Wardwise Treatment Guidelines


Wardwise Treatment Guidelines

Edited By :

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Dr.Salim Al Mamun
MBBS(Raj);CCD(BIRDEM);
CMU(DU)
Medical officer
Tenglahata Uposhastha Kendro
Kazipur , Sirajganj.

drsalimalmamun@gmail.com
http://www.drsalimalmamun.wordpress.com
Management of some poisoning
Poisoning in Medicine Ward

1. Sedative poisoning
Diagnostic tools:
1. H/O of taking sedatives e.g. Sedil, lexotanil, Bopam etc.
2. Pt. may be disoriented or drowsy or in deep sleep.
3. Respiration is normal or depressed.
4. Planter reflex is normal or extensor.
5. Pupils mid dilated & sluggish reaction to light.
Management:
1. Diet- normal, plenty of tea, coffee by mouth if Pt. can swallow
2. NPO till recovery, If pt. is in deep sleep.
3. O2 inhalation 1-4 L/min, if respiration is depressed.
4. Infusion 5% DNS 1000 i/v @ 10 drops/ min.
5. Activated charcoal (Tab. Ultracarbon 2+2+2), if pt. present with in 1 hour.
6. Antidote of Benzodiazepine- Flumazenil, slowly IV, dose 0.2 mg over 30–60 seconds, repeated in 0.5 mg increments as needed up to a total dose of 3–5 mg.
Flumazenil is a benzodiazepine receptor-specific antagonist; it has no effect on ethanol, barbiturates, or other sedative-hypnotic agents.
Flumazenil should not be used in pt. with H/O seizures or in patients with preexisting seizure disorder, toxin induced cardio toxicity, co-ingestion with TCA. The duration of action of flumazenil is short (2–3 hours) and resedation may occur, requiring repeated doses.
Activated Charcoal: Activated charcoal effectively adsorbs almost all drugs and poisons. Poorly adsorbed substances include iron, lithium, potassium, sodium, mineral acids, and alcohols.
(Ref. CMDT 2010)
2. Tricyclic antidepressant poisoning (Tryptin)

Clinical features
1. H/O taking TCA drugs in over doses ie. Amitryptylin
2. Dilated pupil, ileus, and retention of urine.
3. Respiration may depressed.
4. Presence of arrhythmias in ECG may present
5. Hypotension may occur
6. Hyperreflexia with extensor plantar, coma, and seizures.
7. Improvement can be expected within 24 h.

Management
1. NPO till further order or recovery.
2. IV fluids infusion (5% DNS1000cc +5% DA1000cc i.v. @20 drops/min. stat & daily)
3. Gastric lavage may be given after delayed presentation.
4. Tab. Ultracarbon 2+2+2
5. Treatment of arrythmias
6. If convulsion present Diazepam and phenytoin.
7. ECG monitoring during the first 24 h and until ECG changes have disappeared for 12 h.
8. If acidosis present- IV sodibicarb
Note: Sodibicarb available at 7.5% 25 ml
Tips:
• Gastric elimination may be useful for 24 h after ingestion because tricyclics slow gastric emptying.
• Cardiac arrhythmias are more common if there is acidosis. Bicarbonate should be used to achieve an arterial pH of 7.5 urgently.
• If arrhythmias occur with no acidosis and fail to respond to treatment with amiodarone or phenytoin, bicarbonate (25-50 mL 8.4% IV) may still be useful with in 20 min.
• If VT compromising cardiac out put, Lidocaine 50-100mg i.v. should be given.
(Ref. Oxford American Hand book of critical care + Parvin Kumar & M. Clark)

3. Stupifying poisoning (unknown poisoning)
Diagnostic tools:
1. H/O of poisoning during traveling or ingestion or inhalation of foods or other substances by unknown person.
2. Pt. in deep sleep or drowsy
3. Pupil constricted or dilated and light reaction normal or absent
4. Circulation (Pulse & BP) usually normal
5. Respiration normal.
(Contradictory-in OPC poisoning pupil is constricted but bradycardia hypotension & crepitation present in lungs).

Management:
1. NPO till further order
2. Iv fluid Infusion
3. Inj. Omeprazole (40mg) 1 vial i/v slowly stat and daily
4. Continued catheterization (antibiotic if catheterization is done)
5. Monitor vital signs

(Ref. National guideline for management of poisoning)

4. Corrosive Poisoning (strong acid & alkali)
Management:
1. NPO TFO
2. Clearing of the airways
3. O2 inhalation 4-6 L/min
4. Irrigate exposed eyes with sterile cold water or saline at least for 20 minutes and continue until the pt. returns to normal
5. Infusion 5% DNS 1000 + 5% DA 1000 cc i/v @ 20 drops/ min.
6. Inj. Diclofen 1 amp. im stat. & SOS
7. Inj. Omeprazole 40 mg IV slowly stat. & B.D.

Tips:
1. Dilution or neutralization, induction of emesis, gastric aspiration and lavage are contra-indicated.
2. Emulcents- egg white, olive oil, butter, cold milk should be avoided.
3. As there is no specific antidote, symptomatic treatment is to be provided. Neutralization with alkali now a days is not done.
4. Surgical treatment must be considered for any pt grade ll or lll esophageal injury.
5. Diagnostic Endoscopy should be performed within 12-24 hours of alkali ingestion.
6. Corticosteroids have no role in the management of a case and complication. It is rather harmful.
7. Soluble calcium tablet followed by 10% ca gluconate IV can be given in acid ingestion.
8. 1% NaHCO3 irrigation may be given in eye involvement with steroid eye drops.
( Ref. National guideline for management of poisoning)

5. Dhatura Poisoning
Management:
1. NPO TFO
2. Stomach wash with in 1 hour
3. Clearing of the airways
4. O2 inhalation 4-6 L/min
5. Infusion 5% DNS 1000 + 5% DA 1000 cc i/v @ 20 drops/ min.
6. Inj. Omeprazole 40 mg iv slowly stat. & B.D.
7. Physostigmine 0.5 mg to 1 mg s/c stat.
8. Paracetamol suppository
9. Tepid sponging
10. Catheterization done for urinary retention. (antibiotic if catheterization is done).

Tips:
1. If stomach is full, no forceful emesis should be tried.
2. Specific antidote: (l) Physostigmine 0.5 mg to 1 mg s/c to antagonise atropine in a single dose. (ll) Prostigmine is more effective and less toxic than physostigmine in same dose. (lll) Pilocarpine 5 mg s/c, though useful, does not counteract the action of Dhatura on brain, can be repeated 2 hourly at early stage of poisoning.
3. Delirium can be treated with short acting barbiturates.
4. To control marked excitement chlorolhydrate or paraldehyde in moderate dose may be given.
5. Repeated purgation is not recommended.
6. Forced diuresis is not encouraged.
7. Light diet, mainly liquid or semi-liquid should be given if the condition is mild.
8. Other symptomatic treatments.

(Ref. National guideline for management of poisoning)

6. Methanol Poisoning
Management:
1. NPO TFO
2. Stomach wash with in 1 hour
3. Clearing of the airways
4. O2 inhalation 4-6 L/min
5. Infusion 5% DNS 1000 + 5% DA 1000 cc i/v @ 20 drops/ min.
6. Inj. Omeprazole 40 mg iv slowly stat. & B.D.
7. Antidode : Ethanol.
Loading dose: 10% ethanol 7.5 ml/kg IV over 30 to 60 mins
Maintaining dose: 10% ethanol 1.96 ml/kg/hr IV.
If IV not available, then
Orally: 95% ethanol, 0.8 ml/kg followed by 0.1 ml/kg/hr can be given.
Maintaining dose : 0.2 ml/kg/hr. This alcohol should be diluted in water or fruit juice.
Tips:

1. Should be hospitalized and must be treated by an ophthalmologist for his visual problems.
2. Stomach wash although advocated, there is no evidence of affectivity with it.
4. In severe cases pt should be incubated and mechanical respiration should be given.
7. Acidosis should be controlled by infusing sodium bi-carbonate.
8. Sedation can be given cautiously to prevent delirium and restlessness.
9. The antidote for methanol poisoning is ethanol.

(Ref. National guideline for management of poisoning.)

7. Puffer fish poisoning
Management:
1. NPO TFO except medication
2. Stomach wash with in 1 hour with 2% sodibicarb
3. Clearing of the airways
4. O2 inhalation 4-6 L/min
5. Infusion 5% DNS 1000 + 5% DA 1000 cc i/v @ 20 drops/ min.
6. Inj. Omeprazole 40 mg iv slowly stat. & B.D.
7. Tab. Ultracarbon 2+ 2 + 2
8. Atropinization and inj. neostigmine has been used for come round from unconsciousness and restoring neurogenic power both sensory and motor.
Tips:
There is no specific antidote, so only symptomatic treatment:
1. Artificial respiration with oxygen inhalation by mask in mild cases and direct ventilatory support and sedation in severe cases.
2. Purgation and forced diuresis to lessen absorbed poison is not recommended.
3. Steroids for life saving measure although contra-indication persists.
( Ref. National guideline for management of poisoning)

8. Opiate Poisoning
Management:
a. NPO TFO except medication
b. Infusion 5% DNS 1000 cc + 5% DA 1000 cc iv @ 20 d/min
c. Tab Ultracarbon 2 + 2 + 2
d. Inj. Omeprazole 40 mg iv slowly stat. & daily
e. Naloxone can be given to reverse the sign of severe poisoning (coma, respiratory depression or convulsion) within a few minutes but it has a short life and the pt may relapse.

Dose: Administer 0.4–2 mg intravenously, and repeat as needed to awaken the patient. Very large doses (10–20 mg) may be required for patients intoxicated by some opioids (eg, propoxyphene, codeine, fentanyl derivatives).
Caution: The duration of effect of naloxone is only about 2–3 hours; repeated doses may be necessary for patients intoxicated by long-acting drugs such as methadone. Continuous observation for at least 3 hours after the last naloxone dose is mandatory.
9. Paracetamol Poisoning
Management
1. NPO TFO except medication
2. Infusion 5% DNS 1000 cc + 5% DA 1000 cc iv @ 20 d/min
3. Tab Ultracarbon 2 + 2 + 2
4. Inj. Omeprazole 40 mg iv slowly stat. & daily
5. Special antidote: N-Acetylcysteine (NAC), Methionine.
Dose:
 Adult: 150 mg/kg IV in 200 ml of 5% DA over 15 mins, followed by
 50 mg/kg IV in 500 ml dextrose over 4 hours, followed by
 100 mg/kg IV in 1000 ml 5% DA over 16 hours.

With established hepatotoxicity, continue NAC treatment 50 ml/kg in 500 ml of 5% DA over 8 hours.
Repeat until prothrombin time and liver enzyme begin to return to normal.

(Ref. National guideline for management of poisoning.)

10. Savlon poisoning
Diagnostic tools:
1. H/O of ingestion of savlon
2. Burning sensation in throat and upper abdomen.
Management:
1. NPO till further order except medication
2. Irrigate exposed eyes with sterile cold water or saline at least for 20 minutes and continue until the pt. returns to normal.
3. Inj. Omeprazole (40mg) 1 vial i/v slowly stat and daily
4. Inj. Amoxicillin (500mg) 1 vial i/v stat & 8 hourly
5. IV infusion
11. OPC poisoning
Management:
1. External decontamination with water.
2. Remove clothing. Avoid contamination with other personnel.
3. Gastric lavage if pt. resent within 1 hour
4. NPO TFO
5. O2 inhalation 4-6 L/min
6. Tab Ultracarbon 2 + 2 + 2 if present within 1 hour
7. Assisted ventilation as appropriate if respiratory failure
8. Infusion 5% DNS 1000 cc + 5% DA 1000 cc iv @ 20 d/min
9. Inj. Amoxicillin 500 mg iv stat. & 8 hourly
10. Inj. Omeprazole 40 mg iv stat. & daily
11. Atropine 0.6-2 mg repeats after 10-25 min upto atropinasation occurs.
12. Pralidoxime chloride 2 g IV over 4 min, repeated at 4-6 hourly
13. Continued catheterization
14. Monitor vital sign

12 Poisonous snake bite
Polyvalent antisnake venom is effective against the following snake’s venom
1. Cobra
2. Krait
3. Russel’s viper
4. Saw scaled viper
Indication of Polyvalent antisnake venom:
1. Neurotoxic signs
2. Rapid extension of local swelling
3. Acute renal failure
4. Cardiovascular abnormalities
5. Bleeding abnormalities
6. Haemoglobinuria / myoglobinuria

Management:
Assesment
Look for sign of envenometion
1. Polyvalent antisnake venom 10 vial + 100 cc 5% DNS or NS iv @ 60 drops/min
2. If Neurotoxic features- Inj. Atropine 1 amp. iv stat. & 4 hourly, then after 15 min. inj. Neostigmine 4 amp. Subcutaneously 4 hourly.
3. Antibiotic- if risk of infection or Endotrachael intubation done.
4. If features of resp. failure-endotracheal intubation.
5. Follow up 15-30 min. interval by- pulse, BP, Respiratory rate, respiratory movement, adverse effects of antivenom
6. In case of haemostatic abnormalities
• Strict bed rest
• Avoid I/M injection.
• Fresh blood transfusion.
• Avoid NSAID or Aspirin for pain
7.Inj. TT & TIG
8. Iv infusion
Criteria for repeating the initial dose of antivenom:
• If no improvement or deterioration after 1-2 hours
• Persistence or recurrence of blood incoagulability after 6 hours.

Non-poisonous snake bite
Management:
• Symptomatic
• No NSAID ( Analgesic Paracitamol)
• No Sedative & anxiolytics
• Follow up 30 min. interval by- pulse, BP, Resp. rate, resp. movement, features of envenomation.
• After 24 hours if no features of envenomation then discharge the pt.

Respiratory System

1. Allergic rhinitis
Diagnostic tools
1. Frequent sudden attack of sneezing
2. Profuse watery nasal discharge
3. Nasal obstruction.
Management:
Following management either singly or in combination..
1. Antihistamine such as Loratidine
2. Sodium cromoglycate nasal spray
3. Nasal steroid spray e.g. Beclomethason diproprionate, Fluticasone or Budesonide
4. Systemic steroid –in which symptoms are severe.

2. Pneumonia
Diagnostic tools:
1. Fever high grade with cough with sputum (rusty)
2. Chest pain- pleuritic
3. On exam. –feature of consolidation like bronchial breath sound present, vocal resonance increased.
Management:
Uncomplicated CAP (community acquired pneumonia)
1. Antibiotic for 7-10 days
Amoxicilin 500 mg 8 hourly or
Clarithromycin 500 mg 12 hourly
2. Tab. Paracetamol

Severe CAP (2 weeks)
1. Diet- Normal
2. Inj. Ceftriaxone (1gm) 1 vial i/v stat. & B.D
3. Tab. Clarin (500mg) 1+0+1
4. Tab. Paracetamol (500mg) 1+1+1
5. If Chest pain NSAID- Diclofenac sodium
6. Assessment of severity
7. Mechanical ventilation if needed
-Respiratory rate 70 5 5

Category -II management

Pre-treatment wt (kg) Intensive phase Continuation phase
Daily
(First 3 months) Daily
(First 2 months) Daily
(Next 5 months)
Numbers of 4FDC tablets Injection
Streptomycin Numbers of
2 FDC tablets Numbers of
Ehambutol (400 mg) tablets
30-37 2 500 mg 2 2
38-54 3 750 mg 3 3
55-70 4 1 gm* 4 4
>70 5 1 gm* 5 5

4FDC means- 4 fixed drug combination. These 4 drugs are….
1. Rifampicin (R) 150mg
2. Isoniazide (H) 75 mg
3. Ethumbutal (E) 400 mg
4. Pyrazinamide (Z) 275 mg

2 FDC means – 2 fixed drug combination. These 2 drugs are-
1. Rifampicin (R) 150 mg
2. Isoniazid (H) 75 mg.

Q. Why 4 drugs are used in intensive phase?
Ans: To kill rapidly proliferating Mycobacteria.

Q. Why 2 drugs are used in continuation phase?
Ans: To kill the dormant bacteria.

9. Antitubercular drug induced hepatitis
Diagnostic tools
1. H/O of taking Anti TB drugs
2. Yellow coloration of eye & urine
3. Anorexia, nausea & vomiting
4. Investigation- S. Bilirubin- Increased, SGPT-Increased, Alkaline phosphatase- normal, Exclusion of other causes of hepatitis- by HBsAg, AntiHBC, AntiHBE and USG of hapato billiary system & Bil >1.2 mg/dl, SGPT>2 times than normal
Management:
Treatment is symptomatic
1. Stop the offending drugs till hepatitis subside
2. Complete bed rest
3. Diet- normal
4. Tab. Domperidone(10mg) 1+1+1 (1/2 hour before meal, if vomiting)
5. Cap. Omeprazole (20mg) 1+0+1 (1/2 hour before meal)

Tips:
a) Treatment should be restarted when pt. symptomatically well and S. Bilirubin and SGPT become normal.
b) Where there is no scope to do S. Bilirubin and SGPT then Rx. Can be restarted 14 days after the urine or eye become normal.
Ref: Nation guideline of management of tuberculosis.

10. Pneumothorax
Management:
1. Bed rest
2. O2 inhalation
3. Treatment of the underlying cause if any e.g. Pnemonia, COPD etc.
4. Water sealed drainge(percutaneous needle aspiration)- Indication:
i. Immediate decompression prior to definitive therapy in tension pneumothorax
ii. In open or close pneumothorax- Pt. age 15% of hemithorax or significant dysponea.
5. Intercostal tube drainge
i. Tension pneumothorax
ii. Pneumothorax with underlying chronic lung disease e.g. COPD
iii. In open or close pneumothorax -Pt. age > 50 years with >15 % of hemithorax or significant dysponea
iv. When >2.5 L air aspirated or Pneumothorax persists after percuteneous needle aspiration (water seal drainage).
Indication of Surgery in pneumothorax:
1. In all pt. following a second pneumothorax
2. Following first episode of primary pneumothorax
Surgeries are
-Pleurodosis. (Can be achieved by pleural abrasion or parietal pleurectomy at thoracotomy or thoracoscopy).

Advice:
1. Stop smoking
2. Avoid flying 1-2 weeks following full inflation of lung

11. Empyema thorasics
Management
1. Draining of the pus- intercostals tube drainge
2. Antibiotic iv co-amoxiclav or Cefuroxime plus metronidazole
3. Surgical intervention- if IT tube not providing drainge, when the pus is thick or loculated.
4. Surgical decortication of lung – if gross thickening of the visceral pleura is preventing re-expansion of lung.

12. Sarcoidosis
Diagnostic tool
1. Erythema nodosum
2. CXR (P/A)- Bilateral hilar lymphadenopathy
Management:
1. Avoid sun light exposure
2. NSAID for erythema nodosum
3. Steroid-Prednisolone 20-40 mg/day
Indication:
a) Symptoms severe
b) Hypercalcaemia
c) Pulmonary impairement
d) Renal impairement
e) Uveitis

4. Inhaler corticosteroid in asymptomatic parenchymal sarcoid
5. Topical steroid for mild uveitis
6. Severe disease – MTX 10-20 mg / week
-Azathioprine 50-150 mg/day
-Specific TNF alpha inhibitor
7. Cuteneous sarcoid
a) Chloroquine
b) Hydroxychloroquine
c) Low dose thalidomide

13. Pulmonary hypertension
Management:
1. O2 inhalation
2. All pt. should be anticoagulant with warfarin
3. Diuretics
4. Digoxin
5. Specific treatment
d) High dose calcium channel blocker e.g. Amlodipine
e) Prostaglandins such as epoprostenol (prostacyclin) or iloprost therapy
f) PDE inhibitor Sildenafil
g) Oral endothelin antagonist- Bosentan
6. Atrial septostomy
7. Pulmonary thromboendarterectomy
8. Heart- lung transplantation.

14. Acute severe Asthma
Diagnostic tools:
1. Past H/O of asthma
2. Severe breathlessness with cough
3. Patient unable to talk due to breathlessness
4. On exam. Pulse > 110/min, R.rate- > 25/ min, Pt. May be cyanosed, bilateral poly phonic rhonchi present, but chest may be silent.

Management:
1. Diet- normal
2. O2 inhalation 2-5 L/min
3. Propped up position
4. Nebulization with Normal saline 1.5 cc + Salbutamol solution 0.5 cc stat. and 20 min interval for 1 hour then 1-4 hourly.
5. Inj. Hydrocortisone 100 mg 2 vial iv stat. then 4-6 hourly.
6. Inhaler Salbutamol 200 µgm 2 puff stat. & 6 hourly
7. Inhaler Beclomethasone 250 µgm 2 puff 12 hourly (Gargling after use)
8. Tab. Theophylline 400 mg ½ + 0 + ½.

 NB: IV hydrocortisone can be replaced by oral steroid after 24-48 hours.
 Costly regimen- Inhaler Salmetrol & Fludicasone combination. 2 puff 12 hourly. (gargling after use).
 If pt. can buy only one inhaler then give steroid inhaler.
15. Acute exacerbation of COPD
Diagnostic tools:
1. Age > 40 years
2. Smoking H/O
3. Severe breathlessness with cough
4. Previous H/O of hospitalization
5. On exam. Pulse > 100/min, R.rate- > 25/ min, Pt. May be cyanosed, Breath sound vesicular with prolonged expiration,bilateral poly phonic rhonchi & creps present (if infection).

Management:
3. Diet- normal
4. O2 inhalation 1-2 L/min
5. Propped up position
6. Nebulization with Normal saline 1.5 cc + Salbutamol solution 0.5 cc + Ipratropium bromide solution 0.5 cc stat. and 20 min interval for 1 hour then 1-4 hourly.
7. Inj. Hydrocortisone 100 mg 2 vial iv stat. then 4-6 hourly.
8. Inhaler Salbutamol & Ipratropium bromide combination 2 puff stat. & 6 hourly
9. Inhaler Beclomethasone 250 µgm 2 puff 12 hourly (Gargling after use)
10. Tab. Theophylline 400 mg ½ + 0 + ½.
11. Tab. Azithromycin 500 mg 1 + 0 + 0

NB:
 IV hydrocortisone can be replaced by oral steroid after 24-48 hours.
 Costly regimen- Inhaler Salmetrol & Fludicasone combination. 2 puff 12 hourly. (gargling after use).
Antibiotic should be other than the previous one that was used in last 3 month

Renal system

1. Acute glomerulonephritis (Nephritic Syndrome)
Diagnostic tool
1. Swelling of face, leg & eyelid
2. H/O of skin lesion 1-4 weeks before
3. Oliguria, haematuria, fever
4. On exam. –Puffy face, BP-high, leg edema present
-Bed side urine exam. – proteinuria.
– Haematuria
Management
Treatment is supportive, with control of hypertension, edema, and dialysis as needed. Antibiotic treatment for streptococcal infection should be given to all patients and their cohabitants in poststreptococcal AGN.
1. Diet – Normal, protein, salt, fruit, fluid restricted (previous day out put + 400cc)
2. Tab. Cefuroxime axetil (250mg) (in post streptococcal GN then Phenoxymethyl penicillin)
1+o+1
3. Tab. Frusemide (40mg)
1+1+0
4. Tab. Ramipril (1.25mg)
0+0+1 (gradually increasing the dose to titrate BP)
5. Please maintain input out put chart.
 The inflammatory glomerular injury may require corticosteroids and cytotoxic agents.
 Postinfectious Glomerulonephritis- Corticosteroids have not been shown to improve outcome.
(Ref: Harrison’s principle of Internal Medicine)

2. Nephrotic syndrome
Diagnostic tool
1. Generalized edema
2. Massive proteinuria- Frothy urine
3. 24 hours total urinary protein > 3.5 gm
4. Urin volum- normal
5. Usually haematuria absent
Management
1. Diet – Normal, protein, salt, fruit, fluid restricted (previous day out put + 400cc)
2. Tab. Cefuroxime (250mg)
1+o+1
3. Inj. Frusemide(20mg)
1 amp. I/v stat & 1 amp at 8 a.m. & 4 p.m.
5. Tab. Ramipril (1.25mg)
0+0+1 (gradually increasing the dose)
6. Prednisone, 1 mg/kg/d orally
7. Tab. Atrovastatin (10mg) 0 + 0 + 1 after meal (if hypercholesterolemia)
8. Please maintain input output chart.
Tips:
a) Duration of steroid- usually shorter duration (8 weeks) in children but in adult it may take 20- 24 weeks.
b) Patients with frequent relapses and corticosteroid resistance may need cyclophosphamide or chlorambucil to induce subsequent remissions.
(Ref: Harrison’s principle of Internal Medicine +Ref. CMDT 2010)

3. Acute pyelonephritis
Diagnostic tool
1. High fever with chills & rigor
2. Loin pain, dysuria, haematuria, frequency of micturition
3. On exam. – Temperature high
– Renal angle tenderness present.
Management:
1. Diet –normal
2. Antibiotic 1st line (duration10 days)
-Ciprofloxacin (500mg)
-Co-amoxyclav (500/125mg)
3. Tab. Paracetamol if fever
Antibiotic 2nd choice in seriously ill pt. (duration 7-14 days)
• Cefuroxime iv (750mg) 8 hourly
• Gentamycin iv
(Ref: Davidson’s principle & practice of Medicine 21st edition, page 471)
4. Urinary Tract Infection (UTI)
Diagnostic tools:
1. Dysuria, haematuria, frequency of micturition with fever with chills & rigor
2. Urine R/E- pus cell > 5/HPF
3. C/s- growth > 105

Management:
Antibiotic- 3 days in women, 10 days in men
A. First choice
Trimethoprim 200 mg 12 hourly

B. 2nd choice
• Amoxicilin 500 mg 8 hourly or
• Nitrofuratoin 50mg 6 hourly or
• Ciprofloxacin 100mg 12 hourly or
• Co-amoxyclav (250/125mg) 8 hourly
C. In Pregnancy 7 days
• Cephalexin 250mg 6 hourly or
• Amoxicilin 250mg 8 hourly

(Ref: Davidson’s principle & practice of Medicine 21st edition, page 471)

5. Acute renal failure
Diagnostic tools
• H/O of vomiting or diarrhoea or massive blood loss
• Oliguria or anuria
Management:
1. Diet: Protein, salt, fruit restricted
2. Fluid restricted- fluid intake previous day output + 400 cc
3. Infusion Normal saline if pt. dehydrated
4. Antibiotic in case of infection.
5. Cap. Omeprazol (20mg) 1+0 +1
6. Inj. Frusemide (20mg) 2 amp iv stat. and daily (if feature of fluid retension)
7. Maintain input & output chart
Follow up:
• Pulse
• BP
• Hydration status
• Urine out put
• S. creatinine & blood urea
• ECG
Indication of Renal replacement therapy (dialysis or transplantation) in acute renal failure:
1. Hyperkalaemia K+ >6 mmol/L
2. Fluild overload & pulmonary edema
3. Metabolic acidosis
4. Increased plasma urea and creatinine (urea > 180 mg/dl & creatinine >6.8 mmol/L)
5. Uraemic pericarditis/ uraemic encephalopathy
6. Chronic renal failure
Diagnostic tools:
1. H/O of Hypertension or diabetes
2. Pt. complain of anorexia, vomiting, generalized weakness
3. On exam.- Anaemia present
c) Hypertension present
4. S. creatinine- raised.
Management:
1. Diet: Protein, salt & fruit restricted protein 60 gm daily
2. Tab. Calcium carbonate (500mg) 1+0+1
3. Cap. Cholicalciferol (0.25 µgm) 0+1+0
4. Tab. Ferrous sulphate 1+0+1
5. Treatment of the underlying cause like Hypertension, DM etc.
6. If anemia persists after iron therapy then
Inj. Epoietin (25-50IU/kg body wt. once or twice in a week).

Antihypertensive used in CRF
1. First choice- ACEI, ARB, Non-dihydropyridines CCB (Amlodipin)
2. Alpha receptor blocker
3. Betablocker (Atenolol)
N: B: 1-2 week after giving ACEi or ARB if s.creatinine increased 25 % than previous record then stop ACEi or ARB).
Indication of dialysis in CRF (WHO criteria)
1. Uraemic pericarditis
2. Uraemic encephalopathy or neuropathy
3. Pulmonary edema unresponsive to diuretics
4. Severe hypertension if not control by medical management
5. Severe hyperkalaemia not control by medical management
6. Severe bleeding diathesis
7. S. Creatinine > 12 mg/dl or BUN > 100mg/dl
Tips:
Ccr (creatinine clearance) can be estimated from the formula of Cockcroft and Gault:
Ccr = (140- age) × body weight / 72 × S. creatinine (mg/dl)
For women, the creatinine clearance is multiplied by 0.85 because muscle mass is less.
Staging of CKD
Stages of CKD GFR (ml/min/1.73m2)
Stage 1 ≥90 (with evidence of kidney damage)
Stage 2 60-89
Stage 3 30-59
Stage 4 15-29
Stage 5 <15 or dialysis

N: B: kidney damage means pathological abnormalities or marker of damage, including abnormalities in urine tests or imaging studies. Two GFR values 3 months apart are required to assign stage.

CVS diseases
1. Vasovagal syncope
Diagnostic tools
1. Syncope triggered by reduction in venous return due to
a) Prolonged standing
b) Excessive heat
c) Large meal
2. Head up tilt test +Ve.
Pt. is asked to lie on a table that is then tilted to an angel of 60 to 700 for up to 45 min. while ECG & BP are monitored. A positive test is characterized by bradycardia and/ or hypotension associated with typical symptoms.
Management:
I. Life style modifications
i) Salt supplementation
ii) Avoid prolonged standing
iii) Correct dehydration
iv) Avoid missing meal
II. Pt. resistant to life style measure
i) Fludrocortisone
ii) Beta blockers
iii) Disopyramide
3. Dual chamber pace maker if symptoms due to bradycardia.

2. Acute pulmonary oedema
Management:
1. Propped up position
2. O2 high flow 4-6 L/min via face mask
3. Administer Nitrates such as iv GTN 10-200 µg/min or buccal GTN 2-5 mg titrated upwards every 10 min, until clinical improvement occurs or systolic BP falls to 100 mm of Hg.
In other pt. diuretics should be stopped for 24 hours & the ACEi start at low dose.

ACEi Starting dose Target dose
i) Enalapril 2.5 mg 12 hourly 10 mg 12 hrly
ii) Ramipril 1.25 mg daily 10 mg daily.

4. ARB Have similar effect to that of ACEi
Starting dose Target dose
Losarton 25 mg/day 100 mg/day.

5. Combined ACEi & ARB
Indication-HF pt. in those with recurrent hospitalization for HF.
6. Beta blocker therapy
More effective than ACEi in reducing mortality. Bisolol starting dose at 1.25 mg daily increase gradually over 12 weeks to a target maintainance dose of 10 mg daily.
7. Digoxin
To provide rate control
Also in NYHA III, IV
8. Amiodarone
– Effective in pt. of symptomatic arrhythmia
– Should not be used in asymptomatic arrhythmia.
4. Valvular heart disease

Mitral stenosis
Management
Medical management of all valvular diseases is almost same
1. Diet- normal
2. Avoid strenuous exercise
3. O2 inhalation sos
4. Tab. Penoxymethyl penicillin (250mg) 1 + 0 + 1
5. Tab. Frusemide (40mg) 1+0+0
6. Tab. Digoxin 0.25mg 0+0+1 if Atrial fibrillation
7. Tab. Ecospirin (75mg) 0+1+0 (P/C) if Atrial fibrillation
8. In MR ACEI should be given
9. In AR systolic BP should be controlled with Nifedipine or ACEi
Indication of surgery in Mitral stenosis
1. Patient symptomatic despite medical treatment
2. If pulmonary hypertension develops
3. Severe mitral stenosis
4. Pregnancy
2 types of surgery can performed in Mitral stenosis
1. Valvuloplasty
2. Valve replacement
Indication of mitral valvuloplasty in mitral stenosis
1. Significant symptom
2. Isolated MS
3. No (trivial) MR
4. Mobile, non-calcified valve/ subvalve apparatus on Echocardiogram
5. Left atrium free of thrombus
Indication of mitral valve replacement in mitral stenosis
1. MS with MR
2. Rigid & calcified mitral valve cups
Contraindication of surgery
1. Active rheumatic carditis

Mitral regurgitation
Indication of surgery in Mitral Regurgitation (valve replacement or repair)
1. Worsening symptoms
2. Progressive cardiomegally
3. Echocardiographic evidence of deteriorating left ventricular function.

Aortic stenosis
Indication of surgery in Aortic stenosis
1. Development of angina
2. Development of syncope
3. Symptoms of low cardiac output
4. Heart failure
Pt. with moderate to severe stenosis is evaluated every 1-2 year with Doppler Echocardiography to detect progression of severity.

Indication of surgery in aortic regurgitation
1. Symptomatic pt.
2. Asymptomatic pt. should be followed up annually with Echo for evidence of increasing ventricular size, if this occurs or if the end systolic dimension increases to ≥ 55mm the aortic valve replacement should undertaken.

5. Myocardial infarction
Diagnostic tools
1. Classical chest pain > 30 min.
2. ECG changes
3. Biochemical markers e.g. Troponin I.
For diagnosis 2 criteria should be present.
• ECG changes
 ST elevation
 New onset left bundle brunch block
 Evolution of ‘Q’ wave
ECG changes may be isolated or in combination
• Biochemical markers
 CK-MB > 2 fold increase
 Troponin I or T raised level indicate myocardial necrosis.
Management:
1. Complete bed rest
2. Diet- liquid to semisolid
3. O2 inhalation 4-6 L/min
4. GTN spray 2 puff sublingually stat. & sos
5. Tab. GTN SR 2.6 mg 1/2 + 0 + 1/2 + 0
6. Tab. Ecospirin (75mg) 4 tab. Stat. & Tab. Clopidogrel (75mg) 4 tab. Stat.
Then
Tab. Clopidogrel & Aspirin 0 + 1 +0 (after meal)
7. Cap. Omeprazole (20mg) 1 + 0 + 1 ( before meal)
8. Tab. Metoprolol (50 mg) ½ +0 + ½
9. Tab. Ramipril ( 1.25 mg) 0 + 0 +1
10. Tab. Atrovastatin 10 mg 0 + 0 + 1 after meal
11. Inj. Morphine 3 mg iv stat. & SOS (may be repeated after 15 min.)
12. Inj. Stemetil 1 amp. Im stat. Along with Morphine
13. If pt. present with in 12 hours then thrombolysis with Streptokinase or PCI
14. Management of Risk factors e.g. Hypertension, DM etc.
15. Continuous monitoring with pulse rate, rhythm & BP

Mobilization and rehabilitation
 In uncomplicated cases
a) Sit on chair on 2nd day
b) Walk to toilet on 3rd day
c) Return to home on day 5 to 7
d) Gradually increasing activity & return to normal work in 4 to 6 week
 In complicated cases
-Process of mobilization & rehabilitation varies & depends upon the pts functional capacity.

Endocrine system
1. Hypoglycemia
Diagnostic tools
1. H/O of diabetes Mellitus
2. H/O of treatment with Insulin or Secretogogues (e.g. Secrin, Consucon, Limpet etc)
3. H/O of missed or delayed meal
4. Pt. complain headache, dizziness, profuse sweating, palpitation, confusion, drowsy, unconscious
5. On exam.- Bilateral planter extensor
6. Urgent Blood glucose- < 45 mg/dl or 14mmol/L, Keton body on urine present.

Other urgent investigation
I. S. Electrolytes
II. Blood & Urine keton bodies
III. S. creatinine
IV. CBC & Blood culture

Management:
1. NPO TFO
2. O2 inhalation 4-6 L/min
3. Infusion Normal saline
1 L over 30 min.
1 L over 1 hour
1 L over 2 hour
1 L over next 2-4 hours
4. When blood glucose <15.00 mmol/L (270mg/dl) then switch to 5% DA 1 Litre 8 hourly
If pt. still dehydrated then contd. Normal saline and add 5% DA 1 litre 12 hourly
4. Short acting insulin
a) If infusion pump,is available then infuse @ 3-6 units / hour
b) If pump not available 10-20 units IM stat. then 5-10 units hourly. Hourly fall of blood glucose is in the range of 3-4 mmol/L
c) Usual subcutaneous regimen of insulin may be started when the pt. is stable clinically & biochemically & able to take oral food.

5. Potassium replacement
a) None in the first Litre of i.v. fluid unless <3mmol/L
b) If plasma potassium 5.5 mmol/L do not give potassium
6. Broad spectrum antibiotic
7. Continued catheterization
8. Change the posture 2 hourly.

3. HONK (hyperosmolar non-ketotic coma)

Diagnostic tools
1. H/O of DM
2. H/O of irregular treatment or missed dose of Insulin or drugs
3. Stressful condition e.g. infection, trauma, pregnancy
4. On exam. – Severe dehydration, pulse-tachycardia, BP- Hypotension.
5. Investigation- Blood sugar- > 33 mmol/L
a. No keton body in urine
b. Hyperosmolality (> 320 mOsm/ kg)

Hyperosmolality can be calculated by
= 2[Na+] + 2[K+] + [glucose] + urea (all in mmol)
{ Normal osmolality is 280-300 mOsm/kg}

Management:
Same as DK but less insulin is required.
(Ref: Davidson’s principle & practice of Medicine)

4. Cushing syndrome
Management:
Medical treatment before surgery
1. Metyrapone and ketokonazole- the dose should be titrated against 24 hour free urine cortisol level.
2. Treatment of the underlying cause.

Cushing disease
1. Transphenoidal surgery
2. If unsuccessful then bilateral adrenalectomy
Nelson syndrome can be prevented by pituitary irradiation.
5. Addisons disease
Management:
1. Diet- normal
2. Tab. Hydrocortisone 15 mg at morning & 5 mg at 6pm
3. Fludrocortisone 0.05-0.1mg daily

Follow up:
1. Pulse
2. BP
3. S. electrolytes

Advice:
1. If fever double the dose
2. In vomiting inj. Should be given if can not swallow tablet
3. Minor surgery Inj. Hydrocortisone 100 mg im with premedication.
4. Major surgery- Inj. Hydrocortisone 100 mg im 6 hourly until able to take oral tablet
5. Pt. should carry steroid card
6. Bracelet.
6. Addisonian crisis
Management
1. NPO TFO
2. O2 inhalation
3. Infusion normal saline 1000 cc iv @ 30d/min.
4. Infusion 10 % DA 1000cc iv @ 20d/min.
5. Inj. Hydrocortisone 100mg iv stat then im 6 hourly
6. Antibiotic
7. Treatment of the underlying cause.

7. Phaeochromocytoma
Management
a. Definitive treatment is surgery
b. Preparation of pt. before surgery minimum for 6 week
c. Control of HTN by Alpha blocker Phenoxybenzamine 10-20mg orally 6-8 hourly. If tachycardia occurs add betablocker –Propanolol or Labetalol
d. During surgery- Sodium Nitroprusside & short acting alpha antagonist Phentolamine are used to control HTN
e. Postoperative period Hypotension should be managed by -Fluid & Noradrenaline infusion.
8. Hypopituitarism
Management
1. Glucocorticoid replacement
2. Thyroxine 100-150 µgm daily (before this steroid must be given)
3. Sex hormone in men of any age & in female <50 years
4. GH in children & adolescent S/C inj.
5. Treatment of the underlying cause.

9. Prolactinoma
Management:
1. Dopamine agonist (Bromocryptine 1st line drug)
2. Surgery 2nd line treatment.

10. Acromegaly
Management:
1. 1st line treatment is surgery
2. 2nd line treatment is…..
a) Bromocryptine
b) Somatostatin analogue (Octreotide, Lanreotide) slow releasing inj. Every few weeks interval
c) GH receptor antagonist Pegvisomant indicated in whom GH & IGF1 fail to suppress sufficiently by Somatostatin analogue.
11. Diabetes insipidus
Management:
Cranial DI
1. Desmopressin nasal spray 5 µgm in morning & 10 µgm at night. In sick pt. im inj.

Nephrogenic DI
1. Bendroflumethazide 5-10mg/day
2. Amiloride 5-10mg/day
3. Indomethacin 15 mg 8 hourly.

12. Amenorrhoea
Management:
1. Exclude physiological cause e.g. Pg. Menopause etc.
2. Decrease exercise, work load
3. Weight gaining if under weight.

13. Thyrotoxic storm
Management
1. Diet – normal
2. Infusion Normal saline 1000c iv @ 20d/ min
3. Tab. Propanolol 80 mg 6 hourly or 1-5 mg iv 6hourly
4. Sodium ipodate 500mg orally or Dexamethasone 2 mg 6 hourly + Amiodarone
5. Carbimazole if can not take orally then give per rectally
6. Antibiotic
1. Thyrotoxicosis
Management
1. Pt. under 40 years- Tab. Carbimazole 40 -60 mg daily, when pt. euthyroid then 5-20mg for 18 months. If replase occur then –surgery.Subtotal thyroidectomy. Pt. should make euthyroid before surgery by Potassium iodide 60 mg 8 hourly for 2 weeks.
2. If pt. over 40 years – Radio 131I ablation.
Antithyroid drugs
I. Carbimazole 40-60mg daily
II. Methimazole
III. Propylthiouracil (400-600mg daily)

3. Surgery is indicated
Larg goiter.

Note:
 Subjective improvement occur 10-14 days
 Patient biochemically euthyroid at 3-4 weeks. At this time carbimazole should be given at a dose of 5-20mg daily for 12- 15 months.

Thyrotoxicosis in pregnancy
1. Tab. Propylthiouracil 150 mg/day (larger dose cause fetal hypothyroidism).
2. Surgery- if poor compliance. It should be done at 2nd trimester.

15.Graves opthalmopathy
Management
1. Reassurance
2. Methylcellulose eye drop & gell
3. Side shield attached spectacle
4. Prednisolone
5. Sometimes orbital irradiation
6. If loss of visual acquity then urgent surgical decompression.
16. Hypothyroidism
Management
1. Diet – normal
2. Tab. Thyroxine (50µgm) 1 + 0 + 0 ( ½ hour before breakfast)
After 3 weeks
2 + 0 + 0 (½ hour before breakfast)
After 6 week do T3, T4, and TSH then adjust dose of Thyroxine level.
3. Antilipid drugs if hyperlipidaemia.

Note:
1) pt. feel better wuth in 2-3 weeks
2) Reduction in weight & periorbital puffiness occurs quickly
3) Restoration of skin & hair texure and resolution of any effusion take 3-6 months.

Hypothyroidism in IHD
Management
1. Diet- normal, avoid fatty & salty food
2. Tab. Thyroxine (50µgm) 1/2 + 0 + 0 ( ½ hour before breakfast)
Starting dose should be minimum because it can aggravate or precipitate IHD.
Hypothyroidism in Pregnancy
Management
Extra 50µgm/day is required than maintenance dose . Because placenta metabolise thyroxine & increase Thyroxine binding globulin in pregnancy.
T3, T4 & TSH should be assessed in every trimester.
Increased dose of thyroxine is required in the following condition
1. Anticonvulsant drugs
2. Rifampicin
3. Chloroquine
4. Sertraline
5. Aluminium hydroxide
6. Ferrous sulphate
7. Calcium carbonate
8. Malabsorption
9. Pregnancy
17. Myxoedema coma
Diagnostic tools
1. Elderly pt.
2. H/O hypothyroidism
3. Altered consciousness
4. Temperature as low as 25oC.
Management
1. Slow rewarming
2. NG tube feeding
3. O2 inhalation
4. Infusion 5% DNS/ NS
5. Broad spectrum antibiotics
6. Inj. Triiodothyronine (20 µgm) iv stat & 8 hourly, when pt. can take orally then Tab. Thyroxine (50µgm) 1 + 0 + 0 ( ½ hour before breakfast)
7. Inj. Hydrocortisone 100mg im 8 hourly.

Infectious disease
1. Chicken pox in adult or in children
Management
1. Diet – normal
2. Antihistamine
3. Antibiotics
4. Antiviral- oral Aciclovir 800mg 5 times daily for 5 days
In immunocompromised host/ pregnant women Aciclovir 5 mg/kg 8 hourly until pt. improving then complete therapy with oral therapy until all leishon crusting over.
 Visceral involvement (non- CNS) – Aciclovir 5 mg/kg 8 hourly for 7 days.
 Severe complications like encephalitis/ disseminated infection- Aciclovir 10 mg/kg 8 hourly for 14-21 days.
 Lotion claamilon-apply loacaly

2. Shingles or Herpes Zoster
Management
1. Diet – normal
2. Antiviral- oral Aciclovir 800mg 5 times daily
3. Tab. Amitryptylline 25-100mg daily
4. Analgesic –NSAID
Treatment & doses as for chicken pox but typically duration 7-10 days.

3. Infectious Mononeucleosis
Management
1. Diet – normal
2. Antibiotic- penicillin, Avoid Amphicillin or Amoxicillin
3. Steroid – inj. Hydrocortisone 100 mg iv stat. & 6 hourly if pharyngeal edema
4. Return to work governed by pt. physical fitness.

4. Dengue fever
Management
1. Diet – normal, plenty of fluid & home made fruit juice intake
2. Tab. Paracetamol
3. Avoid NSAID, Steroid
4. Fluid management

5. Leptospirosis
Management
1. Diet- normal, salt, fruit. Protein restricted
2. BT if bleeding manifestation
3. Treatment of renal failure
4. Cap. Doxicycline 100 mg 1 + 0 + 1 0r inj. Ceftriacone 1 gm daily
5. If uveitis then oral steroid.
6. Tab. Paracetamol

6.Enteric fever
Management
1. Diet- normal
2. Tab. Paracetamol
3. Antibiotic
Antibiotics that can be used in Enteric fever are—
1. Co-trimoxazole 2 tab. 12 hourly
2. Ciprofloxacin 500 mg 12 hourly
3. Ceftriaxone 2 gm 12 hourly
4. Azithromycin 500 mg daily
Duration of treatment is 14 days.

7. Leprosy
Management
Paucibacillary
1. Diet- normal
2. Tab. Daposone 100mg 1 +0 + 0 ….6 months
3. Tab. Rifampicin 600mg 1 + 0 + 0 one Tab. Monthly for 6 months

Multibacillary
Monthly basis for 12 months
1. Tab. Rifampicin 600mg 1 + 0 + 0
2. Tab. Clofazimine 300mg 1 + 0 + 0
Daily basis for 12 months
1. Tab. Dapsone 100mg 1 tab. daily
2. Tab. Clofazimine 50mg 1tab. daily.
Paucibacillary with single lesion
1. Tab. Ofloxacin 400mg- single dose
2. Tab. Rifampicin 600mg-single dose
3. Tab. Minocycline 100mg- single dose.
8. Rickettsial infection
Management
1. Tetracycline 500mg 6 hourly Or
2. Doxycyclline 100mg 12 hourly Or
3. Chloramohenicol 500mg 6 hourly Or
4. Blood transfusion if haemorrhage
5. Sedation if delirium occurs
Duration of treatment is 7 days.
9. Giardiasis
Management
1. Tinidazole 2 gm stat.
Or
Metronidazole 400mg 8 hourly for 10 days.

10. Filariasis
Management
1. DEC 6 mg /kg daily in 3 divided doses for 12 days.
2. In tropical pulmonary eosinophillia same dose of DEC for 14 days.
Or
3. 300mg DEC single dose
11. Syphilis
Management
Antibiotic- choice Penicillin
Doxicycline if allergic to penicillin except in pregnancy
Azithromycin is a further alternative.

Cure indicated by resolution of clinical sign & decline of non-treponemal test (VDRL) usually to undetectable levels with in 6 months of primary syphilis & 12- 18 months of 2ndary syphilis.
Syphilis in pregnancy
Penicillin is choice.
Erythromycine if allergic to penicilline.
Ceftriaxone 250mg im for 10 days.

12. Gonorrhoea
Management
Uncomplicated
Cefixime 400mg stat. or
Ciprofloxacin 500mg stat. or
Ofloxacin 400mg stat.
Complicated
Quinolone resistance
Ceftriaxone 250 mg im stat or
Spectinomycin 2 gm im stat
In pregnancy & breastfeeding
Cefixime
Ceftriaxone

13. Chlamydial infection
Management
Standard regimen
Azithromycin 1gm single dose or
Doxycycline 100mg B.D. for 7 days.
Alternative regimen
Erythromycin 500mg 6 hourly for 7 days or
Ofloxacin 200 mg 12 hourly for 7 days.

14. Malaria
Uncomplicated
Management:
1. Diet –normal
2. Tab. Artemether & Lumefentrin (Coartem) 4+0+ 4 (for 3 days) (1st line drug)
3. Tab. Paracetamol (500mg) 1+1+1
 Situations where Coartem can not be given…..
a) Pregnancy in first trimester
b) Children 25 kg body wt.) 50 mg morning and evening after meal
• Patients (95%.
Treatment D:
Sodium Antimony Gluconate for PKDL cases
Dose:
20 mg/kg/day in IM route.
Total 6 cycles.
Each cycle consists of 20 days treatment.
Should be an interval of 10 days in between 2 cycles.
Essential to weight the pt every time before starting a new cycle.

Ref: National guideline of diagnosis & management of Kala-azar.

Alimentary tract Disease:

1. Hiccup
Management:

1. Eating 1 TSF of dry granulated sugar.
2. Interruption of the respiratory cycle by breath holding, Valsalva maneuver or rebreathing into a bag.
3. Irritation of the diaphragm by holding knees to chest
4. Tab. Baclofen 1 + 1 + 1
5. Inj. Chlorpromazine 25mg/ml 1 amp. i.m. stat. & B.D. (Before giving LFT & Renal function test should be done)
6. Treatment of the underlying cause.
Other drug can be used treatment
1. Other agents -phenytoin, carbamazepine, benzodiazepines (lorazepam, diazepam), metoclopramide, baclofen, gabapentin, and occasionally general anesthesia.

( Ref. CMDT 2010)

2. Oral ulcer
Management
1. Topical steroid- 0.1% Triamcinolone in orabase (Kenacort oral base )
Or
Choline salicylate 8.7% gel
2. Rarely pt. with very severe recurrent apthous ulcer may need oral steroid.

3. Oral Candiasis
Diagnostic tools
1. Occurs usually in immunocompromised pt. like DM, cytotoxic drugs, steroid, old age etc.
2. White patch in mouth
Management:
1. Nystatin or Amphotericin suspension or Lozens
2. Resistant cases or immunocompromised pt. may require oral fluconazole.

4. Achalasia Cardia
Treatment option:
1. Endoscopic force full pneumatic dilatation
2. Endoscopically directed Botulinum toxin inj. In to the lower oesophageal sphincter
3. If replase occur then surgery- myotomy (Heller’s operation either laparoscopically or open).

5. Gastro Esophagial Reflux Disease( GERD)
Management
1. Omeprazole 20 mg 1 + 0 +1
6. Peptic Ulcer Disease (PUD)
Management
1. Avoid smoking, Aspirin, NSAID
2. H. pylori eradication therapy… duration 7- 14 days.
Cap. Omeprazole 20 mg 1 + 0 +1 ½ hour before meal
Cap. Amoxicillin 500mg 2 + 0 + 2
Tab. Clarithromycin 500mg 1 + 0 + 1
3. Maintainance dose of Omeorazole 20 mg daily.
7. Zolinger- Ellusion syndrome
Diagnostic tools:
1. Severe upper abd. Pain, diarrhea, statorrhoea
2. Poor response to ulcer therapy
3. Endoscopy shows- severe & multiple ulcer in post bulbar duodenum, jejunum & oesophagus.
Management:
1. PPI- larger dose 60- 80mg daily
2. Somatostatin analogue- Inj. Octreotide subcutenously
3. If localized tumor found then resection of the tumor.

8. Non-ulcer dyspepsia (NUD)
Diagnostic tools:
1. Age 6 cm
2. Those whose clinical & Laboratory measurements deteriorate
3. Those not respond after 7-10 days maximal medical treatment.

Maintainance of remission
1. Oral aminosalicylates- Mesalazine or Balsalazine
Sulphalazine has higher side effects but choice in pt. with associated arthopathy. Pt. who frequently relapses despite Aminoslicylate is treated with thiopurines.

13. Irritable bowel syndrome ( IBS)
Diarrhea predominant
Management:
1. Reassuarrance
2. Avoid legumes & excessive dietary fibre
3. Still symptomatic –Loperamide 2-8 mg daily
4. Still symptomatic- Amitryptylline 10 -25 mg at night
5. Still symptomatic-
i) Relaxation therapy
ii) Biofeedback
iii) Hypnotherapy
Constipation predominant
Management:
1. Reassurance
2. High roughage diet
3. Still symptomatic- ispagula, Lactulose
4. Still symptomatic-
i. Relaxation therapy
ii. Biofeedback
iii. Hypnotherapy

Pain & bloating
ManageMent:
1. Mebevarine
2. Peppermint oil
3. Alverine
4. Still symptomatic- Amitryptylline 10- 25 mg at night, Probiotics, Dietary change
5. Still symptomatic-
a. Relaxation therapy
b. Biofeedback
c. Hypnotherapy
14. Anal fissure
Management:
1. Avoid constipation
2. Increase fluid intake
3. Nitric oxide & 0.2% GTN or deltiazem ointment
4. Resistant case- inj. Botulinum toxin
Surgery- Lateral internal anal sphincterotomy or advancement anoplasty.

Haematology
1. Blood transfusion reaction
a) Febrile reaction
Diagnostic tools
 Pt. complain of fever, chills & rigor
 Pt. otherwise normal
Management:
1. Stop the transfusion
2. Paracetamol tab. Or suppository
3. Restart the transfusion at a slower rate
4. Observe the pt. more frequently.

b) Urticaria
Mild allergic reaction
1. Stop the transfusion
2. Give chlorpheniramine 10 mg iv slowly
3. Restart BT at a slower rate
4. Observe frequently.

c) Severe allergic reaction
Diagnosttic tools
1. Bronchospasm, abdominal pain
2. Angioedema, hypotension
Management:
1. Discontinue the transfusion
2. Give Chlorpheniramine 10 mg iv slowly
3. O2 inhalation
4. Nebulize with Salbutamol
5. If severe bronchospasm or hypotension then give inj. Adrenaline 0.5 mg i.m.
6. Send clotted blood sample to the transfusion laboratory
7. Take down blood unit & giving set & return intact to blood bank with all other used/ unused unit.

d)ABO incompatibility
Management:
1. Take down blood unit & giving set & return intact to blood bank with all other used/ unused unit
2. Start i.v. saline infusion
3. Monitor urine out put- maintain urine out >100ml/ hour. Give Frusemide if urine output fall
4. Treat DIC with appropriate blood products
5. Inform hospital transfusion department immediately.
3. Iron deficiency anemia
Management:
1. Diet- iron containing foods like Lal sak, kochu sak etc
2. Tab. Ferrous sulphate 200mg 8 hourly for 3-6 months. If pt. intolerant to ferrous sulphate then Ferrous sulphate 12 hourly or Ferrous gluconate 300 mg 12 hourly
3. Blood transfusion-indication
i) If pt. have angina
ii) Heart failure
iii) Evidence of cerebral anoxia
4. Parentral iron-indication
i) Malabsorption
ii) Chronic gut disease

Follow up:
1. Hb%- Hb% should be rise 1 gm/dl/week
2. Reticulocyte count- Reticulocytosis is evident after 7-10 days.
4.Megaloblastic anaemia
Management:
1. Diet- normal
2. Inj. Hydroxycobalamine 1000 µg i.m. five doses 2-3 days apart then 3 monthly life long
3. Tab. Folic acid 5 mg 1 tab daily for 3 week, then 1 tab. Weekly for life long
4. Ferrous sulphate 200 mg 8 hourly, if initial responses is not maintained & PBF is dimorphic.

5.Spleenectomized Pt.
Management:
1. Vaccinate the pt.
 Pnemococcal
 H.inluenza type B
 Meningococcus C
 Influenza
Vaccination should be done 2-3 weeks before elective surgery. If emergency surgery is done then vaccination should be done after surgery.
2. Pneumococcal reimmunization should be done every 5 yearly
3. Influenza reimmunization should be done yearly basis.
4. Penicillin V 500 mg 12 hourly life long
5. Should carry Bracelet or card.

6.Autoimmune Haemolytic anaemia
Management:
1. Steroid –prednisolone 1 mg/kg/day orally, when Hb% normalized, reticulocytosis resolved dose of steroid should be reduced over 10 weeks
2. Blood transfusion- when developed heart failure or unabated fails in Hb%
3. Splenectomy- if haemolysis fails to respond to steroid or can only be stablished by larger doses.
4. Azathioprine or cyclophosphamide-if splenectomy is not appropriate.

7.Paroxyamal nocturnal haemoglobinuria (PNH)
Diagnostic tools:
 Pt. complain –red brown color urine particularly in morning
 Urine R/E- haemoglobinuria

Management:
1. Diet- normal
2. Blood transfusion
3. Treatment of thrombosis
4. Recently anticomplement C5 monoclonal Ab Ecluzimab is used.

8. Sickle cell anemia
Management:
1. Tab. Folic acid 5 mg 1+ 0 + 0
2. Tab. Penicillin V
3. Hydroxycarbamide
4. Vaccinate against Pneumococcus, H. influenza & Hepatitis B.
Treatment of vaso-occlusive crisis
1. O2 inhalation
2. Rehydration with Normal saline
3. Antibiotic
4. Analgesia with opiate
5. Exchange transfusion
 in life threatening crisis
 Or to prepare the pt. for surgery.

9. Chronic myeloid leukaemia
Chronic phase
1. First line therapy- Imatinib,
If fail to response or progress on therapy- Dasatinib or Nalatinib, Bone marrow transplantation (allogenic)
Or
Hydroxyurea or Hydroxycarbamide or Interferon.
2. Hydroxyurea- if pt. can not afford Imatinib.
Accelerated or blast crisis phase
1. Imatinib
2. Hydroxycarbamide & low dose cytarabine. If fail to response or progress on therapy- Dasatinib or Nalatinib, Bone marrow transplantation (allogenic).

10. Chronic Lymphatic leukaemia
Stage A
No treatment is required.
Stage B & C
1. Chlorambucil, recently Fludarabine plus Cyclophasphamide
2. Corticosteroid- in bone marrow failure or autoimmune cytopenias
3. Blood transfusion if anaemia or thrombocytopenia
4. Antibiotic – infection
5. Radiotherapy-if lymph node causing discomfort or local obstruction & symptomatic splenomegally
6. Splenectomy- to decrease autoimmune destruction of RBC, Hypersplenism & to relieve massive splenomegally.

11. Myelodysplastic syndrome
Management:
1. Blood transfusion
2. Platelet transfusion
3. Erythropoietin & GCSF
4. Allogenic bone marrow transplantation in younger pt.

12. Multiple myeloma
Management:
Asymptomatic –no treatment is required
Symptomatic
1. Plenty of fluid intake
2. NSAID to relieve pain
3. Bisphosphonates
4. Allopurinol
5. Plasmapharesis-in hyperviscosity
6. Chemotherapy
1st line –Thalidomide
Older pt. – Thalidomide plus Melphalan & Prednisolone
In younger pt. -Thalidomide plus allogenic BMT.
7. Radiotherapy- localized bone pain not responding to simple analgesic & pathological fracture, spinal cord compression.

13. Aplastic anaemia
Management:
1. Diet- normal
2. Antibiotic
3. Immune suppressive therapy for older pt. with-Ciclosporin & Antithymocytic globulin
4. Younger pt. < 30 years – allogenic BMT.
14. Myelofibrosis
Management:
1. Diet- normal
2. Tab. Folic acid
3. Blood transfusion
4. Hydroxycarbamide
5. Splenectomy- if symptomatic pancytopenia, enlarged spleen, hypersplenism
6. Allogenic BMT in younger pt.
15. Polycythaemia Rubra vera
Management:
1. Diet- normal
2. Venesection 400-500 ml every 5-7 days until PCV 30 thousand do not require treatment
2. First line therapy for pt. with spontaneous bleeding
A. Prednisolone 1 mg/ kg daily
B. If response to steroid is slow & severe haemostatic failure
 Prednisolone & IVIg
Or
Intravenous anti D
C. Persistent or potentially life threatening bleeding should be treated with platelet transfusion in addition to other therapies
D. Splenectomy- if 2 relapses or primary refractory disease
E. If significant bleeding persists despite splenectomy- low dose steroid, immunosuppressive therapy with Rituximab, ciclosporin & Tacrolimus.
17. Haemophilia
Haemophillia A
1. Resting of the bleeding site by bed rest or splint
2. In severe hemophilia A intravenous infusion of factor VIII concentration
3. In mild to moderate hemophilia A Vasopressin receptor agonist DDAVP 0.3 µg/ kg iv or subcutaneously. Alternatively same effect can be achieved by intranasal administration of 300 µg.
4. Prophylaxis – Factor VIII can be administered 2 or 3 times per week.
Haemophillia B
Factor IX concentration intravenous infusion.
18. Acute leukaemia
Diagnostic tool
1. Fever high grade
2. Generalized weakness
3. Bleeding manifestations e.g.- gum bleeding, epistaxis, etc.
4. On exam. –Anaemia, Lymphadenopathy, Bony tenderness, Hepato-splenomegally.

Urgent Investigation:
1. CBC with PBF

Management:( Supportive)
1. Diet- normal
2. Blood transfusion (before BT PBF should be done)
3. Inj. Eracef (1gm) ivial i/v daily
4. Tab. Paracetamol (500mg) 1+1+1
5. If menorrhagia Tab. Premulate N 2+2+2

For specific management referred to Haematologist.

19. Haemolytic anaemia
Diagnostic tool
1. Generalized weakness
2. No fever, bleeding manifestation
3. On exam.
 No lymphadenopathy, No bony tenderness
 Hepatosplenomegally.

Management:
1. Diet – normal
2. BT
3. Tab. Folison 1+0+0

Dietary advice:
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An approach to diagnosis of Anaemia from examination findings:
 Anaemia + Bleeding manifestation + No lymphadenopathy + No bony tenderness + No Hepatosplenomegally ¬– Aplastic anaemia.
 Anaemia + No Bleeding manifestation + No lymphadenopathy + No bony tenderness + Hepatosplenomegally ¬– Haemolytic anaemia.
 Anaemia + Bleeding manifestation + lymphadenopathy + bony tenderness + Hepatosplenomegally ¬– Acute leaukaemia.

MUSCULO-SKELETAL DISEASES
1. Low back pain (LBP)
Management:
1. Reassurance, explanation
2. Analgesic- paracetamol, NSAID, Muscle relaxants
3. Discourage bed rest
4. Low dose TCA e.g. Amitryptylline
5. Refered for Physiotherapy or manipulation- if return to normal physical activity has not been achieved by 6 weeks.
2. Osteoarthritis
Management:
1. Full explanation of the condition
 Established structured changes are permanent
 Pain & function can be improved
2. Exercise- strengthening & aerobic exercise
3. Hot or cold compression
4. Reduction of adverse mechanical factors
– Weight loss if obese
– Shock absorbing foot wear
– Use of walking stick for painful knee or hip OA.
5. Drug
– Paracetamol
– Topical NSAID
– Oral NSAID
6. Intraarticular inj. Of corticosteroid to relieve pain of knee & thumb base OA
7. Surgery
Indication:
i) OA whose pain, stiffness & reduced function impact significantly on their quality of life
ii) Refractory OA (refractory to non-surgical & adjunctive treatment).
Surgeries are- Osteotomy & joint replacement for knee & hip joint OA.
3. Rheumatoid arthritis
Diagnostic tools:
1. Polyarthritis -3 or more joints pain
2. Hand joint involvement
3. Symmetrical arthritis
4. Rheumatoid nodule
5. Morning stiffness > 1 hour
6. Rheumatoid factor (RA test Positive)
7. Radiological changes
8. Symptoms for more than 6 weeks.

4 or more criteria suggest diagnosis of RA.

Management: (ward or practical mx.)
1. Diet : Normal
2. Cap. Indomethacin (25mg) 1+1+1 (after meal)
3. Cap. Omeprazole (20mg) 1+0+1 ( before meal)
4. Tab. MTX (2.5mg) 3+0+0 ( every saturday)
5. Tab. Folic acid 1+0+0 (every sunday)

Rheumatoid arthritis
Management:(Ideal)
1. Rest
2. Passive exercise
3. NSAID
4. DMARD
5. Anti TNF therapy-if disease activity persists despite adequate trial of 2 DMARD including Methotrexate
6. Corticosteroid-Prednisolone 7.5-10 mg daily. To cover delayed onset of action of DMARD
7. Surgery-indication-when medical treatment fail to pain relief or to prevent tendon rupture.
8. Surgeries are
Synovectomy (wrist or finger tendon sheath)
Osteotomy
Arthodosis or arthoplasty
Follow up in pt. getting MTX initially monthly, then every 3 month
1. Clinical improvement
2. Full blood count and LFTs
4. Ankylosing spondylosis
Management:
Non-pharmacological:
1. Explanation & education
2. Daily back extension exercise including a morning ‘warm up’ routine
3. Avoid prolonged period of inactivity work like driving, computer work etc.
4. Swimming is the best exercise.
Pharmacological treatment:
1. NSAID
2. MTX or sulphasalazine if peripheral arthritis
3. Anti TNF therapy for disease inadequately controlled with above measure
4. Oral corticosteroid- in acute uveitis
Surgery
In severe hip, knee, shoulder joint restriction.
5. Reactive arthritis
Management:
1. Rest
2. NSAID
3. Tetracycline
4. Intraarticular inj. for marked synovitis
5. DMARD
 Persistent marked symptom
 Recurrent arthritis
 Severe keratoderma blenorrhagica
6. Ant. Uveitis- topical, oral, subconjunctival steroid.
6. Psoriatic arthritis
Management:
1. Avoid splint & prolonged rest
2. NSAID
3. Intrarticular inj. of steroid to control synovitis
4. DMARD- Methotrexete
5. Anti TNF therapy in whom DMARD fail
6. Retinoid acitretin
7. Photochemotherapy & methylpsoralin and long wave UV light.

7. Gout
Management:
Acute attack
1. Application of ice pack
2. NSAID
3. Oral Colchicine 0.5 mg 6/8/12 hourly
4. Joint aspiration & intraarticular inj. Of steroid
5. For severe oligo-polyarticular attack- parentral corticosteroid.
Long term management:
1. Correction of predisposing factors
2. Weight loss & reduction of excess alcohol intake especially bear
3. Diuretics should be stopped if possible
4. Avoid sea food, read meat
5. Allopurinol initial dose 100 mg daily (50 mg in elderly), gradually increase the dose up to 900 mg daily.
Follow up:
S. uric acid should be measured 3-4 weeks interval.
Advice to the pt:
During initiation of urate lowering drug acute attack may occur but drug should not be stopped.
Tips:
Acute attack during initiation of urate lowering therapy; oral cholchicine or NSAID can be added.

8. Septic arthritis
Urgent investigation:
1. Synovial fluid for Gram staining & culture
2. Blood for FBC & culture
3. Consider sputum, urine culture
Management:
1. Intavenous Flucloxacillin 2 gm 6 hourly for 2-3 weeks then oral for 6 weeks. Change according to C/S
2. If Penicillin allergy then-Clindamycin 450-600 mg 6 hourly
3. If high risk for Gram negative infection then add Cephalosporin
4. Serial needle aspiration 1-3 times per day
5. Pain relieved by- local ice pack, oral or iv analgesic
6. Physiotherapy from the first day
-Regular passive movement progressing to active movement.
9. SLE
General management:
1. Educate the pt.
2. Avoid sun & UV light exposure, employ sun block
3. Avoid smoking
4. Control hypertension & dyslipidaemia
Mild disease (restricted to skin & joints)
1. NSAID
2. If necessary Hydroxy chloroquine 200-400 mg daily
3. Short course of steroid for rash, synovitis, pleurisy & pericarditis.
Life threatening disease
Affecting kidneys, CNS or CVS requires high dose steroid plus immune suppression.
1. A commonly used regimen- Pulse Methyl prednisolone 500 mg -1 gm iv coupled with cyclophosphamide 2 mg/kg iv repeated at 2-3 weekly interval on 6-8 occasion.
Alternatively in renal involvement Cyclophosphamide can be replaced with Mycophenolate mofetil(MMF) with fewer side effects.
2. Folowing control- prednisolone 40-60 mg daily & Azathioprime, MTX or MMF
3. Co-trimoxazole 960 mg thrice weekly to prevent P. carinii infection due to cyclophosphamide
4. Mesna is given with bolous Cyclophosphamide to reduce risk of haemorrhagic cystitis
5. Lupus nephritis with Antiphospholipid syndrome who have had previous thrombosis require life long warfarin.

10. Systemic sclerosis
A) Raynaud’s syndrome with digital ulcer
1. Avoid cold exposure
2. Use of mittens (heated mittens are available)
3. Calcium antagonist or ARB
4. Antibiotic
a. Intermitten infusion of epoprostenol may benefit severe digital ischaemia
B) Ooesophageal reflux
 PPI
 Metochlopramide or domperidon
 Antibiotic for bacterial overgrowth
C) Hypertension-ACEi even also in renal impairement
D) Joint involvement-Analgesic
E) Pulmonary hypertension- Endothelin-1 antagonist ‘ Bosentan’
F) Corticosteroid & cytotoxic drug are indicated in pt. with
– co-existing myositis or
– fibrosing alveolitis.

11. Polymyositis & Dermatomyositis
Management:
1. Oral corticosteroid 40-60 mg daily
2. iv Methylprednisolone 1 gm daily for 3 days in pt. with respiratory or pharyngeal weakness. If thre is a good response steroid should be reduced by approximately 25% per month to maintain dose of 5-7.5 mg
3. Most pt. require additional treatment with Azathioprine & MTX
4. iv immuneglobulin may be effective in refractoryces.

12. Bechet’s Syndrome
Diagnostic tools
1. Oral ulcer deep & multiple
2. Genital ulcer
3. Skin leishon-erythema nodusum or acneform leishon
4. Migratory thrombophlebitis
5. Anterior or posterior uveitis
6. Neurological sign-brain stem involvement, pyramidal tract signs etc.
Management:
1. Oral ulcer- topical steroid preparation
2. Colchicine for erythema nodusum & arthalgia
3. Thalidomide 100-300 mg daily for 28 days & effective for resistant oral & genital ulcer
4. Corticosteroid & immunosuppressive for systemic disease.

13. Polymyalgia Rheumatica (PMR)
Management:
1. Prednisolone 20-30 mg daily gradually reduce the dose 10-15 mg by about 8 weeks ultimately 5-7.5 mg for 12-14 weeks
2. Immunosuppressive like MTX, Azathioprine when steroid require > 7.5 mg/day.

14. Giant cell arteritis
Management:
1. Prednisolone 60 mg daily

15. Osteoporesis
Non-pharmacological treatment
1. Cessation of smoking
2. Moderation of alcohol intake
3. Dietary calcium intake
4. Exercise
Drug treatment
Indication
1. BMD T score below -2.5 or below -1.5 in corticosteroid induced osteoporeis
2.Vertebral fracture irrespective of BMD (except traumatic vertebral fracture)
Drugs used
1. Alendronate 70 mg/ week or Risedronate 35 mg/ week. Orally on empty stomach & no food should be taken up to 30-45 min. of administration
2. Calcium & vit-D
3. PTH- Teriparatide. Superior to Alendronate. It is expensive, rserve for
a) Szevere osteoporesis BMD T score -3.5 to – 4.0 or below
b) Failure to respond adequately to other treatment.
Duration 24 months, after that Bisphosphonate should be used to maintain BMD. Teriparatide should not be used simultinously with Bisphosphonate.
4. Calcitonin- has analgesic properties. Sometimes used short to medium time in pt. with acute vertebral fracture. Dose s/c or im 100-200 U daily or intranasal spray 200 micro units daily.
5. HRT-primarily indicated for prevention of osteoporesis in women with an early menopause & for treatment of women with osteoporesis in their early fifties who have troublesome menopausal symptoms
6. Calcitrol-recently licensed for treatment of osteoporesis
Surgery
 Hip replacement- total or partial, indicated for intracapsular fracture of femoral neck.
 Kyphoplasty-indicated for acute vertebral compression fracture where there is a significant degree collapse & severe pain.
 Vertebroplasty- indicated for painful vertebral fracture which fails to settle by medical treatment.
Follow up:
1. BMD repeat after 2-3 years
2. NTX (N-Telopeptide) respond quickly than BMD.

16. Osteomalasia & Rickets
Management:
1. Respond quickly to treatment with ergocalciferol 250-100 µgm daily.
After 3-4 months treatment can generally be stopped or the dose of vit-D reduce to maintainance level of 10-20 µgm Cholecalciferol daily except in pt. with Malabsorption in whom higher dose may required.
Follow up:
1. Clinical improvement
2. Elevation in 25(OH)D
3. Reduce in PTH.

Neurology
1. Tension type Headache
Management:
1. Explanation of symptoms
2. Avoid precipitation
3. Analgesics-NSAID
4. Muscle relaxation
5. Amitryptyline
6. Phycotherapy.

2. Migrain
Acute attack
1. Identification & avoidance of precipitating or exacerbating factors such as OCP, smoking
2. Analgesic-NSAID or Paracetamol
3. Metochlopramide or domperidon
4. Severe attack- Sumatryptan, 5-HT agonists
5. Frequent attack are prevented with
 Propanolol
 TCA
 Sodium valproate 300-600mg/day or Topiramate 50 -100 mg/day.
3. Status epilepticus
Management:
Clearing the airway
O2 inhalation

Inj. Diazepam 10mg (Sedil) iv or rectally
Can be repeated after 15 min.

If seizure continued after 30min. then
i.v. Fosphenytoin 15mg/kg at 100mg/min.
Or
i.v. Phenobarbital 10mg/kg at 100mg/min.

If seizure still continued after 30min. then
Start treatment for refractory status with intubation with general anaesthesia with Propofol or Thiopental.

Once status controlled start longer term anticonvulsant medication with one of the following-
a) Sodium valproate 10mg/kg i.v. over 3-5 min. Then 800-2000mg/day.
b) Carbamazepine 400mg by NG tube then 400-1200mg/day.

Guideline for choice of Antiepileptic drugs
Epilepsy type 1st line 2nd line 3rd line
1. Partial or 2ndary GTCS Carbamazepine Sodium valproate Phenobarbital
(200-2000mg/day) Phenytoin
2-3 dose/day

2. Primary GTCS Sodium valproate Lamotrigine Phenobarbital
400-2500/day 60-180mg/day 1-2 dose/day
1-2 dose/day Phenytoin
Carbamazepine
4. Acute stroke
Diagnostic tools
• Sudden onset of weakness of one side of the body or loss of consciousness
• No H/O of fever
• On exam. Hemiplegia and planter extensor in that side.
Management:
1. NG tube feeding
2. O2 inhalation 2-4 l/min
3. Infusion Normal saline 1000cc iv @ 10 drops/min
4. Syrp. Amoxicillin 2 TSF TDS
5. Omeprazole sachet 1 sachet dissolve in ½ glass water then take via NG tube 12 hourly
6. Paracetamol suppository (500mg) 1 stick P/R stat. and SOS
7. Cold tepid sponging
8. Continued catheterization
9. Change the posture 2 hourly
10. Care of the mouth, eye, bowel
11. Treatment of underlying cause like DM, Dyslipidaemia etc.

• If pt. is known hypertensive and taking drug regularly then contd. the drug.
• If pt. is not known hypertensive & BP is high then not give antihypertensive. Antihypertensive should be given in the following condition
-In Ischaemic stroke if BP >220/120 mm of Hg
-In Haemorrhagic stroke > 180/ 110 mm of Hg
• If pt. is Diabetic then start insulin
• If pt. is not known diabetic but blood sugar is >11.1 mmol/L then start insulin.

5. Tetanus
Management
1. O2 inhalation stat 4-6 L/min
2. Nurse in a quite room
3. Avoid unnecessary stimuli
4. NG tube feeding 200 ml 2 hourly
5. Infusion 5% DNS 1000 cc i.v. daily
6. Inj. Benzylpenicillin 600mg iv 6 hourly Or inj. Metronidazole if allergic to Penicillin
7. Inj. TIG 12 amp. i.m. stat.
8. Inj. Diazepam (10mg) 1 amp. i.v. stat & B.D.
9. Change the posture 2 hourly

6. Meningo-encephalitis
Diagnostic tools
1. Fever, Headache
2. Alteration of consciousness
3. On exam.- Neck rigidity present
1. Kernig’s sign present
Management:
1. NG tube feeding 200 ml 2 hourly in sitting posture & maintain the posture for 10 min.
2. Inj. Ceftriaxone (2gm) 1 vial i.v. stat & BD
3. Inj. Dexamethasone 2 amp. i.v. 20 min before giving antibiotics stat & 6 hourly for 3 days
4. Omeprazole sachet 1 packet dissolve in ½ glass water through NG tube BD
5. Continued catheterization
6. Change the posture 2 hourly
7. Care of mouth, eye & bowel
8. If short H/O of fever then add Tab. Acyclovir (400mg) 2+2+2+2+2

Pyogenic Meningitis Choice of antibiotic
1. Pt. present with typical meningococcal rash- Inj. Benzylpenicillin 2.4gm iv 6 hourly
2. Adult aged 18-50 years without typical meningoccal rash – Cefotaxime 2 gm iv 6 hourly or Ceftriaxone 2 gm iv 12 hourly.
3. Pt. in whom penicillin resistant pneumococcal infection is suspected- as for (2) but add Vancomycin 1 gm iv 12 hourly or Rifampicin 600mg iv 12 hourly
4. Adult aged over 50 years and those in whom Listeria monocytogen infection is suspected (Brainstem sign, immunosuppression, diabetic, alcoholic)- as for (2) but add Ampicillin 2 gm iv 4 hourly or Co trimoxazole 50mg /kg iv in 2 divided dose.

7. Encephalitis
Diagnostic tools
4. Fever, Headache
5. Alteration of consciousness
6. On exam. – No Neck rigidity
-No Kernig’s sign.
Management:
1. Same as Mningo-encephalitis
2. If convulsion occurs then add Tab. Carbamazepine (200mg) 1+1+1.

8. Trigeminal neuralgia
Management:
a. Carbamazepine up to 1200 mg daily should be started at low dose. Who can not tolerate it add Gabapentin or Pregabaline.
b. Inj. of Alcohol or Phenol in to a peripheral branch of the nerve.
9. Restless leg syndrome
Management:
1. Clonazepam (0.5-2mg) at night
2. Levodopa 100-200 mg or dopamine agonist at night.

10. Subarachonoid Haemorrhage
Management:
1. Nimodipine 30-60 mg iv for 5-14 days followed by 360 mg for further 7 days.
2. Definitive treatment
a. Insertion of platinum coil in to an aneurysm via endovascular procedure
Or
b. Surgical clipping of the aneurysm neck.
AV malformation –surgical removal, ligation, injection of material to occlude the fistula or draining veins.

11. Transverse Myelitis
Management:
1. Diet – normal
2. Inj. Methylprednisolone 1 gm daily for 3 days
3. Omeprazole
4. Continued catheterization

12. Dementia/ Alzheimer;s disease
Management:
1. Donepezil 10 mg daily
2. Antidepressant in depressive pt.

13. Wernick- Korsakoff disease
Diagnostic tools
1. H/O alcoholism, malabsorption, malnutrition, Hyperemesis gravidarum
2. Acute confusional state (W.encephalopathy)
3. Brain stem sign e.g. ataxia, nystigmus & extraocular muscle weakness particularly lateral rectus.
Management:
1. Intravenous Thiamine 2 vial 8 hourly for 48 hours, then oral Thiamine 100 mg 8 hourly
2. Treatment of the underlying cause.

14. Parkinsonism
Management:
1. Levodopa –carvidopa, 50 mg 8 or 12 hourly increased up to 1000 mg/day. This drug improve bradykinesia & rigidity
2. Anticholinergic-improve tremor & rigidity
3. Trihexyphenidyl (benzhexol 1-4 mg 8 hourly)
4. Orphenadrine 50 -100 mg 8 hourly
3. Dopamine receptor agonist
5. Bromocryptine 1 mg initially then 2.5 mg 8 hourly up to 30 mg/day
6. Pergolide 50 µgm (starting dose) increased to 250 µgm 8 hourly up to 3000 µgm/day.
4. Amantadine
-Use in early of the disease when more potent treatment is not required
-To control dyskinesia produced by dopaminergic treatment.
Dose 100 mg 8 or 12 hourly.
5. COMT inhibitors
Entacapone 200 mg with each dose of levodopa. This prolonged the effect of levodopa & allows levodopa dose to be reduced & given less frequently.
6. Surgery
Stereotactic thalamotomy to treat tremor. Now a days need relatively infrequently
7. Physiotherapy & speech therapy.

15. Huntington’s disease
Symptomatic management
7. Tetrabenazine or dopamine antagonists such as sulpride
8. Antidepressants for depressive pt.
9. Psycological support
10. Genetic counselling for the relatives
16. Rabies
Management:
Established disease
1. ICU support
2. Sedation with Diazepam 10 mg 4-6 hourly
3. Chlorpromazine 50-100 mg if necessary
4. Nutrition & fluid by iv or gastrostomy.
Prevention
Pre-exposure prophylaxis – protection is afforded by 2 intradermal injection of 0.1 ml human diploid cell vaccine or 2 intramuscular inj. Of 1 ml, given 4 weeks apart, followed by yearly booster.
Post exposer vaccination before development of sign symptom. For maximum protection hyperimmune serum and vaccine are required.
Safest antirabies antiserum is human rabies immune globulin, the dose is 20 U/kg, half should be infiltrated around the bite and half im at adifferent site from vaccine.
Safest vaccine is human diploid cell vaccine 1 ml is given intramuscularly on days 0, 3, 7,14, 30 and 90.

17. Cerebral abscess
Treatment:
1. Diet – normal
2. Antibiotic
3. Anticonvulsant- Carbamazepine SR 200 mg B.D.
4. Paracetamol if fever
5. Surgery
Burr-hole aspiration or excision-where presence of a capsule may lead to a persistent focus of infection.

Antibiotic choice is guided by following condition
Frontal lobe
Cefuroxime 1.5 gm iv 8 hourly
Plus
Metronidazole 500 mg 8 hourly.
Temporal lobe & Cerebellum
-Ampicillin 2-3 gm iv 8 hourly
Plus
-Metronidazole 500 mg 8 hourly
Plus
Either Ceftazidime 2 gm iv 8 hourly or Gentamycin 5 mg/ kg iv daily.
Any site
H/O penetrating injury
-Flucloxacillin 2-3 gm iv 6 hourly
Or
– Cefuroxime 1.5 gm iv 8 hourly
Multiple abscesses
-Benzylpenicillin 1.8 – 2.8 gm iv 6 hourly if endocardits or cyanotic heart disease.
– Otherwise Cefuroxime 1.5 gm 8 hourly
Plus
Meteronidazole 500 mg 8 hourly.

18. Idiopathic intracranial hypertension
Management:
1. Weigh reducing diet
2. Avoid any precipitating condition or medication
3. Carbonic anhydrase inhibitor-Acetazolamide
4. Repeated LP
5. Optic nerve fenestration or lumbo-peritoneal shunt if
-Pt. failing to respond
-Chronic papilloedema threatens vision.

19. Lumber disc herniation
Management:
1. Back strengthening exercise
2. Early mobilization
3. Analgesic
4. Inj. Of local anaesthetic agent or corticosteroid, if symptoms due to ligamentus injury or joint dysfunction
5. Surgery
-No response to conservative treatment
-progressive neurological deficits develops
-Central disc herniation with bilateral symptoms & signs & distrubnance of sphincter function require urgent surgical decompression.

20. Fascial nerve palsy
Management:
1. Artificial tear & ointment
2. Eye should be tapped shut overnight
3. Prednisolone 40-60 mg daily for 7 days (should be started with in 72 hours).

21. Guillain-Barre Syndrome
Management:
1. Regular monitoring of the pt. with respiratory function, VC & ABG
2. Artificial ventilation if VC 15 mg/dl
c) Prolonged prothrombin time
d) Co-morbidities- like DM, IHD
Criteria of hospital discharge-
a) Substantial symptomatic improvement
b) A significant downward trend in the serum aminotransferase and bilirubin values and
c) A return to normal of the PT
d) Mild aminotransferase elevations should not be considered contraindications to the gradual resumption of normal activity.
( Ref: Harrison’s principle of Internal Medicine + CMDT 2010)

3. Acute liver failure
Hyperacute liver failure- if jaundice to encephalopathy time 2gm/dl in 24 hours).
5. Close monitoring of the pt. with Pulse, BP, and urine out put and Hb%.
6. If bleeding continues then Therapeutic Endoscopy.
Tips
 A systolic blood pressure less than 100 mm Hg identifies a high-risk patient with severe acute bleeding.
 A heart rate over 100 beats/min with a systolic blood pressure over 100 mm Hg signifies moderate acute blood loss.
 A normal systolic blood pressure and heart rate suggest relatively minor hemorrhage.
 In actively bleeding patients, platelets are transfused if the platelet count is under 50,000/mm3 and considered if there is impaired platelet function due to aspirin or clopidogrel use (regardless of the platelet count).
 Uremic patients (who also have dysfunctional platelets) with active bleeding are given three doses of desmopressin (DDAVP), 0.3 mcg/kg intravenously, at 12-hour intervals.
 Fresh frozen plasma is administered for actively bleeding patients with a coagulopathy and an INR > 1.5.
 In the face of massive bleeding, 1 unit of fresh frozen plasma should be given for each 5 units of packed red blood cells transfused.
 Predictor of rebleeding- clinical predictors of increased risk of rebleeding and death include
a. Age > 60 years,
b. Co morbid illnesses,
c. Systolic blood pressure 100 beats/min, and
e. Bright red blood in the nasogastric aspirate or on rectal examination.
Features of active bleeding: Patients with active bleeding manifested by hematemesis or bright red blood on nasogastric aspirate, shock, persistent hemodynamic derangement despite fluid resuscitation, serious co-morbid medical illness, or evidence of advanced liver disease require admission to an intensive care unit (ICU). Urgent Endoscopy should be performed after adequate resuscitation, usually within 12 hours.
(Ref. CMDT 2010)
6. Acute pancreatitis
Diagnostic tool
1. Severe constant upper abdominal pain may radiate to back relieve by sitting and leaning forwards.
2. Fever & vomiting
3. On exam. – Upper abdominal tenderness but no rigidity and rebound tenderness.

Urgent Investigation
1. S. amylase
2. S. lipase ( if Pt. present after 48 hours)
3. ECG
4. USG of whole abdomen
Management
1. NPO TFO
2. O2 inhalation 4-6 L/ min
3. Infusion Normal saline 1000 cc + 5% DNS 1000 cc i/v @ 20 drops/ min stat and daily
4. Antibiotic-Imipenem (500 mg every 8 hours intravenously) and possibly cefuroxime (1.5 g intravenously three times daily, then 250 mg orally twice daily) administered for no more than 14 days
5. Inj. Omeprazole (40mg) 1 vial i/v stat. & daily
6. Inj. Tramadol HCl (100mg/ml) 1 amp. i.m. stat & 8 hourly
7. NG suction if paralytic illus develops
8. Close monitoring of the pt. with Pulse, BP, and urine out put.
N: B:
• If cause of acute pancreatitis is gall stone then Surgery should be performed after 2 weeks of recovery.
• Oral intake of fluid and foods can be resumed when the patient is largely free of pain and has bowel sounds (even if the serum amylase is still elevated).
(Ref. CMDT 2010 + Oxford American Hand book of critical care.)
7. Chronic pancreatitis
Management:
1. Avoidance of alcohol
2. Analgesia with NSAID or Opiate
3. Oral pancreatic enzyme supplement
4. Dietary fat restriction
5. PPI
6. Coeliac plexus neurolysis or minimally invasive thoracoscopic splaniectomy sometimes required.
(Ref: Davidson)
8. Variceal bleeding
Management:
1. NPO TFO
2. Normal saline 1-2 liter
3. Prophylactic antibiotic – Cephalosporin iv
4. PPI
5. Vasopressor (Terlipressin)-2 mg iv 6 hourly until bleeding stops then 1 mg 6 hourly for further 24 hours
6. Endoscopic procedure to stop variceal bleeding
 Band ligation
-Should be repeated 1-2 week until varices are obliterated. Regular follow up endoscopy is required to identify & treatment of any recurrence of varice.
 Ballon tamponade- Sengstaken-Blakemore tube
7. TIPSS- pt. in whom other treatment is not successful & those with good liver function.
8. Oesophageal transection
– When TIPSS is not available
– Bleeding can not be controlled with other therapies.
9. Portal hypertension
Management:
1. Management of variceal bleeding
2. Primary prevention of variceal bleeding
3. Propanolol 80-160 mg daily or nadalol.( administration of these drugs at doses which reduces heart rate 25% has shown to be effective in primary prevention).
4. Secondary prevention- Beta blocker following banding.

10. Alcoholic liver disease
Management:
1. Cessation of alcohol
2. Nutrition
3. Steroid
Indication:
– Severe alcoholic hepatitis, Maddreys discrimination score >32
Contraindication:
i) Existing sepsis
ii) Variceal haemorrhage
If bilirubin has not fallen 7 days after starting therapy in treatment with steroid, then steroid is unlikely to reduce mortality & should be stopped.
4. Pentoxifylline
5. Use in severe alcoholic hepatitis
6. It appears to reduce incidence of hepato-renal failure
7. Its use is not complicated by sepsis.
5. Liver transplantation

11. NAFLD
Management:
1. Reduce BMI
2. Metformine- 1st line treatment in pt. with DM & NAFLD.
Pioglitazone also improve inflammation & fibrosis.

12. Haemochromatosis
Primary
1. Weekly venesection of 500 ml of blood (250 mg of iron) until S. iron is normal; this may take up to 2 year or more. The aim is to reduce ferittin 1000 µg/ L
Asymptomatic disease is also treated by venesection
4. Screening of HCC by USG

13. Wilson’s disease
Management:
1. Penicillamine –most pt. require 1.5 gm/day (1-4gm/day). The dose can be reduce once the disease is in remission.
Treatment should be continued through out the life including pregnancy. Abrupt discontinuation may precipitate acute liver failure
2. Trientrine dihydrochloride 1.2-2.4 gm/day & Zinc 50 mg 8 hourly, if side effects of penicillin occur.
3. Liver transplantation
– In fulminant liver failure
– Advance cirrhosis with liver failure.
4. Siblings & children of pt. with Wilson’s disease must be investigated & treatment should be given to all affected individual even if they are asymptomatic.

14. Autoimmune Hepatitis
Management:
Prednisolone 40 mg daily
– Dose can be reduced as the pt. & LFT improve. Maintainance therapy is required for at least 2 years after LFT have returned to normal & withdrawl of treatment should not be considered unless liver biopsy is also normal.
– Azathioprine 1-1.5 mg/kg/day allows the dose of prednisolone to be reduced.

15. Primary billiary cirrhosis
Diagnostic tools:
1. Female patient
2. Middle age
3. Flactuating jaundice
4. History of itching.
Asymptomatic
Require monitoring on a yearly basis to assess the onset of symptom & also the disease.
Symptomatic
1. UDCA 13-15 mg/kg/day
2. Liver transplantation if
– Liver failure
– Intractable pruritus
3. Pruritus (Cause- up regulation of opoid receptor & increase endogenous opoid)
Managed by
i) Cholestyramine 4-16gm/day, the powder mixed in orange juice then taken before & after breakfast. It is ineffective in complete billiary obstruction.
ii) Alternative treatment
8. Rifampicin 300 mg/day
9. Naltrexone (opoid antagonist) 25 mg/ day up to 300 mg /day
10. Plasmapheresis
11. Liver support device.
4. Fatigue –no treatmnent , exclude depression & Hypothyroidism
5. Supplementation of fat soluble vitamins
6. Bone disease
Replacement of calcium & vit.D3
Bisphosphonate if evidence of Osteoporesis.

16. Acute cholecystitis
Management:
1. NPO
2. Fluid IV
3. Analgesic-moderate pain-NSAID
4. Severe pain-Pethidine
5. Antibiotic-Cephalosporin (cefuroxime), severely ill add Metronidazple.
6. NG aspiration- if persisting vomiting
7. Surgery should be performed after 6 weeks.

Electrolytes imbalance
1. Ward management of Hyponatraemia
In the ward maximum case of hyponatraemia are hypovoluemic hyponatraemia.
Normal Na+ 135- 145 mmol/L
Hyponatraemia if Na+ 125 mmol/L then oral correction
If Na+ is < 125 mmol/L then iv correction.
 1 TSF table salt contain 96 mmol/L Sodium
 1 L Normal saline contain 154 mmol/L Sodium
 500 ml 3% Sodium contain 512 mmol/L Sodium.

Problem: A pt. present with vomiting followed by unconsciousness. His Na+ is 110 mmol/L. How we will correct his Na+?
Total deficiency = (135 – 110) × 50 × 0.6 mmol/L (His weight is 50 kg).
= 750 mmol/L
Daily correction = 750/3
= 250 mmol/L
So, we have to give 1 L of Normal saline and 1 TSF Table salt daily (approximately) for 3 days.

1. Ward management of Hypenatraemia
Choice of type of fluid for replacement
Hypernatremia with hypovolemia
 Hypovolemic patients should receive isotonic (0.9%) saline to restore the volume deficit and to treat the hyperosmolality.
 After adequate volume resuscitation with normal saline, 0.45% saline or 5% dextrose (or both) can be used to replace any remaining free water deficit.
 Milder volume deficits may be treated with 0.45% saline and 5% dextrose.
Hypernatremia with euvolemia
Water ingestion or intravenous 5% dextrose will result in the excretion of excess sodium in the urine. If the glomerular filtration rate (GFR) is decreased, diuretics will increase urinary sodium excretion.
Hypernatremia with hypervolemia
 Treatment includes 5% dextrose solution to reduce hyperosmolality. Loop diuretics may be necessary to promote natriuresis and lower the total body sodium.
 In severe rare cases with kidney disease, hemodialysis may be necessary to correct the excess total body sodium and water.
3. Treatment of hypocalcaemia
Management:
a) In hyperventilation- rebreathing expired air in a paper bag or administer 5% CO2 in oxygen
b) Inj. 20 ml of 10% solution of Calcium gluconate i.v. slowly stat.
Or
Inj. 20 ml of 10% solution of Calcium gluconate i.m. may be given to obtain a prolonged effect.

4. Treatment of severe hypercalcaemia of malignancy
Management:
1. Rehydration with Normal saline as much as 4-6 L/min. (May need monitoring with CVP in old age or renal impairment)
2. Bisphosphonates e.g. Disodium Pamidronate 90 mg i.v. over 4 hours
3. Additional rapid therapy
a) Forced diuresis with saline & Frusemide
b) Prednisolone 40mg daily
c) Calcitonin
d) Haemodialysis
5. Hypokalaemia
Normal K+ is 3.5-5.5 mmol/L
Hypokalaemia if 2.5 mmol/L.
Intravenous potassium is indicated for patients with severe hypokalemia and for those who cannot take oral supplementation & if K+ is 5.5 mmol/L
Management:
1. iv Calcium gluconate 10 ml of 10 % solution
2. Nebulization with Salbutamol solution
3. iv glucose 50 ml of 50 % (in ward we use 25 % glucose 100 ml) plus inj. Actrapid 5 IU.
These 3 are commonly practiced in the ward. Other treatment options-
1. Inj. Iv Sodium bicarbonate
2. iv Frusemide and Normal Saline
3. Ion –exchange resin (e.g. resonium orally or rectally)
4. Dialysis.

1 Comment (+add yours?)

  1. Dr.Salim Al Mamun
    Feb 03, 2013 @ 17:00:23

    Wardwise Treatment Guidelines

    Reply

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