Neurology
1. Tension type Headache
    Management:
1.          Explanation of symptoms
2.          Avoid precipitation
3.          Analgesics-NSAID
4.          Muscle relaxation
5.          Amitryptyline
6.          Phycotherapy.

2. Migrain
     Acute attack
1.        Identification & avoidance of precipitating or exacerbating factors such as OCP, smoking
2.        Analgesic-NSAID or Paracetamol
3.        Metochlopramide or domperidon
4.        Severe attack- Sumatryptan, 5-HT agonists
5.        Frequent attack  are prevented with
  Propanolol
  TCA
  Sodium valproate 300-600mg/day or Topiramate 50 -100 mg/day.
3. Status epilepticus
      Management:             
                    Clearing the airway
                     O2 inhalation

                    Inj. Diazepam 10mg (Sedil) iv or rectally
                     Can be repeated after 15 min.

                   If seizure continued after 30min. then
                   i.v. Fosphenytoin 15mg/kg at 100mg/min.     
                                Or
                    i.v. Phenobarbital 10mg/kg at 100mg/min.

                   If seizure still continued after 30min. then
                  Start treatment for refractory status with intubation with general          anaesthesia with Propofol or Thiopental.

Once status controlled start longer term anticonvulsant medication with one of the following-
a)      Sodium valproate 10mg/kg i.v. over 3-5 min. Then 800-2000mg/day.
b)      Carbamazepine 400mg by NG tube then 400-1200mg/day.

Guideline for choice of Antiepileptic drugs
Epilepsy type             1st line                 2nd line            3rd line
1. Partial or 2ndary GTCS      Carbamazepine          Sodium valproate         Phenobarbital
                (200-2000mg/day)                                                Phenytoin
               2-3 dose/day

2. Primary GTCS         Sodium valproate        Lamotrigine                Phenobarbital
                          400-2500/day                             60-180mg/day 1-2 dose/day
                          1-2 dose/day                                                     Phenytoin
                                                                                              Carbamazepine
4. Acute stroke
    Diagnostic tools
•      Sudden onset of weakness of one side of the body or loss of consciousness
•      No H/O of fever
•      On exam. Hemiplegia and planter extensor in that side.
Management:
1.      NG tube feeding
2.      O2 inhalation 2-4 l/min
3.      Infusion Normal saline 1000cc iv @ 10 drops/min
4.      Syrp. Amoxicillin 2 TSF TDS
5.      Omeprazole sachet 1 sachet dissolve in ½ glass water then take via NG tube 12 hourly
6.      Paracetamol suppository (500mg) 1 stick P/R stat. and SOS
7.      Cold tepid sponging
8.      Continued catheterization
9.      Change the posture 2 hourly
10.   Care of the mouth, eye, bowel
11.   Treatment of underlying cause like DM, Dyslipidaemia etc.

•      If pt. is known hypertensive and taking drug regularly then contd. the drug.
•       If pt. is not known hypertensive & BP is high then not give antihypertensive. Antihypertensive should be given in the following condition
                  -In Ischaemic stroke if BP >220/120 mm of Hg
                  -In Haemorrhagic stroke > 180/ 110 mm of Hg
•      If pt. is Diabetic then start insulin
•      If pt. is not known diabetic but blood sugar is >11.1 mmol/L then start insulin.

5. Tetanus
Management
1.      O2 inhalation stat 4-6 L/min
2.      Nurse in a quite room
3.      Avoid unnecessary stimuli
4.      NG tube feeding 200 ml 2 hourly
5.      Infusion 5% DNS 1000 cc i.v. daily
6.      Inj. Benzylpenicillin 600mg iv 6 hourly Or inj. Metronidazole if allergic to Penicillin
7.      Inj. TIG 12 amp. i.m. stat.
8.      Inj. Diazepam (10mg) 1 amp. i.v. stat & B.D.
9.      Change the posture 2 hourly

6. Meningo-encephalitis
Diagnostic tools
1.         Fever, Headache
2.         Alteration of consciousness
3.         On exam.- Neck rigidity present
1.      Kernig’s sign present
Management:
1.         NG tube feeding 200 ml 2 hourly in sitting posture & maintain the posture for 10 min.
2.         Inj. Ceftriaxone (2gm) 1 vial i.v. stat & BD
3.         Inj. Dexamethasone 2 amp. i.v. 20 min before giving antibiotics stat & 6 hourly for 3 days
4.         Omeprazole sachet 1 packet dissolve in ½ glass water through NG tube BD
5.         Continued catheterization
6.         Change the posture 2 hourly
7.         Care of mouth, eye & bowel
8.         If short H/O of fever then add Tab. Acyclovir (400mg) 2+2+2+2+2

Pyogenic Meningitis Choice of antibiotic
1.         Pt. present with typical meningococcal rash- Inj. Benzylpenicillin 2.4gm iv 6 hourly
2.         Adult aged 18-50 years without typical meningoccal rash – Cefotaxime 2 gm iv 6 hourly or Ceftriaxone 2 gm iv 12 hourly.
3.         Pt. in whom penicillin resistant pneumococcal infection is suspected- as for (2) but add Vancomycin 1 gm iv 12 hourly or Rifampicin 600mg iv 12 hourly
4.         Adult aged over 50 years and those in whom Listeria monocytogen infection is suspected (Brainstem sign, immunosuppression, diabetic, alcoholic)- as for (2) but add Ampicillin 2 gm iv 4 hourly or Co trimoxazole 50mg /kg iv in 2 divided dose.

7. Encephalitis                   
     Diagnostic tools
4.         Fever, Headache
5.         Alteration of consciousness
6.         On exam. - No Neck rigidity
                     -No Kernig’s sign.
   Management:
1.      Same as Mningo-encephalitis
2.      If convulsion occurs then add Tab. Carbamazepine (200mg) 1+1+1.

8. Trigeminal neuralgia
  Management:
a.       Carbamazepine up to 1200 mg daily should be started at low dose. Who can not tolerate it add Gabapentin or Pregabaline.
b.      Inj. of Alcohol or Phenol in to a peripheral branch of the nerve.
9. Restless leg syndrome
  Management:
1.         Clonazepam (0.5-2mg) at night
2.         Levodopa 100-200 mg or dopamine agonist at night.

10. Subarachonoid Haemorrhage
  Management:
1.         Nimodipine 30-60 mg iv for 5-14 days followed by 360 mg for further 7 days.
2.         Definitive treatment
a.       Insertion of platinum coil in to an aneurysm via endovascular procedure
                Or
b.      Surgical clipping of the aneurysm neck.
                  AV malformation –surgical removal, ligation, injection of material to occlude the fistula or draining veins.

11. Transverse Myelitis
  Management:
1.          Diet – normal
2.          Inj. Methylprednisolone 1 gm daily for 3 days
3.          Omeprazole
4.          Continued catheterization

12. Dementia/ Alzheimer;s disease
  Management:
1.         Donepezil 10 mg daily
2.         Antidepressant in depressive pt.

13. Wernick- Korsakoff disease
     Diagnostic tools
1.        H/O alcoholism, malabsorption, malnutrition, Hyperemesis gravidarum
2.        Acute confusional state (W.encephalopathy)
3.        Brain stem sign e.g. ataxia, nystigmus & extraocular muscle weakness particularly lateral rectus.
   Management:
1.       Intravenous Thiamine 2 vial 8 hourly for 48 hours, then oral Thiamine 100 mg 8 hourly
2.       Treatment of the underlying cause.

14. Parkinsonism
  Management:
1.         Levodopa –carvidopa, 50 mg 8 or 12 hourly increased up to 1000 mg/day. This drug improve bradykinesia & rigidity
2.         Anticholinergic-improve tremor & rigidity
3.         Trihexyphenidyl (benzhexol 1-4 mg 8 hourly)
4.         Orphenadrine 50 -100 mg 8 hourly
3.         Dopamine receptor agonist
5.         Bromocryptine 1 mg initially then 2.5 mg 8 hourly up to 30 mg/day
6.         Pergolide 50 µgm (starting dose) increased to 250 µgm 8 hourly up to 3000 µgm/day.
4.         Amantadine
              -Use in early of the disease when more potent treatment is not required
              -To control dyskinesia produced by dopaminergic treatment.
Dose 100 mg 8 or 12 hourly.
5.         COMT inhibitors
         Entacapone 200 mg with each dose of levodopa. This prolonged the effect of levodopa & allows levodopa dose to be reduced & given less frequently.
6.         Surgery
        Stereotactic thalamotomy to treat tremor. Now a days need relatively infrequently
7.         Physiotherapy & speech therapy.

15. Huntington’s disease
       Symptomatic management
7.         Tetrabenazine or dopamine antagonists such as sulpride
8.         Antidepressants for depressive pt.
9.         Psycological support
10.     Genetic counselling for the relatives
16. Rabies
  Management:
       Established disease
1.          ICU support
2.          Sedation with Diazepam 10 mg 4-6 hourly
3.          Chlorpromazine 50-100 mg if necessary
4.          Nutrition & fluid by iv or gastrostomy.
       Prevention
             Pre-exposure prophylaxis – protection is afforded by 2 intradermal injection of 0.1 ml human diploid cell vaccine or 2 intramuscular inj. Of 1 ml, given 4 weeks apart, followed by yearly booster.
             Post exposer vaccination before development of sign symptom. For maximum protection hyperimmune serum and vaccine are required.
Safest antirabies antiserum is human rabies immune globulin, the dose is 20 U/kg, half should be infiltrated around the bite and half im at adifferent site from vaccine.
Safest vaccine is human diploid cell vaccine 1 ml is given  intramuscularly on days 0, 3, 7,14, 30 and 90.

17. Cerebral abscess
Treatment:
1.         Diet – normal
2.         Antibiotic
3.         Anticonvulsant- Carbamazepine SR 200 mg B.D.
4.         Paracetamol if fever
5.         Surgery
       Burr-hole aspiration or excision-where presence of a capsule may lead to a persistent focus of infection.

Antibiotic choice is guided by following condition
        Frontal lobe
                     Cefuroxime 1.5 gm iv 8 hourly
                      Plus
Metronidazole 500 mg 8 hourly.
       Temporal lobe & Cerebellum
                        -Ampicillin 2-3 gm iv 8 hourly
                                   Plus
                       -Metronidazole 500 mg 8 hourly
                                  Plus
Either Ceftazidime 2 gm iv 8 hourly or Gentamycin 5 mg/ kg iv   daily.
       Any site
                   H/O penetrating injury
                    -Flucloxacillin 2-3 gm iv 6 hourly
                                     Or
                   - Cefuroxime 1.5 gm iv 8 hourly
      Multiple abscesses
                 -Benzylpenicillin 1.8 – 2.8 gm iv 6 hourly if endocardits or cyanotic heart disease.
                  - Otherwise Cefuroxime 1.5 gm 8 hourly
                                         Plus
                  Meteronidazole 500 mg 8 hourly.

18. Idiopathic intracranial hypertension
  Management:
1.        Weigh reducing diet
2.        Avoid any precipitating condition or medication
3.        Carbonic anhydrase inhibitor-Acetazolamide
4.        Repeated LP
5.        Optic nerve fenestration or lumbo-peritoneal shunt if
              -Pt. failing to respond
              -Chronic papilloedema threatens vision.

19. Lumber disc herniation
  Management:
1.       Back strengthening exercise
2.       Early mobilization
3.       Analgesic
4.       Inj. Of local anaesthetic agent or corticosteroid, if symptoms due to ligamentus injury or joint dysfunction
5.       Surgery
          -No response to conservative treatment
          -progressive neurological deficits develops
          -Central disc herniation with bilateral symptoms & signs & distrubnance of sphincter function require urgent surgical decompression.

20. Fascial nerve palsy
  Management:
1.        Artificial tear & ointment
2.        Eye should be tapped shut overnight
3.        Prednisolone 40-60 mg daily for 7 days (should be started with in 72 hours).

21. Guillain-Barre Syndrome
  Management:
1.       Regular monitoring of the pt. with respiratory function, VC & ABG
2.       Artificial ventilation if VC < 1 L
3.       Protection of the airway
4.       Prevention of pressure sore
5.       Plasma exchange or IVIg (should be started with in 14 days).

22. Myasthenia Gravis
  Management:
1.       Pyridostigmine 30-120 mg 6 hourly
2.       Propanthelin 15 mg to control diarrhea & colic
3.       Immunological treatment of M. Gravis are
11.     Thymectomy
12.     Plasma exchange
13.     IVIg
14.     Corticosteroid (must be started in hospital)
15.     Use of other immunesuppressive agent e.g. Azathioprine 2.5 mg/ kg daily.

Hepatobilliary & Pancreatic diseases

1. Liver abscess
Diagnostic tool
1.    Fever high grade, comes with chills & rigor
2.    Upper abdominal pain
3.    Liver enlarged tender.
Organism causing liver abscess
1.      E. histolytica
2.      E. coli
3.      Pseudomonas
4.      Streptococus
5.      Staphylococcus etc.
Management (mixed or undifferentiated liver abscess)
1.    Diet- normal
2.    Antibiotics Before C/S – Ampicillin, Gentamycin & Metronidazole
3.    If severe pain then –Inj. Tramadol HCl 1 amp. i.m. stat & SOS
4.    If fever tepid sponging
7. The underlying source (e.g. biliary disease, dental infection) should be identified and treated.
  Antibiotics are administered for 2–3 weeks, and sometimes up to 6 weeks.
  Fungal abscesses are associated with mortality rates of up to 50% and are treated with intravenous amphotericin B (total dose of 2–9 g) and drainage.
Indication of drainage of liver abscess
 
1.    If the abscess is at least 5 cm in diameter
2.      If the response to antibiotic therapy is not rapid
3.      Fungal abscess
4.      Other suggested indications for abscess drainage are
              -Age of at least 55 years
             -Symptom duration of at least 7 days and
            - Involvement of both lobes of the liver. 
                                                  (Ref. CMDT 2010)
2. Acute hepatitis                         
Diagnostic tool
1.    Yellow colouration of eye & urine
2.    Fever, anorexia, nausea, vomiting, joint pain
3.    On exam. –Jaundice, tender Hepatomegally.

Management
1.    Complete bed rest
2.    Diet- normal
3.    Infusion 10% DA 1000 cc i/v @ 20 drops/ min stat & daily (If nausea and vomiting are pronounced or if oral intake is substantially decreased)
4.    Tab. Ursocol (300mg) 1+0+1   ( if feature of cholestasis e.g. Itching, staterrhoea)
5.    No Paracetamol/ NSAIDs/ Sedatives, antiviral, IM injection
6.    Monitor for liver failure

Follow up:
1.    Pulse, Blood pressure
2.    Orientation, Sleep status
3.    Bowel movement
4.    Urine out put
5.    Flapping tremor
6.    Appearance of new sign, symptoms e.g. itching, staterrhoea etc.

Indication of Hospitalization in a Hepatitis pt.
a)      Pronounced anorexia, vomiting requiring parental nutrition
b)      S. Bilirubin >15 mg/dl
c)      Prolonged prothrombin time
d)     Co-morbidities- like DM, IHD
Criteria of hospital discharge-
a)      Substantial symptomatic improvement
b)      A significant downward trend in the serum aminotransferase and bilirubin values and
c)      A return to normal of the PT
d)     Mild aminotransferase elevations should not be considered contraindications to the gradual resumption of normal activity.
     ( Ref: Harrison’s principle of Internal Medicine + CMDT 2010)

3. Acute liver failure
Hyperacute liver failure- if jaundice to encephalopathy time < 7 days
Acute liver failure- if jaundice to encephalopathy time 7-28 days
Subacute liver failure- if jaundice to encephalopathy time 29 days-12 weeks.

Diagnostic tools
•      Yellow colouration of eye & urine
•      Alteration of consciousness
•      On exam.-Jaundice present
                     - Pt. may be drowsy, disoriented or unconscious
                -Flapping tremor may be present
                -Planter bilateral extensor
Conservative Management (should be in ICU)
1.      NG tube feeding
2.      Infusion 10% DA 1000 cc iv @ 10 drops/ min stat. & daily
3.      Inj. Ceftriaxone(1gm) 1 vial iv stat. & daily
4.      Omeprazole sachet 1 sachet dissolve in ½ glass water then take via NG tube 12 hourly
5.      Syrp. Lactulose 2 TSF TDS (if constipation present)
6.      Inj. Vit. K (10mg) 1 amp. Iv stat. & daily for 3 days
7.      Syrp. UDCA 2TSF TDS
8.      Continued catheterization
9.      Change the posture 2 hourly
10.  Monitor vital signs
Definitive treatment is liver transplantation &
N-acetylcystein in paracetamol induced liver failure.
Follow up:
-          Conscious level by GCS
-          Bowel movement
-          Flapping tremor
-          Pulse, BP, urine out put.
N: B: Target of bowel movement is 2 times daily, if not achieved then increased dose of lactulose from 2TSF to 6 TSF daily. If still target not achieved then give enema simplex.
4. Chronic liver disease
    Diagnostic tools:
               CLD pt. usually present in the ward with complications like huge     ascites, haematemesis & melaena, encephalopathy etc. other mode of presentations are-
1.        Pt. present with swelling of abdomen
2.        H/O of jaundice previously
3.        On exam. – Ascitis& splenomegally
4.        Investigation
1.         Transudative ascitis
2.         USG feature suggestive of CLD & splenomegally
3.         Endoscopy of upper GIT may reveal esophageal varices.       

Management:
1.    General Measures
                                                              i.      Abstinence from alcohol. (If alcoholic).
                                                            ii.      Fluild & salt restricted
                                                          iii.      Vitamin supplementation is desirable.
                                                          iv.      Patients with cirrhosis should receive the HAV, HBV, and pneumococcal vaccines and a yearly influenza vaccine.
                                                            v.      Complete bed rest
2.    Tab. Spironolactone ( 25 mg)
2+2+0
3.    Tab. Frusemide (40 mg)
1+ 0+0
4.    Tab. Propanolol (20mg) {If feature of portal HTN}
1+0+1
5.    If cause of CLD is viral then add Antiviral
6.    If there is constipation then add
                          Syrp. Lactulose 2 TSF TDS
7.    Regular follow up the pt. with pulse, BP, flapping tremor, weight, abdominal girth.
N.B      In patients who cannot tolerate spironolactone because of side effects, such as painful gynecomastia, Amiloride (another potassium-sparing diuretic) may be used in a dose of 5–10 mg orally daily.
Target of bowel movement is 2 times daily. Lactulose can be used up to 6 TSF 8 hourly.
The goal of weight loss in patient with ascitis without associated peripheral edema should be no more than 1–1.5 lb/d (0.5–0.7 kg/d).

Large-volume paracentesis
Indication
a)      In patients with massive ascites and respiratory compromise,
b)      ascites refractory to diuretics, or
c)       intolerable diuretic side effects
N.B
Large-volume paracentesis (4–6L) is effective by giving intravenous colloid such as human albumin (6-8 gm per liter of ascities removed) or another plasma expander.

Target of weight loss is average 1 kg /day. Diuretic should be started with 100 mg Spironolactone then double the dose (up to 400 mg/ day) after 48 hours. If still no desirable effect then add Frusemide 40 mg daily, maximum 160 mg/ day.

5. Haematemesis & Melaena
      Diagnostic tool
1.      H/O vomited out of blood and passes of black tarry stool.
2.      There may be H/O of taking NSAIDs , PUD, CLD
3.      On exam. - Pulse – Tachycardia, BP- may be hypotensive, epigastric  tenderness/mass, feature of CLD – Splenomegally, Ascitis may be present.
     
Management
1.      NPO TFO
2.      Infusion Normal saline 1000 cc + 5% DNS 1000 cc i/v @ 20 drops/ min stat and daily
3.      Inj. Pantoprazole (40mg) 2 vial i/v stat slowly then 5% DA 500 cc + Inj. Pantoprazole  (40mg) 3 vial i/v @ 8 drops /min .
                   Then
Infusion 5% DA 500 cc + Inj. Pantoprazole  (40mg)   2 vials) i/v @ 8 drops /min daily.
4.      Blood transfusion- indicated
                  - If pt. is in shock
                  -or rebleeding/ massive bleeding occurs.
(Feature of rebleeding are Fresh Haematemesis & Melaena with shock or Fall of Hb >2gm/dl in 24 hours).
5.      Close monitoring of the pt. with Pulse, BP, and urine out put and Hb%.
6.      If bleeding continues then Therapeutic Endoscopy.
   Tips
  A systolic blood pressure less than 100 mm Hg identifies a high-risk patient with severe acute bleeding.
  A heart rate over 100 beats/min with a systolic blood pressure over 100 mm Hg signifies moderate acute blood loss.
  A normal systolic blood pressure and heart rate suggest relatively minor hemorrhage.
  In actively bleeding patients, platelets are transfused if the platelet count is under 50,000/mm3 and considered if there is impaired platelet function due to aspirin or clopidogrel use (regardless of the platelet count).
  Uremic patients (who also have dysfunctional platelets) with active bleeding are given three doses of desmopressin (DDAVP), 0.3 mcg/kg intravenously, at 12-hour intervals.
  Fresh frozen plasma is administered for actively bleeding patients with a coagulopathy and an INR > 1.5.
  In the face of massive bleeding, 1 unit of fresh frozen plasma should be given for each 5 units of packed red blood cells transfused.
  Predictor of rebleeding- clinical predictors of increased risk of rebleeding and death include
a.       Age > 60 years,
b.      Co morbid illnesses,
c.       Systolic blood pressure < 100 mm Hg,
d.      Pulse > 100 beats/min, and
e.       Bright red blood in the nasogastric aspirate or on rectal examination.
Features of active bleeding: Patients with active bleeding manifested by hematemesis or bright red blood on nasogastric aspirate, shock, persistent hemodynamic derangement despite fluid resuscitation, serious co-morbid medical illness, or evidence of advanced liver disease require admission to an intensive care unit (ICU). Urgent Endoscopy should be performed after adequate resuscitation, usually within 12 hours.
                                                        (Ref. CMDT 2010)
6. Acute pancreatitis
   Diagnostic tool
1.      Severe constant upper abdominal pain may radiate to back relieve by sitting and leaning forwards.
2.      Fever & vomiting
3.      On exam. - Upper abdominal tenderness but no rigidity and rebound tenderness.

     Urgent Investigation
1.      S. amylase
2.      S. lipase ( if Pt. present after 48 hours)
3.      ECG
4.      USG of whole abdomen
     Management
1.      NPO TFO
2.      O2 inhalation 4-6 L/ min
3.      Infusion Normal saline 1000 cc + 5% DNS 1000 cc i/v @ 20 drops/ min stat and daily
4.      Antibiotic-Imipenem (500 mg every 8 hours intravenously) and possibly cefuroxime (1.5 g intravenously three times daily, then 250 mg orally twice daily) administered for no more than 14 days
5.      Inj. Omeprazole (40mg) 1 vial i/v stat. & daily
6.      Inj. Tramadol HCl (100mg/ml) 1 amp. i.m. stat & 8 hourly
7.      NG suction if paralytic illus develops
8.      Close monitoring of the pt. with Pulse, BP, and urine out put.
N: B:
•    If cause of acute pancreatitis is gall stone then Surgery should be performed after 2 weeks of recovery.
•    Oral intake of fluid and foods can be resumed when the patient is largely free of pain and has bowel sounds (even if the serum amylase is still elevated).
       (Ref. CMDT 2010 + Oxford American Hand book of critical care.)
7. Chronic pancreatitis
  Management:
1.        Avoidance of alcohol
2.        Analgesia with NSAID or Opiate
3.        Oral pancreatic enzyme supplement
4.        Dietary fat restriction
5.        PPI
6.        Coeliac plexus neurolysis or minimally invasive thoracoscopic splaniectomy sometimes required.
                                                                                           (Ref: Davidson)
8. Variceal bleeding
  Management:
1.          NPO TFO
2.          Normal saline 1-2 liter
3.          Prophylactic antibiotic – Cephalosporin iv
4.          PPI
5.          Vasopressor (Terlipressin)-2 mg iv 6 hourly until bleeding stops then 1 mg 6 hourly for further 24 hours
6.          Endoscopic procedure to stop variceal bleeding
  Band ligation
            -Should be repeated 1-2 week until varices are obliterated. Regular follow up endoscopy is required to identify & treatment of any recurrence of varice.
  Ballon tamponade- Sengstaken-Blakemore tube
7.          TIPSS- pt. in whom other treatment is not successful & those with good liver function.
8.          Oesophageal transection
   - When TIPSS is not available
  - Bleeding can not be controlled with other therapies.
9. Portal hypertension
  Management:
1.         Management of variceal bleeding
2.         Primary prevention of variceal bleeding
3.         Propanolol 80-160 mg daily or nadalol.( administration of these drugs at doses which reduces heart rate 25% has shown to be effective in primary prevention).
4.         Secondary prevention- Beta blocker following banding.

10. Alcoholic liver disease
  Management:
1.        Cessation of alcohol
2.        Nutrition
3.        Steroid
Indication:
         - Severe alcoholic hepatitis, Maddreys discrimination score >32
Contraindication:
i)                                Existing sepsis
ii)                              Variceal haemorrhage
               If bilirubin has not fallen 7 days after starting therapy in treatment with steroid, then steroid is unlikely to reduce mortality & should be stopped.
4.        Pentoxifylline
5.         Use in severe alcoholic hepatitis
6.         It appears to reduce incidence of hepato-renal failure
7.         Its use is not complicated by sepsis.
    5. Liver transplantation

11. NAFLD
  Management:
1.        Reduce BMI
2.        Metformine- 1st line treatment in pt. with DM & NAFLD.
Pioglitazone also improve inflammation & fibrosis.

12. Haemochromatosis
    Primary
1.        Weekly venesection of 500 ml of blood (250 mg of iron) until S. iron is normal; this may take up to 2 year or more. The aim is to reduce ferittin <50 µg/ L
2.        Treatment of associated DM & Cirrhosis
3.        Asymptomatic 1st degree family members should be investigated preferably by genetic screening & plasma feritin & iron binding saturation.
      Liver biopsy is indicated if
              -LFT abnormal
              -And/or S. feritin is>1000 µg/ L
      Asymptomatic disease is also treated by venesection
4.        Screening of HCC by USG

13. Wilson’s disease
  Management:
1.    Penicillamine –most pt. require 1.5 gm/day (1-4gm/day). The dose can be reduce once the disease is in remission.
Treatment should be continued through out the life including pregnancy. Abrupt discontinuation may precipitate acute liver failure
2.    Trientrine dihydrochloride 1.2-2.4 gm/day & Zinc 50 mg 8 hourly, if side effects of penicillin occur.
3.    Liver transplantation
-          In fulminant  liver failure
-          Advance cirrhosis with liver failure.
4.    Siblings & children of pt. with Wilson’s disease must be investigated & treatment should be given to all affected individual even if they are asymptomatic.

14. Autoimmune Hepatitis
   Management:
   Prednisolone 40 mg daily
          - Dose can be reduced as the pt. & LFT improve. Maintainance therapy is required for at least 2 years after LFT have returned to normal & withdrawl of treatment should not be considered unless liver biopsy is also normal.
- Azathioprine 1-1.5 mg/kg/day allows the dose of prednisolone to be reduced.

15. Primary billiary cirrhosis
Diagnostic tools:
1.      Female patient
2.      Middle age
3.      Flactuating  jaundice
4.      History of itching.
Asymptomatic
        Require monitoring on a yearly basis to assess the onset of symptom & also the disease.
Symptomatic
1.        UDCA 13-15 mg/kg/day
2.        Liver transplantation if
            - Liver failure
            - Intractable pruritus
3.        Pruritus (Cause- up regulation of opoid receptor & increase endogenous opoid)
       Managed by
i)                    Cholestyramine 4-16gm/day, the powder mixed in orange juice then taken before & after breakfast. It is ineffective in complete billiary obstruction.
ii)                  Alternative treatment
8.         Rifampicin 300 mg/day
9.         Naltrexone (opoid antagonist) 25 mg/ day up to 300 mg /day
10.     Plasmapheresis
11.     Liver support device.
4.        Fatigue –no treatmnent , exclude depression & Hypothyroidism
5.        Supplementation of fat soluble vitamins
6.        Bone disease
         Replacement of calcium & vit.D3
         Bisphosphonate if evidence of Osteoporesis.

16. Acute cholecystitis
  Management:                                               
1.         NPO
2.         Fluid IV
3.         Analgesic-moderate pain-NSAID
4.         Severe pain-Pethidine
5.         Antibiotic-Cephalosporin (cefuroxime), severely ill add Metronidazple.
6.         NG aspiration- if persisting vomiting
7.         Surgery should be performed after 6 weeks.

Electrolytes imbalance
1. Ward management of Hyponatraemia
In the ward maximum case of hyponatraemia are hypovoluemic hyponatraemia.
Normal Na+ 135- 145 mmol/L
Hyponatraemia if  Na+ <135 mmol/L.
Correction:
Before correction total deficiency of Na+ in the body should be calculated.
Total deficiency = (Desired value – Measured value) × body weight × 0.6.
Total deficiency should be corrected with in 3 days.
So, daily correction = Total deficiency/3
Daily correction also depends upon cause, rate of development and severity of Hyponatraemia.
If Na+ is > 125 mmol/L then oral correction
If Na+ is < 125 mmol/L then iv correction.
  1 TSF table salt contain  96 mmol/L Sodium
  1 L Normal saline contain 154 mmol/L Sodium
  500 ml 3% Sodium contain 512 mmol/L Sodium.

Problem: A pt. present with vomiting followed by unconsciousness. His Na+ is 110 mmol/L. How we will correct his Na+?
Total deficiency = (135 - 110) × 50 × 0.6 mmol/L (His weight is 50 kg).
                           = 750 mmol/L
Daily correction = 750/3
                           = 250 mmol/L
So, we have to give 1 L of Normal saline and 1 TSF Table salt daily (approximately) for 3 days.

1.        Ward management of Hypenatraemia 
Choice of type of fluid for replacement
Hypernatremia with hypovolemia
  Hypovolemic patients should receive isotonic (0.9%) saline to restore the volume deficit and to treat the hyperosmolality.
  After adequate volume resuscitation with normal saline, 0.45% saline or 5% dextrose (or both) can be used to replace any remaining free water deficit.
  Milder volume deficits may be treated with 0.45% saline and 5% dextrose.
    Hypernatremia with euvolemia
Water ingestion or intravenous 5% dextrose will result in the excretion of excess sodium in the urine. If the glomerular filtration rate (GFR) is decreased, diuretics will increase urinary sodium excretion.
    Hypernatremia with hypervolemia
  Treatment includes 5% dextrose solution to reduce hyperosmolality. Loop diuretics may be necessary to promote natriuresis and lower the total body sodium.
  In severe rare cases with kidney disease, hemodialysis may be necessary to correct the excess total body sodium and water.
3. Treatment of hypocalcaemia
     Management:
a)       In hyperventilation- rebreathing expired air in a paper bag or administer 5% CO2 in oxygen
b)       Inj. 20 ml of 10% solution of Calcium gluconate i.v. slowly stat.
                       Or
Inj. 20 ml of 10% solution of Calcium gluconate i.m. may be given to obtain a prolonged effect.

4. Treatment of severe hypercalcaemia of malignancy
Management:
1.     Rehydration with Normal saline as much as 4-6 L/min. (May need monitoring with CVP in old age or renal impairment)
2.    Bisphosphonates e.g. Disodium Pamidronate 90 mg i.v. over 4 hours
3.    Additional rapid therapy
a)       Forced diuresis with saline & Frusemide
b)       Prednisolone 40mg daily
c)      Calcitonin
d)      Haemodialysis
5. Hypokalaemia
Normal K+ is 3.5-5.5 mmol/L
Hypokalaemia if < 3.5 mmol/L 
Management:
             Oral correction is safest and easiest way for mild to moderate hypokalaemia K+ >2.5 mmol/L.
             Intravenous potassium is indicated for patients with severe   hypokalemia and for those who cannot take oral supplementation & if K+ is < 2.5 mmol/L.
           1 amp. Inj. Electro- K contains 20 mmol/ L of K+.         2 amp. Inj. In 1 L NS then iv @ 10 d/min.
Precautions:
1.      A rate of 20 mEq/h may be given through a central venous catheter.
2.      Continuous ECG monitoring is indicated, and the serum potassium level should be checked every 3–6 hours.
3.       For the initial administration, avoid glucose-containing fluid to prevent further shifts of potassium into the cells.
4.      Magnesium deficiency also needs to be corrected at the same time, particularly in refractory hypokalemia.
6. Hyperkalaemia
Normal K+ is 3.5-5.5 mmol/L
Hyperkalaemia if > 5.5 mmol/L 
Management:
1. iv Calcium gluconate 10 ml of 10 % solution
2. Nebulization with Salbutamol solution
3. iv glucose 50 ml of 50 % (in ward we use 25 % glucose 100 ml) plus inj. Actrapid 5 IU.
These 3 are commonly practiced in the ward. Other treatment options-
1.      Inj. Iv Sodium bicarbonate
2.      iv Frusemide and Normal Saline
3.      Ion –exchange resin (e.g. resonium orally or rectally)
4.      Dialysis.