2 Standard Treatment Protocols

DOCTOR ON CALL
With

Drugs of Choice
(STANDARD TREATMENT PROTOCOLS)
Based on Current Medical Diagnosis & Treatment & Current Standard
Medical Guidelines in Pakistan

EDITION

2024

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 DOCTOR ON CALL 3

TABLE OF CONTENT
Approaching a Patient
1 History Taking 15
2 Passing IV Line 35
3 Venepunture/Phlebotomy 37
4 Blood Culture 39
5 Blood Transfusion 41
6 Arterial Blood Gas Sampling 46
7 Intramuscular/Intradermal Injection 49
8 Nasogastric Catheterization 50
9 Male Catheterization 51
10 Female Catheterization 52
11 Endotracheal intubation 54
Emergency Medicine
12 ABCDs of Management 57
13 Foreign body Aspiration 67
14 Coma 71
15 Hypertensive emergency Management 78
16 Approach to Diarrhoea 81
17 Status Epilepticus 87
18 Epistaxis (Bleeding through Nose) 89
19 Acute Viral Hepatitis 90
20 Upper Gastrointestinal Bleed 91
21 Hepatic Encephalopathy 94
22 Pyogenic Liver Abscess 96
23 Shock 98
24 Acute Blood Loss (Hemorrhagic Shock) 105
25 Acute Hemolytic Transfusion Reaction 107
26 Dengue Hemorrhagic Fever 108
27 Acute Exacerbation of Asthma 111
28 Status Asthmaticus 112
29 Acute Exacerbation of Chronic Obstructive Pulmonary Disease 114
30 Acute Renal Colic 116
31 Acute Pyelonephritis 117
32 Cardiac Arrest 118
33 Pulmonary Edema 119
34 Pulmonary Embolism 120
35 Intracerebral Hemorrhage (Hemorrhagic Stroke) 122
36 Organophosphate poisoning 123
37 Anaphylaxis 124
38 Benzodiazepines Poisoning 125
39 Opioids poisoning 126
40 Acid/Caustic Ingestion 127

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 4 Standard Treatment Protocols

41 Kerosene Poisoning 128

42 Paraphenylenediamine Poisoning 129
43 Human Bite 131
44 Dog Bite 132
45 Unknown insect Bite 134
46 Snake Bite 135
47 Hypokalemia 138
48 Hyperkalemia 139
49 Hypoglycemia 140
Respiratory System
50 Fever with dry cough 142
51 Fever with productive cough 143
52 Community acquired pneumonia 144
53 Nosocomial/Hospital associated pneumonia 147
54 Ventilator associated pneumonia 149
55 Chlamydia Psittaci Pneumonia 151
56 Mycoplasma pneumonia 153
57 Staphylococcal pneumonia 155
58 Pneumococcal pneumonia 158
59 Lung abscess 160
60 Pulmonary Tuberculosis 162
61 Bronchial asthma 165
62 Chronic Obstructive Pulmonary Disease 168
63 Pleural effusion 170
64 Bronchiectasis 172
Gastrointestinal Diseases
65 Oral ulcers/Aphthous ulcers/Stomatitis 175
66 Gastro Esophageal Reflux Disease (GERD) | Esophagitis 176
67 Gastric Ulcer (Peptic Ulcer) 177
68 Duodenal Ulcer (Peptic Ulcer) 178
69 Functional Dyspepsia 180
70 Hiccups (Singulitis) 181
71 Irritable Bowel Syndrome (IBS) 182
72 Ulcerative Colitis 183
73 Adult Constipation 186
74 Non Alcoholic Fatty Liver Disease (NAFLD) 188
75 Amoebic Liver Abscess (Hepatic Abscess) 189
76 Chronic Hepatitis B Viral Infection 190
77 Chronic Hepatitis C Viral Infection 191
78 Liver Cirrhosis with Ascites (Decompensated liver disease) 193
79 Ascites 195
Cardiovascular Diseases
80 Acute Myocardial Infarction 198
81 Stable angina 202

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82 Unstable angina 203

83 Acute heart Failure with pulmonary edema 204
84 Congestive Cardiac failure with Reduced EF 206
85 Chronic Hypertension 208
86 Infective Endocarditis 213
87 Rheumatic Heart disease 215
Endocrine Disorders
88 Diabetes Mellitus Type 1 (IDDM) 218
89 Diabetes Type 2 (NIDDM) 220
90 Diabetic Nephropathy 222
91 Diabetic neuropathy 223
92 Other Diabetic Complications 225
93 Diabetic Keto Acidosis DKA 226
94 Hyperosmolar Hyperglycemic State HHS 228
95 Hypoglycemia 230
96 Hypothyroidism 231
97 Hyperthyroidism /Thyrotoxicosis 232
98 Hyperprolactinemia 234
99 Pheochromocytoma 235
Renal Diseases
100 Fever with Burning Micturation 237
101 Urinary Tract Infection In Adults 238
102 Acute Pyleonephritis 239
103 Renal Concretions (Nephrolithiasis ) 241
104 Benign Prostatic Hyperplasia (BPH) 243
105 Urinary incontinence 244
106 Urge incontinence 245
107 Stress incontinence 246
108 Overactive Bladder 247
109 Erectile Dysfunction 248
110 Interstitial cystitis 249
111 Nephritic syndrome 250
112 Nephrotic syndrome 251
113 Acute Kidney Injury /Acute Kidney Failure 253
Rheumatological Disease
114 Osteoarthritis 256
115 Arthritis 258
116 Osteoporosis 259
117 Post Menopausal Osteoporosis 261
118 Rheumatoid Arthritis 263
119 Gouty Arthritis 265
120 Post Chikungunya Arthritis 267
121 Plantar Fasciitis 268
122 Polymyalgia Rheumatica 269

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 6 Standard Treatment Protocols

123 Fibromyalgia Syndrome 270

124 Acute Septic Arthritis 271
125 Systemic Lupus Erythematosis 272
CNS Disease
126 Migraine Headache 274
127 Cluster headache 276
128 Tension Headache 278
129 Transient Ischemic Attack 279
130 Cerebrovascular accident (Ischemic Stroke) 280
131 Postherpetic Neuralgia 282
132 Trigeminal Neuralgia/Tic Douloureux 283
133 Bells Palsy 284
134 Parkinson’s Disease 285
135 Alzheimer’s Disease 287
136 Guillain Barre Syndrome 289
137 Cerebral Palsy 291
138 Dhat Syndrome 292
139 Premature Ejaculation 293
140 Insomnia Disorder 295
141 Acute Panic Attack / Stress Disorder 297
142 Generalized Anxiety Disorder 299
143 Bipolar Affected Disorder 300
144 Schizophrenia 302
145 Opiod Withdrawal Syndrome 303
Dermatology Diseases
146 Scabies 305
147 Acne vulgaris 306
148 Psoriasis 308
149 Seborrheic Dermatitis 309
150 Tinea Pedis And Tinea Manuum 310
151 Tinea Corporis (RING WORM) 311
152 Tinea versicolor 312
153 Tinea Cruris 313
154 Melasma (Mask Of Pregnancy) 314
155 Herpes Zoster 315
156 Atopic dermatitis/Atopic Eczema 317
157 Allergic Contact Dermatitis 319
158 Pamper Rash 320
159 Pompholyx 321
Infectious Disease
160 Fever of Unknown Origin 323
161 Fever with chills and rigors 325
162 Sepsis 326
163 Typhoid fever (Enteric fever) 327

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164 Malaria fever (Falciparum malaria) 329

165 Brucellosis 330
166 Weil’s Disease (Leptospirosis) 331
167 Schistosomiasis 332
168 Tick Typhus/Scrub Typhus 333
169 Epidemic Typhus 334
170 Rocky Mountain Spotted Fever 335
171 Syphilis 336
172 Coxiella Brunetti (Q-fever) 338
173 Shigellosis 339
Obstetrics & Gynecology Disease
174 Primary Dysmenorrhea (Menstrual Pain) 341
175 Fever with dry cough in pregnancy-Upper RTI 343
176 Fever with productive cough in pregnancy-Lower RTI 344
177 Typhoid fever (Enteric Fever) in pregnancy 345
178 Malaria fever (Falciform malaria) in pregnancy 347
179 Urinary tract infection (UTI) in pregnancy 349
180 Nephrolithiasis (Renal stone) in pregnancy 350
181 Community Acquired Pneumonia Outpatient in pregnancy 351
182 Community Acquired Pneumonia Inpatient in pregnancy 352
183 Vaginal yeast infection (Vulvo-vaginal candidiasis) 354
184 Chlamydial infection 355
185 Leukorrhea 356
186 Pelvic inflammatory disease 357
187 Trichomoniasis 359
188 Atrophic Vaginitis 360
189 Primary Dysmenorrhea (Menstrual Pain) 361
190 Premenstrual Syndrome 362
191 Mittelschmerz 363
192 Oligomenorrhea 364
193 Endometriosis 365
194 Uterine Leiomyomas (Uterine Fibroids) 366
195 Female infertility 367
196 Polycystic ovary syndrome (PCOS) 368
197 Benign Ovarian Cyst 369
198 Postpartum Hemorrhage 370
199 Nausea and vomiting of pregnancy 371
200 Hyperemesis gravidum 372
201 Pre eclampsia 373
202 Eclampsia 375
203 Iron deficiency anemia in pregnancy 376
204 Megaloblastic anemia (folic acid and vit B 12) in Pregnancy 377
205 Gestational diabetes mellitus 378
206 Hypoglycemia in pregnancy 379
207 Hyperthyroidism in pregnancy 381

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 8 Standard Treatment Protocols

208 Hypothyroidism in pregnancy 382

209 Ectopic pregnancy 383
210 Spontaneous abortion 384
211 Pueperal sepsis
Pediatrics Disease
212 Acute tonsillitis 386
213 Acute epiglottitis 387
214 Laryngotracheobronchitis (Croup) 389
215 Bronchiolitis 391
216 Community acquired pneumonia (CAP) 392
217 Acute asthma attack (status asthmaticus) 395
218 Fever with burning micturition/UTI 396
219 Allergic rhinitis 397
220 Child with dental infection 398
221 Child with ear pain/discharge 399
222 Acute suppurative otitis media 400
223 Management of fever 401
224 Typhoid fever(Enteric fever) 402
225 Malaria fever (Falciform malaria) 404
226 Chickenpox (Varicella) 405
227 Mumps (epidemic parotitis) 406
228 Measles (Rubella) 407
229 H Pylori infection 408
230 Iron deficiency anemia 409
231 Pica eating disorder 410
232 Infantile colic 411
233 Constipation 412
234 Vitamin D deficiency 413
235 Hypocalcaemia 414
236 Oral ulcer (aphthous ulcer) 415
237 Mild to Moderate Gastroenteritis/Acute Diarrhea 416
238 Severe Dehydration/Severe Diarrhea 417
239 Lactose intolerance 419
240 Status epilepticus 420
241 Febrile seizures 422
242 Bacterial meningitis 423
243 Tetanus 425
244 Scabies 427
245 Hypothyroidism 428
246 Hyperthyroidism 429
ENT DISEASES
247 Acute tonsillitis 431
248 Acute pharyngitis 432
249 Acute sinusitis (acute sinus infection) 433
250 Chronic sinusitis 434
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251 Acute Rhinitis 435

252 Allergic rhinitis 436
253 Deviated nasal septum 437
254 Septal hematoma 438
255 Septal abscess 439
256 Adult with ear discharge/infection 440
257 Acute Suppurative Otitis Media 441
258 Chronic suppurative otitis media 442
259 Tinnitus 443
260 Vertigo 444
261 Benign Paroxysmal Positional Vertigo 445
Ophthalmology Disease
262 Stye (hordeolum) 447
263 CHALAZION 448
264 Iritis (Anterior uveitis) 449
265 Acute Mucopurulent conjunctivitis 450
266 Chlamydial Conjunctivitis-Trachoma 451
267 Allergic Conjunctivitis 452
268 Viral Conjunctivitis 453
269 Herpes simplex keratitis 454
270 Blepharitis 455
271 Corneal Abrasion 456
272 Subconjunctival hemorrhage 457
273 Ocular chemical burns injuries (non-mechanical) 458
274 Corneal Foreign Bodies (Mechanical) 459
275 Acute Angle Glaucoma 460
How to calculate IV Drugs that requires Dilation 462
How to calculate Oral Syrup/Suspension Doses. 463
How to calculate ml/hour or drops per min for infusion drugs. 471
COMMONLY AVAILABLE MEDICINE BRANDS IN PAKISTAN 490

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 10 Cardiovascular Diseases

APPROACHING A
PATIENT

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HISTORY TAKING
Importance of history-taking in healthcare:
1. Diagnostic Aid: Patient history often offers vital clues aiding in the diagnosis of
illnesses and medical conditions.
2. Understanding Patient Concerns: Helps in comprehending patient's primary
concerns, symptoms, and their impact on daily life.
3. Establishing Rapport: Builds a trusting relationship between the patient and the
healthcare provider, leading to better communication.
4. Risk Assessment: Assists in evaluating risk factors associated with various health
conditions, aiding in preventive measures.
5. Treatment Decisions: Guides treatment plans based on the patient's history,
including allergies, prior illnesses, and medication use.
6. Identifying Red Flags: Detects warning signs or symptoms that require immediate
attention or further investigation.
7. Monitoring Progress: Enables healthcare providers to track changes in a patient's
health over time and adjust treatment accordingly.
8. Holistic Approach: Offers a comprehensive view of the patient's health, considering
biological, psychological, and social aspects.
9. Cost-Effective: Helps in efficient utilization of resources by narrowing down
diagnostic tests and procedures based on gathered information.
10. Educational Tool: Provides an opportunity to educate patients about their
conditions, medications, and preventive measures.
General Approach for History Taking:
1. Introduce yourself by stating your name and professional designation (e.g., "Hello,
I'm Dr. [Name], from the Medicine department").
2. Confirm the patient's identity by verifying their name and date of birth.
3. Interact with the patient in a friendly and relaxed manner, ensuring they feel
comfortable.
4. Seek permission to discuss the reason for the visit eg: (Is that ok if I ask you some
questions about your vomting?").
5. Maintain confidentiality and respect the patient's privacy throughout the interaction.
6. Try to empathize and understand the patient's perspective and concerns.
7. Assess the patient's mental state, noting any signs of anxiety, irritability, or distress.
8. Position the patient comfortably, sitting about a meter away from you and at the
same eye level.
9. Practice active listening, allowing the patient to express themselves fully.
10. Use clear and simple language while asking questions, avoiding medical jargon, and
employ open-ended queries. Summarize information periodically for clarity.
Components of History Taking
• Personal Data
• Chief Complaint (CC)
• History of Present Illness (HPI)
• Past Medical History (PMH)
• Medication History
• Family History

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 12 Cardiovascular Diseases

• Social History
• Review of Systems (ROS)
• Allergies
• Immunization History
• Psychosocial History
• Nutritional History
• Gynecological/Obstetric History (for female patients)
• Surgical History
• Developmental History (for pediatric patients)
Personal Details:
Name
Age:
Gender:
Address:
Occupation
Religion
Marital status
Date of Admission
Mode of Admission
Chief Complaint (C/C):
Understanding the primary reason for the patient's visit or the main issue they want to address.
Some important points & Questions:
1. Why are you here at the hospital today?
2. What brings you to the hospital?
3. How can I assist you?
4. What seems to be bothering you?
• Each complaint should be written in one line.
• If there are more than one complaint, list them in order of severity or duration.
Chief Complaint (Symptoms) - Duration
• Stomach pain - 2 days
• Headache - 1 week
• Difficulty breathing - 2 hours
• Rash on the arm - 4 days
History
History of present illness:
Two Approaches: OD-PARA approach/SOCRATES Approach can help you for differential
diagnosis and to cover all aspects of information.
SOCRATES Approach
1. Site: Where exactly do you feel the pain?
2. Onset and progression: When did the pain start, and how has it changed
or developed over time?
3. Character: What does the pain feel like? Is it sharp, dull, or crushing?
4. Radiation: Does the pain move to any other areas of your body, like the
jaw, arm, or back?
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5. Associated symptoms and signs: Do you experience any other symptoms

alongside the pain, such as sweating, nausea, vomiting, shortness of breath,
cough, coughing up blood, dizziness, or palpitations?
6. Timing and duration: Does the pain occur at specific times of the day?
How long does each episode of pain last?
7. Exacerbating and alleviating factors: Is there anything that triggers or
eases the pain? For example, does movement, rest, certain foods,
medications, or specific activities make it better or worse?
8. Severity: On a scale from 1 to 10, with 1 being no pain and 10 being the
most severe pain imaginable, how would you rate your current pain level?

OD-PARA approach
1. Onset: When did the main issue start, and how did it begin (slowly,
quickly, suddenly, intermittently, or consistently)?
2. Duration: How often do the symptoms occur, and at what times
(nighttime, throughout the day, in the morning)?
3. Progression: Is the problem improving or worsening? Are there specific
activities or conditions that affect it positively or negatively?
4. Aggravating Factors: Are there any factors that worsen the issue, such as
specific foods or activities?
5. Relieving Factors: Are there any actions, positions, or foods that alleviate
the problem?
6. Associated Symptoms: Are there any other details related to the main
issue that haven't been discussed yet (like nausea, vomiting, or any other
related concerns)? Ask if there's anything else the patient would like to
share regarding the main problem.
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 14 Cardiovascular Diseases

Gastrointestinal System

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Cardiovascular System:

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 16 Cardiovascular Diseases

+ 50 More Pages of History &

Ward Procedures

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 DOCTOR ON CALL 17

Nasogastric intubation

Patient Introduction and Explanation

• Introduce yourself and confirm the patient's identity.
• Explain the necessity and procedure for inserting an NG tube, ensuring informed
consent.
Patient Positioning and Comfort
• Position the patient upright.
• Inquire about nostril preference and ensure patient comfort.
Equipment Preparation
• Gather all necessary equipment.
• Wash hands and wear gloves.
Measurement and Lubrication
• Measure the length of the NG tube needed for insertion.
• Apply lubrication (Xylocaine jelly) to the tube's tip.
Tube Insertion
• Instil lignocaine gel into the patient's nostril.
• Insert the NG tube through the chosen nostril, aiming toward the nasopharynx.
• Prompt the patient to tilt their head forward and swallow water through a straw while
advancing the tube slowly.
Managing Patient Response
• If the patient coughs or gags, retract the tube slightly and allow for recovery.
• Insert the tube to the required length.
Verification and Securing the Tube
• Confirm proper placement of the tube in the stomach by injecting 20ml air and
auscultating over the epigastrium.
• Secure the tube to the nose and face with tape.
Final Steps and Patient Comfort
• Connect a spigot or catheter bag to the NG tube.
• Address any patient inquiries or concerns.
• Ensure patient comfort and express gratitude.
Documentation
• Record the successful placement of the NG tube in the patient's notes.

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 18 Cardiovascular Diseases

A 19 year-old girl was referred to our hospital on March, 2016 due to 4-day fever and cough,
with no pertinent past medical history. Physical examination revealed temperature 37.4°C,
heart rate 120 beats/min, respiration 50 times/min, blood pressure 90/60 mm Hg, and
transcutaneous oxygen saturation 92% without oxygen administration, fatigue, and depressions
in suprasternal fossa, supraclavicular fossa, and intercostal space. She developed hypoxemia,
so the reservoir mask of 6 l/min was utilized for ventilatory support. The right lung showed
diminished breath sounds. Cardiovascular, nervous system, extremities, antinuclear antibodies
(ANAs), and extractable nuclear antigens (ENAs) examinations were normal.
Complaint of (C/O)
• Low grade Fever with chills
• Severe malaise
• Dry cough
• Tachypnea and Dyspnea
Dx: Mycoplasma pneumonia
On Examination (O/E) Management Protocols
• Bronho Breathiung Prevention:
Wheezing and coarse Ø Avoid Triggering factors as M. pneumoniae.
crepitations on Ø Avoid Alcohol long term use /Avoid Smoking
Auscultation Ø Treatment includes 14 days.
• Decreased Breadth
sounds
Definitive:
1st Line
• Dullness on percussion
• Pleuritic chest pain 1. Tab Clarithromycin 500 mg
• Fatigue,Headaches. 1+0+1 BD 14 days
• Myalgia and malaise 1+0+0 OD (Extended release) 14 Days OR
Investigational Findings • Tab Azithromycin 500 mg
• CBC shows normal PO x 1, then 250mg OD 14 days
WBCs .
• Inc CRP ,Inc ESR 2ND Line:
• Markers of hemolysis • Cap Doxycycline 100 mg
positive 1+0+1 BD 14 days OR
• Combs test positive Antibacterial
• Chest X ray PA and • Tab Levofloxacin 750 mg | Moxifloxacin 400 mg |
Lateral View Gemifloxacin 320 mg
Findings: 1+0+0 OD 10-14 days
• Bronchopneumonia : Antibacterial
Poorly defined patchy Symptomatic:
infiltrates 2. Tab Paracetamol 500 mg
Presence of air 2+2+2 TDS for 7 Days
bronchograms 3. Syp Muconyl | Ventolin Expectorant
• Detection of high titre of 2+2 TSF BD | 2+2+2 TDS
cold agglutinins IgM 4. Syp Acefyl | Pulmonol | Cosome E
antibodies on serology 2+2+2 TSF TDS (Not indicated in guidelines)
• PCR (nasopharyngeal 5. Syp/Tab Multivitamins
swab) 2 +0+2 TSF 30 min before meal 30 days
• Serology :Anti
mycoplasma IgG (Most
specific)
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Categorization of the radiographic findings of M. pneumoniae pneumonia.

(a) Lobar or segmental consolidation. Posteroanterior chest radiograph shows a homogenous
dense opacity in the right upper lobe. An air-bronchogram was also noted in the consolidative
lesion in the right upper lobe. (b) Patchy infiltration. Posteroanterior chest radiograph
demonstrates localized ill-defined increased lung opacity in the base of the right lower
lobe. (c) Localized reticulonodular infiltration. The chest radiograph shows localized
reticulonodular lesions in the base of the right lower lobe. (d) Parahilar peribronchial
infiltration. The chest radiograph demonstrates extensive parahilar reticulonodular lesions in the
left upper and lower lung fields.

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 20 Cardiovascular Diseases

BEM 1 month old baby is hospitalized for fever, nasal obstruction, and diarrhea stools. From
his personal history, he is the first child, born at 9 months, with birth weight = 3380g, artificially
fed. Four days after admission, fevers are 39°C; hemocultures are taked in a spike of a fever
that is negative. The diarrheal stools are maintained throughout the first week, the infant is
perfused, and Aminoven is given with hydro-electrolytic rebalancing. From the 8th day of
hospitalization fever reappears after 3 days of afebrility, and productive cough, bronchial and
rallies, difficult appetite. Initially received ceftriaxone, Gentamicin, hydroelectrolytic
rehydration therapy, racecadotril, Lactobacillus reuteri, hydrocortisone succinat, then
Cefoperazone /Sulbactam for 8 days, chest tapotage with slow favorable evolution and weight
recovery over the first 4 days after changing therapy. Afterwards the fever reoccurs; the
hemocultura became positive for Staphylococcus aureus.
Complaint of (C/O)
• High Fever with chills
• Severe malaise
• Productive cough with purulent sputum
• Tachypnea and Dyspnea
Dx: Staphylococcal pneumonia
On Examination (O/E) Management Protocols
• Yellowish greenish Prevention:
sputum Ø Avoid Triggering factors i.e tobacco and alcohol use.
• Decreased Breadth Ø Avoid Alcohol long term use /Avoid Smoking
sounds Ø Treatment includes 5-10 days
• Enhanced Bronchophony Definitive :
• Tactile fremtius ANTI BACTERIAL THERAPY
• Dullness on percussion • Cap Amoxicillin 500 mg
• Pleuritic chest pain 1+1+1 TDS for 7-10 days. OR
• Fatigue,Headaches. • Tab Cloxacillin 500 mg
• Myalgia and malaise 1+1+1+1 QID PO or IV OD 5 days OR
Investigational Findings • Tab Clarithromycin 500 mg
• CBC shows inc WBCs . 1+0+1 BD for at least 7 days OR
• Inc CRP ,Inc ESR • Cap Doxycycline 100 mg
• Inc PCT to diagnose 1+0+1 BD for at least 10 days
Lower respiratory Tract 2nd line Combination:
Infections 1. First Combination
• Sputum culture and Cap Amoxicillin 1gm
blood culture is 1+1+1 TDS 5 days
Investigation of choice PLUS
• Chest X ray PA and 2. Tab Azithromycin / Clarithromycin as above doses
Lateral View Findings: OR
• Bronchopneumonia : 1. 2nd Combination
Poorly defined patchy Cap Amoxicillin 500 mg + Clavulanic acid 125mg
infiltrates 1+0+1 BD x 5 days
Presence of air PLUS
bronchograms 2. Tab Azithromycin 500 mg / Clarithromycin 500 mg
PO x 1, then 250mg OD -5 days /1+0+1 BD - 5 or 7
days
OR

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 DOCTOR ON CALL 21

Management Protocols
1. 3rd Combination
Tab Levofloxacin 750 mg \ Moxifloxacin 400 mg\ Gemifloxacin 320 mg
1+0+0 OD 5-7 days
PLUS
2. Tab Cefpodoxime 200 mg \Tab Cefuroxime 500 mg + Macrolide antibiotics
1+0+1 BD 5 days

Patients not at high risk for mortality but with risk factors for MRSA infection:
1. Inj. Linezolid 600mg/300ml
1+0+1 IV BD 5 days OR
• Inj. Vancomycin 500mg-1g
1+0+1 IV BD 5 days
PLUS
2. Inj. Imipenem + Cilastatin 500 mg
1+1+1+1 IV QID 5-10 days OR
• Inj. Cefepime 2 g
1+1+1 IV TDS 5-10 days OR
• Inj. Piperacillin +Inj. Tazobactam 4.5g
1+1+1+1 IV QID 5 to 7 days OR
• Inj. Meropenem 1g
1+1+1 IV TDS 5-10 days

Patients not at high risk for mortality but with risk factors for VRSA infection:
1. Inj. Linezolid 600mg/300ml
1+0+1 IV BD 5 days OR
PLUS
2. Inj. Imipenem + Cilastatin 500 mg
1+1+1+1 IV QID 5-10 days OR
• Inj. Cefepime 2 g
1+1+1 IV TDS 5-10 days OR
• Inj. Piperacillin +Inj. Tazobactam 4.5g
1+1+1+1 IV QID 5 to 7 days OR
• Inj. Meropenem 1g
1+1+1 IV TDS 5-10 days
Supportive with All:
Ø Nebulization with Ventolin & Clenil
2+2+2 TDS
Ø Inj Dexamethasone 4mg/1ml 4-6 mg
1+0+1 IV BD 5-7 days Corticosteroids if indicated.

Ø Inj. Paracetamol 1g/100ml

1+1+1 IV TDS 5 days then SOS Antipyretic

Ø Inj. Omeprazole 40mg

1+0+0 OD IV Before meal

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 22 Cardiovascular Diseases

Right middle lobe consolidation with an associated cavitating lesion and air
bronchogram. There is a small right sided pleural effusion. The remainder of the
lung fields are unremarkable. There are no abnormalities of the mediastinal
structures, bones or soft tissues.

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 DOCTOR ON CALL 23

Mr TF is a 34-year-old Turkish man. He has been experiencing very painful mouth ulcers for
the past year.He says that he has had at least eight ulcers and each one has lasted around a
fortnight.Mr TF is usually very fit and well and does not take regular medication. However,
he saw one of your partners two months ago complaining of a sore right eye. He was diagnosed
then as having uveitis.He also tells you that he has had a small ulcer on his scrotum, which
was also extremely painful a few months ago.He has noticed that he has been more tired than
usual recently and complains of intermittent muscle and joint pains.What will be the most
likely diagnosis?
Complaint of (C/O)
• Round sore • Painful sore lesion
• Swollen skin around the sores • Problem in teeth chewing and brush
• Irritation of sores by spicy food • Loss of appetite
• Stress/Anxiety
Dx: Oral ulcers/Aphthous ulcers/Stomatitis
On Examination (O/E) Management Protocols
• .Painful sore lesion Preventive:
• Swelling of skin sores • Oral hygiene
• Tenderness during • Lifestyle changes
chewing /Brushing teeth . • Exercise
• Loss of appetite • Avoid Smoking
• Irritation by salty and spicy Definitive :
food. 1. In Mild Cases
Ø Lignocaine Topical gel (Xyloaid)
Apply only on ulcers before meal.
2. In Severe Cases
Ø Kenalog in orabase cream
Apply on ulcers 5 min after meal.
3. In Severe Cases with large ulcers
Ø Hydrocortisone Mucoadhesive Buccal Tablets
Apply on ulcers TDS for 3 – 5 days.
OR
Ø Tab. Prednisolone 5mg (Deltacortil)
1+1+1 TDS PO for 3-5 Days
4. Supportive
Ø Tab Iron- Folic Acid 5mg/Tab vitamin B complex
1+0+0 BD for 3 Months Iron supplement
Ø Syp Nystatin 1000,000iu/ml Drops /Miconazole gel
1+1+1 TDS Antifungal
Ø Cap Omeprazole 40 mg/Cap Esomeprazole 20 mg
1+0+1 OD /HS for 7 Days
Note:
Ø In recurrent cases rule out systemic diseases (Crohn,
Celiac,Lichen Planus, Syphilis, HIV, NSAIDs use,
stress disorder)
Ø In Raised Margins refer for Biopsy

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a
 24 Cardiovascular Diseases

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 DOCTOR ON CALL 25

A 57 years old ,60 kg man with chief complains of fatigue ,a persistent low grade fever ,night
sweats ,arthralgias ,and a 7 kg weight loss, is admitted to the hospital for evaluation .Visual
inspection reveals a Cachetic ,ill appearing man in no acute distress .He has history of
significant mitral prolapse and more recently a dental procedure involving the extraction of four
wisdom teeth .The history of his present illness is noteworthy for the development of symptoms
2 weeks after the dental procedures (about 2 months before admission ).
Complaint of (C/O)
•Fever chills from weeks to months
• Myalgia,weight loss from weeks to months
• Headache ,night sweats
• Shortness of breadth
• Cough
Dx: Infective Endocarditis
On Examination (O/E) Management Protocols
• Fever 38 degree Prevention:
• Petechial skin lesions • Complete bed rest until signs of inflammation
• Subungual splinter disappear.
hemorrhages and jane way • Eat in small portions with poor salt diet
lesions on soles of both feet . • Avoid Alcohol long term use
• Roth spots ,osler nodes are not • Avoid Smoking.
evident High Risk cardiac lesions where antibiotic prophylaxis
is needed.
1. Prosthetic heart valve.
2. Prior endocarditis.
3. Unrepaired cyanotic congenital heart disease.
4. Completely repaired cyanotic heart disease within 6
months.
5. Incompletely repaired cyanotic heart disease with
residual defects.
Spinter hamorrhage, petechial Modified Duke s Criteria:
skin Major Criteria
• Cardiac examination is i. Positive blood culture:
signifcant for grade III/IV Two separate positive blood cultures with
diastolic murmur with mitral microorganism(s) typical for infective endocarditis:
regurgitation . Viridians streptococci, Streptococcus bovis, HACEK
Investigational Findings group, Staphylococcus aureus, community acquired
• CBC : enterococci.
shows anemia ,WBC s raised or
with 60 % polys ,increased ESR Persistently positive blood culture defined as presence of
.CRP and positive RF microorganism consistent with infective endocarditis
• Blood cultures positive for from blood cultures drawn >12 hours apart.
three minor or one major criteria or
Single positive blood culture for Coxiella burnetii or
phase one IgG antibody titre of >1: 800.
ii. Echocardiographic evidence of endocardial
involvement typical Valvular lesions:

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 26 Cardiovascular Diseases
Investigational Findings
• Urine microscopic Hematuria .
• Echocardiography :
Transesophageal echocardiogram,
4-chamber view. There is a large
vegetation seen below the posterior
leaflet of the mitral valve.
Major criteria:
1. Positive blood culture for
infective endocarditis.
2. Evidence of endocardial
involvement (positive echocardiogram
or new valvular regurgitation)
Minor criteria:
1. Predisposing heart condition or
intravenous drug use
2. Fever
3. Vascular phenomena (e.g.
Arterial emboli, septic pulmonary
infarcts, ETC)
4. Immunologic phenomena (e.g.
glomerulonephritis, osler nodes etc.)
5. Microbiological evidence (doesn't
meet a major criterion definition)
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Management Protocols
vegetations, abscess, or new partial dehiscence of
a prosthetic valve New Valvular regurgitation.
Minor Criteria:
• Predisposition; predisposing heart condition
or intravenous drug use.
• Temperature greater than 38.0 C.
• Vascular phenomenon; major arterial
emboli, septic pulmonary infarcts, mycotic
aneurisms, intracranial hemorrhages,
conjunctival hemorrhages, Janeway lesion
• Immunological phenomenon;
(glomerulonephritis; Osler nodes; Roth's
spots; rheumatoid factor)
• Microbiological evidence positive blood
cultures but not meeting major criteria or
serological evidence of active infection with
organism consistent with infective
endocarditis.
Documentation of 2 major / one major and 3
minor / 5 minor criteria allow a diagnosis
Infective endocarditis.
Definitive:
Acute Bacterial Endocarditis or Penicillin
Resistant
1. Inj. Vancomycin 500mg
1+0+1 BD IV for 6 weeks
2. Inj. Gentamycin 80mg
1+1+1 TDS IV for 6 weeks OR
Inj. Ceftriaxone 2g
1+0+1 IV OD for 2 weeks
Subacute Bacterial Endocarditis
1. Inj. Gentamycin 80mg
1+1+1 TDS IV for 2 weeks
For 6 weeks in case of Enterococci
2. Inj. Benzyl Pencillin 2 MU
1+1+1+1 QID IV for 2 weeks if used with
Gentamicin.
1+1+1+1 QID IV for 4 weeks if used single.
For 6 weeks in case of Enterococci. OR
• Inj. Ampicillin 2 g
1+1+1+1 QID IV for 6 weeks
For Staphylococci
IN CASE OF: Valve dysfunction, heart failure,
fungal endocarditis, new heart block ,Annular
abscess ,aortic abscess
Surgery: Valve replacement or valve repair
 DOCTOR ON CALL 27

The authors present a case of a 50-year-old female patient with a history of anemia attributed
to menorrhagias and a depressive disorder. She had also several episodes of tonsillitis during
her childhood. The patient was hospitalized in the cardiology department with symptoms of
fatigue on moderate exertion for several months, with worsening in the month before
hospitalization. At physical examination, discolored skin and mucous membranes were
noted with no other abnormalities of the skin or appendages; on cardiac auscultation,
rhythmic S1 and S2 were found as well as a diastolic murmur at the cardiac apex, best heard
with the patient in a left lateral decubitus position. The remaining physical evaluation,
including gynaecological and neurological examination, showed no other relevant findings.
Complaint of (C/O)
• Fever, malaise and fatigue
• Joint pain
• Exertion moderate from months
• Difficulty in breathing
Dx: Rheumatic Heart disease
On Examination (O/E) Management Protocols
• Syndenham chorea Prevention:
involuntary, irregular • Complete bed rest until signs of inflammation
movements of limbs ,neck disappear.
and head . • Eat in small portions with poor salt diet.
• Skin: subcutaneous • Avoid Alcohol long term use.
nodules • Avoid Smoking.
• Erythema marginatum
• Proper management of pharyngeal infection
• Migratory polyarthritis
• Fever • Tonsillectomy for chronic infected tonsils
Investigational Findings Definitive:
• 12 Lead ECG was done • Inj Benzathine Benzapencillin 1.2 M IU
Eart rate 75 bpm,normal Deep IM stat
electrical axis and dilated Antibiotic OR
left atrium may be . • Tab Erthyromycin 250 mg
• Trans Oesophageal 1+1+1 TDS
Echocardiography Antibiotic (in patient allergic to penicillin )
shows thickening of mitral • Tab Aspirin 300 mg (Disprin)
valves /mitral stenosis /left 3+0+3 3-6 tablets QID for 2 weeks
atrium dilated /moderate Upto maximum tolerated dose or max 8gm/day then
tricuspid regurgitation . Tapered after 2 weeks upto 6 weeks according to
• CBC shows microcytic symptoms & ESR.
,hypochromic anemia With CHF
,Reduced Iron stores and • Tab Prednisolone 5 mg
vitamin B12 levels In divided doses .
• Serum anti parietal o 3 Tablets QID (3+3+3+3) till ESR
antibodies: positive normalize
•Anti intrinsic factor: o 3 Tablets TDS (3+3+3) for 3 days
negative o 3 Tablets TDS (2+2+2) for 3 days
• GI endoscopy: o 2 Tablets BD(2+0+2) for 3 days
Erythema in gastric body o 1 Tablets(1+0+1) BD for 3 days
giving clue of secondary o 1 Tablet OD for 3 day
cause.

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STANDARD
a TREATMENT PROTICOLS : DOCTOR ONCALL
 28 Cardiovascular Diseases

Investigational Findings Management Protocols

In Chorea
• Tab Diazepam 10 mg
1+1+1 OD for 1 Day
Then Tab Diazepam 5mg
1+1+1 till 2 weeks after clinical
improve
If Symptoms Persist
• Tab Haloperidol 1.5 mg
1+1+1 till 2 weeks after clinical
improve
Symptomatic
• Tab Famotidine 40 mg,20 mg
0+0+1 HS
Anti inflammatory in carditis
• Tab Omeprazole 40 mg
0+0+1 HS before meal
Anti inflammatory in carditis

For Secondary Prevention

(A) Echocardiography revealing a
thickening of mitral valve leaflets, with
fusion and calcification of the commissures.
(B) Echocardiography showing maximum
and mean transvalvular mitral gradients of
26 and 14 mm Hg, respectively, and a
functional area of 1 cm2, compatible with
severe mitral stenosis
MR >AR (Acute ) ,MS (Chronic )
Mitral valve 65% cases
Aortic valve 25 % cases
Tricuspid valve 10 % cases
Dilated cardiomyopathy
Pancarditis
• A pelvic USG for any pathological cause
in uterus.
• Anti Streptolysin O titre increased
•Anti Streptococcal DNAse B titre ADB
increased
• Positive throat culture
• Inj Benzathine Benzapencillin 1.2 M
IU
Deep IM every Third week
Tab Penicillin V 500mg
1+0+1 BD for 4 weeks
Jones Criteria:
• Major criteria:
• Carditis (clinical and/or subclinical)
• Arthritis (polyarthritis)
• Chorea
• Erythema marginatum,
• Subcutaneous nodules.
Minor criteria:
• Polyarthralgia
• Fever (≥38.5° F)
• Sedimentation rate ≥60 mm / C-reactive
protein (CRP) ≥3.0 mg/dl
• Prolonged PR interval (unless carditis is
a major criterion)
Long-acting penicillin 1.2 million units
given monthly.
• Until the age of 25 or for 5 years after
the last attack (whichever is longer )
• For long life if there is cardiac affection

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 DOCTOR ON CALL 29

KJ is a 58-year-old female who presents to the emergency department (ED) with complaints of
fever, chills, dysuria, urgency, and back pain. Upon physical exam CVA tenderness is noted; no
other significant physical findings. She has a fever of 101.2°F; however, she is
hemodynamically stable in the ED
Complaint of (C/O)
• Severe back pain
• Pain during micturition
• Fever, chills
• Fatigue
• Nausea ,vomiting
Dx: Acute Pyleonephritis
On Examination (O/E) Management Protocols
• Nausea, vomiting Prevention:
• Fever with chills 1. Drink more liquids /ORS
• Abdominal pain and 2. Avoid Alcohol long term use
tenderness. 3. Avoid Smoking .
• Costovertebral angle 4. Encourage Healthy diet.
tenderness.
Definitive:
• Diarrhea may be
Investigational Findings
Moderate Pyelonephritis:
Start Single IV Anti Biotic dose.
• CBC shows raised • Inj Ceftriaxone 1 g
ESR,WBCs and CRP Then
•UCE: • Tab Ciprofloxacin 500 mg/Tab Levofloxacin 250 mg
Urine Complete 1+0+1 BD
Examination shows Pus For Anti-bacterial
cells and RBCs . • Tab Mefenamic acid 500 mg /Tab Paracetamol 500mg
•BMP shows raised BUN 1+1+1 TDS
USG KUB: For Analgesic
• USG shows • Cran berry Extract sachet
hydronephrosis and 1+0+1 BD
pyelonephritis.
• Urea ,creatinine and Symptomatic:
electrolytes for renal
disorders and dehydration .
• Tab Domperidone 10 mg
• If suspicion of Renal 1+1+1 TDS
stones/Cystitis . Antiemetic
• Urine C/S
• Cap. Esomeprazole 20mg,40mg/Dexlansoprazole
• X ray imaging KUB for 30mg,60mg
obstruction,abscess or
1+0+1 BD/0+0+1 HS
emphysematous
PPI For GI safety.
pyelonephritis .
• CT abdomen with or
without contrast
Shows decreased perfusion
of kidneys

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 30 Cardiovascular Diseases

Investigational Findings Management Protocols

Severe Pyelonephritis:
• MRI abdomen: • Admission & Secure IV line
Pregnancy and Patients • Undergo proper investigations
with contra indications to • Start IV antibiotics and IV fluids
CT • Inj Ceftriaxone 1-2 g /Inj Ciprofloxacin 400mg/100ml/Inj
• USG of the kidneys & Gentamycin 40 mg/2ml
bladder (US KUB) IV BD/TDS
In complicated • Start Analgesic
pyelonephritis, renal Inj Ketorolac 30 mg/ml with Inj Paracetamol 1g/100ml
ultrasound may show IV/SOS
hydronephrosis from a Anti emetic/analgesic
stone or other source of • Treat Sepsis /Underlying cause
Obstruction • Maintain vitals and Follow Blood Culture Reports.
• Hospital stay should last at least 10-14 days.
X ray KUB • Discharge with follow up.

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 DOCTOR ON CALL 31

An 80-year-old woman presents to her general practitioner (GP) with pain and swelling in her
left knee. The pain began 2 days previously and she says that the knee is now hot, swollen and
painful on movement. In the past she has a history of mild osteoarthritis of the hips. She has
occasional heartburn and indigestion. She had a health check 6 months previously and was told
that everything was fine except for some elevation of her blood pressure which was 172/102
mm Hg and her creatinine level, which was around the upper limit of normal. The blood
pressure was checked several times over the next 4 weeks and found to be persistently elevated
and she was started on treatment with 2.5 mg bendrofluamethizide. The last blood pressure
reading was 138/84 mm Hg. There is no relevant family history. She has never smoked and her
alcohol consumption averages four units per week. She takes occasional paracetamol for hip
pain.
Complaint of (C/O)
• Pain in knee ,hip joint 2 days
• Swelling 2 days
• Tenderness 2 days
• Limited range of motion 2 days
• Morning Stiffness usually morning last for 30 minutes 2 days
• High blood pressure 4 weeks
Dx: Osteoarthritis
On Examination (O/E) Management Protocols
• Temperature 37.5 C Prevention:
• Lt,Rt knee 1. Weight loss
swollen,hot,tender 2. Physiotherapy
• Limited flexion 3. Regular exercise
• No other joint affected 4. Medical training therapy
• Movement compromised 5. Targeted muscle growth
• Heberden(DIP) and 6. Limit alcohol (if gives history)
bouchards nodes(PIP) 7. Topical and heat therapy
swollen
• Crepitus on joint Definitive:
movement • Tab Paracetamol 500mg
• Pain in flexion +extension 1+1+1 TDS
Analgesic
Investigational Findings 2nd line:
1st Line: • Tab Paracetamol + Tramadol HCl
Do X Ray of Knee 1+1+1 TDS
Findings: Analgesic
1. Irregular joint space OR
narrowing • Tab Paracetamol + Orphenadrine Citrate
2. Subchondral sclerosis 1+1+1 TDS
3. Osteophytes (bone Analgesic
spurs)
4. Subchondral cysts

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 32 Cardiovascular Diseases

Investigational Findings Management Protocols

3rd line :
• Cap Celecoxib 100,200 mg
1+0+1 BD
NSAIDS

• Tab Diclofenac Potassium 50 mg /Tab Lornoxicam 8

mg
1+0+1 BD
For pain

• Tab Cartigen plus

1+0+1 BD

• Cap Omeprazole 40 mg /Cap Esomeprazole 20 mg

1-0-0 OD /HS
For GIT safety

• Intra articular steroids

Inj K kort 40 mg/ml
Glucocorticosteroids

• Intra articular steroids

Inj Hyaluronic acid
Do complete baselines:
•CBC shows raised WBCs SURGERY
•Raised ESR JOINT REPLACEMENT THERAPY
•Uric acid for Gout (Endoprosthesis)
•Fever with chills in infection If medical and interventional measures fail.
•LFTS, TFTS
• Rule secondary cause may
be SLE, SJOGREN .

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 DOCTOR ON CALL 33

Mr Been is a 66-year-old male patient who comes to the clinic today with complaints of
a painful big toe. Upon examination, the nurse notes that the toe is very red and swollen
at the joint. Mr Been advises the nurse not to touch his toe because it hurts so badly that
he "cannot even wear a sock." The nurse notes a significant decrease in the mobility of
the big toe as well. Mr Been has a history of ulcers, and the nurse notes that he consumes
"several" alcoholic beverages each day. The physician sends Mr Been to the laboratory
for a uric acid level, and the results demonstrate a significant elevation.

Complaint of (C/O)
• Acute joint pain starting from big toe
• Fever and chills
• Redness,swelling .
• Inflammation .
• Tenderness.
• Tophi with ulceration.
Dx: Gouty Arthritis
On Examination (O/E) Management Protocols
• Swelling Prevention:
• Pain at effected joints 1. Regular exercise
• Tenderness ,warmth 2. Rest/physical activity
• Fever in chronic gout 3. Limit alcohol (Beer)
4. Limit smoking
Investigational Findings
5. Diet rich in protein ,red meat and purines .
1ST LINE : 6. Thiazide diuretics and hydralazine are replaced by
Acute gout LOSARTAN
• X RAY :
Lulworth cove lesions . Definitive:
• Synovial fluid analysis : Acute :
Needle shaped crystals • Tab Febuxostat 40 mg/80 mg
Negative birefringent 0+0+1 OD
• CBC: WBCs with
neutrophils raised • Tab Prednisolone 5 mg
40-50 mg per dose in divided doses .
Chronic gout : For pain
• X RAY :
Lulworth cove lesions .
• Synovial fluid analysis : Chronic:
Needle shaped crystals • Tab Allopurinol 100mg,300 mg
Negative birefringent 1+0+1 BD/OD
• CBC:WBCs with Inhibits uric acid synthesis.
neutrophils raised
• Uric acid raised • Tab Probenecid 250 mg/500mg
• ESR raised 1+0+1 BD
• CT/MRI in case of Initiates uric acid excretion
severe cases .
• Tophi with ulceration .

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a
STANDARD TREATMENT PROTICOLS : DOCTOR ONCALL
 34 Cardiovascular Diseases

Investigational Findings Management Protocols

• Urine analysis :
Urate crystals Symptomatic:
deposition •Tab Paracetamol +Tramadol
• 1+0+1 BD
For pain (analgesic)

• Cap Omeprazole 40 mg/Cap Esomeprazole 20 mg

1+0+1 OD /HS
For GIT safety

If these don’t respond then gave :

• Tab Prednisolone 5mg in these divided doses:
• 3 Tablets TDS for 3 days
3+3+3 for 3 days
• 2 Tablets TDS for 3 days
2+2+2 for 3days
• 2 Tablets Bd for 3 days
1 + 1+ 1 for days
• 1 Tablets Bd for 3 days
1 + 0 + 1 for 3 days
• 1 Tablet OD for 3 days
0+ 0 + 1 for 3 days
Steroids (Anti-inflammatory)
• Oral corticosteroids and nonsteroidal anti-inflammatory drugs are
equally effective in the treatment of acute gout.

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 DOCTOR ON CALL 35

A 68-year-old female, with a history of hypertension and diabetes mellitus, presented to the
ED after acute onset of speech difficulty and right-sided weakness. Her symptoms began 3
hours ago. On physical exam, the patient was found to have severe expressive aphasia, right
hemiplegia, and right hemi-sensory loss.
Complaint of (C/O)
• Weakness
• Paralysis
• Impaired Consciousness
• Seizures
Dx: Cerebrovascular accident (Ischemic Stroke)
On Examination (O/E) Management Protocols
• Headache Prevention:
• Nausea,Vomiting Ø Avoid carbonated beverages.
• Paresthesia ,paralysis Ø Avoid Triggering Factors
• Weakness Ø Avoid Alcohol long term use.
• Aphasia ,Dysarthria Ø Avoid Smoking
• Symptoms depend upon General Care
location of stroke Ø Change in posture of patient.
Ø Fluid & Electrolyte balance
Investigational Findings
Ø NG nutrition if patient can’t swallow.
• CT scan investigation of Ø Foley Catheter
choice Ø Compression Stockings
• MRI for further Diagnosis Definitive :
• Baselines for the cause of Elevated blood pressure not to be treated unless
stroke Ø Heart Failure, Renal Failure 0r Hypertensive
Encephalopathy
Ø If systolic BP >220 mmHg or diastolic BP >120 mmHg
on two readings 5 minutes apart, or
Ø If systolic BP is 180-220 mmHg, diastolic BP is 105-120
mmHg; or
Ø Mean arterial BP is >130 mmHg on two readings 20
minutes apart. (If rt-PA is to be given BP should be
<185/110)
Ø If Patient is on Antihypertensive therapy before he
developed stroke
If systolic BP 180-230 mmHg or diastolic BP 105-120
mmHg and thrombolysis need to be done
• Inj. Labetalol 10 mg IV followed by continuous
IV infusion 2-8 mg/min
If BP not controlled then
• Institute Inj Nitroprusside 0.5-1.5 mcg/kg/min then
increased according to patient’s response.
If Hypotension
• Inj 0.9% Normal Saline / Haemaccel IV Stat
If Hypotension persist, then.
• Inj Dopamine 2-20mcg/kg/min

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 36 Cardiovascular Diseases

Dx: Cerebrovascular accident (Ischemic Stroke)

Management Protocols
If Drowsy/unconscious:
It may occur due to cerebral edema.
• Inj. Mannitol 150-200 ml IV 8 Hourly
• Elevate head by 20-30
• Restriction of free water
Thrombolysis (in selected patients only/in 4.5hr of onset):
• Inj Alteplase 90mg (0.9mg/kg)
10 % of Dose IV bolus over 1 min
90% of Dose IV over next 60 mins
Antiplatelet Therapy
• Tab Aspirin 300 mg PO stat then Tab Aspirin 75mg OD
0+0+1 OD
If Alteplase is not given & Hemorrhage is ruled out on CT
If Alteplase is given hold Aspirin for 24 hours
• Tab Clopidogrel 300 mg PO Stat (Loading dose) then Tab Clopidogrel 75 mg
0+0+1 OD for 21 Days.
Discharge Medication:
• Tab Lisinopril 5mg,10mg \Tab Losartan 50mg mg,100mg
1+0+1 OD (According to patients BP)
ACE inhibitors
• Tab Atorvastatin 20mg,40mg/Tab Rosovastatin 10mg,20mg
0+0+1 OD
Statin
• Tab Aspirin 75mg
0+0+1 OD
Blood thinner
• Tab Clopidogrel 75mg
0+0+1 OD for 21 Days only
In patients who cannot tolerate Aspirin Clopidogrel should be continued
Symptomatically:
• Cap.Esomeprazole 20mg,40mg/Dexlansoprazole 30mg,60mg
1+0+1 BD/0+0+1 HS
PPI For GI safety.
• Tab Sertaline 50 mg ,100mg
0+0+1 OD after Breakfast
Antidepressants
• Tab Lorazepam 1mg,2mg
0+0+1 OD HS
Sleep disorders

In Atrial fibrillation, Mechanical valves, Stents, Cardiomyopathy with EF < 35%

• Tab. Rivaroxaban 20mg
0+0+1 OD to (keep patients INR between 2-2.5)

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 DOCTOR ON CALL 37

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 38 Cardiovascular Diseases

Some Pediatric Drugs to be given in mg/kg/day in divided doses

Drugs Dosage Formulation Indications/CI
s Available
Syp.Amoxil 50mg/kg/day 125mg/5ml URTI, Dental Abscess,
(Amoxicillin) BD/TDS 250mg/5ml Skin/Skin structure
Max 1g/Day infections, ENT
infections(OM)
Syp. 30- 156mg/5ml 1st line URTI/GABHS
Calamox/Augmenti 50mg/kg/day 312mg/5ml Skin
n BD/TDS 457mg/5ml ENT
(Amoxil+clavulinic 625mg/5ml Dental Abscess-1st Line
acid)

Syp. 12- 200mg/5ml 2nd line URTI

Azit/Zeecin/Azoma 15mg/kg/day Atypical organisms
x (Azithromycin) OD causing LRTI
Enteric Dose Shigella, campylobacter
20mg/kg/day ,severe dysentery, enteric
fever
Endocarditis prophylaxis
Syp 15mg/kg/da 125mg/5m 2nd line URTI
Klaricid/Rithmo y BD 250mg/5ml Atypical LRTI/ H.pylori cat
(clarithromycin) Max 1g/Day scratch, Ear(OM)
2nd line endocarditis
Syp. Novidat/orcip 15- 125mg/5ml 1st line Dysentry
(ciprofloxacin) 30mg/kg/day 250mg/5ml 2nd line UTI
BD Severe dysentery,
EPEC,ETEC,EIEC STDs
Syp. Flagyl 20- 100mg/5ml ABx induced diarrhea, C.
(metronidazole) 30mg/kg/day 200mg/5ml Difficile infection,
BD/TDS E.Histolytica,
Giardia,H.pylori,vaginosi
s
Syp. Septran/ 50- >2 Months Dysentery, UTI 3-5days,
Septran DS (TMP- 60mg/kg/day 200/40mg/5m
SMX) BD l
400/80mg/5m
l
Syp. 100mg-BD 100mg/5ml Smelly Diarrhea, Anti-
Nitazide/Diatazox (1-3years) infective (Covers Most of
(Nitazoxanide) 200mg-BD organisms causing
(3-11Years) diarrhea in children
including rota)
Dosages and calculation of other Drugs is also given in book

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 DOCTOR ON CALL 39

How to calculate ml/min for infusion drugs.

Step 1: First convert the unit of the stock concentration to the same unit in which
the drug is to be infused to patient.

For example: If a 70kg patient is presented with septic shock and you have to start
norepinephrine inotrope. Norepinephrine is available in stock concentration of
4mg/4ml. The dose of norepinephrine is 0.1mcg/kg/min to 1mcg/kg/min.
1mg = 1000mcg
4mg = 4 X 1000 = 4000mcg
Stock concentration of 4mg = 4000mcg
Step 2: If you dilute norepinephrine injection in 100ml and starting dose of
norepinephrine is 0.1mcg/kg/min.

mg, mcg
dose + kg/min 0 × 𝑤𝑒𝑖𝑔ℎ𝑡(𝑖𝑛 𝑘𝑔) × 𝐷𝑖𝑙𝑢𝑡𝑖𝑜𝑛
𝐦𝐥/𝐦𝐢𝐧 =
stock concentration(mg, mcg)
If infusion must be given in mg/kg/min. The strength of drug should be placed in
mg/min.
If infusion must be given in micrograms(mcg)/kg/min. The strength of drug should be
placed in mg/min.
0.1 mcg/kg/min × 70𝑘𝑔 × 100𝑚𝑙
𝐦𝐥/𝐦𝐢𝐧 =
4000mcg
= 0.175 ml/min
If you want to calculate ml/certain time(i.e hour) (while using infuser or dripset
regulator) then
ml/min X time
0.175 ml/min X 60 = 10.5 ml/hour
Step 2: In order to calculate drops/min
𝐝𝐫𝐨𝐩𝐬/𝐦𝐢𝐧 = ml/min × drop factor(gtt)
= 0.175 X 60 = 10.5 drops/min
Note: For those drugs who are available in market with strength in mg but are infused
in mcg. You have to convent mgs to mcg first.

Note: Certain drugs which are not infused as per mg/kg/min. Rather they are
infused mg/min or mcg/min. For those skip the weight
mg, mcg
dose + min 0 × 𝐷𝑖𝑙𝑢𝑡𝑖𝑜𝑛
𝐦𝐥/𝐦𝐢𝐧 =
stock concentration(mg, mcg)

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 40 Cardiovascular Diseases

MEDICATION MAXIMUM DOSING MONITORING/COMME

STANDAR CONC./ NTS
D INFUSION
INSTRUCTIO
ADMIXTU NS
RE
Adenosine 6 mg/2 mL Give 6 mg ECG, heart rate, blood
vial undiluted initially. pressure
(Adenocard (3 mg/mL)
® directly into If SVT
) given vein over 1--‐2 not Extremely short half life:
Slows undiluted < 10 seconds
seconds. resolved
conduction Not effective for
Administer as in 1--‐2
time through converting A. flutter, A.
proximal as minutes,
the AV node, fib, or ventricular
possible to may
interrupting tachycardia.
trunk (i.e., not follow
the re--‐entry Contraindicated if
in lower arm, with 12
pathways symptomatic
hand, lower mg
through the bradycardia, sick sinus
AV node, leg, or foot). dose. If
If syndrome, 2 nd or 3 rd
restoring not degree AV block (unless
normal sinus administered
resolved pt. has functioning
rhythm. through IV
in 1---2 pacemaker)
line,
minutes,
Onset of administer as
close to pts may
action: follow
immediate heart as
possible. NS with an
Duration:
flush must be addition
seconds
given rapidly, al 12 mg
immediately dose.
following
injection of
adenosine
Amiodaro Load: Peripheral Load: Telemetry monitoring,
Dilute 150 line: Up to 2 150 BP (hypotension occurs
ne mg (3mL) mg/mL mg/100 frequently with initial
(Cordarone in 100 mL mL over rates), HR (arrhythmias:
®
) D5W (1.5 (Concentratio 10 AV block, bradycardia,
Antiarrhythmi mg/mL) ns over 2 minutes VT/VF, torsades de
c agent that (PVC bag mg/mL . pointes), electrolytes
depresses suitable for administered (Not to
conduction loading for longer exceed Pulmonary function test
velocity, dose) than 1 hour 30 within 1 week if possible
slows AV must be mg/mL)
node Maintenan infused via Thyroid function
conduction, ce THEN

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 DOCTOR ON CALL 41

raises the infusion: central line) Liver enzymes

threshold for Dilute 900 Infusio (AST/ALT) Significant
VF, and mg (18 mL) Central line: n: 1 interactions with digoxin
exhibits some in 500 mL Up to mg/min and warfarin (enhances
α and β D5W (1.8 6mg/mL for 6 effect of each, ↓ dose,
blockade mg/mL) hours monitor
activity. It (33.3 digoxin levels, PT/INR)
possesses INFUSION mL/hr =
vasodilatory MUST BE 360
effects which ADMIXED mg),
decrease followe
IN GLASS
cardiac d by 0.5
BOTTLE
workload and mg/min
OR NON--‐
decrease for 18
PVC BAG.
myocardial hours
Amiodaro
oxygen (16.6
ne will
demand. mL/hr =
leach 540 mg)
Myocardial
plastic
uptake is
rapid and anti- from PVC ACLS:
-‐arrhythmic bag 300 mg
effects are IV
clinically Maximum push,
daily dose:
relevant may
2.1 g/day
within hours, repeat
but full effect with
may take days. 150 mg
Exceptionally x 1.
long half life of
40--‐55 days

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 42 Cardiovascular Diseases

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