MEDICAL

TECHNICIAN

HANDBOOK
CFMSS INFO
Colonel-in-Chief Her Majesty, Queen Elizabeth, The Queen Mother

Patron Saint - Saint Luke

Feast of Saint-Luke is 18 October

Motto: CFMSS
Militi Succurrimus We hasten to aid the soldier

CFMS
In Arduis Fidelis Undeterred by difficulties

March Past: Farmer's Boy

Anniversary: 15 January 1959

Description of Crest: Sanguine, the staff of Aesculapius, was selected

to be associated with the crest because of its long recognition as a
symbol of healing. The maple leaves indicate it is Canadian. The
torches indicate it is a school.

2
 THE PRINCIPALS OF LEADERSHIP

Achieve professional competence

Appreciate your own strengths and limitations and persue

self-improvement

Seek and accept responsibility

LEAD BY EXAMPLE !!!!

Make sure that your followers know your meaning and

intent, then lead them to the accomplishment of the mission

Know your soldiers and promote their welfare

Develop the leadership potential of your followers

Make sound and timely decisions

Train your soldiers as a team and employ them up to their

capabilities

Keep your followers informed of the mission, the changing

situation and the overall picture

3
 “It is better to be judged by 12 than carried by 6”

TABLE OF CONTENTS

TOPIC_________________________________PAGE
CFMSS Information 2
Principals of Leadership 3
Chapter 1 - Control of Haemorrhage 5
Chapter 2 - Facial Fractures 9
Chapter 3 - Wounds of the Abdomen 14
Chapter 4 - Fractures of the Pelvis 19
Chapter 5 - Fractures of the Femur 23
Chapter 6 - Crush Injuries 26
Chapter 7 - Management of Shock 30
Chapter 8 - Management of Burns 39
Chapter 9 - Gunshot Wounds and
Fragmentation Wounds
43
Chapter 10 - Combat Stress Reaction 52
Chapter 11 - Use of Morphine 64
Chapter 12 - Chemical Warfare / Battlefield
First Aid
68
Chapter 13 - Intravenous Therapy 84
Chapter 14 - Field Information 96
Chapter 15 - Physical Examination 123
Chapter 16 - Physical Exams 163
Chapter 17 - Miscellaneous information

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Self Breast Exam 195
Management of chemical/ drug OD 198
Four primary reflexes 201
Assessments 202
Insulin shock 217
Diabetic coma 218
Clinical Notebook 219
Shock 221
Sore throat or Strep throat 223
Trauma score 224
Apgar score 226
Glasco Coma scale 227
Ankle injury rules 228
Ottawa knee rule 229
Skin lesions 230
Prefixes / Suffixes 232
Abbreviations 235
Common drug names 239
Childbirth 331
Liquid conversion 370
Temperature conversion 371
Length conversion 372
Drip rates 373
Drugs of choice 375
Classification of drugs by effect 419
Glossary 423
Recipies 434
Anatomical plates 443

5
 CHAPTER 1

CONTROL OF
HEMORRHAGE

6
INTRODUCTION

It is critical that all soldiers know the methods that may be used in the
control of bleeding. Generally, after ensuring that the casualty has an open
airway, and that he can breathe, the second matter for immediate action is the
control of bleeding. Five to ten percent of battle deaths result from injuries in
which good first aid could have controlled the bleeding.
There are three main methods for the control of external bleeding,
these are:
a. Direct pressure (in conjunction with rest and elevation)
b. Indirect pressure (on a pressure point)
c. Tourniquet

DIRECT PRESSURE

Almost all cases of external bleeding from open wounds can be

controlled by direct local pressure. Pressure stops the physical flow of blood
and permits normal blood clotting to occur.
Pressure may be applied by the bare hand, a clean cloth or most
preferable, a sterile pressure dressing. The hand is held tightly over the wound
and is only removed to quickly apply the prepared dressing and bandage.
A pressure bandage accomplishes this ideally when applied as a
broad bandage of even tightness. If the tails of the shell dressing are tied too
tightly, the flow of arterial blood may be cut off.
If the first shell dressing becomes blood soaked, a second dressing is
applied over the first. DO NOT remove the first one as it will disturb the blood
clot formation.

INDIRECT PRESSURE ON A PRESSURE POINT

When direct pressure with reinforced dressings does not control

wound bleeding, pressure applied to an artery can be used to stem the flow of

7
blood to the wound site.
Only rarely does the pressure on a major bleeding artery completely
stop the bleeding at the wound site: This is because in most instances the
wound is supplied by more than just one artery.
Indirect pressure is used for severe bleeding, and is used along with
the direct pressure method. Only two pressure points are of value for field use:
a. The Femoral Artery in the groin
b. The Axillary Artery in the upper arm

Pressure is applied by hand at the pressure point so that the artery is

compressed against the bone and the flow of blood is slowed; this gives natural
clotting a chance to bring the bleeding under control.

TOURNIQUET

When all efforts to control bleeding have failed, (ie. Rest, elevation,
indirect pressure, and two pressure dressings), there is still one more thing you
can do. A tourniquet may be applied. There are two indications for the use of
a tourniquet:
a. Traumatic amputation of a limb
b. A life threatening hemorrhage that cannot be controlled

It must be kept in mind that in cases other than an amputation, that a

tourniquet can cause more damage to an injured limb than was caused by the
original wound. The tourniquet can crush tissue, nerves, and blood vessels.

Tourniquets are not to be used for wounds or amputations below the

knee or elbow, as rarely if ever does the bleeding below the knee or elbow
require tourniquet control.

A properly applied tourniquet may be a lifesaving measure for a

soldier whose bleeding from a major vessel cannot be controlled in any other
way.

There a various types of tourniquets commercially manufactured.

These are usually made from rubber or leather.

8
 Commonly used items in first aid would be the standard triangular
bandage, folded into a width of two inches; or a belt from your trousers. In any
case, the tourniquet must not be less than one inch in width.

9
NEVER USE SUCH THINGS AS ROPE OR WIRE AS THESE ITEMS
WILL DO PERMANENT DAMAGE TO BLOOD VESSELS AND NERVES

APPLICATION OF A TOURNIQUET

a. Fold the triangular bandage to a width of not less than two inches.
b. Wrap the tourniquet around the limb twice at a point as close to the wound
as possible.
c. Tie a granny knot in the bandage. Place a stick or similar item on top of the
knot and tie the ends of the bandage over the stick in a square knot.
d. Use the stick as a handle and tighten as you would turn off a tap until the
bleeding stops. Once it has stopped, DO NOT tighten any further.
e. Secure the stick in place.

USING A B/P CUFF AS A TOURNIQUET

If a blood pressure cuff is being used as a tourniquet, the guage must

be continuously monitored to be sure that the pressure is not being lost
gradually.

As with any type of tourniquet, a note or the letters TK must be

applied to the patient’s forehead along with the time of application.

GENERAL RULES

The tourniquet, once applied, must not be loosened until the casualty
has reached a hospital where a doctor is prepared to deal with the bleeding and
blood replacement in an operating room.

Never cover a tourniquet with a dressing or bandage; leave it out in

full view at all times.

Mark ΑTK on the patient’s forehead along with the time the
tourniquet was applied.
These casualties have a high priority for evacuation.
 CHAPTER 2

FACIAL
FRACTURES
INTRODUCTION

Fractures of the facial bones commonly result from blunt impact:

a. Collision with steering wheel / dashboard
b. Getting hit with blunt object

In our case we will have to add high velocity missels to the list.

FRACTURES OF THE FACE

Signs and symptoms

Bones commonly broken include:

a. The orbit
b. The nose
c. The maxilla
d. The mandible

Signs and symptoms of fractures about the nose and mouth will
include:

a. Obvious deformity
b. Restriction of the normal movement of the jaw
c. Abnormal movement of the jaw
d. Pain when moving the jaw or swallowing
e. Difficulty in speaking
f. Excessive bloody saliva
g. Displacement of teeth alignment

Any casualty who has sustained a direct injury to the mouth or nose
should be considered to have a high risk of facial fracture.
COMPLICATIONS

In all these injuries, extreme care must be taken that the

airway does not become obstructed.

Wounds inside the mouth often accompany fractures of the

jaw and can cause considerable bleeding into the mouth.

Accumulated blood, broken teeth, and dentures can cause the

upper airway (back of the throat) to become blocked.

STABILIZATION

Maintain an open airway; ensure that there is no obstruction in

the mouth. Remove any dentures or broken teeth.

Maintain drainage for the blood and saliva. Tilt the head
slightly to one side. Use a finger to keep the airway open and the
drainage maintained, if the face is badly swollen.

If the casualty vomits, support the jaw with the palm of the
hand and turn head to the injured side.

POSITIONING

Conscious casualty - sitting with the head well forward and

supported to allow secretions to drain freely. Support the jaw with a
soft pad held in place by hand, not a bandage.

Conscious severly-injured casualty - place the casualty in the

recovery position if there is displacement of the chin or soft tissue
damage.

Unconscious casualty - place the casualty in the recovery

position, with the jaw kept well forward.

LE FORTE FRACTURES

Fractures of the midface are described by the Le Fort

classification.
A Le Fort I fracture is a fracture above the level of the palate,
separating the palate from the rest of the midface.

A Le Fort II fracture courses through the nasal bones,

separating the midface from the skull at that level.

A Le Fort III fracture, which is also called craniofacial

disjunction, courses through the glabella, orbits, and frontozygomatic
suture lines, separating the entire midface from the calvarium.

Bilateral fractures are often of different types (e.g., a left Le

Fort II and a right Le Fort III). The significant force required to cause a
midface fracture frequently results in associated injuries.
Clinical features. Edema and ecchymosis in the periorbital area are
commonly seen in midface fractures. Airway compromise may be a
problem, particularly with a Le Fort II or Le Fort III fracture. Palatal
fractures, epistaxis, facial lacerations, and eye injuries are often present.
In addition, cerebrospinal fluid (CSF) leakage may occur. Instability of
the midface can be elicited by grasping the maxillary incisors or
alveolar ridge and gently rocking it in an anterior-posterior direction.
Palpation of the nose, malar eminence, and frontozygomatic suture line
will assist in determining the type of Le Fort fracture. Malocclusion
will often be present.

Evaluation of the airway is of primary importance. Since CNS, ocular,

and cervical spine injuries commonly occur in association with Le Fort
fractures, careful evaluation for such injuries is also mandatory. Facial
films will establish the diagnosis. A Waters' view shows the orbits,
inferior orbital rims, and maxillary sinuses. An anteroposterior skull
film is better for visualizing the frontal sinuses and superior orbital
rims.

3. Management. Control of the airway may be obtained by careful

orotracheal intubation with in-line immobilization. Deforming injuries
with significant bleeding may cause inability to visualize the vocal
cords, in which case a surgical airway is advisable. Blind nasotracheal
intubation, however, is contraindicated, as the normal nasopharyngeal
architecture may be disrupted. Cricothyrotomy or tracheostomy may
be required. Bleeding can usually be controlled with both posterior and
anterior nasal packing and oral packing after endotracheal intubation.
Once the cervical spine has been cleared of injury, raising the head of
the bed will decrease venous pressure and assist in control of
hemorrhage. Application of ice may diminish edema, and an analgesic
is often required. Patients with midface fractures are hospitalized for
airway management and elective fixation.
 CHAPTER 3

WOUNDS OF
THE ABDOMEN
INTRODUCTION

Injuries of the abdomen may result from blunt traumatic force

or may be caused by penetrating objects.
In a motor vehicle accident, the impact with the steering wheel
or dashboard may be sufficient to cause severe injury to organs that lie
in the abdominal cavity. A fall from height with impact on the
abdomen can cause the same injury.
Therefore we can see that wounds of the abdomen are
classified as:
a. Blunt or closed
b. Penetrating or open

BLUNT OR CLOSED ABDOMINAL INJURY

SIGNS:

a. Bruising or marks on the skin

b. Increased pulse
c. Rapid shallow breathing
d. Skin ashen colour
e. Abdomen tender to touch
f. Abdomen may appear swollen / distended
g. Vomiting

FROM THIS LIST OF SIGNS, WE CAN SEE THAT THE

CASUALTY IS SHOWING MANY OF THE SIGNS OF INTERNAL
BLEEDING AND SHOCK.
SYMPTOMS

a. Casualty complains of pain in the abdomen

b. They may complain of being nauseated
c. They may be very anxious
d. They may tell you that they do not want to be moved

We are faced with the possibility that either hollow organs or

solid organs that are contained within the abdominal cavity have been
lacerated or ruptured.
Hollow organs such as the stomach and intestines contain
partially digested food and digestive juices that spill into the abdominal
cavity when punctured. This will produce tenderness, a rigid abdomen
and intense pain.
Solid organs such as the spleen, pancreas and liver have a rich
blood supply, and injury to these usually causes severe bleeding.

TREATMENT FOR BLUNT/CLOSED ABDOMINAL INJURY

a. Transport lying n his back

b. Tilt head to one side - watch for vomiting
c. Ensure that the mouth and throat are clear
d. Observe and record pulse and respiration
e. Treat for shock - keep warm
f. DO NOT give anything to eat or drink
g. Evacuate as soon as possible
PENETRATING OR OPEN
ABDOMINAL INJURY

Examples of the cause of this type of injury would be gunshot

and high velocity missles as well as stab wounds. In this case organs
are usually injured and discharge their contents into the abdominal
cavity.
Signs:

a. Entry and exit wounds from high velocity missels

b. Deep lacerations or stab wounds
c. Increased pulse
d. Rapid shallow respirations
e. Skin colour ashen
f. General signs and symptoms of shock will develop

Symptoms:

a. Abdominal pain
b. Nausea
c. Anxiety

Treatment:

a. Apply clean dressing to all wounds

b. Leave any penetrating instruments in place
c. Stabilize these objects and support them in place
d. Ensure the mouth and throat are clear
e. Observe and record pulse and respiration
f. Treat for shock - keep warm
g. Do not give anything to eat or drink
h. Evacuate as soon as possible
EVISCERATION

Extensive laceration of the abdominal wall may allow organs

to protrude through the wound. In cases like this, the treatment would
be as follows:

a. Follow all steps as per the treatment of the open injury

b. Do not make any attempt to replace the protruding organs
c. Use a wet dressing instead of a dry one. The shell dressing opened
to its largest size and a canteen of water will suffice.
 CHAPTER 4

FRACTURES
OF THE
PELVIS
INTRODUCTION

Injuries to bones and joints, either by direct wounding or by

indirect blast or other trauma, make up a significant number of battle
injuries. Death from these injuries usually results from bleeding and
can be prevented, in most cases, with appropriate care in the field.
Treatment is aimed at preventing the sharp bone fragments
from causing further injury to surrounding muscles, blood vessels and
nerves. Further blood loss and shock can be reduced by proper
splinting and immobilization to prevent the movement of the bones at
the site of the fracture.

FRACTURE OF THE PELVIS

Cause: Missle wound

Crush injury
Fall from height

Signs and symptoms:

Pain in the hips / lower back
May not be able to stand or walk due to pain

Complications:
May be unable to pass urine or may pass blood in the urine due to
injury of the bladder or urethra. High probability of shock: Blood
vessels are usually severed, especially in complicated fractures.
STABILIZATION

1. If medical aid is readily available:

a. Lay the casualty on their back with knees straight or bent and
supported with a folded blanket; and
b. Pad ankles and use a figure eight bandage to secure the feet
together.
Alternative method:

Place padding between the legs and bandage around the feet, ankles
and knees. Use two overlapping broad bandages over the pelvis.

2. If medical aid will be delayed, or transport will be long and rough:

a. Apply two overlapping broad bandages to the pelvis (broad edge of

bandage on injured side, safety pinned on uninjured side).

b. Soft padding between knees and ankles.

c. Apply figure 8 around ankles and feet. Ensure that knot is tied on
edge of boot.

d. Apply broad bandage around knees. Secure to spinal board with

strap or triangular bandage.

e. If casualty feels discomfort with broad bandages, loosen but do not

remove, and support both sides of the pelvis with sandbags or heavy
padding - ie. folded blankets.
 CHAPTER 5

FRACTURES
OF THE
FEMUR
FRACTURE OF THE FEMUR

Cause: It usually takes a powerful force to fracture this bone.

Examples would be high velocity missles, crush injuries, or a fall from
a height.

SIGNS AND SYMPTOMS

- extreme pain at the site of the fracture

- when neck of the femur is fractures, the entire leg, but
expecially the foot, is rolled outward
- fracture of the shaft of the femur; marked deformity
(angulation) and shortening of the thigh

COMPLICATIONS

- Fractures of the distal end of the femur may be associated

with knee and knee ligament injuries.
- There is a great loss of blood into the surrounding tissues;
this leads to shock and therefore the treatment of shock must be seen as
one of the most important factors for your attention in the treatment of
this injury.

STABILIZATION

1. Medical aid is readily available:

All you are required to do is steady and support the limb, and apply
gentle but firm traction until medical aid arrives. Keep the casualty
warm to help prevent further shock.

2. Short smooth move to medical aid:

a. Secure the legs with broad fold bandages

 b. Use lots of padding between the legs (blanket)

c. Move the uninjured leg over against the injured leg

d. Steady and support the limb with gentle traction by pulling

steadily and firmly on the foot, keeping the kneecaps and toes pointing
upwards.

3. Move to medical aid long and rough:

a. Use broad fold bandages:

- below the armpits
- at the pelvis in line with the hip joints
- at the thigh, above and below the site of the fracture
- at the knee
- at the lower legs
- figure 8 at the ankles to include the splint
- long padded splint on the side of the fracture stretching from
the armpit to the boot sole.

*****NOTE*****

Remember to pad well between the legs.

CHAPTER 6

CRUSH
INJURIES
 The Αcrush syndrome is a collection of medical problems
brought on by a significant crush type injury to the muscles attached to
the bones (skeleton / skeletal muscles). This type of problem or injury
was first described in World War II when rescuing victims who had
been trapped under masonary from collapsed buildings after bombing
raids. In peacetime, we may see this type of injury in natural disasters
such as earthquakes, mine cave-ins, or possible vehicle accidents.

Present day terrorist activities using high explosives, and

military operations in cities (ie Northern Ireland) are the present day
causes of this injury for military concern.

Any person who has been crushed beneath falling debris, or

run over, or whose limbs have been compressed for any reason for an
hour or more, is at risk of sustaining a serious crush injury.

The collapse of a building due to an explosion, causes

immediate death for the majority of victims due to the blast effect, the
direct effects of the falling debris, the fire or the compression by the
rubble. Immediate death is mainly caused by severe damage to vital
organs. The survivors whose limbs are pinned under this heavy rubble
trapping them, are the ones that we must be aware of as having suffered
a serious crush injury.
MECHANISM OF INJURY

Sustained compression of a limb stops the proper flow of

blood, which will cause injury to the muscles due to lack of oxygen.

When the limb is removed from the compression, the damaged

muscle releases body fluids and chemicals into the bloodstream. The
casualty may also be suffering from other severe injuries that will
aggravate or cause shock themselves.

After release of the compression, swelling of the affected part

occurs. Plasma moves out of the blood vessels and into the tissue to
cause the swellling. This will reduce the volume of blood available in
circulation and may well cause shock. Kidney failure and sudden heart
failure coupled with shock, gives a poor outlook for this seriously
injured casualty.

A clear history of what happened in a crush injury is often not

available in wartime, and the symptoms sometimes develope silently in
casualties who at first sight appear to be alright. Crush injuries of the
chest, waist, and hips can be missed if a complete physical check is not
done.

Although the part that was compressed may appear normal

when it is released from pressure, paralysis is sometimes present. The
skin at the outer edge of the compressed area may appear red and may
even blister. These signs are often the first indication that the person
has suffered a crush injury.
Shortly after the limb is released from the compression, the
swelling starts. As stated previously, this will cause a drop in blood
pressure and the casualty way quickly go into shock. The crushed limb
will become swollen, tense and hard. The circulation of the blood in
the limb is drastically reduced.
FIRST AID TREATMENT

The first thing we need to do is splint any limbs that have been
crushed. This will help to stabilize any fractures that are present and
minimize any further damage. Do not apply any unnecessary
dressings, and try to move the limb as little as possible.

The transport of this casualty to medical aid as soon as

possible cannot be over stressed. This casualty requires the use of
intravenous fluid, surgical incisions to release the skin's pressure in the
limb, and the use of antibiotics to prevent infection.
 CHAPTER 7

MANAGEMENT
OF
SHOCK
WHAT IS SHOCK?

Shock is when the body tissues are recieving an inadequate supply of

oxygen and energy sources.

Shock is not related to shellshock in any way.

Shock as a diagnosis never stands on its own since an underlying

process is always present.

SHOCK: Oxygen and energy sources deprivation.

- Infection
- Chest injury
- Involuntary nervous system stimulation
- NBCW
- Heat related problem
- Blood, fat or air clots
- Venoms
- Result of blood loss and other body fluids

WHAT CAUSES SHOCK?

Loss of blood - as a result of bleeding which may be:

INTERNAL: chest, abdomen, pelvis, crush injuries, fractures - blood

loss can be 3 to 5 liters.

EXTERNAL: cuts, gashes, open fractures, amputations - blood loss can

be quite severe.
These types of injuries can be as a result from blast,
projectiles, parachuting and MVAs etc.
Loss of body fluids - associated with burns, excessive
sweating, vomiting, diarrhea, not enough to drink etc...
 Infections - as a result of an invasion of body tissues by
disease producing germs - most common cause of death in casualty
with penetrating abdominal wounds.

Chest injuries - these injuries include sucking chest wounds,

collapsed lung, pressure and/or bruising of the heart or the contents of
the stomach being sucked into the lungs.

Involuntary nervous system (stimulation) - this system

controls the function of all body tissues and organs not subject to your
control such as the heart, blood vessels, smooth muscles, glands,
stomach or intestines.

These types of shock may be caused by head injuries, pain or

emotions and the stimulation of the system causes the blood vessels to
enlarge, therefore dropping the blood pressure to a dangerous level.

NBCW - shock can be caused from chemical agents such as nerve gas.
Nerve gas prevents the message from being transmitted between nerve
cells, producing symptoms of wheezing, chest tightness, drooling from
the mouth, tearing, sweating, vomiting, diarrhea, coma.

Antidote - Gas mask and atropine auto-injector.

Cyanide - Cuts down oxygen to cells

- Patient unable to breath
- Decreased heart rate and severe drop in blood pressure
Antidote - Gas mask, amyl nitrate pearls in the mask

Phosgene gas
- Cough, sore throat, chest tightness, feeling sick to the
stomach, headaches and a lot of fluid loss into the lungs.
- No proven treatment known
- Casualty either dies or begins to improve after 48 hours.
Biowarfare agents
- Such as anthrax and viral hemorrhagic fever cause severe
infections.

Miscellaneous
- Heat stress which may occur from wearing NBCD
clothing
for long periods, or from physical activity in a very hot humid

climate.

Venoms
- Bites from venomous snakes, insects or marine animals.

Clots
- Blood, fat or air that may go to the brain, heart or lungs.
This may result from blast injuries or following long bone
fractures such as the femur.

Heart Problems
- Heart failure

SIGNS AND SYMPTOMS OF SHOCK

The signs and symptoms of a soldier in shock will depend on

what caused the shock and what is happening in the body to cause the
shocky state. For example: The soldier having involuntary nervous
system shock due to fear, injury, pain or emotionsl upset will have low
blood pressure associated with a green, white pallor, sweating and a
slow pulse (60 beats/min or less)

Generally speaking, on the battlefield, a soldier in shock is

usually due to loss of blood or body fluids. Their signs and symptoms
will usually demonstrate the following:

Skin - pale, cold, clammy, mottled and a purple colour, diaphoresis is

common
Pulse - The pulse is very fast and weak

Brain - A feeling of fear, restlessness and a state of alertness are soon

replaced by feelings of apathy, confusion, weakness, wild talk,
and all responses go down

Lungs- Breathing in the early stages of shock is rapid and shallow,

and then becomes deep, slow, sighing as death approaches.

Limbs- The limbs are weak and may feel dead or numb

Stomach- They may complain of thirst, nausea and vomiting.

*****DEATH MAY OCCUR IN MINUTES*****

FIRST AID TREATMENT FOR SHOCK

Management at the scene of injury basically includes

removing the casualty from a source that may create further injuries
and then the basic principles of first aid. The ABCs, controlling
bleeding, splinting of fractures, keeping the casualty warm, shock
position and transporting the wounded soldier to the nearest CCP or
UMS.

Personal Hazards
Foremost, do not become a casualty yourself. Protect yourself
and remove the casualty to a safer location.

ABCs
Airway-ensure their airway is open. If the airway is
obstructed, the patient requires the clearing of secretions/debris.
Remember - he may have a neck fracture.

Breathing-check to ensure the wounded soldier is indeed

breathing. If they are not initiate mouth to mouth.

Circulation-check and make sure their heart is beating. If not

start CPR.

Chest wounds-open chest wounds need to be closed with a

dressing.

Bleeding-control visible external bleeding. All extremity

wounds should respond to direct pressure over the bleeding point.
 Warmth-keep the casualty warm with blankets. This is good
prevention and treatment for shock.

Fractures-should be splinted. Transportation of a casualty

without first splinting his fractures can aggravate the injuries and cause
tremendous pain.

Morphine-should be given if the casualty complains of severe

pain. Remember that excess morphine may cause the casualty to
become comatose and stop breathing.

Position-a 5 - 10 degree head down and shoulder down

position may be used. This position allows for improved blood flow to
the brain and protects agains the casualty aspirating their vomitus.

SPECIFIC TYPES OF SHOCK

HYPOVOLEMIC SHOCK
Associated with: Hemorrhage, burns, peritonitis, protracted
diarrhea or vomiting, acute pancreatitis.
TREATMENT: Rapid volume replacement.

SEPTIC SHOCK
Associated with: Infection
TREATMENT: Abscess drainage, antibiotic therapy, fluid
replacement.
CARDIOGENIC SHOCK
Associated with: Myocardial failure, vascular disease.
TREATMENT:Isoproterenol, circulatory assistance

Associated with: Acute cardiac arrhythmias.

TREATMENT: Cardioversion of drug therapy
ANAPHYLACTIC SHOCK
Associated with: Acute systemic antigen-antibody reaction.
TREATMENT: Rapid administration of epinepherine, rapid
hydration, vasopressors, steroids antihistamines.

SHOCK DUE TO IMPEDED BLOOD FLOW

Associated with: Pulmonary embolism
TREATMENT:Heparin, isoproteronol, rapid
digitalization, glucagon, oxygen.

Associated with: Dissecting aneurism.

TREATMENT: Volume replacement, surgery.

Associated with: Cardiac tamponade.

TREATMENT: Pericardicentesis.

ENDOCRINE SHOCK
Associated with: hypopituitarism
TREATMENT: Cortisol, volume replacement

Associated with: Hypothyroidism with myxoedema

TREATMENT: Hydration, lithyronine sodium therapy,
cortisol infusion

NEUROGENIC SHOCK
Associated with: Anesthesia (general, regional, spinal)
TREATMENT: Volume replacement, vasopressors
(occasionally)
 STAGES OF SHOCK
COMPENSATORY PROGRESSIVE DECOMPENSATORY

I II III

VITAL SIGNS

1. TEMP slightly 9 severely 9 (septic 8)

2. PULSE slightly 8 8 weak, thready 9 irregular thready

3.RESPIRATION slightly 8 9 shallow irregular

4. B/ P normal 9 9

5. ORTHOSTATIC mild moderate to severe

BP CHANGES (15-25mmHg) (25 - 50mm Hg)

SKIN: pale, cool cold, clammy cold, clammy

(Hypovolemic) cyanotic
warm, flushed
(septic, neurogenic,
anaphylactic)

URINE OUTPUT: normal or slightly 9 oliguria oliguria or anuria

CNS: restlessness, listlessness, confusion incoherent

irritability apathy confusion , slurred speech
apprehension slowed speech unconsciousness
(possible) 9 or absent
reflexes - dilated pupils
slow to react

BLOOD LOSS:
1. % up to 15 % 20 - 25% 25% or >
2. mls up to 750mls 750-1500mls 1500mls or >

CAPILLARY normal positive positive

BLANCH TEST

FLUID crystalloids crystalloids & crystalloids &blood &

REPLACEMENT blood products blood products
THERAPY:
(Use 3:1 ratio)
 CHAPTER 8

MANAGEMENT
OF
BURNS
INTRODUCTION

Definition - A burn is any damage to the skin or other tissues caused

by heat, radiation or chemicals. The modern battlefield has
considerable potential to create many serious burn casualties.

TYPES OF BURNS

1. Dry heat burns - can be caused by the flame or flash from ignited
gasoline or other fuel, or from explosive devices.

2. Scalds - are caused by contact with hot liquids or steam.

3. Chemical burns - can result from contact with acids, caustic soda,
or any other corrosive chemical.

4. Electrical burns - severe burns can result from the passage of

electrical current through the body.

5. Phosphorous burns - the particles of an exploding phosphorous

grenade can cause severe burning pain and tissue damage if they come
in contact with any body surface.

6. Radiation burns - sources of radiation burns include the sun, and

exploding thermonuclear devices.

MAGNITUDE OF THE INJURY

The severity of any thermal injury (burn) is dependent upon two things:

1. The depth of the burn

2. The area of the burn
These two factors will determine, not only the risk of dying,
but also what the initial treatment that is required will be, the rate of
healing, and the ultimate result.
THE RULE OF NINES

The extent of the body surface burned can be estimated by using the
rule of nines depicted in the chart below.

Head and Neck 9%

Front Chest and Abdomen 18%

Back 18%

Arms 9%
4.5% Front
4.5% Back

Legs 18%
9% Front
9% Back

Groin 1%
DEPTH OF THE BURN INJURY

First degree burns are those burns in which only the

superficial part of the outer layer of the skin has been injured. The skin
turns red but does not blister or actually burn through. A sunburn is a
good example of a first degree burn.

Second degree burns are thos burns in which the outer and
inner layers of skin are both burned to some extent, but the full
thickness of the skin is not destroyed.

Third degree burns are those burns that extend through the
full layer of the skin and into the underlying layer of fat or beyond.
The are becomes dry, leathery and discolored (brown, white or
charred). Clotted blood vessels may be visible under the burned skin,
or the layer of fat may be visible. Nerve endings and blood vessels that
are close to the surface of the skin will have been destroyed by this type
of burn. Because of this, the burned area will be without feeling,
although the surrounding, less severely burned areas will be extremely
painful.
 CHAPTER 9

GUNSHOT
WOUNDS
AND
FRAGMENTS
FROM EXPLOSIVE
DEVICES

INTRODUCTION
 During a time of armed conflict, almost all of our available
military hospital beds will be occupied by people who have sustained
injuries as a result of combat or combat related activities. Proper initial
first aid and care can do much to minimize suffering, long term
disability and death from trauma.

MECHANISMS OF INJURY

Injury results from sudden exposure of the body to a source of

energy. In our case we will deal with the kinetic energy provided in the
from of projectiles (small arms, fragments from artillery rounds and
grenades, etc...) All of these projectiles are, as I am sure you are aware,
capable of causing permanent and sometimes fatal injuries.

The kinetic energy of a bullet in motion, must be converted

from speed to another form of energy when it stops. When it stops
suddenly (as when it hits a soldier) the energy deforms both the bullet
(it often splits up) and the soldier. The human body=s tolerance for
sudden deformity is very limited. A gentle punch of the fist to the nose
will cause the nose to deform temporarily and absorb the energy of the
impact without permanent damage. A violent punch, however, will
cause greater deformity of the tissues of the nose and result in
permanent damage to them. The tissues will continue to deform until
all the kinetic energy is used up. In high energy injuries (bullet
wounds) several parts of the body may be damaged at the same time
(bone, blood vessels, organs).
The amount of kinetic energy that is present in a moving
object is dictated by its mass (weight) and its velocity (speed).

The most important factor is the velocity of the object because

the amount of kinetic energy increases as the object= s speed increases.

The velocity factor is especially significant when considering

the wounding power of firearms. Although larger bullets cause more
damage than smaller ones, (less mass) the speed remains more
important. As the speed of the bullet increases, the amount of damage
produced increases greatly.

Gunshot wounds are seperated into two categories: High

velocity and Low velocity. Bullets travelling at a muzzel velocity
greater than 2000 feet per second, cause high speed injury. Examples
of these weapons are:

FNC1 - 7.62mm, AK47 - 7.62mm, AKM - 7.62mm

C7 - 5.56mm, M16 - 5.56mm, AK74 - 5.45mm

The type and amount of tissue damage is much greater than
that found in low speed bullet injuries. Examples of low velocity
weapons are .22, .38, .45 and 9mm rounds.

The type of injury that occurs from the impact of the bullet
also depends on what part of the body it strikes. Soft tissue such as the
skin can stretch and deform to some degree and sustain only minor
damage. With further deformity caused by our high velocity bullet
however, soft tissues will be torn apart and permanently damaged.

Stronger structures such as bone and solid organs (liver,

spleen) can resist or absorb small impacts. When a large amount of
force is applied, these tissues deform and ultimately break apart,
causing fractures (bone) or ruptures (liver, spleen).

If the bullet fragments on impact, all the energy will be used in

creating a really terrible wound. The external appearance of a bullet
wound can be deceptive. If the bullet enters or leaves the skin end-on,
it will leave a small hole, irrespective of the severe damage it caused
during it= s passage through the tissues; if the bullet leaves the skin
sideways-on to some degree, the hole in the skin will then be large and
ragged.
 When a soldier has been wounded by a missle, you may be
able to clearly see the resulting track in the casualty. To determine
what tissue or structures have been injured, you would visualize what
parts of the body were in the path of the bullet according to the entry
and exit wounds. This is not as simple as it seems: the missle may have
struck bone and been deflected, there may be more than one fragment
even though only one exit wound is present, and damage could have
been caused by secondary missles (bone fragments, pieces of buttons,
coins etc...)

The position of the casualty will have been different and will
have changed several times between the time of the wounding (lying
prone, running, falling) and the time you reach him (sitting or lying
supine) which may cause some confusion as to the original bullet track
in the body.

TEMPORARY CAVITATION

This is the main factor in the considerable destructive effects

of high velocity missles. The penetrating missle releases its energy
rapidly. The energy is absorbed by the local tissues which are
accelerated violently forward and outward. After the missle has passed
through the tissues, they continue to move and pulsate with the
momentum from the missle. A large cavity is created 30 to 40 times
the diameter of the missle. Clothing and debris are sucked into the
depths of the wound.

The high velocity missle (if stable and not tumbling) shears
fairly cleanly through the body. It is the cavitation effects which result
from the rapid transfer of energy from the missle to the tissue that
causes severe wounding. Soft tissues will be pulped, small blood
vessels will be disrupted and bone may be shattered without being
directly hit by the round.

FRAGMENTS FROM EXPLOSIVE DEVICES

 The majority of fragments from explosive devices are of blunt
or irregular shape; they are not aerodynamic and are made of steel or
less dense material. They lose speed rapidly in the air which results in
less tissue penetration depth when compared with the denser
streamlined rifle bullet.

Although the initial speed of these fragments is documented at

the 5900 feet/second range, the wounds observed indicate that the
speed at the impact was less than 1900 feet/second. For this reason,
body armour affords much better protection against these fragments
than against the rifle bullet.

These fragments cause a crush type of tissue injury with little

evidence of temporary cavity stretching. The track made by the
projectile fragment is consistent with its size and is similar to the
wound caused by a single shotgun pellet.
PRINCIPALS OF TREATMENT OF INJURY

As with all other injuries, evaluation of the casualty begins

with checking for an open airway, breathing and circulation. One or
more of these critical body functions is often affected following a
missle injury. Prompt action to restore airway, breathing and
circulation must get your first attention in providing aid for this
casualty.

Gunshot or fragment wounds often result in bleeding of the

damaged tissues, and significant bleeding will result in shock. Injuries
of the head, neck and chest can interfere with the mechanism of normal
breathing. Initially, many casualties are able to compensate for blood
loss or moderate breathing insufficiency. However, with major injury,
these defence mechanisms eventually fail and life signs and vital
functions deteriorate.

Pain and loss of function usually accompany these injuries. Any

casualty who complains of pain should be considered as having
significant injuries of pain or the inability to move a limb does not
mean that the casualty has not received a significant injury. Obviously,
the unconscious injured casualty will not complain at all. In addition,
sometimes the pain of a severe injury will be so great that the casualty
does not realize that they have sustained another equally serious , yet
less painful wound. Therefore a secondary examination must be
carried out to identify other signs of injury: tenderness, swelling,
bruising, deformity, and loss of function in a limb or joint.

Gentle palpation of the chest, back and extremities is meant to identify

areas of tenderness and obvious bleeding from wounds. Your careful
examination will locate all points of wounding and you can set your
priorities for dressings, splints, etc...
Swelling is a very common, non-specific sign of injury. Damaged cells
leak fluid soon after injury. Massive swelling may result from bleeding
into surrounding tissue from damaged blood vessels.

Bruising or discoloration is caused by damage to blood vessels. Blood

leaks into the area of the injury and gives a blue or blue-black
discoloration to the skin and tissues.

When a missle hits the body, it may deform in an attempt to absorb the
impact. All tissue can deform to some minor extent without sustaining
permanent damage. With greater force, however, great tissue damage
and deformity can occur.

Deformity is easily seen in many broken lims as well as in soft tissues

such as the skin that has been stretched or torn beyond its limit.

FIRST AID FOR GUNSHOT WOUNDS

Gunshot or fragment wounds are a form of puncture wound

with unique characteristics that require good initial treatment.
Frequently gunshot wounds will be multiple. You must carefully
locate all wound sites. Usually the wound of entrance is smaller than
the wound of exit when a through and through bullet wound occurs.
The casualty will usually have a small entrance wound on the front
surface of his body, and a large exit wound on the other side.

You must look carefully for the exit wound as it may be

bleeding excessively and yet not be as apparent as the entrance wound.

Open soft tissue wounds can result in extensive bleeding.

More important, once the protective skin layer has been destroyed, the
wound becomes contaminated and will easily become infected.
 The control of bleeding from wounds, whether or not they are
associated with broken bones, is often improved by splinting. Splinting
also reduces the possibility of further damage to an already injured
limb. Therefor, splinting or immobilizing the injured part is an
essential part in our attempts to control bleeding.

As with all bleeding wounds, whenever possible, we must attempt to

elevate the injured part to just above the level of the heart in order to
reduce eventual swelling.

Initially it is most important to assess the extent and severity of the

wound. You must remove any clothing that is covering the wound. It
is better to cut or tear the clothing away from the wound rather than
attempt to remove it in a normal fashion because movement of the
injured part will cause pain and possibly more damage. When cutting
or tearing the clothing, do this with as little movement as possible.
What may seem as an insignificant motion to you, may cause the
casualty excrutiating pain.

Once the wound is clear of any clothing, its severity can be assessed
and treatment begun. Three general rules apply to open soft tissue
wounds:

1. Control bleeding
2. Prevent further contamination
3. Immobilize the part

With open wounds, the amount of bleeding may be extensive and

severe. The first prioity is to control the bleeding by applying a clean,
dry compress bandage to cover the entire wound. Pressure is at first
applied to the wound with your hand until the dressing is made ready.
A triangular bandage may be used to apply further pressure over the
dressing. The injured part should then be splinted in place to prevent
any further movement.
All missle wounds are contaminated.

Contamination occurs as soon as the skin is broken. You will

prevent further contamination by applying dressings. You should not
try to remove material from the wound no matter how dirty it may look.
Rubbing, brushing or washing the wound will only cause further
bleeding. This is a job for the medics to do when they are prepared to
deal with it.

CONCLUSION

After the airway, breathing and circulation have been looked

after, isolated injuries must be stabilized and the casualty brought to
medical aid. In most cases, it is your efforts in first aid in the field that
will allow the casualty to be safely transported. With a casualty that
has suffered multiple injuries, it will be difficult to provide good care in
the field. Delay in getting him to medical aid will lower his chances of
survival. It is generally agreed on that the casualty has the Α Golden
Hour≅ in which to be treated, and transported to medical aid for
definitive treatment. Any delays in the field use up precious time for
these caualties. The large majority of gunshot casualties can be
stabilized in the field.
CHAPTER 10

COMBAT
STRESS
REACTION
INTRODUCTION

Combat stress reaction (CSR) is a term which encompasses an array

of versible effects caused by the stresses of combat. It includes the effects of
tiredness and sleep deprivation, and refers to the temporary psychological upset
causing an inability to function normally (normal function includes the ability
to engage the enemy and survive). CSR encompasses the terms battle fatigue,
battle shock, and critical indident stress as well as older terms such as shell
shock, war neurosis, neuropsychiatric (NP), NYD (Nervous), and combat
exhaustion. The incidence of CSR is related to many factors, including the
length, type and intensity of battle.

It is critical that a distinction be made between CSR and psychiatric

casualties. Psychiatric casualties are those individuals who suffer from a
recognized psychiatric condition, such as a depressive illness, an acute
neurosis, or psychosis. Combat stress reaction is not a psychiatric illness, but if
it is incorrectly managed it can become one.

COMMON SYMPTOMS

Inceased Muscular Tension

a. Momentary freezing (cannot move)

b. Shaking or trembling
c. Speech (stammering or stuttering)

Increased Body Responses

a. Sweating (hands and feet)

b. Poor appetite
c. Vomiting
d. Bowel or bladder frequency
(diarrhea or frequent urination)

Psychologic

a. Noise may provoke anger to fight

 b. Apathy towards self and fellow soldiers
c. Bitter towards all
d. Overly concerned (ie. that he will die or be mutilated)
e. Fatigue (he feels to tired to continue)
f. Euphoria (Laughing, crying or abnormal energy)

At any time in combat, it is normal to display some of the above

symptoms. For example, one may not be able to move or think, or may try to
cheer everyone up in an euphoric manner. Only when such behavior becomes
persistent is it considered abnormal. Remember this is a real war wound and
must be handled honourably.
PREVENTION AND EARLY RECOGNITION

While an attempt should be made during screening to prevent soldiers

who are likely to develope stress reaction disorders from being sent to a theatre
of operations such action is, at best, only a partial solution. There are a number
of preventative measures that can decrease the number of stress reaction
casualties.

Every effort should be made, for example, to develop unit and sub-
unit togetherness, with importance being placed on group identification and
unity. A sense of individual confidence and permanency, strong
communication within and between the ranks, morale, faith in leadership, and a
common trust between members of the unit. Prevention also calls for a strong
social support system that emphasizes family security and well being.
Patriotism and love of country should be fostered and individuals must
understand and identify with national aims and objectives.

The intensity, duration and conditions of expected future operations

must be emphasized by developing high levels of skill and by familiarizing
soldiers with the real ability of the enemy in terms of his tactics, technology,
weapon effects, strengths and weaknesses. The more insiduous aspects of fear
* that of the unknown * can be minimized. Soldiers must be made aware of
the effects of stress and must learn to overcome stress effects without
necessarily becoming a casualty. Proper nutrition, enforced water and sleep
discipline, and physical fitness delay fatigue, which is a major factor of combat
stress.

In order to fulfill their responsibilities, all leaders - especially those at

the junior level - must become familiar with and understand the types of stress
reactions which they will encounter, the warning signs of eventual breakdown,
and the steps to take to either prevent or cope with this particular type of
casualty. They must also be familiar with the measures available before and
during battle to minimize the effects of combat stress.
PRINCIPALS OF MANAGEMENT

The principals of management for personnel suffering from combat

stress have been proven since World War I. So essential have these principals
been to obtainsatisfactory results, they may be considered critical factors.
These principals are:

a. Immediacy

Symptoms of combat stress must be recognized and dealt with as

soon as they appear. The longer proper management is delayed, the more
resistant symptoms are to change. Management should take place in a military
environment, preferably at this unit, and not in a hospital, so that the
suggestible individual not be identified as being sick. An early remidy includes
sleep.
b. Proximity

The further away the soldier is evacuated, the less likely that he will
return to duty. He must be kept as close to the scene of combat as possible to
benifit from the support of the unit and friends. Closeness also eliminates
transportation problems and decreases the secondary gain that might be
obtained from being evacuated some distance from the battlefield. Unit spirit
can be used to aid in the return of unit members who have been kept readily
available for return to duty.

c. Expectancy

From the beginning, it is important the sodier be reassured that he is

experiencing a normal reaction to an abnormal situation, and after rest he will
be returning to his unit. This expectancy, assisted by the repeated firm
suggestions that he will rapidly improve and be ready to rejoin his combat unit,
takes advantage of the suggestible state of the individual, and is extremely
important to his recovery.
 d. Simplicity

Keeping to short and simple methods is also important. Providing the

individual with rest, food, a chance to clean up and the opportunity to talk
about his experience with an understanding group or listner, will speed up
recovery. The soldier should be assigned simple, meaningful, military tasks,
and be supervised in a structured environment by leaders who clearly
understand that the goal is to return him to service and not make him into a
patient.

MILITARY ENVIRONMENT

The individual must be kept away from hospitals and wounded

people or he may mimic all sorts of Α physical≅ illnesses, because in this state
he is very suggestible. He should not have the lables Α sick≅ , Α patient≅ , or
Α wounded≅ applied to him but be treated with military discipline: ie. Stay
within the unit lines, wear a uniform, adhere to military routine and be kept
busy once the first part of the treatment is completed. (Long sleep, shower,
good food). Treat the soldier as a soldier not a patient.
 Combat Stress Reaction:

A Normal Reaction To An Abnormal Situation.

Exhaustion due to combat stress, if not properly monitored before,

during and after a mission, can be a killer. It can cause casualties just as surely
as enemy action. Soldiers pinned under fire for a prolonged period of time may
withdraw into themselves. They can become isolated and despondent or they
may become agitated and needlessly expose themselves to enemy fire. The risk
of Combat Stress Reaction (CSR) increases with the intensity and duration of
the conflict. Mechanized warfare coupled with advanced night vision
equipment allows the enemy to continue operations around the clock. Modern
weapon systems can also attack troops in rear areas allowing little respite.
Leaders will have to push their subordinates relentlessly, under terrible
conditions, to limits far beyond what was ever expected of them before.
Your job is to ensure your subordinates do not succumb to combat
stress. In the pamphlet Combat Stress Reaction: What to do: Self and Buddies,
the normal, common signs of combat stress were described and tips on how to
cope with them were given. You, the leader, need to teach this to your
subordinates. You also need to know the "more serious" signs and leader
actions outlined here.

Combat Stress Reaction:

What Is It?

A natural result of heavy mental / emotional work, facing danger in

tough conditions. Like physical fatigue:

- it depends on level of fitness, experience, training.

- It can come on quickly or slowly.

- It gets better with rest.

Sleep loss and physical discomfort are often also involved but don't
have to be.
Normal Common Signs of Combat Stress Reaction

Physical Signs:

Tension: headache and backache, trembling, fumbling, jumpy,

pounding heart, rapid breathing.
Upset stomach (may vomit). Diarrhoea, frequent urination.
Emptying bowels and bladder at instant of danger.
Fatigue, weariness, distant, haunted ("1000 meter") stare.

Mental and Physical Signs:

Anxiety, worrying, irritability, swearing, complaining.

Difficulty concentrating, remembering, communication.
Awakened by bad dreams, grieving, feeling guilty.
Angry with group, losing confidence with self and unit.

***Many personnel exhibit these signs and yet still perform all essential
duties.

"More Serious" Combat Stress Reaction Signs

Although more serious and requiring more action, these signs do not
necessarily indicate a "casualty" who must be evacuated.
The normal common signs are considered "more serious" if:

- The signs don't improve after the person has had a good rest.
- The person exhibits a change in behaviour (acts funny)
- Can't keep still, constantly moving around.
- Flinching or ducking at sudden movements and sounds.
- Shaking (of arms or whole body), cowering in terror.
- Part of body won't work right, with no physical reason:
- Can't see hand, or arms, or legs
- Can't see (hear or feel), partial loss or total
- Prolonged total immobility, freezing
- Physical exhaustion: slowed down, just stands or sits.
- Vacant stare: spaced out, staggers, sways when stands.
"More Serious" Mental and Emotional Signs

- Rapid talking, constantly making suggestions.

- Arguing, starting fights, deliberately reckless action.
- Inattention to self care, hygiene, indifference to danger.

Memory loss:

- Forget orders, technical skills, bad events.

- Forget time, place, what's going on.

Severe stuttering, mumbling, can't speak at all.

Afraid to fall asleep for fear of nightmares.
Unable to stay asleep.
Seeing or hearing things that are not really there.
Rapid mood shifts: crying spells.
Social withdrawal: silent or sulking, prolonged sadness.
Apathetic: no interest in food or anything.
Hysterical outbursts, frantic or strange behaviour.

Leaders Actions For Combat Stress Reactions

Set the right example of calmness while feeling normal fear.

Know your job well. Keep the group focused on the task at hand.
Assign an easy task to a person showing signs of CSR.
Remind people to use quick relaxation techniques.
Remind everyone that CSR is normal:
- Others have it too (even you).
- Encourage friendly joking about it.
Stay in touch with every member of the group, keep them talking.
Keep everyone informed:
- Explain the situation and objectives.
- Don't hide unpleasant possibilities, rather, present them and
explain how the group will handle them.
- Remain positive, don't dwell on the things that are not going
right.
- Explain what's being done to correct errors.
 - Control rumours, get the facts from your leader.

Rotate jobs when possible so that all share danger / hardship.

Ensure the best possible first aid/medical aid and rapid medical
evacuation.
Don't underestimate the importance of sleep (for you as well as your
men).

- At least four hours per night (six to ten hours preferred).

- Even catnaps (15 - 30 minutes) will help, but people tend to
be temporarily groggy on awakening.

Debrief Your Group After a Traumatic Event

- Have everyone tell what they saw and did.
- Reconstruct and agree on what really happened.
- Resolve any misunderstandings and mistrusts.
- Let feelings be expressed and accepted as normal.
- Focus positively on lessons learned.

Get people with problems at home to talk about them. Watch for changes in
mood after receiving mail or making telephone calls.

Leader Action For "More Serious"

Combat Stress Reaction Signs

If the person's behaviour endangers the mission, self or others, do whatever is

necessary to control them.
If person is upset, calmly try to talk them into cooperating.
If this is unsuccessful, "explain" possible disciplinary action.
If reliability is a problem:
- If person has a personal weapon, unload it.
- Take away weapon only if situation is serious.
- Physically restrain only for safety or transportation.

Reassure everyone that the signs are probably just Combat Stress Reaction and
will go away quickly. Even seemingly very serious signs can improve in
minutes if handled correctly on the spot.
 If "More Serious" Signs Persist
- Remove person to a safe place.
- Don't leave alone, keep them with someone they know.
- Tell your supervisor.
- Have the person examined by a medical officer, especially
if there could be a physical cause for the symptoms.

If it is decided that evacuation for rest or

treatment is not required
(or if it is not possible):

- Treat the same as for normal, common signs (if possible)

- Warm the person if cold/wet; cool if overheated.
- Make sure the person eats, drinks, and sleeps.
- Encourage the person to talk in the group debrief, lend support.
- Assign tasks which the person can do well.
- Keep the supervisor informed.

If it is decided to send the person away for

rest or to be examined by a Medical
Officer:
- Tell the person you are counting on him to get rested and return
quickly.
- Encourage other members of the group to express continued
confidence in the person's ability to perform adequately.
- Have group members visit the person, if possible, to encourage him
to get rested and return soon to help out.
- When the person returns welcome back and put him to work:
- Assign increasingly responsible duties.
- Talk openly about what happened before.
- Convey confidence in the returnee.
 To Prevent Combat Stress Reaction

Integrate replacements quickly. Assign buddies, ensure everyone in the group

gets to know the replacements quickly.
Ensure people remain physically fit.
Train for war, not for peace, train for it, plan for it.
- Impart unit pride.

***Properly managed, casualties will return before a replacement could be

obtained. If necessary preventative actions are taken, there will be low
stress reaction casualties.
CHAPTER 11

THE USE
OF
MORPHINE
KNOWLEDGE OF USE OF MORPHINE FOR NON-MEDICAL
PERSONNEL

Indications for using morphine and when not to use it:

a. First we will cover when you would want to use morphine on a casualty.
Basically you use morphine to relieve severe acute pain. (Amputated arms,
legs, etc...)

Morpine will effectively :

1. Ease their pain
2. Protect your position if the patient is screaming.

b. Now when would you not want to use morphine on a casualty ?

There are four things to look for:

1. Allergy to morphine
2. Head injury
3. Chest injury
4. Face, throat, mouth & jaw injuries

1. Allergy: If you come across a casualty who has a medic-alert bracelet or

necklace on that states they are allergic to morphine, you cannot give them a
shot of morphine. If you do it will put them in an allergic reaction. This
reaction can kill them in a matter on minutes.

2. Head injury: If you give a casualty with a head injury morphine, you:

a. Can mask or confuse the symptoms of the injury to medical

personnel, because the morphine causes changes in control of
the nervous system.

b. Morphine will act as a respiratory depressant on the body. If the

 casualty is having problems breathing this could make it worse.

3. Chest injury: Again as in head injuries, you must remember that morphine
acts as a depressant on your respiratory system. Giving the patient with a chest
injury morphine could stop their breathing.

4. Any facial, throat, mouth & jaw injury: You do not give morphine,
again because morphine is a respiratory depressant.

POSSIBLE SIDE EFFECTS

Now you have come upon a casualty and they do not have any of the
injuries we have just discussed. You give the casualty morphine and now you
have to be aware of the possible side effects. These include:

a. A fall in blood pressure can lead to shock

b. Nausea and vomiting

c. The most important is, morphine can act as a respiratory

depressant, decreasing the casualties rate of breathing.

There are other side-effects to morphine but these three are the ones
that can effect the casualty shortly after giving them the shot.

DOSAGE AND CASUALTY MARKINGS

a. Now you have decided to give a syrette of morphine to a casualty. How

much can you give a person before possibly depressing the casualty= s
breathing and thus endangering them ?

You can give up to two (2) morphine syrettes

to one casualty.
***NO MORE THAN TWO (2)***

The best way for you to give the morphine would be in the casualty’s
thigh (intramuscular). You have less chance of missing or going into an artery
this way.

How long before the morphine takes effect ?

30 to 60 minutes.
How long is the morphine effective ?
2 2 to 7 hours depending on how much you give.

b. You have given the casualty a shot of morphine, you must now let the
medical personnel know how much you have given. This is done in three
ways:

1. Mark a red “M” on the casualty’s forehead

2. Write it again on the casualty’s hand in red

3. Bend the used needle and put it through the casualty’s shirt collar
or jacket so it can be seen

If you don’t have a red marker you will have to stay with the casualty until
medical help arrives. You must inform them.
 CHAPTER 12

CHEMICAL
WARFARE
AND
BATTLEFIELD
FIRST AID
INTRODUCTION

The first aid treatment of chemical poisoning secondary to chemical

warfare agents cannot be considered as part of classic St. John= s First Aid.
While there are minimal civilian applications of the knowledge that will be
presented, it remains for the most part a uniquely military problem.
In a chemical warfare scenario, survivability will depend on two
factors: first the wearing of appropriate personal protective equipment and use
of appropriate preventative treatment, and second (the critical area discussed
here), the immediate treatment of the chemical casualty. This scenario is
somewhat complicated, in that casualties may not present with purely chemical,
but may also be suffering from conventional wounds. The approach outlined
below will detail the priorities in terms of self aid and buddy aid that will
improve chances of survival and eventual evacuation for our soldiers.

DEFINITIONS

Chemical Agent
This agent is a chemical substance which is intended for use in
military operations to kill, seriously injure, or incapacitate men through its
effects on internal body functions.
Chemical agents known to exist, and likely to be encountered on any
future battlefield, can be classified as lethal and non-lethal agents:

a. Lethal Agents

Lethal agents are used in warfare to kill or seriously injure & includes the
following types:

1. Nerve Agents: these agents interfere with the nervous system,

thereby disrupting such essential functions as breathing, muscular
control and vision
 2. Blister Agents: these cause inflammation, blistering of the skin,
and superficial destruction of internal tissue such as the lining of
the respiratory tract

3. Blood Agents: these are absorbed into the body primarily through
inhalation. They prevent the normal transfer of oxygen from the
blood to body tissue, thereby starving the body of oxygen

4. Choking Agents: these affect the respiratory tract: ie. The nose,
throat, lungs, in extreme cases, lungs become filled with liquid and
death results from lack of oxygen.

b. Non-lethal Agents

These agents are used to render individuals incapable of doing their tasks for
periods which could range from minutes to several weeks, but there will
usually be complete recovery. They include riot control and training agents.
Non-lethal agents that may be used in warfare are:

1. Physical Incapacitants: these cause temporary incapacitation and include

the following groups:

a. Tear Agents - these cause irritation to the eyes, a great flow of

tears, and stinging of the skin. In some cases, they produce vomiting and
blisters, and extreme amounts can cause death.

b. Vomiting Agents - these cause irritation of the nose and throat,

acute pain and tightness in the chest, and nausea and vomiting. When used in
confined areas or rooms, death may occur.

c. Other Agents - these cause such effects as fainting, paralysis,

blindness or deafness.

2. Mental Incapacitants: these agents are sometimes referred to as

Α Psychochemical≅ agents and cause temporary mental disturbances which
may be accompanied by unusual physical behaviour. In uncontrolled combat
situations, some deaths or serious injuries may occur, either from massive
overdoses or from accidents involving affected personnel.
GENERAL PRINCIPALS

The skin, eyes, and respiratory tract are the primary routes for chemical agents
entry into the body. First aid managements of the casualties in this situation is
most difficult because:

a. The casualty is wearing NBC personal protective clothing

b. The chemical agent must not contact the skin, eyes or wounds

c. NBC personal protective clothing must be restored to prevent

further contamination.

The enemy will attempt to attack in such a way as to ensure personnel are not
wearing NBC protective clothing and respirators. They may use a smoke
screen, attack at first or last light when visibility is poor, use tear or blister
agents to prevent putting on gloves or mask, and then strike with a nerve agent.
In a chemical attack, immediate reactions should be:
a. Put on respirator

b. Close all openings in NBC protective clothing

c. Carry out personal decontamination procedures and ensure these

procedures are done for casualties who are unable to perform these tasks.

Everyone must wear respirators and full protective clothing, including gloves
and boots, when working in a contaminated environment.

Treatment of chemical casualties is most needed during the first few minutes
after the attack.

TREATMENT IS:
a. Treat respiratory failure and control massive hemmorhage

b. Inject the nerve agent antidote (Atropine) immediately if symptoms of nerve

agent poisoning are present, using the casualty’s auto-injector
c. Check the fit of the patient’s respirator and NBC clothing in case they were
loosened at the time of wounding

d. Locate and determine the size of wounds

e. Decontaminate your gloves using the Fuller’s Earth pads contained in the
respirator pouch

f. Decontaminate the NBC suit, gloves, overboots, respirator, and around the
wound using another Fuller’s Earth pad and decontaminate about the face if the
patient’s mask was dislodged at the time of wounding

g. After ensuring there is no obvious vapour hazard remaining, cut away

clothing from around the wound

h. Again decontaminate your gloves and the outer covering of the patient’s
field dressing

j. Open the dressing and apply it firmly to the wound

k. Cover the dressing with a chemical resistant material, ie. Field dressing
cover, or NBC suit material, to re-establish the full protection of the damaged
suit, and secure with masking tape, string, etc... If an entire part of the suit is
badly damaged, a piece cut out of a spare suit could be used to cover the
damaged area and field dressing

m. Determine the type of liquid chemical agent used by observing the colour
change of the detector paper on the patient and record it on the field medical
card.

AS MANY OF THE ABOVE PROCEDURES AS POSSIBLE SHOULD

BE CARRIED OUT WITH THE PATIENT UNDER COVER FROM
FURTHER CONTAMINATION
IF YOU ARE UNABLE TO MOVE THE PATIENT FROM THE TOXIC
ENVIRONMENT THEN USE HIS GROUNDSHEET FOR COVER
SPECIFIC FIRST AID PROCEDURES

Nerve Agent Poisoning

Nerve agents include GA (tabun), GB (Sarin), GD (Soman), and VX

a. Early Symptoms:
(Not necessarily in order of occurrence)

1. Runny Nose
2. Increased salivation
3. Tightness of the chest
4. Mild shortness of breath
5. Pinpoint pupils, blurring or dimming of vision

b. Later Symptoms:
The early symptoms become more severe. Additional symptoms may occur
as follows (Not necessarily in the order given)

1. Headache
2. Drooling
3. Dizziness and weakness
4. Excessive sweating
5. Abdominal cramps
6. Excessive tearing

c. Dangerous Symptoms
When the agent is swallowed or absorbed via the skin, the early symptoms
will not appear and the following may be the first indication of poisoning:

1. Nausea and vomiting

2. Involuntary urination or defecation
3. Muscle twitching or convulsions
4. Respiratory arrest
Treatment of nerve agent poisoning can be divided into three stages:

1. Prophylaxis
2. Immediate self aid
3. First aid

THE PROPHYLACTIC DRUG

CURRENTLY AVAILABLE TO COMBAT
THE EFFECTS OF NERVE AGENT POISONING
IS PYRIDOSTIGMINE BROMIDE

This drug is presented in tablet form. In an area of operations, each serviceman

will carry a seven day supply consisting of a card or 21 tablets. One tablet is to
be taken every eight hours after the operational commander has ordered the
commencement of the prophylactic regime.

SELF AID

In an area of operations, each soldier will carry three Atropine Oxime auto-
injectors in his mask carrier. If subjected to attack, and if signs and symptoms
of nerve agent poisoning appear, the following self-aid procedures must be
followed:

a. Perform the chemical immediate action drill and immediate

decontamination drill if this has not already been done

b. Take one auto injector from the mask carrier and remove the
polyethylene outer cover

c. Hold the injector in one hand and pull the red safety ring clear

d. Place the yellow end of the injector firmly against the injection site
(the thigh)
 e. Firmly press the thumb on the white end until the injector functions

f. Maintain pressure for a count of five before the needle is withdrawn

g. Then rub the muscle over the injection site to increase the speed of
absorption

h. Fasten the used injector to a pocket of the CW coverall by bending the

needle. This helps to prevent excess injections by keeping track of how
many shots an individual has received. Note that the needle should be
fastened to a pocket to avoid unnecessarily piercing the suit.

FIRST AID

The procedure is similar to that outlined above. The casualty= s own auto
injectors should be used. The steps followed by the provider are:

a. Check that he himself is fully protected

b. Check that the casualty= s mask is functioning correctly

c. Administer an auto injector, and repeat as necessary every 15 minutes to

a maximum of three injections. Used auto injectors are fastened to the
casualty’s pocket by bending the needle

d. Decontaminate the casualty if necessary, and if time permits

e. Attempt to resuscitate the casualty if necessary

f. Evacuate to medical care

BLISTER AGENT POISONING

Blister agents include HD (mustard), L (lewisite), and CX (phosgene oxime).

Mustards normally give rise to problems only after several hours. However
Lewisite and Phosgene Oxime may cause immediate reactions. Signs and
symptoms are as follows:

a. EYES;
Irritation, redness, tearing, and blinking. Liquid agent is more serious than
vapour and could result in permanent blindness if not treated at once

b. INHALATION;
Dry, burning throat, coughing, hoarseness, and fever. Total loss of voice
may be the only apparent symptom

c. SKIN;
Burning sensation, followed by a reddening of the skin. Blisters may form
later. Armpits and crotch are the areas most likely to be affected.

TREATMENT IS AS FOLLOWS

1. SELF-AID
Self aid for casualties who have been hit in the eyes by blister agent (or suspect
that this may be the case) consists of washing the eyes out with large quantities
of water. This procedure must be carried out within five minutes of the attack.
Delaying the treatment beyond five minutes will result in the procedure doing
more harm than good. Do not use Fuller’s earth in the eyes. Apart from the
process of decontamination to remove the agent from the person, there are no
further specific self-aid procedures.
2. FIRST AID

a. On the skin; The aim of first aid for blister agents on the skin is
prevention of secondary infection. The procedure to be carried out is as
follows:

1. Decontaminate to remove any surplus agent (open wounds should be

flushed thoroughly with water)

2. Apply a dressing in the normal way, remembering that the cover of the
dressing may have to be decontaminated if it has been exposed to a liquid
agent.
 3. Restore individual protection by putting a chemical-proof cover on the
dressing. This must be done to protect against the possibility of further
exposure to chemical agents. A chemical proof cover must be applied to all
wounds on the chemical battlefield and may be achieved by using either a
piece of protective material kit - chemical biological C2 - or polyethylene.

It should be noted that the chemical protection provided by polyethylene will

not last for ever. The time protection is provided depends on the thickness of
the polyethylene used. This must be considered as a first aid measure only.

b. In the eyes; The eyes are particularly susceptible to blister agent, liquid
being worse than vapour. The first aid treatment consists of irrigation with
great amounts of water.

c. Inhaled vapour; Inhalation of large quantities of blister vapour can

cause serious damage to the delicate lining of the breathing passages. The first
aid treatment in such cases is the same as for the choking agents.

d. Ingested liquid; Blister agent can also reach the interior of the body by
being swallowed with contaminated food or drink. The first aid treatment in
these cases is as for any corrosive poison. The casualty should be made to
drink large quantities of water to dilute the agent; milk; if it is available, is
preferred. The casualty must not be made to vomit.

BLOOD AGENT POISONING

The common blood agents are AC (hydrogen cyanide), and CK (cyanogen

chloride). Due to the high volatility and relatively low toxicity their use on the
battlefield is limited and they are much more likely to be encountered in
terrorist activities such as poisoning of water supplies. Signs and symptoms
depend on how much agent has been inhaled or ingested and include:

1. Dizziness
2. Inability to hold breath
3. Headache
4. Weakness
 5. CK (cyanogen chloride) may irritate the eyes, nose, and throat, causing
local symptoms in addition to the above.

Specific self and first aid procedures involve primarily evacuation and rest once
clear of the hazard area. More sophisticated treatment measures are available
at the UMS level. Once the vapour has dissipated, those personnel still alive
will likely recover.

CHOKING AGENT POISONING

The choking agents commonly available are CG (phosgene), and CL (chlorine).

Signs and symptoms include:

1. Shortness of breath
2. Choking
3. Inability to exert oneself
4. Unconsciousness and death in severe cases due to lack of oxygen
5. Commonly relapse (reoccurrence of symptoms)

There is no specific first aid treatment available. The following should be

noted:

1. Artificial respiration must not be given. To do so will drive the agent

from the affected part of the lungs to those parts previously unaffected, thus
worsening the condition.

2. The casualty with respiratory distress should be kept in the sitting

position.

3. Pure oxygen if available can be helpful.

4. The casualty should be kept warm.

5. Casualties suffering from choking agent poisoning who apparently

recover often relapse within 24 hours and may die at this stage from cardiac or
respiratory failure. To avoid this, all choking agent casualties must be rested
completely for 48 hours after exposure.
WOUNDS AND INJURIES
IN A CHEMICAL ENVIRONMENT

The first aid treatment for a wound injury sustained in a chemical warfare
environment requires the restoration of individual protection where it has been
breached. Clearly, if the casualty has chemical agent poisoning as well as a
wound injury, he requires to be treated for both. The procedure for
administering first aid to wound or injuries is as follows:

1. The rescuer must ensure that his own personal protection is complete

2. If there is any likely hood of fresh liquid agent falling, treatment should be
delayed until the casualty is under cover. The severity of the wound, distance
from cover, and the tactical situation may make such a procedure impossible to
achieve

3. Before touching the wound, the rescuer must ensure that his own gloves are
decontaminated using the decontamination mitt

4. A dressing should now be applied in the usual way. If applicable, the outer
wrapping may have to be decontaminated. Care should be taken to avoid
contamination of the securing bandage.

5. This dressing must now be made chemical proof, as detailed in the section
on blister agents.

ATROPINE OVERDOSE

It is likely, under certain weather conditions, that the serviceman in his full
individual protective clothing will be close to heat stress. The use of atropine
where no nerve agent has been previously absorbed will upset the sweating
mechanism and may well cause heat illness. All ranks must be aware of this
risk and know that atropine must never be used prophylactically. All ranks
must also be clear on the difference between the signs and symptoms of nerve
agent poisoning and atropine overdose. The signs and symptoms of atropine
overdose are:

1. Dry mouth
2. Dry skin
3. Dilated pupils
4. Tiredness or lethargy

The treatment of overdose is rest. Unless the cases are severe, they should not
be evacuated.

CASUALTY BAGS

The foundation of defence against chemical agents is the provision of complete

protection to the individual. This concept applies equally to the casualty who,
in certain circumstances, may not have complete individual protection.
Instances where a casualty may require to have their individual personal
protection replaced or restored at the point of wounding are:

1. Where gunshot, shrapnel, or burning have destroyed the integrity of

individual protection.

2. Where the casualty is unable to wear a mask due to facial injuries, or

because he is vomiting, choking, or in respiratory distress

3. Where the casualty is unconscious or incapacitated and therefore unable

to put their mask on should the need arise.

To meet these possible situations, the casualty bag has been developed. It is an
envelope of CW protective suit material with a clear plastic window panel at
both ends. It is more than adequate in size to hold a man. It fastens down each
side with velcro and has a waterproof base.

A contaminated casualty/patient who is able to wear a mask can be placed in a

clean casualty bag. This allows him to be handled with much less danger of
transferring that contamination to handlers, other casualties/patients, or casevac
vehicles.
The casualty/patient who cannot wear a mask because they have head or facial
injuries, or are vomiting or short of breath, pose a special problem. If there is a
liquid or vapour hazzard at the time his injury is sustained, then he has little
hope of survival. It is in the situation where a threat exists but no agent is
actually present that alternative respiratory protection can be provided by the
casualty bag. Thus the clean patient who, by virtue of his injuries, cannot wear
a mask, is placed in a casualty bag as soon as possible. This procedure will
offer alternative respiratory protection to the patient should the need arise.
The casualty bag can also be used to restore individual protection at the point of
wounding. Where the CW protective outfit is severely damaged, placing the
casualty in the casualty bag will protect him from liquid contamination.

RESUSCITATION IN CHEMICAL WARFARE

Artificial Respiration

It must be emphasized that, in conditions where a chemical agent vapour

hazard exists, the following methods are not applicable:

1. Mouth to mouth
2. Mouth to nose
3. Laerdal resusci bag
4. Guedal tube

Holger Neilsen and Sylvester method. While these two methods of artificial
respiration can be applied in a chemical vapour hazard with the casualty
wearing a mask, the lung air flow produced in unlikely to be sufficient to help
the casualty.
STRESS CASUALTIES

Casualties related to protective measures in conventional warfare, soldiers are

subjected to many psychological, physiological, and psychiatric pressures. As
a result many become stress reaction casualties. With the introduction of
chemical agents to the battlefield, soldiers will still be required to perform their
normal duties, but will be restricted by their individual CW protective
equipment. The soldier will find his vision, hearing, dexterity, mobility, and
locomotion greatly reduced. These factors, together with the effects of heat
stress and fatigue, may cause the soldiers to become a stress reaction casualty.
Each of these factors can cause casualties in other ways, as follows:

Heat Stress: can occur on any type of battlefield and is one of the most urgent
of all medical emergencies. Immediate treatment must be initiated. The soldier
in a chemical environment is more likely to suffer from heat stress than one on
a conventional battlefield due to his protective equipment.

Fatigue: is more likely to reduce the efficiency of the unit than any other
medical factor. It can take various forms but will ultimately lead to stress
reaction casualties. In a chemical environment, fatigue will occur more rapidly
and soldiers will find it increasingly more difficult to remain alert. Fatigue
reduces concentration and causes carelessness, which eventually will lead to
accidents.
Accidents: Form a large part of the total number of casualties produced in
conventional warfare. When chemical conditions apply, even more accidents
can be expected, particularly as the limitations of the CW outfit, heat stress, and
fatigue degrade the soldier= s performance

Incorrect treatment: Administered during chemical operations can be

expected. First aid and medical personnel will be restricted in their ability to
diagnose symptoms when wearing the CW outfit. The greatest danger apart
from further exposure of the patient to the agent, is the injections of atropine
for a nerve agent poisoning. This may have been administered by;

1. The patient
2. The patient’s buddy
3. The medic
4. The M.O.
5. All of these

The results may be an atropine overdose and possibly, the induction of heat
stress.

Psychiatric and psychological problems

The uncertainty of what to expect in a chemical environment, lack of

confidence in his protective equipment, low morale, and the pressure imposed
by equipment limitations may quickly cause the soldier to give up. He may
become irrational, unpredictable, and may eventually become a chemical
casualty by removing his protective CW clothing while still in a chemical
hazzard area.

Casualties caused as a result of the protective measures adopted need not be

severe providing personnel are:

1. Well trained in the use of the CW protective equipment

2. Confident in their equipment
3. Given adequate rest, food, water
4. More closely supervised by their superiors
5. Kept informed of the situation and of the chemical threat
6. Follow safety procedures laid down in unit SOP= s for the performance of
duties in a chemical environment.
CHAPTER 13

INTRAVENOUS
THERAPY
 Purpose of IV Therapy

1. To replace water and electrolyte deficiencies due to abnormal

losses from drainage, vomiting, diarrhoea or diuresis.

2. To maintain fluid and electrolyte balance to meet the daily

requirements.

3. To provide an avenue for administration of medications or

diagnostic test dyes.

4. To provide an avenue for the administration of blood and

blood components.

Common types of IV fluids Include:

1) nutrient solutions
2) electrolyte solutions
3) alkalizing and acidifying solutions
4) blood volume expanders

Nutrient Solutions

These contain some of carbohydrate (cho) (eg., dextrose, glucose or

levulose and water). Water is supplied for fluid requirements and cho
for calories and energy. For example, 1 litre of d5w provides 170
calories. These solutions are useful in preventing dehydration and
ketosis but do not provide sufficient calories to promote wound
healing or weight gain.

Common solutions:
 1) D5W
2) 3.3% glucose in 0.3% nacl (glucose in saline)
3) 5% dextrose in 0.45% nacl
Electrolyte solutions

These are either NaCl or multiple electrolyte solutions containing

varying amounts of cations and anions. They are commonly used as
initial hydrating solutions. Multiple electrolyte solutions approximate
the ionic profile of plasma and are used to prevent dehydration or to
restore or correct fluid and electrolyte imbalances.

Common solutions:
1) N/S (0.9% nacl)
2) Ringers' solution-contains na, cl, k and ca.
3) Lactated ringers'-contains na, cl, k, ca and lactate which is a salt of
lactic acid that is metabolized in the lIVer to form bicarbonate.

Alkalizing & acidifying solutions

Alkalizing solutions are administered to counteract metabolic acidosis

(eg., lactated ringers). Acidifying solutions on the other hand, are
administered to counteract metabolic alkalosis (eg., 5% dextrose in
0.45% nacl). Note: body fluids are normally maintained within a
precise ph range of 7.35-7.45. This state is slightly alkaline. Prolonged
diarrhoea, starvation or renal impairment can cause metabolic acidosis.
With prolonged vomiting and other conditions that result in excessIVe
amount of bicarb ions in the bloodstream, metabolic alkalosis can
occur.

Blood volume expanders

These are used to increase the volume of the blood following severe
blood loss (eg., haemorrhage or plasma) (Eg., severe burns which
draws large amounts of plasma from the blood stream to the burn site).
Examples: 1) dextran
2) plasma
3) human serum albumin

Medical Considerations in Determining Infusion Rate

1. Surface area of the body - the larger the individual is, the more fluid
and nutrients are required and the faster they are utilized.

2. Condition of the patient - the cardiac and renal status will affect the
rate of administration.

3. Age of the patient - the very old and the very young are sensitive to
fluid overload.

4. Type of solution - IV solutions with medications will generally be at

a slower rate to prevent vein irritation or overdose. Blood transfusions
may also be ordered at a slower rate.

Computation of flow rate

Formula:
Drop factor x volume to be infused/hour

(Gtts/cc) (Cc/hr)
60 min = gtts/min

Example: if a set delIVers 10 gtts/cc and 100 cc are to be infused in

one hour, how many drops/min are required?

10 x 100
60 = 16-17 gtts/min
Factors Affecting IV Flow Rate

1. Height of solution bag - as the height of the bag increases, so does

the pressure and rate.

2. Clot in the needle.

3. Injury to the vein-phlebitis or thrombosis will impede flow.

4. The position and patency of the tubing (eg., kinked tubing or clamp
closed too tightly).

5. Possible infiltration or fluid leakage.

6. Position of the forearm - sometimes a change in the position of the

arm will increase the flow.

Complications from IV therapy

1. Infection

A. Possible cause: poor aseptic technique (eg., failure to keep site

clean or change IV equipment regularly).

B. S & s: swelling, redness, pain or irritation at site and foul smelling

discharge.

2. Thrombophlebitis / phlebitis

This is an inflammation along the vein and may or may not have a
thrombus formation present. (Thrombus is a collection of platelets and
fibrin which adhere to any roughening of the venous wall).

A. Possible cause: injury to the vein either duringvenipuncture or

from needle movement later, irritation to vein from long term therapy,
drug additIVe or use of a vein that is too small to handle the amount
or type of solution or too sluggish a flow rate which allows a clot to
form at the end of the needle or catheter. It canr esult in septicemia and
bacterial acute endocarditis.

B. S & s: sluggish flow rate, swelling, vein is sore, hard, red, cordlike
and warm to touch. May look like a red line above puncture site.

3. Infiltration

Is an accumulation of fluid in the extravascular tissue.

A. Possible causes: needle or catheter displacement (partial or

complete) or leakage of blood around needle or catheter (especially
with the elderly);

B. S & s: swelling at site (pitting in type); may or may not be painful,

swelling of entire limb, coolness of skin around site, absence
of blood back flow, sluggish flow rate;

4. Pyrogenic reaction

Occurs when pyrogens enter the bloodstream.

A. S & s: sudden chills, fever, malaise and headache. Severe reactions

- backache, nausea and vomiting and vascular collapse and shock can
occur if infusion continues; and

5. Pulmonary embolism
Occurs when a substance, usually a thrombus, becomes free floating
and is carried by the venous circulation to the right side of the heart and
into a pulmonary artery.

A. S & s: obstruction may result in circulatory,

Respiratory or cardiac disturbances (eg., sob and
Sudden onset of chest pain); and

6. Air embolism

Air is absorbed into the vascular circulation in a quantity too large or

too rapid to be re-absorbed. Is a greater risk and more common with
central lines than with peripheral ones.

A. Possible causes: container allowed to run dry, air in tubing, loose

connections and during rapid blood transfusion where air gets trapped
due to viscosity;

B. S & s: drop in b/p, weak, rapid and thready pulse, cyanosis, loss of
consciousness, sudden vascular collapse;

7. Circulatory overload/heart failure

More common in the very young, very old or patients with

renal/pulmonary problems.

A. Possible causes: too much fluid or fluid delivered too fast which
increases venous pressure with the possibility of cardiac dilation and
subsequent pulmonary edema;

B. S & s: fatigue, dyspnea, sob, rales, rapid pulse,

Palpitations, lung congestion, narrowing pulse pressures (difference
between systolic and diastolic pressure), edema in extremities and
sacral region, nausea, chest tightness, slowed mental response,
engorged neck veins, increased bp, rapid respirations and decreased
urine output.

1. Condition of the vein

A. Dorsal metacarpals are often used first in order to preserve veins for
further therapy. For elderly, these can be a poor choice - thin, fragile
veins and inadequate securing;

B. Palpation of vein is an important step in determining the condition.

A thrombosed vein may be detected by its lack of resilience, hard,
cord-like feeling, and by the ease with which it rolls;

C. Try to find a vein that is full, soft and unobstructed - not crooked,
hardened, scarred or inflamed. If must use a vein in the lower
extremity, check carefully for varicosity above the venipuncture site;

D. Avoid veins in infected, injured or irritated areas; and

E. If the patient is positioned on his/her side, choose a site on the

opposite side.

2. Purpose of the infusion

A. Two factors will affect the selection of the vein:

1) rate of flow,
2) solution to be infused; and

B. When large quantities of fluid are to be rapidlyinfused, or when

positIVe pressure is indicated,a large vein must be used;

C. High viscosity fluids (eg., packed cells) require a vein with

adequate blood volume; and

D. Hypertonic solutions or solutions with irritating drugs require large

veins.

Insertion technique

1. Dilating the vein

A. Apply a tourniquet firmly 15-20 cm (6-8 in) above the venipuncture

site (eg., if using dorsum of hand apply to forearm and if using forearm
apply to upper arm);

B. When applying a tourniquet, ensure that you can still feel radial
pulse - if not, too tight; and

C. If vein is not sufficiently dilated:

1) massage or stroke the vein distal to site and in the direction of

venous flow to the heart,

2) have patient clench and unclench fist,

3) lightly tap vein with your fingertips,

4) manually apply downward distal pressure on both sides of the

vein,

5) allow arm to dangle at bedside,

6) if the above fails, remove the tourniquet and place heat (warm
compresses to limb for 10-15 mins and then repeat steps 1-5).
D. A bp cuff can also be used to dilate the vein. Inflate cuff, then release it
until the pressure drops just belowthe diastolic pressure -approximately 80-
100 mm of hg is required.
There are 2 methods of insertion: direct and indirect.

Direct or one step method

1. Dilate vein.

2. Stabilize vein by anchoring it with your thumb and stretching the skin
downward. If the vein is in the patient's hand, it may help to flex the
patient's wrist.

3. Remove needle cap, point needle in direction of blood flow and hold it
at a 30% angle above the skin, with the bevel facing up.

4. With one quick motion, pierce the skin with the needle and advance it
into the vein. The cannula enters the skin directly over the vein.

5. To confirm a successful venipuncture check for blood flowback.

Continue to advance the needle/cathlon until it is well within the vein (3-
5mm). Withdraw the needle about 1/2 cm and advance the cathlon to its
final position. Important: if feel any resistance, do not force the catheter.

6. When the cannula's placed correctly, release the tourniquet.

7. Withdraw the needle slowly, observing for blood backflow. As you are
removing the needle, press lightly on the skin over the catheter tip to
prevent bleeding.

8. Connect adaptor of administration set to catheter hub. Keep your finger

pressed against the catheter tip while doing this. When connection is
complete, let the IV fluid flow freely for a few seconds to ensure proper
insertion. Observe for any swelling - if occurs, remove cathlon.

9. Apply tegaderm/op-site over the cathlon and secure tubing to the patient
using non-allergic tape.
Indirect Method

1. Insert cannula at a 45% angle through the skin about 1/2 inch below the
site of entry of vein, with bevel facing up.

2. Decrease the needle angle until the needle's almost level with the skin
surface and direct it toward the vein you have selected. Slowly with a
downward motion, followed immediately by a raising of the point, pick up
the vein, levelling the cannula until flush with the skin.

3. Observe for blood backflow. Continue as per direct method of insertion.

Considerations re IV insertions

1. Although the bevel of the needle is usually facing up, when entering a
small vein use the - bevel-down position.

2. Insert an IV at the distal end of the vein.

3. If possible, do not use sites where flexion and movement of extremity

might dislodge the cathlon, cause a restriction of fluid flow or cause a
phlebitis due to movement of inserted catheter.

4. Consider the duration and purpose of the IV therapy as well as the

condition of the patient.

5. Avoid if possible, veins that feel hard or roll.

6. If a patient is right handed, attempt insertion on left hand.

7. Make only 2 attempts and if unsuccessful, have someone else start the
IV.

8. A sterile cannula is to be used for each IV attempt.

CHAPTER 14

FIELD
INFORMATION
 SURVIVAL

Being isolated, lost and alone can be avoided by remembering the key
word: S-U-R-V-I-V-A-L.

S - SIZE UP THE SITUATION BY CONSIDERING

THE INDIVIDUAL AND THE COUNTRY.
U - UNDUE HASTE MAKES WASTE:
a. DON'T BE TOO EAGER TO MOVE
b. DON'T LOSE YOUR TEMPER

R - REMEMBER WHERE YOU ARE

V - VANQUISH FEAR AND PANIC:

a. TO FEEL FEAR IS NORMAL
b. WHEN INJURED IT IS
DIFFICULT TO CONTROL FEAR
c. PANIC CAN BE CAUSED
BY LONELINESS
d. PLANNING A RESCUE WILL
HELP KEEP THE MIND BUSY

I - IMPROVING:
a. THE SITUATION CAN BE IMPROVED
b. LEARN TO PUT UP WITH NEW AND
UNPLEASANT CONDITIONS

V - VALUE LIVING:
a. HOPE AND A REAL PLAN FOR
 RESCUE REDUCES FEAR AND MAKES
THE CHANCES FOR SURVIVAL BETTER
b. STRENGTH AND HEALTH MUST BE
PRESERVED
c. HUNGER, COLD AND FATIGUE
LOWER EFFICIENCY AND STAMINA
d. REMEMBER YOUR GOAL -- GETTING
OUT ALIVE

A - ACT LIKE THE NATIVES

L - LEARN THE BASIC SKILLS

AIR DEFENCE

WEAPONS EFF AD RANGE (m)

GPMG 7.62mm 1000
C-9 5.56mm 1000
FNC1 7.62mm 800
FNC2 7.62mm 1000
C-6 5.56mm 1000
C-7 5.56mm 800
C-8 5.56mm 800
HMG .50 Cal 1200
CANNON 30mm 2000
MRAAW 1000
LRAAW 3000
Tk (APDS) 1500

WPNS FREE Wpns are fired at any target not

positively recognized as friendly.
WPNS HOLD Wpns are only fired in self defence or
in response to a formal order.
WPNS TIGHT Wpns are fired only at tgts recognized
as enemy.
WPNS UNLMTD Wpns are fired at any target in range.
NOTE
Cautionary order for AD is normally: WPNS

Audible alarms for AD

Source Air Atk Wng All Clr
GENERATOR long warbling sig long clr sig
SIREN one min unbroken one min broken
WHISTLE long blast short blasts
HORN long blast short blasts
VOCAL AIR ATK ALL CLR
OTHER
 PRINCIPALS OF KEEPING WARM

Clean clothing - This is important from a standpoint of both

sanitation and comfort. Dirt and grease will mat clothing and fill the air
pockets. It is very important to change and clean your underwear as often
as possible.

Over heating must be avoided - To stay warm, avoid getting hot.

Overheating causes perspiration, this causes clothing to become damp as
the perspiration fills the air holes in the clothing with heat-conducting
moisture, permitting the body heat to escape. Another reason for avoiding
overheating is that when perspiration evaporates, your body will cool
faster. Overheating can be prevented by ventilation, partially open parka or
jacket, or by removing layers of clothing. In cold weather, it is better to be
slightly chilly than too warm. One of the cardinal rules of cold weather
operations is not to RUN unless you absolutely have to.

Loose and in layers - Clothing and footwear that is too tight

restricts the blood circulation, increasing the danger of frostbite. On the
other hand, clothing must not be won too loose; this will allow movement
of the trapped air between the layers of clothing, resulting in heat loss.

Dry clothing - Moisture will soak into your clothes from both
inside and outside. Frost or snow that collects on your clothing will be
melted by the heat you radiate or by the higher temperature encountered
when you enter heated shelters. Brush or shake off all snow and frost
before entering shelters. Even in the coldest weather you cannot entirely
avoid perspiration. Take advantage of each and every opportunity to dry
out your clothes.

JUDGING DISTANCE AID MEMOIRE

RANGE TO 200 300 400 500 600 700 800

TARGET
(METERS)
HEIGHT OF A 9.1 6.1 4.6 3.6 3 2.6 2.3
MAN
WIDTH OF 2.3 1.5 1 .9 .75 .6 .55
MAN= S
SHOULDER
HEIGHT OF 1.8 1.2 .9 .75 .6 .5 .45
JERRY CAN
WIDTH OF 1.7 1.2 .8 .7 .55 .5 .4
JERRY CAN
QUONSET HUT 17 11 8.4 6.7 5.6 4.8 4.2
2 WAY PAVED 49 32 25 20 16 14 12
ROAD
1 LANE DIRT 15 10 7.6 6.1 5.1 4.4 3.8
ROAD
AVG WIDTH OF 6.7 5.6 4.2 3.4 2.8 2.4 2.1
SIDEWALK
AVG CAR 6.8 4.6 3.4 2.8 2.3 2 1.7
HEIGHT
C7 RIFLE 5 3.3 2.5 2 1.7 1.4 1.3
C9 LMG 5.2 3.5 2.6 2.1 1.7 1.5 1.3
C6 GPMG 6.8 4.2 3.1 2.5 2.1 1.8 1.6

.50 CAL 8.3 5.5 4.1 3.3 2.8 2.4 2.1

M72 NOT 3.3 2.1 1.6 1.3 1.1 .9 .8
EXTENDED

M72 4.5 3 2.2 1.8 1.5 1.3 1.1

EXTENDED
TOW 11 7.4 5.5 4.4 3.7 3.2 2.7
60 MM 5.4 3.6 2.7 2.1 1.8 1.5 1.3
MORTAR
81 MM 6.4 4.3 3.2 2.6 2.1 1.8 1.6
MORTAR
AK – 47 4.4 2.9 2.2 1.7 1.5 1.2 1.1
AK – 74 4.7 3.1 2.4 1.9 1.6 1.3 1.2
SVD SNIPER 6.2 4.1 3.1 2.5 2.1 1.8 1.5
RIFLE
RPK / PKM 5.2 3.5 2.6 2.1 1.7 1.5 1.3
 AGS - 17 4 2.7 2 1.6 1.3 1.1 1
RPG – 7 4.8 3.2 2.4 1.9 1.6 1.4 1.2
RPG - 16 5.5 3.7 2.8 2.2 1.8 1.6 1.4
RPG - 18 5.3 3.5 2.6 2.1 1.8 1.5 1.3
EXTENDED
RPG - 18 NOT 3.6 2.4 1.8 1.4 1.2 1 .9
EXTENDED
82 MM 6.1 4.1 3.1 2.4 2 1.7 1.5
MORTAR TUBE

PATROL TIPS

1. Each man a specific task

2. Designate two pacers

3. Use scouts followed by navigator

4. Use a model during orders

5. Memorise route

6. Cock wpns before leaving platoon positions

7. Use least likely terrain routes

8. Avoid all human habitation

9. Stay off skyline

10. Only cut en wire when necessary

11. Grenades are good if used properly

12. Select predetermined rally points

13. Use Lt automatic weapons of similar cal if possible

14. Carry survival kits

15. Each man, a small length of rope (2m) as belts

16. Binoculars are useful at night

17. Carry sharp knife, spare socks, wire cutters

18. Spare flashlight and radio batteries

19. Become accustomed to dark before leaving

20. Test compass by day

21. Take advantage of all night noises for moving
22. If strong wind blowing, use this as dir of your mov, as enemy blinded

23. Stay off used rds or tracks

24. Avoid lateral mov across en= s front

25. Mors and arty are an aid to nav

26. Always carry wpns at ready posn

27. Never throw trash while on ptl

28. Cover all approaches during halts

29. Don= t smk - it can be seen for miles. Insect repellant, smk, etc can be
smelt from afar

30. Don= t cover up ears even if cold

31. When passing a sig, make certain all understood, then mov
32. Dirty stormy weather is best ptl weather

33. All men should carry a small concealed wpn, such as knife, to be used
in case of capture or other emergency

34. Let men know where they are - pass back all info

35. Offset method on last leg

36. If men are sleepy, avoid prone posn

37. Visual aids

38. Rad check before leaving

39. Avoid routes used by previous ptls

40. Conduct periodic checks to ensure all members of the ptl are still with
you and that no substitutions has occured

PROGRAM AFTER PTL ORDERS

1. Rehersal, wpns testing

2. Rest and food

3. Viewing of grd by all

4. Turn in of pers belongings

5. Pers cam

6. Ln with flanking units

 PATROL REPORT

Designation of patrol Date

TO:
MAPS:
A: SIZE AND COMPOSITION OF PATROL

B: TASK

C: TIME OF DEPARTURE

D: TIME OF RETURN

E: ROUTES (OUT & BACK)

F: TERRAIN
(Description of the terrain - dry, swampy, jungle, thickly wooded, high
brush, rocky, deepness of ravines and draws, conditions of bridges as to
type, size and strength, effect on armour and wheeled vehicles).

G: ENEMY
(Strength, disposition, condition of defences, equipment, weapons, attitude,
morale, exact location, movements and any shift in dispositions). Time
activity was observed; grid reference where activity occured.

H: ANY MAP CORRECTIONS

J: MISCELLANEOUS INFORMATION
(Enemy prisoners and dispositions; identifications, enemy casualties,
captured documents and equipment).

K: CONDITION OF PATROL, INCLUDING DISPOSITION OF ANY

DEAD OR WOUNDED.

M: CONCLUSION AND RECOMMENDATIONS

(Including to what extent the mission was accomplished and
recommendations as to the patrol equipment and tactics).

Signature Rank Organization /unit of patrol

RADIO APPOINTMENT TITLES

COMMANDER SUNRAY
CHIEF OF STAFF MOONBEAM
RCPO (OPERATIONS) SEAGULL
NBC STAFF BOXWOOD
INTELLIGENCE ACORN
ADMIN STAFF MANHOLE
LOGISTICS / QM MOLAR
Q STAFF / EQUIP NUTSHELL
AIR DEFENCE CONROD
AIR RECCE REP SPYGLASS
AIR TRAFFIC CONT BASEBALL
AIR TPT SUPPORT ATOLL
LAND AIR REP HAWKEYE
ARMOUR IRONSIDE
ARMAMENT SHOTGUN
ARTILLERY SHELLDRAKE
ENGINEER HOLDFAST
FAC FORTUNE
GROUND LIASON GLOWWORM
INFANTRY FOXHOUND
MEDICAL STARLIGHT
MET TECH METEOR
MOVEMENTS STAFF CONTRACTOR
ORDNANCE RICKSHAW
PROVOST WATCHDOG
EME BLUBELL
SIGNALS PRONTO
SUPPPLY & TPT PLAYTIME

ALL SENTRIES MUST KNOW:

a. Where they must be while on duty

b. The loc of their comds and how to contact them

c. By day, if posted forward of the main posn, the route that they must take
to return to the posn

d. The direction of the enemy

e. What grid to watch

f. The positions of flanking posts

g. The names of landmarks to their front

h. Details and positions of any intruder alarms or aids such as trip flares

j. The procedure for challenging

k. The password

m. The password for the next 24 hrs if a change is due

n. Orders for opening fire

p. Particulars of friendly ptls in the area

q. The signal for def fire; sentries manning GPMGs laid on fixed lines
must know the signal for them to open fire

r. Times of mounting, relief, and details of the relief system.

 PROCEDURE FOR CHALLENGING

Serial Action by Sentry Action by Person

1 HALT, HANDS UP Halts, raises hands
2 ADVANCE (ONE) Person (or group leader)
orders by voice or sign adv towards sentry= s
posn.
3 HALT! (When the Person halts until
unknown person has recognized by sentry.
approached sufficiently
for sentry to recognize
him or to give
challenge)
4 Challenge (if any) is Reply or password is
given in a low tone given in a low tone
5 ADVANCE ANOTHER Second unknown (or
ONE (or remainder) remainder of group) adv at
AND BE order of sentry to be
RECOGNIZED (sentry recognized. Gp leader, or
calls forward remainder person designated by
one by one or as a gp, as leader must remain with
the sit or his orders sentry to assist in ident
(demand) remainder
 SOLDIER'S CARD

1. SELF DEFENCE. You may use force, up to and including deadly force
when you, your unit, friendly forces or persons with protected status are
faced with an immediate threat of death or grave injury. Certain
limitations, as directed by your commander, have been imposed on the
means of force that you may use to exercise your right to self defence. IF
UNSURE - ASK!

2. PROPERTY. You may use force, up to and including deadly force, in

the presence of an immediate threat of destruction to protected property,
as designated by your commander. For theft, you may use only non-deadly
force.

3. ESCALATION OF FORCE. Any use of force WILL respect the

limitations imposed by these ROE and will respect the following sequence.
If the situation developes too quickly, any of these steps can be bypassed,
as necessary.

A. WARNING: Repeat visual/verbal warnings until it is

clear the person understands you.

B. NON-DEADLY FORCE: If warnings are ignored,

useof non-deadly force can be authorized by the on-
scene commander.

C. SHOW OF ARMED FORCE: If use of non-deadly

force fails or is not possible, loading and aiming of
weapons can be authorized by the on-scene commander.

D. WARNING SHOT. If a show of armed force

fails,warning shots at a safe point of aim can be
authorized by the on-scene commander.

E. DEADLY FORCE. If warning shots fail, use of

deadly force can be authorized by the on-scene
commander.

4. WEAPON CONTROL MEASURES. You will be told what measures

to adopt with respect to magazines, loading, etc. IF UNSURE, ASK!
5. AUTHORITY TO DETAIN. Anyone who presents a threat of death or
grave injury to friendly forces or persons with protected status, or who enters
or attempts to enter an area controlled by friendly forces, or who commits a
serious criminal offense, can be detained using NON-DEADLY FORCE.

6. DEADLY FORCE IS NOT AUTHORIZED TO STOP A FLEEING

DETAINEE.

7. AFTER FIRE ACTION. Every incident involving the firing of weapons

or the use of deadly force WILL be reported to your commander as soon as
possible.

8. SOLDIER= S RULES. All personnel SHALL repect the CODE OF

CONDUCT as stated below.

9. ROE AND LAWS OF WAR VIOLATIONS. As soon as possible, report

to your commander all know or suspected violations to ROE or to the
CODE OF CONDUCT.

10. TIER CONCEPT. There are two tiers for operations. You will be told
which one is in effect.

A. TIER ONE. Under this tier, the use of deadly force is

authorized only as a last resort in self-defence of to defend
PROTECTED PROPERTY from DESTRUCTION. You will be
told what property has been designated as protected and which
persons have protected status. IF UNSURE, ASK!

B. TIER TWO. Under this tier, the use of force is more

permissive BUT WE ARE STILL NOT AT WAR.
You will be given specific direction by your commander.
 CODE OF CONDUCT

1. When acting in defence or in attack, engage only belligerent forces and

military objectives.

2. Only use force which would cause the least amount of incidental civilian
damage, to achieve your objective.

3. Do not alter your weapons or ammunition to increse suffering.

4. Respect civilian property. Looting is prohibited.

5. Respect all cultural objects (museums, monuments, etc) and places of

worship.

6. Do not attack bellingerent forces who surrender. Disarm them and treat
them to the standard which applies to Pws.

7. Treat all civilians humanely. If you detain civilians treat them at least as
well as you would a PW.

8. Do not torture, kill or abuse detainees. Provide adequate food, water and
shelter.

9. Collect the wounded and sick, whether friend or foe, and provide them
with the same treatment.

10. Respect all persons and objects bearing the Red Cross / Red Crescent,
and other recognized symbols of humanitarian agencies.

11. Report and take appropriate steps to stop breaches of these rules.
Disobediance of the law of armed conflict is a crime.
 VEHICLES

LENGTH WIDTH HEIGHT

LOSV 3.06 1.106 1.473

ILTIS 3.974 1.52 1.837
MLVW 7.14 2.46 2.81
M 113 4.75 2.74 2.5
LYNX 4.60 2.41 1.65
A.V.G.P. 5.97 2.53 2.53
LEOPARD 1 7.09 3.25 2.61
HUMMER 4.57 2.15 1.75
M-2 BRADLEY 6.45 3.20 2.57
M-60 6.95 3.63 3.27
M1 ABRHAMS 7.92 3.65 2.38
BTR 60/70 7.22 2.82 2.31
BMD 5.41 2.55 1.77
BMP 6.74 2.94 2.15
ZSU 57-2 8.53 3.27 2.75
ZSU 23-4 6.31 2.95 2.25
PT 76 7.63 3.18 2.19
ACRV 6.35 2.83 2.29
MTLB 5.42 2.85 1.87
T54/55 9.0 3.27 2.32
T62 9.33 3.29 2.38
T64 9.1 3.38 2.29
T72/80 9.2 3.57 2.29
WEAPONS AND STANO DATA

Serial Weapons and Range (M) Basic Maintenance

Equipment load load
1 C7 (M16A2) 400 350 rds 120 rds per
per wpn wpn
AMMO
a. Ball
b. Tracer
RATE
Norm: 5
rds/min
Rapid: 20
rds/min
2 C8 (M16A2 300 350 rds 120 rds per
carbine) per wpn wpn
AMMO
a. Ball
b. Tracer
 RATE
Norm: 5
rds/min
Rapid: 20
rds/min
3 C9 (minimi) 600 800 rds 250 rds per
per wpn wpn
AMMO
a. Ball
b. Tracer
RATE
Sustained rate
750 to 1000
rds/min

Serial Weapons and Range Basic Maintenance

Equipment (M) load load
4 C6 (FN MAG 1200 Armd 220 rds per
58) GPMG 5060 wpn
AMMO Inf 220 rds per
1760 rds wpn
a. Ball per wpn
b. Tracer
RATE
Norm: 110
rds/min
Rapid: 220
rds/min
5 HMG .50 cal
AMMO
a. Ball A Pers
b. Tracer 2000
c. C44 AP
Anti 800
BMP
6 C3 Sniper 600 30 rds 5 rds
Rifle per wpn per wpn
AMMO
a. Ball

CASEVAC REQUEST

1. LOC OF PICK UP SITE

2. RAD FREQ AND C/S AT THE
PICK UP SITE
3. NUMBER OF CAUALTIES.
4. TYPE OF WOUND, INJURY,
ILLNESS FOR EACH CASUALTY.
5. PATIENT NATIONALITY.
6. SECURITY OF PICKUP SITE.
7. LOC OF RV AT PICK UP SITE.
8. SPECIAL EQUIP REQRS.
 WIND CHILL FACTOR

Wind Chill Factor is a numerical index expressed in Watts per Square Meter as a
cooling rate of a nude body in the shade. The cooling effect of any combination of
Temperature and Wind, expressed as the loss of body heat in Watts/meter2. It is only
an approximation because of individual body variations in shape, size, and metabolic
rates.

The parameters at the table below will show and explain what occurs at different Wind
Chill Factors.

800 to 1200 - Comfortable - conditions considered comfortable when dressed for

skiing.

1200 - Conditions no longer pleasant for outdoor activities on overcast days.

1400 - Conditions no longer pleasant for outdoor activities on sunny days.

1600- Conditions become unbearable regardless of weather.

1700 - Freezing of exposed skin begins for Frost Bite Danger most people depending
on the degree of activity.

1800 - Exposed flesh will freeze in 3 minutes.

1900 - Very cold

2100 - Bitterly cold

2200 - Conditions for outdoor travel such as walking become dangerous.

2300 - Exposed areas of the face freeze in less than 1 minute for the average person

2400 - Extremely cold

2700 - Exposed flesh will freeze within 30 seconds for the average person.

WIND CHILL FACTORS

To use the chart below, simply use the present temperature and the approximate wind
speed, and where they intersect, the factor is read in Watts per Square meter.
Normally all figures are read to the nearest hundred.
ie. Temperature -20Ε & wind speed 20 km/hr
Wind chill = 1750 or 1800 watts / sq meter

TEMPERATURE IN DEGREES CELSIUS

+10 +5 0 -5 -10 -15 -20 -25 -30 -35 -40 -45
wind
calm 600 700 800 900 1000 1200 1300 1400 1500 1600 1800 1900
5 600 700 850 1000 1100 1250 1400 1500 1600 1800 1900 2050
10 650 800 900 1050 1200 1300 1500 1600 1750 2000 2000 2200
15 700 900 1000 1200 1300 1500 1650 1800 1950 2100 2250 2400
20 750 900 1050 1250 1400 1600 1750 1900 2050 2250 2400 2550
25 800 1000 1150 1300 1500 1650 1850 2000 2200 2350 2500 2700
30 800 1000 1200 1350 1550 1700 1900 2100 2250 2450 2600 2800
35 850 1050 1200 1400 1600 1750 1950 2150 2300 2500 2700 2900
40 900 1050 1250 1450 1600 1800 2000 2200 2400 2550 2750 2950
45 900 1100 1250 1450 1650 1850 2050 2250 2450 2600 2800 3000
50 900 1100 1300 1500 1700 1900 2100 2300 2500 2650
55 900 1100 1300 1500 1700 1900 2100 2300 2500 2700
60 900 1100 1300 1500 1700 1900 2100 2300 2500 2700
65 900 1100 1300 1550 1750 1950 2150 2350 2550 2750
70 900 1150 1350 1550 1750 1950 2150 2350 2550 2750
75 950 1150 1350 1550 1750 1950 2150 2400 2600 2800
80 950 1150 1350 1550 1750 1950 2200 2400 2600 2800
 WIRE OBSTACLES

Wire Obstacles Stores reqr / 100m Time / 100m Work Party

Concertina Barb Wire Picket Pickets Day Night
Rolls s long short
Low Wire 17 220 2.5 hrs 5 hrs 1 Sect

Single Concertina 7 2 28 0.5 hrs 1 hr 1 Sect

Triple Concertina 20 5 57 1 hr 2 hrs 1 Sect

Cat Wire Type 1 13 7 70 0.75 hrs 1.5 hrs 1 Sect

Cat Wire Type 2 27 10 105 1.5 hrs 3 hrs 1 Sect

Cat Wire Type 3 33 14 140 2 hrs 4 hrs 1 Sect

 TWO MAN BATTLE TRENCH

Emplacement Dimensions Work Time Remarks

Sequence Party
Day Night
STAGE 1 4.0m x 0.75m Remove 2 45 min 1.5 hrs Save turf
Shellscrape turf
STAGE 2 1.6m long, 0.75m wide, 2 2 hrs 4 hrs Dig to armpit depth
Fire Trench 1.55m deep
STAGE 3 Dig out elbow rest 0.25m 2 2.5 hrs 5 hrs
Revet Fire Trench deep by 0.45m wide
STAGE 4 Enlarge non-revetted end 2 6.5 hrs 13 hrs
Shelter Bay OHP by 2.4m in length
STAGE 5 2 7 hrs 14 hrs Dispose of excess
OHC on Fire soil
Trench
STAGE 6 10 2.5 hrs 1.25
Add Ammo Bays, m/hr
Drainage/Grenade
Sumps & Comms
Trenches

MATERIALS FOR TWO MAN BATTLE TRENCH

1. The following mat/stores are required:

Mat / Stores Qty Weight (kg)

SHS Sheets (0.66m x 1.1m) 12 92.6

CGI Sheets (0.66m x 1.8m) 6 43.5 *
Long Pickets (1.8m) 7 36.4 **
Short Pickets (0.6m) 9 15.3 **
Windlassing Wire 40m 1.0
Sandbags 18 18
 TOTAL 190.8 ***

* If performed end sheets are used, the qty of 1.8m CGI decreases to 4 sheets.
The wt of the end sheets is approx 8.0kg.
** If an altn mat is emp as shelter bay sills, the qty of 1.8m and 0.6m pickets can be reduced to
3 and 7 respectively.*** If items in * and ** are emp, the total wt can be reduced to approx
170kg.
 MARKING OF CONTAMINATED
AREAS, EQUIPMENT
AND STORES

PRIME SECONDARY COLORS

DANGER COLOR
MARKINGS INSCRIPTIONS

Rad contam WHITE NONE BLACK

Bio contam BLUE NONE RED

Chem YELLOW NONE RED

contam

Chem RED YELLOW YELLOW

minefld (STRIPE)
(or barrier)

Minefld (or RED NONE WHITE

barrier)
other than
chem

Booby RED WHITE NONE

trapped (STRIPE)
areas

Unexploded RED WHITE NONE

munition (BOMB)
 Chapter 15

PHYSICAL
EXAMINATION
HISTORY

Subjective

All important: Depending on the chief complaint consider everything,

document the essential.
Document presence or absence of fever, chills, nausea, vomiting, diarrhea, chest
pain, shortness of breath and headaches.
If you don't ask, the patient will probably not tell you!

Focus on History of Present Illness

P- What Provokes discomfort

Q- What is the Quality of the discomfort
R- Where is the Region of the discomfort
S- What is the Severity of the discomfort
T- What is the Time sequence

What was the mechanism of injury

What was the pt doing prior to incident
Are there any associated symptoms
Are there any aggravating/relieving factors
Is this a recurrent illness or injury
Is the patient on any medications
Note pt's ETOH, caffeine and smoking habits.
Allergies ASK FOR YOURSELF!
REVIEW OF SYSTEMS: This will help you focus your exam.

General: First Impression. Nutritional status, weight gain/loss, weakness,

fatigue, hydration, status & overall condition

Skin: Changes in skin/nail/hair texture, appearance and color. Rashes, itching,

lumps or infection. Cellulitis, Lymphangitis, lymphadenopathy

Head: Loss of consciousness. Lightheadedness, vertigo, headaches, symmetry,

history of injury, sinus pain, visual disturbance

Ears: Acoustic trauma, hearing loss, tinnitus, drainage, pain, infection,

discharge, vertigo, hearing aids, last audiogram

Eyes: Visual changes, diplopia, epiphora, pain, discharge, light halos, trauma,
photophobia, glaucoma, cataracts, last eye exam, visual acuity, and
Glasses/contacts

Nose/Sinuses: Olfactory changes, stuffiness, drainage, itching, obstruction,

history of trauma, hay fever, nosebleeds, sinus problems.

Throat/Mouth: Hoarseness, enlarged tonsils, bleeding gums, sores, teeth

condition, caries, tongue changes, dry mouth, history of sore throat

Neck: Goiter, pain, masses, nodules, adenopathy, thyroid problems, stiffness,

creptitus, history of injury

Respiratory: Cough, dyspnea, pleurisy, sputum (amt, type, color), asthma,

bronchitis, COPD, emphysema, effusion, TB, last CXR, and smoking history

Cardiac: HTN, hyperlipidemia, rheumatic fever, murmurs, chest

pain/discomfort, orthopnea, dyspnea, edema, last ekg/stress test, CHF,
pericarditis. history of surgeries/procedures/monitors.

Peripheral vascular: Nocturnal pain, claudication, varicose veins,

thrombophlebitis, leg cramps, CHF, DVT
Gastrointestinal: Heartburn, dsyphagia, appetite, indigestion, belching,
flatulence, hematemesis, stool changes, melena, diarrhea, constipation, nausea,
regurgitation, vomiting, history of gallbladder, liver, pancreatic disease, PUD
Genital (male) Hernias, sores, lesions, penile discharge, pain , testicular/mass
discomfort, scrotal mass/discomfort history of STD's, sexual history,
function, problems

Genital (female): Birth control, sexual history/function, STD's, itching, sores,

discharge, last pap/pelvic exam, menarche, menopause, LMP, GPA, menstrual
regularity, frequency, duration, amt Dysmenorrhea, amenorrhea and PMS,

Urinary: Dysuria, polyuria, frequency, stones, pattern change, incontinence,

nocturia, STD, hesitancy, dribbling, hematuria, infections, flank discomfort

Hematologic: Bleeding, bruising, anemias, petechia, history of transfusions,

sickle cell

Endocrine: Thyroid, adrenal, hormonal, heat/cold intolerance, edema, hirsutism,

sweating, excessive thirst, hunger, polyuria, pigment changes

Psychiatric: Anxiety, mood swings, mania, depression, memory loss, insomnia,

suicidal ideations, delusions, hallucinations

Musculoskeletal: Myalgia, stiffness, gout, arthritis, backache. history of

swelling, pain, erythema, tenderness, decreased ROM history of trauma,
overuse.

Neurologic: Syncope, vertigo, seizures, blackouts, parasthesias, paralysis,

tremors, weakness, involuntary movements, equilibrium, LOC.

Other Problems and past medical history:

Consider any other problems which are currently active, comments should
include functional impairment, childhood /adult illnesses, history of trauma,
surgeries, hospitalizations.
Document environmental exposures and Family History when appropriate.
OBJECTIVE

Always start your objective with a opening statement concerning the

patients general appearance and condition.

When you are questioning your patient, remember, it’s not what you find that
gets you in trouble. IT’S WHAT YOU MISS!
SKIN / NAILS / HAIR

Inspect for color changes: brown, gray, bronze, blue/reddish blue, red, yellow,
hypo/hyperpigmentation.

Palpate for skin changes: in moisture, temperature,texture, turgor.

Inspect and palpate nails for changes in texture, color and shape. Look for
infections

Inspect and Palpate hair for changes in quantity,quality, texture and distribution.
Look for infections.

Primary Lesions include: macules, patch, papule, plaque, nodule, tumor, wheal,
vesicle, bullae, pustule.

Secondary Lesions include: Erosion, ulcer, fissure, crust, scale, atrophy, scar,
keloid.

RELAVENT FINDINGS

Edema
Erythema/warmth
Pruritis/tenderness
Scaling/Flaking
Weeping/Discharge (color, amt, type)
Size, color, location, distribution
Asymmetry, borders, elevation

HEAD/FACE

Inspect for symmetry, lesions, rashes, edema, erythema, twitching, involuntary

movements, evidence of trauma/infection.

Palpate for masses, nodules, lymph nodes, salivary glands, Sinus tenderness,
temporal artery tenderness.

RELAVENT FINDINGS

Edema, ecchymosis
 Erythema, exudate, erosions
Obvious deformity
Mastoid tenderness/ Battle sign
Cranial Nerve compromise
Periorbital edema/cellulitis
TMJ tenderness
Signs of infection
Sinus tenderness

EYES

Visual Acuity: Gross exam at 14" tests only near vision! Snellen Chart is more
reliable.
Document as 20/_ OS, 20/_OD, 20/_OU with and without correction if
applicable.,

Inspect the Eyebrows, eyelids, lacrimal apparatus, conjunctiva, sclera, cornea for
edema, erythema, injection, abrasion, infection. Note pupils for
dilation/constriction.

Inspect for position and alignment of eyes. Orthophoric vs evidence of

Strabismus.

Hirschberg's test: Look for the light reflection on corneas. Are They
Symmetrical

Cover/Uncover Test: Tests for Strabismus.

Exotropia, Esotropia, Hypertropia, Hypotropia .

Fields of Confrontation: Cranial nerve II

Tests for peripheral vision. Evaluate both eyes (8 fields) Are they equal to yours

Extra Ocular Movements: Check the 6 cardinal fields

of gaze. Check for nystagmus, convergence, lidlag.

Cranial Nerve III responsible for opening the eye, pupillary constriction, most
extraocular movements.
Cranial Nerve IV responsible for downward, inward movement of eye. (Superior
oblique)- SO4.
Cranial Nerve VI responsible for lateral deviation of eye. (Lateral rectus) LR6.
Fundoscopic Exam: Note the Optic disc for sharp margins, 2:1 cup to disc ratio.
Is there any evidence of Retinal changes (AV nicking, copper wiring, exudates,
wool spots, tapering, banking, neovascularzations.)
Is there any papilledema, retinal detachment, drusen

PERLA:
Pupils, Equal, Reactive to Light and Accommodation.

RELAVENT FINDINGS

PERLA/visual acuity
Injection/erythema/discharge (color, amt, type)
Ciliary/Limbic Flush, Limbic pallor, Hyphema, Dendrites
Foreign Body, abrasions, ulcers, invert eyelids
Anterior chamber depth, IOP
Preauricular Nodes
Fluorescent Stain
Keratoconjunctivitis

EARS
Inspect Auricles and External canal for lesions, nodules,foreign bodies,
deformities, erythema, edema , wax, ecchymosis, discharge.

Palpate for tenderness and masses. Note pre auricular and post auricular nodes.

Auditory Acuity (conductive vs neuro loss)

Whisper test: (gross exam)

Weber test: lateralization to which ear
Rinne test: is AC>BC

Tympanogram: Evaluate Eustachian tube function.

Conductive Loss: may be due to wax, foreign body, otitis media.

Neuro Loss: may be due to Cranial Nerve VIII dysfunction, cochlear damage,
acoustic trauma.
RELAVENT FINDINGS

External ear & canal condition

Lymphadenopathy, hematoma,
Laceration with cartilage exposure
Edema, erythema, abrasions, cerumen
Drainage (color, amount, type)
Tenderness (where)
Foreign body, masses
TM condition (color, intact, mobile, landmarks)
Hearing acuity, Tympanogram
Air Fluid level
Anterior Cone of Light
Mastoid tenderness

NOSE / SINUSES

Inspect for masses, lesions, edema, erythema, deformity. Visualize the mucosa,
note color, consistency, lesions, masses, discharge, exudate, abrasion,
lacerations

Palpate for tenderness,

Percuss frontal and maxillary sinuses. Have patient bend forward. Note increase
in discomfort to sinuses.

Transilluminate with otoscope

RELAVENT FINDINGS

Symmetry, Patency
Ecchymosis, edema, exudate
Bleeding (ant vs post)
Drainage (color, amt, type)
Septal hematoma (fracture)
Polyps
Foreign body
Mucous membrane color
THROAT

Inspect lips, gums, teeth, buccal mucosa, tongue, soft/hard palate, tonsils, uvula,
posterior pharanyx, frenulum, salivary glands.
Note any lesions, masses, edema, erythema, pustules, exudates, ecchymosis,
nodules, masses, discharges, ulcerations, color variations.

RELAVENT FINDINGS

Uvula (midline )
Peritonsillar abscesses
Erythema, edema, (where )
Exudate (color, amt, type, where )
Pustules, vesicles (where )
Breath odor (fetid )
Adenopathy (which ones )
Tonsils (presence/absence)
Ulcerations, Leukoplakia
Oral Hygiene
Rash on face/truck

NECK

Inspect skin, trachea, thyroid, SCM, anterior/posterior triangles.

Note symmetry, lesions, nodules, masses, edema, ecchymosis, erythema.

Palpate all landmarks for tenderness, crepitus, spasm, nodules, masses, nodes.

Lymph node examination: Preauricular, postauricular, occipital, tonsillar,

submandibular, submental, anterior cervical, posterior cervical, supraclavicular.

Assess Range of Motion: Flexion, extension, lateral rotation, lateral bending.

(active and passive)

RELAVENT FINDINGS

Masses, edema
 Nodules
Meningeal signs (kernig, brudzinski)
Erythema, ecchymosis
Rigidity, Suppleness
Tenderness
Thyroid exam
Lymphadenopathy
Range of motion

CHEST AND LUNGS

Inspect anterior/posterior/lateral. Observe rate, rhythm, depth symmetry of

respirations, AP-LAT ratio. Look for retraction/bulging of intercostal spaces,
masses, lesions, deformity.

Percussion: Listen for dull, tympanic, resonant, hyperresonant, flat sounds.

Palpate for tenderness.

Auscultate all lobes, for pneumothorax / consolidation, consider doing CXR

AP/Lat.

RELAVENT FINDINGS

Auscultation (all lobes)

Respiratory expansion
Diaphragmatic excursion
Tactile fremitus
Percussion
Spirometry (before and after)
Pleural rubs
Wheeze, rhonchi, rales (inspiratory / expiratory)
HEART

Inspect for heaves, thrusts, obvious deformity.

Palpate valve areas:

(A) AORTIC -- RUSB at the 2nd ICS
(P) PULMONIC -- LUSB at the 2nd ICS
(M) MITRAL -- LMCL at the 5th ICS
(T) TRICUSPID -- LLSB at the 5th ICS

Auscultate valves with:

Diaphragm for High Pitched sounds: examples- S1, S2, regurgitant murmurs

Bell for Low Pitched sounds: examples- S3, S4, stenotic murmurs

Murmurs are graded 1-6, note location, pitch, intensity, shape, quality, timing.

Systolic Murmurs vs Diastolic Murmurs

(A) stenosis (A) regurgitant
(P) stenosis (P) regurgitant
(M) regurgitant (M) stenosis
(T) regurgitant (T) stenosis

HEART

RELAVENT FINDINGS

Rate, rhythm, regularity

S1, S2, S3, S4
Splits, clicks
Murmurs
Friction rub
Thrills, heaves, thrusts
EKG RELAVENT FINDINGS
Rate
Rhythm
Regularity
Axis
PR/QRS interval
Q's (where), J point changes
BBB's, hypertrophy, hemiblock
ST changes
Sinus, AV, junctional, ventricular origin
WPW, early repolarization
Upright T’s in I, II, V2-6

PERIPHERAL VASCULAR SYSTEM

Inspect, Palpate and Auscultate carotids, abdominal aorta, renal, iliac, femorals,
popliteal, posterior tibial, dorsal pedis, radial, ulnar, brachial pulses.

Look for edema, symmetry, venous, patterns, varicosities, change in

temperature, color, texture differences on all extremities. Include nailbed
assessment.

Palpate for sensory changes, varicosities, pulse differences, cord tenderness.

RELAVENT FINDINGS

Jugular venous distension

Allen's test (radial/ulnar patency)
Thrombophelbitis/ DVT
Compartment Syndrome
Varicosities
Homan's Sign
GASTROINTESTINAL

Inspect abdomen for lesion, masses, distension, erythema, edema, ecchymosis,

color changes, striae.

Palpate (light/deep) for guarding, rigidity, masses, tenderness.

Percuss entire abdomen, liver and spleen.

Auscultate all four quadrants for bowel sounds, listen to aorta, renals, iliac
arteries.

RELAVENT FINDINGS

Masses, aneurysms, bruits

Hepatosplenomegaly
Rigidity, guarding, rovsings
Rebound, referred rebound
Psoas, obturator, cough
Pelvic shake
Ascites (fluid wave)
Murphy's, Cullen's, Grey-Turner's sign

Rectal Exam

sphincter tone, hemocult, fissure, fistula, hemorrhoids, ulceration, excoriation,

infection, lesions,
prostate: size, shape, consistency, boggy, hard, firm, enlarged, nodules,
masses, tenderness.
GENITOURINARY (MALE)

Inspect entire pubic area. note lesions, masses, edema, erythema, ecchymosis,
excoriation, lichenification, discharge, drainage.

Palpate entire pubic area for tenderness, masses, nodules, cysts,

lymphadenopathy.

RELAVENT FINDINGS

Lesions, rash, erythema (Where )

Masses/ nodules/ cysts (where )
Discharge/drainage (color, amt, type)
Scrotal vs testicular involvement
Cremasteric Reflex
Hernias
Spermatic cord
Lymphadenopathy (where )
Rectal exam
Prostate exam
GENITOURINARY (FEMALE)

Inspect entire pubic area. note lesions, masses, edema, erythema, ecchymosis,
excoriation, lichenification, discharge, drainage.

Palpate entire pubic area for tenderness, masses, nodules, cysts,

lymphadenopathy.

RELAVENT FINDINGS

Cervical Motion Tenderness (PID)

Discharge/drainage (color, amt, type)
Rectal
Ectopic, ovarian cyst, endometriosis
Uterine masses, tenderness
Vaginal/introitus condition
Lesion, rashes, erythema, edema
Abortion, miscarriage
STD workup, herpes titer and hepatitis screen.
LOW BACK/HIP EXAM WITH NEURO

Be familiar with all landmarks: iliac crest, ant/posterior iliac spines, sacrum,
lumbars, coccyx, paraspinals, latissimus dorsi, greater trochanter, Sacral-iliac
junction, Sciatic notch.

RELAVENT FINDINGS

Edema, ecchymosis, erythema

Deformity, spasms (where)
Lordosis, scoliosis
Tenderness (where )
Hoovers, Milgrams test
Rectal Exam
Valsalva, (intrathecal pressure)
Kernigs test
Pelvic Rock (Sacroiliac)
Trendelenburg test (hip)
Ober's Test
Range of Motion, Muscle strength
Babinski

Distraction Maneuvers
Sitting Straight Leg Raises
Axial Compression
Light touch

NEURO CHECK L4, L5, S1

L4
Motor- Inversion of foot
Sensory- Medial aspect of foot/calf
Reflex- Patellar

L5
Motor- Dorsiflexion of big toe
Sensory- Dorsum of foot and lateral calf
Reflex- None
S1
Motor- Eversion of foot
Sensory- Lateral aspect foot and sole
Reflex- Achilles

S5- Sphincter tone

KNEE

Observe patient presentation, consider mechanism of injury. Palpate all

landmarks. Consider hip, ankle involvement. Do neurovascular check (L3, L4,
L5, S1, S2). Consider Sensory Specific testing.

RELAVENT FINDINGS

Edema, erythema, ecchymosis, effusion

Deformity, stability, masses, tenderness
Valgus (med collateral)
Varus (lat collateral)
Anterior drawer (anterior cruciate)
Posterior drawer (posterior cruciate)
Lachman's (ACL)
Posterior Sag (PCL)
Apley's compression (meniscus)
Apley's distraction (collaterals)
McMurray's, (meniscus)
Patellar grind (PFS, CMP)
Tinel sign
ROM, muscle Strength (active/passive)
Neurovascular check (L4, L5, S1), sensory specific.

IF no history of direct trauma, consider OVERUSE conditions.

tendonitis
Shinsplints
Stress fracture
PFS/CMP
Osgood Schlatter's
Bursitis (inflammatory, septic)
ANKLE/FOOT

Observe patient presentation, consider mechanism of injury. Palpate all

landmarks. Consider knee, hip, back involvement. Do neurovascular check
( L4, L5, S1). Consider Sensory Specific testing.

Inspect and Palpate all landmarks

RELAVENT FINDINGS

Edema, ecchymosis, erythema, effusion

Lesions, rashes, masses, nodules.
Deformity, tenderness, crepitus (where )
Neurovascular ( L4, L5, S1 ), sensory specific
Stability (ATFL, PTFL, deltoid ligament)
Talar rock, ant drawer
Metatarsal squeeze (morton's neuroma)
Plantar fascia
Squeeze test (Achilles)
Homan's Test (DVT)
ROM, muscle Strength (active/passive)
Bursitis, (inflammatory, septic)

SHOULDER EXAM WITH NEURO

Observe patient presentation, consider mechanism of injury . Palpate all

landmarks. Consider neck, elbow involvement. Do neurovascular check ( C5,
C6, C7, C8, T1, T2). Consider Sensory Specific testing.

RELAVENT FINDINGS

Edema, erythema, ecchymosis, effusion

Deformity, tenderness (where )
Drop arm test (rotator cuff)
Apprehension Test (shoulder stability)
Apley's Scratch test
Winging
ROM, muscle strength (active/passive)
Bursitis (inflammatory, septic,)
Rhomboid vs trapezius spasm
 Shoulder Girdle, axilla, clavicle status
AC separation
Shoulder dislocation
Neurovascular check ( C5, C6, C7, C8, T1, T2).

SHOULDER NEURO EXAM

C5
Motor- Abduct Arm, Bicep flexion
Sensory- Lateral Arm (Axillary nerve)
Reflex- Bicep

C6
Motor- Wrist extension, Bicep flexion
Sensory- Lateral forearm/1st, 2nd digit (musculocutaneous nerve)
Reflex- Brachioradialis

C7
Motor- Wrist flexors, finger extensors, tricep ext.
Sensory- Middle finger
Reflex- Tricep

C8
Motor- Hand Intrinsics, finger flexors
Sensory- Medial forearm/4th and 5th digits (med antebrach cutaneous nerve)

T1-2
Motor- Hand intrinsics, finger abd/adduction
Sensory- Medial Arm ( med.brach cutaneous nerve)
ELBOW/HAND

Observe patient presentation, consider mechanism of injury. Palpate all

landmarks. Consider neck, Wrist involvement. Do neurovascular check ( C5,
C6, C7, C8, T1, T2). Consider Sensory Specific testing.

RELAVENT FINDINGS

Edema, erythema, ecchymosis, effusion

Deformity, nodules, tenderness (where )
Crepitus
Bursitis (inflammatory, septic)
ROM, muscle strength (active/passive)
Snuff box tenderness
Tenosynovitis (inflammatory, infectious)
Sprain, strain, overuse syndrome
Neurovascular check ( C5, C6, C7, C8, T1, T2).
Tendonitis
Flexor, extensor, collateral integrity
Fracture (volar plate, boxer's, bennett's, colle's, nightstick)
Cysts (ganglion)
NEURO/MENTAL STATUS EXAM

Do all 6 components:

1st- Mental Status Exam

Always check this on all patients: Observation is your best tool, These can be
assessed without provoking the pt. Observe the following:

Level of consciousness
Posture and motor activity
Dress, grooming and personal hygiene
Facial Expression, Speech and Language
Manner and affect Mood
Insight and judgement:
Thought content: Perceptions, interpretation of external stimulus.
Thought Process: Sequence, logic, coherence, relevance of thought.

If anything does not seem right in the routine MS exam then check these
cognitive Functions:

Test for memory (recent, remote)

Test for calculation ability
Test for orientation x3 (person, place, time)
Test for abstract thinking (proverbs, similarities)
Test for judgement
Test for general knowledge
Test constructional abilities
Test for new learning ability

2nd CEREBELLAR FUNCTIONS

1. Romberg
2. Pronator sign
3. Heel to toe walk
4. Heel to shin drag
5. Rapid alternating movements (RAM's)
- flipping hands on thighs
- index finger to thumb DIP
3rd MOTOR TESTING

Bilaterally check:
Cranial nerves III, IV, V, VI, VII, IX, X, XI, XII
C5 - T1
L4 - S1
Dermatomes

4th SENSORY TESTING

Bilaterally check:
Cranial nerves I, II V, VII, IX, X,
C5 - T1
L4 - S1
Dermatomes

Sensory specific tests

Sharp/dull
2 point discrimination
Temperature
Vibration
Pain
Light touch
Proprioception

5th REFLEX TESTING

Bilaterally check:

Cranial nerves V, IX, X,

Deep Tendon Reflexes:

C5 - Biceps
C6 - Brachioradialis
C7 - Triceps
L4 - Patellar
S1 - Achilles
Superficial reflexes:

Abdominal reflex - upper T7 - T10

- lower T10 - L1
Cremasteric reflex - L1, L2
Superficial Anal reflex - S2, S3, S4
Babinski sign- upper motor neuron lesion

6th CRANIAL NERVE EXAM

I- Olfactory
Sensory - smell
II- Optic
Sensory - Visual Acuity, Peripheral vision by confrontation.--
Fundoscopic
III- Oculomotor
Motor - EOM, accommodation.(lateral rectus, superior oblique)
IV- Trochlear
Motor - EOM (superior oblique)
V- Trigeminal
Motor- clench teeth (palpate)
Sensory- bilateral 3 sections of face
Reflex- corneal
VI- Abducens
Motor- EOM (lateral rectus)
VII Facial
Motor- raise eyebrow, frown, smile, puff cheeks, show teeth, shut eyes
tightly.
Sensory: taste to anterior of tongue
VIII Vestibulocochlear
Sensory- watch tick, rub fingers, weber, rinne.
IX/X Vagus/Glossopharyngeal
Motor- Listen to voice, say "AH"
Sensory- Taste to Posterior tongue
Reflex- gag
XI Spinal accessory
Motor- Turn head, Shrug shoulders
XII Hypoglossal
Motor- stick out tongue
 Mini-Mental Status Exam
TEST POINTS

Orientation
What is the year, day, month 3
Where are we: Province
Town
Hospital 4
Floor

Registration 3
Name 3 objects (can patient ID
them?)

Attention and Concentration

Serial sevens - start at 100 and count 5
back by 7's. 1 point for each correct
answer. Stop after 5
Can also spell WORLD backwards

Recall
Ask for your three objects to be 3
repeated. 1 point for each correct one.

Language
Name a pencil and a watch 2
Repeat the following:
No if=s, and= s or but= s 1
Follow a three stage command:
- take a paper in your right hand
- fold it in half, and put it on 3
- the floor

Read and obey the following:

- Close your eyes 1
- Write a sentence 1
- Copy design (use clock) 1
Total 30

ADULT HISTORY
GREET PATIENT - Observe for Gait, Alignment, Contour, Symmetry, Skin color
IDENTIFYING DATA
name age marital status race
sex DOB Ethnic origin religion
CHIEF COMPLAINT & duration

HISTORY OF PRESENT ILLNESS (HPI) or MAJOR ACTIVE PROBLEM (MAP)

O - onset (When, how, related factors) P - location of pain
L - location (where, pinpoint, general, radiates) Q - quality, quantity
D - duration (intermittent, constant, how long) R - radiation
C - character (quality, quantity, type) S - severity
A - aggravating factors (activities, position, etc) T - timing
R - relieving factors - aggravating / relieving factors
T - timings (when, how long, how often) - cause limitations,
Associated factors - change of routine
CURRENT MEDICATIONS (Rx & OTC)
ALLERGIES & manifestations
PAST MEDICAL HISTORY

Hospitalizations year treatment or operation

Operations diagnosis complications
Injuries doctor sequelae or disability
Adult illnesses hospital litigation
Childhood illnesses (esp rheumatic fever & rubella)
Ob-Gyn: ( ms x x ) , ( Gr , P , Ab , SB , LC , twins )
LMP or LNMP birth control
menstrual character VD or PID
regularity endometriosis
amount of flow douche
last Pap smear menopausal symptoms
Psychiatric
Recent international travel
Immunizations ( especially tetanus and influenza )
SOCIAL HISTORY
occupation diet smoking drugs homelife
education exercise alcohol sleep military
FAMILY HISTORY : children, siblings, parents, aunts / uncles
similar sx diabetes heart dz liver dz TB
HTN stroke lung dz kidney dz cancer
REVIEW OF SYSTEMS

Episodes of fevers, chills, sweats Episodes of weakness, malaise, fatigue

Weight gain or loss (usual weight)
Skin - changes, bruising, lesions, dry, oily, rashes, sores, lumps, moles, infections, tumors
Head - HA, injuries, loss of hair, color change, hair growth
Eyes - vision changes, redness, excessive tearing, dry, glasses, last refraction
Ears - Hearing, tinnitus, vertigo, discharge, earache, infection
Nose & sinuses - frequent colds, stuffiness, nose bleeds, sinus troubles, discharge
Mouth and throat - bleeding, sores, voice change, pain with swallowing
Neck - lumps, swollen glands, pain, stiffness
Breasts - lumps, pain, discharge, self examination
Cardio-vascular - palpitations, chest pain, murmors, varicose veins, angina
Respiratory - SOB, wheezing, coughing, chest pain, dyspnea, hemoptysis
GI - indigestion, ulcer, changes in BM, blood in stool, hemorrhoids, appetite, abd pain,
nausea, vomiting, constipation,
GU - frequency, urgency, nocturia, hematuria, pain, dysuria
Reproductive -
Female - Obs Hx - # of pregnancies, full term deliveries, abortions, complications,
infertility, libido, method of contraception used - pain, menstrual cycle, age at menarch,
frequency/duration of menses, LMP, abnormal menses, amount of bleeding, pruritis,
discharge, history of STD=s, age of menopause, menopausal symptoms, last PAP & results
Male - penile D/C, Pain, lesions, testicular pain, Hx of STD= s, sex problems, self exam
MSK - extremities & spine- injuries, deformities, muscle/joint stiffness, ROM
Peripheral vascular - leg cramps, vericose veins, blood clots, coldness
CNS - syncope, seizures, weakness, numbness, change in LOC, fainting, paralysis,
memory loss, cognition, behavior, tremors, tics, other involuntary movements, clumsiness,
vertigo, balance, coordination
Hematology - anemia, abnormal bleeding, bruising, past transfusions, blood products
Endocrine vascular - thyroid troubles, heat/cold intolerance, excessive sweating/thirst,
weight loss/gain
Psychiatric - Hx of depression, perceptions, social interactions
General demeanor
Dermatology Disorders and Examination

1.Techniques of exam
a. Inspect and palpate for:
1.vascularity, evidence of bleeding, or bruising
2.color
3.moisture, dryness, sweating, oiliness
4.use back of fingers to check temperature
5.texture
6.thickness
7.mobility and turgor

b. Observe any lesions of the skin for:

1.location and distribution
2.grouping and arrangement
3.types of lesions
4.note color of lesions

c. Inspect and palpate

1.nail beds of fingers and toes
2.the hair for quantity, distribution, texture

2.Common dermatological conditions

a. Contact dermatitis: a chronic or acute inflammation produced
by substances coming into contact with the skin.
Classic examples are poison ivy/poison oak.

1.Signs/symptoms
a.itching
b.scaling
c.rash
d.redness or swelling
e.generally discrete areas are affected, i.e. only those
that were in contact with irritant.
 2.Treatment
a.determine/eliminate causative agent
b.keep area clean and dry
c.antibiotics (if infection has developed)
d.hydrocortisone cream (HC) 1% TAM 0.1% BID on
affected area
e.refer to MO for severe or extensive cases
b. Acne: common inflammatory pilosebaceous disease
characterized by comedones, papules, pustules, inflamed
nodules, and pus (purulent) filled cyst.
1.Types
a. comedones: 2 types
open: black heads
closed: white heads
2.Signs/symptoms
a.Inflamed pustules
b.Superficial cysts and pustules
c.Commonly on face, neck, chest, back, and
shoulders

3.Treatment
a.Wash face with mild soap with warm water
(recommend Dove soap)
b.5-10% benzoyl peroxide applied in the morning
after washing
c.T-stat pads (E-mycin 2% topical) bid after
washing.
d.Retin-A cream (for dry skin) or gel (for oily skin)
0.025% applied qhr after washing
e.Tetracycline 500mg qid or E-mycin 500mg bid (in
severe or refractory cases).
f.If not responsive, consult with MO regarding
Dermatology consult for Accutane therapy.
 c.Urticaria (hives)
1.Signs/symptoms
a.pruritus
b.wheals
c.erythema and edema
d.angioedema - diffuse swelling of loose
subcutaneous tissue
NOTE: Edema of upper airway may produce respiratory
distress.

2.Treatment
a.Remove offending agent if possible (May be
difficult to detect)
b.Discontinue all non-essential meds
c.Oral antihistamine - Diphenhydramine HCL
(Benadryl) 50-100mg q4h or Atarax 25-50mg tid
to qid
d.For pharyngeal or laryngeal angioedema, give
Epinephrine 1:1000 0.3 ml SC and refer to MO or
ER STAT

d.Herpes Simplex: (cold sores) a recurrent viral infection

characterized by a sudden appearance of small vesicles
on base of the skin or mucous membranes, often around
the mouth. Generally Type I but can be Type II from
oral-genital sexual contact.
1.Signs/symptoms
a.Tenderness, pain, mild burning at the site,
headache, malaise, fever prior to eruptions.

b.Itching/tingling sensation
c.Grouped vesicles
d.Typically painful
e.Factors that precipitate lesions: sunburns, food
allergy, onset of menstruation, and disease that may
 produce a fever.

2.Treatment
a.Usually heal in 2-6 weeks
b.Use sunscreens
c.Systemic antibiotics
d.No corticosteroids
e.Drying lotions
f.Antivirals i.e. - Zovirax (Acyclovir) 200mg q4h
five times a day for 5d

e.Herpes Zoster (shingles): an acute viral infection of the

CNS characterized by vesicular eruptions and neuralgic
pain in areas supplied by peripheral sensory nerves
(dermatomes). Same virus that causes chickenpox. The pain
in Herpes Zoster may resemble abdominal disease,
pleurisy, MI, or migraine headaches depending on the
location of involved nerve. One attack usually confers
immunity. Must be seen by MO if on face

1.Signs/symptoms
a.4-5 days prior to eruption
1.Chills, fever, malaise, GI disturbances, and with
or without pain along site of eruption.
2.May have regional lymphadenopathy.

b.4-5 days
1.Characteristic crops or vesicles on an
erythematous base.
2.Involved zone is usually excessively sensitive to
stimuli.
3.Pain may be severe.
4.Vesicles begin to dry and scab on about 5th day.
5.Generally all are crusted and falling off in 2-3
weeks.
 2.Diagnosis
a.Difficult in pre-eruption stage.
b.Made readily after the vesicles appear.

3.Treatment
a.Zovirax 800mg q4h 5 times a day for 7-10 days
(Must be given at onset or will not be helpful).
b.Giving ASA with/without Codeine for pain
administration and corticosteroids may relieve pain in
severe cases.
c.Refer to MO.
f.Chicken pox (varicella)
1.Signs/symptoms
a.9 to 21 days after exposure and 2-3 days before
lesions appear, will have mild headache,
moderate fever, and malaise is present.
b.Itchy "teardrop" vesicle with red areolas.
c.Individual lesions progress from macule to papule
to vesicle with in 6-8 hrs.
d.Upper trunk is most frequent site affected.
e.Starts centrally and spreads distally.
f.Spread by airborne droplets.
g.Pneumonia is the most common serious
complication in adults.

2.Diagnosis
a.Rule out
1.Secondary syphilis (RPR)
2.Impetigo (C&S of lesion)
3.Infected eczema (history)
4.Insect bites (history)
5.Drug rashes (history)
6.Contact dermatitis (history)

3.Treatment
 a.Zovirax 800mg qid for 5 days
b.refer to MO
c.Isolate from people who have not been previously
exposed. (Will require convalescent leave if in
barracks).

g.Impetigo: a superficial skin infection caused by

staphylococcus or streptococcus infection

1.Signs/symptoms
a.arms, face, and legs are commonly affected areas.
b.May follow superficial trauma, break in skin,
pediculosis, scabies, fungal, dermatitis, or insect bites.
c.Lesions vary in size.
d.Lesions progress rapidly from maculopapule to
vesiculopustules or bullar to exudate. Lesions are
often crusted and honey colored.
e.Itching.

2.Treatment:
a.Dynapen (Dicloxacillin) 250mg or Kefelex
(Cephalexin) 250mg qid for 10days
b.Tap water compresses
c.Keep area clean and dry.
d.Topical antibiotic cream
e.treat underlying cause

h.Eczema is characterized as a dermatitis commonly

located to the legs, arms, and hands. Presents as dry,
"cracked", fissured skin. (More common in older
persons). Can be a genetic tendency for dry skin.

1.Signs/symptoms
a.Dry/cracked skin with red fissures and sometimes
lichenification.
 b.Pruritus (burning sensation)
c.Often a history of too frequent bathing in hot,
soapy baths/showers.
d.Diffuse skin involvement without identifiable
borders.
e.Distribution is generalized.
f.Itching

2.Treatment
a.Increase contact with humidified air (above 50%).
Room humidifiers in the bedroom are helpful.
b.Tepid water baths with bath oils and immediate
liberal application of emollient ointments.
c.HC 1% AAA qid until resolved.
d.topical applications of alpha-hydroxy acids, such
as glycolic acid and lactic acid are effective.

i.Furuncles and carbuncles

1.Definition
a.Furuncles: (abcess or boil) are acute, tender
perifollicular inflammatory nodules caused by staphylococci.
b.Carbuncles: a group of furuncles, often extensive,
local sloughing with slow healing.

2.Location
a.Furuncle - neck, face, breast, buttocks
b.Carbuncle- neck, back or trunk, thighs

3.Treatment
a.Treat with intermittent moist heat soaks. Allow to
come to head and drain. Extensive incision may
spread the infection.

b.For the nose or central facial area, it should be

treated with systemic antibiotics.

c.For multiple carbuncles and furuncles, treat same

as "b"

j.Cellulitis: an acute inflammation within the soft tissue

characterized by hyperemia, leukocytic infiltration and
edema.
1.Signs/symptoms
a.Skin temperature is hot.
b.red and edematous
c.lymphangitis (streaking) and lymphadenopathy

2.Diagnosis depends on clinical findings

3.Treatment
a.Dicloxacillin 250mg qid or a cephalosporin orally
b.Rocephin 1gm IM when first seen.
c.Rest and elevate affected part
d.Moist heat
e.Refer to MO
f.Possible admission to hospital.
g.Outline area in pen to determine
progression/regression during follow up.

k.Lymphangitis: an acute inflammation of the lymphatic

channels
1.Signs/symptoms
a.Red streaks, tender and irregular, develop and
extend proximally.
b.Regional lymph nodes are enlarged and tender.
c.cFever, chills, tachycardia, headache, and
leukocytosis

2.Diagnosis
 a.Red irregular streaks, extending toward regional
lymph nodes from peripheral lesion on an
extremity indicates lymphangitis.

3.Treatment
a.Refer to MO

l.Lymphadenitis: inflammation of a lymph node.

1.signs/symptoms
a.may be asymptomatic or may have pain and
tenderness
b.abscess may be present
c.ask about weight loss/night sweats
d.if positive refer to MO

2.diagnosis
a.lymphadenitis and its cause is usually apparent
b.if multiple sites, refer to MO

3.treatment
a.treat underlying cause
b.hot/wet applications
c.abscesses require surgical drainage
d.RTC in 24 hrs for F/U

m.Warts (verrucae) are a common contagious, benign

epithelial tumor caused by papovirus

1.signs/symptoms
a.sharply demarcated
b.rough surfaced
c.round or irregular
d.firm, light gray, yellow, brown, grayish black
tumors 2-10mm in diameter.
e.appears on fingers, elbows, knees, face, scalp
 2.diagnosis by appearance
3.treatment
a.refer to derm clinic or consult with MO
n.Pityriasis Rosea: a self limited, mild inflammatory skin
disease characterized by scaly lesions, occurs at any age,
unknown infectious agent.

1.signs/symptoms
a.herald or mother patch found on trunk 2-10cm in
size
b.patch usually proceeds full rash and is usually
missed
c.erythematous, rose or fawn colored
d.scaly
e.resembles ringworm
f.may itch, Christmas tree pattern

2.diagnosis
a.clinically with woods lamp (cobalt blue)
b.must be able to differentiate from the following
psoriasis
secondary syphilis
c.If unsure, refer to MO.

3.treatment
a.no specific treatment; remission occurs within 4-5
weeks
b.reassure patient
c.oral antihistamines and a topical corticosteroid
d.If patient has severe itch, may give Prednisone
10mg qid until itching subsides then decrease over a
14 day period (can also give 3-5 day burst)

o.Pediculosis: (capitis, corpus, pubis) is an infestation by

lice
 1.signs/symptoms/diagnosis
a.capitis
itching or scaly
check for nits to hair shaft (ie. eggs)
cannot be dislodged, unlike scales

b.corpus
uncommon under good hygiene
nits found in body hair
body louse inhabit seams of clothing worn next
to skin
itching
lesions are common on the shoulders, buttocks,
and abdomen

c.pubis
infests over anogenital region
OVA are attached to skin at base of hairs
scattering of minute specks
sometimes seen as bluish spots on the skin

2.treatment
a.wash and dry affected areas
b.1% gamma benzene hexachloride shampoo (kwell)
apply to affected areas. Apply only to dry hair,
and work well into the affected areas. Leave on for
4 minutes. Apply some water and work into
lather. Rinse all lather away.
c.reevaluate in 7 days
d.dead nits must be combed from hair
e.decontaminate combs, clothing, bedding, etc by
washing at 140F

p.Scabies: a parasitic skin infection characterized by

superficial burrows, intense pruritis and secondary
 inflammation seen as fine wavy dark lines.

1.signs/symptoms/diagnosis
a.pruritis marked, intense at bedtime
b.lesions are the burrows
c.lesions occur predominantly on the following
finger webs
flexor surface of the wrist
elbows
axillary folds
areola of the breast
along beltline and the lower buttocks
d.burrows may be hard to find due to scratching
and/or secondary lesions

2.treatment
a.Kwell lotion or cream applied from tip of chin to
tip of toes. Leave on 12 hours and wash off.
Reevaluate in 12 weeks.

b.10% Crotamiton (Eurax) generally given to young

children or pregnant patients. Apply to whole
body from chin down. Repeat in 24 hrs. Wash off in
48 hours after last application.

q.Tineas (superficial fungal infections)

1.signs/symptoms
a.Capitis (head)
small grey patches with lusterless hairs
may involve all or part of the scalp

b.Cruris (jockitch)
severe itching
typically a half moon shaped plaque with well
defined scaling borders.
 c.Pedis (athletes foot): usually affects 4th and 5th toe
spreading to plantar area. Lesions appear as
macerated areas with scaling borders.

d.Corporis (ring worm): lesions with borders spread

peripherally and clear centrally. Typical scaly
borders
2.Diagnosis confirmed by KOH or culture.
3.Treatment
a.antifungal creams/lotions for 3-4 weeks
b.Refer to MO in severe cases for possible
Griseofulvin or Ketoconazole therapy.
c.Tinea capitis does not respond well to topical
treatment.

r.Tinea versicolor: an infection characterized by multiple

usually asymptomatic patches of lesions varying in color
from white to brown.

1.signs/symptoms/diagnosis
a.tan, brown, white, slightly scaling lesions seen on
neck, chest, abdomen
b.areas do not tan
c.wood light exam

2.treatment
a.Selenium Sulfide (Selsun shampoo): use for one
week at bed time like a lotion, then wash off in
AM. Continue weekly applications afterwards,
applying in shower and washing off after 10
minutes.
b.Watch for skin irritation
c.Advise patient that recurrence is likely and it
doesn’t need to be treated unless patient desires it.
 s.PFB (pseudo folliculitis barbae)
1.signs/symptoms/diagnosis
a.Ingrown hairs resulting in papules, usually on
upper neck.
2.Treat in accordance with Navy or USMC PFB
program.
3.Retin-A at bedtime, Vioform HC in AM, & Benzoyl
peroxide 5% in the AM.

t.Dyshydrosis (pompholyx)
1.signs & symptoms
a.Deep seated itchy vesicles on palms, sides of
fingers and soles. Unkown etiology.
2.Treatment
a.Topical corticosteroid cream tid
b.cold wet compress
c.oral E-mycin, refer to MO
CHAPTER 16

PHYSICAL
EXAMS
 HEAD and NECK

1 HEAD Inspect the hair and the scalp

Inspect the skin for:
Blemishes
Scars
Abnormalities in pigmentation
Bony palpation of the skull checking for:
Depressions
Masses
Deformities

2 EYES

Visual Acuity
Visual fields testing
Alignement
Extra Occular Movements
Compare Pupils:
Direct
Indirect
Consentual
Fundoscopy
Macula
Optic Disc
 Optic Nerve
Blood Vessels

3 EARS Inspection of Pinna

Hearing Test - Finger Rub
Audiometry
TM visualized with otoscope
Webber= s Test
Rinnes Test

4 NOSE Inspection of external contour:

AND Previous break
SINUSES Open wounds / sores
Visual exam of the turbinates, posterior nares, nasal passageway
Palpation and percussion of the sinuses:
Frontal
Maxillary
Transillumination

Inspect the teeth

5 MOUTH Stick out the tongue
AND Check tonsils for inflammation
PHARYN Check Uvula for movement
X Check Mucosa of the mouth
Check for gingivitis

6 NECK Inspect the throat for scars

Sternocledomastoid muscle
Thyroid cartilage
Crychoid cartilage
Swallowing
Trachea midline and palpated
Palpate lymph nodes

7 TEMPOR Inspect the joint

OMANDI Palpate for any deformities
BULAR Range of motion of the jaw
JOINT Open and close
Side to side
Any pain ?
TMJ Reflex:
 Slightly open jaw. Place thumb on mandibular
symphysis.
Lightly tap thumb with reflex hammer.

THORAX and LUNGS

1 PRESENTATION

Gait, Symmetry, Alignment, Contour, Skin

Color, respiratory rate, clubbing, paradoxical movements, retraction, melanomas,
scars, naevus

2 INSPECTION

Sternal Notch
Angle of Louis
Xiphoid Process
2nd Intercostal Space
Floating Ribs - 11th & 12th
Chondro / Sternal Joints
Costo / Chondral Joints
Spinous Process of C7 (Most prominent)
Inferior Angle of Scapula = T6 or 7th rib

Bony Have patient cross arms over chest

Landmarks Observe the shape of the chest.
Is there any abnormal retraction or impairment of movements.
Is there any deformity or asymmetry, cervical lordosis,
thoracic keyphosis, lumbar lordosis

Posterior Chest Inspect the neck for retraction

Observe the shape of the chest for deformity or asymmetry:
Scapular line Barrel chest
Vertebral line Funnel chest
Pigeon chest
Listen to the patient=s breathing
 Observe the frequency, depth, rate, and the rhythm
Observe chest movements: muscle retraction, muscle
bulging, asymmetry
Observe the abdominal wall

Anterior Chest
Midsternal line

Midclavicular
line

Breathing Bradypnea = slow <12 (CNS Depression, O2 toxicity)

Patterns Tachypnea = Rapid, shallow
Hyperventillation = Rapid, moderate to deep
ACheynes-Stokes@ = Irregular, starts slowly, progresses from
shallow to hyperventilation, stops for about 5-10 sec (apnoea)
starts over again.
Kussmall = Regular, deep, laborious, >20
Sighing = Periodical deep inspiration

3 PALPATION Tenderness, Masses, fractured ribs, lymph nodes

Identification Tracheal deviation

of tender
areas

Assessment Place your thumbs along each costal margin, your hand along
of the lateral rib cage. Slide your hands to raise a loose skin fold
abnormalities between your thumbs. Watch for divergence and feel for the
range and symmetry of respiratory movements.

Assessment Place your thumbs at the level of the 10th ribs.

of respiratory
expansion

Respiratory (ninety-nine) Palpate and compare symmetrical areas. Compare

excursion sides.

Use stethescope and hands (use volar side of hands to feel

vibrations)

Results:
Decreased - Soft voice, obstructed bronchus,
 Increased pleural space = air, fluid, blood, tumor
Increased - Lung consolidation = tumor, abscess, pneumonia
Larger than normal bronchi

DO NOT perform over the scapula.

Ensure patient=s arms are crossed over chest

Assessment
of tactile Cervical and axillary
fremitus

Lymph
Nodes

4 PERCUSSION

(While the patient keeps

both arms crossed in
front of the chest)
Tap the middle finger of
the dominant hand onto
middle finger of
opposite hand.
Finger firmly pressed
against thoracic surface.
The tapping motion is In symmetrical locations (always compare both sides
from the wrist only. up and down)

Characteristics:
Flat = Over muscles
Dull = Over liver, heart, consolidated lung tissue
Resonant = Over normal lung tissue
Hyperresonnant = Over emphysema & pneumothorax
Tympany = Over stomach

The Aheart dullness@ extends from the right border

of the sternum to 7-9cm from Mid-Sternal line.

Identify, describe and localize any area of abnormal

percussion note.

Identify the level of diaphragmatic dullness. (For

 pleural effusion or diaphragmatic paralysis)

Diaphragmatic excursion may be estimated by noting

the distance between the levels of dullness on full
expiration and full inspiration. (Normally 5 - 6 cm)

Percuss

5 AUSCULTATION

Over trachea - very loud

Longer and louder on expiration
Equal on inspiration and expiration
Longer on inspiration

Compare symmetrical areas of the lungs from above

down.
(From the apex to the lung base)

Early inspiratory = severe airway obstruction. NOT

modified by cough. (COPD, asthma, emphysema)
Late inspiratory - more peripheral airways. Restrictive
pulmonary diseases. (Pneumonia, CHF, sarcoidosis,
asbestosis, interstitial fibrosis)

Fine crackles on ispiration. Clears with coughing. (Main

bronchi) (CHF, Pneumonia, interstitial fibrosis)

Sibilant = high pitch

Sonorous = low pitch (COPD, asthma, emphysema)

From inflammed pleural surfaces rubbing against one

another

Bronchophony - increased voice sounds

Egophony - same with nasal breathing

Pectoriloquy - clear transmission of whispered voice

Absence with hemopthorax or pneumothorax.

Trachea sounds Ninety-nine - normally the sounds transmitted through the
Bronchial sounds chest wall are muffeled and indistinct
Bronch-vesicular
sounds
Vesicular sounds

Rales or Crackles

Rhonchus

Wheeze or
Rhonchus

Pleural Friction Rub

Sounds Associated
with Consolidation

Transmitted voice Inspect the neck for retraction

sounds Observe the shape of the chest for deformity or
asymmetry:
Barrel chest
Funnel chest
Pigeon chest
Listen to the patient=s breathing
Observe the frequency, depth, rate, and the rhythm
Is there any Bradypnea, Tachypnea, Hyperventillation,
Cheynes-Stokes
Observe chest movements: muscle retraction, muscle
bulging, asymmetry
Observe the abdominal wall

Anterior Chest
Midsternal line

Midclavicular line
The aortic area is the right 2nd interpace close to the sternum.

The pulmonic area is the left 2nd interspace close to the sternum.

Thest two area together are sometimes called the base of the heart.

Aortic-------------> 0 0 <----------Pulmonic

Tricuspid ----------------> 0 0 <-------Apex

Tricuspid area is left 5th interspace close to the sternum.

Mitral (or apical) area is the 5th interspace just medial to the
mid-clavicular line.

Auscultation

S2 is best heard in the Aortic area

S1 is best heard in the Apex Area

A murmur may be heard over all heart areas when present.

 SHOULDER

1 INSPECTION Gait, Symmetry, Alignment, Contour, Skin

Swinging of arms, Atrophy, Signs of distress

2 PALPATION

Bony Strenal Notch

Landmarks Sternoclavicular Joint, Clavicle
and Cartilage Acromion, AcromioClavicular Joint
Coracoid Process (moving the arm helps
finding it)
Greater Humeral Tuberosity
Scapula (superior , inferior poles)
Bicipital Grove
Humerus

Soft Tissues Bursa: Subdeltoid

Subacromion

Muscles (6) Pectoralis Major

Latissimus Dorsi
Deltoid
Trapezius
Sternocledomastoid
Rhomboid

Tendons: Supraspinatus ROTATOR

CUFF
Infraspinatus
Teres Minor
Subscapularis
Bicipital Tendon
(rotate humerus, palpate over
bicipital Αgrove≅
Ligament: Capsule

Axilla: Lymph nodes, Ribs, Serratus

Muscle, Artery

3 RANGE OF MOTION

Active (Evaluate: Abduction and External Rotation

pain, smooth APLEY SCRATCH TEST
movements, (hand over and behind occiput to the
crepitation, real scapula)
ROM)
 Adduction and Internal Rotation
(Hand over opposite shoulder)
(Hand over back pocket)
(Hands over back)

Isolated Active Ranges o

Abduction (True = 30 ) Middle
(With scapula = 120o) Deltoid
Supraspintus
Serratus
Adduction (45o)
(Hand over opposite shoulder)
Pectoralis
Major
Latissimus
Dorsai
External Rotation (45o
) Teres Major
(Keep elbow at 90o) Anterior
Deltoid

Infraspinatus
Internal Rotation (55oo) Teres Major
(Keep elbow at 90 ) Post Deltoid

Subscapular
Flexion (True = 90o) Pectoralis
Major
(With scapula 180o ) (Keep elbow Latissimus
extended) Dorsi
Teres Major

Anterior
Extension (45o) Deltoid
(Keep elbow extended) Coracobrach
ialis
Pectoralis
Major
Biceps

Latissimus
Α Shoulder Shrug≅ Dorsi
Teres Major
Teres Minor
Post Deltoid
Triceps

Trapezius
Levator
Scapulae
Rhomboid(s
)

Passive (evaluate PAIN INHIBITION

carefully) MUSCLE WEAKNESS
SOFT TISSUE IMPINGEMENT
SOFT TISSUE CONTRACTURE
BONY BLOCKAGE
ANKYLOSIS / FUSION
 Shoulder

Abduction
(immobilize scapula or Hand over
shoulder)
Rotation o
(Elbow 90 ) (Shoulder 0o and 90o)
Adductiono
(Elbow 90 ) (From and to abducted
position)
Flexion / Extensiono
(True Flexion = 90 Extension = 45o )
(Hand over shoulder to assess true
range)

Scapula

Retraction
(Position = Α attention≅ , apply anterior
rotation)
Scapular Protraction Α Winging of the
Scapula≅ (Serratus)

4 NEUROLOGICAL EXAMINATION

Sensory (Dermatomes) (7)

Lateral Arm C5
Medial Arm T1
Axilla T2
Axilla to nipple T3
Nipple (approx) T4/T5
Thumb, Lateral forearm C6
Middle Finger C7
Medial hand 4,5 fingers C8

Motor Same as active but with resistance

DTR Biceps C5
Triceps C6
Brachioradialis C7

5 VASCULAR

Skin Color
Hair Growth
Pulsating Masses
Capillary Refill
Peripheral Pulses (Bilat)
Axillary
Brachialis
Radialis
 Ulnar

6 SPECIAL TESTS

Impingement Syndrome Test (Watch for circumduction to

achieve straight arm raise.)

Supraspinatus Tendonitis (Flex shoulder = 90o, adduct

10Ε , internally rotate thumb down for pain)

Bicipital Tendonitis - Α Straight Arm Raising Test≅

(Palpate the tendon over bicipital grove for localized
tenderness)
(Resisted supination, induces more pain/tenderness over the
bicipital groove)

Yergason Test (Rotate the humerus, and assess the bicipital

grove for any displacement of the bicipital tendon from it)

Rotator Cuff Tear - Drop Arm Test

(Abduct the arm = 90o, with external rotation)
(Test weakness against gravity and opposition)

Shoulder Instability (Luxation)

Anterior: Apprehension test - Elbow 90o, Abduct 45o , 90o

, 135o, Apply external rotation
Posterior: Internal Instability - Standing, pull downward on
both arms.

7 RELATED AREAS Myocardial Infarction

Diaphragmatic Irritation
Cervical Pathology
 ABDOMINAL EXAM

1 PRESENTATION

Gait, Symmetry, Alignment, Contour, Skin, Posture, Splinting, Leaning Over

2 VITAL SIGNS

Ensure the patient has an empty bladder prior to the examination.

Place patient in the supine position with his arms by his sides.
If the abdomen is too tense, place a pillow under his knees.
With trauma patients you may have to catheterize the bladder in order to
complete the examination.

3 INSPECTION

Colour Vascular pattern, rashes, striae, linea nigra

Contour Distention (localized and generalized)

Skin Scars

Movements Peristalsis, Pulsations

Bulging Masses, air distention, tumour, bladder, hernia

Anatomy Locate area

Bony Xiphoid process, costal margin, iliac crest, anterior superior

Landmarks iliac spine, symphysis pubis, pubic tubercles, posterior
superior iliac spine.

Umbilicus, inguinal ligament, rectus abdominous, linea

Soft Tissue Alba
femoral triangle and vessels (NAVEL)

4 AUSCULTATION

Auscultate all 4 Right upper quadrant

quadrants or 9 Left and Right Hypochondriac
regions. Left upper quadrant
Epigastric
 Right lower quadrant
Left and Right Lumbar
Left lower quadrant
Umbilical

Bowel Sounds Left and Right Iliac

Hypogastric (Suprapubic)
Vascular Sounds
Frequency = 5 to 35 / min
Spend 2 minutes on each quadrant
Have patient hold his breath. Diminished or absent
peristalsis may mean an ileus. An acute obstruction may
show high pitched tinkling. Peristalsis also diminishes
during the second half of pregnancy.

Bruits: Vascular sounds from the aorta or iliac arteries.

Also over the renal arteries in case of stenosis.

Hums: Low pitched sound of venous origin. Mostly over

the epigastrium or umbilical area.

5 PERCUSSION

Percuss All 4 quadrants over the entire abdomen.

Start away from the painful area and move toward the
painful area
Evaluate Air distention (Tympany)
Presence of free fluid (Dullness)
Proceed with Percussion of major organs

Liver: 6 - 12cm dimension

Start below the umbilicus and percuss upwards following
the mid-clavicular line, then down from above. Make a
line over both spots and measure between them. False
impressions may be produced by right pleural effusion, or
gas in the colon that overlies the liver.

Stomach: The normal percussion is tympany. Maximum

intensity at the ribcage. Increased tympany is found in
shock, post burn period, also associated with pain and
apprehension where air is Α swallowed≅ . It is usually
indicative of an acute abdominal inflammatory process.

Spleen: A small area of dullness is often found over the

10th rib area just anteriorly to mid-axillary line. The
spleen must be looked for in all children as it is often
symptomatic with disorders involving the immune system.
(Infectious mononucleosis, leukaemia)

6 PALPATION

Warm your hands and watch the patient= s face as you

examine the tender area LAST.

This is done in 2 stages: Light Palpation Deep

Palpation
 Light Palpation Light palpation increases patient co-operation and ensures
maximum relaxation. Identify tenderness and muscle
resistance. Ask yourself Α is the tenderness localized of
generalized≅ Α Is the resistance voluntary or
involuntary≅
Deep Palpation Then assess organs, masses, deep seated painful areas,
conditions and peritoneal irritation. Use the pads of your
fingers. One hand is in contact with the abdomen, the
other hand is often used over that hand so one hand feels
while the other directs movement and pressure.

Assess Shape, pulsation, size, tenderness, consistency

Liver: under 11th / 12th ribs in the right upper quadrant

Gallbladder: Palpate below the liver margin, close to the

lateral border of the right Rectus Abdominous muscle
(Murphy= s Point) Localized tenderness usually indicates
an inflammatory process.

Spleen: Have the patient roll onto his side. Look for the
spleen sliding over your fingers. A large spleen is called
Splenomegaly. The condition is called hypersplenism in
the cases of lymphoma, leukaemia, infection (acute or
chronic), cirrhosis.

Kidneys: Both the kidneys are examined from the right

side. The kidney may be felt as you press down (Enlarged
kidney = tumour, hydronephrosis)

Costro Vertebral Angle: Punch

Aorta: Press smoothly over the lower epigastric area just

left of the midline, then feel very gently for lateral
pulsation, using both hands to ensure a more controlled
manoeuvre. Then feel very gently for lateral pulsation
(expansible) associated with aneurysm. (2.5 cm diameter)

7 SPECIAL TESTS

Rebound To identify inflammatory process of the parietal or visceral

Tenderness peritoneum. The sudden release induces a sudden
movement of the intestinal structures.

Psoas Sign Place one hand over the patient= s thigh and ask him to
flex the hip against resistance. (Right leg for appendicitis
and other pelvic inflammatory processes = PID, ovarian
condition) (Left leg for pelvic inflammatory processes)

Flex the patient= s thigh at the hip, knee bent, and resist
abduction of the thigh.
Obturator Sign You are actually resisting the Obturator muscle, and
increasing its volume and stretching the peritoneum.

Shifting dullness. Percuss over one flank and proceed

anteriorly until dullness changes to resonance. Then have
patient turn over onto that side. Proceed with the same
Ascites percussion and evaluate any change of the level of change
Assessment dullness/resonance, which would refer to the fluid level.
 Abdominal fluid wave. Have the patient indent his
abdomen over the midline with one hand. Tap or press on
one side while your other hand rests on the other side of
the abdomen. If fluid is present your Α Other≅ hand will
feel the wave reaching across the abdomen.

Over 40 + AND in acute abdominal conditions

Rectal
Examination
 ELBOW

1 INSPECTION Gait, Symmetry, Alignment, Contour, Skin

Normal exam = slight flexion, slight valgus.
(Women = 10-15o) Bursa, bony irregularities
2 PALPATION
Bony Lateral Epicondyle
Landmarks Lateral Supracondylar Ridge
Radial Head (Pronation-Supination)
Proximal Ulna = Olecranon
Medial Epicondyle
Medial Supracondylaar Ridge
Soft Tissues Antecubital Fossa
Biceps Tendon
Brachial Artery
Ulnar Nerve (Medial)
Medial Collateral Ligament
 Common Flexors:
Brachio-Radialis
Flex Carpi Radialis
Palmaris Longus
Flex Carpi Ulnaris
(Pronator Teres)
Supracondular Lymph Nodes
Olecranon Fossa
Olecranon Bursa
Triceps Tendon
Lateral Muscle Mass
Ext Carpi Radialis Longus + Brevis
Annular Lig (head of Radius)
3 RANGE OF MOTION
Active Flexion 135o - 150o
Extension 0o 0- 5o 0 (Women -5o )
Pronation 85 -90
Supination 90o
Passive Same movements as active

4 NEUROLOGICAL EXAMINATION
Sensory , Dermatomes C5, C6, C7, C8, T1, T2
Motor , As per active but against resistance
Deep Tendon Biceps, Triceps, Brachioradialis
Reflexes
5 VASCULAR
Skin Color
Hair Growth
Pulsating Masses
Pulses
Capillary Refill
6 SPECIAL TESTS
Ligamentous Stability - Colateral Ligament (Test Varus, Valgus)

wrist) Epicondylitis - Α Tennis Elbow≅

Lateral (Tight fist, resist forced Ext of

Medial Epicondylitis - Α Golfer= s Elbow≅ (Resist forced Flex of Wrist)

Ulnar - Cubital Tunnel - Α Tinel Test≅

fossa) Nerve (Tap against the nerve in the
(Neuroma,
 HAND & WRIST

1 INSPECTION Gait, Alignment, Contour, Skin, Symmetry

Observe mvts = picking, grasping, writing, tapping
 Observe joints = dorsal aspect of hand, palmar aspect of hand
“THENAR” prominence & “HYPOTHENAR” prominence

2 PALPATION

Bony Landmarks Ulnar Styloid Process

Radial Styloid Process
Lister’s Tubercle / Radius
Carpal Bones
Scaphoid – Distal to Radius
Triquetrium (Pisiform) – Distal to Ulna
Lunate – In Betweenst
Trapezium – Over 1nd Metacarpal
Trapezoid – Overrd2 Metacarpal
Capitate – Over 3 Metacarpal
Metacarpal Phalangeal = MCP
Interphalangeal – Proximal = PIP & Distal = DIP joints

Soft Tissues Tendons:

Extensor Policis Brevis & Longus = SNUFF BOX
(De Quervain Tensynovitis)
Flex Carpi Radialis
Flex Carpi Ulnaris
(Palmaris Longus – Absent in 7% of population)

Tunnels: (Dorsal 6)
1st – Ext Pol Br, Abd Pol Lg
2nd – Ext Carpi Radialis Lg + Br (Lister’s Tubercle)
3rd – Ext Pol Lg
4th – Ext Digitorium Communis
Ext Indicis Proprius
5th – Ext Digitorum Minimi
6th Ext Carpi Ulnari

(Volar – 2)
1st – Tunnel of Guyon – Ulnar nerve and artery
2nd – Carpal Tunnel – Median Nerve – Flexors

Synovial sheets (Around Flexors in Volar region) =

**SURGICAL NO MANS LAND**

Thenar Eminence
Abd Policis Br
Opponens Policis
Flex Policis Br

Hypothenar Eminence
 Abd Digitorum Minimi
Flex Digitorum Minimi
Opponens Digitorum Minimi

Palmar Aponeurosis (DUPUYTREN’S CONTRACTURE)

Synovium at finger joints (Effusion)

3 RANGE OF MOTION

Active
Wrist
Flexion 80°
Extension 70°
Radial Deviation 20°
Ulnar Deviation 30°
Pronation 85° - 90°
Supination 90° - 95°

Fingers
MCP PIP DIP

Flexion -10° -90° 0 - 110° -10° - +80°

Extension “ “ “

Abduction
Adduction
Opposition of thumb
PIP an DIP
Flexion
Extension

Thumb
MCP (Metacarpal Phalanges)
Palmar Abduction 70°
Palmar Adduction 0°
Extension 50°
PIP
Flexion 50°

DIP
Flexion 90°
Opposition (with each finger)
 Passive
Same Range

4 NEUROLOGICAL EXAMINATION

Sensory Median Nerve C6

Ulnar Nerve C7
Radial Nerve C8

Motor WRIST
Extension Root Nerve Nerve
Ext Radialis Lg & Br C6, C7, C8 Radial
Ext Carpi Ulnaris

Flexion
Flex Carpi Radialis C6, C7 Median
Flex Carpi Ulnaris C8, T1 Ulnar

FINGERS
Extension
Ext Dig Communis C6, C7, C8 Radial
Ext Indicis Proprius
Ext Digiti Minimi

Flexion (Each MCP, PIP, DIP)

Flex Dig Suprficialis = PIP C7, T1 Radial
Flex Dig Profundus = DIP C7, T1 Median

THUMB
Extension
Ext Poll Br = MCP C6, C7 Radial
Ext Poll Lg = PIP C7, T1 Radial

Flexion

Flex Poll Br = MCP C7, T1 Median

Flex Poll Lg = PIP C7, T1 Median

Thenar Eminence
Abd Poll Br Median
Flex Poll Br Median
 Opponens Poll Median
Adduct Poll (Froment’s Sign)

Hypothenar Emminence
Abd Digit Minimi Median
Flex Digit Minimi Median
Opponens Digit Minimi Median

Intrinsic Muscles
Lumbricals
Interossei: Dorsal + Palmar

Pinch Test

Grasp Strength

Brachioradialis C6

Deep Tendon
Reflexes

5
VASCULAR

Radial A. PLS} Skin

Ulnar A. PLS } Capillary Filling

ALLEN TEST – Clench fist, Press both arteries.

Release one at a time

“Modified ALLEN Test: : for each finger

6
SPECIAL TESTS

Tinel Sign
Tap over with medius finger or reflex hammer

Phalen’s Test
Flex wrist at 90° for 60 sec, observe distal parasthesia

DE QUERVAIN TENOSYNOVITIS
 Finklestein’s Test – Oppose Ext of thumb and Lat Deviation of wrist = PAIN

HIP

1 INSPECTION Gait, Symmetry, Alignment, Contour, Skin

Deformity, discoloration, swelling, pelvic tilt, lordosis

2 PALPATION

Bony Landmarks Iliac Crest L4 - L5

Anterior Superior Iliac Spine
Posterior Superior Iliac Spine S2
Symphysis Pubis
Illiac Tuberosities
Pubic Tubercle
Ischial Tuberosity
Greater Trochanter of Femur

Soft Tissues Trochanteric Bursa

Ischial Bursa
Gluteus Maximus Gluteus Medius Gluteus Minimus
Sciatic Nerve
Femoral Triangle - Inguinal Ligament
Adductor Longus
Sartorius
NAVEL - Nerve, Artery, Vein, Empty space,
Lymph nodes

3 RANGE OF
MOTION

Active Abduction (Supine) 45

Adduction 20
Flexion 135
Rotation - Internal 35
External 45
Extension

Flexion-Adduction (have thigh cross over)

Flexion-adduction-external rotation
(have heel over opposite knee)
Extension
(have patient rise from chair both arms crossed over
chest)

Passive (Supine) Flexion (keep one hand under pelvis, assess true ROM)
Abduction (Stabilize Pelvis)
Adduction (Abduct opposite leg)
Rotation in Extension (Supine or prone) Hip extended
Rotation in Flexion (Supine or sitting) Hip flexed at
 90Ε

4 NEUROLOGICAL EXAMINATION

Motor As per Active

Sensory L1, L2, L3, L4, L5, S1

Deep Tendon Achilles Tendon Reflex

Reflexes Patellar Reflex

5 VASCULAR

Pulses, Cap Femoral pulse

Refill, Pulsating Popliteal pulse
masses, Hair Dorsalis Pedis pulse
growth Posterior Tibialis pulse
Capillary refill in toes

6 SPECIAL TESTS

Trendelenburg Pelvic Tilt - Have Patient standing on one leg.

Test
For flexion deformity - Supine with one hand under
Thomas Test pelvis. Flex both legs, extend one leg slowly, assess
any increase of lordosis.
Leg Length
Discrepancy True or apparent - Measure from anterior superior iliac
spine to medial malleolus. Then measure from
umbilicus to medial malleolus.
Ober Test
Abduct leg, flex knee 90Ε . Adduct leg, do the knees
touch.
 KNEE

1 INSPECTION Gait, Symmetry, Alignment, Contour, Skin

Observe Genu Varum (bowleg) Genu Valgus
(knock-kneed)

2 PALPATION

Bony Patella
Landmarks Femoral Condyles
Femoral Epicondyles
Fibular Head
Adductor Tubercle
Tibial Plateau
Tibial Tuberosity

Soft Tissues

Bursa Pre-Patellar bursa

Superficial infrapatellar
Deep infrapatellar
Pes Anserine
Baker= s Cyst (posterior fossa)

Ligaments Medial / Lateral collateral

Cruciate

Tendons Patellar (Osgood-Schlater syndrome)

Biceps Femoris (Lat)

Medial & Lateral

Meniscus
Quadriceps
Muscle
Common Peroneal (fibular neck)
Nerve
Popliteal (NAVEL)
Fossa

Medial
Jointline

3 RANGE OF MOTION
 Active Flexion
Extension

Passive Same as active

4 NEUROLOGICAL EXAMINATION

Sensory , L4, L5, S1

Deep Tendon Achilles Tendon Reflex

Reflexes Patellar Reflex

Motor Same as active but under resistance

5 VASCULAR

Skin Color
Hair Growth
Pulsating Masses
Pulses Femoral
Popliteal
Posterior Tibialis
Dorsalis Pedis
Capillary refill in toes

6 SPECIAL TESTS

Patellar Tap Test for major / minor effusion

Apprehension For patellar dislocation and subluxation

Test
Internal & external rotation on flexion / extension. Note
McMurray any audible or palpable click.

Compression and distraction. Meniscus vs Ligaments

Apley= s
Colateral Ligaments - Lateral ligament (varus stress)
Joint Stability Medial Ligament (valgus stress)
Cruciate Ligaments - Anterior drawer sign +
Lachman test - anterior cruciate
Posterior drawer sign / Sag sign -
posterior cruciate

Percuss the saphenous nerve over the bulbous end (medial

tibial tubercle)
Tinel Sign
 LUMBAR SPINE

1 INSPECTION Gait, Symmetry, Alignment,

Contour, Skin
Normal exam = Observe Cervical
Lardosis, Thoracic Kyphosis,
Lumbar Lordosis, Abdominal wall,
Pelvis.

2 PALPATION

Bony Landmarks Iliac Crest

Anterior Superior Iliac Spine
Posterior Superior Iliac Spine
Pubic Tubercle
Ischial Tuberosity
Greater Trochanter of Femur
Spinous Processes & Facets

Soft Tissues Interspinous ligaments

Supraspinous ligaments
Paraspinal Muscles
Abdominal Muscles
Gluteal Muscles
Sciatic Nerve

3 RANGE OF MOTION

Active Flexion
Extension
Lateral Bending
Rotation

4 NEUROLOGICAL EXAMINATION

Sensory , Deep Tendon Reflexes T12, L1, L2, L3, L4, L5, S1
 Achilles Tendon Reflex
Patellar Reflex

Superficial Reflexes Abdominal Reflex

Cremasteric Reflex

Motor Adduction & Abdiction of legs

Flexion & Extension of legs
Flexion & Extension of knees
Internal & External rotation of legs
(not feet)
Dorsi / Plantar flexion
Inversion / Eversion of ankles

5 VASCULAR

Skin color
Hair growth
Pulsating masses
Pulses Femoral
Popliteal
Posterior Tibialis
Dorsalis Pedis
Capillary refill in toes

6 SPECIAL TESTS

Pathological Reflexes Babinski Test

Oppenheim Test

Neuro segmental innervation Beevor= s sign

test
Kernig test
Meningeal irritation Brudzinski test

Shober (mark at S1-S2, mark 10cm

Evaluate mobility of lower back higher, have Pt bend over &
measure between marks. Normal is
16 - 20 cm.

Hoover test (8 9 )
Cooperation test Pelvic rock test
Patrick or Fabere test (triangle of
Tests to rock sacroiliac joint the hip)

Milgram test
Valsalva maneuver (bear down)
Tests to increase intrathecal
 pressure Straight leg raising with
dorsiflexion of the foot
Well leg straight raising test
Tests to stretch the spinal cord Distraction test (confirm positive
or sciatic nerve straight leg raising while testing the
achilles tendon).
Slump test

FOOT and ANKLE

1 INSPECTION Gait, Symmetry, Alignment, Contour, Skin

Observe Shoes, Pes Planus, Pes Cavus,
Calluses, Nails, Circulation, Skin temp, Swelling,
warts
Ingrown toenails, Hallux Valgus (lateral
deviation of big toe), Hammer toe, Blisters

2 PALPATION

Bony Landmarks Calcaneus

Talus
Navicular
Cuboid
Cuneiforms

Medial 1st metatarsal joint

Navicular tubercle
Talar head
Sustentaculum tali
Medial head

5th metatarsal head

Lateral Styloid process
Cuboid
Peroneal tubercle
Lateral malleolus

Metatarsal heads
Plantar Medial tubercle (calcaneus)

Soft Tissues Bursa 1st metatarsal head

Forefoot Metatarsal spaces (Morton= s Neuroma between
3rd & 4th)
Tibia-Talar joint

Medial Aspect Posterior tibialis tendon (inserts on Navicular)

Anterior tibialis tendon (inserts on cuneiform)
Deltoid ligament
 Lateral Aspect Anterior talo-fibular ligament
Calcaneal-fibular ligament
Posterior talo-fibular ligament
Peroneous longus / brevis

Achilles tendon
Posterior Aspect Posterior bursa (calcaneal & retro-calcaneal)

Calcaneal bursa Fascia

Plantar Aspect

3 RANGE OF
MOTION

Active Dorsiflexion / Plantarflexion

Inversion / Eversion

Passive Same as active

4 NEUROLOGICAL EXAMINATION

Sensory , Deep L4, L5, S1

Tendon Reflexes
Achilles Tendon Reflex
Motor Same as active but under resistance

5 VASCULAR

Skin Color
Hair Growth
Pulsating Masses
Pulses Posterior Tibialis
Dorsalis Pedis
Capillary refill in toes
Pitting Edema
Temperature
Space between toes

6 SPECIAL TESTS

Ankle Instability Anterior Drawer (tear of anterior talo-fibular

ligament)
Medial Tilt (tear of calcaneal-fibular ligament)
Lateral tilt (deltoid tear)
Achilles Instability Thompson Squeeze
 Homan’s Sign DVT

Cranial Nerves

I Olfactory S Sense of smell

II Optic S Vision

III Occulomotor M Proprioception

Pupillary constriction
Elevation upper eyelid
Extra-occular movements: Superior rectus muscle
Inferior rectus muscle
Medial rectus muscle
Inferior oblique muscle

IV Troclear M Proprioception
Extra-ocular movements
Superior oblique muscle

V Trigeminal B Sensory: 1. Opthalmic

2. Maxillary
3. Mandibular
(sensory-anterior 2/3 of tongue)
Motor: Muscles of mastication:
1. Temporal muscle
2. Masseter muscle
3. Ptergoid muscle (lat. Movement of jaw)

VI Abducens M Proprioception
Extra-ocular movements
Lateral rectus muscle

VII Facial B Sensory: Taste - anterior 2/3 of tongue

Motor: Muscles: facial expression
forehead
around mouth, eyes, eyelids
Stapedius muscle (ear)

VII Vestibulocochlear S Hearing

I Equillibrium

IX Glossopharyngeal B Sensory: Taste: Posterior 1/3 of tongue

Mucous membranes: Pharynx
 Tonsils
Middle ear cavity
Carotid sinus
Baro- and chemoreceptors (O2, CO2)
Motor: Swallowing

X Vagus B Sensory: External ear

Taste rear tongue
Viscera: thoracic, abdomen
Motor: Muscles - Pharynx
Larynx
Palate

XI Accessory M Trapezius muscle

Sternocledoimastoid muscle

XII Hypoglossal M Tongue

MONTHLY BREAST SELF-EXAM

To be done same time every

month, 7-10 days after the start
of your period if menstruating.
If not use a fixed day each
month.

There are a number of

recognized methods for
examining your breasts. One
way is using the clock method.
Pretend your breast is a clock.
Using the flat pads of your fingers, press gently but firmly in small overlapping
circles, starting at 12 Oclock, right below to collarbone and moving to the
nipple. Do not miss an hour. Another method would be to examine the breast
in concentric circles starting at the nipple. Carefully examine the area between
the breast and the armpit as that area also contains breast tissue. Examine every
part of the breast. Repeat with other breast. Whichever method you choose, it is
important to be onsistent.
In the Shower

Raise one arm. With fingers flat and soapy, touch every part of each breast, as
above, gently feeling for a lump or thickening. Use your right hand to examine
your left breast, your left hand for your right breast.
Before a Mirror

With arms at your sides, then raised above your head, look carefully for changes in
the size, shape and contour of each breast. Look for puckering, dimpling, or changes
in skin texture, colour or rashes. Check for changes in the nipple such as whether
they have become pulled in.
With one hand on hip, tense and push arm forward to make a pocket under the arm
and use the same method as when lying down to check this area. Repeat on other
side.

With your arm resting on a firm surface, use the same circular motion to examine the
underarm and side rib cage area.

Lying Down

You must also examine your breasts lying down. To balance the breast on the chest,
place a towel or pillow under your right shoulder and your right hand behind your
head. Examine your right breast with your left hand. Repeat on the other side.

Call your physician if you find any changes or abnormalities.

BREAST ASSESSMENMT

NORMAL FINDINGS ABNORMAL FINDINGS POSSIBLE HEALTH

PROBLEMS
Rounded shape, Change in breast Inflammation
small, medium or size; swellings
large size

Symmetrical Marked asymmetry

Skin smooth, Dimpling, redness Scarring,

intact vascularities, carcinoma
edema, retraction

Nipples everted, Nipples inverted Inflammation,

no discharge or crusting, ulcers, abscess,
lesions cracks, discharge malignancy

No swelling in Swelling, tenderness Malignancy

axillae in axillae

No tenderness, Tendernes, masses, Tumor, abscess

masses, or or nodules (note
nodules on location, PT's
palpation position, size,
mobility, consistency,
surface tenderness,
and shape)
 MANAGEMENT OF INTENTIONAL AND ACCIDENTAL
DRUG OR CHEMICAL INGESTION

Over 90% of all poisonings seen in this emergency are with medically
prescribed drugs. Most of all suicide gestures or suicidal attempts.
Frequently there is a mixture of drugs taken, including alcohol.

The remaining 10% constitute accidental ingestion of household products

and usually in this circumstance a good history is obtainable and the
appropriate management protocols can be obtained from the manuals in the
poison control room or by phoning the regional poison control centre.

Management of medical drug overdosage:

1. Classification of level of consciousness -

Grade 1 - responsive to verbal stimulation, fully oriented.

Grade 2 - responsive to minimal painful stimulation
Grade 3 - responsive only to very painful stimuli
Grade 4 - unresponsive to painful stimuli

Grade 1 and 2

a. History is obtained, and if not reliable from the patient, contact

relative or friend either in the department or by phone. Ambulance drivers
usually bring empty bottles with the patient. Record on chart - time of
ingestion and number of pills taken.

b. Do a quick but complete physical, since intercurrent disease might be

present. ie. encephalitis, recent head injury, diabetes, post dictal state.

c. Order 30cc of ipecac, plus 8 to 10 ounces of water, and instruct nurse

to stimulate the oropharynx in ten minutes. Give ipecac despite history of
previous vomiting and despite the length of time since ingestion.

d. If no vomiting occurs, repeat ipecac, and if no vomiting after 20

minutes from the original ipecac, patient should be lavaged and activated
charcoal placed in the stomach.
 e. If salicylate, methanol, or doriden has been ingested or suspected of
being ingested, blood should be taken for this immediately.

f. If any other of the tricyclics have been ingested, the patient should be
electrically monitored in resuscitation and gastric aspirate kept for analysis.

g. Excepting (e) and (f), the patient is clinically observed over the next
three hours, and during this time if the patient is capable of an interview,
then the emergency physician or the social worker should assess the intent
and nature of the overdosage and the psychodynamics behind it.

h. The patient may be kept in the department a total of six hours if

necessary, and if possible a relative or friend should be found to take the
patient home and stay with them for the next twelve hours.

I. Salicylate levels must always be repeated three hours after the initial
test.

Grade 3

a. Do not assume, unless a first hand history is available, that the patient
has overdosed merely because he is unconscious.

b. Establishing an airway in this group is a matter of considerable

judgement and difficulty. If a gag reflex is absent, then do not lavage the
patient unless an endotracheal tube is in place, and do not attempt to give
ipecac. The emergency physician should always be consulted quickly in
this situation prior to any attempts at intubation.

c. When suitable airway has been established, , lavage patient with

activated charcoal, and always use a stretcher which can be put into
trendelenberg position for these cases.

d. Quick but complete physical. Be alert for neurological or metabolic

signs. Start intravenous of ringer=s lactate, take blood for SMA and CBC
and send blood, urine, or gastric content as indicated for drug screen,
indicating which specific drug you are looking for.
 e. Be alert for constricted pupils in the presence of morphine, codeine derivatives,
or lomotil and use narcan IV as specific antidote. Order ethanol levels if there is a
heavy alcohol use also.

f. Some of these patients, if they arrive in the department soon after overdose and
are evacuated quickly, will rapidly regain a high level of consciousness, but all of
these patients should be seen by the psychiatric resident of the social worker prior to
discharge. Most, however, will probably need to be admitted to medicine for one or
two days.

Grade 4

Instructions are exactly the same as for Grade 3 with the following exceptions:

a. Intubation should be done promptly since by definition no gag reflex will be

present, and the patient ventilated with an ambu bag prior to the arrival of the
respirator.

b. Do an astrup, as well as the tests indicated in Grade 3 (d).

c. Call the junior resident in medicine since all of these patients will be admitted.
 THE FOUR PRIMARY REFLEXES

REFLEX ROOTS NEEDED MUSCLES

Ankle Jerk S1 Gastrocnemius

Knee Jerk L2, L3, L4 Quadriceps

Biceps C5, C6 Biceps

Triceps C7, C8 Triceps

ROOTS AND THE PRIMARY MUSCLES THEY SUPPLY

ROOT MUSCLE ACTION

C5 Deltoid Shoulder abduction

C5 Infraspinatus Humeral External Rotation

(check; have patient externally rotate the humerus
with the arm held at the side and flexed at elbow,
as if shooting a gun)

C5, C6 Biceps Flexion of the supinated forearm

C6 Extensor carpi Wrist extension

Radialis and ulnaris

C7 Extensor digitorum Finger extension; Forearm extension at elbow

Triceps

C8, T1 Interossel and Digital abduction & adduction (check: have patient
Lumbricals move fingers apart and together against resistance)

L2, L3, L4 Quadriceps Knee extension, Thigh on hip flexion, Thigh

Iliopsoas adduction
Adductor group

L5 Anterior tibial Ankle and large toe dorsiflexion (check: have

And extensor patient walk on heels)
Hallucis

S1 Gastrocnemius Ankle plantar flexion (check: have patient walk on

 tiptoes)

PHYSICAL ASSESSMENT

NEURO - LOC, pupil orientation,

Movement, strength,
Spinal cord, NEURO vitals,
Pain, verbal response.

RESP - Rate, rhythm, effort, position + exertion tolerence,

Chest tube, size, site, drainage, suction, dressing,
Oxygen, oxygen monitor,
Airway, trach, ETT, ventilator,
Palpation, percussion, findings,
Auscultation findings, cough, expansion, gag reflex.

CVS - Cardiac monitor, rate, rhythm, ectopics, analysis

Skin perfusion, color, turgur, texture, cyanosis, edema
Pulses, nailbed blanching, calf tendernes, BP, JVP, CVP
Heart sounds, palpitations
IV lines, site, type, solution, catheter, rate
Mode of delivery
Arterial line

GI - Diet, type, tolerance, tube feedings, NG site, size, drainage

PH, patency, irrigation, suction, TPN, N, V
Abd size, girth, contour, shape, incisions, dressings, drains
Pulsations, T-Tube, hemovac, ileostomy, gastrostomy
B.S.
Percussion, palpation, findings
Elimination, last BM, colostomy, ileostomy, color
Consistency, AMT, diarrhea, constipation.

GU - Voiding, self, urinal, toilet, last void

Catheter, type, size, patent, secure
Urine, AMT, color, clarity, ketones, protein, blood, Ph
Wt
Dialysis
Menses

MISC - IV blood products, Pt response

 RESPIRATORY ASSESSMENT

Resp rate, rhythm, effort, (accessory muscle use)

Exertion tolerence (SOB), Position tolerence (orthopnea), HOB

Chest tube: type, size, location, suction level, straight drainage, fluctuations, drainage (amt,
color), dressing type, secure

O2 monitor: saturation, alarm limits set

O2 : percentage, source (N/P, mask, tent), humidity

Airway: Trach, ETT, (oral, nasal), size, secure

Ventilator: Type, mode, VT, rate (machine, patient), peep pressure support, airway pressure,
volume (machine, patient), cuff pressure, air in cuff to seal, ventilator temp.

Palpation for discomfort, subcutaneous emphysema

Percussion (resonance, hyper / hyporesonance, dull, tympanic, flat)

Auscultation (chart on lung assessment area)

Chest expansion - bilateral present

Air entry - Audible in all lobes (5)

- Crackles: Inspiratory, expiratory, location
- Wheezes: Inspiratory, expiratory, location
- Rub: Location
- Stridor: Present

Cough: Spontaneous, productive, non-productive, sputum color, amt, consistency, clears

abnormal lung sounds.

Gag reflex: Present

 BREATH SOUNDS

1. Normal breath sounds:

I. Tracheobronchial: Loud, tubular

Heard over trachea, bronchus
Inspiration phase less than expiration

II. Bronchovesicular: Heard between scapula

Inspiration phase is equal to expiration

III. Vesicular: Heard in base of lungs

A soft sound
Inspiration phase greater than expiration

2. Abnormal breath sounds:

I. Crackles: Non-continuous crackling (like hair rubbed between two fingers)

Coarse or fine
Occurs on inspiration, expiration or both
Caused by opening and closing of the alveoli
Ie. Pulmonary edema

II. Wheezes: Musical, high pitched sounds

Occurs on inspiration, expiration or both
Caused by air passing through a narrow airway
ie. Bronchospasm, edema of airway, tumor, foreign body

III. Rub: Grating, continuous sound that varies with respiration, caused by
pleural inflammation.

IV. Stridor: Crowing sound, heard only on inspiration, caused by partial upper
airway obstruction.

PERCUSSION
Resonance: Heard over normal lung tissue

Hyperresonance: Heard over filled lung, ie pneumonia

Flat: Heard over bone, ie scapula

Dull: Heard over solid or fluid filled areas ie heart

Tympanic: Heard over gas filled bowel

HEART SOUNDS

NORMAL:

S1: LUBB

Caused by the closure of the AV valves (tricuspid, mitral), low pitch, long duration

S2: DUPP

Caused by the closure of the semilunar valves (pulmonic, aortic),sharp pitch, short
duration

ABNORMAL:

S3: LUBB DUPP UH

Caused by vibrations when blood hits the non-compliant ventricular wall

Low pitch (beat heard with the stethescope bell) common in children and young
healthy adults.

S4: TUH LUBB DUPP

Caused by vibrations when blood hits the non-compliant ventricular wall

Heard prior to systole. Low pitch (best heard with the stethescope bell) common in
children.
 GASTROINTESTINAL (GI)

Diet: Type, tolerance, amt, nausea, vomiting

NG Tube: Site, size, type, drainage amt, Ph, patency, irrigation, suction

Gastrostomy: Tube feeding, type, amt, tpn

ABD Site: Contour, shape, incisions, dressing, old scars, visible pulsations, girth,
hemovac, T-Tube, drains

B.S.: In 4 quadrants (audible, normal, absent, weak, intense)

Percussion: Tympanic, dull

Palpation: Light only, distended, tenderness, guarding

Elimination: Last BM, colostomy, ileostomy, color, consistency, amt, diarrhea,

constipation.

ABNORMAL BOWEL FINDINGS

1. Normal auscultation shows BS that are soft, intermittent q 2 - 10 seconds, vary in

intensity, frequency and pitch.

2. Abnormal auscultation sounds include:

I. Loud sounds: diarrhea, nervous tension, early intestinal obstruction

II. Weak sounds: decreased peristalsis, constipation, drug related effects

 III. Absent sounds: (none for 5 minutes)
Post bowel surgery manipulation
Electrolyte disturbances, peritonitis
Advanced intestinal obstruction

IV. Bruits heard over arteries with bell of stethescope:

ie. Abnormal, femoral, iliac etc.

Bruits are rushing sounds resulting from turbulent blood flow in

arteriosclerosis, hypertension, aortic aneurysms and abnormal masses compressing
the arteries.

HEAD INJURIES

1. FRONTAL LOBE injuries affect the Motor Areas.

The motor area controls:

- Personality, thought
- Voluntary skeletal muscle use
- Memory
- Emotional behavior
- Concentration
- Verbal expression (Brocha= s)

2. PARIETAL LOBE injuries affect the Sensory Area.

The sensory area controls:

- Touch, taste, tactile recognition

- Proprioreception (distinguish object by touch)
- Interpreting sensations

3. TEMPORAL LOBE injuries affect the Auditory Area.

The auditory areea controls:

- Taste, smell
- Short term memory
- Comprehension of speech (Wernicke= s)

4. OCCIPITAL LOBE injuries affect the Visual Area.

 The visual area controls:

- Recognition of objects

5. THALMUS (in the diencephalon or base of skull) injuries affect:

- Message pathways from the body

- Awareness of pain
- Focusing on vision

6. HYPOTHALMUS injuries affect:

- Temperature control of the body

- ADH, H20 control
- Hormone levels (pituitary)
- Autonomic nervous system
- Appetite
- Sleep
- Emotional response
- Optic chiasma (crossway of optic nerve)

7. CEREBELLUM injuries affect:

- Fine movement
- Balance
- Equillibrium
- Continuous, fluid muscle movement

CLASSIC SIGNS OF INCREASED

INTRACRANIAL PRESSURE

1. Hypertension
2. Widening pulse pressure
3. Bradycardia Pterion
4. Vomiting
5. Headache
6. Change in vision

PTERION: Area where 4 cranial bones meet.

(Temporal, frontal, occipital, parietal)

NOTE:
Inside the circle is known as the Pterion.
This is where the 4 cranial bones meet.

IMPORTANT: This area of bone is very thin and fragile. The Medial
Meningeal artery lies below. Injury to this area is very serious.

D - DEFORMITY
C - CONTUSION
A - ABRASIONS
P - PENETRATIONS

B - BURNS
L - LACERATIONS
S - SWELLING

T - TENDERNESS
I - INSTABILITY
C - CREPITUS

P - PULSE
M - MOTOR FUNCTION
S - SENSATION

D - DISTENTION
R - RIGIDITY

C - CAPILLARY REFILL
S - SKIN COLOR

**CHECK THE BACK**

 SHOCK HEAD INJURY

B/P ↓ ↑
PULSE ↑ ↓
RESP ↑ ↓
L.O.C. ↓ ↑

E.T TUBE SIZING

ADULT: SIZE 7 OR 8

CHILD: THUMBNAIL WIDTH

BABY FINGER WIDTH
EXTERNAL NAIRES

BLOOD LOSS BY SITE

TIBIA: 1 - 1.5 UNITS

RIBS: 1/4 UNIT
FEMUR: 2 UNITS
HUMERUS: 1/2 UNIT
 PELVIS: 2 - 20 UNITS

RULE OF NINES

HEAD = 9%
ARM = 9%
CHEST = 18%
LEG = 18%
BACK = 18%
GROIN = 1%

FLUID REPLACEMENT

3cc OF FLUID FOR EVERY 1cc OF BLOOD LOST

1 UNIT OF FLUID = 500cc

AN ADULT HAS AN AVERAGE OF 10 UNITS

INDICATION FOR MAST PANTS

SYSTOLIC B/P LESS THAN 80mm Hg

SHOCK SYMPTOMS - B/P LESS THAN 100mm Hg
SPINAL SHOCK & PELVIC FRACTURES

B/P BY PULSE

RADIAL PULSE = 80mm Hg

CAROTID PULSE = 60mm Hg
 FEMORAL PULSE = 40mm Hg

(ALL ARE SYSTOLIC B/P)

BREATHING
RATE:

∋ EUPNEA - Normal respiration that is quiet, rhythmic, and effortless

∋ TACHYPNEA - Rapid respiration, marked by quick shallow breaths

∋ BRADYPNEA - Abnormally slow breathing

∋ APNEA - Cessation of breathing

VOLUME:

∋ HYPERVENTILATION - An increase in the amount of air in the lungs,

characterized by prolonged deep breaths, may be associated with anxiety

∋ HYPOVENTILATION - A reduction in the amount of air in the lungs,

characterized by shallow respirations
 RHYTHM:

∋ CHEYNE-STOKES BREATHING - Rhythmic waxing and waning of

respirations, from very deep to very shallow breating and temporary apnea; often
associated with cardiac failure, increased intracranial pressure or brain damage

EASE OR EFFORT:

∋ DYSPNEA - Difficult and labored breathing, during which the individual has a
persistent, unsatisfied need for air and feels distressed

∋ ORTHOPNEA - Ability to breath only in upright sitting or standing position.

BREATH SOUNDS

AUDIBLE WITHOUT AMPLIFICATION:

∋ STRIDOR - A shrill harsh sound heard during inspiration with laryngeal

obstruction.

∋ STERTOR - Snoring or sonorous respiration, usually due to a partial obstruction

of the upper airway.

∋ WHEEZE - A whistling respiratory sound on expiration that usually indicates a

narrowing of the broncial tree.

∋ BUBBLING - Gurgling sounds heard as air passes through moist secretions in

the repiratory tract.

AUDIBLE BY STETHESCOPE:

∋ RALES - Ratteling or bubbeling sounds usually heard on inspiration as air moves

through accumulated moist secretions.

∋ RHONCHI - Coarse, dry, wheezy or whisteling sound, more audible during

expiration as the air moves through tenatious mucous or narrowed bronchi.

∋ CREPS (crepitation) - A dry crackling sound (like crumpled cellophane)

produced by air in the subcutaneous tissue or by air moving through fluid
in the alveoli.

∋ PLEURAL RUB - Coarse, leathery or grating sound, produced by the rubbing

together of the pleura, also called friction rub.

CHEST MOVEMENTS

∋ Intercostal Retraction - indrawing between the ribs

∋ Substernal retraction - Indrawing beneath the breastbone

∋ Suprasternal retraction - Indrawing above the clavicles

∋ Tracheal tug - Indrawing and downward pull of the trachea during inspiration

∋ Flail chest - The balooning out of the chest wall through injured rib spaces;results
in paradoxical breathing during which the chest wall baloons on expiration but is
depressed or sucked in on inspiration.

SECRETIONS AND COUGHING

∋ Hempotysis - The presence of blood in the sputum

∋ Productive cough - A cough accompanied by expectorated secretions

∋ Non-productive cough - A dry, harsh cough without secretions

EARLY MANAGEMENT OF THERMAL BURNS

GUIDELINES: (factors to be considered in the burn patient)

1. Extent of the injury

2. Location of the burn.

3. Circumstances of the injury.

4. Preexisting disease.

5. Age (difficulty in management increases below age 7 and over age 45).
6. Depth of the burn.

CARE OF MINOR BURNS

1. Relieve pain (diazepam - M and meperidine IV)

2. Cleanse, debride and treat wound locally (use dry closed dressing for all outpatients)

3. Prevent infection and tetanus (prophylactic antibiotics for five days.

CARE OF MAJOR BURNS (need organized approach)

1. Estimate extent of injury.

2. Place intravenous catheter in peripheral vein for fluid resuscitation.

3. Insert foley catheter for measurement of hourly urine output.

4. Insert large levine tube for relief of gastric dilatation.

5. Examine mouth, pharynx and lungs to determine adequacy of upper and lower airways
(obstructive symptoms require immediate endotracheal intubation.

6. Draw blood for base-line laboratory determinations.

7. Complete steps under care of minor burns.

FLUID RESUSCITATION (burns of more than 20% of body surface).

1. First 24 hours: restore fluid balance with lactated ringers.

2. 24 - 36 hours: restore plasma volume, supply water.

3. 36 - 48 hours: Give potassium.

PULMONARY COMPLICATIONS

1. Abnormalities associated with peripheral burns: appear 5 - 10 days after injury.

2. Inhalation injury: Usually apparent within 48 hours.

CORONARY CIRCULATION AND INFARCTION

1. Blood that supplies oxygen and nutrients to the heart originates from two
openings at the base of the aortic arch.

2. The left side of the heart is supplied by two main coronary arteries which originate
from a single artery called the left coronary artery (LCA). The LCA biforcates into
the left anterior descending artery and the left circumflex artery. These vessels
supply the following areas of the heart:

i. Left Anterior Descending (LAD) supplies:

- Anterior surface of the left ventricle
- Intreventricular sulcus (area between two ventricles)
- Apex of the heart

ii. Left Circumflex Artery (LCA) supplies:

- AV Sulcus (area between the Atrium and the Ventricle on the left
side).
- Posterior surface of the Left Ventricle
- Lateral surface of the Left Ventricle
- Left Atrium

3. The right side of the heart is supplied by 1 main coronary artery called the Right
Coronary Artery. This vessle supplies the following areas.

i. Right Coronary Artery (RCA) supplies:

- AV Sulcus (area between Atrium and Ventricle)
- SA, AV nodes
- Right Atrium
- Posterior aspect of the Right Ventricle
- Anterior aspect of the Right Ventricle

INFARCTIONS

When the blood supply is inadequate and the demand for oxygen is not met,
Ischemia, injury and necrosis can occur. Although not exact, the following areas
correspond to inadequate coronary artery supply injuries.

a. LAD: Anterior Infarction

b. LCA: Lateral Infarction
c. RCA: Inferior and / or posterior infarction

ANGINA (STABLE & UNSTABLE)

The following is a guide to differentiate between stable and unstable angina:

1. Always check BP, rate and rhythm respirations, pulse, LOC, peripheral
perfusion.
 2. Assess pain as follows:

STABLE ANGINA UNSTABLE

ANGINA

Precipitating Stress, Eating, Commonly no

Factors Exertion precipitating factors

Quality Pressure, Tightness More severe, worse

with movement

Region & Radiation Sternal, radiates, unable to pinpoint one area

Signs & Symptoms Diaphoresis, Nausea, Vomiting, Dyspnea,

Syncope, Uneasiness

Decreased Pulse
Decreased BP
Increased
Apprehension
S3, S4

Time Response to Gradual Onset Sudden onset

Treatment Relief after 30 No relief after 30 min
minutes with nitro
and rest

INSULIN SHOCK

HISTORY:

Food Insufficient
Insulin Excessive
Onset Sudden - Minutes
Appearance Very Weak
Skin Pale and Moist
Infection Absent

SYMPTOMS: (Gastrointestinal)

Mouth Drooling
Thirst Absent
Hunger Intense
Vomiting Uncommon
Abdominal pain Absent

RESPIRATION:

Breathing Normal or shallow

Breath Acetone odour may be present

VISION:
Diplopia (double vision)

NERVOUS SYSTEM:

Headache Absent
Mental state Apathy,irritability merging into unconsciousness

TREMORS:

Convulsions In late stages

Tremors Present

URINE:

Sugar Absent
Acetone May be present

IMPROVEMENT:

Immediate improvement following oral administration of carbohydrate (glucose,

sugar, orange juice, gingerale, candy).

DIABETIC COMA
HISTORY:

Food Excessive
Insulin Insufficient
Onset Gradual (days)
Appearance Extremely ill
Skin Red and dry
Infection May be present

SYMPTOMS: (Gastrointestinal)

Mouth Dry
Thirst Intense
Hunger Absent
Vomiting Common
Abdominal pain Frequent

RESPIRATION:
Exaggerated air hunger

Breath Acetone (sweet, fruity) odour usual

BLOOD PRESSURE: Low Pulse Rapid

VISION: Dim

NERVOUS SYSTEM:

Headache Present
Mental state Restlessness, merging into unconsciousness

TREMORS: Absent

Convulsions None

URINE:

Sugar Present
Acetone Present

IMPROVEMENT:

Gradual within 6 - 12 hour following administration of insulin.

CLINICAL NOTEBOOK
Aaron's sign

This sign is pain of distress occurring in the area of the patient's heart or stomach on palpation of
mcburney's point. It is associated with appendicitis.

Ballance's sign

This sign is fixed dullness to percussion in the left flank and dullness in the right flank that
dissapears on change of positioning. It is suggestive of peritoneal irritation.

Battle's sign

This sign is discoloration (ecchymosis) and swelling behind one or both ears. It is associated
with head trauma and suggestive of basilar skull fracture.

Beck's triad

This sign is systemic hypotension, muffled heart tones, and elevated venous pressure reflected by
neck vein distention. It is suggestive of cardiac tamponade.

Brudzinski's sign

With the patient in the dorsal recumbent position, forwards flexion of the head results in flexion
of the hip and knee. This sign is suggestive of meningeal irritation.

Chvostek's sign

This sign is a facial muscle spasm in the cheek and around the mouth in response to stimulus of
cranial nerve vii. Cranial nerve vii can be stimulated by light percussion of the patient's facial
nerve adjacent to the ear. This is a sign of latent tetany (suggestive of acute hypocalcemia or
hypomagnesemia).

Cullen's sign

This sign is bluish discoloration around the umbilicus, caused by blood extravasating into
surrounding tissues. It is usually associated with hemorrhagic pancreatitis or ectopic pregnancy.

Cushing's triad

This sign is increased systolic blood pressure, decreased heart rate and widenend pulse pressure.
It is a late sign of increased intracranial pressure.

Grey-turner's sign

This sign is subcutaneous bruising around the flanks and umbilicus. It is suggestive of a
retroperitoneal hematoma.

Hamman's crunch

This sign is a crunching sound that is synchronous with the heartbeat and heard on auscultation of
the precordium. It may be caused by alveolar rupture, esophageal tear, tracheal tear, or bronchial
tear. It may be associated with hemothorax, pneumothorax, or respiratory failure.

Homan's sign

This sign is a pain in the calf elicited by passive dorsiflexion of the ankle. Positive sign is
associated with venous thrombosis of the deep veins and diminished blood flow to the lower leg.

Kehr's sign

Irritation of the phrenic nerve causes pain referred to the shoulder (subscapular region), usually
the left side. This sign is associated with splenic rupture, ectopic pregnancy or gastrointestinal
diseases.

Kernig's sign

With the patient supine, flex patient's leg at the hip and knee and then attempt to straighten the
knee. Pain and resistance, along with the inability to extend the legs completely, are suggestive
of meningeal irritation.

Mcburney's sign

This sign is rebound tenderness and sharp pain occuring in the area of the appendix when
mcburney's point (located about 2 inches [5.1cm] above and medial to the right anterior superior
spine of the ilium) is palpated. It is suggestive of appendicitis.

Murphy's sign

This sign is illicited by palpating the abdomen while the patient inhales deeply. This sign is said
to be positive for acute cholecystitis if the patient is unable to breathe deeply because of the pain.
The liver moves downward on inhalation, which brings the patient's gallbladder closer to the hand
of the examiner. This maneuver causes pain if the gallbladder is inflamed.

Psoas sign

This sign is increasing pain occuring in the abdomen when the patient extends the right leg while
lying on the left side, or when the legs are flexed while lying supine. It is suggestive of
appendicitis.

Racoon eyes

This sign is discoloration (ecchymosis) and swelling around one or both eyes. Associated with
head trauma, it is suggestive of basilar skull fracture or facial fracture.

Rovsing's sign

This sign is pain in the patient's right lower quadrant (at mcburney's point) when pressure is
applied in the left lower quadrant. It is suggestive of appendicitis.

Trousseau's sign
This sign is carpopedal spasm after occlusion of blood flow to the hand. The spasm causes the
patient to simultaneously flex the wrist, adduct the thumb, and extend one or more fingers within
minutes after a tourniquet or inflated blood pressure cuff is applied to the same arm. Another
technique to elicit this sign is hyperventilation, in which serum calcium levels are decreased by
the alkalotic state produced. Sign of latent tetany may indicate acute hypocalcemia or
hypomagnesemia. This sign also occurs in osteomalacia.

SHOCK
DEFINITION, PATHOPHYSIOLOGY, GENERAL TREATMENT

DEFINITION:

Shock is a condition in which circulation is inadequate fornormal cellular

function.

PATHOPHYSIOLOGY:

Hypotension, hyperglycaemia, decreased cardiac output, renal

vasoconstriction, tubular necrosis, metabolic acidosis.

GENERAL TREATMENT:

1. Insert two (2) #14 catheters and secure central venous pressure line.
Administer electrolyte solution at rapid rate until central venous pressure rises 5cm
of water above base line measurement.

2. Monitor urinary output with Foley catheter (should be 30 -50 cc/hr)

3. Administer oxygen by mask, and if required, use endotracheal

intubation and positive pressure respiration.

4. Monitor arterial pressure.

5. Record vital signs and note evidence of trauma, colour and texture of
skin, respiratory rate, level of consciousness and blood pressure.

6. Withdraw blood for laboratory studies (CBC, Diff, cell count, Creatine
clearance time or BUN, blood gasses, total protein, A/G ratio, and blood sugar)
and for typing and cross matching.

7. Obtain ECG and X-Ray films.

 SPECIFIC TYPES OF SHOCK

HYPOVOLEMIC SHOCK
Associated with: Hemorrhage, burns, peritonitis, protracted diarrhea or
vomiting, acute pancreatitis.
TREATMENT: Rapid volume replacement.
SEPTIC SHOCK
Associated with: Infection
TREATMENT: Abscess drainage, antibiotic therapy, fluid replacement.
CARDIOGENIC SHOCK
Associated with: Myocardial failure, vascular disease.
TREATMENT:Isoproterenol, circulatory assistance

Associated with: Acute cardiac arrhythmias.

TREATMENT: Cardioversion of drug therapy
ANAPHYLACTIC SHOCK
Associated with: Acute systemic antigen-antibody reaction.
TREATMENT: Rapid administration of epinepherine, rapid hydration,
vasopressors, steroids antihistamines.
SHOCK DUE TO IMPEDED BLOOD FLOW
Associated with: Pulmonary embolism
TREATMENT:Heparin, isoproteronol, rapid digitalization, glucagon,
oxygen.

Associated with: Dissecting aneurism.

TREATMENT: Volume replacement, surgery.

Associated with: Cardiac tamponade.

TREATMENT: Pericardicentesis.
ENDOCRINE SHOCK
Associated with: hypopituitarism
TREATMENT: Cortisol, volume replacement

Associated with: Hypothyroidism with myxoedema

 TREATMENT: Hydration, lithyronine sodium therapy, cortisol infusion

Associated with: Adrenocortical insufficiency.

TREATMENT: Exogenous steroid therapy.

Associated with: Pheochromocytoms.

TREATMENT: Volume replacement, vasopressors
NEUROGENIC SHOCK
Associated with: Anesthesia (general, regional, spinal)
TREATMENT: Volume replacement, vasopressors (occasionally)
SORE THROAT OR STREP THROAT ?

Is an antibiotic required?

Step 1

Determine the patient= s total sore throat score by assigning points to the
following criteria:

CRITERIA: POINT

Temperature > 38 1
No Cough 1
Tender anterior cervical adenopathy 1
Tonsilar swelling or exudate 1
Age 3 - 14 yr 1
Age 15 - 44 y 0
Age > 45 yr -1

Total Score
Step 2

Choose the appropriate mangement suggested below according to the total

throat score.

Chance of streptococccal
Infection in community
Total with usual levels Suggested
score of infection, % management

0 2-3 No culture or
1 4-6 antibiotic is required

2 10 - 12 Culture all; treat only

3 27 - 28 if culture result is
positive

4 38 - 63 Culture all; treat with

penicillin on
cllinical grounds *

*If patient has high temperature or is clinically unwell,

and presents early in disease course.
 TRAUMA SCORE

RESPIRATORY RATE:

10 - 24/min 4
25 - 35/min 3
36/min or greater 2
1 - 9/min 1
None 0

RESPIRATORY EXPANSION:

Normal 1
Reactive/none 0

SYSTOLIC BLOOD PRESSURE:

90mm Hg or greater 4
70 - 89mm Hg 3
50 - 69mm Hg 2
00 - 49mm Hg 1
No pulse 0

CAPILLARY REFILL:

Normal 2
Delayed 1
None 0

The trauma score is a numerical grading system for estimating the severity of
an injury. The score is composed of the Glascow Coma Scale (reduced by
approximately one third total value) and measurements of cardiopulmonary
function. Each parameter is given a number (high for normal and low for
impaired function). Severity of injury is estimated by summing the numbers.
The lowest score is 1, and the highest score is 16.
 Trauma Score Operational Definitions

Respiratory Rate:
Number of respirations in 15 seconds; multiply by four.

Respiratory Expansion
Retractive - use of accessory muscles or intercostal muscle reaction.

Systolic Blood Pressure

Systolic cuff pressure; either arm
- auscultate or palpate
No Pulse - No carotid pulse

Capillary Refill
Normal - nail bed, forehead, or lip mucosa colour refill in 2 seconds or
time taken to mentally repeat Α capillary refill≅
Delayed - more than 2 seconds capillary refill
None - no capillary refill

Best Verbal Response

Arouse patient with voice or painful stimulus

Best Motor Response

Response to command or painful stimulus

Projected estimate of survival for each value of the Trauma Score based on
results from 1,509 patients with blunt or penetrating injury.

Trauma Percentage
Score Survival

16 99
15 98
14 96
13 93
12 87
11 76
10 60
9 42
8 26
7 15
6 8
5 4
4 2
 3 1

APGAR SCORING CHART

HEART RATE:

Over 200 2
Slow (Below 100) 1
Absent 0

RESPIRATORY EFFORT:

Good crying 2
Slow / irregular 1
Absent 0

MUSCLE TONE:

Active motion 2
Some flexion of
extremities 1
Flaccid / limp 0

REFLEX IRRITABILITY:

(response to flick on
sole of foot)

Vigorous cry 2
Some motion / cry 1
No response 0

COLOUR:

Completely pink 2
Body pink / hands &
feet blue 1
Blue / pale 0
GLASGOW COMA SCALE

EYE OPENING:

Spontaneous 4
To voice 3
To pain 2
None 1

MOTOR RESPONSE:

Obeys 6
Localizes 5
Withdraws 4
Flexion 3
Extension 2
None 1

VERBAL RESPONSE:

Oriented 5
Confused 4
Inappropriate 3
Incomprehensive 2
None 1

TOTAL RESPONSE: 3 to 15

Total Glascow Coma Scale Points

14 - 15 = 5

11 - 13 = 4

8 - 10 = 3

5- 7 = 2

3- 4 = 1
 ACUTE ANKLE INJURY IN ADULTS

CLINICAL DECISION RULES

BACKGROUND:

Clinical decision rules for acute ankle injury following

trauma have been established by a series of studies over the past
decade. These studies show that no fractures that require treatment
will be missed if the Ottawa decision rules are followed in the
emergency room and other clinical practice. The provinces of
Alberta and British Columbia have introduced this guideline and they
are in use in many hospitals and practices.

THE OTTAWA DECISION RULES:

- nonpregnant patients 18 years or older
- presenting for the first time
- no cognitive or sensory impairment

When applied, the rules accurately identify cases in which

radiography will not show a fracture.

a. Ankle X-rays are only required if there is pain in the

malleolar zone and any of these findings:
Bone tenderness at posterior edge or tip of lateral malleolus; or
Bone tenderness at posterior edge or tip of medial malleolus; or
Inability to bear weight both immediately and in the emergency
department.

b. Foot X-rays are only required if there is any pain in the

midfoot zone and any of these findings:
1. Bone tenderness at base of 5th
metatarsal; or
2. Bone tenderness at navicular; or
3. Inability to bear weight both
immediately and in the emergency
department.
Definition: inability to bear weight
immediately means that the patient cannot walk unaided for four
steps within the first hour of the injury.

OTTAWA KNEE RULE

X-RAYS IN ACUTE INJURIES

A knee x-ray is only required for a knee injury if the patient has any
of these findings:

1. Age 55 years or older

2. Isolated tenderness of the patella *

3. Tenderness at the head of the fibula

4. Inability to flex to 90 degrees

5. Inability to bear weight immediately and in the

emergency room (4 steps)**

* No bone tenderness of knee other than patella

** Unable to transfer weight twice onto each lower limb
regardless of limping.

Head of Fibula->
 SKIN LESIONS

PURITIS An unpleasant cutaneous sensation which provokes

desire to scratch or rub the skin.May be the mere
prickling, tingling, or its severity may be so intense as
to be intolerable

MACULES Discoloured spots not elevated above the surface.

Variously sized, circumscribed changes in skin colour,
without elevation or depression. They are usually
circular, but may be oval or irregular,and may be
distinct in outline or surrounding area.

PAPULES Small, solid, round, pimple-like elevations.

They may be acuminate, rounded, conical, flat, or
umbilicated, and may appear white, red,
yellowish,yellowish brown, or black.

NODULES These are forms of papules but are larger solid lesions.
They are generally of a persistent character, perhaps
midway between a papule and a small tumour.

TUMOURS Tumours are soft or firm and freely movable or fixed

masses of various sizes and shapes. Tumours have a
tendency to be rounded. Their consistency depends
upon the constituents of the lesion. Some tumours
remain stationary indefinitely, whereas others increase
in size, or break down as a result of infection and
necrosis.

WHEALS Wheals are evanescent, edematous, flat elevations of

various sizes. They are usually oval or of bizarre
contours, whitish or pinkish. These lesions develop in a
few seconds, but disappear slowly. Itching and tingling
are almost always present.

VESICLES Vesicles are circumscribed, epidermal elevations of 1 to

4mm in size, and usually contain a clear fluid. They
may be pale, yellowish, reddish. Vesicles may be
discrete, irregularly scattered,grouped as in herpes
 zoster, or linear as in poison ivy dermatitis.

BULLAE Large irregular fluid containing blisters. They (Blebs)

differ from vesicles only in size, being larger than 1cm.
They are usually single-chambered and located
superficially in the epidermis, so that their walls are
thin and subject to rupture spontaneously or
from slight injury.

PUSTULES Papules, vesicles, or bullae which have become

(Pimples)infected and filled with pus.

PETECHIAE Small pinpoint haemorrhages into the skin.

PURPURIC Discoloured areas due to haemorrhages into the skin.

ECCHYMOSIS A large isolated patch of haemorrhage beneath the

skin, usually due to external violence.

SCALES Scales are dry or greasy laminated masses of keratin.

Generally they are thin, dry, brittle,shiny flakes, but
sometimes they are greasy and dull from the sebum and
sweat. They vary in colour from whitish-greyish to
yellowish or brown from the admixrue of dirt. Scaling
is common in a large number of inflammatory diseases
of the skin.

EXCORIATIONS Linear scratch marks or traumatized area of the skin

FISSURE A crack in the skin usually from marked drying or long

standing inflammation.

ULCER Lesion formed by local destruction of the epidermis and

part or all of the underlying dermis.

CRUST Dried serum on the surface of the skin.

CYST An encapsulated, fluid filled mass in the dermis or the

subcutaneous tissue.
The following are some of the more common prefixes and suffixes
used to describe body conditions and procedures.

Prefixes
(Pertaining to the body)

brach arm
capit head
cardi heart
chole gall
cyst bladder
derma skin
entero intestines
glosso tongue
gastro stomach
hemo blood
hepat liver
laparo abdomen
myo muscle
nephro kidney
neuro nerve
oculo, ophthalm eye
odont tooth
oto ear
osteo bone
oral mouth
pharyn throat
phleb vein
pneumo lung
procto rectum
rhino nose
thorac chest
(Pertaining to conditions)

a or an lacking or absence of
ab away from
ad towards, addition of
ante before
anti against
auto self
contra against, opposed to
dys difficult, painful
endo within
hemi half
hydro water
hyper above, increase
hypo below, under
mal faulty, poor
neo new
oligi scanty, few
ortho straight
peri around
poly many, much
pyo pus
pyro heat, temperature
Suffixes
(Pertaining to body conditions)

algia pain
cele tumor, hernia
emia blood
esthesia sensation
iasis (osis) condition of
itis inflammation
lith stone, calculus
oma growth, tumor
opia vision
osis (iasis) condition of
pathy disease
phobia fear or dread
plegia paralysis
pnea breathing
ptosis drooping, falling
rrhea flow, discharge
therapy treatment
thermy heat
tropic nutrition, growth
trophy nutrition, growth
uric, uria urine

(Pertaining to procedures)

ectomy removal of
plasty to form or build up
(o)rrhaphy repair of
(o)stomy creation of an opening
(o)tomy cutting into
manometer used to measure pressure
meter used to measure
scope,-scopy used to examine by looking into or by
 hearing

ABBREVIATIONS

AA of each
a.c. before meals
ACE angiotensin converting enzyme
ACTH adrenocorticotropic hormone
Ad to, up to
ADH antidiuretic hormone
Ad lib freely
Admov apply
AIDS acquired immunodeficiency syndrome
ALT alanine aminotransferase (formerly SGPT)
AST aspartate aminotransferase (formerly SGOT)
ATP adenosine triphosphate
BCG bacille Calmette-Guérin
bid 2 times a day
BMR basal metabolic rate
BP blood pressure
BSA body surface area
BUN blood urea nitrogen
C Celsius; centigrade; complement
Ca calcium
cAMP cyclic adenosine monophosphate
CBC complete blood count
cGy centigray
Ch. chapter
Ci curie
CK creatine kinase
Cl chloride; chlorine
cm centimeter
CNS central nervous system
CO2 carbon dioxide
COPD chronic obstructive pulmonary disease
CPR cardiopulmonary resuscitation
CSF cerebrospinal fluid
CT computed tomography
cu cubic
D a day
DDX differential diagnosis
D&C dilation and curettage
dL deciliter (= 100 mL)
DNA deoxyribonucleic acid
DTP diphtheria-tetanus-pertussis (toxoids/vaccine)
Dur Dol while pain lasts
D/W dextrose in water
ECF extracellular fluid
ECG electrocardiogram
EEG electroencephalogram
ENT ear, nose, and throat
ERCP endoscopic retrograde cholangiopancreatography
ESR erythrocyte sedimentation rate
F Fahrenheit
FDA U.S. Food and Drug Administration
ft foot; feet (measure)
FUO fever of unknown origin
Gy gray
g gram
GFR glomerular filtration rate
GI gastrointestinal
G6PD glucose-6-phosphate dehydrogenase
GU genitourinary
h hour
Hb hemoglobin
Hcl hydrochloric acid; hydrochloride
HCO3 bicarbonate
Hct hematocrit
Hg mercury
HIV human immunodeficiency virus
HLA human leukocyte antigen
h.d. At bedtime
h.s. Just before sleep
Hz hertz (cycles/second)
ICF intracellular fluid
ICU intensive care unit
IgA, etc immunoglobulin A, etc
IM intramuscular(ly)
INR international normalized ratio
IPPB intermittent positive pressure breathing
IU international unit
IV intravenous(ly)
IVU intravenous urography
K potassium
Kcl potassium chloride
kcal kilocalorie (food calorie)
kg kilogram
L liter
lb pound
LDH lactic dehydrogenase
M molar
m meter
m2 square meter
MCV mean corpuscular volume
mEq milliequivalent
Mg magnesium
mg milligram
MI myocardial infarction
MIC minimum inhibitory concentration
min minute
mL milliliter
mm millimeter
mo month
mol wt molecular weight
mOsm milliosmole
MRI magnetic resonance imaging
N nitrogen; normal (strength of solution)
Na sodium
NaCl sodium chloride
NSAID nonsteroidal anti-inflammatory drug
O2 oxygen
O.D. in the right eye
O.S. in the left eye
O.U. in each eye
o.d. every day
OTC over-the-counter (pharmaceuticals)
oz ounce
P phosphorus; pressure
p.c. After meals
PCO2 carbon dioxide partial pressure (or tension)
pH hydrogen ion concentration
po orally
PO2 oxygen partial pressure (or tension)
PPD purified protein derivative (tuberculin)
ppm parts per million
prn as needed
q every
q.d. every day
q.h. every hour
qid 4 times a day
RA rheumatoid arthritis
RBC red blood cell
RNA ribonucleic acid
SaO2 arterial oxygen saturation
SBE subacute bacterial endocarditis
sc subcutaneous(ly)
sec second
SIDS sudden infant death syndrome
SLE systemic lupus erythematosus
soln solution
sp gr specific gravity
sq square
ss. one half
Stat immediately
STS serologic test(s) for syphilis
TB tuberculosis
tid 3 times a day
TPN total parenteral nutrition
U unit
URI upper respiratory infection
ut dict as directed
ut supr as above
UTI urinary tract infection
WBC white blood cell
WHO World Health Organization
wk week
wt weight
y/o year old
yr year
μ micro-; micron
μg microgram
μL microliter
μm micrometer (= micron)
/ per
< less than
> more than
♀ male
♂ female
℞ prescription
∧ systolic blood pressure
∨ diastolic blood pressure
≠ does not equal
Δ change
↑ increased
↓ decreased
° degree
+ positive
- negative
+ positive or negative
# fracture
Dx diagnosis
Tx treatment
COMMON DRUG NAMES

Abacavir Sulfate (Ziagen)

Abacavir Sulfate and Lamivudine Tablets (Epzicom)
Abacavir Sulfate, Lamivudine, and Zidovudine (Trizivir)
Abarelix (Plenaxis)
Abatacept (Orencia)
Abciximab (ReoPro)
Abelcet (Amphotericin B)
Abilify (Aripiprazole)
Abraxane (Albumin-bound Paclitaxel)
Acamprosate Calcium (Campral)
Acarbose (Precose)
Accolate (Zafirlukast)
Accretropin (Somatropin Injection)
Accupril (Quinapril)
Accutane (Isotretinoin)
Accuzyme (Papain and Urea)
Acebutolol (Sectral)
Aceon (Perindopril Erbumine)
Acetadote (Acetylcysteine Inj)
Acetaminophen (Tylenol)
Acetaminophen and Codeine (Tylenol-Codeine)
Acetaminophen, Isometheptene and Dichloralphenazone (Midrin)
Acetazolamide Injection (Acetazolamide Injection)
Acetazolamide Tablets (Acetazolamide Tablets)
Acetazolamide XR (Diamox Sequels)
Acetic Acid (Vosol Otic)
Acetyl Sulfisoxazole (Gantrisin)
Acetylcholine Chloride (Miochol-E)
Acetylcysteine (Mucomyst)
Acetylcysteine Inj (Acetadote)
Aci-Jel (Vaginal Jelly)
Acidul (Fluoride)
Aciphex (Rabeprazole Sodium)
Acitretin (Soriatane)
Aclovate (Alclometasone Dipropionate)
Acrivastine and Pseudoephedrine (Semprex D)
ActHIB (Haemophilus b Conjugate Vaccine)
Acthrel (Corticorelin Ovine)
Acticin (Permethrin)
Actidose (Actidose Aqua)
Actidose Aqua (Actidose)
Actimmune (Interferon Gamma 1 b)
Actiq (Fentanyl Citrate)
Actisite (Tetracycline (periodontal))
Activase (Alteplase)
Activella (Estradiol, Norethindrone Acetate)
Actonel (Risedronate Sodium)
Actonel with Calcium (Risedronate Sodium with Calcium Carbonate)
Actoplus MET (Pioglitazone Hcl and Metformin Hcl)
Actos (Pioglitazone hydrochloride)
Acular (Ketorolac tromethamine)
Acyclovir (Zovirax)
Acyclovir for Injection (Zovirax Injection)
Acyclovir Transdermal (Zovirax Ointment)
Aczone Gel (Dapsone)
Ad-Ae
Adacel (Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis
Vaccine Adsorbed)
Adagen (Pegademase Bovine)
Adalat (Nifedipine)
Adalimumab (Humira)
Adapalene (Differin Gel .3%)
Adapalene Gel (Differin Gel .1%)
Adderall (Amphetamine Mixed Salts)
Adderall XR Capsules (Amphetamine)
Adefovir Dipivoxil (Hepsera)
Adenocard (Adenosine)
Adenoscan (Adenosine Inj)
Adenosine (Adenocard)
Adenosine Inj (Adenoscan)
Adrenalin (Epinephrine)
Adria (Doxorubicin hydrochloride)
Advair Diskus (Fluticasone Propionate)
Advair HFA (Fluticasone propionate and Salmeterol)
Advicor (Niacin XR & Lovastatin)
Aerobid (Flunisolide)
Aerospan HFA (Flunisolide Hemihydrate)
Af-Al
Afluria (Influenza Virus Vaccine)
Agalsidase Beta (Fabrazyme)
Agenerase (Amprenavir)
Aggrastat (Tirofiban)
Aggrenox (Aspirin, Extended-Release Dipyridamole)
Agrylin (Anagrelide)
Akineton (Biperiden)
Alamast (Pemirolast potassium)
Albendazole (Albenza)
Albenza (Albendazole)
Albumin (Buminate)
Albumin (Human) (Albuminar)
Albumin-bound Paclitaxel (Abraxane)
Albuminar (Albumin (Human))
Albuterol (Albuterol)
Albuterol Inhalation (Proventil HFA)
Albuterol Inhalation Aerosol (Ventolin Inhalation Aerosol)
Albuterol Sulfate Inhalation Aerosol (Proair HFA)
Albuterol Sulfate Inhalation Aerosol (Ventolin HFA)
Albuterol Sulfate Inhalation Solution (Ventolin Nebules)
Albuterol Sulfate Inhalation Solution (Ventolin Solution)
Albuterol Sulfate Syrup (Ventolin Syrup)
Albuterol Sulfate Tablets (Ventolin Tab)
Alcaine (Proparacaine)
Alclometasone Dipropionate (Aclovate)
Aldactazide (Spironolactone and Hydrochlorothiazide)
Aldactone (Spironolactone)
Aldara (Imiquimod)
Aldesleukin (Proleukin)
Aldomet (Methyldopa)
Aldomet Injection (Methyldopate)
Aldoril (Methyldopa-Hydrochlorothiazide)
Aldurazyme (Laronidase)
Alefacept (Amevive)
Alemtuzumab (Campath)
Alendronate Sodium (Fosamax)
Alendronate Sodium & Cholecalciferol (Fosamax Plus D)
Alesse (Levonorgestrel and Ethinyl Estradiol)
Alfenta (Alfentanil)
Alfentanil (Alfenta)
Alfuzosin HCl (Uroxatral)
Alglucerase Inj (Ceredase)
Alglucosidase Alfa (Myozyme)
Alimta (Pemetrexed)
Alinia (Nitazoxanide)
Aliskiren Tablets (Tekturna)
Aliskren and Hydrochlorothiazide Tablets (Tekturna HCT)
Alitretinoin (Panretin)
Alkeran (Melphalan)
Alkeran Injection (Melphalan Hcl Injection)
Allegra (Fexofenadine Hcl)
Allegra-D (Fexofenadine HCl and Pseudoephedrine HCl)
Allegra-D 24 Hour (Fexofenadine HCl 180 and Pseudoephendrine HCl 240)
Alli (Orlistat 60 mg)
Allopurinol (Zyloprim Injection)
Allopurinol (Zyloprim Tablets)
Almotriptan Malate (Axert)
Alocril (Nedocromil)
Alomide (Lodoxamide Tromethamine)
Alora (Estradiol Transdermal System)
Alosetron Hydrochloride (Lotronex)
Aloxi (Palonosetron hydrochloride)
Alpha (Prolastin)
Alpha-Proteinase Inhibitor (Human) (Zemaira)
Alphagan (Brimonidine Tartrate)
Alphagan-P (Brimonidine Tartrate)
Alphanate (Antihemophilic Factor)
Alprazolam (Niravam)
Alprazolam (Xanax)
Alprazolam (Xanax XR)
Alprostadil (Prostin VR Pediatric - Caverject)
Alprostadil Dual Chamber System for Injection (Caverject Impulse)
Alprostadil for Inj (Edex)
Alprostadil Injection (Caverject)
Alprostadil Sterile Powder for Injection (Caverject Powder)
Altabax (Retapamulin)
Altace Capsules (Ramipril)
Altace Tablets (Ramipril Tablets)
Alteplase (Activase)
Altoprev (Lovastatin)
Altretamine (Hexalen)
Alupent (Metaproterenol Sulfate)
Alvesco (Ciclesonide Inhalation Aerosol)
Am-Am
Amantadine Hydrochloride (Symmetrel)
Amaryl (Glimepiride)
Ambien (Zolpidem Tartrate)
Ambien CR (Zolpidem Tartrate)
Ambisome (Amphotericin B)
Ambrisentan Tablets (Letairis)
Amcinonide (Cyclocort)
Amerge (Naratriptan)
Americaine (Benzocaine)
Amevive (Alefacept)
Amicar (Aminocaproic Acid)
Amifostine (Ethyol)
Amikacin (Amikin)
Amikin (Amikacin)
Amiloride (Midamor)
Amiloride and Hydrochlorothiazide (Moduretic)
Amino Acid (Aminosyn II)
Amino Acid (HepatAmine)
Amino Acid and Glycerin (Procalamine)
Amino Acids (TrophAmine)
Amino Acids (Injection) (Travasol)
Aminocaproic Acid (Amicar)
Aminoglutethimide (Cytadren)
Aminohippurate (Aminohippurate sodium)
Aminohippurate sodium (Aminohippurate)
Aminolevulinic Acid (Levulan Kerastick)
Aminosalicylic Acid (Paser)
Aminosyn II (Amino Acid)
Amiodarone (Cordarone)
Amiodarone (Cordarone Intravenous)
Amitiza (Lubiprostone)
Amitriptyline (Elavil)
Amlexanox (Aphthasol)
Amlodipine and Valsartan (Exforge)
Amlodipine Besylate (Norvasc)
Amlodipine Besylate and Benazepril HCl (Lotrel)
Amlodipine Besylate, Atorvastatin Calcium (Caduet)
Ammonul (Sodium Phenylacetate and Sodium Benzoate Injection)
Amoxapine (Asendin)
Amoxicillin (Amoxil)
Amoxicillin Clavulanate (Augmentin)
Amoxicillin Clavulanate Potassium (Augmentin ES)
Amoxicillin Clavulanic Potassium (Augmentin XR)
Amoxil (Amoxicillin)
Amphadase (Hyaluronidase Inj)
Amphetamine (Adderall XR Capsules)
Amphetamine (Amphetamine)
Amphetamine Mixed Salts (Adderall)
Amphotericin B (Abelcet)
Amphotericin B (Ambisome)
Amphotericin B (Fungizone)
Ampicillin (Principen)
Ampicillin and Sulbactam (Unasyn)
Amprenavir (Agenerase)
Amrix (Cyclobenzaprine Hydrochloride Extended-Release Cap)
Amyl Nitrite (Amyl Nitrite)
An-Ao
Ana-Kit (Epinephrine, Chlorpheniramine)
Anabolic steroids (Winstrol)
Anadrol-50 (Oxymetholone)
Anafranil (Clomipramine Hcl)
Anagrelide (Agrylin)
Anakinra (Kineret)
Anastrozole (Arimidex)
Ancobon (Flucytosine)
Androderm (Testosterone Transdermal System)
Androgel (Testosterone Gel)
Anectine (Succinylcholine Chloride)
Angeliq (Drospirenone and Estradiol)
Angiomax (Bivalirudin)
Anhydrous Morphine (Paregoric)
Anidulafungin (Eraxis)
Anisindione (Miradon)
Ansaid (Flurbiprofen)
Antabuse (Disulfiram)
Antagon (Ganirelix)
Antara (Fenofibrate)
Anthralin (Dritho-Scalp)
Anti-Inhibitor Coagulant Complex, Heat Treated (Autoplex-T)
Antihemophilic Factor (Alphanate)
Antihemophilic Factor (Bioclate)
Antihemophilic Factor (Koate)
Antihemophilic Factor (Monoclate-P)
Antihemophilic Factor (Refacto)
Antihemophilic Factor (Xyntha)
Antihemophilic Factor (Recombinant) (Helixate FS)
Antihemophilic Factor (Recombinant) (Kogenate FS)
Antihemophilic Factor (Recombinant) (Recombinate)
Antilirium (Physostigmine Salicylate (injection))
Antipyrine, Benzocaine and Glycerin Dehydrated (Auralgan)
Antithrombin (Thrombate)
Antivenin (Crotalidae) Polyvalent (Rattlesnake Antivenin)
Antivert (Meclizine)
Antizol (Fomepizole)
Anturane (Sulfinpyrazone)
Anusol Hc (Hydrocortisone Cream)
Anzemet Injection (Dolasetron Mesylate Injection)
Anzemet Tablets (Dolasetron)
Ap-Ar
Aphrodyne (Yohimbine)
Aphthasol (Amlexanox)
Apidra (Insulin Glulisine [rDNA origin] Inj)
Apokyn (Apomorphine)
Apomorphine (Apokyn)
Apraclonidine (Iopidine Eye)
Aprepitant (Emend)
Apresazide (Hydralazine and Hydrochlorothiazide)
Apresoline (Hydralazine)
Apri (Desogestrel and Ethinyl Estradiol Tablets)
Aprotinin (Trasylol)
Aptivus (Tipranavir)
Aquamephyton (Aqueous Colloidal Solution of Vitamin K1)
Aquasol A (Vitamin A)
Aqueous Colloidal Solution of Vitamin K1 (Aquamephyton)
Aralen (Chloroquine)
Aramine (Metaraminol)
Aranesp (Darbepoetin Alfa)
Arava (Leflunomide)
Aredia (Pamidronate Disodium)
Arformoterol Tartrate Inhalation Solution (Brovana)
Argatroban (Novastan)
Aricept (Donepezil Hydrochloride)
Arimidex (Anastrozole)
Aripiprazole (Abilify)
Aristospan 5 mg (Triamcinolone Hexacetonide Injection 5 mg)
Aristospan Injection 20 mg (Triamcinolone Hexacetonide Injectable
Suspension)
Arixtra (Fondaparinux Sodium)
Armodafinil (Nuvigil)
Armour Thyroid (Thyroid tablets)
Aromasin (Exemestane)
Arranon (Nelarabine)
Arsenic (Trisenox)
Artane (Trihexyphenidyl)
Arthrotec (Diclofenac Sodium, Misoprostol)
As-At
Asacol (Mesalamine Delayed-Release Tablets)
Ascorbic Acid (Vitamin C)
Asendin (Amoxapine)
Asimia (Paroxetine Mesylate)
Asmanex Twisthaler (Mometasone Furoate)
Asparaginase (Elspar)
Aspirin (Bayer ASA)
Aspirin and Codeine (Empirin Codeine)
Aspirin, Extended-Release Dipyridamole (Aggrenox)
Aspirin, Oxycodone Hydrochloride, Oxycodone Terephthalate (Percodan)
Astelin (Azelastine Hydrochloride)
Astemizole (WITHDRAWN FROM US MARKET) (Hismanal)
Atacand (Candesartan Cilexetil)
Atacand HCT (Candesartan Cilexetil-Hydrochlorothiazide)
Atazanavir Sulfate (Reyataz)
Atenolol and Chlorthalidone (Tenoretic)
Atenolol Inj (Tenormin I.V. Injection)
Atenolol Tablets (Tenormin )
Atgam (Lymphocyte immune globulin)
Ativan (Lorazepam)
Atomoxetine HCl (Strattera)
Atorvastatin Calcium (Lipitor)
Atovaquone (Mepron)
Atovaquone and Proguanil Hcl (Malarone)
Atracurium Besylate (Tracrium)
Atralin (Tretinoin)
Atridox (Doxycycline Hyclate)
Atripla (Efavirenz, Emtricitabine, and Tenofovir Disoproxil Fumarate)
Atromid-S (Clofibrate)
Atropen (Atropine)
Atropine (Atropen)
Atropine (Atropine)
Atrovent HFA (Ipratropium Bromide (Inhalation))
Atrovent Nasal Spray (Ipratropium bromide)
Attenuvax (Measles Virus Vaccine Live)
Au-Ax
Augmentin (Amoxicillin Clavulanate)
Augmentin ES (Amoxicillin Clavulanate Potassium)
Augmentin XR (Amoxicillin Clavulanic Potassium)
Auralgan (Antipyrine, Benzocaine and Glycerin Dehydrated)
Autologous Cultured Chondrocytes for Implantation (Carticel)
Autoplex-T (Anti-Inhibitor Coagulant Complex, Heat Treated)
Avage (Tazarotene)
Avalide (Irbesartan-Hydrochlorothiazide)
Avandamet (Rosiglitazone Maleate and Metformin HCl)
Avandaryl (Rosiglitazone Maleate and Glimepiride)
Avandia (Rosiglitazone Maleate)
Avapro (Irbesartan)
Avastin (Bevacizumab)
Avelox (Moxifloxacin HCL)
Aventyl (Nortriptyline)
Aventyl Sol (Nortriptyline Hcl)
Avinza (Morphine Sulfate)
Avodart (Dutasteride)
Avonex (Interferon beta-1a)
Axert (Almotriptan Malate)
Axid (Nizatidine)
Axid Oral Solution (Nizatidine)
Ay-Az
Aygestin (Norethindrone)
Azacitidine (Vidaza)
Azactam (Aztreonam)
Azactam Injection (Aztreonam Injection)
Azasite (Azithromycin Opthalmic Solution)
Azatadine and Pseudoephedrine (Trinalin)
Azathioprine (Imuran)
Azelaic Acid Cream (Azelex)
Azelastine Hydrochloride (Astelin)
Azelastine hydrochloride (Optivar)
Azelex (Azelaic Acid Cream)
Azilect (Rasagiline)
Azithromycin (Zithromax)
Azithromycin (Zithromax Injection)
Azithromycin (Zmax)
Azithromycin Opthalmic Solution (Azasite)
Azmacort (Triamcinolone Acetonide (inhalation aerosol))
Azopt (Brinzolamide)
Aztreonam (Azactam)
Aztreonam Injection (Azactam Injection)
Azulfidine EN-Tabs (Sulfasalazine Delayed Release Tablets)

B12 (Liver-Stomach Concentrate With Intrinsic Factor)

Bacillus of Calmette and Guerin (Tice)
Bacitracin (Bacitracin)
Baclofen (Baclofen Tablets)
Baclofen (Kemstro)
Baclofen Injection (Lioresal Intrathecal)
Baclofen Tablets (Baclofen)
Bacteriostatic NaCl (Bacteriostatic Saline)
Bacteriostatic Saline (Bacteriostatic NaCl)
Bacteriostatic Water (H2O)
Bactocill (Oxacillin Sodium)
Bactrim (Trimethoprim and Sulfamethoxazole)
Bactroban Nasal (Mupirocin)
Bactroban Ointment (Mupirocin)
Bal in Oil Ampules (Dimercarprol Injection)
Balanced Salt Solution (Bss)
Balsalazide (Colazal)
Baraclude (Entecavir)
Basiliximab (Simulect)
Baycol (Cerivastatin (Removed from Market 8/2001))
Bayer ASA (Aspirin)
Baygam (Immune Globulin)
Bc-Bh
BCG Live (Intravesical) (Theracys)
Becaplermin (Regranex)
Beclomethasone Aerosol (Vanceril)
Beclomethasone Dipropionate HFA (Qvar)
Beclomethasone Dipropionate, Monohydrate (Beconase-AQ)
Beclomethasone Nasal (Beconase)
Beconase (Beclomethasone Nasal)
Beconase-AQ (Beclomethasone Dipropionate, Monohydrate)
Belladonna Alkaloids, Phenobarbital (Donnatal Extentabs)
Belladonna and Opium (Belladonna and Opium)
Benadryl (Diphenhydramine)
Benadryl Injection (Diphenhydramine Injection)
Benazepril (Lotensin)
Benazepril HCl and HCTZ (Lotensin Hct)
Bendamustine Hydrochloride Injection (Treanda)
Benefix (Coagulation Factor IX Recombinant)
Benicar (Olmesartan Medoxomil)
Benicar HCT (Olmesartan Medoxomil-Hydrochlorothiazide)
Bentyl (Dicyclomine)
BenzaClin (Clindamycin & Benzoyl Peroxide)
Benzagel (Benzoyl Peroxide Gel)
Benzamycin (Erythromycin)
Benzocaine (Americaine)
Benzocaine, Aminobenzoate and Tetracaine (Cetacaine)
Benzonatate (Benzonatate Softgels)
Benzonatate Softgels (Benzonatate)
Benzoyl Peroxide Gel (Benzagel)
Benzphetamine (Didrex)
Benztropine Mesylate (Benztropine Mesylate)
Benztropine Mesylate Injection (Cogentin)
Bepridil (Vascor)
Beractant (Survanta)
Betagan (Levobunolol)
Betaine Anhydrous (Cystadane)
Betamethasone (Celestone)
Betamethasone (Diprolene AF)
Betamethasone (Luxiq)
Betamethasone Dipropionate (Diprolene Lotion)
Betamethasone Dipropionate (Diprolene Ointment)
Betamethasone Injectable Suspension (Celestone Injection)
Betapace (Sotalol)
Betapace AF (Sotalol Hcl)
Betaseron (Interferon beta-1b)
Betaxolol Hydrochloride (Betaxolol Hydrochloride Ophthalmic)
Betaxolol Hydrochloride (Kerlone)
Betaxolol Hydrochloride Ophthalmic (Betaxolol Hydrochloride)
Betaxon (Levobetaxolol)
Bethanechol (Bethanechol Chloride)
Bethanechol Chloride (Bethanechol)
Betoptic S (Betoptic S)
Bevacizumab (Avastin)
Bexarotene (Targretin)
Bextra (Valdecoxib)
Bexxar (Tositumomab and Iodine 1131 Tositumomab)
Bi-Bn
Biavax (Rubella and Mumps Virus Vaccine Live)
Biaxin (Clarithromycin)
Bicalutamide (Casodex)
Bicillin C-R 900/300 (Penicillin G Benzathine and Penicillin G Procaine Inj)
Bicillin C-R Tubex (Penicillin G Benzathine and Penicillin G Procaine Inj)
Bicillin Cr (Penicillin G Benzathine and Penicillin G Procaine Inj)
Bicillin L-A Disposable Syringe (Penicillin G Benzathine Disposable
Syringe)
Bicillin L-A Injectable in Tubex (Penicillin G Benzathine Injectable in Tubex)
BiCNU (Carmustine)
BiDil (Isosorbide Dinitrate and Hydralazine Hcl)
Biltricide (Praziquantel)
Bimatoprost (Lumigan)
Bioclate (Antihemophilic Factor)
Biperiden (Akineton)
Bismuth Subcitrate Potassium (Pylera Capsules)
Bismuth Subsalicylate (Helidac)
Bisoprolol and Hydrochlorothiazide (Ziac)
Bisoprolol Fumarate (Zebeta)
Bivalirudin (Angiomax)
Blenoxane (Bleomycin Sulfate Injection)
Bleomycin Sulfate Injection (Blenoxane)
Bleph 10 (Sulfacetamide Ophthalmic)
Blocadren (Timolol)
Bo-Br
Boniva (Ibandronate Sodium)
Boniva Injection (Ibandronate Sodium Injection)
Boostrix (Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis
Vaccine, Adsorbed)
Bortezomib (Velcade)
Bosentan (Tracleer)
Botox (Botulinum Toxin Type A)
Botulinum Toxin Type A (Botox)
Botulinum Toxin Type B (Myoblock)
Brethine (Terbutaline Sulfate)
Bretylium (Bretylium Tosylate Injection )
Bretylium Tosylate Injection (Bretylium)
Brevibloc (Esmolol)
Brevicon (Norethindrone and Ethinyl Estradiol)
Brevital Sod (Methohexital)
Brimonidine Tartrate (Alphagan)
Brimonidine Tartrate (Alphagan-P)
Brimonidine Tartrate, Timolol Maleate Ophthalmic Solution .2%/.5%
(Combigan)
Brinzolamide (Azopt)
Bromfenac (Xibrom)
Bromocriptine Mesylate (Parlodel)
Brompheniramine, Phenylpropanolamine, and Codeine (Dimetane)
Brovana (Arformoterol Tartrate Inhalation Solution)
Bs-Bx
Bss (Balanced Salt Solution)
Budesonide (Entocort)
Budesonide (Pulmicort Turbuhaler)
Budesonide (Rhinocort Aqua)
Budesonide and Formoterol Fumarate Dihydrate (Symbicort)
Budesonide Inhalation Powder (Pulmicort Flexhaler)
Budesonide Inhalation Suspension (Pulmicort Respules)
Bumetanide (Bumex)
Bumex (Bumetanide)
Buminate (Albumin)
Bupivacaine HCI Injections (Sensorcaine)
Buprenex (Buprenorphine)
Buprenorphine (Buprenex)
Buprenorphine HCl and naloxone HCl (Suboxone)
Bupropion Hcl (Wellbutrin)
Bupropion Hcl (Zyban)
Bupropion Hydrochloride Extended-Release (Wellbutrin XL)
Bupropion Hydrochloride Sustained-Release (Wellbutrin SR)
Buspar (Buspirone)
Buspirone (Buspar)
Busulfan (Busulfex)
Busulfex (Busulfan)
Butabarbital Sodium Tablets (Butisol)
Butalbital Compound With Codeine (Fiorinal with Codeine)
Butalbital, Acetaminophen and Caffeine (Fioricet)
Butalbital, Acetaminophen, Caffeine and Codeine Phosphate Capsule
(Fioricet with Codeine)
Butenafine (Mentax)
Butisol (Butabarbital Sodium Tablets)
Butoconazole (Gynazole)
Butorphanol Tartrate (Stadol)
By-Bz
Byetta (Exenatide Injection)
Bystolic Tablets (Nebivolol Tablets)

Ca-DTPA (Pentetate Calcium Trisodium Inj)

Cabergoline (Dostinex)
Caduet (Amlodipine Besylate, Atorvastatin Calcium)
Cafcit (Caffeine Citrate)
Caffeine Alkaloid (Caffeine and Sodium Benzoate Injection)
Caffeine and Sodium Benzoate Injection (Caffeine Alkaloid)
Caffeine Citrate (Cafcit)
Calan (Verapamil HCl)
Calciferol (Ergocalciferol)
Calcijex Injection (Calcitrol)
Calcipotriene and Betamethasone Dipropionate (Taclonex)
Calcipotriene Cream (Dovonex Cream)
Calcipotriene Ointment (Dovonex Ointment)
Calcipotriene Solution (Dovonex Scalp)
Calcitonin-Salmon (Miacalcin)
Calcitonin-Salmon (rDNA origin) (Fortical)
Calcitriol (Rocaltrol)
Calcitrol (Calcijex Injection)
Calcium Chloride (Calcium Chloride Injection 10%)
Calcium Chloride Injection 10% (Calcium Chloride)
Calcium Disodium Versenate (Edetate Calcium Disodium Injection)
Calcium Gluconate (Calcium Gluconate)
Calfactant (Infasurf)
CaloMist Nasal Spray (Cyanocobalamin)
Campath (Alemtuzumab)
Campral (Acamprosate Calcium)
Camptosar Injection (Irinotecan Hydrochloride)
Canasa (Mesalamine)
Cancidas (Caspofungin Acetate)
Candesartan Cilexetil (Atacand)
Candesartan Cilexetil-Hydrochlorothiazide (Atacand HCT)
Candida Albicans (Candin)
Candin (Candida Albicans)
Capecitabine (Xeloda)
Capoten (Captopril)
Capozide (Captopril and Hydrochlorothiazide)
Captopril (Capoten)
Captopril and Hydrochlorothiazide (Capozide)
Carac (Fluorouracil)
Carafate Suspension (Sucralfate)
Carafate Tablets (Sucralfate)
Carbachol (Miostat)
Carbamazepine (Tegretol)
Carbamazepine Extended-Release (Carbatrol)
Carbamazepine XR (Equetro)
Carbatrol (Carbamazepine Extended-Release)
Carbenicillin Indanyl Sodium (Geocillin)
Carbidopa (Lodosyn)
Carbidopa, Levodopa and Entacapone (Stalevo)
Carbidopa-Levodopa (Sinemet)
Carbidopa-Levodopa Sustained Release (Sinemet CR)
Carbinoxamine Maleate and Pseudoephedrine HCl (Rondec)
Carbocaine (Mepivacaine)
Carboplatin (Paraplatin)
Carboprost Tromethamine (Hemabate)
Cardene (Nicardipine)
Cardene I.V. (Nicardipine Hydrochloride)
Cardizem Injection (Diltiazem HCl Injection)
Cardizem LA (Diltiazem)
Cardura (Doxazosin Mesylate)
Carisoprodol (Soma)
Carisoprodol and Aspirin (Carisoprodol and Aspirin)
Carmustine (BiCNU)
Carnitor (Levocarnitine Tablets, Oral Solution, Sugar-Free)
Carnitor Injection (Levocarnitine Injection)
Carteolol (Ocupress)
Carticel (Autologous Cultured Chondrocytes for Implantation)
Carvedilol (Coreg)
Carvedilol Phosphate Extended-Release (Coreg CR)
Casodex (Bicalutamide)
Caspofungin Acetate (Cancidas)
Catapres (Clonidine)
Catapres-TTS (Clonidine)
Caverject (Alprostadil Injection)
Caverject Impulse (Alprostadil Dual Chamber System for Injection)
Caverject Powder (Alprostadil Sterile Powder for Injection)
Ceclor (Cefaclor)
Cedax (Ceftibuten)
Ceenu (Lomustine)
Cefaclor (Ceclor)
Cefadroxil (Cefadroxil Hemihydrate)
Cefadroxil (Duricef)
Cefadroxil Hemihydrate (Cefadroxil)
Cefamandole (Mandol)
Cefazolin and Dextrose for Injection (Cefazolin Injection)
Cefazolin Injection (Cefazolin and Dextrose for Injection)
Cefdinir (Omnicef)
Cefditoren Pivoxil (Spectracef)
Cefepime Hydrochloride for Injection (Maxipime)
Cefixime (Suprax)
Cefizox (Ceftizoxime)
Cefotan (Cefotetan)
Cefotaxime (Cefotaxime for Injection)
Cefotaxime (Claforan)
Cefotaxime for Injection (Cefotaxime)
Cefotetan (Cefotan)
Cefoxitin (Mefoxin)
Cefpodoxmine Proxetil (Vantin)
Cefprozil (Cefzil)
Ceftazidime (Ceptaz)
Ceftazidime (Fortaz)
Ceftibuten (Cedax)
Ceftin (Cefuroxime Axetil)
Ceftizoxime (Cefizox)
Ceftriaxone (Ceftriaxone Sodium and Dextrose Injection )
Ceftriaxone (Rocephin)
Ceftriaxone Sodium and Dextrose Injection (Ceftriaxone)
Cefuroxime (Cefuroxime Injection)
Cefuroxime (Zinacef)
Cefuroxime Axetil (Ceftin)
Cefuroxime Injection (Cefuroxime)
Cefzil (Cefprozil)
Celebrex (Celecoxib)
Celecoxib (Celebrex)
Celestone (Betamethasone)
Celestone Injection (Betamethasone Injectable Suspension)
Celexa (Citalopram Hydrobromide)
CellCept (Mycophenolate Mofetil)
Cellulose (Lacrisert)
Celontin (Methsuximide)
Cenestin (Synthetic conjugated estrogens)
Cephalexin (Keflex)
Cephradine (Velosef)
Cephulac (Lactulose)
Ceprotin (Protein C Concentrate)
Ceptaz (Ceftazidime)
Cerebyx (Fosphenytoin)
Ceredase (Alglucerase Inj)
Ceretec (Technetium Tc99m Exametazime Injection)
Cerezyme (Imiglucerase)
Cerivastatin (Removed from Market 8/2001) (Baycol)
Cernevit (Multivitamins for Infusion)
Certiva (Certiva)
Cerubidine (Daunorubicin)
Cerumenex (Triethanolamine Polypeptide)
Cervidil (Dinoprostone)
Cetacaine (Benzocaine, Aminobenzoate and Tetracaine)
Cetirizine (Zyrtec)
Cetirizine, Pseudoephedrine (Zyrtec-D)
Cetrorelix (Cetrotide)
Cetrotide (Cetrorelix)
Cetuximab (Erbitux)
Cevimeline HCL (Evoxac)
Chantix (Varenicline)
Chemet (Succimer)
Chibroxin (Norfloxacin)
ChiRhoStim (Human Secretin)
Chirocaine (Levobupivacaine)
Chlor-Trimeton (Chlorpheniramine Maleate)
Chloral Hydrate (Noctec)
Chlorambucil (Leukeran)
Chloramphenicol (Chloromycetin)
Chloramphenicol (Chloroptic)
Chlordiazepoxide (Librium)
Chlordiazepoxide and Clidinium (Librax)
Chlorhexidine (Periochip)
Chloromycetin (Chloramphenicol)
Chloroprocaine (Nesacaine)
Chloroptic (Chloramphenicol)
Chloroquine (Aralen)
Chlorothiazide (Diuril)
Chlorpheniramine Maleate (Chlor-Trimeton)
Chlorpromazine (Thorazine)
Chlorpropamide (Diabinese)
Chlorthalidone (Hygroton)
Chlorzoxazone (Parafon Forte)
Cholera Vaccine (Cholera Vaccine)
Cholestyramine (Questran)
Choline Magnesium Trisalicylate (Trilisate)
Choriogonadotropin Alfa Injection (Ovidrel)
Chorionic Gonadotropin (Pregnyl)
Chromic Chloride Injection (Chromium)
Chromium (Chromic Chloride Injection)
Cialis (Tadalafil)
Ciclesonide Inhalation Aerosol (Alvesco)
Ciclesonide Nasal Spray (Omnaris)
Ciclopirox (Loprox)
Ciclopirox (Penlac Nail Lacquer)
Cidofovir (Vistide)
Cilostazol (Pletal)
Ciloxan Ophthalmic Ointment (Ciprofloxacin HCl Ophthalmic Ointment)
Ciloxan Ophthalmic Solution (Ciprofloxacin HCL Ophthalmic Solution)
Cimetidine (Tagamet)
Cinacalcet (Sensipar)
Cinobac (Cinoxacin)
Cinoxacin (Cinobac)
Cipro (Ciprofloxacin)
Cipro I.V. (Ciprofloxacin IV)
Cipro XR (Ciprofloxacin Extended-Release)
Ciprodex (Ciprofloxacin and Dexamethasone )
Ciprofloxacin (Cipro)
Ciprofloxacin and Dexamethasone (Ciprodex)
Ciprofloxacin Extended-Release (Cipro XR)
Ciprofloxacin Hcl (Proquin XR)
Ciprofloxacin HCl Ophthalmic Ointment (Ciloxan Ophthalmic Ointment)
Ciprofloxacin HCL Ophthalmic Solution (Ciloxan Ophthalmic Solution)
Ciprofloxacin IV (Cipro I.V.)
CIS-Sulfur Colloid (CIS-Sulfur Colloid)
Cisapride (Removed from US Market) (Propulsid)
Cisatracurium Besylate (Nimbex)
Cisplatin (Platinol)
Citalopram HBr (Citalopram ODT)
Citalopram Hydrobromide (Celexa)
Citalopram ODT (Citalopram HBr)
Citric Acid, Glucono-Delta-Lactone and Magnesium Carbonate Irrigation
(Renacidin)
Cladribine (Leustatin)
Claforan (Cefotaxime)
Clarinex (Desloratadine)
Clarinex-D 12hr (Desloratadine and Pseudoephedrine Sulfate)
Clarinex-D 24hr (Desloratadine and Pseudoephedrine Sulfate)
Clarithromycin (Biaxin)
Claritin (Loratadine)
Claritin D (Loratadine and Pseudoephedrine)
Clemastin (Clemastine)
Clemastine (Clemastin)
Cleocin HCL (Clindamycin)
Cleocin I.V. (Clindamycin)
Cleocin T (Clindamycin Topical)
Cleocin Vaginal Ovules (Clindamycin)
Climara (Estradiol Transdermal)
Climara Pro (Estradiol, Levonorgestrel Transdermal)
Clindamycin (Cleocin HCL)
Clindamycin (Cleocin I.V.)
Clindamycin (Cleocin Vaginal Ovules)
Clindamycin (Clindets)
Clindamycin & Benzoyl Peroxide (BenzaClin)
Clindamycin Phosphate (Evoclin)
Clindamycin Phosphate, Tretinoin (Ziana Gel)
Clindamycin Topical (Cleocin T)
Clindets (Clindamycin)
Clinoril (Sulindac)
Clobetasol Propionate (Clobex)
Clobetasol Propionate (Olux)
Clobetasol Propionate Cream and Ointment (Temovate)
Clobetasol Propionate Foam (Olux-E)
Clobetasol Propionate Gel (Temovate Gel)
Clobetasol Propionate Scalp Application (Temovate Scalp)
Clobex (Clobetasol Propionate)
Clocortolone (Cloderm)
Cloderm (Clocortolone)
Clofarabine (Clolar)
Clofazimine (Lamprene)
Clofibrate (Atromid-S)
Clolar (Clofarabine)
Clomid (Clomiphene)
Clomiphene (Clomid)
Clomipramine Hcl (Anafranil)
Clonazepam (Klonopin)
Clonidine (Catapres)
Clonidine (Catapres-TTS)
Clonidine Hydrochloride and Chlorthalidone (Clorpres)
Clonidine Injection (Duraclon)
Clopidogrel Bisulfate (Plavix)
Clorazepate (Tranxene)
Clorpres (Clonidine Hydrochloride and Chlorthalidone)
Clotrimazole (Mycelex)
Clotrimazole and Betamethasone (Lotrisone)
Clotrimazole Vaginal Cream (Gyne-Lotrimin)
Clozapine (Clozaril)
Clozapine (Fazaclo)
Clozaril (Clozapine)
Coagulation Factor IX (Human) (Mononine)
Coagulation Factor IX Recombinant (Benefix)
Coagulation Factor VIIa (Recombinant) (Novoseven)
Cocaine (Cocaine)
Codeine (Codeine Sulfate)
Codeine Phosphate (Codeine Phosphate)
Codeine Phosphate and Promethazine HCl (Phenergan-Codeine)
Codeine Sulfate (Codeine)
Cogentin (Benztropine Mesylate Injection)
Cognex (Tacrine)
Colazal (Balsalazide)
Colbenemid (Probenecid and Colchicine)
Colchicine (Colchicine)
Colesevelam Hcl (Welchol)
Colestid (Colestipol)
Colestipol (Colestid)
Colestipol (Colestitabs)
Colestitabs (Colestipol)
Colfosceril Palmitate, Cetyl Alcohol, Tyloxapol Suspension (Exosurf)
Colistimethate Injection (Coly-Mycin)
Collagenase (Santyl)
Coly-Mycin (Colistimethate Injection)
Combigan (Brimonidine Tartrate, Timolol Maleate Ophthalmic Solution .
2%/.5%)
CombiPatch (Estradiol, Norethindrone Acetate Transdermal System)
Combivent (Ipratropium Bromide and Albuterol Sulfate)
Combivir (Lamivudine, Zidovudine)
Combunox (Oxycodone HCl and Ibuprofen)
Compazine (Prochlorperazine)
Compazine Inj (Prochlorperazine)
Comtan (Entacapone)
Comvax (Haemophilus b Conjugate and Hepatitis B Vaccine)
Concerta (Methylphenidate Extended-Release Tablets)
Condylox (Podofilox)
Conivaptan Hcl Injection (Vaprisol)
Conjugated Estrogens (Premarin)
Conjugated Estrogens for Injection (Premarin Injection)
Conjugated Estrogens Vaginal Cream (Premarin Vaginal Cream)
Conjugated Estrogens, Medroxyprogesterone Acetate (Prempro)
Copaxone (Glatiramer Acetate)
Copegus (Ribavirin)
Cordarone (Amiodarone)
Cordarone Intravenous (Amiodarone)
Cordran (Flurandrenolide)
Coreg (Carvedilol)
Coreg CR (Carvedilol Phosphate Extended-Release)
Corgard (Nadolol)
Corlopam (Fenoldopam Mesylate)
Cortaid (Hydrocortisone Cream and Ointment 1.0%)
Cortenema (Hydrocortisone)
Corticorelin Ovine (Acthrel)
Cortisone Acetate (Cortone)
Cortisporin Cream (Hydrocortisone, Neomycin, Polymyxin B)
Cortisporin Ointment (Neomycin and Polymyxin B Sulfates, Bacitracin Zinc,
and Hydrocortisone)
Cortisporin Ophthalmic Ointment (Neomycin and Polymyxin B Sulfates,
Bacitracin Zinc, and Hydrocortisone Ophthalmic )
Cortisporin Ophthalmic Suspension (Neomycin and Polymyxin B Sulfates
and Hydrocortisone Opthalmic Suspension)
Cortisporin Otic Solution (Neomycin and Polymyxin B Sulfates and
Hydrocortisone Otic Solution)
Cortisporin Otic Suspension (Neomycin and Polymyxin B Sulfates and
Hydrocortisone Otic Suspension)
Cortone (Cortisone Acetate)
Cortrosyn (Cosyntropin)
Corvert (Ibutilide)
Corzide (Nadolol and Bendroflumethiazide)
Cosmegen (Dactinomycin)
Cosopt (Dorzolamide Hydrochloride-Timolol Maleate)
Cosyntropin (Cortrosyn)
Coumadin (Warfarin Sodium)
Covera-HS (Verapamil)
Cozaar (Losartan Potassium)
Creon (Lipase, Protease and Amylase)
Crestor (Rosuvastatin Calcium)
Crixivan (Indinavir Sulfate)
Crofab (Crotalidae Polyvalent Immune Fab Ovine)
Crolom (Cromolyn Ophthalmic)
Cromolyn (Opticrom)
Cromolyn Ophthalmic (Crolom)
Cromolyn Sodium (Nasalcrom)
Cromolyn Sodium Inhalation Aerosol (Intal Inhaler)
Cromolyn Sodium Inhalation Solution (Intal Nebulizer Solution)
Crotalidae Polyvalent Immune Fab Ovine (Crofab)
Crotamiton Cream, Lotion (Eurax)
Cubicin (Daptomycin Injection)
Cuprimine (Penicillamine)
Curosurf (Poractant Alfa)
Cutivate (Fluticasone)
Cyanocobalamin (CaloMist Nasal Spray)
Cyanocobalamin (Cyanocobalamin)
Cyanocobalamin (Nascobal)
Cyanokit (Hydroxocobalamin for Injection)
Cyclessa (Desogestrel Ethinyl Estradiol Tablets)
Cyclobenzaprine Hcl (Flexeril)
Cyclobenzaprine Hydrochloride Extended-Release Cap (Amrix)
Cyclocort (Amcinonide)
Cyclophosphamide (Cytoxan)
Cyclosporine (Neoral)
Cyclosporine (Restasis)
Cyclosporine (Sandimmune)
Cyklokapron (Tranexamic Acid)
Cylert (Pemoline)
Cymbalta (Duloxetine Hcl)
Cyproheptadine (Periactin)
Cystadane (Betaine Anhydrous)
Cystagon (Cysteamine Bitartrate)
Cysteamine Bitartrate (Cystagon)
Cytadren (Aminoglutethimide)
Cytarabine Injectable (Cytosar)
Cytarabine Liposome Injection (DepoCyt)
Cytogam (Cytomegalovirus Immune Globulin Intravenous Human)
Cytomegalovirus Immune Globulin Intravenous Human (Cytogam)
Cytomel (Liothyronine Sodium)
Cytosar (Cytarabine Injectable)
Cytotec (Misoprostol)
Cytovene (Ganciclovir)
Cytoxan (Cyclophosphamide)

D. H. E. 45 (Dihydroergotamine)
Dacarbazine (Dtic-Dome)
Daclizumab (Zenapax)
Dactinomycin (Cosmegen)
Dalmane (Flurazepam)
Dalteparin (Fragmin)
Danazol (Danocrine)
Danocrine (Danazol)
Dantrium (Dantrolene Sodium)
Dantrium Capsules (Dantrolene Sodium Capsules)
Dantrolene Sodium (Dantrium)
Dantrolene Sodium Capsules (Dantrium Capsules)
Dapsone (Aczone Gel)
Dapsone (Dapsone)
Daptomycin Injection (Cubicin)
Daranide (Dichlorphenamide)
Daraprim (Pyrimethamine)
Darbepoetin Alfa (Aranesp)
Darifenacin (Enablex)
Darunavir (Prezista)
Darvocet-N (Propoxyphene Napsylate and Acetaminophen)
Darvon (Propoxyphene)
Darvon Compound (Propoxyphene, Aspirin, and Caffeine)
Dasatinib (Sprycel)
Daunorubicin (Cerubidine)
Daypro (Oxaprozin Caplets)
Daypro Alta (Oxaprozin)
Daytrana (Methylphenidate Transdermal)
DDAVP Injection (Desmopressin Acetate Injection)
DDAVP Nasal Spray (Desmopressin Acetate Nasal Spray)
DDAVP Rhinal Tube (Desmopressin Acetate Rhinal Tube)
DDAVP Tablets (Desmopressin Acetate)
DDAVP Tablets (Desmopressin Acetate Tablets)
Decadron (Dexamethasone )
Declomycin (Demeclocycline HCl)
Deconamine (Guaifenesin, Hydrocodone, Pseudoephedrine)
Deferasirox (Exjade)
Deferoxamine (Desferal)
Definity (Perflutren Lipid Microsphere)
Dehydrated Alcohol (Dehydrated Alcohol Injection)
Dehydrated Alcohol Injection (Dehydrated Alcohol)
Delatestryl (Testosterone Enanthate)
Delavirdine Mesylate (Rescriptor)
Delestrogen (Estradiol valerate)
Deltasone (Prednisone)
Demadex (Torsemide)
Demecarium (Humorsol)
Demeclocycline HCl (Declomycin)
Demerol (Meperidine)
Demser (Metyrosine)
Denavir (Penciclovir)
Denileukin Diftitox (Ontak)
Depacon (Valproate Sodium Inj)
Depakene (Valproic Acid)
Depakote (Divalproex Sodium Delayed Release Tablets)
Depakote ER (Divalproex Sodium)
Depakote Sprinkle Capsules (Divalproex Sodium Sprinkle Capsules)
Depo Medrol (Methylprednisolone)
Depo Provera (Medroxyprogesterone)
Depo-SubQ Provera (Medroxyprogesterone Acetate)
DepoCyt (Cytarabine Liposome Injection)
DepoDur (Morphine Sulfate XR Liposome Injection)
Derma-Smoothe Scalp/FS (Fluocinolone Acetonide)
Derma-Smoothe/FS (Fluocinolone Acetonide)
Dermatop (Prednicarbate)
Desferal (Deferoxamine)
Desflurane (Suprane)
Desipramine Hydrochloride (Norpramin)
Desloratadine (Clarinex)
Desloratadine and Pseudoephedrine Sulfate (Clarinex-D 12hr)
Desloratadine and Pseudoephedrine Sulfate (Clarinex-D 24hr)
Desmopressin Acetate (DDAVP Tablets)
Desmopressin Acetate (Stimate)
Desmopressin Acetate Injection (DDAVP Injection)
Desmopressin Acetate Nasal Spray (DDAVP Nasal Spray)
Desmopressin Acetate Rhinal Tube (DDAVP Rhinal Tube)
Desmopressin Acetate Tablets (DDAVP Tablets)
Desogen (Desogestrel and Ethinyl Estradiol Tablets)
Desogestrel and Ethinyl Estradiol Tablets (Apri)
Desogestrel and Ethinyl Estradiol Tablets (Desogen)
Desogestrel Ethinyl Estradiol Tablets (Cyclessa)
Desogestrel, Ethinyl Estradiol and Ethinyl Estradiol (Mircette)
Desonide (Tridesilon)
Desoximetasone (Topicort)
Desoxyn (Methamphetamine Hydrochloride)
Desyrel (Trazodone Hydrochloride)
Detrol (Tolterodine Tartrate)
Detrol LA (Tolterodine Tartrate)
Dexamethasone (Decadron)
Dexamethasone (Dexone)
Dexedrine (Dextroamphetamine)
Dexfenfluramine (FDA Removed From US Market 9/15/97) (Redux)
Dexmedetomidine hydrochloride (Precedex)
Dexmethylphenidate Hydrochloride (Focalin)
Dexmethylphenidate Hydrochloride (Focalin XR)
Dexone (Dexamethasone)
Dexrazoxane (Totect)
Dexrazoxane (Zinecard)
Dextroamphetamine (Dexedrine)
Dextros Injection 5% (Hydrous Dextrose)
Dextrose / Electrolytes No. 48 (5% Dextrose and Electrolyte No. 48 Inj)
Dextrose / Electrolytes No. 75 (5% Dextrose and Electrolyte No. 75 Inj)
Dextrose 5% in 0.9% Sodium Chloride (Dextrose and Sodium Chloride Inj)
Dextrose and Sodium Chloride Inj (Dextrose 5% in 0.9% Sodium Chloride)
Dht (Dihydrotachysterol)
Diabinese (Chlorpropamide)
Diamox Sequels (Acetazolamide XR)
Dianeal Low Calcium (Low Calcium Peritoneal Dialysis Solutions)
Dianeal PD-1 (Peritoneal Dialysis Solution)
Dianeal PD-2 (Peritoneal Dialysis Solution)
Diastat (Diazepam Rectal Gel)
Diazepam (Valium Tablets)
Diazepam Injection (Valium Injection)
Diazepam Rectal Gel (Diastat)
Dibenzyline (Phenoxybenzamine)
Dichlorphenamide (Daranide)
Diclofenac Epolamine Topical Patch (Flector Patch)
Diclofenac Sodium (Solaraze)
Diclofenac Sodium (Voltaren)
Diclofenac Sodium Opthalmic Solution (Voltaren Opthalmic)
Diclofenac Sodium, Misoprostol (Arthrotec)
Dicloxacillin (Dynapen)
Dicyclomine (Bentyl)
Didanosine (Videx)
Didrex (Benzphetamine)
Didronel (Etidronate Disodium)
Dienestrol (Dienestrol)
Diethylpropion (Tenuate)
Difenoxin and Atropine (Motofen)
Differin Gel .1% (Adapalene Gel)
Differin Gel .3% (Adapalene)
Diflorasone (Maxiflor)
Diflucan (Fluconazole)
Diflunisal (Dolobid)
Digibind (Digoxin Immune Fab)
Digitek (Digoxin Tablets)
Digoxin (Lanoxin)
Digoxin Immune Fab (Digibind)
Digoxin Tablets (Digitek)
Dihydroergotamine (D. H. E. 45)
Dihydrotachysterol (Dht)
Dilantin (Phenytoin)
Dilaudid (Hydromorphone Hydrochloride)
Dilaudid-HP (Hydromorphone Hydrochloride Injection)
Diltiazem (Cardizem LA)
Diltiazem Hcl (Tiazac)
Diltiazem HCl Injection (Cardizem Injection)
Dimercarprol Injection (Bal in Oil Ampules)
Dimetane (Brompheniramine, Phenylpropanolamine, and Codeine)
Dinoprostone (Cervidil)
Dinoprostone (Prostin E2)
Dinoprostone cervical (Prepidil)
Diovan (Valsartan)
Diovan HCT (Valsartan and Hydrochlorothiazide)
Dipentum (Olsalazine)
Diphenhydramine (Benadryl)
Diphenhydramine Injection (Benadryl Injection)
Diphenoxylate & Atropine (Lomotil)
Diphtheria and Tetanus (Diphtheria and Tetanus Toxoids)
Diphtheria and Tetanus Toxoids (Diphtheria and Tetanus)
Diphtheria and Tetanus Toxoids and Acellular Pertussis (Infanrix)
Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine (Tripedia)
Diphtheria and Tetanus Toxoids and Pertussis Vaccine Adsorbed USP (DTP)
Diphtheria CRM197 Protein Conjugate (HibTITER)
Dipivefrin (Propine)
Diprivan (Propofol)
Diprolene AF (Betamethasone)
Diprolene Lotion (Betamethasone Dipropionate)
Diprolene Ointment (Betamethasone Dipropionate)
Dipyridamole (Persantine)
Dirithromycin (Dynabac)
Disalcid (Salsalate)
Disopyramide (Norpace)
Disulfiram (Antabuse)
Ditropan (Oxybutynin Tablets and Syrup)
Ditropan XL (Oxybutynin Chloride Extended Release Tablets)
Diucardin (Hydroflumethiazide)
Diuril (Chlorothiazide)
Divalproex Sodium (Depakote ER)
Divalproex Sodium Delayed Release Tablets (Depakote)
Divalproex Sodium Sprinkle Capsules (Depakote Sprinkle Capsules)
DMSO (Rimso-50)
Dobutamine (Dobutamine)
Docetaxel for Inj (Taxotere)
Dofetilide (Tikosyn)
Dolasetron (Anzemet Tablets)
Dolasetron Mesylate Injection (Anzemet Injection)
Dolobid (Diflunisal)
Dolophine (Methadone)
Donepezil Hydrochloride (Aricept)
Donnatal Extentabs (Belladonna Alkaloids, Phenobarbital)
Dopamine (Dopamine Hydrochloride)
Dopamine Hydrochloride (Dopamine)
Dopar (Levodopa)
Dopram (Doxapram)
Doral (Quazepam Tablets)
Doribax (Doripenem for Injection)
Doripenem for Injection (Doribax)
Dornase alfa (Pulmozyme)
Doryx (Doxycycline Hyclate)
Dorzolamide (Trusopt)
Dorzolamide Hydrochloride-Timolol Maleate (Cosopt)
Dostinex (Cabergoline)
Dovonex Cream (Calcipotriene Cream)
Dovonex Ointment (Calcipotriene Ointment)
Dovonex Scalp (Calcipotriene Solution)
Doxacurium Chloride (Nuromax)
Doxapram (Dopram)
Doxazosin Mesylate (Cardura)
Doxepin (Prudoxin)
Doxepin (Sinequan)
Doxepin (Zonalon)
Doxercalciferol (Hectorol)
Doxercalciferol (Hectorol Inj)
Doxil (Doxorubicin Hcl)
Doxorubicin Hcl (Doxil)
Doxorubicin hydrochloride (Adria)
Doxycycline (Monodox)
Doxycycline (Oracea)
Doxycycline Calcium Oral Suspension (Vibramycin Oral)
Doxycycline Hyclate (Atridox)
Doxycycline Hyclate (Doryx)
Doxycycline Hyclate (Periostat)
Doxycycline hyclate (Vibramycin Intravenous)
Dritho-Scalp (Anthralin)
Dronabinol (Marinol)
Droperidol (Inapsine)
Drospirenone and Estradiol (Angeliq)
Drospirenone and Ethinyl Estradiol (Yasmin)
Drospirenone and Ethinyl Estradiol (Yaz)
Drotrecogin alfa (Xigris)
Dtic-Dome (Dacarbazine)
DTP (Diphtheria and Tetanus Toxoids and Pertussis Vaccine Adsorbed USP)
Duagen (Dutasteride)
Duetact (Pioglitazone)
Duloxetine Hcl (Cymbalta)
Duoneb (Ipratropium Bromide)
Duraclon (Clonidine Injection)
Duragesic (Fentanyl Transdermal)
Duramorph (Morphine (injection))
Duranest (Etidocaine HCl)
Duratuss (Guaifenesin and Pseudoephedrine)
Duricef (Cefadroxil)
Dutasteride (Avodart)
Dutasteride (Duagen)
Dutoprol (Metroprolol)
Dyazide (Hydrochlorothiazide and Triamterene)
Dynabac (Dirithromycin)
Dynacirc (Isradipine)
Dynacirc CR (Isradipine)
Dynapen (Dicloxacillin)
Dyphylline (Lufyllin)
Dyrenium (Triamterene)

E.E.S. (Erythromycin Ethylsuccinate)

Echinacea (Echinacea)
Econazole Nitrate (Spectazole)
Eculizumab (Soliris)
Edecrin (Ethacrynic Acid)
Edetate (Endrate)
Edetate Calcium Disodium Injection (Calcium Disodium Versenate)
Edex (Alprostadil for Inj)
Edrophonium Chloride and Atropine Sulfate (Enlon Plus)
Edrophonium Injection (Enlon)
Efalizumab (Raptiva)
Efavirenz (Sustiva)
Efavirenz, Emtricitabine, and Tenofovir Disoproxil Fumarate (Atripla)
Effexor (Venlafaxine Hydrochloride)
Effexor XR (Venlafaxine Hydrochloride)
Eflornithine (Vaniqa)
Efudex (Fluorouracil)
Elaprase (Idursulfase Solution)
Elavil (Amitriptyline)
Eldepryl (Selegiline Hcl)
Eldopaque (Hydroquinone 4% Cream)
Elestat (Epinastine)
Eletriptan hydrobromide (Relpax)
Elidel (Pimecrolimus Cream)
Eligard (Leuprolide Acetate)
Elimite (Permethrin)
Elitek (Rasburicase)
Ellence (Epirubicin hydrochloride)
Elmiron (Pentosan)
Elocon (Mometasone Furoate)
Elocon Lotion (Mometasone Furoate Lotion)
Elocon Ointment (Mometasone Furoate Ointment)
Eloxatin (Oxaliplatin Injection)
Elspar (Asparaginase)
Emadine (Emedastine)
Emcyt (Estramustine)
Emedastine (Emadine)
Emend (Aprepitant)
Emend Injection (Fosaprepitant Dimeglumine Injection)
Emgel (Erythromycin)
Emla (Lidocaine and Prilocaine)
Empirin Codeine (Aspirin and Codeine)
Emsam (Selegiline Transdermal System)
Emtricitabine (Emtriva)
Emtricitabine and Tenofovir Disoproxil Fumarate (Truvada)
Emtriva (Emtricitabine)
Enablex (Darifenacin)
Enalapril (Vasotec)
Enalapril Maleate-Felodipine (Lexxel)
Enalaprilat Injection (Enalaprilat Injection)
Enbrel (Etanercept)
Endocet (Oxycodone and Acetaminophen Tablets)
Endometrin (Progesterone)
Endrate (Edetate)
Enduron (Methyclothiazide)
Enflurane (Ethrane)
Enfuvirtide (Fuzeon)
Enjuvia (Synthetic Conjugated Estrogens, B)
Enlon (Edrophonium Injection)
Enlon Plus (Edrophonium Chloride and Atropine Sulfate)
Enoxacin (Penetrex)
Enoxaparin Sodium Injection (Lovenox)
Entacapone (Comtan)
Entecavir (Baraclude)
Entex La (Guaifenesin and Phenylephrine)
Entex Pse (Pseudoephedrine and Guaifenesin)
Entocort (Budesonide)
Entravirine Tablets (Intelence)
Ephedrine (Ephedrine)
Epinastine (Elestat)
Epinephrine (Adrenalin)
Epinephrine (Primatene)
Epinephrine Auto Injector (Epipen)
Epinephrine, Chlorpheniramine (Ana-Kit)
Epipen (Epinephrine Auto Injector)
Epirubicin hydrochloride (Ellence)
Epivir (Lamivudine)
Eplerenone (Inspra)
Epoetin Alfa (Epogen)
Epoetin Alfa (Procrit)
Epogen (Epoetin Alfa)
Epoprostenol sodium (Flolan)
Eprosartan Mesylate (Teveten)
Eptifibatide (Integrilin)
Epzicom (Abacavir Sulfate and Lamivudine Tablets)
Equagesic (Meprobamate and Aspirin)
Equetro (Carbamazepine XR)
Eraxis (Anidulafungin)
Erbitux (Cetuximab)
Ergamisol (Levamisole Hydrochloride)
Ergocalciferol (Calciferol)
Ergostat (Ergotamine)
Ergotamine (Ergostat)
Ergotamine - Caffeine (Ergotamine Tartrate and Caffeine)
Ergotamine and Caffeine (Wigraine)
Ergotamine Tartrate and Caffeine (Ergotamine - Caffeine)
Erlotinib (Tarceva)
Ertaczo (Sertaconazole Nitrate)
Ertapenem Injection (Invanz)
Ery (Erythromycin)
Ery Ped (Erythromycin Ethylsuccinate)
Eryc (Erythromycin Delayed-Release)
Erythrocin (Erythromycin Lactobionate)
Erythromycin (Benzamycin)
Erythromycin (Emgel)
Erythromycin (Ery)
Erythromycin (Ilotycin)
Erythromycin (Staticin)
Erythromycin and Sulfisoxazole (Pediazole)
Erythromycin Delayed-Release (Eryc)
Erythromycin Ethylsuccinate (E.E.S.)
Erythromycin Ethylsuccinate (Ery Ped)
Erythromycin Lactobionate (Erythrocin)
Erythromycin PCE (PCE)
Escitalopram Oxalate (Lexapro)
Esclim (Estradiol Transdermal)
Eskalith (Lithium Carbonate)
Esmolol (Brevibloc)
Esomeprazole Magnesium (Nexium)
Esomeprazole Sodium (Nexium I.V.)
Essential Amino Acid Inj (Nephramine)
Estazolam (Prosom)
Esterified Estrogens and Methyltestosterone (Estratest)
Estinyl (Ethinyl Estradiol)
Estrace (Estradiol)
Estrace Vaginal Cream (Estradiol Vaginal Cream)
Estraderm (Estradiol Transdermal)
Estradiol (Estrace)
Estradiol (Evamist)
Estradiol (Vagifem)
Estradiol Acetate (Femring)
Estradiol Gel (EstroGel)
Estradiol Transdermal (Climara)
Estradiol Transdermal (Esclim)
Estradiol Transdermal (Estraderm)
Estradiol Transdermal System (Alora)
Estradiol Transdermal System (Vivelle-Dot)
Estradiol Vaginal Cream (Estrace Vaginal Cream)
Estradiol Vaginal Ring (Estring)
Estradiol valerate (Delestrogen)
Estradiol, Levonorgestrel Transdermal (Climara Pro)
Estradiol, Norethindrone Acetate (Activella)
Estradiol, Norethindrone Acetate Transdermal System (CombiPatch)
Estradiol, Norgestimate (Prefest)
Estramustine (Emcyt)
Estratest (Esterified Estrogens and Methyltestosterone)
Estring (Estradiol Vaginal Ring)
EstroGel (Estradiol Gel)
Estrogens (Menest)
Estropipate (Ogen)
Estrostep 21 (Norethindrone Acetate and Ethinyl Estradiol)
Estrostep Fe (Norethindrone Acetate and Ethinyl Estradiol Tablets)
Eszopiclone (Lunesta)
Etanercept (Enbrel)
Ethacrynic Acid (Edecrin)
Ethambutol (Myambutol)
Ethamolin (Ethanolamine Oleate)
Ethanolamine Oleate (Ethamolin)
EtheDent (Sodium Fluoride)
Ethinyl Estradiol (Estinyl)
Ethinyl Estradiol and Ethynodiol Diacetate (Zovia)
Ethiodized Oil (Ethiodol)
Ethiodol (Ethiodized Oil)
Ethionamide Tablets (Trecator)
Ethosuximide (Zarontin)
Ethotoin (Peganone)
Ethrane (Enflurane)
Ethyl Chloride (Ethyl Chloride)
Ethyol (Amifostine)
Etidocaine HCl (Duranest)
Etidronate Disodium (Didronel)
Etodolac (Lodine)
Etodolac Extended Release (Etodolac XR)
Etodolac XR (Etodolac Extended Release)
Etonogestrel Implant (Implanon)
Etonogestrel, Ethinyl Estradiol Vaginal Ring (Nuvaring)
Etopophos (Etoposide Phosphate)
Etoposide (Vepesid)
Etoposide Phosphate (Etopophos)
Etrafon (Perphenazine and Amitriptyline)
Eulexin (Flutamide)
Eurax (Crotamiton Cream, Lotion)
Evamist (Estradiol )
Evista (Raloxifene)
Evoclin (Clindamycin Phosphate)
Evoxac (Cevimeline HCL)
Exelderm (Sulconazole)
Exelon (Rivastigmine Tartrate)
Exelon Patch (Rivastigmine Transdermal System)
Exemestane (Aromasin)
Exenatide Injection (Byetta)
Exforge (Amlodipine and Valsartan)
Exjade (Deferasirox)
Exosurf (Colfosceril Palmitate, Cetyl Alcohol, Tyloxapol Suspension)
Extina (Ketoconazole Foam, 2%)
Extraneal (Icodextrin)
Exubera (Insulin Human [rDNA origin])
Ezetimibe & Simvastatin (Vytorin)
Ezetimibe Tablets (Zetia)

Fabrazyme (Agalsidase Beta)

Factive (Gemifloxacin mesylate)
Factor IX Complex (Konyne)
Factor IX Complex (Proplex-T)
Factrel (Gonadorelin)
Famciclovir (Famvir)
Famotidine (Pepcid)
Famotidine Injection (Pepcid Injection)
Famvir (Famciclovir)
Fansidar (Sulfadoxine and Pyrimethamine)
Fareston (Toremifene)
Faslodex (Fulvestrant)
Fastin (Phentermine)
Fazaclo (Clozapine)
FDG (Fluorodeoxyglucose F18 Injection)
Feiba Vh (Feiba VH)
Felbamate (Felbatol)
Felbatol (Felbamate)
Feldene (Piroxicam)
Felodipine (Plendil)
Femara (Letrozole)
Femcon Fe (Norethindrone and Ethinyl Estradiol Tablets)
Femhrt (Norethindrone Acetate, Ethinyl Estradiol)
Femring (Estradiol Acetate)
Fenfluramine - Removed from US Market (Pondimin)
Fenofibrate (Antara)
Fenofibrate (Fenofibrate 40 mg/ 120 mg)
Fenofibrate (Lipofen)
Fenofibrate (Tricor)
Fenofibrate (Triglide)
Fenofibrate 40 mg/ 120 mg (Fenofibrate)
Fenoldopam Mesylate (Corlopam)
Fenoprofen Calcium (Nalfon)
Fentanyl Buccal Tablet (Fentora)
Fentanyl Citrate (Actiq)
Fentanyl Iontophoretic Transdermal System (Ionsys)
Fentanyl Transdermal (Duragesic)
Fentora (Fentanyl Buccal Tablet)
Ferrlecit (Sodium ferric gluconate)
Fertinex (Urofollitropin)
Fexofenadine Hcl (Allegra)
Fexofenadine HCl 180 and Pseudoephendrine HCl 240 (Allegra-D 24 Hour)
Fexofenadine HCl and Pseudoephedrine HCl (Allegra-D)
Filgrastim (Neupogen)
Finasteride (Propecia)
Finasteride (Proscar)
Fioricet (Butalbital, Acetaminophen and Caffeine)
Fioricet with Codeine (Butalbital, Acetaminophen, Caffeine and Codeine
Phosphate Capsule)
Fiorinal with Codeine (Butalbital Compound With Codeine)
Flagyl (Metronidazole)
Flagyl Injection (Metronidazole Injection)
Flavocoxid (Limbrel)
Flavoxate HCl (Urispas)
Flecainide (Tambocor)
Flector Patch (Diclofenac Epolamine Topical Patch)
Flexeril (Cyclobenzaprine Hcl)
Flo-Pred (Prednisolone Acetate Oral Suspension)
Flolan (Epoprostenol sodium)
Flomax (Tamsulosin Hydrochloride)
Flonase (Fluticasone propionate)
Florinef (Fludrocortisone)
Flourometholone Opthalmic Suspension (FML)
Flovent (Fluticasone Propionate)
Flovent Diskus (Fluticasone Propionate)
Flovent HFA (Fluticasone Propionate HFA)
Floxin (Ofloxacin)
Floxin Otic (Ofloxacin Otic Solution)
Floxin Otic Singles (Ofloxacin Otic Solution)
Floxuridine (Fudr)
Fluarix (Influenza Virus Vaccine)
Fluconazole (Diflucan)
Flucytosine (Ancobon)
Fludara (Fludarabine)
Fludarabine (Fludara)
Fludrocortisone (Florinef)
Flulaval (Flulaval)
Flumadine (Rimantadine)
Flumazenil (Romazicon)
FluMist (Influenza Virus Vaccine)
Flunisolide (Aerobid)
Flunisolide (Nasal Spray) (Nasalide)
Flunisolide Hemihydrate (Aerospan HFA)
Fluocinolone (Fluocinolone Acetonide)
Fluocinolone Acetonide (Derma-Smoothe Scalp/FS)
Fluocinolone Acetonide (Derma-Smoothe/FS)
Fluocinolone Acetonide (Fluocinolone)
Fluocinolone Acetonide (Synalar)
Fluocinolone Acetonide Intravitreal Implant (Retisert)
Fluocinonide (Lidex)
Fluocinonide (Vanos)
Fluorescein (Fluorescite)
Fluorescein and Benoxinate (Fluress)
Fluorescite (Fluorescein)
Fluoride (Acidul)
Fluorodeoxyglucose F18 Injection (FDG)
Fluorometholone (FML Forte)
Fluorouracil (Carac)
Fluorouracil (Efudex)
Fluothane (Halothane)
Fluoxetine Hcl (Prozac)
Fluoxetine Hydrochloride (Sarafem)
Fluoxymesterone (Halotestin)
Fluphenazine (Prolixin)
Flurandrenolide (Cordran)
Flurazepam (Dalmane)
Flurbiprofen (Ansaid)
Flurbiprofen (Ocufen)
Fluress (Fluorescein and Benoxinate)
Flutamide (Eulexin)
Fluticasone (Cutivate)
Fluticasone Furoate (Veramyst)
Fluticasone Propionate (Advair Diskus)
Fluticasone propionate (Flonase)
Fluticasone Propionate (Flovent)
Fluticasone Propionate (Flovent Diskus)
Fluticasone propionate and Salmeterol (Advair HFA)
Fluticasone Propionate HFA (Flovent HFA)
Fluvastatin Sodium (Lescol)
Fluvirin (Influenza Virus Vaccine)
Fluvoxamine Maleate (Luvox Tablets)
Fluzone (Influenza Virus Vaccine)
FML (Flourometholone Opthalmic Suspension)
FML Forte (Fluorometholone)
Focalin (Dexmethylphenidate Hydrochloride)
Focalin XR (Dexmethylphenidate Hydrochloride)
Folacin, Cyanocobalamin & Pyridoxine (Foltx)
Folic Acid (Folvite)
Follistim (Follitropin Beta)
Follitropin Alfa (Gonal-F)
Follitropin Alfa Inj (Gonal-f RFF)
Follitropin Beta (Follistim)
Foltx (Folacin, Cyanocobalamin & Pyridoxine)
Folvite (Folic Acid)
Fomepizole (Antizol)
Fomivirsen (Vitravene)
Fondaparinux Sodium (Arixtra)
Foradil (Formoterol Fumarate)
Foradil Certihaler (Formoterol Fumarate Inhalation Powder)
Forane (Isoflurane)
Formoterol Fumarate (Foradil)
Formoterol Fumarate Inhalation Powder (Foradil Certihaler)
Formoterol Fumarate Inhalation Solution (Perforomist)
Fortamet (Metformin Hcl)
Fortaz (Ceftazidime)
Forteo (Teriparatide (rDNA origin) Injection)
Fortical (Calcitonin-Salmon (rDNA origin))
Fosamax (Alendronate Sodium)
Fosamax Plus D (Alendronate Sodium & Cholecalciferol)
Fosamprenavir Calcium (Lexiva)
Fosaprepitant Dimeglumine Injection (Emend Injection)
Foscarnet Sodium Injection (Foscavir)
Foscavir (Foscarnet Sodium Injection)
Fosfomycin (Monurol)
Fosinopril sodium (Monopril)
Fosinopril Sodium-Hydrochlorothiazide Tablets (Monopril HCT)
Fosphenytoin (Cerebyx)
Fragmin (Dalteparin)
Frova (Frovatriptan Succinate)
Frovatriptan Succinate (Frova)
Fudr (Floxuridine)
Fulvestrant (Faslodex)
Fulvicin (Griseofulvin Microsize)
Fungizone (Amphotericin B)
Furazolidone (Furoxone)
Furosemide (Lasix)
Furoxone (Furazolidone)
Fuzeon (Enfuvirtide)

Gabapentin (Neurontin)
Gabitril (Tiagabine Hydrochloride)
Gadodiamide (Omniscan)
Gadopentetate Dimeglumine (Magnevist)
Gadoteridol Injection Solution (ProHance)
Gadoversetamide Injection (OptiMARK)
Galantamine HBr (Razadyne (formerly Reminyl))
Galantamine HBr ER (Razadyne ER)
Galsulfase (Naglazyme)
Gammagard (Immune Globulin)
Ganciclovir (Cytovene)
Ganciclovir (Vitrasert)
Ganirelix (Antagon)
Gantanol (Sulfamethoxazole)
Gantrisin (Acetyl Sulfisoxazole)
Gardasil (Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18)
Recombinant Vaccine)
Gatifloxacin (Removed from US Market - May 2006) (Tequin)
Gatifloxacin Ophthalmic Solution (Zymar)
Gemcitabine Hcl (Gemzar)
Gemfibrozil (Lopid)
Gemifloxacin mesylate (Factive)
Gemtuzumab Ozogamicin for Injection (Mylotarg)
Gemzar (Gemcitabine Hcl)
Genoptic (Gentamicin Sulfate Ophthalmic)
Genotropin (Somatropin [rDNA origin])
Gentamicin and Prednisolone Acetate (Pred-G)
Gentamicin Sulfate Ophthalmic (Genoptic)
Geocillin (Carbenicillin Indanyl Sodium)
Geodon (Ziprasidone)
Geref (Sermorelin)
Getfitinib (Iressa)
Ginkgo biloba (Ginkgo Biloba)
Ginseng (Korean (Panax) Ginseng)
Glatiramer Acetate (Copaxone)
Gleevec (Imatinib Mesylate)
Gliadel (Polifeprosan 20 with Carmustine)
Glimepiride (Amaryl)
Glipizide (Glucotrol)
Glipizide and Metformin (Metaglip)
Glipizide Extended Release (Glucotrol XL)
GlucaGen (Glucagon [rDNA origin]) for Injection)
Glucagon [rDNA origin]) for Injection (GlucaGen)
Glucophage (Metformin Hcl)
Glucotrol (Glipizide)
Glucotrol XL (Glipizide Extended Release)
Glucovance (Glyburide and Metformin)
Glumetza (Metformin Hcl)
Glyburide (Micronase)
Glyburide and Metformin (Glucovance)
Glycopyrrolate (Robinul)
Glyset (Miglitol)
Go-Lytely (PEG Electrolytes Solution)
Gold Thiomalate (Myochrysine)
Gonadorelin (Factrel)
Gonal-F (Follitropin Alfa)
Gonal-f RFF (Follitropin Alfa Inj)
Goserelin (Zoladex)
Goserelin Acetate Implant (Zoladex Implant)
Granisetron (Kytril)
Granisetron Hydrochloride (Kytril Injection)
Grepafloxacin (Raxar)
Gris Peg (Griseofulvin)
Griseofulvin (Gris Peg)
Griseofulvin Microsize (Fulvicin)
Guaifenesin (Humibid La)
Guaifenesin (Organidin)
Guaifenesin and Codeine (Robitussin Ac)
Guaifenesin and Phenylephrine (Entex La)
Guaifenesin and Pseudoephedrine (Duratuss)
Guaifenesin, Hydrocodone, Pseudoephedrine (Deconamine)
Guanethidine Monosulfate (Ismelin)
Guanfacine (Guanfacine Hydrochloride)
Guanfacine Hydrochloride (Guanfacine)
Gynazole (Butoconazole)
Gyne-Lotrimin (Clotrimazole Vaginal Cream)
H-Big (Hepatitis B Immune Globulin (Human))
H2O (Bacteriostatic Water)
Haemophilus b Conjugate and Hepatitis B Vaccine (Comvax)
Haemophilus b Conjugate Vaccine (ActHIB)
Haemophilus b Conjugate Vaccine (Pedvax HIB)
Haemophilus b Conjugate Vaccine (Prohibit)
Halcinonide (Halog)
Halcion (Triazolam)
Haldol (Haloperidol)
HalfLytely and Bisacodyl Tablets (Sodium Chloride-Sodium Bicarbonate and
Potassium Chloride)
Halobetasol Propionate (Ultravate)
Halog (Halcinonide)
Haloperidol (Haldol)
Halotestin (Fluoxymesterone)
Halothane (Fluothane)
Havrix (Hepatitis A Vaccine, Inactivated)
Healon (Sodium Hyaluronate)
Hectorol (Doxercalciferol)
Hectorol Inj (Doxercalciferol)
Helidac (Bismuth Subsalicylate)
Helixate FS (Antihemophilic Factor (Recombinant))
Hemabate (Carboprost Tromethamine)
Hemin (Panhematin)
HepaGam B (Hepatitis B Immune Globulin (Human))
Heparin (Heparin)
Heparin Lock Flush Solution (Heparin Lock Preservative Free)
Heparin Lock Flush Solution (Lok Pak)
Heparin Lock Preservative Free (Heparin Lock Flush Solution)
HepatAmine (Amino Acid)
Hepatitis A Inactivated & Hepatitis B (Recombinant) Vaccine (Twinrix)
Hepatitis A Vaccine, Inactivated (Havrix)
Hepatitis A Vaccine, Inactivated (Vaqta)
Hepatitis B Immune Globulin (Human) (H-Big)
Hepatitis B Immune Globulin (Human) (HepaGam B)
Hepatitis B Vaccine (Recombinant) (Recombivax)
Hepsera (Adefovir Dipivoxil)
Herceptin (Trastuzumab)
Hexachlorophene (Phisohex)
Hexalen (Altretamine)
HibTITER (Diphtheria CRM197 Protein Conjugate)
Hiprex (Methenamine Hippurate)
Hismanal (Astemizole (WITHDRAWN FROM US MARKET))
Histinex (Phenylpropanolamine, Dextromethorphan and Brompheniramine)
Histinex HC (Phenylephrine, Hydrocodone, CPM)
Histrelin Acetate Subcutaneous Implant (Supprelin LA)
Hivid (Zalcitabine)
HMS (Medrysone 1% Liquifilm Opthalmic)
Humalog (Insulin Lispro (Human Analog))
Humalog 75-25 (75-25 Insulin Lispro Suspension and 25 Insulin Lispro
Injection)
Human Secretin (ChiRhoStim)
Humatin (Paromomycin Sulfate)
Humatrope (Somatropin rDNA Origin)
Humibid La (Guaifenesin)
Humira (Adalimumab)
Humorsol (Demecarium)
Humulin 50-50 (50-50 Human Insulin Isophane Suspension and Human
Insulin Injection)
Humulin 70-30 (Insulin (Human Recombinant))
Humulin N (Insulin (Human Recombinant))
Humulin R (Insulin (Human Recombinant))
Hyalgan (Hyaluronate)
Hyaluronate (Hyalgan)
Hyaluronidase Human Injection (Hylenex)
Hyaluronidase Inj (Amphadase)
Hycamtin (Topotecan Hydrochloride)
Hycamtin Capsules (Topotecan Capsules)
Hycodan (Hydrocodone Bitartrate and Homatropine Methylbromide)
Hycotuss (Hydrocodone Bitartrate and Guaifenesin)
Hydralazine (Apresoline)
Hydralazine and Hydrochlorothiazide (Apresazide)
Hydrea (Hydroxyurea)
Hydrochlorothiazide and Triamterene (Dyazide)
Hydrocodone and Chlorpheniramine (Tussionex)
Hydrocodone and Ibuprofen (Vicoprofen)
Hydrocodone Bitartrate and Acetaminophen (Norco)
Hydrocodone Bitartrate and Acetaminophen (Norco 5/325)
Hydrocodone Bitartrate and Acetaminophen (Vicodin)
Hydrocodone Bitartrate and Acetaminophen (Vicodin ES)
Hydrocodone Bitartrate and Acetaminophen (Zydone)
Hydrocodone Bitartrate and Acetaminophen Oral Solution (Lortab Elixir)
Hydrocodone Bitartrate and Acetaminophen Tablets (Lortab 10)
Hydrocodone Bitartrate and Acetaminophen Tablets (Lortab 2.5)
Hydrocodone Bitartrate and Acetaminophen Tablets (Lortab 5)
Hydrocodone Bitartrate and Acetaminophen Tablets (Lortab 7.5)
Hydrocodone Bitartrate and Guaifenesin (Hycotuss)
Hydrocodone Bitartrate and Homatropine Methylbromide (Hycodan)
Hydrocortisone (Cortenema)
Hydrocortisone (Hydrocortisone Cream and Ointment 2.5%)
Hydrocortisone and Acetic Acid (Vosol Hc Otic)
Hydrocortisone and Pramoxine (Proctofoam)
Hydrocortisone Butyrate (Locoid)
Hydrocortisone Butyrate (Locoid Lipocream)
Hydrocortisone Cream (Anusol Hc)
Hydrocortisone Cream and Ointment 1.0% (Cortaid)
Hydrocortisone Cream and Ointment 2.5% (Hydrocortisone)
Hydrocortisone Probutate Cream (Pandel)
Hydrocortisone Sodium Succinate (Solu Cortef)
Hydrocortisone Valerate (Westcort)
Hydrocortisone, Neomycin, Polymyxin B (Cortisporin Cream)
Hydroflumethiazide (Diucardin)
Hydromorphone Hydrochloride (Dilaudid)
Hydromorphone Hydrochloride Injection (Dilaudid-HP)
Hydroquinone (Hydroquinone (3% Topical Solution))
Hydroquinone (3% Topical Solution) (Hydroquinone)
Hydroquinone 4% Cream (Eldopaque)
Hydrous Dextrose (Dextros Injection 5%)
Hydroxocobalamin for Injection (Cyanokit)
Hydroxyamphetamine Hydrobromide, Tropicamide (Paremyd)
Hydroxychloroquine (Plaquenil)
Hydroxyethyl Starch in Sodium Chloride Injection (Voluven)
Hydroxypropylmethylcellulose (Ocucoat)
Hydroxyurea (Hydrea)
Hydroxyzine (Vistaril)
Hydroxyzine Hydrochloride (Hydroxyzine Hydrochloride)
Hygroton (Chlorthalidone)
Hylan G-F 20 (Synvisc)
Hylenex (Hyaluronidase Human Injection)
Hyoscyamine (Levsin)
Hypertonic Saline (3% and 5% Sodium Chloride Injection)
Hytrin (Terazosin Hcl)
Hyzaar (Losartan Potassium-Hydrochlorothiazide)

Ibandronate Sodium (Boniva )

Ibandronate Sodium Injection (Boniva Injection)
Ibritumomab Tiuxetan (Zevalin)
Ibuprofen (Motrin)
Ibuprofen Lysine Injection (NeoProfen)
Ibutilide (Corvert)
Ic-Green (Tricarbocyanine)
Icodextrin (Extraneal)
Idamycin (Idarubicin)
Idarubicin (Idamycin)
Idursulfase Solution (Elaprase)
Ifex (Ifosfamide)
Ifosfamide (Ifex)
Iloprost (Ventavis)
Ilotycin (Erythromycin)
Imatinib Mesylate (Gleevec)
Imiglucerase (Cerezyme)
Imipenem and Cilastatin (Primaxin IM)
Imipenem and Cilastatin for Injection (Primaxin I.V.)
Imipramine (Tofranil)
Imipramine Pamoate (Tofranil-PM)
Imiquimod (Aldara)
Imitrex (Sumatriptan Succinate)
Imitrex Inj (Sumatriptan Succinate)
Imitrex Nasal Spray (Sumatriptan)
Immune Globulin (Baygam)
Immune Globulin (Gammagard)
Immune Globulin Intravenous (Privigen)
Immune Globulin Intravenous (Human) solution (Rhophylac)
Immune Globulin Subcutaneous (Human) (Vivaglobin)
Imodium (Loperamide Hcl)
Imogam Rabies (Rabies Immune Globulin (Human))
Imovax (Rabies Vaccine)
Implanon (Etonogestrel Implant)
Imuran (Azathioprine)
Inapsine (Droperidol)
Increlex (Mecasermin [rDNA origin] Injection)
Indapamide (Lozol)
Inderal (Propranolol)
Inderal LA (Propranolol)
Inderide (Propranolol Hydrochloride and Hydrochlorothiazide)
Indigo Carmine (Indigotindisulfonate)
Indigotindisulfonate (Indigo Carmine)
Indinavir Sulfate (Crixivan)
Indocin (Indomethacin)
Indocin IV (Indomethacin Inj)
Indomethacin (Indocin)
Indomethacin Inj (Indocin IV)
Infanrix (Diphtheria and Tetanus Toxoids and Acellular Pertussis)
Infasurf (Calfactant)
Infed (Iron Dextran)
Infergen (Interferon Alfacon-1)
Infliximab (Remicade)
Influenza Virus Vaccine (Afluria)
Influenza Virus Vaccine (Fluarix)
Influenza Virus Vaccine (FluMist)
Influenza Virus Vaccine (Fluvirin )
Influenza Virus Vaccine (Fluzone)
Innohep (Tinzaparin)
InnoPran XL (Propranolol Hydrochloride)
Inomax (Nitric Oxide)
Insoluble Prussian blue (Radiogardase)
Inspra (Eplerenone)
Insulin (Human Recombinant) (Humulin 70-30)
Insulin (Human Recombinant) (Humulin N)
Insulin (Human Recombinant) (Humulin R)
Insulin Aspart [rDNA origin] Inj (NovoLog)
Insulin Aspart Protamine and Insulin Aspart (rDNA origin) (NovoLog Mix
70/30)
Insulin Detemir (Levemir)
Insulin Glargine [rDNA origin] Injection (Lantus)
Insulin Glulisine [rDNA origin] Inj (Apidra)
Insulin Human (Velosulin)
Insulin Human [rDNA origin] (Exubera)
Insulin Lispro (Human Analog) (Humalog)
Intal Inhaler (Cromolyn Sodium Inhalation Aerosol)
Intal Nebulizer Solution (Cromolyn Sodium Inhalation Solution)
Integrilin (Eptifibatide)
Intelence (Entravirine Tablets)
Interferon alfa-2a, Recombinant (Roferon-A alfa-2a)
Interferon alfa-2b, Recombinant for Injection (Intron A)
Interferon Alfacon-1 (Infergen)
Interferon beta-1a (Avonex)
Interferon beta-1a (Rebif)
Interferon beta-1b (Betaseron)
Interferon Gamma 1 b (Actimmune)
Intralipid 10% (10% I.V Fat Emulsion)
Intralipid 20% (20% I.V. Fat Emulsion)
Intron A (Interferon alfa-2b, Recombinant for Injection)
Intron A - Rebetol (Ribavirin, Interferon Alfa-2b, Recombinant)
Invanz (Ertapenem Injection)
Invega (Paliperidone)
Inversine (Mecamylamine)
Invirase (Saquinavir Mesylate)
Iodide (Pima)
Ionamin (Phentermine Resin Complex)
Ionsys (Fentanyl Iontophoretic Transdermal System)
Iopidine Eye (Apraclonidine)
Ioxilan (Oxilan)
Iplex (Mecasermin Rinfabate [rDNA origin] Injection)
Ipol (Poliovirus Vaccine Inactivated)
Ipratropium bromide (Atrovent Nasal Spray)
Ipratropium Bromide (Duoneb)
Ipratropium Bromide (Inhalation) (Atrovent HFA)
Ipratropium Bromide and Albuterol Sulfate (Combivent)
Irbesartan (Avapro)
Irbesartan-Hydrochlorothiazide (Avalide)
Iressa (Getfitinib)
Irinotecan Hydrochloride (Camptosar Injection)
Iron Dextran (Infed)
Iron Sucrose Injection (Venofer)
Isentress (Raltegravir Tablets)
Ismelin (Guanethidine Monosulfate)
Ismo (Isosorbide Mononitrate)
Isocarboxazid (Marplan)
Isoflurane (Forane)
Isoniazid (Isoniazid Tablets)
Isoniazid (Nydrazid)
Isoniazid Tablets (Isoniazid)
Isoproterenol (Isuprel)
Isopto Carpine (Pilocarpine)
Isopto Hyoscine (Scopolamine)
Isordil (Isosorbide Dinitrate)
Isosorbide Dinitrate (Isordil)
Isosorbide Dinitrate and Hydralazine Hcl (BiDil)
Isosorbide Mononitrate (Ismo)
Isosulfan Blue (Lymphazurin)
Isotretinoin (Accutane)
Isradipine (Dynacirc)
Isradipine (Dynacirc CR)
Isuprel (Isoproterenol)
Itraconazole Capsules (Sporanox)
Ivermectin (Stromectol)
Ixabepilone (Ixempra)
Ixempra (Ixabepilone)

Jadelle (Levonorgestrel)
Jantoven (Warfarin Sodium Tablets)
Janumet (Sitagliptin Metformin HCL)
Januvia (Sitagliptin Phosphate)
Japanese Encephalitis Virus Vaccine Inactivated (Je-Vax)
Je-Vax (Japanese Encephalitis Virus Vaccine Inactivated)

Kadian (Morphine Sulfate Extended-Release)

Kaletra Capsules (Lopinavir, Ritonavir Capsules)
Kaletra Tablets (Lopinavir, Ritonavir Tablets)
Kanamycin (Kantrex)
Kantrex (Kanamycin)
Kayexalate (Sodium Polystyrene)
KCL in D5LR (Potassium Chloride in Lactated Ringer's and 5% Dextrose
Injection)
KCL in D5NS (Potassium Chloride in 5% Dextrose and Sodium Chloride
Injection)
KCL in D5W (Potassium Chloride in 5% Dextrose Injection)
KCL in NS (Potassium Chloride in Sodium Chloride Injection)
Keflex (Cephalexin)
Kemstro (Baclofen)
Kepivance (Palifermin)
Keppra (Levetiracetam)
Keppra Injection (Levetiracetam)
Kerlone (Betaxolol Hydrochloride)
Ketamine HCl (Ketamine Hydrochloride)
Ketamine Hydrochloride (Ketamine HCl)
Ketek (Telithromycin)
Ketoconazole (Nizoral)
Ketoconazole (Xolegel)
Ketoconazole Cream (Nizoral Cream)
Ketoconazole Foam, 2% (Extina)
Ketoprofen (Orudis)
Ketorolac tromethamine (Acular)
Ketorolac Tromethamine (Toradol Oral)
Ketotifen Fumarate (Zaditor)
Kineret (Anakinra)
Kinevac (Sincalide)
Kinlytic (Urokinase Injection)
Kionex (Sodium Polystyrene Sulfonate)
Klaron (Sodium Sulfacetamide Lotion)
Klonopin (Clonazepam)
Klor-Con (Potassium Chloride)
Koate (Antihemophilic Factor)
Kogenate FS (Antihemophilic Factor (Recombinant))
Konyne (Factor IX Complex)
Korean (Panax) Ginseng (Ginseng)
Kuvan (Saproterin Dihydrochloride Tablets)
Kytril (Granisetron)
Kytril Injection (Granisetron Hydrochloride)

Labetalol (Trandate)
Lac-Hydrin (Lactic Acid)
Lacrisert (Cellulose)
Lactated Ringer's (Lactated Ringer's Injection)
Lactated Ringer's and 5% Dextrose Injection (Lactated Ringer's in 5%
Dextrose)
Lactated Ringer's in 5% Dextrose (Lactated Ringer's and 5% Dextrose
Injection)
Lactated Ringer's Injection (Lactated Ringer's)
Lactic Acid (Lac-Hydrin)
Lactulose (Cephulac)
Lamictal (Lamotrigine)
Lamisil (Terbinafine)
Lamisil Oral Granules (Terbinafine Hydrochloride)
Lamivudine (Epivir)
Lamivudine, Zidovudine (Combivir)
Lamotrigine (Lamictal)
Lamprene (Clofazimine)
Lanoxin (Digoxin)
Lansoprazole (Prevacid)
Lansoprazole (Prevacid NapraPAC)
Lansoprazole for Injection (Prevacid I.V.)
Lansoprazole, Amoxicillin and Clarithromycin (Prevpac)
Lantus (Insulin Glargine [rDNA origin] Injection)
Lapatinib (Tykerb)
Lariam (Mefloquine)
Laronidase (Aldurazyme)
Lasix (Furosemide)
Latanoprost Ophthalmic (Xalatan)
Leflunomide (Arava)
Lenalidomide (Revlimid)
Lepirudin (Refludan)
Lescol (Fluvastatin Sodium)
Letairis (Ambrisentan Tablets)
Letrozole (Femara)
Leucovorin (Leucovorin)
Leucovorin Calcium (Leucovorin Calcium)
Leukeran (Chlorambucil)
Leukine (Sargramostim)
Leuprolide Acetate (Eligard)
Leuprolide Acetate (Lupron Depot)
Leuprolide Acetate for Depot Suspension (Lupron Depot 11.25 mg)
Leuprolide Acetate for Depot Suspension (Lupron Depot 7.5 mg)
Leuprolide Acetate Implant (Viadur)
Leuprolide Acetate Injection (Lupron)
Leuprolide Acetate Injection (Lupron Depot 3.75 mg)
Leuprolide Acetate Injection (Lupron Pediatric)
Leustatin (Cladribine)
Levalbuterol (Xopenex)
Levalbuterol Tartrate Inhalation Aerosol (Xopenex HFA)
Levamisole Hydrochloride (Ergamisol)
Levaquin (Levofloxacin)
Levemir (Insulin Detemir)
Levetiracetam (Keppra)
Levetiracetam (Keppra Injection)
Levitra (Vardenafil HCl)
Levo Dromoran (Levorphanol)
Levobetaxolol (Betaxon)
Levobunolol (Betagan)
Levobupivacaine (Chirocaine)
Levocabastine (Livostin)
Levocarnitine Injection (Carnitor Injection)
Levocarnitine Tablets, Oral Solution, Sugar-Free (Carnitor)
Levocetirizine Dihydrochloride (Xyzal)
Levodopa (Dopar)
Levofloxacin (Levaquin)
Levofloxacin (Quixin)
Levoleucovorin (Levoleucovorin)
Levomethadyl Acetate (Orlaam)
Levonorgestrel (Jadelle)
Levonorgestrel (Plan B)
Levonorgestrel (Unavailable in US) (Norplant)
Levonorgestrel and Ethinyl Estradiol (Alesse)
Levonorgestrel and Ethinyl Estradiol (Lutera)
Levonorgestrel and Ethinyl Estradiol (Trivora)
Levonorgestrel and Ethinyl Estradiol Tablets (Levora)
Levonorgestrel and Ethinyl Estradol Tablets (Lybrel)
Levonorgestrel, Ethinyl Estradiol (Seasonale)
Levonorgestrel, Ethinyl Estradiol (Seasonique)
Levonorgestrel-releasing intrauterine (Mirena)
Levophed (Norepinephrine Bitartrate)
Levora (Levonorgestrel and Ethinyl Estradiol Tablets)
Levorphanol (Levo Dromoran)
Levothroid (Levothyroxine Sodium)
Levothyroxine Sodium (Levothroid)
Levothyroxine Sodium (Levoxyl)
Levothyroxine Sodium (Synthroid)
Levothyroxine Sodium (Thyro-Tabs)
Levothyroxine Sodium (Unithroid)
Levothyroxine Sodium Capsules (Tirosint)
Levoxyl (Levothyroxine Sodium)
Levsin (Hyoscyamine)
Levulan Kerastick (Aminolevulinic Acid)
Lexapro (Escitalopram Oxalate)
Lexiva (Fosamprenavir Calcium)
Lexxel (Enalapril Maleate-Felodipine)
Lialda (Mesalamine)
Librax (Chlordiazepoxide and Clidinium)
Librium (Chlordiazepoxide)
Lidex (Fluocinonide)
Lidocaine (Xylocaine)
Lidocaine and Prilocaine (Emla)
Lidocaine and Tetracaine (S-Caine)
Lidocaine and Tetracaine (Synera)
Lidocaine Hydrochloride Solution (Xylocaine Viscous)
Lidocaine Patch 5% (Lidoderm)
Lidoderm (Lidocaine Patch 5%)
Limbrel (Flavocoxid)
Lincocin (Lincomycin Hcl)
Lincomycin Hcl (Lincocin)
Lindane Lotion (Lindane Lotion)
Lindane Shampoo (Lindane Shampoo)
Lindocaine Hydrochloride Monohydrate (Zingo)
Linezolid (Zyvox)
Lioresal Intrathecal (Baclofen Injection)
Liothyronine Sodium (Cytomel)
Liotrix (Thyrolar)
Lipase, Protease and Amylase (Creon)
Lipitor (Atorvastatin Calcium)
Lipofen (Fenofibrate)
Lipoprotein Outer Surface A Vaccine (Lymerix)
Liposyn (Liposyn II)
Liposyn II (Liposyn)
Lisdexamfetamine Dimesylate (Vyvanse)
Lisinopril (Prinivil)
Lisinopril (Zestril)
Lisinopril and Hydrochlorothiazide (Zestoretic)
Lisinopril-Hydrochlorothiazide (Prinzide)
Lithium Carbonate (Eskalith)
Liver-Stomach Concentrate With Intrinsic Factor (B12)
Livostin (Levocabastine)
Lo Ovral (Norgestrel And Ethinyl Estradiol)
Locoid (Hydrocortisone Butyrate)
Locoid Lipocream (Hydrocortisone Butyrate)
Lodine (Etodolac)
Lodosyn (Carbidopa)
Lodoxamide Tromethamine (Alomide)
Loestrin Fe (Norethindrone Acetate and Ethinyl Estradiol)
Lok Pak (Heparin Lock Flush Solution)
Lomefloxacin Hcl (Maxaquin)
Lomotil (Diphenoxylate & Atropine)
Lomustine (Ceenu)
Loniten (Minoxidil)
Loperamide Hcl (Imodium)
Lopid (Gemfibrozil)
Lopinavir, Ritonavir Capsules (Kaletra Capsules)
Lopinavir, Ritonavir Tablets (Kaletra Tablets)
Lopressor (Metoprolol Tartrate)
Lopressor HCT (Metoprolol Tartrate and Hydochlorothiazide)
Loprox (Ciclopirox)
Lorabid (Loracarbef)
Loracarbef (Lorabid)
Loratadine (Claritin)
Loratadine and Pseudoephedrine (Claritin D)
Lorazepam (Ativan)
Lortab 10 (Hydrocodone Bitartrate and Acetaminophen Tablets)
Lortab 2.5 (Hydrocodone Bitartrate and Acetaminophen Tablets)
Lortab 5 (Hydrocodone Bitartrate and Acetaminophen Tablets)
Lortab 7.5 (Hydrocodone Bitartrate and Acetaminophen Tablets)
Lortab Elixir (Hydrocodone Bitartrate and Acetaminophen Oral Solution)
Losartan Potassium (Cozaar)
Losartan Potassium-Hydrochlorothiazide (Hyzaar)
Lotemax (Loteprednol Etabonate Ophthalmic Suspension)
Lotensin (Benazepril)
Lotensin Hct (Benazepril HCl and HCTZ)
Loteprednol Etabonate and Tobramycin (Zylet)
Loteprednol Etabonate Ophthalmic Suspension (Lotemax)
Lotrel (Amlodipine Besylate and Benazepril HCl)
Lotrisone (Clotrimazole and Betamethasone)
Lotronex (Alosetron Hydrochloride)
Lovastatin (Altoprev)
Lovastatin (Mevacor)
Lovaza (Omega-3-Acid Ethyl Esters)
Lovenox (Enoxaparin Sodium Injection)
Low Calcium Peritoneal Dialysis Solutions (Dianeal Low Calcium)
Loxapine (Loxapine)
Loxapine Succinate (Loxitane)
Loxitane (Loxapine Succinate)
Lozol (Indapamide)
Lubiprostone (Amitiza)
Lucentis (Ranibizumab Injection)
Lufyllin (Dyphylline)
Lumigan (Bimatoprost)
Lunesta (Eszopiclone)
Lupron (Leuprolide Acetate Injection)
Lupron Depot (Leuprolide Acetate)
Lupron Depot 11.25 mg (Leuprolide Acetate for Depot Suspension)
Lupron Depot 3.75 mg (Leuprolide Acetate Injection)
Lupron Depot 7.5 mg (Leuprolide Acetate for Depot Suspension)
Lupron Pediatric (Leuprolide Acetate Injection)
Lutera (Levonorgestrel and Ethinyl Estradiol)
Luvox Tablets (Fluvoxamine Maleate)
Luxiq (Betamethasone)
Lybrel (Levonorgestrel and Ethinyl Estradol Tablets)
Lymerix (Lipoprotein Outer Surface A Vaccine)
Lymphazurin (Isosulfan Blue)
Lymphocyte immune globulin (Atgam)
Lyrica (Pregabalin)
Lysodren (Mitotane)

M-M-R Ii (Measles, Mumps, and Rubella Virus Vaccine Live)

M-R-Vax (Measles and Rubella Virus Vaccine Live)
Macrobid (Nitrofurantoin)
Macrodantin (Nitrofurantoin Macrocystals Capsule)
Macugen (Pegaptanib Sodium)
Mafenide Acetate (Sulfamylon)
Mag Sulfate (Magnesium Sulfate Injection)
Magnesium Sulfate Injection (Mag Sulfate)
Magnevist (Gadopentetate Dimeglumine)
Malarone (Atovaquone and Proguanil Hcl)
Malathion (Ovide)
Mandol (Cefamandole)
Mangafodipir (Teslascan)
Mannitol Injection (Mannitol IV)
Mannitol Injection in Aviva Plastic Container (Osmitrol Injection in Aviva)
Mannitol Injection in Viaflex Plastic Container (Osmitrol Injection in Viaflex)
Mannitol IV (Mannitol Injection)
Maraviroc (Selzentry)
Marinol (Dronabinol)
Marplan (Isocarboxazid)
Matulane (Procarbazine)
Mavik (Trandolapril)
Maxair (Pirbuterol)
Maxalt (Rizatriptan)
Maxaquin (Lomefloxacin Hcl)
Maxiflor (Diflorasone)
Maxipime (Cefepime Hydrochloride for Injection)
Maxitrol (Neomycin, Polymyxin B and Dexamethasone)
Measles and Rubella Virus Vaccine Live (M-R-Vax)
Measles Mumps Rubella Varicella Vaccine Live (Proquad)
Measles Virus Vaccine Live (Attenuvax)
Measles, Mumps, and Rubella Virus Vaccine Live (M-M-R Ii)
Mebaral (Mephobarbital)
Mebendazole (Vermox)
Mecamylamine (Inversine)
Mecasermin [rDNA origin] Injection (Increlex)
Mecasermin Rinfabate [rDNA origin] Injection (Iplex)
Mechlorethamine HCl (Mustargen)
Meclizine (Antivert)
Meclofenamate (Meclofenamate)
Medrol (Methylprednisolone)
Medroxyprogesterone (Depo Provera)
Medroxyprogesterone Acetate (Depo-SubQ Provera)
Medroxyprogesterone Acetate Tablets (Provera)
Medrysone 1% Liquifilm Opthalmic (HMS)
Mefenamic Acid (Ponstel)
Mefloquine (Lariam)
Mefoxin (Cefoxitin)
Megace (Megestrol Acetate)
Megace ES (Megestrol Acetate)
Megestrol Acetate (Megace)
Megestrol Acetate (Megace ES)
Mellaril (Thioridazine HCl)
Meloxicam (Mobic)
Melphalan (Alkeran)
Melphalan Hcl Injection (Alkeran Injection)
Memantine HCL (Namenda)
Menactra (Polysaccharide Diphtheria Toxoid Conjugate Vaccine)
Menest (Estrogens)
Meningococcal Polysaccharide Vaccine (Menomune)
Menomune (Meningococcal Polysaccharide Vaccine)
Menopur (Menotropins Injection)
Menotropins (Pergonal)
Menotropins Injection (Menopur)
Mentax (Butenafine)
Mepergan (Meperidine and Promethazine)
Meperidine (Demerol)
Meperidine and Promethazine (Mepergan)
Mephobarbital (Mebaral)
Mephyton (Phytonadione)
Mepivacaine (Carbocaine)
Meprobamate (Miltown)
Meprobamate and Aspirin (Equagesic)
Mepron (Atovaquone)
Mequinol and Tretinoin (Solage)
Mercaptopurine (Purinethol)
Meridia (Sibutramine Hydrochloride Monohydrate)
Meropenem (Merrem I.V.)
Merrem I.V. (Meropenem)
Meruvax (Rubella Virus Vaccine Live)
Mesalamine (Canasa)
Mesalamine (Lialda)
Mesalamine (Pentasa)
Mesalamine Delayed-Release Tablets (Asacol)
Mesalamine Rectal Suspension Enema (Rowasa)
Mesna (Mesnex)
Mesnex (Mesna)
Mesoridazine Besylate (Serentil)
Mestinon (Pyridostigmine)
Metadate (Methylphenidate Hydrochloride)
Metaglip (Glipizide and Metformin)
Metal-4 Combination (for Neonates) (Neotrace-4)
Metaproterenol Sulfate (Alupent)
Metaraminol (Aramine)
Metastron (Strontium-89)
Metaxalone (Skelaxin)
Metformin Hcl (Fortamet)
Metformin Hcl (Glucophage)
Metformin Hcl (Glumetza)
Metformin Hcl (Riomet)
Methadone (Dolophine)
Methadone Hydrochloride Oral Concentrate (Methadose Oral Concentrate)
Methadose Oral Concentrate (Methadone Hydrochloride Oral Concentrate)
Methamphetamine Hydrochloride (Desoxyn)
Methazolamide (Neptazane)
Methenamine Hippurate (Hiprex)
Methenamine Hippurate (Urex)
Methenamine, Salicylate, Methylene Blue, Benzoic Acid Atropine and
Hyoscyamine (Prosed)
Methergine (Methylergonovine Maleate)
Methimazole (Tapazole)
Methocarbamol (Robaxin)
Methocarbamol and Aspirin (Robaxisal)
Methohexital (Brevital Sod)
Methotrexate (Trexall)
Methoxsalen (Uvadex)
Methoxsalen (Capsules) (Oxsoralen-Ultra)
Methoxy Polyethylene glycol-epoetin beta (Mircera)
Methoxypsoralen (8-MOP)
Methsuximide (Celontin)
Methyclothiazide (Enduron)
Methyldopa (Aldomet)
Methyldopa-Hydrochlorothiazide (Aldoril)
Methyldopate (Aldomet Injection)
Methylene Blue (Methylene Blue Injection)
Methylene Blue Injection (Methylene Blue)
Methylergonovine Maleate (Methergine)
Methylin (Methylphenidate)
Methylin Oral (Methylphenidate HCl Oral Solution 5 mg/5 mL and 10 mg/5
mL)
Methylphenidate (Methylin)
Methylphenidate Extended-Release Tablets (Concerta)
Methylphenidate Hcl (Ritalin)
Methylphenidate HCl Oral Solution 5 mg/5 mL and 10 mg/5 mL (Methylin
Oral)
Methylphenidate Hydrochloride (Metadate)
Methylphenidate Hydrochloride Extended-Release Capsules (Ritalin LA)
Methylphenidate Transdermal (Daytrana)
Methylprednisolone (Depo Medrol)
Methylprednisolone (Medrol)
Methylprednisolone sodium succinate (Solu Medrol)
Methyltestosterone (Testred)
Methysergide maleate (Sansert)
Metipranolol Ophthalmic Solution (Optipranolol)
Metoclopramide (Reglan)
Metolazone (Mykrox)
Metopirone (Metyrapone)
Metoprolol Succinate (Toprol XL)
Metoprolol Tartrate (Lopressor)
Metoprolol Tartrate and Hydochlorothiazide (Lopressor HCT)
Metrodin (Urofollitropin for Injection)
Metrogel (Metronidazole)
Metrogel Vaginal (Metronidazole)
Metrolotion (Metronidazole (lotion))
Metronidazole (Flagyl)
Metronidazole (Metrogel)
Metronidazole (Metrogel Vaginal)
Metronidazole (Noritate)
Metronidazole (lotion) (Metrolotion)
Metronidazole Injection (Flagyl Injection)
Metroprolol (Dutoprol)
Metyrapone (Metopirone)
Metyrosine (Demser)
Mevacor (Lovastatin)
Mexiletine HCl (Mexitil)
Mexitil (Mexiletine HCl)
Miacalcin (Calcitonin-Salmon)
Micafungin Sodium (Mycamine)
Micardis (Telmisartan)
Micardis HCT (Telmisartan, Hydrochlorothiazide)
Miconazole (Monistat-Derm)
Miconazole Nitrate (vaginal) (Monisat Vaginal Cream)
Miconazole Nitrate, 15% Zinc Oxide, and 81.35% White Petrolatum (Vusion)
Micro-K (Potassium Chloride Extended-Release)
Micro-K for Liquid Suspension (Potassium Chloride Extended Release
Formulation for Liquid Suspension)
Micronase (Glyburide)
Micronor (Norethindrone)
Midamor (Amiloride)
Midazolam (Midazolam Injection)
Midazolam (Versed Syrup)
Midazolam Injection (Midazolam)
Midodrine Hydrochloride (Proamatine)
Midrin (Acetaminophen, Isometheptene and Dichloralphenazone)
Mifeprex (RU486) (Mifepristone (RU486))
Mifepristone (RU486) (Mifeprex (RU486))
Miglitol (Glyset)
Miglustat (Zavesca)
Milrinone (Primacor IV)
Miltown (Meprobamate)
Minipress (Prazosin HCl)
Minocin (Minocycline Hydrochloride Oral Suspension)
Minocin Capsules (Minocycline)
Minocin Injection (Minocycline Inj)
Minocycline (Minocin Capsules)
Minocycline Hydrochloride (Solodyn)
Minocycline Hydrochloride Oral Suspension (Minocin)
Minocycline Inj (Minocin Injection)
Minoxidil (Loniten)
Mintezol (Thiabendazole)
Miochol-E (Acetylcholine Chloride)
Miostat (Carbachol)
Miradon (Anisindione)
MiraLAX (Polyethylene Glycol 3350 - OTC)
Miraluma (Technetium Tc99m sestamibi)
Mirapex (Pramipexole)
Mircera (Methoxy Polyethylene glycol-epoetin beta)
Mircette (Desogestrel, Ethinyl Estradiol and Ethinyl Estradiol)
Mirena (Levonorgestrel-releasing intrauterine)
Mirtazapine (Remeron)
Mirtazapine (Remeron SolTab)
Misoprostol (Cytotec)
Mithracin (Plicamycin)
Mitomycin (Mutamycin)
Mitotane (Lysodren)
Mitoxantrone for Injection Concentrate (Novantrone)
Mivacron (Mivacurium)
Mivacurium (Mivacron)
Moban (Molindone Hydrochloride Tablets)
Mobic (Meloxicam)
Modafinil (Provigil)
Moduretic (Amiloride and Hydrochlorothiazide)
Moexipril (Univasc)
Molindone Hydrochloride Tablets (Moban)
Mometasone Furoate (Asmanex Twisthaler)
Mometasone Furoate (Elocon)
Mometasone Furoate (nasal spray) (Nasonex)
Mometasone Furoate Lotion (Elocon Lotion)
Mometasone Furoate Ointment (Elocon Ointment)
Monisat Vaginal Cream (Miconazole Nitrate (vaginal))
Monistat-Derm (Miconazole)
Mono-Vacc (Tuberculin (mono-vaccine))
Monoclate-P (Antihemophilic Factor)
Monodox (Doxycycline)
Mononine (Coagulation Factor IX (Human))
Monopril (Fosinopril sodium)
Monopril HCT (Fosinopril Sodium-Hydrochlorothiazide Tablets)
Montelukast Sodium (Singulair)
Monurol (Fosfomycin)
Morphine (injection) (Duramorph)
Morphine Sulfate (Avinza)
Morphine Sulfate (Roxanol)
Morphine Sulfate Controlled-Release (MS-Contin)
Morphine Sulfate Extended-Release (Kadian)
Morphine Sulfate XR Liposome Injection (DepoDur)
Morrhuate Sod (Morrhuate Sodium (injection))
Morrhuate Sodium (injection) (Morrhuate Sod)
Motofen (Difenoxin and Atropine)
Motrin (Ibuprofen)
MoviPrep (PEG-3350, Sodium Sulfate, Sodium Chloride, Potassium Chloride,
Sodium Ascorbate, Ascorbic Acid )
Moxatag (Moxatag)
Moxifloxacin (Vigamox)
Moxifloxacin HCL (Avelox)
MS-Contin (Morphine Sulfate Controlled-Release)
Mte 5 (Trace Metal-5 Combination)
Mucomyst (Acetylcysteine)
Multi Vitamin Concentrate (intravenous infusion) (MVI)
Multiple Electrolytes and Dextrose Inj (Plasma-Lyte 148d5)
Multiple Electrolytes Inj (Plasma-Lyte 148)
Multiple Electrolytes Inj (Plasma-Lyte 56)
Multiple Electrolytes Inj (Plasma-Lyte 56d5)
Multiple Electrolytes Inj (Plasmalyte A)
Multiple Electrolytes Inj (Plasmalyte R)
Multivitamin, Iron and Fluoride (Poly-Vi-Flor)
Multivitamins for Infusion (Cernevit)
Mumps Skin Test Antigen (Mumps Skin Test Antigen)
Mumps Virus Vaccine Live (Mumpsvax)
Mumpsvax (Mumps Virus Vaccine Live)
Mupirocin (Bactroban Nasal)
Mupirocin (Bactroban Ointment)
Mustargen (Mechlorethamine HCl)
Mutamycin (Mitomycin)
MVI (Multi Vitamin Concentrate (intravenous infusion))
Myambutol (Ethambutol)
Mycamine (Micafungin Sodium)
Mycelex (Clotrimazole)
Mycobutin (Rifabutin)
Mycolog Ii (Nystatin and Triamcinolone Acetonide Cream)
Mycophenolate Mofetil (CellCept)
Mycophenolic Acid (Myfortic)
Mycostatin (Nystatin)
Mycostatin Powder (Nystatin (topical))
Myfortic (Mycophenolic Acid)
Mykrox (Metolazone)
Mylotarg (Gemtuzumab Ozogamicin for Injection)
Myoblock (Botulinum Toxin Type B)
Myochrysine (Gold Thiomalate)
Myozyme (Alglucosidase Alfa)
Mysoline (Primidone)

Nabumetone (Relafen)
Nadolol (Corgard)
Nadolol and Bendroflumethiazide (Corzide)
Nafarelin Acetate (Synarel)
Nafcillin Sodium (Unipen)
Naftifine (Naftin Gel)
Naftifine Hcl (Naftin Cream)
Naftin Cream (Naftifine Hcl)
Naftin Gel (Naftifine)
Naglazyme (Galsulfase)
Nalbuphine hydrochloride (Nubain)
Nalfon (Fenoprofen Calcium)
Nalidixic Acid (NegGram)
Nalmefene Hydrochloride (Revex)
Naloxone (Narcan)
Naltrexone (Revia)
Naltrexone XR Inj (Vivitrol)
Namenda (Memantine HCL)
Naprelan (Naproxen Sodium)
Naprosyn (Naproxen)
Naproxen (Naprosyn)
Naproxen Sodium (Naprelan)
Naratriptan (Amerge)
Narcan (Naloxone)
Nardil (Phenelzine)
Naropin (Ropivacaine Hcl)
Nasacort (Triamcinolone Acetonide)
Nasacort AQ (Triamcinolone Acetonide)
Nasalcrom (Cromolyn Sodium)
Nasalide (Flunisolide (Nasal Spray))
Nascobal (Cyanocobalamin)
Nasonex (Mometasone Furoate (nasal spray))
Natacyn (Natamycin)
Natalizumab (Tysabri)
Natamycin (Natacyn)
Nateglinide (Starlix)
Natrecor (Nesiritide)
Navane (Thiothixene Hcl)
Navelbine (Vinorelbine Tartrate)
Nebcin (Tobramycin)
Nebivolol Tablets (Bystolic Tablets)
Nebupent (Pentamidine Isethionate)
Necon (Norethindrone and Ethinyl Estradiol Tablets )
Nedocromil (Alocril)
Nedocromil (inhalation) (Tilade)
Nefazodone (Serzone)
NegGram (Nalidixic Acid)
Nelarabine (Arranon)
Nelfinavir Mesylate (Viracept)
Nembutal (Pentobarbital)
Neo-Synephrine (Phenylephrine Hydrochloride Ophthalmic Solution)
Neodecadron (Neomycin and Dexamethasone)
Neomycin and Dexamethasone (Neodecadron)
Neomycin and Polymyxin (Neosporin)
Neomycin and Polymyxin B Sulfates and Hydrocortisone Opthalmic
Suspension (Cortisporin Ophthalmic Suspension)
Neomycin and Polymyxin B Sulfates and Hydrocortisone Otic Solution
(Cortisporin Otic Solution)
Neomycin and Polymyxin B Sulfates and Hydrocortisone Otic Suspension
(Cortisporin Otic Suspension)

Neomycin and Polymyxin B Sulfates, Bacitracin Zinc, and Hydrocortisone

(Cortisporin Ointment)
Neomycin and Polymyxin B Sulfates, Bacitracin Zinc, and Hydrocortisone
Ophthalmic (Cortisporin Ophthalmic Ointment)
Neomycin Sulfate (Neomycin Sulfate)
Neomycin, Polymyxin B and Dexamethasone (Maxitrol)
Neomycin,Polymyxin B and Hydrocortisone (Pediotic)
NeoProfen (Ibuprofen Lysine Injection)
Neoral (Cyclosporine)
Neosporin (Neomycin and Polymyxin)
Neostigmine (Neostigmine Methylsulfate (injection))
Neostigmine (Prostigmin)
Neostigmine Methylsulfate (injection) (Neostigmine)
NeoTect (Neotect)
Neotrace-4 (Metal-4 Combination (for Neonates))
Nepafenac (Nevanac)
Nephramine (Essential Amino Acid Inj)
Neptazane (Methazolamide)
Nesacaine (Chloroprocaine)
Nesiritide (Natrecor)
Neulasta (Pegfilgrastim)
Neumega (Oprelvekin)
Neupogen (Filgrastim)
Neupro (Rotigotine Transdermal System)
Neurontin (Gabapentin)
Neutra Phos (Phosphates)
Neutrexin (Trimetrexate Glucuronate Inj)
Nevanac (Nepafenac)
Nevirapine (Viramune)
Nexavar (Sorafenib)
Nexium (Esomeprazole Magnesium)
Nexium I.V. (Esomeprazole Sodium)
Niacin (Niaspan)
Niacin Tablets (Niacor)
Niacin XR & Lovastatin (Advicor)
Niacor (Niacin Tablets)
Niaspan (Niacin)
Nicardipine (Cardene)
Nicardipine Hydrochloride (Cardene I.V.)
Nicotine Inhalation System (Nicotrol)
Nicotrol (Nicotine Inhalation System)
Nifedipine (Adalat)
Nifedipine (Procardia)
Niferex (Polysaccharide-Iron Complex (Capsules))
Niferex-Pn (Polysaccharide-Iron Complex (Tablets))
Nilandron (Nilutamide)
Nilotinib Capsules (Tasigna Capsules)
Nilstat (Nystatin (oral))
Nilutamide (Nilandron)
Nimbex (Cisatracurium Besylate)
Nimodipine (Nimotop)
Nimotop (Nimodipine)
Niravam (Alprazolam)
Nisoldipine (Sular)
Nitazoxanide (Alinia)
Nitisinone (Orfadin)
Nitric Oxide (Inomax)
Nitrodur (Nitroglycerin)
Nitrofurantoin (Macrobid)
Nitrofurantoin Macrocystals Capsule (Macrodantin)
Nitroglycerin (Nitrodur)
Nitroglycerin (Nitrostat)
Nitroglycerin (Transderm Nitro)
Nitroglycerin Lingual Aerosol (NitroMist)
NitroMist (Nitroglycerin Lingual Aerosol)
Nitropress (Nitroprusside Sodium)
Nitroprusside Sodium (Nitropress)
Nitrostat (Nitroglycerin)
Nizatidine (Axid)
Nizatidine (Axid Oral Solution)
Nizoral (Ketoconazole)
Nizoral Cream (Ketoconazole Cream)
Noctec (Chloral Hydrate)
Nolvadex (Tamoxifen Citrate)
Nor-QD (Norethindrone)
Norco (Hydrocodone Bitartrate and Acetaminophen)
Norco 5/325 (Hydrocodone Bitartrate and Acetaminophen)
Norditropin (Somatropin Injection)
Norelgestromin, Ethinyl Estradiol (Ortho Evra)
Norepinephrine Bitartrate (Levophed)
Norethindrone (Aygestin)
Norethindrone (Micronor)
Norethindrone (Nor-QD)
Norethindrone Acetate and Ethinyl Estradiol (Estrostep 21)
Norethindrone Acetate and Ethinyl Estradiol (Loestrin Fe)
Norethindrone Acetate and Ethinyl Estradiol Tablets (Estrostep Fe)
Norethindrone Acetate, Ethinyl Estradiol (Femhrt)
Norethindrone and Ethinyl Estradiol (Brevicon)
Norethindrone and Ethinyl Estradiol (Ortho-Novum)
Norethindrone and Ethinyl Estradiol Tablets (Femcon Fe)
Norethindrone and Ethinyl Estradiol Tablets (Necon)
Norethindrone and Ethinyl Estradiol Tablets (Ovcon)
Norflex (Orphenadrine)
Norfloxacin (Chibroxin)
Norfloxacin (Noroxin)
Norgesic (Orphenadrine Citrate with Aspirin and Caffeine)
Norgestimate and Ethinyl Estradiol (Ortho Tri-Cyclen / Ortho-Cyclen)
Norgestimate and Ethinyl Estradiol Tablets (TriNessa)
Norgestimate, Ethinyl Estradiol (Ortho-Tri-Cyclen Lo)
Norgestrel And Ethinyl Estradiol (Lo Ovral)
Noritate (Metronidazole)
Normal Saline (Sodium Chloride Inj)
Noroxin (Norfloxacin)
Norpace (Disopyramide)
Norplant (Levonorgestrel (Unavailable in US))
Norpramin (Desipramine Hydrochloride)
Nortriptyline (Aventyl)
Nortriptyline Hcl (Aventyl Sol)
Nortriptyline HCl (Pamelor)
Nortriptyline Hydrochloride (Nortriptyline Hydrochloride Capsule)
Nortriptyline Hydrochloride Capsule (Nortriptyline Hydrochloride )
Nortriptyline Hydrochloride Oral Solution (Nortriptyline Hydrochloride Oral
Solution)
Norvasc (Amlodipine Besylate)
Norvir (Ritonavir Capsules, Oral Solution)
Novantrone (Mitoxantrone for Injection Concentrate)
Novastan (Argatroban)
NovoLog (Insulin Aspart [rDNA origin] Inj)
NovoLog Mix 70/30 (Insulin Aspart Protamine and Insulin Aspart (rDNA
origin))
Novoseven (Coagulation Factor VIIa (Recombinant))
Noxafil (Posaconazole)
Nubain (Nalbuphine hydrochloride)
Numorphan (Oxymorphone)
Nuromax (Doxacurium Chloride)
Nutropin (Somatropin (rDNA origin) for Inj)
Nutropin AQ (Somatropin (rDNA origin))
Nutropin Depot (Somatropin (rDNA origin) for Inj)
Nuvaring (Etonogestrel, Ethinyl Estradiol Vaginal Ring)
Nuvigil (Armodafinil)
Nydrazid (Isoniazid)
Nystatin (Mycostatin)
Nystatin (oral) (Nilstat)
Nystatin (topical) (Mycostatin Powder)
Nystatin and Triamcinolone Acetonide Cream (Mycolog Ii)
Nystatin Cream (Nystatin Cream)
Octreotide Acetate (Sandostatin)
Octreotide Acetate Injection (Sandostatin LAR)
Ocucoat (Hydroxypropylmethylcellulose)
Ocufen (Flurbiprofen)
Ocuflox (Ofloxacin Ophthalmic)
Ocupress (Carteolol)
Ofloxacin (Floxin)
Ofloxacin Ophthalmic (Ocuflox)
Ofloxacin Otic Solution (Floxin Otic)
Ofloxacin Otic Solution (Floxin Otic Singles)
Ogen (Estropipate)
Olanzapine (Zyprexa)
Olanzapine and fluoxetine (Symbyax)
Olmesartan Medoxomil (Benicar)
Olmesartan Medoxomil-Hydrochlorothiazide (Benicar HCT)
Olopatadine (Patanol)
Olopatadine Hydrochloride Ophthalmic Solution (Pataday)
Olsalazine (Dipentum)
Olux (Clobetasol Propionate)
Olux-E (Clobetasol Propionate Foam)
Omalizumab (Xolair)
Omega-3-Acid Ethyl Esters (Lovaza)
Omeprazole (Prilosec)
Omeprazole, Sodium Bicarbonate (Zegerid)
Omnaris (Ciclesonide Nasal Spray)
Omnicef (Cefdinir)
Omnipred (Prednisolone Acetate)
Omniscan (Gadodiamide)
Omnitrope (Somatropin [ rDNA origin] Injection)
Oncaspar (Pegaspargase)
Oncovin (Vincristine Sulfate)
Ondansetron Hydrochloride (Zofran)
Ondansetron Hydrochloride Injection (Zofran Injection)
Ontak (Denileukin Diftitox)
Opana (Oxymorphone Hydrochloride)
Opana ER (Oxymorphone Hydrochloride Extended Release)
Oprelvekin (Neumega)
Opticrom (Cromolyn)
OptiMARK (Gadoversetamide Injection)
Optipranolol (Metipranolol Ophthalmic Solution)
Optison (Perflutren)
Optivar (Azelastine hydrochloride)
Oracea (Doxycycline)
Oral Poliovirus Vaccine (Orimune)
Orap (Pimozide)
Orapred ODT (Prednisolone Sodium Phosphate)
Orencia (Abatacept)
Orfadin (Nitisinone)
Organidin (Guaifenesin)
Orimune (Oral Poliovirus Vaccine)
Orlaam (Levomethadyl Acetate)
Orlistat 120 mg (Xenical)
Orlistat 60 mg (Alli)
Orphenadrine (Norflex)
Orphenadrine Citrate with Aspirin and Caffeine (Norgesic)
Orphenadrine Citrate, Aspirin and Caffeine (Orphenadrine Compound)
Orphenadrine Compound (Orphenadrine Citrate, Aspirin and Caffeine)
Ortho Evra (Norelgestromin, Ethinyl Estradiol)
Ortho Tri-Cyclen / Ortho-Cyclen (Norgestimate and Ethinyl Estradiol)
Ortho-Novum (Norethindrone and Ethinyl Estradiol)
Ortho-Tri-Cyclen Lo (Norgestimate, Ethinyl Estradiol)
Orudis (Ketoprofen)
Oseltamivir Phosphate (Tamiflu)
Osmitrol Injection in Aviva (Mannitol Injection in Aviva Plastic Container)
Osmitrol Injection in Viaflex (Mannitol Injection in Viaflex Plastic Container)
OsmoPrep (Sodium Phosphate Monobasic Monohydrate and Sodium
Phosphate Dibasic Anhydrous)
Ovcon (Norethindrone and Ethinyl Estradiol Tablets)
Ovide (Malathion)
Ovidrel (Choriogonadotropin Alfa Injection)
Oxacillin Sodium (Bactocill)
Oxaliplatin Injection (Eloxatin)
Oxandrin (Oxandrolone)
Oxandrolone (Oxandrin)
Oxaprozin (Daypro Alta)
Oxaprozin Caplets (Daypro)
Oxazepam (Serax)
Oxcarbazepine (Trileptal)
Oxiconazole (Oxistat)
Oxilan (Ioxilan)
Oxistat (Oxiconazole)
Oxsoralen-Ultra (Methoxsalen (Capsules))
Oxybutynin Chloride Extended Release Tablets (Ditropan XL)
Oxybutynin Tablets and Syrup (Ditropan)
Oxybutynin Transdermal (Oxytrol)
Oxycodone (Roxicodone)
Oxycodone and Acetaminophen (Percocet)
Oxycodone and Acetaminophen Tablets (Endocet)
Oxycodone HCl (Oxycontin)
Oxycodone HCl and Ibuprofen (Combunox)
Oxycodone Hydrochloride (Roxicodone 15, 30 mg)
Oxycontin (Oxycodone HCl)
Oxymetholone (Anadrol-50)
Oxymorphone (Numorphan)
Oxymorphone Hydrochloride (Opana)
Oxymorphone Hydrochloride Extended Release (Opana ER)
Oxytetracycline (Terramycin)
Oxytetracycline and Hydrocortisone (Terra-Cortril)
Oxytetracycline,Sulfamethizole and Phenazopyridine (Urobiotic)
Oxytocin Injection (Pitocin)
Oxytrol (Oxybutynin Transdermal)

Paclitaxel (Taxol)
Palifermin (Kepivance)
Paliperidone (Invega)
Palivizumab (Synagis)
Palonosetron hydrochloride (Aloxi)
Pamelor (Nortriptyline HCl)
Pamidronate Disodium (Aredia)
Pancrecarb (Pancrelipase)
Pancrelipase (Pancrecarb)
Pancrelipase (Ultrase)
Pancrelipase (Viokase)
Pandel (Hydrocortisone Probutate Cream)
Panhematin (Hemin)
Panretin (Alitretinoin)
Pantoprazole (Protonix Tablets)
Pantoprazole Sodium (Protonix I.V.)
Papain and Urea (Accuzyme)
Papaverine (Papaverine)
Papaverine Hydrochloride Injection (Papaverine Injection)
Papaverine Injection (Papaverine Hydrochloride Injection)
Parafon Forte (Chlorzoxazone)
Paraplatin (Carboplatin)
Paregoric (Anhydrous Morphine)
Paremyd (Hydroxyamphetamine Hydrobromide, Tropicamide)
Paricalcitol (Zemplar Capsules)
Paricalcitol Injection Fliptop Vial (Zemplar Injection)
Parlodel (Bromocriptine Mesylate)
Parnate (Tranylcypromine)
Paromomycin Sulfate (Humatin)
Paroxetine Hydrochloride (Paxil)
Paroxetine Hydrochloride (Paxil-CR)
Paroxetine Mesylate (Asimia)
Paroxetine Mesylate (Pexeva)
Paser (Aminosalicylic Acid)
Pataday (Olopatadine Hydrochloride Ophthalmic Solution)
Patanol (Olopatadine)
Paxil (Paroxetine Hydrochloride)
Paxil-CR (Paroxetine Hydrochloride)
PCE (Erythromycin PCE)
Pediapred (Prednisolone Sodium)
Pediatrace (Pedtrace)
Pediatric Gentamicin (Pediatric Gentamicin)
Pediazole (Erythromycin and Sulfisoxazole)
Pediotic (Neomycin,Polymyxin B and Hydrocortisone)
Pedtrace (Pediatrace)
Pedvax HIB (Haemophilus b Conjugate Vaccine)
PEG Electrolytes Solution (Go-Lytely)
PEG-3350, Sodium Chloride, Sodium Bicarbonate and Potassium Chloride
(TriLyte)
PEG-3350, Sodium Sulfate, Sodium Chloride, Potassium Chloride, Sodium
Ascorbate, Ascorbic Acid (MoviPrep)
Pegademase Bovine (Adagen)
Peganone (Ethotoin)
Pegaptanib Sodium (Macugen)
Pegaspargase (Oncaspar)
Pegasys (Peginterferon alfa-2a)
Pegfilgrastim (Neulasta)
Peginterferon alfa-2a (Pegasys)
Peginterferon alfa-2b (Roferon-A alfa-2b)
Pegvisomant (Somavert)
Pemetrexed (Alimta)
Pemirolast potassium (Alamast)
Pemoline (Cylert)
Penciclovir (Denavir)
Penetrex (Enoxacin)
Penicillamine (Cuprimine)
Penicillin G Benzathine and Penicillin G Procaine Inj (Bicillin C-R 900/300)
Penicillin G Benzathine and Penicillin G Procaine Inj (Bicillin C-R Tubex)
Penicillin G Benzathine and Penicillin G Procaine Inj (Bicillin Cr)
Penicillin G Benzathine Disposable Syringe (Bicillin L-A Disposable
Syringe)
Penicillin G Benzathine Injectable in Tubex (Bicillin L-A Injectable in Tubex)
Penicillin G Potassium (Penicillin G Potassium)
Penicillin G potassium (Pfizerpen)
Penicillin V Potassium (Penicillin VK)
Penicillin VK (Penicillin V Potassium)
Penlac Nail Lacquer (Ciclopirox)
Pentamidine Isethionate (Nebupent)
Pentasa (Mesalamine)
Pentazocine and Acetaminophen (Talacen)
Pentazocine and Aspirin (Talwin Compound)
Pentazocine and Naloxone (Talwin Nx)
Pentetate Calcium Trisodium Inj (Ca-DTPA)
Pentetate Zinc Trisodium Inj (Zn-DTPA)
Pentobarbital (Nembutal)
Pentosan (Elmiron)
Pentothal (Thiopental Sodium)
Pentoxifylline (Trental)
Pepcid (Famotidine)
Pepcid Injection (Famotidine Injection)
Percocet (Oxycodone and Acetaminophen)
Percodan (Aspirin, Oxycodone Hydrochloride, Oxycodone Terephthalate)
Perfluoroalkylpolyether (PFPE), Polytetrafluoroethylene (PTFE) (Skin
Exposure Paste)
Perflutren (Optison)
Perflutren Lipid Microsphere (Definity)
Perforomist (Formoterol Fumarate Inhalation Solution)
Pergolide Mesylate (Permax)
Pergonal (Menotropins)
Periactin (Cyproheptadine)
Perindopril Erbumine (Aceon)
Periochip (Chlorhexidine)
Periostat (Doxycycline Hyclate)
Peritoneal Dialysis Solution (Dianeal PD-1)
Peritoneal Dialysis Solution (Dianeal PD-2)
Permax (Pergolide Mesylate)
Permethrin (Acticin)
Permethrin (Elimite)
Perphenazine (Trilafon)
Perphenazine and Amitriptyline (Etrafon)
Persantine (Dipyridamole)
Persantine (Persantine IV)
Persantine IV (Persantine)
Pexeva (Paroxetine Mesylate)
Pfizerpen (Penicillin G potassium)
Phenazopyridine (Pyridium)
Phendimetrazine (Prelu-2)
Phenelzine (Nardil)
Phenergan (Promethazine)
Phenergan Vc (Promethazine HCl and Phenylephrine HCl Syrup)
Phenergan-Codeine (Codeine Phosphate and Promethazine HCl)
Phenobarbital (Phenobarbital)
Phenoxybenzamine (Dibenzyline)
Phentermine (Fastin)
Phentermine Resin Complex (Ionamin)
Phentolamine Mesylate (Regitine)
Phenylephrine Hydrochloride Ophthalmic Solution (Neo-Synephrine)
Phenylephrine, Chlorpheniramine, and Pyrilamine (Rynatan)
Phenylephrine, Hydrocodone, CPM (Histinex HC)
Phenylpropanolamine, Dextromethorphan and Brompheniramine (Histinex)
Phenytoin (Dilantin)
Phisohex (Hexachlorophene)
Phosphates (Neutra Phos)
Phospholine (Phospholine)
Photofrin (Porfimer Sodium)
Physostigmine Salicylate (injection) (Antilirium)
Phytonadione (Mephyton)
Pilocarpine (Isopto Carpine)
Pilocarpine (Pilopine)
Pilocarpine Hydrochloride (Salagen)
Pilopine (Pilocarpine)
Pima (Iodide)
Pimecrolimus Cream (Elidel)
Pimozide (Orap)
Pindolol (Visken)
Pioglitazone (Duetact)
Pioglitazone Hcl and Metformin Hcl (Actoplus MET)
Pioglitazone hydrochloride (Actos)
Piperacillin and Tazobactam Inj (Zosyn)
Piperacillin Sodium (Pipracil)
Pipracil (Piperacillin Sodium)
Pirbuterol (Maxair)
Piroxicam (Feldene)
Pitocin (Oxytocin Injection)
Pitressin (Vasopressin)
Plan B (Levonorgestrel)
Plaquenil (Hydroxychloroquine)
Plasma-Lyte 148 (Multiple Electrolytes Inj)
Plasma-Lyte 148d5 (Multiple Electrolytes and Dextrose Inj)
Plasma-Lyte 56 (Multiple Electrolytes Inj)
Plasma-Lyte 56d5 (Multiple Electrolytes Inj)
Plasma-Lyte M and 5% Dextrose Inj (Plasma-Lyte Md5)
Plasma-Lyte Md5 (Plasma-Lyte M and 5% Dextrose Inj)
Plasmalyte A (Multiple Electrolytes Inj)
Plasmalyte R (Multiple Electrolytes Inj)
Platinol (Cisplatin)
Plavix (Clopidogrel Bisulfate)
Plenaxis (Abarelix)
Plendil (Felodipine)
Pletal (Cilostazol)
Plexion (Sulfacetamide)
Plicamycin (Mithracin)
Pneumococcal 7-valent Conjugate (Prevnar)
Pneumococcal Vaccine Polyvalent (Pneumovax)
Pneumovax (Pneumococcal Vaccine Polyvalent)
Pododerm (Podophyllin)
Podofilox (Condylox)
Podofilox (Podofilox Topical Solution)
Podofilox Topical Solution (Podofilox)
Podophyllin (Pododerm)
Polifeprosan 20 with Carmustine (Gliadel)
Poliovirus Vaccine Inactivated (Ipol)
Poly-Pred (Prednisolone,Neomycin and Polymyxin B)
Poly-Vi-Flor (Multivitamin, Iron and Fluoride)
Polyethylene Glycol 3350 - OTC (MiraLAX)
Polymyxin B (Polymyxin B Sulfate)
Polymyxin B Sulfate (Polymyxin B)
Polysaccharide Diphtheria Toxoid Conjugate Vaccine (Menactra)
Polysaccharide-Iron Complex (Capsules) (Niferex)
Polysaccharide-Iron Complex (Tablets) (Niferex-Pn)
Polythiazide (Renese)
Pondimin (Fenfluramine - Removed from US Market)
Ponstel (Mefenamic Acid)
Poractant Alfa (Curosurf)
Porfimer Sodium (Photofrin)
Posaconazole (Noxafil)
Potassium Acetate (Potassium Acetate)
Potassium Chloride (Klor-Con)
Potassium Chloride (Slow-K)
Potassium Chloride Extended Release Formulation for Liquid Suspension
(Micro-K for Liquid Suspension)
Potassium Chloride Extended-Release (Micro-K)
Potassium Chloride in 5% Dextrose and Sodium Chloride Injection (KCL in
D5NS)
Potassium Chloride in 5% Dextrose Injection (KCL in D5W)
Potassium Chloride in Lactated Ringer's and 5% Dextrose Injection (KCL in
D5LR)
Potassium Chloride in Sodium Chloride Injection (KCL in NS)
Pralidoxime Chloride (Protopam)
Pramipexole (Mirapex)
Pramlintide Acetate Injection (Symlin)
Prandin (Repaglinide)
Pravachol (Pravastatin Sodium)
Pravastatin Sodium (Pravachol)
Praziquantel (Biltricide)
Prazosin HCl (Minipress)
Precedex (Dexmedetomidine hydrochloride)
Precose (Acarbose)
Pred-G (Gentamicin and Prednisolone Acetate)
Prednicarbate (Dermatop)
Prednisolone (Prednisolone (Tablets))
Prednisolone (syrup) (Prelone)
Prednisolone (Tablets) (Prednisolone)
Prednisolone Acetate (Omnipred)
Prednisolone Acetate Oral Suspension (Flo-Pred)
Prednisolone Sodium (Pediapred)
Prednisolone Sodium Phosphate (Orapred ODT)
Prednisolone,Neomycin and Polymyxin B (Poly-Pred)
Prednisone (Deltasone)
Prefest (Estradiol, Norgestimate)
Pregabalin (Lyrica)
Pregnyl (Chorionic Gonadotropin)
Prelone (Prednisolone (syrup))
Prelu-2 (Phendimetrazine)
Premarin (Conjugated Estrogens)
Premarin Injection (Conjugated Estrogens for Injection)
Premarin Vaginal Cream (Conjugated Estrogens Vaginal Cream)
Prempro (Conjugated Estrogens, Medroxyprogesterone Acetate)
Prepidil (Dinoprostone cervical)
Prescription Prenatal, Postnatal Multivitamin (PrimaCare One)
Prevacid (Lansoprazole)
Prevacid I.V. (Lansoprazole for Injection)
Prevacid NapraPAC (Lansoprazole)
Prevnar (Pneumococcal 7-valent Conjugate)
Prevpac (Lansoprazole, Amoxicillin and Clarithromycin)
Prezista (Darunavir)
Prialt (Ziconotide)
Priftin (Rifapentine)
Prilosec (Omeprazole)
PrimaCare One (Prescription Prenatal, Postnatal Multivitamin)
Primacor IV (Milrinone)
Primatene (Epinephrine)
Primaxin I.V. (Imipenem and Cilastatin for Injection)
Primaxin IM (Imipenem and Cilastatin)
Primidone (Mysoline)
Principen (Ampicillin)
Prinivil (Lisinopril)
Prinzide (Lisinopril-Hydrochlorothiazide)
PrismaSol Solution (Sterile Hemofiltration Hemodiafiltration Solution)
Privigen (Immune Globulin Intravenous)
Proair HFA (Albuterol Sulfate Inhalation Aerosol)
Proamatine (Midodrine Hydrochloride)
Probenecid and Colchicine (Colbenemid)
Procainamide (Procan Sr)
Procainamide (Pronestyl)
Procalamine (Amino Acid and Glycerin)
Procan Sr (Procainamide)
Procarbazine (Matulane)
Procardia (Nifedipine)
Prochlorperazine (Compazine)
Prochlorperazine (Compazine Inj)
Procrit (Epoetin Alfa)
Proctofoam (Hydrocortisone and Pramoxine)
Progesterone (Endometrin)
Progesterone (Prometrium)
Progesterone Injection (Progesterone Injection)
Prograf (Tacrolimus)
ProHance (Gadoteridol Injection Solution)
Prohibit (Haemophilus b Conjugate Vaccine)
Prolastin (Alpha)
Proleukin (Aldesleukin)
Prolixin (Fluphenazine)
Prometh Dm (Promethazine and Dextromethorphan)
Promethazine (Phenergan)
Promethazine and Dextromethorphan (Prometh Dm)
Promethazine HCl and Phenylephrine HCl Syrup (Phenergan Vc)
Promethazine Hydrochloride Injection (Promethazine Hydrochloride
Injection)
Prometrium (Progesterone)
Pronestyl (Procainamide)
Propafenone (Rythmol)
Proparacaine (Alcaine)
Propecia (Finasteride)
Propine (Dipivefrin)
Proplex-T (Factor IX Complex)
Propofol (Diprivan)
Propoxyphene (Darvon)
Propoxyphene Napsylate and Acetaminophen (Darvocet-N)
Propoxyphene, Aspirin, and Caffeine (Darvon Compound)
Propranolol (Inderal)
Propranolol (Inderal LA)
Propranolol Hydrochloride (InnoPran XL)
Propranolol Hydrochloride and Hydrochlorothiazide (Inderide)
Propulsid (Cisapride (Removed from US Market))
Proquad (Measles Mumps Rubella Varicella Vaccine Live)
Proquin XR (Ciprofloxacin Hcl)
Proscar (Finasteride)
Prosed (Methenamine, Salicylate, Methylene Blue, Benzoic Acid Atropine
and Hyoscyamine)
Prosom (Estazolam)
Prostigmin (Neostigmine)
Prostin E2 (Dinoprostone)
Prostin VR Pediatric - Caverject (Alprostadil)
Protamine (Protamines)
Protamines (Protamine)
Protein C Concentrate (Ceprotin)
Protirelin (Thyrel Trh)
Protonix I.V. (Pantoprazole Sodium)
Protonix Tablets (Pantoprazole)
Protopam (Pralidoxime Chloride)
Protopic (Tacrolimus)
Protropin (Somatrem)
Proventil HFA (Albuterol Inhalation)
Provera (Medroxyprogesterone Acetate Tablets)
Provigil (Modafinil)
Provisc (Sodium Hyaluronate)
Prozac (Fluoxetine Hcl)
Prudoxin (Doxepin)
Pseudoephedrine (Sudafed)
Pseudoephedrine and Guaifenesin (Entex Pse)
Pseudoephedrine HCl [extended-release] and Guaifenesin (Pseudovent 400
Capsules)
Pseudoephedrine Hydrochloride, Terfenadine (Removed from market 1998)
(Seldane D)
Pseudovent 400 Capsules (Pseudoephedrine HCl [extended-release] and
Guaifenesin)
Pulmicort Flexhaler (Budesonide Inhalation Powder)
Pulmicort Respules (Budesonide Inhalation Suspension)
Pulmicort Turbuhaler (Budesonide)
Pulmozyme (Dornase alfa)
Purinethol (Mercaptopurine)
Pylera Capsules (Bismuth Subcitrate Potassium)
Pyrazinamide (Pyrazinamide)
Pyrazolopyrimidine (Sonata)
Pyridium (Phenazopyridine)
Pyridostigmine (Mestinon)
Pyrimethamine (Daraprim)

Quadramet (Samarium SM 153 Lexidronam)

Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recombinant
Vaccine (Gardasil)
Qualaquin (Quinine Sulfate Capsules)
Quazepam Tablets (Doral)
Questran (Cholestyramine)
Quetiapine Fumarate (Seroquel)
Quetiapine Fumarate Extended-Release Tablets (Seroquel XR)
Quinaglute (Quinidine Gluconate)
Quinapril (Accupril)
Quinidex (Quinidine)
Quinidine (Quinidex)
Quinidine (Quinidine)
Quinidine Gluconate (Quinaglute)
Quinine Sulfate Capsules (Qualaquin)
Quinupristin and Dalfopristin (Synercid)
Quixin (Levofloxacin)
Qvar (Beclomethasone Dipropionate HFA)

Rabavert (Rabies Vaccine)

Rabeprazole Sodium (Aciphex)
Rabies Immune Globulin (Human) (Imogam Rabies)
Rabies Vaccine (Imovax)
Rabies Vaccine (Rabavert)
Radiogardase (Insoluble Prussian blue)
Raloxifene (Evista)
Raltegravir Tablets (Isentress)
Ramelteon (Rozerem)
Ramipril (Altace Capsules)
Ramipril Tablets (Altace Tablets)
Ranexa (Ranolazine)
Ranibizumab Injection (Lucentis)
Ranitidine Bismuth Citrate (Tritec)
Ranitidine Hcl (Zantac)
Ranolazine (Ranexa)
Rapacuronium (Raplon)
Rapamune (Sirolimus)
Raplon (Rapacuronium)
Raptiva (Efalizumab)
Rasagiline (Azilect)
Rasburicase (Elitek)
Rattlesnake Antivenin (Antivenin (Crotalidae) Polyvalent)
Raxar (Grepafloxacin)
Razadyne (formerly Reminyl) (Galantamine HBr)
Razadyne ER (Galantamine HBr ER)
Rebetol (Ribavirin)
Rebetron (Ribavirin)
Rebif (Interferon beta-1a)
Reclast (Zoledronic Acid Injection)
Recombinate (Antihemophilic Factor (Recombinant))
Recombivax (Hepatitis B Vaccine (Recombinant))
Redux (Dexfenfluramine (FDA Removed From US Market 9/15/97))
Refacto (Antihemophilic Factor)
Refludan (Lepirudin)
Regitine (Phentolamine Mesylate)
Reglan (Metoclopramide)
Regranex (Becaplermin)
Relafen (Nabumetone)
Relenza (Zanamivir)
Relpax (Eletriptan hydrobromide)
Remeron (Mirtazapine)
Remeron SolTab (Mirtazapine)
Remicade (Infliximab)
Remifentanil (Ultiva)
Remodulin (Treprostinil Sodium)
Renacidin (Citric Acid, Glucono-Delta-Lactone and Magnesium Carbonate
Irrigation)
Renagel (Sevelamer Hcl)
Renese (Polythiazide)
Renova (Tretinoin Emollient Cream 0.05%)
Renvela (Sevelamer Carbonate)
ReoPro (Abciximab)
Repaglinide (Prandin)
Requip (Ropinirole Hcl)
Rescriptor (Delavirdine Mesylate)
Rescula (Unoprostone isopropyl)
Restasis (Cyclosporine)
Restoril (Temazepam)
Retapamulin (Altabax)
Retavase (Reteplase)
Reteplase (Retavase)
Retin-A Micro (Tretinoin Gel)
Retisert (Fluocinolone Acetonide Intravitreal Implant)
Retrovir (Zidovudine)
Retrovir IV (Zidovudine Injection)
Revatio (Sildenafil Citrate)
Revex (Nalmefene Hydrochloride)
Revia (Naltrexone)
Revlimid (Lenalidomide)
Reyataz (Atazanavir Sulfate)
Rezulin (Troglitazone (removed from the US market 3/21/00))
Rhinocort Aqua (Budesonide)
Rho(D) Immune Globulin (Human) (Rhogam)
Rhogam (Rho(D) Immune Globulin (Human))
Rhogam Ultra-Filtered Plus (Rhogam Ultra-Filtered Plus)
Rhophylac (Immune Globulin Intravenous (Human) solution)
Ribavirin (Copegus)
Ribavirin (Rebetol)
Ribavirin (Rebetron)
Ribavirin (Virazole)
Ribavirin, Interferon Alfa-2b, Recombinant (Intron A - Rebetol)
Rifabutin (Mycobutin)
Rifadin (Rifampin)
Rifamate (Rifampin and Isoniazid)
Rifampin (Rifadin)
Rifampin and Isoniazid (Rifamate)
Rifampin, Isoniazid and Pyrazinamide (Rifater)
Rifapentine (Priftin)
Rifater (Rifampin, Isoniazid and Pyrazinamide)
Rifaximin (Xifaxan)
Rilutek (Riluzole)
Riluzole (Rilutek)
Rimantadine (Flumadine)
Rimexolone (Vexol)
Rimso-50 (DMSO)
Ringer's and 5% Dextrose Inj (Ringers in Dextrose)
Ringer's Inj (Ringers Injection)
Ringers in Dextrose (Ringer's and 5% Dextrose Inj)
Ringers Injection (Ringer's Inj)
Riomet (Metformin Hcl)
Risedronate Sodium (Actonel)
Risedronate Sodium with Calcium Carbonate (Actonel with Calcium)
Risperdal (Risperidone)
Risperdal Consta (Risperidone)
Risperidone (Risperdal)
Risperidone (Risperdal Consta)
Ritalin (Methylphenidate Hcl)
Ritalin LA (Methylphenidate Hydrochloride Extended-Release Capsules)
Ritonavir Capsules, Oral Solution (Norvir)
Rituxan (Rituximab)
Rituximab (Rituxan)
Rivastigmine Tartrate (Exelon)
Rivastigmine Transdermal System (Exelon Patch)
Rizatriptan (Maxalt)
Robaxin (Methocarbamol)
Robaxisal (Methocarbamol and Aspirin)
Robinul (Glycopyrrolate)
Robitussin Ac (Guaifenesin and Codeine)
Rocaltrol (Calcitriol)
Rocephin (Ceftriaxone)
Rocuronium (Zemuron)
Rofecoxib (Vioxx)
Roferon-A alfa-2a (Interferon alfa-2a, Recombinant)
Roferon-A alfa-2b (Peginterferon alfa-2b)
Romazicon (Flumazenil)
Rondec (Carbinoxamine Maleate and Pseudoephedrine HCl)
Ropinirole Hcl (Requip)
Ropivacaine Hcl (Naropin)
Rosiglitazone Maleate (Avandia)
Rosiglitazone Maleate and Glimepiride (Avandaryl)
Rosiglitazone Maleate and Metformin HCl (Avandamet)
Rosuvastatin Calcium (Crestor)
RotaTeq (Rotavirus Vaccine, Live, Oral, Pentavalent)
Rotavirus Vaccine, Live, Oral, Pentavalent (RotaTeq)
Rotigotine Transdermal System (Neupro)
Rowasa (Mesalamine Rectal Suspension Enema)
Roxanol (Morphine Sulfate)
Roxicodone (Oxycodone)
Roxicodone 15, 30 mg (Oxycodone Hydrochloride )
Rozerem (Ramelteon)
Rubella and Mumps Virus Vaccine Live (Biavax)
Rubella Virus Vaccine Live (Meruvax)
Rynatan (Phenylephrine, Chlorpheniramine, and Pyrilamine)
Rythmol (Propafenone)
S-Caine (Lidocaine and Tetracaine)
Saint John's Wort (St. John's Wort)
Saizen (Somatropin Injection)
Salagen (Pilocarpine Hydrochloride)
Salmeterol Xinafoate (Serevent Diskus)
Salsalate (Disalcid)
Samarium SM 153 Lexidronam (Quadramet)
Sanctura (Trospium)
Sandimmune (Cyclosporine)
Sandostatin (Octreotide Acetate)
Sandostatin LAR (Octreotide Acetate Injection)
Sansert (Methysergide maleate)
Santyl (Collagenase)
Saproterin Dihydrochloride Tablets (Kuvan)
Saquinavir Mesylate (Invirase)
Sarafem (Fluoxetine Hydrochloride)
Sargramostim (Leukine)
Scopolamine (Isopto Hyoscine)
Scopolamine (Transderm Scop)
Seasonale (Levonorgestrel, Ethinyl Estradiol)
Seasonique (Levonorgestrel, Ethinyl Estradiol)
Secretin (Secretin)
Sectral (Acebutolol)
Seldane (Terfenadine (Removed from market 1998))
Seldane D (Pseudoephedrine Hydrochloride, Terfenadine (Removed from
market 1998)
Selegiline Hcl (Eldepryl)
Selegiline Hydrochloride (Zelapar)
Selegiline Transdermal System (Emsam)
Selenium (Selsun)
Selsun (Selenium)
Selzentry (Maraviroc)
Semprex D (Acrivastine and Pseudoephedrine)
Sensipar (Cinacalcet)
Sensorcaine (Bupivacaine HCI Injections)
Septra (Trimethoprim and Sulfamethoxazole)
Serax (Oxazepam)
Serentil (Mesoridazine Besylate)
Serevent Diskus (Salmeterol Xinafoate)
Sermorelin (Geref)
Seroquel (Quetiapine Fumarate)
Seroquel XR (Quetiapine Fumarate Extended-Release Tablets)
Serostim (Somatropin (rDNA origin))
Serostim LQ (Somatropin (rDNA origin) Inj)
Sertaconazole Nitrate (Ertaczo)
Sertraline Hcl (Zoloft)
Serzone (Nefazodone)
Sevelamer Carbonate (Renvela)
Sevelamer Hcl (Renagel)
Sevoflurane (Ultane)
Sibutramine Hydrochloride Monohydrate (Meridia)
Sildenafil Citrate (Revatio)
Sildenafil Citrate (Viagra)
Silvadene (Silver Sulfadiazine)
Silver Sulfadiazine (Silvadene)
Simcor (Simvastatin Niacin Extended Release)
Simulect (Basiliximab)
Simvastatin (Zocor)
Simvastatin Niacin Extended Release (Simcor)
Sincalide (Kinevac)
Sinecatechins Ointment (Veregen)
Sinemet (Carbidopa-Levodopa)
Sinemet CR (Carbidopa-Levodopa Sustained Release)
Sinequan (Doxepin)
Singulair (Montelukast Sodium)
Sirolimus (Rapamune)
Sitagliptin Metformin HCL (Janumet)
Sitagliptin Phosphate (Januvia)
Skelaxin (Metaxalone)
Skelid (Tiludronate)
Skin Exposure Paste (Perfluoroalkylpolyether (PFPE),
Polytetrafluoroethylene (PTFE))
Slo-phyllin (Theophylline, Anhydrous)
Slow-K (Potassium Chloride)
Sod Bicarbonate (Sodium Bicarbonate)
Sod. Acetate (Sodium Acetate)
Sodium Acetate (Sod. Acetate)
Sodium Bicarbonate (Sod Bicarbonate)
Sodium Chloride Inj (Normal Saline)
Sodium Chloride-Sodium Bicarbonate and Potassium Chloride (HalfLytely
and Bisacodyl Tablets)
Sodium ferric gluconate (Ferrlecit)
Sodium Fluoride (EtheDent)
Sodium Hyaluronate (Healon)
Sodium Hyaluronate (Provisc)
Sodium Iodide I 131 (Sodium Iodide I 131 Capsules USP)
Sodium Iodide I 131 Capsules USP (Sodium Iodide I 131)
Sodium Lactate (Sodium Lactate Injection in AVIVA)
Sodium Lactate Injection in AVIVA (Sodium Lactate)
Sodium Oxybate (Xyrem)
Sodium Phenylacetate and Sodium Benzoate Injection (Ammonul)
Sodium Phosphate Monobasic Monohydrate and Sodium Phosphate Dibasic
Anhydrous (OsmoPrep)
Sodium Phosphate Monobasic Monohydrate, Sodium Phosphate Dibasic
Anhydrous (Visicol)
Sodium Polystyrene (Kayexalate)
Sodium Polystyrene Sulfonate (Kionex)
Sodium Sulfacetamide Lotion (Klaron)
Sodium Tetradecyl (Sotradecol)
Solage (Mequinol and Tretinoin)
Solaraze (Diclofenac Sodium)
Solifenacin Succinate (VESIcare)
Soliris (Eculizumab)
Solodyn (Minocycline Hydrochloride)
Soltamox (Tamoxifen Citrate)
Solu Cortef (Hydrocortisone Sodium Succinate)
Solu Medrol (Methylprednisolone sodium succinate)
Soma (Carisoprodol)
Somatrem (Protropin)
Somatropin (rDNA origin) (Nutropin AQ)
Somatropin (rDNA origin) (Serostim)
Somatropin (rDNA origin) for Inj (Nutropin)
Somatropin (rDNA origin) for Inj (Nutropin Depot)
Somatropin (rDNA origin) Inj (Serostim LQ)
Somatropin [ rDNA origin] Injection (Omnitrope)
Somatropin [rDNA origin] (Genotropin)
Somatropin Injection (Accretropin)
Somatropin Injection (Norditropin)
Somatropin Injection (Saizen)
Somatropin Injection (Valtropin)
Somatropin rDNA Origin (Humatrope)
Somatropin, rDNA Origin, for Inj (Tev-Tropin)
Somavert (Pegvisomant)
Sonata (Pyrazolopyrimidine)
Sorafenib (Nexavar)
Soriatane (Acitretin)
Sotalol (Betapace)
Sotalol Hcl (Betapace AF)
Sotradecol (Sodium Tetradecyl)
Sparfloxacin (Zagam)
Spectazole (Econazole Nitrate)
Spectinomycin (Trobicin)
Spectracef (Cefditoren Pivoxil)
Spiriva (Tiotropium Bromide)
Spironolactone (Aldactone)
Spironolactone and Hydrochlorothiazide (Aldactazide)
Sporanox (Itraconazole Capsules)
Sprycel (Dasatinib)
St. John's Wort (Saint John's Wort)
Stadol (Butorphanol Tartrate)
Stalevo (Carbidopa, Levodopa and Entacapone)
Starlix (Nateglinide)
Staticin (Erythromycin)
Stavudine (Zerit)
Stelazine (Trifluoperazine)
Sterile Hemofiltration Hemodiafiltration Solution (PrismaSol Solution)
Stimate (Desmopressin Acetate)
Strattera (Atomoxetine HCl)
Streptase (Streptokinase)
Streptokinase (Streptase)
Streptomycin (Streptomycin)
Streptozocin (Zanosar)
Striant (Testosterone)
Stromectol (Ivermectin)
Strontium-89 (Metastron)
Suboxone (Buprenorphine HCl and naloxone HCl)
Succimer (Chemet)
Succinylcholine Chloride (Anectine)
Sucralfate (Carafate Suspension)
Sucralfate (Carafate Tablets)
Sudafed (Pseudoephedrine)
Sufenta (Sufentanil Citrate Injection)
Sufentanil Citrate Injection (Sufenta )
Sular (Nisoldipine)
Sulconazole (Exelderm)
Sulfacet R (Sulfacetamide and Sulfur)
Sulfacetamide (Plexion)
Sulfacetamide and Prednisolone (Vasocidin)
Sulfacetamide and Sulfur (Sulfacet R)
Sulfacetamide Ophthalmic (Bleph 10)
Sulfadoxine and Pyrimethamine (Fansidar)
Sulfamethoxazole (Gantanol)
Sulfamethoxazole, Trimethoprim, Phenazopyridine (Zotrim)
Sulfamylon (Mafenide Acetate)
Sulfasalazine Delayed Release Tablets (Azulfidine EN-Tabs)
Sulfathiazole, Sulfacetamide and Sulfabenzamide (Sultrin)
Sulfinpyrazone (Anturane)
Sulindac (Clinoril)
Sultrin (Sulfathiazole, Sulfacetamide and Sulfabenzamide)
Sumatriptan (Imitrex Nasal Spray)
Sumatriptan Succinate (Imitrex)
Sumatriptan Succinate (Imitrex Inj)
Sumycin (Tetracycline)
Sunitinib Malate (Sutent)
Supprelin LA (Histrelin Acetate Subcutaneous Implant)
Suprane (Desflurane)
Suprax (Cefixime)
Surmontil (Trimipramine)
Survanta (Beractant)
Sustiva (Efavirenz)
Sutent (Sunitinib Malate)
Symbicort (Budesonide and Formoterol Fumarate Dihydrate)
Symbyax (Olanzapine and fluoxetine)
Symlin (Pramlintide Acetate Injection)
Symmetrel (Amantadine Hydrochloride)
Synagis (Palivizumab)
Synalar (Fluocinolone Acetonide)
Synarel (Nafarelin Acetate)
Synera (Lidocaine and Tetracaine)
Synercid (Quinupristin and Dalfopristin)
Synthetic conjugated estrogens (Cenestin)
Synthetic Conjugated Estrogens, B (Enjuvia)
Synthroid (Levothyroxine Sodium)
Synvisc (Hylan G-F 20)
Syprine (Trientine)

Taclonex (Calcipotriene and Betamethasone Dipropionate)

Tacrine (Cognex)
Tacrolimus (Prograf)
Tacrolimus (Protopic)
Tadalafil (Cialis)
Tagamet (Cimetidine)
Talacen (Pentazocine and Acetaminophen)
Talwin Compound (Pentazocine and Aspirin)
Talwin Nx (Pentazocine and Naloxone)
Tambocor (Flecainide)
Tamiflu (Oseltamivir Phosphate)
Tamoxifen Citrate (Nolvadex)
Tamoxifen Citrate (Soltamox)
Tamsulosin Hydrochloride (Flomax)
Tao (Troleandomycin)
Tapazole (Methimazole)
Tarceva (Erlotinib)
Targretin (Bexarotene)
Tarka (Trandolapril and Verapamil)
Tasigna Capsules (Nilotinib Capsules)
Tasmar (Tolcapone)
Taxol (Paclitaxel)
Taxotere (Docetaxel for Inj)
Tazarotene (Avage)
Tazarotene (Tazorac)
Tazorac (Tazarotene)
Technetium (Technetium)
Technetium Tc99m Exametazime Injection (Ceretec)
Technetium Tc99m sestamibi (Miraluma)
Tegaserod Maleate (Zelnorm)
Tegretol (Carbamazepine)
Tekturna (Aliskiren Tablets)
Tekturna HCT (Aliskren and Hydrochlorothiazide Tablets)
Telbivudine (Tyzeka)
Telithromycin (Ketek)
Telmisartan (Micardis)
Telmisartan, Hydrochlorothiazide (Micardis HCT)
Temazepam (Restoril)
Temodar (Temozolomide)
Temovate (Clobetasol Propionate Cream and Ointment)
Temovate Gel (Clobetasol Propionate Gel)
Temovate Scalp (Clobetasol Propionate Scalp Application)
Temozolomide (Temodar)
Temsirolimus Injection (Torisel)
Tenecteplase (Tnkase)
Teniposide (Vumon)
Tenofovir Disoproxil Fumarate (Viread)
Tenoretic (Atenolol and Chlorthalidone)
Tenormin (Atenolol Tablets)
Tenormin I.V. Injection (Atenolol Inj)
Tenuate (Diethylpropion)
Tequin (Gatifloxacin (Removed from US Market - May 2006))
Terazol 3, Terazol 7 (Terconazole)
Terazosin Hcl (Hytrin)
Terbinafine (Lamisil)
Terbinafine Hydrochloride (Lamisil Oral Granules)
Terbutaline Sulfate (Brethine)
Terconazole (Terazol 3, Terazol 7)
Terfenadine (Removed from market 1998) (Seldane)
Teriparatide (rDNA origin) Injection (Forteo)
Terra-Cortril (Oxytetracycline and Hydrocortisone)
Terramycin (Oxytetracycline)
Teslac (Testolactone)
Teslascan (Mangafodipir)
Testoderm (Testosterone (transdermal))
Testolactone (Teslac)
Testosterone (Striant)
Testosterone (transdermal) (Testoderm)
Testosterone Enanthate (Delatestryl)
Testosterone Gel (Androgel)
Testosterone Transdermal System (Androderm)
Testred (Methyltestosterone)
Tetanus (Tetanus Toxoid)
Tetanus Toxoid (Tetanus)
Tetanus Toxoid Absorbed (Tetanus Toxoid Absorbed)
Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine
Adsorbed (Adacel)
Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine,
Adsorbed (Boostrix)
Tetracycline (Sumycin)
Tetracycline (periodontal) (Actisite)
Tev-Tropin (Somatropin, rDNA Origin, for Inj)
Teveten (Eprosartan Mesylate)
Thalidomide (Thalomid)
Thallium (Thallous Chloride)
Thallous Chloride (Thallium)
Thalomid (Thalidomide)
Theodur (Theophylline)
Theophylline (Theodur)
Theophylline, Anhydrous (Slo-phyllin)
Theracys (BCG Live (Intravesical))
Therapeutic Vitamins with Minerals (Vitacon Forte Capsules)
Thiabendazole (Mintezol)
Thiethylperazine (Torecan)
Thioguanine (Thioguanine)
Thiopental Sodium (Pentothal)
Thioplex (Thiotepa (injection))
Thioridazine (Thioridazine)
Thioridazine HCl (Mellaril)
Thiotepa (injection) (Thioplex)
Thiothixene Hcl (Navane)
Thorazine (Chlorpromazine)
Thrombate (Antithrombin)
Thrombin Topical (Thrombostat)
Thrombostat (Thrombin Topical)
Thymalfasin (Zadaxin)
Thyrel Trh (Protirelin)
Thyro-Tabs (Levothyroxine Sodium)
Thyrogen (Thyrotropin Alfa for Inj)
Thyroid tablets (Armour Thyroid)
Thyrolar (Liotrix)
Thyrotropin Alfa for Inj (Thyrogen)
Tiagabine Hydrochloride (Gabitril)
Tiazac (Diltiazem Hcl)
Ticarcillin and Clavulanate (Timentin)
Tice (Bacillus of Calmette and Guerin)
Ticlid (Ticlopidine Hcl)
Ticlopidine Hcl (Ticlid)
Tigan (Trimethobenzamide hydrochloride)
Tigecycline (Tygacil)
Tikosyn (Dofetilide)
Tilade (Nedocromil (inhalation))
Tiludronate (Skelid)
Timentin (Ticarcillin and Clavulanate)
Timolide (Timolol Maleate-Hydrochlorothiazide)
Timolol (Blocadren)
Timolol Maleate (Timoptic-XE)
Timolol Maleate Opthalmic Solution (Timoptic)
Timolol Maleate-Hydrochlorothiazide (Timolide)
Timoptic (Timolol Maleate Opthalmic Solution)
Timoptic-XE (Timolol Maleate)
Tindamax (Tinidazole)
Tinidazole (Tindamax)
Tinzaparin (Innohep)
Tioconazole (Vagistat-1)
Tiotropium Bromide (Spiriva)
Tipranavir (Aptivus)
Tirofiban (Aggrastat)
Tirosint (Levothyroxine Sodium Capsules)
Tizanidine (Zanaflex)
Tnkase (Tenecteplase)
Tobi (Tobramycin)
Tobradex (Tobramycin and Dexamethasone)
Tobradex Ointment (Tobramycin and Dexamethasone Opthalmic Ointment)
Tobramycin (Nebcin)
Tobramycin (Tobi)
Tobramycin and Dexamethasone (Tobradex)
Tobramycin and Dexamethasone Opthalmic Ointment (Tobradex Ointment)
Tocainide HCl (Tonocard)
Tofranil (Imipramine)
Tofranil-PM (Imipramine Pamoate)
Tolazamide (Tolinase)
Tolcapone (Tasmar)
Tolectin (Tolmetin Sodium)
Tolinase (Tolazamide)
Tolmetin Sodium (Tolectin)
Tolterodine Tartrate (Detrol)
Tolterodine Tartrate (Detrol LA)
Tonocard (Tocainide HCl)
Topamax (Topiramate)
Topicort (Desoximetasone)
Topiramate (Topamax)
Topotecan Capsules (Hycamtin Capsules)
Topotecan Hydrochloride (Hycamtin)
Toprol XL (Metoprolol Succinate)
Toradol Oral (Ketorolac Tromethamine)
Torecan (Thiethylperazine)
Toremifene (Fareston)
Torisel (Temsirolimus Injection)
Torsemide (Demadex)
Tositumomab and Iodine 1131 Tositumomab (Bexxar)
Totect (Dexrazoxane)
Trace Metal-5 Combination (Mte 5)
Tracleer (Bosentan)
Tracrium (Atracurium Besylate)
Tramadol (Ultracet)
Tramadol Hcl (Tramadol Hydrochloride)
Tramadol Hcl (Ultram)
Tramadol HCl Extended-Release (Ultram ER)
Tramadol Hydrochloride (Tramadol Hcl)
Trandate (Labetalol)
Trandolapril (Mavik)
Trandolapril and Verapamil (Tarka)
Tranexamic Acid (Cyklokapron)
Transderm Nitro (Nitroglycerin)
Transderm Scop (Scopolamine)
Tranxene (Clorazepate)
Tranylcypromine (Parnate)
Trastuzumab (Herceptin)
Trasylol (Aprotinin)
Travasol (Amino Acids (Injection))
Travatan (Travoprost)
Travoprost (Travatan)
Trazodone Hydrochloride (Desyrel)
Treanda (Bendamustine Hydrochloride Injection)
Trecator (Ethionamide Tablets)
Trelstar Depot (Triptorelin pamoate)
Trelstar LA (Triptorelin pamoate)
Trental (Pentoxifylline)
Treprostinil Sodium (Remodulin)
Tretinoin (Atralin)
Tretinoin (Vesanoid)
Tretinoin Emollient Cream 0.05% (Renova)
Tretinoin Gel (Retin-A Micro)
Trexall (Methotrexate)
Triamcinolone Acetonide (Nasacort)
Triamcinolone Acetonide (Nasacort AQ)
Triamcinolone Acetonide (inhalation aerosol) (Azmacort)
Triamcinolone Acetonide Cream (Triamcinolone Cream)
Triamcinolone Acetonide Lotion (Triamcinolone Lotion)
Triamcinolone Acetonide Ointment (Triamcinolone Ointment)
Triamcinolone Cream (Triamcinolone Acetonide Cream)
Triamcinolone Hexacetonide Injectable Suspension (Aristospan Injection 20
mg)
Triamcinolone Hexacetonide Injection 5 mg (Aristospan 5 mg)
Triamcinolone Lotion (Triamcinolone Acetonide Lotion)
Triamcinolone Ointment (Triamcinolone Acetonide Ointment)
Triamterene (Dyrenium)
Triazolam (Halcion)
Tricarbocyanine (Ic-Green)
Tricor (Fenofibrate)
Tridesilon (Desonide)
Trientine (Syprine)
Triethanolamine Polypeptide (Cerumenex)
Trifluoperazine (Stelazine)
Trifluridine (Viroptic)
Triglide (Fenofibrate)
Trihexyphenidyl (Artane)
Trilafon (Perphenazine)
Trileptal (Oxcarbazepine)
Trilisate (Choline Magnesium Trisalicylate)
TriLyte (PEG-3350, Sodium Chloride, Sodium Bicarbonate and Potassium
Chloride)
Trimethobenzamide hydrochloride (Tigan)
Trimethoprim (Trimpex)
Trimethoprim and Sulfamethoxazole (Bactrim)
Trimethoprim and Sulfamethoxazole (Septra)
Trimetrexate Glucuronate Inj (Neutrexin)
Trimipramine (Surmontil)
Trimpex (Trimethoprim)
Trinalin (Azatadine and Pseudoephedrine)
TriNessa (Norgestimate and Ethinyl Estradiol Tablets)
Tripedia (Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine)
Triple Vita Drops with Fluoride (Vitamin A, D, C, and Fluoride)
Triptorelin pamoate (Trelstar Depot)
Triptorelin pamoate (Trelstar LA)
Trisenox (Arsenic)
Tritec (Ranitidine Bismuth Citrate)
Trivora (Levonorgestrel and Ethinyl Estradiol)
Trizivir (Abacavir Sulfate, Lamivudine, and Zidovudine)
Trobicin (Spectinomycin)
Troglitazone (removed from the US market 3/21/00) (Rezulin)
Troleandomycin (Tao)
TrophAmine (Amino Acids)
Trospium (Sanctura)
Trovafloxacin and Azithromycin (Trovan - Zithromax)
Trovan - Zithromax (Trovafloxacin and Azithromycin)
Trusopt (Dorzolamide)
Truvada (Emtricitabine and Tenofovir Disoproxil Fumarate)
Trypan Blue (VisionBlue)
Tuberculin (mono-vaccine) (Mono-Vacc)
Tuberculin Purified Protein (Tubersol)
Tubersol (Tuberculin Purified Protein)
Tussionex (Hydrocodone and Chlorpheniramine)
Twinrix (Hepatitis A Inactivated & Hepatitis B (Recombinant) Vaccine)
Tygacil (Tigecycline)
Tykerb (Lapatinib)
Tylenol (Acetaminophen)
Tylenol-Codeine (Acetaminophen and Codeine)
Typhim (Typhoid Vi Polysaccharide Vaccine)
Typhoid Vaccine (Typhoid Vaccine)
Typhoid Vi Polysaccharide Vaccine (Typhim)
Tysabri (Natalizumab)
Tyzeka (Telbivudine)

Ultane (Sevoflurane)
Ultiva (Remifentanil)
Ultracet (Tramadol)
Ultram (Tramadol Hcl)
Ultram ER (Tramadol HCl Extended-Release)
Ultrase (Pancrelipase)
Ultravate (Halobetasol Propionate)
Unasyn (Ampicillin and Sulbactam)
Unipen (Nafcillin Sodium)
Unithroid (Levothyroxine Sodium)
Univasc (Moexipril)
Unoprostone isopropyl (Rescula)
Urex (Methenamine Hippurate)
Urispas (Flavoxate HCl)
Urobiotic (Oxytetracycline,Sulfamethizole and Phenazopyridine)
Urofollitropin (Fertinex)
Urofollitropin for Injection (Metrodin)
Urokinase Injection (Kinlytic)
Uroxatral (Alfuzosin HCl)
Urso (Ursodiol)
Ursodiol (Urso)
Uvadex (Methoxsalen)

Vaccinia Immune Globulin Intravenous (VIGIV)

Vagifem (Estradiol)
Vaginal Jelly (Aci-Jel)
Vagistat-1 (Tioconazole)
Valacyclovir Hydrochloride (Valtrex)
Valcyte (Valganciclovir Hcl)
Valdecoxib (Bextra)
Valganciclovir Hcl (Valcyte)
Valium Injection (Diazepam Injection)
Valium Tablets (Diazepam)
Valproate Sodium Inj (Depacon)
Valproic Acid (Depakene)
Valrubicin (Valstar)
Valsartan (Diovan)
Valsartan and Hydrochlorothiazide (Diovan HCT)
Valstar (Valrubicin)
Valtrex (Valacyclovir Hydrochloride)
Valtropin (Somatropin Injection)
Vanceril (Beclomethasone Aerosol)
Vancomycin Hydrochloride (Vancomycin Injection)
Vancomycin Injection (Vancomycin Hydrochloride)
Vaniqa (Eflornithine)
Vanos (Fluocinonide)
Vantin (Cefpodoxmine Proxetil)
Vaprisol (Conivaptan Hcl Injection)
Vaqta (Hepatitis A Vaccine, Inactivated)
Vardenafil HCl (Levitra)
Varenicline (Chantix)
Varicella Virus Vaccine Live (Varivax)
Varivax (Varicella Virus Vaccine Live)
Vascor (Bepridil)
Vasocidin (Sulfacetamide and Prednisolone)
Vasopressin (Pitressin)
Vasotec (Enalapril)
Velban (Vinblastine Sulfate)
Velcade (Bortezomib)
Velosef (Cephradine)
Velosulin (Insulin Human)
Venlafaxine Hydrochloride (Effexor)
Venlafaxine Hydrochloride (Effexor XR)
Venofer (Iron Sucrose Injection)
Ventavis (Iloprost)
Ventolin HFA (Albuterol Sulfate Inhalation Aerosol)
Ventolin Inhalation Aerosol (Albuterol Inhalation Aerosol)
Ventolin Nebules (Albuterol Sulfate Inhalation Solution)
Ventolin Solution (Albuterol Sulfate Inhalation Solution)
Ventolin Syrup (Albuterol Sulfate Syrup)
Ventolin Tab (Albuterol Sulfate Tablets)
Vepesid (Etoposide)
Veramyst (Fluticasone Furoate)
Verapamil (Covera-HS)
Verapamil (Verelan PM)
Verapamil HCl (Calan)
Veregen (Sinecatechins Ointment)
Verelan PM (Verapamil)
Vermox (Mebendazole)
Versed Syrup (Midazolam)
Verteporfin Inj (Visudyne)
Vesanoid (Tretinoin)
VESIcare (Solifenacin Succinate)
Vexol (Rimexolone)
Vfend (Voriconazole)
Viadur (Leuprolide Acetate Implant)
Viagra (Sildenafil Citrate)
Vibramycin Intravenous (Doxycycline hyclate)
Vibramycin Oral (Doxycycline Calcium Oral Suspension)
Vicodin (Hydrocodone Bitartrate and Acetaminophen)
Vicodin ES (Hydrocodone Bitartrate and Acetaminophen)
Vicoprofen (Hydrocodone and Ibuprofen)
Vidarabine (Vira-A)
Vidaza (Azacitidine)
Videx (Didanosine)
Vigamox (Moxifloxacin)
VIGIV (Vaccinia Immune Globulin Intravenous)
Vinblastine Sulfate (Velban)
Vincasar PFS (Vincristine Sulfate Injection)
Vincristine Sulfate (Oncovin)
Vincristine Sulfate Injection (Vincasar PFS)
Vinorelbine Tartrate (Navelbine)
Viokase (Pancrelipase)
Vioxx (Rofecoxib)
Vira-A (Vidarabine)
Viracept (Nelfinavir Mesylate)
Viramune (Nevirapine)
Virazole (Ribavirin)
Viread (Tenofovir Disoproxil Fumarate)
Viroptic (Trifluridine)
Visicol (Sodium Phosphate Monobasic Monohydrate, Sodium Phosphate
Dibasic Anhydrous)
VisionBlue (Trypan Blue)
Visken (Pindolol)
Vistaril (Hydroxyzine)
Vistide (Cidofovir)
Visudyne (Verteporfin Inj)
Vitacon Forte Capsules (Therapeutic Vitamins with Minerals)
Vitamin A (Aquasol A)
Vitamin A, D, C, and Fluoride (Triple Vita Drops with Fluoride)
Vitamin C (Ascorbic Acid)
Vitamins Prenatal with Zinc (Zenate Prenatal)
Vitrasert (Ganciclovir)
Vitravene (Fomivirsen)
Vivaglobin (Immune Globulin Subcutaneous (Human))
Vivelle-Dot (Estradiol Transdermal System)
Vivitrol (Naltrexone XR Inj)
Voltaren (Diclofenac Sodium)
Voltaren Opthalmic (Diclofenac Sodium Opthalmic Solution)
Voluven (Hydroxyethyl Starch in Sodium Chloride Injection)
Voriconazole (Vfend)
Vorinostat (Zolinza)
Vosol Hc Otic (Hydrocortisone and Acetic Acid)
Vosol Otic (Acetic Acid)
Vumon (Teniposide)
Vusion (Miconazole Nitrate, 15% Zinc Oxide, and 81.35% White Petrolatum)
Vytorin (Ezetimibe & Simvastatin)
Vyvanse (Lisdexamfetamine Dimesylate)

Warfarin Sodium (Coumadin)

Warfarin Sodium Tablets (Jantoven)
Welchol (Colesevelam Hcl)
Wellbutrin (Bupropion Hcl)
Wellbutrin SR (Bupropion Hydrochloride Sustained-Release)
Wellbutrin XL (Bupropion Hydrochloride Extended-Release)
Westcort (Hydrocortisone Valerate)
Wigraine (Ergotamine and Caffeine)
Winstrol (Anabolic steroids)
Xalatan (Latanoprost Ophthalmic)
Xanax (Alprazolam)
Xanax XR (Alprazolam)
Xeloda (Capecitabine)
Xenical (Orlistat 120 mg)
Xibrom (Bromfenac)
Xifaxan (Rifaximin)
Xigris (Drotrecogin alfa)
Xolair (Omalizumab)
Xolegel (Ketoconazole)
Xopenex (Levalbuterol)
Xopenex HFA (Levalbuterol Tartrate Inhalation Aerosol)
Xylocaine (Lidocaine)
Xylocaine Viscous (Lidocaine Hydrochloride Solution)
Xyntha (Antihemophilic Factor)
Xyrem (Sodium Oxybate)
Xyzal (Levocetirizine Dihydrochloride)

Yasmin (Drospirenone and Ethinyl Estradiol)

Yaz (Drospirenone and Ethinyl Estradiol)
Yellow Fever Vaccine (Yf-Vax)
Yf-Vax (Yellow Fever Vaccine)
Yocon (Yohimbine Hydrochloride)
Yohimbine (Aphrodyne)
Yohimbine Hydrochloride (Yocon)

Zadaxin (Thymalfasin)
Zaditor (Ketotifen Fumarate)
Zafirlukast (Accolate)
Zagam (Sparfloxacin)
Zalcitabine (Hivid)
Zanaflex (Tizanidine)
Zanamivir (Relenza)
Zanosar (Streptozocin)
Zantac (Ranitidine Hcl)
Zarontin (Ethosuximide)
Zavesca (Miglustat)
Zebeta (Bisoprolol Fumarate)
Zegerid (Omeprazole, Sodium Bicarbonate)
Zelapar (Selegiline Hydrochloride)
Zelnorm (Tegaserod Maleate)
Zemaira (Alpha-Proteinase Inhibitor (Human))
Zemplar Capsules (Paricalcitol)
Zemplar Injection (Paricalcitol Injection Fliptop Vial)
Zemuron (Rocuronium)
Zenapax (Daclizumab)
Zenate Prenatal (Vitamins Prenatal with Zinc)
Zerit (Stavudine)
Zestoretic (Lisinopril and Hydrochlorothiazide)
Zestril (Lisinopril)
Zetia (Ezetimibe Tablets)
Zevalin (Ibritumomab Tiuxetan)
Ziac (Bisoprolol and Hydrochlorothiazide)
Ziagen (Abacavir Sulfate)
Ziana Gel (Clindamycin Phosphate, Tretinoin)
Ziconotide (Prialt)
Zidovudine (Retrovir)
Zidovudine Injection (Retrovir IV)
Zileutin (Zyflo)
Zileuton Extended Release Tablets (Zyflo CR)
Zinacef (Cefuroxime)
Zinecard (Dexrazoxane)
Zingo (Lindocaine Hydrochloride Monohydrate)
Ziprasidone (Geodon)
Zithromax (Azithromycin)
Zithromax Injection (Azithromycin)
Zmax (Azithromycin)
Zn-DTPA (Pentetate Zinc Trisodium Inj)
Zocor (Simvastatin)
Zofran (Ondansetron Hydrochloride)
Zofran Injection (Ondansetron Hydrochloride Injection)
Zoladex (Goserelin)
Zoladex Implant (Goserelin Acetate Implant)
Zoledronic Acid for Inj (Zometa)
Zoledronic Acid Injection (Reclast)
Zolinza (Vorinostat)
Zolmitriptan (Zomig)
Zoloft (Sertraline Hcl)
Zolpidem Tartrate (Ambien)
Zolpidem Tartrate (Ambien CR)
Zometa (Zoledronic Acid for Inj)
Zomig (Zolmitriptan)
Zonalon (Doxepin)
Zonegran (Zonisamide)
Zonisamide (Zonegran)
Zostavax (Zoster Vaccine Live)
Zoster Vaccine Live (Zostavax)
Zosyn (Piperacillin and Tazobactam Inj)
Zotrim (Sulfamethoxazole, Trimethoprim, Phenazopyridine)
Zovia (Ethinyl Estradiol and Ethynodiol Diacetate)
Zovirax (Acyclovir)
Zovirax Injection (Acyclovir for Injection)
Zovirax Ointment (Acyclovir Transdermal)
Zyban (Bupropion Hcl)
Zydone (Hydrocodone Bitartrate and Acetaminophen)
Zyflo (Zileutin)
Zyflo CR (Zileuton Extended Release Tablets)
Zylet (Loteprednol Etabonate and Tobramycin)
Zyloprim Injection (Allopurinol)
Zyloprim Tablets (Allopurinol)
Zymar (Gatifloxacin Ophthalmic Solution)
Zyprexa (Olanzapine)
Zyrtec (Cetirizine)
Zyrtec-D (Cetirizine, Pseudoephedrine)
Zyvox (Linezolid)
CHILD BIRTH

1. HISTORY

a. Present History

(1) Due date

(2) Ruptured membranes
(3) Vaginal fluid drainage or bleeding
(4) Prenatal care
(5) Age

b. Past History

(1) Number of prior pregnancies

(2) Problems with previous pregnancies
(3) Current medications
(4) Medical illnesses

2. SYMPTOMS

a. Location of pain
b. Regularity and timing of contractions
c. Urge to push
d. Bleeding
e. Swelling of face or extremities

3. SIGNS

a. VITAL SIGNS: Routine, particularly BP for hypertension

b. SKIN: Facial, extremity edema
c. GU: Contraction and relaxation of uterus; vaginal
bleeding or fluid (color, odor); crowning (head visible
 during contraction); abnormal presentation (foot, arm,
cord)
d. APGAR SCORE, if delivery occurs:

OBSERVATION 2 1 0
--------------------------------------------------------------------
Color Pink Pink body Blue
Blue extremities

Respirations Good, Slow, None

crying irregular

Heart Rate >100 <100 None

Muscle Tone Active Flexion of Limp

extremities

Reflex Cough, Grimace Non-

Irritability sneeze responsive

B. STABILIZATION

1. BASIC LIFE SUPPORT

a. Transport in position of comfort if patient not pushing or

bleeding
b. Transport immediately if previous cesarean section,
multiple births, hemorrhage, abnormal presenting part
c. If delivery is imminent, observe 1-2 contractions, then
transport unless delivery in progress
d. Stop ambulance if delivery occurs en route
e. Oxygen 4 to 6 L/min if bleeding is moderate to severe
f. Monitor vital signs
g. If patient delivering:
(1) Use sterile technique
 (2) Guide and control delivery
(3) Suction nose, then mouth, after head delivered and again
after delivery complete
(4) Keep baby level with perineum
(5) Stimulate by drying
(6) Estimate Apgar score
(7) Clamp cord in two places approximately 8-10 inches
from
baby and cut cord between clamps
(8) Mother should nurse baby to aid in uterine contraction
h. If excessive bleeding occurs postpartum:
(1) Massage uterus gently only if necessary to control
hemorrhage
(2) After fluid challenge, apply MAST if BP <90 mmHg
systolic
and signs of hypovolemic shock, inflate per protocol (leg
compartment first, then reassess) (Caution: Treat the
patient, NOT the blood pressure)
i. Do not wait for or attempt to deliver placenta; if
expelled spontaneously, bring to hospital

2. ADVANCED LIFE SUPPORT

a. Administer basic life support

b. IV Fluid: NS or LR TKO or as directed
c. Consider oxytocin administration if excessive bleeding
occurs postpartum

C. BASE CONTACT

1. To consider oxytocin administration or vigorous fluid

administration for excessive bleeding postpartum
2. To consider diazepam administration for seizures
occurring
as a result of eclampsia
D. SPECIAL CONSIDERATIONS

1. Stay calm.
2. Ask patient if she feels as if she is delivering. Women
who have had prior deliveries will know.
3. Episiotomy is never indicated in the field.
4. Abdominal pain in a pregnant woman may not be
secondary to
uterine contractions. Any medical condition or trauma can
occur during or be exacerbated by pregnancy.
5. Do not pull on the cord. Premature delivery of the
placenta may be accompanied by tearing and possibly
severe
bleeding.
6. Eclampsia can complicate any pregnancy and result in
hypertension, peripheral edema, and seizures.
7. Babies can be slippery; do not drop. Bundle baby warmly,
preferably with mother.
Pregnancy

A. Presumptive signs:

1. menstrual suppression;

2. nausea, vomiting, "morning sickness";

3. frequency of micturition;

4. tenderness and fullness of the breasts,

pigmentation and other breast changes;

5. "quickening" i.e. active movements of the fetus as

first perceived by the mother;

6. dark blue discolouration of the vaginal mucous

membrane (Chadwick's sign);

7. pigmentation of the skin and abdominal striae;

8. fatigue.

B. Probable signs:

1. enlargement of the abdomen;

2. fetal outline, distinguished by abdominal

palpitations;

3. changes in the uterus - size and shape and

consistency (Hegar's sign);
 4. changes in the cervix;

5. Braxton Hicks contractions;

6. positive pregnancy tests.

C. Positive signs:

1. fetal heart sounds;

2. fetal movement felt by an examiner;

3. roentgenogram - outline of fetal skeleton.

LABOUR AND DELIVERY

Although a relatively brief part of the dynamic

process of chid-bearing is a period of extreme stress both
physiologically and emotionally. It is a time of crisis in which
intervention at the appropriate time is essential to ensure
optimum health of mother and baby, and to promote
successful resolution of the crisis.

The needs of a woman during the intrapartum period

are:
- to be assured of a safe outcome for herself and baby

- to have relief from distressing pain

- to be sustained by another human being

- to receive adequate explanations and information in order to

understand and have a feeling of control of the situation
confronting her, thereby contributing to her sense of safety.
- to be respected and receive recognition as an individual
human being
- to receive bodily care

Labour, being a period of great emotional and

physical stress, is a period during which the woman requires
intensive care, support and supervision on both emotional
physical level. For many women the presence of her partner
provides a great deal of the needed support.

An important source of comfort and support for the

couple is a sense of confidence and trust in the team of health
care workers caring for the woman. Hopefully, this trust and
confidence has been fostered and developed in the antepartum
period through having an opportunity to meet as may of the
members of the team as feasible. This confidence can be
sustained by the maintenance of good communication between
the couple and those providing care during labour. The couple
needs to now what will be done for the woman, what is
expected of her, and how she is progressing. If the woman is
encouraged to express her feelings, to ask questions, and if she
is given appropriate support, reassurance and information, she
will feel more in control of the situation, and she will remain
more comfortable and better able to participate in the
childbirth experience.
A woman in labour should not be left alone. The
presence of another person, whether it is her partner, nurse or
physician, helps to reassure her, and promotes relaxation and
comfort. If circumstances are such that another person cannot
be in the woman's room at all times, a call system becomes her
means of communication. To maintain the woman's
confidence an immediate response to her signal is essential.
The pregnant woman coming to hospital for
admission, during labour, is usually apprehensive. An attitude
of friendliness and understanding by all personnel involved in
the admitting procedure, will greatly allay the patient's fears.
There should be no undue delay from the time of her arrival at
the hospital until she is ready for examination if the labour
area. As the patient should at no time be left alone, she should
be conducted from the admitting office to the labour area by
responsible personnel. On arrival on the labour floor, an
immediate assessment of the progress of labour should be
made, and immediate priorities of care established.

Following admission, a thorough assessment should

be carried out encompassing reassessment of risk factors.

Not all women experience pregnancy and childbirth

and delivery under optimal physical, psychological and social
conditions and not all babies arrive in the world with equal
chances of survival and health. Therefore it is necessary to be
governed by the concept of "high risk" in maternal and in
neonatal care.

It is estimated that approximately 10% of pregnancies

may be described as high risks and many of these can be
identified preconceptionally or during pregnancy providing an
opportunity for early detection and possible prevention of
major complications. There are several numerical indices
available to facilitate early detection of high risk pregnancies.
Whichever one is utilized must assess physical, social and
psychological factors. Poverty, malnutrition and anemia are
social factors which reduce the chance of carrying to term a
baby of sufficient weight with adequate brain cells. The risks
of pregnancy are increased by marital and family problems.
The pregnant adolescent, the single pregnant woman, the
woman who rejects her pregnancy: the woman who has lost
one or more babies, has previously given birth to a
handicapped child or is a carrier of a congenital disease, etc.
It is important that all these factors which may increase the
risks of pregnancy be recognized and that the pregnant woman
be referred without delay to facilities where she can receive
the most effective help.

Assessment of the health status of the pregnant

woman based on physical, emotional and socioeconomic
factors should include:

a. Complete health history covering:

(i) family history

(ii) past medical and surgical history including

trauma and current status of health problems

(iii) menstrual history

(iv) previous obstetrical and gynaecological

history with special emphasis on conditions
that might affect present pregnancy

(v) history of present pregnancy, including her

own and family's feelings and reactions
towards pregnancy, initial and present

(vi) history of exposure to environmental or

occupational hazards, infection, x-rays, use
of alcohol, tobacco, and drugs (both
prescription and non-prescription)

(vii) diet history

(viii) pattern of activities, work, rest and

recreation

(ix) socioeconomic factors relevant to pregnancy

 such as living conditions, financial status,
work-type and significance to woman and
family

b. complete physical examination including

pelvic and breast examination;

c. laboratory examination;

d. based on the above information, the risk

factors present in the pregnancy should be
evaluated and a risk category established.

Subsequent to the initial assessment the woman

should be assessed at intervals dictated by the progress of her
labour. Certain areas should be included in the continuing
assessment and plan of care:

1. Maternal blood pressure should be checked

and recorded every four hours unless
elevated during labour, in which case it
should be checked more frequently.

2. Temperature and pulse should be checked

and recorded every four hours after
admission or more frequently when
indicated.

3. Contractions should be checked and

recorded for intensity, duration and interval.
This should be done at least hourly during
the latent phase and with increasing
frequency during the active phase.

4. Fetal heart rate should be checked and

recorded frequently. It should be done at
 least every hour during the latent phase of
labour; as soon as the membranes rupture,
every 15 minutes during the active phase,
and at least every five minutes during the
second stage of labour before the mother is
transferred to the delivery room. Slowing of
the fetal heart rate should be looked for
particularly at the end of a contraction.
Constant vigilance of the fetal heart is
required during the process of delivery. Any
slowing of the fetal heart should be reported
immediately.

5. Cervical dilation and effacement. A rectal

or vaginal examination should be carried
out, by trained personnel, at intervals
adequate to monitor the progress of cervical
changes without causing undue discomfort
to the labouring woman. Vaginal
examinations provide the most accurate and
complete information. They must however,
be carried out under antiseptic conditions.

6. Pain or discomfort. Analgesia in labour

should be adequate. This may be
administered as soon as the patient is firmly
established in labour without any significant
adverse effect on the quality of uterine
contractions. Individual orders should be
written for patient medication during labour.
There can be no routine method for the relief
of pain as the needs of women vary. Careful
consideration should be given to the choice
and amount of drugs given during premature
labour because of a depressing or adverse
effect of some drugs on low birth-weight
 and other infants.

7. Nutrition. It is considered unsafe to permit

the intake of food or fluids by mouth once
labour is established because of the reduced
rate of gastric emptying in labour and the
subsequent risk of aspiration under
anaesthesia at delivery. Ketoacidosis and
dehydration are best prevented in labour by
appropriate intravenous infusions of saline
and dextrose solutions.

8. Bladder function. The bladder should be

checked frequently for distention and the
mother should be encouraged to void at least
every three hours. If there is difficulty in
voiding, catheterization may be necessary.

9. Body comfort. A comforting sponge and

frequent back care should be given
throughout labour. Mouth care should be
given to prevent discomfort from dryness,
and to relieve the feeling of thirst.

If the mother has had instruction is specific

relaxation techniques, she should be assisted
in carrying them out. If she has not had
instruction in specific techniques, she should
be
coached in a method of relaxation during
labour.
DIAGNOSIS OF PRESENTATION AND POSITION

The diagnosis of presentation and position involves

abdominal palpation, vaginal or rectal examination,
auscultation, and x-ray examination (in certain doubtful
cases). When one wishes to diagnose the presentation and the
position, he asks himself two question:

"What part is presenting?" and "Where is it in

relation to the mother's pelvis?"

Abdominal palpation - Leopold's maneuvers. First

maneuver is to determine what fetal parts are in the fundus
uteri.

1. Ascertain the outlines of the uterus (Stand

facing the patient's head).

2. Palpate the fundus gently with the palmar

surfaces (not the tips) of the fingers of both
hands to determine which pole of the fetus is
upward. The breech is large, irregular, and
rather soft, whereas the head is hard, round,
freely moveable, and ballottable.

Second maneuver is to determine what fetal parts are

on each side of the abdomen.

1. Place the palmar surfaces of the fingers of

both hands on each side of the abdomen
(both hands side by side, alternately on one
side and then the other), making gently,
 deep pressure.

2. One side feels like a hard resistant plane -

the back.

3. Resistance is less on the other side.

a. There is cystic feeling, that is, like

palpating a cystic mass.

b. Several nodules may be felt - the

fetal small parts. It is easy to locate
the back on one side and fetal small
parts on the other in moderately
thin women; often it is difficult in
tense or obese patients.

After locating the back or fetal parts, determine

whether they are anterior or posterior.

Third maneuver is performed by facing the patients

head and by grasping the lower portion of the abdomen
between the thumb and fingers to determine what is between
them.

1. If the presenting part is not engaged, a

moveable body will be felt.

2. If it is the head presenting, it will be a hard,

round ballottable body; if it is the breech
presenting, a large irregular, softer mass will
be felt.
3. Determine the "cephalic prominence" that is
on which side of the abdomen the head is
more prominent (an obstetric, not an
anatomic term).

4. If the cephalic prominence is on the side

opposite the fetal back and on the same side
as the fetal small parts, the head is flexed
and a vertex presents. If it is on the same
side as the back and opposite the fetal small
parts, the head is extended; therefore the
face or brow presents. When the cephalic
prominence is very prominent, the face
presents; when it is less prominent the
brown presents.

Fourth maneuver:

1. Facing the patient's feet, make deep pressure

with the fingers of both hands, one on each
side, in the direction of the axis of the
superior strait. The information thus
obtained depends to some extent on how far
the head has descended into the pelvic
cavity.

2. If the head presents, the fingers of one hand

will come in contact with a hard, round body
first - the cephalic prominence while the
other hand descends deeper into the pelvis
before reaching the less prominent part of
the head.

3. Here, as in the third maneuver, if the

cephalic prominence is on the same side as
the small part the vertex presents and if it is
 on the side with the back, the face or brow
presents.

4. In breech presentations the information

obtained by this maneuver is less definite.
However, by alternating palpating the
fundus and the area just above the
symphysis pubis, the head can be located.

Auscultation:

1. Auscultation is not always reliable, but in

connection with palpatory findings the point
of maximum intensity of the fetal heart may
be of great diagnostic value, even if not
decisive.

2. The heart sounds are usually heard best

through the back in vertex and breech
presentations.

3. The heart sounds are usually heard best

through the chest in face presentations.

4. In cephalic presentations the heart is heard

best about midway on a line from the
anterior superior spine of the ilium to the
navel. In posterior positions the maximum
intensity is near the flank.

5. In breech presentations it is best heard

usually about the level of or above the navel.

Labour is the process by which the mature or nearly

mature products of conception (fetus and placenta) are
expelled from the maternal body. The term delivery refers
only to the actual birth of the infant at the end of the second
stage of labour.

The precise cause of the onset of labour is not known.

Probably it results from the interaction of a number of factors.

Uterine contractions ("pains")

1. In all languages the work pain is used to

designate the contractions of labour.

2. When the painless contractions that occur at

short intervals throughout pregnancy are
replaced by painful contractions resulting in
cervical dilation, labour has begun; the
"pains" gradually increase in severity,
frequency, and duration.

3. The cause of the pain:

(a) Early in labour it is caused by the

pressure on the nerve endings
compressed between the uterine
muscle bundles or by anoxia of
muscle cells.

(b) Later it is caused by distention of

the pelvic soft tissue by the
descending fetus.

4. The purpose of the contractions is fourfold:

(a) effacement of the cervix,

 (b) dilatation of the lower uterine
segment and cervix,

(c) expulsion of the fetus,

(d) extrusion of the placenta.

The uterine contractions of labour are involuntary.

Only the final efforts at expulsion by the abdominal
muscles and diaphragm are voluntary. Women with
paraplegia have normal but painless uterine
contractions.

5. Interval between contractions:

(a) early in labour the contractions

occur every 15 to 30 minutes and
are usually felt in the back (sacral
region)

(b) the interval between contraction

gradually shortens to 2 or 3
minutes.
6. Duration of each contraction - the
contractions increase in length as labour
proceeds and last from 30 to 90 seconds
(average 1 minute).

7. The force of each contraction transmitted to

a hydrostatic bag in the uterus varies from
25 to 50 mm. Hg, but intramuscular pressure
varies from 25 to 150 mm. Hg in various
areas.
 8. Effect of uterine contractions:

(a) the pregnant uterus between

contractions lies on the spine,

(b) during contractions it rises from the

spine, possible because of
contraction of the round ligaments,
and force the abdominal wall
forward,

(c) the longitudinal diameter lengthens,

(d) the transverse diameter becomes

shorter and decreases the capacity
of the uterine cavity. The infant
and the "bag of waters" are forced
against the lower part of the uterine
body and cervix, resulting in
dilation of these structures and
eventually expulsion of the infant.

COURSE OF LABOUR

Before actual labour begins, there are certain

physiologic prepatory events, which might well be called the
preparatory stage of labour:

"Lightening, settling or dropping". Two or more

weeks before labour the fetal head in most primigravidas
settles into the brim of the pelvis and becomes fixed in the
brim or may even become completely engaged. Lightening in
multiparas usually does not occur until early labour.

1. The upper abdomen becomes flatter because

the fundus uteri is lower.
 2. Consequently, the lower abdomen is more
prominent.

3. Pressure against the diaphragm is relieved

because the baby is lower.

4. Previous difficulty in breathing is relieved.

5. Urination, attributable to pressure by the

presenting part, is more frequent.

Preliminary contractions often accompany "settling" -

false labour pains. Sometimes the cervix is almost completely
effaced and the head engaged before any true labour
contractions occur, especially or in primigravidas.

Effacement of the cervix is a process of shortening or

obliterating cervical canal, blending it with the lower uterine
segment.

Progress of labour. The first stage of labour is the period of

effacement and dilatation of the cervix uteri. It lasts from the
beginning of labour to the complete elimination of the barrier
of the cervix.

The second stage or stage of expulsion extends from

the complete dilatation of the cervix to the birth of the fetus.
The third stage or stage of placental extrusion lasts from the
birth of the fetus to the birth of the placenta.

First stage of labour consists of two phases:

effacement and dilatation of the cervix uteri. At the onset of
labour "the plug of mucous" that has corked the cervical canal
soon escapes, mixed with a little blood, hence its name
"show".

“Effacement"

1. The process of eariously designated as the

cervix is "thinned out", "obliterated", "taken
up", or "shortened", but "effaced" is the
generally accepted term.

2. Effacement begins before labour, in the last

weeks of gestation; in first pregnancies it
may be almost complete before full term.

3. first the cervical walls become gradually

thinner, decreasing in thickness from more
than a centimetre to a few millimetres.

4. At the same time the thinned walls are

"taken up" into the thin lower segment-
retraction.

5. Effacement is really the last step in the

formation of the lower segment.

6. The factors that bring about effacement:

(a) preliminary softening begins

because of anatomical changes,

(b) contractions force the uterine

contents in the direction of least
resistance,
 (c) retraction occurs when the upper
segment pulls against the
presenting part,

(d) the hydrostatic dilator, composed

of the bag of waters, exerts its force
equally in all directions so that it
acts in the direction of least
resistance, thus pushing a small
segment of the bag into the internal
os more and more as labour
progresses,

(e) there is another factor that enters

into consideration - stabilization of
the uterus by the round and
uterosacral ligaments: These being
projections of uterine muscle,
contract with each general
myometrial contraction. The round
ligaments pull the fundus forward,
and the uterosacral ligaments pull
backward on the lower segment
thus assuring that the force of each
contraction will be exerted in the
direction of the pelvic axis.

7. Effacement occurs from above downward;

first, the hydrostatic bags of waters or the
fetal head enters the internal os and then,
aided by the factors mentioned, gradually
thins out the cervix from the internal os to
the external os until its walls have been
reduced to a thickness of only a few
millimetres.
 Dilatation of cervix uteri. Both dilatation and
effacement are accomplished solely by the involuntary
contractions of the uterus. In a primigravida effacement is
almost complete before any appreciable dilatation is achieved,
whereas in a multipara the two processes are most likely to
advance concomitantly. When the more or less circular
opening into the lower segment of the uterus is about 10 cm.
in diameter, dilatation is said to be "complete" or "full". At
this stage of dilatation a fetal head of average size can slip
through the cervical barrier, and usually the residual ring of
cervical tissue moves superiorly toward the fetal neck.

The membranes may spontaneously rupture at any

moment in this process. Exceptionally, they do not rupture
during labour and the baby is born with the membranes over
the head - the "caul". Not infrequently rupture occurs prior to
labour. Labour usually sets in soon after such premature
rupture but may be delayed for days or in exceptional cases
even weeks.

After the membranes rupture there often is a

temporary cessation of contractions. Soon, however, the
contractions recur with increasing force and frequency.

Second stage or expulsion of fetus.

1. The second stage of labour begins upon

completion of cervical dilatation. A variable
degree of fetal descent has occurred during
the dilatation process and remainder is
accomplished during this stage.

2. Now the patient wishes to "bear down", the

diaphragm is fixed, and she cannot resist
contracting the abdominal walls and
pushing. She indeed labours, her face is
 suffused and the face and neck vessels are
distended - she inhales deeply, holds her
breath as long as she can, pushes mightily,
and then suddenly exhales with an explosive
grunt as the muscles of the abdomen and the
diaphragm relax.

3. The patient is relieved for a short interval.

4. The process is then repeated at varying

intervals and with ever-increasing force and
strain.

5. (a) descent is caused by the

force of uterine contractions,
reinforced by the voluntary efforts
of the abdominal wall and
diaphragm.

(b) the force is applied to the breech,

(c) the force is transmitted directly to

the fetal spinal column and thence
to the fetal head,

(d) the curve of the fetal spine tends to

straighten, which adds power to
push the head downward.

6. The head, after retraction of the lower

segment, occupies the pelvic cavity.

7. Soon the head impinges upon the pelvic

floor. The pressure upon the rectum gives
the desire to defecate.
8. After a varying period of such effort, the
pelvic floor begins to bulge with each
contraction.

9. The anus opens.

10. Soon the fetal scalp becomes visible at the

vaginal orifice.

11. The perineum bulges and the vulva dilates

more and more with each contraction.

12. The head usually recedes nearly or

completely out of light between
contractions, until it "crowns".

13. The pelvic floor is thus gradually stretched,

and the perineum becomes thinned out, so
much that with each contraction it appears
about to rupture. Apply moderate pressure
to the baby's head as it is advancing with
contractions, not with the intent of retarding
delivery, but to prevent a rapid, unassisted
birth. It is rapid distention of the perineum
that causes lacerations; also sudden
expulsion of the baby's head at the height of
a contraction may cause injury to his brain.

14. The anus is now distinctly dilated, and the

anterior wall of the rectum protrudes.

15. The head is born by extension, the occiput

hugging the under-surface of thesymphysis
pubis, with the sinciput, brow, and face
 following each other, sliding off the
perineum.

16. As soon as the head is born, it drops down

over the perineum. Do not yield to the urge
to hasten delivery as soon as the head is
born.

17. The neck, which has been twisted as the

head rotated internally, now unwinds,
turning the head to one side, according to
the yet unrotated position of the shoulders
(restitution of the head).

18. Then, when the shoulders rotate internally,

they turn the head farther to the side
(external rotation of the head).

The problem of the cord around the neck is common

and occurs in 25% or 30% of deliveries.
Immediately feel or look for the loop of cord around
the neck. Loosen the loop and gently slip it over the
head. When this is not easily accomplished or the
baby seems endangered, occlude the cord with two
clamps and cut between them.

19. Birth of the shoulders and body.

(a) the anterior shoulders impinge on

the under-surface of the symphysis
pubis, which acts as a fulcrum, and
the posterior shoulder is then born
over the perineum by lateral
flexion,

(b) the anterior shoulder soon follows

 under the symphysis pubis,

(c) rarely the anterior shoulder is born

first,

(d) the body quickly follows by lateral

flexion at the waist.

Third state of labour or birth of placenta -

1. After the baby's birth the uterine

contractions usually cease for a short
interval.

2. The contractions, however, soon recur. The

sudden shrinkage in uterine size after
delivery of the infant is accompanied by a
decrease in the area of the placental site.
The placenta becomes about twice as thick
as it was at the onset of labour, and the
utero-placental union soon is disrupted
through the layer of endometrial spongiosa.

3. After a few minutes the placenta separates

completely, as noted by a modest gush of
blood.

4. It then is forced into the lower uterine

segment, where it may be observed as a
slight bulging above the symphysis pubis.

5. Further contractions push it into the vagina,

and this is indicated by a distinct
 lengthening of the cord outside the vulva.
Do not pull on the cord. Inversion of the
uterus may result.

6. Finally, it is totally expelled.

7. The whole process lasts for 5 to 30 minutes;

occasionally the placenta is extruded almost
immediately after the birth of the fetus.

8. Labour is ended. The uterus lies as a hard

mass above the symphysis, extending almost
or completely to the umbilicus.

Small tears or areas of minor mucosal separation are

common after natural childbirth, but they, as well as more
extensive lacerations, may usually be avoided by careful
technique and prophylactic episiotomy. The cervix and the
vagina should be thoroughly inspected and lacerations should
be repaired at once.

The membranes usually slide out easily. However,

they frequently peel off slowly, remaining adherent after the
placenta is delivered. Therefore, you should not let the weight
of the placenta tear off pieces of membrane that will be
retained in the uterus. If the membranes begin to tear, grasp
them with a clamp and tease them slowly out. The
membranes should be carefully examined to make sure they
are intact. If despite your efforts a piece of membrane
remains, it may be ignored, but a retained piece of placenta
must be removed because of danger of subsequent
haemorrhage.

Management of blood loss. Some loss of blood

during the third stage of labour is inevitable. When one
considers perineal lacerations and tearing of vessels
occasioned by placental separation, the opening of the large
uterine sinuses, and the failure of the uterus to close them by
firm contractions, it is not strange that haemorrhage is a great
danger of the third stage of labour and the immediate
puerperium. Therefore, meticulous care during this stage is
imperative. The average normal blood loss should be less than
400 ml., if care is exercised, it can be kept between 100 and
300 ml.

To prevent too much blood loss:

(a) immediately after the expulsion of the

placenta be sure that the uterus is well
contracted, "like a croquet ball", and kept so
by manual massage as required.

(b) oxytocin, 1ml., may be given I.M. after the

birth of the baby, followed by 0.2 mg.
ergonovine I.M. after delivery of the
placenta. Ergot preparations not
infrequently induce blood pressure elevation
and are probably best not used in
hypertensive or toxaemic patients.

(c) examine the maternal surface of the placenta

to make sure that no piece is missing; also
examine the fetal surface to see that no
vessels are torn off at the edge of the
placenta.

Because of the critical nature of this period patients

should be kept under close observation for a minimum of two
hours. The potential need for emergency assistance in terms
of personnel and equipment make it essential that the woman
be cared for within the labour and delivery area during this
critical period.

Observations of vital signs, fundal height consistency

and position, general condition and comfort, hydration vaginal
flow, bladder size and urine output must be made at intervals
to monitor the adjustment process during this stage. Care to
promote physical comfort and rest should be carried out
according to the needs of the individual mother.

During this period, opportunity and privacy is

possible, should be provided for the mother and father to
establish contact and hold the newborn, unless the condition of
either mother or infant indicates this is not feasible. Provided
the newborn has no obvious anatomical or functional
problems associated with sucking and swallowing, the
mother's request to breast feed should be honoured. These
contacts and interaction with the newborn during this early
period facilitate the bonding relationship. After the two hour
period has elapsed and the mother's condition has stabilized,
she may be transferred to the postpartum area for continuing
care.

Meeting the infant's needs is an interrelated process

and begins immediately after birth. In order of priority, the
infant has a need:

- to adapt physiologically to the change from

intrauterine to extrauterine life

- for a safe and protective environment

- for food, fluid, and sucking pleasure

- to feel warm and comfortable

 - for close human body contact to feel loved
and secure

- for sensory stimulation

Physiological adaptation from Intrauterine to

Extrauterine Life - Immediate priorities of care:

(a) establish respiration - prompt onset of

breathing within 15-30 seconds should be
considered essential to the infant's
subsequent mental and physical
development. To aid the infant:

(i) suction mucous and fluid from the mouth, as

soon as the head and feet are delivered; a
small soft rubber bulb syringe is usually
used, or a soft catheter attached to a
mucous-trap, or a mechanical suction
machine with a built-in safety mechanism
for pressure control; avoid traumatizing the
delicate tissues of the infant's oropharynx,

(ii) continue to position the infant to facilitate

drainage from the oropharynx,

(iii) efforts to stimulate adequate breathing or

crying are usually limited to gentle rubbing
of the infant's back,

(iv) an Apgar score should be taken and

recorded for all infants at one minute and
five minutes from the time both the head and
feet of the baby are visible; accurate timing
 is facilitated by a simple automatic timing
device; no delay in resuscitation should be
allowed while waiting for the recommended
time to elapse. An Apgar score 7-10
indicates the infants condition is good. No
special procedures are necessary. Score of
4-6 means the infant is in fair condition,
may have moderate CNS depression, some
muscle flaccidity, respiratory effort. Air
passage must be cleaned and oxygen given.
Score of 0-3 indicates extremely poor
condition. Resuscitation required
immediately.

(b) attend to clamping and cutting the umbilical

cord. Cord is clamped 2.5 cm. fame skin.
Check cord for presence of 3 vessels -
abnormal vessels indicate possibility of
other birth defects.

(c) protect against excessive heat loss

(i) swaddle the newborn in a warm, absorbent

blanket and place on side in a heated crib

or

(ii) place on side in an incubator or under a

radiant heat shield, dry thoroughly, and
allow to remain uncovered
(iii) all procedures, including emergencies such
as resuscitation, should be performed on the
newborn under thermal protection; the
environmental temperature must be carefully
controlled at 22 - 24 C to prevent
fluctuations
 (iv) dress infant in a diaper and a shirt and wrap
in a fresh blanket before transferring infant
to a bassinet where he is placed on his side

(v) the infant is not given an initial bath to

remove the vernix caseosa,

(vi) instill prophylactic agent against ophthalmia

neonatorum (gonorrhoeal conjunctivitis)
such as silver nitrate 1%, 1-2 drops in the
conjunctivae sac. After diffusion, flush
gently with sterile distilled water.

(d) continuously observe and assess respiratory

pattern to ensure maintenance of adequate
breathing.

(e) continuously and systematically assess the

infant's physiological status during the birth
recovery period.

(i) obtain baseline data regarding vital signs

every 15-20 minutes; monitor and record;
colour, heart and respiratory rates, breathing
patterns, when infant is quiet,

(ii) the first temperature is taken per axilla at the

earliest opportunity and at least every six
hours for the first two days,

(iii) obtain and record baseline data regarding

general condition by a physical examination
to identify any life threatening conditions
requiring immediate intervention.
 ABORTION

Abortion indicates the termination of pregnancy

before the fetus is viable (less than 500 gmx) and usually
before the 20th week of gestation. The limit of 20 weeks is
more legalistic than medical, as birth beyond the 20th week
must be officially reported. However, few infants delivered
prior to the 24th week are likely to survive.

The term "miscarriage" formerly used to designate

expulsions from the third month to viability, is now
considered unnecessary, confusing and unscientific.

Abortion is the term used by most authorities for all

interruptions before viability. Abortions are either spontaneous or
induced, and induced abortions may be either legal (Therapeutic or
criminal).

Incidence. The incidence of abortion is variously

estimated from 10% to 40%, averaging 20% of all pregnancies.
Roughly 10% to 12% of all identified pregnancies are terminated by
spontaneous abortion and it is likely that many other pregnancies
expire very early without ever being recognized or counted. Nearly
75% occur in the second and third months and less than 10% in the
fourth month.

The immediate cause of abortions in the early months is

usually the death of the embryo or fetus. Though the basic etiology
is not determinable in the majority of instances, some of the
conditions that may cause spontaneous abortions are:

1. errors of development inconsistent with life (25%

to 50% of abortions have revealed anatomic or
chromosomal abnormalities),

2. abnormal intrauterine environment,

3. placental abnormalities, for example, large

infarcts, premature separation, and placenta
previa,

4. maternal factors, such as acute infections, psychic

and physical trauma, abnormalities of the
reproductive organs, cervical incompetence, and
possible certain poorly understood endocrine
dyscrasia,

5. teratogenic factors such as drugs, radiation, viral

infections, etc may result in sufficient
malformation to produce abortion.

Symptoms and diagnosis. Bleeding and pain from uterine

contractions are the outstanding symptoms of abortion, varying
according to the stage in which abortion occurs.

In the early stage (1st - 6 weeks of placentation) abortion,

the pain and bleeding are considerable but usually are not excessive.

In intermediate abortion (2nd - 6 weeks) pain and bleeding

are greater than in the early type because of the increased size of the
ovum, firmer attachment, and the tendency toward retention of parts
of the placenta.
 In late abortion (after 12 weeks) there is usually less
bleeding and more pain because there is a fetus to be expelled and
there is a complete placenta that tends to remain attached until after
the birth of the fetus.

Ordinary clinical varieties of abortion:

1. Threatened abortion is defined as bleeding of

intrauterine origin with or without uterine
contractions.

2. Inevitable abortion is diagnosed when continuous

and progressive dilatation of the cervix is noted.
Bleeding and uterine contractions are invariably
present and the membranes may have ruptured.

3. Complete abortion is noted when the products of

conception are expelled in toto.

4. Incomplete abortion is the exception of some but

not all of the products of conception.
Haemorrhage persists until the uterus is empty.

5. Missed abortion is classified as the intrauterine

retention of a fetus for 8 or more weeks after its
demise.

6. Habitual abortion is the occurrence of three or

more spontaneous consecutive abortions.

Generally the diagnosis of abortion is easy when the

patient is known to be pregnant. When pregnancy is doubtful, it
may be quite difficult but can be determined by the presence of
absence of the usual signs of pregnancy.
 Treatment. Threatened abortion. The diagnosis of
pregnancy should be established and the possibility that the
bleeding is originating from the cervix, vagina, or vulva should be
excluded. If the bleeding is uterine in origin and threatened
abortion seems the most likely diagnosis, bed rest, mild sedation,
smooth muscle relaxants may be prescribed individually or
simultaneously. Coitus and orgasm should probably be avoided
until symptoms have ceased.

Symptoms usually abate or progress unchecked, although

occasionally protracted mild bleeding and cramping may occur. It
is will to keep in mind that prognostically the pregnancy is still
intact until such time as cervical dilatation, membranes rupture, or
extrusion of a piece of the conceptus occurs. Patients may bleed for
weeks and still go to term. If the uterus decreases in size, however,
the fetus is probably dead.

Inevitable abortion. When an abortion becomes inevitable,

time, effort, blood, and the health of the patient will be conserved
by terminating the pregnancy promptly. The method to be
employed depends on the amount of haemorrhage and the degree of
dilatation of the cervix.

In incomplete abortion the same methods are employed as

when emptying the uterus in inevitable abortion. If the fetus has
been expelled and there is evidence of placental fragmentation,
curettage is almost invariably required to staunch the continuing
blood flow.

Complete abortion. When the uterus is empty, there is no

need for further interference. Patients and attendants must be
instructed to save everything that has come from the uterus for the
physician's examination so he is always sure the uterus is entirely
empty.
ECTOPIC PREGNANCY

An ectopic pregnancy is any pregnancy situated outside of

the uterine cavity. Most ectopic pregnancies (over 95%) are tubal
gestations, but others occur in such places as the ovary, cervix,
rudimentary uterine horn, and abdominal cavity.

The incidence is approximately 1 in every 150 to 200

infants delivered, and it is commoner in non-white women with a
history of infertility, especially the "one-child sterility" group. The
frequency is greater in lower socioeconomic groups, probably
because of their predisposition to inflammatory disease of the
uterine tubes. The possibility of recurrence of an ectopic pregnancy
is real. An increase in the frequency of ectopic pregnancy may be
related to the use of antibiotics to treat gonococcal salpingitis.
Authorities believe that such treatment may prevent complete
occlusion (tubal), though adhesions between tubal folds or impaired
peristalsis may persist.

The outcome of a tubal pregnancy depends to a large

extent on where in the tube the ovum implants itself. Rupture of the
tube is almost a forgone conclusion, and it is accompanied by
haemorrhage varying in degree of severity.

Frequently it is extremely difficult to diagnose ectopic

pregnancy because no single, invariable reliable feature can be
elicited in every instance. Diagnostic success can be improved if
one is constantly alert to the possible significance of lower
abdominal pain in any woman during her reproductive years and if
one is meticulous about obtaining an accurate history.

Signs and symptoms of a tubal pregnancy are most

commonly those associated with rupture of the tubal wall, followed
by haemorrhage into the peritoneal cavity.
 Pain, lancinating or cramp-like. At times it extends to the
shoulders. It has no time relationship to vaginal bleeding and may
be precipitated by straining or heavy lifting.

Vaginal tenderness, exquisite in character at time of

vaginal examination and especially on motion of the cervix.

Vaginal bleeding or spotting, as a result of separation or

death of the ovum. Bleeding is usually scant, intermittent or
continuous, and the blood may be dark brown in colour.

Uterine changes depend on the duration of the pregnancy.

They are similar to those of an intra-uterine pregnancy as long as
the fetus is alive.

Although 75% of women having tubal gestations give a

history of amenorrhea, about 25% of them do not. The bleeding
these 25% experience may be a pathologic type and not
representative of a true menstrual period, a difference often
revealed only through a carefully taken history.

Nausea and vomiting. These are common general

symptoms caused by peritoneal irritation.

Blood pressure and pulse. Blood pressure falls according

to the severity and suddenness of the intra-abdominal haemorrhage.
Pulse is rapid.

Following haemorrhage, temperature may drop but with

recovery from shock it may rise to between 100 and 101 F, seldom
higher.

Although shock is the commonly given symptom of a

ruptured tubal pregnancy, it actually is present in only a small
number of instances.
 Treatment of an ectopic pregnancy consists usually of
immediate salpingectomy with simultaneous blood transfusion.

LIQUID

CONVERSION TABLE

1 min. 0.06 ml
5 min. 0.3 ml
10 min. 0.6 ml
15 min. 1.0 ml
1 fl dr 4.0 ml
1 1/4 fl dr 5.0 ml
4 fl dr 15 ml
1 fl oz 30 ml
2 fl oz 60 ml
3 fl oz 85 ml
4 fl oz 115 ml
6 fl oz 170 ml
8 fl oz 230 ml
12 fl oz 340 ml
16 fl oz 450 ml
 1 teaspoon = 5 ml
1 tablespoon = 15 ml
1 drop = 0.05ml
1 ml = 1 cc

TEMPERATURE CONVERSION

F C F C F C F C

92.0 33.3 95.8 35.4 99.6 37.6 103.4 39.7

92.2 33.4 96.0 35.6 99.8 37.7 103.6 39.8

92.4 33.6 96.2 35.7 100.0 37.8 103.8 39.9

92.6 33.7 96.4 35.8 100.2 37.9 104.0 40.0

92.8 33.8 96.6 35.9 100.4 38.0 104.2 40.1

93.0 33.9 96.8 36.0 100.6 38.1 104.4 40.2

93.2 34.0 97.0 36.1 100.8 38.2 104.6 40.3

93.4 34.1 97.2 36.2 101.0 38.3 104.8 40.4

93.6 34.2 97.4 36.3 101.2 38.4 105.0 40.6

93.8 34.3 97.6 36.4 101.4 38.6 105.2 40.7

94.0 34.4 97.8 36.6 101.6 38.7 105.4 40.8

94.2 34.6 98.0 36.7 101.8 38.8 105.6 40.9

94.4 34.7 98.2 36.8 102.0 38.9 105.8 41.0

94.6 34.8 98.4 36.9 102.2 39.0 106.0 41.2

94.8 34.9 98.6 37.0 102.4 39.1 106.2 41.3

95.0 35.0 98.8 37.1 102.6 39.2 106.4 41.4

95.2 35.1 99.0 37.2 102.8 39.3 106.6 41.5

95.4 35.2 99.2 37.3 103.0 39.4 106.8 41.6

95.6 35.3 99.4 37.4 103.2 39.6 107.0 41.7

CONVERSION CHART

INCHES TO CENTMETRES TO METRES

INCHES CENTIMETRES METRES

½ 1.25 0.0125

1 2.5 0.025

2 5.1 0.051

3 7.6 0.076

4 10.2 0.10

5 12.7 0.13

6 15.2 0.15

7 17.8 0.18

8 20.3 0.20

9 23.0 0.23

10 25.4 0.25

12 30.5 0.30

18 45.7 0.46

24 61.0 0.61
30 76.2 0.76

36 91.4 0.91

42 106.7 1.07

48 121.9 1.22

54 137.2 1.37

60 152.4 1.52

66 167.6 1.68

DRIP RATES

FOR MACRO DRIP TUBING

( 10 gtts / ml)

ml per Hr gtts/min

30 5
45 8
60 10
75 13
100 17
125 21
150 25
175 29
200 33
225 38
250 42
 275 46
300 50
350 54

DRIP RATES

FOR MICRO DRIP TUBING

( 15 gtts / ml)

ml per Hr gtts/min

15 7
30 7.5
45 11
60 15
100 25
125 31
150 37
175 44
200 50
225 56
 250 63
275 69
300 75
350 87

ANGINA PECTORIS

Drugs of choice

1. Secondary prophylactic treatment for all patients

ASA, enteric coated 325 mg, once daily

2. Initial treatment of symptoms with nitrates

nitroglycerin tablets 0.3-0.6 mg, sublingual prn

or nitroglycerin spray 0.4 mg, sublingual prn

3. All patients who require regular symptomatic treatment should receive a

beta-blocker.
propranolol 40-160 mg, bid
or metoprolol 25-100 mg, bid
or nadolol 20-240 mg, once daily

Second-line therapies

1. If patient has contraindications to beta-blockers, such as reactive airway

disease,
or experiences side effects from beta-blockers
verapamil 80 mg, tid
or verapamil SR 240 mg, once daily
 2. If patient is intolerant of both beta-blockers and verapamil

i. Long-acting nitrates to be used for a maximum of 12 h/day. Nitrates should

be used during high-risk periods, e.g., times when angina is common and
overnight into the early hours of the morning
isosorbide dinitrate 30-60 mg, tid with eccentric dosing
nitroglycerin paste 1-5 cm tid with eccentric dosing
or nitroglycerin transdermal 0.4 mg/h; apply in morning; remove 12 h later
or isosorbide mononitrate 20 mg, in morning and afternoon, 7 h apart

OR
ii. Calcium channel blockers
diltiazem 30-120 mg, tid to qid
or felodipine 5-10 mg, once daily
or nifedipine XL 30-60 mg, once daily
or amlodipine 5-10 mg, once daily

ACNE VULGARIS

Drugs of choice

1. For mild papulopustular acne

ANY benzoyl peroxide 2.5-10% gels or lotions applied topically, hs

2. For more severe papulopustular acne, add topical antibiotics

erythromycin with ethyl alcohol 2% lotion, bid

or erythromycin with ethyl alcohol 1.5% lotion, bid
or clindamycin 1% lotion, bid
or erythromycin/benzoyl peroxide 3%/5% gel, bid

3. For acne with a significant comedo component, replace benzoyl peroxide with

tretinoin 0.01-0.025% gel, hs

or adapalene 0.1% gel, hs or 0.1% cream, hs

Second-line therapies

1. For acne with a significant nodular or cystic component, add systemic

antibiotics

tetracycline 1 g/day divided bid to qid x4 weeks, then 250 mg bid; may be
taken hs only, if tolerated
 or erythromycin base 1 g/day divided bid to qid x4 weeks, then 250 mg bid
or minocycline 50 mg bid, or 100 mg, hs

2. For treatment of resistant cystic or nodular acne where dermatology

consultation unavailable

isotretinoin 0.5-1.0 mg/kg, once daily x16-20 weeks

Additional instructions and notes

-Response to any acne treatment occurs in 6-8 weeks.

-For patients with sensitive skin, avoid excessive irritation; use benzoyl peroxide
lotions instead of alcohol or acetone-based gels, and use lower concentrations of
tretinoin or switch to adapalene.
-There have been no adequate dose-response trials to show increased efficacy of
benzoyl peroxide in concentrations greater than 10%.
-There is no clinical difference between tetracycline and doxycycline. Doxycycline
may be taken twice daily but at greater expense.

CELLULITIS

Drugs of choice

For mild cases

penicillin V
Adults 300-600 mg, qid x 7 days
Children <12 years 25-50 mg/kg per day, divided qid x 7 days
AND either
cloxacillin
Adults 500 mg, qid x 7 days
Children <20 kg 50 mg/kg per day, divided qid x 7 days
or cephalexin
Adults 500 mg, qid x 7 days
Children 25-50 mg/kg per day, divided qid x 7 days

Second-line therapies

If patient is allergic to penicillin - mild cases erythromycin base (adults),

estolate (children)

Adults 1 g, bid to qid x 7 days

Children 30-50 mg/kg per day, divided bid to qid x 7 days
or clindamycin
 Adults 300 mg, qid x 7 days
Children 8-16 mg/kg per day, divided qid x 7 days

Additional instructions and notes

-Severe or complicated cellulitis, including adult erysipelas, "diabetic foot" and toxic
shock-like syndrome, requires admission to hospital.
-As it is sometimes clinically difficult to distinguish between cellulitis due to
Staphylococcus aureus and Streptococcus group A initially, therapy should cover
both organisms.
-Treating cellulitis due to Streptococcus group A does not prevent poststreptococcal
glomerulonephritis.

ATOPIC DERMATITIS

Drugs of choice

1. Topical corticosteroids
i. Moderately potent topical corticosteroid may be used to quell inflammation
and pruritus.

betamethasone valerate 0.1% cream, bid to qid

or triamcinolone 0.1% cream, bid to qid
or fluocinolone 0.025% cream, bid to qid

ii. Weak topical corticosteroids for maintenance therapy

hydrocortisone 1% cream, bid to qid

2. If the itching is not controlled, oral antihistamines

chlorpheniramine
Adults
Children 6-12 years
or brompheniramine
Adults
Children 6-12 years
4-8 mg, hs to bid
2 mg, hs to bid
4-8 mg, hs to bid
2 mg, hs to bid
 or dexchlorpheniramine
Adults 4 mg, tid to qid
Children 6-2 years 1 mg, tid to qid

Second-line therapies

1. Oral antihistamines when sedation effects are unacceptable

loratadine
Adults 10 mg, once daily
Children <12 years 5 mg, once daily
or fexofenadine
Adults 60 mg, bid
Children 7-12 years 30 mg, bid
Children 3-6 years 15 mg, bid

2. Corticosteroids for acute flare-ups

prednisone
Adults 50 mg, once daily x 10 days; then taper by 5 mg/day
Children <12 years 1-2 mg/kg, once daily (maximum 50 mg/day) x 10 days; then
taper by 2.5 mg/day

3. Oral antimicrobials should be administered for secondary infection.

Additional instructions and notes

-Combine the above drug therapies with hydration therapy: tepid bath with
antipruritic or emollient additives, such as oatmeal; pat skin dry and apply emollients
to retain moisture.
-Avoid wool, temperature extremes and drying the skin.
-Ointments may be more effective in some patients, but some people find them too
greasy.
-About 50% of all dermatologic conditions may be managed with medium- or
low-strength corticosteroid preparations.
-Prednisone use should be limited as much as possible due to side effects, poor
efficacy and concerns regarding its use in children. Prednisone should not be used
until after consultation with a dermatologist.
 CONTACT DERMATITIS

Drugs of choice

1. Acute (e.g., poison ivy or poison oak)

I. For acute inflammation characterized by vesicular eruptions with exudation,

oozing and crusting

aluminum acetate/ benzethonium chloride dilute 1:20 with tepid water,soak

gauze and apply for0.5-2 h, changing dressing every 5-15 minutes; repeat tid to qid
ii. For localized areas, moderately potent topical corticosteroids

betamethasone valerate 0.1% cream, bid to qid

or triamcinolone 0.1% cream, bid to qid
or fluocinolone 0.025% cream, bid to qid

iii. To relieve itching, oral antihistamines

chlorpheniramine
Adults 4-8 mg, hs to bid
Children 6-12 years 2 mg,hs to bid
or brompheniramine
Adults 4-8 mg, hs to bid
Children 6-12 years 2 mg, hs to bid
 or dexchlorpheniramine
Adults 4 mg hs to bid
Children 6-12 years 1 mg hs to bid

2. Chronic
Mild, weakly potent to mild, moderately potent topical corticosteroids

betamethasone valerate 0.05% cream, qid

or hydrocortisone 1% cream, bid to qid

Second-line therapies

Acute (e.g., poison ivy or poison oak)

i. To relieve itching, oral antihistamines when sedation effects are unacceptable

loratadine
Adults 10 mg, once daily
Children <12 years 5 mg, once daily
or fexofenadine
Adults 60 mg, bid
Children 7-12 years 30 mg, bid
Children 3-6 years 15 mg, bid

ii. Widespread dermatitis

prednisone
Adults 50 mg, once daily x 10 days; then taper by 5 mg/ day
Children <12 years 1-2 mg/kg, once daily (maximum 50 mg/day) x 10
days; then taper by 2.5 mg/day

Additional instructions and notes

-Wash with soap within 15 minutes after exposure to poison ivy or poison oak.
-There is no evidence that calamine lotion or other shake solutions are of any benefit.
-There is no evidence that any of the above oral antihistamines is more efficacious
than the others for this indication.

SEBORRHEIC DERMATITIS

Drugs of choice

1. For dermatitis

hydrocortisone1% cream, once daily to bid x4 weeks, then prn

2. For dandruff

selenium sulfide 2.5% shampoo, twice weekly x4 weeks, then prn

Second-line therapies

1. For dermatitis

ketoconazole 2% cream, once daily to bid x4 weeks, then prn

2. For dandruff

ketoconazole 2% shampoo, twice weekly x4 week, then prn

or coal tar 2% shampoo, twice weekly x4 weeks, then prn

Additional instructions and notes

-Prescription drugs should be reserved for patients who fail to respond to less-potent
over-the-counter medications.

HEAD LICE

Drugs of choice

permethrin 1% cream rinse, 2 applications, 7-10 days apart

Second-line therapies

pyrethrins/piperonyl butoxide/petroleum distillate topical solution, single

application
or permethrin 5% cream, leave on overnight

Additional instructions and notes

-A second treatment after 2 weeks is recommended in most cases.

-Remove nits daily.
-Treat all family members.
-In general, inanimate objects do not need to be treated; however, all head apparel
should be treated.
 HERPES LABIALIS

Drugs of choice

1. Immunocompetent patient

No drug therapy is recommended.

2. Immunocompromised patient

acyclovir 200-400 mg 5 times a day x 10 days until lesions heal

or valacyclovir 1 g tid x 10 days until lesions heal
or acyclovir IV; therapy in hospital

3. Recurrent herpes labialis in immunocompromised patient

acyclovir 200-400 mg, 5 times a dayx 5 days

or valacyclovir 1 g, tid x 5 days

4. Recurrent (>6 episodes/year) herpes labialis prophylaxis in immunocompetent

and immunocompromised patient
 valaciclovir 500 mg, once daily for up to 1 year
or acyclovir 400 mg, bid for up to 1 year

Second-line therapies

Recurrent herpes labialis in the immunocompromised patient resistant to acyclovir

foscarnet IV therapy in hospital

Additional instructions and notes

-Start using drugs of choice at first sign or symptom or prodrome. Analgesics may be
needed for pain control.
-As a prophylactic measure, patients prone to recurrent herpes labialis should apply
sunscreen with protection factor 15 to lips 1 h before exposure to sun and every hour
thereafter.

HERPES SIMPLES (mucocutaneous)

Drugs of choice

1. Primary episode

acyclovir 200 mg, 5 times a dayx 10 days

or valacyclovir 1 g, bid x 10 days

2. Recurrent infections

acyclovir 400 mg, bid x 5 days or 200 mg, 5 times a dayx 5 days
or valacyclovir 500 mg, bid x 5 days
or famciclovir 125 mg, bid x 5 days

3. Suppression

acyclovir 200 mg, qid x 1 year or 400 mg, bid x 1 year

or famciclovir [7] 250 mg, bid x 1 year

Additional instructions and notes

-Treatment should be started as early as possible.

-After 1 year, therapy may be stopped to reassess the frequency of recurrences.
 HERPES ZOSTER

Drugs of choice

1. Antiviral agents and corticosteroids

acyclovir 800 mg, 5 times a day x 21 days

AND
prednisone 60 mg, once daily for first week; 30 mg, once daily for second
week; 15 mg, once daily for third week

2. If patient is unable to use corticosteroids, antiviral agents only

acyclovir 800 mg, 5 times a day x 7-10 days

or valacyclovir 1000 mg, tid x 7 days
or famciclovir 500 mg, tid x 7 days

Additional instructions and notes

-The incidence of postherpetic neuralgia is strongly age related and tends to be much
less common in patients under 50 years of age. A significant proportion of patients
over 60 years of age continue to have pain after healing of the rash
-Combining acyclovir and prednisone improves quality of life: accelerated time to
total crusting and healing of lesions, cessation of acute neuritis, return to
uninterrupted sleep, return to usual daily activity and cessation of analgesic
therapy.
-Combining valacyclovir or famciclovir with prednisone is likely to yield benefits
similar to those derived from combining acyclovir and prednisone, but no controlled
trials on these combinations have been conducted.
-Treatment must be started within 72 h of the appearance of symptoms; otherwise it
should not be provided.

PSORIASIS

Drugs of choice

1. Topical corticosteroids

i. Face, groin, rectal area Mild, weakly potent

hydrocortisone 1% cream, bid to qid

1% ointment, bid to qid
OR Mild, moderately potent

betamethasone valerate 0.05% cream, bid to qid

0.05% ointment, bid to qid

ii. Antecubital fossa, popliteal fossa, neck, axilla, scalp Mild, moderately potent

betamethasone valerate 0.05% cream, bid to qid

0.05% ointment, bid to qid
OR Moderately potent

betamethasone valerate 0.1% cream, bid to qid

0.1% ointment, bid to qid

iii. Arms legs, trunk Mild, moderately potent

 betamethasone valerate 0.05% cream, bid to qid
0.05% ointment, bid to qid
OR Moderately potent

betametasone valerate 0.1% cream, bid to qid

0.1% ointment, bid to qid
OR Potent

betamethasone 0.05% cream, bid to qid

dipropionate 0.05% ointment, bid to qid

iv. Palms, knees, elbows, soles Potent

betamethasone 0.05% cream, bid to qid

dipropionate 0.05% ointment, bid to qid

OR

Very potent

fluocinonide 0.05% cream, bid to qid

0.05% ointment, bid to qid
OR

Extremely potent

clobetasol 17-propionate 0.05% cream, bid to qid

0.05% ointment, bid to qid

2. Instead of corticosteroids (equivalent to a mild, moderately potent or a

moderately potent preparation)

calcipotriol 50 μg/g cream or ointment, bid (maximum 100 g/week)

3. Therapeutic shampoos containing coal tar (commercially available)

Second-line therapies

1. Coal tar + ultraviolet light (UVB) therapy

OR
2. Anthralin + ultraviolet light (UVB) therapy

Additional instructions and notes

-Always use the least potent steroid preparation possible. Higher potency
corticosteroids can be used for short periods to quell inflammation and pruritus
quickly, but very potent and extremely potent corticosteroids should be used in
consultation with a dermatologist.
-The penetration of topical corticosteroids varies with the site of application. To
minimize systemic absorption, low-potency topical corticosteroids should be applied
to areas of high blood flow (e.g., groin, axillae, face) and high-potency
corticosteroids should be applied to areas of poor penetration (e.g., elbows, knees,
palms, soles).
-Ointments offer maximal steroid release. Creams are the most popular vehicles.
Gels and lotions should be used mainly on the scalp.
-Use occlusive dressings with topical corticosteroids when tolerated.

ROSACEA

Drugs of choice

1. Mild to moderate cases

metronidazole 1% cream apply thin film bid until adequate response

achieved, then reduce frequency of application
or metronidazole 0.75% gel apply thin film bid until adequate response
achieved, then reduce frequency of application
2. Severe cases or cases unresponsive to topical preparations

tetracycline 250 mg, qid for 2 months or until adequate response, then
gradually reduce dose
or erythromycin base 500 mg, bid for 2 months or until adequate
response, then gradually reduce dose
Second-line therapies

Refer severe or recalcitrant cases that are unresponsive to oral antibiotics to a

dermatologist.
 SCABIES

Drugs of choice

permetrin single application hs, removed next morning

Second-line therapies

crotamiton 10% 1-2 applications at 24-h intervals; massage into skin until dry
Additional instructions and notes

-Recommend contact isolation until 24 h after treatment.

-Treat skin-to-skin contacts and all members of the household prophylactically at the
same time as patient is treated.
-Some patients require a second application of permethrin, 7 to 10 days after the
first, if live organisms persist or new lesions appear.
 CANDIDIASIS, ORAL

Drugs of choice

1. Immunocompetent patients

nystatin oral suspension (100 000 units/mL)

Children and adults1-5 mL, qid x 10 days; hold in mouth before swallowing
Infants 1 mL, qid x 10 days; dropped into the mouth and swallowed

2. Immunocompromised patients

i. Treatment
ketoconazole 200-400 mg, once daily with meals x 1-2 weeks
or fluconazole 50-100 mg, once daily with meals x 1-2 weeks
or itraconazole 200 mg, once daily with mealsx 1-2 weeks

ii. Prophylaxis
fluconazole 200 mg, once weekly

Second-line therapies

1. Alternative regimen, if others not tolerated

clotrimazole vaginal tablets 100 mg tablet, sucked qidx 10 days

 2. Long-term suppressive therapy for AIDS patients [2,5]

fluconazole 150 mg, once weekly

or 50 mg, once daily or everyother day

Additional instructions and notes

-As clotrimazole troches are not marketed in Canada, clotrimazole vaginal tablets
may be an effective alternative therapy, although they are not approved for this
indication, and there is only limited objective evidence to support their use.-The
unpleasant taste of nystatin can occasionally cause nausea and reduce compliance.

COUGH, ACUTE

Drugs of choice

No therapy has been shown to be effective in suppressing acute cough

due to an upper respiratory tract infection.

Second-line therapies

dextromethorphan
Adults 30 mg, tid to qid
Children 1-2 mg/kg in 24 h, divided tid to qid
or codeine
Adults 15-30 mg, every 4 h
Children 1-1.5 mg/kg in 24 h, divided into doses every 4 h

Additional instructions and notes

-Cough associated with an upper respiratory tract infection is usually self-limited and
needs no therapy.
-Symptomatic treatment of nonproductive cough with antitussives is necessary only
when coughing interferes with sleep.
-No treatment should be undertaken for a chronic cough before first investigating the
etiology.
-Good hydration is the best expectorant.
-Guaifenesin has no proven efficacy in relieving cough (other than placebo effect).

EAR WAX

Drugs of choice

1. Chronic hard but not impacted wax: occasionally instill light oil or glycerin
into ear canal to soften.

2. When wax is to be removed by physician, instill 2-3 drops light oil nightly for
3 days before visit.

Second-line therapies

Use cerumenolytic agent when light oil fails to soften wax enough to allow
removal by irrigation

triethanolamine polypeptide oleate condensate 10% fill ear canal and leave
15-20 minutes only; then flush with warm water

Additional instructions and notes

-Softening agents need only be used for hard, impacted wax.

-Cerumenex7 should not be used longer than 24 h as it can cause severe contact
dermatitis.
 OTITIS EXTERNA

Drugs of choice

Topical antiseptic - anti-inflammatory

aluminum acetate/ benzethonium chloride otic solution 2-3 drops, tid to qid
or betamethasone disodium phosphate otic solution 2-3 drops, tid to qid

Second-line therapies

1. If infections are unresponsive to first-line agents and susceptible organisms are

proven by culture

chloramphenicol/ hydrocortisone suspension 2-3 drops,tid to qid

or gentamicin/betamethasonedisodium phosphate otic solution 2-3 drops, tid to
qid

2. If fungus identified

clotrimazole 1% cream apply bid

or tolnaftate 1% cream apply bid
 or flumethasone/clioquinol 2-3 drops, tid

Additional instructions and notes

-Ensure good aural toilet. A wick or stent may be necessary for severe swelling of
external canal.
-Otic drops containing an aminoglycoside should not be used longer than 7 days in
the presence of a tympanic membrane perforation. Longer periods of treatment have
been associated with ototoxicity.
-Involvement of cartilage or perichondrium of canal requires admission to hospital
and I.V. administration of antibiotics.

OTITIS MEDIA

Drugs of choice

1. Acute
i. Antibiotic therapy

a. amoxicillin
Adults and children >20 kg 250 mg, tid x 10 days
Children <20 kg 40 mg/kg per day, divided tidx 10 days

b. Children attending daycare or school requiring bid dosing

pivampicillin 40 mg/kg per day, divided bidx 10 days

ii. Relief from pain and fever

acetaminophen
Adults 325-650 mg, every 4 h prn
Children 10-15 mg/kg, every 4 h prn
or ASA
Adults only 325-650 mg, every 4 h prn
AND, if inadequate pain relief add to acetaminophen or ASA
Auralgan7 5 drops, tid to qid

2. Otitis media with effusion

No antibiotics
 3. Recurrent

amoxicillin 20 mg/kg per day, single dosex 1 year

or azithromycin 10 mg/kg per week, single dose x 1 year

4. Bullous myringitis
Treatment is the same as for typical otitis media.

Second-line therapies

1. If verified penicillin allergy

trimethoprim/sulfamethoxazole
Adults 160 mg/800 mg tablet, bidx 10 days
Children 8 mg/kg per day of trimethroprim, divided bidx 10 days
or erythromycin/ sulfisoxazole
Children 40 mg/kg per day of erythromycin, divided qidx 10 days
or clarithromycin
Adults 250 mg, bid x 10 days
Children 15 mg/kg per day, divided bidx 10 days
or azithromycin
Children 10 mg/kg, once daily x 5 days
2. amoxicillin/clavulanate
Adults 250 mg/125 mg tablet, tidx 10 days
Children 40 mg/kg per day of amoxicillin, divided tid x 10 days

Additional instructions and notes

-Antibiotics do not influence resolution of pain in the first 24 h after presentation. By

days 2-7 early use of antibiotics reduces the risk of pain by 40%, although at that
time only 14% of untreated children have pain.
-Optimum duration of antibiotic therapy is uncertain; treatment periods of 2, 3, 5 and
10 days seem equally effective.
-Second-generation cephalosporins (cefaclor, cefixime, cefprozil and cefuroxime
axetil) may also be used for treatment failures.
-There is no evidence of improved clinical cure rates associated with a broader
spectrum of antibiotic therapy.
-Amoxicillin is still the drug of choice if acute otitis media recurs within 2 months.
-Antihistamines and decongestants have not been demonstrated to treat symptoms
effectively or prevent development of complications.
-Four weeks after an episode of acute otitis media, there is a 23-67% prevalence of
otitis media with effusion.

PHARYNGITIS

Drugs of choice

1. Viral
No antibiotic therapy

2. Bacterial

penicillin V
Adults 600 mg, bid or 300 mg, qidx 10 days
Children 25-50 mg/kg per day, divided bid to qid x 10 days

Second-line therapies

1. If patient is allergic to penicillin

erythromycin [1] base (adults), estolate (children)

Adults 1 g, divided bid to qidx 10 days

Children 30-50 mg/kg per day, divided bid to qid x 10 days
or clarithromycin
Adults 250 mg, bid x 10 days
Children 15 mg/kg per day, divided bidx 10 days

2. If treatment with penicillin fails

 cephalexin
Adults 1 g/day, divided bid to qidx 10 days
Children 25-50 mg/kg per day, divided bid to qid x 10 days

Additional instructions and notes

-To determine whether group A beta-hemolytical streptococcal (GAS) infection is

present, the following scoring system should be used: temperature above 38° C (1
point), no cough (1 point), tender anterior cervical adenopathy (1 point), tonsillar
swelling or exudate (1 point), age 3-14 years (1 point), age 15-44 years (0 points),
age >45 years
(-1 point). Patients with 4 or more points have a 38% to 63% chance of streptococcal
infection in a community with the usual level of infection. This score does not apply
in a community where an outbreak of GAS is occurring.

SINUSITIS, ACUTE

Drugs of choice

1. Antibiotic therapy

i. amoxicillin
Adults 500 mg, tid x 10 days
Children <12 years 40 mg/kg per day, divided tidx 10 days

ii. If patient is allergic to penicillin

trimethoprim/sulfamethoxazole
Adults 160 mg/800 mg tablet, bidx 10 days
Children 8 mg/kg per day of trimethoprim, divided bid x 10 days

1. Decongestants
i. Topical
xylometazoline nasal spray or drops

Adults 0.1% spray or drops; 2-3 sprays or 1-2 drops in each nostril tid
Children 7-12 years 0.05% spray or drops; 1-2 sprays or 2-3 drops in each
nostril tid
Children 6 months to 6 years 0.05% spray or drops; 1 spray or drop in each
nostril tid
 or oxymetazoline nasal spray or drops
Adults 0.05% spray or drops; 2-3 sprays or drops in each nostril bid
or ii. Oral
pseudoephedrine
Adults 60 mg, qid
pseudoephedrine
Children 2-12 years 2.5-5 mg, qid

GASTROESPOHOGEAL REFLUX DISEASE

Drugs of choice

1. Mild to moderate
i. Symptom relief

domperidone 10 mg, tid

or alginic acid compound 10-20 mL, pc and hs
or liquid antacids 30 mL, 1 and 3 h pc and hs

ii. Symptom relief and healing

a. H-2 antagonists
cimetidine 400 mg, bid x 6-12 weeks
or ranitidine 150 mg, bid x 6-12 weeks
or famotidine 20 mg, bid x 6-12 weeks
or nizatidine 150 mg, bid x 6-12 weeks
b. cisparide [5] 40 mg/day, divided bid or qid x 6-12 weeks

iii. Maintenance
a. H-2 antagonists
cimetidine 400 mg, bid
or ranitidine 150 mg, bid
or famotidine 20 mg, bid
or nizatidine 150 mg, bid
b. cisapride [5] 20 mg, either hs or divided bid

2. Severe [6]
i. Symptom relief and healing
pantoprazole [7] 40 mg, once daily x 4-8 weeks
 or lansoprazole 30 mg, once daily x 4-8 weeks
or omeprazole [8] 20-40 mg, once daily x 4-8 weeks

ii. Maintenance
pantoprazole 20-40 mg, once daily prn
or lansoprazole [8] 15-30 mg, once daily prn
omeprazole 10-20 mg, once daily prn

Second-line therapies

Mild to moderate - symptom relief and healing

sucralfate liquid suspension 1 g (5 mL), qid x 6-12 weeks

IRRITABLE BOWEL DISEASE

Drugs of choice

1. For constipation

psyllium 3.4 mg (1 rounded tsp) in 240 mL liquid, once daily to tid

or lactulose 30 mL, once daily to tid
or cisapride 5-10 mg, tid (15 minutes before meals)

2. For diarrhea

cholestyramine 4 g, ac, breakfast, dinner or both

or loperamide 2-4 mg, ac or before activity
or diphenoxylate 5 mg, tid

3. For pain

dicyclomine 10 mg, tid (ac)

or pinaverium 50-100 mg, tid with meals
or trimebutine 100-200 mg, tid (30 minutes ac)

4. For bloating

simethicone 40 mg, qid (ac and hs)

5. For bloating, distention, early satiety, nausea, pain, and vomiting

leuprolide 0.5-1.5 mg SC, once daily

 or leuprolide depot 3.75 mg IM once monthly

Additional instructions and notes

-Avoid high fibre and anticholinergic-type drugs for patients with diarrhea. High
fibre intake and fibre supplements should be used by patients with constipation.
-Avoid narcotics for patients with constipation, pain or both.
-Eliminate foods such as lactose, caffeine, fatty foods, alcohol, sorbitol gum or beans
to see if symptoms abate.
-Patients with severe bloating should avoid gas-producing vegetables.
-Patients often become refractory to continuous use of antispasmodic and narcotic
medications. These should be used as temporary interventions for short periods.

WORMS (intestinal)

Drugs of choice

1. Pinworm (Enterobius vermicularis)

mebendazole 100 mg, single dose; repeat in2 weeks

or pyrantel pamoate11 mg/kg, single dose(maximum 1 g); repeat in2 weeks
or albendazole (restricted availability) 400 mg, single dose; repeat
in2 weeks
2. Ascariasis (Ascaris lumbricoides)

pyrantel pamoate 11 mg/kg, single dose (maximum 1 g)

or mebendazole 100 mg, bid x 3 days
or albendazole (restricted availability) 400 mg, single dose

3. Whipworm (Trichuris trichiura)

mebendazole 100 mg, bid x 3 days

or albendazole (restricted availability) 400-600 mg, single dose; in heavy
infections, 400 mg once daily x 3 days

Additional instructions and notes

-Doses for children are the same as for adults.

-Follow-up with pinworm paddles to ensure clearance of parasites.
-Follow-up by checking stool for O&P to verify clearance of whipworm and
ascariasis.
 PROSTATITIS

Drugs of choice

1. Acute bacterial

trimethoprim/ sulfamethoxazole 160 mg/800 mg tablet, bid x30 days

2. Chronic bacterial

trimethoprim/ sulfamethoxazole 160 mg/800 mg tablet, bid x4-16 weeks

3. Culture negative

tetracycline 250 mg, qid x 14 days

or erythromycin base500 mg, qid x 14 days

Second-line therapies

1. Acute bacterial

norfloxacin 400 mg, bid x 30 days

or ofloxacin 300 mg, bid x 30 days
or ciprofloxacin [5] 500 mg, bid x 30 days

2. Chronic bacterial (recurrence)

norfloxacin 400 mg, bid x 10-28 days

or ofloxacin 300 mg, bid x 10-28 days
 or ciprofloxacin [5] 500 mg, bid x 10-28 days

Additional instructions and notes

-Ureaplasma urealyticum or Chlamydia should be suspected when cultures for usual

bacterial pathogens are negative.
-Patients allergic to sulfa drugs may receive trimethoprim alone.
-There is no clinical difference between tetracycline and doxycycline. Doxycycline
may be taken twice daily, but at greater expense.

URETHRITIS

Drugs of choice

1. For gonorrhea

ceftriaxone 250 mg IM, single dose

2. For Chlamydia, Mycoplasma and Ureaplasma

tetracycline 500 mg, qid x 7 days

or doxycycline 100 mg, bid x 7 days
or azithromycin 1 g, single dose

Second-line therapies

1. For gonorrhea

ofloxacin 400 mg, single dose

or ciprofloxacin 500 mg, single dose
or cefixime 400 mg, single dose
or azithromycin 2 g, single dose

2. For Chlamydia, Mycoplasma and Ureaplasma

erythromycin base500 mg, qid x 7 days

or ofloxacin 300 mg, bid x 7 days

Additional instructions and notes

-Empiric therapy should be directed at both gonorrhea and clamydial infections.
-There is no clinical difference between tetracycline and doxycycline. Doxycycline
may be taken twice daily, but at greater expense.

ASTHMA

Drugs of choice

1. Occasional episodic or exercise-induced symptoms - inhaled short-acting

beta-2 agonist, using a metered-dose inhaler (MDI) or equivalent

salbutamol MDI (100 μg per puff) 200 μg, prn

or pirbuterol (250 μg per puff) 500 μg, prn
or terbutaline Turbuhaler7 (500 μg per puff) 500 μg, prn

2. If beta-2 agonists have to be used more than 3 times per week - inhaled
corticosteroids, using an MDI or equivalent

triamcinolone MDI (200 μg per puff)

Adults and children 200 μg, tid to qid
or 400 μg, bid
or flunisolide MDI (250 μg per puff)
Adults and children 500 μg, bid
or beclomethasone MDI (50 or 250 μg per puff)
Adults 500-1000 μg/day, divided bid to qid
Children 4-15 years 100 μg, bid to qid

3. Long-acting beta-2 agonist as a replacement when regular use of short-acting

beta-2 agonists is required; also for those with nocturnal asthma. Not to be
used for acute exacerbations
 salmeterol MDI (25 μg per puff) 50 μg, bid
or formoterol Aerolizer (12 μg per puff) 12 μg, bid

BRONCHITIS, ACUTE

Drugs of choice

For unselected patients with acute bronchitis, the value of antibiotic therapy
remains unclear. Treatment for the majority of patients is largely symptomatic.

Second-line therapies

1. For relief of bronchospasm, inhaled short-acting beta-2 agonist, using a

metered-dose inhaler (MDI) or equivalent

salbutamol MDI (100 μg per puff) 200 μg, prn

or pirbuterol (250 μg per puff) 500 μg, prn
or terbutaline Turbuhaler (500 μg per puff) 500 μg, prn

2. Antibiotics

erythromycin base 1 g/day, divided bid to qid x7 days

or trimethoprim/sulfamethoxazole 160 mg/800 mg tablet, bid x7 days
If particular bacterial pathogens, such as Mycoplasma pneumoniae
or Bordetella pertussis, are identified specific antibiotic therapy is indicated.

Additional instructions and notes

-Remove and avoid irritants, such as cigarette smoke and toxic dusts.
 PNEUMONIA (community acquired)
Drugs of choice

1. Previously well, under 65 years old or both

erythromycin base 1 g/day, divided bid to qidx 10 days

or clarithromycin 250 mg, bid x 10 days
or azithromycin 500 mg, once on first day, then 250 mg, once daily x 4 days
2. Comorbid illness, over 65 years old or both

trimethoprim/sulfamethoxazole 160 mg/800 mg tablet, bidx 10 days

or amoxicillin/clavulanate 500 mg/125 mg tablet, tidx 10 day
or cefuroxime axetil 500 mg, bid x 10 days
AND, if Legionella is suspected, to any of the above add 1 of the following
erythromycin base 1 g/day, divided bid to qidx 3 weeks
or azithromycin 500 mg, once on first day, then 250 mg, once daily x 4 days
or clarithromycin 250 mg, bid x 3 weeks

3. For proven Streptococcus pneumoniae in all patients

penicillin V 300 mg, qid x 10 days

Second-line therapies

1. Previously well, under 65 years old or both

tetracycline 250-500 mg, qid x 10 days

2. If Legionella is suspected and patient is intolerant of macrolides

ciprofloxacin 500 mg, bid x 3 weeks

Additional instructions and notes

-Duration of treatment is arbitrary but common guidelines are: bacterial pneumonias
10 days (except if using azithromycin); Mycoplasma and Chlamydia 14 days;
Legionella 21 days (except if using azithromycin).
-Most untreated Mycoplasma infections resolve in 2 weeks, although radiographic
abnormalities persist for months. Antibiotic therapy can reduce the severity and
duration of symptoms and fever, but cannot prevent the development of
extrapulmonary complications.
-Ciprofloxacin is not indicated for the treatment of uncomplicated
community-acquired pneumonia unless Legionella is suspected and the patient is
unable to tolerate a macrolide (erythromycin, clarithromycin, azithromycin).
CONJUNCTIVITIS, ALLERGIC
Drugs of choice

1. Topical ophthalmic agents

lodoxamide 0.1% ophthalmic solution 1-2 drops each eye, qid

or sodium cromoglycate 2% ophthalmic solution 1-2 drops each eye, qid
or levocabastine 0.05% ophthalmic solution 1-2 drops each eye, bid to
qid
or nedocromil sodium 2% ophthalmic solution 1 drop each eye, bid

Second-line therapies
1. Topical NSAIDs as adjuncts to drugs of choice
diclofenac 0.1% ophthalmic solution 1 drop each eye qid
or ketorolac 0.5% ophthalmic solution 1 drop each eye qid
or fluriprofen 0.03% ophthalmic solution 1 drop each eye qid

2. For rhinoconjunctivits or as adjunctive therapy to drugs of choice

i. Oral antihistamines
chlorpheniramine
Adults 4-8 mg, hs to bid
Children 6-12 years 2 mg, hs to bid
or brompheniramine
Adults 4-8 mg, hs to bid
Children 6-12 years 2 mg, hs to bid
or dexchlorpheniramine
Adults 4 mg, hs to bid
Children 6-12 years 1 mg, hs to bid

II. Oral antihistamines when sedation effects are unacceptable

loratadine
Adults 10 mg, once daily
Children <12 years 5 mg, once daily
or fexofenadine
Adults 60 mg, bid
 Children 7-12 years 30 mg, bid
Children 3-6 years 15 mg, bid
Additional instructions and notes
-When dealing with allergic rhinoconjunctivitis oral antihistamines may be first-line
agents.
-Symptoms may not improve for several days with lodoxamide.
-Soft contact lenses may discolour with sodium cromoglycate.
-Contact lens wearers may use levocabastine b.i.d., applied 10 minutes before
applying contact lenses in the morning and 10 minutes after their removal in the
evening.
CONJUNCTIVITIS, BACTERIAL

Drugs of choice

1. Broad-spectrum topical ophthalmic antibiotics

sulfacetamide sodium 10% ophthalmic solution 2 drops, every 2-3 h x 7 days

or gentamicin 0.3% ophthalmic solution 2 drops, every 2-3 h x 7 days
or polymyxin/trimethoprim ophthalmic solution 2 drops, every 2-3 h x 7 days
2. Treatment with ointment may be easier and more effective in children

bacitracin 500 IU ophthalmic ointment once daily to bid x 7 days

or sulfacetamide sodium 10% ophthalmic ointment once daily to bid x 7 days
or polymyxin/bacitracin ophthalmic ointment once daily to bid x 7 days
Additional instructions and notes

-Emphasize hygiene; hands should be washed before and after touching eyes.
-Lid crusts may be removed by soaking in warm water.
-Contact lens wearers with conjunctivitis should be instructed to discontinue wearing
the lenses until symptoms have completely resolved.
 PELVIC INFLAMMATORY DISEASE

Drugs of choice

1. ceftriaxone 250 mg IM, single dose

OR

2. cefoxitin 2 g IM, single dose

AND
probenecid 1 g, single dose

AND, to either of the above choices, add

tetracycline 500 mg, qid x 2 weeks
or doxycycline 100 mg, bid x 2 weeks

Second-line therapies

1. ofloxacin 400 mg, bid x 2 weeks

or ciprofloxacin 500 mg, bid x 2 weeks
or cefixime 400 mg, bid x 2 weeks

AND, to either of the above choices, add

tetracycline 500 mg, qid x 2 weeks

or doxycycline 100 mg, bid x 2 weeks

OR

2. ofloxacin 400 mg, bid x 2 weeks

AND, 1 of

metronidazole 500 mg, bid x 2 weeks

or clindamycin 450 mg, qid x 2 weeks

Additional instructions and notes

-Admission to hospital is preferred in any of the following circumstances:
adolescence; appendicitis or ectopic pregnancy not excluded; suspected pelvic
abscess; pregnancy; too ill for outpatient management; failed response to outpatient
therapy; follow-up within 72 h not feasible.
-There is no clinical difference between tetracycline and doxycycline.
VAGINITIS

Drugs of choice

1. Candidiasis (antifungicide)
i. Acute

clotrimazole 200 mg tablet intravaginally, hs x 3 days

or clotrimazole 500 mg tablet intravaginally, one time
or miconazole 400 mg ovule intravaginally, hs x 3 days
or tioconazole 6.5% ointment 5 g intravaginally, one time
or terconazole 80 mg vaginal suppository, hs x3 days
or terconazole 0.8% cream 5 g intravaginally, hs x 3 days

ii. Recurrent (4 or more episodes per year)

fluconazole 100 mg, once weeklyx 6 months

or ketoconazole 100 mg, once daily x 6 months
or clotrimazole 500 mg, tablet intravaginally once weekly x 6 months
or itraconazole 50-100 mg, once dailyx 6 months

2. Bacterial vaginosis

metronidazole 2 x 250 mg tablets, bid x 7 days

or metronidazole gel 0.75% 5 g intravaginally, bid x 5 days
or clindamycin 2% cream 5 g intravaginally, once daily x 7 days

3. Trichomoniasis

metronidazole 2 g (250 mg x 8 tablets), single dose

4. Atrophic,
see Menopausal symptoms

Second-line therapies

1. Candidiasis

fluconazole 150 mg, single dose

2. Bacterial

i. If pregnant
clindamycin 300 mg, bid x 7 days

ii. Non-pregnant
 metrondiazole 2 g (250 mg x 8 tablets) single dose

3. Trichomoniasis, if patient in first trimester of pregnancy

clotrimazole 1% cream 5 g intravaginally, once daily x6 days

or clotrimazole 100 mg vaginal inserts, once daily x 6 days
(may suppress symptoms)

4. Trichomoniasis, if patient lactating

metronidazole 2 g (250 mg x 8 tablets), single dose

Additional instructions and notes

-If candidiasis is asymptomatic, treatment is unnecessary.

-In trichomoniasis, partners should be treated to prevent reinfection.
-Fluconazole is contraindicated in pregnancy.
-Although single-dose metronidazole achieves the same immediate rate of clinical
response as does a week course of metronidazole in the treatment of bacterial vaginitis,
higher rates of recurrence have been reported.
 HEADACHE, CLUSTER

Drugs of choice

1. Prophylactic

lithium 300 mg, tid

or verapamil 120 mg, tid

If attacks occur at regular intervals

ergotamine 2-4 mg, sublingual 0.5-1 h before expected attack(maximum 10

mg/week)

2. Abortive

oxygen 6 L/min via nonrebreathing face mask x 15 minutes

or dihydroergotamine 0.25-1 mg SC or IM; may be repeated after 1 h
(maximum 4 mg/day and 16 mg/week)
or 0.5 mg (1 spray) in each nostril; if inadequate response after 15 minutes, repeat
(maximum 4 mg/day and 16 mg/week)
or sumatriptan 20 mg (1 spray) in 1 nostril (may be repeated once in 24 h)
or 6 mg SC, 1 dose (may be repeated once in 24 h)

Second-line therapies

1. Prophylactic

pizotifen 0.5 mg, hs; gradually increase to 2-3 mg/day, divided tid
or methysergide 2 mg hs; gradually increase to 2 mg, qid

2. Abortive

butorphanol nasal spray ( 1 mg per spray) 1 mg in 1 nostril; repeat in 60-90

minutes if adequate pain relief not achieved(maximum 16 mg/day)

Additional instructions and notes

-Avoid ergotamine and sumatriptan in patients with coronary artery disease.

-Methysergide should not be given continuously for longer than 6 months because of
the risk of retroperitoneal or pulmonary fibrosis.
-Butorphanol is potentially addictive and frequent use must be avoided.
HEADACHE, TENSION

Drugs of choice

Analgesics

ASA 325-650 mg, every 4 h

or acetaminophen 325-975 mg, every 4 h
or ibuprofen 200-400 mg, every 4 h

Second-line therapies

1. amitriptyline 75-150 mg, hs

2. If patients do not respond to, or are intolerant of, amitriptyline

fluoxetine 20-40 mg, once daily

Additional instructions and notes

-Nonpharmacologic management should be considered.

-In patients with chronic daily headaches, avoid the regular use of analgesics, which
can perpetuate or cause "rebound headache"
 ARTHRITIS, RHEUMATOID

Drugs of choice

ASA or NSAIDs

ASA, enteric-coated 975 mg qid; titrate up to 1950 mg, qid

or ibuprofen 400-600 mg, qid
or naproxen 250-500 mg, bid
or indomethacin 25-50 mg, tid

Second-line therapies

Disease-modifying antirheumatic drugs (DMARDs)

Additional instructions and notes

-There is no broad consensus on whether salicylates or nonsalicylate NSAIDs should be

the first-line treatment of diagnosed rheumatoid arthritis.
-The initiation of DMARD therapy should not be delayed beyond 3 months for any
patient with an established diagnosis who, in spite of adequate treatment with NSAIDs,
has ongoing joint pain, significant morning stiffness or fatigue, active synovitis or
persistent elevation of ESR or C-reactive protein level. Rheumatology consultation
should be considered for confirmation of the diagnosis and for the decision regarding the
initiation and selection of DMARD. The goal of treatment is to intervene in the disease
before joints are damaged. Any untreated patient with persistent synovitis and joint
damage already documented by joint examination or radiography should start DMARD
treatment promptly to prevent or decrease further damage. DMARDs most commonly
used for rheumatoid arthritis are hydroxychloroquine, sulfasalazine, intramuscular gold
(sodium aurothiomalate or aurothioglucose), oral gold, D-penicillamine and azathioprine
and methotrexate.
 BURSITIS & TENDINITIS

Drugs of choice

1. Patients should be instructed to rest the injury by avoiding painful activities

(not by immobilization), use passive range of motion exercises and apply
local heat or ice packs.

Second-line therapies

1. NSAIDs

ibuprofen 400-600 mg, qid x 14 days

or naproxen 250-500 mg, bid x 14 days
or indomethacin 25-50 mg, tid x 14 days

2. Steroid injection

methylprednisolone 4-80 mg, intra-articular

or triamcinolone 5-40 mg, intra-articular

Additional instructions and notes

-Dose of steroid injection depends on the size of the joint.

-Steroid injections may not be superior to injections of lidocaine or saline for rotator
cuff injury.
-There is little evidence to support the use of any of the common interventions (NSAIDs,
intra-articular and subacromial steroid injection, oral steroids, physiotherapy,
manipulation under anesthesia, hydrodilatation and surgery) in managing shoulder pain.
What evidence there is suggests that NSAIDs and subacromial steroid injections may be
superior to placebo in improving range of abduction in rotator cuff tendonitis and the
addition of steroid injection to NSAIDs does not seem to confer further benefits.
 GOUT

Drugs of choice

There is no consensus on which of the available drugs is most effective in

treating the acute event.

1. Acute treatment

i. colchicine 0.6 mg, every h; continue until symptoms begin to settle; nausea,
vomiting or vertigo develops; or maximum of 6 mg has been reached
OR

ii. NSAIDs

ibuprofen 400-600 mg, qid

or naproxen 250-500 mg, bid
or indomethacin 25-50 mg, tid

2. Prophylactic treatment
i. For patients with gout who excrete more than 700 mg uric acid per day but
who have more than 3-4 attacks per year

allopurinol 200-300 mg/day; adjust dose according to uric acid level

ii. For patients with gout who excrete less than 700 mg uric acid per day

allopurinol 200-300 mg/day; adjust dose according to uric acid level

or sulfinpyrazone
Initial dose 50-100 mg, bid; increase slowly to
Maintenance 100 mg, tid to qid
or probenecid
Initial dose 250 mg, bid x 1 week
Maintenance 500 mg, bid

Second-line therapies

1. Acute treatment
i. Systemic gluococorticoids have been used effectively in the management of
polyarticular gout when colchicine or NSAIDs are contraindicated.

prednisone 30-50 mg, once daily x 3-5 days, then taper by 5 mg/day

ii. Intra-articular glucocorticoids are useful in treating acute gout when only one
joint or bursa is involved.
 iii. corticotropin (restricted availability) 80 IU, single IM injection

2. Prophylactic treatment

i. colchicine 0.6-1.2 mg, once daily

ii. If colchicine alone is ineffective and acute attacks recur frequently, NSAIDs
may be added.

ibuprofen 400-600 mg, qid

or naproxen 250-500 mg, bid
or indomethacin 25-50 mg, tid

Additional instructions and notes

-The affected joint should be placed at rest during treatment.

-The earlier colchicine is administered, the better the response. If the attack is treated
within the first few hours of its onset, a favourable response may be expected in 90% of
cases. If treatment is delayed beyond 12 h, a response will likely occur in about 75% of
cases within 96 h.
-Maintenance doses of colchicine should be prescribed during at least the first 3 months
of treatment with antihyperuricemic drugs (allopurinol, probenecid or sulfinpyrazone) to
prevent the precipitation of an acute attack of gout.
-Dose of steroid injection depends on the size of the joint.
-Although indomethacin may be the most commonly used NSAID in the treatment of
gout there is no evidence to suggest that it is superior to other NSAIDs.
-Sudden lowering of serum uric acid level may precipitate or aggravate an acute episode;
therefore, it is recommended that allopurinol not be introduced during an attack of gout.
 LOW BACK PAIN

Drugs of choice

1. Acute pain (lasting 6 weeks or less)

i. acetaminophen/caffeine/codeine or ASA/caffeine/codeine
codeine dose 30 mg, 2 tablets every 4 h (acetaminophen combination)
OR

ii. NSAIDs

naproxen 250 mg, qid

or piroxican 20-40 mg, once daily
or diflunisal 500 mg, bid

2. Chronic pain (lasting 12 weeks or more)

i. acetaminophen 975 mg, qid

or ii. NSAIDS
naproxen 250 mg, qid
or piroxicam 20-40 mg, once daily
or diflunisal 500 mg, bid

Second-line therapies

Acute pain (lasting 6 weeks or less) - muscle relaxants

dantrolene 25 mg, once daily x 4 days

or carisoprodol 350 mg, qid x 4 days
or baclofen 10-20 mg, tid to qid x 10 days
or cyclobenzaprine 10 mg, qid x 10 days

Additional instructions and notes

-NSAIDs do not appear to be effective in patients with low back pain with sciatica and in
patients with sciatica with nerve root symptoms.
-Most patients improve considerably during the first 4 weeks after seeking treatment, but
66-75% continue to experience at least mild pain at that time and about 33% report
continuing pain of at least moderate intensity.
-Among patients with acute low back pain, continuing ordinary activities within the
limits permitted by the pain leads to more rapid recovery than either bed rest or
back-mobilizing exercises.
-Adding codeine (60 mg) to acetaminophen (600 mg) produces a modest increase in pain
relief. Smaller doses of codeine do not help. Adding caffeine to acetaminophen + codeine
combinations does not yield any benefit in terms of pain relief.
 CLASSIFICATION OF DRUGS BY EFFECT

1. THE FOLLOWING IS A LIST OF DRUGS LISTED AS PER THEIR ACTION OR

EFFECT.

2. ONE OR MORE EXAMPLES OF EACH IS ALSO GIVEN.

ANALGESIC
ACTION: RELIEVES PAIN
EXAMPLE: MORPHINE, ASA

ANTACID
ACTION: NEUTRALIZES GASTRIC ACIDS
EXAMPLE: SODIUM BICARBONATE, AMPHOGEL

ANTIBIOTIC
ACTION: SUBSTANCES PRODUCED FROM LIVING ORGANISMS
THAT DESTROY BACTERIA.
EXAMPLE: PENICILLIN, STREPTOMYCIN

SULPHONAMIDE
ACTION: DRUGS PRODUCED BY SYNTHETIC MEANS, WHICH
ACT AS BACTERIOSTATIC AND ANTI-INFECTIVE AGENTS,
IN THAT THEY CHECK THE GROWTH OF BACTERIA, THUS
ENABLING THE LEUCOCYTES IN THE BODY TO FIGHT OFF
THE INFECTION.
EXAMPLE: SULPHADIAZINE, SULPHAGUANIDINE, GANTRICIN

ANTICOAGULANT
ACTION: PREVENTS CLOTTING IN THE BLOOD STREAM
EXAMPLE: HEPARIN, WARFARIN

ANTIDOTE
ACTION: COUNTERACTS A POISON
EXAMPLE: VARIES ACCORDING TO THE POISON

ANTIEMETIC
ACTION: PREVENTS NAUSEA AND VOMITING
EXAMPLE: GRAVOL, DRAMAMINE, BONAMINE

ANTIHISTAMINE
ACTION: AIDS IN THE CONTROL OF ALLERGIC EFFECTS
EXAMPLE: PYREBENZAMINE, CHLOR-TRIPLON, BENADRYL
ANTIMALARIAL
ACTION: DRUGS USED IN THE TREATMENT OF MALARIA
EFFECTIVE BOTH AS CURATIVE AGENTS AND
SUPPRESSIVE AGENTS TO PREVENT THE DEVELOPMENT OF
THE DISEASE.
EXAMPLE: PRIMAQUINE, QUININE, CHLOROQUINE

ANTIPRURITIC
ACTION: RELIEVES ITCHING
EXAMPLE: CALAMINE, HYDROCORTISONE

ANTIPYRETIC
ACTION: REDUCES FEVER
EXAMPLE: ASA, QUININE COMPOUNDS

ANTISEPTIC
ACTION: CHECKS THE GROWTH OF BACTERIA WITHOUT
HARMING BODY TISSUES
EXAMPLE: ALCOHOL, SAVLON SOLUTION

DISINFECTANT
ACTION: DESTROY BACTERIAL LIFE, MAY BE HARMFUL TO BODY
TISSUES
EXAMPLE: LYSOL, CARBOLIC ACID

ANTISPASMODIC
ACTION: RELIEVES MUSCLE SPASMS
EXAMPLE: PRO-BANTHINE AND DONNATOL

CARDIAC STIMULANT
ACTION: INCREASES AND STRENGTHENS THE ACTION OF THE
HEART
EXAMPLE: ADRENALIN, DIGITALIS

CATHARTIC
ACTION: PURGATIVE MEDICINES
EXAMPLE: MAGNESIUM SULPHATE, CASTOR OIL

LAXATIVE
ACTION: STIMULATES BOWEL MOVEMENTS
EXAMPLE: CASCARA, MINERAL OIL
DIURETIC
ACTION: STIMULATES THE FLOW OF URINE
EXAMPLE: DIURIL, POTASSIUM CITRATE

EXPECTORANT
ACTION: PROMOTES EXPULSION OF SECRETIONS FROM THE
RESPIRATORY SYSTEM
EXAMPLE: MISTURA AMMONIUM CHLORIDE

HAEMATINIC
ACTION: IMPROVES THE QUALITY OF THE BLOOD
EXAMPLE: FERROUS SULPHATE, LIVER EXTRACT

HYPNOTIC
ACTION: INDUCES SLEEP
EXAMPLE: BARBITURATES

NARCOTIC
ACTION: INDUCES SLEEP AND REDUCES PAIN. THESE DRUGS
ARE HABIT FORMING AND SALE IS CONTROLLED BY LAW.
EXAMPLE: MORPHINE AND OPIUM PREPARATIONS.

SEDATIVE
ACTION: REDUCES ACTIVITY OF THE BODY
EXAMPLE: BARBITURATES, MEPROBAMATE

TRANQUILIZER / ATARACTIC
ACTION: HELPS DISTRAUGHT PATIENTS TO SECURE SLEEP AND
OBTAIN RELIEF OF TENSION AND APPREHENSION AS
WELL AS PROMOTING A STATE OF CALM AND RELAXATION.
EXAMPLE: PROMAZINE, MEPROBAMATE, LIBRIUM

VASO-CONSTRICTOR
ACTION: DRUGS USED TO EFFECT CONSTRICTION OF THE BLOOD
VESSELS BY BRINGING ABOUT CONSTRICTION OF THE MUSCLE
FIBRE OF THE BLOOD VESSELS, OR BY STIMULATING THE VASO-
MOTOR CENTRE IN THE MEDULLA.
EXAMPLE: EPINEPHERINE, PHENYLEPHERINE HYDROCHLORIDE

VASO-DILATOR
ACTION: DRUGS WHICH DILATE THE BLOOD VESSELS
EXAMPLE: AMYL NITRATE, NITROGLYCERINE
VACCINE
ACTION: VACCINES ARE SUSPENSIONS OF EITHER
ATTENUATED (WEAKENED) MICRO-ORGANISMS THAT ARE
ADMINISTERED FOR THE PREVENTION OR CURE OF A
DISEASE. THEIR PRIMARY EFFECT IS TO STIMULATE
THE PRODUCTION OF ANTIBODIES WITHIN THE BLOOD
STREAM OF THE VACCINE RECIPIENT, THUS PROVIDING
HIM WITH IMMUNITY AGAINST THE PARTICULAR
DISEASE. THE IMMUNITY MAY BE TEMPORARY OR
PERMANENT, DEPENDING ON THE VACCINE USED.
EXAMPLE: SMALL POX VACCINE, YELLOW FEVER VACCINE

SERUM
ACTION: SERUMS ARE THE SERUMS OF ANIMALS OR HUMAN
BEINGS CONTAINING ANTIBODIES AGAINST SPECIFIC
DISEASES; THESE ARE TRANSFERRED BY INJECTION
INTO THE BLOODSTREAM OF THE PERSON TO BE
PROTECTED. THE IMMUNITY PROVIDED TO THE
RECIPIENT IS ONLY TEMPORARY, WHEN THE
ANTIBODIES DISAPPEAR FROM THE BLOODSTREAM,
IMMUNITY CEASES. THE RECIPIENT DOES NOT
PRODUCE ITS OWN ANTIBODIES AGAINST THE DISEASE.
EXAMPLE: TETANUS ANTITOXIN, IMMUNE SERUM GLOBULIN
GLOSSARY:

ABDUCTION - Moving an extremity away from the body

ABRASION - An area of skin or mucous membrane worn from the
body mechanically by some unusual or abnormal process
ABSCESS - A localized collection of pus
ACIDOSIS - A condition resulting from acid accumulating in the body
ADDUCTION - Bringing an extremity toward the body
ADIPOSE - Of a fatty nature
AEROBIC - Growing only in the presence of oxygen
ALBUMINURIA - Albumin in the urine
ALKALOSIS - A pathogenic condition resulting from accumulation of
base in, or loss of acid from the body
AMBULATORY - Walking or able to walk
AMEBACIDE - A drug that destroys amoeba
ANABOLISM - The constructive process by which the simple products
of digestion are converted by living cells into more complex
compounds and living matter for cellular growth and repair
ANAEROBIC - Growing only in the absence of oxygen
ANALGESIC - A drug used to relieve pain without producing
unconsciousness or impairing mental capacities
ANATOMY - The science of the structure of the body and the
relationship of its parts to each other
ANEMIA - A decrease in certain elements of the blood, especially red
cells and hemoglobin
ANOREXIA - Loss of appetite
ANOXIA - A lack of oxygen that can result in brain damage
ANTHELMENTIC - A drug that expels, paralyzes, or kills intestinal
worms
ANTIBIOTIC - A synthetic product or a product of living
microorganisms that kills or inhibits the growth of undesirable
microorganisms
ANTIDOTE - An agent that counteracts a poison
ANTIGEN - A substance which, under certain conditions, is capable of
inducing the formation of antibodies and reacting specifically with the
antibodies in a detectable manner
ANTIPYRETIC - A drug that lowers elevated body temperature
ANTISEPTIC - A drug or chemical that inhibits the growth of
microorganisms without necessarily destroying them
APNEA - A temporary cessation of breathing
ARTICULATION - The place of union or junction between two or
more bones of the skeleton
ASEPTIC - Clean; free of pathogenic organisms
ASTRINGENT - A drug or preparation that produces shrinkage of
body membranes, especially mucous membranes
ASYMPTOMATIC - Having no symptoms
AUSCULTATION - The act of listening for sounds within the body,
with or without a stethoscope
AVULSED - A forcible separation; also a part torn from another

BACTERICIDE - An agent that destroys bacteria

BACTERIOSTATIC - An agent that inhibits the growth of bacteria
BIOLOGICALS - Medicinal preparations made from living organisms
and their products, including serums, vaccines, antigens, and antitoxins
BLANCHING - Turning white
BLEB - Blister, bubble
BRADYCARDIA - Abnormally slow heartbeat evidenced by a pulse
rate of 60 or less
BRADYPNEA - Abnormally slow breathing
BUCCAL - Referring to the cheek

CARRIER - A person or animal that harbors specific infectious agents

in the absence of discernible clinical disease, and serves as a potential
source of infection for humans
CATABOLISM - A destructive process in which the complex
compounds of the digestive process are reduced to more simple
substances
CATHARTICS - Drugs that promote bowel movement
CHEYNE-STOKES - Breathing characterized by alternating periods of
apnea and deep respirations
CLAMMY - Moist and cold
COAGULATION - Clotting
COAPTATION - To fit together, as the edges of a wound or the ends
of fractured bone; category of splint
COMMUNICABLE - Capable of being transmitted from one person to
another
COMMUNICABLE PERIOD - The period of time in which an
infectious agent may be passed from an infected animal or man to a
receptive host. There may be more than one such period of time during
the course of disease
CONTACT - A person or animal known to have been associated with
an infected person or animal, or a contaminated environment, and to
have had the opportunity to acquire the infection
CONTAMINATION - The presence of an infectious agent or toxin on
the surface of a body or inanimate article, such as clothing, dishes,
surgical dressings or instruments, as well as in food or water
CONTRACTURE - A condition of muscle shortening and fibrous
tissue development which results in a permanent joint deformity
CONTUSION - A bruise
CORROSIVE - A substance that rapidly destroys or decomposes body
tissue at point of contact
CREPITUS - The cracking or grating sound produced by fragments of
fractured bones rubbing together
DEBILITY - The state of abnormal bodily weakness
DEBRIDEMENT - The removal of all foreign matter and devitalized
tissue in or about a wound
DECEREBRATE - A person with brain damage that produces certain
abnormal neurologic signs
DECUBITUS ULCER - Bed or pressure sore
DESQUAMATE - To shed, peel, or scale off
DIASTOLE - The dilation or period of dilation of the heart, especially
of the ventricles
DISINFECTION - The killing of infectious agents outside the body by
physical or chemical means applied directly concurrent-Done during
the treatment of a patient with a communicable disease terminal-Done
after a patient has been discharged or transferred
DISINFESTATION - A physical or chemical means of destroying
animal or insect pests in a particular area
DISTILLATION - Converting a liquid to a vapor by applying heat and
condensing the vapor back to liquid by cooling
DIURESIS - Urine excretion in excess of the usual amount
DIURETICS - Drugs that increase the secretion of urine
DYSPNEA - Labored or difficult breathing

ECCHYMOSIS - A small hemorrhagic spot, larger that a petechia, in

the skin or mucous membrane, forming a nonelevated, rounded or
irregular, blue or purplish patch
ELECTROLYTE - A substance that dissociates into ions in solution or
when fused, thereby becoming electrically conducting
ELIXIR - An aromatic, sweetened, hydroalcoholic solution containing
medicinal substances
EMBOLUS - A clot or other plug brought by the blood from another
vessel and forced into a smaller one, thereby obstructing circulation
EMETIC - A substances that caused vomiting
EMOLLIENT - A drug which softens, soothes, or smoothes the skin or
irritated surfaces
ENCAPSULATED - Enclosed within a capsule
ENDEMIC - The constant presence of a disease in a given locality
ENTERIC - Of or within the intestine
EPIDEMIC - The outbreak of disease in the geographic area in excess
of normal expectations
EPISTAXIS - Nose bleed
ERADICATE - Wipe out; destroy
ERYTHEMA - Redness
ERYTHROCYTE - Red blood cell
EUPNEA - Ordinary, quiet breathing
EXSANGUINATION - Extensive loss of blood due to hemorrhage,
either internal or external
EXTENSION - Straightening or unbending, as in straightening the
forearm, leg, or fingers
EXTRICATION - The process of freeing a victim, such as from a
wrecked car or flooded compartment

FLEXION - Bending, as in bending an arm or leg

FUMIGATION - The destruction of disease producing animals or
insects by gaseous agents
FUNGICIDE - A drug that kills fungus
FURUNCLE - An abscess in the true skin caused by the entry of
microorganisms through a hair follicle or sweat gland
FUSION - Melting

GASTROSTOMY - A surgical opening from the external surface of the

body into the stomach, usually for inserting a feeding tube
GAVAGE - Introducing a substance into the stomach through a tube
GERMICIDE - An agent that kills germs
GESTATION - The period of carrying developing offspring in the
uterus after conception
GLYCOSURIA - Glucose in the urine
GRAM-NEGATIVE - A microorganism that does not retain the purple
dye of Gram's stain
GRAM-POSITIVE - A microorganism that is stained by the purple dye
of Gram's stain

HEMATEMESIS - Vomiting bright red blood

HEMATOCRIT - A determination of the volume percentage of red
blood cells in whole blood
HEMIPLEGIA - Loss of motion and sensation of one side of the body
HEMOGLOBIN - Iron containing red pigment (heme) combined with a
protein substance (globin)
HEMOPTYSIS - Coughing up bright red blood
HEMOSTATICS - Drugs that control external bleeding by forming an
artificial clot
HOST - A man or other living animal affording subsistence or
lodgment to an infectious agent under natural conditions
HYPERGLYCEMIA - Abnormally increased content of sugar in the
blood
HYPERPNEA - Increased rate and depth of breathing
HYPERTENSION - High blood pressure
HYPERTHERMIA - Abnormally high body temperature, especially
that induced for therapeutic purposes
HYPOGLYCEMIA - Low blood sugar
HYPOPNEA - Abnormal shallowness and rapidity of breathing
HYPOSTASIS - Poor or stagnant circulation in a dependent part of the
body or organ, as in venous insufficiency
HYPOTENSION - Low blood pressure
HYPOTHERMIA - Abnormally low body temperature
HYPOVOLEMIA - Abnormally decreased volume of circulating fluid
(plasma) in the body
HYPOXIA - Low oxygen content or tension; deficiency of oxygen in
the inspired air

IMMUNE PERSON - An individual who does not develop clinical

illness when exposed to specific infectious agents of a disease, due to
the presence of specific antibodies or cellular immunity
IMMUNITY - A defense mechanism of the body which renders it
resistant to certain organisms
INCISION - A cut, or a wound produced by cutting with a sharp
instrument
INCOMPATIBLE - Not suitable for combination or simultaneous
administration
INCONTINENT - Unable to control excretory functions
INCUBATION PERIOD - The period of time between the initial
exposure to an infectious agent and the first clinical symptoms of the
disease
INDURATION - An abnormally hard spot or place
INFECTION - A condition resulting when pathogens enter body
tissues, multiply, and cause injury to cells
INFECTIOUS AGENT - An organism capable of producing infection
or disease
INFECTIOUS DISEASE - A disease of man and animal resulting from
an infection
INFESTATION - The establishment and multiplication of small
animals or arthropods (especially insects and rodents) on the body,
clothing, or habitat of individuals or animals
INTRADERMAL - Into the dermis
ISCHEMIA - The lack of blood supply to specific areas due to
constriction or obstruction in the blood vessels
ISOLATION - Procedures taken to separate infected persons or
animals, dispose of their secretions, and disinfect or sterilize the
supplies, equipment, utensils, etc., used for their care, in order to
prevent the spread of disease to susceptible persons or animals.
ISOTONIC - A solution having the same salinity as whole blood

KERATOLYTIC - Removes horny layers of epidermis

LACERATED - Torn
LACERATION - A wound made by tearing resulting in jagged edges
LACRIMATION - The secretion of tears
LACTATION - The production of milk
LATENT - Concealed; not manifest; potential
LAVAGE - To wash out
LESION - Any pathological or traumatic discontinuity of tissue or loss
of function of a part
LEUKOCYTE - White blood cell
LEUKOCYTOSIS - Abnormally high white blood cell count
LEUKOPENIA - Abnormally low white blood cell count
LIGAMENT - A sheet or band of tough, fibrous tissue connecting two
or more bones or cartilages, or supporting an organ, fascia, or muscle
LINIMENT - Solution or mixture of various substances in oily,
alcoholic, or emulsified form intended for external application

MACERATION - Soaking
MALAISE - A vague feeling of bodily discomfort
MASTICATION - Chewing
MEDICAL ASEPTIC TECHNIQUE - The practice that prevents the
spread of pathogens from person to person, place to place, or place to
person
MELENA - Excretion of black tarry stools
METABOLISM - The sum of all the physical and chemical processes
by which living organized substance is produced and maintained. Also,
the transformation by which energy is made available to the organism
METAMORPHOSIS - Change of shape or structure, particularly a
transition from one development stage to another, as from larva to adult
form
MICROORGANISM - A minute, living organism invisible to the
naked eye
MICTURATION - Voiding; urinating
MOTTLED - Marked with blotches or spots of different colors or
shades
MUCUS - A sticky substance secreted by mucous membranes
MYDRIATIC - Any drug that dilates the pupil
MYELIN - -A lipid substance that forms a sheath around certain nerve
fibers
MYELINATED - Covered with a myelin sheath

NECROSIS - The death of tissue, usually in small localized areas

NOSOCOMIAL - Hospital acquired
NUTRITION - The total process of providing the body with
nutriments, and assimilating and using them

OINTMENT - A semisolid, fatty, or oily preparation of medicinal

substances for external application
OPHTHALMIC - Pertaining to the eye
ORGANISM - Any living thing
OSMOSIS - The diffusion of fluids through a membrane or porous
partition
OSSIFICATION - Changing or developing into bone
OXIDATION - The union of a substance with oxygen

PALPABLE - Can be touched or felt

PALPITATION - An abnormal, rapid, regular or irregular beating of
the heart, felt by the patient
PARAPLEGIA - Loss of motion and sensation of the lower half of the
body
PARASITICIDES - Drugs that kill parasites
PARENTERAL - Administering drugs by injection
PARESIS - Slight or partial paralysis
PAROXYSM - A sudden attack, or intensification of the symptoms of
a disease, usually recurring periodically
PATHOGEN - An organism capable of producing disease or causing
infections
PATHOGENICITY - The capability of an infectious agent to cause
disease in a susceptible host
PERCUSSION - The act of striking a body part with short, sharp blows
as an aid in diagnosing the condition by evaluating the sound obtained
PERIPHERAL - Outward part or surface
PERSISTENT - Stubborn; persevering
PETECHIA - A round pinpoint, non-raised purplish red spot caused by
hemorrhage in the skin
PHAGOCYTOSIS - The ingestion and destruction by phagocytes of
cells, microorganisms, and other foreign matter in the blood or tissue
PLEXUS - Network
PRONE - Lying face down
PROPHYLACTIC - The prevention of disease; preventive treatment
PROSTRATION - Utter exhaustion
PRURITIS - Intense itching
PURULENT - Pus filled or containing pus
PUSTULE - A small, inflamed elevation of the skin containing pus

QUADRAPLEGIA - Loss of motion and sensation below the neck

RALES - An abnormal sound, either moist or dry, classified by

location e.g., bronchial rales, laryngeal rales
RESERVOIR - A carrier on which an infectious agent depends
primarily for survival
RESISTANCE - The sum total of body mechanisms that provide
barriers to the invasion of infectious agents or their toxic products
RHINORRHEA - The free discharge of a thin nasal mucus
RHONCHUS - A rattling throat sound due to partial obstruction; a dry
coarse rale in the bronchial tubes

SANITIZATION - The process of cleaning with soap and water or

boiling to reduce the number of organisms to a safe level
SEPSIS - The growth of pathogens in living tissue
SHOCK - Collapse of the cardiovascular system, characterized by
circulatory deficiency and depression of vital functions
SOLUBILITY - The ability of a solid to dissolve in a given amount of
solvent
SPORE - A microorganism in a resting or dormant state that renders it
highly resistant to destruction
SPRAIN - Injury to the ligaments and soft tissues that support a joint
STERILE - Free of all living organisms
STERILIZATION - The process of destroying all organisms on a
substance or article by exposure to physical or chemical agents; the
process by which all organisms, including spores, are destroyed
STERTOROUS - Snoring type breathing sound
STRAIN - Forcible overstretching or tearing of a muscle or tendon
STRIATED - Striped or streaked
STRIDOR - A harsh, high-pitched respiratory sound such as the
inspiratory sound often heard in acute laryngeal obstruction
SUBCUTANEOUS - Under the skin
SUBLINGUAL - Under the tongue
SUPERFICIAL - Of or pertaining to the surface, lying on, not
penetrating below
SUPINE - Lying on the back
SURGICALLY CLEAN - Clean but not sterile
SUSCEPTIBLE - Not resistant. A person or animal who may acquire
an infection or disease when exposed to a specific agent, because his or
her resistance to the agent is lacking or reduced
SUSPECT - A person who may have acquired a communicable disease;
it is indicated by the medical history and clinical presentation
SUSPENSION - A coarse dispersion of finely divided insoluble
material suspended in a liquid medium
SYNCOPE - Faintness or actual fainting
SYNERGIST - A medicine that aids or cooperates with another
SYRUP - Concentrated aqueous solutions of sucrose, containing
flavoring or medicinal substances

TACHYCARDIA - Excessively rapid heart beat, usually over 100

TENDON - A fibrous cord by which a muscle is attached to the
skeleton
THROMBUS - A plug or clot in a blood vessel or in one of the cavities
of the heart, formed by coagulation of the blood. It remains where it
was formed
TINCTURE --Usually an alcoholic solution of animal or vegetable
drugs
TINNITUS - Ringing in the ears
TOXEMIA - Poisonous products in the blood
TOXINS - Poisons
TRACHEOSTOMY - Surgically creating an opening into the trachea
TRIAGE - Sorting casualties to determine priority of treatment

UTICARIA - Hives or welts

UREMIA - A condition resulting from waste products not being
removed efficiently by the kidneys so they remain in the blood

VASCULAR - Pertaining to blood vessels

VASOCONSTRICTOR - Constricts the blood vessels
VASODILATOR - Dilates the blood vessels
VESICLE - -A small blister
VIRULENCE - -The degree of pathogenicity of a microorganism or its
ability to invade the tissues of the host
 SAVLON SOLUTIONS

ALL SAVLON SOLUTIONS MUST BE PRESERVED WITH ETHYL

(7%) OR ISOPROPYL (4%) ALCOHOL. THE DILUTION OF
ALCOHOL SHOULD RESULT IN A 4% CONCENTRATION OF
ALCOHOL.
TO BE REPLACED IN 6 MONTHS

AQUEOUS SOLUTION SAVLON 1:100

TO PREPARE 4500ml (1 GALLON)

SAVLON HOSPITAL CONCENTRATE: 45ml

70% ALCOHOL 256ml
DISTILLED WATER, QS: 4500ml

TO PREPARE 4000ml

SAVLON HOSPITAL CONCENTRATE: 40ml

70% ALCOHOL: 229ml
DISTILLED WATER, QS: 4000ml

TO PREPARE 2250ml (½ GALLON)

SAVLON HOSPITAL CONCENTRATE: 22.5ml

70% ALCOHOL: 128ml
DISTILLED WATER, QS: 2250ml

AQUEOUS SOLUTION SAVLON 1:30

TO PREPARE 4500ml (1 GALLON)

SAVLON HOSPITAL CONCENTRATE: 150ml

70% ALCOHOL 256ml
DISTILLED WATER, QS: 4500ml

TO PREPARE 2250ml (½ GALLON)

SAVLON HOSPITAL CONCENTRATE: 75ml

70% ALCOHOL: 128ml
DISTILLED WATER, QS: 2250ml
 AQUEOUS SOLUTION SAVLON 1:200

TO PREPARE 4500ml (1 GALLON)

SAVLON HOSPITAL CONCENTRATE: 22.5ml

70% ALCOHOL: 256ml
DISTILLED WATER, QS: 4500ml

AQUEOUS SOLUTION SAVLON 1:800

USED FOR VAGINAL DOUCHING

TO PREPARE 2250ml (½ GALLON)

SAVLON HOSPITAL CONCENTRATE: 2.8ml

70% ALCOHOL: 128ml
DISTILLED WATER, QS: 2250ml

TINCTURE OD SAVLON 1:30

TO PREPARE 2250ml (½ GALLON)

SAVLON HOSPITAL CONCENTRATE: 75ml

70% ALCOHOL, QS: 2250ml

TO PREPARE 4500ml (1 GALLON)

SAVLON HOSPITAL CONCENTRATE: 150ml

70% ALCOHOL, QS: 4500ml
 CLINDAMYCIN 1% LOTION

TO PREPARE 60ml

CLINDAMYCIN 150mg CAPSULES: 4 CAPS (600mg)

PROPYLENE GLYCOL: 3ml
70% ISOPROPYL ALCOHOL, QS: 60ml

TO PREPARE 90ml

CLINDAMYCIN 150mg CAPSULES: 6 CAPS (900mg)

PROPYLENE GLYCOL: 4.5ml
70% ISOPROPYL ALCOHOL, QS: 90ml

CLINDAMYCIN 2% LOTION

TO PREPARE 60ml

CLINDAMYCIN 150mg CAPSULES: 8 CAPS (1200mg)

PROPYLENE GLYCOL: 6ml
70% ISOPROPYL ALCOHOL, QS: 60ml

TO PREPARE 90ml

CLINDAMYCIN 150mg CAPSULES: 12 CAPS (1800mg)

PROPYLENE GLYCOL: 9ml
70% ISOPROPYL ALCOHOL, QS: 90ml

CLINDAMYCIN CAPSULES MUST BE USED HERE, EVEN THOUGH

THE FINISHED PRODUCT APPEARS POOR. THE INJECTABLE
CLINDAMYCIN CANNOT BE SUBSTITUTED.

EXPIRES IN 3 MONTHS

DO NOT FILTER
SHAKE WELL BEFORE USING
 ANHALT'S SHAVING CREAM

USED FOR RASHES ON NECK, ETC. CAUSED FROM SHAVING.

MENTHOL: 0.08gm (80mg)

HYDROCORTISONE POWDER 0.25gm (25g CORTATE 1%)
GLAXAL BASE QS (OR DERMABASE) 100gm
(75g SURFABASE OR SURFABASE)

HYDROCORTISONE CREAM CAN BE USED IN PLACE OF

HYDROCORTISONE POWDER.

APPLY THINLY TO BEARDED AREA OF NECK AFTER SHAVING.

EAU d'ALIBOUR

COPPER SULFATE: 1gm

ZINC SULFATE: 1.5gm
CONCENTRATED CAMPHOR WATER: 2.5ml
DISTILLED WATER, QS: 100ml

INSTRUCTIONS TO PATIENT: DILUTE 10ml TO 2000ml WITH

WATER.

CONCENTRATED CAMPHOR WATER

CAMPHOR: 4gm
ALCOHOL 90%: 60ml
DISTILLED WATER, QS: 100ml

OR

CAMPHOR SPIRIT: 10ml

ALCOHOL 99%: 4.5ml
DISTILLED WATER, QS 25ml
 CAMPHOR SPIRIT

CAMPHOR 10% IN ALCOHOL 90%

POISON IVY CREAM

MENTHOL: 0.25gm
CAMPHOR: 0.25gm
BETAMETHASONE 0.1% CREAM: 60gm
SURFABASE, QS: 200gm

HYDROCORTISONE 0.5% IN UNIBASE/SURFABASE

TO MAKE 100g / 200g

HYDROCORTISONE POWDER: 0.5g / 1g

MINERAL OIL (LIQUID PETROLATUM): 10ml / 10ml
UNIBASE / SURFABASE, QS: 100g / 200g

APPLY SPARINGLY AS DIRECTED-

DUPONAL SHAMPOO

SODIUM LAURYL SULFATE 10% 46gm

L.C.D. (COAL TAR SOLUTION 10%: 46ml
WATER, QS: 480ml

HEAT THE WATER, ADD THE SODIUM LAURYL SULPHATE.

AFTER THE SOLUTION IS COMPLETED, ADD THE L.C.D.

DUPANOL (SODIUM LAURYL SULFATE)

SODIUM LAURYL SULFATE: 500gm

COAL TAR SOLUTION: 230ml
WATER, QS 5 LITERS
 LAMONTAGNE CREAM

MENTHOL: 300mg
CAMPHOR: 300mg
EUCERIN: 45gm
DERMABASE: 45gm
BETAMETHASONE CREAM 0.1% 30gm

DUOFILM

16% LACTIC ACID 35ml

16% SALICYLIC ACID 35gm
COLLODION FLEXIBLE 200ml

4 - 5 DROPS DAILY TO WART, ALLOWING TO DRY.

COVER LOOSELY WITH BANDAGE.

USE ETHER TO RECONSTITUTE WHEN GETTING THICK.

CHLORHEXIDINE MOUTH RINSE

CETYLPYRIDINIUM RINSE (CEPECOL) 750ml

CHLORHEXIDINE GLUCONATE 4% (HIBITANE) 25ml
WATER, QS, AD 1000ml

RINSE WITH WATER BEFORE USE.

RINSE WITH 1 TEASPOONFUL FOR ONE FULL MINUTE.
SPIT OUT.
NO EATING OR DRINKING FOR 30 MINUTES AFTERWARDS.

EXPIRES IN 6 MONTHS.

HERPES SOLUTION

MENTHOL ¼% 1.125gm
CAMPHOR 3% 13.5gm
ISOPROPYL ALCOHOL 315ml
WATER, QS 450ml
 BERGER'S SOLUTION

MENTHOL 0.25% 1.25gm

RESORCINOL 2% 10gm
BENZOCAINE 2% 10gm
ZINC OXIDE 40gm
TALC 40gm
CALAMINE 40gm
GLYCERINE aa 20gm 40ml
WATER 120ml
ISOPROPYL ALCOHOL 200ml

DISOLVE MENTHOL IN ALCOHOL.

DISOLVE BENZOCAINE IN ALCOHOL.
DISOLVE RESORCINOL IN WATER.
ZINC IN GLYCERIN.

ACTIVATED CHARCOAL

50mg ACTIVATED CHARCOAL

ADD 400 ml OF WATER AS FOLLOWS:

200ml, SHAKE WELL THEN ADD BALANCE.

ADMINISTER DESIRED VOLUME TO PATIENT.

POTASSIUM PERMANGANATE SOLUTION

1:50,000 (0.02%)

1 5 GARIN TABLET IN 1500ml WATER.

ATHLETES FOOT

MENTHOL 0.06g .072g

HYDROCORTISONE 1% CREAM 25g
MICATIN CREAM 25g

APPLY THREE TIMES DAILY.

 PODOPHYLLUM RESIN BPC.

USE AS WART REMOVER.

PODOPHYLLUM RESIN 3.75g

QS TO 15ml WITH FRIAR'S BALSAM.
DISPENSE IN 15ml DROPPER BOTTLE.

PODOPHYLLUM RESIN 7.50g

QS TO 30ml WITH FRIAR'S BALSAM.
DISPENSE IN 30ml DROPPER BOTTLE.

USING COTTON APPLICATOR, APPLY CAREFULLY TO LESION.

ALLOW TO DRY BEFORE ADDING THE NEXT APPLICATION.
IT SHOULD BE ALLOWED TO DRY BEFORE PT LEAVES THE
OFFICE.

THE INITIAL APPLICATION SHOULD BE ALLOWED TO REMAIN IN

PLACE FOR 1 HOUR THEN WASHED OFF. IF THE INITIAL
APPLICATION IS NOT UNUSUALLY INFLAMMATORY OR PAINFUL,
THE NEXT APPLICATION MAY BE LEFT ON FOR 4 TO 6 HOURS
BEFORE BEING WASHED OFF.

REMOVE WITH SOAP AND WATER.

REAPPLICATION CAN BE CARRIED OUT AT WEEKLY

INTERVALS, IF NECESSARY.
 SODIUM THIOSULFATE SOLUTION

NEUTRALIZES WATER CHLORINE IONS.

USE 2ml OF 10% SOLUTION IN 1 LITER OF BATHWATER.
100g SODIUM THIOSULFATE ANHYDROUS QS TO 1 LITER WITH STERILE
WATER.

COCAINE 5% IN EPINEPHERINE 1:10,000

USE 500mg COCAINE POWDER IN 10ml OF EPINEPHERINE 1:10,000 INJECTION.

USE IN NOSE AS DIRECTED.
EXPIRES IN 1 YEAR.

BETAMETHASONE VALERATE CREAM USP 0.05%

BETADERM 0.1% CREAM X 250g

SURFABASE 250g
EXPIRES 6 MONTHS AFTER MANUFACTURE.

BORIC ACID SOLUTION 2.2%

USE 2.2g OF BORIC ACID QS AD DISTILLED WATER 100ml.

Arteries
Arteries

Arteries
Veins
Veins

Dermatomes
Nerves of Upper Extremities
Nerves of lower extremities

Referred Pain