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🧪 MASTER GUIDE TO POISONING - With Mnemonics

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PART 1: APPROACH TO THE POISONED PATIENT

Initial Assessment - Mnemonic: "ABCDE TOXIN"

• A - Airway (protect, intubate if needed)
• B - Breathing (O2, ventilate)
• C - Circulation (IV access, fluids, monitor)
• D - Disability/CNS (GCS, pupils, seizures)
• E - Exposure/Eliminate (decontaminate, antidotes)
• T - Toxidrome recognition
• O - Obtain history
• X - eXtra labs (glucose, electrolytes, LFTs, RFTs, TFTs)
• I - Investigations (ECG, imaging, drug levels)
• N - Neutralize / Notify poison control

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PART 2: TOXIDROMES (Toxic Syndromes)

2.1 CHOLINERGIC Toxidrome (Organophosphates, Carbamates)

• M - Muscle weakness/fasciculations
• T - Tachycardia (nicotinic can override bradycardia)
• W - Weakness (paralysis)
• T - Tremors
• F - Flushing

• M - Mydriasis (nicotinic), Muscle fasciculations
• A - Agitation
• T - Tachycardia, Tremors
• C - Cramps
• H - Hypertension

1. Atropine - Competitive antagonist at muscarinic receptors (end point: drying of secretions, not pupil dilation). Initial: 1.2-3 mg IV, doubled every 5 min. Hundreds of mg may be needed.
2. Pralidoxime (2-PAM) - Reactivates cholinesterase BEFORE aging occurs. Must be given early.
3. Benzodiazepines - For seizures

• S - Soman (fastest aging - minutes)
• E - Ethyl Sarin
• P - Parathion (hours to days)
• I - Intermediate
• A - Aging irreversible = 2-PAM won't work

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2.2 ANTICHOLINERGIC Toxidrome

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2.3 SYMPATHOMIMETIC (Adrenergic) Toxidrome

• F - Fever (hyperthermia)
• A - Agitation, Anxiety
• S - Sweating (diaphoresis - key difference from anticholinergic)
• T - Tachycardia, Tremors
• H - Hypertension
• H - Hyperreflexia
• H - Hyperthermia

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2.4 OPIOID Toxidrome

• P - Pinpoint pupils (miosis)
• I - Impaired breathing (respiratory depression)
• N - No consciousness (CNS depression/coma)

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2.5 SEDATIVE-HYPNOTIC Toxidrome

• CNS depression, slurred speech
• Respiratory depression
• Ataxia, confusion, amnesia
• Normal pupils (unlike opioids - important distinction)

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2.6 SEROTONIN Syndrome

• C - Clonus (inducible/spontaneous/ocular) - KEY feature
• L - Long hyperthermia (fever)
• A - Agitation
• M - Myoclonus, hyperreflexia
• P - Pressured speech (autonomic instability)

1. Spontaneous clonus
2. Inducible clonus + agitation OR diaphoresis
3. Ocular clonus + agitation OR diaphoresis
4. Tremor + hyperreflexia
5. Hypertonia + temperature >38°C + ocular or inducible clonus

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2.7 Toxidrome Comparison Table

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PART 3: SPECIFIC POISONS & ANTIDOTES

Mnemonic for Key Antidotes: "N-ACETYL FACTS"

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PART 4: INDIVIDUAL POISON PROFILES

4.1 PARACETAMOL (Acetaminophen) Poisoning

• Therapeutic adult: 500-1000 mg/dose (max 4 g/day)
• Toxic: ≥150 mg/kg (single ingestion)
• Lethal: >350 mg/kg

• pH < 7.3 (after resuscitation), OR
• ALL three: PT >100s + Creatinine >300 µmol/L + Grade III-IV encephalopathy

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4.2 SALICYLATE (Aspirin) Poisoning

• Sodium salicylate / Aspirin: 15-20 g
• Methyl salicylate (oil of wintergreen): 5-15 mL

• Early: Respiratory Alkalosis (hyperventilation from direct brainstem stimulation)
• Late: Metabolic Acidosis (AGMA from lactic acid, ketones)
• Classic picture in adults: Mixed respiratory alkalosis + metabolic acidosis
• Children: metabolic acidosis predominates

• Urinary alkalinization with IV sodium bicarbonate (ion trapping - prevents CNS entry)
• Hemodialysis for severe cases
• No specific antidote

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4.3 ORGANOPHOSPHATE / CARBAMATE Poisoning

• Organophosphates: IRREVERSIBLE cholinesterase inhibition (aging occurs)
• Carbamates: REVERSIBLE inhibition (no aging, 2-PAM generally not needed)

1. Decontamination (remove clothes, copious water wash - protect healthcare workers)
2. Atropine: 1.2-3 mg IV, double every 5 min - end point = dry chest/secretions
3. Pralidoxime: Must be given BEFORE aging - reactivates enzyme
4. Benzodiazepines for seizures
5. Succinylcholine AVOIDED (metabolized by plasma cholinesterase → prolonged paralysis)

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4.4 CYANIDE Poisoning

1. Hydroxocobalamin (preferred) - cobalt binds cyanide; turns urine red
2. Amyl nitrite (inhale) → Sodium nitrite (IV) → create methemoglobin which binds cyanide
3. Sodium thiosulfate - converts cyanide to thiocyanate (renally excreted)
4. HBO for combined CO+cyanide poisoning

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4.5 CARBON MONOXIDE (CO) Poisoning

• 100% O2 via non-rebreather mask (reduces CO half-life from 5h → 1h)
• Hyperbaric O2: 2.5-3 ATA (reduces half-life to 20-30 min) - indicated for LOC, neurologic symptoms, COHb >25%, pregnancy

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4.6 METHANOL & ETHYLENE GLYCOL Poisoning

• Methanol → Formaldehyde → Formic acid (retinal/optic nerve damage → blindness)
• Ethylene glycol → Glycolic acid → Oxalic acid → calcium oxalate crystals (kidney)

• Methanol = BLINDNESS (optic nerve)
• Ethylene glycol = kidney STONES (oxalate crystals)

• Fomepizole (4-MP): Competitive inhibitor of ADH - preferred antidote
• Ethanol: Alternative (competes for ADH - but harder to titrate)
• Hemodialysis: Removes toxic metabolites
• Bicarb for acidosis

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4.7 TRICYCLIC ANTIDEPRESSANT (TCA) Poisoning

• CNS depression (sedation, seizures)
• Cardiac toxicity (wide QRS, VT, VF)
• Cholinergic blockade (anticholinergic features)

• QRS >100ms = seizure risk
• QRS >160ms = VT risk
• Terminal R wave in aVR >3mm (most specific for TCA toxicity)
• Brugada pattern (V1-V3)

• Sodium bicarbonate IV: Narrows QRS, treats arrhythmias (by raising pH and increasing Na+)
• Avoid physostigmine
• Benzodiazepines for seizures
• Lipid emulsion therapy for refractory cases

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4.8 IRON Poisoning

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4.9 HEAVY METAL POISONING

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4.10 DIGOXIN Poisoning

• D - Digitalis effect on ECG (scooped ST "Salvador Dali" sagging)
• I - Increased vagal tone (bradycardia, AV block)
• G - GI symptoms (N/V, anorexia)
• O - Objects appear yellow/green (xanthopsia)
• X - Xtra potassium worsens toxicity (hypokalemia potentiates)

• Avoid cardioversion (may cause refractory VF)
• Treat hyperkalemia carefully (NOT calcium - may worsen)

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4.11 BETA-BLOCKER & CALCIUM CHANNEL BLOCKER Poisoning

• Benzodiazepines (if seizures)
• Resuscitation fluids
• Atropine (for bradycardia)
• Vasopressors (norepinephrine)
• Ampicillin... no - ACLS/glucagon
• D - Dextrose (for insulin-euglycemia)

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PART 5: DECONTAMINATION PRINCIPLES

Mnemonic: "GET SAFE"

• G - Gastric lavage (within 1h of large ingestion, airway protected)
• E - External decontamination (skin/eye exposure)
• T - Triggered emesis - AVOID (ipecac no longer recommended)
• S - Single-dose Activated Charcoal (most useful, within 1-2h)
• A - Alkalinize urine (salicylates, phenobarbital - ionizes drug in urine)
• F - Fluid management
• E - Enhanced elimination (hemodialysis, hemoperfusion, charcoal repeat doses)

Activated Charcoal

• Works by adsorption - most drugs EXCEPT:
• Mnemonic: "CHASM" = NOT adsorbed by charcoal
  • C - Caustics (acids/alkalis)
  • H - Heavy metals (iron, lithium, lead)
  • A - Alcohols (methanol, ethanol, ethylene glycol)
  • S - Solvents
  • M - Minerals (electrolytes, K+)

Multi-Dose Activated Charcoal (MDAC)

• Mnemonic: "CAPS D"
  • C - Carbamazepine
  • A - Amitriptyline/dapsone
  • P - Phenobarbital/phenytoin
  • S - Salicylates/theophylline
  • D - Digoxin

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PART 6: ENHANCED ELIMINATION

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PART 7: COMMON ANTIDOTES - MASTER TABLE

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PART 8: SPECIAL POISONING TOPICS

8.1 Snake Bite Management - Mnemonic: "LMNO"

• L - Local care (immobilize, keep at heart level)
• M - Monitor vitals, coagulation, urine
• N - No tourniquet, No incision, No mouth suction
• O - Offer antivenom if systemic features present

8.2 Food Poisoning - Onset Time Clues

8.3 Botulinum Toxin

• Diplopia
• Dysarthria
• Dysphagia
• Descending paralysis

8.4 Caustic Poisoning

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PART 9: FORENSIC TOXICOLOGY ESSENTIALS

Types of Poisons (Medicolegal)

• C - Corrosives (acids, alkalis)
• O - Organic (plant alkaloids: aconite, digitalis, oleander)
• P - Putrefactive/Gaseous (CO, HCN, H2S)
• S - Systemic (metals: As, Pb, Hg)
• M - Medicinal overdose
• I - Insecticides/Agricultural
• P - Psychoactive/Neurological

Postmortem Clues to Poison Identity

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PART 10: QUICK REFERENCE - MASTER MNEMONIC MAP

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⚡ QUICK-REFERENCE GUIDE: ANTIDOTE DOSING, ADMINISTRATION PROTOCOLS & CLINICAL CASES

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SECTION 1: MASTER ANTIDOTE DOSING TABLE

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1. N-ACETYLCYSTEINE (NAC) - Paracetamol Poisoning

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2. NALOXONE - Opioid Poisoning

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3. ATROPINE - Organophosphate / Carbamate Poisoning

4. PRALIDOXIME (2-PAM) - Organophosphate Poisoning

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5. HYDROXOCOBALAMIN - Cyanide Poisoning

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6. FOMEPIZOLE (4-Methylpyrazole) - Methanol / Ethylene Glycol

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7. DIGOXIN-SPECIFIC FAB (Digibind / DigiFab) - Digoxin Toxicity

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8. SODIUM BICARBONATE - Tricyclic Antidepressant (TCA) Poisoning

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9. DEFEROXAMINE - Iron Poisoning

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10. METHYLENE BLUE - Methemoglobinemia

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11. PYRIDOXINE (Vitamin B6) - Isoniazid (INH) Poisoning

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12. FLUMAZENIL - Benzodiazepine Poisoning

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13. GLUCAGON - Beta-Blocker Poisoning

14. HIGH-DOSE INSULIN (HDI) + Euglycemia Therapy

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SECTION 2: CLINICAL CASES WITH FULL MANAGEMENT

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CASE 1: PARACETAMOL (Acetaminophen) Overdose

A 24-year-old woman presents 5 hours after taking "a whole bottle of Tylenol" (approximately 15 g) after an argument. She appears well with mild nausea. Vitals: BP 118/76, HR 88, RR 16, Temp 37.1°C. Labs: Serum acetaminophen level = 280 µg/mL at 5 hours post-ingestion. LFTs normal. INR 1.0.

1. Plot on Rumack-Matthew nomogram - 280 µg/mL at 5h = above treatment line → NAC indicated
2. IV NAC immediately:
   • Bag 1: 150 mg/kg (9 g for 60 kg patient) in 200 mL D5W over 60 min
   • Bag 2: 50 mg/kg in 500 mL D5W over 4 hours
   • Bag 3: 100 mg/kg in 1000 mL D5W over 16 hours
3. If anaphylactoid reaction (flushing, urticaria) during Bag 1: Stop infusion → diphenhydramine 50 mg IV → restart at slower rate
4. Repeat LFTs, INR, creatinine at 24h
5. Psychiatric evaluation before discharge
6. Discharge criteria: LFTs normal, INR <2, NAC course complete, psychiatry clearance

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CASE 2: ORGANOPHOSPHATE Poisoning

A 45-year-old farmer is brought in by family - found unconscious in his field. On exam: miosis, excessive salivation dripping from his mouth, wheezing, incontinence of urine and stool, HR 48, BP 80/50. Clothes smell of pesticide. Fasciculations noted in arms.

1. Decontaminate FIRST - Remove all clothing (bag in biohazard), copious soap + water wash (staff use nitrile gloves - NOT latex)
2. Airway - 100% O2, suction secretions; intubate early (succinylcholine AVOIDED - use rocuronium instead)
3. Atropine (IMMEDIATELY):
   • Start: 3 mg IV
   • Double every 5 min → 6 mg → 12 mg → 24 mg...
   • Target: Chest clear on auscultation (may need 50-100+ mg)
   • This patient may need 200+ mg if massive ingestion
4. Pralidoxime 2-PAM: 2 g IV over 15-30 min → 500 mg/h infusion (give ASAP - before aging)
5. Benzodiazepines (if seizures): Diazepam 5-10 mg IV
6. Fluids for hypotension
7. Monitor: Cholinesterase levels, ECG, LFTs

• Tachycardia is NOT a contraindication to atropine (reflects bronchospasm/hypoxia)
• Pupil dilation is NOT the end point - dried secretions are
• Do NOT use succinylcholine for intubation

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CASE 3: OPIOID Overdose

A 32-year-old man found unresponsive in a public bathroom. Empty syringe nearby. RR 4/min, GCS 3, pupils pinpoint bilaterally, cyanotic. BP 90/60, HR 52.

1. Jaw thrust, BVM ventilation with 100% O2 immediately
2. Naloxone 0.4 mg IV - (Start low if opioid dependence suspected - precipitates withdrawal)
   • Response in 2 min → if no response → 0.4 mg q2-3 min up to 10 mg
   • This patient responds at 0.8 mg total (RR improves to 14, GCS improves)
3. Caution: Effect wears off in 30-90 min - opioid will still be present
4. Naloxone infusion: "Wake-up dose" was 0.8 mg → infusion = (2/3 × 0.8 mg) = 0.53 mg/h IV
5. Observe minimum 4-6 hours after last naloxone dose (8h for long-acting opioids)
6. Admit to monitored unit with infusion running
7. Pulse oximetry and serial neuro checks

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CASE 4: CYANIDE Poisoning (Fire Victim)

A 38-year-old firefighter rescued from a burning warehouse (synthetic materials). GCS 8, BP 80/50, HR 130, RR 28, O2 sat 88% on room air. Lactate = 14 mmol/L. COHb = 15%.

1. 100% O2 via non-rebreather mask (treats both CO and CN poisoning)
2. Hydroxocobalamin 5 g IV over 15 minutes (preferred - safe with elevated COHb, unlike sodium nitrite)
3. Repeat 5 g if no hemodynamic improvement after first dose (max 10 g)
4. Sodium thiosulfate 12.5 g IV if available (adjunct - accelerates detox)
5. Aggressive fluid resuscitation for shock
6. Vasopressors (norepinephrine) if refractory hypotension
7. Consider hyperbaric O2 if dual CO+CN and inadequate response to antidotes
8. Do NOT give sodium nitrite when CO poisoning coexists (worsens hypoxia)

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CASE 5: METHANOL Poisoning

A 55-year-old homeless man presents with sudden severe visual blurring "like looking through a fog," and abdominal pain 12 hours after drinking from an unlabeled bottle. Visual acuity severely reduced. ABG: pH 7.12, HCO3 8 mEq/L. Anion gap = 28. Osmolar gap = 35.

1. Secure IV access; ABG + electrolytes + osmolar gap + methanol level
2. Fomepizole: 15 mg/kg IV over 30 min (IMMEDIATELY - do not wait for methanol level)
3. Sodium bicarbonate 1-2 mEq/kg IV (temporize severe acidosis - pH 7.12 is life-threatening)
4. Folate/Leucovorin 50 mg IV q4-6h (promotes formic acid metabolism → CO2 + H2O)
5. Hemodialysis - URGENT in this patient (visual deficits = end-organ damage; pH ≤7.15; high levels):
   • Continue fomepizole every 4 hours DURING hemodialysis
   • HD removes methanol AND formic acid
6. Monitor methanol level - stop fomepizole when <20 mg/dL + no acidosis

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CASE 6: TRICYCLIC ANTIDEPRESSANT (TCA) Overdose

A 19-year-old with depression took "all her amitriptyline pills" 2 hours ago. Initially drowsy, now GCS 7, HR 145, BP 80/50. ECG: QRS = 148 ms, right axis deviation, prominent R in aVR. Seizing on arrival.

1. Airway first - intubate (GCS 7 + seizures); hyperventilate to pH 7.50-7.55 (this itself narrows QRS via alkalosis)
2. Benzodiazepines for seizures: Lorazepam 2-4 mg IV
3. Sodium bicarbonate - IMMEDIATELY for QRS >100 ms:
   • 1-2 mEq/kg IV bolus (50-100 mL of 8.4%)
   • Repeat until QRS narrows to <100 ms
   • Maintain pH 7.45-7.55 with infusion
4. IV fluids (1-2 L NS) for hypotension; norepinephrine if refractory
5. Monitor ECG continuously - watch for QRS widening, VT
6. If refractory VT/arrest: 20% Intralipid (Lipid Emulsion) 1.5 mL/kg IV bolus
7. Avoid: Flumazenil (can precipitate seizures), phenytoin (may worsen cardiac toxicity), physostigmine

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CASE 7: SALICYLATE (Aspirin) Poisoning

A 65-year-old man presents confused and tachypneic after reportedly ingesting "a large amount of aspirin." Vitals: Temp 38.8°C, HR 118, RR 32. ABG: pH 7.48, pCO2 20 (low), HCO3 14 (low). Serum salicylate = 520 mg/L. Tinnitus reported by family.

1. IV access, continuous monitoring
2. Activated charcoal 50-100 g PO/NG (aspirin forms concretions in stomach - charcoal helps)
3. Urinary alkalinization (key treatment):
   • 3 ampoules (150 mEq) NaHCO3 in 1L D5W + 40 mEq KCl
   • Run at 200-250 mL/h
   • Target: Urine pH ≥7.5-8.0 (ionizes salicylate in urine → ion trapping → enhanced excretion)
   • MUST replace potassium - hypokalemia prevents alkalinization
4. Forced fluids with bicarb infusion (correct dehydration)
5. Hemodialysis indications: Salicylate >700 mg/L, AMS, pulmonary edema, refractory acidosis, renal failure
6. Do NOT intubate unnecessarily - loss of compensatory hyperventilation (respiratory alkalosis) can rapidly worsen acidosis

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CASE 8: DIGOXIN Toxicity

A 78-year-old woman on digoxin 0.25 mg/day for AF presents with vomiting, yellow-tinged vision, and palpitations. ECG: bidirectional ventricular tachycardia, HR 42, complete heart block. Digoxin level = 4.8 ng/mL, K+ = 6.1 mEq/L, Creatinine = 2.4 mg/dL.

1. IV access; NPO; continuous telemetry
2. Digibind dose calculation:
   • Vials = (4.8 ng/mL × 78 kg) ÷ 100 = 3.7 vials → round up to 4-6 vials (chronic toxicity: use 6 vials empirically)
3. Administer Digibind IV over 30 min (bolus if cardiac arrest)
4. Hyperkalemia management:
   • Sodium bicarbonate (K+ redistribution)
   • Calcium resonium/kayexalate orally
   • Do NOT give calcium chloride/gluconate (classically taught as risk of "stone heart" - ventricular fibrillation in hypercalcemia setting)
5. Pacing (external/transvenous) for complete heart block unresponsive to Fab
6. After Fab: Total serum digoxin level rises (now measures bound Fab-digoxin) - ignore levels
7. Monitor potassium carefully (can fall after Fab given)

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CASE 9: BETA-BLOCKER Overdose

A 50-year-old man with hypertension takes all his metoprolol (approximately 2000 mg). He arrives drowsy, BP 70/40, HR 32, blood glucose 48 mg/dL (hypoglycemia from beta blockade).

1. Dextrose 50% 50 mL IV for hypoglycemia (glucagon alone may cause vomiting without glycogen stores)
2. Atropine 1 mg IV (often ineffective in beta-blocker OD but trial warranted)
3. Glucagon 5 mg IV bolus over 1-2 min; then 3-5 mg/h infusion
   • Premedicate with ondansetron (glucagon causes emesis)
4. Calcium chloride 1 g (10 mL of 10%) IV over 5-10 min (adjunct)
5. If refractory (no improvement):
   • High-dose Insulin (HDI): 1 unit/kg regular insulin IV + 50 mL D50 bolus → insulin infusion 0.5-1 unit/kg/h + 10% dextrose
   • Monitor glucose q15 min + K+ q1h
6. Lipid Emulsion (Intralipid): 1.5 mL/kg 20% IV bolus for refractory arrest (lipid-soluble beta-blockers: propranolol, labetalol)
7. ECMO/mechanical support as last resort for refractory cardiogenic shock

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CASE 10: ISONIAZID (INH) Seizures

A 35-year-old TB patient presents with refractory generalized seizures after accidentally ingesting his entire month's supply of isoniazid. Three rounds of diazepam and lorazepam have failed. Persistent status epilepticus.

1. Airway, breathing, circulation - intubate if needed
2. Pyridoxine (Vitamin B6) IMMEDIATELY:
   • Unknown dose ingested → give 5 g IV (70 mg/kg in children) over 5-10 min
   • If amount known (e.g., 50 × 300 mg tablets = 15 g INH) → give 15 g pyridoxine gram-for-gram
3. Concurrent benzodiazepines (continue alongside pyridoxine)
4. Seizures typically stop within minutes of pyridoxine administration
5. Monitor glucose (INH inhibits gluconeogenesis → hypoglycemia)
6. Supportive care - LFTs (INH is hepatotoxic), monitor for lactic acidosis

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CASE 11: CARBON MONOXIDE Poisoning

A family of four is brought in from their home after their gas heater malfunctioned in winter. Father (40): headache, confusion, COHb 35%. Mother (38): syncope, COHb 28%. Two children (8 and 10 years): nausea/headache, COHb 18%. Mother is 16 weeks pregnant.

1. 100% O2 via tight-fitting non-rebreather mask immediately
2. Hyperbaric O2 (HBO) indicated:
   • COHb >25% + neurological symptoms
   • Reduces CO half-life: Room air 5h → 100% O2 = 60-90 min → HBO 2.5 ATA = 20-30 min
3. ECG (CO causes myocardial injury - troponin)
4. Neurological assessment - "delayed neurological sequelae" can occur weeks later

1. HBO therapy regardless of COHb level - fetus is more susceptible; fetal COHb clears more slowly
2. HBO for ALL pregnant patients with CO poisoning regardless of severity

1. 100% O2 via pediatric NRB mask
2. HBO threshold lower in children (more sensitive CNS)

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CASE 12: IRON Poisoning (Pediatric)

An 18-month-old (12 kg) is found with an empty children's chewable iron tablet bottle (50 tablets × 18 mg elemental iron = 900 mg). Currently vomiting blood and has bloody diarrhea 3 hours post-ingestion. BP 70/40 (shock). Serum iron = 620 µg/dL.

1. Resuscitate: 20 mL/kg NS IV bolus; repeat as needed
2. Deferoxamine immediately (serum iron >500 µg/dL + symptomatic shock):
   • 15 mg/kg/h IV (max 35 mg/kg/h)
   • = 15 × 12 kg = 180 mg/h for this child
3. Monitor urine - "vin rosé" (orange-pink) color confirms ferrioxamine excretion; continue until urine clears
4. Abdominal X-ray (iron tablets are radiopaque - confirm tablets present)
5. Activated charcoal NOT effective for iron
6. Gastric lavage within 1h if large ingestion still in stomach
7. Watch for Phase 2 "honeymoon" period (apparent improvement 6-12h) - do NOT discharge, Phase 3 cardiovascular collapse follows
8. LFTs, coagulation, glucose q4-6h

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SECTION 3: SPECIAL ANTIDOTE PROTOCOLS - QUICK REFERENCE CARD

┌─────────────────────────────────────────────────────────────────┐
│           CRITICAL ANTIDOTES - MEMORY CARD                      │
├────────────────┬────────────────────┬───────────────────────────┤
│ POISON         │ ANTIDOTE           │ KEY DOSE                  │
├────────────────┼────────────────────┼───────────────────────────┤
│ Paracetamol    │ NAC                │ 150 mg/kg IV load         │
│ Opioids        │ Naloxone           │ 0.4-2 mg IV; 2/3 rule    │
│ OP/Carbamate   │ Atropine + 2-PAM   │ Atropine: double q5min   │
│ Cyanide        │ Hydroxocobalamin   │ 5 g IV over 15 min        │
│ CO             │ 100% O2 / HBO      │ 2.5 ATA if neurological  │
│ Methanol/EG    │ Fomepizole         │ 15 mg/kg load; q12h      │
│ Digoxin        │ Digibind           │ Level × wt ÷ 100 = vials │
│ TCA            │ NaHCO3             │ 1-2 mEq/kg IV; pH 7.50   │
│ Iron           │ Deferoxamine       │ 15 mg/kg/h IV             │
│ Beta-blocker   │ Glucagon + HDI     │ 5 mg bolus; 1 u/kg ins   │
│ BZD            │ Flumazenil         │ 0.2 mg q1min up to 3 mg  │
│ INH            │ Pyridoxine B6      │ Gram for gram; 5 g if ?  │
│ MetHb          │ Methylene Blue     │ 1-2 mg/kg IV              │
│ Heavy metals   │ BAL / DMSA         │ BAL: 3-5 mg/kg IM q4h    │
│ Warfarin       │ Vit K + 4-factor   │ Vit K 10 mg IV slow      │
│ Heparin        │ Protamine          │ 1 mg per 100 units hep   │
│ Dabigatran     │ Idarucizumab       │ 5 g IV (2 × 2.5 g)       │
│ Rivaroxaban    │ Andexanet alfa     │ Weight/dose-based         │
│ Sulfonylurea   │ Octreotide         │ 50 µg SC/IV q6-12h        │
└────────────────┴────────────────────┴───────────────────────────┘

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SECTION 4: MONITORING PARAMETERS AFTER ANTIDOTE ADMINISTRATION

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💊 ICU DRUGS: MASTER DILUTIONS & ADMINISTRATION GUIDE WITH CLINICAL CASES

Standard ICU Dilution Convention: Most ICU infusions follow the "Rule of 6" or are expressed as mcg/kg/min or mcg/min. All rates given assume a 70 kg adult unless stated. Always use an infusion pump. Central line preferred for vasopressors and concentrated solutions.

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MODULE 1: VASOPRESSORS & INOTROPES

Standard Dilution Principle

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1.1 NOREPINEPHRINE (Levophed) - First-Line Vasopressor

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1.2 EPINEPHRINE (Adrenaline)

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1.3 DOPAMINE

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1.4 VASOPRESSIN (ADH)

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1.5 PHENYLEPHRINE

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1.6 DOBUTAMINE (Inotrope)

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1.7 MILRINONE (Phosphodiesterase-3 Inhibitor)

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Vasopressor Comparison Table (Goldman-Cecil Medicine)

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MODULE 2: SEDATION & ANALGESIA (SAT/SBT Protocol)

SCCM PADIS Guidelines 2018: Target lightest effective sedation (RASS -1 to 0 for most patients). Analgesia-first approach. Daily SAT (Spontaneous Awakening Trial) + SBT (Spontaneous Breathing Trial).

2.1 PROPOFOL

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2.2 MIDAZOLAM (Benzodiazepine)

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2.3 DEXMEDETOMIDINE (Precedex)

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2.4 KETAMINE (Dissociative Anesthetic / Analgesic)

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2.5 FENTANYL (ICU Analgesia - First Line)

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2.6 MORPHINE

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2.7 HYDROMORPHONE (Dilaudid)

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2.8 LORAZEPAM (Ativan) - Benzodiazepine

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MODULE 3: NEUROMUSCULAR BLOCKING AGENTS (NMBAs)

Indications in ICU: Ventilator dyssynchrony, ARDS (protective ventilation), raised ICP, tetanus, status epilepticus, during therapeutic hypothermia. Use alongside adequate sedation + analgesia ALWAYS. Monitor with TOF (Train of Four - target 1-2 twitches).

3.1 CISATRACURIUM (Nimbex) - Preferred ICU NMBA

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3.2 VECURONIUM

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3.3 ROCURONIUM (Zemuron)

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3.4 SUCCINYLCHOLINE

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MODULE 4: CARDIAC DRUGS IN ICU

4.1 AMIODARONE

---

4.2 ADENOSINE

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4.3 METOPROLOL (IV)

---

4.4 DILTIAZEM (IV)

---

4.5 NICARDIPINE (IV) - Hypertensive Emergency

---

4.6 LABETALOL (IV) - Hypertensive Emergency

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4.7 SODIUM NITROPRUSSIDE

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4.8 NITROGLYCERIN (GTN IV)

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MODULE 5: ANTICOAGULATION IN ICU

5.1 UNFRACTIONATED HEPARIN (UFH) - Weight-Based Protocol

---

5.2 ENOXAPARIN (Low Molecular Weight Heparin)

---

5.3 ARGATROBAN (Direct Thrombin Inhibitor) - HIT Management

---

MODULE 6: INSULIN INFUSION (Tight Glycemic Control)

---

MODULE 7: ELECTROLYTE REPLACEMENT INFUSIONS

7.1 POTASSIUM CHLORIDE (KCl)

---

7.2 MAGNESIUM SULFATE (MgSO4)

---

7.3 CALCIUM GLUCONATE / CALCIUM CHLORIDE

---

7.4 SODIUM BICARBONATE

---

7.5 PHOSPHATE REPLACEMENT

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MODULE 8: ANTIEPILEPTIC DRUGS (AEDs) IN ICU

8.1 PHENYTOIN / FOSPHENYTOIN

---

8.2 LEVETIRACETAM (Keppra)

---

8.3 VALPROATE (Sodium Valproate)

---

MODULE 9: STRESS ULCER PROPHYLAXIS & GI DRUGS

9.1 PANTOPRAZOLE / OMEPRAZOLE (IV)

---

9.2 METOCLOPRAMIDE

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MODULE 10: ANTIBIOTICS COMMON IN ICU (IV Dosing)

Note: Doses given for normal renal function (70 kg adult). Always adjust for renal/hepatic impairment and use PK/PD principles in ICU.

---

MODULE 11: SPECIAL ICU INFUSIONS

11.1 OCTREOTIDE - Variceal Bleeding

---

11.2 N-ACETYLCYSTEINE (NAC) - Paracetamol OD

---

11.3 TERLIPRESSIN - Hepatorenal Syndrome / Variceal Bleeding

---

11.4 DEXAMETHASONE (IV) - ICU Uses

---

MODULE 12: CLINICAL CASES - ICU DRUG MANAGEMENT

---

CASE 1: SEPTIC SHOCK - Vasopressor Escalation

A 62-year-old diabetic man admitted with community-acquired pneumonia (CURB-65 = 4). Despite 3L crystalloid, BP = 72/45 mmHg, MAP 54 mmHg, HR 126, SpO2 88%, RR 34, GCS 13. Lactate = 4.2 mmol/L. Temp 39.4°C. Intubated. Cultures drawn.

1. Intubation drugs:
   • Ketamine 100 mg (1.5 mg/kg) IV for induction (preserves hemodynamics)
   • Rocuronium 100 mg (1.5 mg/kg) IV for RSI
   • Start propofol infusion 5-10 mcg/kg/min + fentanyl 50 mcg/h
2. Vasopressor 1 - Norepinephrine (immediate start):
   • Dilution: 8 mg in 250 mL NS = 32 mcg/mL (concentrated - fluid restricted)
   • Start: 0.1 mcg/kg/min = [0.1 × 70 × 60] ÷ 32 = 13 mL/h
   • Titrate up by 0.05 mcg/kg/min every 5-10 min to MAP ≥65 mmHg
3. Escalation - Vasopressin added (NE at 0.25 mcg/kg/min):
   • Dilution: 40 units in 250 mL NS = 0.16 units/mL
   • Fixed dose: 0.03 units/min = 11 mL/h (do not titrate)
4. Antibiotics (within 1 hour):
   • Piperacillin-tazobactam 4.5 g IV q6h (extended 4h infusion) + Azithromycin 500 mg IV q24h
5. Stress ulcer prophylaxis: Pantoprazole 40 mg IV q24h
6. DVT prophylaxis: Enoxaparin 40 mg SC q24h (once bleeding risk assessed)
7. Glycemic control: Insulin infusion targeting glucose 140-180 mg/dL
8. Hydrocortisone (if NE >0.25 mcg/kg/min): 200 mg/day IV (50 mg q6h or 200 mg continuous)

---

CASE 2: ARDS - Sedation, Paralysis, Ventilator Management

A 45-year-old woman (70 kg) with influenza pneumonia, PaO2/FiO2 ratio = 80, bilateral infiltrates, no cardiac cause. Intubated. Severe ventilator dyssynchrony despite deep sedation. RASS -5 not achievable on propofol + fentanyl alone.

1. Sedation optimized:
   • Propofol: 30 mcg/kg/min = [30 × 70 × 60] ÷ 10,000 = 12.6 mL/h of 1% propofol
   • Fentanyl: 100 mcg/h = 10 mL/h (at 10 mcg/mL)
2. Neuromuscular blockade (NMBA - cisatracurium preferred):
   • Dilution: 200 mg in 200 mL NS = 1 mg/mL
   • Loading dose: 0.15 mg/kg = 10.5 mg IV push
   • Maintenance: 3 mcg/kg/min = [3 × 70 × 60] ÷ 1000 = 12.6 mL/h
   • Monitor TOF (Train of Four) - target 1-2 twitches
3. ARDS ventilation settings: TV 6 mL/kg IBW, PEEP 12-16 cmH2O, plateau <30 cmH2O, FiO2 0.8
4. Corticosteroids (severe ARDS):
   • Dexamethasone 6 mg IV q24h (RECOVERY protocol)
5. Prone positioning: 16h prone daily while NMBA running
6. Daily NMBA interruption assessment (like SAT): Check TOF - allow 4/4 before cognitive testing
7. DVT prophylaxis: Enoxaparin 40 mg SC q24h (unless using CRRT - switch to UFH)

---

CASE 3: CARDIOGENIC SHOCK - Inotrope + Vasopressor

A 68-year-old man post-anterior STEMI (door-to-balloon 90 min). BP 85/60, HR 105, cold clammy extremities, JVP elevated, bibasal crackles, SpO2 90%, cardiac output low on Swan-Ganz (CI 1.6 L/min/m2), PCWP 26 mmHg. Intubated for respiratory failure.

1. Inotrope (dobutamine):
   • Dilution: 500 mg in 250 mL NS = 2000 mcg/mL
   • Start: 5 mcg/kg/min = [5 × 70 × 60] ÷ 2000 = 10.5 mL/h
   • Titrate to CI >2.2 L/min/m2 and UO improvement
2. If BP still inadequate (MAP <65) - Add norepinephrine:
   • Dilution: 8 mg in 250 mL NS = 32 mcg/mL
   • Start: 0.05 mcg/kg/min → titrate
3. Furosemide (diuresis for pulmonary edema):
   • 40-80 mg IV bolus; or furosemide infusion 5-20 mg/h if refractory
   • Dilution: 250 mg in 250 mL NS = 1 mg/mL; 10 mg/h = 10 mL/h
4. Amiodarone (if ventricular arrhythmias develop):
   • 150 mg in 100 mL D5W over 10 min → then 900 mg in 500 mL D5W at 1 mg/min (33 mL/h) x 6h → 0.5 mg/min (16.7 mL/h) x 18h
5. Anticoagulation: Heparin 60 units/kg bolus → 12 units/kg/h infusion (ACS protocol)
6. Sedation (light - RASS -1 to 0):
   • Fentanyl 50-75 mcg/h + propofol 5-15 mcg/kg/min

---

CASE 4: HYPERTENSIVE EMERGENCY (Malignant Hypertension)

A 55-year-old man with known hypertension presents with BP 220/130 mmHg, severe headache, blurred vision, papilledema, creatinine acutely risen to 3.2 mg/dL. ECG: LVH. No stroke on CT head.

1. Nicardipine (first-line):
   • Dilution: 25 mg in 250 mL NS = 0.1 mg/mL
   • Start: 5 mg/h = 50 mL/h
   • Titrate by 2.5 mg/h every 5-15 min to target BP reduction
   • Target: Reduce MAP by ≤25% in first hour; then to 160/100 over 2-6h
2. Alternative: Labetalol
   • 20 mg IV over 2 min; repeat 40-80 mg q10 min (max 300 mg)
   • OR infusion: 200 mg in 200 mL NS = 1 mg/mL at 1-2 mg/min
3. If cerebral edema / hypertensive encephalopathy:
   • Mannitol 20%: 1 g/kg IV over 30 min
   • Elevate head of bed 30°
4. Avoid nifedipine sublingual (unpredictable rapid drop → stroke/MI)
5. Close BP monitoring: Arterial line; BP q5-15 min during titration

---

CASE 5: STATUS EPILEPTICUS - Stepwise ICU Protocol

A 30-year-old woman with known epilepsy, convulsing for 35 minutes without stopping (refractory status epilepticus). Now intubated. GCS 5 post-ictal.

• Lorazepam 4 mg IV over 2 min (or diazepam 10 mg IV)
• Repeat once after 5 min if still seizing

• Levetiracetam 60 mg/kg IV (max 4500 mg) over 10-15 min
• Dilution: 3000 mg in 100 mL NS, infuse over 10 min
• OR Fosphenytoin 20 mg PE/kg at max 150 mg PE/min
• OR Valproate 40 mg/kg IV over 10 min

• Propofol infusion: Start 1-2 mg/kg IV bolus → 5-10 mg/kg/h infusion (titrate to burst suppression on EEG)
• OR Midazolam: 0.2 mg/kg IV bolus → 0.05-0.4 mg/kg/h infusion
• OR Thiopental/pentobarbital (for super-refractory SE)

• Thiamine 100 mg IV (before any dextrose)
• Glucose 50% 50 mL IV (if hypoglycemia)
• Continuous EEG monitoring
• Correct precipitants (electrolytes, drug levels, infection)
• Levetiracetam 1500 mg IV q12h as maintenance

---

CASE 6: ICU AF with Rapid Ventricular Response

Post-operative day 1 after aortic valve replacement. Patient develops rapid AF at HR 148, BP 100/65, SpO2 94%. Echo shows preserved EF 55%. No pre-excitation.

1. Amiodarone (preferred in post-cardiac surgery):
   • Loading: 150 mg in 100 mL D5W over 10 min (15 mL/h rapid)
   • Maintenance: 900 mg in 500 mL D5W = 1.8 mg/mL
   • 1 mg/min × 6h = 33 mL/h → then 0.5 mg/min × 18h = 16.7 mL/h
2. If hemodynamically unstable (BP <90): Synchronized DC cardioversion 120-200J immediately
3. Electrolyte correction:
   • KCl: Target K+ >4.0 mEq/L (post-cardiac surgery); give IV KCl 20 mEq over 2h via central line
   • MgSO4: 2 g IV over 30 min (Mg+ >2.0 mEq/L)
4. Rate control (if cardioversion not planned, EF preserved):
   • Diltiazem: 0.25 mg/kg (15-20 mg) IV over 2 min → if rate >110: 0.35 mg/kg → then 5-15 mg/h infusion
5. Anticoagulation: Heparin infusion (therapeutic) if AF >48h; timing per surgical bleeding risk

---

CASE 7: DIABETIC KETOACIDOSIS (DKA) in ICU

A 22-year-old with Type 1 DM, vomiting for 2 days. Glucose 520 mg/dL, pH 7.05, HCO3 8 mEq/L, K+ 3.2 mEq/L, anion gap 32, urine ketones 4+, BP 90/60 (dehydrated), HR 128. Intubated for GCS 8.

1. IV Fluid resuscitation:
   • Normal saline 1L over first hour → 0.9% NS at 500 mL/h for 4h → switch to 0.45% NS with KCl when glucose <250
2. Potassium replacement BEFORE insulin:
   • K+ = 3.2 mEq/L → replace first: 40 mEq KCl in 1000 mL NS over 4h (central line)
   • Start insulin only when K+ ≥3.5 mEq/L
3. Insulin infusion:
   • Dilution: 100 units Regular insulin in 100 mL NS = 1 unit/mL
   • Start: 0.1 unit/kg/h = 7 units/h = 7 mL/h
   • When glucose <250: Switch to D5W + reduce insulin to 0.05 unit/kg/h; add dextrose to maintain glucose 150-200 mg/dL until anion gap closed
4. Potassium replacement ongoing:
   • Check K+ q1-2h; replace 10-40 mEq/h to keep K+ ≥3.5-5.0
5. Bicarbonate: Only if pH <6.9: 50 mEq NaHCO3 in 200 mL NS over 1h (avoid routinely - worsens hypokalemia)
6. Phosphate: Replace if PO4 <1.0 mg/dL (common in DKA)

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QUICK DRUG REFERENCE: DILUTION SUMMARY CARD

╔══════════════════╦═══════════════════════════╦════════════════════╗
║ DRUG             ║ STANDARD DILUTION         ║ CONCENTRATION      ║
╠══════════════════╬═══════════════════════════╬════════════════════╣
║ Norepinephrine   ║ 4 mg in 250 mL NS         ║ 16 mcg/mL          ║
║ Epinephrine      ║ 4 mg in 250 mL NS         ║ 16 mcg/mL          ║
║ Dopamine         ║ 400 mg in 250 mL NS       ║ 1600 mcg/mL        ║
║ Vasopressin      ║ 40 units in 250 mL NS     ║ 0.16 units/mL      ║
║ Phenylephrine    ║ 100 mg in 250 mL NS       ║ 400 mcg/mL         ║
║ Dobutamine       ║ 500 mg in 250 mL NS       ║ 2000 mcg/mL        ║
║ Milrinone        ║ 40 mg in 200 mL NS        ║ 200 mcg/mL         ║
╠══════════════════╬═══════════════════════════╬════════════════════╣
║ Propofol 1%      ║ Ready to use              ║ 10 mg/mL           ║
║ Midazolam        ║ 50 mg in 50 mL NS         ║ 1 mg/mL            ║
║ Dexmedetomidine  ║ 200 mcg in 48 mL NS       ║ 4 mcg/mL           ║
║ Ketamine         ║ 500 mg in 500 mL NS       ║ 1 mg/mL            ║
║ Fentanyl         ║ 1000 mcg in 100 mL NS     ║ 10 mcg/mL          ║
║ Morphine         ║ 50 mg in 50 mL NS         ║ 1 mg/mL            ║
║ Lorazepam        ║ 40 mg in 100 mL NS        ║ 0.4 mg/mL          ║
╠══════════════════╬═══════════════════════════╬════════════════════╣
║ Cisatracurium    ║ 200 mg in 200 mL NS       ║ 1 mg/mL            ║
║ Vecuronium       ║ 100 mg in 100 mL NS       ║ 1 mg/mL            ║
╠══════════════════╬═══════════════════════════╬════════════════════╣
║ Amiodarone       ║ 900 mg in 500 mL D5W      ║ 1.8 mg/mL          ║
║ Diltiazem        ║ 125 mg in 125 mL NS       ║ 1 mg/mL            ║
║ Nicardipine      ║ 25 mg in 250 mL NS        ║ 0.1 mg/mL          ║
║ Labetalol        ║ 200 mg in 200 mL NS       ║ 1 mg/mL            ║
║ Nitroprusside    ║ 50 mg in 250 mL D5W       ║ 200 mcg/mL         ║
║ GTN              ║ 50 mg in 250 mL D5W       ║ 200 mcg/mL         ║
╠══════════════════╬═══════════════════════════╬════════════════════╣
║ Heparin UFH      ║ 25,000 units in 250 mL NS ║ 100 units/mL       ║
║ Argatroban       ║ 250 mg in 250 mL NS       ║ 1 mg/mL            ║
║ Insulin (Regular)║ 100 units in 100 mL NS    ║ 1 unit/mL          ║
╠══════════════════╬═══════════════════════════╬════════════════════╣
║ MgSO4 (eclampsia)║ 4 g in 100 mL NS          ║ 40 mg/mL           ║
║ KCl              ║ 40 mEq in 1000 mL NS      ║ 40 mEq/L           ║
║ NaHCO3 8.4%      ║ Ready to use              ║ 1 mEq/mL           ║
╠══════════════════╬═══════════════════════════╬════════════════════╣
║ Octreotide       ║ 500 mcg in 50 mL NS       ║ 10 mcg/mL          ║
║ Pantoprazole     ║ 80 mg in 100 mL NS        ║ 0.8 mg/mL          ║
╚══════════════════╩═══════════════════════════╩════════════════════╝

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UNIVERSAL RATE CALCULATION FORMULA

┌─────────────────────────────────────────────────────────────┐
│         INFUSION RATE (mL/h) =                              │
│                                                             │
│   Dose (mcg/kg/min) × Weight (kg) × 60 min/h               │
│   ─────────────────────────────────────────────             │
│          Concentration (mcg/mL)                             │
│                                                             │
│   OR for non-weight-based drugs:                            │
│                                                             │
│   Dose (mg/h or mcg/min × 60) ÷ Concentration (mg/mL)      │
└─────────────────────────────────────────────────────────────┘

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CRITICAL SAFETY RULES IN ICU DRUG PREPARATION

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⚕️ POST-MORTEM EXAMINATION REPORT

Master Guide for Forensic Medical Officers — Medico-Legal Cases

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PART A: STANDARD FORMS & LEGAL FRAMEWORK

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FORM 1: REQUISITION / INQUEST ORDER (Police Form)

┌─────────────────────────────────────────────────────────────────────────┐
│           INQUEST PANCHNAMA / REQUISITION FOR POST-MORTEM               │
│                    (Under Sec. 174 / 176 Cr.P.C.)                       │
│                 [Now under BNSS 2023 - Sec. 194 / 195]                  │
├─────────────────────────────────────────────────────────────────────────┤
│ To,                                                                     │
│ The Medical Officer / Forensic Medicine Department,                     │
│ _________________________ Hospital / Medical College                    │
│                                                                         │
│ Sir,                                                                    │
│ You are hereby requested to conduct the Post-Mortem Examination of      │
│ the dead body described below and furnish a report regarding the        │
│ cause of death.                                                         │
│                                                                         │
│ CR No. / Station Diary No.: _______________________                     │
│ Under Section: _____________________ IPC / BNS                         │
│                                                                         │
│ DETAILS OF THE DECEASED:                                                │
│ Name: _______________________________ Age: _____ Sex: __________        │
│ Address: ___________________________________________________            │
│ Religion: __________________ Occupation: ___________________            │
│                                                                         │
│ CIRCUMSTANCES:                                                          │
│ Date & Time of Alleged Death: ______________________________            │
│ Date & Time Body Found: ____________________________________            │
│ Place of Death/Found: ______________________________________            │
│ Circumstances as Reported: _________________________________            │
│ ____________________________________________________________            │
│                                                                         │
│ Body identified by: ________________________ (Name & relation)          │
│                                                                         │
│ Seal of body: Intact / Broken                                           │
│ Labels: Present / Absent                                                │
│                                                                         │
│ Inquest conducted by:                                                   │
│ Name: _________________________ Designation: ___________________        │
│ Station: ________________ District: ___________________________         │
│                                                                         │
│ Date: __________________ Signature: ___________________________         │
└─────────────────────────────────────────────────────────────────────────┘

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FORM 2: STANDARD POST-MORTEM EXAMINATION REPORT

┌─────────────────────────────────────────────────────────────────────────┐
│              POST-MORTEM EXAMINATION REPORT                             │
│          (Medico-Legal Case - Government of India)                      │
├─────────────────────────────────────────────────────────────────────────┤
│ PM Report No.: _____________ Date: _____________ Time: _____________    │
│ Hospital/Institution: __________________________________________        │
│ Department of Forensic Medicine & Toxicology                            │
├─────────────────────────────────────────────────────────────────────────┤
│ SECTION I: IDENTIFICATION DATA                                          │
│                                                                         │
│ Name of Deceased: ___________________________ Age: ____ Sex: ______     │
│ Religion: _______________ Occupation: ____________________________      │
│ Address: _______________________________________________________        │
│ Name of Relative/Identifier: _______________________________            │
│ Relation: __________________                                            │
│                                                                         │
│ Requisition from: ______________ No.: _________ Date: _________         │
│ Police Station: ________________ District: ____________________         │
│ CR/FIR No.: _________________ Under Section: __________________         │
├─────────────────────────────────────────────────────────────────────────┤
│ SECTION II: BODY DETAILS ON ARRIVAL                                     │
│                                                                         │
│ Body received on: ____________ Time: ____________                       │
│ Examination started: _________ Time: ____________                       │
│ Examination completed: _______ Time: ____________                       │
│                                                                         │
│ Body wrapped in: ___________ Seals: Intact / Broken                     │
│ Labels: Present / Absent                                                │
│ Accompanied by: ___________________________________________              │
├─────────────────────────────────────────────────────────────────────────┤
│ SECTION III: EXTERNAL EXAMINATION                                       │
│                                                                         │
│ A. Build: Well-nourished / Average / Thin / Obese / Emaciated           │
│ B. Nutrition: Good / Moderate / Poor                                    │
│ C. Height: _______ cm  Weight: _______ kg                               │
│                                                                         │
│ POSTMORTEM CHANGES:                                                     │
│ 1. Postmortem Lividity (Livor Mortis):                                  │
│    Distribution: ________________________                               │
│    Color: _______________________________                               │
│    Fixed / Shifting: ____________________                               │
│    Estimated PMI: _______________________                               │
│                                                                         │
│ 2. Rigor Mortis:                                                        │
│    Present / Absent / Partially resolved                                │
│    Distribution: ________________________                               │
│    Estimated PMI: _______________________                               │
│                                                                         │
│ 3. Decomposition:                                                       │
│    Absent / Early / Advanced                                            │
│    Features: ____________________________                               │
│                                                                         │
│ EXTERNAL INJURIES (describe each with location, size, nature):          │
│ 1. ____________________________________________________________          │
│ 2. ____________________________________________________________          │
│ 3. ____________________________________________________________          │
│ (Attach injury diagram if needed)                                       │
│                                                                         │
│ EYES:                                                                   │
│    Cornea: Clear / Opaque  Conjunctiva: Pale / Congested / Petechiae    │
│    Pupils: Dilated / Constricted / Equal / Unequal                      │
│    Size R: _____ mm  L: _____ mm                                        │
│                                                                         │
│ FACE: Cyanosed / Pale / Congested / Normal                              │
│                                                                         │
│ MOUTH/LIPS:                                                             │
│    Color: ____________  Froth: Present / Absent                         │
│    Teeth: Complete / Missing _______ Bite marks: ___________            │
│    Tongue: Bitten / Not bitten  Protruding / Not protruding             │
│                                                                         │
│ NECK:                                                                   │
│    Ligature mark: Present / Absent                                      │
│    If present: Position / Direction / Width / Depth / Character         │
│    ___________________________________________________________           │
│                                                                         │
│ CHEST: Symmetrical / Asymmetrical                                       │
│                                                                         │
│ ABDOMEN: Distended / Normal / Scaphoid                                  │
│                                                                         │
│ GENITALIA: Normal / Abnormal ___________                                │
│ Evidence of sexual assault: Yes / No                                    │
│                                                                         │
│ LOWER LIMBS / UPPER LIMBS:                                              │
│    Venepuncture marks: ________                                         │
│    Other marks: _______________                                         │
│                                                                         │
│ CLOTHING:                                                               │
│    Description: ___________________________________________              │
│    Condition: Intact / Torn / Stained / Absent                          │
│    Staining: Blood / Mud / Soot / Others: ________________              │
├─────────────────────────────────────────────────────────────────────────┤
│ SECTION IV: INTERNAL EXAMINATION                                        │
│                                                                         │
│ SCALP: ____________________________________________________              │
│ SKULL: Fracture: Yes / No  Site: ___________________________            │
│ BRAIN:                                                                  │
│    Weight: _______ g  (Normal: 1200-1450 g)                             │
│    Cerebral edema: Present / Absent                                     │
│    Contusions: ____________  Lacerations: _________________             │
│    Epidural/Subdural/Subarachnoid hemorrhage: _______________           │
│    Petechiae: _______________                                           │
│    Gyri: Flattened / Normal  Herniations: ____________________          │
│                                                                         │
│ NECK DISSECTION:                                                        │
│    Hyoid bone: Intact / Fractured  Site: ___________________            │
│    Thyroid cartilage: Intact / Fractured                                │
│    Cricoid: Intact / Fractured                                          │
│    Larynx: Congested / Edematous / Normal                               │
│    Trachea: _______________________________________________              │
│    Carotid arteries: ______________________________________              │
│    Neck muscles: __________________________________________              │
│    Cervical vertebrae: ____________________________________              │
│    Spinal cord: ____________________________________________             │
│                                                                         │
│ CHEST CAVITY:                                                           │
│    Pleural cavity: Fluid: _____ mL (R) / _____ mL (L)                  │
│    Pneumothorax: Present / Absent                                       │
│    Ribs: Fractures at: _____________________________________             │
│    Sternum: _______________________________________________              │
│                                                                         │
│ HEART:                                                                  │
│    Weight: _______ g  (Normal: 250-350 g)                               │
│    Pericardium: Intact / Hemopericardium _____ mL                       │
│    Chambers: Dilated / Normal  Right / Left                             │
│    Coronary arteries: ______________________________________             │
│    Myocardium: Pale / Normal / Hemorrhagic                              │
│    Valves: Normal / Diseased: __________________________                │
│    Aorta: ___________________________________________________            │
│                                                                         │
│ LUNGS:                                                                  │
│    Weight: R: _______ g  L: _______ g  (Normal: ~400 g each)           │
│    Color: ____________  Consistency: _______________                    │
│    Crepitations: Present / Absent                                       │
│    Cut surface: ___________________________________________              │
│    Froth: Present / Absent  Blood-stained: Yes / No                     │
│    Petechiae (Tardieu spots): Present / Absent                          │
│    Pulmonary edema: Present / Absent                                    │
│    Consolidation: ________  Emphysema: ____________________             │
│                                                                         │
│ ABDOMEN:                                                                │
│    Peritoneum: _____________________________________________             │
│    Free fluid: _______ mL  Nature: _______________________              │
│    Bowel: ___________________________________________________            │
│                                                                         │
│ LIVER:                                                                  │
│    Weight: _______ g  (Normal: 1400-1600 g)                             │
│    Color/Texture: ___________________________________________            │
│    Congestion: ____________  Necrosis: ____________________              │
│                                                                         │
│ SPLEEN:                                                                 │
│    Weight: _______ g  (Normal: 150-200 g)                               │
│    Congestion: ____________                                             │
│                                                                         │
│ KIDNEYS: (each)                                                         │
│    Weight: R: _____ g  L: _____ g  (Normal: 120-160 g each)            │
│    Cortex: ___________________________________________________           │
│                                                                         │
│ STOMACH:                                                                │
│    Contents: ________________________________________________            │
│    Volume: ________ mL  Nature: ____________________________            │
│    Mucosa: Congested / Hemorrhagic / Normal                             │
│                                                                         │
│ SMALL INTESTINE / LARGE INTESTINE: ___________________________          │
│                                                                         │
│ URINARY BLADDER: ___________________________________________             │
│    Contents: _________ mL                                              │
│    Urine: Normal / Abnormal _______________                             │
│                                                                         │
│ UTERUS / OVARIES / TESTES (if applicable): ___________________          │
│                                                                         │
│ ADRENALS: ___________________________________________________            │
│                                                                         │
│ VERTEBRAL COLUMN / SPINAL CORD: ____________________________            │
├─────────────────────────────────────────────────────────────────────────┤
│ SECTION V: SAMPLES PRESERVED                                            │
│                                                                         │
│ For Chemical Analysis / Histopathology:                                 │
│ 1. Stomach + contents: Yes / No                                         │
│ 2. Small intestine (30 cm): Yes / No                                    │
│ 3. Liver (500 g): Yes / No                                              │
│ 4. Kidney (one whole): Yes / No                                         │
│ 5. Blood (50-100 mL in sealed container): Yes / No                      │
│ 6. Urine: Yes / No                                                      │
│ 7. Bile: Yes / No                                                       │
│ 8. Vitreous humor: Yes / No                                             │
│ 9. Brain tissue: Yes / No                                               │
│ 10. Lung tissue: Yes / No                                               │
│ 11. Fingernail clippings: Yes / No                                      │
│ 12. Hair (root included): Yes / No                                      │
│ 13. Bone (if chronic poisoning suspected): Yes / No                     │
│ 14. Swabs (if sexual assault): Yes / No                                 │
│ 15. Histopathology sections: Yes / No                                   │
│                                                                         │
│ Preserved in: Saturated NaCl solution / Rectified spirit / No           │
│ preservative (for alcohol analysis)                                     │
│                                                                         │
│ Sent to: FSL / Chemical Examiner on: ___________                        │
│ Reference No.: ______________________________________________            │
├─────────────────────────────────────────────────────────────────────────┤
│ SECTION VI: OPINION                                                     │
│                                                                         │
│ CAUSE OF DEATH:                                                         │
│                                                                         │
│ I (a): ______________________________________________________            │
│        (Immediate cause)                                                │
│                                                                         │
│ I (b): ______________________________________________________            │
│        (Antecedent cause)                                               │
│                                                                         │
│ II:    ______________________________________________________            │
│        (Contributing conditions)                                        │
│                                                                         │
│ Manner of Death: Natural / Accident / Suicide / Homicide /              │
│                  Undetermined                                           │
│                                                                         │
│ Estimated Time Since Death (PMI): ___________________                   │
│                                                                         │
│ Age as assessed: ___________________________________________             │
│                                                                         │
│ Any other opinion: _________________________________________             │
├─────────────────────────────────────────────────────────────────────────┤
│ SECTION VII: CERTIFICATION                                              │
│                                                                         │
│ Examined by:                                                            │
│                                                                         │
│ Name: _______________________________ Qualification: ___________        │
│ Designation: _______________________________________________             │
│ Department: ________________________________________________             │
│ Institution: _______________________________________________             │
│                                                                         │
│ Signature: _________________________                                    │
│                                                                         │
│ Witnessed by:                                                           │
│ 1. Name: _____________________ Designation: ________________            │
│ 2. Name: _____________________ Designation: ________________            │
│                                                                         │
│ Seal of Institution: ________________                                   │
│ Date: _______________________                                           │
└─────────────────────────────────────────────────────────────────────────┘

---

PART B: CAUSE-OF-DEATH SPECIFIC PM FINDINGS & COMPLETED REPORTS

---

REPORT 1: DEATH DUE TO HANGING (Suicidal)

┌─────────────────────────────────────────────────────────────────────────┐
│                   POST-MORTEM EXAMINATION REPORT                        │
│                       DEATH BY HANGING                                  │
├─────────────────────────────────────────────────────────────────────────┤
│ PM Report No.: 01/2026      Date: 09/07/2026    Time: 10:00 AM          │
│ Hospital: General Hospital, ________________                            │
│ Dept. of Forensic Medicine & Toxicology                                 │
├─────────────────────────────────────────────────────────────────────────┤
│ DECEASED: Ramesh Kumar, 35 years, Male                                  │
│ Occupation: Farmer  Address: Village _________, Dist. _________         │
│ Requisition: PI ____________, PS _____________, CR No. _______          │
│ Under Section: 194 BNSS (formerly 174 CrPC)                             │
│ Body received: 09/07/2026 at 08:00 AM                                   │
├─────────────────────────────────────────────────────────────────────────┤
│ EXTERNAL EXAMINATION:                                                   │
│                                                                         │
│ Build: Average.  Nutrition: Moderate.                                   │
│ Height: 165 cm.  Weight: 58 kg.                                         │
│                                                                         │
│ POSTMORTEM CHANGES:                                                     │
│ Livor Mortis: Present over lower extremities and distal parts of        │
│ forearms (consistent with erect or semi-erect suspension position).     │
│ Color: Bluish-purple. FIXED - consistent with PMI 8-12 hours.           │
│ Rigor Mortis: Present in all groups of muscles. Fully established.      │
│ PMI estimated: 8-12 hours prior to examination.                         │
│                                                                         │
│ FACE: Congested. Cyanosed.                                              │
│                                                                         │
│ EYES:                                                                   │
│ Conjunctivae: Congested bilaterally with petechial hemorrhages          │
│ (Tardieu spots). Cornea: Clear.                                         │
│ Pupils: Dilated, equal (5 mm each).                                     │
│                                                                         │
│ MOUTH: Lips cyanosed. Froth (fine, slightly blood-tinged) at            │
│ corners of mouth. Tongue: Protruding slightly beyond teeth. Tip          │
│ of tongue bluish. No bite mark.                                         │
│                                                                         │
│ NECK - LIGATURE MARK (KEY FINDING):                                     │
│ A well-defined, oblique, pale-yellowish/brownish parchment-like         │
│ ligature mark is present encircling the neck.                           │
│ Position: Lower third of neck, above larynx                             │
│ Direction: Oblique, runs upward toward point of suspension              │
│            (left mastoid region - consistent with knot position)        │
│ Width: Approximately 2.5 cm (consistent with rope used)                 │
│ Depth: Well-impressed groove, deeper on right side, less marked         │
│        on left (toward knot - inverted V pattern)                       │
│ Character: Parchment-like, dry, firm, yellowish-brown                  │
│ Extent: Incomplete - does not encircle neck posteriorly                 │
│         (interrupted at point of suspension - TYPICAL of hanging)       │
│ Abrasions: Present along inferior border of mark                        │
│                                                                         │
│ No other external injuries noted.                                       │
│ No defense injuries on hands/forearms.                                  │
│                                                                         │
│ INTERNAL EXAMINATION:                                                   │
│                                                                         │
│ SCALP: No contusion. SKULL: No fracture.                                │
│ BRAIN: Weight 1350 g. Congested. Petechial hemorrhages on surface.      │
│ Cerebral edema present. Gyri: Slightly flattened.                       │
│                                                                         │
│ NECK DISSECTION (done layer by layer from behind):                      │
│ Skin at ligature mark: Shows fibrous compression, dryness.              │
│ Subcutaneous tissue: Dry, compressed whitish band beneath mark.         │
│ Petechial hemorrhages around ligature mark in subcutaneous tissue.      │
│ Neck muscles: Above ligature mark - congested.                          │
│               Below ligature mark - relatively normal.                  │
│ Hyoid bone: INTACT (commonly intact in hanging vs strangulation).       │
│             (Note: Fracture in ~25% cases of hanging, esp. elderly)     │
│ Thyroid cartilage: INTACT. No fracture.                                 │
│ Cricoid cartilage: Intact.                                              │
│ Larynx: Congested mucosa.                                               │
│ Trachea: Congested. No foreign body.                                    │
│ Cervical vertebrae: C1-C7 intact. No fracture-dislocation.              │
│   (Note: Fracture-dislocation of C2 = judicial hanging/"hangman's       │
│   fracture" - NOT present in this case of incomplete suspension)        │
│ Carotid arteries: Intimal tears with sub-intimal hemorrhage             │
│                   (sign of ante-mortem suspension).                     │
│                                                                         │
│ PLEURA: No hemothorax. No pneumothorax.                                 │
│                                                                         │
│ HEART: Weight 290 g. Chambers: Right heart - dilated, engorged          │
│ with dark fluid blood. Left heart - relatively empty. Coronary          │
│ arteries: No significant stenosis. Myocardium: Pale, no infarction.     │
│                                                                         │
│ LUNGS: R: 490 g, L: 460 g. CONGESTED. Edematous. Subpleural            │
│ petechial hemorrhages (Tardieu spots) present on both surfaces.         │
│ Cut surface: Frothy blood-stained fluid oozes on compression.           │
│                                                                         │
│ STOMACH: Contains ~150 mL of partially digested food.                   │
│ Mucosa: Normal. No corrosion.                                           │
│                                                                         │
│ LIVER: Weight 1550 g. Congested. No necrosis.                           │
│ SPLEEN: Weight 180 g. Congested.                                        │
│ KIDNEYS: Both normal weight. Congested cortex.                          │
│ URINARY BLADDER: Contains 80 mL urine. (Incontinence may occur           │
│ at time of death - consistent with history.)                            │
│                                                                         │
│ GENITALS: Penile erection had occurred (consistent with hanging          │
│ - cadaveric priapism from venous engorgement).                          │
├─────────────────────────────────────────────────────────────────────────┤
│ SAMPLES PRESERVED:                                                      │
│ Viscera (stomach + liver + kidney + intestine) in saturated NaCl.       │
│ Blood in plain container (no preservative) for alcohol.                 │
│ Urine preserved.                                                        │
│ Histopathology: Lung, brain, heart tissue fixed in 10% formalin.        │
├─────────────────────────────────────────────────────────────────────────┤
│ OPINION:                                                                │
│                                                                         │
│ CAUSE OF DEATH:                                                         │
│ I (a): Asphyxia due to hanging.                                         │
│ I (b): Compression of neck structures by ligature.                     │
│ II:    Nil.                                                             │
│                                                                         │
│ MANNER: Consistent with SUICIDE (suicidal hanging).                     │
│                                                                         │
│ BASIS:                                                                  │
│ 1. Oblique, ascending ligature mark typical of hanging (not             │
│    horizontal as in strangulation).                                     │
│ 2. Mark incomplete - typical of suicidal hanging.                       │
│ 3. No defense injuries.                                                 │
│ 4. Internal neck injuries consistent with ante-mortem suspension.       │
│ 5. Generalized asphyxial changes: Congestion, petechiae, edema.        │
│                                                                         │
│ PMI: Approximately 8-12 hours prior to examination.                     │
│ Age as assessed: 30-40 years.                                           │
│                                                                         │
│ Examining Officer: Dr. ___________________                              │
│ Qualification: MD/MS (FMT)  Designation: Medical Officer                │
│ Date: _____________  Signature: _____________                           │
└─────────────────────────────────────────────────────────────────────────┘

---

REPORT 2: DEATH DUE TO DROWNING

┌─────────────────────────────────────────────────────────────────────────┐
│                   POST-MORTEM EXAMINATION REPORT                        │
│                       DEATH BY DROWNING                                 │
├─────────────────────────────────────────────────────────────────────────┤
│ PM Report No.: 02/2026      Date: 09/07/2026    Time: 11:00 AM          │
│ DECEASED: Suresh Patel, 28 years, Male                                  │
│ Circumstances: Body found floating in river/well/pond                   │
│ CR No.: __________ Under Section: 174/194 BNSS                         │
├─────────────────────────────────────────────────────────────────────────┤
│ EXTERNAL EXAMINATION:                                                   │
│                                                                         │
│ Build: Average. Height: 168 cm. Weight: 62 kg.                          │
│                                                                         │
│ POSTMORTEM CHANGES:                                                     │
│ Livor Mortis: PINK/RED color (due to cold water environment).           │
│ Distribution: Over posterior surfaces.                                  │
│ Rigor Mortis: Present in all muscle groups.                             │
│                                                                         │
│ SKIN:                                                                   │
│ Generalized GOOSE SKIN (cutis anserina / anserina skin):                │
│ Erection of hair follicles due to cold water - seen on arms, thighs.   │
│ WASHERWOMAN'S HANDS (macerated, pale, wrinkled skin of palms,           │
│ soles, fingertips): Present - suggests prolonged immersion.             │
│ Skin: Pale, sodden, wrinkled.                                           │
│                                                                         │
│ FACE: Pale / slightly cyanosed. Congested.                              │
│                                                                         │
│ EYES: Conjunctivae: Congested. Petechial hemorrhages. Cornea: Clear.    │
│ Pupils: Dilated.                                                        │
│                                                                         │
│ MOUTH/NOSE:                                                             │
│ FINE WHITE FROTH at mouth and nostrils (characteristic of drowning).    │
│ Froth: Copious, fine, persistent, mushroom-shaped on exposure to air.   │
│ (Formed by mixing of air, mucus, and water in airways)                  │
│                                                                         │
│ HANDS: Grasping of weeds/mud/grass may be present (cadaveric spasm -   │
│        sign of ante-mortem entry into water).                           │
│                                                                         │
│ No external injuries (except possible impact injuries if jumped/fell).  │
│ No ligature marks.                                                      │
│                                                                         │
│ INTERNAL EXAMINATION:                                                   │
│                                                                         │
│ SKULL: No fracture. BRAIN: Edematous. Weight 1380 g.                    │
│ Cerebral edema present. Petechiae.                                      │
│                                                                         │
│ NECK: Hyoid intact. No ligature mark. No injury.                        │
│                                                                         │
│ CHEST CAVITY:                                                           │
│ Ribs: Intact. Pleura: Bilateral pleural effusion (water) may be         │
│ present. No pneumothorax.                                               │
│                                                                         │
│ LUNGS (MOST IMPORTANT ORGAN IN DROWNING):                               │
│ Weight: R: 820 g, L: 790 g (MARKEDLY INCREASED - normal 400 g each).   │
│ WATERLOGGED - heavy, voluminous, pit on finger pressure.                │
│ Color: Pale pink to bluish-grey.                                        │
│ Crepitations: PRESENT on palpation (crepitant).                         │
│ EMPHYSEMA AQUOSUM: Over-inflation with water, markings of ribs visible  │
│ on surface (Rib markings present).                                      │
│ Cut surface: Frothy, pale, blood-stained fluid oozes freely.            │
│ Subpleural petechial hemorrhages (TARDIEU SPOTS): Present.              │
│ Pleural surfaces: Impression of ribs visible (Paltauf's sign/spots).    │
│ PALTAUF'S HEMORRHAGES: Subpleural pale pink hemorrhagic areas           │
│ (dilution of blood by water in fresh water drowning).                   │
│                                                                         │
│ HEART: Right chambers dilated, engorged. Left - normal/empty.           │
│ Weight 300 g. No coronary disease.                                      │
│                                                                         │
│ STOMACH:                                                                │
│ WATER IN STOMACH: Contains 200-500 mL of muddy/turbid water.            │
│ (Swallowed during struggle - confirms ante-mortem drowning.)            │
│ Sand, weeds, debris may be present.                                     │
│ Mucosa: Congested, hemorrhagic in places.                               │
│                                                                         │
│ DUODENUM/INTESTINES: May contain water (confirm drowning).              │
│                                                                         │
│ MIDDLE EAR: Hemorrhage into middle ear (Rodriques sign).                │
│                                                                         │
│ SPHENOID SINUS: Water/mud present (confirmatory sign of drowning).      │
│                                                                         │
│ LIVER: Weight 1600 g. Congested.                                        │
│ SPLEEN: Normal. KIDNEYS: Congested.                                     │
├─────────────────────────────────────────────────────────────────────────┤
│ SPECIAL INVESTIGATIONS:                                                 │
│                                                                         │
│ 1. DIATOM TEST (Pfaff's method):                                        │
│    Bone marrow / Femur / Kidney sent for diatom examination.            │
│    Presence of diatoms identical to those in drowning medium            │
│    = CONFIRMATORY of ante-mortem drowning (diatoms reach circulation    │
│    while heart still pumping - not in post-mortem immersion).           │
│                                                                         │
│ 2. GETTLER'S TEST (Chloride test):                                      │
│    Blood chloride: Left heart vs. Right heart comparison.               │
│    Fresh water drowning: Left heart blood MORE dilute than right.       │
│    (Osmotic dilution from absorbed fresh water.)                        │
│                                                                         │
│ 3. STRONTIUM TEST: Serum strontium levels.                              │
│                                                                         │
│ 4. Swabs from genitalia (if sexual assault suspected).                  │
│                                                                         │
│ Samples: Viscera, blood, urine, lung, bone marrow preserved.            │
├─────────────────────────────────────────────────────────────────────────┤
│ OPINION:                                                                │
│                                                                         │
│ CAUSE OF DEATH:                                                         │
│ I (a): Asphyxia due to drowning.                                        │
│ I (b): Immersion in water with aspiration.                              │
│ II:    Nil.                                                             │
│                                                                         │
│ MANNER: Consistent with ACCIDENTAL drowning.                            │
│         (Suicide/Homicide cannot be excluded without further            │
│          investigation - deferred to Investigating Officer.)             │
│                                                                         │
│ Basis: Waterlogged lungs, froth at mouth/nose, water in stomach,        │
│        goose skin, Paltauf's hemorrhages, emphysema aquosum.            │
│                                                                         │
│ PMI: Difficult to estimate due to water immersion. Body may have        │
│      been in water approximately 12-24 hours.                           │
│                                                                         │
│ Signature: Dr. _______________  Date: _______________                   │
└─────────────────────────────────────────────────────────────────────────┘

---

REPORT 3: DEATH DUE TO ELECTRIC SHOCK (Electrocution)

┌─────────────────────────────────────────────────────────────────────────┐
│                   POST-MORTEM EXAMINATION REPORT                        │
│                       DEATH BY ELECTROCUTION                            │
├─────────────────────────────────────────────────────────────────────────┤
│ PM Report No.: 03/2026      Date: 09/07/2026                            │
│ DECEASED: Mohan Lal, 22 years, Male                                     │
│ Circumstances: Found near live electric wire / Contact with appliance   │
│ CR No.: __________ Under Section: 174/194 BNSS                         │
├─────────────────────────────────────────────────────────────────────────┤
│ EXTERNAL EXAMINATION:                                                   │
│                                                                         │
│ Build: Average. Height: 170 cm. Weight: 65 kg.                          │
│                                                                         │
│ POSTMORTEM CHANGES:                                                     │
│ Livor Mortis: Present over posterior surfaces. Bluish-purple.           │
│ Rigor Mortis: Present in all groups.                                    │
│ PMI: Approximately 4-6 hours.                                           │
│                                                                         │
│ FACE: Congested. Cyanosed.                                              │
│ EYES: Conjunctivae petechiae. Dilated pupils.                           │
│                                                                         │
│ ELECTRIC MARK (JOULE BURN / ENTRY WOUND - KEY FINDING):                 │
│ Present on: Right palm (web space between thumb and index finger)       │
│ Size: 2 x 1.5 cm                                                        │
│ Shape: Irregular, central pale crater with surrounding brownish-red     │
│        hyperemia; raised edges; dry, yellowish parchment center.        │
│ Character: Hard, firm, leathery; surrounding blistering present.        │
│ ARBORESCENT (LIGHTNING-TREE/LICHTENBERG FIGURE) markings:              │
│ Present on right forearm - fern-like branching reddish streaks          │
│ along skin.                                                             │
│                                                                         │
│ EXIT WOUND (if present):                                                │
│ Present on: Right foot/heel                                             │
│ Size: 3 x 2 cm                                                          │
│ Character: Larger and more explosive than entry; irregular; blowout     │
│ appearance.                                                             │
│ (Note: Exit wound usually larger and more explosive than entry)         │
│                                                                         │
│ SINGING OF HAIR: Present over right hand and forearm.                   │
│ METALLIZATION: Copper/metalite particles embedded in skin               │
│                (demonstrate with X-ray or chemical analysis).           │
│                                                                         │
│ CLOTHING: Burnt / torn at entry and exit sites.                         │
│ Shoes: Sole may show melted/exit site.                                  │
│                                                                         │
│ INTERNAL EXAMINATION:                                                   │
│                                                                         │
│ SKULL: No fracture (unless thrown by current). BRAIN: Edematous.        │
│ Weight 1360 g. Petechial hemorrhages. Cerebral edema.                   │
│                                                                         │
│ NECK: No injury. Hyoid intact.                                          │
│                                                                         │
│ HEART:                                                                  │
│ Weight 305 g. Cardiac arrhythmia is cause of death (cannot be seen      │
│ on autopsy - diagnosis made from history + electrical evidence).        │
│ Subendocardial hemorrhages may be present.                              │
│ Contraction band necrosis on histopathology (if taken).                 │
│ Right chambers: Engorged, dilated.                                      │
│ Coronary arteries: Patent.                                              │
│                                                                         │
│ LUNGS: Weight 450 g each. Congested. Edematous.                         │
│ Subpleural petechiae. Pulmonary edema present.                          │
│                                                                         │
│ MUSCLES ALONG PATH OF CURRENT:                                          │
│ Right forearm and arm muscles: Vacuolization, disruption visible on     │
│ section. Hemorrhage in muscle bundles.                                  │
│                                                                         │
│ STOMACH: Normal contents. No corrosion.                                 │
│ LIVER: Congested. SPLEEN: Congested. KIDNEYS: Congested.                │
│                                                                         │
│ SPINAL CORD: Hemorrhagic foci may be seen (path of current).            │
│                                                                         │
│ FRACTURES: Vertebral compression fractures possible if thrown.          │
│ TONGUE: Bite mark possible (tetanic jaw spasm at moment of shock).      │
│                                                                         │
│ HISTOPATHOLOGY (IMPORTANT - send sections from entry wound):            │
│ Entry wound: Vacuolization of keratinocytes, "streaming" of nuclear     │
│ chromatin along the direction of current flow.                          │
│ "Nuclear elongation" pattern at bases of rete ridges.                   │
│ Contraction band necrosis in myocardium.                                │
├─────────────────────────────────────────────────────────────────────────┤
│ SAMPLES:                                                                │
│ Viscera for chemical analysis. Blood. Urine.                            │
│ Tissue from entry/exit wound in formalin (histopathology).              │
│ Cardiac tissue in formalin.                                             │
│ Muscle along path of current.                                           │
├─────────────────────────────────────────────────────────────────────────┤
│ OPINION:                                                                │
│                                                                         │
│ CAUSE OF DEATH:                                                         │
│ I (a): Cardiac arrhythmia (ventricular fibrillation) due to             │
│        electrocution.                                                   │
│ I (b): Passage of high-voltage electrical current through body.         │
│ II:    Cerebral edema, pulmonary edema.                                 │
│                                                                         │
│ MANNER: Accidental (Occupational/domestic electrocution).               │
│         Homicidal electrocution rare but cannot be excluded.            │
│                                                                         │
│ Basis: Presence of entry and exit electrical burns with characteristic  │
│ Joule burn morphology, arborescent markings, metallization, and         │
│ generalized asphyxial changes.                                          │
│                                                                         │
│ Note: In lightning strike - multiple entry/exit sites, Lichtenberg      │
│ figures more prominent, clothes blown off, keraunoparalysis,            │
│ ruptured eardrums, cataracts.                                           │
│                                                                         │
│ PMI: Approximately 4-6 hours.                                           │
│ Signature: Dr. _______________  Date: _______________                   │
└─────────────────────────────────────────────────────────────────────────┘

---

REPORT 4: ROAD TRAFFIC ACCIDENT (RTA)

┌─────────────────────────────────────────────────────────────────────────┐
│                   POST-MORTEM EXAMINATION REPORT                        │
│                   ROAD TRAFFIC ACCIDENT (RTA)                           │
├─────────────────────────────────────────────────────────────────────────┤
│ PM Report No.: 04/2026    Date: 09/07/2026                              │
│ DECEASED: Anil Singh, 40 years, Male                                    │
│ Circumstances: Hit by vehicle on highway / Two-wheeler accident          │
│ FIR No.: __________ Under Section: 304A/304 IPC / BNS                  │
│ Police Station: ______________ Investigating Officer: ___________        │
├─────────────────────────────────────────────────────────────────────────┤
│ EXTERNAL EXAMINATION:                                                   │
│                                                                         │
│ Build: Average. Height: 168 cm. Weight: 66 kg.                          │
│                                                                         │
│ POSTMORTEM CHANGES:                                                     │
│ Livor Mortis: Present posteriorly. Color: Bluish-red. Fixed.            │
│ Rigor Mortis: Present in jaw, limbs - Fully established.                │
│ PMI: 6-12 hours.                                                        │
│                                                                         │
│ CLOTHING: Torn, soiled with mud and blood at multiple sites.            │
│ Tire marks/tread impressions: Present on right side of chest.           │
│                                                                         │
│ INJURIES - RTA CLASSIFICATION:                                          │
│                                                                         │
│ A. PRIMARY IMPACT (Direct contact with vehicle):                        │
│    1. Bumper injury:                                                    │
│       Depressed fracture/contusion, anterior aspect left tibia 10 cm   │
│       above ankle (H: 52 cm from heel = bumper height indicator).       │
│    2. Radiator/Hood impact:                                             │
│       Multiple lacerations and contusions: Right shoulder, chest wall.  │
│                                                                         │
│ B. SECONDARY IMPACT (Body thrown onto bonnet/windshield):               │
│    3. Laceration: Scalp, vertex, 6 x 2 cm, bone deep.                  │
│    4. Subdural hematoma (found internally).                             │
│    5. Contusion: Right temporal region 5 x 4 cm.                       │
│                                                                         │
│ C. TERTIARY IMPACT (Fallen to ground):                                  │
│    6. Road rash (graze/abrasion): Extensive, right side of face,        │
│       right elbow, right hip - dirt embedded, parallel linear pattern   │
│       (direction indicates direction of fall/skid).                     │
│    7. Contusion: Right forearm, 8 x 5 cm.                               │
│                                                                         │
│ D. CRUSH/RUNOVER INJURIES (if runover):                                 │
│    8. Tire tread mark: Oblique impression across right chest wall.      │
│    9. Patterned contusion matching tire tread present.                  │
│   10. Crushing fractures: Multiple ribs right side 3rd-7th.            │
│                                                                         │
│ HEAD:                                                                   │
│ Scalp laceration: Vertex - 6 x 2 cm (see above).                       │
│ Contusions: Right temporal x2, left parietal x1.                       │
│ Face: Multiple abrasions. Nose: Fractured (deviated).                   │
│                                                                         │
│ EYES: Right eye: Subconjunctival hemorrhage. Left: Normal.              │
│                                                                         │
│ CHEST: Multiple rib fractures R: 3rd-7th, L: 5th-7th.                  │
│ Paradoxical movement present.                                           │
│                                                                         │
│ ABDOMEN: Distended. Superficial lacerations over left side.             │
│                                                                         │
│ PELVIS: Acetabular fracture - right side.                               │
│                                                                         │
│ LIMBS: Right tibial fracture (bumper injury).                           │
│        Left radius fracture (defensive - raised arm).                   │
│                                                                         │
│ INTERNAL EXAMINATION:                                                   │
│                                                                         │
│ SCALP: Contusions, lacerations as described.                            │
│ SKULL FRACTURES:                                                        │
│ Compound depressed fracture: Right temporal-parietal region 7 x 4 cm.  │
│ Contre-coup fracture: Left temporal fossa (fracture opposite to impact).│
│                                                                         │
│ BRAIN: Weight 1380 g.                                                   │
│ Subdural hematoma: Right side - 80 mL dark clotted blood.              │
│ Extradural hematoma: Right temporal - 40 mL fresh blood.               │
│ Contrecoup contusion: Left temporal/frontal lobe - hemorrhagic.         │
│ Coup contusion: Right temporal lobe.                                    │
│ Cerebral edema: SEVERE. Gyri flattened, herniations of uncus.           │
│ Diffuse axonal injury suspected (histopathology required).              │
│ Brainstem: Petechial hemorrhages. Duret hemorrhages present.            │
│                                                                         │
│ NECK: No fracture. Hyoid intact.                                        │
│ Cervical vertebrae: C4-C5 fracture-subluxation noted.                  │
│                                                                         │
│ CHEST:                                                                  │
│ BILATERAL HEMOTHORAX: R: 600 mL, L: 300 mL dark blood.                 │
│ Pneumothorax: Left.                                                     │
│ Lung lacerations: Right lower lobe - 2 sites.                          │
│ Contused lung: Left lower lobe.                                        │
│ CARDIAC TAMPONADE: Hemopericardium 50 mL.                               │
│ HEART: Myocardial contusion: Anterior wall. Right atrium tear.          │
│ AORTA: Transection of aorta at isthmus (just distal to left            │
│         subclavian origin) - traumatic aortic rupture.                  │
│                                                                         │
│ ABDOMEN:                                                                │
│ Free blood in peritoneal cavity: 800 mL.                               │
│ LIVER: Ruptured, multiple lacerations right lobe.                       │
│ SPLEEN: Ruptured, central hematoma.                                     │
│ KIDNEY: Left kidney contusion. Right: Normal.                           │
│ BLADDER: Ruptured (if full at time of impact).                          │
│ MESENTERY: Contusion, hemorrhage.                                       │
│ PELVIS: Acetabular fracture R + iliac crest fracture L.                 │
├─────────────────────────────────────────────────────────────────────────┤
│ SAMPLES: Blood (for alcohol - no preservative), urine, vitreous humor,  │
│ histopathology (brain for DAI - beta-APP staining).                     │
├─────────────────────────────────────────────────────────────────────────┤
│ OPINION:                                                                │
│                                                                         │
│ CAUSE OF DEATH:                                                         │
│ I (a): Hemorrhagic shock and traumatic brain injury.                    │
│ I (b): Multiple organ injuries due to blunt force trauma.               │
│ II:    Bilateral hemothorax, pneumothorax, traumatic aortic rupture,    │
│        hepatic and splenic laceration.                                  │
│                                                                         │
│ MANNER: ACCIDENTAL - Road Traffic Accident.                             │
│                                                                         │
│ All injuries are consistent with RTA - blunt force trauma, patterned   │
│ contusions, and tire impressions consistent with vehicle impact.        │
│                                                                         │
│ Bumper height: 52 cm from heel consistent with [car type].              │
│                                                                         │
│ Blood alcohol concentration requested (chemical analysis).              │
│ PMI: 6-12 hours. Age: 38-42 years.                                      │
│                                                                         │
│ Signature: Dr. _______________  Date: _______________                   │
└─────────────────────────────────────────────────────────────────────────┘

---

REPORT 5: DEATH DUE TO CARDIAC ARREST (Natural Death)

┌─────────────────────────────────────────────────────────────────────────┐
│                   POST-MORTEM EXAMINATION REPORT                        │
│                    DEATH DUE TO CARDIAC CAUSE                           │
├─────────────────────────────────────────────────────────────────────────┤
│ PM Report No.: 05/2026    Date: 09/07/2026                              │
│ DECEASED: Rajesh Verma, 58 years, Male                                  │
│ Circumstances: Found dead at home; known hypertensive, diabetic.        │
│ CR No.: __________ Under Section: 174/194 BNSS                         │
├─────────────────────────────────────────────────────────────────────────┤
│ EXTERNAL EXAMINATION:                                                   │
│                                                                         │
│ Build: Obese. Height: 168 cm. Weight: 88 kg. BMI: ~31.                  │
│                                                                         │
│ POSTMORTEM CHANGES:                                                     │
│ Livor Mortis: Present over posterior surfaces. Dark bluish-purple.      │
│ Fixed. PMI: 8-12 hours.                                                 │
│ Rigor Mortis: Fully established.                                        │
│                                                                         │
│ Face: Pale / slightly congested.                                        │
│ Eyes: Petechiae absent. Arcus senilis present.                          │
│ Mouth: No froth. No cyanosis. Tongue: Not protruding.                   │
│ Neck: No ligature mark. No injury.                                      │
│ Chest: Surgical scar (if previous CABG/sternotomy): ___________         │
│ Abdomen: Obese. No injury.                                              │
│ Limbs: Lower limb edema: Bilateral pitting, up to ankles.              │
│ No external injuries.                                                   │
│                                                                         │
│ INTERNAL EXAMINATION:                                                   │
│                                                                         │
│ SKULL: No fracture. BRAIN: Weight 1400 g. Mild edema. Old ischemic      │
│ infarct may be present in basal ganglia (chronic hypertension).         │
│                                                                         │
│ NECK: Hyoid intact. Atheromatous carotid arteries.                      │
│                                                                         │
│ CHEST:                                                                  │
│ No hemothorax. Bilateral pleural effusion: R: 200 mL, L: 180 mL        │
│ (consistent with cardiac failure / CCF).                                │
│                                                                         │
│ HEART - PRIMARY ORGAN OF INTEREST:                                      │
│ Weight: 480 g (INCREASED - normal 250-350 g).                           │
│ Shape: Globular (evidence of cardiomegaly).                             │
│                                                                         │
│ PERICARDIUM: Intact. Pericardial fluid: 50 mL straw-colored.            │
│                                                                         │
│ LEFT VENTRICLE:                                                         │
│ Wall thickness: 1.8 cm (THICKENED - normal 0.8-1.2 cm).                │
│ CONCENTRIC HYPERTROPHY - consistent with long-standing hypertension.    │
│                                                                         │
│ RIGHT VENTRICLE: Wall thickness 0.5 cm. Normal.                         │
│                                                                         │
│ CORONARY ARTERIES:                                                      │
│ LAD (Left Anterior Descending): SEVERE stenosis - 90% occlusion at     │
│ proximal one-third. Atheromatous plaque, calcified. Lumen reduced       │
│ to 1 mm.                                                                │
│ LCX (Left Circumflex): Moderate stenosis 60%.                           │
│ RCA (Right Coronary): Moderate stenosis 50%.                            │
│ FRESH THROMBUS: Present in LAD lumen (acute coronary event).            │
│                                                                         │
│ MYOCARDIUM:                                                             │
│ Area of infarction: Anterior wall, interventricular septum.             │
│ Character: Pale, yellowish, soft (48-72 hour old infarct);              │
│            OR Dark mottled (24-48h); OR Pale grey (>1 week old).        │
│ PALLOR and MOTTLING: Present in anterior wall.                          │
│ Subendocardial hemorrhage: Present.                                     │
│ Old infarct scars (fibrous pale areas): Present in posterior wall       │
│ (chronic ischemic heart disease).                                       │
│                                                                         │
│ AORTA: Atherosclerosis - severe. Multiple calcified plaques.            │
│ No dissection.                                                          │
│                                                                         │
│ VALVES: Mitral: Thickened, calcified. Aortic: Calcified (aortic         │
│         sclerosis). No vegetations.                                     │
│                                                                         │
│ LUNGS: Weight: R: 620 g, L: 590 g (INCREASED - pulmonary edema).        │
│ Color: Congested, pink, waterlogged. Cut surface: Frothy fluid.         │
│ Hemosiderin-laden macrophages ("heart failure cells") on smear.         │
│                                                                         │
│ LIVER: Weight 1800 g (INCREASED). "NUTMEG LIVER" pattern:              │
│ Congested, dark red center with pale periphery on cut section.          │
│ Consistent with chronic passive venous congestion (right heart failure).│
│                                                                         │
│ KIDNEYS: Enlarged, congested. Cortex: Granular surface ("granular       │
│ contracted kidney" - hypertensive nephropathy).                         │
│                                                                         │
│ SPLEEN: Weight 250 g. Congested, firm.                                  │
│                                                                         │
│ STOMACH: Empty or minimal contents. Normal mucosa.                      │
│ PANCREAS: Features of diabetes mellitus (islet atrophy, fibrosis).      │
│                                                                         │
│ ADRENALS: Normal.                                                       │
│                                                                         │
│ HISTOPATHOLOGY:                                                         │
│ Myocardium: Contraction band necrosis (very early ischemia, <1h).       │
│             Coagulative necrosis (>4-6h).                               │
│             Inflammatory infiltrate (>24h - PMN, then macrophages).     │
│             Granulation tissue (5-10 days).                             │
│             Fibrosis (>2-3 weeks).                                      │
├─────────────────────────────────────────────────────────────────────────┤
│ SAMPLES: Blood, urine, vitreous humor (for electrolytes - sudden        │
│ cardiac death). Cardiac tissue for histopathology.                      │
├─────────────────────────────────────────────────────────────────────────┤
│ OPINION:                                                                │
│                                                                         │
│ CAUSE OF DEATH:                                                         │
│ I (a): Acute myocardial infarction.                                     │
│ I (b): Acute coronary thrombosis of LAD.                                │
│ II:    Severe coronary artery disease (atherosclerosis), hypertensive   │
│        heart disease (LVH), diabetes mellitus, obesity.                 │
│                                                                         │
│ MANNER: NATURAL.                                                        │
│                                                                         │
│ This is consistent with sudden natural death due to acute coronary      │
│ event on a background of long-standing ischemic heart disease.          │
│                                                                         │
│ PMI: Approximately 8-12 hours.                                          │
│ Age: 55-62 years (consistent with stated age).                          │
│                                                                         │
│ Signature: Dr. _______________  Date: _______________                   │
└─────────────────────────────────────────────────────────────────────────┘

---

REPORT 6: DEATH DUE TO POISONING (Organophosphate)

┌─────────────────────────────────────────────────────────────────────────┐
│                   POST-MORTEM EXAMINATION REPORT                        │
│                    DEATH BY POISONING (OP COMPOUND)                     │
├─────────────────────────────────────────────────────────────────────────┤
│ PM Report No.: 06/2026    Date: 09/07/2026                              │
│ DECEASED: Savitri Devi, 30 years, Female                                │
│ Circumstances: Found unconscious after allegedly consuming pesticide.   │
│ CR No.: __________ Under Section: 302/304/306 IPC (BNS)                 │
├─────────────────────────────────────────────────────────────────────────┤
│ EXTERNAL EXAMINATION:                                                   │
│                                                                         │
│ Build: Average. Height: 155 cm. Weight: 50 kg.                          │
│                                                                         │
│ POSTMORTEM CHANGES:                                                     │
│ Livor Mortis: Present posteriorly. Bluish-purple. Fixed.                │
│ Rigor Mortis: Fully established. PMI: 6-10 hours.                       │
│                                                                         │
│ BODY ODOR: Strong garlic-like / pungent odor from mouth/body fluids.   │
│ (Characteristic of organophosphate/sulphur compounds.)                  │
│                                                                         │
│ FACE: Congested, cyanosed.                                              │
│                                                                         │
│ EYES:                                                                   │
│ PUPILS: CONSTRICTED (MIOSIS) bilaterally - 2 mm each (HALLMARK).        │
│ Conjunctivae: Congested, petechiae present.                             │
│                                                                         │
│ MOUTH:                                                                  │
│ Profuse frothing at mouth - copious, white froth.                       │
│ Tongue: Moist. Not bitten. Excess salivation noted.                     │
│                                                                         │
│ SKIN: Diaphoresis (sweating). Skin appears moist.                       │
│                                                                         │
│ NO EXTERNAL INJURIES.                                                   │
│ No ligature marks. No needle marks (unless IV attempted in hospital).   │
│                                                                         │
│ CLOTHING: May show pesticide stain.                                     │
│                                                                         │
│ INTERNAL EXAMINATION:                                                   │
│                                                                         │
│ SKULL: Intact. BRAIN: Weight 1340 g. CONGESTED. Edematous.              │
│ Petechiae on surface. Cerebral edema.                                   │
│                                                                         │
│ NECK: No injury. Hyoid intact.                                          │
│                                                                         │
│ CHEST: No hemothorax.                                                   │
│                                                                         │
│ LUNGS: Weight: R: 590 g, L: 560 g (INCREASED due to edema).            │
│ Color: CONGESTED, pink-red, heavy, waterlogged.                         │
│ Cut surface: COPIOUS FROTHY FLUID - blood-stained, abundant.            │
│ (Bronchorrhea - excess secretions in bronchi.)                          │
│ Subpleural petechiae (Tardieu spots): Present.                          │
│ Bronchi: Contain frothy fluid.                                          │
│ Bronchospasm features: Distended with trapped air.                      │
│                                                                         │
│ HEART: Weight 290 g. Dilated. Engorged right chambers.                  │
│ Subendocardial hemorrhages.                                             │
│                                                                         │
│ STOMACH:                                                                │
│ Contents: STRONG PUNGENT SMELL - garlic/sulphur odor on opening.        │
│ Volume: ~300 mL greenish-brown liquid.                                  │
│ Mucosa: HYPEREMIC, hemorrhagic, erosions present.                       │
│ Chemical irritant effect visible.                                       │
│ Corrosion: Not present (OP compounds - no direct corrosion).            │
│                                                                         │
│ SMALL INTESTINE: Hyperemic mucosa. Increased secretions.                │
│                                                                         │
│ LIVER: Weight 1580 g. Congested. No necrosis in OP poisoning.           │
│ (Note: In paracetamol - centrilobular necrosis would be present.)       │
│                                                                         │
│ SPLEEN: Congested. KIDNEYS: Congested.                                  │
│                                                                         │
│ URINARY BLADDER: FULL of urine (involuntary urination - cholinergic).   │
│ Urine: ~200 mL. Preserved for toxicology.                               │
│                                                                         │
│ ADRENALS: Normal.                                                       │
├─────────────────────────────────────────────────────────────────────────┤
│ SAMPLES PRESERVED (CRITICAL FOR CHEMICAL ANALYSIS):                     │
│ 1. Stomach + contents (in separate sealed container, NO preservative).  │
│ 2. Liver (500 g) in saturated NaCl.                                     │
│ 3. Kidney (one complete) in saturated NaCl.                             │
│ 4. Small intestine (30 cm with contents) in saturated NaCl.            │
│ 5. Blood: 50 mL in plain container - NO PRESERVATIVE (for OP).         │
│ 6. Urine: 50 mL plain container.                                        │
│ 7. Vitreous humor: 5 mL.                                                │
│ 8. Bile: 10 mL.                                                         │
│ 9. Brain tissue: 200 g.                                                 │
│ 10. Lung tissue for histopathology.                                     │
│ NOTE: All samples sealed separately and labeled with case no. + content.│
│ Sent to: Chemical Examiner, FSL __________________ on ___________       │
│ Ref No.: _________________                                              │
│ Analysis requested: Organophosphate screen, Cholinesterase activity.    │
├─────────────────────────────────────────────────────────────────────────┤
│ OPINION:                                                                │
│                                                                         │
│ CAUSE OF DEATH:                                                         │
│ I (a): Respiratory failure and acute pulmonary edema.                   │
│ I (b): Organophosphate compound poisoning.                              │
│ II:    Cholinergic crisis with bronchorrhea and bronchospasm.           │
│                                                                         │
│ MANNER: Consistent with SUICIDAL poisoning (pending chemical            │
│         analysis confirmation).                                         │
│                                                                         │
│ Basis: Miosis, profuse bronchorrhea, copious froth, garlic odor,        │
│        hyperemic GI mucosa - SLUDGE syndrome features present on PM.   │
│                                                                         │
│ NOTE: Final opinion subject to chemical analysis results.               │
│       Red blood cell cholinesterase activity confirmation essential.    │
│                                                                         │
│ PMI: 6-10 hours. Age: 28-32 years.                                      │
│                                                                         │
│ Signature: Dr. _______________  Date: _______________                   │
└─────────────────────────────────────────────────────────────────────────┘

---

REPORT 7: DEATH DUE TO BURNS (Fire / Flame)

┌─────────────────────────────────────────────────────────────────────────┐
│                   POST-MORTEM EXAMINATION REPORT                        │
│                       DEATH DUE TO BURNS                                │
├─────────────────────────────────────────────────────────────────────────┤
│ PM Report No.: 07/2026    Date: 09/07/2026                              │
│ DECEASED: Geeta Sharma, 24 years, Female                                │
│ Circumstances: Burns (bride burning / accidental kerosene burn)         │
│ CR No.: __________ Under Section: 302/304B/306 IPC                     │
├─────────────────────────────────────────────────────────────────────────┤
│ EXTERNAL EXAMINATION:                                                   │
│                                                                         │
│ BODY WEIGHT: Severely reduced due to fluid loss.                        │
│                                                                         │
│ BURNS ASSESSMENT:                                                       │
│ Using RULE OF NINES:                                                    │
│ Head and neck: 9%  Right arm: 9%  Left arm: 9%                          │
│ Anterior trunk: 18%  Posterior trunk: 18%                               │
│ Right leg: 18%  Left leg: 18%  Perineum: 1%                            │
│ Total BSA Burned: _____% (Document carefully)                           │
│                                                                         │
│ DEGREE OF BURNS:                                                        │
│ 1st degree (erythema only): Areas: _________________                    │
│ 2nd degree (blistering): Areas: ____________________                    │
│ 3rd degree (full thickness - charring, leathery): Areas: ___________    │
│                                                                         │
│ CLOTHING: Burnt/charred at sites corresponding to burn areas.           │
│ Kerosene/petrol odor: Present / Absent.                                 │
│                                                                         │
│ VITAL REACTION (ANTE-MORTEM BURNS):                                     │
│ 1. Vital blistering (fluid inside blisters with protein and leucocytes).│
│ 2. Hyperemia and inflammatory reaction at burn margins.                 │
│ 3. Soot in airways (below glottis = ante-mortem).                       │
│ 4. Pugilistic posture (boxing stance): Due to heat-induced muscle       │
│    contraction - NOT a sign of fighting.                                │
│                                                                         │
│ POST-MORTEM BURNS:                                                      │
│ Dry, leathery, split skin. Peeling. No fluid in blisters. No vital      │
│ reaction at margins.                                                    │
│                                                                         │
│ INTERNAL EXAMINATION:                                                   │
│                                                                         │
│ RESPIRATORY TRACT:                                                      │
│ SOOT: Soot deposits in trachea, bronchi (BELOW CORDS = ante-mortem).   │
│ (Above cords only = post-mortem smoke entry.)                           │
│ Larynx: Edematous, soot-stained.                                        │
│ Trachea: Soot-lined mucosa.                                             │
│ Bronchi: Contain carbonaceous material.                                 │
│                                                                         │
│ LUNGS: CHERRY RED color (Carbon monoxide poisoning concurrent).         │
│ Edematous. Congested. Weight increased.                                 │
│                                                                         │
│ BLOOD: Cherry red (carboxyhemoglobin - CO poisoning from smoke).        │
│ COHb levels requested from FSL.                                         │
│                                                                         │
│ BRAIN: Edematous. Cherry red coloration.                                │
│                                                                         │
│ STOMACH: Stress ulcers (Curling's ulcers) may be present.               │
│ Submucosal hemorrhages along greater curvature.                         │
│                                                                         │
│ HEART: Subendocardial hemorrhages. Fatty changes.                       │
│                                                                         │
│ SKULL: Epidural "heat hematoma" (lenticular, dark red, in temples)      │
│        - NOT a sign of trauma - artifact of heat in burning.            │
│ Note: True traumatic EDH is bright red and has fracture usually.        │
│                                                                         │
│ HEAT FRACTURES: Skull may show "explosion" type fractures from          │
│ steam pressure in diploe - NOT ante-mortem blunt force.                 │
├─────────────────────────────────────────────────────────────────────────┤
│ SAMPLES:                                                                │
│ Blood in plain sealed vial (for COHb estimation - to FSL URGENTLY).    │
│ Vitreous humor. Viscera. Blistered skin biopsy (histopathology).        │
│ Soot swab from airways. Urine for cyanide (if synthetic material burnt).│
├─────────────────────────────────────────────────────────────────────────┤
│ OPINION:                                                                │
│                                                                         │
│ CAUSE OF DEATH:                                                         │
│ I (a): Carboxyhemoglobin poisoning and respiratory failure.             │
│ I (b): Inhalation of smoke and toxic gases.                             │
│ II:    Burns involving ____% BSA (2nd-3rd degree), burn shock.          │
│                                                                         │
│ MANNER: To be determined by investigation. Burns are ANTE-MORTEM        │
│         (vital reaction present; soot below glottis).                   │
│                                                                         │
│ Note: No evidence of blunt force trauma pre-mortem. No fractures        │
│       inconsistent with heat effects. No restraint marks.               │
│                                                                         │
│ Final opinion: Pending chemical analysis for COHb levels and toxicology.│
│                                                                         │
│ Signature: Dr. _______________  Date: _______________                   │
└─────────────────────────────────────────────────────────────────────────┘

---

REPORT 8: DEATH DUE TO FIREARM INJURY

┌─────────────────────────────────────────────────────────────────────────┐
│                   POST-MORTEM EXAMINATION REPORT                        │
│                     DEATH BY FIREARM INJURY                             │
├─────────────────────────────────────────────────────────────────────────┤
│ PM Report No.: 08/2026    Date: 09/07/2026                              │
│ DECEASED: Vikram Singh, 32 years, Male                                  │
│ Circumstances: Gunshot wound                                            │
│ CR No.: __________ Under Section: 302/307 IPC / BNS                    │
│ Request by: Inspector _________, PS __________                          │
├─────────────────────────────────────────────────────────────────────────┤
│ EXTERNAL EXAMINATION:                                                   │
│                                                                         │
│ ENTRY WOUND:                                                            │
│ Location: Right temporal region, 3 cm above the right ear.             │
│ Size: 1.2 x 1.2 cm                                                      │
│ Shape: Circular, punched-out appearance.                                │
│ Edges: INVERTED (pushing inward) - ENTRY.                               │
│ Marginal abrasion collar: Present (2-3 mm wide, around entry).          │
│ Powder tattooing/stippling: Present within 60 cm radius around wound.  │
│ Blackening: Present (contact/close range).                              │
│ Burns of skin/hair: Present (very close/contact range).                 │
│ Contusion ring/abrasion ring: Present.                                  │
│ Muzzle stamp: Present (star-shaped laceration if contact - applied      │
│               muzzle to skin over bone).                                │
│                                                                         │
│ EXIT WOUND:                                                             │
│ Location: Left temporal region.                                         │
│ Size: 3 x 2.5 cm                                                        │
│ Shape: IRREGULAR, stellate, explosive.                                  │
│ Edges: EVERTED (pushed outward) - EXIT.                                 │
│ NO abrasion collar at exit. NO tattooing. NO blackening.                │
│ Size LARGER than entry.                                                 │
│                                                                         │
│ RANGE DETERMINATION:                                                    │
│ Contact shot: Muzzle stamp + cruciate laceration + smoke deposit       │
│               under skin edge.                                          │
│ Close range (<15 cm): Blackening + tattooing + burning.                 │
│ Medium range (15-60 cm): Tattooing without blackening.                  │
│ Long range (>60 cm): Abrasion collar + contusion ring only.             │
│ THIS CASE: Close range (blackening + stippling present).                │
│                                                                         │
│ INTERNAL EXAMINATION:                                                   │
│                                                                         │
│ SKULL: Beveling of skull:                                               │
│ Entry wound: Internal bevel (inner table larger than outer) - ENTRY.   │
│ Exit wound: External bevel (outer table larger than inner) - EXIT.      │
│ Fracture lines: Radiating from both entry and exit.                     │
│                                                                         │
│ BRAIN: Destroyed right temporal lobe. Bullet track visible:            │
│ Hemorrhagic lacerated track from right to left temporal lobe.           │
│ Gunshot residue in track.                                               │
│ Mass hemorrhage. Brain weight: Significantly reduced.                   │
│ Left: Contre-coup laceration.                                           │
│                                                                         │
│ BULLET RECOVERED: Yes / No (if present - describe, photograph,          │
│ handle with gloves, preserve in separate container, hand to police).    │
│                                                                         │
│ CHEST/ABDOMEN: No injury (unless multiple shots).                       │
│ HEART: Pale. No injury.                                                 │
│ LUNGS: Congested. No direct injury.                                     │
├─────────────────────────────────────────────────────────────────────────┤
│ SAMPLES:                                                                │
│ Wound swabs for GSR (gunshot residue).                                  │
│ Blood, urine, vitreous for toxicology.                                  │
│ Bullet (if recovered) handed to IO with proper documentation.           │
│ Skull bone from entry and exit for beveling demonstration.              │
│ Clothing (with GSR markings) handed to FSL.                             │
├─────────────────────────────────────────────────────────────────────────┤
│ OPINION:                                                                │
│                                                                         │
│ CAUSE OF DEATH:                                                         │
│ I (a): Destruction of brain and massive intracranial hemorrhage.        │
│ I (b): Penetrating gunshot wound to head.                               │
│ II:    Nil.                                                             │
│                                                                         │
│ MANNER: HOMICIDAL (single close-range shot, not typical of suicide).    │
│         (Suicidal firearms typically: contact range, temporal/mouth;    │
│          homicidal: variable range, back of head, multiple shots.)      │
│                                                                         │
│ Range of fire: CLOSE RANGE (<15 cm) based on blackening and tattooing. │
│                                                                         │
│ Direction of fire: Right to left (entry right temporal, exit left).     │
│                                                                         │
│ Signature: Dr. _______________  Date: _______________                   │
└─────────────────────────────────────────────────────────────────────────┘

---

PART C: ADDITIONAL MEDICO-LEGAL FORMS

---

FORM 3: INJURY REPORT / WOUND CERTIFICATE

┌─────────────────────────────────────────────────────────────────────────┐
│                      WOUND CERTIFICATE / INJURY REPORT                  │
│                         (MLC Form - Outpatient/Casualty)                │
├─────────────────────────────────────────────────────────────────────────┤
│ MLC No.: _______________  Date: _______________  Time: ________________  │
│ Hospital: ___________________________________________________________    │
│                                                                         │
│ PATIENT DETAILS:                                                        │
│ Name: ________________________________ Age: ______ Sex: ____________    │
│ Address: ___________________________________________________________    │
│ Brought by: _________________________ Relation: ____________________    │
│                                                                         │
│ REFERRING AUTHORITY:                                                    │
│ Police / Magistrate / Self / Relative                                   │
│ FIR No.: ____________ PS: _____________ Date: ______________________    │
│ Referred by (Officer name): ______________________________________      │
│                                                                         │
│ HISTORY AS GIVEN BY PATIENT / INFORMANT:                                │
│ _____________________________________________________________           │
│ _____________________________________________________________           │
│                                                                         │
│ GENERAL CONDITION ON ADMISSION:                                         │
│ Conscious / Unconscious / Semiconscious  BP: ______ Pulse: _____        │
│ RR: _____ SpO2: _____ Temperature: _____                                │
│                                                                         │
│ INJURIES NOTED (each injury described individually):                    │
│                                                                         │
│ Injury 1:                                                               │
│ Nature: Abrasion / Contusion / Laceration / Incised wound / Firearm     │
│ Site: _________________________________ Size: ___________________       │
│ Shape: __________________ Edges: __________________                     │
│ Depth: ___________________                                              │
│ Surroundings: __________________________________________                │
│ Age of injury: Fresh / Old / Intermediate (approx _____ hours/days)     │
│ Ante-mortem / Post-mortem: ___________________                          │
│                                                                         │
│ Injury 2: (repeat as above for each injury)                             │
│                                                                         │
│ RADIOLOGICAL FINDINGS: (if X-ray done)                                  │
│ _____________________________________________________________           │
│                                                                         │
│ OPINION:                                                                │
│ 1. Nature of injuries:                                                  │
│    Simple / Grievous (as per IPC Sec 319-320 / BNS equivalent)          │
│                                                                         │
│ 2. Probable cause:                                                      │
│    Blunt force / Sharp force / Firearm / Self-inflicted / Others        │
│                                                                         │
│ 3. Age of injuries:                                                     │
│    Consistent with alleged time of assault: Yes / No                    │
│                                                                         │
│ 4. Probable weapon used: __________________________________              │
│                                                                         │
│ 5. Whether injuries are sufficient to cause:                            │
│    Death / Grievous injury / Simple injury                              │
│                                                                         │
│ Name: ________________________ Qualification: _____________________     │
│ Designation: ___________________ Signature: _______________________    │
│ Institution: ____________________ Date: ___________________________     │
└─────────────────────────────────────────────────────────────────────────┘

---

FORM 4: VISCERA FORWARDING MEMO (To Chemical Examiner / FSL)

┌─────────────────────────────────────────────────────────────────────────┐
│                      VISCERA FORWARDING MEMO                            │
│                (For Chemical Analysis by FSL / Chemical Examiner)       │
├─────────────────────────────────────────────────────────────────────────┤
│ To,                                                                     │
│ The Director, Forensic Science Laboratory / Chemical Examiner           │
│ Government of _____________________                                     │
│                                                                         │
│ From,                                                                   │
│ Dr. ____________________________                                        │
│ Department of Forensic Medicine                                         │
│ ________________________ Hospital                                       │
│                                                                         │
│ Reference: PM Report No. _______________ Date: ________________________ │
│ CR / FIR No.: _______________ PS: ___________________________________   │
│                                                                         │
│ Details of deceased: Name: _________________ Age: _____ Sex: _____      │
│ Date of PM: _________________ Time: ___________________________________  │
│                                                                         │
│ VISCERA/SAMPLES SENT:                                                   │
│                                                                         │
│ Container No. | Contents          | Preservative      | Quantity        │
│ ─────────────┼───────────────────┼───────────────────┼─────────────    │
│      1       │ Stomach+contents  │ Sat. NaCl soln.   │ Whole           │
│      2       │ Small intestine   │ Sat. NaCl soln.   │ 30 cm + cont.   │
│      3       │ Liver             │ Sat. NaCl soln.   │ 500 g           │
│      4       │ Kidney            │ Sat. NaCl soln.   │ 1 whole         │
│      5       │ Blood             │ None (plain)       │ 50 mL           │
│      6       │ Urine             │ None (plain)       │ 50 mL           │
│      7       │ Vitreous humor    │ None              │ Both eyes       │
│      8       │ Bile              │ None              │ All             │
│      9       │ Brain             │ Sat. NaCl soln.   │ 200 g           │
│     10       │ Lung              │ Sat. NaCl soln.   │ 100 g           │
│     11       │ _______________   │ _________________ │ _____________   │
│                                                                         │
│ Analysis requested:                                                     │
│ [ ] Organophosphate / Carbamate screen                                  │
│ [ ] Alcohol (ethanol) estimation                                        │
│ [ ] Heavy metals (As, Pb, Hg, Tl)                                       │
│ [ ] Cyanide                                                             │
│ [ ] Carbon monoxide (COHb) estimation                                   │
│ [ ] Drug screen (opiates, benzodiazepines, barbiturates)                │
│ [ ] Corrosives (acid, alkali)                                           │
│ [ ] Paracetamol / Salicylate levels                                     │
│ [ ] All poisons                                                         │
│ [ ] Others: ________________________                                    │
│                                                                         │
│ CLINICAL SUSPICION: _________________________________________________   │
│                                                                         │
│ All containers sealed with: Wax seal / Tape seal                        │
│ Sealed in the presence of: ________________________________________     │
│ (2 witnesses to sign)                                                   │
│ Witness 1: _______________________  Signature: ____________________    │
│ Witness 2: _______________________  Signature: ____________________    │
│                                                                         │
│ Forwarded through: Police (IO Name: __________________________)         │
│ Date of forwarding: ____________________                                │
│                                                                         │
│ Signature of MO: ____________________  Date: _______________________   │
│ Designation: _________________________                                  │
└─────────────────────────────────────────────────────────────────────────┘

---

FORM 5: SUPPLEMENTARY OPINION / HISTOPATHOLOGY REQUEST

┌─────────────────────────────────────────────────────────────────────────┐
│               HISTOPATHOLOGY REQUISITION / SUPPLEMENTARY OPINION        │
├─────────────────────────────────────────────────────────────────────────┤
│ To,                                                                     │
│ The Head, Department of Pathology                                       │
│ ___________________________ Hospital / Medical College                  │
│                                                                         │
│ PM Report No.: ____________ Date: _____________ CR No.: ____________    │
│ Name of Deceased: ___________________________ Age: _____ Sex: _____     │
│                                                                         │
│ TISSUES SENT:                                                           │
│ 1. Heart (myocardium, coronary artery cross sections)                   │
│ 2. Lung (bilateral)                                                     │
│ 3. Brain (cortex, brainstem, cerebellum)                                │
│ 4. Liver (portal zone + centrilobular)                                  │
│ 5. Kidney (cortex + medulla)                                            │
│ 6. Specific tissues: __________________                                 │
│                                                                         │
│ All fixed in 10% neutral buffered formalin.                             │
│                                                                         │
│ STAINS REQUESTED:                                                       │
│ [ ] Routine H&E (all tissues)                                           │
│ [ ] Special stains: PAS / Masson's trichrome / Perl's Prussian blue     │
│ [ ] Congo red (if amyloid suspected)                                    │
│ [ ] Oil Red O (fat embolism)                                            │
│ [ ] Beta-APP immunostaining (diffuse axonal injury)                     │
│ [ ] CD68 (macrophage infiltration - age of infarction)                  │
│                                                                         │
│ Clinical question: _______________________________________________       │
│                                                                         │
│ Signature: Dr. _______________ Date: _______________                   │
└─────────────────────────────────────────────────────────────────────────┘

---

FORM 6: DIATOM TEST REQUEST (for Drowning Cases)

┌─────────────────────────────────────────────────────────────────────────┐
│              DIATOM EXAMINATION REQUEST (DROWNING CASES)                │
├─────────────────────────────────────────────────────────────────────────┤
│ To,                                                                     │
│ The Director, Forensic Science Laboratory                               │
│ _____________________________                                           │
│                                                                         │
│ PM Report No.: ___________ CR No.: ___________ Date: ___________        │
│ Deceased: _______________________________                               │
│                                                                         │
│ SAMPLES SENT FOR DIATOM EXAMINATION:                                    │
│ 1. Bone marrow (from femur) - 50 g                                      │
│ 2. Kidney tissue - 50 g                                                 │
│ 3. Brain tissue - 50 g                                                  │
│ 4. Liver tissue - 50 g                                                  │
│ 5. Lung tissue - 50 g                                                   │
│ 6. Water sample from alleged drowning site - 500 mL                     │
│                                                                         │
│ Purpose: Comparison of diatom species and morphology between body       │
│ tissues and drowning medium to confirm/exclude ante-mortem drowning.    │
│                                                                         │
│ Basis: Diatoms entering alveoli during active breathing penetrate        │
│ blood-lung barrier and are carried to distant organs (bone marrow,      │
│ kidney, brain). Presence in bone marrow = strong evidence of            │
│ ante-mortem drowning.                                                   │
│                                                                         │
│ Signature: Dr. _______________ Date: _______________                   │
└─────────────────────────────────────────────────────────────────────────┘

---

PART D: QUICK REFERENCE - PM FINDINGS BY CAUSE OF DEATH

---

Master Diagnostic PM Findings Table

---

Postmortem Interval (PMI) Estimation Chart

---

Legal Framework Quick Reference

---

Important Note: All PM reports are legal documents. They must be written clearly, objectively, and signed by the examining officer. Opinions should be confined to findings observed. The final manner of death in suspicious cases should always be given with the qualifier "pending chemical analysis/further investigation" where applicable. Any corrections must be initialed. Do not overwrite.

---

🏥 MASTER GUIDE: IPD CLINICAL CASES

In-Patient Department — All Specialties

---

HOW TO WRITE AN IPD CASE — UNIVERSAL FORMAT

1. PRESENTING COMPLAINTS (PC)        → Chief symptom + duration
2. HISTORY OF PRESENTING ILLNESS     → Chronological story of the illness
   (HOPI)
3. PAST HISTORY (PH)                 → Similar illness, surgeries, admissions
4. PERSONAL HISTORY                  → Diet, sleep, bowel, bladder, menstrual,
                                        addictions, occupation
5. FAMILY HISTORY (FH)               → Hereditary/communicable conditions
6. SOCIOECONOMIC HISTORY             → SES, living conditions, water/sanitation
7. TREATMENT HISTORY                 → Current and past medications
8. GENERAL PHYSICAL EXAMINATION      → Built, nourishment, pallor, icterus,
   (GPE)                               cyanosis, clubbing, lymphadenopathy,
                                        edema, JVP, pulse, BP, RR, Temp, SpO2
9. SYSTEMIC EXAMINATION              → Focused system(s) in detail
10. PROVISIONAL DIAGNOSIS            → Based on clinical findings
11. DIFFERENTIAL DIAGNOSIS           → 2-3 alternatives
12. INVESTIGATIONS                   → In logical order (bedside → labs → imaging)
13. FINAL DIAGNOSIS                  → After results
14. TREATMENT                        → Non-pharmacological + pharmacological
15. PROGRESS NOTES                   → Day-by-day in-patient notes
16. DISCHARGE SUMMARY               → Condition on discharge + follow-up

---

SECTION 1: INTERNAL MEDICINE (GENERAL MEDICINE)

---

CASE 1: ACUTE MYOCARDIAL INFARCTION (STEMI)

A 58-year-old male, hypertensive, smoker, admitted with severe crushing substernal chest pain radiating to left arm and jaw, with sweating and breathlessness for 2 hours.

---

PRESENTING COMPLAINTS:

1. Severe chest pain - 2 hours
2. Sweating - 2 hours
3. Breathlessness - 1 hour
4. Nausea - 2 hours

HISTORY OF PRESENTING ILLNESS:

PAST HISTORY:

• Hypertension: 5 years, on amlodipine 5 mg OD
• No prior MI, no PCI/CABG
• No diabetes mellitus, no CKD

PERSONAL HISTORY:

• Diet: Non-vegetarian
• Smoker: 20 pack-years
• Alcohol: Occasional
• No regular exercise

FAMILY HISTORY:

• Father died of MI at age 55 (premature CAD)

GENERAL PHYSICAL EXAMINATION:

SYSTEMIC EXAMINATION:

• Apex beat: Not well localized
• S1 S2 heard, S3 gallop present (LV dysfunction)
• No murmurs
• Bilateral fine crepitations at bases (pulmonary edema)

PROVISIONAL DIAGNOSIS:

DIFFERENTIAL DIAGNOSIS:

1. Unstable angina / NSTEMI
2. Aortic dissection (Type A)
3. Acute pericarditis

INVESTIGATIONS:

• ECG: ST elevation ≥1 mm in ≥2 contiguous leads (inferior: II, III, aVF; anterior: V1-V4)
• SpO2 monitoring
• IV access × 2

• Troponin I / T: Elevated (>99th percentile upper reference limit)
• CK-MB: Elevated
• CBC: Leucocytosis (stress response)
• RFT/LFT: Baseline
• Electrolytes: Na+, K+, Ca2+ (K+ critical before thrombolysis)
• Blood glucose
• PT/INR, aPTT (before anticoagulation)
• Lipid profile
• ABG (if breathless)

• CXR PA/AP: Cardiomegaly, Kerley B lines, pulmonary venous congestion
• Echo (bedside): RWMA (regional wall motion abnormality), EF assessment

FINAL DIAGNOSIS:

TREATMENT:

• Primary PCI: Preferred if available within 90 min (cathlab referral)
• Thrombolysis (if PCI not available within 120 min):
  • Streptokinase 1.5 million units IV over 60 min, OR
  • Tenecteplase (TNK-tPA): Weight-based single IV bolus
  • Contraindications: Prior ICH, active bleed, BP >180/110, recent surgery <3 months

• Bed rest, cardiac monitoring, continuous telemetry
• IV access, Foley catheter (urine output monitoring)
• Nil orally until stable; then liquid diet
• Anxiolytics: Lorazepam 1 mg IV PRN

• Beta-blocker: Metoprolol 25 mg BD (start in 24h if stable)
• ACE inhibitor: Ramipril 2.5 mg OD (within 24h)
• DAPT: Aspirin 75 mg + Clopidogrel 75 mg OD × 12 months
• Statin: Atorvastatin 80 mg OD lifelong

PROGRESS NOTES (Day-wise):

DISCHARGE SUMMARY:

• Diagnosis: Acute Anterior STEMI (thrombolysis with TNK-tPA, successful reperfusion)
• EF: 42% (mildly reduced)
• Discharge medications: Aspirin 75 mg + Clopidogrel 75 mg + Atorvastatin 80 mg + Ramipril 2.5 mg + Metoprolol 25 mg BD + Furosemide 20 mg OD
• Follow-up: Cardiology OPD in 1 week; Repeat Echo at 6 weeks
• Advice: Strict smoking cessation, cardiac rehabilitation, low-salt diet

---

CASE 2: COMMUNITY-ACQUIRED PNEUMONIA (CAP)

A 45-year-old male presents with high-grade fever, productive cough with rusty sputum, right-sided pleuritic chest pain, and breathlessness for 5 days.

PRESENTING COMPLAINTS:

1. Fever - 5 days
2. Cough with rust-colored sputum - 4 days
3. Right-sided chest pain worsening on breathing - 3 days
4. Breathlessness - 2 days

HOPI:

GPE:

• Confusion: No (0)
• BUN >7 mmol/L: Yes (1)
• RR ≥30: No (0)
• BP <90/60: No (0)
• Age ≥65: No (0)
• Score = 1 → Low risk, outpatient vs. inpatient (borderline)
• PSI/PORT score calculated → Class III → Admit

SYSTEMIC EXAMINATION - RESPIRATORY:

• Inspection: Decreased chest expansion right side
• Palpation: Increased tactile fremitus right infrascapular
• Percussion: DULL on right infrascapular and axillary regions
• Auscultation: Bronchial breathing + coarse crepitations right lower zone; Aegophony positive

PROVISIONAL DIAGNOSIS:

DIFFERENTIAL DIAGNOSIS:

1. Pulmonary tuberculosis (sputum AFB)
2. Lung abscess
3. Pleural effusion with underlying consolidation

INVESTIGATIONS:

• CXR PA: Right lower zone consolidation (homogeneous opacity with air bronchogram)
• CBC: TLC 18,400/µL (neutrophilia), N: 84%, L: 10%
• CRP: 92 mg/L (elevated)
• PCT (Procalcitonin): 1.8 ng/mL (bacterial)
• Sputum C/S: Gram-positive diplococci (Streptococcus pneumoniae)
• Blood cultures × 2: Pending
• S. pneumoniae urinary antigen: Positive
• RFT, LFT, Electrolytes, Blood sugar: Baseline
• HIV screening: (if risk factors)
• ABG: pH 7.44, PaO2 58 mmHg, PaCO2 32 mmHg → Type 1 respiratory failure

TREATMENT:

• Admit to ward; O2 via face mask 6-8 L/min (target SpO2 ≥94%)
• Semi-recumbent position
• IV access; oral hydration/IV fluids
• Incentive spirometry
• Physiotherapy - chest percussion

PROGRESS NOTES:

DISCHARGE:

• Tab. Amoxicillin-Clavulanate 625 mg TDS × 5 more days
• Pneumococcal vaccine at 6-8 weeks
• Influenza vaccine
• Stop smoking advice
• Follow-up in 6 weeks with repeat CXR

---

CASE 3: DIABETIC KETOACIDOSIS (DKA)

A 24-year-old known Type 1 diabetic female admitted with vomiting, abdominal pain, deep rapid breathing, and confusion for 12 hours. Omitted insulin for 2 days.

PRESENTING COMPLAINTS:

1. Vomiting - 12 hours
2. Abdominal pain - 12 hours
3. Deep rapid breathing - 8 hours
4. Confusion - 4 hours

HOPI:

GPE:

SYSTEMIC EXAMINATION:

• Abdomen: Diffuse tenderness (DKA itself causes pseudoperitoneum - exclude surgical cause)
• CNS: Drowsy, responding to voice; pupils equal and reactive

PROVISIONAL DIAGNOSIS:

INVESTIGATIONS:

• Glucometer: HI (>500 mg/dL) → Confirm with lab
• Urine dipstick: Ketones 4+, Glucose 4+

• Blood glucose >250 mg/dL ✓
• pH <7.3 ✓
• HCO3 <15 mEq/L ✓
• Anion gap >12 ✓
• Urine/serum ketones positive ✓

TREATMENT PROTOCOL:

• IV access × 2 (large bore)
• 0.9% Normal saline: 1 L over first hour (correct shock/dehydration)
• O2 via NRB mask
• Catheterize (urine output monitoring - target >0.5 mL/kg/h)
• NGT if vomiting persisting

• K+ = 3.2 → Replace first: KCl 40 mEq in 1L NS over 4h (central line)
• DO NOT start insulin until K+ ≥3.5 (insulin shifts K+ intracellularly → fatal hypokalemia)

• Regular insulin 0.1 unit/kg/h IV (= 7 units/h for 70 kg)
• Target glucose fall: 50-70 mg/dL/hour
• When glucose <250 mg/dL: Switch IV fluid to D5W + reduce insulin to 0.05 units/kg/h

• 0.9% NS: 500 mL/h × 4h → 250 mL/h × 4h → 125 mL/h as tolerated
• When glucose <250: Add dextrose to maintain glucose 150-200 mg/dL
• Total deficit: Approximately 5-8 L

• Glucose hourly
• Electrolytes (K+) every 2h
• ABG every 2-4h
• Urine output hourly
• GCS every 2h

• Blood glucose <200 mg/dL
• pH >7.3
• HCO3 ≥15 mEq/L
• Anion gap <12

• Give first SC dose of long-acting insulin 2h BEFORE stopping IV insulin
• Resume usual insulin regimen

PROGRESS NOTES:

DISCHARGE:

• Insulin regime adjusted
• DM education: Sick day rules (NEVER omit insulin even if not eating)
• Self-monitoring blood glucose (SMBG)
• HbA1c in 3 months
• Endocrinology OPD follow-up

---

CASE 4: UPPER GI BLEED (Variceal)

A 50-year-old male with known alcoholic liver cirrhosis admitted with hematemesis (2 large episodes, ~500 mL fresh blood) and melena for 6 hours.

PRESENTING COMPLAINTS:

1. Vomiting blood - 6 hours (2 episodes, ~500 mL)
2. Passage of black tarry stools - 4 hours
3. Dizziness and weakness - 4 hours

HOPI:

GPE:

SYSTEMIC EXAMINATION:

• Abdomen: Moderate ascites, splenomegaly, liver edge not palpable (cirrhosis)
• Hands: Palmar erythema, Dupuytren's contracture, leuconychia, flapping tremor (hepatic encephalopathy)
• Chest: Spider angiomata × 4

INVESTIGATIONS:

• CBC: Hb 6.8 g/dL, PCV 22%, Platelet 68,000 (hypersplenism)
• PT/INR: 2.4 (coagulopathy of liver disease)
• LFT: Bilirubin 4.2, Albumin 2.8, ALT 78
• RFT: Creatinine 1.6, BUN 42 (blood in gut)
• Electrolytes: Na 128, K 3.0
• Blood group and crossmatch (4 units PRBC)
• ABG

• CXR: No free air (exclude perforation)
• USG abdomen: Portal hypertension, splenomegaly, ascites - no thrombus

TREATMENT:

• 2 large bore IV cannulas (14-16G)
• IV NS/Ringer's lactate: 500 mL rapidly (avoid over-expansion → re-bleed)
• Target Hb 7-8 g/dL (restrictive transfusion strategy = better outcomes)
• Blood transfusion: 2 units PRBC (crossmatched)
• FFP: 2 units (for coagulopathy, INR >2)
• Platelet transfusion if <50,000 before endoscopy

• Endoscopic variceal ligation (EVL) - primary modality
• If active bleed not controlled: Sclerotherapy (cyanoacrylate for gastric varices)
• Balloon tamponade (Sengstaken-Blakemore tube) if EVL fails - bridge to TIPS

• Propranolol: Restart when stable (reduces portal pressure, prevents re-bleed)
• Repeat EVL sessions every 2-4 weeks until variceal obliteration
• TIPS (Transjugular Intrahepatic Portosystemic Shunt): If 2 endoscopy sessions fail

• Lactulose 30 mL TDS (reduce ammonia)
• Avoid sedation, avoid protein excess
• Rifaximin 550 mg BD (adjunct)

• Spironolactone 100 mg + Furosemide 40 mg OD
• Albumin 1.5 g/kg on Day 1 of SBP diagnosis (if concurrent)
• Fluid restriction to 1.5 L/day

DISCHARGE:

• Propranolol (titrate to HR 55-60 or reduce resting HR by 25%)
• EVL repeat in 2 weeks
• Lactulose + Rifaximin
• Complete alcohol cessation (counselling referral)
• Liver transplant evaluation

---

CASE 5: STROKE / CVA (Ischemic)

A 65-year-old hypertensive male with sudden onset left-sided weakness, facial deviation, and slurred speech for 2 hours.

PRESENTING COMPLAINTS:

1. Sudden weakness of left arm and leg - 2 hours
2. Deviation of mouth - 2 hours
3. Slurred speech - 2 hours

HOPI:

GPE:

SYSTEMIC EXAMINATION - CNS:

• Higher functions: Alert, oriented, dysarthria
• Cranial nerves: CNVII LMN palsy left side (face)
• Motor: Left upper limb 0/5, left lower limb 1/5 (power)
• Tone: Decreased left (acute phase)
• Reflexes: Brisk left, Babinski positive left
• Sensory: Diminished to touch/pain left side
• Cerebellar: Not assessable
• No meningism

PROVISIONAL DIAGNOSIS:

INVESTIGATIONS:

• Non-contrast CT head (NCCT): Rule out hemorrhage → NEGATIVE for bleed (dark CSF spaces, no hyperdense lesion in first 6h)
• ECG: AF with normal ventricular rate
• Blood glucose (hypoglycemia mimics stroke): 128 mg/dL
• INR/PT: 1.1 (not on anticoagulant)
• CBC, RFT, Electrolytes

TREATMENT:

• Time window: Within 4.5 hours of onset (patient at 2h → ELIGIBLE)
• Contraindications checked: No recent surgery, no bleed on CT, BP controllable, no coagulopathy
• Alteplase 0.9 mg/kg IV (max 90 mg):
  • 10% as bolus over 1 min
  • Remaining 90% over 60 min infusion
• Monitor: BP every 15 min during infusion, neurological checks

• For thrombolysis: Bring BP to <185/110 before starting
• Labetalol 10-20 mg IV or Nicardipine 5 mg/h
• After thrombolysis: Keep <180/105 for 24h

• Large vessel occlusion on CTA (MCA M1) → EVT within 24h of onset
• Transfer to neurointerventional suite

• Aspirin 300 mg STAT + Clopidogrel 75 mg OD (dual antiplatelet × 21 days for minor stroke)

• DEFER anticoagulation 2-14 days (hemorrhagic transformation risk)
• After CT confirms no bleed at 5-7 days: Start DOAC (Rivaroxaban 20 mg OD or Apixaban 5 mg BD)
• WARFARIN if valve disease (target INR 2-3)

• Nil orally (swallowing assessment with GUSS tool first)
• NG tube feeding if dysphagia
• IV fluids: NS (not dextrose - may worsen cerebral edema)
• Head end elevation 30°
• Avoid hyperthermia (paracetamol for temp >37.5°C)
• DVT prophylaxis: Enoxaparin 40 mg SC + TED stockings
• Monitor glucose: Keep 140-180 mg/dL (both hypo and hyperglycemia worsen outcome)
• Urinary catheter (retention risk)

• Physiotherapy: Range of motion, positioning
• Speech therapy: Dysarthria/aphasia
• Occupational therapy
• Neurology/Rehab team

DISCHARGE:

• DOAC for AF (Apixaban 5 mg BD)
• Antihypertensive: Perindopril 4 mg OD
• Statin: Atorvastatin 40 mg OD
• Antiplatelet (if no anticoagulation)
• Physiotherapy and speech therapy (outpatient)
• Target BP <130/80, LDL <70 mg/dL

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CASE 6: SEPSIS / SEPTIC SHOCK

A 72-year-old diabetic male admitted with high fever, low BP, confusion, and decreased urine output for 24 hours (source: UTI).

PRESENTING COMPLAINTS:

1. Fever with chills - 3 days
2. Burning micturition, foul-smelling urine - 3 days
3. Confusion - 24 hours
4. Low BP, weakness - 12 hours

GPE:

INVESTIGATIONS:

• Lactate: 4.8 mmol/L (>2 = sepsis; >4 = septic shock)
• Procalcitonin: 28 ng/mL
• Blood cultures × 2 (before antibiotics)
• Urine R/M: Pus cells +++, bacteria +++
• Urine C/S: Sent (result in 48h)
• CBC: TLC 22,000; CRP 180
• RFT: Creatinine 2.8 (AKI), BUN 64
• ABG: pH 7.28, HCO3 14, lactate 4.8

SURVIVING SEPSIS BUNDLE (1-HOUR BUNDLE):

1. Measure lactate (done - 4.8 mmol/L)
2. Blood cultures × 2 BEFORE antibiotics
3. Broad-spectrum antibiotics STAT:
   • Piperacillin-Tazobactam 4.5 g IV q6h + Gentamicin 5 mg/kg OD
4. Crystalloid: 30 mL/kg NS IV over 3 hours (2100 mL for 70 kg)
5. Vasopressors if MAP <65 after fluids:
   • Norepinephrine: Start 0.1-0.5 mcg/kg/min (target MAP ≥65 mmHg)

• ICU admission (SOFA ≥8, vasopressor requirement)
• Central line (CVP monitoring)
• Arterial line (continuous BP)
• Foley catheter (UO target >0.5 mL/kg/h)
• Hydrocortisone 200 mg/day IV if vasopressor-refractory
• Insulin infusion for glucose >180 mg/dL
• DVT prophylaxis
• Stress ulcer prophylaxis (pantoprazole)
• Source control: Urology consult (urinary tract - catheterization/drainage)

DISCHARGE:

• Culture-directed antibiotics for 5-7 days total
• Urology follow-up (stone/BPH if UTI source)
• Diabetes management optimization

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SECTION 2: SURGERY

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CASE 7: ACUTE APPENDICITIS

A 22-year-old male with pain starting around the navel and shifting to right iliac fossa over 24 hours, with nausea, vomiting, and fever.

PRESENTING COMPLAINTS:

1. Pain abdomen - 24 hours (central → RIF)
2. Nausea and vomiting - 20 hours
3. Fever - 12 hours
4. Anorexia - 24 hours

HOPI:

GPE:

• Temp: 38.2°C, HR 98/min, BP 120/76, RR 18
• Anxious, guarding right side on walking
• No jaundice, no lymphadenopathy

SYSTEMIC EXAMINATION - ABDOMEN:

• Inspection: Moves poorly with breathing right side; no distension
• Palpation: Maximum tenderness at McBurney's point (1/3 from ASIS to umbilicus)
  • Rebound tenderness: Positive (peritoneal irritation)
  • Rovsing's sign: Positive (LIF pressure causes RIF pain)
  • Psoas sign: Positive (pain on right hip flexion)
  • Obturator sign: Positive (pain on internal rotation of right hip)
  • Guarding/rigidity: +1 right lower quadrant
• Percussion: Tenderness
• Auscultation: Reduced bowel sounds

INVESTIGATIONS:

• CBC: TLC 16,400, Neutrophils 88% (left shift)
• CRP: 78 mg/L
• Urine R/M: Normal (rule out UTI/renal colic)
• Urine pregnancy test (females): Negative
• Blood group and crossmatch
• BMP baseline
• USG abdomen: Non-compressible, enlarged appendix >6 mm; periappendiceal fat stranding
• CT abdomen + pelvis (if USG inconclusive): Confirms - appendicular diameter 9 mm, periappendiceal inflammation

FINAL DIAGNOSIS:

TREATMENT:

• Nil orally from time of diagnosis
• IV Ringer's Lactate 1L over 8h
• Inj. Ceftriaxone 1g IV stat (pre-op antibiotic)
• Inj. Metronidazole 500 mg IV stat
• Inj. Ondansetron 4 mg IV (anti-emetic)
• Consent for laparoscopic appendicectomy
• Anaesthesia fitness

• Under GA
• 3-port technique (umbilical 10mm + suprapubic 5mm + left iliac fossa 5mm)
• Identify appendix, mesoappendix divided, base ligated (Endoloop/stapler)
• Appendix retrieved in endobag
• Peritoneal lavage if pus present
• Drains only if perforation
• Specimen to histopathology (exclude carcinoid/Crohn's)

• IV antibiotics continued 24h (uncomplicated) or 5-7 days (perforated)
• Start oral liquids in 6h if laparoscopic
• Analgesia: Paracetamol + Diclofenac
• DVT prophylaxis: LMWH + stockings
• Discharge Day 1-2 post-op (laparoscopic)

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SECTION 3: OBSTETRICS & GYNAECOLOGY

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CASE 8: ECLAMPSIA

A 24-year-old primigravida at 35 weeks gestation admitted with convulsions at home, BP 180/120, and pedal edema for 2 weeks.

PRESENTING COMPLAINTS:

1. Convulsions - 1 episode, 1 hour ago (tonic-clonic, duration 2 min)
2. Severe headache - 3 days
3. Blurring of vision - 2 days
4. Swelling of feet - 2 weeks

OBSTETRIC HISTORY:

• Primi gravida, 35 weeks (LMP-based)
• ANC: Irregularly attended (3 visits only; last visit BP noted as 140/90 at 30 weeks - not followed up)
• No prior hypertension before pregnancy

GPE:

OBSTETRIC EXAMINATION:

• Fundal height: 34 weeks size
• FHR: 148 bpm (reassuring)
• Presentation: Cephalic
• Station: -3 (not engaged)
• Cervix: Closed, uneffaced

INVESTIGATIONS:

• Urine dipstick: Protein +++
• Urine albumin: 24h - 4.8 g/day (severe range)
• CBC: Hb 10.2, Platelets 98,000 (HELLP developing)
• LFT: AST 120, ALT 98 (elevated - HELLP)
• LDH: 680 (elevated)
• Peripheral smear: Schistocytes (hemolysis)
• RFT: Creatinine 1.4
• Coagulation: PT 16s, aPTT 42s
• USG with Doppler: Fetal wellbeing assessment; uterine artery notching; umbilical artery absent end-diastolic flow

TREATMENT:

• Left lateral position (prevent aspiration)
• O2 10 L/min via NRB mask
• IV access × 2
• Continuous fetal monitoring (CTG)

• Target: SBP 140-155 mmHg, DBP 90-105 mmHg
• Labetalol: 20 mg IV → repeat 40 mg → 80 mg at 10 min intervals (max 300 mg)
• Hydralazine: 5-10 mg IV q20 min
• Oral: Nifedipine 10 mg sublingual/oral

• Eclampsia = indication for urgent delivery regardless of gestational age
• If cervix favorable (Bishop score ≥6): Induce labor (oxytocin)
• If cervix unfavorable or fetal distress: Emergency LSCS
• Continue MgSO4 during labor and for 24h post-delivery

• Strict fluid balance (risk of pulmonary edema - restrict to 80-100 mL/h)
• Foley catheter hourly output
• Steroid: Dexamethasone 12 mg IM q12h × 2 doses (fetal lung maturity at 35 weeks)
• ICU/HDU admission

PROGRESS NOTES:

DISCHARGE (Day 5):

• Oral antihypertensives: Labetalol 200 mg BD + Nifedipine LA 30 mg OD
• MgSO4 course complete
• Advise: Home BP monitoring, OPD follow-up in 1 week
• Risk counselling: 25-40% recurrence risk in next pregnancy
• Reassess antihypertensives at 6 weeks postpartum

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SECTION 4: PAEDIATRICS

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CASE 9: PEDIATRIC FEBRILE SEIZURES + BACTERIAL MENINGITIS

A 14-month-old male child brought with high fever and 2 episodes of generalized tonic-clonic convulsions lasting >5 minutes each, with bulging fontanelle and neck stiffness.

PRESENTING COMPLAINTS:

1. Fever - 2 days (high grade)
2. Convulsions - 2 episodes (today, each >5 min)
3. Vomiting - 5 episodes
4. Irritability and lethargy - 1 day

HOPI:

BIRTH HISTORY:

IMMUNIZATION HISTORY:

GPE:

NEUROLOGICAL EXAMINATION:

• Neck stiffness: Present (meningism)
• Kernig's sign: Positive (resistance to knee extension when hip flexed)
• Brudzinski's sign: Positive (involuntary hip flexion when neck flexed)
• GCS: 10/15 (E2V3M5) - post-ictal + encephalopathy
• Pupils: 4mm, equal, reactive
• Fundoscopy: Papilledema present (raised ICP confirmed)

PROVISIONAL DIAGNOSIS:

INVESTIGATIONS:

• CBC: TLC 24,600, Polymorphs 92%, Platelets 58,000
• CRP: 212 mg/L, PCT: 48 ng/mL
• Blood culture × 2 (STAT, BEFORE antibiotics - 10-15 min window only)
• Blood glucose: 48 mg/dL (HYPOGLYCEMIA - treat immediately)
• Electrolytes: Na 122 (SIADH - hyponatremia)
• RFT: Normal
• Coagulation: PT 18s, APTT 52s (DIC risk)

• Cerebral edema, no mass, no herniation → LP safe after mannitol

TREATMENT:

• IV access (IO if no IV access)
• O2 via face mask
• Dextrose: D10W 2 mL/kg IV for hypoglycemia (correct glucose first)

• 0.15 mg/kg IV q6h × 4 days
• Reduces neurological sequelae (deafness, neurological disability)
• Give 15-20 min BEFORE antibiotics (reduces cytokine-driven inflammation)

• Head elevation 30°
• Mannitol 0.5-1 g/kg IV over 20 min (if herniation signs)
• Restrict fluids to 2/3 maintenance initially (SIADH → correct hyponatremia slowly)
• Correct Na+ by no more than 10-12 mEq/L per 24h (rapid correction → central pontine myelinolysis)
• 3% NaCl: 3-5 mL/kg if severe symptomatic hyponatremia

• Active seizure: Lorazepam 0.05-0.1 mg/kg IV (or diazepam 0.2 mg/kg IV/PR)
• Maintenance AED: Levetiracetam 20 mg/kg IV loading → 15 mg/kg/day divided BD
• Phenobarbital if unavailable: 20 mg/kg IV loading

• Close contacts: Rifampicin 10 mg/kg BD × 2 days (or Ciprofloxacin single dose in adults)
• Notify public health authority (notifiable disease)

• ICU/PICU admission
• Continuous monitoring: Neuro checks every hour, BP, urine output
• Cooling blanket for hyperthermia
• NPO initially; NG feeds if stable
• DVT prophylaxis not routine in young children

PROGRESS NOTES:

DISCHARGE:

• Complete 14-day course (7 days IV + 7 days oral)
• Audiology follow-up (sensorineural hearing loss in 10-30%)
• Neurodevelopmental assessment at 6 weeks
• COMPLETE immunization catch-up schedule
• Meningococcal vaccine (ACWY and B) for child + close contacts

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SECTION 5: IPD PROGRESS NOTE FORMAT

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DAILY PROGRESS NOTE TEMPLATE

┌──────────────────────────────────────────────────────────────┐
│ DATE: ___________  TIME: ___________  DAY: Day ___ of IPD    │
│ Ward: ________  Bed No.: _______  IP No.: ________________   │
├──────────────────────────────────────────────────────────────┤
│ SUBJECTIVE (Patient's complaints):                           │
│ ____________________________________________________________  │
│                                                              │
│ OBJECTIVE (Clinical findings today):                         │
│ Temp: ____°C  HR: ____/min  BP: ____mmHg  RR: ____/min       │
│ SpO2: ____% on ____L O2  Weight: ____kg  UO: ____mL/h        │
│                                                              │
│ Examination:                                                 │
│ General: ___________________________________________________  │
│ System-specific: ___________________________________________  │
│                                                              │
│ Investigation results today:                                 │
│ ____________________________________________________________  │
│                                                              │
│ ASSESSMENT:                                                  │
│ ____________________________________________________________  │
│                                                              │
│ PLAN (for next 24 hours):                                    │
│ 1. __________________________________________________________ │
│ 2. __________________________________________________________ │
│ 3. __________________________________________________________ │
│                                                              │
│ Signature: _____________  Designation: _________________     │
└──────────────────────────────────────────────────────────────┘

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DISCHARGE SUMMARY FORMAT

┌──────────────────────────────────────────────────────────────┐
│               DISCHARGE SUMMARY                              │
│ IP No.: ________  Ward: ________  Bed: _______               │
├──────────────────────────────────────────────────────────────┤
│ Patient: ________________  Age: ___  Sex: ___                │
│ DOA (Date of Admission): ________  Time: ________            │
│ DOD (Date of Discharge): ________  Time: ________            │
│ Length of Stay: _________ days                               │
│ Admitted under: Dr. _________________________                │
├──────────────────────────────────────────────────────────────┤
│ PRESENTING COMPLAINTS: ______________________________________ │
│                                                              │
│ DIAGNOSIS (Final):                                           │
│ Primary: ___________________________________________________ │
│ Secondary: _________________________________________________ │
│ Comorbidities: _____________________________________________ │
├──────────────────────────────────────────────────────────────┤
│ HOSPITAL COURSE (Brief summary):                             │
│ ____________________________________________________________  │
│ ____________________________________________________________  │
├──────────────────────────────────────────────────────────────┤
│ KEY INVESTIGATIONS:                                          │
│ ____________________________________________________________  │
├──────────────────────────────────────────────────────────────┤
│ PROCEDURES DONE:                                             │
│ ____________________________________________________________  │
├──────────────────────────────────────────────────────────────┤
│ CONDITION AT DISCHARGE:                                      │
│ □ Stable  □ Improved  □ Unchanged  □ LAMA  □ DAMA           │
│ □ Referred to ___________________                            │
├──────────────────────────────────────────────────────────────┤
│ DISCHARGE MEDICATIONS:                                       │
│ 1. __________________________________________________________ │
│ 2. __________________________________________________________ │
│ 3. __________________________________________________________ │
│ (Attach separate prescription)                               │
├──────────────────────────────────────────────────────────────┤
│ DIETARY ADVICE: ____________________________________________  │
│ PHYSICAL ACTIVITY: _________________________________________  │
│ SPECIAL INSTRUCTIONS: ______________________________________  │
├──────────────────────────────────────────────────────────────┤
│ FOLLOW-UP:                                                   │
│ OPD: ________________________  Date: ______________________  │
│ Tests to bring: _____________________________________________│
│ Emergency: Return immediately if ___________________________  │
├──────────────────────────────────────────────────────────────┤
│ Consultant: Dr. ________________________  Sign: _________    │
│ Resident: Dr. __________________________  Sign: _________    │
│ Institution Stamp: ____________________                      │
└──────────────────────────────────────────────────────────────┘

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QUICK REFERENCE: COMMON IPD CASES ACROSS SPECIALTIES

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What's Inside (35 KB, fully formatted)

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Cases Included

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Document Features

• Colour-coded headers (blue case banners, teal section headers)
• Dosing tables with doses, routes, mechanisms, and timing
• Scoring tools (KDIGO AKI stages, GOLD COPD, Garden classification, BWS thyroid storm score, SCORTEN, Ranson, Burch-Wartofsky)
• Clinical pearls (e.g., iodine must be given 1h AFTER PTU; pilocarpine contraindicated when IOP >40; silver sulfadiazine avoided in SJS caused by sulfonamides)
• Final summary table — all 10 diagnoses with critical treatment in one page