COMMON TREATMENT ORDERS (for fresh graduates)

1. Unclassified ward com laints - Raised BP - Decreased BP - Decreased / no urine output - Decreased SaO2 - Pain - Headache - Fever - Nasal allerg - Drug allerg - Sore throat - S!in rash - Nocturnal leg cra"p - #nso"nia - Di$$iness - %&nor"al &ehaviour - 'iolent patients - Pruritis - Red e e / e e disco"(ort - Drug )ithdra)al s "pto"s *drug addicts+ - Nocturnal irrita&ilit - Oral ulcer - Palpitation 2. !a"orator# results - Decreased hae"oglo&in - Decreased platelet count *plus (ul(ill indication (or trans(usion+ - Raised #NR - pH,-.1 - H po!alae"ia - H per!alae"ia - H pernatrae"ia - H ponatrae"ia .. Res irator# - /ough "edications - /hest in(ection / pneu"onia - #ntu&ation - 'entilator settings - /O%D drugs 0 12 - %nti-3B drugs - Hae"opt sis 4. Cardiac - Fast %F - /hest disco"(ort *%/S+ 5. $astrointestinal - /o((ee ground vo"iting - /onspitaion - D spepsia - %&do"inal pain *anti-spas"otics+ - 'o"iting - Diarrhoea - Hae"orrhoid 6. Ner%ous s#stem - Stro!e / /'% - 7pileps - Sei$ure attac! - /NS tu"our / hae"orrhage )ith "ass e((ect -. Endocrine - D8# drip *(asting o( D1 patients+ - H pogl cae"ia *H9sti2 ,..5+ - #ncreased H9sti2 - Sliding scale o( %ctrapid H1 - H pergl ce"ia *poor D1 control+ - 3h roto2icosis
1

:. Miscellaneous - /ontrast allerg - Drug overdose - 3h ro2ine replace"ent - ;out

- /ellulitis - D'3 - 1enorrhagia - <nit

conversion - /reatinine clearance

&' UNC!ASS()(ED *ARD COM+!A(NTS Raised BP (if SBP >180 or DBP >90) - /hec! the stress level= previous record - >oo! (or chest pain= SOB= headache= &lurred vision= (undi changes - %dalat Retard 2?"g PO stat 2 1 or BD - /aptopril 6.25"g po @4H prn i( SBP AB21? or DBP AB11? - Betaloc 25"g BD #( eating not allo)ed 0 patient conscious= %dalat 5"g su&lingual 2 1 #( eating not allo)ed 0 patient unconscious= la&etalol 5"g #' stat * up to 2?"g #' over 2 "in+ Decreased BP (esp: SBP<90) - Shoc!= di((erentiate &et)een cardiogenic and non-cardiogenic= and (urther identi( the underl ing causeC treat accordingl - Dithhold anti-H3 drugs - Fluid resuscitation *v cautious in /RF or HF+ - ;elo(usine 5??"l FR 21 Or NS 5??"l FR 21 #notropes - Dopa"ine - 1g in 5??"l NSE give 1?-4?"l/hr or 4E1= 1-2?"l/hr Dol&uta"ine dripE - 25?"g in 5?"l D5= 5"g/"l= 1"l/hr - %drenaline drip * )e )ould give dopa"ine (irst+ - .?"g in 5??"l NSE give 5-2?"l/hr or 6"g in 1??"l NS 1-2?"l/hr * Dard E ."g in 4-"l NS= give 5 "l/hr + Decreased or no urine output - /hec! BP/P= #/O= te"perature= h dration status= /'P 0 drain outputs *i( an + - Di((erentiate &et)een causes o( Post-renal: (eel (or &ladder F/- &edside &ladder scan= chec! Fole patenc Renal: creatinine level Pre-renal: (eel peripheries= chec! h dration status= G'P= ede"a= crep= PR e2a" *i( indicated+= /HR *i( indicated+

For pre-renal causes - i( non-cardiogenic= treat )ith (luid challenge= e.g. NS 5??"l FR or @1H or @2H 21 - ;elo(usine 5??"l FR or @1H 21 - NS 25?"l @1H 21 i( cardiogenic= according to BP consider inotropes *e.g. dopa"ine+ / lasi2 *e.g.lasi2 2? or 4?"g iv stat 21+ - Set up /'P Decreased SaO2 - So"e causes to consider *and "an "ore+E - /ardiacE /HF= %1#= arrh th"ia= etc 7/; - /hestE pneu"othora2= pneu"onia= pul"onar e"&olis"= "ucus= /O%D= %PO etc/HR - /hec! vitals= G'P= oede"a= listen to chest= heart sound - /HR *<0P+ / %strup / R>F3C F/- cardiac en$ "es/7/; *i( cardiac causes+ - ;ive O2 .5/5?/1??I *not to e2ceed N// 2>/"in in /O%D+ - Suction (or sputu" -'enturi "as! - #ntu&ation / %"&u &ag - 3reat underl ing causes
-

Pain - Panadol 5??"g @#D prn PO/PR - Dologesic ta& 1 @#D PO prn - Dolo2ene /o .2"g Jid po prn - Dolo2ene /o 5?"g #1# J6h prn -'oltaren -5-15?"g PO dail -3ra"adol 5?"g #1# @6H prn *&e)are o( resp distress 0 nausea+ *cp. Pethidine-tra"adol )ea!er= slo)er onset et longer durationK + Higher doses -5/1??"g= FreJuent @4H = #' (or" (aster onset &ut need "onitoring - Pethidine 5?/-5/1??"g #1# J6h prn *&e)are o( resp distress+ !ocal a lication - %nalgesic &al" >% tds prn - Ru&esal 25g >% tds prn - 'oltaren gel >% tds good (or post-trau"atic in(la""ation - 1orphine 4/:/1?"g S//iv J6h prn - Hirudoid >% tds prn good (or drip site )ound - Napros n 25?"g BD PO
4

Headac e - Docu"ent ;/S= &rie( H2 and P/7 to r/o sinister causes - Panadol 5??"g @#D PO prn !e"er Post-op fever: - Dithin 4: hoursE usuall atelectasis - 4: hours to 5 da sE chest in(ection= <3#= drip sites= etcL - %(ter 5 da sE )ound in(ection= intra-a&do"inal a&scess= D'3 /o""on causesE post-op causes *as descri&ed+ resp *pneu"onia= <R3#+= <3#= drip sites= )ounds= g nae *in (e"ale+= ;#= 7N3= drug-induced= tu"our= etcL
- Revie)

"edications *K on %/B+= la& results *e.g. on %/B alread 0 D// on decreasing trendK+ For atelectasis : - chest ph sio - encourage deep &reathing - o&serve trend o( (ever For other causes: - Septic )or!up i( not doneE - Bld 2 /BP/D/= //S3 - Sputu" 2 //S3/R1 - 1S< 2 //S3/R1 - /HR - #( indicated= start e"pirical anti&iotics - Panadol 5??"g @#D PO prn i( te"p AB.:.5 degrees *For neutropenic (ever= can give Fortu" 1g #' @:H+ --ce(ta$idi"e #asa$ a$$er%& 're$ief of s&(pto(s of a$$er%ic r initis - Phenergan 25"g 3DS PO - /larit ne ta& 1 3DS PO Dru% a$$er%& - H drocortisone 1??"g #' @6H
5

- Piriton

1?"g #' @:H Sore t roat - /epacol/DeJuadin/Strepsils ta& 1 @#D PO prn / - ?.2I /hlorhe2idine 1/D 1?"l >% 3DS - 3h "ol gargle 1/D 1?"l >% 3DS S)in ras - 72clude allergic reactions - S nalar /r ?.?25I or ?.?5I >% 3DS - Diprogenta /r >% BD *&eta"ethasone dipropionate + #octurna$ $e% cra(p - Baclo(en 5"g tds PO *"uscle rela2ant+ *nso(nia - Piriton ta& 1 po 2 1 - %tivan ?.5-1.?"g Nocte PO 2 1 - #"ovane -.5"g Nocte PO 2 1 * $opiclone+ Di++iness If sudden onset and severe - H2 and P/7 to e2clude sinister causes *e.g. stro!e+ /p tone 0 po)er &oth sides -SO>K Non speci(ic K 'ertigo * Hallpi!eMs "aneuver + - HMsti2 stat= BP erect and supine -Bld 2 /BP - Ste"etil ta& 1 tds prn - Ste"etil 12.5"g #1# J6h prn - Ser / *1erislon+ ta& 1 tds po prn ,o(itin%- #ausea - >oo! (or underl ing cause *e.g. S/7 o( "edications+ - 1a2olon 1?"g tds po - 1a2olon 1?"g #1/#' @6h prn ./nor(a$ /e a"iour - For those )ith ps chi histor = not (or drug overdose - Haloperidol 2-1?"g @4H-@:H *"a2 1:"g dail + #1#/#'C usuall 5"g #1# @6H prnC hal( dose (or elderl
6

,io$ent patients - Haloperidol 2.5"g #1# 2 1 - Pulse o2i"etr = cardiac "onitor= BP/P @1H 2 4 Pruritis - %(ter e2cluding allergic reactionsE - %Jueous crea" >% tds prn - 7ura2 crea" >% tds prn - /ala"ine /r /lotion >% @#D - Piriton ta& 1 tds po prn Red e&e or e&e disco(fort - Do e2clude sinister causes (irstN *e.g. loo! (or ciliar (lush+ - ;utt H pro"ellose 2 drops >% B7 tds - 1eth lcellulose e edrop 2 drops >% BD B7 Dru% 0it dra0a$ s&(pto(s (Dru% addicts) - Ph septone *"ethadone+ 1? or 15"g tds po prn - Ph septone 1?"g or 1"l iv @6H prn - 1orphine 1?"g iv @6H prn #octurna$ irrita/i$it& - #"ipra"ine 1? or 25"g Nocte Ora$ u$cer - %c clovir /r >% 3DS Pa$pitation - #nderal 1?"g 3DS PO prn * propranolol+ *onl (or s "pto"atic R2C al)a s loo! (or underl ing cause= e.g. arrh th"ia= %1#..+ Hiccup 1. Paper &ag (or sel( re-&reathing *!"#+ 2. largactil 25"g #' 2 1

,' !A-ORATOR. RESU!TS Decreased H/ - /hec! vitals Look for underlying cause: - PR e2a" * e2clude PR &leeding Osurgicall o&ligation - Bld 2 iron pro(ile= 30S *F/- /BP= clotting pro(ile= H& pattern+ - Stool 2 occult &lood 2 . * i( no o&vious PR &leeding+ - 3rans(use i( H& , :C ai" at raising H& to a&ove : a(ter trans(usion *7ach unit o( pac!ed cells raise H& (or a&out 1g/dl+ * No)ada s seldo" Pust give 1 unit pac!ed cells + - /an consider giving lasi2 2?"g iv a(ter each pint o( trans(usion i( still conscious - /hec! post trans(usion H& *F/- RF3+ - For 1DS anae"ia= treat onl i( s "pto"atic #( an pro&le"s related to &lood trans(usion e.g. Patient )ith ;roup % Rh Ove = onl ;roup % Rh Fve &lood a/v = consult hae"atologist Decreased p$ate$et count (p$us fu$fi$$ indication for transfusion) - 4 or 6 units platelet conc FR 2 1 Raised *#R - 3rans(use 4 units FFP FR 2 1= then re-chec! #NR Platelet A -? 0 #NR , 1.. can tolerate procedures. e.g. 3%/7= 7R/P= %&scess drainage= P3BD insertion 0 P/N NoteE FFP cannot sta long in the circulation= onl give it an hour &e(ore an procedure. #( not= Pust )aste FFP pH < 121 - 5?"l :.4I NaH/O. over 1 hour * even 1??"l is (ine O1??"l per &ottle + - Re-chec! Bld 2 %B; a(ter)ards H&po)a$ae(ia >oo! (or co""on causes= e.g. diuretics= vo"iting= etc If cause not obvious, or persistent hypoK, or severe hypoK (K !"#$: chec! spot seru" 8 and os"olarit = urine 8= &aseline 7/; S&rup 34$ 2g PO @2-.H 2 2-. doses Or s$o0 3 *:""ol 8/6??"g ta&s+ ta& 1 @D/BD/3DS PO #ntravenous 8 supple"ent i( severe or NPO *8,B 2.5""ol/l+ ;ive 4?-12?""ol/dE DonMt e2ceed 4?""ol/hr= use large vein
:

1onitor 8= 7/;= urine output= consult #/< %void de2trose *lead to (urther drop in seru" 8 level+ ;ive separatel or add to original #'F= e.g.E 2?""ol 8/l in 25?"l NS= @2H 2 1 NS 5??"l @6H/pint F 15""ol 8/l/pint *i.e. 6?""ol 8/l/da + <suall )ill re-chec! Bld 2 8 a(ter supple"ent i( original 8,..? /onsider h po1g (or persistent h po8 Dard has preparation o( NS 5??"l F 1? ""ol 8/l /pint or NS 5?? "l F 2? ""ol 8/> /pint #( ordered 15 ""ol 8/> /pint = Dard needs to get it (ro" Phar"ac

H&per)a$ae(ia K %& - 7/;= cardiac "onitoring - 1? "l 1?I ca$ciu( %$uconate iv stat )ith cardiac "onitor *over . "in+ - D* dripE 5?"l D5? F :-1?u %ctrapid H1 #' over .? "in - Repeat 7/; in 5 "in *i( original 7/; sho)ed h per 8 changes+ - Repeat Bld 2 Na and 8= HMsti2 K not very high ( &$ - Resoniu" / 15g" @6H/3DS PO/PR - Resoniu" % *)atch-out Na and H2O overload+ 15g" @6H/3DS PO/PR -$%&'( ! # - Rechec! Bld 2 Na/8 a(ter)ards H&pernatrae(ia - Rechec! &lood= clinical sign *palpitation+ - 5??"l D5 over 4 hr )* H&ponatrae(ia - /hec! seru" os"ol= cortisol= 3SH= urine os"al= Na * al)a s re"e"&er adrenal insu((icienc + - /hec! drug *lasi2+= RF3 - 3reat according to underl ing causes - Re. House"an Hand&oo! #( 1.?-1.4 reduce diuretic dose #( 125-12Q Stop diuretics 0 (luid restriction inta!e to 1.5 >/da #( ,125 Stop diuretics 0 (luid restriction to 1 >/da

/' RES+(RATOR. 4ou% (edications - 1ucol ticsE (lui"ucil 2??"g tds * "ore e2pensive+ = +,-./ acet lc sterine - &isolvon :"g tds * cheaper+ 01. - 72pectorantsE 17S 1?"l tds 23 - /ough suppressantsE ethnine or phensed l 1?"l tds= pro"ethasine co"pund 1?"l &d - OthersE 7li2ir Benadr l= /o2illana 4 est infection - pneu(onia - Bld 2 /BP */BP/D/ i( (e&rile+= >/RF3= //S3 *i( (e&rile+ - Sputu" 2 //S3/R1= %FB s"ear= //S3 - Septic )or!up i( (e&rile - /HR .nti/iotics: - %ug"entin .-5"g tds po or %ug"entin 1.2g iv @:H - <nas n .-5"g BD po or <nas n -5?"g iv @:H - 8lacid 25?"g or 5??"g BD po * /larithro" cin+ - Rinace( -5?"g #' @:H or Rinnat 25? or 5??"g -D PO - Flag l 5??"g #' @:H or Flag l 2?? or 4??"g 3DS PO - - Sulpera$one 1g iv @:H or @12H - 3a$ocin 4.5g #' @:H -/ipro(lo2acin 2??"g iv @12H or /ipro(lo2acin 25?"g po BD ->evo(lo2acin */ravit + a. /o""unit acJuired pneu"oniaE 5??"g dail PO/#' 2 1-2 )ee!s &. /o"plicated <3# E 25?"g #'/PO Dail 2 1? da s c. <nco"plicated <3# E 25?"g Dail 2 . da s <nco"plicated a&do. O3 Pre-op 1 dose and then post op 2 doses /op"plicated a&do O3 e.g. appendicitis )ith rupture 1 )ee! course o( anti&iotics * single does o( proph la2is anti&iotics is e((ective in "ost clinical situation * should &e given Pust prior to the O3 or at the ti"e o( O3. % (urther dose us given in prolonged operation lasting A 4 hours. #n co"plicated O3= a (ull course o( anti&iotics should &e given + For aspiration pneu'onia: - Re"e"&er to as! cho!ing H2 - occup 2 s)allo)ing assess"ent
1?

- Flag

l 5??"g iv @:H plus iv aug"entin - Rinace( -5?"g iv @:H - Rinnat 25?"g or 5??"g BD po - /ipro(lo2acin 2??"g iv @12H - /ipro(lo2acin 25?"g po BD *ntu/ation ( 2 dru%s 0ou$d /e %i"en) - 3hiopenton 15?"g iv - Su2a"ethoniu" 5?"g iv - 7ndotracheal tu&e "ar!ed at 22-24c" help )ith cricoid pressure -"a!e sure suction read - %ir 7ntr * Rt B >t + 5 points auscultation = See chest e2pansion - SaO2 1??I - /hec! /HR e2clude an pneu"othora2/ chec! position post-intu&ation ,enti$ator settin%s #nitial settingsE S#1' "ode *i( spontaneous &reathing+ /1' "ode *i( resp "uscle paral sed+ 3idal volu"e *3'+E ?.5> *5??"l/5?!g+ Pressure supportE :-1?""Hg Sensitivit E F/- 2""Hg FiO2E 1??I RRE 12-15/"in *i( raised #/P= need h perventilationC RRE 1:-2?/"in+ PFRE 4? #7 ratioE 1 to 2 or 1 to . *(or o&structive air)a disease+C 1 to 1 (or restrictive air)a disease+ P77P *positive end e2pirator pressure+E 4-5 c"H2? If need sedation: Fight4 Dor"icu" . or 5"g #' stat 2 1= then .?"g in 5?"l NS in(use 2-."l/hr If the follo(ings occurred (hile on ventilator: Decreased SaO2 /hec! )hether pneu"othora2 #ncrease FiO2 *!eep "a2 ,6?I+ #ncrease P77P *increase recruit alveoli= decrease dead space+ #ncreased /O2 #ncrease RR
11

#ncrease tidal volu"e *)ash out /O2+ Sedation *"ore s nchroni$ed &reathing+ %lar" *high pressureC s"all 3'+ Fighting vs "achine BA sedate Pneu"othora2 / pleural e((usion Bloc! tu&e BA suction %lar" *high 3'C lo) pressure+ >ea!ing air BA chec! BP lo) 1ust chec! )hether pneu"othora2

4O.D dru%s 5 67 - 'entolin 2.5 or 5"g ne& *no longer used a(ter S%RS+ - %trovent ?.25 or ?.5"g ne& *no longer used a(ter S%RS+ - 'entolin 2 or 4 pu(( @4h or @#D - %trovent 2 or 4pu(( @4h or @#D - Bisolvon 1 ta& 3DS PO or Flui"ucil 2??"g 3DS PO - 17S 1? "l 3DS PO - Prednisolone .?"g @D PO or H drocortisone 1??-2??"g #' @6H or @:H - Brican l ?.25/?.5"g S/ J12h or Brican l durule 5"g BD PO - 3heodur 1?? or 2??"g BD PO - %"inoph lline drip 25?"g in 5??"l NS over 2?"in J12h - /hest ph sio 0 PFR BD .nti'8B dru%s - Ri(a"picin 45?"g @D - #sonia$id .??"g @D - P ra$ina"ide 1.5g @D - 7tha"&utol :??"g @D - 'it B6 1?"g @D Hae(opt&sis ( 4. $un%9 tu/ercu$osis 5 /ronc iectasis - Bld 2 %B; - Sputu" 2 %FB 2.= c tolog = //S3= R/1 - 13-2 test i( 3B suspectede - 3ransa"ine 5??"g #' stat then @6H or @#D PO - #n(or" i( increased hae"opt sis Three air"orn transmitted dis0 T-1 measles1 %aricella 2oster
12

3' CARD(AC !ast .! - /ardiac "onitoring= EC$ 12 leads * note the rh th"- sinus tach cardia + - <rgent consult "edical - Digo2in *o"it i( %R ,6?+ >oading doseE ?.25"g iv stat= then @:H 2. * need to &e diluted (irst + 1aintenanceE ?.125-?.25 "g @D po *?.?625"g (or elderl + - %"iodarone drip >oadingE 15?"g in 1??"l D5 over .? "in 1aintenanceE 6??"g in 5??"l D5E 2?"l/hr #arro0 co(p$e7 tac &cardia : /on(ir" it is the case )ith 7/; 1. 'agal "aneuvers contradicted in patient )ith carotid &ruit 2. %3P 1?"g rapid #' push *short hal( li(e+ )ait (or at least 2 "inutes &e(ore ne2t dose %3P 2?"g rapid #' push )arn patient o( transient (lushing 0 chest disco"(ort .. 'erapa"il *isoptin+ 2.5"g #' 15 "inutes i( tach cardia persists 0 BP sta&le 4. #( BP not sta&le= then s nchroni$ed D/ cardioversion Brad&acardia: 1. Reall &rad acardia K %ssess the rh th" oursel( 2. /linicall sta&leK /onscious state= BP= SOB congestive heart (ailureneed o( atropine= 3/P or inotrope as stated in house"an hand&oo! .. /auses o( &rad acardia 12 leads - 7/; a. drugs- &eta-&loc!er revie) drug chart &. Ph siologicalE h pother"ia c. PathologicalE rh th" sinus node disease * sic! sinus s ndro"e+ 0 %trioventricular &loc! . degrees= h poth roidis" 4 est disco(fort (.4S) - Blood 2 /8= >DH *cardiac en$ "es+ = 3roponin 3 @:H 2. - 7/; stat= then @:H 2. - #n(or" 1O F/- urgent consult "edical *i( li!el %/S= e.g. raised 3n3+ - %spirin 16?"g che)ed stat - NitratesE 3N; ta& 1 S> prn If chest pain at rest regardless of )*+: - #so!et in(usion 5?"g in 1??"l NS= at 4"l/hr *"a2 2?"l/hr+
1.

- Nitrocine

25"g in 1??"l NS= at 4"l/hr

If chest pain subsided - #sordil 1?"g tds po - Nitroder" 1?"g >% @D - %spirin 16?"g che)ed stat= then @D *)ith triact+ - /artia 1??"g @D PO - Beta-&loc!ers *i( no contraindications= and not in HF+ - Betaloc 25"g BD PO - >1D heparin *i( pain not controlled or high ris! (eatures present+ - 7no2aparin ?.1"g/!g S/ @12H - Fra2iparine S/E ?.4"l BD i( BD ,5?!g ?.5"l BD i( BD 5?-5Q!g ?.6"l BD i( BD A6?!g - Others i( indicatedE %/7-#= /a &loc!er D,8 : %. Reall D'P K /linicall unilateral leg s)elling= )ar"th= redness= dilated veins *s "pto"s+ Ho"anMs sign = an SOB= BP/Pulse *sign+ Ris! (actorsE old age = "alignanc = O3 esp. pelvic surger = O/ pills <rgent <S Doppler to con(ir" B %(ter con(ir"ation 1. /o"plete &ed rest 2. 7/;loo! (or S1@.3.= right ventricular heart strain .. /HRE an linear atalectasis 4. 1onitor BP/P/SaO2 @1H 2 6 = i( sta&le then @4H 5. 7no2aparin ?.4"l S/ @12 H * (or BD , 4?!g+ 6 ./onsult "edical (or )ar(arin dosage

14

4' $ASTRO(NTEST(NA! 4offee %round "o(itin% - /hec! BP/P= </O= do a&do"inal= PR e2a"= F/- /HR *(ree gas+ - Stop aspirin or )ar(arin - Special alert i( H2 o( cirrhosis *K &leeding esophageal varices+E urgent consult surgical - NPO e2cept "ed= give #'F= BP/P= </O @1H-@4H * #' angiocatheter+ - R5T to BSB= aspirate @1H-@4H )ole# insertion i( in shoc! - -lood 2 /BP *For ne)l ad"itted <;#B= need to )or!up (or underl ing cause= e.g. & Bld 2 /BP= >/RF3= clotting= hepatitis status= aFP= 3 pe and Screen+ - Rantac 5?"g iv @:H 56758 - %nti-encephalopath E lactulose 1?-2?"l @4-:H - /onsult surgical 2 O;D If 'assive , vo'iting fresh blood: - 'itals @1H - Hae"ocue statC Bld 2 /BP= clotting pro(ile= 3 pe and Screen - >osec 4?"g iv @24H *o"epra$ole+ - <rgent consult surgical 2 Kassess"ent F/- urgent O;D */all (or senior (or help N + - 3rans(use pac!ed cells / FFP according to &ld results 4onstipation - Dulcola2 ta& 1 PR 21 stat - Fleet ene"a PR 2 1 stat - Seno!ot -.5 or 15"g Nocte po prn - >actulose 1?"l &d/tds po prn -1eta"ucil 1?"l BD/3DS PO * orange in color+ D&spepsia - 1g3ri 1?"l tds po - 3riact or 1 lanta ta& 1 tds po - ;elusil ta& 1 tds po - ;asteel ta& 1 tds po prn 9:0

15

./do(ina$ pain (anti'spas(otics) - 72clude surgical causes (irst & e2a"ining the patient - Holopon ta& 1 tds po prn - Buscopan ta& 1 tds po prn or Buscopan 2? or .? or 4?"g #1/#' @6H prn DonMt use it in #.O.1 asthenia ;ravis= urinar retention due to prostate h pertroph Diarr oea - /hart #/O= F/- #'F supple"ent - >oo! (or underl ing causes= prescri&e the (ollo)ings onl i( indicatedE - 8aopectate 1?"l Jid po prn - >o"otil ta& 1 Jid po prn * to overco"e the side e((ect o( neotig"ine in 1;+ - #"odiu" ta& 1 Jid po prn Hae(orr oid - Fa!tu supp ta& 1 BD or oint"ent >% tds - H locaine Pell >% tds prn - 1eta"ucil 1 sachet tds po 6%nusil 1 ta& Dail PR

16

7' NER8OUS S.STEM Stro)e - 4,. - NPO e2cept "ed= #'F - BP/P/SaO2 @4H - Neuro O&s @1H 2 1/- *;/S+ - Bld 2 /BP= >/RF3= clotting= glucose= (asting lipid= (asting glucose - /HR= 7/; - <rgent /3 &rain *plain+ - <rgent consult "edical 2 assess"ent - O(( anti-H3 drugsC treat onl i( reall high= e.g. BPA2??/1?? - O(( aspirin= anti-platalets until hae"orrhagic stro!e e2cluded & /3 &rain - >i"& and chest ph sio - /onsult occupation 2 s)allo)ing assess"ent :pi$eps& - %B/= O2= glucose= HMsti2= electrol tes - ;ive D5? 5?"l iv= thia"ine 1??"g iv - #' dia$epa" 1?"g &olus - Repeat dose in 5 "in - Phen toin 16-1:"g/!g iv over .?"in= then .??"g po/iv - /onsult anaesthetist= #/< - 1onitor BP/P= RR= 7/;= te"p - r/o in(ection= poisoning= anti-convulsant )ithdra)al Sei+ure attac)s - /onvulsion chart= F/- neuro-o&s - #( not spontaneousl su&side in 1?"in= can considerE - 'aliu" 5"g iv stat 2 1 4#S tu(our or ae(orr a%e 0it (ass effect - De2a"ethasone 1?"g #' 2 1 then 4"g @6H #' - Dilantin 5??"g #' 2 1 or 5??"g in 1??"l NS over .?"in 2 1C then 1??"g @:H #' - Pepcidine 2?"g iv @12H - 1annitol 25?"l iv over 2?"in= then @:H - 3ransa"ine 1g #' 2 1 then 5??"g @6H iv

1-

9' ENDOCR(NE D3* drip (for fastin% of D6 patient) -./ #//'l 0&-12, plus the follo(ings: HMsti2 4---11 11-11--22 A22 %ctrapid H1 ? 5 1? 15 2? 8/> ? 5 1? 15 2?

*e.g. D1? 5??"l F 1?u %ctrapid H1 F 1?""ol 8/l @:H/pint+ H&po%$&cae(ia (H;sti7 <<2=) >s0eatin% 9 di++iness9 fee$ 0ea) - 5?"l D5? iv stat 21 * &etter to give either 4?"l or 6?"l as the pac!age li"itation+ F/- D1? J6h or J:h /pint F/- HMsti2 @1H F/- neuro-o&s Oral (or" de2trose even &etter as the sugar )ould not overshot and then dropped Juic!l *ncreased H;sti7 - 15-2?E %ctrapid H1 4< S/ 21 - 2?-24E %ctrapid H1 6< S/ 21 - A24E %ctrapid H1 :< S/ 21 / &etter in(or" S$idin% sca$e of .ctrapid H6 .$0a&s e7c$ude infection /efore %i"in% insu$in ? - /hec! HMsti2 @4H or @6H= then %ctrapid H1 according to the (ollo)ing scalesE
- 'ersion

1E %ctrapid H1 ? 4 6 : #n(or"

- 'ersion

2E %ctrapid H1 ? 2 4 6 : 1? F #n(or"

HMsti2 ,1. 1.-15 15-2? 2?-25 A25

HMsti2 ,11 11-14 14-11--21 21-2: A2:

1:

- Or

Pust order single strength according to HMsti2 reading= e.g. - %ctrapid H1 6u sc tds prn i( HMsti2 A16 *or o"it i( HMsti2 ,1?+ H&per%$&ce(ia (poor D6 contro$) - /hec! H&%1c= glucose= %B; i( D8% suspected - <rine (or !etone= sugar= al&u"in 8 &roto7icosis - Propranolol 2?"g BD PO Or #nderal 2?"g 3DS PO - Prop lthiouracil 1??"g 3DS PO - /ar&i"a$ole 1?"g 3DS PO

1Q

:' M(SCE!!ANEOUS 4ontrast a$$er%& - H drocortisone 2??"g #' on call to radiolog depart"ent Dru% o"erdose - NPO= give #'F - BP/P/SaO2 @4HC Neuro-o&s @1H (or 1/-C /ardiac "onitor - Suicidal precaution - <rgent &ld 2 /BP/D/= clotting= %B;= >/RF3= glucose= /aPO4= a" lase= to2icolog *paraceta"ol= salic late= &en$odia$epa"= ethanol+ - <rine (or to2icolog - ;astric lavage (or to2icolog 8 &ro7ine rep$ace(ent - Start at ?.?25"g @DC chec! 3F3 to "onitor the dose @out - /olchicine 1"g stat= then ?.5"g @2H until pain su&side/diarrhoea/"a2 dose o( 6"g reached - Napros n 25?"g BD PO 4e$$u$itis - On e2a"= note an (luctuation *)hich indicate underl ing a&scess+= i( Fve= &edside needle aspiration to loo! (or pus aspirates *usuall done & 1O+ - Note D1C &ld 2 /BP= >/RF3= //S3C )ound s)a& 2 //S3 - H-ra o( the a((ected partE to e2clude underl ing osteo" elitis / septic arthritis - a"picillin and clo2acillin 5??"g iv @6H - #( "ild= a"picillin and clo2acillin 5??"g @#D PO 2 1/52 D,8 - Dar(arinE #NR ,1.5 E 4"g #NR 1.5-2E 2.5"g #NR 2-2.5E 1.5"g #NR 2.5-.E 1"g #NR A. E o"it
2?

OrderE -/o"plete &ed rest -BP/P @1H 2 4 -#NR -<rgent /HR= 7/; -7no2aparin ?.4"l @12H S./. - <rgent consult "edical 2 D'3 6enorr a%ia - 3ransa"ine 5??"g @#D PO Anit con"ersion - ""Hg 2 ?.1...2 B !Pa 4reatinine c$earance *14?-age+ 2 BD*in !g+ --------------------------- H 1.?2 *(e"ale+ or 1.2. *"ale+ seru" /r Or /r/l B *24 hr /r / seru" /r+ 2 ?.; END ;

21

/o""on /linical /7"ergenc case 1. ;#E a. Bariu" 7ne"aE - Fluid diet - HB - /onsent 0 allergic H2 - 8lean prep 2> PO 2 1 &. /olonoscop E - Fluid diet - HB - /onsent 0 allergic H2 - 8lean Prep 2> PO 2 2 * Nocte= %" + %voided in closed loop #.O c. PPP 2 he"icolecto" -F1N )ith #'F 2D1S /da -/onsent -Bld /BP= R/>F3= /7%0 H "atch -/HR 0 7/; -HB 2 Proph lastic %nti&iotics #' $inace( 0 #' (lag l -Fole 0 R leMs tu&e on call to O3 -8lean Prep 2> PO 2 2 2. HBP * (ollo) protocol+ E a. 3%/7E -F1N )ith #' (luid -BldE /BP= >.RF3= #NR/%P33= %FP= %B; -/onsent 0 allergic h2 -HB proph lactic anti&iotics e.g. aug"entin 1.2g" on call to H ra -/isplatin 2?"g #' .. <rolog E a. %RO<E - Feel (or &ladder/ &ladder scan - D%3 - /BP= >/RF3= /aPo4 ;lucose - /S< 2 //S3 - 8<B -Fole to BSB &. Hae"aturia E - D%3 - 7ncourage (luid inta!e - /BP= >/RF3= /aPO4= ;lu= #NR/%P33 - Save urine 2 inspection - 1S< 2 //S3
22

- 71< 2 %FP 2 . - <rine 2 c tolog 2 . - 8<B - P ridiu" 1 ta& tds 2 1/52 - Nitro(urantoin 5?"g @#D 2 1 /52 i( (e&rile c. >oin painE - D%3 - /%P= >/RF3= /aPO4 = ;lu - 1S< 2 //S3 - 8<B - Dologesic 1 ta& @#D / 'otaren 25"g tds prn 4. 'ascular a. P'D E - F1N )ith #' (luid -/BP= >/RF3= #NR/%P33 -HB -consent 0 allergic H2 5. Pre-op careE Bo)el preparation (or colon Steroid (or drug allerg #' heparin (or oral )ar(arin 6. Post-op careE Post op Da K PainE P/% pain a((ects &reathing = thus eas to have pneu"onia Post-op (everE causes according to the post-op da s <rine output Dound care

2.

TACROLIMUS (FK506 / PROGRAF) Therapeutic actio ! The mainstay of immunosuppressive drug for you after liver transplantation. Tacrolimus is similar to that of Cyclosporin A. It lowers the activity of the immune system and in turn keeps the body from rejecting the transplanted organ. "o#a$e! A small yellow capsule 0. mg per capsule A small white capsule ! mg per capsule A red"grey capsule mg per capsule The dosage needs to be adjusted in accordance with the blood levels# graft function and evidence of side effect# such as renal impairment.

A%&er#e / #i%e e''ect#!

$ausea# vomiting# diarrhea# constipation %haking hands# headaches Alopecia# sweating &ypertension $ephroto'icity Increased calcium and blood sugar levels

Re(ar)!

!. Tacrolimus is best given on an empty stomach# so it is ideal to give it before meals or (") hours after meals. (. Tacrolimus needs to be given appro'imately !( hours apart so that a constant level is in the blood stream to prevent organ rejection. *efore breakfast and after dinner are ideal times. ). The dosage of Tacrolimus is different for each individual patient. +nly the doctor can adjust the dosage in accordance with the blood ,- 0. level. /. 0ost"liver transplantation patients must have regular follow"ups and blood"taking after discharge.

24

C*CLOSPORI+ A (SA+"IMMUM +,ORAL) Therapeutic actio ! +ne of the immunosuppressive drugs. It acts by inhibiting T"cell activation. *y lowering the activity of the immune system# it keeps the body from rejecting the transplanted organ. "o#a$e! A ( mg per capsule and !00 mg per capsule. The dosage needs to be adjusted in accordance with the blood levels# graft function# and evidence of side effect# such as renal impairment.

A%&er#e / #i%e e''ect#!

$ausea# vomiting# diarrhea %haking hands &eadaches# sweating &ypertension $ephroto'icity

Re(ar)!

!. %imilar to ,- 0.# Cyclosporin A is best given on an empty stomach# so it is ideal to give it before meals or (") hours after meals. (. Cyclosporin A needs to be given appro'imately !( hours apart so that a constant level is in the blood stream to prevent organ rejection. *efore breakfast and after dinner are ideal times. ). The dosage of Cyclosporin A is different for each individual patient. +nly the doctor can adjust the dosage in accordance with the blood Cyclosporin A level. /. 0ost"liver transplantation patients must have regularly follow"ups and blood"taking after discharge. . 0atients who develop hypersensitivity to this drug should stop to take it and inform the Transplant Team doctor immediately.

25

M*COP-,+OLAT, MOF,TIL (MMF) Therapeutic actio ! 1ycophenolate mofetil has been used for the treatment of acute rejection and for prevention of rejection. It could be used in conjunction with other immunosuppressants. "o#a$e! A%&er#e / #i%e e''ect#! ( 0 mg per capsule

$ausea# vomiting# diarrhea &yperlipidemia 2ower the white cell count and increase the risk of bacterial or viral infection

Re(ar)!

Contraindication to known hypersensitivity to 11, and for breast"feeding women.

M*FORTIC (M*COP-,+OLIC ACI") Therapeutic actio ! It is indicated for the prophyla'is of acute transplant rejection in adult patient. "o#a$e! A%&er#e / #i%e e''ect#! Re(ar)! A lime green tablet !30 mg per tablet A pale orange red tablet ).0 mg per tablet 4iarrhea# 2eukopenia# Infection !. Contraindication to known hypersensitivity to mycophenolate sodium# mycophenolic acid and 11,. (. 0recaution to pregnancy and breast"feeding women. ). 1yfortic tablets should not be crushed and should be swallowed whole.

26

PR,"+ISOLO+, Therapeutic actio ! 0rednisolone is given with other drugs to prevent acute rejection. "o#a$e! A%&er#e / #i%e e''ect#! A white color tablet with mg per tablet. This drug will be withdrawn during the first post"transplantation year.

&igh blood pressure from fluid retention 5astric ulcer 6eight gain due to increase appetite $ight sweating Cushingoid facies 1uscle weakness# osteoporosis Increase blood sugar level Increase risk of infection Increase bruising Impaired vision

Re(ar)!

0rednisolone is best given with milk and food. Inform doctor if there are signs and symptoms of infection. 7egular body weight check up.

2-

LAMI.U"I+, (/,FFI0) Therapeutic actio ! Inhibits the replication of hepatitis * virus. "o#a$e! A%&er#e / #i%e e''ect#! !00 mg per tablet

$ausea# vomiting# diarrhea# abdominal discomfort ,ever# malaise# musculoskeletal pain# rash Cough# insomnia# headache# alopecia 2actic acidosis Thromobocytopenia 7aised liver en8ymes and serum amylase

Re(ar)!

Contraindication to breast"feeding women. 2amivudin is best used in patients with active hepatitis * infection and post liver transplantation. Close monitoring is necessary to prevent the reverse of hepatitis * virus.

URSO",O0*C-OLIC ACI" (URSOFALK) Therapeutic actio ! 4issolution of cholesterol gallstones in the gall bladder and the gall bladder function must be intact. "o#a$e! A%&er#e / #i%e e''ect#! Re(ar)! A white color capsule ( 0 mg per capsule# 00 " !( 0 mg daily Calcification of gallstones may occur during treatment. 2iver function parameter should be monitored. Contraindication to e'isting pregnancy and breast"feeding women.

2:

FLUCO+A/OL, Therapeutic actio ! An anti"fungal drug for prevention and treatment of candidal and cryptococcal infection. "o#a$e! A%&er#e / #i%e e''ect#! Re(ar)! 0 " /00 mg daily adjusted according to severity of infection9 duration of therapy is about ) months. $ausea# vomiting# diarrhea# abdominal pain &eadache# %kin rash# &ypokalemia It is well absorbed by oral administration. 7inse mouth for ) minutes before swallowing. 4o not eat and drink within )0 minutes after taking the drug.

AC*CLO.IR Therapeutic actio ! An anti"viral drug for prevention and treatment of viral infection such as herpes. "o#a$e! A%&er#e / #i%e e''ect#! Re(ar)! /00 mg per tablet and ) times daily9 duration of therapy is about ) months. $ausea# vomiting# diarrhea# abdominal pain $ot suitable for patients with known Acyclovir hypersensitivity and impaired
2Q

renal function.

S,PTRI+ Therapeutic actio ! "o#a$e! A%&er#e / #i%e e''ect#! Re(ar)! Antibacterial drug to prevent bacterial infection /30 mg per tablet daily9 duration of therapy is about ) months. $ausea# vomiting# diarrhea# rash Contraindication to pregnancy and breast"feeding women.

+*STATI+ Therapeutic actio ! An anti"fungal drug for prevention and treatment of candidiasis and oral infection "o#a$e! +ral suspension ml each time and / times daily9 it is well absorbed by rinsing mouth for ) minutes before swallowing. 4o not eat and drink within )0 minutes after taking the drug. $ausea# vomiting# diarrhea

A%&er#e / #i%e e''ect#!

.?