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1. Treatment
1. Elixir diphenhydramine 12.5mg/ml #1 before sleep one spoon
1. available for >2y/o and pregnant
2. Tab melatonin 3 mg 1/2 tab before sleep #10 for children
3. For intermittent sleep
1. Tab lorazepam 10 mg qhs#30
2. or tab zolpidem 5mg qhs #30
4. For pt who cannot start sleep
1. Cap flurazepam 15 mg qhs #30
2. or Tab flurazepam 30 mg qhs #30
5. Tab doxepin 10 mg qhs #30
2. D/C drugs after 2-3 weeks of use and correction of sleeping
3. Do not D/C benzo without tapering
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1. High risk group
1. icterus in first 24 hours
2. >15% direct bili
3.
1. Check
1. Bilirubin Total and Direct
2. CBC, diff
3. retic count, Blood group and Rh (infant and mother)
4. PBS
5. G6PD
6. Direct coombs
7. TSH, T3, T4
8. U/A, U/C
9. BS
2. Prolong Icterus
1. >2 weeks in term
2. >3weeks in preterm
3. Deciding for phototherapy or blood exchange is on specialists
1. BP > 140/90
if age>60 y/o ⇒ BP > 150/90
2. if there were any secondary cause for HTN, refer the pt to specialists otherwise, start treatment
3. Check:
1. CBC, BUN, Cr, Na, K, Ca U/A
2. TSH, FBS, TG, CHOLESTROL, LDL, HDL
3. URIC ACID, Urine Alb/ Urine Cr
4. CXRAY, ECG
4. First line treatment
1. ACIs
1. tab captopril 25, 50 mg bid, tds, qid
2. tab enalapril 5, 10 mg bd, qd
3. tab lisinopril 5, 10 mg bid, qd
2. ARBs
1. Tab losartan 25, 50 mg qd or bid
2. Tab valsartan 40, 80, 160 mg qd
3. CCBs:
1. Tab amlodipine 5 mg qd
2. Tab Diltiazem 60, 120 mg qd
4. Thiazide:
1. Tab Hydrochlorothiazide 50 mg qd
5. check BP after starting medication in 2-4 weeks
6. if started ACE/ARBs, check Na, K, BUN, Cr after one week
7. Goal of treatment BP<130/80
8. After using 3 drugs, if BP is not controlled, refer the pt for secondary causes
9. Combined Pills:
1. tab Losamix-H 50/12.5 mg (losartan, thiazide)
2. tab Valtizide 80/12.5 or 160/12.5 (Valsartan, thiazidde)
3. Tab valfort 5/160/12.5 (Amlodipine, valsartan, thiazide)
10. Tab Indapamide 1.25, 2.5 mg qd
1. another thiazide
2. less side effects than hydrochlorothiazide
11. If Cr>1.5 and GFR<30 ⇒ do not use Thiazide
12. ACIs may cause cough but resolves after 1 month of cessation
13. If Heart failure + Pulmonary edema + HTN
1. ACIs or ARBs
2. Tab frusemide (Lasix) 40 mg bid #30
14. If Angina or LVF is present use b-blockers
1. Tab metoprolol 50, 100 mg bid #60
2. do not use in
1. heart block
2. asthma
3. COPD with active wheezing
4. HR< 55 bpm
5. Pt follow-up
1. side effects:
1. Angioedema in ACIs
2. hyperkalemia in ACIs or ARBs
2. orthostatic hypotension
6. Urgent HTN: high BP without end-organ damage
Emergency HTN: high BP with end-organ damage
7. Emergency HTN treatment
1. IV drugs
2. Reach goal in 48 hours
3. start po drugs in 6-12 hours
4. in 2-4 hours, reduce 25% of BP to reach 160/100
8. Urgent HTN treatment
1. repeat BP check in 30 minutes
2. if still high, start Po drugs:
1. captopril
2. amlodipine
3. hydrochlorothiazide
3. after BP reaches <180/120, discharge with PO drugs and re-visit in 1-7 days
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1. Treatment
1. Lotion Calamine D bid
2. Tab vit c daily
3. Tab hydroxyzine 25mg bid
4. Solution aluminum chloride 20% qhs for 7 nights, wash hands in the morning, after treatment weekly only
5. tab oxybutynin 5 mg 1/2 tab bid
6. tab propranolol 10 mg bid #30
#
1. DDx:
1. Inferior MI
2. CNS problems
2. Treatment
1. Amp chlorpromazine 50mg/2cc IM #1
1. or tab Chlorpromazine 25mg qid #25
2. or Scored tab baclofen 10 mg qid #30
#
1. Migraine
1. Treatment:
1. tab Ibuprofen 400 mg q8-12h #30
2. or tab diclofenac 50-100 mg q8-12h #30
3. or Tab naproxen 250 mg q8h #30
4. tab metoclopramide 10 mg q12h #20 if N/V
5. if not controlled:
1. tab sumatriptan 50 mg #20
2. or Nasal spray sumatriptan 20 mg #1 (for age 12-17 y/o start with spray 10 mg)
3. or Amp sumatriptan 6 mg SQ #1
6. if recurrent:
1. Tab ergotamine with 1-2 mg #30, 2 tab stat repeat q30min (max 6 tabs)
7. Combined pills:
1. tab Treximet (Sumatriptan + naproxen) 85-500 mg q6h #30 for age >12 y/o
2. Tab Novafen q6h #30
3. Tab Excedrin q12h #30
2. Emergency treatment
1. Amp ketorolac 30 mg IV
2. Amp metoclopramide 10 mg IV + Amp dexamethasone 4-8 mg IM
3. Prophylaxis:
1. Tab propranolol 20 mg q12h #60
2. or Tab metoprolol 50-100 mg q12h #60
3. Tab amitriptyline 10 mg qd #60
4. if not controlled at all ⇒ REFER the PT
1. Tab Na-valproate 300-1000 mg bid
2. or Tab Topiramate 25 mg qid or 50 mg bid
2. Tension headache
1. Treatment:
1. tab Ibuprofen 400 mg qid #30
2. or tab Naproxen 250 mg tid #30
3. or Tab ACA qid #30
4. or Tab Ergotamine C 1-2 mg #30
2. prophylaxis
1. tab amitriptyline 10-150 mg qd
3. Cluster headache
1. O2 therapy
2. Amp sumatriptan 6mg SQ
3. Discharge the pt with
1. Tab verapamil 80 mg q8h #40
2. tan Naproxen 250 mg q8h #30
3. Tab prednisolone 50 mg #15 taper in 2 weeks
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1. Migraine Headache
1. treatment
1. Amp ketorolac 30mg IM
2. Amp betamethasone IM
3. Serum N/S 100cc IV
4. Tab Naproxen 500mg #30 q8h
5. Tab sumatriptan 50mg #10, 1 pill in headache, 1 pill 2 hrs later if still + headache
1. or Tab ergotamine-c 1-2mg #30, 2 tabs if headache
2. Prophylaxis
1. Tab inderal 20mg bid
1. or Tab amitriptyline 10mg qhs
2. Tension headache in pregnancy
1. Tab acetaminophen 500mg #30 q8h
2. Amp apotel 1gr in 500cc N/S IV slow infusion
3. check BP is crucial
3. Red Flags
1. Trauma specially in last 3 days
2. decreased LOC
3. High grade fever
4. Neurologic deficit
5. on Narcotics
6. Worst ever headache
4. If referred the pt, do not prescribe anything
5.
#
1. emergency CT scan without contrast in:
1. GCS<13
2. GCS<14-13 if no cure in 1-2 hours
3. base skull Fx sign and symptoms
4. GCS<15 with severe constant headache, vomiting, 2 times seizure at least, penetrating Fx, focal neurological deficit
2. emergency CT in children if:
1. >3 times vomit or seizure
2. <1 y/o with GCS<15 or >1 y/o with GCS<14
3. >1 hr of amnesia
4. >5 cm sign of Fx or laceration
5. >40 km/hr crash or >1 m fall
#
1. warming the pt. with 37-39 C water
2. avoid dry heat
3. Tetanus vaccination and AB therapy
#
1. Orders:
1. Neck x-ray AP and lateral
2. Chest x-ray AP and lateral
3. Abdominal x-ray
4. CT scan if the object is radiolucent
5. For magnets:
1. Endoscopy in 12 hours
6. For batteries
1. double density on x-rays
2. upper endoscopy in 2 hours
7. Other objects, endoscopy in 24 hours if
1. obstruction
2. no move in 24 hours
3. no passage through esophagus
8. in stomach and bowel, do surgery or endoscopy if:
1. >4weeks
2. >5*2.5 cm (>3cm for children)
3. abnormal bowel picture
4. >1week in one section
5. for batteries in stomach, do endoscopy if:
1. diameter >2cm
2. ≥ 2days in stomach
3. N/V and abdominal pain
9. Sharp objects, do endoscopy ⇒ if ≥3 days stay in one place
#
1. Approach
1. exam with slit lamp
2. for anesthesia
1. Drop opht tetracaine 0.5% 1-2 drop SD
3. discharge if does not penetrate into globe with:
1. oint opht erythromycin 0.5% #1 qid
2. drop tear opht artificial 0.5% #1 qid
3. drop opht sulfacetamide 10% #1 qid 2drops