TTreatment Guide

A guide to the management of common OPD and ER Oiseases

ONDUTY RX Guide for House officer. New Medical Offlcers.

Intemees and trainees
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Copyright © 2021
All right reserved no part of this
publication may be reproduced distributed
in and form or by any means or store in
database or retrieve system without writer
written permission of the authors.

Published by: FAROOQ KITABGHAR

Shop No, 32, 33 Urdu Bazar, Karachi - Pakistan
Mobile: 0346-0029860
Email: farooqkitabghar @ gmail.com

Sole Distributer: Classic Book Shop

Shop No, 35, New Urdu Bazar Karachi
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Mobile: 0346-4453474

Javed Medical Book Shop

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.
Opp . Main OutdoorGate Near Ganga
Ram Hospital, Lahore
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Email: javedgaba 92 @ gmail.com

Creative Dept: RIGHTWAY GRAPHICS (Karachi & Dubai UAE)

Nazeer Jabbar - Shahryar Irshad & Abdul
Wahab
 DED1CATION
TI 1 IS NOTES IS DEDICATED TO MY LOVING PARENTS ( MY IMMUNITY ) WHO ALW A '* s
WALK IN WHEN OTHERS WALK OUT, MY BROTHER SHUJAT ALI AND TARIQ ALI

TO MY UNCLE NEUROSURGEON DR. SHAMSHER ALI KHAN

( FOR HIS UNCONDITIONAL LOVE AND SUPPORT )

TAZAR

TO OUR LEGENDS WHO ARE MORE THAN JUST TEACHERS

.
DR AHMAD MUR .
ABBAS ( DIMS)
WORDS CAN’T EXPLAIN MY FEELINGS OF GRATITUTE FOR YOU
DOCTORS’ INSTITTE OF MEDICAL SCIENCES

AND TO MY ALL BELOYED FRIENDS

I am thank ful to Almighty Allah who gave me the courage to write the 1" edition of this Book
DOCTOR ON DUTY HOUSEJOB TREATMENT GUIDE with great support from my friends,
teachers and family. This book has been designed to lill a unique niche for the house oITicers,
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
3

o
Any set of guidelines can provide only genera! suggestions for dinica! practice and practitioners must «
use their own dinical judgment in treating and addressing the needs of each individual patienl, taking °
into account patient’s unique dinical 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 g-
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. CO

I welcome comments, suggestions, and constructive criticism of this notes, which may be emailed at CP
.
asifali983@gmail com

Si
ro
YOU CANALSO FOLLOWUS ONFACEBOOK PAGE: drasifkhann

SOMEBEAUTIFUL OUOTES

Whatever you do, do with determination. You have one li fe to live; doyour work with passion and give
.
your best Whetheryou want to be a chef, doctor, actor, ora mother, bepassionate toget the best
result.

Whenever a doctor cannot do good, he must be kept from doing harm.

The natura1 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 bene fit from his illnesses.

DR . ASIF AU KHAN
 CONTENTS PAGE NO.

CHAPTER - 1 - HISTORY TAKING AND EXAMINATION PAGE NO # 11

CHAPTER - 2 SYMPTOMS AND QUESTIONARY PAGE NO # 19

CHAPTER -3 PROCEDURES AND WARD SKILLS PAGE NO # 23

1. Passing IV line (1V cannulation )
2. Setting up a drip
3. Venepuncture/phlebotomy
4. VACUTAINER TUBE GUIDE - Draw tubes
5. Blood cultures
6. Blood transfusion
7. Guidelines for blood transfusion
8. ArteriaI Blood Gas ( ABGs) Sampling
9. Intramuscular, subcutaneous, and intradermal drug
injection
10. Nasogastric intubation
11. Male catheterization
12. Female catheterization
13. Endotracheal intubation
14. Joint Aspiration ( Arthrocentesis)
15. Lurnber puncture
16. Paracentesis Abdominis ( Ascitic tapping )
17. Paracentesis Thoracis ( Pleural fluid
tapping/Thoracentesis
18. Bedside Blood Glucose Measurement
19. Scrubbing up for theatre
20. Simple Suturing
CHAPTER-4 PRESCRIB1 NG , ADMINISTRATIVE AND
COMMUNICATION SKILLS PAGE NO # 57
21. Explaining skiUs
22. Endoscopies explanation
23. Obtaining consent
24. Breaking bad news
25. Requesiing investigations for histopathology ofspecimen
after procedure
.
26 Call to other department/consultation form
27. Dischargeplanning and negotiation
28. Taking Consent for LAMA/ DAMA
29. Death confirmation and death certification o
n
-
©
r

CHAPTER -5 MEDICINE COMMON OPD DISEASES PAGE NO # 69 E -

30. Fever with hunting micturition
31. Urinary Tract infection (UTI ) o»
32. Pyelonephritis OPD Rx 1
33. Urolithiasis/Nephrolithiasis s
-
34. Fever with dty cough +/ Sore throat
35. Fever with Productive cough
36. Productive cough with Postnasal drip
37. Fever with Chills and rigors
38. Asthmatic patient with severe coughing
39. Enteric fever (typhoidfever)
40. Malaria fever ( Falciparum fever)
41. Sore Throat
42. Tonsilitis/ Pharyngitis
43. Acute Sinusitis
44. Allergic Rhinitis
45. Child with Nasal discharge, cough, watery eyes
46. Child with ear pain
47. Child with Ear discharge/infection
48. Adult with Ear discharge/infection
49. Oral Ulcer (Aphthous Ulcer )
50. Gastro-Esophageal Rejlex Disease (GERD)
51 . Gastric Ulcer ( Peptic ulcer )
52. Duodenal Ulcer ( Peptic ulcer)
53 . Helicobacter Pylori Infection
 54. Liver Abscess OPD Rx
-
55. Chronic Hepatitis B viral lnfection
56. Chronic Hepatitis-C lnfection
57. Decompensated Chronic Liver Diseases ( DCLD)
58. lron Deficiency Anemia OPD Rx
59. Mcgaloblastic Anemia OPD Rx
60. Irritable Bowel syndrome ( IBS )
61. Ulcerative Colitis OPD Rx
-
62. Diabetes Mellitus Type 2 OPD Rx
63. Myocardial Infarction Prophylaxis Rx
64. Adult Constipation OPD Rx
65. Pulmonary Tuberculosis OPD Rx
66. Vaginal Candidiasis
67. Chlamydial lnfection
68. Leucorrhea

-
CHAPTER -6 NEURO PSYCHIATRIC MEDICINE PAGE NO # 100
69. Migraine Headache
70. duster Headache
71. Tension Headache
72. Ischaemic stroke (CVA )
73. Postherpetic neuralgia
74. Trigeminal Neuralgia
75. Bell 's Palsy ( Facial Palsy/7th CN Paralysis)
76. Parkinson 's Disease
77. Alzheimer’s Disease
78. Dhat Syndrome ( Semen leakage after urination )
79. Premature ejaculation (rapid/early ejaculation)
80. Insomnia Disorder
81. Anxiety and Depression
82. Panic Attack
83. Panic Disorder
84. Generalized anxiety disorder (GAD)
85. Schizophrenia
86. Opioid Withdrawal syndrome symptomatic Rx
CHAPTER -7 NEUROSURGERY PAGENO # 117
87. Sciatica Pain
88. Brachialgia (Cervical Radiculopathy / Pinched nerve )
89. Conservative treatment of Back pain
90. Epidural Hematoma/ Extradural hematoma ( EDH )
91. Subdural Hematoma ( SDH )

CHAPTER -8 BONES AND JOINTS PAGE NO # 130

92. Osteoporosis
93. Post-menopausal Osteoporosis
94. Arthritis o
o
95. Post Chikungunya Arthritis
96. Osteoarthritis conservative Rx
97. Rheumatoid Arthritis
—
o
i

a.

98. Gouty Arthritis •<

i
CHAPTER -9 SKIN ( DERMATOLOGY ) PAGE NO # 139
99. Scabies E.
100. Facial Acne/ Acne vulgaris »
101. Psoriasis
102. Seborrheic Dermatitis (Seborrheic eczema)
103. Tinea pedis/ ( Athlete's foot )/ and Tinea rnanuum
104. Tinea Corporis ( Ring worm)
105. Tinea varsicolor ( pityriasis varsicolor)
106. Tinea cruris (Jock itch)
107. Shingles ( Herpes-zoster)

CHAPTER- 10 EMERGENCY/ACUTE MEDICNE PAGE NO it 150

108. The primary and secondary surveys
109. Evaluation and management of Coma in ER
110. Evaluation of hypertension in ward/ER
111. Hypertensive emergency management
112. Approach to Diarrhea
113. Gastroenteritis of infectious origin
114. Acute Gastroenteritis/ Food poisoning ER Rx
115. Status epilepticus (Seizures/ Fits) ER Rx
116. Bleeding through Nose ER Management
117. Diabetic Ketoacidosis ( DKA ) ER Rx
I IR. Acute Viral Hepatitis ( Hepatitis A/Jaundice ) ER Rx
-
119. Upper Gastrointeslinal bleeding ER/Ward Rx
120. Upper Gastrointeslinal bleeding T CLD ER/Ward Rx
121. Hepatic Encephalopatby
122. Amoebic Liver Abscess
123. Pyogenic Liver Abscess
124. Acute Blood loss ( Hemorrhagic shock )
125. Acute Haemolytic Transfusion Reaction ER Rx
126. Dengue fever with severe/ Progressive thrombocytopenia
127. Iron Deficiency Anemia ER/ ward Rx
128. Megaloblastic A nemia ER/Ward Rx
129. Acute leukemia ER/ ward Rx
130. Thrombotic Thrombocytopenic Purpura ( TTP ) ER/ward Rx
131. Aplastic Anemia ER/ ward Rx
132. Acute Asthma ER Rx
133. Status Asthmaticus ER Rx
134. Acute exacerbation of chronic obstructive pulmonary disease
( AECOPD) ER Rx
135. Acute Renal Colic pain (2° Nephrolilhiasis) ER Rx
136. Pyelonephritis ER/Ward Rx
137. Acute chest pain/ Acute Coronaiy syndrome ER/Ward Rx
138. Cardiac Arrest ER/Ward Rx
139. Pulmonary edema ER/Ward Rx
140. Acute myocardial infarction ER/Ward Rx
141. Pulmonary embolism ER/Ward Rx
’
142. Fever with ALOC ER/Ward Rx
143. Meningi1is in complete detail
144. Bacterial Meningitis ER/Ward Rx
145. Viral Meningitis ER/Ward Rx
146. HSV Encephalitis ER/Ward Rx
147. Traumatic Brain lnjury ER/Ward Protocol
148. Pneumocepha/ usER/Ward Rx
149. Subarachnoid Hemorrhage ( SAH )ERJWard Rx
150. Intracerebral hemorrhage ( Hemorrhagic stroke) ER/Ward Rx
151. Ischaemic Stroke ER/Ward Rx
152. Anaphylaxis ER/Ward Rx
153. Organophosphate Poisoning ER/Ward Rx
154. Benzodiazepines poisoning ER/Ward Rx
155. Opiates/Opioid Poisoning ER/Ward Rx
 156. Acids/Caustic IngestionER/Ward Rx
157. Human Bite ER/Ward Rx
158. Dog Bite ( Rabies Virus) ER/Ward Rx
159. Unknown Insect Bite ER/Ward Rx
160. Snake Bite ER/Ward Rx
161. Hypokalemia ER/WARD Rx
162. Hyperkalemia ER/WARD Rx
163. Hypoglycemia ER/Ward Rx

CHPATER - 11 COVID- 19 ( coronavirus disease 2019) PAGE NO it 222

o
CHAPTER - 12 SURGERY PAGE NO it 229
164. Approach to management of acute abdomen O
165. Acute Appendicitis Q
-
166. Acute cholecystitis •<
167. Cholelithiasis 3
168. Choledocolithisis 2
169. Anal fissure 1
2
170. Hemorrhoids
171. Acute Pancreatitis
1g-.
172. Intestinal Obstruction
173. Peritonitis 2° GI perforation

CHAPTER - 13 COMMON DRUG BRANDS IN PAKISTAN PAGE NO # 249

- -
174. Non Steroidal Anti inflammatory Drugs
( NSAIDS)/Analgesic/ Antipyretics/Opioids analgesics
175. Commonly used antibiotic drug brands
-
176. Commonly A nti hypertensive drug brands
177. Commonly Oral hypoglycemic drug brands
178. Commonly Injectable hypoglycemic drug brands
-
179. Commonly used anti depressant drvg brands
180. Commonly used Benzodiazepines, anxiolytic drug brands
-
181. Commonly used Anti Epileptic drug brands
182. Commonly used Anti Psychotic drug brands
-
183. Commonly used Anti-Allergic/antihistamine drug brands
-
184. Commonly used anti tussive cough suppressant drug brands
185. Commonly used laxative drug brands
186. Commonly used Anti Peptic Ulcer drug brands
-
 - -
187. Commonly used Anti Emetic/Anti Vertigo drug brands
188. Commonly used Musele Relaxant drug brands
189. Commonly used Muliivitamins/ Iron, supplements drug brands
-
190. Commonly used Anti Vira! drug brands
191. Commonly used Dermatological/Skin drug brands
192. Commonly Antacids, Anti-Flatulence and Anti-Spasmodic
drug brands

CHAPTER - 14 PAEDIATRIC AND NEONATAL PAGE NO # 289

DRUG DOSAGE WITH NATIONAL AND
INTERNATIONAL DRUGS BRAND NAMES
 1 History Taking and Examination

Principles for Good Clinical Diagnosis

> Thcre arc threc main steps to making a correct diagnosis:
.
1 Comprchensive history taking of the patient
2. Good and completc 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 patienfs
problem .
> It enables doetors to make accurate provisional diagnosis.
ijjjTOTTQfW
1. Introdiice yourself: give your name and your job ( e.g. Dr. Asif, Medicine dept. etc...)
2. Iden ti ty: confirm you’re speaking to the correct patient ( name and date of birth)
3. Treat patient appropriately in a friendly relaxed way.
4. Permission: confirm the reason for seeing the patient (‘Tm going to ask you some questions
about your cough, is that OK?”)
5. Confidentiality & respect patient privaey.
6. Try to see things from patient point of view.
7. Understand patient undemeath 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, interrupting, direct questions &
summarizing. COPYRIGHT-2021
Componcnts of History Taking
FAROOQ KITAB GHAR KARACHI
. Personal Details:
Name:
Age: JCHS
Gender:
Address: W V1
Occupation •'
u* tiS
Religion
Marital status
Date of Admission
^
j\ j
_-
JUx u fc il / US JUJ J
_
> JI

Mode of Admission vc«<* W s3 J J 1 v

^ ’
^ uii»
 2 Symptoms And Questionary

> Most of the patients coming to the Emergeney Department have the following symptoms:
1 . Fcvcr 2. Pain
3. Dyspnea 4. Cough
5. Vomiting 6. Diarrhea
7. Fits 8, Wcakncss
9. Headache 10. Mass

• To elaborate a symptom fully , the doctor must ask relevant questions from the patient about his
complaints.
• This will help him to know the details of symptoms and so to make an appropriate diagnosis.
• Following are the questions regarding various symptoms:
• ..
N B duration of each symptom must be asked beforc asking the patient for other details of
symptoms

I . REVER
1 . What is the mode of onset of fever, i.e. sudden or gradual?
2. Is fever associated with rigors or sweating?
3. What is the grade of fever, high grade or low grade?
4. What is the pattem of fever? Whether it is continuous remittent or intcrmittent?
.
5. Is the fever associated with any other complaint such as vomiting, diarrhea abdominal pain , ro
e/
chest pain, hemoptysis, headache, Jaundice or hematuria?

2. PAIN
1 . What is the site of pain?
2. What is its duration? COPY RIGHT -2 021
3. Is it continuous or intermittent? FAROOQ KITAB GHAR KARACHI
I . Example, continuous epigastric pain is feature of gastritis while pain coming intermittently is
feature of duodenal ulcer.
4. The pain localizcd or diffuse?
5. Radial ion of pain: Does it radiate? If so to which direction? Pain in left chest radiating to left
arm is which suggestive of ischemic heart disease. Pain in flanks radiating to groins is feature
of ureteric (stone) pain
6. Rcfcrred pain: pain is right hypochondrium referred to tip of right shoulder is suggestive of
gall bladder pain i.e. cholecystitis
7. What is the character of pain?
Pain can be of following character
» Buming » Stabbing or crushing
» G ripp ing heaviness » Pricking
» Dull » Colicky
» Throbbing » band like

.
8. Shifting of pain: pain of appendicitis first occurs around umbilicus, then it is shified (and
localized to right iliac fossa )
9. What is the intensity of pain, severe, moderate or mild?
10. What are the factors which aggravate the pain in? Pain in the chest, aggravated on exertion is
suggestive of ischemic heart disease. Pain in upper abdomen aggravated by intake of milk can
be due to cholecystitis. Pain in chest aggravated by respiration and cough is suggestive of
pleurisy.
 3 Procedures And Ward Skills

Passing IV line ( IV cannulation ) COPY RIGHT -2021

FAROOQ KITAB GHAR KARACHI
1. -
A pair of non sterile gloves
2. A toumiquet
3. Alcohol sterets or prepackaged chlorhexidine and alcohol sponge
4. An IV 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
-
5. A pre filled 5 ml syringe containing saline flush
6. An adhesive plaster/ transparent film dressing
7. Introduce yourself to the patient.
8. Confirm his name and date of birth.
9. Explain the procedure and obtain his consent. For example, “ I would like to insert a thin plastic T3
o
tube into one of the veins on your arm. The tube will enable you to receive intravenous fluids and
prevent you from becoming dehydrated. You may feel a sharp scratch when the needle is inserted, c
but only the plastic tube will remain in the vein. Do you have any questions?” re

10. Ask him on which arm he would prefer to have the cannula.
11. Ask him to expose this arm.
£
12. Gather the equipment in a clean tray. aj
13. Wash your hands. CO
14. Position the patient so that his arm is fully extended. Ensure that he is comfortable.
15. Apply the toumiquet proximal to the venepuncture site.
W
16. Select a vein by palpation: the bigger and straighter the better. Try to avoid the dorsum of the
hand and the antecubital fossa if possible ( may be uncomfortable on flexion ).
-
17. Don a pair of non sterile gloves.
18. Clean the skin with an alcohol steret and let it dry.
19. Remove the cannula from its packaging and remove its needle cap.
20. Tell the patient to expect a ‘sharp scratch’.
21. Anchor the vein by stretching the skin and insert the cannula at an angle of approximately 30
degrees.
22. Once a flashback is seen, advance the whole cannula and needle by about 2 mm.
23. Pull back slightly on the needle and continue to hold the needle while advancing only the cannula
into the vein.
24. Release the toumiquet.
25. Occlude the vein by pressing on the vein over the tip of the cannula.
26. Remove the needle completely, and immediately put it into the sharps box.
27. Cap the cannula with the same cap that was on the end of the needle or heplock
28. Fix the cannula by applying an adhesive plaster ( tegaderm ) or transparent film dressing
29. Flush the cannula with 5 ml normal saline to prevent blood from occluding it.
30. Dispose of clinical waste in a clinical waste bin.
31. Ensure that the patient is comfortable and inform him of possible complications (e.g. pain,
erythema ).
32. Thank the patient.
 COPY RIGHT -2021
Joint Aspiration ( Arthrocentesis) FAROOQ KITAB GHAR KARACHI
1 . Introduce yourself to the patient.
2. Confirm his name, age, and Bed number.
3. Explain the proccdure and obtain his consent.
4. Position the patient on a bed with the joint, e.g. knee, well supported
5. Gathcr the equipment
6. Wash and dry your hands.
7. Put on sterile gloves.
8. For the knee, use a latcral approach
9. Draw a line on the lateral edge of the patella between the upper and middle thirds.
TJ
10. Then aim for 1 -2 cm below this point o
11 . Clcan with chlorhexidine solution from the centrc outwards and allow to dry
e
12. Apply refrigerant alcohol spray at the point you have marked for needlc insertion re

13. Use a green needle, and advance it at 90° to the skin, heading between the patella and femoral
condylc, and aspirating as you go until joint fluid is aspirated
14. Collect as much as required for analysis or, for symptomatic relief, until dryness is achieved
15. The needle can be left in situ and the syringe changed if an injection is required, e.g. steroids
16. Cover the wound with a small sterile dressing
17. Record the procedure and the amount, colour and consistency of fluid aspirated
18. Ensure that the patient is comfortable.
19. Thank the patient.
20. Discard any rubbish.
VVhat to do
> Introduce yourself.
> Look to comfort and privacy.
> Determine what the patient already knows.
> Determine what the patient would like to know .
> Warn the patient that bad news is coming.
> Break the bad news.
> Identify the patient' s main concerns.
> Summarise and check understanding.
> Offer realistic hope or appropriate reassurance .
> Arrange follow- up. ro

> Try to ensure there is someone with the patient when he leaves.

How to do it
> Be sensitive. .
> Be empathetic. 00

> Maintain eye contact. 3

> Give information in small chunks.
> Repeat and clarify. ro
cro
> Regularly check understanding. o
> Give the patient time to respond. Do not be afraid of silence or of tears. 5
> Explore the patient's emotions. 3
> Use physical contact if this feels natural to you. o
> Be honest. If you are unsure about something, say you will find out later and get back to the patient.
o

VVhat not to do
00
> Hurry.
> Give all the information in one go, or give too much information.
> Use euphemisms or medical jargon.
> Lie or be economical with the truth.
> Be blunt. Words are like loaded pistols, as Jean- Paul Sartre once said.
> Prognosticate ("She's got six months, maybe seven" ).

COPY RIGHT - 2021

FAROOQ KITAB GHAR KARACHI
i INTERNAL MEDICINE COMMON
OPD DISEASES AND ITS
PRESCRIPTION

COPY RIGHT - 2021

FAROOQ KITAB GHAR KARACHI
 5 Internal Medicine Common OPD Diseases

FEVER WITH BURNING MICTURATION Rx

Name: Age: Sex: , Date ,
T< .. B.P: Pulse:. Rate ( RR )..

A Fever with burning

Micturition &
C/C:
1. Fever 1. Tab Levofloxacin 250mg/ 500mg ( Leflox /Qumic )
2. Lower abdominal pain —
I - I I , I - 0 - 1 (TDS/BD)
3. Burning micturition OR Cap Cefixime 400mg ( Cefspan/Cefiget )
4. Dysuria 0 - 0 - 1 (OD) =
5. Hematuria ro
2. Tab Mefenamic Acid 250mg/ 500mg ( Ponstan/Ponstan forte ) 2L
I - l - l , I - 0 - 1 (TDS/BD)
oOR Tab Paracetamol SOOmg ( Panadol /Calpol) s.
—
I — I I (TDS) §:
3. Syp Sodium Acid Citrate (Citralka ) C3

2 Teaspoonfull BD/TDS in a glass water 3

5
®
lf Nausea /vomiting then add
o
.
4. Syp/Tab Domperidone (Motilium Syp lmg/ml Tab 10mg)
o
5
ro
Investigation: a>
» CBC
» Urea, creatine and
ø
t For Childrens
co
ro

electrolytes
» Urine D/R 1. Syp Nalidixic Acid 250mg ( Negram / Nilacid )
» Urine C/S OR Syp Ciprofloxacin 125 mg / 250mg (Novidat / Mytill)
» U/S KUB OR Syp Co-trimoxazole (Septran/Septran DS)
» X-ray KUB 1- 2 Tsp. TDS/ BD

2. Syp Antipyretic (Brufen/Brufen plus/Panadol/ Panadol DS)

1- 2 Tsp. TDS/ BD

3. Syp Cranmax aqua (Hilton) OR Syp Cenova (Getz)

1- 2 Teaspoonful BD/OD

4. If nausea vomiting add Syp Gravinate 1- 2 Tsp. BD/TDS

COPY RIGHT - 2021

FAROOQ KITAB GHAR KARACHI
 TYPHOID FEVER ( ENETRIC FEVER ) Rx
Name: Age : Sex:. , . Date
T< B.P: Pulse:. Rate ( RR ) .

A Entericfever
C/C:
.
1 Fever low then
gradually 'T' to 104.9 F 1. Tab Azithromycin 500mg ( Zetro/Bectizith/ Azomax )
2. Headache 0-0- 1 ( OD )
3. vomiting
4. Weakness and fatigue 2. Tab Mefenamic Acid 250mg/ 500mg ( Ponstan/Ponstan forte)
5. Muscle aches TDS, BD / 1 - 1 - 1 , I - 0 - I
6. Relative bradycardia
7. Loss of appetite 3. Syp Lysovit OR Syp Tresorix forte
8. Abdominal pain 2 tsp. two times /2 - 0 - 2
9. Rash ( Rose spot )
10. Diarrhea & 4. Omeprazole 40mg (Zoltar , Risek )
constipation in Childs Once daily ( OD)
«J slu 30 «JløS
^ *
lf Nausea / vomiting then add
Treatment 5. Syp/Tab Domperidone ( Motilium Syp lmg/ml, Tab 10mg)
( 7 TO 14 DAYS)
cXl CJUUO 30
^
Diaenosis: Mnemonic 'BASLT
l“ week: Blood culture
nd
2 week: Antigen test / Widal
,d
72x
3 week: Stool culture 1. Syp Azithromycin 200mg ( Zetro/Bectizith)
th
4 week: Urine culture OR Syp Cefixime 100mg/ 200mg (Cefspan/Cefiget)
1- 2 Tsp. BD/TDS

> For Children 2. Syp Antipyretic ( Brufen/Brufen plus/Panadol/Panadol DS)

1- 2 Tsp. TDS/BD

3. Syp Lysovit OR Syp Leaderplex

1- 2 Tsp. BD/OD

Alternative drugs which is use in the treatment of Typhoid fever include:

• Flouroquinolone:Ciprof1oxacin * / Ofloxacin/ Moxifloxacin
• Cephalosphorine: Cefixime/ Ceftriaxone* (Titan/Rocephine )
> ANTIBIOTICS: • Macrolide:Azithromycin * ( Macroab/Azomax )
• Chloromphenicol:* Caution it can cause aplastic anemia
• Sulphonamides: sulfamethoxazole+trimethoprim(septran)
r NSAIDS: • Ibuprofen / Paracetamol / Mefenamic acid
> TONICS: • Glyvesol/Tresorix/Lysovit/Leaderplex

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FAROOQ KITAB GHAR KARACHI
 ACUTE SINUSITIS ( Sinus infection ) Rx
Name: Age : Sex:. Date .
Temperature: B.P: Pulse:. Rate ( RR ) .

A
C/C:
Sinusitis
Rx
• Anosmia: Loss of smell
• Blockage/obstruction of 1. Tab Fexofenadine 60mg + Pseudoephedrine 120mg ( Fexet- D)
Nasal + — + — I (OD )
• Congestion/ Cough
• Discharge: Purulent 2. Tab Co- Amoxiclave 375mg, 625 mg, lg ( Augmentin, Amoxiclave)
discolored nasal discharge 1 — 1 — 1 (TDS), I — + — I (BD)
• Ear pressure/fullness
• Facial pain , Fever 3. Tab Mefenamic acid( Ponstan, Ponstan Fort )
• Generalized malaise /Fatigue I - I - I (BD)
• Headache/Halitosis
4. Vaporization 2-3 time/day

Investigation: R
“ x 2nd Alternative Rx
» CBC
» X-Ray PNS 1. Tab Fexofenadine 120mg ( Fexet, Telfast )
» CT scan PNS + - + - I ( OD )

2. Tab Clarithromycin 250mg/500mg ( Klaricid/Claritek )

I - + - I ( BD )

3. Tab Aceclofenac lOOmg ( Acenac, Acelo)

I - + -- I (BD)

4. Vaporization 2-3 time/ day

Rx ,
3 d Alternative Rx

1. Tab Loratidine lOmg ( Fexet, Telfast )

+ - + - I (OD), I - + - I ( BD )

2. Tab Moxifloxacin 400mg (Øoxiget, ISaxiox )

+ - + - I (OD)

3. Tab Diclofenac potassium 50mg ( Caflam, Cataflam)

I — + — I (BD)

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FAROOQ KITAB GHAR KARACHI
 Chronic Hepatitis CInfection Rx -
Name: Age: Sex:. Date.
Ti ire: B. P:. Pulse:. Rate ( RR ).

A HCV infection
C/ C: 72x
Incubation period: 2 weeks to 6
months 1 . Cap. Sofosbuvir 400 mg ( Sofomac/Sofohil/Sofiget )
Acute course features 0 + 0 + 1 ( OD )
» Asymptomatic in 80% of cases
» Symptomatic ( see "Acute viral 2. Cap. Daclatasvir 60mg( Maclinza /Clavir / Daclaget )
hepatitis" ) 0 + 0 + 1 ( OD )
» Malaise, fever , myalgias,
arthralgias 3. -
Tab L methylefolate 400 mcg ( Myfol/ Maxfol/ Folate )
» RUQ pain , tender hepatomegaly 0 + 0 + 1 ( OD )
» Nausea, vomiting, diarrhea
» Jaundice, possibly pruritus HCV with Cirrhosis add on
4. Cap Ribavirin 400 mg( Viron / Novia / Ribazole )
Chronic course features 0+0+1 ( OD )
» Seen especially in asymptomatic
individuals ( up to 85%), as the In this case mostly Patient complaint about constipation
disease may go undiagnosed and lf present than treatwith
treatment may be delayed or 5. Syp Lactulose ( Duphalac/ Lilac)
never initiated ( carrier state ). -
20 30ml HS
» Findings often mild, nonspecific
(e.g., fatigue ) 6. Cap Esomeprazole 40 mg ( Nexum / Esso )
» Liver cirrhosis ( up to 25% of cases ) 0 + 0 + 1 ( OD)
within 20 years of infection
» Extrahepatic features ( common )
<=Urt 30
^ «Jl**
2 nd Alternative Rx

Investieation: ( Maclusa / Hilvel / Velpaget )

» CBC, U /C/ E, LFTs, PT & INR 1 . .
Cap Sofosbuvir 400 mg + Velpatasvir lOOmg
» U /S whole Abdomen, CXR Or Cap Sofosbuvir 400 mg + Ledipasvir 90 mg
-
» HBsAg and Anti HCV 0+0+1 ( OD ) (Syneget- LS )
» HCVRNAPCR
2. Cap Ribavirin 400mg( Viron / Novia / Ribazole )
0+0+ 1 (TDS)

3. Tab L methylefolate 400 mcg ( Myfol / Maxfol/ Folate )

-
0+0+1 (OD)

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FAROOQ KITAB GHAR KARACHI
 6 Neuro Psychiatric Medicine

MIGRAINE HEADACHE Rx

Name: Age : Sex: Date .

Ti ire: B.P:. Pulse: Resp. Rate ( RR ) .

A Migraine headache
C/C:
• One sided Throbbing head
pain ( Pulsating) For Acute Attack:
• Sensitivity to light 1. Sumatriptan + Naproxen sodium ( Sumoxen )
( Photophobia ) +/- Inj Toradol 30mg x IV x Stat ( Dilute in 4-5ml D/ W )
• Sensitivity to sound
( Phonophobia )
For Prophylaxis:
• Nausea & vomiting
2. Cap Flunarizine 5mg ( Sibelium, Lunar )
• visual or neurologic auras
2 caps. at night/OD
• Duration: 4-72 hr

3. Tab Naproxen 250mg/500mg ( Synflex, Neoprox )

OD/BD

4 . Cap Omeprazole 40mg ( Risek, Losec )

OD / 0 + 0 + 1
vlu-o 30 cAgi

+/-
5. Tab Propranolol ( Inderal 10mg)
BD / 1 + 0 + 1

Tab Acetaminophen / Paracetamol

> Alternative Drugs for Rx Tab. Paracetamol + Tramadol: Distalgesic, Tramol plus
of migraine NSAIDs:
- Tab. Naproxen sodium: Synflex 550mg, Neoprox 250mg , SOOmg
- Tab. Diclofenac potassium: Caflam, Dyclo- P
Ergots alkaloids:Ergotamine, Dihydroergotamine
5-HT agonists :Sumatriptan
IV antiemetic's useful for severe cases: Metoclopramide
Prophylaxis includes:
1. Beta blockers:Tab propranolol (Inderal lOmg, 40mg)
2. Tricyclic antidepressants:Tab amitriptyline (Tryptanol 25 mg )
3. calcium channel blockers:Tab verapamil 40m
4 . Cap Flunarizine:Cap Sibilium 5mg
5. Tab. /Syp. Valproate sodium 250mg/500mg/CR (Epival)
6. Topiramate: Hitop 25mg, 50mg
7. Pizotifen: Mosigar Tab. / Syp
8. Pizotifen+B.Complex: Mosigar- V Syp.

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FAROOQ KITAB GHAR KARACHI
 Insomnia DisorderRx
Name: Age: Sex:, Date .
Temperature: B.P:. Pulse:. Resp. Rate ( RR ).

A
C/ C:
Initial or sleep- onset insomnia: difficulty 1. Tab Alprazolam 0.5mg, 0.25mg, lmg ( Alp, Praz )
initiating sleep Q+Q+ j
(Only for »horM»rm uu bccjinc of hl
| h rttk o( jddiction, Dccreaic ilcep

Middle or sleep- maintenance insomnia: latency and number of awakenlnfs during sleep)

frequently waking from sleep OR

Late or sleep-offset insomnia: awakening Tab Eszopiclone lmg, 2mg, 3mg (Clonexa ) x OD
early in the morning OR Tab Zolpidem lOmg ( Stillnox, Zolp, Xolnon) x OD
Nonrestorative sleep: feeling fatigued
after waking 2. If chronic insomnia advice Antidepressant
Tab Trazodone ( Deprel) OR Co-Depricap x OD
DSM- 5 diagnostic criteria
» Problems initiating or maintaining sleep, or awakening early in the morning and being unable to
return to sleep
» Symptoms occur 3 days/week for 3 months
» Symptoms cause functional impairment or distress
» Symptoms are not caused by an underlying substance or medication use
» Symptoms occur despite hå ving enough time to sleep
» No underlying or coexisting psychiatric or medical disorder that explains symptoms
Behavioral therapy
Sleep hygiene
» No alcohol 4-6 hours preceding sleep
» No stimulants: Caffeinated drinks and nicotine should be avoided 3-4 hours before bedtime.
» Regular exercise is beneficial but should be avoided 6 hours before bedtime.
» Quiet, dark, pleasantly cool bedroom and a comfortable bed
» No large meals before bedtime

Stimulus control therapy: Insomnia disorder may cause the bed and bedroom to become cues for arousal
rather than sleep. Stimulus control instruetions aim to correct this by re- establishing the association of the
bed and bedroom with sleep.
» Advise waking up at regular times (also during the weekend and holidays).
» Discourage engaging in other activities in bed such as working or reading.
» Leave the bedroom when unable to fall asleep within 20 minutes ( e.g., to read or listen to music ) and
return only when sleepy.
» Advise against afternoon naps; if taken, this should not take place after 3 p.m. and naps should be no
longer than 1 hour.

Sleep restriction therapy

» A cognitive behavior therapy for patients with chronic insomnia, where the amount of time spent in
bed is restricted to their average estimated sleep time.
» When sleep efficacy (total sleep divided by time spent in bed ) is greater than 90%, the amount of time
spent in bed is increased.
» This has been shown to reduce sleep latency.

Cognitive-behavioral therapy (CBT): preferred treatment for chronic insomnia

 CONSERVATIVE RX OF BACK PAIN

Name: ... Age: Sex:. . Date

Temperature: B. P : Pulse:. Rate ( RR ) ..

A
C/C:
• Numbness and tingling sensation in 6. Tab Tizinadine 2 mg, 4 mg ( Movax, Ternalin)
your arms, hands, leg, and foot I — 0 — 1 / 0 — 0 — I ( BD, OD)
• Pain radiates to buttocks and lower
extremities. 7. Tab Naproxen sodium 550mg ( Synflex )
• Pain or feeling of cramps in the legs I — 0 - 1 (BD) 119
after standing for a long period of
time or while walking. 8. Tab Mecobalamin 500mcg ( Methycobal, Cobalamin)
• Pain relieved by sitting or lying —
I 0 - 1 (BD) f
e
down and increase by standing or
walking. 9. Cap Esomeprazole 40mg (Nexum, Esso ) s=
• The pain usually goes away when 0 - 0 - 1 (OD) «a
ro
the person either bends forward or <=Jv 30 •
sits down ( Pain relieved by forward
* *
flexion)
• Pain exacerbated by standing and NOTE: ADVISE LUMER BUILT TO TRAUMA TO SPINE PATIENT OR
walking. AFTER MRI L/ S SPINEIF ANY INDICATION
DO, VITAMIN-D & CALCIUM LEVEL

nd
2 alternative Rx of backache &
1. Cap Gabapentin 100mg/ 300mg ( Neogab, Gabix )
1 - 0 - 1 ( BD )

2. Tab Naproxen sodium 550mg ( Synflex )

—
1 0 — I (BD)

3. Tab Mecobalamin 500mcg ( Methycobal, Cobalamin)

l - O - l ( B D)

4. Cap Omeprazole 40mg ( Risek, Ruling)

0 - 0 - 1 (OD)
30 c - j

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FAROOQ KITAB GHAR KARACHI
7. Treatment of EDH
> Initial resuscitation
• IV f luids: R /L (if hypotension is present )
• Intubation
> Management of elevated intraeranial pressure
• Head elevation, If patient is intubated, hyperventilation, Mannitol (clinically avoid)
• MANNITOL IS CONTRAINDICATED IN EDH: EDH is already known as expanding
hematoma , by giving Mannitol ICP A Brain Edema will decreases -> will lead to brain
Shrinkage -> it will provide more space to bleeding and EDH will increases.
• Mannitol - Mechanism of action -> Mannitol exerts its ICP- lowering effects via two
mechanisms - an immediate effect because of plasma expansion and a slightly delayed effect
related to its osmotic action. The early plasma expansion reduces blood viscosity and this in
turn improves regional cerebral microvascular f low and oxygenation. It also increases
intravascular volume and therefore cardiac output. Together , these effects result in an 125
increase in regional cerebral blood f low and compensatory cerebral vasoconstriction in brain
regions where autoregulation is intact, resulting in a reduetion in ICP.
> Surgical management
ff
C

• First - line: urgent craniotomy and hematoma evacuation

• Second - line : emergency burr hole =
ca
ro
> EDH is one of the most urgent neurosurgieal emergencies that may need prompt evacuation.

8 . Acute management checklist

Urgent neurosurgery consult for consideration of surgical intervention and ICP monitoring
Airway management: anesthesiology consult
Establish IV access.
Identify and treat any underlying coagulopathy.
Stop all anticoagulants and NSAIDs (ineluding aspirin).
Urgent anticoagulant reversal in all patients who require surgery
Consider hematology consult for complex cases (e.g. , patient with recent direct oral
anticoagulant use).
Identify and treat any complications (e.g., elevated ICP, seizures)
Euthermia: antipyretics for fever
Euglycemia
Euvolemia: IV f luids for hypovolemia
Identify and treat the underlying cause.
Close observation and GCS monitoring
Admit to neurosurgieal ICU.
Repeat CT head
» If clinically stable: Repeat within 4- 8 hours.
» In the case of clinical deterioration or new neurologie def icits: Repeat immediately.

9 . Prognosis
> Mortality rate: depends on preoperative condition of patient
• Almost zero in patients without severe neurologieal impairment (GCS > 8)
• Patients in deep coma: ~ 20%
> Factors associated with a worse prognosis:Low Glasgow Coma Scale scores before surgical
intervention, Delay in treatment and Age > 75 years

10 . Complications: Transtentorial herniation, Respiratory failure and death

 8 Bones And Joints

OSTEOPOROSISRx
Name: Age: Sex:, Date .
Ti e: B.P: Pulse:. Rate ( RR ).

A
C/C: 72%
Low back pain which
radiate around the trunk 1. lnjCholechalceferol( lndrop- D/Miura - D )
or down the limb
A gradual loss of height Once weekly / 2 weekly give acc . Serum vit.D3 level
and appearance of
thoracic kyphosis 2. Tab. Diclofenac potassium ( Caflam, Dyclo-P)
Difficulty in bearing Two times a day / 1 - + - 1
weight
Depression 3. Tab Osteocare
History of fractures + - + - I (OD )

4. Cap. Omeprazole 40mg ( Risek, Zoltar )

+ - + l (OD) «

Do complete baseline labs:

CBC, LFTs, TFTs S. Tab. Alendronate sodium ( Drat )
Urea, creatinine, electrolyte, Once weekly on empty stomach
serum calcium & 24 hr urine Ca, U4 Oii*
vitamin-D level & Serum PTH

Do X-ray for suspected fracture

72%
Gold standard investigation is:
Dexa scan (Bone densitometry ) 1. lnjCholechalceferol( lndrop-D/Miura- D )
jUi JV
-
fl
-
Lj AJ jJ < &
Once weekly/2 weekly give acc . Serum vit.D level
3

2. Tab. Øaproxen sodium 250mg, 500mg ( ffllexin, Heoprox )

Two times a day / 1 - + - 1

3. Tab Øalsan-D
+ - + - I (OD )

4. Cap. Esomeprazole 40mg ( Nexum, Øsso )

+ - + - 1 (00)
_Lirl 30
e
^JU O
*
^
5. Tab. Alendronate sodium (Drat )
Once weekly on empty stomach
jd£ Oif
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FAROOQ KITAB GHAR KARACHI
 9 Skin ( Dermatology )

Scabies Rx
Name: Age: Sex:. . Date
B.P:. Pulse: Rate ( RR ) . ..

A Scabies
C/C:
» Incubation period: approx . 3-6 weeks 1. Treat all family members, whether symptomatic or
following infestation. asymptomatic
» Intense pruritus that increases at night 2. Launder all clothing and bedding 139
» Burning sensation
» Skin lesions 3, Permethrin 5% Cream/Lotion ( Lotrix/Mitonil) C >
£
Eiongated, erythematous papules Day - 1 take bath, dry your skin with separate towel and 5'
Burrows of 2-10 mm in length apply permethrin 5% cream/lotion below collar line a
ro
Scattered vesicles filled with clear (face spared)
3
or cloudy fluid Day- 2 Apply permethrin 5% cream/lotion only,
Excoriations, pustules, and without bath 2.
<_
secondary infection Day- 3 No application of permethrin 5%, take only bath £
Predilection sites
-
» Always use
Wrists ( flexor surface )
Medial aspect of fingers 4. Tab Loratidine lOmg ( Softin/Loril )
Interdigital folds (hands and feet ) OR Tab Levocetrizine 5mg ( Belair / Xyzal)
Male genitalia ( e.g., scrotum,
penis) Oral Ivermectin: especially indicated in large outbreaks or
All other intertriginous areas of severe forms of scabies
the skin (anterior axillary fold,
buttocks)
Periumbilical area or waist Æx
Additionally in children, elderly 1. Permethrin 5% Cream/Lotion ( Lotrix/Mitonil)
persons, and immunosuppressed Day - 1 take bath, dry your skin with separate towel and
patients: scalp, face, neck, under apply permethrin 5% cream/lotion below collar line
the nail, palms of hands, and soles ( face spared)
of feet Day- 2 Apply permethrin 5% cream/lotion only,
without bath
Day- 3 No application of permethrin 5%, take only bath
Always use

2. Syp Loratidine lOmg (Softin/Loril )

OR SypLevocetrizine 5mg ( Belair / Xyzal )
1-2 TSP OD/BD

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FAROOQ KITAB GHAR KARACHI
 EVAMJATION AND MANAGEMENT OFCOMA
IN EMERECENCY PEPARTEMT

v
COMA - STABILIZING l \ EMERGENCY DEPARTMENT:
» Altered state of consciousness
» Coma is a common reason for visits to cmcrgency room .
» One of the most difficult condition to manage because:
- Complex prcscntation
- Multiple potcntial ctiologics
So a systematic approach is needed to manage coma patients

THE PHENOMENON OF CONSCIOUSNESS requires two intact and intcrdcpendenl physiological

and anatomical componcnts
1 . AROUSAL and its undcrlying ncural substrate -> dcpends on Ascending Reticular Activating System
( ARAS ) and Dicncephalon
2. AWARENESS -> requires the functioning of Cerebral Cortex .

Any problem in ARAS/ Dicnccphalon/ccrebral cortex -> results in Coma E .g. Drugs. trauma etc. can
aflcct thcsc systems resulting in coma

jijM ÉffXir
mi
» The Greek word ‘korne’ means dcep sleep.
» Coma is charactcrizcd by an unintcrruptcd loss of capacity for arousal .
Eycs -closed/open
Sleep/ wakc cycles- disappear
On vigorous stimulation, only a reflex response is elicited instead of conscious response.

» In coma. the paticnt is dceply unconscious and thcre is no response evoked by cxtcmal or intcmal stimuli .
» Acutc and potcntially lifc- thrcatcning emcrgency .
» Evaluation of a comatosc paticnt dcmands a System approach for appropriate diagnostic and thcrapcutic
endeavors.
» Urgent steps - to prevent/ minimize permanent brain damage from reversible causc.

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FAROOQ KITAB GHAR KARACHI
THE COM MON CAUSES OF COMA ARK :
Infcction and Drug and Toxins
Structural brain lesions Mctabulic & systemic inflummaton Knvironmcntal
disordcr pathology Pathology Othcrs
Any spacc occupying Any infcction Or Any Drug/ poison
-
Icsions/ injury/ trauma > inflammation can lcad to toxicity, can lcad to
can lcad to COMA COMA COMA
» Traumatic Brain » Anoxia & hypoxia » .
Bactcriul viral Or » Barbiturate » Psychogcnic
injury ( most Common ) fungal meningitis » Organophosphorus coma
» Subarachnoid bleed » Hypcrcapnia » Mcningocnccphalitis » Opioids » Hypovolemia
» Intraccrcbral blccd - Asthma » Acutc disseminated » Sedative » Hypoperfusion
» Ischacmic infarction - C02 Nccrosis cncephalomyclitis » Alcohol overdose » Eclampsia
» Global cerebral » Hypotension shocks » Severe Sepsis » Carbon monoxide » Cardiae causes
hypoperfusion » Hypoglyccmia » Syphilis » Arsenie poisoning 153
» Hydroccphalus » Hyperglycemia » Cerebral malaria » Hypothermia
» Cerebral venous sinus » DKA » Waterhouse » Hyperthermia
m
thrombosis » Hyponatremia Frcdrick’s syndrome » Heat stroke 3
co
» Basilar artery » I lypcmatrcmia » Complicatcd typhoid » Snake bite
te
occlusion » Hypocalccmia » Systemie infcction » Dog bite ro
» Central pontinc » Hypercalccmia » Unknown poison 3
<
•

hcniorrhagc » Enccphalopathy
» Central pontinc - Hypertensive
myelinolysis - Hepatic 5
» Large hemisphere - Uremie
ro
masses - Mctabolic
» Pituitary apoplexy - Wcmickc’s § :
» Cerebral abscess - Hypoxic 3
» SDH » Hepatic failurc
» EDH » Myxodema coma
» Intracranial SOL » Adrcnal crisis
» Tentorial herniation » Uremia

GLASGOW COMA SCALE ( GCS )

» Spontancously 4
EYE OPENING » To speech 2
» To pain 3
» None I
» Oriented (Time, placc and person) 5
» Confused 4
-> VERBAL RESPONSE » Inappropriatc words 3
» Incomprchcnsiblc sounds 2
» None I
» Obeys command 6
» Localizes to pain 5
MOTOR RESPONSE » Withdrawals from pain 4
» Flexion to pain ( Decorticate ) 3
» Extension to pain ( Dcccrcbratc) 2
» None I
> Minimum score of GCS: 3
> Maximum score of GCS: 15
> If GCS is <9, airway should be secured with intubation and protected from inspiration
2. Newly diagnosed hypcrtension with BP < 150/90 mm Hg: Begin therapy with one primary
antihypertensive.
3. Newly diagnosed hypertension with BP > 150/90 mm Hg: Begin therapy with two primary
antihypcrtensives.
4. CHOICE OF ANTIHYPERTENSIVE DRUG:
-
» YOUNG PATIENT AGE <55: Angiotcnsin convcrting enzymc inhibitor ( ACEI ): Captopril
(Capotcn ), Lisinopril ( Zestril ) and Enalapril ( Rcnitcc )., In case of dry cough/angiocdcma then switch
to angiotcnsin reccptor blockcr ( ARB): Valsartan ( Diovan ), Losartan ( Eziday ), Tclmisartan ( Tasmi )
» OLD PATIENT AGE >55: Calcium channcls blockcr (CCB): Amlodipine ( Norvasc), Nifedipine
( Adalat )
» In adults with chronic kidncv disease: initial ( or add-on ) treatment should include an ACE inhibitor 159
or ARB to improvc kidney outcome.
» Do not combine an ACE inhibitor with an ARB to treat hypertension ( NICE 2019) - m
» lf BP not respond to single therapy advice combine drugs: ACEI / ARB + CCB
-
- Amlodipine + Pcrindopril: Amlod P/Coversam ( 4mg/5mg, 8mg/5mg, 8mg/ 10mg) CT3
CD

Amlodipine + Valsartan : Newday/Dioplus ( 5/80mg, 5/ 160mg, 10/ 160mg )

» lf not controlled with Combine two drugs ( ACEI / ARB + CCB), add diuretics
» For Resistant hypertension: Uncontrolled HTN with three classes of antihypertensive drugs and the =
3»

drug should include ‘Thiazides \ for example PATIENT ON ACEI/ARB + CCB + THIAZIDES and CD
2
-
BP still not controlled then ADD ALPHA BLOCKER OR BETA BLOCKER
1:
» Treatment of hypertension in pregnancy
-
1 ) First line treatment: methyldopa, labetalol, hydralazine, and nifedipine 1
- -
2 ) Second line treatment: thiazidcs, clonidine ( alpha 2 agonist )
-.
3) Contraindicated: furosemide, ACE I ARB, renin inhibitors ( aliskiren )
.
5 Follow up-
» Rcasscss within 4 weeks of initiating or changing phannacological therapy.
» lf the treatment goal is not rcached with one drug, increase the dose of the initial drug or add a second
drug.
» lf the treatment goal cannot be reached with two drugs: Add a third drug.
» Evaluate for secondary causes of hypertension.
» lf blood pressure is controlled: Reassess after 3-6 months and annually thereafter.

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FAROOQ KITAB GHAR KARACHI
 UPPER GASTROINTESTINAL BLEED Rx

A UGIB: approx. 70-80% of

gastrointestinal hemorrhages Æx
The source is located proximal to 1. Airway:
the ligament ofTreitz » Secure patienfs airway
C/C: » Place patient head down to minimize risk of aspiration
» Anemia due to chronic blood » Suction maybe require to clear airway - blood/vomitus
loss » Consider elective intubation (ETT) in patients with ALOC or
» Acute hemorrhage: signs of respiratory stat and severe, ongoing hematemesis
circulatory insufficiency or .
2 Breathing: Check Sp02& Give high flow 0210-15L/L
hypovolemic shock 3. Circulation:
Tachycardia Pass IV line ( 2 Large bore IV cannula x 20 gauge)
Hypotension ( dizziness, » Start IL 0.9% Normal Saline (0.9% N/S) x IV x Stat
collapse, shock ) » Vitals monitoring: BP, PR, RR, Temperature, Sp02x 1-
m
Reduced vigilance 2hourly =
malaise/ weakness Assess severity: Tachycardia suggest 10% volume loss, tro
orthostatic hypotension 20% loss and shock >30% loss ro
» Melena: black, tarry stool Send labs: CBC ( anemia, thrombocytopenia), U/C/ E 3
-c
» Hematemesis:bleeding in the ( AKI/ARI), PT APTT & INR, LFTs (Pre-Existing Liver disease),
t»
mouth, throat, or esophagus and ABGs.
(coffee ground emesis) Consider 'O' Negative blood (universal donor) in emergency TO

» Hematechezia ( rarely) » Cross matching with Arrange 2 units/Pint of PCVs 2

TO
» FFPs if PT/INR is increased OR active bleeding
» Risk factors: Inj Octreotide O . lmg/ ml = lOOmcg (Sandostatin) x 2 § :
1) Alcohol use Ampule in lOOml 0.9% N/S in IV chamber x 10-12 3
2) Tobacco use drops/minute x BD
3) liver disease » Inj Omeprazole 40mg (Risek) x IV x Stat than 80mg in lOOml
4) repeated NSAID/aspirin use 0.9% N/S in IV chambers ( lOOml burrete set ) lOdrops x IV x
5) chronic vomiting BD
6) history of peptic ulcer disease » Inj Ringer Lactate ØR /IØ IL x IV x OD
» Inj Ceftriaxone lg x IV x BD ( 2g x OD)
» Scoring System for UGIB » Inj Metronidazole 500mg/100ml x TDS
.
1 ROCKALL SCORE » Inj. Haemaccel 500ml x IV x SOS (hypotension/shock)
.
2 MODIPIED FORREST » Inj Vitamin-K x IV x OD 0/- Inj Tranexamic acid 500mg-lg
.
3 G - BLATCHFORD SCORE (SOS)
0. Disability 0 Exposure
» Surgical » Keep NPO patient
1) EGD:lnjectionepinephrine » Pass Nasogastric tube and attach bag - monitor x hourly
therapy, sclerotherapy, » Consider folly's catheterization
ligation, or thermal coagulation » Bowel care: Lactulose, skilex
2) transjugular intrahepatic » Correct underlying cause
portasystemic shunt (TIPS) » Radiology: U/S whole abdomen, CØR, CT abdomen with
3) open surgical procedure contrast, Angiography
( Laparotomy) » Esophagogastroduodenoscopy (UGD)0 diagnostic &
therapeutic
» UGIB - Hematemesis or melena —* EGD — if negative,
perform colonoscopy to rule out LGIB

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FAROOQ KITAB GHAR KARACHI
 HEPATIC ENCEPHALOPATHY Rx

A Hepatic Encephalopathy
C/C: Zx
1. Disturbances of consciousness, ranging
from mild confusion to coma 1. Airway:
2. Multiple neurological and psychiatric » Ensure patient is maintaining own airway
disturbances like: » Assess and secure stable airway
» Asterixis 2. Breathing: Check Sp02& Give high flow 02 as appropriate
» Fatigue, lethargy, apathy 3. Circulation:
» Memory loss » Pass IV line ( IV cannula )
» Impaired sleeping patterns » Vitals monitoring: Check BP, PR, RR, Temperature,
» Irritability Sp02
» Disoriented, socially aberrant »> Send labs: CBC, UCE, LFTs, RBS, PT & INR, Urine D/R, m
behavior ( for e.g., alpha feto-protein level, Total protein AG ratio, blood 3
ro
defecating/urinating in public, ammonia and ABGs. CO
CD
shouting at strangers, etc.) » Inj Haemaccel x IV x Stat
5
» Slurred speech » Inj Omeprazole 40mg (Risek ) x IV x OD
» Muscle rigidity » Inj Ceftriaxone lg ( Rocephin) x IV x BD
» Inj Metronidazole 500 mg ( Flagyl) x IV x TDS 5
» Inj Dextrose 10% at the rate of 100ml/hr x IV x ro
Triggers
2
1. Deterioration of liver function OD/BD ro
2. Infections (e .g., spontaneous bacterial » Inj Albumin 20%/50ml x IV x OD «:
peritonitis)
3. Gastrointestinal bleeding
» Syp Lactulose ( Duphalac ) 15-60 x PO/NG x 4-6 hourly
» Tab Rifaximin 550mg ( Rifixa ) x PO/NG x BD
s
4. Constipation » Syp Hepa- Merz x 2TSP PO/NG x BD/TDS
5. Portal vein thrombosis » Inj Vitamin- K x IV x SOS
6. Hypovolemia/exsiccosis and electrolyte 4. Disability & Exposure
disturbances ( hypokalemia, » Urgent enemata in ER/ward
hyponatremia ) » Avoid triggers i.e. Restriction of protein diet
7. Renalfailure » Give high glucose diet and Bowel care
8. Excessive protein consumption » Pass nasogastric tube for feeding
» Pass Fole/ s catheterization
» Radiology: U/S whole abdomen, CXR, CT abdomen
with hepatic protocol, CT/MRI Brain (Cerebral
edema )
» Correct underlying cause
GRADES OF HEPATIC ENCEPHALOPATHY
STAG ES FEATURES
1 Anxiety , Mild Confusion, slurred speech, reversed sleep, apathy, asterixis
2 + Moderate confusion, disoientation, rigidity .
3 + Severe confusion, somnolence, incontinent, babinski's sign
4 + Coma

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FAROOQ KITAB GHAR KARACHI
 IRON DEFICIENCY ANEMIA ER / Ward Rx
Name: Age: Sex:.„ Date.
Temperature: B.P: ... Pulse: Resp. Rate ( RR )..

A 72x
C/C: IDA
Signs and symptoms of anemia 1. Airway:
» Fatigue » Ensure patient is maintaining own airway
» lethargy » Assess and secure stable airway
179
» Pallor .
2 Breathing: Check Sp02& Give high flow 02 as appropriate
» Cardiac: tachycardia, 3. Circulation:
angina, dyspnea on » Maintain intravenous (IV) access m
3
exertion, pedal edema » Start 0.9% Normal Saline (0.9% N/S) x IV x Stat CD
Brittle nails, koilonychia , hair » lf hypotension: Inj Haemaccel x IV x Stat CD
loss, Pica, dysphagia » Vitals monltoring: Check BP, PR, RR, Temperature, Sp02 3
•c
Angular cheilitis: inflammation » Send labs: CBC, Iron studies, Peripheral smear, and Rectic
and fissuring of the corners of count, U/C/E, LFTs, RBS, Stool D/ R, PT INR, and ABGs. 3>

the mouth » lf Hb<7:Cross matching with Arrange 2 units/Pint of PCVs 5

ro
Atrophic glossitis: erythematous, » Inj Iron sucrose ( Venofer /Ferrotein- S ) 100- 200mg diluted in
edematous, painful tongue with lOOml 0.9% N/S regularly for 3 days OR on alternative days
loss of tongue papillae ( smooth, ( total 3 doses) s3:
bald appearance) » Inj Neurobion x IV x stat on alternative day
4. Disability & Exposure
IDA may also manifest as » Dietary modifications
Plummer- Vinson syndrome » Infants and young children: restrict cow's milk intake, use
(PVS): triad of postcricoid iron- fortified formula, introduce iron-rich foods (pureed
dysphagia, upper esophageal form)
webs, and iron deficiency anemia » Adults: increase consumption of iron-rich diet ( meats, iron -
fortified food, fresh green leafy vegetables)
» Treat the underlying disease (e.g., antihelminthics for
hookworm, OCPs for menorrhagia)
» Radiology: CXR, US whole abdomen, X -ray abdomen
» DC on Rx
.
1 Tab Iberet Folie 500mg x PO x OD
.
2 Syp Maltofer x 2TSP x BD

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FAROOQ KITAB GHAR KARACHI
 THROMBOTIC THROMBOCYTOPENIC PURPURA (TTP ) ER / WARDRx
Name: Age: Sex: Date .
Temperature: B.P:. Pulse:. Resp. Rate ( RR ).

C/C: Æx
TTP patients are typically 1. Airway:
previously healthy adults. » Ensure patient is maintaining own airway
The pentad of clinical findings » Assess and secure stable airway
consists of: 2. Breathing: Check Sp02& Give high flow 02 as appropriate
1. Fever 3. Circulation:
183
2. Neurological signs and » Maintain intravenous (IV ) access
symptoms » Start 0.9% Normal Saline (0.9% N/S) x IV x OD m
3
Altered mental status, delirium » Vitals monitoring: Check BP, PR, RR, Temperature, Sp02 ro
Seizure, focal defects, stroke » Send labs: CBC, U/C/E, LFTs, RBS, Urine D/R, ABGs a
ro

-8
Headache, dizziness » lf Hb<7: Cross matching with Arrange 2 units/Pint of PCVs
<
3. Low platelet count » Avoid Platelets transfusion if possible
(i.e. thrombocytopenia ) » Prompt initiation of plasma exchange therapy ( PEX ) x 5-6L per »
Petechiae, purpura day for 3-5 days/until platelets are higher & LDH normal
ro
Mucosal bleeding » ConsiderGlucocorticoids - Prednisone l- 2mg/kg/day
Prolonged bleeding after minor » Inj Neurobion lampule x IV x OD ro
cuts » Inj 5% D/ W lOOOml x IV x OD
4. Microangiopathic hemolytic » Inj Omeprazole 40mg ( Risek ) x IV x OD 2
anemia » Inj Ceftriaxone lg x IV x BD
Fatigue, dyspnea, and pallor » Fever: Paracetamol infusion x IV x SOS
Jaundice » Severe Cases: Inj Rituximab ( Ristova )
5. Impaired renal function 4. Disability & Exposure
Hematuria, proteinuria » Treatment should be started after a presumptive diagnosis is
Oliguria, anuria made based on clinical features and initial labs ( e.g., blood
count, peripheral smear, and creatinine).
» Precautions: Avoid Intramuscular injection, tooth brushing,
Investigation: shaving and combing as risk of bleeding. Avoid antiplatelet
CBC ( TLC,PLT), Peripheral Blood ( aspirin/clopidogrel ), anticoagulants ( Heparin/ warfarin),
smear, Rectic count, direct NSAIDs and corticosteroids
coomb test, heptoglobin, Urea, » Monitoring and correction
creatinine and electrolyte, LFTs, - Fluid status abnormalities
Uric acid level, Urine D/ R, LDH, - Electrolyte disturbances
blood sugar, PT APTT. - Acid-base abnormalities
ADAMTS13 activity and inhibitor - RBC transfusions
testing: i ADAMTS13 activity » Radiology: CXR, ECG

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FAROOQ KITAB GHAR KARACHI
 TRAUMATIC BRAIN INJURY ( HEAD TRAUMA ) ER / WardRx
VSumatic Brain Injury (TBI )
C/C:
Red Flag Signs in head injury
TZx
1. Airway:
» Impaired consciousness level
» Ensure patient is maintaining own airway
» Dilated pupils which do not
» Suction maybe require to clear airway - blood/vomitus
respond to light ( "fixed and
» Assess and secure stable airway
dilated" )
» lf the GCS is 8 or less, or is rapidly deteriorating - intubation
» Signs of basal skull fracture
2. Breathing: Check Sp02& Give high flow 02 as appropriate, consider
» Focal neurological deficit or
intubation of patient.HIGH FLOW 02if patient presents with
visual disturbances
pneumocranium ( Pneumocephalus)
» Seizures or amnesia
3. Circulation:
» Significant headache or
» Pass IV line { IV Cannula ) 203
nausea and vomiting
» Vitals monitoring: BP, PR, RR, Temperature, Sp02x l- 2hourly
» Send labs: CBC, U/C/E, LFTs, PT APTT & INR, RBS, and ABGs. m
» Cross matching with Arrange 2 units/Pint of PCVs 3
>» Start 0.9% N/S OR R/L IL x IV x Stat to
CD
» Consider Inj.Haemaccel 500ml x IV x SOS(hypotension/ shock )
» lf seizures: Give Inj Diazepam ( Valium) 10mg/ 2ml x diluted in 8ml -3
c
N/ S OR D/ W x ( 2mg upto lOmg) x Slow IV (Over 5min.)
» lf recurrent seizures: Inj levetiracetam 500mg - lg in lOOml 0.9% 5CD
N/S x IV slow over 15- 20minutes
» lf N/V: Inj Dimenhydrinate 50mg/ lml (Gravinate) x IV x stat
» Inj Mannitol 250ml x IV x stat then lOOml x BD (® 90/ min
( According to the pts. age & weight ), avoid Mannitol in EDH
s:
» Pain: Inj Ketorolac 30mg (Toradol) in 4- 5 ml 0.9% N/S x IV
I
» Inj Omeprazole 40mg (Risek ) x IV x stat
» Inj Ceftriaxone lg ( Rocephin) x IV x stat
» Inj Alphacholine ( Neurocholine) 500mg- lg x IV x stat
4. Disability & Exposure
» Immobilisation of neck with cervical collar
» CNS:Monitor pupillary reflexes and GCS level
» lf GCS <8 intubate the patient, HDU/ICU admission
» Examine carefully for lacerations, evidence of facial fractures, or
depressed skuli fractures. Ensure to check for signs of basal skull
fractures, such as bruising around eyes ('racoon eyes' ), bruising
behind the ears (Battle' s sign), clear discharge from nose or ear
(CSF rhinorrhoea or CSF otorrhoea ), blood bulging from middle ear
(haemotympanum), or any obvious penetrating injury.
» Urgent CT scan brain plain and CT scan of cervical spine
» Referral to Neurosurgery
Intrapare nchymal IntraventricuUr Subarachnoid Subckiral Epidural Pneumocranium

OO 000
 BENZODIAZAPINES POISONING Rx

Name: Age: Sex: Date .

Temperature: B.P:. Pulse:. Resp. Rate ( RR ).

A
C/C:
CNS depression 1. Airway:
» Lethargy » Ensure patient is maintaining own airway
» Somnolence » Assess and secure stable airway
» Respiratory depression
» Mild hypotension
2. Breathing: Check SpO.> & Give high flow 02 as appropriate
» Hypotonia and
hyporeflexia 3. Circulation:
» Ataxia » Pass IV line (IV cannula )
» Slurred speech » Start 0.9% Normal Saline (N/S ) x IV x Stat
» Vitals monitoring: Check BP, PR, RR, Temperature, Sp02
Differential diagnosis » Send labs: CBC, U/C/E, LFTs, RBS, PT, INR, ABGs and urine
Other substances that lead to a drug toxicology
sedative hypnotic toxidrome » Crystalloid fluid: Inj R /L & 0.9% N/S IL x IV x BD/TDS
after an overdose ( e.g., alcohol, » Inj Omeprazole 40mg ( Risek ) x IV x OD
barbiturates, and anticonvulsants » Inj Ceftriaxone lg x IV x BD ( 2g x OD)
such as phenytoin) » Inj. Haemaccel 500ml x IV x SOS (hypotension/shock )
» Inj Flumazenil lmg/ lOml
Nystagmus, which typically Routine use of flumazenil for benzodiazepine overdose is not
accompanies alcohol and recommended
phenytoin overdose, is absent in Should be used in caution because it causes seizures
the case of benzodiazepine The recommended initial dose of Flumazenil is 0.3 mg IV lf
overdose. the required level of consciousness is not obtained within 60
seconds, a further dose of 0.1 mg can be injected and
Mechanism of action: repeated at 60- second intervals, up to a total dose of 2 mg
Benzodiazepines are indirect or until the patient awakes.
GABAA agonists that bind to If drowsiness recurs, an intravenous infusion of 0.1- 0.4
GABA- A receptors —* T affinity of mg/h may be useful.
GABA to bind to GABAA receptors
-» f GABA action -* T opening 4. Disability & Exposure
frequency of chloride channels -* » Consider early HDU/ICU Admission
hyperpolarization of the » Pass Nasogastric tube and foll/ s catheter
postsynaptic neuronal membrane » Monitor pupillary reflexes and GCS level
—> decreased neuronal excitability » Observe patient for 12- 24hours
Decreases the amount of REM » Radiology:0 R , CT brain
sleep in the sleep cycle

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FAROOQ KITAB GHAR KARACHI
 HUMAN BITE ER / Ward Rx
Name: Age: Sex: Date
Temperature: B.P: . Pulse: Resp. Rate ( RR ) ..

A
C/ C: Human bite
Human bites ( which usually occur 1. Airway:
during fights) lead to infections
» Ensure patient is maintaining own airway
which, if neglected, almost
invariably produce a highly » Assess and secure stable airway
destructive, necrotizing lesion
2. Breathing: Check SpO:& Give high flow 02 as appropriate
contaminated by a mixture of
aerobic and anaerobic organisms. 3. Circulation:
A deiiberately inflicted bite on m
» Pass IV line ( IV cannula ) 3
the hand or elsewhere should be ro
considered as contaminated » Vitals monitoring: Check BP, PR, RR, Temperature, Sp02 to
CD

» Send labs: CBC, U/C/E, LFTs, PT, APTT & INR 3

c
•

» IV Fluid: Ringer Lactate/ 0.9% N/S x IL x IV x stat

» Inj Imitate 0.5ml x IM x stat, repeat after 4 weeks 5
ro
5
» Give Inj hydrocortisone 200mg ( Solu-cortif ) + Pheniramine «

maleate 25mg ( Avil) x IV x Stat B:

§
» Analgesia: Paracetamol, oral/ lV for pain
» Inj Co- Amoxiclave 1.2g ( Augmentin) Or Inj Ceftriaxone lg
(Titan/Rocephin) x IV x BD
» Inj Omeprazoie 40mg (Risek ) x IV x Stat

4. Disability & Exposure

» Human bite bacteriologically dirtiest bite
» Wound:Clean thoroughly; do not suture
» Extensive irrigation and debridement in OR with Antibiotics
» Counsel the patient and discharge on
1) Tab Co- Amoxiclave ( Augmentin) 62 Smg x TDS, lg x BD
2) Tab Danzen DS/ Tab Danzen forte x PO x TDS
3) Tab Paracetamol (Panadol/Calpol) x PO x TDS
4) Cap Risek 40mg x PO x OD

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FAROOQ KITAB GHAR KARACHI
 11 COVID 19 ( Coronavirus Disease 2019 )
> - -
Introduction COVID 19: COVID 19 is an acute infectious respiratory disease caused by
- -
infection with the coronavirus subtype SARS CoV 2, first detected in Wuhan, China, in
-
December 2019. COVID 19 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 prcvalcnce

» The disease is currently spreading worldwide
» It is currently 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
i load speech

E
8
—
05
»

a>
» 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
h for up to a few days depending on the material
>•
Latex, aluminum, copper: 8 hours
-O Cardboard: 24 hours
i Countertops, plastic, stainless steel: 1-3 days
a Wood, glass: 5 days
Q
» Fecal-oral transmission: Evidence that both SARS-CoV and MERS-CoV are exereted
feeally suggests that fecal-oral transmission is possible

^ >
>
Zoonotic Disease: especially from eivet cats, camels Bats
Incubation period: 2-14 days ( average 5 days)
> Range from: Common cold to middle east respiratory syndrome
> Clinical features range from:Clinicai courses range from: very mild to developing into severe
-
with pneumonia and even critical with life threatening complications such as ARDS, shock, and
organ dysfunetion..

> 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-CoV-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
severity of the disease.
» Cases of possible reinfection have been reported
> Management of hospitali / ed patients
1 . Maintain ABCD& E
-
2. Administer 02 therapy via nasal canula: 1 6 L 02/min if Sp02 <93%
3. Careful with patients with COPD: a Sp02 of 90-93% is appropriate
4. Regular monitoring: BP, Pulse, Rcspiration, Sp02 and temperature
5. Supportive earerStay hydrated and plenty of rest
6. Fever management : Inj Paracetamol lg/ 100ml x IV x TDS/SOS
7. IV fluid: Inj 0.9% N/S and Ringer Lactate IL x BD/TDS
8. Empiric antibiotic therapy: Inj Clarithromycin 500mg ( Klaricid ) x BD, OR Inj
Moxifloxacin 400mg ( Moxiget ) x OD for secondary infection
-
9. Anticoagulation: for all hospitalized COVID 19 pt. unless there is a high risk of bleeding.
Inj Enoxaparin sodium 80mg (Clexane) x 100 lU /kg ( 1.5mg/kg ) x SC x OD
-
Alternative: Inj Fondaparinux ( Arixtra ) 5 10mg x SC x OD
10. Corticosteroids: Bascd 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 NIH COVID-19 Treatment Guidelines Panel recommends
-
using dexamethasone in patients with COVID 19, doses of CS are:
- -
Inj Dexamethasone 4mg/ lml ( Decadron ) - adults: 6 mg PO/1V once daily for 7 10 days
- Inj Hydrocortisone lOOmg (Solu-cortif ) - adults: 50 mg IV every 8hr. for 7-10 days
- Tab Prednisolone 5mg ( Deltacortril ) - adults: 40 mg/day PO given in 1 -2 divided doses for
-
7 10 days
- -
Inj Methylprednisolone ( Solu-Medrol ) 32mg/day( 0.5 l mg/kg/day ) x IVgiven in 1 2 -
-
divided doses for 7 10 days
.
11. To date there is no spccific medicine recommcnded to prevent or treat the new Coronavirus.
12. Consider experimental therapies ( e.g., convalescent plasma, lopinavir/ ritonavir ) only in the
context of a clinical trial or according to local protocols.
.
13. Tocilizumab: Treatment with tocilizumab whether administered intravenously or
subeutaneously, might reduce the risk of invasive mechanical ventilation or death in patients
-
with severe COVID 19 pneumonia
14. Antiviral drugs for COVID- 19
» Remdesivir: Remdesivir was granted an Emergency Use Authorization by the FDA ( May
1, 2020), which concluded that the possible benefits of the drug currently outweigh the
risks of its use based on the following:
- Potential risk of a serious or life-threatening course of disease in patients infected with
-
SARS CoV-2
- No validated alternative treatment for COVID-19 available at this time
- Preliminary results from a randomized, controlled clinical study in the US with about
1000 patients with COVID- 19 indicate a slightly faster time to recovery in patients
treated with remdesivir compared to those treated with placebo.
- Based on current evidence, the NIH COVID-19 Treatment Guidelines Panel
recommends using remdesivir in hospitalized patients with COVID- 19 who do not
need oxygen supplementation through a high- flow device.
- Adults Dose: 200 mg IV on day 1 , followed by 100 mg once daily for 4-9 days
» Favipiravir ( brand name: Avigan®; approved in Japan )
15 . Intensive care:
Indications: Admit to 1CU and initiate intubation if any of the following are present:
» Signs of respiratory failure
» Dyspnea with hypoxemia
» Tachypnea ( RR > 30/min ) COPY RIGHT - 2021
FAROOQ KITAB GHAR KARACHI
4. Aortic dissection
» Sudden onset of severe, sharp tearing chest or abdominal pain that radiates to the back
» Hypotension, syncope, neurological symptoms
» Asymmetrical blood pressure, pulse deficit
» New diastolic murmur (due to aortic regurgitation )
» Symptoms of myocardial ischemia
» Diagnostic findings:
- -
Elevated D dimer
-ECG: nonspccific ST-segment changes

-
-CXR: widening of the aorta
CT angiograpliy of chest /abdomen / pelvis: intimal flap with false lumen
-Echocardiography: proximal aortic dissection , tamponade, aortic regurgitation

5. Gl pcrforation & Peritonitis:

» Sudden onset of diffuse abdominal pain
» Nausea, vomiting C3
» Constipation/obstipation ra
» Diffuse abdominal guarding, rigidity, and rebound tendemess s
» Absent bowel sounds i.
tn
» Loss of liver dullness on RUQ percussion
» Diagnostic findings: are
- -
Abdominal x ray: pneumoperitoneum

6. ->
Acutc Appendicitis: Pain in the iliac fossa McBumey's sign positive
» RLQ, epigastric, and/or pcriumbilical pain ( migrating abdominal pain )
» Fever, Nausea, anorcxia
» Guarding, tendemess, and rebound tendemess in the RLQ
» Diagnostic findings:
- Neutrophilic leukocytosis
- Abdominal CT scan with IV contrast : distended appendix with periappendiceal
fat stranding
- U /S whole Abdominal: noncompressible, aperistaltic, distended appendix, probe
tendemess in the RLQ, Target sign

7. Mechanical bowel obstruction

» Colicky abdominal pain
» Obstipation/bioating
» Progressive nausea and vomiting ( late finding)
» Diffuse abdominal distention, tympanic abdomen, collapsed rectum on DRE
» Tinkling bowel sounds
» History of abdominal surgery
» Diagnostic findings:
- - X ray abdomen: 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

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FAROOQ KITAB GHAR KARACHI
 Acute cholecystitis Rx

A
C/ C:
Risk Factors: Fat, Female, Forty Flatulent,
72%
1. Maintain ABCD& E
Fertile
2. No feeding by mouth (NPO) 2-3 days
RUQ pain
» Typically more severe and prolonged ( > 3. Pass Nasogastric tube and Foley's catheterization
6 hours) than in biliary colic 4. Aspiration through NG Tube: Aspiration of HCI decreases
» Postprandial the stimulus to the secretion of bile. Spasm of gall
» Radiation to the right scapula ( due to bladder may come down. After 2- 3 days, pain comes
referred pain from phrenic nerve down, signs ( tenderness ) disappear and abdomen
irritation ) becomes soft. NG tube is removed, clear oral fluid is
Guarding given for 2-3 days followed by soft diet. After 6 weeks,
Fever, malaise, anorexia the patient is advised to undergo elective
Nausea and vomiting cholecystectomy.
P/ E on palpation: 5. Vitals monitoring: Check BP, PR, RR, Temperature, Sp02
» RUQ tenderness to palpation 6. Start IV fluid: 0.9% N/S, R / L, D/W 5% x IV x BD/TDS
» Peritoneal signs may indicate 7. Inj Toradol 30mg x dilute in 3-4 ml water x IV x TDS
perforation Alternative: Inj Tramol lOOmg/lnj Kinz lOmg, 20mg
» Gallbladder may be palpable 8. Inj Omeprazole 40mg ( Risek ) diluted in lOml 0.9% N/S x
Positive Murphy sign: sudden pausing IV x OD
during inspiration upon deep palpation of 9. Inj Metronidazole 500mg/ 100ml ( Flagyl) x IV x TDS
the RUQ due to pain, Murphy sign may 10. Inj Paracetamol 500mg/ 100ml ( Provas) ( SOS)
be falsely negative in patients > 60 years. 11. Inj Claforan lg / Zinacef 1.5g x BD
Boas sign: hyperesthesia to light touch in I will not go with Ceftriaxone because according to
RUQ or infrascapular area literature patient receiving ceftriaxone can develop
acute cholecystitis: ceftriaxone- associated sludge can
Send labs: CBC, Urea, creatinine, trigger existing gallstones to become symptomatic,
electrolyte (U/C/E), LFTs e gamma GT, PT ceftriaxone pseudolithiasis can transform into ceftriaxone
& INR, amylase, lipase, Viral marker (Anti
gallstones, or the patient can become symptomatic from
HCV, HBsAg), CRP
preexisting cholecystolithiasis unrelated to ceftriaxone
Imaging: Abdominal USG, CT scan
abdomen with contrast Chest x-ray, ECG, therapy.
and echocardiography. 12. Inj Dimenhydrinate 50mg (Gravinate) x IV x stat
HIDA scan: nonvisualization of the G.B lf severe vomiting than Inj Ondensetron 8mg/4ml (Onset )
- Diluted in 50- 100 ml 0.9% N/S over 15- 20minutes.
13. Bowel care: if constipation give Lactulose/Skilex drop

Di; criteria for acute

Local signs of inflammation Murphy sign, RUQ pain, tenderness, or mass
Systemic signs of inflammation Fever, I CRP, Leukocytosis
Radiology findings Any radiology finding characteristic of acute cholecystitis
Interpretation
Suspected diagnosis:>l local sign of inflammation PLUS i l systemic sign of inflammation
Definite diagnosis:>l local sign of inflammation PLUS i l sign of systemic inflammation PLUS any
characteristic imaging finding
 13 Common Drug Brands in Pakistan

Commonly Prescribe Drugs with Brands Name in Pakistan (recently Updated)

Non-Steroidal Anti - inflammatorv Drugs ( NSAIDS)/ Analgesic/ Antipvretics/Opioids analgcsics

» Tab Panadol, Tab Calpol

Paracetamol » Syp Panadol, Syp Calpol
( Acetaminophen ) » Syp Panadol DS, Syp Calpol 6plus 249
» Panadol drop, Tempol plus drop
» Provas lOOml IV Infusion, Bofalgan lOOml IV Infusion co
» Napa suppository 125mg, 250mg, and 500mg 3

1
Paracetamol + Caffeinc » Tab Panadol Extra, Tab Calpol plus =
1 3

Paracetamol + » Tab Panadol CF s

CO

Pseudoephedrine + » Tab Reltus CF IL

Chlorpheniramine maleate 5*
a
Ibuprofen
»
»
Tab Brufcn 200mg, 400mg, 600mg
Syp Brufcn, Syp Brufcn DS
I
» Inj Xalcvc 400mg/4 ml ( Dilute in l OOml N/S = IV)
» Inbufin 400mg/ lOOml IV infusion
» Brufcn cream

Dexibuprofen » Tab Tercica 200mg, 300mg, and 400 mg

» Syp Tercica lOOmg

Ibuprofen + codeine » Tab Brufcn Plus

phosphate

Mefenamic acid » Tab Ponstan, Tab Ponstan forte

» Syp Ponstan, Syp Dollor, Syp Pollor DS

Codeine phosphate + » Tab Napadoc

Paracetamol + Caffeine

Diclofenac sodium » Tab Voltral 25mg, 50 mg, IOOmg ( SR )

» Tab Voren 25mg, 50mg, IOOmg (SR )
» Inj Voren 75mg/5ml, Inj Voltral 75mg/5 ml
» Voltral Emulgel , Dicloran gel

Diclofenac potassium » Cataflam 50mg, Tab Caflam 50mg

 INJECTABLE ANTI - DIABETIC/ INJECTABLE HYPOGLYCEMIC DRUG BRANDS

Dulaglutidc » Inj Trulicity 0.75 mg/0.5ml

» Inj Trulicity 1.5mg/0.5ml

Liraglutidc » Inj Victoza 6 mg/ml

Insulin Lispro » Humalog 100 units/ ml ( 3.5mg/ ml ) subcutaneous use

» Humalog kwikPen 100 units/ ml (3.5mg/ ml ) subcutaneous
use

Insulin Lispro ( 25% ) & » Humalog Mix25 100-units/ ml ( 3.5mg/ ml ) subcutaneous use 263
Insulin protamine ( 75% ) » Humalog Mix25 kwikPen 100 units/ml ( 3.5mg/ ml )
subcutaneous use ->
C

Insulin Lispro (50% ) & » Humalog Mix50 100-units/ ml (3.5mg/ ml ) subcutaneous use
Io
Insulin protamine (50% ) » Humalog Mix 50 kwikPen 100 units/ ml ( 3.5mg/ ml ) C3

subcutaneous use ca
ro
3
Insulin Aspart » NovoRapid Flexpen 100 units/ml subcutaneous use i.
» NovoMix 30 100 units/ ml subcutaneous use = •

Insulin Aspart (30% ) & a;

Insulin Aspart Protamine » Novomix 30%/70% FlexPen x 100 units/ ml subcutaneous
(70%) use 1
Insulin Glulisine » Apidra SoloStar 100 units/ ml subcutaneous use

Insulin Glargine » Lantus 100 units/ml subcutaneous use

» Lantus SoloStar 100 units/ml subcutaneous use
» Basagine 100 units/ ml subcutaneous use
» Toujeo 100 units/ ml subcutaneous use
» Toujeo 100 units/ ml subcutaneous use

Insulin Detemir » Levemir 100 units/ml subcutaneous use

» Levemir Flexpen x 100 units/ ml subcutaneous use

Human insulin injection » Humulin-R ( Regular ) x 100 units/ml SC/IV use

( rDNA origin ) ( Neutral ) » Insuget- R x 100 units/ ml SC/IV use
» Actrapid x 100 units/ml SC/IV use

Human insulin ( rDNA » Humulin-N ( NPH ) x 100 units/ml subcutaneous use

origin ) and human insulin » Insuget- N x 100 units/ ml subcutaneous use
isophane

70% human insulin » Humulin 70/30 x 100 units/ ml subcutaneous use

isophane and 30% human » Insuget 70/30 x 100 units/ ml subcutaneous use
insulin ( rDNA origin )
 COM MON LY USED ANTI - DEPRESSANT DRUG BRAM) IN PAKISTAN
USUAL MAXIMU
GENERIC BRAND DAILY M 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 20mg, Tab Floxac 20mg

Citalopram » Tab Cipram 20mg

» Tab Celesta 20mg -
20 40 mg 40 mg
» Tab Cipramil 20 mg
» lab Cilalo 20 mg

» Tab Cipralex lOmg, 20mg

Escitalopram » Tab Estar 5mg, lOmg, 20mg
» Tab Pexncw 5mg, lOmg, 20mg -
10 20 mg 20 mg
» Tab Citanew 5mg, lOmg, 20mg
» Tab Safepram 5mg, IQmg, 20mg

Fluvoxamine » Tab Flaverin 50mg, lOOmg -

100 300 mg 300 mg
» Tab Voxamine 50 mf, lOOmg

» Tab Seroxat 20mg, Tab Seroxatc 25mg

Paroxetine » Tab Seroxat CR 12.5mg
20-30 mg 50 mg
» Tab Paraxyl 20mg
» Tab Paraxyl CR 12.5mg, 25mg and
37.5mg

Sertraline » Tab Zoloft 50mg

» Tab Sestrin 50mg and lOOmg -
50 150 mg 200 mg
» Tab Sert 50mg and lOOmg
» Tab Preloft 50mg and lOOmg

Venlafaxine » Tab Enpress 37.5mg and 75mg

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

Desvenlafaxinc » Tab Lafaxine ER 50mg

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

Duloxetine » Cap Dulan 20 mg, 30mg and 60mg

» Cap Lyta 20 mg, 30mg and 60mg 30-60 mg 120 mg
 14 Paediatric and Neonatal Drug Dosage with National and
International Drugs Brand Names

Generic Name: Pa racet a mol

> Ilrand Name with Drug Coneentration:

» Syp Panadol ( I 60mg/5ml ), Syp Panadol Fort ( 250mg/5ml )
» .
Syp Tempol ( 120 mg/5ml ) Syp Tempol 6plus ( 250mg/5ml )
» Syp Calpol, Syp Calpol 6 plus
» Peadiatric Drops: Panadol Drops (60mg/20ml ), Tempol 6plus drops ( 100mg/20ml )
» IV Infusion: Inj Provas lg/ 100 ml, Inj Bofalgan Ig/ lOOml
» IM Inj. Provas 300 mg/2 m! 289
» PR: Napa Suppository 125mg, 250mg, 500mg
> Route: Per Orally ( PO), Intravenous ( IV ), Per Rectal ( PR ), Intramuscular ( IM )

> -
Dosage:Recommended dose 7.5 15mg/ kg/dose ( 4 6 Hourly ) - S
cu
;

ir
Oj
Neonatal Dose Peadiatric Dose OLm

Intravenous loading dose:20 mg/ kg/dose Intravenous: 2

O
=
Si
Intravenous Maintenance dose: -
Children < 2 years: 7.5 15 mg/kg/dose
a
every 6 hours
-
PM A 28 32 weeks:10 mg/kg/dose every 12 hours Maximum daily dose: 60 mg/kg/day ca
a
Maximumdaily dose:22.5 mg/kg/day £
-
Children 2 12 years: 15 mg/kg every 6 ro
-
PM A 33 36 weeks: 10 mg/ kg/dose every 8 hours hours or 12.5 mg/kg every 4 hours
|
Maximumdaily dose:40 mg/ kg/day Maximum single dose: 15 mg/kg

PM A >37 weeks: 10 mg/kg/dose every 6 hours

Maximum daily dose: 75 mg/kg/day 2
5
=
Maximumdaily dose: 40 mg/kg/day Per Oral: s
- -
aj

10 15 mg/ kg/dose every 4 6 hours as

Per Oral: needed ; do not exceed 6 doses in 24 s
hours CD

- -
GA 28 32 weeks: 10 12 mg/kg/dose every 8 hours &
Maximum daily dose: 40mg/kg/day
a
-
GA 33 37 weeks <10 days: 10-15 mg/kg/dose
ca
every 6 hours
Maximum daily dose:60 mg/kg/day w
g
-
Term neonates >10 days:12 15 mg/kg/dose every W
6 hours
Maximum daily dose:90 mg/kg/day
1

IV Administration:Give undiluted or dilute to a coneentration of 1 mg/ mL in Dextrose 5%

water ( D5%W ) or 0.9% Normal Saline (0.9% N /S).Use within 1 hour of dilution.

Overdoses of Paracetamol can e treated with cetylcysteine.

Generic Name: Ibuprofen

> Brand Name with Drug Concentration:

» Syp Brufen ( 100 mg/5ml ), Syp Brufen DS ( 200mg/5ml )
» Syp Bludol ( 100mg/5 ml ), Syp Bludol DS ( 200 mg/5ml )
» IV lnfusion: Inj Inbufin 400 mg/ 100ml, Inj. Xalcve 400mg/4ml ( must diluted before use)
> Koute: PO, Intravenous ( IV )

> -
Dosage:Recommended dose 10 mg/ kg/dose x 4 6 hourly ( max daily dose - 40mg/kg/day )
Initial dose: 10 mg/kg/dose followed by 2 doses of 5 mg/kg/dose given 24 hours and 48 hours after
the initial dose. Administer over 15 minutes. Use birth weight to calculate all doses. Hold second
and third doses if urine output is <0.6 mL/kg/hr; may give when renal function improves.
Closure of PDA: First dose: 10mg/ kg and second and third: 5mg/kg at 24 hrs interval

Generic Name: Indomcthacin

> Brand Name with Drug Concentration:Inj Liometacen 50mg/ Ampule

> Routc: Intravenous ( IV )

> Indications: Closure of patent ductus arteriosus, prevention of intraventricular hemorrhage.

> -
I)osage:IV dose in Neonates for PDA: 0.2 mg/kg initially followed by 2 doses at 12 24 hours
intervals.
Treatment of PDA : Usually 3 doses per course:
Age at Ist dose Ist dose 2 nd dose 3rd dose
< 48 hrs. 0.2 mg/kg 0.1 mg/kg 0.1 mg/kg
-
2 7 days 0.2 mg/kg 0.2 mg kg
/ 0.2 mg/kg
> 7 days 0.2 mg/kg 0.25 mg/kg 0.25 mg/kg
-
Give doses 12 24 hrs.Apart.
Longer treatment courses maybe used: 0.2 mg/kg/day for up to5-7 days.
Prevention of IVH for infants with a birth weight < Ikg or gestational age <28 weeks: 0.1 mg/kg q
24 hours for 3 doses beginning at 6- 12 hr of age.

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Generic Name: Ondansctron

> Brand Name with Drug Concentration:

» Inj Zofran 4 mg/2 ml , Inj Zofran 8mg/4ml
» Inj Onset 8mg/4ml
» Inj Onseron 4mg/2 ml, Syp Onseron 4mg, Tab Onseron 8mg

> Route: IM , IV, PO

> Indications: Prcvention of Postoperative vomiting, chcmothcrapy induced vomiting, Radiation
induced vomiting, uncontrolled/severe vomiting
> Dosage for >6months: Safety and efficacy not established in infants < 6 months
-
» IV: 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% N/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 1 mg
> Route: IM , IV, PO

> Dosage for >6 months:

» - -
IV:Children > 2 year: 10 20 mcg/kg half an hour before chemotherapy; 2 3 doses may be given .
( PO is given in adults: 1 mg BD or 2 mg OD 1 hour before chemotherapy )

Generic Name: Metoclopramidc

> Brand Name with Drug Concentration:

» Syp Maxolon (5mg/ ml ), Inj Maxolon ( 10mg/2 ml )
» Syp Metadon ( 5 mg/ ml ), Inj Metadon ( 10mg/2 ml )

> Route: IV, PO

> Indications: Gastroesophageal reflux, prevention of nausea and vomiting due to various causes,
symptomatic treatment of diabetic gastric stasis.
> Dosage:
Neonatal dosage: 0.033-0.1 mg/ kg/dose orally or slow IV push every 8 hours
Child 1 month-1 year and bodyweight up to 10 kg: 0.1 mg/kg twice daily( max. 1 mg)
-
Child 1-3 years and body weight 10-14 kg: 1 mg 2-3 times daily
-
Child 3-5 years and body weight 15-19 kg: 2 mg 2-3 times daily
-
Child 5-9 years and body weight 20-29 kg: 2.5 mg 3 times daily
Child 9-18 years and bodyweight 30-60 kg: 5 mg 3 times daily
Child 15-18 years and bodyweight over 60 kg: 10 mg 3 times daily
Generic Name: Cephalexin

> Brand Name with Drug Concentration:

» Syp Keflex 125mg/5ml, Syp Keflex 250mg/5ml
» Syp Ceporex 125mg/5ml, Syp Ceporex 250mg/5ml
» Pediatrics Drops: Syp Keflex lOOmg/ lml, Syp Ceporex lOOmg/ lml

> Route: PO
> - -
Dosage: 25 100 mg/kg/day divided every 6 8 hourly ( Max: 4 g/day ).

Generic Name: Cefazolin

> Brand Name with Drug Concentration :

» Inj Kefzol 500mg/ vial
» Inj Kefzol lg/ vial

> Route: IV, IM

> Dosage:
» Neonates:
PNA < 7 days: 40 mg/kg/day divided every 12 hourly.
PNA > 7 days :
- < 2000 g: 40 mg/kg/day divided every 12 hourly.
- >2000 g: 60 mg/kg/day divided every 8 hourly.
» Infants and children: 50-100 mg/kg/day divided every 8 hourly. ( Max: 6 g/day ).

Generic Name: Cefaclor

> Brand Name with Drug Concentration:

» Syp Ceclor 125mg/5ml, Syp Ceclor 187mg/5ml, Syp Ceclor 250mg/5 m!
» Syp Ceclor 125 mg/5ml, Syp Ceclor 250mg/5ml
» Pediatrics Drops:Ceclor 50mg/ lml, Cefalor 50mg/ lml

> Route: PO
> Dosage:
» 20-40 mg/kg/day divided every 8- 12 hourly PO; ( Max: 2g/day ).
» Twice daily option is for otitis media and pharyngitis.
 𝗝𝗔𝗩𝗘𝗗 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞 𝗦𝗛𝗢𝗣 𝗟𝗔𝗛𝗢𝗥𝗘
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