HO Muar Medical

7/28/2019 HO Muar Medical

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ContentsResp ....................................................................................................................................................... 3

Asthma .............................................................................................................................................. 7

COAD .................................................................................................................................................. 8

Suspected bronchiectasis .............................................................................................................. 8

Bronchopneumonia........................................................................................................................ 8

Pulmonary Embolism ..................................................................................................................... 9

Drugs.................................................................................................................................................. 9

Cardiology ............................................................................................................................................... 3

Stable Angina ................................................................................................................................... 3

AMI ..................................................................................................................................................... 4

APO..................................................................................................................................................... 4

Arrhythmia....................................................................................................................................... 4

New Onset AF ............................................................................................................................... 4

SVT ................................................................................................................................................. 4

Infective Endocarditis .................................................................................................................... 5

CCF...................................................................................................................................................... 5

Uncontrolled Hypertension .......................................................................................................... 5

Hypertension ................................................................................................................................... 5

CRHD- tooth extraction .................................................................................................................. 5

Drugs.................................................................................................................................................. 3

Renal.................................................................................................................................................... 10

Acute Renal Failure....................................................................................................................... 10

Chronic Renal Failure................................................................................................................... 11

Nephrotic Syndrome..................................................................................................................... 11

Electrolyte Disturbances ............................................................................................................. 11

Hypokalaemia ............................................................................................................................ 11

Hyperkalemia ............................................................................................................................ 11

Na.................................................................................................................................................. 12

Hypocalcemia............................................................................................................................. 12

Infectious Ds.......................................................................................................................................... 12

Suspected Dengue ............................................................................................................................ 12

TB ...................................................................................................................................................... 15


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Neuro .................................................................................................................................................... 15

Stroke ................................................................................................................................................ 15

Fits ..................................................................................................................................................... 15

Status Epilepticus .............................................................................................................................. 16

Acute psychosis ................................................................................................................................. 17

Endrocrine ............................................................................................................................................. 17

Hypoglycemia .................................................................................................................................... 17

Diabetes ............................................................................................................................................ 17

DKA ................................................................................................................................................ 18

HONK ............................................................................................................................................. 18

Thyroid .............................................................................................................................................. 19

Hyperthyroid ................................................................................................................................. 19

Thyroid Storm ............................................................................................................................... 19

Hypothyroid ...................................................................................................................................... 19

Myxoedematous Coma ................................................................................................................. 19

Hypothyroidism ................................................................................................................................. 19

Serious Metabolic Acidosis: pH


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Cardiology

MAP= 1/3 SBP + 2/3 DBP

If pt on aspirin develop epigastric pain, change to cardiprin. !UGIB

Entry criteria:UA or NSTEMII c as ischemic pain at rest within past 24H, with evidence of CAD (ST segment

deviation or +marker)UA NSTEMI STEMI

Normal CE Incr CE STE

Clexane X3/7, BD. OD if Creat

clearance


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AMI

Aspirin 300 mg stat & 150 mg OD

T. Plavix 300 mg stat & 75 mg ON

T. alprazolam 0.25 mg ON

GTN: S/L GTN 1/1PRN IV morphine 2.5 mg stat & PRN

IV Maxalon 10 mg stat

IV ranitidine 50 mg TDS

Face mask 5L O2

T. Lovastatin 20 mg ON

With cardiogenic shock:

o IV Dobutamine 500mg in 50cc NS run 3cc/H IV dopamine IV dobutamine

o NBM w IVD 2 pint NS

APO

1. CXR-cardiomegaly, kerly A&B

2. Serial ECG/CE X3

3. ABG

4. IV Lasix 40mg stat & OD/BD/TDS

5. Strict I/O: CBD,CVP (can use condom catheter)

6. Fluid restriction 1L/day

7. (if creps present) Neb Combivent stat, 1/2Hly X2, 2Hly X2, 4Hly

8. Prop up

9. O2 5-10L/min10.T.aspirin 150mg OD

11.T. Ticlid

12.KIV ACE inhibitor (if RP normal)

Arrhythmia

New Onset AF

Acute Mx

IV amiodarone 300mg in 50cc NS over 1H, followed by 500mg in 1 pint D5% run over

23H WITH cardiac miotoring

IV Digoxin 0.25 mg in 50cc ND over 1H

Digoxin PO 0.5mg BD, 0.125-0.25mg OD.

Keep K>4.0

SVT

? carotid massage

IV adenosine 6mg

IV adenosine 12 mg X2 (2 min interval)


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IV verapamil 5-10mg over 2 min (if not on B blocker)

OR IV atenolol 2.5mg (@ 1mg/min)

SVT, AF- 50-100J synchronize

VT w pulse: IV lignocaine 20% 50-100mg

VT pulseless (hemodynamically unstable): 360J CPR

Torsades de pointes: IV Ca Gluconate

Infective Endocarditis

Cardinal signs: fever, hematuria, splenomegaly, murmur

Mx

IV C-pen 4 Mu X4/52

IV Gentamicin 80mg TDS X2/52, 240mg OD

CCF

Causes: MADHATEN- MI, Anemia, Drug noncompliance, HPT, Antithyroid, Thyrotoxic,

Ethanol, Right Heart Failure.

1. IV Lasix 40mg stat then OD/BD

2. Prop up pt

3. Fluid restriction 800cc /day or 500cc/day

4. Strict I/O

5. O2 if needed

6. Chest physio

7. Neb Combivent if SOB

8. +ACE inhibitor, digoxin, spironolactone

Uncontrolled Hypertension

IV GTN (50mg in 50 cc NS @ 3cc per hour)

CRIB

VS 2 Hly

Strict IO

Antihypertensive: T.Captopril

KIV for aspirin/ticlid

Allow orally, low salt diet

BP Hly

Hypertension

Exclude urgency, emergency

If not compliant, use old medications

Rpt BP in 1H: If still high: IV GTN 10 mg in 50cc NS at 3cc/H

BP 2 Hly and titrate accordingly

CRHD- tooth extraction

1. Withold warfarin

2. IV Heparin 25000 u in 50 cc NS, run @ 2cc/H

3. IV Unasyn 1.5g (1H pre and 6H post etraction)

4. Withold IV Heparin 2H prior to extraction

5. Restart T warfarin/Heparin 6H post extraction if no bleeding


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6. TCA 2/12

7. Ref warfarin to 1.5mg post tooth extraction

8. T Lasix 20mg OD

Drugs

ACE inhibitor perindropril (Coversyl) T. 2/4/ 8mg OD CI: Renal artery

stenosis

AR:Gi disorder,

dizziness, headache

Enalapril 2.5/5/10 mg BD

Captopril 6.25mg TDS

12.5 mg BD/TDS

18.75mg TDS

25mg BD/TDS

50mg TDS

Ranipril 2.5mg BD

10 mg ODAlpha blocker Prazosin 1/10 mg BD

Max 6mg TDS

CHF due to

mechanical

obstruction

Doxazosin 1/16 mg OD

ARB Irbesartan 150/300 mg OD

Losartan

(Cozaar/Hzaar)

50mg OD

100 mg OD

Telmisartan (micardis) 20/40/80 mg OD

Valsartan (diovan) 30/50/80/160 mg OD

Beta blocker Metoprolol (betaloc) 50/100 mg BD

200mg OD

cardioselective

Propanolol 20/40/80320 mg/

BD

bisoprolol Not absolutely CI in

COPD

Atenolol 50/100 mg OD

Carvedilol (cardio-

selective)

3.125/6.25mg BD

Betaprolol 10/40 mg OD

Beta and alpha2 blocker Labetolol 100mg BD

800 mg TDS

Carvedilol 12.5 mg OD50mg OD

CCB Amlodipine 5/10 mg OD

Nifedipine 10/30mg TDS

Diltiazem 30/60 mg TDS

Filodipine T. 5mg BD

T. 10mg OD

Centrally acting Methyldopa 125/250 mg BD/TDS

Max 1g TDS

hepatotoxic

Diuretics HCTZ T. 25mg OD

Max 200mg OD

Lasix T. 20/40 mg OD/BD


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Spiranolactone T. 25mg OD

Lipid lowering Lovastatin T. 20/40 mg ON

Simvastatin T. 20/40 mg ON

Atorvastatin T. 20/40 mg ON

Pravastatin T. 20/40 mg ON

Gemfibrozil (brandname- Lopid)

T. 300mg Active liver disease

Inotropes

Dopamine 20 mcg/kg/min

Single strength: 200 mg in 50 cc NS

400mg in 50cc NS at 72cc/H

Indication: non hypovolemic

shock

CI: tachyarrhythmia, VF,

pheochromocytoma

Dobutamine 250 mg in 50cc

500 mg in 500cc run 3cc/HInitial: 0.5-1.0 mcg/kg/min

Maintenance 2.5-20 mcg/kg/min

Max 40 mcg/kg/min, up to 20cc/H

Indication: hypotension, heart

failureCardiogenic shock

Noradrenaline 4mg in 50cc

8mg in 50CC

0.005-0.5 mcg/kg/min, up to 20 cc/H

Indication: septic shock where

peripheral vascular resistance is

low

Resp

PEFR children (ht in cm-100) X5, then +100

PEFR Men [( htX5.48+ 1.58) - (ageX0.041)] X60

PEFR women [(htX3.72 +0.24) (age X 0.03)] X60

NP 3L

VM 28 35 50%

HFM 10 15 L/min

Intubation*if CO2 retention- max VM 28%

s

Asthma

1. Ix: FBC, RP, Coags, ABG, GM, RBS, Sputum C&S, CXR, ECG if >40,

a. CXR: hyperinflated lung when R>5th rib, L> 6th rib. Sulcus widened, flattened

diaphragm

2. Prop up pt

3. Neb combivent 4Hly

4. Neb Pulmicort 1mg BD/TDS


8/25

5. IV Hydrocortisone 100mg QID X1/7 then T.Prednisolone 30mg OD X5/7

6. MDI Budesonide 400mg BD

7. MDI Berodual 2/2 TDS

8. O2 3L NP

9. PEFR chart BD

10.V/S 4Hly, keep SpO2>95%

11.Check inhaler technique

12.Chest physio

13.T.Bisolvent 8mg TDS

14.Pneumonia: Augmentin/EES

15. If not improving: IV Aminophylline or T.Neulin 2/2 or 1/1 TDS

COAD

1. Ix: FBC/BUSE/Coags/RBS, ABG, Sputum C&S, CXR

2. Neb combivent 4Hly

3. Neb ventolin 2 Hly if severe (alternate w neb combivent)4. IV hydrocortisone 100mg QIDX1/7

5. Neb Pulmicort 1mg BD/TDS

6. O2 3L NP

7. MDI Budesonide 400 mg BD

8. MDI Berodual 2/2 TDS

9. Check inhaler technique

10.PEFR chart

11. If no improvement, (d/w MO) KIV for IV Aminophylline 250mg/500mg in 50 cc NS over 24H

AND T. Neulin

Suspected bronchiectasis

Persistent cough, copious purulent sputum, intermittent hemoptysis

Signs: clubbing, coarse insp cresp, wheeze

1. Ix: FBC, BUSE, LFT, ESR, ABG, ECG, Mantoux, Sputum AFBX3, Sputum C&S

2. IV Unasyn 1.5g TDS

3. T. EES 800mg BD

4. O2 3L NP

5. CRIB

6. Neb A:V:N 2:1:2 if worsening (atrovent, ventolin, NS)

7. MDI Combivent 2 puff TDS8. Postural drainage later

9. Chest physio

10.

Bronchopneumonia

A/B options:

o IV Unasyn 1.5g TDS+ T.EES 820 mg QID

o IV Augmentin 1.2g TDS + T.EES 820 mg QID

o HCAP: IV Tazosin 4.5mg stat & TDS, or renal dose 2.25 mg TDS

T.PCM 1g TDS

Tepid sponging


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Decongestant:

o T. Piriton 4mg TDS

CAP: strep pneumonia, moxarella

HAP: G-ve, Klebsiella, Enterobacter, Pseudomonas, ACBC ESBL. 3rd-4th line: cefipime, tienam,

imipenem

A/B choice

o 1st line: Augmentin w EES

o 2nd line: Unasyn, cefuroxime, augmentin

o 3rd line: fortum, cefobid

Pulmonary Embolism

Ix

o ABG: hypoxia, hypocapnia

o ECG: SI, Q III, T III. Sinus tachycardia, RBBB, R ventricular strain, RAD

o D dimer

o CXR

o Spiral CT

O2 supplement

Prop up pt

Heparin infusion

Drugs

Anticholinergic Atrovent (Ipatropium)

Short acting Bagonist VentolinRespolin (salbutamol) 2 puff PRN

Long acting B

agonist

Serevent (salmeterol) 2 puff TDS

Long acting

anticholinergic

Spiriva (Tiotropium)

steroid Budesonide (inflammide)

Combo Combivent (Ipatropium

+albuterol)

2 puff TDS/PRN

Seretide (salmaterol &

fluticasone)


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RenalCreatinine clearance Cockcroft-Gault formula

0.88 if male

Normal F95, M120

Acute Renal Failure

Dx: rapidly rising Urea and creat, oliguria (U/O 20 40 1.2 500


11/25

Chronic Renal Failure

Indications for dialysis

o Urea>30, Creat >300

o K>6

o

HCO3


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d. Acidosis: tx cause of acidosis, consider IV NaHCO3 1mmol/g over 5 mins

Mx

1. 5-6: oral kalimate 5/10/15 g TDS. Stop when K7 OR K>6 AND QRS widening, give cocktail

3. Cocktail:

a. IV 50cc D50% (bolus, over 5min) +IV Actrapid 10 u

b. 10cc IV Ca Gluconate 10% (1-2 amp) over 5-10 mins w ECG monitoring

c. Repeat ABG, KIV resonium A

4. (If expected persistent hyperK-RF, crush injury), Resonium A 15g TDS

5. IV NaHCO3 1mmol/kg over 5 min (caution: fluid overload)

6. Perform dialysis

Na

Requirement: 1-2mmol/kg/d

Na maintenance= (2XBW)/ 177

Na deficit = (140-Na) X 0.6 (young) or 0.5 (old) X BW, divide by 17.7

1 pint= 150 mmol/L

Mist NaCl= 1g/5ml, 1ml=3.5 mmol

Correct < 12 mmol/24H

00

Hypocalcemia

Fast correct

o IV 20cc 20% Ca gluconate over 20 mino IV 10cc 10% Ca gluconate over 10 mins

ECG: Prolonged QT, corrected QT =QT/square root of RR. Normal 0.38-0.42

Infectious Ds

Suspected Dengue

Warning signs: incr Hct/decr PC, fluid accumulation(PEffusion/ascites), abdominal pain,

persistent vomiting, tender hepatomegaly, mucosal bleeding, restlessness/lethargy, WHO definition: ALL of

o Continuous high grade fever 2-7 days

o Hragic diathesis OR +ve tourniquet test OR shock

o PC20% to baseline) OR evidence of plasma leakage

Course: incubation 4-7D, febrile D1-3, critical D4-5, recovery D6-10

Hct: F>40%, M>46%

Hess test: BP cuff between SBP & DBP 5 mins, >20 petechiae/2.5cm2 area

DF Thrombocytopenia + leukopenia+warning signs


13/25

DHF Thrombocytopenia + Hct

+ warning sign

DHF w compensated shock Normal BP

DHF w decompensated shock Systolic hypotension

WHO grading

DF: Hct normal, thrombocytopneia

DHF: thrombocytopenia, Hct

Grade 1: positive Hess test

Grade 2: spontaneous bleeding

Grade 3: compensated shock (rapid weak pulse, pulse pressure100, BD if 60-100, TDS if 50-60, QID if 30-50,

2. Tx Platelet if


14/25

Dengue CME question

1. Severe Dengue, D4 illness, compensated shock, with warning signs, critical phase

2. How to manage Ht 153.4 kg Wt 68 kg

a. Ideal body weight

b. Run fluid bolus 5-10cc/kg NS over 1H

c. Refer GA

d. Dengue serology

3. Why the above regime

a. Fluid resuscitation for compensated shock

4. How soon to repeat FBC

a. Right after finishing bolus

b. To decide if require further fluid resuscitation

5. HR 118 BP 100/86Hct 47

a. Inadequate fluid resuscitation

b. Repeat bolus 5-10cc/kg NS over 1H

6. Hct 38 BP 92/76. Imp and mx

a. Decompensated shock

b. Suspect bleeding tendencies

c. Blood transfusion: WB or PC

d. Further fluid bolus

7. Warning sign


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8. Hct

TB

If started tx: sputum Ogawa, sputum Bactec Notify PHI

Fill in TB form

TB counselling

Eye assessment

Hemoptysis chart

3L NPO2

Contact tracing

TB w/up

Anti TB regime

Daily dose Biweekly dose

Mg/kg Max (mg) Mg/kg Max (mg)

Isoniazide 5-8, recom 5 300 15-20 1200

Rifampicin 10-15recom 10 600 15-20 600

Pyrazinamide 20-40, recom 25 1500 50 3000

Ethambutol 15-25, recom 20 1200 50 2000

Streptomycin 15-20 1000 15-20 1000

Pyroxidine 10 mg OD

Neuro

Stroke

Ix: FBC, RP RBS, FSL, Ca/Mg/PO4/Alb, Coags, ESR, ECG, Echo (if have ht problem), KIV CT

brain, CXR (TRO aspiration pneumonia).

Withhold all antiplatelet until CTBrain

BP: keep MAP


16/25

Causes:

o Missed dose, incorrectly timed dose, incorrect dosage

o Switching meds

o Sleep deprivation

o Stress

o Alcohol/drug use

o Menses

o Acute illness: esp vomit/diarrhea decreases drug absorption

Mx

1. IV Phenytoin loading dose: 750 mg in 100cc NS over 1H, maintenance 100mg TDS, then T.

Phenytoini 300 mg ON

2. IV Diazepam 5mg PRN

3. Fit chart

4. NBM

5. GCS chart

6. (If Focal)- KIV CT brain

7. T. Folate 5mg OD

Status Epilepticus

Dx

1. Seizures lasting >15 mins OR multiple seizure episode without regaining full consciousness in

between

Mx

1. RBS/GM, FBC, RP/LFT, Ca, Mg, Alb, ABG. KIV toxicology/drug level

2. Emergency Mx:

a. Protect airway: roll pt to lateral position.

b. Take V/S & GM, tx hypotension/arrhythmia/hyperthermia

c. IV Diazepam 5-10 mg stat, repeat every 5 min (MAX bolus 40 mg)

3. (If required): IV Diazepam infusion- 30 mg Diazepam in 500 NS or D5% run over 8H (MAX 100

mg /day)

4. IV Phenytoin loading dose 750 mg/100cc NS over 1H Followed by IV Phenytoin 100mg bolus

every 6-8H

a. (15-18 mg/kg eg. 750-1000 mg in 100cc NS over H

b. under ECG & BP monitoring: wo arrhythmia

5. If seizure persist w phenytoin loading dose,

a. IV phenobarbitone 10mg/kg eg. 600mg over 10min

b. If persist: IM Paraldehyde 5100mL OR IV Lignocaine 50 mg KIV followed by 50-

100mg in 250cc D5% over 1Hc. If persist: refer GA


17/25

6. KIV ventilation if spont resp inadequate (pO2


18/25

o FBS : 4.4-6.1

o HbA1c :


19/25

Thyroid

Hyperthyroid

Initial 4-6wk Maintenance

Carbimazole 30-40 mg OD 5-10 mg OD

Max 60mg ODPTU 300-450 mg OD 50-100 mg OD

Propanolol 30-60mg OD

Thyroid Storm

Cardinal sx: severe tachycardia, hyperthermia, GI sx (vomit, diarrhea, abdo cramp, jaundice),

delirium

Precipitating factors: stress, surgery, radio-iodine therapy in poorly prepared pt, MI

Mx

FBC, BUSE, septic wup, TFT

Rehydrate

T. propranolol T. 40-50mg TDS (except in CCF). IV propranolol 2mg TDS/QID.

IV Dexamethasone 2mg QID, IV hydrocortisone 200mg QID (block T4T3)

PTU 150-200mg QID

Carbimazole 15-20mg QID

Hypothyroid

MaintenanceL-thyroxine 50-100 mcg OD 100 mcg OD

Myxoedematous Coma

Ix

o ABG: hypercapnia

o FBC, BUSE, GM, TFT

o ECG: short Q wave

L-thyroxine

Hypothyroidism

15 D5%

Serious Metabolic Acidosis: pH


20/25

a. 1/3 (BE-5) (wt) =x, give x/2

b. 0.5 x BW x (24-HCO3)

c. 1 mL 8.4% NaHCO3=1 mmol NaHCO3.

Hematology

Warfarin Overdose

Plan

o Daily Coags,

o Wo for bleeding tendencies

o If bleeding:

Withhold warfarin

Vit K/FFP (d/w MO first)

o Avoid green vegetables: cabbage(bunga kubis), spinach(bayam), mustard (sawi),

soya bean, peanuts, alcohol

s

Drug & blood reaction

Anaphylaxis

Swelling>itchy

o IM prednisolone 40 mg stat

o IV Hydrocortisone 100 mg stat

o T. piriton 4 mg TDS

Itchy>swelling

o IM piriton 10-20 mg stat

o T. prednisolone 5 mg OD

Hypersensitivity IV Hydrocortisone 100mg QID

IV piriton 1amp TDS (slow)

IVD 2 pint

Neb combivent if SOB

Insect bite: IV cloxacillin 500mg QID

d


21/25

Ix

Anemic W/up TIBC, serum iron (green)

Serum Ferritin (gel)

PBF

FBC

+ Hb Electrophoresis (GSH bottle)

Connective Tissue ds w/up LE cells X3

ANA, BNF

Anti ds DNA

C3,C4

ASOT

RF

Lumbar Puncture RBS, serum protein

AFB

Biochemistry (protein, glucose)

Cell count/FEME/ Gram stainC&S

India ink

Latex agglutination)

Viral Study (HSV/Enterovirus)

Multiple myeloma w/u Ca PO4 albumin

Skeletal survey

Urine for Bence Jones proteins

ESR

PBF

Serum protein electrophoresis (gel tube)

Pleural fluid- ABC GM stat or RBS!!

AFB

Biochemistry (pH, LDH, glucose, protein)

FEME (cell count)

C&S

Cytology

Renal w/up RP, Ca, PO4, Alb

HIV, HEP B/c, VDRL

USG KUB

24 H urine protein

24H urine Creatinine clearance

Septic w/up Blood, urine, sputum C&S

WWF (gel bottle)

BFMP X3 (blood film malarial parasite)

UFEME

FBC, GSH

+ ESR, CRP

Stool w/up Stool C&S, ova & cyst, FEME

TB w/up CXR

ESR

Sputum & Blood C&S

RP/LFT

Sputum AFBX3

Mantoux test


22/25

HV/Hep B/Hep C

Drugs

ABxAmoxycillin T. 1g BD

Augmentin (Amoxycillin +

Clavulanic acid)

IV 1.2g TDS

T 625mg BD, 625mg TDS for

pneumonia

Azithromycin (macrolide) IV 500mg /1g OD

T. 500 mg OD

Bactrim (trimethoprim&

sulfamethoxazole)

2/2 BD

Bacampicillin (prodrug of

ampicillin)

T 400 mg BD

Benzylpenicillin IM 1.2/2.3 megaunit weekly in

syphilis

IV slow infusion 7.2g daily in 6

divided dose

IV 2-4 megaunit QID

C-penicillin IV 3.5g QID

T 125 mg QID

Cefuroxime (2nd

gen) IV 1.5g stat, 750mg BD

T. 250mg BD

Cefobid (Cefoperazone, 3rd

gen) IV 500mg/1g BD

Ciprobay (ciprofloxacin) T. 200 mg BD

IV 400-800mg OD

Claforan (Cefotaxime, 3rd

gen) IV 1g QID normally change

to T.Zinnat

T. 1g BD (max 12g/d)

Clarithromycin (macrolide) T 500mg OD/BD/TDS

Clindaymycin T. 400 /600 mg QID

Cloxacillin IV 1g QID

T. 500mg QID

Doxyxycline T. 100 mg BD

EES (erythromycin

ethylsuccinate)

T. 800mg BD/ 400mg QID

(max 4g/d)

Flagyl (Metronidazole) IV 500 mg TDS

T. 400mg BD

Fortum (Ceftazidine, 3rd

gen+antipseudomonal)

IV 1g TDS 2g BD 2gTDS

Imipenem IV 500mg TDS/QID

Meropenem IV 500 mg OD 1g TDS

Rocephine (Ceftriaxone) IV 2g stat, 1g OD

Sulfaperazone (Cefoperazone

+sulfabactam)

IV 1-2g BD

Tazosin (tazobactam

+piperacillin)

IV 4.5mg TDS

Tienam (imipenem +cilastatin) IV 1g BD


23/25

Unasyn

(ampicillin+sulfabactam)

IV 1.5-3 g TDS (max 12g/d)

T 375mg BD

Vancomycin IV 1g OD

Zinacef (cefuroxime) 750mg TDS

Zinnat T. 500mg BD

H pylori eradication

o C.lansoprazole 20 mg BD, T. Amoxycillin 1 g BD, T. Clarithromycin 500 mg BD 2/52

o THEN C. lansoprazole 30 mg OD 6/52

Meningitis IV Rocephin 2g stat & BD

IV Acyclovir 500mg stat & TDS

Prophylaxis of meningococcalmeningitis

IM ciprobay 2g statT. Ciprobay 500mg stat

T.Ampicillin 600mg 2 days

Pneumonia (partially tx) IV cefotaxime 1g QID

T. Clarithromycin 500mg BD

Sxmatic Relief

Actifed 1/1 TDS

(triprolidine 2.5mg,

pseudoephedrine 60mg)

Decongestant

DONT give


24/25

Procedures

PDIndication

1. Creat>300,

2. Metabolic acidosis

3. HperK >6

4. Uremic encphalopathy

Documentation

PD done aseptic technique under the supervision of Dr.. Consent taken

SpO2 maintained >95% throughout procedureGood inflow & outflow observed, no immediate complications noted. Clear PD fluid

Plan:

PF for 60 cycles

Isotonic solution in/out first 6 cycles

a. In 5-10 mins

b. Out 10-20 mins

c. No retention

Then for the 7th cycle onwards: in 10 mins, retain 20 mins, out 15 mins

Inform if PD poor flow/blood stained/ leaking/ ssx of peritonitis

Others:

(IF TURBID)Add IV Genta 8mg in each PD bag until clear

Wo for ssx peritonitis

IV Dormicum 2.5mg during PD (If pt resist, add 2.5mg)-monitor SpO2

CVP

Normal 8-12

Tip of CVP: 2nd ICS. If too deep- low reading, too peripheral- high reading.

IJVC

Placement in R atrium

Documentation

Pronouncing Death

Informed by SN

Pt put on VS monitoring & Cardiac monitor


25/25

Active bagging & CPR commenced

1 amp of atrophine/adrenaline given via PERIPHERAL LINE

However

o Serial BP measurement and pulse checking done

o BP & SpO2 unrecordable, pulse absent,

o Asystole on cardiac monitor

o No spontaneous breathing, no heart sound

o Pupils fixed and dialted

Pronounce death at

Cause of death

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