In the name of Allah

The most gracious, The most merciful

MASTER THE CHAMBER

Medicine, Paediatrics, Surgery, Eye, ENT, Obstetrics & Gynaecology,
X-ray, ECG and USG

DR. MD. MEHEDI HASAN LEMON

MBBS (Mymensingh Medical College, M-48) BCS (Health)
BCS (Health), FCPS Part-1 (Medicine), PGT (Medicine)
CCD (BIRDEM), DMU (BITMIR)
Medical Officer, Ministry of Health and Family Welfare.
Ex- Medical Officer, BSMMU.
Ex-Honorary Medical Officer, Mymensingh Medical College Hospital, Mymensingh.

DR. MOHAMMAD RASEL

MBBS (Mymensingh Medical College, M-49)
BCS (Health); FCPS Part-1 (Medicine)
Medical Officer
Ministry of Health & Family Welfare.
 Contents
Topics Page
STARTING CHAMBER PRACTICE
 Prescription writing 2
 Strategies to enhance adherence 2
 Difficult doctor patient interactions 2
 Breaking bad news 3
HEALTHY LIVING
 Diet 6
 Medicine 7
 Exercise 7
 Sleep 7
 Smoking cessation 8
PRESCRIBING IN SPCIAL SITUATIONS
 Safe drugs in pregnancy 11
 Drugs to avoid during breast feeding 13
 Prescribing for the elderly 13
 Prescribing for children 15
PRINCIPLES OF PAIN CONTROL
 Strategies of pain management 17
 The analgesic ladder 17
 Addition of co-analgesics and adjuvant drugs 18
 Referral 18
 Pain-relieving drugs 18
 Drug dosage 19
 Morphine and other strong Opioids 19
 MEDICINE
Common approaches

 Fever 22
 Acute abdomen/Abdominal pain 27
 Vomiting 30
 Dyspnoea 34
 Cough 37
 Hemoptysis 38
 Per rectal bleeding 39
 Purpura 40
 Swelling of the body 41
 Ascites 44
 Vertigo 45
 Anaemia 48
 Polyarthritis 51
 Headache 56
 Weight loss 57
 Obesity 58
 Hypercholesterolemia 60
Gastrointestinal System

 Peptic ulcer disease 65

 Non-ulcer dyspepsia 67
 GERD 68
 Constipation 69
 Acute appendicitis 70
 Ulcerative colitis 71
 Crohn’s disease 73
 Irritable bowel syndrome 74
 Acute pancreatitis 75
 Chronic pancreatitis 76
 Aphthous ulcer 77
 Oral candidiasis 78
 Achalasia cardia 79
Hepatology

 Acute viral hepatitis 79

 Liver abscess 80
 Chronic liver disease 81
 Hepatic encephalopathy 83
 Non-alcoholic fatty liver 84
 Chronic cholecystitis 84
 Cardiovascular System

 Hypertension 86
 Anti hypertensive drugs 86
 Choice of antihypertensive drugs 86
 HTN in special situation 87
 Severe hypertension 88
 Hypertensive urgencies 88
 Hypertensive emergencies 88
 Myocardial infarction 90
 Unstable angina 93
 Chronic stable angina 95
 Acute left ventricular failure 96
 Chronic heart failure 98
 Atrial fibrillation 99
 Acute rheumatic fever 100
 Mitral stenosis 101
Respiratory System

 Asthma 103
 COPD 107
 Community acquired pneumonia 108
 Pulmonary tuberculosis 111
 Common cold 114
 Rhino sinusitis 115
DM & Endocrinology

 Diabetes mellitus 117

 Diet and discipline 118
 Starting of drug therapy 118
 Rx algorithm 119
 Drug selection 120
 Initiation and titration of drugs 121
 Insulin guideline 122
 Rx of complications 123
 Hypothyroidism 130
 Hyperthyroidism 131
 Drug induced Cushing’s syndrome 131
 Addison’s disease 132
Nervous System

 Migraine 134
 Tension-type headache 135
 Epilepsy 135
 Bell’s palsy 139
 Parkinson’s disease 139
 Acute vestibular failure 140
 Benign paroxysmal positional vertigo 140
 Restless leg syndrome 140
 Stroke 141
 Bacterial meningitis 144
 Tubercular meningitis 146
 Viral meningitis 149
 Status epilepticus 150
 GBS 152
 Lumbar disc herniation (PLID) 152
 Acute transverse myelitis 153
Nephrology

 Urinary tract infection 155

 Acute pyelonephritis 157
 Chronic kidney disease 157
 Urge incontinence (overactive bladder syndrome) 159
 Overflow incontinence 159
 BEP 160
Psychiatry

 Schizophrenia 162
 Bipolar affective disorder 162
 Depression 164
 Generalized anxiety disorder 165
 Panic disorder 166
 Obsessive compulsive disorder 166
 Somatoform disorder 167
Dermatology &Venerology
 Scabies 169
 Tenia capitis 170
 Tenia corporis 171
 Tenia cruris 172
 Tenia pedis/Tenia mannum 173
 Paronychia 174
 Pityriasis versicolor 175
 Psoriasis 176
 Alopecia areata 177
 Androgenic alopecia 177
 Urticaria 178
 Cold sores 179
 Pediculosis (lice infestation) 179
 Eczema and dermatitis 180
 Lichen simplex chronicus 182
 Acne 182
 Impetigo 184
 Cellulitis and erysipelas 185
 Folliculitis 185
 Boils 186
 Carbuncles 186
 Warts 187
 Molluscum contagiosum 188
 Callosities 188
 Melasma 189
 Vitiligo 189
 Lichen planus 190
 Generalized hyperhidrosis 191
 Focal hyperhidrosis 192
 Miliaria 193
 Erectile dysfunction 194
 Premature ejaculation 195
 Gonorrhea 196
 Chlamydial infection 197
Haematology

 Iron deficiency anaemia 199

 Hereditary hemolytic anaemia (thalassaemia) 200
 Megaloblastic anaemia 201
 Multiple myeloma 202
 Hemophilia 203
 DVT 203
 Idiopathic thrombocytopenic purpura 204
 Polycythaemia rubra vera 204
 Acute leukemia 205
 Chronic myeloid leukemia 206
 Chronic lymphocytic leukemia 207
 Aplastic anaemia 208
 Hodgkin’s lymphoma 209
 Non-Hodgkin’s lymphoma 210
Rheumatology

 Mechanical back pain 212

 Osteoarthritis 213
 Anlylosing spondilitis 214
 Osteoporosis 215
 RA 216
 SLE 218
 Acute gout 219
 Septic arthritis 220
 Reactive arthritis 220
Electrolyte Imbalance

 Hyponatremia 222
 Hypernatremia 223
 Hypokalemia 224
 Hyperkalemia 225
 Hypocalcaemia 226
 Hypercalcaemia 227

Poisoning
 OPC poisoning 229
 Benzodiazepine poisoning 230
 TCA poisoning 231
 Travel related poisoning/commuters poisoning/unknown 232
poisoning
 Paracetamole poisoning 233
 Kerosene poisoning 234
 Corrosive poisoning (herpic/savlon/any acid/any alkali) 235
 Snake bite 236
Infectious Disease

 Viral fever 239

 Dengue 239
 Malaria 241
 Enteric fever 244
 Rickettsial fever (scrub typhus group) 245
 Leptospirosis 246
 Measles 247
 Chicken pox (varicella) 248
 Herpes zoster 248
 Mumps 249
 Acute watery diarrhoea 249
 Cholera 250
 Bacillary dysentery 251
 Amoebic dysentery 251
 Seasonal influenza 252
 Leprosy 252
 Kala azar 253

Sleep disorders

 Insomnia 255
 Restless leg syndrome 256
 PAEDIATRICS
 Growth & development 258
 Acute Bronchiolitis 259
 Nasal polyp 259
 Common cold 260
 Thrush (oral candidiasis) 260
 Constipation 260
 Hypothyroidism 261
 Measles 261
 Chicken pox (varicella) 262
 Migraine 262
 Bell’s palsy 263
 Mumps 263
 Awd with no dehydration 264
 Awd with some dehydration 264
 Awd with severe dehydration 265
 Severe persistent diarrhoea 266
 Dysentery 267
 Pneumonia 268
 Severe pneumonia 268
 Acute Bronchiolitis (mild case) 269
 Acute Bronchiolitis (severe case) 270
 Intermittent asthma 271
 Persistent asthma 272
 Acute severe asthma 273
 Acute viral fever 273
 Acute ottitis media 274
 Dengue fever 274
 Acute viral hepatitis 275
 Enteric fever 276
 Malaria 277
 Kala-azar 278
 Recurrent abdominal pain 279
 Non specific abdominal pain 280
 Peptic ulcer disease 280
 Haemorrhoids 281
 Juvenile 281
 Juvenile colonic polyp 281
 Acute tonsillitis 282
 Henoch-schonlein purpura 282
 Juvenile idiopathic arthritis 283
 Growing pain 283
 Club foot 284
 Acute Glomerulonephritis 284
 Nephrotic syndrome 285
 Urinary tract infection (cystitis) 286
 Urinary tract infection (pyelonephritis) 286
 Febrile convulsions 287
 Hookworms 287
 Ascariasis 288
 Herpes simplex virus infection 288
 Nocturnal enuresis 288
 Epilepsy 289
 Cerebral palsy 290
 Autism 292
 Attention deficit/Hyperactivity disorder 293
 PICA 293
 Thumb sucking 293
 Umbilical sepsis 293
 Newborn of HBsAg positive mother 293
 Umbilical hernia 294
 Mastitis 295
 Estrogen withdrawal bleeding 295
 Caput succedaneum 295
 Cephal hematoma 295
 Vacuum caput 296
 Commonly used drugs 297
SURGERY
 Rx following casualty OT(includes excision of all 312
swellings)
 RTA/physical assault 313
 Head injury 314
 Acute abdomen 315
 Acute appendicitis 316
 Appendicular lump 317
 Appendicular abscess 318
 Intestinal obstruction 319
 GOO due to pyloric stenosis 320
 GOO due to carcinoma stomach 321
 Colorectal carcinoma 322
 Anal fissure 323
 Fistula-in-ano 324
 Hemorrhoids/piles 325
 Acute cholecystitis 326
 Chronic cholecystitis 327
 Empyema gall bladder 328
 Mucocele gall bladder 329
 Obstructive jaundice 330
 Acute pancreatitis 331
 Acute retention of urine due to BEP 332
 Acute retention of urine due to stricture urethra 333
 Rupture urethra 334
 Renal stone 335
 Ureteric stone 336
 Inguinal hernia 337
 Hydrocoele 338
 Epididymo-Orchitis 338
 Torsion of testis 339
 Cellulitis 340
 Diabetic foot 341
 Breast abscess 342
ENT
 Sore throat 344
 Acute tonsillitis 345
 Hoarseness 346
 External ear furunculosis 347
 Otomycosis 347
 Allergic rhinitis 348
 Furunculosis of nose (vestlbulitis) 349
 Acute rhino sinusitis 349
 Acute parotitis 350
 Impacted wax 351
 ASOM 351
 CSOM 352
 Epistaxis 353
EYE
 Acute conjunctivitis 355
 Allergic conjunctivitis 355
 Chalazion 356
 Infected Chalazion 356
 Herpes zoster ophthalmaticus 357
 Orbital Cellulitis 357
 Painful red eye 357
GYNAECOLOGY
 Leucorrhoea 359
 Vaginal candidiasis 359
 PID 360
 Generalized weakness/body ache 360
 Generalized/focal burning sensation of body 361
 Postponing menstruation 361
 Primary amenorrhoea 361
 Secondary amenorrhoea 362
 Dysmenorrhoea 362
 Puberty menorhhagia 362
 PCOS 363
 Hirsuitism 363
 DUB 364
 Fibroid uterus 364
 Adenomyosis 365
 Ovarian cyst (tiny: few mm) 366
 Ovarian cyst (3-7cm) 366
 Ovarian cyst (complex/>9cm) 367
 Dyspareunia 367
 Pruritus vulvae 367
 Premenstrual syndrome 368
 Uterine prolapse 368
 Ca cervix 369
 Early menopause 369
 Menopause 369
 Conventional HRT 370
OBSTETRICS
 Antenatal visit 372
 Missed period 373
 Vomiting in pregnancy 373
 UTI pregnancy 374
 GDM 374
 Pregnancy with HTN 375
 Pregnancy with diarrhoea 375
 Pregnancy with PV bleeding 376
 Pregnancy with anaemia 376
 Pregnancy with backache 377
 Constipation in pregnancy 377
 Leg cramps in pregnancy 377
 Oedema in pregnancy 278
 Heartburn in pregnancy 278
 Varicose vein in pregnancy 378
 Haemorrhoids 379
 Leucorrhoea in pregnancy 379
 Headache in pregnancy 379
 Vertigo in pregnancy 380
 Insomnia in pregnancy 380
 Fever in pregnancy 380
 Common cold in pregnancy 381
 Oligohydromnios 381
 Rh negative mother 381
 Pregnancy with bronchial asthma 382
 Pre-eclampsia 382
 Inadequate secretion of breast milk 383
  Suppression of breast milk 383
 Breast engorgement 383
 Mastitis 384
 Breast skin infection 384
 Post partum care 384

DENTISTRY
 Tooth avulsion 387
 Toothache 387
 Periapical abscess 388
 Lateral periodontal abscess 389
 Dental caries 389
 Adult type periodontitis 390
 Juvenile periodontitis 390
 Inflammatory gingival enlargements 390
ECG
 Physiology of conduction system of heart 393
 Basics of ECG 395
 ECG leads 400
 Normal ECG morphology 406
 Normal ECG pattern 408
 Systematic interpretation guideline for ECG 410
 Sinus tachycardia 429
 Sinus bradycardia 430
 Sinus arrhythmia 430
 Atrial fibrillation 430
 Atrial flutter 431
 Ventricular tachycardia 432
 Supraventricular tachycardia 434
 Ventricular fibrillation 434
 Torsades de pointes 435
 First-degree atrioventricular block 435
 Second-degree atrioventricular block 436
 Third-degree atrioventricular block 437
 Hypokalemia 438
 Hyperkalemia 438
 Dextrocardia 439
 Myocardial infarction 440
 Myocardial ischemia 447
 Left ventricular hypertrophy 448
 LVH with strain 450
 Right ventricular hypertrophy 451
 RVH with strain 452
USG REPORTS 454
 PRESCRIPTION WRITING

1. Patient details: Full name, address, and age/date of birth if <12y

2. Date
3. Full name of the drug (not abbreviated), with quantity to be supplied and dose
interval (avoid the use of decimal points, e.g. for quantities <1g, write in mg).
4. If you want a description of the drug included on the label, then write it on the
prescription (e.g. ‘for asthma’)
5. Deletion of any unused space (e.g. by striking through)
6. Signature of the prescriber in ink
7. Name and address of the prescriber
8. Computer-issued prescriptions: Same information as their handwritten equivalents
but must still be signed in ink by the responsible clinician.

STRATEGIES TO ENHANCE ADHERENCE

1. Educate the patient: About the medical condition, risks and benefits of therapy and
alternatives using understandable language.
2. Consider patient’s perspective and keep a nonjudgmental attitude
3. Maintain contact: Through follow up visits and phone calls
4. Keep care as simple and inexpensive as possible: e.g. using less costly medications,
once daily or combination formulations and drugs that are not affected by meal.
5. Give written instructions
6. Encourage self monitoring: So that patient feels a sense of control over his/her own
health e.g. RBS, home BP, exercise, food diary etc.
7. Identify and address barriers: e.g. time, money, transportation, functional illiteracy,
depression, mental illness, cognitive dysfunctions etc.
8. Focus on positive benefits of treatment and reinforce patient’s efforts
9. Discuss adherence strategies e.g. use of medications long sheets, alarms, reminder
etc.

DIFFICULT DOCTOR PATIENT INTERACTIONS

Patient related characteristics:

1. Mental disorder
2. Multisomatoform disorder
3. Panic disorder
4. Dysthymia
5. Generalized anxiety
6. Major depression
7. Alcohol abuse or dependence
8. High health care utilization
9. More acute or chronic problems
10. Tendency to bring up new problems at last moment
11. Demanding or controling
 EXERCISE

1. Aerobic exercise:
 150 minutes or more moderate to vigorous intensity aerobic exercise per week.
 Daily exercise or not more than 2 days elapse between exercise sessions is
recommended and spread over at least days per week.
 Aerobic activity last at least 10 minutes with the goal of 30 minutes or more per
day.
2. Resistance activities: 2-3 sessions per week non consecutive days. e.g. push up, pull
up, weight lifting etc.
3. Breaking up bouts of sedentary activity: Every 30 minutes by briefly standing,
walking or performing other light activities.
4. Daily 60 minutes or more exercise: To gain weight loss in overweight or obese patient

SLEEP

Definition of ‘a good night’s sleep’:

1. <30min to fall asleep

2. Maintenance of sleep for 6–8h
3. <3 brief awakenings/night
4. Feels well rested and refreshed on awakening

Principles of ‘sleep hygiene’:

1. Don’t go to bed until you feel sleepy

2. Don’t stay in bed if you’re not asleep
3. Avoid daytime naps
4. Establish a regular bedtime routine
5. Reserve a room for sleep only (if possible). Do not eat, read, work, or watch Tv in it
6. Make sure the bedroom and bed are comfortable, and avoid extremes of noise and
temperature
7. Avoid caffeine, alcohol, and nicotine
8. Have a warm bath and warm milky drink at bedtime
9. Take regular exercise, but avoid late night hard exercise (sex is OK)
10. Monitor your sleep with a sleep diary (record both the times you sleep and its quality)
11. Rise at the same time every morning regardless of how long you’ve slept

Complications of insomnia:

1. ↓Quality of life
2. ↓Concentration and memory, affecting performance of daytime tasks
3. ↓Relationship problems
4. ↑Risk of accidents: 10% motor accidents are related to tiredness.
 COPD
C/C: Rx
1. Male smoker above 40 years of Salbutamol+Iptratropium bromide DPI
age 1 capsule to be inhaled with device
2. Breathlessness, coughs, sputum (Bexihaler)- to be continued
production and fever for…
O/G/E: Triotropium 18mcg DPI
Pulse: 1 capsule to be inhaled with device
BP: (Bexihaler) BD- to be continued
Temperature:
Respiratory Rate: Tab. Doxofylline 200mg
Flapping Tremor: 1+0+1- to be continued
Cyanosis:
Oedema: Tab. Prednisolone 10mg
3+0+0 (A/M)- 5-10 days
Respiratory system examination:
Ronchi: + Cap. Omeprazole 20mg
Breath sound: Vesicular with prolonged 1+0+1 (B/M)–While taking prednisolone
expiration
Creps: +
Advice:
Investigations: 1. Take medicine regularly
1. CXR PA view 2. If there is any breathlessness, cough or
2. ABG feeling of chest tightness, use Salbutamol
3. PEFR DPI
4. Spirometry with reversibility 3. You must gurgle after use of
5. Sputum analysis Salmeterol+Fluticasone 250 Cozycap
6. ECG 4. Avoid dust andd other things that induce
your breathlessness
5. Quit smoking and avoid taking jorda and
Tamak pata etc.
6. Never take medicine like cortan/cotson
without suggestion from registered
physician.
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 HYPOTHYROIDISM
C/C: Rx,
1. Weight gain Tab. Levothyroxine 50 microgram
2. Cold intolerance 1+0+0- In early morning empty stomach- 3weeks
3. Fatigue, weakness
4. Menorrhagia, Then,
5. Dry skin Tab. Levothyroxine 50 microgram
6. Dry hair 2+0+0- In early morning empty stomach- 3weeks
On examination:
1. Pulse: Bradycardia Increase the dose in every 3 weeks until TSH, FT4
2. Oedema: Non pitting oedema is within normal limit.
3. Ankle Jerk: Delayed
relaxation
Investigations:
1. TSH: 0.2–4.5 mU/L
2. FT4 : 9–21 pmol/L
3. ECG: Sinus bradycardia, Signature
low voltage ECG
4. Thyroid scan  In younger patients: Initiate at 100 µg per
5. Thyroid peroxidase day
autoantibody  If ischemic heart disease present: 25
Advices: microgram/day initially then increase
1. It’s a lifelong treatment. Do slowly
not alter the dose without  In pregnancy: Add 25 microgram with
consulting the physician previous dose.
2. Consult me after 6 weeks
with TSH and FT4 report
 BELL’S PALSY

C/C: Rx,
1. Pain around the ear followed by Tearfresh liquigel 10mg/ml
unilateral weakness with deviation of 1 drop in affected eye SOS- if drying
mouth for.. sensation
2. Dimished salivation and tear secretion
for... If <72h after onset of symptoms:
LMP: Tab. Prednisolone 25mg
P/H: DM, HTN, immunosuoppression, 1mg/kg in morning for 14 days.
URTI Cap. Omeprazole 20mg
1+0+1 (B/M)- 14 days
O/E:
 Lower motor neuron type of No role but is prescribed conventionally:
paralysis of facial nerve. Tab. Acyclovir 400mg
 Absence of wrinkling in forhead 1+1+1+1+1- 10 days [Discouraged to
 Unable to close eye prescribe]
 Bell’s phenomenon:+
Advice: Refer:
1. Protect eye—tape lid shut and pad 1. If recovery is not starting
at night after 3week
2. Glasses in the day 2. For tarsorraphy if complete
or long-standing palsy
If unacceptable cosmetic result—may benefit
from plastic surgery
 GENERALIZED ANXIETY DISORDER

C/C: Rx,
1. Symptoms of sympathetic overactivity - Start with (SSRIs + benzodiazepine) and
Palpitations, sweating, dry mouth, withdraw Benzodiazepines over 2-4 weeks
increased frequency, abdominal distress Tab. Escitalopram10mg
2. Sleep disturbance 1 +0+0
3. Forgetfulness or worrying too much. Or,
4. Persistent anxiety, present all the time Tab. Paroxetine10mg
5. Tremulousness, shakiness, generalized 1+0+0 [Can be increased up to 37.5
aches, restlessness. mg/day at the interval of 1 week]
6. Apprehension, worries of future, Or,
irritability, sleeplessness. Tab. Sertraline50mg
7. Intensity, duration and frequency of the 1+0+0 [can be increased up to 200
anxiety and worry are far out of mg/day after 5-6 weeks in increments of
proportion to the actual likelihood or the 50 mg]
impact of the feared event and it
interferes with the task in hand.
And,
Investigations: Tab. Diazepam5mg
1. RBS 1+0+1 [5-20 mg/day]
2. TSH, FT3, FT4 Or,
3. ECG Tab. Clonazepam0.5mg
Nonpharmacological Rx: 0+0+1
1. Reassurance
2. Psychological support
3. Encouragement. Signature
Anxiety management: relaxation exercises, Refer to psychiatrist: If severe anxiety with
breathing exercises, meditation, and yoga. marked functional impairment plus:
1. Risk of self-harm/suicide, or
2. Significant co-morbidity
(e.g. substance misuse,
personality disorder or
complex physical health
problems), or
3. Self-neglect, or
4. Inadequate response to drug
 SCABIES

Basic Informations:

 Causative Organism: Sarcoptes scabiei.

 Sites: Commonly interdigital area, fingers,
ulnar edge of hand, wrist.
 Mode of Transmission:
1. Direct skin contact from affected
individual.
2. From bed sheet, clothing.
 Complications:
1. Secondary bacterial infection.
2. Eczematization and lichenification.
3. Poststreptococcal glomerulonephritis.

Model Prescription:

C/C: Rx,
1. Intense itching, mostly at night. Permethrin 5% cream
2. Presence of same symptoms Apply generously after bath at bedtime entire
among family members. surface of the body below neck (except face).
O/E: Minimum contact period 8-12 hours; and is to
1. Burrows present. be washed off next morning. May be repeated
2. Papular lesions, excoriations at after 7 days
the sites of predilection.
Tab. Cetirizine 10mg
Investigations: 0+0+1- 2 weeks.
 Not performed usually
 Burrows and mite can be seen If secondary infection present: add
in hand lens. Tab. Azithromycin 500mg
Advice: 1+0+0- 7 days
1. All family members/close If poor compliance or immunosuppression or
contacts should be treated heavy infestation, add
simultaneously
2. Disinfection of bedding and Tab. Ivermectin 3mg or 6mg
clothing by ordinary laundering 200mcg/kg Stat (Single dose)
and sun exposure is required.
3. Improve personal hygiene by by Signature
daily bath with soap and water. Special treatment considerations:
 Permethrin and benzyl benzoate appear to be
safe in pregnancy and lactation.
 Benzyl benzoate is safe in children <2 years
of age, but duration of use should be limited
to 12 h. Ivermectin is contraindicated in
children <15 kg.
 ACUTE BRONCHIOLITIS
Clinical features: Rx
1. Cold for 2-4 days followed by Syrup. Diphenhydramine hydrochloride
cough, wheeze and rapid 10mg/5ml
respiration. 1 TSF for every 8 kgs QDS- 7 days
2. Lower chest indrawing,
3. Difficulty in feeding,
4. Excessive crying due to
hypoxaemia,
Signature
5. Cyanosis and respiratory failure. Hospitalize immediately, if any
Investigations: of the following develop:
1. CBC: Normal or minimal increase 1. Chest indrawing,
in total leucocyte counts with 2. Poor feeding
relative lymphocytosis. 3. Cyanosis
2. CXR PA view: May show 4. Altered sensorium
hyperinflation and small atelectasis. 5. Convulsions
Advice: 6. If there is no improvement or
deterioration at any time during the
1. For associated nasal block, normal
illness, the patient should be
saline drops in both nostrils as and
managed as severe disease.
when required, especially before
feeds,
2. Use of home remedies (ginger,
honey, tulsi) for control of cough
and plenty of liquids orally.
 PNEUMONIA

C/C: Rx
1. Fever for…
2. Respiratory distress for… Syrup. Cefixime 100mg/5ml
3. Cough for… 1 TSF 12 hourly for each 20 kg
O/E:
Appearance: Chest indrawing, Fast Syrup. Paracetamol 120mg/5ml (if fever)
breathing 1 TSF for each 8kg TDS or QDS
Temperature:
Lung: Crepitation
Syrup. Levosalbutamol 1mg/5ml
Investigations:
1. CBS with ESR (if breathing difficulty)
2. CXR PA view 1 TSF TDS for each 10kg
Advices:
1. Take medications properly. Syrup. Ambroxol 15mg/5ml (if cough)
2. Avoid cold, dirt, pollen, < 5years: ½ TSF TDS
woolen cloths. > 5 years: 1 TSF TDS
3. Cleaning Nose with normal
saline drop Syrup. Ondansetron 4mg/5ml (if vomiting)
4. Bathing with lukewarm < 4 years: 0.15mg/kg TDS
water > 4 years: 1 TSF TDS
Signature with date
 VAGINAL CANDIDIASIS/MINILIASIS

C/C: Rx,
1. P/V discharge for ... Tab. Ornidazole 500mg
2. Irritating: ++ 1+0+1(A/M)- 5 days
3. Foul smelling Cap. Fluconazole 150mg
4. Dyspareunia 1 tab weekly for 6 weeks
P/V/E: Gynomix vaginal suppository [Only for
Thick and profuse/scant secretion: + married woman]
Foul smelling: + 1 stick P/V at night -12 nights

Investigations: If itching present:

1. VIA Tab. Fexofenadine 120mg
2. Urine RE 0+0+1
3. FBS, 2H ABF If irritation present:
Advice: Cream. Hydrocortosone 1%+ Miconazole
1. Maintain personal hygiene 2%
2. Wash private parts with luke Apply locally-14 days
warm water
3. Use cotton undergarments Husband should be treated with nystatin
ointment locally after each act of coitus- 7
days
Signature
 ANTENATAL VISIT
C/C: Pregnancy/Amenorrhoea for … weeks Rx,
Before 12 weeks of pregnancy:
O/G/E: Tab. Zifolet (Zink+folic acid)
Anaemia: 5mg+20mg
Pulse: 0+0+1- Continue
BP:
Temperature After 12 weeks of pregnancy:
Jaundice: Tab. Ipec Plus (Iron+folic acid
Edema: +zinc)
Weight:
1+0+0- Continue
Height:

LMP: Tab. B-complex

EDD: 1+1+1-Continue
Abdomen Examination:
Uterine Height: Tab. Calcin-O (Calcium) 740mg
Foetal Heart Rate: 0+1+0- Continue
Tab. Pantoprazole 20mg
Investigations: 1+0+1- ½ hour before meal- If
Investigation at 1st visit: acidity occurs
1. CBC
2. Blood grouping & Rh typing
3. HBsAg Signature
4. VDRL Advice:
5. RBS For 1st trimester:
6. Urine: RME 1. Avoid travel
2. Avoid heavy exercise
7. USG of Lower Abdomen
3. Avoid coital act
4. Eat fresh fruits and
In subsequent visits:
vegetables
1. Urine: RME 5. Follow up after 2-3 months
2. Hb% or at 24 weeks
3. RBS For 2nd trimester:
4. USG of Lower Abdomen 1. Eat fresh fruits and
vegetables
Advice: 2. Follow up after 2-3 months
At least 4 visits- or at 32 weeks
rd
1st: Within 16 weeks For 3 trimester:
2nd: Between 24-28 weeks 1. Eat fresh fruits and
3rd: At 32 weeks vegetables
4th: At 36 weeks 2. Follow up after 2-3 months
or at 32 weeks
 NORMAL CHEST X RAY

Figure: Normal chest X ray: Trachea (1), Carina (2), right main bronchi
(3), left main bronchi (4), right hilar structure (5), left hilar structure (6),
right horizontal fissure (7), right cardiac border formed by right atrium
(8), left cardiac border formed by ventricle (9), aortic knuckle (10),
descending thoracic aorta (11), right paratracheal line (12), right
hemidiaphragm (13), left hemidiaphragm (14), right costophrenic angle
(15), left costophrenic angle (16), gastric air bubble (17), gas in colon
(18)
First degree heart block:
1. PR interval is prolonged: > 5 small squares (1)
2. Every P wave is followed by a QRS complex (2)