INTERNAL

MEDICINE X CHI CHI NOTES X PGI MADRID

HYPERTENSIVE WORK UP AGE WORK UP UGIB WORK UP STROKE WORK UP
- 12 Lead ECG - Fecalysis - CBC with PC with - Plain Cranial CT scan
- Chest Xray - CBC with PC BTRH - CBC with PC
- CBC with PC - Na, K - Fecalysis - BUN, Crea, Na, K
- BUN, Crea, Na, K, - Abdominal Xray - FBS, Lipid profile
- FBS, SGPT, SGOT, - DRE patient - 12 Lead ECG
- Lipid profile - CXR
- Urinalysis

- PT, PTT, INR

COMMON EMERGENCY ROOM COMPLAINTS

DIFFICULTY OF BREATHING ABDOMINAL PAIN DIZZINESS WEAKNESS
- Hook to Oxygen as Always bear in mind that Rule out any other causes of
soon as the patient abdominal pain is an angina dizziness such as
arrived with (+) equivalent - Elevated BP
Desaturation - Loose bowel
Labs to request: movement
Labs to request: - 12 Lead ECG Decreased CBG
- CBC with PC - CBC with PC
- BUN, Crea - Urinalysis
- Na, K - Na, K
- 12 Lead ECG - BUN, Crea

ER Medications:
- Hydrocortisone 100
mg/vial – Give 200
mg TIV (Except PTB)
- Furosemide 20
mg/ampule

FOR Allergic cough

- Cetirizine 10 mg/tab
ODHS x 5 days

For cough:
- Erdosteine
300mg/cap TID x 5
days
 DRIPS

1. DOPAMINE DRIP 2. DOBUTAMINE DRIP

- For cardiogenic shock - Dose dependent effect

<2 mcg/kg/min Renal vasodilation Infusion rate: 2.5 mcg/kg/min – 10 mcg/kg/min

Inotropic Maximun: 10-20 mcg/kg/min
2-10 mcg/kg/min Increase CO with little or no
change in SV/HR
- Due to its vasodilatory effect at higher doses
Vasoconstriction
>10 mcg/kg/min (Increase SVR, LV filling pressure,
Dobutamine drip rate = Desired dose(mcg/kg/min) x wt (kg)
Decrease HR) cc/hr Dobutamine factor

Infusion rate: 2-5 mcg/kg/min Dobutamine dose =Dobutamine drip rate (cc/hr) x Dobutamine factior
Maximun: 20-50 mcg/kg/min cc/hr Body weight in kg

Dopamine drip rate = Desired dose(mcg/kg/min) x Body wt (kg) Dobutamine factor

cc/hr Dopamine factor - 16.6 = 1 ampule
- 33.2 = 2 amp
Dopamine dose =Dopamine drip rate (cc/hr) x Dopamine factor
cc/hr Body weight in kg
<2 mcg/kg/min Minimal chonotropic to moderate
chonotropic effect
Dopamine factor: >10 mcg/kg/min I moderate chonotropic but effect with
- 13.3 = 1 ampule vasodilatory effect thus not good for
- 26.6 = 2 ampules decrease SVR

3. NORPINEPHRINE DRIP 4. NICARDIPINE DRIP

- Septic shock Dose: 5-15 mg/hr
- Potent vasodilator
- Initial vasopressor Computation:
mg/hr i = cc/hr
FACTOR 0.1 mg/cc
0.133 1 amp (2 mg)
0.266 2 amp (4 mg) Preparation:
0.532 4 amp (8 mg) - D5W 90 cc + 1 amp (10 mg/10 ml) x 10 cc/hr
- (1 mg/hr to 15 mg/hr)
2-15 mcg/kg/min
Max: 15 mcg/kg/min – study shows if BP cannot be raised 5. POTASSIUM DRIP
to >90 mmHg at this dose there is a little chance that it will
at higher doses. PNSS 80 cc/hr + 40 mEqs KCl x 20cc/hr (8 mEq/hr)
40/100 x 20 = 8 mEqs/hr
Shortcut method:
6. TERBUTALINE DRIP
Norepinephrine drip rate: Desired dose (mcg/min)
NE Factor D5W 250 CC+ 5 amps x 10-30 cc/hr
 MYOCARDIAL INFARCTION INFERIOR WALL MI
Labs to request: - Hydrate the patient
- CBC with PC - PNSS x 8 hours ; reassess patient from time to
- Urinalysis time to prevent congestion
- 12-L ECG - Volume dependent
- BUN, Crea, FBS, Na, K - Usually patients are hypotensive
- Lipid profile - Can do fast drip up to 500 cc if no improvement
- Trop I may start with inotropes.
- Chest Xray PA

IVF: D5W 500 ml x 10 ml / hour

Therapeutics:
- Aspirin 80 mg/tab, 40 tabs now then OD
- Clopidogrel 75 mg/tab, 4 tabs now then OD
- Carvedilol 6.25 mg/tab , 1 tab OD
- Captopril 25 mg/tab , 1 tab OD

AGE URINARY TRACT INFECTION

Labs: Labs:
- Urinaysis, Fecalysis - Urinaysis
- CBC with PC - CBC with PC
- BUN, Crea, Na, K, CBG - BUN, Crea

ER Meds: ER Meds:
- HNBB 10 mg/amp - HNBB 10 mg/amp
- Metoclopromide 10 mg/ amp - Metoclopromide 10 mg/ amp
- Omeprazole 40 mg/vial - Tramadol + Paracetamol 37.5mg + 325mg / amp,
- Paracetamol 300 mg / amp - Loading Dose: Ceftriaxone 1g vial x 2

Home Medications: Home Medications:

- Metronidazole 500 mg BID x 7days - Nitrofurantoin 100 mg QID x 7 days
- HNBB 10 mg TID x 3 days - Ciprofloxacin 500 mg / tablet BID for pain
- Omeprazole 40 mg 30 mins before breakfast x 14 - Tramadol + Paracetamol 37.5mg + 325 mg tablet
days BID or PRN for pain
- ORS
- Racecadotril 100 mg TID x 5days

UROLITHIASIS APD
Labs to request: Labs to request:
- Urinalysis - 12 Lead ECG
- CBC with PC - Chest Xray
- BUN, Crea - CBC with PC
- KUB ultrasound - Urinalysis
- Na, K, SGPT, SGOT
ER Medications: - BUN, Crea
- If patient is in severe pain you can give:
Tramadol 50 mg / ml – 1 ml TIV ER Medications:
SE: Nausea and vomiting - Omeprazole 40 mg/vial – Give 1 vial TIV
- HNBB 20 mg/ amp – Give 1 amp
Home Medications:
- Potassium Citrate tablet TID x 3 months Home Medications:
 - Sambong tablet TID x 3 months - Omeprazole 40 mg – Take 30 mins before breakfast
- Tramadol + Paracetamol 37.5mg + 325 mg tablet for 14 days
BID or PRN for pain - Aloh mgoh (maalox) TID after meals 5 days
- HNBB 10 mg TID 3 days

BRONCHIAL ASTHMA IN ACUTE EXACERBATION COMMUNITY ACQUIRED PNEUMONIA

- Upon arrival check for O2 saturation and Request for:
auscultate the patient for any wheezing - CBC, PC
- If in severe distress hook to O2 immediately - Chest Xray
- No Line because it causes congestion - BUN, Crea, Na, K
- ABG (Optional)
ER Medications:
- Hydrocortisone 100 mg/vial – Give 200 mg TIV If in severe DOB: Nebulize with salbutamol
- Salbutamol + Ipratropium every 15 minutes
OR Home Medications:
- Salbutamol + Ipratropium every 15 minutes - Azithromycin 500 mg/tablet OD x 3 days or 5 days
ALTERNATE with Budesonide every 15 minutes - Cefpudoxime 200mg capsule BID x 7 days
- Budesonide + Formoterol (Symbicort) 160/4.5 mcg
Home Medications: 2 puffls BID
- Salbutamol + Ipratropium neb q 8 hours
- Montelukast + Levocetirizine 10mg / 5mg tablet
OD

PTB HYPERTENSIVE URGENCY

Labs at OPD basis:
- Sputum AFB JNC 7: Situations associated with severe BP elevation
- Sputum GS/CS without progressive target organ dysfunction.
- Gene expert
Labs to request AT ER:
Medications: - 12 LEAD ECG
- Salbutamol + ipratropium TID - BUN, Crea
- Levopront 120ml 5ml TID 5 days - Na, K
- Omeprazole 40mg tab 30mins before
- Tranexamic acid 500mg cap TID vomiting of blood ER Medications:
- Metoclopromide 10mg tab TID for vomiting - Hook to O2 nasal cannula
- Clonidine 75 mcg sublingual q 15 mins – check BP
after 15 minutes
OR
- Clonidine 75 mcg + Amlodipine 10 mg/tab

If after 3 doses of clonidine and still, the BP is elevated.

Start Nicardipine drip:

Nicardipine drip
- 10 mg in 90 cc PNSS to run at 10 cc/hour
- Titrate by increments of 5 cc/hour (To maintain
BP (<150/90)

Home Meds:
- Either continue current maintenance medications
OR
 - Amlodipine 10 mg / tab OD
- Irbesartan 150 mg / tab OD
- Prepare a Hypertensive work up (CBC with PC,
BUN, Crea, Urinalysis, 12-L ECG, Na, K, Chest
Xray, SGPT, SGOT, Lipid profile)

HYPOKALEMIA HYPERKALEMIA
K deficit = (3.5 - actual) /0.27) ×100 - Potassium >5.5
- Decreased renal potassium excretion – Most
Labs to request AT ER: common cause
- 12 Lead ECG
- Na, K Labs to request AT ER:
- CBC with PC - 12 Lead ECG
- Urinalysis - Na, K
- CBC with PC
ER Medications: - Urinalysis
Kalium durule tablet
- 10 meqs S/Sx:
- 1 tablet every hour - Predominantly CARDIAC in nature
- (0.1 Increased in Potassium) - Sinus arrest
- V tach /V Fib
KCL drip - Sinus bradycardia
- 1amp - 40 meqs / amp - Asystole
- 5 meqs/hour x 8 hours
- 80 cc PNSS in soluset + 30 meqs KCl (0.2 Classic ECG:
Increased in Potassium) - Peaked T waves
- Loss of P wave
- Widened QRS complex
- Sinusoidal pattern

Management:
1. Cardioprotection
- From arrhythmic effects of hyperkalemia
- 10 ml of 10% Ca gluconate (Give thru IV push 2-3
minutes)
- Dose should be repeated if no changes in ECG

2. Cellular districution
- Shifts potassium inside the cells
a. GI solution: D50-50 + RI
- MC side effect is Hypoglycemia therefore
should follow D10 Water at 50-75 cc/hr

b. Salbutamol nebulization