Dr Siva Sankar K 1

© MBBS MCH TVM

Dr Firdause A H THE GP NOTE
MBBS MCH TVM
Edited by Dr Firdause . A . H , GMC TVM

This is not an alternative to any textbook, or attending the class/clinics.

Advise reading or have a copy of:1. Manual of Emergency Medicine by Lippincott,
2.The Washington manual of medical therapeutics 3. Oxford handbook of clinical medicine
4.Pediatric prescriber by Dr santhosh kumar,5.GP as specialty by Prakash Mahajan,
6.Handbook of Emergency Medicine by Suresh S David, 7. CIMS 8.Practical prescriber by
Golwalla,9.Any book of ECG basics & chest X-ray, 10.General Practice, a practical manual by
Ghanashyam vaidya. Also have basic knowledge of drugs C/I in pregnancy/lactation, and

pediatric dosenote
Pls edit this of common medicines.
yourselves, if you come across any mistake.
Caution:Don’t go to an ICU setup with this knowledge alone;you will be in deep trouble
(patients also).
FEVER

Fever, if oral T >98.90F (at AM) or T>99.9 0F (at PM)

Note: 0C*1.8 +32=0F
Note: In case of fever with chills, suspect UTI, malaria, pneumonia, cellulitis, abscess,influenza,
leptospirosis, dengue, gastroenteritis, meningitis, tonsillitis, IMN, TB etc
P’mol C/I in severe liver dise ases, renal impairment, infants < 2 kg.
Rx
1.inj P mol 2cc ( 150 /1 ml ) im st (if t>100 0 F). 100 ml(1000mg) infusion available(T.N Paracip)
[for children 10-15 mg/kg/dose,1.5cc/1cc im st] (for infants and small children give
suppositories (T N:-Anamol), normally available as 80,125,170,250 mg; for <5 kg not
recommended); Inj Dolonex (piroxicam) 2cc IM st ATD if allergic to P/L
2.Tepid sponging with luke warm water st & SOS;give IV fluids for very high fever.
3.Do BRE,ESR/CRP,URE , if infection is suspected & give Antibiotics for infection
4.T or Syp Meftal may be given Stat for high fever
5.Antiulcerants(especially if certain antibiotics like macrolides, NSAIDs, steroids are
provided).
6.Multivitamin tablets with Vit B complex, vit C.
7.Steam inhalation for relieving ENT congestion.
Antibiotics
Note:In general, for mild infections use milder antibiotics
1.C Mox or Novamox 500mg 1-1-1 x 5 days (amox icillin)
Indications:for RTI including bronchitis,sinusitis,otitis media, UTI
2.C Roscillin 500mg 1-1-1-1 x 5 days (ampicillin)
Indications:for RTI including bronchitis,sinusitis,otitis media, UTI
3.C or T Augmentin/Augpen/Mox CV 625/375 1-0-1 x 5 days (amox +clavulanic acid)
T.N:-T Moxiforce-CV or Mega-CV 625,Novaclav 625 , kid tab-228.Do se: 20 mg/kg/dose BD
Indications:for RTI , UTI, dental, skin and soft tissue infections, intra abdominal and
gynaecological sepsis, cat scratches,infected animal/human bites).
4.C Novaclox 1-1-1 x 5 days (amoxicillin +dicloxacillin)(dramaclox)(ped tab available)
5.C Megapen 1-1-1-1 x 5 days (ampi cillin +cloxacillin)(kid tab available)
6.C Aldinir or Zefdinir 300mg 1-0-1 x 5 days (cefdinir)(very expensive)
Indications:pneumonia,a/c exacerbations of c/c bronchitis, Ent ,skin)
7.C Phexin/ sporidex 500mg 1-1-1-1 x 5 days (cephalexin)
Indications:For bone and joint infections, pharyngitis, skin and soft tissue,tonsillitis, UTI
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8.T Azithral or Azee 500mg 1-0-0 x 3 days 1hr before food(azithromycin)
(specific for respiratory infections)(also for skin,STD’s, PID, urethritis, cervicitis)
9 T Roxid 150mg 1-0-1 x 5 days 30 min before food (roxithomycin)
(for RTI, ENT, skin & soft tissue, genital tract infections)
10.T Droxyl 500mg 1-0-1 x 5 days (cefadroxil);Syp ( 125 / 5 or 250/5) available
(30 mg/kg/day in 2 div doses)(strep throat infections, UTI,skin)
11.T Taxim-O/ topcef 50/100/200mg(DT tab available) 1-0-1 x 5 days (cefixime)
(resp, urinary, biliary infections)
12.T Ceftas-AL1-0-1 x 5 days (cefixime+ambroxol+lactobacillus spores)
13.T Ciplox 500mg(100/250/750) 1-0-1 x 5 days (ciprofloxacin)(for UTI,bone,soft tissue,
gynaecological,wound infection, Bact gastroenteritis, Respiratory)(all other FQ’s C/I in children)
14.T Norflox 400mg 1-0-1 x 5 days (norfloxacin)( for UTI & GIT problems) (adv ise to drink more
water).Best , if taken empty stomach with water, don’t take with diary products
15.T Oflox /Zenflox 200mg 1-0-1 x 5 days (ofloxacin)(c/c bronchitis, other respiratory, ENT)
16.T Levobact or Levoday or Loxof 500mg 1-0-0 x 5 days (levofloxacin) (advise to drink more water)
17.T Septran/Bactrim d.s. 1-0-1 x 5 days (sulfamethoxazole 800 +trimethoprim 160)
(advise to drink more water) Syp availabl e( 200 + 40)/5 ml
18.T Proflox 400mg 1-0-1 x 5 days (pefloxacin) ( for UTI & GIT problems)
19.T Cepodem/Monocef-o/podocef/macpod 100/200mg 1-0-1x 5 days(cefpodoxime)
(for RTI, UTI, skin and soft tissue).
20.T Klox (cloxacillin) 250/500 mg tds/Qid(furuncle, abscess, carbuncle, impetigo, osteomyelitis,
bites), syp ( 125 / 5) (100-200mg/kg/day in 4 divided doses)
21.T clarithro/claribid/synclar (clarithromycin) 250/500 mg 1-0-1(resp, skin & soft tissue)
22.T Altacef 250/500 1-0-1(cefuroxime)(URI, LRI, UTI)
For children and infants most pediatric medicines are available in syrup/Drops.
1-3 yrs =1/2 tsp tds; 3-6 yrs =1 tsp tds; 6-10 yrs =2 tsp tds or 1/2 adult tabs .
This can be used as a rough guideline to prescribe common pediatric medicines . The dose should
be adjusted according to the built and weight .
Commonly used antibiotics in children
1.Syp Amoxicillin (125 / 5 or 250/5) [T N:- mox,Novamox](DT 125, 250 mg available)
Dose: 30-50 mg/kg daily in divided doses Q8H or Q12H. In Practice 15 mg/kg/dose Q8H
Novamox Dps (100 /1) available
Syp Augmentin/Mox CV 228 / 5, 156 / 5, 312 / 5 available,(Amoxicillin + clavulanic acid) Novamox
CV/Mox CV dps,each 1 ml contain amox=80 mg,clavulanic acid=11.4 mg. Augmentin/ Mox
CV Syp 457 (400 + 57)/5ml, 156(125 + 31)/5ml, 228(200+28)/5ml, 312(250 +62) available.
2.Syp Ampicillin(125 / 5 or 250/5) Dose is 50-100 mg/kg /daily in divided doses Q6H
3.Syp Azithromycin(100 / 5 or 200/5) {T N:- azee, ATM}(Dose for children above 6 months-10
mg/kg/day for 5 days)
4.Syp Cefixime (50 / 5 or 100 / 5 ) {T N:- taxim-o,topcef}(8 mg/kg/day in divided doses Q12H),
Dps 25/1 available
5.Syp Septran (sulfamethoxazole 200+ trimethoprim 40)(6-10 mg/kg/24 hr(TMP) div into 2
PO)(dose calculated in terms of mg of TMP).Paed tablets: (100+20)
6.Syp Ampoxin Or Syp Roscilox(ampicillin +cloxacillin)
7.Syp Synclar/Maclar(125 / 5)(clarithromycin)(15 mg/kg/day in 2 divided doses)
(URTI,LRTI,sinusitis,otitis media etc)(125 DT available)
8.Syp Kefpod/Macpod(50 / 5 or 100/5)( cefpodoxime)(10 mg/kg/day div into 2 doses PO)
(LRTI,URTI)
9.Syp Phexin(cephalexin)(125 / 5 or 250/5) (50-100 mg/kg day in 3 or 4 doses PO)(DT 125, 25 0 mg
100 /
available). Phexin Dps 1 125
available.
/
10.Syp Altacef (cefuroxime)( 5)(30 mg/kg/day div into 2-3)

For pregnant ladies

Amoxicillin,cephalosporins, ampicillin & cloxacillin combination,amoxicillin & clavulanate combination,
Penicillin G. Azithromycin(class B)
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Antipyretics
Note:- In Children, if fever is accompanied by rashes,esp vesicular or maculo papular suspect
Chickenpox or Measles respectively. In measles, the child is usually sick looking with, rashes
starting from face.
1.T Calpol/Panadol/Dolo 500mg/650mg 1-1-1-1 x 3 days( p’mol or acetaminophen)
2.T Ibugesic or brufen 200/400/600mg 1-0-1 x 3 days(ibuprofen)
3.T Meftal or ponstan 250mg/500 1-1-1x3 days(mefenamic acid)(ideal for dental pain)
4.T Pirox /Dolonex 20mg 1-0-0 x 3 days(piroxicam)
5.T Ibugesic Plus 1-0-1 ( ibuprofen+ P’mol)
6.T Meftal forte/ meftagesic(Meftal 500 + P/L 450)
For children
1.Syp P’mol(125 / 5 or 250/5)(10-15 mg/kg/dose x 4 times)(C/I in less than 2 kg)
T N:- Calpol,crocin,dolo,febrinil,febrex etc.(Calpol, Dolo,Babygesic,Crocin,Febrinil dps available)
Nopain dps(15 ml) ( 100 / 1) available, Tab 125 available
2.Syp Ibuprofen(100 / 5)(8-10 mg/kg/dose x 3 times)(may precipitate aspirin induced asthma, so
don’t give to asthmatic or dyspnoeic pts).Syp ibugesic plus(ibuprofen 100 + P/L 162.5 /5 ml)
Another formula: dose in ml= wt / 2
3.Syp Meftal(50/5 or 100/5) (generally not used < 6 months)(8 mg/kg/dose x 3 times a day)
(DT-Tab 100 available); ( wt x 4/10 = dose in ml, applicable only for 100 /5 formulation)
Syp Meftagesic(P/L 125 mg, mefenamic acid 50mg/5 ml)
For pregnant ladies
P ‘mol only
Vitamins
Usual dose: 1 tab od or bd
1.T Beplex forte(syp available)(vit B complex with folic acid, vit C, )
2.T Bicozinc(syp available)(vit B complex with Folic acid , vit C, Zn sulphate)
3.C Becosules(syp available)(vit B complex with Folic acid, vit C)
4.C Nutrolin B plus(syp available) (vit B complex with Folic acid, lactobacillus)
5.T Polybion (syp available)(vit B complex with Folic acid, vit C)
6.T Neurobion forte (syp available)(vit B complex)
7.T BC (β- carotene, vit E, vit C -antioxidants)
8.T Celin 500mg OD(vit C)
9.T MVT OD(multivitamins)
10.T Health Ok ( multiviamins, multiminerals, aminoacids with taurine & ginseng)
11.T Becozym C Forte OD (vit B + vit C)
For children
1.Syp/Dps A to Z(vit A,vit B complex, vit C,vit D,Fe,Se,iodine)
2.Syp Zincovit(vit A,vit B complex, vit D,vit E,Cu,Se,Zn,iodine),
3.Syp /Dps Delices(Vit A,B,D,E, aminoacids, antioxidants)
4.Syp osto-polybion D(Vit B12,Vit D3, Ca2+)
5.OH-D3 /Ultra D3 /Bon D light dps(400 IU/ml)(Vitamin D3 or cholecalciferol) 1 ml OD for infants
Iron preparations (can be given in pregnancy)

1.T Autrin(fe fumarate + folic acid +b12 +c) od

2.T Macalvit / Shelcal(ca carbonate+vit D3) od (syp Shelcal & Shelcal kid tab available)
3.T Fefol-Z(fe sulph+ folic acid +b12 +c+Zn) od
4.Syp Vitcofol(fe fumarate+ folic acid +b12)
5.T orofer –XT( 0-1-0)(elemental Fe + folic acid)Dps /Syp available
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Anti ulcerants
1.T Rantac/zinetac/aciloc 150 mg 1-0-1(ranitidine)(30 min before food)
(Ped dose 2 mg/kg/dose x 2 PO,1-2 mg/kg/dose IV ), syp rantac 7 5/5
2.T Pantocid 40 mg 1-0-0(pantoprazole)(30 min before food)(ped dose: 1 mg/kg/dose PO OD)
T Pantop-IT(with itopride), Pantop-L(with levosulpiride). Inj Pantop 40 mg iv od/bd
3.T Rabicip/happi/Razo 20 mg 1-0-0(rabeprazole-fast acid suppression). Inj rabicip 20 mg iv od
4.C Omez 20 mg 1-0-0 empty stomach(omeprazole)(1 hr before meal)
5.C Rabicip D/Roles-D (with domperidone) , Pantop- D( with domperidone)
6.T Lanzole 30 mg 1-0-0 (lansoprazole)
7.T Lesuride 25 mg 1-0-0; Inj Lesuride 25 mg iv od
8.Digene 2tsp tds(Simethicone+Mg(OH)2+Al(OH)2+ Na carboxymethylcellulose)
9.Gelusil MPS 2tsp tds(Simethicone+Mg(OH)2+Al(OH)2+Mg Al silicate)
10.Rantac MPS(Magaldrate+Simethicone)
11.Mucaine(Mg(OH)2+ Al(OH)2+ oxethazaine)
12.Tricaine MPS(Simethicone+Mg(OH)2+Al(OH)2 +oxethazaine)
13.Syp sucralfate (ulcer prote ctive)
Antacids: 1-2 ml/kg/dose in infants;5-15 ml/dose every 4-6 hr in children
Note: Take antacids 2 hr before or after ingestion of the drug to prevent drug interaction
For children
Syp or Tab rantac, T Pantop, T Junior Lanzole 15 mg OD(1mg/kg/day)
For pregnant women
1. Digene 2tsp tds
2. Gelusil MPS 2tsp tds and other antacids
3.T Ranitidine, famotidine. Inj Rantac can also be given
Steam inhalation may be with
1.Vicks/amrutanjan/tulsi leaves/2-3 dps of essential oils like eucalyptus oil,camphor etc
2.Tincture Benzoin
3.Karvol Plus / Sinarest / Nosikind inhalant capsule (camphor, chlorthymol, eucalyptol, menthol,
terpineol)
COUGH
Pharyngeal demulcents provide symptomatic relief in dry cough arising from throat.
Note:give antibiotics if infection is suspected.Advise an X-ray chest, AFB sputum for otherw ise
unexplained Cough>2-3 weeks not responding to antibiotics or cough with haemoptysis/chest
pain/PUO/weight loss. Advise adequate hydration to help expectoration.
For bronchodilation and expectoration:
1.Syp Ascoril / Capex bron / Bro-Zedex 2tsp tds x 3-5 days (terbutaline sulphate +brom hexine+
guaiphenesin)(Tab available)
2.Syp Bricarex A / Cosome A / avocof / Mucosolvin/ instaryl-P 2tsp tds x 3 days (terbutal ine
sulphate +ambroxol hcl+ guaiphenesin)
3.Syp Asthalin expectorant 2tsp tds (salbutamol+ guaiphenesin)
Dosage: <6 yr= 5-10 ml tid, 6-12 yr= 10 ml tid
4.Syp Ambrolite-S 2tsp tds x 3 days ( salbutamol +ambroxol hcl+ guaiphenesin)
5.Syp Ambrodil-S 2tsp tds x 3 days (salbutamol +ambroxol hcl)
6.Ascoril- LS Syp or Dps(levo salbutamol +ambroxol+Guaiph)
7.Syp Dilosyn Expectorant(Methdilazine HCl+ ammon Cl+Na citrate)
8.Syp Piriton Expectorant (Chlorpheniramine maleate+ammon Cl+Na citrate)
9.Syp Grilinctus BM or instaryl(terbutaline sulphate +bromhexine)(Tab and Paed syp available)
 5
(for Bronchial asthma, a/c & c/c bronchitis,bronchiolitis, other bronchospastic disorders)
10.Syp Mucolite /ambrolite 2tsp tds x 3 days (Ambroxol)
Syp Ambrodil (15/5 or 30/5) 2tsp tds <2y=7.5 mg bd, 2-5y=7.5 mg bd/tid, 6-12 y= 15 mg bid
Ambrodil/AX/xputum paed Dps (7.5 / 1 ) <6 month- 0.5 ml bd,6-12 month- 1ml tds,12-24 month-
2ml tds
11.T Mucolite/ambrodil (ambroxol) 30 mg tds
12.T Bromex (BH) 8 mg bd/tds
13.T Mucinac 200/600 mg bd/tds (acetylcysteine)
For children: Syp Asthalin ( 2 / 5 )(0.1-0.2 mg/kg/dose Q6H) after food.

For cough suppression:

1.Syp Viscodyne D 2tsp tds x 3 days(tripolidine hcl+ pseudoephed rine +dextromethorphan hbr)
2.Syp Actifed DM 2tsp tds x 3 days(tripolidine hcl + phenyl propanolamine+DM hbr)
Dosage: 6month-2 yr=1.25 ml, 2-5 y= 2.5 ml, 6-12y= 5 ml, >12 y= 10 ml
3.Syp Piriton/ Dilo-Dx / solvin cough/ Cheston CS 2tsp tds x 3 days(CPM + DM hbr)
4.Syp Cosome 2tsp tds x 3 days(CPM +DM hbr+phenylpropanolamine hcl)
Dosage:2-6 y=1.25 – 2.5 ml, 6-12 y= 5 ml, >12y= 10 ml
5.Syp Ascoril-C/Linctus codeine/codistar /corex 2tsp tds x 3 days(Codeine Phosphate + CPM)
6.Syp Alex cough formula 2tsp tds x 3 days(CPM+Phenylephrine+ DM Hbr)
Dosage:1-5 y=1.25 ml, 6-12y=2.5 ml,>12 y=5 ml tid/qid
7.Syp Ascoril-D 2tsp tds x 3 days(tripolidine hcl+ phenylephrine+DM hbr)
Dosage:2-5 y=2.5ml tds, 6-12 y= 5 ml tds,>12y=10 ml tds
8.Syp T-minic cough 2tsp tds x 3 days(Phenylephrine hcl +DM hbr)
9.Syp coscopin Plus (Chlorpheniramine maleate+ammon Cl+Na citrate + noscapine)
10.Syp Ambrolite-D 2tsp tds (pseudoephedrine hcl +DM hbr+cetrizine)
11.Syp Zedex 2tsp tds(bromhexine hcl+DM hbr)Dosage: 2-6 y=2.5 ml, 6-12 y= 5 ml
12.Alex Paed Dps /Solvin Cold Dps (CPM+Phenylephrine)

13.Flucold Dps(phenyl propanolamine+

14.Syp Zedex-p(DM+bromhexine CPM)
+phenylephrine); 2-6= ½ tsp, 6-12= ½-1 tsp,(for paediatric
cold, cough)
15.Syp Zerotuss (levocloperastine fendizoate)(cloperastine- cough suppressant acting on CNS)
16.Syp Benadryl (diphenhydramine)
T Cheston-DT(CPM+phenyl propanolamine+ BH),T Codifos(codeine) 10 mg, T Sedosolvin
(DM+CPM+BH)
T Deletus (DM + tripolidine + phenylephrine)
Note:codeine c/I in asthmatics; codeine as a cough suppressant is not recommended for < 2yrs.

For pregnant ladies give Syp Ascoril, Syp Grilinctus (DM hbr + guaiphenesin + CPM),
Syp Benylin expectorant(Guaifenesin +DM Hbr) or Syp Robitussin DM

For diabetics: Productive cough-Ascoril SF, Macbery-XT;

Dry cough-Robitussin CF(DM hbr + guaiphenesin+ psuedoephedrine)
Tusq-Dx(DM hbr + CPM +phenylephrine hydrochloride ),
Benylin Adult , Alex sugar free , zerotuss- SF can also be given

Lozenges: Alex/Chericof (Dextromethorphan 5 mg), Tusq-D (DM + Amylmetacresol),

strepsils(benzyl alcohol, metacresol)
 6
Analgesics
NSAIDS
1.T Voveran/Diclonac/Dicloran 50 mg bd(Diclofenac sodium)( suppository 12.5mg,
100mg available.TN:Jonac)
2.T Ibugesic/Brufen 400-600 mg tds(Ibuprofe n) (other T N:- brufen, Ibuflam mar)(100
mg/5 ml susp available)
3.T Meftal 250-500 mg tds(M efenamic acid) (other T N:- Ponstan, Medo l)(100 mg/5 ml
susp available)
4.T Dolokind 100mg bd(aceclofe nac ) (other T N:- Aceclo, Zerodol)
5.T Ketanov 10 mg Qid( Ketorolac)(for Post operative, dental, a/c musculoskeletal, renal
colic, migraine, pain due to bony metastasis)
6.T Pirox 20 mg OD (piroxicam)(for osteo/rheumatoid/ acute gouty arthritis)
7.T indocid/ articid 25-50 mg BD-QID (indomethacin)(musculoskeletal & joint disorders)
8.T Etoshine/etody 60-120 mg OD(etoricoxib)(for osteo/rheumatoid/ acute gouty arthritis)
Note: Avoid NSAIDs in Dengue,severe liver/kidney d/s,active cerebral hemorrhage,GI
bleeding etc. NSAIDs may also increase the risk of having a stroke or MI in pt’s with existing
cardiovascular disease. In such cases give T Naproxen 250/500 mg bd(T.N Artagen)
Opioid Analgesics
1. T Trambax or Tramazac (tramadol) 50 mg tds
2.T Fortwin 25 mg Qid( Pentazocin)
Combinations
1.T Ultracet or Palitex or Dolzero or acuvin(Tram adol+ P’mol)
2.T Dynapar (Diclofenac + p’mol) (Inj available)
3.T Zerodol-P or aceclo plus or Hifenac-P or Dolokind- Plus (Aceclofenac+ P’mol)
4.T Durapain (Diclofenac sodium SR +Tramadol IR)
5.T Ibugesic Plus/combiflam (ibuprofen + P’mol)
Note:- for pregnant ladies give P’mol only
Injections: P/L, Diclofenac, Tramadol, Ketorolac, Piroxicam, Pentazocin etc
Tramadol may cause nausea( give emeset),dizziness,sleepiness,sweating, lowering of
seizure threshold
Abdominal Pain
Common causes: Renal calculi,appendicitis, pancreatitis, intestinal obstruction, peptic
ulcer, Gastroenteritis, cholecystitis, GERD,UTI, medications,mesenteric ischemia etc
Note:In case of renal colic there will be colicky pain radiating from the loin to groin and
h/o similar episodes in the past. All abd pain above the level of umbil icus, rule out
I.W.M.I. Also rule out DKA.
Examination of genitourinary system in men should be performed in all cases of a/c abd
pain to r/o testicular torsion.
The immediate treatment of renal pain/colic is bed rest & application of warmth to site.
Inv: S.amylase & lipase, URE,BRE, X-ray abdomen erect view, USS/CECT
abdomen, ECG, RFT etc. R/o pregnancy in female pt’s before subjecting to x-rays.
1.Inj Voveran 1 am p IM st ATD or
Inj Tramadol 1amp IM or IV st(+ emeset)
 9
5.ORS(Electrokind, electrosip,elect) in small sips( unit dose 4.3 g packet to be mixed with 200
ml & multidose 21.5 g packet to be mixed with 1 L or 5 glasses of boiled & cooled water).
Dosage after each purge: <6months :50 ml or 1/4 glass, 6months-2years: 50-100ml(1/4-1/2
glass), 2years-5 years:100-200 ml(1/2-1 glass), >5years: as much as able to drink.If child vomits,
wait for 10 min & then resume feeding. Also give Plenty of oral fluids (home available)
6.Report blood or pus in stools
For children, also give Zn,(0.5 mg/kg/day or 10 mg daily for age 2-6 months & 20 mg for >6
months). T.N: Z & D syp/dps(Zn sulphate) or Mintonia syp(Zn acetate) x 2 weeks (syp 10 or 20
mg/5 ml or Dps 20mg/1ml). Below 2 months not indicated.
Note:- if very severe, for adults give Imodium / Lopamide 2mg ( loperamide) 2 tabs stat, then
1 tab after each episode (C/I in <4 yrs and in acute infective diarrhoea and pregnancy)
For Pregnant ladies:-
Give ORS, Darolac sachet, oral fluids
Child-hood diarrhea/ADD
No dehydration→well alert, eyes normal, tears present, mouth & tongue moist, normal thirst,
skin pinch goes back quickly:50-100 ml ORS (if <2 yr) & 100-200 ml ORS (if 2-10 yr) per purge
For >10 yrs as much as wanted. Generally,give one teaspoon every 1-2 minutes.
For some dehydration→restless, irritable, eyes sunken, tears absent, mouth & tongue dry,
thirsty & drink eagerly, skin pinch goes slowly→75 ml/kg ORS in 4 hr and if dehydration
subsides 10-20ml/kg after each stool. If not repeat 75 ml/kg ORS in 4 hr.
For severe dehydration →lethargic or unconscious, eyes very sunken & dry, tears absent,
mouth & tongue very dry, drinks poorly or unable to drink, skin pinch goes back very
slowly→IVF Ringer Lactate 30 ml/kg in ½ hr followed by 70 ml/kg in next 2 ½ hr .In infants <12
months 1 hr & 5 hr respectively
If macroscopic blood,pus,mucus, foul smell , treat as DYSENTRY. Do Stool culture.
1.T Ciplox TZ 1-0-1 x 5 days(ciplox + tinidazole)// Zenflox-OZ (ofloxacin 200 mg+ ornidazole
500 mg) (others:norflox,ampicillin,doxycyclin,cotrimoxazole)

2.C
Or TZedott or Redotil 100mg
Lomotil(atropine (racecadotril)
sulphate, 1-1-1
diphenoxylate x 3 days
HCl)
3.T Nutrolin B(Ped tab available)/ C Vizylac/ C Darolac 1-1-1 , T VSL 3(probiotic) (0-1-0),
Syp or C Enterogermina (bacillus claus ii, probiotic)Enterogermina dose: adults: 1 Capsule bd or
tds; children:1 capsule od or bd or Syp 5ml bd, breast feeding infants 5 ml od or bd for 2-5 days
4.T Cyclopam/ Buscopan 1 SOS if abdominal pain
5.Check BP, If low or if dehydrated, give IVF RL/ Isol yte P +DNS
6.T Rantac 150 mg 1-0-1(Proton Pump Inhibitors may cause drug induced diarrhea)
7.Fluid managment same as above;Plenty of oral fluids
In PEDIATRIC cases , old regime: SEPTRAN(cotrimoxazole) or GRAMONEG 300/5 (Nalidixic
acid)(55 mg/kg/day in 3-4 div doses; not to be used below 3 months) .
New regime: ciprofloxacin15mg/kg bd. Cefixime can also be given
Note:- 5 % /10% dextrose not given
Anaphylactic shock
1.Inj Adrenaline 0.5mg IM or SC(in children: 0.01 ml/kg; don’t exceed 0.5 ml per dose)
(Repeat every 5-10 min in case patient doesn’ t improve);1 ml amp of 1:1000 solution, 1mg/ml
2.IV glucocorticoids(hydrocortisone sod.succinate 100-200 mg;10 mg/kg in children & max 100
mg) in severe/recurrent cases.
3.Antihistaminics (chlorpheniramine 10-20 mg) IM /slow IV
4.Put the pt in reclining position, administer O2 at high flow rate and perform cardiopul monary
resuscitation if required.
 10
Patient with wheeze
Monitor SpO2 , work of breathing, Respiratory rate etc.
Note:In all cases of first episode of wheeze, r/o FB , irrespective of age(take CXR)
1.Nebulise with Salbutamol(albuterol) 1cc in 3- 4cc NS + O2 x 3 times at 20 min intervals in
moderate and severe cases(or lesser if there is clinical improvement). Dose in children is
0.03ml/kg with 3 ml NS. 150 mcg/kg/dose, but min dose is 0.5 ml or 2.5mg salbutamol.For mild
cases, one nebulization may be enough.In usual practise give, 0.5 ml for <5yrs, 1ml for >5 yrs.
In severe cases, Nebulisation can be done by combining Salbu(2.5-5mg) & Ipratropium
bromide(0.5mg) or Duolin(levosalbu + ipratropium). Ipravent dosage: <5 yr :-125 mcg(0.5ml)&
> 5 yr:- 250 mcg(1ml)(12.5 mcg/kg/dose).Budesonide :Children 12 months to 8 years of age:-
0.5 to 1mg OD, or divided and given twice a day, <1yr:0.5 mg. commonly given in croup.
Note: Inhaled salbutamol & terbutaline should not be used on any regular basis; inhaled
Salbutamol,salmetrol, ipratropium bromide,Beclomethasone,Budesonide are safe in
pregnancy.
2.Inj Deriphyllin 1 amp iv st (5mg/kg/dose IM in children)(given in pregnancy)
3.Inj Efcorlin(hydrocortisone) 100mg //Inj Methyl prednisolone 120 mg// Inj Betnesol 4 mg iv st.
For children with severe dyspnoea , administer ster oids after 1 st nebulization
Dose: Inj Efcorlin (10 mg/kg st & 4mg/kg Q6H), Inj Methyl pred(2mg/kg st & 1mg/kg Q6H) iv
4.T Deriphyllin retard 150 mg 1-0-1 x 5 days after food/T Theoast halin 1-1-1(>12 yrs) or
½-½-½(if <12yrs) Or T Asthalin 4mg tds or T Bricanyl or Bricarex(Terbutaline) 5mg tds or
T Deriphyline (Theophylline Hydrate+etophylline) tds .Deriphyllin C/I in seizure
Syp Deriphyllin( 50 / 5 etophylline 46.5 and theophylline 12.75)(5mg/kg/dose PO tds),
For children: Syp asthalin( 2 / 5 )(0.1-0.2 mg/kg/dose Q6H or dose in ml= wt /4) After food
5. If response to bronchodilators not satisfactory, early use of steroids advised.T Prednisolone
10 mg tds X 3-5 days; for children: 1mg/kg/day in 2-3 divided doses x 3-5 days.
6.Antibiotics if associated infection(fever,purulent sputum) or ineffective cough & retention of

secretions.
7.Cough syrup containing Bronchodilator & Mucolytics
8.Advise inhalational medications if affording- Asthalin,Ventorlin(both Salbu), Budenase AQ or
Budecort or Pulmicort or Rhinocort (Budesonide)- start with 400 or 200 mcg BD & step down
with response.Others: Seroflo / Esiflo / combitide (salmeterol + fluticasone), aerocort(levosalbu+
beclomethasone), foracort (formoterol+ budesonide), maxiflo(fluticasone + formoterol).
Rotahaler or metered dose inhaler(MDI) may also be used.
Alternatives to the order 4 would be –T Theoasthalin(Salbutamol+Theophylline)(syp available),
T Unicontin 400 or 600mg(Theophylline); T Levolin(levosalbu) 1mg or 2mg(Syp 1/5)(0.05
mg/kg/dose qid); T AB Phylline(ac ebrophylline) 100 mg BD or Syp 50mg/5ml, 2-5 yrs 2.5 ml
bd/tds, >5 yr 5ml bd; T Doxophylline 200 mg 1-0-1 may be used instead of deriphylline, as it has
better cardiac & CNS safety profile (D phylline,Doxiflo, Doxobid, Doxoril)
For A/c Bronchiolitis, neb with 3% saline 3ml Q1-2H or alternate with salbutamol.
S/E of salbutamol & Deriphyllin : tremors, palpitation, nervousness
Common causes of shortness of breath: Asthma, pneumonia,bronchitis,hyperventilation,
pleuritis, COPD, CCF, MI, pulmonary edema,bronchiolitis, pneumothorax,FB,ILD, anxiety,
pulmonary embolism, cardiac tamponade,10 P HTN,pleural effusion,metabolic acidosis, severe
anaemia, obesity, ARDS
Signs of CO 2 retention: Confusion, flapping tremor, bounding pulse. Look for associated
cardiovascular(chestpain,palpitation,sweating,nausea) or respiratory (cough, wheeze,
haemoptysis) symptoms.
Note: levolin has better cardiac safety profile than asthalin, hence preferred in cardiac patients.
 11
Dog Bite
( also cat,bandicoot,monkey,cattles,bats,wild animals etc)
1. Immediate flushing and washing the wounds, scratches and the adjoining areas with plenty of
soap and water for at least 10 minutes is very importan t.Dont squeeze/cover the wound
2. Wash with betadine/spirit
3. Inj Rabipur/verorab (rabies vaccine) 0.1ml ID on both shoulders on day 0,3,7,28
If given IM, then Rab ipur 1ml or verorab 0.5 ml on day 0,3,7,14 ,28
(IM is given in immunocompromised pts)
4. Inj TT 0.5ml IM st if indicated
5. Advise to observe the cat /dog for 10 days & to r/w if the animal dies/behaves abnormally.
For class 3 wound, also give
6. Inj equirab 40 IU(immunizing unit)/kg [maximum dose infiltrated around the bite wound and any
remaining volume is given IM(usually gluteal region) away from the site of rabies vaccine] or
0.133ml/kg. If Human Ig : 20 IU/kg or 0.133 ml/kg
For 75 kg or more: 10 ml(3000 IU equirab or 1500 IU HRIG)
7. Antibiotics like augmentin
Class 3
 All bites or scratches with oozing of blood on neck, head, face, palms and fingers
 Lacerated wound on any part of the body
 Multiple wounds 5 or more in number
 Bites from wild animals
Note:Bite wounds shouldn’t be immediately sutured; if necessary put minimum no of loose
sutures. Ideally it should be done 24-48 hrs later under the cover of anti-rabies serum locally.
If previously fully vaccinated with rabies cell culture vacci nes, then only IDRV day 0,3 dose
(single site) is requir ed. Pre-exposure Prophylaxis: IDRV 0,7, 28, 0.1 ml single site
Rabies vaccine & RIG are not contraindicated in pregnancy.

Injury
Time of arrival, time & place of occurence of injury, cause of injury, 2 id marks, brought by
whom(address also) should be noted.
1.C & D (wound toilet). Ideally with NS. Betadine, H 202 , cetrimide, savlon(cetrimide+chlorhexidine)
etc may be used for contamina ted wounds only.Look for any foreign body in the wound.
2.Inj TT 0.5 ml im st(Same for all age), if indicated.
3.Inj tetglob (Immun oglobulin, tetanus) 250 IU deep IM St ATD(for deep & large wounds,
contaminated wounds)(Same dose for all age)
4. Excise all devitalised tissue s. Remove any foreign body in the wound. If needed, suture.
Suture the wound without any dead space inside the wound.
Materials needed:- needle holder, forceps (artery , thumb), needle(cutting/ reverse cutting-skin,
round body/tapering- fascia, soft tissue,muscle & tissues that are easy to penetrate) , suture
material-usually silk, nylon,prolene (non-absorbable) or catgut,vicryl,monocryl(absorbable). Usually
skin is sutured with 3-0 nylon or 4-0(smal ler). Suture should n’t be too tight.
Don’t suture if a) underlying tendon is cut,
b) underlying bone is fractured.
c) caused by dog bite (especially stray dogs) or human bite
Give adequate support/immmobilization of the region.
Note: Prima ry suturing (done within 6 hrs) shouldn’t be done if there is edema/infection/
devitalised tissues/hematoma. Here delayed primary suturing (48 hrs-10 days)can be done.
This time is allowed for the oedema/hematoma to subside.Secondary suturing (10-14 days) is
done in infected wounds.
 13
Abrasion
1.Inj TT 0.5 ml IM stat if indicated.
2.C & D.Preferably dressing is not necessa ry.
Large abrasions or skin loss lesions may be dressed with cuticell(non medicated), cuticell-c or
bactigras (chlorhexidine), jelonet(non medicated paraffin gauze dressing), cuticell plus
(polymyxin B, bacitracin, neomycin)
3.T-bact oint,Metrogyl-P Gel, Megaheal(colloidal siver), Sepgard ointment(feracrylum), Neosporin
powder/oint [zinc bacitracin, neomycin sulphate, polymyxin B sulphate], healex spray(Benzocaine
+poly vinyl polymer), cetrimide, Savlon(cetrimide+ chlorhexidine), Neosporin-H for L/A
4.Oral antibiotics , if Diabetic / multiple abrasi ons
5.Analgesics + Serratiopeptidase
6.Vit C, Rantac
I&D
Diagnosed based on Fluctuation.
I & D by Hilton’s method
Ask patient to lie down to avoid shock induced by pain. Start an IV fluid. Incision put
parallel to neurovascular structures.Press at root with cotton, till frank blood comes. Clean
well with betadine.Dress with GM(glycerine Mag sulf) to reduce edema at the site.
Check RBS, Urine sugar.

Suture Removal
1.Clean with Betadine
2.Cut close to skin using Blade no. 11 or 10
3.Avoid thread from outside entering inside
4.Remove intermittent sutures to prevent Gaping.
Days of suture removal:-
Thyroid- 4-5 days Scalp- 5 days Abdominal- ~10 days
Inguinal- 8-9 days Knee- 10 days Ankle,foot- 14 days

Burns
Attend only if burns <15 %. Refer large Burns to surgery.Do BRE, LFT, RFT
Put iv line before edema develops. R/o inhalational injury(burns in closed space, fire work
accidents, high velocity explosion).Rapid primary survey is performed to assess the ABCs.
Any constricting clothing and jewelry should be removed to prevent these items from exerting a
tourniquet like effect after the development of burn edema.Don’t apply ice to burns
1.Inj fortwin 1cc IM / IV st or Tramadol (& emeset). For severe burns morphine 5 mg iv Q8H
2.Clean gently with copius volume of cold water for 20 minutes, as it will minimize degree
of burns,then with betadine
3.Smear antiseptic ointment like soframycin(framycetin) for face, silverex(silver sulfadiazine)
for trunk & limbs; Fusidic acid oint(fucidin-L, fucibact, fusiderm), Betadine etc
4. Inj TT 0.5 cc IM st if indicated.
5. Inj tetglob 250 IU IM st ATD
6.Oral Antibiotics(iv antibiotics like taxim, metrogyl for severe burns)
7.IV fluids(Ringer Lactate is preferred) using parkland’s formula (4ml/% burn/ kg body
wt/24hrs) with half given during first 8 hours & remaining half given during next 16 hours.
8.Inj Dexona 2cc IV/IM Q12H x 2 days(dexamethasone) or hydrocortisone(efcorlin)
9.Inj Pantop/Rantac to prevent curling’s ulcer.
10.For severe burns requiring admission ,give O 2 ,RT,CBD & measure urine output.
Note:give cold water compress,large blisters may be deroofed with a sterile needle or
aspirated; leave blisters on the palms or soles intact. Immobilisation is suggested for upper
limb burns.For chemical and eye burns irrigate with copious volume of water
 14
Chest Trauma
Rapidly fatal conditions: tension pneumothorax,flail chest, open pneumothorax, massive
hemothorax,cardiac tamponade(engorged neck veins,hypotension,muffled heart sounds)
Potentially fatal conditions evolving less acutely: simple pneumothorax,Rib fracture and
contusion,blunt cardiac injury, traumatic asphyxia, thoracolumbar vertebral injury,
scapular/sternal fracture,esophageal perforation,subcutaneous emphysema,
diaphragmatic rupture, pulmonary contusion,
Diagnosis: history, physical examination, X-ray, CT etc
Immediately refer the patient to higher centre without any delay

COPD a/c Exacerbation + LRTI

Inv: SPO 2, CXR, CBC
1.Oxygen inhalation
2.Nebulisation at 2L/min,
with Duolin propped up
(ipratropium position,
bromide+ Q4H Temp chart.
levosalbutamol) + Budecort sos
3.Inj Methyl Prenisolone 120mg iv stat, followed by 60 mg iv Q8H
4.Inj terbutaline 0.5ml S/c Q8H
5. Inj aminophyllin 250/500 mg in 250/500 ml NS/ 5D Q8H over 4 hr or Inj deriphyllin.
Note: deriphyllin may cause tachycardia, whereas aminophyllin is cardioprotective.
6.Inj Monocef 1g iv BD ATD
7.Inj levofloxacin/ Azithromycin 500mg iv OD
8.Inj Pantoprazole 40 mg iv OD
9.T prednisolone 10 mg tds (after a/c phase). At discharge also prescribe Seroflo (salmeterol +
fluticasone) 100/250 MDI or Rotahaler, T Deriphylline, asthalin, syp ambroxol etc.
Note: In COPD pts not responding to treatment, suspect pneumothorax
Laryngo-tracheo-bronchitis(Viral Croup)
C/f: a/c stridor, barking cough, hoarseness , respiratory distress
1.Oxygen inhalation
2.Inj dexamethasone 0.6 mg/kg iv st
3.Nebulise with budesonide 1 mg
4.For severe cases, Nebulise with adrenaline 1:1000, 2-5 ml
5.i/v antibiotics for bacterial croup(ampicillin or 3 rd gen cephalosporins)
6.Adequate hydration.
Incessant crying of infants/children
Note:-mostly due to intestinal colic due to hunger, worms, constipation, over feeding, aerophagy, food
intolerance,sepsis/infection like meningitis, AOM,medications, discomfort from wet diaper, feeling cold, baby
needs to be held, nasal block, ear ache ,loose stools, ,intususception , GERD ,physiological etc
Examine all limbs, trunk, back, orifices
Advise regarding proper feeding of the baby.Feeding, Burping & carrying the baby upright in
shoulder may bring relief
Adequate breast feeding: 15-20 min sucking, then 2-3 hrs hrs sleep or rest. Frequent
urination.1-6 liquid stools per day & gaining weight.
1.Syp Carmicide or syp Cyclopam (10/5)(0.5 mg/kg/dose) or Syp P’mol st
2.Syp Phenergan (5mg/5ml)(1mg/kg/dose) or Syp Pedicloryl ( 500/5) 0.5 ml/kg st
3.Saline nasal dps for nasal block; 2 0 Q4H
For infants:
1.Carmicide /colicaid/cyclopam-DF Dps( simethicone,Dill oil,fennel oil) or colimex/cyclopam
(dicyclomine 10 / 1, dimethicon 40 / 1). Colicaid dose: Infant <6 mths: 5-10 drops; infant 6-12 mths:
10-20 dps;over 1 yr: 20 dps qid before food or SOS.
Indications:Infantile colic, flatulent dyspepsia, regurgitation.
Note: Syp carmicide adult (Na citrate, citric acid, tincture cardamom,tinc cinnamon, alcohol, ginger
oil)
 15
Allergy/pruritus(itch)/urticaria(hives)
Look for offending food or drugs(cutaneous drug eruption) ,insect bite, parasites, etc.
Conditions associated with generalized pruritus without a rash: obstructive jaundice, Fe deficiency,
lymphoma, carcinoma(especially bronchial) ,CKD,DM,gout, HIV, senile pruritus, hyper or
hypothyroidism.Look for any breathing difficulty like stridor.
Inv: FBC, ESR, urea, electrolytes, TFT,LFT, P Smear. Allergy testing can be suggested.
1. Inj avil 1amp IM st (if severe) or Inj Atarax (hydroxyzine) 1 amp IM st
2. Inj Efcorlin/betnesol/Dexona 1 amp iv st
3. T Piriton(CPM) 2/4/8 mg tds/ bd (0.1 mg/kg/dose x 3; 2-6 yr: 1mg Q6H, 6-12 yr:2 mg Q6H) or
T Cetrizine 10 mg 0-0-1(poor antipruritic action) or T Atarax 10-25 mg 1-1-1 (Syp atarax 10/5 ,dps 6/1
2mg/kg/day in 3-4 divid doses ) or T Levocet 10mg(0-0-1)(levocetrizine) or T Avil 25/50 mg
4.T Rantac 150(1-0-1)[ H2 blockers have adjuvant beneficial action in certain causes of urticaria,who
don’t adequately respond to H 1 antagonist alone]
5.T wysolone(prednisolone) 0.5 mg/kg bd/tds x 3 days for severe cases .
T Wysolone(prednisolone) 5/10/20/40 mg bd/tds (Syp omnacortil 5mg/5ml Dps 5mg/1ml available,
2mg/kg/24 hr div into 2-4 PO, asthma:0.5-2 mg/kg/24 hr); Betnesol 0.5mg/1ml Dps available
(0.2 mg/kg/24 hr div into 2 to 3 PO), Dexona Dps 0.5mg/1ml (0.2 mg/kg/day).T betnesol 0.5/ 1 mg ;
T dexona 0.5/ 2 /4 mg ;T Deflazacort (cortimax)1/6/30 mg, Syp Dezacor 6mg/5ml available.
6.Calamine Lotion(calamine + Zn oxide)(T N: Calacreme, Calaminol, calamyl); calosoft (calamine+
aloevera+ liquid paraffin), Calskin (calamine + diphenhydramine + camphor + alcohol)
Lactocalamine(Zn oxide, Zn carbonate, light kaolin, glycerin, castor oil,aqua, aloe vera)
For children
Syp Atarax 1 0/5 or Dps 6mg/5ml(2mg/kg/day in 3-4 divid ed doses ) or
Syp Avil( 15/5) (0.5 mg/kg/dose x3) or cetrizine or chlorpheniramine maleate(CPM)
For pregnant ladies: chlorpheniramine maleate,cetrizine, diphenhydramine
Note: look for anaphylactic like reactions, if present give Inj Adrenaline.
Insect Bite Reaction
Treatment same as
Note: for infected above
insec t bite Mupirocin Oint can be given
Epistaxis
Aetiology:Trauma ,Systemic HTN,URI, F B , DNS, drying of mucosa ,drugs, septal perforation,
liver/kidney disease, a/c general infection, vitamin k deficiency, malignancy,atherosclerosis etc
Inv: CBC, Plt ct,ESR, aPTT, PT-INR, BT,CT, P smear,RFT,LFT,X-ray PNS (water’s). Check BP
1.Keep head elevated, avoid exertion,aspirin, blowing of nose for 24 to 48 hrs. Reassure the pt
2.If severe Close nose by pinching and breath via mouth for 5-10 minutes.
3.Cold compress to nasal area.Keep icecubes in handkerchief over nose. If bleeding still
present, a cotton gauze impregnated with adrenaline & lignocaine is inserted & nose pinched for
another 10 minutes. Use Gelfoam (absorbabl e gelatin compressed sponge) if discrete bleeding
point identified.
4.If not controlled, Give Inj Tranexa (tranexamic acid) 500mg slow iv st or Etamsylate iv st
5.Oral Antibiotics(e.g augmentin or cephalexin) or topical antibiotics to prevent sinusitis
6.keep Check on pulse, systemic hypertension,respiration.

7.Give anti-allergics for mild sedatio n like avil or cetrizi ne if required

8. For benign cases, oxymetazoline nasal spray/dps(nasivion) can be given.
9.T Cosklot 250/500 1-1-1(etamsylate)
Note: if not controlled, Pressure packing of the nose & Admit the pt .
Refer the Pt to ENT
 28
Left ventricular failure

S/s: dyspnoea at rest that rapidly progresses to a/c respiratory distress, orthopnoea ,
PND, pink frothy sputum
Signs: distressed, pale, sweaty, tachypnoea, gallop rhythm, pulmonary edema(basal
crepitations), Pulsus alternans, pitting edema, raised JVP

Feature of RHF: raised JVP, hepatomegal y, ascites, bilateral pitting pedal edema

Inv: CBC, urea, electrolytes, ECG, CXR

CXR in LVF: features can be remembered as ABCDE ie Alveolar edema,kerley B lines,
Cardiomegaly, D ilated prominent upper lobe vessels, pleural E ffusion

Rx
Ideally LVF should be managed in ICU
The management of a/c pulmonary edema can be remembered as L M N O P ie
Lasix, morphine, oxygen, & propped up position
1.Sit the pt up/CBD
2.Bed rest
3.Oxygen inhalation
4.Inj Lasix 20- 80 mg iv st followed by 40 mg Q8H or Q12H( if there is no significant fall in
BP)(larger doses required in renal failure)
Note:Pt currently treated with furosemide may receive twice the daily oral dose by
intravenous administration.
5.Inj Morphine 2mg iv st ( + inj phenergan 25 mg iv st)( may be repeated as needed
every 5-10 minutes
6.Inj NTG infusion(only if the pt is in ICU)
7.Inj Aminophylline 250 mg in 20 ml NS iv bolus Q8H.
8.ACE inhibitors
9.Positive likeagents
inotropic Enalapril
such5mg
as 1-0-1(if BP above 120 mm
dopamine/dobutamine Hgbe
may & creatinine
needed in <pt’s
1.5with
mg/dl)
concomitant hypotension or shock.
10.Manage precipitating causes like MI/ infections/arrhythmias

Causes of pumonary edema

LVF, ARDS, fluid overload(renal failure, iv fluids),hypertensive crisis, neurogenic
causes( seizures , head injury etc)

Hypoglycemia
C/f: sweating, trembling, pounding heart, hunger, anxiety, confusion, drowsin ess,
speech difficulty, inability to concentrate,seizure, nausea, tiredness, headache,
irritability, anger, incordination
1.Check GRBS; if very low give 25% Dextrose 3 or 4 amp( 1 amp= 25 ml) or 25D 75 or
100 ml infusion or 50%D 25-50 ml; followed by 5%D infusio n because insulin has

prolonged action.
2.GRBS should be repeated every 10 minutes until>100 mg/dL
Note: All cases of unexplained hypoglycemia should have an ECG taken.
For infants: 2ml/kg & children: 4ml/kg 25 % dextrose or D10 if RBS <40.
Pt may be observed for 24 hours.
 29
Hyperglycemia

The diagnosis of DM can be established using any of the following criteria:

HBA1C≥6.5%
FBS≥ 126 mg/dL. A positive value should be confirmed with a rpt test.
Symptoms of diabetes(polyuria,polydipsia, fatigue, wt loss) & a RBS ≥200 mg/dL
OGTT≥200 mg/dL at 2 hrs after ingestion of 75 g of glucose.
Prediabetes
Impaired fasting glucose: FBS≥100 & ≤125 mg/dL
Impaired Glucose tolerance:2-hr glucose 140-199 mg/dL after ingesting 75 g glucose.
A1C in the range 5.7% to 6.4%
Note: Lifestyle modification, including a balanced hypocaloric diet to achieve 7% wt loss
in overwt pt’s & regular exercise of ≥150 min per week, is recommended for persons
with prediabetes to prevent progressi on to T2DM.
Diabetic pt review - 1. Fasting urinalysis for glucose, ketone, albumin, 2. FBS/PPBS,
HbA1c 3.LFT, RFT, TFT 4. BP monitoring( targe t in DM is <130/8 0) 5. Enquire about
Hypoglcaemic episode 6. Eye examination 7. Lower limb & feet examination.
The blood pressure target for pt’s with diabetes is <130/80. ACEI/ARB is recommended
as first line therapy. For those pt’s not at goal, a diuretic should be added.
The lipid target are as follows: LDL <100 mg/dL, Total Cholesterol<150 mg/dL, HDL>40
mg/dL in men & >50 mg/dL in women. In pt’s with known cardiovascular d/s or two risk
factors in addition to DM, the LDL should be <70 mg/dL, preferably using high-dose
statin therapy.
Aspirin should be advised in pt’s with diabetes & older than 40 yrs or who have other
risk factors. Low dose (75-150 mg) is appropriate for primary prevention
Note: Advice Physician consultation
Hyperglycemia>300 mg/dL on more than one consecutive test should prompt testing for
DKA
Rx
Monotherapy
For obese patients: T Metformin 500mg(1-0-1) after meals;
For non-obese patients:sulfonylureas(2nd gen- glibenclamide,glipizide,glimepiride)
Combination therapy using sulfonylureas may be needed, if monotherapy is
unsuccessful.
Pioglitazone is prescribed as a second line therapy with metformin or third line therap y
in combination with sulphonylurea & metformin
Voglibose is used for lowering PPBS.
Insulin Therapy
 Addition of NPH insulin at bed time to control FBS in addition to OHAs. Then twic e
daily NPH or consider adding Regular insulin to NPH. Regular insulin needs to be
taken 30 mins before meals.
 Insulin therapy given for pt’s presen ting with DKA or with high glucose leve ls to
prevent glucose toxicity.
 30
Dosage of insulin
It is ideal to start with a small dose & gradually increase at intervals of 2-3 days till the
optimum dose is achieved as judged by the blood glucose level. The initial dose
required can be calculated at the rate of 0.5 U/kg/day for Type 1 and 0.2 U/kg/day for
Type 2 DM. If the pt is not symptomatic 50% of the calculated dose can be given initially
& the dose can be gradually increased by 4 units every 3 rd/4th day. If the pt is
symptomatic, the calculated dose can be given in full at the start and adjusted
subsequently. Illness often increases insulin requirements despite reduced food intake.
For pt’s naive to insulin, a starting dose of basal insulin should equal 0.2 U/kg. If the
presenting B sugar level is >200 mg/dL, adding premeal insulin is appropriate.The dose
should be 0.2 U/kg divided by three meals. A correction dose of 1 to 2 U per 50 mg/dL
of B sugar, beginning at 150 mg/dL , can be added to the premeal dose s.
Common preparations:
Soluble/regular H.Insulin:- H.Actrapid, Huminsulin-R
Human isophane insulin(NPH):- Huminsulin-N / Human insulatard
H regular insulin+ isophane(NPH) insulin, 30/70 or 40/60 or 50/50:- Huminsulin / H actraphane /
H Mixtard (40 IU/ml, 10 ml)
Metformin 500 mg/1g (Glyciphage,glycomet,walaphage,glumet,cetapin-XR)
Glimepiride 1 or 2 mg (Glimy,Amaryl,Diapride,azulix )
Glibenclamide 2.5/5 mg (Daonil,glinil,glucosafe)
Gliclazide 30/40/60/80 mg (glicron,glyred,reclide)
Pioglitazone 15/30 mg (pioglit,diavista,P-glitz,piozone)
Voglibose 0.2/0.3 mg (Volix, vocarb, volibo,PPG)
Glimepiride+ metformin (Amaryl-M,Amaryl-M2,Diapride Forte,Gluformin G1, Gluformin G2,
Glimy-M, glyciphage-G)
Glibenclamide + metformin(Daonil-M, glinil-M)
Gliclazide + metformin (glycard-M, glyred-M,glychek-M)
Metformin + Voglibose( Gluconorm-V)
Vidagliptin + metformin (galvusmet)
Pioglitazone + metformin(cetapin-P, diavista-M, gluconorm-P, glyciphage-P,walaphage- PZ)
Pioglitazone + glimepiride( glimy-P,pioglit-G, pioglar-G)
Glimepiride+ metformin + Pioglitazone(Amaryl-MP 1 or 2, Glyciphage PG1/PG2, tribet 1 or 2)
Glimepiride+ metformin +Voglibose (Volix trio 1,Volix trio forte 1, Gluconorm-VG)

Diabetic Ketoacidosis
c/f->
 Anorexia, nausea, vomiting, polyuria, feeling thirsty
 Abdominal pain, flushed hot, dry skin
 Altered sensorium/coma, blurred vision
 Kussmaul’s breathing- fruity odour in breath due to aceton e
 Features of volume depletion, dehydration or co-existe nt infection may be present
Diagnosis requires
mmol/l, moderate acidosis(pH<7.3),
ketonemia hyperglycemia(>250 mg/dl), bicarbonate< 15
or ketonuria(+++).
Inv:- RBS, Urine sugar & acetone, BRE, URE, S. Na, K, urea,creatinine,ABG, Serum
amylase. Features of a pre-renal type of renal failure due to volume depletion may also
be seen, ECG to look out for electroly te imbalance & for unsuspec ted myocardial
ischemia.
 31
Rx
1.IVF NS 1L over 30 min( if cardiac function normal), 1L over 1 hr, 1L over 2hr, 1L over
next 2-4 hrs. Those >65 yrs or with CCF need less saline more cautiously.Once blood
glucose decreases to 200-250 mg/dl, start IVF DNS @ 50 to 100 ml/hr over a parallel
line.
2.Inj Regular Insulin 10 to 15 U iv st (0.15 U/kg)
Another option is to give RI 0.3 U/kg, half iv & half sc or im st f/b inj 0.1 u/kg/hr sc or im.
Note: Subcutaneous absorption of insulin is reduced in DKA because of dehydration;
therefore, using intravenous routes is preferable
3. Continuous Regular Insul in infusion in 1 pint NS @ 5 to 10 U/hr(or 0.1 U/kg /hr)
(100 U in 500 ml of 0.9% NS infused @ 50 ml/hr or 14 drops/min delivers a 10 U/hr
infusion or 50 U in 500 ml of 0.9% NS infused @ 100 ml/hr or 25 drops/min delivers a
0 0 0
10 U/hr infusion
90kg-22 0/min;100).For 600kg,
kg-25 /min50U in 1 pint
delivers 0.1NS at 15 /min; BG
U/kg/hr.Check 70 kg-17
hourly/min;80kg- 20 /min;
initially.A decrease
in BG levels of 50 to 75 mg/dl/hr is an appropriate response.If no reduction in 1st
hour,rate of infusion should be increased by 50-100 % until an appropriate response is
observed or repeat the iv loading dose. Excessively rapid correction @ >100 mg/dl/hr
should be avoided to reduce the risk of osmotic encephalopathy. Once BG level
decreases to 250 mg/dl, the insulin inf usion rate should be decreased to 0.05 U/kg/hr to
prevent dangero us hypoglycemia. Maintenance insulin infusi on rates of 1 to 2 U/hr can
be continued (indefin itely) until the pt is clinically improved. Once oral intake resumes,
insulin can be administered s/c & the parenteral route can be discontinued. Restoration
of the usual insulin regimen by s/c injection should not be instituted, until the pt is able
to eat and drink normally.
Note: Give a s/c dose (~10 U) of insulin 1/2 hr-1 hr prior to discontinuing insul in infusion.
A rough estimate of the amount of insulin required for s/c administration can be
calculated from the total amount of insulin given in the infusion till the time RBS became
<200-250 mg/dl. This amount of insulin is given in three divided doses.

4.RBS every if1-2

5.Antibiotics hrs/urine
infection sugar acetone chart/ electrolytes every 4 hrs.
suspected
6.ECG
7.Catheterisation if pt unconscious or if no urine passed after 3-4 hrs of starting fluid
replacement.
8. Ryle’s tube aspiration to keep stomach empty in unconscious or semiconscious pts
9. K+ replacement.
K+ levels can fluctuate severely during the treatment of DKA, because insulin decreases
K+ levels in the blood by redistributing it into cells. K + should be added routinely to the IV
fluids from second or third liter of fluid replacement except in pts with hyperkalemia(>6
mmol/L & or ECG evidence), renal failure, or oliguria.
If baseline serum K + levels are <3.3 mmol/L (<3.3 mEq/L), insulin therapy should not be
commenced until the K + level reaches 3.3 mmol/L. Likewise, if K + levels reach <3.3
mmol/L at any point of treatment, insulin should be stopped and K + replaced
intravenously. In all patients with a K + level <5.3 mmol/L and an adequate urine output
of >50 mL/hour, 10 to 20 mmol (10 to 20 units [mEq]) of K + per hour should be given
routinely to prevent hypokalaemia caused by insulin. If the K + level is >5.3 mmol/L
replacement is not needed but K + level should be checked every 2 hours
Complications of DKA
Cerebral edema due to excessive rapid correction of DKA.
Rebound ketoacidosis due to premature cessati on of IV insulin infusion or inadequate
doses of s/c insulin after the insulin infusion has been discontinued.
 32
Lactic acidosis due to prolonged dehydration, shock, infection etc
Arterial thrombosis, Shock, aspiration pneumonia etc
Hyperglycemic hyperosmolar Nonketotic coma(HONK) or HHS(hyperosmolar
hyperglycemic state)
It is characteris ed by severe hyperglycemia (>600 mg/dl) & dehydrati on without
ketoacidosis.Treatment is similar to DKA with two exceptions:
1.Fluid requirements are often higher (with 0.45% saline) &
2.Total insulin requirements are less(~half the dose of insulin recommended for DKA)
UTI
c/f :Fever with chills , Burning sensation during micturition,frequency, abd pain,
Burning pain on micturition indicates urethritis. Suprapubic pain, frequency, dysuria:-
cystitis; High fever, toxicity, flank pain, tender renal angles:- pyelonephritis; palpable
kidney swelling:hydronephrosis.
Inv: URE ,RFT , C & S etc. Ur ine culture is must for recurrent infection, children,
pregnancy, DM, Indwelling catheter, older people, failure of initial therapy
1.T P/L 500 mg tds X 3 days or T cyclopam(for ureteric/renal colic)
2.T Norflox 400mg 1-0-1 X 5-7 days for uncomplicated UTI ( for men give for more
days) or T Furudantin 50/100 mg (nitrofurantoin) 1-0-1(if resistant or recurrent UTI).
For upper UTI give antibiotics for 7-14 days.
(others:Cefpodoxime,cephalexin,cotrimoxazole,amoxicillin + clavulanic acid etc)
Norflox, ofloxacin,nalidixic acid,ciplox are C/I in pregnancy & lactation
Note:Always collect urine in a sterile bottle before giving antibiotics.
If C & S is done, give antib iotics only till the result comes. Once the resul t comes,
Antibiotic can be changed according to the report
3.Syp Citralka ( Di Na hydrogen citrate) 2 tsp in one tumbler of water tds( can be given
in pregnancy)
4.T pyridium (phenazo pyridine) 200 mg 1-1-1 x 2 days( it is a urinary anal gesic. It
produces reddish discolouration of urine. So warn about it. Not to be used for more than
2 days.C/I in pregnancy)(12 mg/kg/24 hr div into 3 for 2 days)
5.Plenty of oral fluids(~2L or more / day)
Note: In pediatric cases we may give cefixime, septran or gramoneg.Refer all pediatric
UTI to pediatrician for work up(MCU, USG etc),as child below 5 yrs(especially < 2 yrs)
are vulnerable for permanent renal damage following UTI.
T Urikind/Urispas (Flavoxate) 200 1-1-1 (for d ysuria, urgency, nocturia, suprapubic pain,
frequency & incontinence, bladder spasm due to catheterization etc)(given in pregnancy)
Hematuria
Aetiology: UTI,pyelonephritis, trauma, Hemorrhagic cystitis, nephrolithiasis,kidney injury
(from accidents),a/c prostatitis, urethral stricture,drugs(like penicillin, anticoagulants like
aspirin, heparin,certain anticancer drugs), food dyes like beet root, neoplasm, TB,
traumatic urethritis due to sexual intercourse or masturbation, allergy, strenuous
exercise, viral illness, glomerulonephritis, excessive coagulation therapy, urethral FB,
renal infarction, myoglobinuria, hemoglobinuria.
Inv: URE, BRE, RFT, USG abdomen etc
Advise medicine/Nephrology consultation.
 33

Hyperventilation
Aetiology: stress or anxiety, stroke, head injury, DKA, metabolic acidosis, bleeding,
infection, heart/lung disease, drugs, pregnancy,severe pain
1. Breath into a paper/plastic bag
2. O2 inhalation
3. Propped up position
4. Diazepam if necessary

Hypertension
(pts with newly discovered asymptomatic hypertension or asymptomatic known
hypertensive patients with elevated BP)
Acute lowering of BP is unnecessary and may be harmful in asymptomatic
patients.
Just advise them to consult their primar y physician for therapy change.Asymptomatic
Pt with newly discoverd BP, should be advised to consult physician to start on
antihypertensive therapy. Reduce BP, if greater than 220/110.
Don’t give Nicardia /Lasix to reduce hypertensi on in an asymptomatic, otherwise normal
patient as it causes sudden decrease in blood perfusion to organs and may lead to end-
organ damage.
Note:a/c reduction of BP is required only in hypertensive emergency like MI with HTN,
stroke with HTN, hypertensive encephalop athy etc

Palpitation
Aetiology:physiological, psychogenic, organic
Organic conditions include MR,AR,AF, ectopics,anemia,thyrotoxicosis,fever of any
cause, hypoglycemia (pounding heart), drugs causing brady cardia and tachycardia etc.
Check for anemia, hyperthyroidism,LVH, arrhythmias
1.T ativan 1mg 1-0-1 (lorazepam)
2.T Ciplar 10mg tds(propranolol); Physician consultation

Chest pain
Aetiology: a/c MI,angina,aortic dissection, tension pneumothorax, pulmonary embolism,
GERD, pericarditis, pneumonia, chest wall pain, pleurisy, empyema, bronchitis, cervical
spondylosis.
Inv: ECG, CXR, Trop T/ Trop I/ CPK MB
A patient is diagnosed with MI if two (probable) or three (definite) of the following criteria
are satisfied:

1.Clinical
2.Changes history of ischemic
in serial type chest pain lasting for more than 20 minutes
ECG tracings
3.Rise and fall of serum cardiac biomarkers
Note: Trop T becomes + ve only after 6 hrs, CPK-MB + ve afte r 4 hrs,
Window period for thrombolysi s: 12 hrs
 34
Heartburn/pyrosis/cardialgia/acid indigestion
Etiology:gastritis,GERD, IHD etc
Inv: ECG all leads to r/o ACS.
1.inj Pantop/Ranitidine,
2.Antacids
3.C or syp Aristozyme bd/tid after food
Note: 10% of cases of discomfort due to cardiac causes are improved with antacids
Avoid overweight,avoid lying down soon after a meal,avoid late meals,avoid smoking,
avoid tight fitting clothe s,elevate the head end of bed, avoid foods that trigger heartburn.

Unstable Angina
1.O2 inhalation
2. Absolute Bedrest. Later graded ambulation 2 min in the morning & 5 min in the
evening.
3.300 mg dispirin(don’t give ecospirin as it is enteric coated & thus delayed release ) st
followed by 75 mg/150 mg ecospirin 0-1-0
4.If normal BP s/l sorbitrate(isordil) 5mg/10 mg st & 1-1-1
5.T Clopidogrel(clopilet/clopikind) 75 mg x 4 tab & 1-0-0
6.If severe pain persists,IV morphine 2-3 mg/pethidine 50-100mg(may cause vomiting)
Note:C/I in asthmatics, COPD, already in hypotension
7. Metoclopramide10 mg / phenergan 25 mg for nausea/vomiting associated with
Morphine
8.If BP low, don’t give lasix.
9. β blockers, e.g T metoprolol 25 / 50 1-0-1(Monitor Pulse Rate) or T Carvedilol 3.125-
25mg (Cardivas) bid or nebivolol 5-40 mg daily(Nebicard)
10.ACE inhibitors, e.g T envas(enalapril) 2.5/5 mg 1-0-1(monitor BP, RFT)

11.T Atorvastatin 40 mg st & 10mg 0-0-1

12.Heparin/LMW Heparin(clexane )i.e. Inj heparin 5000 U s/c Q6H x 5 days Or
Inj clexane (enoxaparin )0.6 ml s/c BD(if RFT normal).
13.Syp cremaffin HS (as stool softner); semi solid diet.
In those patients not tolerating Sorbitrate, we may give T.Monotrate 20mg 1-1-0
 Aspirin + Clopidogrel Combinations: T.Complatt, T.Deplatt-A, T.Cidogrel-A
T. Complatt CCU-> a unique combination with high loading doses of Aspirin &
Clopidogrel for initiating therapy in cases of emergency. Consists of 2 tabs, one of
which has to be dispersed in water & the other to be swallowed whole.
Discussed in det ail in HS man ual
Note: Unstable angina:ST depression or new T inversion and Trop T –ve,
NSTEMI: ST depression or T ↓ and Trop T +ve , STEMI: ST elevation and Trop T +ve
Nocturnal leg cramps
Etiology: peripheral artery disease, spinal stenosis, drugs( like statins, diuretics, BP drugs),
DM, dehydration, diarrhoea,fatigue, OA, pregnancy, hyper/hypothyroidism,CKD, cirrhosis,
electrolyte
1.Analgesicsabnormalities, B complex deficiency, dialysis, idiopathic etc
2.Vit B12(Cap Meganeuron OD Plus 0-0-1)/T Shelcal OD/ C evion 400 mg OD,
3.T gabapentin(Gabantin) 300 mg od.
4.Plenty of oral fluids, stretching, massage
 35
Status Epilepticus
Occurrence of Seizures for more than 20 min or fits occurring in succession without
regaining consciousness in between.
R/o hypoglycemia
Course->
 Stoppage of current Anti-epileptic medication.
 Metabolic conditions like Hypoglycemia, Hyponatremia
 Infections like Meningitis, Encephalitis
 Other causes of seizures like ICSOL, Trauma etc.
The aim of treatment is to control seizure first and then identify any correctable cause
and treat it if possible.
Rx:
 Maintenance of airway + throat suctioning
 Maintain iv line & draw bl ood for metabolic work up
 Intravenous antiepileptic medications
1.Lateral position
2.Inj Lorazepam 4 mg iv st/ inj diazepam 10 mg iv st over 2 minutes
3.Send RBS
4.Inj 25% dextrose 100 ml iv st
5.Inj thiamine 100 mg iv st
6.Inj phenytoin(eptoin) loading dose 10-20 mg/kg( 20 mg/kg first dose as 50 mg/min in
running NS).Usually it is given as inj eptoin 600/800/1000 mg in 100 ml NS(1 pint NS if
dose >1000 mg) over 20 min.
Phenytoin should not be injected through the same cannula as lorazepam because of
the possibility of crystallization. IV lines should be flushed prior to and after the
administration of phenytoin. Watch for hypotension & arrhythmia during infusion. Don’t

exceed 50 mg/min infusion rate as this may cause hypotension/cardiovascular collapse.

7.Later inj phenytoin 100 mg Q8H or inj Levipil(levitiracetam) 500mg or inj Na valproate
250 mg iv Q8H
8.If even after step 6, no improvement, rpt diazepam & ½ dose phenytoin
If still no improvement refer the patient to physician/ neurologist
Haemoptysis
Etiology: TB, a/c LVF, MS, bronchiectasis, pulmonary embolism, AVM, a/c bronchitis,
lung abscess, suppurativ e pneumonia, bronchial CA, trauma, SLE, FB, parasites,
mycetoma, hemophilia, aortic aneurysm, pulmonary infarction, leukemia ,
drugs(anticoagulants , aspirin, cocaine)
Inv: CBC, coagulation studies, URE, AFB, ANA,ECG, CXR, Chest CT,
Physician consultation
1.Reassure the pt;Q4H temp chart, I/O chart, pulse/BP chart(w atch for hypotension)
2.Prevent aspiration; raise foot end, turn head to one side
3.Absolute bed rest

4.Broad spectrum antibiotics

5.Blood transfusion if systolic BP less than 90 mmHg or massive hemoptysis.
6.Antitussives like codeine 5 ml tds
7.Bronchodilators
8.Sedation e.g: diazepam
9.Inj ethamsylate 500 mg iv Q8H.
 38
Ramipril [2-5mg OD] (ACE inhibitor)
Cardace, Cardiopril, Ramace, Ramihart

Losartan [ 25- 100 mg OD](ARB)

Losar,Losakind, Repace, Zaart, Tozaar

Olmesartan(20/40 mg)- oImetime

Atenolol + amlodipine
Amlong-A, Amcard-AT,Amlokind-AT, Stamlo beta, Aten-AM, Amlopres-AT

Atenolol + Nifedipine- Beta Nicardia, Presolar

Amlodipine + Losartan
Amcard LP, Amlokind-L, Amchek Z, Amlopres- Z, Amlotin HS,

Atenolol + Amiloride + Hydrochlrothiazide (for moderate to severe HTN not controlled

by monotherapy)
Beta-Bidurst, BP-Loride, Hipres D

Metoprolol + Hydrochlorothiazide- Betaloc-H, Selopres

Losartan + hydrochlorothiazide- Losar-H, Repace-H,

Telmisartan +hydrochlorothiazide- Telma-H,Telmikind-H

Telmisartan+ Amlodipine- Telista-AM, Telmikind-AM

Telmisartan + Metoprolol - Telmikind Beta

Prazosin(1-20 mg/day)- Prazopress

Nitroglycerin(2.6/6.4 mg) - Nitrolong

Hyperlipidaemia

Inv: 12-hour fasting lipid profile, TFT,RFT,RBS.

Note: screening for hypercholesterolemia should begin in all adults aged 20 yrs or older.
Causes of 2 0 hyperlipidaemia: hypothyroidism,Renal failure, nephrotic syndrome,
alcohol,DM, drugs like steroids, oral contraceptives, diuretics.

Note: measurement of fasting lipids is indicated if the total cholesterol is >200 mg/dl, or
HDL cholesterol is < 40 mg/dl. If fasting profile can’t be obtained, total & HDL
cholesterol should be measured.
Rx
st
1 line therapy: Statins are given .
2nd line: fibrates, e.g bezafibrate,fenofibrates or cholesterol absorption inhibitors, e.g
ezetimibe(useful combined with a statin to enhance LDL reduction).
Response to therapy should be assessed after 6 weeks.
 39
For hypertriglyceridaemia fibric acid derivatives are given. E.g bezafibrate.
Note: Statins are associated with myalgia, myositis, abdominal pain, derangement in
LFT , raised CPK. Give T Levocarnitine for associated muscle pain. T.N: carnisure
Drugs containing levocarnitine: C evion- LC, T nurokind-LC

Atorvastatin [10-20mg OD HS]

Atorlip, Atorva, Aztor, Vasolip, Statlip, Storvas, Lipikind

Rosuvastatin(5/10/20 mg OD)
Rosuvas, Novastat, Lipirose, Razel

Fenofibrate(200 mg OD) - Lipicard, Stanlip

Atorvastatin + Fenofibrate
Stator-F, Lipikind-F

Atorvastatin + Ezetimibe
Atorlip EZ,Storvas-EZ

Hyperuricemia
Etiology:renal d/s, drugs(e.g diuretics, immunosuppressive drugs), alcohol, starvation,
hypothyroidism, obesity,psoriasis, purine rich diet(organ meat, seafood, dried beans,
dried peas, mushrooms), vit B3,genetic, etc.
Rx
T Febuxostat(febutaz/febuget) 40/80 mg 1-0-0(monitor S.creatinine)

Steroid tapering
 If steroids are taper ed too quickly, wit hdrawal symptoms can occur, such as joint
pain, fatigue, dizziness, muscle pain, vomiting, shortness of breath, fainting,
headaches, low blood sugar, fever, nausea etc
 One view is that tapering is not necessary in short term therapy (14 days or less)
 Gradual withdrawal of systemi c corticosteroids is advisable in patient s who have
received more than 2 weeks treatment or have history of adrenal suppression or
have had repeated courses of steroids or received doses at night or have received
Prednisolone >40mg daily or equivalent (e.g. dexamethason e 6mg) for any length of
time

Prednisolone tapering
A decrease in dose is usually made every 2-3 days
Reduce dose by 2.5- to 5.0-mg decrements every 3–7 days until physiologic dose (5 to
7.5 mg of prednisolone per day) is reached.
Other recommendations state that decrements usually should not exceed 2.5 mg every 1–2
weeks

Dexamethasone tapering
In patients who have received less than 14 days of dexamethasone therapy, treatment
may be abruptly discontinued without adverse events, because the HPA axis is not
suppressed. Dexamethason e tapering schedules are often prescribed for short-term
therapy, and usually consi sts of a reductio n in dose of 2-4 mg every 1-3 days, by eith er
reducing the dose and/or the interval.
 40
Hypothyroidism

C/f: cold intolerance, fatigue, poor memory, constipation, menorrhagia, myalgias, hoarseness,
somnolence
Rare manifestations: carpal tunnel syndrome, deafness, hypoventilation, pericardial or pleural
effusions.

Diagnosis
 TSH is the best initial test. A normal value exclu des primary hypothyroidism, and a
markedly elevated value(>20 µU/mL) confirms the diagnosis. Mild elevation(<20 µU/mL)
may be due to nonthyroidal illness, but usually indicates mild(or subclinical) primary
hypothyroidism, in which thyroid function is impaired but increased secretion of TSH
maintains free T4 levels. These pt’s may have nonspecific symptoms that are compatible

with hypothyroidism
measured & a mild increase
if TSH is moderately in S.cholesterol
elevated, or if secondary& LDL. Plasma free
hypothyroidism T4 should be
is suspected, and
pt’s should be treated for hypothyroidism if free T4 is low
 ECG

Rx
Thyroxine is the drug of choice. The average replacement dose is 1.6µg/kg PO daily, and most
patients require doses between 75 and 150 µg/d. In elderly patients, the average replacement
dose is lower. The need for lifelong therapy should be emphasized. Thyroxine should be taken
30 minutes before a meal, preferably morning.
Initiation of a therapy.
 Young & middle-aged adults should be started on 100µg/d. This regimen gradually corrects
hypothyroidism, as several weeks are required to reach steady-state plasma levels of T4.
Symptoms begin to improve within a few weeks.
 In otherwise healthy elderly patients, the initial dose should be 50 µg/d.
 Patients with cardiac disease should be started on 25 to 50 µg/d and monitored car efully for
exacerbation of cardiac symptoms.
Follow-up
 In primary hypothyroidism, the goal of therapy is to maintain plasma TSH within the normal
range. TSH should be measured 6 to 8 weeks after initiation of therapy. The dose of
thyroxine should then be adjusted in 12- to 25- µg increments at intervals of 6 to 8 weeks
until TSH is normal. Thereafter , annual TSH measurement is adequate to monitor therapy.
 In secondary hypothyroidism, TSH cannot be used to adjust the rapy. The goal of therapy is
to maintain the free T4 near the middle of the reference range. The dose of thyroxine
should then be adjusted at 6 to 8 weeks intervals until this goal is achieved.Thereafter ,
annual T4 measurement is adequate to monitor therapy.
 CAD may be exacerbated by the treatment of hypothyroidism. The dose of thyroxine should
be increased slowly in pt’s with CAD, with careful attention to worsening angina, heart
failure, or arrhythmia.

 Hypothyroidism may impair survival in critical illness by contributing to hypoventilation,

hypotension, hypothermia, bradycardia, or hyponatremia.
 In pregnancy thyroxine dose increased by an average of 50% in the first half of pregnanc y.
 Subclinical hypothyroidism should be treated with thyroxine if any of the following are
present: a) symptoms compatible with hypothyroidism, b) a goitre, c) hypercholesterolemia

that warrants
monitored treatment,
annually, or d) the plasma
and thyroxine TSHstarted
should be is >10µU/mL. Untreated
if s/s develop pt’s should
or S.TSH be to
increases
>10µU/mL.

T.N: Thyronorm, eltroxin

 41
Sensory Disturbances
Pins & needles, pricking, band like, lightning pain, knife like, twisting, pulling, tightening,
burning, aching, numbness, other raw sensations
Aetiology: neurological or non neurological. Neurological: PNS or CNS lesions, Non
neurological: hyper ventilation, hypocalcemia, hysterical/non organic
Peripheral neuropathy causes: direct trauma, compression, entrapment, DM, leprosy,
HIV, alcohol, vitamin deficiency, hypothyroidism, drugs (like FQ, metronidazole,
phenytoin, linezolid), paraneoplastic, liver failure, renal failure etc.
For peripheral neuropathy/ Neuropathic Pain/ fibromyalgia
1.T Carbamazepine 200 mg 1-1-1(Tegrital,Epilep, Zen, Mazetol etc) or
T Amitryptilline 10 mg HS(Tryptomer) or T Duloxetine 30mg (Dulane,dutin) 0-0-1 or
C Maxgalin(pregabalin) 75/150 mg od or C Gabantin(g abapentin) 300 mg od
C Maxgalin-M/Pregastar M(pregabalin + methylcobalamin), Gabamax Gold/ Pregastar
Plus (B complex, pregabalin), T Nurokind-G(Mecobalamin + Gabapentin)
2. Analgesics - Mefanamic Acid [Ponstan, Meftal]
3.T BC or Neurobione forte or other multi vitamins with Vit B12 or T Benalgis
(Benfotiamine)100 mg 1-1-1; T Benalgis can be given for sciatica, diabetic neuropathy /
nephropathy/ retinopathy, & other painful nerve conditions.
4.Physician consultation
Facial Nerve Palsy
Aetiology-> ASOM, Inflammatory, Idiopathic[bell’s]
1. Antibiotics. In cases of DM always gi ve strong antibiotics
2. Analgesics
3. Steroid—wysolone 40mg 1-0-0 X 5-7 days, tailing by 10 mg/day
4. In cases of Bell’s Palsy give Acyclovir 800mg 5 times daily x 7-10 days

5. Pad
6. Lubrex/refresh
& bandage(carboxymethylcellulose)
eye; use dark glasses. Eye dps;

Trigeminal Neuralgia
DoC is Carbamazepine 200mg tds
Rx same as above
Giddiness/syncope
Etiology:
1.Hypoglycemia-> h/o DM + Cold extremities, Sweating-> give 25% or 50% dextrose.
2.Vasovagal attack-> Can occur due to prolonged standing, excessive heat or
large meal. Keep the pt in lying down posit ion & feet elevated
3.Bradicardia- drugs(beta blockers, verapamil, diltiazem, digoxin), AV block, SA
node disease
4.Tachycardia-AF, SVT
5.Postural Hypotension- hypovolemia, sympathetic degeneration(DM, Parkinson’s
disease, old age), drugs(ant i anginals, antidep ressants, neuroleptics) can cause or
aggravate the condition. Advise to avoid prolonged standing and to get up slowly from
sitting or lying down position.
6.Carotid sinus hypersensiti vity- when pressure is applied to neck e.g. wearing a
tight collar
7.Myocardial ischemia; LV outflow tract obstruction- AS, HOCM
Note: Whenever a pt is brought with c/o unconsciousness, r/o head injury
 42
Motion Sickness
1.T. Avomine 25mg about 1-2hrs before journey[Promethazine theoclate]
2.Avoid alcohol,dietary excess, reading. Position themselves where there is least
motion,a supine/recumbent position with the head braced is best. Keeping the axis of
vision at an angle of 45 0 above horizon may reduce susceptibility.

Memory defects & Forgetfulness

R/o treatable causes like Vit B12 deficiency, hypothyroidism, SDH
1.T Citicholine (strocit) 500 mg 1-0-1 Or
2.T piracetam 400 mg 1-1-1; T strocit plus(citicholine+ piracetam) or
3.T Donamem 0-0-1 (donepezil 5 or 10 mg + memantine 5 mg)

Headache
Primary headache syndromes : migraine with (classic) or without (common) aura,
tension headaches, cluster headaches, rebound headache, trigeminal neuralgia,
temporal arteritis
Secondary headache: have specific etiologies & symptoms vary depending on
underlying pathology, i.e., SAH, HTN,sinusitis, tumour, glaucoma,SDH, meningitis,
encephalitis, vasculitis, obstructive hydrocephalus, intracerebral hematoma, cerebral
ischemia or infarction, dental problems, pseudotumour cerebri,optic neuritis.
Systemic causes include fever, viremia, hypoxia, CO poisoning, hypercapnia, allergy,
anemia, caffeine withdrawal etc.
Clinical presentation: the sudden onset of severe headache(worst ever headache) or
a severe persistent headache that reaches maximum intensity within a few seconds or
minutes warrants immediate investigation for possible SAH. There may be a loss of
consciousness at the onset of SAH.
Physical examination
Check BP, pulse. Look for possible bruits. Check temporal arteries.
If neck stiffness
present, & meningismus(resistance
then consider to tenderness
meningitis.Check sinus passive neck flexion,headache
over maxillary & frontaletc)
sinuses.
If papilledema observed, consider an intracranial mass, meningitis or idiopathic
intracranial HTN.
Inv: CT Brain to exclude secondar y etiologies.
Rx
Analgesics
Note: Naproxen is the preferred NSAID in people with high risk of cardiovascular
complications like stroke, MI
In pt’s presenting with headache,fever,polymyalgia rheumatica , tenderness & sensitivity
on the scalp, raised ESR , suspect Giant-c ell arteritis.Start treatment immedi ately with
prednisolone (30-40 mg/day, tapered off in 4-6 weeks)to prevent blindness.

Migraine

In case of any headache R/o refractive errors. Ask for throbbi ng/pulsating nature,

chronicity,
photophobia,whether U/L or B/L, Duration, presence/absence of nausea/vom iting,
phonophobia
Also ask for any aura->visual blackouts, diplasia, nasal block, giddiness, fortification
spectra.
Also ask for any precipitation factors-> like TV, food, alcohol,caffeine, mental stress,
sleep deprivation etc.
 43
Rx:
1. Inj Migranil [dihydroergotamine]1mg iv over 2-3 min/im stat [C/I in pregnancy,
lactation, HTN,CAD] Or T.Migranil 2 tabs, rpt after 30 min if necessary.
Note: ergotamine preparations should be best avoided since they easily lead to
dependence.
2. Inj P’mol 2cc im stat[if 1 not available]
3. Inj phenergan 25mg or perinorm or stem etil-> for nausea
4. T.Alprax 0.5mg stat
5. T metoclop-P st( meto clopramide + P mol) or T Domstal-P(domperidone + P/L) st Or
6. T Headset st & SOS (sumatriptan suc cinate, Naproxen)(Only for A/c migraine
& cluster headache attack)(in elderly, avoid sumatriptan due to risk of CVA, MI) Or
7. T Clotan 200 mg (tolfenamic acid) st & SOS (for a/c migraine)

8. Headache
Prophylaxiscalender
is considered if a pt has at least 3 disabling migraines per month.
1. T.Flunarizine 10 mg HS x 2 weeks-1mnth[T.sibelium/Fine/Flugraine] Or
2. T.Inderal 20mg 1-0-1[ propranolol] (C/I in BA, CCF, POVD, Severe bradycardia) or
3. T sodium valproate 200 mg 0-0-1 x 1 week f/b 1-0-1 to continue or
4. T amitriptylline 25 mg HS

Tremor
Aetiology: alcohol withdrawal tremors, drug induced(salbutamol, deriphylline,
metoclopramide), hyperthyroidism, parkinsonism, senile tremors, hypoglycemia, stress
induced, vitamin deficiency(thiamine, B12), CKD, liver failure, Stroke,traumatic brain
injury, Hypocalcemia, hyponatremia, caffeine or alcohol induced
Inv: TFT, RFT, LFT, S.electrolytes,
1. T ciplar 40 mg 1-0-1(for essential tremors). Dose has to be tapered gradually over
several days. C/I in RAD, bradycardia, AV block, shock, severe hypotensi on, etc
2. T Alprax 0.25 mg 1-0-1 for stress induced tremor.
3. C Gabapentin OD
For tremors due to parkinsonism give T Syndopa(levodopa + carbidopa) bd,
T pacitane or parkin 2mg (trihexyphenidyl) bd

Caries Tooth
Rx:
1. Analgesics->Brufen
2. Antibiotics; Amoxicillin, Metronidazole
Dental consultation
Gum Abscess
Rx:
1. Antibiotics; Amoxicillin, Metronidazole
2. Analgesics ; Vit C
3. Warm saline gargle, Apply Pressure
4. Refer to dentist for I & D
Gingivitis
Rx:
1. Clohex Plus oral rinse(chlorhexidine)
2. Vit C
3. Antibiotics
4. Analgesics
 44

Cheilosis/angular stomatitis
Etiology: Iron/Vit B 12 deficiency, infection
1. C. Becosules Z/ Berocin CZ [vit B-complex, C & Zinc] 1-0-1x 5dys, then 0-0-1.
Other drugs with Vit B12: Matilda forte, ME-12, trinerve
2. Antibiotics like septran / Erythromycin may be given
3. Inj Trineurosol H/ neurobion forte(Vit B1 100mg,B6 50mg,B12 1000mcg ) im od

Halitosis
Aetiology->Gingivitis, poor oral Hygiene,smoking,dry mouth, Caries Tooth , hepatic
failure, uremia,DKA, bronchiectasis, lung abscess, atrophic rhinitis,alcohol,etc.
Rx:
1. Metrogyl DG gel[chlorhexidine gluconate, metronidazole] or
Hexidine mouth wash or Betadine Mouth Gargle
T Metrogyl may be given for severe cases.
2. Maintain proper oral hygiene
3. Tongue cleaning twice daily
4. Chewing gum help in production of saliva, prev enting dry-mouth.
5. Holding 2 curry leaves in the mouth for 5-7 min utes decreases bad breath

Aphthous Ulcers
Aetiology-> Vit/Fe/folate Deficiency, Antibiotic Induced etc.
Rx:
1. Vit B 12 +Vit C+ Antioxidants; adequate hydration
2. Dologel for pain or Dologesic gel(has Lignocaine), Dentogel(lignocaine+
choline salicylate), Lexanox QID (Amlexanox,anti-inflammatory) or
3. Chlorhexidine mouth wash/ betadine mouth wash, or
4. Kenacort /oraways/Tess oral paste for LA(triamcinolone) or
5. Antibiotics like tetracyclin 250 mg dissolved in 50 ml of water administered as
a mouth rinse for 3 min(to coat ulcers) & then to be swallowed, Qid or
6. Syp Sucralfate (sparacid) 5-10 mL PO swish and spit/swallow Qid.
Biopsy of the ulcer may be needed, if it does n’t heal.
In cases of herpetic gingivos tomatitis: Rx-> given as above + T. Acyclovir daily [Acivir,
Zovirax, Herperex]

Oral Candidiasis(Oral Thrush)

Aetiology: stress, drugs, immunocompromise, dry mouth, Cancer, smokers, oral
dentures,etc
1.Candid mouth paint[clotrimazole]
2.Chlorhexidine oral rinse
3.Vit C
Dry Mouth(xerostomia)
R/o drugs- antihistamines,atropine group, clonidine,methyl dopa, tricyclic
antidepressants, anti-parkinsonian drugs, bronchodilators, DM with polyuria, ill fitting
dentures, fungal infection of mouth, dehydration, radiotherapy, HIV infection
Rx:1.Diabetes control, treatment of candidiasis, sugar free chewing gum, adequate
hydration, avoid alcohol containing oral rinses,avoid salty/dry foods/alcohol/caffeine etc
2.E-saliva oral spray 3 to 4 times(Na carboxymethylcellulose,sorbitol, kcl,Nacl,Mgcl 2,
CaCl2,K dihydrogen PO 4)
 45
Opthalmology

Whatever be the opthalmic solution, not more than a drop needs to be instilled
into the conjunctival sac at a time because the conjunctival sac holds only 10-15
microliters of fluid at a time & the average volume of one drop is 60 microliter.
Only the frequency of instillation needs to be adjusted depending on the clinical
condition.
If an eye drop & an eye ointment has to be instilled at the same time, instill the
drop first followed by ointment.

Conjunctivitis
C/f: Bacterial:conjunctival congestion with matting of lashes, mucopurulent discharge,

gritty sensation, normal pupil, viral: conjunctival congestion, watery discharge, gritty
sensation.
1.Moxiflox /Gatilox / Ciplox(not preferred ) eye drops 1 0 Q1H-Q4H as per severity.
2.Frequent Washing. Dark glasses, if photophobia. Never pad & bandage.
3.Tocin(tobramycin) eye oint at night to prevent glueing of the eyelashes in the morning
4.If severe -> Antihistamines, Anagesics, Antibiotics[Oral] e.g Ciplox
Note: no role for prophylactic topical antibiotics in unaffected eye.
In children give tobramycin e/d
Eye pain causes : ocular pain - conjunctivitis, corneal abrasions/ulcerations, burns,
blepharitis, chalazion,stye;
orbital pain -glaucoma,iritis,optic neuritis, sinusitis, migraine, trauma
A/c red eye: conjunctivitis, glaucoma, injury, iritis,keratitis, scleritis, blepharitis,SCH etc
Scleritis
Systemic therapy is always required.
1.Oral NSAIDs like indomethacin (100 mg od).
2.Steroid + Antibiotics e/d e.g:

Betnesol-N[betamethasone
 Toba-DM [dexamethasone, sodium phosphate,
tobramycin] e/d or neomycin sulphate] e/d or
 Microflox-DX [ciprofloxacin hydrochloride, dexamethasone] e/d
Superficial punctuate Keratitis
Mainly due to viral infections, So give Acyclovir.
C/f: pain, photophobia, lacrimation,
1. Acivir or Zovirax or Herperex eye drops 1 drop Q4H
2. Topical steroids
3. Tobramycin [eyebrex,toba,tocin] or moxiflox (milflox)e/d to prevent 2 0 infection.
4. Artificial tears like Refresh eye drops.
Corneal Ulcer
C/f: redness, pain, watering, photophobi a, redness, foreign body sensation etc
R/o DM
1. Pad & bandage;hot fomentation; dark goggles
2. Moxiflox /Ciplox/ Tobra eye drops; i f the corneal ulcer is not res ponding to above
treatment in two days time or the ulcer is more than one mm size at the time of
presentation fortified antibiotic eye drops(cefazo lin & gentamycin) should be
given.
Fortified Cefazoline(Reflin) e/d 1 0 Q1H-Q2H;it is prepared by adding 5-10 cc distilled
water into a vial of injection cefazoline 500 mg to get a strength of 50-100 mg/ml. The
solution should be kept in refrigerator & every 3 rd day fresh e/d should be prepared as
cefazoline is not stable in aqueous solution.
 46
Fortified gentamicin (13.6 mg/ml) e/d Q1H-Q2H;prep ared by reconstituti ng
gentamicin (0.3%) e/ d with gentamicin (40 mg/ml) injection . inject 2 mL of gentamycin,
40 mg/mL, directly into a 5-mL bottle of gentamycin 0.3%, ophthalmi c solution
3. Vit C; Analgesics & antiinflammatory drugs.
4. 1% atropine or 2 % homatrop ine e/d tds to relieve ciliary spasm.
Refer to Ophthalmology.
Never prescribe steroid eye drops if corneal ulcer is suspected, as it will lead to
rapid corneal perforation

Fungal Corneal Ulcer

C/f: pain, watering , photophobia, blurred vision, redness of eye, FB sensation
1.Natamycin (5%) e/d (Natamet) hourly during day time & Q2H during night or

Ketoconazole
2.Atropine eye drops(Phytoral) or Voriconazole e/d x 6-8 weeks
e/d tds.
3.T.Flucan / Syscan 150mg OD [Fluconazole] x 2-3 weeks
4.Analgesics, Vitamins, hot fomentation, dark goggles(for photophobia) etc
Simple Allergic conjunctivitis
1. Antihistamines, NSAIDs, cold compress
2. Winolap/Optihist pat(olopatadine) 0.1 % e/d , 1 or 2 dps bid at an interval of 6-8 hrs.
3.Dexamethasone e/d 0.05% qid.(solodex-J, Low-Dex)
Note: Steroid e/d should be used only in severe & non-responsive cases & for short
duration.
Hordeolum Internum, Externum, Chalazion
Disorder of the eyelid. It is an acute focal infection (usuall y staphylococcal) involving
either the glands of Zeis (external hordeolum, or styes) or, less frequently, the
meibomian glands (internal hordeola).Most hordeola eventually point & drain by
themselves.
Rx

1.Antibiotic
2.P’mol eye Oint/drops[moxiflox/tobra] to be applied to affected lid margin
/ brufen
3.Hot sponging
4.Oral antibiotics if severe; Amoxyclav/Ciplox

Blepharitis
Inflammatory d/s of eyelid usually chronic & involves the part where the eyelashes grow.
Rx
1.Steroid + antibiotic eye oint application at lid margin
Eg.ciplox+ dexamethasone (ciplox-D),tobramycin+ dexa (tobaren-D) bd x 2 weeks
2.Antibiotic e/d
3.Oral antibiotics
4.Treat scalp dandruff

Corneal abrasion
C/f: pain, watering of eyes, photophobi a
Rx
1.Wash with NS if FB’s are present
2.Instill Homatropine eye drops( T.N Homide) followed by antibiotic eye ointment
3.Pad & Bandage
4.Advice to instill antibiotic eye drops eg.Moxiflox Q4H at home
5.R/w next day.
 62
Intertrigo
Inflammation of the body folds. Bacterial/fungal/viral
Commonly Candidial infection, usually involves the lateral two interdigital spaces, inner
thighs,genitalia, under the breasts, underside of the belly, behind the ears. Sometimes
there may be superimposed bacterial infecti on
1.T. Flucos 150mg once weekly x 1 month
2.Aciderm G for L/A x 10 days[betamethasone, gentamycin, clotrimazole]
3.C Carofit 1-0-0 x 1 month[vit C, vit E, zinc sulphate, beta carotene, carrot]

Pyodema
(impetigo, folliculitis,furuncle, carbuncle,tropical ulcer etc)
1.Antibiotics ->Ampiclox/ciplox/amoxclav/doxycycline/ cephalosporins

2.Analgesics,
3.T-bact antihistamines
/Futop/Neosporin Oint for LA bd
4.Saline washing – One tsp salt in 2 glasses of water
5.Good hygiene.
Impetigo:Highly contagious bacterial skin infection,primarily caused by Staphylococcus

Dandruff
1.Warm oil Massage; after 10 min, apply Nizral 2 % shampoo on to scalp for a period of
ten minutes; then wash away all the oil. Rpt twice or thrice weekly x 2 months
Other options include Danclear shampoo, KTC medicated shampoo,Scalpe/Dandrop
shampoo [Ketoconazole + Zn pyrithione]
2.Ionax-T[Coal tar + Salicylic acid] :-> relieves itching & flaking in dandruff,
seborrheic dermatitis & psoriasis of the scalp.
Acne Vulgaris
 Wash the face with soap & hot water 2-3 times a day.
 Avoid excessive exposure to sun.

Persol-AC Gel or Benzac
[benzoyl peroxide](start as -once
AC 2.5%
daily,-during
5%, apply; wait (for
day time) for 2black
min & then wash
heads) or off
 Clindac A gel [clind amycin] for inflammatory & pustular lesi on
Clinmiskin cream -> Clindamy cin, Niacinamide. or
 Retino-A/eudyna cream, to be appli ed 2-3 times a week HS(for bla ck heads)
 C Doxycycline 100 1-0-1 x 10 days or T Azithromycin 500 mg od x 5 days
 Other drugs used: Azelaic acid 2% or Adapelene 0.1 % gel( adaferin, deriva)
Deriva-CMS gel(adapelene + clindamycin)
T isotretinoin 10 or 20 mg(isotret)(0.5mg/kg/day) at night (teratogenic)
 With all anti-acn e creams look for irritation, dryness, redness, itchin g, burning every
10-15 days.
Alopecia
Aetiology: Poor nutrition,tinea capitis, hyper/hypothyroidism,prregnancy, SLE,Diabetes,
Drugs(eg. Steroids), excessive dandruff
Check for iron deficiency. Do FBC, LFT, RFT,TFT, S.Fe, Ferritin
1.Multivitamins (with biotin)e.g.T Xtraglo OD x 1 month(biotin,L-methionine, L-cysteine)
or Keraglo-Men
2.ProAnagen or Keraglo eva(gamma lenolenic acid, multivitamin, natural extracts).
Shampoo
For Alopecia areata: Diprov ate scalp lotion(beta methasone) or Flucort lotion
(fluocinolone). Apply OD
For androgenetic alopecia: Minoxidil topical solution BD. 2% for women, 5 % for men
(T N: hair 4 U, morr, morr-F)
 63
Corns & callosities
Usually they go by themselves, once the irritating factor is avoided. Use proper fitting
footwear or MCR footwears.
1.Keratolytic agents like Salicyli c acid 40% pads and plaster or solution. Apply & leave
for 4-5 days. Also used- 40% urea cream, and 12% lactic acid cream.
Note:patients with peripheral neuropathies should avoid or use topical salicylic acid with
caution.
TN:- cleanoderm/duofilm(salicylic acid+ lactic acid) lotion/solution daily x 3 weeks
2.Carnation Decorn corn caps(s alicylic acid), To be kept in position with the corn for
few days. To be reapplied again till the corn drops out.

Contact Dermatitis

Definitivecausal
potential treatment of allergic
agents; contact
otherwise , thedermatitis is the
patient is at identification
increased risk forand removal
chronic or of any
recurrent dermatitis
1.Wet compresses/ saline soaks
2.Emollients Emoderm/novasoft or calamine may be beneficial in chronic cases.
3.Oral antihistamines like T CPM 4mg 1-0-1
4.Topical corticosteroids like clobetasol are the mainstay of treatment.
Note:When choosing a topical glucocorticosteroid, match the potency to the location of
the dermatitis and the vehicle to the morphology (ointment for dry scaling lesions; lotion
or cream for weeping areas of dermatitis).
5.For severe acute allergic contact dermatiti s or widespread and severe chronic
dermatitis, systemic glucocorticosteroids may be required( administered for 2 weeks).

Excessive Sweating/hyperhydrosis
Seen in Hypoglycemia, MI, Defervescence in fevers, Hyperthyroidism, Vasovagal
attacks, Rheumatic fever, gout, nervous excitement,alcohol/drug withdrawal, anxiety etc.

1.Palmoplantar/
2.Losweat powderaxillary sweating: Aldrychlorhexidine
for LA(miconazole, lotion for LA )HS(aluminium chlorohydrate) or

Stasis Dermatitis
Due to venous stasis on the lower portions of legs.
1.Wet compresses/saline soaks for 5 minutes(10 teaspoon salt in 20 glass of water)
2.Emollients like Emoderm/Novasoft(white soft paraffin, liquid paraffin)
3.T Caldob 500 mg OD (ca 2+ Dobesilate)
4.Topical corticosteroids like triamcinolone 0.1 %(T.N: Ledercort oint)
5.Daily use of elastic stockings.Raise leg end of bed at night by 15 cm( 2 brick).
Pediculosis
C/f: LNE-> Sub occipital & post auricular
C/o may be itching & constant ulceration.
1. Antibiotics like Ampiclox
2. Medicare, Zeromite[Permethrin 1%]
Massage into scalp, Bath after 10 min & then comb. Rpt after 7-10 days to kill nits
3. T ivermectin 12 mg single dose to be taken on empty stomach(0.2 mg/kg)
4. Anti inflamatory-> brufen
5. Rantac / Omeprazole
6. T.Celin 500mg OD / BD
In case of lice ulcer in Axill a, Permethrin Cream for L/A. Petrol atum ointment, is the
preferred treatment for infestations of the eyelashes and eyebrows.
 64
Ringworm infection of skin(Tinea/Dermatophytosis)
Most of the cases are managed with topical preparations. Topical thera py is indicated
for limited infection of the body, groin, superficial involvement of the beard region, palms,
& soles
Nizral(ketoconazole 2%) or exifine(terbinafine 1%) or fungitop(miconazole 2%) or
candid(clotrimazole 1%) or whitfield ointment(benzoic acid 6%, salicylic acid 3%).
Duration of the therapy is 4 to 6 weeks or 2 weeks more after clearance of lesions.

Tinea Versicolor(Pityriasis versicolor)

 Azoles,Terbinafine ,Ciclopirox olamine,selenium sulfide are used.
 Each application is allowed to remain on the skin for at least 10 minutes pri or to
being washed off. In resistant cases, overnight applic ation can be helpful.

 Ketoconazole crm/soln/Miconazole/Clotrimazole
In cases of extensive everysolution[
Tinea versicol or, Ketoconazole night forNizral
2 weeks.
] to be applied
15 min before taking bath, twice weekly. After bath any of the above preparations
may be applied locally.
 Another option is preparation contain ing Selenium sulphide 2.5% [Selsu n shampoo]
for 5 to 10 minutes appli cation daily for 3-4 weeks. But tak e care to avoid conta ct
with gold as it is corrosive.
 Systemic therapy: T Fluconaz ole 400 mg st. Rpt after 2 weeks if required.

Seborrhoeic dermatitis
1.Nizral shampoo for scal p & body wash twice weekly.
2.Keto-B cream for LA (ketoconazole+ betamethasone) x 5 days
After 5 days Ketoconazole oint 2%(nizral) for LA BD x 2 weeks

Scabies
 Permethrin 5% lotion is the DOC.I t is applied from the neck down, usuall y before

bedtime, and
application left on forsufficient
is normally about 8 tofor14 hours,
mild t hen washed
infections. off in the
For moderate to mor ning.
severe One
cases,
another dose is typically applied 7 to 14 days later Or
 Initially scrub bath is advised to open up the burrow s. Then apply Gamm a Benzene
Hexachloride(lindane) 1% Lotion [Scaboma] for a period of atleast 10-12 hours and
Rpt scrub bath.All clothes,towels & bed sheets etc should be washed well(ideally in
hot water) & dried in sun or if possible ironed well.It may be repeated after 1 week
 Ideally, treat all family members at a time
 Apply over entire body, below the neck t o toes
 Scabies may also get infec ted, so in such cases, give antibi otics eg. Ampiclox
 Antihistamines
 Another option is T.Ivermectin. If > 50kg give two 6mg tabs at early morning on
empty stomach. If <50 kg give 3mg tabs . Rpt after 2 weeks
 Crotorax/Eurax(crotamiton) 2-3 times a day , can also be given

Itching due to prickly heat in summer(miliaria rubra)

1.Bath 2 times per day, avoi d tight clothing

2.Sprinkle Nycil powder or Candid dust ing powder bd
3.T Cetrizine 10mg HS x 5 days
4.T vit C 500 mg BD
5.Emoderm/Calamine lotion/oint
 65
Eczema
The term eczema is almost synonymous with dermatiti s. They refer to distinctive
reaction patterns of the skin, which may be due to a variety of a/c or c/c causes.The
basic pathological features are Spongiosis(edema of epidermis with the formation of
intraepidermal vesicles) & Acanthosis(thickening of epidermis in the c/c stage)
May be of two types:
1.Dry Eczema-> without oozing
2.Wet Eczema-> with oozing,it may be infected, in such cases R/o DM.
Several types ->Atopic, Seborrhoeic, Irritant, Allergic etc.
The aim of treatment is to control the inflammatory process & also to control the
infection, if present.
1. Antithistamines

2.
3. Saline soaks/
Steroids, wetapplications
Topical compressesof Betametha sone or Beclomet hasone
4. Antibiotics like Ampiclox if needed.
5. In cases of fungal infect ions, as evidenced by severe pruritus, giv e antifungals.
6. T. Calcium Dobesilate 500 mg BD as adjuvant th erapy in pt’s with venous ulcers
& stasis dermatitis; C Nutrolin B

Psoriasis
Scaly lesions over extensor aspect[mainly]
1. Dipsalic/betnovate-S/betasalic/Saltopic lotion/ointment [betamethasone, salicylic acid]
or Diprovate MF cream [betamethas one, lactic acid, salicycli c acid, urea, sodium
lactate] bd for L/A .
2. Antihistamines to prevent scratching.
3. T Calcium OD/BD, liquid paraffin for LA;
4. Oral antibiotics like Doxycycline bd for a/c psoriasis
5. Cetrilak mild shampoo for scalp (cetrimide)

Note: Dry scaly

moisturizing conditions
cream like Psoriasis,
e.g Elovera cream to Atopic dermatitis,
be applied Ichthyosis
after bathing requires
[vi t E, aloe vera]
Strecth marks, striae, cracked nipples , dark circles :
1.Alovit-AF cream for L/A. [lactic acid, vitamin E, sunflower oil, aloe]
Antioxidants:
It is a usual practice to give antioxidants- C Evion 400mg /T Carofit / T antoxid OD
x 1month
Fissuring of soles(athlet’s foot /tenia Pedi s)
Keep the foot dry. Foment in hot water for 10 mins, 2 times daily, foll owed by drying
and application of antibiotic & keratolytic ointments.
1.Moisturex cream (urea, lactic acid,propy lene glycol, liquid paraffin) for LA Or
Salytar-ws/Salicylix-SF(salicylic acid) to be applied on the hard skin only or vaseline.
2.If secondary infection : Surfaz –SN or candid-B for LA
Note: if inflamed or swollen, give antibiotics, anti inflammatory drugs, steroids

Premature Graying of Hair

Aetiology: vit B12 deficiency, thyroid d/s, FA deficiency, chemotherapy,using electric
dryers/ concentra ted hair dyes, etc
1.T Curlzvit 1-0-0(contains PABA)
2.Altris Gel for LA(Melitane)
 66
Herpes zoster
1.T Acyclovir 800 1-1-1-1-1 x 7-10 days( efffective only if started within 48 hours)
Other antivirals used are Famciclovir 500 mg tds or Valacyclovir 1gm tds
2.Analgesics like Ibuprofen or P’mol
3.For sever cases: Oral steroids like prednisolone 40-60 mg/day x 1 week tapered
over 1-2 weeks.
4.Calamine for LA;T-bact for LA;Acyclovir cream for LA
5.Oral Antibiotics if secondary infection.
6.Rest
7.For postherpetic neuralgia: T gabapentin 300 mg OD x 3 weeks

Icthyosis
Avoid using strong soaps/excess sun exposure
After a bath , apply emollients or moisturizers to prevent scaling & dryness.
Moisturex cream for LA
Other topical preparati ons: Retino-A cream(tr etinoin) for LA OD or Daivonex oint for
LA(calcipotriol) or Keralin oint for LA(salicylic acid, benzoic acid,hydrocortisone) or
Copriderm(Betamethasone, urea, lactic acid, propylene glycol, salicylic acid) for LA

Hyper pigmentation of skin

Also blemishes, dry scaly surface, mottling, wrinkles, rough & leathery texture,
sagging of loose skin, melasma
Avoid perfumes, hair dyes etc. Treat anemia if present.
1. Reduce sun exposure;Apply Sun screen agents eg: sper lotion for LA 30 min before
going outside(octinoxate , avobenzone , oxybenzone , zinc oxide).
2. Skinlite cream(Hydroquinone, Tretinoin, Mometasone Furoate) HS
Note: Apply at night only. Should be applied in limited quantity only
Or Retino-A, Eudyna(tretinoin)
Or Brite-Lite cream for LA at night(glycolic acid, kojic dipalmitate)
For lips: also give a moisturizer, emoderm Oint for LA( white soft paraffin);quit smoking.
For Keloids & hypertrophic Scars: opexa Gel (Dimethicone, ascorbyl tetraisopalmitate)
or contractubex gel(h eparin,allantoin) or Retino-A(Tretinoin) LA OD at night.

Warts
Caused by HPV
1.Salicylix-SF 12% cream(sal icylic acid) for LA or
2.Imiquad/Nilwart cream(imiquimod) for LA on alternate days ; wash after 8 hours.

Dry skin/Xeroderma
Etiology:Zn & essential fatty acid deficiency,end-stage renal disease, hypothyroidism,
HIV, malignancies,sjogren’s syndrome, neurologic disorders, drugs, topical preparations
containing alcohol, detergents, harsh bathing soaps, vitamin A/D deficiency, winter etc
1.Emolients/moisturizers e.g Emoderm/Elovera/Novasoft for LA
2.Adequate hydration

Herpes simplex
1.For initial infection:Acyclovir cream(Zovirax) for LA
2.T Acyclovir 200 mg 1-1-1-1-1 or 400 1-1-1 x 7- 10 days (5-20 mg/kg Q8H )
Dermatology consultation.
 96
Common injections Amp/vial volume - Total strength

Adrenaline 1ml-1mg
Atropine 1ml/2ml- 0.6mg/1.2 mg
Aminophylline 10ml-25mg/ml
Avil(pheniramine maleate) 2ml-22.75mg/ml
Atarax(hydroxyzine) 2ml-25 mg/ml
Betnesol 1ml-4mg
Buscopan(hyoscine) 1ml-20mg
Chlorpheniramine maleate 1ml-10 mg
Cyclopam(dicyclomine) 2ml- 20mg
Ca gluconate
Deriphylline 10ml-100mg/ml
2ml-220mg(each ml, etofyl 84.7 mg+Theo 25.3mg)
Diazepam 2ml-10mg
Dexona 2ml-8mg
Dopamine 5ml-200mg
Dobutamine 5ml-250mg
Ethamsylate 2ml- 125mg/ml
Eptoin(phenytoin) 2ml-100mg
Emeset(ondansetron) 2ml/4ml- 4mg/8mg
Fortwin(pentazocine) 1ml-30 mg
Gentamycin 2ml-80mg
Ketorolac 1ml-15mg
Kcl(15% w/v) 10ml-150mg/ml or 2meq/ml
Lasix(furosemide) 1ml/2ml-10 mg/20 mg
Midazolam 5ml-5mg
Nitroglycerine 5ml-25mg
Na bicarbonate 10ml-7.5% w/v each ml
Noradrenaline 2ml- each ml contains norad 0.2 % w/v
P’mol 2ml-150mg,2ml-150mg/ml, 3ml-150mg/ml
Perinorm 2ml-10mg
Phenergan 2ml-50mg
Rantac(ranitidine) 2ml-50mg
Serenace(haloperidol) 1ml-5mg
Stemetil(prochlorperazine) 1ml-12.5mg
Terbutaline 1ml-0.5mg
Tramadol 1ml-50mg
Tranexa 5ml-500mg
VitaminK 1ml-10mg
Voveran(diclofenac) 3ml-75 mg
Respules
Asthalin 2.5 ml-2.5 mg, respirator solution 15 ml- 5mg/ml
Ipravent 2ml-500mcg, respirator solution 15 ml-250mcg/ml
Levolin 2.5ml-0.31 mg/0.63 mg/1.25 mg
Duolin 2.5 ml-ipra 500mcg+ levosalbu 1.25 mg
Budecort 2ml-0.25mg/0.5 mg/1mg
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Ampicillin

Aminopenicillin; Mainly effective against Grain +ve & also some gram –ve
1. Drops 100mg/ml
0-1.5 months > 0.5ml qid (8 drops)
1.5-5 months > 1ml qid (16drops)
2. Syrup:125mg/5ml or 250mg/5ml
3. Cap:250mg or 500mg
Indications: UTI, RTI, meningitis, cholecystitis,
May be combined with gentamycin or third gen cephalosporin s
Always give test dose.
Complication > May produce rashes, especially in cases of IMN. It may be combined
with sulbactum
Dosage (given
is 50-100 parenterally
mg/kg/day only) doses, oral.
in 4 divided
Usual pediatric inj dose: 50 mg/kg Q6H if > 7 days of age, Q8H if <7 days of age.
T.N: Roscillin, Campicillin, Presmox

Amoxicillin
Preferred over ampicillin for bronchitis,UTI,
Dose: 0.25- 1 g tds oral/im, children: 30-50 mg/kg/24 hr div into 2 or 3 PO
T.N: Mox, Novamox

Cloxacillin
More active than methicillin against pencillinase producing staph.
Dose: 500 mg Q6H oral/iv, children: 100 mg/kg/day
C 250 mg, 500 mg, syp 125/5 available
T.N: klox

Coamoxiclav
Addition of clavulanic acid (β- lactamase inhibitor) re-establishes the activity of
amoxicillin against β-lactamase producing resisitant staph aureus
Indications: skin/soft tissue infections, intra abdominal & gynaecological sepsis, urinary,
biliary, respiratory infections
Dose: 1.2 g iv bd/tds
T.N: Mega-CV, Augmentin. T 375, 625, 1g available.

Cephalexin
1st generation cephalosporin.
Indications
 Severe LRI
 Infections during pregnancy
 Bone & joint infections, skin & soft tiss ue infections
 Pharyngitis, tonsillitis, UTI
 CSOM, ASOM
 Usually combined with Metrogyl in cases of mild diar rhea + URI or LRI
Dose> 50-100mg/kg/day in 4 divided doses > similar to Ampicillin
T.N: Phexin, Sporidex, Blucef, Citacef, Lexin
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Cefadroxil
1st generation cephalosporin
Indications
 Pharyngitis
 Skin & soft tissue infections
 UTI
May produce gastritis, nausea, epigastric distress
Available as Tab 125, 250, 500 & Syp 125/5ml, 250/5ml & drops 100mg/ml
Dose 30mg/kg/day in 2 divided doses orally
T.N: cefadur, droxyl,cefastar
Cefazolin
1st generation cephalosporin
Available
Indicationsas 125mg, 250mg, 500mg, and 1g vials
 Surgical prophylaxis
 Bone and joint infections
 Skin and soft tissue infections
 Speticemia
 Pneumonia, UTI
Doses > 50-100mg/kg/day in 4 divided doses im or iv(similar to Ampicillin)
For im use either distilled water or normal saline may be used as the diluent. For iv use
10ml distilled water is to be used. It may be administered over a period of 3-5 min
For newborn, 20mg/kg/dose 12 th hourly if <7 days and 8 th hourly if > 7 days
T.N: Maxicef-O,Reflin
Cefaclor
2nd generation cephalosporin
Available as 250mg cap, dry syp or readymade suspension 125 or 187 mg/5ml and
drops 50mg/5ml.
Dose 40mg/kg/day in 2 or 3 divided doses
Indications
 PUO in children
 LRI
 Intra abdominal infections like Cholecystitis Appendicitis, Pancreatitis
T.N: Distaclor, Keflor.
Cefuroxime Axetil
2nd generation. Preventing bacterial infections before, during, or after certain surgeries.
Other indications: Respiratory infections, uncomplicated skin & soft tissue,UTI
Dose: 250-500 mg BD, children:30 mg/kg /day div into 2-3, IM/IV:100 -150 mg/kg/24 hr
div into 3. Adult iv dose: 1.5 g Q8H
T.N: Ceftum,Spizef, altacef
Cefixime
Oral 3 rd generation cephalosporin
Available as susp 50 or 100mg/5ml and T or Cap 100mg or 200mg
Strong antibiotic useful especially in diabetic patients and in other serious infections,
Useful for continuation therapy after initial parenteral therapy.Highly active against
enterobacteriaceae, H influenzae. Not active against Staphylococci and Pseudomonas.
Other indications: RTI, uncomplicated UTI, STD, typhoid fever
Doses -> 8mg/kg/day, od or bd.
T.N: Taxim-o,Milixim,Fixx, Extracef, Cefspan, topcef, Ceftiwin,Omnix
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Cefotaxime
3rd generation. Indications > Meningitis, Specticemia, serious bone and soft tissue
infections
Dose > 100-200mg/kg/day in 4 divided doses im or iv. In newborn, 50mg/kg/dose 12 th
hourly, if < 7 days old & 8 th hourly if > 7 days old. Available as 250mg, 500mg & 1g
vials.Usual Adult dose: 1g iv tds
May be reconstituted with D5, D10 or NS.
T.N: Taxim, Omnatax,
Ceftazidime
Parenteral 3rd generation cephalosporin
Highly Active against Pseudomo nas aeruginosa. Also, Gram –ve coverage, synergistic
action with Aminoglycosides
Available as Inj 250mg, 500mg,
Dose > 100-150mg/kg/day & 1g. doses im or iv. Max of 6g/d ay
in 3 divided
T.N: Fortum , Psedocef.
Ceftriaxone
3rd generation cephalosporin. Effective against Gram+, gram- & some anaerobes
Indications
Enteric fever (DOC is Ciprofloxacin 500mg bd x 2 wks)


Bacterial Meningitis


Abdominal sepsis, Septicemias



Compicated UTI


Dose > 50-100mg/kg/day in 2 doses im or iv. May be reconstituted with D5, D10 & NS
Do not mix other antimicrobials.Available as Inj 250mg & 1g.usual adult dose 1g iv bd
T.N: Monocef, Monotax, Ciplacef.

Cefdinir
Oral 3 rd generation cephalosporin
Wide spectrum with gram + & gram – coverage, Good activity against Beta-lactamase
producing strains. Effective in RTI – both upper and lower and skin & soft tissue
infections.
Dose > Adults 300mg bd x 10 days or 600mg od x 10 days; children 14mg/kg in 2
divided doses or even as a single dose.
T.N: Aldinir, Cefdins, available as syp 125/5ml and 300mg cap; Expensive

Cefpodoxime Proxetil
3rd generation. Useful mainly in respiratory tract infection , skin & soft tissue infectio ns
and also in cases of uncomplicated UTI. Highly active against enterobacteriaceae &
streptococci. Not against pseudomonas
Available as a T 100mg, 200mg or as dry syrup 50 or 100mg/5ml.
Dose> 10mg/kg/day in 2 divided doses, to be taken with food.
T.N: monocef-o, cepodem, podocef
Cefoperazone + sulbactum
rd
3 generation
Useful cephalosporin
for empirical + β- spectrum,
therapy.Wide lactamase including
inhibitor. pseudomonas.Achieves high
biliary concentratio n & hence useful in case of cholecystitis
Indications: Severe urinary, biliary, respiratory, skin-soft tissue infections, meningitis,
septicaemia
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Dose: 1 or 2 g iv in adults in two divided doses.Usual adult dose: 1.5 g iv bd.
In children, 50-200mg/ kg in 2 divided doses.
T.N: cefactum,cefpar SB(very costly)

Doxycycline
Tetracycline
Indications
 Leptospirosis treatment & prophylaxis
 Scrub typhus, malaria prophylaxis, brucellosis, cholera
 Prophylaxis for COPD exacerbation
 Acne, UTI, RTI like a/c bacterial rhinosinusitis,
 Chlamydia, gonorrhoea, prevention of STD’s following sexual assault

 Inflammation
Dose: of thebd,
100 mg/ 200mg gums
children: 5mg/kg/day div into 2 PO or OD
T.N: Doxy-1
Gentamicin
Aminoglycoside. Wide spectrum, mostly gram negative including pseudomonas
Remember oto and nephrotoxicity
Dose>5-7.5 mg/kg/24 hr div into 2 or 3 doses im or iv. In ca se of neonates give 2.5
mg/kg Q12H.Usual adult dose: 80 mg iv od/bd
Available as vials of 100mg, 250 mg and 500 mg/ml.
T.N: garamycin

Amikacin
Widest spectrum of activity than other aminoglycosides
Usual adult dose : 500 mg iv od/bd
Dose:15mg/kg/day
T.N: mikacin

Vancomycin
Glycopeptide; Useful mainly against staphylococcus , MRSA
Indicated in septicemia, bone & joint infections. LRTI and skin & soft tissue infection s.
Dose->500mg 6th hourly or 1g iv 12 th hourly in adults. In children 40-60 mg/kg/day in 4
divided doses. Administrated slow iv only. Monitor auditor y & renal functions
T.N: Vanlid, vanmax
Teicoplanin
Semisynthetic Glycopeptide; Has lesser nephrotoxicity when compared with
vancomycin
Mainly active against staphylococci
Dose->10mg/kg once daily im or iv; Available as 200 mg & 400 mg vials.
T.N: targocid
Aztreonam
Monobactam; Novel Betalactam antibiotic, active against pseudo monas and
enterobacter. Poor acti vity against gram +ve cocci and anaerobes
Indications: hospital acquired infections srcinating from urinary, biliary, GI & female
genital tracts.
Dose->100mg/kg/day in 3 or 4 divided doses im or iv. Smaller dose for neonates
May be reconstituted with D5, D10 or NS for iv infusions
T.N: Azenam, Trezam 250 mg /500mg /1g Inj
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Modes of ventilation: Controlled mechanical ventilation (CMV), assist control mechanical
ventilation(ACMV), intermittent mandatory ventilation(IMV), pressure support ventilation(PSV),
Volume support ventilation(VSV)

Initial ventilator set-up

Check for leaks
Check O2 is flowing
FiO2 : 0.6-1
VT :5-10 mL/kg
Rate: 10-15/min
I:E ratio : 1:2
Peak pressure ≤35 cm H 2O
PEEP : 3-5 cm H 2O

Setting up the ventilator

Tidal volume:values of 6-7 mL/kg ideal body weight. Smaller VT & minute volume may be
needed in severe airflow limitation(e.g. Asthma, a/c bronchitis) to allow prolonged expiration
Respiratory Rate: usually set in accordance with VT to provide minute ventilation of 85-
100mL/kg/min.
Inspiratory flow: usually set between 40-80 L/min. Higher flow rates are more comfortable for
alert patients. This allows for longer expiration in pt’s with severe airflow limitation, but may
result in higher peak airway pressures.
I:E ratio: A function of RR, V T, inspiratory flow, & inspiratory time. Prolonged expiration is useful
in severe airflow limitat ion while a prolonged inspiratory time is useful in ARDS to allow slow-
reacting alveoli time to fill. Alert pt’s are more comfortable with shorter inspiratory times & high
inspiratory flow rates.
FIO2: set according to arterial blood gases, usual to start at FIO 2 = 0.6 -1, then adjust as per
ABG & pulse oximetry.
Airway pressure: In pressure-controlled or - limited modes, a peak airway pressure can be
set(ideally ≤30 cm H2O). PEEP is often increased to maintain FRC when compliance is low.

Adjusting the ventilator

Adjustments are usually made in response to ABG, pulse oximetry, pt agitation or discomfort, or
during weaning. Migration of the ET, either distally to the carina or beyond, or proximally such that
the cuff is at vocal cord level, may result in agitation, excess coughing, & a deterioration in ABG.
Tube migration or obstruction should be considered & rectified before changing ventilator settings or
sedative dosing.
The choice of ventilator mode depends upon conscious level, the no of spontaneous breaths
being taken, & ABG. Many spontaneously breathing pt’s can cope adequately with pressure
support ventilation alone. However a few intermittent mandatory breaths(SIMV) may be needed
to assist gas exchange or slow an excessive spontaneous rate. The paralysed/heavily sedated
pt will require either volume- or pressure-controlled ventilation. Earlier use of increased PEEP is
advocated to recruit collapsed alveoli & thus improve oxygenation in sever respiratory failure.

Low PaO2 : increase FIO2/PEEP/I:E ratio. Consider increasing pressure support/pressure

control or V T. In CMV consider increasing sedation ± muscle relaxants.

High PaO 2: decrease FIO 2 or I:E ratio or PEEP or level of pressure control/pressure support if
VT adequate.

High PaCO2: increase V T (if low) or RR. Reduce rate if too high( to reduce intrinsic PEEP),
reduce dead space. In CMV, increase sedation ± muscle relaxants

Low PaCO2: decrease RR, V T

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ADVANCED CARDIAC LIFE SUPPORT ALGORITHMS

PULSELESS ARREST ALGORITHM

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BRADYCARDIA ALGORITHM
 107

TACHYCARDIA ALGORITHM
 108
Sample Referral letter
Date:
Time:
To whom it may concern

Sir/madam
I’am referring Mr./ Smt ..............., ......yrs, a k/c/o ................. .....................
now presented with c/o .................................................................................................
O/e, he/she has.............................................................................................................
The investigation done show.........................................................................................
My clinical impression is ...............................................................................................
I have given the following treatment..............................................................................

I’am referring him/her to you, for expert evaluation, care & Management. Kindly do the
needful.

Thanking you
Your’s sincerely
Signature

WHAT TO DO WHEN A PATIENT DIES

When a pt dies, write the following format, in the pt’s case sheet irrespective of the
cause of death.

00:00
Pt gasping 1.Inj Atropine 1 amp, inj adrenaline 1 amp iv st
Pulse not palpable , BP unre cordable 2.Inj Dopamine 400 mg in NS @ 14 dps/ min
CPR started

Pt intubated;Ambu
Note: bag ventilation
2010 ACLS guidelines given atropine administrati on for PEA/asystole
excludes

00:05
Pulse, BP unrecordable 1.Inj Atropine 1 amp, inj adrenaline 1 amp
CPR & Ambu bag ventilation continued 2.Inj Dopamine

00:10
Pulse, BP unrecordable 1.Inj Atropine 1 amp, inj adrenaline 1 amp
CPR & Ambu bag ventilation continued 2.Inj Dopamine

00:15
Pulse, BP unrecordable
ECG shows no cardiac activity
No spontaneous respiratory effort
Pupils Dilated & fixed

Irrespective of all resuscitative efforts, pt expired at _ _:_ _ am/pm on _ _/_ _/_ _(Date)
Pt declared clinically dead.

Signature
******