Management of Patients

NEUROLOGY
Page Diagnosis: Cerebrovascular Accidents (CVA) – Ischemic

14 stroke
Investigations Plans
CT brain – urgent 1. Monitor vital signs
FBC 2. Keep nil by mouth
RP/LFT/Ca2+/Mg2+/PO4/C 3. Glasgow Coma Scale (GCS) charting
K 4. IV drip 3 pints NS/24 hours
PT/APTT/INR 5. RT insertion (if gag reflex absent)
RBS (reflo) stat 6. CBD insertion
FBS/FSL – within 24 H or 3 7. Ventilatory support
mo after stroke 8. Insulin therapy if reflo > 10 mmol/L
ECG 9. Target INR is 2.0 – 3.0 (except in prosthetic
CXR valve)
ECHO 1.6 – 2.5: elderly age >75
LP – if suspect SAH 2.5 – 3.5: bileaflet or tilting disc valve
Young patients: 3.0 – 4.0: caged ball or caged disc valves
- ANA 10. Medications:
- Anti- - T. Aspirin 75 mg OD (withhold if
cardiolipin hemorrhagic stroke)
- Lupus - T. Lovastatin 20 mg ON
anticoagul - T. Prochlorperazine (stemetil) 1.5 mg
ant TDS
- Lactate - T. Dabigatran (direct anti-thrombin
- Protein C inhibitor) 110 mg – 150 mg BD
- Protein S 11. Withhold anti hypertension
- 12. Refer to stroke team for rehabilitation (speech
Antithrom therapy, physiotherapy)
bin III 13. For family to buy DVT stockings
- Homocystein
level
- Activated
protein C
resistance
- Prothrombin
gene
mutation
- Factor V
Leiden
Diagnosis: Cerebrovascular Accidents (CVA) –

Hemorrhagic stroke (Subarachnoid Hemorrhage – SAH)
CT brain – urgent 1. Monitor vital signs
FBC 2. Keep nil by mouth
RP/LFT/Ca2+/Mg2+/PO4/C 3. Glasgow Coma Scale (GCS) charting
K 4. IV drip 3 pints NS/24 hours
PT/APTT/INR 5. RT insertion (if dizziness)
RBS (reflo) stat 6. CBD insertion
FBS/FSL – within 24 H or 3 7. Ventilatory support
mo after stroke 8. MAP should be kept around 110 mmHg
ECG Target BP: 160/90 mmHg
CXR Cerebral Perfusion Pressure (CPP): 60 – 80 mmHg
ECHO 9. Insulin therapy if reflo > 10 mmol/L
LP – if suspect SAH 10. Target INR is 2.0 – 3.0 (except in prosthetic
MRI valve)
Angiography 1.6 – 2.5: elderly age >75
Young patients: 2.5 – 3.5: bileaflet or tilting disc valve
- ANA 3.0 – 4.0: caged ball or caged disc valves
- Anti- 11. Medications:
cardiolipin - T. Omeprazole 20 mg ON
- Lupus - IV Mannitol
anticoagul 12. Refer to neurosurgeon (HKL)
ant 13. For family to buy DVT stockings
- Lactate
- Protein C
- Protein S
-
Antithrom
bin III
- Homocystein
level
- Activated
protein C
resistance
- Prothrombin
gene
mutation
- Factor V
Leiden
Diagnosis: Epilepsy/Seizure
FBC 1. Prop up patient
RP/LFT/Ca2+/Mg2+/PO4/C 2. Monitor vital signs
K 3. Keep nil by mouth
RBS (reflo) stat 4. For oxygen therapy
ECG 5. Fit and GCS charting
CXR 6. For CBD and RT insertion
7. Medications:
- IV Diltiazem 5 mg PRN
- T. Epilim 300 mg BD

Shakir Ariff Bin Zulkifli | Management of Patients
PULMONOLOGY
Diagnosis: Acute Pulmonary Oedema (APO)
K 3. High flow mask (FM) O2 10 L/min
Page CKMB/Trop I (within 6 4. SpO2 monitoring 4 hourly
14 hours) 5. Medications:
PT/APTT/INR - IV Furosemide 60 – 80 mg stat & TDS
ABG - IV Morphine 2.5 – 5 mg stat
ECG - S/L GTN I/I PRN
CXR a. T. Digoxin 0.125 (if atria l fibrillation
ECHO (AF))
URINE FEME 6. Fluid restriction to 500 – 800 ml/day
7. Strict I/O charting
8. Withhold beta-blocker in acute episode
9. May need IV Aminophylline 250 – 500 mg stat
10. For ECHO later
11. To inform if SOB/chest pain
Diagnosis: Pleural Effusion

K 4. SpO2 monitoring 4 hourly (Keep SpO2 > 98%)
CKMB/Trop I (within 6 5. For therapeutic and diagnostic pleural tapping
hours) 6. KIV to start anti-TB if (+) TB
PT/APTT/INR 7. KIV refer respi team
ESR Light’s Criteria
CRP TRANSUDATE EXUDATE
ABG Se. protein < 0.5 > 0.5
Sputum AFB x 3 Se. LDH < 0.6 < 0.6
Sputum C+S
Comments Uncomplicated
CXR
Complicated:
Peritoneal tapping:
• pH < 7.2
- Tissue à
• Glucose
cytology
- Biochemical: < 3.3
- Protein mmol/L
- Glucose • LDH
- pH high
- LDH Causes Increased venous Increased leakiness of
- Amylase pressure/ pleural capillaries
- C+S hypoalbuminaemia/ secondary to infection/
- AFB hypothyroidism and inflammation/
Meig’s syndrome malignancy
Diagnosis: Acute Exacerbation of Bronchial Asthma

(AEBA) secondary to chest infection
K 3. High flow mask O2 5 L/min PRN
ABG pre and 1H post oxygen 4. SpO2 monitoring 4 hourly
PEFR pre and post nebulizer 5. Maintain Sp)2 > 88 – 90%
Blood C+S 6. To repeat ABG an hour after administration of
Sputum C+S oxygen
Sputum FEME 7. Neb Ipratropium bromide (Atroven)/ Salbutamol
CXR – Albuterol sulphate (Ventolin)/ Normal saline
(AVN) 1:2:1 or combivent 2/4/6 hourly
8. Medications:
- IV aminophylline 250 mcg over 20
min (do not give bolus to patient’s
taking oral) – severe/life-threatening
- IV Hydrocortisone 100 mg TDS (or T.
Predsinolone 30 mg – 60 mg OD for
5 – 10 days)
- IV MgSO4 2g (4ml) given over 20 min
– severe/life-threatening
- MDI Budesonide 400 mcg BD
- MDI Salbutamol 2 puffs PRN
- Syr. Benadryl 15 ml TDS
(asthma/COPD pt)
- T. Bisolvon 8 mg I/I TDS
Mild CAP (1 week)
- T. Augmentin 1.2g stat & TDS (or T.
Augmentin 625 mg BD) OR
- T. EES 800 mg BD (or T.
Azithromycin 500 mg OD)
- Recent antibiotics: both
Moderate and Severe CAP (1 week)
- IV Azithromycin 500 mg OD PLUS
- T. Augmentin 625 mg BD
Lung Abscess/Empyema (4 – 6 weeks)
- IV Ceftriaxone 2g OD PLUS
- IV Metronidazole 500 mg TDS & T.
Metronidazole 400 mg TDS
Acute Exacerbation of Chronic Bronchitis
- T. Azithromycin 500 mg OD
- Pseudomonas aeruginosa:
T. Ciprofloxacin 500 mg BD
9. To assess and teach MDI technique by
pharmacist
10. For chest physiotherapy
11. To inform if SOB worsening/chest tightening
Diagnosis: Pneumonia
K 3. O2 PRN
ESR/CRP 4. SpO2 monitoring 4 hourly
Cold agglutinin (if suspect 5. IV drip 2 – 3 pints/24 hours
mycoplasma) 6. Tepid sponging (if fever)
Page Blood C+S 7. Neb AVN 1:2:1 stat & 6 hourly
Sputum C+S 8. Medications:
14 Sputum FEME - IV Augmentin 1.2 g stat & TDS (or T.
Sputum AFB x 3 Augmentin 625mg BD)
ABG - Syr. Benadryl 15ml TDS
CXR - IV Rocephin (if partially
Pleural aspiration (if effusion treated/HAP/aspiration)
(+)) - T. Bisolvan 8mg I/I TDS (if (+)
Bronchoscopy (lung abscess) sputum but can’t cough)
ECHO - T. EES 400 mg BD (or T.
URINE FEME Azithromycin 500 mg OD)
Atypical Pneumonia: Mild CAP (1 week)
- Serology for - T. Augmentin 1.2g stat & TDS (or T.
mycoplas Augmentin 625 mg BD) OR
ma, - T. EES 800 mg BD (or T.
Chlamydia Azithromycin 500 mg OD)
, legionella - Recent antibiotics: both
- PCR Moderate and Severe CAP – not requiring
- mechanical ventilation (1 week)
Immunoflo - IV Azithromycin 500 mg OD PLUS
rescence/ - T. Augmentin 625 mg BD
Giemsa - Pseudomonas infection:
staining IV Piperacillin/Tazobactam 4.5 g IV TDS PLUS
for IV Gentamicin 5 mg/kg OD PLUS
Pneumocy IV Azithromycin 500 mg OD
stis carinii Moderate and Severe CAP – requiring mechanical
ventilation (1 week)
- IV Azithromycin 500 mg OD
- Klebsiella pneumonia (ESBL)
IV Imipenem 500 mg QID
- MRSA
IV Vancomycin 1g BD
Lung Abscess/Empyema (4 – 6 weeks)
- IV Metronidazole 500 mg TDS & T.
Metronidazole 400 mg TDS
9. For chest physiotherapy
10. Ill patients not responding to conventional
treatment:
- Bronchoalveolar lavage
- Percutaneous lung aspiration
- Lung biopsy (transbronchial/open lung
biopsy)
Diagnosis: Tuberculosis (TB)

FBC 1. Monitor vital signs
RP/LFT/Ca2+/Mg2+/PO4/C 2. Face mask 5L O2/min
K 3. KIV to start anti-TB
ESR/CRP 4. O2 therapy if needed
Sputum Acid Fast Bacilli
(AFB) x3
Sputum FEME
Sputum C+S
Mantoux test
CXR

CARDIOLOGY
Diagnosis: Acute Coronary Syndrome (ACS)
Page Investigations Plans
14 FBC
RP/LFT/AST/Ca2+/Mg2+/PO4/
1. Prop up patient and rest in bed
2. Monitor vital signs
CK 3. BP every 15 – 30 minutes then 1 – 2 hourly
LDH 4. O2 PRN
FBS/FSL 5. SpO2 monitoring 4 hourly
CK/CKMB/Trop I 6. ECG daily & on chest pain
PT/APTT/INR 7. Maintain INR: 1.5 – 2.5
ABG 8. Medications:
ECG – stat & post streptokinase - IV Morphine 2.5 mg – 5 mg PRN
FSL CM - IV Maxolon 10 mg PRN (and on
RBS (reflo) stat morphine)
- S/C Clexane 60 mg stat and BD x
3/7
- S/C Fundaparinox (factor Xa
inhibitor) 2.5 mg OD (not for
renal impairment pt)
- S/L Glycerin Trinitrate (GTN) I/I
PRN
- T. Aspirin 300 mg stat & 75 mg OD
(not for ICB pt)
- T. Isordil 10 mg BD/TDS
- T. Lovastatin 20 mg ON
- T. Vasteral (anti-ischemic) 20 mg
TDS
9. To inform if SOB/chest pain
Diagnosis: Acute Coronary Syndrome (ACS) - STEMI

FBC 1. Prop up patient and complete rest in bed
K 3. O2 PRN
LDH 4. SpO2 monitoring 4 hourly
CK/CKMB/Trop I 5. ECG monitoring for 48 hours and if chest pain
PT/APTT/INR 6. To inform if SOB/chest pain
FBS/FSL CM 7. Medications:
RBS (reflo) stat - IV Furosemide (Lasix) 40 mg OD/BD
ABG - IV Maxolon 10 mg PRN (and on
ECG Morphine)
- stat - IV Morphine 2.5 mg – 5 mg PRN (if
- post improve after S/L GTN)
streptoki - IV Streptokinase 1.5 million units in
nase 100 ml saline over 60 min
CONTRAINDICATION: recent surgery, bleeding
tendency, recent MI, recent streptokinase, on anti-
coagulant
- S/C Fundaparinox 2.5 mg OD x 5/7
(not for renal impairment pt)
- S/L Glycerin Trinitrate (GTN) I/I PRN
- Syr. Lactulose 15ml TDS
- T. Alprazolam (Xanax) 0.5 mg ON
(not for ICB pt)
- T. Clopidogrel (Plavix) 75 mg OD x
1/12
- T. Metoprolol 25 – 50 mg BD
- T. Perindopril 2 – 4 mg OD (target: 8
mg OD)
Diagnosis: Fast Atrial Fibrillation (AF)

FBC 1. Rest in bed
K 3. ECG chest pain
PT/APTT/INR 4. To inform if SOB/chest pain
TFT 5. Cardiac monitoring
FBS/FSL 6. Medications:
RBS (reflo) stat - IV Amiodarone 300 mg in 100 ml
ECG 0.5% over 1 hour & 400 – 800 mg
CXR for next 23 hours
ECHO - S/C Clexane 60 mg stat & BD
If fast AF due to ACS,
(not for ICB pt)
- T. Amiodarone 200 mg TDS 1/52 à
200 mg BD 1/52 à 200 mg OD 1/52
- T. Perindopril 2 – 4 mg OD
7. Counsel for warfarin
8. Aim:
Rate control: T. Propranolol 20 – 80 mg TDS OR T.
Metoprolol 50 mg TDS
Rhythm control: T. Digoxin 0.125 mg OD
Anti-thrombotic: clexane
Diagnosis: Congestive Cardiac Failure (CCF)

K 3. High flow mask (FM) O2 10 L/min & PRN
Trop I 4. SpO2 monitoring 4 hourly (maintain SaO2:
ECG >90%)
CXR 5. Neb AVN 1:2:1 stat & 6 hourly
RBS (reflo) 6. Fluid restriction to 1000 ml/day
Urine FEME 7. Strict I/O charting
ECHO 8. ECG on chest pain
9. Medications: (to continue old meds)
- IV Furosemide 40 – 80 mg TDS
- S/L GTN I/I if systolic BP > 100
mmHg
- T. Aspirin 74 mg OD
- T. Digoxin 0.125 mg OD
- T. Metoprolol 50 mg OD
- T. Omeprazole 20 mg OD
- T. Slow K+ 1.2 g BD
Page 10. To inform if SOB/chest pain
14
Diagnosis: Hypertensive Crisis (Emergency/Urgency)
K 3. To keep BP at 160/90 mmHg (diastolic BP: 100-
PT/APTT/INR 110 mmHg)
FSL Emergency: within a few hours – to prevent organ
ABG damage
Blood C+S Urgency: slowly
ECG stat 4. BP hourly till stable (BP control within 4 hours)
Funduscopy 5. CBD insertion
UFEME 6. Medications:
CXR CAD and Heart Failure
- IV GTN 50 mg in 250 ml NS or D5%
= 200mcd/ml; 10 mcg/min :
3ml/hour
* Start at 5 – 10 mcg/min and titrate until desired
BP is achieved (max: 200 mcg/min)
Pheochromocytoma
- T. Prazosin (thiazide) 0.5 mg stat and 1
mg TDS (if no hypokalemia)
Aortic Dissection
- IV Esmolol 2.5 g in 250 ml NS or
D5% to a concentration of 10 mg/ml
Loading dose: 500 mcg/kg/min for 1 min;
Maintenance dose: 50 mcg/kg/min and titrate (not
more than every 4 min within a range of 50 – 200
mcg/kg/min)
Pulmonary Oedema
- IV Furosemide / IV GTN
Hypertension in pregnancy
- IV Hydralazine 50 mg in 500 ml NS =
100 mcg/ml; 50 mcg/min = 30
ml/hour
5 – 20 mg, repeated if necessary at about 15 – 30
min interval
IVI Hydralazine 50 – 150 mcg/min
- IV Labetolol 25 – 50 mg over 1 – 5
min repeated every 5 – 10 min until
max dose of 200 – 300 mg or until
desired BP achieved (T. Labetolol
200 mg BD)
IVI Labetolol 200 mg in 200 ml D5% running at 1
– 2 mg/min (1 – 2 ml/min)
*Excessive bradycardia: IV Atropine 0.5 – 2 mg in
divided doses of 0.5 mg
- IV MgSO4
Stroke
- IV Esmolol/T. Amlodipine 10 mg BD
7. To refer ENT if BP still high

GASTROENTEROLOGY & HEPATOLOGY

Diagnosis: Acute Gastroenteritis (AGE)
RP/LFT/Ca2+/Mg2+/PO4/C 2. IV drip 3 – 5 pints NS/24 hours (see hydration
K status)
Blood C+S (if fever) 3. Correct electrolytes accordingly
Stool FEME 4. Encourage oral intake
Stool C+S 5. Strict I/O charting
Stool ova + cyst 6. Medications:
Stool occult blood HEALTHY: 5 days
Urine FEME IMMUNOCOMPROMISED: longer
Urine C+S - Infection:
Empirical
IV Ciprofloxacin 500 mg BD or T. Ciprofloxacin
400 mg BD for 3 – 5/7
Specific
Salmonella septicaemia: IV Ciprofloxacin 400 mg
BD
Severe shigellosis: T. Ciprofloxacin 500 mg BD
Severe campylobacter: T. EES 250 mg TDS/ T.
Ciprofloxacin 500 mg BD
Giardiasis: T. Metronidazole 400 mg TDS
Amoebic dysentery: T. Metronidazole 800 mg
TDS
Traveller’s diarrhea: T. Ciprofloxacin 500 mg BD
- IV Metoclopramide (Maxolon) 10 mg
stat & TDS
- IV Ranitidine 50 mg TDS
- ORS per purge
- Anti diarrhea (not for dysentery)
- T. Diphenoxylate 5 mg à 1 tab each loose
stool
- T. Loperamide 4 mg à 1 tab each loose
stool
- T. Lomotil I/I stat & TDS
Diagnosis: Gastro-esophageal Reflux Disease (GERD)

RP 1. Monitor vital signs
2. Correct all electrolytes accordingly
3. Medications:
- IV or C. Omeprazole 20 mg / 40 mg OD
- Syr. MMT 15 ml TDS
- T. Ranitidine 150 mg BD
Page
14
Diagnosis: Upper Gastrointestinal Bleeding (UGIB)

RP/LFT/Ca/Mg/PO4 2. Secure airway (intubate if necessary)
PT/APTT/INR 3. RT insertion – free flow
GXM 4. Strict I/O chart
RBS (reflo) 5. Correct all electrolytes accordingly
ECG 6. KIV central line for CVP
7. KIV FFP if INR > 1.5
8. Medications:
- IV or C. Omeprazole 20 mg / 40 mg OD
- Syr. MMT 15 ml TDS
Diagnosis: Alcoholic Liver Disease (ALD)

RP/LFT/Ca2+/Mg2+/PO4 2. Watch out for uremic symptoms
RBS/FSL 3. Daily weight measurement
PT/APTT/INR 4. Diet: low salt/protein and high calorie diet
Alpha-fetoprotein (FTP) 5. Restrict fluid
Hep B/Hep C 6. Strict I/O charting
USG Hepato-biliary system 7. Medications:
(HBS) - T. Spironolactone 100 mg BD
- T. Furosemide 40 mg BD
- T. Thiamine 100 mg BD
8. KIV stab peritoneal tapping if symptomatic

POISONING & DRUG OVERDOSE

Diagnosis: Paracetamol Poisoning (>150 mg/kg in children
or 20 tablets in adults)
RP/LFT/AST- daily 2. Suicidal precaution
Bilirubin - daily 3. Keep nil by mouth
PT/APTT/INR daily 4. IV drip 4 – 5 pints NS/24 hours
Se. acetaminophen (4H, 8 - 5. Correct electrolytes accordingly
24H) 6. Ryles tube (RT) insertion – free flow
Se. cholinesterase (4H, 8H) 7. Gastric lavage if present within an hour
Se. salicylate (4H, 8H) 8. Activated charcoal stat 1g/kg if present within 4
Urine paraquat hours (10 tabs TDS)
VBG 9. IV Vitamin K (correct hypoprothrombonaemia)
Suspected fulminant liver 10. Medications:
failure: - IVI N-acetyl-cystein continuous in D5%
- Serum - 150 mg/kg in 200 ml over 15 min
glucose - 50 mg/kg in 500 ml over 4 hours
- ABG - 100 mg/kg in 1000 ml over 16 hours
- IV Ranitidine 50 mg TDS (if allergic to
acetylcystein)
- T. Acetylcysteine 140 mg/kg stat & 70
mg/kg every 4 hours for 17 additional
doses
*Hepatic failure need longer duration of >72 hours until
clinical improvement seen or INR <2.0
11. Refer psychiatry
Diagnosis: Organophosphate Poisoning

RP/LFT/Ca2+/Mg2+/PO4 2. Keep nil by mouth
PT/APTT/INR 3. Ryles tube (RT)insertion with 4 hourly
ABG aspiration/free flow
Se. acetaminophen (4H, 8 - 4. Cardiac monitoring
24H) 5. Gastric lavage if possible
Se. cholinesterase (4H, 8H) 6. IV fluids 3 pints NS
Se. salicylate (4H, 8H) 7. Medications:
Urine paraquat - IV Pralidoxine 1 g TDS x 1/7
Urinary sodium - IVI Atropin 5 mg/hour
diphosphate - Maintain pupils dilatation
Urine FEME - PR > 120
ECG - T. Charcoal 50 g stat and 25 g 4 hourly
RBS (reflo) 8. Allow liquid diet when patient is able to tolerate
CXR – every 3 days orally
Diagnosis: Paraquat Poisoning

FBC – every 3 days 1. Monitor vital signs
RP/LFT/Ca2+/Mg2+/PO4 2. Avoid oxygen unless PaO2 falls <60 mmHg or
– every 3 days patient is severely dyspnoea
RP daily 3. Ryles tube (RT)
ABG 4. Gastric lavage if possible
Gastric lavage/aspirate, 5. IV fluids 4 – 5 L/day (NS and D5%) for first
urine and blood for 24hours then 3L/day orally or IV for several days
toxicology screening 6. Strict I/O charting
Lavage for paraquat 7. Watch out for SSx of fluid overload
Urine for paraquat 8. To correct electrolytes accordingly
Urinary sodium 9. Medications:
Page diphosphate - 300 ml Fuller’s earth (15% suspension)
14 CXR – every 3 days via nasogastric tube (NGT) ASAP then
20 ml Fullers’s earth hourly, till
diarrhea complete PR passage of
Fuller’s earth OR
- Activated charcoal 50 g stat and 25 g 4
hourly for several days OR
- MgSO4 30 ml 4 hourly till diarrhea and
passage of Fuller’s earth OR
- Mannitol 20% 200 – 250 ml stat
- IV Furosemide 40 mg BD or T.
Furosemide 40 mg BD
- IV Methylprednisolone 15 mg/kg +/- IV
Cyclophophamide 15 mg/kd followed
by IV Dexamethasone at high doses
10. Allow liquid diet when patient is able to tolerate
orally

ENDOCRINOLOGY
Diagnosis: Uncontrolled Diabetes Mellitus (DM)
RP/LFT/Ca2+/Mg2+/PO4 2. Withhold OHA
FBS/FSL 3. Continue other medications
RBS (reflo) stat and hourly 4. For diabetic diet and counseling
VBG 5. Medications:
ABG Reflo 15 – 20 mmol/L
Urine ketone stat and - S/C Actrapid 6 – 8 units stat then TDS
hourly - Omit if < 6 mmol/L
Urine FEME - Reflo an hour later
- Withhold OHA
- Continue other medications
Reflo > 20 mmol/L
- S/C Actrapid 10 – 12 units stat
- Reflo an hour later
- Inform MO
- KIV Insulin sliding scale
Diagnosis: Diabetic Ketoacidosis (DKA)

FBC 1. Monitor vital signs and reflo hourly
RP/LFT/Ca2+/Mg2+/PO4 2. IV drip 4 – 5 L/day with NS
RBS (reflo) stat and - 1 L over 1 H
hourly - 1 L over 2 H
VBG - 1 L over 4 H
ABG - 1 L over 6 H
Urine ketone stat - 1 L over 8 H
Urine FEME 3. If reflo <15 mmol/L, to over ride with IV DS
CXR 4. To correct any electrolyte imbalances
5. Medications:
- S/C Actrapid 6 units stat
- IV Insulin sliding scale
To start at 6 units/hour
To give stat IV actrapid if reflo HIGH
To reduce insulin to 3 units/hour if reflo <15 mmol/L
and change all IVD regime to DS
Diagnosis: Hyperglycemia (reflo: > 15 mmol/L)

Reflo stat 1. Monitor vital signs
VBG 2. Medications:
Urine ketone - S/C Actrapid stat
Diagnosis: Hypoglycemia
RP/LFT/Ca2+/Mg2+/PO4 4. Watch out for SSx of hypoglycemia
RBS (reflo) stat 5. IV drip 1pint D10%/24 hours
FSL/FBS CM 6. Encourage oral intake
Urine FEME 7. Strict I/O charting
CXR 8. If insulin/OHA overdose:
- > 3 mmol/L: encourage orally
- < 2 mmol/L:
D50%/50 cc stat
IVD ½ pint D5/24 hours
Diagnosis: Nephrotic Syndrome (triad: proteinuria,

hypoalbuminaemia (alb: <25), oedema)
RP/LFT/AST/Ca2+/Mg2+/P 2. Monitor BP 2 hourly (Target BP: 125/75 mmHg)
O4 3. KIV to refer nephro
FSL 4. Nephrotic chart
PT/APTT/INR 5. Daily weight measurement
ESR 6. Diet: low salt and high protein diet
Blood C+S 7. Restrict fluid: 1L/day
HIV/Hep B/ Hep C 8. Strict I/O charting
C3, C4, ANA, dsDNA 9. Medications:
Urine FEME - T. Furosemide 40 mg BD
24 hour urine protein 10. For ACE Inhibitor later (T. Perindopril 2mg
CXR OD)

Page Shakir Ariff Bin Zulkifli | Management of Patients
14
NEPHROLOGY
Diagnosis: Acute Renal Failure (ARF)
RP/LFT/Ca2+/Mg2+/PO4/C 2. Watch out for SSx of uraemia
K 3. Fluid management:
ESR/CRP Hypotensive patients:
ANF/anti dsDNA - Fluid challenge with 250 ml NS over
Urine FEME 15 min
Urine C+S - If CVP does not increase by 2 cm, to
ECG repeat fluid challenge up to 500 –
CXR 1000 ml NS
AXR - Stop if CVP: 5 – 10 cmH2O
USG Kidney-Ureter-Bladder - Establish urine > 40 ml/hour
(KUB) - If not, give IV Furosemide 40 – 120
mg at 10 – 30 mg/hour
Euvolaemic patients:
- Start IV Furosemide as above
Fluid overload patients:
- Restrict fluid
- Start IV Furosemide as above
- Consider dialysis if not improved
4. Blood pressure
Hypotension
- Volume expansion, vasopressors
Hypertension
- BP should be controlled
5. Correct any electrolyte imbalances
Metabolic acidosis
0.5 x Body weight (kg) x Base deficit
Base deficit: 24 – Actual HCO3
1 ml of 8.4% NaHCO3 provides 1 mmol/L of NaHCO3
6. Nutrition:
Protein: 0.8 – 1.2 g/kg/day (higher protein intake if in
hypercatabolic state)
NaCl: 2 – 4 g/day
Caloric intake: 35 – 50 kcal/kg/day
Potassium: 40 mmol/day (if dialysed)
Diagnosis: Urinary Tract Infection (UTI)

RP/LFT/Ca2+/Mg2+/PO4/C 2. Tepid sponging
K 3. Medications:
ESR/CRP Uncomplicated UTI
RBS - IV Cefuroxime 1.5 g stat & 750 mg
Urine FEME TDS or T. Cefuroxime 250 - 500 mg
Urine C+S BD for 3-7/7
AXR Complicated UTI
USG KUB - Same as above but 7-10/7 according to
C+S

METABOLIC & ELECTROLYTES DISORDERS

Diagnosis: Hyperkalemia (K+ >5.5)
RP 1. Monitor vital signs
ECG stat 2. Check sample lysed/not
- Tall T 3. Stop all medications causing hyperkalemia
- Prolonged Diuretic/ACE-inhibitor/mist KCl/spironolactone
PR 4. Medications:
interval - Sodium polystyrene sulphonate
- Broad QRS (Resonium – K+ binder): 15 – 30
complex mg 3- 4 times daily OR
- Small P - Calcium polysterene sulphonate
wave (Kalamate): 5 – 10 mg TDS 3 – 4
- “sign wave” times daily
- As enemas:
Resonium: 30 g in 100 ml 3 – 4 times daily OR
Kalamate: 30 – 60 g in 200 ml 3 – 4 times daily
- Furosemide/Thiazide
5. KIV lytic cocktail/insulin chase:
- IV Ca gluconate 10% 10 ml within 2-5
minutes/10 minutes
- IV Actrapid 10 units in 50 ml 50%
dextrose (infused over 30 min) with
cardiac monitoring
- Continuous dextrose infusion D5%
- 50 ml of 8.4% NaHCO3 over 5
minutes or diluted with D5%
6. Alternatives:
- IV Sodium bicarbonate 100 – 200 ml
in 15 – 30 min
- IV Salbutamol 0.5 mg in 15 min or 10
mg (nebulizer)
7. For hemodialysis or peritoneal dialysis if above
fails
Diagnosis: Hypokalemia (K+ <3.5 )

Deficit:
(4.0 – K+) x 0.6 x body weight
13.4 (mmol/L)
Page Investigations Plans
14 RP/Ca2+/Mg2+ 1. Monitor vital signs
- Slow correct: repeat 2. Stop all medications causing hyperkalemia
CM or after 3/7 Diuretic/ACE-inhibitor/mist KCl
- Fast correct: repeat 3. Medications:
within an hour 2.5 – 3.4 mmol/L (slow correction)
stat - Mist KCl 15 ml TDS x 3/7
TFT - Slow K+ 1.2 g OD
ECG stat - Add 1g KCl in each pints of 4 pints NS
< 2.5 mmol/L (fast correction)
- 1 g KCl in 100 NS/1hour
< 2.0 mmol/L (fast correction)
- 2 g KCL in 200 NS/2 hours

OTHERS
Diagnosis: Allergies
2. Medications:
- IV or T. Piriton 10 mg TDS
- IV Ranitidine 50 mg TDS
- T. Hydrocortisone 100 mg TDS
- T. Prednisolone 30 mg OD
Diagnosis: Symptomatic Anaemia

FBC, reticulocyte count 1. Monitor vital signs
FBP 2. IV drip 5 pints NS/24 hours
GXM 2 pints PC 3. To withhold any anti-hypertensive
RP/LFT/Ca2+/Mg2+/PO4/C 4. Medications:
K - IV Omeprazole 40 mg OD
Iron studies - T. Ferrous fumarate 200 mg OD
TFT - T. Lovastatin 20 mg ON
PT/APTT/INR 5. To inform/refer nephro
VBG 6. Transfuse 2 pints PC with IV Furosemide 20 mg
Per rectal (PR) in between
ECG
URINE FEME
RBS (reflo) QID
Diagnosis: Viral Fever

PT/APTT/INR 2. Treat accordingly
Scrub Thyphus 3. Medications:
Blood C+S - Acute pharyngitis: Thymol gargle
Urine C+S - Runny nose: T. Loratadine 10 mg TDS

WORKOUT INVESTIGATIONS/TUBE
ALL PATIENTS FBC Purple
RP/LFT/Ca/Mg/PO4 Green
PT/APTT/INR Light blue
Anemia FBP (double forms) Purple

Se. Iron/Se. Ferritin/TIBC Red
Vit B12/Folate (double forms) Red
Hb Electrophoresis (double forms) Purple
Autoimmune ANA Red

C3, C4 Red
RF Red
dsDNA Red
ESR Red
Cancer (tumor markers) Ca125

CEA
ASA
Alpha-fetoprotein (AFP)
Ca-99 (send to HKL)
Dengue FBC Purple

RP/LFT/CE Green
Se. Lactate Grey (in ice box)
NS1/Dengue IgM Red
PT/APTT/INR Light blue
VBG
Blood Film Malaria Parasite (BFMP) x3
Leptospirosis Red
DVT Fibrinogen/D-dimer
Hemolytic FBC/Reticulocyte count/FBP Purple

LDH Red
Coomb’s Test Red
Page VSB
14 Poisoning Se. Cholinesterase Red

Se. Salicylate Red
TDM Paracetamol
Urine Paraquat Red
Septic FBC Purple

CRP Red
Blood C+S Blood C+S bottles
Thrombophilia 4 blue bottles

Tuberculosis ESR
Serum AFB x 3
Viral screening
Sputum AFB x 3
Sputum C+S
Pleural fluid AFB
Mantoux test
CXR
Viral 2 yellow bottles (double forms)

- HIV/Hep B/ Hep C/ Mycoplasma/VDRL
NORMAL VALUES
Values Units
Hb 12 – 15 g/dL
WBC 4 – 10 10’9/L
Plt 150 – 410 10’9/L
Hct 36 – 46 %
PT 11.2 – 14.4 sec
INR 0.8 – 1.2
APTT 31.5 – 46.7 sec
Urea 2.8 – 7.2 sec
Sodium (Na) 136 – 145 mmol/L
Potassium (K) 3.5 – 5.1 mmol/L
Chloride (Cl) 98 – 107 mmol/L
Uric Acid 150 – 420 umol/L
Creatinine 45 – 84 umol/L
Total Protein 64 – 83 g/L
Albumin 35 – 50 g/L
Globulin 25 – 39 g/L
A/G Ratio 0.9 – 1.8
Total Bilirubin 3.4 – 26.0 umol/L
ALP 40 – 150 u/L
ALT < 55 u/L
AST 5 – 34 u/L
LDH 105 – 333 IU/L
Lactate 0.5 – 2.2 mmol/L
Magnesium (Mg) 0.73 – 1.06 mmol/L
Calcium (Ca) 2.10 – 2.55 mmol/L
Phosphate (PO4) 0.74 – 1.50 mmol/L
Amylase 25 – 90 u/L
Trop T < 0.1 ug/mL
Trop I < 0.04 ug/mL
CK 38 – 120 ng/mL
pH 7.35 – 7.45
pO2 75 – 100 mmHg
pCO2 35 – 45 mmHg
HCO3 22 – 28 mEg/L
BE -2 - +2
CRP 0 – 0.5 mg/L
ESR 0 – 10 mm/hour
GGT 9 – 64 u/L
High lymphocyte – viral, chronic bacterial

High neutrophil – acute bacterial

Management of Patients

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Management of Patients

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NEUROLOGY

Page Diagnosis: Cerebrovascular Accidents (CVA) – Ischemic

Diagnosis: Cerebrovascular Accidents (CVA) –

Diagnosis: Pleural Effusion

Diagnosis: Acute Exacerbation of Bronchial Asthma

Diagnosis: Tuberculosis (TB)

Diagnosis: Acute Coronary Syndrome (ACS) - STEMI

Diagnosis: Fast Atrial Fibrillation (AF)

Diagnosis: Congestive Cardiac Failure (CCF)

GASTROENTEROLOGY & HEPATOLOGY

Diagnosis: Gastro-esophageal Reflux Disease (GERD)

Diagnosis: Upper Gastrointestinal Bleeding (UGIB)

Diagnosis: Alcoholic Liver Disease (ALD)

POISONING & DRUG OVERDOSE

Diagnosis: Organophosphate Poisoning

Diagnosis: Paraquat Poisoning

Diagnosis: Diabetic Ketoacidosis (DKA)

Diagnosis: Hyperglycemia (reflo: > 15 mmol/L)

Diagnosis: Nephrotic Syndrome (triad: proteinuria,

Diagnosis: Urinary Tract Infection (UTI)

METABOLIC & ELECTROLYTES DISORDERS

Diagnosis: Hypokalemia (K+ <3.5 )

Diagnosis: Symptomatic Anaemia

Diagnosis: Viral Fever

Anemia FBP (double forms) Purple

Autoimmune ANA Red

Cancer (tumor markers) Ca125

Dengue FBC Purple

Hemolytic FBC/Reticulocyte count/FBP Purple

14 Poisoning Se. Cholinesterase Red

Septic FBC Purple

Thrombophilia 4 blue bottles

Viral 2 yellow bottles (double forms)

Shakir Ariff Bin Zulkifli | Management of Patients

High lymphocyte ​– viral, chronic bacterial

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High lymphocyte – viral, chronic bacterial