COMMON MISTAKES

In
DOCTOR'S PRESCRIPTIONS
By
Dr / Abdullah Rabie3 Ezz
BENHA Medical School EGYPT

:


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Index

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Hypertension Management
:
:
Hypertension Emergency
: "
" .
:
Hypertension Urgency
:

Nice Times

 :
:
: / " "

/ ..
.. ..
B5
.
/
.. .
/ ..
) - -- (
)---( ..
..
.

 / ..


.. ..

..
)

) :
Lipoic 600 Tab : lopid 300
.
/ ..
..
..
.

 /
.. ..

.. :

..
.. ..

.
/ ) ..
: ( ..
..
.. ..
.

 / ..



)( ..
..
..
.. :


.. .
/ ..
.. - -

.

 /
..

..
..

: -
-
.
/ ..
..

- -
) (.

 :
:
:
/
Nasal drops contain decongestants

Afrin-Balkis-Nasostop-Nasotal-Rhinex
4
Rebound Congestion
" "
:
Local decongestant
Low bl. supply to nasal epithelium

Chemical Rhinitis
Decongestants
.. :
Oral decongestant

/
:
anthraquinon
..

bisadocodyl


Lactulose
/
/ psychosis
/
/ vit e
: /

" " /
" "
masking
Peritonitis

/
:

Griseofulvin

Griseovin syrup
..
..
/
:
:
furamipe furamebe
genuphil genuofil
duphaston duspataline
piascledine
Paxeladine
...

/
Diclofenac Na
:
Olfen-Declophen-Dolphen-RheumafenRhumaren-Voltaren
:
1/
Hypertensive Patients
Fluid Retention
" Paracetamol "
2/
Gastric Impairment Peptic Ulcer
:
Declophenac K

Dolphin-K Oflam-Cataflam-Rapiflam
Gastric Side Effect Of Declo.Na
3/
History of asthma with aspirin intake Lactating Women Hepatic Impair Acute
Rhinitis .

/
:

Hydroxycobalamine
B12

Neurovit-Neuroton-Neurobion-Tri-B

Declophenac Na


Depovit-B12
.
/8
:
:
-
.
.. ..
..

 anti-microbial
Mag Citrate

.. ..
/9
Allopurinol :
.. " " Gout
Allopurinol
Zyloric 100 or 300
.. Stable gout patient
Acute Gout Case
.. Zyloric Acute

Acute
COLCHICINE
dose .. 3 ..
Indomethacin


Toxic Signs Of Colchicines' Toxicity

Emesis and Abdominal Pain
..

Colmediten tab.

Colchicine tab.
.
/10
: Quinolones
Points ..
:
.. :
Bactiflox-Ciprocin-Ciprofar-CiprofloxacinRancif-Levanic-Unibiotic-Ofloxin-Peflox

 :
/
..
) (
/
Subjected .. CNS
..
/
..
/
.. ..
Photo-Sensitivity
/

NSAIDS Hypersensitive

/

Creatinine Clearance
29 ..
..
/

Nalidram 500 tab.

.. Urinary tract infection
..
.
/
Quinlones antacid
Quinlones
.
Quinolones

/11
" .. " :
.. "
. " ..
.. .. ..
-
- Quinolones
Ciprofloxacin
Macrolides Azithromycin
Erythromycin Penicillin Rifampicin
.
Quinolones Macrolides :
Interaction
Ciprofloxacin
Ca Fe Vitamins ..
Interaction ..

 :
Ca
Fe ..
..
.. Cephalexine
/12
Digoxin " : " Licorice
" " mild toxicity
Digoxin !!
.. !
.. " "
.. !!
.. Licorice
Aldosterone .. Hypokalemia
..
.. Toxicity

/ 13
Hypotensives In Pregnancy :
-
- supine hypotensive syndrome

effortil cortilon

maternal hypoperfusin abortion

.
/14
Lipid Regulating agent , Cholestyramine :
..
:
Questran sachets
or
Cholestran packets

 :

..

Digoxin
..
:
..
.. ..
:

Mild blood thinning effect
.. Warfarin or heparin

Powerful Blood Thinners
.. - -
Thinning !!
.

/15
" Sine up & no flu & congestal " Under 1 Y

chlorphenramine maleate
Neonates
premature

Severe CNS Excitation and high risk of Seizures
/16
:
..
Systemic Corticosteroids
Short-acting predinsone or
predinsolone
..

 :
Acrivastine
Semprex capsules
Astemizole Loratidine ..
..
/17
Urosolvin :

has Teratogenic effect on fetus
/18
:
..
!!
Spasmofen
+ .

/19
Ciprofloxacin
:

..
Anthrax
.. ..

Joint Damage and ,
Severe musculo-skeletal disorders

Arthritis Arthralgia
.. "
.

/20
" " :
:

" "
- .
/21
Dospa Ampoule

buscopan amp dospa amp
buscopan
.
/22
Acyclovir : Chicken pox
Acyclovir
..

 Acyclovir .. ..
Chicken pox

" Oral Acyclovir " Zovirax
Complicated Pneumonia

I.V Acyclovir and Hospitalization
Pneumonia
Maternal death
.. Acyclovir
Seizures
.. ..
/23
:
antinal Nifuroxazide
Inhibitng Peristalis
Loperamide
Lomotil immodium

 ..

GIT Atony Severe Constipation
/24
Salbutamol under 2 years :

Less Effective


Protection .
/25
Orphenadrine :
Muscle relaxant

Fetal worm
Reproduction

 .. Norflex
.. ..
Orphenadrine
..
!!
.. .
/26
Severe Vomiting In Child :



Zantac i.v or i.v.i
:
Slow intravenous 2 mg /kg over 2 minutes

slow i.v.i over 10 minutes on 20ml normal saline
.

/27
Gentamycin :

3 mg / kg
2- 3
Single dose
5%

" ..
" .
..
..
.. ..
..
:
.. Severe infection
.. -

 Not renal impaired

..
plasma gentamicin level
1 ..
/28
: post-menopausal osteoporosis
..
:
Oestrogen Replacement
Raloxifene Evista
Calcitonin
D
Alendronate Fosamax
osteomax
. D
..
Fractures other comp.

 pain management Post-M.O.

NSAIDS narcotics Nerve blockers
melocam . ..
COX2 inhibitors
.. Celebrex


..
:
..
.
/29
: Steven Jenson Syndrome
Life Threatening and Emergency Condition

:

 .. ..
" "

.. ..
:
Hepatic Impaired
Immune-compromised
Malnourished
Penicillin allergic
..
:




SJ.Syndrome
.

/30
:

..
:


.
: ..
.. ..
.. :
/
..
..
" : "
:
: Pneumonia

/31
diazepam anxiety
:
0.12-0.8 mg/kg/day PO

0.04-0.2 mg/kg IM/IV

/32
: Ergotamine

..
..
:
/
Marked vasoconstrictor
/

 / any risk factor

/ " "
uterine contractions
restrict by its v.c effect bl.supply to fetus
/ :
Macrolides antidepressant antifungal
: 2 mg at attack
.. ..
.. .
: side effect ..
nausea and vomiting following 1st dose
:
v.c effect
prolonged therapy
Flunarizine Sibeliu
: " "
.

 :
:
/
:
/ " "
:
NSAID injection voltaren , liometacine,
ketofan
:
Liometacin,visceralgine,dexamethasone,
atropine, avil , glucolynamine , lasix
:
: NSAID

renal impairment
) NSAID (
Renal and hepatic impairment

 acute renal failure

- dolphin - acute renal
failure !!
.
- -
impacted stones
calcular anuria
emergency interference to relieve the
obstruction

history of bilateral stone

.
:
:
: guide line iv
drip central pain killer pethidine

 : renal colic gastritis

reflex gastritis
.. stress ulcer


acute gastritis
.
: - -

- -
\

severe back pressure on both kidneys
calcular anuria
pressure overload
vital signs .

/
:
:
/ antidematous drugs reparil
alphintern ..
. digestive enzymes
/ muscle spasm
Muscle relaxant i.v
respiratory apnea
Myolax Profenid Gel
.. .
/
Enzyme inhibition in the liver
half life Tegretol
Enzyme inducers

 10 mg/kg/day
15-25 mg/kg/day
. Tremors
/ culture



organism
e.coli klebsiella
e.coli
meronem tienam
..
+ .

/
:
: dr_muslema
: : streptococcal tonsillitis
/ broad spectrum antibiotic
infection gram +ve spectrum
:
Erythromythin /
1st generation cephalosporins as ceporex /
Also , oral penicillin is very effective as ospen.
/ .
/ 3rd G. Cephalosporins .
/ oral .
/ strept Nasal
discharge Watery Mucoid

 : UTI :
/ asymptomatic
Fever+ dysuria
:
sever napkin dermatitis /valvovaginitis
irritation wet diaper .
/ Broad spectrum antibiotic
Emox /ceporex culture
sulpha / amino glycosids/nitrofurnatoin
Very Effective
/ Recurrent UTI
renal function CRF reflux
calculi US IVP
long term prophylaxis
broad spectrum resistance
nitrfurnatoin

 / alkalizing agent epimag or

citromag aminoglycosids
/ UTI antipyretic
bladder analgesics
Wash Urinary System sulpha
) (septazol calculi
/
" " :
: / " "

/ -
"" 3 successive days only
/ + gastric
irritation and vomiting
/ macrolides erythromycin
.
/ .

 / G6PDD diclofenac , brufen

.
/ .
/ side effects


.
/
" " :
: / " "
/ primpran amp
extra pyramidal manifestations
reversible
.
/
Rey's Syndrome
.

 :
anti pyretic .
/
dehydration

anti biotic
)cefoperazon (cefozon
50 mg/kg/day
enterohepatic circulation

dehydration
.

 :
HYPERTESION MANAGEMENT
:
/ :
:
"
" ..
..
..
..
:
3 3 :
/
/ Stage 1
/ Stage 2
.. ..
..

 :
Stage .. ..
:

CBC
Creatinine
Fasting Glucose
total Cholesterol
HDL
+
Urine analysis
ECG
:

Cardiac problem

Risk factor

Diabetes

Renal Problem

 :
" Life-style
modifications Drug-therapy
" " ..
:

" "
/ .. ..
Life-style ..
" Life-Style "
/ .. ..
Life-style ..
.. ..
/ " " Stage 1 3 :
/ " " ..
life-style 3 ..
stage / ..

 / Risk factors " " ..

.. .. life-style
.. .. /
..
/
.. .. ..
stage 1
/ stage 2
..
:
Hi-normal .. without D.M .. life-style only
Hi-normal .. with D.M .. Drug-Therapy
Stage 1 .. without risk.fs nor cardiac or renal
problem nor D.M .. Life-style only and recheck
after 3 months

" Stage 1 .. with 1 risk factor " as hyperlipedimia

but no other problems nor D.M .. life-style only
and recheck after 3 months

Stage 1 .. with more risk.fs and other problems

or D.M .. Drug Therapy
Stage 2 .. drug therapy
/ :

Be a good picker for drug , to benefit ur patient

Life style modifications :

"
" ..

.. ..

 :
A/ Diuretics
- -
"
.. .. B
blockers .. " ..

..

k-sparing diuretic
" " :
A/
Frank Diuretics
" Combined : ".
: indapamide
:
Diurex-Natrilix-Natrilix SR-Inamide
: Severity

 : Furesemide
:
Lasix 40- Lafurex 20 , 40
: .. 40 ..
.. .. ..
..
: Spironolactone
:
Aldactone 25 , 100-Epilactone 25- Spectone 100
: .. ..
B/
Combined Diuretics :
1/
: k-sparing
Hydro.C.Thiazide + Spironolactone

Aldactazide-Spirozide

Furesmide + Spironolactone

Lasilactone 50 ,100
2/
B-Blockers :

.. ..
: 10 .
:
Chlorthalidone + Atenolol

Blokium diu - Tenedone

Amiloride + Atenolol

Atenoretic Teklo

H.C.Thiazide + Bisoprolol

Lodoz 2.5, 5, 10 - Concor plus

3/
ACE-Inhibitors :
H.C.Thiaz.
:

Benazapril

Cibadrex

Captopril

Capozide - Farcopril plus - Capojed-H

Enalapril

Ezapril-co - Co-renitac

B/ Beta Blockers


Cardiac morbidity and mortality
..

Some Worse clinical outcome
20%
coronary events 40%
MI ..
:
Uncomplicated hypertension

monotherapy 1st line ttt
Of-Choice :
1/
Complicated HTN
angina post-MI Arrhythmia CHF

2/
HTN + Frequent migraine attacks
HTN + Resting Tachycardia
HTN+ Palpitation
3/
Uncontrolled HTN by Other ttt. Lines
8
:
Brady-cardiac
Broncho-Athmatic
has peripheral circulatory disturbances
has untreated Myocardial Insufficiency
.. ..

BisoProlol and Metoprolol
: " "
Metoprolol , in :
Betaloc-Betacor
. :
Bisoprolol , in :
Combined Free
Hydrocholorthiazide

 : free
Concor 2.5 , 5 , 10
:
Selected individually
5 10
..
: compined

Lodoz 2.5/5/10
Concor plus
.
C/ ACE-Inhibitors :
ACEI
Early carido-renal and multi-organ Death
.
CHF
Heart Attacks Stroke
..
:
ACEI = HTN + CHF + or - D.M


Diabetic Nephropathy
ACEI
.. ..
i.e

decrease ACEI elimination
Impaired renal
:

Renal artery stenosis
..
:
1/
side effect Cough
..
2/
ACEI
Angionecrotic edema .

" ACEI " :

" "
:
Captopril
:
Capoten 25,50 - Capotril 25,50
:

" Postural
" Hypotension
- -

HY.Ch.Thiaz.
:
:
Capozide - Farcopril plus - Capojed-HHypodress-D

 :
Enalapril
:
Enalapril 5 ,20 - Ezapril 10,20Renitac 5,20
:


Compined H.C.Thiazide

co :

Co-Renitac
Ezapril-Co
or
Thiazopril

 :
ACEI HY.C.Thiazide
" "
" " :
Cibadrex 10/12.5 - Cibadrex 10/25
" "

MonoZide 10/12.5 - MonoZide 20/12.5

" " ACEI

Tritace comp 5/25

Tritace Ls 2.5/12.5

:
one or 2 tablets " 2.5 or 5 or 10 or 20 " daily

 :

HYPERTESION EMEREGENCY
:
" "

/ EOD
End organ damage
:
The most common clinical presentations of
hypertensive emergencies include :

A/Acute left ventricular failure

:
Fine bilateral and basal crepitations then
bubbling sound may be heard
Pulmonary edema

 :
Lowering preload by :
R/lasix
&
R/nitroglycerin I.V

Lowering after load by :

R/ACEIs


B/Acute aortic dissection
Aneurism


Unequal pulse


:
BB V.Dilators


Nifedipin and Na nitroprussiad
shearing force

Brain auto regulation & stroke risk

.

C/Acute coronary syndrome &Ischemia

Ischemia

sympathetic pathway
:
R/Nitrate
R/BB
R/morphine
MI streptokinase
180/100

D/Acute intracranial stroke Hag. Vs Infarction

Hypertensive
emergency
Disturbed Brain auto
regulation
Good perfusion


AHA :
Infarction stroke
220/120
%
Thrombolytic
185/110

R/sodium nitroprusside IV

 ) (

impaired neurogenic control of cardiovascular
system

.
Hag. stroke
re-bleeding
/
%

dihydropiridine calcium blocker
R/Norvasc
OR
R/Epilat retard


Antagonize cerebral vasospasm that occur with
intracranial Hag.
Vasospasm
VC

E/ Hypertensive encephalopathy

:
Brain Hyper perfusion
Cerebral Edema

Vasospasm
vasospasm cerebral ischemia


.
:
R/sodium nitroprusside IV

cerebral blood flow
20%
:

 Hypertensive encephalopathy

Hypertensive
encephalopathy

acute glomerular nephropathy / Eclampsia

:
R/Mgso4
AND / OR
R/methyldopa
AND / OR
R/hydralazine
AND / OR
R/Nitroprusside

Hypertension Emergency

 :
HYPERTESION Urgency

: /




End Organ Damage
: %

/


-
-
.

 / /
:
COMMON MISTAKES
In
DOCTOR'S PRESCRIPTIONS
By
Dr / Abdullah Rabie3 Ezz
BENHA Medical School EGYPT

:
/ :
Http://www.egymedicine.net
/ " "
/ " "
/ " "