Treatment Guideline For Intern Doctors in Medicine Ward

First part
01. Patient with abdominal pain 01-02

02. Patient with dyspnoea 03-05
03. Patient with fever 06-08
04. Unconscious patient / Semiconscious patient / CVD 09-12
05. Haematomasis & Malaena 13
06. Haemoptysis 14
07. Epitaxis 15
08. Patient with CLD 16
09. Hepatic Encephalopathy 17
10. Viral hepatitis 18
11. Liver abscess 20
12. Electrolyte imbalance 21-25
13. Patient with paraperesis/quadriperesis 26
14. Spinal cord compression 27
15. Patient with convulsion 28
16. Patient with vertigo 29
17. Syncope 31-32
18. Patient with vomiting 33
19. Renal failure 35-40
20. Antihypertensive drug 41-47
21. Patient with oedema 48
22.CLD 49
23. AGN & NS 50
24. Poisoning 51-65
25. Acute coronary syndrome 66-68
26.Atrial fibrillation 69-70
27. Patient with joint pain & swelling 71-81
28. Pneumonic consolidation 82-83
29. Patient with pleural effusion 84-91
30. Hepatitis B 92-96
31. Patient with bleeding spot 101-103
32. Patient with anaemia 104-110
33. Patient with headache 111-114
34. H/O in patient with headache 115-116
35. H/O in patient with DM 17
36. H/O in patient with fever 18
37. H/O in patient with dyspnoea 19
38. H/O in patient with CVD 20
39.Approach to patient with dyspepsia 119-
40. Treatmemnt Of Gerd 120
41. Irritable Bowel Syndrome 121-122
42. Fatty Liver 123-124
43. Approach to a patient with SOL in the liver 125
44. Approach to a patient with hepato cellular carcinoma 126
45. Approach to patient with Bells palsy / VII nerve Palsy 127-128
46. Enteric fever 129-130
47. MALARIA 131-134
48. Approach to patient with PUO 135-136
49. Approach to patient with sepsis or septicemia 137-138
50 Approach to patient with KALA-AZAR 139-141
51. approach to pt with DM 142-163.
52. Multiple myeloma 164-166
53. Approach to a patient with pancytopenia 167
54. Approach to a patient with ALL 168
55. Chronic myeloid leukemia 170
56. Thalassamia 171-172
57. lymphoma 173-174
58. Approach to patient with stroke : 175
59. TIA 179
60. GCS 180
61. stroke (extra not for all) 181-193
62. Approach to patient with dysphagia 194-195
63. Approach to a patient with hepatosplenomegaly 196-198
64. Approach to patient ascites 199-200
65. Find out the site of lesion from the presenting complaint
201-204
or focal sign
66. approach to a patient with back pain: 205
When I was intern doctor my CA was too busy to give me time

We always remained scared during receiving patient. What will b the pt complaint & what will b the Dx
, how will I proceed . and what will b the Rx
Will I call my CA ?
If I call him will he angry with me ?. specially at night it was night mare for us
When I become CA. I saw still today the intern doctor are facing same problem.
They confusing during receiving a patient and giving treatment and they have to wait for mid level
visit even for simple management .
In round mid level discus uncommon d/d and management which academically important but
practically burden to intern doctor .
That why I try to write a guide line for intern doctor , who are new for in medicine ward
It is written on basis of my practical experience in medicine ward and round of note of different
teachers
Please do not use it as reference to others specially to mid-level ( only text can use as reference )
It is only for u and help u only when u r beginner.
If any contradiction Please follow the text book
Though It is made for intern doctor of MU-1 (w--15) , it will be my pleasure & honor If intern doctor of
MU-II and MU-III use it
There may be some printing mistake and spell of pen so pl forgive me and correct spontaneously
If any clumsiness or if u failed to understand of any thing written here pl call me on 01912104673
With thanks
Dr. Shamol
Assistant registrar
MU-I, MMCH
Treatment profile for intern doctor
A PATIENT WITH ABDOMINAL PAIN
First exclude
Perforation by
Obliteration liver dull ness
broad like rigidity
rebound tenderness ( peritonitis )
Appendicitis
Pain in R I F MB tenderness
rebound tenderness ( peritonitis )
CBC urine RME
Intestinal obstruction
Cramping pain
abdominal distension by percussion
vomiting constipation
bowel sound
Investigation of choice
Plain x-ray abdomen in erect posture including both dome of diaphragm
Exclude perforation and
intestinal obs. Subacute obs.
Next investigation
USG of whole abdomen to exclude HBS AND PANCREASE
Pancreatitis
cholecystis cholelithiasis
liver abscess
If suspect pancreatitis
pain epigastric with tenderness
not relief by ordinary treatment
Pl do CBC, serum amylase
If the patient is middle aged
Pl do ECG to exclude MI / angina
Then seen
Murphy sign to exclude cholecystitis
Then exclude
Cystitis and UTI by
burning sensation micturation
suprapubic tenderness
Pylonephritis by
ab.pain fever and renal
agnle tender ness
do urine RME
Renal colic
If female patient with lower abdominal pain
Ectopic pregnancy --- H/O amenorrhea
PID by married women and pelvic discharge
Then look for PUD
Fever with upper abdominal pain never think pud think infective cause
Cholecystitis , liver abscess , pylonephritis , pancreatitis
Dr. shamol 1
Choice of investigation
Plain x-ray abdomen in erect posture including both dome of
diaphragm
USG of whole abdomen
Treat on admission
Bed rest
NPO
NG suction 2 hrly
Inj. Normal saline 1000 ml

o+
Inj. Heatman 1000 ml
I V @ v 20 drop / min
Inj. Ciprofloxacin 100 ml

1 bag iv bd
Inj. Ranison 50 mg or inj. P.P.I 40 mg
1 amp iv stat and 8 hrly 1 vial iv stat and daily
Inj. Anadol 100mg
1 amp IM stat and 8 hrly
Inj. Algin / norvis
2 amp iv stat and 8 hrly if ( clamping pain )
If suspect appendicitis or peritonitis

Inj . metronidazole 500mg
1 bag iv stat and 8 hrly
Caution
Never use the Toradolin in upper abdominal pain if u cannot exclude PUD
Toradolin use in renal colic and UTI
No anti-biotic is needed in pud
Dr. shamol 2
A PATIENT WITH DYSPNEA
A----Acidosis DKA, uremia CRF / ARF

B----Bronchial asthma
C----COPD
D---- DKA
E----Thrombo embolism / emotional / pulmonary edema
F---failure left heart failure
Bronchial asthma
Young patient , H/O previous attack , allergy

Wheeze ronchi vesicle breath sound with prolong expiration
COPD
Confused with LVF

H/O cigerate smoking old age cough for years with sputum
Crep +++ ronchi tongue cyanosis wheeze
eye congested tongue cyanosis
bounding pulse warm periphery flapping tremor
lip pursing , barrel shape chest , apex beat not palpable , liver dullness lower down
If COPD patient present with edema then it is called cor-pulmonalae
LVF
Tachycardia / pulsus alternus

Cyanosis
Gallop rhythm
Othropnea
Sweating and could periphery
Basal crep +
HTN +/-
If lung is clear but patient is dyspnic Cause is Uremia CRF / ARF

DKA
Then functional HCR before thinking it first
Pl do ECG
RBS
S.creatine
CXR should be done when patient is settle and
Should be done immediately your are thinking pneumothorax
Sudden sever respiratory distress Is due to

Pneumothorax -----breath sound diminish and percussion is hyper resonance
LVF
Dr. shamol 3
BRONCHIA ASTHMA COPD / CORPULMONALAE
1. Diet normal 1. Diet normal

2. O2 inhalation low flow 2 l
2. O2 inhalation
3. Nebulization stat and sos or 4/ 6 hrly
(Sul.sol 1ml+.5 ml ipr.sol +1.5 ml normal sal .)
(Sul.sol 1ml+.5 ml ipr.sol +1.5 ml normal sal .)
4. Tab. Ciprocin 500 mg / levox 500 mg
4. Tab. Ciprocin 500 mg / levox 500 mg
1+0+1 0+0+1
1+0+1 /. 0+0+1
Or ideally patient is rich / very severe
5. Sulprex inhaler
Tab. Moxaclav 625 mg
2 puff qds
1+ 1+1
6. Beclomin inhaler
5. Sulprex inhaler
2 puff tds
2 puff qds
7. Inj. Cotson
6. Beclomin inhaler
2 amp iv sat and
1 amp iv 6 hrly 2 puff tds
7. Inj. Cotson
8. Inj. Ranison 50 mg / cap omeprazole 20mg
1 amp iv 8 hrly / 1+ 0+ 1 2 amp iv sat and
1 amp iv 6 hrly
In some case 8. Inj. Ranison 50 mg / cap omeprazole 20mg
We use
1 amp iv 8 hrly / 1+ 0+ 1
Ticamet inhalar (salmetrelol + flucortisone ) in rich
2 puff bid 9. more crep present // oedem present
Montelukas 10 mg
Inj. lasix
0 +0 +1
For rescue therapy mainly in discharge 2 amp / amp iv stat .
Tab .cortan 20 mg
1 amp iv bd or
1 + 0 + 0 for 7 days
less severe mild cerps
Tab. Fusid plus
1+ 1+ 0
10. Tab contin 400 mg
+0+
In some case
We use in rich
Ticamet inhalar (salmetrelol + flucortisone )
2 puff bid
For rescue therapy mainly in discharge
Tab .Cortan 20 mg
1 + 0 + 0 for 7 days
Dr. shamol 4
LEFT VENTRICULAR FAILURE
O2 In halation
Propped up position
Inj. Lasix
2 amp iv stat and
2 amp iv repeat after 30 min up to 160 mg
GTN
anril sprays
anti HTN drug
When you are in confusion between LVF AND COPD

Then give Inj. Lasix 2 amp iv stat and repeat after hr with COPD treat, if patient feel better
after giving lasix then it was LVF
Sign of severe asthma

STEP COPD
Silent chest
Tachycardia > 120
Exhaustion
Pulsus paradoxious
Cyanosis / patient cannot speak
02 decrease Co2 increase
Peak expiratory flowmetry < 60 %
Dehydration due hyperventilation
Dr. shamol 5
FEVER
Fever is two type one is emergency
Patient with fever of 1 to 5 days and followed by unconscious
d/d is cerebral malaria / encephalitis / meningo-encephlitis
Ist see neck rigidity
Endemic area of malaria
Do ict for malaria and cbc and CSF study
1. Diet NG feeding
200 ml 2 hrly
2. Inj. Ceftron 2gm

1 vial iv bd
3. Inj. Libot -25 100 ml

I v @ 10 d/min
4. Inj . 5% DNS 500 ml

+
Inj. Jasoquine 3 amp
Iv @ 30 d/min stat (over 4 hrs)
Then
5. Inj . 5% DNS 500 ml

+
Iv @ 30 d/min (over 4 hrs) 8 hrly
In between jasoquine drip
6. Inj. Hartman 1000 ml

I v @ 10 d/min
7. Inj.ranison 50 mg
1 amp iv 8 hrly
If patient is rest less then
8. Inj .perol
1amp i.m. stat
9. Continuous catheterization
10. If you suspect viral encephalitis then

Tab. virux 400 mg
2+2+2+2+2
11. When patient can take orally then replace
Tab.Jasoquine 300 mg 2 + 2 + 2
Dr. shamol 6
Fever 1st look for duration more than 7 days or less then 7 days
High / low
Character continued / intermittent / remittent
Chill and rigor---------------------------------------malaria /cholangitis /UTI (pylonephritis)/
pneumonia
Head ache and vomiting
Neck rigidity meningitis
Cranial nerve palsy ---- vi palsy ---- TBM
Eye anaemia ..lukaemia / aplastic anaemia
Jaundice viral hepatitis , leptopirosis ( renal invol urine RBC, leukocytosis, bil ), malaria ,sepsis
Running nose and malaise -------common cold / viral fever
Mouth -----------Sore throat , Tonsillitis
Ear --------Otitis media
Cervical lymphadenopathy Lukaemia , lymphoma , TB , viral
Boney tenderness Acute lukaemia
Lung
Cough , crep ,
Consolidation , effusion
Tenderness on percussion pneumonia / lung abscess
Abdomen
Liver if tender then-- liver abscess
Spleen---enteric , malaria , kala-azar
Clubbing and changing murmur and vasculitis ------Infective endocarditis
Rash
Renal angle tenderness
Supra-pubic tenderness
UTI
Hepato-billary tenderness
Joint pain full swelling
Relative bradycardia
NEVER DO WIDAL TEST BEFORE 7 DAY

if fever is less than 7 days then cause may be VIRAL , PNEUMONIA , MP,
If more then 7 days then TYPHOID AND MALARIA, other
CBC
URINE RME
RBS
WIDAL TEST IF > 7 days
If more than >7
Pl do CXR PA
USG OF whole abdomen
In endemic zone more then one month do kala-azar
If suspect TB do TB investigation
CBC ,MT,
RBS, CXR PA,
sputum AFB
if efusion the fliud study
Dr. shamol 7
WHEN DIAGNOSIS IS UNDER EVALUATION THEN TREATMENT
Bed rest
Diet normal
Tab. Ciprofloxacin 500mg
1+0+1
Cap. Omeprazole 20 mg
1+0+1
Tab. Omidone 10 mg
1 + 1 +1
Tab. P/C
1 tab . when temp. more > 101
Maintain temp. chart
If you suspected TB then before AFB result come ----Donot give ciprofloxacin / Moxaclav
If suspect simple RTI then tab. Azithromycine 500 mg 0+0+1
If suspect simple UTI then tab cipro 500 or furocer 250mg 1+ 0 + 1 and urine for CS
If prolong fever and patient is toxic and do following
Diet normal
Inj . 5% DNS 1000 ml

I v @ 10 d/min
Inj. Ceftron 2gm

1 vial iv bd
1+0+1
Tab. P/C
1 tab . when temp. more > 101
Maintain temp. chart
If u want to add anti malarial in combination then do this
o Tab.Jasoquine 300 mg
2+2+2
o Tab. Omidone 10 mg
1 + 1 +1
o Oral glucose
In case of treatment of pneumonia

Tab . Moxaclav 625 mg
1 + 1 +1
Tab . Clarin 500 mg
1 + 0 +1
Dr. shamol 8
UNCONSCIOUS PATIENT / SEMICONSCIOUS PATIENT / CVD
First think structural ( CVD ) and then think metabolic
CVD ----- Sudden onset / previously well --patient was Walking /Sleeping / Doing normal activity
Focal neurological sign such as --- hemi/mono paresi, aphasia , cerebellar sign .
Haemorrhagic ---- head ach / vomiting /HTN /unconsciousness
If neck rigidity present then sub arachnoid haemorrhage
Infarctive stroke .usually conscious .. hemi/mono paresi, aphasia
A patient with severe head ache pl do the following

If with fever ------ meningitis / encephalitis
ICSOL ---- vomiting + long HO head ache + papillaedema
Haemorrhagic stroke .. HTN unilateral focal sign
HTN encephalopathy ------ HTN, bilateral planter extensor / papillaedema
INFECTIVE CAUSE
Meningitis /encephalitis /cerebral malaria ---fever unconsciousness, neck rigidity +/-
TBM / abscess ----- prolong H/O fever / semiconscious / neck rigidity +/-
Not respond to other treatment
TRAUMA
HO Recent head injury or h/o head injury 2/3 month ago
METABOLIC
1. DKA ----D --- Known or unknown case DM without treat with infection
K --- urine keton body kenotic breath
---- Acidosis --- kussmal breathing
Patient present with semiconscious/ respiratory distress /lung clear
dehydration / bed smell
Any DM patient with respiratory distress 1.DKA
2.then LVF
2. Uraemia ------- anaemia /HTN/ edema / respiratory distress
HO of renal disease ----CRF / GN / hypovolumia
3. Hepatic encephalopathy------jaundic /ascites / HO of liver disease /

sign of hepatic insufficiency
4. HTN encephalopathy ------ malignant HTN, bilateral planter extensor / papillaedema
CT-normal
5. HONK
6. ELECTROLYTE IMBALANCE
Hyponatraemia --------- HO vomiting / elderly anorexic patient / +/- fever
No focal sign think electrolyte
Single vomiting may cause severe hyponatraemia
NEOPLASTIC
Primary ----- vomiting and head ache long HO. Fundoscopy.. papillaedema
Dr. shamol 9
DRUG AND TOXIC
Drug overdose
Poisoning . Opc/ dutura / alcohol intoxication
DEFICIENCY
vitamin B1
EXAMINATION
A----------AIRWAY clear or not , Suction---for secretion
B--------evidence of respiratory distress----increase R/R , chest in drawing, crep ++ aspiration

pneumonia
C-------- BP. Pulse sign of dehydration ..
GCS
Cranial nerve palsy -------3rd / 7th nerve , p
Pupil ----- unequal ----- herniation
Pinpoint ------ pontine haemorrhage
Neck rigidity -----
Temperature
Bp ---- - HTN ---hemorrhagic stroke / HTN encephalopathy
Pulse
Anaemia + jaundice + oedema ------ Uraemia
Polycythemia + lung crep ++ HO lung disease + edema + cyanosis ++---- hypoxic
encephalopathy
Heart --- murmur
Lung ---- crep . Respiratory distress lung clear is DKA / uraemia / HCR
Carotid bruit ----
Hand ---- sweaty with cold clammy hand
hypo glycaemia -- HO DM , BP normal , pulse incre.
MI --- chest pain +/- , BP decrease , pulse decrease
Hypovolumic shock -- BP decrease , pulse feeble
dehydration , HO fluid loss
Do neurological examination
Motor
Jerk
Planter ---
Bilateral extensor -- -encephalopathy
Unilateral extensor .CVD
Dr. shamol 10
TREAT MENT OF UNCONCIOUS PATIENT AND CVD
A ..clear away with suction if secretion
B . O2 inhalation is respiratory distress / inj. Lasix if creps +
C . Dopamine bp less than SBP 90 / FLIUD correction if dehydration
Diet NG feeding
200 ml 2 hrly
Inj. Ceftron 1 gm
1 vial iv bd If only haematoma with out ventricular
Extension
Continue same treatment
the cause is infarctive stroke
Inj. Oradexon
pl. add
1 amp iv stat and 8 hrly
tab .Clopid AS
0 + 1 +0
Inj. Ranison 50 mg
tab. Cerevas 5 mg
1+1+1
Chang posture 2 hrly Tapper the oradexon
Continuous catheterization If the patient is hyperlipidaemia and
IHD
Maintain I/O chart Give Statin
Tab. Atova 10 mg
If convulsion 0+0+1
o Inj . sedil 1amp iv stat and then
o Tab. Diphedan 100mg

1+0+2
o Rest less
o Inj. Perol
1amp im stat
If HTN then
o Tab. Camlodin 5 mg (NORMAL) / repril 5 mg ( CVD)
Dr. shamol 11
HAEMORRHAGE WITH VENTRICULAR EXTENSION
A ..clear away with suction if secretion
B . O2 inhalation is respiratory distress / inj. Lasix if creps +
C . Dopamine bp less than SBP 90 / FLIUD correction if dehydration
Diet NG feeding
200 ml 2 hrly
Inj. Ceftron 1 gm
1 vial iv bd

Inj. Oradexon
Inj. Ranison 50 mg
Inj. Osmosol 500 ml

300 ml 60 drop/ min
100 ml 30 drop / min 8 hrly for 5 day
o Tab. Nimocal 30 mg
2+2+2+2+2
o Tab. Diphedan 100mg

1+0+2
Tab. repril 5 mg
0+0+1
o Cap. Anadol 50 mg
1 +0 +1
o Rest less
Inj. Perol
1amp im stat
IF Constipated
Syp. D-LUC
2 TSF TDS
Chang posture 2 hrly

Continuous catheterization
Maintain I/O chart
Dr. shamol 12
HAEMATEMESIS AND MALAENA
Is medical emergency
Look for -------pulse .BP ..shock
------Anaemia
-------Urine out put
Immediately open an IV channel with inj.Hartsol
Bloold grouping and cross matching
Give one unit of blood and keep ready two donor
Diet --- normal
Inj. Hartman 1000ml

I V @ 20 D / min
Inj. Moxin 500 mg

1 amp iv 8 hrly
Inj. PPI 40 mg
1 vial I V stat and daily
Tab . ulsec 1 gm
1 + 1+ 1 + 1+ 1 1 hr before meal
Inj .caprolysin
1 amp glass of water PO stat and 8 hrly
Then take HO any

NSAID drug.
PUD.
Liver disease / jaundice.
CLD varices .
Look for renal failure
Lymphoadenopathy , boney tenderness+ fever + hepato-splenomegaly leukemia
Ascites + splenomegaly -----CLD
Investigation
1st choice of investigation endoscopy of upper GIT
To exclude D/D -----CBC, PBF

------S.CREATINE , RBS . PT
Dr. shamol 13
HAEMOPTYSIS
------Anaemia
Diet --- normal
Inj. Hartman 1000ml

I V @ 20 D / min
Cap . Moxin 500 mg (never use cipro group if u suspect TB as it mask the AFB )
1+ 1+1
Inj. Frabex
1 amp iv stat and then
Tab. Frabex / traxyl 500 mg

1+ 1+1
Cap . omeprazole 20 mg
1+ 0 + 1
Tab. Sedil 5mg

0+ 0 +1
CBC, MT
The D/D of S.CREATINE ,
Bronch. Ca RBS
PTB CXR
Chr./acute Bronchitis Sputum for AFB and
Bronchiectasis malignant cell
MS
Look for bronchogenic CA

Lymph node
Clubbing
Bone pain
SVO
Dr. shamol 14
EPISTAXSIS
------Anaemia
Stop bleeding first with appropriated procedure

If fail to stop and give a call to asst. registrar of ENT
Find out the cause

Look for SYSTEMIC ----HTN And renal failure
LOCAL ------------PNS and DNS
OTHER leukamia / lymphoma
hepatosplenomegaly
boney tenderness
rash , HO fever
lympadenopathy
investigation
Diet --- normal CBC, PBF

platelete count ,
Inj. Hartman 1000ml CT , BT
I V @ 20 D / min RBS
S.CREATINE
Cap . Moxin 500 mg XRAY PNS
1+ 1+1
Inj. Frabex
1 amp iv stat and then
Tab. Frabex / traxyl 500 mg

1+ 1+1
Cap . omeprazole 20 mg
1+ 0 + 1
Tab. Sedil 5mg

0+ 0 +1
Dr. shamol 15
CLD patient may present
hepatic encephalopathy (unconscious / alterconscious )
with out encephalopathy (ascites / jaundice )
with SBP (bdominal pain / fever )
with out encephalopathy

salt restriction
tab. ciprofloxacin 500 mg daily wt loss only

1 + 0 +1 ascites 0.5 kg
with peripheral oedema 1 kg
cap. omeprazole 20 mg Dose minimum max
1 + 0 +1 frusemide 40 mg 160 mg
spirilactone 50-100 400
tab. fusid plus
1+1+0 refractory ascites
failure to decrease wt loss 0.5 kg/d
after 1 wk of max dose of combin
syp. D-LUC
diuretic (f-160 , s400 )
3 tsf tds
no NSAID, sedative , hypnotic
paracentesis
Draw ascitic fluid 2- 4 L every day or alternate
can draw 2-4 l fluid /day
day
with out albumin
maintain I/O chart dont draw fluid if patient in
encephalopathy / near to
maintian wt chart
if pt has varices tritrate dose of indever

tab. indever 40mg untill pulse become 25 % of
+0+ basal decrease when pulse come
below 60
if pt comes with abdominal pain / fever then
inj. ceftriaxon 1 gm
1 vail iv bd
if patient complain adominal pain

inj. anadol 100mg 1 amp im stat
inj. algin 1 amp iv stat
Dr. shamol 16
HEPATIC ENCEPHALOPATHY
A ..
B .
C .
Diet NG feeding
protien restricted Based on CHO diet + dub water
200 ml 2 hrly total 10 feed
Inj. Ceftron 1 gm
No NSAID ,Sedative,hypnotic, ACE inh
1 vial iv bd
Inj. 5%DA 1000 ml / INJ. HARTMAN 1000 ML

Inj. Ranison 50 mg
inj. konakion 10 mg
1 amp iv stat and daily for 5 days to diagnosed CLD
SGPT
syp. D-LUC S.blirubin
3 tsf tds
s.albumin / AG ration
prothrobin time
enema simplex stat and bd
HBSag
some like to give tab.
Asitic fluid study
o metronidazole 400mg +1/2 +1/2
Chang posture 2 hrly

in case of encephalopathy
SGPT
S.blirubin
prothrobin time
Maintain I/O chart
S.creatinine
S. electrolyte
in special situation
Hepato renal syndrome
----- when decrease urine out put and s.creatine
dobule and >2.5 mg / dl with in two weeks .
give nj. normal saline 1000ml
IV @ 20 /D MIN
OR
INJ. HUMAN ALBUMIN / INJ .ALBUTIN 50 ML )
IF patient is restless the with the parmisson of senior give
inj. Dormicum 7.5 mg
Dr. shamol 17
amp im / iv stat
viral hepatitis
diet normal
Inj. 5%DA 1000 ml / INJ. HARTMAN 1000 ML if pt is nausea / vomiting

cap. omeprazole 20 mg
1 + 0 +1
no NSAID, sedative , hypnotic
to diagnosed
tab. omidone 10 mg
SGPT
1+1+1
S.blirubin
syp. D-LUC prothrobin time
3 tsf tds HBSag
inj. konakion 10 mg TO exclude obstuction
1 amp iv stat and daily for 5 days
if itching present then give

tab. ursocol / ulive 300 mg
1+1+1
or konakoin
questarn ( cholestyramin ) when prothrombin time deference
1 saucet 12 hrly or 8 hrly is more the 4 .
acute viral hepatitis we can give
konakion with out doing PT.
Look for consciousness / drowsy and disoriented
Bowel pass / haematemesis /malaena
Dangerous complication of viral hepatitis fulminative hepatic failure

Difference between acute liver disease chronic liver disease
Albumin @ AG ratio normal decrease @ alter
USG normal coarse echo structure
FACTOR PREDISPOSING HEPATIC ENCEPHALOPATHY
BBleeding from GIT haematemesis @ malaena

C--- constipation
D---drug sedative , hypnotic , NSAID ,
E---electrolyte imbalance , hypokalaemia
FFever indicate infection
Minus top
T--- trauma
Ooperation
Pparacentasis
Dr. shamol 18
Follow up
Level of consciousness
Jaundice
Dehydration
Flapping tremor
Pulse , BP, Cyanosis
Abdomen
Percussion distension
Bowel sound
Fever / Temp.
Constipation / bowel pass
Bladder (urine out put )
Rebound tenderness
Abdominal girth
Planter extensor
Daily weight
Point 1 Point 2 Point 3

Prothrombin time < 4 4-------6 >6
Albumin >3 2.5----3.5 > 2.5
Bilirubin <2 2-------3 >3
Ascites None Mild to moderate Marked
Encephalopathy None 1/2 3/4
Child 1 = < 7 = well compensated
Child 2 = 7--9 = slightly decompensate
Child 3 = > 9 = decompensate
Dr. shamol 19
LIVER ABSCESS
Diet normal
Tab. Ciprofloxacin 500 mg

1+0+1
Tab. metronidazole 400 mg

2+2+2
1+0+1
Indication for aspiration of liver abscess
Tab. Anadol 50 mg (if pain)
1+1+1 If the abscess is more 5 cm
If in the left lobe
If impending to rupture
If patient is toxic then give following Not responding to medical therapy
Inj. Ciprofloxacin 100 ml

1 bag IV bd
Inj . metronidazole 500 mg

1 bag IV 8 hrly
Dr. shamol 20
ELECTROLYTE IMBALANCE
Effect of hypokalaemia
Skeletal muscle weakness --- flaccid paralysis / quadriparesis /parapersis but
reflex present .
Cardic muscle -------------- arrhythmia , ectopic beat
Visceral muscle ------------ paralytic ileus
ECG T flat , invert and appearance of U wave
Normal K level 3.5 to 5 .5 mmol / L

No treatment require if not > 3
If k level > 2.5 or some body say > 2
Correct orally
=such as Dub water , fruit K containing
= Syp. KT ( KCl ) 1 tsf = 15 meq
3 tsf tds
=some body prefer
Inj. Hartman if patient of IV fluid
If patient K level is < 2.5 or < 2
Oral
Plus

+
Inj. K T 2 amp
--------------------------------------
IV @ 20 D / min
REMMEBER FTHE FOLLOWING
1 amp KT contain = 20 m mol kcl

Max. rate of infusion 10 meq/ l in hour
Max 2 amp in 1L normal saline
So never give 2 amp + 1 L normal saline I n less then 4 hours
So never give 2 amp + 1 L normal saline more then 40 D/ min
1000 ml fluid if in 10 D/ min takes 24 hours

20 D/ min takes 12 hours
Dr. shamol 21
HYPER KALAEMIA
If K > 5.5 mmol/ l is called hyperkalaemia
Treatment is needed when > 6 mmol/ l
Reconfirm it is true or false
Cause of hyperkalaemia
ACE inhibitor
Flucid plus / spirolcatone
ARF / CRF
Pulse --- Bradycardia
Pl do ECG
67 : Tall tent shape T
7---8 : wide QRS complex
> 8 : sine wave
Remove the source of K containing drugs and fluid ( cholera saline )
1. Membrane stabilization
Inj. Calcium gluconate

2 amp ( 10 ml) I V over 10 minutes daily for 5 days
2.Insulin + Glucose
Inj .Libot -25 100 ml

+
Inj. Actrapid HM 10 unit
IV @ 20 D/ min daily for 5 days
3. Nebulization with blocker not use now
4. If acidosis present then
Give inj. Sodi-bi-carb 25 ml

2 amp Iv slowing stat and sos
5. k -Exchange resin
Kayexalate
15 gm TDS before meal
Dr. shamol 22
Electrolyte imbalance
Normal Na = 135 145 mmol / L
Hypo-natraemia
No treatment is needed if serum sodium < 130 mmol
Classify the hyponatraemia
Edematous Dehydration Normal dehydration

CCF Vomiting SIADH
Cirrhosis Diarrhea Meningitis
NS CVD
CRF osmolarity Tumor
Bronchogenic carcinoma
Pneumonia
First see this hypo natraemia is

Acute ----- need immediate treatment
OR
Chronic ------be cautious before treatment
In edematous patient --- hyponatraemia
Treatment is only restriction of water
Clinical presentation
Drowsy, disorientation
Confusion, convulsion , coma and restlessness
Classification
Mild -------------- 135 to 125
Moderate -------- 124 to 115
Severe ------------ < 115
IT IS BETTER TO UNDER CORRECTION THEN OVER CORRECTION
IN MILD ----- 135 ---- 125

Oral correction with
Table salt and
ORS only
Some prefer to give Inj. Normal saline 0.9%Nacl
MODERATE -------- 124 to 115

Oral
+
Inj. Normal saline 0.9% Nacl 2L
SEVERE ------------ < 115 some body prefer <110

Oral
Dr. shamol 23
+
3 % Nacl with caution
Before giving 3% Nacl think the following
Always consult with senior before giving it
It only avail able in Dhaka
It should be correct slowly with micro burette set
Never give it in hypo volumic patient.
No need to give If the patient is conscious and well oriented (chronic hyponatraemia )
WORKING FORMULA
32 drop / min
Never correct more then 10 m mol / L per day
Because there is chance of central pontine demyelination
1L 3% Nacl 513 mmol

TBW: total body
1L 0.9% Nacl 154 mmol water
== body wt 0.6
Na in fluid ---- measured Na
1 litre fluid will correct Na in mmol === -----------------------------------------------------
T.B.W + 1
Na in fluid - measured Na
1 litre fluid will correct Na in mmol
T.B.W 1
TBW
A patient of 50 kg Na level is 113 = 50 0.6
Na in fluid ---- measured Na = 30 kg
1 litre of 3% fluid will correct Na in mmol === ---------------------------------------
T.B.W + 1
513--113
= ----------------------------
30 +1
= 13 mmol
Max Na correction is 0.5 mmol / hr

Acute : with in 48 hr
Chronic ; correction not needed
When Na level become 120 mmol / l then u should be come cautious
Dr. shamol 24
HYPER NATRAEMIA
Due to decrease water

Diabetes incipedus
Psychogenic poly-dypsia
Na level > 145 mmol .
Choice of fluid is Inj. D.A
One liter DA will decrease sodium can calculate from the following formula
0 ---- measured Na
1 litre DA will decrease Na in mmol === -----------------------------------------------------
T.B.W + 1
A patient with Na level 160 mmol / L
0 ---- 160
1 litre DA will decrease Na in mmol === -----------------------------------------------------
50 0.6 + 1
==160/ 31
== 5 m mol
In one day u can give max 3.5 l fluid

But we donot give more then 2 liter fluid to avoid pulmonary edema
Max correction is 10 mmol per day
Osmolarity = 2 NA + 2k + urea + RBS in mmol
Dr. shamol 25
A PATIENT WITH PARAPERESIS / QUADRIPARESIS
GBS
Hypokalaemia
SPINAL CORD COMPRESSION ------------- 4 T
1. Trauma
2. Tumor 1.multiple myloma 2. Secondaries
3. TB
4. Transvers myelitis
GBS
CLUE T O DX
Reflex abscence
Sensory intact and no bladder and bowel involment
Orther feature
Gradual onset , ascending type , HO diarrhea / fever
DANGEROUS COMPLICATION : Respiratory distress

How will u access vital capacity clinically
Ask to count from 1 to onward with birth holding
If patient can count up to 30 the vital capacity is 3 liter
When vital capacity is less then 1.5 liter then patient will need ICU support .
GBS may present with dysphagia / dysarrthia
DD OF GBS IS HYPOKALAEMIA
To exclude it please do electrolyte
HYPOKALAEMIA
Clue to diagnosis
Only weakness but reflex present and planter flexor
Other
Proximal myopathy
Sensory intact and no bladder and bowel involment
HO diarrhea /
Unable to standing from squatting position
HYPOKALAEMIA PERIODIC PARALYSIS
After heavy meal , exercise patient develop quadriparesis
May have HO of previous semillar attack
Dr. shamol 26
SPINAL CORD COMPRESION
At least two of the following
Motor
Spastic paraparesis
Reflex exaggerated
Planter extensor (may be equivocal )
Sensory involvement ;
Definite sensory level
Bladder bowel involvement
Either retention or incontinence
If a patient with recent short HO of feature spinal cord compression with or without fever or
infection
Than think for acute transvers myelitis (if u suspect never forget to do fundoscopy )
Treatment of acute transvers myelitis
Inj . normal saline 100 ml

+
Inj. Methyl prednisolone 1 gm
-------------------------------------------
IV @ 40 drop / min for 3 days
In case of simple spinal cord compression
Bed rest
Physiotherapy
Tab . ciprofloxacin 500gm
1+ 0 + 1
Tab . neuro B
1+ 0 + 1
Tab .flexibec 10mg (muscle relaxant)
1+1+1
Tab. Tryptin 25 mg
0 + 0+ 1
Dr. shamol 27
A PATIENT WITH CONVULSION
DEF OF
CONVULSION
SEIZURE
EPILEPSY
CAUSE OF CONVULSION
Hypoglycaemia
Electrolyte imbalance mainly hyponatraemia , hypocalcaemia ,
CVD mainly hemorrhagic , may be in infarctive
ICSOL ---fundoscopy
Meningitis and encephalitis fever will present
Hepatic encehalopathy ---ascites / jaundice
Uraemic encephalopathy ARF ,CRF
Hypoxic encephalopathy COPD , shock
Hypertensive encephalopathy malignant HTN , Papilliedema
STATUS EPILEPTICUS
When series of seizure occurring with out regaining awareness between attack over period of 30
mins.
TREATMENT OF CONVULSION
No value of giving IM Inj. In convulsion
1. Immediately give
Inj. Sedil 10 mg
1 amp iv slowly stat and
Repeat after 15 mins . If patient wt is 40 kg
2. If not controlled Inj. Fosfophenytoin Cal. Dose : 20 40 = 800 mg = 8 amp.
Inj. Fosfine 100mg Then give 8 amp of inj. fosfine in
20mg/kg Bwt IV at of 100mg/ min normal saline via micro infusion set
over 8 mins.
3. If not controlled-
Repeat of calculated dose hr. later
4. Phenobarbitone may given in change of Fosfophenytoin
Inj. Phenobarbitone 200mg

Difference between seizure and
10mg/kg Bwt IV at of 100mg/ min
pseduoseizure
Seizure have
5. Then give prophylacting drug
Inj. Diphedan 100mg (phenytoin ) Tongue bite ,
1+0+2 Incontinence
Or And post ictal amnesia
if the patient is restless then do following
Inj. Phenobarbitone 200mg / tab. Barbit
amp im bd 1+0+1
Dr. shamol 28
A PATIENT WITH VERTIGO
CAUSE CENTRAL
Cerbellar cause ( TIA, Infarction, And, Hemorrhage )
AND
PERIPHERAL
BPPV
Meneiar disease
Labirynthitis
OTHER
Migraine
D/ D
This is not actual vertigo but the patient called it vertigo. This false vertigo should be excluded
TIA
Arrythmia
Hypoglycaemia
Anaemia
Postural hypotension ( DM, diuretic , hypovolumia ,)
APPROACH TO A PATIENT WITH VERTIGO

First exclude cerebellar cause
Examfor cerebellar sign Nystagmus
Finger nose test
Rapid alternative test
Heel seen test
Ask the patient to stand --- if the patient fall or stand on broad base gait
---- Patient fall toward site of lesion (if pt fall rt side = lesion in rt side)
Vertigo is mild but persist all the time
BPPV
Very severe which Vertigo occur in one specific direction
Vertigo occur in head movement ( and also lying to sitting/sitting to standing)
So severe vertigo that patient is lying stiffness and u cannot do examination properly
Halpik sign positive , vomiting +/ -
Meneiar disease
Vertigo with tinnitus , deafness +/-
If u suspect then give a call to ENT department
Labirynthitis
HO of fever
Nausea and vomiting
Ataxia
Other cause excluded
Take h/o
Heart disease , diabetes , hypertension
Drug HO of diuretic , hypertension
Dr. shamol 29
Anaemia
Migraine
INVESTIGATION
RBS
S.Creatinine
ECG
Electrolytes with permission of the senior
If suspect cerebellar cause pl do MRI of brain
Look for
Anaemia
BP ( postural hypotension --- BP on lying and then measure after 2 min and before 3
min of standing . If difference > 20 / 10 then it present)
Pulse for arrhythmia
Carotid bruit TIA
See cerebellar sign Nystagmus ( horizontal )
Finger nose ,
Rapid alternative ,
Heel seen
Ask the to stand
Heart and lung
Holpik test
Neurological examination
Fundoscopy exam to exclude papilledema .
TREATMENT
Bed- rest
Diet --normal

IV @ 15 D /min
Tab. Norium 5 mg / if old patient 60 yr s then 0 + 0 + 1

1 tab stat then
1+ 0+1
Tab. Stemitil 5 mg
1+ 1+1
Tab. Perkinil 5 mg
+0
1+ 0+1
Dr. shamol 30
SYNCOPE
Exclude Cardiac Cause
Arrhythmia (Brady/Tachy) VT ,VE, by pulse and ECG
LVF ---- Decrease cardiac out put
Aortic stenosis --- murmur and Echo-cardiacgraphy
Carotid hypersensitivity ------- Carotid bruit
Hypertrophic cardiomyopathy ---- Echo
Cervical spondylosis ----- Neck movement and X-ray cervical spine
Neurological cause
TIA
SEE
Epilepsy
PULSE
Vasovagal syncope
BP for postural hypertension
Cough
Carotid bruit
Defecation Heart for murmur AS
Micturation Move of cervical spine
Prolong standing Neurological exam + cerebellar sign
Anaemia
Cardiac syncope
Pallor ,palpitation , chest pain , dyspnea
Recovery < 1 min , quick recovery
Neurological syncope
Seizure may present
Recovery > 1 min slow recovery
Tongue bite
Incontinence
Exclude the cause that similar to syncope
Anaemia
TIA
Postural hypotension ( Drug , DM, )
Investigation
ECG
CXR
ECHO
RBS
X-RAY CERVICAL SPINE
CAROTID COLOR DROPPLER
Dr. shamol 31
A diabetic patient come to u with Sweating with cold clammy skin / hand
1. hypoglycemia --- HO of insulin of oral hypoglycaemic drug , +/ - missed meal
--- sweaty , tremor , palpitation, but BP normal
2. MI ---- Chest pain and breathlessness and sweaty hand, decrease BP
FRIST EXCLUDE HYPOGLYCAEMIA THEN MI

SO PL DO RBS FIRST AND THEN ECG
Mangment of hypoglycaemia
Oral fruit juice , sugar
And give
Inj. Libott 25 100ml (25% glucose )

IV @ 20 D/min
Then
Inj , 5% DA 1000ml maintenance
IV @ 20 D/min
Stop insulin and oral hypoglycemic drug
Further evaluate dose
Reduction 25% of current dose
Educate the patient about and treatment of hypoglycaemia
A PAIENT WITH BRADY CARDIA

IST exclude
Complete heart block
Inf.MI
Then think sinus bradycardia
HO of beta blocker
Ca-channel blocker
Hypothyroid -- cold intolerance and delayed relaxation of ankle jerks
Dr. shamol 32
A PATIENT WITH VOMITING
Diet normal and ORS
Inj. Normal 1000ml or 2000ml according to dehydration

I V @ 20 D / min
Inj .ciprofloxacin 100ml if cause is infective

1 bag IV BD
Inj. Ranison 50 mg / Inj. P.P.I. 40mg

1 amp iv stat and 8 hrly 1 vial IV stat and daily
Inj. Vergon / inj. Stemetil / Emistat

1 amp I M stat and sos and tds
Tab. Omidone 10 mg or tab. Emistat

1+1+1
Access the patient

Pulse
BP
Urine output
Dehydration
Do
SGPT
S.Creatinie
RBS
S. electrolyte -- necessary unless the patient is drowsy and disoriented
A PATIENT WITH VOMITING FIRST EXCLUDE THE FOLLOWING

CNS pathology ICSOL BY fundoscopy
HEPATITIS
URAEMIA
AND also think about Addison and 2ndary adrenocortical insufficiency
Dr. shamol 33
CAUSE OF VOMITING
A
Acute abdomen ----
acute intestinal obs.
Acute cholecystistis ,
pancreatitis
B
Bacterial ( gastroenteritis +) viral hepatitis
C
CNS
ICSOL
CVD
Meningitis and encephalitis
Migraine
Head injury
D
Drug
NSAID
Digoxin
Jasoquine
Opiate
MTX and cytotoxic drug
E
Electrolyte imbalance and metabolic cause
DM-dka
URAEMIA ARF, CRF
Addison and adrenocortical insufficiency
F
Functional
Bulimia nervosa
G
Gastric cause
GOO
PUD
H
Hormone
Pregnancy
Oral contraceptive pill
I
Infective
UTI
Any infection
We will look for C and E cause
Patient with vomiting must do fundoscopy to exclude ICSOL

Dr. shamol 34
RENAL FAILURE
Cause of ARF
PRERENAL
Decrease blood supply to kidney ( hypovlaemia )
1. Absolute hypovolaemia
Blood loss
Fluid loss RENAL CAUSE ( TIA )
o Diarrhea 1. ACUTE TUBULAR NECROSIS
o Vomiting Ischaemia --- from renal
o Pancreatitis Toxin
o Burn Exogenous --Drug
3rd space loss Gentamycin,
o Peritonitis Endogenous
o Intestinal obs. Bacterial toxin ( infection)
2. Relative hypovlaemia Malaria
Sepsis vasodilatation 2. AGN
MI, CCF , CLD --- Decrease CO oligouria , HTN, RBC ,Protein +/++
3. Renal artery stenosis oedema , sudden onset ,HO infection
By stenosis
Thrombosis 3. INTERSTITIAL DISEASE
Embolism Drugs (fever, arthritis , rash )
Eosinophilia
Patient with non oligouric renal

POST RENAL failure always find for drus
Stone induced AIN
Stricture
BEP
ANY PATIENT WITH ARF

Following are over look
Any sepis / infection
Intestinal obs. And peritonitis
Drug H/O
Look for stone /stricture / BEP
Cause of CRF (DGHS Director General of Health Service )
DDiabetic G-Glomerulo nephritis Hhypertension SSLE / vasculitis
Others Renal artery stenosis and Polycystic disease , Amylodosis
Dr. shamol 35
HOW WILL U DIFFERENTIATED ARF FROM CRF
By
H/O ,
Eaxm,
Biochemical ,
Imaging
ARF CRF
History Short / abrupt onset Insidious onset
Predisposing factor No previous HO
HO hypovolaemia Occational finding
HO infection Anorexia , vomiting
Drugs H/o Recurrent edema
Obstruction HO--DGHS
HO heat , liver disease
Examination Patient is more symptomatic Anaemia
Feature of hypovlaemia HTN
Oligouria Proteinuria
Bp is normal except in (AGN) Oedema + / -
Biochemical investigation
Urine RME Normal Proteinuria
Except AGN prt and RBC
Serum creatinine Increased Increased
Serum electrolyte May hyperkalaemia May hyperkalaemia
Ca and PO4 Ca and PO4 -- normal Ca --decrease , PO4 -increase
USG NORMAL Kidney size decrease ( < 9 cm)
With echogenic cortex
So we can differentiate CRF from ARF

By in CRF
Anaemia and HTN present
Ca and PO4 --- Ca ---decreased and

PO4--- increased
USG of KUB ------ Kidney size decrease ( < 9 cm)

With echogenic cortex
A patient with S.creatinine raise and have Anaemia HTN and Protienuria
IS equal to CRF unless other wise proved
CRF with normal kidney size ------ is DM
CRF with large kidney size -------- is Polycystic kidney and Amylodosis and Hydronephrosis
Dr. shamol 36
Polycystic kidney --- HTN , haematuria , multiple cyst , may palpable kidney
Stage of CKD Stage -1 find out cause

Stage -1 kidney damage with normal GFR
Stage -2 kidney damage mild GFR 60-89 Stage -2 only HTN
Stage -3 kidney damage morderateGFR 30-59
Stage -4 kidney damage severe GFR 30-59 Stage -3 Anaemia ,Ca , PO4 , HTN
Stage 5 renal failure GFR < 15
Old CRF stage 3 Stage -4 Above all + K , Acidosis
ESRDlife is impossible with out dialysis or
Transplantation. Stage 5 Neurological disorder
In stage 4 pl do artery venous fistula
Treatment Fluid restriction

1. Diet Only if edema present
Fluid 3 l Previous day out put +500 ml
Protein normal (60 mg /day ) Salt
2. Correction of anaemia ( 10 to 12 gm /dl) 1 tsf is = 5 mg = 6 mmol
Blood transfusion Patient will Cook with tsf whole day
Erythropoitin ( in rich patient ) Protein restriction should be done
Other If S.creatinine > 2.6 mg /dl
Tab. Feofol
1+0+1 1 piece of meat = 6.4 gm ( match box size) protein
3. For hypocalcaemia 1 cap milk = 6.4 gm protein
Tab. Dicaltrol ( 0.25mg ) 1 egg albumin = 6.4 gm protein
0+0+1
4. For binding dietary PO4
Tab. Calbo 500mg
1+1+1
5. PPI HTN
Tab, Pantonix 20 mg Target BP = 130 / 80 mm of Hg
1+0+1 = 125/ 75 mm of Hg if prot uria > 1 g
6. Anti HTN if needed (single or combination) Choice of anti HTN is
Tab. Angilock 50mg / camlodin / alphapress
0 + 0 +1 1. Aldestorones receptor blocker (angilock 50mg)
7. If edema / decrease out put Or ACE Inhibitor dont use if K , oligouria
Tab. Fusid
1+1+1 / 1 + 1+0 2. If not control or can not use ACE inhb.
8. If vomiting calcium channel blocker Amlodipin / Diltiazem
Tab. Omidone 10 mg
1 + 1+ 1 3. Alpha blocker -Tab.alpha press 1mg 1 + 1 + 1
9. If infection non nephrotoxic anti biotic
Inj.ceftriaxone / amoxycilin /azythromycine 4. Diuretic Tab.Hypen-SR 1.5 mg (indepamide)
Tab. pefloxacin
Dr. shamol 37
Nephrotoxic
Drug should be avoided if s.creatinine Indication for dialysis
1. persistent Serum k > 6 mmol / l no respond toRx
Ranitidine
2. Serum creatinin > 600 mg
Cephalosporin except (ceftriaxone )
3. serum urea 180 mg ( 30 mmol/L)
Ciprofloxacin / levofloxacin
4. HCO3 level < 10 mg
NSAID
5. ureamic pericarditis
Gentamycin ,
6. pulmonary edema
Omeprazole can given
But cause interstitial nephritis, 7. ureamic encephalopathy
s.craeatin, pus cell in urine
Sing symptom of CRF

Investigation for CRF
A Hb %
Anaemia S.creatinine
Acidosis S .eclectrolyte including Ca @ PO4
Urine RME
B USG of whole abdomen with special
Renal osteodystrophy osteomalacia , osteoporosis attention to kidney size @ prostate
,osteosclerosis , ostitisfibrosa RBS
C cardiac cause
HTN In some case
Uraemic pericarditis UTP
Pericardial temponad and LVF ANA
C-ANCA / P-ANCA
D Dermopathy HBsAg
Yellow coloration Anti HCV
Pruritis
E Endocrine
Hyper-pTH
Hyper prolactaemia amenorrhea , galactorrhea , loss libido ,
Infertility
F Retention of fluid edema
G GIT
Dr. shamol 38
Nausea , vomiting , anorexia
Hiccough
H Haemological
Bleeding from any where
Bruise , Echymosis
Epistaxis , haematemesis
I evidence of infection
K kidney polyuria and nocturia
M Muscle
Myopathy
Muscle cramp
N Neurological
Sensory : neuropathy ,parasthesia , reduce sensation
Motor : foot drop
Autonomic
Treatmen of ARF
Presentation of ARF
Anuria ,Oligouria and pre renal ( hypovolaemia )
Complication acidosis kussmal breathing ( hyperventilation )
Hyperkalaemia
Uraemia semiconscious ness and coma , convulsion
Def
Sudden and reversible loss of renal function which develop over period of days or weeks with
accompany by reduction in urine volume .
Findout the underlying cause

Pre-renal any hypovlaemia
Septicemia , Any infection , HUS (following bloody diarrhea )
Any drug
AGN / RPGN
Look for ----- Bladder palpable /or not , Prostate and Stricture to exclude post renal cause
If the patient taking NSAID and ACE inhibitor stop immediately
Dr. shamol 39
Rx of ARF
If patient is in hypovlaemia ( BP , pulse )
Give inj. Normal saline 2000 ml

Look for urine out put if not increased and stop fluid otherwise will develop pulmonary edema.
If the patient is Anuric but no Hypovolaemic
Diet protein restriction

Fruits restriction (due to avoid hyperkalaemia )
Fluid 500ml + previous day out
If urine out is not increased
be aware of giving fluid it will caused pulmonary edema
To increased urine out put Stop

Inj.lasix or fusid NSAID
2 or 4 amp IV stat and 2 amp IV 8 hrly ACE inhibitor
If urine out put not increased do forced diuresis Rainitidin
Gentamycin
Inj. Normal saline 80 ml Cephalosporin
+ Ciprofloxacin
Inj. Lasix 10 amp
IV @ 4 d / min
If not increased go for dialysis
If evidence of infection
Inj.ceftriaxone 1 mg
I vial iv stat and BD INVESTIGATION OF ARF
Give PPI S.creatinine
Inj pantonix 40 mg
S.electrolyte including HCO3
I vial iv stat and daily
Urine RME
If acidosis present USG of whole abdomen with special
Inj. Sodi-bicarb 25 ml attention to kidney size @ prostate
2 vial IV stat and TDS until acidosis is corrected RBS
If suspect infection ( with
If hyperkalaemia permission of senior )
Manage the hyperkalaemia see (electrolyte chapter) o CBC
o PBF
Maintain I/O chart o ICT for malaria
Catheterization if patient is anuric / unconscious

Otherwise collect in put
Auscultation
Auscultate the base of the lung for pulmonary edema If pt. in diuretic phase of ARF
Auscultate the heart for pericarditis Input = out put , daily = 5 /4 L fluid
IV= 2 L , Hartman + normal saline
Oral = fluid intake + ORS + Dub water
Dr. shamol 40
Antihypertensive drug
o A ----- ACE inhibitor--- Ramipril 5-10 mg daily or

o Lisinopril 10-40 mg daily
o Enalapril 20 mg daily
o Benazapril
o Captopril
Angiotensive receptor blocker .
o losartan 50-100 mg daily,
o valsartan 40-160 mg daily
B-------Beta blocker --- cardioselective

o Metoprolol (100-200 mg daily),
o atenolol (50-100 mg daily) and
----combined - and -adrenoceptor antagonists
o carvedilol (6.25-25 mg 12-hourly)
---- nonselective
propranolol 40 mg to 160 mg use in anxiety palpitation and portal
HTN
C---Ca channel blocker --- dihydropyridines
o Amlodipine (5-10 mg daily)---vaso-selective
------rate-limiting calcium antagonists
o Diltiazem (200-300 mg daily,) --- intermediate
o Verapamil (240 mg daily) cardioselective --use in SVT
D--------Diuretic ---- thiazide

o Indepamide hypen-SR 1.5 mg 1 + 0+ 0
Vasodilator --- -blocker
o Prazosin (0.5-20 mg daily in divided doses) tab .-press 1 mg
Centrally acting drugs
o Methyldopa (initial dose 250 mg 8-hourly)

o Clonidine (0.05-0.1 mg 8-hourly)
DEFINITION OF HYPERTENSION
Category Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg)

Hypertension
Grade 1 (mild) 140-159 90-99
Grade 2 (moderate) 160-179 100-109
Grade 3 (severe) 180 110
Isolated systolic hypertension
Dr. shamol 41
Grade 1 140-159 < 90
Grade 2 160 < 90
BASIC PRINCIPAL
o FIRST EXCLUDE CONTRAINDICATION
o THEN LOOK WHICH ONE IS PREFER FOR COXSIT PROBLEM
o NEVER STOP BETA BLOCKER SUDDENLY TAPPER IT GRADUALLY
o IF PATIENT BP IS CONTROLL WITH CURRENT DRUG S NO CHANGE IS NEEDED IF
OHTHER INDICATION
ACE INHIBITOR / ANGIOTENSIVE RECEPTOR BLOCKER
Contraindication
o Hyperkalaemia
o Oligouria or ARF
o In hypovolaemic patient
o Pregnancy and Renal artery stenosis
o CLD
o COPD (Angiotensive receptor blocker )
Indication
o DM Losartan 50-100 mg daily, Angilock
o CKD
o CVD
o HEART FAILURE Ramipril 5-10 mg daily Repril / remicard
o LV dysfunction / hypertrophy / DCM
o POST MI
SIDE EFFECT
DRY COUGH
Postural hypotension To avoid it pl. give first dose in night .
Electrolytes and creatinine should be checked before and 1-2 weeks after commencing therapy. If
s.creatinine is increased 25 30 % after 1 / 2 weeks then stop drug.
Also stop. If pt develop oligouria , hyperkalaemia , or deteriorated renal function
BETA BLOCKER
Contraindication
Bronchial asthma / COPD
Heart block / if pulse less than 60
DM
Psoriasis
PVD
Dr. shamol 42
Hear failure ( can use in Carvedilol compensated heart failure )
Indication
Myocardial infarction, Metoprolol (100-200 mg daily) / tab.atenolol cardipro 50 mg 1 +0 + 0
Angina -------Metoprolol (100-200 mg daily) / atenolol tab.cardipro 50 mg 1 +0 + 0
Heart failure stable----only carvedilol (6.25-25 mg 12-hrly) tab. Carvista 6.25 mg + 0 +
Atrial fibrillation ----- Metoprolol (100-200 mg daily), tab. Betaloc 50mg 1 + 0 + 1
HTN of young patient with out contraindication
Before giving beta blocker see following
HO DM , COPD, asthma , heart failure
Auscultate lung for spasm and pulse for bradycardia
Why beta blocker not use In DM

It will mask the sign +symptoms hypoglycaemia ( tremor / tachycardia / sweating )
Can given with cautiously if DM with angina + stable heart failure carvedilol
CA CHANNEL BLOCKER
Contraindication
Heart block,
Heart failure
Complication
o Amlodipin
Flushing, head ache
Palpitations and
Fluid retention
o verapamil is
constipation
o verapamil @ Diltiazem
may cause bradycardia.
indication
Amlodipin --
Any patient /Elderly patient with out heart failure
isolated systolic HTN
CRF
COPD /Bronchial asthma
The rate-limiting calcium antagonists
Diltiazem 200-300 mg daily,
Verapamil 240 mg daily
o can be useful when hypertension coexists with angina
o verapamil use in SVT
Dr. shamol 43
DIURETICS
Indication
isolated systolic HTN

in elderly patient
in heart failure
in renal failure
Contraindication
DM ,
gout ,
hypokalaemia
indepamide -- tab. Hypen SR 1.5 mg 1+ 0 +0
VASODILATOR ---
-blocker
Tab. Alpha press 1 mg 1+ 1+ 1
Hypertension in special situation
In DM CHOICE ARE ACORDINGINLY
1. ACE I / ANG.BLOCKER Losartan 50-100 mg daily, Angilock

2. Ca CHANNEL BLOCKER
3. Alpha BLOCKER
IN HEART FAILURE
1. ACE I / ANG.BLOCKER Ramipril 5-10 mg daily Repril / ramicard

2. +/- DIURETIC
3. BETA BLOCKER
a. only carvedilol (6.25-25 mg 12-hrly) tab. Carvista 6.25 mg + 0 +
IHD
1. BETA BLOCKER Metoprolol (100-200 mg daily), tab. Betaloc 50mg 1 + 0 + 1

2. ACE I / ANG.BLOCKER Ramipril 5-10 mg daily Repril / remicard
3. Ca CHANNEL BLOCKER (ditiazem)
Dr. shamol 44
CRF
1. ACE I / ANG.BLOCKER Losartan 50-100 mg daily, Angilock

2. Ca CHANNEL BLOCKER Amlodipine 5-10 mg daily
3. Alpha BLOCKER Tab. Alpha press 1 mg 1+ 1+ 1
4. WITH DIURETIC
5. AT LAST BETA BLOCKER
STROKE / CVD

ISOLATED SYSTOLIC HTN

2. DIURETIC indepamide -- tab. Hypen SR 1.5 mg 1+ 0 +0
PVD
COPD

2. ANG.BLOCKER Losartan 50-100 mg daily, Angilock
GOUT

Contraindication
o BETA BLOCKER
o DIURETIC
Dr. shamol 45
Target organ
Retina
Blood vessel
Heart
Kidney
Brain
What should look in HTN patient

Eye fundoscopy
Investigation a patient with HTN Eyelid xanthalasma hyper lipid
Face cushing
To see complication Carotid bruit
Heart shifting apex beat
Chest X-ray: to detect AS , gallop , Basal creps +
Cardiomegaly, LV type BP
Coarctation of the aorta PULSE AF , radio-femoral delay
Heart failure pulmonary edema Other peripheral pulse PVD
Kidney palpable ---poly cystic kidney
ECG finding Renal Bruit --- renal artery stenosis
LVH with strain Anaemia and oedema -CRF
IHD
S.creatinine HO
RBS Smooking ,
URINE RME --- protein uria Alcohol ,
Lipid profile OCP , Steroid
USG to see KUB DM
IHD
Dr. shamol 46 STROKE
CKD
Hypertensive crisis
Hypertensive emergency
Hypertensive urgency
Hypertensive emergency
Severe elevation of BP > 180 / 120 mm of Hg complicated by evidence impending or progressive

target organ damage .
They require immediate reduction of BP reduction ( not necessarily to normal )
Exam .
Goal of therapy is BP not
HTN Encephalopathy more then 25 % in 1 st hour.
Intracerebral haemorrhage Then target BP
Acute MI 160/110 mm Hg in next 6 hrs
Acute LVF Sudden fall may cause
Acute pulmonary edema o Cerebral ischemia
Unstable angina o Renal ischemia
Eclampsia o Coronary ischemia
Then reduction of BP to normal
Treatment in ICU with monitor in next 24 -48 years .
Parental administration of Anti- HTN ,
Hypertensive urgency
Severe elevation of BP with target organ damage
Upper level of stage ii with
Severe head ache

Epistaxis
Dyspnea
Severe anxiety
Patient is noncompliant or inadequate treated HTN with little or inadequate treated HTN with little or no
Target organ damage
Dr. shamol 47
Any patient with edema do the next
Approach to a patient with edema What ever the cause.
Urine RME
Remembering the following S.creatinin
Kidney cause RBS
AGN USG of whole abdomen
NS ECG and CXR
Heart cause If patient is very poor first do
CCF , Cor-pulmonalae simple urine to exclude NS /AGN
Anaemic heart failure
Liver cause
Try several times to establish this three, if failed then the look for following
Hypothyroidism
Malnutrition
Drug NSAID ,Calcium channel blockers
Think about the heart cause
Corpulmonalae
CCF --DCM ,
Anaemic heart failure
Patient have ---

Copd , respiratory distress , cough sputum ,
Orthropnea , Exertional dyspnea , PND
Corpulmonalae
Exam cyanosis , lung crep + , spasm ,ronchi , vesicular breath sound with prolong expiration
Eye congested , flapping tremor , bounding pulse and warm periphery ,barrel shape chest
ECG P pulmonalae , RVH ,
CXR emphysematous change /low flat diaphragm ant .rib touch diaphragm at 7 rib. Post rib
At 11 rib.. tubular heart shadow .
CCF Triad of CCF

Typical HO of breathlessness
Exam Murmur, HO IHD , Apex beat shifted , o Depended Oedema
lung Crep (++ ) , AF / loud first sound o Tender hepatomegaly
ECG Feature of ischemia , o Increased JVP
CXR -- Cardiomegaly / DCM Hepato-jugular reflex
Heat coagulation test negative
If anaemia then --- Anemic heart failure or CRF No stigmata of CLD
ECG
CXR cardiomegaly
Dr. shamol 48 S.albumin , AG ratio --- normal
Stigmata of CLD
CLD o Spider /gyna./testicular atrophy
o Ascites / splenomegaly / engorged vein
HO JAUNDICE Negative
o No HO dyspnea /lung / heart diaease
o Stigmata of CLD is o JVP absent, tender liver absent
o Hepatic faces , o NO HO of renal disease /skin infection
o Spider navi , gynaecomastia Investigation
o Loss pubic and body hair o positive
o Ascites , spleenomegaly , engorged vein o HBsAg + , S.albumin , AG ratio
o Testicular atrophy o USG of liver
o Not tender hepatomegaly o Endoscopy varices
o JVP normal o Negative :
o Urine RME no prt , RBC
RENAL CAUSE o ECG and CXR normal

IF ABOVE TWO CAUSE IS EXCLUED BY HO AND EXAMINATION

THEN DO SIMPLE HEATCOAGULATION --- IF POSITIVE THEN IT RENAL
CAUSE UNLESS OTHER WISE PROVED .
o AGN and NS is diagnosis of exclusion (from CCF and CLD)
AGN NS
HO of post. streptococcus infection Insidious on set
skin infection /Sore throat May previous HO similar
Otitis media / fever / chest infection DM / NSAID / SLE (Joint pain )
Sudden on set Hepatiti B and hepatitis C
Oligouria / HTN / Old age exclude malignancy by
Edema No HTN
Complicaition - LVF , HTN encephalopathy Urine ---protein ++ , RBC and RBC cast -
Urine ---protein ++ , RBC and RBC cast + UTP > 3 gm
UTP < 3 gm s.creatinine-normal , S.Albumin , S.lipid
S.creatinine may , C 3 / C4 / ASO titer C-ANCA ,PANCA / ANA
Examination
No JVP and tender Hepatomegaly and no chest and heart finding exclude CCE
No stigmata of CLD (gynaecomastia, spider , leuconychia ,testicular atrophy ,jaundice ),

No splenomegaly ,engorged veins ---Exclude CLD
CXR and ECG no cardiac / lung abnormality is detected
USG of whole abdomen .CLD is excluded and kidney size normal
If these three cause exclude then thing the following

Hypothyroid Puffy face, Baggy eye field, Loss lateral 1/3 eye brows, Hoarseness of voice and
Delayed relaxation of ankle reflex and T3, T4, TSH
Hypo albuminia --- Lose motion and Mal-absorption and s. albumin decrease
DM --- DM nephropathy and vasomotor tone
Dr. shamol 49
Drug --- NSAID and Ca channel blocker
Treatment of AGN Treatment of NS
o Diet Diet
o Protein restriction Normal and salt restriction
o Fruits restriction (to avoid hyperkalaemia ) Fluid restriction in case massive edema
o Fluid 500ml + previous day out 750 ml / day
Antibiotic Diuretic
o Tab. Pen-V 250 mg
1+1+1+1 Tab. Fusid plus 1+ 1+ 0
Diuretic If massive edema them
Tab. Lasix or inj .lasix depend on out put Inj. Lasix 1 or 2 amp IV BD (at 8am, 4pm)
1 + 1 +0 / 1amp iv BD If suspect AGN donot give fusid plus
Anti HTN Give only Fusid to avoid hyperkalaemia
Tab. Camlodin 5 mg if HTN present
1 + 0 +0 Antibiotic
Ani ulcerant Infection is common so give broad spectum
Tab. Pantonix 20 mg antibiotic
1 + 0 +1 Amoxicillin /Cefixime / Ceftriaxone
Maintain in put and out put chart
Maintain BP chart To Reduce Proteinuria
Maintain heat coagulation chat ARB or ACEI
Tab. Angilock 25 mg
IF YOU SUSPECT
Maintain RPGN
in put and out put chart 0+0+1
Give
Maintain BP chart Statin (to decrease cholesterol)
Inj Normalheat
Maintain saline 100 ml chat
coagulation Tab. Atova (Atorvastin) 10mg
+
Inj . Methyl prednisolone 1 gm Anti ulcerant
Iv @ 30 d/ min for 3 days Tab. Pantonix 20 mg
1+0+1
Steroid (give only permission of CA) 1mg /kg
Tab Cortan (prednisolone) 20 mg

2 + 0 + 0 A/ M
Calcium
Tab .Calbo 500mg
Nephro-nephritic syndrome 1 +0 + 1 or 0 + 1 + 0
Maintain in put and out put chart
When both this present (may have HTN)
Maintain BP Chart
1. UTP ---> 3 gm
2. Urine RMERBC and RBC cast present
Maintain heat coagulation chart
In some case if FSGS / steroid resistant

Tab. Endoxan (cyclophosphamide ) 50 mg
2 mg / kg body wt.
Dr. shamol 50
POISONING
OPC may be accidental an suicidal
The patient will present to u with HO ingestion of poison that use in agriculture field to kill the
insect on.
Following sing symptom you will find
MUSCARINIC
Smell of OPC
Salivation
Constricted pupil ATROPIN DOSE
Bradycardia ( 20% may have tachycardia ) There is many protocol for atropine .
Other hypotension and sweating, lacrimation It depend on severity of poisoning
Lung : creps ++++++ (see later )
Give bolus dose
NICOTINIC Inj .Atropin
Fasciculation and muscle twitching and 10- 20amp iv stat
weakness of muscle Then
CNS Inj. Atropin
Coma , confusion , 5- 15 amp 5 to 15 min interval untill
Convulsion , respiratory depression sign of atropinisaion appear.
Treat ment of OPC
When sign of opinisation appear
Ask the patient attendant stomach was is given or not
Tapering the dose such as
If not then give it .
Inj. Atropin
Ask patient attendant to change the clothes and give him
15 amp iv 30 min
bath to prevent the subcutaneous absorption .
10 amp iv 30 min
NG insertion 5 amp iv 30 min
Keep the patient NPO 5amp iv 1 hr
Give iv channel with 5amp iv 2hr
Inj . DNS or Normal saline 1000ml 4 amp iv 4 hr
IV @ 20 D/ min 2 amp iv 4hr
Give inj .Atropin
Pl see the dose from the side box
Inj. PAM
2 amp iv over 10 min stat and
Pralidoxime
Give another 2 amp. In drip inj . DNS/ normal saline
Dose : 30 mg /kg BWT over 10 minutes
Inj. Cefriaxon 1 gm We give Inj. PAM 2 amp iv over 10 mins
1 gm iv BD
Inj . ranison or inj. Pantonix 40 mg The maintenance dose is
1 amp iv 8 hrly 1 vial iv stat and daily 8- 10 mg / kg / hr in infusion drip
Catheter must be done immediately after atropine started This may be given in current fluid or
Maintain atropine chart Given with another channel
If patient is restless / or convulsion We give 2 amp in 1000 ml in NS or DNS
Inj. Sedil
1amp iv stat and daily
If patient is still restless
Dr.
Inj.shamol
Perol 51
1 amp im stat
Point 0 Point 1 Point 2
Fasciculation no Present not gerneralized Present and generalized
Respiration < 20 > 20 > 20 with cyanosis
Consciousness Conscious and rational Impaired but Respond to Impaired but not respond
If covulsion (add extra 1) verbal command to verbal command
Pulse > 60 41-60 < 40
Pupil > 2 mm < 2 mm Pin point
ASSESSMENT OF SEVRITY OF OPC POISONING
MILD 0---3
MODERATE 4--- 7
SEVRE 8----11
SING OF ATROPINIZATIN ( PHD in CS )
P---Pulpil not pin point

Hheart rate > 80 Some body prefer doubling dose
DDry axilla First give
CClear chest Inj.atropine
SSystolic BP > 80 mm of Hg 10 to 20 amp. Iv stat and doubling the dose until sign of
atropinisation appear
A patient come to u with no clear cut HO and Sign Such as
symptoms of OPC poisoning then
how will U exclude the OPC poisoning ? 10 amp iv stat then
10min 20 amp iv
Give test dose of Atropine ( inj. Atropine 2 amp iv stat)
10min 40amp
Look for the dilation of pupil after 5 mins if pupil become iv after 5 min then
full dilated
It was not a case of OPC poisoning 10min 80amp iv
10min 160 amp iv
A patient of opc poisoning suddenly become restless and agitated ? D/D of intermediated
Then think and about over atropinisation syndrome is the aspiration
Do the following pneumonia
Give inj. Sedil 1 amp slow IV stat and
Reduce the current dose of atropine Aspiration pneumonia
And patient is still restless then give Focal creps in lung
Inj. Perol 1 amp IM stat . In intermediated syndrome
Creps whole over the lung
A patient was responding to treatment and u r tapering the atropine but suddenly u noticed that the
patient is Become disoriented and drowsy with generalized weakness and respiratory distress .
On examination huge creps over both lung field . whatever the pupil condition ( constriction or normal )
U r dealing with a case of intermediated syndrome
Do re-atropinisation, give inj. Atropin 20 amp iv stat and give it iv every 5 min interval until patient
Lung become crep. Free .and patient condition improved and again taper slowly .
Dr. Ifshamol
not improved and give CALL TO ICU other52 wise pt will die from respiratory failure
Treatment of atropine intoxication / over atropinisation
When the five point have reached ( PHD in CS) and patient become violent and restless and
agitated
Then think for over atropinisation
If patient become over atropinisation do following
Stop inj. Atropine for 30 min
Give inj.sedil / inj. perol depending on the situation
Observe after 30 min and if the patient settled then
Restart atropine at 70 80 % of previous rate
Dr. shamol 53
Drug overdose
Benzo-diazepam poisoning
Do not be worried
Lethal dose is more then 40 / 50 tab.
Dangerous complication is
o Respiratory distress or respiratory arrest , -- main complication
o Hypotension ,
o Cardiac arrymia (some times may be )
patient come with diazepam poisoning then do the following Presentation BDZ poisoning
Unless combined with other
sedatives (e.g. alcohol or tricyclics)
Look patient is unconscious nor not
effects of overdosing are generally
If patient is conscious
mild.
Give stomach wash if come within one hours
Drowsiness
( we give it in emergency )
Slurred speech
Nystagmus
Inj . normal saline or DNS 1000 ml Hypotension (mild)
IV @ 20 d / mins Ataxia
Coma
Inj cetriaxone 1 gm ( pt . attendens compliance ) Respiratory depression
1 vail IV stat and BD Cardiorespiratory arrest (with iv
administration)
Inj. Pantonix 40 mg / inj. Ranison 50 mg
1 vail iv stat / 1 amp iv stat and 8 hrly
Not all this investigation is necessary
Bp stable and u may give ( bp > 110 ) diuretic But done for the satisfication of the pt.
Inj. Lasix attendance .
1 amp iv stat for diuresis Pl do
ECG
If patient is unconscious / act like unconscious RBS
Then give S.creatinine
NG suction SGPT
Catheterization S.electolyte
Last 2 investigation consult with senior
Indication for flumazenil ( we do not practice here )
Severe overdose may require use of the benzodiazepine antagonist, flumazenil,

E.g. comatose patients particularly where the diagnosisLook the Patientand
is uncertain for
Patients with significant cardiorespiratory depression. Any dyspnea / res.distress
Flumazenil is given as Pulse
o an iv bolus of 0.2mg followed by BP
o a further bolus dose of 0.1mg every 2 to3 minutes until the patient is rousable
o maximums dose is 1 mg
Dr. shamol 54
You can remember this if u r interested
Assessment of poisoning in the unconscious patient

Sign Consider
Hypoventilation Opiates, ethanol, benzodiazepines
Hyperventilation Metabolic acidosis (aspirin, paracetamol), gastric
aspiration, carbon monoxide
Pinpoint pupils Opiates, organophosphates
Dilated pupils Methanol, anticholinergics, tricyclics, LSD
Bradycardia beta -blockers, digoxin, opiates
Tachyarrhythmias Tricyclics, anti-cholinergics, caffeine, theophylline,
lithium, digoxin
Hyperthermia Ecstasy, amphetamines, anti-cholinergics
Pyramidal signs, ataxia, hypotnia, hyper-reflexia Tricyclics or anti-cholinergic agents
and extensor plantars
Hypertension Cocaine, amphetamines, ecstasy
NB: Occasionally patients present where poisoning is suspected but not known. Even where the history
suggests self-poisoning be aware that serious underlying disease may be present. For example, patients
who feel very ill will often self-medicate with aspirin and paracetamol.
Dr. shamol 55
A PATIENT WITH TRICYCLIC ANTI DEPRSSION POISONING Investigation
First look that the patient is unconscious / or not First ECG to see
Immediate look for the Tachy. , ST depression , QT
Pulse ----arrhythmia / tachycardia ] prolongation , arrhythmia
BP - hypotension RBS
Respiration rate / rhythm and any res. distress S.creatinine
Level of consciousness S .electrolyte
If patient is conscious
Complications
Give stomach wash if come within 12 hours of Severe intoxication causes
ingestion ( ref. acute med. Oxford ) Deep coma with respiratory depression,
( we give it in emergency ) Cardiac arrhythmia , ischaemia hypoxia,
Activated charcoal tab. Ultracarbon 20 tab stat A metabolic acidosis.
Inj . normal saline or DNS 1000 ml

IV @ 20 d / mins Prognostic features
Inj cetriaxone 1 gm ( pt . attendens compliance ) Death may follow ingestion of as little as

1 vail IV stat and BD 1000mg of a tricyclic.
Inj. Pantonix 40 mg / inj. Ranison 50 mg Prolongation of the QRS >100ms suggests

1 vail iv stat / 1 amp iv stat and 8 hrly significant intoxication with a high risk of
convulsion;
Bp stable and u may give ( bp > 110 ) diuretic a QRS >160ms is generally seen before
Inj. Lasix ventricular arrhythmias develop.
1 amp iv stat for diuresis Patients with ischaemic heart disease
(especially post MI) and conduction defects
If patient is unconscious / Alter level of consciousness are particularly at risk
Then give
See ABC
NG suction
Clinical feature ofTCA
Catheterization
Monitor ECG 3 to 4hrly if u suspect arrhythmia or
Anti-cholinergic features are
cardiac change
o Dry mouth,
Monitor Bp 4 hrly o Dilated pupils, Blurred vision,
Severe hypotension requires inotropic support o Sinus tachycardia, Urinary
Severe acidosis should be corrected with iv NaHCO3 retention,
Control seizures with diazepam (1 amp iv stat ). o Myoclonic jerking, agitation, and
Respiratory failure Referr the pt ICU even hallucinations.
Sinus tachycardia and arrhythmias that do not Cardiac arrhythmic effect on the heart,
compromise cardiac output do not need treatment. If profound hypotension, convulsions, and
output is failing then correct any acidosis or hypoxia coma
before considering anti-arrhythmics.
Tricyclic coma may last 24 to 48 hours. In many patients recovery is marked by profound
agitation and florid visual and auditory hallucination (central anticholinergic syndrome).
Dr. shamolSedation may be necessary (e.g. po diazepam
56 or chlormethiazole).
A PATEINT WITH BETA BLOCKER POISONING Investigation
Immediate look for the First ECG @ then
Pulse ----arrhythmia /bradycardia RBS
BP - hypotension S.creatinine
Lung bronchospasm S .electrolyte
Sign of hypoglycemia
If patient is conscious Pt .with pre-existing impaired
myocardial contractility are vulnerable
Give stomach wash if come within 1 hours of ingestion to moderate overdoses of BB.
( we give it in emergency ) The ECG
o mild :1st degree heart block
Inj . DNS 1000 ml ( prevent hypoglycemia ) o moderate to sever : widen of
IV @ 20 d / mins ORS @ prolongation OT
Inj cetriaxone 1 gm ( pt . attendens compliance /)

CF of BB overdose
1 vail IV stat and BD
Sinus bradycardia
Hypotension
Inj. Pantonix 40 mg /
1 vail iv stat / Cardiac failure
Cardiac arrest (asystole or VF)
Monitor ECG 4 hrly . Bronchospasm (rare in non-asthmatics)
Record BP regularly (at least every 15 minutes). Drowsiness
RBS with glucometre hrly HallucinationsFits (esp. with
Treat the complication if present propranolol)
Hypotension ( we will not use / referr to ICU) Coma
o Inj. glucagon Hypoglycaemia (rare
o (50to 150g/kg iv followed by an infusion of 1
to 5mg/h)
Bradycardia
o Inj.atropine Bradycardia: do one after another
o 1 or 2 amp iv 8 hourly . if not inmproved see
box bradycardia 1. 1st atropine alone 1 or 2 amp iv 8
Convulsions hourly
o Inj. Sedil 1 amp iv stat and sos 2. Isoprenaline infusions (5to 50g/min)
3. If the bradycardia persists and the
Bronchospasm: patient is in cardiogenic shock a
o Treat with high-dose nebulized salbutamol transvenous pacing wire should be
o (5 to 10mg) or 1 or 2 ml sol with 2 ml NS stat inserted
@ sos
Hypoglycemia Bronchospasm:
o Inj. Libot -25 100 ml followed by
o 1. Treat with high-dose nebulized
o Inj. 10% DA 1000 ml as maintenance dose salbutamol (5 to 10mg) or 1 or 2 ml sol
with 2 ml NS stat @ sos
2. an aminophylline infusion should be
used (e.g. 0.5mg/kg/min).
Dr. shamol 57
DHATURA POISONING / STUPEFY POISONING
An unconscious patient come to u with out attendants by police or unknown people and the patient
was found unconscious in bus / rail station or lunch station.
Or patient may comes to u with his attendance with HO that he ate some thing in bus and followed he
cannot remember anything and lost all his money.
So do not be worried this is a case of dutura poisoning
Patient will be ok with in 24- 48 hr give only supportive care
If u r confused then u exclude CVD and electrolyte imbalance and head injury
A ..clear away with suction if secretion See vital sign

Pulse
B . O2 inhalation if respiratory distress / inj. BP
Lasix if creps + Respiration
Heart
C . Dopamine BP less than SBP 90 / FLIUD GCS
correction if dehydration Neurological exam
Fundoscopy
Diet NG feeding Evidence of external injury
200 ml 2 hrly
D/D of dhatura poisoning
Inj. Normal saline 1000 ml CVD
I V @ v 20 drop / min Head injury
Electrolyte imbalance
Inj. Amoxycillin 500mg
1 vial iv 8 hrly
Inj. Ranison 50 mg Investigation

ECG
Continuous catheterization RBS
Maintain input out put chart S.Creatinine
Give medicine and NG @ catheter from poor fund S.Electrolyte
Never give costly medicine and investigation as
patient attendant are not available
Dr. shamol 58
A PATIENT WITH CORROSIVE POISONING / CHEMICAL POISONING THIS INCLUDE
Acid , alkali , Bleaching powder ,
Harpic , savelon , Shampoo and kerosin
There is some no in case of corrosive poisoning Complication of Chemical
poisoning is
TREATMENT OF CORROSIVE
Do not give stomach wash / NG suction Chemical pneumonitis
Do not try to do induce vomiting ( because of aspiration

pneumonia )
Keep the patient NPO for 6 hrs
Inj. DNS 1000 or 2000 ml
Iv @ 20 D / min
Inj.ceftriaxone 1 gm
1 vial IV BD
Inj. Pantonix 40 mg
1 vial IV stat and daily
If patient complaint pain
Inj. Anadol 100mg / inj. Toradolin or nalbun 2
1 amp im stat and TDS
If patient ingest chemical other than Acid and alkali
Patient may give liquid paraffin
Syp. Entacid plus 2 TSF TDS
Mode of action acid and alkali
Dr. shamol 59
Dr. shamol 60
MANAGEMENT OF SNAKE BITE POISONOUS AND NONPOISONOUS
Most of the snake of our country are nonpoisonous
Poisonous snake are Cobra @ krait in all area
Green pit viper found only in chittagonj
First take HO that pt see the snake or not
See bite mark present or not
Frist take HO snake bite / bite marks / is it snake or If present then
other animal Poisonous snake bite
Release the tourniquet Two frank mark in equal distance apart
First loose the tourniquets to maintain circulation Non poisonous
Then remove all tourniquet keeping only one Multiple marks
Then gradually remove last one Absence bite mark
Warn the patient attendants that removing of this Does not exclude poisonous snake bite
tourniquet may produced sign of poisoning It absence in Krait bite
Bed rest Look for local envenoming

Rapid swelling or extension of swelling
Inj. Normal saline 1000 ml Blister and necrosis
IV @ 10 D / min
The look neurological sign .
Cap .Moxin / Cephradine 500 mg (if local wound ) Most of the snake bite in our country are
1+ 1 + 1 produce neuro. Sign (cobra @ Krait )
Cap . Omeprazole 20 mg Only green pit viper produce haema. Sign

1+ 0 + 1 that found in chittagonj only
Inj. TT / Tetanus Toxoid ( if local wound )

1 amp IM stat
Look for following neurological sign
Inj. TIG ( if local wound contaminated ) Nasal voice
1 amp IM stat (in separate hand ) Ptosis
Opthalmoplegia
If patient complaint pain Dysphagia
Tab. Paracetamol 500mg 1 + 0 + 1 Broken neck sign
Dyspnea
Never give the following Difficult in opening mouth and
Inj. Oradexon protruding tongue
Inj Avil Unconscious
And NSAID
Observe the patient at least for 24 hours Hematological (not in our country )
If no sign symptom appear with in this period Gum bleeding , epistaxis ,
Then discharge the patient Bruise and echymosis
Other sign
Dark color urine / oliguria
Vomiting
Dr. shamol 61 Collapses
As soon as u or patient attendant noticed any neurological sign / symptom inform ur CA and
immediate start polyvalent antivenom
TREATMENT OF POISONOUS SNAKE BITE

Before start polyvalent antivenom do the following
Take written informed consent from patient attendant
Informed the patient may has 50% chance to die due to reaction of antivenom and
100 % chance to die with out antivenom .
Dose of antivenom Dose is the same irrespective to age n sex
Total vial = 10 vial , each vial dilute with 10 ml distilled water (if vials are not in dilute form )
Mix this 10 vial(100 ml) with 100 ml NS saline and give in 1 hour via micro burette set
Inj. Normal saline 100
+
Inj . Antivenom 10 vial
IV @ 60 D/ min
Some want to Give following before starting anti-venom to prevent anaphylactic reaction
Inj. Cotson 100 mg 1 vial IV stat
Inj .avil 1 vial IV stat
Additional treatment indicated for neurotoxic feature
Atropine Neostigmine regimen
1st Inj. Atropin
15 gm / kg body weight IV stat then
Inj. Neostigmine
50-100 gm / kg body weight SC stat and repeat every 4 hrly until neuro .sign improved
Give call to ICU as patient may need assisted ventilation for respiratory paralysis
WHAT WILL U DO IF PATIENT DEVELOP ANAPHYLITIC REACTION
Inj. Adrenaline 1:1000 Sign and symptom of anaphylactic reaction

For adult = 0.5ml IM (500 gm) Intense itching
For child = 0.o1 mg / kg Urticaria
6-11 yr. = 0.25 ml IM Angio-edema
1-5 yr. = 0.125 ml IM Dyspnea due to Bronchospasm
Inj. Avil ( in case of child 0.2mg /kg) Laryngeal edema
1 amp slow iv after dilution Hypotension
Inj. Cotson
1 vial iv stat @ 8 hrly
Inj. Ranitidine
Rx started at the earliest sign of anaphylaxis
such as a spot of urticaria or onset itching
Dr. shamol 62
Dr. shamol 63
Most common snake bite in Bangladesh is cobra and krait
Cobra
Usually bite in limb ]
Bite mark present
Produce local envenoming (blister and necrosis and rapid extension of swelling bitten limb )
Produce neurological feature
No haematological feature
Krait
Bite any where in the body
May have no bite mark
No local envenoming
Produce neurological feature
No haematological feature
Recommended first aid
20 MINUTES WHOLE BLOOD CLOTTING TEST (20 WBCT)
It usually negative in hour country as most of the poisonous snake bite in our country is due to Cobra
and Krait . it only positive viper ( green pit V.) that found in chittagang of this country
Dr. shamol 64
Electrocution / Electric burn
First look that the patient is conscious or not

Most dangerous complication of electrocution is If pt is conscious
Ventricular fibrillation so see pulse and BP Not worried
Do urgent ECG See pulse for arrhythmia
If this are normal then patient is restless due to pain And do immediate ECG
Look for burn and If this is ok then give
Other injury supportive treatment .
Rx agonizing pain
If the patient has no pulse and BP and semiconscious
Give CPR and try revert Ventricular fibrillation
If the patient cardiac status is normal , do following
Immediately give Electric burn is 3rd degree burn

Inj. Toradolin 30 mg / Torax 30 mg Give TT and TIG
1 amp I M stat Give anti-biotic
Inj. Ranisone Give silcream for burn
1 amp IM stat
Inj. Normal saline 1000 ml for channel maintain
IV @ 10 D / min
Cap .Cephradine 500 mg
1 + 1 + 1+ 1
Inj. TT / Tetanus Toxoid ( burn present )
1 amp IM stat in one hand
Inj. TIG
1 amp IM stat in another hand
Tab. Torax 10 mg ( NSAID)
1+1+1 or 1+ 0 +1
Cap . Omeprazole 20 mg
1+ 0 +1
Silceam (silver sulpha diazin )
Apply over the burn area TDS or QDS
Dr. shamol 65
WASP bite
Patient present with HO bite Main problem is the pain which is

And with severe pain and Difficult to control .
See pulse and BP
Another complication is anaphylactic
Shock .characterized by
Give Bp ---hypotension
Inj. Toradolin 30 mg Stridor laryngeal spasm
1 amp im stat and sos Lung wheeze
Inj. Ranisone Kidney oligouria
1 amp IV stat
Inj. Oradexon / inj.Cotson
I amp IV stat and 8 hrly
Inj. Avil
1 amp IM / IV stat
U may need strong pain killer like inj.nalbun -2 Exam .
If BP is low then inj. Normal saline 1000 ml Pulse
Then BP
Cap . amoxycilline or cephradine 500 mg Auscultation of lung
1+1+1 I/O chart
Tab . deslor 10 mg Do
0 + 0+ 1 ECG
Cap. Omeprazole 20 / tab. Ranitidine 150 mg S.Creatinine
1+ 0 + 1
Tab. Flexi 100 mg /Tab. Torax 10 mg
1+ 0 + 1
Dr. shamol 66
ACUTE CORONARY SYNDROME
A patient with coronary artery disease may present to u with
Chronic stable angina
Acute coronary syndrome
Acute coronary syndrome Is consist of
STEMI (ST elevation MI)abrupt occlusion with acute ischaemia leading to infarction
NSETMI / Non Q Wave MI---partial occlusion and distal ischaemia with minor enzyme release
UA (unstable angina )-- non occlusive thrombosis with normal cardiac enzyme
Clinical presentation -------------- Ischaemic chest pain
Working diagnosis --------------acute coronary syndrome
STEMI
ECG -----------------------------
NSETMI
( + ) AMI
Biochemical markers --------
( -) UA
Patient present with cardiac chest pain

Characterized by central chest pain
Chocking / tightening / heaviness
Radiation and autonomic feature (nausea / vomiting /sweating ) + /-
STEMI STEMI
CF: ECG: mainly ST elevation
Cardiac chest pain > 30 min
ECG : Other change
New onset LBBB
ST elevation
Enzyme : Evolution of Q wave
Toponin I ---Markedly Raised
Dr. SHAMOL 66
NSETMI
NSETMI
CF: ECG
Cardiac chest pain > 30 min Mainly ST depression / T inversion
ECG :
ST depression > 1 mm Other change are
T inversion Transient ST elevation
Enzyme : Nonspecific change
Toponin I ---less Markedly Raised
UA
CF:
Cardiac chest pain less than 15 mins
ECG :
Normal ECG
Transient ST elevation / depression
T-inversion
Enzyme :
Toponin I --- normal
Normal / Non ACS

Chest pain
ECG : normal at during chest pain
8/12 hrs after 1st ECG
Enzyme
Normal after 8/12 hrs of chest pain
A patient come to u with chest pain do following

First exclude non cardiac chest pain
Then do ECG and
Look for ST elevation , ST depression , T inversion
If found then do enzyme Toponin-I ( ST elevation needs not to do enzyme )
If ECG is normal but cardiac chest pain is persist then repeat ECG 1 / 2 hours later
Dr. SHAMOL 67
Treatment of coronary syndrome Thrombolytic therapy
Bed rest Absolute 1. Streptokinase

Continuous monitor heart rate , pulse , rhythm , BP If ST elevation < 12 hrs
O2 inhalation
Sublingual GTN 2. Inj .claxane / cardinex 60 iu
Anryl spray I penfil SC BD
2 puff sublingual stat and sos Indication
Open IV channel STEMI > 12 hrs
Inj. Normal saline 1000ml NSTEMI
For pain relief UA
Inj. Morphin / pethedin
I amp slow iv stat
Inj. Vergon
1 amp IM stat
Anti platelet
Tab. Ecosprin 75 mg Rx of IHD
4 tab. crushed and chewed
Tab. Clopid (clopidogrel ) 75 mg 1. Diet normal
4 tab stat 2. Nitroglycerine
Tab. Nido card / anril SR 2.6 mg
Now Think for Thrombolytic therapy and do enzyme + +0
Pl see the side box 3. Beta blocker
Tab .betaloc 50 mg (Metoprolol )
+0 +
Continued treatment acs 4. If HTN / Heart Failure / LVH
Give anti ischaemic drug ACEI
Tab.repril / tab. Ramicard 2.5 mg
1. Nitroglycerine
0+0+1
Tab. Nido card / anril SR / GTN 2.6 mg
+ +0 5. Anti platelet
Tab. Ecosprin 75 mg
2. Beta blocker
0+1+0
Tab .betaloc 50 mg (Metoprolol )
Tab. Clopid (clopidogrel ) 75 mg
+0 +
0+1+0
3. If HTN / Heart Failure
Combination of both
ACEI
Tab. Clopid AS
Tab.repril / tab. Ramicard 2.5 mg
0+1+0
0+0+1
6. Statin (anti lipid )
4. Anti platelet
Tab.Atova 10 mg ( atorvastitin)
Tab. Ecosprin 75 mg
0+0+1
0+1+0
Tab. Clopid (clopidogrel ) 75 mg 7. If heart failure
Tab. Carvista (carvidolol ) 6.5 mg
0+1+0
+0 +
5. Statin (anti lipid )
Tab . Fusid plus / fusid
Tab. Anzitor / Atova 10 mg ( atorvastin )
1 +0 + 0
Dr. SHAMOL 68
ATRIAL FIBRILLATION
Cause of atrial fibrillation to remember it MITHA
Mitral valvular heart disease
Ischaemic heart disease
Thyrotoxicosis
H-hypertension
Lone / idiopathic
Other cause
Alcohol
Symptoms of atrial fibrillation
Cardiomyopathy
Asymptomatic
Congenital heart disease
Palpitation,
Chest infection
Breathlessness and
Pulmonary embolism
Fatigue.
Pericardial diseas
And feature of under lying disease
Chest pain ---if IHD
AF classified as
Heart failure if poor LV function
Stroke ---if Thrombo- embolism
Paroxysmal , Hyperthyroidism
Less than 7 days Alcohol
Persistence , Chest infection
More than 7 days to 1 year
Permanent
More than one years
The patient is cardiac compromised or not compromised
If cardiac compromised if following are present
Rapid ventricular rate
SBP<90 mm of Hg Drugs For AF
Heart failure A- Amidarone (rate control )
Impaired consciousness B- Beta-blocker (rate @ rhythm control)
TREATMENT is immediate cardioversion Metaprolol
C- Calcium channel blocker (rate control)
If non cardiac compromised Verapamil or
Way of treatment is to Diltiazem
Revert sinus rhythm D- Digoxin (rate control)
Rate control If Thrombo-Embolism
Rhythm control Low molecular heparin (Inj.Cardinex , Claxane )
1 unit / kg B-wt SC bd for 5 days .
Then
A patient with AF Tab. Warin 5 mg or 2.5 mg
Look for cardiac status 0 + 0 + 1 for 6 month ( maintain INR 2-3 )
Murmur
Any chest disease
Thyroid gland , feature of toxicity ,
Feature of chest disease
HO alcoholism
Do
ECG
Echo
If u give warfarin then do INR
Dr. SHAMOL 69
A patient with af with non cardiac compromised
U give only the beta blocker with out any hesitation

Tab . Betaloc (Metaprolol ) 50mg
+ o + up to 200 mg per days
Or tab. Cordarone (Amidarone)100 mg
+ 0+ to 1+ 0 + 1
If patient has asthma then do then give
Tab cardizem (ditiazem ) 60 mg
+0+
If patient heart rate is less then 100 no Role of giving Digoxin
Beta-blockers and rate-limiting calcium antagonists are often more effective than digoxin at controlling
the heart rate during exercise and may have additional benefits in patients with hypertension and/or
structural heart disease. Combination therapy (e.g. digoxin + atenolol)may be given .
Poorly controlled and symptomatic AF can be treated by deliberately inducing complete heart block with
transvenous catheter radiofrequency ablation;
Risk factors for thromboembolism in atrial fibrillation

A-age over 65
B- hypertension
C CVD- Previous ischaemic stroke or transient ischaemic attack
D- Diabetes mellitus
E- Echocardiographic features of: left ventricular dysfunction,
left atrial enlargement or mitral annular calcification
F- Heart failure
And
Mitral valve disease
Risk group
Very high---Previous stroke or transient ischemic attackWARIN + Ecospirin
High----Age > 65 and one other risk factor-------- Ecospirin
Moderate
Age > 65, no other risk factors-- Ecospirin
Age < 65, other risk factorsEcospirin
LowAge ----< 65 and no other risk factors
Dr. SHAMOL 70
A PATIENT WITH JOINT PAIN AND SWELLING
Diagnosis of arthritis depend on age and sex of the patient
If patient age is 515 yrs (20 +/- 5)

First think for Rheumatic fever
Then think for JIA
When this two are excluded if male
Reactive arthritis
Ankylosing sopondylitis
If patient age is male and age is 20 30 years

1st think for Ankylosing sondylitis (axial involvement)
Then think for Reactive arthritis
If patient is male and is > 30 years

1st think for rheumatoid arthritis
Then think for reactive arthritis
Any female is comes to u with oligo/ ploy arthritis

1st think for rheumatoid arthritis
Then think for the SLE
If patient age <20 years
Rheumatic fever
JIA
Any male patient comes to u with

Painful, Red, Hot, Tender, swelling, metatarsal joint
May associated peripheral joint
Think for GOUT
A patient with scales skin lesion with oligo-arthritis

` Psoriatic arthritis
Cause mono arhtritis
Involvement of DIP Gout
Gout Reactive arthritis
Psoriasis Septic arthritis
Osteoarthritis Pseudo gout
Trauma / TB
Haemophilia
Dr. SHAMOL 71
A patient with joint pain fills up the following question
Age ( see DD the according to age )

Sex
Duration
Onset sudden Trauma , viral arthritis
Gradual Inflammatory
HO of previous attack of sudden pain joint /
HO of diarrhea and sexual exposure 1-3 week before onset symptom
Joint information
Number of joint Oligo( 4or/less ) / poly ( 5 or more )
Character of joint large or small
Hand joint involvement / wrist joint
Joint of lower limb
Joint tenderness and swelling
Temperature over joint
Deformity joint and wasting of limb
Morning stiffness
Migratory arthritis
Joint subluxation (RA)
Systemic information
Fever
Rash ( SLE / JIA)face / other part of body
Oral ulcer and alopecia
Pain and stiffness more rest and decrease in activity
Involvement of spine
Low back pain
Sacro-ilitis
Restriction of spine movement / schober test
HO sore throat in patient less
Extra articular manifestation
Lung
Auscultation effusion feature
Expansibility (AKS)
May be have P-HTN / type -2 respiratory (AKS)
Heart pericardial effusion / aortic regurgitation
Eye conjunctivitis / Uvitis --Reactive / AKS
Prostatitis / Uvitis /Planter fascitis -- Reactive / AKS
Dr. SHAMOL 72
CRITERIA FOR DIAGNOSIS OF RHEUMATOID ARTHRITIS
Morning stiffness (> 1 hour) Type of SLE

Arthritis of three or more joint areas Classic SLE
Arthritis of hand joints When many criteria present
Symmetrical arthritis Definite SLE
Rheumatoid nodules When 4 or more criteria
Rheumatoid factor Probable SLE
Radiological changes When 3 or more criteria
Duration of 6 weeks or more Possible SLE
When 2 or more criteria
Diagnosis of RA is made with four or more of the following:
Diagnostic citeria of SLE A child with acute arthritis

DOPAMIN RASH
JAHIR
D- Discoid rash
J--JIA
O- Oral ulcers Oral or nasopharyngeal ulceration, which may be painless AAcute leukemia
HHenoch Scholien
P- Photosensitivity Iinfective (viral )
RRheumatic fever
A- Arthritis-Non-erosive, involving two or more peripheral joints
M- Malar rash- Fixed erythema, flat or raised, sparing the nasolabial folds
I -- Immunological disorder-Anti-DNA antibodies in abnormal titre or

Presence of antibody to Sm antigen or
Positive antiphospholipid antibodies
N- Neurological disorder - Seizures or psychosis NEUROPATHIC
(CHARCOT) JOINTS
R- Renal disorder-Persistent proteinuria > 0.5 g/day or Diabetic neuropathy
Cellular casts (red cell, granular or tubular) Hindfoot
A-ANA Syringomyelia
Shoulder, elbow, wrist
S- Serositis- Pleuritis, Pleural effusion , pericarditis , pericardial effusion Leprosy
Hands, feet
H- Haematological disorder- Haemolytic anaemia or Tabes dorsalis
Leucopenia2 (< 4 109/l), or Knees, spine
Lymphopenia2 (< 1 109/l), or
Thrombocytopenia2 (< 100 109/l)
Dr. SHAMOL 73
Adult still disease / JIA
if u want to remember in one sentence S.ferritin > 10,000
Young patient ( 16-35 yrs)with Oligoarthritis , Fever ,
Maculo papular ,Organomegaly with Serositis Deference between
where Rheumatic fever is excluded . Rh.Fever and JIA
Diagnostic criteria In RF there is no wasting but in
To remember FARASLR-231 0 JIA muscle wasting is present
Each of the 4 criteria
F-Fever (chill @ rigor )
A-Arthralgia or Arthritis (knee , wrist, ankle)
R-Rheumatoid factor negative
AANFnegative
Plus 2 of the following

Serositis (pluritis , pericarditis ) HO attack of pharyngitis
Splenomegaly 2-3 weeks ago
Liver enlarge
Leucocytosis > 15000 Migratory polyarthritis
Lymphadenopathy One heal and another joint start
Rash maculo-papular rash Pan carditis
Pericarditis
Pain / Rub
RHEUMATIC FEVER Myocarditis
Children (most commonly between 5 and 15 years) or young adult Dyspnea
JONES CRITERIA FOR THE DIAGNOSIS OF Tachycardia
RHEUMATIC FEVER Endocarditis
Major manifestations major early MCPS pass korese Changing murmur
M--Migratory Polyarthritis (75%)
C--Chorea
P--Pan Carditis
S--Subcutaneous nodules
Early --Erythema marginatum Investigation
Minor manifestations moni FRCP FAL korese CBC- Leucocytosis,
F--Fever ESR,CRP : raised
R--Raised ESR ASO titres: rising titres, orlevels of
C--CRP > 200 U (adults), > 300 U (children)
P--Previous rheumatic fever
F---First-degree AV block Chest X-ray:
o cardiomegaly;
A--Arthralgia
o ]pulmonary congestion
L--Leucocytosis
ECG:
o first- and rarely second-
PLUS
degree heart block;
Supporting evidence of preceding streptococcal infection:
o Features of pericarditis; T-
Recent scarlet fever, wave inversion; reduction in
Raised antistreptolysin 0 or QRS voltages
Other streptococcal antibody titre,
Positive throat culture Echocardiography:
2 MAJOR OR I MAJOR +2 MINOR +supportive evidence o cardiac dilatation and valve
abnormalities
Dr. SHAMOL 74
REACTIVE ARTHRITIS AND
Disease of young age 16-35 yrs old

Acute
Asymmetrical Oligoarthritis affecting the large and small joints of the lower limbs,
with development of urethritis, conjunctivitis (in about 50%) and
HO following sexual exposure or an attack of dysentery wks 1-3ago .
Achilles tendinitis or plantar fasciitis may be present .
There may be considerable systemic Disturbance with fever, weight loss and vasomotor changes in the
feet.
Always look the penis of patient and eye of the patient
Exceptional case
In some case Symptoms and signs of urethritis or conjunctivitis may be minimal or absent and there
may be no clear history of prior dysentery.
Organism responsible (SSC)

REITER'S DISEASE Additional extra-articular features
Bacterial dysentery-
Classic triad* Circinate balanitis (20-50%)
Salmonella,
Non-specific urethritis Keratoderma blennorrhagica
Shigella,
Conjunctivitis (50%) (15%)
Campylobacteror Yersinia, or
Reactive arthritis Nail dystrophy
Sexually acquired infection with
Buccal erosions (10%
Chlamydia
ANKYLOSING SPONDYLITIS
second and third decades, with a male:female ratio of about clinical features common to seronegative
3:1 spondarthritis
The onset is usually insidious, over months or years, Asymmetrica
recurring episodes of low back pain and Oligoarthritis (lower > upper limb)
Sacroiliitis and spondylitis
marked stiffness
Radiation to the buttocks or posterior thighs may be Inflammatory enthesitis
misdiagnosed as sciatica Familiar
Symptoms are most marked in the early morning and after Rheumatoid factor negative
inactivity and Are relieved by movement Extra-articular features
Pain on sacroiliac compression, and conjunctivitis, buccal ulceration,
Restriction of movements of the lumbar spine in all urethritis, prostatitis,
directions. Schober test negative .loss of lumbar lordosis bowel ulceration
Involvement of peripheral joint in 10 % case Pustular skin lesions, nail dystrophy
chest expansion restricted and apical fibrosis ,type 2 res. Erythema nodosum
Failure Anterior uveitis
Extra-articular features of ankylosing spondylitis Aortic root fibrosis (aortic
Anterior uveitis (25%) and conjunctivitis (20%) incompetence, conduction defects)
Prostatitis (80% men)-usually asymptomatic
Seronegative spondarthritides RAPE
Cardiovascular disease
o (AR , MR , Pericarditis ) R-Reactive arthritis, Reiter's syndrome
o Cardiac conduction defects A-Ankylosing spondylitis
Amyloidosis P-Psoriatic arthropathy
Plantar fasciitis, Achilles tendinitis and tenderness over bony E-enteropathic , inflammatory bowel
prominences as the iliac crest and greater trochanter result disease (Crohn's disease, ulcerative colitis)
from inflammatory enthesopathy.
Dr. SHAMOL 75
Clue to quick diagnosis
Any female patient with ( also in male )
Symmetrical hand joint involvement , morning-stiffness more 1 month with or with out
deformity goes favor of rheumatoid arthritis ---look dx criteria
Any female patient with

Oral ulcer , alopecia, Malar rash , joint pain , goes favor of SLE
Pl. look hematological (pancytopenia ) and urinary finding (protein / RBC)
And do ANA if positive do anti- ds DNA
Any patient less than 16 year old

Migratory arthritis (one healed another involve ),fever ,
with or without carditis (chest pain/ dyspnea / palpitation )
it will be Rheumatic fever unless other wise proved -- go to Jones criteria
If RF is excluded
Then think it as JIA look for FARA SLR 2310
Fever , Rash , Wasting or Deformity , Serositis , Organo-megaly and RA negative a
Leukocytosis
Male patient of 16- 35 yr with oligo-arthritis

With lower limb arthritis , asymmetrical ,
With or with out HO dysentery / sexual exposure Reactive arthritis
look for urethritis , conjunctivitis
Any male patient of 16- 30 year of old

With long HO of low back pain , morning stiffness ,
Pain and stiffness more in morning and inactivity and relieved by activity
With positive schober test / tenderness on sacroiliac compression ASK
Any male patient with

With the sudden severe pain hot , red , tender 1st metatarsal phalangeal joint with
It is gout
DD of chronic gout
DD of acute gout Pseudogout
Septic arthritis Osteoarhrosis
Traumatic Psoriatic arthritis
Pseudogout Rheumatoid arthritis
Psoriatic arthritis
Reiter disease
Any patient with

Tightening of hand , and skin can not pinch up , loss of wrinkling of forehead
Difficult to see anaemia by pulling lower lid
Difficulty in opening of mouth , and HO Raynauds s systemic sclerosis
See CREST Calcinosis , Raynud , Esophageal ,Sclerodactyly , Telangiectasia
Difficulty in swallowing , breathing
Dr. SHAMOL 76
Patient with arthritis common investigation
CBC-----------leukocytosis still disease , rheumatic fever , septic arthritis
------------ESR highly raised
-------------Hb % normal / decrease
PBF ----pancytopenia --SLE , felty syndrome in RA
RA-factor ----
Urine RME --- protein / RBCin SLE , in RA if amyloidosis ,
S.creatinin
If u want of exclude SLE , Do ANA
JIA/ still
Rheumatoid arthritis Common investigation for RA negative
Common RA + ANF and s.ferritin > 10000
x-ray of hand joint and other joint USG organomegaly
earliest dx by CXR-
Anti-CCP anti body
(Cyclic citrullinated peptide )
Ankylosing spondylitis
Common investigation RA
SLE x-ray SI joint ---
CBC Aneamia , pancytopenia , high ESRsome times start from lower part of joint with
Only thrombocytopenia irregularity , marginal sclerosis and later on
Urine prontiein uria / RBC /RBC cast fusion of SI joint
24 hr total urinary protein , CRP normal X-ray lumbosacral spine / cervical spine
ANApositive in 90 % case Squaring of vertebra and fusion of ant.
Anti-ds DNA positive in 30- 50 % case Longitudinal ligament , bamboo spine
And anti-sm (simth )10 20 % case positive HLA B 27--- positive in 90 % case
Serum anti-phospholipid syndrome and CRP --- raised
Complement C3 , C4 (decrease in active disease )
x-ray joint normal
GOUT
Reactive arthritis CBC ESR is high , exclude lukaemia
CBC neutrophilic leukocytosis , ESR CRPhigh
Urine RME pus cell , sterile on culture Urea and creatinin to exclude CRF
CRP high RBS
ANA and RA negative S.uric acid
X-ray of effected joint Lipid profile
CONFIRM : aspiration from the joint , bursa to
see MSUM monosodium urate monohydrate
Crystals under polarized microscope
Rheumatic fever
CBC neutrophilic leukocytosis , ESR , CRP high
ASO titer in child > 300, Adult > 200
ECG 1st degree heart block
Dr. SHAMOL 77
Treatment of Ankylosing spondylitis
The Treat of AKS
aims are to 5. DMARD use
Use if axial with peripheral joint involvement
relieve pain and stiffness,
maintain a maximal range of skeletal mobility
a. Tab. Salazine ( tab. Sulpha salazin ) 500 mg
avoid deformity.
+ 0 + -- for one week
1. General measure
1 + 0 + 1 -- for one week
2 + 0 + 2------continue
Education the patient about disease nature
Exercise and physiotherapy is the main stay of Or
treatment r Tab . MTX 2.5 mg (methotrexate 7.525 mg)
Regular daily back extension exercises 3 + 0 + 0 on Friday(once weekly )
Including a morning 'warm-up' routine, Tab . folison 5 mg
Avoid prolonged periods of inactivity (e.g. 0 + 0+ 1 on Saturday
driving, computer work)
Swimming is ideal exercise. Before start DMARD do the
Poor bed and chair posture must be avoided s.creatine and SGPT
Follow up
2. For pain s.creatine and SGPT and ESR monthly
NSAID any of the following always (after if u suspect marrow suppression then do CBC
meals ) if u give steroid pl give calcium
Tab . Naprox 500 mg / 1 + 0 +1 / 1+ 1 +1 tab. Calbo 500 mg
Naproxen 1 + 0 +1
Tab. Flexi 100 mg 1+0+1
Aceclofenac
Tab .clofenac 50 mg 1+0+1
Diclofenac sodium REATIVE ARTHRITIS
Cap .indomet 25 mg 1+0+1 1. Bed rest
Indromethacin 2. For Pain NSAID
Tab. Inflam 400mg 1+0+1 See the AKS
Ibuprofen 3. Add a H2 blocker or omeprazole
A long-acting NSAID at night is particularly helpful Tab. Ranitid / seclo 20 mg
for marked morning stiffness 1+0+1
Tab.clofenacSR 0 + 0+ 1 4. Severe case / un relieved pain
May add and opiate if pain is severe Steroid can be used
Cap . anadol 50 mg 1+0+1 Tab. Cortan 20mg (prednisolone 20 30 mg )
Tramadol o 1 + 0 +0
3. Add a H2 blocker or omeprazole 5. Antibiotic
Tab. Ranitid / seclo 20 mg Cap. Tetracycline 500 mg
1+0+1 1+1+1+1
4. Use of steroid 6. DMARD use in case of recurrent attack
If the pain is not control by NSAID Tab. Salazine ( tab.Sulphasalazin)500 mg -1st choice
Acute uveitis
Tab . MTX 2.5 mg (methotrexate 7.525 mg)
Tab. Cortan 20mg (prednisolone 20 30 mg )
o 1 + 0 +0
7. if eye change consult with the department of
If persistent plantar fasciitis
EYE
Local corticosteroid injections
Dr. SHAMOL 78
Treat of rheumatoid arthritis
MTX --- 4- 6 week s to work
1. Physical rest complication of MTX
Nausea and vomiting main complication
2. Physiotherapy Bone marrow suppression
Hepatic fibrosis
Interstitial lung disease
3. For Pain NSAID Give anitemitic before start MTX
See Ankylosing spondylitis Tab. Omidone 1+ 1+ 1
4. Add a H2 blocker or omeprazole Salazine
Tab. Ranitid / seclo 20 mg Agranulocytosis
1+0+1 Rash
Steven Johnson syndrome
5. STEROID as DMARD takes 4 12 wks to work GIT upset
To relief pain and inflammation Reversible sterility
Tab. Cortan 20mg (prednisolone 20 30 mg )
o 1 + 0 +0 So do periodic 1 to 3 monthly
CBC ,
6. if u give steroid pl give calcium S.creatinine ,
tab. Calbo 500 mg
SGPT
1 + 0 +1
7. DMARD use from very 1st day of Dx
Tab . MTX 2.5 mg (methotrexate 7.525 mg)

Assess the response
3 + 0 + 0 on Friday(once weekly ) To remember it PGTin medicine
Clinical
Tab . folison 5 mg Pain
0 + 0+ 1 on Saturday Grip strength
Tab omidone Joint tenderness
1 + 1+ 1 ----day before MTX taking Morning stiffness
Laboratory
Other drugs are ESR
sulfasalazine CRP
Plasma viscosity
poor prognosis:
higher baseline disability
female gender
involvement of MTP joints
positive rheumatoid factor
disease duration of over 3 months.
Dr. SHAMOL 79
Treatment of SLE INDICATION OF STEROID
1. Mild disease not responding to
1. Then see is any life threatening condition / this disease is mild Tab. Reconil @ NSAID
or moderate or with involvement of organ
2. Moderate disease ( Rash , Synovitis
2. Mild disease (only fever , arthralgia , arthritis) @ or Pleuro-pericarditis )
cutaneous lesion
3. Severe active disease with
Avoid sun ray @ Explanation of disease involvement of organ heart , kidney
NSAID ,CNS and hematological
Tab.Reconil 200 mg ( hydroxychloroquine 200 400 mg) abnormality
3. If no response and moderate and active disease with rash

synovitis , plueropericarditis
Or
4. And with major organ involve heart , kidney , CNS and I.v. methylprednisolone combination
hematology with pulse i.v. cyclophosphamide
Steroid / Tab. Prednisolon methylprednisolone
5. Life threatening condition such Inj. 5% DA 200 ml

Lupus nephritis and +
CNS involvement Inj . methylprednisolone 1 gm
I.v. methylprednisolone combination with IV @ of 30 d/ min
pulse i.v. cyclophosphamide
Followed by
Tab.pednisolone
1 mg / kg body weight
Dose of steroid
Cyclophosphamide
With out major organ involvement
Prednisolone 0.250.5. mg / kg body weight 0.5to 1 mg / m2 of body surface area in
With major organ involvement 500 ml DA .
Prednisolone 1 to 1.5 mg / kg body weight Monthly for 6 cycle then
Start Every 3 monthly for 6 cycle
45 mg to 60 mg daily single dose for 4 8 wks Then
Reduced 10 mg weekly until 30 mg then
25 mg / day for one week then
20 mg / day for one week then
15 mg / day for one month then
Reduced 2.5 gm every 2 weeks as follows
1st day 15 mg
2nd day 12.5 mg for 2 week
Then
1st day 12.5 mg
2nd day 10.mg for 2week so on
Dr. SHAMOL 80
Treatment of rheumatic fever Toxicity of aspirin
1. Bed rest ---- Temperature subsice Mild toxic effects include
Mild toxic
Leucocyte
effectscount
include
andnausea,
ESR normal
tinnitus and deafness; more serious ones are vomiting,
2. tachypnoea
Aspirin and acidosis. Aspirin should be continued until the ESR has fallen and Nausea,
then gradually tailed
off.Starting dose is 60 mg/kg body weight per day, divided into six doses. Tinnitus and
In adults, 100 mg/kg per day (a maximum of 8 g per day). Deafness;
Aspirin should be continued until the ESR has fallen and then More serious ones are vomiting,
gradually taper Tachypnoea and acidosis.
3. STEROID
Should be given in with carditis or Maximum 8 gm / min
severe arthritis not respond to aspirin
Tab.Prednisolone,
1.0-2.0 mg/kg per day in divided doses,
continued until the ESR is normal then taper
4. cap . Omeprazole 20 mg
1+0+1
5. Antibiotic (to eliminate any residual streptococcal infection.)
Inj. Benzathine penicillin
1.2 million U i.m. stat or
Tab. phenoxymethylpenicillin 250 mg (pen-V)
1+ 1+ 1+ 1 for 10 days
6. secondary prevention
Inj. Benzathine penicillin
1.2 million U i.m. monthlyor oral
Tab Pen-V ( phenoxymethylpenicillin) 250 mg
1+ 0 +1
Duration of 2ndary prevention
Up to the age of 21, or
Treatment should be extended to 5 yrs after lasrt attack ,which one
is longer
. In those with residual heart disease, prophylaxis should continue
until 10 years after the last episode or 40 years of age,
JIA
Rest and assurance

Physio therapy
1. To relieved pain
NSAID
2. cap . Omeprazole 20 mg
1+0+1
3. Steroid
4. DMA RD
Dr. SHAMOL 81
Any patient with consolidation
PNEUMONIC CONSOLIDATION DD
Patient comes to u with Pneumonia
High grade fever (days to week ) TB
Short HO Bronchogenic carcinoma
Chest pain
With or with out cough / dyspnea
On examination patient is usually toxic (not all case) Common inf. In DM / immune
Tenderness on percussion suppression
RTI
Bronchial breath sound
Crep +++ UTI
Investigation
CBC --- Neutrophilic Leucocytosis To exclude TB
--- ESRmay high but persistent high in TB / CA
Long HO
RBS- as DM cause immune suppress --- more prone to RTI
Fever low grade (weeks to
CXR PA view 12to 18 hrs to come radiological shadow.
month)
MT---
Not responding to Rx
Sputum for AFB
High ESR with normal CBC
MT @ sputum for AFB
Treatment of pneumonia X-ray change not resolve after
Bed rest 2 weeks Rx
O2 inhalation ESR persistently high
Tab . Moxaclav 625 mg ---2 wks
1+1+1
Tab. Clarin 500 mg ----2 wks Some times Bronchogenic CA
1+0+1 First present as consolidation .
Cap . Omeprazole 20 mg so keep in mind CA lung in
1+ 0 + 1 case pneumonia .
If pain is severe then give Look for lymphadenopathy ,
Inj. Anadol 100 mg / inj.Clofenac feature of SVO
1 amp im stat
Horners and paraneoplastic
Then
feature
Cap . Anadol 50 mg
Do sputum for malignant cell
1+0+1
Severe case Give antibiotic for 2 week and
Inj . Fimoxiclav 1.2 mg / Inj. Cefriaxone 2 mg if lesion persist and TB is
1 vial IV 8 hrly / 1 vial IV BD excluded then do
+ Do USG guided FNAC
Tab. Clarin 500 mg ----2 wks
1+0+1
During discharge Adv to do CXR and CBC after 2 wks
common
Para-pneumonic effusion-
A patient with pneumonia fever not subside after taking Empyema-
antibiotic ? what are the underlying cause Pneumothorax- Staph. Aureus
Dx may be wrong ( it may be TB , CA) lung abscess
Inadequate dose or wrong drug , not taking drug un common
Complication has been developed ( empyema ) ARDS, renal failure
Hepatitis,
Pericarditis,myocarditis,
Meningoencephalitis
DR. SHAMOL 82
POOR PROGNOSTIC CRITERIA
LABORATORY (COAL-UREA_)
CLINIACL ( to remember ABCD LobeRT)
A--AGE >60 C----POSITIVE BLOOD CULTURE
B--BP SYSTOLIC <90, DIASTOLIC <.60 O-----HYPOXAEMIA PO2 <8 KPA
C---CONFUSION A----SERUM ALBUMIN < 2.5gm
D---UNDERLYING DISEASE L------
Lobe-MORE THAN ONE LOBE LEUCOPENIA <4000 OR
R--RESPIRATORY RATE >30/MIN LEUCOCYTOSIS < 20,000
T--TEMPERATURE > 38.3 Urea--- UREA > 7mmol/l
For place of treatment follow the CURB 65 If score

C---Confused patient 0/1 home treatment
U--- urea > 7mmol/l 2short hospital stay Rx
R----respiratory rate >30/MIN 3-- Rx hospital as severe pneumonia
B--- BP systolic <90, diastolic <.60 4/5ICU support needed .
65Age more than 65
1 point for each feature present
Discharge from hospital Common organism in CAP MSC in low

When patients are clinically stable S--Streptococcus pneumoniae
with C---Chlamydia pneumoniae
No more than one of the following M---Mycoplasma pneumoniae
(to remember SPORT-ing )
Law--Legionella pneumophila
S------Systolic BP < 90 mmhg
P---pulse /Heart rate > 100/min
Less common to remember HSC
O---Sao2 < 90%
H--Haemophilus influenzae
R--Respiratory rate > 24/min
T--Temperature > 37.8C SStaphylococcus aureus
Ing---inability to maintain oral C --Chlamydia psittaci
intake and abnormal mental status
U have not memorized the following / just for those who are over interested
Mycoplasma pneumoniae Children and young ad Haemolytic anaemia /Stevens-Johnson syndrome
. Myocarditis/Pericarditis/ Meningoencephalitis/ Guillain-Barr syndrome
Legionella pneumophila Cooling tower/ confusion, /high fever and diarrhoea.

Hyponatraemia/Elevated liver enzymes Hypoalbuminaemia
Chlamydia psittaci Contact with birds, hepatosplenomegaly

Coxiella burnetii (Q fever) high fever, conjunctivitis, hepatomegaly, endocarditis
Staphylococcus aureus multilobar shadowing, cavitation, abscesses. Dissemination to other site

osteomyelitis, endocarditis or brain abscesses. Mortality up to 30%
DR. SHAMOL 83
a patient with the pleural effusion
U should remember the following DD ( unilateral ) Think pneumonia if

TB High grade fever (days to week )
Pneumonia Short HO
Bronchogenic carcinoma Chest pain marked
Cough with / with out sputum
Think TB if following are present Dyspnea +/-
Long HO (weeks to months ) Patient is usually toxic (not all case)
Fever is low grade / some time absent Tenderness on percussion
Patient mainly complaint Crep +++ just above effusion
Chest tightness
Or breathless ness
Chest pain absent Pleural fluid study
Weight loss / TB contact Color
straw TB
Long HO (> 3wks) of Cough and sputum
Turbid / pus pneumonia /empyma
Haemoptysis +/ -
Hemorrhagicca bronchus
Serous -- transudative
If bronchogenic CA Biochemical
Usually middle age to old age See protein and glucose
HO of smoking If protein more than > 3 gm Exudative
No HO of fever Cytology
Chest pain may present , haemoptysis +/- See inflammatory cell
Hoarseness of voice Neutrophil and lymphocyte
Cervical lymph adenopathy Malignant cell
Feature of superior vena-cava obstruction Only given
Horner syndrome o when suspected malignancy
meiosis ,Ipsilateral partial ptosis,Enophthalmos, o Or hemorrhagic effusion .
anhydrosis Otherwise not routinely given
Clubbing Micro biological
Pancoast chest ((pain in the shoulder and inner arm) GM stain and AFB stain
Sign of paraneoplastic syndrome Practically valueless
Common investigation
CBC -- Neutrophilic Leucocytosis TB
Exudative with lymphocyte predominant
Normal CBC with persistent high ESR- in TB / CA
Parapneumonic
RBS
Exudative with Neutrophil predominant
MT
Sputum for AFB and CXR PA Malignant
Exudative with malignant cell present with
Pleural fluid aspiration and study for biochemical ,
cytology , malignant , microbiology hemorrhagic fluid
If suspect malignancy Do
sputum for Malignant cell
FNAC for lymphnode Hemorrhagic effusion
USG or CT guided FNAC Does not clot and uniformed distribution
Traumatic
Central lesion bronchoscopy and biopsy
Clot on the tube or standing
DR. SHAMOL 84
Examination finding of effusion
Trachea shift only in massive effusion
Percussion stony dull Clinical DD on basis on dull ness on percussion /
Vocal resonance and Fremitus --- decreased radiological DD (on haziness )of pleural effusion
Breath sound ---- decrease Consolidation
These all always comparison with normal side Trachea central and
breath sound bronchial,
cerps +
Fibrosis
Trachea same side and
What will u do if suspect pl.effusion ? breath sound bronchial
wasting of over lying chest ,
If u r suspect any pleural effusion both Rib crowding present ( space between corresponding
radio logically and clinically then rib is decrease )
confirm it by aspiration of fluid . Collapse
If bronchus is patent
If u failed do bluntly then aspirate the Trachea same side
fluid under USG guidance . Bronchial breath sound
If bronchus is not patent
Trachea same side
Breath sound diminish
Maximum aspiration per day is ?
1.5 L
removing more than 1.5 litres in one
episode is inadvisable as there is a small
risk of re-expansion pulmonary oedema.
Pleural effusion is clinaclly detect if Fluid is
500 ml
Radiological detected in PA view if Fluid is
What will u do if pus comes on aspiration ?
200 ml
It indicate that the Patient develop empyema
Radiological detecte in Lateral view if Fluid is
Needs IT tube insertion in the chest .
100 ml
Please give a call to surgery ?
USG can detect as small amount Fluid
When Dx is not establish or on receiving pt If think or suspect this is a case of tubercular

give the following Rx pleural effusion
Bed rest Before diagnosis is confirmed do not give the
Cap. Amoxicillin 500 mg following drugs Such as
1+1 +1 Ciprofloxacin / levofloxacin ,
Cap. Omeprazole 20 mg any quinolol group
1+0 +1 Moxaclav and clarithromycin
Tab . p /c
1 tab stat if temp > 101 0 Sent the sputum for AFB before starting this .
Aspiration of pleural fluid and send for single dose of this drug may cause sputum
study positive case in to sputum negative .
Maintain Tem chart
DR. SHAMOL 85
When clinical history and examination and fluid study report are suggestive Tuberculosis
Give CAT---1 with steroid
First take the weight of the patient
WT: 45 kg
CAT 1
Diet normal
Intensive phase
Anti-TB drugs
4FDC drugs such as ------- 2 month
RIEZ --
Tab. Rimstar 4FDC for 2 month
Rifampicin
3+ 0 + 0 before meal from 17-7-09 to 16 9-09
Isoniazid
Ethambutol
Tab remactazid 450 mg for 4 month
1+0+0 before meal from 17-09 09 to 16-1-10 Pyrazinamide
Continuation phase
2FDC drugs -------------4 month
Tab. Pyrol 20 mg for 6 month
RI
0+0+1
Rifampicin
1+0+1 Isoniazid
Weight 4 FDC (Rimstar 4 FDC)

Steroid
Tab. Cortan 20 mg after meal
30-37 2
2+0+0 for 1 month
1 + 0 for 1wk
38-54 3
1+ 0 + 0 for 1 wk
+ 0+ 0 for 1 wk
55-70 4
Tab .calbo (calcium ) 500 mg >70 5
1+ 0 + 0 ------------------- 2 month
Weight 2 FDC
For easy remember if patient weight is
(To remember it--- rimstar---432 , remactazid---211 ) 30-37 1 Remactazid 300
More than 50 kg
Rimstar 4 FDC ----4 tab., Remactazid 300 ---2 tab 38-54 1 Remactazid 450
Less than 50 kg
Rimstar 4 FDC ----3 tab., Remactazid 450 ---1 tab 55-70 2 Remactazid 300
Less than 30 kg
Rimstar 4 FDC ----2 tab., Remactazid 300 ---1 tab
Indication of CAT 2
Indication of CAT-1 Should be given
New smear-positive patient Relapse
New smear negative PTB extensive parenchyma involve Treatment after interruption /
Extra pulmonary TB default
Meningeal , Treatment failure
Miliary In single word, if a patient get
Pericardial , Pleural effusion previously anti TB
Spinal , Intestinal TB, dessiminiated TB Next time u have to give CAT--2
DR. SHAMOL 86
Dose of streptomycin
` Weight inj. Streptomycin Tab.Ethambutol
Cat 2 to remember it 235 ( 1 amp = 1 gm) (400 mg )
(2-streptomycin, 3- Remstar4 FDC, 5-Remactazid) 30-37 500 mg 2
Intensive phase
First 2 months --- Inj.Streptomycin IM daily 38-54 750 mg 3
First 3 months ----- Remistar FDC
Continuation phase 55-70 1000 mg 4
Next 5 months ---- Remactazid + Ethambutol Dose of streptomycin is should not exceed
750mg daily dose
Patient weight is 45 kg Rifampicin ------ 10 mg/kg, max 600 mg

INH-------- 5 mg/kg, max 300 mg
Diet normal Ethambutol---- 1520 mg/kg
Pyrazinamide----- 2025 mg/kg, max 2 g
Inj. Streptomycin 1000mg for 2 month Streptomycin -----15 mg/kg daily,
2/3 amp im stat and daily 17-7-09 to 16 9-09
Radiological finding of TB in CXR
Tab. Rimstar 4FDC for 3 month
Patchy opacity
3+ 0 + 0 before meal from 17-7-09 to 16 10-09
Pleural effusion
Tab Remactazid 450 mg for 5 month Hilar lymphadenopathy- unilateral,
1 + 0 + 0 before meal from 17-10 09 to 16-3-10 paratracheal or mediastinal)
Collapse
Tab. Pyrol 20 mg for 6 month
Consolidation
0+0+1
Cavitation / lung abscess
Cap. Omeprazole 20 mg Pleural effusion
1+0+1
Steroid and calcium as previous dose Indication of steroid in TB
TB with Serosal involvement
Pleural effusion
Pericardial effusion
Ascitis
Tb Does Not Involved The Following
Tuberculous meningitis
Myocardium
Skeletal muscle Genitourinary TB
Thyroid Endocrine TB (Addison )
MT test positive False negatives

when induration more than > 10 mm Severe TB (25% of cases negative)
It is not diagnostic test but supportive investigation Newborn and elderly
The test does not differentiate between HIV (if CD4 count < 200 cells/ml)
TB infection Recent infection (e.g. measles) or
TB disease Immunisation
BCG vaccination Malnutrition
It some time negative in TBM @ Intestinial TB Immunosuppressive drugs
Malignancy
Sarcoidosis
DR. SHAMOL 87
Pulmonary TB
TB effecting the lung parenchyma only (tuberculous mediastinal and hilar lymph node and pleural
effusion with out lung abnormality are extra pulmonary TB )
Extra pulmonary TB
Smear positive case
Pleural effusion
A patient with
At least 2 sputum positive specimens Pericardium ,peritoneum
Or Intestine
One sputum positive specimens for AFB plus CXR Military TB
abnormality consistent with active TB Meningitis
Or Spinal and genitourinary
One sputum positive specimens for AFB plus culture Lymph node
positive for Mycobacterium TB Bone joint and skin
Smear negative pulmonary TB

A patient with symptoms suggestive of TB with Extra pulmonary TB is never
infectious .
3 sputum specimens negative for AFB and
Persisting symptoms after a course antibiotics and
Again 3 sputum specimens negative for AFB and
CXR abnormality consistent with Active TB and In TBM Neurologic sequelae are
Decision by a medical officer documented in 25% of treated case.
Some definition
New case --- who have never received anti- TB drugs or received less than one months
Relapse -----A patient who previously received treatment and was cured or treatment completed And
. again developed Smear positive pulmonary TB.
Treatment failure --- A patient who while treatment ,remain smear positive or became smear
Positive again at 5 month or more after the start of treatment
OR
Patient was initially sputum negative but again become sputum at the end of 2 months
Miliary TB
Blood-borne dissemination . CRYPTIC TB
2-3 weeks of fever, Age over 60 years
night sweats, anorexia, weight loss and a dry Intermittent low-grade PUO
cough. Unexplained weight loss, general debility
Hepatosplenomegaly may be present (Hepatosplenomegaly in 25-50%)
headache indicate co-existent TBM. Normal chest X-ray
Auscultation is normal,. Blood dyscrasias; leukaemoid reaction,
pancytopenia
Fundoscopy -------choroidal tubercles.
Negative tuberculin skin test
chest X-ray ---fine 1-2 mm lesions ('millet seed')
throughout the lung fields. Confirmation by biopsy (granulomas and/or
acid-fast bacilli demonstrated) of liver or
Anaemia and leucopenia may be present.
bone marrow
DR. SHAMOL 88
TB with Normal Chest X-ray
Small radiological lesions Potts disease
Endobronchial tuberculosis
Cryptic tuberculosis The spine is the most common
site for bony TB (Pott's disease),
which usually presents with
ActiveTB Inactive TB chronic back pain and
Sputum Positive Negative Typically involves the lower
thoracic and lumbar spine
Symptoms Equivocal Equivocal
The infection starts as discitis and
Creps Marked Less Marked spreads along the spinal ligaments
Radiology Soft shadows Calcification to involve the adjacent anterior
Cavitation Tracheal shift vertebral bodies
Serial extension Hilar elevation Paravertebral and psoas abscess
Diaphragm tenting Present cord compression
Change of fissure
In TB collapse vertebra with intervertebral When collapsed vertebra with intervertebral

space reduced ( disc is involved ) space maintained ( disc not involved )
Six months of therapy is appropriate for all

patients with new-onset, uncomplicated pulmonary 2nd line Anti TB
or extrapulmonary disease. 1. The injectable aminoglycosides, kanamycin,
However, 9-12 months of therapy should be and amikacin
considered if the patient is HIV-positive, 2. he injectable e capreomycin;
Meningitis should be treated for a minimum of 12 3. The oral agents ethionamide, cycloserine,
months. 4. the fluoroquinolone antibiotics. third-
generation agents are preferred: levofloxacin,
In TBM we give prednisolone 1 mg/ kg for 4week and gatifloxacin , and moxifloxacin
then taper on 4 wks 5. Amithiozone (thiacetazone). Other drugs of
In Harrison unproven efficacy
Inj. dexamethasone (0.4 mg/kg per day given IV and 6. Second-line agents include clofazimine,
tapering by 0.1 mg/kg per week until the fourth week, when amoxicillin/clavulanic acid, and linezolid
0.1 mg/kg per day was administered; followed by 4 mg/d
given by mouth and tapering by 1 mg per week until the
fourth week, when 1 mg/d was administered.
DR. SHAMOL 89
Isoniazid Rifampicin Pyrazinamide Streptomycin Ethambutol
Peripheral Hepatitis Gout 8th nerve Retrobulbar
neuropathy1 damage neuritis
Febrile reactions Hepatitis Arthralgia

Hepatitis2 Rash Gastrointestinal Rash Peripheral
Rash Gastrointestinal disturbance Nephrotoxicity neuropathy
Lupoid disturbance Hyperuricaemia Agranulocytosis Rash
reactions Interstitial nephritis Rash
Seizures Thrombocytopenia Photosensitisation
Psychoses Haemolytic anaemia
A patient developed jaundice after taking Anti TB drug?

what will u do ?
Do the following Tab. Pyrazinamide 500 mg
Stop the drugs immediately + 0 +0
1/3 + 0 +0
Do liver function test ( SGPT and s.bilirubin )
+ 0 +0
When test become normal or near to normal
1 + 0 +0
Strar anti TB drug in challenging dose 2 + 0 +0
Start with low dose single less hepato toxic drug Then
Goes its optimum dose gradually and Ethambutol 400 mg
Start one by one drug and + 0 +0
Finally give combination drug 1 + 0 +0
Due to unknown mechanism jaundice does not develop 2 + 0 +0
First give pyrazinamide ---Ethambutol ----INH---last Then start such manner
Rifampicin INH @ rifampicin
Choice of drug is deffer from DR to DR Then goes to combination drug again
Some side effect and what to do

Side effect Offending drug What to do
Anorexia , nausea , abdo. Pain Z, R Give drugs after meal
Joint pain Z Aspirin
Burning sensation INH Pyridoxine 100 mg daily
Orange R Reassurance
Skin ,rash All drugs If not severe anti- histamine
If severe stop drugs
Deafness , vertigo ,nystagmus Streptomycin Stop streptomycin and give
Ethambutol
Jaundice All especially INH , Z ,R See above
Vomiting and confusion All , think acute liver failure Stop and do liver function
Visual impairment Ethambutol Stop ethambutol
Shock , purpura , ARF Rifampicin Stop Rifampicin
DR. SHAMOL 90
Anti TB in special situation
In Acute Viral Hepatitis
Pregnancy In Acute Viral hepatitis the treatment should be
All drugs are safe in pregnancy stopped until acute hepatitis phase is resolved .
Except in streptomycin
when it is necessary to treat TB during acute viral
Which is Ototoxic to fetus
hepatitis
Breast feeding The combination of streptomycin and Ethambutol
No contractindication . baby should combination give for Max 3 month is safest option
be breast feed until the stage of hepatitis has subsided
After recovery from hepatitis give Rifampicin and

INH during the continuation phase
Treatmen in DM
Same dose schedule as in
normal but DM should be
treated with insulin . Patient with renal failure
INH, Rifampicin, Pyrazinamide are excrete in bile
These can be given in normal does in renal failure
Streptomycin and Ethambutol are excrete by kidney
Give in reduced dose where kidney function can be
closely monitor
New smearing positive case with after other wise these two should be omitted
Interrupting treatment
Length of Rx Length of interruption Smear Treatment

< 1 month <1 month No need Continue Cat -1
12 + Continue Cat -1. with 1
month extra
- Continue Cat -1
>2 + Restart cat -1

- Flow chart
Less than 2 month Less than 2 month + Continue Cat -1. with 1
month extra
- Continue Cat -1
Less than 2 month + if Rx < 5 Restart cat -1
+ if Rx > 5 Restart cat -2
- Flow chart
More than 2 month Less than 2 month + if Rx < 5 Restart cat -1

+ if Rx > 5 Restart cat -2
- Flow chart
More than 2 + Restart cat -2
- No
DR. SHAMOL 91
HEPATITIS B
Acute B viral hepatitis no needs of treatment --- 95 % resolve spontaneously

Acute C viral hepatitis needs of treatment ----- 95 % turn into chronic
Acute viral hepatitis Chronic viral hepatitis

Clinical
Prodrome present (nausea / vomiting /anorexia ) No prodome
Short HO < 1 month Jaundice present Usually absent if present duration is > 3 month
No stigmata of CLD Stigmata CLD present Ascites , splenomegaly ,
spider and gynaecomastia , testicular atrophy
Bio-chemical
Prothrombin time increased Prothrombin time increased in Acute on chronic
Albumin and A:G ratio normal hypoAlbuminia and A:G ratio alter
Viral marker HBs Ag + < 6 months Viral marker HBs Ag + > 6 months
Anti-HBC Ig G negative Anti-HBC Ig G positive
Imaging ( USG )
Shows liver Hypo echoic Coarse echo structure
Inflammation of gall bladder (Chloe cystitis ) Ascites @ or Spleno-megaly
Normal
If patient comes to u with HBS Ag positive what will u do

wait for 6 months and tell him comes after 6 month
then do HBs Ag again if positive and it is either
Carrier or --------no Rx is needed
Chronic active viral hepatitis ---- Rx is needed
Chronic active hepatitis

Criteria for carrier 1. HBs Ag positive > 6months
1. HBs Ag positive > 6months 2. ALT > 2 times (persistent / intermittent )
2. ALT normal 3. HBe Ag +
3. HBV-DNA level undetectable 4. HBV-DNA level > 10 5 copies
4. Biopsy: minimal hepatitis ( Knodal score ) 5. Biopsy: moderate / bridging hepatitis ( Knodal
5. anti- HBc ( + ) score )
if all these are positive than it is carrier
in our subcontinent there is mutated virus so
Do the following HBe Ag may be negative . So negative HBe Ag
No treatment is needed Does not exclude the chronic active hepatitis so
Patient will do normal activity treatment give if other criteria fulfilled
Stop smoking and alcohol consumption
it aggravate CLD
Do not donate blood
Sexual partner should be vaccinated Practically we see
HBs Ag positive > 6months
Breast feeding allowed
ALT > 2 times (persistent / intermittent) (60)
Give anti viral therapy
Single test for Chr. Viral hepatitis
Anti-HBC Ig G positive
Dr. shamol 92
Dug use in HBV
Interferons/ Pegylated interferons
Adefovir
Lamivudine
Interferons/ Pegylated interferons Interferon should not given compensate, if
u give it in compensated CLD it may be turn
DOSE into Decompensate.
Interferon standard
Sub cutaneous thrice weekly
Pegylated interferons Contractindication
180 mg Sub cutaneous wkly Decompensated CLD
Thyroid anti body
Duration Neuro-psychiatric manifestation
Pregnancy
If HBe Ag positive ---- 6 month
If HBe Ag negative ------ 1 years
Side effect Sign of decompensation

Flu like syndrome Ascites
Alopecia Jaundice
Bone-marrow suppression Encephalopathy
Reversible Azospermia
Neutropenia
Lamivudin
Oral and cheap and easily avail able Tab. Adefovir 10 mg
Dose 1+ 0+ 0 --- given at morning ----1 year

Tab . lamivir 100 mg Complication
1 + 0 + 0 ----------------before meal Nephrotoxic
In case of child 3 mg / kg body wt Renal function monitor
Duration Advantage does not grow resistance
At least one year Can use in Decompensate CLD
Goal of therapy
Can given in pregnancy
Short term goal
Can given in decompensated CLD
ALT normal
DNA level
Chance of resistance so some body prefer to give
With Adefovir with lamivudin Sustained Seroconversion
Long term goal
Prevent cirrhosis
Prevent HCC
Seroconversion
If patient is HBe Ag positive developed Anti- If patient HBe Ag negative
HBe Ag then it is called Seroconversion In such patient seroconversion will be
Sustained seroconversion achieved when HBs Ag will be negative
If anti- HBe Ag persist more than 6 month then in the blood
it is called sustained seroconversion
Dr. shamol 93
Follow up of treatment
Clinically How will u see the drug resistant
Biochemical
ALT By seeing the DNA level
Anti-HBe Ag If DNA level increased than it indicate drugs
DNA level resistant
To see drugs complication
Adefovir --- Renal function
Interferon ---- neutrophilia count
A patient comes to u with HBs Ag and want to go foreign ?
Or patient with HBs Ag positive and want to make it negative ?
No , He can not go to foreign as there is no chance of spontaneous Removal

of HBs Ag( chance of spontaneous recovery 0.5% year )
Interferon can clear the virus 10 % per year , no role of oral anti viral
therapy
Come to 6 month later and Repeat HBs Ag
if positive then look for whether it carrier and chronic Active hepatitis
Mother HBs Ag + chance to spread to baby A pregnant woman with HBs Ag +

is 90 %
HBs Ag does not cross the placenta Rx usually not given in pregnancy
It spread peri natal via blood during delivery During Anti natal check up see
vis umbilical vein Patient DNA level
If DNA is increasing Rx may given
Choice of drug is--- Lamivudin
What will u do A HBs Ag + mother give birth a child ?
With in 24 hr s of Delivery give Ig G If lady on interferone but recently
Both active and passive immunization should be done become pregnant what will u do ?
after delivery Stop interferon
Switch on to lamivudin
Wife of HBs Ag + husband

Do HBs Ag of wife
If doctors get needle is stick injury what
Immunized her if negative Will u do ?
Until developing immunization ( 36 mon) pl. use First see he is vaccinated or not
barrier contraceptic method
If not give immunoglobulin ( Ig G )
If she become positive do not immunized her .
Followed by active immunization
If doctors is immunized then see triter
Indication of Immunoglobin Do accordingly level of triter
Infant born Of HBs Ag (+)mother
After needle prick injury
After sexual contact with HBs Ag
(+) women
Dr. shamol 94
Patien is chronic viral hepatitis COMPLICATIONS OF ACUTE VIRAL
HBs Ag + and Anti-HBC Ig G positive HEPATITIS
Acute liver failure
A patient is vaccinated Cholestatic hepatitis
HBs Ag -ve and Anti HBS + ve Aplastic anaemia
Chronic liver disease and cirrhosis
Level of vaccination (hepatitis B and C)
If triter is Relapsing hepatitis
< 10 ---non responder ---Double dose full immunization FATE OF ACUTE VIRAL HEPATITIS
10 --- 100 mild responder --Double dose single immuniz.
> 100 ------ full immunized --- no vaccine needed the Most of them spontaneous resolution
patient is fully protective
Plus above complication
Vaccine schedule inj. engerix-B
1 amp. IM on 0--- 1 ------6 month
HBeAg---- indicates continued active

Which one is more infectious? replication of the virus in the liver .
HBV > HIV
Anti-HBe ----implies that replication is
HBV > HCV
occurring at a much lower level .
Can u give vaccine to a patient with HBs Ag positive?

No , if u Vaccinated him it will be wastage of money
Test for
Hepatitis A --- Anti-HAV Ig M

Hepatitis C --- Anti HCV and HCV RNA
Feature of acute hepatitis
Hepatitis E anti HEV Ig M
Non-specific prodromal
Headache,
Only B @ C have chronic form only 5 -10 %
Myalgia, arthralgia,
Nausea and anorexia usually begain few days to
Only 15 20 % of them develop
2 weeks before development of jaundice
complication , HCC , cirrhosis , hepatic
Vomiting and diarrhoea may follow and decompensarion
abdominal discomfort is common.
They spread in parental and sexual routes.
Dark urine and pale stools
Other have only faecoral routes
PHYSICAL SIGNS.
HAVcan spread sexually in perverted
The liver is often tender but only minimally
(oro-anal sex )
enlarged.
Occasionally, mild splenomegaly and cervical
lymphadenopathy are seen. (with Epstein-Barr
virus infection.)
Hepatitis B Virus not cytopathic it act
Symptoms do not last more than 3-6 weeks.
immunologically
HAV --- is not also cytopathic
HEV ---t is cytopathic ( damage the liver cell )
HEVit dangerous in old age
In late pregnancy mortality high
Chance of fulminative hepatic failure is more
jaundice more deeper and prolong than the
acute HAV
Dr. shamol 95
Treat ment of viral hepatitis
diet normal to diagnosed

SGPT
Inj. 5%DA1000 ml / INJ. DNS 1000 ML if pt is nausea S.blirubin
o I V @ v 20 drop / min //vomiting prothrobin time
HBs Ag
cap. omeprazole 20 mg USG of whole abdomen
o 1 + 0 +1 TO exclude obstuction
tab. omidone 10 mg
o 1+1+1
syp. D-LUC konakoin

o 3 tsf tds when prothrombin time deference
is more the 4 .
inj. konakion 10 mg acute viral hepatitis we can give
1 amp iv stat and daily for 5 days konakion with out doing PT.
if itching present then give

tab. ursocol / ulive 300 mg
o 1+ 1 + 1
Or In hepatocelluar jaundice
questarn ( cholestyramin ) ALT > 6 times
1 saucet 12 hrly or 8 hrly In obstructive jaundice
Alkaline phospahtase > 2.5
No NSAID , Sedative , Analgesic , Hypnotics
If patient is HBs Ag +ve than counseling patient to do

following
o Check the HBs Ag status of wife or sexual partner
o Use barrier contraception method
o Adv. Not to donate blood
Dr. shamol 96
Approach to a patient with bleeding spot or purpuric spots
U should differential diagnosis in Ur mind?

o ITP
o Dengue
o Leukemia
o Aplastic anaemia
o Drug rash
o Henoch scheonlein purpura
o Septicaemia
o DIC
o SLE (Rheumatoid arthritis)
o Meningococcal septicemia
o Vasculitis ---SBE
o Survy and hemophilia
o Metabolic ------CRF and CLD
Rarely
1st see it is purpura or not

---purpura not blanches on pressure
Then see it is palpable and pain full if yes then it is due to vasculitis
If not then -----due to thrombocytopenia
Then see the patient fever or not

If fever absent then cause is
o ITP
If Fever present then cause
o Leukemia
o Aplastic anemia
o Septicemia
o Meningococcal septicemia
o Vasculitis SBE
o DIC
Think for dengue
If rash appear after fever subside
The patient reside in Dhaka / recent visited to Dhaka
Take history of Henoch scheonlein purpura if patient child
Rash in buttock and lower limb
Arthritis, fever, bloody diarrhea,
Abdominal pain, Haematuria
Any drug history
Pt will give history the bleeding spot appear after taking some drug
Then look for anaemia
Leukemia (toxic, boney tenderness, Organomegaly +/- )
Aplastic anemia (fever +/-, not toxic)
CRF if with HTN, edema, with vomiting
With arthritis
SLE -------look for oral ulcer, alopecia, malar rash
Gum bleeding, Screw hair, Haemoarthrosis----Scurvy
DR.SHAMOL 101
At last think for septicemia and DIC
If source septic foci ---septic abortion, fever, evidence of infection
Multi organ involved, Immuno-compromised, jaundice, haematuria
Look for meningeal irritation ---and unconsciousness and rash Meningococcal septicemia
CLD ---
History and examination
At last look for splenomegaly
To exclude hypersplenism
Anaemia leukemia, aplastic , CRF
CML
Jaundice septicemia / CLD
Mylodysplastic syndrome
Cervical / other lymphoadenopathy
Boney tenderness leukemia
Hepto-splenomegaly leukemia ,
INVESTIGATION
Fever
Toxicity
CBC and PBF:
Oral ulcer, alopecia, malar rash SLE
Pancytopenia aplastic anemia
ArthitisSLE, Henoch scholein ,
Increase TC and blast cell leukemia
Rash in buttock and lower limb
Only thrombocytopenia ---ITP
Arthritis, fever, bloody diarrhea, H.Scholein
Neutrophilic leukocytosis septicemia
Abdominal pain, Haematuria
Purpura palpable or not
Platelet count
Pain full or not
Prothrombin time
Edema
PTT, BT CT
Fundoscopy
Urine RME for haematuria vasculitis , DIC
Bone marrow
Aplastic anemia --- hypo plastic marrow
Leukemia ---blast cell Minimum investigation
ITPincrease megakaryocyte CBC
PBF
SLE --ANA Bone marrow
CRFuremia Platelet count
If suspect liver disease prothrombin time BT, CT
If suspect dengue PCV and anti-Ig M Urine RME and
Serum creatinine
USG of whole abdomen to see splenomegaly USG of whole abdomen
DR.SHAMOL 102
First open a channel with
Inj. Hartman 1000 ml
ITP ----------------------------
Child and adult IV @ 10 d/ min
<6 month acute Send blood for grouping, PBF, CBC, platelet
> 6 month chronic
Female are affect than male If fever then
Due to autoantibody (IgG ) against platelet membrane Inj. ceftron 1 gm
Glycoprotein IIb , III a 1 vial IV stat and bd
Clinical feature
CF 1+ 0 + 1
Every thing is no expect purpuric spot After sending blood for CBC and PBF give
No fever , no boney tenderness , organomegaly , one unit of blood and wait for the result
No anemia , pt not toxic
In child it occur 2-3 weeks after a viral illness During discharge
Please exclude SLE Tab. cortan 20 mg
2 + 0+ 0 after meal for 4 wk and then taper.
Management Tab. Calcium 500 mg
Children 0 + 1+ 0
Self-limiting within a few weeks
In case of mild bleeding no specific treatment
Indication for prednisolone

DRUGS INHIBITING PLATELET
Moderate to severe purpura, bruising or epistaxis,
FUNCTION
a platelet count less than 10 109
NSAIDs
Dose
Aspirin
Tab. prednisolone 2 mg/kg daily.
Indometacin
The platelet count usually rises promptly within 1-3 days.
Phenylbutazone
Sulfinpyrazone
Indication for immunoglobulin (IVIgG) @ platelet transfusion
Antibiotics
Persistent epistaxis,
Penicillins
Gastrointestinal bleeding,
Cephalosporins
Retinal haemorrhages or
Dextran
Any suggestion of intracranial bleeding
Heparin
-blockers
ADULT
Treatment with prednisolone 1 mg/kg daily for 4 to 6 wks and taper.
Relapses should be treated by increasing the dose of prednisolone
Indication for immunoglobulin (IVIgG). And platelet transfusion
Persistent bleeding IgG (1mg/kg) for 3 to 5 days
Indication for splenectomy Diagnosis
>2 relapse o Clinical features
If still bleeding continue daily prednisolone 5 mg / day o Thrombocytopenia
o Marrow examination (usually increased
2
megakaryocytes)
o Exclusion of secondary causes of
thrombocytopenia
o Reliable tests for antiplatelet antibodies
are not widely available.
DR.SHAMOL 103
Approach to patient with anemia
When u receive a patient with anemia, u will find that patient will come with
1. Only anemia
2. Anemia with fever aplastic anemia / leukaemia / Kala-azar / lymphoma
3. Anemia with bleeding manifestationaplastic anemia / leukemia
4. Anemia with edema with / without respiratory distress heart failure
5. Anemia with vomiting + HTN + ---CRF
6. Anemia with HO blood loss Hamoptysis , Hamatemesis , Epistaxis
So during receiving a patient with anemia it keep mind that 2-6 is medical emergency. Where anemia
is the manifestation of other disease. U have to give attention to that disease more.
Any patient comes to u with anemia then u have diagnosed the patients anemia
o Clinically mild / moderate and severe
o Morphologically Cause of iron deficiency anemia?
o And then find out etiology Chronic blood loss
Peptic ulceration,
Morphological
Occult blood
Microcytic, hypochromic
o CA stomach
Iron deficiency
o Colorectal malignancy,
Thalassaemia
Anaemia of chronic disease (in some case ) Inflammatory bowel disease,
Macrocytic Hookworm
MCV>95 fl Drug
Megaloblastic: vitamin B12 or folate o Chronic use of aspirin orNSAIDs,
deficiency o Steroid
Chronic haemoptysis
Non-megaloblastic:alcohol, liver disease,
Haemorrhoid
Myelodysplasia,
In case of female
Normocytic anemia
Pregnancy
o Anemia due to acute blood loss
PPH
o Anemia of chronic disease
Menorrhagia
o Aplastic aneamia
Mal absorption
coeliac disease
CAUSES OF FOLATE DEFICIENCY gastric surgery
Diet Hypochlorhydria in the elderly due to
Poor intake of vegetables proton pump inhibitors
Malabsorption
e.g. Coeliac disease Cause of B12 deficiency
Increased demand Low in take
Pregnancy Vegan, pregnancy
Cell proliferation, Gastric (IF)
e.g. haemolysis Pernicious anaemia (autoimmune)
Drugs* Congenital deficiency of IF
Certain anticonvulsants (e.g. phenytoin) Total or partial gastrectomy
Contraceptive pill Intestinal
Certain cytotoxic drugs (e.g. methotrexate) Tropical sprue
Celiac disease@Crohns disease
Chronic pancreatic insufficiency
Bacterial over growth
DR.SHAMOL 104
HISTORY U WILL TAKE IN PATIENT
WITH ANEMIA In eye aneamia
Dietary history.vegetable / meat Jaundice haemlytic anemia + lymphoma
For iron deficiency Fundoscopy ------optic atrophy ---B12
HO PUD Tongue for glossitis , angular cheilosis
HO haematomesis and malaena Cervical Lymph node leukemia / lymphoma
HO pain , vomiting , Boney tenderness
Alteration of bowel habit / mucous stool Leukonychia some time it only sufficient to
HO no antihelminthic drug for long time Dx the iron deficiency anemia
Drug HO NSAID , steroid Fever
Ho haemorrhoid / haemoptysis Toxic
HO PPH , pregnancy , menorrhaegia Hemolytic face anemia
HO any gastric surgery and mal-absorption Any purpura or echymosis
HO glossitis / dysphagia Hepatomegaly leukemia , lymphoma ,kala-azar
HO for B 12 Splenomegaly haemolytic anemia
Vegetarian / vegan Intra abdominal lymph node
Gastric or intestinal surgery HTN CRF
Pregnancy Edema ---heart failure
Malasorption Any abdominal lymph node
Neurological HO
Glove and stocking paraesthesiae Neurological examination
Motor weakness and loss of Sensory parasthesia / numbness
vibration and proprioception SCD spinal cord Joint sense position
loss of memory (Dementia) Vibration
visual abnormality (Optic atrophy) Memory test
Painful glossitis ('beefy' red tongue)/ smooth Jerk and planter reflex
tongue
Angular cheilosis HO for suspect aplastic anemia
Vitiligo and Skin pigmentation
Take any drug before anemia
Folic acid Exposure to DDT, OPC, Radiation
Less vegetable in take HO recent pregnancy
Haemolysis leukamia other haem.malignancy HO jaundice HBV, HCV
Drug Primary idiopathic / autoimmune
Certain anticonvulsants (e.g. phenytoin)
Contraceptive pill In Aplastic anemia there is no Organomegaly
Certain cytotoxic drugs (e.g. methotrexate)
FEVER aplastic , leukemia

Bleeding mainifestation kala-azar
The condition where MCV increased
Edema anemic heart failure Liver disease,
Breathlessness Hypothyroidism,
Hyperlipidaemia and
Old age myelodysplastic syndrome /CGL Pregnancy.
Arthritis/ connective tissue diseaseanemia of Alcoholism
chronic disease
DR.SHAMOL 105
PBF is the most important investigation .so u must do it before Common investigation
Before giving blood transfusion. PBF
CBC
PBF finding is--- microcytic and hypochromic then u must think s.creatinine
2 D/D RBS
Iron deficiency Anaemia USG of whole abdomen
Hemolytic anaemia If suspect iron def.
Endoscopy of upper GIT
Hemolytic anaemia Stool and colonoscopy
Hepatosplenomegaly Iron deficiency Anaemia

Haemolytic faces To Dx
Jaundice Serum . ferritin
Investigation Do USG to exclude splenomegaly which will alter
Hb elcetrophoresis confirm the the Dx
diagnosis. To find out etiology
If PBF comment it haemolytic STOOL RME helminthes
anemia donot hesitance to do Hb STOOL FoR OBT
electrophoresis If positive then do Colonoscopy
PBF if finding is macrocytic then first exclude non megaloblastic cause of macrocytosis such as:
The condition where MCV increased

but anemia Which one is more common?
Liver disease, Folic acid deficiency is more common
Hypothyroidism, then vitamin B12
Hyperlipidaemia and As because B12 store > 3 years
Pregnancy.@Alcoholism Folic acid store > 3 month
B12 --animal source meat
Folic acid vegetables and destroy
PBF
during cooking
Macrocytic anemia with hypersegmented
neutrophil
Other investigation
Can thalassamic patient present with
Low serum B12 macrocytic anemia?
Low serum Folate level Yes, due Folic deficiency as excessive
RBC folate > accurate than serum production RBC depletes the normal
folate folate level.
Following test not done here , u may know That why TAB. Folic acid is use in
Schilling test thalassamia in one tab daily for
Parietal cells Ab prophylacting
Actually U have not do any test, we Dx
the case clinically
DR.SHAMOL 106
Some time u find in PBF o Never correct folic acid deficiency before
Combined deficiency that RBC is dimorphic correcting B12 if there is concomitant B12
That means there are both folic acid and iron deficiency present .
deficiency .
If not then it is may be sederoblast -- to diagnose o If correct folic acid deficiency with out
it need bone marrow . correcting the vit B12 deficiency it will
cause sub acute combined degeneration
Clinically u search for both Iron and folic and B12 of spinal cord.
Deficiency for etiology.
If not found and patient age is old then with

permission ur CA u may do bone marrow exclude
Hematological malignancy Anemia of chronic disease
o Usually normocytic normochromic .it is
due to chronic infections, chronic
inflammation or neoplasia.
Anaemia with hepato-splenomegaly Causes are due to
Iron an B12 and folic def Excluded CRF
Look for hematological malignancy and Connective tissue such as
other cause of hypersplenism RA
SLE
Pathogenesis
The various cytokines (e.g. IL-1 and TNF-)
Suppress the erythropoietin .
Old man with refractory anemia DX
o Think for myelodysblastic PBF-- normocytic and norm chromic
syndrome
o Heamatological malignancy Serum ferritin normal or increase
o CRF TIBC decrease
In this case always do bone marrow to Excluding that The anemia is not due to :
exclude the hematological malignancy o to bleeding,
o haemolysis or
o marrow infiltration
MCV > 95
If PBF shows target cell, stomatocyte Then think liver disease do LFT
If PBF shows Dimorphic Do bone marrowto see sederoblast (-) / (+)
If PBF showsdysplastic change with cytopenia Mylodysblastic syndrome do bone marrow
If PBF showhyper segmented neutrophil and Megaloblastic anemia
low serum folate and B12 level
DR.SHAMOL 107
Treatment depend severity of anemia:
Most of patient comes to u with Hb less then 7 gm /dl
If patient Hb level is < 7 gm /dl give fresh blood
I unit of whole blood will correct 1 gm/ dl
TREATMENT OF IRON DEF. ANEMIA
INDICATION OF BLOOD TRANSFUSION

o Severe anemia
o Angina,
o Heart failure or
o Evidence of cerebral hypoxia
Other wise
Tab. Ferrous sulphate 200 mg 8 hrly
120 mg of elemental iron per day
Duration:
Continued for 3-6 months
But we give combination Zn + Fe + Folic acid

Cap. ZIF cl
1+ 0 + 1 -----3 to 6 month
Also treatment of primary cause
Complication
o Dyspepsia and
o Altered bowel habit.
How will assess the respond? A failure to respond
o Non-compliance,
The haemoglobin should rise by 1mg/dl every 7-10 days o Continued blood loss,
Reticulocyte response will be evident by 1 week. o Malabsorption or
o Incorrect diagnosis.
o The occasional patient with
malabsorption or
o chronic gut disease
DR.SHAMOL 108
INDICATION OF BLOOD TRANSFUSION
o Severe anemia How will assess the respond
o Angina, Reticulocyte count will increase 5th-10th days
o Heart failure or Haemoglobin will rise by 1g/dlweek
o Evidence of cerebral hypoxia
Vitamin B12 deficiency is treated with Which one cause neurological symptom ?
Initial dose Vitamin B12 deficiency is associated with
inj. hydroxycobalamin 1000 g neurological disease in up to 40% of cases
1 i.m. in 2 or 3 days apart for five doses
Daily requirement of Vitamin B12 is ?
Maintain dose 1 g daily
inj. hydroxycobalamin 1000 g
1 Amp IM every 3 months for life long.
For neurological manifestation Never give folic acid with out B12 in
A sensory neuropathy for 6-12 months patient with B 12 deficiency.
What else will u give? If u give then what will happen?
Iron supplementation It will cause sub acute combined
degeneration of spinal cord.
Treatment of folic acid deficiency
Tab. Folic acid / folison 5 mg Folic acid use in as prophylacting ?

1 + 0+ 0 -----for 3 wks In pregnancy
1 + 0+ 0 once weekly for maintenance Hemolytic anemia
MTX
When PBF finding is combined deficiency
Give combination of (Zn+Fe+folic acid+ B12) When will u give Folison to prevent neural
CAP. Zif-cl tube defect?
1 +0 + 1 She have to take it before conception as
Tab B50 forte neural tube formed with first 3 wks
1 + 0 +1
DR.SHAMOL 109
Aplastic anemia
Pt present with severe anemia and infection in late case bleeding manifestation
PBF Normocytic with pancytopenia (anemia, neutropenia, thrombocytopenia) 7
No Organomegaly or bony tenderness
Bone marrow dry trap or hypo plastic marrow
HO ---
Recent drug
o Viral hepatitis HBV, HCV
o Pregnancy
o Radiation
o Insecticide ---DDT, OPC , Carbamate
o Fanconi anemia
Rx
For infection-----
o Antibiotic ---usually broad spectrum, if fever then gives Inj. Ceftron 1 gm BD
For anemia----
o Blood transfusion to keep it 10 gm/dl
Specific treatment
If the patient age < 30 years Allogenic bone marrow transplantation
If not then
Immunesupressor therapy cyclosporine + antithymocyte globulin
Prognosis is poor 50 % will die.
OLD age
Only supportive therapy and follow up (monthly CBC and PBF)
Immunesupressor therapy cyclosporine + antithymocyte globulin
If multiple releaps think for MDS and even AML
myelodysplastic syndromes (MDS) are a group of biologically and clinically heterogeneous

clonal disorders characterised by ineffectivehaematopoiesis and peripheral cytopenia due to
increased apoptosis andby a variable tendency to evolve to acute myeloblastic leukaemia.
Myelodysplastic Syndrome Drug we may use in aplastic anemia

Age usually old > 50 Diet normal
Patient may present with Inj. Ceftron 1gm
Mild to moderate anemia which is refractory to treatment 1 vial IV bd
Recurrent Infection: Neutropenia and dysfunctional granulocytes:. Tab . Neoral 100mg (cyclosporine)
Thrombocytopenia: Dysfunctional platelets: spontaneous 1+0+1
Bruising, Purpura, Bleeding gums. Tab. Anapolon 50 mg
Presentation ranges from mild Anaemia to profound pancytopenia. 1+ 0 + 1
Splenomegaly commonly occurs Somebody use
Dysplastic change in PBF and Bone Marrow Inj. Decadorabolin
1 amp im monthly or 3wkly
DR.SHAMOL 110
Approach to A patient with headache u should have the following D./ D in ur mind
And have to exclude three emergency condition of head ache (SIM)

Sub arachnoid haemorrhage --Acute, severe headache with stiff neck but without fever
ICSOLlong HO daily morning head ache, vomiting, papillaedema , focal neuro- sign
Meningitis and encephalitis --Acute, severe headache with stiff neck and fever and LP
SO any patient with head u must do fundoscopy and with out fundoscopy if u Dx any head
ache it will be a crime .
Primary head ache Secondary head ache

o Migraine o Subarachnoid heamorrhage
o Tension head ache o ICSOL
o Cluster headache o Meningitis
o Raised intracranial pressure o Drug
o Benign paroxysmal headaches o Viral fever
o Trigeminal neuralgia o HTN
Local cause
Sinusitis
Refractory error
Glaucoma
Next u try to establish head ache in tension type and migraine ?
Tension type headache Migraine

Site Bilateral , occipital , vertex Usually unilateral , may bilateral
Character Dull diffuse , band like pressure Throbbing pain
on head or vertex
Radiation From occipital to forward Localized
Toward neck muscle and neck
Duration and frequency Many hours to day , even month Last for 24 hr to 72 hrs
Called chronic > 15 days per
month , more marked as day
progress
Severity Mild to moderate Moderate to severe
Prodrome Absent Visual aura , tingling sensation
Numbness over affect area
Nausea vomiting,
Photo phobia @ phono phobia Absent Present
Aggravating factor Work load cheese, chocolate or red wine
Depression OCP, bright light , loud noise ,
Anxiety menstruation ,changing weather
, citrus food , travel
Frequency Infrequently daily , episodic , Sub acute , acute , weekly ,
Chronic monthly , before menstruation
DR .Shamol 111
Simplified Diagnostic Criteria for Migraine
Repeated attacks of headache lasting 472 h in patients with a normal physical examination, no other
reasonable cause for the headache, and:
At least 2 of the following features: Plus at least 1 of the following features:
Unilateral pain Nausea/vomiting
Throbbing pain Photophobia and phonophobia
Aggravation by movement
Moderate or severe intensity
Classical' migraine Patients with triad of SAH (sub arachoid hemorrhage )

paroxysmal headache, nausea and/or vomiting,
and an 'aura' are said to have migraine with aura. o Sudden severe headache and
Common' migraine:Those with paroxysmal o Dramatic onset
headache (with or without vomiting) but no o Thunderclap headache , sudden blow to back
'aura' are said to have migraine without aura to head
o Pt said he never experience such type head
HEADACHE OF RAISED INTRACRANIAL ache ever before
PRESSURE: o Vomiting and neck stiffness and
o Worse in morning, improves through the day. unconsciousness and may focal neurological
o Associated with morning vomiting. sign
o Worse bending forward. o Patient may conscious and pain
o Worse with cough and straining. o No fever @ do CT scan
o Relieved by analgesia. o If CT-scan negative u r confident enough that
o Dull ache, often mild. this SAH then do LP after 12 hr to see
o Transit loss of vision xanthochromia .
If u fundoscopy u will find the sign of pallaedema

In some case HTN @ bradycardia @ focal
neurological sign.
Pupillary dilation
Fever with head ache
o If neck rigidity ---meningitis.
HOW will u differentiate between tension head ache o If with heaviness head with sinus
and migrainous head ache? tenderness ----sinusitis.
o Malaise and running nose viral fever
Head ache be may be due to

o Refractory error
Cluster Headache (Migrainous Neuralgia)
Periodic, severe, unilateral periorbital pain
accompanied by
o Unilateral lacrimation,
o Nasal congestion and
o Conjunctival injection,
Brief (30-90 minutes).
not persist for more than 10-15 minutes
DR .Shamol 112
TREAMENT OF MIGRAIN TREAMENT OF TENSION HEAD ACHE
Lifestyle modification
Regular exercise, During acute attack: / severe
Regular sleep patterns, Tab.Naprox / Tab. Naprosyn 500 mg
Avoidance of excess caffeine and alcohol, 1+ 0+ 1 ---2 Day
Avoidance of acute changes in stress levels Tab. Omidone
----------------------------------------------------------- 1+1+1---2 Day
During acute attack: Cap. Seclo 20 mg
Tab.Naprox / Tab. Naprosyn 500 mg 1+ 0 + 1 ---2 Day
1+ 0+ 1 Tab. Sedil 5 mg
Tab. Omidone 1 tab stat
1+1+1 ---------------------------------------------------
Cap. Seclo 20 mg Prophylaxis :
1+ 0 + 1 low-dose amitriptyline (10 mg nocte increased
Tab. Sedil 5 mg gradually to 30-50 mg)
1 tab stat.
-------------------------------------------------- Tab. Tryptin 10 mg
In severe attack patient need injectable 0+0+1
NSAID Tab. Frenxit
Inj. Torax 30 mg I amp IM stat 1 + 1 +0
Inj. Ranison 1 amp IM stat
Inj. Sedil 1 amp IM stat
---------------------------------------------------------
For prophylaxis
One of the following
Tab. Pizo-A 0.5 mg (pizotifen 1.5-3.0 mg/day)) Cluster headaches
0 + 0+ 1-----continue Periodic, severe, unilateral periorbital pain
Tab. Tryptin 25 mg (amitryptilin 10-50 mg) accompanied by
0 + 0+ 1-----continue o unilateral lacrimation,
Tab. Indever 40 mg (propranolol 80-160 mg) o nasal congestion and
+0+ o conjunctival injection,.
We prefer 1st one The pain is very severe@characteristically brief
---------------------------------------------------------- (30-90 minutes).
Advice the patient that if u feels that u will be U should not R x patient
attack by head ache soon or at beginning head Call ur CA
ache: u should take o Inhalation of 100% oxygen; for 1520 min.
o Acute attacks are usually halted by
o Tab. Ace subcutaneous injections of sumatriptan
2 tab stat o U may manage like migraine severe attack
o Tab omidone o Prophylaxis
2 tab stat 1. Prednisone 1 mg/kg up to 60 mg qd,
o Tab sedil tapering over 21 days
1 tab stat 2. Verapamil 160960 mg/d
3. Lithium 400800 mg/d
DR .Shamol 113
THESE ARE UNCOMMON HEAD ACHE U NEED NOT TO REMEMBER THIS PAGE.
Trigeminal Neuralgia Temporal arteritis

o Age > 50 o Elderly patient
o Unilateral. o Severe throbbing pain
o Along the Distribution of 2nd and 3rd o The pain is intractable lasting until Rx
division of trigeminal nerve territory commence with steroid
o Severe pain and Brief. o Unilateral pain with tenderness over scalp
o Sharp, short, stabbing, pain, like hot red overlying superficial temporal artery
needle. o The artery is thicken and tender but not
o This pain is brief and repetitive and pain pulsatile
free interval is last for weeks. o The patient feel pain chewing and talking
o Aggravating by chewing , speaking due to ischaemia of maseter muscle .
washing face , shaving , brushing teeth
Rx ---Steroid Tab. Prednisolone 80 mg daily
Rx for the first 46 weeks
Tab. Carbamazepine (up to 1200mg) Tab. Cortan 20 mg
Alternately: 4 + 0 +0 after meal
Gabapentin or Phenytoin may be effective
BENIGN INTRACRANIAL HTN

o Women Chronic Daily Headache
o Obese
o Present with head ache with palledema o when a patient experiences headache on 15
o Pt have raised ICP with out mass lesion, days or more per month
ventricular dilation and impaired consciousness cause
o Some time diplopia and visual disturbance Chronic migraine
Investigation Chronic tension head ache >4hrs
o The CT is normal, with normal-sized or small Chronic cluster headache
ventricle Chronic paroxysmal hemicrania <4 hrs
o lumbar puncture shows the raised CSF pressure
Rx Post traumatic
o Reduce wt , withdraw medication Chronic CNS infection
o The carbonic anhydrase (inhibitor, acetazolamide), Inflammatory, (Giant cell arteritis)
may help to lower intracranial pressure. Post infectious
o Repeated lumbar puncture can be done
o Non responding case lumbo-peritoneal shunt Treatment
Precipitating factor Tricyclic anti depression low doses (1025
o Tetracycline, and rarely vitamin A, retinoids, mg daily )
o Addison's disease Tab. Tryptin 10 mg
o Withdrawal of corticosteroid therapy. 0 + 0 + 1 ---continue
If sleep hamper pt daily activity then give it at
12 hr before the time morning awaken or
Tab. Norium 10 mg (Flunarizine)
1 + 0 + 0 ---continue
DR .Shamol 114
History in patient with head ache
Acute
Sub acute / chronic
Unilateral
Bilateral
Fever followed by head ache
Neck rigidity
Kernigs sign
Prodrome :
Nausea / vomiting :
Parasthesia and numbness :
Frequency of attack
Focal neurological sign
Bradycardia + HTN (systolic )
Long HO daily morning head ache
Morning vomiting.
Worse bending forward.
Worse with cough and straining.
Relieved by simple analgesia.
Dull ache, often mild.
Severe throbbing pain
Transit loss of vision / refractory error
Aggravate by
OCP, bright light ,
loud noise , menstruation ,
changing weather, menstruation
Along the direction of V nerve
Nasal congestion ,
unilateral lacrimation
conjunctival congestion
Papillaedema
Thunderclap headache and
Not responding to Rx
How many day in month
Nasal discharge + tenderness over sinus
Head ache with malaise :
HO of lumber puncture
DR .Shamol 115
Approach to patient with dyspepsia
NON-ULCER DYSPEPSIA
This is defined as chronic dyspepsia (pain or upper abdominal discomfort) in the absence of organic
disease.
The patient present with Clue to diagnosis
o Upper abdominal discomfort / pain A patient with upper abdominal pain.
o Early satiety, USG : Normal
o Fullness, Endoscopy : Normal
o Bloating and nausea usually after meal Cause is non ulcer dyspepsia
Usually young (<40 yr) and female
On examination
No signs, no weight loss
Except inappropriate tenderness on abdominal palpation
Appearance may reveal anxiety and depression
Before diagnosis it please exclude Dyspepsia
In older patient exclude Carcinoma. Cause
In PUD. PUD
Gastritis
PLEASE EXCLUDE THE ALARM SIGN IN Esophageal spasm
PATIENT : Functional (non ulcer dyspepsia)
Ca colon
ALARM' FEATURES IN DYSPEPSIA
Non GIT
o Weight loss
Pancreatic disease
o Anaemia
o Cancer,
o Vomiting
o Chronic pancreatitis
o Haematemesis and/or melaena
Hepatic disease
o Dysphagia
o Hepatitis,
o Palpable abdominal mass
o Metastases
Investigation
o USG of whole abdomen Other cause
o ENDOSCOPY Renal failure (uremia)
o ECG Drug
o RBS NSAID
o S. Creatinin Steroid
Iron and digoxin
TREATMENT :
o Explanation and reassurance. Some body prefer anti H.
o Fat And milk restriction may help in some people Pylori therapy
Pl Add
o Tab. Motigut 10 mg (Domperidone 10 20 mg 8 hrly )
1+ 1+ 1--- hr before meal
o Cap . Omeprazole 20 mg
1+ 0 + 1 hr before meal
Low-dose amitriptyline is sometimes of value if associated wt anxiety
o Tab. Triptin 10 mg
0 + 0 + 1 ----continue
Dr. shamol 119

TREATMEMNT of GERD
Patient presented to u with
Heartburn and regurgitation of sour material into the mouth
A few present with atypical chest pain which may be severe, can mimic angina and is probably due to
reflux-induced oesophageal spasm.
Treatment of GERD
Life style modification:

o Weight reduction,
o Not to go bed after eating
o Avoid ingesting large quantities of fluids with meals
o Sleeping with the head of the bed elevated by about 46 in.
o Stop smoking
o Avoid consuming fatty foods, coffee, chocolate,
Alcohol, mint, orange juice, and
o Avoid some medications such as
o Anticholinergic drugs,
o Calcium channel blockers,
o Other smooth-muscle relaxants
DRUG therapy
Tab. Omidone 10 mg
1 + 1 + 1-- hr before meal
1 + 0 + 1 --- before meal
IN Refractory case double the dose of Omeprazole :
Predisposing factor
o Reduced lower esophageal
sphincter tone,
o Increase intra-abdominal pressure SURGURICAL TREATMENT:
rises.( Pregnancy and obesity) Ant reflux surgery, in which the gastric
o Hiatus hernia fundus is wrapped around the esophagus
o Delayed oesophageal clearance (in (fundoplication)
case of Oesophagitis )
o Gastric contents
o Defective gastric emptying
Dr. shamol 120

Diagnostic Criteria for Irritable Bowel Syndrome
Irritable bowel syndrome (IBS) is a functional bowel disorder in which abdominal pain is associated
with defecation or a change in bowel habit.
CLINICAL FEATURES OF IRRITABLE BOWEL SYNDROME:
o Altered bowel habit (alternate episodes of diarrhea and constipation)

o Colicky abdominal pain
o Abdominal distension Diagnostic Criteria for IBS
o Rectal mucus Recurrent abdominal pain or discomfort b at least 3 days
o Feeling of incomplete defecation per month in the last 3 months associated with two or
more of the following:
Constipated: Pellety stools with abdominal pain o Improvement with defecation
Or proctalgia. o Onset associated with a change in frequency of stool
Diarrhoea : Frequent defecation but o Onset associated with a change in form (appearance)
Produce low-volume stools of stool.
Some no
o No nocturnal symptoms. a
Criteria fulfilled for the last 3 months with symptom
o NO rectal bleeding onset at least 6 months prior to diagnosis.
o No fever
o No Anemia b
Discomfort means an uncomfortable sensation not
o No lose weight and described as pain.
o are constitutionally well.
o No rise of ESR
Physical examination: abdominal bloating and variable tenderness to palpation. persistent diarrhea
after a 48-h fast, and presence of nocturnal diarrhea or steatorrheal stools argue against the diagnosis of
IBS.
Investigation to exclude D/D D/ D of IBS
CBC ---ESR --carcinoma o IDB
Colonoscopy ---exclude malignancy and TB o Intestinal TB
Stool for OBT and RME o Malignancy
Treatment of constipation
Rome criteria for constipation : Advice
o Drink profuse water
At least 2 of the following o Take fiber rich diet daily
o Vegetable and fruits
o Straining at least 25 % of defecation Give glycerine suppository
o Hard and lumpy stool at least 25 % of defecation 4 stick PR stat and sos
o Incomplete sensation at least 25 % of defecation Syp. AVolac (lactulose )
o Feeling of obstruction at least 25 % of defecation 2/3 TSF TDS
o Manipulation at least 25 % of defecation If poor pt give
o Pass of stool less then 3 times of week Tab. Laxena
2+0+2
If patient still constipated then give
Enema simplex
Dr. shamol 121

Incase of Diarrhea predominant IBS-D
The list of food which may
o Explanation and Reassurance cause diarrhea, bloating,
o Dietary modification if it precipitates the symptom cramping or flatulence should
o Tab. Imotil 2 mg (loperamide 2-8 mg) daily be avoided in appropriate
o 1 + 0 + 1 ----continue till diarrhea subside we don not use it patient:
o Quastran sachet (cholestyramin 4 g with meals)
1 sachet daily o Coffee,
o Anti spasmodic if pain o Disaccharides,
1. Tab. Mave 135 mg (Mebeverine ) o legumes, and cabbage,
+0+ o excessive fructose and
o Tricyclic antidepressor o artificial sweeteners, such
2. Triptin 10 mg (Amitriptylin 10 25 mg at night ) as sorbitol or mannito
0+0+1 o Milk and milk product
o PPI (as some have associated dyspepsia )
3. Cap .Omeprazole 20 mg What findings suggest organic

1+0+1 disease instead of IBS?
o New onset of symptoms in an
elderly patient
Incase of constipation predominant IBS-C o Pain that interferes with
o Explanation and Reassurance normal sleep patterns
o Dietary modification o Weight loss
High-fiber diets and bulking agents o Anemia
o Stool softerner o Blood in the stools
o Ispaghula o Pain on awakening from sleep
o Syp. D-luc (lactulose 1020 g bid ) o Diarrhea that awakens the
2 tsf BD ot TDS patient
o In case of poor u may use o Fever
o Tab Laxena o Steatorrhea
2+0 +2 o Physical exam abnormalities
o Anti spasmodic
o Tab. Mave 135 mg (Mebeverine )
+0+
o Tricyclic antidepressor
o Triptin 10 mg (Amitriptylin 10 25 mg at night )
0+0+1
Dr. shamol 122

What will u do if a patient comes to u with USG which comments that he has a FATTY LIVER?
Do not worry fatty liver is clinically insignificant except in following case:
Alcoholism
Drug
DM
Dyslipidaemia
Hypothyroid
HO jaundice (HBV, HCV)
Obesity
Following HO should be taken:

Ho alcoholism
HO of DM or feature of DM
Look for xanthalaesma
Look for jaundice and HO jaundice
Feature of hypothyroid like
Hypo thyroid face ---puffy face with buggy
Buggy eyelid and loss of lateral 1 /3 of
Eye lid, hoarse ness of voice,
bradycardia , delayed relaxation of
Ankle jerk.
BMI of the patient
Look for stigmata of CLD
USG shows Fatty liver Elevated serum transaminases, no history of alcohol abuse and a
negative chronic liver disease screen.
Investigation
USG of HBS and Pancrease
RBS
If suspect Dyslipidaemia fasting lipid profile
Liver function test SGPT, S.Billirubin
if u suspected HYPO THYROID then do
T3, T 4, TSH.
TREATMENT
No treatment is necessary
Reduction of weight
Rx of cause
Avoid Alcohol, Smoking
Dr. shamol 123

Ulcerative colitis Crohn's disease
Risk factors More common in non-/ex-smokers More common in smokers
Appendicectomy protects
Anatomical Colon only; begins at anorectal Any part of gastrointestinal tract from
distribution margin with variable proximal mouth to anus; patchy distribution-'skip
extension lesions'; Perianal disease common ,such
as anal fissure , fistula and skin tag
Type of lesion Continuous lesion 'skip lesions'',shortened colon, absence of
haustra (lead-pipe sign)
Presentation Bloody diarrhea , tenesmus , mucous NO bloody diarrhea ,abdominal pain,
discharge diarrhoea, weight loss all common these
three are the cardinal feature , oral ulcer
Histology Superficial lesion , Inflammation Deep and transmural ulcer
limited to mucosa; crypt distortion, common(submucousal ); deep fissuring
cryptitis, crypt abscesses, loss of ulcers, fistulae; patchy changes;
goblet cells
Management 5-ASA; corticosteroids; azathioprine; Corticosteroids; azathioprine;
colectomy is curative methotrexate; infliximab; nutritional
therapy; surgery for complications is not
curative
How differentiate between ulcer of TB and Chrons Disease

TB ulcer --- transverse, continuous, high up caecum
Chrons ulcer --- longitudinal / transmural , Asymmetrical Skip stricture
Ulcerative colitis only in colon, lesion is confluent, superficial, loss of vascular pattern, slough
Mucosa,, granularity, friability and ulceration , touch on bleeding
Investigation DD of chrons if present

o CBC ESR raised , Hb decreased , with lump
o Stool culture to exclude superinfection o Ileal TB
o Blood culture to exclude septicemia o CA caecum
o Specific investigation o Lymphoma
o Colonoscopy o IBS
o Appendix abscess*
DD of ulcerative colitis
A young boy comes to u with bloody diarrhea with optic atrophy
o No lump
-------Dx is IBD --
o Shigellosis
o Colonic carcinoma
o Chrons disease
Dr. shamol 124

Approach to a patient with SOL (space occupying lesion) in the liver:
If u found any SOL in the liver following may be the differential diagnosis
o Secondaries in the liver
o Hepato cellular carcinoma
o Hydatid cyst What are the primary sites in
o Liver abscess (see liver abscess chapter ) case of SOL in liver?
Secondaries in liver: o Lung
No need to find out primary cause as it is difficult o Colon
to find primary site. So better to do USG FNAC o Ca stomach
form the SOL. o Uterus
o Thyroid
So if any pt comes to u with SOL Pl do o Pancreases
BT, CT, platelet count, prothrombin time o Breast
If prothrombin time > 4 sec then give
Inj. Konakion 10 mg, 1 amp IV stat .and for 3 day What investigation u will do to find out
the primary site?
o 1st investigation is the USG of whole
Treatment depend on patient conditions abdomen which may told us it is gut
Palliative treatment only origin or not
Diet : normal o CXR PA view
Cap. Omeprazole 20 mg o Endoscopy of upper GIT
1+0+1 o COLONSCOPY
If pain complaint o Other CBC , RBS ,
Cap. Anadol 50 mg / Inj. Anadol 100 mg o SGPT , S. creatinin
1+0+1
Or What HO will u take and exam will u do in 2ndaries
Tab. Torax 10 mg / Inj . Torax 30 mg in liver ?
1 + 0 +1 Vomiting, anorexia, virchows gland CA stomach
If needed (anorexia + vomiting ) Alteration bowel habit, ---secondary
Inj. DNS 1000 ml Female breast lump
------------------------- Chest pain and clubbing and haemoptysis- Ca lung
IV @ 20 d / min
HCC 2nd in the liver

Tenderness Tender hepatomegaly Non tender hepatomegaly
Number Single lesion Multiple lesion
Umbilication Present Absent
Bruit Present Absent
Bio chemical marker Alpha feto protein + (60%) CEA +
Clinically how how will u differentiate between HCC @ 2nd in liver?
Primary case sing of hepatic insufficiency present such as ascites, splenmegaly , spider , jaundice
Palmer erythema , leuconychia , gynaecomastia testicular atrophy
Patient is more toxic in primary case it is more pain ful
Secondary only hepatomegaly which hard and non tender , left supraclavicular gland
Plus ---see the difference between HCC @ 2ndaries in the liver
Dr. shamol 125

.
Approach to a patient with hepato cellular carcinoma
Hepatocellular carcinoma may present to us with ---feature of cirrhosis / CLD

Or present to with out feature of cirrhosis
o Risk of HCC is four times
When present with cirrhosis higher in HBeAg-positive
o The patient has HO CLD / HBS ag (+) individuals than in those
o Patient may have ascites / Splenomegaly who have HBsAg alone.
o Spider navi , gynaecomastia , jaundice o AFP is positive in 60 %.
o weight loss, anorexia and abdominal pain o HCC take blood supply
o Sudden appearance of lump or hepatomegaly from the hepatic artery.
Patient may present with out cirrhosis or CLD

o Hepatomegaly with tumours larger > 5 cm) High-risk patients are
o Abdominal pain and weight loss are more common. o Cirrhosis due to
o Fever o Hepatitis B and C,
o Examination may reveal hepatomegaly or a right o Haemochromatosis,
hypochondrial mass o Alcohol and
o 1-antitrypsin deficiency.
o Willson disease is protect

Treatment: against HCC
Hepatic resection
Liver transplantation
Percutaneous ablation
o Ethanol injection
o Radiofrequency ablation
Chemoembolisation
o Adriamycin and gelfoam
IN OUR SETTING DO NOT RX HCC We council the patient about Rx will

ONLY GIVE PALIATIVE RX costly but not effective.
Diet: normal
1+0+1
If pain complaint
Cap. Anadol 50 mg / Inj. Anadol 100 mg
1+0+1
Or
Tab. Torax 10 mg / Inj . Torax 30 mg
1 + 0 +1
If needed (anorexia + vomiting)
Inj. DNS 1000 ml
-------------------------
IV @ 20 d / min
Dr. shamol 126

Approach to patient with Bells palsy / VII nerve Palsy
o At first confirm that it is upper motor type or lower motor type (Bells palsy)
o Associated with hemiparesis
o or aphasia or diarrhea , dysphasia ,
o Nasal voice or nasal regurgitation
o Other cranial nerve palsy (6 @ 8)
o Onset is sudden (bell palsy) or gradual ((ICSOL)
o Any other feature raised intracranial pressure (head ache and vomiting)
o Bilateral / unilateral
o Look for blister in the ear (Ramsay hunt )
Clue to diagnosis:
Do the seven nerve test for upper and lower motor lesion
If following present then it will be a case Bells palsy:
Ask the patient close eye Pt eye will remain open on affected side
If Pt can close eye , try to open his eye when u

U can easily open the eye of affected side but
ask him to keep it close strongly can not open the healthy eye
Ask for wrinkling Wrinkling of forehead will be absent for in
affected side
Ask him to blow the mouth and try to push the Air will be leaked through affect side of the
blow cheek with finger mouth
Ask for show his teeth Angle of mouth will be deviated to the health
side
Look for naso labial fold Disappear on the affected side
Ask for weak ness jaw during chewing Weak ness of jaw of affected side
And accumulation of food particle Food particle will be accumulate in mouth of
affected side
If these are positive then it will be LMN type of facial nerve palsy specially BELL S PALSY
Why not upper motor --- in UMN upper half of face survive such as p
Patient can close eye force fully
Wrinkling present
UMN most of the time associated with hemiparesis
Than look that it is bilateral or not
o Cause of bilateral VII nerve
Look for bilateral Ptosis (myasthenia gravis)
palsy
Look for increasing hearing
GBS
Look external ear canal for blister
SARCOIDOSIS
Look for VI = VIII nerve
Lyme disease
How will identify the bi lateral

facial nerve palsy:
Ask the patient to smile but the pt
will not able to do it .
Dr. shamol 127

Rx of Bells palsy: o Some important point of BellS
palsy
o Tab. Virux 400 mg
2 + 2 +2 + 2 +2 ----7 days o The lesion is within the facial canal
o Tab. cortan 20 (prednisolone 1 mg / kg body wt) and may be due to reactivation of
2 + 0 +0 AM for 7 days latent herpes simplex virus 1
o Cap. omeprazole 20 mg infection.
1+0+1 o Patient complained pain around the
o Tab. Neuro- B ear preceding the unilateral facial
1+0+1 weakness
Eye care o Hyperacusis may present
o SQmycetin eye drops o May loss taste sensation
2 drop BE TDS o Prednisolone 40-60 mg daily for a
o SQmycetin eye ointment week may speed recovery if started
Apply over the eye before sleep within 72 hours
o 80% of patients recover
Use eye glass (eye shield) all the time spontaneously within 12 weeks
Use eye pad (made of cotton or gauze) during sleep
Physiotherapy of upper eyelid muscle
Physiotherapy of muscle of angle mouth
Dr. shamol 128

Enteric fever:
Any fever more than 7 days one DD is typhoid fever
Usually patient present with high fever with relative bradycardia with coated tongue and some
time caecal gugling . Fever does not touch the base line with out antipyretic
Relative Bradycardia:
The clinical feature of enteric fever: Pulse is often slower than would be
expected from the height of the
First week temperature.
To remember--- MY FRCH degree For 10 c increase temperature pulse
o My--Myalgia will increase more then > 10 b/ min
o F--Fever
o R--Relative bradycardia
o C--Constipation RASH
o H--Headache May appear on the upper abdomen
o Degree --Diarrhoea and vomiting in children and on the back as sparse, slightly
raised, rose-red spots, which fade
on pressure.
End of first week
To remember it --- R.C. DAS Spleen
R --Rose spots on trunk Around the 7th-10th day the spleen
C -Cough becomes palpable
D-Diarrhoea
A-Abdominal distension
S--Splenomegaly CBC leucopenia
Ist week Blood culture
End of second week 2nd week stool culture
Delirium, Widal test --- high titre ( 1:160)
Complications, then coma and death (if untreated) never do it before 7 days@ this test is
not diagnostic test
Do MP and ICT for malaria
13.41 COMPLICATIONS OF TYPHOID FEVER
CXR
Bowel :
Urine RME
o Perforation (ulcerated Peyer's patches occur at
the end of the second week or during the third
week ) o Headache (80%),
o Haemorrhage o Cough (30%),
Septicaemic foci :( first week) o Myalgias (20%),
Bone and joint infection (arthritis / osteomylitis ) o Malaise (10%),
Meningitis o Arthralgia (24%).
Cholecystitis o Anorexia (55%),
Pneumonia o Abdominal pain (3040
Toxic phenomena : o Diarrhea (2228%)
Myocarditis o Constipation (1316%).
Nephritis o coated tongue (5156%),
o Splenomegaly (56%), and
o Abdominal tenderness (45%).
Dr. shamol 129

IF U IN GP: When will fever subside?
In less severe case Pyrexia may persist for up to 5 days
Tab. Azithromycin 500 mg (Zimax ) after the start of specific therapy.
1 + 0 + 1 -----5 days
IF U IN HOSPITAL:
Inj. Ceftriaxone 2 mg Treatment of The chronic carrier

1 vial IV bd ------10to 14 days o Should be treated for 4 weeks with
ciprofloxacin
o Cholecystectomy may be necessary in
Coma vigil: some cases.
Critically ill patients with enteric fever those with shock and
obtundation , coma , confusion need high dose IV steroid is
needed .
Inj. Oradexon IV
( Dexamethasone 3-mg initial dose followed by eight doses
of 1 mg/kg every 6 h)
DD fever with jaundice

o Viral hepatitis
LEPTOSPIROSIS (Weil's disease): o Leptospirosis
o Malaria
Characterised by o Septicaemia
o Fever, o Lymphoma
o Haemorrhages, (conjunctival ) o TB
hemorrhage/ hyperaemia )
o Jaundice (hepatomegaly )
o Renal impairment Cause of death: renal failure
o Leucocytosis
Hepatic involvement:
Renal involvement: due to impaired renal Deep jaundice, Hepatomegaly
perfusion and acute tubular necrosis Hepatic failure or encephalopathy
May present as oliguria or anuria, Thrombocytopenia may present in 50% of cases
In urine RME : Presence of albumin,
RBC and RBC casts in the urine.
Investigation:
o CBC :Leucocytosis
Treatment o SGPT @ S.bilirubin increased
Cap .Doxycycline 100 mg o Urine RME : RBC , protein , cast
1 + 0 + 1 for 1 week or o S.Creatinine : increased
Inj. Ceftriaxone 1 gm o USG : Hepatomegaly
I vial IV BD ------7 days o Prothrombin test :
Dr. shamol 130

MALARIA
Is common fever our country?
o There some endemic area in our country (asks UR CA about those area) .any patient comes from
that area with fever Malaria will be the one of the differential diagnosis:
o Malaria fever may not follow any specific pattern
o U have to take HO does the fever comes with chill and rigor Fever with chill and rigor
o Patient may need blanket
o And fever subside by sweating Malaria
UTIpylonephritis
Before going to discuss of malaria treatment u must simply remember Cholangitis
The following treatment of malaria for practical purpose in ward
Patient with fever of 1 to 5 days and followed by
unconscious If u suspected a patient with fever is
Treat it as cerebral malaria with encephalitis Suffering from malaria but ICT is
1. Diet NG feeding Is negative
200 ml 2 hrly Rx is
2. Inj. Ceftron 2gm
1 vial iv bd Tab. Jasoquin 300 mg
3. Inj. Libot -25 100 ml 2+2+2------7 days
I v @ 10 d/min Tab . omidone 10 mg
4. Inj . 5% DNS 500 ml 1 + 1+ 1
+ Oral glucose
Iv @ 30 d/min stat (over 4 hrs) Jasoquine cause ----
Then Severe vomiting so give omidone
5. Inj . 5% DNS 500 ml Hypoglycaemia --give glucose
+
Iv @ 30 d/min (over 4 hrs) 8 hrly If ICT positive
In between jasoquin drip U may give any one of the following
6. Inj. Hartman 1000 ml regime
I v @ 10 d/min REGIM : --1
7. Inj.ranison 50 mg Tab. Coartem/ lumertam
1 amp iv 8 hrly 4 tab stat and
If patient is rest less then 4 tab 8 hr later
8. Inj .perol Then
1amp i.m. stat 4+ 0 + 4 for 2 days
9. Continuous catheterization Total 24 tab. :
10. If you suspect viral encephalitis then
Tab.virux 400 mg REGIM 2
2+2+2+2+2 Tab. Jasoquin 300 mg
11. When patient can take orally then replace 2+2+2------7 days
Tab.Jasoquine 300 mg 2 + 2 + 2 Tab . omidone 10 mg
1 + 1+ 1
Oral glucose
Dr. shamol 131

Now we will discuss national guide on malaria, u need not remember it
Classification of malaria
In plasmodium Falciparum case / In plasmodium Vivax
Falciparum Malaria (FM)
1. Uncomplicate malaria (UM) 1. Vivax Malaria (VM)
Fever and HO of fever with in last 48 hrs Fever and HO of fever with in last 48 hrs
Exclude other cause of fever Exclude other cause of fever
From endemic area From endemic area
RDT positive for Falciparum RDT positive for plasmodium Vivax
2. Severe Malaria (SM)
In our hospital we do
ICT for MALARIA
SEVERE MALARIA :
Fever and HO of fever with in last 48 hrs
One and more of the following feature of severity:
ABCDEFGHIJK
a) Anaemia , ( haematocrit <15% , Hb <5 gm/dl )
Acidosis
ARDS
b) Behavior change ,
Bleeding tendency
c) Convulsion , (more 2 time in 24 hrs)
Coma, (cerebral malaria )
CVS-collapse (algid malaria) (Systolic BP <80 mmHg)
d) Drowsy ,
Disoriented,
Dyspnea (ARDS, pulm.edema, Acidosis)
e) Pulmonary edema
f) Fluid and electrolyte imbalance
g) Hypoglycaemia (< 2.2 mmol /dl )
h) Haemoglobinuria
i) ICT positive /RDT +
j) Jaundice (clinical )
k) A Renal failure / Oligouria (<17 ml/hr or 400 ml/ 24 hr,S.
creatinine >3.0 mg/dL)
And severe prostration

Extreme generalized weakness , so patient can not walk stand
or sit with out assistance and in small child is unable to eat .
Dr. shamol 132

Treat of Malaria according to the national guide line
Falciparum cases
Uncomplicated Malaria (UM) SEVERE MALARIA
Option one Injectable Jasoquin initially 20mg / kg BWT
Artemether + Lumefantrin Bolus dose followed by maintenance dose of
10 mg / kg BWT until patient take able to
Tab. Coartem/ lumertam orally. for detail
4 tab stat and
4 tab 8 hr later SEE cerebral malaria treatment
Then
4+ 0 + 4 for 2 days In severe malaria what ever the Dx have to give
Inj. Ceftriaxone 2 gm IV BD
Total 24 tabs.
Option 2 Complication of oral quinine
Quinine (Q7) 1. Hypoglycemia
Tab. Jasoquin 300 mg 2. Tinnitus
2+2+2------7 days 3. Head ache
Tab . omidone 10 mg 4. Rare case steroid psychosis
1 + 1+ 1
Oral glucose
Option 3 Complication of IV quinine

Quinine (Q7) + tetracycline / Doxycycline (D7) 1. Hypoglycemia
Tab. Jasoquin 300 mg 2. circulatory collapse
2+2+2------7 days 3. arrhythmia (prolong of QT)
Days later
Cap Doxicap 100 mg
1 + 0 + 1 ---- 7 days OR
Cap. Tetracycline 500mg
1 + 1 + 1 + 1-----7 days
Treatment of vivax :
Malaria and pregnancy
According to guide line:
QUININE @ CHLOROQUINE are save in all
To CQ3 + PQ14 trimester of pregnancy
1. Chloroquine 150 mg (442)
Tab . Jasoquine Primaquine and doxycycline is are contract
1st day 4 tab stat (10 mg /kg) indicated in pregnancy.
2nd day 4 tab stat (10 mg /kg)
3rd day 2 tab stat (5 mg /kg) Tab. Coartem is contract indicated in 1st trimester
2. Primaquine (0.3mg) of pregnancy . so better to avoid it in pregnancy .
Tab. Jasoprime 15 mg
1 + 0 + 0 ---14 days BUT WE USE JASOQUINE IN PREGNANCY
WE USE JASOQUINE IN ALL FORM OF MALARIA P. Falciparum @ P . Vivax
Dr. shamol 133

Not need to be remember as intern doctor
Manifestation/complication Immediate management
Coma (cerebral malaria) Maintain airway
Nurse on side
Exclude other treatable causes of coma (e.g. hypoglycaemia,
bacterial meningitis)
Avoid harmful ancillary treatments such as corticosteroids,
heparin and adrenaline (epinephrine)
Intubate if necessary
Hyperpyrexia Tepid sponging, fanning, cooling blanket
Antipyretic drug
Convulsions Maintain airway
Treat promptly with diazepam or paraldehyde injection
Hypoglycaemia Measure blood glucose
Give 50% dextrose injection followed by 10% dextrose infusion
(glucagon may be ineffective)
Severe anaemia (packed cell volume Transfuse fresh whole blood or packed cells if pathogen
< 15%) screening is available
Acute pulmonary oedema Nurse at 45, give oxygen, venesect 250 ml of blood into donor
bag, give diuretic, stop intravenous fluids
Intubate and add PEEP/CPAP (p. 193) in life-threatening
hypoxaemia
Haemofilter
Acute renal failure Exclude pre-renal causes
Check fluid balance, urinary sodium
If urine output is inadequate despite fluid replacement, give
diuretic/dopamine
Peritoneal dialysis (haemofiltration or haemodialysis if
available)
Spontaneous bleeding and Transfuse screened fresh whole blood (cryoprecipitate/fresh
coagulopathy frozen plasma and platelets if available)
Vitamin K injection
Metabolic acidosis Exclude or treat hypoglycaemia, hypovolaemia and Gram-
negative septicaemia
Give oxygen
Shock ('algid malaria') Suspect Gram-negative septicaemia
Make blood cultures
Give parenteral antimicrobials
Correct haemodynamic disturbances
Aspiration pneumonia Give parenteral antimicrobial drugs
Change position
Physiotherapy
Give oxygen
Dr. shamol 134

Approach to patient with PUO / not need to read, see only when cannot manage fever:
o Some time u will get a patient who is admitted in your hospital. U has done some routine
examination. But failed to establish any diagnosis and treat the patient with both anti typhoid and
anti malarial. But fever does not subside then think it as PUO.
. Major Causes of Fever of Unknown Infectious Causes of Fever of Unknown Origin
Origin
To remember BAU (Bangladesh agriculture
Big 3 university ) TOSS RBC
To remember AIN 1. B--Biliary system infections (may have no right
1. Infection upper quadrant tenderness
2. Neoplasm 2. A--Abscesses
3. Autoimmune disease 3. U--Urinary tract infections (in absence of related
symptoms )
Little 6 4. T--Tuberculosis (especially miliary disease)
To remember GFR @ PDF 5. O--Osteomyelitis (vertebrae,mandible, sinuses)
1. Glaucomatous disease 6.S-- Subacute bacterial endocarditis (murmur
2. Regional enteritis usually present, beware of previous antibiotics)
3. Familial Mediterranean fever 7. S--Spirochetal infection (leptospirosis, Borrelia)
4. Drug fever 8. R--Rickettsial infection
5. Pulmonary emboli 9. B--Brucellosis (animal exposure, unpasteurized
6. Factitious fever cheese)
10. C--Chlamydia
11. EpsteinBarr virus, cytomegalovirus
12. Fungal infection (Cryptococcus, histoplasmosis)
13. Parasites (malaria, toxoplasmosis,
trypanosomiasis)
Autoimmune Diseases That Cause PUO
SP ASP ke SMS Neoplastic Causes of PUO
1. Systemic lupus erythematosus
2. Stills disease To remember Police HALL rent korse
3. Hypersensitivity angiitis
4. Polymyalgia rheumatica, combined with 1. H-Hepatoma (generally not metastatic liver
temporal arteritis(elderly patients and cause disease)
proxi-mal muscle weakness, visual symptoms, 2. A-Atrial myxoma
and ahigh ESR.) 3. L-Lymphoma (especially Hodgkin, PelEbstein
5. Polyarteritis nodosa fever)
6. Mixed connective tissue disease 4. L-Leukemia (aleukemic or preleukemic phase)
7. Subacute thyroiditis (thyroid is tender.) 5. Rent-Renal cell carcinoma (high sedimentation
rate)
Dr. shamol 135

Fever is extremely common in ICU
2. A systematic approach to diagnosis is critical.

3. Key sites of infection include these:
a) Lungs (critical to differentiate colonization from infection)
b) Intravenous and intra-arterial lines
c) Urinary tract (at high risk secondary to prolonged bladder
catheterization)
d) Wounds (particularly in the early postoperative period)
e) Sinuses (in patients with nasotracheal tubes)
4. Noninfectious causes include pulmonary emboli, drug fever, and old
hemorrhage.
5. Empiric antibiotics need to be streamlined based on culture results.
6. Prolonged broad-spectrum antibiotic coverage predisposes to
colonization with highly resis-tant bacteria, fungemia, Clostridium difficile
colitis, and drug allergies.
Dr. shamol 136

APPROACH TO PATIENT WITH SEPSIS OR SEPTICEMIA :
o Some time u get a patient comes to u with fever or HO other infection (septic abortion ) or
immune compromised with jaundice , Renal failure or involvement (S. Creatinine + RBC
in urine ) with jaundice with alter level of consciousness or coma with / with out purpuric
spots .------such case is due to
o Septicaemia
Definitions Used to Describe the Condition of Septic Patients
Bacteremia Presence of bacteria in blood, as evidenced by positive blood cultures

Septicemia Presence of microbes and their multiplication or their toxins in blood
Systemic inflammatory Two or more of the following conditions:
response syndrome (SIRS) (1) fever (oral temperature >38C) or hypothermia (<36C);
These are 4 cardinal sign (2) tachypnea (>24 breaths/min);
(3) tachycardia (heart rate >90 beats/min);
(4) leukocytosis (>12,000/dl), leukopenia (<4,000/dl), or >10% bands;
may have a noninfectious etiology
Sepsis SIRS that has a proven or suspected microbial etiology

Severe sepsis (similar to Sepsis with one or more signs of organ dysfunctionfor example:
"sepsis syndrome")
1. Cardiovascular: Arterial systolic blood pressure <90 mmHg or mean
arterial pressure <70 mmHg that responds to administration of intravenous
fluid
2. Renal: Urine output <0.5 mL/kg per hour for 1 h despite adequate
fluid resuscitation
3. Respiratory: PaO2/FIO2 <250 or, if the lung is the only dysfunctional

organ, <200
4. Hematologic: Platelet count <80,000/L or 50% decrease in platelet

count from highest value recorded over previous 3 days
5. Unexplained metabolic acidosis: A pH >7.30 or a base deficit Pud 5.0

mEq/L and a plasma lactate level >1.5 times upper limit of normal for
reporting lab
6. Adequate fluid resuscitation: Pulmonary artery wedge pressure

>12mmHg or central venous pressure > 8 mmHg
Dr. shamol 137

Sepsis with hypotension (arterial blood pressure <90 mmHg systolic,
Septic shock or 40 mmHg less than patient's normal blood pressure) for at least 1 h
despite adequate fluid resuscitation;
orNeed for vasopressors to maintain systolic blood pressure >90 mmHg

or mean arterial pressure >70 mmHg
Refractory septic shock Septic shock that lasts for >1 h and does not respond to fluid or pressor
administration
Multiple-organ Dysfunction of more than one organ, requiring intervention to maintain
dysfunction syndrome homeostasis
(MODS)
Treatment of septic shock patient / sepsis
o O2 inhalation
o NG feeding
IV FLUID
o
o Sepsis syndrome is systemic inflammatory Inj. Normal saline 2000ml
response syndrome (SIRS) caused by microbial ---------------------------------
products. Viruses (dengue fever), fungi IV @ 30 drops / min
(Candida), and noninfectious diseases
(pancreatitis, tissue ischemia, severe trauma) can If patient in shock
also cause SIRS. Inj. NS 500 ml
o Severe sepsis is defined as SIRS caused by +
microbial products that is associated with organ Inj. Dopamine 2 amp
dysfunction ---------------------------------
o Septic shock is shock associated with sepsis IV @ 20 to 32 micro drops / min
thatis unresponsive to volume replacement. Appropriate antibiotic (By the senior)
o Bacteremia does not always cause sepsis U will give:
syndrome, and sepsis syndrome is not always Inj. Cetriaxaone 2gm 1 Vial IV BD
caused by bacteremia.
PPI or H2 blocker
Inj pantonix 40 mg IV stat and daily
Think as septic syndrome if u sees following:
Or
o There is no specific diagnostic test for the
Inj . Ranison 1 amp iv 8hrly
septic response.
Continuous catherization
o A patient with suspected or proven infection
Maintain I/O
include
Maintian electrolyte and maintain glycaemic
Fever or hypothermia,
Controll and /renal function.
Tachypnea, tachycardia, and
Leukocytosis or Leukopenia
Pt will need ICU support so contact with ICU.
o Acutely altered mental status,
o Thrombocytopenia,
o An elevated blood lactate level,
o Hypotension should suggest the diagnosis.
Dr. shamol 138

Approach to patient with KALA-AZAR:
U will think the patient as Kala-Azar if the patient have the following HO
H/O fever more than 2 weeks
Residing/Traveling in endemic area
Splenomegaly(some case hepatomegaly also )
Weight loss
Anemia
Typhoid and malaria are excluded
ICT for Kala-azar are positive
Whole Mymensingh are endemic Zone especially TRISHAL, FULBARIA, MUKTAGHACHA
What investigation u will do to Dx kala-azar or STEP to Dx the kala-azar?
Before go to diagnosis KALA-AZAR FIRST EXCLUDE THE ENTERIC FEVER@ MALARIA:
What are the finding of CBC?

CBC ---progressive leucopenia with relative Leucopenia monocytosis
lymphocytosis Progressive leucopenia with
o ESR is highly raised lymphocytosis
o Hb --- Hbdecrease and ESR is raised
PBFpancytopenia
Immunological test what do u mean by Progressive
o ICT for Kala-azar leucopenia ?
o RK-39 if do u serial CBC total count will
o DATDirect agglutination test decrease day by day
Definitive test suppose 7 days ago TC was 7000 then 5
o Splenic puncture day later TC become 4000
o Bone marrow aspiration what will be the ESR ?
To see complication, and routine test ESR will be highly raised more than 100
USG of whole abdomen or near to 100
CXR- PA view What we detect (antigen or antibody) in ICT @
URINE RME when they appear ?
SGPT, RBS, S.Creatinine All these detect antibody and appear after 2/3 wks
ECG after infection. These tests remain positive for several
months after cure.
Cause of anemia in kala-azar
Anaemia may result from
o Bone marrow infiltration, Describe the fever of kala-azar
o Hypersplenism, Fever- usually insidious and may be associated
o Autoimmune hemolysis & with chills and rigors. Fever intensity
o Bleeding. decreases over time and patient may
Cause of bleeding in kala-azar become afebrile for weeks to month followed
This occurs as a result of thrombocytopenia by relapse of fever.
Or also due drug sodium stibo gluconate
Dr. shamol 139

What are the complication of kala-azar
Treatment of kala-azar in ur ward? 1. Secondary infections:
o Pneumonia
Diet normal o Tuberculosis
o Amoebic or bacillary dysentery
Antibiotic as secondary infection is common o Gastroenteritis
Tab .Ciprofloxacin 500mg o Herpes zoster
Inj. Stibatin
1+0+1 o Chickenpox
o Skin infections, boil, cellulitis,
1 vail = 30ml,
Inj . Normal saline 100 ml scabies
1ml=100mg
+ o Cancrum oris
20 mg / kg-BWT
Inj. Stibatin (20kg /BWT) 8ml 2.Bleeding manifestation-
--------------------------------------- from nose, retina, GIT etc.
IV @ 10--2o drops /min 30 day 3. Post Kala-azar Dermal
Leishmaniasis(PKDL)
Cap. Omeprazole 20 mg 4. Post kala-azar laryngitis and colitis
1+0+1 5. Post kala-azar splenomegaly
6. Glomerulonephritis
See pulse and BP before and after stibatin 7. Nephrotic syndrome
o Do ECG in every seven days 8. Cirrhosis of liver
o Do CXR if patient complaints cough @
Fever (to see consolidation consolidation ) How will u understand Response to
o If complaints of bleeding do platelet count and give treatment?
fresh blood A good response results in
o If ECG shows Ischaemia then reduced dose o Decrease fever
o If patient complaint any discomfort then stop the o A feeling of well-being,
stibatin and do ECG and see pulse and BP o Gradual decrease in splenic size,
o Weight gain and recovery of blood
counts
Next
Amphotericin B
Liposomal amphotericin B
Liposomal amphotericin B in the treatment of kala-azar --The recommended

schedule is 3mg/kg for 5 days , 7th day , 14th day --- it is better it have no
nephrotoxicity and save in pregnancy
amphotericin B1 mg / kg body weight slow iIV infusion over 4-6 hours for
20 days
What do u mean by Relapse , Reinfection , Resistant ?

Relapse after cure again occurrence of kala-azar with in 6 months When will u told it relapse?.
Reinfection after cure again occurrence of KAlA-azar after 6 month Relapse is indicated by
Resistanceno respon to drug o Enlargement of the spleen,
Treatment of Relapse, Reinfection, Resistance? o Return of fever,
o Weight loss and
Relapse Sodium antimony gluconate (SAG) /inj. Stibatin for 40- 60 o Decline in blood counts
days or Amphotericin B
Reinfection Amphotericin B
Resistance---- Amphotericin B or pentamidine isothionate
Dr. shamol 140

What are the comoplicaton in stibatin
1st cordiatoxicity
Minor- myalgia, arthralgia
Why PKDL developed ? Major-arrhythmias, Heart failure, oedema,
PKDL usually develops 6 months-5 years following an attack jaundice, decreased urine
of untreated or incompletely treated kalaazar
What are side effects of Amphotericin B?
Can PKDL occur with out previous HO of kala-azar ? Thrombophlebitis, diarrhoea and vomiting,
However 15% of PKDL cases occur without thepreceding are extremely common.
history of kala-azar. Serious adverse events, such as
o Renal or hepatic toxicity,
What are present of PKDL ? o Hypokalaemia, t
They have only skin lesion which are the area of hypo- o Hrombocytopenia,
pigmentation or hyper pigmentation. It may be macular, o Myocarditis .
papular, nodular or mixed.
Main side effect is nephrotoxic
Is these lesions are infective or not?
Yes, these contain LD body
What is investigation to Dx
Skin slit smear --- it see LD body
What is the differential diagnosis of PKDL?

In contrast to leprosy, sensation over the lesions is
preserved& the lesions do not ulcerate.
What is the treatment of PKDL?

Sodium Antimony Gluconate (SAG)
Dose: 20 mg/kg body wt daily for 20 days per cycle
Route: IM/IV
Duration: Six cycles with 10 days interval between cycles
Organism and vector of kala-azar?

It is a protozoa name Leishmania donovani
Vector is the phlebotomine sandfly.
Man is the only reservoir
Dr. shamol 141

Approach to a patient of diabetes an
DIABETES patient may comes to u with the following way

o As an unknown case (First presentation)
o AS known case with complication of uncontrolled DM
o Due to other disease with coexisting DM (control / uncontrolled)
o Acute life threatening condition (DKA, Hyper osmolar coma, Hypolgycaemia )
Any patient with DM presented to u with DKA

Unconsciousness / semi ----------
consciousness The patient have
Drowsy / disoriented / Hyperglycaemia
With or without respiratory distress Sever dehydration
Please exclude Acidic breathing with lung clear
o Hypolgycaemia Ketonic breath
o DKA Drowsy ,disoriented or nomal
o Hyper osmolar coma,
If these are excluded then go for
CVD, Uremia, electrolyte imbalance
A diabetic patient with comes to with Respiratory

distress pl exclude: HYPO
DKA(lung clear / ketonic smell ) HO of insulin / oral hypoglycaemic
MI with LVF (sweating / cold clammy skin / BP) drug in take
CRF (Anemia , HTN ,Edema ) Miss meal
A diabetic patient comes to u with Sweaty and Cold

clammy hand:
Then Pl exclude
Hypoglycemia (BP normal / increase@ ho of
Insulin or OHD intake) Hyper glycaemia
MI or LVF (Dyspnea , BP, chest pain +/-)
Management of DKA :
Patient with D---diabetic
Kketonemia in urine keton body +++
AAir hunger or kussmaul breathing
Dr .Shamol 142
Treatment of DKA.
Maintain AAirway
BBreathing
CCirculation
NG suction and keep NPO 48 hr if
Fluid Basic principal of DKA Mx
ml 1. correction of dehydration with
Inj. Normal saline 1000ml
Drop/ min= -------- appropriated fluid .
IV @ 500drop/ min(running)
4 X hr 2. short acting soluble insulin
Then
Inj. Normal saline 1000ml If 1000ml in 1 hr : 3. broad septum antibiotic
1000 4. correction electrolyte imbalance
IV @ 250drop/ min (1 hr)
Drop/ min= -------- hypokalaemia
Then
4 X1
Inj. Normal saline 1000ml
= 250 d/min
IV @ 125drop / min (2 hr) Fluid : 6L (4L NS + 2 L 5%DA)
Then
Inj. Normal saline 1000ml 1st L NS in hr
IV @ 60drop/ min (4 hr) 2nd NS in 1 hr simply doubling
Then give rd
3 NS in 2 hr
Inj. 5 % DA 1000 ml 4th NS in 4 hr
IV @ 30drop/ min (8 hr)
Then Then when RBS < 15 mmol
Inj. 5 % DA 1000 ml 1st L 5 %DA in 8 hr
IV @ 30drop/ min (8 hr) 2nd L 5 %DA in 8 hr
------------------------------
Short acting soluble insulin: via micrburete set 6L in 24 hr
Inj. Normal saline 100 ml If still dehydrated, continue 0.9%
+ saline and add 5% dextrose 1
Inj Actrapid HM (u-100 ) 24 unit liter per 12 hrs.
IV @ 24 D / min until blood glucose < 15 mmol / L (6 unit/hr)
When blood glucose
RBS is < 15 mmol/ L: IV @ 12D / min Short acting soluble insulin
RBS is < 10 mmol/ L : IV @ 8 D / min (2 unit/hr) Insulin 24 units soluble insulin in 100
ml 0.9% saline i.v. via micro burette
When RBS 8 or 7 mmol/ L or continuously decreased
6unit / hr until RBS <15(24D / min)
Consult with senior for next management @ do the following
3unit / hr until RBS <10 (12D / min)
Stop insulin drip do the following
2 unit / hr when RBS 10 (8D /min)
Inj. 5 % DA 1000 ml
+
Alternative
Inj Actrapid HM (u-100 ) 10- 15 unit
10 to 20 unit IM stat and
IV @ 10-20drop/ min
then
If patient is able to take oral food then u switches over to
6 units IM hrly initially
subcutaneous as
3 units IM hrly when blood glucose <
Inj . Actrapid HM u100, s-100
15 mmol/l (270 mg/dl)
8+ 8+ 6 SC 15 min before meal (after 48 hr)
2 units IM hrly if blood glucose
If RBS > 10- 15 m mol /l then again start insulin drip
declines < 10 mmol/l(180 mg/dl)
Aim for fall in blood glucose of 3-6 mmol/l
Antibiotic Inj. Ceftriaxone 1 or 2 gm vial I V BD
(55-110 mg/dl) per hour
Anti -ulcerant inj. Ranison 1 amp IV 8 hrly
Rapid correction is dangerous as it cause
Correction of K ----see next page cerebral edema
Dr
Change posture 2 hrly with eye care
.Shamol 143
Complication of DKA
o Cerebral oedema
Potassium Acute respiratory distress syndrome
o Thromboembolism
o None in first litre of i.v fluid unless < 3.0 mmol/l o Disseminated intravascular coagulation
o If plasma potassium < 3.5 mmol/l, give 40 mmol added (rare)
potassium (inj. KT 2 amp ) o Acute circulatory failure
Give in 1 litre of fluid
Avoid infusion rate of > 20 mmol/hr
o If plasma potassium is 3.5-5.0 mmol/l, give 20 mmol
Treatment of cerebral Oedema
added potassium (inj. KT 1 amp)
May be caused by
o If plasma potassium is > 5.0 mmol/l, or patient is o very rapid reduction of blood glucose.
anuric, give no added potassium
o Use of hypotonic fluids and/or
o Bicarbonate
o .High mortality.
o Treat with mannitol, oxygen.
Clinical feature which u will got in ward
Patient usually come to u with feature dehydration (BP,
tongue dry, Tachycardia ), semi consciousness , air
hunger. When u r confusion it is DKA or not @
Patient may unknown case of DM or if known case then patient have no money then :
not on anti-diabetic therapy and patient have infection Urgently do RBS with glucometer and
such fever or abscess or infection Send urine for keton body and contact
with diagnostic centre to collect the
report within hours . if keton body
present treat it as ketoacidosis .
Now do S.electrolyte with HCO3
Sign symptom of DKA
Dehydration
Hypotension (postural or supine)
Cold extremities/peripheral cyanosis
Tachycardia
Air hunger (Kussmaul breathing)
Smell of acetone
Hypothermia
Confusion, drowsiness, coma (10%)
Abdominal pain
Nausea, vomiting

Dr .Shamol 144
Approach to a patient with DM with hypo glycaemia :
Suppose u r setting in intern room watching TV Hindi serial suddenly a patient comes to u with lot of
attendant that they told u that our patient is diabetic and he become unconscious with sweaty hand ----
What DD will come to ur mind ---1. Hypoglycemia 2. MI

What will u do? Without hesitation u should corrected the hypoglycemia and urgently DO an ECG
@ see BP ,if BP is normal or increased then it is hypoglycemia Autonomic symptoms
Sweating
If look at the patient is unconsciousness or not Pounding heart
Or he is able to take food orally or not Hunger
If the patient is able to take food orally then give Tachycardia
Oral carbohydrate as form of Tremor
Orange juice / glucose
Sugar (4 6 tsf sugar in a glass of water) CNS:
What ever carbohydrate u gets near ur hand Confusion
IV fluid: Convulsion
Inj. 25 % glucose (Libott-25 / Nutridex 100 ml / 250 ml) Drowsy
----------------------------------------------------------- Inability to concentrate
IV @ 20 D / min Slurring speech
st
(1 give 5%DA and ask the pt bring immediately ) BP is normal or increased
Followed by (differentiating point from MI ,where
Inj. 10 % DA 1000 ml BP fall usually )
--------------------------------
IV @ 20 D/ min With following HO
HO insulin or oral hypoglycaemic
Stop insulin or other oral Hypoglycemic drug immediately drug intake followed by
Do FBS and 2 hr ABF next day @ 20to 30 % reduction of o Missed, delayed or inadequate
dose of insulin and oral hypoglycemia drug . meal
o Unexpected or unusual exercise
o Alcohol
What will u do if a patient with hypoglycemia come to u with o Errors in oral hypoglycaemic
unconsciousness but 25% or 5% DA is not available? agent or insulin dose /schedule /
Give him NG tube and give glucose / orange juice/ sugar via it administration
o Gastroparesis due to autonomic
neuropathy
HYPOGLYCAEMIA When hypoglycaemia o Malabsorption
(blood glucose < 3.5 mmol/l (63 mg/dl))
occurs in a person with diabetes it is a result
of treatment and not a manifestation of the
disease itself.
SPONTANEOUS HYPOGLYCAEMIA
When hypoglycaemia develops in non-
diabetic people,(if < 3 mmol/L) it is called
'spontaneous' hypoglycemia..
Dr .Shamol 145
First u have to differentiated it is Type I and type II
Type 1 Type 2
Typical age at onset < 40 years > 50 years
Duration of symptoms Weeks Months to years
Body weight Normal or low Obese
Ketonuria Yes No
Rapid death without treatment with insulin Yes No
Autoantibodies Yes No
Diabetic complications at diagnosis No 25%
Family history of diabetes Uncommon Common
Other autoimmune disease Common Uncommon
Diagnostic criteria:
Dr .Shamol 146
Diagnostic Criteria of DM (Non-Pregnant Adults)
A person can be diagnosed as a diabetic, if any two of the following criteria are present
1. More than one characteristic symptom and sign of DM.
2. Fasting venous plasma glucose >7.0 mmol/L.
3. Random venous plasma glucose taken at least two hours after eating or
after taking 75 gm glucose is >11.1 mmol/L.
4. Presence of diabetic retinopathy.
5. Random sample on more than one occasion >11.1 mmol/L
Indications for oral glucose tolerance test (Box 21.11)

o Fasting plasma glucose 6.1-7.0 mmol/l (110-126 mg/dl)
o Random plasma glucose 7.8-11.0 mmol/l (140-199 mg/dl)
* In asymptomatic patients two samples are required to confirm diabetes.

N.B. HbAlc (see above) is not used for diagnosis.
21.10 ORAL GLUCOSE TOLERANCE TEST (OGTT)
o Unrestricted carbohydrate diet for 3 days before test
o Fasted overnight (for at least 8 hrs)
o Rest before test (30 mins); no smoking; seated for duration of test
o Plasma glucose measured before, and 2 hrs after, 75 g glucose load
'Stress hyperglycaemia'
There are some conditions where blood sugar and usually disappears after the acute illness has
resolved,
o During pregnancy,
o Infection,
o Myocardial infarction or
o Other severe stress, or
o During treatment with diabetogenic drugs such as corticosteroids.
SYMPTOMS OF HYPERGLYCAEMIA Healthy levels

o Thirst, dry mouth BMI 25kg/m2
o Polyuria BP 130/80 mm Hg
o Nocturia Nephropathy <120/70
o Tiredness, fatigue
o Recent change in weight
o Blurring of vision FBG 6.0mmol/l
o Pruritus vulvae, balanitis (genital candidiasis) ABF 7.8 mmol/l
o Nausea; headache RBG 8.0 mmol/l
o Hyperphagia; predilection for sweet foods HbA1C 7%
o Mood change, irritability, difficulty in Tch <200 mg%
concentrating, apathy TG <150 mg%
HDLc >40 mg%
LDLc <100 mg%
U/microalb-<30mg/24hr
Dr .Shamol 147
COMPLICATIONS OF DIABETES
Macrovascular
Microvascular/neuropathic
Retinopathy, cataract o Coronary circulation
o Impaired vision o Myocardial ischaemia/infarction
Nephropathy o Cerebral circulation
o Renal failure o Transient ischaemic attack
o Stroke
Neuropathic
Peripheral neuropathy o Peripheral circulation
o Sensory loss o Claudication
o Motor weakness o Ischaemia
Autonomic neuropathy
o Postural hypotension
o Gastrointestinal problems (gastro paresis; altered bowel
habit)
Foot disease
o Ulceration
o Arthropathy
Targets of glycemic level in hospitalized patientst

Critical care unit Patient-4.5-6.1 mmol/dl
Non critical care units preprandial--5- 7 .2mmol/L , Postpandial < 10 mmol/L
Prelabor- preprandial 5.3 mmol/, postprandial <6 .7 mmol /L
Labor & Delivery 5.5 mmol/L
Replacement insulin:( discontinue OHA)In:

Secondary failure,
Pregnancy,
liver disease
kidney disease,
severe infection,
Trauma,stress,drug interaction
Dr .Shamol 148
Following HO should be taken during receiving of Diabetes mellitus
Age (Type I / Type II).. Hand
Newly diagnosed . Muscle wasting
Previously for yr/ month . and pt on Dupytren contracture..
Insulin . Payer sign ..trigger sign .
Oral. Leg
Family history . Peripheral pulse
Drug HO steroid Intermittent claudication (PAD)
Other co-morbid disease Diabetic Foot Examination
HTNFor ..On . Colour.
IHD Ulceration.
TIA/ STROKE .. Dryness.
CHRONIC PANCREATITIS Callous formation
PRESENT COMPLAINT Infection(cellulites ).
Polyuria, polyphagia, polydipsia(type i) Evidence of injury..
Cough, fever,(RTI).. Hair loss..
Fever with dysuria (UTI) Feature of somatic neuropathy
Fatigue, lethargy. Sensory
Recent change in weight (type I/II) Buring and Parasthesia .
Loss(TI)/gain(T2)/unchanged
Numbness /Cold periphery ..
Palpitation..
Pain/Touch .
Chest pain(IHD)
Vibration ...Propioception.........
Cold and sweaty hand (hypo/ MI)..
motor
Swollen leg/puffy face (CRF /NS)
Knee jerkAnkle jerk
Delirium, confusion, unconscious(hypo /DK/hyper)
Muscle weakness .
General examination
Muscle wasting /leg pain (amyotrophy)
BMI..oral cavitycandiasis
AUTONOMIC NEUROPATHY
Anaemia (CRF) ..
GASTRO-ENTEROLOGY
Appearance (2ndary cause )..
Dysphagia
Eyepupil reflex lost
Gastro paresis
Blurring of vision . Cranial nerve..
Nocturnal diarrhoea
Xanthelasma, (hyper lipidaemia )
Constipation
Cataract(complication )
GENITOURINARY
Fundoscopy .. urinary incontinence,
pulse auto. Neuropathy. Recurrent infection
Resting tachycardia ..
Erectile dysfunction
Fixed heart rate
SUDOMOTOR
BP..
Gustatory sweating
Postural hypotension
Respiratory rate .. Nocturnal sweats without hypoglycaemia
Kussmaul respirations (DK/ CRF) Anhidrosis;
Signs of dehydration Fissures in the feet
Skin fungal infection . Tenia pades... Vasomotor
Cold Feet Dependent oedema.........
Dr .Shamol 149
Treatment of the Diabetic patient
3D
1. Discipline Target of modalities of treatment are
2. Diet 1. To improve beta cell function
3. Drug 2. To reduce hepatic glucose output
3 . to reduce insulin resistance in peripheral tissue i.e.
muscles, adipose tissues.
1. Drug
Choice of drug depend on following
(a) Type of Diabetes Mellitus (type I or II)
(b) BMI status (obese or non obese)
(c) Other associated complications
(d) Severity of hyperglycaemia
(Mild /moderate/severe)
A) On the basis on Type I @ Type II

Type one is always insulin
Type II needs OHA or insulin or both
B) On basis BMI status

Obese
Non obese
C) With Other associated complications
Whatever the type and status of BMI choice is Insulin
D) On basis of severity of hyperglycemia
Guidelines
Mild Fasting Glucose (FPG <10.0) mmol/L
-Diet and Exercise
Moderate FPG > 10.0 mmol/L - <14.0 mmol/L
Diet and Exercise.
Wait for 2 4 weeks,
If 2-4 wks no improvement, Then Start OHA
(But we start oral hypoglycemic agent)
Severe FPG >14.0
Initiate insulin.
Dr .Shamol 150
E. Exercise Role of exercise in management of DM
.
Precautions and Limitations:
Exercise has to be individualized. Start gradually with personal cardiac tolerance. Must
Not be excessive so to cause pain or inflict injury.
Contraindication:
a. Coronary heart disease,
b. Proliferative retinopathy,
c. Severe neuropathy,
d. Neprhopathy,
e. Osteoarthritis,
f. Ketonuria.
Methods of exercise:
o Stretching Exercise Free hand exercise
Duration 10 minutes to be followed by
o Aerobic Exercise (minutes i.e., brisk walking, swimming, cycling, jogging.
Treadmill, static cycling)
Duration at least 30 min at least 3 times a week.
Assessment of adequate exercise where no cardiac problem exist. Elevation of heart rate
200% times of basal rate.
Drug use as oral hypoglycemic agent:
OHA
Three types of OHA
1. Secretagogues
2. Sensitizers
3. Reduced glucose absorption from GI Tract.
1. Insulin Secretagogues:
A. SULPHONYLUREA
Examples Starting dose Max. daily dose
Glibenclamide (5 mg) 1.25 mg 2.5 mg 15 mg

Glipizide (5 mg) 2.5 mg 5 mg 40 mg
Gliclazide (80 mg) 20 mg 40 mg 320 mg
Glimepride 1 mg / 2 mg 0.5 mg 6 8 mg
o Preferably single dose as the drugs have long plasma half life.
o If high dose is needed give it two divided dose
o But never give in three divided doses
o U can increased the dose every 1 to 2 weekly until desirable glycaemia achieved
o FBS and 2HrABF for at least two days each week.
Dr .Shamol 151
GLICLAZIDE
Tab . Dimerol 80 mg Tab . Dimerol 80 mg + 0 + 0 if not controll
Tab . Comprid 80 mg Tab . Dimerol 80 mg 1 + 0 + 0 if not control
Tab . Consucon 80 mg Tab . Dimerol 80 mg 1 + 0 + 1 if not controll
GLIMEPRIDE
Tab. Secrin 1mg or 2 mg Tab. Secrin 1 mg , + 0 + 0 if not controll
Tab. Amaryl 1mg or 2 mg Tab . Secrin 1mg 1 + 0 + 0 if not controll
Tab . Losucon 1 mg / 2 mg Tab . Secrin 2 mg 1 + 0 + 0 if not controll
GLIPIZIDE
Tab. Diactin 5 mg Tab. Diactin 5 mg + 0 + 0 if not controll
Tab. Glimerol 5mg / Actin 5 mg Tab. Diactin 5 mg 1 + 0 + 0
B. GLINIDES

Rapaglinide 0.5 mg 8 mg
Nateglinide 120 mg 360 mg
o Should be taken 3 times 10 20 minutes before meal

o No meal: No dose.
o Suitable for post prandial surge that it decrease glucose after meal
o Suitable for patients with irregular meal habits.
o Duration of action: 2 4 hours, onset of action after 5 10 min.
o Preferable, where hypoglycemia tendency is more. Old age particularly reluctant to take food in
amount and frequency
Rapaglinide
Tab. Nomopil 0.5 mg / 1 mg / 2 mg Tab. Nomopil 0.5 mg 1 + 1 + 1, 10min before meal
Tab. Premil 0.5 mg / 1 mg / 2 mg Tab. Nomopil 1 mg 1 + 1 + 1 , 10 min before meal
Tab . Singlin 0.5 mg / 1 mg / 2 mg No meal no pill
Nateglinide
Tab . Nopik 120 mg Tab . Nopik 120 mg 1+ 1 + 1
Special attention
OHA should be avoided in
o Renal impairment (S. Creatinin>2.5)
o Hepatic impairment both acute and chronic diseases.
o So stop drug if patient develop ARF and jaundice
o Do SGPT and S. Creatinin before drug started
Dr .Shamol 152
2. INSULIN SENSITIZERS
A. BIGUANIDES:

Metformin 500 mg /850 mg 500 mg 2000 mg
It is taken 1-3 divided doses with meals or just after meal. (as it does GIT upset )
Disadv.: It may cause GIT , lactic acidosis
DO : S.Creatinin and liver function before start therapy
DO FBS and 2 HABF 2weekly and HBA 1c 3 monthly
Contraindication
o Hepatic and renal impairment (S. Creatinine > 1.5 mg/dl in male and 1.4 mg/dl in female)
o increasing proteinuria,
o predisposition to lactic acidosis,
o heart failure, (CCF)
o severe infection or trauma,
o Dehydration, and alcohol
o pregnancy and lactation
commercial name of metformin
Tab . Comet 500 mg / 850 mg Tab Comet 500 mg
Tab. Oramet 500 mg / 850 mg (drug int.) 0+1 + 0 after meal or
Tab. Nobesit 500 mg / 850 mg (incepta) 1 + 0 + 1 after meal
Tab . Glucomet 500 / 850 mg (aristo Tab. Comet 850 mg
0 + 1 + 0 after meal
B. THIAZOLIDINEDIONES
Rosiglitazone 4 mg / 8 mg 4 mg 8 mg
Pioglitazone 15 mg / 30 mg 15 mg 45mg
Dose : daily morning dose

Informed the patient that:
o Decrease in glucose may not be apparent for 4 weeks
o Maximum effcacy of dose may not be observed before 4-6 months
Contraindications:
o ALT >2.5 times the upper limit of normal
o Hepatic disease
o Alcohol abuse
o NYHA class III or IV
o Thiazolidinediones are indicated
As monotherapy and
In combination with
Metformin,
Sulfonylureas, and
Insulin
o Combining 2 sensitizers from different drug classes produces an additive effect
Pioglitazone and metformin or
Rosiglitazone and metformin
Dr .Shamol 153
Side effect:
o Edema
o Weight gain
o Congestive cardiac failure
o Anemia
Some commercial name
Pioglitazone
Tab . Toss 15 mg or 30mg Tab. Toss 15 , 1 +0 + 0
Tab. Toss 15 , 2 + 0 + 0
Tab Piodar 15 mg / 30 mg Tab Glucozon 15 mg / 30 mg
Tab. Pioglin 15 / 30 mg Tab. Diaglit 15 mg / 30 mg
Rosiglitazone
Tab. Sensulin 2mg / 4 mg Tab. Sensulin 2 mg 1 + 0 + 0
Tab. Rosit 2 mg / 4 mg Tab . Sensulin 4 mg 1 + 0 + 0
Combination of Metformin and Pioglitazone

Tab . Rezulin 15/500 or 15 / 850 mg Tab . Rezulin 15/500mg , 1 + 0 + 0
Tab . compimet 500 / 850 mg
Combination of Metformin and Rosiglitazone

Tab .Sensimet 1 (metformin 500 + rosiglitazone1mg) Tab . Sensimet 1 or 2 1 + 0 + 0
Tab . sensimet 2 (metformin 500 + rosiglitazone 2 mg) Tab . sensimet 1 or 2 DS
((metformin 1000mg + rosiglitazone1mg))
3. OTHERS :
Reduced glucose absorption from GI tract decrease postprandial hyperglycemia

Acarbose 50 mg 25 50 mg 300 mg in divided dose
DOSE: 1 3 times with first Bite of meal
Major side effect: Diarrhea,
Abdominal pain,
Flatulence
Commercial name
Tab. Glucobay 50 mg Tab .Glucobay 50 mg + +
Tab . Glucobay 50 mg 1 + 1 + 1
Dr .Shamol 154
What will start oral hypoglycaemic therapy?
o First exclude the indication of insulin in this patient :
o Second if pt with TYPE-2 DM and blood glucose is high than start insulin first
o Because if u give insulin than it will give rest beta cell for the time being other wise beta cell
become exhausted if give u oral hypoglycemic agent that at the stimulated them to produce insulin .
o So pt with type II DM first give insulin in first presentation and when beta cell increased production
to insulin again than transferred him in to OHA
o How will u understand that Beta cell getting started function or switch over to OHA
o Pt will produce sign symptom of hypoglycemia in same dose in which he was previously Euglycemic
Suppose patient receiving 30 unit insulin / day and his Blood sugar is control with that amount of
insulin . Now patient complaint of repeated attack of hypoglycemia with that amount of insulin. so u
think that patient Beta cell is working . gradually decrease the dose of insulin then switch on to oral
hypoglycemic therapy
How will u start
First mono therapy low dose
If not control increase dose
If not control then add combination therapy
If not control goes to insulin
Obese BMI > 25 Non obese BMI < 25

Metformin SULPHONYLUREA
Tab Comet 500 mg one of the following
0 + 1 + 0 after meal if not control Gliclazide (80 mg)
1 + 0 + 1 after meal o Tab . Dimerol 80 mg
Or + 0 + 0 if not controll (BM)
Tab. Comet 850 mg 1+ 0 + 0
0 + 1 + 0 after meal Glimipride 1 or 2 mg if patient is old
o Tab. Secrin 1 mg ,
+ 0 + 0---before meal (BM)
OR
Glinide
Rapaglinide
o Tab. Nomopil 0.5 mg
1 + 1 + 1,10min before meal
If not control If not control
ADD one of the following Add one of the following
SULPHONYLUREA 1. Metformin
GLINIDE Tab Comet 500 mg
OR 0 + 1 + 0 after meal if not control
TZD 1 + 0 + 1 after meal
o Pioglitazone 2. TZD
Tab. Toss 15 , Pioglitazone
1 +0 + 0 Tab. Toss 15 ,
1 +0 + 0
If not control If not control
Insulin Insulin
Dr .Shamol 155
Insulin
We have four type insulin on the basis of onset and duration of absorption insulin from sit of it it injected
Type Generic name Onset Peak Max. Commercial name

Ultra short acting insulin analogues- 5-15 30-90 <5 h Take immediately
lispro, min min before meal / during
aspart, meal and thrice daily
glulisine
Short acting / rapid Soluble 30-60 2-3hr 5-8 hr 15 min before meal
regular mins and thrice daily
Intermediate acting Basal 2-4 hr 4-10 10-16 Usually once daily at
Lente hr Hr night and may given
Isophane (NPH- BD
Neutral protamin
hagedorn )
Long acting Insulin analogues- 2-4 hr No 20-24 Once daily
Glargine, peak hr
Detemir
Combination /mixed Short and intermediate 30-60 Dual 10-16 BD 15 min before
acting mins Hr meal .
50% NPH/ 50% regular 2/3 given at morning
70% NPH/ 30% regular and 1/3 given at
night
U may why short or ultra short or basal
Name of insulin Commercial name

Ultra short acting INJ .NOVORAPID (aspart)
Short acting / rapid Inj. ACTRAPID HM U-40 / U-100
Inj. ACTRAPID HM U-100 ACTRAPID PENFILL---1662 TK
u-100, s-100 ACTRAPID NOVOLET 2720 TK
4 + 4 + 4 , +/- 2 SC 15 min MAXULIN R U- 40 / U-100
Before meal . INSULR U- 40 / U-100
HUMULINR U- 40 / U-100
INSUMAN RAPID U100
Intermediate acting INSULATARD HM U40
INSULATARD HM PENFIL
Inj. INSULATARD HM U40 INSULATARD HM NOVOLET
u-4o HUMULINN U40
S-40 MAXSULINN U40
0 + 0 + 4 , SC 15 min before INSUMAN BASAL U40
meal. INSULN U40
Dr .Shamol 156
Long acting LANTUS U100 TK 5000 NOT WE USE
Combination /mixed MIXTARD 50 U-40 or U-100

MIXTARD 30 / 70 U-40 or U-100
Inj . Mixtard 50 u-40 ,s-40 MIXTARD 50 PENFILL OR MIXTARD 50 FLEXPEN
16 + 0 + 8 , +/-2 SC 15 min MIXTARD 30 / 70 PENFILL OR MIXTARD 30 / 70
before meal . FLEXPEN
MAXSULIN 50 /50 U-40 or U-100
MAXSULIN 30 /70 U-40 or U-100
SIDE-EFFECTS OF INSULIN THERAPY

Hypoglycaemia
Weight gain
Peripheral oedema (insulin treatment causes salt and water retention in the short
term)
Insulin antibodies (animal insulins)
Local allergy (rare)
Lipodystrophy at injection sites
HYPOKALAEMIA
Indication of insulin
Insulin
Insulin therapy is indicated in those who meet the following criteria:
1. Type 1 DM patients
2. Type 2 DM patients
1. Who remain persistently symptomatic hyperglycaemic on maximum dose
of oral agents and diet (primary/secondary failure).
2. Acute stress, such as
* Infection
* Trauma
* Myocardial infarction
* Stroke
3. Diabetes with advanced complication
* Eye disease: Prolifertive retinopathy
* Kidney disease: Serum Creatinine >2.5 mg/dl.
* Acute metabolic neuropathy
4. History of ketosis/ketoacidosis (DKA/HONK)
5. Symptomatic hyperglycaemia;
6. Lean, symptomatic patients;
7. Prior to surgery;
8. pregnancy
At least 3-4 months planning prior to conception;
Throughout pregnancy;
Also, if planning for pregnancy.
Dr .Shamol 157
How will u start insulin?
Our body has two type of body secretion
One basal secretion ---continuous steady secretion is about 24 unit / day
Another is bolus secretion ---only surge after meal 3 time = 24 unit / day
So total daily secretion is 48 unit / day. For this reason if total daily dose is more than
48 unit then add intermediate acting insulin .
Dose of insulin is:

(0.2 0.4 unit/kg body wt/day), usually we count 0.3unit / kg body wt /day
IN CASE OF SHORT ACTING DOSE

Give it three divided dose subcutaneously 15 min before meal
If u gives the insulin for the first what ever the weight u should start as follow
Inj . Actrapid HM U100 , S100
4 + 4 + 4, +/- 2 SC 15 min before meal for 2 days
Increased + 2 unit with each dose until urine sugar becomes blue
When Urine become blue then advise FBS and 2HABF before further increasing dose
If patient show any symptoms of hypoglycemia then decrease 2 unit from each dose
ADD INTERMEDIATE ACTING / BASAL INSULIN IF
o If total daily dose is more than 48 unit such as

Inj . Actrapid HM u100 , s100
18 + 18 +16, +/- 2 SC but target glucose level not achieved
o If fasting glucose(12 mmol/l) not achieved but 2 HABF (8mmol/ l) is achieved

14 + 14+12, +/- 2 SC 15 min meals (FBS-14, @ 2HABF-8)
Pl. add
Inj. Insulatard HM
0+ 0 + 4 SC at night and increased 2 unit after 2 or 3 day interval until target achieved
So pl give order as follow
18 + 18 +16, +/- 2 SC 15 min before meal
Inj. Insulatard HM
0+ 0 + 4 SC at night
o Low dose(<10 u/day),no dose

o ~1unit/Kg/day-physiological dose
o 1-2unit/Kg-pathological doses
o >2unit/Kg-resistance
Dr .Shamol 158
IN CASE OF COMBINATION THERAPY (intermediate and one part rapid acting insulin)
We usually use short action insulin in hospital but some time u will find that some physician
prescribed mixed insulin therapy for those who do not want to take injection 3 times /day
Should be given in two divided dose:
First calculated the initial dose as 0.2 to 0.4 unit/ kg /day and then give
Two-third of this calculated dose may be given in the morning BBF and
One-third at night before dinner

For example: If a person weighing 60 kg needs 24 units/day, then 16 units would be given in the
morning and 8 units would be given in the evening.
Inj . MIXTARD 50 /50 OR Inj. MIXTARD 30 / 70 U---100, S-100

16 + 0 + 8, SC 15 min before meal
DM patient is newly diagnosed DM with FBG 16 A patient with on short acting insulin but his
fasting is not control or getting > 48 unit /day
Diet : diabetic diet
Do regular exercise Diet : diabetic diet
Inj . Actrapid HM u100 , s100 Do regular exercise
4 + 4 + 4, +/- 2 SC 15 min BM for 2 days Inj . Actrapid HM u100 , s100
6+ 6 +4 , +/- 2 SC 15 min BM for 2 days 16+ 16 +14 , +/- 2 SC 15 min BM
8+8+6, +/- 2 SC 15 min BM for 2 days Inj. INSULATARD U40 S10
Tab .NeuroB 0 + 0 + 4 , SC at night
1+0+1 Tab .NeuroB
Cap. Omeprazole 20 mg 1+0+1
1+0+1 Cap. Omeprazole 20 mg
Maintain DM chart 1+0+1
Maintain DM chart
A patient with DM wants to get 2 dose insulin / day. patient need 24 unit /day
Diet : diabetic diet

Do regular exercise
Inj . MIXTARD u100 , s100
16+ 0 +8 , +/- 2 SC 15 min BM
Tab .NeuroB
1+0+1
1+0+1
Maintain DM chart
Dr .Shamol 159
A 30 years obese leady newly diagnosed DM . A 30 years non obese leady newly diagnosed DM .
FBS13 mmol/l and 2HABF 18 mmol/ l , BMI 30 FBS13 mmol/l and 2HABF 18 mmol/ l , BMI 25
With HTN, and lipid (LDL135 ) With HTN, and lipid (LDL135 )
Diet ---Diabetic diet (low calorie diet ) Diet -Diabetic diet (wt maintaining diet )
( See diet char ) ( See diet char )
Exercise : 30 min each days Exercise : 30 min each days
Tab Comet (Metformin) 500 mg Tab . Dimerol (Gliclazide)80 mg
0 + 1 + 0 after meal, if not control + 0 + 0 (BM) ,if not controll
1 + 0 + 1 after meal 1+ 0 + 0
Tab. NeuroB Or
1+ 0 + 1 Tab . Secrin(Glimipride) 1mg
Anti HTN or 1 + 0 + 0
Tab Angilock 50 mg if not contraindicated Tab. NeuroB
0+0+1 1+ 0 + 1
AntiLipid (statin ) Anti HTN
Tab .Atova 10 mg Tab Angilock 50 mg if not contraindicated
0 + 0+ 1 0+0+1
Maintain DM chart AntiLipid (statin )
Tab .Atova 10 mg
0 + 0+ 1
Maintain DM chart
40 yr old obese male newly diagnosed DM. A 50 years non obese leady previous diagnosed
FBS20 mmol/l and 2HABF 27 mmol/ l , BMI 30 DM on OHA with pneumonia , FBS17 mmol/l
With HTN, and lipid (LDL135 ) and 2HABF 25 mmol/ l , BMI 25
With HTN, and lipid (LDL135 )
Diet ---Diabetic diet (low calorie diet ) Diet ---Diabetic diet ( calorie diet )
( See diet chart ) ( See diet chart)
Exercise : 30 min each days Exercise : 30 min each days
Inj . Actrapid HM u100 , s100 Inj . Actrapid HM u100 , s100
4 + 4 + 4, +/- 2 SC 15 min BM for 2 days 4 + 4 + 4, +/- 2 SC 15 min BM for 2 days
6+ 6 +4 ,+/- 2 SC 15 min BM for 2 days 6+ 6 +4 ,+/- 2 SC 15 min BM for 2 days
8+8+6, +/- 2 SC 15 min BM for 2 days 8+8+6, +/- 2 SC 15 min BM for 2 days
Tab. NeuroB Antibiotic
1+ 0 + 1 Tab . Moxaclav 625mg
Anti HTN 1+1+1
Tab Angilock 50 mg if not contraindicated Tab. NeuroB
0+0+1 1+ 0 + 1
AntiLipid (statin ) Anti HTN
Tab .Atova 10 mg Tab Angilock 50 mg if not contraindicated
0 + 0+ 1 0+0+1
Maintain DM chart AntiLipid (statin )
Tab .Atova 10 mg
0 + 0+ 1
Maintain DM chart
Dr .Shamol 160
55 yr old male come to us with unconsciousness & A 42 yrs lady newly diagnosed case of DM was on
right sided hemi paresis , and convulsion .CT yet short acting soluble insulin 16+ 16 +14, total > 48
not done , BP180/ 110 mm of Hg RBS but his FBS 13 and 2 HrABF 16 . having HTN and
22.5mmol/ l dyslipidemia
Aairway Diet ---Diabetic diet ( calorie diet )

B---breathing ( See diet chart)
C---circulation Exercise : 30 min each days
Diet : Diabetic (total 10 feed 6 to 10 pm )
NG feeding 100 ml 2hrly expect the major 3 meal Inj . Actrapid HM u100 , s100
At 8 am -------400 ml 16+ 16 +14 ,+/- 2 SC 15 min BM
At 2 pm--------400 ml Pl. Add
At 8pm---------400 ml Inj. Insulatard
Inj. Actrapid HM U100 , S100 0 + 0 + 4 SC at night
6 + 6 + 4 , +/- SC 15 min before 3 major meal
Inj. Normal saline 1000 ml Tab. NeuroB
IV @ 10 d/ min 1+ 0 + 1
Inj. Ceftron 1 mg Anti HTN
I via iv stat and BD Tab Angilock 50 mg if not contraindicated
Inj. Oradexon 0+0+1
1 amp IV 8 hrly AntiLipid (statin )
Inj. Ranison 50 mg Tab.Atova 10 mg
1amp IV 8 hrly 0 + 0+ 1
Tab . Ripril 5mg Maintain DM chart
0+0+1
Tab . Diphedan 100 mg
0+0+3
SQmycetin eye drop
2 drop qds
Gel ora cream
Apply over the tongue tds
Continuous catherization
Change posture 2 hrly
Maintain DM chart
Dr .Shamol 161
Diet
Depend on patient body weight or BMI
If patient is obese than ---low calorie diet
If patient is non obese or under weight ----weight maintaining diet
The k.cal of food he will consume is depend on his ideal body wt in relation to his height
Suppose patients actual wt is 60 kg but according to height his ideal body weight should be 55.
then his diet will be calculate on his ideal body wt (55 kg). That means he will get diet of 55 kg
person .
Suppose patients actual wt is 40 kg but according to height his ideal body weight should be 55.
then his diet will be calculate on his ideal body wt (55 kg) .That mean he will get diet of 55 kg
person
Patient occupation Require K.cal per day

Sedentary worker 30 kcal /kg / day
Moderate worker 40 mg/ kg/ day
Heavy worker / rickshaw puller 50 mg / kg / day
Calculation of wt of body from patient height
From heightweight chart

Working formula one ----BWT in cm100
Working formula two ----5 fee=50 kg + (1 inch X 2.5 )
Working formula one

Calculate the body weight from height:
Step 1. Measure the patient height in feet and inch
Step2. Then convert it in to Cm
Step3. Then deduct 100 from it
Step4 what u get it will be the ideal weight for that person in
That height
Example. A sedentary worker have 5feet 3inch height having 50 kg wt how will u calculate his Calorie
Requirement .
First find out the ideal weight of this patient in that height (5feet 3 inch)
Step . 1 patient height 5 feet and 3 inchs
Step . 2 convert it in cm
5 x12 + 3 = 63 X 2.54 = 160 cm
Step. 3 . 160cm 100 = 60 cm
Step 4 . This 60 is the patient s ideal wt in kg for that height
AS he sedentary worker his Calorie requirement will be

60 x 30 = 1800 k .cal per day
Dr .Shamol 162
Working formula Two
Calculate the body weight from height
Step 1. Measure the height of the patient in feet and inch
Step.2 . for 5 feet = 50 kg
And extra one inch = 2.5 kg
Example : A sedentary worker patient having height is 5 feet 4 inch what will be the ideal weight and
what will be his calories requirement
For 5 feet = 50 kg
And for 4 inch = 4 x2.5 = 10 kg
Total weight is 50 +10 =60 kg
So patient daily calories requirement is 60 x 30 = 1800 k .cal
In case of pregnant leady Pl add extra 400 Kcal
When I was intern doctor my CA was too busy to give me time

We always remained scared during receiving patient. What will b the pt complaint & what will b
the Dx , how will I proceed . and what will b the Rx
Will I call my CA ?
If I call him will he angry with me ?. specially at night it was night mare for us
When I become CA. I saw still today the intern doctor are facing same problem.
They confusing during receiving a patient and giving treatment and they have to wait for mid level
visit even for simple management .
In round mid level discus uncommon d/d and management which academically important but
practically burden to intern doctor .
That why I try to write a guide line for intern doctor , who are new for in medicine ward
It is written on basis of my practical experience in medicine ward and round of note of different
teachers
Please do not use it as reference to others specially to mid-level ( only text can use as reference )
It is only for u and help u only when u r beginner.
If any contradiction Please follow the text book
Though It is made for intern doctor of MU-1 (w--15) , it will be my pleasure & honor If intern
doctor of MU-II and MU-III use it
There may be some printing mistake and spell of pen so pl forgive me and correct spontaneously
If any clumsiness or if u failed to understand of any thing written here pl call me on 01912104673
With thanks
Dr. Shamol
Assistant registrar
MU-I , MMCH
Dr .Shamol 163
Multiple myeloma
Q A 60yrs old man comes to with complained of generalized body ache with anemia ..what is ur Dx
My ----diagnosis is multiple myeloma
Q. Old patient with bone pain what are the differential diagnosis?
Multiple myeloma (with anemia ) Presentation of multiple myeloma
CRF(with HTN+ anemia) Paraplegia (due to cord compression )
Osteoporosis (female) CRF or nephritic syndrome
Malignancy (boney metastasis ) Septicemia/ infection
Hyper viscosity syndrome
Diagnostic criteria Hyper calcaemia
The diagnosis of myeloma requires two of
the following criteria:
increased malignant plasma cells in

Investigation to establish MM
the bone marrow
serum and/or urinary paraprotein CBCHb anemia , ESRhighly raised
skeletal lesions. In Xray PBFnormocytic normochromic anemia +
increased roleuax formation
Xray skulllytic lesion
Suspected case X-ray spine
When u suspect a patient is suffering from MM Immunoglobulin electrophoresis
Old age Creatinine
Patient have bone pain / fracture vertebra Urine RME
Feature of hyper viscosity Blood calcium
o Head ache , dizziness , Albumin
o Black out , blurring of vision , Serum 2-microglobulin
o Coma Alkaline phosphatase
Feature of hypercalcaemia
o Dry mouth , dehydration If suspect multiple myeloma if got typical history with high ESR
o Poly urea , polydipsia, lethargy First do ---PBFfind usually normocytic anemia with increase
Fever ---infection roleuax formation
Anemia Then do Xray skull to see lytic lesion
Oedema ---CRF , Nephrotic syndrome Then do urinary Bence jonce protein positive in 20 % case
Then do immunoglobulin electrophoresis
o IgG 55% & I g A 21 %
Other
Creatinine---usually increase
Urine RME---protein
Blood calcium---hypercalcaemia
Albumin----decreased

Dr .Shamol 164
Treatment of multiple myeloma
Rx of
Supportive Hyper viscosity in multiple myeloma
High fluid intake Rehydration with fluid
Inj. Normal saline 1000 ml (if suspect hypercalcaemia ) Iv and oral
IV @ 10 d / min daily Plasmapheresis
Correction of Anemia
With blood transfusion to keep Hb > 10 gm / dl
Tab . ZIF Cl 1+ 0 +1
For pain Rx of Hypercalcaemia
Cap. Anadol 50 mg High fluid intake
1+ 0 + 1 Diuresis frusemide
Tab . Naprox , Indomet , or other NSAID Bisphosphonate ( Aldronic acid)
For hyper calcaemia et Steroid
Bisphosphonate ( Aldronic acid) Rx of bone pain
Tab Ostel 10 mg Analgesic
1 + 0 +0 it should be taken In empty stomach in If not relieved and localized pain
morning and remaining sitting for hours Give radiotherapy
anti ulcerate
1+0+1
To prevent hyper urecaemia Chemo therapy option in MM
Tab Esloric 100mg (Allopurinol ) MP therapy
1+0+0 MP therapy
MMelphelan (tab alkeran 2mg ) (8mg/ kg m2 )
PPrednisolone (1 mg kg/ wt)
Specific therapy: Give orally daily for 45 day and repetition of
MP therapy this cycle until paraprotien level level have
MMelphelan (tab alkeran 2mg ) (8mg/ kg m2 ) stopped falling remain stable level for 3 months
Tab. alkeran 2 mg 2+ 0 + 2 for 4days (plateau phase )
pPrednisolone (1 mg kg/ wt) In renal failure the dose of melphelan should be
Tab. Cortan 20 mg reduced to 1/3
2 + 0 + 0 for 4days others drugs
And repetition of this cycle 46 weekly Thalidomide (has anti-angiogenic effects
against tumour blood vessels)
It also use with dexamethason in refractory
myeloma
cause of renal failure in MM
to remember DNA of HIP JOINT
P--paraprotien deposit
H--hypercalcaemia
I--infection
D--dehydration
N--NSAID
A--Amyloidosis
Dr .Shamol 165
Poor prognostic criteria in MM
To remember it TABU (Indian actress ) plasma Hb level koto ?
Tthrombocytopenia
Aalbumin (severe hypoalbuminia )
B2 microglobulin
U--Urea
Plasma ---plasma cell leukemia
Hbhemoglobin < 7 gm / dl
Staging
CMH(combined military hospital ) Xray korte jao
Stage I Stage II Stage III
All of the following Fitting neither One or more of the following
1. C-calcium ----< 12 mg / dl I 1. C-calcium ----> 12 mg / dl
2. Mlow M protein Or 2. Mlow M protein
a. IgG < 5 gm/ dl III a. IgG >7.5 gm/ dl
b. IgA < 3 gm/ dl b. IgA > 5 gm/ dl
c. Urinary para protein < 4 gm/ dl c. Urinary para protein> 12 gm/ dl
3. HHb % > 10 gm/ dl 3. HHb % <8.5 gm/ dl
4. Xray---normal bone X-ray 4. Xray---Advance lytic lesion
Stage A Stage B
Serum creatinine < 2 mg / dl Serum creatinine > 2 mg / dl
Complication Prognosis
Pathological fracture : Rx radiotherapy Standard treatment
Cord compression o Most patient survive for 42 month
Renal failure
Septicemia
Hyper viscosity syndrome

Dr .Shamol 166
Approach to a patient with pancytopenia
During round with midlevel u may find a PBF report that shows u (or u find a PBF report during receiving patient )
Pancytopenia (anaemia, leucopenia or thrombocytopenia)
Or Bicytopenia (any two of these anaemia, leucopenia or thrombocytopenia)
What will u do?

Ur next investigation will b to see the Hb (if not yet done) or assess the anemia clinically
And urgent do the platelets count
Do blood grouping and cross matching
Give one unit of fresh blood if needed
Treatment Look for central cause

Diet : Neutropenic diet Central cause
Blood transfusion to keep the Hb > 10 gm /dl To remember ALL of MMC
Antibiotic AAplastic anemia
Inj. Ceftriaxone 2 gm L-- Lymphoma
o 1 vial IV BD L-- Acute leukaemia
Cap. Omeprazole M-- Myeloma
o 1+ 0 + 1 M-- Myelodysplastic syndromes
If patient hav fungal infection CCarcinoma
Cap . Flugal 50 mg Peripheral cause due to hypersplenism
o 1+0+1 CLD with portal hypertension
Following may give with consult with senior Kala-azar
Platelets transfusion if thrombocytopenia < 30 , Malaria
000 or where it not available give fresh blood . In female patient u most exclude
SLE
In some case of sever neutorpenia we may give
In some case of megalosblastic anemia
Inj . filastin 30 u SC stat
What u look in pt with pancytopenia

Sex ---if female exclude SLE
If old age look for leukemia / mylofibrosis , myeloma
If child also look for leukemia
How will this case present to u? Eye
Usually the patient presented to u with Anemia ---all of DD
Fever(Neutropenia / leucopenia) Jaundice lymphoma , leukemia , CLD
Anemia ---pallor Lymphadenopathy ---lymphoma
Bleeding manifestation ---Due Boney tenderness ---leukemia
thrombocytopenia Hepatosplenomegaly ---leukemia , lymphoma and
o Gum bleeding , purpura , ecchymosis mylofibrosis and all the peripheral causes
Hepatospleenomegaly But it is absent then think for aplastic anemia
Ascites CLD
If joint pain , alopecia , oral ulcer, rash,
photosensitivity
Dr .Shamol 167
What investigation u wants to do in patient with?
In CBC Hbdecreased in all cases
ESR---highly raised in MM , Kala-azar , SLE
MM---immature cell like myelocyte and metamyelocyte
PBF Leukemia ---blast cell

mm--- Normocytic anemia with increase roleuax formation
Aplastic anemia & other ---pancytopenia
Platelet count To see platelete and risk hemorrhage or platelet is needed or not
Bone marrow Leukemia ---blast cell
Aplastic anemia ---dry tap or hypo cellular marrow
KALA-AZARbone marrow shows LD body
USG To see hepatosplenomegaly
Hope u will diagnosis after doing the bone marrow if not then refer to Dhaka for heamatologist
To exclude SLE ANA
Urine RME---albumin , RBC ,
S. creatinine
To exclude Kala-azar ICT for kalaazar (although bone marrow shows ----LD )
To exclude malaria ICT for malaria
How will u differentiate between aplastic anaemia / leukemia / ITP?

Acute leukemia Aplastic anemia ITP
Clinical feature Fever high grade Only fever and Only bleeding
Toxic Bleeding manifestation manifestation
Present Nontoxic Non fever or non toxic
Boney tenderness Present Absent Absent
Hepato-splenomegaly Present Absent Absent
PBF Leukocytosis with Pancytopenia Only thrombocytopenia
Blast cell
Bone marrow Hyper cellularity with Hypocellur marrow or dry Increased megakaryocyte
increased blast cell tap
Clinical presentation of acute leukemia On examination

Usually present with Toxic and irritable
Fever and toxicity Anemia
Anemia Boney tenderness
+ /- bleeding (gum bleeding , purpur) Hepato spleeno megaly and lyphmadenopathy (+ + + )
Other manifestation Bleeding spots purpura
Lymphadenopathy
Organomegaly ---hepatosplenomegaly
o Arthritis
o Sore throat
Name some causes of high ESR ---TB , KALA-AZAR , Multiple myeloma, malignancy and connective tissue disease
Dr .Shamol 168
How will u differ from AML from ALL
ALL AML
Age Child (1-5 age) Adult
Lymphadenopathy Present Usually absent
PBF---type of blast cell Lymphoblast Myeloblast
Bone marrow Lymphoblast Myeloblast
Auer rods in the cytoplasm of blast Absent Present
cells
Prognosis Better prognosis Not so
Investigation Treat of acute leukaemia is Supportive and specific

Complete blood count Diet : neutropenic diet
Hb% decreased Do blood grouping and cross matching
TC----increased Correction of anaemia
ESR increased With fresh blood
PBF------Anemia --- Target haemoglobin is10gm/dl
WBC ---increased blast cell Control of infection
Platelete thrombocytopenia Empirical therapy with broad spectrum antibiotics
Bone marrow examination o Inj . ceftriaxone 1 gm / 2 gm 1 vial iv BD
Not necessary to Diagnosis we it when confused it is The following given with consult with senior
myeloblast or lymphoblast . Anti-fungal if fungal infection
And also To see hyper celularity with alter myloid Anti-viral if herpes simplex
erythoid ratio and increased blast cell (>20%) cytogenetics Prophylaction drugs against --Pneumocystis
and immunological phenotyping carinii (with co-trimoxazole)
USG ----to hepatosplenomegaly and intra abdominal Hyperuracemia
Allopurinol tab . Esloric 100 mg 1 + 0 + 0
lympho
PPI or H2 blocker
CXR -----
If patient complaint pain
Inj . Anadol 100 mg 1 amp IM stat or BD
What r the newer treatment In leukemia ? or cap . anadol 50 mg 1 + 1 + 1
Recent trends in Rx of leuk
Next
o Monocional Abs to the leukemia blasts.
Call the depart of radio and oncology for chemotherapy
o BCG
Before giving chemo do the
o Interleuk in 2
o Activated natural killer cells SGPT
o B.M. transplantation S.Creatinine
Fever (> 38C) lasting over 1 hour in a neutropenic patient Poor prognostic criteria of acute lymphoblastic leuk
(absolute neutrophil count < 1.0 109/l) indicates possible To remember ATPLevel-- 3
septicaemia. Age < 2 yrs > 10
Rx : Aminoglycoside (e.g. gentamicin) and a broad- TLC > 1,00,000
spectrum penicillin (e.g. piperacillin/tazobactam).but we Plat < 25,000
use ceftriaxone 2 gm IV BD L3 CNS infiltration
Continue
What r the Signs of remission?
At least 3 days after fever subside
Signs of remission are
o Improvement of C/P
o B.M blasts below 5%
o No blast in peripheral blood
Dr .Shamol 169
Chronic myeloid leukemia
Suppose in evening duty ur receiving a old patient age65 yr with Ho generalized weakness on general examination u got
only anemia. Suddenly when r palpate the abdomen u find huge splenomegaly .it is CML / CGL
How can u diagnose the CML---by only doing CBC
Investigation in case of CGL

CBC Hb%
TC >One lakh (100000to 500000)
DC N-- , L--
But other cell present (usually myeloid series )
Promyelocyte
Metamyelocyte (30---40%)
Myelocyte (10---20%)
Myeloblast but less < 10 %
PBF CGL
Rx of patient with CML What r the phase of CML

Diet: normal or neutropenic diet A When will u tell it acute leukemia?
Anti biotic If blast cell > 70 %
If patient in blast crisis or infection What are phase of CML
Inj. Ceftriaxone 1 or 2 gm I V BD A --Accelerate
Anemia correction BBlast crisis
With blood transfusion Cchronic phase
Tab . Zif Cl 1+0+1 What is Philadelphia (Ph) chromosome??
PPI This is a shortened chromosome 22 and is the result of a
Cap. Omenix 20 mg 1 + 0 + 1 reciprocal translocation of material with chromosome 9.
For hyper urecaemia The break on chromosome 22 occurs in the breakpoint
Tab. Esloric 100 mg (allopurinol ) cluster region (BCR). The fragment from chromosome 9
1+0 +0 that joins the BCR carries the abl oncogene, which forms a
Specific treatment : chimeric gene with the remains of the BCR. This BCR ABL
chimeric gene codes for a 210 kDa protein with tyrosine
Tab. Enliven 100 mg (imatinib) kinase activity-cause cellular proliferation
4+ 0 +0 ----for 18 month
Or Is presence of Ph chromosome bad or good?
cap . Hydra 500mg (hydroxy urea ) Presence Ph chromosome is good as it respond to therapy
2+ 0 + 2 ---( 14 gm /day ) how imatinib act ?
Follow up in case of hydra It inactive the tyrosine kinase activity
Do CBC every 3 wkly
Target to lower down the CBC bellow 20,000
Stop drug if < 10,000
Chronic Phase: respond to treatment and lasting 3-5 years
Accelerated Phase : more difficult to control

Blast Crisis : here it turn into acute leukaemia either myeloid (70%) or lymphoblastic (30%), which is relatively
refractory to treatment
Dr .Shamol 170
Hemolytic anemia / thalassamia
In most of the case u will get the thallasamia patient as diagnosed case and comes to for blood transfusion
Treatment
Clinical presentation of thallassaemia
Diet: Pt is usually young
Avoid iron contain food such as Generalized weakness due to anemia
Liver, beef, On general examination
oral iron tablet Haemolytic face-- depressed nasal bone, malar
Regular blood transfusion Prominence , frontal bossing
To keep the Hb level above 10 gm / dl Severe anaemia
Only packed cell is given Mild jaundice
Alimentary system examination
Vitamin and folic acid supplementation
Tab. Folic acid 5 mg o Hepato-splenomegaly
0 + 0+ 1 --------continue
Blackish skin hemochromatosis
Vitamin C increase iron excretion
Iron chelation
If present with edema then Dx will be the anemic
Parental
heart failure
Desferrioxamine : 30 to 50 mg/kg/day given by
subcutaneous infusion
But in out ward we give it after giving before DC

Some prefer
Inj. DA 500 ml
+
Inj. Desferal 2amp
I v @ 25 /d min
Somebody prefer it to give it in blood during blood

transfusion ?
What investigation u want to do ?

PBF --- Microcytic-Hypochromic , Anisopoikilocytosis, Target cells,
fragmented cells , large numbe Of Nucleated red cells
Hb % ----to see how many bag is needed (one unit of blood correct 1 gm Hb% )
Increased reticulocyte count (normal < 2 %)
What is the Definite test for diagnosis thalassaemia ?
haemoglobin electrophoresis
. Minimal to no HbA, elevated HbF and HbA2
What are the other investigations?
USG OF whole abdomen if patient complaind abdominal pain
Gall stone
Serum ferritin
What is the X-ray finding in thalassamia ? Not we do to Dx
X-Ray Skull shows
Widening of the diploeic space with a "hair on end" appearance.
Dr .Shamol 171
What are the complications of thalassaemia ? What are the Indication of splenectomy?
o Bronz diabetes deposition of iron
o Growth retard / dwarfism Huge splenomegaly due to pressure
o Gallstone ---pigmented stone effect
o CLD If patient need repeated blood
o Hypogonadism due to deposition of iron in to hypothalamus transfusion in a short interval
o (Hypopituitarism )The anterior pituitary is involved (200 to 250ml / kg packed cell per year
o Heart failure Due to anaemia to maintain an Hb level at 10 g/dl ).
Due to haemochromatosis Feature of hypersplenism
o Joint pain pseudogout due deposition of iron in to synovial
fluid
o Neurological examination encephalopathty
o Hyper pigmentation
MANAGEMENT OF THE SPLENECTOMISED PATIENT
Before splenectomy against organism you hav to vaccinated the patient ?

Meningococcal group C
Haemophilus influenzae type B,
Pneumococcal
When will you give the patient vaccine?
At least 2-3 weeks before elective splenectomy
When boster dose given ?
Pneumococcal re-immunisation should be given at least 5-yearly
Influenza vaccine annually
Life-long prophylactic penicillin V 250 mg 12-hourly
What extra measure you should take in patient with splenectomy ?
In septicaemia, splenectomised patients should be resuscitated and given intravenous

antibiotics to cover pneumococcus, Haemophilus and meningococcus
The risk of malaria is increased
Animal bites should be promptly treated with local disinfection and antibiotics, to
prevent serious soft tissue infection and septicaemia
What will he carry with him ?
A card or bracelet should be carried by splenectomised patients to alert health professionals
to the risk of overwhelming sepsis,
Dr .Shamol 172
A patient with lymphoma
If u find any patient with generalized lymphadenopathy following will be the differential diagnosis
Lymphoma
Leukemia
Disseminated TB
Anemia hepatosplenomegaly
jaundice ascites
boney tenderness intra abdominal lymphadenopathy
toxic or not feature of intestinal obstruction
feature of SVO feature of para plagia
swell neck lymphnode examination detailed ----
congest eye night sweating
engorged neck vein wt lose
What will u look during examination of lymphnode ?

Lymph node examination of this patient reveals that patient have
generalized lymph adenopathy involving cervical, right axillary group and left
inguinal group . There multiple, discrete, rubbery ,nontender lymph node of
variable size and shape largest of them in cervical region is 2x 1 cm and in right
axillarys region is 1.5x1 cm and left inguinal region is 2x 1.5 cm .these lymph
node are not fixed with underlying structure or over lying skin and having no
discharging sinus
How will u differentiated between and Hodgkin and non Hodgkin lymphoma
To remember the color of HCC IS Pale & Red
Hodgkin Non Hodgkin lymphoma HCC IS Pale & Red
1. Lymph node Localized to single Axial group Peripheral HHodgkin
(cervical , mediastinal , para Ccentral lymph
aortic ) Ccontagious
2. Mesenteric Not involved Commonly involved Iitching
and waldeyer Ssystemic
ring
feature
3. Spread of LN Contagious Non contagious
Pale-- Pel-ebstein
4. Systemic Common Less common
feature fever
5. Pruritus Common Less common RED-- Reed
6. Pel-ebstein May occur Does not occur Sternberg cells--
fever
7. Extranodal Less common common
involvement
8. Histology Reed Sternberg cells (hall Absent
mark ) present
Dr .Shamol 173
Investigation
Full blood count and PBF
may be normal.
A normochromic, normocytic anaemia
lymphopenia,
An eosinophilia or a neutrophilia may be present.
ESR may be raised.
Chest X-ray may show Bilateral hilar lymphadenopathy @ mediastinal
widening
USG of whole abdomen to see intra-abdominal lymphadenopathy
FNAC or biopsy of lymph node
LDH measurements, as raised levels are an adverse prognostic factor
CT scan of chest and abdomen for staging.
Renal function tests before start chemo.
Liver function test to see before chemotherapy or see hepatic
infiltration.
CLINICAL STAGES OF HODGKIN LYMPHOMA (ANN ARBOR CLASSIFICATION
CLINICAL STAGES OF HODGKIN LYMPHOMA (ANN ARBOR CLASSIFICATION)

Stage Definition
I Involvement of a single lymph node region (I) or extralymphatic site (IA E)
II Involvement of two or more lymph node regions (II) or an extralymphatic site and lymph node regions
on the same side of (above or below) the diaphragm (IIE)
III Involvement of lymph node regions on both sides of the diaphragm with (III E) or without (III) localised
extralymphatic involvement or involvement of the spleen (III S) or both (IIISE)
IV Diffuse involvement of one or more extralymphatic tissues, e.g. liver or bone marrow
A No systemic symptoms
B Weight loss, drenching sweats
The lymphatic structures are defined as the lymph nodes, spleen, thymus, Waldeyer's ring, appendix and
Peyer's patches.
Dr .Shamol 174
Approach to patient with stroke :
Pt with stroke may present to you in following :
Unconsciousness with or without hemiparesis
Conscious with one or more of the following feature
Hemiparesis
Aphasia or dysphasia ---unable to talk or difficulty in talking
o Motor cannot talk but obey command---if u ask to show the tongue then he can protrude the tongue
o Sensory --- cannot talk & also cannot obey command---if u ask to show the tongue then he cant do it
Monoparesis ---weakness of single limb (hand or leg )
Cranial nerve palsy
Feature of brain stem stroke (to remember ABCD)
o A__Ataxia, --loss of balance
o D--Diplopia---double vision
o B---vertigo and/or bilateral weakness
o D---And 3D disarthia (articulation ), dysphagia (swallowing ), dysphonia (tone )
o C---crossed hemiplegia (weakness of limb of one side & cranial nerve palsy of opposite side )
Sudden severe head ache followed neck rigidity with or without unconsciousness
Cerebellar sign
Sensory problems
If the patient is unconscious / acute confusion state then see chapter where we discuss the management of
unconscious patient .(first exclude the other causes of unconsciousness )
During receiving patient u should the take following What examination u will do?
Onset is GCS if unconscious
o sudden (stroke )or Neck rigidity , kernings sing
o gradual (ICSOL) Pupil --unequal --herniation
Activity prior the stroke such working , sleeping Pinpoint ------ pontine haemorrhage
,or excited ,agitated Non reacting brain stem
History of head and vomiting Cranial nerve palsy -------3rd / 7th / 6th nerve
The patient is HTN / DM / IHD Pulse irregular ---AF , bradycardia ---hge or ICSOL
Now take the history of focal sign BP--- high BP indicatehemorrhagic stroke
Hemiparesis / monoparesis Carotid bruit ---
Aphasia or dysphasia Fundus ---papilla edema -ICSOL , hge
Crainial nerve palsy Heart rhythm (atrial fibrillation)
Feature of brain stem stroke Murmurs (sources of embolism) and
o Ataxia, --loss of balance Apex beat shift or not
o Diplopia---double vision Peripheral pulses (generalised arteriopathy)
o vertigo and/or bilateral weakness Rt Left
o And 3D disarthia (articulation ), Jerk
dysphagia (swallowing ), dysphonia Clonus
History sudden severe thunderclap head ache Planter
Chronic daily head ache with morning vomiting Tone (Flaccid or spastic)
HO trauma to head or Ho fall Muscle power
Fever (indicate aspiration pneumonia ) Hofman
Cerebellar sign
Dr .Shamol 175
If the patient is unconscious or confused If patient is conscious and able to take food orally
A ..clear away with suction if secretion then do the following :
B . O2 inhalation is respiratory distress / inj. Diet : normal
Lasix if creps + Inj. Normal saline 1000 ml
C . Dopamine BP less than SBP 90 / FLIUD I V @ v 20 drop / min
correction if dehydration Tab . ciprofloxacin 500 mg
Diet NG feeding 1 + 0 +1
200 ml 2 hrly Cap. omeprazole 20 mg or Tab . Ranitid 150 mg
Inj. Ceftron 1 gm 1+0+1
1 vial iv bd If patient is HTN
Inj. Normal saline 1000 ml Tab. Repril 5 mg
I V @ v 20 drop / min 0+0+1
Inj. Oradexon Sedative or anxiolytic if pt complained insomnia
1 amp iv stat and 8 hrly Tab . Rivotril 0.5 mg
Inj. Ranison 50 mg 0+ 0+ 1
Chang posture 2 hrly If the patient CT show ischaemic stroke
Continuous catheterization Taper the oradexon
Gelora cream Inj . Oradexone
Apply over the tongue tds 1 amp IV BD ---1day
SQmycetin eye drop 1 amp IV daily ----1day
Apply over both Eye qds Pl add
Maintain I/O chart Anti-platelet
If convulsion Tab . clopid AS (both aspirin & clopidogrel )
o Inj . sedil 1amp iv stat and then 0 +1 + 0
o Tab. Diphedan 100mg Statin
1+0+2 Tab . Atova 10 mg
o Rest less 0 + 0+ 1
o Inj. Perol Cerebral oxygenotor any one of the following
1amp IM stat Tab cerevas 5mg 1+ 1 +1 or
If pt is still restless then Tab .Neurolap 1 + 1+ 1+
Tab. Perol 5mg 1 + 0 + 1
Tab. Perkinil +0 + If infarction is massive
If HTN then Donot give Ecospirin and clopidogrel
o Tab.Repril 5 mg 0 + 0 + 1 If patient is poor give only Aspirin
Tab . Ecosprin 75mg 0+ 1 +0
If CT show s only haematoma with outventricular If patient hav ventricular extens or SAH
exten Add
Pl add the following Tab . NImocal 30 mg
Tab. Diphedan (phenytoin ) 100 mg 2+2+2+2+2 ----for 21 day from date of stroke
1 + 0 + 2 or 0 + 0 + 3 for one month Inj. Osmosol 500 ml (if midline shifting )
Gradually trapper the Oradexone 300 ml 60 drop/ min
Inj . Oradexone 100 ml 30 drop / min 8 hrly for 5 day
1 amp IV BD ---1day Tab. Diphedan (phenytoin ) 100 mg
1 amp IV daily ----1day 1 + 0 + 2 or 0 + 0 + 3 for one month
And If pain
Adjust anti-HTN drug to control BP Inj. Anadol 100 mg I amp IM stat
or
Cap. Anadol 50 mg 1 + 1+ 1
Dr .Shamol 176
Minimum investigation u gives the patient
Fasting lipid profile and
during receiving the patient
S. Electrolyte only given with consult wit
ECG
the senior
RBS
Never give CBC in stroke patient as it will
S. Creatinine wastage of money
CT-scan of brain
How will u differentiate between and infarctive and hemorrhagic stroke

Haemorrhagic stroke Infarctive stroke
Occur during activity , excitement Occur in normal activity and even in sleep
Head ache and vomiting and unconscious Have feature of risk factor HTN , hyper
Patient has HTN with irregular anti-HTN lipidaemia
therapy Carotid bruit and murmur and AF
BP highly raised
A patient is unconscious due to stroke in following condition Haemorrhagic ---- head ach / vomiting /HTN
In hemorrhagic stroke with or without ventricular exten. Unconsciousness
Sub arachnoid hemorrhage If neck rigidity present then sub arachnoid
In ischaemic stroke or infarctive stroke pt is conscious expect in haemorrhage
following condition : Infarctive stroke .usually conscious
o If brain stem infarction hemi/mono paresi, aphasia
o If massive infarction
o If associated with electrolyte imbalance
complication of bed ridden patient
Young patient with stroke cause

A- Aspiration pneumonia Old patient with stroke cause
B- Bedsore See following are present or not
HTN
C- Constipation Valvular heart disease
DM
D- DVT
IHD HTN
E- Electrolyte imbalance Vasculitis
Atherosclerosis
F- Frozen shoulder / pain full shoulder
In young patient AVM
Urinary tract infection
See heart for murmur Rupture Barry aneurysm
Depression and anxiety
Hyperlipidaemia
Oteosporosis
C OMPLICATION OF SUB ARACHNOID HAEMORRAGHE

INTRACRANIAL EXTRACRANIAL
To remember I Here Hyponatreamia
I--Cerebral ischaemialinfarction Cardiac arrhythmias
H---Hydrocephalus Pulmonary oedema
E---Expanding' haematoma Gastric haemorrhage (stress ulcer].
R---Rebleeding
E---Epilepsy.
Dr .Shamol 177
This is not for all (only who are interested )
cause of haemorrhic stroke Cause of stroke in young patient

to remember ABCD To remember CAT HAS vasculitis
A---Arteriovenous malformation C-- Cardiac embolism (MS )
Amyloid angiopathy A-- Premature atherosclerosis
B --Hypertension T-- Thrombophilia
C--- Coagulopathy Protein C
Anticoagulant therapy Protein S
Blood dyscrasia Antithrombin III
Thrombolytic therapy HHomocystinuria
3.DRUGS A-- Antiphospolipid antibody syndrome
Alcohol S-- Systemic lupus erythematosus
Amphetamines Vasculitis
Cocaine +
CAUSES OF SAH
Aneurysm 70-75%
Etiology of stroke : A-V malformations 5%
Stroke is Two on etiology Of all strokes: Bleeding diathesis
- ISCHAEMIC stroke 85% Anticoagulants
- HAEMORRHAGE 15% Turnours
Vasculitis --15%
Thrombotic
Atheromatons Non-atheromatous diseases of the vessel wall
I . Large vessel occlusion or stenosis 1. Collagen disease e.g. rheumatoid arthritis
(e-g. carotid artery) systemic lupus erythematosis (SLE)
2. Branch vessel occlusion or stenosis 2. Vasculitis e.g, polyarteritis nodosa ,trmporal arteritis
middle cerebral artery) 3. Granulomatous vasculitis e.g. Wegener"
3. Perforating vessel occlusion grmulomatosis
(lacunar infarction)
EMBOLISATTON (25%)
1 . From Artery The heart:
Atheromatous plaque - valvular heart disease
inthe intracranial or - Arrhythmias
extracranial arteries or - Ischaemic heart disea
From the aortic arch. - Bacterial and non- bacterial
endocarditis
- Cardiomyopathy
Hemorrhagic stroke ( 20 % )
Into brain substance or parenchyma ---15% Subarachnoid space ----5%
Cause---- see above Primary when hemorrhage confine in to ventricle and
subarachnoid space
Secondary ---when it extend from b rain substance to
ventricle or sub arachnoids space
For causes ----See above
Dr .Shamol 178
TIA
These are the focal neurological attacks which are sudden in onset, resolve within 24 hours or less and
leave no residual deficit. DD of TIA
In ward pt will present to u with Partial seizures,
The complaint of weakness but on examination u will Hypoglycemia,
get nothing Syncope
HO unconsciousness but now he is normal
Or during receiving pt u neurological sign but on evening
round
1. Reduced flow through a vessel: 2.Blockage of the passage of flow

by embolism
a fa11 in perfusion pressure, arising from plaques in
e.g. cardiac dysrhythmia associated with aortic arch or
localized stenotic cerebrovascular extra cranial vessels or
from the heart
Anterior (90 %) Posterior (7%)

Carotid territory Vertebrobasjlar territory,
Hemiparesis Loss of consciousness
Hemi sensory disturbance, Bilateral limb rnoror/sensory
Dysphasia dysfunction
Binocular blindness Monocular blindness
(amaurasis fugax) Vertigo, tinnitus,
Diplopia, dysarthria
not singly, but in with each other
5-10% TIA turn into stroke in next year :

Treatment of TIA :
Anti platelet:
Tab . Clopid As
0 + 1 +0
Statin
Tab . Atova 10 mg
0+ 0+ 1
If HTN ACE inhibitor
Dr .Shamol 179
GCS
Eye opening Verbal response
Spontaneous 4 TO remember OC in AC now
O 5
Orientated
Know place ,
person , time
C 4
To speech 3 Confused
talks in
sentences but
disorientated
IN 3
A Inappropriate talk Utter
occasional
words rather
To pain 2 than sentences
IN 2
C Incomprehensive Groans , grunts
, but no ward
now 1
No vocalization /
No response 1 none
Dr .Shamol 180
Motor response
To remember OLD FEN
O Obeys 6
commands
L Localizes to pain: 5 brings hand up beyond chin to

supraorbital pain
D withdrawal to 4 No localization to supraorbital

pain: pain but the patient flex the
elbow .if you give nail bed
pressure
F Abnormal flexion 3
to pain
E Extension to 2 extends elbow to nail bed

pain: pressure
N No response 1
Dr .Shamol 181
If u think u loaded with stroke chapter please do not read further ?
What do mean by lacunars infarction?
Occlusion of deep penetrating arteries produces sub cortical infarction characterized by preservation of cortical
function - language, other cognitive and visual functions.
Size of infarction To remember AD (asst.director )ke SMS koro

0.5-1.5 cms in diameter M---Pure motor hemiplegia 5'1%
Sites : S-----Sensorimotor 20%
periventricular white matter and basal ganglia 80% A---Ataxic hemiparesis 10%
in cerebellum and brain stem20% S----Pure sensory 7%
D---DysarthnalClurnsy hand 6%
Pure motor hemiplegia Pure sensory
Clinical: Numbness and tingling of contra lateral face and

Clinical: Equal weakness of contra lateral face, arm limbs. Sensory examination may be normal
and leg with dysarthria Vessells: thalamogeniculate A.
Vessells: Lenticulostriate A.
Ataxic hemiparesis 10% DysarthnalClurnsy hand 6%
Ant . limb of internal

capsule
Clinical: Dysarthria due to weakness of ipsilateral face And

Clinical: Mild hemiparesis with more tongue associated with clumsy but strong contralateral arm.
marked ipsilateral limb ataxia
Vessells: Perforating branch of Basilar A.
Pure sensory 7%
Clinical: Dysarthria, dysphagia and even mutism occur with mild facial and no limb weakness or clumsiness.
Vessells: henticulostriate A
.
Dr .Shamol 182
Blood supply to the brain
Vertebral artery arise from subclavian artery

Then is passs through the foramen of the
transverse processes of the mid-cervical
vertebrae
At the lower border of the pons, it unites with
opposite vertebral artery to form the basilar
arter
(a) superior pontinc,

(b) inferior pontine and
(c) medullary levels.
1. Superior cerebellar artery
2. Anterior inferior cerebellar artery
3. Posterior inferior cerebellar artery (PICA) which
arises from the vertebral artery.
1& 2 arise from basilar artery
Dr .Shamol 183
Area supply the blood vessel : PCA
Ant. Communicating artery
ACA
Post.Comunicating
cclusion at the insula All cortical branches are invoIved -

Contralateral hemiplcgia (leg relatively spared) Dominant
Contralateral hemianaesthesia and hemianopia Aphasia
Non-dominant
Neglect of contralateral limbs
Dressing difficulty
Dr .Shamol 184
Anterior Cerebral Artery
Occlusion proximal to the anterior comunicating A.
normally well tolerared because of the cross flow.
Distal occlusion results in
weakness and cortical -..
sensory loss in the contralateral lower limb with
associated incontinence.
contralateral grasp reflex is present.
Proximal occlusion results in
'cerebral' paraplegia with lower limb weakness,
sensory loss, incontinence and
presence of grasp, snout and palmomental reflexes.
Bilateral frontal lobe infarction may result in
akinetic mutim or deterioration in conscious level.
Circle of wills
anterior communicating artery Anterior cerebral artery
Middle cerebral artery

Posterior communicating artery
posterior cerebral artery

Internal carotid artery
Vertebral artery
Basilar artery
Dr .Shamol 185
Site of haematoma
In hypertensive parienrs,
up to 70% occur in the
basal ganglia Thalarnic
region.
SUPRATENTORIAL HAEMATOMA Cerebellar HAEMATOMA PONTINE HAEMTOMA

Mass effect: Sudden onset of Sudden onset of headache with Sudden loss of consciousness
headache followed by either a subsequent developing either QuadrapIegia
rapid loss of consciousness or a Cerebellar and brainstem Respiratory irregularities +
gradual deterioration in symptoms and signs, slowed respiration
conscious level over 24-48 hours. severe ataxia, Pinpoint pupils, pyrexia
Focal sign dysarthria, Skewed(dysconjugate eye
Hemiparesis, hemisensory loss nystagmus, movements
and homonymous Hemianopia vertigo and vomiting Death h often follows.
III nerve palsy indicates CSF obstruction 4 hydrocephalus
transtentorial herniation. with symptoms and signs of
ICP.
with symptoms and signs of
T ICP.
Dr .Shamol 186
Site of SAH
CT scan Confirms the diagnosis of SAH in 95 % case (if within 48 hr of bleeding )
throughout the
cortic'cal sulci
basal cisterns
Sylvian and
Inter hemispheric
Over sylvian or lateral sulcus Inter hemispheric fissure - anterior communicating

aneurysm
Within ventricular system

Blood restricted to the interpeduncular region and not
extending into the lateral SyEvian or interhemispheric
fissures (i.e. a 'perimesencephalic' pattern)
blood in the sulci
Dr .Shamol 187
What r the site of aneurysm :
Intracranial aneurysms Fusiform dialatiota and

are usually saccular, ectasia of the carotid and
occurring at vessel the basilar artery may
bifurcations follow atherosclerotic
damage.
Rupture seldom occurs unril the aneurysm is over 6 mrn in diameter.

Those Over 2.5 cm are termed 'giant' aneurysms.
CLINICAL PRESENTATION
1. Rupture (90%)
2. Compression from aneurysm sac (7%)
A large internal carotid
artery aneurysm (or
anterior communicating
artery aneurysm) may
compress
The pituitary stalk
Optic nerve or chiasma
Dr .Shamol 188
A posterior communicating artery
aneurysm may produce a III nerve
palsy. This indicates aneurysm
expansion and need for urgent
treatment,
posterior communicating artery
III nerve
Dr .Shamol 189
C OMPLICATION OF SUB ARACHNOID HAEMORRAGHE
INTRACRANIAL EXTRACRANIAL
To remember I Here Hyponatreamia
I--Cerebral ischaemialinfarction Cardiac arrhythmias
H---Hydrocephalus Pulmonary oedema
E---Expanding' haematoma Gastric haemorrhage (stress ulcer].
R---Rebleeding
E---Epilepsy.
Cerebral ischaemia/infarction Several factors probably contribute to the development of cerebral ischaemia or
infarction: it is due to reflex Vasospasm . vasospasm occur due to release of vasoconstrictor substance in CSF from
blood clot .
For this which drug is
use
Nimodipin ---the
calcium chanal blocker
?
How they act they act
via reflex vasospasm
HYDROCEPHALUS
Following SAH, cerebrospinal fluid drainage may be impaired by:
Communicating hydrocephalus
- blood clot within the basal cisterns
- obstruction of the arachnoids villi
Obstructive hydrocephalus
- blood clot within the ventricuIar system
EXTRA CRANIAL COMPLICATIONS Hyponataemia
Myocardial infarction/ cardiac arrhythmias: Due to SIADH secretion
ventricular fibrillation Gastric haemorrhage
These problems are likely to occur secondarily to
catecholamine reIease following ischaemic damage to
the hypothalamus.
Pulmonary oedema: this occasionally occurs after SAH,
probably as a result of massive sympathetic discharge;
Dr .Shamol 190
What r the feature of 3rd nerve palsy? Short case Examine the 3 rd nerve ?
look at the patient face (ptosis ) what
Ptosis (complete ) examination you want to do ?
Divergent squint
Pupil dilated
Both direct and indirect light reflex are lost
Loss accommodation reflexes
unable to move the eye upward ,downward and
medially
what will be the direction of eye of in III nerve lesion ?
eye ball will rotated down ward and laterally
Cause of unilateral ptosis Bilateral ptosis

1. 3rd nerve palsy 1. Myasthenia gravis
2. Horners syndrome 2. Tabes Dorsalis
3. trauma 3. myopathy
4. congenital a. Myotonia dystrophica
b. fascio-scapulo humeral myopathy
c. occulo pharyngeal myopathy
4.bilateral horners syndrome

How will be differ between UMN and LMN of facial palsy
1. wrinkling present on affected side 1. wrinkling absent in affected side

2. eye ball can be closed 2.eye ball remained opened on affect sides
3. only lower part of the face involved 3. both upper and lower part involved
4. No hyperacusis or taste is affected 4. Hyperacusis or taste may affected
5. usually associated with hemiplegia 5. not
Cause unilateral facial nerve palsy? Cause of bilateral facial nerve palsy?
Bell's palsy (idiopathic). Guillain-Barre syndrome .
Herpes zoster. Sarcoidosis
Cerebellopontine angle tumours. Lyme
Parotid tumours.
Skull fracture.
Dr .Shamol 191
Horner's syndrome
To remember PEMA
Pptosis it partial as 30% of laveator palbre superior is supplyby sympathic nerv e and rest
of is supplied by III nerve .
E---enopthalmus Small eye
M---meosis Constriction of pupil
A----anhydrosis Absent of sweating
Brain stem Middle fossa

Intrinsic tumour, e.g. Tumour,
gliorna granuloma
Vascular lesion
Syringobulbia
Cervical cord Enternat carotid artery
Intrinsic turnour e.g. Trauma and
glioma occlusion/dissection
Syringomyelia
Anterior roofs C8, T7 Cervical sympathetic chain

Tumour, e.g, Carcinoma of the apex of the
neurofibroma lung {Pancoast syndrome)
Lower brachial plexus
palsy
But in your ward if got any case of horners syndrome first exclude the CA bronchus so look for
Clubbing , cervical lymphadenopathy , voice change ,
Do CXR to exclude bronchgenic carcinoma
Approach to patient with herpes Zoster : SHINGLES (HERPES ZOSTER)

In your GP practice or some time during receiving the patient u may find a patient with unilateral vesiclular rash any
part of the body . import thing it does not cross the midline . usually it is confined to single dermatome .
Diet normal
Tab. Virux 400mg
2+ 2+ 2+ 2 +2------7days
Apply virux ointment
Over the affected area tds
Tab. Tryptin 25 mg
0+0 +1
Tab . gabapen or pregabalin 300 mg
+ 0 + or 1 + 0 + 1
Cap . omeprazole
1+ 0 +1
Dr .Shamol 192
Cause of 3rd nerve palsy (for those who are over interested)
Mid brain Orbital fissurelorbii
When BILATERAL + oculomotor nucleus Look for PRoPTOSlS and
When III nerve lesion is associated with associated involvement of the
TREMOR - red nucleus or IV, VI and FIRST DIVISION of the
CONTRALATERAL HEMIPARESIS --cerebral peducle (WEBER'S SYNDROME) v NERVES
Cause : Causes :
Infarction, demyelination, Orbital tumour,
intrinsic tumour,e.g glioma, granuloma,
basilar aneurysm compression - Periosfeiris
.
Interpeduneular cistern Cavernous sinus

When III nerve lesion is associated with: Look for associated involvement
Deterioration of Conscious level of IV, VI and
Cause is transtentorial herniation 1st dlvlsldn of V nerve
Retro-orbital pain +/- Sub Arachnoid haemorrhage - Turnour e.g.
causes id aneurysm compression pituitary adenoma,
(posterior communicating Or basilar aneurysm) meningioma,
Meningism + other Cranial nerve palsies ) metastasis,
Basal meningitis due to nasopharyngeal ca
TB, syphilitic, bacteria!, funga rcinorna
carcinomatous - Intracavernous aneurysm
Pupil reaction spared Sudden onset - Cavernous sinus throrn bosis
Nerve trunk infarction
H yperlension,
Diabetes,
Polyarteritis nodosa,
Dr .Shamol 193
Approach to patient with dysphagia
In medicine ward u may find patient is dysphagia if u find such a patient u have to search for the following DD
Just exclude
Mechanical -----mainly ---CA esophagus
Next ----neurological causes
Third ----some pain full causes such oral ulcer, candidacies, tonsillitis. Sore throat
Mechanical Neuromuscular (dysmotility
Oesophageal cancer Achalasia
Stricture Pharyngeal pouch
Extrinsic compression, Myasthenia gravis
o e.g. lung cancer
o Enlarge thyroid
Systemic sclerosis
Neurological Odynophagia or painful causes

Cerebrovascular accident Painful mouth ulcers
Bulbar or pseudobulbar palsy Mouth or throat infections, e.g. quinsy, glandular fever
Oesophagitis
Mechanical Rx
Gradual onset Depend on the causes :
Initially problem with solid than liquid food Diet liquid if causes is mechanical or pt able to drink
Food sticking after swallowing and can localize the Otherwise @ must in neurological causes :
level of obstruction with finger NG feeding (if u failed and call to anesthesiology )
pain less Give IV fluid if pt cannot take orally
the patient is anemic and wt loss Inj . DNS 1000 ml
Inj . HS 1000 ml
IV @ 20 D/ min
IF dysphagia is neurological then give antibiotic to
prevent aspiration pneumonia
Inj . Ceftron 1 gm
1 vial IV BD
PPI or H2 blocker
Neurological Investigation
Sudden on set Clinically differentiated it is neurological or mechanical
Initially problem with liquid food If suspected mechanical is investigation is
Difficulty in initiating swallowing Endoscopy of upper GIT
You will one or more of the following neurological If suspect neurological cause then do
feature : MRI of brain
Dysarthria , hoarsness of voice ,nasal regurgitation Other investigation
other cranial nerve palsy ,Loss gag reflex & arching CBC---anemia and high ESR goes malignancy
of soft palate ,deviation uvula CXRto any compression
Hemiparesis , emotional liability , fasciculation of Routine investigation
tongue ECG , RBS , S.Creatinine

Pl see the chapter where u can learn the difference between Bulbar and pseudo bulbar palsy
Dr .Shamol 194
You have to query following question In patient with dysphagia
Onset Gradual mechanical cause (ca or )
Sudden neurological causes
Type of food that cause dysphagia initially Liquid first---neurological cause
Solid first ---mechanical
Both ---in late stage or advance stage
Time of dysphagia Difficulty in initiating swallowing neurological
Food sticking after swallowing ----mechanical
Painful or pain less
Choking or nasal regurgitation In neurological causes
Dysarthria , hoarsness of voice , other cranial nerve palsy Neurological causes
Loss gag reflex & arching of soft palate ,deviation uvula
,Hemiparesis , emotional liability
Anemia , weight loss , lymphadenopathy Carcinoma
Bilateral ptosis , with easily fatigability usually at evening Myasthenia gravis
Generalized cachexia , with fasciculation of tongue MND
Look for enlargement of thyroid and thymus
Look for any feature of bronchogenic carcinoma
search for systemic sclerosis
Tightening of skin over hand and face
Difficulty in opening mouth
Difficulty in seeing anemia by pulling the lower palpable
conjunctiva by the examinee
Now see anemia , smooth tongue , kilonychia Iron deficiency anemia , palmer v
Psychological Only label it if endoscopy & neurological exam is
normal
Some terminology regarding GIT system

Anorexia Loss of appetite
Xerostomia Dry mouth
Water brash Sudden appearance of excessive saliva in the mouth
Painful lips, tongue and mouth
Dysgeusia Altered taste sensation
Dysphagia Difficulty swallowing
Globus Sensation of a lump in the throat
Odynophagia Pain on swallowing
Heartburn Burning retrosternal discomfort radiating upward
Flatulence Belching
Dyspepsia Indigestion
Early satiety Premature fullness on eating
Nausea Feeling sick / vomiting
Haematemesis Vomiting fresh or altered blood
steatorrhoea Fatty stools, pale, greasy, difficult to flush away
Haematochezia Rectal bleeding
Melaena Black, tarry and offensive stools
Icterus Jaundice /Yellow discoloration of skin and sclerae
pruritus Generalized itchiness
Dr .Shamol 195
Approach to a patient with hepatosplenomegaly
If any patient come to with hepatosplenomegaly following will be the differential diagnosis :
Cause of hepatosplenomegaly
KamaL-3 my thal
Ka-Kala-azar
Ma-Malaria
L1-CLD with portal HTN
L2-Lymphoma
L3---Leukemia
Old age
My--Mylofibrosis
Chronic myeloid leukemia
Incase of child
Thal--Hemolytic anemia
At least if examiner asked what else then say

disseminate TB
First see that this hepatosplenomegaly is associated with fever or not :
If it associated with fever
First exclude
Kala-azar
Malaria
Lymphoma
Leukemia
At last disseminated TB
If it is without fever then exclude
CLD with portal HTN
Lymphoma
Chronic myeloid leukemia (in old age to middle age )
Hemolytic anemia(young age )
In general examination;
Appearance Hemolytic faces thalassaemia
Hepatic faces --CLD
Anemia Kala-azar, lymphoma , leukemia and

Thalassaemia
Jaundice CLD , lymphoma and thalassaemia
Lymph node Lymphadenopathy lymphoma , CLL
Temp ---increased Kala-azar and
Boney tenderness Leukemia
Look for stigmata of CLD
Palmer erythema Spider naevi Gynaecomastia
Engorged vein Ascites Testicular atrophy
Dr .Shamol 196
Look for Point in favor of ur diagnosis are
Hemolytic anemia Pt is usually young
Hemolytic face depressed nasal bone,malar
Prominence
Severe anemia and mild jaundice
Hepato-splenomegaly
Blackish skin hemochromatosis
CLD Stigmata of CLD
Hepatic faces
Jaundice
Palmer erythema
Spider naevi
Gynaecomastia
Engorged vein
Ascites
Testicular atrophy
Hepato-splenomegaly
Kala-azar Endemic zoon whole mymensingh .
Anemia
Temperature / HO fever
Hepatosplenomegaly
Lymphoma Anemia / jaundice
Generalized lymphadenopathy
Hepato-splenomgaly
Fever and wt loss
Leukemia Anemia
Patient toxic
Boney tenderness
Lymphadenopathy + / -
Hepato-splenomegaly
If the patient is old age
Chronic myeloid leukemia Anemia
Hepato splenomegaly
Myelo fibrosis Anemia
Hepato splenomegaly
Investigation you have to done

CBC HbDecreased , Kala-azar, malaria ,Lymphoma , Leukemia , Hemolytic anemia
Leucopenia ---Kala-azar
Leucocytosis ---in leukemia
Myelocyte , metamyelocyte ,and other immature cell
ESR---increased in all cases
PBF Pancytopenia ---kala-azar , leukemia
Blast cell ----in leukemia
Microcytic , hypo chromic anemia with fragment , nucleated RBC --Thalssaemia
CXR Para hilar lymphaedenopathy , para tracheal lymphadenopathy lymphoma
Pachy opacity in TB ,
USG In CLD---coarse echo structure of liver , ascites , splenomegaly
Para-aortic , para-pancreatic lymphadenopathy ----in lymphoma
Dr .Shamol 197
If u suspect CLD HBsAg
A-Gratio
S. Albumin
SGPT
liver Scan
endoscopy to see varices
Kala-azar ICT for Kala-azar
Thalassaemia Do Hb electrophoresis
Bone marrow Kala-azar , leukemia , myelofibrosis
Lymphnonde FNAC and In case of lymphoma
biopsy
If u find a patient with just palpable spleen following will be the differential diagnosis :
What are causes of just palpable spleen?
Enteric fever
Malaria
Subacute bacterial endocarditis
SLE
Other cause of spelnomegaly
o Lymphoma
o Leukemia
o CLD with Portal HTN
o Disseminated TB
See the b ox hepatosplenomegaly

For SBE Clubbing ,splinter haemorrhage , murmur
Enteric fever / malaria Temp ,
SLE / connective tissue disease Joint swell & tenderness Rash & female patient , alopecia , oral ulcer ,
photosensitivity
Fever with splenomegaly Fever with ascites A patient with hepatomegaly A patient with
o Kala-azar o Abdominal TB with ascitis splenomegaly with ascits
o Malaria o Lymphoma CCF o CLD
o Enteric fever o leukaemia Hepatoma with secondary o Lymphoma
o SBE in the peritoneum o leukaemia
o Lymphoma Lymphoma o Dessiminated TB
o leukaemia Dessiminated TB
o Dessiminated TB HCC with Chirrohsis of
liver with portal HTN
Dr .Shamol 198
Approach to patient ascites :
If any patient comes to with ascites u must have the following differential diagnosis :
The differential diagnosis
CLD with portal HTN
Abdominal TB
Intra abdominal malignancy
CCF
NS
If patient have only ascites without leg edema If patient have ascites with leg edema
Then Then
First think ---Abdominal TB First thought -- CLD with portal HTN
Then ------intra abdominal malignancy Next thought is NS or CCF
Then -----u thought --- CLD with portal HTN
HO Investigation
Jaundice Urine RME & S. Creatinine --exclude NS
Dyspnea , orthropnia ,cough with sputum
USG
Alteration of bowel habit
CLD --Coarse echo structure of liver , ascites ,splenomegaly
Diarrhea , blood mixed stool , mucus
CCF-- Hepatomegaly with passive venous congestion with dilation IVC
Weight loss
maliganancy ---Any mass
TB---ascites and splenomegaly
NS---normal
Asicitic fluid study
Transudative ---in CLD + NS+CCF
Exudative -----TB , Malignancy
Liver function test (AG ratio and )
+ viral marker + endoscopy
ECG +CXR + CBC + MT
CLD with portal HTN Stigmata of CLD Investigation

Hepatic faces Liver function test
Jaundice o A-Gratioalter
Palmer erythema o S. Albumin decreased
Spider naevi o SGPT
Gynaecomastia HBsAg---may +
Engorged vein USG of whole abdomen
Ascites Endoscopy to see varices
Testicular atrophy At last liver scan
splenomegaly Ascetic fluid study transudative (protient
less then 3 gm/dl)
SAAG
Abdominal TB Low grade Fever CBC with ESR

Weight loss / cachexic MTmost of the case negative
Doughy feeling CXR---may positive in
Alteration of bowel habit Ascetic fluid study
Auscultation of lung may crep + Straw color , exudative ( >3 gm/dl)
HO recurrent sub acute intestinal Endoscopy to exclude CLD
obstruction Colonoscopy or barium follow through
Dr .Shamol 199
Intra abdominal Anemia CBC with ESR
Malignancy Weight loss / Ascetic fluid study
Verchows gland (left supraclavicular Hemorrhagic color , exudative ( >3 gm/dl)
LN)Or other lymphadenopathy Endoscopy to exclude CLD of find CA stomach
Alteration of bowel habit Colonoscopy
USGmass in gut or liver
Heart failure Raised JVP CXR PA view ---cardiomegaly

Tender hepatomegaly ECG change
Depended edema Echo cardiograpy ---
Lung crep +/- USGhepatomegaly with passive
Ronchi / vesicular breath sound venous congestion with dilation IVC
prolong expiration
Murmur +/-
Left para sternal heave
Apex beat shifted
Nephritic syndrome Generalized edema Urine RME albumin ++ , RBC
Decreased urine out put 24 hr total urinary protein
No other finding USG ---normal
Heat coagulation is positive
Dr .Shamol 200
Find out the site of lesion from the presenting complaint or focal sign
Do not read just look at
Impairment of conscious level.
VisuaI field deficit.
Dysphasia (if dominant hemisphere)
Plus contra lateral
Facial nerve palsy upper motor
Hemiplegia
Contra lateral cerebral

hemisphere
Alert.
Facial nerve palsy upper motor
Hemiplegia
Contra lateral Internal capsule
Conjugate gaze deviation of Eye

towards the weak limbs (impaired
movement towards thc 'normal'
limb).
Lower motor neuron facial palsy
opposite the weak limbs
Contra lateral pontine lesion
Contra lateral cortex
Dr .Shamol 201
Pain and temperature loss on
the same side as the weakness
And a Homer's syndrome and
weak palate and tongue on the
apposite side.
Contra lateral medulary lesion
Visual field deficit.

Dysphasia (if dominant
hemisphere).
Discriminatory sensory deficit
Monoplegia .
Contra lateral cortical lesion
Pain and temperature loss on the

opposite side to the limb wcakness
And a Horner's syndrome and
proprioception loss on the same
side
Ipsilateral spinal lesion C1--C4
Pain and remperaturc loss in the

opposire leg,
Proprioception Ioss on the same
side
MONOPLEGIA (l;eg )
Dr .Shamol 202
Facial movements lost but vertical
eye movements retained
'locked-in syndrome'.
Bilateral pontine lesion
TETRAPLEGIA (syn. QUADRA-PLEGIA )

Discriminatory sensory loss.
'Frontal' incontinence.
(Pain and temperature sensation
intacf.)
PARAPLEGIA
Para sagital lesion
Sensory level' - impairment Or

loss of all sensory rnodalides.
Hcsirancy of micturition or
acute urinary retention.
Bilateral thoracic spinal cord

PARAPLEGIA
Dr .Shamol 203
Upper motor neuron signs are
important in detecting level of
cord damage (since lower motor
neuron signs may result from
either segmental damage or root
damage from a higher level )
Site of the lesion is cerebral

hemispheres, the internal capsule,
and the thalamus.
Decorticate posture results from damage to one or both corticospinal

tracts. In this posture, the arms are adducted and the elbows are flexed,
with the wrists and fingers flexed on the chest. The legs are stiffly extended
and internally rotated, with plantar flexion of the feet.
Pontine hemorrhage
Brain stem infarction.
Brain stem tumor.
Cerebral lesion
Hepatic encephalopathy
Hypoglycemic encephalopathy.
Decerebrate posture results from damage to the upper brain stem. In this Hypoxic encephalopathy
posture, the arms are adducted and extended, with the wrists pronated Posterior fossa hemorrhage
and the fingers flexed. The legs are stiffly extended, with plantar flexion of
the feet.
Dr .Shamol 204
During receiving patient u may got a patient with back pain:
First you have to exclude this pain is
Radicular pain or not
Any neurological feature present or not such as
o Motor weakness
o Sensory ---
loss of sensation in specific dermatome ,
Numbness and tingling sensation or Parasthesia in specific dermatome
Saddle anesthesia (loss of sensation around perineum )
o Autonomic
Bladder and bowel involvement
SLR test
Femoral nerve test
Jerk
Then exclude ---Does the pt have fever, wt loss or history malignancy to exclude malignancy, TB,
myeloma,
Then exclude ---Akylosing spondylitis ---morning stiffness, compression test and retraction test hip
and sober test . Arthritis of hip joint (osteoarthritis )
If these are exclude then u r dealing with
Mechanical pain or
Pain due to degenerative change in the spine or vertebra
Any patient comes to u with low back pain following are common cause
Mechanical back pain (musculoskeletal )

Prolapsed intervertebral disc (PLID)
o Radiculopathy (feature of nerve root compression )
o Myelopathty (feature of spinal cord compression / CAUDA EQUINA)
Ankylosing spondylitis
Pathological pain/deformity (e.g. osteomyelitis, tumour, myeloma, osteoporosis )
Osteoporotic vertebral fracture resulting in kyphosis
Lumber Spondylosis / osteoarthritis
Spinal instability (e.g. spondylolisthesis )
Spinal stenosis
HIP joint arthritis (TB, septic , osteoarthritis)
investigation u want to do Xray LS spine Both view (digital )

CBC MRI of LS spine
ESRincreased inflammatory , TB , malignancy if u suspect spondyloarthropathy :
ESRnormal in mechanical back pain Xray SI joint oblique view
routine , Xray hip joint if suspect TB of hip joint
RBS , S.creatinine ,
urine RME ---pus cell
DR. Shamol 205

treatment of low back pain :
rest in the hard bed
FOR PAIN
NSAIDS(one of the following )
Tab. Aceclofenac (Flexi+ reservix+ )100 mg
o 1+ 0 + 1
Tab . Naproxen 500 mg
o 1+1 +1
Tab . ketorolac (Torax 10 mg)
o 1+ 1+ 1
if the pain is severe then give (one of the following )
inj . Torax 30 mg 1 amp IM stat or BD
inj. Clofenac (Diclofenac 75 ) 1 amp IM stat or BD
voltalin suppository 1 stick PR stat or BD
inj. Anadol (Tramadol ) 100mg 1 amp IM stat or BD
MUSCLE RELAXANT (one of the following )
Tab. Myolax or mydocam (tolperison )50mg
1 + 1 + 1 or 1 + 0 +1
Tab Beclo (beclofen ) 10 mg
1 + 1 + 1 or 1 + 0 +1
NEURO VITAMIN
Tab . NeuroB or solbion (B1+B12+B6)
1+0+1
DIAZEPAM
Tab . sedil 5 mg
0+0+1
H2 blocker or PPI
tab. Neotack 150 1+0+1
cap . omperazol 1 + 0 + 1
IF NEUROPATHIC PAIN / RADICULOPATHY OR PARASTHESIA
Amytriptilin
o Tab . Triptin 25 mg (amytriptylin 50 to 150 mg )
1+0+1
Pregabalin or gabapentin
o cap . pregaba 100 mg or 75 mg or 150 mg
+ 0 + then 1 + 0 + 1
or
o tab .Gabapen 300mg
+ 0 + then 1 + 0 + 1
if not subside
call the orthopedics for traction
prognosis of PLID
About 70% of patients improve by 4 weeks.
Persistent neurological deficit at 6 weeks is an indication to consider
surgery
How will differentiate the mechanical from musculoskeletal pain?
Mechanical Inflammatory pain
Relation with rest & activity Increased in activity and It increased in rest and relieved
relieved by rest by activity
Morning stiffness Absent Present
Systemic feature Absent Present
ESR Normal Increased
DR. Shamol 206

This question u should ask in patient with low back pain:
Acute onset Mechanical
Insidious onset Inflammatory
Relation with rest and Mechanical pain --- increased in activity and relieved by rest
activity
Morning stiffness Inflammatory
Pain pattern Dose it radiate below the knee? if yes then radicular pain
Asymmetrical or Unilateral All this goes favor of radiculopathy
leg pain
Weakness of limb or
difficulty in walking
Saddle anaesthesia (loss of
perianal sensation )
Sensory abnormality ,
Parasthesia/ tingling
sensation / segmental
loss of sensation
Bladder and bowel Difficulty with micturition
involvement Loss of anal sphincter tone or faecal incontinence
Ho fever / wt loss
Ho malignancy
Drug history (steroid )
Age + ho of trauma
Pain more mark on standing Spinal stenosis
or walking
Heavy lifting and twisting Mechanical pain
(e.g. construction,
mining, agriculture and
nursing). Psychological
factors (e.g. job
dissatisfaction,
depression, anxiety)
Clinical examination
Jerk and planter
SLR
Femoral nerve stretch test
Sensory exam pain & touch
Look the spin for gibbous &
tenderness
Academically low back pain is classified in 4 category

Mechanical pain Inflammatory pain Non mechanical Specific cause / spinal cause
pain
Malignancy Spondylolysis and
Osteoporosis spondylolisthesis
Fracture Spinal stenosis
Prolapsed intervertebral
disc
Spondylysis
DR. Shamol 207

Features Radicular (nerve root) pain
Unilateral leg pain
Severe, sharp, lancinating quality worse than low back pain
Pain is aggravated by coughing, sneezing and straining at stool
Pain radiates beyond knee
Paraesthesia in same distribution
Nerve irritation signs (SLR positive & femoral nerve test positive)
Motor, sensory or reflex signs (limited to one nerve root)
Prognosis reasonable (50% recovery at 6 weeks)
FEATURES OF CAUDA EQUINA SYNDROME
Difficulty with micturition

Loss of anal sphincter tone or faecal incontinence
Saddle anaesthesia
Progressive motor weakness/gait disturbance
Sensory level
FEATURES OF SIMPLE MECHANICAL LOW BACK PAIN
Pain varies with physical activity (improved with rest)
Sudden onset, precipitated by lifting or bending
Recurrent episodes
Age 20-55
Pain limited to back or upper leg
No clear-cut nerve root distribution
Systemically well
Prognosis good (90% recovery at 6 weeks
asymmetric local paraspinal muscle spasm and tenderness, and
painful restriction of some but not all movements
spinal stenosis
'pseudoclaudication'----discomfort in the legs on walking that is relieved by rest, bending forwards or
walking uphill.
DR. Shamol 208

U have to clear idea about following terminology:
Scoliosis: lateral curvature of the spine Kyphosis:Forward bending of the spine

(normally thoracic spine )
Lordosis: Backward bending of spine Gibbus

(normally lumbar spine )
Spondylosis:. degenerative change in the spine
Spondylolysis:
defect in the pars interarticularis of a vertebral arch
(B)
Spondylolisthesis: the anterior slip of one vertebra Retrolisthesis: the posterior slip of one
on an inferior vertebra (A) vertebra on an inferior vertebra
DR. Shamol 209

Intervertebral discs act as shock absorbers for the bony spine.
A tough outer layer - the annulus fibrosis surrounds a softer central nucleus pulposus.
With age Discs degenerate, the fluid within the nucleus puIposus gradually drying out.
Disc collapse produces excessive strain on the facet joints, i.e. the superior and infcrior articulatory
processes of each vertebral body, and leads to degeneration and hypertrophy
Disc protrusion is two types

Central Disc protrusion---
cause myelopathy but in lumber region it cause cauda equine syndrome as here spinal cord end
L1 only conus medullaries present or tuff of nerve roots present
Lateral Disc protrusion----nerve root compression
DR. Shamol 210

central disc protrusion
lateral disc protrusion

Lateral disc herniations usually compress the nerve root exiting through the foramen below the affected level, e.g. an
L3/4 disc lesion will compress the L4 nervc root, but Iarge disc protrusions or a free fragment may compress any
adjacent root
some time facet joint hypertrophy may cause

nerve root compression
DR. Shamol 211

What examination u have to do in patient with low back pain
Aim of the investigation to exclude ----radicular pain or inflammatory arthritis
Straight leg raisingtest or SLR to see L5 and S1 root compression or sciatic nerve compression .
The sciatic nerve runs behind the pelvis, manoeuvres designed to put tension on the lower nerve roots (L4 exiting
the L4/5 foramen, L5 exiting the L5/S1 foramen.
Now ask the patient to lift up his legs keeping knee
straight .ask the patient to inform u if he notice any pain
and keep the leg in that position.now measure the angle
between the couch and the leg .normal angle is (80-90 0).

SLR is positive when it is less than 60 0
Dorsiflexion of the foot while the leg is elevated

aggravates the pain.
Crossed leg raise:

Elevation of one leg will produced pain in the opposite
leg
Reverse leg raising Tests (femoral stretch ) done for irritation of higher nerve roots (L4 and above)
The femoral nerve lies anterior to the pubic so straight-leg raising or other forms of hip flexion do not increase its
root tension.
Problems with the femoral nerve roots may cause
quadriceps weakness and/or diminished knee jerk on
that side.
DR. Shamol 212

L4 Quadriceps wasting and weakness;
Sensory impairment over medial calf;
Impaired knee jerk
L5 Wasting and weakness of dorsiflexors of foot or ankle
sensory impairment over lateral calf and dorsum of foot
weakness of extensor of great toes .
S1 Extensor digitorum brevis;
sensory impairment over lateral calf and dorsum of foot.
Lateral disc protrusion---distribution of pain Central disc protrusion distribution of pain
See the movement of spine :
DR. Shamol 213

Schober's test for forward flexion.
Mark the skin in the midline at the
level of the dimples of Venus; (mark A).
Using a tape measure, draw two
marks,
o one 10 cm above (mark B) and
o one 5 cm below this (mark C).
Place the end of the tape measure on
the upper mark (B) and ask the patient
to 'touch the toes'
The distance from mark B to mark C
should increase from 15 to more than
20 cm
The red Flag sign

History
Age-presentation under age 20 or over age 50
Character-constant, progressive pain unrelieved by rest
Location-thoracic pain
Past medical history-carcinoma, tuberculosis, human
immunodeficiency virus (HIV), systemic corticosteroid use
Constitutional-sweats, malaise, weight loss
Major trauma
Examination
Painful spinal deformity
Severe/symmetrical spinal deformity
Saddle anaesthesia
Progressive neurological signs/muscle-wasting
Multiple levels of root signs
DR. Shamol 214

Now see the sensory impairment present or not
To remember it
Just pocket L1
Full pocket L2
At the end of full pocket up
to end of knee joint L3
Now divide the rest of leg
in two part medial and
lateral half
Medial half supplied by ----
L4
Lateral half + dorsum of
foot (except 5 th toe )L5
Sole of foot ---S1
When u lie / sit down the
part of limb touch bed or
chair S2
Around the perineum S ,3,4
,5
Name the root value of jerk / reflex?

Planter S1
Ankle jerk S1 S2
Knee jerk L3 L 4
Supinator jerk C5 C6
Bicep jerk C5 C6
Tricep jerk C6 C7
To remember from below to upward: 11, 2 -----3, 4 ------5, 6 ---5, 6---6,7Root value of abdominal
reflex T8---12
Plain X-rays are rarely helpful in patients with acute mechanical low back pain, unless
red flags are present .
By the age of 50, 60% of women and 80% of men have radiographic features of
'spondylosis' (vertebral sclerosis and osteophyte, and OA of apophyseal facet joints).
DR. Shamol 215

look for
Alignment of the in Xray lumbar
spinous processes spine .
The width of the look for normal
apophyseal joints scotty dog
look appearance .
vertical fracture if any misshapen
lines. suggest a
fracture or
dislocation .
and also look for :
osteophyte present
or not
note any fracture present or not

note any osteophyte present or not
note any undue widening of the interspinous and

measure the distance or of the disc space. verrebrel
body, apophyseal joints, lamina or spinous process,
e.g. anterior wedge collapse
DR. Shamol 216

DR. Shamol 217
U hav not to memorize this only to see this chart when u cannot find out causes of limb pain
joint ----
arthritis radiculopathy / nerve root causes
- osteoarthritis cervical spondylosis
- rheumatoid arthritis cervical disc prolapsed
- infective arthritis
(acute, chronic - TB
Bone Brachial plexus / pelxopathy

- osteomalacia cervical rib
- primary tumour: apical bronchial tumor
osteosarcoma sarcoma brachial neuritis
secondaries (neuralgic arnyotrophy)
metastasis
myeloma
infective
osteomyelitis
other
osteoporosis
Paget's disease
blood vessel peripheral nerve
- PAD---intermittent peripheral neuropathy
claudication peripheral nerve injury
- venous stasis
- collagen vascular disease
- paraprotienemia
muscle
with wasting and weakness
- polymyositis
- polyrnyalgia rheumatica
with mass
- tumours
rhabdomyosarcoma,
- rnyositis ossificans
I
Blood vessel : Muscle pain
Pain brought on by exertion (cIaudication), relieved localized or specific muscle
by rest. Wasting and weakness +/- palpable mass.
Pain at rest in pale, pulseless limb (occIusion). Bone pain :
Pain associated with paraesthesia and digital pallor Diffuse, aching pain + / - palpable mass.
(Raynaud's).
JOINTS - Radiculopathy :
Pain localized to affected joint. Unilateral pain, more on sneezing, cough, goes below
Tenderness on palpation. the knee. Sensory loss , motor , jerks absent
Movements restricted and painful PLEXUS OR PERIPHERAL NERVE-
Wasting of surrounding muscles may follow. Burning pain, sweating, cyanosis and edema of
extremity, and Associated neurological deficit.
DR. Shamol 218

Pain in lower limb
joint ---- radiculopathy or nerve root
arthritis - PLID or
- osteoarthritis - spinal stenosis
- rheumatoid arthritis
- infective arthritis
(acute, chronic - TB
vessel Lumbosacral plexus /
- intermittent claudication pelxopathy
- venous stasis - pelvic malignancy
- collagen vascular disease - infective - psoas abscess
- paraprotienemia - pregnancy
Bone peripheral nerve

- osteomalacia - partial nerve injury
- primary tumour: - peripheral neuropathy
osteosarcoma sarcoma - meralgia paraesthetica
secondaries
metastasis
myeloma
infective
osteomyelitis
other
osteoporosis
Paget's disease
muscle
with wasting and weakness
- polymyositis
- polyrnyalgia
rheumatica
with mass
- tumours
rhabdomyosarcoma,
- rnyositis ossificans
Meralgia para asthetica:

It burning and tingling sensation over the outer aspect of the thigh which increased on standing
or by walking due to a localized neuritis of lateral cutaneous nerve of thigh
A patch of sensory impairment may bc evident over the outer aspect of thigh.
DR. Shamol 219

Approach to patient with dyspnea in hospital during admission
Most common causes of dyspnea in ward
A PATIENT WITH DYSPNEA
A----Acidosis DKA, uremia CRF / ARF

B----Bronchial asthma
C----COPD
D---- DKA
E----Thrombo embolism / emotional / pulmonary edema
F---failure left heart failure or CCF
Tension pneumothorax
First quick assessment of the patient HO, clinical exam and relevant investigation keep those DD in mind
first attack or previous if previous attack then what was the diagnosis , any discharge paper or
attack prescription of doctor , CXR , ECG it will help u to reach quick diagnosis
but always see the patient clinically never solely depend on the paper
whatever the designation of prof even if she or he is ur unit head
quick ask some question dose the pt have asthma
(may be give u the clue ) COPDchronic persistent cough with productive sputum +/- breathless
and smoker
any heart disease --- HTN , IHD, Previous MI
DM
renal disease CKD
orhopnea
History of allergy
first look for edema if patient having edema ---then it heart failure or corpulmonalae
present or not but remember it CKD with acidosis may present to u with oedema and
breathlessness (clue to Dx is HTN and anaemia)
next look for JVPif raised (for quick assessment just any pulsation
present in neck or not if present then its CCF )
first look the patient in which position breathlessness is more
if it is more in lying and patient cant / doesnt want of lying position
eye anaemia CRF , anaemic heart failure

congestionCOPD / corpulmonalae
mouth lip pursing COPD
tongue cyanosis --any one of the above
always absent ACIDOSIS
JVP JvpRaised then its heart failure
supra sternal recession , supra-clavicular
hand pulse
bounding pulse , warm periphery , flap COPD
tachycardia / pulsus alternus cold clammy skinheart failure
BP hypertension ---CKD,LVF
hypotension all (MI with LVF, tension penumothorax )
breathing patter all have hyper ventilation
acidotic or air hunger / acidic smell--- DKA/ ureamia
clubbing ILDwith /without corpulmonalae
bronchiectasis ==with / with out corpulmonalae
eisengmenger syndrome
oedema
chest any rhonchi and vesicular breathsound with prolong expiration
bilateral basal crep+ / whole lung case ---heart failure
clear / normal Acidosis /pulmonary embolism /psychogenic
apex beat
not locate =--emphysemaCOPD
shifted Heart failure
palpable P2 and Heave hear failure
silent chest asthma
percussion hype resonance and obliteration of upper broder of liver dull
ness COPD
percussion hyperresonance and breath sound diminish tension
peumothorax
AGE young asthma
Old copd
abdomen tender hepatomegaly
Ascetics fluid
look for DVT
eye if dyspnea but chest clear

JVP ACIDOSIS (DKA and uraemia)
pulse pulmonary embolism
BP psychogenic
edema
heart and lung
abdomen
Indication of antibiotic in asthma? )
fever with purulent sputum
suspect bacterial sinusitis
overlap COPD
Concomitant pneumonia
frequent exacerbation
asthma control
DR. LEAN control Partly controlled uncontroll

(any present
in any week)
day time symptoms None (twice/wk) >twice/wk 3 features of partly
Rescue or reliever treatment None (twice/wk) >twice/wk controlled asthma present in
need any wk
Lung function (PEF or FEV1) Normal <80% predicted
or personal best
(if known) on any
day
Exacerbation None 1/yr 1 in any wk
Limitations of activities None Any
Nocturnal None Any
symptoms/awakening
acute exacerbation of asthma

Rx on admission
Diet normal
O2 inhalation high-flow 60%
Nebulization stat and 4 to 2 hrly or SOS(depending on severity )

(sultolin sol 1 ml (5 mg) + ipramide sol. 1 ml (250 g) mixed with 2 ml normal saline )
Antibiotic only in selective case (see below )

Give antibiotics if:
Inj. Cotson 1oo mg
2 amp iv sat and Any of the following condition
1 amp iv 6 hrly present
Inj. Ranison 50 mg / cap omeprazole 20mg 1. Fever with purulent sputum

1 amp iv 8 hrly / 1+ 0+ 1 2. Suspect bacterial sinusitis
3. Overlap COPD
Sulprex inhaler 100 g (sulbutamol and ipratropium ) 4. Concomitant pneumonia
2 puff qds 5. HO Frequent exacerbation of
Asthma
Beclomin inhaler 250 g (beclomethasone)
2 puff tds
if the patient is in rich

sulprex and beclomin may replaced by long-acting bronchodilator combine with Flucortisone

2 puff bid
and add
Tab Monas (Montelukas ) 10 mg
0 +0 +1
if not control give
IV magnesium sulphate 1.22.0 g over 20 mins,
inj . NALEPSIN 4% 100ml (4gm Magnesium sulphate lOOml i.v solution)
give bottle over 20 mins
aminophylline 5 mg/kg loading dose over 20 mins followed by a continuous infusion at 1 mg/kg/hr
discharge medication in patient with bronchial astma
criteria for discharge if ESPN--
ESPN
E delivery of asthma education and indentify the triggering factor
S stable on discharge medication
P PEF should have reached 75% of predicted or personal best
N nebulised therapy should have been discontinued for at least 24 hours
advice
an appointment with a GP or asthma nurse within 2 working days of discharge
follow-up visit to your hospital in a months
during discharge give Stage III management

Sulprex inhaler 100 g (sulbutamol and ipratropium ) or Azmasol / sultolin 100 g (sulbutamol)
2 puff qds for few days and then SOS
Beclomin inhaler 250 g (beclomethasone)
2 puff tds
in rich patient (instead of beclomin)
Ticamet inhalar 125 or 50(salmetrelol + flucortisone ) / Bexitol-F 25/125 0r 25/50
2 puff bid
Tab Monas (Montelukas ) 10 mg Indication for rescue therapy
0+O+1 FCPS & MD
For rescue therapy F --fall of PEF below 60% of the s personal best
Tab .cortan 20 mg (after meal ) recording
1 + 0 + 0 for 7 days
CSleep disturbance or awakening
CAP. PPI (pantonix 20)
1+0+0 Pprogressive worsening symptoms and PEF day by
day
Ssymptoms so severe that need nebulizer or
inj.bronchodilator
Mmorning symptoms persist up to mid day
D --diminishing response to an inhaled bronchodilator
Step --1 SABA--sos
step--2 SABASOS
+
ICS ---BD
step--2 SABASOS Good response to LABA
+ continue LABA
ICS ---BD inadequate respond
Pl...Add continue LABA
LABA increase ICS (800 g/dayif not already )
No response to LABA
stop LABA
Increase inhaled steroid to 800 g/day.*
If still inadequate institute
trial of other therapy
leukotriene receptorantagonist or (tab.monas 10 mg)
theophylline SR (contine 400mg +0+ )
step4 SABA
(4 drug ) +
ICS(Increasing inhaled 2000 g/day)
+
leukotriene receptorantagonist or theophylline SR
+
add fourth drug (which not added in step three)
leukotriene receptor antagonist,
SR theophylline,
2 agonist table
step 5 prednisolone therapy--a single daily dose in the morning (lowest dose)
Maintain high-dose inhaled steroid at 2000 g/day*
step up if not control

criteria DR.LEAN
Step down if asthma control for three month gradually go step down
first decrease oral / ICS around 2550% every three months
then decrease gradually other controller drug LTRA , theophyline
SABA sultolin and azmasol inhaler

sulprex inhaler (salbutamol BP & ipratropium bromide)
LABA BEXITROL Inhaler 25mcg/puff
SALMATE Inhaler
ICS lnhaler BECLOMlN 100 or 250Square
DECOMlT (Beclomethasone dipropionate)
LABA+ ICS Bexitrol-F Inhaler 25/50 , 25/125,25/250
Ticamet 50 , 125, 250 (salmeterol fluticasone)
LTRA Montelukast sodium
MONTAIR 10mg
MONAS Tab.
REVERSAIR Tab.
THEOPHYLLINE Theophylline sodium
ASMANYL 400 SR Tab.
CONTINE-400 Tab
Mild case (first try ) (moderate to severe case)

one SABA , ICS, and LTRA if not control then
azmasol inhaler azmasol inhaler
2 puff sos 2 puff sos
lnhaler BECLOMlN 250 Bexitrol-F Inhaler 25/125
2 puff bd or tds 2 puff bd
Tab. MONAS 10 mg Tab. MONAS 10 mg
0+0+10 0+0+10
avoid triggering factor plus or minus
avoid analgesic / Tab ASMANYL 400 SR / contine
indication of steroid inhaler + 0+
1133 still not controll or mild exacerbation give rescues
11 exacerbation in the last 2 years therapy
1night awaken 1 / wks Tab .cortan 20 mg (after meal )
3 HO 3 symptoms/wks 1 + 0 + 0 for 7 days
3 need inhaled 2-agonists 3/wks CAP. PPI (pantonix 20)
1+0+0
always advice gurgle after using steroid inhaler for poor patient
adv to use respore chamber tab . purisal 2
IPREX Respirator Solo. Square 1+0+1
Ipratropium bromide 250mcg/ml tab. Alarid 1 mg
SULTOLIN Respirator Soln_ Square 1+0+0
Salbutamol sulphate Smg/ml tab . oradexon 0.5 mg
1+0+0
Cough variant asthma?

It is the variant of asthma where the dry nonproductive cough is main symptoms and absence of
classical symptoms like breathlessness and wheeze .
diagnostic criteria :
DAB (doctor association of bangladesh)
Ddry cough for 6 to 8 wks
AAbsence of dyspnea
Bbronchial hyper-responsive ness
give SABA
azmasol inhaler
2 puff sos
or ICS
lnhaler BECLOMlN 250
2 puff bd or tds
if not control give LTRA
Tab. MONAS 10 mg
0+0+10
if not control Tab .cortan 20 mg (after meal )
1 + 0 + 0 for 7 days
Exercise induced asthma?

When transient breathlessness (or reduction of lung function) occurs during vigorous exercise is called
exercised induced asthma.
occur due to entry of dry air into airway
single dose of just before starting exercise (any one )
SABA
azmasol inhaler Non-pharmacological management
2 puff
Sodium cromoglycate 1. Warm up before exercise
INTAL 5 Inhaler 2. Breath trough nose
2 puff
3. Brief rest during exercise
persistent symptoms than (any one )
LABA+ ICS 4. Take rescues medicine at start of
Bexitrol-F Inhaler 25/50 , 25/125, exercise
2 puff BD
LTRA
Tab. MONAS 10 mg
0+0+10
Asthma + heart failure Asthma with arrhythmia (AF)

1. Diuretic (frusemide ) can given
2. ARB (losartan ) 1. CCBdiltiazem , verapramil
3. carvidelol (carvista 6.5 mg +0+ )in low 2. amioderone
dose can be give 3. digoxin
4. digoxin can be given avoid
(ACE inhibitor better to avoided as it causes dry 1. Beta-blocker
cough) 2. aminophyline / theophyline
Asthma with HTN asthma with IHD
give antiplatelet drug :
1. CCB first tried with aspirin 75 mg (0+1+0)
2. thiazide diuretics if not tolerate than switch to clopid 75 mg (0+1+0)
3. ARB anti-anginal drug :
avoid avoid
1. non-selective Beta-blocker non-selective Beta-blocker avoided
2. ACE inhibitor selective Beta-blocker can given if pt tolerate
3. selective beta-blocker (better to avoid but can give
given if pt tolerate) CCB( diltiazem , verapramil)
nitrate (GTN, nitrin sr or anril sr)
asthma must be control because asthma
causes hypoxia aggravated angina
asthma with rheumatology disorder diabetes with asthma
Avoid 1. steroid can use / should be used ---but as
NSAID steroid causes hyperglycaemia so monitor
use painkiller as (one or both) blood glucose regularly and adjust the drug
1. paracetamol (napa2+2+2) anti-diabetic drug
2. tramadol HCl(cap. Anadol 50mg 1+0+1 ) 2. sulphonylurea can given
if not control use steroid 3. sever case /acute exaggeration insulin may
1. oral tab Cortan 2o mg 1 +0+0) needed /betterto guve
2. intra-articular steroid 4. avoid metformine in uncontroll or acute
exaggeration
5. theophylline should avoided as it reduce the
hypoglycaemic effect of oral drug
Asthma in pregnancy
all drug can be given in pregnancy and lactation what do u mean by asthma like syndrome
such as 1. COPD
1. SABA --2-agonists, 2. LVF
2. ICSinhaled steroids, 3. ILD
3. theophyllines, 4. churg-strauss syndrome
4. prednisolone, 5. tropical pulmonary eosinophila
5. chromones. 6. post nasal drip
Oral leukotriene receptor antagonists: 7. GERD
Not omit if patient on it previously before 8. drug-ACEI
pregnancy
Steroids:
those who are on maintenance dose> 7.5 mg/
day should receive hydrocortisone100 mg 34
times daily during labour
clinical course: one-third worsen, one-third
remain stable and one-third improve
.
acute severe asthma Life-threatening features
RIPP OPC khele CBC & ESF bare
R Respiratory rate 25 breaths/min O SpO2< 92% orPaO2 < 8 kPa (60 mmHg)
I Inability to completesentences in 1 breath P PEF < 33%predicted
P PEF 3350% predicted CPaCO2 raised or Normal
PPULSE 110 beats/min
C Cyanosis
B Bradycardia or arrhythmias ,Bp Hypotension
C Confusion, Coma
E Exhaustion
S Silent chest
R respiratory effort is Feeble
acute exaggeration of COPD
COPD / CORPULMONALAE
1. Diet normal
2. O2 inhalation low flow 2 l
(Sul.sol 1ml+1 ml ipr.sol +2 ml normal sal .)
4. Antibiotic any one
Tab. Moxaclav 625 mg
1+ 1+1
Tab. Ciprocin 500 mg / levox 500 mg
1+0+1 0+0+1
5. Sulprex inhaler
2 puff qds
6. Beclomin 250 inhaler
2 puff tds
7. Inj. Cotson
2 amp iv sat and
1 amp iv 6 hrly
8. Inj. Ranison 50 mg / cap omeprazole 20mg
1 amp iv 8 hrly / 1+ 0+ 1
9. more crep present // oedem present
Inj. lasix
2 amp / amp iv stat.
1 amp iv bd or (8am and 4 pm )
less severe mild cerps
Tab. Fusid plus
1+ 1+ 0
10. Tab contin 400 mg
+0+
In some case
We use in rich
2 puff bid
For rescue therapy mainly in discharge
Tab .Cortan 20 mg
1 + 0 + 0 for 10 days
Reducing exposure to noxious particles and gases

stop smoking
avoid
1. indoor / outdoor pollution
2. biofuel mass and
3. infection
vaccination
stage I above plus
Mild SABA
FEV1/FVC < 0.70 combination sultolin and ipratropium bromide
FEV1 80% predicted inhaler Sulprex
2 puff qds / Tds or /SOS
stage II SABASOS
Moderate Add regular treatment with one or more long-acting bronchodilators
FEV1/FVC < 0.70 1. LABA
FEV1 5079% predicted BEXITROL Inhaler/ SALMATE Inhaler 25mcg/puff
2 puff BD
2. theophylline
Tab ASMANYL 400 SR /tab contine
+ 0+
3. phosphodiester inhibitors
Roflumilast
Add rehabilitation
stage III stage II plus add
severe ICS- if repeated exacerbations
FEV1/FVC < 0.70 Beclomin 250 inhaler
FEV1 3049% predicted 2 puff tds
or
Combination with LABA
Bexitrol-F Inhaler 25/125
2 puff bd
stage IV above plus ADD
Very severe long-term oxygen if chronic respiratory failure
FEV1/FVC < 0.70 Consider surgical treatments
FEV1 < 30% predicted or 1. bullectomy
FEV1< 50% predicted if 2. lung volume reduction surgery (LVRS)
respiratory failure present
indication
ABG in clinically stable patientson optimal medical therapy at least in two occasions 3 weeks
apart:
PaO2 < 7.3 kPa (55 mmHg) irrespective of PaCO2 and FEV1 < 1.5 L
PaO >27.38 kPa (5560 mmHg) plus pulmonary hypertension, peripheral oedema or nocturnal
hypoxaemia
the patient has stopped smoking.
Us at least 15 hrs/day at 24 L/min to achieve a PaO2 > 8 kPa (60 mmHg) without unacceptable rise
In PaCO2
mild to moderate
1. Reducing exposure to noxious particles and gases
a. stop smoking
b. avoid
i. indoor / outdoor pollution
ii. biofuel mass and
iii. infection
2. 2.antibiotic if if exaggeration of symptoms
3. any one according patient financial condition
a. Tab. Moxaclav 625 mg
i. 1 + 1 + 1
b. Tab. Ciprocin 500 mg
i. 1+0+1
c. levox 500 mg
i. 0+0+1
4. Sulprex inhaler
2 puff qds
5. Beclomin 250 inhaler
2 puff tds
6. Tab ASMANYL 400 SR /tab contine
+ 0+
7. Tab .Cortan 20 mg (moderate to severe dis )
1 + 0 + 0 for 10 days
in case severe
instead of beclomin give
Combination with LABA +ICS
Bexitrol-F Inhaler 25/125
2 puff bd

Treatment Guideline For Intern Doctors in Medicine Ward

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Treatment Guideline For Intern Doctors in Medicine Ward

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What are the guidelines for treating a patient with COPD?

What are the guidelines for treating a patient with COPD?

What are the different stages of COPD severity?

What are the different stages of COPD severity?

First part

01. Patient with abdominal pain 01-02

When I was intern doctor my CA was too busy to give me time

A PATIENT WITH ABDOMINAL PAIN

Inj. Normal saline 1000 ml

Inj. Ciprofloxacin 100 ml

If suspect appendicitis or peritonitis

A----Acidosis DKA, uremia CRF / ARF

Young patient , H/O previous attack , allergy

Confused with LVF

If COPD patient present with edema then it is called cor-pulmonalae

Tachycardia / pulsus alternus

If lung is clear but patient is dyspnic Cause is Uremia CRF / ARF

Sudden sever respiratory distress Is due to

1. Diet normal 1. Diet normal

When you are in confusion between LVF AND COPD

Sign of severe asthma

2. Inj. Ceftron 2gm

3. Inj. Libot -25 100 ml

4. Inj . 5% DNS 500 ml

5. Inj . 5% DNS 500 ml

In between jasoquine drip

6. Inj. Hartman 1000 ml

If patient is rest less then

10. If you suspect viral encephalitis then

NEVER DO WIDAL TEST BEFORE 7 DAY

If suspect simple RTI then tab. Azithromycine 500 mg 0+0+1

If prolong fever and patient is toxic and do following

Inj . 5% DNS 1000 ml

Inj. Ceftron 2gm

Maintain temp. chart

If u want to add anti malarial in combination then do this

In case of treatment of pneumonia

First think structural ( CVD ) and then think metabolic

A patient with severe head ache pl do the following

3. Hepatic encephalopathy------jaundic /ascites / HO of liver disease /

A----------AIRWAY clear or not , Suction---for secretion

B--------evidence of respiratory distress----increase R/R , chest in drawing, crep ++ aspiration

C-------- BP. Pulse sign of dehydration ..

A ..clear away with suction if secretion

B . O2 inhalation is respiratory distress / inj. Lasix if creps +

C . Dopamine bp less than SBP 90 / FLIUD correction if dehydration

o Inj . sedil 1amp iv stat and then

o Tab. Diphedan 100mg

A ..clear away with suction if secretion

B . O2 inhalation is respiratory distress / inj. Lasix if creps +

C . Dopamine bp less than SBP 90 / FLIUD correction if dehydration

Inj. Normal saline 1000 ml

Inj. Osmosol 500 ml

o Tab. Diphedan 100mg

Chang posture 2 hrly

Diet --- normal

Inj. Hartman 1000ml

Inj. Moxin 500 mg