URINARY TRACT INFECTIONS

Clinical Diagnosis Risk Factors

1. dysuria 1. History of UTI

2. changes on frequency & 2. History of Urolithiasis
urgency in urination
3. hematuria
4. fever
5. flank pain
6. lower abdominal pain
7. absent vaginal discharge
8. absent vaginal irritation
9. back pain

ASSESSMENT

1. Initial assessment Diagnostic Test

- vital signs (fever) 1. Urinalysis

2. Physical Examination
- flank pain/lower abdominal
- reports of dysuria,
hematuria

MANAGEMENT

Antibiotic treatment depends on the initial &

definite UTI condition.

OPD/ER
Do urinalysis or urine GS.
Start oral antibiotics empirically based on gram stain results
Refer to the list of antibiotics below.
ORAL ANTIBIOTICS
1. Ofloxacin 400mg BID
2. Ciprofloxacin 500mg BID
3. Cefixime 400mg OD
4. Cefuroxime 500mg BID
5 Co-amoxiclav 625mg TID
Follow up after 3 - 7 days.

Symptoms resolved?
 YES NO

Continue antibiotics for 7 days Admit patient.

No further treatment
Perform urine GS & CS.
Consider doing radiologic
evaluation
Xray, renal ultrasound)
Repeat urinalysis.
May start on IV therapy.
May change antibiotics if no
improvement.
Parenteral Antibiotics
Ampicillin 1gm every 6 hours
Ofloxacin 200-400 mg every 12 hours
Cefriaxone 1-2gm every 24 hours
Ceftazidime 1 – 2 gm every 24 hours
Ciprofloxacin 250-400mg every 12 hours
Gentamycin 3-5mg/kg BW every 24 hours
Ampi-Sulbactam 1.5 gm every 6 hours
Piperacillin-Tazobactam 2.25-4.5gm every 6-8 hours
(plain abdominal

Symptoms completely resolved?

YES NO

No further treatment Continue present

management.
Antibiotic choice should
Discharge be guided by
urine CS
results once available.
May repeat urine CS, if
indicated.
Consider referral to
Specialist.
BRONCHIAL ASTHMA

Clinical Diagnosis Risk Factors

on & off cough 1. Family History of Asthma

breathlessness 2. Exposure to allergen/ irritants
chest brightness 3. Viral & Respiratory Tract
dyspnea Infections
wheezing (auscultation) 4. Cigarette smoking

*gets worse at night and

aggravated by allergens
or after an exercise

ASSESSMENT

1. Initial Assessment Diagnostic Test

- Vital Signs a. Forced Expiratory Volume in 1
second (FEV1)
2. Physical Examination b. Peak Expiratory Flow Rate (PEF)
- Auscultation of breath c. Airway Hyperresponsiveness
Sounds (wheezing)

MANAGEMENT

Bronchial Asthma in Acute Exacerbation (In ER)

1) Give Inhaled bronchodilators (e.g. Salbutamol, Terbutaline, Ipatropium) and

systemic steroids (e.g. oral : Prednisone, IV: Hydrocortisone).
2) May give O2 therapy if with hypoxemia.
3) Do ABG for severe signs & symptoms of respiratory failure.
4) Have chest Xray done.
5) Watch out for signs & symptoms of respiratory failure such as altered
sensorium, hypoxemia, & hypercapnia.

Symptoms Resolved?

YES NO

HOSPITAL ADMISSION
No further treatment.
May discharge once stable.
Continue bronchodilator & Signs & Symptoms
steroids if needed. of Resp. Distress
Close follow-up.
YES NO

Admit to ICU Admit to Ward

 Chronic Asthma

1) Control of airway hyperresponsiveness.

2) Assess impact and exposure to allergens/irritants
3) Classify patient with asthma according to severity.

PARAMETER INTERMITTENT SEVERITY

Mild-moderate Severe
Daytime symptoms Monthly Weely Daily
Nocturnal awakening <monthly Monthly - Weekly Nightly
Rescue B2 agnonists use <weekly Weekly – Daily Several times a day
PEF or FEV1 >80 % pred. 60 – 80 % pred. <60 % pred.
Treatment needed to Occasional prn B2 Regular ICS + LABA Combination ICS +
control asthma agonists only combination LABA + OCS
4) Consider the following:
Acute Asthma Persistent Asthma
-Inhaled B2 agonists -Inhaled corticosteroids
-Systemic / oral steroids -Fixed dose combination of long acting B2
-Inhaled Ipratropium bromide + inhaled agonists and inhaled corticosteroids
B2 agonists

ANTI-INFLAMMATORY CONTROLLERS GENERIC NAME

Inhaled corticosteroids+LABA Budesonide + Formoterol
Fluticasone + Salmoterol
Inhaled corticosteroids Beclamethasone dipropionate
Budesonide
Fluticasone
Oral corticosteroids Methylprednisolone
Prednisone
Anti-leukotrienes Montelukast
Mast cell stabilizer Na cromoglycate
Bronchodilator Controllers LABA
Inhaled Formoterol
Salmeterol
Procaterol
Oral Formoterol
Procaterol
Salbutamol
Terbutaline
Xanthine derivative Theophylline
Bronchodilator Relievers SABA
Inhaled Salbutamol
Terbutaline
SABA
Oral Salbutamol
Terbutaline
Anti-cholinergic Ipratropium
Anti-cholinergic + SABA Ipratropium + Fenoterol
Ipratropium + Salbutamol
Xanthine derivative Theophylline
 COMMUNITY ACQUIRED PNEUMONIA IN ADULTS
Clinical Diagnosis
1. cough
2. Fever (T>37.8C
3.Difficulty of breathing
4. Tachypnea (RR> 20bpm)
5. Tachycardia (CR >100BPM)
6. Diminished breath sounds
7. Ronchi, crackles or wheeze
1. Initial Assessment
- Vital Signs
2. Physical Examination
- Presence of adventitious
breath sounds
1) Classify patients by risk categories to help determine the need for hospitalization.
Low Risk CAP
Stable Vital Signs
RR <30bpm
PR <125bpm
SBP>90mmHg
DBP>60mmHg
No or stable co morbid
conditions
No evidence of extra pulmonary
sepsis
No evidence of aspiration
Chest Xray:
Localized infiltrates
No evidence of Pleural
Effusion nor abscess
Not Progressive within 24hrs
to 50% in 24 hrs
OPD
Risk Factors
1. Exposure to People with Pneumonia
2. Cigarette Smoking
3. Advanced Age
ASSESSMENT
Diagnostic Test
1. Chest Xray
2. Complete Blood Count
MANAGEMENT
Moderate Risk CAP High Risk CAP
Unstable Vital Signs Any of clinical feature of
RR >30bpm moderate CAP plus any of the
PR > 125bpm following:
Temp >40C or <35C
shock or signs of hypoperfusion
-hypotension
Unstable co morbid conditions -altered mental state
(uncontrolled DM, active -Urine output <30ml/hr
malignancies, CHF, unstable -hypoxia or acute (PaO2
CHD, renal failure on HD, <60mmHg)
uncompensated COPD, hypercapnea (PaCO2
decompensated liver disease) >50mmHg)
Evidence of extra-pulmonary
sepsis (hepatic, hematologic,
gastrointestinal, endocrine)
Suspected aspiration
Chest Xray: Chest Xray as in moderate CAP
multilobar infiltrates
Pleural Effusion/Abscess
Progression of Findings
WARD ICU
 2) For moderate & high risk CAP, may have gram stain or culture of pulmonary
secretions. ABGs could also be done to detect hypoxemia.
3) Initial empiric therapy based on risk stratification is recommended.

ANTIBIOTIC DOSAGE ANTIBIOTIC DOSAGE

LOW RISK CAP B – Lactams w/ B- lactamase 625 mg TID or 1 g BID

inhibitor: 750 mg BID
B – Lactams: Co-amoxiclav
Amoxicillin 500 mg TID Sultamicillin
Trim/sulfonamide: 500 mg TID
Cotrimoxazole 160/800 mg BID 2nd Gen. Cephalosporins:
Cefuroxime axetil

Macrolides:
Azithromycin 500 mg OD
Clarithromycin 500 md BID

MODERATE CAP 2nd Gen. Cephalosporins:

Cefuroxime IV 1.5 g q 8h
Macrolides: Cefoxitin IV 1 – 2 g q 8h
Erythromycin IV 0.5 – 1 g q 6h
Azithromycin PO or IV 500 mg q 24h 3rd Gen. Cephalosporins:
Clarithromycin PO or IV 500 mg q 12h Ceftriaxone IV 1 – 2 g q 24h
Cefotaxime IV 1 – 2 g q 8h
B- lactams w/ B-
lactamase inhibitor:
Sulbactam – Ampicillin IV 1.5 g q 8h

HIGH RISK CAP 3rd Gen. Cephalosporins:

Ceftriaxone 1 – 2 g q 24h
Macrolides: Cefotaxime 1 – 2 g q 8h
Erythromycin 0.5 – 1 g q 6h Ceftizoxime 1 – 2 g q 8h
Azithromycin 500 mg q 24h
Clarithromycin 500 mg q 12h Antipseudomonal B-lactams:
Gentamicin 3mg/kg q 24h Ceftazidime 2 g q 8h
Tobramycin 3mg/kg q 24h Cefipime 2 g q 8-12h
Ticarcillin-clavulanate 3.2 g q 6h
Piperacillin-tazobactam 2.25 – 4.5 g q 6h
 Sulbactam –cefoperazone 1.5 g q 12h
Imipenem 500 mg q 6h
Meropenem 1 – 2 g q 8h

Others:
Oxacillin 1–2gq4–6h
Clindamycin 600 mg q 8h
Metronidazole 500 mg q 6 – 8h
 RESPONSE TO THERAPY

Symptom Reduction Persistent of Symptoms

stable vital signs oxygen administration

clear breath sounds hydration (IV fluids, oral
(-) crackles, wheezes intake)
(-) fever Anti pyretic if needed
Bronchodilators
CPT

STREAMLINING OF EMPIRIC ANTIBIOTIC THERAPY

(based on results of culture)

May switch to oral antibiotics when signs of infection are

resolving within 72 hours.

ANTIBIOTIC DOSAGE
CEFUROXIME 800MG BID
CEFIXIME 100-200MG BID
CO-AMOXICLAV 1GM BID
SULTAMICILLIN 750MG BID
AZITHROMYCIN 500MG OD
CLARITHROMYCIN 500MG OD
MOXIFLOXACIN 400MG OD

HOSPITAL DISCHARGE

Patients with stable vital signs for 24 hours and able to

maintain oral intake maybe discharged.

DENGUE
Clinical Diagnosis Risk Factor

1. fever 11. hypotension 1. History of Bleeding Disorders

2. headache 12. narrowing pulse 2. Previous History of Dengue
3. retro-orbital pain pressure 3. Patient coming from endemic of
4. myalgia 13. cold clammy skin DHF
5. athralgia 14. restlessness/
6. abdominal pain change in sensorium
7. nausea, vomiting
8. hemorrhagic manifestations
9. rashes
10. rapid & weak pulse

ASSESSMENT

1. Initial assessment Diagnostic Test

- vital signs – BP= decrease BP 1. Laboratory Test
(narrowing pulse pressure) - CBC (thrombocytopenia,hemo
2. Physical Examination concentration, decrease WBC)
- petechiae, ecchymosis - APTT, PT
- reports of bleeding (mucosa. - ESR
GI) - Dengue NS1
- PCR

MANAGEMENT

OPD
Obtain vital signs.
Review medical history, watch out for bleeding.
Perform laboratory work ups.
Encourage patient to increase oral intake.
Start on symptomatic treatment (Paracetamol for fever).
Classify dengue infection:
Dengue Fever versus Dengue Haemorrhagic Fever
• Thrombocytopenia with concurrent hemoconcentration differentiates Grades I
and II DHF from classic DF.
• Increased capillary permeability is the main pathophysiology that differentiates
DHF/DSS from DF. Based on the severity of capillary permeability, DHF is
graded into grade I to IV.
• Therefore your notification is to be either DF or DHF.
Dengue Shock Syndrome
All the above 4 criteria for DHF must be present, plus evidence of circulatory
failure manifested by: • rapid and weak pulse
• narrow pulse pressure less than 20mmHg
or manifested by
• hypotension for age
• cold clammy skin and restlessness
 WHO grading of DHF/DSS

Grade I In the presence of haemoconcentration, fever and non-specific

constitutional symptoms, a positive torniquet test is the only
haemorrhagic manifestation
Grade II spontaneous bleeding in addition to the manifestation from Grade I

Grade III* circulatory failure, pulse pressure less than 20 mmHg but systolic
pressure is still normal
Grade IV* profound shock, hypotension or unrecordable blood pressure.
*Grades III and IV are classified as DSS.

Symptoms unresolved, or patient is diagnosed to have

Dengue Hemorrhagic Fever or Dengue Shock Syndrome.

HOSPITAL ADMISSION

Start IV Fluid Therapy.

Watch out for bleeding or signs of shock.
Monitor hematocrit and platelet count.
May perform Dengue NS1, APTT, PT,etc.
Vital signs and urine output hourly.
May have volume replacement or blood transfusion
if necessary.
Avoid aspirin & NSAIDs.
Avoid IM injections.
Consider radiologic evaluation.
Watch out for complications:
1. Profound bleeding/hemorrhage
(Epistaxis, melena, hematemesis, hematochesia)
2. Myocarditis ( bradycardia, chest pain)
3. Encephalitis ( seizure, coma)
4. Pleural effusion/pneumonia
(Dyspnea, cough, cyanosis)

HOSPITAL DISCHARGE

Patient vitals signs are stable. No more febrile episodes.

Stable hematocrit level.
Visible clinical improvement
Return of appetite
Adequate urine output.
No respiratory distress
ACUTE BRONCHITIS

Clinical Diagnosis Risk Factors

1. cough for 1 week 1. History of Pulmonary Disease

2. purulent sputum - COPD, Asthma
3. fever 2. Smoking
4. chills
5. chest pain
6. difficulty of breathing
7. hoarseness of voice
8. adventitious sounds

ASSESSMENT

1. Initial assessment Diagnostic Test

- vital signs Chest Xray

2. Physical Examination
- productive cough
- reports of dyspnea,
- wheezes, ronchi, rales

MANAGEMENT

OPD

Obtain vital signs, review medical history.

No routine lab. tests or diagnostics for uncomplicated
acute bronchitis.
Encourage rest especially if there is fever.
Adequate hydration.
Avoid pulmonary irritants.
No antibiotics needed for uncomplicated acute bronchitis.
If a patient can not sleep due to cough, antitussive therapy
may be helpful.
May give Paracetamol for fever and pain.
Follow up for 2 – 3 days.

Persistence of symptoms such as difficulty of breathing, fever

severe cough and poor oral intake.
An alternate admissible diagnosis exists – Bronchial Asthma in
Acute Exacerbation, COPD, & Hypertension.
 HOSPITAL ADMISSION

Start on IV therapy.
Consider doing radiologic evaluation.
Continue Paracetamol for fever and pain.
If there is bronchospasm, dyspnea or wheezing is significant,
start short acting B2 agonists bronchodilators.
Antibiotics may be considered in those at high risk of
serious complications because of pre-existing
co-morbidity.
Antibiotics may be used for patients who have 2 or more of
of the following symptoms:
- increased sputum volume
- increased sputum purulence
- increased dyspnea

HOSPITAL DISCHARGE

Patient vitals signs are stable. No more febrile episodes.

Able to tolerate oral medications.
Patient is free from signs of respiratory distress.
ACUTE GASTROENTERITIS

Clinical Diagnosis Risk Factors

1. changes in character & 1. History of Diarrheal Infection

frequency of stool
2. vomiting
3. abdominal pain
4. maybe accompanied by
signs of dehydration

ASSESSMENT

1. Initial assessment Diagnostic Test

- vital signs 1. Laboratory Test
- Fecalysis
2. Physical Examination - Complete Blood Count
- abdominal tenderness - Serum Electrolytes
- reports of weight loss
- skin turgor

MANAGEMENT

OPD
Obtain vital signs, review medical history of patient.
Hydrate patient. Encourage to increase oral intake of
fluids.
Assess for severity of dehydration. (if any)
Send specimen for fecalysis.
May give medications such as Loperamide, Racecadotril,etc.

Symptoms unresolved, patient is with signs of dehydration.

 HOSPITAL ADMISSION

1. Start on IV therapy.
2. Have laboratory work ups done such as FA, CBC,
and serum electrolytes.
3. BRAT (Banana, Rice, Apple, Tea) Diet
4. Monitor vital signs every 4 hours
5. Monitor intake and output
6. Estimate severity of dehydration.
7. Rehydrate over 3 – 4 hours with ORS.
8. May replace substantial losses with ORS.
9. Repeat Fecalysis, Stool Culture
10. May give Zinc and Vitamin A supplementation (for child).
11. Consider referral to a specialist.
12. Use antibiotics for the following conditions:
- Febrile or gross in stool, elderly with concomittent illness (diatetic, or steroids
or WBC 716,000.00
a. If without vomiting: Give ciprofloxacin 500mg tab BID x 3-5 days or
Norfloxacin 400mg tab BID x 3-5 days
Co-trimoxazole forte tab BID x 3-5 days
b. If with vomiting: Give IV antibiotics
c. If Amebiasis suspect: Metronidazole 500mg tab QID X 7 days
- Specific treatment
a. If Shigella: co-trimoxazole forte tab BID x 3days
b. If Salmonella or ETEC: Ciprofloxacin 500mg tab BID x 5 days
c. If Clostridium difficile : Metronidazole 500mg tab BID x 10 days
d. If Yersinia enterolitica : Ci[rpfloxacin 500mg tab x 3 days
e. If Giardia lanublia : Metronidazole 250mg TID x 5 days
- Symptomatic Medications:
a. Pain: Hyosicine-N-butylbromide (Buscopan) 1 tab TID or 1 amp IV
every 6-8 hours
b.Vomiting: Metoclopromide (Plasil)) 1 amp IV every 8 hours PRN
c.Diarrhea: Loperamide 2 caps initially then 1 capsule after
each bowel movements. Avoids loperamide in amebiasis

HOSPITAL DISCHARGE

-Patient vital signs are stable.

-Patient is free from signs of dehydration.
-Good skin turgor
-Able to feed/tolerate oral intake.
-Decrease in frequency of defecation.
CORONARY ARTERY DISEASE

Clinical Diagnosis Risk Factors

1. Chest pain 1. History of Heart Disease

2. Unexplained indigestion 2. Smoking
3. Radiating pain in neck, jaw 3. History of DM
shoulders, back, or both arms 4. Age : Men – 45 & up

5. dyspnea Women – 55 & up

6. nausea, vomiting 5. Lifestyle (stress, overwork,
7. diaphoresis little physical activities)

ASSESSMENT

1. Initial assessment Diagnostic Test

- vital signs 1. ECG
2. 2D echocardiogram
2. Physical Examination 3. Lipid Profile
- reports of dyspnea, chest pain

MANAGEMENT

OPD

Obtain vital signs, review medical history.

Perform ECG.
Provide supplemental oxygen for presence of dyspnea.
May give nitrates and or pain medications for chest pain.
Monitor vital signs.

Persistence of symptoms, patient’s condition is not

resolving. Progression of chest pain & dyspnea.
 HOSPITAL ADMISSION

1) Start on IV therapy.
2) Monitor vital signs.
3) Place patient on bed rest.
4) Continue supplemental oxygen as indicated.
5) Low fat, low salt diet
6) I & O q shift & record
7) Limit visitors
8) ECG stat then repeat 12-24 hours
9) Consider doing radiologic evaluation.
10) Perform lipid profile test & cardiac biomarkers.
11) 2D ECHO with Doppler once stable
12) May have CBC, Serum electrolytes ( Na, K, Ca, Mg )
13) Check for RBS, BUN & Creatinine
14) Perform Lipid profile, PT & PTT
15) Order for evaluation of CK-MB, CPK –Total, Troponin T & I
16) Pharmacologic treatment:
Nitrates ( defer for SBP less 90 mmhg ) for chest pain
- Transderm patch 5-10 mg OD
- Isosorbide mononitrate ( Imdur ) 60mg OD
- Isosorbide Dinitrate ( Isordil ) 10-20mg TID
- Isosorbide Dinitrate ( Isoket ) Drip for 24-48 hours
Pain Relief
- Morphine I.V stat then PRN ( defer for SBP less than 90mmhg
Thrombolytic Therapy
- Aspirin 325 mg tab now then OD
- Streptokinase 1.5 I.U in 100cc 0.9cc NaCl over 1 hour
In a soluset. Watch out for hypotension and arrythmias
- Clopidogrel 75mg tab OD
Heparin : for large anterior wall M.I, atrial fibrillation,
Persistent chest pain on presence of LV Thrombus
- Heparin 5,000 units at 14 mgtts/min using an infusion set.

HOSPITAL DISCHARGE

Patient is hemodynamically stable.

Patient is free from chest pain & dyspnea
CHOLECYSTITIS

Clinical Diagnosis Risk Factors

1. abdominal pain 1. Advanced Age

2. fever 2. Gender : Male
3. nausea, vomiting 3. Vascular Disease Smoking
4. abdominal tenderness 4. Diabetes Mellitus
5.Trauma

ASSESSMENT

1. Initial assessment Diagnostic Test

- vital signs 1. Laboratory Test
- CBC (Leukocytosis)
2. Physical Examination - SGOT, SGPT
- abdominal tenderness - Bilirubin
- Serum Electrolytes
2. Ultrasound of the Abdomen
3. Biliary Scintigraphy
4. Magnetic Resonance Imaging
5. Computed Tomography

MANAGEMENT

1) Obtain vital signs, review medical history.

2) NPO to rest the gallbladder
3) Start on IV therapy. Provide adequate hydration.
4) Perform CBC, serum electrolytes, bilirubin, etc.
5) Consider radiologic evaluation such as ultrasonography,
biliary scintigraphy, CT scan or MRI.
6) Consider ALP, Amylase & Lipase to check for gallstone or
pancreatitis.
7) If the patient is vomiting, or there is evidence of ileus or
gastric distention, NGT placement is appropriate.
8) May give Indomethacin to reverse inflammatory changes
& improve gallbladder contractility.
9) Intravenous antibiotics are usually commenced empirically or
if there has been no improvement over 12 hours with
conservative management.
Antibiotics:
a.) Ampicillin Sulbactam I.V. or
Co- Amoxiclav I.V ( for uncomplicated cases)
b.) Ciprofloxacin, Ceftazidime Piperacillin-Tazobactam I.V.
( for diabetic and debilitated patients to cover for gram negative sepsis)
Pain reliever: Demerol 25.50mg I.V every 6 hours
Surgical cholecystectomy is the treatment of choice.
Determine risk for surgery.
 Persistence of symptoms, patient’s condition is not resolving.
Deterioration, signs of generalized peritonitis, emphysematous
perforation / gangrene.

SURGICAL MANAGEMENT
(Open Cholecystectomy of Laparoscopic Cholecystectomy)

a) Emergency in those patients with complications

b) In those without complications, early surgery is
recommended for stable patients.

HOSPITAL DISCHARGE

Patient vitals signs are stable.

Patient is free from abdominal pain and signs & symptoms of
infection or complications.
DIABETES MELLITUS

Clinical Diagnosis Risk Factors

1. Polyuria 1. Family History of DM

2. Polydipsia 2. Diet
3. Polyphagia 3. Age : > 40 years old
4. Unexplained weight loss 4. Obesity
5. Recurrent blurred vision 5. Cigarette Smoking
6. Habitual Physical Inactivity

ASSESSMENT

1. Initial assessment Diagnostic Test

- vital signs 1. Fasting Blood Sugar
2. Glycosylated Hemoglobin (HBA1C)
2. Physical Examination 3. RBS
- Obese 4. Lipid Profile

MANAGEMENT

OPD

Obtain vital signs, review medical history.

Check for the weight of the patient.
Perform blood sugar tests.
Give health education on proper nutrition, &regular physical activity.
Classify if it is Type 1 or Type 2 DM.
Pharmacologic interventions should be considered.

Biguanide
Insulin secretagogue
Alpha-glucosidase inhibitor
TZD (Insulin sensitizers)
Incretin enhancer
Incretin mimetic (GLP-1)
Metformin
Sulfonylurea meglitinides
Acarbose
Rosiglitazone, pioglitazone
Sitagliptin, saxagliptin
Liraglutide

Persistence of symptoms, patient’s condition is not resolving.

(Diaphoresis, pallor, tremor, tachycardia, paresthesia, nausea, vomiting
visual disturbances, hypotension, weakness, & confusion.
 HOSPITAL ADMISSION

Start on IV therapy esp. for patients vomiting, unable to drink.

Monitor vital signs & NVS.
Record intake & output accurately, call MD if UO less than 30cc/hour.
Monitor blood glucose levels every 4 to 6 hours.
Perform ECG, obtain CXR as needed.
Check urine for ketones.
Check for BUN, creatinine & serum electrolytes.
Patients with HPN should be treated with a regimen that includes either
An ACE Inhibitor or an Angiotensin Receptor Blocker
For age 40 and up statin therapy
Use aspirin therapy for diabetics with history of stroke more than 40 y/o
Consider combination therapy if FBS is greater than 140.
Consider adding insulin earlier in the regimen.

Insulin Therapeutic Considerations and Availability

Insulin Type/Action
Fast-acting (clear):
B Onset 0.5-1 h.
O Peak 2-4 h.
L Duration 5-8 h.
U Rapid-acting analogue (clear):
S Onset 10-15 min.
Peak 60-90 min.
Duration 4-5 h.
B Intermediate-acting (cloudy):
A Onset 1-3 h.
S Peak 5-8 h.
A Duration up to 18 h.
L Extended long-acting ana-
logue (clear):
Onset 90 min.
Duration 24 h
P Premixed (cloudy): A single
R vial contains a fixed ratio of
E insulin (% rapid- or fast-acting
M to % intermediate-acting
I insulin)
X
Trade Names
• Humulin®-R (insulin human)
• Novolin®ge Toronto (insulin
human)
• ApidraTM (insulin glulisine)
• Humalog® (insulin lispro)
• NovoRapid® (insulin aspart)
• Humulin®-N (insulin isophane)
• Novolin®ge NPH (insulin isophane
• Lantus® (insulin glargine)
• Levemir® (insulin detemir)
• Humalog® Mix25TM Mix 50TM
• Humulin® (30/70)
• Novolin®ge (30/70, 40/60, 50/50)
• NovoMixTM 30

HOSPITAL DISCHARGE

Patient vitals signs are stable. Blood glucose level is within

normal limits.
Able to tolerate oral medications.
Patient is free from signs & symptoms of hypo-/hyperglycemia.
HYPERTENSION

Clinical Diagnosis Risk Factors

a BP of 140/90 mmHg & 1. Smoking

higher recorded on 2. Physical Inactivity
at least 2 occasions 3. Overweight
4. High Fat Diet
Stage I : 5. Excessive salt Intake
140-159 / 90-99 6. Excessive alcohol consumption
7. Family History of Hypertension,
Stage II : Heart Disease or Stroke
>160 / > 100 8. Age : Men (45 years & up)
Women (55 years & up)

ASSESSMENT

1. Initial Assessment Diagnostic Test

-Vital signs (BP readings) 1. Laboratory Tests
- Urinalysis
2. Physical Examination - Blood Chemistry
- Height & Weight - Fasting Blood Sugar
- Auscultation of heart - Lipid profile
- Serum Electrolytes
- Creatinine
2. Chest X-ray
3. Electrocardiogram
4. 2D Echo (if indicated)

MANAGEMENT

OPD
Check for the blood pressure.
Perform laboratory work ups.
Classify whether Stage I or II Hypertension.
Start oral anti-hypertensive medications.
Without compelling indications: With compelling indications:

Stage I:
-for HPN Stage I without
compelling indications, thiazide
are the primary drugs of choice.
May consider ACEI, ARB,BB, CCB
or combination
Stage II:
-two drug combination for
for most (usually thiazide - type
diuretic and ACE,ABB,BB or
CCB)
-for HPN with compelling
indications the following
May be used:
a. Diuretics – heart failure,
high coronary disease risk,
dizziness, recurrent Stroke
prevention.
b. Beta Blockers- Post MI,
heart failure, high coronary
disease risk, diabetes
 c. ACE Inhibitor-heart failure,
high coronary disease risk,
DM, recurrent stroke
prevention, chronic kidney
disease, Post MI.
d. Angiotensin II Reception
Blocker-heart failure, DM,
chronic kidney disease
e. Calcium Channel Blocker -
High Coronary Disease Risk, DM
f. Aldosterone Antagonist –
heart failure, Post MI.

Symptoms unresolved after giving oral anti-hypertensive

medications.
Patients with hypertensive urgencies, or those with upper
levels of Stage II hypertension associated with severe
headache, shortness of breath, epistaxis or severe anxiety

HOSPITAL ADMISSION

Monitor vital signs esp. blood pressure.

Review patient’s medical history.
Perform diagnostic tests such as lab.tests, ECG,etc.
Consider doing radiologic evaluation.
May give oral short acting agent such as captopril & clonidine.
The following formulary parenteral drugs maybe used
Vasodilator (Na Nitropresside)
Nicardipine HCl
Nitroglycerin
Hydralazine HCl
Adrenergic Inhibitor (Esmolol HCL)

HOSPITAL DISCHARGE

Patient is hemodynamically stable. Vital signs are of normal

range or BP is controlled.
No shortness of breath or headache