Saturday, January 31, 2015

Photoshoot for Photobook

So today we had a photography session for our batch photobook.

The official set

The unofficial sets of photos:

With friends who came during the session


Posing posinggg

Cute face. Blerghh.

Walking around campus

Ooookayyy too much. Too much. LOL

Have a good dayy, people!! :D

Friday, January 30, 2015

Long Case with Prof. How

Patient 1

35-year-old intravenous drug user with underlying Hepatitis C, presented with 3 days history of high-grade fever associated with lethargy. Last heroine injection was two days prior admission. Patient had history of needle sharing.

Physical examination revealed a medium build man lying in 45' propped up position. Clubbing was noted. There was no stigmata of IE and no sign of heart failure. Vital signs normal. On cardiovascular examination, JVP was not raised. Pansystolic murmur was heard at left sternal edge, grade 3/6, no radiation, prominent on inspiration, presence of pulsatile liver. Other systemic examinations were normal.

1. Provisional diagnosis?
Infective Endocarditis without complication

2. Complications of IE?

  • Cardiac lesions eg. aortic root abscess leads to complete AV block and left ventricular failure
  • Immune complex deposition eg. vasculitis, glomerulonephritis
  • Embolic phenomenon eg. abscesses in brain, heart, kidney, spleen, gut, lung

3. HIV symptoms and signs?

Taken from this website

4. Investigations?

  • Blood C&S taken 3 sets at different time and site 
  • FBC to check for anemia and leukocytosis
  • UFEME for microscopic haematuria
  • LFT because this patient has Hep C, look at liver enzymes, albumin
  • HIV/VDRL screening
  • ESR/CRP will be raised
  • ECHO to look for any valve vegetations
  • CXR to look for cardiomegaly
  • ECG to look for long PR interval

5. If this patient's albumin is low in LFT, what test do you want to do next?
Do PT/APTT to look at coagulopathy, because low albumin may indicate liver cirrhosis.

6. If this patient's AST and ALT raised, do you want to treat?
Yes, we treat hepatitis by giving PEGinterferon alpha 2a/2b and Ribavirin.

7. Duke criteria for IE?

Taken from this website

8. Which antibiotics you give?

  • For right-sided Staph aureus : Gentamicin + Cloxacillin
  • For left-sided Strep viridans : Gentamicin + Benzylpenicillin

Patient 2

75-year-old female with underlying COPD, bronchiectasis and pulmonary TB on maintenance phase, presented with 3 days history of fever and 2 days history of shortness of breath and haemoptysis.

Physical examination revealed a cachexic elderly female, looked pale and lethargic, on nasal prong. Patient afebrile, RR 30, BP 120/70, HR 84, SpO2 95% under NP. BCG scar present. No leg edema. 

On respiratory examination, trachea shifted to the right. Chest expansion reduced at lower zone of right lung, with reduced air entry, dullness on percussion. Bibasal crepitations present.

On cardiovascular examination, JVP was not raised. Pansystolic murmur was heard at lower left sternal edge.

1. Differentials?

  • Relapse of bronchiectasis
  • Lung carcinoma
  • Aspergilloma

2. Causes of haemoptysis? Remember BATTLE CAMP

  • Bronchitis/Bronchiectasis
  • Aspergillosis
  • TB
  • Tumor
  • Lung abscess
  • Emboli
  • Coagulopathy
  • Autoimmune/alveolar haemorrhage
  • Mitral stenosis
  • Pneumonia

3. Investigation?

4. Management? 
ABC, antipyretic, antibiotic etc.

5. Side effects of anti-TB? Must know ok!

  • Isoniazid : hepatitis, neuropathy, pyridoxine deficit, agranulocytosis
  • Rifampicin : hepatitis, orange discolouration of urine and tears, flu-like syndrome
  • Ethambutol : optic neuritis
  • Pyrazinamide : hepatitis, gout
  • Streptomycin : ototoxicity

Thursday, January 29, 2015

Night 'Revisionn'

Studying can be boring sometimes. It's just too much to read and revise.

I never meant to break your heart
I won't let this plane go down
I never meant to make you cry
I'll do what it takes to make this fly

You gotta hold on
Hold on to what you're feeling
That feeling is the best thing
The best thing, alright
I'm gonna place my bet on us
I know this love is heading in the same direction
That's up

These two are my favs! :D
G'dnight y'all!

Monday, January 26, 2015

Long Case with Dr. Nik Fatnoon

Patient 1

A 23-year-old female presented with worsening shortness of breath for two days duration and progressive bilateral leg swelling for one day duration. She has Type 2 Diabetes Mellitus, hypertension and chronic kidney disease. No evidence of liver or heart failure.

Physical examination revealed a morbidly obese patient, pale but not jaundiced. Edema was noted up to mid thigh bilaterally. Patient afebrile, BP 138/84, HR 84, RR 14, SpO2 96 under room air. Urine dipstick was not done. All systemic examinations were normal.

1. Provisional diagnosis?
Fluid overload secondary to chronic kidney disease

2. Investigations?
ABG first, because patient might die of respiratory fatigue. Then do ECG to look for acute coronary event, rule out heart failure. If ECG has acute changes and ABG has acidosis, then you cannot dialyse patient! Third, do RP to look at increase level of urea and creatinine. Others: CXR, FBC, 24h urinary protein, LFT.

3. Management?
Since this patient presented with SOB, resuscitate first. Based on ABG and SpO2 result, give oxygen. Monitor and adjust accordingly. 

For leg swelling, give oral or IV Frusemide. Insert branula. Dose depends on response. Monitor urine output. If patient's condition does not improve, consider peritoneal dialysis. Put patient on restriction of fluid, depends on this patient's previous ROF.

Manage the cause of fluid overload. Does the patient has sepsis? Any drugs given? Patient non-compliant? Manage precipitating factors. 

Manage complications of worsening renal failure like uremia, uremic encephalopathy or sepsis. Manage risk factors: DM and HPT.

Patient 2

58-year-old female presented with jaundice and tea-coloured urine for three weeks duration. She had history of taking herbal medications one month prior to the symptoms. She had history of left breast carcinoma 10 years ago, mastectomy done and 6 cycles of chemotherapy completed in HTAA.

Physical examination revealed a thin build female who looked lethargic and dehydrated. She was on IV hydration and urinary catheter. She had generalised jaundice of body and eyes. Patient afebrile, BP 130/90. 

On abdomen examination, tenderness noted at epigastric area. Liver was palpable 3cm below costal margin. Shifting dullness was positive. No stigmata of chronic liver diseases or metastasis. Breast examination revealed 6cm scar at left breast from mastectomy. Right breast was normal. Other systemic examination was normal.

1. Provisional diagnosis?
Hepatitis secondary to taking herbal medications

2. Investigations?
LFT, PT/APTT, Hep B/C viral screening, FBC, RP, US HBS, LDH.

3. Management?
No need to resuscitate because she was well! The jaundice was caused by herbal medications, so stop the medications and monitor patient. Anticipate all the complications of jaundice like hepatic encephalopathy, acute bleeding secondary to coagulopathy, acute renal failure secondary to hepatorenal syndrome and hypoglycemia.

Taken from this website

Saturday, January 24, 2015

Saturday Saturday

Attended a talk in the morning, went to a wedding in the evening.

It would be better if they get better photos of the speakers.
They can make the photos bigger, and the background...okay shut up, Nurul Ain.
Stop complaining! Jeez.

Tentative of the program

Right after the event ended, I took my sisters to my best friend's wedding! :D

Izzatul & Aizad

Awwww :)

Beautiful set!

I hope their marriage will last forever and ever! Amiiinnnn :D 

Finding the one.

Friday, January 23, 2015

Long Case with Dr. Hasnur

Patient 1

Mr. M, 80 years old, an ex-smoker with underlying hypertension, hyperlipidemia, gastritis and ischaemic heart disease, presented with sudden onset of left-sided chest pain for one day duration. The pain was burning in nature, radiate to left axilla, shoulder and back, duration was more than 10 minutes, not relieved by GTN, pain score 10/10. It was associated with shortness of breath and palpitation. There was no history of orthopnea or PND.

He was diagnosed as myocardial infarct in 2000, was unsure of any intervention done on him. There was previous history of similar episodes in the past, but always relieved by GTN. He is on T. Isosorbide Dinitrate, T. GTN, T. Lovastatin, T. Perindopril, T. Cardipin, T. Amlodipine. He is a known case of sinus bradycardia.

Physical examination showed no stigmata of infective endocarditis, no raised JVP. Patient afebrile, HR 43 regular rhythm and volume, BP 100/60, RR 18. Cardiovascular examination normal. S1 S2 heard with no murmur.

1. Provisional diagnosis?
Acute myocardial infarct

2. Differentials?
  • Acute coronary syndrome (STEMI, NSTEMI, unstable angina)
  • Pulmonary Embolism
  • Aortic dissection
  • Pericarditis

3. Investigations?
FBC, PT/APTT, cardiac biomarkers, ECG, CXR, ECHO

4. Management? MONAsH
  • Morphine
  • Oxygen
  • Nitroglycerin eg. GTN
  • Aspirin
  • Heparin
Long term : control risk factors, stop smoking, cardiac rehab, lifestyle modification, continue aspirin, patient education etc.

Patient 2

Puan K, a 50-year-old female with underlying Type 2 Diabetes Mellitus and hypertension, presented with one week history of worsening shortness of breath associated with progressive lower limb and body swelling. It was associated with orthopnea, PND and reduced effort tolerance. She was just discharged from HTAA three weeks ago, and swelling had reduced after discharge. She was put on ROF 600 ml/day.

Physical examination revealed a medium build lady who looked pale. BP 180/60. She had distended abdomen and bilateral pedal edema. Fluid thrill positive, sacral edema present. Respiratory examination revealed fine crepitations heard bilaterally.

1. Differentials?
Fluid overload secondary to:
  • Heart - IHD or hypertensive cardiomyopathy
  • Renal - CKD or nephrotic syndrome
  • Liver - CLD or liver congestion

2. Investigations?
FBC, RP, LFT, CXR, Funduscopy, screen for risk factors etc.

3. Management?
ACE-i, manage risk factors, patient education etc.

Tips : Read on Multiple Sclerosis, Parkinson's, stroke, spastic paraperesis and spinocerebellar ataxia for Pro Exam clinical cases.

Thursday, January 22, 2015

Short Case with Dr. Kuan

Patient 1

Middle-aged man, medium build, lying 45' on nasal prong 3L/min, looked tachypneic. Clubbing of fingers noted with tar staining at left fourth finger. Chest expansion was reduced at both lower lungs. Lungs were hyperresonant on percussion. Fine crepitations heard bilaterally. 

1. Causes of lower lobe fibrosis? CRABSS
Cryptogenic fibrosing alveolitis, RA, Asbestosis, Bleomycin, SLE, Scleroderma

2. Causes of clubbing?
Lung carcinoma, empyema, abscess, bronchiectasis, IE, congenital heart disease, Chron's

3. Investigations?
FBC, BUSE, sputum C&S, ABG, spirometry, high resolution CT

4. Provisional diagnosis?

Patient 2

Patient had left homonymous hemianopia.

1. How do you test patient's eyes?
Test cranial nerve 2, 3, 4 and 6.
Read complete examination at this website.

2. Complete examination with?
Funduscopy, UL and LL neurological examination

3. Provisional diagnosis?
Left homonymous hemianopia secondary to lesion at parietal or occipital of right-sided brain.

4. How do you know the lesion is on the right side?
Trace back the pathway. In this patient, the lesion is at number 3 (right side of brain), so the patient has left homonymous hemianopia (patient cannot see temporal of left eye and nasal of right eye). Understand the diagram ok!

5. Differentials?
  • Cortical stroke at right cerebral hemisphere
  • Space-occupying lesions eg. tumour, abscess, cyst, bleeding

6. Management of ischaemic stroke?
  • Admit patient to ward
  • Swallowing test, check gag reflex for nutrition 
  • Monitor vital signs, urine output
  • Screen for risk factors eg. HPT, DM, IHD, HPL
  • Do ECHO and carotid artery Doppler to look for cause
  • DVT prophylaxis and prevention of bed sore
  • Aspirin + statin, Thrombolysis
  • Patient education, moral and psychosocial support
  • Chest and limb physiotherapy
  • Refer dietician

Wednesday, January 21, 2015

Short Case with Dr. Shahrin

Patient 1

Middle-aged man on nasal prong, had intercostal recession. On respiratory examination, chest expansion reduced at lower lungs, with reduced air entry. Coarse crepitations heard bilaterally.

1. Provisional diagnosis?
Bronchiectasis with underlying COPD

2. How to differentiate JVP and Carotid pulse? (taken from this website)

Patient 2

Middle-aged man sitting comfortably at 45' on one pillow. Respiratory examination revealed a deviated trachea to the left side. Chest expansion was reduced at left lower lobe with reduced air entry, dull on percussion and reduced vocal resonance.

1. Differential diagnoses?
Lung collapse and Pleural Effusion

2. How to differentiate between these two?
Taken from UM Xpress Revision

3. Other differentials?
Pulmonary fibrosis, AECOPD and Bronchiectasis

4. How to differentiate between COPD and Asthma?
Taken from CPG Management of COPD

5. Causes of pansystolic murmur?

6. Causes of Mitral Regurgitation?
  • Rheumatic heart disease
  • Infective endocarditis
  • Papillary muscle dysfunction eg. left ventricular failure, cardiomyopathy, MI
  • Connective tissue disease eg. RA, AS, Marfan's
  • Congenital eg. mitral valve prolapse, endocardial cushion defect
  • Surgery or trauma

7. Differences between UMN and LMN?
Taken from this website

8. How do you know that a lesion originates from a spinal cord?
Look if patient has sensory level or urinary/bowel incontinence

9. How do you test for facial nerve?
Taken from this website

10. Give 5 causes of LMN palsy.
  • Idiopathic (Bell's palsy)
  • Parotid tumour
  • CPA tumour
  • Otitis media
  • Ramsay Hunt syndrome

More causes here:
Taken from this website

11. How do you perform cerebellar examination? (PINARD'SH)
  • Past pointing
  • Intention tremor
  • Nystagmus
  • Ataxia
  • Rebound
  • Dysdiadokinesia
  • Slurred speech
  • Heel to shin test

Read the complete examination at this website

Tuesday, January 20, 2015

Long Case with Dr. Kuan

Patient 1

15-year-old Malay teenager presented with 2 days history of high-grade fever, facial puffiness and bilateral leg swelling. She also complained of frothy urine and oliguria. She had history of skin infection (impetigo) a month ago. No history of orthopnea or PND. No history of abdominal pain, jaundice or tea-coloured urine.

Physical examination revealed a obese girl (BMI 40) with no SLE features, CBD attached with smoky and frothy urine. She was not pale or jaundiced. There was no facial puffines or bilateral leg swelling. BP 130/70, HR 90, RR 20. Abdomen looked full. No hepatosplenomegaly. Kidneys were ballotable. Shifting dullness negative. Respiratory and cardiovascular examination were normal.

1. What else do you want to check in patients with metabolic syndrome?

  • Check BP
  • Xanthelasma on face
  • Acanthosis nigricans at axilla, neck, back
  • Sensation of lower limbs, glove and stocking distribution
  • Non-healing ulcer, gangrene
  • Shiny, atrophic changes of legs and feet
  • Fungal infection in between toes

2. Provisional diagnosis?
Post-streptococcal acute glomerulonephritis 

3. Differential diagnoses?

  • Nephrotic syndrome
  • Mixed nephrotic and nephritic
  • UTI (pyelonephritis)
  • Acute on chronic renal failure
  • Lupus nephritis

4. Investigations?

  • Blood - FBC, UFEME, RP, 24h urinary protein, Urine C&S, Serum Ca/Mg/Phos, PT/APTT, Lipid profile, LFT, ESR, VBG, ASOT, C3/C4, ANA/anti-dsDNA, Rh factor
  • Imaging - KUB ultrasound, CXR, Renal biopsy if indicated

5. What parameters do we have in UFEME?
pH, specific gravity, colour, leukocyte, erythrocyte, nitrite, glucose, ketone, protein, bilirubin, urobilinogen   

6. Differentials for bilateral renal enlargement?

  • Hydronephrosis
  • Obstructive uropathy
  • Polycystic kidney disease
  • Diabetic nephropathy
  • Acromegaly
  • Amyloidosis
  • Renal cell carcinoma

7. What can you see in KUB ultrasound?

  • Kidney size
  • Renal parenchyma, increase echogenicity in CKD
  • Look for stones
  • Pelvicalyceal system dilated in CKD
  • Thinning of cortex in CKD
  • Dilated ureter
  • Bladder - look for stone, tumour, lesion, thickened wall etc.

8. Corrected calcium formula?
[0.8 x (40 - albumin in g/L)] + calcium in mmol/L 

9. Anion gap formula? (difference between plasma cations and anions)
Na + K - Cl - HCO3
Normal range : 10 - 18 mmol/L

10. Cockroft-Gault equation? taken from this website

11. Serum osmolarity formula?
2(Na + K) + urea + glucose
Normal range : 280 - 300 mmol/L

12. Management for this patient?

  • Pharmacological - Antibiotic (Amoxicillin or Macrolides), ACE-i to reduce proteinuria, diuretic like Frusemide, no need to start steroid yet in view of positive blood culture in this patient
  • Non-pharmacological - Admit patient, monitor VS, weight and urine output, restriction of fluid, refer nephrologist, manage risk factors like DM, obesity, HPT, DVT prophylaxis, prevention of bed sore, patient education

Patient 2

54-year-old Orang Asli, an ex-smoker (1 pack per day, for 15 years) with underlying COPD, presented with 2 days history of worsening dyspnea associated with low-grade fever, productive cough and wheezing. The symptoms were partially relieved by inhaler. On the day of admission, he was unable to walk or talk in full sentence.

He is on MDI Berodual and MDI Budesonide. He had multiple admissions to hospital for similar complaints, 2-3 times for the past 3 years. His last admission was in December 2014. He had never been in ICU or intubated before. No surgical intervention done.

Physical examination revealed a man in respiratory distress, on nasal prong 3L/min with intravenous hydration, sputum pot with whitish sputum noted on table. He was using accessory muscles to breathe. He was febrile 37.5 'C, RR 20, HR 100, BP 100/70. There was clubbing noted on both hands, no BCG scar on left arm. JVP was not raised. He had barrel chest, increase in AP diameter. Trachea was centrally located. Lungs were hyperresonant on percussion. Air entry equal. Generalised rhonchi was heard bilaterally.

1. Occupational lung diseases?

  • Coal - pneumoconiosis
  • Sand - silicosis
  • Shipyard/plumbing/wiring/roofing/mechanic - asbestosis => mesothelioma

2. Provisional diagnosis?

3. Differential diagnoses?

  • Bronchiectasis
  • Pneumothorax
  • Pulmonary tuberculosis
  • Lung carcinoma

4. Causes of upper and lower lobe lung fibrosis? (taken from this website)

5. Can we give 100% oxygen in COPD patients?
In patients with Type 2 respiratory failure, we cannot give 100% oxygen because they have chronic carbon dioxide retention. They are used to that condition, so we must maintain that hypoxic drive. We must aim for PaO2 60 mmHg (8 kPa) or SpO2 90% okay!  

6. Investigations?
CXR, ABG, FBC, Sputum C&S, CRP, throat swab, RP, ECG, RPG, LFT, Lipid profile, high resolution CT to look at lung parenchyma

7. ECG findings in pulmonary hypertension?

  • Peaked P wave (P pulmonale)
  • Tall R wave
  • Right axis deviation
  • Left ventricle hypertrophy

8. Management for this patient?
Acute - Resuscitation, monitor vital signs, give SABA or SAMA or Combivent, or if not relieved give oral prednisolone or IV aminophylline, can give symptomatic treatment for cough and fever, give mucolytic and antipyrexic. Monitor SpO2, hydrate patient, DVT prophylaxis, close monitoring, aggressive chest physiotherapy, respiratory rehab, vaccination, nutrition, refer dietician.

9. Common organism that can cause bronchiectasis is Pseudomonas. Which antibiotics can cover for Pseudomonas?

  • Cephalosporin - Cefobid, Ceftazidime (3rd), Cefepime (4th)
  • Aminoglycoside - Tobramycin, Gentamicin
  • Carbapenem - Imipenem, Meropenem
  • Quinolone - Ciprofloxacin (2nd), Levofloxacin (3rd), Moxifloxacin (4th)
  • Tazocin (Tazobactam + Piperacillin)

10. Prolonged use of macrolides (eg. Erythromycin) can improve exacerbation of bronchiectasis. How?
By reducing biofilm on lung surface, so there is no opportunity for bacteria to grow there. But be careful with macrolides, they can cause hearing loss!

Monday, January 19, 2015

Sunday, January 18, 2015

10 Random Things.

1. My Mom asked me to order 3 photobooks. Finished uploading the files online.

2. My little sister wanted to go bowling. I would rather stay at home and do my thing though.

3. Short Case with Dr. Hadzri and Long Case with Dr. Yousof. Have to finish writing those.

4. CPGs. Need to re-read those.

5. On call this morning. I used to like Sundays.

6. My best friend is getting married next week. I'll be helping with her henna.

7. They were crashing weddings. So sweet :)

8. 17 Things To Expect When You Date A Girl Who's Used To Being On Her Own. This is so true. Falling in love is a scary thing.

9. My Mom said I will end up being single even at age 30 if I am so choosy. That's much better than ending up with a wrong person.

10. Being a daughter is difficult. Raising a daughter is more difficult.

Friday, January 16, 2015

Long Case with Dr. Yousof

Patient 1

Miss C, a 22-year-old Chinese female with underlying SLE, diagnosed 5 years ago was electively admitted for renal biopsy due to persistent cloudy and frothy urine. Her last relapse was 7 months ago, where she presented with fever, facial puffiness, periorbital edema and leg swelling. She had amenorrhea since 3 months ago.

On examination, patient was alert and comfortable. She was on urine catheter, with cloudy and frothy urine. She had moon face, facial puffiness, small multiple macular rash on cheeks as well as multiple purplish striae noted on both lower limbs. Vital signs normal. No significant findings on system examinations.

1. Investigations?
Urinalysis, FBC, RP, LFT, Ca/Mg/Phos, PT/APTT, ESR/CRP, ANA/anti-dsDNA, C3 C4, CXR to look for cardiomegaly or pleural effusion.

2. Management?

  • General - Admit patient to medical ward, Nephrotic chart, Strict I/O chart, Measure urine albumin, Measure weight
  • Pharmacology - Review old medications, Refer nephrologist, ACE-inhibitor
  • Non-pharmacology - Patient education on compliance to medication, wear sunscreen or hat when going out, avoid direct sunlight

3. SLICC criteria to diagnose SLE?

2012 SLICC Criteria
Taken from this website

Patient 2

Mr. R, a 26-year-old Malay man, diagnosed as epilepsy 13 years ago, presented with multiple seizure episodes for one day duration. The first seizure started at night when he was sleeping, 10 minutes duration, generalised tonic clonic seizure with uprolling of eyes and drooling of saliva. There was no urinary or bowel incontinence. Post-ictal, he had severe headache, drowsy, lethargy and retrograde amnesia. Second attack happened 15 minutes later with similar presentation. Post-ictal, he vomited out water and food particles. He had 4 more attacks after that, 15 minutes gap between each other, duration of 3-6 minutes, increasing in severity. After the sixth attack, he had loss of consciousness and was brought to the hospital. He suffered left lip swelling and gum bleeding.

Prior to attack, her mother noticed him being easily lethargic, had low mood and less talkative than usual. No history of drug intake, no trauma, no fever, neck stiffness, no weakness or numbness, no hypoglycemic symptoms reported.

He was diagnosed as epilepsy at age 13, first presentation generalised tonic clonic seizure. He is on T. Carbamazepine and T.Keppra (Levetiracetam). He is on regular follow-up at MOPD. He had attack every 2-3 months. No significant family or developmental history, no childhood trauma or infection. He is a smoker for 13 years, 5-6 sticks per day.

No significant findings on physical examination.

1. Spot diagnosis?
Status epilepticus!

2. Definition of status epilepticus?
Seizures lasting for more than 30 minutes OR repeated seizures without intervening consciousness.  

3. Common causes?

  • Non-compliance to medication
  • Infection
  • Metabolic imbalance (hypoglycaemia etc)
  • Underlying brain tumour, abscess etc.

4. Which diseases are more prone to get epilepsy?
Neurofibromatosis and Tuberous sclerosis

5. Investigations?

6. Complications of tonic clonic seizure?

  • Rhabdomyolysis causing renal failure
  • Respiratory failure (diaphragm tonic)
  • Metabolic acidosis (body uses more oxygen)
  • Hyperpyrexia 

7. Management?

  • Remove any dentures or anything inside mouth
  • KNBM, secure airway
  • Establish lines, give IV Diazepam or Lorazepam to stop seizure
  • Monitor vital sign, Sp02, urine output
  • If patient still has seizure, give another dose of Diazepam after 10 minutes
  • If still not controlled, give Phenytoin
  • If still persist, TRANSFER TO ICU!
  • In ICU, can give another bolus of Phenytoin or Intubate or Phenobarb or Anaesthesia