QR Klinik Kesihatan Setting, by Dr Gerard Loh
DM
Basal Insulin
s/c Insulatard/Humulin N - start 0.1 U/kg or 10U ON
FBS Mx
<4 Reduce 2U
4-6 Maintain Dose
8-12 Increase 2U
>12 Increase 4U
* switch to Biphasic insulin when total dose >25units or 0/4U/kg/day
Biphasic Insulin
s/c Mixtard 30/70 – start 0.4IU/kg/day : 2/3 prebreakfast, 1/3 predinner
T4 TSH
Hyperthyroidism Raised Low
Subclinical Hyperthyroidism Normal Low
Hypothyroidism Low Raised
Subclinical Hypothyroidism Normal Raised
Hyperthyroidism
History: Physical examination:
-weight loss despite good appetite -goitre (usually with/without bruit) in Graves’ disease
-excessive sweating especially at night, in cold weather -proximal muscle weakness, hyperreflexia
-warm, sweaty palms
-excitability, irritability, tremulousness
-fine finger tremors
-palpitations -lid retraction, lid lag
-resting tachycardia
*continue therapy for Initial therapy Maintenance therapy
1-2 years. for 4-6 weeks (gradual reduction over
3-6 months from initial dose)
Carbimazole 30-45 mg/day 5-10 mg/day
Propylthiouracil 300-450 mg/day 50-100 mg/day
Beta-blockers are useful for symptomatic relief initially,
provided there are no contraindications, e.g. asthma.
propranolol 30-120 mg/day
atenolol 25-50 mg/day
HYPOTHYROIDISM
Hypothyroidism is due to deficiency of thyroid hormones resulting in a hypo-metabolic state. The causes are:
Primary - autoimmune thyroid disease - thyroid agenesis, post-thyroidectomy, post-radioiodine therapy
Secondary - hypopituitarism
Clinical Features
Apathy, fatigue
* Cold intolerance Less common features are:
* Slow speech * Menorrhagia
* Facial puffiness * Hoarse voice
* Weight gain * Depression
* Constipation * Psychosis
* Coarse features
Management
Starting Dose Maintenance
L-thyroxine 50 or 100 ug/day 100 - 200 ug/day.
25 ug/day (IHD)
ASTHMA Acute mx
Sx mild Moderate Severe
Altered Consciousness - - +
Physical Exhaustion - - +
Talks in Sentences Phrases Words
Pulsusparadoxus NO +/- PALPABLE
Central cyanosis - - +
RONCHI + + SILENT CHEST
Use acc. muscles - Moderate MARKED
Sternal Retraction - Moderate MARKED
Initial PEF >60% 40-60% <40%
SpO2 >93% 91-93% <90%
OUTCOME Discharge May need admit ADMIT
Mx: 1) Neb Salb 1) Neb Combivent x 3 1) Neb Combivent x 3 / cont
< 1 yo: 0.5 : 3.5 2) O2 8L/min 2) O2 8L/min
>1yo : 1:3 3) Oral Prednisolone 3) IV Hydrocort 5mg/kg QID 1/7
or 4) IVI Salbutamol continous
MDI Salb in spacer Bolus: 5-10mcg/kg/10mins, then
4-6 puffs (<6yo) Infusion: 0.5-1mcg/kg/min
MDI 8-12 puffs ( >6yo) 5mg in 50ml
ventolin 200mcg 2 puff 1amp = 0.5mg (5mcg = x 10amp)
PRN 2) Oral prednisolone 0.6ml/kg = 1mcg/kg/hr
Fluticasone 125mcg 2 puff SyrPred 1mg/kg/day max 20mcg
BD for 3-5/7
Budesonmide 125mcg BD * S/C Bricanyl (terbutaline)
Seretide 25/125 1 puff BD Reasses after 60mins Reasses after 60mins 0.005-0.01mg/kg (max 0.4mg) every
Qvar 100mcg BD if no improvement if no improvement, 5-10mcg/kg
Tx as moderate Tx as severe 15-20mins
Montelukast /singulair 4mg
granules * IV MgSO4 50%
(Chew @8pm) Bolus: 0.1ml/kg(50mg/kg) in 20mins
IV hydrocort 4-5mg/kg *IV Aminophyline
QID for 1/7, Bolus:6mg/kg bolus then
then change to Infusion: 0.5-1.0mg/kg/hr
Syr Prednisolone
1-2mg/kg OD for 5/7 *Mechanical ventilation and observation in
HDW/ICU
Classification
1) Intermittent : - EIA
2) persistent : + EIA, + need for prophylaxis MDI
Degree of Asthma severity
Intermittent Mild persistent Mod Persistent Severe Persistent
Daytime sx < 1x / week > 1x /week Daily Daily
Nocturnal sx <1x / month >2x / month >1x / week Daily
EIA - + + Daily
Exacerbations Brief > 1x / month > 2x / month >2x /mo frequent
Not affecting sleep Affect sleep/activity Affect sleep/activity Affect sleep/activity
PEFR/FEV1 Normal lung fn >80% 60-80% < 60%
GINA – Level of asthma control (after starting MDI)
Controlled Partly controlled Uncontrolled
Daytime sx - > 2x / week > 3 of partly controlled
Nocturnal sx - + features
Limit activities /EIA - +
Exacerbations - > 1 / year
Lung Fn test Normal < 80% predicted best
Need for reliever - > 2x / week 1 in any week
Peak Expiratory Flow values for Optimal Asthma Control
Predicted Mean Values for Healthy Adults
FEMALE
1.4m 1.45m 1.5m 1.55m 1.6m 1.65m 1.7m 1.75m 1.8m
16/25 358 377 395 414 433 451 570 469 508
30 348 366 385 404 422 441 460 478 497
35 337 356 374 393 412 430 449 468 487
40 327 345 364 383 401 420 439 457 476
45 316 335 353 372 391 409 428 447 466
50 306 324 343 362 380 399 418 446 455
55 295 314 332 351 377 388 407 426 445
60 285 303 322 341 359 378 397 415 434
65 274 293 311 330 349 367 386 405 424
70 264 282 301 320 338 357 376 394 413
75 253 272 290 309 328 346 365 384 403
80 243 261 280 299 317 336 355 373 392
85 232 251 269 288 307 325 344 363 382
MALE
1.5m 1.55m 1.6m 1.65m 1.7m 1.75m 1.8m 1.85m 1.9m
16 438 456 474 492 509 527 545 563 581
18 493 511 529 547 564 582 600 618 636
20/25 536 554 572 590 607 625 643 661 679
30 525 542 560 557 595 612 630 647 665
35 513 531 548 565 582 599 616 633 650
40 502 519 536 553 569 586 603 619 636
45 491 507 524 540 556 573 589 606 622
50 480 496 512 528 544 560 576 592 606
55 468 484 500 515 531 547 582 578 593
60 457 472 488 503 518 533 549 564 579
65 443 468 483 498 513 528 543 558 573
70 435 449 464 478 493 507 522 536 551
75 523 438 452 466 480 490 508 522 536
80 412 426 440 453 467 481 495 508 522
85 410 414 428 441 454 468 481 495 508
AGE
Acute GastroEnteritis
Abdomen turgor General Condition Eyes sunken, Turgor
Signs of shock = Tachycardia, weak peripheral pulse, delayed CRT, cold peripheries, depressed mental state
Assess
General Condition Well, alert Restless, irritable Lethargic, unconscious
Sunken eyes - + +
Offer Fluid Drinks normally Drinks eagerly, thirsty Not drinking, poor
Pinch skin (abdomen) Skin goes back immediately Skin goes back slowly Skin goes back slow >2sec
DEHYDRATION MILD (<5%) Moderate (5-10%) Severe (>10%)
Treatment Plan A (Tx at home) Plan B Plan C
- Give extra fluid (ORS/H20) - Give ORS over 4 hours - Start IVD immediately!
- Cont feeding on demand - Reassess after 4 hours
- Return when poor oral intake,
fever, bloody stool
ORS 8 sachets at home ORS over 4 hours 0.9 % NS bolus 20ml/kg then reassess
<2 yo : 50-100ml after BO <6kg : 200-400ml Correction +maintenance
>2yo : 100-200ml after BO 6-10kg : 400-700ml
- give frequent small sips frm 10-12kg : 700-900ml
cup/spoon 12-19kg : 900-1400ml
* if vomit, wait 10mins then give
slowly (1 spoon/2-3mins)
AMENORRHOEA
ACUTE PHARYNGITIS
RHINOSINUSITIS
ACUTE OTITIS MEDIA
RHEUMATOLOGY
Rheumatoid Arthritis
HFMD
Anti HPT CVS Asthma
Amlodipine 2.5/5/7.5/10mg OD Imdur-Isosorb monoN, 30/120mg OD MDI Ventolin 200mcg 2puff PRN
Adalat 10-30mg tds ASA 75/150mg OD MDI Qvar 100mcg BD (beclomethasone)
Felodipine 5-10mg OD Clopidogrel 75mg OD MDI Atrovent 40mcg TDS (Ipratrop. bromide)
Ticlopidine 250mg BD MDI fluticasone 125mcg BD
Diltiazem 30-60mg TDS
Carvedilol 3.125/6.25/12.5/25mg BD Accuhaler seretide 25/125, 50/250, 50/500 BD
Metoprolol 50/100/150 BD Digoxin 0.25-0.5mg OD (salmeterol/fluticasone)
Atenolol 50/100mg OD
Antilipids Turbohaler symbicort 160/4.5 or 320/9 mcg BD
Lovastatin 20-80mg ON Simvastatin
HCTZ 12.5/25mg OM (budesonide/formoterol)
10-20-80mg ON Atorvastatin 10-
Lasix 40-80mg OD
80mg OD Lipitor
Gemfibrozil 600mg BD lopid T Neulin SR 250mg BD
Perindopril 2/4/6/8mg OD
Enalapril 5-20mg BD
Antibx Peds Anti Hpt Peds Asthma peds
Syr Augmentin 18mg/kg BD Syr Nifedipine 0.25-0.5mg/kg Syr prednisolone 1mg/kg OD
Syr Amoxicilin 15mg/kg Syr Captopril 0.1-0.5mg/kg (up to Syr Salbutamol 0.1mg/kg TDS
Syr EES 20mg/kg BD 1mg) Singulair Granules 4mg ON
Syr Pen V 15mg/kg QID Syr/IV Frusemide 1mg/kg OD/QID Syr Bromhexine 0.3mg/kg TDS
Syr Spironolactone 1mg/kg BD
Syr Cefuroxime 15mg/kg QID Bromhexine / Syr Actifed
Syr Clarithromycin 10mg/kg BD > 12 yo : 10ml , 6-12 yo : 5ml
Syr Unasyn 15mg/kg BD 2-6 yo : 2.5ml , < 2 yo : 1.25ml
Syr Azithromycin 15mg/kg (Day1)
7.5mg/kg (D2-5) OD Syr Piriton 0.1ml/kg (CI < 2yo)
Combination drugs Skin GIT peds
Cozaar = Losartan ; 5/50 Calamine lotion Syr Domperidone 0.25mg/kg TDS
(amlo+losartan) Fungal-miconazole cream Syr Omeprazole 0.4mg/kg BD
Scabies-Benzyl Benzoate 25% ON 3/7 Syr Ranitidine 2mg/kg, IV ranitidine 1mg/kg
Hyzaar = Losartan + HCTZ; Hydrocortisone cream 1% Syr Lactulose 0.5ml/kg
100/12.5 Neomycin 0.5% ORS 10ml/kg
Betnovate Cream
Syr Folate 500mcg/kg/day
Exforge = Amlo/Valsartan Acryl Flavin
Syr Fe fumarate 80-140mg BD
5-10/160
Antihistamines Eye drops Ear drops
Loratadine 10mg OD Chloramphenicol eye drops CMC ear drop
Piritone 4mg TDS Artificial tears impacted wax Cerumol
Decongestant – Actifed 1/1 tds Eye Glo (Dacrolux hypromellose
0.3%)
Antibx Analgesics Misc
Bactrim 11/11 BD Voltaren 50mg tds Xray KUB: liquid paraffin 30ml ON +
Bacampicilin 400mg BD Paracetamol 1g QID T Bicasodyl 1/1 BD 2/7
Amoxicilin 500mg TDS Celebrex 200mg BD
EES 400mg BD LMS cream Vaginal candidiasis- Canestan Pessary 1/1 ON
Cloxacilin 250-500mg QID Vertigo - Stemetil 5mg tds
Flagyl 400mg TDS Papase 1/1 BD Parkinsonism- Sinemet 100/25mg TDS
IM Benzathine Pen. 2.4 MegaU
Colchicine 0.5mg TDS/till purge Gout - allopurinol 150mg OD
Doxycycline 100mg OD
Augmentin 625mg BD
