survival the finalist

8/10/2019 Survival the Finalist

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100%


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Emergency room 14Infectious treatment 26

Dengue 37Leptospirosis 40

Scrub typhus 40Melioidosis 41Septic shock,Early-goal directed therypy 42Malaria infection 43Parasite infection 45

HIV infection 47Oppotunistic infection of HIV 48CNS toxoplasmosis 48CMV,MAC,Candida infection 49PCP infection 49

Cryptococcal meningitis 50Facial palsy(Bell,Ramsay hunt) 51GI treatment 53

Diarrhea/food poisoning 61Constipation 61

GERD 61Dyspepsia 62


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H.pylori infection 62Liver abscess 63Hepatic encephalopathy 64Cirrhosis 65UGIB 67Esophageal varices 70Abdominal paracentesis 72Corrosive ingestion 73

Cardiology treatment 74Murmur 83Acute coronary syndrome 84Heart failure 87Pericarditis 88Rheumatic heart disease 89Infective endocarditis 90Atrial fibrillation 92CCU 93

Chest treatment 94Thoracocentesis 99Acute asthmatic attack 100COPD exacerbation 101

Pneumonia 103Pharyngitis/URI 104


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Bronchitis/bronchiolitis 104Tuberculosis 105Acute pulmonary edema 107ARDS 108Small cell lung cancer 108SVC obstruction 108Flu H1N1 109

Neuro treatment 110Head injury 124Ischemic stroke 125Hemorrhagic stroke 126Bacterial meningitis 127Seizure 128Status epilepticus 129Myasthenia gravis 130Dizziness 130Anxiety 130Alcohol withdrawal 130Migraine 131Cluster headache 131Tension headache 131

Neuroleptic malignancy syndrome 132Acute dystonia 132


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Renal treatment 133UTI 134Nephrotic syndrome 134Acute renal failure 135End stage renal disease 136SIADH 137Contrast induced nephropathy 137

Endocrine 138Metabolic syndrome 139Hypoglycemia 139Diabetic ketoacidosis 140Graves disease 141Hypothyroidism 141Thyroid strom 142Adrenal insuffiency 145

Hematology 146Snake bite 147Febrile neutropenia 149Thalassemia 150AIHA 150ITP,TTP 151

HIT 152Polycythemia vera 152


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Essential thrombocytosis 153Hodgkin lymphoma 153Multiple myeloma 153Deep vein thrombosis 154G6PD deficiency 155Tumor lysis syndrome 155Hypercalcemia of malignancy 156Hemophilia 156Blood transfusion 157

Rheumatology 158Septic arthritis 159Rheumatoid arthritis 160Gout 161

Lab treatment 162Hyponatremia 165Hypernatremia 166Hyperkalemia 167Hypokalemia 168Hyper/hypomagnesemia 169Hyper/hypophosphatemia 169Hypocalcemia 169

ABG 170Metabolic acidosis/alkalosis 172


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Toxicology 174Paracetamol overdose 175Naloxone 175Heparin overdose 175ASA overdose 175Organophosphate poisoning 176Benzodiazepine poisoning 176Paraquat poisoning 177Amphetamine poisoning 178

ENT 179Allergic rhinitis 183Vertigo 184Acute otitits media 185Chronic supparative otitis media 185Rhinosinusitis 185Nasopharyngeal carcinoma 186Nasopharyx angiofibroma 186Meniere () 186

Eye 187Strabismus, amblyopia 189Eye burn 190

Foreign body in eye 190Hordeolum 190


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Acute angle closure glaucoma 190Corneal lesion 191Preseptal/orbital cellulitis 191UV superficial keratoconjunctivitis 191Blurred vision 192Red eye 193Trauma eye 194

Dermatology 195Herpes zoster infection 199Genital herpes 199Cellulitis,erysipelas 199Tenia 199Acne 200Alopecia 201

Orthopaedics 202Myalgia 210Neurogenic shock 210Osteomyelitis 210

General Surgery 211Appendicitis 215Pre/post op for appendectomy 218

Pre/post op for PU perforation 219Symptomatic gallstone(cholelithiasis) 220


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Acute cholecystitis 220Acute cholangitis() 220Gut obstruction 221Acute pancreatitis 222 Sengstaken-Blakemore 223

Plastic surgery 225Cleft lip,cleft palate 227Burn 228

Pediatric surgery 231eventration of the diaphragm 234diaphragmatic hernia 234esophageal atresia 234Neonatal abdominal distention 235infantile hypertrophic pyloric stenosis 235Hirschprung 235NEC 236Intusseption 236UGIB/LGIB 237imperforate anus 238Biliary atresia 239Hernia/hydrocele 240

undescended testis 241omphalocele/gastroschisis 241


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posterior urethral valve 242Urology 243

BPH 244Scrotal mass 244Orchitis,epididymitis 245Renal calculi 245

Pediatrics 246CPR in pediatrics 247Emergency drug in pediatrics 250 254Antiobiotics, Neofax 260Ballard score 263Basic knowledge 264Vaccination 266 269 271Nursery 272Congenital hypothyroidism 273Birth asphyxia 276Seizure in newborn 276IRDS 277

Persistent pulmonary hypertension of NB 278Bronchopulmonary dysplasia 279


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Apnea of prematurity 279Patent ductus arteriosus 280Neonatal jaundice 281 on phototherapy 284 exchange 285Polycythemia 286Early prophylaxis anemia 286Total exchange 287Hemolysis 288Neonatal hypoglycemia 289Neonatal with maternal HIV 290PCP,VDRL 290Lymphoid interstitial pneumonitis 291Neonatal herpes simplex 291Chickenpox 291Anaphylaxis 293Viral exanthema 294Kawasaki disease 297Tetralogy of fallot 298Hypoxic spell 298Infective endocarditis 299

Rheumatic heart disease 300Eczema 301


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Atopic dermatitis 301Intertigo 302Colic 302UTI 303Febrile convulsion 304Epilepsy/status epilepticus 305Dengue hemorrhagic fever 306Stidor 307Viral croup 308Acute epiglottis 310Bacterial tracheitis 310Retropharyngeal abscess 310Common cold, acute pharyngitis 311Acute otitis media 313Acute bronchitis,bronchiolitis 314Pneumonia 315Acute post-strep. Glomerulonephritis 318Nephrotic syndrome 319Anemia 320Hyponatremia 321Hypernatremia 322

Hypokalemia,hyperkalemia 322Correct acidosis 322


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Adrenal insufficiency 323Down syndrome 324

OB-GYN 326EKG 329Birds ventilator 339

Hypertension 356DM 359Dyslipidemia 368CKD 373Thyroid 376


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Emergency room


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Adrenaline(1:10) IV drip start 5d/min(No max dose)

Adenosine6mg IV push + ->12mg IVSVT 1-2

Amiodarone(CORDARONE)

150mg IV drip in30min Then

600(900)mg + D/W450cc IV in24hr(30ml/hr x6hr then 15ml/hr x18hr)Hold BP


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Pulseless arrest


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Bradycardia


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Tachycardia with pulse

SVT (RR DDx : sinus tachycardia,AF)


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SVT

-RR DDx : sinus tachycardia,AF-Adenosine 6mg iv rapid push + NSS 10ml(double syringe technique)

-Repeat 12mg * 2doses (if not improve in 2-10min)1)

Cordarone 300mg + 5% DW 100ml iv drip in 1hr

Then Cordarone 900mg + 5%DW 500ml iv drip24hr2)

If CPRcordarone 300mg iV push -> 150mg iV q3min

-maintenance :-verapamil(isoptin)(40) 1x3 0 pc-propranolol(10,40) 1x3 0 pc

AF

-digoxin 0.5mg IV-> 0.25mg IV(max1.5mg)


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Atropine

-symptomatic bradycardiaAtropine 0.6mg IV push (max3g)Dopamine

(2:1) 5-10d/min max30d/min

(1:1) 10d/min max60d/min

**dose 10-15min (5-15g/kg/min)**Dose(g/kg/min) = 100xratexconc/BWx6****Tachycardia

Dobutamine short term

(2:1) 5d/min max30d/min(1:1) 10d/min max60d/min**dose15min keep BP 90/60mmHg**BP


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NTG

-(1:5)NTG20mg + 5%DW100ml IV drip 3-5d/minTitrate1-2d/min keep BP


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Hydrocortisone(adrenal insufficiency, septic shock)

-100mg IV q8hr-300mg + 5%D/W1000ml IV 40ml/hrMannitol, glycerine, lasix

- herniation -20%mannitol 75ml(1g/kg) IV drip in15min q6hr

If BP1.030 off1doserebound effect OR

-10%glycerosteril 500ml IV 20ml/hr 2week

- pressure-lasix **acute renal failure, hypotension,hypovolemia, dialysis, heart failure, lung congest

Fluid challenge

CVP 14 : 50ml in 10min

Change >5 : Inotrope2-5 : re-exam in 10min


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Hypovolemic shock

I II III IV

Bl. loss 2000bl. loss 40PR 100 >120 >140BP normal decreased

PP

NormalIncrease

decreased

RR 14-20 20-30 30-40 >35UO/hr >30 20-30 5-15 -

CNS Slightlyanxious Mildlyanxious Anxiousconfused Confusedlethargic*blood volumn = 70ml/kg(), 80ml/kg()


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Anaphylaxis

-Adrenaline(1:1,000) 0.01ml/kg IM at lateral thighMax 0.5ml(1/2amp) repeat q5min-CPM 0.25mg/kg(10mg = 1amp) IV stat -> 1x3 0 pc-dexamethasone 4-5mg IV q6hr-serum tryptase at1-2hr after symptom

-IV fluid(DNSS,RLS), dopamine, inhale 2-agonistAnaphylaxis shock

Adrenaline(1:1,000) 1amp IV push q2-5min

then continuous infusion 1-4d/min

ER-diclofenac 75mg/3ml IM-tramadol 100mg/2ml IM-dimenhydrinate 50mg/ml IV ()-hyoscine(buscopan) 20mg/ml IV

-Ranitidine 50mg/2ml IV


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Dog bite

-pre-exposure : day o,7,28-post-exposure : day o,3,7,14,30-TT o.5ml IM at o,1,6months ( 10yr)

>5yr 1 >10yr 1

-verorab 0.5ml IM, 0.1ml ID-PCEC 1ml IM, 0.1ml ID- >3

6month 2 (day0,3)-ERIG 40IU/kg, HRIG 20IU/kg intralesion -> IM- dilute HRIG 1:10 -amoxycillin, augmentin, doxycycline


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Infectious


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Strep. Penicillin, amoxicillin

Stap. CloxacillinMycoplasma Erythromycin

Pseudomonas

Tazocin 4.5g IV q6hrTienam 500mg IV q8hrMeropenam 1g IV q8hr

Sulperazone 1.5g IV q12hrMRSA Vancomycin 1g IV q12hr


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Penicillin group

Penicillin G sodium(0.5,1,5MU) IM/IV 230MU/Day(Adult)IV 100,000-250,000 u/kg/Day(Child) devide q4-6hr

PEN V

(cap400000u, tab200000,400000u,

S.100000,200000u/tsp)1-2cap/tab bid-tid(Adult)1 tap 0 qid(Children)

Ampicillin(100mg/kg/Day)

1 gm IV q6hrAmoxicillin

(250,500mg S.125,250mg/tsp)30-80mg/kg/Day tid

AUGMENTIN/AMOKSIKLAV

20-40mg of amoxy/kg/Day;1)tid 375,625mg, S.156,

375mg/tsp2)bid S.228,457mg/tsp,tab 1gm


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Cloxacillin

(tab250,500mg,S.125mg/tsp)(50-100mg/kg/Day)1x4 0 ac1 gm IV q6hr

UNASYN(sultamicillin)

(Ampicillin1gm + Sulbactam 500mg)

(tab 375,750mg) BBB750mg 0 bid,1.5mg IV q6-8hr -> 3gm IV q8hr

TAZOCIN(Piperacillin4gm+Tazobactam500mg)4.5gm IV q6hr

Tetracycline group

Tetracycline (250,500mg) 1tab 0 qid pcDoxycycline (100mg) 1 tab 0 bid pc


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Cephalosporins

1

st

generation

Cephalexin(IBILEX)

(tab250,500mg,S.125mg/tsp)25-50mg/kg/Day tid-qid

Cefazolin

(vial 1gm)

0.5-1gm IV/IM q6-12hrMAX 6gm/Day keflex 1x4 0 ac,hs

2

nd

generationCefaclor(DISTACLOR)

(S.125,250mg/tsp)20-40mg/kg/Day tid

Cefoxitin 1 gm IV q6hr (anti-anaerobe)

Cefuroxime(ZINACEF)

(tab250,500mg//S.125,250mg/tsp)

750mg IV q8hr250-500mg 0 bid(Adult)125mg 0 bid(Children)

**cefotaxime 2g IV 8hr for liver impairment


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3

rd

geneartion

OMNICEF(Cefdinir) (100mg) 2 tab 0 bid125mg/5mlMEIACT

(Cefditoren)(100mg)2 tab 0 bid

cefixime

(Cefspan)

6mg/kg/dose 0 bid pc

2x2 0 pc(cef-3)Ceftriaxone(ROCEPHIN)

2gm IV OD2gm IV q12hr(CNS infection)

Ceftazidime

(FORTUM)

1-2gm IV q8hr

SULPERAZONe(Cefoperazone+Sulbactam)(500/500, 1000/500mg)1.5gm IV q12hr

4

th

generation

MAXIPIME(Cefepime)

500mg1gm IV q12hr 2gm IV q12hr

CEFROM(Cefpirome) 1-2gm IV q12hr


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Macroline group

Erythromycin(ILOSONE)

(250mg, S.125,200mg/tsp)30-80mg/kg/Day tid

Roxithromycin

(RULID)

(100,150,300mg)300mg/Day

5-8mg/kg/Day bidClarithromycin

(KLACID)(tab500mg, S.125mg/tsp)15mg/kg/Day bid

Midecamycin(MIOTIN)

(tab 200mg S.200mg/tsp)

20-40mg/kg/Day tid-qid10kg1/2 tsp 0 tid20kg1 tspadult600-1200mg/Day

Azithromycin(ZITROMAX)

(cap250mg, vial500mg,

S.200mg/tsp; 15ml/bott)500mg IV OD10-20mg/kg/dose OD *3Day (URI)MAC prophylaxis in HIV pt.

1,200mg 0 weekly


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Quinolone group

G-6-PD deficiencyNorfloxacin(LEXINOR)

(tab100,400mg)15mg/kg/Day 1 tab 0 bid

Ofloxacin(TARIVID)

(100mg)2 tab 0 bid

Ciprofloxacin(CIPROBAY)

400mg IV q12hr(tab 250,500mg) 1 tab 0 bid

Levofloxacin(CRAVIT)

500mg IV OD1tab 0 OD

AVELOX(Moxifloxacin) (tab 400mg)1 tab 0 or IV OD

UROFLOX(Rufloxacin)

(200mg)Cystitis->2tab 0 single doseother load 2tab then 1 tab 0

OD *5Day


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Aminoglycoside group

CCrKanamycin (1gm) 1.5mg/kg/DayStreptomycin 1gm 1-2times daily IM

Gentamicin 2.5mg/kg/dose IV q8hrAdult (5mg/kg) 240mg IV OD

AMIKIN(Amikacin)

(250, 500mg) 15mg/kg/Day500-750 mg IV OD

NETROMYCIN(Netilmicin)

200mg IV OD(40-50kg)300mg IV OD(50-90kg)

Lincosamide group

Lincomycin(600mg/2ml)10-20mg/kg/dose IM OD

Clindamycin(DALACIN-C) 600mg IV q8hr or(tab150,300mg) 600-800mg/Day


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Others

Vancomycin 1gm IV q12hr(Adult)40mg/kg/Day (Children)

TARGOCID(Teicoplanin)

(200mg)400mg load then 200mg IV/IM OD*Vanco

Fosfomycin(FOSMICIN)

1 gm IV q12hr2gm() IV q12hr-> 4gm IV q12hr

TIENAM(Imipenem and cilastatin)(1gm)500mg IV q6hr MAX 50mg/kg/Day

Meropenem

(powder 500mg, 1gm)1gm IV q8hr10-20mg/kg IV q8hr (Children)Meningitis ->2gm IV q8hr continuous

over 3hr

INVANZ(Ertapenem)

1gm IV OD


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Acyclovir

500mg IV q8hr CNS infection,

(tab 200mg) 1x5 in HSV 7-10day(tab 400mg) 2x5 in HZV 5-7day

Griseofulvin(500mg)0.5-1gm/Day(Adult)10mg/kg/Day(Children)

Ketoconazole (200mg)1tab 0 OD Lesion 1wk

Fluconazole(DIFLUCAN)

1 tab 0 OD or bidProphylaxis crypto DIFLUCAN(200)

2tab 0

Itraconazole(SPORAL)

(100,200mg) 1 tab 0 OD/bid(200mg) 0 bid*7Day short intermittent Rx Pityriasisungium(ONYCHOLYSIS)

Metronidazole(FLAGYL)

(tab 200,400mg S.200mg/tspinj.500mg)500mg IV q 8hr(400mg) 1 tab 0 tid


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Dengue

-fever + leucopenia + thrombocytopenia-hepatomegaly-sign bleeding tendency : TT +ve-plasma leakage : hemoconcentration

: pleural effusion,ascites,elyte

-WBC -> AL -> Plt -> Hct-dengue titer IgM,IgG,NS-1-CBC with platelet, FBS, BUN, Cr, Elyte, Ca, LFT-record I/O, V/S-Hct q4hr if change >4% pls. notify-ASA,NSAIDs GI bleeding- 5%DNSS/2-colloid if crystalloid not improve

Dextran,10%Haes-steril

- dengue encephalopathy-shock IVdextrose-colloid 10ml/kg/hr -> Hct 10%- crystalloid 7->5->3->1->KVO- dextran 30ml/kg/day coagulopathy, renal failure


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-NG tube bleeding

- -> Primolut-N bleeding- treat shock10cc/kg/hr -> 2hr -> 7cc/kg/hr -> 5cc/kg/hr ->4-6hr -> 3cc/kg/hr -> 6-10hr -> KVO then off**Total fluid M+5%def in24-48hr

Grading

Grade 1 TT +ve

Grade 2Spontaneous Bleeding

HemoconcentrationGrade 3

Circulation failureCold, clamsy skin

Grade 4 shock

Grading

DF No hemoconcentrationDHF Grade I,IIDSS Grade III,IV


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treatment

Grade 1,2 IV maintainance+5%def

Grade 35%D/Nss 10ml/kg/hr 1-2hr5%D/Nss 7ml/kg/hr 1-2hr5%D/Nss 1-2ml/kg/hr

Grade 4

5%D/Nss 20ml/kg/hr 1-2hr

Then

observe

A acidosis Appetite

B Bleeding BradycardiaC Hypocalcemia Convalescent rashD Decrease dextrose diuresis


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Leptospirosis

-thrombocytopenia, Jaundice, hepatomegalyconjunctival suffusion, NO lymphadenopathy-severe case = Weils disease-CBC, UA, BUN, Cr, Elyte, LFT-CXR lung hemorrhage

-lepto titer-ceftriaxone 2gm IV OD-doxycycline(100) 1x2 0 pc x7day-motilium 1x3 0 ac (doxycycline )-thrombocytopenia : platelet lung hemorrhage-+/-dexa 8mg IV q6hr x4day + methylprednisolone1g IV x3day then prednisolone 0 1mg/kg x7day

-renal complication -> dialysisif urine output clindamycin, azithromycin

-domperidone 1x3 0 ac


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Melioidosis

- clinical improve-melioid titer, IF for melioid(urine, sputum)-ultrasound -> hepatic&spleen abscess-fortum 2g IV q8hr x2week (mortality50%)-augmentin 2.4g IV loading dose then 1.2g IV q4hr

(clavulanic acid > 750mg/day)( failure rate)

-imipenam, sulperazone, meropenam 1g IV q8hr-ertapenam -maintenance 5months

-bactrim 3x2 -> amoxicillin, augmentin-doxycycline 1x2

CCr>50 CCr25-50 CCr10-25 CCr


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Septic shock

-CBC with slide for DIC-BUN, Cr, elyte, PT, PTT, INR, LFT-UA,UC-CXR +/- sputum G/S,C/S-DTX stat then q2hr keep 80-200mg%

-0.9%NSS 1000ml IV load200ml in 15min then 120ml/hr-dopamine(2:1) IV 10d/min titrate BP>90/60mmHg-record V/S q1hr if metronidazole)-cut down : record CVP q2hr keep 8-12cmH2OEarly goal-directed therapy

-detect 6-CV catheter ScvO2 >70%

-CVP > 8-12mmHg-MAP > 65mmHg-urine output 0.5ml/kg/hr


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SIRS

-BT >38, 90, 20, 0.75mg/kg/wks 8wks

- primaquine-1sttrimester : quinine + clindamycin 7day-2nd,3rdtrimester : artesunate+clindamycin 7day


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-P. falciparum infection

-artesunate(50) 4tab OD 3day +Mefloquine(250) 4tab OD day2 -> 2tab OD day3-quinine(300) 2tab 0 tid x7day +doxycycline(100) 1tab 0 bid x7day orTetracycline(250) 1tab 0 qid x7day or

Clindamycin(300) 1tab 0 bid x7day- : clindamycin 10mg/kg IV q8hr

Age Artesunate(50) Mefloquine(250)

day 1 2 3 1 2 35-11mo 1/2 1/2 1/2 - 1/2 -1-6yr 1 1 1 - 1 -7-13yr 2 2 2 - 2 1>13yr 4 4 4 - 4 2

-artesunate 2.4mg/kg IV q12hr x1day then 2.4mg/kgIV OD x5-7day + mefloquine 3tab 0 stat then2tab stat in6-8hr


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Parasite infection

--mebendazole(100) 1x2 0 pc x3day-albendazole(200) 2tab 0 stat

-Stongyloides stercoralis-albendazole 400mg x3-7day

-ivermectin 200g/d x2day(IM host 7day)-cappillaria philipinensis

-mebendazole(100) 1x2 0 pc x20day-albendazole 400mg OD x10day

-Gnathostomiasis-ivermection 100g/kg/day x2day-albendazole 400mg bid x21day

-Opisthorchis viverrini-praziquentel 25mg/kg 0 tid x1day

-praziquentel 40mg/kg 0 hs-Entamoeba Histolytica

-metronidazole 750mg 0 tid x5-10day-Giardia lambria

-metronidazole 250-750mg 0 tid x7-10day


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-fasciolopsis buski

-praziquentel 25mg/kg/dose tid x1day-Isospora belli-bactrim 1x4 10day

-cysticercosis-albendazole(200) 2x2 0 pc x8-30day(14day)

-dexamethasone

-alter:praziquentel 50-100mg/kg/day tid x30d.-filariasis

-diethylcarbamazine(DEC) 6MKD x14day +Doxycycline(100) 1x2 x14day-albendazole 400mgbid x21day

-tinea species-praziquentel 5-10mg/kg single dose


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HIV infection

1.GPO-vir Z 250AZT250 + 3TC150 + NVP2001tab 0 q12hr

2.GPO-vir s 30d4T30 + 3TC150 + NVP200

1tab 0 q12hr**d4T SE 6

Lipodystrophy,peripheral neuropathy**change -> GPO-virZ, TDF+3TC+NVP/EFV

3. AZT/d4T 1tab 0 q12hr3TC 1tab 0 q12hrEfavirenz(600) 1tab 0 hs 1sttrimester

-PPE : pruritic popular eruption

-co-infection : HBV -> 3TC,tenofovir-F/U q3-6months : CD4,viral load-responseviral load4-6month-P24Ag Ab-NAT(nucleic acid amplification test)


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Oppotunistic infection in HIV

CD4 200 3

CD4 100 3Cryptococcus,penicillosisHistoplasmosis,toxoplasmosis

CD4 50 3CNS toxoplasmos is

-pyrimethamine(25)200mg 0 stat then 1x2 0 pc

bactrim, doxycycline-sulfadiazine(500) 2tab 0 tid,hs-folinic acid(leucoverin)(5) 1x3 0 pc -pyrimethamine 1x3 0 pc + clindamycin 600mg IV q6hr-dexa 5mg IV q6hr x3-5day for brain edema-treat 4-6wks


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CMV treatment

-gancyclovir 5mg/kg/dose IV q12hr x2-3wksMAC treatment

-clarithromycin(500) 1x2 0 pc + Ethambutol 15MKDCandida treatment

-oropharynx : clotrimazole10mg 4-5/ x2wks

-esophageal : fluconazole(200) 1x1 0 pc x2-3wksPCP infection

-, , , sat drop, bilateral diffuse infiltrate-ABG if PaO2 35mmHg-cotrimoxazole 5mg/kg/dose 0f trimetroprim 3amp(80mg/amp) + 5%D/W 100ml IV drip in1hr q8hr then4x3 0 pc 21

- bactrim clindamycin 600mg IV q8hr +primaquine 15-30mg OD

-prednisolone(5)8tab 0 bid 5day8tab 0 OD 5day4tab 0 OD 11day

-prophylaxisBactrim(80) 2tab 0 OD


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Cryptococcal meningitis

-admit-duration >2wks-symptoms increase ICP : AOC, severe headache,visual loss, hearing loss

-signs increased ICP : papilledema, CN VI palsy

-neurodeficit-LP : OP>20cmH20-hydrocephalus

- visual loss, hearing loss, OP>40, coma consult neuro Sx for drainage

-Induction-amphotericinB 0.7-1mg/kg/day +5%DW500ml IV dripin4hr OD x6-10wks

-fluconazole(200) 600-800mg/day x10-12wks

-CPM 1amp, Para 2tab, IV fluid induction-maintenance-fluconazole(200) 1x1 0 OD life long

-F/U K, Mg,


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Facial palsy, LMN type

1.

Bells palsy :-sudden onset, no CNS lesion, no CP lesion-ear painvesicle, NSHL, tinnitus, vertigo-Recurrent facial palsy a.If < 14

-Prednisolone (5 mg) 4x3 0 pc Prednisolone 1mg/kg/day 1 2

- Ranitidine (300 mg) 1x2 0 pc for vasodilator

b.

If > 14 observe or refer EMG facial nerve decompression

- Vitamin B complex 1x3 oral pc**CP angle tumor CN7,8>5 cerebellum


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2.Ramsay Hunt syndrome

Triad: 1 ipsilateral facial palsy (LMN)2. Ear pain+tinnitus (SNHL, vertigo )3. Vesicle in ear canal

Rxa.Antiviral drug(high dose) 5-10

-Acyclovir 800 mg 5

- Valcyclovir 1000 mg 3 b.Prednisolone 1 mg/kg/day 2 (

post herpetic neuralgia->amitryptyline)

c.

Dry eye cared.NSAIDs for pain control


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GI


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Antidiarrhea + stool forming

(diarrhea sepsis )KAOPECTAL(Kaolin+Pectin)

1-2tsp tid

ERFUZIDE/ERCEFURYL

(Nifuroxazide)

< 6 1tsp bid> 6 1tsp tid

Adult1-2cap qidULTRACARBON

(Activated Charchol)2 tab 0 tid

SMECTA(Dioctahedral smectite)

(sachet 3gm)

Adult 3sachet/Day1-2yr 1-2sachet/Day


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Antacid for dyspepsia

aluminium hydroxide (500mg) 1x3Antacid suspension(alum milk + simethicone)

(240ml)30ml 0 tid

M. carminative (180ml) 30ml 0 tid pcSimethicone(air-x) (80mg) 1x3 0 pc

Sodium bicarbonatemixture

60ml

,


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Anti-ulcer

Cimetidine (200,400mg)200mg tid or 400mg bidSucralfate(ulsanic)

(1gm) 1gm 0 q4hrGI bleed 5gm NG feed

Alum milk 0.5-1ml/kg/dose tid-qid

Ranitidine50mg IV q8hr(150mg) tab bid pc6mg/kg/Day MAX 300mg

Omeprazole

(MIRACID/O-Sid)

(20mg,vial40mg)

1tab bid acPREVACID FDT(Lansoprazole)

(15,30mg) OD

NEXIUM

(Esomeprazole)

(20,40mg, vial 40mg)Use in severe renal insuff 1x1,

20-40mg IV OD

CONTROLOC(Pantoprazole)

(20,40mg, vial40mg) renal insuff orhepatic dysfunction

PARIET(Rabeprazole) (10,20mg) 1 tab o OD ac


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...57...

Laxative

Unima Enema 10cc 0 bid *3Day P

DUPHALAC(Lactulose) colon

infant 1tsp/Day1-6 2tsp/Day7-14 3tsp/Day

30cc tid/hs In Hepatic Encep.MOM 30ml 0 hs Renal failureELP co 30ml 0 hs

bisacodyl(dulcolac) 5mg 2xhs senokot 2xhs

HemorrhoidDAFLON 2x3 4day -> 2x2 3day -> 2x1

PROCTOSEDYL1 tab rectal suppo. *7Day(steroid + local analgesic)

SENOKOT 2 tab 0 hsBISACODYL 1-2 tab 0 hsMUCILIN 1 sachet bidFORLAX (10gm) 1 sachet bidFYBOGEL 1 sachet bid

DUPHALAC(Lactulose) 30cc hs/tid In HE


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Antiemetic

PLASIL(Metoclopamide) (tab 10mg, vial10mg/2ml)0.25mg/kg/doseMOTILIUM

(Domperidone)(tab 10mg, S.5mg/tsp)0.2mg/kg/dose

DRAMAMINE

(Dimenhydramine)

(tab50mg,vial50mg/ml,1mg/kg/dose)

5mg/kg/DayNASEA

(Ramosetron)(tab0.1, vial0.3mg)0.3mg 0 OD (MAX 0.6mg)

ONSEA

(Ondansetron)

(8mg/tab, 8mg/4ml/vial)

2x2

N/V from chemo, post-OP8mg IV q12hr, 4mg IV q6hr


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GI-Bleeding

(Goal HR100 PT>15 Plt>50,000)Sandostatin(octreotide)

5 amp + 5%D/W 500cc IV drip20ml/hr 5Day

Vit K 10 mg IV OD *3 DayThiamine 100mg IV *3Day

Transamine 1 amp IV q 8hr

CONTROLOC80mg IV push IV drip 8mg/hrIV *72hr(drip 5hr/ 1)CONTROLOC 40mg IV q 12hr

NEXIUM80mg + 5%D/N/2 500cc IV drip in10hr continue for 24hr *3Dayno rebleed in 24hr switch to oral

20%Albumin 50cc IV drip in 30min q6hr(8hr)

10% AMINOSOL 500cc IV drip in 24hr8%,10% AMINOLEBAN 500cc IV drip in 24hr

10%Calciumgluconate

10cc IV push or drip in 1hr


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Others

Cyproheptadine 1/2-1 tab 0 tid ac

APPITITE STIMULANTCOMBIZYM(Pancreatin)

1-2 tab during meal

SAMARIN

(Silymarin)

treat liver Dz, cirrhosis (70,140mg)140mg 0 tid

maintenance 70mg 0 tidMETADOXIL

(Metadoxime)(tab/bott 500mg)Rx alcoholic liver 2tab or 2bott daily

HEPACAP(Phospholipid,B1,B2,B6,B12,Nicotinamide,

Vit E)1x3


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Diarrhea/Food poisoning ( VS AGE )

-motilium(domperidone) 1x3 0 ac-buscopan 1amp IV stat // 1x3 0 pc-plasil(metroclopamide) 1amp IV q8hr // 1x3 0 ac-ORS-norfloxacin(400) 1x2 0 pc x 3day if infection

-metronidazole(4oo) 1x3 0 pc x5day : amoebic-ciprofloxacin(500) 1x2 0 pc x5day : IM host-tetracycline(250) 2x4 0 pc x3day : vibrio cholera-doxycycline(100) 1x2 0 pc-stool for parasite

Constipation

-MOM 30ml 0 pc -lactulose 30ml 0 hs-senokot 2tab 0 hs

-dulcolac 2tab 0 hsGERD

-omeprazole(20) 1x2 0 ac-flatulance 1x3-domperidone 1x3 0 ac


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Dyspepsia

-ranitidine (150) 1x2-hyoscine (10) 1x3-alum milk 30ml 0 tid pc-domperidone(10) 1x3 0 ac+/- ranitidine,hyoscine IV

H. pylori infectionTreat 1-2weeks-omeprazole (20) 1x2 0 ac-clarithromycin(500) 1x2 0 ac-amoxycillin(500) 2x2 0 pc

-> tetracycline(500mg) 1x4 0 ac-metronidazole(400) 1x2 0 pc- : CAO,CMO,MAO

-PU : GU treat 8wks, DU treat 6wks-sequential therapy()

-PPI + amoxicillin 1g bid x5day thenPPI + clarithromycin 1x2 x10day


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Liver abscess

1.pyogenic abscess-most common cause : ascending cholangitis-mellioid : -ALP increase-cefoxitine 2g IV q6hr (empirical)

-surgical drainage2.amoebic abscess( )

-homosexual esp. fecal-oral route-E. histolytica-echo wall, -metronidazole(400) 1x3 0 pc x7dayimprove-surgical drainage


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Hepatic Encephalopathy

-CBC,UA,BUN,Cr,Elyte,LFT,PT,PTT,INR-DTX stat-5%DN/2 1000ml IV drip 80ml/hr-low protein diet-lactulose 30ml 0 q4hr hold if diarrhea >3/day

Via oral,NG intracranial p.-correct precipitate cause-thiamine 100mg IV ODx3day-vitK 10mg IV OD x3day- +/-metronidazole 400mg 1x3 0 pc

BIG SCALP : blood transfusion, infection, GI bleed,sedation, constipation, alkalosis, low K,protein diet high


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Cirrhosis

-aldactone(25) 1x4 0 pc or-lasix(40) 1x1 // HCTZ(50) 1/2-2tab/day-propanolol(10) 1x2 0 pc

-> HR , splancnic vasoconstriction-Vit K 30mg IV stat then 10mg IV OD x3day

-lactulose 30ml 0 q4-8hr until >3/ (HE)(lactulose->lactic acid-> NH3->NH4

+ ammonia absorb)

Cirrhosis knowledge

*distort of hepatic architecture + regeneration nodule* PHT *splenic vein + mesenteric vein -> portal vein*TIPs sinusoid encephalopathy

*all cirrhotic pt. -> scope


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Child-Pugh score

Measure 1 2 3 units

Bilirubin (total)3)

mol/l(mg/dl)

Serum albumin >35 28-35


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UGIB knowledge

Approach-stabilize-access severity-endoscopy : Dx/therapeutic-warm IV 2line 18

- PT,PTT,INRKeep

-Hct 30% (20%healthy scope)-INR 1.5, platelet 50,000

*larvageNSS active bleed &scope

*UGIB stable 12hr scope*GV severe> EV flow*recent MI scope30

*grading from endoscopy risk of recurrent1.clean based2.flat(pigment) spot3.adheren clot4.visible vessel(non-active bleeding)5.active bleeding


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*basic treatment :

adrenaline(1:10,000) 10-30cc + thermal coagulation*omeprazole 40mg IV q12hr recurrent

*scope2 Sx*cirrhosis, bleeding EV keep Hct25% vessel

* --(co-morbid,)


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UGIB

-warm 0.9%NSS 1000ml 2large line IV free flow load200-300ml in 15min then IV drip 100-120ml/hr-CBC,BUN,Cr,Elyte,LFT,PT,PTT,INR,CLO test-retain foley cath-NG irrigate & retain NG bag

-record V/S q1-2hr if BP120/minpls. notify

-record urine output q4hr keep>120/4hr-DTX q4hr keep 80-200mg%-G/M PRC2unit, FFP2-4unit, Plt. Conc.10unit

-PRC drip unit3hr hold IV Hct 3hr

-FFP IV drip in 4hr or free flow hold IV then repeat PT,PTT,INR FFP 4hr

-plt. Conc. IV free flow-serial Hct q4hr keep>30% or drop>3% pls. notify-omeprazole 80mg stat then 40mg IV q12hr-controloc80mg+5%DW100ml IV drip in1hr then 40mg+5%D/W100ml IV drip 20ml/hr(8mg/hr)

-scope day2


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Esophageal varices

-sandostatin 6amp + 5%DW 250ml IV 20ml/hr bleed off (5day)-propanolol(10) 1/2x1 keep HR60/min( splanchnic blood flow portal HT)-correct coagulation

-Vit K 30mg IV stat then 10mg IV OD x3day( PT,INR)

-Plt. Conc. If FFP 2unit IV drip q8hr

-> lasix 40mg IV


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Non-variceal bleeding

Shock/active bleed stable

Recuscitaion PPI/EGD in24hr

Not improve improve non-varice varice

OR Emer PPI/EGD therapeutic scope

D/C

Variceal bleeding

(case cirrhosis, EV)Shock/active bleed stable

-Sengstagen Blakemore EGD in 24hr-sandostatin

Varices non-varicebleed bleed

EVL/sclerosingOR Emer sandostain, ATB prophylaxis10-14day


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Abdominal paracentesis

PMN CultureSBP(no Sx condition)

>250 1

CNNA >250 negativeMNB 250 >1

- Abdominal paracentesisCell diff,count,G/S,C/S,Alb,LDH,Sugar,Total protein

-F/U abdominal paracentesis in 2-3day- Paracentesis SAAG (serum-ascites albumin gradient)(Serum Alb Abdominal Alb) > 1.1 = Portal hypertension

-Empirical treatment-ampicillin + Gentamicin-Cefotaxime 1g IV q6hr 2g IV q8hr-Ceftriaxone 2g IV OD

-Augmentin 1.2g IV q8hr- Cr>1 : Albumin 1.5g/kg IV drip in 6hr


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Corrosive ingestion

-NPO, NG, larvage, charcoal-0.9%NSS 1000ml IV 80ml/hr-CBC,Bun,Cr,Elyte-film acute abdomen series : perforation-PGS2.4munit IV drip in4hr / augmentin 1.2g IV q8hr

-omeprazole 40mg IV q12hr-scope in 6-12hr if>48hr -> risk to perforate

Endoscopic finding in corrosive ingestion

0 normal exam

1 edema and hyperemia of the mucosa2a

friability, hemorrhage, erosion, blister, whitishmembranes, exudates and superficial ulceration

2b 2a + deep discrete or circumferential ulceration

3

multiple ulceration and areas of necrosis

defined by areas of brown-black or grayishdiscoloration

grade 0-2a grade 2b-3 esophageal stricture

NPO, IV fluid 48hr, ATB*F/U 3wks,3mo,6mo,1yr -> esophageal dilatation


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Cardiology


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ASA (baby = 65mg) (Gr.I = 81mg) (Gr.V = 325mg)

MI prophylaxis 75-325mg ODStent implantation 325mg 2hr procedureJRA 80-100MKD 5-6times/day

Pain/fever325-650mg q4-6hr(max4g/day)

MS/joint disorder 2.4-3.6g/day divided dose

rt-PA(Alteplase)

0.9mg/kg IV over 60min with 10% doseinitial bolus 1min

PLAVIX(Clopidogrel) (75mg) 1 tab 0 OD

PLETAAL(Cilostazol)

(50mg) 1-2tab 0 bidRx claudication, PAD, IAS

CLEXANE

(Enoxaparin)

(40mg 0.4cc, 60mg 0.6cc)

1mg/kg Sc bid MI

Heparin4,000unit IV load then heparin(100:1)

6d/min (80Unit/Kg)F/U PTT,PTT ratio q6hr keep 2.0-2.5


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TRANSAMINE(Tranexamic

acid)

(cap250,500mg,amp50mg/ml) OR 1-2amp IV or IMMenorrhagia 4cap(1gm) tid

Sodium

Nitroprusside

0.25-0.5g/kg/min IV continuous with

ECG monitoring increase 0.5g

MAX 10g/kg/minISORDIL

(Isosorbidedinitrate)

(10mg)1 tab 0 tid ac

ISORDIL (5mg) 1 tab SL prn.

- IHD ASA, ACEI, STATIN, Beta-Blockers- Heart failure1)ACEI 2)ALDACTONE EF

3)ARB 4)Hydralazine + Nitrate5)Beta-Blocker(stableCHF->Bisoprolol,Carvidiol, Metoprolol)


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ACE Inhibitors

ACEI & ARB Proteinuria ( LVEV 2mg/dl -> dose)(renal artery stenosis)

ENARIL(Enalapril)

(5,20mg) 1tab OD or bidMAX 40mg

ACCUPRIL (5,10,20,40mg) 1tab 0 ODMAX 80mg

CAPTOPRIL(25mg) 1tab 0 bidMAX 50mg 0 bid

TRITACE(Ramipril) (2.5,5,10mg) 0 ODMAX 10mg/DayTANATRIL(Imidarpil)

(5,10mg) 0 OD

COVERSYL

(Perindopril)

(2,4,8mg) 0 OD

MAX 8mg


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ACEI Side effect

C CoughA AngioedemaP ProteinuriaT Taste changeO Hypotension

P Pregnancy changeR RashI Increase reninL Low AT II


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Angiotensin II antagonists

DIOVAN(Valsartan) (80,160mg) ODCO-DIOVAN

(Valsartan+HCTZ)(80/12.5,160/12.5,160/25mg) OD

APROVEL(Irbesartan)

(150,300mg) OD micro-> overt proteinuria

CO-APROVEL(+HCTZ) (150/12.5,300/12.5) ODBLOPRESS

(Candesartan)8,16mg(MAX) OD

BLOPRESS PLUS(+HCTZ) (8/12.5mg) OD

MICADIS(Telmisartan) (40,80mg)20-40mg OD MAX 80mgMICADIS PLUS(+HCTZ) (40/12.5,80/12.5mg) ODCOZAAR(Losartan) (50,100mg(MAX)) OD

FORTZAAR(Losartan + HCTZ)

(100/25mg) OD

OLMETEc(Olmesartanmedoxomil)

(20,40mg) OD cytochrome P450 50%

EXFORGE(Amlo/Valsatan) (5/160,10mg/160mg) 1 tab 0 OD


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Calcium antagonists

HERBESSOR

(30,60mg)HERBESSOR SR(90mg)(Diltiazem) 0 bidIV 20mg bolus(AF/SVT)continuous IV 10mg/hr(HT)

ISOPTIN SR(Verapamil) (240mg) OD-bid

ADALAT(5, 10mg)/NELAPINE(5,10mg)/NELAPINESR(20mg) (Nifedipine) 5-10mg 0 tidMAX 20mg tid

NORVASC(Amlodipine)

(5,10mg(MAX)) 0 OD

PLENDIL(Felodipine)

(2.5,5,10mg)5-10mg 0 OD MAX 20mg

MADIPLOT(Manidipine) (10,20mg)5mg OD MAX 20mgZANIDIP

(Lercanidipine)(10mg)1020(MAX) OD


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NIMOTOP(Nimodipine)

(tab 30mg, vial 10mg/50cc)IV drip 1-2mg/hr 1mg/hr(MAX 5mg/hr) 7-14Day then 2 tab6times daily SAH # total 21Day;treat CVA 1 tab o qid, IV drip

3d/min keep SBP 140-180mmHg

CARDEPINE(Nicardipine)

(Cap 40, Amp 2,10mg)1-2cap OD; 5mg/hr IV increase by2.5mg/hr q 5-15min MAX 15mg/hr

Beta-blockersPropanolol (10, 40mg) 1 tab 0 tidAtenolol (50, 100mg)1-2 tab 0 OD MAX 100mgMetoprolol

(betaloc)

(100, 200mg) 1/2tab 0 OD MAX 200mg

(Selective Beta 1)()Carvediol(DILATREND)

(12.5, 25mg) 1tab 0 OD(Beta1+Beta2)

Bisoprolol(CONCOR)

(2.5, 5mg)5-10mg(MAX)daily(Selective-Beta1)


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Other antihypertensives and diuretics

MINIPRESS(Prazosin) (1,2mg) 0.5mg bid-tidCARDURA

(Doxazosin mesylate)(1,2mg)XL(4mg) MAX 8mg OD

Methydopa

(ALDOMET) (125mg) 2 tab 0 tid

HCTZ(50mg)25-50mg daily MAX 100mg/Dayisolated hypertension

LASIX(Furosemide)

40mg, tab500mg, amp500mg) 1mg/kg IV/IM40mg IV (Good renal Cr1)250mg (Cr>2)

ALDACTONE(Spironolactone)

(25,100mg)2tab(25) 0 OD MAX 200mg

MODURETIC(Amiloride 5mg+HCTZ 50mg)1-2tab daily MAX 4tab


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Murmur

-Pansystolic-TR,MR-VSD at LLPSB

-Systolic ejection murmur (SEM)-AS,PS

-ASD at pulmonic area-pulmonary hypertension at pulmonic area

-Diastolic ejection murmur-AR,PR-MS,TS (mid-diastolic)(MS AF)

-Continuous murmur-PDA


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Acute coronary syndrome

-risk : DM, HT, DLP, smoking-Hi-light : STEMI, Pathologic Q wave, new LBBB-unstable angina VS NSTEMI : Trop-T-morphine 3mg IV stat if persistant chest pain-oxygen canula 3LPM keep O2sat>95%

-isodil(5) 1tab SL stat until 3tab hypotension-ASA gr.V 1tab stat-plavix(75) loading dose

-8tab stat -> primary PCI-thrombolytic agent

-75yr : 1tab stat loading dose

-4tab stat -> reperfusion therapy-CBC,PT,PTT,INR,UA,BUN,Cr,Elyte,FBS,lipid profile

-CPK,CK-MB,trop-T,EKG12lead-CK-MB,Tn-T in6hr,EKG at ward -> new LBBB,STEMI-ASA gr.V 1x1 0 pc -plavix(75) 1x1 0 pc-isodil(5) 1tab SL prn for chest pain-isodil(10) 1x3 0 ac // imdur(ISMN) 1 tab 0


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-simvastatin(20) 1xhs

-senokot 2tab 0 hs-ativan(0.5) 1xhs-enoxaparin0.6ml Sc q12hr x3-5day(renal insuf.0.4ml)-streptokinase1.5munit+NSS100ml IV drip1hr for STEMI-hydrocortisone 300mg IV push SK

-NTG(1:5) IV start 5d/min titrate q5min until painsubside or SBP ASA, ACEI, STATIN, -Blockers--Blockers

infarction cardiogenic shock :-atenolol 5mg IV in5min repeat in5min-atenolol 50-100mg/day

-statin group-atorvastatin 80mg/day 2months : standard

-control LDL


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TIMI score

-age >65years-3risk of CAD history-known case CAD (stenosis>50%)-ASA in 7day-Severe angina (>2times/24hr)

-ST depress >0.5mm physical exam-cardiac marker +ve

Risk of CAD

1.FH of CAD2.HT3.Hypercholesteralemia4.DM5.smoking

** TIMI sore 4 -> PCI in48hr


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Heart failure

-systolic HF = EF


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...88...

Heart failure OPD

-captopril(25) 1/2-1tab 0 bid pc-HCTZ(50) 1/2tab 0 bid pc

-digoxin 2tab 0 stat then 1tab OD

-ISDN(10) 1/2tab 0 pc +-hydralazine(10) 1x4 0 pc

Pericarditis

- ATB,Anti TB drug-NSAIDs Ibuprofen-ASA 800mg q6-8hr -> step down 800mg/wks-corticosteroid 0.5-1mg bid in day1 then 0.5mgbid x3month-pericardiocentesis


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...89...

Rheumatic heart disease

-strep gr.A esp. pharyngitis (skin )-Jones criteria (permanent damage)1.carditis : involve endo/myo/pericarditis2.migratory polyarthritis : asymmetrical, largejoint, response to aspirin

3.sydenham chorea : muscle weakness, pronatordrift 2(late clinical >3month)

4.subcutaneous nodule : extensor surface5.erythema marginatum :

-carditis : NSAIDs + steroid 2MKD-Primary prophylaxis-Benzathine penicillin G 1,2oo,ooo unit single dose-Penicillin V(500) 1x2 0 pc x10day-amoxycillin(500) 2x1 0 pc x10day

- penicillin-azithromycin(500) 1x1 0 pc x5day-clarithromycin(250) 1x2 0 pc x10day-clindamycin 450-600mg tid 0 pc x10day


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-Secondary prophylaxis

-Benzathine penicillin G 1,2oo,ooo unit IM q1month-penicillin V 250mg 1x2 0 pc-penicillin : macrolide 250mg 0 bid pc

-complication-AR +full expiration

-MR Infective endocarditis

-SBE : viridian strep. -> pen G-ABE, IVDU : S.aureus -> dicloxacillin, vancomycin-native valve : congenital disease-> viridian strep.-prosthetic valve-early 2mo After sx : s. epidermidis-late >2mo After sx : strep,stap

-mitral valve max, IVDU -> tricuspid valve

-RF : structural heart disease -> IVDU


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-splinter hemorrhage

Janeway lesion : non-painful on palm and soleOslers node : painful nodule : finger/toeRoth spot : exudates,edematous,hemorrhageEmbolic phenomenon

-ASD secondum, MVP prophylaxis

-prophylaxis-amoxycillin 50mg/kg, 2g

-Strep.-PGS 3mU IV q4hr + genta 1mg/kg IV q8hr x2wksthen PGS 4wks

-cefazolin 2g IV q8hr x4wks-Enterococci-ampicillin 2g IV q4hr + genta x2wks thenampicillin 4wks

-S.aureus-cefazolin 2g IV q6hr + genta x2wks thencefazolin 4wks

-MRSA-vancomycin 15mg/kg IV q12hr


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...92...

Atrial fib rillation

1.clinical unstable (BP drop, dyspnea, conscious change)-sedate-synchronized cardioversion (50->100->200J)

2.clinical stable-digoxin keep HR


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...93...

CCU

-keep K>4, Mg>2-renal failure Cr>1.4 -> fluimucil 3x2 0 pc

CAGCardiac catheteriazationartery

PCI Percutaneous coronaryintervention

PTCAPercutaneous transluminalcoronary angioplasty

PTMC Percutaneous transluminal mitralvalve commissurotomyHct keep >30, INR 1.5-2.0

PBMVPercutaneous balloon mitralvalvuloplasty

CABG

Coronary angioplasty bypassgraft-indication-triple vessel disease

-failed PCI-Class III


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chest


95/376

...95...

Mucolytic

BISOLVON(Bromhexine) (4mg/5ml) 1/2tsp tid5-10 -> 1-2tsp tid>10 -> 2tsp tid, 8mg 1x3 0 pc

Carbocysteine

(FLEMEX)

Adult2tab 0 bid

AMICOF Child 1cc/kg/Day

FLUIMUCIL(Acetylcysteine)

(100, 200, A200, A600mg)2200mg/Day2-6400mg/Day

>6

600mg/DayGlycerylguaiacolate

100mg 0 bid


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Cough depressant

dextrometrophan 1x3 0 pcM.tussis sip when cough

ROPECT,ROMILAR 1tab 0 tid

DecongestantMAXIPHED

(Pseudoephedrine)(tab 30, 60mg S.30mg/tsp)1mg/kg/dose tid-qid

Ephedrine0.1%,0.25%,0.5%,1% ac,hs

3-5ILIADIN(Oxymetazoline)

0.025% drop/spray1-2drops bid-tid each nostril

NASONEX(Mometasone furvate)NASOCORT(Triamcinolone acetonide)

BECONASE(Beclomethasone)FLIXONASE(Fluticasone)2spray each nostril OD maintainance 1spray


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...97...

Antihistamine + decongestant

DIMETAPP (Brompheniramine + Phenylephrine)2-4 1/2tsp4-6 1tsp>6 1.5tsp ; tid or qid

CLARINASE

(Loratadine + Pseudoephedrine) bid

(CLARINASE 24hr) OD

Bronchodilatora) Nebulizer

Ventolin NB 0.10ml/kg/dose

MDI 1-2puff prn q4-6hrAsmasal soln0.03ml/kg/dose MAX 1ml

b) Oral

VENTOLIN(Salbutamol)(S.2mg/tsp) 0.1mg/kg/dose q 6hr

2mg/tab 1x3 0 pcBRICANYL(Terbutaline)(S.1.5mg/tsp) 0.075mg/kg/dose q6hr3-6yr -> 1/2-1 tsp7-15yr -> 1-2tsp tid>15yr -> 2.5mg/tab 1x3,2x3

**MDI /DPI : turbuhaler(vapex),accuhaler()


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Anti-asthma

meptin 25g,syrupTheophylline(THEODUR)

(200mg) 1-2tab

SPIRIVA(Tiotropium)

Handihaler 1cap inhalation OD

SERETIDEACCUHALER

(Salmeterol+Fluticasone propionate)(25/50,50/100, 50mg/250mg)1puff bid

SERETIDE

EVOHALER

(25/50, 25/125, 25/250)

1puff bidRHINOCORTPULMICORT

(Budesonide)

Turbuhaler 2click bid(100-200mg/click)MAX 800mg/Day

SYMBICORT

(Budesonide + Formoterol fumarate)

Turbuhaler (80/4.5, 160mg/4.5mg) ODor bid rescuemaintenance

SINGULAIR(Montelukast)

1tab OD step2 asthma ICS


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...99...

Film AP chest

c-spine Vertebral endplate clavicle Medial end lateral endscapula lung fieldAir fluid Not seen in stomach

Thoracocentesis

-cell count, cell diff, G/S, C/S, AFB-protein, LDH, sugar-ADA >40-60 suspected TB-Light criteria for exudates

-parapneumonic effusion-positive for G/S, C/S-pH110


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Acute asthmatic attack

-o2canula 3-5LPM keep O2 sat>90%-ventolin 0.03ml/kg q15min x3dose via O2flow 6-8L/min-severe attack : poor air entry-> bricanyl 0.01ml/kg sc-PEFR berodual-Dexa 4-5mg IV q6hr -> prednisolone30-60mg/day OD

7 -HM

-salbutamol MDI 2puff prn-seretide(25/250) 1puff bid-prednisolone(5) 1MKD

-asthmatic drug controller-low dose ICS : budesonide, fluticasone -> -oral steroid-long acting 2-agonist

-salmeterol/formeterol DPI 1puff bid, MDI 2puff-theophylline (theodur 10MKD 0 bid pc)-anti-leukotriene

-montelukast 10mg 0 hs-zafirlukast 20mg 0 bid

Atopy : asthma + allergic rhinitis + atopic dermatitis


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COPD exacerbation

MILD -Berodual 1NBx3dose at ER if response -> D/c-prednisolone(5) 2x3 0 pc x5-7day-bromhexine 1x3 0 pc-augmentin(625) 1x3 0 pc x7-10day

-berodual MDI 2puff prn for dyspnea q4hr(2-agonist + ipatropium bromide)

Severe

-admit

-oxygen canula 3LPM keep O2sat>90%-dexa 10mg IV stat then 5mg IV q6hr-hydrocortisone 200mg IV stat then 100mg IV q6hr-berodual 1NB q4hr- prednisolone(5) 2x3 0 pc

-CBC,Sputum,CXR-augmentin 1.2g IV q8hr if infection-if sat intubation


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...102...

GOLD criteria for COPD

Class I(mild) II(moderate) III(severe) IV(very severe)

FEV1/FVC 80% FEV150-80% FEV1 30-50% FEV1


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...103...

Pneumonia CURB-65

C ConfusionU Urea (BUN>20)R RR >30/minB BP 65years

0-1 OPD case2 IPD case>2 ICU

Pneumonia

-cef-3 2g IV OD-clarithromycin(500) 1x2 0 ac-fortum 2g IV q8hr CCr +Clindamycin 600mg IV q8hr-paracetamol(500) 2tab prn q4-6hr

-bromhexine 1x3 0 pcPneumonia OPD(healthy + no ATB in3months)

-clarithromycin(500) 1x2 0 ac-azithromycin(500) 1tab 0 stat then 1/2tab OD


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...104...

Pneumonia

OPD Roxithro,clarithro,azithro7-10day

OPD+ heart/lung dz.

+gram negAmoxy/augmentin +Macrolide 0 7-10day

IPD Cefotaxime,cef-3,augmentin + macrolide

IPD ICU-Penam + IV macrolide pseudomonas

Pharyngitis/URI-para 2tab 0 prn q 4-6hr-amoxycillin(500) 2x2 0 pc-CPM(4) 1x3 0 pc-bromhexine 1x3 0 pc

Bronchitis / bronchiolitis

-para 2tab 0 prn q4-6hr-bromhexine 1x3 0 pc-rozithromycin(150) 1x2 0 ac

-clarithromycin(500) 1x2 0 ac


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TB treatment

INH(Isoniazid) 5mg/kg/Day (100mg) 3 tab 0 hs

Rifampicin 10mg/kg/Day50kg600mg1 tab hs

Pyrazinamide 25mg/kg/Day (500mg) 3 tab 0 hs

Ethambutol 15mg/kg/Day (400mg) 2 tab 0 hs

Streptomycin 15mg/kg/Day750mg/Day IM OD>50kg->1gm/Day IM OD,

- IRZE must Add Vitamin B6(Pyridoxine) 1 tab 0 hs- Clinical improve in 1wks, sputum AFB-VE in 2-3moF/U LFT after treatment 2weeksF/U sputum AFB 2,4,6mo + CXR 2,6mo

-low serum albumin dose

hepatotoxicity(I,R,Z)-low GFR, poor renal function ZES-pregnancy : IRE, liver disease : ISE, cidal : IRZS*Rimstar-4 (I75,R150,Z400,E275) 2

75kg -> 5tab 55-75kg > 4tab38-54kg -> 3tab 2tab


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2nd line drug for TB

50kgThiacetazone 150mg/dayAmikacin15MKD IM OD

500 750 1,000

Kanamycin

15MKD IM OD 500 750 1,000Ofloxacin 7.5-15MKD(200) 2x2 0 pc

400 600 800

Ciprofloxacin 750mg/day

Para-amino-salicylateacid 200MKD(1g) 4x2 0 pc

8g 10g 12g

Cycloserine10-20MKD(250)

2tab 0 + 1tab hs

500 500 750

Ethionamide10-20MKD(250)2tab 0 pc+ 1tab hs

800 1,000 1,200

*TB meningitis : 2IRZE+7IR F/U LP*CAT2 (2IRZES,1IRZE,5IRE)


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Acute pulmonary edema

-cause : MI,MS,MR,HT,CHF-CBC,BUN,Cr,BS,Elyte,EKG,CXR,ABG-on HL-basic

-

-MO 3mg IV slowly push-lasix 40mg IV push-NTG 0.4mg SL SBP > 100

-clinical not improved

-NTG(1:10) 10mg + 5%DW 100ml IV 6d/min-SBP


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...108...

ARDS

-CXR : diffuse bilateral infiltrationA AcuteR Ratio PaO2/FiO2


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...109...

Flu H1N1

-adult : oseltamivir(tamiflu) 75mg 1tab 0 bid x5day-children :40kg 75mg 0 bid x5day


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...110...

Neurology


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...111...

II VA,VF,fundoscopic

III,IV,VI Light reflex, EOMV

Pinprick sensation, jawCorneal V VII

VII Close eye, show teethVIII Doll eye, caloric test, weber, rinne

IX,X Gag reflex, uvula shift

XI,(stenocleidomastoid,trapezius)

XIIProtrude tongue lesion

lesion-+sensory level -> spinal cord- + glove&stoking -> PNS-Dolls eye -> cerebral cortex frontal lobe

-Caloric test -> nystagmas-kernig sign -> -> -Brudzinski sign -> > -UMN : spasticity, increase reflex, BBK +ve

-LMN : normal tone, hyporeflexia, BBK ve


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...112...

weakness

UMN LMNNumbness

Yes no yes no

Motor neuron dz muscle, NMJ dermatome->nerve root

-contralateral brainstem nerve -> nerve-cerebral lesion glove&stoking ->

peripheral neuropathy-ipsilateral hemicord lesion


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...113...

Anticonvulsant

free symptoms >2yr slow reductionPhenobarb

Gr.I 1-2tab 0 bid-tid pc(60-240mg/day)

DILANTIN(Phenyltoin)

(50mg feed ,100mg)MAX 600mg/Day

*100mg IV q 8hr or(100mg) 3tab 0 hs or(50mg) 2tab 0 tid

Free dilantin level

=[dilantin/(0.2xalbumin)]+0.1S/E dilantin

Nystagmus, diplopia, ataxia,cerebellar signs +ve, hepatotoxic,N/V, skin rash(TEN,SJS)

** gum hypertrophy

1)Test EOM2)Test nystagmus3)Finger To Nose


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...114...

DEPAKINE(Na Valproate)

(200mg)/CHRONO(500mg)

heart Disease*400mg IV q8hr, 1x2 0 pc*Depakine sol. 2-2.5cc 0 q8-12hr*15mg/kg loading2,000mg IVdrip in 24hr 1mg/kg/hr

Carbamazepine

(200mg)/TEGRETOL(600mg)10-20mg/kg/DayAgranulocytosis epilepsy : 1-2tab 0 tid-qid

trigeminal neuralgia : 1x3TRILEPTAL(Oxcarbazepine)

(300, 600mg)600-2,400mg/Day 0 bid

TOPAMAX(Topiramate)

(25,50,100mg)Treat migraine (25mg) 0 hs

NEURONTIN(Gabapentin)

(cap 300,400, tab600mg)900mg/3dose to 3,600mg/Day

LYRICA(Pregabarin)

(75,150,300mg)(75)x2 -> (150)x2 -> MAX (300)x2


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...115...

Anxiolytic drug(benzodiazepine)

ultrashort Midazolam(dormicum)Short

Lorazepam(ativan)Alprazolam(xanax)

intermediate Diazepam(valium)

Diazepam(VALIUM) 0.1-0.3mg/kg IV/IM0.3-0.5mg/kg rectal suppLorazepam

(ANXIRA/ATIVAN)(0.5, 1mg)0.52mg 0 daily; 2-4mg IV

RIVOTRIL

(Clonazepam)

(0.5, 2mg)

1-1.5mg tid maintenance 3-6mg/DayXANAX

(Alprazolam)(0.25,0.5,1mg)0.25-0.5mg tid MAX 10mg/Day

FRISIUM

(Clobazam)

(5mg)

20-30mg dailyTRANXENETRANCON

(5, 10mg)anxiety, insomnia 520mg/Day


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...116...

Antidepressant

Amitriptyline (10,25mg)75-150mg/Day in divided doseNORTRILEN

(Nortriptyline)(10, 25mg)10-25mg bid-tid // 150-225mg/Day

Fluoxetine

(PROZAC)

(20mg)

1 tab 0 OD MAX 80mg

ZOLOFT(Sertraline)

(50mg)Treat depress, OCD, PTSD, Panic,

Social phobia

1tab 0 OD MAX 200mg/DayHypnotic and sedative

Chloral hydrate(100mg/ml)0.5ml/kg/dose(25-50mg/kg/dose)q6-8hr

MAX 1g/doseDORMICUM

(Midazolam)(tab 15mg, amp 15mg/3ml)1-2tab 0 hs 1/2tab 0 hs

STILNOX(Zolpidem

hemitartrate)

(10mg)

1tab(MAX) 0 hs


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...117...

Antipsychotic

Haloperidol(HALDOL)

(tab5mg, drop2mg/ml, amp5mg)0.5-1mg bid5-25mg IM or slow IV

Chlorpromazine (100mg) 25mg tid // 25-50mg IM

Clozapine(CLORIL)

(25, 100mg) treat schizophreniastart 12.5mg 0 bid-> to target300-450mg/Day within 2-3wk

LAMICTAL

(Lamotrigine)

(25, 50, 100mg)treat bipolar prevent mood

episode25mg OD-bid totarget 200-400mg OD-bid


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...118...

Antiparkinsonian drug

Selegiline 5-10mg in 2divided dose

SINEMET

(Carbidopa+Levodopa)(25/100, 25mg/250mg) (25/100)1tab tid Increase 1tab everyday(25/250) 1/2tab OD to bid increase

1/2tab everyday (MAX 8tab)COMTAN

(Entacapone)(200mg) 1 tab/dopa()max 2,000mg/Day

SIFROL(Pramipexole)

(0.25, 1mg)

0.125(1wk) -> 0.25(2wk) -> 0.5(3wk) 0tid up to 4.5mg/Day(MAX)decrease dose in pt. with levodopa

ARTANE(Trihexyphenidyl)

(2, 5mg)treat drug induced parkinsonism

5-10mg ODtreat parkinsonism 1mg -> 1stDay,

2mg -> 2ndDay, increase 2mguntil 6-10mg/Day

Bromocriptine (2.5mg) as dopamine agonist4-12tab 0 tid (treat parkisonism)


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...119...

Neurodegenerative drug and others

EXELON(Rivastigmine)

(1.5,3,4.5,6 mg)(1.5 mg)tab bid -> 3 -> 4.6 ->6mg bid(MAX)

TANAKARN

(Ginkgo biloba ext)

1 tab tid or 2 tab bid Improvecognitive and neuron-sensorialdisorders in aging

SERMION(Nicergoline)

(10,30mg)(10) 0 tid or (30) 0 bid

REMINYL(Galantamine)

(4,8mg)

(4) bid 4wk(8) bidat least 4wk MAX 12mg bid

ARICEPT

(Donepezil)

(5, 10mg)5mg/Day MAX 10mg/Day

Treat mild-moderately severeAlzheimers dementia

CEREBROLYSIN

protein-free hydrolysate in soln

(Amp 1, 5, 10ml) IM up to 5cc,IV up to 10cc, IV drip 10-30cc;

1 amp IV q 8hr


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...120...

ENCEPHABOL(Pyritinol)

(100,200mg)300-600mg ODChild 50-300mg OD >= 6wk

METHYCOBAL(Mecobalamin)

(Amp/tab 500mcg)1tab 0 tid

1amp IM or IV 3time/wk

NOOTROPIL(Piracetam)

(Cap400mg, Tab800,1200mgAmp 1gm,3gm, Vial12gm)(1200)bid or(800)tidChild 30-50mg/kg/DayRx CVA12gm IV bolus-> 12gm/Day

Methylphenidate(CONCERTA)

(18, 36mg)18-54mg/Day at morningtreat ADHD

MINIRIN(dDAVP)(Desmopressin

acetate)

(tab 0.1, 0.2, spray 0.1mg/ml)Central DI tab 0.1-0.2 tidNasal 10-20mcg 1-2 time;0.025ml IN q 4hr hold if urine


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...121...

Recombinant

activated factorVIIa(rFVIIa)

4hr

ICH

Methylprednisolone

Spinal cord injury30mg/kg bolus dose thenmaintenance 5.4mg/kg/hr for

24hr( cc.- Increase intracranial pressure Sx midline shift >1cm, 0.5-1 gray zone


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...122...

Glasgow coma scale(Severe head injury GCS 3-8)Eye opening

4 spontaneously 3 to speech2 to pain 1 no response

Best verbal5 orientate 4 confused

3 inappropriate words2 incomprehensible sounds 1no response

Best motor

6obeys commands 5 localizes pain4 withdrawal 3 flexion to pain2 extension to pain 1 no response

Silent area of brain

1)Pineal gland midline lesion2)Frontal lobe

3)Temporal Rt.dominant4)Parietal5)Occipital


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...123...

concussionTransient loss of conscious


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...124...

Head injury

-Admit-NPO-CBC,BUN,Cr,elyte-CXR-film skull series + c-spine portable

-CT brain emergency-0.9% NSS 1,000ml IV drip 80ml/hr-record V/S q 1hr then q2hr-observe neurosign q2hr if GCS drop>2 pls. notify-if depress skull fracture

- >10mm. -> pneumocephalus, FB-PGS 2.4munit IV q4hr-chloramphenicol 1g IV q6hr-mannitol

Goal of stroke

BP


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...125...

Ischemic stroke

-CBC,UA,BUN,Cr,Elyte,FBS,lipid profile,LFT,VDRL,TPHA-CT brain-CXR,EKG12lead--observe neurosign q4hr if GCS drop2 pls. notify

-simvastatin 1xhs-ASA gr.V 1x1 0 pc, clopidogrel(75) 1x1 0 pc-losec(20) 1x2 0 ac-B1-6-12 1x3 0 pc

-folic acid 1x1 0 pc -> decrease homocysteine-IV dextrose -> brain toxic- cardioembolic cause

-EKG,echo-warfarin(3) 1x1 0 hs -> keep INR 2-3

prosthetic valve keep 2.5-3.5 (3mo-1yr)-enoxaparin

-control BP


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...126...

Hemorrhagic stroke

-CBC,UA,BUN,Cr,Elyte,Ca,Mg,P,albumin-LFT,PT,PTT,INR-NPO--record V/S q2hr if BP>180/110mmHg pls. notify

-NTG(1:5) 3drop/min titrate2dropkeep SBP140-160mmHg

-nicardipine 20mg + NSS 80ml(1:5) IV 5ml/hr-record urine output q4hr keep>120ml/4hr-DTX q1hr keep80-200mg%-observe neurosign q2hr if GCS drop2 pls. notify-CT brain emergency-dexa 10mg IV stat then 5mg IV q6hr-on ETT if GCS drops

Midline shift

-hyperventilation-IV fluid-mannitol/glycerol, diuretic, steroid


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...127...

Bacterial meningitis

-empirical 2weeks-cefotaxime 2g IV q6hr-cef-3 2g IV q12hr-vancomycin 1g IV q12hr

-specific

-salmonella : cef-3 2g IV q12hr-H.influenza : ampicillin + chloram-pseudo. : fortum 2g IV q8hr-S.aureus : cloxacillin 9-12g/day

-meningococcemia- : ciprofloxacin 750mg 0 stat

Rifampicin 600mg 0 bid x2day


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...128...

Seizure

-mens -> increase estrogen -> decrease seizurethreshold-recovery position--clear airway + mouth gag + oxygen canula 3LPM

-BS,CBC,BUN,Cr,Elyte,dilantin/depakine level-valium 1amp IV push-thiamine 100mg IV-50%glucose 50ml IV push

CBZ,PHT Partial,GTCVPA Generalized,JME

ethosuximide Absence seizurevigabatin Infantile spasm

** clonazepam


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...129...

Status epilepticus

-valium 10mg IV stat slowly push orlorazepam 4mg IV stat-B1 100mg IV + 50%glucose 50ml IV push-Phenyltoin(dilantin) load 20mg/kg(750mg) + 0.9%NSS100ml IV drip in 1/2hr (rate dilantin load 10mg/kg 1dose-monitor BP if max 30mg/kg- -> ETT+ventilation -> Phenobarbital1,ooomg + NSS50ml IV drip in15min

-dormicum 5mg IV push then 1mg/hr


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...130...

Myasthenia gravis

-test : prostigmine1/2amp IM 15,30,45min-atropine 1amp 15min SE-mestinon(60)(pyridostigmine) 1x3 0 pc(max16tab/day)15-30min 3-6hr

-prednisolone(5) 2x3 0 pc -> 5mg/day q2wks

-CaCO3(1250) 1x1 0 pc-ET-tube -> if RS failure-IVIG, thymomectomy, plasmapharesis

Dizziness-dimenhydrinate(50) 1x3 0 pc-domperidone 1x3 0 ac-3B 1x3 0 pc

Anxiety

-diazepam(5) 1xhs

-amitriptyline(10) 1x2 0 pcAlcohol withdrawal

-valium 1amp IV stat repeat q15min-thiamine 100mg IV OD x7day-3B 1x3 0 pc, folic acid 1x1-diazepam(2) 1x2, diazepam(5) 1xhs


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...131...

MigraineDx4-6month

-para(500) 2tab 0 prn-ibuprofen(400) 1x3 naproxen,diclofenac-cafegot(ergotamine) 1tab 0 q6hr for headache(max6tab/day)

-prophylaxis

-propranolol(40) 1x2 0 pc-amitriptyline(10) 1x1,1x2-flunarizine 5-10mg/day-topiramate 50-200mg/day

Cluster headache

-cafegot 1tab 0 q6hr-litium(300) 1x2 0 pc-attack O2mask with bag

Tension headache

--amitryptyline(25) 1xhs-fluoxetine 20mg


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...132...

Neuroleptic malignancy syndrome

-confusion, agitation, high fever, high BP,tachycardia, sweating-severe muscle rigidity, dystonia-increase CPK, myoglobinuria, leukocytosis, ARF-off antipsychotic drug

-oxygenation, hydration, nutrition-bromocriptine 2.5-5mg 0 tid-dantrolene 1mg/kg IV ->repeat dose max 10mg/kg

Acute dystonia

-torticollis, oculogyrus crisis-benztropine(cogentin) 1-2mg IM/IV-diazepam 5-10mg IV-artane continue oral


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...133...

Renal


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...134...

UTI

-lower : norfloxacin(400) 1x2 0 pc x3dayPreg : 0minef(100) 2x2 0 pc x7day-upper :

-cef-3 2g IV OD fortum 2g IV q8hr-gentamicin 240mg IV OD then

-ciprofloxacin(500) 1x2 0 ac 14-ofloxacin(200) 1x2 0 pc

-urethritis : cef-3 250mg IM + doxy 1x2 7dayNephrotic syndrome

-proteinuria (UPCI >3.5), hypoalbuminemia,hypercholesterolemiaedema(periorbital swelling)-prednisolone 1MKD (max60mg) 2weeks

Not improve improve

Cont. until urine protein 0.75MKD 4-6wksNegative 12wks

Tape off in 6-12monthRenal biopsy


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...135...

Acute renal failure

-correct Elyte-low salt, high carbohydrate diet-record I/O keep UO>0.5ml/kg/hr-lasix40mg IV then titrate dose-dopamine

-dialysis-BUN/Cr >150/10-K >7.0 with fail medication-fluid overload-uremic pericarditis-refractory metabolic acidosis

prerenal ATN

Urine sp. Gr. >1.020 40 20


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...136...

End stage renal disease

-CBC,UA,BUN,Cr,Elyte,Ca,Mg,P,albumin-CXR-lasix80mg IV stat then 1g IV drip in 24hr-oxygen mask with bag 10LPM-retain foley cath

-G/M PRC if anemia-record urine output keep>200ml/4hr-low protein diet, low salt diet-restrict oral fluid CCr off-hydralazine(25) 1x3 0 pc Cr>1.8-madiplot(10) 1x2 0 pc

-aldomet(250) 1x3 0 pc-lasix(500) 1/2x2 0 pc-NaHCO32x3 0 pc -> treat metabolic acidosis-caltrate(600) 1x2 0 pc-FBC 1x3 0 pc-folic acid 1x1 0 pc


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...137...

Renal failure round

A Anemia, acidosis(Uremia)B Blood pressureC Ca, Mg, PD Diet proteinE Elyte potassium

F Fluid I/OG Glucose

SIADH

1)hyponatremia, hypoosmolar 1003)urine Na >40mmol/L4)euvolemia5)renal, adrenal, thyroid : normal

Contrast-induced nephropathy

-NSS 1-1.5ml/kg/hr 8-12hr -NAC 600mg bid


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...138...

Endocrine


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...139...

Metabolic syndrome

-central obesity (90cm male, 80cm female)-TG>150 -HDL85 -FBS>100 DM

* waist circumference1. 10 2.

3. 4.

Hypoglycemia

-CBC,UA,BUN,Cr,elyte,DTX stat-FBS 50%glucose

-50%glucose 50ml IV stat-10%DN/2 1000ml IV 100ml/hr-DTX q1hr keep 80-200mg%-off DM drug


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...140...

Diabetic ketoacidosis

*volumn--(K)-(NaHCO3)--CBC,BUN,Cr,elyte,FBS,UA-serum ketone, urine ketone-EKG, ABG

-0.9%NSS 1,000ml->1,000ml->500->250ml->maintain-DTX stat then q1hr-RI 10unit IV + RI 10unit Sc -> DTX-RI(1:1) 100unit + 0.9%NSS 100ml IV 10ml/hr(10u/hr)-control DM 50-75/hr(RI2)-if DTX 5%DN/2 + RI drip-acidosis -> 7.5%NaHCO3 50ml IV push-if EKG tall peak Twave -> Rx/treat>50ml/hr

-bradycardia hyperK->atropine 1amp IV x2dose-keep BP>90/60mmHg -> dopamine-DTX q1hr, Elyte q2hr-correct Na = Na+ [BS-100/100x1.6]


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...141...

Graves disease

-PTU(50) load 100mg 0 tid -> euthyroid in4-6wk ->maintenance 50mg bid-MMI(5) 1x2 0 pc-propranolol(40) 1/2tab 0 tid pc

Hypothyroidism

-L-thyroxine(o.1mg/tab)Young : 1tab 0 OD acAging : 1/4tab 0 OD acCHD : 1/4tab 0 OD ac

Lid retraction Upper lid limbusLid lag upper lid


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...142...

Thyroid strom

Temperature37.2-37.7 537.8-38.2 1038.3-38.8 1538.9-39.3 20

>40 25GI symptom

normal 0diarrhea 10

Unexplained jaundice 20CNS

normal 0agitation 10

Delirium,psychosis 20Seizure,coma 30


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...143...

CVS

HR90-109 5110-119 10120-129 15130-139 20

>140 25CHF

no 0Pedal edema 5

Bibasilar rales 10Pulmonary edema 15

AF

no 0yes 10

Precipitate

no 0yes 10


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...144...

45 Thyroid strom-PTU 600mg load then 300mg q6hr(rectal suppo)MMI 120mg rectal suppo. OD-SSKI/Lugol solution KI 200mg/day bidx7day

(1SSKI = KI 50mg, 1lugol = KI 10mg) PTU 1hr (10drop oral q6hr)-dexamethasone 5mg IV q12hr x3day T4->T3- : paracetamol

-5%DN/2 1000ml + Bco 2ml IV


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...145...

Adrenal insufficiency

-Hx of steroid use- adrenal hormone-post-op/radiation of pituitary gland-postpartum bleeding -> Sheehan

-unexplained shock

-Lab : hyponatremia, hyperkalemia, met. Acidosis: hypoglycemia: serum cortisol


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...146...

Hematology


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...148...

-indication for antivenom (hematotoxin)

-VCT>30min-plt


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...149...

Febrile neutropenia

-BT>38.3

o

c, >38

o

c 1hr-ANC50, ANC


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...150...

Thalassemia

-FeSO4->folic acid-desferoxamine25MKD Sc in12hr x5day/week

-deferiprone oral75MKD 0 tid pc

desferoxamine 2times/weekAIHA

-DCT +ve, ICT ve (HS -> negative)-warm type(IgG)

-prednisolone 1-1.5MKD 7 HbHb>10 5-10mg/wk 20mg/day5mg/month off

-folic acid, anti-HIv, ANA- severe anemia

-cold type(IgM)-acrocyanosis-, steroid-warm-folic acid

- cross-match less-incompatable


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...151...

ITP

-keep platelet >30,000-prednisolone 1MKD oral 2wk 1month plt.>100,000 5-10mg/wk 20-30mg/day 5-10mg/mo off

-pulse dexamethasone 40mg/day 0 x4day q2wk

x4cycle-pulse methylprednisolone 30MKD-severe : IVIG

-400MKD x5day-1g/kg/day x2day

TTP

-MAHA + decrease plt. + fluctuate neuro sign-ADAMTS 13-DDx : HUS renal

-plasma exchange plt,LDH normal-steroid

-dexamethasone 40mg/day x4day-methylprednisolone 1g/day x3day

-folic acid-plt. -> thrombosis


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...152...

HIT

-heparinplt-2do-do stop heparin-do start non-heparin anticoagulant :fondaparinux

-2dont-dont give warfarin : increase skin necrosis-dont give platelet

-2diagnosis-lab-DVT : most complication

-fondaparinux->warfarin plt.>150,000 3-6mo.-heparin antibody HIT

Polycytemia vera

--vasomotor : headache, transient neuro/ocularParesthesia-low dose heparin, atarax-phlebotomy : keep Hct male


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...153...

Essential thrombocytosis

-hydroxyurea, -interferon-NSAIDsHodgkin lymphoma

-reed-sternberg cell-B-symptom : fever, night sweat, weight loss

-alcohol induced pain and pruritus-metastasis to LN

Multiple myeloma

-plasma cell

-CRAB syndrome-monoclonal gammopathy, end organ damage-early treatment

-hydration-decrease hypercalcemia

-decrease pain, anemic symptom


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...154...

Deep vein thrombosis

-Homans sign : positive-Virchow triad : venous stasis, vascular injury,hypercoagulopathy

-D-dimer, Doppler U/S-enoxaparin Sc CCR>30 CCr

monitor observe bleed-observe clinical bleeding-heparin 80unit/kg loading then 18unit/kg maintain PTT,PTT control q6hr 1.5-2.5 ( antidote = protamine sulfate)

-heparin 3-5 platelet countheparin induced thrombocytopenia

-warfarinheparin INR 2.5-3.0off heparin INR 2

--off heparin 6hr-off LMWH 1-2day-off warfarin 5day-start 1-2day


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G-6-PD deficiency(X-linked resessive)

Sulfa groups, Quinolone groups, Antimalarials, Aspirin,Chloramphenical, PAS(Para-aminosalicylate- TB),Methylene blue, Dapzone( Leprosy),Furazolidone(Anti-diarrhea pectin +kaolin),Nitrofurantoin(ATB), Nitrofurazone(ATB),

(Fava beans), Naphthalene tumor lysis syndrome

-BUN rising, azotemia, ARF-decrease Ca level from hyperphosphatemia-increase uric acid, K, PO4 level-lactic acidosis-allopurinol 300-600mg/day OD,bid 1-2wks-alkalinized urine pH5.6-7.0 by 0.9%NSS + 7.5%NaHCO3Off pH>7.0

-fluid loading 2-3L-10%calcium gluconate 50-100mg/kg IV slowly ifclinical hypocalcemia


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Hypercalcemia of malignancy

-IV fluid urine3-lasix if adequate volumn status-bisphosphanate Cr30

-pamidronate60-90mg +NSS 500ml IV in2-4hr-zoledronic acid 4mg +Nss 100ml IV 15-30min

-ibandronate 6mgIV in1-2hr-calcitonin Ca>15

4-8unit Sc q6-12hr-steroid 40-60mg/day for malignancy

HemophiliaHemophilia A

-cryoprecipitate 1U/kg IV q12hr (2%)-1factor VIII 100unit-mild 20-30%, moderate 50%, severe 100%

Hemophilia B-FFP/cyro-removed plasma 1U/kg IV q24hr (1%)


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PRC (200ml/U) 10-15ml/kg 3% / unitPlt. conc 0.2u/kg 25,000-30,000FFP(180-250ml/u) 10ml/kg Factor VIII,IX,XICryoprecipitate 0.1u/kg Factor VIII 10-15% 4hr

FFP, plt.conc, cryoprecipitate free flowBlood transfusion

-PRC : AgVS Ab-plasma :

A : A,ABB : B,ABAB : ABO : A,B,O,AB


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Rheumatology


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Septic arthritis

-non-GC : acute monoarthritis-GC : acute polyarthritis, skin lesion, tendonsheath involvement

normal inflam Septic

Appearance clear

Clear -

opaque OpaqueWBC 2,000 >5,000PMN 50% >75%

Culture - - +

disease - RAcyrstal infection

GCCef-3 2g IV OD x14dayRx partner : ciprofloxacin 500mg 0

Non-GC

Gram +ve cocci : cloxa 1g IV q6hrGram ve bacilli : cef-3 2g IV ODcephalosporin :

ciprofloxacin 400mg IV q12hr


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Rheumatoid arthritis

-criteria Dx : 47 6wks1.morning stiffness >1hr2.polyarthritis >3joint3.arthritis hand joint4.symmetrical joint (except : DIP)

5.rheumatoid nodule : most common olecranon6.serum rheumatoid factor7.radiographic change

-NsAIDs :-naproxen 250mg bid-diclofenac 25mg tid

-DMARDs : immunomodulatory agents-chloroquine 250mg/day orhydroxychloroquine 200mg bid

macular toxicity -> F/U eye-metrotaxate 5-7.5mg/week -> F/U LFT-sulfasarazine 500-1,000mg bid


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LAb treatment


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- Rapid shallow breathing index

= RR(/min) /TV(L); if4 = Renal- Correct reticu locyte count;correct

= reti(%) * (Hct / normal Hct)

- Correct ca lcium

= {0.8*(4-Albumin)} + Ca- GFR

= [(140-age)*kg]/[72*serum Cr] *(0.85 female)- Serum Osm

= (2Na) + (Glu/18) + (BUN/2.8)- Uprotein/Cr ratio

= X gm/Day of protein; if>3.5 nephritic- PaO2/Fio2


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Blood Gas(PaO2>80, PaCO2= 40, pH 7.4, HCO3= 24)

PAO2= (713*FiO2)(PaCO2/0.8); (A-a)DO2 12ketoacidosis, lactic acidosis, renal insufficiency,if normal gap renal tubular acidosis

-Alkalosis(Change PaCO2) = 0.6* (ChangeHCO3) andurine Cl if > 20mEq/L mineralocoricoid excessor profound K depletion


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Hyponatremia

-correct Na

+

= (-)xBWxo.5-o.6-treat -> osmotic demyelination syndrome

Spastic quadriplegia, dysarthria, dysphagia- TBW = 60% BW = 0.6xkg = xL

Na 10mmol/L/day = 10x/24hr3%NaCl Na 513mmol/L

513mmol 1,000ml -> 10x -> $ml $ml/24hr -> *ml/hr

-euvolemia -> 3%NaCl 300cc IV 3BW/20 cc/hr(2cc=1mEq) 2(125-Na)hr

-hypovolemia -> 0.9%NaCl 1000ml IV BW/2 d/min 2(125-Na)hr

-NaCl 1tab = 10mEq

* central pontine myelinolysis(CPM) -> quadriplegia, (>12mEq/day) F/U elyte q2hr


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Hypernatremia

-water def. = TBWx(Na-140/140)()TBW : =0.5BW , =0.4BW

-rateNa = 0.5mEq/L/hr (


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Hyperkalemia

**off-Ca-bicarb-RI--Kx-check lasix-mix dialysis**off: ACEI,spironolactone,beta-blocker,NSAIDs**tall peak T wave,QT ,PR -> QRS , P->sine wave

K>8

hemolysis, Plt>106, WBC >105-kayexalate 30g +20%sorbitol 50ml 0 q3hr x3dose-kalimate30g + 100ml 0 q3hr x3dose(rectal suppo)-50%glucose 50ml + RI10unit IV push ESRD-10%calcium gluconate 10ml IV push (K>6.5)(membrane)(EKG change)-7.5%NaHCO3 50ml IV push in5min-10%DW 500ml + RI10unit IV drip in1hr-albuterol 0.5mg IV // 10-20mg NB

-lasix 20-40mg IV push-bricanyl 0.5mg Sc q4hr-adrenaline 2amp + DW100ml IV 10ml/hr


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Hypokalemia

-KCl elixir 30cc 0 q3hr x 3dose-add in IV maximum 80mEq -> plebitis-central


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Hypermagnesemia

-10%calcium gluconate 10ml + 5%D/W100ml IV in 10minHypomagnesemia

- hypokalemia, hypocalcemia-50%MgSO4 4ml + 5%DW 100ml IV drip in 4hr x3day

Hyperphosphatemia

-CaxP >55 : aluminium hydroxide 30ml 0 tid-CaxP


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* hypoxemia hypoxia

hypoxemic hypoxia* PaO2hypoxemia room airFiO2 PaO2/FiO2 >500* A-a gradient

PaO2 + PaCO2 (room air)


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*metabolic acidosis

H

+

->HCO3buffer -> RS center -> kussmal breathing -> PaCO2

*metabolic acidosis1.normal gap = Na-(Cl+HCO3) 162.1.pure2.2.not pure

Delta gap/delta HCO3 = anion gap-12/24-HCO3Delta gap/delta HCO

3

Interpretation

=1 (0.8-1.2)Pure wide gap withmetabolic acidosis

1.2)Wide gap metabolic

acidosis withmetabolic alkalosis


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Metabolic acidosis

Expected CO2= 1.5HCO3+ (8+/-2)Metabolic alkalosis

Expected CO2= 0.7HCO3+ (20+/-2)

CO

2

pH HCO

3

Acute acido 10 0.08 1Acute alkalo 10 0.08 2Chronic acido 10 0.03 4Chronic alkalo 10 0.02 5


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Toxicology


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Paracetamol overdose (toxic dose 150mg/kg,>7.5g/day)

-CBC,BUN,Cr,Elyte,LFT-acetaminophen level at4-24hr-NG larvage & retain NG (


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Organophosphate poisoning

-cholinesterase SLUDGE syndrome + miosisbronchoconstriction bradycardia

-larvage, activated charcoal-atropine1-2amp IV push q15min until secretion

keep PR 3-6amp IV push-coma -> atropine10amp + 5%D/W200ml IV 15drop/min-pralidoxime (1amp = 1g)

1-2amp + NSS100ml IV drip in30min repeat q6hr(max 12g/day)

Benzodiazepine poisoning

-diazepam, clorazepate, lorazepam, alprazolam-Flumazenil 0.2-0.3mg IV push then 0.3-0.5mg IV

q1min (max dose 3-5mg)(monitor EKG)- TCA overdose -> QRS prolong

QUOMEM(Bupropion)

treat nicotine dependence aidto smoking cessation1tab OD *3Day 1tab bidMAX 2tab/Day


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Paraquat poisoning

-,,,- -30%fuller earth 200ml 0 q2-4hr-MOM 30ml 0 q4hr diarrhea-5%DN/2 1,000ml IV 100-250ml/hr

-lasix 20mg IV qid-cyclophosphamide 5MKD (q8hr)-dexamethasone 10mg IV q6hr-CPM(4) 1x4 0 pc 1week-vit C 6g/day-vit E 2tab 0 qid


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Amphetamine overdose

- -tachycardia, tachypnea, hypertension,hyperthermia, mydriasis, diaphoresis, neuro. Def.

-Elyte,BUN,Cr,CPK,LFT,PT,CXR,EKG-urine for methamphetamine

-CT brain for seizure, coma-activated charcoal-IV fluid, oxygen-diazepam 5mg IV then repeat-treat HT : sedation, sodium nitroprusside


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ENT


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Weber test

SNHL Lat. To better earCHL Lat. To poorer earNormal, Not lateralized

Severe/profound SNHL Rinne test

Normal,SNHL AC>BC (+ve)CHL AC=BCCHL BC>AC

Severe SNHL


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Antihistamine

H1 1

st

generation

diphenhydramine(25-50mg) 1x2 0 pc

Cyproheptadine(2-4mg) 1x3

CPM(Chlopheniramine)

(tab 4mg, S.2mg/tsp)0.35mg/kg/Day tid or qid

ATARAX

(Hydroxyzine)

(tab 10mg, S.10mg/tsp)1-2mg/kg/Day bid


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H1 2

nd

generation

cetirizine (10mg) 1tab 0 hsCLARITYNE

(Loratadine)

(tab10mg,S.5mg/tsp)BW30kg10mg OD

AERIUS(Desloratadine)

(Tab 5mg, S. 2.5mg/tsp)

1-51/2tap OD6-111/2tab/1tsp OD>121tab/2tsp OD

TELFAST

(Fexofenadine)

(30,60,180mg)

60mg bid or 180mg OD6-1130mg 0 bid

Actifed(NASOLIN)

(Pseudoephedrine 30mg+Tripolidine 1.25mg/5ml)

1mg/kg/dose of

pseudoephredine tid-qid


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Allergic rhinitis(,,, )

1

st

gen. sedating-CPM(4mg) 1x3 0 pc-diphenhydramine(benadryl) 25-50mg q4-6hr

2

nd

gen . non-sedating

-cetirizine(zyrtec) 10mg 1x1 0 pc

-loratadine(clarityne) 10mg 1x1 0 pc-fexofenadine(telfast) 60mg 1x2 0 pc

Combination antihistamine/decongestant

-pseudoephedrine(maxiphed) 30mg q4-6hr-actifed 1x3 0 pc-clarinase 1x2 0 pc

Intranasal corticosteroids

-rhinocort 2sprays each nostril bid-nasocort/nasonex 2sprays each nostril OD

Antileukotriene

-montelukast(singulair) 10mg oral OD


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Acute otitis media

-strep. Pneumoniae, H. influenza-, , -amoxycillin (40-90MKD) x10day -> augmentin-penicillin -> macrolide

Chronic suppurative otitis media

->3mo. + ,,-- cholesteatoma -> Pseudomonas, S.aureus-ofloxacin ear drop 6-10drop bid-ciprofloxacin ear drop

Rhinosinusitis

- -5 10-Amoxycillin -> augmentin

-doxycycline, clarithromycin


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Nasopharyngeal carcinoma

-, EBV-male > female : 3:1-upper cervical lymph node enlargement- -epistaxis

-CN VI palsy -> diplopiaNasopharyngeal angiofibroma

-epistaxis + nasal obstruction--CN 2,3,4,5,6- biopsy

Meniere ()-true vertigo-tinnitus

-hearing loss


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EYE


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...188...

Topical eye

*Atropine ED Mydriatic effect or treat uveitis closed-angle glaucomaOpsil-A

Irritation Hista-opH -> dry eye Genteal ED

Spersallerg EDTear Tear natural,opsil tear,NATEARATB Chloram ED -> aplastic anemia

Polyoph/Xanalin;Neomycin+polymycinB

Toblex ED (Tobramycin)Fucithalmic(Fusidic acid)Chloram eye ointmentTerramycin eye ointment

steroid

Dexa-oph

acute angle closure glaucoma5

Anes. 0.5%tetracaine,benoxitrate HCl-opthalmoscope -> 1%tropicamide(mydriacyl)


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Eye burn

-irrigate free flow -> pH normal-Mydriacyl for decrease accommodation-ATB + pressure patch

Foreign body in eye

-remove

-ATB ointment + pressure patch 24hr-F/U 24hr-poly-oph 1x4 eye drop x5day

Hordeolum

-paracetamool 2tab 0 prn q4-6hr-dicloxacillin(250) 1x4 0 ac-Poly-oph -warm compression,

Acute angle closure glaucoma

-miotic drug : 2%pilocarpine q15min x4dose--blocker : 0.5% timolol 1 bid

COPD,asthma-CAI (sulfa) : acetazolamide

diamox(250) 2tab 0 stat-hypersomotic : oral glycerine 1mg/kg 0 stat


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Blurred vision

pin holeImproved not improvedRefractive error pain

Yes NoConsult eye + corneal lesion corneal scar

CataractNo Yes post. Segment dz

Pupil>3mm keratitisCorneal ulcer consult eye

admitNo yesPost. Segment dz acute glaucomaUveitisAdmit admit

CRAO

-sudden onset visual loss, -cherry red spot-ATB eye drop-acetazolamide 500mg IV // 2cap 0-carbogen(95%O2) in10min every 2hr x2day


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Trauma eye

-ruptured cornea/sclera-exposure uveal tissue-soft eye()-marked subconjunctival hemorrhage-marked chemosis

Yes NoCBC,CXR,TT ant. chamberNPO no yesFilm orbit R/O Fx,FB hyphemaAdmit admiteyeshield

FB abrasion conj. LacerationRemove remove 1cm

Admit ATB ointment admit 24hrF/U

Ruptured globe injury

, pressure,eye shield, ,IV ATB : cefazolin+gentamicin, TT


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Dermatology


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FUCIDIN

(Fucidic acid)

FUCIDIN H(+Hydrocortisone acetate)

FUCICORT(+Betamethasone valerate)Treat infected eczemaBACTROBAN(Mupirocin)

(2%) apply tid for 10Day

Silver sulfadiazine

(DERMAZIN)

Treat burn, pressure sore,

infected woundROACCUTANE(Isotretinoin)

(Cap10,20mg)0.5mg/kg/DayMaintenance0.1-1

Benzyl benzoate treat scabies and mite,

prevention of scrub typhus

JACUTIN

(0.3%Gamma Benzene Hexachloride)treat scabies, pediculosis 12hr

Selenium sulfide Rx seborrheic dermatitis, tineavesicolor 15

10%Urea cream dry and rough skinPHYSIO GEL atropic dermatitis 1-2month

PROTOPIC(Tacrolimus) (0.03% Children, 0.1% Adult)


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ELIDEL

(Pimecrolimus)

(1% infant to adult)

treat atropic dermatitis5%LCD() Lesion Psoriasis

DAIVONEX(Calcipotriol)

apply OD MAX 4wkDAIVOBET(+Betamethasone)apply bidDAIVONEX SCALP SOLnapply bid

Treat psoriasis

Minoxidil(2%, 5% lotion)apply 1cc bidTreat alopecia androgenetica

Fenasteride (1mg)1tab OD -> Increase hair growth &prevent hair loss

DUOFILM/VERRUMAL/CONCON

(Salicylic acid)

keratolytic

treat wart, corn, callus


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KENAKORT-A(10, 40mg/ml) Keloid, inflame joint, tendon,shealth, bursa

HIRUDOID/FORTEREPARIL GEL

Inflam, injury, phleblitis

Steroid(1gm 1 30gm)S/E : Acne,Striae,Telangiectasia,Hypopigment,Hertulism

Mild0.02%TA, Prednisolone 0.5%,1%Hydrocortisone

Moderate0.1% TA, Betametasone dipropionate(mod to potent), Dermatop

Potent 0.5%TA, Topicort, Esperson, Betametasone

Very Potent Dermovate, Clobetasol dipropionate0.05%


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Herpe

survival the finalist

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