Practical StandardPrescriber Practical Standard Prescriber Seventh Edition LC Gupta MD FAMS DSc (Hon) Kusum Gupta PhD (Hon) Abhitabh Gupta MD DMRE New Delhi, India JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • Ahmedabad • Bengaluru • Chennai • Hyderabad Kochi • Kolkata • Lucknow • Mumbai • Nagpur • St Louis (USA) J M Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd Corporate Office 4838/24 Ansari Road, Daryaganj, New Delhi-110002, India, Phone: +91-11-43574357 Registered Office B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi - 110 002, India, Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021, +91-11-23245672, Rel: +91-11-32558559, Fax: +91-11-23276490 +91-11-23245683 e-mail:
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[email protected] Practical Standard Prescriber © 2009, LC Gupta, Kusum Gupta, Abhitabh Gupta All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher. This book has been published in good faith that the material provided by contributors is original. Every effort is made to ensure accuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only. 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 Practical Standard Prescriber 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 (Crohn’s Disease) ................ 48 42. Secondary Biliary Cirrhosis ................................ 49 43. Sprue Syndrome (Tropical Sprue) .................... 50 44. Typhoid Fever ...................................................... 51 45. Upper Gastrointestinal Haemorrhage ............. 52 46. Vincent’s Stomatitis ............................................. 53 47. Viral Hepatitis (Infectious Hepatitis) ................ 54 48. Wilson’s 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 Practical Standard Prescriber 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 Meniere’s 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. Practical Standard Prescriber 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 Addison’s Disease .............................................. 255 AIDS ..................................................................... 256 Chronic Lymphatic Leukemia ......................... 257 Chronic Myeloid Leukemia ............................. 258 Congestive Cardiac Failure .............................. 259 xxii Practical Standard Prescriber 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 Hodgkin’s 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 Hodgkin’s 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 Practical Standard Prescriber 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. Bell’s Palsy ........................................................... 432 Brachial Neuralgia .............................................. 433 Broadman’s 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 Parkinson’s Disease ............................................ 445 Polyneuropathy .................................................. 446 Raised Intracranial Tension ............................... 447 Sciatica .................................................................. 448 Subarachnoid Haemorrhage ............................ 449 Stroke ................................................................... 449 Tension Headache .............................................. 451 xxvi Practical Standard Prescriber 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 Hodgkin’s 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 ½ 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 Essentials of Diagnosis • Constant, severe pain and tenderness in right hypochondrium or epigastrium. • Nausea, vomiting, fever, chills. • Jaundice. • Leucocytosis. • Positive Murphy’s 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 3 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 Essentials of Diagnosis • Anorexia, epigastric fullness, nausea. 4 Practical Standard Prescriber • 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 Essentials of Diagnosis • Acute pain around umbilicus or right iliac fossa in a child. Gastrointestinal Diseases 5 • 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 Essentials of Diagnosis • 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. 6 Practical Standard Prescriber 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 Essentials of Diagnosis • 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) Gastrointestinal Diseases 7 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 Essentials of Diagnosis • 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. 8 Practical Standard Prescriber 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 infection—Injection 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 Ryle’s tube. If respiratory distress then oxygen. ALCOHOLIC HEPATITIS Essentials of Diagnosis • Anorexia, nausea, abdominal discomfort in a patient after a recent period of heavy drinking. • Tender hepatomegaly and often jaundice. Gastrointestinal Diseases 9 • 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. 10 Practical Standard Prescriber AMOEBIASIS Intestinal Amoebiasis Essentials of Diagnosis • 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 Gastrointestinal Diseases 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 Essentials of Diagnosis 1. Acute pain during and after defecation. 2. Bright red blood with stool. 3. Tendency for constipation due to fear of pain. 12 Practical Standard Prescriber 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 Essentials of Diagnosis • 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. Gastrointestinal Diseases 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 Essentials of Diagnosis • Pain and tenderness in right iliac fossa with signs of peritoneal irritation (muscle guard and +ve Rovsing’s 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. 14 Practical Standard Prescriber • 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. Gastrointestinal Diseases 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 Essentials of Diagnosis • 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 16 Practical Standard Prescriber Nalidixic acid 1 gm 6 hourly. or Tetracycline 500 mg 6 hourly. Antispasmodics if needed. BOTULISM Essentials of Diagnosis • 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. Gastrointestinal Diseases 17 CANCER COLON Essentials of Diagnosis • 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 Essentials of Diagnosis • Progressive dysphagia even to liquids. • Anaemia, weight loss. 18 Practical Standard Prescriber • Chest pain—Unrelated 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) Essentials of Diagnosis • 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. Gastrointestinal Diseases 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 Essentials of Diagnosis 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. 20 Practical Standard Prescriber 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 Essentials of Diagnosis • 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 Virchow’s (left supraclavicular) nodes, Krukenberg’s tumour in female, enlarged hard nodular liver, ascites, pelvic mass and pathological fractures denote metastasis. Gastrointestinal Diseases 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 Essentials of Diagnosis • 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. 22 Practical Standard Prescriber Treatment Cholecystectomy and choledochostomy. Basketting and ECSWL. CHOLERA Essentials of Diagnosis • 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 Gastrointestinal Diseases 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 Essentials of Diagnosis • 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. 24 Practical Standard Prescriber CHRONIC GASTRITIS Essentials of Diagnosis • 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. Gastrointestinal Diseases 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. • Drugs—Anaesthesia, 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. 26 Practical Standard Prescriber 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 constipation—Tablet Cisapride 10 mg twice a day. DIVERTICULAR DISEASE OF COLON (Diverticulosis) Essentials of Diagnosis • 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. Gastrointestinal Diseases 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) Essentials of Diagnosis • 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. 28 Practical Standard Prescriber DUODENAL ULCER Essentials of Diagnosis • 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. Antacids—Digene tablet or Get 2 tab or 2 teaspoon 2-3 hrs after meals. Gastrointestinal Diseases 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. 30 Practical Standard Prescriber 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 Essentials of Diagnosis • 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 Gastrointestinal Diseases 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 Essentials of Diagnosis • 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. 32 Practical Standard Prescriber 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 Essentials of Diagnosis • Common in children below 10 years. • Severe ulceration of oral mucous membrane associated with systemic signs, i.e. fever, lymphadenopathy (cervical) and malaise. Gastrointestinal Diseases 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. 34 Practical Standard Prescriber 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 Essentials of Diagnosis • 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. Gastrointestinal Diseases 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 Essentials of Diagnosis • Abdominal pain. 36 Practical Standard Prescriber • • • • 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. Gastrointestinal Diseases 37 NAUSEA AND VOMITING Simple causes of vomiting are: • Alimentary disorders, irritation, inflammation or mechanical disturbances at any level of GI tract. • Central nervous system—Increased intracranial pressure, stroke, migraine, infection, toxins and radiation sickness. • Endocrine disorders—Diabetic acidosis, adrenocortical crisis, pregnancy, starvation, lactic acidosis. • Drugs—Morphine, Meperidine, Codeine, anticancer drugs. • Psychological disorders—Reaction 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. 38 Practical Standard Prescriber 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 Ringer’s 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. Gastrointestinal Diseases 39 NODULAR CIRRHOSIS Essentials of Diagnosis • 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. 40 Practical Standard Prescriber 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 persists—Human 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 Gastrointestinal Diseases 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 Essentials of Diagnosis • Frequent passage of blood mixed stool (bloody diarrhoea). 42 Practical Standard Prescriber • 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. Gastrointestinal Diseases 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 sulphadrugs—Ampicillin, 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 44 Practical Standard Prescriber 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. Important—Broad spectrum antibiotics should never be given orally as they may cause or wosen diarrhoea. PARALYTIC ILEUS (Functional Obstruction) Essentials of Diagnosis • 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. Gastrointestinal Diseases 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 Essentials of Diagnosis • 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. 46 Practical Standard Prescriber • 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 Essentials of Diagnosis • • • • Insidious onset. Pruritus followed by jaundice. Hepatosplenomegaly. Xanthomatous lesions around eyelids. Gastrointestinal Diseases 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 Essentials of Diagnosis • Painless rectal bleeding in a child. Treatment Simple polypectomy by avulsion. 48 Practical Standard Prescriber REGIONAL ENTERITIS (Crohn’s Disease) Essentials of Diagnosis • • • • 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 malaise—Iron vitamin B12 and supple- ments of potassium and magnesium. Gastrointestinal Diseases 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 Essentials of Diagnosis • 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. 50 Practical Standard Prescriber SPRUE SYNDROME (Tropical Sprue) Essentials of Diagnosis • 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. Gastrointestinal Diseases 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 Essentials of Diagnosis • 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. 52 Practical Standard Prescriber 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. Essentials of Diagnosis • 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. Gastrointestinal Diseases 53 Treatment Complete bed rest. Ice cold saline gastric lavage through Ryle’s 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. VINCENT’S STOMATITIS Essentials of Diagnosis • Ulcer surface covered with grey pseudomembrane surrounded by erythema. • Fever, gingival bleeding, lymphadenopathy. 54 Practical Standard Prescriber Treatment Metronidazole 200 mg tds × 5 days. Cap Becosule 1 daily. Alkaline mouth wash. VIRAL HEPATITIS (Infectious Hepatitis) Essentials of Diagnosis • 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. Gastrointestinal Diseases 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 A—Human normal immunoglobulin 0.002 ml/kg IM soon after exposure. Hepatitis B—Vaccine 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. WILSON’S DISEASE Essentials of Diagnosis • Symptoms of cirrhosis (jaundice, portal hypertension, splenomegaly) or chronic atypical hepatitis. 56 Practical Standard Prescriber • 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 Essentials of Diagnosis • • • • Severe uncontrollable peptic ulcer syndrome. Gastric hypersecretion. Elevated serum gastrin more than 300 pg/ml. Gastrinoma of pancreas, duodenum or at other ectopic site. Gastrointestinal Diseases 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 Essentials of Diagnosis • 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. Essentials of Diagnosis • 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 Practical Standard Prescriber 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 Ringer’s 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 Essentials of Diagnosis • 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 Respiratory Diseases 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 Practical Standard Prescriber ATYPICAL PNEUMONIA (Mycoplasma Pneumonia) Essentials of Diagnosis • 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. Respiratory Diseases 63 BRONCHIAL ADENOMA Essentials of Diagnosis • 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 Essentials of Diagnosis • Recurrent attacks of dyspnoea, cough with mucoid tenacious sputum and wheezing. • Expiratory rhonchi all over chest. • Symptoms promptly reversible with bronchodilators. • X-ray chest—normal in early cases. Emphysematous changes with pneumothorax in late cases. 64 Practical Standard Prescriber 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 inhalation—Take deep breath for 5-10 seconds. Two puffs to be inhaled at the interval of 5 minutes. Alternative is Terbutaline inhalation. If no relief—hospitalise Severe acute asthma—Diagnostic 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. Respiratory Diseases 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 Practical Standard Prescriber Chronic asthma Avoid known allergens. Stop smoking. Drugs. Preventives—Beclate 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. Respiratory Diseases 67 BRONCHIECTASIS Essentials of Diagnosis • 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 Practical Standard Prescriber 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. Respiratory Diseases 69 BRONCHIOLAR CARCINOMA Essentials of Diagnosis • • • • 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 Practical Standard Prescriber BRONCHO-PNEUMONIA Essentials of Diagnosis • 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 child’s 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. Collapse—Stimultants like Coramine or Micoren. Fever—Crocin/Mejoral may be used. Respiratory Diseases 71 CHRONIC BRONCHITIS Essentials of Diagnosis • 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 cough—Codein 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 Practical Standard Prescriber 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. Respiratory Diseases 73 EMPHYSEMA Essentials of Diagnosis • 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 Practical Standard Prescriber Treatment Mild physical activity. Avoid pulmonary irritants, i.e. smoking, exposure to dust, humid or cold air. Control of bronchial secretion—Mucous 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. Respiratory Diseases 75 EMPYEMA Essentials of Diagnosis • 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 Practical Standard Prescriber HAEMOPTYSIS Essentials of Diagnosis • 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 Respiratory Diseases 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. Note—Haemostatic 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 Practical Standard Prescriber 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 Essentials of Diagnosis • 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 Respiratory Diseases 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. Injection Gentamicin 80 mg 8 hourly. Pseudomonas Injection Gentamicin 80 mg 8 hourly. or injection Cabelin 8 gm IM in 24 hours. or Ticarcillin 15-20 gm/day IM for 10 days. 80 Practical Standard Prescriber 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 Essentials of Diagnosis • Septic fever and sweats, sudden expectoration of large amounts of purulent, foul smelling or rusty sputum, occasional haemoptysis. Respiratory Diseases 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 Practical Standard Prescriber 100 per cent oxygen inhalation to check growth of anaerobic organisms. Supportive therapy as rest, high protein diet, vitamin supplements, etc. MEDIASTINAL TUMOUR Essentials of Diagnosis • 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. • Horner’s 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. Respiratory Diseases 83 Treatment Depends upon the primary disease and histologic characteristic of the mass. PLEURAL EFFUSION Essentials of Diagnosis • 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 Practical Standard Prescriber 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 aspiration—Choose 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. Respiratory Diseases 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 patient’s 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 Essentials of Diagnosis • 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 Practical Standard Prescriber 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 Essentials of Diagnosis • 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. Respiratory Diseases 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 1½-2 times of the normal. 88 Practical Standard Prescriber 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. Respiratory Diseases 89 PULMONARY TUBERCULOSIS Essentials of Diagnosis • 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 Practical Standard Prescriber 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 ½ 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 months—continuation 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. Respiratory Diseases 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 Practical Standard Prescriber 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. Respiratory Diseases 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 Practical Standard Prescriber 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 Essentials of Diagnosis • It is a rare disease. • X-ray chest shows hilar adenopathy, nodular or fibrous infiltration of both lungs. Respiratory Diseases 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 Essentials of Diagnosis • Sudden onset of chest pain referred to the shoulder or arm on the involved side, associated with dyspnoea, cyanosis. 96 Practical Standard Prescriber • 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 Foley’s 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. Respiratory Diseases 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 Essentials of Diagnosis • 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 Practical Standard Prescriber 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 Essentials of Diagnosis • 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Essentials of Diagnosis • 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 I—Minimal arteriolar narrowing. Grade II—Marked narrowing, arteriovenous thickening. Grade III—Cotton-wool exudates and flame shaped haemorrhages. Grade IV—Any 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 Cushing’s 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 Practical Standard Prescriber • 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 Cushing’s 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 β-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 β blockers. ACE inhibitor plus Thiazide diuretic. β-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 Practical Standard Prescriber Hospitalise patient. If response inadequate—Injection Lasix 80 mg IV. If still response inadequate—Injection Diazoxide 150 mg IV rapidly. Repeat as needed at 5 mm interval till total of 600 mg. If response inadequate—Injection 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 Essentials of Diagnosis • 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 Practical Standard Prescriber • 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 2½ 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 Practical Standard Prescriber 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 tachycardia—institute 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 Practical Standard Prescriber 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 Essentials of Diagnosis Major criteria 1. 2. 3. 4. 5. Carditis. Sydenham’s 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 Practical Standard Prescriber 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 Essentials of Diagnosis • 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 Practical Standard Prescriber • 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 1½ hours). Streptococcus viridans—It 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 Practical Standard Prescriber 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 Essentials of Diagnosis • 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. 122 Practical Standard Prescriber 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 Essentials of Diagnosis • • • • • • • • • 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. Gram’s 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 Essentials of Diagnosis • 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. 124 Practical Standard Prescriber 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. Essentials of Diagnosis • 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. Skin Diseases 125 CONTACT DERMATITIS Essentials of Diagnosis • 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. 126 Practical Standard Prescriber 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 Essentials of Diagnosis • 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 Essentials of Diagnosis • 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 Essentials of Diagnosis • It is a non-contagious inflammatory disease. 128 Practical Standard Prescriber • 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 Reassure the patient. 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 Essentials of Diagnosis • • • • • • • • • 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 don’t respond to it. Oral acyclovir prophylaxis may be effective. Antistreptophylococcal antibiotics are used in secondary infection. Tropical therapy is not effective. 130 Practical Standard Prescriber ERYTHEMA NODOSUM Essentials of Diagnosis • 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 Essentials of Diagnosis • 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 Essentials of Diagnosis • 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. 132 Practical Standard Prescriber 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 Essentials of Diagnosis 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 Essentials of Diagnosis • 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. 134 Practical Standard Prescriber 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 Essentials of Diagnosis • 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 Gram’s 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. 136 Practical Standard Prescriber 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 Essentials of Diagnosis • 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 Essentials of Diagnosis • 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. 138 Practical Standard Prescriber MILIARIA Essentials of Diagnosis • 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 Essentials of Diagnosis • 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 Essentials of Diagnosis • • • • • • • • 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. 140 Practical Standard Prescriber 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 Essentials of Diagnosis 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. Whitfield’s ointment or Pragmatar cream at night. Diprovate or Cortilate cream or Elocon ointment locally once a day for a month. 142 Practical Standard Prescriber RINGWORM Essentials of Diagnosis • 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. Whitfield’s 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 Essentials of Diagnosis • 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, patient’s 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 (12½% 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. 144 Practical Standard Prescriber 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 Essentials of Diagnosis • 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 Essentials of Diagnosis • 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. 146 Practical Standard Prescriber 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 Essentials of Diagnosis • 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 Essentials of Diagnosis • 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. 148 Practical Standard Prescriber 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 Essentials of Diagnosis • 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 Essentials of Diagnosis • • • • 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. 150 Practical Standard Prescriber • 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 Essentials of Diagnosis • Excessive perspiration. • Skeletal muscle tension—Tension headache, backache. • Sighing respiration. • Hyperventilation syndrome—Dyspnoea, dizziness, paresthesia. • Functional gastrointestinal disorders—Abdominal pain, diarrhoea, constipation. • Cardiovascular irritability—Transient systolic hypertension, tachycardia, fainting. • Genitourinary dysfunction—Urinary 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 Practical Standard Prescriber 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 Essentials of Diagnosis • • Loss of pleasurable interest. Spontaneity is gone. Psychiatric Diseases 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 Practical Standard Prescriber HYSTERIA Essentials of Diagnosis • 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 therapy—Some 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. Psychiatric Diseases 155 PHOBIC REACTION Essentials of Diagnosis • 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 Essentials of Diagnosis • Persistent disorder of mind resulting in abnormally aggressive and seriously irresponsible conduct. 156 Practical Standard Prescriber • 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 Essentials of Diagnosis 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. Psychiatric Diseases 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 Practical Standard Prescriber 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 Essentials of Diagnosis • Thinking appears bizarre, illogical and chaotic. • Preoccupation with ideas derived from day dreams and fantasies, hallucinations and delusions. Psychiatric Diseases 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 Practical Standard Prescriber 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 ½-1 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 Practical Standard Prescriber 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 Essentials of Diagnosis • Cervix may appear normal, eroded or chronically infected. Gynaecological Disorders 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-Wertheim’s hysterectomy. Postoperative radiotherapy. In stage III and IVpalliative treatment. CARCINOMA OF BODY OF UTERUS Essentials of Diagnosis • 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 Practical Standard Prescriber 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 Essentials of Diagnosis • 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 Essentials of Diagnosis • • • • It is a histological diagnosis. Mucopurulent discharge. Low backache partly relieved by rest. Aching in low abdomen and pelvis. Gynaecological Disorders 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 Practical Standard Prescriber DYSFUNCTIONAL UTERINE BLEEDING Essentials of Diagnosis • 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. Gynaecological Disorders 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 Essentials of Diagnosis • 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 Practical Standard Prescriber 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 Essentials of Diagnosis • 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. Gynaecological Disorders 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 Essentials of Diagnosis • 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 Practical Standard Prescriber INCOMPLETE ABORTION Essentials of Diagnosis • 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 Essentials of Diagnosis • • • • 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. Gynaecological Disorders 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 Essentials of Diagnosis • 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 Practical Standard Prescriber Treatment Reassure the patient. 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 Essentials of Diagnosis • 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. Gynaecological Disorders 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 μg of βestradiol daily. MONILIAL VAGINITIS Essentials of Diagnosis • Vaginal thrush is caused by yeast like organism, Candida albicans. 174 Practical Standard Prescriber • 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 Essentials of Diagnosis • 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. Gynaecological Disorders 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 Essentials of Diagnosis • 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 Practical Standard Prescriber THREATENED ABORTION Essentials of Diagnosis • 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 βhCG 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 Gynaecological Disorders 5th day 9th day 14th day 177 2000 units 1000 units 1000 units TRICHOMONAS VAGINITIS Essentials of Diagnosis • 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 Practical Standard Prescriber VAGINITIS INFANTILE VAGINITIS Essentials of Diagnosis • 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 Essentials of Diagnosis • 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 Practical Standard Prescriber ACUTE OTITIS MEDIA Essentials of Diagnosis • 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. Ear and Nose Diseases 181 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 toilet—Removal of mucopus from canal by Hydrogen peroxide instillation. Myringotomy—To be performed when there is persistent collection of mucopus in middle ear causing continued deafness and recurrence. CHOLESTEATOMA Essentials of Diagnosis • • • • 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 Practical Standard Prescriber Treatment Removal of cholesteatoma under general anaes- thesia with the help of aural microscope and daily aural toilet thereafter. Mastoidectomy—Simple, 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 Essentials of Diagnosis • • • • 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. Ear and Nose Diseases 183 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 drops—Nebasulf 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 Practical Standard Prescriber Sensory Neural Deafness The common causes are: • Presbyacusis or degeneration of hair cells in old age causing deafness. • Ménière’s 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 Essentials of Diagnosis • • • • 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. Ear and Nose Diseases 185 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 Practical Standard Prescriber 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. Ear and Nose Diseases 187 EPISTAXIS Examine the patient and ascertain the site of bleeding. If bleeding is from Little’s 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 Tilley’s 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 Practical Standard Prescriber intranasal polyps, malignancy, leukaemia, haemangioma of nose, telangiectasis and injury to nasal structures. LOCALIZED OTITIS EXTERNA Essentials of Diagnosis • 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 Ear and Nose Diseases 189 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: • Ménière’s disease. • Injury to ear. • Positional vertigo. • Labyrinthine. • Diseases of acoustic nerve, cerebellum and cardiovascular system. VERTIGO DUE TO MÉNIÈRE’S DISEASE Essentials of Diagnosis • Sudden onset of vertigo, nausea and vomiting in middle aged. 190 Practical Standard Prescriber • 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 Essentials of Diagnosis • 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 Practical Standard Prescriber 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 Essentials of Diagnosis • 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 Practical Standard Prescriber • Third nerve palsy • Iris damage due to acute glaucoma • Pharmacological mydriasis ii. Small poorly reacting pupil • Horner’s 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 Essentials of Diagnosis • Eye is uncomfortable but not painful. • Photophobia is present. • Discharge may be purulent, mucopurulent or watery. 196 Practical Standard Prescriber • 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 cases—Cap Ampicillin 500 mg qid. CORNEAL ULCER Essentials of Diagnosis • • • • 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 Essentials of Diagnosis • Sudden rapid diminution or loss of vision in the affected eye. • Flashes of light, transient attacks of decreased vision. 198 Practical Standard Prescriber • 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 Essentials of Diagnosis • • • • • 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 Ciliary’s 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 Practical Standard Prescriber According to the causative factor. Treatment Diseases of Children 201 DISEASES OF CHILDREN ACUTE RHEUMATIC FEVER Essentials of Diagnosis • 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 101-103°F. Shows daily variation of 1-3°F. 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 Practical Standard Prescriber 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. Diseases of Children 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 Essentials of Diagnosis • • • • • • • 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 Practical Standard Prescriber AORTIC STENOSIS Essentials of Diagnosis • 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 Essentials of Diagnosis • Dyspnoea on exertion. • Angina pectoris on heavy exertion. • Palpitation due to forceful heart beat. Diseases of Children 205 • Syncopal attacks may be due to cerebral anoxia. • Diastolic murmur—High 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 nitrates—If chest pain and AR. 3. Arrhythmia—Treated vigorously. 4. Syphilitic aortitis—Penicillin 5 lacs 6 hourly × 10 days. 5. Valve replacement. BRONCHOPNEUMONIA Essentials of Diagnosis • Onset is acute with fever which rises rapidly up to 103° F. 206 Practical Standard Prescriber • 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. Diseases of Children 207 Essentials of Diagnosis • 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 Practical Standard Prescriber CONGENITAL SYPHILIS Essentials of Diagnosis • 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. • Hutchinson’s 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. Essentials of Diagnosis • Incubation is 2-7 days. Diseases of Children 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 Essentials of Diagnosis • 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 Practical Standard Prescriber • 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 unilateral—20,000 IU. If Tonsillar involvement is bilateral—40,000 IU. If Tonsillar and pharyngeal involvement—60,000 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. Diseases of Children 211 INDIAN CHILDHOOD CIRRHOSIS Essentials of Diagnosis 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 Practical Standard Prescriber Penicillamine may be tried. Diuretics for oedema and ascites—Lasix 2 mg/kg/ day. INFANTILE DIARRHOEA Essentials of Diagnosis Dietic diarrhoea • Excess of fat—Loose, 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 Diseases of Children 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. Don’t 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 hypopotassemia—Add KCl 1 ml or 2 mEq in 100 ml glucose. If infant is toxic—Colistine sulphate 1-2 tsf qid. or Furoxone ½ 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 ½-1 tsf tds. KWASHIORKOR Essentials of Diagnosis • Generalised oedema. Extremities often cold, hands and feet may be dusky. 214 Practical Standard Prescriber • 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 Essentials of Diagnosis • Child is irritable and cries excessively. Diseases of Children 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 Practical Standard Prescriber Essentials of Diagnosis • Prodromal symptoms are like that of flu. • Non-productive cough, watering redness of eyes and fever. • Koplick’s spots appear as tiny table salt crystals on cheek’s 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. Diseases of Children 217 MITRAL REGURGITATION Essentials of Diagnosis • 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 severe—Mitral valve replacement/valvoplasty. 2. Infective endocarditis should be brought under control before surgery. MITRAL STENOSIS Essentials of Diagnosis • • • • May be congenital or rheumatic in origin. Undue dyspnoea on exertion. Blood stained sputum. Palpitation with regular or irregular rhythm. 218 Practical Standard Prescriber • 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, Kerley’s 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 Essentials of Diagnosis • It is a virus disease of children and portal of entry is upper respiratory tract. Incubation period is 16-21 days. Diseases of Children • • • • • • • • 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° – 104°F, 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. Essentials of Diagnosis • Prodromal stage— Coryza, sore throat or cough. Fever, drowsiness and sweating. Fever touches normal in 36-48 hours and rises again. 220 Practical Standard Prescriber • Pre paralytic stage — Fever up to 39°C 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. Diseases of Children 221 RICKETS Essentials of Diagnosis • 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 Practical Standard Prescriber SCURVY Essentials of Diagnosis • 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 Diseases of Children 223 greatest during catarrhal stage. Symptoms are of upper respiratory catarrh. Essentials of Diagnosis • 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 Essentials of Diagnosis • 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 Essentials of Diagnosis • • • • • • 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 Practical Standard Prescriber 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 available—Injection 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 failure—cyanosis 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 exhausted—Put on mechanical ventilation to restore pH between 7.38-7.42. 228 Practical Standard Prescriber ACUTE RETENTION OF URINE Essentials of Diagnosis • 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 bladder—Tab Urecholine 25-30 mg tds or use self intermittent catheterisation. Medical Emergencies 229 If stricture urethra—Endoscopic urethrotomy or open urethroplasty or dilatation. If enlarged prostate—Prostectomy. If obstructive calculus—Endoscopic extraction of calculus. AGRANULOCYTOSIS Chloramphenicol, Phenylbutazones, Chlorpromazine, Barbiturates may cause it. Essentials of Diagnosis • • • • • 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 Practical Standard Prescriber ANAPHYLACTIC SHOCK Essentials of Diagnosis • 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 Essentials of Diagnosis • 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 Essentials of Diagnosis • Drowsiness to deep coma. 232 Practical Standard Prescriber • 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 Essentials of Diagnosis • • • • 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 Practical Standard Prescriber In severe analphylactic reaction, Adrenaline injection 0.5 ml subcutaneous and Corticosteroid— Prednisolone 20 mg single dose. BURNS Essentials of Diagnosis • • • • 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 Ringer’s lactate. Antibiotics to prevent secondary infections. Skin grafting for raw areas. CARDIAC ARREST Essentials of Diagnosis • Important causes are—Myocardial 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 Practical Standard Prescriber Remove obstructing substances, i.e. dentures, food, mucus, blood from pharynx with fingers. Chest thump—Strong blow to midsternal area may terminate asystole and ventricular tachycardia. Mouth-to-mouth respiration. Cardiac massage—Place 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 asystole—Rule out fine ventricular fibrillation by ECG. or Injection Isoprenaline 1-2 mg IV. Injection Decadron 8 mg IV. If ventricular fibrillation—External DC defibrillation given. If refractory ventricular fibrillation—Injection 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 Essentials of Diagnosis • 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 Essentials of Diagnosis • Isotonic loss of salt and water seen in diarrhoea, vomiting, gastric and intestinal suction. 238 Practical Standard Prescriber • 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 Ringer’s lactate solution in comatose patients, palsma/blood loss or in burns, etc. Meet potassium loss in vomiting, diarrhoea. DHATURA POISONING Essentials of Diagnosis • 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 106°F. • 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 Essentials of Diagnosis • History. • Long submersion in water may lead to cerebral anoxia. • Loss of consciousness. • Cardiac arrest and it may cause death. 240 Practical Standard Prescriber 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. Ringer’s lactate solution IV. ECTOPIC PREGNANCY Essentials of Diagnosis • • • • • • 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 findings—Fullness 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 Essentials of Diagnosis • 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 Practical Standard Prescriber Essentials of Diagnosis • 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 stat—Dramatic 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 Essentials of Diagnosis • History of exposure to cold, drowning or swimming in cold water, myxoedema, morphine poisoning, etc. • Body temperature below 35°C. • 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 > 32°C. If temp < 32°C— 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 Practical Standard Prescriber Essentials of Diagnosis • • • • • 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. Symptomatic treatment. Medicolegal responsibilities. Medical Emergencies 245 PROFUSE VAGINAL HAEMORRHAGE Essentials of Diagnosis • 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 girls—Ethinyl 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 Practical Standard Prescriber RENAL COLIC Essentials of Diagnosis • 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 Essentials of Diagnosis • There may be fang marks. • Local features—Severe local pain, numbness, tingling, local oedema, redness, warmth, bleeding from site. • General—Nausea, vomiting, headache, fever, urticaria. • CNS—Muscular paralysis, ptosis, squint, facial weakness, respiratory paralysis. • CVS—Cardiotoxin 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 Practical Standard Prescriber 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. Antihistaminics—Inj Avil 1 amp stat may be given. Analgesics—Inj 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 diuresis—Mannitol 20 per cent, 350 ml slow IV. In respiratory failure, Oxygen inhalation or IPPV. If bleeding—Transfuse fresh blood or platelet. — Fibrinogen 300-600 gm IV. Medical Emergencies 249 SPONTANEOUS PNEUMOTHORAX Essentials of Diagnosis • 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 Practical Standard Prescriber 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 Essentials of Diagnosis Allergic reactions • • • • Urticaria. Sore throat, joints pain, fever. Angioneurotic oedema. Lymphadenopathy. Management Antihistaminics—Inj Avil 2 cc stat IV. Corticosteroids—Inj 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 Symptomatic treatment. Inj Penicillin for throat infection. 252 Practical Standard Prescriber MISCELLANEOUS ACUTE LEUKAEMIA Essentials of Diagnosis • • • • • • • 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 38°C. • 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 Practical Standard Prescriber • In leukaemic leukaemia less than 1000 white cells. • Bone marrow—Hypercellular 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. α-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. ADDISON’S DISEASE Essentials of Diagnosis • • • • • Weakness, weight loss. Pigmentation of skin and mucous membrane. Hypotension. Hyponatraemia and hyperkalaemia. Diminished urinary Cortisol, 17 Hydroxy corticoids and 17 Ketosteroids. 256 Practical Standard Prescriber 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 don’t 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 Essentials of Diagnosis 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 Essentials of Diagnosis • 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. Prednisolone—If severe marrow failure or autoimmune phenomenon supportive—Regular blood transfusion and infections. 258 Practical Standard Prescriber CHRONIC MYELOID LEUKAEMIA Essentials of Diagnosis • 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 Essentials of Diagnosis • 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 supplement—Syrup 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 Practical Standard Prescriber Tab Deriphylline retard 1 bd. For severe failure add vasodilators Salbutamol 4-12 mg tds. or Captopril—Initial dose 6.25 mg. or Enalapril—Initial dose 1.5-2.5 mg. or Lisinopril—Initial dose 2.5 mg. DIABETES INSIPIDUS Essentials of Diagnosis • • • • • 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 Essentials of Diagnosis • • • • • • • 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 Practical Standard Prescriber 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 Essentials of Diagnosis • • • • 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 Practical Standard Prescriber 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 Essentials of Diagnosis • • • • • • • • 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 Essentials of Diagnosis • Skin dry and hot, often hyperpyrexia. • Confusion, disorientation and coma. • History of exposure to hot environment. 266 Practical Standard Prescriber 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. HODGKIN’S DISEASE Essentials of Diagnosis • • • • 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. Essentials of Diagnosis • 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 Practical Standard Prescriber • 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 Essentials of Diagnosis • 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 Essentials of Diagnosis • 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 Practical Standard Prescriber LEFT VENTRICULAR FAILURE Essentials of Diagnosis • 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 Essentials of Diagnosis • 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 41°C. • 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 Practical Standard Prescriber 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 Essentials of Diagnosis • • • • • 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 Essentials of Diagnosis • 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 Practical Standard Prescriber 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 Essentials of Diagnosis • 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-HODGKIN’S LYMPHOMA Essentials of Diagnosis • Painless, discrete, firm to hard lymph node enlargement. • Unlike Hodgkin’s lymphoma skin, bones, eyes, breast, testes are involved. • Absence of Sternberg-Reed giant cells in lymph node biopsy. Treatment Radiotherapy as in Hodgkin’s 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 Hodgkin’s disease. Combination of chemotherapy and radiotherapy in selected cases. 276 Practical Standard Prescriber OBESITY Obesity is when person weighs more than 20% of expected weight. Obesity is defined as an excess of adipose tissue. Essentials of Diagnosis • 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 Cushing’s 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 Don’t 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 Essentials of Diagnosis • Myosis, red eyes and red tears. • Sweating, salivation, diarrhoea, dyspnoea and blurred vision. • Muscle twitchings and convulsions. • History of exposure to pesticides. 278 Practical Standard Prescriber 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. Essentials of Diagnosis 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 Essentials of Diagnosis • • • • 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 Practical Standard Prescriber 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. Essentials of Diagnosis • • • • 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Young’s 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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. Meat—4/5 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Practical Standard Prescriber + 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Ringer’s 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 count–4000 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 Practical Standard Prescriber 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 infections–tuberculosis, 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 Practical Standard Prescriber Protozoal • Malaria, kala-azar, amoebiasis • Monocytic leukaemia • Hodgkin’s 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 • Loeffler’s syndrome. Blood Count 337 Blood Dyscrasias • • • • Eosinophilic leukaemia Chronic myeloid leukaemia Following irradiation Hodgkin’s disease. EOSINOPENIA • Administration of ACTH, adrenaline and ephedrine • Response to stress: Traumatic shock, surgical operations, burns, acute emotional stress, exposure to cold. • Endocrine disorders: Cushing’s disease and acromegaly. • Aplastic anaemia, SLE. BASOPHILIA • • • • • Chronic myeloid leukaemia Polycythemia vera Cirrhosis of liver Early stages of Hodgkin’s 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 Practical Standard Prescriber 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. Hodgkin’s, 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 Practical Standard Prescriber 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 Hodgkin’s 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 • Chronic myeloid leukaemia • Paroxysmal nocturnal haemoglobinuria. COOMB’S TEST It is positive in autoimmune haemolytic anaemia i. Idiopathic. 342 Practical Standard Prescriber ii. Secondary to • Lymphoma • Infectious mononucleosis • 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 Practical Standard Prescriber 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 patient’s 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 Gaucher’s disease and Banti’s spleen. • von Willebrand’s disease. Functional Platelet Defects Platelets are adequate in number but defective in function leading to increase in bleeding time. • Glanzmann’s thrombasthenia • Storage pool disease • Bernard-Soulier’s disease • Cyclooxygenase deficiency • Thromboxane synthetase deficiency. 346 Practical Standard Prescriber 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 • Obstructive jaundice • 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) Mild–5.25% of normal Moderate–1.5% 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 Willebrand’s 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 Practical Standard Prescriber 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. Lymphoblasts–10-20 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 Practical Standard Prescriber 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 • Infectious mononucleosis • Tuberculosis • Benign lymphocytosis. ii. Intoxications • Eclampsia • Burns • Mercury poisoning. Blood Count 351 iii. Malignant diseases with bone marrow metastasis • Multiple myeloma • Myelofibrosis • Hodgkin’s 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 • Iron deficiency anaemia. Haemoglobin-F Normal 0.1%. 352 Practical Standard Prescriber Increase Physiological Pathological • • • • • • Foetal life Thalassaemia Haemoglobinopathies Hereditary persistent haemoglobin Juvenile CML Fanconi’s 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 Practical Standard Prescriber 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 Practical Standard Prescriber Indirect 0.2 to 0.7 mg/100 ml. Rise of Indirect Serum Bilirubin • In haemolytic disease or reactions. • Gilbert’s disease. Rise of Total Serum Bilirubin • Acute and chronic hepatitis • Biliary tract obstruction–gallstones 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 Cushing’s 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 Addison’s disease • Excess of water in take or inappropriate ADH secretion. 358 Practical Standard Prescriber 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 Practical Standard Prescriber Low • Starvation with malnutrition • Agammaglobulinemia • Lymphatic leukaemia. SERUM FIBRINOGEN Normal 0.2 to 0.4 gm/100 ml. 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 Practical Standard Prescriber SERUM URIC ACID Normal 3.0 to 7.5 mg/100 ml. 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 Normal 0.2 to 0.6 mg/100 ml. 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). • Boeck’s sarcoid • Paget’s 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 Practical Standard Prescriber 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 • Addison’s 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 Practical Standard Prescriber • 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 µg/ml. Increased • Chronic infection • Malignancy • Collagen vascular disease. Blood Biochemistry 367 Reduced • Iron deficiency anaemia. RHEUMATOID FACTOR Positive Rheumatoid Factor • • • • • • • • Rheumatoid arthritis (80%) Connective tissue disease—Scleroderma Chronic infection–Syphilis, leprosy, tuberculosis After drugs–Procainamide, Isoniazid Other diseases–Primary 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 α-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 μg/dl 60-180 Somogyi units per per litre Contd... 368 Practical Standard Prescriber 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 μg/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 μg/dl 5-20 μg/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 Practical Standard Prescriber 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 μU/ml 3.5-8.0 mcg/100 ml 105 ± 35 mg/dl 305 ± 32 μg/dl 20-45% 7-25 μg/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 Practical Standard Prescriber 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 (Bodansky’s method) < 0.6 unit per decilitre (Fishman lerner; tartrate sensitive) 0.5-2.0 units (Gutman’s 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 37°C 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 Practical Standard Prescriber 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 μU/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 μg/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 Practical Standard Prescriber 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 μg/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 μ in 24 hrs 100-250 mmol/24 hrs (varies with intake) 0 0-25 μg 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 μg/24 hrs 0-6 μg/24 hrs 1-11 μg/24 hrs 4-25 μg/24 hrs 4-31 μg/24 hrs 0-14 μg/24 hrs 0-72 μg/24 hrs 5-100 μg/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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 • Tuberculous meningitis. Massive Coagulation • Polyneuritis • Spinal block. Blood Stained • Trauma due to needle • Spinal cord trauma • Intracerebral haemorrhage. 381 382 Practical Standard Prescriber 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 Practical Standard Prescriber Increased • Uraemia. Decreased (below 620 mg%) • Tuberculous meningitis. CALCIUM • Normal 5.7 to 6.8 mg%. Increased • Froin’s syndrome. Decreased • Tetany. ACID-BASE EQUILIBRIUM • Normal pH 7.4 to 7.6. Remains Unaltered • Hydrocephalus • Serous meningitis • Cerebral tumours. Acidosis • Acute meningitis • Uraemia • Tuberculous meningitis. 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 Practical Standard Prescriber 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... Lympho’s 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 Practical Standard Prescriber 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 Practical Standard Prescriber GLUCOSE TOLERANCE TEST 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 Cushing’s 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 • Addison’s 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 Practical Standard Prescriber 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 • Gaucher’s 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 Practical Standard Prescriber Micronormoblastic • Iron deficiency anaemia. 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 Bone Marrow Aspiration 395 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 Practical Standard Prescriber Bone Marrow Aspiration 397 Secondary Carcinoma • Carcinoma cells in groups. Gaucher’s 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 Practical Standard Prescriber RENAL FUNCTION TESTS CONCENTRATION TEST (SPECIFIC GRAVITY TEST) The patient is not allowed water after 5 PM Normal specific gravity–1.025. 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 normal–Mild impairment 20 to 40% of normal–Moderate 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 Practical Standard Prescriber 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 Bergh’s 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 reaction–Obstructive jaundice. Indirect/delayed direct reaction–Haemolytic jaundice. Direct reaction–Jaundice 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 GLUCOSE TOLERANCE TEST 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. Normal–Individuals 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 Practical Standard Prescriber 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 Normal 0.61 to 1.40 gm/100 ml. 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 Normal 0.9 to 1.2 gm/100 ml. 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 Practical Standard Prescriber Increased 50 to 200 units • Subclinical or aniecteric viral hepatitis • Laennec’s 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 • Obstructive jaundice • 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 Practical Standard Prescriber Esterified Cholesterol • 60 to 70% of total. Increased • • • • • Obstructive jaundice 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 Practical Standard Prescriber 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 Hodgkin’s disease Cirrhosis liver Pregnancy. Decreased • Wilson’s 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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. Fundus Examination 417 • 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 Practical Standard Prescriber 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. Fundus Examination 419 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 Practical Standard Prescriber • 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. Fundus Examination 421 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 Practical Standard Prescriber RENAL SYSTEM ACUTE GLOMERULONEPHRITIS Essentials of Diagnosis • Fullness of face. • Low urinary output. • Fever 101° to 103°F 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 hypertension—Tab Nepresol 1/2 to 1 tds or Tab Alphadopa 10-65 mg/kg 1 day and Tab Lasix 2 mg/kg. ACUTE NEPHRITIC SYNDROME Essentials of Diagnosis • • • • 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 Practical Standard Prescriber ACUTE PYELONEPHRITIS It is due to acute inflammation of parenchyma and pelvis of kidney. It may be unilateral or bilateral. Essentials of Diagnosis • Onset sudden with pain in one or both loins, radiating to iliac fossa or suprapubic area. • Dysuria, vomiting. • Body temperature 100° to 104°F 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 Essentials of Diagnosis 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 ATN—Injection Lasix 200-250 mg slow IV repeat upto 1-2 gm/day. 426 Practical Standard Prescriber 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 hyponatraemia—Restrict fluids or dialysis. Restrict protein intake—Give 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 Essentials of Diagnosis • 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 Essentials of Diagnosis • Irreversible damage to nephron leads to chronic renal failure. • Commonly implicated diseases are glomerulonephritis, diabetes mellitus, chronic pyelonephritis hypertension and polycystic disease. 428 Practical Standard Prescriber • 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 Essentials of Diagnosis • 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 Practical Standard Prescriber Essentials of Diagnosis • 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 Essentials of Diagnosis • 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 frost—Deposition 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 Practical Standard Prescriber NEUROLOGICAL DISEASES BELL’S PALSY Essentials of Diagnosis • 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 Essentials of Diagnosis • 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. BROADMAN’S AREAS OF BRAIN Occipital Lobe Area 17 Area 18, 19 Visual cortex Visual association areas 434 Practical Standard Prescriber 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 Essentials of Diagnosis • 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. Neurological Diseases 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 Essentials of Diagnosis • Compression of 8th cervical and first dorsal root by enlarged transverse rib or a small rib or fibrous band from 7th cervical vertebra. 436 Practical Standard Prescriber • 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 Horton’s headache Hair’s syndrome, histamine cephalgia and migrainous neuralgia. Essentials of Diagnosis • 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. Neurological Diseases 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 Essentials of Diagnosis Grand mal type • Tonic spasm of all muscles with sudden onset. • Aura may be present but generally patient looses consciousness without any warning. 438 Practical Standard Prescriber • 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 jerks—Some 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. Neurological Diseases 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, ½ od increase by ½ 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 ½ hour if attack recurs. Can also be given 0.5 mg/kg followed by injection Phenytoin 15-20 mg IV slowly over ½ hour and repeat every hour for 4 doses. Injection Paraldehyde 10 ml deep IM (5 ml in each buttock). 440 Practical Standard Prescriber 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 Essentials of Diagnosis • 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. Neurological Diseases 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 Practical Standard Prescriber • 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 Essentials of Diagnosis • • • • • • 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. Neurological Diseases 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. Essentials of Diagnosis • • • • • • • • • • 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. Kernig’s 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 Practical Standard Prescriber 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 Essentials of Diagnosis • 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. Neurological Diseases 445 MULTIPLE SCLEROSIS Essentials of Diagnosis • 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 don’t help much in preventing relapse. Immunosuppressive therapy with methotrexate/ cyclophosphamide may help. PARKINSON’S DISEASE Essentials of Diagnosis • Rigidity, akinesia. • Pill rolling action tremors. • Previous history of encephalitis, drug intake. 446 Practical Standard Prescriber 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. Essentials of Diagnosis • 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. Neurological Diseases 447 Treatment Rich, high protein diet. Hot packs and analgesics. Vitamin B1 and B12. Corticosteroids in relapsing cases. Demyelinating neuropathies. RAISED INTRACRANIAL TENSION Essentials of Diagnosis • 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 Practical Standard Prescriber Emergency ventricular/cisternal puncture or ventriculo-atrial/thecoperitoneal shunt surgery. Treatment of primary cause. SCIATICA Essentials of Diagnosis • 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. Neurological Diseases 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 Essentials of Diagnosis • 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 Essentials of Diagnosis • Sudden onset of neurological deficit. 450 Practical Standard Prescriber • 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 oedema—Inj Mannitol 350 ml (20%) IV in ½ hr on Glycerol 1 oz by Ryles tube tds or Inj Decadron 8 mg 6 hrly for 48 hrs and then taper. Neurological Diseases 451 Treatment of the primary cause like heart lesion, atherosclerosis. Revascularisation of brain by transcranial external to internal carotic anastomosis. TENSION HEADACHE Essentials of Diagnosis • • • • 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 don’t help Anxiolytics and antideppressants help. TRANSIENT ISCHAEMIC ATTACKS Essentials of Diagnosis • It may be caused by embolization. • Onset is abrupt without warning. 452 Practical Standard Prescriber • 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 Essentials of Diagnosis • Brief episodes of stabbing facial pain. Neurological Diseases 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 Practical Standard Prescriber HAEMATOLOGY ACQUIRED APLASTIC ANAEMIA It may be idiopathic, secondary to hepatitis B, and chloramphenicol. There is no family history. Essentials of Diagnosis • 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 Essentials of Diagnosis • • • • • • 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. Essentials of Diagnosis • Positive family history. Females are carriers. • Bleeding in joints causing deformities and contractures. • Normal bleeding time and prothrombin time. 456 • • • • Practical Standard Prescriber 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. HODGKIN’S DISEASE Essentials of Diagnosis • • • • 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 Practical Standard Prescriber Essentials of Diagnosis • 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 Essentials of Diagnosis • 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 Practical Standard Prescriber ORAL DISEASES ACUTE NECROTIZING ULCERATIVE GINGIVITIS It is an infective disease with progressive ulceration of inter dental papillae. Essentials of Diagnosis • 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 Essentials of Diagnosis • Pits, fissures and interproximal surfaces are the most susceptible areas of tooth decay. 462 Practical Standard Prescriber • 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. Essentials of Diagnosis • 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 Essentials of Diagnosis • 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 Practical Standard Prescriber 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. Essentials of Diagnosis • 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 Practical Standard Prescriber 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 Practical Standard Prescriber 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 Cow’s milk Almond 58 Egg 13.3 Cashewnut 46 Mutton 13.3 Groundnut 40 Fish 19.5 3.5 3.2 Appendix 479 IMPORTANT SOURCES OF 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 IMPORTANT SOURCES OF 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 Practical Standard Prescriber 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 Cal“A” 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 Cal“A” 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 — 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 Practical Standard Prescriber 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 — — — 7 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 5 0 357 Contd... Appendix Contd... Food Pro- Fat tein gm gm Cal- Iron Vit cium mg “C” mg 483 Vit Cal“A” 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 Practical Standard Prescriber 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 Cal“A” 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 Practical Standard Prescriber 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 Cal“A” 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 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 — 4 — — 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