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First part

01. Patient with abdominal pain

01-02

02. Patient with dyspnoea

03-05

03. Patient with fever

06-08

04. Unconscious patient / Semiconscious patient / CVD

09-12

05. Haematomasis & Malaena

13

06. Haemoptysis

14

07. Epitaxis

15

08. Patient with CLD

16

09. Hepatic Encephalopathy

17

10. Viral hepatitis

18

11. Liver abscess

20

12. Electrolyte imbalance

21-25

13. Patient with paraperesis/quadriperesis

26

14. Spinal cord compression

27

15. Patient with convulsion

28

16. Patient with vertigo

29

17. Syncope

31-32

18. Patient with vomiting

33

19. Renal failure

35-40

20. Antihypertensive drug

41-47

21. Patient with oedema

48

22.CLD

49

23. AGN & NS

50

24. Poisoning

51-65

25. Acute coronary syndrome

66-68

26.Atrial fibrillation

69-70

27. Patient with joint pain & swelling

71-81

28. Pneumonic consolidation

82-83

29. Patient with pleural effusion

84-91

30. Hepatitis B

92-96

31. Patient with bleeding spot

101-103

32. Patient with anaemia

104-110

33. Patient with headache

111-114

34. H/O in patient with headache

115-116

35. H/O in patient with DM

17

36. H/O in patient with fever

18

37. H/O in patient with dyspnoea

19

38. H/O in patient with CVD

20

39.Approach to patient with dyspepsia

119-

40. Treatmemnt Of Gerd

120

41. Irritable Bowel Syndrome

121-122

42. Fatty Liver

123-124

43. Approach to a patient with SOL in the liver

125

44. Approach to a patient with hepato cellular carcinoma

126

45. Approach to patient with Bell‘s palsy / VII nerve Palsy

127-128

46. Enteric fever

129-130

47. MALARIA

131-134

48. Approach to patient with PUO

135-136

49. Approach to patient with sepsis or septicemia

137-138

50 Approach to patient with KALA-AZAR

139-141

51. approach to pt with DM

142-163.

52. Multiple myeloma

164-166

53. Approach to a patient with pancytopenia

167

54. Approach to a patient with ALL

168

55. Chronic myeloid leukemia

170

56. Thalassamia

171-172

57. lymphoma

173-174

58. Approach to patient with stroke :

175

59. TIA

179

60. GCS

180

61. stroke (extra not for all)

181-193

62. Approach to patient with dysphagia

194-195

63. Approach to a patient with hepatosplenomegaly

196-198

64. Approach to patient ascites

199-200

65. Find out the site of lesion from the presenting complaint or focal sign

201-204

66. approach to a patient with back pain:

205

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

We always remained scared during receiving patient. What will b the pt complaint & what will b the Dx

, how will I proceed . and what will b the Rx

Will I call my CA ?

If I call him will he angry with me ?. specially at night it was night mare for us

When I become CA. I saw still today the intern doctor are facing same problem.

They confusing during receiving a patient and giving treatment and they have to wait for mid level

visit even for simple management .

In round mid level discus uncommon d/d and management which academically important but

practically burden to intern doctor .

That why I try to write a guide line for intern doctor , who are new for in medicine ward

It is written on basis of my practical experience in medicine ward and round of note of different

teachers

Please do not use it as reference to others specially to mid-level ( only text can use as reference )

It is only for u and help u only when u r beginner.

If any contradiction Please follow the text book

Though It is made for intern doctor of MU-1 (w--15) , it will be my pleasure & honor If intern doctor of

MU-II and MU-III use it

There may be some printing mistake and spell of pen so pl forgive me and correct spontaneously

If any clumsiness or if u failed to understand of any thing written here pl call me on 01912104673

With thanks

Dr. Shamol

Assistant registrar

MU-I, MMCH

Treatment profile for intern doctor

A PATIENT WITH ABDOMINAL PAIN

First exclude Perforation by Obliteration liver dull ness broad like rigidity rebound tenderness ( peritonitis ) Appendicitis Pain in R I F MB tenderness rebound tenderness ( peritonitis ) CBC urine RME Intestinal obstruction Cramping pain abdominal distension by percussion vomiting constipation bowel sound

Investigation of choice Plain x-ray abdomen in erect posture including both dome of diaphragm Exclude perforation and intestinal obs. Subacute obs. Next investigation USG of whole abdomen to exclude HBS AND PANCREASE Pancreatitis cholecystis cholelithiasis liver abscess

If

suspect pancreatitis pain epigastric with tenderness not relief by ordinary treatment Pl do CBC, serum amylase

If

the patient is middle aged

Pl do ECG to exclude MI / angina Then seen Murphy sign to exclude cholecystitis Then exclude Cystitis and UTI by burning sensation micturation suprapubic tenderness Pylonephritis by ab.pain fever and renal agnle tender ness do urine RME Renal colic If female patient with lower abdominal pain Ectopic pregnancy --- H/O amenorrhea PID by married women and pelvic discharge Then look for PUD Fever with upper abdominal pain never think pud think infective cause Cholecystitis , liver abscess , pylonephritis , pancreatitis

Choice of investigation

Plain x-ray abdomen in erect posture including both dome of diaphragm

USG of

whole abdomen

Treat on admission

Bed rest

NPO

NG suction 2 hrly

Inj. Normal saline 1000 ml o +

Inj. Heatman

1000 ml

I V

@ v

20 drop / min

Inj. Ciprofloxacin 100 ml

1 bag iv

bd

Inj. Ranison 50 mg

or

1 amp iv stat and 8 hrly

Inj. Anadol 100mg

1 amp IM stat and 8 hrly

inj. P.P.I 40 mg

1 vial iv stat and daily

Inj. Algin / norvis 2 amp iv stat and 8 hrly if ( clamping pain )

If suspect appendicitis or peritonitis Inj . metronidazole 500mg 1 bag iv stat and 8 hrly

Caution Never use the Toradolin in upper abdominal pain if u cannot exclude PUD Toradolin use in renal colic and UTI No anti-biotic is needed in pud

A PATIENT WITH DYSPNEA

A----Acidosis DKA, uremia CRF / ARF B----Bronchial asthma C----COPD D---- DKA E----Thrombo embolism / emotional / pulmonary edema F---failure left heart failure

Bronchial asthma

Young patient , H/O previous attack , allergy Wheeze ronchi vesicle breath sound with prolong expiration COPD

Confused with LVF H/O cigerate smoking old age cough for years with sputum Crep +++ ronchi tongue cyanosis wheeze eye congested tongue cyanosis bounding pulse warm periphery flapping tremor lip pursing , barrel shape chest , apex beat not palpable , liver dullness lower down

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

LVF

Tachycardia / pulsus alternus

Cyanosis

Gallop rhythm

Othropnea

Sweating and could periphery

Basal crep +

HTN +/-

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

Then functional HCR

before thinking it first

Pl do ECG RBS S.creatine CXR should be done when patient is settle and Should be done immediately your are thinking pneumothorax

Sudden sever respiratory distress Is due to Pneumothorax -----breath sound diminish and percussion is hyper resonance LVF

BRONCHIA ASTHMA

 

COPD / CORPULMONALAE

 

1. Diet normal

1. Diet normal

 

2. O 2 inhalation

2. O 2 inhalation low flow 2 l

 
 

3. Nebulization stat and sos or 4/ 6 hrly

3. Nebulization stat and sos or 4/ 6 hrly

(Sul.sol 1ml+.5 ml ipr.sol +1.5 ml normal sal .)

(Sul.sol 1ml+.5 ml ipr.sol +1.5 ml normal sal .)

4. Tab. Ciprocin 500 mg /

levox 500 mg

4. Tab. Ciprocin 500 mg /

levox 500 mg

 

1+0+1

 

0+0+1

 

1+0+1

/.

0+0+1

 
 

Or ideally patient is rich / very severe

5. Sulprex inhaler

 

Tab. Moxaclav 625 mg

 

2

puff qds

   

1

+

1 + 1

6. Beclomin inhaler

 

5. Sulprex inhaler

 

2

puff tds

 

2

puff qds

 

7. Inj. Cotson

 

6. Beclomin inhaler

 

2

amp iv sat and

   

1

amp iv 6 hrly

2

puff tds

 

8. Inj. Ranison 50 mg / cap omeprazole 20mg

7. Inj. Cotson

1

amp iv 8 hrly

/

1+ 0+ 1

2

amp iv sat and

 
 

1

amp iv 6 hrly

   

8. Inj. Ranison 50 mg / cap omeprazole 20mg

In some case We use

Ticamet inhalar (salmetrelol + flucortisone ) in rich 2 puff bid Montelukas 10 mg 0 +0 +1 For rescue therapy mainly in discharge Tab .cortan 20 mg

1

amp iv 8 hrly

/

1+ 0+ 1

9. more crep present // oedem present

 

Inj. lasix

 
 

2 amp / amp iv stat .

1 amp iv bd

or

1 ½

+ 0 + 0

for 7 days

   
 

less severe mild cerps

 
 

Tab. Fusid plus

 

1+ 1+ 0

10. Tab contin 400 mg

 
 

½

+ 0 + ½

 

In some case We use in rich Ticamet inhalar (salmetrelol + flucortisone ) 2 puff bid For rescue therapy mainly in discharge Tab .Cortan 20 mg

1 ½

+ 0 + 0

for 7 days

 

LEFT VENTRICULAR FAILURE

O 2 In halation

Propped up position

Inj. Lasix 2 amp iv stat and 2 amp iv repeat after 30 min up to 160 mg

GTN

anril sprays

anti HTN drug

When you are in confusion between LVF AND COPD Then give Inj. Lasix 2 amp iv stat and repeat after ½ hr with COPD treat, if patient feel better after giving lasix then it was LVF

Sign of severe asthma STEP COPD

Silent chest

Tachycardia > 120

Exhaustion

Pulsus paradoxious

Cyanosis / patient cannot speak

0 2 decrease Co 2 increase

Peak expiratory flowmetry < 60 %

Dehydration due hyperventilation

FEVER Fever is two type one is emergency Patient with fever of 1 to 5 days and followed by unconscious d/d is cerebral malaria / encephalitis / meningo-encephlitis Ist see neck rigidity Endemic area of malaria Do ict for malaria and cbc and CSF study

1.

Diet NG feeding 200 ml 2 hrly

2.

Inj. Ceftron 2gm

1

vial iv bd

3.

Inj. Libot -25 100 ml

I

v @ 10 d/min

4.

Inj . 5% DNS 500 ml

 

+

 

Inj. Jasoquine 3 amp

Iv

@

30 d/min stat (over 4 hrs)

Then

5.

Inj . 5% DNS 500 ml

+

Inj. Jasoquine 1 ½ amp

Iv @

30 d/min (over 4 hrs) 8 hrly

In between jasoquine drip

6. Inj. Hartman 1000 ml

I v @ 10 d/min

7. Inj.ranison 50 mg

1 amp iv 8 hrly

If patient is rest less then

8. Inj .perol

1amp i.m. stat

9. Continuous catheterization

10. If you suspect viral encephalitis then Tab. virux 400 mg 2 + 2 + 2 + 2 + 2

11. When patient can take orally then replace Tab.Jasoquine 300 mg 2 + 2 + 2

Fever 1 st look for duration more than 7 days or less then 7 days

High / low

Character continued / intermittent / remittent

Chill and rigor---------------------------------------malaria /cholangitis /UTI (pylonephritis)/ pneumonia

Head ache and vomiting

Neck rigidity …………………………meningitis

Cranial nerve palsy ---- vi palsy ---- TBM

Eye anaemia ……

Jaundice …viral hepatitis , leptopirosis ( renal invol urine RBC, leukocytosis, bil ), malaria ,sepsis

Running nose and malaise -------common cold / viral fever

Mouth -----------Sore throat , Tonsillitis

Ear --------Otitis media

Cervical lymphadenopathy …………Lukaemia , lymphoma , TB , viral

Boney tenderness ……………Acute lukaemia

Lung …………

lukaemia

/ aplastic anaemia

Cough , crep ,

Consolidation , effusion

Tenderness on percussion pneumonia / lung abscess

Abdomen

Liver if tender then-- liver abscess

Spleen---enteric , malaria , kala-azar

Clubbing and changing murmur and vasculitis ------Infective endocarditis

Rash

Renal angle tenderness

Supra-pubic tenderness

UTI

Hepato-billary tenderness

Joint pain full swelling

Relative bradycardia

NEVER DO WIDAL TEST BEFORE 7 DAY if fever is less than 7 days then cause may be VIRAL , PNEUMONIA , MP, If more then 7 days then TYPHOID AND MALARIA, other

CBC

URINE RME

RBS

WIDAL TEST IF > 7 days

If more than >7 Pl do CXR PA USG OF whole abdomen

In endemic zone more then one month do kala-azar

If suspect TB do TB investigation ………………

CBC ,MT,

RBS, CXR PA,

sputum AFB

if efusion the fliud study

WHEN DIAGNOSIS IS UNDER EVALUATION THEN TREATMENT

Bed rest

Diet normal

Tab. Ciprofloxacin 500mg 1 + 0 + 1

Cap. Omeprazole 20 mg

1 + 0 + 1

Tab. Omidone 10 mg

1 + 1 +1

Tab. P/C

1 tab . when temp. more > 101

Maintain temp. chart

If you suspected TB then before AFB result come ----Donot give ciprofloxacin / Moxaclav

If suspect simple RTI then

If suspect simple UTI then

tab. Azithromycine 500 mg

0 + 0 + 1

tab cipro 500 or furocer 250mg 1+ 0 + 1 and urine for CS

If prolong fever and patient is toxic and do following

Diet normal

Inj . 5% DNS 1000 ml I v @ 10 d/min

Inj. Ceftron 2gm

1 vial iv bd

Cap. Omeprazole 20 mg

1 + 0 + 1

Tab. P/C 1 tab . when temp. more > 101

Maintain temp. chart

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

o

Tab.Jasoquine 300 mg

2

+ 2 + 2

o

Tab. Omidone 10 mg

1

+ 1 +1

o

Oral glucose

In case of treatment of pneumonia

Tab . Moxaclav 625 mg

1 + 1 +1

Tab . Clarin

500 mg

1 + 0 +1

UNCONSCIOUS PATIENT / SEMICONSCIOUS PATIENT / CVD

First think structural ( CVD ) and then think metabolic

CVD ----- Sudden onset / previously well --patient was Walking /Sleeping / Doing normal activity Focal neurological sign such as --- hemi/mono paresi, aphasia , cerebellar sign .

Haemorrhagic

---- head ach / vomiting /HTN /unconsciousness If neck rigidity present then …sub arachnoid haemorrhage

Infarctive stroke ….usually conscious

hemi/mono paresi, aphasia

A patient with severe head ache pl do the following

If with fever ------ meningitis / encephalitis

ICSOL ---- vomiting + long HO head ache + papillaedema

Haemorrhagic stroke …

HTN encephalopathy ------ HTN, bilateral planter extensor / papillaedema

HTN …unilateral focal sign

INFECTIVE CAUSE Meningitis /encephalitis /cerebral malaria ---fever unconsciousness, neck rigidity +/- TBM / abscess ----- prolong H/O fever / semiconscious / neck rigidity +/- Not respond to other treatment

TRAUMA

HO Recent head injury or h/o head injury 2/3 month ago

METABOLIC

1. DKA ----D --- Known or unknown case DM without treat with infection K --- urine – keton body … kenotic breath ---- Acidosis --- kussmal breathing Patient present with semiconscious/ respiratory distress /lung clear dehydration / bed smell

Any DM patient with respiratory distress 1.DKA 2.then LVF

2. Uraemia ------- anaemia /HTN/ edema / respiratory distress HO of renal disease ----CRF / GN / hypovolumia

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

4. HTN encephalopathy ------ malignant HTN, bilateral planter extensor / papillaedema CT-normal

5. HONK

6. ELECTROLYTE IMBALANCE Hyponatraemia --------- HO vomiting / elderly anorexic patient / +/- fever No focal sign think electrolyte Single vomiting may cause severe hyponatraemia

NEOPLASTIC Primary ----- vomiting and head ache long HO…. Fundoscopy

papillaedema

DRUG AND TOXIC

Drug overdose Poisoning ……. Opc/ dutura / alcohol intoxication

DEFICIENCY vitamin …B 1

EXAMINATION

A----------AIRWAY

clear or not , Suction---for secretion

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

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

GCS ……………

Cranial nerve palsy -------3 rd / 7 th nerve , p

Pupil ----- unequal ----- herniation

Pinpoint ------ pontine haemorrhage

Neck rigidity -----

Temperature

Pulse

Anaemia + jaundice + oedema ------ Uraemia

Polycythemia + lung crep ++ HO lung disease + edema + cyanosis ++---- hypoxic encephalopathy

Heart --- murmur

Lung ---- crep …. Respiratory distress lung clear is DKA / uraemia / HCR

Carotid bruit ----

Hand ---- sweaty with cold clammy hand

Bp

HTN ---hemorrhagic stroke / HTN encephalopathy

---- -

hypo glycaemia -- HO DM , BP normal , pulse incre.

MI --- chest pain +/- , BP decrease , pulse decrease

Hypovolumic shock -- BP decrease , pulse feeble dehydration , HO fluid loss

Do neurological examination

Motor

Jerk

Planter ---

Bilateral extensor -- -encephalopathy

Unilateral extensor ….CVD

TREAT MENT OF UNCONCIOUS PATIENT AND CVD

A …

clear

away with suction if secretion

B …. O 2 inhalation is respiratory distress / inj. Lasix if creps +

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

Diet NG feeding 200 ml 2 hrly

Inj. Ceftron 1 gm

1 vial iv bd

Inj. Normal saline 1000 ml

I V

@ v

20 drop / min

Inj. Oradexon

1 amp iv stat and 8 hrly

Inj. Ranison 50 mg 1 amp iv stat and 8 hrly

Chang posture 2 hrly

Continuous catheterization

Maintain I/O chart

If convulsion

o

Inj . sedil 1amp iv stat and then

o

Tab. Diphedan 100mg

o

Rest less

1+0+2

o Inj. Perol 1amp im stat

If HTN then

If only haematoma with out ventricular Extension Continue same treatment

the cause is infarctive stroke

pl. add tab .Clopid AS

1 +0

0 +

tab. Cerevas 5 mg 1 + 1 + 1 Tapper the oradexon

If the patient is hyperlipidaemia and IHD Give Statin Tab. Atova 10 mg 0 + 0 + 1

o Tab. Camlodin 5 mg (NORMAL) / repril 5 mg ( CVD)

HAEMORRHAGE WITH VENTRICULAR EXTENSION

 

A …

clear

away with suction if secretion

B …. O 2 inhalation is respiratory distress / inj. Lasix if creps +

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

Diet NG feeding

 

200

ml 2 hrly

 

Inj. Ceftron 1 gm

 

1

vial iv bd

 

Inj. Normal saline 1000 ml

 

I V

@ v

20 drop / min

 

Inj. Oradexon

 

1

amp iv stat and 8 hrly

 

Inj. Ranison 50 mg

 

1

amp iv stat and 8 hrly

Inj. Osmosol 500 ml 300 ml 60 drop/ min

 

100

ml 30 drop / min 8 hrly for 5 day

 

o

Tab. Nimocal 30 mg

 

2+2+2+2+2

 

o

Tab. Diphedan 100mg

 

1+0+2

 

Tab. repril 5 mg

 

0+0+1

 

o

Cap. Anadol 50 mg 1 +0 +1

o

Rest less Inj. Perol 1amp im stat

IF

Constipated

 

Syp. D-LUC

2

TSF TDS

 

Chang posture 2 hrly

Continuous catheterization

Maintain I/O chart

HAEMATEMESIS AND MALAENA

Is medical emergency Look for -------pulse ….BP … shock ------Anaemia -------Urine out put Immediately open an IV channel with inj.Hartsol Bloold grouping and cross matching Give one unit of blood and keep ready two donor

Diet --- normal

Inj. Hartman 1000ml

I V

@

20 D / min

Inj. Moxin 500 mg 1 amp iv 8 hrly

Inj. PPI

40 mg

1 vial I V stat and daily

Tab . ulsec 1 gm 1 + 1+ 1 + 1+ 1

1 hr before meal

Inj .caprolysin 1 amp ½ glass of water PO stat and 8 hrly

Then take HO any NSAID drug. PUD. Liver disease / jaundice. CLD varices . Look for renal failure Lymphoadenopathy , boney tenderness+ fever + hepato-splenomegaly leukemia Ascites + splenomegaly -----CLD Investigation

1 st choice of investigation endoscopy of upper GIT

To exclude D/D -----CBC, PBF ------S.CREATINE , RBS . PT

HAEMOPTYSIS Is medical emergency Look for -------pulse ….BP … shock ------Anaemia -------Urine out put Immediately open an IV channel with inj.Hartsol Bloold grouping and cross matching Give one unit of blood and keep ready two donor

Diet --- normal

Inj. Hartman 1000ml

I V

@

20 D / min

Cap . Moxin 500 mg (never use cipro group if u suspect TB as it mask the AFB )

1 +

1 + 1

Inj. Frabex

1 amp iv stat and then

Tab. Frabex / traxyl 500 mg

1 +

1 + 1

Cap . omeprazole 20 mg

1

1 +

0

+

Tab. Sedil 5mg

0 +

0

+ 1

The D/D of

Bronch. Ca PTB Chr./acute Bronchitis Bronchiectasis MS

Look for bronchogenic CA

Lymph node

Clubbing

Bone pain

SVO

CBC, MT S.CREATINE , RBS CXR Sputum for AFB and malignant cell

EPISTAXSIS Is medical emergency Look for -------pulse ….BP … shock ------Anaemia -------Urine out put Immediately open an IV channel with inj.Hartsol Bloold grouping and cross matching Give one unit of blood and keep ready two donor

Stop bleeding first with appropriated procedure If fail to stop and give a call to asst. registrar of ENT

Find out the cause

Look for

SYSTEMIC ----HTN And renal failure

LOCAL ------------PNS and DNS OTHER leukamia / lymphoma hepatosplenomegaly boney tenderness rash , HO fever lympadenopathy

 

investigation

Diet --- normal

CBC, PBF platelete count , CT , BT RBS S.CREATINE XRAY PNS

Inj. Hartman 1000ml

I V

@

20 D / min

Cap . Moxin 500 mg

1

+

1 + 1

   

Inj. Frabex

 

1

amp iv stat and then

Tab. Frabex / traxyl 500 mg

1

+

1 + 1

 

Cap . omeprazole 20 mg

 

1

+

0

+

1

Tab. Sedil 5mg

 

0

+

0

+ 1

CLD patient may present hepatic encephalopathy (unconscious / alterconscious ) with out encephalopathy (ascites / jaundice ) with SBP (bdominal pain / fever )

with out encephalopathy

 salt restriction  tab. ciprofloxacin 500 mg daily wt loss only ascites –0.5 kg
 salt restriction
 tab. ciprofloxacin 500 mg
daily wt loss only
ascites –0.5 kg
1
+ 0 +1
with peripheral oedema 1 kg
Dose
minimum
max
 cap. omeprazole 20 mg
frusemide
40 mg
160 mg
1
+ 0 +1
spirilactone 50-100
400
 tab. fusid plus
1
+ 1 + 0
 syp. D-LUC
refractory ascites
failure to decrease wt loss 0.5 kg/d
after 1 wk of max dose of combin
diuretic (f-160 , s—400 )
3
tsf tds
paracentesis
 Draw ascitic fluid 2- 4 L every day or alternate
day
 can draw 2-4 l fluid /day
with out albumin
maintain I/O chart
 dont draw fluid if patient in
encephalopathy / near to
maintian wt chart
tritrate dose of indever
 if pt has varices
untill pulse become 25 % of
tab. indever 40mg
½ + 0 + ½
basal decrease when pulse come
below 60
 if pt comes with abdominal pain / fever then
inj. ceftriaxon 1 gm
1 vail iv bd
 if patient complain adominal pain
inj. anadol 100mg 1 amp im stat
inj. algin
1 amp iv stat
no NSAID, sedative , hypnotic

HEPATIC ENCEPHALOPATHY

No NSAID ,Sedative,hypnotic, ACE inh

A …

B ….

C …….

Diet NG feeding protien restricted Based on CHO diet + dub water 200 ml 2 hrly total 10 feed

Inj. Ceftron 1 gm

1 vial iv bd

ml 2 hrly total 10 feed  Inj. Ceftron 1 gm 1 vial iv bd 

5%DA 1000 ml / INJ. HARTMAN 1000 ML

Inj.

 

I V

@ v

20 drop / min

Inj. Ranison 50 mg 1 amp iv stat and 8 hrly

inj. konakion 10 mg

1 amp iv stat and daily for 5 days

syp. D-LUC 3 tsf tds

enema simplex stat and bd

some like to give tab.

o metronidazole 400mg ½ +1/2 +1/2

Chang posture 2 hrly

Continuous catheterization

Maintain I/O chart

in special situation

Hepato renal syndrome ----- when decrease urine out put and s.creatine dobule and >2.5 mg / dl with in two weeks . give nj. normal saline 1000ml IV @ 20 /D MIN OR INJ. HUMAN ALBUMIN / INJ .ALBUTIN 50 ML )

to diagnosed CLD

SGPT

S.blirubin

s.albumin / AG ration

prothrobin time

HBSag

USG of whole abdomen

Asitic fluid study

in case of encephalopathy

SGPT

S.blirubin

prothrobin time

S.creatinine

S. electrolyte

IF patient is restless the with the parmisson of senior give inj. Dormicum 7.5 mg

½ amp im / iv stat viral hepatitis

diet normal

5%DA 1000 ml / INJ. HARTMAN 1000 ML if pt is nausea / vomiting

Inj.

 

I V

@ v

20 drop / min

no NSAID, sedative , hypnotic

cap. omeprazole 20 mg

1 + 0 +1

tab. omidone 10 mg

1+1+1

syp. D-LUC

3 tsf tds

inj. konakion 10 mg 1 amp iv stat and daily for 5 days

if itching present then give

tab. ursocol / ulive 300 mg 1 + 1 + 1 or

questarn ( cholestyramin ) 1 saucet 12 hrly or 8 hrly

Look for consciousness / drowsy and disoriented Bowel pass / haematemesis /malaena

to diagnosed

SGPT

S.blirubin

prothrobin time

HBSag

USG of whole abdomen TO exclude obstuction

konakoin

when prothrombin time deference is more the 4 .

acute viral hepatitis we can give konakion with out doing PT.

Dangerous complication of viral hepatitis fulminative hepatic failure

Difference between Albumin @ AG ratio USG

FACTOR PREDISPOSING HEPATIC ENCEPHALOPATHY

acute liver disease normal normal

chronic liver disease decrease @ alter coarse echo structure

BBleeding from GIT haematemesis @ malaena C--- constipation D---drug sedative , hypnotic , NSAID , E---electrolyte imbalance , hypokalaemia FFever indicate infection

Minus top

T--- trauma

Ooperation

Pparacentasis

Follow up

Level of consciousness

Jaundice

Dehydration

Flapping tremor

Pulse , BP, Cyanosis

Abdomen

Percussion distension

Bowel sound

Fever / Temp.

Constipation / bowel pass

Bladder (urine out put )

Rebound tenderness

Abdominal girth

Planter extensor

Daily weight

 

Point 1

Point 2

Point 3

Prothrombin time

<

4

4-------6

> 6

Albumin

> 3

2.5----3.5

> 2.5

Bilirubin

< 2

2-------3

> 3

Ascites

None

Mild to moderate

Marked

Encephalopathy

None

1 / 2

3 / 4

Child 1 = < 7 = well compensated

Child 2 = 7--9 = slightly decompensate

Child 3 = > 9 =

decompensate

LIVER ABSCESS

Diet normal

Tab. Ciprofloxacin 500 mg

1 + 0 + 1

Tab. metronidazole 400 mg

2 + 2 + 2

Cap. Omeprazole 20 mg 1 + 0 + 1

Tab. Anadol 50 mg (if pain)

1 + 1 + 1

If patient is toxic then give following

Inj. Ciprofloxacin 100 ml

1 bag IV bd

Inj . metronidazole 500 mg

1 ½

bag IV 8 hrly

Indication for aspiration of liver abscess

If the abscess is more 5 cm

If in the left lobe

If impending to rupture

Not responding to medical therapy

ELECTROLYTE IMBALANCE

Effect of hypokalaemia Skeletal muscle weakness --- flaccid paralysis / quadriparesis /parapersis but reflex present . Cardic muscle -------------- arrhythmia , ectopic beat Visceral muscle ------------ paralytic ileus ECG T flat , invert and appearance of U wave

Normal K level 3.5

No treatment require if not > 3

to 5 .5 mmol / L

If k level > 2.5 or some body say > 2

Correct orally =such as Dub water , fruit K containing

= Syp. KT ( KCl )

1 tsf = 15 meq

3 tsf tds =some body prefer Inj. Hartman if patient of IV fluid

If patient

K level is < 2.5

or < 2

Oral

Plus

Inj. Normal saline 1000 ml

+

Inj. K T

--------------------------------------

IV

2 amp

@

20 D / min

REMMEBER FTHE FOLLOWING

1 amp KT contain = 20 m mol kcl

Max. rate of infusion

Max 2 amp in 1L normal saline

So never give 2 amp + 1 L normal saline I n less then 4 hours

So never give 2 amp + 1 L normal saline more then 40 D/ min

10 meq/ l in hour

1000 ml fluid if in 10 D/ min takes 24 hours

20

D/ min takes 12 hours

30

D/ min takes 8 hours

60

D/ min takes 4 hours

HYPER KALAEMIA If K > 5.5 mmol/ l is called hyperkalaemia Treatment is needed when > 6 mmol/ l Reconfirm it is true or false Cause of hyperkalaemia ACE inhibitor Flucid plus / spirolcatone ARF / CRF

Pulse --- Bradycardia

Pl do ECG 6—7 : Tall tent shape ― T ― 7---8 : wide QRS complex

6 —7 : Tall tent shape ― T ― 7---8 : wide QRS complex > 8
6 —7 : Tall tent shape ― T ― 7---8 : wide QRS complex > 8
6 —7 : Tall tent shape ― T ― 7---8 : wide QRS complex > 8

> 8

: sine wave

Remove the source of K containing drugs and fluid ( cholera saline )

1. Membrane stabilization

Inj. Calcium gluconate 2 amp ( 10 ml) I V over 10 minutes daily for 5 days

2.Insulin + Glucose

Inj .Libot -25 100 ml

+

Inj. Actrapid HM 10 unit

IV @

20 D/ min

daily for 5 days

3. Nebulization with β blocker

not use now

4. If acidosis present then

Give inj. Sodi-bi-carb 25 ml 2 amp Iv slowing stat and sos

5. k -Exchange resin

Kayexalate 15 gm TDS before meal

Electrolyte imbalance

Normal

Na = 135 145 mmol / L

Hypo-natraemia No treatment is needed if serum sodium Classify the hyponatraemia

< 130 mmol

Edematous

Dehydration

Normal dehydration

CCF Cirrhosis NS CRF osmolarity

Vomiting

SIADH Meningitis CVD Tumor Bronchogenic carcinoma Pneumonia

Diarrhea

First see this hypo natraemia is Acute ----- need immediate treatment OR Chronic ------be cautious before treatment In edematous patient --- hyponatraemia

Treatment

is only restriction of water

Clinical presentation Drowsy, disorientation Confusion, convulsion , coma and restlessness

Classification Mild -------------- 135 to 125 Moderate -------- 124 to 115

Severe ------------

< 115

IT IS BETTER TO UNDER CORRECTION THEN OVER CORRECTION

IN MILD ----- 135 ---- 125 Oral correction with

Table salt and ORS only Some prefer to give Inj. Normal saline 0.9%Nacl

MODERATE -------- 124 to 115 Oral

+

Inj. Normal saline 0.9% Nacl 2L

SEVERE ------------ Oral

< 115 some body prefer <110

+

3 % Nacl with caution Before giving 3% Nacl think the following

Always consult with senior before giving it

It only avail able in Dhaka

It should be correct slowly with micro burette set

Never give it in hypo volumic patient.

No need to give If the patient is conscious and well oriented (chronic hyponatraemia )

WORKING FORMULA 32 µ drop / min Never correct more then 10 m mol / L per day Because there is chance of central pontine demyelination

1 L

3% Nacl

513 mmol

1 L

0.9% Nacl

154 mmol

Na in fluid ---- measured Na

1 litre fluid will correct Na in mmol === -----------------------------------------------------

1litre fluid will correct Na in mmol

A patient of 50 kg

Na level is 113

T.B.W

+

1

Na in fluid - measured Na

T.B.W

1

Na in fluid ---- measured Na

1 litre of 3% fluid will correct Na in mmol === ---------------------------------------

T.B.W

513--113

+ 1

= ----------------------------

=

30 +1

13

mmol

TBW: total body water == body wt × 0.6

TBW

= 50

= 30 kg

× 0.6

Max Na correction is 0.5 mmol / hr Acute : with in 48 hr Chronic ; correction not needed When Na level become 120 mmol / l then u should be come cautious

HYPER NATRAEMIA

Due to decrease water Diabetes incipedus Psychogenic poly-dypsia

Na level

> 145 mmol .

Choice of fluid is Inj. D.A

One liter DA will decrease sodium can calculate from the following formula

0 ---- measured Na

1 litre DA will decrease Na in mmol === -----------------------------------------------------

T.B.W

+

1

A patient with Na level 160 mmol / L

0 ---- 160

1 litre DA will decrease Na in mmol === -----------------------------------------------------

50 × 0.6 + 1

==160/ 31 == 5 m mol

In one day u can give max 3.5 l fluid

But we donot give more then 2 liter fluid to avoid pulmonary edema

Max correction is

10 mmol per day

Osmolarity = 2 NA + 2k + urea + RBS

in mmol

A PATIENT WITH PARAPERESIS / QUADRIPARESIS

GBS

Hypokalaemia

SPINAL CORD COMPRESSION ------------- 4 T

1. Trauma

2. Tumor 1.multiple myloma 2. Secondaries

3. TB

4. Transvers myelitis

GBS

CLUE T O D X Reflex abscence Sensory intact and no bladder and bowel involment

Orther feature Gradual onset , ascending type , HO diarrhea / fever

DANGEROUS COMPLICATION : Respiratory distress How will u access vital capacity clinically Ask to count from 1 to onward with birth holding If patient can count up to 30 the vital capacity is 3 liter When vital capacity is less then 1.5 liter then patient will need ICU support . GBS may present with dysphagia / dysarrthia

DD OF GBS IS HYPOKALAEMIA To exclude it please do electrolyte

HYPOKALAEMIA

Clue to diagnosis Only weakness but reflex present and planter flexor

Other

Proximal myopathy Sensory intact and no bladder and bowel involment HO diarrhea / Unable to standing from squatting position HYPOKALAEMIA PERIODIC PARALYSIS After heavy meal , exercise patient develop quadriparesis May have HO of previous semillar attack

SPINAL CORD COMPRESION

At least two of the following

Motor

Spastic paraparesis Reflex exaggerated

Planter extensor (may be equivocal ) Sensory involvement ; Definite sensory level Bladder bowel involvement

Either retention

or incontinence

If a patient with recent short HO of feature spinal cord compression with or without fever or infection Than think for acute transvers myelitis (if u suspect never forget to do fundoscopy )

Treatment of acute transvers myelitis

Inj . normal saline 100 ml

+

Inj. Methyl prednisolone 1 gm

-------------------------------------------

IV @

40 drop / min for

3 days

In case of simple spinal cord compression

Bed rest Physiotherapy Tab . ciprofloxacin 500gm 1+ 0 + 1 Tab . neuro B 1+ 0 + 1 Tab .flexibec 10mg (muscle relaxant)

1 + 1 + 1

Tab. Tryptin 25 mg

0 + 0+ 1

A PATIENT WITH CONVULSION

DEF OF CONVULSION SEIZURE EPILEPSY

CAUSE OF CONVULSION Hypoglycaemia Electrolyte imbalance mainly hyponatraemia , hypocalcaemia , CVD mainly hemorrhagic , may be in infarctive ICSOL ---fundoscopy Meningitis and encephalitis fever will present Hepatic encehalopathy ---ascites / jaundice Uraemic encephalopathy ARF ,CRF Hypoxic encephalopathy COPD , shock Hypertensive encephalopathy malignant HTN , Papilliedema

STATUS EPILEPTICUS When series of seizure occurring with out regaining awareness between attack over period of 30 mins.

TREATMENT OF CONVULSION

1. Immediately give Inj. Sedil 10 mg 1 amp iv slowly stat and Repeat after 15 mins .

2. If not controlled Inj. Fosfophenytoin Inj. Fosfine 100mg 20mg/kg Bwt IV at of 100mg/ min

3. If not controlled- Repeat ½ of calculated dose ½ hr. later

No value of giving IM Inj. In convulsion

If patient wt is 40 kg Cal. Dose : 20 × 40 = 800 mg = 8 amp.

Then give 8 amp of inj. fosfine in normal saline via micro infusion set over 8 mins.

4. Phenobarbitone may given in change of Fosfophenytoin

Inj. Phenobarbitone 200mg 10mg/kg Bwt IV at of 100mg/ min

5. Then give prophylacting drug

Inj. Diphedan 100mg (phenytoin ) 1 + 0 + 2 Or if the patient is restless then do following

Inj. Phenobarbitone 200mg / tab. Barbit

½ amp im bd

1 + 0 + 1

Difference between seizure and pseduoseizure Seizure have

Tongue bite ,

Incontinence

And post ictal amnesia

A PATIENT WITH VERTIGO CAUSE CENTRAL Cerbellar cause ( TIA, Infarction, And, Hemorrhage )

AND

PERIPHERAL

OTHER

BPPV

Meneiar disease

Labirynthitis

Migraine

D/ D This is not actual vertigo but the patient called it vertigo. This false vertigo should be excluded

TIA

Arrythmia

Hypoglycaemia

Anaemia

Postural hypotension ( DM, diuretic , hypovolumia ,)

APPROACH TO A PATIENT WITH VERTIGO First exclude cerebellar cause Examfor cerebellar sign Nystagmus Finger nose test Rapid alternative test Heel seen test Ask the patient to stand --- if the patient fall or stand on broad base gait ---- Patient fall toward site of lesion (if pt fall rt side = lesion in rt side) Vertigo is mild but persist all the time

BPPV

Very severe which Vertigo occur in one specific direction Vertigo occur in head movement ( and also lying to sitting/sitting to standing)

So severe vertigo that patient is lying stiffness and u cannot do examination properly

Halpik sign positive

, vomiting +/ -

Meneiar disease Vertigo with tinnitus , deafness +/- If u suspect then give a call to ENT department Labirynthitis HO of fever Nausea and vomiting Ataxia Other cause excluded Take h/o Heart disease , diabetes , hypertension Drug HO of diuretic , hypertension

Anaemia

Migraine

INVESTIGATION

RBS

S.Creatinine

ECG

Electrolytes with permission of the senior

If suspect cerebellar cause pl do MRI of brain

Look for

Anaemia BP ( postural hypotension --- BP on lying and then measure after 2 min and before 3 min of standing . If difference > 20 / 10 then it present)

Pulse for arrhythmia Carotid bruit TIA See cerebellar sign Nystagmus ( horizontal ) Finger nose , Rapid alternative , Heel seen Ask the to stand

Heart and lung Holpik test Neurological examination Fundoscopy exam to exclude papilledema .

TREATMENT

Bed- rest

Diet --normal

Inj. Normal saline 1000 ml

IV @

15 D /min

Tab. Norium 5 mg / if old patient 60 yr s then 0 + 0 + 1 1 tab stat then

1 +

0 + 1

Tab. Stemitil 5 mg

1 +

1 + 1

Tab. Perkinil 5 mg

½ + 0

½

Cap. Omeprazole 20 mg

1 +

0 + 1

SYNCOPE Exclude Cardiac Cause

Arrhythmia (Brady/Tachy) VT ,VE, by pulse and ECG

LVF ---- Decrease cardiac out put

Aortic stenosis --- murmur and Echo-cardiacgraphy

Carotid hypersensitivity ------- Carotid bruit

Hypertrophic cardiomyopathy ---- Echo

Cervical spondylosis ----- Neck movement and X-ray cervical spine Neurological cause

TIA

Epilepsy

Vasovagal syncope

Cough

Defecation

Micturation

Prolong standing

Cardiac syncope Pallor ,palpitation , chest pain , dyspnea Recovery < 1 min , quick recovery Neurological syncope Seizure may present Recovery > 1 min slow recovery Tongue bite Incontinence Exclude the cause that similar to syncope Anaemia TIA Postural hypotension ( Drug , DM, )

Investigation

ECG

CXR

ECHO

RBS

X-RAY CERVICAL SPINE

CAROTID COLOR DROPPLER

SEE PULSE BP for postural hypertension Carotid bruit Heart for murmur AS Move of cervical spine Neurological exam + cerebellar sign Anaemia

A diabetic patient come to u with

Sweating with cold clammy skin / hand

1. hypoglycemia --- HO of insulin of oral hypoglycaemic drug , +/ - missed meal

--- sweaty , tremor , palpitation, but BP normal

2. MI ----

Chest pain and breathlessness and sweaty hand,

decrease BP

FRIST EXCLUDE HYPOGLYCAEMIA THEN MI SO PL DO RBS FIRST AND THEN ECG

Mangment of hypoglycaemia

Oral fruit juice , sugar And give

Inj. Libott 25 100ml (25% glucose )

IV @

20 D/min

Then

Inj , 5% DA 1000ml maintenance

IV @

20 D/min

Stop insulin and oral hypoglycemic drug

Further evaluate dose

Reduction 25% of current dose

Educate the patient about and treatment of hypoglycaemia

A PAIENT WITH BRADY CARDIA IST exclude

Complete heart block

Inf.MI

Then think sinus bradycardia

HO of beta blocker

Ca-channel blocker

Hypothyroid

-- cold intolerance and delayed relaxation of ankle jerks

A PATIENT WITH VOMITING

Diet normal and ORS

Inj. Normal 1000ml or 2000ml according to dehydration

I V

@

20 D / min

Inj .ciprofloxacin 100ml if cause is infective 1 bag IV BD

Inj. Ranison 50 mg 1 amp iv stat and 8 hrly

/

Inj. P.P.I. 40mg 1 vial IV stat and daily

Inj. Vergon / inj. Stemetil / Emistat 1 amp I M stat and sos and tds

Tab. Omidone 10 mg or tab. Emistat 1 + 1 + 1

Access the patient Pulse BP Urine output Dehydration

Do SGPT S.Creatinie RBS S. electrolyte -- necessary unless the patient is drowsy and disoriented

A PATIENT WITH VOMITING FIRST EXCLUDE THE FOLLOWING CNS pathology ICSOL BY fundoscopy HEPATITIS URAEMIA AND also think about Addison and 2ndary adrenocortical insufficiency

CAUSE OF VOMITING

A

 

Acute abdomen ----

acute intestinal obs.

Acute cholecystistis ,

pancreatitis

B

 

Bacterial ( gastroenteritis +) viral hepatitis

C

 

CNS

ICSOL

CVD

Meningitis and encephalitis

Migraine

Head injury

D

 

Drug

NSAID

Digoxin

Jasoquine

Opiate

MTX and cytotoxic drug

E

 

Electrolyte imbalance and metabolic cause

DM-dka

URAEMIA ARF, CRF

Addison and adrenocortical insufficiency

F

 

Functional

Bulimia nervosa

G

 

Gastric cause

GOO

PUD

H

 

Hormone

Pregnancy

Oral contraceptive pill

I

Infective

UTI

Any infection

We will look for C and E cause

Patient with vomiting must do fundoscopy to exclude ICSOL

34

Dr. shamol

RENAL FAILURE

Cause of ARF PRERENAL

Decrease blood supply to kidney ( hypovlaemia )

1. Absolute hypovolaemia

Blood loss

Fluid loss

RENAL CAUSE ( TIA )

o

Diarrhea

1. ACUTE TUBULAR NECROSIS

o

Vomiting

Ischaemia --- from renal

o

Pancreatitis

Toxin Exogenous --Drug Gentamycin,

Endogenous Bacterial toxin ( infection) Malaria

2. AGN oligouria , HTN, RBC ,Protein +/++ oedema , sudden onset ,HO infection

o

Burn

3 rd space loss Peritonitis

o

o

Intestinal obs.

Sepsis vasodilatation

MI, CCF , CLD --- Decrease CO

By stenosis

Thrombosis

3. INTERSTITIAL DISEASE Drugs (fever, arthritis , rash ) Eosinophilia

Patient with non oligouric renal failure always find for drus

Embolism

POST RENAL

Stone

 

Stricture

BEP

2. Relative hypovlaemia

3. Renal artery stenosis

ANY PATIENT WITH ARF Following are over look

Any sepis / infection

Intestinal obs. And peritonitis

Drug H/O

Look for stone /stricture / BEP

Cause of CRF (DGHS Director General of Health Service )

DDiabetic

G-Glomerulo nephritis

Hhypertension

SSLE / vasculitis

Others Renal artery stenosis and Polycystic disease , Amylodosis

HOW WILL U DIFFERENTIATED ARF FROM CRF By

H/O ,

Eaxm,

Biochemical ,

Imaging

 

ARF

CRF

History

Short / abrupt onset Predisposing factor

Insidious onset No previous HO

HO hypovolaemia

Occational finding

HO infection

Anorexia , vomiting

Drugs

H/o Recurrent edema

Obstruction

HO--DGHS

HO heat , liver disease

Examination

Patient is more symptomatic Feature of hypovlaemia Oligouria Bp is normal except in (AGN)

Anaemia HTN Proteinuria Oedema + / -

Biochemical investigation

   

Urine RME

Normal Except AGN prt and RBC

Proteinuria

Serum creatinine

Increased

Increased

Serum electrolyte

May hyperkalaemia

May hyperkalaemia

Ca and PO 4

Ca and PO 4 -- normal

Ca --decrease , PO 4 -increase

USG

NORMAL

Kidney size decrease ( < 9 cm) With echogenic cortex

So we can differentiate CRF from ARF By in CRF

Anaemia and HTN present

Ca and PO 4 --- Ca ---decreased and PO 4 --- increased

USG of KUB ------ Kidney size decrease ( < 9 cm) With echogenic cortex

A patient with S.creatinine raise and have Anaemia HTN and

Protienuria

IS equal to CRF unless other wise proved

CRF with normal kidney size ------ is DM

CRF with large kidney size -------- is Polycystic kidney and Amylodosis and Hydronephrosis

Polycystic kidney --- HTN , haematuria , multiple cyst , may palpable kidney

Stage of CKD Stage -1 kidney damage with normal GFR Stage -2 kidney damage mild GFR 60-89 Stage -3 kidney damage morderateGFR 30-59 Stage -4 kidney damage severe GFR 30-59 Stage 5 renal failure GFR < 15 Old CRF stage 3 ESRDlife is impossible with out dialysis or Transplantation. In stage 4 pl do artery venous fistula

Stage -1 find out cause

Stage -2 only HTN

Stage -3

Anaemia ,Ca ↓, PO 4 , HTN

Stage -4 Above all + K ↑ , Acidosis

Stage 5 Neurological disorder

Treatment

Fluid restriction Only if edema present Previous day out put +500 ml Salt 1 tsf is = 5 mg = 6 mmol Patient will Cook with ½ tsf whole day Protein restriction should be done If S.creatinine > 2.6 mg /dl

1. Diet Fluid 3 l Protein normal (60 mg /day )

 

2. Correction of anaemia ( 10 to 12 gm /dl) Blood transfusion Erythropoitin ( in rich patient ) Other Tab. Feofol

 

1

+ 0 + 1

 

1

piece of meat = 6.4 gm ( match box size) protein

3. For hypocalcaemia Tab. Dicaltrol ( 0.25µmg )

0 + 0 + 1

 

cap milk = 6.4 gm protein 1 egg albumin = 6.4 gm protein

1

4. For binding dietary PO 4 Tab. Calbo 500mg

 
 

1

+ 1 + 1

5. PPI Tab, Pantonix 20 mg

   

HTN Target BP = 130 / 80 mm of Hg = 125/ 75 mm of Hg if prot uria > 1 g Choice of anti HTN is

1

+ 0 + 1

6. Anti HTN if needed (single or combination) Tab. Angilock 50mg / camlodin / alphapress 0 + 0 +1

 

1.

Aldestorones receptor blocker (angilock 50mg)

7. If edema / decrease out put Tab. Fusid

 

Or ACE Inhibitor –don’t use if K ↑ , oligouria

1+1+1 /

1 + 1+0

2.

If not control or can not use ACE inhb.

8. If vomiting Tab. Omidone 10 mg 1 + 1+ 1

calcium channel blocker Amlodipin / Diltiazem

3. Alpha blocker -Tab.alpha press 1mg 1 + 1 + 1

9. If infection non nephrotoxic anti biotic Inj.ceftriaxone / amoxycilin /azythromycine Tab. pefloxacin

4. Diuretic Tab.Hypen-SR 1.5 mg (indepamide)

Dr. shamol

37

 

Nephrotoxic Drug should be avoided if s.creatinine ↑

Ranitidine

Cephalosporin except (ceftriaxone )

Ciprofloxacin / levofloxacin

NSAID

Gentamycin ,

Omeprazole can given But cause interstitial nephritis, ↑s.craeatin, ↑pus cell in urine

Indication for dialysis

1. persistent Serum k > 6 mmol / l no respond toR x

2. Serum creatinin > 600 µmg

3. serum urea 180 mg ( 30 mmol/L)

4. HCO 3 level < 10 mg

5. ureamic pericarditis

6. pulmonary edema

7. ureamic encephalopathy

Sing symptom of CRF

A

 

Anaemia

Acidosis

B

Renal osteodystrophy osteomalacia , osteoporosis ,osteosclerosis , ostitisfibrosa

C cardiac cause HTN Uraemic pericarditis Pericardial temponad and LVF

D Dermopathy Yellow coloration Pruritis

Investigation

Hb %

S.creatinine

S .eclectrolyte including Ca @ PO 4

Urine RME

USG of whole abdomen with special attention to kidney size @ prostate

RBS

for CRF

In some case UTP ANA C-ANCA / P-ANCA HBsAg Anti HCV

E Endocrine Hyper-pTH Hyper prolactaemia amenorrhea , galactorrhea , loss libido , Infertility

F Retention of fluid edema

G GIT

Nausea , vomiting , anorexia Hiccough

H

Haemological Bleeding from any where Bruise , Echymosis Epistaxis , haematemesis

I

evidence of

infection

J

K

kidney polyuria and nocturia

M

Muscle

Myopathy

Muscle cramp

N

Neurological Sensory : neuropathy ,parasthesia , reduce sensation Motor : foot drop Autonomic

Treatmen of ARF

Presentation of ARF Anuria ,Oligouria and pre renal ( hypovolaemia ) Complication acidosis kussmal breathing ( hyperventilation ) Hyperkalaemia Uraemia semiconscious ness and coma , convulsion

Def

Sudden and reversible loss of renal function which develop over period of days or weeks with accompany by reduction in urine volume .

Findout the underlying cause Pre-renal any hypovlaemia Septicemia , Any infection , HUS (following bloody diarrhea ) Any drug AGN / RPGN

Look for ----- Bladder palpable /or not , Prostate and Stricture to exclude post renal cause

If the patient taking NSAID and ACE inhibitor stop immediately

R x

of ARF

If patient is in hypovlaemia ( BP ↓, pulse )

Give inj. Normal saline 2000 ml Look for urine out put if not increased and stop fluid otherwise will develop pulmonary edema. If the patient is Anuric but no Hypovolaemic

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

To increased urine out put Inj.lasix or fusid 2 or 4 amp IV stat and 2 amp IV 8 hrly If urine out put not increased do forced diuresis

Inj. Normal saline 80 ml

+

Inj. Lasix

10 amp

IV @

4 dµ / min

If not increased go for dialysis

If evidence of infection Inj.ceftriaxone 1 mg I vial iv stat and BD

Give PPI Inj pantonix 40 mg I vial iv stat and daily

If acidosis present Inj. Sodi-bicarb 25 ml 2 vial IV stat and TDS until acidosis is corrected

If hyperkalaemia Manage the hyperkalaemia see (electrolyte chapter)

Maintain I/O chart

Catheterization if patient is anuric / unconscious Otherwise collect in put Auscultation Auscultate the base of the lung for pulmonary edema Auscultate the heart for pericarditis

Dr. shamol

40

Stop

NSAID

ACE inhibitor

Rainitidin

Gentamycin

Cephalosporin

Ciprofloxacin

INVESTIGATION OF ARF

S.creatinine

S.electrolyte including HCO 3

Urine RME

USG of whole abdomen with special attention to kidney size @ prostate

RBS

If suspect infection ( with permission of senior )

o

CBC

o

PBF

o

ICT for malaria

If pt. in diuretic phase of ARF Input = out put , daily = 5 /4 L fluid

IV=

Oral = fluid intake + ORS + Dub water

2 L , Hartman + normal saline

Antihypertensive drug

o A ----- ACE inhibitor--- Ramipril 5-10 mg daily or

o

Lisinopril 10-40 mg daily

o

Enalapril 20 mg daily

o

Benazapril

o

Captopril

Angiotensive receptor blocker .

o

losartan 50-100 mg daily,

o

valsartan 40-160 mg daily

B-------Beta blocker --- cardioselective

o

Metoprolol (100-200 mg daily),

o

atenolol (50-100 mg daily) and

----combined β- and α-adrenoceptor antagonists

o carvedilol (6.25-25 mg 12-hourly)

---- nonselective

propranolol 40 mg to 160 mg use in anxiety palpitation and portal HTN

C---Ca channel blocker --- dihydropyridines

o Amlodipine (5-10 mg daily)---vaso-selective

------rate-limiting calcium antagonists

o

Diltiazem (200-300 mg daily,) --- intermediate

o

Verapamil (240 mg daily) cardioselective --use in SVT

D--------Diuretic ---- thiazide

o Indepamide hypen-SR 1.5 mg 1 + 0+ 0

Vasodilator --- α-blocker

o Prazosin (0.5-20 mg daily in divided doses) tab .α-press 1 mg

Centrally acting drugs

o

Methyldopa (initial dose 250 mg 8-hourly)

o

Clonidine (0.05-0.1 mg 8-hourly)

DEFINITION OF HYPERTENSION

Category

Systolic blood pressure (mmHg)

Diastolic blood pressure (mmHg)

Hypertension

Grade 1 (mild)

140-159

90-99

Grade 2 (moderate)

160-179

100-109

Grade 3 (severe)

≥180

≥110

Isolated systolic hypertension

 

Grade 1

140-159

< 90

Grade 2

≥160

< 90

BASIC PRINCIPAL

o

FIRST EXCLUDE CONTRAINDICATION

o

THEN LOOK WHICH ONE IS PREFER FOR COXSIT PROBLEM

o

NEVER STOP BETA BLOCKER SUDDENLY TAPPER IT GRADUALLY

o

IF PATIENT BP IS CONTROLL WITH CURRENT DRUG S NO CHANGE IS NEEDED IF OHTHER INDICATION

ACE INHIBITOR / ANGIOTENSIVE RECEPTOR BLOCKER

Contraindication

o

Hyperkalaemia

o

Oligouria or ARF

o

In hypovolaemic patient

o

Pregnancy and Renal artery stenosis

o

CLD

o

COPD (Angiotensive receptor blocker )

Indication

 

o

DM

 

Losartan 50-100 mg daily, Angilock

o

CKD

o

CVD

   

o

HEART FAILURE

Ramipril 5-10 mg daily Repril / remicard

o

LV dysfunction / hypertrophy / DCM

o

POST MI

 

SIDE EFFECT DRY COUGH Postural hypotension To avoid it pl. give first dose in night . Electrolytes and creatinine should be checked before and 1-2 weeks after commencing therapy. If s.creatinine is increased 25 30 % after 1 / 2 weeks then stop drug. Also stop. If pt develop oligouria , hyperkalaemia , or deteriorated renal function

BETA BLOCKER

Contraindication Bronchial asthma / COPD Heart block / if pulse less than 60 DM Psoriasis PVD

Hear failure ( can use in Carvedilol compensated heart failure )

Indication Myocardial infarction, Metoprolol (100-200 mg daily) / tab.atenolol cardipro 50 mg 1 +0 + 0

Angina -------Metoprolol (100-200 mg daily) / atenolol tab.cardipro 50 mg

Heart failure stable----only carvedilol (6.25-25 mg 12-hrly) tab. Carvista 6.25 mg ½ + 0 + ½ Atrial fibrillation ----- Metoprolol (100-200 mg daily), tab. Betaloc 50mg 1 + 0 + 1

1 +0 + 0

HTN of young patient with out contraindication Before giving beta blocker see following HO DM , COPD, asthma , heart failure Auscultate lung for spasm and pulse for bradycardia

Why beta blocker not use In DM It will mask the sign +symptoms hypoglycaemia ( tremor / tachycardia / sweating ) Can given with cautiously if DM with angina + stable heart failure carvedilol

CA CHANNEL BLOCKER

Contraindication

Complication

Heart block,

Heart failure

o

Amlodipin

Flushing, head ache

Palpitations and

Fluid retention

o

verapamil is

constipation

o

verapamil @ Diltiazem

may cause bradycardia.

indication

Amlodipin --

Any patient /Elderly patient with out heart failure

isolated systolic HTN

CRF

COPD /Bronchial asthma

The rate-limiting calcium antagonists

Diltiazem 200-300 mg daily,

Verapamil 240 mg daily

o

can be useful when hypertension coexists with angina

o

verapamil use in SVT

DIURETICS

Indication

isolated systolic HTN

in elderly patient

in heart failure

in renal failure Contraindication

DM ,

gout ,

hypokalaemia

indepamide -- tab. Hypen SR 1.5 mg 1+ 0 +0

VASODILATOR ---

α-blocker

Tab. Alpha press 1 mg 1+ 1+ 1

Hypertension in special situation

In DM CHOICE ARE ACORDINGINLY

1.

ACE I / ANG.BLOCKER

Losartan 50-100 mg daily, Angilock

2.

Ca CHANNEL BLOCKER

3.

Alpha BLOCKER

IN HEART FAILURE

1.

ACE I / ANG.BLOCKER Ramipril 5-10 mg daily Repril / ramicard

2.

+/- DIURETIC

3.

BETA BLOCKER

a. only carvedilol (6.25-25 mg 12-hrly) tab. Carvista 6.25 mg ½ + 0 + ½

IHD

1. BETA BLOCKER Metoprolol (100-200 mg daily), tab. Betaloc 50mg 1 + 0 + 1

2. ACE I / ANG.BLOCKER Ramipril 5-10 mg daily Repril / remicard

3. Ca CHANNEL BLOCKER (ditiazem)

CRF

1.

ACE I / ANG.BLOCKER Losartan 50-100 mg daily, Angilock

2.

Ca CHANNEL BLOCKER Amlodipine 5-10 mg daily

3.

Alpha BLOCKER Tab. Alpha press 1 mg 1+ 1+ 1

4.

WITH DIURETIC

5.

AT LAST BETA BLOCKER

STROKE / CVD

1. ACE I / ANG.BLOCKER

2. Ca CHANNEL BLOCKER Amlodipine 5-10 mg daily

Ramipril 5-10 mg daily Repril / remicard

ISOLATED SYSTOLIC HTN

1. Ca CHANNEL BLOCKER Amlodipine 5-10 mg daily

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

PVD

1. Ca CHANNEL BLOCKER Amlodipine 5-10 mg daily

COPD

 

1. Ca CHANNEL BLOCKER Amlodipine 5-10 mg daily

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

GOUT

1. ACE I / ANG.BLOCKER

2. Ca CHANNEL BLOCKER Amlodipine 5-10 mg daily

Ramipril 5-10 mg daily Repril / remicard

Contraindication

o

BETA BLOCKER

o

DIURETIC

Investigation a patient with HTN To see complication  Chest X-ray: to detect  Cardiomegaly,

Investigation a patient with HTN

To see complication

Chest X-ray: to detect

Cardiomegaly, LV type

Coarctation of the aorta

Heart failure pulmonary edema

ECG finding

LVH with strain

IHD

S.creatinine

RBS

URINE RME --- protein uria

Lipid profile

USG to see KUB

Dr. shamol

46

Target organ

Retina

Blood vessel

Heart

Kidney

Brain

What should look in HTN patient

Eye fundoscopy

Eyelid