Archive
Dyslipidemia and hyperlipidemia
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1. Check
1. LDL, HDL, Cholesterol, TG
2. check every 5 years
3. check 6-8 weeks after treating the pt
2. Primary prevention
1. If LDL>190
1. ASCVD>10% ⇒ moderate dose Statin
2. ASCVD 5-10% ⇒ discuss starting drugs
3. ASCVD<5% ⇒ only F/U
4. Repeat checkups after 6-8 weeks of treatment
5. Goal: decrease 50% in LDL level
3. Statins:
1. Tab Atorvastatin (10, 20, 40mg) start with 10-40 mg , max 80 mg/day
2. tab Lovastatin 20 mg, start with 20-40 mg max 80 mg/day
3. tab Rosuvastatin (5, 10, 20 mg) start with 10-20 mg max 40 mg/day
4. Fibrates
1. Tab Gemfibrozil (450, 600 mg) bid
2. tab Gemfibrozil 300 mg bid max 1200 mg /day
3. cap fenofibrate (100, 200 mg ) qd, start with 50-100 mg/day max 200 mg qd
5. Bile chelators:
1. Powder cholestyramine 4gr bid before meal
2. tab nicotinic acid 100 mg tds or qid
3. tab ezetimibe 10 mg qd (block bile absorption)
4. tab fish oil bid
6. Approach:
1. First line drugs
1. Statins: tab atorvastatin 40 mg po qd #30
1. Statins are more effective on LDL
2. may cause myositis ⇒ check CPK, ALT, AST, ALP
3. may cause rise LFT
4. check LFT, TSH, FBS, CK, lipid profile before starting drugs
2. Fibrates: Cap gemfibrozil 300 mg bid #90
1. do not prescribe with statins
2. more effective on TG
3. start with one of them
2. 2nd line drugs: if first line was not effective, add these drugs
1. tab nicotinic acid 100 mg tds #130
1. first week 1 pill
2. 2nd week 2 pills
3. 3rd week 3 pills
2. Tab Niacin 50mg qd up to 2gr/day
3. tab fish oil bid effective on TG
4. Powder cholestyramine 4gr bid with food
Drug interactions
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1. Salbutamol/Seroflu ::: Propranolol ⇒ lower salbutamol effect
2. Antibiotics ::: OCP ⇒ lower OCP effects
3. Omeprazole :::: Clopidogrel ⇒ lower Plavix effect, use pantoprazole instead
4. Theophylline ::: Cipro/Oflox ⇒ theophylline poisoning
5. Gemfibrozil ::: atorvastatin ⇒ increase risk of myositis
6. Gentamycin ::: furosemide ⇒ ototoxicity
7. Sildenafil/Tadalafil ::: Nitrate ⇒ lowering BP
8. macrolides (erythro/ clarythro) ::: atorvastatin ⇒ increase level of atorvastatin
9. captopril/enalapril ::: spironolactone/triamterene ⇒ hyperkalemia
10. Warfarin ::: NSAIDs/cotri/metronidazole/phenytoin ⇒ warfarin toxicity
11. MTX ::: NSAIDs ⇒ increase MTX level
12. Methadone ::: SSRI/domperidone/clarythro ⇒ arrhythmias
13. ergotamine ::: sumatriptan ⇒ vasoconstriction
14. mebendazole ::: metronidazole ⇒ SJS
15. PROMETHAZINE ::: metoclopramide ⇒ extrapyramidal syndrome
16. Rakuten (isotretinoin) ::: tetracyclines/doxycycline/vitamin A
DKA
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1. Orders:
1. imp: DKA
2. ACT: CBR
3. Vital signs: close observation
4. Diet: NPO
5. Condition: urgent
6. IV line 2* fix
7. CVS q1h
8. ECG
9. POM & CHM
10. O2 therapy if SpO2<94%
11. internal folly fix + check intake & output
12. Check
1. CBC, diff
2. Na, K, Ca, P, Mg
3. VBG, ABG
4. U/A, U/C, BUN, Cr
5. BS, HbA1c
6. C-Peptide
7. TSH, T3, T4
8. ANTI-TTG IgA
9. CRP, ESR,
10. ALP
11. B/C
13. Check BS q1h
14. check VBG q2h
15. Check k q4h
16. Check Na, K, Mg, Ca, P, BUN q4h
17. IV hydration
1. start with serum N/S 10-20 cc/kg IV infusion in 1 hours, repeat if diuresis was not started (distract it from the whole fluid that should be given)
2. start 1000/10kh + 50/20 kg+ 20/kg cc IV maintenance
3. add deficit: 10cc*w*10-7%
18. Potassium
1. k<3.2 : 80meq/lit kcl
2. 3.2<k<4.5: 40meq/lit kcl
3. 4.5<k<5.5: 20meq/lit kcl
4. k>5.5: no KCl added
19. Insulin
1. only start when k>3.3
2. Serum HS 500cc + 0.1 unit/kg regular insulin ?cc/hr IV infusion
3. after resolving DKA, start insulin with 1unit/kg/day (1/3 basal, 2/3 regular) SQ with 30 minutes at least overlap with IV insulin
20. HCO3
1. if pH<6.9
2. NaHCO3 (100mmol) in 400cc/2hr H2O + 20meq KCl IV infusion
21. if + Headache, refractory vomiting, decreased LOC (in favor of brain edema)
1. Mannitol 1gr/kg/15min, repeat 30 mins later if no response seen
2. Types of fluids:
1. start hydration with N/S
2. give insulin in HS
3. BS<250 mg/dl ⇒ HS + DW5%
4. 150<BS<200 ⇒ HS + DW7.5%
5. 100<BS<150 ⇒ HS + DW10% + insulin 1/2
6. BS<100 ⇒ HS + DW12.5% + insulin 1/2
3. DKA criteria
1. BS>200
2. VBG: pH<7.3, HCO3<15
3. BHOP>3
4. Ketonuria
4. Resolved DKA criteria
1. pH>7.3
2. HCO3> 15
5. Goal of BS:
1. children: 150-180 mg/dl
2. adult: 100-150 mg/dl
6.
Diarrhea
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1. IV therapy
1. for adults:
1. Serum 1/3 2/3 1-2 lit IV infusion
2. for Children
1. start with N/S 20cc/kg in 20 minutes repeat if needed *3
2. Dehydration: w*(5-10-15)*10cc
3. Maintenance (100-50-20cc/kg)
4. if febrile >38C ⇒ 120cc/1 C
5. Type of serum: HS + DW5%
1. Serum DW5% ? cc + 30meq kcl + 112meq NaCl ⇒ 1/2 in 8 hours and 1/2 in 16 hours
6. for each time defecation ⇒ 10cc/kg cc from HS + DW5%
7. for each time vomiting ⇒ 4cc/kg cc from serum N/S 1 lit + 10meq/lit kcl
2. N/V
1. Amp ondansetron 4mg IV (0.15mg/kg)
1. or Amp plasil 10mg IV (0.1-0.2 mg/kg)
3. Abdominal pain
1. Amp hyoscine #1 IM
1. or Amp dicyclomine #1 IM
2. or Tab dicyclomine 10 mg qid #20
3. or Elixir dicyclomine 10mg qid #1
4. Inflammatory diarrhea ⇒ use Ab therapy
1. >48 hrs
2. bloody
3. >40 C fever
4. >50 y/o and severe abdominal pain
5. tropical passenger
6. >70 y/o
7. immunodeficient
8. severe watery diarrhea (vibrio)
9. chef or hospital staff
5. Ab therapy
1. Tab ciprofloxacin 500 mg #6 po bid
2. for pregnancy and <18 y/o
1. Tab azithromycin 500 mg #3 qd
3. or
1. Amp ceftriaxone 1 gr IV stat
2. Amp Apotel 1gr IV stat
4. for Giardia, Amebic
1. Tab metronidazole 250 mg #20 tds
5. if Hx of Ab therapy or suspicious of C. diff
1. Tab metronidazole 500 mg tds #30
1. or Vial vancomycin 1gr #10 PO
2. Cap familact #60 BID
6. Non-inflammatory diarrhea
1. Tab loperamide 2mg po #8, 2tab stat, 1tab/defecation, max 8 tabs
1. or Tab diphenoxylate and atropine #8 q6h for 2 days
7. Pro-biotics in 2 hours post Ab therapy
1. Cap familact #60 bid for adults
2. Drop Pedilact 5 drops bid (1m/o-2y/o)
3. Sachet Kidilact BID (mixed with food)
8. PO hydration
1. Mild:
1. Powder ORS 50cc/kg in 4 hours
2. Moderate to severe
1. Powder ORS 75cc/kg in 4 hours
3. Handmade ORS: 4 tea spoon of sugar + 1/2 tea spoon of salt in 1 lit H2O
9. Fever + N/V + Inflammatory diarrhea
1. Amp ondansetron 0.15mg/kg
2. syrup acetaminophen 10-15mg/kg qid
1. or amp acetaminophen 150 mg IV stat
3. Syrup zinc sulfate 5mg/5ml 0.5mg/kg bid
4. syrup azithromycin 120mg po start then 60 mg po qd for 4 days
10. Check
1. S/E, S/C
2. U/A, U/C
3. CBC, diff
4. B/C
5. NA, K, BUN, Cr
Diaper Rash
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1. Treatment
1. oint zinc oxide 2% #1 PRN
1. or Powder sucralfate #1 PRN
2. Oint hydrocortisone 1% bid #1
3. For bacterial infection:
1. Oint mupirocin 2% bid #1
4. For candida infection with satellite lesions
1. cream clotrimazole 1% bid #1
1. or oint nystatin bid #1
2. or cream ketoconazole 2% bid #1
2. do not use steroids with anti fungal
3. if after 3 days of treatment with anti biotics, the pt is still symptomatic with new satellite lesions, treat candida
4. DDx: millia
1. keratin pearl
2. no need for treatment
Diabetes mellites
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1. Diagnostic criterion:
1. FBS>126
2. HbA1c>6.5
3. 2hpp>200
4. Random BS>200 + typical symptoms
5. if one is positive, repeat it or use two of them to confirm diagnosis
2. Treatment
1. Tab metformin 500 mg qd #30 (increase every 2 week about 500 mg daily, max dose/day 2 gr)
2. Tab gliclazide 30 mg #30 before meal
3. or Tab sitagliptin 50 qd #100
4. Tab Zipmet (Metformin + sitagliptin) 50/500 or 50/1000 mg
3. Insulin
1. start when after triple therapy:
1. BS is not well controlled
2. GFR<30
3. high Cr
4. FBS>250 from beginning
2. Start with 0.3-0.4 u/kg
3. Vial insulin regular
4. vial insulin NPH
4. Goal of treatment
1. FBS<130 check every 2 weeks
2. HbA1c<7 check every 3 month
3. 2hpp<180
Depression
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1. All choices for prescription:
1. SSRIs:
1. Cap Fluoxetine (Prozac) 10, 20mg, and syrup 20mg/5ml
1. Contraindicated in
1. DM
2. Seizure poorly controlled
3. CKD
4. Liver disease
2. side effects:
1. headache
2. anxiety
3. anger
4. xerostomia
5. N/V
6. GI upset
7. sleep problem as بیخوابی
3. in Breast feeding and pregnancy, with measuring advantages V.s disadvantages
2. Tab sertraline (Asentra, Zoloft) 25, 50, 100mg
3. Tab Citalopram (Celexa) 20, 40mg
4. Tab Paroxetine 10, 20, 30mg
5. Tab Escitalopram (Lexatal) 5, 10, 20mg
2. SSRIs have drug interaction with methadone
2. How to choose:
1. young, no PMHx, lack of energy
1. Cap fluoxetine 10mg #100 qd at morning
2. with PMHx and DHx:
1. Tab Asentra 25mg #100 qd
1. or Tab Lexatal 5mg #100 qd
3. postnatal depression
1. Tab Prozac 10mg #60 qd
4. for impotence:
1. Tab sildenafil 50mg #30 1hour before intercourse
2. Tab bupropion 75,100, 150mg #30 qd
3. Refer if:
1. no proper care
2. misdiagnosis
3. need for paraclinic
4. possibility of homicide or suicide