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Steps for Patient Management

Steps for Patient

Management

a comprehensive manual for medical students

Dr. Soran Mohammed Gharib

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Dr. Soran M. Gharib

2015

Cover and interior design: Mardin Uzeri

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All rights are reserved.No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission of the author.

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Dr. Soran M. Gharib

In The Name of God

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The Hippocratic Oath swear to fulfill, to the best of my ability and judgment, this covenant:I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to

follow.I

will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife

or the chemist's drug. I

will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery. I

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Dr. Soran M. Gharib

will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. I must tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this

responsibility must be faced with great humbleness and awareness of my own frailty.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and

economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure. I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as

the infirm. I

f I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to

preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

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About this bookletDear student, this booklet you are holding in your hands is the accumulative fruition of nearly a decade’s earnest endeavor. I have been in charge of serving medical students for quite a time now and never lost rejoices and enthusiasm hitherto.

This booklet employs a bulletin based approach and attempts to funnel what I regard as practical and useful into your ever expanding realm of medical knowledge.

I have prioritized quality over quantity. The content has been condensed as much as essentiality permits. As an experienced practitioner, I have filtered the boundless dimensions of clinical basics into a comprehensive guide that will provide you with the confidence you need towards a successful medical career.

Dr. Soran M. Gharib

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Dr. Soran M. Gharib

About The AuthorInternist-Rheumatologist

Medical Doctor ( MD, MBChB)Internist ( Member of American college of

Physician)ACPMember of (American college of Rheumatology)ACRMember of BSR ( British Society for Rheumatology)

Mini- MBA ( Cambridge international college )Member of Importer & Exporter Union Kurdistan

Region of IraqCertificate In medical LASER therapy ( USA)

Diploma In HR Management07702142283

[email protected] : Soran Mohammed Gharib

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TABLE OF CONTENT

History Taking……………………….………..

……….11

General Physical Examination…….………..

……..21

Investigation………………………………………

….…28

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Dr. Soran M. Gharib

Treatment……………………………………..

…………31

Common Diseases…………………………..

………..39

Injection …………………………………………..

…….51

Cannulation

…………………………………………….52

Stomach Tube (NG ) Tube………………….

……….53

Main Types of Infusion Fluids…………………..…54

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References…………………………………………….…55

Other Products of the Author ………………….…56

Patient management Steps In Medicine

1. History taking

2. Physical Examination.

3. Investigation (according to differential diagnosis).

4. Diagnosis.

5. Treatment.

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Dr. Soran M. Gharib

History TakingIntroduction

From the very moment you see the patient, it is crucial to show professionalism and establish a first impression that evokes a feeling of comfort and trust. From here onwards, the patient will be more inclined to corporate and provide you with precise responses.

Keep the following tips in mind:

Always greet the patient

Alertness; from the moment you first see the

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patient you should employ your eye, ears, nose and hands in a systematic fashion to collect the information

tell the patients your name and why you are talking to them

Always give the patient your whole attention and never take shortcuts

Try to observe the patient’s walk (gait) in the room. Experienced practitioners can suspect and foresee certain conditions such as thyroid diseases, hemiplegia, cyanosis and other symptoms and signs by a mere look at how the patient walks

You may meet a patient who cannot talk your language. When conducting an interviewed through an interpreter, keep your questions short and simple and have them translated answered one at a time.

All question should not be asked in the leading way, so patient is left with a free choice of answers, e.g. if you say, “the pain moves to the right hand sides, doesn’t it?” So the patient may answer you yes, just to please you, but the question should be, “does the pain ever move?” and “where does it go?”

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Dr. Soran M. Gharib

How to Take the History

1- NASOR

This acronym sums up the most basics information to be gathered from your patient.

Name: should be triple name Age: in years Sex: male or female Occupation: brief description of job Residence (location): where (s)he lives

You may also ask about blood group, marital status

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and religion.

2-Chief Complaint and Duration

The chief complaint is the driving factor that makes the patient visit the hospital. Use short accurate questions to acquire the singular main reason the patient decided to visit you.

3- History of Present Illness

A-Pain

Pain is the unpleasant sensation of varying intensity. Tenderness may be assign detected by doctors or may be a symptom detected by the patient when he feels painful area.

Ask about the following to investigate pain:

SiteThe site describes the location and depth of the painful area. This is the most important factor to indicate the source of the pain. The patient may not be able to point out the exact site of the pain. Also ask the patient about the depth of the pain, common responses are superficial or deep.

SeverityThis is how strongly the patient perceives the pain. Does the pain stop the patient from going to work? Or keep him awake at night? Pain severity is frequently expressed in terms

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Dr. Soran M. Gharib

of mild, moderate, and severe.

Aggravating FactorsAnything which make the pain worse (e.g. exercise)

Relieving Factors Anything which make the pain better (e.g. rest, heat)

Diurnal Variation How does the pain behave in a 24-hour time span? For instance, some pains worsen at night and alleviate during day time.

Radiation Some types of pain move within a repeating pattern, with the origin of the pain prevailing. For example, Sciatica is lower back pain that radiates down the leg and into the foot.

Shifting (Referred) Painorigin of pain is in one site later pain shifts to another site and pain at original site disappears.

Associated Features Is the pain correlated with any other condition?For example, abdominal pain may be associated with vomiting.

Onset TimeDescribes the elapsed time period before the pain causes discomfort; usually addressed in

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terms of sudden and gradual.

Nature of the PainSpecifies how the pain is felt. (e.g. burning pain, throbbing pain, stabbing pain)

B-Vomiting

The following details must be deduced through methodical inquiry:

1. Frequency(more than 5 times a day should be admitted)

2. Color3. Contains blood or not

Does it contain blood?4. Associated with diarrhea or not

C-Diarrhea

Ask about how often the patient defecates. You should ask about frequency defecation, colors, consistency with clear concise questions. If it turns out that the patient has diarrhea, make sure you know the following details:

1-Frequency2-Color3-Contain mucus or not4-Associated with vomiting or not

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Dr. Soran M. Gharib

5-Amount6-Contain blood or not (important!) If the feces contain blood, ask further questions about the characteristics of the blood. Fresh blood originates from the lower GIT, dark blood from the upper GIT.

Investigations are done via a General Stool Examination (GSE).

D- Fever and Rigor

If the patient has a fever, it usually fits one of these categories:

Continuous: always high. Remittent: sometime becomes low but never

reaches baseline temperature. Intermittent: high temperature, then reaches

baseline.

E- Dehydration

Dehydration is usually associated with the following signs and symptoms:

1. Absence of tears2. Dry tongue3. Loss of skin elasticity4. Increased pulse rate 5. Decreased BP6. Decreased urine output

Tarry (dark) stool

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4- Review of body systems

GIT, Respiratory, CVS, Urinary and Genital, CNS

A-Gastrointestinal Tract (GIT, Elementary System)

AppetiteIncreased, decreased or unchanged?

Diet Weight Vomiting Diarrhea

B-The Respiratory System

CoughHow often does it come? Does it come in certain posture? Is it dry or wet?

SputumIts quantity, color, smell, taste

Hemoptysis Mean presence of blood in sputum

Dyspnea Cyanosis

C- The Cardiovascular System

Breathlessness (dyspnea)(like in respiratory system)Orthopnea: is the dyspnea occurring when lying flat. While paroxysmal nocturnal dyspnea is a sudden attack of dyspnea in the middle of the night which awakens the patient.

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These forms of dyspnea are commonly seen in the heart disease.

PainCardiac pain is retrosternal or sometimes epigastric which may radiate to the neck or left arm. Its natures usually constricting,, it’s usually related to exercise.

PalpitationEpisodes of tachycardia experienced by the patient or fluttering of the heart

Cough Sputum

(same as respiratory system)

D- The Urogenital System

ThirstHow often does the patient become thirsty? Does (s)he drink excessive water?

MicturitionHow often does the patients pass urine? Is it painful? Nature and site of the pain?

UrineIs there any blood in the urine? Color? Smell? Quantity?

E-The Nervous System( CNS )

Any history of stroke? Changes in the sense of smell, vision, or hearing?

Peripheral nerves; ask about paralysis or weakness, any loss of cutaneous sensation of the pain, touch, temperature, presence parathesisea (tingling) in the limbs.

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5-Past medical history

In a medical encounter, a past medical history (abbreviated PMH), is the total sum of a patient's health status prior to the presenting problem. (e.g. hypertension, diabetic)

6-Past surgical history

Have any operations been done previously? When? Which operation? Did it have complications?

7-Drug history

Has the patient taken any drugs? How often? Any reported allergies towards specific drugs?

8-Family history

Are any diseases running in his or her family? (e.g. hypertension)

9-Socioeconomic history

Ask about marital status, smoking, drinking alcohol, about unusual eating habit? Also ask about their source of their water and whether they keep animals at homeGeneral Physical Examination

1. You should be on the right side of the patient.

2. Is the patient conscious or not?

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Dr. Soran M. Gharib

3. Comfortable or not?4. Cooperative or not?5. Orientation of patient for time, place &

person?

Vital Signs

Vital signs are measurements of the body's most basic functions. The four main vital signs routinely monitored by medical professionals include the following:

1. Pulse rate Normal range: 60-100 bpm

2. Blood Pressure Normal range: 120-80 mmHg

3. Respiratory rate (RR) Normal range: 16±2 breaths per minute

4. Temperature Normal range: 37±0.4 °CThe temperature in the axilla= temp. + 0.5The temperature in the rectum= temp. - 0.5

Examination of the mouth

1- Cyanosis: a bluish discoloration of the skin resulting from poor

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circulation.

There are 2 types of cyanosis: Central cyanosis (on the tip of tongue and lips) Peripheral cyanosis (on the tip of the fingers)

2- Pallor: pale color of the skin.We carefully examine the color of the tongue.

3- Jaundice: Is a yellowish discoloration of the skin or conjunctiva. In mouth We look at the frenulum.

Examination of the neck

We examine the thyroid gland and the following lymph node groups through gentle palpation:

Submental Submandibular Preiauricular

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Dr. Soran M. Gharib

Postauricular Occipital Supraclavicular Cervical

Hand examination

Pallor(by comparing it with your hand)

Clubbing is a deformity of the fingers and fingernails associated with a number of diseases, mostly of the heart and

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https://en.wikipedia.org/wiki/Heart_disease

https://en.wikipedia.org/wiki/Nail_(anatomy)

https://en.wikipedia.org/wiki/Finger


lungs.We test the angle of the nail to determine the presence of clubbing.

Peripheral cyanosis Tremor (Fine, Resting, Flapping)

Resting tremor mostly indicates Parkinson’s disease. However, a flapping tremor is usually found in heart, renal, and liver failure.

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https://en.wikipedia.org/wiki/Lung_disease

Dr. Soran M. Gharib

Lower limb examination

Clubbing Cyanosis Edema (Unilateral or Bilateral)

Pitting edema is examined by the Rule of One; that is pressing the thumb for one minute against the area behind the medial malleolus and depressing the skin one

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centimeter. If the depression persists, the test is positive.

If the swelling is present in both limbs, it is called bilateral edema. The main causes of bilateral edema are heart failure, liver failure and renal failure.

Bilateral edema with swelling of the face is caused by renal failure.

An increase in the pulsation of the jugular vein (jugular pulse) with bilateral edema is caused by heart failure.

Lymph node obstruction causes unilateral edema.

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Investigations

1-Blood investigations:-

Hb%normal range: 11-18%

P.C.V normal range: 42±5%

WBC normal range: 4000-11000 cells/μL

ESR normal range: 0-15 mm/hrHigh levels of ESR means either malignancy or severe inflammation

Blood group

2-Random Blood Sugar (RBS)normal range: 60-180 mg/dL

3-Fasting Blood Sugar (FBS)normal range: 60-150 mg/dL

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4- Renal function test (kidney function test) Urea à normal range: 15-45 mg/dLSerum Creatinine à normal range: 0.1-1.2 mg/dL

5- T.S.B (Total Serum Bilirubin)normal range: 0.1-1.2 mg/dL

6- S. Cholesterol normal range: 150-240 mg/dL

7- S. Triglyceridenormal range: 60-190 mg/dL

8- G.S.E (General Stool Examination)

9-G.U.E (General Urine Examination)

10- PT pregnancy test either positive or negative

11- IGg & IGm (for salmonella) either positive or negative

13- Rose Bengal test either positive or negative

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Radiology

The most common radiologic diagnostic tools include:

X-Ray

C.T. scan

MRI

Others: Ultra Sound U/S

ECG

Treatment :

Drug Forms30


Tablet

Capsule

Ampule

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Dr. Soran M. Gharib

Vial

Syrup

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Suppository

Ointment

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Dr. Soran M. Gharib

Drops

Pain killers (Analgesics)

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1-Paracetamol (Panadol™)

Found as ampule, tab, drop, syrup and suppository

Function of paracetamol (indication):- To relieve pain and decrease fever

Tab for mild pain. Ampoule for severe pain.

Rx (Treatment):Paracetamol tab 1x3 (10)

Paracetamol is safe in pregnancy Syrup is used for children. Suppository also for children Paracetamol suppository 1x3 Paracetamol syrup 1X3; tablespoon for adults Coffee spoon -1X3 for child Suppository is more effective than the syrup in

decreasing fever, so it is used for children with tonsillitis

2-Diclofenac Sodium (Cataflam™, Voltaren™)

Its injection is by IM (never IV) Found as ampoule, tab, suppository and

ointment Indication: Pain and spasm Voltaren is contraindicated in:

Hypertension Gastric ulcer

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https://en.wikipedia.org/wiki/Panadol_(brand)

Dr. Soran M. Gharib

Duodenal ulcer Asthma Pregnancy Its side effect is bleeding in the case of high

doses

3- Tramadol

Used for severe pain Routes of administration are IM, IV, or

subcutaneously When it is used by IV, it may lead to vomiting.

Therefore before injection of Tramal. Intravenously, you should inject Plasil (Metoclopramide) which has anti-vomiting effects. Hoverer in the case of IM, it will not lead to vomiting.

Tramal should be dispensed only on prescription

Tramal in high doses may lead to addiction It is found as ampoule and tab

4-Pethidine

Found only as ampoule Its use may lead to addiction Used by IM and IV In the case of IV, it’ll lead to vomiting, so it

should be used with Plasil It affects the brain so it may lead to slight

anesthesia and the patient may fall asleep subsequently

Used for severe pain

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Other drugs

1- Metoclopramide (Plasil™)

It’s used against vomiting and nausea It’s found as ampoule, tab (1*2 before meal),

syrup and drop (for children) Used by IM or IV

2-Furosamide(Lasix™)

It is a diuretic Found as ampoule (IM/IV), tab Used in hypertension

3-Hydrocortisone (H.C.) Found as veil. Used by IM and IV Indication

Allergy Asthma Anaphylactic shock.

Example:Rx of asthma:

1. O2

2. Vial of hydrocortisone 3. Ventolin inhaler (leads to bronchodilation)

Antibiotics Most of them are found as vial.

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Dr. Soran M. Gharib

1-Ceftriaxone

It has a very wide range of use; used for both G-ve and G+ve bacteria

Used for infections such as typhoid fever, brucellosis

Also used in pneumonitis It’s given as 1x2

2-Metronidazole(Flagyl™)

Antiparasitic Used for diarrhea Found as tab, and as bottle (500 mg), also

found as syrup

Common Diseases

Urinary tract infection ( UTI )

UTI In pregnancy (admission case)

Treatment:

1. Cannula

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2. Fluid3. Antibiotics like claforan 1x34. Analgesia like paracetamol ampule 1x2

UTI (outpatient)

Treatment:

1. Suprax capsule (400 mg) 1x12. Paracetamol tab 1x2

Influenza or flu-like illness:

The patient is commonly presented with fever, sore throat, headache, generalized body ache, runny nose, cough, bone pain, and loss of appetite.

Treatment:1. Decadrone ampule (8mg) 1x22. Voltaren ampule if it’s not contraindicated 1x1

or paracetamol ampule 3. Lortin tab or fexofenadine tab 1x14. Paracetamol tab or dolocold tab 1x35. Solvodin syrup if there is coughing with it6. Antibiotic like suprax capsule 1x1 or

azithromycine capsule 1x1 if there is bacterial infection.

Tonsillitis in children:

The child is usually presented with fever, hedache, runny nose, and sometimes with bone pain and

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abdominal pain.

Rx:

1. Ampiclox syrup 1x4 by teaspoon or azithromycine syrup 5cc x1 for 3 days

2. Paracetamol suppository or syrup 1x33. Lortin syrup 1x1 by teaspoon

Common cold in adults:

The patient comes with runny nose, sore throat, and loss of appetite.

Rx:

1. Tolux tab 1x3 or Tullin D tab 1x32. Anti-flu tab or anti-cold tab 1x33. Vicks inhaler (Eucaliptus)4. Paracetamol tab 1x35. Decadrone ampule 1x16.

Common cold in children:

• The patient come with runny nose , sore throat , loss of appetite.

Rx • 1-Tullin D syrup 1x3 or Rhinoraz Syrup 1x3• 2-lortin syrup 1x1( if you give Rhinoraz so you don’t

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need to give lortin)• 3-Paracetamol syrup 1x3

Urinary tract infection (UTI)

The patient usually comes with dysuria and pain in loin region, either unilateral or bilateral, or pain in suprapubic region over bladder.

And occasionally, the patient may have fever, rigor, vomiting or nausea.

Send for GUE and you see pus cell in GUEIf there is blood in urine better to send for abdomibal us to exclude renal stone.

You can use one or combination of the followings:

Uricole powder: Uricol effervescent granule :For UTI m stone

1. Ciprodar tablet (500 mg) 1x2;it is contraindicated in pregnancy and it should not be given to patient under age of 18.(Instead, we can use suprax)

2. Gentamicine ampule 1x23. Urisept tab 1x34. Rawatin X tab5. Paracetamol tab 1x3 or voltaren tab or ampoule

if there is no contraindication

Typhoid Fever:

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Dr. Soran M. Gharib

The patient may come with(fever, rigor and abdominal pain, generalized body ache, dizziness, muscle pain, bone pain, headache, loss of appetite, sweating) for more than one week Send for :IGg and Igm for salmonella if both positive then u decide that this is typhoid fever or at least if IGm is positive means he has typhoid fever . Blood culture (more sensitive) Treatment:

1. Paracetamol ampule or tab 1x3 2. Antibiotic such as ceftriaxone vial (1 gm) 1x23. IV fluid (1000 cc GS)4. Antipyretic (Paracetamol ampule 1x3)5. Doxydar capsule 1x2 6. Multivitamine four 1x1

Brucellosis:

The patient may come with (fever, rigor and abdominal pain, generalized body ache, dizziness, muscle pain, bone pain, headache, loss of appetite, sweating joint pain)

for more than one week send for Rose Bengal test, if it is positive so it is brucellosis.

best investigation is sending for IGg and IGm for brucella by ELISA test if positive so its brucellosis.

or you can send blood for CS.

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Treatment:

1. Ceftriaxone vial 1x2 or gentamicine (80 mg for adult, 40 mg for children) 1x2

2. Paracetamole ampule 1x23. Capsule Rifampicine 1x24. Capsule Doxydar 100 mg 1x2 5. Bactrim tab 1x2 6. Vila streptomycin 1gm 1x1 IM

Toothache:

Rx:

1. Voltaren ampule if there is no contraindication 1x1 IM

2. Voltaren or paracetamol tab 1x33. Flagyl tab 1x3 4. Amoxicillin capsule 1x35. Citrolin mouth wash 1x2 every time for 5

minutes for mouth wash and gargling. Citrolin is an antiseptic mouth wash and gargle with anesthetic properties used for gingivitis, oropharyngitis, throat infections, and tonsillitis.

6. Lidocaine spray for severe toothache.

Irritable bowel syndrome (IBS):

The patient comes with abdominal distension,

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Dr. Soran M. Gharib

abdominal pain, flatulence, constipation and sometimes diarrhea, anxiety, and nervousness.

1. Buscopan tab 1x3 2. Librax (chlordizepoxide) (5 mg) clidinium

bromide tab (2.5 mg) 1x3 before meal3. Duspatalin (mebeverine)tab 1x3 before meal4. Stelabid (isopropamide+trifluperazine)1x3

before meal5. Lactulose syrup 1x3 or bisacodyl tab 1x1 if

there is constipation with it

Diabetes Mellitus

1. Glucophage (metformin) tab (500 mg) 1x2 or

(850 mg) 1x12. Glibinclamide (daonil) tab (5 mg) 1x13. other new oral hypoglycemic tablets4. insulin (soluble and lenti)

Nausea and Vomiting

You can use one of the following according to age and severity of vomiting:

Plasil (metochlopromide) ampule (10 mg) 1x1 (IV/IM)

Plasil tablet 1x3 before meal Motilium tablet (10 mg) 1x3 or syrup before

meal Plasil drop for children; to prevent nausea and

vomiting

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1-3 years old = 10 drops x 3 3-5 years old = 20 drops x 3 5 years old = 40 drops x 3

Plasil syrup : 1x3 by teaspoon before meal for children and enterostop tab 1x3 for 5 days if there is diarrhea with it, rehydration, antibiotic on need.

Gastric pain or epigastric pain

You can give one or combination of 2 or more of the following according to the severity of gastric pain:

1. Tagamet (cimitidine) ampule (200 mg) 1x2 (IV/IM)

2. Losec (omeprazole) capsule (20 mg, 40 mg) 1x2 before meal

3. Losec vial (20 mg, 40 mg) 1x2 or as infusion4. Ranitidine (zantac) tablet (150 mg) 1x2 before

meal or zantac ampule (50 mg) IM/IV5. Maalox plus tab; for epigastric pain6. Malos syrup; for epigastric pain

1x3 tablespoon for adult 1x3 teaspoon for child

7. Gaviscon syrup; for epigastric pain

1x3 tablespoon for adult after meal 1x3 teaspoon for child after meal

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Cough Syrups

Syrup bromhexine (solvodine) syrup 1x3 by spoon for productive cough

Syrup tussileit 1x3 by teaspoon for pediatric age group for productive cough

Syrup exidil (theophylline) 1x3 by teaspoon for pediatric age group for productive cough

Syrup samilin 1x3 for adult and pediatric for productive cough

Syrup ventolin (salbutamol) (a bronchodilator) 1x3 by teaspoon for pediatric age group for dry cough

Syrup ketotifin 1x1 for pediatric for allergy for dry cough.

Syrup calmex 1x3 for adult and pediatric for productive cough.

Diarrhea and Vomiting

Investigation: send for General stool examination (GSE), S. Electrolytes , RFT, and monitor urine output. Treatment of DVD:

1. Cannula 2. IV fluid either RL (Ringer lactate), NS (normal

saline), or GS(glucose saline)3. Flagyl tab (or syrup for children) 1x3, or

ciprodar tab 1x2 or 1x3, or doxydar capsule (100 mg) 1x2 or (200 mg) 1x1

4. Plasil tab (or syrup for children) 1x3 before meal or plasil ampule 1x2

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5. Buscopan ampule (or syrup for children) for abdominal pain 1x2 or buscopan tab 1x2

Note:If vomiting occurs less than 5 times per day, there is no need for admission and no need for IV fluids, treat him as an outpatient.

Herpes Simplex (Herpes Labialis)

Skin lesions are visible on the patients lips.

1. HC Or allermine tab or syrup 1x22. Acyclovir (zovirax) tab 1x5 or ointment 1x3

Note: Zovirax eye ointment is better than skin ointment

Eye problems:

Patient may come with red, painful, and runny eyes. You can prescribe one, two, or more of the following according to the severity of the disease:

Chloramphenicol eye drop, 2 drops x3 Tetracycline eye ointment 1x1(at night) Gentamicin eye ointment 1 x1 (at night)

Acne

1. Doxydar capsule (100 mg) 1x2 after meal2. Ben oxide Gel or Lotion 1x1;Applied at night

and washed in the morning with soap3. Retane or isortin (isotretinoic acid) (10 mg , 20

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Dr. Soran M. Gharib

mg, 40 mg) 1x1 4. lincin (clindamicin) lotion 1x1 : either 1% or

2%; squeeze few drops of that solution on a small piece of cotton or face pad and apply to affected area twice daily after cleaning skin with soap and rinsing well with water

5. Clindamycine lotion 6. Golmar no acne soap 1x1

Loss of Appetite

Use one of the following:

Cyproheptadine (periactin) tablet (4 mg) 1x3 before meal for adults

Cyproheptadine (periactin) syrup 1x3 before meal for children

Rouza (pizotifen) syrup 1x2 for adults and children

Earache

1. Otocain ear drop: 3 drops x3; for pain in ear2. Antibiotic such as ciprodar ear drop 1x23. Paracetamol or NSAID may be needed

Constipation:

You can use one of the following: Cascara tab (5 mg) 1x2 or you can use (senna

or sennade) tab: 2 tabs at night Bisacodyl tab or suppository (10 mg, 5mg) 1x1

or (2.5 mg) 1x1 in children Laxidyl suppositpry (10 mg) 1x1 for adult and

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(5 mg) 1x1 for child Laxidyl tab 1x1 or laxidyl suppository 1x3 Lactulose syrup 1x2 by teaspoon in children or

elderly Abdominal pain

One of the following:

Buscopan ampule 1x1 Buscopan tab 1x2

Injection Intravenous (IV) injection

To ensure that the needle is within a vein, draw the syringe’s plunger. If blood is drawn, then you are within a vein.

Intramuscular (IM) injection A common site for this kind of injection is the upper lateral quadrant of the buttock.

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Dr. Soran M. Gharib

When you inject the syringe, draw a small amount. If this test yields blood, don’t inject in that place because the blood means you hit the vein.

CannulationIntravenous (IV) cannulation is a technique in which a cannula is placed inside a vein to provide venous access. Venous access allows administration of fluids, medications, nutrition, and chemotherapy.

Cannula types

Yellow cannula is used for children

Green cannula is the largest one and it’s used for shock conditions

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After the green, the brown and blue and then pink come in size

Stomach tube (Nasogastric tube, NG)

A nasogastric tube is a special tube that carries food and medicine to the stomach through the nose.

When we use the NG tube, to ensure that it reaches the stomach, inject some amount of air in the tube while simultaneously putting the stethoscope on the stomach. You should hear the sound of bubbling of air in the stomach.

NG tube is frequently used for gastric lavage and for cerebrovascular accident CVA patients.

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Dr. Soran M. Gharib

(Those patients can’t eat by mouth so he receives food and drugs by the tube.)

Main Types of Infusion Fluids

An infusion set is used to intravenously administer fluids into the patient’s body.

Most bottles have 500 ml volumes.

1. Ringer’s LactateThis fluid is frequently used in dehydration. It doesn’t have contraindications.

2. Glucose Saline (GS)Contains dissolved glucose that provides

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energy.It has one main contraindication due to its glucose content; it may not be used for diabetic patients.

3. Normal Saline (NS)Contains a solution of NaCl. This solution is contraindicated in hypertensive patients.

References:

1-Hutchisons Clinical Method Michael Swash , 21st Editio 2002

2-Macleods Clinical ExaminationGraham Douglas ,11th Ediction,2005

3-Mannual of Practical MedicineR.Alagappan, 1st Edition, 1998

4-Davidsons Principles and Practice of MedicineHaslet , Chilvers , Boon, Colledge,Hunter 19th Edition ,2002

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Dr. Soran M. Gharib

5-The ECG Made Easy John R. , Hampton , 5th Edition,1998

6-Essentials of Applied ElectrocardiographyAtul Luthra ,1st Edition ,1993

7- http://meded.ucsd.edu UC UC San Diego , Division Of Medical Education 8- www.osceskills.com9-My daily practice

10- www.medicinenet.com

Other Products of the Author:

Preparing the following Medical books : 1-History taking and Physical examination in Medicine 2-Guide For Newly Graduated Doctors 3-Clinical Orthopedic.4- Clinical Gynecology .5- Clinical ENT .6- Clinical psychiatry .7- Clinical Neurology .8- 25 Cases in Clinical pediatric .

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http://www.medicinenet.com/

http://www.osceskills.com/

http://meded.ucsd.edu/


9- History taking and physical examination in surgery .10- The most important subject for 4,5, 6 th stages that you have to know before the exam .11- OSCE exam for 6th stage .12- ECG interpretation.13- Common abdominal signs and symptoms .14-Theory exam Of previous years for 6th stage

15- Collection of physiology exam of previous years for second stage medical students.

P

Other Products In Kurdish Lnaguage:

1-Hypertension2- Diabetes Mellitus.3-First Aid4-Breast cancer5-Leukemia6-AIDS7-Acne8-LASIK9-Mobile hazardous10-Typhoid Fever11-Sleep Disorders12-Rheumatodi Arthritis

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Dr. Soran M. Gharib

13-Osteo Arthritis

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