Steps for Patient Management
Steps for
Patient
Management
a comprehensive manual for medical students
Dr. Soran Mohammed Gharib
2015
1
Dr. Soran M. Gharib
Cover and interior design:
Mardin Uzeri
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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Steps for Patient Management
3
Dr. Soran M. Gharib
In The Name of God
4
Steps for Patient Management
The Hippocratic Oath
I
I
I
I
I
I
I
swear to fulfill, to the best of my ability and judgment,
this covenant:
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.
will apply, for the benefit of the sick, all measures which
are required, avoiding those twin traps of overtreatment
and therapeutic nihilism.
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.
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.
will respect the privacy of my patients, for their problems
are not disclosed to me that the world may know.
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.
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Dr. Soran M. Gharib
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
I
I
will prevent disease whenever I can, for prevention is
preferable to cure.
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.
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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Steps for Patient Management
About this booklet
Dear 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
7
Dr. Soran M. Gharib
About The Author
Internist-Rheumatologist
Medical Doctor ( MD, MBChB)
Internist ( Member of American college of Physician)ACP
Member of (American college of Rheumatology)ACR
Member of BSR ( British Society for Rheumatology)
Mini- MBA ( Cambridge international college )
Member of Importer & Exporter Union Kurdistan Region of
Iraq
Certificate In medical LASER therapy ( USA)
Diploma In HR Management
07702142283
dr.soran_medicine@yahoo.com
Fb : Soran Mohammed Gharib
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Steps for Patient Management
TABLE OF CONTENT
History Taking……………………….………..……….11
General Physical Examination…….………..……..21
Investigation………………………………………….…28
Treatment……………………………………..…………31
Common Diseases…………………………..………..39
Injection …………………………………………..…….51
Cannulation …………………………………………….52
Stomach Tube (NG ) Tube………………….……….53
Main Types of Infusion Fluids…………………..…54
References…………………………………………….…55
Other Products of the Author ………………….…56
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Dr. Soran M. Gharib
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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Steps for Patient Management
History Taking
Introduction
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 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
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Dr. Soran M. Gharib
12

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?”
Steps for Patient Management
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 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.
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Dr. Soran M. Gharib
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:
 Site
The 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.
 Severity
This 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 of mild,
moderate, and severe.
 Aggravating Factors
Anything 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.
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Steps for Patient Management
 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) Pain
origin 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 Time
Describes the elapsed time period before the pain
causes discomfort; usually addressed in terms of
sudden and gradual.
 Nature of the Pain
Specifies how the pain is felt. (e.g. burning pain,
throbbing pain, stabbing pain)
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Dr. Soran M. Gharib
B-Vomiting
The following details must be deduced through methodical
inquiry:
1. Frequency
(more than 5 times a day should be admitted)
2. Color
3. 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-Frequency
2-Color
3-Contain mucus or not
4-Associated with vomiting or not
5-Amount
6-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.
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Steps for Patient Management
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 tears
2. Dry tongue
3. Loss of skin elasticity
4. Increased pulse rate
5. Decreased BP
6. Decreased urine output
Tarry (dark) stool
4- Review of body systems
GIT, Respiratory, CVS, Urinary and Genital, CNS
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Dr. Soran M. Gharib
A-Gastrointestinal Tract (GIT, Elementary System)





Appetite
Increased, decreased or unchanged?
Diet
Weight
Vomiting
Diarrhea
B-The Respiratory System





Cough
How often does it come? Does it come in certain
posture? Is it dry or wet?
Sputum
Its quantity, color, smell, taste
Hemoptysis
Mean presence of blood in sputum
Dyspnea
Cyanosis
C- The Cardiovascular System

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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.
Steps for Patient Management




These forms of dyspnea are commonly seen in the
heart disease.
Pain
Cardiac 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.
Palpitation
Episodes of tachycardia experienced by the patient or
fluttering of the heart
Cough
Sputum
(same as respiratory system)
D- The Urogenital System



Thirst
How often does the patient become thirsty? Does (s)he
drink excessive water?
Micturition
How often does the patients pass urine? Is it painful?
Nature and site of the pain?
Urine
Is 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?
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Dr. Soran M. Gharib
Peripheral nerves; ask about paralysis or weakness, any loss
of cutaneous sensation of the pain, touch, temperature,
presence parathesisea (tingling) in the limbs.
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 home
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Steps for Patient Management
General Physical Examination
1.
2.
3.
4.
5.
You should be on the right side of the patient.
Is the patient conscious or not?
Comfortable or not?
Cooperative or not?
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 °C
The temperature in the axilla= temp. + 0.5
The temperature in the rectum= temp. - 0.5
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Dr. Soran M. Gharib
Examination of the mouth
1- Cyanosis: a bluish discoloration of the skin resulting from
poor 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.
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Steps for Patient Management
Examination of the neck
We examine the thyroid gland and the following lymph node
groups through gentle palpation:







Submental
Submandibular
Preiauricular
Postauricular
Occipital
Supraclavicular
Cervical
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Dr. Soran M. Gharib
Hand examination




24
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
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.
Steps for Patient Management
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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
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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Steps for Patient Management
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Dr. Soran M. Gharib
Investigations
1-Blood investigations: Hb%
normal range: 11-18%

P.C.V
normal range: 42±5%

WBC
normal range: 400011000 cells/μL

ESR
normal range: 0-15 mm/hr
High 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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Steps for Patient Management
4- Renal function test (kidney function test)
Urea  normal range: 15-45 mg/dL
Serum Creatinine  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. Triglyceride
normal 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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Dr. Soran M. Gharib
Radiology
The most common radiologic diagnostic tools include:

X-Ray

C.T. scan

MRI
Others:
 Ultra Sound U/S

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ECG
Steps for Patient Management
Treatment :
Drug Forms
Tablet
Capsule
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Dr. Soran M. Gharib
Ampule
Vial
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Steps for Patient Management
Syrup
Suppository
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Dr. Soran M. Gharib
Ointment
Drops
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Steps for Patient Management
Pain killers (Analgesics)
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)
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Dr. Soran M. Gharib



Found as ampoule, tab, suppository and ointment
Indication: Pain and spasm
Voltaren is contraindicated in:
 Hypertension
 Gastric ulcer
 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




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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
Steps for Patient Management


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
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:
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Dr. Soran M. Gharib
1. O2
2. Vial of hydrocortisone
3. Ventolin inhaler (leads to bronchodilation)
Antibiotics
Most of them are found as vial.
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
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Steps for Patient Management
Common Diseases
Urinary tract infection ( UTI )
UTI In pregnancy (admission case)
Treatment:
1.
2.
3.
4.
Cannula
Fluid
Antibiotics like claforan 1x3
Analgesia like paracetamol ampule 1x2
UTI (outpatient)
Treatment:
1. Suprax capsule (400 mg) 1x1
2. 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:
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Dr. Soran M. Gharib
1. Decadrone ampule (8mg) 1x2
2. Voltaren ampule if it’s not contraindicated 1x1 or
paracetamol ampule
3. Lortin tab or fexofenadine tab 1x1
4. Paracetamol tab or dolocold tab 1x3
5. Solvodin syrup if there is coughing with it
6. 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 abdominal pain.
Rx:
1. Ampiclox syrup 1x4 by teaspoon or azithromycine
syrup 5cc x1 for 3 days
2. Paracetamol suppository or syrup 1x3
3. Lortin syrup 1x1 by teaspoon
Common cold in adults:
The patient comes with runny nose, sore throat, and loss of
appetite.
Rx:
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Steps for Patient Management
1.
2.
3.
4.
5.
6.
Tolux tab 1x3 or Tullin D tab 1x3
Anti-flu tab or anti-cold tab 1x3
Vicks inhaler (Eucaliptus)
Paracetamol tab 1x3
Decadrone ampule 1x1
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
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 GUE
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Dr. Soran M. Gharib
If 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 1x2
3. Urisept tab 1x3
4. Rawatin X tab
5. Paracetamol tab 1x3 or voltaren tab or ampoule if there
is no contraindication
Typhoid Fever:
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)
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Steps for Patient Management
Treatment:
1.
2.
3.
4.
5.
6.
Paracetamol ampule or tab 1x3
Antibiotic such as ceftriaxone vial (1 gm) 1x2
IV fluid (1000 cc GS)
Antipyretic (Paracetamol ampule 1x3)
Doxydar capsule 1x2
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.
Treatment:
1. Ceftriaxone vial 1x2 or gentamicine (80 mg for adult,
40 mg for children) 1x2
2. Paracetamole ampule 1x2
3. Capsule Rifampicine 1x2
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Dr. Soran M. Gharib
4. Capsule Doxydar 100 mg 1x2
5. Bactrim tab 1x2
6. Vila streptomycin 1gm 1x1 IM
Toothache:
Rx:
1.
2.
3.
4.
5.
Voltaren ampule if there is no contraindication 1x1 IM
Voltaren or paracetamol tab 1x3
Flagyl tab 1x3
Amoxicillin capsule 1x3
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, abdominal
pain, flatulence, constipation and sometimes diarrhea, anxiety,
and nervousness.
1. Buscopan tab 1x3
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Steps for Patient Management
2. Librax (chlordizepoxide) (5 mg) clidinium bromide tab
(2.5 mg) 1x3 before meal
3. Duspatalin (mebeverine)tab 1x3 before meal
4. Stelabid (isopropamide+trifluperazine)1x3 before meal
5. 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)
1x1
2. Glibinclamide (daonil) tab (5 mg) 1x1
3. other new oral hypoglycemic tablets
4. 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
 1-3 years old = 10 drops x 3
 3-5 years old = 20 drops x 3
 5 years old = 40 drops x 3
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Dr. Soran M. Gharib

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 infusion
4. Ranitidine (zantac) tablet (150 mg) 1x2 before meal or
zantac ampule (50 mg) IM/IV
5. Maalox plus tab; for epigastric pain
6. 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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Steps for Patient Management
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
47
Dr. Soran M. Gharib
mg) 1x1
4. Plasil tab (or syrup for children) 1x3 before meal or
plasil ampule 1x2
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 1x2
2. 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)

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Steps for Patient Management
Acne
1. Doxydar capsule (100 mg) 1x2 after meal
2. Ben oxide Gel or Lotion 1x1;Applied at night and
washed in the morning with soap
3. Retane or isortin (isotretinoic acid) (10 mg , 20 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 ear
2. Antibiotic such as ciprodar ear drop 1x2
3. Paracetamol or NSAID may be needed
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Dr. Soran M. Gharib
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 (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
50
Steps for Patient Management
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.
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.
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Dr. Soran M. Gharib
Cannulation
Intravenous (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

After the green, the brown and blue and then pink
come in size
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Steps for Patient Management
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. (Those patients
can’t eat by mouth so he receives food and drugs by
the tube.)
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Dr. Soran M. Gharib
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 Lactate
This fluid is frequently used in dehydration.
It doesn’t have contraindications.
2. Glucose Saline (GS)
Contains dissolved glucose that provides 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.
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Steps for Patient Management
References:
1-Hutchisons Clinical Method
Michael Swash , 21st Editio 2002
2-Macleods Clinical Examination
Graham Douglas ,11th Ediction,2005
3-Mannual of Practical Medicine
R.Alagappan, 1st Edition, 1998
4-Davidsons Principles and Practice of Medicine
Haslet , Chilvers , Boon, Colledge,Hunter 19th Edition ,2002
5-The ECG Made Easy
John R. , Hampton , 5th Edition,1998
6-Essentials of Applied Electrocardiography
Atul Luthra ,1st Edition ,1993
7- http://meded.ucsd.edu
UC UC San Diego , Division Of Medical Education
8- www.osceskills.com
9-My daily practice
10- www.medicinenet.com
55
Dr. Soran M. Gharib
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 .
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.
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Steps for Patient Management
P
Other Products In Kurdish Lnaguage:
1-Hypertension
2- Diabetes Mellitus.
3-First Aid
4-Breast cancer
5-Leukemia
6-AIDS
7-Acne
8-LASIK
9-Mobile hazardous
10-Typhoid Fever
11-Sleep Disorders
12-Rheumatodi Arthritis
13-Osteo Arthritis
57