Management of Common Medical Conditions in

General Medicine Ward

Created by:
Dr. Prithwiraj Maiti
MBBS (WBMC)
House Physician, Dept. of General Medicine
R.G.Kar Medical College
Kolkata, India
Email: [email protected]

Resources used:
1. API journals
2. PubMed central indexed journals
3. Medscape
4. Other journals and articles.
Disclaimer: Although all directions stated in this documents are
constructed based on evidence based medicine, there may be
significant differences in opinion regarding management of the cases
among physicians. So, every direction must be individualized as per
patient profile and clinical scenario. This document may act just as a
guidebook to write direction in medicine ward.
 Table of Contents
1. Cardiovascular system: (Page 1-9)
a. STEMI
b. NSTEMI
c. Acute LVF
d. Acute decompensation of chronic right heart failure
e. Severe anemia + Heart failure
f. Atrial fibrillation with fast ventricular rate
g. Atrial flutter
h. Ventricular tachycardia
i. Viral myocarditis.
2. Central nervous system: (Page 10-17)
a. Ischemic CVA
b. Hemorrhagic CVA
c. Subarachnoid hemorrhage
d. Acute spinal cord injury
e. Meningoencephalitis
f. Hypertensive encephalopathy
g. Seizure disorder/ Status epilepticus
h. Convulsion in a known chronic alcoholic
i. Suspected GB syndrome
j. Acute transverse myelitis.
3. GI system: (Page 18-23)
a. Alcohol intoxication
b. Alcohol withdrawal
c. Acute pancreatitis
d. Decompensated chronic liver disease
e. Hepatic encephalopathy
f. Hematemesis ± Melena
g. Jaundice under evaluation
h. Acute gastroenteritis.
4. Urinary system: (Page 24-28)
a. Urinary tract infection (UTI)
 b. Chronic kidney disease (CKD)
c. Diabetic nephropathy
d. Obstructive uropathy
e. Acute glomerulonephritis
f. Nephrotic syndrome.
5. Poisonings: (Page 29-34)
a. Organophosphate
b. Cypermethrin
c. Paraquet
d. Benzodiazepines
e. Corrosive acid/ substances
f. Copper sulfate
g. Paracetamol.
6. Respiratory system: (Page 35-39)
a. Hemoptysis/ chronic cough under evaluation
b. Significant LRTI/ LRTI + Sepsis
c. Acute exacerbation of COPD (AECOPD)
d. AECOPD + LRTI
e. Aspiration pneumonia.
7. Infection: (Page 40-43)
a. Fever under evaluation
b. Dengue fever
c. Typhoid fever
d. Malaria
e. Sepsis.
8. Hematopoietic: (Page 44)
a. Anemia under evaluation
b. Generalized lymphadenopathy.
9. Miscellaneous: (Page 45-49)
a. Snake bite
b. Scorpion bite
c. Unknown bite
d. Hyperemesis gravidarum
e. DKA.
 1

CARDIOVASCULAR SYSTEM
STEMI
Definition:
STEMI is defined as new ST elevation at the J point in at
least 2 contiguous leads of ≥2 mm in men and ≥1.5 mm in
women in leads V2-V3 and/or ≥1 mm in other contiguous
limb leads.
Note:
STEMI shows ST segment elevation in ECG (due to full thickness injury of heart
muscle) and later progress to a Q-wave. For this reason, it is also called a Q-wave
myocardial infarction (QWMI). The ultimate ECG findings of STEMI are ST-
segment elevation, pathological Q-wave formation and T-wave inversion.
Direction:
1. Salt restricted diet
2. Moist oxygen inhalation (if needed)
3. T. Aspirin (75) 4 tab STAT and 1 tab OD × Cont.
4. T. Clopedogrel (75) 4 tab STAT and 1 tab OD × Cont.
5. T. Atorvastatin (40) 2 tab STAT and 1 tab OD × Cont.
6. T. Ramipril (2.5) 1 tab OD × Cont.
7. T. Nitrocontin (2.6) 1 tab BD (8 AM & 4 PM) × Cont.
8. T. Metoprolol (25) ½ tab BD × Cont. [If BP is low, avoid it]
9. T. Alprazolam (0.5) 1 tab OD HS × Cont.
10.Inj. Pantoprazole (40) IV BD × Cont.
11.Inj. Ondansetron (4) IV TDS × Cont.
12.Thrombolysis:
Inj. Streptokinase 1.5 million units to be diluted in 100 ml NS and to be
given over 30-45 min
Note: Thrombolysis in acute STEMI is done usually within 12 hours of onset
of symptoms and only if there is no pathological Q wave.
OR,
Inj. Tenecteplase (available via special indent only) IV bolus STAT over 5
seconds
 2

Body weight (kg) Amount of Tenecteplase Amount of reconstituted

powder in mg solution in ml
<60 30 6 ml
60-70 35 7 ml
>70 40 8 ml
The most common complication encountered during Tenecteplase therapy
is bleeding. Should serious bleeding (not controlled by local pressure)
occur, any concomitant heparin or antiplatelet agents should be
discontinued immediately

Absolute contraindications for fibrinolytic use in STEMI:

 Prior intracranial hemorrhage (ICH)
 Known structural cerebral vascular lesion
 Known malignant intracranial neoplasm
 Ischemic stroke within 3 months
 Suspected aortic dissection
 Active bleeding or bleeding diathesis (excluding menses)
 Significant closed head trauma or facial trauma within 3 months
 Intracranial or intraspinal surgery within 2 months
 Severe uncontrolled hypertension (unresponsive to emergency therapy)
 For streptokinase, prior treatment within the previous 6 months.
13.Inj. Enoxaparin (60 U) SC BD × Cont.
[If thrombolysis is done, start Enoxaparin at least 30 min after thrombolysis,
preferably from the next day]
14.Syrup Lactulose 3 TSF OD HS × Cont.
Plan:
1. RB
 3

2. ECG 12 lead
3. Trop T
4. Date for echocardiography
5. Cardiology referral.

NSTEMI
Note: The usual ECG findings of NSTEMI are ST-segment depression or T-wave
inversion. NSTEMI does not show ST segment elevation in ECG (due to partial
thickness injury of heart muscle) and later does not progress to a Q-wave. For this
reason, it is also called a non–Q-wave myocardial infarction (NQMI).
Direction:
1. Salt restricted diet
2. Moist oxygen inhalation (if needed)
3. T. Aspirin (75) 4 tab STAT and 1 tab OD × Cont.
4. T. Clopedogrel (75) 4 tab STAT and 1 tab OD × Cont.
5. T. Atorvastatin (40) 2 tab STAT and 1 tab OD × Cont.
6. T. Ramipril (2.5) 1 tab OD × Cont.
7. T. Nitrocontin (2.6) 1 tab BD (8 AM & 3 PM) × Cont.
8. T. Metoprolol (25) ½ tab BD × Cont. [If BP is low, avoid it]
9. T. Alprazolam (0.5) 1 tab OD HS × Cont.
10.Inj. Pantoprazole (40) IV BD × Cont.
11.Inj. Ondansetron (4) IV TDS × Cont.
12.Inj. Enoxaparin (60 U) SC BD × Cont.
13.Syrup Lactulose 3 TSF OD HS ×
Cont.

ADD Inj. Morphine (10 mg/ml)

to be diluted in 5 ml NS & to be
given over 5 min (if pain is not
controlled).
 4

Plan:
1. RB
2. ECG 12 lead
3. Trop T
4. Date for echocardiography
5. Cardiology referral.

Acute LVF

Patients presents with acute onset severe SOB; clinical findings are bibasal fine
crepts ± gallop (3rd heart sound) ± high BP.
Note: Always do an ECG and a Trop-T in a case of suspected acute LVF to rule out
AMI. Always note the BP before initiating treatment.
Direction:
1. Salt restricted diet
2. Daily water intake <1.5 liter/day
3. Propped up position
4. Moist oxygen inhalation
5. Nebulization with Levo-salbutamol (Levolin) 4 hourly
6. Inj. Lasix 2-3 amp IV STAT and 2 amp IV TDS × Cont.
[Always decide the dose of Lasix after measuring the BP]
7. Inj. Nitroglycerin 1 amp in 500 ml NS to be given in 15 microdrops/ min
[Only if BP is sufficiently high; monitor BP every 4 hourly]
8. Inj. Morphine 1 amp to be diluted in 10 ml NS and to be given slowly over
10 minutes (Give only if SpO2 is near normal as it may cause respiratory
depression if given while on severe respiratory distress with low SpO2)
9. Inj. Pantoprazole (40) IV BD × Cont.
10.Inj. Ondansetron (4) IV TDS × Cont.
11.Syrup Lactulose 3 TSF OD HS × Cont.
12.An antibiotic may be added (Co-amoxiclav/ Azithromycin) if associated
infection is suspected.
 5

Note: In case of cardiogenic shock (low/ unrecordable BP/ pulse), administer

Noradrenaline (4 ampule in 100 ml NS in 15 microdrops/min) and once getting
feeble pulse, merely recordable BP; maintain it with Dopamine (2 ampule in 100
ml NS in 15 microdrops/ min).
Plan:
1. ECG 12 lead
2. Trop-T
3. RB
4. An ABG may be done (in selected/ doubtful cases)
5. CXR PA view (may be planned after stabilization to rule out infective cause)
6. Echocardiography (Later on).

Acute decompensation of chronic right heart failure

Patients usually presents with bilateral pitting edema + SOB ± raised JVP ± signs of
LHF ± cardiogenic shock (low/ unrecordable pulse/ BP).

Direction:
1. Salt restricted diet
2. Daily water intake <1 liter/day
3. Propped up position
4. Moist oxygen inhalation
5. Nebulization with Levo-salbutamol (Levolin) 4 hourly
6. Inj. Lasix 2 amp IV STAT and 2 amp IV TDS × Cont. [after measuring the BP]
7. In case of cardiogenic shock, administer Noradrenaline and Dopamine
8. T. Metoprolol (25) ½ tab BD × Cont.
9. Inj. Pantoprazole (40) IV BD × Cont.
10.Inj. Ondansetron (4) IV TDS × Cont.
11.Syrup Lactulose 3 TSF OD HS × Cont.
Plan:
1. RB
 6

2. ECG 12 lead
3. Trop-T
4. Date for echocardiography (later on).

Severe anemia + Heart failure

Direction:
1. Propped up position
2. Moist oxygen inhalation
3. Nebulization with Levo-salbutamol (Levolin) 4 hourly
4. Inj. Lasix 2 amp IV STAT and 2 amp IV TDS × Cont. [after measuring the BP].
Plan:
1. RB
2. Save 2 blood samples for sending Iron profile and Peripheral blood smear
next day (before transfusion)
3. Urgent PRBC requisition and transfusion.

Atrial fibrillation with fast ventricular rate (Patient stable)

The patient most often presents with palpitation and/ or chest discomfort.
A diagnosis is made by feeling the pulse (irregularly irregular) and may be
confirmed by ECG. A typical ECG in AF shows no P waves and an irregular
ventricular rate.
Direction:
1. Salt restricted diet
2. Propped up position
3. Moist O2 inhalation (if needed)
4. T. Metoprolol (25) 1 tab STAT and ½ tab BD × Cont.
5. T. Digoxin (0.25) ½ tab OD × Cont. (5 days/week)
6. T. Atorvastatin (20) 1 tab OD HS × Cont.
7. Syrup Lactulose 2 TSF OD HS × Cont.
8. In case of associated pulmonary edema causing respiratory distress:
 7

Inj. Lasix 2 amp IV STAT and 2 amp IV TDS × Cont. [after measuring the BP].
Plan:
1. RB
2. ECG
3. Date for echocardiography
4. Cardiology referral
5. PT-INR [In non-valvular AF, the usual target INR is between 2.0 and 3.0]
6. FT4, TSH
7. Fasting lipid profile (may be planned after discharge).
Note: After getting PT-INR report and getting a CHADS2 scoring of >2,
anticoagulation with warfarin may be started.

Atrial fibrillation with fast ventricular rate (Patient unstable)

Direction:
All of the above + Chemical cardioversion by:
Inj. Amiodarone (150 mg) 1 amp slow IV over 10 minutes -> If no response ->
Repeat.

Atrial flutter
Flutter waves (“saw-tooth” pattern) are best seen in leads II, III, aVF; may be
more easily spotted by turning the ECG upside down.
 8

Direction:
1. Salt restricted diet
2. Propped up position
3. Moist O2 inhalation (if needed)
4. T. Metoprolol (25) 1 tab STAT and ½ tab BD × Cont.
5. T. Digoxin (0.25) ½ tab OD × Cont. (5 days/week)
6. T. Atorvastatin (20) 1 tab OD HS × Cont.
7. Syrup Lactulose 2 TSF OD HS × Cont.
8. Inj. Verapamil (2.5 mg/ml) 2 amps (total 5.0 mg) slow IV over 2 min -> No
response -> May repeat the dose after 30 min.
Plan:
1. RB
2. ECG
3. Date for echocardiography
4. Cardiology referral
5. FT4, TSH.

Viral myocarditis
Patients usually presents days to weeks after a viral infection with cardiac
symptoms like chest discomfort, palpitation, dyspnea. On examination, often
tachycardia is found. ECG may show sinus tachycardia or mimic an AMI or acute
pericarditis (Widespread concave ST elevation and PR depression throughout
most of the limb leads and precordial leads).
Note: Coronary arteries are normal as seen in
coronary angiography.
Often there are features of DCM (bibasal fine
crepts + with SOB).
Direction:
1. Normal diet
2. Propped up position
 9

3. Moist O2 inhalation (in needed)

4. Inj. Lasix 2 amp IV BD/ TDS × Cont.
5. T. Metoprolol (25) ½ tab BD × Cont.
6. Serial ECG is essential in managing myocarditis. In case of significant atrial/
ventricular arrhythmia, specific antiarrhythmic agents (Amiodarone/
Verapamil) should be promptly given.
Plan:
1. RB
2. Serial ECG 12 lead
3. CXR PA view: To exclude any associated pericardial effusion.
 10

CENTRAL NERVOUS SYSTEM

Ischemic CVA
Direction:
1. Salt restricted diet/ Ryle’s tube feeding (if patient is unable to feed)
2. T. Aspirin (75) 1 tab OD HS × Cont.
3. T. Atorvastatin (40) 1 tab OD HS × Cont.
4. Inj. Pantoprazole (40) IV BD × Cont.
5. Inj. Ondansetron (4) IV BD × Cont.
6. If area of ischemia exceeds 1/3rd of one cerebral hemisphere/ is wide in
size, add Mannitol:
Inj. Mannitol (100) 3 bottles IV STAT -> Inj. Mannitol (100) IV TDS × Cont.
7. If there is associated seizures/ involuntary movement of muscles, add
Phenytoin:
Inj. Phenytoin (100) IV TDS × Cont.
8. Syrup Lactulose 3 TSF OD HS × Cont.
Note: If BP is high, don’t add antihypertensive agent in direction immediately as it
may increase the ischemic penumbra.
Plan:
1. RB
2. ECG 12 lead (to rule out any cardiac abnormality like AF)
3. Lipid profile
4. CT-Scan
5. FT4 and TSH.
NOTE:
In case of posterior circulation ischemic CVAs add anti-vertigo agents:
1. T. Vertin (24) 1 tab TDS × Cont. OR
2. Inj. Stemetil 1 amp IM BD × Cont.
 11

Hemorrhagic CVA/ Intracranial hemorrhage (ICH)

Direction:
1. Salt restricted diet/ Ryle’s tube feeding (if patient is unable to feed)
2. Catheterization (if needed)
3. Inj. Mannitol (100) 3 bottles IV STAT -> Inj. Mannitol (100) IV TDS × Cont.
4. If there is associated seizures/ involuntary movement of muscles, add
Phenytoin:
Inj. Phenytoin (100) IV TDS × Cont.
5. Inj. Pantoprazole (40) IV BD × Cont.
6. Inj. Ondansetron (4) IV BD × Cont.
7. Syrup Lactulose 3 TSF × Cont.
8. Add antihypertensive if BP is high: Usually start with Amlodipine: 5/10 mg
OD BBF depending on the BP. In case of very high BP (> 180/110), use of IV
antihypertensive (IV Enalapril/ IV Lasix) may be necessary.
Plan:
1. RB
2. ECG 12 lead
3. CT scan
4. Lipid profile.
Note: Always consider referring to a higher center/ a state medical college
having 24 hour emergency neurosurgery facility (after consulting with your
neurosurgery department).

Subarachnoid hemorrhage (SAH)

Direction:
1. Salt restricted diet/ Ryle’s tube feeding
2. Inj. Mannitol (100) IV TDS × Cont.
[Note: Give STAT dose of Mannitol if SAH is new/ there is associated
Intraventricular extension]
3. T. Nimodipine (30) 2 tablets 4 hourly × Cont.
[Note: It will continue for 21 days]
 12

4. Inj. Pantoprazole (40) IV BD × Cont.

5. Inj. Ondansetron (4) IV BD × Cont.
6. Syrup Lactulose 3 TSF × Cont.
7. Add Inj. Lasix STAT accordingly if BP is very high.
Plan:
1. RB
2. CT scan
3. PT-INR
4. MR angiography (later on)
5. Neurosurgery referral.
Note: Always consider referring to a higher center/ a state medical college
having 24 hour emergency neurosurgery facility (after consulting with your
neurosurgery department).

Acute spinal cord injury in case of hanging

Direction:
In case of severe cases, always write a referral to CCU and counsel the patient
party about grave prognosis.
1. Immobilization of cervical spine through cervical collar
2. If presented within 8 hours of injury*:
Inj. Methyl-Prednisolone (2 gram) to be dissolved in 100 ml of NS and to be
given in 30 minutes -> Inj. Methyl Prednisolone (2 gram) dissolved in 100 ml
of NS IV TDS × Cont.

[Note that, standard dose of Methyl-Prednisolone in case of acute spinal

cord injury is 30 mg/kg bolus over 15 minutes and maintenance dose 5.4
mg/kg/hr for next 24 hours]

3. Fluid imbalance to be corrected gradually because overzealous fluid

administration may lead to cerebral edema
May give: IVF DNS (500) 12 hourly × Cont.
 13

4. Inj. Pantoprazole (40) IV TDS × Cont. [to combat steroid induced gastritis]
5. Inj. Ondansetron (4) IV BD × Cont.
6. Inj. Mannitol (100) IV TDS × Cont.
7. Inj. Phenytoin (100) IV TDS × Cont. [if convulsions occur]
8. NPM
9. Continuous monitoring of vitals (especially BP) is necessary in severe
cases (if possible in CCU). Vasopressors should be used in hypotension.
Plan:
1. RB
2. ECG 12 lead
3. MRI cervical spine (in case of suspected fracture/ dislocation)
4. Psychiatry refer [Later on].

Meningoencephalitis
Direction:
Start empirical therapy [antibiotic + antiviral] before diagnosis is made.
1. Normal diet/ Ryle’s tube feeding (if unable to feed)
2. Inj. Ceftriaxone (2 gram) IV BD APST × Cont.
3. Inj. Vancomycin (500) in 100 ml NS IV BD × Cont.
4. Inj. Acyclovir (500) in 100 ml NS IV TDS × Cont.
5. Inj. Decadron (8) IV QDS × 4 days
[Note: The timing of dexamethasone administration is crucial. If this agent
is used, it should be administered before or with the first dose of
antibacterial therapy (to counteract initial inflammatory burst consequent
to antibiotic mediated bacterial killing).]
6. Inj. Pantoprazole (40) IV BD × Cont.
7. Inj. Ondansetron (4) IV BD × Cont.
8. Inj. Mannitol (100) IV TDS × Cont.
9. Inj. Phenytoin (100) IV TDS × Cont.
10.Inj. Diazepam 1 amp IM SOS [in case of convulsion]
11.Inj. DNS (500) 12 hourly × Cont. [Before starting Ryle’s tube feeding].
 14

Note: Based on LP report, change to antibiotic only/ antiviral only later on.
Plan:
1. RB
2. ECG 12 lead
3. CT scan
4. Lumbar puncture [Later on]
5. Blood culture [in selected cases only, i.e. suspected sepsis].

Hypertensive encephalopathy
Direction:
1. Salt restricted diet/ Ryle’s tube feeding (if unable to feed)
2. Use IV antihypertensive agents aggressively to lower the BP.
o Inj. Labetalol 4 amp IV STAT over 2 minutes: Preferred or,
o (Inj. Enalapril 1 amp + Inj. Lasix 2 amp) IV STAT.
3. T. Amlodipine (10) OD BBF × Cont.
4. T. Atorvastatin (40) OD HS × Cont.
5. Inj. Mannitol (100) 3 bottles IV STAT -> Inj. Mannitol (100) IV TDS × Cont.
6. Inj. Pantoprazole (40) IV BD × Cont.
7. Inj. Ondansetron (4) IV BD × Cont.
Plan:
1. RB
2. ECG 12 lead
3. CT scan
4. Lipid profile.
Note: Always keep checking on serum Na+ closely, as hyponatremia and
hypertensive encephalopathy often share same clinical presentation.
Status epilepticus
Direction:
1. Normal diet
2. Inj. Lorazepam 1 amp IV STAT
 15

3. Inj. Phenytoin 10 amp to be diluted in 500 ml of NS and to be infused over 4

hours -> Inj. Phenytoin (100) IV TDS × Cont.
4. Inj. Pantoprazole (40) IV BD × Cont.
5. Inj. Ondansetron (4) IV BD × Cont.
Plan:
1. RB
2. ECG 12 lead
3. CT scan -> If normal -> Plan for MRI
4. Plan EEG.

Convulsion in a known chronic alcoholic

Direction:
Usually due to alcohol withdrawal.
1. Hepatic diet
2. Inj. Lorazepam 1 amp IV STAT
3. Inj. Valproic acid (300/ 500) in 100 ml NS IV BD× Cont. and/or
Inj. Levetiracetam (500) IV BD × Cont.
6. Inj. Pantoprazole (40) IV BD × Cont.
7. Inj. Ondansetron (4) IV BD × Cont.
8. T. Librium (10) QDS × Cont.
9. Syrup Lactulose 3 TSF OD HS × Cont.
Always exclude hepatic encephalopathy.
Plan:
1. RB
2. ECG 12 lead
3. CT scan
4. LFT.
 16

Suspected GB syndrome
Direction:
Before confirmation of diagnosis, management is usually conservative.
1. Normal diet
2. Inj. Pantoprazole (40) IV BD × Cont.
3. Inj. Ondansetron (4) IV BD × Cont.
4. Syrup Lactulose 3 TSF OD HS × Cont.
Plan:
1. URGENT NCV OF THE AFFECTED LIMBS
2. RB
3. ECG 12 lead
4. LP [to be planned]: Albumino-cytological dissociation is characteristic (CSF
finding appears 7 days after onset of symptoms)
5. Neuromedicine referral.
After diagnosis is confirmed, IV-IG should be initiated.
Dosage: 400 mg/kg IV OD × 5 days.

Acute transverse myelitis (ATM)

Note: GB syndrome can be distinguished from ATM because it does not localize to
a specific spinal segment.
Direction:
1. Normal diet
2. Inj. Methyl-Prednisolone (1 gram) dissolved in 100 ml NS IV OD × Cont.
[Duration: 3-5 days depending upon the outcome]
3. Inj. Pantoprazole (40) IV BD × Cont.
4. Inj. Ondansetron (4) IV BD × Cont.
5. Syrup Lactulose 3 TSF OD HS × Cont.
Plan:
1. MRI Lumbosacral spine with screening of cervical and thoracic spines
 17

2. LP and CSF study

3. Neuromedicine referral for further evaluation.
 18

GI SYSTEM
Alcohol intoxication
Direction:
1. IVF D5:DNS 1:1 8 hourly
2. Inj. MVI 1 ampule in each alternate bottle of IVF
3. Inj. Pantoprazole (40) IV BD × Cont.
4. Inj. Ondansetron (4) IV BD × Cont.
Plan:
In doubtful cases, consider doing a urinary TOX-screen (when suspecting another
associated intoxication) and a CT scan (when suspecting a CNS condition/ CVA).
Plan for discharge on next day.

Alcohol withdrawal
Note:
Always exclude other possible conditions before coming to a confirmatory
diagnosis of alcohol withdrawal. For this purpose, a NCCT brain and blood tests
(RB and LFT) may be necessary. Carefully enquire and note the last date of
taking alcohol in BHT.
Direction:
1. T. Librium (Chlordiazepoxide) 10 mg 1 tab QDS × Cont.
2. Inj. Diazepam 1 amp IM/ Inj. Lorazepam 1 amp IV SOS
3. Add Inj. Valproate (300/500) or Inj. Levetiracetam (500) in case of recurrent
convulsions
4. Inj. MVI/ Inj. Thiamine 1 amp dissolved in 10 ml NS/DNS slow IV OD× Cont.
5. Inj. Pantoprazole (40) IV BD × Cont.
6. Inj. Ondansetron (4) IV BD × Cont.
Plan:
1. RB
2. CT scan (in doubtful cases)
 19

3. LFT (later on).

Acute pancreatitis
Direction:
1. NPM
2. Inj. IVF D5:DNS 1:1 6-8 hourly
3. Inj. Pantoprazole (40) IV BD × Cont.
4. Inj. Ondansetron (4) IV BD × Cont.
5. Inj. Drotin 1 amp IV BD × Cont.
6. Inj. Tramadol 1 amp IM SOS (in case of severe abdominal pain only)
7. IV antibiotics:
a. Routine cases: Inj. Ceftriaxone (1 gm) IV BD APST × Cont.
b. In case of suspected/ proven necrotizing pancreatitis:
Inj. Imipenem-Cilastatin (500) IV TDS × Cont. OR
Inj. Meropenem (1 gm) IV TDS × Cont.
Plan:
1. RB
2. Serum amylase + Serum lipase
3. LFT [ALT>150 is suggestive of gallstone pancreatitis]
4. USG whole abdomen
5. CE-CT whole abdomen (if USG already done)
6. CRP
After getting the Amylase-Lipase report
7. Serum Calcium Can be planned for later to rule out hypercalcemia and
8. LDH hyperlipidemia as potential cause of pancreatitis
9. ± Fasting lipid profile.
Note: On discharge paper, give Pancreatic enzymes for at least 1 week.
Decompensated chronic liver disease
Direction:
 20

1. Hepatic diet/ Bland diet

2. Inj. Lasix* 2 amp IV TDS × Cont.
3. T. Aldactone* (25/ 50/ 100) 1 tab OD × Cont. [Dose depends upon the
degree of accumulation of fluid in body; i.e. ascites/ pedal edema]
*Always rule out hepatic encephalopathy before administering diuretics.
4. Inj. Cefotaxime (1 gm) IV TDS × Cont.
5. T. Rifaximine (550) 1 tab BD × Cont.
6. Inj. Pantoprazole (40) IV BD × Cont.
7. Inj. Ondansetron (4) IV BD × Cont.
8. Syrup Lactulose 3 TSF OD HS × Cont.
9. T. Multivitamin 1 tab OD × Cont.
Plan:
In both males and females:
1. RB
2. LFT
3. HbSAg
4. Anti-HCV
5. PT-INR
6. USG whole abdomen
7. Ascitic fluid tap: Protein, Sugar, Cell type, Cell count, LDH, ADA.
In females the following special tests should be included:
1. Ascitic fluid for M cell block (to look for malignant cells)
2. Serum CA-125.
Note: Indent albumin if hypoalbuminemia is found in LFT.

Hepatic encephalopathy
Direction:
1. Ryle’s tube feeding
2. Syrup Lactulose 3 TSF BD × Cont.
3. Lactulose enema BD × Cont.
 21

4. IVF DNS (500) 12 hourly × Cont.

5. Inj. MVI in each alternate bottle of IVF
6. Inj. Cefotaxime (1 gm) IV TDS × Cont.
7. T. Rifaximine (550) 1 tab BD × Cont.
Plan:
1. RB
2. LFT
3. HbSAg
4. Anti-HCV
5. PT-INR
6. USG whole abdomen
7. Upper GI endoscopy.

Hematemesis ± Melena
Direction:
1. NPM
2. IVF NS:DNS 1:1 8 hourly
3. Inj. Pantoprazole (40) 2 amp in every bottle of NS
4. Inj. MVI 1 amp in each bottle of DNS
5. Inj. Terlipressin (2 amp) IV STAT -> 1 amp IV TDS × Cont.
6. Inj. Ondansetron (4) IV TDS × Cont.
7. Inj. Cefotaxime (1 gm) IV TDS × Cont.
8. Inj. Vitamin K IV OD × Cont. (should be given after having a look on PT-INR)
9. Inform SOS.
Plan:
1. RB
2. PRBC requisition
3. Upper GI endoscopy
4. PT-INR
5. USG whole abdomen.
 22

Jaundice under evaluation

It is essentially an outdoor treatment; but sometimes patients get admitted.
Direction:
1. Bland diet
2. IVF NS:DNS 1:1 8 hourly [----- try to reduce the amount of fluid gradually]
3. Inj. MVI 1 amp in each alternate bottle of DNS
4. Inj. Pantoprazole (40) IV BD × Cont.
5. T. UDCA (Urso-deoxy-cholic-acid) [300 mg] TDS × Cont.
6. Syrup Lactulose 3 TSF OD HS × Cont.
Plan:
1. RB
2. LFT
3. Hepatitis profile: Anti-HAV IgM + HbSAg + Anti-HCV [± Anti-HEV IgM]
4. USG whole abdomen.

Acute gastroenteritis (AGE)

It is essentially an outdoor treatment; but sometimes patients get admitted.
Direction:
1. Bland diet
2. Plenty of ORS to take
3. IVF NS:DNS 1:1 6 or 8 hourly [depending upon the degree of volume loss]
4. Inj. Ceftriaxone (1 gm) IV BD APST× Cont.
5. Inj. Metrogyl (100 ml: 400 mg) IV TDS × Cont.
6. Inj. Pantoprazole (40) IV BD × Cont.
7. Inj. Ondansetron (4) IV TDS × Cont.
Note:
In case of suspected GI sepsis, change antibiotic to Meropenem/ Piperacillin-
Tazobactum.
 23

Plan:
1. RB
2. ? Stool for OPC
3. Discharge in stable condition.
 24

Urinary System

UTI
Direction:
1. Normal diet
2. Plenty of water to take: 3-4 liters/ day
3. T. PCM (650) TDS × Cont. and 1 tab SOS
Infusion PCM IV SOS (if needed in high grade fever)
4. Inj. Ceftriaxone (1 gm) IV BD APST × Cont. or,
Inj. Levofloxacin (500) IV OD × Cont.

Note:
Change Ceftriaxone to Inj. Piperacillin-Tazobactum (4.5 gm in 100 ml NS) IV
TDS × Cont. [in case of suspected urosepsis]
5. Inj. Pantoprazole (40) IV BD × Cont.
6. Inj. Ondansetron (4) IV TDS × Cont.
Plan:
1. RB
2. Urine for RE/ ME
3. Urine for culture and sensitivity [in selected/ recurrent cases only]
4. USG whole abdomen [in selected cases only].
Note: In complicated UTI/ urosepsis, the next phase of treatment and choice of
antibiotic should be guided as per report of urine culture-sensitivity report.

CKD
1. Renal diet (low protein diet + avoid acidic fruits)
2. Daily water intake <1.5 liter/day
3. Inj. Lasix 2 amp IV TDS × Cont.
4. Add T. Metolazone (5 mg OD) in case of generalized edema
5. Add Ceftriaxone if an infection is suspected.
 25

Plan:
1. RB
2. Serum ferritin/ Iron profile
3. ECG 12 lead
4. Nephrology/ Dialysis refer.

Note: Hyperkalemia in CKD

I. If serum K+ is slightly high (5.1 – 6 mmol/L): Add Potassium binding sachet:
1 in one cup of water BD × Cont.
II. Hyperkalemia with typical ECG features:
All patients with a serum K+ value ≥ 6.0 mmol/L
should have an urgent 12-lead ECG.
Typical features of hyperkalemia are:
a. Peaked T waves
b. Diminished P waves
c. Wide QRS complex.
Management: Administer 10 ml of 10% Calcium
gluconate slow IV over 2-5 minutes.
NOTE: IV calcium antagonises the cardiac membrane excitability thereby
protecting the heart against arrhythmias. It is effective within 3 minutes as
shown by an improvement in the ECG appearance (e.g. narrowing of the
QRS complex). The dose should be repeated if there is no effect within 5-
10 minutes. The duration of action is only 30-60 minutes, so further doses
may be necessary if hyperkalemia remains uncontrolled. As IV calcium
does not lower serum K+, other interventions are urgently required.
III. Management of documented hyperkalemia with a serum K+> 6.0 mmol/L:
10 units soluble insulin with 25 gm of glucose (100 ml of 25D).
Note that, the efficacy of insulin-glucose is increased if given in
combination with nebulized salbutamol.
 26

Diabetic nephropathy
Direction:
1. Diabetic diet
2. Daily water intake <1.5 liter/day
3. Inj. Lasix 2 amp IV TDS × Cont.
4. Inj. Ceftriaxone (1 gm) IV BD APST × Cont.
5. Control of hyperglycemia by regular insulin
6. Add T. Metolazone (5 mg OD) in case of generalized edema
Plan:
1. RB
2. ECG 12 lead
3. Nephrology/ Dialysis refer.

Obstructive uropathy
Prior to addressing the specific therapy for obstruction, a physician must
investigate and begin treatment of the life-threatening complications of
obstructive uropathy (i.e. pulmonary edema, hypovolemia, urosepsis,
hyperkalemia etc.).
Direction:
1. Catheterization
2. Daily water intake <1.5 liter/day
3. Inj. Lasix 2 amp IV TDS × Cont.
4. Inj. Ceftriaxone (1 gm) IV BD APST × Cont.
5. K-Binding sachet (1 in a cup of water) BD × Cont. [in case of hyperkalemia]
6. Syrup Lactulose 3 TSF OD HS × Cont.
Plan:
1. RB
2. ECG 12 lead
3. USG whole abdomen
4. Urine for RE/ ME (if suspected for UTI)
 27

5. Urosurgery referral
6. Nephrology/ Dialysis referral (if urea/ creatinine is high).
In case of suspected Uremic Encephalopathy:
Always try to arrange for urgent dialysis of the patient.

Acute glomerulonephritis
Direction:
1. Salt restricted diet
2. Daily water intake <1.5 liter/day
3. Inj. Lasix 2 amp IV TDS × Cont.
4. Inj. Ceftriaxone (1 gm) IV BD APST × Cont.
5. T. Amlodipine (5) OD BBF × Cont.
Plan:
1. RB
2. Urine for RE and ME
3. Serum C3 and C4 [Low C3 levels are found in almost all patients with acute
PSGN; C4 levels may be slightly low]
4. USG whole abdomen
5. CXR PA view Digital [in case of suspected streptococcal pneumonia only].

Suspected nephrotic syndrome (Proteinuria ++)

It is essentially an outdoor case.
Plan:
1. RB
2. FBS, PPBS
3. Urine for RE and ME
4. 24 hour urinary protein excretion
5. Serum C3 and C4
6. Fasting lipid profile
 28

7. HbSAg, Anti-HCV, HIV (I & II)

8. ASO titer, ANA
9. USG whole abdomen
10.c-ANCA and p-ANCA
(In special cases only. Testing for ANCA is not indicated in typical nephrotic
syndrome, because that test is associated with rapidly progressive
glomerulonephritis, which presents with a nephritic picture rather than one
that is typically nephrotic)
11.PT-INR (if renal biopsy is planned).
 29

POISONINGS

Organophosphate poisoning
Direction:
1. NPM
2. Gastric lavage with at least 4 liter of NS*
3. IVF NS:DNS 1:1 8 hourly
4. Inj. Atropine (5 amp) in each bottle of NS** - ↑Gradually till targets of
atropinization are achieved
5. Inj. Pantoprazole (40) IV BD × Cont.
6. Inj. Ondansetron (4) IV BD × Cont.
7. Inj. Pralidoxime (PAM) 2 amp (1 gm/vial: A total of 2 gm) in 100 ml of NS to
be given in 20 minutes
8. Inj. Diazepam 1 amp IM SOS.
Plan:
1. RB
2. ECG 12 lead.
Special notes:
*Gastric lavage decreases absorption by 42% if done at 20 minutes and by 16% if
performed at 60 minutes.
**
 30

Cypermethrin poisoning
Direction:
1. NPM
2. Gastric lavage (if needed)
3. IVF NS:DNS 1:1 8 hourly
4. Inj. Pantoprazole (40) IV BD × Cont.
5. Inj. Ondansetron (4) IV BD × Cont.
6. Inj. Phenytoin (100) IV TDS × Cont.

Plan:
1. RB
2. ECG 12 lead.

Paraquet
PARTY COUNSELLING ABOUT THE OUTCOME IS MANDATORY.
Direction:
1. NPM
2. Gastric lavage (if needed)
3. IVF NS:DNS 1:1 8 hourly
4. Inj. MVI 1 amp in each bottle of DNS
5. Inj. Pantoprazole (40) IV BD × Cont.
6. Inj. Ondansetron (4) IV BD × Cont.
7. T. Vitamin C 1 tab BD × Cont.
8. T. Vitamin E 1 tab BD × Cont.
Plan:
1. RB
2. ECG 12 lead
3. Dialysis refer with viral marker report (HbSAg + anti-HCV + HIV I & II) as
soon as possible.
 31

Benzodiazepines
Direction:
1. NPM
2. Gastric lavage (if needed)
3. IVF NS:DNS 1:1 8 hourly
4. Inj. Pantoprazole (40) IV BD × Cont.
5. Inj. Ondansetron (4) IV BD × Cont.
6. Inj. Flumazenil ½ amp in 10 ml NS to be given
over 1 min and rest ½ amp in 1st bottle of NS
slowly over 4 hours.*
Note:
Give Flumazenil only to the patients in disoriented/ semiconscious state.
Plan:
1. RB
2. ECG 12 lead.

Corrosive acid/ substances

Direction:
1. NPM
2. IVF NS:DNS 1:1 8 hourly
3. Inj. Pantoprazole (2 amp) in each bottle of NS × Cont.
4. Inj. Ondansetron (4) IV TDS × Cont.
Warning: Never do gastric lavage in case of corrosive substance poisoning.
Plan:
1. RB
2. ECG 12 lead
3. ENT refer
4. Upper GI endoscopy 6 weeks after ingestion.
 32

Copper sulfate
Direction:
1. NPM (Except medications)
2. IVF NS:DNS 1:1 8 hourly
3. Inj. Pantoprazole (2 amp) in each bottle of NS
[to prevent erosive gastropathy]
4. Inj. MVI 1 amp in each bottle of DNS
5. Inj. Ondansetron (4) IV TDS × Cont.
6. T. D-Penicillamine (500) 1 tab 6 hourly × Cont.
7. Inj. Ceftriaxone (1 gm) IV BD APST × Cont.
Note:
Suspect methemoglobinemia if there is a low peripheral saturation (Sp02) in the
presence of a normal arterial saturation (in ABG) in the presence of cyanosis. If
possible, methemoglobin levels should be assessed. This is treated by IV
methylene blue 2 mg/kg (in 5% dextrose) -> Repeat if cyanosis persists beyond 1
hour. Note that, methylene blue is contraindicated in G6PD deficiency.

Plan:
1. RB
2. Amylase and Lipase
3. ECG 12 lead
4. LFT
5. PRBC requisition [if Hb level falls due to copper induced hemolysis]
6. Dialysis refer with viral marker report (HbSAg + anti-HCV + HIV I & II) as
soon as possible*
7. CCU refer if aspiration pneumonia develops.
* The recovery of renal function following copper sulfate ingestion is observed to
be slow and incomplete. It takes a long time and multiple dialysis before the
patient becomes independent of dialysis.
 33

Paracetamol
Direction:
1. NPM (Except medications)
2. Inj. Pantoprazole (40) IV BD × Cont.
3. Inj. Ondansetron (4) IV BD × Cont.
4. Oral NAC:
Oral NAC (600 mg) is the drug of choice for the treatment of
acetaminophen overdose. The FDA-approved dosage regimen for oral NAC
starts with a loading dose of 140 mg/kg, followed by 17 doses, each at 70
mg/kg, given every 4 hours. The total duration of the treatment course is
72 hours.
Alternative and simplified regimen (for a 60 kg body weight patient):
Oral NAC (600) 14 tab STAT-> 7 tab every 4 hour × Cont.
Note:
IV N-acetyl cysteine (NAC):
Indications:
 Altered mental status
 GI bleeding and/or obstruction
 A history of caustic ingestion
 Potential acetaminophen toxicity in a pregnant woman
 Inability to tolerate oral NAC because of emesis refractory to proper use of
antiemetic.
Dose:
200 mg/ml inj. available in 2 ml and 5 ml ampules.
 Loading Dose: 150 mg/kg in 200 mL of 5D administered over 1 hr
 Dose 2: 50 mg/kg in 500 mL of 5D administered over 4 hr
 Dose 3: 100 mg/kg in 1000 mL of 5D administered over 16 hr.
Plan:
1. RB
2. LFT
 34

3. Amylase and Lipase.

 35

RESPIRATORY SYSTEM

Hemoptysis/ chronic cough under evaluation

Direction:
1. Normal diet
2. T. PCM (650) 1 tab SOS
3. Inj. (Amoxicillin + Clavulanic acid) 1.2 gm IV TDS APST × Cont.
4. Syrup Expectorant 2 TSF TDS × Cont.
Plan:
1. RB
2. Digital CXR PA view
3. Sputum for AFB
4. Sputum for Gram stain ± C/S (in selected cases only)
5. PRBC requisition (in case of massive hemoptysis).

Significant LRTI/ LRTI + Sepsis

Direction:
1. Normal diet/ Ryle’s tube feeding (if patient is unable to feed)
2. Moist O2 inhalation (if needed)
3. T. PCM (650) 1 tab TDS × Cont. and 1 tab SOS or,
Infusion PCM BD × Cont. [in seriously ill patient unable to feed]
4. Inj. (Piperacillin + Tazobactum) 4.5 gm in 100 ml NS IV TDS × Cont.
5. Inj. Levofloxacin (500) IV OD × Cont.
6. Inj. Pantoprazole (40) IV BD × Cont.
7. Inj. Ondansetron (4) IV BD × Cont.
Plan:
1. RB
2. CRP
3. Digital CXR PA view
 36

4. Sputum for gram stain, AFB stain ± Culture and sensitivity (if needed)
5. ABG (if needed).

AECOPD
Direction:
1. Moist O2 inhalation
2. Nebulization with Levolin 4 hourly
3. Nebulization with Duolin 6-8 hourly
4. Nebulization with Budicort 12 hourly
5. Inj. Hydrocortisone (100) 1 amp IV STAT and 1 amp IV TDS × Cont.
6. Inj. Lasix 2 amp IV STAT and 1 amp IV BD/ TDS × Cont. [If crepts+]
7. Inj. Pantoprazole (40) IV BD × Cont.
8. Inj. Ondansetron (4) IV BD × Cont.
9. Inform SOS.
Plan:
1. RB
2. CRP
3. Digital CXR PA view
4. ABG.

Note: Correct any electrolyte imbalance as found in ABG promptly.

1. Hyponatremia: 3% NaCl IV BD/ TDS/ QDS slowly over 10 minutes
[depending upon the Na+ level]
2. Hypokalemia: Syrup Potclor 2 TSF/ 3TSF TDS or Inj. KCL 1 amp in 500 ml NS
[depending upon the K+ level].
Basic calculations:
Hyponatremia
1 liter of 3% NaCl contains 513 mmol of Na+
Normal serum Na+ is: 135-145 mmol/L
 37

Daily Na+ requirement is about 2 mmol/kg.

Na+ deficit= Body weight × [Desired Na+ - Serum Na+] × Sex ratio [M: 0.6 & F: 0.5]

Desired Na+= 120-125 meq/l.

Suppose we get an asymptomatic male patient of 60 Kg with a serum Na+ level of
105.0 mmol/L and we want to make it 125 mmol/L. We proceed this way:
1) Na+ deficit= 60 × [125-105] × 0.6= 720 mmol
2) Daily Na+ requirement = 2 x 60 = 120 mmol
3) Total Na+ requirement = 720+120 = 840 mmol Ξ 1.64 liter of 3% NaCl.

Hypokalemia
1 amp of KCl contains 5 ml of 2 mmol/ml solution; that means a total of 10 mmol.
10 mL of KCl syrup = 20 mmol of K+

Normal level of serum K+ is 3.5-5.0 mmol/L

Daily K+ requirement is about 1 mmol/kg.
K+ deficit= [Lower limit of K+ - Serum K+] × Body weight × 0.4

Suppose we get an asymptomatic patient of 60 Kg with a serum K+ level of 3.0

mmol/L. We proceed this way:
1) Deficit of potassium in mmol = (3.5 - 3.0) x 60 x 0.4 = 12 mmol
2) Daily potassium requirement = 1 x 60 = 60 mmol
3) Total requirement = 12+60 = 72 mmol Ξ 7 amp of KCl/ d Ξ 36 ml KCl syrup/d.

AECOPD + LRTI
Direction:
1. Moist O2 inhalation
 38

2. Nebulization with Levolin 4 hourly

3. Nebulization with Duolin 6-8 hourly
4. Nebulization with Budicort 12 hourly
5. Inj. Hydrocortisone (100) 1 amp IV STAT and 1 amp IV TDS × Cont.
6. Inj. (Piperacillin + Tazobactum) 4.5 gm in 100 ml NS IV TDS × Cont.
7. Inj. Levofloxacin (500) IV OD × Cont.
± Inj. Linezolid (600) IV BD × Cont.
8. Inj. Pantoprazole (40) IV BD × Cont.
9. Inj. Ondansetron (4) IV BD × Cont.
10.Inform SOS.
Plan:
1. RB
2. CRP
3. Digital CXR PA view
4. ABG
5. Sputum for gram stain ± Culture and sensitivity (if needed).
Note:
Respiratory distress in a known case of Bronchogenic CA is also treated as LRTI.

Aspiration pneumonia
Direction:
1. Moist O2 inhalation
2. Nebulization with Levolin 4 hourly
3. Nebulization with Duolin 6 hourly
4. Inj. Meropenem (1 gm) IV TDS × Cont.
5. Inj. Metrogyl (100 ml) IV TDS × Cont.
6. T.PCM (650) TDS × Cont. or, Infusion PCM IV BD × Cont. (if critically ill)
7. Inj. Pantoprazole (40) IV BD × Cont.
8. Inj. Ondansetron (4) IV BD × Cont.
9. Inform SOS.
 39

Plan:
1. RB
2. CRP
3. Digital CXR PA view
4. Sputum for gram stain ± Culture & sensitivity
5. ABG
6. CCU refer urgently (for mechanical ventilation).
 40

INFECTION

Fever under evaluation

Direction:
1. Normal diet
2. T.PCM (650) TDS × Cont. and 1 tab SOS
3. Inj. Ceftriaxone (1 gm) IV BD APST × Cont.
4. Inj. Pantoprazole (40) IV BD × Cont.
5. Inj. Ondansetron (4) IV BD × Cont.
Plan:
1. RB
2. ECG 12 lead
3. CRP
4. If UTI is suspected: Urine RE/ ME
5. If Dengue is suspected: Dengue NS1 (day 3-4) and Dengue IgM (day 5-6)
6. If LRTI is suspected: CXR PA view Digital, Sputum for gram stain & C/S
7. If Typhoid fever is suspected: Typhidot IgM
8. If associated hemoptysis/ chronic cough: Sputum for AFB.

Dengue fever
Direction:
1. Normal diet
2. T.PCM (650) TDS × Cont. and 1 tab SOS (if temperature > 102◦F)
3. IVF NS (500) 4/6 hourly [depending upon the Volume status/ PCV]
4. Inj. MVI 1 amp in any 2 bottle of IVF in a day × Cont.
5. Inj. Pantoprazole (40) IV BD × Cont.
6. Inj. Ondansetron (4) IV TDS × Cont.
 41

Note:
In suspected Dengue shock syndrome (BP low/ not recordable); give 3 bottle of
NS in jet STAT -> if still BP not recordable -> administer Noradrenaline (4 ampule
in 100 ml NS in 15 microdrops/min) and once getting feeble pulse, merely
recordable BP; maintain it with Dopamine (2 ampule in 100 ml NS in 15
microdrops/ min).
Plan:
1. RB
2. LFT (to rule out dengue hepatitis)
3. Serum Amylase-Lipase (in case of retractable abdominal pain; to rule out
dengue pancreatitis)
4. Dengue NS1 (day 3-4) and Dengue IgM (day 5-6)
5. Platelet requisition (if platelet ≤20000/cu.mm)
6. FFP requisition (in case of coagulopathy with/ without deranged LFT)
7. PRBC requisition (in case of massive bleeding).

Typhoid fever
Although it is an OPD case, sometimes (especially when complications are
suspected) got admitted. While treating in OPD, DOC is T. Cefixime (200) BD PC
for 5-7 days. 2nd DOC is Azithromycin (500) OD for 5 days.
Direction:
1. Bland diet
2. IVF NS:DNS 1:1 8 hourly
3. Inj. Ceftriaxone (1 gm) IV BD APST × Cont.
4. T. PCM (650) 1 tab TDS × Cont. and 1 tab SOS
5. Inj. Pantoprazole (40) IV BD × Cont.
6. Inj. Ondansetron (4) IV TDS × Cont.
7. Inj. Drotin 1 amp IV BD × Cont.
8. Inform SOS.
 42

Plan:
1. RB
2. CRP
3. Serum Amylase and Lipase
4. Typhidot IgM (It becomes positive within 2-3 days of infection)
5. USG whole abdomen (if GI complications are suspected).

Malaria
P.vivax malaria
It is an OPD case. DOC is T. Chloroquine (Brand name: Lariago-DS) 2 tab STAT and
1 tab at 8 hour, 24 hour and 48 hour : A total of 5 tablets.
P.falciparum malaria
Direction:
1. Bland diet
2. T. PCM (650) TDS and 1 tab SOS
Infusion PCM if temperature >103◦F.
3. IVF NS (500) 8 hourly × Cont.
4. Inj. Artesunate 2 amp in 1st bottle of NS
Inj. Artesunate 1 amp in 2nd bottle of NS
Inj. Artesunate 1 amp in any 1 bottle of NS after 1st day × Cont.
*1 amp of artesunate= 60 mg.
5. Inj. Pantoprazole (40) IV BD × Cont.
6. Inj. Ondansetron (4) IV TDS × Cont.
7. Inform SOS.
* A loading dose of 2 mg/kg should be followed by 1 mg/kg after 4 hours and 24
hours. Thereafter a dose of 1 mg/kg should be given daily until the patient is able
to tolerate oral artesunate or for a maximum of 7 days. [WHO Guidelines]
Plan:
1. RB
2. LFT
 43

3. Serum Amylase and Lipase

4. Digital CXR PA view (if needed; i.e. in case of SOB).
Note: In case of ARF, increase the amount of IVF and prepare for dialysis [send
blood for triple serology].

Sepsis
In addition to conservative management, empirical choice of antibiotic depends
upon the suspected/ confirmed source of sepsis. Choice of specific antibiotic
depends upon culture and sensitivity report.
1. LRTI + Sepsis: (Piperacillin + Tazobactum) + Levofloxacin ± Linezolid
2. Urosepsis: (Piperacillin + Tazobactum) + Levofloxacin / Meropenem +
Levofloxacin
3. Aspiration pneumonia: Meropenem + Metrogyl ± Linezolid
4. GI sepsis: Meropenem + Metrogyl ± Linezolid
5. Necrotizing pancreatitis: (Imipenem + Silastatin)/ Meropenem.
 44

HEMATOPOIETIC SYSTEM

Anemia under evaluation

Direction:
Symptomatic management.
Plan:
1. RB
2. Peripheral blood smear
3. Iron profile
4. Stool for OPC
5. Digital CXR PA view
6. USG whole abdomen
7. PRBC requisition (only after all blood investigations are sent).

Generalized lymphadenopathy
Direction:
Symptomatic management.
Plan:
1. RB
2. Peripheral blood smear
3. Digital CXR PA view
4. USG whole abdomen
5. PT-INR -> Pathology refer for FNAC of a palpable lymph node
6. General surgery refer for lymph node biopsy (only if indicated)
7. Sputum for AFB (if TB is suspected).
 45

MISCELLANEOUS

Snake bite
Immediate plan:
1. 20 min Whole blood clotting time (20WBCT)*
2. Urine for occult blood test (OBT)
* A few milliliters of fresh venous blood should be placed in a fresh, clean and dry
glass vessel preferably test tube and left undisturbed at ambient temperature for
20 minutes. After that tube should be gently tilted to detect whether blood is still
liquid and if so then blood is incoagulable. The test should be carried out every 30
minutes from admission for 3 hours and then hourly after that. (Ideally)

Hematotoxic snake bite

If above two tests confirm hemotoxic snake bite, the direction will be following:
1. Bland diet
2. IVF NS (500) 8 hourly
3. T. PCM (650)/ T. Tramadol 1 tab SOS (for pain control)
4. Inj. AVS 10 amp in each bottle of NS (to be infused over 1 hour)**
5. Inj. Pantoprazole (40) IV BD × Cont.
6. Inj. Ondansetron (4) IV BD × Cont.
** After initial ASV dose, no additional ASV should be given until the next clotting
test at 6 hours. This is due to the inability of the liver to replace clotting factors in
less than 6 hours. If WBCT is still more than 20 minutes, repeat dose of 10 vials of
ASV should be continued 6 hourly till coagulation is restored.

Later plan:
1. RB
2. Amylase and Lipase
3. PT, INR
 46

4. ECG 12 lead.
Note: Prepare for dialysis if ARF develops.

Neurotoxic snake bite

Suspect neurotoxic symptoms if there is loss of the gag reflex, failure to cough or
respiratory distress.
Direction:
1. Bland diet
2. Moist O2 inhalation
3. IVF NS (500) 8 hourly
4. T. PCM (650)/ T. Tramadol 1 tab SOS (for pain control)
5. Inj. AVS 10 amp in each bottles of NS (to be infused over 1 hour)**
6. Inj. Glycopyrrolate^ (1 ml) IV STAT -> Inj. Neostigmine 1 amp IM STAT
7. Inj. Pantoprazole (40) IV BD × Cont.
8. Inj. Ondansetron (4) IV BD × Cont.
** After initial ASV dose, no additional ASV should be given until the next clotting
test at 6 hours. This is due to the inability of the liver to replace clotting factors in
less than 6 hours. If WBCT is still more than 20 minutes, repeat dose of 10 vials of
ASV should be continued 6 hourly till coagulation is restored.

^ Inj. Glycopyrrolate is available in 5 ml vial in a concentration of 0.2 mg/ml. The

dose of Glycopyrrolate is 0.2 mg IV; i.e. 1 ml.
Plan:
In addition to the plans of hematotoxic snake bite, write a CCU refer for need of
mechanical ventilation as soon as you diagnose a neurotoxic snake bite.
 47

Scorpion bite
Usually manageable in ER.
Direction:
i. Inj. Phenergan (Promethazine) 1 amp IM STAT
ii. Inj. Hydrocortisone (100) IV STAT
iii. Inj. Tetanus 0.5 ml IM STAT.
Discharge after keep in observation for 2-3 hours with/without an antibiotic
course (Ex.: Coamoxiclav).

Unknown bite
Most important thing to do is exclude snake bite.
Plan:
1. 20WBCT
2. Urine for OBT.
If evidence of hemotoxicity/ neurotoxicty is found, treat accordingly.
Otherwise give Tetanus and Hydrocortisone and discharge after observation for 2-
3 hours.

Hyperemesis gravidarum
Direction:
1. Bland diet
2. Inj. Pantoprazole (40) IV BD × Cont.
3. Inj. Ondansetron (4) IV BD × Cont.
4. T. (Doxylamine + Pyridoxine) 1 tab QDS × Cont.
5. IVF NS:DNS 1:1 8 hourly
6. Inj. MVI 1 amp in each alternate bottle of DNS
7. Inform SOS.
 48

Plan:
1. RB
2. Amylase and Lipase
3. Urine for RE, ME and ketone bodies
4. LFT
5. FT4 and TSH
6. USG whole abdomen.

DKA
Initial plan:
1. Urine for ketone body
2. RB
3. ABG
4. CRP.
Latest Guidelines:
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Direction:
1. IVF NS (500) 2 bottles IV STAT
↓
2. IVF NS (500) 6 hourly × Cont.
3. Inj. Human regular insulin 30 units in each bottle of NS × Cont.
4. Inj. KCl 1 amp in each alternate bottle of NS × Cont.
5. Inj. Pantoprazole (40) IV BD × Cont.
6. Inj. Ondansetron (4) IV BD × Cont.
7. Diabetic diet.
Note:
1. Regular CBG monitoring is necessary; when CBG comes to <250 mg/dl, omit
insulin temporarily, start DNS -> after CBG gets >250 mg/dl for a permissive
time, change insulin to 0.05 U/Kg/H & Do another ABG -> Change to SC
insulin as per guidelines.
2. If sepsis is suspected/ proven in a patient of DKA/ uncontrolled diabetes,
always start with high generation antibiotics combination like Meropenem
+ Teicoplanin / Linezolid.
3. ½ NS or ½ DNS is not available in Medicine ward so we have to work with
NS/ DNS.

HONC
In case of HONC, fluid requirement is higher than DKA. Other aspects of
management are similar. In HONC, we have to start with 4 bottles of NS STAT and
then 1 bottle every 2-4 hourly.