 0.5ML im stat
Hemotoxic Poisonous Snake Bite
• Inform Seriousness • Inj ASV 100U in 250ml TDS Stat
• Written Concent
• Do MLC
• GM Dressing locally • Inj ASV 60/100U in 250ml TDS
• Limb elevation • Inj Ampi 500mg 1-1-1
• Inj Pan 40mg 1-0-0
• Inj Emset 8mg 1-1-1
• Inj ASV Test Dose stat • Iv 3 pt NS 24 hrly
• Inj TT 0.5ML im stat • T Chymerol forte 1-0-1
Neuroparalytic Poisonous Snake Bite
• Inform Seriousness • Inj ASV 100U in 250ml TDS Stat
• Written Concent • Inj Rantac 50mg stat
• Do MLC • Inj Emset 8mg stat
• GM Dressing locally
• Limb elevation / Physiotherapy • Inj ASV 60/100U in 250ml TDS
• Inj Rantac 50mg BD
• Inj ASV Test Dose stat • Inj Emset 8mg TDS
• Inj TT 0.5ML im stat • T Chymerol forte BD
• Inj Atropine 1ml stat +
(Neostigmine 1ml × 4 times at 2
min intervals Stat ) every 10min till
Ptosis/Dyspnea recovers
 AFI
___yrs old Male / Female patient No Rash
b/b relatives to CPRH casualty No Joint Pain
Today At ___ with c/o
No Retro orbital Pain
No Breathlessness
Fever with Chills
No Dysuria Oligouria
Rash
No Cough Cold
No Diarrhea
No Nausea Vomiting Giddiness
No Chest Pain
Fever with Chills (Acute Viral Fever)
Inform Seriousness • Iv 3° NS & 2° RL
Written Concent • Inj Augmentin 1.2 gm BD
• Inj Pan 40mg BD
Adv • Inj Emcet 8mg TDS
1. Cxr • Tab PCM 500mg TDS
2. Rlab • Tab MVBC BD
3. Dengue Maleria Widal • Tab Cetrizine 10mg HS (if rash)
4. U r/m
W/f signs of Distress
 Diarrhoea
___yrs old Male / Female patient • No S/O Dehydration
b/b relatives to CPRH casualty • No Hematemesis
Today At ___ with c/o
• No Fever
• No Vomiting
• Loose stools & Vomtiting
• No H/o travel to Endemic area
• Fever with Chills
• No H/O recent Antibiotic use
• No Chest Pain Breathlessness
AGE
Inform Seriousness • Iv 3° NS & 2° RL
Written Concent • Inj Cipro 100cc BD
Drink plenty of water • Inj Metro 100cc TDS
• Inj Rantac 50mg BD
Iv 1° NS Stat • Inj Emcet 8mg TDS
• Tab AD100 BD (Avoid in Febrile
Do ECG rule out ACS !! Desentry)
• Tab Sporolac TDS
• ORS QID

W/f signs of Distress

 UTI
___yrs old Male / Female patient • No Chest Pain Breathlessness
b/b relatives to CPRH casualty • No rash
Today At ___ with c/o
• No Diarrhea
• No Vomiting
• Fever with chills
• No Hematemesis
• Burning Micturition
Inform Seriousness • Iv 3° NS & 2° RL
Written Concent • Inj Cirpo 100cc BD (if High Fever)
Drink plenty of water • Inj Pan 40mg OD
• Inj Emcet 8mg TDS
• Tab Uritop 100mg BD
• Tab PCM 500mg TDS
• Syp Cital 1tsp in a glass of water TDS
• ORS QID

W/f signs of Distress

 Myocardial Infarction
___yrs old Male / Female patient • No Epigastric Pain
b/b relatives to CPRH casualty • No Vomiting
Today At ___ with c/o
• No Diarrhea
• No Syncope
Note – ECG shows classical ST-T
changes with reciprocal changes • No Convulsions
and Raised Enzymes (STEMI) • No Sweating
Or Only raised Enzymes without • No Palpitations Breathlessness
ST-T changes (Non STEMI) Orthopnea
Chest Pain STEMI
Inform Seriousness • Inj Rantac 50mg BD
Written Concent • Inj Emset 8mg TDS
• Tab Ecosprin 300mg Stat
• Tab Clopitab 300mg Stat • Tab Ecosprin 150mg HS
• Tab Atorva 80 mg Stat • Tab Clopitab 75mg HS
• Tab Sorbitrate S/L 10mg Stat • Tab Atorva 40 mg HS
• Inj Avil 1 amp stat • Tab Sorbitrate S/L 10mg HS
• Inj Rantac 50mg Stat
• Inj Emset 8mg Stat • Tab Alprax 0.25 mg HS
• Inj Hydrocort 100mg stat • Tab Dulcolax 10mg Hs
• Inj STK 15 lakh U in 100ml NS over
45 mins slowly (if required)
Definitive Rx of MI – PTCA (1 st Choice)
• 2nd Choice - Thrombolysis • 3rd Choice – Inj Nikoran 48mg
over 24hrs
1. Reduce Myocardial
Contractility – Decreasing
myocardial O2 demand
2. Vasodilation – Increase blood
supply to myocardium Like
nitrates
Unstable Angina
Inform Seriousness • Inj Fluxem 0.6 ml BD × 5 days
Written Concent • Inj Rantac 50mg BD
• Inj Emset 8mg TDS
Note – ECG shows T inversions
without ST Elevation and No • Tab Ecosprin 150mg HS
Raised Enzymes
• Tab Clopitab 75mg HS
• Tab Atorva 40 mg HS
• Tab Sorbitrate S/L 10mg SOS
Non Cardiac Chest Pain (Gastritis)
Inform Seriousness • IV NS 1° + Pan 80mg stat (if
Written Concent required)
• Tab Pan 40 OD
• Tab MVBC BD
• Syp Mucaine gel 1tsp TDS
• Syp Sucralfet 1tsp TDS
 Atrial Fibrillation
___yrs old Male / Female patient • No Epigastric Pain
b/b relatives to CPRH casualty • No Vomiting
Today At ___ with c/o
• No Diarrhea
• No Syncope
Note – ECG shows absent P wave
with irregular RR Intervals • No Convulsions
• No Sweating
• No Palpitations Breathlessness
Orthopnea
Atrial Fibrillation – Rate Control Choose One
Inform Seriousness • Inj Dilzem 12.5mg stat till HR
Written Concent <100/min
→ 17.5 mg stat till HR <100/min

• Inj Digoxin 0.5mg stat till HR • Inj Cordarone 150mg stat till HR
<100/min <100/min
→0.5 mg stat till HR <100/min →300mg in 100ml NS Slowly over
6 Hrs till HR < 100/min
→0.5 mg stat till HR <100/min
→600mg in 100ml NS Slowly over
6 Hrs till HR < 100/min
 SVT
___yrs old Male / Female patient • No Epigastric Pain
b/b relatives to CPRH casualty • No Vomiting
Today At ___ with c/o
• No Diarrhea
• No Syncope
Note – ECG shows absent P wave
with irregular RR Intervals • No Convulsions
• No Sweating
• No Palpitations Breathlessness
Orthopnea
SVT – Rate Control Choose One
Inform Seriousness • Inj Dilzem 12.5mg stat till HR
Written Concent <100/min
→ 17mg stat till HR <100/min
• Vagal Massage for 10 min
• Inj Adenosine 6mg f/b 10ml NS • Inj Cordarone 150mg stat till HR
stat repeat two times Till HR <100/min
<100/min →300mg in 100ml NS Slowly over 6 Hrs
• Inj Digoxin 0.5mg stat till HR till HR < 100/min
<100/min →600mg in 100ml NS Slowly over 6 Hrs
→0.5 mg stat till HR <100/min till HR < 100/min
→0.5 mg stat till HR <100/min
 Alcoholic Liver Disease
___yrs old Male / Female patient • No Loss of Consciousness
b/b relatives to CPRH casualty • No Abdominal Distension
Today At ___ with c/o
• No icterus
• Yellowish Discolouration of eyes
• No Altered sensorium
• Abdominal Distension
• No Hematemesis
• Altered Sensorium
• No oligouria
• Involuntary Movements

Take BSL !!
ALD Hepatic Encephalopathy
• Inj Thimine 1amp in 100ml NS OD
Inform Seriousness • Inj Hepamerz 1amp in 100ml NS OD
Written Concent • Inj Rantac 50mg BD
High Rise Sugar Diet • Inj Emcet 8mg SOS
• Inj Lasix 40mg 1-1-0
Iv D25 + MVI stat TDS • Tab Liv52 2×TDS
HBW with 700ml NS + 300ml • Tab Udiliv 300mg BD
Duphalac TDS
• Tab Rifagut 550mg BD
• Syp Lactulose 30cc HS
• Syp Mucaine Gel 1tsp TDS
ALD Rum Fits
Inform Seriousness • Inj Thimine 1amp in 100ml NS OD
Written Concent • Inj Eptoin 100mg iv TDS
• Inj Rantac 50mg BD
• Inj Eptoin 1gm in 100ml NS Stat • Inj Emcet 8mg TDS
• Iv 1° DNS/D25 + MVI Stat • Tab/Inj lopez 2mg BD
ALD Withdrawal
Inform Seriousness • Iv 2° DNS & 2° D5%
Written Concent • Inj Thimine 1amp in 100ml NS OD
• Inj Pan 40mg BD
• Inj Emcet 8mg TDS
• Iv 1° D25 + MVI Stat • Tab/Inj Lopez 2mg BD
• Tab MVBC BD
• Syp Mucaine Gel 1tsp TDS
 Stroke
___Yrs old Male / Female patient • No Head Injury
b/b relatives to CPRH casualty • No Convulsions
Today At ___ with c/o
• No Loss of Consciousness
Sever Headache
• No Vomiting
One Sided Weakness of Body with
Facial Deviation • No pain in abdomen
Convulsions +/- • No Chest pain or Breathlessness
• Not k/c/o any Major Illness
Hemorrhagic Stroke
Inform Seriousness • Iv 1° DNS & 1° NS 24hrly
Written Concent • Inj Mannitol 100ml TDS
I/O Charting • Inj Eptoin 100mg TDS
TPR/BPZ/ SpO2 Monitoring • Inj Dexa 4mg TDS
• Inj Lasix 20mg 1-1-0
• Inj Mannitol 100ml iv stat • Inj Pan 40mg OD
• Inj NTG 25mg in 1° NS @16/min • Tab Atorva 20mg HS
Stat (Till BP <140/90) • Tab Amlo 5mg BD
Ischemic Stroke
Inform Seriousness • Iv 1° DNS & 1° NS 24hrly
Written Concent • Inj mannitol 100ml TDS
I/O Charting • Inj Eptoin 100mg TDS (If
TPR/BPZ/ SpO2 Monitoring Convulsions)
• Inj Monocef 1gm BD
• Inj Mannitol 100ml iv stat • Inj Pan 40mg OD
• Inj NTG 25mg in 1° NS @16/min • Tab Atorva 20mg HS
Stat (Till BP <140/90) • Tab Ecosprin 75mg HS (Only
after confirm CT Report)
 Convulsions or Status
___Yrs old Male / Female patient • No Head Injury
b/b relatives to CPRH casualty • No Loss of Consciousness
Today At ___ with c/o
• No Diarrhea
• No Limb Weakness
Convulsions .... No of Episodes
• No Cough with Expectorations
Nature – Focal / GTCS
• No Burning Micturition
a/w Froathing , Urinary or Fecal
Incontinence , Uprolling of • No Vomiting
Eyeballs , Lip Smaking • No Deep Abscesses
Ask History of Travel
Convulsions
Inform Seriousness • Iv 2° DNS & 2° D5%
Written Concent • Inj Diazepam 2mg Stat (if Active Convulsion)
Do MLC if Brought • Inj Eptoin 800mg in 100ml NS stat (If GTCS)
Unconcious • Tab Eptoin 100mg TDS (If GTCS)
W/f signs of Distress • Inj Leveteracetam 1gm in 100ml NS stat
(only if Focal Secondary Generalised)
Check BSL !!! • Tab Leveteracetam 500mg BD
(only if Focal Secondary Generalised)
• Tab Folic Acid 5mg OD
 Meningitis
___Yrs old Male / Female patient • No Head Injury
b/b relatives to CPRH casualty • No Loss of Consciousness
Today At ___ with c/o
• No Diarrhea
Fever with Chills
• No Limb Weakness
Altered Sensorium
• No Cough with Expectorations
Convulsions
• No Burning Micturition
• No Vomiting
• No Deep Abscesses
Ask History of Travel
Meningitis
Inform Seriousness • Iv 3° NS & 2° RL
Written Concent • Inj Monocef 2 gm/ Magnazone 1.5gm BD
Do MLC if Brought Unconcious • Inj Amikacin 500mg BD /Metro 100cc TDS
W/f signs of Distress • Inj Pan 40mg BD
• Inj Emcet 8mg TDS
• Inj Diazepam 2mg Stat (if • Inj Febrinill 2cc (SOS)
Active Convulsion) • Inj Eptoin 100mg Stat & TDS
• Inj Eptoin 800mg in 100ml NS • Tab Acyclovir 800mg TDS (SOS)
stat (If Convulsions) • Tab Doxy 100mg BD (SOS)
• Tab PCM 500mg TDS
 DKA
___Yrs old Male / Female patient • No Diarrhea
b/b relatives to CPRH casualty • No Limb Weakness
Today At ___ with c/o
• No Cough with Expectorations
Nausea Vomiting
• No Burning Micturition
Breathlessness
• No Pain in abdomen
• No Deep Abscess
 DKA
Inform Seriousness • IV NS 2 ° stat
Written Concent →IV 2° NS after 15 min
I/O Charting →IV 2° NS after 30 min
TPR/BPZ/ SpO2 Monitoring →IV 2° NS after 60 min
→IV 2° NS after 2 Hrs
• Inj HAI 10 Stat (0.1 U/Kg) • Inj Monocef 1gm BD
• Inj HAI 50U in 1° NS @ 30/50°/min • Inj Pan 40mg OD
• IV NS @ 150 ml/Hr • Inj Emset 8mg TDS
• Inj Sodabicarb 30/50cc Stat (SOS) • Tab Sodamint 2-2-2
• Tab MVBC BD
 CKD
___Yrs old Male / Female patient • No Diarrhea
b/b relatives to CPRH casualty • No Limb Weakness
Today At ___ with c/o
• No Cough with Expectorations
Oligouria
• No Burning Micturition
Nausea Vomiting
• No Pain in abdomen
Breathlessness
• No Deep Abscess
CKD • Inj Monocef 1gm BD
• Inj Pan 40mg OD
Inform Seriousness
• Inj Emset 8mg TDS
Written Concent
• Inj Sodabicarb 50cc Stat (SOS)
Fluid & Salt Restriction
• Inj Lasix 40mg 1-1-0
I/O Monitoring
• Inj EPO 4000U Thrice a WK
• Tab Sodamint 2-2-2
Adv – Urgent RFT + Tripple H Test
• Tab ApcalD 0-1-0
for Hemodialysis
• Cap Vit D3 Once a wk
Do Fistula Workup (B/L UL Colour
Doppler) • Tab MVBC BD
• Anti HTN According to Choice (SOS)
Note – AntiHTN • Tab Amlo 5mg
• Tab Telma 40mg
• Inj NTG 25mg in 1° NS @ • Tab Arkamine 0.1mg
8/16°/min till BP <140/90
• Tab CTD 12.5/25mg
• Tab MetXL 25mg
• Inj Labetelol 10mg in 10ml NS
slowly over 10mins • Tab Lasix 20-80mg
• Tab Lasilactone (20/50)
• Inj Lasix 20-80mg • Tab Aldactone 50mg
• Inj Cardiovas • Tab Diamox ?
• Inj
Death Gasping Notes
Time – 45 min before
S/B Med II JR Rx
GC – Poor - CPR
P – 140/min - Inj Atropine 2cc stat
BP – Systolic 60 mmHg - Inj Adrenaline 2cc Stat

S/E
CVS – S1S2 + Tachycardia
RS – B/L Crepts +
CNS – Pupils Mid Dilated SRTL
Time – 30 min before
S/B Med II JR Rx
GC – Poor - CPR
P – Feeble - Inj Atropine 2cc stat
BP – Not Recordable - Inj Adrenaline 2cc Stat

S/E
CVS – S1S2 Muffled
RS – B/L Crepts +++
CNS – Pupils Mid Dilated MRTL
Time – 15 min before
S/B Med II JR Rx
GC – Poor - CPR
P – Not Recordable - Inj Atropine 2cc stat
BP – Not Recordable - Inj Adrenaline 2cc Stat

S/E
CVS – S1 S2 Absent
RS – No Spontaneous Respiration
CNS – Pupils Fixed Dilated NRTL
Time of Death Declare
S/B Med II JR
Inspite of All Medications and Efforts Patient didn’t Respond to
treatment
ECG was take which does not show any electrophysiological activity
Therefore patient is declared dead on __/__/____
At __:__
Body is _________