TITLE
FEVERFEVER

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 less than 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.

P’mol C/I in severe liver diseases, renal impairment, infants less than 2 kg.

Anti ulcerantsAnti 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)

COUGHCOUGH

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)

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)

2ml 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)

Abdominal PainAbdominal 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

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 seizuresFebrile 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.

VomitingVomiting

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 stoolsLoose 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

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

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).

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

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,

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

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 shockAnaphylactic 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.

Patient with wheezePatient 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

In severe cases, Nebulisation can be done by combining Salbu(2.5-5mg) & Ipratropium

> 5 yr:- 250 mcg(1ml)(12.5 mcg/kg/dose).Budesonide :Children 12 months to 8 years of age:-

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 1 st 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

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.

Dog Bite ( also cat,bandicoot,monkey,cattles,bats,wild animals etc)Dog Bite ( also cat,bandicoot,monkey,cattles,bats,wild animals etc)

( 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.

InjuryInjury

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.

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.

AbrasionAbrasion

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

BurnsBurns

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

Chest TraumaChest 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 + LRTICOPD 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)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 3 rd gen cephalosporins)

6.Adequate hydration.

Incessant crying of infants/childrenIncessant 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

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)

Allergy/pruritus(itch)/urticaria(hives)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 ReactionInsect Bite Reaction

Treatment same as Allergy/pruritus(itch)/urticaria(hives)

Note: for infected insect bite Mupirocin Oint can be given

EpistaxisEpistaxis

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

Nasopharyngitis/ cold/ acute coryzaNasopharyngitis/ 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.

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)

Sore ThroatSore 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

ParotitisParotitis

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 throatForeign 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.

LaryngitisLaryngitis

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

TonsillitisTonsillitis

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 bronchiolitisA/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

QuinsyQuinsy

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 epiglottitisA/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( 3 rd 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

Nasal bone fracturesNasal 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 noseFuruncle 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.

SinusitisSinusitis

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 PolypNasal Polyp

1.Antiallergics(oral or nasal spray can be used)

2.Analgesics

3.Antibiotics if there is evidence of infection;Ent consultation

Otalgia(Earache)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,

Wax in the EarWax 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 externaA/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.

VertigoVertigo

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.

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

TinnitusTinnitus

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

StridorStridor

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

AOMAOM

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)

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.

ConstipationConstipation

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)

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 mouthBitter 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.

AnorexiaAnorexia

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/SingultusHiccups/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/flatulenceContinous 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

Epigastic PainEpigastic 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 childrenDyspepsia & 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 aniAnal 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

Note: Albendazole C/I in pregnancy & lactation

2.T avil 25 mg HS & SOS

Joint sprainJoint 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 painPain 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)

Neck PainNeck 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

Back PainBack 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 painHeel pain

Aetiology: Plantar fascitis, achilles tendonitis,heel spurs, stress fractures, bursitis etc

Inv: X-ray foot

First Aid in FracturesFirst 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.

AnaemiaAnaemia

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 consciousnessFall/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/weaknessFeeling 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

InsomniaInsomnia

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 PatientAggressive 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 tremorsChronic 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 intoxicationA/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)

ShiveringShivering

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

HypotensionHypotension

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)

OedemaOedema

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

Left ventricular failure/ Acute pulmonary edemaLeft ventricular failure/ Acute pulmonary edema

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)

HypoglycemiaHypoglycemia

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.

Pt may be observed for 24 hours.

Diabetic KetoacidosisDiabetic 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

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

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.

mmol/L at any point of treatment, insulin should be stopped and K+ replaced

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

UTIUTI

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)

HematuriaHematuria

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.

HyperventilationHyperventilation

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

HypertensionHypertension

(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 end

organ damage.

Note:a/c reduction of BP is required only in hypertensive emergency like MI with HTN,

stroke with HTN, hypertensive encephalopathy etc

PalpitationPalpitation

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 painChest 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

Heartburn/pyrosis/cardialgia/acid indigestionHeartburn/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 AnginaUnstable 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 3.125-

25mg (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

Status EpilepticusStatus 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

HaemoptysisHaemoptysis

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

Systemic HypertensionSystemic Hypertension

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

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

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 1 st 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.

Antihypertensives which can be used safely in pregnancy:->

 Alpha Methyl Dopa

 Nifedipine

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)

HyperlipidaemiaHyperlipidaemia

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

1 st line therapy: Statins are given .

2 nd 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.

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

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

HyperuricemiaHyperuricemia

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)

HypothyroidismHypothyroidism

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

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

For peripheral neuropathy/ Neuropathic Pain/ fibromyalgiaFor 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 PalsyFacial 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

Giddiness/syncopeGiddiness/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

Motion SicknessMotion 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)

HeadacheHeadache

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.

MigraineMigraine

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

TremorTremor

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 ToothCaries Tooth

Rx:

1. Analgesics->Brufen

2. Antibiotics; Amoxicillin, Metronidazole

Dental consultation

Gum AbscessGum Abscess

Rx:

1. Antibiotics; Amoxicillin, Metronidazole

2. Analgesics ; Vit C

3. Warm saline gargle, Apply Pressure

4. Refer to dentist for I & D

GingivitisGingivitis

Rx:

1. Clohex Plus oral rinse(chlorhexidine)

2. Vit C

3. Antibiotics

4. Analgesics

Cheilosis/angular stomatitisCheilosis/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

HalitosisHalitosis

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 UlcersAphthous 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)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)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)

ConjunctivitisConjunctivitis

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

ScleritisScleritis

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 UlcerCorneal 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 3 rd 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 UlcerFungal 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, ChalazionHordeolum 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

BlepharitisBlepharitis

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.

A/c DacrocystitisA/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 glaucomaA/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 iridocyclitisA/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

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