Practical Standard Prescriber, 7th Edition

Practical Standard
Prescriber
Practical Standard
Prescriber
Seventh Edition
LC Gupta MD FAMS DSc (Hon)
Kusum Gupta PhD (Hon)
Abhitabh Gupta MD DMRE
New Delhi, India
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Practical Standard Prescriber
2009, LC Gupta, Kusum Gupta, Abhitabh Gupta
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First Edition:
Sixth Edition:
Reprint :
Seventh Edition:
1984
2001
2002, 2004, 2005, 2007
2009
ISBN 978-81-8448-550-9
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd. NOIDA
To
Revered Sh RC Lahoti
Ex-Chief Justice of India
who helped and guided us
at every turning point of life
Contributors
Abhishek Gupta MD DRM DNB MNAMS
DIFI Centre, New Delhi
Jawahar Jain MBBS MBA DSc (Hon)
Delhi University
Lakhpat Lodha MD
Medical College, Jodhpur
PK Pande MD
LNPPI, Gwalior
Parul Gupta MBBS
Jhansi
Preeti Gupta MBBS DGO
Gwalior
Priya Verma MDS
New Delhi
Puneet Rastogi MD DM
Medical College, Gwalior
Sekhar Jaiswal MBBS
Srinagar
Sheevi Rastogi MBBS DGO
Gwalior
Sujata MS Mch DNB
Safdarjung Hospital, New Delhi
Vandna Mangal MD
Medical College, Jaipur
Preface to the Seventh Edition

This revised seventh edition of Practical Standard
Prescriber, owes to the popular demand of students,
residents and general practitioners. Jaypee Brothers
Medical Publishers (P) Ltd. is proud to present this in its
continuing efforts to serve the medical profession.
Treatment part has been totally revised and updated.
Certain new diseases have also been included.
LC Gupta
Kusum Gupta
Abhitabh Gupta
Preface to the First Edition

The drug world is expanding at a very fast pace. New
drugs are continuously being added and obsolete ones
are withdrawn. Age old regimens which once enjoyed
mass acceptance and reputation are being replaced with
newer concepts. A busy practitioner or a new incumbent
to the profession should keep himself abreast of these
developments and reorient himself to the changing
circumstances. Drug resistance is frequently being
encountered and is the main cause of treatment failure.
In this small work, attempt has been made to enumerate
the standard drugs to be prescribed for a particular
disease. In case of intolerance or drugs resistance,
alternative regimens are also inserted. However, the
choice of drugs depends upon the treating physician.
Over prescription is certainly to be avoided and drug
abuse is to be kept at minimum.
Doctor shopping is a common feature of the present
time. Readymade prescription is available across the
counter from mini modified doctors and there is no
need to present the patient before the doctor. Such a
trend is certainly hazardous.
Correct dosage, duration of therapy, contraindications, adverse reactions, drug interactions, side
effects and toxicity should be kept in mind while writing
a prescription. The economic status of the patient and
xii
his occupation should be given due consideration.

Ailments which are otherwise innocuous and selflimiting should be handled tactfully. For reaching at a
correct diagnosis, the cardinal symptoms, signs,
pathologic and laboratory findings are also incorporated
in this book. However, correct diagnosis is left to
ingenuity of the prescriber.
In a developing country where many people are
below poverty line with high illiteracy rate, one may
find it extremely difficult to afford costly medicines for
miraculous cure, or discriminate between safe and
dangerous drugs. They wholly and fully depend upon
the prescriber who may be a doctor, a quack or a friend.
Under such circumstances the cheap, effective and
harmless medicines are to be tried first rather than
jumping to the newer and less known products.
Aggressive marketing and unabated advertising
through mass media by some drug manufacturers to
push their product creates confusion and dilemma in
the minds of innocent consumers. Some products
without a rational basis become the household remedy
and every home possess them. Such practice is certainly
detrimental to the ethics of medical profession.
LC Gupta
Contents
Contents
xiii
GASTROINTESTINAL DISEASES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Achalasia Cardia ..................................................... 1

Acute Cholecystitis ................................................ 2
Acute Gastritis ........................................................ 3
Acute Mesenteric Lymphadenitis ....................... 4
Acute Mesenteric Vascular Occlusion ................. 5
Acute Organic Small Bowel Obstruction ............ 6
Acute Pancreatitis .................................................. 7
Alcoholic Hepatitis ................................................. 8
Amoebiasis ............................................................ 10
Anal Fissure .......................................................... 11
Aphthous Stomatitis ............................................ 12
Appendicitis .......................................................... 13
Bacillary Dysentery ............................................. 15
Botulism ................................................................. 16
Cancer Colon ........................................................ 17
Cancer Oesophagus ............................................ 17
Candidiasis (Thrush) ........................................... 18
Carcinoma of Liver ............................................. 19
Carcinoma of Stomach ....................................... 20
Choledocholithiasis ............................................. 21
Cholera .................................................................. 22
Chronic Cholecystitis .......................................... 23
Chronic Gastritis .................................................. 24
Constipation ......................................................... 25
xiv Practical Standard Prescriber
25. Diverticular Disease of Colon (Diverticulosis) 26

26. Dumping Syndrome
(Post-Gastrectomy Syndrome) .......................... 27
27. Duodenal Ulcer ..................................................... 28
28. Gastric Ulcer .......................................................... 30
29. Haemorrhoids ...................................................... 31
30. Herpetic Stomatitis .............................................. 32
31. Hiccup .................................................................... 33
32. Intestinal Tuberculosis ........................................ 34
33. Irritable Bowel Syndrome .................................. 35
34. Nausea and Vomiting ......................................... 37
35. Nodular Cirrhosis ................................................ 39
36. Non-Specific Ulcerative Colitis .......................... 41
37. Paralytic Ileus (Functional Obstruction) .......... 44
38. Peptic Oesophagitis ............................................. 45
39. Primary Biliary Cirrhosis .................................... 46
40. Rectal Polyp .......................................................... 47
41. Regional Enteritis (Crohns Disease) ................ 48
42. Secondary Biliary Cirrhosis ................................ 49
43. Sprue Syndrome (Tropical Sprue) .................... 50
44. Typhoid Fever ...................................................... 51
45. Upper Gastrointestinal Haemorrhage ............. 52
46. Vincents Stomatitis ............................................. 53
47. Viral Hepatitis (Infectious Hepatitis) ................ 54
48. Wilsons Disease ................................................... 55
49. Zollinger-Ellison Syndrome ............................... 56
Contents
xv
RESPIRATORY DISEASES
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
Acute Bronchitis ................................................... 58

Adult Respiratory Distress Syndrome ............. 59
Atelectasis .............................................................. 60
Atypical Pneumonia
(Mycoplasma Pneumonia) ................................. 62
Bronchial Adenoma ............................................. 63
Bronchial Asthma ................................................. 63
Bronchiectasis ....................................................... 67
Bronchiolar Carcinoma ....................................... 69
Broncho-Pneumonia ........................................... 70
Chronic Bronchitis ............................................... 71
Emphysema .......................................................... 73
Empyema .............................................................. 75
Haemoptysis ......................................................... 76
Haemothorax ....................................................... 77
Hydrothorax ......................................................... 78
Lobar Pneumonia ................................................ 78
Lung Abscess ........................................................ 80
Mediastinal Tumour ............................................ 82
Pleural Effusion .................................................... 83
Pulmonary Oedema ............................................ 85
Pulmonary Thromboembolism ........................ 86
Pulmonary Tuberculosis ..................................... 89
Sarcoidosis ............................................................. 94
Spontaneous Pneumothorax ............................. 95
Tension Pneumothorax ...................................... 96
xvi Practical Standard Prescriber
75. Traumatic Pneumothorax .................................. 97

76. Viral Penumonia .................................................. 97
HEART DISEASES
77.
78.
79.
80.
81.
82.
Angina Pectoris ..................................................... 99

Heart Disease ...................................................... 102
Hypertension ...................................................... 104
Myocardial Infarction ........................................ 109
Rheumatic Fever ................................................ 114
Sub-Acute Bacterial Endocarditis ..................... 117
SKIN DISEASES
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
Acne Vulgaris ...................................................... 121

Allergic Contact Dermatitis .............................. 122
Bed Sores ............................................................. 123
Boil ........................................................................ 124
Contact Dermatitis ............................................. 125
Dermatophytosis ................................................ 126
Discoid Lupus Erythematosus .......................... 127
Eczema ................................................................. 127
Erythema Multiforme ........................................ 129
Erythema Nodosum .......................................... 130
Exfoliative Dermatitis ........................................ 130
Folliculitis ............................................................. 131
Gonorrhoea ......................................................... 132
Herpes Simplex ................................................... 133
Contents
97.
98.
99.
100.
101.
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
xvii
Herpes Zoster ..................................................... 134

Impetigo .............................................................. 135
Infantile Eczema ................................................. 136
Lichen Planus ...................................................... 136
Malignant Melanoma ......................................... 137
Miliaria ................................................................. 138
Pediculosis ........................................................... 138
Pemphigus ........................................................... 139
Psoriasis ............................................................... 140
Ringworm ........................................................... 142
Scabies .................................................................. 143
Seborrhoeic Dermatitis ...................................... 144
Syphilis ................................................................. 145
Tinea Versicolor .................................................. 146
Urticaria ............................................................... 147
Venous Insufficiency Leg Ulcer ........................ 148
Warts .................................................................... 149
PSYCHIATRIC DISEASES
114.
115.
116.
117.
118.
119.
120.
Anxiety ................................................................. 151

Depression ........................................................... 152
Hysteria ............................................................... 154
Phobic Reaction .................................................. 155
Psychopath .......................................................... 155
Psychosis .............................................................. 156
Schizophrenia ...................................................... 158
xviii
GYNAECOLOGICAL DISORDERS
121.
122.
123.
124.
125.
126.
127.
128.
129.
130.
131.
132.
133.
134.
135.
136.
137.
138.
139.
Amenorrhoea ..................................................... 161

Cancer Cervix ..................................................... 162
Carcinoma of Body of Uterus .......................... 163
Cervicitis .............................................................. 164
Delaying Menstruation ...................................... 165
Dysfunctional Uterine Bleeding ....................... 166
Dysmenorrhoea ................................................. 167
Habitual Abortion .............................................. 168
Hypermesis Gravidarum .................................. 169
Incomplete Abortion ......................................... 170
Inevitable Abortion ............................................ 170
Leucorrhoea ........................................................ 171
Menopause .......................................................... 172
Monilial Vaginitis ................................................ 173
Premenstrual Tension ........................................ 174
Senile Vaginitis .................................................... 175
Threatened Abortion ......................................... 176
Trichomonas Vaginitis ....................................... 177
Vaginitis ............................................................... 178
EAR AND NOSE DISEASES
140.
141.
142.
143.
Acoustic Neuroma ............................................. 179

Acute Otitis Media ............................................. 180
Cholesteatoma ................................................... 181
Chronic Simple Otitis Media ............................ 182
Contents xix
144.
145.
146.
147.
148.
149.
150.
151.
152.
Deafness .............................................................. 183

Deviated Nasal Septum .................................... 184
Diseases of Nose ................................................ 185
Ear Diseases ........................................................ 186
Epistaxis ............................................................... 187
Localized Otitis Externa .................................... 188
Secondary Otitis Media ..................................... 189
Vertigo ................................................................. 189
Vertigo Due to Menieres Disease .................. 189
EYE DISORDERS
153.
154.
155.
156.
157.
158.
159.
160.
Acute Glaucoma ................................................. 191

Cataract ............................................................... 192
Conjunctival Discharge ..................................... 193
Conjunctivitis ...................................................... 195
Corneal Ulcer ...................................................... 196
Detachment of Retina ....................................... 197
Iritis ....................................................................... 198
Redness of Eye ................................................... 199
DISEASES OF CHILDREN
161.
162.
163.
164.
165.
Acute Rheumatic Fever .................................... 201

Anaemia .............................................................. 203
Aortic Stenosis .................................................... 204
Aortic Regurgitation ......................................... 204
Bronchopneumonia ........................................... 205
xx
166.
167.
168.
169.
170.
171.
172.
173.
174.
175.
176.
177.
178.
179.
180.
181.
Chicken Pox ........................................................ 206

Congenital Syphilis ............................................ 208
Dengue ................................................................. 208
Diphtheria ........................................................... 209
Indian Childhood Cirrhosis ............................. 211
Infantile Diarrhoea ............................................ 212
Kwashiorkor ....................................................... 213
Marasmus ............................................................ 214
Measles ................................................................ 215
Mitral Regurgitation .......................................... 217
Mitral Stenosis .................................................... 217
Mumps ................................................................. 218
Poliomyelitis ....................................................... 219
Rickets .................................................................. 221
Scurvy .................................................................. 222
Whooping Cough .............................................. 222
MEDICAL EMERGENCIES
182.
183.
184.
185.
186.
187.
188.
189.
190.
Acute Alcohol Intoxication ............................... 224

Acute Morphine Poisoning .............................. 225
Acute Respiratory Failure ................................ 226
Acute Retention of Urine .................................. 228
Agranulocytosis ................................................. 229
Anaphylactic Shock ........................................... 230
Arsenic Poisoning .............................................. 230
Barbiturate Poisoning ....................................... 231
Bee Sting .............................................................. 233
Contents xxi
191.
192.
193.
194.
195.
196.
197.
198.
199.
200.
201.
202.
203.
204.
205.
206.
207.
208.
Burns .................................................................... 234

Cardiac Arrest .................................................... 235
Cardiogenic Shock ............................................. 237
Dehydration ........................................................ 237
Dhatura Poisoning ............................................. 238
Drowning ............................................................ 239
Ectopic Pregnancy ............................................. 240
Frost Bite ............................................................. 241
Hypoglycemia .................................................... 241
Hypothermia ...................................................... 243
Injuries to Vulva, Vagina .................................. 243
Poisoning ............................................................. 244
Profuse Vaginal Haemorrhage ....................... 245
Renal Colic .......................................................... 246
Snake Bite ............................................................ 247
Spontaneous Pneumothorax ........................... 249
Suicidal Behaviour ............................................. 250
Transfusion Reactions ....................................... 251
MISCELLANEOUS
209.
210.
211.
212.
213.
214.
Acute Leukemia ................................................. 252

Addisons Disease .............................................. 255
AIDS ..................................................................... 256
Chronic Lymphatic Leukemia ......................... 257
Chronic Myeloid Leukemia ............................. 258
Congestive Cardiac Failure .............................. 259
xxii
215.
216.
217.
218.
219.
220.
221.
222.
223.
224.
225.
226.
227.
228.
229.
230.
231.
232.
233.
234.
Diabetes Insipidus .............................................. 260

Diabtetes Mellitus .............................................. 261
Diabetic Ketoacidosis ........................................ 263
Filaria ................................................................... 264
Heatstroke .......................................................... 265
Hodgkins Disease ............................................. 266
Hookworm Infestation ..................................... 267
Hyperkalemia ..................................................... 268
Lactic Acidosis ..................................................... 269
Left Ventricular Failure ..................................... 270
Malaria ................................................................. 271
Multiple Myeloma .............................................. 272
Myasthenia Gravis ............................................. 273
Nephrotic Syndrome ........................................ 274
Non Hodgkins Lymphoma ............................ 275
Obesity ................................................................. 276
Organophosphorus Poisoning ........................ 277
Roundworm ....................................................... 278
Tapeworm Infestation ...................................... 279
Threadworm ....................................................... 280
GENERAL INFORMATION
235. Immunisation ...................................................... 282

236. Weights and Measures ...................................... 282
Contents
xxiii
DIET THERAPY
237.
238.
239.
240.
241.
242.
243.
244.
245.
246.
247.
248.
Diabetes Mellitus ................................................ 288

Diarrhoea and Dysentery ................................. 292
Gout ...................................................................... 293
Hypertension ...................................................... 294
Infective Hepatitis .............................................. 295
Ischemic Heart Disease ..................................... 297
Kwashiorkor and Marasmus ........................... 298
Nephrotic Syndrome ........................................ 300
Obesity ................................................................. 301
Peptic Ulcer ......................................................... 303
Some of Available Drugs .................................. 304
Underweight ....................................................... 330
BLOOD COUNT
249. Normal Blood Count ......................................... 332

250. Red Cell Morphology ........................................ 339
BLOOD BIOCHEMISTRY
251. Blood Biochemistry ............................................ 354
CEREBROSPINAL FLUID
252. Cerebrospinal Fluid ........................................... 380
xxiv
GLUCOSE TOLERANCE TEST

253. Glucose Tolerance Test ...................................... 390
BONE MARROW ASPIRATION
254. Bone Marrow Aspiration .................................. 393
RENAL FUNCTION TESTS
255. Renal Function Tests .......................................... 398
LIVER FUNCTION TESTS
256. Liver Function Tests ........................................... 400
FUNDUS EXAMINATION
257. Changes of Fundus in Different Diseases ....... 416
RENAL SYSTEM
258.
259.
260.
261.
262.
263.
Acute Giomerulonephritis ................................ 422

Acute Nephritic Syndrome ............................... 423
Acute Pyleonephritis .......................................... 424
Acute Renal Failure ............................................ 425
Benign Prostatic Hyperplasia ........................... 426
Chronic Renal Failure ........................................ 427
Contents
xxv
264. Neurogenic Bladder ........................................... 428

265. Obstructive Uropathy ........................................ 429
266. Uraemia ............................................................... 430
NEUROLOGICAL DISEASES
267.
268.
269.
270.
271.
272.
273.
274.
275.
276.
277.
278.
279.
280.
281.
282.
283.
284.
285.
286.
287.
Bells Palsy ........................................................... 432

Brachial Neuralgia .............................................. 433
Broadmans Areas of Brain ............................... 433
Cerebral Stroke .................................................. 434
Cervical Rib Syndrome ..................................... 435
Cluster Headache ............................................... 436
Common Headache ........................................... 437
Epilepsy ................................................................ 437
Infective Polyneuritis ......................................... 440
Intracerebral Haemorrhage ............................. 441
Intracranial Tumours ......................................... 442
Meningitis ............................................................ 443
Migraine ............................................................... 444
Multiple Sclerosis ................................................ 445
Parkinsons Disease ............................................ 445
Polyneuropathy .................................................. 446
Raised Intracranial Tension ............................... 447
Sciatica .................................................................. 448
Subarachnoid Haemorrhage ............................ 449
Stroke ................................................................... 449
Tension Headache .............................................. 451
xxvi
288. Transient Ischaemic Attacks ............................. 451

289. Trigeminal Neuralgia ......................................... 452
HAEMATOLOGY
290.
291.
292.
293.
294.
295.
Acquired Aplastic Anaemia .............................. 454

Constitutional Aplastic Anaemia ..................... 455
Haemophilia-A ................................................... 455
Hodgkins Disease .............................................. 456
Thalassemias ....................................................... 457
Polycythemia Rubravera .................................. 458
ORAL DISEASES
296.
297.
298.
299.
300.
301.
302.
Acute Necrotizing Ulcerative Gingivitis ......... 460

Bad Breath (Halithosis) ...................................... 461
Dental Caries ....................................................... 461
Hand, Foot and Mouth Disease ....................... 462
Recurrent Aphthous Stomatitis ........................ 463
Sharp Stabbing Pain ........................................... 464
Xerostomia .......................................................... 465
DISEASES OF BONES AND JOINTS
303.
304.
305.
306.
Acute Osteomyelitis ........................................... 466

Ankylosing Spondylitis ..................................... 467
Goutyarthritis ..................................................... 468
Osteoartheritis .................................................... 469
Contents
xxvii
307. Psoriatic Arthritis ................................................ 471

308. Rheumatoid Arthritis ......................................... 472
309. Tuberculosis of Bone Joints ............................... 474
APPENDIX
310.
311.
312.
313.
314.
315.
316.
317.
Expenditure of Calories/Hour ........................ 476

Food and Nutrition ........................................... 476
Important Sources of Cholesterol mg/100 gm ... 478
Important Sources of Fat .................................. 478
Important Sources of Iron mg/100 gm ......... 479
Important Sources of Proteins gm/100 gm .. 479
Showing Approximate Values ......................... 480
Table of Food Value/100 gm ........................... 480
GASTROINTESTINAL DISEASES
ACHALASIA CARDIA
Essentials of Diagnosis
Dysphagia, initially intermittent with food apparently sticking at the level of xiphoid cartilage, associated with retrosternal discomfort.
Regurgitation immediately following ingestion and
delayed regurgitation in chronic cases.
Cough and dyspnoea due to pressure of dilated
oesophagus on trachea and bronchi.
Aspiration of material to tracheobronchial tree may
cause bronchiectasis, lung abscess or pulmonary
fibrosis.
X-ray shows conical tapering of distal oesophagus
and fluoroscopy shows ineffectual and purposeless
peristalsis with dilatation.
Treatment
Anticholinergics to relieve spasm of oesophagus.
Tab Probanthine or Buscopan, one tablet thrice

daily hour before meals.
Nifedipine 10 mg thrice daily is beneficial.
2 Practical Standard Prescriber

To avoid irritant substances like salicylates.
NSAIDs. Alcohol, spicy food, gulping of food and

swallowing unchewed food particles should be
avoided.
Avoid lying down for 2-3 hours after taking food.
Oesophageal dilatation using pneumatic bag
under fluoroscopic guidance.
Oesophago-cardio-myotomy may be required in a
few cases.
ACUTE CHOLECYSTITIS
Constant, severe pain and tenderness in right hypochondrium or epigastrium.
Nausea, vomiting, fever, chills.
Jaundice.
Leucocytosis.
Positive Murphys sign.
Plain X-ray shows gallstones in 15 per cent cases.
Treatment
Rest in bed.
Nothing to be taken orally.
IV fluids 5 per cent Dextrose/ringer solution.
Gastrointestinal Diseases
Analgesics/sedatives like Fortwin 30 mg slow IV
or IM or Phenargan (Morphine is contraindicated

as it causes spasm of sphincter of oddi).
Antibiotics are needed.
Injection Ampicillin 500 mg, 6 hourly IV or IM
and injection Gentamycin 60 mg 12 hourly IV
or IM
and injection Metrogyl 100 mg 8 hourly IV
Injection B complex 2 ml IM or IV on alternate day
Once acute attack subsides allow fat free liquid diet
and later on fat free soft diet may be taken.
Surgery is indicated if
Patient develops peritonitis.
Failure of medical treatment for 48 hours.
Operative
If conservative treatment fails to bring relief or the pain,
tenderness and systemic sysmptoms are aggravated
indicating perforation/gangrene-immediate cholecystectomy is advised. Elective cholecystectomy is performed in those who respond to conservative treatment.
ACUTE GASTRITIS
Anorexia, epigastric fullness, nausea.
Diarrhoea, colic, haematemesis, fever, chills, headache and malaise are common when caused due to
toxins or infections.
Epigastric tenderness present.
Endoscopy differentiates acute simple gastritis from
erosive gastritis, peptic ulcer or a mucosal laceration
(Mallory-Weiss syndrome).
Treatment
Bed rest.
Bland soft diet.
Mucaine gel or digene gel 2 tsf thrice daily after
meals.
Tab Ranitidine 150 mg twice daily or Ramotidine
20 mg twice daily.
Tab Probanthine twice daily.

Tab Sucralfate 1 gm tds if NSAIDs induced
erosions.
Specific antidotes for corrosive poisons.

Treat infective cause if any.
ACUTE MESENTERIC
LYMPHADENITIS
Acute pain around umbilicus or right iliac fossa in a
child.
Anorexia, nausea, vomiting, fever.

Tenderness in right iliac fossa without any signs of
peritoneal irritation.
Marked leucocytosis.
History of recent or current upper respiratory
infection.
Treatment
Rest and soft nutritious diet.
Broad spectrum antibiotic preferably Amoxicillin
1 tds for 7 days.
ACUTE MESENTERIC
VASCULAR OCCLUSION
Severe abdominal pain, nausea, fecal vomiting and
bloody diarrhoea.
Severe prostration and shock.
Abdominal distention, tenderness, rigidity.
Leucocytosis and haemoconcentration.
Treatment
1. Restoration of fluid, electrolyte and colloid balance.
2. Decompression of the bowel.
3. Heavy doses of broad spectrum antibiotics to
prevent sepsis.
Laparotomy should be done as soon as possible and

gangrenous bowel is to be resected. Embolectomy
and thrombectomy may be possible if there is isolated
thrombus/embolus in a major artery. Anticoagulants
are not indicated.
ACUTE ORGANIC SMALL

BOWEL OBSTRUCTION
Colicky abdominal pain, vomiting, constipation
borborygmus.
Tender distended abdomen.
Audible peristalsis.
X-ray evidence of gas or multiple gas and fluid
levels without movement of gas.
Little or no leucocytosis.
Treatment
Supportive measures
a. Decompression by nasogastric suction.
b. Correction of fluid, electrolyte and colloid deficit.
c. Broad spectrum antibiotic if strangulation is
suspected (i.e. Gentamicin/Ampicillin IM/IV
Metrogyl)
Surgical measures are indicated in

Fever, leucocytosis, abdominal rigidity/ascites,
blood in the faeces means strangulation and

immediate surgery is essential.
If in an uncomplicated case with adequate decompression pain does not subside and flatus does not
pass, operation is inevitable. Surgery consists of
relieving the obstruction and removal of gangrenous bowel with reanastomosis.
ACUTE PANCREATITIS
Sudden, severe epigastric pain with radiation to back
in an alcoholic or in those with known biliary disease.
Fainting attacks, sweating, vomiting.
Fever, leucocytosis, paralytic ileus in some patients.
Elevated serum and urinary amylase and lipase.
History of previous episodes specially after dietary
excesses.
Treatment
Nil orally. Fluid and electrolyte balance to be
maintained.
Several litres of IV fluid replacement as patient is
invariably dehydrated.

Continuous gastric suction to reduce vomiting and
distension of gut.
For pain, injection Pethidine 100 mg IM or
Morphine 15 mg IM.
Injection Atropine 0.6 mg IM or injection Proban-
theline 15-30 mg six hourly to reduce gastric, duodenal and pancreatic secretion and to relieve spasm
of sphincter of oddi.
Antibiotics for secondary infectionInjection
Ampicillin 500 mg 6 hourly and Gentamycin 60-80
mg eight hourly.
Calcium gluconate 10 per cent as 10 ml slow IV
twice or thrice if serum calcium is low.
Liquid Gelucil or Divol or Siloxagen one table
spoonful hourly through Ryles tube.
If respiratory distress then oxygen.
ALCOHOLIC HEPATITIS
Anorexia, nausea, abdominal discomfort in a
patient after a recent period of heavy drinking.
Tender hepatomegaly and often jaundice.
Fever, splenomegaly, ascites, encephalopathy, abdominal pain and tenderness when present, further
support the diagnosis.
Elevated serum alkaline phosphatase. (Rarely more
than three times of normal value). Increased SGOT,
serum bilirubin, elevated serum globulin and
depressed albumin.
Liver biopsy is confirmatory.
Treatment
Avoid alcohol.
Hydration is to be maintained by oral fluids or IV
supplementation.
Vitamin K for elevated prothrombin time as 10 mg
IM.
Vitamin B supplementation especially thiamine
and folic acid.

Low dose steroids to be used only if everything
else fails.
If patient has severe dehydration elevated proth-
rombin time (> 1.5 times of normal), intractable

nausea or vomiting, marked rise of bilirubin, hepatic encephalopathy, azotemia person may require
hospitalisation.
AMOEBIASIS
Intestinal Amoebiasis
Frequent passage of loose offensive stool, often
mixed with blood and mucus.
Abdominal cramps.
Gaseous distention, vague abdominal pain often
with insomnia and depression.
A sensation of incomplete clearance of bowel even
after frequent stool.
Frequent stools with offensive gangrenous sloughs,
dark blood, pus, prostration and dehydration in fulminant cases.
Constipation alternating with diarrhoea, tender palpable descending and sigmoid colon in chronic cases.
Haematophagous amoebas in stool are diagnostic,
cysts in the stool are evidence of quiescent infection.
Sigmoidoscopy shows flask shaped ulcers, raised
button like ulcers or mouse eaten appearance.
Treatment
Acute
Tab Metrogyl 800 mg tds for 5 days (children 50
mg/kg/day in three divided doses).
or
11
Tinidazole 2 gm/day for 5 days.

or
Tab Secnidazole 2 gm as single dose.
or
Diloxamide furoate 500 mg plus Metrogyl 400 mg
tds for 5 days
or
Tab Furamide 500 mg tds for 10 days.
For abdominal pain Tab Buscopan or Capsule Spasmoproxyvon bd or tds.
In dehydration IV fluids may be given.
Chronic Amoebiasis
Tab Diloxamide Furoate 500 mg tds 10 days.
or
Tab Furamide 500 mg tds 10 days.
or
Dependal-M 1 tds 10 days.
In amoebic hepatitis and liver abscess same
treatment is to be given.
ANAL FISSURE
1. Acute pain during and after defecation.
2. Bright red blood with stool.
3. Tendency for constipation due to fear of pain.
Treatment
Mineral oil and stool softners daily. Mild laxative-
Syp Cremaffin 2-3 tea spoon hs.
Anal suppositories twice daily.

Local application of Gentian violet 1 per cent Xylo-
caine 4 percent jelly locally 1/2 hour before passing

stools or sos.
Anal dilatation.
Surgical excision if all above measures fail or
recurrence occurs.
APHTHOUS STOMATITIS
Shallow ulcers with erythematous base, covered with
pseudomembrane (greyish exudate).
Often painful and usually recurrent.
May be associated with inflammatory bowel disease,
prolonged fevers, infectious mononucleosis history
of emotional stress.
Treatment
Avoid spices, tobacco, hot food.
Bland diet.
Good oral hygiene.
Aqueous Chlorhexidine 0.2 per cent mouth wash.
13
Efcorlin pellets (glaxo) allow pellet to dissolve in
close proximity to ulcer 3-4 times daily.

or
Trimonalone 0.1 per cent in dental paste apply as
thin coating to ulcer thrice a day.
Tetracycline or Mystecline capsule 250 mg, dissolve
one capsule in water and rinse mouth 3 times a
day.
Glycerine or Zytee for topical application.
If pain tablet Paracetamol 1 tds.
Patient to be reviewed within 3 weeks to ensure
healing has occured otherwise ulcer must be
biopsied.
APPENDICITIS
Pain and tenderness in right iliac fossa with signs of
peritoneal irritation (muscle guard and +ve
Rovsings sign).
Low grade fever, vomiting, constipation.
Polymorphonuclear leucocytosis.
Rectal tenderness is common in pelvic appendicitis;
psoas and obturator signs are positive. X-ray abdomen shows radiopaque shadow consistent with
faecolith in the appendix area.
In infants and aged the prodromal symptoms as well

as localised signs are minimum until perforation
occurs.
Tender mass in the iliac fossa with continuous
fever, malaise, toxicity and marked leucocytosis
indicate appendicular abscess. Pelvic abscess tends
to protrude into vagina/rectum.
Septic fever, chills, hepatomegaly and jaundice with
appendicitis indicate appendicular perforation,
pyelophlebitis.
Treatment
Complete bed rest.
Nothing orally.
Laxatives and narcotics are absolutely contraindicated.
IV glucose saline.
Nasogastric intubation with gastric lavage.
Inj Ampicillin 500 mg 6 hourly IV, Inj Gentamycin
80 mg IM 8 hourly, Inj Metrogyl 1 g 8 hourly IV.
Appendicectomy within 48 hrs.
Surgical
In uncomplicated cases appendicectomy is performed
as soon as fluid imbalance and systemic disturbances
are controlled.
15
Appendicular Mass
Conservative
Bed rest.
Fluid diet.
Record temperature, pulse and size of mass.
If mass enlarges and pyrexia continues then drain
the abscess.
Appendicectomy after 3 months of resolution of
mass.
BACILLARY DYSENTERY
Frequent stools with blood and mucous (Red currant
jelly).
Abdominal cramps.
Fever, malaise and prostration.
Pus in stool.
Organisms isolated on stool culture.
Treatment
Correct dehydration IV fluids or Electral powder
orally.
Ampicillin 500 mg 6 hourly.
or
Septran DS 1 tablet twice daily.
or
Nalidixic acid 1 gm 6 hourly.

or
Tetracycline 500 mg 6 hourly.
Antispasmodics if needed.
BOTULISM
Sudden onset of diplopia, dry mouth, dysphagia,
dyspnoea, cranial nerve paralysis, muscle weakness
progressing to respiratory paralysis.
History of recent ingestion of home canned or unusual foods.
Toxin demonstrated in the food by mouse innoculation and identified with specific antisera.
Treatment
Stomach wash if diagnosed early.
ABC botulinus anti-toxin.
Maintenance of oxygenation and ventilation by
good respiratory drainage (elevation of foot end)

aspiration or tracheostomy and mechanical
respiration if necessary.
Parenteral fluids.
Antibiotics if pneumonitis develops.
17
CANCER COLON
Blood in the faeces, anaemia, asthenia.
Palpable colonic mass (especially in ascending
colon).
Altered bowel function, i.e. progressively increasing
constipation (left colon) or diarrhoea.
Sigmoidoscopic and X-ray evidence of the
neoplasm.
Treatment
Surgical resection of the lesion and its regional
lymphatics after adequate bowel preparation in

early cases.
In late cases with invasion or obstruction palliative
resection.
Preoperative irradiation 2000 to 2500 R, in 10 sittings over 12 days increases resectability and improves survival.
CANCER OESOPHAGUS
Progressive dysphagia even to liquids.
Anaemia, weight loss.
Chest painUnrelated to eating implies local extension of tumour.

Barium swallow shows irregular, frequently annular
space occupying lesions.
Treatment
Irradiation is best, if upper half of oesophagus is
involved.
In absence of metastasis, tumours of lower half may
be treated by resection and oesophago-gastrostomy

or jejunal or colonic interposition. Gastrostomy for
palliation in hopeless cases may be done to improve
nutrition. Cure rate in best hands is only 5 to 10
per cent.
CANDIDIASIS (THRUSH)
Creamy-white curd like patches surrounded by
erythema.
Pain, fever and lymphadenopathy in some cases.
Treatment
Saturated solution of sodabicarb for mouth wash.
One per cent gentian violet to be painted three times
daily on the patches.
19
Nystatin tablet or Mycostatin tablet dissolved in
Glycerine and applied locally and oral Nystatin

500,000 units three times daily or Nystatin mouth
wash.
or
Tab Ketoconazole 200 mg tds.
Chronic candiasis
Oral lesions may respond only to IV Amphotericin
with or without Fluconazole or Ketoconazole.
CARCINOMA OF LIVER
1. Hard, enlarged, tender liver with or without palpable
nodules.
2. Symptoms of long-standing cirrhosis with sudden
deterioration in the condition of the patient.
3. Bloody ascites.
Anaemia, cachexia, hepatic bruit or friction rub.
Primary site of malignancy (stomach), colon or
other parts of GI tract.
Alfa-foetoprotein positive in 50 per cent case of
hepatoma.
Ultrasound and CT scan.
Liver scanning with 99mTc. Sulfur colloid and liver
biopsy are confirmatory.
Treatment
Cytotoxic drugs, irradiation or surgery have not
proved effective.
When benign or malignant hepatic neoplasms are
encountered in ladies taking oral contraceptives,

discontinuation of contraceptives may cause
regression of benign tumours (i.e. focal nodular
hyperplasia).
Alcohol injection into tumour.
CARCINOMA OF STOMACH
Anaemia, asthenia and anorexia in patients over 40
years of age.
Palpable abdominal mass.
Occult blood in stool.
Gastroscopic and X-ray abnormality with positive
cytological examination.
The less common manifestations include postprandial distress simulating peptic ulcer and
diarrhoea due to associated achlorhydria. Enlarged
Virchows (left supraclavicular) nodes, Krukenbergs
tumour in female, enlarged hard nodular liver,
ascites, pelvic mass and pathological fractures denote
metastasis.
21
Radiological findings vary according to the type of

lesion, i.e. ulcerative, polypoid, infiltrating or combinations. The findings can be summarised as:
Ulcer more than 1 cm in diameter.
Annular narrowing near pylorus or in fundus.
Pyloric elongation, narrowing or rigidity.
Diffuse fibrosis (linitis Plastica).
Hyper rugosity.
Treatment
If distant metastasis is present palliation with radia-
tion therapy, with 5 fluorouracil, gastroenterostomy or palliative resection can prolong life.
If the tumour is localised to stomach sub-total
gastrectomy is the standard treatment.
CHOLEDOCHOLITHIASIS
Sudden, severe, right upper quadrant abdominal
pain radiating to scapula.
Nausea, vomiting, fever, jaundice, leucocytosis.
History of such recurrent attacks persisting for hours.
Chills with gram-ve shock in cases of acute suppurative cholangitis.
Enlarged tender liver in some cases.
Laboratory investigations show features of obstructive jaundice with hypoprothrombinemia.
Treatment
Cholecystectomy and choledochostomy.
Basketting and ECSWL.
CHOLERA
Sudden onset of explosive diarrhoea.
Stool if grey, turbid without any faecal odour, blood
or pus (rice water stool).
Rapid development of dehydration, acidosis, hypokalaemia, hypotension.
Positive stool culture and agglutination of vibrios
with specific sera.
Fever is absent but vomiting may coexist.
Treatment
Oral solution consists of
Pot chloride
Glucose
Water up to
1.5 gram
20 mg
1 litre
or
Sodium chloride
5 gram
Glucose
Water up to
23
20 gram
1 litre
Antibiotics
Tetracycline 500 mg 6 hourly for 5 days.
or
Chloramphenicol 500 mg 6 hourly.
or
Doxycycline 100 mg daily.
or
Ofloxacin 200 mg 12 hourly, Dehydration is to be
compensated.
CHRONIC CHOLECYSTITIS
History of frequent attacks of biliary colic (i.e. right
upper quadrant abdominal pain referred to right
scapula).
Flatulant dyspepsia with fatty food intolerance.
Non-functioning gall bladder on IV cholecystography or presence of gallstones.
Treatment
Cholecystectomy.
CHRONIC GASTRITIS
Asymptomatic or vague non-descriptive upper
abdominal distress.
Mild epigastric tenderness or no physical findings
whatsover.
Ulcer or cancer like syndrome, often with gross haematemesis.
Gastroscopy shows mucosal atrophy as evidenced
by visualisation of blood vessels through mucosa.
Biopsy shows varying degrees of atrophy and infiltration of lamina propria with lymphocytes and
plasma cells.
Treatment
For atrophic gastritis causing B12 malabsorption and
pernicious anaemia Injection vitamin B12
Anti-ulcer regimen, i.e. antacid, anticholinergic, H2
receptor blockers and mild tranquilizer.
For achlorhydria 1 to 2 tsf of dilute HCl in fruit
juice sipped with meals.
Avoidance of alcohol, tobacco, spices and hot foods.
25
CONSTIPATION
Patient should be considered to be constipated only if
defaecation is explainably delayed for days or if stools
are unusually hard, dry, and difficult to expel. Causes
of constipation are:
Dietary factors-highly refined or low fibre foods,
inadequate fluids.
Physical inactivity, inadequate exercise and prolonged bed rest.
Pregnancy.
Advanced age.
DrugsAnaesthesia, antacids, ganglion blocking
agents, iron salts, opiates.
Treatment
Cathartics and enema should not be used.
Foods with high fibre content such as bran and raw
fruits and vegetables may be helpful.

8 to 10 glasses of fluids daily are to be taken.
Dulcolax 10-15 mg acts within 6-12 hours.
Glycerine suppository, a potent rectal agent for
lubricating hard faecal matter; 3 gm acts in 30

minutes.
Naturolax or Igol or Ispaghula one tsf with water

at night daily
or
Tab Dulcolax 1-2 tablet at bed time.
or
Cremaffin 2-3 teaspoonful after dinner.
For chronic constipationTablet Cisapride 10 mg
twice a day.
DIVERTICULAR DISEASE OF COLON

(Diverticulosis)
Intermittent cramping and left lower abdominal
pain.
Constipation or constipation alternating with
diarrhoea.
Tenderness in left lower quadrant.
X-ray evidence of diverticula, thickened interhaustral folds, narrowed lumen on Barium enema.
Treatment
Capsule Ampicillin 500 mg 6 hourly or capsule
Tetracycline 500 mg 6 hourly.
Clear liquid diet.
27
If severe disease patient may be hospitalised with
bowel rest IV fluids and antibiotics. Combination

of Ampicillin and Aminoglycosides with additional
amoebic coverage with Metronidazole or Clinamycin is given.
Surgery is indicated if patient does not respond to
therapy or develop peritonitis.
Recurrent diverticulitis may lead to stricture perforation and can be an indication for elective
hemicolectomy.
DUMPING SYNDROME
(Post-gastrectomy Syndrome)
Sweating, tachycardia, pallor, abdominal cramps,
weakness and in severe cases syncope within 20
minutes of meal.
Treatment
Frequent small feeds with high protein, moderately
high fat and low carbohydrate.
Fluids should be taken in between meals but not
soon after the meals.
Sedatives and anticholinergics.
DUODENAL ULCER
Epigastric pain 1/2 to 1 hour after meals or nocturnal pain, both relieved by food, antacid or
vomiting.
Chronic and periodic symptoms.
Epigastric tenderness, often with guarding and unilateral spasm of rectus over duodenal bulb.
Ulcer crater or deformity of bulb noted in Barium
meal.
Pylorospasm, gastric hypermotility and irritability
of the bulb with difficulty in retaining the barium are
indirect evidences of duodenal ulcer.
Gastric analysis shows acid in all cases and hypersecretion in some cases.
Few patients may present with vague dyspepsia or
typical symptoms due to anxiety.
Direct visualisation by endoscopy.
Treatment
2 to 3 weeks of rest.
Nutritious diet taken at regular intervals; restriction
of coffee, tea, cola, beverages, alcohol and smoking. First few days with bland liquid diet with gradual
change over to soft solid diet in 4 to 8 weeks time.
AntacidsDigene tablet or Get 2 tab or 2 teaspoon
2-3 hrs after meals.
29
Aluminium hydroxide in tablet form being inert is
not very useful. Magnesium oxide and Calcium

carbonate combinations are best. Magnesium is
contraindicated in renal impairment and calcium
salts may cause hypercalcaemia (polyuria, polydypsia, anorexia, constipation, etc.). Liquid forms
are preferable. Initially given hourly then changed
to 1 and 3 hours after each meal and at bed time.
Antacids may cause phosphate depletion especially
the aluminium salts.
Omeprazole 20 mg od for 1 month.
Parasympatholytics
These are of questionable value as the dose required
to produce significant gastric antisecretory effect may
cause blurring of vision, urinary retention and
constipation. They are helpful in relief of refractory
pain and are given 1/2 hour before meal and at bed
time. They are contraindicated in glaucoma, gastric
ulcer, pyloric stenosis, hiatus hernia, bladder neck
obstruction, etc.
H2 Receptor Antagonist
Famotidine 20 mg twice daily.
Rantidine 300-600 mg daily for 6 weeks.
Therapy continued for 4 to 6 weeks and then
maintenance dose of 300 (Ranitidine)/40(Famotidine)
mg at bed time given for six months.
Look for gynaecomastia, galactorrhoea, gout as adverse

effects
Phenylbutazone, Reserpine, Indomethacin and
analgesics should be discontinued if possible as they
aggravate the condition. To eliminate H.pylori from
gastric mucosa-Metrogyl 400 mg tds plus Amoxicillin
250 mg tds for one week.
GASTRIC ULCER
Epigastric distress, relieved by vomiting, antacid.
Epigastric tenderness and muscle guarding.
Ulcer demonstrated by Barium meal and X-ray or
gastroscopy (Oedema, spasm, convergence of gastric mucosal folds).
90 per cent heal in 12 weeks on medical therapy.
Pain onset
Sequence
Site
Radiation to
back
Relief
Hydrochloric
acid
Ba meal
Gastric ulcer
Chronic duodenal ulcer
2.5 to 4 hours
after meals
Comfort - food
- pain - comfort
Epigastrium
Common
15 minutes to 2 hours
after meals
Pain - food - comfort
Taking alkalis
Normal
After food
++
Stomach
empties slowly
Empties fast
Right half of gastrium

Rare
31
Treatment
Avoid spicy food, alcohol and smoking.
Intensive antacid therapy and H2 receptor blockers:
H2 receptor antagonists are more effective than

antacids in healing gastric ulcer.
Sucralfate and bismuth salts 1 g qid on empty
stomach.
If no response or unsatisfactory improvement is
seen with antacid and Cimetidine or Ranitidine
surgical resection is the answer.
Recurrence, perforation, obstruction or
uncontrollable haemorrhage require surgical
intervention.
HAEMORRHOIDS
Rectal bleeding and discomfort following defaecation. Protrusion and pain around anus.
Haemorrhoids visible on anal inspection or anoscopic examination.
Treatment
1. Lower roughage diet.
2. Regulation of bowel habit with mineral oil or stool
softeners.
3. Warm sitz bath (hip bath) for 15 min, 2-3 times a
day.
4. Soothing anal suppository 2 to 3 times daily.

5. Xylocaine 2 per cent topical ointment before and
after defaecation.
6. Diasomin (150 mg) (Daflon) 2 cap twice daily to
tds for 1 week.
7. Antibiotics preferably Ampicillin for 5 to 7 days to
combat any infection if present.
8. The use of heparin containing oint. (Hirudoid) or
Hydrocortisone ointment (Proctosedyl) are of value
once acute pain and bleeding are controlled.
9. Control other precipitating/aggravating factors
like obesity, chronic cough, portal hypertension, etc.
Surgical Treatment
Injection of sclerosing agents but recurrence occurs
in 5 per cent cases.
Band ligation.
Excision.
HERPETIC STOMATITIS
Common in children below 10 years.
Severe ulceration of oral mucous membrane associated with systemic signs, i.e. fever, lymphadenopathy (cervical) and malaise.
33
Cytologic smear showing pathognomonic pseudogiant cells is confirmatory.

Treatment
Local Idoxuridine application or 5 per cent Acyclo-
vir cream (Zovirax).
Oral Acyclovir 400-1000 mg/day for 12 months if
frequent cold sores.
HICCUP
It is a transient phenomenon and may occur as manifestation of many diseases such as neuroses, CNS
disorders, GIT disorders, etc. It may be only symptom
of peptic oesophagitis.
Treatment
Slow deep breathing.
Neooctinum 30 drops in a glass of water every 4
hourly.
or
Neooctinum dragees 1 tds.
Tab Valium 2 mg tds.
If no response then
Injection Largactil (Chlorpromazine) 25 mg IM
or 50 mg orally.

Antispasmodics, i.e. Atropine sulphate 0.3-0.6 mg
subcutaneously.
Amylnitrate inhalation may be effective.

Antacids-Gelucil/Digene tab after each meal.
If it still persist
Gastric lavage with ice cold saline or 1 per cent soda
bicarb solution.
INTESTINAL TUBERCULOSIS
Fever, anorexia, nausea, flatulence, food intolerance
and distension after food.
Chronic abdominal pain varying from mild to
severe cramps.
Mild to severe diarrhoea.
Doughy feelings of abdomen on palpation.
X-ray findings according to type of lesion, i.e. irritability and spasm particularly in caecal region, irregular hypermotility of the intestinal tract, irregular
filing defects (hypertrophic type of lesion) are noted.
Persistent narrow beam of barium in small bowel
(string sign) is seen. Biopsy and animal innoculation
are confirmatory. The presence of tubercle bacilli in
stool does not correlate with intestinal involvement.
35
Treatment
INH 300 mg od
Rifampicin 450 mg/day if body weight is 55 kg.
Above 55 kg body weight 600 mg daily should be

given in a single dose before breakfast.
Pyrazinamide.
< 50 kg
1.5 gm
50-75 kg
2 gm
> 75 kg
2.5 gm
It may be given in single dose or in 2 divided doses.
Ethambutol 25 mg/kg body weight as single dose.
Supplementary multivitamins and Pyridoxin
40 mg daily.
Low residue high protein diet.
Surgical Treatment
Indications
1. Localised hypertrophic lesion.
2. Stenosis of bowel.
3. Perforation of tuberculous ulcer.
IRRITABLE BOWEL SYNDROME

Abdominal pain.
Altered bowel function, constipation or diarrhoea.

Hypersecretion of colonic mucosa.
Flatulence, nausea and anorexia.
Varying degree of anxiety of depression.
Treatment
Reassure and explain nature of illness to patient.

Avoid stress.
Avoid fried foods, alcohol, tea and coffee.
Regular meals and adequate sleep is essential.
If pain and distension
Tab Mebenerine (Colospa) 100 mg tds
Tab Spasril 1 tds
or
Tab Librax 1 tds
Tab Ispaghula or Isogel 1 tsf once or twice day.
If main complaint is of frequent, loose stools with
urgency then
Tab Lopramide (Imosec) 2 mg once or twice daily.
or
Tab Codeine phosphate 30 mg once or twice daily.
or
Tab Diphenoxylate (Lomotil) 2.5 mg once or twice
a day.
37
NAUSEA AND VOMITING

Simple causes of vomiting are:
Alimentary disorders, irritation, inflammation or
mechanical disturbances at any level of GI tract.
Central nervous systemIncreased intracranial
pressure, stroke, migraine, infection, toxins and
radiation sickness.
Endocrine disordersDiabetic acidosis, adrenocortical crisis, pregnancy, starvation, lactic acidosis.
DrugsMorphine, Meperidine, Codeine, anticancer
drugs.
Psychological disordersReaction to pain, fear or
displeasure, chronic anxiety reaction, anorexia
nervosa, psychosis.
Treatment
i
Simple acute vomiting following dietary or alcoholic indiscretion or during morning sickness of
early pregnancy do not require much of treatment.
Withhold foods temporarily and give 5 to 10 per
cent Dextrose saline solution IV.
Avoid lukewarm beverages.
Antiemetics, i.e. Perinorm, Emidoxyn, Avomin are
better for preventing vomiting.

Sedatives alone or with anticholinergic may be
helpful with psychogenic vomiting.

Domperidone is better as it has no parkinsonian
side effects.
ii. If symptomatic
Injection Perinorm IM.
or
Injection Stemetil 12.5 mg IM.
or
Injection Metachlorpramide (Reglan) 10 mg IV or
IM.
or
Tablet Perinorm or Domperidone one tds
or
Tablet Eskazine 1 mg tds.
Withhold food temporarily and start IV fluids
5 per cent Dextrose or Ringers lactate or Glucose
saline to correct dehydration.
iii. Eradicate the cause
If psychogenic vomiting sedatives alone or with
anticholinergics. Injection Phenargan IM.
If vomiting is following chemotherapy or
radiotherapy then tab Oncoden 4-8 mg tds Injection
2 mg/ml.
39
NODULAR CIRRHOSIS
Anorexia, weight loss, anaemia, nausea, vomiting,
abdominal pain, diarrhoea.
Palpable, firm liver with blunt edges.
Ascites.
Amenorrhoea, impotence, sterility.
Spider naevi, palmar erythema.
Splenomegaly, jaundice in some cases.
Gynaecomastia, testicular atrophy, axillary and
pectoral alopecia are additional findings.
Pleural effusion, ankle oedema, haematemesis are
late findings.
Flapping tremor, dysarthria, delirium and
drowsiness are present in pre-coma state.
Laboratory findings include bromosulphthalein
retention, elevated LDH, SGOT, alkaline phosphatase, bilirubin, decreased albumin, and elevated
gamma globulin.
Liver biopsy shows diffuse fibrosis and nodular
regeneration throughout the liver.
Treatment
Salt upto 500 mg and fluid restriction
Diuretic like Frusemide.
Stop alcohol completely.

High protein diet (100 gm), if required injection
Albumin 5 per cent or 20 per cent IV.

Iron and folic acid for correction of anaemia.
Vitamin K injection 10 mg IM.
Tab Propanolol 20 mg twice to reduce portal
pressure.
If ascites is present
Tab Spironolactone (Aldactone) 100-200 mg/day
increasing by 100 mg every 3 days if no
improvement (suggested by 1 kg weight loss in 3
days)
If no response add Frusemide 20 mg increased to a
maximum of 120 mg.
Check for electrolyte imbalance especially
hypokalaemia and alkalosis.
If ascites persistsHuman Serum Albumin 5-20 per
cent 50-100 ml IV.
In large ascites panacentesis is done.
If hematemesis is present
Injection Vitamin K, 10 mg IV for 3 days.
Injection Pitressin 20 CC diluted in 100 ml 5 per
cent Glucose over 10 minute.
or
Injection Glypressin 2 mg IV 6 hourly for maximum
4 dose.
or
41
Injection Somatostatin 250 mg bolus followed by
250 mg/hour.
Balloon tamponade under vigilant supervision
endoscopic sclerotherapy may be done on emergency basis since risk of rebleeding is high.
For long-term endoscopic sclerotherapy-injection
of Varcies is done at the interval of 1-2 weeks.
Propanolol is given in increasing daily dosage to
achieve a pulse rate of 60/minute to check rebleeding. Shunt surgery and liver transplantation in
suitable cases.
If precoma is suspected
Restrict protein.
Neomycin 1 gm 6 hourly orally or through nasogastric tube, or
Streptomycin 1 gram six hourly by tube, or
Ampicillin 500 mg 6 hourly, or
Lactulose 30 ml tds, or
Metrogyl 800 mg/day.
NON-SPECIFIC
ULCERATIVE COLITIS
Frequent passage of blood mixed stool (bloody
diarrhoea).
Spontaneous remissions and exacerbations.

Lower abdominal cramps with mild abdominal
tenderness usually on rectosigmoid area.
Anaemia, no stool pathogens.
Barium enema and X-ray shows irritability and fuzzy
margins to pseudopolyps, shortening of colon,
narrowing of lumen, loss of haustral markings.
Sigmoidoscopic findings include hyperaemia,
petechiae and minimum granularity in mild cases
to ulceration and polypoid changes in severe cases.
Mucosa is friable and bleeds easily.
Victims are adolescents or young adults.
Treatment
Severe fulminant disease
i. Immediate hospitalisation as there lies chance of
haemorrhage, perforation, toxic megacolon,
sepsis, etc. endangering life.
ii. Stoppage of oral intake, IV fluids and electrolytes, nasogastric suction if colon is dilated.
iii. Broad spectrum antibiotic singly or in
combination as a prophylaxis against sepsis
(Ampicillin, Chloramphenicol and Gentamicin).
iv. Prednisolone 300 mg IV daily at 6 hourly
interval.
43
v. Surgery: If patient remains toxic and colonic

dilatation does not improve within 8 to 12 hrs
colonic resection is indicated. Selective colectomy
may be performed in those who fail to improve
in the long run.
Moderate disease (Patient is not toxic but
diarrhoea, anaemia, asthenia are present)
Hospitalisation and only cooked foods devoid of
milk and mild products to be taken.

Prednisolone 20 to 40 mg daily, then reduced to
5 mg per week. Hydrocortisone 100 mg retention

enema each night.
Sulfasalazine 2 to 4 gm daily in divided doses. If
patient is sensitive to sulphadrugsAmpicillin,
Cephalosporin are the alternatives.
Mild disease (No systemic signs, only
painless bleeding)
Diet devoid of milk and milk products.
Sulfasalazine 2 to 4 gm orally daily in divided doses
as prolonged maintenance therapy.
Hydrocortisone enema 100 mg every night until
lesion heals.
Surgery is indicated for patients with refractory
disease. Widespread involvement of colon, massive
haemorrhage or extracolonic complications (growth

suppression) or perirectal disease. Total colectomy
with permanent ileostomy is the surgery of choice.
In severe cases retention enema of steroid at night
daily for 6 days. Injection Efcorline 100 mg or tablet
Betnesol 8 tablets dissolved in 100 ml normal saline
and given as slow rectal drip with patient in left
lateral position. Effort is made to retain enema
overnight.
ImportantBroad spectrum antibiotics should
never be given orally as they may cause or wosen
diarrhoea.
PARALYTIC ILEUS
(Functional Obstruction)
Continuous abdominal pain, distension, vomiting
and constipation.
History of precipitating factors, i.e. after surgery,
peritonitis.
Minimal abdominal tenderness and decreased or
absent bowel sounds.
X-ray evidence of gas and fluid in the bowel.
45
Treatment
Postoperative ileus responds to restriction of oral
fluid intake. Severe and prolonged ileus requires

nasogastric suction and IV fluids with complete
restriction on oral intake. Potassium depletion in
postoperative cases is often a cause for prolonged
ileus and needs potassium supplement under
proper ECG control.
When conservative treatment fails surgical
decompression with enterostomy or caecostomy
may be done. If ileus is secondary to electrolyte
imbalance, severe infection, pneumonitis, intraabdominal/back injury, the ileus is managed as
above plus treatment of the primary disease.
PEPTIC OESOPHAGITIS
Retrosternal burning, pain and heaviness.
Symptoms aggravated by recumbency or increased
abdominal pressure, relieved by upright position.
Nocturnal regurgitation with cough and dyspnea in
some case.
Hiatus hernia on X-ray.
Common in middle aged obese females or with
patients of increased intra-abdominal pressure.
Oesophagoscopy showing hyperaemia and

ulceration.
Erosion when seen is confirmatory. Biopsy is mandatory to exclude malignancy.
Treatment
Advise patient not to lie down immediately after
food and to sleep with head end of bed being raised
9" to 10".
Weight reduction if obese and avoidance of tight
belts/corsets.
Antacid 2 tab to be chewed 1 hr after each meal
and at bed time.
Large hiatus hernia or paraoesophageal ones
requires surgical correction.
Ranitidine 150 mg twice daily for 4 to 6 weeks.
PRIMARY BILLIARY CIRRHOSIS

Insidious onset.
Pruritus followed by jaundice.
Hepatosplenomegaly.
Xanthomatous lesions around eyelids.
47
Serological tests reflect cholestasis with elevated

alkaline phosphatase, 5 nucleotidase, cholesterol,
bilirubin.
Serum is positive for antimitochondrial antibodies.
Mainly in ladies of age group 40 to 60 years.
Treatment
Cholestyramine to relieve pruritus.
Vitamin A, K and D for steatorrhoea (Parenteral
administration).
Corticosteroids and Azathioprine in selected cases.
Portal hypertension (enlarged spleen, ascites, oeso-
phageal varices) to be treated as discussed under

nodular cirrhosis.
Liver transplantation.
RECTAL POLYP
Painless rectal bleeding in a child.
Treatment
Simple polypectomy by avulsion.
REGIONAL ENTERITIS
(Crohns Disease)
Insidious onset.
Intermittent bouts of diarrhoea, low grade fever.
Pain, tenderness and often mass in right iliac fossa.
Symptoms due to bowel perforation, i.e. localised
abscess, internal/external fistula, peritonitis.
Extra-intestinal manifestations like:
a. Arthritis, subacute migratory, asymmetrical,
polyarthritis lasting for one to two weeks principally involving knees and ankles.
b. Erythema nodosum.
c. Uveitis.
Treatment
General measures
Diet should be high in calories and vitamins and
low in fat and roughage.

For diarrhoea.
Tab Diaphenoxylate or Loperamide.

For general malaiseIron vitamin B12 and supple-
ments of potassium and magnesium.
49
Tab Salazopyrine 500 mg thrice daily.

Tab Prednisolone 0.25-0.75/k/day for 3-4 months.
If seriously ill-injection Hydrocortisone 100 mg 8
hourly or IV Dexamethasone 8 mg 8 hourly.

If above therapy fails then
Azathioprine 2.5 mg/kg/day
or
Mercaptopurine 1.5/kg/day
If acute suppuration indicated by fever,
leucocytosis and tender mass then
Injection Ampicillin 4-8 gm IV daily followed by
2-4 gm orally.
SECONDARY BILIARY
CIRRHOSIS
Symptoms of long standing cholestasis either due
to carcinoma head of pancreas or choledocholithiasis.
Serum is negative for mitochondrial antibodies.
Treatment
Removal of causative factors are symptomatic
treatment.
SPRUE SYNDROME
(Tropical Sprue)
Pale, bulky, greasy, frothy, foul smelling stool with
increased faecal fat on chemical analysis.
Weight loss and multiple vitamin deficiency.
Impaired intestinal absorption of glucose, vitamins
and fat.
Hypochromic or megaloblastic anaemia. X-ray-herring bone appearance.
Skin pigmentation.
Treatment
Complete rest in severe cases and restriction of
activity in mild case.
Diet: High protein, low carbohydrate and low fat
diet.
Folic acid 10 to 20 mg daily orally or intramus-
cularly for a few weeks corrects diarrhoea, anorexia, weight loss, glossitis and anaemia. Once
acute symptoms subside patient can be maintained
on Folic acid 5 mg daily.
Antibiotics: Broad spectrum antibiotic 250 mg
6 hourly for few days.
Cap Minicycline 100 mg twice daily.
51
Prednisolone: 50 mg daily for first few days and
then maintained on 15 mg daily. It increases absorption of nitrogen, fat and has a nonspecific effect in
producing euphoria and increase appetite. For
malabsorption and steatorrhoea-Pancreatic enzymes-Merckenzyme tabs 2 with meals.
TYPHOID FEVER
Gradual onset of malaise, headache, sore throat,
cough and finally pea-soup diarrhoea or constipation.
Slow rise (Step-ladder) of fever to maximum and
then gradual lowering down of fever is common
with maximum temperature at evening hours
(variation less than 2F). Temperature never becomes
normal.
Relative bradycardia, splenomegaly, abdominal
tenderness and distention, with rose spots.
Leucopenia, positive blood culture in first week and
positive stool and urine culture.
Positive widal test with increasing titre.
Treatment
Drug of choice
Ciprofloxacin 500 mg bd 10 days or Tefloxacin
400 mg bd or Norflox 400 mg bd or Ofloxacin 200
mg bd or Cefuraxime 500 mg bd 7 days.
Hydrocortisone 100 mg IV 8 hourly in severely
toxic patients, the danger of perforation should be
weighed carefully.
Parenteral fluid and vitamins control fever.
High calorie and low residue diet.
Perforation needs immediate surgery.
UPPER GASTROINTESTINAL
HAEMORRHAGE
There may be rapid loss of sufficient blood to cause
hypovolaemic shock.
There is usually history of sudden weakness or
fainting associated with or followed by black tarry
stools or vomiting.
Malena occurs in all patients and haemataemesis in
50 per cent patients.
There is usually no pain and the pain of peptic
ulcer often stops with the onset of bleeding.
There may be a history of peptic ulcer, chronic liver
disease, alcohol excess or severe vomiting.
53
Treatment
Complete bed rest. Ice cold saline gastric lavage
through Ryles tube till returning fluid is clear.

Reassure the patient.
Inj Calmpose or Valium 10 mg IM. Repeat after
8 hours if necessary.
Inj Stemetil 12.5 mg IM.
If state of shock:
Inj Plasma IV drip.
or Inj Lomodex 500 ml.

Inj Glucose saline 500 ml.
Indications for blood transfusion are:

Pulse rate more than 130/minute.
Systolic BP less than 90 mm Hg.
Hb less than 60 per cent.
O2 inhalation may be required.
VINCENTS STOMATITIS
Ulcer surface covered with grey pseudomembrane
surrounded by erythema.
Fever, gingival bleeding, lymphadenopathy.
Treatment
Metronidazole 200 mg tds 5 days.
Cap Becosule 1 daily.
Alkaline mouth wash.
VIRAL HEPATITIS
(Infectious Hepatitis)
Anorexia, nausea, vomiting influenza like syndrome.
Fever, soft enlarged tender liver, jaundice.
Abnormal liver function tests with elevation of
SGOT, SGPT and LDH.
Liver biopsy is characteristic.
Treatment
Bed rest at the initial stage of the disease with gra-
dual return to normal activity in convalescence.
Plenty of oral Glucose or IV Glucose 10 per cent if
oral intake is hampered due to nausea/vomiting.
A palatable diet with less fat. If patient shows any
signs of impending coma, protein should be

withheld.
Plenty of vitamin B-Complex and vitamin K.
Liv-52 can be given empirically at the dose of 2 tab
tds for 1 to 2 months.
55
If jaundice is progressive, Corticotropin or
Prednisolone. Prednisolone is given for 20 days at

the dose of 2 tab (5 mg tab) tds for 5 days, 1 tab tds
5 days, 1 tab bd 5 days and 1 tab od 5 days.
Phenobarbitone if restlessness occurs.
1 per cent Phenol with Calamine lotion or Cholestyramine 4 gm daily to reduce itching.
Neomycin/Paramomycin only when precoma
occurs. Serum hepatitis is transmitted by infected
blood or blood products. Its incubation period is
long (6 weeks to 6 months) and its onset is more
insidious. The clinical picture is similar to that of
infectious hepatitis. The blood of the patient is
positive for Australia antigen.
Prophylaxis
Hepatitis AHuman normal immunoglobulin 0.002
ml/kg IM soon after exposure.
Hepatitis BVaccine Engerix B given IM in deltoid
muscle. Same dose for all ages in 3 doses. Second dose
1 month after first dose and third dose 6 months after
1st dose.
WILSONS DISEASE
Symptoms of cirrhosis (jaundice, portal hypertension,
splenomegaly) or chronic atypical hepatitis.
Basal ganglion dysfunction like rigidity, Parkinsonian

tremor.
Kayser-Fleischer rings are pathognomonic (fine
pigmented granular deposits in membrane of the
cornea).
Low serum ceruloplasmin (less than 20 mg), increased urinary copper excretion.
Treatment
Oral Penicillamine 1 to 1.5 gm daily in divided
doses is the drug of choice, to be continued

indefinitely.
If patient is intolerant to Penicillamine, Triethylene
teramine may be tried.
ZOLLINGER-ELLISON
SYNDROME
Severe uncontrollable peptic ulcer syndrome.

Gastric hypersecretion.
Elevated serum gastrin more than 300 pg/ml.
Gastrinoma of pancreas, duodenum or at other
ectopic site.
57
Treatment
For prolonged period/Famotidine/Ranitidine/
Omeprazole may be given in higher doses.
Omeprazole 40-80 mg od.

If unresponsive to drugs surgical resection is
advised.
RESPIRATORY DISEASES
ACUTE BRONCHITIS
Productive cough (mucoid to mucopurulent).
Fever.
Rhonchi and crepitation in the chest with occasional
wheeze.
Absence of X-ray findings.
Treatment
Bed rest with complete prohibition of smoking.
Hot drinks such as tea, coffee to help expectoration.
Steam or tincture benzoin co-inhalation to relieve
cough.
If non-productive cough is exhausting then give
Linctus codein one teaspoonful thrice daily.
If cough is productive Benadryl expectorant or Zeet
expectorant 1 teaspoonful thrice daily.
Antibiotics to be prescribed only in severe or
complicated cases to prevent secondary infection
Respiratory Diseases
59
and in children. Ampicillin or Amoxycillin 250-500

mg four times daily.
Antipyretics (Crocin) or analgesics (Dispirin) to
relieve fever and pain.
ADULT RESPIRATORY
DISTRESS SYNDROME
This term describes the non-cardiogenic pulmonary
oedema occurring in association with massive trauma,
hypotension of any cause, cardiopulmonary bypass
procedures, severe infections, septicaemia, narcotic over
dose, etc. There is damage to pulmonary capillary endothelium producing increased permeability, interstitial
and alveolar haemorrhage and oedema.
Dyspnoea, tachypnoea, anxiety, altered sensorium.
Arterial hypoxaemia with hypocapnoea.
Diffuse alveolar and interstitial infiltrates on chest Xray.
Decreased pulmonary compliance, i.e. arterial
oxygen saturation does not increase inspite of
increasingly high concentration of inspired oxygen.
60
Treatment
Hospitalise the patient.
Treat underlying cause.
High flow oxygen via mask or endotracheal tube.
If despite this PaO2 is not maintained, or If respiratory failure then.

Mechanical ventilation with large tidal volume (15
ml/kg) or positive end expiratory pressure
method.
Fluid balance by Saline or Ringers lactate 20-25
ml/kg/day IV.
Broad spectrum antibiotics for suspected site of
sepsis.
Injection Lasix 40-80 mg IV. Low dosage Dopamine
to maintain satisfactory urine output.
ATELECTASIS
Acute cases: Dyspnoea, tachycardia, cyanosis, chest
pain, fever and hypoxaemia.
Chronic cases: No symptoms, only diagnosed on Xray.
Important signs include retraction and immobility
of chest on one side, displacement of mediastinum
towards affected side, impaired percussion note on
61
affected side with hyper resonance on healthy side,

diminished to absent breath sounds on affected side.
Radiological findings consistent with atelectasis are
lobar or segmental density, often homogeneous with
reduction in the size of the affected lobe. Tracheal
deviation to affected side with elevation of diaphragm in massive atelectasis.
Treatment
Oxygen inhalation.
Relief of pain with low doses of Morphine or
Pethidine.
Relief of obstruction:
i. Removal of foreign body by bronchoscopic

manoeuvre.
ii. Removal of secretion by mucolytics (Bromhexine), bronchodilators, postural drainage.
iii. Tracheal suction.
Antibiotics to prevent infection in atelectic lung.
Ampicillin 250-500 mg four times.
Assisted ventilation: Tracheostomy may be
performed for the purpose of reducing the dead
space and to facilitate aspiration of secretions. Intermittent positive pressure breathing greatly helps
the seriously ill patient.
In postoperative atelectasis the main treatment is
induction of hyperventilation and stimulation of
coughing.
62
ATYPICAL PNEUMONIA
(Mycoplasma Pneumonia)
Increasing intensity of cough with scanty sputum.
Minimal signs on chest examination, i.e. rales and
other signs of consolidation.
X-ray shows pulmonary infiltration often extensive,
disproportionate to physical findings.
Normal WBC count.
Fever is constant, low grade without chill and patient
does not appear seriously ill inspite of extensive chest
lesions and continued fever.
Treatment
Bed rest.
General supportive treatment as for pneumococcal
pneumonia.
Antibiotics only in severe cases.
Ampicillin or Erythromycin 500 mg 6 hourly for
2 weeks are preferable.

Analgesic + antipyretics to control pain and fever.
63
BRONCHIAL ADENOMA
Insidious onset of dry cough with localised wheeze.
Haemoptysis in 25 to 30 per cent cases.
Evidence of bronchial obstruction leading to collapse,
bronchiectasis.
Bronchoscopy and biopsy or exploratory thoracotomy confirms the diagnosis. As the tumour does
not exfoliate, sputum examination is not helpful.
Treatment
The ideal treatment is lobectomy. Fewer noninvasive
pedunculated adenomas may be removed by
bronchoscopy but serious bleeding may occur.
BRONCHIAL ASTHMA
Recurrent attacks of dyspnoea, cough with mucoid
tenacious sputum and wheezing.
Expiratory rhonchi all over chest.
Symptoms promptly reversible with bronchodilators.
X-ray chestnormal in early cases. Emphysematous
changes with pneumothorax in late cases.
64
Treatment
Acute attack
Get out of bed.
Take extra puff of aerosol inhaler.
Take some hot tea or beverage or sips of warm
water.
Injection of Adrenaline 0.5 ml subcutaneously.

If aerosol is ineffective, prolonged repeated attacks
at night causes immobilisation then start course of

Prednisolone 5 mg tablet, 2 tablets tds. Then
reduce dose gradually.
Asthaline inhalationTake deep breath for 5-10
seconds. Two puffs to be inhaled at the interval of
5 minutes. Alternative is Terbutaline inhalation.
If no reliefhospitalise
Severe acute asthmaDiagnostic features are:
Lack of response to normal medication.
Inability to talk or complete a sentence.
Increasing tachycardia and respiratory rate.
Pulsus paradoxus.
Hypotension.
Silent chest.
Cynosis.
Increasing distress and exhaustion.
Hospitalise.
65
Arterial blood gas estimation.

X-ray chest to rule out pneumothorax.
Oxygen at high flow rate 6-8 litre per minute by
nasal prongs or mask.
Injection Aminophylline 250 mg IV or 6 mg/kg IV
slowly over 30 minutes followed by 0.6 mg/kg/

hr.
Injection Hydrocortisone 5 mg/kg IV six hourly.
Double dose if no improvement in 8 hours.
Nebulisation by Salbutamol or Terbutaline 2.5 mg,
2-4 hourly.
If improvement is seen, reduce nebulisation to
6 hourly.
If no response
Injection Salbutamol 200 mg/IM or 100 mg IV.
or
Injection Terbutaline 0.25-0.5 mg SC or IV over 10
minute followed by maintenance dose of 12.5 mg/

minute.
Antibiotics if evidence of infection-fever, purulent
sputum.
After attack subsides
Tab Tedral SA or Asthalin SA twice a day.
or
Tablet Terbutaline 2.5-5 mg tds.
Phensedyl linctus 1 tsf hs.
66
Chronic asthma
Avoid known allergens.
Stop smoking.
Drugs.
PreventivesBeclate inhalation, metered dose

inhaler 50 mg per metered dose, 2 inhalations 3-4 times
daily.
or
Rotacaps 200 mg inhaled in rotahaler 3-4 times
daily.
or
Oral Prednisolone or Betamethasone at minimum
effective dose.
Sodium Cromoglycate inhalation by metered dose
inhaler 2 puffs 4 times daily.
Ketofen 1 mg tab, 1-2 tablets with food.
Relievers
Salbutamol 2-4 mg bd or Theophylline SR 200 mg bd
Exercise induced asthma.
Inhalations of Salbutamol.
or
Terbutaline prior to exercise or Sodium chromoglycate inhalation.
67
BRONCHIECTASIS
Chronic cough with profuse, purulent sputum.
Bilateral basal coarse crepitations with rhonchi.
Clubbing of fingers, haemoptysis.
Signs of general toxaemia, e.g. anaemia, anorexia,
weight loss, etc.
Pulmonary osteoarthropathy, varying degree of
dyspnoea.
Sputum production is more during change of
posture. Sputum often separates into three layers,
i.e. sediment, fluid and foam on standing.
Plain X-ray chest shows increased pulmonary
markings at bases with multiple radiolucencies.
Bronchogram shows saccular, cylindrical or fusiform
dilatations with loss of normal tree in full bloom
pattern of the terminal bronchi.
Treatment
Bed rest.
Avoid exposure to smoke, dust, fumes.
Warm, dry climate is preferable.
Mucolytic agents, i.e. acetylcysteine by aerosol to
liquify thick sputum.
A hot drink before postural drainage may help to
liquify sputum. Attempts to dislodge the secretions
68
should be made by coughing and by percussing

the affected part of the chest. Drainage should be
done for 10 minutes.
Ampicillin 500 mg four times daily or Septran DS
twice daily.
Adequate nutrition.
Indications for surgical resection are:
Unilateral bronchiectasis with more than 1 ounce
of sputum in 24 hours.
Repeated major infections in bronchiectatic area.

Young adults.
Contraindications of surgery are:

Old age.
Poor cardiorespiratory reserve.
Bilateral extensive disease.
Other antibiotics
Ciprofloxacin 500 mg twice daily.
or
Pefloxacin 400 mg twice daily.
To be continued till sputum becomes mucoid.
If acute infection does not subside or recurs quickly
culture sputum and prescribe antibiotic as per
sensitivity.
69
BRONCHIOLAR CARCINOMA
Patients are in the age group of 50 to 60 years.

Chest pain with copious watery or mucoid sputum.
Bilateral involvement is very common.
Dyspnoea, cyanosis, dullness on percussion, clubbing, cor pulmonale, etc.
Chest X-ray shows bilateral, discrete or diffuse
lesions.
Sputum cytology is diagnostic.
If the lesion is unilateral, localised without extrapulmonary metastasis surgical removal is indicated.
Sputum cytology, bronchoscopy, biopsy of palpable
nodes, mediastinoscopy, tomography and scanning
procedures determine the exact location, extent and
spread of the disease.
Treatment
Early detection and surgical removal before meta-
stasis occurs.
Small doses of cytotoxic drugs with radiotherapy
offer some hope of improved palliation.

As a precautionary measure chest X-ray once a
year for smokers above 40 years of age is recommended.
70
BRONCHO-PNEUMONIA
Fever, cough, dyspnoea.
Greenish-yellow expectoration with mixed bacterial
flora on culture.
Leucocytosis.
Patchy infiltration in X-ray.
Varied signs of rhonchi, fine crepitation and bronchial
breathing.
Treatment
In case of infants and young children disease has to
be treated on emergency basis.

Good nursing is essential to conserve childs
energy.
Sedatives may be given if child is restless and
distressing.
High concentration of O2 will relieve distress.
Crystalline Penicillin 5 lacs units IM 6 hourly or
Amoxycillin 25 mg/kg/day in divided doses 6-8

hourly.
In dry cough, linctus may be given.
CollapseStimultants like Coramine or Micoren.
FeverCrocin/Mejoral may be used.
71
CHRONIC BRONCHITIS
Productive cough of longer duration (at least 2 years)
getting worse in winter or on exposure to cold.
Dyspnoea in advanced cases.
Fever is absent except during acute exacerbations.
Widespread rhonchi, basal crepitations and prolonged expiration.
X-ray shows prominent broncho-vascular markings.
Treatment
Sources of possible chronic irritation should be avoi-
ded, i.e. smoking, allergenic agents, fumes, dust

and other irritants.
For non-productive coughCodein phosphate 15
to 30 mg every 4 hours.
For thick sputum.
1. Inhalation, and expectorants.
2. Mucolytic agents, i.e. Bromhexine.
For bronchial spasm. Terbutaline 2.5 to 5 mg 4
hourly.
or
Salbutamol 4 mg 6 hourly.
Antihistamines and short-term Prednisolone in case
of allergy, i.e. Prednisolone 5 mg 4 times daily for 3
72
to 4 days and then gradually reduced and eliminated over next 7 days.
Antibiotics preferably Ampicillin or Ciprobid if
sputum is purulent. Use of maintenance dose of
antibiotics at half the dose to reduce severity and
duration (but not frequency) is advisable in deserving cases. Long acting Penicillin are preferable if
patient is not sensitive to Penicillin.
No response
Capsule Cephalexine 500 mg qid.
or Cefaclor 250 mg twice daily.
or Cefuroxine 250 mg twice daily.
or Azithromycin 250 mg daily.
or Lomofloxacin 400 mg daily.
For bronchospasm
Injection Aminophylline 500 mg IV slowly or
Salbutamol-Theophylline 2 tds.
For persistent spasm
Tab Prednisolone 400 mg daily 7 days. Followed
by maintenance of 10 mg daily.
Treatment of acute/chronic respiratory failure is
discussed separately.
73
EMPHYSEMA
Insidious onset of exertional dyspnoea gradually
progressing to dyspnoea at rest.
Prolonged expiration with wheezing.
Barrel shaped chest, accessory muscles of respiration
are acting.
Often ineffective productive cough.
Old history of asthma, bronchitis, fibrotic pulmonary
disease or a familial predilection.
Over aerated lung fields with flattened diaphragm
on chest X-ray.
Varying signs and symptoms of respiratory acidosis,
i.e. tetany, headache, tremor, etc.
Percussion note is hyper-resonant, with diminished
breath sounds, prolonged high pitch expiratory
phase.
Signs of anoxia, i.e. clubbing, cynosis.
Right heart failure with depressed/enlarged liver in
terminal stages.
Pulmonary function tests confirm respiratory
obstruction. The simplest outdoor tests being the
inability in putting out a burning match stick at a
distance of 1 foot or exhaling the total vital capacity
in more than 5 seconds.
74
Treatment
Mild physical activity.
Avoid pulmonary irritants, i.e. smoking, exposure
to dust, humid or cold air.
Control of bronchial secretionMucous liquifica-
tion by giving plenty of fluids, Bromhexine and

facilitation of expectoration by giving expectorants.
Control of respiratory infection by giving the
appropriate antibiotic. When mixed organisms are
likely, long course of Tetracycline is preferable.
Relief of respiratory obstruction by use of bronchodilators, preferably in the aerosol form. Salbutamol
or Ventolin are preferred.
Breathing exercises to improve alveolar ventilation,
i.e.
a. To exhale through closed lips gradually and as
completely as possible.
b. Rapid inhalation.
c. To contract abdominal muscles gently during
expiration.
Intermittent positive pressure breathing for patients
of advanced respiratory acidosis.
Corticosteroids in lowest doses especially to
patients of chronic bronchitis.
Phlebotomy especially if polycythemia is troublesome.
75
EMPYEMA
Signs of pleural effusion.
Fever, toxicity, pleural pain.
Frankly purulent exudate on thoracocentesis. Lack
of bacterial growth suggests tuberculosis.
Treatment
Aspiration of pus every second or third day.
Antibiotics preferably according to culture and
sensitivity test. Pending culture report, crystalline

Penicillin 10 lacs IM 6 hourly is started. So also intrapleural instillation with 5 lacs units diluted in 5 to 10
ml of saline is done.
Intercostal drainage if there is no improvement
with antibiotic and aspiration.
Breathing exercises as soon as signs of general toxicity disappear.
In chronic empyema there are recurrent attacks of
fever and chest pain. Anaemia, weight loss, clubbing
of fingers, chest wall deformity, bronchopleural
fistula or sinus tract to skin may occur. The treatment
consists of decortication of pleura and evacuation of
pus combined with proper chemotherapy.
76
HAEMOPTYSIS
Signs and symptom of pulmonary or cardiac
diseases.
Blood is coughed up.
Blood is bright red, frothy and mixed up with
sputum.
Reaction alkaline.
Sputum becomes rusty next day.
Common Causes
Pulmonary tuberculosis.
Mitral stenosis.
Lung diseases, i.e. bronchiectasis, acute pneumonia,
infarct, fibrosis.
Ulceration of larynx or trachea.
Haemoptysis
Haematemesis
Blood is coughed up
Blood is alkaline and
bright red
Part of body is frothy
Blood is mixed with sputum
Previous history of
respiratory disease
Normal stools
Episode lasts for days
Blood is vomited
Blood is acidic, brown
in colour
Blood not frothy
No mixed sputum
Previous history of gastric
illness
Stools are black and tarry
Brief episode
77
Treatment
Inj Calmpose or Valium 10 mg IM. If small haemo-
ptysis. Tab Calmpose 1 stat.
In severe cases inj 100 mg Pethidine.

Bed rest in semi-reclining position and leaning on
the elbow on affected side to minimise aspiration

of blood.
Blood transfusion if profuse bleeding.
Antitussive if cough is exhaustive or troublesome.
Small doses of Codein or other cough suppressive
may be given.
Antibiotics are of preventive use to avoid
secondary infection.
NoteHaemostatic agents are of no value in control
of haemoptysis.
HAEMOTHORAX
The common causes are trauma, tumours, tuberculosis
and pulmonary infarction. The pleural sac is to be evacuated at the earliest with thoracocentesis and water seal
drainage. If bleeding continues thoracotomy is indicated. Surgical removal of blood clots may be necessary.
78
HYDROTHORAX
In hydrothorax the effusion fluid is serous or transudate
with specific gravity less than 1015 and protein content
less than 3 gm per cent. It is commonly associated with
congestive heart failure, obstruction of superior vena
cava, cirrhosis, hypoproteinemia, etc. Thoracocentesis
should be done to relieve dyspnoea and the treatment
is for the underlying causes.
LOBAR PNEUMONIA
Chest pain, fever, chills, cough with rusty sputum
toxaemia and tachypnoea.
Chest X-ray shows pulmonary infiltration often lobar
in distribution.
Examination shows classical signs of consolidation,
i.e. dullness, inspiratory crepitation, absent breath
sounds to bronchial breathing VF and VR increased.
Pneumococci present in sputum, identified on culture.
Leucocytosis.
Treatment
Inj Procaine Penicillin 6 lacs IM twice daily in mild
cases and Inj Crystalline Penicillin 10 lacs IM six
79
hourly in severe cases. If patient is sensitive to Penicillin start Cephalexin or Erythromycin. Treatment
should continue for 3 days after defervescence.
or injection Ampicillin 500 mg 6 hourly.
or cap Synthromycin 500 mg 6 hourly.
If patient is sensitive to Penicillin capsule Cephalexin
500 mg 6 hourly.
or injection Cephaloridine 500 mg 6 hourly.
Antibiotics according to causative organism
(pneumococcal is a common causative organism).
Ampicillin 500 mg cap 6 hourly.
or Ciprofloxacin 500 mg twice daily.
or Pefloxacin 400 mg twice daily.
or Ciforclor 500 mg twice daily.
Staphylococcal (Abscess formation is common).
Cloxacillin 500 mg 6 hourly.
For amoebic organism.
Injection Metrogyl 400 mg tds.
Injection Gentamicin 80 mg 8 hourly.
Klebsiella
Chloramphenicol 500 mg six hourly.
Pseudomonas
or injection Cabelin 8 gm IM in 24 hours.
or Ticarcillin 15-20 gm/day IM for 10 days.
80
O2 inhalation (humidified).
Treat shock and pulmonary oedema if present.
Manage toxic Delirium with Diazepam or Pheno-
barbitone.
Pleuritic pain can be relieved with Codein phos or
by spray of Ethylchloride over the skin.
Abdominal distension can be relieved with naso-
gastric suction, Inj Neostigmine methyl sulphate

or by passage of flatus tube.
Congestive cardiac failure and cardiac arrhythmia
need proper treatment.
If marked improvement does not occur after 72
hours of effective treatment, consider these 3 main
possibilities.
1. Presence of empyema, lung abscess, endocarditis,
meningitis.
2. Infection by organisms other than pneumococcus
and resistant to the drug.
3. Possible drug fever or any associated disease.
LUNG ABSCESS
Septic fever and sweats, sudden expectoration of
large amounts of purulent, foul smelling or rusty
sputum, occasional haemoptysis.
81
The above symptoms appear 1 to 2 weeks after possible aspiration, bronchial obstruction (carcinoma) or
previous pneumonia.
Signs of consolidation with cavernous breathing on
physical examination.
X-ray shows cavity with fluid level.
Weight loss, anaemia and pulmonary osteoarthropathy in chronic abscesses of 8 to 12 weeks
duration.
Treatment
Injection Chloramphenicol 500 mg 6 hourly.
or Injection Cefotaxine 1 gm twice daily.

or Injection Gentamicin 80 mg 8 hourly.
or Cap Cephalexin 500 mg 6 hourly.
or Anaerobic organism Tab Metronidazole 400 mg
tds.
Inj Cryst Penicillin 6 lacs IM 6 hourly or Erythromycin 500 mg 6 hourly (in patients allergic to Penicillin) for 2 weeks. If the patient improves continue
treatment for 1 to 2 months. If fever does not
subside even 2 weeks after therapy or abscess diameter is more than 6 cm in diameter or with very
thick cavity wall consider surgical resection.
Drainage of the cavity either by:
a. Postural drainage with clapping over the
abscess site.
b. Bronchoscopic drainage if possible.
82
100 per cent oxygen inhalation to check growth of
anaerobic organisms.
Supportive therapy as rest, high protein diet,
vitamin supplements, etc.
MEDIASTINAL TUMOUR
Substernal pain, occasionally radiating to shoulder,
neck, arm mimicking cardiac pain.
Tracheal/bronchial compression may cause stertorous breathing, cough, dyspnoea and pulmonary
infections.
Hoarseness due to compression of left recurrent
laryngeal nerve.
Mild to severe dysphagia due to external compression of oesophagus.
Superior vena cava syndrome, i.e. dilated neck veins,
collateral veins on thoracic wall, fullness of neck and
face.
Horners syndrome, i.e. miosis, ptosis, and enophthalmos due to compression of sympathetic outflow.
Many tumours are asymptomatic and are only discovered on routine X-ray.
X-ray of chest after barium swallow, lymph node
biopsy of supraclavicular/cervical nodes, mediastinoscopy confirms the diagnosis.
83
Treatment
Depends upon the primary disease and histologic
characteristic of the mass.
PLEURAL EFFUSION
Dyspnoea if effusion is large or of rapid onset,
asymptomatic in minimal effusion of gradual onset.
Pleuritic pain often precedes the effusion.
Stony dullness on percussion, decreased breath
sounds, decreased to absent vocal fremitus, shifting
away of mediastinum.
The underlying pulmonary/cardiac disease may be
a source of major symptoms, e.g. pulmonary tuberculosis, bronchogenic carcinoma, infarction, thoracic
duct obstruction (chylous effusion).
X-ray evidence: Obliteration of costophrenic angle is
the earliest sign. Triangular homogenous shadow of
the fluid with apex in the axilla is noted in later cases.
Distribution of fluid in the interlobar fissures or in
loculated form may be noted as also shifting of
mediastinum.
Thoracocentesis is the definitive diagnostic procedure.
84
Treatment
Rest in bed till fluid gets absorbed, nourishing diet,
vitamins.
Fluid should be removed otherwise.
i. Fibrin is deposited.
ii. Pleura becomes thickened.
iii. Re-expansion of lung is hampered.
iv. Frozen chest may develop.
Indications for aspiration of fluid are:
i. Large effusion up to clavicle.
ii. Bilateral effusion.
iii. Fluid is haemorrhagic or has high content of
protein.
If effusion is tuberculous anti-tuberculous
treatment is to be given.
Corticosteroids should be given in large effusions
who are acutely ill or if loculation of fluid has
occurred.
Effusion due to malignant tumours.
Pleural aspirationChoose an intercostal space
over the area of maximum dullness. Infiltrate local
anaesthetic to parietal pleura after cleaning the area.
Put in the needle through the space and aspirate
through syringe.
If malignant, i.e. rapid accumulation after repeated
aspiration then inject Tetracycline.
Drain the effusion over night by intercostal tube.
85
Tetracycline HCl 500 mg dissolved in 20 ml saline is
injected into pleural space via the intercostal tube

followed by further 20 ml saline. The tube is then
clamped for 6 hours during which time the patients
position is changed frequently. The tube is then
unclamped and free drainage allowed till no further
fluid escapes. The tube is then removed.
Effusion tends to reaccumulate rapidly and requires
frequent removal. An attempt should be made to
control the reformation of fluid by irradiation of
hemithorax or intrapleural cytotoxic drugs.
PULMONARY OEDEMA
Chest pain, dyspnoea, orthopnoea.
Presistent cough with copious frothy expectoration
often blood tinged.
Bubling rales over lower lobes then spreading all
over chest.
Sweating, hypothermia.
Treatment
O2 inhalation by continuous or intermittent posi-
tive pressure method.
86
Tracheal suction.
IV Frusemide 40 mg.
IV Aminophylline 500 mg.
Correction of metabolic/respiratory acidosis by
administration of Soda-bicarb.
Hydrocortisone upto 1 gm IV daily.
Treatment of specific condition precipitating the
attack, i.e. treatment of left heart failure with
Digoxin, etc. Treatment of circulatory overload by
venesection or trapping of blood in lower limbs by
application of sphygmomanometer cuffs to thighs
and inflating them half way between systolic and
diastolic pressure.
PULMONARY
THROMBOEMBOLISM
Sudden onset of dyspnoea, anxiety (with or without
substernal pain), signs of acute right heart
failure and circulatory collapse in large pulmonary
emboli.
Pleuritic pain, cough, haemoptysis, pleuritic friction
rub, fever with signs of consolidation and in some
cases of pleurisy develop 12-24 hours later due to
pulmonary infarction.
87
Gradually developing unexplained dyspnoea with

or without X-ray densities may indicate repeated
minor embolisation to the lungs.
History of thrombophlebitis is commonly present.
Recent myocardial infarction, infective endocarditis,
mitral stenosis may be discovered as the cause of
discharge of embolus to the lungs.
X-ray may show: (a) density signifying congestive
atelectasis or pulmonary infarction, (b) small pleural
effusion, (c) raised poorly mobile diaphragm.
Cardiovascular signs include tachycardia, accentuation of P2, wide splitting of aortic and pulmonary
valve sounds, diastolic gallop. Shock, cyanosis and
elevated central venous pressure.
Lung scanning and pulmonary angiography are
confirmatory.
Transient ECG changes in 10 to 20 per cent cases
showing deep S wave in lead I, prominent Q wave,
inverted T in lead III and right axis deviation.
Treatment
100 per cent oxygen therapy.
Heparin 1000 IU IV followed by 5000 IU every 4
hourly for 5 to 7 days or 1000 IU IV by infusion

every hour. Heparin administration is monitored
by partial thromboplastin time, prothrombin time
which would be 1-2 times of the normal.
88
For pain give Morphine 15 mg IM or 5 mg IV.
Avoid these agents if there is shock. IM route should

not be used in heparinised patients.
Treatment of shock with Dopamine and Noradrenaline.
Antibiotics to prevent secondary infection.
Aminophyline and digitalis to control dyspnoea
and heart failure.
Pulmonary embolectomy for massive emboli not
responding to therapy.
Follow-up treatment
Recurrence of emboli inspite of adequate anti-
coagulants may require venacaval interruption.
Warfarin should be continued for a period of 3 to 6
months in patients with risk factor (prior history of

thromboembolism).
Prevention
Patients over age of 40 who are to undergo surgery
may be given 5000 IU of heparin subcutaneously 12
hourly from the day of operation till fully ambulatory.
No laboratory monitoring is required with this mini
dose therapy. Patients with deep vein thrombosis or
postpartum pelvic thrombophlebitis should
receive adequate anticoagulant therapy. Phlebography
and 125 fibrinogen procedures greatly facilitate
diagnosis of deep vein thrombosis. Colour Doppler
ultrasonography also helps in this.
89
PULMONARY TUBERCULOSIS
Malaise, easy fatigability, anorexia, weight loss
evening rise of temperature, night sweat.
Cough, haemoptysis, apical crepitations.
Signs of consolidation, cavity, bronchitis.
Positive tuberculin skin test, especially a recent
conversion from negative to positive.
Sputum positive for AFB, bacilli discovered in
tracheal/gastric washings.
X-ray chest shows apical or sub-apical infiltration
often with cavities. Hilar lymph node enlargement
with small parenchymal calcification denotes primary
infection. Fibrotic disease with dense, well delineated
streaks may dominate the picture. Solitary nodules,
miliary lesions, lobar consolidation (acute caseous
pneumonia) may be seen and present difficult
problems in differential diagnosis. Serial films,
lordotic views are essential in establishing tubercular
activity and evaluating response to therapy.
Treatment
Drug therapy
Bed rest for few days during the acute stage, i.e.
with fever, severe cough, haemoptysis.
90
Fresh case
Initial phase of 2 months-4 drugs regime.
Capsule Rifampicin 450 mg/day if body weight is
< 55 kg and 600 mg if body weight is > 55 kg to be
given hour before breakfast.
Tab INH 300 mg/day.
Pyrazinamide in single or two divided doses
< 50 kg
1.5 gram
50-70 kg
2 gram
> 75
2.5 gram
Tablet Ethambutol 25 mg/kg single dose next 4
monthscontinuation phase Rifampicin + INH
In 3 drug regime Rifampicin and INH is given with
Streptomycin for 3 months after which Streptomycin
is discontinued and INH + Rifampicin continued for
another 6 months.
Streptomycin
1 gm IM daily or twice weekly. Vestibular damage with
vertigo may limit its use.
INH
5 to 10 mg/kg daily orally. Pyridoxine 25 to 50 mg daily
orally be supplemented during INH therapy to counter
act peripheral neuropathy seen in patients taking INH,
look for toxic hepatitis due to INH.
91
PAS
4 to 5 gm three times daily orally after food. Gastric
irritation, dermatitis, drug fever, hepatitis may limit its
use.
Ethambutol
15 mg/kg orally daily as a single dose. Monitor visual
acuity during therapy and discontinue and replace with
PAS if there is decreased visual acuity (retrobulbar
neuritis). Do not prescribe it to children in whom visual
acuity cannot be monitored.
Rifampicin
10 to 20 mg/kg daily orally on empty stomach to the
maximum of 600 mg. It can replace INH. When added
to INH it may increase hepatotoxicity of the latter.
Itching with or without rash, orange discolouration of
urine and offensive odour of sweat may occur. Drug
interaction with Rifampicin are frequent. It makes oral
contraceptives, Tolbutamide and Warfarin less effective.
Thiacetazone
150 mg daily orally. It can be combined with INH. There
is no advantage of giving it with PAS.
Second Line Drugs
Pyrazinamide:
20 to 30 mg/kg weight to a
maximum 1 gm daily orally in two
divided doses.
92
Morphazinamide:
Taken after food. Look for Hepatocellular dysfunction during

therapy.
Ethionamide and Prothionamide

1 gm daily orally in two divided doses after food; gastric
side effects are quite common and drug should be
avoided during pregnancy, in diabetics, alcoholics and
in epileptics.
Cycloserine
250 mg twice daily in adults and 100 mg/kg weight in
children. It is best combined with Ethionamide.
Capreomycin
1 gm IM daily. Dose not to exceed 20 mg/kg/day. After
3 months frequency of injection is better reduced to
three weekly. It is very costly and is prescribed in
Streptomycin resistant cases.
Viomycin and Kanamycin
1 gm IM daily. Renal and ototoxicity limit their use.
They have cross resistance with Streptomycin.
Drug regimens for newly diagnosed cases.
1. Streptomycin 1 gm + INH 30 mg + PAS 10 gm.
2. Streptomycin 1 gm + INH 300 + Ethambutol
800 mg.
3. Streptomycin 1 gm + INH 300 + Rifampicin
600 mg.
93
4. INH 300 mg + Ethambutol 800 + Rifampicin

600 mg.
Any of the above regimen can be continued for 3
months for initial intensive chemotherapy. It is then
followed by any one of the following regimen for rest
15 months:
INH 300 mg + PAS + Thiacetazone 150 mg.
INH 300 mg + Ethambutol 800 mg.
INH 300 mg + Rifampicin 600 mg.
9 months and 6 months regimens are also under
trial but with higher relapse rates.
Resistant Cases
The duration of chemotherapy is for one year after two
consecutive sputum cultures are shown to be ve.
Regimens. Two second line drug regimens:
i. INH + Ethambutol + Pyrazinamide.
ii. INH + Ethionamide + Pyrazinamide.
iii. INH + Ethambutol + Rifampicin.
iv. INH +Pyrazinamide + Rifampicin.
Three second line drug regimens:
i. INH + Ethionamide + Cycloserine + Pyrazinamide.
ii. INH + Ethambutol + Ethionamide + Pyrazinamide.
iii. INH + Ethambutol + Pyrazinamide + Rifampicin.
iv. INH + Capreomycin or Kanamycin + Pyrazinamide + Rifampicin.
94
INH is continued in these regimens even if culture

shows resistance to INH.
Corticosteroids. Low dose Corticosteroid for shortterm may be beneficial in extensive disease with severe
toxic symptoms. To be given in addition to anti-tuberculous drugs.
Surgery
Pulmonary resection is indicated in any of the following
circumstances:
i. When there is localised pulmonary nodule and
the possibility of cancer cannot be excluded.
ii. For bronchial stenosis.
iii. For any localised chronic focus that has not
improved substantially after 3 to 6 months of
adequate drug therapy with persistence of AFB
in sputum.
Thoracoplasty may occassionally be used to reduce
pleural dead space after a large pulmonary resection
thus minimizing distention of healthy lung or to close a
chronic empyema space.
SARCOIDOSIS
It is a rare disease.
X-ray chest shows hilar adenopathy, nodular or
fibrous infiltration of both lungs.
95
AFB negative so also Mantoux test.

Occasionally skin, bone, uveal tract, salivary glands
and myocardium are also involved.
Biopsy of lymph nodes and skin shows noncaseating epithelioid cell granuloma.
Often asymptomatic inspite of gross pulmonary
changes.
Treatment
Spontaneous resolution is common. Asympto-
matic, non-progressive cases do not need treatment.

For progressive symptomatic cases.
Prednisolone 40 mg daily for 1 month. If there is
improvement reduce the dose gradually to 20 mg
and continue till clearance occurs.
If there is no improvement with 40 mg daily oral
dose for 1 month then gradually reduce and discontinue the drug.
SPONTANEOUS
PNEUMOTHORAX
Sudden onset of chest pain referred to the shoulder
or arm on the involved side, associated with
dyspnoea, cyanosis.
96
Decreased chest movement, hyper resonance,

decreased breath sounds, mediastinal shift away
from the involved side, obliteration of liver and
cardiac dullness depending upon the side involved.
Coin sound or bell sound test positive.
X-ray shows retraction of the lung from parietal
pleura.
Treatment
Bed rest till air leak is stopped.
Inj Pethidine 100 mg or Morphine 15 mg for pain.
Codein sulphate 15 mg 4 hourly to suppress the
annoying dry cough.
O2 inhalation if there is dyspnoea.

Aspiration or intubation with under water seal.
TENSION PNEUMOTHORAX
It is a medical emergency. A trocar is introduced into
the 2nd space anteriorly and once the tension has been
relieved a Foleys catheter is introduced into pleural
space either through the trocar or by direct incision and
attached to a water trap with the end of the tube 1 to
2 cm below water. A suction pump with a maximum
vacuum of 30 cm of water may be attached to the water
trap.
97
TRAUMATIC PNEUMOTHORAX
This is an emergency. Open chest wounds (sucking
wounds) must be made air tight immediately by any
available means (e.g. bandage, handkerchief) and closed
surgically as soon as possible.
Traumatic pneumothorax due to lung puncture or
laceration is managed as spontaneous pneumothorax.
VIRAL PNEUMONIA
Constitutional symptoms more prominent, i.e.
fever, dyspnoea, malaise.
Cough is less troublesome and mucoid with scanty
sputum.
Few physical signs inconsistent with X-ray findings.
Depressed leucocyte count.
X-ray shows homogeneous shadows with ill-defined
edges or ground glass appearance with finely nodular opacities not corresponding to anatomical lobes
or segments.
Failure of resolution with antibiotic.
98
Treatment
Symptomatic for cough, pleural pain.
A broad spectrum antibiotic either Ampicillin
250-500 mg 6 hourly to avoid bacterial super

infection.
Tab Crocin to control fever and pain.
In cyanosis and dyspnoea O2 is to be given.
Heart Diseases
99
HEART DISEASES
ANGINA PECTORIS
Retrosternal transient pain, squeezing or pressure
like appearing during exertion: radiating to neck,
left shoulder or left arm, relieved completely with
rest.
Exercise stress test with ECG shows ST depression
by 2 mm but 35 per cent of cases may have normal
ECG (those only with single artery involvement).
Coronary angiography shows stenosis of coronary
arteries.
Radio-isotope studies with thallium 201 are
supportive.
Angina pectoris
Coronary thrombosis
Attack comes on exercise.

With cold and emotions
Pain soon goes off
At anytime
Patient becomes restless,
collapsed sweating
flushed
Contd...
100
Contd...
Angina pectoris
Coronary thrombosis
Attack lasts a few minutes

BP++
ESR normal
Heart sound audible
Transaminase test negative
Attack lasts for hours

BP Falls
ESR Raised
Feeble
Test is positive
Treatment
During attack
Nitroglycerine under the tongue, acts in 1 to 2
minutes.
Amyl nitrate pearls, crushed and inhaled acts in 10
seconds.
Sorbitrate 10 mg or Monosorbitrate tab 20 mg three
times daily orally or sublingually. Peritrate 1 tab

daily.
Calmpose 1 tab twice daily.
Inderal 40 mg tab three times daily or Metoprolol
50-100 mg bd Propranolol (Inderal) is avoided if
there is left ventricular failure and bronchial asthma,
heart block or low blood pressure.
Supporting measures
Cut down smoking.
Heart Diseases
101
Reduce obesity with diet and exercise.

Control hyperlipidemia with Gemifibrozil 300
mg 2 caps bd before meals or Lovastatin 20-40 mg

od with dinner.
To have regular graded exercise.
Avoid stress, treat anaemia and control hypertension, diabetes.
Respiratory angina
Isoptin 1 tab three times a day, Sorbitrate 1 qid.
Nifedipine 20 mg tds.
Diltiazem 40-120 mg daily as 30 or 60 mg tds.
Apply Nitrobid oint 2 percent on 2" to 3" of skin
surface and cover with a plastic wrap during sleep.
Tab Aspirin 75-150 mg/day.
Nocturnal angina
Hypnotex or Valium at bed time.
Rule out early cardiac decompensation and if so
start digoxin and diuretic.

Balloon angioplasty for proximal stenosis
(excluding left main) or Nitroglycerine.
Coronary by pass surgery

Disabling angina not responding to drugs.
Unstable angina with repeated infarctions.
Major stenosis (50-70%) of the proximal segment
with a healthy distal segment.
102
Unstable angina
Hospitalise in CCU.
Rule out myocardial infarction.
Bed rest.
Oxygen inhalation.
Tablet Sorbitrate one tab 3 hourly.
Nifedipine 10 mg tds.
or Tablet Diltiazem 30-60 mg tds.
Tab Propanolol 40 mg 1-2 tds.
Tablet Aspirin 1 od.
If no response
Injection Nitroglycerine (nitro-bid) 5 ml IV infusion
in 5 per cent Dextrose or normal saline at the rate of
2.5-5 mg/minute and gradually increase it.
Monitor heart rate and BP.
HEART DISEASES
In developed countries cardiovascular diseases are
responsible for approximately 50 per cent of deaths of
which coronary heart disease (25%), hypertension (20%,
especially in Japan), rheumatic heart diseases (2%),
congenital heart disease (1%) and pulmonary heart diseases are the important ones. Pulmonary heart disease
is common in communities consuming excess cigarettes
and exposed to severe atmospheric pollution. Under
Heart Diseases
103
age of fifteen congenital heart disease is the major problem. Over this age coronary disease and hypertension
are likely, pulmonary heart disease is largely confined
to men over 45.
Manifestations of Heart Diseases
The most common symptoms are dyspnoea, fatigue,
chest pain, palpitation and oedema. Dyspnoea or
paroxysmal nocturnal dyspnoea (the first symptom of
left ventricular failure or tight mitral stenosis). Anxiety
states, cardiac neuroses can produce any form of
dyspnoea. Fatigue is common in low output states and
heart failure. It is often the chief complaint in congenital
heart disease, cor pulmonale, and mitral stenosis. Chest
pain occurs in angina pectoris (intermittent myocardial
ischaemia), myocardial infarction, myopericarditis,
pericardial effusion or tamponade, aortic dissection or
aneurysm, pulmonary infarction. Palpitation is the
consciousness of irregular forceful or rapid beating of
the heart and is common with sinus tachycardia or
premature ventricular systoles.
The valuable signs of the heart disease are:
1. Oedema of dependent parts due to right heart
failure associated with engorged neck veins.
2. Cyanosis: (a) Central cyanosis is seen on warm
parts like insides of the lips, cheeks, tongue,
conjunctiva and is caused by right to left shunts,
pulmonary arteriovenous fistulas, chronic lung
104
diseases and pneumonia. Administration of 100

per cent oxygen decreases cyanosis due to parenchymal lung disease whereas that due to shunt
remains unaffected. (b) Peripheral cyanosis occurs
in presence of normal oxygen saturation and is
caused by slowed circulation through peripheral
vascular beds. Reduced cardiac output due to heart
failure, pulmonary/mitral stenosis are the
common causes.
3. Murmurs: A soft short systolic murmur at any
valve area is innocent if there are no other abnormalities and if it changes markedly with respiration and position. The louder a systolic murmur
the more likely it is to be of organic origin.
Diastolic murmurs are always organic and may be
due to dilatation of the heart, i.e. myocarditis and anaemia, dilatation of aortic ring (marked hypertension),
deformity of a valve, rapid diastolic flow or intracardiac
shunts.
HYPERTENSION
Persistently raised BP above 160/100 mmHg in a
person above 60 years or 140/90 in persons
below 50 years. If the mean BP is less than 107 mmHg
Heart Diseases
105
or the increase is purely systolic as in old people due

to loss of elasticity in their major arteries, do not
label them as hypertensive.
Occipital headache worse in morning, light headedness, tinnitus, palpitation.
Retinal changes:
Grade IMinimal arteriolar narrowing.
Grade IIMarked narrowing, arteriovenous
thickening.
Grade IIICotton-wool exudates and flame shaped
haemorrhages.
Grade IVAny of above + papilloedema, i.e. obliteration of physiological cup, blurring of disc margin.
Loud aortic second sound and early systolic ejection
click.
Left ventricular enlargement with heave.
Symptom of left ventricular failurein advanced cases,
aldosteronism, pheochromocytoma, coarctation of
aorta, acute nephritis or chronic nephritis, preeclampsia, increased intracranial pressure of any
cause and collagen diseases.
Signs of Cushings syndrome.
Malignant hypertension means sustained elevation
of diastolic pressure above 130 mmHg causing
widespread arteriolar necrosis with ischaemic atrophy of nephrons. The important symptoms are, headache, visual disturbances, somnolescence, signs of
acute hypertension, encephalopathy or pulmonary
oedema.
106
Laboratory findings depend upon the cause of hypertension; routine examination for specific gravity, pus
cells, RBC casts, blood urea/nitrogen, serum
creatinine, serum potassium, urinary excretion of
17-hydroxy corticosteroids should be done.
X-ray chest may show an enlarged left ventricle or
rib notching due to coarctation of aorta. IVP may be
required for diagnosing polycystic kidney and
chronic pyelonephritis.
ECG shows left ventricular hypertrophy with signs
of coronary artery disease. Prolonged QT interval
(hypokalaemia) is an indication of Cushings disease
or aldosteronism.
Blood pressure should be recorded in the both arms
and legs. Major vessels including abdominal aorta,
iliac vessels and renal vessels should be auscultated
for bruits (narrowing).
Quantitative repeated urine culture may prove
chronic pyelonephritis. In this disease pyuria is frequently absent and bacilluria is intermittent.
Demonstrable bacilluria in a clean fresh urine sample
suggests chronic pyelonephritis.
More specialised studies like selective angiography,
renal vein renin determinations, radio-isotope excretion studies and differential urinary function studies on each kidney may be required for establishing
renal artery stenosis.
Heart Diseases
107
Treatment
The principle is to initiate treatment with a single drug
and then to add agents with a different mode of
action till BP is controlled.
First line drugs
Diuretics-Thiazides or Lasix (Frusemide) or combination of Lasix with Spironolactone or -blockers
cardioselective (Atenolol, Metaprolol, Acetabutolol)
or noncardioselective (Propranolol). They are preferred in patients with concomitant ischaemic heart
disease.
Calcium antagonist:
Nifedipine 10-20 mg
ACE inhibitors: Captopril, Enalapril Lirinopril or

Amlodipine can be used the above three drugs cannot
be used.
Second line drugs
Combination of drugs to be used if single drug does
not reduce BP to within a target range.
Calcium antagonist plus blockers.
ACE inhibitor plus Thiazide diuretic.
-blocker plus Thiazide diuretic.
Hypertension emergency
Nifedipine 5 mg sublingually every 10 minutes till
diastolic BP < 110 mmHg. Then 5-10 mg 6 hourly

up to total dose of 60 mg in 24 hours.
108
Hospitalise patient.
If response inadequateInjection Lasix 80 mg IV.
If still response inadequateInjection Diazoxide
150 mg IV rapidly. Repeat as needed at 5 mm

interval till total of 600 mg.
If response inadequateInjection Nitroprussidedissolve 50 mg vial in 2 ml glucose water and further
diluted in 500 ml 5 per cent Glucose.
Start with 0.5 mcg/kg/minute and adjust dose till
BP reaches at desired level.
or Hydralazine 5 to 20 mg IM 2-4 hourly.
Mild Hypertension (Diastolic 90-110)
Thiazides (e.g. Esidrex) or Lasix for one week, if not
controlled add Reserpin, Hydralazine, Methyldopa,
Clonidine or Propranolol.
Moderate Hypertension (Diastolic 110-130)
Treat with a diuretic (Thiazide) + any of the second line
drugs from beginning. Combination of Hydralazine +
Propranolol (Corbetazine) is best as betablocker Propranolol counteracts the sympathetic stimulation caused
by Hydralazine and consequently the combination has
fewer side effects.
If there is associated renal failure then Hydralazine,
Methyldopa, Clonidine are preferred. Guanethidine
should replace rather than be added to other agents.
Heart Diseases
109
Caution
MAO inhibitors if combined with antihypertensive
drugs may precipitate hypertensive crisis.
Remember Minoxidil is the most powerful oral
hypotensive vasodilator agent.
Severe Hypertension (Diastolic above 130)
Prompt and immediate treatment with rapid acting
drugs preferable in injectable form.
Reduce weight if obese.
Low salt diet.
MYOCARDIAL INFARCTION
Sudden, prolonged, constricting anterior chest pain
referred to neck, left shoulder, inner side of left arm
with sweating, not relieved by rest or Nitroglycerine
often having symptoms of shock, cardiac failure.
Rarely painless presenting as acute congestive heart
failure, syncope, cerebral thrombosis or unexplained
shock.
Fever, leucocytosis, raised ESR, raised CPK-MB,
SGOT and LDH.
110
ECG shows elevated ST, abnormal Q waves and later

on symmetric inversion of T waves.
Radio-isotope imaging with Technetium 99 pyrophosphate confirms the infarction as well localised
hotspots.
Treatment
Relieve pain first with.
Fortwin 30 mg IM for mild pain.
Pethidine 100 mg IM or severe pain.
or
Morphine 15 mg IM.
If patient is still restless add 25 mg of Phenergan.
Morphine 2.5 mg slow IV every 15 minutes if pain
is uncontrolled and severe. Morphine is contraindicated if respiration is below 12/min or PCO2, is above
45 mmHg. Patients on Morphine be advised not to situp or stand as it may cause fainting due to venous
pooling leading to decreased cardiac output.
Oxygen inhalation. Positive pressure breathing is
better avoided as it often decreases venous return
and aggravates myocardial ischaemia.
Complete bed rest for 2 days and then permitted
to sit-up in bed or bed side chair, to go for
bathroom, to shave, to feed, etc. If there is no
complication patients can return to work after 3
months. For reperfusion-Thrombolytic therapy.
Heart Diseases
111
Injection Streptokinase (Streptase) 1,500,000 units

in 100 ml saline, over 60 minutes IV or 750,000 units as
slow IV repeated after 30 minutes.
or Injection Urokinase 250,000 units in 10 ml 5 per
cent Dextrose as bolus IV over 5-10 minutes followed
by 250,000 units in 50-100 ml drip over 30 minutes.
or Injection Apteplase (TPA) 10 mg bolus followed
by 50 mg over 1 hour and 40 mg over second hour.
This may be preceded by injection Phenargan 10 mg
and injection Hydrocortisone 100 mg in 100 ml 5 per
cent Dextrose to suppress allergic reaction.
If in severe shock or CCF, previous thrombotic or
embolic episodes or severe lung disease is evident
then anticoagulants.
Anticoagulant therapy.
Heparin 5,000 IU IV 8 hourly 1st day.
Dindevan 50 mg or Warfarin 5 mg 2 tab tds 1st day.
2nd day Warfarin/Dindevan 1 tab tds.
3rd day onwards: 1 or 2 tab to keep prothrombin
time 2 times of normal.
Disprin and Sorbitrate to continue for 3-5 years.
Diet: Liquid diet 1st day, salt restricted semi-solid
diet from 2nd day onwards. Full diet only after
1 week.
Bowels: If constipated Cremaffin or Agarol 1 to 2 tsf
at night or mild enema may be given.
Thrombolytic therapy and angioplasty in suitable
cases.
112
Complications
Shock: Continuous oxygen.
Sodabicarb 7.5 per cent 100 ml IV.
Noradrenaline 4 mg/500 ml Dextrose slow IV drip
so as to maintain systolic BP around 100 mgHg.
or
Mephentine 300 mg in 500 ml Dextrose drip.
or
Dopamine 1 to 2 mcg/kg/min IV drip.
Intra-aortic balloon counter pulsation technique in
protracted cases.
Cardiac Failure
Lasix 40 mg daily.
Lanoxin 0.5 mg IM/IV then 0.25 mg tab twice a day
till failure is controlled.
Arrhythmias
Start 5 per cent Dextrose IV drip.
Ventricular Premature Beats
Gesicard or Xylocard (2%) 50 mg IV in one minute as
bolus and then 2 mg/minute with IV drip for next 24
to 48 hours.
If ineffective
Inj Pronestyl 750 mg IV drip over 30 to 60 minutes.
or
Heart Diseases
113
Inj Norpace 200 mg loading dose followed by

100 mg 6 hourly.
or
Inj Mexitil 100 mg IV bolus followed by 100 mg
infused over 1 hour, 250 mg over next 2 hours and 0.5
mg/min thereafter or Amiodarone 400-800 mg pd.
Prophylaxis Against Recurrence
Pronestyl 250 mg 4 times daily.
or
Quinidine 200 mg 4 times daily.
or
Inderal 20 mg 4 times daily.
or
Regubeat 100 mg 4 times daily.
or
Mexitil 200 mg three times daily continued for 4 weeks.
For ventricular tachycardiainstitute above
treatment or electric cardioversion.
For ventricular fibrillation: Immediate DC shock.
Ventricular Tachycardia
Rapid ventricular rate > 120/minute.
Tab Mexiletine 150 mg tds.
or
Tab Metoprolol 25-50 mg twice daily correct
hypokalaemia and hypomagnesaemia. If rate < 120/min
usually self limiting.
114
Ventricular Fibrillation
DC shock (220) If this fails then.
DC shock (360J).
Adrenaline 1 ml 1:1000 IV.
10 sequences of 5:1 compression ventilation.
Sinus Bradycardia
Atropine 0.3 mg IV or Isoprenaline 2 mg in 500 ml 5 per
cent Dextrose IV drip, finally cardiac pacemaker.
RHEUMATIC FEVER
Major criteria
1.
2.
3.
4.
5.
Carditis.
Sydenhams chorea.
Subcutaneous nodules.
Erythema marginatum.
Fleeting polyarthritis.
Minor criteria
1.
2.
3.
4.
5.
Fever
Polyarthralgia.
Prolongation of PR interval.
Increased ESR.
Increased antistreptolysin-O titre.
Heart Diseases
115
With two or more major criteria diagnosis of rheumatic fever is certain. The minor criteria are only the
non-specific manifestations and are of diagnostic help
when associated with more specific features.
Carditis
May manifest as: (a) fibrinous pericarditis or with
effusion, (b) frank congestive failure due to dilatation
of weak inflamed myocardium and (c) mitral or aortic
diastolic murmurs due to dilatation of valve rings.
Prevention of Recurrent Attacks
a. Avoid contact with patients having streptococcal
throat infections.
b. Drug prophylaxis with Penidure LA-12 every 4 weeks
or oral Penicillin 2.5 lac units daily before breakfast.
Oral Penicillin is less reliable. Adult should receive
prophylaxis for 5 years after an attack whereas
children should be given throughout the school going
years continued up to age of 25. Alternatively give
Sulphadiazine 1 gm daily if patient is sensitive to
Penicillin or Erythrocin 250 mg 12 hourly.
c. Prompt therapy of streptococcal sore throat with
24 hours will prevent most attacks of rheumatic
fever.
116
Treatment
Bed rest till fever subsides, ESR is normal and rest-
ing pulse rate is normal, maintain good nutrition

and gradual return to normal activities over
months.
Salicylates.
Sodium salicylate is preferred but is contraindicated if there is associated cardiac failure. Aspirin
can be substituted for Salicylate in same doses, i.e.
4 to 5 gm or 100 mg/kg weight daily in divided
dose. Add any conventional antacid with each dose
of Aspirin to reduce gastric irritation. Salicylates do
not alter the course of the disease but only
reduce fever, relieve pain and joint swelling. Early
toxic symptoms due to Salicylates are tinnitus,
nausea and vomiting.
Inj Procaine Penicillin 4 lacs IM daily 10 days to
eradicate any existing streptococci in throat.
If allergic to Penicillin, Erythromycin 50 mg/kg/
day in 4 divided doses.
In severe cases and Prednisolone 1-2 mg/kg/day
in 4 divided doses for 3 weeks and then gradually
reduce, first omit the night then evening and
finally the day doses in another 3 weeks. Corticosteroids do not prevent cardiac damage or minimize it, and only act as potent anti-inflammatory
Heart Diseases
117
drug superior to Salicylates and are of special values

if there is carditis.
In treatment of congestive failure of carditis, digitalis
is not very effective and may rather further irritate
the myocardium producing arrhythmia. Hence it
should be used with extreme caution.
Rheumatic echorea
Phenobarbitone 6 mg/kg/day and/or Largactil
2 mg/kg/day
Taper as symptoms improve
Serenace (Haloperidole) 0.25 mg tab 1-3 day
Tab Diazepam 2 mg tds.
SUB-ACUTE BACTERIAL
ENDOCARDITIS
Continued fever, weight loss, anaemia, arthralgia.
Petechiae, splenomegaly.
Heart murmurs or evidence of congenital heart
disease.
Haematuria.
Blood culture positive for Streptococcus viridans or
faecal streptococci.
118
Embolic phenomena to brain, lungs, intestine, spleen

and kidney.
Splinter haemorrhages beneath nails, clubbing.
Treatment
Penicillin G 5 to 10 million units daily in divided
dose for 3 to 4 weeks.
Add Probenecid 0.5 gm orally tds to enhance blood
levels of Penicillin.
For Streptococcus faecalis

In addition to Penicillin G add one Aminoglycoside
preferably Gentamicin 5 mg/kg/day. Penicillin by
weakening the cell wall facilitate entry of Aminoglycocides into the organism. Continue treatment for 5 to 6
weeks.
If recurrence occurs a second course of properly
selected drugs often for longer duration is recommended.
If there is embolism, anticoagulants may be added.
If there is associated myocarditis with congestive
failure add digitalis and diuretic. Use Potassium salts
of Penicillin. If aortic insufficiency develops and
progresses refer the patient for early prosthesis
after 2 weeks of intensive antimicrobial therapy.
Inspite of bacteriologic cure 50 per cent cases progress to cardiac failure in 5 to 10 years principally
due to valvular deformity.
Heart Diseases
119
Hospitalise.
Take blood culture before starting treatment
(preferably and sets of cultures over 1 hours).

Streptococcus viridansIt is the commonest organism.
Injection Benzyl penicillin 2 million units 4 hourly
for 4 weeks plus injection Gentamicin 3 mg/kg/day
IV 8 hourly for 2 weeks followed by:
Capsule Amoxycillin 6 gm/day for 2 weeks. If
allergy to penicillin then injection Erythromycin
lactobionate 4 gm/24 hours plus Rifampicin 10 mg/
kg/day.
or Injection Vancomycin or injection Cephalothine
are other alternatives.
If Staph. aureus
Injection Methiathin 10 gm IV daily.
Injection Cephalothin 12 gm IV daily for 4 weeks.
Pyocyaneus
Injection Colistin 1.5 million units IM 8 hourly for 2
weeks.
If fungal
Injection Amphotericin IV test dose 5 mg over 2 hours
gradually increasing at the end of one week to 1 mg/
kg/day.
120
Plus Flucytosine 100-200 mg/kg/day in 4 divided

doses.
Follow-up
Tab Pentids 800 mg bd for years together.
Record daily temperature twice for 3 months after
stopping therapy.
Blood cultures should be done at 2, 4 and 6 weeks.

Treatment of dental sepsis if any.
Skin Diseases
121
SKIN DISEASES
ACNE VULGARIS
Starts as papules at puberty and common sites are
cheeks, chin, nose, back and shoulders.
Permanent scars on skin if left untreated and
uncared.
Clinical picture is of black heads, inflammatory
papules, pustules or cyst.
It is often familial and found in oily skin.
Treatment
Local area to be washed properly with soap 2-3
times a day.
Oxytetracyclin 250 mg bd is often adequate for 10
days.
Minocycline 100 mg daily
Vitamin A and C in high doses.
Oral Retinoids or local Isotretinoin ointment.
Local application of Eskamel/Clearacil ointment
after wash.

Capsule Doxycycline 100 mg twice day for 10 days
then 1 daily for 20 days.

Locally Pernox or Persol gel 2.5 or 5 percent apply
at night for 2-3 months use Lyramycin or Erythromycin cream or solution if there develops inflammatory and pustular lesions.
Retino-A cream or Eudyna cream applied 2-3 times
a week only at night for 3-4 months.
ALLERGIC CONTACT DERMATITIS

Itching.
Erythema is often followed by vesicles/bullae.
There may be secondary infection.
There will be a history of previous episode of
itching.
History of repetitive exposure to causative factors.
Patch test with agent is positive.
In acute phase there will be tiny vesicles weepy and
crusted lesions.
Affected area is hot and swollen.
Grams stain and culture will rule out impetigo/secondary infection.
Skin Diseases
123
Treatment
Localised involvement can be managed by topical
agents.
In acute weeping dermatitis compresses are used.
Calamine lotions may be used in dried cases.
Mild potency triomcinolone 0.1 % to high potency
steroids are useful.

In acute cases one may give prednisone 60 mg for
4-7 days.
BED SORES
Special type of ulcers due to impaired blood supply
and tissue nutrition due to prolonged pressure.
Skin overlying sacrum and hips is commonly involved.
Patient is old, paralyzed or unconscious patient.
Treatment
Good nursing care is needed.
Early treatment requires antibiotic powders and
absorbent bandage.
Established lesion requires surgery for debridement
and dressing.

Spongy foam may be put under the pressure points
of body.
BOIL
It is a deep seated infection involving hair follicle and
adjacent subcutaneous tissue.
Pain and tenderness may be prominent.
Abcess is round or conical.
It enlarges, becomes fluctuant and then softens and
bursts automatically within a few days.
Coagulase positive Staphylococcus aureus is the causative organism.
Carbuncle consists of joining hair follicles with multiple drainage point.
Treatment
Aspirin controls fever and pain

Systemic corticosteroids help.
Be careful of diabetes.
Cyclosporine in doses of 3-5 mg/kg per day is useful.
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125
CONTACT DERMATITIS
The erruption begins at the contact with the causative
agent.
Site gives a clue to the probable allergen, i.e. at wrist
due to watch, in axilla due to deodorant, at dorsum
of foot due to nylon socks, at lips due to lipstick, etc.
Treatment
All suspected allergens should be avoided. The use
of soap should be prohibited.

Patient should be instructed not to scratch. Scratch-
ing may spread the erruption.
Hydrocortisone in lotion is effective both as an anti-
pruritic and as an anti-inflammatory agent.
Antihistaminics should be given orally 1 tab bd for
2-3 weeks.
After recovery patient may be advised not to get
himself exposed to the allergen again.
Acute weeping dermatitis

Lactocalamine lotion or Flucort H cream to be applied
twice a day for 7 days.
Subacute lesions
Zovate or Beclate cream twice a day for 7 days.
Chronic lesions
Cortilate or Dermozyme ointment twice daily for 2
weeks.
If marked lichenification
Dipsalic or Reziderms ointment. If extensive and
chronic.
Tab Prednisolone 2 bd for 10 days then 1 bd 10
days.
DERMATOPHYTOSIS
It is fungal infection of the feet and hands.
Disease starts on the sides of the toes and webs as
interdigital maceration and scaling.
May be erythema, vesiculation and soreness
followed by fissuring.
Treatment
3% Salicylic acid in alcohol at bed time and 10%
Boric acid foot powder in the morning.
1% Gentian violet in water may be applied.

Miconazole or Cotrimazole 2% local application.
Griseofulvin 1 qid for 21 days or Ketoconazole 200-
400 mg daily.
Skin Diseases
127
DISCOID LUPUS ERYTHEMATOSUS

On face there will be localised red plaques.
Scaling and follicular plugging.
Dyspigmentation.
Arms are mostly involved.
Permanent hair loss and loss of pigmentation.
Lesions may be covered by dry, horny adherent
scales.
Treatment
Protect body from sun light
Use sun blocker with high SPF > 30
High potency corticoid creams to be applied each
night
Chloroquine sulfate 250 mg daily may be effective

Thalidomide is a potent teratogen but is very effec-
tive in refractory cases
Disease is persistent but life does not remain in
danger.
ECZEMA
It is a non-contagious inflammatory disease.
Stimuli may be exogenous.

Erythema, oedema, vesiculation, oozing, weeping
and crusting in acute stage.
After healing up of eruption there is a residual
pigmentation of the skin.
In chronic stage there is a lichenification.
Treatment
Non-irritating detergent should be used instead of
soap.
For secondary infection Neomycin ointment is
useful.
Antibiotics may be given orally, i.e. Ampicillin
250 mg 4 times daily.
Hydrocortisone ointment, cream, lotion applied
once, or twice daily will relieve pruritus, i.e.

Betnovate or Flucort-N.
Antihistaminics orally are helpful.
Avil Tab 1 thrice daily.
In acute oozing eczema without secondary
infection.
Tab Prednisolone 5 mg 2 tab bd 5 days. Then
2 tab 1 bd 4 days followed by 1 tablet daily 4
days.
Zovate M cream twice a day.
In chronic lichenified lesion locally inject hydrocortisone or Kenacort intralesionally.
Skin Diseases
129
ERYTHEMA MULTIFORME
It is an acute inflammatory skin disease.

It may follow outbreak of herpes simplex.
It may present as recurring oral ulceration.
There is sudden onset of symmatic erythematous
skin lesions with history of recurrence.
Lesion may be macular, papular, urticarial or purpuric.
Centre of lesion is clear with concentric erythematous rings.
In erythema multiforme major multiple lacerations
are present at two or more sites making eating food
difficult.
Skin biopsy is diagnostic.
Tracheobronchial mucosa and conjunctiva may be
involved.
Treatment
Corticosteroids are usually given although a few
patients dont respond to it.
Oral acyclovir prophylaxis may be effective.

Antistreptophylococcal antibiotics are used in
secondary infection.
Tropical therapy is not effective.
ERYTHEMA NODOSUM
It is a symptom complex of tender, erythematous
nodules on extensor surface of lower legs.
It lasts for six weeks and may reoccur.
Slow regression over several weeks.
Lesions of 1 -10 cm are pink to red.
Treatment
Treat the underlying cause.
Primary therapy is with nonsteroidal anti-inflam-
matory agents.
Standard solution of Potassium iodide 5-15 drops
three times daily.
In painful lesions complete bed rest is advised.

Systemic corticosteroids may be given.
EXFOLIATIVE DERMATITIS
Patchy erythema spreading rapidly.
Fever, shivering and malaise.
Scales may be large or fine.
Whole skin becomes red, warm to touch and is
thickened.
Hair become brittle and fall.
Skin Diseases
131
Management
Bed rest.
Keep the patient comfortable in cool temperature.
Daily bath followed by oily application.
Antiallergic, i.e. Avil tab 1 tds
Steroids 30-40 mg, Prednisolone daily till improvement. Then patient is kept on maintenance dose.
FOLLICULITIS
It is caused by staphylococcal infection especially in
diabetics
When lesion is deep seated in head and neck it is
called sycosis.
Gram-negative folliculitis develops during antibiotic
treatment.
Steroid acne is a type of folliculitis seen in systemic
corticosteroid therapy.
Eosinophilic folliculitis shows urticarial papules with
eosinophilic infiltration in AIDS.
Pseudo folliculitis is seen as in growing hair in beared
area.
There may be burning to internse itching
There will be pustules of hair follicules.
Treatment
Proper control of diabetes.
Anhydrous ethyl alcohol containing 6.25% alu-
minium chloride may be applied locally.

Systemic antibiotics may be applied.
Eosinophilic folliculitis may be treated with 2.5%
selenium sulfide 15 minutes daily for 3 weeks.
GONORRHOEA
In females
Discharge, dysuria, frequency and urgency.
Difficulty in walking, soreness around parts, burning
while passing urine
Vulva is swollen and reddened.
In males
Thick creamy, greenish yellow purulent discharge.
Severe pain during micturition with frequency and
urgency.
Symptoms are more marked in posterior urethritis.
Skin Diseases
133
Management
Penicillin is the drug of choice.
In uncomplicated gonorrhoea. Procaine penicillin
G 2,400,000 units/Norfloxacin 800 mg/Ampicillin

3 gm/Ciprofloxacin 500 mg/Azithromycin 1000
mg stat.
Tetracyclines, Erythromycin and Chloramphenicol
500 mg 6 hourly upto 2-4 grams; Spectinomycin
for resistant case.
HERPES SIMPLEX
It involves orolabial and genital areas.
There develops small grouped vesicles on an
erythematous base.
Regional lymph glands become swollen and tender.
Tzanck smear is positive for multinucleated giant
cells.
Main symptom is burning and stinging.
Neuralgia is severe.
Lesions heal with in a week.
It is the main cause of genital ulceration.
Treatment
Acyclovir is very effective. It may even be given
IV dose is 200 mg five times daily for 7-10 days.
In recurrent cases 400 mg twice daily of Acyclovir
for many days is advised.
HERPES ZOSTER
Pain and hyperaesthesia along the nerves.
Fever 102-103 F.
Small vesicles occur in crops, content becomes
purulent.
Regional glands are painful and tender.
Each crop dries in a week.
Rash is usually unilateral.
Management
Calamine lotion for local use.
Aspirin or Novalgin 1 thrice daily 5 days.
Antibiotics in case of infection: Ampicillin cap 1 qid
5 days.
Corticosteroids for anti-inflammatory effect to cut
down course of disease, severity and to prevent

neuralgia.
Skin Diseases
135
Large doses of B1, B6, B12, Neurobion inj daily 5 to
7 days.
Tab Diazepam (Valium) 1 at bed time.

Acyclovir orally and Idoxyuridine oint locally.
Tab Zonirax or Herpes 800 mg 5 times a day for 7
days. It is effective only if started within 2 days.
Injection Kenacort 40 mg/ml 1 ml weekly.
IMPETIGO
These are weeping or encrusted lesions.
There are superficial blisters full of purulent material.
Positive Grams stain.
Bacteria may be cultured.
Itching ++
Face and other exposed parts are commonly
involved.
Treatment
Local antibiotics are not effective
Systemic antibiotics work well. Doxycycline 100 mg
twice daily for 5 days may be given.

Crusts and weepy areas may be treated by com-
presses.
INFANTILE ECZEMA
Eczema occurring in infants upto the age of 2 years.
Acute inflammation with erythema, oedema,
scaliness with vesicles and scratching.
There may be automatic recovery after the age of
two.
Treatment
Soap substitute or mineral oil may be used to clean
the skin.
If a contact aetiology is suspected the causative
agent should be searched for and to be eliminated

from the environment.
Antihistaminic therapy will be useful.
Under no consideration X-ray therapy should be
given, ultraviolet rays usually do more harm.
Hydrocortisone cream or ointment (1%) is a
valuable preparation. Oral Corticosteroids should
be avoided.
LICHEN PLANUS
It is an inflammatory pruritic disease of skin and
mucous membrane.
Skin Diseases
137
These are flat topped papules with fine white streaks.

Distribution is symmetrical.
Stitching is mild to severe
Papules are 1-4 mm in diameter.
Treatment
Topical corticosteroids applied twice daily helps.

Topical tacrolimus appears effective in oral and vagi-
nal erosive lichen planus.
Oral corticosteroids may be required but disease in
general persists for months.
MALIGNANT MELANOMA
Pigmented skin lesion with recent change in appearance.
Colour may range from red, black and bluish.
Border is irregular.
Lesion may be flat or raised and from macules to
papules.
Treatment
After histological diagnosis excision is the line of
therapy.
MILIARIA
Heat rash generally develops on trunk due to hot
moist environment causing plugging of sweet ducts.
There will be burning, itching small papules.
Pustules may cause prostration.
A lesion consists of small, superficial red, thin walled
aggregated papules.
Treatment
Prevention includes antibacterial preparation prior
to exposure.
Triamcinolone acetonide lotion is useful.

Doxycycline one tab twice daily is useful for five
days in secondary infection.
PEDICULOSIS
It is a parasitic infestation of skin of scalp, trunk and
pubic area.
There will be pruritus with excoriation.
Nits on skin and hair shafts.
Occasionally a sky blue macule.
Skin Diseases
139
Itching may be intense

A few patients may develop pyoderma.
Treatment
Affected clothes should be washed in Luke warm
water.
For pubic lice lindane lotion or cream is applied.

Sexual contacts should be treated.
Nits are removed maticulously with a fine tooth
comb.
PEMPHIGUS
Bullous skin disorder of poor prognosis.

First lesion may occur in any part of the body.
There is an offensive, characteristic odour.
Later on eruptions may become generalised along
with itching, loss of weight and anaemia.
Bullae arise from a normal skin with erythema
around.
Bullae tends to be tense due to contained serum.
Rupture of bullae leaves a raw, exuding surface which
becomes crusted.
When crusts are shed, pigmentation remains for
many weeks/months.
Treatment
Hospitalise the patient.
High calorie, high protein diet.
1% aqueous Gentian violet is soothing and reduces
bacterial infection or dress with Sofratulle and

Neosporin ointment.
Cap Ampicillin 250-500 mg 1 qid 7 days to
overcome secondary infection or Cap Doxycycline
100 mg bd for 10-20 days.
Tab Prednisolone 120-150 mg in divided doses.
Reduce slowly to maintenance dose of 10-20 mg/
daily.
Betnovate-N ointment apply twice daily.
Betnesol-N eyedrops 6 hourly for 7 days at least.
Cyclophosphamide + Methotrexate.
Cyclophosphamide 200 mg daily then reduced to
50 mg od Tab vit C 500 mg 1 bd for 20 days.
PSORIASIS
It is a familial, chronic, recurrent disease of unknown
origin.
Well circumscribed erythematous dry plaques of
various size covered with mica like silvery scales.
Skin Diseases
141
Removal of scales may expose a thin membrane

giving rise to pinpoint bleeding points.
Extensor aspect of extremities especially elbows,
knees, occiput are the commonly affected sites.
Treatment
Removal of precipitating cause if known.
Warm climate helps to check relapse.
Coal tar local application.
Vitamin B1, B6, B12 IM may be helpful.
PUVA therapy.
Steroid ointment under occulsive dressing is helpful,
i.e. Betnovate-N or Flucort-N.
Methotrexate orally in resistant cases.
Acute psoriasis: Cap Doxycycline 100 mg bd 10

days. Tennovate or Excel cream twice a day for 14
days.
Chronic psoriasis:
Salicylic acid 3 parts.
Benzoic acid 5 parts.
Imulsifying ointment to 100.
To be applied on lesions twice a day.
Whitfields ointment or Pragmatar cream at night.
Diprovate or Cortilate cream or Elocon ointment
locally once a day for a month.
RINGWORM
Superficial fungal disease of smooth skin, tinea
corporis is known as ringworm.
Lesions are asymmetrically distributed and are of
various sizes.
These are erythematous, scaly plaques, circinate with
a central clear area.
At times several concentric rings may develop.
There is always a definite border often vesicular in
character.
Itching often during night hours.
Treatment
Avoid soap and keep the part dry. Change the
under garments frequently.
Whitfields ointment is useful.
Antifungal ointment; Dermoquinol oint to be
applied three times a day or Canesten cream or
Imidil cream.
Tab Griseofulvin 500 mg daily for 3 to 5 weeks.
Tab ketoconazole 200 mg twice daily or Tab
Fluconagole 50-100 mg/day for 2-4 weeks.
Skin Diseases
143
SCABIES
It is a contagious disease caused by Sarcoptes scabiei.
Severe itching which becomes worse at night
especially in children.
Burrow is a elevated greyish tortuous or dotted line
in the skin.
Black spots in inter digital folds, around nipple,
genitalia, buttocks, medial aspects of thighs.
Treatment
All the family members should be treated at a time.
The clothes, bed linen, towels should be boiled,
ironed and changed frequently.
If there is secondary infection it should be treated
first.
Septran 1 bd 5 days.
After proper bath, patients body should be allowed
to dry and Ascabiol or Benzyl benzoate 25%

solution should be applied from the toe to neck for
3 consecutive days (12% in children).
or
Scaboma lotion 1% or Crotorax ointment or
lotion.
or
Sulphur ointment 10% for adults, 5% for children
and 2.5% for infants is to be applied below neck on
4 consecutive nights.
or
Mitigal, Dimethyl diphenyl disulphide is used as a
10% solution in liquid paraffin for 3 nights.

or
Gamabenzene hydrochloride used as cream or
lotion after bath for 3 days.
Tab Avil 1 bd 3 days if itching is more.
SEBORRHOEIC DERMATITIS
Excessive oiliness.
Greasy scaling of scalp is accompanied by discomfort
and pruritus leading to scratching.
With superadded pyogenic infection disease may
spread to the sides of the nose, eyebrows, margins
of eyelids.
There may be dry scaling of scalp resulting in loss of
hair.
Treatment
Savlon or Cetavalon concentrate 4 tsf to a glass of
water to be used as shampoo twice a week.
Medicated shampoo once or twice weekly (Selsun).
Proper hygiene, low fat diet and increased vitamins.
Skin Diseases
145
Antibacterial measures in pyogenic superadded
infections. Ampicillin Cap 250 to 500 mg qid for

5 days.
Psychiatric help may be advisable.
Avoid using oil on scalp.
SYPHILIS
Chancre is the initial evidence.
Chancre is single in the form of erosion of an ulcer,
painless and not tender.
Base is indurated, floor is clean with serous
discharge.
Usually found over genitals, lips, tongue and
fingers.
Chancre heals with atrophic scar even without any
treatment.
Regional lymph nodes are bilaterally enlarged,
discrete, rubbery in consistency and not tender.
Headache, fever, malaise and arthralgia which is
worst at night.
Management
Early syphilis
Benzathine penicillin 2.4 mega units.
or
Procaine penicillin G in oil, 4.8 mega units at one
time and 1.2 mega units for 2 injections three days
apart.
or
Procaine penicillin G 6 lacs units daily for 8 days.
Late syphilis
Benzathine penicillin 6-9 mega units in divided
doses.
If patient is allergic to Penicillin. Erythromycin 500
mg qid for 3 to 4 weeks.

Tetracycline is another alternative 30 to 40 gm over
10 to 15 days.
TINEA VERSICOLOR
Upper trunk is mostly involved.
Velvety, pink/brown macules. These can be scraped
easily.
Hyperpigmented form is not uncommon.
Mostly asymptomatic, only a few develop itching.
Macules are 4-5 mm in diameter.
Thick walled budding spores may be seen under
microscope.
Skin Diseases
147
Treatment
Selenium sulphide lotion may be applied from neck
to waist from 5 to 15 minutes.

Ketoconazole shampoo over chest and back for 5
minutes.
Ketoconazole 200 mg daily for 1 week gives short-
term cure.
Single dose of 400 mg.
Ketoconazole may not work in hot humid

wheather.
Imidazole creams, solutions and lotions are useful.
URTICARIA
Spontaneous development of wheals produced by a
transudate through the injured walls of arterioles
and capillaries, may be due to ingested food or drug,
bite of insects or parasites.
Circumscribed areas of oedema may be slightly pink
in colour.
Trunk is the common site.
In children papules and vesicles may develop
instead of wheals.
Treatment
Careful history may give indication if it is due to
ingested food or drugs.
Antihistamine therapy is useful. Citrazine tab daily
5 days.
Corticosteroids should be given in acute attack but
may not be very useful in chronic patients.
Soothing lotions or creams with 2% Phenol,
Menthol or Camphor may be used.
Deworming may be done.
VENOUS INSUFFICIENCY
LEG ULCER
History of venous insufficiency like thrombophlebitis.
There may be immobility of calf muscles as in
paraplegia.
There will be irregular ulceration often on medical
aspects of lower leg above medial malleolus.
Oedema and hyperpigmentation.
Skin breaks down and eventually sclerosis of skin
takes place.
Skin Diseases
149
Treatment
Compression stockings reduce oedema.
Compression should achieve a pressure of 50 mm
Hg below knee and 40 mmHg at the ankle.
Ulcer is treated with metronidazole gel to reduce
bacterial growth and odour.
Red dermatitis skin is treated with corticosteroid
ointment.
Ulcer is then covered with an exclusive hydro
active dressing.
Complete healing of ulcer may take 4-6 months.

Some ulcers may require grafting.
Cultured epidermal cell grafts are very useful al-
though costlier.
Ciprofloxacin 500 mg twice daily is useful.

Zinc supplementation is beneficial.
WARTS
These are caused by human papilloma viruses.

There are no symptoms.
Anogenital warts may produce itching.
These are verrucous papules on skin or mucous
membrane not larger than 1 cm in diameter.
Incubation period is 2-18 months and spontaneous

cures are noted.
Recurrences in 50% cases develop.
Flat warts are better seen under oblique illumination.
Subungual warts may be dry and fissured.
Plantar warts look like corns.
In AIDS wart like lesions may be caused by varicella
zoster virus.
Treatment
Liquid nitrogen is applied to achieve a thaw time of
20-45 seconds.
Liquid nitrogen may result in depigmentation.
Any salicylic acid products may be used.
5% cream of Imiquimod helps in clearing external
genital warts.
Anogenital warts may be treated carefully every
2-3 weeks with 25% podophyllum resin.

Plantar warts may be removed by blunt dissec-
tion.
CO2 laser is effective for treating recurrent warts.
Bleomycin diluted to 1 unit /ml may be injected
into warts.
Psychiatric Diseases
151
PSYCHIATRIC DISEASES
ANXIETY
Excessive perspiration.
Skeletal muscle tensionTension headache, backache.
Sighing respiration.
Hyperventilation syndromeDyspnoea, dizziness,
paresthesia.
Functional gastrointestinal disordersAbdominal
pain, diarrhoea, constipation.
Cardiovascular irritabilityTransient systolic hypertension, tachycardia, fainting.
Genitourinary dysfunctionUrinary frequency,
dysuria, impotence, frigidity.
Patient feels very sick/frightened during a short
period.
Treatment
Give attention to the root problem of the patient.
Reassure him.
152
Tab Diazepam (Valium or Calmpose) 5 mg tds.
or Tab Lorazepam (Larpose, Ativan, Trapex) 1 mg

tds.
or Tab Chlordiazepoxide (Librium) 10 mg tds.
or Tab Alprazolam (Alprax, Alzolam) 0.25 mg
1 mg daily.
or Tab Oxazepam (Serepax) 15 mg tds.
or Tab Buspirone (Buscalm) 5 mg tds.
Antipsychotic agents, effective against anxiety associated with high distractibility.
Tab Melleril 10 mg tds.
In anxiety associated with depression tricyclic antidepressants are effective.
Tab Imipramine 25 mg tds.
or Tab Amitryptiline 10 mg tds.
or Tab Doxepin 10 mg tds.
or Tab Chlomipramine 10 mg tds.
Antidepressants are effective in anxiety associated
with depression. Tab Tryptomer 10 mg thrice daily.
DEPRESSION
Loss of pleasurable interest.

Spontaneity is gone.
153
Realistic worries and bodily discomforts are prominent in awareness.

Mild depressive patient feels physically fit and does
his usual work.
Severely depressive, seems gloomy, hopeless and
loss of self-esteem.
Thinking, speech and movements are slowed.
Agitated depressed patient complains endlessly
about aches, pains, fatigues, feeling of unworthiness
or guilty fears.
Restless sleep/insomnia are prominent symptoms.
Anorexia and weight loss.
Sexual disinterest and incapacity.
Treatment
Give kind attention and reassurance.
Suicide risk is to be evaluated.
Antidepressant drugs, Tryptomer 1 tds 25 mg.
Doxepin, Trazodone.
Tricyclic antidepressants
Tab Imipramine (Depsol, Antidip) 25 mg tds, daily
dose is 75-300 mg).

or Tab Amitryptiline (Tryptomer, Serotena) 10 mg
tds daily.
or Tab Doxepin (Spectra, Doxetar) 10 mg tds.
or Tab Clomipramine (Anafranil, Clonil) 10 mg tds.
154
HYSTERIA
Somatic and/or psychological symptoms without
any organic basis.
Symptoms serve the primary or secondary gain.
Symptoms cannot be explained in term of known
organic diseases.
They have no anatomical basis.
Symptoms seldom occur when the patient is alone
and are exaggerated in presence of a sympathetic
audience.
Symptoms change qualitatively and quantitatively
with different examiners.
Treatment
Isolation of the patient from the pathogenic envi
ronment. Reassurance and sympathetic attention.

Placebo therapySome iron preparations or intramuscular injections of distilled water.
Chlorpromazine 50 mg tds for 2 to 3 days or
Diazepam 10 mg IM relieves psychological tension.
Hypnosis helps in relieving the symptom by its
value of suggestibility.
Psychotherapy.
155
PHOBIC REACTION
It is a persistent excessive fear attached to an object
or a situation which in reality is not significant source
of danger.
Perspiration, tremors, pallor, tachycardia, rapid
breathing, diarrhoea, vomiting and tightness in the
chest.
Attack to panic lasts as long as patients face the phobic subject or situation.
Common phobic situations are darkness, brightness,
depth and heights.
Treatment
Psychoanalysis, deconditioning, hypnosis, reassur-
ance, group therapy, environmental manipulations.
Mild tranquillizers may be helpful like Calmpose 5
mg tds.
Tab Depsonil 25 mg thrice daily.

Tab Librium 10 mg thrice daily.
PSYCHOPATH
Persistent disorder of mind resulting in abnormally
aggressive and seriously irresponsible conduct.
156
Antisocial behaviour.
Unexplained failures in love and job.
Irresponsibility and inability to distinguish between
truth, and falsehood, good and bad, moral and
immoral.
Shallow and impersonal response to sex life.
Inability to sex life.
Inability to accept blame.
Treatment
Very difficult and unsatisfactory. No drug seems
to help in correcting them in behaviour.
PSYCHOSIS
Manic type
Elated, unstable mood. The mood is one of excess
gaiety, euphoria, disinhibition and may be ecstasy.
Transitory brief moments of depression.
There may be boisterous joking, unrestrained good
humour.
His thinking demonstrates flight of ideas, easy
distractability, absence of self criticism, little true self
awareness, tendency to blame others and at times
poor judgement.
157
Excessive speech may result in hoarseness of voice.

There is difficulty in falling asleep and when asleep
awakens early.
Little increase in sexual drive and potency.
Depressed type
Depressed, difficulty in thinking, psychomotor
retardation.
Patient feels extremely inadequate, no confidence
and may feel that he is a worthless person.
Attraction of life seems meaningless and without
value.
Memory and orientation are intact.
Develops suicidal tendencies.
Frightening dreams are common.
Treatment
Hospitalisation
Manic states
Tab Haloperidol 10 mg tds.
If extrapyramidal symptoms develop as a side
effect then give.
Tab Pacitane 2 mg tds.
or Tab Phenargan 25 mg one twice a day.
Prophylaxis of mania.
Tab Lithium one tablet thrice a day.
158
or Tab Tegretol 200 mg one twice a day. The dose

of Tegretol may be increased upto 1000-1200 mg daily
till optimum response is obtained.
or Tab Valparin (Sodium valporate) 200 mg one
thrice a day.
Depressive state
Although ECT is more effective but drug therapy is
usually tried first.
Tricycles (Treptomer) 25 mg tds.
or Tab Doxepin (Spectra) 25 mg tds.
or Tab Clomipramine (Clonil) 25 mg tds.
or Tab Amoxapine (Demolox) 50 mg tds.
or Tab Alphrazolam (Alprax) 0.5 mg tds.
or Tab Trazodone (Trazonil) 50 mg 2 hs.
Chlordiazepoxide 10 mg (Librium) + Diazepam
(Valium) 5-10 mg qid.
ECT is treatment of choice in acutely suicidal
patient or in patient refractory to drugs 6-8
treatments are sufficient.
SCHIZOPHRENIA
Thinking appears bizarre, illogical and chaotic.
Preoccupation with ideas derived from day dreams
and fantasies, hallucinations and delusions.
159
Mood is inconsistent or exaggerated. There may be

indifference, shallowness, constriction, flatness.
Develops contradictory feelings, attitudes, wishes or
ideas towards a given object, person or situation.
False, troubling impression that others are talking
about him.
Delusion that CBI is after me.
Treatment
Acute stage
In an emergency when patient is aggressive and
excited.
Injection Chlorpromazine (Largactil) 50 mg IM 12
hourly or injection Haloperidol (Serenace) 5 mg
IM every hour till adequately sedated.
If mildly agitated patient
Injection Eskazine 1 mg IM 8 hourly and tab
Pacitane 2 mg tds.
For out patient treatment
Tab Chlorpromazine 50 mg tds.
Tab Trifluoperazine 5 mg tds.
Tab Trihexyphenidyl 2 mg tds.
or Tab Loxapine 25 mg 1 tds.
Tab Procyclidine 2.5 mg tds.
or Tab Pimozide 2 mg bd.
Tab Procyclidine 2.5 mg thrice a day.
For chronic schizophrenic patients.
160
Injection Fluphenazine deconate (Anatensol) 12.5

mg IM every 2 weeks.
or Tab Haloperidol deconate (Depidol LA) 50-100
mg every 2-4 weeks.
or Fluanxol depot 20 mg IM every 2 weeks 20-40
mg every 2-3 weeks.
For resistant schizophrenia
Tab Clozapine (Lozapin) 25 mg -1 bd.
Gynaecological Disorders
161
GYNAECOLOGICAL DISORDERS
AMENORRHOEA
Unphysiological absence or cessation of menstruation due to local, constitutional, psychogenic and
endocrinal factors.
Physiological amenorrhoea is found in pregnancy,
before puberty, after menopause and during lactation (lactation amenorrhoea).
Primary amenorrhoea may be due to psychic shock,
anorexia nervosa, psychosis, depression, ovarian
dysgenesis, infantile or hypoplastic uterus.
Secondary amenorrhoea may be due to chronic illness, i.e. tuberculosis, malnutrition/anaemia and
obesity.
Treatment
Progesterone withdrawal test
Tab Farlutal 10 mg 1 daily 10 days. If withdrawal
results it indicates anovulation. Induce ovulation if
patient desires child bearing.
162
If withdrawal negative.
Oestrogen + Progesterone withdrawal.
Tab Premarin (1.25 mg) for 25 days.
or Tab Lynoral (0.05 mg) for 25 days followed by
Tab Farlutal (10 mg) od from 16th to 25th day.
or Tab Orgametril (5 mg) two daily 16th to 25th
day.
If oestrogen + progesterone withdrawal negative.
Ref to gynaecologist for outflow tract evaluation.
If positive evaluate for hypothalamopituitary. If
FSH, LH low or normal and hormone withdrawal
with progesterone positive give.
Tab Serophene (Clomiphene citrate) 50 mg daily
from 2nd day for 5 days. Next cycle 100 mg daily for 5
days.
or Clomiphene + hCG 10,000 IU on 12th or 13th
day. If no response then hMG/hCG therapy.
If prolactin elevated.
Tab Proctinol initially 2.5 mg for 5-7 days in 2
divided doses after weeks increase the dose to 5 mg
for 25 days.
CANCER CERVIX
Cervix may appear normal, eroded or chronically
infected.
163
Cervix is hard to touch and bleeds on examination.

It is friable and fixed.
Loss of appetite, loss of weight and anaemia is noted.
Pain is a late feature.
Treatment
High protein and vitamin diet to correct anaemia.
Treat sepsis by douches, antibiotics and urinary
antiseptics.
Surgery in stage I and II, Radical abdominal hyste-
rectomy with lymphadenectomy-Wertheims

hysterectomy.
Postoperative radiotherapy. In stage III and IVpalliative treatment.
CARCINOMA OF
BODY OF UTERUS
Irregular continuous postmenopausal bleeding.
Leucorrhoea in fungating polypoidal mass in late
stage.
Pyometra and abdominal lump.
Abdominal pain, cachexia, loss of weight, anaemia,
etc.
164
Treatment
General improvement of health, correction of
anaemia.
Total hysterectomy with bilateral oophorectomy.
Surgery and irradiation.
Radiotherapy in advanced stages.
Large doses of progesterone in advanced cases
offers palliation.
CERVICITIS
ACUTE CERVICITIS
Mainly gonococcal or perpueral in origin.
Cervix is congested, enlarged, swollen, mucous
membrane pouting at the external OS.
Cervix is tender with profuse purulent discharge.
CHRONIC CERVICITIS
It is a histological diagnosis.
Mucopurulent discharge.
Low backache partly relieved by rest.
Aching in low abdomen and pelvis.
165
Deep seated dyspareunia.

Contact bleeding, menorrhagia and congestive
dysmenorrhoea.
May result in infertility.
Treatment
Tetracycline in full doses 500 mg 6 hourly for 10
days to overcome gonorrhoea.
Douching only to remove discharge and odour
temporarily.
Electric or diathermy cauterisation to destroy
diseased area.
When endocervix and external OS are badly affec-
ted, remove the whole area by doing one excision.
Clotrimazole and Econazole vaginal cream/tab.
DELAYING MENSTRUATION
Due to certain unavoidable circumstances, examinations, sports competition, etc. one may desire to delay
the menstruation for her convenience.
Primulor-N one tablet thrice daily.
or
Primovlar/any oral contraceptive once daily at bed
time.
or
Tab Orgametril 2 tablets daily until bleeding is desired. The first dose should not be later than day 22.
166
DYSFUNCTIONAL
UTERINE BLEEDING
Bleeding from a non-inflammatory non-neoplastic
uterus.
There may be history of amenorrhoea for 1 to 2
months followed by irregular bleeding.
75 per cent patients are of paramenopausal age
group.
Psychic or emotional disturbances.
Treatment
Mid cycle spotting
Tab Lynoral 0.01-0.05 mg from 12th-16th day of cycle.
Menorrhagia
i. If patient desires pregnancy ovulation induction
with Clomiphene citrate.
ii. If pregnancy not desired.
Tab Regestrone 10 mg.
or
Tab Primolut N 10 mg
or
Tab Duphaston 10 mg bd for 21 days.
It may continue for 3 cycles. If no improvement
diagnostic curettage may be done.
167
Continuous prolonged bleeding per vagina Tab Premarin

1.5-2.5 mg/day till bleeding stops. Then 1.25 mg daily
for 20 days. Tab Farlutal 10 mg/day to start after 15
days of above tablet for 10 days.
Premenstrual spotting.
Tab Farlutal 10 mg.
or Tab Regestrone 10 mg.
or Tab Duphaston 10 mg from 16th to 25th day.
DYSMENORRHOEA
Painful menstruation.
Fear of sex, unsatisfied sex urge, anxiety and worry
may cause dysmenorrhoea.
Pain sensation arises in uterus and is related to muscle
contraction.
It starts just before and after menstruation and lasts
about 12 hours.
Pain is colicky in nature starting in hypogastrium
and radiates to inner thighs and never goes below
knee.
Treatment
Teach young girls to have a proper outlook of
menstruation, sex and health.
168
Tab Baralgan or Cap Spasmoproxyvon 1 bd during
menstrual period.
Tab Stilboestrol 1 mg daily from 5th to 12th day of
the cycle.
Tab Mestranol 5 mg daily from 13th to 25th day.

Practice exercises for dysmenorrhoea.
HABITUAL ABORTION
Three consecutive pregnancies ending is spontaneous abortion.
Rh incompatibility test, VDRL positive for syphilis,
thyroid function test for hypothyroidism, blood
sugar estimation for diabetes and study of the
chromosome patterns of wife and husband are to be
done.
Treatment
Injection Gestone 50 mg daily until 10-12 weeks of
gestation till foetal movements are seen on

ultrasound.
Tab Fertugard 5 mg tds continue for 1 week after
pains have subsided.
169
or Injection Puberogen (HCG) 1000 I units daily till

threat is over. Then 5000 units once a week till foetal
heart sounds are heard.
Tab Folic acid 5 mg twice daily.
HYPEREMESIS GRAVIDARUM
Morning sickness starting around sixth week and
abates around 12th week.
Vomiting is persistent and follows every meal or
drink.
Weakness, giddiness, exhaustion, passes scanty
urine.
Symptoms of dehydration in severe cases.
Treatment
Isolation and reassurance.
Correct dehydration by parentral fluids.
Vitamins B 1 and B2 in sufficient quantity.
Antihistaminics help in sedation and control vomit-
ing.
Plenty of carbohydrates to combat hypoglycaemia.
170
INCOMPLETE ABORTION
After incomplete abortion, bleeding does not stop
but varies from day-to-day and heavy from timeto-time.
Uterus is soft and enlarged.
Internal OS remains open.
Treatment
Dilatation of cervix and exploration of uterus
under general anaesthesia.
Expelled material should be examined for placenta.
INEVITABLE ABORTION
Bleeding per vagina.

Painful uterine contractions.
Dilatation of cervix.
Ballooning of the upper vagina, tenderness of uterus
and pyrexia.
Treatment
Confine the patient to bed until abortion is
complete.
171
Pethidine 100 mg to relieve pain and anxiety.

Packing of uterus is avoided because it may hide
haemorrhage resulting in shock.
If bleeding is profuse, continuously or inter-
mittently give 5 units of Oxytocin or 0.5 mg of

Ergometrine.
In severe anaemia blood transfusion may be given.
In favourable circumstances removal of any
remaining placenta by means of finger, sponge
forceps or curette.
Bimanual massage of uterus or Oxytocin IV helps
in uterine retraction.
Hot intrauterine douche of water may be helpful
after curettage.
LEUCORRHOEA
Excessive normal discharge, white or cream when
fresh but leaves brown yellow stain on clothing.
It may cause excoriation and soreness of vulva but
no pruritus and is never offensive.
Microscopically it contains mucus, epithelial debris
and organisms of various kinds.
If pus is not found then only it is a true leucorrhoea.
172
Treatment
Cleanliness is to be ensured by bathing and regular
change of under clothings.

Finding of non-specific bacteria on culture from
vagina without pus does not justify administration

of antiseptics, suplhonamides and antibiotics.
Imidil vaginal tab to be kept in vagina at bed time
for 6 days.
Cauterisation of cervical erosion helps in repeated
leucorrhoea. Improve her general health.
MENOPAUSE
Gradual cessation of menses because ovaries stop
reacting to the stimulus of the anterior pituitary gland
as an ageing effect.
Profuse irregular bleeding is never a symptom of
menopause.
There may be depression, excitability, nervousness,
irritability and inability to concentrate.
Palpitation, night sweats, hot flushes and precordial
pains are common.
173
Atrophy, dryness of vagina may cause dyspareunia.

Tender breasts, osteoporosis, menopausal hypertension is common.
Treatment
Tab Librium three times daily.

Inj Mixogen one amp IM once a month.
Ethinyl oestradiol 0.05 mg/day.
Dienestrol cream to be used locally in vagina.
Hormone replacement therapy

Tab Premarin 0.625-1.25 mg/day for 25 days every
month.
Or Tab Synoral 0.02-0.05 mg/day for 25 days
every month followed by Tab Farutal 10 mg 10-12
days each month to prevent endometrial hyperplasia
HRT can also be given in the form of transdermal
route via dermal patches which release 50-100 g of estradiol daily.
MONILIAL VAGINITIS
Vaginal thrush is caused by yeast like organism,
Candida albicans.
174
Discharge is typically thick, white, cheesy tending to

form plaques which are highly adherent to vaginal
wall. Vaginal wall becomes diffusely reddened and
oedematous.
Vulval pruritus is associated with discharge.
Treatment
Candid or Canesten vaginal tablet 1-2 inserted daily
for 6 nights.
Betadine vaginal pessaries 2 pessaries at bed time
for 14 days.
Gentian violet 2 per cent aqueous solution.
PREMENSTRUAL TENSION
Period of premenstrual tension varies from 3 to 10
days before menstrual period.
Heaviness of breasts due to congestion and fluid
retention.
Heaviness of lower abdomen.
Migraine and ocular disturbances.
Tachycardia and hot flushes.
Psychogenic imbalance, i.e. irritability, anxiety,
depression, fear, impulses of aggression and
destruction.
175
Treatment
Educate and reassure the patient and divert the
attention from menstrual cycle problem.

Avoid salt.
Tab Larpose 1 mg twice daily.
Tab Ethisterone 5 mg daily.
Tab Lasix 1 daily starting from one day before
expected period for 2-3 days.
SENILE VAGINITIS
Small multiple reddened areas seen in vault and
around urethral orifice.
Postmenopausal yellowish discharge, may be with
excoriation and soreness of vulva.
Cervical cytology or biopsy is essential to rule out
malignancy.
Treatment
To
restore vaginal resistance oestrogen

preparations in full doses for 3 weeks. May be
repeated after a gap of one week.
Local antiseptics are of no use.
Local oestrogens combined with lactic acid may be
of some use.
176
THREATENED ABORTION
Uterine bleeding during early pregnancy.
Fresh blood is bright red. Dark brown blood means
that active bleeding has ceased.
Cervix is not dilated but there is slight bleeding.
Passage of blood clots and fever shows that abortion
is inevitable.
There may be backache and slight lower abdominal
discomfort due to uterine contractions.
Treatment
Bed rest.
Gestanin tablet 1 tds.
If hCG titre is low gestenon or Uniprogesterone

50 mg daily till fetal heart movement seen on
ultrasound.
Or
Injection Profasi (hCG) 1000 IU daily till threat
is over then 1000 IU once a week till fetal heart
movements seen.
Or
Tab Fertugard 2-4 tablets daily initially followed by 3 tablets daily till 5th month of pregnancy.
Or
Injection Puberogen
1st day
2000 units
3rd day
2000 units
5th day
9th day
14th day
177
2000 units
1000 units
1000 units
TRICHOMONAS VAGINITIS
It is not common in virgins, children and old women.
Cream coloured, frothy, purulent vaginal discharge
of sudden onset.
Pruritus and itching being felt around and within
introitus.
Vaginal tenderness and congestion results in
dyspareunia.
Treatment
Metronidazole 200 mg thrice daily for one week
orally or Tinidazole 2 g stat or 300 mg tds for 7

days for both husband and wife.
Husband may be treated simultaneously because
90% of them harbour the parasites on urethra
beneath the prepuce.
Coitus should be avoided during course of treatment. Pimafucin 100, one od for 10 days in
vagina.
178
VAGINITIS
INFANTILE VAGINITIS
Pain and soreness of the vulva.
Vulva may become reddened, oedematous or
excoriated.
Discharge may be blood stained if some foreign body
or polyp is there.
Treatment
If due to any foreign body then it should be
removed.
Antibiotics/Sulphonamides or fungicides should be
given.
If infection does not clear, Ethinyloestradiol (0.01
mg) is given orally thrice daily for a month.
Local instillation of 0.5% aqueous solution of
mercurochrome is helpful.
Ear and Nose Diseases 179
EAR AND NOSE DISEASES
ACOUSTIC NEUROMA
Slowly progressive perceptive unilateral deafness.
Unsteady gait.
Symptoms of raised intracranial pressure, i.e.
headache, vomiting.
Associated with horizontal nystagmus, facial nerve
paresis, loss of corneal sensation.
Lumbar puncture shows increased CSF pressure and
raised protein.
Treatment
It is only surgical and depends on site and size of the
tumour. Large tumour growing into cerebellopontine
angle needs immediate removal by a skilled neurosurgeon while small tumours in the canal are removed
by opening through the mastoid and approaching the
canal by removing the semicircular canals.
180
ACUTE OTITIS MEDIA

Severe earache in an young baby or school going
child who screams in agony or bangs his head or
pulls the affected ear.
Fever, vomiting, even convulsions.
Conductive deafness.
Instant relief of pain after discharge of mucopus from
affected ear.
Ear drum shows congestion of handle of malleus,
margin of tympanic membrane inflamed, bulging
of tympanic membrane or perforation that discharges mucopus to external ear. The discharge may be
seen to be pulsating, reflecting light intermittently
(light house sign).
Mastoid tenderness, often oedema.
Signs of facial nerve paralysis, meningitis, even brain
abscess may be seen in fulminating cases.
Associated with it are chronic sinusitis, adenoids,
measles, scarlet fever, etc.
Treatment
Bed rest and plenty of fluids.
Analgesics to relieve pain.
Oral Penicillin or perferably injectible form for a
minimum 7 days or until tympanic membrane

looks normal and deafness disappears.

Capsule Ampicillin 250-500 mg qid.
or Cap Amoxycillin 250-500 mg tds.

or Cap Cephalexin 250-500 mg qid.
or Tab Erythromycin 250 mg qid.
or Tab Norflox 400 mg bd.
or Tab Ciprofloxacin 500 mg bd.
or Tab Roxithromycin 150 mg bd.
Aural toiletRemoval of mucopus from canal by
Hydrogen peroxide instillation.
MyringotomyTo be performed when there is
persistent collection of mucopus in middle ear
causing continued deafness and recurrence.
CHOLESTEATOMA
Foul recurrent aural discharge.

Deafness often severe.
Earache and vertigo.
On examination, attic perforation often discharging
white scales, or with pedunculated aural polyp
bleeding on touch and causing vertigo on pressure.
Audiogram shows conductive deafness.
X-ray shows non-pneumatised mastoid and bony
erosion by cholesteatoma.
182
Treatment
Removal of cholesteatoma under general anaes-
thesia with the help of aural microscope and daily

aural toilet thereafter.
MastoidectomySimple, modified or radical
mastoidectomy according to degree of destruction
of middle ear by cholesteatoma.
Treatment of Complications
Labyrinth is infected either through a fistula in the lateral semi-circular canal or through oval window by
erosion of cholesteatoma. Ultimately the infection passes
to membranous labyrinth with destruction of cells in
cochlear and vestibular organs.
CHRONIC SIMPLE OTITIS MEDIA

Gradually increasing deafness.

Recurrent discharge from the ear.
Occasional earache.
On examination a central perforation exposing
promontory, round and oval windows, often
opening of the eustachian tube is visible.
Audiogram shows conductive deafness.
X-ray shows pneumatic mastoid.
X-ray PNS may show sinusitis or DNS.
Treatment
Aural toilet if there is discharge and protective
dressing, e.g. Silicone eardrops.
Control of infection of PNS and nose and throat.

Proper antibiotic in full course to control residual
middle ear infection. Ciprobid 500 mg bd for 5 days.
Tympanoplasty and reconstruction of ossicular
chain.
All such patients are advised not to have head bath,
to plug their ears during bath and to use a prophylactic decongestant nasal drop.
Clear and dry the ear.
Use ear dropsNebasulf drops, Chloromycetin
drops, or Gentamicin drops 3-5 drops thrice daily till
ear becomes dry.
DEAFNESS
Deafness is of two types conductive and sensory
neural.
Conductive Deafness
The common causes are wax, chronic otitis externa, acute
suppurative and secretory otitis media, cholesteatoma,
otosclerosis and perforation.
184
Sensory Neural Deafness

The common causes are:
Presbyacusis or degeneration of hair cells in old age
causing deafness.
Mnires disease.
Trauma by high pitched loud noises, e.g. artillery
men, pop groups, noisy machine or fractures of
petrous temporal bone.
Infection and destruction of labyrinth by cholesteatoma or mumps virus.
Disease of auditory nerve, i.e. neurofibroma.
DEVIATED NASAL SEPTUM

Nasal obstruction.
Occasional headache and pain around the eye.
Smell unimpaired.
Deviation visualised after the mucous membrane is
shrinked with application of adrenaline 1:1000.
Treatment
Operation either submucous resection or septal

repositioning.
Indications for Operation

Deviation of the septum is extremely common and few
selected cases only, as listed below, need surgical
correction.
1. Total or sub-total obstruction of one nasal cavity by
a bony or cartilaginous deflection.
2. Obstruction to the drainage of one of PNS.
3. As an operation of access to a bleeding point in
epistaxis.
4. As an operation of access to the ethmoidal and
sphenoidal sinuses.
DISEASES OF NOSE
The common symptoms of nasal disease are:
Nasal obstruction leading to nasal voice, mouth
breathing, crowding of teeth, high arched palate,
shortness of nose especially if obstruction originates
in childhood and is unrelieved.
Nasal discharge may be mucopus, mucous, blood or
CSF (fracture cribriform plate of ethmoid).
Sneezing especially in allergic rhinitis.
Loss of sense of smell.
Headache and facial discomfort if there is associated
sinus disease or osteomyelitis.
186
EAR DISEASES
The main symptoms of ear diseases are:
Pain in ear
This is generally due to otitis media, boil or impacted
wax. There may be referred pain from posterior third
of tongue, tonsil or a carious molar tooth.
Discharge from ear
A watery discharge is due to diffuse otitis externa
and often results in crusting at the orifice.
A purulent discharge comes from a boil in the canal.
A mucopurulent discharge comes from middle ear
during acute or benign chronic suppurative otitis
media. It is pale yellow and odourless.
A foul smelling discharge is an evidence of attic
cholesteatoma or marginal granulations.
Blood stained discharge is due to an aural polyp or
acute otitis media, with bleeding into the middle ear.
Tinnitus
Noise in ear causes lot of distress specially at night
when patient is sleeping. There may be no
abnormality in their ears or upper respiratory tract
but it may occur in otosclerosis and in chronic otitis
media.
EPISTAXIS
Examine the patient and ascertain the site of bleeding. If
bleeding is from Littles area, insert a cotton wool soaked
with 4 per cent lignocaine and 1 in 1000 solution of
adrenaline and squeeze the end of the nose for few
minutes. If bleeding recurs, bleeding points should be
sealed by application of chemical or electrical cautery.
When bleeding is from nasal mucosa, e.g. hypertension,
pressure can be put by passing an inflatable bag into
the nasal cavity and by filling it with air or water.
Nasal pack is the other alternative easily available and
commonly practised. For this purpose 1/2" wide gauze
of about 1.2 meters is sufficient for one side. The gauze
is impregnated with vaseline or an anti-infective agent
like Bismuth iodoform paraffin paste, and is introduced
using Tilleys nasal dressing forceps.
An antibiotic cover is essential. If blood flows down
the nasopharynx a post-nasal pack may be necessary.
In uncontrolled epistaxis disruption of some arterial
supply should be considered.
Patient should be put on bed rest, nursed in propped
up position, should be given sufficient fluid to drink
and phenobarbitone to allay his anxiety.
Once bleeding has stopped the cause should be searched for. The commonest causes are hypertension, acute
exanthemata, bleeding and coagulation disorders,
188
intranasal polyps, malignancy, leukaemia, haemangioma of nose, telangiectasis and injury to nasal
structures.
LOCALIZED OTITIS EXTERNA

Due to infection of hair follicle in the cartilaginous
external canal by Staphylococus aureus.
Earache made worse by moving or touching pinna.
Orifice is red and swollen.
Treatment
Wicks soaked in Glycerine and MagSulph paste are
generally placed in canal each day.

Inj Crystalline Penicillin IM 5 lacs qid is to be given.
Soluble Aspirin to relieve pain.
Sofradex cream
or Betnovate-N cream
or Millicortin vioform cream
If associated furunculosis capsule Ampicillin 250 mg
qid or Doxycycline 100 mg bd
SECONDARY OTITIS MEDIA

It is a common cause of deafness in childhood as a
result of obstruction of eustachian tube.
Deafness in children without pain but may be dullness
of ear.
Tuning fork tests and audiometry test may show
deafness to be conductive type.
No ear discharge.
There may be symptoms of enlarged adenoids and
chronic sinusitis.
VERTIGO
The following ear disorders may cause vertigo:
Mnires disease.
Injury to ear.
Positional vertigo.
Labyrinthine.
Diseases of acoustic nerve, cerebellum and cardiovascular system.
VERTIGO DUE TO MNIRES DISEASE

Sudden onset of vertigo, nausea and vomiting in
middle aged.
190
Tinnitus prior to and during attack.

Progressive sensory neural deafness.
Frequent remissions and exacerbations.
Treatment
Bed rest in dark, quiet room.
Avomine 25 mg 6 hourly by mouth.
In severe cases with vomiting Phenergan 25 mg
with Largactil every 6 hourly.

Restriction on fluid intake to 3 cups a day.
Complete salt restriction.
Abstinence from smoking.
To avoid undue mental stress and overwork.
Decompression of saccus endolymphaticus to
reduce pressure on membranous labyrinth.
When the ear is severely deaf with troublesome
vertigo: the best method for relief of vertigo is
destruction of labyrinth.
Injection Luminal 30 mg IM twice daily.
or Injection Calmpose 10 mg IM twice daily.
Tab Stemetil 12.5 mg.
or Tab Marzine or tab Dramamin 1 bd.
or Tab Diligan 1 tds.
or Tab Vertin 1 tds.
Eye Disorders
191
EYE DISORDERS
ACUTE GLAUCOMA
Severe pain and tenderness of eye.
Pain is along trigeminal nerve to produce severe
hemicrania.
Within few hours patient may complain of misty
vision and seeing of rainbows or halos around bright
lights.
Progressive loss of vision.
Congestion of eye is more prominent.
Cornea becomes cloudy.
Pupil becomes irregularly dilated and is frequently
oval or vertical in shape.
Pupils fail to react to light and accommodation.
Treatment
Advise to consult ophthalmic surgeon to avoid risk
of irreparable blindness.
192
Keep the pupil presistently contracted by putting
Pilocarpine 4% very frequently every 5 min for 1

hour, then every hour for 6 hours and then 2 hourly.
Tab Diamox (Acetazolamide) 500 mg stat and 250
mg 6 hourly to reduce intraocular tension in all
cases of glaucoma.
IV Mannitol 350 ml at rate of 40 drops/minute/
oral glycerol.
Oral Potklor 1 tsf tds
Timolol 0.25-0.5% eyedrops for chronic cases.
CATARACT
Generally in an old age.
Gradual painless loss of vision.
During development of cataract diplopia, polyopia
may develop.
Usually the lens of one eye is first affected.
Later on both eyes may develop complete opacity
and become greyish white in colour.
Management
No effective medical treatment is known.
Operation is the only choice when cataract is
matured.
Intraocular lens implantation is advisable.
Eye Disorders
193
CONJUNCTIVAL DISCHARGE
Purulent
Watery discharge
Tearing + ropy
Discharge
Bacterial infection
Conjunctivitis
Corneal infection
Viral conjunctivitis
Keratitis
Allergic conjunctivitis
Ocular Discomfort
Watering is due to inadequate tear drainage and
obstruction of lacrimal drainage.
Itching is due to allergic eye disease.
Burning is due to dryness of eye, atropine drug or
ocular disease.
Photophobia is due to corneal disease
Foreign body sensation is due to corneal or conjunctival foreign body
Ocular pain is due to trauma, infection or raised
intraocular pressure.
Pupils
Pupils are commonly examined for size, reaction to light
and accommodation.
i. Large poorly reactive pupil.
194
Third nerve palsy

Iris damage due to acute glaucoma
Pharmacological mydriasis
ii. Small poorly reacting pupil
Horners syndrome
Neurosyphilis
Extraocular Foreign Bodies
Most of foreign bodies are small coal, dust, steel, wings
of insect.
Essentials of diagnosis
Sudden discomfort in eye
Reflex blinking
Irritation if the foreign body is in sulcus subtarsalis
or embedded in cornea.
Lacrimation
Blepharospasm.
Treatment
Wash the eye with plenty of clean water or saline.
Most of the foreign bodies will be washed out by

this.
If foreign body is sticking it should be removed
after proper aseptic precautions by a specialist.
Industry worker should use goggles while at work
as a preventive tool.
Eye Disorders
195
Injury by Chemicals and Burns

Burn injury can be caused by hot water, steam, explosive powder, acid/alkalis.
Essentials of diagnosis
Red eye with swelling of lids/conjunctiva.

Marked blephrospasm.
Photophobia.
Marks of burns on surrounding skin.
Marked congestion and chemosis.
In severe cases cornea appears dull and opaque.
Treatment
Wash the eye thoroughly with plenty of water
immediately
If corneal erosion is there treat it like an ulcer.

If cornea is not involved steroids may be used
locally to prevent formation of symblepharon.
CONJUNCTIVITIS
Eye is uncomfortable but not painful.
Photophobia is present.
Discharge may be purulent, mucopurulent or
watery.
196
Hyperaema is superficial.
Intraocular tension, size and reaction of the pupils
remain unaffected.
Treatment
Avoid dust and sunshine. Purulent exudates should
be washed with preboiled water before instillation

of antibiotic drops.
Frequent instillation of broad spectrum antibiotic
drops depending on the severity of the disease such
as Soframycin, Garamycin, Chloramphenicol or
Neosporin eye ointment.
Decongestant drops such as Tetrahydrozoline eyedrops (Visine) Naphazoline (Clearine eyedrops).
These drops are instilled three or four times a day.
Antibiotic ointment at bed time, i.e. Neosporine or
Soframycin. In severe casesCap Ampicillin 500
mg qid.
CORNEAL ULCER
Eye is severely painful.

Photophobia and blepharospasm are marked.
Free running of water from eyes.
Floor of ulcer readily stains with Fluoroscein eyedrops.
Eye Disorders
197
Infiltration around the margin of ulcers by dye.

There is a tendency to perforate.
Treatment
Protection of eyeball by applying pad and bandage.
Two hourly Soframycin and Neosporin drops or
ointment.
Atropine eyedrops or ointment three times a day.
Ridinox eyedrops in cases of viral ulcer, i.e.
Herpes simplex.
Sometimes local cauterisation is needed.
Systemic antibiotics and anti-inflammatory drugs
like, Peelox and Ibuprofen may be given. If large

ulcer fortified Soframycin 15 mg/ml every hour
alternately with fortified Cefazolin 50 mg/ml
every hour.
DETACHMENT OF RETINA
Sudden rapid diminution or loss of vision in the
affected eye.
Flashes of light, transient attacks of decreased
vision.
198
Floating specks in front of eyes.

Crescentic tear is most frequent.
Greyish red colour at the fundus.
Management
No effective medical treatment.
Produce aseptic choroiditis around the hole by
means of laser coagulation or perforation

diathermy/electrolysis.
IRITIS
Severe pain.
Circumcorneal congestion.
Photophobia and lacrimation.
Affected pupil is smaller and reacts sluggishly to light.
Visual acuity is not necessarily diminished.
Treatment
Eyes need protection.
Pain can be relieved by giving Disprin/Analgin
group of drugs thrice daily.
Local treatment.
Atropine 1% eyedrops three to four times daily.
or
Eye Disorders
199
Atropine 1% eye ointment three times daily
(Atropine hypersensitivity is more common with

Atropine ointment than drops).
Corticosteroid eyedrops 4-6 times a day. Dexamethasone (Decadron). Betamethasone (Betnesol).
Hydrocortisone drops (Allucort).
Cortisone eye ointment at bed time, i.e. Betnesol,
Cambisone and Kenalog-S ointment.
Hot fomentation.
Sub conjunctival injection of Corticosteroids like
Betamethasone 1/2 cc mixed with injection
Mydricaine (combination of Atropine, Adrenaline
and Xylocaine) 0.3 cc can be repeated after 12 hours.
Systemic treatment
Anti-inflammatory drugs like Ibuprofen, Oxyphenylbutazone one thrice daily.
Antibacterial or antibiotic drug like Septran DS
twice daily.
REDNESS OF EYE
It is due to hyperaemia of conjunctiva, episcleral or
Ciliarys vessels
Subconjunctival haemorrhage
Mild
+ to ++
No effect
Clear
Normal
Organism
Conjunctival Diffuse
redness
Pain
Discharge
Vision
Cornea
Pupil size
Smear
Acute
conjunctivitis
Common Causes
Circumcorneal
Moderate
None
Blurred
Clear
Small
No organism
Acute
uveitis
++
Watery or purulent
Blurred
Clarity changes
Normal
Organism in
corneal ulcer
Mainly
circumcorneal
Trauma
infection
200
According to the causative factor.
Treatment
Diseases of Children
201
DISEASES OF CHILDREN
ACUTE RHEUMATIC FEVER

Migratory or flitting signs of joint inflammation and
pain.
Single cycle of fever for 10 to 15 days, each joint
inflamed for 4-6 days, recovers and is not again
affected.
Fever may rise to 101-103F. Shows daily variation
of 1-3F. Fever may last from few days to weeks.
Systolic murmur of mitral regurgitation is the early
sign. Basal diastolic murmur of AR is heard.
Mitral stenotic murmur develops only some years
after acute episode of rheumatic fever.
ESR is elevated with leukocytosis. PR interval is
prolonged on ECG.
Management
Rest and nursing care.
Patients with carditis should be kept in bed till
202
a. Intensity of heart murmur has diminished,

b. Sleeping pulse rate is below 100 per minute,
c. Patient starts gaining weight.
High protein and high calorie diet.
Oral Penicillin 200,000 units qds for 10 days.
or
If allergy to Penicillin.
Erythrocin 250 mg qds for days (50 mg/kg/day).
Aspirin 60 mg/pound per day in 6 divided doses
with milk or after meals for one week and then
doses are to be reduced.
Steroids are to be given when there is cardiac
enlargement or cardiac failure. Prednisolone 2 mg/
kg/day for 3-6 weeks.
Symptomatic treatment.
Cardiac failure Digitalis in small dose, oral
diuretics and oxygen.
Pain and restlessness Codein for dry cough and
pain or Morphine if needed.
Rheumatic Chorea
Prophylaxis of rheumatic fever.
Phenobarb 6 mg/kg/day and or Largactil 2 mg/
kg/day taper as symptoms improve.
Serenace 0.25 mg tab 1-3 days or Calmpose 2 mg
tds.
203
Treat every attack of sore throat vigorously.

Injection Penidura LA 12 lacs units once in 3 weeks at
least up to 20 years of age or 5 years after last attack
whichever period is longer.
or
If allergic to Penicillin, Erythromycin 250 mg bd.
ANAEMIA
Lemon yellow tint of body.

Breathlessness, palpitation, fatiguability.
Headache, vertigo, irritability.
Anorexia, haemic murmur.
Splenomegaly, Koilonychia.
Oedema of feet.
Hb percent will be low, ESR may be raised.
Management
Iron, oral or IM for iron deficiency anaemia.

Mebex in cases of hookworm infestation.
B12 or Folic acid for megaloblastic anaemia.
Testosterone or anabolic steroid for aplastic anaemia.
Corticosteroid, i.e. Prednisolone 40-60 mg daily for
autoimmune haemolytic anaemia.
204
AORTIC STENOSIS
Dyspnoea on effort is often the first symptom, orthopnoea and paroxysmal dyspnoea follow as a result
of left ventricular failure.
Dizziness is most frequent when standing.
Syncopal speels begin after onset of left ventricular
failure.
Systolic thrill in second right interspace. Ejection systolic murmur.
Interval between apex beat and radial pulse prolonged.
Low systolic BP with narrowed pulse pressure.
Management
1. Always recommend surgical valve replacement
even though the symptoms are slight or absent.
AORTIC REGURGITATION
Dyspnoea on exertion.
Angina pectoris on heavy exertion.
Palpitation due to forceful heart beat.
205
Syncopal attacks may be due to cerebral anoxia.

Diastolic murmurHigh pitched murmur maximal
in early diastole.
Water hammer or collapsing pulse.
Visible arterial pulsations in neck.
Wide pulse pressure.
ECG shows left ventricular hypertrophy.
Management
1. Left ventricular failure of chronic aortic regurgitation.
Digitalis (Digoxin).
Salt restriction.
Diuretics.
2. Nitroglycerine and long acting nitratesIf chest
pain and AR.
3. ArrhythmiaTreated vigorously.
4. Syphilitic aortitisPenicillin 5 lacs 6 hourly 10
days.
5. Valve replacement.
BRONCHOPNEUMONIA
Onset is acute with fever which rises rapidly up to
103 F.
206
Dyspnoea is constant, cough is dry and painful.

Child looks exhausted with half open eyes. There
may be diarrhoea and vomiting.
Restlessness, delirium, insomnia, apathy and convulsions may occur.
Hyperventilation may lead to dehydration.
Coarse crepitation heard all over chest.
Management
Good nursing and frequent feeds of dilute milk.
Sedatives may be given if restlessness is dis-
tressing.
Crystalline Penicillin 5 lacs IM 6 hourly.
or
Ampicillin 100 mg/kg/day.
or
Amoxycillin 50 mg/kg/day.
Sedative cough linctus, oxygen in cyanosis.
In collapse stimulants to be given.
Fever to be controlled by sponging or with Paracetamol.
CHICKENPOX
Causative agent is varicella zoster virus and transmission is through drouplets. Incubation period is 14-15
days. Period of infectevity is 7 days before eruption.
207
Headache, sore throat and fever for 24 hours.
Earliest lesions on buccal and pharyngeal mucosa.
Rashes develop in crops at first on back then chest,
abdomen, face and limbs.
At first macules, in a few hours become pink papule
which soon turns into vesicle. Vesicle turns into pustules in 24 hours. Scabs in 2 to 5 days.
Distribution is centripetal, more on upper arms and
thighs, upper part of face and in concavities.
Crops mature very quickly and spots dry up in 48
hours then new crops appear.
Itching may develop.
Generalised lymphadenopathy may be seen.
Complications include pneumonia and post-varicella
encephalitis.
Treatment
Isolation and bed rest.
For pruritus calamine lotion.
Antihistaminics by mouth.
For pneumonia a course of erythromycin + B complex.
For encephalitis oxygen and corticosteroids.
208
CONGENITAL SYPHILIS
Anaemia, wasting, fever, fretfulness.
Infant undersized, marasmic, wrinkled face and
wizened appearance.
Eyebrows disappear.
Hoarseness of voice due to laryngitis.
Liver is enlarged, firm, smooth, non-tender.
Periosteitis of shafts of long bones.
There may be maculopapular, circular, slightly elevated skin rashes which do not itch.
Iritis or choroiditis.
Hutchinsons teeth.
Management
Penicillin is the drug of choice. Total dose of 200,000
units per pound given as 20,000 units per pound

daily of PAM.
DENGUE
It is caused by group B arbovirus, transmitted by bite of
Aedes mosquito a domestic habitat, a day biter.
Incubation is 2-7 days.
209
Sudden onset of high fever.

Sore throat, conjunctival injection and facial flushing.
After 2-3 days of fever rashes appear on dorsum of
hand and feet and spreading centrally.
Some patients develop petechial rashes and GIT
haemorrhages
Leucopenia is a hall mark of disease.
Thrombocytopenia occurs.
Complications include pneumonia, orchitis and
iritis.
Treatment
Treatment is symptomatic.
Patient dies due to circulatory failure within 1-2
days.
Antibiotics are given to check chest complications.
DIPHTHERIA
Maximum age incidence between 2-5 years. Mode
of infection is by droplet. Incubation period 2-6 days.
Insidious onset with excessive salivation.
Thin and glistening membrane white in early stage
and becomes thick and opaque later on.
210
Membrane is adherent and bleeds on forcible

removal.
Edge of membrane is well demarcated and shows
inflammation.
Low grade pyrexia, pallor and listlessness.
Difficulty in breathing.
Management
Complete bed rest. Admit in hospital.

Liquid diet.
IV Glucose.
Antitoxin by IV drip or IM injection as a single
dose.
If Tonsillar involvement is unilateral20,000 IU.
If Tonsillar involvement is bilateral40,000 IU.
If Tonsillar and pharyngeal involvement60,000
IU.
If Laryngeal and nasopharyngeal involvement
80,000 IU.
Antibiotics Penicillin 250,000 units IM every 6
hours/Erythromycin 250 mg 6 hourly for 5 to 7
days.
O2 inhalation. If respiration remains distressed
tracheostomy may be done.
211
INDIAN CHILDHOOD
CIRRHOSIS
Early stage
There may be infective hepatitis.
Child becomes irritable, is off colour and does not
play.
Diarrhoea, low grade fever, flatulence.
Liver is just palpable and firm with sharp margins.
Late stage
Child looks ill and frankly jaundiced.

Abdomen becomes prominent with superficial veins.
Liver is palpable with spleen too.
Oedema of ankles, puffiness of face and ascites.
Child may die of hepatic coma, intercurrent infection
or bleeding episode.
Management
Full diet rich in protein. Extra butter or ghee to be
avoided.
Methionine and choline in the form of syrups.
Neomycin 50-100 mg/kg/day orally.
Steroids in cases of marked anorexia or persistent
jaundice.
212
Penicillamine may be tried.

Diuretics for oedema and ascitesLasix 2 mg/kg/
day.
INFANTILE DIARRHOEA
Dietic diarrhoea
Excess of fatLoose, curdled and foul smelling stools.
Excess of carbohydrates Loose, green fronthy, acid
stools.
Infective diarrhoea
Onset with loose diarrhoea type of stools, greenish
slightly offensive with mucus and curd. Number of
stool varies from 2 to 10 with slight fever. In severe
cases rapid dehydration may set in.
Parenteral diarrhoea
Due to acute otitis media, mastoiditis, meningitis and
tooth eruption.
Management
Acute diarrhoea
Electral or Prolyte powder 2 tsf in 100 ml water
213
ORS
NaCl
3.5 gm
2.5 gm
NaHCO3
KCl
1.5 gm
Glucose
20 gm
To be dissolved in 1 litre of water.
Dont stop breastfeeding.
If moderate to severe dehydration when oral fluids
are not tolerated then IV fluids 200-250 ml/kg in
24 hours.
If signs of hypopotassemiaAdd KCl 1 ml or 2
mEq in 100 ml glucose.
If infant is toxicColistine sulphate 1-2 tsf qid.
or Furoxone tsf qid.
or Gramoneg 50 mg/kg in 2-3 divided doses.
or syrup Metrogyl 15-20 mg/kg/day in 3 divided
doses is amoebic dysentery.
If above drugs fail then
Injection Gentamicin 4 mg/kg IM in 2-3 divided
doses
Neutrolin B syrup -1 tsf tds.
KWASHIORKOR
Generalised oedema. Extremities often cold, hands
and feet may be dusky.
214
Child appears apathetic but resents attention.

Oedema appears on feet and face and often spreads
to involve all parts of the body.
Skin erythema soon changes into pigmented patches.
Hair becomes discoloured and brittle. Many of the
hair can be pulled out easily.
Diarrhoea is a prominent feature with watery
offensive stools.
Management
Use of adequate proteins and impart education to
mothers about diet for such children.
3 to 5 gm of proteins per kilogram of expected
body weight, low sugar diet, palatable and

digestible with small frequent feeds.
Skimmed milks and milk proteins are most satisfactory source of proteins.
Multivitamin drops/syrup may be given. B complex syp 1 tsf daily.
If concurrent respiratory or urinary infection to be
treated with systemic antibiotics.
Vitamin AD capsule 1 daily.
MARASMUS
Child is irritable and cries excessively.
215
Sharp features with monkey face. Progressive loss

of subcutaneous fat.
Sunken and lustreless eyes with sunken anterior
fontanelle.
Apathy and lack of playful movements.
Delayed milestones, delay in learning to sit, stand
and walk.
Failure to gain weight and height.
Abdomen may be sunken and any reveal the
outlines of the intestines beneath.
Management
Diet
Adequate intake of calories, fats, vitamins and
carbohydrates.
Frequent feeds are to be given.

Groundnuts and soya bean preparations are to be
given.
Educate the parents about the requirement of diet
as 50 calories per pound. Multi-vitamins may be

given.
Correct infection and infestation like roundworms.
MEASLES
It is a systemic viral disease transmitted by infected
droplet. Incubation period is 10-12 days.
216
Prodromal symptoms are like that of flu.
Non-productive cough, watering redness of eyes and
fever.
Koplicks spots appear as tiny table salt crystals on
cheeks mucous membrane.
After 3-4 days rash appear on face.
Fever rises abruptly but subsides once eruption of
rashes is complete.
To start rashes are pin head papules and coalesce to
form brick red morbiliform rash.
Rash fades after 4 days in order of appearance.
Eyes and pharynx becomes congested.
Lymph nodes of angle of jaw and posterior cervical
region are enlarged.
Complications include encephalitis, otitis and myocarditis.
Treatment
Isolation. Communicability is more in pre-erup-
tive stage till rashes remains.

Bed rest
Cough suppressant.
Saline eye sponge and nasal drops.
Erythromycin/antibiotic to prevent respiratory infection.
Gammaglobulin 0.25 ml/kg can modify the course
of disease.
Live attenuated virus disease prevents the disease.
217
MITRAL REGURGITATION
Effort dyspnoea progressing to orthopnoea and
paroxysmal cardiac dyspnoea.
Dramatic onset of pulmonary oedema.
Pansystolic murmur, high pitched blowing starts
immediately after the first sound.
Soft first heart sound.
Third heart sound usually audible at apex due to
rapid filling of LV.
X-ray shows LA and LV enlargement.
Management
1. If valve disease predominant and symptoms
severeMitral valve replacement/valvoplasty.
2. Infective endocarditis should be brought under
control before surgery.
MITRAL STENOSIS
May be congenital or rheumatic in origin.

Undue dyspnoea on exertion.
Blood stained sputum.
Palpitation with regular or irregular rhythm.
218
Cyanosis usually peripheral due to low cardiac

output and central cyanosis due to pulmonary
congestion.
Highly coloured cool cyanotic patches over cheeks.
Presystolic and mid diastolic thrill may be felt.
On X-ray, double contour of right heart border,
elevation of left main bronchus, posterior
displacement of barium filled oesophagus, Kerleys
B lines and straightening of left heart border.
Management
Prevention of recurrence of rheumatic fever by
giving Benzathine penicillin G 1.2 million IM once a
month.
To check atrial fibrillation digitalis may be given.
To prevent pulmonary oedema diuretics are
necessary.
Surgical mitral valvotomy. Indications are:
Uncontrolled atrial fibrillation.
Pulmonary oedema.
Following embolism.
MUMPS
It is a virus disease of children and portal of entry is
upper respiratory tract. Incubation period is 16-21
days.
219
There will be moderate fever, sore throat.

Swelling of face on the affected side.
Pain or tenderness beneath angle of lower jaw.
Swelling of parotid gland reaches its maximum on
3rd day, remains at peak for 2 days and then subsides.
Lobe of ear is centre of swelling and is tender.
Skin over parotid gland is red, shiny and tender.
Fever may be 103 104F, remittent or intermittent
and falls by lysis in 3 days.
Orchitis, epididymitis and otitis media are its complications.
Treatment
Rest and isolation in bed for 10 days

Liquid or semisolid food
Mouth wash
Aspirin/ combiflame for 3-5 days
Prednisolone 15 mg qds if swelling is severe.
POLIOMYELITIS
It is caused by RNA virus which replicates in GI tract.
Virus is stable having three types 1, 2 and 3.
Prodromal stage Coryza, sore throat or cough. Fever, drowsiness and sweating. Fever touches normal in 36-48 hours and rises again.
220
Pre paralytic stage Fever up to 39C with pain stiffness in back. Hyperesthesia of skin develops. Kerning
sign is positive.
Flickering movements in muscles may be seen.
Patient remains active.
Paralytic stage There is still fever. Paralysis develops within five days of onset of disease. It progresses
for 1-3 days.
Lower limbs are mostly affected especially quadriceps, tibialis anterior and paroneal group. In upper
limb deltoid is affected.
Diaphragm and intercostals muscles may be
affected.
Convalescence Initial paralysis diminishes to some
extent. Paralysis is flaccid type and often contraction
persists.
Treatment
Rest in bed.
Sedation and moist heat.
Splints to paralysed muscles.
Lastly gentle massage together with active and
passive movements.
To prevent the disease best is vaccination.
221
RICKETS
Head is larger with frontal bossing. Anterior
frontanelle is larger and there is delayed closure.
Beading of ribs specially 4th, 5th, and 6th. Lateral
spinal curvature is common.
Epiphyseal enlargement of wrists and ankles, knock
knee and bow legs.
Pot belly due to weakness of abdominal muscles
restlessness at night with rolling of head over
pillows.
Delay in dentition.
On X-ray, fraying and cupping of distal ends of radius
and ulna.
Management
Proper exposure of body to sun light.
Vitamin D 1200 units daily.
Massive doses of vitamin D 600,000 iu in oil
solution.
Compound of calcium and phosphorus preferable.
Ostocalcium tab 2 bd may be given.
222
SCURVY
More common in artificial fed children.
Child becomes fretful, pallor or tenderness of legs
cause child to cry whenever touched. Digestive
disturbances and loss of weight.
Gums may swell up into large purple fleshy masses
which bleed on touch, teeth become loose.
X-ray shows increased density of long bones as white
lines. Signet ring appearance of epiphysis. Ground
glass appearance of shaft of diaphysis and pencil
lining of cortex.
Management
Child should be disturbed as little as possible. The
cot may be lined with cotton.
Inj. Redoxon forte 500 mg IM stat or vit C drops 20
drops tds.
Vitamin C 100 mg twice daily.

3 to 4 ounces of fresh orange juice or tomato juice
daily.
WHOOPING COUGH
It is caused by gram-negative cocobacillus Bordetella
pertussis. Incubation period is 7-16 days. Infectivity is
223
greatest during catarrhal stage. Symptoms are of

upper respiratory catarrh.
Cough becomes paroxysmal.
Each paroxysm consists 15-20 short coughs followed
by deep inspiration.
Closed glottis produces whoop.
Episodes of chocking and apnoea may be a major
manifestation.
There may be engorged conjuctiva periorbital edema
and petechial haemorrhage.
Scattered ronchi heared in chest.
X-Ray chest may show enlarged mediastinal nodes
and patchy atelectasis.
Treatment
Erythromycin 50 mg per kg of body weight in
4 divided doses is drug of choice.
A short course of steroid may shorten the clinical
course.
Prevention includes three injections of pertuses
vaccine. Pertuses suspension is incorporated in triple

vaccine with alum, precipitated diphtheria and tetanus toxoid. Booster injections are called for one
and five years after the initial course.
MEDICAL EMERGENCIES
ACUTE ALCOHOL
INTOXICATION
Smell or alcohol is characteristic.
Gastric irritation, nausea and vomiting.
Irrelevant talks, incoordination.
Hypotonia, depressed jerks.
Pupils normal or slightly dilated.
In severe intoxication
Loss of jerks.
Extensor plantar response.
Dilated pupils.
Irregular breathing.
Coma.
Death may occur due to medullary paralysis.
Management
Removal of unabsorbed poison by gastric lavage.
Correct hypoglycaemia by 50 per cent Glucose, 50
ml IV.
Medical Emergencies
225
If patient is still drowsy give 5 per cent Glucose
drip for 4 to 6 hours with Inj Vitamin B complex 2 ml.
If patient still does not improve give Mannitol diure-
sis by IV infusion fo 350 ml of 20 per cent Mannitol.

For irritable retching and acute alcoholic excitation
give 10 mg Diazepam.
Haemodialysis if blood ethanol concentration > 7500
mg/L or if metabolic acidosis.
ACUTE MORPHINE POISONING

Pin point pupil.

Respiratory depression.
Cyanosis.
Hypothermia.
Hypotension.
Coma.
Treatment
0.6-12 mg of Atropine sulphate is injected as
physiological antidote.
Apomorphine hydrochloride 6 mg is also given.

Stomach wash first with plain water for chemical
examination then with 0.2 per cent KMNO4.
226
Nalorphine or Naltrexone for respiratory depres-
sion.
Hot coffee or strong tea.

2 gm of Sodabicarb with 250 ml of tea helps in
preventing acidosis.
Shock is treated with IV 5 per cent Glucose with
Noradrenaline if the blood pressure is very low.

O2 inhalation if cyanosis is present.
Position patient correctly to avoid risk of aspiration

of vomitus. Naloxone 0.4-1.2 mg IV dose may be
repeated if pupillary constriction and respiratory
depression are not reversed within 1-2 minutes.
If Naloxone is not availableInjection Lethidrone
(Nalorphine) 10 mg IV stat. Watch for dilatation of
pupils and acceleration of respiratory rate. Repeat
10 mg after 1 hour if respiration slows. Total dose not
to exceed 40 mg.
ACUTE RESPIRATORY
FAILURE
Sudden inability of the respiratory apparatus and
heart to maintain adequate arterial oxygen.
Important causes are chronic airway obstruction,
chronic bronchitis, emphysema, asthma.
Medical Emergencies
227
Restlessness, headache.
Confusion, tachycardia.
Central cyanosis, hypotension.
Depressed respiration.
Management
Type I respiratory failure (acute failurecyanosis
is a presenting feature). High concentration of O2

at 6 L/minute.
Type II respiratory failure (chronic failure, cor
pulmonale) Treat cause, i.e. infection, massive
pleural effusion, drug overdose, etc).
Oxygen by nasal prongs 24 per cent or ventimask
28 per cent. Repeat ABG to ensure that PO2 is maintained at over 50 mm Hg. If this cannot be achieved
use respiratory stimulant or mechanical ventilation.
Ampicillin injection 500 mg 6 hourly. or
Injection Benzyl penicillin 2 mega units IM 12
hourly. After 48 hours if sputum culture report is
available give antibiotics according to sensitivity.
Injection Aminophylline 500 mg IV slowly in
5 per cent Dextrose over 6 hours.
Tab Salbutamol 4 mg 6 hourly.
If patient is drowsy or unable to cough give
Injection Doxaprem by continuous IV infusion 1-3
mg/minute. If level of conciousness deteriorates
or patient is exhaustedPut on mechanical
ventilation to restore pH between 7.38-7.42.
228
ACUTE RETENTION OF URINE

Obstruction distal to bladder leads to retention of
urine, i.e. prostatic enlargement, bladder neck
obstruction. Vesical diverticulum, calculi or growth
in pelvic cavity, neurogenic bladder.
To start there will be hesitancy, poor stream and
terminal dribbling.
Bladder may be distended.
If not attended promptly may cause minimal hydronephrosis and renal failure.
Management
If patient is in bed, make him sit or stand and pass
urine. Hot water bag alternating with cold water bag
to lower abdomen may help.
If not relieved, catheterize bladder with strict
asepsis, use 12 or 14 F guage catheter for females
and 16 or 18 F for males.
If cather cannot to passed do a suprapubic cystostomy with a 10 to 14 F catheter.
Urinary antiseptics like Tab Septran DS 1 bd or
Norflox/Uroflox 400 mg twice daily.
Definitive treatment
If hypotonic bladderTab Urecholine 25-30 mg
tds or use self intermittent catheterisation.
Medical Emergencies
229
If stricture urethraEndoscopic urethrotomy or
open urethroplasty or dilatation.
If enlarged prostateProstectomy.
If obstructive calculusEndoscopic extraction of
calculus.
AGRANULOCYTOSIS
Chloramphenicol, Phenylbutazones, Chlorpromazine,
Barbiturates may cause it.
History of taking offending drugs.

Sore throat followed by chills.
Increasing fever and dysphagia.
Areas of necrosis seen in tonsillar region.
Enlarged cervical lymph nodes.
Management
Withdrawal of offending drugs.

Isolation of patient in sterile room.
Gentamicin 60 mg 8 hourly IM or Inj Ampicillin 500
mg 6 hrly or Inj Cephalosporin 500 mg 6 hrly or Inj

Cefotaxime 1 g bd.
230
ANAPHYLACTIC SHOCK
Rapid onset of urticaria.
History of taking Penicillin injection or any other
injection capable of causing anaphylactic shock.
Choking of throat.
Difficulty in breathing.
Nausea/vomiting.
Management
IV Adrenaline 0.5 ml, 1:1000 in 10 ml saline slowly
over a period of 5 minutes. It may be given SC

also.
IV or IM Hydrocortisone Hemisuccinate 100 mg
or 8 mg Dexamethasone may be repeated after 4
hours.
Inj Avil 20 mg stat.
Clear the airway and give O2.
ARSENIC POISONING
Patient complains of sensation of heart and burning
pain in throat.
Medical Emergencies
231
Violent purging with distressing tenesmus and

burning sensation at rectum.
Stool resembles rice water stool of cholera but mixed
up with blood.
Urine is suppressed, scanty.
Distressing cramp in calf muscles and severe
restlessness.
Painful cutaneous eruptions.
Mind remains clear but there may be delirium,
convulsions and lockjaw.
Clonic or tonic spasms preceding death.
Treatment
Vomiting should be encouraged and copious drinks
of warm water are given. Emetics may be given.
Stomach wash with KMNO 4 is to be done.

BAL 3 mg/kg/body weight every 4-6 hours for
2 days, then every 6-8 hours.
Butter is useful as it prevents absorption of arsenic.

Massage to relieve cramps.
IV drip 5 per cent Glucose to combat shock.
BARBITURATE POISONING
Drowsiness to deep coma.
232
Hypotonia of limbs.
Depression of deep reflexes. Plantars may be
extensors.
Hypotension.
Hypothermia, shock and anuria.
Bullous rash on skin.
Dilated and non-reacting pupil.
Hyporeflexia.
Treatment
Forced alkaline diuretics to be started unless contraindicated by presence of organic heart disease or renal
failure or severe hypotension, shock or anemia or
respiratory paralysis. IV line to be sarted and patient
catheterised. Each cycle consist of 5 per cent Dextrose
saline 500 ml +10 ml Kesol 15 per cent with 7.5 per cent
Sodabicarb 150 ml and Mannitol 25 per cent 350 ml.
Fluids to be given at the rate of 350-400 ml/hour. The
number of cycles and duration of treatment depends
on severity of poisoning and response to treatment.
Stomach is washed with warm water and activated
charcoal or tannic acid, 10-15 gm of sodium sulphate
is left after wash.
In severe cases O 2 inhalation and artificial
respiration are started.
Best antidotes are Bemegride or Megimide and
Leptazol. These are given in 5 per cent Glucose
Medical Emergencies
233
drip in a dose of 15 mg of Leptazol and 50 mg of

bemegride every 5 minutes till pharyngeal and
laryngeal reflexes return.
Amphetamine sulphate 10 mg may be given to
shorten the duration of coma.
Noradrenaline may be given if blood pressure is
too low.
BEE STING
History of bee bite.

Local pain, swelling.
Itching, erythema and wheal formation.
In severe bite, urticaria, oedema of glottis,
bronchospasm, etc.
Management
Remove sting by scraping with blade or finger nail.

Do not grasp with forceps to avoid squeezing more
venom from sac into skin.
Local application of antihistaminic cream.
Analgesics like Novalgin.
Oral antihistamine, i.e. Avil 1 tds.
234
In severe analphylactic reaction, Adrenaline
injection 0.5 ml subcutaneous and Corticosteroid

Prednisolone 20 mg single dose.
BURNS
History of burn.
Blisters/ulcer.
Severe pain.
Symptoms of shock.
Management
Put off the fire by:
a. Falling and rolling on the floor in a blanket to

put out the flames.
b. Water is an effective and comfortable agent to
put off the flames.
c. Immersion in cold water relieves pain and
minimises thermal damage.
Wound should be covered with sterile dressings.
Chemical burns should be washed off with plenty
of water.
All burns except minor ones need hospitalisation.
Medical Emergencies
235
Relief of pain by analgesics. Tab Novalgin sos.

Clean the parts by soap water or 1 per cent Savlon,
put vaseline gauze and change dressing on 3rd day

only.
Fluid balance is to be maintained by giving IV
Ringers lactate.
Antibiotics to prevent secondary infections.
Skin grafting for raw areas.
CARDIAC ARREST
Important causes areMyocardial infarction, rapid
over dose of anaesthesia, sudden obstruction of
airways, digitalis, electric shock, anaphylaxis.
Sudden collapse.
Unconsciousness.
Cyanosis/cessation of heart sounds and respiration.
Dilated pupils.
Management
Put the patient in supine position.
Establish an open airway.
Hyperextend the neck.
236
Remove obstructing substances, i.e. dentures, food,
mucus, blood from pharynx with fingers.
Chest thumpStrong blow to midsternal area may
terminate asystole and ventricular tachycardia.
Mouth-to-mouth respiration.
Cardiac massagePlace heel of palm of left hand
over xiphoid covering it crosswise with right hand.

Give firm compression with weight of body to push
sternum an inch or more. Do this 60 times per
minute.
Injection Sodabicarb 50 ml 7.5 per cent. Repeat
after 10 minutes.
Injection Adrenaline (1:1000) dilute 1 ml in 20 ml
saline and inject 1 ml IV or intracardiac every 10
minutes. If above measures fail heart action to be
checked by ECG.
If asystoleRule out fine ventricular fibrillation by
ECG.
or
Injection Isoprenaline 1-2 mg IV.
Injection Decadron 8 mg IV.
If ventricular fibrillationExternal DC defibrillation
given.
If refractory ventricular fibrillationInjection
Bretylium torylate 100 mg IV.
Effective external cardiac massage.
If BP is low then 30 mg Mephentermine in 500 ml
of 5 percent Glucose at the rate of 20-30 drops/
minute.
Medical Emergencies
237
CARDIOGENIC SHOCK
Important causes are myocardial infarction, acute
cardiac arrhythmias, embolism, etc.
Cold and clammy skin.
Peripheral cyanosis.
Rapid thready pulse.
BP persistently less than 50 mm Hg.
Oliguria.
Restlessness.
Management
Oxygen by nasal catheter 4-6 L/min.
Noradrenaline 2 mg in 500 ml of 5 per cent Glucose
or Dopamine dobutamine drip.
IV Digoxin 0.25 mg diluted with 5 per cent Glucose.

Inj furosemide 50-80 mg IV.
Inj Aminophylline 250 mg in 20 ml of 20 per cent
Glucose.
Dexamethasone 8 mg 4-6 hourly.
DEHYDRATION
Isotonic loss of salt and water seen in diarrhoea,
vomiting, gastric and intestinal suction.
238
Nausea, anorexia, vomiting, apathy, weakness,

orthostatic syncope.
Poor skin turgor.
Dry shrunken tongue, sunken eyes.
Postural hypotension.
Weak thready pulse, low BP.
Management
Accurate intake and output chart.
IV isotonic saline in vomiting and diarrhoea.
IV Ringers lactate solution in comatose patients,
palsma/blood loss or in burns, etc.

Meet potassium loss in vomiting, diarrhoea.
DHATURA POISONING
There is feeling of impending suffocation with a
change in the voice. Vomiting often occurs.
Giddiness and staggering gait. Face is flushed, pupils
widely dialated. Diplopia or photophobia may
develop. Light reflex is lost.
Skin is hot and dry with rise of temperature, may be
upto 106F.
Sensation of itching and burning all over the body.
Medical Emergencies
239
Patient becomes restless with peculiar behaviour.

He develops pill rolling movement.
Death occurs due to heart failure or respiratory
paralysis.
Treatment
Stomach is washed with weak solution of KMNO 4
or 2-4 per cent tannic acid.

Emetic-apomorphine hydrochloride is given.
Strong tea is a useful antidote.
Stimulants like coramine or cardiazol may be given.
Pilocarpine nitrate (6-15 mg) subcutaneous, is
physiological antidote of atropine.
Artificial respiration and O 2 inhalation.
Paraldehyde is given to loosen excitement.
Diuretics and purgatives may be given to eliminate
poison.
DROWNING
History.
Long submersion in water may lead to cerebral
anoxia.
Loss of consciousness.
Cardiac arrest and it may cause death.
240
Management
Establish an airway and maintain it.

Maintain circulation with external cardiac massage.
Sodabicarb solution 7.5 per cent IV.
Aminophylline 0.2 gm IV if there bronchospasm.
Ringers lactate solution IV.
ECTOPIC PREGNANCY
Acute, severe abdominal pain.

Fainting attacks.
Amenorrhoea of short duration.
Feeling of something bursting in abdomen.
Bleeding per vagina is scanty.
Low BP, fast pulse, cold and clammy skin, air hunger
and thirst.
Marked tenderness in iliac fossa. No rigidity.
PV findingsFullness of fornices more on affected
side.
Management
100 mg Inj Pethidine IM.
Start IV fluids or plasma expanders if blood is not
available.
Confirm the diagnosis by colpopuncture.

Perform exploratory laparotomy.
Medical Emergencies
241
FROST BITE
History of constant exposure to cold.
Numbness, tingling and burning sensation in the
extremities.
Skin may be white or yellow in colour.
Associated oedema.
Blisters, necrosis and gangrene.
Management
Warm the patient with blankets and give hot soup/
coffee.
Remove all coverings from injured parts.
Gradual rewarming with water or air.
Analgesics for pain, i.e. Novalgin.
Give Tetanus toxoid 1 cc. stat.
Antibiotics in open wounds, Septran DS 1 bd 5
days.
No dressings to be applied.
HYPOGLYCEMIA
It is caused by excessive dose of insulin or oral
hypoglycaemic agents or a missed meal or vigorous
physical excercise by a diabetic.
242
Palpitation, sweating, mental confusion and
drowsiness.
Coma with or without neurological deficit.
Cool sweaty skin, full bounding pulse and suggestive
history.
History
Onset
Skin
Tongue
Pulse
BP
Breath
Urine
Blood sugar
Hyperglycaemic
coma
Hypoglycaemic
coma
Missed insulin
Slow
Dry
Dry
Small volume
Reduced
Acetone smell
Sugar ++ ketone ++
400 mg%
Missed meals
Rapid
Moist
Moist
Normal
Normal
Normal
Absent. No. Ketone
60 mg%
Management
Collect blood and send for sugar estimation.
50 ml of 50% Glucose IV statDramatic recovery
usually occurs. Give oral Glucose or food too.
If hypoglycaemia is due to long acting sulphony-
lurea or long acting insulin it can recur after few

hours. Give Corticosteroids and observe the patient
for 48 hours.
Medical Emergencies
243
HYPOTHERMIA
History of exposure to cold, drowning or swimming
in cold water, myxoedema, morphine poisoning, etc.
Body temperature below 35C.
Bradycardia, lowering of blood pressure and slow
respiration.
Uncontrolled rigors, clouding of consciousness.
Cause of death is respiratory arrest and ventricular
fibrillation.
Management
Remove the person from cold environment.
Use of blankets, use of heater or immerse in warm
Water if core temperature > 32C. If temp < 32C

gastric or rectal lavage with warm saline, warm
IV fluids.
Artificial respiration.
Correction of metabolic acidosis.
INJURIES TO VULVA, VAGINA

Common causes are postcoital virgin young girls,
postabortal or after operations.
Direct/indirect trauma.
244
Profuse bleeding.
Swelling.
Signs of shock and collapse.
Retention of urine in case of periurethral avulsion.
Vaginal tear or haematoma.
Treatment
Resuscitation of patient.
Suturing of laceration under anaesthesia.
Cold compresses in haematoma.
Prophylactic antibiotic therapy.
POISONING
General Principle of Management
i.
ii.
iii.
iv.
v.
vi.
Removal of unabsorbed poison.

Removal of absorbed poison.
Maintenance of vital functions and general care.
Administration of antidotes.
Medicolegal responsibilities.
Medical Emergencies
245
PROFUSE VAGINAL
HAEMORRHAGE
Common causes are complications of pregnancy
abortion, fibroid, carcinoma, IUD, etc.
Pain lower abdomen.
Anaemia, weakness, fatigue.
Attacks of giddiness, fainting.
Palpitation, breathlessness.
Per speculum-profuse bleeding through OS and clots
in vagina.
Management
Complete bed rest.
Inj Pethidine 100 mg stat and if required may be
repeated after four hours.
Inj Vit K IV, vit C and Calcium gluconate IV slowly.

Dilatation and curettage may be done, except in
unmarried girls.
Oestrogens are effective and cheaper in young
girlsEthinyl oestradiol 0.05 mg tab, 1 mg every

two to three hourly till bleeding stops, later on one
daily for 21 days.
Progesterone (Primolut N 5 mg) may be given
during last 10 days to reduce withdrawal bleeding.
246
RENAL COLIC
It may be caused by stones, pus, blood, papillae or
tumour.
Constant nagging pain in loin between 12th rib and
iliac crest.
Pain generally radiates towards urethra.
There may be tenderness over renal angle.
Fever may be moderate to high with rigors in
pyelonephritis.
There may be associated nausea and vomiting and
suppression of urine. Patient may complain of
haematuria.
Urine examination, X-ray KUB/IVP may be helpful.
Management
Control of pain by use of parenteral antispasmodics
like Buscopan 2 ml or analgesics like Fortwin 30

mg or Pethidine 100 mg or Diclofenac 3 ml or
Ketorolac 30 mg.
If pain is not relieved treat the patient like that of
acute abdomen, i.e.
Nil orally.
IV fluids.
IV/IM antispasmodics, i.e. Inj Baralgan or Inj
Fortwin.
Medical Emergencies
247
Investigate by X-ray abdomen, ultrasound

abdomen.
If associated infection send urine culture and start
antibiotics accordingly.
SNAKE BITE
There may be fang marks.
Local featuresSevere local pain, numbness,
tingling, local oedema, redness, warmth, bleeding
from site.
GeneralNausea, vomiting, headache, fever,
urticaria.
CNSMuscular paralysis, ptosis, squint, facial
weakness, respiratory paralysis.
CVSCardiotoxin causes cardiac dysfunction, i.e.
tachycardia, hypotension, shock, cardiac failure,
cardiac arrhythmias.
Cobra and krait causes constitutional symptoms
more than local symptoms. Neurotoxicity is more.
Russel and scaled vipers cause severe local symptoms
and haemorrhagic tendency.
Management
Local
Apply tourniquet 2" proximal to bite. It should be
tight enough to stop lymphatic flow, the route of
absorption.
248
In late cases
Elevation of the limb.
Mag sulph compresses.
Heparinoid ointment.
Some antibiotic.
Freeze dried antisnake venom is reconstituted by
adding distilled water. After intradermal test give
20 ml IV slowly in 15 minutes.
It can be repeated after 2 hours.
General
Tetanus toxoid 1 ml IM.
AntihistaminicsInj Avil 1 amp stat may be given.
AnalgesicsInj Voveran 1-3 ml IM stat followed
by Tab Ibuprofen 1 tds may be given.
Corticosteroids in cases of severe shock and allergic
reactions. Inj Efcorlin 100 mg or Inj Decadron 4 mg

IV stat and repeat 6 hourly.
In acute renal failure, Mannitol diuresisMannitol
20 per cent, 350 ml slow IV.
In respiratory failure, Oxygen inhalation or IPPV.
If bleedingTransfuse fresh blood or platelet.
Fibrinogen 300-600 gm IV.
Medical Emergencies
249
SPONTANEOUS
PNEUMOTHORAX
Important causes are trauma, subpleural tuberculosis, emphysematous bulla, post-pneumonic cyst.
Sudden onset of pleuritic chest pain.
Dyspnoea.
Vomiting and sweating.
Cyanosis, low BP, fast pulse.
Hyperresonance and reduced breath sounds.
X-ray will show sharpened contrast between air and
relaxed lung.
Management
Closed and mild case needs no treatment, except
sedatives and cough linctus.

In severe cases
100 mg Pethidine or Inj Pentazocine 30 mg or Inj
Ketorolac 30 mg.
Propped up position.
O2 inhalation.
Drainage of air by introduction of needle in 4th/
5th intercostal space, just posterior to anterior

axillary line connected to an under water seal.
250
Cough linctus Codein 1 tsf tds.

Broad spectrum antibiotics.
Surgery needed if lung fails to re-expand or if there

is persistent air leak due to bronchopleural fistula.
SUICIDAL BEHAVIOUR
It may be self destruction, escape from difficulties,
aggression directed at others and appeal for help.
Repeated statements expressing suicidal wish or a
history of previous attempt.
Depression or schizophrenia.
Suicidal note.
Presence of long illness-cancer or paralysis, etc.
Personality disorder, hysterical, drug dependence,
etc.
Management
Hospitalise the patient in a protected ward.
Electroconvulsive therapy.
Tricyclic group of antidepressants, i.e. Depsonil or
sedation with major/minor tranquillizers.
Assurance and psychotherapy.
Medical Emergencies
251
TRANSFUSION REACTIONS
Allergic reactions
Urticaria.
Sore throat, joints pain, fever.
Angioneurotic oedema.
Lymphadenopathy.
Management
AntihistaminicsInj Avil 2 cc stat IV.

CorticosteroidsInj Decadron 2 cc stat IV or Inj
Efcorlin 100-200 mg IV stat.

Febrile reactions
May occur 1-24 hours after transfusion due to
improper sterilisation.
Patient gets chills, fever, headache, nausea and
vomiting.
Management
Inj Penicillin for throat infection.
252
MISCELLANEOUS
ACUTE LEUKAEMIA
Abrupt or insidious onset, common in children.

Tiredness, weakness, fatigability, marked pallor.
Spleen slight to moderately enlarged.
Lymphadenopathy specially in lymphatic leukaemia.
Tenderness over sternum and other bones.
Liver is enlarged may be with jaundice.
Fever, malaise and prostration.
Acute myeloid leukaemia

Total white cell count over 50,000/cu mm.
Peripheral blood film shows increased number of
typical or atypical myeloblast.
Bone marrow shows more than 20 per cent blast
cells.
Daunorubicin IV alternate days 3 doses.
Ara-C IV twice daily 10 days.
More than one course may be required to induce
remission.
Miscellaneous
253
Consolidation
Ara-C IV twice daily 10 days.

Daunorubicin IV alternate days 3 doses.
Etopside IV daily 5 days.
Amisacrine daily IV for 5 days.
3 courses given at 4-6 weeks interval. Once remission
is achieved, patient must undergo bone marrow
transplantation if HLA matched sibling donor is
available and patient is < 45 days.
Before specific treatment is given following
supportive treatment is to be given:
i. If hyperuricaemia
Plenty of fluids alkaline
is present
Citrate 2 tsf tds with water
Tab Zyloric 100 mg tds.
ii. Thrombocytopenia Platelet transfusion
iii. Anemia
Packed cell transfusion
iv. If fever 38C.
Injection Ceftazidime (Fortum) 1-2 g 8 hourly.
or Injection Gentamicin 80 mg 8 hourly.
or Injection Carbenecillin 5 gm IV 6 hourly.
If these fail then
Injection Amikacin 500 mg 12 hourly IV.
or Injection Ciprofloxacin 200 mg IV bd.
or Injection Ceftazidime 1-2 gm 8 hourly IV.
Acute lymphatic leukaemia
Total white cell count, more than 500,000 predominantly lymphoblasts.
254
In leukaemic leukaemia less than 1000 white cells.

Bone marrowHypercellular marrow with
depression of erythropoeisis, granulopoeisis and
thrombopoeisis.
Management
AML
Cyclophosphamide and Prednisolone until marrow
is hypoplastic.
Transfusion of packed red cells from stored blood.

Treatment of infection with broad spectrum
antibiotic.
ALL
Oncovin 1 mg IV weekly with Prednisolone 40 mg
daily, along with supportive therapy.
Induction (4 weeks)
Vincristine IV weekly for 4 weeks.

Oral Prednisolone daily 4 weeks.
-asparaginase IM weekly 3 weeks.
Daunorubicin IV daily 2 days.
Intensification (1 week)
Vincristine IV one dose.
Daunorubicin IV daily 2 days.
Prednisolone oral daily 2 days.
Miscellaneous
255
Etoposide IV daily 5 days.

Cystosine arabinocide IV daily 5 days.
Thioguanine oral daily 5 days.
CNS prophylaxis (3 weeks)

Cranial radiation 24 GY fractionated. Intrathecal
methotrexate weekly 3 also given twice during
induction and once with each intensification course.
Maintenance therapy (2 years)
Methotrexate oral weekly 2 years.

6-Mercaptopurine oral daily 2 years.
Prednisolone oral 5 days each month 2 years.
Vincristine IV one dose monthly 2 years.
ADDISONS DISEASE
Weakness, weight loss.

Pigmentation of skin and mucous membrane.
Hypotension.
Hyponatraemia and hyperkalaemia.
Diminished urinary Cortisol, 17 Hydroxy corticoids
and 17 Ketosteroids.
256
Treatment
Increased salt intake. Take 1 tsf salt daily in addition
to what is used in cooking.
Prednisolone 5 mg morning and 2.5 mg in evening
as replacement.
0.05 mg of Fluorohydrocortisone in selected
patients.
AIDS
Transmission of HIV is mostly through sex and sharing
needles/blood transfusion. Breastfeeding, Kissing,
casual contact sharing towel/bed sheet dont transmit
the disease.
Immune Abnormalities
Depletion of T4 lymphocytes.
Impaired lymphocyte proliferation.
Impaired NK cell activity.
When to Suspect AIDS
Kaposi sarcoma.
Unexplained lymphadenopathy.
Prolonged fever of unknown origin.
Primary CNS lymphoma.
Early dementia.
Unexplained weight loss.
Repeated Herpes zoster.
Opportunistic infections.
Miscellaneous
257
Standard ELISA test has a sensitivity of 99.5% but with
low specificity of 13%. Hence positive western blot gives
definite diagnosis. Antibodies appear 1-3 months after
infection. Patients with CD4 cell count below 200cumm
are at high-risk.
Treatment
Antiretroviral therapy for HIV disease
AZT
100 mg 5 times daily
Abacavir
300 mg bid.
Adefovir
60 mg qid.
Indinavir
800 mg tds
Ritonavir
600mg bd.
Delaviridme
400 mg tds
CHRONIC LYMPHATIC LEUKAEMIA

Absolute lymphocytosis and leucocytosis.
Lymph node enlargement usually non-tender and
generalised.
Anaemia, hepatosplenomegaly.
Treatment
Tab Chlorambucil 0.1-0.2 mg/kg daily.
or Tab Cyclophosphamide (Endoxan) 50-100 mg.

1-3 times daily. Give in cycles upto 2 weeks.
Corticosteroids 40 mg daily. PrednisoloneIf
severe marrow failure or autoimmune phenomenon supportiveRegular blood transfusion and
infections.
258
CHRONIC MYELOID LEUKAEMIA

Unexplained fever, splenomegaly.
Leucocytosis with blast cells, promyelocytes,
myelocytes appearing in peripheral blood.
Bone marrow aspiration shows dominant promyelocytes and myelocytic series with blast cells less
than 30 per cent. Marrow is hypercellular.
Philadelphia chromosome is positive and leucocyte
alkaline phosphatase is negative.
Treatment
Hydroxyurea 1.5-2 g/day PC within 1-2 wks TLC
starts to fall. Thereafter continue with maintenance

dose 0.5-2 g/day indefinitely. If not tolerated then.
Busulfan 2-4 mg orally daily.
or A interferon daily subcutaneous injection 3-9
MU.
600 rads to spleen or low dose total body irradiation.
Radioactive phosphorus 1-2 mci every 1-2 weeks.
DAT regime if patient goes to blast crisis.
Miscellaneous
259
CONGESTIVE CARDIAC FAILURE

Dyspnoea on exertion often progressing to orthopnoea.
Crepitations at lung bases.
Tender hepatomegaly, dependent oedema, enlarged
neck veins.
Prolonged arm to tongue circulation time.
Evident heart lesion or dilatation.
Treatment
Bed rest, salt restriction, small feeds.
Tab Lanoxin (or Cardioxin) 2 tablets every six hours
for 4 doses. Then one or two tablets daily (to keep

pulse about 80/minute) for six days a week.
Tab Lasix 40 mg or Esidrex 50 mg-1 every morning
for 3 days. Then one on alternate day for 3 doses
and then one once a week.
Potassium supplementSyrup Potklor 1 tsf bd.
Low dose Heparin 5000 units in selected cases.
Add Verapamil 80-120 mg/day for tachycardia.
Preload and after load reduction in refractory heart
failure with oral Sorbitrate and Hydralazine.
If excess dyspnoea-O2 inhalation.
Injection Aminophyline 0.025 mg IV twice a day
for 3 days then once a day for 3 days.
260
Tab Deriphylline retard 1 bd.

For severe failure add vasodilators Salbutamol
4-12 mg tds.
or CaptoprilInitial dose 6.25 mg.
or EnalaprilInitial dose 1.5-2.5 mg.
or LisinoprilInitial dose 2.5 mg.
DIABETES INSIPIDUS
Inability to concentrate urine.

Large and dilute urine rarely less than 3 litres daily.
Excessive thirst and resulting disturbance of sleep.
Deficiency of ADH secretion.
Inability of distal tubules and collecting ducts of
nephrons to respond to ADH (Nephrogenic diabetes
insipidus).
Treatment
Pitressin IM 10-20 units of aqueous solution twice
daily or 5-10 units Pitressin tannate in oil every

2 to 3 days.
Chlorpropamide 250 mg daily.
Chlorthiazide 500 mg in Vasopressin resistant cases
to reduce urine volume.
Miscellaneous
261
DIABETES MELLITUS
Usually gradual in adults but acute in children.

Polyuria, intense thirst.
Nocturia.
Polyphagia.
Weight loss, weakness and lassitude.
Pruritus vulvae in females and balanitis in males.
Leg cramps, crops of boils, loss of libido and
impotence in middle age.
Blurring of vision may develop.
High fasting blood sugar content > 120 mg%.
Urine may be positive for sugar.
Treatment
Low calorie diet.
Low carbohydrate, high protein diet.
Lots of green vegetables to be consumed.
Sulphonylureas stimulate production of Insulin +
extrapancreatic hypoglycaemic effect. These are
given to maturity onset diabetes of average weight
not controlled by diet.
Diabetic of normal weight stabilised on Insulin not
more than 30 units daily without developing ketosis
any time.
262
Obese patient
DBI-TD one with breakfast if not controlled after
2 weeks.
Diabinese tab 250 mg.
or Daonil or Euglucon 5 mg one tablet with

breakfast.
DBI-TD one after dinner.
If not controlled.
Inj Insulin.
Non-obese patient
1/2 Tab Daonil or Euglucon with breakfast. It may
be increased to 1 tablet.
If not controlled.
Diabinese 500 mg with breakfast watch for 2 weeks.
Even if not controlled.
Euglucon or Daonil
2 tab with breakfast, one after dinner.
If still not controlled.
Inj. Lente insulin 15 units subcutaneous before
breakfast.
Dose may be increased according to urine sugar.
If dose of Lente insulin exceeds 50 units/day.
Inj soluble Insulin 20 units once before breakfast
with.
Inj NPH or Lente insulin 20 units.
Miscellaneous
263
If urine sugar ++ before lunch increase soluble

insulin by 2 units before breakfast.
If urine sugar ++ before dinner increase NPH Or
Lente insulin by 2 units before breakfast.
If control is still difficult.
Inj Plain insulin:
20 units before breakfast
20 units before lunch
15 units before dinner.
Adjust dose according to urine sugar.
DIABETIC KETOACIDOSIS
Polyuria, thirst, vomiting, lethargy.

Abdominal pain, anorexia.
Kussmaul breathing, rapid thready pulse.
Elevated blood sugar, Plasma ketone and low
bicarbonate.
Urine is positive for ketone bodies.
Treatment
Rapid rehydration with 4-6 litres of isotonic saline
within 12 hrs.
Low dose Insulin 6-8 units per hour by IV infusion.
264
Bicarbonate IV if plasma pH is below 7.2.

IV Potassium, 1 ampoule to each bottle of saline
infusion from 3rd bottle onwards under ECG

control.
Insuline infusion is to be continued till ketosis clears
up. Once blood sugar reaches around 250 mg
percent NaCl is replaced by 5 per cent Dextrose
saline.
FILARIA
Usually high fever with rigors.

Nausea and vomiting during attacks.
Tender inflamed lymphatics are seen as red streaks.
Itching, irregular erythematous swelling of skin
scattered over the body.
Lymph glands swollen, firm and tender, generally
of groins.
Secondary gram-positive bacterial infection in breast
may develop.
Microfilariae in peripheral blood collected about midnight.
Gland biopsy to identify adult worm.
Miscellaneous
265
Management
Acute lymphangitis
Tab Banocide forte, 100 mg thrice daily for 3 weeks.
Inj Terramycin 100 mg bd IM.
Tab Paracetamol 1 sos.
Tab Brufen 1 thrice daily.
Tab Sugarnil 1 tds.
Post-lymphangitic oedema
Elevation of the extremity at night.
Elastocrepe bandage during day time.
Cough sedative.
Tab Betnesol may be given.
1 tds 5 days.
1 bd 5 days.
1 daily 5 days.
In Chyluria complete rest. Omit fat from diet.
Saline purge.
HEATSTROKE
Skin dry and hot, often hyperpyrexia.
Confusion, disorientation and coma.
History of exposure to hot environment.
266
Treatment
Inj Novalgin 3 ml IM stat.
Tab Paracetamol 1 qid.
Immediate cooling of body by ice packs or
immersion in cold water.
100 per cent oxygen.

IV 50 per cent Dextrose Saline Infusion 2500 ml/
day.
Small doses of Chlorpromazine to control shivering
during cooling in conscious patient 50-100 mg IM

every 4-6 hrs.
Support of peripheral circulation with Dopamine
infusion.
HODGKINS DISEASE
Firm, non-tender, rubbery lymph node enlargement.

Irregular fever, weight loss, pruritus, sweating.
Exacerbations and remissions.
Lymph node biopsy shows Sternberg-Reed giant
cells.
Treatment
Chemotherapy
MOPP regime.
Miscellaneous
267
Mechlorethamine 6 mg/m2 IV day 1 and 8.

Vincristine 1.4 mg/m2 IV day 1 and 8.
Procarbazine 100 mg/m2 orally for 14 days.
Prednisolone 40 mg/m2 orally for 14 days in cycle
1 and 4.
Total duration of therapy is 6 cycles with 2 weeks
of drug free period in between two cycles. Cyclophosphamide may be substituted for Mechlorethamine.
HOOKWORM INFESTATION
Infective larva penetrate human skin and reach blood
stream-lung capillaries-alveoli-oesophagus-jejunum
where they attach to mucosa.
At the point of entry, generally in between toes
develops a ground itch.
Skin becomes dry and anaemic.
Hair becomes dry and scanty, oedema of feet
develops.
Epigastric discomfort, tenderness and diarrhoea. It
may contain blood and mucus.
268
Palpitation, functional murmurs, fast pulse, low BP

and little cardiac enlargement.
Hypochromic microcytic anaemia.
Physical and mental tiredness.
Detection of ova in stools or worms after drugs or
otherwise.
Management
If Hb% is below 5 gm per cent it is advisable to raise
the Hb% before giving deworming drugs like
Mebendazole, Albendazole or Pyrantel.
Deworming with Mebendazole 100 mg bid
3 days.
Albendazole 400 mg hs or Pyrantel palmoate
500 mg (10 mg/kg) hs.
HYPERKALAEMIA
Features of acidosis like dehydration, twitching,
tremors, muscle weakness, lethargy.
Associated renal failure, adrenal hypofunction.
ECG changes like tall T waves, dysrrhythmia.
Raised serum potassium.
Miscellaneous
269
Treatment
10 per cent Glucose, 200 ml IV in 20 minutes with
10 units of soluble Insulin.

Calcium gluconate 10 cc, 10 per cent slow IV.
Sodium bicarbonate 2 ampoules (20 mEq) IV.
Cation exchange resins like Sodium Polystyrene
Sulfonate 20 gm orally 4 times daily along with

sorbitol.
Dialysis when situation is more demanding or
previous methods fail.
LACTIC ACIDOSIS
Features of acidosis like lethargy, dehydration.
Wide anion gap.
Evidence of precipitating factors like shock, drugs
intake.
Raised plasma lactate.
Treatment
Rapid bicarbonate infusion to raise the pH to 7.2.
Treatment of primary disorder like shock.
Trial of dichloracetate and dichlorpropionate.
270
LEFT
VENTRICULAR FAILURE
Dyspnoea, orthopnoea, paroxysmal nocturnal
dyspnoea.
Frothy blood tinged sputum.
Batwing appearance to floppy opacities in lung fields.
Evident primary heart disease or hypertension.
Treatment
Prop up position.
Frusemide 40-80 mg IV.
Digoxin 0.25-0.5 mg IV.
Morphine 15 mg IM or Inj Pethidine 100 mg IM.
Inj Siquil 10 mg IM or Stemetil 25 mg IM.
Inj Nitrogylcerine 20-25 mg/min IV (Titrate
according to systolic BP).
Sorbitrate 10 mg 6 hourly.
Aminophylline 500 mg slow IV.
Rotating tourniquet or phelbotomy to reduce
venous return to heart.
Treatment of precipitating/primary disease.
Miscellaneous
271
MALARIA
Lassitude, loss of appetite, headache, chilliness.
Cold stage lasts for 1/2 hour. Patient feels cold and
shivers; may chatter his teeth and covers himself
with blanket.
He develops severe headache and vomiting.
Temperature goes on rising.
Hot stage lasts for 1-6 hours. He may be burning hot
and may be delirious, vomit continues. The face is
flushed, skin becomes dry and burning. Temperature
may rise to 41C.
Sweating stage: Develops perspiration. Temperature
drops, patient becomes comfortable and falls asleep.
Usually spleen is enlarged and in children liver may
become tender.
Classical bouts of fever appear at regular intervals.
Management
Bed rest.
Get blood tested for MP.
Tab Chloroquine 600 mg (4 tab) stat with food or
milk 2 Tablets after 8 hour. then 2 tab daily for

3 days.
272
Tab Primaquine 7.5 mg bd 5 days.

Control fever with Paracetamol.
For chloroquine resistant cases

Tab Metakelfin 2 stat, Quinine 2 350 mg tid for
14 days.
Prophylaxis-Tab Resochin/Camoquin 2 at bed time
once a week.
Tab Crocin sos.
MULTIPLE MYELOMA
Bone pain, bone fracture on trivial trauma.

Recurrent infection, weight loss.
Raised ESR and serum globulin.
Bence Jones proteinuria.
Immature and atypical plasma cells in bone
marrow.
Monoclonal bands in serum immunoelectrophoresis.
Treatment
High fluid in take (about 3 L/day) and prompt
treatment of infections with antibiotics.
Miscellaneous
273
Pulse therapy consisting of: (1) Vincrystine 1 mg
IV. (2) Cyclophosphamide 100 mg/m2 for 4 days.

(3) Prednisolone 60 mg/m2 for 4 days.
This course is repeated every 4 weeks, once acute
symptoms are controlled maintenance therapy is with
intermittent.
Melphelan 7 mg/m2 for 4 days.
Prednisolone 60 mg/m2 for 4 days.
Plasmapheresis when myeloma protein is too high
with hyperviscosity syndrome.
Treat hypercalcaemia.
Dialysis if oliguric renal failure.
MYASTHENIA GRAVIS
Drooping or eyelids towards evening.
Diplopia, weakness in chewing, swallowing and
speaking.
Muscle weakness progressively increases as muscles
are used.
Pupils are never affected and muscle involvement is
bilateral.
Common in females in third decade.
Decremental response more than 10 per cent on EMG.
Positive edrophonium and neostigmin tests.
274
Treatment
Neostigmine 15 mg 4 hourly along with atropine
derivatives.
Thymectomy and irradiation to thymus.
Corticosteroids when response to Neostigmine is
inadequate.
Plasmapheresis.
Immunosuppressants like Azathioprine 2 mg/kg
daily.
NEPHROTIC SYNDROME
Proteinuria, specially albuminuria.
Hypoproteinaemia with reversal of normal albumin
globulin ratio.
Hypercholesterolaemia.
Lipiduria with oval fat bodies and lipid crystals in
urine.
Oedema in the form of anasarca and effusion.
Management
The patient should be confined to bed.
Protein intake of 100 gm daily with restriction of
salt.
Miscellaneous
275
Diuretic, i.e. Esidrex 25 mg thrice daily orally.

Corticosteroid 0.5 mg per kg thrice daily for 15
days and later on should be tapered gradually

(Prednisolone). In steroid resistant casesCyclophosphamide 2-3 mg/kg for 3-6 weeks. Lasix
2 mg/kg/day. Potklor 1 tsf bd.
NON-HODGKINS LYMPHOMA
Painless, discrete, firm to hard lymph node enlargement.
Unlike Hodgkins lymphoma skin, bones, eyes,
breast, testes are involved.
Absence of Sternberg-Reed giant cells in lymph node
biopsy.
Treatment
Radiotherapy as in Hodgkins lymphoma.
Chemotherapy with either MOPP regime or COPP
regime. The latter consists of Cyclophosphamide,

Oncovin, Procarbazine and Prednisolone given in
the same manner as in Hodgkins disease.
Combination of chemotherapy and radiotherapy
in selected cases.
276
OBESITY
Obesity is when person weighs more than 20% of
expected weight. Obesity is defined as an excess of adipose tissue.
Body mass index more than 30%.
Upper body obesity is more harmful than lower body
obesity.
Normal BMI is 18.5-24.9, overweight is BMI = 2529.9, Class I obesity 30 34.9, class II obesity is 3539.9 and class III obesity is BMI >40.
High waist hip ratio > 1.0 in men and >0.85 in women
have a greater risk of diabetes, stroke and coronary
heart disease.
There is a genetic influence causing obesity.
Hypothyroidism and Cushings syndrome may also
result in obesity.
Treatment
It requires a greatest will power to loose weight.
Consume less of calories. Avoid fats, sweets, pine-
apple, banana and mangoes.
Consume lot of salads and green vegetables which
contains minimum of calories.
Start walking at least 3-4 km daily and indulge in
exercises.
Miscellaneous
277
Dont miss any meals but consume lesser quantity
of preparation of your choice.
No drug has been found of great success.

Activity
Dressing and
undressing
Sitting at rest
Walking
Running
Reading
Sweeping
Expenditure Activity
of calories
33
15
130-200
500-900
20
120
Mental work
Sawing wood
Cycling
Climbing
Wrestling
Scrubbing floor
Expenditure
of calories
7
420
180-300
200-900
900
260
ORGANOPHOSPHORUS
POISONING
Myosis, red eyes and red tears.
Sweating, salivation, diarrhoea, dyspnoea and
blurred vision.
Muscle twitchings and convulsions.
History of exposure to pesticides.
278
Treatment
Removal of unabsorbed poison from skin and GI
tract by gastric lavage.
Atropine sulphate 2 mg IM/IV every 5 minutes till
pupils are dilated and maintenance of atropinisation.
Pralidoxime 1 gm IV after full atropinisation
(30 mg/kg).
Inj Diazepam 10-15 mg IM.

Respiratory support and oxygen inhalation.
Inj Ampicillin 500 mg 6 hrly if respiratory infection.
ROUNDWORM
Man acquires the infection by swallowing the larvae
with contaminated food.
Larval phase
Cough severe dyspnoea may also occur.
Fever with eosinophilia may also occur.
Ill-defined abdominal pain.
Adult worm phase
Intestinal colic and passage of worms in stool.
Malabsorption, malnutrition and distension of
abdomen.
Ocassionally worms are vomitted out.
Miscellaneous
279
Management
Levamisole 2.5 mg/kg in single dose.
or
Piperazine derivative 75 mg/kg body weight in
two divided doses on successive days.

or
Mebendazole 100 mg twice daily for 3 days.
TAPEWORM INFESTATION
Passage of segments of the worm in the stool.

Vague abdominal pain, occasionally diarrhoea.
Characteristic eggs in the stool.
Brain cysticercosis manifests as seizure, mental
deterioration and hydrocephalus.
Treatment
Niclosamide 2 gm single dose for T. solium, T. sagi
nata and D. latum and for 5-7 days for H. Nana.

Paromomycin 75 mg/kg (max 4 gm) single dose.
Dichlorophen 6 gm single dose.
Mebendazole 200 mg twice daily for 3 days.
Albendazole 400 mg single dose.
Praziquintel for cysticercosis.
280
THREADWORM
Adult worms in the colon and rectum. Gravid female
emerges from the anus to deposit the eggs on the
perianal skin. These eggs if swallowed liberate the larvae
which mature in intestines.
Anal and perianal itching.

Loss of appetite, abdominal discomfort.
Girls may develop vulvovaginitis.
Under microscope ova can be seen.
Management
Proper sanitation and hygiene.

Piperazine compound 75 mg/kg body weight daily
for one week.
Vanquin 5 mg/kg body weight in single dose. Can
be repeated after one week.

or
Mebendazole single oral dose of 100 mg may be
repeated after a week.
All infected members of the family should be
treated simultaneously.
General Information
281
GENERAL INFORMATION
Latin Terms used in Prescriptions

QS (Quantum sufficient)
Aq (Aqua destillata)
Ss (Semis)
Ad
Mist
Gargarisma
Misce
Fiat
Ac (anti-cibcus)
bd (bis in dies)
tds (ter in dies sumendus)
c (cum)
Cm (cras mane)
HS (Hora Somni)
Om Noct (Omni nocte)
PC (Post Cibus)
Rept
State (Statim)
As much as is sufficient
Distilled water
Half
Sufficient to produce
A mixture
A gargle
Mix
Make
Before meals
Twice a day
To be taken thrice a day
With
Next morning
Every night
Every morning
After meals
Repeat
Immediately
282
IMMUNISATION
1st week
BCG vaccination.
6 weeks to 3rd month DPT (Diphtheria.
4th month
Tetanus toxoid.
5th month
Pertussis vaccine).
Oral polio (Three doses).
9 months
Measles.
2 years
Typhoid vaccine.
3 years
Booster dose Triple
antigen and polio.
5 years
Another booster dose of
Triple antigen and polio.
Because smallpox has been eradicated from the
world there is no need of smallpox vaccination.
WEIGHTS AND MEASURES

Metric System
Measure of mass
1 microgram
1 milligram (mg)
1 kilogram (kg)
0.001 milligram
0.001 gram
1000 grams
General Information
283
Measure of capacity
1 Litre
1 Millilitre
1000 cc
1 cc
Imperial Systems
Measure of mass
16 Ounces
60 Grains (grs)
8 Drachms (437.5 grs)
1 pound (lb)
1 drachm
1 ounce (oz)
Measure of capacity
60 Minims (Mins)
8 fl. dr or (480 Mins)
16 fl. ounce
20 fl. ounce
1 Gallon
1 fl. drachm
1 fl. ounce
1 pound
1 pint
10 pounds
Relation of Imperial and Metric Measures

1 kilogram (kg)
1 Gram (G)
1 Milligram
1 Gm
4 Gm or 4 cc
30 gm or 30 cc
460 gm
15432 grains or 35.27 ounces

or 2.2046 pounds
15.432 grains
1/60 grains
15 grains
1 drachm
1 ounce
1 pound
284
Capacity
1 Litre
1 millilitre (ml)
1 Pint
1 fl ounce
1 fl drachm
1 minim (min)
1.7598 pints or 35.19 fl ozs

16.894 minims
568.25 ml or 0.568 litre
28.412 ml
3.5515 ml
0.059192 ml
Domestic Measures and Weights

The equivalents are only approximates
1 Drop
3/4 minim
1/20 cc
1 Tea spoon
1 drachm
4 cc
1 Dessert spoon
2 drachm
8 cc
1 Table spoon
4 drachm
15 cc
1 Wine glass
2 ounces
60 cc
1 Cup
5 to 6 ounces
1 Glass
8 ounces
1 Tumbler
10 ounces
Table of Proportionate Doses for Different Ages
The adult dose being represented by one, the dose for
different age groups, should be as mentioned below:
Age
Dose
Age
Dose
under 1 year
under 2 years
under 3 years
under 4 years
1/12
1/8
1/6
1/4
under 7 years
under 14 years
under 20 years
From 21 to 64
years
1/3
1/2
2/3
1
General Information
285
Under 12 years the proportionate dose may be calculated by the Youngs formula:
Age
=
Adult dose
Age + 12
Inhalations
Menthol inhalation
Menthol
grs
10
Rectified spirit
Oz
i
20 drops to 1 pint of steaming water. It is used in
cases of throat congestion, tracheitis and laryngitis.
Tincture Benzoin with Menthol
Menthol
grs
30
Eucalyptus oil
min
30
Oil of cinnamon
min
10
Compound of Tr
Oz
i
Benzoin add
20 drops to 1 pint of steaming hot water. It is used in
cases of throat infections, tracheitis and laryngitis.
Enemas
Glycerine enema
Glycerine 2 drachm to 2 ounces with or without warm
water.
286
Soap enema
Soft soap
Warm water upto
Oz
Oz
i
20
Starch enema
Starch
gr
120
Water upto
Oz
5
Rub the starch to a smooth paste with a little water
add boiling water to obtain a suitable consistency.
Glucose and Saline Enema
Glucose
gr
438
Sodium chloride
gr
81
Warm water upto
Oz
20
Glucose saline enema is given slowly at body
temperature about 5 to 19 Ozs to adults and 2 to 4 Ozs
to Children.
Golden Rules for Prescribing Medicines
Prescription should be short simple and to the point. It
is important to mention the hour of the day when
medicines are to be given:
1. Gastric sedatives as bismuth salts are best given on
empty stomach for their local action.
2. Cod liver oil preparations are to be given after
meals.
General Information
287
3. Mineral acids are given after meals.

4. Alkalies when used to neutralise acid secretion
should be given after food, when given as a systemic alkaliser should be given between meals.
5. Takadiastase and pepsin should be given in an
empty stomach for local action.
6. All stomachic and bitter tonics are to be given
quarter to half an hour before food.
7. Morphine should not be given to head injury cases.
8. Hypnotics should be taken after meals half an hour
before going to bed.
9. Antacids to be given after meals and anticholinergic during or before meals.
10. Castor oil and saline purgatives should be given
early morning as they take only a few hours to act.
Slow acting pills should be given at bed time.
288
DIET THERAPY
DIABETES MELLITUS
Proteins
Fats
Carbohydrates
Calories
Minerals
Vitamin
What to be
avoided
Protein content should be normal

1 gram/kg. In children it may be
increased.
Fats should be moderate. Excessive
fat is forbidden.
Carbohydrate intake must be minimised in order to reduce blood sugar.
Total calories should be adequate for
the growing children and underweight persons. In obese patients it
might be necessary to reduce calories.
Adequate amounts should be
supplied.
Vitamin B complex group should be
taken to prevent and treat polyneuritis.
Sweet drinks and carbonated drinks
are to be avoided.
Diet Therapy
289
Cakes, Pastries, cream, dried and

caned fruits, sweet pickles, jaggeries,
sweet meats are to be avoided.
Soups
Thin vegetable soups supply less
calories. Obese persons are encouraged to take large quantities which
would fill up their stomach and give
them a sense of satiety.
Green vegetables Diabetics should consume lot of
green vegetables which are poor
source of calories. While 100 gm of
potato will give about 100 calories.
Brinjals, spinach, tomatoes can be
consumed in plenty. Salads with lime
or vinegar is useful.
Fruits
Dried fruits and nuts are avoided
being very rich in calories. Since bananas and mangoes have a high caloric
content they are best avoided.
Orange, sweet lime or apple can be
taken.
Dessert
Sweets and ice-creams or custard is
not allowed but small quantity of jelly
can be taken on occasions.
Sugar, honey or Obese diabetic is not allowed any of
jaggery
these. One tea spoon of each of these
gives 20 calories. Instead of these
290
Egg, fish,
chicken
Cooking media
Tea, coffee
aspartame a sweetening agent can be

used. Brand name Sugar free is
available in India.
Diabetic is allowed one egg or a
single helping of meat, chicken or
fish.
Ghee, oil, butter, all are rich in calories. An obese diabetic is allowed 1
tea spoon full per meal while thin
diabetic can have one table spoon.
Tea and coffee are permitted but milk
and sugar are to be regulated at
minimum.
Unsweetened drinks like soda are not
restricted.
Diet Sheet (for an obese diabetic)

Early morning
Breakfast
Lunch
Afternoon
Light tea without sugar.

Tonned milk 1 cup.
Papaya 2 slices.
Fulka 2.
Or rice 1 medium bowl.
Dal thin 1/2 medium bowl.
Leafy vegetable 1 medium bowl .
Salad at plenty.
Light tea 1 cup without sugar.
Bread 1 thin slice.
Diet Therapy
291
Dinner
Fulka 2 small.
Or rice 1 medium bowl.
Vegetable 3/4 bowl.
Oil for cooking 1 tea spoonful.
Diet provides 1000 calories, 40 gram proteins.
Diet Sheet (for an underweight diabetic)

Early morning
Breakfast
Light tea with little sugar.

Bread 2 slices.
Fruit one.
Lunch
Fulka 4.
Rice 1 medium bowl.
Dal 3/4 medium bowl thick.
Or fish 2 pieces.
Or lean meat 2 pieces.
Leafy vegetables 1 medium bowl.
Salad 1 medium bowl.
Oil for cooking 1 teaspoonful.
Afternoon
Light tea 1 cup.
Bread 1 slice.
1 biscuit.
Dinner
Fulka 4 small.
Rice 1 medium bowl.
Dal 1 medium bowl.
Vegetable 1 medium bowl.
10 PM
Milk 1 glass.
Diet will provide 2000 calories, 65 gram protein and
350 gram carbohydrate.
292
DIARRHOEA AND DYSENTERY

Proteins
Skimmed milk and curd, khichri

should be given.
Fats
These may aggravate the diarrhoea
and are best avoided.
Carbohydrates Fruit juices and Electral powder, etc.
may be given.
Calories
Adequate calories are required. For
undernourished surplus calories are
needed.
Minerals and
Diarrhoea may result in loss of
fluids
fluids and electrolytes. Fluid must be
replaced promptly.
If vomiting exists intravenous fluids should be given.
Spices, condiments, pickles and sweets are to be avoided.
Diet Sheet
Early morning
Breakfast
Lunch
5 PM
Light tea.
One cup butter milk.
Well cooked rice 2 bowl or 3 fulka
Curd medium bowl.
1/2 bowl vegetable.
Banana 1.
Light tea.
2 salted biscuits.
Diet Therapy
293
Dinner
Fulka 2.
Dal 3/4 bowl.
Vegetable 1/2 bowl.
Diet will provide about 1500 calories, 35 gm
proteins and 350 gm of carbohydrate.
GOUT
Persons suffering from gout can have normal diet
except that they must avoid substances rich in purine.
Substances rich in purine are:
Vegetarian food Beans, peas, brinjals, cauliflower,
spinach, pulses, mushroom.
Non-vegetarian Liver, kidney, meat extracts fish
food
Milk, egg, sweets, cereals containnegligible purine content.
Proteins
50 to 60 gram of proteins preferably
of vegetable origin.
Fats
Fats are to be restricted to avoid
obesity and fats cause urate retention.
Carbohydrates Carbohydrates should be the main
source of calories supply.
Calories
Extra calories may precipitate gout.
Vitamins
Adequate supplements are required.
Fluids
Increased intake of fluids will facilitate excretion of uric acid in urine.
Tea and coffee. A few cups are
294
permitted as they contain methyl

purines which are not converted to
uric acid. Alcohol should be avoided
as it may precipitate an acute attack
of gout.
HYPERTENSION
Proteins
Fats
Carbohydrate
Minerals
In mild hypertension 50-60 gram of

proteins may be consumed but in
severe hypertension protein should
be cut down to 20 gram because it is
difficult to achieve salt restriction
without protein restriction.
High intake of animal fats and hydrogenated oils should be discouraged
because saturated fats results in
atherosclerosis. Saffola oil or kardi oil
should be used.
It should make the major bulk of
calories required for daily activities.
In case of obesity calories should be
cut.
Sodium must be restricted in
majority of hypertensives because it
causes water retention.
Diet Therapy
295
Fluid restriction is necessary.

Articles like pickles, chutney, pastries, salted biscuit,
egg and tinned foods should be avoided.
Drugs containing sodium like Aspirin, Corticosteroid should be ideally avoided. Extra salt and baking
powder may not be used.
Diet Sheet
Early morning
Breakfast
One cup light tea.

One cup milk with minimum sugar
and cream.
Lunch
Fulka 4 small
Dal 1 medium bowl thin
Green vegetable 1 bowl
Oil for cooking 2 tsf only
Curd 3/4 bowl without salt and sugar.
Afternoon
Light tea with minimum sugar.
Evening
One orange.
Dinner
Fulka 3 small thin.
Green vegetables 3/4 bowl.
Diet provides about 2000 calories, 40 gram fat.
INFECTIVE HEPATITIS
Proteins
With mild jaundice 50-60 gram of

proteins are allowed but in severe
296
Fats
Carbohydrates
Calories
Vitamins
jaundice with bilirubin more than 10

to 15 mg per cent the protein intake
should be reduced to 40 gm per day.
In jaundice fats are little restricted.
Large quantities of fluid carbohydrates are given as they provide
major source of calories. In cases of
nausea and vomiting intravenous
Glucose should be given.
2000-2500 calories/day.
Supplements of vitamin B complex
with vitamin C are believed to be
useful.
Diet Sheet
Early morning
Breakfast
10 AM
Lunch
3 PM
6 PM
Milk half cup (fat free).

Sugarcane juice 150 ml.
Jam 1 tea spoon.
Sugarcane juice/orange juice,
1 glass.
3 fulka.
1/2 bowl rice.
Thin dal 1/2 medium bowl.
Butter milk 1 cup.
Sago pudding.
Milk 1/2 cup or light tea.
Fruit juice 1 cup.
Banana one.
Diet Therapy
297
Dinner
Roti medium size 2.

Well cooked dal 1/2 bowl.
Mixed fruits.
Diet provides 2400 calories, 40 gram proteins,
25 gram fats and 500 gram carbohydrate.
ISCHAEMIC HEART DISEASE

Proteins
Fats
Carbohydrates
Calories
Vitamins
Normal intake of 50 to 60 gram.

Cholesterol is to be kept in low
limits.
Following fats have higher amount
of saturated fatty acid.
Animal fats. Pork, beaf, meat
Fats. Dairy products like cream
butter, ghee.
Oils. Groundnut oil.
Carbohydrates are responsible for
endogenous synthesis of cholesterol
and triglycerides hence excess is to
be avoided.
Obesity burdens the heart. Reduction
of calories help to lose weight.
Nicotinic acid reduces lipids in blood.
Adequate potassium and calcium in
blood is required to prevent arrhythmias.
298
Miscellaneous
Smoking and alcohol are to be restricted.
Diet Sheet
Early morning
Light tea 1 cup with minimum sugar

and milk.
11 AM
Bread 2 slices with butter milk
without fat.
Lunch
Chapatis 4 thin without ghee.
Rice 1 medium bowl
Pulses 1 medium bowl
Salad as desired
Green leafy vegetables 1 bowl
4 PM
Light tea without sugar
6 PM
Any fruit, orange, papaya
Dinner
3 Fulka
3/4 bowl dal
More of salad.
3/4 bowl green vegetables.
Diet will provide about 1600 calories.
KWASHIORKOR AND MARASMUS

Proteins
20 per cent of total calories should be

supplied by proteins. This amounts
to 3 to 5 gram per kg of the expected
body weight. Best source of protein
Diet Therapy
299
is milk and Bengal gram. National

Institute of Nutrition has formulated
an energy-protein rich mixture to
treat PEM.
Whole wheat (roasted)
40 gram
Bengal gram
16 gram
Groundnut
10 gram
Jaggery
20 gram
86 gram
Total energy
330 calories
Protein
11.3 gram.
Fats
15 to 20 per cent calories can be
derived from fats.
Calories
Daily requirement for the child is
90-100 calories per kg of expected
body weight.
Vitamins
Multivitamins are helpful as patients
of malnutrition develops vitamin
deficiency.
Minerals
Serum potassium level is markedly
low. Calcium supplements as Calcium
lactate is useful. Iron therapy is
advisable.
Diet Sheet
Early morning
Milk 1 cup with sugar.

Banana 1.
Egg 1.
300
Lunch
Rice 1/2 bowl.

Dal 1/2 bowl.
Curd 1/2 medium bowl.
5 PM
Milk 1 cup.
Biscuits sweet-2.
7.30 PM
Dal 1/2 cup/bowl.
Fulka 1.
Mixed vegetable 1/2 bowl.
9 PM
1 cup milk.
Diet provides about 1200 calories.
NEPHROTIC SYNDROME
Proteins
High protein diet containing 100-140

gram of protein is advised as there is
massive loss of protein in urine.
Groundnut, dal and chana are rich in
proteins. Soya bean and skimmed
milk powder are good source of
proteins.
Fats
1 gm/kg of body weight.
Calories
2500-3000 calories/day.
Minerals
During the stage of water logging or
oliguria low sodium is usually advised. Butter, salted biscuits, preserved
fish, papad, chutney are to be avoided.
When oedema subsides salt restriction is not needed.
Diet Therapy
301
Diet Sheet
Early morning
Breakfast
Light tea.
Milk 1 glass.
Egg one, 2 bread slices.
10 AM
Roasted groudnut 15 gram
Chana 15 gram.
Lunch
Chapaties 2 with ghee.
Rice bowl 1.
Dal 1 medium bowl.
Meat4/5 pieces.
or
Paneer.
Curd 3/4 bowl.
Evening
2 Biscuits.
1 Glass milk.
Groundnut cake or besan ladoo.
Dinner
Chapaties 3 with ghee.
Rajmah 1 bowl.
Potato + Nutrinuget 1 medium bowl
Milk made sweet dish or ice-cream,
etc.
Diet will provide about 2600 calories, 100 gram.
OBESITY
Proteins
Fats
About 1 gram/kg of body weight.

These should be restricted as they are
concentrated source of energy.
302
Carbohydrates
Vitamins and
minerals
Miscellaneous
Substances rich in carbohydrates like

potatoes, sweets, icecreams. Bulk
substances such as fruits and green
vegetables are not restricted.
Fat and water soluble vitamins both
are necessary. An excess in salt restriction is helpful in weight reduction.
Liberal water intake before food may
reduce the intake of food.
Avoid snacks, biscuits, etc.
Regular exercise will burn extracalories
Avoid fatty fried articles.
Alcohol has to be omitted.
Diet Sheet
Early morning
Breakfast
Lunch
4 PM
Dinner
Light tea one cup.

Butter milk 1 cup without sugar
Papaya 2-3 slices.
Fulka 2-3 small and thin.
Rice 1/2 medium bowl.
Dal 1 medium bowl.
Thin Butter milk 1 glass.
Light tea.
1 biscuit.
Fulka 3 small.
Pulses 1/2 medium bowl.
Diet Therapy
303
Green vegetables 1 bowl.

Salad at liberty.
Diet will provide about 1200 calories..
PEPTIC ULCER
It is one disease where proper dietary management is
more beneficial than pure drug therapy.
Proteins
Normal 1 gram per kilogram of body
weight. Milk proteins are best because
these will not irritate gastric mucosa
unlike meat.
Fat
Fat consumption is better because it
forms a protective layer over mucosa.
Fats stimulate enterogastrone which
inhibits gastric secretion. Visible fats
like butter, ghee and cream are helpful
but fried hard articles may aggravate
the symptoms.
Carbohydrates Potatoes and cereals are useful. Raw
vegetables and cooked vegetables are
harmful.
Sufficient calories should be provided to maintain
health.
Frequent feeding to neutralize HCl is needed. It
should be soft, smooth and preferably cold.
304
All the fruits with edible seeds should be avoided.

Salty, spicy or acidic food should be avoided.
Coffee, tea, alcohol and smoking should be stopped.
Diet Sheet
Early morning
Breakfast
Milk 1 cup
Bread 2 slices with 2 tea spoon butter
Boiled egg one.
Lunch
Fulka 3 small with little ghee. Rice one
medium bowl, well cooked dal 3/4
medium bowl.
Well cooked vegetable 1 bowl.
2 PM
Milk 1 cup.
5 PM
Banana 1.
Dinner
Fulka 3 small.
Rice 1 medium bowl.
Well cooked dal 3/4 bowl.
Bed time
1 cup milk.
Diet will provide about 2300 calories, 60 gram
proteins, 20 gram fat and 300 gram carbohydrate.
SOME OF AVAILABLE DRUGS

Antacids
Agre antacids
Alma carb
Tablet
Tablet
Duphar
Glaxo
Diet Therapy
Alucinol
Aludrox-MH
Famocid
Digene
Diovol
Gelusil
Mucaine
Polycrol forte gel
Magacone
Ranitidine
Ocid
Tablet
Tablet/Suspension
Tab
Tablet/Suspension
Tablet/Suspension
Tab/Liquid
Suspension
Suspension
Tablet
Tablet 150 mg
Cap
305
Franco-Indian
Wyeth
Sun Pharma
Boots
Carter Wallace
Warner
Wyeth
Nicholas
Shalak
Torrent
Cadila
Laxative, Purgative and Lubricant

Agarol
Emulsion
Warner
Cremaffin
Emulsion
Boots
Dulcolax
Tablet
German Remedies
Evacuol
Granules
Griffon
Glaxenna
Tablet
Glaxo
Pursennid-IN
Tablet
Sandoz
Laxatin
Tablet
Alembic
Milk of Magnesia Liquid
Alembic
Dependal-M
Furoxone
Kaltin with
neomycin
Tinidazole
Antidiarrhoeals
Tablet
SK and F
Tab/Suspension SK and F
Suspension
Abbott
Tab
Aristo
306
+ Ciprofloxacin
(Citizol)
Meganeg
Tinibal-N
Tindiflox
Tab
Tab
Tab
Dabur
Zydus cadila
Kontest
Ancoloxin
Avomine
Emidoxyn
Marzine
Pregnidoxin
Reglan
Reggi
Domstal
Perinorm
Antiemetics
Tablet
Tablet
Tablet
Tablet
Tablet
Tab/Inj/Syrup
Tab/Syrup
Tab
Tab/Inj
Allenburys
May and Baker
Rallis
Wellcome
Unichem
Cosme Farma
Shalaks
Torrent
IPCA
Decongestants
(For common cold)
Actifed plus
Tablet
Wellcome
Bodryl
Tablet
Parke Davis
Capramin
Tablet
Glaxo
Cinaryl
Syrup/Tab
Themis
Cosavil
Tablet
Hoechst
Dristan
Tab/Syrup
Manners
Eskold
Tab/Syrup
SK and F
Vikoryl
Tab/Suspension Alembic
Diet Therapy
Analgesics and Antipyretics

Tablet
IDPL
Tab/Syrup
Wellcome
Tab/Syrup
Duphar
Tablet
Reckitt and
Colman
Fortwin
Tablet/Inj
Ranbaxy
Mejoral
Tablet
Cosme Farma
Micropyrin
Tablet
Nicholas
Novalgin
Tab/Inj
Hoechst
Ultragin
Tab/Inj/Syrup
Manners
Pyremol
Tablet
Alembic
Proxyvon
Cap
Wockhardt
Apidin
Calpol
Crocin
Disprin
Non-steroid Anti-inflammatory Drugs

Algestin
Brufen
Brufamol
Dolocap
Esgipyrin
Reducin/
Reducin-A
Sugarnil
Idicin
Oxalgin
Meftal
Tab/Inj
Tab 200/400/
600 mg
Tab
Capsule
Inj/Tab
Tablet
Alembic
Boots
Tablet
Capsule
Tablet
Capsule
SG Chemicals
IDPL
Cadila
Blue Cross
Shalaks
Unique
SG Chemicals
Unique
307
308
Toldin 10/20 mg Tablet

Flurbiprofen
Tablet
Algipan
Medicreme
Relaxyl
Rubriment
DBI
Daonil
Diamicron
Diabinese
Euglucon
Glyciphage
Insulins
Rubefacient
Cream
Cream
Cream
Liniment
Anti-diabetics
Tablet
Tablet
Tab
Tab
Tablet
Soluble Zinc
suspension lentae
Isophane (NPH)
Torrent
FDC
Wyeth
Rallis
Franco Indian
German remedies
USV and P
Hoechst
Serdia
Pfizer
Bohringer-Knoll
Franco Indian
boots
Diuretics
Aldactone
Diamox
Diural
Dytide
Hythalton
Lasix
Navidrex
Tablet
Tablet
Tab/Inj
Tablet
Tablet
Tab/Inj
Tablet
Searle
Cyanamid
Alembic
SK and F
SG Chemicals
Hoechst
Ciba Geigy
Diet Therapy
Nephril
Xipamid
Tablet
Tablet
Pfizer
German Remedies
Urinary Anti-infective and Anti-spasmodic

Campicilin
Genticyn
Gramoneg
Pyridacil
Pyridium
Septran DS
Fortwin
Uroflox
Reflobid
Norflox
Supristol
Urobiotic
Urolucosil
Ultrox
Cap/Syrup
Injection
Tablet
Tablet
Tablet
Tab/Ped Susp/
Ped Tab
Inj
Tab
Tab
Tab
Tab/Ped Tab/Susp
Capsule
Liq Tab
Tablet
Cadila
Nicholas
Ranbaxy
Ethnor
Warner
Wellcome
Ranbaxy
Torrent
Cadila
Cipla
German
Pfizer
Warner
Ethnor
Corticosteroids and Related Drugs

Bletacortril
Betnelan
Betnesol
Decadron
Deltacortril
Tab/Forte Tab
Tablet
Tab/Inj Oral
Drops
Tab/Inj
Tab/Forte
Tab/Inj
309
Pfizer
Glaxo
Glaxo
MSD
Pfizer
310
Dexona
Hostacortin-H
Kenacort
Ledercort
Lycortin-S
Walcort
Wycort
Wymesone
Wysolone
Butapred
Corthist
Dexabolin
Docabolin
Perideca
Inj/Tab
Tablet
Tab/Inj
Tablet
Tablet
Tablet
Injection
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tab/Susp
Ledoxan
Leukeran
Zexate
Intaxel
Tamofen
Tab/Inj
Tab
Tab
Tab
Tab
Cadila
Hoechst
Sarabhai
Cynamid
Lyka
Carter Wallace
Wyeth
Wyeth
Wyeth
Biochem
Inga
Organon
Organon
MSD
Anticancer Drug
Dabur
Wellcome
Dabur
Dabur
Torrent
Anti-hypertensive
Adelphane
Aldephane
Esidrex
Aldomet
Arkamin
Tablet
Tablet
Ciba Geigy
Ciba Geigy
Tablet
Tablet
MSD
Unichem
Diet Therapy
Ciplar
Emdopa
Inderal
Ismelin
Nephril-R
Nepresol
Serpasil
Betacard
Pinadol
Aceten
Betaloc
Atenol
Lorvas
Nepresol
Tab/Forte
Tab/Inj
Tablet
Tab 10/40/80 mg
Tab 10/25 mg
Tablet
Tablet
Tab/Inj
Tablet
Tablet
Tablet 25 mg
Tablet
Tab
Tablet
Tablet
Cipla
IDPL
ACCI
Ciba Geigy
Pfizer
Ciba Geigy
Ciba Geigy
Torrent
Ranbaxy
Wockhardt
Astra
NPIL
Torrent
Ciba
Vasoconstrictors
(For migraine)
Cafergot
Migranil
Migril
Vasograin
Tablet
Tablet
Tablet
Tablet
Sandoz
Inga
Wellcome
Cadila
Sulphonamides
Bactrim
Ciplin
Fortrim
Tab/Pediatric Tab Rosche

Tab/Susp
Cipla
Tab/Paed Tab
Bombay drug
311
312
Septran DS
Synastat
Tab/Susp
Tab/Susp
Wellcome
Roussel
Antituberculous Drugs
Albutol
Ambistryn-S
Bi-Teben
Erbazide
Etibi
Eufacin
Inapas
Isokin
Isokin-T
Isonex
Myambutol
Pas dumex
Rifamycin
Rimpacin
Themibutol
Tibitol
Tablet
Injection
Tablet
Tablet
Tab 200/400 mg
Capsules
Tab/Granules
Tab 300 mg
Tablet
Tab 50/100 mg
Tablet
Granules
Cap 150/300 mg
Cap 100 mg
Tab 200/400 mg
Tab 200/400 mg
Fungivin
Grifungin PG
Grisovin FP
Grivin FP
Indifulvin
Tab 125 mg
Tablet
Tablet
Tablet
Tablet
Alkem
Sarabhai
Bayer
Mac
Pharmed
Euphoric
Neopharma
Warner
Warner
Pfizer
Cyanamid
Pfizer
Biochem
Cadila
Themis
PCI
Antifungals
Eurphoric
Reno
Glaxo
Cosme farma
IDPL
Diet Therapy
Mycostatin
Walavin-FP
Tablet
Tablet
313
Sarabhai
Carter Wallace
Calcium Preparations
Calcima ACD
Calcinol F
Calcinol
Calcium Sandoz
With Vit C and D
and B12
Kalzana
Malcavit
Ostocalcium
Tablet
Syrup
Tablet
Injection
Cipla
Raptakos
Raptakos
Sandoz
Tab/Syrup
Syrup/Inj
Tab/Syrup
Sandoz
Sandoz
Glaxo
Vitamin A Preparations
Adexolin
Adiplon-12
Aquasol-A
Aquasol A-D
drops
Aquasol A-E
Arovit
Cap/Liquid
Drops
Capsule
Liquid
Glaxo
Khandelwal
USV and P
USV and P
Capsule
Tab/Inj/Drops
USV and P
Roche
Nasal Drops
Betnesol-N-nasal Drops
Catazol
Drops
Dristan nasal
Drops
drops
Glaxo
Bengal Chemicals
Manners
314
Efcorlin nasal
drops
Endrine
Nasivion
Otrivin
Drops
Allenburys
Drops
Drops/Paed
Drops/Paed
Wyeth
Merck
Ciba Geigy
Aural Preparations
Chloromycetin
eardrops
Genticyn
Eye/Ear
Hamycin
Otek
Neosporin-H
Paraxin eardrops
Terramycin ear
Tyotocin
Drops
Parke Davis
Drops
Nicholas
Drops
Drops
Drops
Drops
Drops
Drops
HAL
FDC
Wellcome
Boehringer-K
Pfizer
MSD
Albucid
10% 20% 30%

Drops
Ointment
Aplicaps
Nicholas
Drops
10% 20% 30%
Drops
Nicholas
East India
Eyedrops
Alcycline
Chloromycetin
aplicaps
Genticyn
Locula
Alembic
Parke Davis
Diet Therapy
Soframycin
ophthalmic oint
Vanmycetin
Zinco sulfa
Oint
Mac
Drops
Drops
FDC
BELL
315
Anti-allergic Drugs
Actidil
Avil
Benadryl
Dilosyn
Foristal
Foristal Lon tab
Histacort
Incidal
Longifene
Practin
Astelong
Cetzine
Zadine
Tablet
22.5/45 mg Tab/
Syrup/Inj
Cap/Syrup
Tab/Syrup
Tablet
Tablet
Tablet
Tablet
Tab/Syrup
Tab/Syrup
Tab
Cap/Tab
Tab/Syrup
Wellcome
Hoechst
Parke Davis
Allenburys
Ciba Geigy
Ciba Geigy
SINS
Bayer
Nni UCB
MSD
Torrent
Glaxo
Schering
Anti-scabies Drugs
Ascabiol
Benhex
Benzoscab
Crotorax
Dermoscab
Emscab
Emulsion
Cream
Ointment
Cream/Lotion
Ointment
Lotion
May and Baker

Searle
UNILOIDS
SG Chemicals
Chowgule
MM Lab
316
Gamaderm
Tetmosol SOL
Lotion
Solution/Soap
Vilco
SK and F
Topical Antifungal Drugs

Bradex Vioform
Dermoquinol
Multifungin
Multifungin-H
Mycoderm
Tinaderm
Tineafax
Daktar in 2%
Surfaz
Econazole
Hamycin
Cream
4% and 8% tube
Power/Soln/Oint
Ointment
Dusting powder
Soln
Ointment
Oint
Oint
Oint
Susp
Ciba Geigy
East India
Boehringer
Boehringer Knoll
FDC
Fulford
Wellcome
Ethnor
Franco Indian
Sarabhai
HAL
Topical Anti-Infective Preparation

Achromycin oint
Burnol
Cetavlex cream
Cetavlon conc
Chloromycetin
topical
Dettol antiseptic
cream
Furacin
Genticyn topical
Ledermycin oint
Ointment
Cream
Cream
Soln
Cream
Powder/Cream
Cream
Ointment
Cyanamid
Boots
ACCI
ACCI
Parke Davis
Rickett and
Colman
SK and F
Nicholas
Cyanamid
Diet Therapy
Nabasulf
Neosporin
Savlon
Soframycin skin
Betadine
Fucidin-Leo
Genticyn topical
Ointment/Powder
Powder/Oint
Cream/Liquid
Ointment
Oint/Lot
Oint
Oint
Pfizer
Wellcome
ACCI
Roussel
Wockhardt
Wallace
Nicholas
Topical Steroid Preparation

Betnovate
Betnovate-N
Betnovate-C
Cambison oint
Cortoquinol
Decadron cream
Furacin-S
Flucort
Flucort-C
Flucort-N
Flucort Sol
Kenalog-S skin
Ledercort
Nebacortril skin
Neosporin-H
Sofradex cream
Wycort oint
Cream and Oint

Cream/Oint
Cream/Oint
Ointment
Cream
Cream
Cream
Cream
Cream
Cream
Cream
Ointment
Cream
Ointment
Ointment
Cream
Ointment
Glaxo
Glaxo
Glaxo
Hoechst
East India
MSD
SK and F
Lyka
Lyka
Lyka
Lyka
Sarabhai
Cyanamid
Pfizer
Wellcome
Roussel
Wyeth
317
318
Plasma Expanders
Dextran 70
Dextraven
Dextrose 2.5%
Dextrose 5%
Dextrose 10%
Dextrose 20%
Dextrose 25%
and 50%
Rallis-Fison
Rallis
Mc Gaw
Duphar/Mc Gaw/Flexflac
Mc Gaw/Flexflac
Mount Mettur/Mc Gaw
Mount Mettur
Dextrose and Sodium Chloride

Dextrose (2.5%) Mount Mettur/Mc Gaw
Sodium chloride
(0.45%)
Dextrose (5%)
Duphar/Mc
Gaw/Flexflac
Sodium chloride (0.9%)
Dextrose
Mount Mettur/
Mc Gaw/Flexflac
Sodium chloride
Haemaccel
Fluid
Hoechst
Lomodex
Fluid
Rallis-Fison
Mannitol 5%
Fluid 500 ml
Mc Gaw
10% and 20%
Mannitol
350 ml
Unichem
Molar lactate sol
Mount Mettur/
Mc Gaw
Diet Therapy
Ringers lactate
540 ml
500 ml
319
Mount Mettur/
Mc Gaw
Sodium Chloride
Sodium chloride 540 ml
0.45%
Sodium chloride 540 ml
0.9%
Mc Gaw/Mount
Mettur
Duphar/Mc Gaw
Vitamin B and Vitamin C

Preparations/Multivitamin
Becosule
Becozym forte
Bejectal
Beneuron
Beplex forte
Berin
Bevidox
Bivinal forte
Vit C
Cebexin
Cecon-500
Celin
Cap/Syrup
Tablet
Injection
Capsule
Tab/Inj
Tablet
Tablet
Capsule
Tablet
Tab/Drops
Tablet
50/100/500 mg
Chewcee
Tablet
Cobadex forte
Tablet
Dolo neurobion Tablet
Pfizer
Roche
Abbott
Franco Indian
Anglo French
Glaxo
Abbott
Alembic
IDPL
Abbott
Glaxo
Cyanamid
Glaxo
Merck
320
Hexavit (M vit)
Multivitaplex
forte
Neurobion
Neuroxin-12
Polybion
Redoxon
Surbex
Surbex-T
Vidaylin
Visyneral
Vitneurin
Tablet
Cap/Elixir/Drops
IDPL
Pfizer
Tab/Forte
Tab/Inj
Inj/Forte Inj
Tab/Inj/Syrup
Tab/Inj
Tablet/Syrup
Tablet
Drops/Syrup
Drops/Syrup
Ampoule
Merck
Cadila
Merck
Roche
Abbott
Abbott
Abbott
USV and P
Glaxo
Food Products
Alprovit
Procasenol
Protinex
Protinules
SYU
Liquid
Granules
Granules
Powder
Granules
Alcopar
Antepar
Decaris
Helmacid
Mebex
Granules
Elixir
Tab 150/50 mg
Granules
Tablet
Alkem
MSD
Pfizer
Alembic
AFD
Anti-helminthics
Wellcome
Wellcome
Ethnor
Glaxo
Cipla
Diet Therapy
Mintezol
Nilcaris
Vanpar
Wormin
Vermisol
Alminth
Tablet
Tab 150 /50 mg
Suspension
Tablet
Tablet
Tablet
321
MSD
Bombay Drug
Parke Davis
Cadila
Khandelwal
Torrent
Bronchospasm Relaxants
Alupent
Asmapax depot
Asthalin
Broncordil
Cortasmyl
Deriphyllin
Sedonol
Tedral
Tedral SA
Terbutaline
Bricanyl
Asthalin
Autohaler
Beclate
Tab/Inj/Syrup
Tablet
Tab/Syrup
Elixir
Tablet
Tab/Inj
Tablet
Tab/Liquid
Tablet
Tablet
Inhaler
Inhaler
Inhaler
Inhaler
German Remedies
Nicholas
Cipla
Neo Pharma
Roussel
German Remedies
East India
Warner
Warner
Astra
Astra
Cipla
Cipla
Cipla
Cough Expectorants/Sedatives
Avil Expectorant Syrup
Hoechst
Benadryl
Syrup
Parke Davis
Expectorant
Corex
Syrup
Pfizer
322
Dilosyn Exp
Dristan Exp
Piriton Exp
Soventol Exp
Soln
Tab/Syrup
Liquid
Liquid
Allenburys
Manners
Glaxo
Boehringer
Knolls
May and Baker
Alembic
May and Baker
Tixylix
Zeet Exp
Phensedyl
Liquid
Syrup
Linctus
Autrin
Dexorange
Dumasules
Erythrotone
Fefol spansule
Folinate B-12
Folvron-F
Hematrine
Livogen
Neoferilex S
Plastules B-12
Rarical
Rubration
Tonoferon
Iron Preparations
Capsule
Cyanamid
Syrup
Franco Indian
Capsule
Pfizer
Cap/Syrup
Nicholas
Capsule
SK and F
Cap/Liquid
Alembic
Cap/Liquid
Cyanamid
Capsule
Sandoz
Capsule
Allenburys
Liquid
Rallis
Capsule
Wyeth
Tablet
Ethnor
Elixir
Sarabhai
Syrup/Drops
East India
Alcyclin
Althrocin
Cap/Paed drops
Tab/Granules
Antibiotics
Alembic
Alembic
Diet Therapy
Bacipen
Campicillin
Combiotic
Doxycaps
Emycin
Erythrocin
Garamycin
Olymox
Ampiclox
Alcephin
Cifran
Minicyclin
Genticyn
Hostacyclin 500
Kaypen
Klox
Ciprobid
Althrox
Norflox
Ledermycin
Paraxin
Penidura LA 6,
LA 12, LA 24
Synthocilin
Thromycin
Capsule
Dry Syrup/Inj
Injection
Capsule
Tablet
Tablet
Injection
Cap
Cap
Cap
Tab
Cap
Injection
Dragees
Tab/Granules
Cap/Syrup
Tab
Tab
Tab
Cap/drops/
Syrup
Cap/Dry Syrup
Injection
Alembic
Cadila
Pfizer
Reno
Themis
Abbott
Fulford
Shalaks
Biochem
Alembic
Ranbaxy
Plethico
Nicholas
Hoechst
HAL
Lyka
Zydus cadila
Alembic
Cipla
Cyanamid
Cap/Inj/Drops
250/500 mg
Tablet
PCI
B Knoll
Wyeth
IDPL
323
324
Veripen
Penglobe
Alcizon
Alcephin
Carbelin
Ceflad
Cephaxin
Flemipen
Sisocin
Ciprofloxacin
Tab/Forte
Tablet
Injection
Capsule
Injection
Injection
Cap/Syrup/Inj
Capsule
Injection
Tab
Alembic
Astra
Alembic
Alembic
Lyka
Biochem
Biochem
FDC
Biochem
Sarabhai
Enzymes and Digestives

Bestozyme
Combizyme
Digiplex
Dispeptal
Panzynorm
Unienzyme
Vitazyme
Tab/Syrup
Dragees
Syrup
Tablet
Tablet
Tablet
Liquid
Biological Evans
Neo Pharma
Rallis
B Knoll
German Remedies
Unichem
East India
Local and Systemic Drugs for

Vaginal and Urethral Conditions
Compeba
Dienoestrol
Flagyl
Giardyl
Kemicetine
vaginal
Tablet
Cream
Tab 200/400 mg
Tab/Susp
Suppositories
IDPL
Ethnor
May and Baker
IPCA
SG Chemicals
Diet Therapy
Metrogyl
Tab 200/400 mg
Mycostatin
Vaginal Tab
Vaginal
Talsutin Vaginal Vaginal Tab
325
Unique
Sarabhai
Sarabhai
Vaginal Preparations
Betadine
Floraquin
Hamycin
Gynodaktarin
Natamycin
Pessary
Pessary
Vaginal Tablet
Vaginal Tablet
Vaginal Tablet
Wockhardt
Searle
HAL
Ethnor
Martel-Hammer
Anti-spasmodics and Anti-cholinergics

Buscopan
Tab/Inj
compositum
Antrenyl
Tab/Drops
Antrenyl duplex Tablet
Bardase
Tab/Liquid
Belladenal IN
Tablet
Belladenal IF
Tablet
Retard
Daricon
Tablet
Cibalgin
Tablet
Piptal
Drops
Spasmindon
Tab/Inj
Spasmo-Proxyvon Injection
German
Remedies
Ciba
Ciba
Parke Davis
Sandoz
Sandoz
Ciba
Ciba
Chem pharma
Indo pharma
Wockhardt
326
Antimalarials
Chloroquin
Tablet
Cadiquin
Nivaquin
Camoquin
Daraprim
Lariago
Metakelfin
Quinarsol
Injection
Injection
Tablet
Tablet
Syrup/Tab/Inj
Tablet
Tablet
Bengal
immunity
Cadila
M and B
Parke Davis
Wellcome
IPCA
Water Brushel
Cipla
Anginal Drugs and Coronary Vasodilator

Cardilate
Ciplar
Inderal
Isoptin
Isorpil
Neocor
Peritrate
Peritrate SA
Segontin
Sorbitrate
Tablet
Tablet
Tablet
Dragees/Inj
Tab/Sulingual
Tablet
Tablet
Tablet
Tablet
Sublingual Tab
Wellcome
Cipla
ACCI
B Knoll
Manners
Warner
Warner
Warner
Hoechst
Nicholas
Anti-anginal
Angised
Calcigard
Clinium
Tablet
Tablet
Tablet
Wellcome
Torrent
Ethnor
Diet Therapy
Ildamen
Isomack
Tablet
Tablet
327
German Remedies
Biochem
Peripheral Vasodilator
Arlidin
Complamina
Duvadilan
Cyclospasmol
Nicidal
Repaverine
Xanthomina
Tablet
Tab/Amp
Tab/Inj
Tablet
Tablet
Tablet
Tablet
USV and P
German Remedies
Duphar
Martin Haris
Cipla
Retort
Cipla
Tranquilizers
Atarax
Ifibrium
Larpose
Meprindon
Equanil
Calmpose
Librium
Valium
Drops/Inj/Syrup
Tablet
Tablet
Tablet
Tablet
Tab/Syrup/Inj
Tablet
Tablet
UCL
Unique
Cipla
Indo Pharma
Wyeth
Ranbaxy
Roche
Roche
Hypnotics and Sedatives

Non-barbiturates
Calcibronat
Tab/Inj/Syrup
Barbiturate Plain
Luminol
Tab/Inj
Phenobarbitone Tablet
Sandoz
Bayers
Deys/IDPL
328
Gardenal
Tab/Inj
Barbiturate Combination
Vesparax
Tablet
May and Baker

UCB
Sympathomimetics and Analeptics

Nikethamide
Strychnine
Cardiazol
Veritol
Coramine
Levophed
Mephentine
Injection
Injection
Inj/Tab
Injection
Tab/Inj/Drops
Injection
Injection
Bengal Immunity
Bengal Immunity
B Knoll
B Knoll
Ciba
Deys
Wyeth
Sex Hormones/Hormonal Contraceptives

Voldays 21
Norcyclin
Ovral
Lyndiol
Norlestrin
Orlest
Anovlar-21
Gynovlar-21
Primovlar-30
Ovulen
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Glaxo
Ciba
Wyeth
Organon
P. Davis
P. Davis
Schering
Schering
Schering
Searle
Androgens and Combinations

Testosterone
Triolandern
Injection
Injection
Bengal Immunity
Ciba
Diet Therapy
Aquaviron
Injection
Aquaviron B-12 Injection
Sustanon
Injection
Testoviron
Injection
Uni-testron depotInjection
For Acne
Soap
Cream
Acnelak
Acnelak
Acnebenz
Ethisterone
Clinestrol
Ovucyclin
Honvan
Lynoral
Ind Schering
Ind Schering
Organon
Ind Schering
Unichem Lab
Shalaks
Shalaks
Shalaks
Oestrogen and Combinations

Tablet
BPL
Injection
Glaxo
Injection
Ciba
Tablet
Khandel Lab
Tablet
Organon
Progestogens and Combinations

Progesterone
Injection
Lutocyclin
Progesterone
Gestanin
Prolution
UNI progestin
Inj/Tab
Tablet
Tablet
Injection
Injection
Bengal
Immunity
Ciba
PCI
Organon
Schering
UCB
329
330
Antioxidant
Zemin
Cap
Shalaks
Zollpam
Alprax
Alzolam
Zolax
Tab
Tab
Tab
Tab
UV Dew
UV Dew Plus
UV AVO
Cream 10, SPF

SPF 18+
SPF 25+
Anxiolytic
Shalaks
Torrent
Sun Pharma
Intas
Sun Screens
Shalaks
Shalaks
Shalaks
UNDERWEIGHT
Proteins
Fats
Carbohydrates
1.5 gm/kg or more.

These are encouraged to increase
weight. However, care should be
taken because excessive fats produce
diarrhoea.
Produce flatulance and gastrointestinal disorder.
If taken before actual meals may
decrease the appetite.
Sweet potatoes, potatoes, finger
chips, biscuits, soya bean prepara-
Diet Therapy
Vitamin
331
tions, groundnuts will help in gaining weight.

Should be supplemented in sufficient
quantity.
Sweetened juices, cheese, butter,
bread, jam, dried nuts and fruits, eggs
and meat with gravy are encouraged.
332
BLOOD COUNT
NORMAL BLOOD COUNT

RBC COUNT
Men
4.5 to 5.6 million/cu mm.
Women
3.9 to 5.6 million/cu mm.
Total leucocyte count4000 to 11000/cu mm of blood.
Differential leucocytes (in adults)
Polymorphs (neutrophils) 55-65%
Lymphocytes 20-35%
Monocytes 3-10%
Eosinophils 1-6%
Basophils (0-1%).
LEUCOCYTOSIS
An absolute increase in leucocytes is referred to as leucocytosis, i.e., above 11000 cells per cu mm of blood.
Blood Count 333
Neutrophilia
Physiological
In muscular activity
Infants during first few days
During last week of pregnancy
Emotional disturbances
Extreme heat and cold.
Pathological
Acute infections due to staphylococcus, streptococcus, pneumococcus, gonococci and septicaemia,
acute appendicitis, osteomyelitis, etc.
In intoxications
Gout, diabetic coma, cirrhosis of liver, intestinal
obstruction, uraemia.
Myeloid leukaemia
After acute haemorrhage
In malignant tumours
Poisons like carbon monoxide, chloroform, ether
Myocardial infarction
Serum sickness.
LEUCOPENIA
A reduction in the number of leucocytes below
4000/cu mm.
334
Infections
Bacterial
Typhoid fever, paratyphoid fever, brucellosis, miliary
tuberculosis.
Viral
Influenza, measles, infective hepatitis.
Protozoal
Malaria, kala azar, relapsing fever.
Defective Bone Marrow Function
Aplastic anaemia
Megaloblastic anaemia.
Bone Marrow Involvement
Secondary carcinoma
Malignant lymphoma
Myelosclerosis
Multiple myeloma.
Sensitivity to Drugs (Agranulocytosis)
Sulphonamides
Thiouracil
Amidopyrine
Phenylbutazone
Chloramphenicol.
Blood Count 335
Shock
Traumatic
Anaphylactic.
Irradiation
Exposure to X-ray and radioactive substances.
LYMPHOCYTOSIS
Relative lymphocytosis occurs in conditions showing
polymorphonuclear leucopenia. Absolute lymphocytosis occurs in:
Pertussis
Infectious mononucleosis
Chronic lymphatic leukaemia
Chronic infectionstuberculosis, syphilis, infective
hepatitis
Mumps, measles, chickenpox
Thyrotoxicosis.
LYMPHOPENIA
Administration of ACTH
In conditions of stress and carcinomatosis
Excessive radiation.
MONOCYTOSIS
Bacterial infections
Tuberculosis, typhoid, brucellosis
Subacute bacterial endocarditis.
336
Protozoal
Malaria, kala-azar, amoebiasis
Monocytic leukaemia
Hodgkins disease.
EOSINOPHILIA
Allergic Disorders
Asthma, drug allergy
Serum sickness
Urticaria.
Parasitic Infestations
Intestinal worms
Hydatid cyst
Bilharziasis.
Drug Administration
(with or without drug allergy)
Liver extract, penicillin
Chlorpromazine
Streptomycin.
Skin Diseases (Allergy Type)
Eczema
Exfoliative dermatitis.
Pulmonary Eosinophilia
Tropical eosinophilia
Loefflers syndrome.
Blood Count 337
Blood Dyscrasias
Eosinophilic leukaemia
Chronic myeloid leukaemia
Following irradiation
Hodgkins disease.
EOSINOPENIA
Administration of ACTH, adrenaline and ephedrine
Response to stress: Traumatic shock, surgical operations, burns, acute emotional stress, exposure to cold.
Endocrine disorders: Cushings disease and
acromegaly.
Aplastic anaemia, SLE.
BASOPHILIA

Polycythemia vera
Cirrhosis of liver
Early stages of Hodgkins disease
Lead poisoning (punctuate basophilia).
PLASMA CELLS
These are normally not present in peripheral blood, but
may be found in:
Measles, chickenpox (plasmacytoid lymphocytes)
Multiple myeloma with spillover
Plasma cell leukaemia.
338
PLATELETS
Normal value: 150,000-450,000/cu mm.
THROMBOCYTOPENIA
(Below 150,000/cu mm)
Idiopathic thrombocytopenic purpura

Leukaemia (usually acute leukaemias)
Aplastic anaemia
Multiple myeloma
Hypersplenism
Drug reactions
Megaloblastic anaemia.
THROMBOCYTOSIS
(Count above 450,000/cu mm)
Polycythemia vera, essential thrombocythemia

After splenectomy
After haemorrhage
After parturition
After severe injuries, major surgical operations.
PANCYTOPENIA
When all the three elements of blood are reduced:
Subleukaemic leukaemia
Aplastic anaemia
Bone marrow infiltration, i.e. Hodgkins, multiple
myeloma or secondary carcinoma deposit.
Hypersplenism.
Blood Count 339
Megaloblastic anaemia
Disseminated sclerosis.
RED CELL MORPHOLOGY

HYPOCHROMIA (Increase in central pallor)
Iron deficiency anaemia

Thalassaemia
Sideroblastic anaemia
Anaemias of chronic diseases.
MACROCYTES
(Larger than small lymphocytes)
Myeloblastic anaemia
Hepatic disease
B deficiency
Aplastic anaemia
Congenital dyserythropoietic anaemia
Pure red cell aplasia.
TARGET CELLS
Obstructive liver disease

Thalassaemia
Haemoglobin C disease
Haemoglobin D disease.
340
SPHEROCYTES
Hereditary spherocytes
Autoimmune haemolytic anaemia
Cl. welchii infection
Post-burn patients.
LEUCOERYTHROBLASTIC PICTURE
(Immature myeloid and erythroid cells
appearing in peripheral blood)
Myeloproliferative disorders:
Polycythemia vera
Myelofibrosis
Haemolytic anaemias
Leukaemias
Bone marrow involvement with Hodgkins
carcinoma or lymphoma
Leukaemoid reactions.
RETICULOCYTE COUNT
Stained with brilliant cresyl blue appears as bluish
strands in cytoplasm due to precipitation of ribosomes
and RNA.
(Normal 0.1-2%).
Increased
Haemolytic anaemia
Nutritional anaemia on therapy.
Blood Count 341
Reduced
Aplastic anaemia
PNH.
INCREASED PLASMA HAEMOGLOBIN
(Normal 0.4 mg/100 ml)
G6 PD deficiency
PNH
Black water fever
Cold haemoglobinuria
Autoimmune haemolytic anaemia.
LEUCOCYTE ALKALINE
PHOSPHATASE SCORE
Increased
Infection
Leukaemoid reaction
Myelofibrosis
Aplastic anaemia
Polycythemia vera.
Decreased
Paroxysmal nocturnal haemoglobinuria.
COOMBS TEST
It is positive in autoimmune haemolytic anaemia
i. Idiopathic.
342
ii. Secondary to
Lymphoma
Mycoplasma pneumonia
Cold agglutinin disease.
LUPUS ERYTHEMATOSUS (LE) CELLS
Positive LE Cells in Blood
Systemic lupus erythematosus (70-80%)

Rheumatoid arthritis (10%)
Occasionally other collagen diseases
Active chronic lupoid hepatitis (10%)
Malaria
Drugs-Hydralazine, Procainamide.
ERYTHROCYTE SEDIMENTATION RATE (ESR)

Two methods are employed commonly:
Westergren Method
0-5 mm in men
0-7 mm in women.
Wintrobe Method
0-9 mm in men
0-20 mm in women.
ESR not raised
In relatively inactive infections, i.e., influenza
Chronic focal dental infection.
Blood Count 343
In benign tumour and early sarcoma

Ectopic pregnancy
Psychoneurotic diseases.
ESR raised
Pregnancy from 4th month

Anaemia (except sickle cell)
Acute myocardial infarction
Carcinomatosis
Pulmonary tuberculosis
Acute gout
Extensive tissue damage-burns
Acute infections
After fracture and operation.
ESR decreased
Polycythaemia vera
Congestive cardiac failure
Whooping cough, dehydration.
ESR very rapid increase
Temporal arteritis
Kala-azar
Some cases of multiple myeloma
Rheumatoid arthritis
Leukaemia
Haemolytic anaemia
Chronic renal disease
Sarcoidosis.
344
ESR in diagnosis
To distinguish functional from organic disease.
In active rheumatoid arthritis, acute gout and infective arthritis, it is markedly raised while in osteoarthritis it remains practically normal.
In myocardial infarction it is raised while in angina it
is not.
It differentiates cancer of stomach from peptic ulcer.
It is raised in pelvic inflammation and not in unruptured ectopic gestation.
ESR in prognosis and treatment
In fevers, a rising ESR suggests progress of the
disease.
In rheumatic fever it is a specially sensitive index of
persistent rheumatic infection.
In coronary thrombosis repeated determination
serves as a guide of healing and in management of
patients activities.
In acute nephritis, the rate remains high in patients
passing into chronic stage.
Fragility of erythrocytes
Normal: Begins in 0.45-0.30% NaCl
Completes in 0.33-0.30% NaCl.
Increased
Hereditary spherocytosis
Congenital haemolytic jaundice.
Blood Count 345
Decreased
Pernicious anaemia
Hypochromic anaemia
Obstructive jaundice
After splenectomy.
BLEEDING TIME
Normal is 2-10 minutes, but in some individuals it may
extend upto 11 minutes.
Bleeding Time is Prolonged
In thrombocytopenia.
Hereditary functional platelet defects.
In acute haemorrhagic exanthemata.
In atrophy of bone marrow as in aplastic anaemia.
In excessive destruction of platelets by spleen as in
Gauchers disease and Bantis spleen.
von Willebrands disease.
Functional Platelet Defects
Platelets are adequate in number but defective in
function leading to increase in bleeding time.
Glanzmanns thrombasthenia
Storage pool disease
Bernard-Souliers disease
Cyclooxygenase deficiency
Thromboxane synthetase deficiency.
346
COAGULATION TIME
Normal values for clotting time are 9-15 minutes.
Reduced
After meals
In typhoid
After haemorrhage and general anaesthesia
In endocarditis
After splenectomy.
Prolonged
In haemophilia A, B, and Factor XI deficiency
Chloroform and phosphorus poisoning. Here the
fibrinogen forming function of liver in hampered
Excessive CO2 in blood
Occasionally in leukaemia.
COAGULANT FACTOR DEFECTS
Haemophilia A
(Factor VIII pro-coagulant activity deficiency)
Mild5.25% of normal
Moderate1.5% of normal
Severe < 1% of normal.
Blood Count 347
Haemophilia B
(Christmas disease)
Due to factor IX deficiency.
Both haemophilia A and B are X linked diseases
transmitted by female carriers.
von Willebrands Disease
It is due to deficiency of factor VIII related antigen
deficiency.
PACKED CELL VOLUME (PCV)
Normal value
Male: 47% (47-54).

Female: 42% (36-47).
MEAN CORPUSCULAR HAEMOGLOBIN (MCH)

Hb in gm/1,000 ml of blood
in microMCH =
microgram
RBC in millon/C mm
Normal value 27 to 32.
Raised
Macrocytic anaemia.
Low
Hypochromic anaemia.
348
MEAN CORPUSCULAR HAEMOGLOBULIN

CONCENTRATION(MCHC)
MCV =
Hb
in gm/100 ml blood
______________________________________
PCV%
100
Normal 32 to 38%.
Raised
Not possible. Red cell stroma cannot hold greater
than normal cancentration of Hb.
Low
Iron deficiency.
MEAN CORPUSCULAR VOLUME (MCV)
MCV =
PCV
I in ml/100 ml of blood in cubic microns
_______________________________________________________________
RBC in million/cu mm
Normal value 78 to 94 cubic microns.

Raised
Macrocytic anaemia.
Low
Microcytic hypochromic anaemia.
COLOUR INDEX (CI)
Hb expressed as a %age of normal
Blood Count 349
CI =
14.5 gm Hb as 100%)
_____________________________________________________
RBC expressed as %age of normal)
Normal values 0.9 to 1.1.

Raised
Pernicious anaemia.
Low
Iron deficiency anaemia.
HAEMATOLOGICAL DIAGNOSIS OF LEUKAEMIA
Myeloblasts 10-25 m in diameter, round to oval nucleus
2/3 of cell size, chromatin strands with 2 or more
nucleoli, auter rods present. Lymphoblasts10-20 m in
diameter, 1-2 nucleoli more compact chromatin with
less cytoplasm.
Cytochemical Characteristics
Acute myeloblastic leukaemia
Myeloperoxidase positive
Siedor black positive
Chloroacetate elastase positive.
Acute monoblastic leukaemia
Non-specific esterase positive.
350
ALL
Periodic acid schiff (PAS) positive.
Hairy cell leukaemia
Tartrate resistant acid phosphatase positive.
Acute megakaryoblastic leukaemia
Platelet peroxidase positive.
Leukaemoid reaction
The total leukocyte count is often in the range of 50,000
cu/mm mimicking leukaemia.
i. Infections
a. Myelocytic or myeloblastic
Pneumonia
Meningitis
Diphtheria
Tuberculosis.
b. Lymphocytic
Whooping cough
Chicken pox
Tuberculosis
Benign lymphocytosis.
ii. Intoxications
Eclampsia
Burns
Mercury poisoning.
Blood Count 351
iii. Malignant diseases with bone marrow metastasis

Multiple myeloma
Myelofibrosis
Hodgkins disease
iv. Following severe haemorrhage, sudden haemolysis.
HAEMOGLOBIN ELECTROPHORESIS
It is done for diagnosis of abnormal haemoglobins like
Hb, S, C, D, E, H, Barts.
In alkaline pH electrophoresis (pH 8-9):
Slowest moving Hb-HbA2 C, E
Fastest moving Hb-HbH, Barts.
Haemoglobin A2
Normal 2.0-2.9%.
Increase
Beta-thalassaemia trait
Myeloblastic anaemia
Haemoglobinopathies.
Decrease
Haemoglobin-F
Normal 0.1%.
352
Increase
Physiological
Pathological
Foetal life
Thalassaemia
Haemoglobinopathies
Hereditary persistent haemoglobin
Juvenile CML
Fanconis anaemia.
IMMUNOGLOBULIN ESTIMATION
IgG
1200 mg/dl
IgA
280 mg/dl
IgM
100 mg/dl
IgD
3 mg/dl
IgE
10-20 mgm/dl
70%, IgG2 18%, IgG3 8%
IgG1
IgG4
4%, IgA1 75%, IgA2 25%.
All immunoglobulins are decreased in:
Severe combined immune deficiency
Thymic aplasia
Ataxia telangiectasia
X-linked agammaglobulinaemia
Transient hypogammaglobulinaemia of infancy
Common varied immunodeficiency.
IgA Deficiency
Bronchiectasis and chronic lung infections
Blood Count 353
Giardiasis
SLE and rheumatoid arthritis.
IgM Deficiency
Wiskott-Aldrich syndrome
IHA: Iso haemaglutination
ELISA: Enzyme linked immunosorbent assay
BFT: Bintolite flocculation test.
354
BLOOD BIOCHEMISTRY
SERUM MAGNESIUM
Elevated
Renal insufficiency.
Decreased
Acute fluid loss from GI tract

Chronic alcoholism
Chronic hepatitis
Chronic renal loss
Hypervitaminosis D.
SERUM PHOSPHORUS: INORGANIC

Normal
Children 4 to 7 mg/100 ml
Adults 3 to 4 mg/100 ml.
Elevated
Renal insufficiency
Hypoparathyroidism
Hypervitaminosis D.
Blood Biochemistry
Decreased
Hyperparathyroidism
Rickets and osteomalacia
Steatorrhoea
Antacid ingestion.
SERUM TRIGLYCERIDES
Normal
Below 165 mg/100 ml.
Elevated
Primary hyperlipoproteinemias
Hypothyroidism, diabetes mellitus
Nephrotic syndrome, use of contraceptive pills
Biliary obstruction.
Decreased
Primary hypolipoproteinemias
Malabsorption
Malnutrition.
SERUM BILIRUBIN
Normal total 0.3 to 1.1 mg/100 ml.
Direct
0.1 to 0.4 mg/100 ml.
355
356
Indirect
0.2 to 0.7 mg/100 ml.
Rise of Indirect Serum Bilirubin
In haemolytic disease or reactions.
Gilberts disease.
Rise of Total Serum Bilirubin
Acute and chronic hepatitis
Biliary tract obstructiongallstones or due to
cancer head of pancreas.
SERUM CALCIUM
Normal 9.6 to 10.9 mg/100 ml.
Raised
Hyperparathyroidism (20 mg%)

Hypervitaminosis D (17 mg%)
Multiple myeloma
Cushings syndrome.
Decreased
Hypoparathyroidism
Osteomalacia, rickets
Malabsorption syndrome
Acute pancreatitis.
Blood Biochemistry
357
CHLORIDES
Normal 350 to 275 mg/100 ml.
Increased
Excessive salt in diet

Over treatment with saline solution
Decreased excretion in urinary tract obstruction
Acute and chronic nephritis with low intake of
proteins
Decompensated heart disease.
Decreased
Abnormal loss such as in severe diarrhoea and vomiting excessive sweating
Overtreatment with diuretics
Renal failure.
SODIUM
Normal 136 to 145 mEq/L.
Low
Severe diarrhoea and vomiting
Failure of sodium retention in Addisons disease
Excess of water in take or inappropriate ADH
secretion.
358
High
Excessive replacement of sodium-oral or IV
Excessive replacement of sodium-hyper-aldosteronism
Failure of water retention
Diabetes insipidus.
SERUM CHOLESTEROL
Normal 150 to 250 mg/100 ml, 60-75% as esterified.
Raised
Xanthomatosis
Physiological in pregnancy
Alcohol and fatty diet consumption
Myxoedema
Diabetes mellitus
Obesity
Nephrotic syndrome
Amyloid disease of kidney
Familial hyperlipoproteinemias.
Low
Hyperthyroidism
Acute infections
Anaemia with malnutrition.
Blood Biochemistry
PLASMA PROTEINS
Total proteins 6 to 8 gm/100 ml.
SERUM ALBUMIN
Normal 3.5 to 5.5 gm/100 ml.
Raised
Haemoconcentration
Shock
Dehydration.
Low
Malnutrition
Starvation
Glomerulonephritis
Hepatic insufficiency
Leukaemia and other malignancies.
SERUM GLOBULIN
Normal 1.5 to 3 gm/130 m.
Raised
Hepatic diseases, e.g. infective hepatitis

Multiple myeloma
Some bacterial and viral infections
Typhus, leishmaniasis and malaria.
359
360
Low
Starvation with malnutrition
Agammaglobulinemia
Lymphatic leukaemia.
SERUM FIBRINOGEN
Raised
Rheumatic fever
Arthritis
Glomerulonephritis.
Decreased
Eclampsia of pregnancy
Severe anaemia
Typhoid
Primary and secondary fibrinolysis
Acute and chronic hepatic insufficiency
Disseminated intravascular coagulation
Hypofibrinogenemia
Metastatic carcinoma of prostate.
NITROGEN COMPOUNDS
Normal Values
Nonprotein nitrogen (NPN)
Blood urea nitrogen (BUN)
Serum creatinine
15 to 35 mg/100 ml
10 to 40 mg/100 ml
0.7 to 1.5 mg/100 ml.
Blood Biochemistry
361
Increased
Renal insufficiency
Nephritis, acute renal failure
Urinary tract obstruction.
Increased nitrogen metabolism with decreased
renal blood flow.
Dehydration, gastrointestinal bleeding
Decreased renal flow
Shock, adrenal insufficiency
Congestive cardiac failure.
Decreased
Hepatic failure
Nephrosis
Low protein diet.
UREA/CREATININE RATIO
Increased
High protein diet

Increased catabolism
Fever, burns, steroid therapy
Wasting in severe illness
Urinary stasis with urea reabsorption.
Decreased
Protein restriction
Excessive vomiting
Liver disease with impaired urea production.
362
SERUM URIC ACID

Raised
Due to increased purine synthesis and decreased uric
acid excretion, i.e. gout
Overproduction of uric acid chronic haemolytic
anaemias, psoriasis
Reduction in renal excretion of uric acid diuretics,
Ethambutol, chronic renal disease
Starvation ketosis.
Low
Aspirin therapy.
SERUM CREATINE
Raised
Hyperparathyroidism
Rheumatoid arthritis
Heart failure.
SERUM ALKALINE PHOSPHATASE
Normal 5 to 13 KA or 2 to 5 Bodansky units per 100 ml.
Raised
Osteoblastic bone disease (Severe osteomalacia,
osteogenic sarcoma, metastatic carcinoma bones).
Blood Biochemistry
363
Hepatic duct obstruction (due to stone, stricture or

neoplasm).
Hepatic disease resulting from drugs (Chlorpromazine and Methyltestosterone).
Boecks sarcoid
Pagets disease
Myeloid leukaemia
Hyperparathyroidism
Physiological (Pregnancy, alimentary hyperglycaemia, exposure to ultraviolet rays, in children).
Low
Hypothyroidism
Growth retardation in children.
ACID PHOSPHATASE
Normal 1-5 KA units or 0.5 to 2 Bodansky units/
100 ml.
Raised
Carcinoma prostate with secondary bone metastasis
and occasionally in acute myelocytic leukaemia.
SERUM AMYLASE
Normal 0.5 to 2 Bodansky units (80-180 Somogyi Units/
100 ml).
364
Raised
Acute pancreatitis
Carcinoma of pancreas
Certain cases of perforated peptic ulcer
Acute cholecystitis
Cirrhosis liver
Mumps
Renal failure.
Low
Necrotising hepatitis
Severe burns
Toxaemia of pregnancy.
SERUM LIPASE
Normal 0.2 to 1.5 units.
Raised
Acute pancreatitis
Cholelithiasis with jaundice
Liver cirrhosis
Intestinal obstruction
Duodenal ulcer.
SERUM POTASSIUM
Normal 14 to 20 mg per 100 ml (2.5-5.0 mEq/L).
Blood Biochemistry
365
Raised
Addisons disease
Renal insufficiency
Intestinal obstruction with vomiting.
Low
Inadequate intake
Starvation.
Inadequate absorption
Vomiting, diarrhoea, malabsorption syndrome.
Increased renal loss
Diuretics
Steroid therapy and hyper-aldosteronism.
Renal diseases
Chronic pyelonephritis
Acute renal failure
Renal ischaemia
De Toni-Fanconi syndrome.
SERUM IRON
Normal 75 to 175 mcg/100 ml.
Raised
Haemochromatosis.
Aplastic anaemia
Haemosiderosis
366
Haemolytic disease
Pernicious anaemia.
Low
Iron deficiency anaemia

Anaemia of chronic diseases
Nephrosis
Chronic renal insufficiency
Paroxysmal nocturnal haemoglobinuria.
IODINE
Normal 3.5 to 8 mcg/100 ml.
Raised
Pregnancy
Hyperthyroidism
Active stage of thyroiditis.
Low
Hypothyroidism
After Reserpine.
SERUM FERRITIN
Normal 10-200 g/ml.
Increased
Chronic infection
Malignancy
Collagen vascular disease.
Blood Biochemistry
367
Reduced
RHEUMATOID FACTOR
Positive Rheumatoid Factor
Rheumatoid arthritis (80%)

Connective tissue diseaseScleroderma
Chronic infectionSyphilis, leprosy, tuberculosis
After drugsProcainamide, Isoniazid
Other diseasesPrimary biliary cirrhosis
Acute/chronic hepatitis
Sarcoidosis
Lymphoma.
CHEMICAL CONSTITUENTS OF BLOOD

For some procedures, the reference values may vary
depending upon the method used.
Conventional units
Acetoacetate, plasma
Aldolase
-Amino nitrogen, plasma
Ammonia, while blood
venous
Amylase, serum
decilitre; 0.8-3.2 units
< 0.3 mmol per litre

0-8 units/litre
3.5-5.5 mg/dl
80-110 g/dl
60-180 Somogyi units per
per litre
Contd...
368
Contd...
Conventional units
Ascorbic acid, serum
Leukocytes
Base, total serum
Bicarbonate, serum
Bilirubin, total serum
(Millory Evelyn)
Direct, serum
Indirect, serum
Bromsulphalein BSP
(5 mg per kg of body
weight intravenously)
Calcium, serum
Calcium, ionised
Carbon dioxide content
Plasma (sea level)
Carbon dioxide tension
arterial blood (sea level)
Carotenoids, serum
Ceruloplasmin, serum
Chlorides, serum (as Cl)
Cholesterol, serum total
Esters
0.4-1.0 mg/dl
25-40 mg/dl
145-155 mmol/litre
23-29 mmol/litre
0.3-1.0 mg/dl
0.1-0.3 mg/dl
0.2-0.7 mg/dl
5% or less retention
after 45 minutes
2.2-2.7 mmol/litre;
9-11 mg/dl
1.1-1.4 mmol/litre
4.5-5.6 mg/dl
21-30 mmol/litre; 50-70
volume % per litre
35-45 mm Hg
50-300 g/dl
27-37 mg/dl
98-106 monol/litre
150-250 mg/100 mg
68-76% of total
cholesterol
Contd...
Blood Biochemistry
369
Contd...
Conventional units
Cholinesterase
Serum
Erythrocytes
Copper serum
(mean ISD)
Cortisol (competitive
protein binding)
Creatine phosphokinase
Serum (Total)
Females
Males
Isoenzymes, serum
Creatinine, serum
Cryoglobulins, serum
Fatty acids, free
(nonesterified) plasma
Fibrinogen, plasma
Folic acid, serum
Gamma glutamyl transferase
(transpeptidase), serum
Gastrin, serum
Glucose (fasting), plasma
Normal
Diabetes mellitus
0.5-1.3 pH unit
0.5-1.0 pH unit
114 14 g/dl
5-20 g/dl
at 8.00 AM
10-70 units/millilitre
25-90 units/millilitre
fraction 2 (MB)
< 5% of total
< 1.5 mg/dl
0
0.7 mmol/litre
160 to 415 mg/dl
6-15 ng/ml
4-60 units/litre
40-200 mg/dl
75-105 mg/dl
> 140 mg/dl
Contd...
370
Contd...
Conventional units
Haptoglobin, serum
(mean 1 SD)
Hydroxybutyric
dehydrogenase, serum
17-Hydroxycorticosteroids
Immunoglobulins, serum
IgG
IgA
IgM
Insulin, serum or plasma,
fasting
Iodine protein bound, serum
Iron, serum
Males and females
(mean 1SD)
Iron binding capacity
serum (mean SD)
Saturation
17-Ketosteroids
Men
128 25 mg/dl
0-180 milli units/ml
(IU)
(30) (RosalkiWilkinson) 114-290
units/ml
(Wroblewski)
2-10 mg/day
800-1500 mg/dl
90-325 mg/dl
45-150 mg/dl
6-26 U/ml
3.5-8.0 mcg/100 ml
105 35 mg/dl
305 32 g/dl
20-45%
7-25 g/day
Contd...
Blood Biochemistry
371
Contd...
Conventional units
Women
Lactic acid, blood
Lactate dehydrogenase
isoenzymes, serum
LDH1
LDH2
LDH3
LDH4
LDH5
Leucine aminopeptidase,
serum
Lipase, serum
4-15 mg/day
< 1.2 mmol/litre
22-37% of total
30-46% of total
14-29% of total
5-11% of total
2-11% of total
14-40 milli units/ml
(IU) (30)
1.5 units (CharryCrandall)
Lipids, total, serum
450-850 mg/100 ml
Magnesium, serum
0.8-1.3 mmol/litre
5-Nucleotidase, serum
0.3-2.6 Bodansky units
per decilitre
Nitrogen, nonprotein, serum 15-35 mg/dl
Osmolality, serum
280-300 mOsmol/kg of
serum water
Oxygen, content
Arterial blood (sea level) 17-21 volume %
Venous blood, arm
(sea level)
10-16 volume %
Contd...
372
Contd...
Conventional units
Oxygen % saturation
(sea level)
Arterial blood
Venous blood, arm
Oxygen tension, blood
P50, blood
pH, blood
Phenylalanine, serum
Phosphatase, acid, serum
97%
60-85%
80-100 mmHg
26.27 mmHg
7.38-7.44
Less than 3 mg/100 ml
0.10-0.63 unit (Besseylowry method)
0.5-2.0 units (Bodanskys
method)
< 0.6 unit per decilitre
(Fishman lerner; tartrate
sensitive)
0.5-2.0 units (Gutmans
method)
0.2-1.8 international
units
1.0-5.0 units (KingArmstrong method)
0.0-1.1 units (Shinowara
method)
Phosphatase, alkaline, serum 0.8-2.3 units (BesseyLowry method)
Contd...
Blood Biochemistry
373
Contd...
Conventional units
2.0-4.5 units (Bodansky
method)
2.0-4.5 units (Gutman
method)
21-91 international units
per litre at 37C
4.0-13.0 units (KingArmstrong method)
2.2-8.6 units (Shinowara
method)
Phosphorus, inorganic,
serum
Phospholipids, serum
Potassium, serum
Proteins, total, serum
Protein fractions, serum
Albumin
Globulin
Alpha1
Alpha2
Beta
Gamma
Protoporphyrin, free
erythrocyte (EP)
1-1.4 mmol/litre
150-250 mg/dl
3.5-5.0 mmol/litre
5.5-8.0 g/dl
3.5-5.5 g/dl
2.0-3.5 g/dl
0.2-0.4 g/dl
0.5-0.9 g/dl
0.6-1.1 g/dl
0.7-1.7 g/dl
16-36 mg/dl red blood
cells
Contd...
374
Contd...
Conventional units
Pyruvic acid, blood
Sodium, serum
Sulphate, inorganic, serum
Testosterone
Women
Men
Prepubertal boys and girls
Thyroid stimulating
hormone (TSH)
Thyroxine, free serum
Thyroxine (T4), serum
radioimmunoassay
Thyroxine binding globulin
(TBG) serum, (as thyroxine)
Triiodothyronine (T3), serum
by radioimmunoassay
Thyroxine iodine, serum
Transaminase, serum
Glutamic oxaloacetic
(SGOT, AST)
Transaminase, serum
< 0.15 mmol/litre

136-145 mmol/litre
0.8-1.2 mg/100 ml
< 100 ng/dl
300-1000 ng/dl
5-20 ng/dl
< 5 U/ml
1.0-2.1 nano gm/100 ml
4-12 ng/dl
10-26/100 ml
80-100 ng/dl
2.9-64 mcg/100 ml
10-40 karmen units per
millilitre
6-18 units per litre
10-40 karmen units per

millilitre
Glutamate, Pyruvate (SGPT, 3-26 units per litre
ALT)
Contd...
Blood Biochemistry
375
Contd...
Conventional units
Triglycerides, serum
Uric acid, serum
Males
Females
Urea
Blood
Plasma or serum
Urea nitrogen, whole blood
Vitamin A, serum
Vitamin B12, serum
40-150 mg/100 ml
2.5-8.0 mg/dl
1.5-6.0 mg/dl
21-43 mg/100 ml
24-49 mg/100 ml
10-20 mg/dl
20-100 g/dl
200-600 pg/ml
REFERENCE VALUES FOR URINE

For some procedures, the reference values may vary
depending upon the method used.
Conventional units
Acetone and acetoacetate,
qualitative
Addis count
Erythrocytes
Leukocytes
Casts (hyaline)
Albumin
Qualitative
Quantitative
Negative
0-130,000/24 hrs
0-650,000/24 hrs
0-2000/24 hrs
Negative
10-100 mg/24 hrs
Contd...
376
Contd...
Conventional units
Aldosterone
Alpha amino nitrogen
Amylase
Bilirubin, qualitative
Calcium (10 mEq or 200 mg
calcium diet)
Catecholamines
Chloride
Chorionic gonadotrophin
Copper
Creatine, as creatinine
Adult males
Adult females
Creatinine
Creatinine clearance
Males
Females
Cystine or cysteine,
qualitative
Dehydroepiandrosterone
Delta aminolevulinic acid
Estrogens
2-10 g/day
0.4-1.0 g in 24 hrs
35-260 Somogyi units
per hour
Negative
< 3.8 mmol in 24 hrs
< 150 mg in 24 hrs
< 100 in 24 hrs
100-250 mmol/24 hrs
(varies with intake)
0
0-25 g in 24 hrs
< 50 mg in 24 hrs
< 100 mg in 24 hrs
1.0-1.6 g in 24 hrs
140-150 ml/min
105-132 ml/min (1.73
sq metre surface area)
Negative
Less than 15% of total
17 ketosteroids
1.3-7.0 mg/24 hrs
Contd...
Blood Biochemistry
377
Contd...
Conventional units
Males
Estrone
Estradiol
Estriol
Total
Females
Estrone
Estradiol
Estriol
Total
Glucose, true(oxidase,
method)
Gonadotropins, pituitary
3-8 g/24 hrs

0-6 g/24 hrs
1-11 g/24 hrs
4-25 g/24 hrs
4-31 g/24 hrs
0-14 g/24 hrs
0-72 g/24 hrs
5-100 g/24 hrs
(Markedly increased
during pregnancy)
50-300 mg in 24 hrs
10-50 mouse units/24

hrs
Hemoglobin and myoglobin Negative
qualitative
Hemogentisic acid
Negative
qualitative
17-Hydroxycorticosteroids 2-10 mg/day
5-Hydroxyindoleacetic
2-9 mg in 24 hrs
acid (5-HIAA)
17-Ketosteroids
Men
7-25 mg/day
Women
4-15 mg/day
Contd...
378
Contd...
Conventional units
Magnesium
Metanephrines
Osmolality
pH
Phenolsulfonphthalein
excretion (PSP)
Phenylpyruvic acid,
qualitative
Phosphorus
Porphobilinogen
Porphyrins
Coproporphyrin
Uroporphyrin
Potassium
Pregnanediol
Males
Females
Proliferative
Luteal phase
6.0-8.5 mEq/24 hrs

< 1.3 mg/day
38-1400 mOsm/kg
water
4.6-8.0 average 6.0
(Depends on diet)
25% or more in 15 min
40% or more in 30 min
55% or more in 2 hrs
(After injection of 1 ml
PSP intravenously)
Negative
0.9-1.3 gm/24 hrs
None
50-250 mcg/24 hrs
10-30 mcg/24 hrs
25-100 mmol in 24 hrs
(Varies with intake)
0.4-1.4 mg/24 hrs
0.5-1.5 mg/24 hrs
2.0-7.0 mg/24 hrs
Contd...
Blood Biochemistry
379
Contd...
Conventional units
Postmenopausal phase
Pregnant 16 weeks
Pregnant 20 weeks
Pregnant 24 weeks
Pregnant 28 weeks
Pregnant 32 weeks
Pregnant 36 weeks
Pregnant 40 weeks
Pregnanetriol
Protein
Sodium
Specific gravity
Titratable acidity
Urate
Urobilinogen
Vanillylmandelic acid
(VMA)
0.2-1.0 mg/24 hrs

5-21 mg/24 hrs
6-26 mg/24 hrs
12-32 mg/24 hrs
19-51 mg/24 hrs
22-66 mg/24 hrs
23-77 mg/24 hrs
23-63 mg/24 hrs
Less than 2.5 mg/24
hrs in adults
< 150 mg in 24 hrs
100 to 260 mmol in 24
hrs
1.003-1.030
20-40 mmol/24 hrs
200-500 mg/24 hrs
(with normal diet)
1-3.5 mg in 24 hrs
< 8 mg/day
380
CEREBROSPINAL FLUID
Normal cerebrospinal fluid is clear, colourless and faintly

alkaline. It has specific gravity from 1.006 to 1.008. In
normal adult total volume of CSF is 100 to 150 ml.
Normal daily production is 100 ml. So there is practically
complete turnover daily.
PRESSURE
Normal in horizontal position 60 to 150 mm of water.
Sitting Position
200 to 250 mm of water.
Increased tension
Intracranial tumour
Meningitis
Intracranial haemorrhage
Hydrocephalus
Benign intracranial hypertension, encephalitis.
Decreased tension
Subdural haematoma
Spinal subarachnoid block
Cerebrospinal Fluid
Block in the region of foramen magnum

Repeated lumbar punctures.
APPEARANCE
Clear Fluid
Normal
Syphilis
Maningism
Hydrocephalus
Diabetes mellitus
Uraemia
Poliomyelitis
Tuberculous meningitis.
Turbidity
Presence of excess cells
(Erythrocytes, White cells, microorganisms)
Meningitis.
Fine Spider Web Clot
Massive Coagulation
Polyneuritis
Spinal block.
Blood Stained
Trauma due to needle
Spinal cord trauma
Intracerebral haemorrhage.
381
382
Xanthochromia (Yellow/Colouration)
Following haemorrhage into CSF (old)
High Proteinous fluid
Subdural haematoma.
PROTEIN
Normal, CSF contains 15 to 45 mg% of protein. The
ratio of albumin to globulin is 3:1. In most cases albumin increases more than globulin.
Increase of albumin
Cerebral tumour
Encephalitis.
Increase of globulin
Complete spinal subarachnoid block due to cord
tumour
Caries of spine
Cerebrospinal syphilitic meningitis.
GLUCOSE
The level in CSF depends on the blood glucose level at
the time fluid is withdrawn and the presence of pyogenic
organisms or inflammatory cells in the CSF that use up
sugar in their metabolism. CSF glucose is 20-30% less
than the corresponding blood glucose level.
Normal 50 to 80 mg%.
Cerebrospinal Fluid
Remains Normal in
Aseptic meningeal reaction
Syphilitic meningitis.
Increased
Diabetes mellitus
Uraemia
Encephalitis.
Decreased
Tuberculous meningitis
Insulin shock
Pyogenic meningitis.
CHLORIDES
Normal values.
Children
625 to 670 mg%.
Adults
720 to 760 mg%.
No Change in Level
Tumours
Encephalitis
Brain abscess
Chronic degenerative disease.
383
384
Increased
Uraemia.
Decreased (below 620 mg%)
CALCIUM
Normal 5.7 to 6.8 mg%.
Increased
Froins syndrome.
Decreased
Tetany.
ACID-BASE EQUILIBRIUM
Normal pH 7.4 to 7.6.
Remains Unaltered
Hydrocephalus
Serous meningitis
Cerebral tumours.
Acidosis
Acute meningitis
Uraemia
Cerebrospinal Fluid
385
CYTOLOGICAL LEUCOCYTE COUNT

It is done within first half hour after withdrawal
because on longer standing cells begin to disintegrate.
Normal:
Adults 0 to 10 cells/cu mm
Children 0 to 20 cells/cu mm
Cell Count:
Between 13 to 100 Cell/cu mm
Neurosyphilis
Encephalitis
Disseminated sclerosis
Tuberculous meningitis
Cerebral tumour.
Polymorphonuclear Leucocytosis
Pyogenic meningitis
Acute syphilitic meningitis
Early poliomyelitis.
Malignant Cells
Malignant growth of brain or spinal cord.
Eosinophils
Pathognomonic of cerebral or spinal cysticercosis.
Plasma Cells
In neurosyphilis.
Total
protein
60-150
mm
water
15-30
mg%
100 ml
Pressure
Markedly increased
Raised
Clear
Turbid
and colourless
Appearance
MENINGITIS
Virus
Brain
abscess
Markedly increased
Raised
Increased
Raised
Increased
Raised
Clear or Usually Clear

slightly clear
opalescent
Pyogenic TB
Normal
Test
Increased
Usually
normal
Clear
and
colourless
Syphilis
meningo
vascular
Yellowish
if complete
block,
slightly
yellow or
clear if incomplet
Diminished
Cont...
Greatly Greatly
increa- increased
sed
Raised
Turbid
or frothy
blood
Subara- Spinal
chnoid
tumour
haemorrhage
Cerebrospinal Fluid Picture in Some Diseases
386
Cells
Chlorides
50-70
mg%
100 ml
Sugar
100-200
per c.
mm
many
lymphocytes
Normal Normal
50-500 Lympoper c.
cytes
mm
increalympho-sed
cytes
predominant
Reduced
Brain
abscess
Normal Normal
Virus
MENINGITIS
Reduced
Pyogenic T.B.
Markedly reduced or
absent
720-750 Redumg%
ced
100 ml
0-5 lym- Large
phocy- number
tes per
of polyc. mm
morphs
Normal
Test
Cont...
Lymphos
increased
Normal
Normal
Syphilis
meningo
vascular
Cont....
Large
Usually
number normal
of red
cells
Normal Normal
Normal Normal
Subara- Spinal
chnoid
tumour
haemorrhage
Cerebrospinal Fluid
387
* Wasserman reaction.
Sterile
Virus
Sterile
Brain
abscess
MENINGITIS
Myco.
tuberculosis
Sterile
Bacteria
Causal
organism
isolated
Normal Pyogenic T.B.
Test
Cont.
Sterile
W.R.*
usually
positive
Syphilis
meningo
vascular
Sterile
Sterile
Subara- Spinal
chnoid
tumour
haemorrhage
388
Cerebrospinal Fluid
389
BACTERIA AND PARASITES

Pyogenic organisms on smear and culture in purulent
meningitis.
Tubercle bacilli in tuberculous meningitis (culture and
guinea pig inoculation).
Flagellated trypanosomes in sleeping sickness more
easily seen in CSF than in blood.
SEROLOGICAL
Wasserman reaction is positive in neurosyphilis.
390
Normal Curve
Fasting blood sugar 80 to 120 mg% and peak of curve
not more than 180 mg%. After 2 hours of taking glucoseblood sugar returns to normal fasting level or a little
lower.
Diabetic Curve
Fasting blood sugar above 120 mg
A value above 180 mg is recorded at some time
during the test.
The blood sugar does not return to normal within
2 hours.
A positive urine test for sugar is obtained.
Lag Curve
Normal fasting blood glucose level
Blood sugar rises above 180 mg during test
After 2 hours blood sugar level falls at or below
normal fasting level.
Urine sample may be positive when blood sugar
level is higher than 180 mg%.
Glucose Tolerance Test
391
OTHER CAUSES OF LOWERED GLUCOSE

TOLERANCE
Sepsis
Cushings syndrome
Acromegaly
Hyperthyroidism
Severe liver damage
After steroid therapy.
INTRAVENOUS GLUCOSE TOLERANCE TEST

Indications
Inadequate absorption of glucose from intestines as in:
Steatorrhoea
Pancreatic islet cell tumours
Addisons disease
Hypopituitary stage.
Give 20 to 30 gm of glucose IV.
Normal
Never rises more than 180 mg%
Returns to normal in about one hour.
Diabetes
Rises above 180 mg% during one hour
Does not return to normal.
392
CORTISONE GLUCOSE TOLERANCE TEST

Cortisone increases gluconeogenesis by the liver and
leads to a higher blood sugar level with a glucose load.
This is a test for latent diabetes and for uncovering nondiabetic carriers of the diabetic trait. 50 mg Cortisone
acetate is given by mouth 8 and 2 hours before the
standard 100 mg GTT.
Result:Test is positive when 2 hours blood sugar value
is higher than 140 mg/100 ml.
Bone Marrow Aspiration 393
BONE MARROW ASPIRATION
BONE MARROW EXAMINATION

It is done for the diagnosis of following conditions:
Acute leukaemias
Kala-azar
Niemann-Pick disease
Gauchers disease
Sideroblastic anaemia
Congenital dyserythropoietic anaemia
Pure-red cell aplasia.
BONE MARROW BIOPSY
It is done for diagnosis of:
Myelofibrosis
Staging of lymphoma
Diagnosis of carcinoma metastasis to bone
Therapeutic assessment in acute leukaemia therapy.
ACTIVITY OF ERYTHROPOIESIS
Normoblastic
Normally
Haemolytic anaemia.
394
Micronormoblastic
Megaloblastic
Nutritional B12, folic acid deficiency

Steatorrhoea
Anaemia of pregnancy
Pernicious anaemia.
MYELOID/ERYTHROID RATIO
Normal 2:1 to 8:1.
High
Leukaemia
Low
Anaemia
OTHER ABNORMALITIES
Aleukaemic Leukaemia
Abnormal cells are absent in peripheral blood but
present in large numbers in bone marrow.
Multiple Myeloma
Bone marrow infiltration with plasma cell/myeloma
cells.
Normal
Normal
Neutrophils and
metamyelocyte
All types but

few early forms
Intermediate
and late normoblast
Feature
Cellularity
Predominant
cells
Myeloid cells
Erythroid cells
Megaloblasts
and normoblast in varying
proportions
Few giant metamyelocytes and
hypersegmented
Neutrophils
Megaloblasts
and normoblasts in all
stages
Increased
Tropical macrocytic anaemia
Normoblast in
all stages and
with irregular
scanty cytoplasms, cell size
small
All types, but

few early forms.
Cell often small
Normal/Increased
Micronormoblasts
Iron deficiency
microcytic
anaemia
Bone Marrow Biopsy
Cont....
All forms, many

myelocytes,
basophils
increased
Normoblast in all
stages
Granulocytes
Increased
Chronic myeloid
leukaemia
Normal
Few, mature
Few, mature
Few, mature
Present
2:1 to 8:1
Feature
Lymphocytes
Plasma cells
Monocytes
Megakaryocyte
Myeloid
erythroid ratio
Cont....
1:5 to 1:7
Present
Few, mature
Increased often
Few, mature
Tropical macrocytic anaemia
1:1 to 1:4
Present
Few, mature
Few, mature
Few, mature
Iron deficiency
microcytic
anaemia
Very few
Very few
Few, mature
(sometime more)
Megakaryocytes
increased
3:1 to 7:1
Chronic myeloid
leukaemia
396
Secondary Carcinoma
Carcinoma cells in groups.
Gauchers Disease
Reticulum cells stuffed with lipid (Glucocerebroside).
Malaria
Parasites inside RBC.
Kala-azar
L D bodies in monocytes.
Aplastic Anaemia
Bone marrow hypocellular
Megakaryocytes not seen
Granulopoiesis/erythropoiesis depressed.
Agranulocytosis
Granulocytic series of cells decreased.
398
RENAL FUNCTION TESTS
CONCENTRATION TEST (SPECIFIC

GRAVITY TEST)
The patient is not allowed water after 5 PM
Normal specific gravity1.025.
Failure to concentrate urine above 1.020 is
suggestive of renal impairment. Specific gravity only to
1.010 is suggestive of severe damage.
Results are unreliable if:
Severe water or electrolyte imbalance
Pregnancy
Shock
Chronic liver disease
Adrenal cortical insufficiency.
UREA CLEARANCE TEST
Normal 75 mg/minute.
40 to 60% of normalMild impairment
20 to 40% of normalModerate impairment
Below 20%Severe impairment of renal function.
Renal Function Tests
UREA/CREATININE RATIO
Increased
High protein diet

Increased catabolism
Fever, burns, steroid therapy
Wasting in severe illness
Urinary stasis with urea reabsorption.
Decreased
Protein restriction
Excessive vomiting
Liver disease with impaired urea production.
399
400
LIVER FUNCTION TEST
Indications
Detection of liver damage in absence of jaundice.

Differential diagnosis of jaundice.
Differential diagnosis of hepatic enlargement.
As a parameter of response to medical treatment.
BILIRUBIN METABOLISM
Normal
Free bilirubin (Indirect)
Conjugated bilirubin (Direct)
Latent jaundice
Visible jaundice
Up to 1 mg%
0.8 mg%
0.2 mg%
up to 2 mgm%
2.5 mgm% or
more
Direct Van Den Berghs Reaction

Add 1 ml of reagent to 1 ml of serum. Three types of
reactions are noted.
Immediate
A violet colour due to formation of diazobilirubin in
10 to 30 seconds.
Liver Function Test
401
Delayed
No change in appearance for 5 to 15 minutes, then
reddish colour appears which turns into violet.
Biphasic
Red colour appears immediately and takes a longer
time to become violet.
Indirect Reaction
It determines serum bilirubin quantitatively. 1 ml of
serum is mixed with 2 ml of 95% alcohol. After centrifuging to 1 ml of fluid and 0.25 ml of reagent, add 0.5 ml
of alcohol. A reddish violet colour develops immediately.
Prompt direct reactionObstructive jaundice.
Indirect/delayed direct reactionHaemolytic
jaundice.
Direct reactionJaundice due to liver damage.
DIFFERENTIAL DIAGNOSIS OF JAUNDICE
Haemolytic (Prephatic jaundice)
It is due to excessive destruction of red blood cells and
liver is unable to conjugate all the bilirubin so there is
rise in serum free bilirubin.
Jaundice due to liver diseases (Hepatic)
Direct bilirubin is increased. In hepatic disease there is
increase in direct reacting bilirubin fraction. With
402
bilirubin in urine, liver diseases causing this are viral

hepatitis, cirrhosis of liver and toxic hepatitis.
Post-hepatic (Obstructive jaundice)
It may be due to carcinoma of head of pancreas, bile
duct obstruction, pancreatitis and gallstones in bile duct.
CAUSES OF PREDOMINANTLY UNCONJUGATED
HYPERBILIRUBINEMIA
Prolonged fasting
Sepsis
Neonatal jaundice
Hepatitis
Cirrhosis liver.
After Drugs
Pregnandiol
Chloramphenicol.
CAUSES OF PREDOMINANTLY CONJUGATED
HYPERBILIRUBINEMIA
Recurrent intrahepatic cholestasis

Cholestatic jaundice of pregnancy
Viral hepatitis
Oral contraceptives
Methyl testosterone
Sepsis and stones
Stricture and tumour of bile ducts.
Liver Function Test
403
Lab
investigation
Hemolytic
(Pre-hepatic)
Obstructive Hepatocellular
(Post-hepatic) (Hepatic)
Serum
bilirubin
Urine
bilirubin
Urine urobilinogen
Stool colour
Flocculation
Turbidity test
Serum alkaline phosphatase
Serum total
cholesterol
Indirect
Direct
Biphasic
Absent
Present
Present
Increased
Increased
Dark colour
Negative
Absent or
decreased
Clay colour
Negative
Normal
Increased
Slightly
increased
Normal
Increased
Decreased
Pale
Positive
URINE UROBILINOGEN
Normal 0.2 to 1.2 units.
Absent
Complete obstruction to bile flow may be due to
stone/tumour
Decreased
Post-hepatitis
Early phase of hepatic jaundice
404
Increased
Haemolytic jaundice
Cirrhosis of liver
Metastatic carcinoma
Congestive cardiac failure
Pulmonary infarct.
FAECAL STERCOBILINOGEN
Normal Value 50 to 300 Ehrlich units in 130 gm of faeces.
Causes are same as for urine urobilinogen.
CARBOHYDRATE METABOLIC TEST
Galactose Tolerance Test
A single dose of 40 gm of galactose is given by mouth.
If more than 3 gm appears in 5 hours, then liver function
is impaired.
Positive
In infective and toxic jaundice.
Negative
Chronic liver disease

Cirrhosis of liver
Carcinoma of liver
Early extrahepatic biliary obstruction.
Liver Function Test
405

In liver diseases fasting blood sugar level is normal or
low and the occurrence of subnormal values by the 5th
hour after taking glucose is a distinguishing feature
between diabetes mellitus and liver diseases.
EPINEPHRINE TOLERANCE TEST
A high carbohydrate diet is given for 3 days. Fourth
day fasting blood sugar level is done and patient is given
0.01 mg of epinephrine per kg/body weight. The blood
sugar is determined 30-60 minutes after the epinephrine
is given.
NormalIndividuals show rise of 40 to 60 mg%.
Subnormal Response
Cirrhosis
Hepatitis
Glycogen storage disease (genetic deficiency of glycogenolytic enzyme).
PLASMA PROTEINS
Serum albumin normal value 3.5 to 5 gm/100 ml.
Decreased
Cirrhosis
Active hepatitis
Prolonged cholestasis.
406
The degree of hypoalbuminaemia correlates with

the severity of chronic liver diseases. It is the best indicator of successful medical treatment in cirrhosis of liver.
SERUM GAMMAGLOBULIN
Increased
Acute hepatitis (slight hyperglobulinaemia).
Cirrhosis (marked hyperglobulinaemia).
Serum globulin if 7 gm/100 ml or more is prognostically a bad omen.
ALPHA GLOBULIN
Normal level 0.8 to 1.1 gm/100 ml.
Increased
Inflammatory disease of liver
Injury to liver.
BETA GLOBULIN
Reduced
Cirrhosis.
Increased
Bile duct obstruction
Xanthomatous biliary cirrhosis.
Liver Function Test
407
ALBUMIN/GLOBULIN RATIO
Normal 1.7:1.
Reduced
Cirrhosis with jaundice.
Increased
Xanthomatous biliary cirrhosis.
SERUM ENZYMES
Alkaline Phosphatase
Normal value 1.5 to 4.5-Bodansky units
4 to 13-King Armstrong units.
Slight to Moderate Increase
Hepatitis
Cirrhosis.
Striking Increase
Extrahepatic biliary obstruction

Primary biliary cirrhosis
Carcinoma of liver
Liver abscess
Bony metastasis and fractures.
TRANSAMINASES
i. Serum glutamic oxaloacetic transaminase (SGOT)
Normal 6 to 40 international units/L.
408
Increased
50 to 200 units
Subclinical or aniecteric viral hepatitis
Laennecs cirrhosis
Tumour invasion.
200 to 500 units
Less severe liver necrosis.
1000 to 3000 units
Severe viral hepatitis.
Other Causes
ii.
CO2 poisoning
Myocardial necrosis
Skeletal muscle necrosis.
Serum glutamic pyruvic transaminase (SGPT)
Normal 6 to 36 Karmen units/L.
Increased
Hepatocellular damage
Myocardial and skeletal muscle necrosis.
LACTIC DEHYDROGENASE
Normal 60 to 230 international units per litre.
Liver Function Test
409
Moderate increase
Damage to heart, liver, skeletal muscles and brain.
High increase
Leukaemias and lymphomas.
Decreased
Impaired hepatic protein synthesis.
5-NUCLEOTIDASE
In hepatic disease both 5-nucleotidase and alkaline
phosphatase are elevated while in primary bone diseases the alkaline phosphate only is elevated.
Other enzymes: GGT and OCT are elevated is serum in
hepatobiliary diseases.
SERUM AMMONIA
Normal 100 micro gm%.
Increased
Cirrhosis
Severe hepatitis
Severe heart failure
Cor pulmonale.
SERUM CHOLESTEROL
Normal cholesterol 150 to 250 mg%.
410
Esterified Cholesterol
60 to 70% of total.
Increased
Intrahepatic obstruction
Atherosclerosis
Obesity
Diabetes mellitus.
SERUM IRON
Normal 80 to 180 micro gm%.
Increased
Haemochromatosis
Viral hepatitis
Hepatic necrosis.
TURBIDITY AND FLOCCULATION TEST
1. Cephaline cholesterol flocculation test.
Positive Test
2.
Acute/Chronic hepatic disease

Hepatitis
Cirrhosis of liver
Fatty liver with jaundice
Thymol turbidity test.
Liver Function Test
Positive Test
Liver diseases
Kala-azar
Malaria
Sarcoidosis
Collagen disorders.
SERUM ALDOLASE
Normal Males: below 33 units (W and C)
Females: below 19 units (W and C).
Elevated
Myocardial infarction
Muscular dystrophy
Haemolytic anaemia
Metastatic prostatic carcinoma
Leukaemia
Acute pancreatitis and hepatitis.
SERUM BICARBONATE
Normal 22 to 28 mg/litre.
Elevated
Metabolic alkalosis
Protracted vomiting
Potassium deficiency
Consumption of soda-bicarbonate.
411
412
Respiratory Acidosis
Due to:
Pulmonary emphysema
Heart failure
Respiratory depression.
Decreased
Metabolic Acidosis
Diabetic ketosis
Persistent diarrhoea
Renal insufficiency
Ingestion of acidifying salts
Salicylate poisoning
Starvation.
Respiratory Alkalosis
Hyperventilation.
CERULOPLASMIN AND COPPER
Normal.
Ceruloplasmin
25 to 43 mg/100 ml.
Copper
70 to 200 micro gm/100 ml
95% of copper is bound to ceruloplasmin.
Liver Function Test
413
Elevated
Hyperthyroidism
Infection
Acute leukaemia
Hodgkins disease
Cirrhosis liver
Pregnancy.
Decreased
Wilsons disease
Nephrosis
Malabsorption syndrome.
Creatine-Phosphokinase (CPK)
Normal 10 to 50 IU/litre.
Elevated in injury to heart muscle. Polymyositis,
dermatomyositis hypothyroidism, cerebral infarction.
In myocardial infarction CPK rises rapidly within
3 to 5 hours.
414
FUNDUS EXAMINATION
During fundoscopy examination it is usually possible to

examine the optic disc, surrounding retina, vitreous and
the choroid. Normal fundus is bright red in colour.
OPTIC DISC
Normal shape
Normal diameter
Normal colour
Round or oval
About 1.5 mm in diameter
Pale pink
Blurred Margin
Papillitis
Papilloedema
Secondary optic atrophy following papillitis/
papilloedema.
Colour
Pale/Greyish White
Optic atrophy.
Hyperemic with Swollen Disc
High hypermetropia.
Fundus Examination 415
Deep Pink
Oedema of head of the optic nerve due to raised
intracranial pressure.
Papillitis due to any cause.
PHYSIOLOGICAL CUP
In central part of the disc there is usually a depression
known as physiological cup. Cup is paler than surrounding disc and through it retinal vessels enter and leave
the eye. Normal cup and disc ratio is 1:3.
RETINAL BLOOD VESSELS
These radiate dichotomously into many branches as
they run towards periphery to retina. Normal ratio of
diameter of vein and artery is 3:2. Arteries are lighter
red in colour, narrower than vein and have a bright
salivary longitudinal streak at the centre where light is
reflected from their convex walls. Normally artery
crosses the vein.
Spontaneous retinal artery pulsation is always
pathological and is noted in:
Glaucoma
Aortic regurgitation
Exophthalmic goitre
Orbital tumour
Syncope.
Spontaneous venous pulsation is present normally
in 10 to 20% of the cases.
416
MACULAR MARGIN
It is usually as a small circular area of deep red colour
situated about 2 disc diameter, i.e. 3 mm from temporal
border of the optic disc. It is supplied by twigs from the
superior temporal arteries and a few branches direct
from the disc. At the centre of the macular region there
is a small depression known as fovea which is lighter
on colour and often shines. There are no retinal blood
vessels at the fovea itself.
CHANGES OF FUNDUS IN
DIFFERENT DISEASES
GLAUCOMA
Cup and disc ratio alters
Position of cup becomes vertical
Blood vessels appear to be broken off at the disc
margin.
PAPILLOEDEMA
Disc swelling is more than 2 to 3 dioptres.
Increased redness of the disc with blurring of its
margin.
Physiological cup becomes filled in and cannot be
seen clearly.
Retinal veins become slightly distended and congested.
Even on pressure, venous pulsation remains absent.

It occurs in cases of brain tumour.
OPTIC NEURITIS
Loss of vision, either central scotoma or complete
blindness.
Hyperaemic disc.
Swelling of disc is usually less, i.e. about 2 to 3 dioptres.
Distention of retinal veins less marked than papilloedema.
Sign of inflammation, i.e. hazy viterous and retinal
exudate.
In retrobulbar neuritis disc appears normal in acute
stage.
OPTIC ATROPHY
Optic disc is paler than normal and may even be
white.
There is reduction of the disc capillaries.
Number of capillaries that cross the disc margin is
reduced from 10 to 7.
In primary atrophy disc is flat and white with clear
cut margins.
In secondary atrophy disc is greyish white, slightly
swollen and its edges are rough.
418
Optic atrophy may result from:

Interference with the blood supply of the optic nerve.
Pressure on the nerve may be intraocular, intraorbital
or intracranial.
Following optic neuritis or trauma.
Due to toxicity of tobacco or alcohol.
RETINAL ARTERIOSCLEROSIS
It occurs either as an exaggeration of the general ageing
process or in association with hypertension.
Broadening of the arterial light reflex, producing a
copper wire or silver wire appearance.
Tortuosity of the vessels.
Nipping, indentation or deflection of the veins where
they are crossed by the arteries.
White plaques on the arteries.
Flame shaped haemorrhages and Cotton-wool
exudates in the region of macula.
HYPERTENSIVE RETINOPATHY
Grade I
Only mild narrowing or sclerosis of the retinal blood
vessels.
Grade II
Changes in retinal vessels are more marked and
characterised by signs of sclerosis at the arteriovenous crossing and generalised or localised narrowing of the arterioles. Retinopathy is still not present.
Grade III
Retinal wool spots with haemorrhages with marked
sclerotic changes in the arterioles
Oedema of the disc not present.
Grade IV
Papilloedema with diffuse retinopathy
Spastic and organic narrowing of the arterioles.
DIABETIC RETINOPATHY
Formation of microaneurysms as tiny red spots
around macula.
Minute haemorrhages and punctate exudate
(microlesions).
Retinal haemorrhages are punctate or round and
the exudates as waxy yellow white in appearance.
Haemorrhages extended to vitreous result in retinitis
proliferans.
Covering of macula or retinal detachment may cause
blindness.
May or may not be associated with hypertension.
Arteriovenous ratio becomes 2:4.
SEVERE ANAEMIA
Fundus may be paler.
Few small flame shaped haemorrhages with wooly
exudate.
420
Retinal veins are more tortuous and dilated than

arteries.
POLYCYTHEMIA
Retinal vessels are dark, tortuous and dilated.

Cyanotic background of the fundus.
Oedema of the optic disc.
Retinal haemorrhages may be present.
LEUKAEMIA
Retinal veins are dilated and tortuous.

Arteries and veins may be yellowish in colour.
Fundus becomes paler.
Retinal haemorrhages of various types are noted
specially round with pale centre.
OCCLUSION OF CENTRAL ARTERY OF RETINA

Optic disc and surrounding retina are pale.
Presence of Cherry red spot at the macula in
contrast to milky pallor of adjacent area.
Retinal arteries become narrow similar to thread.
OCCLUSION OF CENTRAL VEIN
Intense swelling of the optic disc with gross venous
dilatation.
Numerous retinal haemorrhages extending from
disc in all directions.
CHOROIDITIS
Acute
One or more, round or oval, yellowish whitish
patches deeper to retinal vessels.
Patches have ill-defined edges and vitreous may be
hazy.
Chronic
Yellowish areas become flat, white scars with
pigment around their edges are seen.
TOXAEMIA OF PREGNANCY
Usually occurs in ninth month and rarely before the
sixth month.
Nasal branches of retinal arteries become narrow
It is followed by spasmodic contraction
Exudative retinal detachment may be present
Other signs of hypertensive retinopathy may be
noted.
422
RENAL SYSTEM
ACUTE GLOMERULONEPHRITIS
Fullness of face.
Low urinary output.
Fever 101 to 103F at the onset and becomes normal
in 7-10 days.
BP is raised.
Malaise, anorexia, vomiting and headache.
Urine volume diminished to 300-600 ml, specific
gravity raised, hyaline, blood and epithelial casts,
culture is sterile.
ESR is raised.
Management
Bed rest for 2-4 weeks till gross haematuria subsides.
Fluids should be restricted to 1/2 litre plus the
volume of previous day urinary output till oedema

subsides.
Protein consumption should be controlled. Salt
intake should be low.
Renal System 423

Suitable antibiotic for primary infection.
Septran 2 bd 5 days to be given.
For moderate hypertensionTab Nepresol 1/2 to

1 tds or Tab Alphadopa 10-65 mg/kg 1 day and Tab
Lasix 2 mg/kg.
ACUTE NEPHRITIC SYNDROME

Haematuria and Proteinuria are hallmarks.

Some degree of azotemia.
Low serum C3 complement.
Raised antibody titre to streptococcal antigen like
ASO anti-streptokinase and anti-DNA titres.
Treatment
Treatment is supportive.
Bed rest till haematuria subsides.
Fluid and salt retention.
Loop diuretics to promote diuresis.
Protein restriction if there is azotemia.
Course of erythromycin 7-10 days to eradicate
streptococci.
424
ACUTE PYELONEPHRITIS
It is due to acute inflammation of parenchyma and pelvis
of kidney. It may be unilateral or bilateral.
Onset sudden with pain in one or both loins, radiating
to iliac fossa or suprapubic area.
Dysuria, vomiting.
Body temperature 100 to 104F with rigors.
Tenderness and gurgling in the lumbar region.
Urine is dark due to blood and pus. Reaction acidic.
Polymorphonuclear leucocytosis.
Management
Bed rest with tepid sponging.

Plenty of fluids in diet.
Alkaline mixture, i.e. Alkacitrone 1 tsf tds.
Ampicillin 250 mg six hourly or Septran (80 mg) 1
tab twice daily for 5 to 7 days.
Norfloxacin 400 mg bd 7-10 days.
Tab Nalidixic acid 1 gm qid.
or
Injection Gentamicin 60-80 mg 8 hourly alone or
with Ampicillin or Cephalexin 500 mg 6 hourly.
or
Injection Ciprofloxocin 200 mg bd IV.
Tab Pyuridium 100 mg tds for dysuria.
Renal System 425
ACUTE RENAL FAILURE

Pre-oliguric stage
Lethargy, headache, nausea and vomiting.
Oliguric stage
Lasts for 4-10 days. Complete anuria is rare.
Uraemic symptoms
Nausea, vomiting, diarrhoea, hiccough.
Hyperkalaemia shows
Paraesthesias, depressed reflexes, general weakness,
flaccid paralysis.
Diuretic stage
Urinary output is increased to 1000 ml in 24 hours.
Management
Rule out renal obstruction or retention by catheteri-
zation, KUB and USG.
Correct fluid imbalance if any and restore BP. Res-
trict fluid intake if anuria. It should be output plus

500 ml plus 200 ml per degree of fever if any.
Treat infection.
If ATNInjection Lasix 200-250 mg slow IV repeat
upto 1-2 gm/day.
426
or Injection Mannitol 20 percent 250 ml IV over 30

minutes.
If hyperkalemia (weakness, drowsiness, bradycardia, tall peaked T waves serum K > 6 mEq/L).
Injection Calcium gluconate 10 percent 10-20 ml
IV.
If acidosis use IV NaHCo3 (mEq/L = body weight
0.3 base deficit).
If hyponatraemiaRestrict fluids or dialysis.
Restrict protein intakeGive carbohydrate 100-150
gm daily.
Indications for dialysis
If serum K > 6.5 mEq/L.
Severe acidosis.
Pulmonary oedema, fluid over load.
Encephalopathy, pericarditis.
Steadily increasing serum creatinine > 10 mg%.
BENIGN PROSTATIC HYPERPLASIA

Urinary frequency.
Urinary urgency and nocturia due to incomplete
emptying.
Sensation of incomplete emptying and terminal dribbling.
Renal System 427
On rectal examination prostate is usually enlarged

with a rubbery consistency and frequently loss of
median furrow.
Chills and fever indicates infection.
Indurated and tender prostate suggests prostatitis
Stony hard, nodular prostate indicates carcinoma.
Prostatic specific antigen is moderately enlarged.
Treatment
Prazocin, doxazosin and Adrenergic blockers may
improve voiding in some patients.

The 50 C reductase inhibitor finasteride 5 mg daily
may reduce size of prostate.

Larger benign prostate needs suprapubic approach
of prostectomy.
CHRONIC RENAL FAILURE

Irreversible damage to nephron leads to chronic
renal failure.
Commonly implicated diseases are glomerulonephritis, diabetes mellitus, chronic pyelonephritis
hypertension and polycystic disease.
428
By products of proteins and amino acids metabolism instead being excreted are retained in body.
Many small molecular weight substances are also
retained
GFR falls to 10 to 20%.
Treatment
40 gram of proteins is permitted. If blood urea
exceeds 60 mg proteins are restricted to 20 gram

daily.
Water intake should be adjusted
Potassium containing food and fruits are to be
restricted.
Aluminum hydroxide 400 mg four times daily
controls hyperphosphataemia.
Supplement of vitamin B complex and regular injection of anabolic steroids minimize catabolism
thus reducing urea load.
Dialysis prepares patients for renal transplantation.
For renal transplantation HLA matched sibling
donors are preferred.
NEUROGENIC BLADDER
It is caused by vesical dysfunction due to congenital
abnormality, injury and myelomeningocele. Syphilis,
diabetes mellitus, brain or spinal cord tumor may result
it.
Renal System 429
Partial or complete urinary retention.
Inadequate emptying.
In spinal cord injury shock bladder is atonic and distended with continuous overflow dribbling.
With lower spinal cord lesion bladder becomes flaccid.
Upper cord lesion produces an automatic or spastic
reflex bladder which empties spontaneously.
Cystourethroscopic evaluation determines the
degree of bladder outlet obstruction.
Treatment
Continuous catheter drainage in flaccid paralysis
of bladder due to spinal cord injury.
In automatic bladder condom catheter drainage.

Oxybutynin chloride 5 mg reduces detrusor spas-
ticity and involuntary contractions.
Sphincter dysynergia respond to doxazocin
mesylate 1 mg or terazocin 1 mg twice daily.
OBSTRUCTIVE UROPATHY
Chronic urine obstruction results in hydronephrosis,
renal atrophy and chronic renal failure. Urinary infection and stone formation may take place.
430
Flank pain with micturition.
Renal colic although pain is constant with fluctuation
in intensity.
Distension of collecting system.
Hypertension especially in unilateral obstruction.
Urine examination shows pyuria, crystalluria and
haematuria.
KUB X-ray may show radiopaque stone.
Treatment
Depends on the causative factor.
Any spasmodic tablet/injection gives temporary
relief.
URAEMIA
Headache, vertigo, muscular weakness and
twitching.
Apathy and inability to concentrate, restlessness
neuralgic pains.
Reflexes exaggerated.
Dryness of mouth, tongue coated brown or grey.
Anorexia, polydipsia, nausea and vomiting.
Renal System 431
Ammonical odour of breath.

Uraemic frostDeposition of greyish white crystals
mostly on the face, neck and chest.
Laboratory findings
Elevation of non protein nitrogen in blood.

Oliguria with low specific gravity.
Blood uric acid elevated.
Serum creatinine elevated and chlorides diminished.
Management
Low protein diet with adequate salt.

Increased fluid intake. In dehydration IV 5 per cent
Glucose saline.
Sodium lactate 5-10 gm thrice daily to combat
acidosis.
Antibiotics to combat infection. Septran 2 bd 5
days.
Treatment of hypertension and heart failure.

Dialysis.
Ampicillin 2 gm daily to reduce urea production.
432
NEUROLOGICAL DISEASES
BELLS PALSY
Sudden onset of lower motor facial paralysis
manifesting as inability to close the eye, sagging angle
of mouth and poor buccinator tone.
Pain behind the angle of jaw and history of exposure
to cold.
Treatment
Tab Prednisolone 40-60 mg daily for 5-10 days.
Tab Aspirin 325 mg tds.
Neostigmine 15 mg daily for 5-10 days.
Faradic stimulation of facial nerve.
Prophylactic antibiotic eyedrops and tarsorrhaphy
to prevent exposure keratitis.
Plastic surgery in selected cases.
Decompression of facial canal if deemed necessary.
Infrared rays treatment and massage of facial
muscles of paralyzed side.
Neurological Diseases
433
BRACHIAL NEURALGIA
Pain and paresthesia in upper limb and shoulder area.
Neck becomes rigid and flexed towards the side of
lesion.
Tendon reflexes diminish.
Acute disc protrusion may develop severe pain, muscular spasm and rigidity of neck muscles.
Occipital headache worse in early morning hours.
Vertebro-basilar ischaemia Flexion may cause a
brief attack of giddiness or drop attack.
X-ray may show endophytes.
Treatment
Bed rest.
Analgesics in acute pain.
Cervical collar may be used day and night.
Exercises for neck and shoulder.
Head traction with or without manipulation.
BROADMANS AREAS OF BRAIN

Occipital Lobe
Area 17
Area 18, 19
Visual cortex
Visual association areas
434
Parietal Lobe
Area 3, 1, 2
Area 5, 7
Area 41
Area 42
Area 38, 40,20,21,22
Principal sensory areas

Sensory association area
Primary auditory cortex
Associate auditory cortex
Association areas.
Frontal Lobe
Area 4
Area 6
Principal motor area

Part of extrapyramidal
circuit
Eye movement
Motor speech area.
Area 8
Area 44
CEREBRAL STROKE
Sudden onset of neurological deficit.
Patient has history of hypertension, diabetes, and
atherosclerosis.
Distinctive neurological signs reflect the area of brain
affected.
Middle cerebral artery occlusion leads to contralateral hemiplegia, hemi-sensory loss and homonymous hemianopia.
435
Anterior cerebral artery occlusion causes weakness,

cortical sensory loss and homonymous hemianopia.
Occlusion of posterior cerebral artery may develop
contralateral hemisensory disturbances, spontaneous pain and hyperpathia.
Vertebral artery occlusion may be clinically silent.
Occlusion of major cerebellar artery produces vertigo, nausea, and ataxia.
Massive carebellar infarction may lead to coma, tonsillar herniation and death.
Treatment
Intravenous thrombolytic therapy within first 3
hours.
In acute stage cortisone IV is given to reduce brain
oedema. Dexamethasone 16 mg/daily may be

given.
MR angiography should be got done.
CERVICAL RIB SYNDROME

Compression of 8th cervical and first dorsal root by
enlarged transverse rib or a small rib or fibrous band
from 7th cervical vertebra.
436
Pain and paresthesia along inner border of fore arm

and hand. Pain increases by raising the arm above
head.
Attacks of recurrent coldness in arms and digits with
pallor or cyanosis.
Nerve becomes tender on pressure.
Management
Surgical intervention may be required.
Injections of B1, B 6 and B 12 on alternate days may
help.
CLUSTER HEADACHE
It is also known as Hortons headache Hairs syndrome,
histamine cephalgia and migrainous neuralgia.
It can be confused with trigeminal neuralgia.
It is an unilateral headache.
Pain starts 2-3 hours after falling asleep during the
phase of REM sleep.
Headache is intense, non-throbbing around orbit.
Eyes become red with lacrimation and rhinorrhoea.
Attack lasts for 2-3 hours and returns every night.
On lying down pain increases.
437
Treatment
Prednisolone 60-80 mg daily or triamicilone 80 mg
daily
Verapamil 40-80 mg daily.
COMMON HEADACHE
Migrain
Cluster
headache
Quality of
Location
Duration
Throbbing
Unilateral
6-40 hours
Boring
Unilateral
2-3 hours
Frequency
Other symptoms
Sporadic
Nausea
vomiting
Psychogenic
headache
Dull
Diffuse
Anu
duration
Sporadic
Often
Visual aura Depression
EPILEPSY
Grand mal type
Tonic spasm of all muscles with sudden onset.
Aura may be present but generally patient looses
consciousness without any warning.
438
Tonic spasms are followed by clonic phase involving

face, arms and legs.
There is typical epileptic cry due to spasm of respiratory and laryngeal muscles.
BP falls, pupils are dilated and there may be
incontinence of urine.
Patient may bite his tongue with fronthing from
mouth.
After regaining consciousness patient goes for sound
sleep.
Petit mal type
It is common below 14 years of age.
There may be momentary loss of consciousness with
or without falling.
Staring look or eyes are tilted up.
Attack may appear several times a day.
Myoclonic jerksSome time simple twitching of
individual muscle may be noted.
Psychomotor type
Emotional state of mind either with fear, horror or
outrage.
Feeling of epigastric sensation.
Hallucinations of smell, taste and vision.
Disturbances of memory are present.
439
Focal Fits
In focal fits symptoms depend on location of lesion
in the brain.
Management
Generalised seizures
Keep patient in quiet room.

Give O2 if required.
Protect from external injury.
Injection Diazepam 10 mg or Lorazepam 4 mg IV.
Tab Phenytoin 100 mg tds after meals.
If not Controlled Add

Tab Carbamazapine 200 mg thrice a day.
or Tab Mysoline (Primidone) 250 mg, od increase
by every week till 1 tds or Sodium valproate 200
mg bd.
These are to be given for 5 years after last attack
without break.
Status epilepticus
Injection Diazepam 0.2-0.4 mg/kg IV over 5 minu-
tes. Repeat after hour if attack recurs. Can also

be given 0.5 mg/kg followed by injection Phenytoin 15-20 mg IV slowly over hour and repeat
every hour for 4 doses.
Injection Paraldehyde 10 ml deep IM (5 ml in each
buttock).
440
If seizures persist
Injection Thiopentone 1 gm in 500 ml 5 percent
Dextrose slow IV.
Myoclonic Seizures
Sodium valproate 200-300 mg bd.
If not controlled
Clonazepam 1-6 mg/day.
or
Nitrazepam 10 mg tds.
INFECTIVE POLYNEURITIS
Ascending lower motor neuron palsy usually
preceded by upper respiratory infection.
Sensory involvement is minimal to nil.
CSF shows albumino-cytological dissociation.
Treatment
Inj Ampicillin 500 mg 6 hrly.
ACTH 80 mg IV or Prednisolone 40 mg daily for a
short period.
Hot packs and splinting of paralysed parts.

Physiotherapy to paralysed muscles once muscle
power returns.
441
Supportive therapy with vitamins and analgesics.
Plasma exchange or IV immunoglobulin therapy

of short duration improve prognosis of ventilation.
INTRACEREBRAL
HAEMORRHAGE
Capsular haemorrhage
Unconsciousness.
Face usually flushed, cyanosed and sweating.
Breathing stertorous.
Superficial and deep reflexes lost.
Retention of urine and faeces.
BP raised, Blood in CSF.
Cortical haemorrhage
Patient generally remains conscious.
Convulsions.
Paralysis of one or more limbs.
Aphasia or hemianopia.
Pontine haemorrhage
Patient comatose.
Convulsions of legs.
Vomiting.
Pin point pupil.
442
Contralateral hemiplegia.
Hyperpyrexia.
Management
Patient should be propped up in bed.
Airway is maintained, O2 and ventilation if hypoxic
cyanosis.
Nasal feeding, catheterization.
Coramine subcutaneously.
Controlled lowering of BP.
Crystalline penicillin 0.5 mega unit 4-6 hourly.
Treatment of brain edema.
Surgical removal of clot.
INTRACRANIAL TUMOURS
Generally early morning and night headaches.

Projectile vomiting without hyperacidity symptoms.
Giddiness, mental dullness and apathy.
Convulsions.
Double vision.
Paroxysms of yawning or hiccough specially with
growth in posterior fossa.
443
Management
Investigate fully.
Symptomatic relief by antiedema measures.
Surgical removal easier with meningiomas and
acoustic neuromas.
For invasive growth, partial removal, decompres-
sion or radiotherapy.
MENINGITIS
It may be bacterial/viral/spirochaetal or parasitic.
Generally young children are affected.

Incubation period is 1-5 days.
There will be abrupt onset with severe headache.
Fever, pain in neck and back.
Rigors and convulsions.
In meningeal stage headache will be severe.
Kernigs sign will be positive.
Exaggeration of deep jerks.
Leucocytosis between 20,000 30,000 per cu/mm.
CSF will be turbid/purulent. Pressure will be
increased.
444
Treatment
High doses of antibiotics.
Sedatives to lumbar puncture to lower down the
CSF pressure.
8 mg dexamethasone IV every 8 hourly.

Mannitol 25 gm in 250 ml. over a period of 1-2
hours.
MIGRAINE
May have familial history.
It develops generally before the age of 15.
Nausea, vomiting scintillating scotomas, photophobia, hemianopia.
Blurred vision.
Management
Analgesics like Aspirin and Codein if attack is mild.
Ergotamine tartrate 0.25 to 0.5 mg IM or 1-2 mg
tablet or Tab Migranil 2 tab stat.
Propranolol has been found useful in some
patients 20 mg bd or qid if needed. For in between

attacks Amitryptiline/Clonidine 25 mg bd or tds.
If no response Librium 5 mg or Larpose 2 mg bd.
445
MULTIPLE SCLEROSIS
Weakness, numbness, tingling and unsteadiness in
limb.
Retrobulbar neuritis.
Diplopia.
Urinary sphincter disturbance.
Relapses are more common in 2-3 months.
MRI is a better tool to diagnose it. It is a multifocal
white matter disease.
Treatment
60 to 80 mg of prednisone is given daily for one
week and taper it slowly. Long-term corticosteroids dont help much in preventing relapse.
Immunosuppressive therapy with methotrexate/
cyclophosphamide may help.
PARKINSONS DISEASE
Rigidity, akinesia.
Pill rolling action tremors.
Previous history of encephalitis, drug intake.
446
Treatment
Levodopa 500 mg 2-10 tab daily starting from a
low dose with gradual increment every 4th day till

optimal response.
Amantidine 100-200 mg daily.
Atropine like drugs.
Benzhexol 2-10 mg in divided doses.
Procyclidine 10-30 mg in divided doses.
Orphenadrine 400 mg daily.
Bromocryptine 1.25 mg to 10 mg daily.
POLYNEUROPATHY
There may be simultaneous impairment of many
peripheral nerves. Alcohol, isoniazid, lead, arsenic,
deficiency of vitamin B1, B12, etc. may cause it.
Numbness, tingling, burning sensation pain in calf
muscles.
Extensors area affected more than flexors.
Atrophy of muscles and flaccidity.
Dryness and excessive sweating of extremities
Postural hypotension and impotence.
Tendon reflex absent or reduced.
447
Treatment
Rich, high protein diet.

Hot packs and analgesics.
Vitamin B1 and B12.
Corticosteroids in relapsing cases.
Demyelinating neuropathies.
RAISED INTRACRANIAL TENSION

Generalised headache, projectile vomiting without
nausea.
Deterioration of consciousness and mental function.
Feature of brain herniations.
Evident primary cause like tumour, haemorrhage,
massive infarction or infection.
CT scan shows hypodense diffuse areas.
Management
Decadron 4 mg 4 times daily IM/IV.
Mannitol 1.5 mg/kg rapid IV over 1/2-1 hour 2-3
times daily.
Frusemide 40 mg IM bd.
Acetazolamide 100 mg tds.
High dose of barbiturates in hopeless cases.
448
Emergency ventricular/cisternal puncture or
ventriculo-atrial/thecoperitoneal shunt surgery.
Treatment of primary cause.
SCIATICA
Pain in the distribution of sciatic nerve or its branches.
True sciatic neuritis due to nerve injury and postherpetic neuralgia.
Mechanical pressure on nerve- Protruded lumbar
disc, arachnoiditis haemorrhage or infection.
Sacroilitis, arthritis may result it.
Sciatica may be the first sign of spinal caries.
Restriction of straight leg raising.
Intensification of pain back and leg during rotatory
extension of lumbar spine suggesting ruptured disc.
Spondylolisthesis may develop backache after prolonged standing or bilateral sciatica.
Sacroiliac arthritis causes alteration of pain. First in
one buttock and posterior thigh then pain transfers
to other side.
Benign spinal tumour causes progressive severe neurological signs.
Intermittent claudicating is caused by affection of
internal iliac artery.
449
Treatment
Rest in bed with hard boards to support back.
Analgesics as required
Heat and massage
Lumbar corset worn at all times
In last surgical intervention may be required
according to causative factor.
SUBARACHNOID HAEMORRHAGE
Sudden severe headache never experienced before.
There may be nausea, vomiting or loss of consciousness.
Patient is confused and irritable.
Nuchal rigidity.
Other signs of meningeal irritation.
Treatment
CT is more useful in first 24 hours.
Surgical intervention is needed.
STROKE
Sudden onset of neurological deficit.
450
Prolonged coma is uncommon unless there is

cerebral haemorrhage or massive brain oedema.
Convulsions may occur at outset.
Advanced atherosclerosis, hypertension or a source
of embolus are evident.
Prior history of transient ischaemic attacks, or
reversible ischaemic neurological deficit.
The neurological deficit may be in the form of
aphasia, hemiplegia, hemianaesthesia, cranial nerve
deficit, deaf-mutism or a movement disorder
depending upon the area of brain involved, CT scan
shows the infarction or haemorrhage.
Treatment
Anticoagulants during the stage of stroke in evolu-
tion or embolic stroke. Inj Heparin 5000 IU intravenous every 8 hrs for 24 hours.
Antihypertensive agents to control hypertension
and insulin for diabetes mellitus.
Physiotherapy to paralysed muscles.
Antiplatelet drugs to reduce platelet stickness like
Aspirin 325 mg daily alone or in combination with
Dipyridamole 150-300 mg daily.
Vasopressors when there is diffuse cerebral arterial
spasm.
Measures to control brain oedemaInj Mannitol
350 ml (20%) IV in hr on Glycerol 1 oz by Ryles
tube tds or Inj Decadron 8 mg 6 hrly for 48 hrs and
then taper.
451
Treatment of the primary cause like heart lesion,
atherosclerosis.
Revascularisation of brain by transcranial external
to internal carotic anastomosis.
TENSION HEADACHE
Headache is bilateral and diffuse.

Sense of tightness and pressure in head.
Onset is gradual and persistent for a few days
Patient is able to sleep but whenever he gets up
develops pain.
It is worst during worry, anxiety, tension and excitement.
Treatment
Analgesics dont help
Anxiolytics and antideppressants help.
TRANSIENT ISCHAEMIC ATTACKS

It may be caused by embolization.
Onset is abrupt without warning.
452
Recovery occurs within a few minutes.

There may be weakness and heaviness of contralateral arm, leg, face.
There may be slowness of movement, dysphagia or
mono-ocular visual loss on opposite side.
During attack there may be flaccid weakness, sensory change, hyperflexia or extensor plantar response
on the affected side.
Vertebrobasilar ischaemic attacks may develop vertigo, ataxia, diplopia, blurring of vision, weakness
on one or both sides.
Attacks may occur frequently in some cases.
When frank stroke occur it develops during first 48
hours.
Treatment
Medical treatment is to prevent further attacks.
In embolization of heart treatment may be initi-
ated with 5000-10000 units of heparin.
325 mg of aspirin reduces the frequency of TIA

Patient needs close watch.
TRIGEMINAL NEURALGIA
Brief episodes of stabbing facial pain.
453
It is unilateral. Pain shoots towards one side of ear.

Eating, touching and movements trigger the pain.
Spontaneous remissions for several months or longer
may occur.
As disorder progresses pain becomes more frequent.
Symptoms remained confined to the distribution of
trigeminal branch/nerve.
Neurological examination shows no abnormality.
Treatment
Tegretol 200-400 mg. thrice a day. Ataxia and gin-
givitis are side effects.
Baclofen 10-20 mg. thrice daily.

Gabapentine another anticonvulsant may be added
upto 2400 mg in 3 divided doses.
Surgery may not show any abnormality.
454
HAEMATOLOGY
ACQUIRED APLASTIC ANAEMIA

It may be idiopathic, secondary to hepatitis B, and
chloramphenicol. There is no family history.
History of aspirin, chlorthiazide, Chloropromazine,
chloromycetin, diethyl stilboestrol, isoniazid, quinine, tetracycline.
Whole body irradiation 300-500 reds can result in
complete loss of hemopoietic activity.
Treatment
Blood transfusion.
Early bone marrow transplantation in case of reticu-
locytes count < 1%, platelet count 20,000/cumm,

Bone marrow lymphoid element 7%.
Androgens have limited role.
Haematology
455
CONSTITUTIONAL APLASTIC ANAEMIA

Pancytopenia, reticulopenia.
Hypoplastic marrow.
Skeletal anomalies.
Chromosomal breaks.
Elevated serum iron.
Increased AML in these patients.
Treatment
Prednisone 1 mg /kg /day + oxymethalone 5 mg/
kg/day till Hb reaches 12 gm %. Then give maintenance dose.

Bone marrow transplantation.
HAEMOPHILIA A
It is an X-linked recessive disease due to deficiency of
factor VIII.
Positive family history. Females are carriers.
Bleeding in joints causing deformities and contractures.
Normal bleeding time and prothrombin time.
456
Platelet count normal.

5 30 % of normal factor VIII in mild disease
3 5 % of normal fctor VIII moderate disease
< 3% of normal in severe cases.
Treatment
Fresh frozen plasma.

Lyophilized factor VIII.
Haemarthrosis needs immobilisation by splinting.
Bleeding into skin and muscle requires single dose
of 20 units/kg of factor VIII.
Epsilon aminocaproic acid gm/m2 PO every
6 hours is hlpful in minor dental surgery.
Plasma alone is inadequate to increase factor VIII
level for safe surgery.
Small skin wounds and epistaxis may respond to
ice packs and pressure or desmopressin which
temporarily raises factors VIIIC.
HODGKINS DISEASE
Superficial lymph node in neck enlarges first.

Glands are painless, leathery to feel and discrete.
In 70% splenomegaly is marked.
In 50% cases liver is enlarged.
Haematology
457
There will be cachexia and loss of weight.

Mild fever and night sweats.
Anaemia due to haemolysis.
Pain at the site of disease after drinking alcohol.
Metastatic Growth
Localised pain in bones. Sclerotic deposits on X-ray.
CNS Paresthesia and pains.
Mediastinal pressure Dyspnoea, stride and dysphagia.
Respiratory laryngeal paralysis, collapse of lungs,
pleural effusion.
GIT Ascites and jaundice.
Genitourinary Haematuria, pyuria and flank pain.
Treatment
Radiation therapy is useful in early phase of dis-
ease.
Advanced disease is treated with combination
chemotherapy of adriamycin, bleomycin and

decarbonizers.
THALASSEMIAS
It is a hereditary defect in globin chain synthesis transmitted by autosomal recessive traits.
458
Normal to increased serum iron and iron binding
capacity.
Target cells, basophilic stippling, microcytosis more
marked than hypochromia.
Serum ferritin and serum unconjugated billirubin
levels are increased.
Marked erythroid hyperplasia
X ray shows sunray experience of skull, widening of
tables and expansion of medullary cavity of metacarpals.
Treatment
Frequent red cell transfusion to keep Hb around
10 gram %
Folic acid supplement but no iron.
Splenectomy if hypersplanism
Bone marrow transplantation
Gene therapy is a distinct possibility
Deferoxamine 2-6 g, /day by infusion pump.
Vitamin C to chelate the excess of stored iron.
POLYCYTHEMIA RUBRA VERA

There is an excessive red cell production by a hyperplastic bone narrow.
Haematology
459
Onset is insidious with cerebral symptoms.
Cyanosis of distal portion of extremities with swelling and pain.
Red colour of mucous membrane.
Epistaxis and blood shot eyes.
Duodenal ulcer may develop.
Dyspnoea and massive haemoptysis.
Fundus congested and tortuous vessel.
Weakness, lassitude, fatigue and pruritus.
Raised haematocrit with leucocytosis and increased
platelet count.
Leucocyte alkaline phosphatase raised.
Hyperplasia of bone narrow.
Treatment
Avoidance of strain. Low iron and low animal
proteins.
Venesection if haematocrit is above 55% daily
venesection of 500 ml to reduce PCV below 52%.
Busulphan If 32p is not available daily dose of it is
4-6 mg. Maintenance dose is 1-2 mg daily.
460
ORAL DISEASES
ACUTE NECROTIZING
ULCERATIVE GINGIVITIS
It is an infective disease with progressive ulceration of
inter dental papillae.
Anaerobic gram-negative organisms are involved.
Moderate to severe gingival tenderness causing pain
when eating/brushing.
Pain is dull boring in character.
Bad breath (halitosis) and unpleasant metallic taste
Gums bleed spontaneously.
A grey pseudomembrane lies over gingival tissues.
Profuse bleeding on removal of membrane is noted.
Pyrexia, malaise and cervical lymphadenopathy are
common features.
Treatment
Irrigate the tissues.
Chlorhexidine mouth rinse.
Oral Diseases
461
Metronidazole 200 mg TDS for five days.

Scale / polish after acute phase.
Advise patient to avoid smoking.
BAD BREATH (HALITOSIS)

Most important causes are:
Smoking
Alcoholism
Sepsis.
Drugs causing bad breath are:
Disulfiram
Chloral hydrate
Dimethyl sulphoxide
Psychological diseases:
Depression
Hypochondria
Diabetic ketoacidosis
Constipation.
Treatment depends on the causative factor.
DENTAL CARIES
Pits, fissures and interproximal surfaces are the most
susceptible areas of tooth decay.
462
Enamel caries does not give rise to symptoms. So is

early caries of dentine.
Extensive lesions often cause discomfort to patients
when eating food.
White areas of enamel hypocalcification
More advanced lesions cause grey / black spots.
Active caries of dentine is soft.
X-ray of interproximal or occlusal caries helps.
Treatment
Prevention Diet and improve oral hygiene. Use
of fluorides helps.
Monitor at regular intervals.
Antibiotics and anti-inflammatory analgesic drugs.
Restoration.
Extraction.
HAND, FOOT AND

MOUTH DISEASE
It is caused by virus coxsackie A 16. It affects young
children.
Low grade fever, coryza
Lymphadenopathy
Oral Diseases
463
Sore mouth with refusal to eat.

Small, multiple vesicular and ulcerative oral lesions
on tongue and buccal mucosa.
Treatment
It is a self limiting disease.
No specific treatment is needed.
RECURRENT APHTHOUS STOMATITIS

These are painful recurrent ulcers of mouth.
There will be prodromal tingling sensation.
Eating, swallowing will increase pain and discomfort.
Cervical lymph nodes may be enlarged.
Buccal mucosa, floor of mouth are involved.
Size is 2-5 mm shape is round or elliptical. Edges are
inflamed with red margins.
Major aphthous ulcers are larger one to ten in number on lips, cheeks tongue and soft palate.
Treatment
There is no specific treatment.

Tetracycline mouth wash for 5-7 days is helpful.
1.5% cortisone acetate applied locally is effective.
Chemical cautery reduces pain.
464
SHARP STABBING PAIN

Poor Response to Analgesic
Exposed dentine.
Caries, cracked tooth.
Early pulpitis.
Trigeminal neuralgia.
Dull/throbbing boring pain is associated with - (Response to analgesics).
Apical and lateral peridontitis
Dry socket
Tumors
Atypical odontalgia
Atypical facial pain
Burning pain is noted in
Burning mouth syndrome
Post-herpetic neuralgia
Pain on biting/touching indicates acute periodontitis/pericoronitis.
Pain on hot/cold suggests
Exposure of root
Caries
Defective restoration
Pulpitis.
Pain with sweet foods suggests
Exposure of caries
Dentinal hypersensitivity.
Oral Diseases
465
Pain related to meals indicate

Salivary gland obstruction
TM joint disorder.
XEROSTOMIA
Dryness of mouth is a clinical manifestation of salivary
gland dysfunction.
Dry and burning sensation.
Mucosa appears normal but poor oral hygiene is
noted.
Tricyclic antidepressant drugs may develop xerostomia Excessive use of diuretics may also cause it.
Mucosa in severe cases may appear dry and atrophic, sometimes inflamed or more often pale and
translucent.
Tongue papillae may be atrophied.
Riboflavin and nicotinic acid deficiency may be seen.
Treatment
Only symptomatic relief is possible.
476
APPENDIX
EXPENDITURE OF
CALORIES/HOUR
Activity
Calories
Dressing
33
Sitting at rest
15
Standing
20
Running
500-900
Sewing
25-30
Reading
20
Sweeping
110
Knitting
31
Activity
Calories
Mental work
7-10
Sawing wood
420
Cycling
180-300
Climbing
200-900
Wrestling
980
Rifle cleaning
50
Brick laying
240
Scrubbing floor
260
FOOD AND NUTRITION

Water soluble vitamins B complex and vitamin C
cannot be stored in body, hence excessive
consumption is a waste. It puts load on kidneys to
filter these out.
Appendix
477
Milk is a poor source of vitamin C and iron, but

provides class-I proteins.
Hard boiled egg and salad provides negative calories.
Each gram of whisky gives 7 empty calories. Every
time you drink, it damages your brain cells which
are never regenerated.
Pure ghee, dalda or refined oil provides same amount
of 9 calories per gram. Pure ghee increases serum
cholesterol level, a predisposing factor of heart
attack.
Cashewnuts, pista, badam and groundnuts all are
having more or less same nutritional values hence it
is better to consume groundnuts instead of spending
much more money on sophisticated nuts.
Pressure cooked foods are light, fluffy and easily
digestible. Loss of heat labile nutrients is also
minimized.
Certain enzymes are inactivated by cold freezing
and refrigeration.
Soda water contains only 5 calories while Fanta,
Limca, Thums up contain about 90 calories.
Liver can store large amounts, i.e. 100,000 international units of vit. A. These reserves may last for 6
months. Excessive consumption of vit. A may result
in headache, irritability, nausea, vomiting and anorexia.
None of the vitamins yields energy.
478
IMPORTANT SOURCES OF
CHOLESTEROL MG/100 GM
Food
Cholesterol
Food
Butter
280
Egg white
Cheese
145
Egg yolk
Cream
140
Chicken
Milk
Egg hen
Cholesterol
0
1330
40
11
Liver
250
498
Fish
50
IMPORTANT SOURCES OF FAT

Food
% Fat
Food
% Fat
Ghee
100
Soya bean
Butter
81
Cows milk
Almond
58
Egg
13.3
Cashewnut
46
Mutton
13.3
Groundnut
40
Fish
19.5
3.5
3.2
Appendix
479
IRON MG/100 GM
Food
Iron (mg)
Bajra
Wheat whole
Bengal gram
Peas dry
Soya bean
Bitter gau
Egg
8.8
5.3
8.9
4.4
11.3
9.4
2.1
Food
Iron (mg)
Jaggery
Betel leaves
Coriander
Methi
Mint
Tomato
Mutton
11.4
5.7
1.0
16.9
15.6
2.4
2.5
PROTEINS GM/100 GM
Food
Wheat
Rice
Maize
Bengal gram
Lentil
Peas dried
Green gram dal
Soya bean
Protein
11.8
7.0
11.1
17.1
25.1
19.7
24.0
42.0
Food
Egg hen
Fish
Mutton
Milk (cow)
Milk (human)
Groundnut
Almond
Gingelly seeds
Protein
13.3
21.5
18.3
3.5
1.2
26.7
20
18.2
480
SHOWING APPROXIMATE VALUES

Food
Quantity
Wt
(gm)
Chapaties
Rice
Pulse
Omelette
Bread
Biscuits
Milk
Banana
Apple
Butter
Ghee
Sugar
Groundnut
2
57
1 plate
100
1 cup
150
1
39
2 slice
46
2
16
1 cup
703
1
100
1
66
Table spoon 20
Table spoon 15
1 teaspoon
5
30 gm
-
Calo- Protries
eins
193
110
284
77
120
64
300
99
42
58
1345
20
165
Fats
(gm)
5
6
16
5.8
4.0
1.6
9.0
1.2
0.2
0.1
8
5.5
0.2
9
5.7
1.0
2.0
6.0
0.2
0.3
0.1
15
14
TABLE OF FOOD VALUE/100 GM

Food
Pro- Fat
tein gm
gm
Cereals Rice
Raw milled
6.8
Par boiled
6.4
0.5
0.4
Cal- Iron Vit

cium mg C
mg
10
9
3.1
4.0
0
0
Vit CalA ories

mcg
0
0
345
346
Contd...
Appendix
Contd...
Food
Flakes
Puffed
Wheat
Whole flour
Flour
refined
Suji
Bread white
Millets
Bajra
Jowar
Maize
Ragi
Pulses Dals
Bengal gram
Black gram
Green gram
Red gram
Whole Dal
Bengal gram
Green gram
Lentil
(Masur)
Peas dry
Pro- Fat
tein gm
gm
Cal- Iron Vit

cium mg C
mg
481
Vit CalA ories

mcg
6.6
7.5
1.2
0.1
20
20
20.0
7.6
0
0
0
0
346
325
12.1
11.0
1.7
0.9
48
23
11.5
2.5
0
0
29
25
341
348
10.4
7.8
0.8
0.7
16
11
1.6
1.1
0
0
348
245
11.6
10.4
11.1
7.3
5.0
1.9
3.6
1.3
42
25
10
344
5.0
5.8
2.0
6.4
0
0
0
0
132
47
90
42
361
349
342
328
20.8
24.0
24.5
22.3
5.6
1.4
1.2
1.7
56
154
75
73
9.1
9.1
8.5
5.8
1
0
0
0
129
38
49
132
372
347
348
335
17.1
24.0
5.3
1.3
202
127
10.2
7.3
3
0
189
92
360
334
25.0
19.7
0.7
1.1
69
75
4.8
5.1
0
0
294
39
343
315
Contd...
482
Contd...
Food
Pro- Fat Caltein gm cium

gm
Rajmah
22.9 1.3 260
Moth beans 23.6 1.1 202
Soya bean 43.2 19.5 240
Nuts and Seeds
Groundnut 25.3 40.1
90
Til
18.3 43.0 1450
Poppy seeds 21.7 19 1584
Cashewnut 21.2 47
50
Almond
20.8 59
230
Dry coconut 6.8 62
40
Milk and Milk Products
Milk cow
3.2 4.1 120
Milk buffalo 4.3 8.8 210
Milk goat
3.3 4.5 170
Curd
3.1 4.0 149
Butter milk
0.8 1.1
30
Cheese
24.1 25.1 790
Khoa
14.6 31.2 650
Whole milk
powder
25.8 26.7 950
Skimmed
milk powder 38.0 0.1 1370
Iron Vit Vit Calmg C A ories

mg mcg
5.8
0
346
9.5
0
9
330
11.5
0 426 432
2.8
10.5
5.0
4.5
2.7
0
0
37
60
567
563
408
596
655
662
0.2
0.2
0.3
0.2
0.8
2.1
5.8
2
1
1
1
174
160
182
102
0
67
117
72
60
30
348
421
0.6
4 1400
496
1.4
357
Contd...
Appendix
Contd...
Food
Pro- Fat
tein gm
gm
Cal- Iron Vit

cium mg C
mg
483
Vit CalA ories

mcg
Egg and Meal

Egg hen
13.3 13.3
60
2.1
0 600 173
Mutton
18.5 13.3 150
2.5
0
194
Goat meat 21.4 3.6
12
118
Chicken
26.0 0.6
25
109
Beef
22.6 2.6
10
0.8
2
0
114
Pork
18.7 4.4
30
2.2
2
0
114
Liver sheep 19.3 7.5
10
6.3 20
0 150
Fish
Pomfrets
17.0 1.3 200
0.9
87
Hilsa
21.8 19.4 180
2.1 24
273
Prawn fresh 19.1 1.0 323
5.3
89
Fish fresh
high fat
11.2 5.8 240
2.3
138
Fish dry
5.5 2.7 315
3.5
255
Crab
8.9 1.1 1370 21.2
59
Green Leafy Vegetables
Amranth
4.0 0.5 397 25.5 99 5520
45
Bathua
3.7 0.4 150
4.2 35 1700
30
Cabbage
1.8 0.1
39
0.8 124 1200
27
Colocasia
green leaves 3.9 1.5 227 10.0 12 10270
56
Contd...
484
Contd...
Food
Pro- Fat
tein gm
gm
3.3 0.6
Cariander
Drumstick
leaves
6.7
Methi
4.4
Lettuce
2.1
Raddish
leaves
3.8
Palak
2.0
Bulbs and Tubers
Beet root
1.7
Carrot
0.9
Raddish
0.7
Onion
1.2
Potato
1.6
Colocacia
3.0
Yam
1.2
Other Vegetables
Drum stick
2.5
Capsicum
1.2
Karela
1.6
Beans french 1.7
Beans cluster 3.2
Peas
7.2
Cal- Iron Vit Vit Calcium mg C A ories

mg mcg
184 18.5 135 6918
44
1.7
0.9
0.3
440
395
50
7.0 220 6780

16.5 52 2300
2.4 10 990
92
49
21
0.4
0.7
265
73
3.6
10.9
81 5300
28 5580
28
26
0.1
0.2
0.1
0.1
0.1
0.1
0.1
18
80
35
47
10
40
50
1.0
2.2
0.4
0.7
0.7
1.7
0.6
10
0
3 1890
15
0
2
0
17
0
0
0 260
43
48
17
50
97
97
79
0.1
0.3
0.2
0.1
0.4
0.3
30
10
20
50
130
20
5.3 120
1.0 137
1.8 88
1.7 24
4.5 49
1.5
9
110
420
125
130
200
80
26
24
25
26
60
93
Contd...
Appendix
Contd...
Food
Fruits
Amla
Guava
Grape
Lemon
Mosambi
Orange
Juice
Lichi
Melon
Papaya
Pineapple
Sitaphal
Strawberry
Tomato
Apple
Bael fruit
Banana
Cherries
Figs
Jack fruit
Mango
Chiku
Pro- Fat
tein gm
gm
0.5
0.9
0.7
1.0
0.8
0.7
0.2
1.1
0.3
0.6
0.4
1.6
0.7
0.9
0.2
1.8
1.2
1.1
1.3
1.9
0.6
0.7
0.1
0.3
0.1
0.9
0.3
0.2
0.1
0.2
0.2
0.1
0.1
0.4
0.2
0.2
0.5
0.3
0.3
0.5
0.2
0.1
0.4
0.1
Cal- Iron Vit

cium mg C
mg
50
10
20
70
40
26
5
10
32
17
20
17
30
48
10
85
17
24
80
20
14
28
485
Vit CalA ories

mcg
1.2 600
9
1.4 212
0
0.2 31
0
2.3 39
0
0.7 50
0
0.3 30 1104
0.7 64
15
0.7 31
0
1.4 26 170
0.5 57 665
1.2 39
++
1.5 37
0
1.8 52
15
0.4 27 350
1.0
1
0
0.6
3
55
0.9
7
78
1.3
7
1.0
5 162
0.5
7 175
1.3 16 2740
2.0
6
95
58
51
32
57
43
65
48
61
17
32
46
104
44
20
59
137
116
64
37
88
74
98
Contd...
486
Contd...
Food
Pro- Fat
tein gm
gm
Fats and Oil

Butter
Ghee (cow)
Ghee
(buffalo)
Vanaspati
Refined oil
Miscellaneous
Dates
2.5
Coriander
seeds
14.1
Methi
26.2
Chillies
green
2.9
Betel leaves 3.1
Biscuits
salted
4.5
Biscuits
sweet
5.4
Fish liver
oil
Honey
0.3
Cal- Iron Vit

cium mg C
mg
Vit CalA ories

mcg
81.0
100.0
960
600
730
900
100.0
100.0
100.0
240
750
750
900
900
900
0.4
120
7.3
25
317
16.1
5.8
630
160
18.0
14.1
0
0
940
95
288
335
0.6
0.8
30
230
1.2 111 175

7.0
5 5760
29
44
6.6
534
6.4
450
100
0

5 0.9
900
320
Contd...
Appendix
Contd...
Food
Jaggery
Mushroom
Papad
Sago
Sugarcane
juice
Pro- Fat
tein gm
gm
0.4 0.1
4.6 0.8
18.8 0.3
0.2 0.2
0.1
0.2
487
Cal- Iron Vit Vit Calcium mg C A ories

mg mcg
80 11.4 165 383
6 1.5 12
0
43
80 17.2
288
10
1.3
351
10
1.1
39

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Practical Standard

Preface to the Seventh Edition

Preface to the First Edition

Practical Standard Prescriber

his occupation should be given due consideration.

Achalasia Cardia ..................................................... 1

xiv Practical Standard Prescriber

25. Diverticular Disease of Colon (Diverticulosis) 26

Acute Bronchitis ................................................... 58

xvi Practical Standard Prescriber

75. Traumatic Pneumothorax .................................. 97

Angina Pectoris ..................................................... 99

Acne Vulgaris ...................................................... 121

Herpes Zoster ..................................................... 134

Anxiety ................................................................. 151

Practical Standard Prescriber

Amenorrhoea ..................................................... 161

Acoustic Neuroma ............................................. 179

Deafness .............................................................. 183

Acute Glaucoma ................................................. 191

Acute Rheumatic Fever .................................... 201

Practical Standard Prescriber

Chicken Pox ........................................................ 206

Acute Alcohol Intoxication ............................... 224

Burns .................................................................... 234

Acute Leukemia ................................................. 252

Practical Standard Prescriber

Diabetes Insipidus .............................................. 260

235. Immunisation ...................................................... 282

Diabetes Mellitus ................................................ 288

249. Normal Blood Count ......................................... 332

Practical Standard Prescriber

GLUCOSE TOLERANCE TEST

Acute Giomerulonephritis ................................ 422

264. Neurogenic Bladder ........................................... 428

Bells Palsy ........................................................... 432

Practical Standard Prescriber

288. Transient Ischaemic Attacks ............................. 451

Acquired Aplastic Anaemia .............................. 454

Acute Necrotizing Ulcerative Gingivitis ......... 460

Acute Osteomyelitis ........................................... 466

307. Psoriatic Arthritis ................................................ 471

Expenditure of Calories/Hour ........................ 476

Tab Probanthine or Buscopan, one tablet thrice

2 Practical Standard Prescriber

NSAIDs. Alcohol, spicy food, gulping of food and

Analgesics/sedatives like Fortwin 30 mg slow IV

or IM or Phenargan (Morphine is contraindicated

Anorexia, epigastric fullness, nausea.

4 Practical Standard Prescriber

Tab Ranitidine 150 mg twice daily or Ramotidine

Tab Probanthine twice daily.

Specific antidotes for corrosive poisons.

Anorexia, nausea, vomiting, fever.

1 tds for 7 days.

6 Practical Standard Prescriber

Laparotomy should be done as soon as possible and

ACUTE ORGANIC SMALL

Surgical measures are indicated in

blood in the faeces means strangulation and

Several litres of IV fluid replacement as patient is

8 Practical Standard Prescriber

and folic acid.

rombin time (> 1.5 times of normal), intractable