Topic: Wardwise Treatment Guidelines For Intern Doctors

Wardwise Treatment Guidelines For Intern Doctors
Edited By :

Dr.Salim Al Mamun

Management of some poisoning
Poisoning in Medicine Ward

1. Sedative poisoning
Diagnostic tools:
1.       H/O of taking sedatives e.g. Sedil, lexotanil, Bopam etc.
2.       Pt. may be disoriented or drowsy or in deep sleep.
3.       Respiration is normal or depressed.
4.       Planter reflex is normal or extensor.
5.       Pupils mid dilated & sluggish reaction to light.
1.     Diet- normal, plenty of tea, coffee by mouth if Pt. can swallow
2.     NPO till recovery, If pt. is in deep sleep.
3.     O2 inhalation 1-4 L/min, if respiration is depressed.
4.     Infusion 5% DNS 1000 i/v @ 10 drops/ min.
5.     Activated charcoal (Tab. Ultracarbon 2+2+2), if pt. present with in 1 hour.
6.     Antidote of Benzodiazepine- Flumazenil, slowly IV, dose 0.2 mg over 30–60 seconds, repeated in 0.5 mg increments as needed up to a total dose of 3–5 mg.
Flumazenil is a benzodiazepine receptor-specific antagonist; it has no effect on ethanol, barbiturates, or other sedative-hypnotic agents.
Flumazenil should not be used in pt. with H/O seizures or in patients with preexisting seizure disorder, toxin induced cardio toxicity, co-ingestion with TCA. The duration of action of flumazenil is short (2–3 hours) and resedation may occur, requiring repeated doses.
Activated Charcoal: Activated charcoal effectively adsorbs almost all drugs and poisons. Poorly adsorbed substances include iron, lithium, potassium, sodium, mineral acids, and alcohols.
                                                   (Ref. CMDT 2010)
2. Tricyclic antidepressant poisoning (Tryptin)

Clinical features
1.      H/O taking TCA drugs in over doses ie. Amitryptylin
2.      Dilated pupil, ileus, and retention of urine.
3.      Respiration may depressed.
4.      Presence of arrhythmias in ECG may present
5.      Hypotension  may occur
6.      Hyperreflexia with extensor plantar, coma, and seizures.
7.      Improvement can be expected within 24 h.

1.       NPO till further order or recovery.
2.       IV fluids infusion (5% DNS1000cc +5% DA1000cc i.v. @20 drops/min. stat & daily)
3.       Gastric lavage may be given after delayed presentation.
4.       Tab. Ultracarbon 2+2+2
5.       Treatment of arrythmias
6.       If convulsion present Diazepam and phenytoin.
7.       ECG monitoring during the first 24 h and until ECG changes have disappeared for 12 h.
8.       If acidosis present- IV sodibicarb
Note: Sodibicarb available at 7.5% 25 ml
•  Gastric elimination may be useful for 24 h after ingestion because tricyclics slow gastric emptying.
•  Cardiac arrhythmias are more common if there is acidosis. Bicarbonate should be used to achieve an arterial pH of 7.5 urgently.
•   If arrhythmias occur with no acidosis and fail to respond to treatment with amiodarone or phenytoin, bicarbonate (25-50 mL 8.4% IV) may still be useful with in 20 min.
•  If VT compromising cardiac out put, Lidocaine 50-100mg i.v. should be given.
(Ref. Oxford American Hand book of critical care + Parvin Kumar & M. Clark)

3. Stupifying poisoning (unknown poisoning)
Diagnostic tools:
                                   1.            H/O of  poisoning during traveling or ingestion or inhalation of foods or other substances by unknown person.
                                   2.            Pt. in deep sleep or drowsy
                                   3.            Pupil constricted or dilated and light reaction normal or absent
                                   4.            Circulation (Pulse & BP) usually normal
                                   5.            Respiration normal.
(Contradictory-in OPC poisoning pupil is constricted but bradycardia hypotension & crepitation present in lungs).

1.       NPO till further order
2.       Iv fluid Infusion
3.       Inj. Omeprazole (40mg) 1 vial i/v slowly stat and daily
4.       Continued catheterization (antibiotic if catheterization is done)
5.       Monitor vital signs
                    (Ref. National guideline for management of poisoning)

4. Corrosive Poisoning (strong acid & alkali)
1.     NPO TFO
2.     Clearing of the airways
3.     O2 inhalation 4-6 L/min
4.     Irrigate exposed eyes with sterile cold water or saline at least for 20 minutes and continue until the pt. returns to normal
5.     Infusion 5% DNS 1000 + 5% DA 1000 cc i/v @ 20 drops/ min.
6.      Inj. Diclofen 1 amp. im stat. & SOS
7.      Inj. Omeprazole 40 mg IV slowly stat. & B.D.


1.       Dilution or neutralization, induction of emesis, gastric aspiration and lavage are contra-indicated.
2.       Emulcents- egg white, olive oil, butter, cold milk should be avoided.
3.       As there is no specific antidote, symptomatic treatment is to be provided. Neutralization with alkali now a days is not done.
4.       Surgical treatment must be considered for any pt grade ll or lll esophageal injury.
5.       Diagnostic Endoscopy should be performed within 12-24 hours of alkali ingestion.
6.       Corticosteroids have no role in the management of a case and complication. It is rather harmful.
7.       Soluble calcium tablet followed by 10% ca gluconate IV can be given in acid ingestion.
8.       1% NaHCO3 irrigation may be given in eye involvement with steroid eye drops.
                               ( Ref. National guideline for management of poisoning)

5. Dhatura Poisoning
1.     NPO TFO
2.     Stomach wash with in 1 hour
3.     Clearing of the airways
4.     O2 inhalation 4-6 L/min
5.     Infusion 5% DNS 1000 + 5% DA 1000 cc i/v @ 20 drops/ min.
6.      Inj. Omeprazole 40 mg iv slowly stat. & B.D. 
7.      Physostigmine 0.5 mg to 1 mg s/c stat.
8.     Paracetamol suppository
9.     Tepid sponging
10.                         Catheterization done for urinary retention. (antibiotic if catheterization is done).
1.    If stomach is full, no forceful emesis should be tried.
2.    Specific antidote: (l) Physostigmine 0.5 mg to 1 mg s/c to antagonise atropine in a single dose. (ll) Prostigmine is more effective and less toxic than physostigmine in same dose. (lll) Pilocarpine 5 mg s/c, though useful, does not counteract the action of Dhatura on brain, can be repeated 2 hourly at early stage of poisoning.
3.  Delirium can be treated with short acting barbiturates.
4.  To control marked excitement chlorolhydrate or paraldehyde in moderate dose may be given.
5.  Repeated purgation is not recommended.
6.  Forced diuresis is not encouraged.
7.  Light diet, mainly liquid or semi-liquid should be given if the condition is mild.
8.  Other symptomatic treatments.
                                (Ref. National guideline for management of poisoning)

6. Methanol Poisoning
1.       NPO TFO
2.       Stomach wash with in 1 hour
3.       Clearing of the airways
4.       O2 inhalation 4-6 L/min
5.       Infusion 5% DNS 1000 + 5% DA 1000 cc i/v @ 20 drops/ min.
6.        Inj. Omeprazole 40 mg iv slowly stat. & B.D.
7.       Antidode : Ethanol.
                          Loading dose: 10% ethanol 7.5 ml/kg IV over 30   to                                                                                   60 mins
                               Maintaining dose: 10% ethanol 1.96 ml/kg/hr IV.
                                                 If IV not available, then
                              Orally: 95% ethanol, 0.8 ml/kg followed by 0.1 ml/kg/hr can be given.
                           Maintaining dose : 0.2 ml/kg/hr. This alcohol should be diluted in water or fruit juice.

1. Should be hospitalized and must be treated by an ophthalmologist for his visual problems.
2. Stomach wash although advocated, there is no evidence of affectivity with it.
4. In severe cases pt should be incubated and mechanical respiration should be given.
7. Acidosis should be controlled by infusing sodium bi-carbonate.
8. Sedation can be given cautiously to prevent delirium and restlessness.
9. The antidote for methanol poisoning is ethanol.

                             (Ref. National guideline for management of poisoning.)

7. Puffer fish poisoning
1.     NPO TFO except medication
2.     Stomach wash with in 1 hour with 2%  sodibicarb
3.     Clearing of the airways
4.     O2 inhalation 4-6 L/min
5.     Infusion 5% DNS 1000 + 5% DA 1000 cc i/v @ 20 drops/ min.
6.     Inj. Omeprazole 40 mg iv slowly stat. & B.D.
7.     Tab. Ultracarbon 2+ 2 + 2
8.     Atropinization and inj. neostigmine has been used for come round from unconsciousness and restoring neurogenic power both sensory and motor.
      There is no specific antidote, so only symptomatic treatment:
1. Artificial respiration with oxygen inhalation by mask in mild cases and direct ventilatory support and sedation in severe cases.
2. Purgation and forced diuresis to lessen absorbed poison is not recommended.
3. Steroids for life saving measure although contra-indication persists.
                                ( Ref. National guideline for management of poisoning)

8. Opiate Poisoning
a.           NPO TFO except medication
b.           Infusion 5% DNS 1000 cc + 5% DA 1000 cc iv @ 20 d/min
c.            Tab Ultracarbon 2 + 2 + 2
d.           Inj. Omeprazole 40 mg iv slowly stat. & daily
e.            Naloxone can be given to reverse the sign of severe poisoning (coma, respiratory depression or convulsion) within a few minutes but it has a short life and the pt may relapse.

Dose: Administer 0.4–2 mg intravenously, and repeat as needed to awaken the patient. Very large doses (10–20 mg) may be required for patients intoxicated by some opioids (eg, propoxyphene, codeine, fentanyl derivatives).
Caution: The duration of effect of naloxone is only about 2–3 hours; repeated doses may be necessary for patients intoxicated by long-acting drugs such as methadone. Continuous observation for at least 3 hours after the last naloxone dose is mandatory.
9.    Paracetamol Poisoning
1.       NPO TFO except medication
2.       Infusion 5% DNS 1000 cc + 5% DA 1000 cc iv @ 20 d/min
3.       Tab Ultracarbon 2 + 2 + 2
4.       Inj. Omeprazole 40 mg iv slowly stat. & daily
5.       Special antidote: N-Acetylcysteine (NAC), Methionine.
 Adult: 150 mg/kg IV in 200 ml of 5% DA over 15 mins, followed by
 50 mg/kg IV in 500 ml dextrose over 4 hours, followed by
 100 mg/kg IV in 1000 ml 5% DA over 16 hours.

With established hepatotoxicity, continue NAC treatment 50 ml/kg in 500 ml of 5% DA over 8 hours.
Repeat until prothrombin time and liver enzyme begin to return to normal.
                               (Ref. National guideline for management of poisoning.)

10. Savlon poisoning           
Diagnostic tools:
1.     H/O of ingestion of savlon
2.     Burning sensation in throat and upper abdomen.
1.       NPO till further order  except medication
2.       Irrigate exposed eyes with sterile cold water or saline at least for 20 minutes and continue until the pt. returns to normal.
3.       Inj. Omeprazole  (40mg) 1 vial i/v slowly stat and daily
4.       Inj. Amoxicillin (500mg) 1 vial i/v stat & 8 hourly
5.       IV infusion
11. OPC poisoning
1.  External decontamination with water.
2.  Remove clothing. Avoid contamination with other personnel.
3.  Gastric lavage if pt. resent within 1 hour
5.  O2 inhalation 4-6 L/min
6.  Tab Ultracarbon 2 + 2 + 2 if present within 1 hour
7.  Assisted ventilation as appropriate if respiratory failure
8.  Infusion 5% DNS 1000 cc + 5% DA 1000 cc iv @ 20 d/min
9.  Inj. Amoxicillin 500 mg iv stat. & 8 hourly
10.       Inj. Omeprazole 40 mg iv stat. & daily
11.       Atropine 0.6-2 mg repeats after 10-25 min upto atropinasation occurs.
12.       Pralidoxime chloride 2 g IV  over 4 min, repeated at 4-6 hourly
13.       Continued catheterization
14.       Monitor vital sign

12 Poisonous snake bite
         Polyvalent antisnake venom is effective against the following  snake’s  venom
1.       Cobra
2.       Krait
3.       Russel’s viper
4.       Saw scaled viper
Indication of Polyvalent antisnake venom:
1.     Neurotoxic signs
2.     Rapid extension of local swelling
3.     Acute renal failure
4.     Cardiovascular abnormalities
5.     Bleeding abnormalities
6.     Haemoglobinuria / myoglobinuria

                     Look for sign of envenometion
1.     Polyvalent antisnake venom 10 vial + 100 cc 5% DNS or NS iv @ 60 drops/min
2.     If Neurotoxic features- Inj. Atropine 1 amp. iv stat. & 4 hourly, then after 15 min. inj. Neostigmine 4 amp. Subcutaneously 4 hourly.
3.     Antibiotic- if risk of infection or Endotrachael intubation done.
4.     If features of resp. failure-endotracheal intubation.
5.     Follow up 15-30 min. interval by- pulse, BP, Respiratory rate, respiratory movement, adverse effects of antivenom
6.     In case of haemostatic abnormalities
•        Strict bed rest
•        Avoid I/M injection.
•        Fresh blood transfusion.
•        Avoid NSAID or Aspirin for pain 
                    7.Inj. TT & TIG
                   8. Iv infusion
Criteria for repeating the initial dose of antivenom:
•         If no improvement or deterioration after 1-2 hours
•         Persistence or recurrence of blood incoagulability after 6 hours.

Non-poisonous snake bite
•         Symptomatic
•         No NSAID ( Analgesic Paracitamol)
•         No Sedative & anxiolytics
•         Follow up 30 min. interval by- pulse, BP, Resp. rate, resp. movement, features of envenomation.
•         After 24 hours if no features of envenomation then discharge the pt.

Respiratory System

1. Allergic rhinitis
Diagnostic tools
        1. Frequent sudden attack of sneezing
        2. Profuse watery nasal discharge
        3. Nasal obstruction.
     Following management either singly or in combination..
1.      Antihistamine such as Loratidine
2.      Sodium cromoglycate nasal spray
3.     Nasal steroid spray e.g. Beclomethason diproprionate, Fluticasone or Budesonide
4.     Systemic steroid –in which symptoms are severe.

2. Pneumonia
Diagnostic tools:
1.       Fever high grade with cough with sputum (rusty)
2.       Chest pain- pleuritic
3.       On exam. –feature of consolidation like bronchial breath sound present, vocal resonance increased.
   Uncomplicated CAP (community acquired pneumonia)
                    1. Antibiotic for 7-10 days
                        Amoxicilin 500 mg  8 hourly or
                       Clarithromycin 500 mg  12 hourly
                    2. Tab. Paracetamol

     Severe CAP (2 weeks)
1.       Diet- Normal
2.       Inj. Ceftriaxone (1gm) 1 vial i/v stat. & B.D
3.       Tab. Clarin (500mg) 1+0+1
4.       Tab. Paracetamol (500mg) 1+1+1
5.       If Chest pain NSAID- Diclofenac sodium
6.       Assessment of severity
7.       Mechanical ventilation if needed
       -Respiratory rate <7
3. Haemoptasis
  Assesment & diagnosis of underlying cause

1.       Upright position or on the side of the lesion if known
2.       O2 inhalation high flow 4-6 L/min.
3.       iv Fluid Normal saline
4.       Blood transfusion if needed
5.       If chest X-ray shows central lesion then rigid bronchoscopy under GA to secure bleeding point.
6.       Treatment of the underlying cause.
N: B: Blood demand form should be given to all pt. for blood grouping & crossmatching.
4. Bronchiectasis
          Productive cough
        Bilateral Coarse creepitation
A)        Physiotherapy-duration 5-10 mins. Once or twice daily.
i)                   Drained lobe should be upper most
ii)                Deep breathing followed by forced expiratory maneuvers (the active cycle breathing technique)
iii)              Percussion of the chest wall with cupped hands
iv)              Devices (positive expiratory pressure mask)
B)        Antibiotic-Required larger dose & longer duration ( 1-2 weeks) according to C/S.
                Ciprofloxacin 250-750 mg 12 hourly or Ceftazidim 1-2 gm 8 hourly.
C)        Haemoptasis-managed by treatment of the underlying infection. In severe cases percutenous embolisation of the bronchial circulation.
D)        Surgical treatment- Indication
i)                   Young pt.
ii)                Confined to single lobe or segment on CT
iii)              In progressive form of bronchiectasis resection of the destroyed areas of lung.
E)         Airflow obstruction-inhaled bronchodilator (Salbutamol) & corticosteroid (Beclomethasone).
5. Common cold
1.      Tab. Paracetamol 0.5-1 gm 4-6 hourly
2.      Nasal decongestant- Xylometazoline
3.      Antihistamine
6. Acute pharyngitis
Diagnostic tools
1.      Sore throat
2.      Horse voice or loss of voice
3.      Painful unproductive cough
1.       Tab. Paracetamol 0.5-1 gm 4-6 hourly
2.       Steam inhalation (warm water gargaling)
3.       Antibiotic if complicated.

7. Sinusitis
Diagnostic tools:
1.       Fever
2.       Severe unilateral pain over maxillary or other sinuses
3.       Purulent nasal discharge
1.       Steam inhalation
2.       Nasal decongestant- Xylometazoline
3.       Antibiotic Co-amoxiclav for 7 days.
4.       Analgesics
8. Tuberculosis
    Diagnostic tools:
            Sputum for AFB
            Chest X Ray
Standardized treatment regimen for each category (Adult)
Category -1 management
Pre-treatment wt (kg)            Intensive phase                     Continuation phase
    (First 2 months)                          Daily
              (Next 4 months)
     Numbers of 4FDC tablets                  Numbers of 2 FDC tablets
    30-37                        2                                   2
    38-54                        3                                   3
    55-70                       4                                  4
    >70                       5                                  5

Category -II management

Pre-treatment wt (kg)                 Intensive phase                  Continuation phase
   (First 3    months)              Daily
  (First 2 months)                           Daily
             (Next 5 months)
      Numbers of 4FDC tablets           Injection
   Streptomycin     Numbers of
  2 FDC    tablets           Numbers of
    Ehambutol (400 mg)    tablets
   30-37          2         500 mg         2                2
  38-54          3         750 mg         3                3
  55-70          4         1 gm*         4                4
>70          5         1 gm*         5                5

4FDC means- 4 fixed drug combination. These 4 drugs are….
1.       Rifampicin (R) 150mg
2.       Isoniazide (H) 75 mg
3.       Ethumbutal (E) 400 mg
4.       Pyrazinamide (Z) 275 mg

2 FDC means – 2 fixed drug combination. These 2 drugs are-
1. Rifampicin (R) 150 mg
2. Isoniazid (H) 75 mg.

Q. Why 4 drugs are used in intensive phase?
Ans: To kill rapidly proliferating Mycobacteria.

Q. Why 2 drugs are used in continuation phase?
Ans: To kill the dormant bacteria.

9. Antitubercular drug induced hepatitis
Diagnostic tools
1.      H/O of taking Anti TB drugs
2.      Yellow coloration of eye & urine
3.      Anorexia, nausea & vomiting
4.      Investigation- S. Bilirubin- Increased, SGPT-Increased, Alkaline phosphatase- normal, Exclusion of other causes of hepatitis- by HBsAg, AntiHBC, AntiHBE and USG of hapato billiary system & Bil >1.2 mg/dl, SGPT>2 times than normal
    Treatment is symptomatic
1.     Stop the offending drugs till hepatitis subside
2.     Complete bed rest
3.     Diet- normal
4.     Tab. Domperidone(10mg) 1+1+1     (1/2 hour before meal, if vomiting)
5.     Cap. Omeprazole (20mg) 1+0+1    (1/2 hour before meal)

a)     Treatment should be restarted when pt. symptomatically well and S. Bilirubin and SGPT become normal.
b)    Where there is no scope to do S. Bilirubin and SGPT then Rx. Can be restarted 14 days after the urine or eye become normal.
                       Ref: Nation guideline of management of tuberculosis.

10. Pneumothorax
1.      Bed rest
2.     O2 inhalation
3.     Treatment of the underlying cause if any e.g. Pnemonia, COPD etc.
4.     Water sealed drainge(percutaneous needle aspiration)- Indication:
                                                                   i.            Immediate decompression prior to definitive therapy in tension pneumothorax
                                                                 ii.            In open or close pneumothorax- Pt. age < 50 years with pneumothorax > 15% of hemithorax or significant dysponea.
5.     Intercostal tube drainge
                                                                        i.            Tension pneumothorax
                                                                      ii.            Pneumothorax with underlying chronic lung disease e.g. COPD
                                                                   iii.            In open or close pneumothorax -Pt. age > 50 years with >15 % of hemithorax or significant dysponea
                                                                   iv.            When >2.5 L air aspirated or Pneumothorax persists after percuteneous needle aspiration (water seal drainage).
Indication of Surgery in pneumothorax:
1.     In all pt. following a second pneumothorax
2.     Following first episode of primary pneumothorax 
Surgeries are
             -Pleurodosis. (Can be achieved by pleural abrasion or parietal pleurectomy at thoracotomy or thoracoscopy).   

1.      Stop smoking
2.      Avoid flying 1-2 weeks following full inflation of lung

11. Empyema thorasics
1.     Draining of the pus- intercostals tube drainge
2.     Antibiotic iv co-amoxiclav or Cefuroxime plus metronidazole
3.     Surgical intervention- if IT tube not providing drainge, when the pus is thick or loculated.
4.     Surgical decortication of lung – if gross thickening of the visceral pleura is preventing re-expansion of lung.

12. Sarcoidosis
Diagnostic tool
1.       Erythema nodosum
2.       CXR (P/A)- Bilateral hilar lymphadenopathy
1.       Avoid sun light exposure
2.       NSAID for erythema nodosum
3.       Steroid-Prednisolone 20-40 mg/day
a)      Symptoms severe
b)     Hypercalcaemia
c)      Pulmonary impairement
d)     Renal impairement
e)     Uveitis

4.       Inhaler corticosteroid in asymptomatic parenchymal sarcoid
5.       Topical steroid for mild uveitis
6.       Severe disease    - MTX 10-20 mg / week
                               -Azathioprine 50-150 mg/day
                               -Specific TNF alpha inhibitor
7.       Cuteneous sarcoid
a)     Chloroquine
b)    Hydroxychloroquine
c)     Low dose thalidomide

13. Pulmonary hypertension
1.       O2 inhalation
2.       All pt. should be anticoagulant with warfarin
3.       Diuretics
4.       Digoxin
5.       Specific treatment
d)    High dose calcium channel blocker e.g. Amlodipine
e)     Prostaglandins such as epoprostenol (prostacyclin) or iloprost therapy
f)      PDE inhibitor Sildenafil
g)     Oral endothelin antagonist- Bosentan
6.       Atrial septostomy
7.       Pulmonary thromboendarterectomy
8.       Heart- lung transplantation.

14. Acute severe Asthma
  Diagnostic tools:
1.     Past H/O of asthma
2.     Severe breathlessness with cough
3.     Patient unable to talk due to breathlessness
4.     On exam. Pulse > 110/min, R.rate- > 25/ min, Pt. May be cyanosed, bilateral poly phonic rhonchi present, but chest may be silent.

1.     Diet- normal
2.     O2 inhalation 2-5 L/min
3.     Propped up position
4.     Nebulization with Normal saline 1.5 cc + Salbutamol solution 0.5 cc stat. and 20 min interval for 1 hour then 1-4 hourly.
5.     Inj. Hydrocortisone 100 mg 2 vial iv stat. then 4-6 hourly.
6.     Inhaler Salbutamol 200 µgm 2 puff stat. & 6 hourly
7.     Inhaler Beclomethasone 250 µgm 2 puff 12 hourly (Gargling after use)
8.     Tab. Theophylline 400 mg ½ + 0 + ½.

 NB:  IV hydrocortisone can be replaced by oral steroid after 24-48 hours.
 Costly regimen- Inhaler Salmetrol & Fludicasone combination. 2 puff 12 hourly. (gargling after use).
 If pt. can buy only one inhaler then give steroid inhaler.
15. Acute exacerbation of COPD
Diagnostic tools:
1.     Age > 40 years
2.     Smoking H/O
3.     Severe breathlessness with cough
4.     Previous H/O of hospitalization
5.     On exam. Pulse > 100/min, R.rate- > 25/ min, Pt. May be cyanosed, Breath sound vesicular with prolonged expiration,bilateral poly phonic rhonchi & creps  present (if infection).

3.     Diet- normal
4.     O2 inhalation 1-2 L/min
5.     Propped up position
6.     Nebulization with Normal saline 1.5 cc + Salbutamol solution 0.5 cc + Ipratropium bromide solution 0.5 cc stat. and 20 min interval for 1 hour then 1-4 hourly.
7.     Inj. Hydrocortisone 100 mg 2 vial iv stat. then 4-6 hourly.
8.     Inhaler Salbutamol & Ipratropium bromide combination 2 puff stat. & 6 hourly
9.     Inhaler Beclomethasone 250 µgm 2 puff 12 hourly (Gargling after use)
10.                  Tab. Theophylline 400 mg ½ + 0 + ½.
11.                  Tab. Azithromycin 500 mg 1 + 0 + 0

 IV hydrocortisone can be replaced by oral steroid after 24-48 hours.
 Costly regimen- Inhaler Salmetrol & Fludicasone combination. 2 puff 12 hourly. (gargling after use).
Antibiotic should be other than the previous one that was used in last 3 month

Renal system

1. Acute glomerulonephritis (Nephritic Syndrome)
  Diagnostic tool
1.      Swelling of face, leg & eyelid
2.      H/O of skin lesion 1-4 weeks before
3.      Oliguria, haematuria, fever
4.      On exam. –Puffy face, BP-high, leg edema present
                          -Bed side urine exam. - proteinuria.
                                                               - Haematuria
Treatment is supportive, with control of hypertension, edema, and dialysis as needed. Antibiotic treatment for streptococcal infection should be given to all patients and their cohabitants in poststreptococcal AGN.
1.      Diet – Normal, protein, salt, fruit, fluid restricted (previous day out put + 400cc)
2.      Tab. Cefuroxime axetil (250mg) (in post streptococcal GN then Phenoxymethyl penicillin)
3.      Tab. Frusemide (40mg)
4.      Tab. Ramipril (1.25mg)
      0+0+1         (gradually increasing the dose to titrate BP)
5.      Please maintain input out put chart.
  The inflammatory glomerular injury may require corticosteroids and cytotoxic agents.
  Postinfectious Glomerulonephritis- Corticosteroids have not been shown to improve outcome.
(Ref: Harrison’s principle of Internal Medicine)

2. Nephrotic syndrome
Diagnostic tool
1.      Generalized edema
2.      Massive proteinuria- Frothy urine
3.      24 hours total urinary protein > 3.5 gm
4.      Urin volum- normal
5.      Usually haematuria absent
1.       Diet – Normal, protein, salt, fruit, fluid restricted (previous day out put + 400cc)
2.       Tab. Cefuroxime (250mg)
3.       Inj. Frusemide(20mg)
                   1 amp. I/v stat & 1 amp at 8 a.m. & 4 p.m.
               5.  Tab. Ramipril (1.25mg)
                0+0+1  (gradually increasing the dose)
6. Prednisone, 1 mg/kg/d orally 
7. Tab. Atrovastatin (10mg) 0 + 0 + 1 after meal (if hypercholesterolemia)
8. Please maintain input output chart.
a)      Duration of steroid- usually shorter duration (8 weeks) in children but in adult it may take 20- 24 weeks.
b)      Patients with frequent relapses and corticosteroid resistance may need cyclophosphamide or chlorambucil to induce subsequent remissions.
(Ref: Harrison’s principle of Internal Medicine +Ref. CMDT 2010)         

3. Acute pyelonephritis
Diagnostic tool
1.      High fever with chills & rigor
2.      Loin pain, dysuria, haematuria, frequency of micturition
3.      On exam. - Temperature high
                             - Renal angle tenderness present.
1.    Diet –normal
2.    Antibiotic 1st line (duration10 days)
-Ciprofloxacin (500mg)
    -Co-amoxyclav (500/125mg)                                                                                       
3.    Tab. Paracetamol if fever
     Antibiotic 2nd choice in seriously ill pt. (duration 7-14 days)
•    Cefuroxime iv (750mg) 8 hourly
•    Gentamycin iv
   (Ref: Davidson’s principle & practice of Medicine 21st edition, page 471)
4. Urinary Tract Infection (UTI)
Diagnostic tools:
1.    Dysuria, haematuria, frequency of micturition with fever with chills & rigor
2.    Urine R/E- pus cell > 5/HPF
3.    C/s- growth > 105

     Antibiotic- 3 days in women, 10 days in men
A.      First choice
Trimethoprim 200 mg 12 hourly

B.       2nd choice
•         Amoxicilin 500 mg 8 hourly or
•         Nitrofuratoin 50mg 6 hourly or
•         Ciprofloxacin 100mg 12 hourly  or
•         Co-amoxyclav (250/125mg) 8 hourly
C. In Pregnancy 7 days
•         Cephalexin 250mg 6 hourly  or
•         Amoxicilin 250mg 8 hourly

   (Ref: Davidson’s principle & practice of Medicine 21st edition, page 471)

5. Acute renal failure
Diagnostic tools
•  H/O of vomiting or diarrhoea or massive blood loss
•  Oliguria or anuria
1.      Diet: Protein, salt, fruit restricted
2.      Fluid restricted- fluid intake previous day output  + 400 cc
3.      Infusion Normal saline if pt. dehydrated
4.      Antibiotic in case of infection.
5.      Cap. Omeprazol (20mg) 1+0 +1
6.      Inj. Frusemide (20mg) 2 amp iv stat. and daily (if feature of fluid retension)
7.      Maintain input & output chart
Follow up:
•  Pulse
•  BP
•  Hydration status
•  Urine out put
•  S. creatinine & blood urea
•  ECG
Indication of Renal replacement therapy (dialysis or transplantation) in acute renal failure:
                1. Hyperkalaemia K+ >6 mmol/L
                2. Fluild overload & pulmonary edema
                3. Metabolic acidosis
                4. Increased plasma urea and creatinine (urea > 180 mg/dl & creatinine >6.8 mmol/L)
                5. Uraemic pericarditis/ uraemic encephalopathy
6. Chronic renal failure
Diagnostic tools:
1.      H/O of Hypertension or diabetes
2.      Pt. complain of anorexia, vomiting, generalized weakness
3.      On exam.- Anaemia present
c)      Hypertension present
4.      S. creatinine- raised.
1.      Diet: Protein, salt & fruit restricted protein 60 gm daily
2.      Tab. Calcium carbonate (500mg) 1+0+1
3.      Cap. Cholicalciferol (0.25 µgm) 0+1+0
4.      Tab. Ferrous sulphate 1+0+1
5.      Treatment of the underlying cause like Hypertension, DM etc.
6.      If anemia persists after iron therapy then
Inj. Epoietin (25-50IU/kg body wt. once or twice in a week).

Antihypertensive used in CRF
1.      First choice- ACEI, ARB, Non-dihydropyridines CCB (Amlodipin)
2.      Alpha receptor blocker
3.      Betablocker (Atenolol)
N: B: 1-2 week after giving ACEi or ARB if s.creatinine increased 25 % than previous record then stop ACEi or ARB).                                                                                                                 
Indication of dialysis in CRF (WHO criteria)
1.    Uraemic pericarditis
2.    Uraemic encephalopathy or neuropathy
3.    Pulmonary edema unresponsive to diuretics
4.    Severe hypertension if not control by medical management
5.    Severe hyperkalaemia not control by medical management
6.    Severe bleeding diathesis
7.    S. Creatinine > 12 mg/dl or BUN > 100mg/dl
       Ccr (creatinine clearance) can be estimated from the formula of Cockcroft    and Gault:
        Ccr = (140- age) × body weight / 72 × S. creatinine (mg/dl)
For women, the creatinine clearance is multiplied by 0.85 because muscle mass is less.
Staging of CKD
Stages of CKD                             GFR (ml/min/1.73m2)
Stage 1                                               ≥90 (with evidence of kidney damage)
Stage 2                                               60-89
Stage 3                                               30-59
Stage 4                                               15-29
Stage 5                                                <15 or dialysis

N: B: kidney damage means pathological abnormalities or marker of damage, including abnormalities in urine tests or imaging studies. Two GFR values 3 months apart are required to assign stage.                       

CVS diseases
1. Vasovagal syncope
Diagnostic tools
1.      Syncope triggered by reduction in venous return due to
a)      Prolonged standing
b)      Excessive heat
c)      Large meal
2.      Head up tilt test +Ve.
         Pt. is asked to lie on a table that is then tilted to an angel of 60 to 700 for up to 45 min. while ECG & BP are monitored. A positive test is characterized by bradycardia and/ or hypotension associated with typical symptoms.
                                            I.      Life style modifications
i)                    Salt supplementation
ii)                  Avoid prolonged standing
iii)                Correct dehydration
iv)                Avoid missing meal
                                         II.      Pt. resistant to life style measure
i)                    Fludrocortisone
ii)                  Beta blockers
iii)                Disopyramide
                    3. Dual chamber pace maker if symptoms due to bradycardia.

2. Acute pulmonary oedema
1.      Propped up position
2.      O2 high flow 4-6 L/min via face mask
3.      Administer Nitrates such as iv GTN 10-200 µg/min or buccal GTN 2-5 mg titrated upwards every 10 min, until clinical improvement occurs or systolic BP falls to < 110 mm of Hg.
4.      Frusenide iv 50-100mg
5.      iv opiates e.g. Morphine
6.      Ionotropic agent- to augment cardiac out put in particularly hypotensive pt.
7.      Insertion of intraaortic ballon pump
              - in pt. with acute Cardiogenic pulmonary edema secondary to myocardial iscahemia.
        Monitoring of the pt. with
a)      Cardiac rhythm
b)      BP & Pulse oximetry
3. Chronic heart failure
          General measure
1.      Education of the pt.
2.      Diet
     - Good general nutrition
     - Weight reducing diet for obese.
3. Alcohol
      - Moderation or elimination
      - Abstinence in alcohol induced cardiomyopathy.
4. Smoking cessation
5. Exercise – regular moderate aerobic exercise with in limit of symptoms
6. Vaccinatuion- influenza & pneumococcal.
       Pharmacologiocal therapy
1.      Diuretic therapy
  Frusemide oral
   Frusemide iv in pt. with severe chronic HF particularly in presence of chronic renal impairement in which edema persist despite oral loop diuretics.
    Aldosteron receptor antagonist e.g. spironolactone & eplerenone. They improve long term clinical outcome in pt. with severe HF or HF following acute MI.
2.      Vasodilator therapy
- Nitrates
3.      ACEi
      Can easily be started in otherwise stable pt & SBP>       100 mm of Hg.
      In other pt. diuretics should be stopped for 24 hours & the ACEi start at low dose.

                       ACEi                    Starting dose          Target dose
                  i) Enalapril             2.5 mg 12 hourly        10 mg 12 hrly
                 ii) Ramipril              1.25 mg daily              10 mg daily.

4.      ARB Have similar effect to that of ACEi
                                                      Starting dose          Target dose
                            Losarton                 25 mg/day               100 mg/day.

5.      Combined ACEi & ARB
Indication-HF pt. in those with recurrent hospitalization for HF.
6.      Beta blocker therapy
         More effective than ACEi in reducing mortality. Bisolol starting dose at 1.25 mg daily increase gradually over 12 weeks to a target maintainance dose of 10 mg daily.
7.      Digoxin
      To provide rate control
      Also in NYHA III, IV
8.      Amiodarone
- Effective in pt. of symptomatic arrhythmia
- Should not be used in asymptomatic arrhythmia.
4. Valvular heart disease

Mitral stenosis
      Medical management of all valvular diseases is almost same
1.      Diet- normal
2.      Avoid strenuous exercise
3.      O2 inhalation sos
4.      Tab. Penoxymethyl penicillin (250mg) 1 + 0 + 1
5.      Tab. Frusemide (40mg) 1+0+0
6.      Tab. Digoxin 0.25mg 0+0+1 if Atrial fibrillation
7.      Tab. Ecospirin (75mg) 0+1+0 (P/C) if Atrial fibrillation
8.      In MR ACEI should be given
9.      In AR systolic BP should be controlled with Nifedipine or ACEi
Indication of surgery in Mitral stenosis
1.      Patient symptomatic despite medical treatment
2.      If pulmonary hypertension develops
3.      Severe mitral stenosis
4.      Pregnancy
2 types of surgery can performed in Mitral stenosis
        1. Valvuloplasty
        2. Valve replacement
Indication of mitral valvuloplasty in mitral stenosis
1.      Significant symptom
2.      Isolated MS
3.      No (trivial) MR
4.      Mobile, non-calcified valve/ subvalve apparatus on Echocardiogram
5.      Left atrium free of thrombus
Indication of mitral valve replacement in mitral stenosis
1.      MS with MR
2.      Rigid & calcified mitral valve cups
Contraindication of surgery
         1. Active rheumatic carditis

Mitral regurgitation
Indication of surgery in Mitral Regurgitation (valve replacement or repair)
1.      Worsening symptoms
2.      Progressive cardiomegally
3.      Echocardiographic evidence of deteriorating left ventricular function.

Aortic stenosis
Indication of surgery in Aortic stenosis
1.                  Development of angina
2.                  Development of syncope
3.                  Symptoms of low cardiac output
4.                  Heart failure
Pt. with moderate to severe stenosis is evaluated every 1-2 year with Doppler Echocardiography to detect progression of severity.

Indication of surgery in aortic regurgitation
1.                  Symptomatic pt.
2.          Asymptomatic pt. should be followed up annually with Echo for evidence of increasing ventricular size, if this occurs or if the end systolic dimension increases to ≥ 55mm the aortic valve replacement should undertaken.

5. Myocardial infarction
Diagnostic tools
1.      Classical chest pain > 30 min.
2.      ECG changes
3.      Biochemical markers e.g. Troponin I.
For diagnosis 2 criteria should be present.
•         ECG changes
  ST elevation
  New onset left bundle brunch block
  Evolution of ‘Q’ wave
    ECG changes may be isolated or in combination
•         Biochemical markers
  CK-MB > 2 fold increase
  Troponin I or T raised level indicate myocardial necrosis.
1.    Complete bed rest
2.    Diet- liquid to semisolid
3.    O2 inhalation 4-6 L/min
4.    GTN spray 2 puff sublingually stat. & sos
5.    Tab. GTN SR 2.6 mg 1/2 + 0 + 1/2 + 0
6.    Tab. Ecospirin (75mg) 4 tab. Stat. & Tab. Clopidogrel (75mg) 4 tab. Stat.
       Tab. Clopidogrel & Aspirin   0 + 1 +0 (after meal)
     7. Cap. Omeprazole (20mg) 1 + 0 + 1 ( before meal)
8. Tab. Metoprolol (50 mg) ½ +0 + ½
9. Tab. Ramipril ( 1.25 mg) 0 + 0 +1
10. Tab. Atrovastatin 10 mg     0 + 0 + 1 after meal
11. Inj. Morphine 3 mg iv stat. & SOS (may be repeated after 15 min.)
12. Inj. Stemetil 1 amp. Im stat. Along with Morphine
13. If pt. present with in 12 hours then thrombolysis with Streptokinase or PCI
14. Management of Risk factors e.g. Hypertension, DM etc.
15. Continuous monitoring with pulse rate, rhythm & BP

Mobilization and rehabilitation
  In uncomplicated cases
a)      Sit on chair on 2nd day
b)      Walk to toilet on 3rd day
c)      Return to home on day 5 to 7
d)     Gradually increasing activity & return to normal work in 4 to 6 week
  In complicated cases
-Process of mobilization & rehabilitation varies & depends upon the pts functional capacity.

To be continue... ... ...