เวชบำบัดวิกฤตพื้นฐาน Fundamental in Critical Care

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Fundomeniol in Criticol Core

6nrriil 10

l1. Approach to Criticatty patients 48

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'117
ruulyn{'lun1?E un {rJ.runrlndfi f, rlJrrtrnr u,:su drnfifn finur ulrvr rT 127
nn?uni gftfittg 149
171
3. n r16uufi'r6to nr:fn r*rtun rt g ua {rj.runr.In 190

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4. Practical CPR algorithm 2010

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5. Post-Cardiac Arrest Car6

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qinf nawgj

6. Practical and uselul Monitoring parameterc for Critically lll patients

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7 Shock Early Assessm€nt
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8, Vascular Access

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9. Hemodynamic Monitoring

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10. Central Venous Pressure

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11. Fluid Therapy

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Vasoactive Drugs

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'13, Tissue Psrfusion 215
223
nnSuni 0frfi119 234
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14. Cardiogenic Shock 277

qlni nan{ 295
307
15. EKG: Cardiac 330
337
qinf noo! 354
383
16. EKG: Non Cardiac 415
453
q{n! now! 470

17. Septic Shock: Approach and Managam6nt

T,ni ililfiui
q{nf no'togi
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ta. nrrrdrn'qaoit Surviving Sepsis Campaign Guidelina 2012

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19. Mechanical Ventilation: Modes and Settings

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20. Bird's Ventilator

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21. nlirJfrLrnlo{drufl'rulqtul:nfiiant;drt1
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22. Tailored Made Ventilator Adiustm€nt

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zs. n1lrrfihfl r1t4tfo.,rdurfrolfi rnio,,::iru rsb

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24- RBspiratory Waveform Interpretation

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25, Noninvasive Positive Pressure Ventilation

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26. Weaning from Mechanical Ventilator

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27. Merial Blood Gas Analysis and Clinical Application 618

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28. Short Note in Prortable Ch€st X-ray Interpretation

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29. Management of Acute Kidney Injury

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ou. Sodium and Water Disord€rs

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31. Fota$ium Disord€rs

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32. Sedation, Analgesia and Neuromuscular Blocl€de in ICU

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39. nfl ytrlsnrrrnndfinrr.lrulunrrgm{rhuntr:inqn

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Approach to Critically lll patients

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un:inqn niruunnti{rfiuT io':riunrrgrrn{il'lunfn uiorm:r'rfninqnu&u rldo.rfieruiunyn-nur
rfluorir'-rfilur1nf,qnr rdo'lfi{rrT uinqqroniin mvnrurrnT:nlflurir finrrvumndarrrjuu u",

lfininurnrriountqo

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orn r#{e cldn cirrlfluurnr ud

annnrna'rf;rhuinqn
{ilrainqolflu{:Jradflnrrfr,r.ruro,rrluurdll n?suiarnrurv:.ruroruoiur; yrh.oru

fiilrva'lati'r.:rdu! n'u nSordu'rrionrrfi lflnrodroli!,uudu *n:nirtr{{:-hrJrfiu6inld.iirjldiir
nr:5ncr

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rirtriaiar:eir-:1 rirmuldnern.,rrlanqnnh,rru lu{r.1ru#uflnfirlrjlfiiunrzfnurar.irognfio,run;
fi'urir$

. ri'eotirr{r-hudinrrrrdurdofu?cc:dr.r'rufilr nrfio {rJru#ii acute coronary syndrome

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aucutflut?n

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drrquu':.'rrrnduourfiu6inlfiloulSrfirlrildi!nrrfnurodr':qndo': rravrlurrar

ilmif,?riilslxalfirJauinqn (pathophysblogy of critically ill patients)

gfi{rluinqno;nornnnruernfiurrqrs,,:1:nunyndun:ru uridrfifiituiu6o nrrvriufia':

purrvrodc:rirlfifinr:drtrutotoilrteir',r1 rfrulilotir': rdtrlvrnu :la tir ttn;fin::l.1 n1lno\:

I:noorfi adrirb{nr''ulut,to,firdt run'rlfi {r-tru r6trSiold

1:nr3onrruluu:.,rIeun:.rfili{tiar"ur:dr.,:1 rdaumirfiotirlriuwrri'ulduri qt"fit}rqlurr:l

sia oruoiar: (severe multiple trauma) ql-firnq1v'illfiprr:.: (severe burn) vial:nn'lrjou
dnrnl,qurr:,: (severe pancreatiris) ddl'lfiflx-u'trsi're 1 \rJo'rrr:nri'rtrfirild rirunlrr.rftq:Jrnfi'lu

:;rJul?rnrluurfioq niu 6on lri'irqc lflue.rncrrvq'lor;rirtfifiilrufi tissue hypoxia Q1nnll1']o
16oo11o,:oiurysill r'rtfiota.xoir,t1 rdotnrirdorjr,::rn15r lmuttipte organ dysfunction) fl'l:
rfietnlty'rhrdufioi,rvrz'lri'jro;lfinOrrnqto':t'rhro.rnio tfioornnrrllfto:1n6fl'l{ metabolic (du
hyperkalemia. hypokatemia, hypercatcemia, hypocalcemia) fiortdrtri{16u rfion1;ri'rlctqo
rduorn ventricutar fibrilation ri'ue;rfr}J{nr:r6ludi0 fiiorfinnr?vfanld tunr'lndlfi'u nr:d

aiur: io:yluvfi.rt rdorurirfin.oororir'h{rfionluftn n6rr.,i metabolic fiordoir.nndu oro

rirlfinrrdr.,:ruraroiur:niru6u1 rfiulrJ lu{rJrurfiafiinld:raa:rdumaluurBoi:irurlou
:rilvlonpldri'ruwu4fifi t

nrr:Jfirihinur{rl2senqn (approach to criticallv ill patients}1

rda{erndnu ;tat{r-truinqn#finrrl.r1ull:olrin':fr rrn;rdu,:rdanr:rfru6inTaurirrirr rmvd
flgunfi:Jruo;fio.Jfiuur6ntunr:rJfrrifiinu'rdunnoi'r.:qrnr{ilrurnr11l 6ouvrufiu Jn6o;olu.l:cdfi
n:rodronru{ 'lu nhnr:o:rqfiuYnofio.rilii6nr:oir.l1 lu'[dnr:ifiqdEillnttfirr-,rlfinr:inurl:Jsrril
riuoou uuolu{:-huinqnuo:{tJrnqnrduriu nr':ilfiilfiinuda.:t? e'lnnr: ::tfiuodr.::rol5r lrapid

assessment) n1: frrjhnr:f,fiin uianr:inrrqnriu (resuscitation) ornrfufu'fiinr:ins{u::u:

riorliiolfiornr:{rJrun.lii lstaoitlzationl finr':tflT ::i.t (monitoring) {r-[udrui6nr: rrwtniolfia

oiryr rdo6ontrnr:rirrfiuT:nuo:nr:inur ri.rdrruntilvfio.:'lfin, :inurohn'r'l;Ila (specific veat-
ment) l:Iutrnr td i,rfiudndr a

mflJ:cfiuoti1{xxal5x (rapid assessment)

drdrn'rp'lunr:fnuT {rlrainqm'lfir.J:;R srndrrSe6s nr:ifildutrfi1d'lr{rhuriuo{lunrr;
inqnniolrj firrflu firhuoglunT:or'l: rdu uwrr{rfiufrrJrsfiornr:fiH lri$06 fioBtrrrfiu ffdar
arduir{:JruorefinT:6on t?arfiu{:-l':ofrnrutc}1a! t5r fiarfirr6a': frfi4{'lfinr:ifiqo'unrr:

Approach to Criticall,v Ill parients 'llain{ tixfina 3

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utugffi I ufifrn a16fli1jnt1Inununofi zulnqn

x'ru'lmlu (respiratory tairurel nr::J:;rfiudoriiu:J:cifidoirrfluuo:drd'qrririiolu{d'lur.ro.rd1,l

niu r-h;ifi1d:'rql6!ilqluur\r :vr6nr:r5lu6oq rjr:ifirSunriron arnr:fiuo.r ornr:ld jrr

nllfcfirYr-rarnrflrcor ddrA'cgdadryqrrudrrr (vitar signs) n'nnrw nrrfia:Jnrarffr n-nnruynr:rrulq :yntr

srme urlSsrfiunr:rdurdaor.rSoor:rir qooorunrrnmr'luudnc::!u rnlln-niln6fi
darldi!nr:insrlor u 15.l

ur'aluflrymrdrflu:Jqnrinqnro.rfi:Jruufir uvrnriccdo.,rifinr,:r'nsrotir.:rro r5r rfionrrqn
fitfiT:arrurlarmrruhjrjtofur:du1 rllo,irn-0fi'lfintiusr,lruro,:ar-urcrir{1 u.,ndrou1ric.u..,rn

n'uqild

nr:inurgnr6u (resuscitation and stabilization)

nr:fnurqnlf,ufi r-nqrJ:;crdrfi oo"onr:'lfi {r_hurfiuornnrr;inqnd*rrJ:;nor:drs nr.::

rirlonrarfiu nTx6on nrufio nn'rro metaboric nn:il-rlo ldufieri',lrr; lilofirJrur{uinrln vio

fi ulrnn::lrun r:t o,:nrr: inqor udr uvu rjq:ld"lfi nrrfnurqh rv,ncI:nri oIil

rlrlilfninrlnduSlu

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.ir{r-huo;doildilnr:innratjrlriurir.rfi (early) tmvntiinurovdalarrrr:n ttfiItn::!?un111D.t

I:n.[dorjr,,::rorrir loufilontru:ra.:nlringlddq tetr (goal directed therapy) n"?0j1111a',:n1:

fnurfia'rdu uur fi nd 1d rrri

. cardioputmonary resuscitation rrvryrfc;fi0.r{FlnrTtfid o.lfl1otfioafioun'j, 4 u1fi

. Septic shocka, r|lurido\r{o nr:tri{rtrurlutrnfio n Terunfl il 6'u1fl fi n n n"! d tnfudil n A
65(mean arterial pressure >
. :ovr 1u{:Jrudfinru6'u1aficrrlnfio{rn ) R'11: tissue

hypoxiald$rn1:ufil.fl 10ur-on1lrrdlm'?na,,:oonfirculufiooorfiaoritrqifino (superior

vena caval oxygen saturation) 1nn'i'l 70%

. Acule ischemic strore ulmfi:dol{onr:'1fi thrombolysis nrulu g drlrr

loudo4nniooo6nrT|#ti'lunr:inuriirdn3ruernnr:6nurodr'rg"enu (evidence based

information)

i6nr:tnun'r}id rfluornolunr:lfinr:Snurqnriulri'jro; rilunlx:'lsrq:'lfivfi'n ABcs Iqu A
6o airway xio{nnr;yrr.rrrutctrirf,aldobl{rlT unruhld. B 6o breathing tioo-onr:'hl{ilrunrutl

uo:muhodrworfiu{ ltflv c 6a circutation u?onr:{nnr:1fi:;:-rulynriuu16oondu{::d'lrJnfi

rdaufiln tissue hypoperfusion 1arofi{aunt{udrrfu{rjrudrflu cardiac arest u3osldu'i.|ev
rfiq cardiac arrest 'lfiri'rrfu CAB sequence n1x ACC/AHA guideline 20101 rta;ffiar1

ril:rurn1:inqnoir.rl t:rfiuld'j, nr:urunrlroflrnqil { tissue hypoxia ttni organ dysfunction
d.,rnr:rir u ril 6 oTqui6dl iv rrfi rynr ri't n ejridlo anr.t

nr:li]nilr.tr1uh (airway management)

{rl.ltrinqn\j,irl: rflun1;'torino;fi:;dlnrrin6nno.r (alteration of consciousness) e1n
cerebral perfusion inoAdUn'nyfan fiioq'lnR1 ftgl n6rn1{ metabolic niu hypoxia, metabolic
acidosis, azotemia nismnrou}nrSonr:n:vrln:v tfioudcrol nr:fi:vd'lnr:fA6fiaurirti{rhu

orofidunn nioinr:qofturnr,l 6urr omnrotyvnioriraru :lrrYrarur:dcpr6vrurur ioulfi

mr,rrfiunruhvrtgnqnfiur'r'tri{rhunrtrtodrurn lrnoonitqu nnoatutfinnr:fiotdo'lu onl'rnnrr

qnd1n"fl

nr:ionr:'lfir'r''tvrule riJoloi,til::no1firfl n1:rl:s rfiurr'ovrutl'irfinrniruacnrnvialri
fir-lruorqfiornr:uaor,rto.':nrrfiru'lq [fl']eirurn riur lrifinlvrutrl.irurfiraon ttncltJnCfr firfinr:
qcuYupu:,r 'lu:rufrfinr:qorYul rne:fio16u,r ru'lcrdrldrfiu.rd'l lourovrr;odr':0'ttfiul stridor

ilrdlarnr:lrulor{rdrurn niu rXnuruluriroluler{r 6aring of alar nasi) unvnt:dlso.l
suorasternal notch r.tnl lutardr rfior,udnuru:niud uvrn6o;do,,rrflqrr',1vru'tolnun'r:{nir
uou{rJrurflu head ti6-chin tift lurnoldu cervical spine iniury lfirir jaw thrust) rrolrirdoi.l
ru anrjnol un v tolu;lurjrn nnaocu'lddafi r ulc f,rbinr r:n rfl nfl 'rona'ldd

Approach to Criticall.v lll patients 'lvsimi $iufiOa s

nr:rirurnuh ft reathing)

rdorflonr,nrrulo{rJ'ruldudr unvrrir:do.rrJ::du'ir{rJruurr'lolftaiiilrj fi11{ruhlrjld uyrnrj

cvfia,rli'lu rulo (respiratory support) 'lu{rJrudnru'lcldrsrlcdo.,rldfunrr:Jr: rfiuirnr,hld

nonlu.rflSold lnuriudn:rfiru'h d.rnr:o{:vn'h.r t o-zo ni,vurfi 1u{:lrldmu'hdr (ern metaboric

encephatopathy fi?olrnur miasr:fiurlniin; orrdooldfunr.:drunruhrdufiu

{rJrunrrldfunrr:Jrv rfiu'irnru'leohurnnislri nsrfiru'lcrdrn:rlrn unvmulooontirlrn
tnan"nuruvnrruruhrirn'ru'rnldnsirulrdrdrrdu drunr:uru'leoonnrurnrvd{rnncrnfi rufi
nr:ldndurda intercostat muscte llnsnd.urdanrjrrio.r (rectus abdominis) lun1:nrulcoan
fl.rolrru'hldrdur wheeze lurjromulman {,Jrudinr:yru'lgdrrrnnr:ldfi.rnr:drurfi6onr!

rrrlfimmnu $iu nr:oronidqrs nslunruGufiru'h nrr'tfiu..nriulurufinaonl'llli rudnrm u
bronchospasm nnocnunr:ldyiorrutl unv,riru ru'lo rdo{:_truornrrlilddn

{:hudldiunrrti?unrs'lqodro' orrfinr:nruhn:lu, nld rvurin'n:J:cfiuTou'ldfin-nnr:

rfardu rnrpo':nr:nrulorirurnlu[:Jrunojldorlrfluornviaurulofinr:qn,rt r.n,*rn, JuiiJn
niodurfiu\J {rhufinT:godrn-n finrrfiarrdalunnaoo [ncrlaottrrfirJ (venrirator
pn€umonia. VApl fi volume overtoad rioelnolfr'luriaoJao (pneumorhorax) """o"i",*

nr:inrr:cuulilariuu (circulation)

n"ldldnsiranrrdr'lufunaunralfrifinr:riruiiq ud.,rlrnn'uvrnririrgnr:nra'lcudr o'ud1r
siolj6o nrnJ::rfiu:vlulrnriuu6ao tun{l{r-hudfi cardiac arr.st ayfio,,:ldfunrrrir enernal

cardiac massage n1l|lr1r?1r'rnnD{n1r:Jfi'tifinrnirufiln (cardiopumonary resusciration, cpR)

siru{r-hu6urvfio,,rldfunr:rj:rrfiu'iroflunmvdanniolri rr:r:ntr6on .olan6onrrdrruorrar

r;r.rylnorialrfiaordlvriraoninul:Jrdu.ltdordorirrl uovo:d.,rcrnli{:Jrsfinr:yrh.,rruraror-urv
rir.r1 fi I rror wrdudinlun'qo

rirnrrld'uTnfin unvfirr':nrm'nlfludorirdro,r tissue pedusionld udfii'i.rn-ori,iludru

trnfieiinr:uncrvd!nrr o:16uons$o4n lnavr"rl,rJrirnrl.rn-u1nfinrodu lmean arreriar pressure,
MAP) fioun'j1 65 rJr,.:har ilwon'jthjrufinrr:6on ud{rhuirfruLnnmr.rn-ulnftnn,.:orjr6rorr
fint;6onrir1 deir rean arteriar pressure unn,jrra'.dr.:du rryurjerdotq.l:yrinr,rrldduxo

mnnr:q:roirrnrudul rr:iru'lunrr:J:lrfiu rtiu capiflary tifling time 6lfirnri,,: r:dlorlrfofi

oluru:Joom:

rdonmlnu'ir{:Jrao{lunt:f;on unnriclda{uunrfinnmy6on.jrrflurfioloTnlorduio{o

otn :;in'uo:nr:o:rsdrrnru niu ':vlfrnr:rfrur6on rlvin'tfi rj.rvifirirurilon rj:yifrldiu

ql?ruq drr.rnfunrro:redr,rnruddrdry 60 vorume status Tounl:fr??o rdurfiaoo'rnjoo 6ugurar
vein), skin turgor ld !!nca'rn'rrufln{ro.,rnr:q'rrrda'luoiur:oir,r1 unvrdocrf,an.r?J cardiogenic

rrffdT doiflqndus'lu

shock utltrrjl;fiooyrinr:n:mfiu[do,':fiu 6onT :nT rcadulvtfltr'rlq (electrocardiographv' ECG)
rufl rn.nn:.tcr6oFtyltvo! cardiac enrymes rdofiucTunrrifqdulquvid nrrvfiannoi duon
;yfloorn cardiogenic shock a;fin1fl1nf,T Td{uvnaatdoFl n'r:inu'rc;rflulil'iuvlr'l rdurn'u fio
hio, tiratirt:rar5't

fivrr:firnlrri:aa::nrf'jiruiOnoc:nrifl.u:tdurrfui1drynS'ropbnjinurfiir'runr{orJr(uardrfhiy6thnmmiar)u'orrol5orflourno1ox{:fluonnlrdrr;dfiourniu{r-'thuunfirf:i
!ft rfiuuflntir:fio{:sitiqc-ufrfiiln6onrr:J:: tfiudlto: rrju {rJradldilur B-blocker

nr:innrsiolrl (post resuscitation management)

nr:innrrYuorousio!,lrnlornd{:;ur{uornn':inqn ua;fiorm:n,:dudr 6otfinr:inur
rJ:r6'lr.l:;no.:'[fi{r]ruhindl{arr:inqn6n (maintenance therapy fiio supportive therapy) Snur
I:nirrnrydriurnqouour'tuiSurl.ud (specitlc therapy) untn'llilo.rriuT:ntionrr:d rfiodu

::mirsnr:inur (preventive therapy)

nr:inflilrsdurjtvno{t (supportive therapy}

nr:fnurrl:;nurh:not 6onr:inrrrdo'hl{lruo,:6ino{ld nlonlqlnrvrli::n'j-ronr:

:aflnnr:inuroi ryr.r:I:n lsulrjr6h6inniondu\rJ{nm:inqn nr:inrrtrdrdosdorfio.:trnnr:

inr**iruGiorqn riu d,lrhnoudrunr:ingr r:du :vRoillsu l4nrtuul6an ftemodynamic

suppod) n1;?ufirulo rdarir'lfirdardooirll ldiuoanireudrfiu.rnootjrtciorda,,r rdu {1rufifi

pn"uronia fifi acute respiratory failure l,Lfl:6on urb{uflnnrr:6an {rJrufiornr:nofi
""u"r"
udr urdti,,rnldo.ildiunr:rjrlu, ubcial:hun'jrrjooo:6du nr:tnurlurofi:Jru
rua:ldiuu'rrJfriru:

fioqjlun{ld:l1funr:1fisrnir nr:1fif,,na1},r'r1 (nutritionat support) rY"ri6 enterat ltfl; parenteral

nr:in*r qttJarnr:rdanonrrr.t-lriqtaururir':1

n1'inulmllrq'hrurgla.:T:a (treatment of primary illness)

rflurirufiairdrpdqoodroudom:r;Hndlhsa.:nr:5nc1r:lrirfisrduloa rr:i{:,Jruo;ldirnr:

inur:l:;d'l r;no.16.luryrnluTnddryi{ofinu tu{rhudti,:lriy:runr:ifiqdu uvtrtiunvfirq;60':

aitfiunrwrdo4adrunr:nr:l:yr-fi rdrrfiu o:rqdr,:nruTsunv t6unLLnc{n'lfifinr:n:rodud'l'r rflu
sir,i,t v.:dTnfln'rfi.tnrn6fre:1d[nyflo{rl rfiuolorntlrir invasive investigation otiLdtlo

lu{:-huduvlntirrr!nr:ifiedutn[[fir c;fieoldi!nr:rr':rrnrunrrinurfr':n'r:tnur:lrv6'r-l
rh:cro,: un:nr:insrdrr ry r:iu {:-trudtfiiunr:drstlrshnrrldf!nrtmo uzuunqoldtaia'ldrl
nru'lo rdoo'rn.r:ffi nr:tfiurrJfrfiru:o;ldr'!nldiu til1urltr61ildiun1rinE1"i'lwrr;du1 6nviolri

o eir':1:

Approach ro criricall,v Ill patienls haiai dwftqn 7

:.rv rfiuddro'qii,wr':r'o{1udrud6o n1t?1\r uflunr:inulriuoyfio.rnhu'.,rfiolo{urrrdrnr
to:uxruvta.:firhu :trrv.rqoquJinrruarudriror-r{:Jra 1f,r{rJauJfinn-r61 un:ryr6rtr-hurola

nr:florfiuarrvuil:nfrou flCU preventive care)

nr:fnuruiotirafiifl!ro;nr:inBriJ:td'r.nl:;naloir.:1 tum{rhuinqnrflunr:inurr.finr:
rirri'nonr: rtiu nr:ldvionrfllo rfrotirunruto{rhairtfi:vlrnra'hrru nr:'lderucruunon r6on
ln'olfior;rir tfinr:orm: ionruriutumonrfioq nr:'ldoruo?urlosn: rneirdd.utduorionr:fi

nrrsur:ndou ns.rr!fi'rirJfrfnnnr: d{:huorlinrrc un:ndoulrnnr:'ldqrJn:ni rdu fin pneu-

mothorax c'lnnrt'ldorucrumnan Goorir iniemar jugular vein rufiuir:rrorfiqrln:ofioir.r1 da{
luri'r{ilru rliu carheter related blood stream infection (cRBSt) ?'rnnlrnlf,.ru6l1uunan 6andr
drunnr.:'liurur

nrr:urrndoudrfioltunrsirdlrrni.rareluu:mufiuuiiin uioni{rhudaoogl:,,rviur:rn

n'irfinr: r5ladr'ld.iru ua:orqirtfifinr:rdourowrraiurc rf,oduld fiiruoruor ruu':rrtflarfiu

uunr:tfionrrvuvnndaurnsirdrr'ls niu r,:fla.orYu ventilator associated pneumonia rvnoir

dra nrrdr.'rfiaug.rriauunvndlodrru'gfirhu nr:{ar{:-hulfiuau6:u;grrJ.llu.rru 30-45" nr:ndrriol

r.Jrnfirhudra chbrhexidine nr:ni{nJrdd:,rogluaT uaoornioltjru ruto nr:ldvionrrihdorrr:n

86rf,Nxsun; secretion 'lu subglottic area ooon?unlinqnldrnio.:rirunlrlo1nar5rdqorio

nr.rndor},tdnr:1d (earty weaning) rfludu

ICU monitoring'

Monitoring 6anr:rflrr:i,rornr:laod ru Tnrllddornlrnn.r:n:moir.:1 uiu

. n11n:?eilrn1u (ctinicat monitortng) rdu n.l1nrl?fn vital signs nT2"oehuruf,oc,n:

siarirllr

. n'r:'ldrniolio niu nr:fonrubld'rloraanfirouorn:Jorudr (putse oximerry) n.m

n:rlndu},rlflrrirtloairlra'ordo.,,: (continuous EKG monitoring)

. nr:'ldrnio.rfi oirlnilnr:riirrinnnrtri.ul uiu nrrn:tioRrudurnoo16onoirdrunaro

(central venous pressure monitoring) nr:o:re,t"onrrtJd'u'luuogo6aouo,:lor:lao

(putmonary artery pressure) nr:inarrlduluroan rfioourr.lat.lxriardoo (arterial

pressure monitoring)

nTlrHr:yilarnrlta,,:drhufinrrtdr6'rgotir,,:lrntunr:guo{:Jruinqor rdo,,:ernnr:ra'rrfiu
I:naor{ilrafinr:r:ldauurJaorsrunyuvirrido,,,:finnrlnr:nirfiul;nrdarJ:ydunr:colf,ualdanr:

ttfnur [ncnlfiuorlurvrrlnr:lnurria}l riunlfilrcfia.:finllrirurq;tunr:rrdaln 6ol:dol

::n'uornr:nronfifinldarir.rgndor otrr':orirrl'ornnr:drduriolnilnrrftdrfluotir.,r6 ourrnu:Jo

nt!1ua'lnqnau5'11.1

Hn,fio4nfi1dlnruvr:rlrlcdufifi!.lndofla4n un t nr: tt anndalnldaajrt:olnal :tunltdlontt

rilr:;i.:dc'rriu'luna{rJruinqnr:lfi nai, r'(ulnrio1 l:J

Communication

nr:danr:rYl{rJrurn:E'1fi{il?flfiolfudrudrn'q'lunr:lJfrrjhl"nur{rJ'luinqn nr:door:fi6

rir'lfiurnduavfiuld{o4atol{rJrurrfianr:iiodtratirtgndo.,t flrr.tr:nlonnrrrirrfiuT:nil'.revril6uu

1ilor.ir,r:rn rEr#tvn.,:6lln:rr,:iru ttri{tJrtr llavryr6o-ur;rfiurl::lstrflunt:nno,: t6an ttutrr,tnr:
inurdarefi r't tFanvnrurrttiafinrrr r6iu,rq.r niu rfi'erfiunr:aird'nfnurrdrutfio:curuvuottio
rir{erurei,r6ordatuf,:-hu septic shock dtfinrrlrrdu.:tunrrnlT n'oq.l nr:door:dfirl:;firfinrlTrirtfr
fi rarm:n udsjrr5ruuri q1r6{ilraadrrt{rto rrn;fi ssucrou

nr:doar:d6un:arilaledr'hifrlnrunnrvn:uir.:{rhurro:rprFrflu}Jodr',::tl?u n::lru

nr:insr rfl ilrId'dr ud ao{on"n rrfi ,:6.rortjrlJ qinr:aofl a':iot'[d

Medical records

nr:nt{oXo{rJruluurt:vriuufintrudrn"q'lu{rJrannnu rra;finrudrd'r1€i.:1u{rhuinqn

rdomrn{rhunojrdl:ldirnr:n:re du (investigation) firurnn'jrttnvrjounir{rjrur{r1 1l 6nrfufi
nr:rirrTnnnr:fionfinllrdu''r finr:rirrfiul:ndtrotilra;url:r duuldirl rrov:-iou finr:insrfi

firrnun:omr druurja,,rldiril trn:ilouni,: nr:noliufin{orn{r.rfiu arirotflu:;:.lu nrrn'ro''tltlar
n{fufinrrnsrfi! consent {orm rfiafinr:li'rrinnnr:arir.la:lfiru :rln":-lnr::iufin progress note

odroorirrauorir'tfifirRur:nna'rrmrvrruflo4n'ludruoir'r1 lat{ilrilfiiru gnfiar d'uqt tflu

rJ:;lutriuri{rJrurot unvfi I lostal.rrvodr,tfi'ttfr ofidot-nrlfl{rfiedu

f,?:J

nrrquainur{rhuinqo'hildruo6un:firl:vilvinrnr.Yu urvt de:dosfinm rfir'lc'lua'nr+ru:

ro.r{ilrrfifiinqn#finlrvinqnfrfiarurda,uo.:nr:uduiinr,riaffl:n rm:ndoudlurr:r trtnrtilfr:r"fi
inurodr,rmorSrrfrotr{{:-hu:ao6inirrufiinr::"nurttq<ir lur:to.tnru t5u:Jru rHr:;ideru'ldi6

nr:drr1 arir,rmrrvor finr:doar:fi6n't'lufil:vn'jr,ruuvrtifrrlinurttal::u'jr,:firufi::{rJrarrn:

rgrfi 6nnetfrnr:o,,:da4nodrtnnfiotun;nrufiru ri':rilodq: tfluo{dil::nouddrrYryfiri, binnnr:

l-nBlqdTA6lqn,lllTAYal Y., \i

9l\t tQ t?

Approach ro Critically nl patlets bafurt fiisftqi 9

]onflf&t{6{

1. HodrlrueE B, Hern HG. An appmach to critically ill pati€,tts. West J Med 2001J ZS:3gA_gS.
2. Biwrs E Nguysn B, Havstad S. et al. Early Goal-Dir€ct€d lhsrapy in the Treatment ot SevBl€ S€p€is and Septic

Shock. N Eng J Msd 2001;345:1368-72

3. Dsllinger BP, Levy MM, Carlst JM, et al. Surviving S€psis Campaign: internatjonal guid€1nes for manag6ment of

sewrg s€psls and s€ptlc shock -2009. Crjt Car€ M€d 2008:96:A96_927.

4. Hovrell MD, €t al. Routins moflitodng of criticslly llt patients In: ltwin R$. (eds)lntensi'/€ Car€ Medicin€| fundtuani4

Lippincott williams & witkinc 2,m8235-55.

10

61 tlA H9rUtt ?€JUeU1 n' idldt'l

[[U']141\: [UnlTFl

ialtorautglttatom' a1 fl :uuu 6{'l145uun finu1 ltl^lvl€J

nn1unx nNwLUfi

{rhunm;inqn lflu{rh rfifior nr:ufn fiarnr: ttnva'ln1: ttdo\:lurr:$'luvar u::LLt.l

rirulur!rinrfluiqrnrvnm:uivotiaur6oa (hemodynamics) untflQYIT'1.1::llurlh lrespiratory
system) rranqlndorofirlerrtu:;ll6u1dr'hinr:nuainur{r-huurn un:finT trirbdoulrnlau}J6n
rinfinurrfl dv?o uvrrtifiqiltvriil-nfirrur6o'irnr:otrrn{rirur rirdurn rflunr:; rir'hilrlalrnqrra
fnur{:Jrun{ld ufifioi.rufirnr:quo{rIan{rftrildurnodr'rfifi4 rfia.rqrnfrrlur6o (concept) 'lu
nr:q ua{rJrrfifn lou nr:ounfiLltututirdlflur!rlmiir{rmrurrrrri{q rrainr+rodrturn rfiaternlri
1fi'ldnm:.rnrrur:n rarr:druorfl:nrosriMrriu rnrvrrititfio':finrrrferrlrRrr:r:nluartritr6ul dru

rdu dnunrani id'q€irar q6nronf tndtivrsrofifin errruitunr:nttnfiil'rutrin'lri'ld1firanr;

"luuo{rhu'la6grvir#u ri,:aru:arirnrrrf}.hhrqn6'ldl6'lutro{rhuarfiry n?ofio'rqnriu'ldfilu
dr'lfintrr:o:ira6in{rtrulfiniuvirsfi d.r Hnlfifirlefl fi a-o:r n rr:o o6iorge 'iu

dnurwra.:no{:Jeu

r. rf uro{rJrriifi nr:6nnrrrfl r::i't (monitoring) 1nr:llotlrtria rfi a.r

z. fi fi r unvrf ua :vrururnoqjluro{rhundoo 24 d'xT n

3. finr:rj:;oru,rruotirsrflu::utvtt'ir':firtu'rvrrifiinur fiulusrvrn firu unr6{irLrdrrJinur

rras!nfllnifll.Jnlrrrvrntinrm6u1 ttir mdtn: rin nr sn r vrrir:l"o

4, fi ltu.lvtr'olunrtinurflilrudtrirruorilurrurvrrt:JirlG (protocol) ttju weaning guideline.

septic shock guideline, AFDS guideline

uul r.tlunrnttn{ ']Bl4findfiflry rllfl1u:yuud1fliu{nfimrl &11116 nn?unf 0frfir1'5 11

a-nuluvro.ofril?u

t. {:-hufidqrgrrufill lvitat signsy lrin,td lar ranr:flqnrd.ru btood pressure, heart

rate Llay respiratory rale

:rz. {ilrur"ntfi:J:zi6hj'ld nia,rernfin.r:tdyiotirur,rruhua:raia{tiruyrutc fi,:nr:n:rc

irr n r adr-lde'rn"o
s. {r-hafnldiunrfnuruaru::1r1rvrior1 riu niu nrrld cenrrar venous catheter. n.r:

'ldrnia.,:rirun'ruh, nr:innrlnunr:y,lan 16oo ftemodiatysis). n1:rir plasmapheresis
+. {r1'lu'ldfunr:6nnurffr:;iruaru::ur.ruloll riu niu Ere monitor, pulse oximetry.

capnography, EEG monitor

s, {:-htfinruinnri{raor rijouliu!rfi uun"l{r-hrfir"nuriuno{r-lrtrorfry rdor*narnr:
rfnn.ir

dnrru:aotqr6
t . ryr6finrtrimnfi'.rrna,: fiornr:dolnnr.linuurnn.ir{:Jrutuna{rhacrfrg:Jn6

z. q;rfi fi nmr rniun lr,lni.wr:r1fi fi nrruf, nraonlri rmrr:o siofi uy{yrdfiinur

annnrcr alr llilildfi f; .rr.hcat fitunr:rJfi ri6,rrun uainrr {:Je unrin

1. finr:rirvrurflu:vu' io"ntl uaru (plan) riaunr:rir.,rrumua'ro-lnlldrd'rgiuoiruro.
ilrgnr rfio'lornfirJrunrinairu'lrdfiilqrrraru:vr.tt.lrrtalriu nr::-nur6rnr:tfinrudrd'qryl:vll
rAo4nttntlnnoutYU a; u

e. finrufrtugruiunr:qunfi:-huinqn !?iu cardiac arresr. shock. respiratory faiture.

renal failure, serious electrolyte imbalance, liver failure, seizure. abnormal bleeding

3. rfl!{frfin?riltdhlunr:oun{druorir,ro: 16ro rda.:ornriru.rufirJreryfnq:l rnrdo

r:Jis!rfiuuriuirurudrhuvY.rnlintuna{rJruarfq'tulruvrdurniufiarm:nrJiun"rtfi6nldodr,r

ri'ilr'lun :rfl {ilr ra ulunrr yan riu

+. fdn:J:rqnduocnr:uilar:{anr:iouofifii.rurumn Tosnr:uunuaydo4nlldruiirflu
iorfi cci,r uardo4aluiirui.irflun.lrrnlu horlud$rflull]ldril

s. :Jlnur*ryrricrrrrdrrl rfratfiualn.l: lntdo.rdrfit-jrnrurfiuto,:urrfortrrirrr

fl1N1?0d1ri1iliffr'ldc5'rrfi a'rln nur;nrriu{:Jrut5o1il

o. rniu ri'nuclunr:daar: (communication skitt) lnl ronr;r,rnu;tunr:'lfida1o*ri
{ilrurrnrqrfi T"nucnr:landn5.ru (breaking bad news} un:fin;'lunrtuirr:nrrlr-oufi,t

rrdo.:mnda,,rrJf riG.'rrudrllrfiqnarn:rnro::a-t ufl vfi fl 1nfi o.tu d14fl rlrisrfi

12 rlflildnlnqoduslu

q vi .ir. il qu1}lsl u:cu:J
unf,:Jeufi fi
rlnil1.:liln1xg

nlrq ra f, il? udfi fl ql1rvnl ul;llllliu mj,llddu z dru d'.od

1. n1:fnElfiLilun1:inB1?'1t$t'li (specific disease) dofinrrilchrrrY'lurroiocl:o Ldu nr:
inurl:n6ordoTouurdrulafir n'l:inuld?u steroids dlfii:rfiLhu sLE il4,tfia1n1lluur\t d'in1r
r-mr, lildruftilfi nttutnnrir:trnno{:-huorfirylrnrin

2. nr:incr r:nr :zno,t (supportive care) d.tfia riJunr:inurnd'nlulafg uaYrl'n rfr n'l?

inrrnrr:drirtfi{rhur.rraqjfi'loig nju shock, heart failure, respiratory .railure' acute kidney

iniury

Supportive care

f irsnc16uodnr:rier:nlrtutlpin;:;u:J fi',od

1. Hemodynamics
rran'tdrflu z riru 6o dtuflo.l macrocirculation lln: microcirculation

'lusiruso.r macircirculation ldrrri

1) Blood pressure'hinrudrri'qrYlnm:6on lnuflu'll1 inu1 mean arterial pressure

gvrnnl lfioqjd 65 rl. rofl tunrriiiifinrl.rd'uTnfiqqllrriou n-llfnul?:dr MAP non{njl MAP

rdilrirfiu zsy. lun:rfiiifi hypertensive crisis u3a hypertensive emergency n'l:flon?1ld'uTafin

'hjnr:norfrcurfiull fia;r?ue:rfiq organ ischemia lfi lnttanr:'lufi rs stroke

2) Heart ra'te'lfrffxrrrfrdrprl:-rnrrvrirhtfiufioc-'rtr; lnaralT r:firrirhrfiurioun'ir 60
nfrdourfi uiournnir too ni-rsiourfi fil rrvrvrri{fnur da,: fivt'nu:lu nr: dru EKG monitor finnll
dru EKc monitor nl:'lfin':rilau'letuil:cr6u1o,r rhythm. ST-T change, T wave inversion, QT

interval

3) nr:n:rrirtnr !:stfiu volume status rdu edema. skin turgor, .iugular venous

pressure (JVP). fine crepitation

4) Intaker' output balance ltinlldr6'r1'jr:J? rsurirlsu:rlrfiuriotro dolnr:f,'t:
rirrdrrfil aonr:rirfrtri r,riadorn,:firiroonlnanr:'hlurrfui.l6l''r?; (diuretic) r.r5olou dialysis
u3oLi nr:ntrnr:rirurruor:rirfinrnirc:rdrl:Iurleinvr-ur1nflltut'l ar rrn:ornr:d'hidr{r!J'lu

rusin;iu

; :rrs) vasopressor tLfl i notrope lfi nr I ldr dry n-ltfi n ua ;n'rur rulurol orarfr 'ld

fi ,rnrr:rwr:ndouiiarrrfi on*uqrnnrrldurtuturog.r

6) cenvat venous catheter trfinrrudrd'qluriotn'ruv ma.: nruaru 'lnuqlrnnrl
rirEii,:fi troon ii,l'lrjnr:lfiu right main bronchus rio'tcrnnrr finddrn'jrd rloruoruorq t{Tlil

rr xul{luf'rloufxsffndf{rUyl a10rJUUd1ffllfnffu j 1111{ nnfMi nffBJg 13

oHlu .igr,t atrium Jd' nmc rrr:nfoudorq rfioduqrnnr:lir centrat venous catheterization mu

pneumothorax. hemothorax lxtJfi\:fi,t cenval venous pressure (CVp) ttn:n,trrr n*n uonoand

!.lfio,rosr"rttv ofiuvr,r central venous catheter 'jrfinrta'nrfl! ttn.J v5ofi discharge yiolri lu

n:rfiiiaruoruornnr:d'r venesection (venous cutdown) lfi:Jfr:t-fi r:iu rd urn-u

7) Pulmonary artery catheter (fi1fi)

8) Pacemaker rflurn{o,:n::fiu{,:yrynrrlfiuta,rriric'ldtun:nifr{:hulitu oradycardia

frdo'hirfioornrr rrr-i.ildrfiu temporary pacemaker ufly permanent pacemaker 'ludru:ra.:

!temporary pacemaker u"':qrtJf :n rridd'tf transcutaneous temporary pacemaker LLR;
transvenous permanent pacemaker 'tfidtrnnit pacemaker rir.rrur.rSolrj o-n:rnr:rfiura,rrirlc
n:\t-n!igm\r i[']T:-a \.

Lxl

tudruro,l microcircutation lduri

1) Urine ourput 'ludrudorqJ:: rfiu:.ll.rfiun-r.r renat system ld

2) Capittary refitting test drdrnirrJnft 6o6.r poor tissue perfusion uddrr5rndnJnfi
oroda,,rrior:rurdru'jr{ilrua{lunrr! hyperdynamic state r?ah

s; 'lun:rfifior':'rold orod,ln:rc lactate level Scvo, (centrat venous oxygen saturation)

2. Cardiovascular syslem
1) Heart tailure lid,,rrnn intafer' output batance .j.r intake rJlnn.jr output yiaLj

urar!uan ::tnr heart lailure oDnrflu systolic heart failure r!0: diastolic heart failure nt:,]:
ruurrrr'lunr::-nurdrlniu :?rlfirdowr'tfl,ll nlln!fli{adnic{ (precipitating tactor) 'lunr:rfin

heart failure d'tu

2) Acute coronary syndrome ifiodridlquilr;ifi nrrn.nlndu!{flr#l'lo uny cardiac
muscte enzyme ttunoon'tdrflu e n{l6o ST etevation un3 non-ST etevation {i.:uriildlunr:

inurfiRlr unndrrriu 1fi:;fn:vr"l'lun'nu oarn cardiac muscle enzyme {ilfitolrnar dynrtr

n'r.]: (miu septic shock, RV dysfunction, muscle disease) uonqrnddot:vi,,rn1?yrrfiindau

:To u rav{r : nrr vfr'ln rdu ft o c-oyt rr n I nrr c rll tnda! otu

3) Peripheral vascular disease fiaeadr pulse 4 extremities !d o fi6?1 d16'rx-'h

{rJra aortic dissection, acute arteriat embotism lourolr:1u{,:-Jradtdur norepinephrine 'lu
{rJrufi rfi uroia peripherat vascutar disease arcfl"r'lfi aoor6oorfil1uu:rld

4) Pericardiat disease fiarr#r6"qtufir-hudlflu tuberculosis, matignancy. autoimmune

oisease fnrda'rfinfi,rrfrovrlnrilrirui,:fiT:roonfr une{n'nrruv grobular heart shape dafirrrfio.,r
nrrodr':nra'jrfin"nraucflo\r cardiac tamponade yishj:rln'anr:otrroafiulv{flry"r'le.jrfia-nuru;to*r

generalized low voltage y5ofi electriacal alternans yiobj

14 r'rndllininqmCr5lu

3. Respiratory system
1) nr:o:rodrinru trinrurird'qrilri'or:rnr:mu'lc'jrdr (bradypnea) fi54lir (tachyp-

neal dnuruvtotnlltlluto (respiratory pattern) 'jrrfluru-riln rriu Yru'hnoldu (rapid shallow

breathing), nruhfio!fin lototflu Kussmaul breathing vio central hyperventilation), filuh

r5rdrdnilrYu (Chyne-stokes respiration). fi'rfltqfirfiu.i striCor ii.lrj'rfi,] upper ainrvay obstruction,
n'r:vrulelou'ldnd'rludofio.o (rectus abdominis musclel d':ritfi,: lower airway obstruction v5o
diaphragmatic weakness uonalndrtl:n:?e:ttntuvtt.lt;:.tlu'rfl'le q;do''fl,i:Jondruvn-.:tola
rfio,rcrn rfluol'rttv .odtfio pneumonia fi50 atelectasis 16i1u

2) Endotracheal tuoe lfinrudrdqriutlro q"runriuran endotracheal tube dotq:rc

aaurYtn'trnrj.,,:fi upper incisor tto:sl'rttudo1a.t n1u endotracheal tube lolugelnnrvlrirufid
lt:?{Bn

3) Ventilator settings #lddeu'lvqi ldrrri eiro's ventilator, VcV (volume control

ventilation), PCV (pressure control ventilation), PSV (pressure support ventilation), SlIIV
(synchronous intermittent mandatory ventilation) do.,t6on'u parameters 'tuttoing mode d'tlnn

'lrnr:urrhror{rJru$o:rnda{drEiv'rulefiilfl'ui{fiuffioLj finT r: rm:ndou'tunr:'ldrnio{:iruvruh
nialil

4) chest x-ray lrifi nrrloh rflufifi aorirunlt:'rf,vr:r.oan4nriu duriuornr:un:arnr:
runn.rla.:{rJrud nJduuurla,'r 'lunr:iirr-rnrnrirufi5h:rton'lu{rJrunrinriu tfinrtrdrfi'rpriuqrun'l'r
rotnrrrirui,,rfin:?{on (exposure lechnique) oluRruun:viorirt'i (tube and line) ltn:vlurE-
antrfi r,uturl o o rirtc do,rfi o.t ttfl v mediasti n um

5) Arterial blood gas hjficrrruq"r rfludfioodtn:rorlniu dufi::ornr:tto;orfl't:rfln\t

ro.:{r-tru'iirrlfiuurt:Jn,r 'lun'r:ajru arterial blood gas fu do'':fiuu.-lldau'jrrfll arterial blood gas

qirfiialrj nrrdru oxygenation, ventilation uot acid-base imbalance rlnnir orjrut:.Jonaronr:

acid-base imbalance rfi u,,lodr,,r rdur

6) Secretion dotdr tnndnusu:lo,'t secretion fifinr:1116uurr nr d,,:arldri,rnrrv

ventilator associated pneumonia ryne1 rJ3r.nrul6oodoonfiurulrn ri,'rd'jrfitJruaqj'lunrr: massive

hemoptysis fiio alveolar hemorrhage a'nuructnut:dtflu pink frothy sputum rilddr{:-lrtaqj
'lunrr; pulmonary edema nio volume overload flTlriotrr:n'ldoru sucrion'ldfiiotdf,1u suction
ldlilqo fio':6nfi':n1rs endotracheal tube obstruction fio.:rirnr:dduu endotracheal tube ti'ufi

7) weaning fiotrilr:rullrfl:-huri.ifinrrildrrflufiortaiviotiruvrulcun:tir:do,':'l{rnio.r
rirlflrs'twSolri firlrifinrlrirrflu}i5l€rftJruaanqlnrnia.,,:drBfiruh rfl:r:nT :tdviadrunruh

no:tdrnio{drufir ouru a: [d a-n:r rduflunr:fi n ventilator associated pneumonia fi,ldrli

a'n:rnrlq,rdu

urxm0lxn1iauarhhuflrindfiilrur4,]ualo1:uuriluiurinilnt' \L$v{ @nluni qfrfit1lg ls

4. Renal system

1) n'nn:xad'Nn1u rdufinr: :yrfiu votume status, dnlnryla$joorr:fiaanrt,t Fotey

catheter. 6['ru Foley catheter d' niohj. finr?cn::rnrvrJcarrs 6r (fu btadder) nio.lil lu{rha

trunr:rir rectal examination rfron:refirnrrl benign prostatic hypertrophy (BpH) d.io1atflu

fll!fiq?Ja{ acute kidney iniury 1d 1fid{rnnfira.iflon'rrc :Jonrr:firfl6o,1rfil ru'lfflu{:_h#fi

dehydration nio jaundice ingrrrfinqr rquld'lufirl'lsiifi hematuria. intravascutar hemotysis

rio(hemoglobinuria) rhabdomyolysis (myoglobinuria)

2) Acute kidney injury (So1616o acute renal failure) fl{BT?on'l BUN, creatjnine

3t!R: urinalysis rfioc'r lflu rrunf,']rtrfifla\r acute kidney injury aonrflu ::n,lt 6o arru4otn

pre-renal, renal rro: post-renalTouda.luunortuq post-renal oonlfildriourolo 11nr:r'nr*r<itrtn:

lla;nr:5nur :;niu:J:yno.o 'hierrudrd''or_lu6olor:rirTnrfiarlfinu::a:ro.i acute kidney injury

iuflilruidfinrrr rdu,JRrtunr:rfiFt acute kidney inlury 1nt rau'r:{ilrtd'Ifi nephrotoxic drugs r.rio

contrast media do{trtar:rirtrlnlut arfl o

3) Renal replacement therapy (peritoneal dialysis. hemodialysis. continuous renal

replacement therapy) tfin:ronolfiari.tdlo.: renal replacement therapy lloin;rjr:rnyr erid'ulu

nr:inur rtnsnr:6nntr:ufir::i',: Inaualtynrrlfin nfitoe electrolvtes nr:fiqrtrtnrr d'ulnfifit
rro:odu}llfirll'rto'lu{rhufildilnr:rir hemodiatysis uSo continuous renat reptacement rherapy

4) Electrolytes and acid-base disorders.lrifinrrileilrfluyr'fio,tnl1e electrolytes

rnrTu nrrairn:rcfinruehrflulu{rJrufifinrr;fi'rlerfiufioo',rr,rr: ndrrrdotun'r:nrl'tedauu:,r

{rJrufrfiflaorrloon rn (potyuria) finruiliufia,,rfion1r potassium, catcium, phosphorus,
magnesium Inudatu n nn?ura'rilarnr:vrr,rn6fi nua;ndu\,,lflrri.:lodrtrola

5. Gastrointeslinal sysl€m

1; nrrm:roir.onru lfinrrucu'hfi:-rnt:rrfior Iaundice) ttR;a']nttuflntytrtyfirfio,:

(abdominat signs) aurnrou'u riu nrr:gr:tir'lurjo.rfial (ascites) lufi:hudfiornr: rctrlol

t6uu niu (acule abdomen) dorrir rectal examination rrn;atitfiltnr; liver dullness Ld a

2) Frequency of stoot passage fio,:lrtnrrudli'rgrrl{:Jrufifiorn'r:r{0..:rfiuy5ot4o,iHn

dilrufrfiarnr:fia.r 6ufia.rffinoonorn fecat incontinence rario lu{rhuiifiornr:fi0.:rfiuda,r6n

6I't!fiqfln enteral feeding drar.lnn*.,r riio,,:r, n bowet function un'o:iulrirrirn'u {ilruda{lu

1a6gfio,r:;i,rotir'lfirfinornr:rlorgn rfio.rqrnfi:hur fi'rdr-nfinr,:dr,:rurorn'.rlfidriounirrnfi

3) Gastrointestinal bleeding nu1firi.,r ,pp", ct ble€ding ttn: tower ct bteeding siru

ludfinrflu upper ct bteeding dr rilu'ldrYrnr run un:nrrvu :nfiouflnnr:fnnr{r-hlurin lu
airudrfluorrnnfiol usnaan rfu variceat bleeding !!n: non-variceat bteeoing {ilfirruur.,:'lu

nr:g ttninuroirrfi'u dru upper Gl bteeding drfiodr*rnilnr:inurfi:Jrsnrin rin rflu stress mucosal

16 rxrniT fainqndlrllu

retated utcer anelndtT.tfionthfi.lfitnrr'ltiurio,,:niu upper Gl bleeding lunilruvu"ndfidorild
flnurour:1u{rJrufifinurlil'lfirnia,rtirailru'leurunir 48 rirlu.,l uodu coagulopathy)

4) Acute abdomen conditions n'l1tl:?901n11[fl o.Jvl'].]fi uu'lrua\t qlu!i.\illlulluf!l r!!rn lq

ornr:ugallfilriforeu rdow'rn{rhun4ldrinlA sedation, analgesics ttio muscle relaxant ritlfi
nr:u arunfiernnrnldirfl nr'lr acute abdomen dnuldriouiuqrhunrin ldrrri peritoniris. acute

cholecystitis, ischemic bowel disease ltflc acute pancreatitis

6. Nutrition

1) Route of nutritional support fi z :J::tnl6a enteral nutrition un; parenteral
nutrition lun:ddhififloriuto,:nr:ldrr':t6uormr n'::tfion enteral nutrition lioulfltJo ilttour:n
t6an16nn'ruvrrt ldu nasogastric tube, gastrostomy tube, nasoduodenal tube, nasojejunal

tuue n:dii"hjn'rlr:nlfivrtrdrortr:ld6triqrtnlr tflu parenteral nutrition {i.:oro'hifl't.t central
vein uia peripherat vein ff'ld

2) Composition of nutritional support n'ri,lfi.:rJi}l.]rurn-,,:'tru (calories) d{rleuld:"1
n:;crudo6iru?o',ror:orvr:rdr,,:1 lduri protein, carbohydrate, fat, vitamin. mineral laurirfi''lfi,,t

I:nuo;nr, vii{rhurfu n"{ddo,l6qnl! blood sugar, electrolytes. BUN. creatinine, nilrogen

balance (dr.irtflu)

3) Complications of enterau parenteral nutrition n'nlrrrlndoufieirfi'rpto\t enteral
nutrition ddrn"q lduri diarrhea, ileus. feeding content [r6od1*t nrr:ul:ndousao parenteral
nutrition ddln't! lduri hyperglycemia, electrolytes imbalance, central line infection, cholestasis

lonmndnr:lfi nutritional support tu{tJru malnutrition lu:it,rll:n fiat::t"tnr:tfio refeeding

syndrome L6l a

7. Nen ous system

1) consciousness (level and content) fi0,:!r;tfiu:to"lnrruffrnoYrto.:{ilru1nuld

Glassgow coma score firfi:hufi:sn"ramlff,nn"rfi rrJduuu:.Jn''r datuunlfildro o'jrtfluf,rtvsr

c'rnluR o,r iouonauo.r fl'r u4ntuoro.:fiotuunriolil'jrto aT:noqjfi supratentoriat area rt5o

infratentorial "r"" rda.:crn rnrflu:os}n'lu inlratentorial area e:finl i!dru rnnirrdo{qrn

space un:rn'it 1u{:-hurrinfildur sedation ttn: muscle relaxant datvthnr:tuJnan:;o"rnru

1fl nn'lo?un?'ltJt: n::?{

2) flrU 'ryn*t*u!:l::aunar.:finurioulu{rhunrin ldttri cerebrovascutar disease,
status epilepticus. central nervous sysiem infection d.rdo.rn'rrldirnrrinurlouitehu

s1 flq;n'rndrlrdariauur.:lu{rhunrin d,,rfin'rrudrdqrdamrnorofiHorirhirfionrry

nrutldrunr (respiratory failure) d'lorlrfifnoul'rnfi::lu:J::g.trldrunnr.,t unr:vlutJ:lerrtdru
oru loutonrv peripheral nerve, neuromuscular junction. muscle fivilrjaululafig ldrrri

uu'rr1\{ nlinunrhhuufinfrfiflryt4lilnluryuudrl.lfufnfrnur utn{ ranluni pfrfit1r1 lj

myasthenia gravis. Guillian-Barre syndrome, critically ill neuromyopathy, myopathy elnu,l

tlflYnaInfio|,ldfiftnilfln'

8. Endocrine system

1) Blood sugar controt 6xrn nrrdu;hm1fltut6oafl1iag1ild?{ .140-1g0 n./nfl.

d,rlrifinruunnoirlrYu:;u'irolodgaru:n:aunylafisdaun::r dtnrrnrt.,nllunr?sinqnnxrtd
regular insulin fi'roonqnfdu mn{rJrari'rfi tissue hypoperfusion nr:'ld intravenous insutin

lvlrda,rcrnnrtlf insutin ur! subcutaneous injeaion orlr:nr.ri,rzuonr:oonqvrfld

2) Glycemic emergency ld'rrri trypogtycemia. diabetic ketoacidosis (DKA),
hyperglycemic hyperosmotar non-kerotic acidosis (HHNK) fi.,ldao'ldiunr:fnlrlouiudru n.n
1fi insulin 'lunurofia,rrrnrfrain:fl DKA rlay HHNK fia.r:yitnrr; hypokatemia d,:rfindrrril
'ldrono !r.:mfl rfi n hypokatemia luut{}J.tn drorofrtfi{rhuffiu6inld

3) Adrenat crisis fintudrfi'ru-1u{rhu6anfi'ldfior:u''rdrfiwuaufir !!n: vasopressor
rrdrfion,,rfin1?:6an folravrr:'tu septic shock lrir'hirfionrr: criticatty itt retated corticosleroid

insufficiency riatiun'jr clRcl) niaarelulfflu{rJrufildirnrrinrrfixu corticosteroids rJ'lriou

rtfl ? lnon'l: r11J!?ulu tt?.tfl3u

uinnradNr{u4r)irTrhfiyrvofitddn"rrl"rrilgoranro.ytnyroiddrYful nthctyioronidtecsrtis'tiusff!i!Jfrliulmfn)Dda(e.dlue:mlnarucoodm.aluRdlrdua:;.f,ilnld:yfirt-n.,rrr

tfia{qrnBUnrry non thyroidal illness (sick euthyroid synOrome) 1dr-iou

s1 du1 iiarorilfi ltiu pheochromocytoma d-re:fi:)ryrr'[un1:n.]llq blood pressure

9. Hematologic system
1) Anemia orrrqvr'r'ltlriat ld'rrri nrr:16aaoan nt:rqrsrfroo tdad{or:,re rnrfiul

nrrrfinrdaouo,:rrorn (hemolysis) rs{dfi0,:drnr:g perinherat btood smear iuniunr:nljrfin"runrj.r

16oooonfi lcirldrsrorio rioufr lrfior:rurtfi rfi an

2) Abnormalities ol white blood cell counts fi 2 ::rnn ldm leukooenia ttoc

leukocytosis lou teukopenia orqll'ld'tu febrite neutropenia i0 sepsis d1urrr,,r fi,:fio,rldiu

nr:inuri:lriru n11: teukocytosis arlrflunrrymolduo,lsianr:6qrdofr1uu:..: u6o hematotogic
malignancy dtarorfia tumor tysis syndrome dulrld

3) Bleeding tendency rfiafiflrpntianoon do.,rythnr:utnriou'jrlflu bcalized bteeding
trio systemic bleeding firrflu systemic bleeding 6.cfior:rurrio'jrrfiuflrpnrfi platelets, coagulation

factor riO fibrinolytic system 'trinr:d,:n5?C platelet count LLnt coagulogram lrnrfiunrU
e. 1t<llltrlourl!tJ!dt!na .nJl

4) Blood transfusion rfioq:ltirdooiliodru :vnolts,lrfion doirnrcnourouo.jr'hi
16oonnndount: doubte check rnlo fio.ln:rfil.irnrrtfir6aqniodru:l:;na:Jroi16ooore rfin

18 rltdlfninqnd sru

0-urlrlufit6iqriatrirtr'ld 6ofiatfiorsrTiltil1rti{drltu0tjrolnfifio bjnr:donr:}i16oqviodru
::no:.ruo.:rdaolnsl*fifiori,:ii' nju nr:dt fresh frozen plasma (FFP) IoufiXarJ::o,l6rfrorrir
:J3urruorlir'[uvaonrfiao niarfjarrfinrrl.lfin!nhrr,:rio':rJf,rifinrdnilrjfim:rirri'nnnr:lunruttd,l
lu{rhuinqnorinrt:rnb hemoglobinlid z-g nil/on. untiuurtnm:q:fnur:vd'! hemoglobin

1ld to nirlno. ldud acute bleeding (un[i portal hypertensive bleeding fio::"nur::nitl

nematocdt 'ljd 25Tol, acute coronary syndrome, n1: resuscitate sePtic shock tu O rirllrt rr:n
rrurr:nr:tfirdaoru'flnrifiarfin'r"r :;rio'::i.o triu chronic hemolytic anemia, hyperviscosity
syndrome ldo{crnnr:lfi rdanlune$mrirdlirlfirfi o heart faiture ld

10. Infection

1) Fever orrnqro'il{'lu{:J:rnin dru'lnrlrfioelnnl:fiotda urifidn.l'rurulririaufi

lrj'[d' rfiorqrnnrrfiordo nju drug {ever, thrombophlebi'tis, crystal induced arlhritis, deep venous
thrombosis. acute pancreatitis, myocardial infarction, intracranial tesion n"'lriuliia{:JrafiH6'l
lrlldfinrrnqrrornnr:6o16'orora}J nr:rirnr:n:rcdr,inrubin:rlfiru lrinr:drtrrrJfl6ru;1ou1rjfi

1l0U\:t

2) Gommon sources of inlection o'1!!t11-i.,1nr:fi4 rdofrnild au 6a cenlral venous

catheler, ventilator associated pneumonia (VAP), intraabdominal infection, urinary tract infection,
bed sore, sinusitis 1fifinrl.r::r.r-n:;r-,1'lunr:ifiodunrrfiordo'lu:;u.trtr.ot6utlf,ar?: (urinary tract

infection) 'lunrriifrfi pyuria drorcifiedutfiuoi',: da':drnr:onrldronruhin:ilfiruriau'hinr:incr
draur:J{'6ru:rmro

3) Infectious control and multidrugs resistant organisms nio.Jernfi ravfnfinl:

finrdofrlurr:,r {i':arrda,ria'rnulaut$ contact precaution. droplet precaution, airbome precaution
fidrfi'ryfrqo6onrrfirrfioorir,rgni6 Insfi'a.:drrfioriauuo:rd'rfi.rn.io{rhu lrirjrfiofilruhrfrurfl:-hu

lririrrioir:J:ovr (rririlru) lifidrrrGu,rao.r{rhu 'li stetho"cope rarrvfirha:rrrful fi.riinr:

:v6nl{60ln:-rus.rurornlu'hro,: rdoluuoin:1o6glrirufiaufi'u n-,:lYuriaudrurrJfr6ru:tun:dao,:
ntlfinrdo'lul:,rvru'rilrfl (nosocomial infection) err:flnurfiollaloo ur.r:.ruruuro':nrulrro.ldoh
T:.:urrurnriul riourora

+) nrrujaaorYulunr:rirfi'nnnrrro.runorn: drniufirj'lsii6nrda Hrv rrflr heoatitis

virus riud.rfi dornifirfi.,:raro

11. Skan

n"nuuc:aulinfifi:vri.,,:drulvqjr.r"nrfiocrnf,rurtur 6.Jfio.tfinmr.rf'jrduurfiur uri anfiu

minor drug rash fiu lltiur ttu!'lo tf u major drug rash (njt-t Sieven-Johnson syndrome, toxic

epidermal necrolysis, exfoliative dermatitis) d,rfiotrirnr:uqnurvr'ufi :oaI:ndfinrrruritd'ty6n
6onr:6ordo1uu:,r (severe infection) uonmndrT,:fi:ouTrndftrnri.:6u1 iifintuaird'rg ttju petichiae,
purpura, vasculitis, eschar 6'lfltl.l't:ndrruvl:alfi

rrrxrfl$hn1:auafilx0xrindfiflru.u.lualarclj1jd114i1lfnilnn l|tLnyti nn:run€ qfrfrrx| 19

12. Musculoskeletal: arthritis, fracture
Cryslat induced arthriris !fluflqJfi1nro1:oiodnlldrjau rinria}irfioornr:1tfi1ri.tf

tfuarrunernnr:6ordo odr.,rl:finlrrdanu{rtrudfif,qul acute monoarrhitis fiarifildauunl:nrrn
septic arthritis floutff a

rracture finl.ld':Jouiu{:-hunrin fnrltu{:-hug.:oradfi osreoporosis'io pathotogic
fracture oririouudr 6.rrfravrhfien::rJfluru1n!'r,iou'l\r niu bed bath vionfino'r arovrh'hirfio
fracture ld

13. Psychiatry: delirium, depression, psychosis
rdo,lernfi rJrililfndruinqjfnbjf fr n m".r 4olrilduiomr nTdvi orirunr u'lq ilhtrirfi nfl rgm

vrr{6errrldirflnir{ilrurh1:J uvrnJdorvr"rnr'::Jrv rfiu{rJru lnoiru!'jrrtrJ'1ufifi agitation u&uoglu

ndrornrrtn::y'i'r{ detirium. depression rlo psychosis rlr:rynr:fnsr unynr:ldartu{rJ.rtr

luoin: n ai urfufi nrrl un n o{rt flu

fidrdq6oornr:nr.rinnmio,r{Urtrnsird leruranr: detirium drulnqjfn rflul:nvrrt
n1u (organic causes; firirlfirfioornr:rr.,rinrrr o'.niurrnmfi.ror:finnrrrflr:;r-rolr4rliirdroro

ad,il:lufthldfi agitarion do{runorn{rhlfrfinruriurJro lpain; d.rdo.llfi anargesics 1rl,tri
tfiurnri benzodiazepine mia antipsychotic 'lunsjuo,r detirium 'ldurnaj:.r antipsychotic rJ'lr.i

ldtrrnsjr benzodiazepine tunr:inurrdo.olrnurn.l:{ulfirfio deririumld flnriu'lufi .ru detirium
tremens ii.,,:dodri benzodiazepine'lunr:inu.l

14. Pharmacology: review ot medications, drug interaction
fir-huyrinfinr:'ldutnrsrfio dtfilonrarfin:J4^fiiarriulunr:tfiur (drug interaction)

ornr:lt.lorir'tso.tfidruarq tfinmniJndr{ 16a{1a{ur rloorl rfiorrn:loi:tla.,:urlrin.,rfr uvlrrinr:
rrruun:rqfiornhd.rnrrinsr lq o'ir urd'ldfinrrilchrfluyialrirfiu.:ln n.:flrurflr ldurlfifioa

fiqorrvirfrar rflu}]1rfi

orir6 rJirifl'rnr nr:r-rriruro.,rur Terurorr:tun{rdmirun:'lnyrh,rrufinrlnfi or-ir,rl:

fiorrrnr:}iu'nlifiru;1unrlrdlndr,nurnndsariu ludrr zq rirlr.rru:n n1:'tfiu16rJruroMrr'

{rJrulrifinrrrlnvrdo,ryr,rlnr rda':qrnnr:lnurnr:60 rdaluu:ofio.,rld::niru'rdq,:vro'lutirt u:n

15. Surgery: post-operative surgical complications
rfra{rhurrinldirnr:njrsYeRcfinrry rrtndollrnnr:njrsr-arrfioduldirln'h{r]'ru6rlr6'r

q',niu uilvrrii.rfia.tu:ruirn'r:l,jrei'ofi{rl.ruldfiriuo:riahlrfionrrcuyt:ndouov'l:'ldrir',run:o:oua
{rjr u:T uriurdr oi'r mioo dr,rl:

16. Others: familial relationships, financial problems, legal problems

rfi o{ilrunrinrdr:bnr:fnnrtut:.0nlrl.rn unondrflurnduonernfi{ruudr qrfi

20 rrrnilininqndu5, u

ofiuto,rfirJrufifinrrHlnflrjldEi,rudouLin'jrrYu r-iouni'riryrfinajrdfnfinr:llan.:aonoio:lnnrnr

r1tnlr uvrflflrjtv rvf, ldoocrnr,rrl lniununlnruislnfi,lrn o-.:furl vlti6'lnr:qoqu fufi,,l *nc
.J
rl, tlSlr?u/ru16fllJXUnqxru

iu:r#f,:Jrafifindr *rvrifiotlt{tornr: tlnvnnnr:inur'l#{:Jruvr:rrL tu:rufir{:hufilri!

6lnn'r *rvrddo.:ud.:otnr:un;nt:innr Toulfidoqnlunrnr'ltrlfiuriqJ1Gflfiillo.o{:Jrulourirfi,lfi.:

:ldunr:dnuun:'1dnm;ro.,r{irfi.: firlfiioXodrflu:tun:t6uetnneurfiu'[rJororir'tfi{fufi.r

fuauun:u:lnnmurruto,,:ria4ofio}L rY',:drrvrnddo,rr{rh'i'r{rhuiifiornr:urinrtu filonrorfin
nm:inqrrldfnaanreor s,lfuirlilnrdfinrtrfuhrrri{rJrurpr6{rhuirarnr:o;urunSodduadr.:
rniuououn'jr {rJr uwfi unrr:inqnoi.t

'lugruvrinfinurunvrf riiafia.ttfifio4n rdurrYlnr:inrr{:Jru ltianr:u{mirr51fl (breaking
bad news) fiatlSnurunvrd::d'rriruuiollurfor{oriaurlnnie rfi01fi{o4ndlrtrrrd{rJrurtnv

rg'r 6 q n do 'r uo r vr:'r niu

nr:nhfi'nonr:1nadr't fi0.:tabart 0uEJo 'lunr:fnul (consent torml ntrdrrn tflu

u-qnnrrdfiorrirlunrr:qnliu (emergency procedure) rrnvrrinur:nrirl riauld rrfirrr{':rg16

fi:hm:ru'lunruun".t

rird'ulo'lrlrfitunr:u{tarnt: otonr:inur ta'lunlr.rOuuo unt:inur un:ta autopsy

tun5rultlJ:l?ulflut']n

t. crfi niur 1n:vr'tardrun4vrrlu (T? lqrlqJnr?tl)
e. ior rr:nrfitalfirun4trrrt

g. fr rio.:drriourrnrt6u'lniu

q. drlatirrfiornia rrnrr6EJrflu

5. :J Ejl nl ulu

o. ql ir rir or

nrudlyriudrarrgr6fi neimdr.':du 6aqmrdrril"uf,nru oru1afi n fi,r rfl u;rJ uunrudl.n{ud

dnlldritudrulurllud.,rallvru odrd:finrunnn:sunir'lalrildinerritlriuf,ia'rqrfin-.'rnrit
frsf,u 'lfi6ontraz-ulflu€.r niu luurrn:ounirinr r:qrrunrr.,lfi'u lrildogdruniuun:lilld

oqjn'r:r.1ori :1n:o{lunmr.rguaro.:ih rdorln:d'tdrdodottonlr.rEuuarornnt:ritvt-nnnr: 'hino

ornilrto.r{:-l'lu

rdo,llrnn'r::-nu, {rJrunrinrtu finirtddruq'r uvrrriar:ldvriuurn:iifioqjorir,rfirrir ldnrrr
orrr:n'lunr:quafnurfi Ts ua;rurur flolniunmc rrvl:ndouiirfindulfirioufiqn Mrdwrirli'

uu1fl1rhn1:n afrdrur4rindfiflry1.t1finiu:yuud1 fufinfinu lluali{ Mn?uni nfifrrvr 2l

nrafi uilfufinnrrri.r rfiuT:n
rda,,,nrn{r/ruinqor finr:r fi uur nmrano.rnl: olnrtuflor un;nr:inurfi rjarjn.jr!,iilru

to::ror n'',rusu6,lnrrriuuriufinlu,:runrroirfiuT:natir.:riour-uo; n:s,r iliaarer{uuu.lnn.j.rd

riTir rflu nr:rdsuriufinnr:rfrriul:n c::iruf,nnrrmr:uio4a un;ff*rrn:rvririolaotjr.'lrflu::uu
uanlrndlr'ufinnr:olrfiul:nflorfluron6['rryr']{n{firJ'ruarir.,rnu'-: iirorrr:nn:.roroilldnruyd{rrn
fiflqrrrfiadulunr:gua{rJru:ruriu uvrnrid'a{rcdnurcla.jr 6fu1crd1il1driuu fio.ird.rrtuldl#

nh uuvu"r'hfuiuu:iufinnr:rfrrfiul:nntrflrgrrro,,r{rlrulourfuulTufinnrur:llrdr.r1d,,ra:oaondo,,r

ri!nr:errrnfi ru un;r{rrftnt:inar

n1?d{[x:

finn'nn"'l'[rtd'.:d

1. derr:fi ruyln:rufr fi orn'r:rfn rionroirt;fi arnrrrfn
z. dt rr:'lfi nr;du trruu{,ofi ,rilcpnrfi r-h a fl ryuriorlrfi odl uo: uuryrrlufi'lr
s. fi,t:;finlirorJoir nr:ni''rrr:fi6cyrirutfifuhuldiilnr:fnr*ror.jrrriarfiar rirtr{fi:ha

:JoaorrYu

+ druir {ilr u1ula6 a d'arrir:r un: 16 Ern d'ra.jr fi:Jr u:rulndcrilrr n fl rfllfi d,: urrvl dfi fnur

darri'efiu'lcffr[eirrornorliu nialflfi rflunr::uriuvutifi orirr;
s, hiar:fi"'rnr::..rrudcrrr:nvrhldtunnrnarriutfhiuuntiiio girr:dr

fl'Hodrfiallf,ftJxufilin

1 . rniur{owor{r-hu nruJ un:rinuyfi .t'1fi ulunr:oun ftJrurrin
z. rfioir n: fir6n'irlrior r:nc?1:runc r6un16 tfilnllufinl{

o. rfi ofi {ilrofitnri trtfi{ilrunrfi ourrorrJnG
+.'lu:ru{ilruuirrio{rJruirri rfi o{rJrufi:lrynr fio{oon:rrnfiiri,rnroufi.jrq:ir',ruou

rfi u'fl,ofi orrr otird.,rnr:inu.rloslrildoonrrquarid'rurfl uo'unrn

s. rfio{r-Jrufirlrynrtulru;fia{rr: da,:liuufufinnr:r{rriuT:arnr.ra ur(.lro;h1rjfirhu

:rafinura.rfufimr

e. rl'rlriorrr:n ufllu1cgrrld tfirJinur uvrvrtir.l::chfiru un:orcrrfntJnln'r laudau
:ru.uru*ttri:;lh:irun?aorer:ffia..:rirnr:.:rl:r:lda4nun;:J::rfiufiaXnernfirhu

15u!SoErudr

drrj
'lunr:rflurinfinsrulrrfifu nrrn uafi:Jrunrin6a lflunr:fiq ua:nr:riuuifidrdry nrtrf

runvvr"nr*:fildrrnnr:gunfirJrurrinrfluildrn'nr-lunrrflnnluhhinilnutrrntifinrr i!fieaorlfin.rr:J

12 !2fiJlfninqnCq

flnilu !fiunruilto\:n, nillru rdorJfi:Ifilfirinfincruuflthvrfinn, 'uqflt'lunrrqrrnfnrn{rJeun{ld

rTnlrc$ncrcnnfiiilnfinerrilrdlf,iir'tunrtqun{rlrunrlnwrfludqrulunrliurmfl6d6siokilu

ou'tnn

n rtrfr surf,r #*r n r:ffnurtunrr g ua ffrJ r umrin

nn?uni ffimg

nr:rfi suirdl nr:inr*rlunr: g ua {rJr unrin

irftnlrinr*rtu{:Jruilfnil"nfilfluiruru*rrn d.,:orclirlfirfioR.nrffr-rsufiuunrnrifiingr
unsnururnfi funid.,rldf doriui.oinn-nrtir}fl u nr:d.rnr:fnur o-rd

t. lilfinr:fnurdru:Jrnt dr ds.niuuniluluird{nrdnutyirfil riuuoirflln:riiri.lsiru
anirialrr:orold niu lutru:ni cardiopurmonary resuscitation (cpn) drunvrriolrr:ndrnrr

inurfirr:hnuldrlfilau utolir cpn lsieudr {,,rrrriuun'rdrnr::-nurtunrsnn'.:
z. r{uuird.rnrrinr*rdrunrufioidri'rudru n.rorufi adslfiEiruasn uovo{:fdrr:sirdrrn

n*o

s. firddri.urnur{T finturirdrnr:inrr wrrr:fio,jrrfluroR5r1t1l1\rn0r4!1u rioriuufio lfi

l'nrirdanrtrif lridarnr:uoyarnrufi odadrrlulnattr
oose; 'lf+ir,iunu'rdooonlur::n"nhudrr'lnnnrr'rffnluunrr.rurio,rsofii.oluhiTrtidu'rnnrr'trri:EinJ.rlrvraiusonplroesruso{r,,:rnyrr:ntfilurur:rJnfl{fiilriwrdr.{rufinilsatlafit
{:Jruldiunrrinuradr'.rrfurir$

s. uuT Urrc"on'rdnlilnrrinurrflunall rdonrr rfiu:vrisli rtrlq:rlsoudrdrnr:fnur
1fiiru ffi vlhhluurlrndirdrd'rnrrinurnho'ruldirunruunvlrifiLnu

e. nr:rfiBuaif,tnr:innrhlnrriui.i'unvlror'lunrrdrnrrr-nurfirulnn*,: rdomrnlunrrgun

{lJrululaig nr:d'rnr:fnrrlrildd,rrfiu.r:i'r.rnourdruovqouduraliuMrusu rdooorn{:hufi

nrrrilfiuurldn,,.:arjr',rsio!do{ fufi0.,:rjfunid,,rnrrinryr'lfinr rveiJd!firJ.:uuo{n::radru

24 rltr-i1flRinqrlfiu5'tu

d'rodrtdobd riud'rorir.om:afunr:inrrluluird.rnr:innr druuyrriarurrnrir\Jrliu'ld
'Ifi mrrvorriu{rJruusio::'ttt

1. Bespiratory system
1) Endotracheal tuoe iun:rfiiildnfttt:n tfi:::puro tla;nrudntflutsufirr'rsrr rfiuurlu

upper incisor

2) Ventilator selting lio o*ygen preparation 6u lnasal cannula' oxygen mask' oxygen

mask with bag)

3) Parameter dfiotlilr:;ittunr:tdrnda.rriruvru'lo trju tidal volume' peak inspiratory

pressure. respiratory rate

4) Parameter frdolrilr:;irrfr'1il niu oxygen saturation, respiratory rate
5) chest x-ray 1ri.l'rrildo.rrirrlniu
6) Bronchodilator (fi']fi)

7) Intercostal drainage (lCD) 'ldrrri drurusrnfro{o ol apply suction uia clamp fl'lu
tco 6osrr itrrulfl.: lcD content ioon

Hemodynamics and cardiovascular system
'1) tvftuid o?fli1n1::rrornirrfunrodarov rfl'j'rq;rdrhfluurinl{u 1:rrorrr:rrn:urdru

tdu antibiotics)

2) vasopressors !!ng vasodilator orug biuono'fi:rfi'tfi nrtrldlflu tta:vlernr:n'rurru

turoro.rurllitiuu5ou {i{orerflu ug/kg/min u3o ugr/min lia mg/hr rrdrrrsi r:mvl

lalurfi'ld
3) Parameter frda':rHr::r"o 'l6rrri blood pressure, heart rate
4) EKG monitor tLn! EKG I z teads 'lu{rJrudfierrrrtfiltrionr:tfio arrhythmia lunrrfi

fio{luIofig lrifinrTr.rirrflufio'rd.: EKG monitor tr:tvtfluurn:3'ruro,rlo6gtunr':

gua{:JruaEjudr

s) rnio',rfiodu.i dfia.rriuulunhd,,rnr:inur 1firfi1 tdu pacemaker, intraaortic balloon

oumo

3. Renal system

1) lV tluid aT.n:o :ltfiu'l lriarufi'rJrirdln, :inurdru hemodynamics ld
2) Electrolytes and mineral correction 'lu{rLruiifiarnr:rfnlrn nr:usn lV line fild
'lunr:llfi electrolytes oone'ln lV tine d]dlun'r: resuscitation tdonrulridlouttn:n'irl

n'ElirJlri1ii\rnrinurlunr:4uafirlaorfrn on?uni gfrfittrg Zs

oann"atalftJru 1/lia vi,inr:6ooru electrolytes. mineral uny renatfunction test (BUN, creatinine)

t aa"tnlu

3) Parameter fifiarrilr:;r-.,r lduri urine output

4) Diarvsis order (firfi) lsun.r'irfi:hurir diatysis lnriEto rdu perironear diarysis.

hemodialysis, continuous renal replacement lherapy

4. Gl and nutrition
1) Enterar nutrition 'lfinelllx rJ3}|rsr:, carories uns trrnr protein fifi xu16fri ]Jon

nrrrun''lunr:tri route lunr:'hi ua:tri:lulr borus u6o NG drip Tor parameter fi6o,: rflr:;r-.,r

6o feeding content. NG content

2) Parenterat nutrition 1firfi1 trtdrurru ?lrnt, catories uoy ?rrru protein fiff}u1fifi

Tat parameter fido.:rilr::i..: 6o capillary blood glucose. serum etectrotytes. magnesium.
phosphate 1o u rallr;lurirr drJnrlirr:n

s1 nrrtfi stress urcer prophyraxis rilr:rur'hiludrhufifiuurTrjul"f rnia.,:rirsfirul,?rflu
narurun'jr +a frlu,r niolu:rufifi coagutopathy

+; nrfi e t bteeding omfifl1r'tfi proton pump inhibitor drip. somatostatin rfiaaer

splanchnic perfusion

s; 1un:rfiiifrnr:inurTnu'1fi Sengstaken-Btakemore tube tunr:inur variceat bteeding
dotninunrirnriniirir,'r ua;darfinrr::riorvirodrlrrn rdarorn gastric bartoon arorfiaurrfr
esophagus drhirfio esopnageat rupture ld

5. Nervous system
1) Parameter fifio,: rflr::ir lduri tevel of consciousness 16nmrruTnn'l$ Gtassgow coma

scale). pupil size'tufi ru increase intracranial pressure, a.tnltdn
2) ulyr1{:mu ::wrffild:-ioulu{rhuinqn 1d'uri u'rfiut'n lanticonvutsants; drflrfi ru

fiarnr:rfn rindo'rifirfluurvuo rflmrrroonr6ooeirsiordat. urdrrfifnur mvasthenia oravis d
fio,rfi nr: fiturnurlurrsinyr"u

31 nr:n:rtrrrfio.lilfrj6nr: niu CT brain 1nr:n'rfi,:fl.onrrr1lnoflrYffio,JfiLhflriaud, :l
rfi o,rcrnfi o,Jfruonanrufi .;. rtc, Etvc, lumbar puncture

6. Hematologic system

1) Blood transfusion dlfiriauldrrd packed red cell. plateret concentrate. fresh frozen
plasma. cryoprecipitate. reukocyte poor brood nrr'lin, lrvirn'.f'rrflurra:fidorj,ldnr:1d rrn;

26 r?urildoinrlBflus'tl,l

dom;rin:;r"ilu{il?fl fi 'hir6on4nr1u

z) Parameter fido.rrilr:;i.rlu{rJrufrld packed reo cett niolufiilrufifitfioooon 6a seriat

hematocrit

s) nrrsi.:o:rom,,tlnfinirrLrrdaiiuuiunT rifiedul:nuiorfjofinnrilnrnnr:inur niu'lu{ilru

febrile neutropenia nt:fioslr absolute neutrophil count (ANC) a1n ceC t,liolu{ilrufio'rdu

n11; disseminated intravascular coagulation (DlC) nxr6i.ln:xa CBC lSalmrl blood smear
tio'lroro,r loug'irfinl?Y microangiopathic hemolytic anemia (MAHA blood picture)
du

riunr:drn:ro D-dimer !tn: fibrinogen level tfludu

7. lnfection
1) ltrn?tfldfiUttn:d.:ou sepsis n'']ln:'lq hemoculture nr:ldadrtfiau 2 specimenslnu

rfrlc{'rorjr,:o:rqvrr{ peripheral veins anriu'lun:ridtd cenvat line lrurutfiu +e rirlr.r,l rfil

d'rod1.rm:rocrn cenlral line 6ru

z1 rfrud,'rd-rn:rlrda wtrc rdanr nr:iiedu}n6ordafiRtdl ttnvnr:fiotfloutto: ttlnrla

d{oios!:rodrunulordru dro;ldnarSerirtfrour:noiofiu'lcnrrinsrldadroliuvi'ltfi ttiu n:tflc'rdu

community acquired pneumonia e'ltei,t sputum gram stain (E [0.J) !!fl: sputum culture for

bacteria

s) nr:1fiurdru1n6 fiqr:rurlfiurn:ar.,nqr.rrdoriolttdFofi'r lun:rfidfinrrrtioriru niu

aqjlunrrv severe sepsis ria septic snocx do.ldlur'hivriufi lstat dosel drutnronrunc',1tffl

d.rdrn:rloir,r1 tfiouvrrsrdariuuioutLfir

8. Endocrine
t1 urfitdrlou lduri insulin uflv hydrocortisone
2) Flarameter ddorrflr:;it ldrrri capillary blood glucose (u1.ttt?inrian'jr point of care

testing (POCT) glucose)

9. Analgesics, sedation and muscle relaxant
d'ruln{rflurrnunrrtuaon t6oon"rsio rdoo 1oufi li'nrrurutfild conscious sedation

(Ramsay scate rc 'rfll 2-3 v?aarcts score dufrtfiu:rMrrTu; trrrufi'rurn riun{!ra rrd'r {rlrtr

6u urnlrilfir?un{:Jru {ilrunnr birJ:: rfiufi'rn'rrtdr rflulunrrtsurlnu tol.i1! muscle relaxant
n'::rirnr:rqorionotul6ta{ sedation uflJ muscle relaxant rfia :vdu'ivo'un':lri6indrlo.:

{rJru riuav t ni,'r (aait interruption o{ sedation) rrsiorq\rifinrrilo"rrflun:fifrrflu early ARDS

'lu qa d'rTrr.ru:n

n1:rfiu ri1d{nlrinu'rlunr:nua{rJrau fin nnizuni nfrftmg 27

10. Procedures

lduri n"ornnr:drr1 atird n:rcaor'h consent form tfrr?flriaEJ rrn:do,:rfiutr orocedural

note rrlfl'rnrlyur:ndauqrnnr:ritfi'nonr:drurf, la

11. Consultation orders

'lduri nT:ni.nlinsrnrirurir.rllourl5nsrrvirfrirlflu fiayriuoyrio'lfirfinnrrrfrlaunir-ruurrj

drflurdlro{'lf, ar::cdn-j, urnfiilflur{T roililunrrlua{:rrunrin rilufffioryaf,r}ru'llarnml
ldidgn siruuuvr6orrrdr,:1 fifuilinurriu qrounua;'lfiarrrrfiuror.rirpn.rrld:"rrJinur d,r
dr rru;rirlltuarqrrrrtcrriolri rrrryoilfi!fi:Jrufild

4u?s:191t 1
rluo'trJ 50 fl 1:nrj::drfr'.rrdt DM. HT 1diiln.r:r-mr1d1u metformin (500 mg) 1 x 3 pc,

enalapril (5 mg) 1x2 pc

!{rJrumdfia.rqnrdurflo,rrrnfiyorrrdourJruru o drlm fiId 1o e:rodr{nru BT 39,0

c' HR 12Olmin, BP 110/50 mmHg. RR 28lmin, bronchial breath sound and crepitation at RUL

O, saturation 85%o

virulai endotrachear tube rfio.'ra1n{rJrafiornr:naurvdarmn uururnrsGsr vorume
ventitator rrblviru ufir ({rhtrnrin oo fiTn nfil)

inr:r.0fi unoosir o rir.rr{r#tnr:tnurd rfl ul:.ild

nrnfl arooirdl1 nr:iner
firlelfludificdgrfl se,re." community acquire pneumonia losfiT:n :ylhdrr6u6o

DM [[ni hypertension
1. 'tei endotracheal tube rfio,re1n0{lunrrl frypoxemic respiratary faiture (oxygen

saturation < 90% ixtJdx respiratory distress)

z. n'r:ne,trnio'::irufirrrlc nr:rfionrflu controt mode Touovrfisnlfiu vcv fiio pCV fi"td
lrifinrrrrrernrir.:niu R?lot'.,:rrlu restrictive lung disorder Ioulfi tidal volume tutern'r (6-8 la.t
nn.) expiratory time :Jnfi a"o:rnr:urul*5?nir:Jn6 1to-z+l urfi nior5rnirfir'l"rrflu1

s. fla"'rtaiviodruilru'hfia'rnir portable chest x-ray rfiaool"lrnrj,rro{ endorracheat rube
lta;rfio :yrfiulttrr6nnttto.rlloa, nr:ritnttor:,lq aderial blood gas ldo :vrfiu oxygenation,

ventitation [lfly acid-base disorder lr4orflurruryr,r'lunr:rlilrn{o,rtiruyrulesialt

+. ar:ririibi nr:rdaniifi catorie rdo{crnd:hu:rrftrilda {'lunr.::6on ar:rirdlfi orc

rirnirfld urido$i'.:rjrnrinra',rTonrafiq:rfin putmon"ry edema lrn capilary reakage !fi0.,r?1n

R'l?l sepsis

28 r'mirrintnqaCugru

,1T1ttl drsdr.rnid.rnrrfnrnd riulrlf,

'lUtl 1$ t?41
Admit o1q:nl:Ic1u
On endotracheal tube, No. 8, malk 23 cm Diet as one day order
at upper incisot Record V/S, l/O as usual

. On ventilator : VCV mods iledication

Pr€ssure triggBr -2 cmHro, FiO, 0.4, r Cettriaxone
TV 480 mL PFR 60 LPM, PEEP 5 cmHP'
Sig. 2 gm V OD with stat dose
RR 24lmin Omgprazole
Keep PIP < 35 cmHro, k€€p tidal volume Sig. 40 mg V OD
Paracetamol (500 mg)
3'60-550 mL RR < 32lmin, O, saturation Sig. 2 tabs oral pm for BT > 38.5 C
> 92Vi' q 4-6 hrs

Portable CXR a1ufiD6o
Arterial blood gas
5% D/NSS 1.000 mL :r{srj:c{rn"r
Sig. V drip 80 mUhr

Record vital sign q t hr, il MAP > 65 mmHg

or SBP < 90 mmHg, pleas€ notify
R€tain Foley cath€t€r
K€€p urine outpd > 30 ml/hr
Blood lor BS, BUN, Cr, Electrolytes
NPO excepi medicalion
On NG tube
Blood lor CBC
Tako H/C x ll sp€cimens
sputum for gram stain (1a slid€ lifrlvll'ld

d?u), c/s for bacteria

POCTglucoseqOhr

nliriuun'1#\rnliinr*rlunr:gua{rllruv fra nniuni nfifiwg 29

5. nxlfinnlrJ virar sign larft-haodrr'lndfio'lurirru:n rdo.,nrnfiTanrcrfin septic shock

ld d{tnnqrn diastolic blood pressure fltt iitdofi.tnrry vasodilatation

o. rdo.,rmnfirJruflnorr:ro.clrjld orcrilr:nlrld Foby catherer yioo.rolai condom ld

lrrn rflrfi:Jrrtrul drunrrfiasrr irrruflaflm: tu:rudnr:fiornrrvrnr'rIil,: rfjo.,rernhjlrilc.jr
BP fitold 100/50 l.r.tian dru:-u{rJ.laiifinrun''uloficrc.,,rrrriau r;rfiu,tnanio'lri

7. nr:d,rq:rl renal {unction test rria:J:; rfiuyririiro,,rln d,:arcfinrr .irrflutunr:

fururosrd'ruoafiul,firylr:or *nyd,rst:lq electrotyte rfludugru'lunrr:J::rfiuqnn:ndr,l

runvnnrnfiaui

a. tu:rudr6ifl trionrlfionrr; sepric shock 6aar: t tpo liriau

s. arr'ld nasogastric tube rfiaalrndo,lnr:aorJilrrun un:y!1,[1yo,r?nr iilarorfio

dulfinruvn*'rnr:id endotrachear tube unvrdotri enrerat feeding luriusialil lurnorrr:ntrild)
10. d.,rqi?? CgC rfjo$rnc.rffanrrvnr:6n rda rfiarnr teukocytosis (with pMN pre-

domination)

11. d.,tst'i?? hemoculture 2 specimens yl1,t peripheral vein riourhnr:'hiurdrurniiyt

tz. rfian"tnr:td endotracheat tube rrdr da aru:fin:rq lfllus'ld nr:li'rn.r:n?tq rflrJfiJ
ninr:dar gram stain niouanrdadot:n d.,rar:mnr:rvrr: rda uunfiriu

t g. 6nmr :;a-rltilnrn'lul6oo (pocT gtucose) rdo,:mn{ilru:rudrflururrru *n;finr:

fierdolurdao Ianrofifirhue: rfio::n-lrirnrafio:JnGfildlrn rY,,rr:o'lrirnrogoua:r:oiurirmnoir

80nruer:.r :c Fri:ldlnr nlfi o {lutir,: 1 40- 1 n./en.

1+. rfionoT druoodn tu:ruddan cettriaxone nlo,Jcrnn:ouoqud'alun{ma\: community
acquire pneumonialdd unvda.,:#.rriufi (stat dose) nrurn-.tn.r:rfi!d{ai.rsl:rosirol rfiorur:ldaudr

1s. 'lti stress ulcer prophylaxis rfjooornfiuudrilfi{rhul;fi0-ri.firnCo,rrruhururfiun.jr

qe drlili learfion proton pump inhibitor (1'11n1 fi orlr:nr6an H2 anragonist.ld)

to. urnq1{ n1::c!Jfif'o rcuir rfrolore:hiulaeH lrinr:tfririr prn for fever nr::: fi

trernu'im;'hirdaioorumnfildurnn'ilrirler rdoil6nrdu.rarr ffuaulunr:biur

t z. 'kjhiur l:ltrrrurfio,rcrnlufiLhflnrr;inqn nr:'tri orat hypogtycemic orug firfiqrd
srr lrjsrur:nnronr:ninronr:fnutdurjuou'ld nrn:yniurirnraar nr:fiqr:rurlfi short acting

insutin !!yru airuuraonrun"ulnfiorg,l 'lrjnr:lfiluflhurrud ldo{q'rnnrr d'ulnfiqFiou{rrilnfi

iu{rJrufi fi nlrd'uTnfi mallnriou

30 !.rffd.ldnlflqfidu5'ru

ft,iiles:rrrd z
nrlrorq +o fl rriifio':qn riurdo'ternfiornr:idorr:riu fi1{lruru 3 riu:hnr?utsr pE:

BT 39.5 C, HR 130/min. BP 80/30 mmHg, RR 26/min. CVS/RS normal, CVA tenderness right

side ({ilrunrin so fiInnir)

arn rii e q-r odr'tnhdtnr:fnrrd liu\I6

2U?l t1C1 lur t1A1
r Diei as one day order
. Admit alqln:: €.1 . Record V/S as usual
. On oxygen cannula 3 LPI\4
. Keep oxygen saturation > 94% Medication
. NSS 1.000 mL
. Ceftriaxone
Sig- V drip in 30 min
Sig. 2 gm V OD with stat dose
Becord V/S q 10 min
. Paracetamol (500 mg)
lt IV1AP < 65 mmHg or SBP
< 90 mmHg, please notify Sig. 2 tabs oral prn for BT > 38.5 C q 4-6 hrs

On Foley catheter o'tulJogo
Keep urine output > 25 muhr
:l'a ::irfre
Blood for BUN, Cr. Electrolyles

NPO except medication

Blood for CBC
Take H/C x ll specimens
U/4, urine C/S for bacteria
POCTglucoseq6hr

nrgfioda

:rio:Jr rchq"r

!1r I fl nnorra'1 d{fl '}lif lt 1

'hinr:iicii'E tflu acute pyelonephritis with septic shock

t. lfioanircu rfiomrnfirhuostunm:fion lurrufhioir rfluda{'tif endotracheat tube

ldomrnlil1da41un'riv respiratory distress

2. n1t keep oxygen saturation n?5'lti lnn'j1 94-95%

s. fimrru1'hlcr:fl rdo.rorn{rlruo{'lun'l1r shocklaun?rlfirr:r]rrSelurjrnr:n lur1ud
lrinr:'lsnrnfiaro{ ftuid chattenge ltiu 200 rrn]u 15 u1fi rda,'talndrrra:lrivtiunr: lurrud

nrrrfioun"1,inn1:inurlunr:nnaridrauffn u:ln?uni nfrfimt 3r

rdo.rerne:reir.rnru:vlrirlr'do un:nrulqadlurnrud'ilnfi i.,rarlrrnlfior:rirtuo-sr:rrirld rriu soo-
1,000 rra.'lu so urfi :;y.ir.rnr:lfiorlirluo'n:r r5r nr:rfu rfiu{lonrflu:cuytirfi creoitation

vSakj vrnfiuoo,:'irlfin purmonary edema {i':arerflo'1d?rn inlravascurar vorume lfiu vionrr;

capillary teakage yrnrfi odrln"l desaturation nr:riq.t:ruraodn:r15r'lunr:'lfi or:u*r
4. 6oorrr vrtar sign lororlfinr'uvn t o-t s urfi Tnufirfltrrrudalfi mean arteriar pressure

adr',rriou 65 rJ rJ. ?afi

5. rf,o.rorn firhuadtunrr;6on {,rnr:rirnr:lt: rfiurl?rrru:Joarry uiio4lirlfin acute

kidney injury r?alri

6. cr':td':st:re renal {unction test rdarl:vtfiunr:dr,lrulo.:'lm rrflr electrotvtes r14'fl

:yrfi unornfi o uirro:onn:noir.l

z. weo f,ilrurfio,rlrnorj'lunmyfon
8. 6i,ralxe CBC rfian:rotrrn'ngruto,l bacterial infection uonerndnr:t:: rfiu
hematocrit n"'rdruronir rfionr':;6oornnr:fiordoviolri (rriu disseminated intravascutar

coagulation)

9. 6i.,tn:?? urinalysis !!n: urine culture for bacteria rfiowtnatf,gnrty acute pyelo-

neDhritis

t0. fiosrru::qi frrnnlunrtinurnrr: septic shock lnanruqrtfiadd 140-180 n,inn.
t t. L{urdruenfin lu:rtdrdan ceftriaxone 2 gm un:dotnlufinrund'.lfirfiud.,rai.,:n:re

oirol lfiorvrr:rdoufir

tz. flraalfr rfio.:ernfi ru:rufldgtlrn d,:e:vrh}i oxygen consumption n.:yrnlfilri

aonn

$IU?U:IUYi_I 3

tlu01E/ 60 fl ifilat OV. HT. dystipidemia lfiur gtipizide (5 mg) i x 2 ac. enataprit (10
lmg) 1x 1 pc, simvastatin (10 mg) x1hs

rrfifiaran riurdo{qrnr6uyfironr.Jruru 1 dxll,r fiarnrrrrtounn pE:BT gz.5 c. HR

110/min. BP t35/90 mmHg, RR 26lmin, 02 saturation 93%, CVS : LV heave. normal 51/S2, no
murmur, RR : fine crepitation both lower lungs

0:xa EKG t4t! ST depression at tead Vi-V4 (f,il?uyfn 60 fiIonfir)

3nr:rrfi uoer,rsir o d rsdr #.r nr::"nrrfi rfl ultld

32 rrnirrintnqndugru

ml.ld s fnatiroririi.rn"r:inurdrf,ul:If,

,lU'| t?frl . Diet as one day order

. Admit o'lqlffiflffltl o Recod V/S, l/O as usual

. On ox)'gen cannula 5 LPM M€dloaton
. Ke€p 02 saturation > 94% Enoxaparin
Sig. 0,6 mL SC q 12 hr x 3 days
Portable chest X-raY ASA (325 mg)
ASA (325 mg)
Sig. 1 tab oral ch€w stat Sig. 1 tab oral pc
Clopidrogrel (75 mg)
Sig. 4 tabs oral stat Clopidrogrcl (75 mg)
lsosorbide dinitrate (5 mg)
Sig. 1 tab sublingual slal Sig. I tab oral pc

RecordV/Sq1hr lsosorbide dinltrate (10 mg)
lf MAP < 65 mmHg or SBP < 90 mmHg, Sig. 1 tab oral tid ac
HR > 120/min, please notily Enalapril (10 mg)
Blood fior CK-MB, troponin T
Sig. I tab oral pc
Monitor EKG
EKG 12 leads U2 nr Waer simrrastatin (10 mg)

Furooemide Sig. I tab oral hs .
Sig. 40 mg V stat
MOM
e Record urine output rflu mL 1nn{.rd voio Slg. 15 mL oral hs

Blood for BUN, Cr, El€ctroMes (+ Mg) e Lorazepam (0.5 mg)

NPO except medication Sig. 1 tab oral hs

POCTglucoseqohr flU AAB
:rinrj::ird'r

f,1ufiado

:rin:Jr rl'rt[r

tn4flE D\tn'1d{n1ainyl
trtrnr:ificdglfiu acule coronary syndrom€ (non ST elEvatlon) with left sided h€art
faiture lnufilznrJt{rn'rfio DM, hypertension, dyslipidemia

t. tfiaonireurilooflnf,rhuoglun'n! acute coronary syndrome iruiu left sided heart

tailure Inufi hypoxemia 9'1fl rrentilation-perfuslon mismatch lrtufnrn1:d:flli oxygen saturation

Dd1.lilou s4%

n.nrflsunhd'rn't:inurtunr, aruaftJronlirn nnfiunf nfifiutg 3i

2. d.tntte portabte chest x-ray rfrodluTunr:if,rdu teft sided heart faiture d,:unlt

n:?1 arterial blood gas oldrjfin?1ili1lflil [vn.t: oxygenation fl1!,]l n?i,tu pulse oximefryld
d?u ventilation fiar r:nnrn'l6'i1flu hyperventitation [rfl: acid-base disorder fiarlrtnnro
ld'jrtflu acute respiratory alkatosis (g'rn hypocapnia) aqjudr o"',rrfurfionlrnt?o arteriat blood
gas lillfirilfi uuuiln.onrrinur i,rlrildrirmrurnmdufirJrarrErd

s. tlinr:inurtdordudrrfir acute coronary syndrome fio ASA ctopidrogrel un:lfr

tt'toorn-nr6uriranfia nitrate d.lal.n:nbildynruflulu lufidrdanrfu subtinguat form

q. fiotnunrud'uTnfin llncfiflq: rdarqrntufidrud rilu acute coronary syndrome fi
nr':ri6uurrrln,rrrwranrf,nSnr:'[ua rluu16ooldnnannor d:ynolfiunrltfi niirate rrft:rirlfi

ornr:r5rr,rriranddu usifrfiilodr{rdu,,r#drn"rg6a nypotension ufl; tachycardia

E. rrnornrl6:lrrironddu fihjfio,rfitr:nl'Ifr morphine lriehrfl!fio,,rri1fitJ MoNA n?!
druror.ral'rl'hifi m:rurlfi mlrralnil{ rauoinv:ru

o. tfirirnr:urnriob'lrflhuo{1un{:l unsrabte angina (high risk) y6o non-ST etevarion
Ml lounr:efirc CK-MB !!ar troponin-T Tnfl rn Cr-[4e q{n.j,rfhilnfi fiifitdurfu non-Sr

elevation Ml

7. dlnl:frrx? EKG 12 leads rialr nioonr:uldsuu nt uay monitor EKG 12 leads

lfi a{orndo{fi nsnlnm:*yr:ndaufi drdrl6a arrhythmia

L tri furosemide rda,:qtn fi:-huod'tunm: left sided heart tailure Teurioudcylfi

furosemide do,,r urilodrnrufil1nfisilrinirfiulil rfrolvrnriio'hialrfir r:rir'bififle nr?;00n ln
ri't'lfi intra-vascu tar volume n n n.: rir'lfi nru o'ulnfi m sirld

g. nr:fioartrdt-l'rmrwld furosemide 6o rlimnrisorr:daon lnu:iufinrlilrrurJcsrr:
1nnirfi riruiaot; lunT sifi fi :Jr u'hir'rt:fi o orodarlei Foley catheter

10. 1fi6un1il renal lunction test uny electrolyte Toriral,trc rfralfi furosemide cclng
hypokalemia, hypomagnesemia dlnr:{ubirfi n cardiac arrhythmia "ld

r L nr:'lfi ttpo liriau ufja{ernET,ililuri'hlunrr:qnl6udorlrfiodu nju nrrs heart faiture
ra.,rfuJraorofi lrnntueurirtfifi orld endotracheat tube

I z. n:rc:ynitldrsr'rnrn 6 iid { lda.:q'rnfi eurflurulfix1 fflB1r;ri"'lrirnrntfia{iurier

140-180 ft"/na.

t s. fi crrmlli tow motecular wei g ht heparin ruto.ror n rfl unr:inurlu {,r-1,: ufi rflu acute
coronary syndrome tun{#rflu non ST-etevation nrnfillufi renal dysfunction 'lfinotu.roflr

a.,,:riurn z+ d':Ila

t+. uT dfiortfi'lunr:inur acute coronary syndrome 6a ASA, ctopidrogret, ACEI, starin

J4 r.)lJu1uolnqnnaug1l.l

ts, lu{rJrufi'rflu acute coronary syndrome 6o,t:;l-.:tio,:arrl tniln rrn; r{attta.:ryn tnlo
nttr lniun trn;nr:fida.rr:-irqror::or?i''l'lfi acute coronary syndrome rflu rndu

10. Ljn,l{ri oral hypoglycemic drug lu1il:#{thuoflunrrvinqnogj tdomrnlriarr.rr:n
monltfienltoonq Bdrt-6 fl'lnrtinlR{\: nl1farcl?rul .lrfi4itlu sh. ort acting insulin

fItir.tes:ruii +
t1uo1q 67 fl ifirda COPD'[dfxu'] bronchodilator rrflv inhaled steroids

rrdruarn, :nor ntdau o dr1tJ.:tiautJrT:{ url-rrn ralv:6ltrfis.:riu PE : BT 38.5 c. HR

120/min. BP 140/90 mmHg, RR 32lmin, O, saturation 80%, respiratory paradox, accessory
muscle usages, RS : wheezing both lungs

yiru'ld endotracheal tube rirulurflraiu! volume ventilator tfirrdr ({ilrunrin oo fiInnr"l;

01l1\t1A'! 4 ttdn{n?- AU1. \t6.''lfln{nlllnEvlYlL1iJU4t'!J\r nlefr

oi
r11tlfl or,ro,0n1fl{n11rnn1

nr:ifiodeiu{rJru:.ud6u copo with acute exacerbation with respiratory failure

t. {rhaaglunT; hypoxemic respiratory taiture i.rda,,:'ld endotracheal tube rrn:

rdo.n, n{:Jrufi bronchospasm fi:utt:.,r c'tcn:t6on endotracheal tube rurnlnqj tdo.:orn

o1nldlud?,rllruhoontudruto.r lower airway oonu'rnaqjufi': d'r'hjnrilriarnrnaonurn'lutjrtlu
upper airway 6n ua;nr:'ld endotracheal tube nli'ldfrflfli1:Jn6rfrnrlou rfja.,:ornlufirJT u Coeo
q;fi trachea !1xni1 nfie1n hyperinflation fla\:loor

z. nr:d.unia.nirumu'la6??1d controt modelqunr:rfion vcv rio Pcvtifin':rrunndrr

niu nr:fi,r tidal volume 6-8 ila.hn. (fiSorioEjni'rrrn'r'1!flu) hi expiratory time u1u rrflr respiratory
rate fi o u n'irrl nfi (g- t z n{.rturfi } rd o'lfi lrarlu nr:rrulooon ufi u'tl,r o

e. yn"':'ld endorracheal tube n1:d.rn:re portable chest x-ray Llflognirrr,rri.raon endotra-
cheat tube rro:1u:rrddolgnr:rrv:ndouro.r coPD iid16'.U60 pneumothorax uov'lu:rudfi

lfi ralr;rr6ou]u dalqfifi pneumonia irild':ufi?olri

4. n'r?n:'re arterial blood gas'lu case d:Jr:rdurirdqo{dt{o,,t ventitation LrA: acid-

base disorder rfludrnq lounr:sotlilnrr: permissive hypercapnia Iaflfloillfi pH rJ'tnn'j1
z.zo 6lflunr:niu,rvra lrinrr:Jfi lnia.rrirsfirulcruld pH 7.3s-7.40 lu:rlr;rirtfifia.:'ld minute

ventilation mn rirtfirfin auto-PEEP q1tJtJ.lld

s, rior:rurlfi bronchodilaior rdo.,rorn:rudfi bronchospasm 1u:rEldr6on Beroduat d.:

fin'.rquf b"tu-Z agonist ttflv anticholinergic effect

o, fierrrur'lrt dexamethasone rfiafnur copo with acute exacerbation

nrrrdaurirdonrrinurlunr:nuafittrsufin nn?uni nfrfrmg 35

nr1\ti 4 d'roeir.re:rdrnr:fnrrfi riulild

?u t2a1 iufi trsr

Admit 0'tqtnfi|Jt,tB Diet as one day order
Fecord V/S, l/O as usuat
On endotracheal tube. No. I, mark 24 cm
Medication
at upper incisor
. Ceftriaxone
. On ventilator: VCV mode
Sig,2gmVOD
Pressure trigger -2 cmHro. FiO, 0,4, TV 360
. Azithromycin
mL PFF 60 LPM. PEEP 5 cmH,O,
Sig. 500 mg V OD
RR 15/min
. Omeprazole
Keep PIP < 35 cmHro, TV 300-500 mL,
FF < 30/min, O, saturation > 88% Sig. 40 mg V OD
Portable CXR
o Paracetamot (500 mg)
ABG
Sig. 2 tabs oral prn lor BT > 38.3 C
Berodual (2:2) NB stat then q 2 hr q 4-6 hrs

Dexamethasone fllU ago

Sig. 10 mg V stat then 5 mg V q 6 hrs :rifl r:ehfr")

Fentanyl

Sig. 50 ug V stat then 50 ug/hr
5% D/NSS/z 1.000 mL
Sig. V drip 80 mUhr
EKG 12 leads

Retain Foley catheter

Keep urine output > 120 mU 4 hr
Blood Jor BUN, Cr. Electrolytes
Retain NG tube

NPO except medication
Blood for CBC
sputum gram stain 1rfrl stioe lfiulrvrtin:rr1.
sputum C/S for bacleria

. POCT glucose q 6 hr

N1UfiBfio

:r,{nrj:: c'r ffr

36 rlud,rfflSnqndugl

z, tdo.,rorn{rlruliu'hfia tta: set r;spiratory rate m'r tfiatiluaolonl61n15tf,9 auto-

prep diriurdolfirrnrlunr:t1u'lqaoflulu1{o 6.:nr:'|fi sedation lu:rlflria'::16on morphine

rda,:mnrrn::{u}ifinr:vo,r histamine d.orir'lfi bronchospasm luur.tdu tu:T ld6orfion fentanyl

e. orflilfiqr:t{tu:-rud rdo,rlrn{rhulrio{'llnrr: snoct 6sar:tfionor:a'tvr:fifi calorie

un:{r.hudfi nr:nalrvfinr:4rp rirri'rvnlnliurute

g. fior:rurn:l EKG 12 leads rfia,lmn:Jodutdu':lalnr:tfin coeo iichfiqfianlrflullli

fofirfluiodurduwo.:n'11tfin acute coronary syndrome ttiu16urriu lrtn'lu:rafir.rtulc a'rc'hjficr:rur
errxq EKG ld)

10. 14e1rrudd Foley catheter rdo.rorn{thuflan'rr;ra.:lrilfi rrcirfiotlrn{r-hu:rufhild

o{lunrr; snoct o'oriu6.:'hjdatfioorrr.rrlnam:qnd'r1il.r rrsttfilfirnrudfloRrr;aon 0.5 n /nn/
tr. Tnu6ornrrln z-q cirT 'ttLvru

.'1 1 fi:?q renal function lfludu3ru ttn:fi1lq electroMesloararT ;rfio'tfiu'l bronchodilator

nvn::{u beta-z agonist {irri,tfi potassium rdrutndrrndu drlfrrfio nypokalemia

12. n?: NPo {:huliriou un:ar:td nasogastric tuoe rdo,rern}rn.ltd endotracheal
tuoe'lvrir orlfinrl; abdominal distension loarqflr:'ludr.tii hold oronasal mask riaunr:'ld

endotracheal tube un;n'n doalfirfis abdominal distension rirli bronchospas. 1uu:'lttu

rda{rrn:Ji rn: ooanar

1 3. d.':tn'r? CBC rfi aurndnSrulo,:nr:rfi onr:fi o tdo

14. ri.:n:re hemoculture 2 specimens n1?911'l!!fin{fl0'ln'r:6ordoleutr r sputum gram

6lstain Iatd.rtfl ']crdorr''t rrunfi

ts. rfionurfiruXafirtflu ceftriaxone llfl s macrolides vn-{etnd,t9]ttqnr:wtr:rdorrfir tfi

arnq'lfl

10. fiqlrnrtri stress ulcer prophylaxis rdo,rlrn{r,hufi rrur}iufio.:tfirnlordrulnutq

urun'ir +e rirlr.r,r

{rtea:rud s

iimuolq 3s mdfiarqnriurfiolrrn rod:uvrruru 3 io lntiur5orl fi}i ee : er

39.0 C. HR 110/min. BP 140/90 mmHg, BR 16/min, CVS/ RS/ abdomen : normal. NS :
E1V2M4, DTR 2+ all. no Babinski's sign. stiff neck positive t{rJrurirnrin oo filanil)

i sn r:r.r uanr n'ro tir.r n"r dr n rr:"nurd rfl ulillfi

n1irf,u,{1d0n1r;nyrlunr:auaafurnrfrtr nnFunf nftfiwg 5/

5 riilrldnr:rlrfi n"?o ri'r,,r r'r"'r d{ nr:r"nurd

ir$ rT ar iufi nsr
. Admit 01q:nr? t'ltl
. On endotracheal lube No. 7.5 mark 29 cm . Diet as one day order
. Record V/S, l/O as usual
at upper incisor
Medication
o On ventilator : PCV mode
. Ceftriaxone
Pressure trigger -2 cmHrO, Fi02 0.4,
Sig. 2 gm V q '12 hrs with stat dose
lP 15 cmH,O. l:E = 1:2. PEEP 5 cmHrO.
RR lslmin . Omeprazole

Keep tidal volume 480 600 mL PIP < 30 Sig. 40 mg V OD

cmH,O, RF < 28lmin. O, saturation > 94% . Paracetamol (500 mg)

. Portable CXR Sig. 2 tabs oral prn tor fever
. Arterial blood gas (BT > 38,0 C) q 4-6 hrs
. 5% D/NSS 1,000 mL
alu 0t0
sig. v drip 80 muhr :ria::irn"r

. On Foley catheter
. Keep urine ouiput > 120 mV 4 hr
. Retain NG tube

NPO except medication

tRecord neuro sign q hr

ll GCS +I > 2. pupil unequal size or not
react to light, seizure, please notity

CT brain with contrast

Lumbar puncture : CSF for protein, sugar.

cell count. Cr/S, C/S for bacteria. Indian ink

1rfir t mckiuvivrrin:ro;

. Blood for CBC, BS. BUN, Cr, Electrotytes

H/C x ll specimens

POCTglucoseq6hrs

aTU AtO

:fifl r:"i'rfil

38 rftdltininqndul

rilqHatorrdld'{n1rifl lt1

lurrudifidtr acute meningoencephalitis rdolmnlu{rtru meningitis lour,nfil;lritt'il
riurrril:fi encephalitis visfinrr;ltY]rndou6utoo meningitis drufiru

t. tdaocrn rvdu classgow coma score lirloun'jr e 6':fior:ru{6i endotracheal

tube tfi afl 0.,:riunrrgodra'n (prevent aspiration)

z. nr:srs{ rnio'rli?unrutctu:rud nr:r6ontflu control mode louorqtdontflu vcv r5a

pcv flld loudlorfluiloq:lnG lfituro tio.t volume nfi (8-10 lJo-/nn.) l:E oilurnrudilnfi o"q:'l
n'r:nrulooqj'lurnrudrJnfi 0o-ts ni.rnlfi)

3. d.xflt1e portable chest x-ray rfiogal'rrrurj{fl8'J endotracheal tube ua;tfraq:ou

I:nlunoor ttrarlrfinldlrn aspiration uiaaretfiolrn hemaiogenous spreading a'ln bacteremia

6{ tfincrn bacterial meningitis

4. mi're arterial blood gas trn-{st'.ttn{o,rdrfl vratt ntdfi}jfi:otflrnfr iloo oro'ldrrar
nin: s-to urfinruvd{qls,'t rn;a{ti'luvruto frour:nn:rt arterial blood gas ld

s. 16onar:rir {:lrulrifinrrv shock fi;o hypoperfusion nr:rfionriu dextrose solution
o. rdorl'rn{rJrulriour:niaorr;to':'[d nr:ld Foley catheter ttnvfinnu irrruflonrr;

dilrichrflufia.:6nnu1ndrfur rda,,:ornlrildo{iunr?; shock aro6onruJirrzuflcn'r':;r1n e-+

rirl*:

z. rdarorn{:-hr:rfldld enootracneat tube 6tnr:'lei nasogastric tube tdane abdominal

distension nrundrnrr'id endotracheal tube'iuil1 uaYem NPo {{rariou

L nrr6nnr otn'nvr1{:v:JU ?td'tvrra':{:Jru Inu6onrtJornr:t'n ttn;o'ln1?tt6ln,Jta,J

increase intracranial pressure 1u:J:;t6utatrjruqr'l nolouotsiarLd'l (6'td0fi{ transtentorial
herniation) lurol olriruonfi hi rvir i'u (ft dofi'r uncal herniation)

ig. ficr:ru'r CT brain with contrast tdotti,nn1.1; increase intracranial pre*sure fi

rfialrn space occupying tesion da{luutrrrudlriotn:nsrrrcdronruld (silent area) aanl

odrl'hfinlrluonrudfrlriarrrrnni cr brain Id olrricr:rurdr lumbar puncture.l tnuffld

10, fialTu'rr"l lumbar puncture lnrudo.:m:rq5o opening pressure lLfli closing pressure
'tuvirrvEuFrtr rfianfin ldfl.:qrnra,inrrfirrirnotiotfio.rtfio{ernn'r:c*nyir ttlovti lumbar puncture

vr'r}inrrr.rdutja.rfiargrdu rirlfi pressure d*rlaqdu uanerndnr:eiro'l're cetl count. cell

differentiation, gram stain, culture for bacteria dr: protein r!flv sugar lnudo'tdtt iu!rfiuuY:.1
blood sugar dlutfluo

11. d{qr?c cac tfionrun'nputo.lnlr6ntdauilafi riu

12. d,tqtxe renal function test LLn: electrolyte rfiorJ:; rfiuqa rn6o rrdrra;qnn:noir'l

nrliuur'f"iiirn1:invrhnr:4uafirJrarafrn nn?uni 7frfrtxg 39

13- 6ilni?? hemoculture 2 specimens loutfiud'rodr.rn:lrcrn peripheral vein tfiomrn
drdunt'l: seosis

1 +. finnrm;d'rrirnldrn 6 d.ilil.l inur:vd'ufrfi rolfi ad'ludr,,: r qo-r ao un,raa.

ts. fier: rtfiurdrulei'r lflu cefrriaxone loutlirluroEJrrflu z rvirrowuror.rnorrfiabi

ul sjru btood brain barrierld vr",:dnr:1fiurdru1nfindun-rnnnr:flor gram srain. indian ink LLac

runnr:n'ryrda

t o. fior:nl'lfi stress utcer prophytaxis ldo,oornfi ururlirtunr:ldlnia.tdrufirutcuru

rfiun'ir qa rrlil{

t z. nr:'hiuraeldyiodrnrlnnld{:-trudruiidu ldorcrn'ldlu{rJrufi frI:n::rrLrJ:;orvr
drunnrr q;n:ydu'tfi rfi nrnrrdnld

$u?ut1glt 6

t'rus'rr 30 i dla:ltinlrsrnon ni,ldrdou'lurrq:rrrrruflo,tornil-ra.,: ua;fiarnr:

tn1;nnuru urfi pe : BT 37.9 C, HR 100/min. Bp eOnO mmHg. RR 2Olmin, CVS/ RS/

abdomen : normat. NS : E3V5MS. pupit equat size rdatornfirhufiu yiruldn:ro POCT gtucose
16 to msx

tru:fi nho,rrirnrtl:; rfi u fi 1ufi arnr:d'nn"rfir

nr:r':fi 6 ugn.rn'radr.rnhsion.r:inrrfi rflul:J'ld

rrnnalunrrinur
hlnrrifieasrflu atcohotic intoxication with hypoglycemia

t. 'lu:rudlri6a.ild endotracheal tube tda{qrn classgow coma score rnn.ir 8 st:tq

dr,:nrsntt:yllnr:firutqadlurnild'ilnfi rrnylrjfiornr:LLfi6,irlo,r respirarory distress o*,rriue'.'r
lfitfiuo oxygen cannuta adr,:rdurrjrt; rfiu.i a

2. n?xq blood sugar rdafiuriunrl: hypoglycemia

3. a??e renat function test fiuduSru

4. nila etecirotyte r$jo :: lfiunnn:aeirr uny rnfio ui lourailr;lufiilrufi6rfil:.rruru
c;fi hypokalemia troy hypomagnesemia ernnt:flqtfiU potassium ua: magnesium ttrln

5. fiq1lru1 NPo liriotl rdo,rorn{rJruiornrrr-n un;fiIanranr:rfior aspiration ldc,,r
o. 'lfi oiazepam 10 mg yll.run0or6ono'r rdauuaornr:fnta.lfirJru louornr:rnto.:

{rJrfl :T udilro:rfioc1n atcoholic intoxication rrn: hypogtycemia

40 r'rrdlfninqndlg1u

nr:rcii e oirodr.rnid.rnr:dnnrnlflu}Ia

1U?t t?41 ?u l?fl'l

. Admit alq:nll tlu . Diet as one day order
r Record V/S, l/O as usual
. On oxygen cannula 5 LPM
. feep O, saturation > 95o/o Medication
. Blood for BS, BUN, Cr, Electrolytes, Calcium.
RlUIJOYA
Phosphate, Magnesium. albumin
rfifl r;eh6"r
Retain NG lube

NPO

Diazepam 10 mg V stat

Record neuro sign

lf cCS J > 2, pupil unequal size, seizure,

please notify
Thiamine 100 mg V stat then 5004 glucose

50 mL V push

10% D/NSS 1,000 mL
Sig. V drip 100 mL/hr
POCT glucose 15 min later

Keep POCT glucose 100-200 mg%

z. finnrlnr:t duurl fl{vn.l:yuu!::dlr lnufrnn1 a1ntld'n Glassgow coma score

:rLfl nniu'rgo,Ilri'run'flun1:qorduo{naufl {

e, fierrril{fi thiamine 100 mg rioun'r:'lrt 50% glucose rflarorn{rJruiidlq:rvu"n fin
finr:rrn thiamine rrn}in'r:ufi'hn'r':; hypogtycemialounl:'lftilff1ntuflru;d{:Jrm'rn trriamine

rradc:drdlmrnlil'tfi1ri16 rfia.tqrnnr:r{r Kreb's cycle'[u glucose metabolism "irrflufiot'tfi

thiamine

g. rfrorrfillnrr; hypogtycemia dtu 5oo/o glucose ud': fiatnudtucr:n:n1u 10%
dextrose rfrailorriulf(frrfin hypogtycemia dr ttntfinmlmvd'u Pocr glucose 6n to-ts urfi

n1flf,u rild\rntfinurlunr:4unfirtralrirn llln.:;unf nfrfiutg 41

fl,i:lru:rad z

ir{.roru ss ufiriollnriuniolornrrJqa6 d En nc.r carorid putse lrild ere riu

lsinus bradycardia ld epinephrine rftrnrn z mg ld ET-tube dlnlr cpB yrs.J rJo s urfi rioorn

riuld nosc io ep ld i 10/60 mmHg oioufi:irufinr:orn, :r'nuru generarized tonic cronic
seizure (fi rurfn so fiTaniuy

7n r:rr fi ua n.r or''ra dr.r a'r d,: n rrinsrd rfl ulilld
zartr.:id 6'raair.rn:rd,rnr:5nurfi rfluIilrfr

?ltft t1a1 iud ylar

r Admit ICU a1u:n:t Diet as one day order
. On endolracheal tube, No. 7.5, mark 22 cms Fecord V/S, l/O as usual
Medication
at upper incisor
. Phenytoin 300 mg in NSS 100 mL
. On ventilator : VCV mode Sig. V drip in t hr

Pressure thgger -2 cmHrO, Fiq 0,4, TV S00 . Omeprazole

mL, PFR 60 LPM, PEEP 5 cmH?O. RR 1s/min Sig. 40 mq V OD
Keep PIP < 35 cmHro. TV 400-600 mL
HFI < 28lmin, O, saturation > 94% Q',lutJAaA

. Portable CXR :n"f,rj:Jahq'?

o ABG ffio1d end tidat co, monitoring)
o EKG 12 leads

. Monilor EKG
. Record V/S q t hr

lf SBP < 90 mmHg, N4AP < 65 mmHg. please

notify

5% D/NSS 1,000 mL
Sig. V drip 80 mUhr
On Foley catheier
Keep urine output > 25 muhr
Blood for BS, BUN, Cr. Electrolytes, Calcium,
lvlagnesium. phosphate, albumin
Retain NG tube

NPO

Diazepam 10 mg V stat
Phenytoin 750 mg in NSS 100 mL
Sig. V drip in 15 min

tRecord neuro sign q hr
f GcS J > 2. pupil unequal size, seizure.

please notily

. POCT glucose q 6 hrs

nlu axa

L rrio:l:gei1 ol'"1

42 !?rdltinlnqodullu

lllq A!O\t€oJ1f,\tnlttnH'l

t. nr:ilfl:Jrulitu intensive care unit t'lnfll l?rlli'r'[d tfio',llrnnr:gttn{t-hu post

cardiac arrest fid':iifia.rrilr:vi.rvn1ti ?sfl'lr loutaurvnrrfinnl nffldnSnlr'lfifltiuutdoo
ttngt! !n'l?t11uh

z. nr:ms,rrniomirufirutr'hln''trn{o.:rirultrulot fiouniurlaoilunr':vrin6louoY,l tidal volume
lid s-ro o./nn. dnrlnrr lut? 10-16 nirlurfi 'hn:ridnlnr6anrflu vcv mode n?l6nq1

PIP (peak inspiratory pressurelLiriu 35 tlJ.fl llfl: lfl1?:ftlutimrulcr5r rto:a?:6q0|1|J exhaled

tidal volume

3. lu post cardiac arrest care nt:innt:vn'u?a{ oxygen saturation > 94% trflY end
tidal CO, oglrtirr ss-+o mmHg tun:dfllrjfi end tidal co, tfierrxe arterial blood gas leu

Snur:co-! Pa.co,\id 4o-4s mmHg

4. d.''srixe portable chest x-ray rdoqrirrrnrj,:ra,tviorirutrulo

5. nr're EKG 12 leads tfron:rq 1fl1t qn?"rtJftn:lnn^totv"rtqddrtritfiff cardiac arrest

:*n cfi n rxc mon itor tfi a lfl ttvi.:n'rr :rir'lq tfi u fi n{.rvr

6. fioonu vitat sign nn 1 d'?Til,t rdawrntu{rhln{rdfirturTr:udrnnnrcmfnr:lvnriuu

rfianlrjn,rd lun:rfifr{rJruo{tu1o6g rrnfiuonraninr:lnn riuur6oo'trin',rfi uia'tdil vasoactive

drug Rrrtim'i rurlsi arterial line

7. d.inix? renal function test rfiar.Jrvdunrinht1ulo.l'ln a'.tal1v'J]J acute kidney injury

(AKl) e1n post cardiac arrest e1nnl:d tAaol:lrdu,':lfifioun,i ttfl:d.tfli1e electrolytes, calcium,
magnesium, phosphate rdanrnr ruqla.lu'r'lc tfiufiodtve: rtnztfiarrar wqta,tnr:fn

8. nrl NPo {truliriou rfio'rernrru;d{:Jrtdn
s, aru:d{rl'lufiornr:ir'n i''ilriurnqonrrdntflu diazepam to mg louo'r tlrqfl0\:01n'tt

d'nlu{rJru:rad6ofit hypoxic ischemic encephalopathy lrnfianqrn post cardiac arrest

to. rdolfiurnqor'n[dr da{qr d':uurn"ut'nloro uav'lfinr:inuru:-ru status epileptjcus

ldrn! luddrdon phenytoin d,,rdac oitute 'lu saline lf, o fi1n dilute lu d.*tro"" solution QY
nnnrnou drnr: orip phenytoin lrinr: arip tfiu so rn./urfi tun:nifirfluT:orirlouiol:nri'l'tfi

nonrrurSrrornrdfiurn'r lutruvfilfi phenytoin o:datfionrrnmln"ulnfin rfio,,rcrn phenytoin

rir'lfinrrilri'ulnfisrnnn d uanqrndu-.trir'lfirfio ventricutar arrhythmia'ld 6{nx:6o monitor EKG
tru:'hiur

1i . vtinr:6nnr neuro sign In 1 ddil{ lurJ:; r6uta,: classgow coma score, pupil

tlF; seizure

tz. finnrr:::d'rrirn'lo1n G iixlx,: lnuinurr:o-rldrnratfio{lurjr.r 140-180 n,/nn.

nr:rflo ri'r#\'nlri.rurlunr:auafiUran fin nniunf nfrfiwg 4j

ts- 1udru6'rd'rnrr5-nBrnaool fifl:rurlfi phenytoin riu maintenance doselou dirute

tt-l saline solution

t+. fier:rurbi proton pump inhibitor rfiorflu stress ulcer prophylaxis rrio,,:ernfirlru
fi uudrirfio.rldrniasdrfl nruterfiun.ir ae 4'rh,r

ffrlrg:ruii e

mfraru ao fl ifoi:'rr SLE t flriou'tdfinrrirjoafl rflu RtHnld prednisotone zo mg/day

rrfirioranrfiulfiarernfiornr:Totl rfifiaorrndurruru t drlorri'lo rarr:urir1 pE: BT

38.3 C, HR 130/min, BP 90/40 mmHg. RR 35/min, 02 saturation 8b%o (lruild Oxygen mask

with bag 10 LPM). RS:fine crepitation both tungs ({rJrtuu"n SO filnnir1

e01 :r,1fi * n o,r sr"r o air,l n"rd,t nr:fn urfi ufl ulilld

lfi n sl afl o{e"1d'\r n']€inu1

t. {rhurdrdd 1o rorn:ufit1 lufir-hrfr'lfiiunrrifirdarflu sre un;16 steroids'tu

nrrinuTrrriou 6ofir pneumonia lu immunocompromise host rrsirfiarcrnfir-hufi desaturation

adr.r:rrnluruvfitd oxygen mask with bag 1o LpM ix:JfiuFrreir.rnrul6 fine crepitation flB.l

tJooflYr 2 firl rrn;'trjfivdnerula.,rnrrrur'fiar:u*rturnaolfionrnu i.r6sfl.r acute respiratory distress

syndrome (ARDS) il1nfiqo

z. nr:n''rrcria.:drafiralqlu nRos fu nr:'l$rflu controt mode tumouu:n Ieualq 16onrflu

vcv fi54 Pcv mode fr1fi lfisi,r rnia.JdlrJHruterLU! restrictive tung disorder 6o tow tidat vorume
(6 mukg), l:E normat. RR r5rn'ir n6 0 6-24 ng,t/urfi ySolrnn.irfiro"r rflu1 un:nt:fior:rur1d
positive end expiratory pressure (PEEp) firrnn,ir s zl.rh lotrrirs*ufia: z-s r:.t.J.l

3. 6oorrl.t paramerer fio"rrflulfiotdrn?o,rdrunrtr'lq nrtoirodr{frfian rflu vcv mode i,r
tdanGonrrl PIP, exhaled tidal volume. FiR, oxygen saturation fi.,rtulgdrflu ARoS nr:fnur

trd'r oxygen saturation }ildrurnn'jr 90% (as-92%) uanerndrfiatd prep'lunr:inur fio,r

:ri,truorioyrofiraninr:bariuul6oodrt 6,rfinr:1fr pEEp qyd'illfi inrrathoracic pressure Lfi

du d{fi venous return floa{ ua:orerhlfinrr d'uTafioraon,rld

4. d,rnrle portable chest X-ray rfio:J:: rrl'usir rry .r?o,lyiodruyrulc nrr :r.t!tt.:roa

rarEnnruro,rtJoo rrar ventilator induce tung in1ury firfioduqrnnr:'l{ pEEp (nju pneumothorax,
pneumomediastinum) ni.ln:rl arterial blood gas rdo:J::rfiu oxygenation, ventilation LLni
acid-base batance rfio:J:;1ut{tunr:l5lroio,:tiruyrfliqeiotj

s. lu:rud Bp 90/40 mmHg 6r mean arteriat pressure nt.tnit o5 u.rl:ou 6,:fi0.1
rirnrrtfiar:rir oejr,rl:fisrr:Jtu:.rurfhjsrrtliorrfrlos rynfin tv botus rfio.,rorn{rlrs rflu aRos

M rrtrjrfnlnqndugrl

srvnsd firseir.,rn'rd,rnrrimtrfi rflul:Id

r?t1 . Diet as ons day order
Admit o1q:n:rxlr0.t r Record V/S, l/O as usual
On €ndotracheal tube I No. 7,5, mark 22 cms
On ventilator : VCV mode M€dication
Flow lrigger 2 LPM, FiO, 0.6, TV 300 ml-
. Cettriaxone
IPFR 40 LPM. PEEP cmH,O. RR 24lmin
Sig. 2 gm V OD with stat dose
Kssp PIP < 35 cmHro. TV 250-350 mL,
. Co-trimoxazole 2 amps in 5% DW 100
qRR < 3zmin, saiuration > 90%
mL
Portable cxR
Arterial blood gas Sig. V drip in 30 min q 12 hrs with stat

NSS 200 mL dose
Sig- V drip in 15 min
. Omepra.zols
R€cordV/sq1hr
Sig. 40 mg OD
l{ SBP < 90 mmHg, MAP < 65 mmHg
On Fol€y catheter . Paracetamol (500 mg)
Keep urine output > 25 ml-/min
Blood for BUN. Cr. Electrolyte€ Sig. 2 tabs oral prn for Jever (BT > 38.3)
F€tain NG tube q 4-6 hrs

NPO nlsfiBdo
Blood for CBC (with p€ripheral blood smear), :rinrj:srir fi'r
direct Coomb's test, LFT

H/C x ll specimsn
Stool s),€m for parasit€
Sputum fresh smear, G/s (rfiu stiOe biunnrj
651{), C/S for bacteria, sputum lor Giemsa/
IFA for PCP
POCTglucos€q6hrs
Hydrocortisone 200 mg in 5% DW 100 mL
V drip in 24 hr

orafioda
rriorj'::ohdr

nlliduFi'riionliYnurlunr:nuadttranin nn?unf nfifirug 45

n1{ridlrdTodl{r'ro15?rfiulil rryribior#rirdlrfir}-flurjaootir.:r?arir d{rirno hypoxemia
fr1uu:-rld 6rnr:lfiortirdr rro;6onu lflr:;r-.:nrr: hypoxemia Tornr:rfionorrutrtfin crystat-

loids nau

6. sr'orltrrflr:zi.r vitat sign nn I drfu.r odr,rl:frntr1utirtfifinrr}fror:rirlua-q:r rfr

do.rfinr:rffr:;r-.rfrn'ird rdu riiolfic.r:rihnru zoo rn. 'lu is urfi fiar:r-onrrrud'ulnfinnilfi dia

:;rfiunrtnaldua,r

z. {!rua qjlunrr;6an 6.rnr:vrinr: :;rfiu irrruilocn;arir ndfin nr:ld Fotey

catheter unyfr 6o'w:JirrrurlncrryToufi rfl ryrJrfl fi 0,5 xn,/nn./srJ.

A. dtn:retfionrfia :rtfiu renal function iest !!ny electrolytes rfun*utru

g. rdo,oor n'lurru:dnru n'ulnfi m n'r i{ a?: Npo liriou

t o. luilrr 16urr,rlnfiniyrur {rhl:rldrnalfi:'lnr:iriqafl ntHn ori16r nr:si,rn:re cBC
viiorn peripheral blood smear 'jrrdrldnir etHe uiohj uiorilu disseminated intravascurar
coagutation (DIc) [u{ona1nfi:i1u:rudfinr:6ortrofilanrorfio otc ld

t t. nr:fi 0rdannntu:rad6ofr.nJooa-nrourfludrri'rytu{:hrifi1dfi steroids mda uonarn

q;6afi.rnrrFnrdaurafi6uTnulidilufiTfiarurqfrrflu}.Id6n6opneumocystisjeroverci pneumonia

fj,:d4.,:rirnr:d.,rn:rtro?r'ry ugnornddo{o sputum fresh smear rfian:,:lrr strongyloides larva

drs rfja.,rornvuiufi'lfl1rudlfi steroids ld ou

r e. tu:radfil,ifia,ldunr:6nrda itdrn:rc hemocutture 2 specrmens ttflsfl\:ai?o stool
exam tfjo{qrnfiLht:ttd1d steroids ffTonrnni?:sn't?ltr.l strongyloides larva ld

ll!\!, tg. r duuul prednisotone dtdrflu nyorocortisone rdalornrru:riftJruodlunrr;fian

fr'tL t'r 4Lut;ia,rnrtnqfrlJr a{ urrr.Jytt'r r6uarnr: rra:fi0-:nr:qtBla{ glucocorticoids trnt
[q

mineralocorticoid elfect tunr:rfi lntr:ldulnfi n

t+. n:rq:;drdrmlafin 6 dd$J.r inur::orriroralifi tqo-teo rn.laa.

ts. lun:rfifidallrirwrdoriol:n rilr:rurlriurfio:olnn gram negative bacteremia t.:

uilr{riouiufl:hrlfrrflu Sre fi'td steroids'lunr:fnuurriau d':lrilurfinra:.lnqr.rrda pneumocystis

jeroverci

te. rda,rernfirhu:rfldfi uurliilfia,r"[drnio.rdrryruhurun.ir 48 ri.rll,r 6.:nr:'hi srress

ulcer prophylaxis

f,r.leu:'ruii s
r1uo1g 6s f, ifiqd'u DM, HT. cKD ioomyoon 300 uoJiu ilnrrr-nurfirunr:rir

hemodiatysis g n*.,rr dilorf' nilqnrirt'lrildrrrir hemodiatysis rfia.,rlrnlrifielrfint rdl ni.,,:d