The GP Book Kerala

1

Dr Siva Sankar K

© MBBS MCH TVM Dr Firdause A H MBBS MCH TVM

THE GP NOTE Edited by Dr Firdause. A . H , GMC TVM

This is not an alternative to any textbook, or attending the class/clinics. Advise reading or have a copy of:1. Manual of Emergency Medicine by Lippincott, 2.The Washington manual of medical therapeutics 3. Oxford handbook of clinical medicine 4.Pediatric prescriber by Dr santhosh kumar,5.GP as specialty by Prakash Mahajan, 6.Handbook of Emergency Medicine by Suresh S David, 7. CIMS 8.Practical prescriber by Golwalla,9.Any book of ECG basics & chest X-ray, 10.General Practice, a practical manual by Ghanashyam vaidya. Also have basic knowledge of drugs C/I in pregnancy/lactation, and pediatric dose of common medicines. Pls edit this note yourselves, if you come across any mistake. Caution:Don’t go to an ICU setup with this knowledge alone;you will be in deep trouble (patients also).

FEVER Fever, if oral T >98.90F (at AM) or T>99.90F (at PM) Note: 0C*1.8 +32=0F Note: In case of fever with chills, suspect UTI, malaria, pneumonia, cellulitis, abscess,influenza, leptospirosis, dengue, gastroenteritis, meningitis, tonsillitis, IMN, TB etc P’mol C/I in severe liver diseases, renal impairment, infants < 2 kg. Rx 1.inj P mol 2cc (150 /1 ml) im st (if t>1000 F). 100 ml(1000mg) infusion available(T.N Paracip) [for children 10-15 mg/kg/dose,1.5cc/1cc im st] (for infants and small children give suppositories (T N:-Anamol), normally available as 80,125,170,250 mg; for <5 kg not recommended); Inj Dolonex (piroxicam) 2cc IM st ATD if allergic to P/L 2.Tepid sponging with luke warm water st & SOS;give IV fluids for very high fever. 3.Do BRE,ESR/CRP,URE , if infection is suspected & give Antibiotics for infection 4.T or Syp Meftal may be given Stat for high fever 5.Antiulcerants(especially if certain antibiotics like macrolides, NSAIDs, steroids are provided). 6.Multivitamin tablets with Vit B complex, vit C. 7.Steam inhalation for relieving ENT congestion.

Antibiotics Note:In general, for mild infections use milder antibiotics 1.C Mox or Novamox 500mg 1-1-1 x 5 days (amoxicillin) Indications:for RTI including bronchitis,sinusitis,otitis media, UTI 2.C Roscillin 500mg 1-1-1-1 x 5 days (ampicillin) Indications:for RTI including bronchitis,sinusitis,otitis media, UTI 3.C or T Augmentin/Augpen/Mox CV 625/375 1-0-1 x 5 days (amox +clavulanic acid) T.N:-T Moxiforce-CV or Mega-CV 625,Novaclav 625 , kid tab-228.Dose: 20 mg/kg/dose BD Indications:for RTI , UTI, dental, skin and soft tissue infections, intra abdominal and gynaecological sepsis, cat scratches,infected animal/human bites). 4.C Novaclox 1-1-1 x 5 days (amoxicillin +dicloxacillin)(dramaclox)(ped tab available) 5.C Megapen 1-1-1-1 x 5 days (ampicillin +cloxacillin)(kid tab available) 6.C Aldinir or Zefdinir 300mg 1-0-1 x 5 days (cefdinir)(very expensive) Indications:pneumonia,a/c exacerbations of c/c bronchitis, Ent ,skin) 7.C Phexin/ sporidex 500mg 1-1-1-1 x 5 days (cephalexin) Indications:For bone and joint infections, pharyngitis, skin and soft tissue,tonsillitis, UTI

2 8.T Azithral or Azee 500mg 1-0-0 x 3 days 1hr before food(azithromycin) (specific for respiratory infections)(also for skin,STD’s, PID, urethritis, cervicitis) 9 T Roxid 150mg 1-0-1 x 5 days 30 min before food (roxithomycin) (for RTI, ENT, skin & soft tissue, genital tract infections) 10.T Droxyl 500mg 1-0-1 x 5 days (cefadroxil);Syp (125 /5 or 250/5) available (30 mg/kg/day in 2 div doses)(strep throat infections, UTI,skin) 11.T Taxim-O/ topcef 50/100/200mg(DT tab available) 1-0-1 x 5 days (cefixime) (resp, urinary, biliary infections) 12.T Ceftas-AL1-0-1 x 5 days (cefixime+ambroxol+lactobacillus spores) 13.T Ciplox 500mg(100/250/750) 1-0-1 x 5 days (ciprofloxacin)(for UTI,bone,soft tissue, gynaecological,wound infection, Bact gastroenteritis, Respiratory)(all other FQ’s C/I in children) 14.T Norflox 400mg 1-0-1 x 5 days (norfloxacin)( for UTI & GIT problems) (advise to drink more water).Best , if taken empty stomach with water, don’t take with diary products 15.T Oflox /Zenflox 200mg 1-0-1 x 5 days (ofloxacin)(c/c bronchitis, other respiratory, ENT) 16.T Levobact or Levoday or Loxof 500mg 1-0-0 x 5 days (levofloxacin) (advise to drink more water) 17.T Septran/Bactrim d.s. 1-0-1 x 5 days (sulfamethoxazole 800 +trimethoprim 160) (advise to drink more water) Syp available( 200 + 40)/5 ml 18.T Proflox 400mg 1-0-1 x 5 days (pefloxacin) ( for UTI & GIT problems) 19.T Cepodem/Monocef-o/podocef/macpod 100/200mg 1-0-1x 5 days(cefpodoxime) (for RTI, UTI, skin and soft tissue). 20.T Klox (cloxacillin) 250/500 mg tds/Qid(furuncle, abscess, carbuncle, impetigo, osteomyelitis, bites), syp (125 /5) (100-200mg/kg/day in 4 divided doses) 21.T clarithro/claribid/synclar (clarithromycin) 250/500 mg 1-0-1(resp, skin & soft tissue) 22.T Altacef 250/500 1-0-1(cefuroxime)(URI, LRI, UTI) For children and infants most pediatric medicines are available in syrup/Drops. 1-3 yrs =1/2 tsp tds; 3-6 yrs =1 tsp tds; 6-10 yrs =2 tsp tds or 1/2 adult tabs. This can be used as a rough guideline to prescribe common pediatric medicines. The dose should be adjusted according to the built and weight.

Commonly used antibiotics in children 1.Syp Amoxicillin (125 /5 or 250/5) [T N:- mox,Novamox](DT 125, 250 mg available) Dose: 30-50 mg/kg daily in divided doses Q8H or Q12H. In Practice 15 mg/kg/dose Q8H Novamox Dps (100 /1) available Syp Augmentin/Mox CV 228 /5, 156 /5, 312 /5 available,(Amoxicillin + clavulanic acid) Novamox CV/Mox CV dps,each 1 ml contain amox=80 mg,clavulanic acid=11.4 mg. Augmentin/ Mox CV Syp 457 (400 + 57)/5ml, 156(125 + 31)/5ml, 228(200+28)/5ml, 312(250 +62) available. 2.Syp Ampicillin(125 /5 or 250/5) Dose is 50-100 mg/kg/daily in divided doses Q6H 3.Syp Azithromycin(100 /5 or 200/5) {T N:- azee, ATM}(Dose for children above 6 months-10 mg/kg/day for 5 days) 4.Syp Cefixime (50 /5 or 100 /5 ) {T N:- taxim-o,topcef}(8 mg/kg/day in divided doses Q12H), Dps 25/1 available 5.Syp Septran (sulfamethoxazole 200+ trimethoprim 40)(6-10 mg/kg/24 hr(TMP) div into 2 PO)(dose calculated in terms of mg of TMP).Paed tablets: (100+20) 6.Syp Ampoxin Or Syp Roscilox(ampicillin +cloxacillin) 7.Syp Synclar/Maclar(125 /5)(clarithromycin)(15 mg/kg/day in 2 divided doses) (URTI,LRTI,sinusitis,otitis media etc)(125 DT available) 8.Syp Kefpod/Macpod(50 /5 or 100/5)( cefpodoxime)(10 mg/kg/day div into 2 doses PO) (LRTI,URTI) 9.Syp Phexin(cephalexin)(125 /5 or 250/5) (50-100 mg/kg day in 3 or 4 doses PO)(DT 125, 250 mg available). Phexin Dps 100 /1 available. 10.Syp Altacef (cefuroxime)(125 /5)(30 mg/kg/day div into 2-3) For pregnant ladies Amoxicillin,cephalosporins, ampicillin & cloxacillin combination,amoxicillin & clavulanate combination, Penicillin G. Azithromycin(class B)

3 Antipyretics Note:- In Children, if fever is accompanied by rashes,esp vesicular or maculo papular suspect Chickenpox or Measles respectively. In measles, the child is usually sick looking with, rashes starting from face. 1.T Calpol/Panadol/Dolo 500mg/650mg 1-1-1-1 x 3 days( p’mol or acetaminophen) 2.T Ibugesic or brufen 200/400/600mg 1-0-1 x 3 days(ibuprofen) 3.T Meftal or ponstan 250mg/500 1-1-1x3 days(mefenamic acid)(ideal for dental pain) 4.T Pirox /Dolonex 20mg 1-0-0 x 3 days(piroxicam) 5.T Ibugesic Plus 1-0-1 ( ibuprofen+ P’mol) 6.T Meftal forte/ meftagesic(Meftal 500 + P/L 450) For children 1.Syp P’mol(125 /5 or 250/5)(10-15 mg/kg/dose x 4 times)(C/I in less than 2 kg) T N:- Calpol,crocin,dolo,febrinil,febrex etc.(Calpol, Dolo,Babygesic,Crocin,Febrinil dps available) Nopain dps(15 ml) (100 /1) available, Tab 125 available 2.Syp Ibuprofen(100 /5)(8-10 mg/kg/dose x 3 times)(may precipitate aspirin induced asthma, so don’t give to asthmatic or dyspnoeic pts).Syp ibugesic plus(ibuprofen 100 + P/L 162.5 /5 ml) Another formula: dose in ml= wt / 2 3.Syp Meftal(50/5 or 100/5) (generally not used < 6 months)(8 mg/kg/dose x 3 times a day) (DT-Tab 100 available); ( wt x 4/10 = dose in ml, applicable only for 100/5 formulation) Syp Meftagesic(P/L 125 mg, mefenamic acid 50mg/5 ml) For pregnant ladies P ‘mol only

Vitamins Usual dose: 1 tab od or bd 1.T Beplex forte(syp available)(vit B complex with folic acid, vit C, ) 2.T Bicozinc(syp available)(vit B complex with Folic acid , vit C, Zn sulphate) 3.C Becosules(syp available)(vit B complex with Folic acid, vit C) 4.C Nutrolin B plus(syp available) (vit B complex with Folic acid, lactobacillus) 5.T Polybion (syp available)(vit B complex with Folic acid, vit C) 6.T Neurobion forte (syp available)(vit B complex) 7.T BC (β- carotene, vit E, vit C -antioxidants) 8.T Celin 500mg OD(vit C) 9.T MVT OD(multivitamins) 10.T Health Ok ( multiviamins, multiminerals, aminoacids with taurine & ginseng) 11.T Becozym C Forte OD (vit B + vit C) For children 1.Syp/Dps A to Z(vit A,vit B complex, vit C,vit D,Fe,Se,iodine) 2.Syp Zincovit(vit A,vit B complex, vit D,vit E,Cu,Se,Zn,iodine), 3.Syp /Dps Delices(Vit A,B,D,E, aminoacids, antioxidants) 4.Syp osto-polybion D(Vit B12,Vit D3, Ca2+) 5.OH-D3 /Ultra D3 /Bon D light dps(400 IU/ml)(Vitamin D3 or cholecalciferol) 1 ml OD for infants Iron preparations (can be given in pregnancy) 1.T Autrin(fe fumarate + folic acid +b12 +c) od 2.T Macalvit / Shelcal(ca carbonate+vit D3) od (syp Shelcal & Shelcal kid tab available) 3.T Fefol-Z(fe sulph+ folic acid +b12 +c+Zn) od 4.Syp Vitcofol(fe fumarate+ folic acid +b12) 5.T orofer –XT( 0-1-0)(elemental Fe + folic acid)Dps /Syp available

4 Anti ulcerants 1.T Rantac/zinetac/aciloc 150 mg 1-0-1(ranitidine)(30 min before food) (Ped dose 2 mg/kg/dose x 2 PO,1-2 mg/kg/dose IV ), syp rantac 75/5 2.T Pantocid 40 mg 1-0-0(pantoprazole)(30 min before food)(ped dose: 1 mg/kg/dose PO OD) T Pantop-IT(with itopride), Pantop-L(with levosulpiride). Inj Pantop 40 mg iv od/bd 3.T Rabicip/happi/Razo 20 mg 1-0-0(rabeprazole-fast acid suppression). Inj rabicip 20 mg iv od 4.C Omez 20 mg 1-0-0 empty stomach(omeprazole)(1 hr before meal) 5.C Rabicip D/Roles-D (with domperidone) , Pantop- D( with domperidone) 6.T Lanzole 30 mg 1-0-0 (lansoprazole) 7.T Lesuride 25 mg 1-0-0; Inj Lesuride 25 mg iv od 8.Digene 2tsp tds(Simethicone+Mg(OH)2+Al(OH)2+ Na carboxymethylcellulose) 9.Gelusil MPS 2tsp tds(Simethicone+Mg(OH)2+Al(OH)2+Mg Al silicate) 10.Rantac MPS(Magaldrate+Simethicone) 11.Mucaine(Mg(OH)2+ Al(OH)2+ oxethazaine) 12.Tricaine MPS(Simethicone+Mg(OH)2+Al(OH)2 +oxethazaine) 13.Syp sucralfate (ulcer protective) Antacids: 1-2 ml/kg/dose in infants;5-15 ml/dose every 4-6 hr in children Note: Take antacids 2 hr before or after ingestion of the drug to prevent drug interaction For children Syp or Tab rantac, T Pantop, T Junior Lanzole 15 mg OD(1mg/kg/day) For pregnant women 1. Digene 2tsp tds 2. Gelusil MPS 2tsp tds and other antacids 3.T Ranitidine, famotidine. Inj Rantac can also be given Steam inhalation may be with 1.Vicks/amrutanjan/tulsi leaves/2-3 dps of essential oils like eucalyptus oil,camphor etc 2.Tincture Benzoin 3.Karvol Plus / Sinarest / Nosikind inhalant capsule (camphor, chlorthymol, eucalyptol, menthol, terpineol) COUGH Pharyngeal demulcents provide symptomatic relief in dry cough arising from throat. Note:give antibiotics if infection is suspected.Advise an X-ray chest, AFB sputum for otherwise unexplained Cough>2-3 weeks not responding to antibiotics or cough with haemoptysis/chest pain/PUO/weight loss. Advise adequate hydration to help expectoration. For bronchodilation and expectoration: 1.Syp Ascoril / Capex bron / Bro-Zedex 2tsp tds x 3-5 days (terbutaline sulphate +bromhexine+ guaiphenesin)(Tab available) 2.Syp Bricarex A / Cosome A / avocof / Mucosolvin/ instaryl-P 2tsp tds x 3 days (terbutaline sulphate +ambroxol hcl+ guaiphenesin) 3.Syp Asthalin expectorant 2tsp tds (salbutamol+ guaiphenesin) Dosage: <6 yr= 5-10 ml tid, 6-12 yr= 10 ml tid 4.Syp Ambrolite-S 2tsp tds x 3 days ( salbutamol +ambroxol hcl+ guaiphenesin) 5.Syp Ambrodil-S 2tsp tds x 3 days (salbutamol +ambroxol hcl) 6.Ascoril- LS Syp or Dps(levo salbutamol +ambroxol+Guaiph) 7.Syp Dilosyn Expectorant(Methdilazine HCl+ ammon Cl+Na citrate) 8.Syp Piriton Expectorant (Chlorpheniramine maleate+ammon Cl+Na citrate) 9.Syp Grilinctus BM or instaryl(terbutaline sulphate +bromhexine)(Tab and Paed syp available)

5 (for Bronchial asthma, a/c & c/c bronchitis,bronchiolitis, other bronchospastic disorders) 10.Syp Mucolite /ambrolite 2tsp tds x 3 days (Ambroxol) Syp Ambrodil (15/5 or 30/5) 2tsp tds <2y=7.5 mg bd, 2-5y=7.5 mg bd/tid, 6-12 y= 15 mg bid Ambrodil/AX/xputum paed Dps (7.5 /1 ) <6 month- 0.5 ml bd,6-12 month- 1ml tds,12-24 month2ml tds 11.T Mucolite/ambrodil (ambroxol) 30 mg tds 12.T Bromex (BH) 8 mg bd/tds 13.T Mucinac 200/600 mg bd/tds (acetylcysteine) For children: Syp Asthalin ( 2 /5 )(0.1-0.2 mg/kg/dose Q6H) after food. For cough suppression: 1.Syp Viscodyne D 2tsp tds x 3 days(tripolidine hcl+ pseudoephedrine +dextromethorphan hbr) 2.Syp Actifed DM 2tsp tds x 3 days(tripolidine hcl + phenyl propanolamine+DM hbr) Dosage: 6month-2 yr=1.25 ml, 2-5 y= 2.5 ml, 6-12y= 5 ml, >12 y= 10 ml 3.Syp Piriton/ Dilo-Dx / solvin cough/ Cheston CS 2tsp tds x 3 days(CPM + DM hbr) 4.Syp Cosome 2tsp tds x 3 days(CPM +DM hbr+phenylpropanolamine hcl) Dosage:2-6 y=1.25 – 2.5 ml, 6-12 y= 5 ml, >12y= 10 ml 5.Syp Ascoril-C/Linctus codeine/codistar /corex 2tsp tds x 3 days(Codeine Phosphate + CPM) 6.Syp Alex cough formula 2tsp tds x 3 days(CPM+Phenylephrine+ DM Hbr) Dosage:1-5 y=1.25 ml, 6-12y=2.5 ml,>12 y=5 ml tid/qid 7.Syp Ascoril-D 2tsp tds x 3 days(tripolidine hcl+ phenylephrine+DM hbr) Dosage:2-5 y=2.5ml tds, 6-12 y= 5 ml tds,>12y=10 ml tds 8.Syp T-minic cough 2tsp tds x 3 days(Phenylephrine hcl +DM hbr) 9.Syp coscopin Plus (Chlorpheniramine maleate+ammon Cl+Na citrate + noscapine) 10.Syp Ambrolite-D 2tsp tds (pseudoephedrine hcl +DM hbr+cetrizine) 11.Syp Zedex 2tsp tds(bromhexine hcl+DM hbr)Dosage: 2-6 y=2.5 ml, 6-12 y= 5 ml 12.Alex Paed Dps /Solvin Cold Dps (CPM+Phenylephrine) 13.Flucold Dps(phenyl propanolamine+ CPM) 14.Syp Zedex-p(DM+bromhexine +phenylephrine); 2-6= ½ tsp, 6-12= ½-1 tsp,(for paediatric cold, cough) 15.Syp Zerotuss (levocloperastine fendizoate)(cloperastine- cough suppressant acting on CNS) 16.Syp Benadryl (diphenhydramine) T Cheston-DT(CPM+phenyl propanolamine+ BH),T Codifos(codeine) 10 mg, T Sedosolvin (DM+CPM+BH) T Deletus (DM + tripolidine + phenylephrine) Note:codeine c/I in asthmatics; codeine as a cough suppressant is not recommended for < 2yrs. For pregnant ladies give Syp Ascoril, Syp Grilinctus (DM hbr + guaiphenesin + CPM), Syp Benylin expectorant(Guaifenesin +DM Hbr) or Syp Robitussin DM For diabetics: Productive cough-Ascoril SF, Macbery-XT; Dry cough-Robitussin CF(DM hbr + guaiphenesin+ psuedoephedrine) Tusq-Dx(DM hbr + CPM +phenylephrine hydrochloride ), Benylin Adult , Alex sugar free , zerotuss- SF can also be given Lozenges: Alex/Chericof (Dextromethorphan 5 mg), Tusq-D (DM + Amylmetacresol), strepsils(benzyl alcohol, metacresol)

6 Analgesics NSAIDS 1.T Voveran/Diclonac/Dicloran 50 mg bd(Diclofenac sodium)(suppository 12.5mg, 100mg available.TN:Jonac) 2.T Ibugesic/Brufen 400-600 mg tds(Ibuprofen) (other T N:- brufen, Ibuflammar)(100 mg/5 ml susp available) 3.T Meftal 250-500 mg tds(Mefenamic acid) (other T N:- Ponstan, Medol)(100 mg/5 ml susp available) 4.T Dolokind 100mg bd(aceclofenac ) (other T N:- Aceclo, Zerodol) 5.T Ketanov 10 mg Qid( Ketorolac)(for Post operative, dental, a/c musculoskeletal, renal colic, migraine, pain due to bony metastasis) 6.T Pirox 20 mg OD (piroxicam)(for osteo/rheumatoid/ acute gouty arthritis) 7.T indocid/ articid 25-50 mg BD-QID (indomethacin)(musculoskeletal & joint disorders) 8.T Etoshine/etody 60-120 mg OD(etoricoxib)(for osteo/rheumatoid/ acute gouty arthritis) Note: Avoid NSAIDs in Dengue,severe liver/kidney d/s,active cerebral hemorrhage,GI bleeding etc. NSAIDs may also increase the risk of having a stroke or MI in pt’s with existing cardiovascular disease. In such cases give T Naproxen 250/500 mg bd(T.N Artagen) Opioid Analgesics 1. T Trambax or Tramazac (tramadol) 50 mg tds 2.T Fortwin 25 mg Qid( Pentazocin) Combinations 1.T Ultracet or Palitex or Dolzero or acuvin(Tramadol+ P’mol) 2.T Dynapar (Diclofenac + p’mol) (Inj available) 3.T Zerodol-P or aceclo plus or Hifenac-P or Dolokind-Plus (Aceclofenac+ P’mol) 4.T Durapain (Diclofenac sodium SR +Tramadol IR) 5.T Ibugesic Plus/combiflam (ibuprofen + P’mol) Note:- for pregnant ladies give P’mol only Injections: P/L, Diclofenac, Tramadol, Ketorolac, Piroxicam, Pentazocin etc Tramadol may cause nausea( give emeset),dizziness,sleepiness,sweating, lowering of seizure threshold Abdominal Pain Common causes: Renal calculi,appendicitis, pancreatitis, intestinal obstruction, peptic ulcer, Gastroenteritis, cholecystitis, GERD,UTI, medications,mesenteric ischemia etc Note:In case of renal colic there will be colicky pain radiating from the loin to groin and h/o similar episodes in the past. All abd pain above the level of umbilicus, rule out I.W.M.I. Also rule out DKA. Examination of genitourinary system in men should be performed in all cases of a/c abd pain to r/o testicular torsion. The immediate treatment of renal pain/colic is bed rest & application of warmth to site. Inv: S.amylase & lipase, URE,BRE, X-ray abdomen erect view, USS/CECT abdomen, ECG, RFT etc. R/o pregnancy in female pt’s before subjecting to x-rays. 1.Inj Voveran 1 amp IM st ATD or Inj Tramadol 1amp IM or IV st(+ emeset)

7 2.Inj Buscopan 1 amp IM or IV st ATD(hyoscine butyl bromide, anti spasmodic) or Inj cyclopam 2cc IM st (Dicyclomine HCl, anti spasmodic) 3.Inj Pantop 40 mg iv st or Rantac 50 mg iv st If pain is very very severe: Inj Fortwin 1amp IV/IM + Inj Phenergan 1amp IM /IV st 4.T voveran 50 mg 1-0-1 or T Buscopan 10 mg tds or T Cyclopam (Dicyclomine HCl 20 mg + P/L 500 mg) 1-1-1(SOS in pregnancy) or, T Zerodol spas/aceclo spas(aceclo+ drotaverine); For children:Syp Cyclopam(Dicyclomine 10 mg+ simethicone)(10/5) (generally not used <6 months)(0.5 mg/kg/dose x 3 times)(> 6 months:up to 5 mg/dose,children 10 mg/dose) 5.T Pantop OD; for children:- T Junior Lanzole OD; Plenty of oral fluids Loin pain, etiology:renal colic, UTI,pyelonephritis,PUJ obstruction,muscular pain, herpes zoster, PCKD, cholecystitis, glomerulonephritis, BPH, AAA, renal infarction, kidney tumours, LPH syndrome(Loin Pain Hematuria), lumbar hernia. Febrile seizures Age gp →6 months to 6 yrs. C/f: May present with frank fits or more commonly uprolling of eyes ,loss of consciousness, they may also vomit or have increased secretions (foam at the mouth). The body may go stiff, then generally twitch or shake (convulse). The seizure normally lasts for less than five minutes.The child's temperature is usually greater than 38 °C (100.4 °F) 1.Inj Diazepam 0.2mg/kg iv to be given very slowly to avoid respiratory depression(per rectum can be given). May be repeated after 3-5 minutes if needed Or Inj Lora 0.1 mg/kg iv st can also be given Or Diazepam suppository 0.5 mg/kg PR(per rectum)(additional 0.25 mg/kg after 10 min if needed) Note:- in case of respiratory depression give painful stimulus or ambu bag for few minutes 2.Tepid sponging + P’mol. Check GRBS. 3.Oxygen inhalation.Clothing around the neck should be loosened. 4.Semiprone position and throat suctioning 5. Protect the child from injury.Keep under observation for some time.Monitor Vitals. Prescription on discharge as prophylaxis:1.Syp P’mol)( 125 /5 ) Qid 2.Syp Calmpose(Diazepam)(2/5) for first 2 days of fever(0.2-0.3mg/kg/dose x 3 times) (T.Valium/calmpose 2/ 5 /10 mg); T Frisium (clobazam) 5/10/20 mg(0.5-1 mg/kg/day in 2 div doses) if diazepam fails. Above 3 yr start with 5 mg OD. 3.Tepid sponging SOS Note:- the above three instructions to be followed for first 2 days whenever there is a fever. 4.Syp Mox( 125 /5 ) tds x 5 days if any associated infection 5.Syp Nutrolin B bd x 5 days All children below 1yr-11/2 yr presenting with first episode of febrile seizures should be referred to higher centre after initial treatment as LP is indicated.

8

Vomiting Causes:gastroenteritis, migraine,drugs,pregnancy, food poisoning,alcoholic gastritis, renal colic, peptic ulcer,viral hepatitis,cholecystitis, labyrinthine disorders, uremia,dengue,appendicitis, pyelonephritis hypokalemia etc

R/o MI,CVA,raised ICT, hypertensive encephalopathy, DKA, poisoning(like odollum-hypotension, bradycardia, weak pulse, diarrhoea) Inv:FBC, RFT,LFT, RBS, S. Amylase,ABG,ECG, AXR, CT head etc 1 Inj Emeset(2mg /1ml) (0.1 mg/kg/dose) (Ondanestron) 4mg/8mg iv / Inj Perinorm(5mg /1ml) 1 amp iv / Inj Stemetil(prochlorperazine) 12.5mg im ST/ Inj Phenergan(25mg /1ml) 25mg iv(0.5-1 mg/kg/dose IM/IV in children). For severe vomiting, Inj Perinorm + Emeset can be given. If vomiting is due to chemotherapy, give Inj Emeset 4mg iv Q3H 2.Inj Rantac 50 mg iv ST or Inj Pantop 40 mg iv st 3. Check BP, If low give IVF RL/ Isolyte P +DNS 4.T Domstal(Domperidone)10mg(5mg, 10 mg DT Tab available) 1-0-1 x 2 days(15-30 min before meals) & SOS or T Emeset 4/8 mg bd Or T Perinorm(metoclopramide)10mg tds(30 min before meals) or T phenergan (promethazine) 25mg bd 5.T Zofer MD 1 SOS(mouth dispersible preparation of ondanestron) 6.T Rantac 150 mg 1-0-1 x 3 days

For children:Syp Domstal(1mg /1ml) (0.2 mg/kg/dose x 3 times)(Domperidon) or Syp Grandem(Granisetron) (1mg /5ml) (20 microgram/kg/dose PO) or Syp Phenergan(5mg/5ml)(1mg/kg/dose),Syp emeset or Vomikind(2mg /5ml)(children above 5 yrs:4mg/dose PO tds, for smaller children:0.1 mg/kg/dose bd/tds), Syp Perinorm(5/5)(0.1 mg/kg/dose; may ppt seizure)Vomistop Dps(Domperidon) 1mg /1ml ,10mg /1ml available For Pregnant ladies:T Doxinate 2 tab HS(Doxylamine + Pyridoxine) Or perinorm Or T Avomin(Phenergan) SOS & tds or T Pregnidoxin(Meclizine HCl) SOS & tds or T Emeset. Inj Perinorm(IV or IM) or Emeset (IV) or Phenergan(IM) can be given Note:-In adults we may give perinorm, but it is better avoided in children as it may produce extrapyramidal symptoms. Phenergan has the advantage that it may be used for the treatment of extrapyramidal symptoms. It also produces some sedation. If vomiting is due to chemotherapy , Emeset is the best. If Drug induced extrapyramidal reaction occurs (Drugs: antipsychotics like haloperidol,chlorpromazine, antiemetics like stemetil,cinnarizine) 1.Stop offending drug 2.T Diazepam 1 st 3.Inj diazepam 2cc IM or IV or Inj Phenergan 2cc IM or IV

Loose stools Find out whether it is diarrhoea, pseudodiarrhoea, fecal incontinence from history Aetiology:infection,drugs(certain antibiotics/PPI), a/c IBD, toxin, food intolerance, diverticulosis Ask for associated fever(r/o leptospirosis), blood/pus in stools, abdominal pain,consistency of stools etc. 1.C Zedott or Redotil 100mg (racecadotril, 1.5 mg/kg/dose in children) or Redotil 10 or 15 or 30 mg sachet x tds can also be given or T Lomotil(atropine sulphate, diphenoxylate HCl) (C/I for children <6 yr, pregnancy)1-1-1 x 3 d Note: Lomotil not used nowadays. 2.T Nutrolin B/ C Vizylac/C Darolac(lactobacillus combinations) 1-1-1(darolac sachet available) 3.T Cyclopam/ Buscopan 1 SOS, for abdominal pain. 4.Check BP, If low give IVF RL/ Isolyte P +DNS

9 5.ORS(Electrokind, electrosip,elect) in small sips( unit dose 4.3 g packet to be mixed with 200 ml & multidose 21.5 g packet to be mixed with 1 L or 5 glasses of boiled & cooled water). Dosage after each purge: <6months :50 ml or 1/4 glass, 6months-2years: 50-100ml(1/4-1/2 glass), 2years-5 years:100-200 ml(1/2-1 glass), >5years:as much as able to drink.If child vomits, wait for 10 min & then resume feeding. Also give Plenty of oral fluids (home available) 6.Report blood or pus in stools For children, also give Zn,(0.5 mg/kg/day or 10 mg daily for age 2-6 months & 20 mg for >6 months). T.N: Z & D syp/dps(Zn sulphate) or Mintonia syp(Zn acetate) x 2 weeks (syp 10 or 20 mg/5 ml or Dps 20mg/1ml). Below 2 months not indicated. Note:- if very severe, for adults give Imodium / Lopamide 2mg ( loperamide) 2 tabs stat, then 1 tab after each episode (C/I in <4 yrs and in acute infective diarrhoea and pregnancy) For Pregnant ladies:Give ORS, Darolac sachet, oral fluids Child-hood diarrhea/ADD No dehydration→well alert, eyes normal, tears present, mouth & tongue moist, normal thirst, skin pinch goes back quickly:50-100 ml ORS (if <2 yr) & 100-200 ml ORS (if 2-10 yr) per purge For >10 yrs as much as wanted. Generally,give one teaspoon every 1-2 minutes. For some dehydration→restless, irritable, eyes sunken, tears absent, mouth & tongue dry, thirsty & drink eagerly, skin pinch goes slowly→75 ml/kg ORS in 4 hr and if dehydration subsides 10-20ml/kg after each stool. If not repeat 75 ml/kg ORS in 4 hr. For severe dehydration→lethargic or unconscious, eyes very sunken & dry, tears absent, mouth & tongue very dry, drinks poorly or unable to drink, skin pinch goes back very slowly→IVF Ringer Lactate 30 ml/kg in ½ hr followed by 70 ml/kg in next 2 ½ hr .In infants <12 months 1 hr & 5 hr respectively If macroscopic blood,pus,mucus, foul smell , treat as DYSENTRY. Do Stool culture. 1.T Ciplox TZ 1-0-1 x 5 days(ciplox + tinidazole)// Zenflox-OZ (ofloxacin 200 mg+ ornidazole 500 mg) (others:norflox,ampicillin,doxycyclin,cotrimoxazole) 2.C Zedott or Redotil 100mg (racecadotril) 1-1-1 x 3 days Or T Lomotil(atropine sulphate, diphenoxylate HCl) 3.T Nutrolin B(Ped tab available)/ C Vizylac/C Darolac 1-1-1 , T VSL 3(probiotic) (0-1-0), Syp or C Enterogermina (bacillus clausii, probiotic)Enterogermina dose: adults: 1 Capsule bd or tds; children:1 capsule od or bd or Syp 5ml bd, breast feeding infants 5 ml od or bd for 2-5 days 4.T Cyclopam/ Buscopan 1 SOS if abdominal pain 5.Check BP, If low or if dehydrated, give IVF RL/ Isolyte P +DNS 6.T Rantac 150 mg 1-0-1(Proton Pump Inhibitors may cause drug induced diarrhea) 7.Fluid managment same as above;Plenty of oral fluids In PEDIATRIC cases , old regime: SEPTRAN(cotrimoxazole) or GRAMONEG 300/5 (Nalidixic acid)(55 mg/kg/day in 3-4 div doses; not to be used below 3 months) . New regime: ciprofloxacin15mg/kg bd. Cefixime can also be given Note:- 5 % /10% dextrose not given

Anaphylactic shock 1.Inj Adrenaline 0.5mg IM or SC(in children: 0.01 ml/kg; don’t exceed 0.5 ml per dose) (Repeat every 5-10 min in case patient doesn’t improve);1 ml amp of 1:1000 solution, 1mg/ml 2.IV glucocorticoids(hydrocortisone sod.succinate 100-200 mg;10 mg/kg in children & max 100 mg) in severe/recurrent cases. 3.Antihistaminics (chlorpheniramine 10-20 mg) IM /slow IV 4.Put the pt in reclining position, administer O2 at high flow rate and perform cardiopulmonary resuscitation if required.

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Patient with wheeze Monitor SpO2 , work of breathing, Respiratory rate etc. Note:In all cases of first episode of wheeze, r/o FB , irrespective of age(take CXR) 1.Nebulise with Salbutamol(albuterol) 1cc in 3- 4cc NS + O2 x 3 times at 20 min intervals in moderate and severe cases(or lesser if there is clinical improvement). Dose in children is 0.03ml/kg with 3 ml NS. 150 mcg/kg/dose, but min dose is 0.5 ml or 2.5mg salbutamol.For mild cases, one nebulization may be enough.In usual practise give, 0.5 ml for <5yrs, 1ml for >5 yrs. In severe cases, Nebulisation can be done by combining Salbu(2.5-5mg) & Ipratropium bromide(0.5mg) or Duolin(levosalbu + ipratropium). Ipravent dosage: <5 yr :-125 mcg(0.5ml)& > 5 yr:- 250 mcg(1ml)(12.5 mcg/kg/dose).Budesonide :Children 12 months to 8 years of age:0.5 to 1mg OD, or divided and given twice a day, <1yr:0.5 mg. commonly given in croup. Note: Inhaled salbutamol & terbutaline should not be used on any regular basis; inhaled Salbutamol,salmetrol, ipratropium bromide,Beclomethasone,Budesonide are safe in pregnancy. 2.Inj Deriphyllin 1 amp iv st (5mg/kg/dose IM in children)(given in pregnancy) 3.Inj Efcorlin(hydrocortisone) 100mg //Inj Methyl prednisolone 120 mg// Inj Betnesol 4 mg iv st. For children with severe dyspnoea, administer steroids after 1st nebulization Dose: Inj Efcorlin (10 mg/kg st & 4mg/kg Q6H), Inj Methyl pred(2mg/kg st & 1mg/kg Q6H) iv 4.T Deriphyllin retard 150 mg 1-0-1 x 5 days after food/T Theoasthalin 1-1-1(>12 yrs) or ½-½-½(if <12yrs) Or T Asthalin 4mg tds or T Bricanyl or Bricarex(Terbutaline) 5mg tds or T Deriphyline (Theophylline Hydrate+etophylline) tds .Deriphyllin C/I in seizure Syp Deriphyllin( 50 /5 etophylline 46.5 and theophylline 12.75)(5mg/kg/dose PO tds), For children: Syp asthalin( 2 /5 )(0.1-0.2 mg/kg/dose Q6H or dose in ml= wt /4) After food 5. If response to bronchodilators not satisfactory, early use of steroids advised.T Prednisolone 10 mg tds X 3-5 days; for children: 1mg/kg/day in 2-3 divided doses x 3-5 days. 6.Antibiotics if associated infection(fever,purulent sputum) or ineffective cough & retention of secretions. 7.Cough syrup containing Bronchodilator & Mucolytics 8.Advise inhalational medications if affording- Asthalin,Ventorlin(both Salbu), Budenase AQ or Budecort or Pulmicort or Rhinocort (Budesonide)- start with 400 or 200 mcg BD & step down with response.Others: Seroflo / Esiflo / combitide (salmeterol + fluticasone), aerocort(levosalbu+ beclomethasone), foracort (formoterol+ budesonide), maxiflo(fluticasone + formoterol). Rotahaler or metered dose inhaler(MDI) may also be used. Alternatives to the order 4 would be –T Theoasthalin(Salbutamol+Theophylline)(syp available), T Unicontin 400 or 600mg(Theophylline); T Levolin(levosalbu) 1mg or 2mg(Syp 1/5)(0.05 mg/kg/dose qid); T AB Phylline(acebrophylline) 100 mg BD or Syp 50mg/5ml, 2-5 yrs 2.5 ml bd/tds, >5 yr 5ml bd; T Doxophylline 200 mg 1-0-1 may be used instead of deriphylline, as it has better cardiac & CNS safety profile (D phylline,Doxiflo, Doxobid, Doxoril) For A/c Bronchiolitis, neb with 3% saline 3ml Q1-2H or alternate with salbutamol. S/E of salbutamol & Deriphyllin : tremors, palpitation, nervousness Common causes of shortness of breath: Asthma, pneumonia,bronchitis,hyperventilation, pleuritis, COPD, CCF, MI, pulmonary edema,bronchiolitis, pneumothorax,FB,ILD, anxiety, pulmonary embolism, cardiac tamponade,10 P HTN,pleural effusion,metabolic acidosis, severe anaemia, obesity, ARDS Signs of CO2 retention: Confusion, flapping tremor, bounding pulse. Look for associated cardiovascular(chestpain,palpitation,sweating,nausea) or respiratory (cough, wheeze, haemoptysis) symptoms. Note: levolin has better cardiac safety profile than asthalin, hence preferred in cardiac patients.

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Dog Bite ( also cat,bandicoot,monkey,cattles,bats,wild animals etc) 1. Immediate flushing and washing the wounds, scratches and the adjoining areas with plenty of soap and water for at least 10 minutes is very important.Dont squeeze/cover the wound 2. Wash with betadine/spirit 3. Inj Rabipur/verorab (rabies vaccine) 0.1ml ID on both shoulders on day 0,3,7,28 If given IM, then Rabipur 1ml or verorab 0.5 ml on day 0,3,7,14,28 (IM is given in immunocompromised pts) 4. Inj TT 0.5ml IM st if indicated 5. Advise to observe the cat /dog for 10 days & to r/w if the animal dies/behaves abnormally. For class 3 wound, also give 6. Inj equirab 40 IU(immunizing unit)/kg [maximum dose infiltrated around the bite wound and any remaining volume is given IM(usually gluteal region) away from the site of rabies vaccine] or 0.133ml/kg. If Human Ig : 20 IU/kg or 0.133ml/kg For 75 kg or more: 10 ml(3000 IU equirab or 1500 IU HRIG) 7. Antibiotics like augmentin Class 3 All bites or scratches with oozing of blood on neck, head, face, palms and fingers   Lacerated wound on any part of the body  Multiple wounds 5 or more in number Bites from wild animals  Note:Bite wounds shouldn’t be immediately sutured; if necessary put minimum no of loose sutures. Ideally it should be done 24-48 hrs later under the cover of anti-rabies serum locally. If previously fully vaccinated with rabies cell culture vaccines, then only IDRV day 0,3 dose (single site) is required. Pre-exposure Prophylaxis: IDRV 0,7, 28, 0.1 ml single site  Rabies vaccine & RIG are not contraindicated in pregnancy.

Injury Time of arrival, time & place of occurence of injury, cause of injury, 2 id marks, brought by whom(address also) should be noted. 1.C & D (wound toilet). Ideally with NS. Betadine, H202 , cetrimide, savlon(cetrimide+chlorhexidine) etc may be used for contaminated wounds only.Look for any foreign body in the wound. 2.Inj TT 0.5 ml im st(Same for all age), if indicated. 3.Inj tetglob (Immunoglobulin, tetanus) 250 IU deep IM St ATD(for deep & large wounds, contaminated wounds)(Same dose for all age) 4. Excise all devitalised tissues. Remove any foreign body in the wound. If needed, suture. Suture the wound without any dead space inside the wound. Materials needed:- needle holder, forceps (artery , thumb), needle(cutting/ reverse cutting-skin, round body/tapering- fascia, soft tissue,muscle & tissues that are easy to penetrate) , suture material-usually silk, nylon,prolene (non-absorbable) or catgut,vicryl,monocryl(absorbable). Usually skin is sutured with 3-0 nylon or 4-0(smaller). Suture should n’t be too tight. Don’t suture if a) underlying tendon is cut, b) underlying bone is fractured. c) caused by dog bite (especially stray dogs) or human bite Give adequate support/immmobilization of the region. Note: Primary suturing (done within 6 hrs) shouldn’t be done if there is edema/infection/ devitalised tissues/hematoma. Here delayed primary suturing (48 hrs-10 days)can be done. This time is allowed for the oedema/hematoma to subside.Secondary suturing (10-14 days) is done in infected wounds.

12 5. Antibiotics :- C Megapen (Ampiclox)(1-1-1-1) or Ampiclox+ Metrogyl; Children: augmentin,cefixime Metrogyl dose: 200 mg 1-0-1, syp 200/5 30-50mg/kg/24 hr div into 3 PO.Give strong antibiotics in DM For infected wounds,ulcers give mupirocin oint(Bactroban,mupin,T-bact), futop oint (Fusidic acid) Megaheal(colloidal silver), Neosporin powder(neosporin,polymyxinB,bacitracin Zn). For buccal mucosal injury-Metrogyl DG gel or Dentogel. Mupirocin also given for folliculitis, furunculosis etc. 6.Analgesics +Serratiopeptidase(anti inflammatory):- C Lyser D/Lizole- D(Diclofenac+ serrapeptase) 1-0-1 x 3 days after food; T Zymoflam-D/ Alanz-D(diclofenac, trypsin, bromelain, rutoside). For children give syp ibugesic For severe contusion: T chymoral forte 1-1-1-1 (trypsin, chymotrypsin) or T Zymoflam/ Rutoheal / Enzomac ( trypsin, bromelain, rutoside) 7.Vitamins (deficiency of vit A & C -poor wound healing). 8.T.Rantac 1-0-1 9.Fluid & electrolyte balance 10. Change the dressing once in 2 days.Inspect the sutured wound in 48 hrs. Tetanus prophylaxis in wound management Clean, minor wounds  If uncertain h/o previous vaccination or fewer than 3 doses: give vaccine  3 or more previous doses: no need to vaccinate unless≥10 years since last dose. All other wounds  If uncertain h/o previous vaccination or fewer than 3 doses: give vaccine & tetanus Immunoglobulin (TIG)  3 or more previous doses: give vaccine if ≥5 years since last dose Note: The practise of giving Inj TT every 6 months is wrong, as frequent TT may decrease immune response. Note: Simple suture: - Superficial wounds, face ,neck; Mattress suture:- Deep wound, upper & lower limb. For injuries associated with severe bleeding, do Hb, PCV.

For phlebitis, thrombophlebitis, swelled up injection sites,haematoma: Thrombophob Oint (heparin sodium), T Serrapeptase,warm compresses, rest to the part etc.

Haematoma: If minimal may resolve spontaneously;If massive, may require drainage or aspiration For periorbital ecchymosis(black eye) & SCH due to trauma, : Moxiflox/gatiflox/ciplox eye drops, cold compress, T Serratiopeptidase & ophthal consultation For muscle injuries: ice, compression, elevation

Crush injuries:Look for degloving, compartment syndromes;Extensive removal of devitalised tissue & fasciotomy may be required;Monitoring of Renal function & urine output is needed. Give IV fluids generously(6 -12 L over 24 hr) In trauma involving ear auricle: only skin is approximated & sutured with 5.0 or 4.0 prolene (cartilage is spared).

Soft tissues of the neck: Open wounds are frequently associated with vascular involvement. A patent airway may be compromised by progressive soft tissue swelling. Perform pressure tamponade. Tracheostomy may be needed. Injury of larynx/trachea are a/w subcutaneous emphysema, airway obstruction, dysphonia, lack of thyroid cartilage prominence. Note on Specific Lacerations Scalp: shaving of the hair has shown to increase the rate of infection and should n’t be performed. Hair may be trimmed, if needed. Lacerations of the eye lid margin or those involving the medial fifth of the lid should be referred to a surgeon or ophthalmologist as improper repair may produce disastrous and disabling consequences. Eyebrows must never be shaved because in a small percentage of patients, regrowth may n’t occur.

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Abrasion 1.Inj TT 0.5 ml IM stat if indicated. 2.C & D.Preferably dressing is not necessary.

Large abrasions or skin loss lesions may be dressed with cuticell(non medicated), cuticell-c or bactigras (chlorhexidine), jelonet(non medicated paraffin gauze dressing), cuticell plus (polymyxin B, bacitracin, neomycin) 3.T-bact oint,Metrogyl-P Gel, Megaheal(colloidal siver), Sepgard ointment(feracrylum), Neosporin powder/oint [zinc bacitracin, neomycin sulphate, polymyxin B sulphate], healex spray(Benzocaine +poly vinyl polymer), cetrimide, Savlon(cetrimide+ chlorhexidine), Neosporin-H for L/A 4.Oral antibiotics , if Diabetic / multiple abrasions 5.Analgesics + Serratiopeptidase 6.Vit C, Rantac

I&D Diagnosed based on Fluctuation. I & D by Hilton’s method Ask patient to lie down to avoid shock induced by pain. Start an IV fluid. Incision put parallel to neurovascular structures.Press at root with cotton, till frank blood comes. Clean well with betadine.Dress with GM(glycerine Mag sulf) to reduce edema at the site. Check RBS, Urine sugar. Suture Removal 1.Clean with Betadine 2.Cut close to skin using Blade no. 11 or 10 3.Avoid thread from outside entering inside 4.Remove intermittent sutures to prevent Gaping. Days of suture removal:Thyroid- 4-5 days Scalp- 5 days Inguinal- 8-9 days Knee- 10 days

Abdominal- ~10 days Ankle,foot- 14 days

Burns Attend only if burns <15 %. Refer large Burns to surgery.Do BRE, LFT, RFT Put iv line before edema develops. R/o inhalational injury(burns in closed space, fire work accidents, high velocity explosion).Rapid primary survey is performed to assess the ABCs. Any constricting clothing and jewelry should be removed to prevent these items from exerting a tourniquet like effect after the development of burn edema.Don’t apply ice to burns 1.Inj fortwin 1cc IM / IV st or Tramadol (& emeset). For severe burns morphine 5 mg iv Q8H 2.Clean gently with copius volume of cold water for 20 minutes, as it will minimize degree of burns,then with betadine 3.Smear antiseptic ointment like soframycin(framycetin) for face, silverex(silver sulfadiazine) for trunk & limbs; Fusidic acid oint(fucidin-L, fucibact, fusiderm), Betadine etc 4. Inj TT 0.5 cc IM st if indicated. 5. Inj tetglob 250 IU IM st ATD 6.Oral Antibiotics(iv antibiotics like taxim, metrogyl for severe burns) 7.IV fluids(Ringer Lactate is preferred) using parkland’s formula (4ml/% burn/ kg body wt/24hrs) with half given during first 8 hours & remaining half given during next 16 hours. 8.Inj Dexona 2cc IV/IM Q12H x 2 days(dexamethasone) or hydrocortisone(efcorlin) 9.Inj Pantop/Rantac to prevent curling’s ulcer. 10.For severe burns requiring admission ,give O2 ,RT,CBD & measure urine output. Note:give cold water compress,large blisters may be deroofed with a sterile needle or aspirated; leave blisters on the palms or soles intact. Immobilisation is suggested for upper limb burns.For chemical and eye burns irrigate with copious volume of water

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Chest Trauma Rapidly fatal conditions: tension pneumothorax,flail chest, open pneumothorax, massive hemothorax,cardiac tamponade(engorged neck veins,hypotension,muffled heart sounds) Potentially fatal conditions evolving less acutely:simple pneumothorax,Rib fracture and contusion,blunt cardiac injury, traumatic asphyxia, thoracolumbar vertebral injury, scapular/sternal fracture,esophageal perforation,subcutaneous emphysema, diaphragmatic rupture, pulmonary contusion, Diagnosis: history, physical examination, X-ray, CT etc Immediately refer the patient to higher centre without any delay COPD a/c Exacerbation + LRTI Inv: SPO2, CXR, CBC 1.Oxygen inhalation at 2L/min, propped up position, Q4H Temp chart. 2.Nebulisation with Duolin (ipratropium bromide+ levosalbutamol) + Budecort sos 3.Inj Methyl Prenisolone 120mg iv stat, followed by 60 mg iv Q8H 4.Inj terbutaline 0.5ml S/c Q8H 5. Inj aminophyllin 250/500 mg in 250/500 ml NS/ 5D Q8H over 4 hr or Inj deriphyllin. Note: deriphyllin may cause tachycardia, whereas aminophyllin is cardioprotective. 6.Inj Monocef 1g iv BD ATD 7.Inj levofloxacin/ Azithromycin 500mg iv OD 8.Inj Pantoprazole 40 mg iv OD 9.T prednisolone 10 mg tds (after a/c phase). At discharge also prescribe Seroflo (salmeterol + fluticasone) 100/250 MDI or Rotahaler, T Deriphylline, asthalin, syp ambroxol etc. Note: In COPD pts not responding to treatment, suspect pneumothorax

Laryngo-tracheo-bronchitis(Viral Croup) C/f: a/c stridor, barking cough, hoarseness, respiratory distress 1.Oxygen inhalation 2.Inj dexamethasone 0.6 mg/kg iv st 3.Nebulise with budesonide 1 mg 4.For severe cases, Nebulise with adrenaline 1:1000, 2-5 ml 5.i/v antibiotics for bacterial croup(ampicillin or 3rd gen cephalosporins) 6.Adequate hydration. Incessant crying of infants/children

Note:-mostly due to intestinal colic due to hunger, worms, constipation, over feeding, aerophagy, food intolerance,sepsis/infection like meningitis, AOM,medications, discomfort from wet diaper, feeling cold, baby needs to be held, nasal block, ear ache ,loose stools, ,intususception , GERD ,physiological etc Examine all limbs, trunk, back, orifices Advise regarding proper feeding of the baby.Feeding, Burping & carrying the baby upright in shoulder may bring relief Adequate breast feeding: 15-20 min sucking, then 2-3 hrs hrs sleep or rest. Frequent urination.1-6 liquid stools per day & gaining weight. 1.Syp Carmicide or syp Cyclopam (10/5)(0.5 mg/kg/dose) or Syp P’mol st 2.Syp Phenergan (5mg/5ml)(1mg/kg/dose) or Syp Pedicloryl (500/5) 0.5 ml/kg st 3.Saline nasal dps for nasal block; 20 Q4H For infants:

1.Carmicide /colicaid/cyclopam-DF Dps( simethicone,Dill oil,fennel oil) or colimex/cyclopam (dicyclomine 10 /1, dimethicon 40 /1). Colicaid dose: Infant <6 mths: 5-10 drops; infant 6-12 mths: 10-20 dps;over 1 yr: 20 dps qid before food or SOS. Indications:Infantile colic, flatulent dyspepsia, regurgitation. Note: Syp carmicide adult (Na citrate, citric acid, tincture cardamom,tinc cinnamon, alcohol, ginger oil)

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Allergy/pruritus(itch)/urticaria(hives) Look for offending food or drugs(cutaneous drug eruption),insect bite, parasites, etc. Conditions associated with generalized pruritus without a rash: obstructive jaundice, Fe deficiency, lymphoma, carcinoma(especially bronchial) ,CKD,DM,gout, HIV, senile pruritus, hyper or hypothyroidism.Look for any breathing difficulty like stridor. Inv: FBC, ESR, urea, electrolytes, TFT,LFT, P Smear. Allergy testing can be suggested. 1. Inj avil 1amp IM st (if severe) or Inj Atarax(hydroxyzine) 1 amp IM st 2. Inj Efcorlin/betnesol/Dexona 1 amp iv st 3. T Piriton(CPM) 2/4/8 mg tds/ bd (0.1 mg/kg/dose x 3; 2-6 yr: 1mg Q6H, 6-12 yr:2 mg Q6H) or T Cetrizine 10 mg 0-0-1(poor antipruritic action) or T Atarax 10-25 mg 1-1-1 (Syp atarax 10/5 ,dps 6/1 2mg/kg/day in 3-4 divid doses) or T Levocet 10mg(0-0-1)(levocetrizine) or T Avil 25/50 mg 4.T Rantac 150(1-0-1)[ H2 blockers have adjuvant beneficial action in certain causes of urticaria,who don’t adequately respond to H1 antagonist alone] 5.T wysolone(prednisolone) 0.5 mg/kg bd/tds x 3 days for severe cases. T Wysolone(prednisolone) 5/10/20/40 mg bd/tds (Syp omnacortil 5mg/5ml Dps 5mg/1ml available, 2mg/kg/24 hr div into 2-4 PO, asthma:0.5-2 mg/kg/24 hr); Betnesol 0.5mg/1ml Dps available (0.2 mg/kg/24 hr div into 2 to 3 PO), Dexona Dps 0.5mg/1ml (0.2 mg/kg/day).T betnesol 0.5/ 1 mg ; T dexona 0.5/ 2 /4 mg ;T Deflazacort (cortimax)1/6/30 mg, Syp Dezacor 6mg/5ml available. 6.Calamine Lotion(calamine + Zn oxide)(T N: Calacreme, Calaminol, calamyl); calosoft (calamine+ aloevera+ liquid paraffin), Calskin (calamine + diphenhydramine + camphor + alcohol)

Lactocalamine(Zn oxide, Zn carbonate, light kaolin, glycerin, castor oil,aqua, aloe vera) For children Syp Atarax 10/5 or Dps 6mg/5ml(2mg/kg/day in 3-4 divided doses ) or Syp Avil(15/5) (0.5 mg/kg/dose x3) or cetrizine or chlorpheniramine maleate(CPM) For pregnant ladies: chlorpheniramine maleate,cetrizine, diphenhydramine Note: look for anaphylactic like reactions, if present give Inj Adrenaline.

Insect Bite Reaction Treatment same as above Note: for infected insect bite Mupirocin Oint can be given

Epistaxis Aetiology:Trauma ,Systemic HTN,URI, F B , DNS, drying of mucosa ,drugs, septal perforation, liver/kidney disease, a/c general infection, vitamin k deficiency, malignancy,atherosclerosis etc Inv: CBC, Plt ct,ESR, aPTT, PT-INR, BT,CT, P smear,RFT,LFT,X-ray PNS (water’s). Check BP 1.Keep head elevated, avoid exertion,aspirin, blowing of nose for 24 to 48 hrs. Reassure the pt 2.If severe Close nose by pinching and breath via mouth for 5-10 minutes. 3.Cold compress to nasal area.Keep icecubes in handkerchief over nose. If bleeding still present, a cotton gauze impregnated with adrenaline & lignocaine is inserted & nose pinched for another 10 minutes. Use Gelfoam (absorbable gelatin compressed sponge) if discrete bleeding point identified. 4.If not controlled, Give Inj Tranexa (tranexamic acid) 500mg slow iv st or Etamsylate iv st 5.Oral Antibiotics(e.g augmentin or cephalexin) or topical antibiotics to prevent sinusitis 6.keep Check on pulse, systemic hypertension,respiration. 7.Give anti-allergics for mild sedation like avil or cetrizine if required 8. For benign cases, oxymetazoline nasal spray/dps(nasivion) can be given. 9.T Cosklot 250/500 1-1-1(etamsylate) Note: if not controlled, Pressure packing of the nose & Admit the pt . Refer the Pt to ENT

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Nasopharyngitis/ cold/ acute coryza 1.T cetrizine(alerid/okacet/cetzine) 5mg 1-0-1 or T Levocetrizine (hatric)5mg(Syp Hatric 2.5/5) OD or T Avil 25mg 1-1-1 or T Rupanex (Rupatadine)10 mg OD x 3 days or T Piriton 4mg tds (chlorpheniramine) or T allegra 120/180 mg od/bd(fexofenadine) For pediatric case: T cetrizine(6-12 months: 2.5 mg OD,12 months - 6 yrs: Initially 2.5 mg OD, which may be increased to 2.5 mg BD, or Syp alerid/cetzine(Cetrizine)(5mg/5ml)(0.25 mg/kg/dose HS/BD) or T-minic /alex Dps(CPM 2mg/1ml, phenylephrine) & T-minic syp(CPM 2mg/5ml, phenylephrine) Levocetrizine is effective at half the dose of cetrizine or 0.1 mg/kg HS For pregnant ladies: Cetrizine or chlorpheniramine can be given 2.Saline Nasal Dps or Decongestants like nasivion, otrivin. If nasal congestion:Nasivion (Oxy metazoline) or Nasoclear SND/Otrivin S(NaCl) or Otrivin / Xylomist (Xylometazoline) 20-20-20 Note: Nasal decongestants should not be used more than 3 days in a row as it may cause rebound congestion. Nasal decongestants should be used very cautiously in hypertensive patients. In children give Saline Nasal drops or Nasivion-P; don’t give Nasivion(only for adults) Note:- for pregnant ladies otrivin and nasivion can be given 3.Steam inhalation For seasonal allergic rhinitis: 1. T Odimont LC/ Montek LC/ Romilast-L/ Monticope (montelukast 10+ levocetrizine 5). T.Montelukast LC Ped/ Romilast-L (monte 4+ LC 2.5), Syp Montina-L/ romilast-L(Monte 4mg + LC 2.5mg per 5 ml)available. Montair 4mg sachet available.<6 yr: 4 mg tab or sachet OD , >6 yr: 5mg OD, >12 yrs: 10 mg T Allegra-M(fexofenadine + montelukast) 2.Nasal decongestants e.g nasivion, otrivin 3.Topical steroids. E.g. Rhinocort ,Budenase AQ , budecort nasal spray one puff BD (budesonide) (effective for both allergic & vasomotor rhinitis, nasal polyposis); combinase AQ N-spray(azelastine+ fluticasone), azelast(azelastine), Momeflo nasal spray(mometasone), Fluticone/flomist/flutiflo nasal spray (fluticasone), Rhinase/Beclate Nasal Spray/Drops (beclomethasone) Precautions in allergic rhinitis : Avoid carpets, woollen clothing,fur pets like cats & dogs; keep house dust free If cold + fever:1.T Wikoryl or Sinarest or Febrex Plus or T-minic Plus or Tusq-P or Alex-P 1-1-1x 3 days(Syp & Dps available) )(Pmol+Phenylephrine HCl +Chlorpheniramine maleate)(Wikoryl Dps 125/1) 2.T Rinostat or Flucold (Syp and Dps available) 1-1-1x 3 days (P’mol+Phenylpropanolamine +CPM) 3.T Nasivion (Pmol+Phenylephrine HCl+Caffeine+Diphenhydramine HCl) 4.T Hatric 3(Pmol+ pseudoephedrine+CPM) For cold + fever + cough 1.Syp Fluzet or Alex-P (Pmol+Phenylephrine HCl +CPM+ Dextromethorphan) 2.Syp Nasocare Plus or Pedia-3 (Pmol+Pseudoephedrine HCl +CPM+DM) 3.T Sudin+(Pmol+Phenylephrine HCl +CPM+Guaiphenesin+Bromhexine HCl) 4. Syp Sinarest (Pmol+Phenylephrine HCl +CPM+Na citrate +menthol) Note: T Sinarest AF- with out P mol (Syp or Dps available)

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Sore Throat Aetiology:infection(a/c pharyngitis - 80% viral, retropharyngeal & parapharyngeal infections),malignancy, ulcers,trauma,referred pain due to angina, reflux esophagitis etc 1.Antibiotics if any associated infection. E.g Azithromycin, augmentin 2.Analgesics like ibugesic plus 3.Steam inhalation,bed rest, plenty of fluids 4.Warm saline gargle x 3 times/day or Betadine gargle in 10ml of warm water tds 5.Throat lozenges Note: refer peritonsillar abscess to ENT, as it requires I & D Parotitis Commonly due to stone. 1. Antibiotics e.g.Ampiclox / Cephalexin. If no response give Taxim 2. Anti-inflammatory drugs 3. Adequate hydration, oral hygiene, local heat 4. L/A of Ichthammol Glycerine to reduce edema. 5. Lime juice & other Citrus fruits to promote salivary secretion In cases of Mumps(viral Parotitis), Rx: hydration,rest, analgesics, hot/cold compresses over the parotid (to relieve pain). Food which promote salivary flow should be avoided. Complications:Orchitis,Ophritis,Pancreatitis,aseptic meningitis etc. Advise scrotal support & cold compresses for orchitis Foreign body throat C/f: cough, stridor, aphonia,dyspnoea, haemoptysis, hoarseness,respiratory arrest, recurrent pneumonia, asthma Inv: CXR, Digital X-ray soft tissue neck - lateral & AP view, CT chest Perform Heimlich’s maneuver. If unsuccessful, Immediately refer to ENT. Laryngitis C/f: hoarseness, inability to speak, Dry sore burning throat, cough, dysphagia, fever, cold, hemoptysis,dyspnea, Increased production of saliva, swollen lymph nodes in the throat, chest, or face, sensation of swelling in the area of the larynx 1.Voice rest, steam inhalation, cough suppressants, plenty of oral fluids, 2.Antibiotics (e.g Azithromycin) if due to bacterial infection 3.Rantac/pantoprazole if due to GERD Other causes of hoarseness of voice: vocal cord nodules, thyroid problems, allergies, inhalation of respiratory tract irritants, smoking,CA, trauma, GERD,postnasal drip etc Globus sensation/globus pharyngis(feeling of lump in the throat) Etiology: GERD,inflammation of the throat, postnasal drip, stress/psychogenic,smoking, inadequate relaxation of swallowing muscles, hypertrophy of the base of tongue, LPR Rx 1.T Pantop 40mg OD for GERD. ENT consultation if s/s persists

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Tonsillitis C/f: sorethroat, fever, odynophagia, Examine throat and look for congestion, enlargement of tonsils, tonsils with purulent material at the crypts(follicular) & membrane over the tonsils(membranous). Jugulodigastric Lymph nodes are swollen & tender in a/c tonsillitis 1.Antibiotics like Amoxycillin, Azithromycin. In pt’s with h/o treated recurrent a/c tonsillitis give Augmentin. 2.Analgesics 3.Warm saline gargle, Bed rest, plenty of oral fluids Note: Tonsillitis or pharyngitis in children are usually due to streptococci. If not treated properly with antibiotics, rheumatic heart disease or glomerulonephritis may result.

A/c bronchiolitis C/f: cyanosis,respiratory distress, prolonged expiration,fine creps & rhonchi 1.Oxygen 2.IV fluids 3.Antibiotics like altacef 4.Nebulisation (with adrenaline, 3% Normal Saline, asthalin), Saline Nasal Drops Quinsy C/f: sore throat, fever, dysphagia, trismus, muffled speech/hot potato voice, inflammed oropharynx, swollen tonsil, uvula pushed to opposite side. Take swab & sent for pus C & S. 1.IV fluids 2.IV antibiotics(cephalosporin +/- metronidazole) x 7-10 days 3.Analgesics 4.Inj Dexona 8 mg iv st (single dose) 5.Refer to ENT for Drainage of pus A/c epiglottitis C/f:fever, sore throat, dyspnoea, rapidly progressive respiratory obstruction, drooling of saliva, hyperextended neck, x-ray lateral view: swollen epiglottis- thumb sign Note: A toungue blade or indirect laryngoscopic examination should not be done in children with suspected epiglottitis as it might induce laryngospasm. 1.Oxygen 2.IV antibiotics( 3rd generation cephalosporin) 3.Adequate hydration 4.Inj Dexona Note:In severe cases endotracheal intubation or tracheostomy may be needed. Foreign body in Nose A foreign body must always be excluded in a child with unilateral nasal discharge.

C/f: nasal block, pain, blood stained discharge.  Keep head at 45/90 degree. Attempt only if FB can be seen.  Take from below upwards. Most of the FB can be removed by using an eustachian catheter which is passed gently past the FB & dragged along the floor.  Give Antibiotics if trauma +. For procedural sedation, in children,give Syp Pedicloryl(triclofos Na)(500/5 ) 0.5ml/kg(up to 50 mg/kg can be given). Pedicloryl can be used in insomnia, recurrent colic, restlessness, fretfulness etc

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Nasal bone fractures C/f: traumatic epistaxis, edema, ecchymoses, crepitation, subcutaneous emphysema, Inv: Digital x-ray Nasal bone Rt & Lt, lateral view R/O CSF Rhinorrhoea;look for septal hematoma If there is # & if nose is swollen, reduction is performed after edema subsides(~ 1 week) Rx : C Mox, T lyser-D, T Pantop, Nasivion ND

Furuncle of the nose 1.Warm compresses 2.Systemic antibiotics like cephalexin; T-bact oint for LA 3.Analgesics 4.I & D of the abscess Note: the furuncle should not be squeezed due to the danger of spread of infection to the cavernous sinus For Vesibulitis, Rx is the same, give Clox, remove the crusts with cotton dipped in H202. Sinusitis Aetiology: URI, DNS,Trauma, Tooth infection {mainly upper} C/f:headache, malaise, nasal block,purulent rhinorrhoea,URI, fever. In ethmoiditis there may be lid edema, lacrimation, dull headache etc Look for PNS tenderness Inv: X-ray PNS (water’s view, open mouth)(for frontal sinus- Lateral view also),CT scan 1.T. Cetrizine / T. CPM 2.Analgesics 3.Antibiotics: amoxclav/azithro/doxy/cefuroxime axetil 4.Steam inhalation with Amrutanjan/ vicks/ Tincture Benzoin, 15-20 minutes after nasal decongestion for better penetration. 5.Nasal Decongestants:Nasivion(0.05%)[oxymetazoline], Otrivin(0.1%), OtrivinP(.05%) [xylometazoline] dps/spray. Oral decongestants may also be given. 6.Hot fomentation.Local heat to the affected sinus Nasal Polyp 1.Antiallergics(oral or nasal spray can be used) 2.Analgesics 3.Antibiotics if there is evidence of infection;Ent consultation

Otalgia(Earache)

Aetiology: a/c otitis.media, csom,Furuncle, impacted wax, o.externa, otomycosis,trauma, herpes zoster, myringitis bullosa, mastoiditis, eustachian tube obstruction, extradural abscess, referred causes like caries tooth, ulcerative lesions of oral cavity or tongue, a/c tonsillitis, peritonsillar abscess etc 1.Analgesics 2.Ear Dps: Otogesic(polyethylene glycol, dibucaine, dihydroxymethylcarbamide,glycerin) Ear Antiseptic Preparations: Ciplox dps(ciprofloxacin),Zenflox Dps (ofloxacin), Otobiotic-SF(ofloxacin + clotrimazole+ lignocaine),candid/surfaz(clotrimazole,lidocaine) Preparations with steroids: otocin-o/otobiotic plus/clotrin-AC(oflox, lidocaine, beclomethasone, clotrimazole), candibiotic(chloramphenicol, lidocaine, beclo, clotri), Otobiotic( neomycin + Beclomethasone+ clotrimazole + lignocaine), 3.ENT consultation C/c otorrhoea causes: Serous: otitis externa, purulent: otitis media, foul smelling: cholesteatoma, bloody discharge: trauma,

20 Wax in the Ear Impacted wax can cause earache, itchiness, reflex cough, dizziness, vertigo, tinnitus, some hearing loss 1.Dewax/Soliwax/clearwax/waxolve/otorex/Waxonil(paradichlorobenzene + terpentine + benzocaine+ chlorbutol) e/d 30 tds for softening x 5 days 2.Syringe the ear after a few days. Ear buds should n’t be used to remove impacted wax. They are for the pinna only.As the wax softens deafness may increase. Foreign body in ear Living: Insects should be killed first by instilling or spraying lignocaine or normal saline or oil drops. Later it can be removed using a crocodile forceps or by suction. If a/w any infection give combiderm ear pack. Non-living: small, irregular FB’s can be removed with forceps & syringe. Forceps should not be used to remove smooth objects, as they tend to move inwards. Do syringing only for nonswelling FB. After FB removal, examine TM. Trauma to external auditory canal Mostly by instrumentation either by pt or physician.If bleeding +, r/o facial Nerve palsy; take HRCT temporal bone; give inj tranexa. Minor lacerations heal, while major lacerations should be treated by packing the external canal with medicated wicks & anitbiotic steroid drops to prevent canal stenosis. Advise not to use cotton tipped applicators like ear buds. A/c otitis externa 1. Antibiotics e.g ampiclox/amoxyclav/ciplox 2. Analgesics 3. Local heat 4. Ear pack of 10% ichthammol glycerine or antibiotic steroid cream.e.g combiderm (Clotrimazole, beclometasone dipropionate, neomycin). Remove the pack after 24-48 hours. 5. Ciplox ear drops 20 tds(for associated bacterial infection) Otomycosis(fungal infection of ear canal) C/f: itching,pain, watery discharge with musty odour, ear blockage, HOH(hard of hearing) 1.Ear toilet/suction/mopping; medicated ear pack/wicks (e.g Combiderm or Bestopic-N or Sigmaderm-N: beclomethasone, clotrimazole, neomycin) for 24-48 hrs. 2.After 24-48 hrs Candid e/d. 3.Analgesics;Oral Antibiotics(if associated bacterial infection)-> e.g.amoxyclav. 4.Avoid antibiotic e/d.No water in the ear.Ear must be kept dry. Vertigo May be central or peripheral. Central vertigo may occur as a part of CVA , migraine, epilepsy, multiple sclerosis, tumours. Peripheral vertigo is usually more severe Peripheral causes: meniere’s d/s, BPPV, Head trauma, drugs, labyrinthitis etc Check BP, GRBS 1.Inj Stemetil(prochlorperazine) 12.5 mg IM st( can be given in pregnancy). Inj Diazepam,also may be given for severe vertigo.Parenteral Stemetil is the most effective drug for controlling violent vertigo & vomiting. 2.T stemetil 5 mg 1-0-1 or T Vertin/Betavert(Betahistine) 16/32 mg tds or T Stugeron(cinnarizine) 25 mg tds/ 75 mg HS. S/e is sedation & is more with vertin. Betahistine C/I in asthmatics, ulcer pts. 3.T Pantop All these can be used in combinations. Never give for more than 4 weeks. Withdraw as early as possible. Diazepam can also be used in combination.

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Perforation of tympanic membrane C/f: pain, bleeding, hearing loss Uncomplicated perforation usually heals by itself; perforations not healed by 3 months can be repaired. Treatment is aimed at controlling otorrhoea. 1.Systemic antibiotics & Analgesics/ Antihistamines. Keep ear dry. 2.Ear drops are avoided unless contaminated;ENT consultation Tinnitus Aetiology: Wax, fluid in middle ear,otitis media,ototoxic drugs, anemia, HTN, hypotension, hypoglycemia, migraine,epilepsy, arteriosclerosis, psychogenic 1.T Bilovas 1 tds(ginkgo biloba) 2.Antidepressants

Stridor High pitched noisy breathing caused by larger airway obstruction, usually the larynx and trachea associated with dyspnea. Stridor is indicative of a potential medical emergency and should always command attention. Wherever possible, attempts should be made to immediately establish the cause of the stridor (e.g., foreign body, vocal cord edema, tracheal compression by tumor, functional laryngeal dyskinesia, epiglottitis, acute laryngitis, diphtheria, peritonsillar abscess, IMN, etc) If due to airway edema: 1. Nebulization with racemic adrenaline/epinephrine (0.5 to 0.75 ml of 2.25% racemic adrenaline added to 2.5 to 3 ml of normal saline) 2.Dexamethasone 4-8 mg IV q 8 - 12 h 3.Oxygen by face mask; propped up position; inj deriphyllin may also be given. Immediately refer the pt to ENT/surgery AOM A/c infection of middle ear cavity usually following an URTI. Aetiology: URI, FB, Trauma: c/f: earache,deafness, tinnitus, fever,vomiting, seizure etc 1. Antibiotics: Amoxclav/ azithro/Cephalexin/Cefixime/ cefuroxime axetil etc. 2. Oral decongestants +antihistamines+ antipyretics (e.g Wikoryl/ Hatric-3/Nasivion) 3. Nasivion ND 20 tds(children <2 yrs: Saline ND, >2yrs:Nasivion -P ND). Avoid ear dps 4. T/Syp Vizylac/Nutrolin-B 5. Dry local heat to relieve pain; ear toilet/suction if discharge present.keep ear dry. Note: All eye drops can be put in the ear, but not the reverse Perichondritis of pinna Secondary to lacerations, hematoma & surgical incisions, ear piercing (especially piercing of the cartilage). Inflammation of the pinna is followed by abscess formation between the cartilage & the perichondrium with necrosis of the cartilage, as the cartilage survives only on blood supply from the perichondrium. C/f: fever, painful red ear, fluid draining from the wound, swollen ear,etc Diagnosed by history of trauma to the ear and the ear is red and very tender,. 1.iv antibiotics as early as possible; inj ciplox, inj metrogyl x 7 days 2.T Lyser-D, Pantop 3.Daily local dressings at early stage with T-bact & once abscess has formed, incision is made along the natural fold, & the devitalized cartilage is removed.

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Constipation Aetiology:physiological, IBS, drugs, lack of fibre and water, anorectal disease, metabolic, DM, intussusception,neurologic, Ca, motility disorder 1.T Dulcolax/Gerbisa 5mg/10mg/20mg Hs(bisacodyl)(5mg HS for child>6yrs, 0.3 mg/kg/day OD) (Suppository, 5mg if <2y & 10mg if >2y) (Suppository can be given in pregnancy) or Syp Cremaffin 5ml-15ml HS(Liquid paraffin , MgOH2); or Syp smuth or cremaffin plus(liq paraffin,Na picosulfate, MgOH2) or Syp lactulose(10/15) (infants:2.5-10 ml/day, 0.5 ml/kg/dose)(>2 yr start with 5ml x 2; > 5 yrs 10 ml x 3 ) 2.Proctoclysis enema can also be given(after checking bowel sounds) For pregnant ladies : Dulcolax supp x 2 HS, Dietary fibres(cyber powder 1-2 tsp in 50-100 ml of water/fruit juice/milk), ispaghula(cardiolax 2 tsp in a glass of water od /bd), lactulose(Duphalac, Looz)

Bitter taste in mouth 1.Stop the drug if any, causing it and use enteric coated tablets 2.Antacids like Digene 2 tsp Q4H 3.Chew cardamom, chocolate etc; plenty of oral fluids.

Anorexia Aetiology:gastritis,carcinoma,TB,CCF,renal/respiratory failure, drugs, alcohol,infective fevers, hyperparathyroidism, physiological, psychogenic, 1.Syp Practin (2/5) 1tsp tds x ½ hr before meals (Cyproheptidine,anti histamine) ( For Ped 0.25 -0.5 mg/kg/24 hr div into 3. 2-6 yrs:2mg/dose) or Bayers tonic(liver fraction, alcohol)15 ml Bid preferably before meals or T Apetone/T Practin / T Ciplactin 2mg or 4mg ½ hr before meals (Cyproheptidine)

Hiccups/Singultus Aetiology: benign, IWMI, DKA,aortic aneurysm, mediastinitis,CVA,renal/hepatic,respiratory failure, liver abscess, hepatitis,cholecystitis,alcohol ingestion,pericarditis,pneumonia, empyema, esophageal obstruction etc

1.Mucaine gel 2tsp Q2-4H(oxethazaine,Mg hydrox,Aluminium hydrox) Note: Mucaine can also be used for gastroesophagitis, heart burn) 2.T Perinorm /Cyclopam/ Buscopan or T Baclofen (most effective)(T.N- Liofen) 5 or 10 mg tds 3.T Largactil 50mg st & tds(preferred for intractable hiccough) 4.C pantop 40 OD 5. Breathing in & out in a plastic/paper bag.Breath holding as long as possible. Drink Ice cold water If severe

1.Inj Metoclopramide 2cc iv or Haloperidol, 2 -10 mg IM or Largactil(chlorpromazine) 2cc IM/IV 2.Xylocain viscous (Lignocaine) 30ml to drink

Continous belching/flatulence R/o I.W.M.I. Ask pt to eat slowly; avoid aerated drinks/talking during meals, chewing gums etc. Advise to close the mouth while belching.Avoid gas forming foods such as cabbage, cauliflower, beans, peas, onions, nuts, apple, cucumber etc 1.T perinorm tds 2.Antacid preparations with methylpolysiloxane or dimethicone like Gelusil MPS 3. Aristozyme Cap or syp or Dps bd/tid after meals

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Epigastic Pain Aetiology:Oesophagitis, oesophageal spasm, gastritis, duodenitis, peptic ulcer disease, gastric volvulus, Biliary colic, acute pancreatitis,Acute coronary syndrome, aortic dissection, hepatitis , cholecystitis, cholangitis, etc

Dyspepsia & For weight gain in children 1.Syp Carmicide 2.5–5ml tds in children & 5–10ml tds in adults [sodium citrate + citric acid + alcohol] 2.C Aristozyme 1 tds [diastase, pepsin]. Diastase is a digestive enzyme; also has antiflatulent action. Aristozyme Syp & Dps available

Rectal Bleeding/hematochezia/melena Aetiology:Hemorrhoids,fissure,fistula,rectal trauma, rectal FB,proctitis, carcinoma, IBD,polyp, diverticulosis, infectious diarrhea, any cause of brisk upper GI bleeding,meckel’s diverticulum, angiodysplasia, intussusception,drugs, coagulation disorder, uremia etc Inv: FBC, U & E, LFT, Coagulation profile Medicine/Surgery consultation

Anal itching/pruritus ani Aetiology:infection,dietary irritants, anxiety, dermatitis, diarrhea, poor hygiene etc 1.T mebex 100mg bd x 3days(Syp mebex 100/5 , dose same as adult) or T albendazole 400 mg st & rpt after 2 weeks (as booster). For child <2 yrs - 200 mg. Note: Albendazole C/I in pregnancy & lactation 2.T avil 25 mg HS & SOS Joint sprain Commonly involve ankle & wrist joints C/f: pain, swelling, restriction of movement, contusion 1.RICE- rest, ice application, compression(using dressing/crepe bandages), elevation Crepe bandage size(in cm),adult: knee 15, ankle 10, wrist 8;children:knee 10, ankle 8, wrist 6 2.Analgesics Pain of muscle spasm / musculoskeletal/osteoarthritic pain 1.Foment with hot water bag 3 times per day for c/c pain;local ice application for a/c inflammation 2.Diclonac /volini (diclofenac)/ ketorol/ketanov (ketorolac),Dolonex/pirox (piroxicam) for LA 3.T Ibugesic plus bd /pirox 20 mg OD /ketorol 10 mg Qid/ etoshine(etoricoxib) 60mg / 90mg or 120mg OD 4.T Bidanzen or Flanzen or Lyser forte 10 mg tds (serrapeptase) or T chymoral forte Qid 1/2 hr before food (trypsin, chymotrypsin) or T zymoflam/Rutoheal (trypsin, bromelain, rutoside) if contusion +. 5.Inj Myoril(thiocolchicoside) 4 mg IM st for muscle spasm Muscle relaxants + NSAID combinations T Robinax 500mg Qid(methocarbamol), T Myoril 2/4/8 mg (Thiocolchicoside) Ibugesic-M (Ibuprofen + methocarbamol), Xykaa MR 4/8 mg( P mol + Thiocolchicoside) Robinaxol(methocarbamol 350 + P mol 250) , Volitra MR,Bruspaz(Diclo+ Thiocol), Mobiswift –D or Myospas D (metaxalone 400 + Diclo),Orthokind-P 400(etodolac 400+ P/L 500), Aceclo-MR(aceclo+P mol +chlorzoxazone), Thioceclo SR/Thiox OD(aceclo+ Thiocol) Robinaxol-D(Methocarbamol+ P/L +Diclofenac), Etoshine MR( etoricoxib + Thiocol)

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Neck Pain Aetiology:spinal ,extraspinal, psychogenic. Extraspinal causes include ACS,brachial plexus pain, shoulder disease, pancoast tumour of lungs, carpal tunnel syndrome, retropharyngeal abscess, carotid artery dissection, etc. Others include stress, prolonged postures,minor injuries,over use, whiplash,RA, torticollis, ankylosing spondylitis, head injury,SAH,lymphadenitis etc. The common neck pain radiating to one arm is cervical spondylosis with radiculopathy. 1.Inj Voveran 2cc IM st ATD if very severe pain 2.T voveran 50mg bd after food 3.T Decadron 1mg tds x 5days after food( if acute pain)(dexamethasone) While giving steroids, always prescribe calcium + vit D3( Trade name- Shelcal, Shelcal-CT, Bio-D3 plus, minosta, macalvit, Rockbon-D) also, to prevent osteoporosis 4.Gelusil MPS 2 tsp tds 5.Volini/Voveran (diclofenac) or Pirox gel / dolonex gel (piroxicam) or Thiox gel( Diclo + thiocolchicoside, methylsalicylate, menthol) for LA 6.Neck collar; ortho consultation

X-ray Views Ankle/elbow/shoulder/ hip/knee,forearm,leg,wrist - AP/lateral Foot/hand/- AP/oblique C spine/T-L spine/ L-S spine- AP/lateral Chest- PA view Acromioclavicular Jt- AP view X-ray pelvis with both hips- AP view Back Pain Aetioligy:musculoligamentous strain/sprain, osteoarthritis of spine, spinal stenosis, spondylolisthesis, degenerative, osteoporotic vertebral collapse, renal or urethral colic, ruptured intervertebral disc, pneumonitis, pleurodynia, rib fracture, pneumothorax, aortic dissection, aortic aneurysm, P embolism, pyelonephritis, malignancy(10 or 20), pancreatitis, cholecystitis, herpes zoster , ankylosing spondylitis , myeloma, etc. Factors indicating serious pathology: wt loss,fever, night pain,cancer history, age > 55 yrs 1.Give analgesics,muscle relaxants, 2. Voveran or pirox gel for LA 3.T Duloxetine 30 mg 0-0-1; Ortho consultation

Heel pain Aetiology: Plantar fascitis, achilles tendonitis,heel spurs, stress fractures, bursitis etc Inv: X-ray foot

First Aid in Fractures 1. Analgesic 2. If there is a open wound near the fracture site, clean it thoroughly and cover it with sterile dressing. No attempt should be made to put the bone lying out inside. 3. Immobilise the limb with a Splint; Splint should be long enough to fix one joint above & one joint below the suspested # site.For traumatic head or neck injury, suspect a cervical fracture unless otherwise proved & apply a cervical collar (preferably a Philadelphia collar). A backboard/spineboard can be used to stabilize the remainder of the spinal column; Refer the patient to ortho as soon as possible.

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Anaemia Can cause exertional dyspnoea,lethargy, fatigue, weakness, pallor, tachycardia, dizziness, loss of concentration, headache, hypotension, tinnitus,glossitis, angular cheilosis, koilonychia Most c/c illnesses(e.g infection,Malignancy,renal d/s) are accompanied by a moderate fall in Hb level. Inv: CBC, red cell indices,reticulocyte count, peripheral smear, s ferritin, Bone marrow biopsy etc Rx for iron deficiency anemia 1.Dexorange (contains ferric ammonium citrate, cyanocobalamine and folic acid)15-30 ml bid after meals; children 2-5 yrs 5ml; 5-12yrs 10ml bid after meals  Dexorange Cap (1 cap bid after meals) & Paed Syp available or  T orofer –XT( 0-1-0)(elemental Fe + folic acid)Dps /Syp available,  C autrin/HB plus/hemfast.  Tonoferon(Fe, FA, B12) Syp(80/1) or Dps(25/1) Dose: 6 mg/kg/day after food, 2-3 months.  Hemsi-PD drops(fe, FA, B12)( Fe - 30mg/1ml) Iron supplements need to be taken for several months for iron deficiency. Iron supplements may cause dark stools, stomach irritation etc. Iron supplements may also be given for children with wheeze. 2.Vit C (vit C improves the absorption of iron) Fall/impaired consciousness Aetiology: Orthostatic hypotension, carotid sinus syndrome, neuro cardiogenic syncope,cardiac arrythmias, structural heart diseases,stroke , Parkinsonism, arthritic changes, neuropathy, neuromuscular disease or vestibular disease, visual impairment, dementia, post prandial hypotension, urinary incontinence, low blood pressure, hypoglycemia, emotional distress, and lack of sleep, hyper ventilation, head trauma, ICH, seizure disorder,DKA, alcohol or drug intoxication, dehydration, CO inhalation, hyponatremia, hypo/hypercalcemia, high g-force, uremic/hepatic/hypertensive encephalopathy, Medications (Polypharmacy ,Sedatives, Cardiovascular medications etc), hyper/hypothermia, There may be a loss of consciousness at the onset of SAH Feeling tired or fatigue/weakness Aetiology:physiological, psychogenic, organic Organic conditions include CCF, MI, AS,MR, C/c fatigue syndrome(CFS),myocarditis, P HTN, hypothyroidism, hyperthyroidism, COPD, anemia, c/c renal/liver disease, drugs, hypotension, dehydration, infection/fever, IE, IMN, CVA, depression,electrolyte disturbance like hyponatremia, hypokalemia;DM,occult malignancy, hypoglycemia,TB, HIV,hepatitis, etc 1. IV fluids after checking BP , GRBS 2.C Becadexamin 1 bd(multivitamin) or T neurobion forte or fe/folic acid;Physician consultation

26 Insomnia Advise brisk walk in the evening,hot bath before sleep, reading in bed; use drugs as last resort. T nitrest or Zolfresh 10 or 5mg HS(zolpidem) If associated with anxiety give T clonazepam 0.5 mg or T lora/ativan 2mg (0-0-1)(lorazepam) or T Alpraz 0.5mg HS(alprazolam) or T diazepam Conditions mimicking or directly resulting in anxiety: anemia, hypoglycemia, hypoxia, hyperkalemia, alcohol or drug withdrawal, vertigo, thyrotoxicosis, hyponatremia, hyper/hypocapnia, poor pain control(e.g IHD), CNS disorders Aggressive Psychiatric Patient 1.Inj Lorazepam 2/4 mg IM st or Inj Serenace(haloperidol)2cc IM st or Inj Calmpose (diazepam)2cc iv st or Inj Olanzapine 10 mg IM st. Inj Serenace 5 mg +phenergan 12.5, serenace + lorazepam can be given for severe cases 2.T Diazepam 5 mg tds or T largactil 25mg tds;Psychiatry consultation For pregnant ladies: Haloperidol Chronic alcoholic with tremors For withdrawal symptoms(anxiety, sweating, tremor, impairment of sleep, convulsions, hallucinations,etc) 1.Inj lorazepam or Diazepam or Chlordiazepoxide 1 amp deep im or slow iv st 2.Inj Thiamine 1 amp iv st 3.T Lora 2mg 1-1-2 or 1-1-1-2 or T Calmpose 5mg (1-1-2) or T Librium(Chlordiazepoxide) 25mg 1-1-1-2 x 5-7 days 4.T thiamine 100 mg od/bd (T Benalgis) x 5-7 days 5.T Baclofen 5 mg 1-1-1 (to decrease craving) A/c alcoholic intoxication Presents with Hypotension,gastritis,hypoglycemia,collapse,respiratory depression. R/o SDH 1.Gastric lavage only if pt is brought immediately after ingesting alcohol, Maintain patent airway & prevent aspiration of vomitus. Maintenance of fluid & electrolytic balance 2.Correction of hypoglycemia by glucose infusion till alcohol is metabolized 3.Inj Thiamine 100 mg in 500 glucose infusion 4.T thiamine 1-0-1 x 5-7 days 5.T librium 10/25 (1-1-2) Shivering Aetiology:hypothermia, post operative 1.Cover with blankets.Drink warm non-alcoholic beverages to prevent dehydration. 2. Inj Dexona /efcorlin 1 amp iv st, & or Inj Avil for shivering; 3.Inj Tramadol 1 amp IM(for post-operative shivering) Note: Antihistamines have prophylactic value in blood/saline infusion induced rigor

27 Hypotension C/f: fainting, light headedness, dizziness, blurred vision, increased thirst,nausea 1. Give head low position 2. Start intravenous drip of NS or RL or DNS, fast infusion 3. Dopamine is given if there is associated cardiac failure/cardiogenic/septic shock. Dopamine 400mg in 5% Dextrose @ 10 dps/mt, check BP half hourly & inc or dec no of dps. Dopamine contraindicated in hypovolaemic shock. 4. Address the underlying problem(eg sepsis, MI,blood loss, adrenal insufficiency etc) Oedema Aetiology: generalised-cardiac failure, Cor pulmonale, liver/renal disease, malnutrition, angioedema, myxoedema, drugs causing Na retention like steroids. Localized-infection,trauma,burns, insect bites/stings,DVT, Thrombophlebitis, vericose vein, venous obstruction, gout, etc. Inv: Chest Xray, BRE, URE, LFT, RFT,TFT, USS of the local site Unilateral edema  Cellulitis: diffuse swelling of one leg with severe tenderness. Start antibiotics, analgesics  DVT- swelling of legs with maximum tenderness on the calf Admit for heparin therapy  Filariasis: long standing pitting edema on one leg, which is non tender. Intermittent fever with rigours DEC, elastocrepe bandage, elevation of leg, paracetamol  Gout: tender swelling behind great toe Generalised edema  Cardiac oedema: over legs in a pt of known heart disease. Refer to physician  Angioneurotic edema/Drug induced edema: Sudden onset with itching, urticaria, hoarse voice, dyspnoea Sudden onset of swelling of face including lips, eyelids & feet following drug intake Withdraw the drug, give antihistamines, steroids  Myxoedema or hypothyroidism: non pitting oedema, puffiness of face, wt gain, hoarse voice, lethargy Do T3, T4, TSH  Premenstrual edema Restrict salt, give lasix  Renal Generalised oedema more on face & in the morning. Do urine examination T Dytor 10mg(1-0-0)(torasemide) or T Lasix 40 mg (1-0-0)(Furosemide) Restrict salt, syp potklor if diuretics are given for a long period. Nephrology consultation.  Hepatic oedema Known alcoholic develops ascitis & oedema over legs. T Aldactone, iv human albumin if S. Albumin low  Anemia with hypoproteinaemia Seen in poor patients. Pallor, stomatitis, puffiness of face etc. Treat anaemia.  Idiopathic oedema

28 Left ventricular failure S/s: dyspnoea at rest that rapidly progresses to a/c respiratory distress, orthopnoea, PND, pink frothy sputum Signs: distressed, pale, sweaty, tachypnoea, gallop rhythm, pulmonary edema(basal crepitations), Pulsus alternans, pitting edema, raised JVP Feature of RHF: raised JVP, hepatomegaly, ascites, bilateral pitting pedal edema Inv: CBC, urea, electrolytes, ECG, CXR CXR in LVF: features can be remembered as ABCDE ie Alveolar edema,kerley B lines, Cardiomegaly, Dilated prominent upper lobe vessels, pleural Effusion Rx Ideally LVF should be managed in ICU The management of a/c pulmonary edema can be remembered as L M N O P ie Lasix, morphine, oxygen, & propped up position 1.Sit the pt up/CBD 2.Bed rest 3.Oxygen inhalation 4.Inj Lasix 20- 80 mg iv st followed by 40 mg Q8H or Q12H( if there is no significant fall in BP)(larger doses required in renal failure) Note:Pt currently treated with furosemide may receive twice the daily oral dose by intravenous administration. 5.Inj Morphine 2mg iv st ( + inj phenergan 25 mg iv st)( may be repeated as needed every 5-10 minutes 6.Inj NTG infusion(only if the pt is in ICU) 7.Inj Aminophylline 250 mg in 20 ml NS iv bolus Q8H. 8.ACE inhibitors like Enalapril 5mg 1-0-1(if BP above 120 mm Hg & creatinine < 1.5 mg/dl) 9.Positive inotropic agents such as dopamine/dobutamine may be needed in pt’s with concomitant hypotension or shock. 10.Manage precipitating causes like MI/ infections/arrhythmias Causes of pumonary edema LVF, ARDS, fluid overload(renal failure, iv fluids),hypertensive crisis, neurogenic causes( seizures, head injury etc)

Hypoglycemia C/f: sweating, trembling, pounding heart, hunger, anxiety, confusion, drowsiness, speech difficulty, inability to concentrate,seizure, nausea, tiredness, headache, irritability, anger, incordination 1.Check GRBS; if very low give 25% Dextrose 3 or 4 amp( 1 amp= 25 ml) or 25D 75 or 100 ml infusion or 50%D 25-50 ml; followed by 5%D infusion because insulin has prolonged action. 2.GRBS should be repeated every 10 minutes until>100 mg/dL Note: All cases of unexplained hypoglycemia should have an ECG taken. For infants: 2ml/kg & children: 4ml/kg 25 % dextrose or D10 if RBS <40. Pt may be observed for 24 hours.

Hyperglycemia

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The diagnosis of DM can be established using any of the following criteria:

HBA1C≥6.5% FBS≥ 126 mg/dL. A positive value should be confirmed with a rpt test. Symptoms of diabetes(polyuria,polydipsia, fatigue, wt loss) & a RBS ≥200 mg/dL OGTT≥200 mg/dL at 2 hrs after ingestion of 75 g of glucose. Prediabetes Impaired fasting glucose: FBS≥100 & ≤125 mg/dL Impaired Glucose tolerance:2-hr glucose 140-199 mg/dL after ingesting 75 g glucose. A1C in the range 5.7% to 6.4% Note: Lifestyle modification, including a balanced hypocaloric diet to achieve 7% wt loss in overwt pt’s & regular exercise of ≥150 min per week, is recommended for persons with prediabetes to prevent progression to T2DM. Diabetic pt review- 1. Fasting urinalysis for glucose, ketone, albumin, 2. FBS/PPBS, HbA1c 3.LFT, RFT, TFT 4. BP monitoring( target in DM is <130/80) 5. Enquire about Hypoglcaemic episode 6. Eye examination 7. Lower limb & feet examination. The blood pressure target for pt’s with diabetes is <130/80. ACEI/ARB is recommended as first line therapy. For those pt’s not at goal, a diuretic should be added. The lipid target are as follows: LDL <100 mg/dL, Total Cholesterol<150 mg/dL, HDL>40 mg/dL in men & >50 mg/dL in women. In pt’s with known cardiovascular d/s or two risk factors in addition to DM, the LDL should be <70 mg/dL, preferably using high-dose statin therapy. Aspirin should be advised in pt’s with diabetes & older than 40 yrs or who have other risk factors. Low dose (75-150 mg) is appropriate for primary prevention Note: Advice Physician consultation Hyperglycemia>300 mg/dL on more than one consecutive test should prompt testing for DKA Rx

Monotherapy For obese patients: T Metformin 500mg(1-0-1) after meals; For non-obese patients:sulfonylureas(2nd gen- glibenclamide,glipizide,glimepiride) Combination therapy using sulfonylureas may be needed, if monotherapy is unsuccessful. Pioglitazone is prescribed as a second line therapy with metformin or third line therapy in combination with sulphonylurea & metformin Voglibose is used for lowering PPBS. Insulin Therapy  Addition of NPH insulin at bed time to control FBS in addition to OHAs. Then twice daily NPH or consider adding Regular insulin to NPH. Regular insulin needs to be taken 30 mins before meals.  Insulin therapy given for pt’s presenting with DKA or with high glucose levels to prevent glucose toxicity.

30 Dosage of insulin It is ideal to start with a small dose & gradually increase at intervals of 2-3 days till the optimum dose is achieved as judged by the blood glucose level. The initial dose required can be calculated at the rate of 0.5 U/kg/day for Type 1 and 0.2 U/kg/day for Type 2 DM. If the pt is not symptomatic 50% of the calculated dose can be given initially & the dose can be gradually increased by 4 units every 3rd/4th day. If the pt is symptomatic, the calculated dose can be given in full at the start and adjusted subsequently. Illness often increases insulin requirements despite reduced food intake. For pt’s naive to insulin, a starting dose of basal insulin should equal 0.2 U/kg. If the presenting B sugar level is >200 mg/dL, adding premeal insulin is appropriate.The dose should be 0.2 U/kg divided by three meals. A correction dose of 1 to 2 U per 50 mg/dL of B sugar, beginning at 150 mg/dL, can be added to the premeal doses. Common preparations: Soluble/regular H.Insulin:- H.Actrapid, Huminsulin-R Human isophane insulin(NPH):- Huminsulin-N / Human insulatard H regular insulin+ isophane(NPH) insulin, 30/70 or 40/60 or 50/50:- Huminsulin / H actraphane / H Mixtard (40 IU/ml, 10 ml) Metformin 500 mg/1g (Glyciphage,glycomet,walaphage,glumet,cetapin-XR) Glimepiride 1 or 2 mg (Glimy,Amaryl,Diapride,azulix ) Glibenclamide 2.5/5 mg (Daonil,glinil,glucosafe) Gliclazide 30/40/60/80 mg (glicron,glyred,reclide) Pioglitazone 15/30 mg (pioglit,diavista,P-glitz,piozone) Voglibose 0.2/0.3 mg (Volix, vocarb, volibo,PPG) Glimepiride+ metformin (Amaryl-M,Amaryl-M2,Diapride Forte,Gluformin G1, Gluformin G2, Glimy-M, glyciphage-G) Glibenclamide + metformin(Daonil-M, glinil-M) Gliclazide + metformin (glycard-M, glyred-M,glychek-M) Metformin + Voglibose( Gluconorm-V) Vidagliptin + metformin (galvusmet) Pioglitazone + metformin(cetapin-P, diavista-M, gluconorm-P, glyciphage-P,walaphage- PZ) Pioglitazone + glimepiride( glimy-P,pioglit-G, pioglar-G) Glimepiride+ metformin + Pioglitazone(Amaryl-MP 1 or 2, Glyciphage PG1/PG2, tribet 1 or 2) Glimepiride+ metformin +Voglibose (Volix trio 1,Volix trio forte 1, Gluconorm-VG)

Diabetic Ketoacidosis c/f->  Anorexia, nausea, vomiting, polyuria, feeling thirsty  Abdominal pain, flushed hot, dry skin  Altered sensorium/coma, blurred vision  Kussmaul’s breathing- fruity odour in breath due to acetone  Features of volume depletion, dehydration or co-existent infection may be present Diagnosis requires acidosis(pH<7.3), hyperglycemia(>250 mg/dl), bicarbonate< 15 mmol/l, moderate ketonemia or ketonuria(+++). Inv:- RBS, Urine sugar & acetone, BRE, URE, S. Na, K, urea,creatinine,ABG, Serum amylase. Features of a pre-renal type of renal failure due to volume depletion may also be seen, ECG to look out for electrolyte imbalance & for unsuspected myocardial ischemia.

31 Rx 1.IVF NS 1L over 30 min(if cardiac function normal), 1L over 1 hr, 1L over 2hr, 1L over next 2-4 hrs. Those >65 yrs or with CCF need less saline more cautiously.Once blood glucose decreases to 200-250 mg/dl, start IVF DNS @ 50 to 100 ml/hr over a parallel line. 2.Inj Regular Insulin 10 to 15 U iv st (0.15 U/kg) Another option is to give RI 0.3 U/kg, half iv & half sc or im st f/b inj 0.1 u/kg/hr sc or im. Note: Subcutaneous absorption of insulin is reduced in DKA because of dehydration; therefore, using intravenous routes is preferable 3. Continuous Regular Insulin infusion in 1 pint NS @ 5 to 10 U/hr(or 0.1 U/kg/hr) (100 U in 500 ml of 0.9% NS infused @ 50 ml/hr or 14 drops/min delivers a 10 U/hr infusion or 50 U in 500 ml of 0.9% NS infused @ 100 ml/hr or 25 drops/min delivers a 10 U/hr infusion ).For 60 kg, 50U in 1 pint NS at 150/min; 70 kg-170/min;80kg- 200/min; 90kg-220/min;100 kg-250/min delivers 0.1 U/kg/hr.Check BG hourly initially.A decrease in BG levels of 50 to 75 mg/dl/hr is an appropriate response.If no reduction in 1st hour,rate of infusion should be increased by 50-100 % until an appropriate response is observed or repeat the iv loading dose. Excessively rapid correction @ >100 mg/dl/hr should be avoided to reduce the risk of osmotic encephalopathy. Once BG level decreases to 250 mg/dl, the insulin infusion rate should be decreased to 0.05 U/kg/hr to prevent dangerous hypoglycemia. Maintenance insulin infusion rates of 1 to 2 U/hr can be continued (indefinitely) until the pt is clinically improved. Once oral intake resumes, insulin can be administered s/c & the parenteral route can be discontinued. Restoration of the usual insulin regimen by s/c injection should not be instituted, until the pt is able to eat and drink normally. Note: Give a s/c dose (~10 U) of insulin 1/2 hr-1 hr prior to discontinuing insulin infusion. A rough estimate of the amount of insulin required for s/c administration can be calculated from the total amount of insulin given in the infusion till the time RBS became <200-250 mg/dl. This amount of insulin is given in three divided doses. 4.RBS every 1-2 hrs/urine sugar acetone chart/ electrolytes every 4 hrs. 5.Antibiotics if infection suspected 6.ECG 7.Catheterisation if pt unconscious or if no urine passed after 3-4 hrs of starting fluid replacement. 8. Ryle’s tube aspiration to keep stomach empty in unconscious or semiconscious pts 9. K+ replacement. K+ levels can fluctuate severely during the treatment of DKA, because insulin decreases K+ levels in the blood by redistributing it into cells. K+ should be added routinely to the IV fluids from second or third liter of fluid replacement except in pts with hyperkalemia(>6 mmol/L & or ECG evidence), renal failure, or oliguria. If baseline serum K+ levels are <3.3 mmol/L (<3.3 mEq/L), insulin therapy should not be commenced until the K+ level reaches 3.3 mmol/L. Likewise, if K+ levels reach <3.3 mmol/L at any point of treatment, insulin should be stopped and K+ replaced intravenously. In all patients with a K+ level <5.3 mmol/L and an adequate urine output of >50 mL/hour, 10 to 20 mmol (10 to 20 units [mEq]) of K+ per hour should be given routinely to prevent hypokalaemia caused by insulin. If the K+ level is >5.3 mmol/L replacement is not needed but K+ level should be checked every 2 hours Complications of DKA Cerebral edema due to excessive rapid correction of DKA. Rebound ketoacidosis due to premature cessation of IV insulin infusion or inadequate doses of s/c insulin after the insulin infusion has been discontinued.

32 Lactic acidosis due to prolonged dehydration, shock, infection etc Arterial thrombosis, Shock, aspiration pneumonia etc Hyperglycemic hyperosmolar Nonketotic coma(HONK) or HHS(hyperosmolar hyperglycemic state) It is characterised by severe hyperglycemia (>600 mg/dl) & dehydration without ketoacidosis.Treatment is similar to DKA with two exceptions: 1.Fluid requirements are often higher (with 0.45% saline) & 2.Total insulin requirements are less(~half the dose of insulin recommended for DKA)

UTI c/f :Fever with chills , Burning sensation during micturition,frequency, abd pain, Burning pain on micturition indicates urethritis. Suprapubic pain, frequency, dysuria:cystitis; High fever, toxicity, flank pain, tender renal angles:- pyelonephritis; palpable kidney swelling:hydronephrosis. Inv: URE ,RFT , C & S etc. Urine culture is must for recurrent infection, children, pregnancy, DM, Indwelling catheter, older people, failure of initial therapy 1.T P/L 500 mg tds X 3 days or T cyclopam(for ureteric/renal colic) 2.T Norflox 400mg 1-0-1 X 5-7 days for uncomplicated UTI ( for men give for more days) or T Furudantin 50/100 mg (nitrofurantoin) 1-0-1(if resistant or recurrent UTI). For upper UTI give antibiotics for 7-14 days. (others:Cefpodoxime,cephalexin,cotrimoxazole,amoxicillin + clavulanic acid etc) Norflox, ofloxacin,nalidixic acid,ciplox are C/I in pregnancy & lactation Note:Always collect urine in a sterile bottle before giving antibiotics. If C & S is done, give antibiotics only till the result comes. Once the result comes, Antibiotic can be changed according to the report 3.Syp Citralka ( Di Na hydrogen citrate) 2 tsp in one tumbler of water tds( can be given in pregnancy) 4.T pyridium (phenazo pyridine) 200 mg 1-1-1 x 2 days( it is a urinary analgesic. It produces reddish discolouration of urine. So warn about it. Not to be used for more than 2 days.C/I in pregnancy)(12 mg/kg/24 hr div into 3 for 2 days) 5.Plenty of oral fluids(~2L or more / day) Note: In pediatric cases we may give cefixime, septran or gramoneg.Refer all pediatric UTI to pediatrician for work up(MCU, USG etc),as child below 5 yrs(especially < 2 yrs) are vulnerable for permanent renal damage following UTI. T Urikind/Urispas (Flavoxate) 200 1-1-1 (for dysuria, urgency, nocturia, suprapubic pain, frequency & incontinence, bladder spasm due to catheterization etc)(given in pregnancy)

Hematuria Aetiology: UTI,pyelonephritis, trauma, Hemorrhagic cystitis, nephrolithiasis,kidney injury (from accidents),a/c prostatitis, urethral stricture,drugs(like penicillin, anticoagulants like aspirin, heparin,certain anticancer drugs), food dyes like beet root, neoplasm, TB, traumatic urethritis due to sexual intercourse or masturbation, allergy, strenuous exercise, viral illness, glomerulonephritis, excessive coagulation therapy, urethral FB, renal infarction, myoglobinuria, hemoglobinuria. Inv: URE, BRE, RFT, USG abdomen etc Advise medicine/Nephrology consultation.

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Hyperventilation Aetiology: stress or anxiety, stroke, head injury, DKA, metabolic acidosis, bleeding, infection, heart/lung disease, drugs, pregnancy,severe pain 1. Breath into a paper/plastic bag 2. O2 inhalation 3. Propped up position 4. Diazepam if necessary

Hypertension (pts with newly discovered asymptomatic hypertension or asymptomatic known hypertensive patients with elevated BP) Acute lowering of BP is unnecessary and may be harmful in asymptomatic patients. Just advise them to consult their primary physician for therapy change.Asymptomatic Pt with newly discoverd BP, should be advised to consult physician to start on antihypertensive therapy. Reduce BP, if greater than 220/110. Don’t give Nicardia /Lasix to reduce hypertension in an asymptomatic, otherwise normal patient as it causes sudden decrease in blood perfusion to organs and may lead to endorgan damage. Note:a/c reduction of BP is required only in hypertensive emergency like MI with HTN, stroke with HTN, hypertensive encephalopathy etc

Palpitation Aetiology:physiological, psychogenic, organic Organic conditions include MR,AR,AF, ectopics,anemia,thyrotoxicosis,fever of any cause, hypoglycemia (pounding heart), drugs causing bradycardia and tachycardia etc. Check for anemia, hyperthyroidism,LVH, arrhythmias 1.T ativan 1mg 1-0-1 (lorazepam) 2.T Ciplar 10mg tds(propranolol); Physician consultation

Chest pain Aetiology: a/c MI,angina,aortic dissection, tension pneumothorax, pulmonary embolism, GERD, pericarditis, pneumonia, chest wall pain, pleurisy, empyema, bronchitis, cervical spondylosis. Inv: ECG, CXR, Trop T/ Trop I/ CPK MB A patient is diagnosed with MI if two (probable) or three (definite) of the following criteria are satisfied: 1.Clinical history of ischemic type chest pain lasting for more than 20 minutes 2.Changes in serial ECG tracings 3.Rise and fall of serum cardiac biomarkers Note: Trop T becomes + ve only after 6 hrs, CPK-MB + ve after 4 hrs, Window period for thrombolysis: 12 hrs

34 Heartburn/pyrosis/cardialgia/acid indigestion Etiology:gastritis,GERD, IHD etc Inv: ECG all leads to r/o ACS. 1.inj Pantop/Ranitidine, 2.Antacids 3.C or syp Aristozyme bd/tid after food Note: 10% of cases of discomfort due to cardiac causes are improved with antacids Avoid overweight,avoid lying down soon after a meal,avoid late meals,avoid smoking, avoid tight fitting clothes,elevate the head end of bed, avoid foods that trigger heartburn.

Unstable Angina 1.O2 inhalation 2. Absolute Bedrest. Later graded ambulation 2 min in the morning & 5 min in the evening. 3.300 mg dispirin(don’t give ecospirin as it is enteric coated & thus delayed release ) st followed by 75 mg/150 mg ecospirin 0-1-0 4.If normal BP s/l sorbitrate(isordil) 5mg/10 mg st & 1-1-1 5.T Clopidogrel(clopilet/clopikind) 75 mg x 4 tab & 1-0-0 6.If severe pain persists,IV morphine 2-3 mg/pethidine 50-100mg(may cause vomiting) Note:C/I in asthmatics, COPD, already in hypotension 7. Metoclopramide10 mg / phenergan 25 mg for nausea/vomiting associated with Morphine 8.If BP low, don’t give lasix. 9. β blockers, e.g T metoprolol 25 / 50 1-0-1(Monitor Pulse Rate) or T Carvedilol 3.12525mg (Cardivas) bid or nebivolol 5-40 mg daily(Nebicard) 10.ACE inhibitors, e.g T envas(enalapril) 2.5/5 mg 1-0-1(monitor BP, RFT) 11.T Atorvastatin 40 mg st & 10mg 0-0-1 12.Heparin/LMW Heparin(clexane )i.e. Inj heparin 5000 U s/c Q6H x 5 days Or Inj clexane (enoxaparin)0.6 ml s/c BD(if RFT normal). 13.Syp cremaffin HS (as stool softner); semi solid diet. In those patients not tolerating Sorbitrate, we may give T.Monotrate 20mg 1-1-0  Aspirin + Clopidogrel Combinations: T.Complatt, T.Deplatt-A, T.Cidogrel-A T. Complatt CCU-> a unique combination with high loading doses of Aspirin & Clopidogrel for initiating therapy in cases of emergency. Consists of 2 tabs, one of which has to be dispersed in water & the other to be swallowed whole. Discussed in detail in HS manual Note: Unstable angina:ST depression or new T inversion and Trop T –ve, NSTEMI: ST depression or T ↓ and Trop T +ve , STEMI: ST elevation and Trop T +ve Nocturnal leg cramps Etiology: peripheral artery disease, spinal stenosis, drugs( like statins, diuretics, BP drugs), DM, dehydration, diarrhoea,fatigue, OA, pregnancy, hyper/hypothyroidism,CKD, cirrhosis, electrolyte abnormalities, B complex deficiency, dialysis, idiopathic etc 1.Analgesics 2.Vit B12(Cap Meganeuron OD Plus 0-0-1)/T Shelcal OD/ C evion 400 mg OD, 3.T gabapentin(Gabantin) 300 mg od. 4.Plenty of oral fluids, stretching, massage

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Status Epilepticus Occurrence of Seizures for more than 20 min or fits occurring in succession without regaining consciousness in between. R/o hypoglycemia Course->  Stoppage of current Anti-epileptic medication.  Metabolic conditions like Hypoglycemia, Hyponatremia  Infections like Meningitis, Encephalitis  Other causes of seizures like ICSOL, Trauma etc. The aim of treatment is to control seizure first and then identify any correctable cause and treat it if possible. Rx:  Maintenance of airway + throat suctioning  Maintain iv line & draw blood for metabolic work up  Intravenous antiepileptic medications 1.Lateral position 2.Inj Lorazepam 4 mg iv st/ inj diazepam 10 mg iv st over 2 minutes 3.Send RBS 4.Inj 25% dextrose 100 ml iv st 5.Inj thiamine 100 mg iv st 6.Inj phenytoin(eptoin) loading dose 10-20 mg/kg( 20 mg/kg first dose as 50 mg/min in running NS).Usually it is given as inj eptoin 600/800/1000 mg in 100 ml NS(1 pint NS if dose >1000 mg) over 20 min. Phenytoin should not be injected through the same cannula as lorazepam because of the possibility of crystallization. IV lines should be flushed prior to and after the administration of phenytoin. Watch for hypotension & arrhythmia during infusion. Don’t exceed 50 mg/min infusion rate as this may cause hypotension/cardiovascular collapse. 7.Later inj phenytoin 100 mg Q8H or inj Levipil(levitiracetam) 500mg or inj Na valproate 250 mg iv Q8H 8.If even after step 6, no improvement, rpt diazepam & ½ dose phenytoin If still no improvement refer the patient to physician/ neurologist

Haemoptysis Etiology: TB, a/c LVF, MS, bronchiectasis, pulmonary embolism, AVM, a/c bronchitis, lung abscess, suppurative pneumonia, bronchial CA, trauma, SLE, FB, parasites, mycetoma, hemophilia, aortic aneurysm, pulmonary infarction, leukemia , drugs(anticoagulants , aspirin, cocaine) Inv: CBC, coagulation studies, URE, AFB, ANA,ECG, CXR, Chest CT, Physician consultation 1.Reassure the pt;Q4H temp chart, I/O chart, pulse/BP chart(watch for hypotension) 2.Prevent aspiration; raise foot end, turn head to one side 3.Absolute bed rest 4.Broad spectrum antibiotics 5.Blood transfusion if systolic BP less than 90 mmHg or massive hemoptysis. 6.Antitussives like codeine 5 ml tds 7.Bronchodilators 8.Sedation e.g: diazepam 9.Inj ethamsylate 500 mg iv Q8H.

Drugs predisposing to renal dysfunction

36

NSAIDs, ACE inhibitors,Lithium, radiographic contrast media, Aminoglycosides,PPI , penicillins,chemotherapy Newly Detected Systemic Hypertension If BP not alarmingly high, advise salt restriction & review for BP check up after ~1 wk. Ideally, before starting drugs, R/O secondary HTN. Clinically look for Renal Bruit. Hypertension: investigation for all patients  Urinalysis for blood, protein & glucose  Blood urea, electrolytes & creatinine.  Blood glucose  S. total & HDL cholesterol  12- lead ECG(LVH, CAD) Drug treatment is recommended in:-

 In patients with sustained SBP≥160 Hg or sustained DBP≥100 mm Hg.  In patients with sustained systolic BP in the range 140-159 mm/Hg, and/or diastolic BP in the range 90-99 mm/Hg , the decision depends on the risk of coronary events, presence of diabetes or end-organ damage(i.e.renal impairment etc ) Treatment goal <140/90 mmHg(<130/80 in diabetes/CKD). Reduce BP slowly. Hypertension should not be diagnosed on the basis of one measurement alone, unless it is >210/120 mm Hg or accompanied by target organ damage.Two or more abnormal readings should be obtained, preferably over a period of several weeks, before therapy is considered. Initially monotherapy, then go for multitherapy, if not controlled. Monotherapy If >55 yrs, 1st choice is a Ca2+ channel blocker or a thiazide. If <55 yrs, 1st choice is ACE-i(or ARB if ACE-i intolerant). T clonidine(arkamine) 0.1 mg preferred in renal pts. In elderly hypertensive pt’s(>60 yrs), start diuretics as initial therapy.Ca2+ antagonist/ ACEI/ARB are also effective. Multitherapy  When a second drug is needed, it should be generally be chosen from among the other first-line agents.A diuretic should be added first, as doing so may enhance effectiveness of the first drug.  Another method is, in combination one out of two groups A (ACEI/ARB) or B (β blockers) is combined with C (calcium channel blocker) or D (thiazide diuretic) ie. A/B + C/D. In refractory pts, when 3 agents are to be used, A+C+D is a good choice.ACE-i with CCBs is better than a combination of ACE-i with diuretic. β blockers are not a 1st line for HTN  In pt’s with stage 2 HTN, therapy may be initiated with a 2 drug combination, typically a thiazide diuretic + Ca2+ antagonist/ACEI/ARB/β-blockers.

37  Antihypertensives which can be used safely in pregnancy:->  Alpha Methyl Dopa  Nifedipine

 ACE inhibitors & thiazides are contraindicated in pregnancy  In all cases of CAD – Systemic HTN, beta blockers are the best option, followed by ACE inhibitors, Diuretics, Angiotensin receptor blockers(ARB).  Before starting beta blockers r/o bronchospasm, POVD etc.  Ca2+ antagonist should be used with caution in a/c MI.  In hyperthyroidism + hypertension give beta blockers, anti thyroid drugs  In HTN + LVH, ACEI have greatest effect on regression.  In case of CCF give ACE inhibitors or ARB.  In obese hypertensive pt’s, weight reduction is the primary goal of therapy.  In DIABETIC NEPHROPATHY, give ACE inhibitors(best). Any pt started with ACE inhibitors requires RFT at 2 wks. Drugs used for hypertensive crisis Inj Lasix 20/40mg iv stat (frusemide) T Aceten S/L stat (1/4 th of a tablet)(captopril-ACEI) C.Nicardia 10/5mg S/L stat [nifedipine(CCB)] C Beta Nicardia S/L stat [atenolol(beta blocker) + nifedipine(CCB)] T Arkamine 0.1mg stat (Clonidine=alpha2 bloker)(nt preferred as it cause severe rebound hypertension)(it is preferred in renal pts)  Nitroglycerine infusion(to be given in icu setting only)     

Brands : Amlodipine [5-10mg OD] (CCB) Amlodac, Amlopres,Amlokind, Amlosafe, Amlovas, Stamlo Atenolol [25-100mg OD] (beta blocker) Aten, Beten, Tenolol, Tensimin. Nifedipine [5-20mg bd] (CCB) Nicardia(Cap), Nicardia retard(tab), Calcigard(both cap & tab) Metoprolol [50-100mg bd] (beta blocker) Metolar, Betaloc,Gudpres-XL, Meto-ER, Revolol-XL(last 3 sustained release tabs) Telmisartan(40-80 mg /day)(ARB) Telma,Telpres, Telmikind Cilnidipine(5/10/20 mg)(CCB)- cilacar, cilaheart Methyldopa [250mg tds] (alpha 2 stimulator) Alphadopa, Emdopa Enalapril [5-20mg OD] (ACE inhibitor) Envas, Nuril, Enpril

38 Ramipril [2-5mg OD] (ACE inhibitor) Cardace, Cardiopril, Ramace, Ramihart Losartan [ 25- 100 mg OD](ARB) Losar,Losakind, Repace, Zaart, Tozaar Olmesartan(20/40 mg)- oImetime Atenolol + amlodipine Amlong-A, Amcard-AT,Amlokind-AT, Stamlo beta, Aten-AM, Amlopres-AT Atenolol + Nifedipine- Beta Nicardia, Presolar Amlodipine + Losartan Amcard LP, Amlokind-L, Amchek Z, Amlopres- Z, Amlotin HS, Atenolol + Amiloride + Hydrochlrothiazide (for moderate to severe HTN not controlled by monotherapy) Beta-Bidurst, BP-Loride, Hipres D Metoprolol + Hydrochlorothiazide- Betaloc-H, Selopres Losartan + hydrochlorothiazide- Losar-H, Repace-H, Telmisartan +hydrochlorothiazide- Telma-H,Telmikind-H Telmisartan+ Amlodipine- Telista-AM, Telmikind-AM Telmisartan + Metoprolol - Telmikind Beta Prazosin(1-20 mg/day)- Prazopress Nitroglycerin(2.6/6.4 mg) - Nitrolong Hyperlipidaemia Inv: 12-hour fasting lipid profile, TFT,RFT,RBS. Note: screening for hypercholesterolemia should begin in all adults aged 20 yrs or older. Causes of 20 hyperlipidaemia: hypothyroidism,Renal failure, nephrotic syndrome, alcohol,DM, drugs like steroids, oral contraceptives, diuretics. Note: measurement of fasting lipids is indicated if the total cholesterol is >200 mg/dl, or HDL cholesterol is < 40 mg/dl. If fasting profile can’t be obtained, total & HDL cholesterol should be measured. Rx 1st line therapy: Statins are given . 2nd line: fibrates, e.g bezafibrate,fenofibrates or cholesterol absorption inhibitors, e.g ezetimibe(useful combined with a statin to enhance LDL reduction). Response to therapy should be assessed after 6 weeks.

39 For hypertriglyceridaemia fibric acid derivatives are given. E.g bezafibrate. Note: Statins are associated with myalgia, myositis, abdominal pain, derangement in LFT , raised CPK. Give T Levocarnitine for associated muscle pain. T.N: carnisure Drugs containing levocarnitine: C evion- LC, T nurokind-LC Atorvastatin [10-20mg OD HS] Atorlip, Atorva, Aztor, Vasolip, Statlip, Storvas, Lipikind Rosuvastatin(5/10/20 mg OD) Rosuvas, Novastat, Lipirose, Razel Fenofibrate(200 mg OD) - Lipicard, Stanlip Atorvastatin + Fenofibrate Stator-F, Lipikind-F Atorvastatin + Ezetimibe Atorlip EZ,Storvas-EZ Hyperuricemia Etiology:renal d/s, drugs(e.g diuretics, immunosuppressive drugs), alcohol, starvation, hypothyroidism, obesity,psoriasis, purine rich diet(organ meat, seafood, dried beans, dried peas, mushrooms), vit B3,genetic, etc. Rx T Febuxostat(febutaz/febuget) 40/80 mg 1-0-0(monitor S.creatinine) Steroid tapering  If steroids are tapered too quickly, withdrawal symptoms can occur, such as joint pain, fatigue, dizziness, muscle pain, vomiting, shortness of breath, fainting, headaches, low blood sugar, fever, nausea etc  One view is that tapering is not necessary in short term therapy (14 days or less)  Gradual withdrawal of systemic corticosteroids is advisable in patients who have received more than 2 weeks treatment or have history of adrenal suppression or have had repeated courses of steroids or received doses at night or have received Prednisolone >40mg daily or equivalent (e.g. dexamethasone 6mg) for any length of time Prednisolone tapering A decrease in dose is usually made every 2-3 days Reduce dose by 2.5- to 5.0-mg decrements every 3–7 days until physiologic dose (5 to 7.5 mg of prednisolone per day) is reached. Other recommendations state that decrements usually should not exceed 2.5 mg every 1–2 weeks

Dexamethasone tapering In patients who have received less than 14 days of dexamethasone therapy, treatment may be abruptly discontinued without adverse events, because the HPA axis is not suppressed. Dexamethasone tapering schedules are often prescribed for short-term therapy, and usually consists of a reduction in dose of 2-4 mg every 1-3 days, by either reducing the dose and/or the interval.

40 Hypothyroidism C/f: cold intolerance, fatigue, poor memory, constipation, menorrhagia, myalgias, hoarseness, somnolence Rare manifestations: carpal tunnel syndrome, deafness, hypoventilation, pericardial or pleural effusions. Diagnosis  TSH is the best initial test. A normal value excludes primary hypothyroidism, and a markedly elevated value(>20 µU/mL) confirms the diagnosis. Mild elevation(<20 µU/mL) may be due to nonthyroidal illness, but usually indicates mild(or subclinical) primary hypothyroidism, in which thyroid function is impaired but increased secretion of TSH maintains free T4 levels. These pt’s may have nonspecific symptoms that are compatible with hypothyroidism & a mild increase in S.cholesterol & LDL. Plasma free T4 should be measured if TSH is moderately elevated, or if secondary hypothyroidism is suspected, and pt’s should be treated for hypothyroidism if free T4 is low  ECG Rx Thyroxine is the drug of choice. The average replacement dose is 1.6µg/kg PO daily, and most patients require doses between 75 and 150 µg/d. In elderly patients, the average replacement dose is lower. The need for lifelong therapy should be emphasized. Thyroxine should be taken 30 minutes before a meal, preferably morning. Initiation of a therapy.  Young & middle-aged adults should be started on 100µg/d. This regimen gradually corrects hypothyroidism, as several weeks are required to reach steady-state plasma levels of T4. Symptoms begin to improve within a few weeks.  In otherwise healthy elderly patients, the initial dose should be 50 µg/d.  Patients with cardiac disease should be started on 25 to 50 µg/d and monitored carefully for exacerbation of cardiac symptoms. Follow-up  In primary hypothyroidism, the goal of therapy is to maintain plasma TSH within the normal range. TSH should be measured 6 to 8 weeks after initiation of therapy. The dose of thyroxine should then be adjusted in 12- to 25- µg increments at intervals of 6 to 8 weeks until TSH is normal. Thereafter , annual TSH measurement is adequate to monitor therapy.  In secondary hypothyroidism, TSH cannot be used to adjust therapy. The goal of therapy is to maintain the free T4 near the middle of the reference range. The dose of thyroxine should then be adjusted at 6 to 8 weeks intervals until this goal is achieved.Thereafter , annual T4 measurement is adequate to monitor therapy.  CAD may be exacerbated by the treatment of hypothyroidism. The dose of thyroxine should be increased slowly in pt’s with CAD, with careful attention to worsening angina, heart failure, or arrhythmia.  Hypothyroidism may impair survival in critical illness by contributing to hypoventilation, hypotension, hypothermia, bradycardia, or hyponatremia.  In pregnancy thyroxine dose increased by an average of 50% in the first half of pregnancy.  Subclinical hypothyroidism should be treated with thyroxine if any of the following are present: a) symptoms compatible with hypothyroidism, b) a goitre, c) hypercholesterolemia that warrants treatment, or d) the plasma TSH is >10µU/mL. Untreated pt’s should be monitored annually, and thyroxine should be started if s/s develop or S.TSH increases to >10µU/mL. T.N: Thyronorm, eltroxin

Sensory Disturbances

41

Pins & needles, pricking, band like, lightning pain, knife like, twisting, pulling, tightening, burning, aching, numbness, other raw sensations Aetiology: neurological or non neurological. Neurological: PNS or CNS lesions, Non neurological: hyper ventilation, hypocalcemia, hysterical/non organic Peripheral neuropathy causes: direct trauma, compression, entrapment, DM, leprosy, HIV, alcohol, vitamin deficiency, hypothyroidism, drugs (like FQ, metronidazole, phenytoin, linezolid), paraneoplastic, liver failure, renal failure etc. For peripheral neuropathy/ Neuropathic Pain/ fibromyalgia 1.T Carbamazepine 200 mg 1-1-1(Tegrital,Epilep, Zen, Mazetol etc) or T Amitryptilline 10 mg HS(Tryptomer) or T Duloxetine 30mg (Dulane,dutin) 0-0-1 or C Maxgalin(pregabalin) 75/150 mg od or C Gabantin(gabapentin) 300 mg od C Maxgalin-M/Pregastar M(pregabalin + methylcobalamin), Gabamax Gold/ Pregastar Plus (B complex, pregabalin), T Nurokind-G(Mecobalamin + Gabapentin) 2. Analgesics - Mefanamic Acid [Ponstan, Meftal] 3.T BC or Neurobione forte or other multi vitamins with Vit B12 or T Benalgis (Benfotiamine)100 mg 1-1-1; T Benalgis can be given for sciatica, diabetic neuropathy / nephropathy/ retinopathy, & other painful nerve conditions. 4.Physician consultation Facial Nerve Palsy Aetiology-> ASOM, Inflammatory, Idiopathic[bell’s] 1. Antibiotics. In cases of DM always give strong antibiotics 2. Analgesics 3. Steroid—wysolone 40mg 1-0-0 X 5-7 days, tailing by 10 mg/day 4. In cases of Bell’s Palsy give Acyclovir 800mg 5 times daily x 7-10 days 5. Lubrex/refresh (carboxymethylcellulose) Eye dps; 6. Pad & bandage eye; use dark glasses. Trigeminal Neuralgia DoC is Carbamazepine 200mg tds Rx same as above Giddiness/syncope Etiology: 1.Hypoglycemia-> h/o DM + Cold extremities, Sweating-> give 25% or 50% dextrose. 2.Vasovagal attack-> Can occur due to prolonged standing, excessive heat or large meal. Keep the pt in lying down position & feet elevated 3.Bradicardia- drugs(beta blockers, verapamil, diltiazem, digoxin), AV block, SA node disease 4.Tachycardia-AF, SVT 5.Postural Hypotension- hypovolemia, sympathetic degeneration(DM, Parkinson’s disease, old age), drugs(anti anginals, antidepressants, neuroleptics) can cause or aggravate the condition. Advise to avoid prolonged standing and to get up slowly from sitting or lying down position. 6.Carotid sinus hypersensitivity- when pressure is applied to neck e.g. wearing a tight collar 7.Myocardial ischemia; LV outflow tract obstruction- AS, HOCM Note: Whenever a pt is brought with c/o unconsciousness, r/o head injury

42 Motion Sickness 1.T. Avomine 25mg about 1-2hrs before journey[Promethazine theoclate] 2.Avoid alcohol,dietary excess, reading. Position themselves where there is least motion,a supine/recumbent position with the head braced is best. Keeping the axis of vision at an angle of 450 above horizon may reduce susceptibility. Memory defects & Forgetfulness R/o treatable causes like Vit B12 deficiency, hypothyroidism, SDH 1.T Citicholine (strocit) 500 mg 1-0-1 Or 2.T piracetam 400 mg 1-1-1; T strocit plus(citicholine+ piracetam) or 3.T Donamem 0-0-1 (donepezil 5 or 10 mg + memantine 5 mg) Headache Primary headache syndromes : migraine with (classic) or without (common) aura, tension headaches, cluster headaches, rebound headache, trigeminal neuralgia, temporal arteritis Secondary headache: have specific etiologies & symptoms vary depending on underlying pathology, i.e., SAH, HTN,sinusitis, tumour, glaucoma,SDH, meningitis, encephalitis, vasculitis, obstructive hydrocephalus, intracerebral hematoma, cerebral ischemia or infarction, dental problems, pseudotumour cerebri,optic neuritis. Systemic causes include fever, viremia, hypoxia, CO poisoning, hypercapnia, allergy, anemia, caffeine withdrawal etc. Clinical presentation: the sudden onset of severe headache(worst ever headache) or a severe persistent headache that reaches maximum intensity within a few seconds or minutes warrants immediate investigation for possible SAH. There may be a loss of consciousness at the onset of SAH. Physical examination Check BP, pulse. Look for possible bruits. Check temporal arteries. If neck stiffness & meningismus(resistance to passive neck flexion,headache etc) present, then consider meningitis.Check sinus tenderness over maxillary & frontal sinuses. If papilledema observed, consider an intracranial mass, meningitis or idiopathic intracranial HTN. Inv: CT Brain to exclude secondary etiologies. Rx Analgesics Note: Naproxen is the preferred NSAID in people with high risk of cardiovascular complications like stroke, MI In pt’s presenting with headache,fever,polymyalgia rheumatica , tenderness & sensitivity on the scalp, raised ESR , suspect Giant-cell arteritis.Start treatment immediately with prednisolone (30-40 mg/day, tapered off in 4-6 weeks)to prevent blindness. Migraine In case of any headache R/o refractive errors. Ask for throbbing/pulsating nature, chronicity, whether U/L or B/L, Duration, presence/absence of nausea/vomiting, photophobia, phonophobia Also ask for any aura->visual blackouts, diplasia, nasal block, giddiness, fortification spectra. Also ask for any precipitation factors-> like TV, food, alcohol,caffeine, mental stress, sleep deprivation etc.

43

Rx: 1. Inj Migranil [dihydroergotamine]1mg iv over 2-3 min/im stat [C/I in pregnancy, lactation, HTN,CAD] Or T.Migranil 2 tabs, rpt after 30 min if necessary. Note: ergotamine preparations should be best avoided since they easily lead to dependence. 2. Inj P’mol 2cc im stat[if 1 not available] 3. Inj phenergan 25mg or perinorm or stemetil-> for nausea 4. T.Alprax 0.5mg stat 5. T metoclop-P st( metoclopramide + P mol) or T Domstal-P(domperidone + P/L) st Or 6. T Headset st & SOS (sumatriptan succinate, Naproxen)(Only for A/c migraine & cluster headache attack)(in elderly, avoid sumatriptan due to risk of CVA, MI) Or 7. T Clotan 200 mg (tolfenamic acid) st & SOS (for a/c migraine) 8. Headache calender Prophylaxis is considered if a pt has at least 3 disabling migraines per month. 1. T.Flunarizine 10 mg HS x 2 weeks-1mnth[T.sibelium/Fine/Flugraine] Or 2. T.Inderal 20mg 1-0-1[propranolol] (C/I in BA, CCF, POVD, Severe bradycardia) or 3. T sodium valproate 200 mg 0-0-1 x 1 week f/b 1-0-1 to continue or 4. T amitriptylline 25 mg HS Tremor Aetiology: alcohol withdrawal tremors, drug induced(salbutamol, deriphylline, metoclopramide), hyperthyroidism, parkinsonism, senile tremors, hypoglycemia, stress induced, vitamin deficiency(thiamine, B12), CKD, liver failure, Stroke,traumatic brain injury, Hypocalcemia, hyponatremia, caffeine or alcohol induced Inv: TFT, RFT, LFT, S.electrolytes, 1. T ciplar 40 mg 1-0-1(for essential tremors). Dose has to be tapered gradually over several days. C/I in RAD, bradycardia, AV block, shock, severe hypotension, etc 2. T Alprax 0.25 mg 1-0-1 for stress induced tremor. 3. C Gabapentin OD For tremors due to parkinsonism give T Syndopa(levodopa + carbidopa) bd, T pacitane or parkin 2mg (trihexyphenidyl) bd Caries Tooth Rx: 1. Analgesics->Brufen 2. Antibiotics; Amoxicillin, Metronidazole Dental consultation Gum Abscess Rx: 1. 2. 3. 4.

Antibiotics; Amoxicillin, Metronidazole Analgesics ; Vit C Warm saline gargle, Apply Pressure Refer to dentist for I & D Gingivitis

1. 2. 3. 4.

Clohex Plus oral rinse(chlorhexidine) Vit C Antibiotics Analgesics

Rx:

44 Cheilosis/angular stomatitis Etiology: Iron/Vit B 12 deficiency, infection 1. C. Becosules Z/ Berocin CZ [vit B-complex, C & Zinc] 1-0-1x 5dys, then 0-0-1. Other drugs with Vit B12: Matilda forte, ME-12, trinerve 2. Antibiotics like septran / Erythromycin may be given 3. Inj Trineurosol H/ neurobion forte(Vit B1 100mg,B6 50mg,B12 1000mcg) im od Halitosis Aetiology->Gingivitis, poor oral Hygiene,smoking,dry mouth, Caries Tooth , hepatic failure, uremia,DKA, bronchiectasis, lung abscess, atrophic rhinitis,alcohol,etc. Rx: 1. Metrogyl DG gel[chlorhexidine gluconate, metronidazole] or Hexidine mouth wash or Betadine Mouth Gargle T Metrogyl may be given for severe cases. 2. Maintain proper oral hygiene 3. Tongue cleaning twice daily 4. Chewing gum help in production of saliva, preventing dry-mouth. 5. Holding 2 curry leaves in the mouth for 5-7 minutes decreases bad breath Aphthous Ulcers Aetiology-> Vit/Fe/folate Deficiency, Antibiotic Induced etc. Rx: 1. Vit B 12 +Vit C+ Antioxidants; adequate hydration 2. Dologel for pain or Dologesic gel(has Lignocaine), Dentogel(lignocaine+ choline salicylate), Lexanox QID (Amlexanox,anti-inflammatory) or 3. Chlorhexidine mouth wash/ betadine mouth wash, or 4. Kenacort /oraways/Tess oral paste for LA(triamcinolone) or 5. Antibiotics like tetracyclin 250 mg dissolved in 50 ml of water administered as a mouth rinse for 3 min(to coat ulcers) & then to be swallowed, Qid or 6. Syp Sucralfate (sparacid)5-10 mL PO swish and spit/swallow Qid. Biopsy of the ulcer may be needed, if it does n’t heal. In cases of herpetic gingivostomatitis: Rx-> given as above + T. Acyclovir daily [Acivir, Zovirax, Herperex] Oral Candidiasis(Oral Thrush) Aetiology: stress, drugs, immunocompromise, dry mouth, Cancer, smokers, oral dentures,etc 1.Candid mouth paint[clotrimazole] 2.Chlorhexidine oral rinse 3.Vit C Dry Mouth(xerostomia) R/o drugs- antihistamines,atropine group, clonidine,methyl dopa, tricyclic antidepressants, anti-parkinsonian drugs, bronchodilators, DM with polyuria, ill fitting dentures, fungal infection of mouth, dehydration, radiotherapy, HIV infection Rx:1.Diabetes control, treatment of candidiasis, sugar free chewing gum, adequate hydration, avoid alcohol containing oral rinses,avoid salty/dry foods/alcohol/caffeine etc 2.E-saliva oral spray 3 to 4 times(Na carboxymethylcellulose,sorbitol, kcl,Nacl,Mgcl2, CaCl2,K dihydrogen PO4)

45 Opthalmology Whatever be the opthalmic solution, not more than a drop needs to be instilled into the conjunctival sac at a time because the conjunctival sac holds only 10-15 microliters of fluid at a time & the average volume of one drop is 60 microliter. Only the frequency of instillation needs to be adjusted depending on the clinical condition. If an eye drop & an eye ointment has to be instilled at the same time, instill the drop first followed by ointment. Conjunctivitis C/f: Bacterial:conjunctival congestion with matting of lashes, mucopurulent discharge, gritty sensation, normal pupil, viral: conjunctival congestion, watery discharge, gritty sensation. 1.Moxiflox /Gatilox / Ciplox(not preferred) eye drops 10 Q1H-Q4H as per severity. 2.Frequent Washing. Dark glasses, if photophobia. Never pad & bandage. 3.Tocin(tobramycin) eye oint at night to prevent glueing of the eyelashes in the morning 4.If severe -> Antihistamines, Anagesics, Antibiotics[Oral] e.g Ciplox Note: no role for prophylactic topical antibiotics in unaffected eye. In children give tobramycin e/d Eye pain causes: ocular pain- conjunctivitis, corneal abrasions/ulcerations, burns, blepharitis, chalazion,stye; orbital pain-glaucoma,iritis,optic neuritis, sinusitis, migraine, trauma A/c red eye: conjunctivitis, glaucoma, injury, iritis,keratitis, scleritis, blepharitis,SCH etc Scleritis Systemic therapy is always required. 1.Oral NSAIDs like indomethacin (100 mg od). 2.Steroid + Antibiotics e/d e.g:  Betnesol-N[betamethasone sodium phosphate, neomycin sulphate] e/d or  Toba-DM [dexamethasone, tobramycin] e/d or  Microflox-DX [ciprofloxacin hydrochloride, dexamethasone] e/d Superficial punctuate Keratitis Mainly due to viral infections, So give Acyclovir. C/f: pain, photophobia, lacrimation, 1. Acivir or Zovirax or Herperex eye drops 1 drop Q4H 2. Topical steroids 3. Tobramycin [eyebrex,toba,tocin] or moxiflox (milflox)e/d to prevent 20 infection. 4. Artificial tears like Refresh eye drops. Corneal Ulcer C/f: redness, pain, watering, photophobia, redness, foreign body sensation etc R/o DM 1. Pad & bandage;hot fomentation; dark goggles 2. Moxiflox /Ciplox/ Tobra eye drops; if the corneal ulcer is not responding to above treatment in two days time or the ulcer is more than one mm size at the time of presentation fortified antibiotic eye drops(cefazolin & gentamycin) should be given. Fortified Cefazoline(Reflin) e/d 10 Q1H-Q2H;it is prepared by adding 5-10 cc distilled water into a vial of injection cefazoline 500 mg to get a strength of 50-100 mg/ml. The solution should be kept in refrigerator & every 3rd day fresh e/d should be prepared as cefazoline is not stable in aqueous solution.

46 Fortified gentamicin (13.6 mg/ml) e/d Q1H-Q2H;prepared by reconstituting gentamicin (0.3%) e/ d with gentamicin (40 mg/ml) injection. inject 2 mL of gentamycin, 40 mg/mL, directly into a 5-mL bottle of gentamycin 0.3%, ophthalmic solution 3. Vit C; Analgesics & antiinflammatory drugs. 4. 1% atropine or 2 % homatropine e/d tds to relieve ciliary spasm. Refer to Ophthalmology. Never prescribe steroid eye drops if corneal ulcer is suspected, as it will lead to rapid corneal perforation Fungal Corneal Ulcer C/f: pain, watering, photophobia, blurred vision, redness of eye, FB sensation 1.Natamycin (5%) e/d (Natamet) hourly during day time & Q2H during night or Ketoconazole eye drops(Phytoral) or Voriconazole e/d x 6-8 weeks 2.Atropine e/d tds. 3.T.Flucan / Syscan 150mg OD [Fluconazole] x 2-3 weeks 4.Analgesics, Vitamins, hot fomentation, dark goggles(for photophobia) etc Simple Allergic conjunctivitis 1. Antihistamines, NSAIDs, cold compress 2. Winolap/Optihist pat(olopatadine) 0.1 % e/d , 1 or 2 dps bid at an interval of 6-8 hrs. 3.Dexamethasone e/d 0.05% qid.(solodex-J, Low-Dex) Note: Steroid e/d should be used only in severe & non-responsive cases & for short duration. Hordeolum Internum, Externum, Chalazion Disorder of the eyelid. It is an acute focal infection (usually staphylococcal) involving either the glands of Zeis (external hordeolum, or styes) or, less frequently, the meibomian glands (internal hordeola).Most hordeola eventually point & drain by themselves. Rx 1.Antibiotic eye Oint/drops[moxiflox/tobra] to be applied to affected lid margin 2.P’mol / brufen 3.Hot sponging 4.Oral antibiotics if severe; Amoxyclav/Ciplox Blepharitis Inflammatory d/s of eyelid usually chronic & involves the part where the eyelashes grow. Rx 1.Steroid + antibiotic eye oint application at lid margin Eg.ciplox+ dexamethasone (ciplox-D),tobramycin+ dexa (tobaren-D) bd x 2 weeks 2.Antibiotic e/d 3.Oral antibiotics 4.Treat scalp dandruff Corneal abrasion C/f: pain, watering of eyes, photophobia Rx 1.Wash with NS if FB’s are present 2.Instill Homatropine eye drops( T.N Homide) followed by antibiotic eye ointment 3.Pad & Bandage 4.Advice to instill antibiotic eye drops eg.Moxiflox Q4H at home 5.R/w next day.

47 A/c Dacrocystitis Rx 1. Broad spectrum antibiotics like ciplox 2. Analgesics 3. Local hot compress 3-4 times a day; I & D if abscess points Foreign body eye Commonly seen on the cornea. If pt has FB sensation & FB can’t be localised, evert the upper eyelid to r/o UTC(upper tarsal conjunctival) FB. Copius irrigation should be done with 1pint normal saline in case of multiple FB in the cul de sac. Removal done under aseptic precautions Anaesthetize the conjunctival sac with 0.5 % proparacaine (preferred) or 4% Xylocaine twice at 5 minutes interval. Eyelids are separated with speculum or using thumb & index finger. Remove the corneal FB with a 23G/ 25G/26G needle. While removing the FB, the needle should be held parallel to the corneal surface to prevent accidental penetration. After removal , instill a drop of homatropine, apply antibiotic eye drops/ointment, pad & bandage. Blunt injury to eyeball For mild injuries topical cyclopegics eg. Homatropine e/d bd & topical steroids qid would suffice. If IOP is raised, T Acetazolamide 250 mg tds is also given. The eye is patched to protect the eye from further trauma. Note: In penetrating injuries wound has to be repared under LA/GA; gently pad the eye without instilling any e/d or ointment. Broad spectrum parenteral antibiotics should be started eg. Ciplox, genta A/c congestive glaucoma It is an ophthalmic emergency C/f: pain in the affected eye, headache, vomiting, congested eye, hazy cornea, tender stony hard eye on palpation, shallow AC, middilated vertically oval non-reacting pupil. IOP must be lowered immediately. 1. IV Mannitol 20% , 200 ml in 20 minutes 2. T Diamox(acetazolamide) 250 mg tds 3. Dexamethasone e/d Q4H to tackle uveitis 4. Timolol e/d 0.5 % bd Refer to ophthalmology. A/c iridocyclitis C/f: acute red eye, moderate to severe pain, watering, photophobia, defective vision; circum corneal congestion, small sluggishly acting irregular pupil, ciliary tenderness etc 1. Atropine e/d tds 2. Prednisolone acetate e/d Q2H-Q4H depending on severity to be tapered over a period of 4-6 weeks. Note: never stop topical steroids abruptly as it will precipitate uveitis. 3. Dark goggles

48 IBS(Irritable Bowel syndrome) C/f: recurrent abdominal pain, abdominal bloating, alternating episodes of diarrhoea & constipation, mucus in stools, feeling of incomplete defecation. Diagnosis is mostly clinical. Diet: avoid excess tea, coffee, fried food etc. Increase leafy vegetables & fruits (if constipation predominant). Note: fibre rich diet can cause bloating & occasional impaction if ingestion is not accompanied by adequate volume of liquid. Also explain the nature of the illness to stressful situations. 1.T Colospa / Morease (mebeverine - antispasmodic) 100 1-1-1 2.T Librax / Spasril (chlordiazepoxide + clidinium bromide) 1-1-1 Note: T Normaxin (chlordiazepoxide + clidinium bromide+dicyclomine) tds can also be given 3.C Econorm (saccharomyces Boulardii) 250 1-0-1 4.T Amitriptylline 10-25 mg HS. Liver abscess C/f: fever, chills,jaundice,wt loss, tender hepatomegaly,intercostal tenderness, dry cough, pain in the right shoulder etc. Inv:CBC, LFT, Blood C&S,coagulation profile,Stool RE, CXR,USG abdomen, CCT. Rx For pyogenic liver abscess: iv antibiotics e.g cephalosporin (3rd gen) ± gentamycin For amoebic liver abscess/Amoebiasis: 1. Inj Metrogyl 500 iv Q8H x 7-10 days or T metrogyl 400/800 mg tds or T Tinidazole / ornidazole 2g daily x 3-5 days(After 10 days give T Diloxanide 500 mg tds x 10 days ) + Inj CP 10 LU iv q6H ATD x 5 days 2.T Chloroquine 250 2-0-2 x 2 days followed by 1-0-1 x 10-14 days Needle aspiration for large abscess or if the response to chemotherapy is not prompt. Prevention is by avoiding fresh uncooked vegetables or drinking unclean water. Scrub typhus C/f: high grade continous fever with HSM & lymphadenopathy. Eschar in a hidden wet area of the body. Inv: IgM, IgG Scrub C Doxy 100 1-0-1 x 5-7 days Rheumatoid arthritis C/f: pain, early morning stiffness(>30 min), joint swelling,tenderness,rheumatoid nodules. Suspect the diagnosis if there is symmetric arthritis in 3 or more joints (especially involving small joints). Inv:ESR,CRP,RF, anti-CCP antibody, x-ray, ultrasound,MRI General measures: Education, Exercise, Diet(lipid lowering diet, fibre rich), Physiotherapy. 1.NSAIDs e.g Indomethacin 25/50 mg 1-1-1, Lornoxicam 4-8mg 1-0-1, Etoricoxib 90120 mg OD or Naproxen 250/500 mg BD etc 2.DMARDs e.g T HCQ (hydroxychloroquine) 200-400 mg OD( s/e retinal toxicity). Also used are methotrexate,sulphasalazine, leflunomide etc. 3.T Wysolone(low dose in early stages for disease modifying effects & high dose for severe disease) Note:before commencing DMARD therapy, check CBC, LFT,RFT, CXR, visual acuity(if HCQ is given).

49 Suspected Weils Leptospirosis with jaundice, renal impairment & haemorrhages. c/f-> fever, myalgia, conjunctival congestion,calf tenderness, oliguria, icterus,HSM etc. Inv-> BRE, URE, ECG, CXR, RFT, LFT,Blood C & S,peripheral smear, Weils IgM. Investigate for DD’s like Dengue (NS1 antigen,IgM, IgG), malaria, typhoid, scrub typhus. Classical picture: ESR ↑, TC ↑ , polymorphs ↑, moderate elevation of SGOT/PT, abnormal & serially increasing levels of urea & creatinine, elevated S.Bilirubin. 1. Temp chart, I/O chart, Daily platelet count chart, RFT. 2. Inj CP 20 LU iv Q6H ATD//Inj. Taxim 1 gm BD // Inj.doxycycline[As hyclate: Initially, 200mg on day 1 followed by 100mg daily in a 0.1-1 mg/ml solution infused over 1-4 hr] x 5 days or T Doxy-1 100mg 1-0-1[prophylaxis](after food; take plenty of water, otherwise sticks to esophagus; avoid direct sunlight exposure) x 5-7 days 3. If not taking orally, IVF like DNS with polybion 4. Inj P’mol 2 cc im sos;Tepid sponging sos 5. Inj Pantop 40mg iv od 6. Syp Looz 1 oz (30 ml) tds Suspected Dengue c/f-> Fever,headache, gastroenteritis, Myalgia, Conjunctival congestion. There may be bleeding manifestation, rash, altered level of consciousness or syncope. Inv->Same as above . Serial Platelet count is of significance. NS1 antigen +ve by 1st week, IgM +ve by 2nd week, IgG +ve by 3rd week Classical picture:PCV ↑, TC ↓ , lymphocytic dominance, ESR normal, plt ↓ when fever subsides 1. Temp chart, I/O chart, Platelet count chart, RFT 2. T P’mol 500mg 1-1-1 & Inj P’mol 2cc im sos// Tepid sponging sos 3. If not taking orally, IVF like NS or RL 4. Inj Pantocid 40 mg iv od 5. Platelet transfusion sos(PLC<10,000 without bleeding or<50,000 with bleeding) 6. Adequate bed rest; Note: Chikungunya presens as sudden onset of fever, crippling joint pain, headache, lymphadenopathy, conjunctivitis, maculopapular rash, fatigue etc.Rx; Rest, fluids, NSAIDs like Naproxen or P’mol. T Chloroquine 250 mg/day may help in c/c arthritis. A short course of steroids may also be useful. Suspected Meningitis c/f->Fever + vomiting + headache,Seizures, Altered sensorium, Cranial nerve deficits, neck stiffness,+ kernig’s/ brudzinski’s sign. Altered sensorium more common in encephalitis. Inv->BRE, URE, RFT, LFT, LP, CT Brain(prior to LP if signs of raised ict or FND), Blood c/s, Urine c/s(if suspected UTI), Sputum AFB etc. 1. 4th hourly Temp chart , I/O chart 2. Inj CP 40 LU iv Q4H ATD Or Inj Monocef 2g iv bd ATD 3. Inj Mannitol 20 % 100ml iv Q8H 4. Inj thiamine 100mg iv bd 5. If not taking orally, IVF DNS or NS, as dehydration is common. 6. Inj Pantocid 40mg iv od 7. Inj P’mol 2cc im sos// Tepid sponging sos 8. Inj Phenytoin 100 mg iv q6h( for Px & control of seizures). 9. RTF, Bladder catheterization sos, frequent change of position q2h, intermittent throat suction if unconscious.

50  If Encephalitis is suspected add Inj Acyclovir 500mg iv Q8H x 14/21 days  If H influenza infection is suspected or established(usually in children), prophylaxis is needed for contacts if child < 5yrs is at home.T Rifampicin 600 mg (20 mg/kg) single dose x 4 days(warn about orange discolouration of urine & other body secretions).  If meningococcal infection is suspected or established, chemoprophylaxis with T Rifampicin(10 mg/kg/dose) 600mg bd x 2 days or T Ciplox 500mg single dose is to be taken.  In pediatric cases treat with Inj Ceftriaxone 100mg/kg/day in 2 divided doses. Another regime is taxim + Amikacin. Treat according to culture and sensitivity. Note: 1st dose empirical antibiotic should be given on clinical suspicion, prior to all inv. Suspected Enteric Fever(Typhoid fever) c/f->Fever with Splenomegaly, headache, lethargy,abdominal pain, dry cough,poor appetite,generalized aches,constipation followed by diarrhoea,epistaxis,malena. Inv->Routine investigations(leucopenia with relative lymphocytosis) , Widal test , 2 samples 7-10 days apart; O titre>1/160 & H titre >1/320 is significant(a single absolute value of O titre >200 or an increasing titre of O over one week especially a four-fold rise is considered positive), blood c/s, Clot culture DoC is Ciprofloxacin. Other drugs used: Ceftriaxone, cefotaxim,cefixime,Azithromycin Rx 1. Temp chart, I/O chart 2. Inj Ciplox 200mg iv bd x ~ 10-14 days/Inj Monocef 1-2 g iv bd ATD T ciplox 500-750 mg bd for 10-14 days can also be given. 3. Inj or Tab P’mol sos + Tepid sponging 4. If not taking orally, IVF DNS, NS, RL, Isolyte P->as required 5. w/f signs of perforation, other complications like arthritis etc & get expert opinion & management. 6. Blood transfusion sos. Tetanus Diagnosis is clinical -> Trismus, Tonic spasms, Opisthotonus, h/o injury Rx 1. Keep in a quiet, dark room , with minimal handling 2. O2 inhalation and respiratory support sos 3. Inj Telglob 5000 IU im.(Each vial contains 250 IU. So 20 vials are required. Sites->Deltoid, Anterolateral aspect of thigh. Give as multiple doses as early as possible) 4. Inj Diazepam 0.2 mg/kg Q4H or more frequently 5. Muscle relaxants 6. IVF->DNS or NS; Ryle’s tube feeding, care of bladder 7. Immunization after recovery 8. Tracheostomy and mechanical ventilation sos. Infective Endocarditis Prophylaxis Px is recommended for following conditions: prosthetic valves, previous endocarditis, CHD(not all),cardiac transplant recipients with valvular heart disease. Px is given only for : Dental or upper respiratory tract procedures or procedures on infected skin, skin structures , musculoskeletal tissue->  Standard prophylaxis: Amoxycillin 2g PO 1 hour before the procedure.  Unable to take PO : Ampicillin 2g IM or IV or cephazolin/ ceftriaxone 1g IM or IV within 30 min before procedure.

51 If allergic to Penicillin: Clindamycin 600mg PO or cephalexin 2g PO or azithromycin/clarithromycin 500 mg PO 1 hour before the procedure.  Penicillin allergic & unable to take PO: Clindamycin 600 mg IV, or cephazolin / ceftriaxone 1 g IV within 30 min before procedure. 

TB Prophylaxis Px In <6 years->T INH 10mg/kg OD X 6months. In adults, there is no proven benefit for prophylaxis. Post- exposure Prophylaxis in HIV Do baseline BRE, URE, LFT, RFT, HIV,HBsAg,anti HCV, ELISA Rx 1. T Zidolam (zidovudine 300 mg+ lamivudine 150 mg)1-0-1 X 4 weeks (Basic regime) or Extended basic regime includes T Indinavir 400mg 2-2-2 or Efavirenz 600 mg Od X 4 weeks(+ Basic regime) 2. T Domstal 10mg 1 sos 3. Repeat investigations at 4 weeks, 3 months, 6 months 4. Weekly Hb monitoring ( zidovudine - hematological toxicity) Post-exposure Prophylaxis in Hepatitis B Rx 1. Hepatitis B immunoglobulin is to be given as early as possible(within 24 hours). Dose-> 0.06ml/kg 2. Active immunization with Inj Engerix B or Inj Shanvac B 1ml IM X 3 doses (0, 1month,6 month) then check titre. Upper GI Bleed Inv->Hb, PCV, Blood grouping & crossmatching ,RFT, LFT, HBsAg, Anti HCV, USS Abdomen, OGD scopy. Rx: 1. Nil per orally(NPO) 2. Ryles tube aspiration 3. Inj Octreotide 50 microgm iv st, followed by 25 microgm/hr infusion till 4 hrs after bleeding stops or till pt is taken to endoscopy. Or Inj terlipressin 1 mg(1mg/10ml) iv q8H(it is very costly~ Rs 1500 per 10 ml) 4. Inj Pantop 40mg iv od Or Inj omez(omeprazole) 80mg iv st f/b 8mg/hr infusion 5. IVF 2 DNS, 2NS, 2% 5D in 24 hrs. 6. Blood Transfusion/FFP sos. 7. Inj vit K 1 amp (10 mg) iv/sc OD x 3 days 8. Bowel wash with lactulose BD 9. Syp lactulose 30 ml tds( if not NPO) 10.Inj taxim 1 g iv Q8H 11.T Misoprostol 200mg 1-0-1(If thought to be associated with irritant drugs like NSAID’s. Also stop the offending drugs)

52 Hepatic Encephalopathy Ideally Refer to a higher centre Upper GI Bleed may be associated. Hence orders and investigations may be similar. INV->BRE, Platelet count, PCV, Peripheral smear, Blood grouping, URE, LFT, RFT, ECG, PT-INR, APTT, Blood Ammonia levels, HBsAg, AFP (alpha feto protein), Serum Ferritin(to r/o secondary haemochromatosis)USS abd, OGD Scopy, RBS. Rx: 1. Ryle’s tube aspiration(for upper GI bleed), NPO, I/O chart 2. Packed cell transfusion sos 3. Give NS if BP is low. Once BP is rectified, NS is not to be given 4. Inj Octreotide 50 microgm st, followed by 25 microgm/hour infusions, ideally till OGD scopy is done and endoscopic sclerotherapy is done. It is to be given in 5% Dextrose, Never in NS. 5. Inj Vit K 1 amp s/c or iv od x 3 days 6. Inj Pantop 40mg iv od or Inj omez(omeprazole)80mg iv st f/b 8mg/hr infusion 7. Inj thiamine 100 mg(Trineurosol H)iv bd x 7 days if alcohol related liver disease. 8. Inj Ampicillin 500mg iv Q6H ATD/ Inj taxim 9. T Rifagut (rifaximine) 400 1-1-1 (gut sterilizer)(thru Ryle’s tube, or orally if there is no hemetemesis & sensorium is normal). 10. Bowel wash with lactulose enema bd 11. Syp Looz 30ml tds(if not NPO)(r/o ileus/bowel obstruction before oral lactulose) 12.Inj Hepamerz/analiv(L-ornithine L-aspartate) 5g(10 ml) iv bd if RFT is normal 13.If Vomiting present, Inj Emeset 4 mg iv Q8H 14.Inj Mannitol 20% 100ml iv Q8H, if RFT is normal. 15.IVF DNS 2 pint, NS 2 pint , 5%D 2 pint in 24 hrs..Fresh blood/FFP transfusion 16.If stable ofter OGD scopy, propranolol (to decrease portal HTN) may be started at a dose of 20mg 1-0-1. Dose may be adjusted so as to cause of 25% decrease in pulse rate 17.T Monotrate 20mg 1-0-1(isosorbide mononitrate)(Px for variceal bleedeing) 18.If Ascites is present give T Aldactone 25 (1-0-1)(spironolactone)(to decrease fluid overload) or T Lasilactone(furosemide + spironolactone) 1-0-0. Refractory ascites means no response to Aldactone. 19.If Viral Hepatitis was the cause of CLD give T Lamivudine 100mg od or tenofovir, probably long term. 20.Clinical worsening of the patient may due to the development of Spontaneous Bacterial Peritonitis. The patient may present with suddenly developing abdominal pain, with rebound tenderness, absent bowel sounds and fever. In such cases, do a diagnostic tap and send for cytology study. Diagnosed if PMN >250cells/µL or if >50% polymorphs, cloudy nature of fluid and positivity on culture-> mostly E coli. A culture of mixed organisms may indicate a hollow viscus perforation. Give Inj Taxim 2g iv Q8H till clinical improvement(for a minimum of at least 5 days). Other options include AmoxClav or other 3rd generation Cepholosporins or Genta. 21.If Ascites is present do therapeutic tap, ideally only after giving Human Albumin intravenous infusion or FFP. 22.Any CLD patient with ascites, give long term prophylaxis with T Norflox 400mg Once daily to prevent SBP. Diet in Hepatic Encephalopathy 1. Restrict Proteins 2. Fluid intake should be such that the daily weight loss is not more than 1 kg. 3. Carbohydrate rich diet.

53 Factors Which Preceipitate hepatic encephalopathy 1. Uraemia-spontaneous or diuretic induced. 2. Drugs like Sedatives, Hypnotics or Antidepressants 3. GI Bleeding 4. Excessive protein intake 5. Large volume paracentesis 6. Hypokalemia 7. Infections 8. Constipation 9. Trauma,Development of portosystemic shunts Correction of metabolic abnormalities Hypokalemia (K+ <3.5 mEq/L):If S. K+ >2.5 give Syp Potklor (Pottasium chloride) 1-2 meq/kg/day in 1 glass water(15ml=20 meq =1.5g )if normal urine output. Oral doses of 40 mEq are generally well tolerated & can be given as often as every 4 hours. Traditionally, 10 meq of pottasium are given for each 0.10 mEq/L decrement in S. K+. Monitor S. K+ every 4 hr.Monitor ECG, urine output.If S. K+ <2.5 , give iv pottasium. Administer 4 g of Inj KCl in 100 ml of NS over 4 hrs. Replace at 10 -20 mEq/hr if urine output is normal. Hypocalcemia: Inj calcium gluconate 10 ml 10% slow iv over 10 minutes.Also check phosphorus (for hyperphosphatemia)& Mg(for hypomagnesemia). Hyponatremia: fluid restriction(hypertonic saline is reserved for very severe cases) Viral Hepatitis C/F: fever, malaise,fatigue, anorexia, nausea, arthralgia, jaundice,pruritus, headache, abdominal pain, Inv: Hep A: AST & ALT rise 22-40 d after exposure, & usually return to normal over 520 weeks.IgM rises from day 25 & signifies recent infection.IgG remains detectable for life.Hep B: HBsAg(surface antigen) is present from1 to 6 months after exposure. HBeAg is present for 11/2 - 3 months after the a/c illness & implies high infectivity.The persistence of HBsAg for >6months defines carrier status.Antibodies to HBcAg(anti-HBc) imply past infection. Antibodies to HBsAg(anti HBs) alone imply vaccination. HCV: anti-HCV antibodies, SGOT:SGPT <1:1 until cirrhosis develops. Admit if ->  >15 Bilirubin, prolongation of PT  Enzymes grossly elevated, Coagulopathies  Significant Vomiting, abdominal pain, malaise  Ascites and Encephalopathy, Hypoglycemia,Co-morbid conditions Among investigation, the prolongation of PT is the earliest marker. If the test value exceeds the control value by >4sec, it is considered abnormal. Rx: Mainly supportive 1.Absolute bed rest, avoid alcohol 2.Protein and fat restricted, carbohydrate rich diet. 3.T Silybon (silymarin, herb derivative used as hepatoprotective)140mg 1-0-1 4.T Udihep/Udiliv/Ursochol (ursodeoxycholic acid/ursodiol) 300mg 1-0-1. Note: ursodiol used in cholestasis, cirrhosis, other hepatic disorders) 5.Inj Vit K 1 amp s/c od x 3 days if coagulopathy is suspected. 6.Avoid P’mol. Do tepid sponging for fever 7.Hepatic drip(Usually in children if oral feeds are not well tolerated. (100ml NS 400ml 10% glucose + 5ml 15% KCL + 2ml Polybion) Note:Fulminant hepatitis, C/c Hep B, a/c or c/c Hep C may require specific antivirals.

54 ADD/Gastroenteritis C/f: Diarrhoea, vomiting, abdominal discomfort,fever etc. Inv: BRE, RFT, electrolytes,stool RE, C & S etc. 1. 4th hrly Temp chart , I/O chart 2. Inj Ciplox 200mg iv BD [Ciprofloxacin] or T Ciplox 500 mg bd 3. Inj Metrogyl 500mg iv Q8H[Metronidazole] or T Metrogyl 400 mg tds 4. Inj Rantac 50mg iv tds [Ranitidine] 5. Inj P’mol 2cc im sos 6. Inj Cyclopam / Buscopan 1 amp im sos[dicyclomine / hyoscine butylbromide] 7. Plenty Of Oral Fluids/ORS.If not taking orally IVF RL/DNS/NS 8. C.Hydral or Redotil 1-1-1[Racecadotril] Note: C Doxy 100mg bd x 3-5 days can also be given. Malaria C/f: fever, shivering, headache, jaundice, joint pain, vomiting, convulsions,HSM. Do RMT,peripheral smear for malarial parasite, RFT, LFT etc. 1.4th hrly temp chart 2.For uncomplicated malaria: chloroquine 250 mg 4 tabs st, 2 tabs after 6 hrs, 24 hrs & 48 hrs.For P ovale & P.vivax same as above + T Primaquine 15mg 1-0-0 x 14 days Note:G6PD deficiency must be ruled out before starting primaquine. For uncomplicated P.falciparum- T artisunate 4 tab daily x 3 days, SP (sulpho methoxazole pyremethamine) 3 tablets on day 1. For severe cases -artesunate 2.4 mg/kg iv/im given on admission, then at 12 hrs & 24 hrs & then OD. 3. Inj 25% Dextrose 100ml iv Q8H 4. Inj Pantoprazole 40mg iv od;If not taking orally, IVF 2 pint DNS; P’mol for fever. Chemoprophylaxis(<6 weeks): doxycycline 100 mg OD in adults(1.5 mg/kg for children> 8 yrs) 2 days before travel & continued for 4 weeks after leaving the malarious area. Influenza / H1N1 C/f:fever,cold, sore throat, muscle pain, head ache, cough, tiredness etc 1.Antipyretics, analgesics, cough medications, antibiotics for 20 infection 2.Antiviral agents: T. Oseltamivir 75 mg bd x 5 days(tamiflu). Syp Oseltamivir (12mg/ml) Prophylaxis: T. Oseltamivir 75 mg OD x 10 days

Pneumonia C/f: fever, chest pain, dyspnea, hemoptysis, productive cough, malaise, chills,rigors, other non specific s/s like myalgia, headache, abdominal pain, nausea, vomiting, diarrhea, anorexia,wt loss, altered sensorium. Inv: CXR, CBC, ABG,pulse oximetry, LFT , U & E, blood culture, CRP, Hospitalised pt’s should have regular monitoring of pulse, RR,BP, O2 saturation. Assess severity using CURB-65 Rx In pt’s with mild community acquired pneumonia, amoxicillin may be used. Out Pt- macrolides(Azithromycin 500 mg PO od single dose followed by 250mg PO daily x 4 more days) or doxycycline(100 mg PO x 5 days), In pt’s with exposure to antibiotics within the last 90 days or those with comorbidities, use a respiratory FQ monotherapy or β-lactam(like amox high dose 1g tds) + a macrolide x 5 days IP, non ICU pt’s, choose one option from below: β-lactam im /iv(ceftriaxone/cefotaxim) + macrolide iv/oral(Azithromycin)  β-lactam im /iv + doxycycline iv/oral  FQ(antipneumococcal) iv/im(levoflox)

55  If the pt is younger than 65 yrs with no risk factors for drug-resistant organisms, administer macrolide iv/oral For ICU pt’s, choose one from below: β-lactam iv + macrolide iv  β-lactam iv + FQ(antipneumococcal) iv  If the pt has a documented β-lactam allergy, administer iv FQ(antipneumococcal) + aztreonam iv For pt’s with increased risk of infection with Pseudomonas, choose one from below: Antipseudomonal β-lactam iv (piptaz,cefepime,meropenem,imipenem)+ antipseudomonal FQ(ciprofloxacin,levofloxacin)  Antipseudomonal β-lactam iv + aminoglycoside iv + macrolide iv// FQ(antipneumococcal)// if the pt has β-lactam allergy, give aztreonam iv + aminoglycoside iv + FQ(antipneumococcal) iv  4th hourly temp chart, PR/RR/BP monitoring. SpO2 monitoring for severe cases.  Supportive: rest, adequate hydration, symptomatic treatment for fever,bodyache, pleuritic chest pain,O2 inhalation,Nebulisation with salbutamol for 20 min Q6H,inj deriphylline Q8H, syp Ambroxol 2tsp tds, chest physiotherapy, rpt x-ray on day 7. Atypical pneumonia: azithromycin Aspiration pneumonia: cephalosporin + metronidazole+ respiratory FQ Hospital acquired: aminoglycoside iv + antipseudomonal penicillin iv or 3rd gen cephalosporin Filariasis Acute lymphangitis & lymphadenitis, Tropical eosinophilia: T DEC 100 mg 1-1-1 x 3 weeks(Hetrazan, Banocide)(children-6mg/kg/day div into 3) Prophylaxis T DEC 300 mg + albandazole 400mg one dose yearly Tropical eosinophilia, c/f- cough aggravating at night, asthmatic attacks, weakness, wt loss, low fever, enlarged spleen, prominent LN in the neck etc For persistent eosinophilia & c/c dry cough, T prednisolone may be given Chronic Lower limb ischemia Advice: 1.care of the foot  Inspect the foot daily for accidental injury  Ensure cleanliness of foot, socks, foot wear  Look for any ulceration or inflammation, avoid tight shoes  Avoid over heating/cooling of foot  Don’t walk barefooted 2. Stop smoking & start walking 3. Lose weight, if overweight/obese. 4. Look for hyperlipidemia, anemia,DM 5. T Trental 400mg 1-1-1(Pentoxifylline) 6. T Pletoz 50-100mg 1-0-1(Cilastazol) (C/I in CCF) 7. T Nialip 375mg 1-1-1(Nicotinic acid) Surgery consultation if evidence of advanced ischemia(rest pain, gangrene), presence of DM, rapid progress of the disease, if leg pain during exertion interferes with patient’s occupation.The leg pain of peripheral arterial disease must be distinguished from other causes of leg pain, such as arthritis,muscle pain, radicular pain,spinal cord compression, thrombophlebitis, anemia & myxedema.

Lumps

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Examine the lump/swelling as well as the regional lymph nodes. If the lump is a node, examine its area of drainage. Also examine the circulation & nerve supply distal to any lump. Etiology: Lipomas,cysts, Lymph nodes, sebaceous cysts, fibromas, cutaneous abscesses, rheumatoid nodules, dermoid cysts, ganglia,malignant tumours of connective tissue, neurofibromas, keloids, granuloma, bursa, warts, papilloma etc Inv: BRE, Microbiolgcal inv for appropriate suspected infections, for cyst- aspiration followed by microscopy culture & cytology, FNAC, excision biopsy, USG,doppler, CT/MRI. Surgery consultation. Head injury  Ask for h/o LOC, vomiting, seizure, bleeding from ear, nose mouth.  Assess pupillary reaction. A difference in pupil diameter of >1 mm is abnormal  Assess level of consciousness using GCS.  Examine the scalp for wound, deformity, tenderness.  Observe for bleeding or CSF leak from ear or nose. Other evidence of # of base of skull includes Raccoon eyes, Battle’s sign.  If BP is low, search for other causes of hypotension like intraabdominal bleeding, because hypotension is very unlikely in a pure head injury.  Suspect associated cervical spine injury in an unconscious head injury pt.So manipulation of the neck should be minimised & with special care. A cervical collar may be applied till a cervical injury is ruled out. Any insult to the brain is manifested as signs of raised ICT like bradycardia, deterioration in the level of consciousness, hypertension. In case of tachycardia, look for other injuries like blunt trauma abdomen, chest injury, # pelvis. In case of altered level of consciousness r/o other causes like alcoholism, meningitis, hyper/hypoglycemia, epilepsy, metabolic abnormality, drug intoxication, poisoning etc. Immediate care: ABCD is the order of examination & resuscitation. Suture the scalp wounds at the earliest as it can result in significant blood loss. 1.NPO,Monitor vitals 2.Anti meningitic regime (if skull # or pneumocephalus etc) Inj Ceftriaxone 1g iv Q12H x 21 days Inj Amikacin 500 mg iv Q12H x 21 days Inj Metrogyl 500 mg iv Q8H x 21 days 3.Inj Mannitol 20% 100 ml iv Q8H (not given in EDH, pneumocephalus) 4.Inj Eptoin 100 mg iv Q8H 5.Inj Thiamine 100 mg iv bd x 5 days 6.Put Ryle’s tube, Catheterize the pt. 7.Start IV fluids if the pt is in shock, but avoid fluid overload. 8.Daily RBS, Na+, K+ 9.Repeat CT if GCS falls. Note: Inj Aravon(edaravone) 30 mg(20 ml) iv bd (neurotrophic drug, reduces cerebral edema & infarction) is also given. Avoid dextrose containing IV fluids especially 5%D, as it can raise ICT Apply rigid or philadelphia neck collar for all head injury pt’s until cervical spine X-ray has ruled out any abnormalities.

57 A/c Cholecystitis C/f: upper abdominal pain, nausea, vomiting, fever,jaundice Inv: FBC, URE,RFT, LFT,USG abdomen, CT abdomen 1.Bed rest 2.NPO 3.IV fluids, continous nasogastric aspiration, antiemetics 4.Analgesics 5.Antibiotics such as ceftriaxone/ciplox/ taxim+metrogyl //cefaperazone + sulbactum, piperacillin+ tazobactum etc. 6.Surgery consultation A/c Appendicitis C/f: Rt lower quadrant pain, periumbilical pain, nausea, vomiting, anorexia, diarrhoea, constipation, Rebound tenderness, pain on percussion, rigidity, and guarding Inv: FBC, URE,RFT, LFT,CRP,USG abdomen, CT abdomen 1.Bed rest 2.NPO 3.IV fluids 4.Nasogastric suction 5.Analgesics,antiemetics 6.Antibiotics if perforated /gangrenous appendicitis or peritonitis, e.g taxim + metrogyl 7.Surgery consultation A/c Pancreatitis C/f: abdominal pain/tenderness/guarding/distension, nausea, vomiting, diarrhoea,fever, jaundice, hematemesis or melena, dyspnea, tachypnea, diminished bowel sounds, left side basal lung creps, hypotension etc Inv:FBC, RFT, LFT,S.electrolytes with S.calcium, CRP,BUN,Lipid profile, S.Amylase, S.lipase, LDH, USG abdomen, CT abdomen 1.Bed rest 2.NPO 3.Aggressive iv fluid therapy, continous nasogastric aspiration, antiemetics 4.Analgesics like tramadol 5.Antibiotics only if associated infection is suspected 6.Inj Ranitidine or Pantoprazole 7.Inj octreotide 100 µg iv or s/c bd/tds x 3 days Note: also treat metabolic complications like hyperglycemia, hypocalcemia etc For c/c pancreatitis: T Creon 10,000U 1-1-1 x 2 weeks(lipase, amylase, protease) A/c intestinal obstruction Etiology: adhesion, hernia, carcinoma, intussusception, volvulus C/f: abdominal pain, distension, vomiting, absolute constipation, visible peristalsis Examine hernial orifice to r/o hernial obstruction/strangulation. Do PR examination to r/o rectal pathology. Inv:BRE, URE, LFT, RFT, S.electrolytes, X-Ray Abdomen(distended bowel loops, multiple air fluid levels in established cases of obstruction), USG abdomen, CECT, 1.Nasogastric aspiration 2.IV fluids & electrolytes correction, blood transfusion if needed. 3.Antibiotics e.g taxim + metrogyl Refer to surgery for early surgical intervention.

58 Peritonitis Etiology: Localized or generalized; localized due to inflammation of underlying viscera. Generalized due to perforation / hemorrhage. C/f: guarding, severe tenderness, rigidity, silent abdomen, rebound tenderness Inv:CBC, URE, RBS, S amylase, S electrolytes, urea, creatinine, plain x-ray abdomen erect view,USG abdomen, CT scan 1.NPO 2.IV fluids 3.Nasogastric aspiration 4.Analgesics & Antibiotics( e.g taxim/ciplox + metrogyl) 5.Emergency surgical intervention. Testicular/scrotal Pain or Swelling Aetiology: a/c epididymoorchitis, testicular torsion, inguinal hernia, hydrocele, varicocele, spermatocele Inv: USG doppler scrotum The sudden onset of testicular pain in a young man or child suggests testicular torsion , a true urologic emergency. Immediate surgery/urologic consultation is required. Swelling, retraction, and severe discomfort are important signs of testicular torsion. Testicular torsion occurs unilaterally & may follow or be precipitated by exercise or may occur spontaneously. This leads to the abrupt cessation of blood flow & testicular ischemia & infarction, which is likely to be irreversible after 12 hrs. Piles 1.Proctosedyl oint(Butyl amine Benzoate+Framycetin +Hydrocortisone acetate);Faktu (policresulen, cinchocaine);Shield(Hydrocortisone,lidocaine,Zn oxide, allantoin) or Anovate (beclomethasone +phenylephrine+lidocaine) or Smuth cream (calcium dobesilate, lignocaine, hydrocortisone, Zn)for LA. 2.Syp Cremaffin 3tsp HS(HS means at bed time from latin word ‘ hora somni’) 3.T Venusmin/Venux 300 tds (Diosmin) or Daflon (diosmin + hesperidin) tds 4.T Caldob(Calcium dobesilate) od/bd 5.Antibiotics; NSAID’s for acute attack. 6.Sitz bath for 20 minutes twice daily; 7.Fibre rich diet ;plenty of oral fluids; surgery consultation Perforated peptic ulcer C/f: general peritonitis, shock Inv: plain X-ray abdomen- free gas under diaphragm, S. Amylase to r/o pancreatitis 1.NPO 2.IV fluids 3.Analgesics & Antibiotics Refer to surgery for early surgical intervention. Felon(whitlow or terminal pulp space infection) C/f:Throbbing pain, red swollen warm tender pulp or finger tip 1.Warm water or saline soaks 2.I & D if pus +(using a midline/midlateral incision that adequately divides the fibrous septa.Do not divide vertical fascial strands (septa).The incision should not cross the distal interphalangeal (DIP) joint to prevent formation of a flexion contracture at the DIP flexion crease. Probing is not carried out proximally to avoid extension of infection into the flexor tendon sheath.Pack gauze loosely into the wound to prevent skin closure.

59 Apply a loose dressing, splint the finger, and elevate the hand above the heart. Update tetanus immunization. 3.C Megapen 1-1-1-1 4.T Lyser-D If Rx delayed, complications : skin necrosis, septic arthritis, osteomyelitis, tenosynovitis.Infectious flexor tenosynovitis & deep space infections require emergency care.Infection involving little finger should be treated aggressively as the infection can spread to the palm of hand.

Skin Ulcers Causes: venous stasis, arterial insufficiency, DM,lymphoedema,vasculitis, malignancy, infection(TB, syphilis), trauma(pressure),Drugs, pyoderma Diabetic ulcers most often occur on the pt’s heel or on the plantar surface of the metatarsal heads. Venous stasis ulcers most often occur on the medial aspect of the pt’s lower leg or ankle & are associated with c/c edema.Arterial insufficiency ulcers tend to occur distally on the tips of the toes or at or near the lateral malleolus Inv : FBC,RBS,LFT, RFT, skin & ulcer biopsy, C & S of discharge, x-ray of the limb/part to look for periostitis/osteomyelitis or gas in the soft tissues. Chest x-ray , Mantaux test in suspected case of tuberculous ulcer, FNAC of the limb node, arterial/venous doppler. Rx

Optimize nutrition, stop smoking, correct anaemia, protein & vitamin deficiency. Analgesics, give rest to the part. Clean wounds are treated with minimal debridement,& damp gauze or hydrogel based dressings. Ulcer cleaning is done using Normal Saline(better & ideal), or diluted povidone Iodine. Antiseptic solutions such as hydrogen peroxide, Povidone-iodine etc should not be routinely used as they are toxic to tissues & impede healing. Oxum Spray(super-oxidised solution), megaheal ointment can also be used. Pt’s with suspected infected diabetic foot ulcer should be admitted for impatient wound care & broad spectrum antibiotic therapy directed at both gram +ve and gram -ve organisms. Infected wounds require a thorough exploration with drainage of all abscess cavities & debridement of infected, necrotic, or divitalized tissues. Wound cultures should be obtained prior to initiation of antibiotics. In the acute phase parenteral treatment is indicated. For mild infections limited to soft tissues, 1 to 2 weeks of therapy is enough; moderate or severe infections require 2 to 4 weeks of antibiotics. For osteomyelitis involving viable bone, 4 to 6 weeks of IV therapy may be indicated. Topical antibiotics may be given for infected ulcers. Antibiotics are not required once healthy granulation tissues are formed. Once granulates, defect is closed with Secondary suturing, skin graft, flaps. Pressure ulcers Prevention

Skin care: skin should be kept well moisturized, but protected from excessive contact with extraneous fluids. Take care during transfers to avoid friction & shear stress. Frequent repositioning at a minimum of every 2 hours.Bowel & bladder care. Appropriate support surfaces: air/ water mattresses Treatment Debridement, wound cleansing, dressings(e.g.sofra tulle) ensuring wound base remains moist, systemic antibiotic therapy, nutrition(high protein diet, vitamins especially vit C). Note: Phenytoin powder/ointment is also effective in treating pressure ulcers.

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Deworming/Drenching Symptoms of worm infestation: abdominal pain/ itching, blood in stools, wt loss, gagging, rashes, anal itching, etc  In a normal child deworming usually done > 1yr.In a child with pica, 9 month.  Repeat every 6 months upto 6 yrs, every 1yr up to 12yr.  May be in every 2 yrs in adults, every 3 months in case of pica. After deworming, give vitamins/Iron/Appetizer.In pica, give Fe  2nd dose on 15th day for extra intestinal coverage  Not given in case of Fever  Ideally do stool RE for ova/parasites, then decide the best deworming therapy.  Advise to cut nails regularly. Pyrantel pamoate [<2yrs: safety & efficacy not established] (11mg/kg/day single dose) Syp 250mg/5ml; Rpt after 15 days.  Upto 3yrs half bottle HS  >3yrs, one bottle HS TN: Expent/Nemocid/Shalminth Piperazine citrate [DoC in worm vomiting] (safe in pregnancy)  75-100 mg/kg OD x 2 days; adult 4 g OD x 2 days  1-2 yrs:5ml, 2-5 yrs:10 ml, >5 yrs: 15 ml  Worm allergy , Rx-> Nil orally, IVF, Piperazine Citrate [Antepar]120mg/kg HS x 2dys, (750mg/5ml) Repeat on 15th day adult : 4mg [30ml] one bottle. Up to 12 yrs, 2gm, give in small doses over few hours. Albendazole [ Zentel, Bendex 400, Albend]  400mg HS, Rpt on 15th day  Syp 200mg/5ml available;Below 2 yrs - 200mg HS, ≥2 yrs- 400 mg HS Mebendazole [hook worm infestation]  T Mebex 100mg bd X 3 dys  Syp Mebex 100mg/5ml Calculation of rate of fluid infusion Routine IV set, 1ml=15 drops Drop rate per minute from fluid volume to be infused in one hour: Volume in ml/hour ÷ 4 = Drop rate/minute For more than one hour: Volume to be infused ( in ml) = Drop rate / minute Duration of infusion in hours x 4 Drop rate per minute from fluid volume to be infused in 24 hours: Fluid in litre/24 hours x 10 = Drop rate/minute Perfect method to calculate fluid volume from drop rate in 24 hrs: Drop rate x 96 = volume in ml per 24 hr Microdrip set, 1ml = 60 drops Number of microdrops per minute = volume in ml/hour Site where lignocaine with adrenaline should not be used Digits, tip of nose, pinna of ear, shaft of penis Because it causes local vasoconstriction, if it is used around end arteries, it may cause gangrene.

61 Dermatology In dermatology nature of treatment depends on the stage of disease. More acute the condition, less strong the local applications, e.g. Lotions for a/c conditions, creams for sub a/c conditions, creams/ointments for c/c conditions. Areas near the eyes & genitals should be treated with mild strength preparations. Hydration of the skin before topical application enhances absorption Calamine Lotion can cause dryness of skin & thereby may lead to itching. So it’s use is now limited to urticaria. Antifungals: 1.Sebifin cream [terbinafine, benzy alcohol] 2.Candid, Surfaz, Canesten, Canazole [Clotrimazole] 3.Candid B, Clocip-B [Clotrimazole + Beclomethasone] 4.Ketovate cream, nizral cream [Ketoconazole] 5.Nizral shampoo, Phytoral shampoo, Dandoff solution[Ketoconazole] 6.Fungitop gel, Candistat Cream [Miconazole] 7.Olamin, Batrafan,onylac[ Cyclopirox olamine] Antifungals + Antibacterials + Steroid: 1.Clobenate GM cream[clobetasol, gentamicin, miconazole] 2.Clocip NB cream[beclomethasone, clotrimazole, neomycin, chlorocresol] 3.Sigmaderm, candiderma[beclometasone, clotrimazole, gentamycin] 4.Betnovate GM [betamethasone, gentamycin, miconazole] 5. Surfaz-SN(clotrimazole+ betamethasone+neomycin) 6.Totalderm +(oflox, ornidazole, terbinafine, clobetasol) Steroid + antibacterial/antifungal 1. Dipgenta, Gentopic [ betamethasone, gentamycin] 2. Eumosone G [clobetasone + gentamycin] 3. Tenovate G [clobetasol + gentamycin] 4. Eumosone M [clobetasone + miconazole] Antibacterials: 1. T-bact/ Bactroban( mupirocin 2%) 2. Futop/fucidin(fusidic acid) 3. Sisomicin cream 4. Neosporin oint Paronychia Most common hand infection. Another infection is felon(commonly bacterial,viral also) A/C paronychia is commonly bacterial(Staph). If soft tissue swelling is present without fluctuance, the infection may resolve with warm soaks 3-4 times daily.If abscess, do I & D. Drain the pus by making an incision over the eponychium. If there is a floating nail, removal of nail is required. 1.C.Ampiclox 1-1-1-1 x 5 days or amoxiclav or cephalexin or doxycycline. 2.T.Lyser D 1-0-1 X 5 days 3.Fucidin or T-bact oint for LA C/c paronychia is commonly due to fungal infection 1.T. Flucos 150mg once weekly X 6 months[fluconazole] for c/c paronychia. 2.Topical antifungals like Daktarin(miconazole) or Onylac nail lacqer(ciclopirox) to be applied over the affected nails at bed time. Should be applied starting from the skin adjacent to the nail bed.Use the brush provided to apply into crevasses & ridges.Cut nails weekly & rub over the nails using accessory provided once every week.

62 Intertrigo Inflammation of the body folds. Bacterial/fungal/viral Commonly Candidial infection, usually involves the lateral two interdigital spaces, inner thighs,genitalia, under the breasts, underside of the belly, behind the ears. Sometimes there may be superimposed bacterial infection 1.T. Flucos 150mg once weekly x 1 month 2.Aciderm G for L/A x 10 days[betamethasone, gentamycin, clotrimazole] 3.C Carofit 1-0-0 x 1 month[vit C, vit E, zinc sulphate, beta carotene, carrot] Pyodema (impetigo, folliculitis,furuncle, carbuncle,tropical ulcer etc) 1.Antibiotics ->Ampiclox/ciplox/amoxclav/doxycycline/ cephalosporins 2.Analgesics, antihistamines 3.T-bact /Futop/Neosporin Oint for LA bd 4.Saline washing – One tsp salt in 2 glasses of water 5.Good hygiene. Impetigo:Highly contagious bacterial skin infection,primarily caused by Staphylococcus Dandruff 1.Warm oil Massage; after 10 min, apply Nizral 2 % shampoo on to scalp for a period of ten minutes; then wash away all the oil. Rpt twice or thrice weekly x 2 months Other options include Danclear shampoo, KTC medicated shampoo,Scalpe/Dandrop shampoo [Ketoconazole + Zn pyrithione] 2.Ionax-T[Coal tar + Salicylic acid] :-> relieves itching & flaking in dandruff, seborrheic dermatitis & psoriasis of the scalp. Acne Vulgaris  Wash the face with soap & hot water 2-3 times a day.  Avoid excessive exposure to sun.  Persol-AC Gel or Benzac - AC 2.5% - 5%, apply; wait for 2 min & then wash off [benzoyl peroxide](start as once daily, during day time) (for black heads) or  Clindac A gel [clindamycin] for inflammatory & pustular lesion Clinmiskin cream -> Clindamycin, Niacinamide. or  Retino-A/eudyna cream, to be applied 2-3 times a week HS(for black heads)  C Doxycycline 100 1-0-1 x 10 days or T Azithromycin 500 mg od x 5 days  Other drugs used: Azelaic acid 2% or Adapelene 0.1 % gel(adaferin, deriva) Deriva-CMS gel(adapelene + clindamycin) T isotretinoin 10 or 20 mg(isotret)(0.5mg/kg/day) at night (teratogenic)  With all anti-acne creams look for irritation, dryness, redness, itching, burning every 10-15 days.

Alopecia Aetiology: Poor nutrition,tinea capitis, hyper/hypothyroidism,prregnancy, SLE,Diabetes, Drugs(eg. Steroids), excessive dandruff Check for iron deficiency. Do FBC, LFT, RFT,TFT, S.Fe, Ferritin 1.Multivitamins (with biotin)e.g.T Xtraglo OD x 1 month(biotin,L-methionine, L-cysteine) or Keraglo-Men or Keraglo eva(gamma lenolenic acid, multivitamin, natural extracts). 2.ProAnagen Shampoo For Alopecia areata: Diprovate scalp lotion(betamethasone) or Flucort lotion (fluocinolone). Apply OD For androgenetic alopecia: Minoxidil topical solution BD. 2% for women, 5 % for men (T N: hair 4 U, morr, morr-F)

63 Corns & callosities Usually they go by themselves, once the irritating factor is avoided. Use proper fitting footwear or MCR footwears. 1.Keratolytic agents like Salicylic acid 40% pads and plaster or solution. Apply & leave for 4-5 days. Also used- 40% urea cream, and 12% lactic acid cream. Note:patients with peripheral neuropathies should avoid or use topical salicylic acid with caution. TN:- cleanoderm/duofilm(salicylic acid+ lactic acid) lotion/solution daily x 3 weeks 2.Carnation Decorn corn caps(salicylic acid), To be kept in position with the corn for few days. To be reapplied again till the corn drops out. Contact Dermatitis Definitive treatment of allergic contact dermatitis is the identification and removal of any potential causal agents; otherwise, the patient is at increased risk for chronic or recurrent dermatitis 1.Wet compresses/ saline soaks 2.Emollients Emoderm/novasoft or calamine may be beneficial in chronic cases. 3.Oral antihistamines like T CPM 4mg 1-0-1 4.Topical corticosteroids like clobetasol are the mainstay of treatment. Note:When choosing a topical glucocorticosteroid, match the potency to the location of the dermatitis and the vehicle to the morphology (ointment for dry scaling lesions; lotion or cream for weeping areas of dermatitis). 5.For severe acute allergic contact dermatitis or widespread and severe chronic dermatitis, systemic glucocorticosteroids may be required( administered for 2 weeks). Excessive Sweating/hyperhydrosis Seen in Hypoglycemia, MI, Defervescence in fevers, Hyperthyroidism, Vasovagal attacks, Rheumatic fever, gout, nervous excitement,alcohol/drug withdrawal, anxiety etc. 1.Palmoplantar/ axillary sweating: Aldry lotion for LA HS(aluminium chlorohydrate) or 2.Losweat powder for LA(miconazole, chlorhexidine ) Stasis Dermatitis Due to venous stasis on the lower portions of legs. 1.Wet compresses/saline soaks for 5 minutes(10 teaspoon salt in 20 glass of water) 2.Emollients like Emoderm/Novasoft(white soft paraffin, liquid paraffin) 3.T Caldob 500 mg OD (ca2+ Dobesilate) 4.Topical corticosteroids like triamcinolone 0.1 %(T.N: Ledercort oint) 5.Daily use of elastic stockings.Raise leg end of bed at night by 15 cm( 2 brick). Pediculosis C/f: LNE-> Sub occipital & post auricular C/o may be itching & constant ulceration. 1. Antibiotics like Ampiclox 2. Medicare, Zeromite[Permethrin 1%] Massage into scalp, Bath after 10 min & then comb. Rpt after 7-10 days to kill nits 3. T ivermectin 12 mg single dose to be taken on empty stomach(0.2 mg/kg) 4. Anti inflamatory-> brufen 5. Rantac / Omeprazole 6. T.Celin 500mg OD / BD In case of lice ulcer in Axilla, Permethrin Cream for L/A. Petrolatum ointment, is the preferred treatment for infestations of the eyelashes and eyebrows.

64 Ringworm infection of skin(Tinea/Dermatophytosis) Most of the cases are managed with topical preparations. Topical therapy is indicated for limited infection of the body, groin, superficial involvement of the beard region, palms, & soles Nizral(ketoconazole 2%) or exifine(terbinafine 1%) or fungitop(miconazole 2%) or candid(clotrimazole 1%) or whitfield ointment(benzoic acid 6%, salicylic acid 3%). Duration of the therapy is 4 to 6 weeks or 2 weeks more after clearance of lesions. Tinea Versicolor(Pityriasis versicolor)  Azoles,Terbinafine ,Ciclopirox olamine,selenium sulfide are used.  Each application is allowed to remain on the skin for at least 10 minutes prior to being washed off. In resistant cases, overnight application can be helpful.  Ketoconazole crm/soln/Miconazole/Clotrimazole every night for 2 weeks.  In cases of extensive Tinea versicolor, Ketoconazole solution[ Nizral ] to be applied 15 min before taking bath, twice weekly. After bath any of the above preparations may be applied locally.  Another option is preparation containing Selenium sulphide 2.5% [Selsun shampoo] for 5 to 10 minutes application daily for 3-4 weeks. But take care to avoid contact with gold as it is corrosive.  Systemic therapy: T Fluconazole 400 mg st. Rpt after 2 weeks if required. Seborrhoeic dermatitis 1.Nizral shampoo for scalp & body wash twice weekly. 2.Keto-B cream for LA (ketoconazole+ betamethasone) x 5 days After 5 days Ketoconazole oint 2%(nizral) for LA BD x 2 weeks Scabies  Permethrin 5% lotion is the DOC.It is applied from the neck down, usually before bedtime, and left on for about 8 to 14 hours, then washed off in the morning. One application is normally sufficient for mild infections. For moderate to severe cases, another dose is typically applied 7 to 14 days later Or  Initially scrub bath is advised to open up the burrows. Then apply Gamma Benzene Hexachloride(lindane) 1% Lotion [Scaboma] for a period of atleast 10-12 hours and Rpt scrub bath.All clothes,towels & bed sheets etc should be washed well(ideally in hot water) & dried in sun or if possible ironed well.It may be repeated after 1 week  Ideally, treat all family members at a time  Apply over entire body, below the neck to toes  Scabies may also get infected, so in such cases, give antibiotics eg. Ampiclox  Antihistamines  Another option is T.Ivermectin. If > 50kg give two 6mg tabs at early morning on empty stomach. If <50 kg give 3mg tabs. Rpt after 2 weeks  Crotorax/Eurax(crotamiton) 2-3 times a day , can also be given Itching due to prickly heat in summer(miliaria rubra) 1.Bath 2 times per day, avoid tight clothing 2.Sprinkle Nycil powder or Candid dusting powder bd 3.T Cetrizine 10mg HS x 5 days 4.T vit C 500 mg BD 5.Emoderm/Calamine lotion/oint

65 Eczema The term eczema is almost synonymous with dermatitis. They refer to distinctive reaction patterns of the skin, which may be due to a variety of a/c or c/c causes.The basic pathological features are Spongiosis(edema of epidermis with the formation of intraepidermal vesicles) & Acanthosis(thickening of epidermis in the c/c stage) May be of two types: 1.Dry Eczema-> without oozing 2.Wet Eczema-> with oozing,it may be infected, in such cases R/o DM. Several types ->Atopic, Seborrhoeic, Irritant, Allergic etc. The aim of treatment is to control the inflammatory process & also to control the infection, if present. 1. Antithistamines 2. Saline soaks/ wet compresses 3. Steroids, Topical applications of Betamethasone or Beclomethasone 4. Antibiotics like Ampiclox if needed. 5. In cases of fungal infections, as evidenced by severe pruritus, give antifungals. 6. T. Calcium Dobesilate 500 mg BD as adjuvant therapy in pt’s with venous ulcers & stasis dermatitis; C Nutrolin B Psoriasis Scaly lesions over extensor aspect[mainly] 1. Dipsalic/betnovate-S/betasalic/Saltopic lotion/ointment [betamethasone, salicylic acid] or Diprovate MF cream [betamethasone, lactic acid, salicyclic acid, urea, sodium lactate] bd for L/A . 2. Antihistamines to prevent scratching. 3. T Calcium OD/BD, liquid paraffin for LA; 4. Oral antibiotics like Doxycycline bd for a/c psoriasis 5. Cetrilak mild shampoo for scalp (cetrimide) Note: Dry scaly conditions like Psoriasis, Atopic dermatitis, Ichthyosis requires moisturizing cream e.g Elovera cream to be applied after bathing [vit E, aloe vera] Strecth marks, striae, cracked nipples, dark circles : 1.Alovit-AF cream for L/A. [lactic acid, vitamin E, sunflower oil, aloe] Antioxidants: It is a usual practice to give antioxidants- C Evion 400mg /T Carofit / T antoxid OD x 1month Fissuring of soles(athlet’s foot/tenia Pedis) Keep the foot dry. Foment in hot water for 10 mins, 2 times daily, followed by drying and application of antibiotic & keratolytic ointments. 1.Moisturex cream (urea, lactic acid,propylene glycol, liquid paraffin) for LA Or Salytar-ws/Salicylix-SF(salicylic acid) to be applied on the hard skin only or vaseline. 2.If secondary infection : Surfaz –SN or candid-B for LA Note: if inflamed or swollen, give antibiotics, anti inflammatory drugs, steroids Premature Graying of Hair Aetiology: vit B12 deficiency, thyroid d/s, FA deficiency, chemotherapy,using electric dryers/ concentrated hair dyes, etc 1.T Curlzvit 1-0-0(contains PABA) 2.Altris Gel for LA(Melitane)

66 Herpes zoster 1.T Acyclovir 800 1-1-1-1-1 x 7-10 days( efffective only if started within 48 hours) Other antivirals used are Famciclovir 500 mg tds or Valacyclovir 1gm tds 2.Analgesics like Ibuprofen or P’mol 3.For sever cases: Oral steroids like prednisolone 40-60 mg/day x 1 week tapered over 1-2 weeks. 4.Calamine for LA;T-bact for LA;Acyclovir cream for LA 5.Oral Antibiotics if secondary infection. 6.Rest 7.For postherpetic neuralgia: T gabapentin 300 mg OD x 3 weeks Icthyosis Avoid using strong soaps/excess sun exposure After a bath , apply emollients or moisturizers to prevent scaling & dryness. Moisturex cream for LA Other topical preparations: Retino-A cream(tretinoin) for LA OD or Daivonex oint for LA(calcipotriol) or Keralin oint for LA(salicylic acid, benzoic acid,hydrocortisone) or Copriderm(Betamethasone, urea, lactic acid, propylene glycol, salicylic acid) for LA Hyper pigmentation of skin Also blemishes, dry scaly surface, mottling, wrinkles, rough & leathery texture, sagging of loose skin, melasma Avoid perfumes, hair dyes etc. Treat anemia if present. 1. Reduce sun exposure;Apply Sun screen agents eg: sper lotion for LA 30 min before going outside(octinoxate , avobenzone , oxybenzone , zinc oxide). 2. Skinlite cream(Hydroquinone, Tretinoin, Mometasone Furoate) HS Note: Apply at night only. Should be applied in limited quantity only Or Retino-A, Eudyna(tretinoin) Or Brite-Lite cream for LA at night(glycolic acid, kojic dipalmitate) For lips: also give a moisturizer, emoderm Oint for LA( white soft paraffin);quit smoking. For Keloids & hypertrophic Scars: opexa Gel (Dimethicone, ascorbyl tetraisopalmitate) or contractubex gel(heparin,allantoin) or Retino-A(Tretinoin) LA OD at night. Warts Caused by HPV 1.Salicylix-SF 12% cream(salicylic acid) for LA or 2.Imiquad/Nilwart cream(imiquimod) for LA on alternate days ; wash after 8 hours. Dry skin/Xeroderma Etiology:Zn & essential fatty acid deficiency,end-stage renal disease, hypothyroidism, HIV, malignancies,sjogren’s syndrome, neurologic disorders, drugs, topical preparations containing alcohol, detergents, harsh bathing soaps, vitamin A/D deficiency, winter etc 1.Emolients/moisturizers e.g Emoderm/Elovera/Novasoft for LA 2.Adequate hydration Herpes simplex 1.For initial infection:Acyclovir cream(Zovirax) for LA 2.T Acyclovir 200 mg 1-1-1-1-1 or 400 1-1-1 x 7- 10 days (5-20 mg/kg Q8H) Dermatology consultation.

67 Hand-Foot-mouth Disease C/f:fever, feeling tired, generalized discomfort, loss of appetite, and irritability.Skin lesions/rash followed by vesicular sores with blisters on palms of the hands, soles of the feet, buttocks, around the nose,mouth and lips.HFMD usually resolves on its own after 7–10 days. 1.Antihistamines 2.Antipyretics 3.Adequate fluid intake, preferably Cold fluids. Avoid spicy foods. 4.Soothing lotions like calamine lotion for rashes. Dyschromias in children Most commonly hypopigmentation of face Aetiology:Pityriasis alba, tinea versicolor, etc 1.Deworm 2.Multivitamins,Calcium supplements,Leafy vegetables & milk in diet, 3.Advise to use Dermadew baby soap(glycerin,aloe vera, coconut oil etc) or Dove/Pears soap for bathing. 4.Moisturizers like elovera/cetaphil lotion for LA to be applied just after bathing. 5.If no improvement, Eumosone cream (clobetasone) for LA x 1 week.

Chickenpox/varicella Infection is by exposure to respiratory droplets, or direct contact with lesions, within a period lasting from three days prior to the onset of the rash, to four days after the onset of the rash. Centripetally distributed vesicles. Keep the skin clean by frequent showers. Avoid vigorous rubbing. 1.T Acyclovir 800 mg(Zovirax 200,400,800 mg available) (1-1-1-1-1) x 7 days 2.T CPM; T Rantac 3.Calamine Lotion for LA after bath; or Mupirocin Oint for LA onto the vesicles. If 20 infection: Amoxiclav / azithromycin Note: Acyclovir for Paed 20 mg/kg QID or 80 mg/kg/day div into 5 doses,Zovirax(400/5) Balanitis(balanoposthitis) C/f: Pain, discharge, redness 1.Gentle retraction of the foreskin daily and soak in lukewarm water to clean penis and foreskin. Avoid soaps when inflammation is present. Use a moisturising cream/ointment (emollient) to clean, instead of soap. 2. Clotrimazole LA for candidial balanitis. 3.Mild Steroids like Betamethasone 0.05% for inflammation in addition to antibiotic creams Note: steroid creams shouldn’t be used alone, as it may worsen the infection 4.Antibiotic ointments like neosporin, if bacterial infection suspected. Non-specific urethritis in Men 1.T Azithromycin, 1gm, single oral dose or 2.T Doxycycline 100 mg bd x 7-14 days or 3.T Levoflox 500 mg Od x 7 days or 4.T Oflox 300 mg PO bd x 7 days Note: Tinidazole may be combined with azithro/doxy. Photodermatitis 1. Avoid Sun exposure 2. Apply sunban lotion 20 minutes before going out. 3. Betamethasone for LA at night for 1-2 weeks. 4. T Cetrizine 10 mg HS

68 Common Psychiatric Disorders Note: Ideally Always Refer the pt to a Psychiatrist. Bipolar Disorder Manic episode In aggressive pt’s: Inj haloperidol 5mg IM, or Inj Lora 2 mg IM or Inj Olan 10 mg im st. 1.T Valproate 500 1-0-1 [Lithium is the DOC] 2.T Olanzapine 5 mg 0-0-1 or Risperidone 1 or 2 mg 1-0-1 or T Haloperidol 5mg 1-0-1 or T Quetiapine 100 mg 0-0-1(Antipsychotics) 3.T Lora 1mg 0-0-1 Depression episode 1.T Escitalopram 5 mg 0-0-1 x 2 weeks; after 2 weeks 10 mg HS x 2 weeks(T.N-Nexito, stalopam, szetalo, cilentra, citel, citofast) 2.T Clonazepam 0.5 mg 0-0-1 x 2 weeks; after 2 weeks 0.25 mg HS x 2 weeks(T.Nclonotril, clonafit, epizam, lonazep,rivotril) Obsessive Compulsive Disorder 1.T Fluoxetine 20 0-0-1 or sertraline 50 mg 0-0-1 or escitalopram (SSRIs) 2.T Quetiapine 100 mg 0-0-1 or risperidone or olanzapine (for augmenting SSRIs) 3.Antianxiety agents like nitrazepam 10 0-0-1 (for augmentation) Panic attack Intense fear with s/s related to various systems like sweating, palpitation, feeling of choking, trembling,sweating, chest discomfort,dizziness, For aggressive pt’s ,Inj Lora 2mg IM or slow iv st or Inj Diazepam 10 mg slow iv or IM or Inj Serenace 5mg IM St. 1.Antidepressants like SSRI eg Escitalopram or 2.BZD eg T clonazepam 0.5 mg 1-0-1 x 4 weeks, then tapered off. Generalized anxiety disorders(GAD) Characterized by excessive, uncontrollable and often irrational worry, that is, apprehensive expectation about events or activities  Cognitive behavior therapy  Pharmacotherapy 1.SSRIs: E.g. escitalopram 10 mg 1-0-0 or sertraline 50 mg 1-0-0; SNRIs:T duloxetine 20 1-0-0 or T desvenlafaxine 50 1-0-0 ; Tricyclic antidepressants like T amitriptyline 10 1-0-1 x 2 weeks 2.Benzodiazepines. They should n’t be used for long time because they are associated with the development of tolerance, psychomotor impairment, cognitive and memory impairments, physical dependence and a withdrawal syndrome 3.T Pregabalin or Gabapentin OD Schizophrenia If pt is aggressive: Inj lora 2mg IM or slow iv, or inj haloperidol 5 mg IM + phenergan 25mg IM st or Inj olan 10 mg IM. 1.Anttipsychotics E.g: T risperidone 1mg 1-0-1 or T olan 15 mg 0-0-1 or T clozapine 25 0-0-1(for refractory pt’s) or T ziprasidone 20 1-0-1 or T quetiapine 25 1-0-1 or T aripiprazole 15 1-0-0 2.Depot injections eg fluanxol(flupentixol) given for c/c schizophrenics every 2-4 weeks. 3.T Parkin 2mg bd(trihexyphenidyl) to prevent dystonic movements/extrapyramidal symptoms/akathisia associated with antipsychotics; BZD or β-blockers are also used.

69 Obs & Gyn

Menorrhagia (hyper discharge of menses) In 20-40 age group, give Tranexa MF[tranexamic acid + mefenamic acid] 1-1-1 X 5 days If > 40yrs, it is better to refer to gynaecologist, as D&C is a must. In younger girls always R/O haematological causes. 1.T Regestrone or T Primolut-N 5mg bd(Non ethisterone acetate) or T Tranexa-MF(1-1-1) 2.T Sylate 500mg (1-1-1-1) till bleeding stops(Ethamsylate) 3. Iron tablets (T autrin, C conviron, C dexorange, C fesovit spansule, C fefol spansule) 1-2 daily.

Amenorrhea(absence /abnormal stoppage of menses)  R/o Pregnancy(Do Urine Pregnancy Test), lactation, menopause  R/o hypothyroidism, hypoprolactinemia If hypothyroid, start thyroxine Estimate serum Prolactin & if low, give Bromocriptine 2.5mg HS Also do CT scan for microadenoma  If thyroid & pituitary status normal, induce withdrawal bleeding with T Meprate or Provera or Modus 10mg OD/BD X 5-10dys [Medroxyprogesterone Acetate]. Usually periods may occur in 1wk. However, if it fails, do FSH level estimation, which if low indicates a pituitary lesion & if high indicates an ovarian lesion  It is obvious that Pt should be referred after R/o pregnancy, in a GP setup.

Discharge PV  Cases with whitish discharge may be due to Vulvovaginal Candidiasis – give candid V6 cream or Cansoft CL vaginal tab(clindamycin+clotrimazole) 1 pv HS x 1 week or T Fluconazole 150 mg single dose or AF kit(fluconazole x1 morning+azithromycin x1 afternoon+ ornidazole x2 night) single day dose for both partners. All 4 tablets can be taken at night also.  Greenish yellow Purulent discharge may be due to Trichomonas infection.Treat both partners.Give metronidazole 500mg TDS x 7dys/Tinidazole 2g single dose For bacterial vaginosis, give T Metronidazole 500 mg bd orally x 7 days or clindamycin 300 mg bd x 7 days

Pelvic Inflammatory Disease Risk factors include multiple sexual factors, IUD insertion, young age, bacterial vaginosis, cervicitis etc C/f: May present with bilateral lower abdominal pain, abnormal vaginal discharge, menometrorrhagia,postcoital bleeding, fever, nausea Inv: BRE, ESR, CRP, USS 1. Inj Ceftriaxone 250 mg IM single dose + 2. T Oflox 400 1-01 + T.Metrogyl 500mg 1-0-1 x 14 days or T Doxy 100 1-0-1 + T.Metrogyl 500mg 1-0-1 x 14 days

Early Pregnancy  Pt may present with pain, which may be due to Abortion, Ectopic gestation, Vesicular mole, pregnancy with torsion of ovarian cyst.  Other 1st trimester complications-UTI,a/c urinary retention, hyperemesis gravidarum  Always confirm live Intra Uterine Gestation with USS  GCT ideally at 20-24 wks  GTT with 100g glucose over 3 hrs in abnormal GCT cases  Do ICT in Rh negative cases

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Postponement of Periods  T. Primolut-N 5mg 1-0-1[Norethisterone] ;start 3-5 days before expected date of periods, up to needed. Another brand is Regestron

Post-coital contraception  Within 72hrs , I -PILL 1 tab st & 1 tab 12 hr later [levonorgestrel] Or single 1.5 mg dose or  IUCD insertion within 5 days or  Mifepristone 600mg [200mg x 3] as a single dose (with in 72 hrs) followed 2 days later by 4mg of misoprostol [T.Misoprost] as single dose.  Mifepristone, T N: T. Mtpill,T.unwanted, T.Mifegest Cost~1000rs.

Injectable Contraceptives  Inj Depot Provera (Medroxyprogesterone Acetate)150mg deep IM (or 104 mg sc) every 90 days during first 5 days of menstrual cycle  Inj Noristerat (norethisterone enanthate) 200 mg deep IM during first 5 days of menstrual cycle at 2 months interval

Dysmenorrhea(painful menstruation) 0

1 Dysmenorrhea: Pain in lower abdomen & may radiate to the back & legs; may be accompanied by nausea, vomiting, diarrhoea, headache, malaise. 20 Dysmenorrhea: dull pain , deep seated in pelvis with no radiation. 1. Inj cyclopam/ voveran 1 amp IM st ATD 2.T cyclopam or Baralgan tds x 3 days or T Meftal-Spas(Mefenamic acid+ dicyclomine) or T Drotin-M(drotaverine + mefenamic acid). Note:If pt doesn’t respond to the treatment, suspect endometriosis Enhancement of Lactation 1.C.Lactare 2-2-2 x 5 days(asparagus racemosus 200 mg,withania somnifera100mg etc) 2.T perinorm 10 mg(1-1-1) x 5 days

Suppression of lactation T. B-long (pyridoxine) 100 mg 2-2-2

Menopause  Nutritious diet with proteins, wt bearing exercises  Calcium + Vitamin D  Pap smear / Breast examination Bleeding pv in pregnancy During first trimester,Mnemonic :AGE IS Low Abortion,Gestational trophoblastic disease( e.g vesicular mole), ectopic pregnancy, implantation bleeding,spotting, lower GU tract causes like cervical or vaginal bleed. During second or third trimester :Pacenta praevia , placental abruption,preterm labour Inv: CBC,coagulation profile, β-hCG,URE, USS Refer to O & G.

71 Drugs C/I in lactation Ciplofloxacin,fluconazole,iodine,iodides,ketoconazole,metformin,tetracycline,amiloride, amphetamine, ethosuccimide,indomethacin,anti cancer drugs, chloramphenicol, ergotamine, amiodarone, etc Drugs to be used with special precaution in lactation: ACEI, acyclovir,aminoglycosides,amlodipine, ampicillin, amoxicillin, anticonvulsants, antihistamines, azithromycin, beta blockers, atorvastatin, corticosteroids,cotrimoxazole, ephedrine, furosemide, losartan, metoclopramide, metronidazole, montelukast, morphine, naldixic acid,nifedipine, norfloxacin, omeprazole, pencillins, ranitidine, theophylline, Carbamazepine, isoniazid etc. Avoid tramadol, diazepam, ketorolac etc Hyperemesis gravidarum C/f: nausea followed by excessive vomiting, severe dehydration, confusion, low BP, DD:vesicular mole, multiple pregnancy, hepatitis, Appendicitis,Biliary Disease,DKA,Esophagitis,Fatty Liver, Gastroenteritis, GERD, Hyperparathyroidism, Hyperthyroidism, Irritable Bowel Syndrome, Nephrolithiasis, Pancreatitis, Acute Intermittent Preeclampsia, peptic ulcer disease, Acute Paralytic Ileus/Bowel Obstruction Inv: PCV,S.electrolytes, β-hCG, TFT, LFT, URE,urine acetone, USS to r/o multiple pregnancy, vesicular mole Look for dehydration Rx 1.Inj phenergan or emeset or perinorm 2.IV fluids 3.Vit B1(thiamine) / B6 4.T Doxinate (doxylamine + pyridoxine) Fibroadenosis, Cyclic Mastalgia Rx: 1. Vit E 200-600mg OD( Evion) 2. NSAIDs(oral & topical) 3. Alprax 4. Proper Breast Support 5. Refer to Surgeon Eclampsia C/f: seizures, high BP, proteinuria, associated with pregnancy. Inv: Hb, Plt ct, S.electrolytes, urea, creatinine, LFT, coagulation profile. 1. Left lateral position, protect airway, administer Oxygen. 2. Ensure wide bore iv access 3. Administer loading dose of Inj Magnesium sulphate 20 % solution, 4 g slow iv over 5 10 minutes. Follow promptly with inj MgSO4 50 %, 2-5 g in each buttock as deep IM. Maintenance therapy is given as inj MgSO4 1g/hr infusion for 24 hrs. After each 4 hr, Check urine output, RR & examine Knee jerk & monitor for adverse effects of MgSO4 like urinary retention, muscle weakness, respiratory distress. Note: In eclampsic pt’s with low BP or decreased urine output, MgSO4 should be withheld, iv fluids administered & seizures controlled with Diazepam or lorazepam. Warn the pt of the warm feeling that will be felt when MgSO4 is administered. Pregnant mother with sudden onset of LOC or severe headache should be suspected as eclampsia. Postpartum eclampsia should be suspected in pt’s with worsening oedema & BP within 2 weeks of delivery.

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Basic ABG analysis 1.Look at the pH. pH <7.35 is an acidosis; pH >7.45 is an alkalosis 2.CO2 concentration (normal conc: 4.7-6.0 kPa, PaCO2: 35-45 mm Hg). CO2 is an acidic gas. It is raised in acidosis & lowered in alkalosis. Look whether the change (in CO2 conc )is in keeping with the pH, i.e whether the change in pH & change in CO2 conc are in the same direction: increase/decrease or not. If it is in keeping with the change in pH, or both pH & CO2 either simultaneously increase or decrease, then it is due to a respiratory problem. If there is no change in CO2 conc , or an opposite one to that of pH, then the change is compensatory. 3.HCO3 concentration (normal conc:22-28 mmol/L). Look whether the change (in HCO3 conc )is in keeping with the pH. HCO3 is alkaline; it is raised in alkalosis & lowered with an acidosis. If it is in keeping with the change in pH, it is due to a metabolic problem. Note: Arterial PaO2: 80-100 mm Hg, Venous: 28-48 mm Hg Eg: A patient’s ABG shows pH 7.04, CO2 2.0 kPa, HCO3 8.0 mmol/L. So here there is an acidosis as the pH is <7.35. The CO2 is low, and thus it is a compensatory change. The HCO3 is low & is thus the primary change ie a metabolic acidosis.

Poly Trauma Patient Rigorous evaluation is important for pts with multiple injuries.Begin the initial assessment using the mnemonic ABCD A Upper Airway is established & maintained with cervical spine control. B Breathing (or the adequacy of air exchange) is evaluated & established. C Circulation- blood pressure is evaluated & corrected, & bleeding is arrested. D Deficits of neurologic function are identified & treatment is initiated. Airway All patients presenting with head, neck, or facial trauma, or neurologic symptoms such as weakness or abnormalities of mental status after trauma, however subtle, must be assumed to have injuries to the cervical spine, unless otherwise proved, and strict attention must be given to immobilization of the neck If the patient can speak normally, a reasonable airway probably exists. Patients without inspiratory effort & those with a GCS score of 8 or less require intubation to establish & secure a functional airway. Pharynx must be assessed to exclude local obstruction related to posterior movement of the tongue or the presence of swelling, bleeding, secretions, or gastric contents. Rigid suction & manual extraction should be used to clear the pharynx of any foreign body.Obstruction of airway caused by posterior movement of the tongue may be quickly corrected by the insertion of an oral airway & or the head-tilt chin-lift technique(if no neck injury) or jaw-thrust maneuver(if neck injury is suspected). Breathing After an airway is secured & ventilation with O2 initiated, the adequacy of air exchange must be assessed. Look for RR > 30/min, unequal chest movements, gross tracheal deviation , flapping chest wounds. Bilateral & symmetric breath

73 sounds (best heard in axilla) should be present immediately after intubation or other airway establishment. When problems associated with endotracheal intubation are excluded & ventilation /oxygenation remains inadequate, hemothorax, simple/tension pneumothorax, flail chest, aspiration etc must be considered & corrected if present. Circulation Blood pressure is evaluated & bleeding arrested. Evaluating the patient’s pulse, skin colour, & level of consciousness can be performed very quickly & it can provide a rapid bedside assessment of the adequacy of circulation. External bleeding should be controlled by direct pressure. IV access should be established using 16 G cannula. IV fluids & blood replacement should be done. Deficit of neurologic function are identified & treatment initiated. Initially the patient’s overall neurologic status may be simply classified as alert, responsive to verbal stimuli, responsive to painful stimuli, or unresponsive to all stimuli.Use GCS. Rapidly reversible causes of CNS depression, including hypoglycemia, wernicke encephalopathy, opiate overdose must be considered & prophylactically treated. Exposure Patients may be undressed(maintain privacy) for complete evaluation.

Secondary assessment The posterior neck, back, chest & abdomen are inspected & palpated for local skin disruption or tenderness. Injury to the larynx/trachea can occur from either blunt or penetrating trauma; subcutaneous emphysema, airway obstruction, dysphonia, lack of thyroid cartilage prominence are seen in such trauma.Tracheostomy is needed in the presence of unstable airway.Patient with intra-abdominal bleeding or injury require urgent laparotomy. Assessment of vision may be undertaken in conscious patients. Bilateral equal breath sounds & heart sounds should again be evaluated.The genitalia are examined. The extremities are examined for evidence of hematoma, crepitus, deformity, & peripheral pulses. Perform CCT (chest compression test), PCT(pelvic compression test), SLR(straight leg raise test). Look for tenderness /crepitations of rib. Look for spine tenderness/ long bone injuries, palpate for peripheral pulses. Look for intra-oral injuries. Look for Battle’s sign & Racoon eye. Catheterise if pt is intubated or GCS is deteriorating. Give Inj TT(if indicated), IV fluids(avoid dextrose, give NS/RL), Analgesics (avoid tramadol as it may cause drowsiness & thus may interfere with clinical assessment of pt). Fractures are aligned & splinted. Radiological studies are done after the patient is stabilised.  Chest x-ray PA view, X-ray C spine AP/lateral view, USS abdomen, CT Brain, X-ray pelvis with both hips  CT Brain with C-Spine screening may be done in patients with head injury & suspected cervical spine injury.

74 Other Medical Emergencies Hanging Inv: CXR, x-ray c-spine, ABG, electrolytes,creatinine, CT- brain with C-spine screening. Early aggressive oxygenation is life saving; majority of pt’s recover with ventilator management. 1.Oxygen by face mask at 8L/min. Intubate & ventilate if SpO2 <90 % or GCS <9 2.Protect C-spine with hard cervical collar until x-rays have ruled out fracture. 3.Inj Mannitol 20% 100 ml iv st over 20 minutes 4.Inj Dexona 8 mg iv st & tds or Inj Methyl pred 1g iv st (to prevent tracheal edema). 5.Inj eptoin 100 mg iv q8h for prevention & control of seizure. 6.Inj Rantac or Pantop Note: aggressive behaviour is due to hypoxia & should prompt ventilatory management. Associated methods of DSH such as poisoning or drug overdose should be kept in mind. ARDS or aspiration pneumonia is a frequent event. All DSH pt’s need psychological evaluation & support, prior to discharge. Drowning(Submersion injury) C/f: altered consciousness,cardiopulmonary arrest, tachypnoea, dyspnoea, hypoxia, metabolic acidosis, Inv: ECG, ABG, RBS, electrolytes, CXR,X-ray c-spine(to r/o neck involvement in diving accident), CT Head(in pt’s with altered mental status or unclear history), bronchoscopy may be necessary for removal of inhaled sediments. Examine oral cavity. 1.100% O2 by mask. Airway suction,OPA. If pt still dyspnoeic use CPAP or intubate. 2.Monitor blood sugar, BP (for hypotension),SpO2, ECG( for dysrhythmias) 3.Inj methyl pred 1g iv st or Dexona 8 mg iv st & tds 4.Immobilise the neck with hard cervical collar. 5.Aggressive warming is mandatory in the presence of hypothermia. Remove the wet clothing before the victim is wrapped in warming blankets. 6.Inj taxim 1g iv Q8H; Inj Metrogyl 500 mg iv bd. 7.Treat complications; cerebral edema: IV mannitol; Bronchospasm: bronchodilators (neb with salbutamol, inj deriphyllin); metabolic acidosis: sodium bicarbonate & mechanical ventilation; seizures: eptoin; pulmonary edema: lasix Electrical injuries C/f: Entry & exit burns may be present. Haemorrhage behind the intact tympanum is an occasional feature in lightning injury; perforation of the tympanic membrane is common. High energy electrical injury causes massive muscle damage with myoglobinuria. Ventricular fibrillation may occur. In males burns may occur on the undersurface of the scrotum. Inv: CBC, ECG,LFT,URE for myoglobin, RFT, CPK,ABG 1. Administer Oxygen 2. Monitor ECG for arrhythmia. 3. CBD, spine immobolization 4. Hydrate all pt’s with RL 10 ml/kg/hr during initial resuscitation. Hydration is the key to reduce the morbidity of electrical injury. 5. Provide pain relief. 6. Mannitol when there is elevated CPK level & or myoglobinuria. This provides diuresis for prevention of a/c tubular necrosis & renal failure, secondary to myoglobinuria. 7. Fasciotomy may be needed to improve circulation in circumferential burns or when compartment syndrome is suspected. 8. Look for acidosis, if present give bicarbonate

75 Snake bite Inv; CBC, electrolytes, RBS, creatinine, coagulation profile, URE, Monitor BT, CT, aPTT every 4 hours & WBC count every day. Monitor RFT every day (urine output, urea, S creatinine, S electrolytes). Observe for e/o envenomation : local bleeding, swelling, ptosis, respiratory depression, diplopia, dysphagia, severe pain. Examine extra ocular movement. Single breath count(>20 - normal) to be tested every 15 minutes in suspected cobra or krait bites. If an extremity is bitten, it should be kept slightly dependant. IV access should be established in an unbitten extremity.Observe for ascending cellulitis. Apply tourniquet proximal to site of bite(loose enough to allow a finger in between). Release tourniquet 1 hr after ASV or every 30 min advance proximally if swelling advances. Rx 1.Hourly pulse/BP chart; 4th hourly temp chart;I/O chart 2.Inj TT 0.5 ml IM st. 3.ASV is given if there is local reaction or signs of systemic envenomation. Inj ASV 5 vials (in case of local reaction only) or 10 vials (for moderate systemic envenomation) & 15 vials(for severe systemic envenomation) diluted in NS as iv infusion 16-20 drops per minute over 1-2 hrs. 4.Premedicate with Inj efcorlin or methyl pred, inj Avil 20 min prior to ASV 5.Inj Metrogyl 500 mg iv Q6H ATD 6.Inj Ampicillin 500 mg iv Q6H ATD 7.Inj Rantac 50 mg iv Q8H 8.Inj clox 500 mg iv Q6H or T Klox 500 1-1-1-1 9.Glyceryl Mag sulph for LA; surgical management of local reaction with excision of areas of necrosis. 10.In case of neurotoxic snake bite coming with ptosis, give all the above plus the following: Inj Neostigmine 0.5 mg q30 min, 1 hr, 2 hr & then 4 hr intervals + inj atropine 0.6 mg iv before every injection of neostigmine. 11.Nephrology consultation for appropriate renal failure management. 12.IV FFP or whole blood transfusion (if clotting abnormalities persisits). Note: Non-poisonous bites can be observed for 24 hrs, coagulation parameters repeated & discharged. Pulmonary embolism Aetiology:Thrombosis in peripheral veins, Major surgeries, major trauma, indwelling venous catheter, pregnancy, puerpeurium, woman on oral contraceptives or HRT. C/f: unexplained hypotension, haemoptysis,unexplained dyspnoea, chest pain, hiccoughs, pleuritic or chest pain aggravated by deep breaths, new adult onset asthma. Inv: ECG(tachycardia, S1 Q3 T3),D-dimer, ABG, WBC, Coagulation study, CXR, Ct angiography 1.Administer Oxygen 2.Propped-up position 3.Avoid fluid overload. 4.Inj Heparin 5000 IU as iv bolus. Note:Investigate aPTT,INR & repeat Heparin Q6H to maintain an INR of 3. Note:Suspect PE in unexplained dyspnoea;no baseline investigation is diagnostic. Start heparin on suspicion of diagnosis.

76 ACS-STEMI Give loading dose of aspirin 325mg , clopilet 300 mg, atorva 40mg,sorbitrate 10mg s/l st Admit in ICU 1.Absolute Bed rest 2.Hourly BP, PR; Q4H temp chart 3.If pt is in severe pain give Inj Morphine 2-4 mg iv st + Inj phenergan 25 mg iv st 4.Inj SK 1.5 MU in 100 ml NS over 1 hr with continous BP monitoring. In case of allergy to SK, administer efcorlin, avil. Note: thrombolysis is indicated if given within 12 hours of onset of symptoms & it is most effective when given in the first 3 hours of symptom onset. Thrombolysis is C/I in pt’s with ST depression(unless posterior MI suspected) 5.Inj NTG 50 mg in 1 pint NS starting at 2 drops/min(for relief of chest pain & or control of BP)(titrate upwards to a max of 12-14 drops). 6.T Ecospirin 150 0-1-0 7.T Clopidogrel 75 1-0-0 8.T Atorva 10 mg 0-0-1 9.T Metolar 25-100 1-0-1(β-blockers are not given if HR,60/1’ or systolic BP< 90 mm Hg) 10.T Envas 2.5-5 mg 1-0-1 11.T Sorbitrate 10 mg s/l tds(after checking BP) & 5mg s/l sos 12.T Rantac 150 1-0-1 13.Syp Lactulose 30 ml HS(as stool softner). Note: Bradycardia: if the pulse rate is low, it is a clue that the pt may be having a bradyarrhythmia like complete heart block.Mild degrees of bradycardia don’t require any intervention in the casualty. Severe Bradycardia may be treated with Inj Atropine 1.2 mg iv stat after definite ECG diagnosis. The vagolytic dose of atropine is 2 mg, so give 2-3 ampoules of atropine with a relatively fast push. T Alupent (orciprenaline)10 mg may be given for mild cases of bradycardia. A/c on CKD Inv: BRE, URE, RFT, LFT, ECG,RBS, Urine C & S, USG abdomen, CXR, S.Ca/P 1.Q4H temp chart 2.Daily I/O chart, weight chart,RFT, RBS, ABG,hemogram 3.Restrict Na+, K+ 4.Input= output + 500 ml 5.Inj lasix 40 mg iv Q8H(use diuretics if oedema, weight gain, hyponatremia, uncontrolled HTN) or T Lasix 40 1-1-0 6.Treat hyperkalemia 7.If acidosis : T sodabicarb 1-1-1 8.T shelcal 500 mg OD 9.Treat underlying factors like anaemia,infection, DM, HTN, hyperlipidemia, obstruction. 10.Dialysis if indicated. Hyperkalemia (S. K+ >5.0 mEq/L) C/f: muscle weakness/cramps, paraesthesia, hypotonia, focal deficits, ECG: tall peaked T waves,prolonged PR & QRS, loss of P waves,sine wave pattern. 1.Nebulisation with salbutamol Q8H 2.Inj Ca gluconate 10% 10 ml over 10 min iv Q8H. 3.Inj RI 8U in 25% D 100 ml iv Q8H. 4.K-bind 1/3 rd sachet(5mg)(calcium polystyrene sulfonate) in 10 ml sorbiline (tricholine citrate, sorbitol) TDS.

77 CVA S/s: Change in alertness,consciousness, sense of hearing/taste.Clumsiness/Confusion/ loss of memory, balance, coordination.Seizure/weakness in the face,arm,or leg (usually unilateral). Difficulty in swallowing/ writing / reading/ walking/ speaking/ understanding others;Lack of control over the bladder or bowels.Dizziness, vertigo,headache, decreased vision, double vision, or total loss of vision.Numbness or tingling on one side of the body; Personality, mood, or emotional changes. Changes that affect touch and the ability to feel pain, pressure, or different temperatures Inv: CT Brain, ECG, FBC, RBS, If CT report pending 1.RTF/CBD 2.Inj Mannitol 20% 100ml over 20 min iv Q8H 3.Inj Ranitidine 50 mg iv Q8H 4.C Diamox(acetazolamide) 250 1-1-1

If CT shows IC Bleed 1.RTF/CBD, Q4H temp chart. 2.Inj Mannitol 20% 100ml over 20 min iv Q8H 3.Inj Ranitidine 50 mg iv Q8H 4.Inj eptoin 100 mg iv Q8H 5.T Atorvastatin 10 mg 0-0-1 6.Syp Cremaffin 30 ml tds 7.C Diamox 250 1-1-1 8.IVF as /if necessary 9.T Amlo 2.5-5 mg bd to maintain a target BP of 150/90 10.Oral glycerine 30 ml tds for 3-5 days 11.Frequent change of position, intermittent throat suction if unconscious. 12.Neurosurgery consultation If CT shows SAH also give T Nimodipine 30 mg 2-2-2-2-2-2 If CT shows Infarct 1.RTF/CBD, Daily BP monitoring, Q4H temp chart. 2.Inj Mannitol 20% 100ml over 20 min iv Q8H 3.Inj Ranitidine 50 mg iv Q8H 4.T Ecospirin 325 mg st & 150 0-1-0 5.T Atorvastatin 10 mg 0-0-1 6.Syp Cremaffin 30 ml tds 7.C Diamox 250 1-1-1 8.Inj Strocit(citicholine) 500 mg tds or T Strocit 500 mg 1-1-1 for 3-5 days 9.T Amlo 2.5-5 mg bd to maintain a target BP of 150/90 10.Oral glycerine 30 ml tds for 3-5 days 11.IVF as /if necessary 12.Neurosurgery consultation 13.Frequent change of position, intermittent throat suction if unconscious. Delirium Sudden transient, usually reversible confusional state occuring with physical / mental illness. C/f:decreased attention, fluctuating confusion, disorganized thinking, decreased mobility, incontinence & obtundation. Aetiology: infections, metabolic & electrolyte abnormalities, hypoglycemia, alcohol or sedative withdrawal etc. Inv: pulse oximetry, ECG, RBS, CBC, electrolytes, URE, LFT, RFT, CT head, LP.

78 Cardiac arrest Check carotid pulse, confirm pupillary reaction, start basic life support. Consider advanced life support if defibrillator available. Cardiac thump if rhythm can be monitored. Don’t repeat cardiac thump. Start external chest cardiac massage(ECCM) Place the pt on a flat & hard surface. Extend the jaw & keep neck extended. Stand at a height higher than the pt. Keep the hands straight & elbows extended at 1800. Place both hands over the sternum, one above the other. Give firm steady compression to the chest wall squeezing the heart between the sternum & vertebra. Give compressions approximately 4cm in depth at a rate of 30 cardiac compression & 2 assisted respirations. Continue cardiac compressions unremittingly till pt is revived or decision to discontinue ECCM is made. Interrupt cardiac compressions only for giving assisted respirations or DC shock. Check cardiac rhythm to see for any ventricular fibrillation; if so connect defibrillator & charge to 200 joules non synchronized shock. Make sure no one touches the cot or the pt & the provider does not touch the cot. Apply conductive jelly to the pads of the fibrillator & place it at the right & left axilla respectively. Press both buttons of the pads simultaneously to deliver the shock. Check the monitor to see whether the rhythm has reverted to normal sinus rhythm. If yes discontinue ECCM & make sure the pt is stable with normal BP. Otherwise continue ECCM till decided on giving a second or if necessary third shock. Assisted ventilation should be given at the rate of 2 mouth to mouth breathing(or preferably use an ambu bag) for every 30 cardiac compressions. If mouth to mouth respiration is applied insert a gauze in between the mouths.ECCM should be discontinued only after such a decision has been made taking into all considerations. Needlestick injuries Immediate care For needlestick injuries & for skin exposure: wash with soap & water. For mucous membrane splash e.g eyes: make the pt lie down, open the concerned eye & allow 1 pint of NS (connected to an iv set) to run freely into the conjunctival sac. Treatment  Exposure to Hepatitis B positive pt. If not vaccinated administer HBIG x one dose & Initiate vaccination. If previously vaccinated, Test for anti-HBs antibody levels. If anti-HBs antibody > 10 mlU/ml- reassurance & no specific treatment is needed; if anti-HBs antibody < 10 mlU/ml- administer HBIG x one dose & Initiate revaccination.  If exposure to HCV source: check for HCV antibody & LFT at 0, 3 & 6 months, & follow-up.  Exposure to HIV source: immediate chemoprophylaxis( Pg No.51) & test for HIV antibodies after 6 weeks, 3 months & 6 months following the exposure.

79 Adrenal crisis It is a medical emergency. It is caused usually due to rapid withdrawal of longterm steroid therapy, drugs such as ketoconazole, phenytoin, rifampin & frequently due to septic shock. C/f: unexplained shock, usually refractory to resuscitation. H/o nausea, vomiting, abdominal pain, hyperthermia or hypothermia. Inv: RBS, S.cortisol, electrolytes, creatinine, WBC 1. Inj hydrocortisone 100 mg iv bolus (after collecting sample for S.cortisol level) Q6H, until pt is stable. 2.Replenish volume deficit. Poisoning General principles of management Hypoglycemia must be excluded in all comatose patients. Early identification of the toxic substance saves time & decreases toxicity.If possible, retrieve the container of the offending substance for identification. Primary care  Airway Assess airway for obstruction; remove oral secretions. If the pt is comatose, insert oropharyngeal airway(OPA). Nurse the pt in left semiprone position.  Breathing Most poisons that depress consciousness also impair respiration. If breathing is inadequate, intubate & ventilate.  Circulation Establish venous access, connect pt to an ECG monitor. Correct hypotension with IV fluids. Decontamination Terminate topical exposure to poison by removing contaminated clothing & washing skin with soap & water. Terminate ingested exposure to poison by performing gastric lavage with a wide bore orogastric tube (32- 40 F in adults, 16-28 F in children)(Ryle’s Tube is inadequate). Unprotected airway in a comatose pt : first perform intubation & then perform lavage. Sent sample for toxicological study. Take CXR Note: gastric lavage is C/I in :- ingestion of corrosives (acids, alkalis, oxidants) or volatile hydrocarbons(kerosene, petrol). Detect & correct hypoglycemia, seizures (BZD preferred over phenytoin) & hyperthermia Continous RT aspiration, maintain NPO for 48 hrs; resume feeding on day 3.  Emergency antidote administration  Others 1.IVF 5%D 2 pints & DNS 3 pints 2.Inj taxim 1g iv Q8H 3.Inj Metronidazole 500 mg iv Q8H Care of comatose pt: care of bladder, bowel, eyes, skin, joints & buccal mucosa. Prevention of aspiration into lungs: frequent change in position, clearing of airways, throat suction. Treatment of complications- pulmonary edema, cerebral edema, a/c renal failure & hepatic failure. Continous O2 inhalation & assisted ventilation if needed.  Psychiatry consultation on Day 5.

80 OP poisoning Inv: S. Pseudocholinesterase, stomach wash sample for toxiclology analysis. 1.Decontaminate skin - change clothing; wash with soap & water. Induce emesis, if the pt is conscious stomach wash is done with salt water; if unconscious pt, RT wash is given. 2.4th hourly temp/BP chart Hourly pulse, atropine, pupil chart Continous RT aspiration for 48 hrs, CBD, NPO for 48 hrs, Care of comatose pt: care of bowel, bladder, eyes, skin, joints & buccal mucosa. Prevention of aspiration into lungs: frequent change in position, clearing of airways, throat suction. Restrain the pt if needed; give intermittent throat suction; start refeeding by 72 hrs if conscious & bowel sounds +. 3.Inj atropine 30-40 mg iv st(for moderate poisoning) & 100 mg iv st (for life threatening) ; or alternatively 1-3 g iv bolus, then titrate according to persistence of bronchorrhoea by giving the double of the previously used dose every 5 minutes till atropinisation is achieved. Check for signs of atropinisation- dry skin, mucous membrane, fever, tachycardia, dilated pupils. Maintain atropinisation for 5-7 days, till the effect of poison weans off. Inj atropine 50 mg in 500 ml 5D 16 drops per minute(over 8 hrs) q8h, without producing psychotic behaviour. 4.Inj Pralidoxime(Aldopam) 25-50 mg/kg iv bolus( 1-2 g in 100 ml NS iv over 20 min, then 500 mg bd) 5.T Distenil 10 1-1-1(activated charcoal) 6.Inj taxim 1g iv q8h ATD as Px. 7.Inj Metrogyl 500 mg iv q8H. 8.Inj pantocid 40 mg iv od 9.IVF 5D 2 pints, NS 3 pints. 10.Inj haloperidol 5 mg iv st & sos if violent behaviour. 11.Syp cremaffin 30 ml tds. Odollum poisoning Explain prognosis Inv:ECG, toxicological analysis of gastric aspirate 1.If the pt has bradycardia, give inj atropine 1 or 2 amp iv st & Inj Atropine 1.2 mg iv sos if the HR < 50/min 2.Stomach wash if the pt is conscious 3.RTA/CBD 4.Syp cremaffin 30 ml tds 5.T Distenil 10 1-1-1 6.Inj Rantac/Pantop 7.IVF as necessary. Also address two associated complications: hyperkalemia & heart blocks.

81

Adult Glasgow coma Scale

Eye Opening Response

Spontaneous--open with blinking

4

Opens to verbal command, speech, or shout

3

Opens to pain, not applied to face(a peripheral pain stimulus, such as squeezing the lunula area of the patient's fingernail is more effective than a central stimulus such as a trapezius squeeze, due to a grimacing effect).

2

None

1

Oriented(Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.)

1.

Confused conversation, but able to answer questions(The patient responds to questions coherently but there is some disorientation and confusion.)

2.

Verbal Response

Inappropriate responses, words discernible(Random or exclamatory articulated

4

speech, but no conversational exchange. Speaks words but no sentences.)

3

Incomprehensible speech(Moaning but no words.)

2

None

1

Obeys commands for movement

6

Purposeful movement to painful stimulus( e.g., brings hand up beyond chin when supra-orbital pressure applied.)

Withdraws from pain(Absence of abnormal posturing; unable to lift hand past chin with supra-orbital pain but does pull away when nailbed is pinched)

Motor Response

5

5 4

Abnormal (spastic) flexion, decorticate posture accentuated by pain (flexor response: internal rotation of shoulder, flexion of forearm and wrist with clenched fist, leg extension, plantarflexion of foot)

3

Extensor (rigid) response, decerebrate posture accentuated by pain (extensor response: adduction of arm, internal rotation of shoulder, pronation of forearm and extension at elbow, flexion of wrist and fingers, leg extension, plantarflexion of foot)

2

None

1

Individual elements as well as the sum of the score are important. Hence, the score is expressed in the form eg ."GCS 9 = E2 V4 M3 at 07:35". Generally, brain injury is classified as:   

Severe, with GCS < 8-9 Moderate, GCS 8 or 9–12 (controversial) Minor, GCS ≥ 13.

82

Abscesses Cutaneous abscesses with true fluctuance ( the perception that true pus is contained within the tissues) are best treated with routine incision and drainage. Local cutaneous infection without fluctuance will not benefit from I & D.These patients should be instructed to apply heat to the area 4-6 times per day, receive an appropriate antistaphylococcal antibiotic such as cloxacillin or cephalexin, and be reevaluated in 24 to 48 hrs; patients should be told that at that time the abscess may be ready for I & D Note: Refer Deep and large abscesses to a surgeon. Pateints who appear systemically ill with high fever or rigors, those with extensive abscesses, or those with diabetes or other immunocompromising conditions should be considered candidates for hospital admission and surgical consultation The method employed is Hilton’s method Ask the Pt to lie down to avoid shock induced by pain. The area overlying and surrounding the abscess is prepared with povidone-iodine. Local anaesthesia is provided depending on the size and depth of the abscess. Large abscesses are given circumferential field anaesthesia which require 5 to 10 min for the area to become anaesthetized.Small to moderate sized abscesses are adequately anaesthetized simply by directly instilling the anaesthetic agent along the tract to be incised. Lignocaine is infiltrated superficially in the overlying skin till blanching is seen. Actual incision should proceed along normal skin lines to minimize subsequent scar formation. Always remember to make an adequate incision for complete initial or continued drainage.The incision should be of adequate length to allow exploration and subsequent drainage of the abscess over the next several days.Clean well with betadine.An incision is made into the skin (on the point of maximum tenderness) & deep facia. After incision, as much purulent material should be removed as possible by pressing at the root with cotton or exploration with artery forceps, till frank blood comes. A sinus forceps is passed through the opening in the deep fascia towards the site of the suspected abscess. Once the pus is seen coming out, the blunt sinus forceps is opened to enlarge the opening, & to break the locules. Once the pus is removed, the bleeding from the granulation tissue is stopped by a tight pack of roller gauze soaked in betadine ointment or GM(glycerine Mag Sulfate) or H2O2 to reduce edema at the site. The two ends of the roller gauze are kept out of the cavity before dressing so that the whole pack is subsequently taken out & nothing is left inside.The pack is removed after 48 hrs and repeat packing may be done with the roller gauze soaked in Xylocaine jelly to minimise pain.No further tight packing is necessary. Stress the need for 24-48 hr follow-up in patients with significant abscess as pus can recollect. Institute antibiotic treatment for 3 to 5 days or recommend hospital admission in patients with significant cellulitis, systemic evidence of infection, or compromise of the immune system (including DM) An appropriate analgesic should be provided to patients for 24 to 36 hrs if needed. Note: Never incise a cellulitis as there is risk of bactaraemia

Excision of nail Complete Excision of nail may be required in many conditions like trauma, infection etc The procedure is quite mutilating and is better if referred to a surgeon.

Anaesthesia of the digit is achieved through digital block with lignocaine. If required incisions are put, oriented proximally as a continuation of LNF. The nail is grasped & rotated outwards both from medial and lateral side.

83

Digital Nerve Block Digital blocks are extremely useful for anesthetizing the digit, there by facilitating the repair of lacerations, paronychia drainage, nail removal and so on. Each digit is supplied by two dorsal and palmar nerve branches. To obtain adequate anesthesia, all 4 branches must be anesthetized with local instillation. A small gauge needle is inserted dorsally, into the web space and should touch the periosteum at the base of the proximal phalanx; after withdrawing the needle slightly, 1.0 to 1.5 ml of anesthetic agent, usually 1% lignocaine without epinephrine/adrenaline, is then injected. Without withdrawing the needle, it may then be redirected toward the plantar corner until it is palpable on the palmar surface and a similar volume of anesthetic agent injected. This procedure must be repeated on the opposite side of the digit and will produce total anesthesia within 10-15 minutes. For nail removal, wing block may also be given.

Bites and Stings C/f- pain, edema, warmth, tenderness over sting site, nausea, vomiting, urticarial rash, tachypnoea, wheezing, respiratory arrest, hypotension, shock, airway obstruction due to laryngeal edema Usually encountered are cases involving snake, honeybees,wasps,spiders,scorpion, etc. Patients with no history of angioedema, bronchospasm, urticaria or anaphylaxis should be observed for 1 to 2 hrs and carefully monitored for evidence of evolving anaphylaxis.The wound must be examined for a stinger, which should be removed by gentle scraping with blade to prevent further envenomation. Do not grasp with forceps or fingers in order to avoid expressing more venom from the poison sac into the skin.The wound should be thoroughly cleaned, tetanus prophylaxis administered if appropriate, and ice applied. Patient who remain asymptomatic 2 hrs after the injury may be discharged with instructions to return immediately if shortness of breath, wheezing, generalized pruritus, oropharyngeal swelling, or rash occurs. In scorpion stings, advise elevation for 24 to 48 hrs Rx Check airway, Inj avil, Inj efcorlin, Inj adrenaline(if bronchospasm), remove stings, apply ice , elevate extremity to limit edema Scorpion stings are very painful, so infiltrate the area with lignocaine 2% through the puncture wound. Look for systemic symptoms. If present refer. Snake bite-first aid

If an extremity is involved, it should be placed in neutral position below the heart; intravenous access should n’t be established in the bitten extremity. Wounds should n’t be incised and oral suction is not recommended. The placement of an arterial interrupting tourniquet is not advised; alternatively compression or constriction bands which are placed proximally around the bitten extremity and interrupt venous and lymphatic flow may be helpful. The band is placed so that a finger slips under the band and distal arterial pulsations are easily palpated. Bands may be made from clothing, rope, rubber gloves etc. O2 should be administered and the patient transported as soon as possible.

84 CARDIOPULMONARY RESUSCITATION (CPR) First confirm cardiac arrest; absence of repiratory efforts, absence of major pulse like carotid is diagnostic of cardiopulmonary arrest.If pulse +, open the airway & give ventilation. Healthcare providers, should perform all 3 components of CPR (chest compressions, airway, and breathing).For an unconscious adult, CPR is initiated using 30 chest compressions. Perform the head-tilt chin-lift maneuver to open the airway and determine if the patient is breathing. Before beginning ventilations, rule out airway obstruction by looking in the patient’s mouth for a foreign body blocking the patient’s airway. CPR in the presence of an airway obstruction results in ineffective ventilation/oxygenation and may lead to worsening hypoxemia. Positioning CPR is most easily and effectively performed by laying the patient supine on a relatively hard surface, which allows effective compression of the sternum. The health care provider giving compressions should be positioned high enough above the patient to achieve sufficient leverage, so that he or she can use body weight to adequately compress the chest. Chest compression The heel of one hand is placed on the patient’s sternum, and the other hand is placed on top of the first, fingers interlaced. The elbows are extended and the provider leans directly over the patient. The provider presses down, compressing the chest at least 2 inches. The chest is released and allowed to recoil completely.Chest compressions are to be delivered at a rate of at least 100 compressions per minute. With the hands kept in place, the compressions are repeated 30 times at a rate of 100/min. The key thing to keep in mind when doing chest compressions during CPR is to push fast and hard. Care should be taken to not lean on the patient between compressions, as this prevents chest recoil and worsens blood flow. After 30 compressions, 2 breaths are given (see Ventilation). Of note, an intubated patient should receive continuous compressions while ventilations are given 8-10 times per minute or 1 breath/6-8 seconds. This entire process is repeated until a pulse returns or the patient is transferred to definitive care. When done properly, CPR can be quite fatiguing for the provider. If possible, in order to give consistent, high-quality CPR and prevent provider fatigue or injury, new providers should intervene every 2-3 minutes (ie, providers should swap out, giving the chest compressor a rest while another rescuer continues CPR). Ventilation If the patient is not breathing, 2 ventilations are given via the provider’s mouth or a bagvalve-mask (BVM). The mouth-to-mouth technique is performed as follows : The nostrils of the patient are pinched closed to assist with an airtight seal.The provider puts his mouth completely over the patient’s mouth.The provider gives a breath for approximately 1 second with enough force to make the patient’s chest rise. Effective mouth-to-mouth ventilation is determined by observation of chest rise during each exhalation. Failure to observe chest rise indicates an inadequate mouth seal or airway occlusion. As noted , 2 such exhalations should be given in sequence after 30 compressions (the 30:2 cycle of CPR). When breaths are completed, compressions are restarted. If available, a barrier device (pocket mask or face shield) should be used.More commonly, a BVM can be used, which forces air into the lungs when the bag is squeezed. Several adjunct devices may be used with a BVM, including oropharyngeal and nasopharyngeal airways.The BVM or invasive airway technique is performed as follows:The provider ensures a tight seal between the mask and the patient’s face.The bag is squeezed with one hand for approximately 1 second, forcing at least 500 mL of air into the patient’s lungs.Next, the provider checks for a carotid or femoral pulse. If the patient has no pulse, chest compressions are begun.

85 Fluid Balance and IV fluid therapy Fluid requirement In a normal person fluid requirement over 24 hr is roughly 2500 ml. Normal daily losses are through urine(1500 ml), stool(200 ml), & insensible losses(800 ml). This requirement is normally met through food(1000 ml) & drink (1500 ml). Intravenous fluids are given if sufficient fluids can’t be given orally. About 2500 ml fluid containing roughly 100 mmol Na+ & 70 mmol K+ per 24 hr are required. Thus a good regimen is 2L of 5% Dextrose and 1 L of 0.9% saline every 30 hr with 20 mmol of K+ per litre of fluid. Remember that all cannulae carry a risk of MRSA infection, so always resume oral fluid intake as soon as possible. In sick pt’s, don’t forget to include additional sources of fluid loss when calculating daily fluid requirements, such as drains, fever, or diarrhoea Assessing fluid balance Underfilled

Tachycardia, postural drop in BP, ↓ capillary refill time, ↓ urine output, cool peripheries, dry mucous membrane, ↓ skin turgor, sunken eyes Over filled

Pitting edema of the sacrum, ankles, or even legs & abdomen, tachypnoea, bibasal crepitations, pulmonary edema on CXR, ↑ JVP Pottasium in IV fluids

Pottasium can be given with 5% dextrose, or 0.9% saline, usually 20 mmol/L or 40mmol/L. K+ may be retained in renal failure, so beware giving too much IV. GI fluids are rich in K+, so increased fluid loss from the gut(eg diarrhoea, vomiting, high-output stoma, intestinal fistula) will need increased K+ replacement. The maximum concentration of K+ that is safe to infuse via a peripheral line is 40 mmol/L, at a maximum rate of 20 mmol/h. Note Elderly pt’s are more prone to fluid overload, so give iv fluids with care Pancreatitis: aggressive fluid resuscitation is required in a/c pancreatitis Fever, burns: large amounts of fluid can be lost unseen through transpiration. Liver failure: these pt’s often have a raised total Na+, so restrict 0.9 % saline Heart failure: use IV fluids with care to avoid fluid overload. Shock: resuscitate with colloid or 0.9% saline via large bore cannulae. Hypertonic dextrose(10% or 50%): irritant to veins, so infusion sites inspected & flushed with 0.9% saline after use. In children- Maintenance requirement Upto 10 kg: 100 ml/kg/24 hr; 10-20 kg: 1000 ml + 50 ml/kg/24 hr for the weight above 10 kg; more than 20 kg: 1500 ml + 20 ml/kg/24 hr for the weight above 20 kg. Add approx. 1ml 15% KCl(=2mEq) per 100 ml fluids like NS. Isolyte-P already contains K+, & hence K+ need not be added to isolyte-P. In case of significant dehydration, poor pulse etc., give NS 20-30 ml/kg & reassess.

86

Postoperative Patient Routine Care in all post-op patients

IVF DVT prophylaxis, Pulmonary toilet: early mobilization, incentive spirometry Medications: antiemetics, peptic ulcer prophylaxis, Pain ctrl, antibiotics, Lab tests General complications

Pyrexia May be due to atelectasis, tissue damage, blood transfusions. Look for signs of wound infection,UTI, chest infection, cannula site erythema, peritonism, endocarditis,DVT. Send FBC, CRP, RFT, LFT Confusion/agitation/disorientation Look for hypoxia, urinary retention, MI, stroke,infection,alcoholwithdrawal, drugs, liver/renal failure Dyspnoea/hypoxia Sit up, give O2, monitor peripheral O2 by pulse oximetry. Examine for evidence of pneumonia, aspiration, LVF, pulmonary embolism,pneumothorax, Send FBC,ABG,CXR,ECG Decreased urine output Look for blocked catheter, little replacement of lost fluid, ARF (following shock, drugs, transfusion, trauma). Aim for urine output >30 ml/h in adults Nausea/vomiting: look for emetic drugs(opiates,digoxin, anaesthetics), mechanical obstruction, ileus. Send AXR A/c retention of urine If pt is in bed, make him sit up or stand to pass urine. Warm water bag to the lower abdomen or pouring water to the leg/foot may help If not relieved give inj buscopan If still not relieved, catheterise. Hypotension Inadequate fluid input(monitor urine output),hemorrhage(r/w wounds & abdomen).Also consider sepsis, cardiogenic/neurogenic causes, anaphylaxis.Look for evidence of MI, Pulmonary Embolism. Check pulse,BP. If severe, tilt bed head down (unless cardiogenic)& give O2, IVF(unless cardiogenic) BP ↑: may be from pain, urinary retention, missed medication, inotropic drugs ↓ Na+ :look pre-op level. SIADH can be precipitated by perioperative pain, nausea, opioids, chest infection. Over administration of iv fluids may exacerbate the situation. Correct slowly.

87 Specific complications Thyroid surgery

Dyspnoea: tracheal obstruction due to hematoma in the wound.Relieve by immediate removal of stitches or clips. Voice muffled/different due to intubation & local edema, injury to rec Laryngeal nerve. Mastectomy Arm lymphoedema, skin necrosis Colonic surgery Sepsis, ileus, fistula, anastomotic leak, hemorrhage, obstruction from adhesions, trauma to ureters, spleen. Laparotomy Wound dehiscence leading to burst abdomen with evisceration of bowel. Put the gut back into the abdomen, place a sterile dressing over the wound, give iv analgesics, IVF. Call Ur seniors. Small bowel surgery Diarrhoea,malabsorption Biliary surgery Biliary colic,jaundice,hemetemesis, pancreatitis,post-op hemorrhage, biliary peritonitis Tracheostomy Stenosis,mediastinitis,surgical emphysema Splenectomy A/c gastric dilatation, thrombocytosis, sepsis Genitourinary surgery Septicemia Hemorrhoidectomy Constipation,infection, bleeding, stricture Bariatric surgery Dumping syndrome,wound infection,hernias,diarrhoea,malabsorption Hernioplasty Infection, mesh extrusion,FB reaction, Mesh inguinodynia causing Hyperaesthesia & pain along the distribution of ilioinguinal or iliohypogastric nerves.

88

ECG Basics

Six Limb leads – L1, L2, L3, aVR, aVL, aVF Six Chest Leads – V1 V2 V3 V4 V5 and V6 L1, L2 and L3 are called bipolar leads aVR, aVL, aVF are called unipolar leads Inferior wall:11, 111, aVF Lateral wall:1, aVL, V4, V5, V6(V5 and V6 record events of left lateral wall To record right side events V2R to V6R are needed – In dextrocardia, in RV infarction) Anterior wall:V1 to V4(V1 and V2 record events of septum) (V3 and V4 record events of the anterior wall) Axis of ECG LEAD 1

LEAD AVF AXIS

Positive Positive

Positive Negative

Normal Possible LAD Is lead 11 positive? Yes-> Normal No-> LAD(left axis deviation)

Negative

Positive

RAD(right axis deviation)

Negative

Negative

Extreme Axis deviation

Standardization – 10 mm (2 boxes) = 1 mV P Wave is Atrial contraction – Normal 0.12 sec or 120 ms PR interval is from the beginning of P wave to the beginning of QRS- Normal up to 0.2s QRS is Ventricular contraction –Normal 0.08 sec or 80 ms ST segment – Normal Isoelectric (electric silence) QT Interval – From the beginning of QRS to the end of T wave , Normal:- 0.40 sec RR Interval – One Cardiac cycle, 0.80 sec X-Axis represents time - Scale X-Axis – 1 mm = 0.04 sec Y-Axis represents voltage - Scale Y-Axis – 1 mm = 0.1 mV One big square on X-Axis = 0.2 sec (big box) Two big squares on Y-Axis = 1 milli volt (mV) Each small square is 0.04 sec (1 mm in size) Each big square on the ECG represents 5 small squares => 0.04 x 5 = 0.2 seconds 5 such big squares => 0.2 x 5 = 1sec = 25 mm One second is 25 mm or 5 big squares One minute is 5 x 60 = 300 big squares Sinus Rhythm – Each P followed by QRS, R-R constant P waves – always examine for in L2, V1, L1 QRS positive in L1, L2, L3, aVF and aVL; Neg in aVR R wave progression from V1 to V6 Normal T↓ in aVR,V1, V2 T inversions in V2, V3 and V4 – Juvenile T ↓ Similarly in women also T↓ Low voltages in obese women and men If in, ECG the R-R intervals are not constant-sinus arrythmia Ischemia produces ST segment depression with or without T inversion

89 Injury causes ST segment elevation with or without loss of R wave voltage Infarction causes deep Q waves with loss of R wave voltage. Upward sloping depression of ST segment is not indicative of IHD It is called J point depression or sagging ST seg Downward slopping or Horizontal depression of ST segment leading to T↓ is significant of IHD

Evolution of Acute MI

Acute Anterior MI  Significant Q waves, ST elevation and T inversions in Leads V2, V3 and V4  Q waves and T inversion in L1  If only V1 and V2 show the changes it is called septal MI Acute Anterio-Lateral MI  Significant Q waves, ST elevation and T inversions in Lead 1, aVL, V5 and V6  This is the most common form of MI Acute Inferior wall MI Significant Q waves, ST elevation and T inversions in Lead II, Lead III, aVF Acute True Posterior MI  Lead V1 shows unusually tall R wave (it is the mirror image of deep Q),ST ↓, peaked T  V1 R/S > 1, Differential Diagnosis - RVH Hyperkalemia  Small or absent P waves  Atrial fibrillation  Wide QRS  Shortened or absent ST segment  Wide, tall and tented T waves Hypokalemia  Small or absent T waves or inverted T  Prominent U waves  T wave is the tent house of K (pottasium)  More K – tall T, less K -flat or inverted T Atrial Fibrillation  The heart rate is irregularly irregular  The R-R intervals are very different from beat to beat  There is narrow QRS tachycardia

90  There are no P waves – instead small fibrillary waves called ‘ f ’ waves are seen especially in V1. Atrial Flutter  The heart rate is regular or variable  Atrial rate is 300 per minute  All P waves are not conducted to ventricles  The R-R intervals very depending on the AV conduction ratio  The QRS is narrow : < 0.12 sec  The P waves have a ‘saw toothed’ appearance called ‘F’ waves Ventricular Tachycardia  A wide QRS tachycardia is VT until proved otherwise. Features suggesting VT include:  Evidence of AV dissociation  Independent P waves  Beat to beat variability of the QRS morphology  Very wide complexes (> 0.14 ms)  The QRS is similar to that in ventricular ectopics  Concordance (chest leads all positive or negative) Pathological Q wave  The pathological Q wave of infarction in the respective leads is due to dead muscle  It is deep in amplitude–more than 25% of the succeeding R wave,or more than 4 mm  Its duration is > 0.04 sec or > 1 small box  It is seen in Leads facing the infarcted muscle mass Normal Q waves  The normal Q wave in lead I is due to septal depolarization  It is small in amplitude – less than 25% of the succeeding R wave, or less than 3 mm  Its duration is < 0.04 sec or one small box  It is seen in L1 and sometimes in V5, V6 T Wave Inversion  Deep symmetric inverted T waves in more than 2 precordial(chest) leads  85% of the patients with such T wave ↓ had > 75% stenosis of the coronary artery  T wave ↓ are significantly associated with MI or death during follow up Right Atrial Enlargement  Always examine Lead 2 for RAE  Tall Peaked P Waves, Arrow head P waves  Amplitude is 4 mm ( 0.4 mV) - abnormal Causes:  Pulmonary Hypertension, Mitral Stenosis  Tricuspid Stenosis, Regurgitation  Pulmonary Valvular Stenosis ,Pulmonary Embolism  Atrial Septal Defect with L to R shunt Left Atrial Enlargement  Always examine V 1 and Lead 1 for LAE  Biphasic P Waves, Prolonged P waves  P wave 0.16 sec, ↑ Downward component Causes:  Systemic Hypertension, MS and or MR  Aortic Stenosis and Regurgitation  Left ventricular hypertrophy with dysfunction  Atrial Septal Defect with R to L shunt

91 Right Ventricular Hypertrophy  Tall R in V1 with R >> S, or R/S ratio > 1  Deep S waves in V4, V5 and V6  The DD’s are RVH, Posterior MI, Anti-clock wise rotation of Heart  Associated Right Axis Deviation, RAE  Deep T inversions in V1, V2 and V3, Absence of Inferior MI Left Ventricular Hypertrophy  High QRS voltages in limb leads  R in Lead I + S in Lead III > 25 mm  S in V1 + R in V5/V6 > 35 mm or V5/V6 R wave ht > 25 small squares  R in aVL > 11 mm or S V3 + R aVL > 24 ♂, > 20 ♀  Deep symmetric T inversion in V4, V5 & V6  QRS duration > 0.09 sec, Associated Left Axis Deviation, LAE Complete RBBB  Complete RBBB has a QRS duration > 0.12 sec  R' wave in lead V1 (usually see RSR' complex)  S waves in leads I, aVL, V6, R wave in lead aVR  QRS axis in RBBB is -30 to +90 (Normal)  Incomplete RBBB has a QRS duration of 0.10 to 0.12 sec with the same QRS features as above.  The "normal" ST-T waves in RBBB should be oriented opposite to the direction of QRS Complete LBBB  Complete LBBB has a QRS duration > 0.12 sec  Always pathological  Prominent S waves in lead V1, R in L I, aVL, V6  Usually broad, Bizarre R waves are seen, M pattern  Poor R progression from V1 to V3 is common.  The "normal" ST-T waves in LBBB should be oriented opposite to the direction of QRS  Incomplete LBBB looks like LBBB but QRS duration is 0.10 to 0.12 sec, with less ST-T change.  This is often a progression of LVH changes Myocarditis  Diffuse T wave ↓  Saddle shaped ST elevation Dextrocardia  Rt axis deviation; Positive QRS complex(with upright P & T waves) in aVR  Lead 1- inversion of all complexes(global negativity-inverted P & T,negative QRS)  Absent R wave progression in the chest leads (dominant S wave through out) Pericarditis  ST↑ in all leads( bulges downwards/concave upward)( In MI ,ST segment elevation bulges upwards)  PR segment depression Pulmonary embolism  Sinus tachycardia,  anterior T wave inversion,  S1Q3T3, RBBB, low amplitude deflections Long QT Syndrome (QT> 440 ms) C/f: syncope, Seizures, sudden death, Etiology: inherited, drugs like certain antibiotics, antidepressants, antihistamines, diuretics, heart medications etc, QT prolongation in the course of other diseases, e.g MI, cerebral hemorrhage Inv: S.K, Mg, Na, TFT, ECG(of the pt & family members), genetic study. Rx: beta blockers Miscellaneous:P wave >2.5 small segment ht- P pulmonale( Rt atrial enlargement), P wave >2.5 small segment breadth and notch- P mitrale( Lt atrial enlargement)

LABORATORY VALUES BRE Hb Males:13.5-17.5 g/dl Females:12-15.5 g/dl

RBC count Males:4.5-6.5 x 1012/L Females: 3.8-5.8 x 1012/L Normal Reticulocyte count: 0.8 – 1.5 % Red cell distribution Width(RDW):42.5±3.5 fL or 12.8±1.2% Direct count Polymorphs(neutrophils): 40-75% Lymphocytes: 20-50% Monocytes: 2-10% Eosinophils :1-6% Basophils : <1% Absolute eosinophil count: 50-350/mm3 Total count Adults: 4,000-11,000 Infants(1 yr): 6,000-16,000, at birth (10,000-25,000) Platelets:1,50000-4,00000 PCV Male(40-54%) Female(37-47%) ESR Male(0-9 mm/hr) Female(0-20 mm/hr) - wintrobes method Male(0-15 mm/hr) Female(0-20 mm/hr) – westergen method Coagulation screening tests Normal bleeding time : 2-7 min Normal clotting time : 4 -9 min Prothrombin time:12-15 sec aPTT(activated partial thromboplastin time):28-31 s INR: 1 Thrombin time:<20 s(control ± 2 sec) LFT SGOT or AST: <40 units/ml(12-38 U/L) SGPT or ALT : <40 units/ml(7-41 U/L) S Alkaline Phosphatase: adult 30-120 U/L, children <350 IU/L S Albumin: 3.5-5.5g/dL or gm% S Bilirubin(Total): 0.3-1.3 mg/dL S Bilirubin(Direct or conjugated): 0.1-0.4 mg/dL S Total protein:6.7-8.6 g/dL Gamma glutamyl transpeptidase: 0-40 IU/L RFT B Urea:20-40 mg/dL Urea Nitrogen(BUN):7-20 mg/dl S Creatinine: 0.6- 1.6 mg% S Uric acid: 3.1-7mg/dL(males), 2.5-5.6 mg/dl(females)

92

93 S.Electrolytes S Na : 136-145mM/L S K: 3.5-5.4 mM/L S Ca,total: 8.5 -10.5 mg% S P: 2.5 - 4.5 mg/dL S Mg: 1.5-2 mEq/L S Cl:102-109 mEq/l Lipid profile Total cholesterol:150-200mg%, borderline high: 200-239 mg/dl, high undesirable:≥240 mg/dl Triglycerides:50-160 mg%(<160 mg/dl) HDL: 40-60mg%(desirably >60mg%), low:<40 mg/dl LDL:80-160mg% (desirably <130mg%, borderline high:130-159 mg/dl, high undesirable: ≥160 mg/dl)

Cardiac Biomarkers LDH:115-221 u/l C Tn i: 0-0.08 ng/ml C Tn T:0-0.01 ng/ml Creatine kinase: males:51-294 U/L, females:39-238 IU/L CK-MB:0-5.5 ng/ml Blood sugar monitoring Fasting (8hrs of fasting with no calorie intake);Normal:70-100 mg/dl, In DM≥ 126 mg/dl Post prandial(2hrs after 75 mg glucose intake) :<140 mg/dl, In DM >200 mg/dl RBS>200 in DM HbA1c :4-6% ( a rise of 1% corresponds to an approx average increase of 36 mg/dl (2 mmol/L)in blood glucose.

TFT T4: 5.4-11.7 µg/dl or 70-151 nmol/L T3: 77-135 ng/dl or 1.2-2.1nmol/L TSH:0.4-5 µU/ml or 0.4-5 mU/L FT3: 1.4-4.2 pg/ml FT4:0.8-2 ng/dl Plasma Proteins Albumin: 3.5-5.5 g/dL Globulin: 2-3.5 g/dL Fibrinogen:0.2-0.4 g/dL A/G:1.5-3:1 Others C reactive protein:0-10 mg/L S Ferritin: 30-250 ng/ml or µg/L(males), 10-150 ng/ml(females) PSA: 0-4 ng/ml β –HCG: <3 mIU/L or IU/L Prolactin: 2-20 ng/ml (males), 2-30 ng/ml(females), 10-209 ng/ml(pregnant woman) S. Amylase : 20-96 u/l S. Lipase:0-160 U/L Rheumatoid factor: <30 IU/ml S Vit B12:140-980 ng/L LDH:208-460 U/L

94 Urine examination pH:5-9 Colour: pale yellow to deep amber Specific gravity ,quantitative:1.002-1.028 Protein excretion(24 hr):<150 mg/day Protein qualitative:negative Gucose excretion, quantitative(24 hr):50-300 mg/day Glucose , qualitative:negative Porphobilinogen:negative Urobilinogen:1-3.5 mg/day Microalbuminuria(24 hr): 0-30 mg/24 hr Red cells:0-2/hpf WBC:0-5/hpf Epithelial cells:0-2/hpf Bilirubin:0.02 mg/dl or negative Bence-jones protein: negative Casts Hyaline cast- dehydration, strenuous exercise Granular cast- CKD, strenuous exercise RBC cast(always pathological)- glomerulonephritis, vasculitis WBC cast- inflammation/infection Stool examination Coproporphyrin:400-1000 mg/day Fecal fat excretion:<6 g/day Occult blood:negative(<2 ml blood/day) Urobilinogen:40-280 mg/day Gases, arterial Bicarbonate(HCO3-): 22-30 mEq/L pH: 7.35-7.45 Pco2: 22-45 mmHg Po2: 72-104 mmHg Total CO2: 23-30 mmol/L or 100-132 mg/dL H+: 35–45 nmol/L (nM) Red cell indices Mean corpuscular volume, MCV: 80 - 100 femtoliter Mean corpuscular haemoglobin,MCH: 27 - 32 picograms/cell Mean corpuscular hemoglobin concentration, MCHC: 32 - 36 grams/deciliter Ascitic Fluid Analysis Total count- less than 500 WBC/µL Polymorphs- less than 250 /µL CSF analysis

Opening pressure: 90-180 mm H2O Appearance & colour: clear, colourless Blood cell count,WBC: <5, RBC:<5 Glucose: 50-80 mg/dl or > 60% of blood level T protein: 15-60 mg/dl or < 0.45 g/L Oligoclonal bands: negative

95 Catheters The size of Foley catheter is measured commonly using french scale. It is abbreviated as F or Ch(charriere, it’s inventor). The diameter of a french catheter can be determined by Dividing the French size by 3, i.e D (mm)= Fr / 3. An increase in French size corresponds to a larger external diameter. The commonly available catheters in our wards are F 12(white), 14(green), 16(orange), 18(red). The colour corresponds to the colour of the balloon port. The volume of the fluid recommended to inflate the balloon is marked in the drainage port. During catheterization, insert to the hilt;wait until urine emerges before inflating the balloon. Remember to reposition the foreskin in uncircumcised men after the catheter is inserted to prevent massive edema of the glans & paraphimosis. In men , stretch the penis perpendicular to the body & then insert the catheter. Position of women: knees flexed, hips abducted with heels together Urine output should be >400 ml in 24 hr or >0.5ml/kg/hr Ryle’s Tube Place lubricated tube in nostril with it’s natural curve promoting passage down, rather than up. Advance directly backwards(not upwards). When the tip is estimated to be entering the throat, rotate the tube by ~180 to discourage passage into the mouth. Advance the tube into the esophagus during a swallow. It may be easier to swallow with a sip of water.Advance >60 cm. Common size FG12(white), FG14(green), FG16(orange) Cannula In contrary to a catheter , in needle- gauge size, an increase in gauge corresponds to a smaller diameter needle. Purple 26 G 13 ml/min Yellow 24 G 23ml/min( commonly used in pediatrics) Blue 22 G 36 ml/min Pink 20 G 65ml/min Green 18 G 96 ml/min Grey 16 G 180 ml/min Hypodermic Needle Brown 26 G, Purple 24 G,Blue 23 G, Grey 22 G, Green 21 G, Yellow 20 G, Pink 18 G Suction Catheter 6(green), 8(blue),10(black),12(white) Endotracheal Tube Common size(mm)- adults: 6, 6.5, 7, 7.5, 8, 8.5; children: 3, 3.5, 4, 4.5, 5 Venturi mask 24%- blue 2L/min, 28% white 4L/min,31% orange 6L/min, 35% yellow 8L/min,40% red 12L/min, 60% green 15L/min

96

Common injections

Amp/vial volume - Total strength

Adrenaline 1ml-1mg Atropine 1ml/2ml- 0.6mg/1.2 mg Aminophylline 10ml-25mg/ml Avil(pheniramine maleate) 2ml-22.75mg/ml Atarax(hydroxyzine) 2ml-25 mg/ml Betnesol 1ml-4mg Buscopan(hyoscine) 1ml-20mg Chlorpheniramine maleate 1ml-10 mg Cyclopam(dicyclomine) 2ml- 20mg Ca gluconate 10ml-100mg/ml Deriphylline 2ml-220mg(each ml, etofyl 84.7 mg+Theo 25.3mg) Diazepam 2ml-10mg Dexona 2ml-8mg Dopamine 5ml-200mg Dobutamine 5ml-250mg Ethamsylate 2ml- 125mg/ml Eptoin(phenytoin) 2ml-100mg Emeset(ondansetron) 2ml/4ml- 4mg/8mg Fortwin(pentazocine) 1ml-30 mg Gentamycin 2ml-80mg Ketorolac 1ml-15mg Kcl(15% w/v) 10ml-150mg/ml or 2meq/ml Lasix(furosemide) 1ml/2ml-10 mg/20 mg Midazolam 5ml-5mg Nitroglycerine 5ml-25mg Na bicarbonate 10ml-7.5% w/v each ml Noradrenaline 2ml- each ml contains norad 0.2 % w/v P’mol 2ml-150mg,2ml-150mg/ml, 3ml-150mg/ml Perinorm 2ml-10mg Phenergan 2ml-50 mg Rantac(ranitidine) 2ml-50mg Serenace(haloperidol) 1ml-5mg Stemetil(prochlorperazine) 1ml-12.5mg Terbutaline 1ml-0.5mg Tramadol 1ml-50 mg Tranexa 5ml-500mg Vitamin K 1ml-10mg Voveran(diclofenac) 3ml-75 mg Respules Asthalin 2.5 ml-2.5 mg, respirator solution 15 ml- 5mg/ml Ipravent 2ml-500mcg, respirator solution 15 ml-250mcg/ml Levolin 2.5ml-0.31 mg/0.63 mg/1.25 mg Duolin 2.5 ml-ipra 500mcg+ levosalbu 1.25 mg Budecort 2ml-0.25mg/0.5 mg/1mg

97

Ampicillin Aminopenicillin; Mainly effective against Grain +ve & also some gram –ve 1. Drops 100mg/ml 0-1.5 months > 0.5ml qid (8 drops) 1.5-5 months > 1ml qid (16drops) 2. Syrup:125mg/5ml or 250mg/5ml 3. Cap:250mg or 500mg Indications: UTI, RTI, meningitis, cholecystitis, May be combined with gentamycin or third gen cephalosporins Always give test dose. Complication > May produce rashes, especially in cases of IMN. It may be combined with sulbactum (given parenterally only) Dosage is 50-100 mg/kg/day in 4 divided doses, oral. Usual pediatric inj dose: 50 mg/kg Q6H if > 7 days of age, Q8H if <7 days of age. T.N: Roscillin, Campicillin, Presmox

Amoxicillin Preferred over ampicillin for bronchitis,UTI, Dose: 0.25- 1 g tds oral/im, children: 30-50 mg/kg/24 hr div into 2 or 3 PO T.N: Mox, Novamox

Cloxacillin More active than methicillin against pencillinase producing staph. Dose: 500 mg Q6H oral/iv, children: 100 mg/kg/day C 250 mg, 500 mg, syp 125/5 available T.N: klox

Coamoxiclav Addition of clavulanic acid (β- lactamase inhibitor) re-establishes the activity of amoxicillin against β-lactamase producing resisitant staph aureus Indications: skin/soft tissue infections, intra abdominal & gynaecological sepsis, urinary, biliary, respiratory infections Dose: 1.2 g iv bd/tds T.N: Mega-CV, Augmentin. T 375, 625, 1g available.

Cephalexin 1st generation cephalosporin. Indications  Severe LRI  Infections during pregnancy  Bone & joint infections, skin & soft tissue infections  Pharyngitis, tonsillitis, UTI  CSOM, ASOM  Usually combined with Metrogyl in cases of mild diarrhea + URI or LRI Dose> 50-100mg/kg/day in 4 divided doses > similar to Ampicillin T.N: Phexin, Sporidex, Blucef, Citacef, Lexin

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Cefadroxil 1st generation cephalosporin Indications  Pharyngitis  Skin & soft tissue infections  UTI May produce gastritis, nausea, epigastric distress Available as Tab 125, 250, 500 & Syp 125/5ml, 250/5ml & drops 100mg/ml Dose 30mg/kg/day in 2 divided doses orally T.N: cefadur, droxyl,cefastar

Cefazolin 1st generation cephalosporin Available as 125mg, 250mg, 500mg, and 1g vials Indications  Surgical prophylaxis  Bone and joint infections  Skin and soft tissue infections  Speticemia  Pneumonia, UTI Doses > 50-100mg/kg/day in 4 divided doses im or iv(similar to Ampicillin) For im use either distilled water or normal saline may be used as the diluent. For iv use 10ml distilled water is to be used. It may be administered over a period of 3-5 min For newborn, 20mg/kg/dose 12th hourly if <7 days and 8th hourly if > 7 days T.N: Maxicef-O,Reflin

Cefaclor 2nd generation cephalosporin Available as 250mg cap, dry syp or readymade suspension 125 or 187 mg/5ml and drops 50mg/5ml. Dose 40mg/kg/day in 2 or 3 divided doses Indications  PUO in children  LRI  Intra abdominal infections like Cholecystitis Appendicitis, Pancreatitis T.N: Distaclor, Keflor.

Cefuroxime Axetil 2nd generation. Preventing bacterial infections before, during, or after certain surgeries. Other indications: Respiratory infections, uncomplicated skin & soft tissue,UTI Dose: 250-500 mg BD, children:30 mg/kg/day div into 2-3, IM/IV:100-150 mg/kg/24 hr div into 3. Adult iv dose: 1.5 g Q8H T.N: Ceftum,Spizef, altacef

Cefixime Oral 3rd generation cephalosporin Available as susp 50 or 100mg/5ml and T or Cap 100mg or 200mg Strong antibiotic useful especially in diabetic patients and in other serious infections, Useful for continuation therapy after initial parenteral therapy.Highly active against enterobacteriaceae, H influenzae. Not active against Staphylococci and Pseudomonas. Other indications: RTI, uncomplicated UTI, STD, typhoid fever Doses -> 8mg/kg/day, od or bd. T.N: Taxim-o,Milixim,Fixx, Extracef, Cefspan, topcef, Ceftiwin,Omnix

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Cefotaxime 3rd generation. Indications > Meningitis, Specticemia, serious bone and soft tissue infections Dose > 100-200mg/kg/day in 4 divided doses im or iv. In newborn, 50mg/kg/dose 12th hourly, if < 7 days old & 8th hourly if > 7 days old. Available as 250mg, 500mg & 1g vials.Usual Adult dose: 1g iv tds May be reconstituted with D5, D10 or NS. T.N: Taxim, Omnatax,

Ceftazidime rd

Parenteral 3 generation cephalosporin Highly Active against Pseudomonas aeruginosa. Also, Gram –ve coverage, synergistic action with Aminoglycosides Available as Inj 250mg, 500mg, & 1g. Dose > 100-150mg/kg/day in 3 divided doses im or iv. Max of 6g/day T.N: Fortum , Psedocef.

Ceftriaxone 3rd generation cephalosporin. Effective against Gram+, gram- & some anaerobes Indications  Enteric fever (DOC is Ciprofloxacin 500mg bd x 2 wks)  Bacterial Meningitis  Abdominal sepsis, Septicemias  Compicated UTI Dose > 50-100mg/kg/day in 2 doses im or iv. May be reconstituted with D5, D10 & NS Do not mix other antimicrobials.Available as Inj 250mg & 1g.usual adult dose 1g iv bd T.N: Monocef, Monotax, Ciplacef.

Cefdinir rd

Oral 3 generation cephalosporin Wide spectrum with gram + & gram – coverage, Good activity against Beta-lactamase producing strains. Effective in RTI – both upper and lower and skin & soft tissue infections. Dose > Adults 300mg bd x 10 days or 600mg od x 10 days; children 14mg/kg in 2 divided doses or even as a single dose. T.N: Aldinir, Cefdins, available as syp 125/5ml and 300mg cap; Expensive

Cefpodoxime Proxetil rd

3 generation. Useful mainly in respiratory tract infection , skin & soft tissue infections and also in cases of uncomplicated UTI. Highly active against enterobacteriaceae & streptococci. Not against pseudomonas Available as a T 100mg, 200mg or as dry syrup 50 or 100mg/5ml. Dose> 10mg/kg/day in 2 divided doses, to be taken with food. T.N: monocef-o, cepodem, podocef

Cefoperazone + sulbactum 3rd generation cephalosporin + β- lactamase inhibitor. Useful for empirical therapy.Wide spectrum, including pseudomonas.Achieves high biliary concentration & hence useful in case of cholecystitis Indications: Severe urinary, biliary, respiratory, skin-soft tissue infections, meningitis, septicaemia

100 Dose: 1 or 2 g iv in adults in two divided doses.Usual adult dose: 1.5 g iv bd. In children, 50-200mg/kg in 2 divided doses. T.N: cefactum,cefpar SB(very costly)

Doxycycline Tetracycline Indications  Leptospirosis treatment & prophylaxis  Scrub typhus, malaria prophylaxis, brucellosis, cholera  Prophylaxis for COPD exacerbation  Acne, UTI, RTI like a/c bacterial rhinosinusitis,  Chlamydia, gonorrhoea, prevention of STD’s following sexual assault  Inflammation of the gums Dose: 100 mg/ 200mg bd, children: 5mg/kg/day div into 2 PO or OD T.N: Doxy-1

Gentamicin Aminoglycoside. Wide spectrum, mostly gram negative including pseudomonas Remember oto and nephrotoxicity Dose>5-7.5 mg/kg/24 hr div into 2 or 3 doses im or iv. In case of neonates give 2.5 mg/kg Q12H.Usual adult dose: 80 mg iv od/bd Available as vials of 100mg, 250 mg and 500 mg/ml. T.N: garamycin

Amikacin Widest spectrum of activity than other aminoglycosides Usual adult dose : 500 mg iv od/bd Dose:15mg/kg/day T.N: mikacin

Vancomycin Glycopeptide; Useful mainly against staphylococcus , MRSA Indicated in septicemia, bone & joint infections. LRTI and skin & soft tissue infections. Dose->500mg 6th hourly or 1g iv 12th hourly in adults. In children 40-60 mg/kg/day in 4 divided doses. Administrated slow iv only. Monitor auditory & renal functions T.N: Vanlid, vanmax

Teicoplanin Semisynthetic Glycopeptide; Has lesser nephrotoxicity when compared with vancomycin Mainly active against staphylococci Dose->10mg/kg once daily im or iv; Available as 200 mg & 400 mg vials. T.N: targocid

Aztreonam Monobactam; Novel Betalactam antibiotic, active against pseudomonas and enterobacter. Poor activity against gram +ve cocci and anaerobes Indications: hospital acquired infections originating from urinary, biliary, GI & female genital tracts. Dose->100mg/kg/day in 3 or 4 divided doses im or iv. Smaller dose for neonates May be reconstituted with D5, D10 or NS for iv infusions T.N: Azenam, Trezam 250 mg /500mg /1g Inj

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Ciprofloxacin FQ; wide spectrum, Active mainly against gram-negative. Indications UTI,Bacterial gastroenteritis,Typhoid,Respiratory infections,bone,soft tissue, gynaecological & wound infections, gram - ve septicemia, conjunctivitis, Dose: 250 - 750 mg BD oral, 100-200 mg BD iv, For children: 20-30 mg/kg/24 hr div into 2 PO/IV

T.N: cifran, ciplox CAUTION: Don’t prescribe NSAIDs & FQ together at a time, because of it’s seizurogenic potential.

Norfloxacin FQ. Effective against a wide range of gram +ve, gram -ve organisms including pseudomonas. Not effective against anaerobes Indications  A/c UTI - 400 mg bd x 7-10 days  C/c UTI - 400 mg bd x 4 weeks and then 400 mg od x 12 weeks(especially in cases of reflux as seen in ultrasound scan)  Dysentry 200-400 mg bd x 5 days  Urological procedures in neutropenic patients-> 400 mg bd x 8 weeks T.N: norflox, uroflox

Ofloxacin Highly potent FQ. Useful in serious infections like septicemia Dose->200mg iv infusion over 30 min or oral-200 mg bd T.N: oflacin, bactof

Levofloxacin FQ; Very useful in resp infections,skin/soft tissue infections. May be used in combination with pencillins in pneumonia. Dose->500 mg od x 5 days oral or inj T.N:levobact, levoday, glevo

Linezolid Oxazolidinone, Active against MRSA,VRSA,VRE, penicillin resistant streptococci Restrict use to serious hospital acquired pneumonia, febrile neutropenia, wound infections to prevent emergence of resistance. Available as 300ml infusion; each 100ml contains 200mg. 600 mg tablets available Usual adult dose 600 mg iv bd, children: 10 mg/kg/dose Q12H PO/IV T.N: Linox, Lizoforce

Azithromycin Macrolide with high activity on respiratory pathogens. Indications:  RTI, Atypical pneumonia,  Uncomplicated Skin & skin structure infections,  STD’s, prevention of STD’s following sexual assault,genital ulcer disease,  Cat scratch disease,  a/c PID etc Dose: 500 mg PO/IV OD x 3 days,children: 10 mg/kg/day on first day, then 5mg/kg/day on days 2-5. T.N: Azee, Atm, Azimax

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Piperacillin +Tazobactum Piperacillin: ureidopenicillin. Tazobactum: β- lactamase inhibitor. Indications: peritonitis, pelvic/urinary/respiratory infections Concurrent use of gentamycin is advised. Dose: 4.5 g iv Q8H, 200-300 mg/kg/24 hr div into 4 doses, im or iv. Term newborn:<7days, 50 mg/kg/dose Q8H; and >7days, Q6H T.N: Piptaz

Meropenem Carbapenem; Active against both gram-positive & gram-negative bacteria, aerobes & anaerobes It is the reserve drug for the treatment of septicemia, intra abdominal & pelvic infections Usual adult dose: 1 g iv bd,children: 60 mg/kg/day div into 3 doses IV T.N:Meronem

Metronidazole Activity for anaerobic organisms. Usual adult dose 500 mg iv Q8H, oral- 400 mg tds, children:30-50 mg/kg/24 hr div into 3 PO. Tab 200, 400 & Syp 200/5 available T.N: Metrogyl,Flagyl Tinidazole Similar to metronidazole, better tolerated,long duration of action, higher cure rate Usual iv adult dose : 800 mg infusion once daily. Tab 300mg, 500 mg, 1g available T.N: Tiniba

Combinations Cefixime 200 + ofloxacin 200: Mahacef Plus,Milixim-O,Cefolac-O, zenflox-plus Cefixime 200 + Ornidazole 500: Milixim-OZ,Cefolac-OZ Cefixime + clavulanic acid : Milixim-CV Cefixime 200 + Azithromycin 500/250 : Azifine-C, Cefolac-AZ Ornidazole 500 + ofloxacin 200: Ornof, Oflomac-OZ Azithromycin 250/500+ Levofloxacin 250/500: Azifine-L Cefuroxime axetil 250/500 + Clavulanic acid 125: Altacef CV, Forcef-CV Cefpodoxime + clavulanic acid :Kefpod CV, Monocef-O CV Cefpodoxime + Ofloxacin: Macpod-O Cefpodoxime + Azithromycin: Macpod-AZ Cefpodoxime + Levofloxacin: Macpod LX

THE GP NOTE Edited by Dr Firdause A.H, GMC, Trivandrum

103 Vaccination Courtesy: National Immunization Program, IAP Recommendation, 2014 Update Birth :BCG, OPV -0, Hep B1 6 weeks: DTwP 1, OPV-1, Hep -B2, Hib 1(meningitis), Rotavirus 1, PCV 1 10 weeks: DTwP 2, OPV-2, Hib 2, Rotavirus 2, PCV 2 14 weeks :DTwP 3, OPV-3, Hib 3, Rotavirus 3, PCV 3 6 months: Hep -B3, 9 months: MMR 1 or Measles 12 months: Hep A 1 15 months: MMR 2, Varicella 1, PCV booster, 16-18 months: DTwP B1, OPV B1, Hib B 1, 18 months: Hep A 2 2 years : Typhoid 1 4-6 years: DTwP B2, , Varicella 2, Typhoid 2 10-12 years : Tdap/ Td/TT, HPV , note: HPV 2(1 month after 1st dose), HPV 3(after 6 months), 16 yrs: Td/TT Note: HPV 2(1 month after 1st dose), HPV 3(after 6 months),Two doses of HPV vaccine for adolescent/preadolescent girls aged 9-14 years For two-dose schedule, the minimum interval between doses should be 6 months Three dose schedule for adolescent girls aged 15 years and older to continue Note: if measles vaccine is given at 9 months, then MMR 1 at 12-18 months & 2nd dose 8 weeks after 1st dose. Varicella 2 can be given anytime 3 months after 1st dose. Note: for 6, 10 & 14 week vaccination, always give paracetamol Q6H for 1day. Others Meningococcal vaccine: recommended over 2 yrs of age, single dose 0.5 ml s/c or IM, T N : Mencevax A & C PCV : Pneumococcal conjugate vaccine, T N :Prevenar Pneumococcal Polysaccaride vaccine : after 2 yrs of age, one booster dose after 5 years of age, T N :Pneumo 23 (0.5 ml IM) Varicella Vaccine, T N : Varilrix Rotavirus, T N: Rotarix, HPV, T N: Gardasil, Cervarix; Typhoid Vaccine ,T N: Typherix(IM) Hepatitis B, T N: Engerix-B IM Hepatitis A , T.N: Havrix 0.5 ml IM MMR, T.N: Tresivac 0.5 ml s/c; Hib Vaccine, T N: Hiberix (IM) Cholera vaccine: given for children above 1 yr, 2 doses 2 weeks apart. JE Vaccine : 1st above 8 months of age, 2nd dose at 16-18 months, T.N:JEEV Influenza: 1st dose above 6 months, 2nd dose after 1 month , T.N: Fiuarix

Ventilatory support Modern ventilators deliver a gas flow with a cycling mechanism to cut airflow during expiration.The ventilator breath may be volume controlled (a predetermined tidal volume is delivered), pressure controlled(gas flow is at a pre-determined pressure), or volume controlled with a limited pressure( the ventilator delivers a preset VT within a pressure limit unless the lungs are non-compliant or airway resistance is high. Various mixed modes are also available.

104 Modes of ventilation: Controlled mechanical ventilation (CMV), assist control mechanical ventilation(ACMV), intermittent mandatory ventilation(IMV), pressure support ventilation(PSV), Volume support ventilation(VSV) Initial ventilator set-up Check for leaks Check O2 is flowing FiO2 : 0.6-1 VT :5-10 mL/kg Rate: 10-15/min I:E ratio : 1:2 Peak pressure ≤35 cm H2O PEEP : 3-5 cm H2O Setting up the ventilator Tidal volume:values of 6-7 mL/kg ideal body weight. Smaller VT & minute volume may be needed in severe airflow limitation(e.g. Asthma, a/c bronchitis) to allow prolonged expiration Respiratory Rate: usually set in accordance with VT to provide minute ventilation of 85100mL/kg/min. Inspiratory flow: usually set between 40-80 L/min. Higher flow rates are more comfortable for alert patients. This allows for longer expiration in pt’s with severe airflow limitation, but may result in higher peak airway pressures. I:E ratio: A function of RR, VT, inspiratory flow, & inspiratory time. Prolonged expiration is useful in severe airflow limitation while a prolonged inspiratory time is useful in ARDS to allow slowreacting alveoli time to fill. Alert pt’s are more comfortable with shorter inspiratory times & high inspiratory flow rates. FIO2: set according to arterial blood gases, usual to start at FIO2 = 0.6 -1, then adjust as per ABG & pulse oximetry. Airway pressure: In pressure-controlled or - limited modes, a peak airway pressure can be set(ideally ≤30 cm H2O). PEEP is often increased to maintain FRC when compliance is low. Adjusting the ventilator Adjustments are usually made in response to ABG, pulse oximetry, pt agitation or discomfort, or during weaning. Migration of the ET, either distally to the carina or beyond, or proximally such that the cuff is at vocal cord level, may result in agitation, excess coughing, & a deterioration in ABG. Tube migration or obstruction should be considered & rectified before changing ventilator settings or sedative dosing. The choice of ventilator mode depends upon conscious level, the no of spontaneous breaths being taken, & ABG. Many spontaneously breathing pt’s can cope adequately with pressure support ventilation alone. However a few intermittent mandatory breaths(SIMV) may be needed to assist gas exchange or slow an excessive spontaneous rate. The paralysed/heavily sedated pt will require either volume- or pressure-controlled ventilation. Earlier use of increased PEEP is advocated to recruit collapsed alveoli & thus improve oxygenation in sever respiratory failure. Low PaO2 : increase FIO2/PEEP/I:E ratio. Consider increasing pressure support/pressure control or VT. In CMV consider increasing sedation ± muscle relaxants. High PaO2: decrease FIO2 or I:E ratio or PEEP or level of pressure control/pressure support if VT adequate. High PaCO2: increase VT (if low) or RR. Reduce rate if too high( to reduce intrinsic PEEP), reduce dead space. In CMV, increase sedation ± muscle relaxants Low PaCO2: decrease RR, VT

105 ADVANCED CARDIAC LIFE SUPPORT ALGORITHMS PULSELESS ARREST ALGORITHM

106 BRADYCARDIA ALGORITHM

107 TACHYCARDIA ALGORITHM

108 Sample Referral letter Date: Time: To whom it may concern Sir/madam I’am referring Mr./ Smt ..............., ......yrs, a k/c/o ................. ..................... now presented with c/o ................................................................................................. O/e, he/she has............................................................................................................. The investigation done show......................................................................................... My clinical impression is ............................................................................................... I have given the following treatment.............................................................................. I’am referring him/her to you, for expert evaluation, care & Management. Kindly do the needful. Thanking you Your’s sincerely Signature WHAT TO DO WHEN A PATIENT DIES When a pt dies, write the following format, in the pt’s case sheet irrespective of the cause of death. 00:00 Pt gasping 1.Inj Atropine 1 amp, inj adrenaline 1 amp iv st Pulse not palpable , BP unrecordable 2.Inj Dopamine 400 mg in NS @ 14 dps/min CPR started Pt intubated;Ambu bag ventilation given Note: 2010 ACLS guidelines excludes atropine administration for PEA/asystole 00:05 Pulse, BP unrecordable CPR & Ambu bag ventilation continued

1.Inj Atropine 1 amp, inj adrenaline 1 amp 2.Inj Dopamine

00:10 Pulse, BP unrecordable CPR & Ambu bag ventilation continued

1.Inj Atropine 1 amp, inj adrenaline 1 amp 2.Inj Dopamine

00:15 Pulse, BP unrecordable ECG shows no cardiac activity No spontaneous respiratory effort Pupils Dilated & fixed Irrespective of all resuscitative efforts, pt expired at _ _:_ _ am/pm on _ _/_ _/_ _(Date) Pt declared clinically dead. Signature

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