Topic: Continuation of Wardwise Treatment Guidelines for Intern Doctors

Endocrine system
1. Hypoglycemia
Diagnostic tools
1.        H/O of diabetes Mellitus
2.        H/O of treatment with Insulin or Secretogogues (e.g. Secrin, Consucon, Limpet etc)
3.        H/O of missed or delayed meal
4.        Pt. complain headache, dizziness, profuse sweating, palpitation, confusion, drowsy, unconscious
5.        On exam.- Bilateral planter extensor
6.        Urgent Blood glucose- < 45 mg/dl or <2.5mmol/L
Management
     Mild to moderate Hypoglycaemia (pt. are conscious and able to take oral   food.)
    Most cases are treated by pt. himself or by a family member.
1.      Stop the drugs
2.      15 gm glucose drink by mouth e.g. equivalent food e.g. a glass of soft drink or fruit juice or meal (if it is due)
3.      If symptoms appear with in half an hour then repeat the treatment
4.      If recurrent hypoglycaemia follows hospitalization is to be considered
5.      Make necessary modification of treatment.

     Severe Hypoglycaemia
     Diagnostic tool
- H/O of treatment with Insulin or Secretogogues (e.g. Secrin, Consucon, Limpet etc)
- Only neuroglycopenic symptoms like drowsiness, Convulsion & coma.
    Management:
1.      For type 1 DM inj. Glucagon 1mg IM stat, if recovery is satisfactory then consider another shot.
2.      In type2 DM administer 10-25 ml of intravenous 50% dextrose (In our ward we give 25% dextrose)
3.      Identification & correction of the underlying cause of hypoglycaemia
4.      Make necessary modification of treatment.


2. Diabetic ketoacidosis
Diagnostic tools
1.       H/O of DM
2.       H/O of irregular treatment or missed dose of Insulin or drugs
3.       Stressful condition e.g. infection, trauma, pregnancy
4.       On exam. - Severe dehydration, pulse-tachycardia, BP- Hypotension, acidotic breathing, there may be acetone smell in breath, unconsciousness.
5.       Investigation- Blood sugar- > 14mmol/L, Keton body on urine present.

Other urgent investigation
                                         I.      S. Electrolytes
                                      II.      Blood & Urine keton bodies
                                   III.      S. creatinine
                                   IV.      CBC & Blood culture

Management:
1.       NPO TFO
2.       O2 inhalation 4-6 L/min
3.       Infusion Normal saline
        1 L over 30 min.
        1 L over 1 hour
        1 L over 2 hour
        1 L over next 2-4 hours
4. When blood glucose <15.00 mmol/L (270mg/dl) then switch to  5% DA 1 Litre 8 hourly
If pt. still dehydrated then contd. Normal saline and add 5% DA 1 litre 12 hourly
4.       Short acting insulin
a)       If infusion pump,is available then infuse @ 3-6 units / hour
b)       If pump not available 10-20 units IM stat. then 5-10 units hourly. Hourly fall of blood glucose is in the range of 3-4 mmol/L
c)      Usual subcutaneous regimen of insulin may be started when the pt. is stable clinically & biochemically & able to take oral food.


5.       Potassium replacement
a)      None in the first Litre of i.v. fluid unless <3mmol/L
b)      If plasma potassium  < 3.5mmol/L, give 40 mmol (2 amp. KT inj.) in 1 litre fluid
c)      If plasma potassium  3.5-5.5 mmol/L , give 20 mmol (1 amp. KT inj.) in 1 litre fluid.
d)     If plasma potassium  > 5.5 mmol/L do not give potassium
6.       Broad spectrum antibiotic
7.       Continued catheterization
8.       Change the posture 2 hourly.


3. HONK (hyperosmolar non-ketotic coma)

Diagnostic tools
1.    H/O of DM
2.    H/O of irregular treatment or missed dose of Insulin or drugs
3.    Stressful condition e.g. infection, trauma, pregnancy
4.    On exam. - Severe dehydration, pulse-tachycardia, BP- Hypotension.
5.    Investigation- Blood sugar- > 33 mmol/L
a.    No keton body in urine
b.    Hyperosmolality (> 320 mOsm/ kg)

Hyperosmolality can be calculated by
        = 2[Na+] + 2[K+] + [glucose] + urea (all in mmol)
             { Normal osmolality is 280-300 mOsm/kg}

Management:
               Same as DK but less insulin is required.
                        (Ref: Davidson’s principle & practice of Medicine)







4. Cushing syndrome
Management:
   Medical treatment before surgery
1.        Metyrapone and ketokonazole- the dose should be titrated against 24 hour free urine cortisol level.
2.        Treatment of the underlying cause.

Cushing disease
1.       Transphenoidal surgery
2.       If unsuccessful then bilateral adrenalectomy
Nelson syndrome can be prevented by pituitary irradiation.
5. Addisons disease
Management:
1.        Diet- normal
2.        Tab. Hydrocortisone 15 mg at morning & 5 mg at 6pm
3.        Fludrocortisone 0.05-0.1mg daily

Follow up:
1.        Pulse
2.        BP
3.        S. electrolytes

Advice:
1.      If fever double the dose
2.      In vomiting inj. Should be given if can not swallow tablet
3.      Minor surgery Inj. Hydrocortisone 100 mg im with premedication.
4.      Major surgery- Inj. Hydrocortisone 100 mg im 6 hourly until able to take oral tablet
5.      Pt. should carry steroid card
6.      Bracelet.
6. Addisonian crisis
  Management
1.         NPO TFO
2.         O2 inhalation
3.         Infusion normal saline 1000 cc iv @ 30d/min.
4.         Infusion 10 % DA 1000cc iv @ 20d/min.
5.         Inj. Hydrocortisone 100mg iv stat then im 6 hourly
6.         Antibiotic
7.         Treatment of the underlying cause.

7. Phaeochromocytoma
  Management
a.       Definitive treatment is surgery
b.      Preparation of pt. before surgery minimum for 6 week
c.       Control of HTN by Alpha blocker Phenoxybenzamine 10-20mg orally 6-8 hourly. If tachycardia occurs add betablocker –Propanolol or Labetalol
d.      During surgery- Sodium Nitroprusside & short acting alpha antagonist Phentolamine are used to control HTN
e.       Postoperative period Hypotension should be managed by -Fluid & Noradrenaline infusion.
8. Hypopituitarism
Management
     1. Glucocorticoid replacement
     2. Thyroxine 100-150 µgm daily (before this steroid must be given)
     3. Sex hormone in men of any age & in female <50 years
     4. GH in children & adolescent S/C inj.
     5. Treatment of the underlying cause.

9. Prolactinoma
      Management:
1.      Dopamine agonist (Bromocryptine 1st line drug)
2.      Surgery 2nd line treatment.

10. Acromegaly
Management:
1.      1st line treatment is surgery
2.      2nd line treatment is…..
a)      Bromocryptine
b)      Somatostatin analogue (Octreotide, Lanreotide) slow releasing inj. Every few weeks interval
c)      GH receptor antagonist Pegvisomant indicated in whom GH & IGF1 fail to suppress sufficiently by Somatostatin analogue.
11. Diabetes insipidus
Management:
Cranial DI
      1. Desmopressin nasal spray 5 µgm in morning & 10 µgm at night. In sick pt. im inj.

Nephrogenic DI
1.      Bendroflumethazide 5-10mg/day
2.      Amiloride 5-10mg/day
3.      Indomethacin 15 mg 8 hourly.

12. Amenorrhoea
Management:
1.      Exclude physiological cause e.g. Pg. Menopause etc.
2.      Decrease exercise, work load
3.      Weight gaining if under weight.

13. Thyrotoxic storm
Management
1.      Diet – normal
2.      Infusion Normal saline 1000c iv @ 20d/ min
3.      Tab. Propanolol 80 mg 6 hourly or 1-5 mg iv 6hourly
4.      Sodium ipodate 500mg orally or Dexamethasone 2 mg 6 hourly + Amiodarone
5.      Carbimazole if can not take orally then give per rectally
6.      Antibiotic
1.  Thyrotoxicosis
Management
1.    Pt. under 40 years- Tab. Carbimazole 40 -60 mg daily, when pt. euthyroid then 5-20mg for 18 months. If replase occur then –surgery.Subtotal thyroidectomy. Pt. should make euthyroid before surgery by Potassium iodide 60 mg 8 hourly for 2 weeks.
2.    If pt. over 40 years – Radio 131I ablation.
Antithyroid drugs
                               I.      Carbimazole 40-60mg daily
                            II.      Methimazole
                         III.      Propylthiouracil (400-600mg daily)

3.    Surgery is indicated
                      Larg goiter.
                     
Note:
   Subjective improvement occur 10-14 days
  Patient biochemically euthyroid at 3-4 weeks. At this time carbimazole should be given at a dose of 5-20mg daily for 12- 15 months.

Thyrotoxicosis in pregnancy
1.      Tab. Propylthiouracil 150 mg/day (larger dose cause fetal hypothyroidism).
2.      Surgery- if poor compliance. It should be done at 2nd trimester.

15.Graves opthalmopathy
  Management
1.      Reassurance
2.      Methylcellulose eye drop & gell
3.      Side shield attached spectacle
4.      Prednisolone
5.      Sometimes orbital irradiation
6.      If loss of visual acquity then urgent surgical decompression.
16. Hypothyroidism
Management
1.      Diet – normal
2.      Tab. Thyroxine (50µgm) 1 + 0 + 0 ( ½ hour before breakfast)
After 3 weeks
        2 + 0 + 0   (½ hour before breakfast)
    After 6 week do T3, T4, and TSH then adjust dose of Thyroxine level.
3.      Antilipid drugs if hyperlipidaemia.

Note:
1)      pt. feel better wuth in 2-3 weeks
2)      Reduction in weight & periorbital puffiness occurs quickly
3)      Restoration of skin & hair texure and resolution of any effusion take 3-6 months.




Hypothyroidism in IHD
Management
1.        Diet- normal, avoid fatty & salty food
2.        Tab. Thyroxine (50µgm) 1/2 + 0 + 0 ( ½ hour before breakfast)
      Starting dose should be minimum because it can aggravate or precipitate IHD.
Hypothyroidism in Pregnancy
Management
         Extra 50µgm/day is required than maintenance dose . Because placenta metabolise thyroxine & increase Thyroxine binding globulin in pregnancy.
T3, T4 & TSH should be assessed in every trimester.
Increased dose of thyroxine is required in the following condition
1.        Anticonvulsant drugs
2.        Rifampicin
3.        Chloroquine
4.        Sertraline
5.        Aluminium hydroxide
6.        Ferrous sulphate
7.        Calcium carbonate
8.        Malabsorption
9.        Pregnancy
17. Myxoedema coma
Diagnostic tools
1.       Elderly pt.
2.       H/O hypothyroidism
3.       Altered consciousness
4.       Temperature as low as 25oC.
Management
1.        Slow rewarming
2.        NG tube feeding
3.        O2 inhalation
4.        Infusion 5% DNS/ NS
5.        Broad spectrum antibiotics
6.        Inj. Triiodothyronine (20 µgm) iv stat & 8 hourly, when pt. can take orally then Tab. Thyroxine (50µgm) 1 + 0 + 0 ( ½ hour before breakfast)
7.        Inj. Hydrocortisone 100mg im 8 hourly.             








   
Infectious disease
1.      Chicken pox in adult or in children
Management
   1. Diet – normal
   2. Antihistamine
   3. Antibiotics
   4. Antiviral- oral Aciclovir 800mg 5 times daily for 5 days
       In immunocompromised host/ pregnant women Aciclovir 5 mg/kg 8 hourly until pt. improving then complete therapy with oral therapy until all leishon crusting over.
  Visceral involvement (non- CNS) - Aciclovir 5 mg/kg 8 hourly for 7 days.
  Severe complications like encephalitis/ disseminated infection- Aciclovir 10 mg/kg 8 hourly for 14-21 days.
  Lotion claamilon-apply loacaly

2.      Shingles or Herpes Zoster
Management
1.      Diet – normal
2.      Antiviral- oral Aciclovir 800mg 5 times daily
3.      Tab. Amitryptylline 25-100mg daily
4.      Analgesic –NSAID
Treatment & doses as for chicken pox but typically duration 7-10 days.

3. Infectious Mononeucleosis
    Management
1.       Diet – normal
2.       Antibiotic- penicillin, Avoid Amphicillin or Amoxicillin
3.       Steroid – inj. Hydrocortisone 100 mg iv stat. & 6 hourly if pharyngeal edema
4.       Return to work governed by pt. physical fitness.
   


4. Dengue fever
    Management
1.       Diet – normal, plenty of fluid & home made fruit juice intake
2.       Tab. Paracetamol
3.       Avoid NSAID, Steroid
4.       Fluid management
                           
5. Leptospirosis
    Management
1.       Diet- normal, salt, fruit. Protein restricted
2.       BT if bleeding manifestation
3.       Treatment of renal failure
4.       Cap. Doxicycline 100 mg 1 + 0 + 1 0r inj. Ceftriacone 1 gm daily
5.       If uveitis then oral steroid.
6.       Tab. Paracetamol

6.Enteric fever
Management
1.       Diet- normal
2.       Tab. Paracetamol
3.       Antibiotic
Antibiotics that can be used in Enteric fever are—
1.     Co-trimoxazole 2 tab. 12 hourly
2.     Ciprofloxacin 500 mg 12 hourly
3.     Ceftriaxone 2 gm 12 hourly
4.     Azithromycin 500 mg daily
Duration of treatment is 14 days.

7. Leprosy
    Management
          Paucibacillary
1.          Diet- normal
2.          Tab. Daposone 100mg 1 +0 + 0 ….6 months
3.          Tab. Rifampicin 600mg 1 + 0 + 0 one Tab. Monthly for 6 months

         Multibacillary
             Monthly basis for 12 months
1.          Tab. Rifampicin 600mg 1 + 0 + 0
2.          Tab. Clofazimine 300mg 1 + 0 + 0
             Daily basis for 12 months
1.      Tab. Dapsone 100mg 1 tab. daily
2.      Tab. Clofazimine 50mg 1tab. daily.
        Paucibacillary with single lesion
1.          Tab. Ofloxacin 400mg- single dose
2.          Tab. Rifampicin 600mg-single dose
3.          Tab. Minocycline 100mg- single dose.
8. Rickettsial infection
Management
1.          Tetracycline 500mg 6 hourly Or
2.          Doxycyclline 100mg 12 hourly Or
3.          Chloramohenicol 500mg 6 hourly Or
4.          Blood transfusion if haemorrhage
5.          Sedation if delirium occurs
               Duration of treatment is 7 days.
9. Giardiasis
    Management
1.          Tinidazole 2 gm stat.
                         Or
      Metronidazole 400mg 8 hourly for 10 days.

10. Filariasis
   Management
1.       DEC 6 mg /kg daily in 3 divided doses for 12 days.
2.       In tropical pulmonary eosinophillia same dose of DEC for 14 days.
                                Or
               3. 300mg DEC single dose
11. Syphilis
Management
         Antibiotic- choice Penicillin
  Doxicycline if allergic to penicillin except in   pregnancy
Azithromycin is a further alternative.

Cure indicated by resolution of clinical sign & decline of non-treponemal test (VDRL) usually to undetectable levels with in 6 months of primary syphilis & 12- 18 months of 2ndary syphilis.
Syphilis in pregnancy
Penicillin is choice.
Erythromycine  if allergic to penicilline.
Ceftriaxone 250mg im for 10 days.

12. Gonorrhoea
Management 
   Uncomplicated
       Cefixime 400mg stat. or
       Ciprofloxacin 500mg stat. or
       Ofloxacin 400mg stat.
    Complicated
     Quinolone resistance
            Ceftriaxone 250 mg im stat or
            Spectinomycin 2 gm im stat
     In pregnancy & breastfeeding
            Cefixime
            Ceftriaxone

13. Chlamydial infection
Management
Standard regimen
     Azithromycin 1gm single dose or
      Doxycycline 100mg B.D. for 7 days.
Alternative regimen
       Erythromycin 500mg 6 hourly for 7 days or
       Ofloxacin 200 mg 12 hourly for 7 days.






14. Malaria
   Uncomplicated
        Management:
1.       Diet –normal
2.      Tab. Artemether & Lumefentrin (Coartem) 4+0+ 4 (for 3 days) (1st line drug)
3.      Tab. Paracetamol (500mg) 1+1+1
  Situations where Coartem can not be given…..
a)      Pregnancy in first trimester
b)      Children < 5kg body weight
In these situation Tab. Jasoquine (Quinine) for 7 days.
Dose schedule of Quinine (Jasoquine)
Drug                               Weight in kg
    3-9    10-19    20-29    30-39    40+    Duration
Tab. Jasoquine
(Quinine)300mg    ¼ Tab. TDS    ½ Tab. TDS    1 Tab. TDS     11/2Tab.TDS    2Tab.TDS    7 days
Alternative regimen for uncomplicated malaria
•    Quinine for 7 days + Tetracycline 7 days (Q7+T7) or
•    Quinine for 7 days + Doxycycline 7 days (Q7+D7)
Tetracycline: 250 mg 6 hourly for 7 days
Doxycycline: 100mg 12 hourly for 7 days
 
 


Severe Malaria                   
          Management:
1.      NG tube feeding 200 ml 2 hourly in sitting posture & maintain the posture for 10 min.
2.       Infusion 5% DA 500 cc + inj. Quinine (Jasoquine) (300mg) 4 amp i.v. @ 30 drops /min stat. (suppose pt.’s body wt. 60 kg)
                           Then
Infusion 5% DA 500 cc + inj. Quinine (Jasoquine) (300mg) 2 amp i.v. @ 30 drops /min 8 hourly.
[Loading dose of Quinine (Jasoquine) is 20mg/kg; maintenance dose is 10mg/kg].
3. Infusion Nutridex 25% 250 cc i.v. @ 20 drops/min   stat & 12 hourly
  4. Omenix sachet 1 packet dissolve in ½ glass water through NG tube BD
  5. Tab. Paracetamol (500mg) 1+1+1
  6. Continued catheterization
  7. Change the posture 2 hourly
  8. Care of mouth, eye & bowel
  9. Follow up the pt. with urine output, Blood sugar, GCS.
Tips:

When pt. able to take orally then switch from IV to oral therapy. In severe malaria Quinine should be given total (IV + oral) 7 days.

(Ref. National Guideline for diagnosis & management of Malaria. )

1.  Kala-azar 
     Management
Treatment-A
    (Oral Miltefosine) 1st line of treatment for Kala-azar     patients.
           Recommended dose schedule:
•         Adults (>25 kg body wt.) 50 mg  morning and evening after meal
•         Patients (<25 kg body wt.) 50 mg in the morning after meal
•         Children (2-11 years age) 2.5 mg/kg daily in two divided dose
           
       Duration:
1.      Miltefoscine should be given daily for 28 days.
2.      In case of missed doses, treatment up to 35 days is recommended.

       Contra-indications:
                   1. Women during pregnancy.
                   2. Married women of child bearing age who are not using         contraceptives regularly and are at risk of becoming pregnant.
                   3. Women who are breast feeding.
                   4. Infants.

       Treatment-B
                                            i.      Sodium Antimony Gluconate for Kala-azar Treatment failure cases with Miltefosine and
                                          ii.      when Miltefosine is not available
        Dose:
•         Should be given at a dose of 20 mg/kg body wt.
•         Daily IM injection for 30 days.
•         After each injection keeps the pt lying on the bed under observation for at least half an hour.
•         Unused reconstituted drug should be discarded within 24 hours of preparation.
•         ECG monitoring before treatment and weekly during treatment should be performed.
               Since alternate relatively safe drugs are now available, SAG should be phased out national programmed.
                                     
   Treatment C
        Amphotericin-B deoxycholate or liposomal amphotericin-2nd line of  treatment for Kala-azar

               
Dose:
o   1 mg/kg daily in IV infusion(in 5% DA) for 20 days.
             Liposomal Amphotericin B
                Dose: 3 mg/kg for 5 days in IV form.
                 No side effects with cure rate >95%.
Treatment D:
              Sodium Antimony Gluconate for PKDL cases
Dose:
        20 mg/kg/day in IM route.
        Total 6 cycles.
        Each cycle consists of 20 days treatment.
        Should be an interval of 10 days in between 2 cycles.
        Essential to weight the pt every time before starting a new cycle.
       
Ref: National guideline of diagnosis & management of Kala-azar.











Alimentary tract Disease:

1. Hiccup
Management:

  1. Eating 1 TSF of dry granulated sugar.
2. Interruption of the respiratory cycle by breath holding, Valsalva maneuver or rebreathing into a bag.
  3. Irritation of the diaphragm by holding knees to chest
   4. Tab. Baclofen 1 + 1 + 1
   5.  Inj. Chlorpromazine 25mg/ml 1 amp. i.m. stat. & B.D. (Before giving LFT & Renal function test should be done)
    6. Treatment of the underlying cause.
Other drug can be used treatment
1.      Other agents -phenytoin, carbamazepine, benzodiazepines (lorazepam, diazepam), metoclopramide, baclofen, gabapentin, and occasionally general anesthesia.

                                                     ( Ref. CMDT 2010)

2. Oral ulcer
Management 
1. Topical steroid- 0.1% Triamcinolone in orabase  (Kenacort oral base )   
                          Or
        Choline salicylate 8.7% gel
2. Rarely pt. with very severe recurrent apthous ulcer may need oral steroid.


3. Oral Candiasis
Diagnostic tools
              1. Occurs usually in immunocompromised pt. like DM, cytotoxic drugs, steroid, old age etc.
             2. White patch in mouth
Management:
1.        Nystatin or Amphotericin suspension or Lozens
2.        Resistant cases or immunocompromised pt. may require oral fluconazole.

4. Achalasia Cardia
    Treatment option:
1.        Endoscopic force full pneumatic dilatation
2.        Endoscopically directed Botulinum toxin inj. In to the lower oesophageal sphincter
3.        If replase occur then surgery- myotomy (Heller’s operation either laparoscopically or open).
                                                             
5. Gastro Esophagial Reflux Disease( GERD)
Management       
       1. Omeprazole 20 mg 1 + 0 +1
6. Peptic Ulcer Disease (PUD)
Management
1.        Avoid smoking, Aspirin, NSAID
2.         H. pylori eradication therapy… duration 7- 14 days.
                   Cap. Omeprazole 20 mg 1 + 0 +1 ½ hour before meal
       Cap. Amoxicillin 500mg 2 + 0 + 2
       Tab. Clarithromycin 500mg 1 + 0 + 1
3.        Maintainance dose of Omeorazole 20 mg daily.
7. Zolinger- Ellusion syndrome
      Diagnostic tools:
1.        Severe upper abd. Pain, diarrhea, statorrhoea
2.        Poor response to ulcer therapy
3.        Endoscopy shows- severe & multiple ulcer in post bulbar duodenum, jejunum & oesophagus.
     Management:
1.        PPI- larger dose 60- 80mg daily
2.        Somatostatin analogue- Inj. Octreotide subcutenously
3.        If localized tumor found then resection of the tumor.

8. Non-ulcer dyspepsia (NUD)
    Diagnostic tools:
1.        Age< 40 years
2.        Complains anorexia, bloating, abd. Pain
3.        Exclusion of PUD by endosopy of upper GIT

    Management:
1.        Explanation & reassurance
2.        Avoid fatty foods
3.        Domperidone 10-20mg 8 hourly
4.        H2 antagonist- Ranitidine if night pain or heart burn
5.        Low dose amitryptyline

                                                                                                         
9. Coeliac disease
    Management
1.        Correct iron, folate, Calcium and/ or Vit.D
2.        Avoid glutein life long (avoid wheat, rye, barly & initially oats)
3.        If pt. are refractory then treatment with corticosteroid or immunsuppressive
  Follow up:
              1.Circulating anti endomycial antibody.
10. Tropical sprue
  Management
1.        Tetracycline 250mg 6 hourly for 28 days
2.        Folic acid 5 mg daily.

11.Blind loop syndrome
Management
1.        Treatment of the underlying cause
2.        Tetracycline 250mg 6 hourly for 7 days. Metronidazole 400 mg 8 hourly or Ciprofloxacin 250 mg 12 hourly is an alternative. Some pt. require treatment up to 4 weeks.
3.        In chronic cases Vit. B12 inj. i.m should be given.
4.        If pt. with motility disorder such as DM, scleroderma- Loperamide 2 mg 4-6 hourly.

12. Ulcerative colitis
   Active proctitis
     Mild to moderate
           1st line therapy
1.        Mesalazine enema or suppository
2.        Oral Mesalazine
3.        Topical steroid – who intolarent  to topical Mesalazine
4.        Pt. who still fail to respond- oral Prednisolone 40 mg daily.

      Acute left sided or extensive UC
      Mildly active disease
1.        High dose aminoslicylate
2.        Topical aminosalicylate or steroid
3.        Oral steroid if aminosalicylate therapy ineffective.

         Severe UC
1.        Intravenous fluid with nutritional support
2.        Intavenous steroid Mehylprednisolone 60 mg daily or Hydrocortisone 400 mg daily should be given as a continuous infusion
3.        Topical and oral aminosalicylates
4.        Intravenous Ciclosporin or Infliximab who do not promptly respond to steroid.

     Indication of colectomy:
1.        Pt. who developed colonic dilatation > 6 cm
2.        Those whose clinical & Laboratory measurements deteriorate
3.        Those not respond after 7-10 days maximal medical treatment.

       Maintainance of remission
1.        Oral aminosalicylates- Mesalazine or Balsalazine
Sulphalazine has higher side effects but choice in pt. with associated arthopathy. Pt. who frequently relapses despite Aminoslicylate is treated with thiopurines.




13. Irritable bowel syndrome ( IBS)
      Diarrhea predominant
          Management:
1.        Reassuarrance
2.        Avoid legumes & excessive dietary fibre
3.        Still symptomatic –Loperamide 2-8 mg daily
4.        Still symptomatic- Amitryptylline 10 -25 mg at night
5.        Still symptomatic-
i)                    Relaxation therapy
ii)                  Biofeedback
iii)                Hypnotherapy
  Constipation predominant
         Management:
1.        Reassurance
2.        High roughage diet
3.        Still symptomatic- ispagula, Lactulose
4.        Still symptomatic-
i.                    Relaxation therapy
ii.                  Biofeedback
iii.                Hypnotherapy

Pain & bloating
      ManageMent:
1.        Mebevarine
2.        Peppermint oil
3.        Alverine
4.        Still symptomatic- Amitryptylline 10- 25 mg at night, Probiotics, Dietary change
5.        Still symptomatic-
a.       Relaxation therapy
b.      Biofeedback
c.       Hypnotherapy
14. Anal fissure
  Management:
1.        Avoid constipation
2.        Increase fluid intake
3.        Nitric oxide & 0.2% GTN or deltiazem ointment
4.        Resistant case- inj. Botulinum toxin
  Surgery- Lateral internal anal sphincterotomy or advancement anoplasty.













Haematology
1. Blood transfusion reaction
      a) Febrile reaction
          Diagnostic tools
   Pt. complain of fever, chills & rigor
   Pt. otherwise normal
         Management:
1.         Stop the transfusion
2.         Paracetamol tab. Or suppository
3.         Restart the transfusion at a slower rate
4.         Observe the pt. more frequently.

     b) Urticaria
        Mild allergic reaction
1.         Stop the transfusion
2.         Give chlorpheniramine 10 mg iv slowly
3.         Restart BT at a slower rate
4.         Observe frequently.

    c) Severe allergic reaction
Diagnosttic tools
1.         Bronchospasm, abdominal pain
2.         Angioedema, hypotension
        Management:
1.         Discontinue the transfusion
2.         Give Chlorpheniramine 10 mg iv slowly
3.         O2 inhalation
4.         Nebulize with Salbutamol
5.         If severe bronchospasm or hypotension then give inj. Adrenaline 0.5 mg i.m.
6.         Send clotted blood sample to the transfusion laboratory
7.         Take down blood unit & giving set & return intact to blood bank with all other used/ unused unit.

   


   d)ABO incompatibility
         Management:
1.         Take down blood unit & giving set & return intact to blood bank with all other used/ unused unit
2.         Start i.v. saline infusion
3.         Monitor urine out put- maintain urine out >100ml/ hour. Give Frusemide if urine output fall
4.         Treat DIC with appropriate blood products
5.         Inform hospital transfusion department immediately.
3.         Iron deficiency anemia
Management:
1.         Diet- iron containing foods like Lal sak, kochu sak etc
2.         Tab. Ferrous sulphate 200mg 8 hourly for 3-6 months. If pt. intolerant to ferrous sulphate then Ferrous sulphate 12 hourly or Ferrous gluconate 300 mg 12 hourly
3.         Blood transfusion-indication
i)                                If pt. have angina
ii)                              Heart failure
iii)                            Evidence of cerebral anoxia
4.         Parentral iron-indication
i)                                Malabsorption
ii)                              Chronic gut disease

Follow up:
1.         Hb%- Hb% should be rise 1 gm/dl/week
2.         Reticulocyte count- Reticulocytosis is evident after 7-10 days.
4.Megaloblastic anaemia
   Management:
1.         Diet- normal
2.         Inj. Hydroxycobalamine 1000 µg i.m. five doses 2-3 days apart then 3 monthly life long
3.         Tab. Folic acid 5 mg 1 tab daily for 3 week, then 1 tab. Weekly for life long
4.         Ferrous sulphate 200 mg 8 hourly, if initial responses is not maintained & PBF is dimorphic.

5.Spleenectomized Pt.
    Management:
1.         Vaccinate the pt.
  Pnemococcal
  H.inluenza type B
  Meningococcus C
  Influenza
Vaccination should be done 2-3 weeks before elective surgery. If emergency surgery is done then vaccination should be done after surgery.
2.         Pneumococcal reimmunization should be done every 5 yearly
3.         Influenza reimmunization should be done yearly basis.
4.         Penicillin V 500 mg 12 hourly life long
5.         Should carry Bracelet or card.

6.Autoimmune Haemolytic anaemia
    Management:
1.      Steroid –prednisolone 1 mg/kg/day orally, when Hb% normalized, reticulocytosis resolved dose of steroid should be reduced over 10 weeks
2.      Blood transfusion- when developed heart failure or unabated fails in Hb%
3.      Splenectomy- if haemolysis fails to respond to steroid or can only be stablished by larger doses.
4.      Azathioprine or cyclophosphamide-if splenectomy is not appropriate.

7.Paroxyamal nocturnal haemoglobinuria (PNH)
        Diagnostic tools:
  Pt. complain –red brown color urine particularly in morning
  Urine R/E- haemoglobinuria

       Management:
1.       Diet- normal
2.       Blood transfusion
3.       Treatment of thrombosis
4.       Recently anticomplement C5 monoclonal Ab Ecluzimab is used.

8. Sickle cell anemia
Management:
1.        Tab. Folic acid 5 mg 1+ 0 + 0
2.        Tab. Penicillin V
3.        Hydroxycarbamide
4.        Vaccinate against Pneumococcus, H. influenza & Hepatitis B.
Treatment of vaso-occlusive crisis
1.       O2 inhalation
2.       Rehydration with Normal saline
3.       Antibiotic
4.       Analgesia with opiate
5.       Exchange transfusion
  in life threatening crisis
  Or to prepare the pt. for surgery.

9. Chronic myeloid leukaemia
       Chronic phase
1.         First line therapy- Imatinib,
If fail to response or progress on therapy- Dasatinib or Nalatinib, Bone marrow transplantation (allogenic)
                        Or
Hydroxyurea or Hydroxycarbamide or Interferon.
2.         Hydroxyurea- if pt. can not afford Imatinib.
      Accelerated or blast crisis phase
1.        Imatinib
2.        Hydroxycarbamide & low dose cytarabine. If fail to response or progress on therapy- Dasatinib or Nalatinib, Bone marrow transplantation (allogenic).





10. Chronic Lymphatic leukaemia
   Stage A
               No treatment is required.
    Stage B & C
1.        Chlorambucil, recently Fludarabine plus Cyclophasphamide
2.        Corticosteroid- in bone marrow failure or autoimmune cytopenias
3.        Blood transfusion if anaemia or thrombocytopenia
4.        Antibiotic – infection
5.        Radiotherapy-if lymph node causing discomfort or local obstruction & symptomatic splenomegally
6.        Splenectomy- to decrease autoimmune destruction of RBC,  Hypersplenism & to relieve massive splenomegally.

11. Myelodysplastic syndrome
     Management:
1.         Blood transfusion
2.         Platelet transfusion
3.         Erythropoietin & GCSF
4.         Allogenic bone marrow transplantation in younger pt.

12. Multiple myeloma
Management:
    Asymptomatic –no treatment is required
     Symptomatic
1.         Plenty of fluid intake
2.         NSAID to relieve pain
3.         Bisphosphonates
4.         Allopurinol
5.         Plasmapharesis-in hyperviscosity
6.         Chemotherapy
         1st line –Thalidomide
         Older pt. - Thalidomide plus Melphalan & Prednisolone
         In younger pt. -Thalidomide plus allogenic BMT.
7.         Radiotherapy- localized bone pain not responding to simple analgesic & pathological fracture, spinal cord compression.


13. Aplastic anaemia
Management:
1.         Diet- normal
2.         Antibiotic
3.         Immune suppressive therapy for older pt. with-Ciclosporin & Antithymocytic globulin
4.         Younger pt. < 30 years – allogenic BMT.
14. Myelofibrosis
Management:
1.        Diet- normal
2.        Tab. Folic acid
3.        Blood transfusion
4.        Hydroxycarbamide
5.        Splenectomy- if symptomatic pancytopenia, enlarged spleen, hypersplenism
6.        Allogenic BMT in younger pt.
15. Polycythaemia Rubra vera
Management:
1.        Diet- normal
2.        Venesection 400-500 ml every 5-7 days until PCV <45%
3.        Hydroxycarbamide
4.        Aspirin 75 mg daily
5.        Radioactive phosphorous for older pt.

16. ITP (idiopathic thrombocytopenic purpura)
Management:
1.        Stable compensated ITP & platelet count >30 thousand do not require treatment
2.        First line therapy for pt. with spontaneous bleeding
A.         Prednisolone 1 mg/ kg daily
B.         If response to steroid is slow & severe haemostatic failure
  Prednisolone & IVIg
              Or
     Intravenous anti D
C.         Persistent or potentially life threatening bleeding should be treated with platelet transfusion in addition to other therapies
D.         Splenectomy- if 2 relapses or primary refractory disease
E.          If significant bleeding persists despite splenectomy- low dose steroid, immunosuppressive therapy with Rituximab, ciclosporin & Tacrolimus.
17. Haemophilia
                    Haemophillia A
1.      Resting of the bleeding site by bed rest or splint
2.      In severe hemophilia A intravenous infusion of factor VIII concentration
3.      In mild to moderate hemophilia A Vasopressin receptor agonist DDAVP 0.3 µg/ kg iv or subcutaneously. Alternatively same effect can be achieved by intranasal administration of 300 µg.
4.      Prophylaxis – Factor VIII can be administered 2 or 3 times per week.
                  Haemophillia B
                                      Factor IX concentration intravenous infusion.
18. Acute leukaemia
Diagnostic tool
1.    Fever high grade
2.    Generalized weakness
3.    Bleeding manifestations e.g.- gum bleeding, epistaxis, etc.
4.    On exam. –Anaemia, Lymphadenopathy, Bony tenderness, Hepato-splenomegally.

Urgent Investigation:
1.      CBC with PBF

Managementsad Supportive)
1.      Diet- normal
2.      Blood transfusion  (before BT PBF should be done)
3.      Inj. Eracef (1gm) ivial i/v daily
4.      Tab. Paracetamol (500mg)  1+1+1
5.      If menorrhagia Tab. Premulate N 2+2+2

For specific management referred to Haematologist.


19. Haemolytic anaemia
Diagnostic tool
1.    Generalized weakness
2.    No fever, bleeding manifestation
3.    On exam.
  No lymphadenopathy, No bony tenderness
  Hepatosplenomegally.

Management:
1.      Diet – normal
2.      BT
3.      Tab. Folison   1+0+0

Dietary advice:
1) AvqiY wmivc Lv‡eb bv |
2) Lvevi †jvnvi cv‡Î iwbœv Ki‡eb bv |
3) Lvevi cv‡Î ev ciciB dj LvIqv hv‡e bv |
4)  AwaK †jŠn hy³ Lvevi Gwi‡q Pjyb |
            †hgb-   
                 gvsm Ges gvQ :
                      Miy I Lvwmi gvsm, KwjRv, wW‡gi Kzmyg, Bwjk gvQ, ˆK gvQ, wPZj, †Usiv,   †QvU gv‡Qi ïUwK
                 kvKmâx :
                       KPz kvK, jvj kvK, cvjs, cy&uB kvK, dzj Kwc, cyw`bv I a‡b cvZv, wkg, eiewU, gUikywU, KvK‡ivj, KuvPv †cu‡c, mRbv |
                 dj :
                       Avbvim †e‡`bv, kwidv, †LRyi, ZigyR
                 Lv`¨kl¨ I Zv ‡_‡K ˆZix Lvevi :
                        Kb©‡d¬•, ‡jŠn ‡gkv‡bv wkï Lv`¨- wb‡Wv, †mwijvK
                 Wvj :
                         †Qvjv I ‡Qvjvi Wvj
                wewea :
                         ¸o, ev`vg, wKmwgm, wZj, cvb, wRiv, a‡b, mwilv |
5) Kg †jŠnhy³ Lvevi Lv‡eb
           †hgb-
               gvQ :
                      iæB gvQ, KvZjv gvQ, csMvm gvQ, †evqvj gvQ, gv¸o gvQ, cywU gvQ
               mâx :
                      evav Kwc, wgwó Avjy, Kijv, kmv, wS½v, KuvPvKjv, jvD, PvjKzgov |
              dj :
                      wjPz, cvKv †c‡cu, Kgjv †jey, †ej, Rvgiæj, AvvZv,AvgjwK, KvMwR †jey |
              Lv`¨ kl¨ :
                      Pvj, gq`v |
              Wvj :
                      gmyi |
             wewea : gay, `y`, `y» RvZ Lv`¨- ‰`, Qvbv BZ¨v`x |
An approach to diagnosis of Anaemia from examination findings:
  Anaemia + Bleeding manifestation + No lymphadenopathy + No bony tenderness + No Hepatosplenomegally ¬– Aplastic anaemia.
   Anaemia + No Bleeding manifestation + No lymphadenopathy + No bony tenderness + Hepatosplenomegally ¬– Haemolytic anaemia.
  Anaemia + Bleeding manifestation + lymphadenopathy + bony tenderness + Hepatosplenomegally ¬– Acute leaukaemia.









MUSCULO-SKELETAL DISEASES
1. Low back pain (LBP)                                                               
Management:
1.       Reassurance, explanation
2.       Analgesic- paracetamol, NSAID, Muscle relaxants
3.       Discourage bed rest
4.       Low dose TCA e.g. Amitryptylline
5.       Refered for Physiotherapy or manipulation- if return to normal physical activity has not been achieved by 6 weeks.
2. Osteoarthritis
  Management:
1.         Full explanation of the condition
  Established structured changes are permanent
  Pain & function can be improved
2.         Exercise- strengthening & aerobic exercise
3.         Hot or cold compression
4.         Reduction of adverse mechanical factors
          - Weight loss if obese
          - Shock absorbing foot wear
          - Use of walking stick for painful knee or hip OA.
5. Drug
         - Paracetamol
         - Topical NSAID
         - Oral NSAID
6. Intraarticular inj. Of corticosteroid to relieve pain of knee & thumb base OA
7. Surgery
Indication:
           i) OA whose pain, stiffness & reduced function impact significantly on their quality of life
           ii) Refractory OA (refractory to non-surgical & adjunctive treatment).
Surgeries are- Osteotomy & joint replacement for knee & hip joint OA.
3. Rheumatoid arthritis
Diagnostic tools:
1.      Polyarthritis -3 or more joints pain
2.      Hand joint involvement
3.      Symmetrical arthritis
4.      Rheumatoid nodule
5.      Morning stiffness > 1 hour
6.      Rheumatoid factor (RA test Positive)
7.      Radiological changes
8.      Symptoms for more than 6 weeks.

4 or more criteria suggest diagnosis of RA.

Management: (ward or practical mx.)
1.    Diet : Normal
2.    Cap. Indomethacin (25mg) 1+1+1  (after meal)
3.    Cap. Omeprazole (20mg)  1+0+1  ( before meal)
4.    Tab. MTX (2.5mg) 3+0+0  ( every saturday)
5.    Tab. Folic acid    1+0+0 (every sunday)

Rheumatoid arthritis
   ManagementsadIdeal)
1.      Rest
2.      Passive exercise
3.      NSAID
4.      DMARD
5.      Anti TNF therapy-if disease activity persists despite adequate trial of 2 DMARD including Methotrexate
6.      Corticosteroid-Prednisolone 7.5-10 mg daily. To cover delayed onset of action of DMARD
7.      Surgery-indication-when medical treatment fail to pain relief or to prevent tendon rupture.
8.      Surgeries are
         Synovectomy (wrist or finger tendon sheath)
         Osteotomy
         Arthodosis or arthoplasty
Follow up in pt. getting MTX initially monthly, then every 3 month
     1. Clinical improvement
     2. Full blood count and LFTs
4. Ankylosing spondylosis
   Management:
      Non-pharmacological:               
1.        Explanation & education
2.        Daily back extension exercise including a morning ‘warm up’ routine
3.        Avoid prolonged period of inactivity work like driving, computer work etc.
4.        Swimming is the best exercise.
       Pharmacological treatment:
1.         NSAID
2.         MTX or sulphasalazine if peripheral arthritis
3.         Anti TNF therapy for disease inadequately controlled with above measure
4.         Oral corticosteroid- in acute uveitis
        Surgery
                In severe hip, knee, shoulder joint restriction.
5. Reactive arthritis
  Management:
1.         Rest
2.         NSAID
3.         Tetracycline
4.          Intraarticular inj. for marked synovitis
5.         DMARD
  Persistent marked symptom
  Recurrent arthritis
  Severe keratoderma blenorrhagica
6.         Ant. Uveitis- topical, oral, subconjunctival steroid.
6. Psoriatic arthritis
  Management:
1.      Avoid splint & prolonged rest
2.      NSAID
3.      Intrarticular inj. of steroid to control synovitis
4.      DMARD- Methotrexete
5.      Anti TNF therapy in whom DMARD fail
6.      Retinoid acitretin
7.      Photochemotherapy & methylpsoralin and long wave UV light.




7. Gout
    Management:
        Acute attack
1.                  Application of ice pack
2.                  NSAID
3.                  Oral Colchicine 0.5 mg 6/8/12 hourly
4.                  Joint aspiration & intraarticular inj. Of steroid
5.                  For severe oligo-polyarticular attack- parentral corticosteroid.
     Long term management:
1.                  Correction of predisposing factors
2.                  Weight loss & reduction of excess alcohol intake especially bear
3.                  Diuretics should be stopped if possible
4.                  Avoid sea food, read meat
5.                  Allopurinol initial dose 100 mg daily (50 mg in elderly), gradually increase the dose up to 900 mg daily.
Follow up:
         S. uric acid should be measured 3-4 weeks interval.
Advice to the pt:
         During initiation of urate lowering drug acute attack may occur but drug should not be stopped.
Tips:
       Acute attack during initiation of urate lowering therapy; oral cholchicine or NSAID can be added.

8. Septic arthritis
      Urgent investigation:
1.         Synovial fluid for Gram staining & culture
2.         Blood for FBC & culture
3.         Consider sputum, urine culture
Management:
1.         Intavenous Flucloxacillin 2 gm 6 hourly for 2-3 weeks then oral for 6 weeks. Change according to C/S
2.         If Penicillin allergy then-Clindamycin 450-600 mg 6 hourly
3.         If high risk for Gram negative infection then add Cephalosporin
4.         Serial needle aspiration 1-3 times per day
5.         Pain relieved by- local ice pack, oral or iv analgesic
6.         Physiotherapy from the first day
-Regular passive movement progressing to active movement.
9. SLE
General management:
1.      Educate the pt.
2.      Avoid sun & UV light exposure, employ sun block
3.      Avoid smoking
4.      Control hypertension & dyslipidaemia
   Mild disease (restricted to skin & joints)
1.        NSAID
2.        If necessary Hydroxy chloroquine 200-400 mg daily
            3.   Short course of steroid for rash, synovitis, pleurisy & pericarditis.
  Life threatening disease
       Affecting kidneys, CNS or CVS requires high dose steroid plus immune suppression.
1.       A commonly used regimen- Pulse Methyl prednisolone 500 mg -1 gm iv coupled with cyclophosphamide 2 mg/kg iv repeated at 2-3 weekly interval on 6-8 occasion.
Alternatively in renal involvement Cyclophosphamide can be replaced with Mycophenolate mofetil(MMF) with fewer side effects.
2.       Folowing control- prednisolone 40-60 mg daily & Azathioprime, MTX or MMF
3.       Co-trimoxazole 960 mg thrice weekly to prevent P. carinii infection due to cyclophosphamide
4.       Mesna is given with bolous Cyclophosphamide to reduce risk of haemorrhagic cystitis
5.       Lupus nephritis with Antiphospholipid syndrome who have had previous thrombosis require life long warfarin.

10. Systemic sclerosis
A)                Raynaud’s syndrome with digital ulcer
1.      Avoid cold exposure
2.      Use of mittens (heated mittens are available)
3.      Calcium antagonist or ARB
4.      Antibiotic
a.       Intermitten infusion of epoprostenol may benefit severe digital ischaemia
B)                Ooesophageal reflux
  PPI
  Metochlopramide or domperidon
  Antibiotic for bacterial overgrowth
C)                Hypertension-ACEi even also in renal impairement
D)                Joint involvement-Analgesic
E)                 Pulmonary hypertension- Endothelin-1 antagonist ‘ Bosentan’
F)                 Corticosteroid & cytotoxic drug are indicated in pt. with
- co-existing myositis or
- fibrosing alveolitis.

11. Polymyositis & Dermatomyositis
     Management:
1.      Oral corticosteroid 40-60 mg daily
2.      iv Methylprednisolone 1 gm daily for 3 days in pt. with respiratory or pharyngeal weakness. If thre is a good response steroid should be reduced by approximately 25% per month to maintain dose of 5-7.5 mg
3.      Most pt. require additional treatment with Azathioprine & MTX
4.      iv immuneglobulin may be effective in refractoryces.

12. Bechet’s Syndrome
    Diagnostic tools
1.        Oral ulcer deep & multiple
2.        Genital ulcer
3.        Skin leishon-erythema nodusum or acneform leishon
4.        Migratory thrombophlebitis
5.        Anterior or posterior uveitis
6.        Neurological sign-brain stem involvement, pyramidal tract signs etc.
   Management:
1.        Oral ulcer- topical steroid preparation
2.        Colchicine for erythema nodusum & arthalgia
3.        Thalidomide 100-300 mg daily for 28 days & effective for resistant oral & genital ulcer
4.        Corticosteroid & immunosuppressive for systemic disease.

13. Polymyalgia Rheumatica (PMR)
  Management:
1.        Prednisolone 20-30 mg daily gradually reduce the dose 10-15 mg by about 8 weeks ultimately 5-7.5 mg for 12-14 weeks
2.        Immunosuppressive like MTX, Azathioprine when steroid require > 7.5 mg/day.

14. Giant cell arteritis
  Management:
1.       Prednisolone 60 mg daily

15. Osteoporesis
   Non-pharmacological treatment
1.          Cessation of smoking
2.          Moderation of alcohol intake
3.          Dietary calcium intake
4.          Exercise
Drug treatment
   Indication
1.       BMD T score below -2.5 or below -1.5 in corticosteroid    induced osteoporeis
2.Vertebral fracture irrespective of BMD (except traumatic vertebral fracture)
Drugs used
1.        Alendronate 70 mg/ week or  Risedronate 35 mg/ week. Orally on empty stomach & no food should be taken up to 30-45 min. of administration
2.        Calcium & vit-D
3.        PTH- Teriparatide. Superior to Alendronate. It is expensive, rserve for
a)      Szevere osteoporesis BMD T score -3.5 to - 4.0 or below
b)      Failure to respond adequately to other treatment.
                       Duration 24 months, after that Bisphosphonate should be used to maintain BMD. Teriparatide should not be used simultinously with Bisphosphonate.
4.        Calcitonin- has analgesic properties. Sometimes used short to medium time in pt. with acute vertebral fracture. Dose s/c or im 100-200 U daily or intranasal spray 200 micro units daily.
5.        HRT-primarily indicated for prevention of osteoporesis in women with an early menopause & for treatment of women with osteoporesis in their early fifties who have troublesome menopausal symptoms
6.        Calcitrol-recently licensed for treatment of osteoporesis
       Surgery
  Hip replacement- total or partial, indicated for intracapsular fracture of femoral neck.
  Kyphoplasty-indicated for acute vertebral compression fracture where there is a significant degree collapse & severe pain.
  Vertebroplasty- indicated for painful vertebral fracture which fails to settle by medical treatment.
Follow up:
1.      BMD repeat after 2-3 years
2.      NTX (N-Telopeptide) respond quickly than BMD.

16. Osteomalasia & Rickets
   Management:
1.        Respond quickly to treatment with ergocalciferol 250-100 µgm daily.
  After 3-4 months treatment can generally be stopped or the dose of vit-D reduce to maintainance level of 10-20 µgm Cholecalciferol daily except in pt. with Malabsorption in whom higher dose may required.
Follow up:
1.        Clinical improvement
2.        Elevation in 25(OH)D
3.        Reduce in PTH.

সেলিম


Re: Continuation of Wardwise Treatment Guidelines for Intern Doctors

diatery advice of haemolytic anaemia can not be read!