Dr Sunil’s One Page Solutions for General Practice K Sunil Ravinder Paul
INDEX
A
Abacavir 63
Abdominal distension 64
Abdominal pain 127, 225
acute 227
differential diagnosis 226
chronic 228
Abdominal paracentesis tapping 375
Abortion 277
medical abortion 277
surgical abortion 277
Abscess 64, 168, 394
aspiration 375
brain 386
Brodies 306
cold 78
nonlactational 166
peritonsillar 212, 322, 323
Abstain 203
Acanthosis nigricans 195
Acebrophylline 316
Aceclan 131
Aceclofenac 107, 131
Acetaminophen 154, 419
Acetic acid 143
Acetylcysteine 154
Acid
prophylaxis 373
suppression 239
Acidosis 28
Acne 195
inflammatory 195
rosacea 196
vulgaris 205, 211
differential diagnosis of 205
Actinic keratosis 212
Acupressure 60
Acupuncture 60, 126
Acute coronary syndrome 135, 178
Acute respiratory distress syndrome 100
Acute unilateral painful edema, etiology of 45
Acyclovir 61, 121, 264, 419
Adenoma 332
Adenosine 406
Adrenal crisis 103
Adrenal insufficiency, acute 103
Adrenaline 8, 369, 404, 406, 411
injections and infusions 408
dose 408
indications 408
Advanced cardiac life support 160, 370
Advanced cardiovascular life support 403
Advanced trauma life support 158
classification 97
Aeromonas 235
Agitation 311
Airway
and breathing 136
obstruction 156
protect 74
Alanine aminotransferase 454
Albendazole 3, 253, 397
Albumin 428
excretion, abnormalities in 18
Albuminuria 460
Alcohol
intake 183
type 88
Aldosterone 177
antagonist 176, 178
Alfuzosin 254
Alkaline phosphatase 454
Allen's test 345
Allergic dermatitis 398
Allergic reaction 54, 403, 404
Allergic rhinitis, treatment of 214
Allopurinol 202
Alopecia areata 196, 209
Alpha blockers 69, 112
Alpha hemolytic streptococci 376
Alpha-glucosidase inhibitor 34
Alprax 65
Alprazolam 65, 75, 279, 309
Amikacin 115
Amiloride 178
Amine precursor 334
Aminopenicillins 202
Aminophylline 406, 422
infusion 409
Amiodarone 328, 406, 420
Amitriptyline 61, 75, 84, 200, 310
Amlodipine 69, 70, 420
Amoxclav 106
Amoxicillin 6, 115, 239
Amrinone 407
Anabolic steroids 251
Anaerobes
bacteria 382
predominate 376
Anal fissure 229
acute 229
chronic 229
etiology 229
Analgesic 373, 403
ladder 133
Anaphylactic shock 102
clinical features 102
etiology 102
treatment 102
Anaphylaxis 28, 385, 403, 404
Anastomoses, stoma of 237
Ancylostoma duodenale 397
Anemia 1
blood transfusion in 3
etiology of 1, 2
family history of 3
pernicious 1
treatment of 2
Anesthesia 368, 374
infiltration 369
laryngeal mask 74
topical 371
types of 368
Aneurysms 347
classification 348
Angina 173
pectoris 70, 178
unstable 183
Angioedema 385
Angiotensin-ii receptor blockers 68
Animal bite 6, 55, 138
wound, treatment of 6
Ankylosing spondylitis 353
Ann Arbor classification 80
Anorectal discharge 265
Anorexia 50
and weight loss 4
red flags 4
treatment 5
Antecubital fossae, dermatoses of 207
Anthracyclines 422
Anthrax 357, 358
Antibiotic 377, 383, 385
actions, barriers to 383
dilution 383
dosage 380
groups 385
prophylaxis 141
resistance 383
spectrum of 381
treatment, duration of 384
Anticardiolipin antibodies 354
Anticholinergics 373
Anticoagulants 9
for deep vein thrombosis 406
Antidiabetic agent 34
Antidote 154, 406
Antiemetics 134, 373, 403
Antifungal medicine 414
Antifungal treatment 194
Antihypertensive agent 420, 421
Antimicrosomal antibodies 354
Antioxidants 88, 432
Antiphospholipid syndrome 353
Antiplatelet 8, 181
restart 8
Antipyretics 403
Antirheumatic drugs, disease modifying 297
Antiseptics 435
Antisnake venom, indications for 139
Antispasmodics 403
Antiviral drugs 382
dosage 382
Anxiety 308, 311
diagnosis 308
treatment 308
Anxiolytics 373
Aortic dissection 152, 170, 174
Aphthous stomatitis, recurrent 189
Aphthous ulcers 189, 217
diagnosis 217
differential diagnosis 189
etiology 189, 217
investigations 189
treatment 190, 218
Apixaban 9
Appendicectomy 436
Appendicitis 230
acute 230
diagnosis 230
differential diagnosis of 231
investigations 230
scoring 230
treatment 231
Appetite stimulants 433
Arm
dermatoses of 207
edema 45
Arrhythmias 112
Arsenic 154
Arterial carbon dioxide pressure 156
Arterial disease, peripheral 341
Arterial insufficiency 396
Arterial occlusion, acute 342
Arterial oxygen pressure 156
Arthritis 292, 294, 469
acute 292, 294
chronic 294
comparison of 293
etiology 292
seronegative 295
Arthropathy 40
Artificial blood 14
Artificial insemination donor 259
Ascariasis 355
Ascitic fluid
analysis 463
cell count 464
inspection 463
infection categorization 464
Aspartate transaminase 354
Aspirin 8, 181, 420
Asthma 313, 314, 317
acute 317
intermittent 316
persistent
mild 316
moderate 316
severe 316
Atenolol 69, 152
Atherosclerosis 341, 343
investigations 341
Athletes foot 202
Atopic dermatitis 208
diagnosis of 205
Atorvastatin 43, 180
Atraumatic needles 375
Atrial fibrillation 365
Atropine 154, 373, 374, 404, 411
infusion 407
Autoimmune
bullous disorders 202
disease 16, 353, 469
hemolysis 3
orchitis 262
thyroiditis 328
Autologous serum therapy 204
Autonomic nervous disorders 111
Autonomic signs 185
Avian influenza 357
Avulsed tooth 55
Axillary hairs 198
Azaprine 309
Azelaic acid 196, 202
Azithromycin 106, 196, 285, 320
Aztreonam 397
B
Bacteria
atypical 382
classification of 376
Bacterial arthritis, suspected 293
Bacterial vaginosis 285
Balanced diet daily 87
Baldness, treatment 197
Banned drugs 423
side effects 423
used for 423
Barbiturates 112, 154
Basal cell carcinoma 362
Basal insulin 36
Basic life support 160
Basophil 449
B-complex and minerals 432
Beclomethasone 315
Bed sore 117
Bee sting 55
Beef tapeworm 397
Behavior therapy 92
Bell's palsy 5
clinical features 5
etiology 5
investigations 5
treatment 5
Benign breast lumps
natural history of 163
treatment of 164
Benign positional vertigo, diagnosis of 123
Benzalkonium cream 198
Benzodiazepine 64, 112, 154, 309
Benzoyl
peroxidase 198
peroxide 196
Beta blockers 69, 154, 176, 177, 181, 309, 336
Betahistine 122
Betamethasone 398
valerate 205
Biguanides 35
Bilastine 203
Bile acid sequestrants 43
Biopsy 78, 168, 218, 478
excision 479
incision 479
types of 478, 479
Bioterrorism 355, 358
Bisoprolol 69, 177
Bisphosphonates 134
Bitter taste
etiology 190
treatment 190
Black fever 356, 357
Bladder
carcinoma in situ of 270
stone 275
Blastocystis 235
Bleeding 7, 55, 405
diathesis 9
etiology 7
examination 8
external 98
gums 190
etiology 190
treatment 190
nose 55
place of 98
postoperative 98
red flags 7
site of 148
stop 8
tendency 9
Blepharitis 222
Blood
and blood transfusion 10
and urine tests 160
component 10, 11
transfusion, indications for 12
composition 10
conservation 13
fractions 10, 11
glucose level, self-monitored 32
group 10, 11
loss 405
substitutes 14
supply assessment 255
test 53, 168
volume loss 97
Blood pressure 66
investigations 67
staging of 67
systolic 71
treatment 68
Blood sugar
fasting 31
levels 31
random 31, 136
Blood transfusion
complications 12
prevention of 13
methods to reduce 13
reactions, treatment of 12
Blue nevus 210
Body odor, treatment 197
Body ringworm 203
Bone
and joint 397
healing 142
pain, chronic 286
Borrelia vincentii 188
Botulism 358
Bowel resection 436
Boyd's grading 344
Brachial plexitis 130
Bradycardia 139
Brain 355
attack, acute 29
damage, prevention of 23
death, criteria for 151
injury
secondary 149
treatment 150
Brainstem reflexes 151
Breast 162, 469
cysts 168
infections 166
support garments 163
Breast abscess 166
treatment 166
Breast cancer 164
clinical features 165
diagnosis 165
risk factors 164
screening 165
treatment 165
types of 165
Breast lumps 163
investigations 164
Breast pain 162
chart, maintain 162
Breath malodor 192
Breathing 159
difficulty 26
Breathlessness 170
Bromocriptine 163, 279
Bronchial asthma 398
Bronchitis 394
Bronchodilators 316, 413
Bronchospasm 71, 74
exercise-induced 316
Bronchospastic disease 70
Brucellosis 357
Budesonide 315
turbuhaler 315
Buerger's disease 343, 345
Bulk laxative 233
Bullous pemphigoid 202
Bumetanide 177
Bupivacaine 368, 369
Bupropion 84, 104
Burn 135
chemical 55
classification of 135
complications of 137
electrical 137
estimation of 135
pathophysiology of 135
respiratory 137
size and depth of 136
treatment 136
types of 135
unit, indications for 136
wound 55
treatment of 136
Burning building 56
Burning mouth syndrome 191
etiology 191
treatment 191
Buserelin 279
Buspirone 84
Bywaters syndrome 304
C
Caffeine 154
Calamine lotion 121
Calcipotriol 195
Calcitonin 334
Calcium
channel blockers 69
gluconate 407
metabolism 340
stones 271, 273
tablet 432
Calculation of body mass index 90
Calicivirus 235
Callus 206
Calpol 58, 131
Campylobacter 235, 357
jejuni 376
Cancer 333, 359
detect 359
etiology 359
investigations for 359
staging of 360
treatment of 361
Cancrum oris, spread of 188
Candida albicans 285, 376
Candidiasis 209
treatment of 197
Capreomycin 115
Capsaicin 41, 132
patch 126
Captopril 177
Carbamate 154
Carbamazepine 61, 132
Carbohydrates 42
Carbon
dioxide laser 195
monoxide 154
Carcinoma 168, 188
oral cavity, staging of 219, 360
Carcinoma tongue 220
clinical features 220
investigations 220
treatment of 221
Cardiac arrest 156, 157, 160
Cardiac chest pain, ischemic 172
Cardiac enzymes 178, 180
Cardiac stress tests 182
Cardiogenic shock 103, 404
etiology 103
investigations 103
type 103
Cardiology 469
Cardiopulmonary emergency 404
Cardiopulmonary resuscitation 144, 160
Cardiovascular agent 420, 421
Cardiovascular changes 430
Cardiovascular system 369, 403
Carmustine 422
Carotid angiogram 347
Carotid arteriogram 347
Carotid artery
disease 347
stenosis 347
Carpal tunnel syndrome 130
Carvedilol 69, 177
Cast, type of 461
Cavernous venous thrombosis 396
Cefadrox 106
Cefadroxil 106, 320
Cefazolin 106
Cefixime 266, 285
Cefoperazone 397
sulbactam 38
Ceftazidime 397
Ceftriaxone 49
Cefuroxime axetil 320
Celiac disease 353
Cellulitis 14, 105
clinical features 14
complications 14
differential diagnosis 15
investigations 15
recurrent 393
treatment 15
Centchroman 163
Central femoral joint arthritis 298
Central nervous system 184, 366, 386, 406
dysfunction of 159
Central venous pressure 375
Cephalexin 320
Cephalosporins 202
dosage 378
spectrum of 379
Cereals 87
Cerebrospinal fluid 114
analysis 466
Cervical 395
etiology 292
nodes, drainage area of 77
radiculopathy 129
rib 346
Cervical pain 291
examination 292
red flags 291
Cervical-spine immobilization 158
Cervicitis 285
Cetirizine 203
Chagas disease 355
Charcoal, activated 154
Charcot arthropathy 40
Chemical peeling 195
Chest pain 172
cardiac causes 173
differential diagnosis of 180
gastrointestinal causes 174
noncardiac causes 172
Chickenpox 120, 393
Chikungunya 49, 50, 355, 357
Chlamydia 325
trachomatis 265
Chloasma 200
Chlordiazepoxide 309
Chlorhexidine washes 198
Chloroquine 396
Chlorpheniramine 200
maleate 203, 405
Chlorpromazine 64, 251
Chlorthalidone 69, 70
hydrochlorothiazide 177
Chlorzoxazone 107, 132
Choking 55
Cholecystectomy 436
Cholera vaccine 119
Cholestasis 251
markers of 453
Cholesterol 41
absorption inhibitor 43
Cholestyramine 43
Cholinergic agent 233
Cholinergic symptoms 152
Cholinesterase inhibitors 154
Chondromalacia patella 298
pain of 298
Chronic kidney disease 15, 17
complications 19
dialysis 19
diet 19, 20
etiology 17
stages of 17
treatment of 18
Chronic lower limb ischemia, etiology of 343
Chronic obstructive pulmonary disease 313, 314, 365
Cilnidipine 69
Cilostazol 344
Cinnarizine 122
Ciproflox 254
Ciprofloxacin 320
Cisplatin 422
Citalopram 310
Clarithromycin 106, 115, 239, 320
Clavulanate 115
Clavulanic acid 6, 397
Clindamycin 38, 106, 196, 397
Clobetasol propionate 201, 205
Clofazimine 115
Clomipramine 260
Clopidogrel 8, 180, 420
Clostridium
difficile 235
species 376
Clotrimazole 203
paint 194
Cloxacillin 106
Coagulation tests 456
Coamoxiclav 251
Codeine 131
Cognitive behavioral therapy 126
Cognitive restructuring 92
Colchicine 198
Cold compress 422
Colesevelam 43
Collapse, causes for 111
Colloid 72, 425
composition of 426
nodule 330
Colonoscopy 231
Coma 21
etiology 22
physical examination 22
Commensal microbial flora 376
Common cold 24, 49
Communication 441, 442
channels of 441
modes of 441
types of 441
Compartment syndrome 304
Complete blood count 447
Compression syndromes 130
Confusional state, acute 29
Congestive cardiac failure 404
Congestive heart failure 366, 404
Conjunctivitis 222
Connective tissue disease 353, 469
investigations 354
mixed 353
Conscious sedation 372
advantages 372
disadvantages 372
drug in 185
monitoring 372
Consciousness, loss of 111
Constipation 231
alarm symptoms 231
chronic primary 366
complications 232
etiology 232
investigations 232
physical examination 232
red flags 231
treatment 233
Contact dermatitis, diagnosis of 205
Contraception 277
drugs 277
method 277
Coombs test 3
Copper
containing intrauterine device 277
sulfate 154
Core needle biopsy 169, 375
Coronary angiogram 180
Coronary artery disease 179, 183
Coronary heart disease 339
Coronavirus disease-2019 (COVID-19) 357, 358
Correct lifting techniques 291
Corticosteroid 134, 398
inhaled 315, 316
injections 60
Cortisone 398
Corynebacterium 201
minutissimum 198
Coryneform bacilli 376
Cough 317
acute 318
chronic 319
expectorants 319
investigations 319
suppressants 319
treatment 319
Coumadin 154
Cracks on soles 24
etiology 24
treatment 24
Creatinine 136
phosphokinase 456
Crisis Management Committee, role of 446
Crisis
dealing with 445
prevent 445
reaction to 445
reasons for 445
Critically ill patient 25
assessment 27
evaluation of 25
treatment 28
Crohn's disease 353
Cruris 202
Crush syndrome 304
Cryptosporidiosis 235
Crystalloids 72, 425
composition of 425
Cubital tunnel syndrome 130
Culdocentesis 375
Curare 155
Curling's ulcer 117
Cushing's ulcer 117
Cutting needle 375
Cyanide 155
poisoning 155
Cyclical mastalgia 162
pathophysiology of 162
Cyclophosphamide 422
Cycloserine 115
Cyclosporiasis 235
Cyproheptadine 204
Cysticercosis 355
Cystine stones 273
Cysts, superficial 399
Cytomegalovirus 454
Cytoplasmic antineutrophil cytoplasmic antibodies 354
Cytoprotective agents 239
Cytotoxic drugs, extravasation of 422
Cytotoxins 138
D
Dabigatran 9
Dacarbazine 422
Dairy products 87
Dakin's solution 143
Danazol 163, 279
Dandruff, treatment of 197
Dapoxetine 260
Dapsone 196, 198
Darifenacin 270
de Quervain's tenosynovitis 131
Decarboxylation 334
Decubitus ulcer 117
Deep subcutaneous injection 372
Deep vein thrombosis 350
complications 351
prevention of 351
treatment of 351
Deflazacort 398
Delirium 29, 145, 311
etiology 30
history and clues 30
red flags 29
treatment 30
Dementia 366
Dengue 49, 50, 355, 357
Depression 309, 366
diagnosis 309
medicines 412
treatment 310
Dermatitis, perioral 211
Dermatology, steroids in 205
Dermatomyositis 353
Desmopressin 8
Deworm 3
Dexamethasone 64, 84, 398, 405, 407
Dextropropoxyphene 131
Dextrose 411
Diabetes 470
related complications 33
screening 32
Diabetes mellitus 31, 41, 405, 454
complications 33
diagnosis of 31
investigations 34
red flags 31
treatment 34, 35
types of 31
Diabetic foot 37, 470
complications 38
etiology 38
infection, treatment for 40
investigations 38
red flags 37
signs 38
symptoms 38
treatment 38
Diabetic ketoacidosis 146
signs 146
symptoms 146
Diabetic neuropathy 40
Diabetic sensorimotor neuropathy 40
Diaphoresis 311
Diarrhea 234
acute 234
after eating 236
chronic 236
causes of 237
classification 234
management 234
Diathermy 8
Diazepam 132, 185, 309, 373, 402, 407
Diclofenac 107, 131
Diclofenac gel 126, 163
Dicyclomine 133
Didanosine 63
Dietary cholesterol 42
Diethyl carbamazepine citrate 396
Diethylcarbamazine citrate 397
Differential cell count 466
Digestive enzymes 433
Digitalis 155
therapy 429
Digoxin 176, 177, 407
Diltiazem 69, 402, 407
Dimenhydrinate 84
Dimercaprol 154
Dipeptidyl peptidase-4 inhibitor 34
Dipropionate 315
Direct antiglobulin test 3
Discoid lupus erythematosus 208
Disinfection 435
Dix–Hallpike maneuver 123
Dizziness 121
Dobutamine 402, 404
infusion 410
powder 407
Docetaxel 422
Doctor's kit 411
Doctor's prescription 480
Doctor-patient relationship 443
Dolo 131
Domperidone 84
Dopamine 402, 404
antagonist 163
infusion 409
reuptake inhibitor 310
Doxepin 75, 200, 310
Doxycycline 6, 49, 196, 266, 320
Dracunculiasis 355
Dracunculus medinensis 397
Dress syndrome 202
Drotaverine 133
Drug 154, 328, 367, 377, 385
antianaerobic 381
anticonvulsants 413
antidepressant 112, 134, 413
antiepileptic 185
antifungal 381
antihypertensive 68, 70, 71, 112
anti-inflammatory 60, 316
antimicrobial 377
antiretroviral 63
antithyroid 336
asthma 413
causing fever 415
emergency 402, 411
extravasation 421
risk factors for 421
hormones 414
intoxication 151
local anesthetic 369
nonhormonal 279
pain relief 131
reactions, adverse 71, 385
safe and unsafe 416
side effects of 374
strength of 406
tranquilizers 414
Drug-food interaction 412
Ductal carcinoma in situ 164
Ductal discharge 168
Duloxetine 41, 310
Duodenal ulcer 8, 237
complications 238
drug for 239
etiology 237
signs 238
symptoms 238
treatment 238
Dyeing hair, treatment of 197
Dyslipidemia 41, 71, 183, 470
drugs for 43
lipid profile 41
signs 41
symptoms 41
treatment 42, 43
values for lipids 41
Dysmenorrhea 278
primary 278
secondary 278, 279
Dyspepsia 239
etiology 240
reflux-like 240
symptom subgroups 240
Dysphagia 241
etiology 241
investigations 241
red flags 241
Dyspnea 28, 170
etiology 170, 172
evaluation of 171
investigations 171
red flags 170
sudden onset of 170
Dysuria 276
and frequency, differential diagnosis of 275
E
Ear 367, 386
infections 212
Ebola 355, 357, 358
virus diseases 355
Echinococcosis 357
Echinococcus 355, 397
Echis 139
Ecosprin 180
Ecthyma 395
Ectopic thyroid 329
Eczema, nummular 206, 207, 208
Eczematous eruptions of face 208
Edema 44
bilateral 45
etiology 44
generalized 45
history 45
treatment of generalized 46
Edematous erythroderma 202
Edge biopsy 479
Edrophonium 139
Elbows, dermatoses of 207
Electrocardiogram 183
Electrolytes 424, 428
Emergency tracheostomy indications 158
Empiric antibiotic therapy 397
Empiric treatment 386
Enalapril 68, 177
Endocarditis 393
Endocrine abnormalities 162
Endometriosis 280
complications 280
etiopathogenesis 280
investigations 280
risk factors 280
signs 280
symptoms 280
treatment 280
Endoscopic retrograde cholangiopancreatography 251
Endotracheal intubation 74, 158, 370
Enterobacter 325, 376
Enterobacteriaceae 376
Enterococcus faecalis 254, 376
Enzymes 360
Eosinophilia 466
Eosinophils 449
Epicondylitis 398
Epidermoid cancer 361
Epididymitis 266
acute 266
chronic 267
Epididymo-orchitis 266
causes of 267
Epilepsy 147, 184
Epinephrine 402
Episcleritis 222
Epistaxis 10, 212, 321
etiology 321
investigation 321
treatment 321
Epithelioma 361
Epsilon-aminocaproic acid 8
Epstein–Barr virus 454
Epulis 216
differential diagnosis 216
investigation 216
treatment 216
types 216
Erectile dysfunction 70, 254
etiology 255
investigations 256
red flags 254
treatment 256
Erosive gastropathy 244
Erythema
multiforme 188
nodosum, treatment of 197
Erythrasma 198, 209
Erythrocyte sedimentation rate 451
etiology 451
investigations 451
Erythromycin 196, 199
Erythroplakia 193
Escherichia coli 376
Escitalopram 310
Esmolol 154, 402
Esomeprazole 239
Esophageal burns 398
Esophagitis 252
diagnosis 252
etiology 252
signs 252
symptoms 252
treatment 252
Ethambutol 115
Ethionamide 115
Ethylene 155
glycol 155
Excessive hair 198
loss, treatment of 198
Exenatide 92
Exercise 90
Exophthalmos 336
Eye 221, 367
disease 355
needles 375
red 222
F
Facial impetigo, differential diagnosis of 209
Famciclovir 121
Fast test, diagnosis 186
Fat embolism 305
etiology 305
pathogenesis 305
signs 305
symptoms 305
Fat necrosis 164
Fatigue 46
etiology 47
questionnaire 47
treatment 48
Feeling tired 46
Feet, pigmented tumors of 210
Felodipine 70
Fenofibrate 43
Fentanyl 132, 373
Fever 48, 50, 470
etiology of 49, 50
investigations 52
of unknown origin 48
Fibrate 43
Fibrin sealant 8
Fibrinolytic medicines 8, 9
Fibroadenoma 163
Fibroid 281
complications 281
etiology 281
investigations 281
location 281
treatment 282
Fight bites 7
Filariasis 356, 396
Fine-needle aspiration 162
cytology 375, 478
Finger injury 55
First aid 54
Fistula 115, 118
etiology 118
investigations 118
treatment 118
Fistula-in-ano 241
classification 242
etiology 241
investigations 242
treatment 242
Fits 147, 184
Fixed bullous dermatosis, generalized 202
Flail chest 303
Flail segment 159
Flat tail sea snake 138
Flat warts 204
Flatulence/gas 242
investigations 242
treatment 242
Flavivirus 49, 355
Flucloxacillin 251
Fluconazole 194, 199, 203, 285
Fludrocortisone 398
Fluid
and electrolytes, loss of 146
distribution 428
resuscitation 136
types of 425, 426, 428
Flu-like
illness 49
symptoms 311
Flumazenil 154
Flunisolide 315
Fluocinolone metamide 205
Fluoroquinolones 38, 379
dosage 379
spectrum of 380
Fluoxetine 310
Fluticasone 315
propionate 201, 205
Folliculitis 105
Fondaparinux 9
Food, type of 87
Foot
care advice 39
end elevation 72
Foreign body 56, 109
reaction 206
swallowed 56
Forgarty's catheter, embolectomy with 343
Fortwin 150, 402
Fracture 55, 301
classification 301
complications of 303
etiology of 301
healing 302
factors affecting 302
ribs 303
signs 302
symptoms 302
treatment of 302
Frequent attenders 480
Frozen section biopsy 479
Fumigation 435
Fungal nail infection 201
Furosemide 69, 152, 177, 279
Fusidic acid 198
Fusion inhibitors 63
G
Gabapentin 41, 132
gel 126
Galactorrhea 168
Gangrene 105
Gas gangrene 395
Gastrectomy 436
Gastric ulcer 237
complications 238
drug for 239
etiology 237
signs 238
symptoms 238
treatment 238
Gastritis 244
Gastroesophageal reflux disease 243, 366
clinical manifestations 243
complications of 243
investigations 243
pathophysiology 243
treatment 244
Gastrointestinal bleeding 240
Gastroparesis 244
etiology 245
treatment 245
Gastropathy 244
Gel foam 8
Gemfibrozil 43
General anesthesia 373
procedure 373
General health checkup 470
Genital candidiasis 197
Genital ulcer 264
diagnosis 264
etiology 264
treatment 264
Genital warts 265
clinical features 265
etiology 265
investigations 265
treatment 266
Genitourinary 253, 366, 390, 470
Geriatric problems and management 365
Giant fibroadenoma 163
Glibenclamide 35
Glipizide 35
Glossodynia 191
GLP-1 agonist 34
GLPI analog 34
Glucagon 154
Glucagon-like peptide 1 agonist 34
Glucocorticoids 398
Glucose
test for 33
tolerance, impaired 285
Glycemic load 87
Glycemic reduction 34
Glycopyrrolate 373
Goiter, classification of 330
Gonococcal urethritis 265
Good sleep
hygiene 75
tips for 75
Goodsall's rule 242
Goserelin 279
Gout 299, 367
investigations 300
treatment 300
Graft-versus-host disease, severe 202
Gram stain 465, 466
result 293
Gram-negative
aerobic bacilli 376
anaerobes 376, 382
bacteria 382
rods 293
Gram-positive
bacteria 195, 382
cocci 293
Granuloma
annulare 210
inguinale 267
Grave's disease 328, 336, 353
Guinea worm 397
Gynecomastia 169
clinical appearance 169
grade 169
investigations 169
treatment 170
H
H1N1 357
H5N1 357
H7N9 357
Haemophilus
ducreyi 376
influenzae 119, 376, 378
Hair
concretions stones 198
premature graying of 201
smell malodorous axilla, treatment of 198
Halitosis 192
diagnosis 192
etiology 192
pathophysiology 192
treatment 192
Halobetasol propionate 205
Haloperidol 30, 64, 134
Halothane 251, 374
Hansen's disease 356
Hantavirus 357
Hashimoto's thyroiditis 353
Head injury 147, 151
complications of 150
Headache 57
alarm symptoms 57
examination 57
first-line treatment 58
investigations 58
patient education 58
preventive prophylactic treatment 58
primary 58
secondary 58
Healing, type of 141
Hearing 367
Heart
block 70, 71
disease, congenital 112
Heart attack 55
first aid for 180
preventing 183
signs 178
Heart failure 152, 174, 176
clinical features 175
diuretic therapy for 177
dosing of 177
features 176
investigations 175
precipitants 175
stages 176
systolic 176
treatment choices 176
Heartburn 413
Heel pain 59, 60
prognosis 60
symptoms 60
treatment 60
Helicobacter pylori 376
infection 237
Hemangioma 348
Hematological causes 7
Hematospermia 258
etiology 258
investigations 258
treatment 258
Hematuria 256
etiology 257
investigations 257
red flags 256
Hemi thyroidectomy 332, 334
Hemicolectomy 436
Hemithyroidectomy 334
Hemoglobin 447
concentration 1
Hemolytic anemia 3
causes of 3
Hemolytic transfusion reaction, acute 12
Hemophilia 14
Hemoptysis 321
etiology 321
investigations 322
red flags 321
Hemorrhage
classification 97
extradural 148, 149
intracerebral 148, 152
intracranial 148
massive internal 112
pulmonary 49
revealed 98
subdural 148, 149
Hemorrhagic shock, treatment of 98
Hemorrhoidectomy 436
Hemorrhoids 245
classification 245
investigations 245
treatment 245
Hemostasis 99
Hemotoxins 138
Hendra 357
Henoch–Schönlein purpura 225
Heparin 9, 155, 402, 420
therapy 343
Hepatic damage, markers of 452
Hepatic diseases, drug in 246
Hepatic failure, drug dosages in 419
Hepatic synthesis function, markers of 453
Hepatitis 246, 251
A 119
virus 454
B 119, 393
virus 454
C virus 454
D virus 454
E virus 454
etiology 246
Hepatocellular pattern 455
Hepatotoxicity 415
Hereditary disease 95
Hernia repair 436
Herpes simplex virus 62, 265, 454
Herpes zoster 60
clinical features 60
complications 60
treatment 61
Hiccups 64
etiology 64
treatment 64
Hidradenitis suppurativa 198, 395
Hip, irritable 294
Hirsutism 198, 285
Hoarseness of voice 212, 322
etiology 322
treatment 322
Hodgkin's lymphoma 80
Hoffmann's test 130
Homicidal ideation 311
Homogeneous enlargement 331
Honey crust 395
Hookworm 397
Hormonal treatment 279
Hormones 360
Human diploid cell vaccine 7
Human immunodeficiency virus 61
clinical features of 61
infection 63
diagnosis of 63
Human papillomavirus 119, 265
Human rabies immunoglobulin 7
Hyaluronidase 422
Hydatid disease 397
Hydatidiform mole 328
Hydralazine 112
Hydration 23
Hydrocelectomy 437
Hydrochlorothiazide 69
Hydrocortisone 398, 405
cream 205
injection 411
Hydrogen peroxide 143
Hydroquinone 202
Hydroxychloroquine 297
Hydroxyzine 203
Hyoscine 374
butylbromide 65, 133, 402
Hypercalcemia 340
medical treatment of 340
Hypercapnia 74
Hypercholesterolemia 42
Hyperemesis gravidarum 328
Hyperkalemia 29, 415
Hyperlipidemia 70
secondary prevention of 43
Hyperosmotic solutions 422
Hyperparathyroidism 340
Hyperplastic candidiasis 193
Hypersensitivity reaction 398
Hypertension 19, 41, 65, 365, 474
accelerated 151
etiology 65
primary 65
secondary causes of 65
Hypertensive crisis 67
Hypertensive emergency 151, 152
diagnosis 151
red flags 151
treatment 152
Hyperthyroid 331
crisis 337
Hyperthyroidism
congenital 328
signs of 335
symptoms of 335
Hypertrophic scar 144
Hyperuricemia 299
Hypocalcemia 29, 151, 152, 341
Hypoglycemia 415
clinical features 152
etiology 152
investigations 153
treatment 153
Hypokalemia 71
Hyponatremia 29
Hypoparathyroidism 341
Hypotension 29, 71, 72, 153
etiology 72
postural 112
treatment of 72
Hypothyroid 331
Hypothyroidism 338
etiology 338
signs 338
symptoms 338
treatment 338
Hypovolemic shock 97, 151
etiology 97
pathophysiology 97
use of
blood in 428
colloids in 428
Hypoxemia 74
Hypoxia 28, 29, 149
treatment 74
I
Ibuprofen 58, 107, 131
Ice massage 60
Ideal body weight 90
Idiopathic facial nerve palsy 5
Ifosfamide 422
Ilaprazole 239
Iliotibial band syndrome 298
Imipenem 106, 115, 397
Imiquimod 266
Immunization 119, 161
active 7
Immunoglobulin 6
G 354
Immunomodulators 316
Impalement 55
Impetigo 105, 209, 395
Incontinence, types of 269
Indapamide 69, 70
Indigestion 239
etiology 240
Infection 397
depth of 105
type of 140
Infectious agents 202
Infectious diarrhea
causes of 234
management of 235
Infectious disease 474
Infertility 258, 285
Inflammatory crystalline disease 294
Inflammatory noncrystalline disease 294
Influenza 49, 119
live attenuated 120
Ingrown toenail removal 437
Inguinal hernia block 371
Inhaler technique, metered dose 315
Inherited coagulation disorders 7
Inotropes 72
Insect bites 210, 398
Insecticides 153
Insomnia 75
etiology 75
red flags 75
treatment 75
Insulin 34, 36, 147
calculation for dose of 37
delivery devices for 37
indications 36
resistance syndrome 32
side effects of 37
Intense pain, prolonged 173
Intermittent claudication 344
Intracranial pressure, increased 149
Intradermal injection 372
Intradermal rabies vaccine 7
Intrauterine insemination 259
Intravenous fluids 424
indications for 424
Iodine
deficiency goiter 330
intake, excess 328
Iron 155, 433
preparations 412, 414
replacement 2
salts 155
Iron deficiency anemia 1, 4, 240
treatment for 2
Irritable bowel syndrome 247, 366
diagnosis 248
differential diagnosis 247
investigations 248
pathogenesis 247
red flags 247
symptoms 247
treatment 248
types of 247
Ischemia, treat 39
Ischemic heart disease 178, 183, 404
Ischemic stroke 152
Isoniazid 155
Isotope scan 286, 326
Isotretinoin 196
Itching 199
etiology 199
investigations 199
types of 199
Itraconazole 203
Ivermectin lotion 200
J
Japanese encephalitis 119, 357
vaccine 120
Jaundice 250, 474
clinical approach to 250
differential diagnosis 251
evaluation of 251
Jock itch 202
Johnson syndrome 202
Joint
aspiration 375
disease, assessment of 294
injections 375
instability 294
involvement, pattern of 295
pain 293
prosthesis, infected 392
redness 299
Jugular vein septic phlebitis 396
Juvenile fibroadenoma 163
K
Kala azar 357
Kanamycin 115
Kaposi's sarcoma 210
Keloid 144, 398
Keratitis, superficial 222
Keratolysis, pitted 201
Ketamine 134, 374
Ketoconazole 203
shampoo 203
soap 203
Kidney
diseases of 15
failure 16
function, tests to monitor 16
injury
acute 15
causing 18
stones 271
algorithm for 274
King cobra 138
Klebsiella 254, 276, 325, 376
granulomatis 267
Knee
joint 297
pain syndrome, anterior 298
Kojic acid 202
Krait 138
Kyasanurforest disease 357
L
Labetalol 152
Lactate dehydrogenase 452
Lactational mastitis 166
Lactic acidosis 431
etiology 431
treatment 431
Lamivudine 63
Langer's lines 143
Lansoprazole suppresses 239
Laryngeal edema 74
Laryngoscopy, indirect 327
Laryngospasm 385
Lassa fever 357
Laxatives 134
Lead 155
Left bundle branch block 183
Leg
ulcer, causes of 352
unilateral 45
Leishmaniasis 356
Lemierre's disease 396
Lentigo 212
Leprosy 356
Leptospira card test 49
Leptospirosis 49, 357
Lesion, benign 359
Lethargy 71
Leukoplakia 193
treatment of 193
Leukotriene
modifier 316
receptor antagonist 316
Leuprorelin 279
Levocetirizine 203
Levofloxacin 106, 115, 254, 320
Levonorgestrel oral 277
Levosalbutamol 315
Lhermitte's sign 129
Lichen planus 188, 193, 210
treatment of 194
Lichen simplex 207
complex 201
Lichenoid reaction 188
Lidocaine 260, 402
patch 126, 132
Lifestyle modification 68, 345
Ligament injury 56
Lightning 55
Lignocaine 163, 368, 369, 374
Limb
ischemia, critical 344
threatening 395
Linezolid 106, 115, 397, 421
Lingual thyroid 330
Lip, cancer of 221
Lipid
abnormality, secondary causes of 42
disorders 42
Liraglutide 92
Lisinopril 177
Listening skills 443
Lisuride maleate 163
Liver
function test 452
tests, abnormal 454
transaminase levels, abnormal 456
Liver disease 474
drugs for 246
severe 416
types of 452
unsafe drugs in 416
Local anesthesia 375
complications of 369
discontinue injection of 369
Local anesthetic systemic toxicity 369
treatment of 369
Loop diuretics 177
Loratadine 203
Lorazepam 185
Losartan 68
Lovastatin 43
Lovenox 155
Low backache 286
acute 290
chronic 290
etiology 287
examination 289
investigations 290
red flags 286
Low glycemic index 87
Lower limb
ischemia
acute 342
chronic 342, 345
pain 131
Ludwig's angina 192, 212, 395
clinical features 193
complications 193
treatment 193
Lugol's iodine 336
Lumbar sympathectomy 437
Lung
cancer 365
disease, interstitial 170
wet 100
Lymph node 77, 114, 264
enlargement 49
etiology of 78
Lymphadenopathy 76, 78, 474
Lymphatics 353
Lymphedema 76
classification of 79
complications 79
investigations 79
treatment of 79
chronic unilateral 45
Lymphocytes 449, 466
Lymphogranuloma venereum 267
Lymphoma 79
investigations 80
radiotherapy in 80
symptoms 79
Lysis 181
M
Macrolides 251, 320
Magnesium sulfate 155
Malabsorption 366
Malaria 356, 357, 396
Mammalian bite 6
Mammary duct
ectasia 168
clinical features of 168
fistula 168
Mammography 162, 168, 169
Marburg 357, 358
Marjolin's ulcer 143, 362
Massive blood transfusion 13
Mast cell stabilizers 316
Mastalgia 162
Mastectomy 437
Measles 208
Meckel's diverticulum 237
Meclizine 84
Medically unexplained problems 480
Medication extravasated 422, 423
Melanoma
malignant 210, 363
treatment 363
Melasma 200
clinical features 200
treatment 200
Ménière's disease 122
Meningitidis 376
Meningitis 386
Meningococcal
conjugated 119
polysaccharide 119
vaccine 119
Menopausal symptoms 282
Menstruation related disorders 285
Mental status
altered 74
change in 15
Meperidine 311
Meropenem 106, 397
Mesenteric adenitis 225
Mesenteric vascular occlusion 225
Mestinon 155
Metabolic acidosis 430
clinical features 430
diagnosis 430
treatment 431
Metabolic coma 22
etiology 23
investigations 23
specific neurologic signs 23
Metabolic syndrome 32
Metacarpophalangeal joints 7
Metaproterenol 154
Metastasis cancer 77
Metastatic cancer 64
Metaxalone 107
Metformin 34, 35, 92, 195, 251
Methanol 155
Methemoglobin cyanide poisoning 155
Methicillin susceptible Staphylococcus aureus 198
Methicillin-resistant Staphylococcus aureus 38, 382
Methotrexate 155, 297
Methyldopa 64
Methylprednisolone 316, 398
acetate 398
succinate 398
Methylxanthines 316
Metoclopramide 65, 84, 373
Metolazone 69, 177
Metoprolol 69
Metronidazole 6, 38, 106, 239
cream 196
Miconazole 203
Micropoint needle 375
Microsporidiosis 235
Midazolam 185, 373
Migraine 59, 82
Miliaria rubra 201, 205, 206, 207
Mind and body techniques 126
Minerals 412
Minocycline 196
Mirabegron 270
Mirtazapine 310
Mismatched blood transfusion 12
Mitiglinide 35
Molecular tests 78
Molluscum contagiosum 200
treatment of 200
Mometasone 315
furoate cream 205
Monoarthritis 292
Monoarticular arthritis, attack of 299
Monoclonal antibodies 165
Monocytes 449
Monofilament 108
Mononeuritis multiplex 96
Mononuclear cells 466
Montelukast 316
Moraxella 376
Morphine 41, 132, 150, 181, 373
sulfate 155
Moxifloxacin 115, 397
Mucaine gel 65
Mucocele 216
Mucocutaneous ulcer 62
Mucolytics 320
Mucosa, ulcer of 188
Mucous membrane 140
Mucous retention cyst 216
Multidrug combination products 64
Multinodular goiter 332
clinical features 332
investigations 332
pathogenesis 332
treatment 332
Multiple endocrine neoplasia syndromes 334
Multiple organ dysfunction syndrome 100
Multivitamins 432
Mumps 82
clinical features 82
complications 82
orchitis 262
treatment 82
Muscarinic receptor blockers 155
Muscle
damage 49
injury 56
spasm, pain with 288
weakness 292
Muscle cramps 82
etiology 82
treatment 82, 83
Musculoskeletal disorders 286
Musculotendinous syndromes 130
Mycobacteria 376, 382
Mycoplasma 197, 325
genitalium 265
pneumoniae 202
Myocardial depression 139
Myocardial infarction 29, 70, 153, 170, 179, 183, 365
acute 404
Myofascial pain syndrome 131
N
Nafcillin 422
Nail candidiasis 197
Naproxen 131
Nasal prongs 74
Nateglinide 35
National AIDS Control Organization guidelines 63
National Cancer Institute 104
National Tuberculosis Control, revised 115
Nausea and vomiting 83
complications 84
etiology 83
red flags 83
treatment 84
Neck
compression test 129
distraction test 129
Neck pain 291
etiology 292
examination 292
red flags 291
Necrotizing fasciitis 105
Necrotizing ulcerative gingivitis, acute 188
Needles 375
size 375
Neisseria gonorrhoeae 265, 376
Neostigmine 155
Nephritic syndrome 16
Nephrolithotomy 437
Nephrology 474
Nephrotic syndrome 15
Nephrotoxicity 385
Nerve
blocks, peripheral 371
conduction studies 96
function assessment 255
healing 142
Netherland rule 299
Neurodermatitis 201
Neurogenic claudication 344
Neurological changes 430
Neurological deterioration 74
Neurological problems, primary 29
Neurological symptoms 95
Neurology 475
Neuromuscular block 139
Neuropathic joint disease 40
Neuropathic pain 126
Neuropathy, peripheral 94
Neurotoxins 138
Neutrophils 466
Niacin 43
Nicotine
gum 104
replacement therapy 104
Nifedipine 69, 70, 152
Nippa 357
Nipple discharge 167
blood stained 169
clinical significance 167
color 167
cytology of 168
diseases with 168
etiology 167
red flags 167
treatment of 169
Nitrates 181
Nitrofurantoin 251
Nitroglycerin 152, 181, 402, 404
Nitroprusside 402
Nnsteroidal anti-inflammatory drugs 403
Nocturnal limb pain 294
Nonalcoholic fatty liver disease 454
Nonbreast pain 162
Noncalcium stones 271
Noncyclical mastalgia 162
Noncytotoxic drugs, extravasation of 422
Non-Hodgkin's lymphoma 80
Noninflammatory 292
closed comedones 195
Non-ST elevation myocardial infarction 178
Non-steroidal anti-inflammatory drugs 134, 163, 297
Non-steroidal creams 202
Nonvegetarian foods 87
Nonverbal behavior 443
Noradrenaline 404
infusion 408
Norepinephrine 279, 310, 402
Norovirus 235
Nucleic acid amplification test, cartridge-based 114
Numbness 94
Nutrition 23, 432
O
Obesity 71, 85
complications 85
etiology 85
investigations 85
red flags 85
treatment 85
Obsessive compulsive disorder 312
behavior 312
subcategories of 312
symptoms 312
treatment 313
Occult primary, treatment of 81
Octreotide 8
Ofloxacin 115, 254
Ointments 385
Oleander 154
Olmesartan 68
Omalizumab 316
Omega-3
content of oil 88
fatty acids 43
Onchocerciasis 356
Ondansetron 84, 373
Onychomycosis 201
Opioids 64, 155
Oral cancer 221
Oral candidiasis 197
Oral cavity 216
anatomy 219
cancer, treatment 219, 220
ulcers of 188
Oral corticosteroids 316
Oral epithelial lesions, potentially premalignant 218
Oral fluids, role of 235
Oral glucose tolerance test 32
Oral hypoglycemic agents 35
Oral polio vaccine 119
Oral rehydration salts 235
Organ failure, sepsis-related 101
Organochloride 154
Organophosphate cholinesterase inhibitors 155
Organophosphorus poisoning 29
Orthostatic hypotension 112
Osmotic laxative 233
Osteoarthritis 293, 295, 297, 344, 367, 399
red flags 297
treatment 298
Osteomyelitis 305, 392
classification 305
infecting organisms 305
investigations 306
signs 305
symptoms 305
treatment 306
Osteoporosis 306, 367
classification 307
investigations 307
red flags 306
risk factors 306
signs 307
symptoms 307
treatment 307
Otitis externa 212
Ovarian cancer 282
minimise chances of 283
risk factors 282
symptoms 282
Oxygen 181
therapeutic agents 14
Oxyspas 270
P
Pain 124
assessment of 125
chronic 133
classification 124
decreases 173
distribution 129, 289
drug for 402
duration and site of 124
etiology 124
increases 173
investigations 126
location of 224
radiation of 173
radicular back 288
red flags 124
retro-orbital 49
treatment 126
type 124
yellow flags 124
Painful edema, treatment of acute unilateral 45
Palliative care 133, 134
Palpitations 93
etiology 93
heart beat 93
investigations 93
physical examination 93
red flags 93
treatment 94
Pantoprazole 136, 239
Papilloma 168
Papular eruptions of
hands 210
differential diagnosis of 210
trunk 210
differential diagnosis of 210
Papular urticaria 207
Paracentesis biochemistry 465
Paracetamol 58, 107, 131, 132, 402
overdose 251
Parasomnias 75
classification 75
features 75
Parathormone mobilizes calcium 340
Parathyroids 340
Parenteral iron 3
Parenteral nutrition 434
composition 434
Paresthesia 96
Paresthetic areas 96
Parkinson's disease 112
Paronychia 395
Paroxetine 260
Paroxysmal nocturnal dyspnea 179
Parsonage–Turner syndrome 130
Pass Ryle's tube 23
Pasteurella multocida 376
Patellofemoral pain syndrome 298
Pediatric drug doses 307, 399, 400
Pediatric immunization schedule 119
Pediatric surgery 308
Pelvic inflammatory disease 283
clinical presentation 283
etiology 283
investigations 283
treatment 283
Penicillin 155, 377, 422
allergic 239
dosage 377
spectrum of 378
Penile block 371
Pentazocine 131
Peptic ulcer 237
diseases 237
Perianal hematoma 252
treatment 252
Pericarditis 174
Periductal mastitis 166, 168
complex 168
Peripheral neuropathy
etiology 94
investigations 96
red flags 94
treatment 96
Peripheral smear findings 450
Peripheral vascular disease 341
Peritonitis 437
Permethrin shampoo 200
Persistent sinus, causes of 118
Pertussis 394
Pethidine 131, 373
Pharmacodynamics 367
Pharyngitis 212, 322
Phenelzine 311
Phenergan 150, 402
Phenobarbital 154
Phenobarbitone 185
Phenothiazines 112
Phentolamine 422
Phenylephrine 402
Phenytoin 132, 185
Phobias 309
Phyllodes tumor 164
Physical activity 90
Physical inactivity 71
Pigmented nevus 210
Piperacillin 397
Piroxicam 131
Pitressin 405
Pityriasis
rosea 211
versicolor 211
Plague 357, 358
Plant poisons 154
investigation 154
treatment 154
Plantar fascia 59
Plantar fasciitis 59, 307
Plantar warts 204, 206
Plasma
pH, normal 429
rang, normal 454
Platelet 450
evaluation 450
Pleural aspiration 375
Pleural effusion 324
etiology 324
investigations 324
Pleural fluid 114, 465
analysis 465
etiology 465
biochemistry 466
Pleurisy 64
Pneumococcal polysaccharide 119
Pneumococcal vaccine 119
Pneumococci 382
Pneumocystis Jiroveci pneumonia 64
Pneumonia 325, 365
etiology 325
significance of 325
treatment 325
Pneumonitis 326
Pneumothorax 29
Podophyllin 266
Podophyllotoxin 266
Poison 154, 406
Polyarthralgia 292, 295
etiology 295
red flags 295
symptom pattern 295
Polycystic ovarian syndrome 284
symptoms and signs 284
Polymerase chain reaction 294
Polymyositis 353
Polytrauma 158
Pompholyx 201, 206, 208
Pork tapeworm 397
Postacne scars 196
Postdental extraction bleeding 99
Postextraction dental bleeding 195
etiology 195
treatment 195
Post-traumatic stress disorder 309
Potassium 19, 147
deficiency 429
clinical features 429
etiology 429
deficit 429
foods
high 20
low 20
in blood, level of 19
iodide 197
magnesium citrate 273
sparing diuretics 178
supplements 429
Povidone-iodine 143
Prandial insulin 36
Prasugrel 9
Pravastatin 43
Prazosin 69
Preauricular sinus 117
Prednisolone 198, 201, 204, 316, 398
Preeclampsia 152
Pregabalin 41, 132
Pregnancy
drug 416
dosages in 419
safe drugs in 416
unsafe drugs in 418
Premalignant lesion of, oral cavity 193
Premature ejaculation 260
etiology 260
treatment 260
Premenstrual syndrome 278
diagnosis 278
differential diagnosis 278
etiology 278
signs of 278
symptoms of 278
treatment 279
Preoxygenation 373
Prescription writing 480
Pressure
offloading 39
sore 117, 396
Prickly heat 201
Prilocaine 371
cream 260
Probable discharge 167
Probiotic 235
vaginal capsules 285
Prochlorperazine 84, 122, 251
Prodrome, lack of 112
Prokinetic agent 233
Prolactin 256
Promethazine 84
Pronator teres syndrome 130
Prophylaxis 393
pre-exposure 7
surgical 393
Propionibacterium 195
colonization of 195
Propofol 185
Prostate 260
investigation 260
treatment 261
Prostatectomy 437
Prostatic hyperplasia, benign 470
Prostatitis 253
bacteria in 254
classification of 254
investigations 254
symptoms 253
treatment 254
Protease inhibitors 63
Protein 360
electrophoresis 96
Proteus mirabilis 254
Prothionamide 115
Proton pump inhibitors 239, 373
Pruritus 199
Pruritus ani 201, 252
etiology 252
investigations 253
treatment 253
Pseudogout, acute 301
diagnosis 301
treatment 301
Pseudolymphadenopathy 267
Pseudomonas 276, 376, 382
Psoriasis 207-211, 399
Psoriatic arthritis 353, 399
Psychiatry 308
Pterygium 222
Pudendal nerve block 372
Pulmonary changes 430
Pulmonary edema 152
acute 176
Pulmonary embolism 29, 170, 352
drugs and dose 406
Pulmonary function tests indications 458
Purified chick embryo cells 7
Pyelolithotomy 437
Pyoderma 105, 201
arise, secondary 105
Pyomyositis 396
Pyrazinamide 115, 251, 421
Pyrethroid 154
Pyrexia of unknown origin 53
classic 50
Pyridoxine 279
Q
Qbrexza 110
Quality of life 95, 295
Quinapril 177
Quinine 155
Quinolones 251
R
Rabeprazole 239
Rabies 356, 357, 393
Radical mastectomy, modified 165
Radioactive iodine 336
Ramipril 68, 177
Ranitidine 204
Ranula 216
differential diagnosis 216
treatment choices 216
types 216
Rashfree cream 253
Raynaud's disease 346
Raynaud's phenomenon 346
Raynaud's syndrome 345
Reconstructive ladder 143
Rectal enemas 233
Rectum, abdominoperineal excision of 436
Red cell distribution 448
Reflex loss 129, 292
Reiter's syndrome 295
Relaxation techniques 126
Renal artery stenosis 70
Renal disease, end-stage 16
Renal failure 96
drug 418
dosages in 410
Renal function test 169, 451
Repaglinide 35
Respiratory 313
arrest 157
diseases 475
failure 156
system 397, 405
Restlessness 29
Reticulocyte count 448
Rh (rhesus) group 11
Rheumatic fever 399
Rheumatic heart disease 393
Rheumatoid arthritis 293, 295, 296, 399
investigations 296
medical management of 297
Rhinitis 213
etiology 213
treatment 213
Rib fractures, multiple 159
Rickettsiosis 49
Rifampicin 115, 251, 421
Rifaximin 397
Rift valley fever 357
Ringworm 202
Risedronate 412
Rivaroxaban 9
River blindness 356
Road traffic accident 151
Romberg's test 96
Ropivacaine 368
Rosacea 205, 211
differential diagnosis of 211
Rosuvastatin 43
Rotavirus 119, 235
Rotterdam's criteria 284
Round body needles 375
Roux-en-Y gastric bypass 92
Roxithromycin 320
Rubella 208
Runners' knee 298
Russell's viper pit viper 138
S
Salbutamol 315
Salicylates 155
Saline laxative 233
Salivary gland 225, 475
surgery 438
Salmonella 235, 295, 376
Salmonellosis 357
Sarcoidosis 64
Saw-scaled viper 138
Scabies 201, 210
Scalp block 371
Scalpel blades 375
Scaphoid fracture 304
investigations 304
signs 304
symptoms 304
Scarlet fever 208
Schistosomiasis 356
Scleritis 222
Sclerosing adenosis 164
Sclerosis, systemic 353
Scorpion
bite 7
sting 139
signs 139
symptoms 139
treatment 140
Scrotal swelling 262
Seborrheic dermatitis 207-209, 211
Secnidazole 285
Seizure 29, 147, 184
differential diagnosis 184
etiology 184
type of 184, 185
Selective serotonin reuptake inhibitors 250
Self-breast examination 165
Seminal fluid analysis 467
Sensitive teeth 194
etiology 194
treatment 194
Sensorcaine 374
Sensory loss 129, 289, 292
Sentinel lymph node biopsy 479
Sepsis 29, 397
red flags 101
Septic arthritis differential diagnosis 292
Septic pelvic vein thrombosis 396
Septic shock 100
causes of 101
treatment of 101
Seroconversion illness, acute 61
Serological tests 54
Serotonin 279
and norepinephrine reuptake inhibitor 310
antagonist 310
syndrome 311
Serotonin-norepinephrine reuptake inhibitor 41
Serratia 325
Sertraline 260, 310
Serum glucose 31
Sexual development 255
Sexual thoughts 313
Sexually-transmitted infection 263
etiology 263
investigations 263
prevention of 263
SGLT-2 inhibitor 34
Sharp pleuritic pain 173
Shigella 376
Shingles 60
Shock 26, 96, 155, 403
classification for 96, 98
electric 55
hemorrhagic 98
hypoadrenal 103
initial treatment of 428
refractory 73
treat hypovolemic 428
vasovagal 103
Shoulder abduction sign 129
Sick sinus syndrome 112
Sideropenic dysphagia 193
Sigmoidoscopy 231
Sildenafil 256
Siloderm cream 198
Silodosin 270
Simvastatin 43
Sinus 115, 117
investigations for 118
of Valsalva aneurysm, rupture of 170
treatment of 118
Sinusitis 214
clinical features 214
investigations 214
treatment 214
Sjögren syndrome 353
Skeletal muscle relaxants 126, 185, 403
Skin
diseased 105
hyperpigmentation 202
loss 143
suture, size for 109
tension lines 143
Skin and soft tissue 397
infections 394
Skin cancer 361
common 364
Skin infection
investigations 105
superficial 105
treatment 105, 106
Sleep, abnormal behaviors during 75
Sleeping pills 414
Sleeve gastrectomy 92
Small pox 358
Smoker's palate, reverse 193
Smoking
cessation 103
treatment 104
Fagerstrom test for 103
Snakebite 7, 56, 138, 155
Snoring 215
etiology 215
investigations 215
red flags 215
symptoms 215
treatment 215
Soak 60
Sodium 20
bicarbonate 147, 405
effects of 21
hypochlorite 143
intake down 21
nitroprusside 152
infusion 410
valproate 185, 251
Sodium deficiency 430
clinical features 430
treatment guidelines 430
Sodium-glucose cotransporter-2 inhibitor 34
Soft tissue infection, treatment 105, 106
Solifenacin 270
Solitary nodule 331
treatment 332
Somatostatin 8
Sorbitrate 180
Sore mouth 191
Sperm injection, intracytoplasmic 259
Spinal origin, pain of 288
Spinal trauma 399
Spine problems 289
Spirochetes 376
Spironolactone 178, 279
Splenectomy 438
Sprain 56
Spurling's test 129
Sputum examination, information 318
Squamous cell cancer 361
investigations 361
treatment 362
Squamous cell carcinoma 143, 212
ST elevation myocardial infarction 178
Standard ventilator settings 74
Staphylococcal skin scolding syndrome 396
Staphylococcus 38, 209, 376, 382
aureus 166, 376
epidermidis 376
Statins 43, 181
Status epilepticus 184
first aid 184
Stavudine 63
Sterile pyuria 267
etiology 267
investigations 268
Steroid 198, 202, 205
hormone tests 457
Steven–Johnson syndrome 202, 385
Stiffness 295
Still's disease 353
Stomach wash 23
Stomatitis 191
drug 191
etiology 191
Stone
passage rate 272
types of 271
Stool
examination 463
routine test, interpretation of 463
Strain 56
Strangulated bowel 225
Strangulated hemorrhoids, treatment of 246
Streptococcus 38, 197, 209, 276, 376, 382
faecalis 376
pneumoniae 376
pyogenes 198
Stress management 92
Stretching exercises 60
Stroke 155, 185, 366
primary prevention of 187
secondary prevention of 187
types of 186
Struma ovary 330
Subaponeurotic injection 372
Subcortical cysts 299
Subdermal infiltration 372
Subdiaphragmatic collections 64
Submucosal fibrosis 193
treatment of 194
Succimer 154
Sudden collapse 111, 155
etiology 156
red flags 155
Sugars, uncontrolled 37
Suicide 313
risk assessment 311
Sulbactam 397
Sulfonylurea 34, 35, 251
Surgical gut 108
chromic catgut 108
plain catgut 108
Suture 107
alternatives to 110
classification of 107, 109
complications of 109
line care 109
material, characteristics of 107
needles 375
removal day 109
uses of 109
Sweating 110
causes 110
treatment 110
Swelling 295
Swimming emergencies 56
Swine flu 357
Sycosis barbae 209
Syncope 103, 111
causes for 111
common causes of 112
differential diagnosis for 112
etiology 111
examination 111
investigations 112
red flags 111
treatment 112
Syndrome X 32
Synovial fluid analysis 294
Syphilis 189
secondary 210
Syphilitic alopecia 209
Syphilitic glossitis 193
Syringomyelia 130
Systemic antifungals 203
Systemic lupus erythematosus 353
T
Tachyarrhythmia 29
Tachypnea 26
Tacrolimus 196
Tadalafil 256
Taenia
saginata 397
solium 397
Tamoxifen 163
Tamsulosin 270
Tapentadol 131
Taper cut needle 375
Tazobactam 397
Tear cancer 362
Telmisartan 68
Temazepam 75
Temporal arteries 126
Tendinitis 399
Tendon healing 142
Tenofovir 63
Tenosynovitis 399
Tensile
behavior 107
strength 108
Terazosin 69
Terbinafine 203
Testosterone 256
gel 256
Tetanus 393
immunization history 120
prophylaxis 120
toxoid 120
booster 6
Tetany 341
Tetracaine 371
Tetracycline 239
Tetralid 371
Theophylline 154, 176
Thiazide 69, 70
diuretics 177, 273
related diuretic 177
Thiazolidinediones 35
Thioacetazone 115
Thiocolchicoside 107, 132
Thiopentone 185, 374
Thoracic outlet syndrome 130
Throat 387
Thromboangiitis obliterans 345
treatment of 345
Thyroglossal duct cyst 329
Thyroid 326
antibodies 326, 328
cancer
risk factors for 331
treatment of 334
carcinoma 333
investigations 333
risk factors 333
disease 475
investigations for 327
eye disease 336
function tests 96, 326, 456
imaging 329
neoplasms, classification of 333
peroxidase 354
solitary nodule of 327
stimulating hormone 168
storm 337
sudden enlargement of 331
swelling 331
investigations for 327
whole 331
Thyroidectomy 332, 438
partial 332
subtotal 332
total 332, 334
types 332
Thyroiditis 328, 330, 332, 337
types 337
Thyrotoxic crisis 337
Thyrotoxicosis 335, 336
acute 337
classification of 335
signs of 335
symptoms of 335
Thyroxine 412
ingestion, excess 328
Ticlopidine 9
Tigecycline 421
Tinea
capitis 202, 208, 209
corporis 203
cruris, differential diagnosis of 211
faciei 209
pedis 206
versicolor 203
treatment 203
Tingling 94
Tinidazole 239
Tiredness 113
Tissue transglutaminase antibodies 250
Tizanidine 107, 132
Tolterodine 270
Tongue
surgical anatomy of 220
tie 217
ulcers of 188
Tonsillitis 212, 322
Tooth
injuries 7
socket, gum bleed from 9
Topical antimicrobials 385
Torsemide 69, 177
Torsion testis 268
clinical features 268
investigations 268
treatment 268
Toxic
adenoma 328, 335
epidermal necrolysis 202, 203
goiter, diffuse 335
multinodular goiter 328, 335
thyroid, pregnancy and 336
Toxicity 369
Tracheostomy 438
Tramadol 41, 131
Tranexamic acid 8
injection 10
Transaminases 453
Transcriptase inhibitors, reverse 63
Transcutaneous nerve stimulation 96
Transient ischemic attack 185
Transvaginal method 372
Tranylcypromine 311
Trauma 95, 140, 158, 405
classification 140
fluid resuscitation in 159
series 160
severe 49
Traumatic brain injury 148
pathophysiology of 148
Travelers' diarrhea 235
Tremor 112
Triamcinolone acetonide 194, 398
Triamterene 178
Trichomonas vaginalis 265, 285
Trichomycosis axillaris, treatment 198
Trichotillomania 209
Tricyclic antidepressants 40, 132, 154, 200, 250, 309
Trigger zones, injection into 375
Triglycerides 41
Triple drug therapy, rationale of 239
Triptorelin 279
Trismus 194, 217
clinical features 195
etiology 194
grading of 194, 217
investigations 195
treatment 195
Trocar point needle 375
Tropical diseases 355
Troponin 178
Trunk, scaly eruptions of 211
Tuberculosis 113, 189
abscess, treatment of 79
investigations 113
red flags 113
treatment of 115
Tuberous xanthoma 207
Tubes 375
chest tube 375
Foley catheter 375
Ryles tube 375
Tularemia 358
Tumor
antigens 360
benign 359
invasion, Clark's level of 363
markers 328, 360, 457
classification of 360, 457
uses 457
Typhoid 120, 393
U
Ulcer 115
characteristics 362
chronic 117
classification 116
features 264
healing, treatment 116
in oral cavity 217
classification 217
site of 217
types 217
leg 119
like dyspepsia 240
medication 413
oral 119
rodent 362
trophic 117
venous 143, 352
Ulcerative colitis 295
Ulipristal acetate oral 277
Unconscious
care of 23
management of 151
Upper limb pain 128
differential diagnosis 129
etiology 128
physical examination 129
Ureaplasma urealyticum 265
Uremia
signs of 18
symptoms of 18
Ureterolithotomy 438
Urethral discharge 265
etiology 265
investigations 265
treatment 265
Urethral smear 277
Urethral syndrome 275
Urethritis 265
Uric acid 300
stones 273
Urinalysis, accuracy of 462
Urinary casts 461
Urinary catheterization 136
Urinary incontinence 366
and frequency 268
etiology 268
red flags 268
investigations 269
treatment 270
Urinary stones 271
clinical features 271
differential diagnosis 271
etiology 271
investigations 271
management of 272
Urinary tract infection 274
clinical manifestations 275
investigations 275
microbiology of 274
prevention of 276
red flags 274
symptoms of 275
treatment 275
Urine
alkalization 154
analysis, indications 459
black 460
blue 460
brown 460
green 460
orange 460
red 459
white 460
Urispas 270
Urticaria 203, 399
V
Vaccination, routes of 120
Vaginal discharge 285
Vaginitis 285, 392
Vaginosis 285, 392
Vagotomy 438
Valacyclovir 121, 264
Valvular heart diseases 366
Vancomycin 38, 106, 397
Vardenafil 256
Varenicline 104
Variceal bleed 8
Varicella 208, 393
Varicella zoster 120
virus 454
treatment 120
Varicose veins 349
pathophysiology of 349
treatment of 350
Vascular disease 341, 476
Vascular malformations 348
Vasculitis 294, 343, 353
Vasomotor symptoms, treatment for 282
Vasopressin 8, 402, 405
Vasospastic disorders 343
Vasovagal syncope 112
Venipuncture 375
Venlafaxine 41, 132, 279, 310
Venom
classification 138
glands 138
Venous disease
classification of 349
complications 349
investigations 350
Venous plasma 31
Venous stasis 396
Ventilation 74
Ventilator support 74
Ventilatory effort 151
Verapamil 69
Vertigo 121
classification of 122
etiology 121
peripheral vertigo 122
red flags 121
symptom 121
treatment 122
Vesicles 264
Vesiculobullous 188
eczema 201
Vestibular neuronitis 123
Vibrio 376
Vincristine 155
Viral fever 48, 358
Viral infections 54
acute 202
Virchow's triad 351
Vision disorders 367
Visual acuity 187
Visual fields 187
Vital signs 27, 98
Vitamin 412, 414, 432
B12 deficiency 1
C deficiency 190
D tablets 432
K 8, 154
deficiency 190
Vitiligo 204, 207
Voriconazole 421
Voveran 131
SR 131
Vulvovaginal atrophy, treatment for 282
W
Waldeyer's ring 77
Warfarin 9
Warning signs 57
Warts 204, 212
treatment 204
Water retention 162
Weakness 123, 129
Wedge biopsy 479
Weight loss 123
Weight reduction 183
Weil's syndrome 49
West Nile fever 357
Whipple's triad 152
White blood cell 294
evaluation 449
Whooping cough 394
Woods lamp illumination 202
Woods light fluorescence 211
Worms 397
Wound 138, 143
care 6, 143
adjunctive treatments for 39
classification, surgical 140
complications of 143
foreign body 56
infected 396
nail puncture 396
trauma 120, 393
type 140
Wound healing 141
factors affecting 141
phases of 141
types of 141
Wrist pain 304
Wuchereria bancrofti 396
Y
Yellow fever 357
vaccine 120
Yersinia 235, 376
Z
Zerodol 131
Zidovudine 63
Zika 357
Zinc cream 253
Zohar–Fineberg obsessive compulsive screen 313
Zolpidem 75
Zoonotic diseases 355, 357
×
Chapter Notes

Save Clear


General Topics/Common Diseases/ProblemsCHAPTER 1

 
1.1 ANEMIA
 
Red Flags
Iron deficiency anemia
Pernicious anemia and B12 deficiency
Iron deficiency anemia in men
Systemic features (e.g., weight loss, fever, night sweats, malaise, and fatigue)
Iron deficiency in postmenopausal women
Psychiatric symptoms (e.g., depression, delirium, and dementia)
Failure to respond with oral iron therapy
Neurological problems (e.g., peripheral neuropathy and subacute degeneration of spinal cord)
Weight loss, malaise, fever, and night sweats
Cardiac symptoms (e.g., chest pain and heart failure)
Worsening or new symptoms
Gastrointestinal (GI) symptoms (especially GI bleeding)
WHO definition of anemia
Adult male
Adult female
Hemoglobin concentration
<13 g/dL
<12 g/dL (<11 g/dL in pregnancy)
Hematocrit (HCT)
<39%
<36%
Anemias arise because red blood cell (RBC) production is inadequate or RBC lifespan (normally 120 days) is shortened through loss from circulation or destruction.
zoom view
 
Etiology
  • Iron deficiency anemia
  • Anemia of chronic disease (ACD) [infections, connective tissue disease (CTD), and malignancy]
  • Chronic kidney disease (CKD) and chronic renal failure (CRF)
  • Blood loss (hemorrhage)
  • Hemolysis
  • Drugs (e.g., chemotherapy and drugs)
Etiology may be determined on the basis of mean corpuscular volume (MCV) [when complete blood count (CBC) or hemogram is done], but if there is associated leukocyte abnormality or platelet abnormality, or patient is not responding to treatment in 4 weeks despite treating an apparent cause, consider bone marrow biopsy or bone marrow aspiration.2
 
Etiology of Anemia (Based on MCV) and Investigations
Low MCV: < 80 = Microcytic anemia
Normal MCV: 80–100 = Normocytic anemia
High MCV: >100 = Macrocytic anemia
Etiology
  • Iron deficiency
  • Hemoglobinopathy (e.g., thalassemia), ACD (e.g., infection, CTD, and neoplasm)
  • Lead poisoning ↓
  • Sideroblastic anemia
  • Anemia of chronic disease/Inflammation (e.g., infection, CTD, and neoplasm)
  • Chronic kidney disease and CRF
  • Bone marrow failure (e.g., aplastic anemia and leukemia)
  • Bleeding
  • Early nutritional anemia (e.g., folic acid or B12 deficiency)
  • Alcohol
  • Liver disease
  • Folic acid or B12 deficiency
  • Hemolysis
  • Hypothyroidism
  • Drugs
Investigations (choices include)
Peripheral smear
Stool occult blood
Iron profile:
1. Serum iron
2. Transferrin
3. Ferritin
4. Total iron-binding capacity (TIBC)
Gastrointestinal workup may include:
  Endoscopy
  Colonoscopy
  Capsule enteroscopy
  Tc-labeled Meckel's scan
  Bleeding scan (Tc-labeled with RBC)
  Angiography
  Perioperative enteroscopy
Hb electrophoresis (Hb variant analysis) HbA, HbA2, HbF helps to diagnose thalassemia
Peripheral smear
Serum ferritin, serum iron and TIBC (may be normal or increased)
Renal function test (RFT)
Chest X-ray (CXR), Mantoux test
CTD workup
Neoplasm workup [ultrasound (US), CT, MRI, and biopsy]
Bone marrow biopsy
Peripheral smear
Serum folic acid level
Serum B12 level
Liver function test (LFT) (increased indirect bilirubin + increased reticulocyte count suggests hemolysis)
Thyroid-stimulating hormone (TSH)
Reticulocyte count
Parameters
Normal values
Iron deficiency
Thalassemia
Sideroblastic
Inflammation
Renal disease
Peripheral smear
Normochromic normocytic
Microcytic hypochromic
Microcytic/hypochromia with targeting
Variable
Microcytic/hypochromic/normocytic
Normocytic
MCV (fL)
80–100
60–90
<80
80–90
90
Serum iron (SI) (µg/L)
50–150
<30 (low)
Normal or high
Normal or high
<50
Normal
Serum ferritin (µg/L)
50–200
<15 (low)
50–300
50–300
30–200
115–150
TIBC (µg/L)
300–360
>360 (high)
Normal
Normal
<300
Normal
Marrow iron stores
1–3+
0
2–4+
1–4+
Saturation (%)
30–50
<10
10–20
Normal
 
Treatment of Anemia
Treatment for iron deficiency anemia (choices include)
Treatment of anemia of chronic disease (e.g., CKD) (choices include)
Treatment of macrocytic anemia (choices include)
Iron replacement
Oral iron:
LIVOGEN or AUTRIN or DEXORANGE or 1 capsule/tablet once daily with food for 6 weeks and reassess. May add vitamin C to augment absorption. Avoid taking with antacids
Compliance may be checked by asking color of stool (if stool is dark or black, it means patient is taking medicine regularly)
Hemoglobin should increase by 2 g/dL by the end of 3 weeks and if it is not increasing, it may be due to noncompliance, continued blood loss, or incorrect diagnosis
Continue for 3 months after hemoglobin has returned to normal
Treat the cause
Treat the cause3
Parenteral iron:
HEMFER (iron sucrose) 2 ampules in 1 bottle of normal saline (NS) over 4 hours; give twice weekly till hemoglobin increases to 10–12 g
FERINJECT (ferric carboxymaltose): Up to 1,000 mg iron bolus over 15 min/week
Blood transfusion (BT), packed red blood cells (PRBC), 300 mL gives 200 mg iron (i.e. ↑Hb by 1 g/dL)
Deworm: ZENTEL (albendazole) 1 tablet immediate dose and repeat after 10 days or MEBEX (mebendazole) 1 bd for 3 days and repeat after 10 days
Erythropoietin* (EPOX/EPREX/HEMAX) 2,000–4,000 U/mL; SC once a week
Tablet folate 5 mg od
Gastrointestinal workup/investigation (consider occult GI malignancy in older people), e.g., endoscopy, colonoscopy, etc. and treat the cause
HEMFER IV (iron sucrose); give twice weekly till hemoglobin increases to 10–12 g
Neurobion forte IM daily for 1 week, once a week for 1 month and then once a month
* Erythropoietin (SC EPO) 50–100 units/kg SC once a week to maintain a hematocrit >30%.
 
Blood Transfusion in Anemia
Anemia itself is not an indication for BT. A second trigger factor listed below must be present for BT. At least two units of PRBCs should be given. Single unit transfusion is not advised.
Anemia/Hb level
Second trigger
Blood transfusion (BT)
<7 g/dL
Symptoms such as hypotension, tachycardia
Indicated
<8 g/dL
Elderly > 65 year, LVD, PVD, history of stroke, and chronic obstructive pulmonary disease (COPD)
Indicated
Acute blood loss > 1,500 mL
Trauma patient
Indicated
7–8 g/dL
Needs minor surgery, and patient is young and healthy
Not indicated
 
Hemolytic Anemia
Causes of hemolytic anemia by mechanism
Location
Mechanism
Examples
Mode
Red blood cells Intrinsic deficiency
Enzyme defects
Glucose-6-phosphate dehydrogenase (G6PD) or pyruvate deficiency
Hereditary
Hemoglobinopathies
Sickle cell anemia
Membrane abnormalities
Hereditary spherocytosis paroxysmal nocturnal hemoglobinuria (PNH)
Extrinsic
Immune-mediated
Autoimmune, drug induced (lead, copper, and oxidizing agents)
Acquired
Hemolysis
Prosthesis, transfusion reactions
Infections
Malaria, Bartonella, Babesia, and Clostridia
Organ dependent
Liver failure and hypersplenism
Microangiopathic
Thrombotic thrombocytopenic purpura and prosthetic valve leak
 
Investigations and Clues for Hemolytic Anemias
Blood picture may show spherocytes.
Increased reticulocyte count (RI > 2%), increased lactate dehydrogenase (LDH), increased indirect bilirubin, decreased haptoglobin, and positive urinary hemosiderin (suggest hemolytic anemia)
Autoimmune hemolysis: Coombs test = Direct antiglobulin test (DAT) is positive (if agglutination occurs when antisera against immunoglobulins or C3 are applied to patient RBCs)
Intravascular: Increased LDH, decreased haptoglobin, hemoglobinemia, hemoglobinuria, and hemosiderinuria
Extravascular: Splenomegaly
Family history of anemia, personal or family history of cholelithiasis4
 
Key Points
  • Palate is the best place to look for anemia (tongue and eye can be misleading).
  • Initial investigation should be a hemogram or CBC with MCV and blood picture; then select appropriate investigation(s) depending on MCV. MCV helps to diagnose type of anemia.
  • Iron deficiency anemia: Serum ferritin level is <15 µg/mL (microgram per milliliter), caused by bleeding unless proved otherwise, and responds to iron therapy. In microcytic hypochromic anemia, consider GI malignancy in elderly, deworming children and menorrhagia in young females of reproductive age group.
  • Anemia of chronic disease [CKD, infections, rheumatoid arthritis (RA), inflammatory bowel disease (IBD), and malignancy] may have mild-to-moderate normocytic anemia or microcytic anemia. Treat the underlying cause.
  • In thalassemia, microcytosis is disproportionate to degree of anemia. There is a family history or lifelong personal history of microcytic anemia. Microsites, hypochromic target cells, and acanthosis are seen in peripheral blood smear.
  • If patient is very pale, liver or spleen is enlarged, has bleeding tendencies or not responding to treatment, they need further evaluation and referral.
 
1.2 ANOREXIA AND WEIGHT LOSS
 
Red Flags
  • Unexplained and/or rapid weight loss (>10% in 6 months)
  • Symptoms suggestive of malignancy
  • Eating disorder
  • Depression
  • Night sweats
  • Fever
  • Lymphadenopathy [especially left supraclavicular scalene node enlargement (Virchow's node)]
  • Past history of cancer
  • Abnormal blood tests
  • Abnormal physical examination
 
Etiology and Investigations
Etiology
Investigations (choices include), and clues from history
Anemia
CBC (refer Chapter 1.1)
Infections (fever)
CBC, CXR, LFT, Hepatitis A, B, C, HIV [HBsAg, HBcAb, HAV (IgM, IgG), HIV]
Metabolic:
Diabetes
Hyperthyroidism
Fasting blood sugar (FBS), postprandial blood sugar (PPBS), HbA1c
TSH, FT3, FT4
Cancer, lymphoma, and leukemia
CBC, endoscopy, colonoscopy, US, CT/MRI, and biopsy
Renal disease
Creatinine, urea, urine examination, US
Liver disease
LFT, PT, and US
Drugs
History of metformin, antimalarial, antibiotics
Psychogenic
Anxiety and depression
Miscellaneous tricky situations:
Child
Psychological or study related
Female
Pregnancy, family problems with spouse or child
Male
Alcoholic, malignancy
 
History and Diagnosis
History
Clues/Diagnosis
Fever, hepatitis, jaundice
Fever and jaundice
Cough, low-grade fever
Tuberculosis (TB)
Fatigue, breathlessness on exertion, palpitation, leg pain, nausea, vomiting, loss of appetite, blood in vomit or stool, postprandial, and dark color urine, does not feel as looking at food, postprandial fullness, change in bowel habits
Anemia, hepatitis, carcinoma stomach, and colon5
Diet and eating habits
Current medications (antibiotics, metformin, and antimalarial)
Drug induced
Addictions
Alcohol, paan, and cigarettes
Psychiatric history
Anxiety or depression
 
Checklist
Check for anemia, jaundice, and lymph nodes
Auscultate chest (for TB, etc.)
Palpate abdomen for spleen or liver enlargement (systemic illness)
Check for lumps/masses to rule out cancer (carcinoma, e.g., stomach/liver)
 
Treatment (Choices Include)
Rule out organic/psychogenic causes at the starting of treatment
Deworming
Mebendazole (MEBEX) 1 bd for 3 days, repeat after 1 week albendazole (ZENTEL) 400 mg immediately, repeat after 1 week
Appetizing tonics
ZINCOVIT/BETONIN/NEOGADINE ELIXIR
Protein supplements
THREPTIN DISKETTES three biscuits thrice daily or three scoops of protein powder (B-protein)
B-complex injections
NEUROBION injection
 
Key Points
  • Rule out anemia, infections (e.g., hepatitis and TB), malignancy (e.g., stomach carcinoma), side effects of drugs (metformin, antibiotics, and antimalarial), and substance abuse (alcohol, paan/betel nut, etc.)
  • Anorexia is a common phenomenon during and after most fevers.
  • Weight loss with increased appetite could be due to diabetes mellitus (DM), hyperthyroidism, worms, parasites, malabsorption, or Addison's disease.
 
1.3 BELL'S PALSY (IDIOPATHIC FACIAL NERVE PALSY)
 
Etiology
Reactivation of latent herpes simplex virus-1 (HSV-1)
 
Clinical Features
Unilateral weakness of facial muscles. Unable to close eye or smile properly on affected side, may be associated with ipsilateral hearing loss.
Diagnosis can be made clinically in patients with:
Typical presentation
No risk factors or preexisting symptoms for other causes of facial paralysis
No lesions of herpes zoster in external ear canal
Normal neurological examination with exception of facial nerve involvement
 
Investigations (Choices Include)
In uncertain cases, investigations may include erythrocyte sedimentation rate (ESR), fasting blood sugar (FBS) for DM, Lyme titer, angiotensin-converting enzyme level, abdomen and chest imaging for possible sarcoidosis, lumbar puncture for possible Guillain–Barré syndrome, or MRI scanning.
 
Treatment (Choices Include)
Combination treatment with Valacyclovir (VALCIVIR) 500 mg twice a day for 5 days and prednisolone (WYSOLONE) 60–80 mg/day for 5 days, speeds up recovery. Physiotherapy including electrical nerve stimulation may be tried in selected cases.6
Key Points
  • Self-limiting in most cases, although full recovery of affected facial muscle may take up to 3 months.
  • Patient should protect eye with a patch and artificial tears [MOISOL (methylcellulose) eye drops].
  • Refer urgently for ophthalmological assessment, if eyelid does not fully cover cornea when closure is attempted.
  • Incomplete paralysis in 1st week is favorable sign. Recovery is possible.
  • Search for underlying cause, if recovery has not started within 6 weeks of onset of symptoms.
  • Aberrant reinnervation may occur during course of recovery, giving rise to unwanted facial movements (e.g., eye closure when mouth is moved) or crocodile tears (tears in eyes during salivation).
 
1.4 BITES (MAMMALS, ANIMALS AND FIGHT BITES)
 
A. Animal/mammalian Bite
Dog, cat, bat, ferret, monkey, horse, sheep, goat, mongoose, jackal, and hyena bite or scratch or lick on abraded skin need rabies vaccine
(Rat, rodent rabbit, hare, squirrel, guinea pig, hamster, gerbil, and chipmunk bite wounds do not need rabies vaccine.)
 
Treatment of Animal Bite Wound
  1. Wound care:
    • Wash with soap and water for 5–10 minutes. Irrigate wound for 5–10 minutes. Use 19G needle with 20 mL syringe or 35 mL piston to produce a pressure of 8 psi. Disinfect/Clean wound with betadine. Deride if necessary.
    • Avoid suturing the wound. Delayed primary closure is recommended (i.e., suture the wound after 3–5 days of dressing).
    • Puncture wounds should be left unsutured.
    • Elevate affected part
  2. Antibiotics: Select appropriate antibiotics listed below (3–5 days as prophylaxis or 10–15 days for established infections). If patient is allergic to amoxicillin, use levofloxacin or ciprofloxacin. Consider adding metronidazole, if necessary.
    Bite
    Pathogens
    Antibiotic choices
    Dog
    Eikenella corrodens, Staphylococcus aureus (S. aureus), Streptococcus, Pasteurella multocida (P. multocida) + anaerobes
    Amoxicillin/clavulanic acid (AUGMENTIN or CLAVAM)
    Cat
    P. multocida, S. aureus + anaerobes
    Amoxicillin/clavulanic acid (AUGMENTIN or CLAVAM)
    Human
    Streptococcus viridans (S. viridans), S. aureus + anaerobes
    Amoxicillin/clavulanic acid (AUGMENTIN or CLAVAM)
    Monkey
    Eikenella corrodens, S. viridans
    Amoxicillin + clavulanic acid (AUGMENTIN or CLAVAM)
    Rat
    Streptobacillus moniliformis, Leptospira
    Amoxicillin/clavulanic acid) (AUGMENTIN or CLAVAM)
    Snake
    Pseudomonas, Enterobacteriaceae
    Amoxicillin + clavulanic acid (AUGMENTIN or CLAVAM)
    Shellfish
    E. risopath
    Doxycycline 100 mg IV bd
    Meat bone
    E. risopath
    Doxycycline 100 mg IV bd
    Poultry sting
    Aeromonas
    Cloxacillin + gentamicin
    Leech
    Aeromonas hydrophila
    Ciprofloxacin (CIFRAN)
  3. Tetanus toxoid (TT) booster
  4. Vaccinations/Immunoglobulins
    1. Post-exposure prophylaxis (PEP)
      Post-exposure prophylaxis
      No previous immunization
      Previous immunization
      Dog, cat, bat, ferret, monkey, horse, sheep, goat, mongoose, jackal, and hyena bite or scratch or lick on abraded skin need rabies vaccine
      Rabies types:
      Furious
      Paralytic
      Passive immunization: (immunoglobulins):
      Recombinant rabies monoclonal antibody R – Mab (RABISHIELD) 2.5 mL =100 IU. Give 3.3 IU/kg directly into wound. This is the best.
      or
      Human rabies immunoglobulin (HRIG) 20 IU/kg infiltrate into the wound and rest IM in (gluteus muscle)
      PLUS
      HDCV/PCEC
      1 mL in deltoid on days 0 and 3
      or
      IDR) 0.2 mL intradermal in right and left deltoid muscle on day 0, 7 and 287
      Following unprovoked or suspicious dog or cat bite, immediately begins prophylaxis. If animal develops rabies during a 10-day observation period or if dog or cat is suspected of being rabies, begin vaccination sequence immediately
      Active immunization (vaccines):
      Human diploid cell vaccine/purified chick embryo cell vaccine 1 mL in deltoid for adults (lateral thigh in children) on days 0, 3, 7, 14, and 28 postexposure
      or
      Intradermal rabies vaccine, 2 sites 0.1 mL, each site intradermal (R and L deltoid region) on day 0, 3, 7 and 21
      [HRIG: human rabies immunoglobulin; HDCV: human diploid cell vaccine; PCEC: purified chick embryo cells; IDRV: intradermal rabies vaccine (Bharat Biotech)]
      All or as much of the full dose of HRIG should be injected into the wound and the remaining vaccine should be injected IM into the deltoid. Do not give HRIG at the same site or through the same syringe with other rabies vaccine.
      Administer in deltoid for adults; anterolateral thigh may be used for children (to avoid sciatic nerve injury and reduce adipose tissue depot delivery, the gluteus is not used).
    2. Pre-exposure prophylaxis (PrEP): Primary vaccine is given for people who work as laboratory staff in research laboratories, animal handlers, wildlife officers, children, and travelers in rabies-affected areas. Vaccine is given on day 0, 7, 21, or 28 and a booster may be required every 6 months to 2 years
 
B. Fight Bites
Fight bites [tooth injuries to metacarpophalangeal (MCP) joints] should be treated more aggressively than human bites. These injuries occur when patient strikes another person in the mouth with a closed fist. Inoculation of sheath of tendon occurs as closed fist has extensor tendons at maximal length. Damaged contaminated sheet retracts up carrying saliva and bacteria. A small metacarpophalangeal skin laceration may appear innocuous but significant infection may be evolving. History suggesting a small skin laceration metacarpophalangeal joint should prompt thorough evaluation. Fight bites have an infection rate up to 75% and approximately 60% have deep structure involvement including tendon injury, joint involvement, and fractures. These injuries should be washed out in emergency department or in operating room and should be seen by a surgeon immediately.
 
C. Snakes/Scorpion Bite/Sting
Refer Chapters 3.5.2 and 3.5.3.
 
Key Points
  • The more complex the wound, the more it should be irrigated.
  • All lacerations of the metacarpophalangeal joint are to be considered as a fight bite.
  • Consider rabies prophylaxis in all mammalian bites
  • Proper antibiotic coverage for mammalian bites, fight bites should include antibiotics to cover beta lactamase producing bacteria.
 
1.5 BLEEDING
 
Red Flags
  • Bruising over face, neck, and trunk
  • Petechiae and/or purpura on extremities and trunk
  • Bleeding from multiple sites
  • Sepsis
  • Fever
  • Systemic symptoms (e.g., weight loss, malaise, fatigue, fever, and night sweats)
 
Etiology
Hematological causes
General causes
Inherited coagulation disorders [e.g., Hemophilia A, Christmas disease, and von Willebrand's disease (vWD)]
Vitamin K deficiency (e.g., dietary and malabsorption)8
Idiopathic thrombocytopenic purpura (ITP)
Liver disease
Leukemia
Drugs (e.g., anticoagulants, antiplatelet therapy, and steroids)
Myelodysplasia
Renal failure
Myelofibrosis with splenomegaly
Shock
Meningococcal septicemia and other sepsis, disseminated intravascular coagulation (DIC)
Systemic lupus erythematosus (SLE)
Antiphospholipid syndrome
Nutritional (e.g., vitamin C deficiency)
 
History
Subset
Inference
Examples
Site of bleeding:
Suspect defect in platelet or
Vessel coagulation disorder
Nonsteroidal anti-inflammatory drugs (NSAIDs), ITP, leukemia, aplastic anemia
Hemophilia, liver failure, DIC, and anticoagulants
Age:
Inherited cause
Acquired or milder inherited causes
Family history:
Acquired defect or no defect in hemostasis
Hemophilia A or B, vWD
Clinical scenario:
Rule out extrinsic anticoagulation
vWD, HELLP syndrome
Rule out bleeding from arteries and veins
 
Examination (Checklist)
Pallor, gum hypertrophy, jaundice, lymphadenopathy, hepatosplenomegaly, and bony or sternal tenderness
Hematological and general conditions may cause bruising and bleeding (refer table above)
Coagulopathies, abnormal platelet function, or abnormal blood vessel walls are important causes.
 
Methods/Drugs to Stop Bleeding (Choices include)
Apply local pressure or pack or ligate the bleeder
Adrenaline (with NS or local anesthesia, e.g., xylocaine to pack a wound)
BOTROCLOT (use for nasal bleeding, e.g., hemocoagulase)
Vitamin K 5–10 mg PO or IV (liver disease)
Tranexamic acid (TXA) (TRANFIB) (for major trauma) 500–1,000 mg PO or IV thrice daily
Epsilon-aminocaproic acid (EACA) (HEMOSTAT) 5 mg tds PO for capillary bleeding
Fibrin sealant/gel foam (e.g., liver tear)
Ultrasound (harmonic scalpel)
Diathermy
Vasopressin, octreotide, somatostatin, and desmopressin (e.g., duodenal ulcer and variceal bleed)
 
When to Stop, Restart Antiplatelet, Anticoagulant, Fibrinolytic Medicines before Surgery and Choice of Reversal Agents
Drug
Stop before surgery
Restart after surgery
Reversal agent (choices include)
1. Antiplatelets
Aspirin/NSAIDs
No need to stop for local anesthesia cases or spinal anesthesia.
Stop 3 days before surgery for epidural anesthesia
12 hours after surgery
Platelet transfusion Desmopressin9
Clopidogrel
5–7 days before surgery
12–24 hours after surgery
Platelet transfusion Desmopressin
Prasugrel
7 days before surgery
Ticlopidine
14 days before surgery
2. Anticoagulants
Heparin
6 hours before surgery
6 hours after surgery
Protamine
Warfarin
4–5 days before surgery
12–24 hours after surgery
Vitamin K 10 mg IV FFP
LMWH like Enoxaparin
12 hours before surgery if on prophylactic treatment or 24 hours if on treatment for DVT
None
Dabigatran
7 days before surgery
24 hours after surgery
None
Fondaparinux
3 days before surgery
12 hours after surgery
None
Rivaroxaban, apixaban
3 days before surgery
6 hours after surgery
None
3. Fibrinolytics
Streptokinase, Urokinase
No clear data available
No clear data available
Tranexamic acid EACA
 
Investigations (Choices Include)
Complete blood count with peripheral smear
Clotting screen:
Platelet count: Normal = 150,000–450,000
Prothrombin time (PT): A difference of more than 4 seconds between control and test is significant (normal = 6.5–11.9)
Activated partial thromboplastin time (aPTT): A ratio of >1.5 times between control and test is significant [International Normalized Ratio (INR): > 1.3 is significant](normal = 0.7–1.2)
Bleeding time (BT): Normal = 2–7 minutes
Clotting time (CT): Normal = 3–8 minutes
Liver function test
Urea and electrolytes
Human immunodeficiency virus (HIV), hepatitis B and C [blood borne infection (BBI) screen]
 
Interpretation of Investigations
Platelet
PT
aPTT
Diagnosis
Normal
Normal
ITP, aplastic anemia
Treatment with anticoagulants, liver failure, and vitamin K deficiency
Normal
Normal
Abnormal
Hemophilia (factor X, factor VII, and factor XI), heparin treatment and vWD
Normal
Normal
Normal
Factor XIII deficiency and renal failure
Normal
Normal
Vitamin K deficiency
Normal
Abnormal
Liver cell failure
Normal
Normal
Dengue, leptospirosis, aspirin, and NSAIDs
 
General Instructions for Patients with Bleeding Diathesis or Bleeding Tendency
Avoid intramuscular (IM) injections
Avoid NSAIDs, as it interferes with platelet function
Consult a hematologist prior to any surgical procedure
Persistent or profuse bleeding should always be shown to a local physician/hematologist.
Gum bleed from tooth socket:
One tablet of TXA (TRANFIB, CYKLOKAPRON) 500 mg to be made as fine powder and mix with one teaspoon of water to make a paste. This is applied at local site of bleed (at least 10–15 minutes), can be swallowed later.
In case of generalized bleed, dissolve tablet in 15 mL water. Keep in mouth for 5 minutes and then swallow.
If bleeding does not stop by local measures, tablet/capsule can be taken orally.
Dose 500 mg tid for an adult initially and can be increased to 1 g every 6 hours (dose in children is 50–100 mg/kg/day). This may be continued till the bleeding stops. Systemic TXA (oral/intravenous) is contraindicated in patients with hematuria.10
Epistaxis:
Tranexamic acid injection 500 mg (TRANFIB 1 mL = 10.0 mg) can be drawn in and instilled into the nose drop by drop and pinch nose.
Once a vial is opened and drawn in a syringe, it may be kept in refrigerator (4–8°C) for a maximum of 24 hours.
If injection is not available, one tablet may be finely powdered and mixed with 5 mL of water and the above instruction may be followed.
Girls who have achieved menarche: In case of heavy menstrual bleeds, tablet Ovral L one tablet three times a day for 2–3 days followed by one tablet twice a day for 2 days and then once a day for a total of 28 days (in case of normal menses, hormonal control of bleed is not required).
 
1.6 BLOOD AND BLOOD TRANSFUSION
 
Blood Composition (Total Volume is 5 Liters)
Constituents
Function
RBC
Carry oxygen to body organs and tissues.
WBC
Neutrophils, lymphocytes, monocytes, eosinophils, and basophils
Defense
Platelets
Platelets + fibrin = clot
Plasma
(Water, salts, proteins and clotting factors)
Albumin, immunoglobulins, clotting factors, and fibrinogen
Immune function and clotting
 
Blood Components/Blood Fractions
Procedure of splitting whole blood to blood components is called cytapheresis. Eight blood components or flood fractions are obtained from whole blood
zoom view
 
Blood Groups (Two Major Groups are ABO and Rh)
 
ABO Group (Karl Landsteiner Discovered Blood Groups)
Blood group is classification of blood based on presence or absence of certain substances (proteins) on blood cell surface. Like eye color, blood group is determined from genes.
Blood group
Antigens on RBC membrane
Antibodies in plasma
A
A
Anti-B
B
B
Anti-A
AB (Universal receiver)
A and B
No antibody
O (Universal donor)
No antigen
Anti-A and anti-B11
Blood transfusions—who can receive blood from whom?
People with blood group O are called “Universal donors”.
People with blood group AB are called “Universal recipients”.
 
Rh (Rhesus) Group
In addition to ABO group, another antigen is present on the RBC is called Rh factor.
If Rh D antigen is present, it is Rh + and if not present, it Rh –
Importance of Rh group:
During pregnancy, if mother is Rh negative, and father is Rh positive, baby's blood group will be Rh positive as it is dominant and if not treated, baby can have serious complications.
Rhesus disease is a condition where antibodies in pregnant women's blood (Rh negative) destroy her baby's blood cells (this is known as hemolytic disease of new born) and is diagnosed by indirect Coombs test in mother.
All Rh negative women during pregnancy get anti–D injection at 28 weeks and 34 weeks.
Check cord blood:
  • If baby is Rh+, give another injection of anti–D to mother.
  • If cord blood of baby is Rh-, there is no need to give anti–D injection to mother.
 
Blood Grouping and Cross Match
Blood grouping
Cross match
How to do
A, B, and Rh D agglutinins are added to donated blood
Donors RBC are mixed with recipient's serum
Time taken
5 minutes
15 minutes
Uses
Blood transfusion
Pregnancy (Rh incompatibility)
Investigating cases of paternity dispute
Done before blood transfusion to give the right blood group
 
Blood Components/Fractions
Component
Amount (mL)
Storage
Shelf life
Indications
Transfusion time
Packed red blood cell (PRBC)
300
4°C
40 days
<4 hours
Leukocytes
Platelet concentrate
50 mL = 1 unit
22°C
5 days
<20 minutes
Fresh frozen plasma
1 unit = 200 mL
(usually 3–4 unit are given) (5–10 mL/kg)
−18°C
365 days
Within 2 hours
Cryoprecipitate (from cooling plasma to 4° C and collecting the precipitate)
1 bag = 20 mL (usually 10 bags are given)
Contains VII, Fibrinogen and VWF
−18°C
365 days
<20 minutes
Albumin (5% and 25%)
Immunoglobulins (IgG, IgM, IgA, IgD and IgE)
Coagulation factor 8 and 9
Whole blood (not used now a days)
400 mL
4°C
35 days
<4 hours
 
Indications for Blood Component Transfusion (Mnemonic = ABCT)
Anemia
Bleeding (trauma, intraoperative, postoperative)
Coagulopathy (congenital/acquired bleeding disorders)
Thrombocytopenia (decreased production/chemotherapy/tumor infiltration)
 
Blood Transfusion Complications
Immediate/Acute (<24 hours)
Delayed (>24 hours)
Transfusion reactions:
Allergic
Febrile
Hemolytic
Infections:
HIV, hepatitis C, and hepatitis B
Others: Hepatitis A, malaria, brucellosis, and trypanosomiasis
Transfusion-related acute lung injury (TRALI)
Iron overload
Septic shock
Post-transfusion purpura (PTP)
Transfusion associated cardiac overload (TACO)
Graft versus host disease (GVHD)
Hypothermia
Hyperkalemia
Hypocalcemia
Air embolism
 
Treatment of Blood Transfusion Reactions
Acute hemolytic transfusion reaction (AHTR) (Mismatched blood transfusion)
Etiology
ABO incompatibility
Site of hemolysis
Intravascular
Pathophysiology
Hemoglobin released is bound by serum haptoglobin. Hemoglobin is filtered in kidney. Hemoglobinuria and renal failure
Symptoms and signs
Fever, dyspnea, headache, loin pain, hypotension acute renal failure, jaundice, DIC, hypotension, and bleeding
Treatment
ICU admission, cardiac monitor, and pulse oximetry:
Stop transfusion
Send blood samples
Donor and recipient for cross match and group, blood coagulation screen, LFT, creatinine, urea
Normal saline infusion (maintain urine output >100 mL/h). Insert Foley catheter.
Diuretics (mannitol or furosemide)
Maintain BP
Intubation and ventilation serious cases
Anuria: Treat as acute renal failure (ARF)
Disseminated intravascular coagulation: Treat with appropriate blood components
Allergic reaction (mild) (urticaria and itching)
Slow or stop transfusion
Chlorpheniramine 10 mg IV
Restart transfusion at a slow rate
Observe more frequently
Anaphylaxis
Stop transfusion
Oxygen IV fluids NS (as fast as possible). Adrenaline IM. Chlorpheniramine
Salbutamol nebulization13
Nonhemolytic febrile transfusion reaction (NHFTR)
Slow or stop transfusion
Temperature > 1.5°C (patient stable). Give paracetamol. Restart transfusion at a slower rate
Observe more frequently
TRALI (clinical features of left ventricular hypertrophy (LVH) fever, chills)
Stop transfusion
Oxygen, endotracheal intubation, and ventilate if necessary
Bacterial contamination/septic shock
Stop transfusion
Antibiotics
Transfusion associated cardiac overload (TACO)
Slow or stop transfusion
Give oxygen and diuretic, e.g., furosemide
 
Prevention of Blood Transfusion Complications
Safety check list for Laboratory staff, Nurses, and doctors
Use blood transfusion only if needed
Give to right patient
Check group and cross match compatibility. Check expiry date. Check for signs of hemolysis/leakage
If any acute complication is noted, stop transfusion and review
 
Methods to Reduce Blood Transfusion (i.e., Blood Conservation)
History
Enquire about bleeding history (past, present, family, and drug history)
This helps to detect patients with coagulation/bleeding disorder
Perform coagulation screen, platelets, PT, APTT, TT, LFT, and correct before surgery whenever possible
Drugs
Stop drugs like aspirin, clopidogrel, heparin, warfarin 5–7 days before surgery
Treat anemia with Iron supplements/B12/erythropoietin
Tranexamic acid 1 g half hour before surgery for major cases/trauma-associated shock
Procedures
Temporary measures to control bleeding (pressing/lacking)
Tourniquets, vasoconstrictors (e.g., LA with adrenaline)
Electrocautery, lasers, and embolization
Fibrin sealants (e.g., liver surgery and cardiac surgery)
Auto transfusion (use your own blood)
Predonation
1 Unit of blood per week 2–4 weeks before surgery
Isovolumic hemodilution
1-1.5 L of blood taken just before surgery in OT and replaced by 1–1.5 L of saline
Cell salvage
Intraoperative cell salvage: During surgery, blood that flows is collected, washed, and infused back to patient
Postoperative cell salvage: Blood collected after surgery in drains is infused back to patient
 
Massive Blood Transfusion
Massive transfusion causes a lethal triad of coagulopathy, hypothermia, and acidosis.
Definition
>10 units of PRBC in 24-hour period or
>4 units of blood in 1 hour, or
Replacement of entire circulating blood volume with blood products in 24 hours
Indications
Hemorrhagic shock/polytrauma/penetrating injuries
Bleeding seen in focused assessment with sonogram in trauma fast US/CT scan (abdomen/pelvis)
Patients with systolic BP < 90 mm Hg with bleeding
Heart rate > 120 bpm with bleeding
Complications
Coagulopathy
Hypothermia
Citrate toxicity
Hyperkalemia (increase K+), acidosis
Hypocalcemia (decrease Ca2+)
Volume overload
Transfusion-associated lung injury (TRALI)
Transfusion-associated cardiac overload (TACO)
Blood transfusion reactions (allergic, febrile, or hemolytic)
Air embolism
Prevention of MT reactions
If MT is required, give PRBC, plasma, FFP, and platelets in a ratio of 1:1:114
 
Hemophilia
Introduction
Hemophilia A is deficiency of factor 8
Hemophilia B is deficiency of factor 9 (Christmas disease)
Affects males, females are carriers. Severity of disease depends on level of clotting factors
Signs and symptoms
Frequent spontaneous bleeding into joints, muscles, and soft tissue (pain precedes bleeding)
Epistaxis, bleeding gums, hematuria, and central nervous system (CNS) bleeding
Investigations
Factor 8 or 9 (reduced levels)
APPT (prolonged)
Platelets normal, prothrombin time normal
Treatment choices
Hemophilia A:
  • Factor 8 concentrate (plasma/genetic modified)
  • Cryoprecipitate (rich source of factor 8)
  • Fresh frozen plasma
  • Deamino arginine vasopressin (DAVP)
Hemophilia B:
  • Platelet concentrate is given which contains factor 9
 
Artificial Blood/Oxygen Therapeutic Agents (OTAs)/Blood Substitutes
Types
1. Hemoglobin based oxygen carriers (HBOCs). Artificial blood is designed for sole purpose of transporting oxygen throughout body. HBOCs (0.08–0.1 μ) vaguely resemble blood. They are very dark red or burgundy and are made from sterilized hemoglobin and are extremely good at carrying dissolved gases
2. Perfluorocarbons
Advantages
No compatibility testing
Free from blood borne infections
Prolonged shelf life and requires no refrigeration
Disadvantages
Still under research and development
Not approved by FDA
 
Key Points
  • Avoid unwanted blood transfusion.
  • Lab data is not sufficient especially in acute and ongoing bleeding
  • PRBC transfusion is indicated in:
    • Acute and ongoing bleeding even if Hb is in normal limits
    • Chronic anemia if patient is symptomatic and Hb is <7 g/dL
  • Platelet transfusion is indicated if there:
    • Thrombocytopenia or platelet dysfunction
    • If platelet count is <50,000/mL for minor surgical procedures
 
1.7 CELLULITIS
 
Definition
Spreading subcutaneous infection by β-hemolytic Streptococcus (Streptococcus releases hyaluronidase and streptokinase).
 
Clinical Features
Swollen, warm, red, painful, and fever
Lymphangitis (lymphatic draining affected areas become inflamed and are seen as red streaks)
Lymphadenitis (lymph nodes swollen and tender)
 
Complications
Abscess
Septicemia
Precipitating factor for diabetic ketoacidosis (DKA)15
 
Differential Diagnosis
Erysipelas
Stasis dermatitis
Lipodermatosclerosis or sclerosing panniculitis
Contact dermatitis
Popular urticaria
 
Investigations (Choices Include)
WBC count, RBS/FBS/PPBS
Blood culture and sensitivity (C/S)
Microscopy, C/S of fluid (aspiration from point of maximum inflammation, leading edge or most intense area of induration)
X-ray/CT/MRI
 
Treatment (Choices Include)
Antibiotics: Penicillin/cefazolin/cefadroxil/levoflox/amoxiclav
Analgesics
Anti-inflammatory drugs
Rest (immobilization)
Elevation (helps to reduce edema)
Note: Refer Chapters 1.4, 12.2.14.9 for more details.
 
Key Points
  • Cellulitis most often presents unilaterally.
  • Stasis dermatitis is a common mimic of cellulitis and results from long-standing history of chronic venous stasis and decreased tissue perfusion
  • Pain out of proportion to exam should prompt physician to consider necrotizing soft tissue infections.
  • Observation and serial examination will aid in treatment and evaluation for alternate diagnosis.
  • History and physical exam will direct physician in differentiating cellulitis from its mimics.
  • Double incision fasciotomy for severe cellulitis and lymphangitis decreases the incidence of persistent lymphedema.
 
1.9 SOME COMMON DISEASES OF KIDNEY AND CHRONIC KIDNEY DISEASE
 
1. Common Kidney Diseases
Kidney disease occurs when the kidneys are damaged and cannot function properly. Numerous conditions and diseases can result in damage to the kidneys, thus affecting their ability to filter waste from the blood while reabsorbing important substances. Generally, kidney disease may present or develop in a few different ways.
Acute kidney injury (AKI)—rapid loss (over a few hours or days) of kidney function. It may be recognized when a person suddenly produces urine much less frequently and/or has a dramatic increase in the level of waste products in the blood that the kidneys normally filter out. AKI is often the result of trauma, illness, or a medication that damages the kidneys. It is most common in people who are already hospitalized such as those who are critically ill and in intensive care unit. If damage caused by AKI persists, it can eventually progress to CKD.
Chronic kidney disease occurs over time lasting over 3 months and common causes are diabetes and high BP (hypertension).
Nephrotic syndrome: It is characterized by the loss of too much protein in the urine and caused by damage to glomeruli. A primary disorder of the kidney or secondary to an illness or other condition, such as cancer or lupus can cause nephrotic syndrome. Along with high amount of protein in urine, signs and symptoms of nephrotic syndrome include a low albumin in blood, higher than normal lipid levels in blood, and swelling (edema) in levels of legs, feet, and ankles.16
Kidney failure, also called end-stage renal disease or ESRD, is the total or near total loss of kidney function and is permanent. Treatment with hemodialysis or kidney transplant is the only option at this stage of kidney disease to sustain life.
Risk factors for kidney disease are:
Diabetes: A sustained high level of blood glucose from uncontrolled diabetes can over time damage the nephrons in the kidneys. This can be avoided by maintaining a good glucose control.
Family history of kidney disease : Polycystic kidney disease (PKD)
Glomerulonephritis (chronic nephritis or nephritic syndrome)
Obstruction: Kidney stone or tumor
Autoimmune disease: Systemic lupus erythematosis or Goodpasture's syndrome
Infections: Strep infections of throat or skin, skin infection impetigo, endocarditis, or a viral infection.
Toxins : Contrast dyes used for imaging procedures and certain medication
Prerenal azotemia: Severe burns, severe dehydration, or septic shock
 
Tests Commonly Used For Screening and Diagnosis
The National Kidney Foundation and the National Kidney Disease Education Program (NKDEP) recommend that people who are at high risk be screened for kidney disease to detect it in its earliest. Risk factors include diabetes, high BP, heart disease, or a family history of these or kidney disease.
Tests
Comments
Urine albumin
This test may be done on a 24-hour urine sample or both urine albumin and creatinine can be measured in a random urine sample and the albumin/creatinine ratio (ACR) can be calculated. The American Diabetes Association recommends ACR as a preferred test for screening for albumin the urine (microalbuminuria)
Urine analysis
This is a routine test that can detect protein in the urine as well as RBCs and white blood cells. These are not normally found in the urine and if present, may indicate kidney disease
Urine total protein or urine to creatinine ratio (UP/CR)
Detects not just albumin but all types of proteins that may be present in the urine
Estimated glomerular filtration rate (eGFR)
A blood creatinine test or possibly a cystatin C test is performed in order to calculate the eGFR. The GFR refers to the amount of blood that is filtered by the glomeruli per minute. As a person's kidney function declines due to damage or disease, the filtration rate decreases and waste products begin to accumulate in the blood
Urea (urea nitrogen or BUN)
Level of this waste product in blood increases as kidney filtration declines. Increased BUN levels suggest impaired kidney function, although they can also be elevated due condition that results in decreased blood flow to the kidneys, such as congestive heart failure (CHF), heart attack, or shock
Creatinine clearance
Measures creatinine levels in both a sample of blood and a sample of urine from a 24-hour urine collection. Results are used to calculate the amount of creatinine that has been cleared from the blood and passed in to the urine. This calculation allows for a general evaluation of amount of blood that is being filtered by kidneys in a 24-hour time period
 
Tests to Monitor Kidney Function
If a person has been diagnosed with a kidney disease, several laboratory tests may be ordered to help monitor kidney function. Some of these include:
Tests
Comments
BUN and creatinine
Measured from time to time to see if kidney disease is getting worse
Calcium and phosphorus
Calcium and phosphorus in the blood, blood gases (ABGs), and the balance of serum and urine electrolytes can also be measured as these are often affected by kidney diseases
Hemoglobin
Measured as a part of CBC, may also be evaluated as the kidneys make a hormone erythropoietin, that controls RBC production and this may be affected by kidney damage
Erythropoietin
May be measured directly, although this is not a routine test
Parathyroid hormone (PTH)
Controls calcium levels, is often increased in kidney disease and may be checked to help determined, if enough calcium and vitamin D are being taken to prevent bone damage
Cystatin C
May sometimes be used as an alternative to creatinine to screen for and monitor kidney dysfunction in those with known or suspected kidney diseases
Blood and urine beta-2 microglobulin (B2M)
May be ordered along with other kidney function tests to evaluate kidney damage and disease and to distinguish between disorders that affect the glomeruli and the renal tubules17
 
Tests to Help Determine the Cause/Guide Treatment
Tests
Comments
Urine analysis with a urine culture
May be done when someone has symptoms suggesting infections to confirm the presence of a bacterial infection
Hepatitis B or C testing
To detect a hepatitis viral infection associated with some types of kidney disease
Antinuclear antibody (ANA)
To help identify an autoimmune condition such as lupus that may be affecting the kidneys
Kidney stone risk panel
Evaluates a person's risk of developing a kidney stone to help guide and monitor treatment and prevention
Kidney stone analysis
Determines composition of a kidney stone passed or removed from the urinary tract and may be done to help determine the cause of its formation, to guide treatment, and prevent recurrence
Complement tests (C3 and C4)
May be tested and monitored
Urine protein electrophoresis
To determine the source of a high level of protein in the urine
Myoglobin
In people who have had extensive damage to skeletal muscles (rhabdomyolysis), a urine myoglobin test may be ordered to determine the risk of kidney damage. With severe muscle injury, blood and urine levels of myoglobin can rise very quickly
 
2. Chronic Kidney Disease
 
Etiology
  • Diabetes
  • Hypertension
  • Glomerulonephritis
  • Polycystic kidney disease
  • Reflux nephropathy and other congenital renal diseases
  • Interstitial nephritis, including analgesic nephropathy
 
Stages of Chronic Kidney Disease
zoom view
Chronic kidney disease is present if any features listed below are present for >3 months.
  • Pathologic damage: Biopsy shows glomerulosclerosis, tubular atrophy, and interstitial fibrosis.
  • Abnormalities in blood: Elevation of BUN and serum creatinine over at least 3 months, anemia, hypocalcemia, and hyperphosphatemia.
  • Abnormalities in urine test: Urine sediments/proteinuria can be a forerunner of CKD.18
Abnormalities in albumin excretion
Test
Spot microalbumin collection (µg/mg creatinine)
Normal
<30 mg/dL
Increased urinary albumin excretion
>30 mg/dL
Historically, ratios between 30 and 299 have been called microalbuminuria and those 300 mg/dL or greater have been called macroalbuminuria (clinical albuminuria = albumin in urine)
  • Imaging: Findings of small echogenic kidneys bilaterally < 9–10 cm by ultrasonography support a diagnosis of CKD (normal or even large kidneys with CKD can be seen with adult PKD, diabetic nephropathy, HIV-associated nephropathy, multiple myeloma, amyloidosis, and obstructive uropathy).
  • History of kidney transplantation
  • GFR < 60 mL/min/1. 73 m2
 
Symptoms and Signs of Uremia
Organ system
Symptoms
Signs
General
Fatigue and weakness
Chronically ill
Skin
Pruritus, easy bruisability
Pallor, ecchymosis, excoriations, edema, and xerosis
ENT
Metallic taste in mouth, epistaxis
Urinous breath
Eye
Pale conjunctiva, retinopathy
Pulmonary
Shortness of breath
Rales, pleural effusion
Cardiovascular
Dyspnea on exertion, retrosternal pain on inspiration (pericarditis)
Hypertension, cardiomegaly, and friction rubs
Gastrointestinal
Anorexia, nausea, vomiting, and hiccups
Genitourinary
Nocturia, erectile dysfunction
Isosthenuria
Neuromuscular
Restless legs, numbness, and cramps in legs
Neurologic
Generalized irritability and inability to concentrate, decreased libido
Stupor, asterixis, myoclonus, and peripheral neuropathy
 
Treatment of Chronic Kidney Disease
  1. Correct reversible causes of kidney injury causing CKD:
    Reversible factors
    Diagnostic clues
    Infection
    Urine culture and sensitivity tests
    Obstruction
    Bladder catheterization and renal US
    Extracellular fluid volume depletion
    Orthostatic BP and pulse (decreased BP and increased pulse upon sitting up or standing from a supine position)
    Hypokalemia, hypercalcemia and hyperuricemia
    Serum electrolytes, calcium, phosphate, and uric acid
    Nephrotoxic agents
    Drug history
    Hypertension
    BP, chest radiograph
    Congestive heart failure
    Physical examination, chest radiograph, and echocardiogram
    Anemia
    Iron deficiency/B12 deficiency/EPO deficiency
  2. Diet:
    Protein restriction
    0.6 g/kg body weight for patients with stage 4 and 5 CKD
    At least 50% protein intake should consist of high biological value protein
    Salt restriction
    80–120 mmol/day (NaCl) = 1 teaspoon salt
    Water restriction
    In fluid overloaded patients, daily intake should be < 800–1,000 mL/day
    Potassium restriction
    Avoid potassium-rich foods such as tender coconut water, banana, citrus fruit, and dates (when GFR falls below 10–20 mL/min or if patient is hyperkalemic)
    Phosphorus restriction
    Avoid eggs, beans, dairy products, cola beverages (when pH is high)
    Magnesium restriction
    Avoid magnesium containing laxatives and antacids in CKD19
  3. Treatment of complications or comorbidities:
    Hypertension
    Maintain BP < 130/80 mm Hg
    Proteinuria
    Angiotensin receptor blockers (ARBs)/ACE inhibitors are drugs that have proven effect in decreasing proteinuria and prevent progression of diseases
    Diabetes
    Maintain FBS 90–130 mg/dL, HbA1c < 7
    Short-acting insulin preferred (e.g., plain insulin)
    If oral hypoglycemic agents (OHA) are to be used, short-acting sulfonylureas (e.g., gliclazide/glipizide) are preferred
    Anemia
    When Hb is < 10 g/dL:
    Erythropoietin (WEPOX, EPOTRUST) 4,000 units twice weekly SC (80–20 units/kg body/week)
    Check transferrin saturation and ferritin. If transferrin saturation < 20% or ferritin < 200 mg/mL, give iron sucrose 200 mg in 100 mL NS over 1 hour weekly once for 5 weeks followed once monthly; parenteral iron (FERINJECT and QRON) (iron sucrose) (refer Chapter 1.1)
    Target Hb should be 11–12 g/dL
    Bone disease—renal osteodystrophy (hyperphosphatemia, hypocalcemia and hypovitaminosis D) (↑ PTH)
    Hyperphosphatemia:
    Phosphate binders, calcium-containing binder: Ca acetate (LANUM 667 mg tds/PHOSTAT tds)
    Noncalcium-containing binder: Sevelamer (REVYLAMER 400 mg tds)
    Hypocalcemia:
    Calcium carbonate (SHELCAL)
    Hypovitaminosis D:
    1,25(OH2), calcitriol, i.e., active form of vitamin D3 (LARETOL/ONE-ALPH)
    High uric acid
    If uric acid is > 8 mg/dL, febuxostat (FEBUGET/FEBUTAZ 40 mg od, morning) or [allopurinol (ZYLORIC 100 mg tds), dose should be decreased in azotemia]
  4. Dialysis (indications):
    Type
    Indications
    Hemodialysis or peritoneal dialysis (PD)
    Anuria > 24 hours
    Fluid overload unresponsive to diuretics
    Refractory hyperkalemia
    Severe metabolic acidosis
    Uremic symptoms (encephalopathy, gastritis, and pericarditis)
 
Potassium and Chronic Kidney Disease Diet
 
What is potassium and why is it important?
Potassium is a mineral found in many foods. It plays a role in keeping heartbeat regular and muscles working right. It is the job of healthy kidneys to keep right amount of potassium in body. However, when kidneys are not healthy, one needs to limit certain foods that can increase the potassium in blood to a dangerous level. If potassium level is high, one may experience weakness, numbness and tingling or irregular heartbeat, deteriorating, VT or VF, and cardiac arrest.
 
What is a safe level of potassium in blood?
If it is 3.5–5.0
Safe zone
If it is 5.1–6.0
Caution zone
If it is higher than 6.0
Danger zone
 
How to keep potassium level from getting too high?
One should limit foods that are high in potassium; renal dietician will help to plan the diet.
Eat a variety of foods, but in moderation
Leach potassium-rich vegetables before using (leaching is a process by which some potassium can be pulled out of the vegetable)
Do not drink or use the liquid from canned fruits and vegetables or juices from cooked meat.
Almost all foods have some potassium, size of the serving is very important.
A large amount of a low-potassium food can turn into a high-potassium food.
 
What foods are high in potassium (>200 mg per portion)?
Following table lists foods that are high in potassium. The portion size is ½ cup unless otherwise stated. Check portion sizes. While all the foods on this list are high in potassium, some are higher than others.20
High-potassium foods
Fruits
Vegetables
Other foods
Apricot, raw (2 medium) and dried (5 halves)
Avocado (¼ whole)
Banana (½ whole)
Dates (5 whole)
Dried fruits
Figs, dried
Grapefruit juice
Kiwi (1 medium)
Mango (1 medium)
Orange(1 medium)
Orange juice
Papaya (½ whole)
Pomegranate (1 whole)
Pomegranate juice
Prunes
Fruits
Prune juice
Raisins
Artichoke
Bamboo shoots
Baked beans
Butternut squash
Refried beans
Beets, fresh and then boiled
Black beans
Broccoli, cooked
Brussels sprouts
Chinese cabbage
Carrots, raw
Dried beans and peas
Greens
Lentils
Legumes
Vegetables
Mushrooms, canned
Parsnips
Potatoes, white and sweet
Pumpkin
Bran/Bran products
Chocolate (1.5–2 ounces)
Granola
Milk, all types (1 cup)
Molasses (1 tablespoon)
Nuts and seeds (1 ounce)
Peanut butter (2 tablespoon)
Salt substitutes/low salt
Salt-free broth
Yogurt
Nutritional supplements: Use only under the direction of doctor or dietician
 
What foods are low in potassium?
Following table lists foods that are low in potassium. The portion is ½ cup unless otherwise noted. Eating more than one portion can make a low-potassium food into a high-potassium food.
Low-potassium foods
Fruits
Vegetables
Other foods
Apple (1 medium)
Apple Juice
Apple sauce
Apricots, canned in juice
Blackberries
Blueberries
Cherries
Cranberries
Fruit cocktail
Grapes
Grape juice
Grape fruit (½ whole)
Mandarin oranges
Peaches, fresh (1 small), canned (½ cup)
Pears, fresh (1 small), canned (½ cup)
Pineapple
Pineapple juice
Plums (1 whole)
Raspberries
Strawberries
Tangerine (1 whole)
Watermelon (limit to 1 cup)
Asparagus (6 spears)
Beans, green or wax
Cabbage, green and red carrots, cooked
Cauliflower
Celery (1 stalk)
Corn, fresh (½ spear) and frozen (½ cup)
Cucumber
Eggplant
Kale
Lettuce
Mixed vegetables
Mushrooms, fresh
Okra
Onions
Parsley
Peas, green
Peppers
Radish
Watercress
Yellow squash
Zucchini squash
Rice
Noodles
Pasta
Bread and bread products (not whole grains)
Cake (angel, yellow)
Coffee (limit to 8 ounces)
Pies without chocolate or high-potassium fruit
Cookies without nuts or chocolate
Tea (limit to 16 ounces)
 
Sodium and Chronic Kidney Disease Diet
 
What is sodium?
Sodium is a mineral found naturally in foods and is a major part of table salt.21
 
What are the effects of eating too much sodium?
Some salt or sodium is needed for maintaining water balance in the body. But, when kidneys lose the ability to control sodium and water balance, one may experience the following:
Thirst
Fluid gain (swollen ankles, pedal edema, and puffiness of face)
High BP especially in salt sensitive people
Limit the amount
Food to limit because of their high-sodium content
Acceptable substitutes
Salt and salt seasonings
Table salt, seasoning salt, garlic salt, onion salt, celery salt, meat tenderizer, and flavor enhancers
Fresh garlic, fresh onion, garlic powder, onion powder, black pepper, lemon juice, low sodium/salt-free seasoning blends, and vinegar
Salty foods
High sodium sauces such as barbecue sauce, steak sauce, soy sauce, teriyaki sauce, oyster sauce salted snacks such as crackers, potato chips, corn chips, pretzels, tortilla chips, nuts, popcorn, and sunflower seeds
Homemade or low-sodium sauces and salad dressings (vinegar, dry mustard) unsalted popcorn, pretzels, tortilla, or corn chips
Cured foods
Ham, salt pork, bacon, sauerkraut, pickles, pickle relish, and olives
Fresh beef, veal, pork, poultry, fish, and eggs
Luncheon meats
Hot dogs, cold cuts, deli meats, sausage, and spam
Low-salt meats
Processed foods
Buttermilk, cheese, soups, tomato products, vegetable juices, canned vegetables, macaroni and cheese, spaghetti, commercial mixes, frozen prepared foods, and fast foods
Natural cheese (1–2 oz per week)
Homemade or low-sodium soups, canned food without added salt
Homemade casseroles without added salt, made with fresh or raw vegetables, fresh meat, rice, pasta, or unsalted canned vegetables
 
Hints to Keep Sodium Intake Down
Cook with herbs and spices instead of salt, read food labels, and choose those foods low in sodium.
Avoid salt substitutes and specially low-sodium foods made with salt substitutes because they are high in potassium.
When eating out, ask for meat or fish without salt, ask for gravy or sauce on the side; these may contain large amounts of salt, and should be used in small amounts.
Limit use of canned, processed, and frozen foods.
 
Understanding Information about Food Labels
Understanding the terms:
Sodium free: Only a trivial amount of sodium per serving
Very low sodium: 35 mg or less per serving
Low sodium: 140 mg or less per serving
Reduced sodium: Foods in which level of sodium is reduced by 25%
Light or lite in sodium: Foods in which sodium is reduced by at least 50%.
Simple rule of thumb: If salt is listed in first five ingredients, the item is probably too high in sodium to use.
All food labels now have milligram (mg) of sodium listed. Follow these steps when reading sodium information on the label:
  1. Know how much sodium is allowed each day: Remember that there are 1,000 mg in 1 g. For example, if the diet prescription is 2 g of sodium, limit is 2,000 mg/day. Consider sodium value or other food to be eaten during the day.
  2. Look at package label and check serving size: Nutrition values are expressed per serving. How does this compare to the total daily allowance? If sodium level is 500 mg or more per serving, item is not a good choice.
  3. Compare labels of similar products: Select lowest sodium level for same serving size.
 
1.10 COMA
A coma patient is unarousable and unable to respond to external events or inner needs (although reflex posturing may be present). Coma is a major complication of serious CNS disorders. It can result from seizures, hypothermia, metabolic disturbances or structural lesions causing bilateral cerebral hemispheric dysfunction, or a disturbance of the brainstem reticular activating system. Mass lesion involving one cerebral hemisphere may cause coma by compression of the brainstem. All comatose patients should be admitted to hospital and referred to a neurologist or neurosurgeon.22
Physical examination
Immediate treatment (choices include) (“GOT-FAN MD” mnemonic)
  • CAB (circulation, airway, breathing)
  • CNS examination:
    • Pupils and doll's eye movement
    • Focal neurological deficits
    • Reflexes
    • Signs of meningism
    • Signs of increased ICT (hypertension, headache, decreased pulse rate, vomiting, and seizures)
Glucose 50%
50 mL, IV
Oxygen
8 L/min
Thiamine
100 mg, IV
Flumazenil
2 mL (0.2 mg) IV (max 10 mL = 1 mg)(benzodiazepine overdose)
Atropine
0.3–0.6 mg (organophosphorus poisoning)
Naloxone
400 mg, SC/IM (for opioid overdose)
Mannitol 20%
0.25–1 g, IV over 10 min [for increased intracranial pressure (ICP)]
Dexamethasone
16 mg IV stat + 8 mg, IV 8 hourly (if suspecting adrenal insufficiency)
 
Etiology and Investigations
Etiology (mnemonic “MIND”)
Investigations (choices include, select appropriately)
Metabolic
CBC, RBS, Na, K, Ca LFT, RFT
Infections
CBC
Widal and malarial parasite in febrile patient
Urine analyses
Culture and sensitivity (C/S) of blood, urine, pus, tissue
LP (CSF fluid analysis)
CT (brain)
Neurological
CT (trauma)
MRI (stroke, seizure, infection, and neoplasm)
Drugs
Toxic substance screening, e.g., drugs and poison
 
Take a Good History from Attendants
History
Probable diagnoses
Diabetes on (OHA/insulin, diabetic untreated or diabetic missed drugs or on irregular treatment)
Hypoglycemia, DKA, or hyperosmolar coma or cerebrovascular accidents (CVA)—thrombosis
Hypertension, hypertensive encephalopathy
Stroke, hemorrhage, or SAH
Epilepsy
Postictal state
Drug history
Drug overdose
COPD, bronchial asthma
Carbon dioxide narcosis, hypoxia
Ischemic heart diseases (IHD), heart disease
Acute myocardial infarction (MI), embolic stroke, and brady- or tachyarrhythmia
Renal disease
Uremic encephalopathy
Metabolic acidosis
Liver disease
Hepatic encephalopathy
On diuretics
Hyponatremia (diuretics)
Hypokalemia
Other electrolyte imbalance
Bleeding tendency or anticoagulation
Intracerebral hemorrhage
 
Metabolic Coma
Etiology
Specific neurologic signs
Investigations
Etiology
Specific neurologic signs
Investigations
Hypoxia
Respiratory problem, cardiac problem, polytrauma resuscitation, and attempted suicide
Oxygen saturation, CXR, and ECG
Hyperosmolar diabetic coma
Coma, seizures, and focal signs
Blood glucose > 1,100 mg, high serum osmolality23
Diabetic ketoacidosis
Clouding of consciousness, but rarely coma
Ketonuria
Blood glucose > 250 mg%
Hypoglycemia
High variability, including coma, seizure, and focal signs
Blood glucose < 60 mg%
Hepatic encephalopathy
Tremor, asterixis (wing beating); final stage, severe clouding of consciousness
LFT, PT
Uremia
Delirium, seizures, myoclonus, asterixis; final stage, and clouding of consciousness
Serum creatinine, urea, and potassium
Disequilibrium syndrome
Muscle cramps, seizures, coma
Postdialysis, urea, sodium, and osmolarity
Hyponatremia
Clouding of consciousness; seizures and coma only in case of rapid change of serum sodium level
Serum sodium < 126 mg
Hypernatremia
Delirium, muscle weakness, and coma only in case of rapid change
Serum sodium >156 mg
Hypocalcemia
Delirium, headache, and muscle weakness
Calcium and phosphate in serum and urine, parathormone
Hypercalcemia
Bone/Joint pain, delirium, pseudopsychotic behavior, seizures
Calcium and phosphate in serum and urine, and parathormone
Thiamine deficiency
Wernicke's encephalopathy; rarely coma (suspect in alcoholics)
Vitamin B level
 
Prevention of Secondary Brain Damage
Secondary brain injury is commonly due to increased ICP.
It is a physiologic response, which occurs hours or even after days after primary brain injury due to hypotension or decreased cerebral blood flow (from local edema/bleeding/increased ICP).
Cause
Prevention/Treatment choices
Hypoxia (if SpO2 is <93%)
Supplement with oxygen 8 L/min and maintain SpO2 >94%
Intubate and ventilate
Hypotension
Maintain SBP around > 90 mm Hg [mean arterial pressure (MAP) > 70 mm Hg]
Maintain normotension
Raised ICP
Hypoxia and hypotension are main causes of increased ICP
Clinical features may include agitation, lethargy, focal neurological deficit, nonreactive pupils or
Cushing's Triad Bradycardia, hypertension, or irregular respiration
Neutral head and neck position
Medical treatment
(choices include)
IV mannitol
Hypertonic saline
Dexamethasone
Surgical treatment
Craniotomy: (evacuation and decompression)
Hypercapnia (increased CO2 levels)
Ventilation to achieve normocapnia
Hypoglycemia/hyperglycemia
Maintain RBS around 150 mg/dL (normoglycemia), avoid dextrose containing solutions
Infection
Start appropriate antibiotics
Convulsions/seizures
Phenytoin, Levipill (PO/IV)
 
Care of Unconscious Patient (Checklist)
  1. Pass Ryle's tube (stomach wash, if poisoning/GI bleed is suspected)
  2. Catheterize bladder. If urinary retention. (Connect condom drainage, if incontinent).
  3. Nutrition and hydration: Start Ryle's tube feeding at the earliest, if there are no contraindications, as IV fluids alone will not give enough calories and nutrients. Total parenteral nutrition is expensive. Enteral nutrition is started with either premixed preparations or locally available freshly prepared (using items such as rice, dal, oil, egg, etc.).
  4. Care of eyes to prevent exposure keratitis. Use eye shields to keep eyes closed.
  5. Care of back to prevent bedsores. Frequent change of position (every 2 hours) to keep skin dry by using talcum powder. Use water/air bed.
  6. Chest physiotherapy and intermittent throat suction to clear secretions.24
  7. Maintain oral hygiene by wash/suction.
  8. Nurse in lateral position to avoid aspiration.
  9. Care of endotracheal tube. Periodic sterile suction and transient cuff deflation.
  10. Care of IV access line, look for evidence of infection.
  11. Follow aseptic precautions. Change cannula, if there is evidence of cellulitis or thrombophlebitis.
  12. Avoid hypertonic solutions. Avoid extravasation of hypertonic solution, contrast material and drugs.
  13. Prevent DVT.
  14. Stabilize the neck with rigid collar, in cervical spine injury is ruled out.
  15. Avoid supine position.
  16. Do not place pillow.
 
Key Points
  • Coma is defined as persistent loss of consciousness.
  • Remember the mnemonic MIND for etiology of coma:
    • M: Metabolic
    • I: Infection
    • N: Neurological
    • D: Drugs
  • In an unconscious patient, if pupils are reacting well and equally, and no neurological deficit is present, coma etiology may be metabolic (diabetes or uremia) or intoxication (alcohol or sedatives).
  • Evaluate CNS, pupils, eye position, and focal deficits (lateralizing signs and meningeal irritation)
  • Consider antidotes (GOT-FAN) (Glucose, Oxygen, Thiamine, Flumazenil, Atropine, Naloxone)
  • In elderly patients, consider hyponatremia, treat with 3% saline infusion, aim for Na of 125–130 mg/dL and correct slowly.
  • Consider endotracheal intubation, if patient has apnea or SpO2 < 90% or Glasgow coma scale (GCS) < 8.
  • CT study may still be normal in bilateral hemispheric infarction, small brainstem lesions, encephalitis, meningitis, closed head trauma, sagittal sinus thrombosis, and subdural hematomas that are isodense to adjacent tissue.
 
1.13 CRACKS ON SOLES
 
Etiology
Medical conditions
Diabetes mellitus (DM), leprosy, fungal infection, and hypothyroidism
Acquired
Excessive sweating, aging, deficiency of vitamin A, and zinc
Genetic/dermatological
Palmoplantar keratosis, hyperhidrosis, and psoriasis
 
Treatment (Choices Include)
Soak feet in warm water for 20 minutes to soften feet. Use pumice stone for scrubbing feet if needed.
SALICA (salicylic acid 20%)—apply and cover with cling film.
COTARYL (urea and salicylic acid)
DK gel (miconazole) or CANDID (clotrimazole) ointment
SEBIFIN (terbinafine) tablets 250 mg od for 2 weeks
ZOCON (fluconazole) 150 mg one tablet twice weekly for 6 weeks
RETINO-A 0.05%
SUPER GLUE (apply locally after thorough cleaning to seal cracks)
Vaseline + lemon juice (mix in equal volumes and apply)
Ripe banana mash application
DALDA or VANASPATI (apply and cover with cling film and wear a pair of socks)25
 
Patient Education
  • Wear soft MCR footwear (chappals/slippers)
  • Avoid standing in stagnant blue detergent soap water, while washing clothes
  • Avoid steroid ointments for sole of feet
  • Wear kitchen gloves and rubber shoes
  • Avoid pouring detergent water on feet
 
1.14 CRITICALLY ILL PATIENT (IN ICU) (Refer also Chapters 1.10, 1.14, 1.15 and 3)
 
1.14.1 CHECKLIST FOR EVALUATION OF CRITICALLY ILL PATIENT
 
A Framework—Think Head to Foot
Region
System(s)
Clinical parameters
Investigations/Monitoring
Treatment (choices include)
Head
Neurology
GCS
Pupils
Limb movement
Reflexes
Imaging (CT/MRI)
EEG/EMG
Sedation
Analgesia
Muscle relaxant
Anticonvulsant
Chest
Respiratory
Respiratory rate
Tidal volume
Pattern of breathing
Breath sounds
Wheeze, crackles
Hb
SpO2
ABG
CXR
US
CT (lungs)
Airway
Suctioning
Ventilator setting
Nebulizer treatment
Physiotherapy
Hemodynamic
Pulse rate
Blood pressure
Jugular venous pressure (JVP)
Temperature
Heart sounds
Murmurs
Pulse pressure variability
CVP
Passive leg raising
NT pro BNP
CK-MB
Troponin
ECHO
Inotropes
Vasodilators
Antihypertensive drugs
Anti-ischemic drugs
Abdomen
Kidney fluid/Electrolytes
Hydration status
Edema
Abdominal distension
Organomegaly
Ascites
Bowel sounds
Stool
Intake/Output
Fluid balance
Electrolytes
Urea
Creatinine
IV fluids
Additives
Diuretics
Liver
GI
Pancreas
Nutrition
Blood glucose
Ketones
Liver function test
Intra-abdominal pressure (IAP)
Nutrition
GI bleed prophylaxis
Prokinetic agents
Spleen
Hematology
Hemostasis
Infection
Temperature
Lines
Drains
Tubes
Deep vein thrombosis (DVT)
GI bleed
Hb, WBC, platelets
Coagulation profile CRP
Procalcitonin
Ultrasound abdomen
CT abdomen
Antiplatelets
Anticoagulants
Antithrombotic stockings
Transfusions
Antimicrobial drugs
Change indwelling devices
Other
Miscellaneous
Trauma wounds
Decubitus ulcers
Eye care
Ethical issues
Emotional
Spiritual
Specific counseling26
Head
Differential diagnosis depends on whether there is depression of sensorium and focal neurological deficits:
Vascular: Subarachnoid/parenchymal hemorrhage
Infection: Meningitis
Neoplasm
Chest
Rapidity of intervention needed depends on hemodynamic status/oxygenation status:
Acute MI
Dissecting aneurysm
Tension pneumothorax
Pulmonary embolism
Pericarditis
Abdomen
Etiology may be hemorrhage, inflammation, ischemia, infection, perforation and obstruction (HIPO):
Perforated/ischemic bowel
Leaking abdominal aneurysm
Acute pancreatitis
Ectopic pregnancy
Splenic rupture
Retroperitoneal hemorrhage
Limbs
Cellulitis/pyomyositis
Deep vein thrombosis
Arterial occlusion
Compartment syndrome
Joints
Single: Septic, injury, neoplasm, gout, loose bodies, erythrocytes (hemarthrosis) multiple—rheumatoid, spondyloarthropathy, CTD, and osteoarthrosis
Breathing difficulty/Tachypnea
Airway obstruction:
Parenchymal/Fluid: Pneumonia/pulmonary edema [left ventricular failure/acute respiratory distress syndrome (LVF/ARDS)]
Pleural problems: Pneumothorax, pleural effusion
Vascular: Pulmonary embolism
Acidosis: Ketoacidosis, lactic (sepsis)
Anemia: Bleed
Shock
Cold shock:
Hypovolemia: Fluid/blood loss
Low output: Cardiac tamponade, tension pneumothorax, pump failure, and arrhythmia
Obstruction: Massive pulmonary embolism
Warm shock:
Sepsis
Anaphylaxis
Poisoning, can be cold or warm shock
Drugs or spinal cord lesion can alter the response and hence type of shock
Fever/Rash
Staphylococcus/Streptococcus
Meningococcus
Sepsis syndrome
Rickettsiae
Stevens Johnson/toxic epidermal necrosis (drugs/infection)/DRESS syndrome
Restlessness
Restlessness in a critically ill patient should be assumed to be due to cerebral hypoxia unless proven otherwise. SpO2 and BP should be checked, and, if they are normal, other causes can be considered. Restlessness and delirium are often due to a metabolic encephalopathy, occult sepsis is also a possible cause. A rapid assessment of all systems can be done by asking an unintubated patient, “How are you?” A relevant audible answer indicates a patent airway and adequacy of cerebral perfusion and oxygenation. This obviously cannot be done for intubated/sedated patients who will need indirect evaluation of organ function. A useful mnemonic to remember causes of altered sensorium is:27
“PAIN COMES” mnemonic:
P: Poisoning
A: Alcohol
I: Infection (meningitis, encephalitis, and sepsis)
N: Neurological (trauma, space-occupying lesions, CVA, and seizures)
C: Carbon dioxide retention
O: Oxygen low (hypoxia)
M: Metabolic (hepatic coma, uremia, myxedema coma, and hypoadrenalism)
E: Electrolyte abnormalities—hyponatremia and hypercalcemia
S: Sugar (hypoglycemia)
(refer also Chapter 1.15)
Coma/Delirium/ Seizures
Remember the mnemonic “MIST”:
Metabolic:
  • Endogenous
  • Hypo- /hyperglycemia, sodium- and calcium-related abnormalities
  • Organ failure: Respiratory, hepatic, renal, and hypertensive encephalopathy exogenous
  • Drugs/alcohol related (intake/withdrawal)
Infection:
  • Meningitis, encephalitis, abscess, malaria, enteric fever, and sepsis
Stroke/SOL
Trauma/tumor
 
Critically Ill Patient Assessment
Airway
Obstruction? Clear obstruction → Intubate if necessary and maintain airway
Breathing
No spontaneous respiration or noisy breathing → Ventilate
Circulation
No palpable pulse → Start cardiopulmonary resuscitation (CPR)
Vital signs
Temperature, pulse (heart rate), respiration (TPR), BP, SpO2, and GCS
Laboratory tests/ICU profile
CBC, RBS, SpO2, urea, creatinine, electrolytes (Na+, K+), LFT, CXR, ECG, blood gas, and urine analysis
Consider
“GOT FAN”—Glucose, Oxygen, Thiamine, Flumazenil, Atropine, and Naloxone. However, in an alcoholic, consider giving “T” before “G”
zoom view
28
 
Treatment (Choices Include)
Give specific therapy whenever possible.
Ensure oxygen saturation (SpO2) is compatible with survival, i.e., usually > 80% and preferably > 90–95%.
Mechanical ventilation if any respiratory failure.
 
1.14.2 CHECKLIST FOR PATIENT ON VENTILATOR SUPPORT (FAST HUGS BID)
FAST HUG should be done at least once a day for ICU patient on ventilator support.
F: Feeding
A: Analgesia
S: Sedation
T: Thromboprophylaxis
H: Head up position
U: Ulcer prophylaxis
G: Glycemic control
S: Spontaneous breathing trial
B: Bowel
I: Indwelling catheter
D: De-escalation of antimicrobial and other pharmacotherapies
 
1.14.3 EMERGENCIES IN ICU
Respiratory
Cardiovascular
Neurological
Hypoxia:
  • Pneumothorax
  • Pulmonary embolism
  • Alveolar collapse/fluid (infection, ARDS, and edema)
  • Circuit problems if on ventilator
  • Ventilator malfunction
Hypotension:
  • Tension pneumothorax
  • Pulmonary embolism
  • Myocardial infarction
  • Sepsis
  • Hyperkalemia
  • Anaphylaxis
Depressed sensorium:
  • Hypoxia
  • Hypoglycemia
  • Hypotension
  • Hypercapnia
  • Sedation
  • Sepsis
  • Primary neurological event
Dyspnea/tachypnea:
  • Hypoxia
  • Acidosis
  • Pneumothorax
  • Alveolar collapse/fluid (infection, ARDS, and edema)
  • Pulmonary embolism
  • Anaphylaxis
Bradycardia:
  • Organophosphate poisoning
  • Hypoxia
  • Hyperkalemia
  • Hypoglycemia
  • Myocardial infarction (inferior)
Seizures:
  • Hypoglycemia
  • Hyponatremia
  • Hypocalcemia
  • Primary neurological event
Tachycardia:
  • Pneumothorax
  • Pulmonary embolism
  • Sepsis
  • Myocardial infarction (anterior)
  • Tachyarrhythmia
Problem
How to diagnose
What to do
Acidosis
Arterial blood gas
Treat cause
Consider need for dialysis
Anaphylaxis
Check for medications in past hour
Adrenaline, ensure airway and oxygen
Alveolar problem
Chest X-ray (infection, ARDS, and edema)
Increase positive end-expiratory pressure (PEEP), physiotherapy, negative fluid balance, and antibiotics
Circuit problems
Leak (including cuff leak, tube displacement), block
Run hand over circuit, place hand on trachea, chest movement, note airway pressures, resistance to manual ventilation, CXR
Use Ambu bag, localize leak
Inflate ET/TRACH cuff to appropriate pressure
Reposition/suction ET/TRACH tube, if needed
Pull back ET tube, if endobronchial intubation
High CO2
Arterial blood gas
Adjust settings on machine or start ventilation29
Hyperkalemia
K+ level
Calcium IV, followed by glucose/bicarbonate, β2 agent; dialysis
Hypocalcemia
Ca level
Calcium IV
Hypoglycemia
RBS
Glucose IV
Hyponatremia
Measure on blood sample
Depends on etiology
Hypotension
BP
Fluid/inotropes
Hypoxia
SpO2, ABG
Increase fraction of inspired oxygen (FiO2)
If unconscious and unintubated, intubate
Myocardial infarction
ECG, CK-MB, Troponin I
Aspirin, β-blocker, LMW heparin; thrombolysis/percutaneous transluminal coronary angioplasty (PTCA)
Organophosphorus poisoning
History
High-dose atropine bolus (up to 60–100 mg in 15 minutes) and infusion
Pneumothorax
Percuss, auscultate, needle test, and CXR
Chest tube
Primary neurological problems
Asymmetrical movement/pupils/plantar response; CT scan
As appropriate
Pulmonary embolism
Lower limp swelling, D-dimer, ECG, CXR, color Doppler, and ECHO
Anticoagulation, thrombosis
Seizures
Clinical
Lorazepam IV, phenytoin slow IV, correct glucose, calcium
Continuing seizures—give propofol and intubate, start midazolam infusion, consider encephalitis, cerebral venous thrombosis, etc.
Sepsis
White cell count, cultures, procalcitonin, imaging
Line changes, appropriate antibiotics
Tachyarrhythmia
ECG
If BP low, electrical Rx
If BP normal, consider whether physiological or pathological rhythm
Investigations in ICU CBC, creatinine, urea, Na+, K+, LFT, CXR, ECG, SpO2, blood gas analysis
 
1.15 DELIRIUM (Restlessness, Acute Confusional State, Acute Brain Attack)
 
Definition
Confusion is lack of clarity in thinking and delirium is used to describe an acute confusional state.
 
Red Flags
  • Sodium < 125 mmol/L or >145 mmol/L
  • Raised calcium (>11 mg/dL)
  • Severe headache
  • Sudden onset of symptoms such as dysphasia
  • Rapid deterioration
  • Fever or hypothermia
  • Seizure
  • Features of raised ICP (bradycardia + hypertension, papilledema)
  • Introduction of new medication (e.g., overdose or adverse effects)
  • Alcohol misuse
  • Recent surgery30
 
Etiology and Investigation
Etiology (‘MIND ATE' is the mnemonic for delirium)
Investigations (select appropriately, choices include)
Metabolic (acute):
Electrolytes (Na+, K+), RBS, Ca+, P, Mg, ABG
RBS
SpO2, ECG, CXR, ABG
LFT, ammonia
RFT (creatinine, urea, urine analysis)
Infection
Infection screen: CBC, urine analysis, C/S of blood, urine, pus, tissue; widal and quantitative buffy coat (QBC) in febrile patients, CXR, US abdomen
Neurologic:
MRI/CT
ECG/MRI
CT
MRI, CSF fluid analysis
MRI
CT, MRI
Drugs/substance abuse: Narcotics, benzodiazepines, digoxin, OHA, insulin, alcohol withdrawal, lysergic acid diethylamide (LSD), cocaine
Check drug/medications of patient, urine and blood toxicology screening
Autoimmune disease: For example, lupus
CBC, autoimmune serology (ANA, ANA profile if ANA is positive)
Toxins: Organophosphorus poisons, e.g., pesticides
Toxic substance screening (cholinesterase levels)
Endocrine:
FBS, RBS, K+
TSH, free T4
TSH, free T4
Calcium, parathyroid level
Cortisol
B12, folate, thiamine
Miscellaneous:
Check if patient is in pain
Check if bladder is palpable
Check temperature
 
History and Clues
History of diabetes, jaundice, and alcohol
Suggests metabolic problem
History of fever, headache, and vomiting
Suggests infection
History of fever, headache, vomiting, blurred vision, ↑BP, ↓pulse, convulsions, and trauma
Suggests neurological problem
Current medications
Narcotics, benzodiazepines
Substance abuse
Alcohol, opium, LSD, and cocaine
Poisons
Pesticides
 
Checklist
Temperature, pulse, respiration rate, BP, SpO2 (oxygen saturation)
Airway, breathing, and circulation
General examination
Trauma, stigmata of liver disease, neck stiffness, and smell of breath (clue to diagnosis)
Neurological examination
↑BP, ↓pulse, focal deficit = (ICT), pupil size, reflexes: Babinski, asterixis (liver flap)
Systemic examination
CVS, RS, and abdomen
 
Treatment (Choices Include)
  1. Try to identify the cause and treat the cause.
  2. SERENACE (Haloperidol) 2.5–5 mg IM/IV stat and every 4 hours, in elderly patient start with 2.5 mg. Add PHENERGAN (promethazine) 15–25 mg IM or IV with Serenace to prevent extrapyramidal side effects. This drug combination helps to sedate restless or agitation people, but can make them more confused due to anticholinergic effects of Phenergan.
  3. QUETIAPINE 100–200 mg PO, od31
  4. Consider antidotes “GOT FAN” (if needed) (refer Chapter 1.10 for more details):
    Glucose
    Oxygen
    Thiamine
    Flumazenil
    Atropine
    Naloxone
  5. When there is increased ICP (signs of meningism: ↑BP, ↓pulse, headache, vomiting, seizures, papilledema, or ↓RR) (refer Chapter 1.10 for treatment choices).
 
1.16 DIABETES MELLITUS
 
Red Flags
  • Hypertension
  • Cardiovascular disease (CVD), cerebrovascular disease, and peripheral vascular disease
  • End organ damage (diabetic retinopathy and nephropathy)
  • Skin and soft tissue infections
  • Recurrent urinary tract infection (UTI)
  • Peripheral neuropathy
  • Foot ulcers
  • Diabetic ketoacidosis
 
Types of Diabetes Mellitus
Type 1
Beta cell destruction deficiency and includes latent autoimmune diabetes of adulthood
Type 2
Insulin resistance progressive loss of beta cells
Specific causes
Maturity-onset of diabetes in young (MODY)
Gestational
Diagnosed usually in the second-and-third-trimester
 
Diagnosis of Diabetes Mellitus: Blood Sugar Levels (Venous Plasma/Serum Glucose)
Test
Normal
Prediabetic/Impaired glucose tolerance
Diabetes mellitus
FBS
70–99 (3.9–5.5 mmol/L)
101–125 [impaired fasting glucose (IFG)] (5.6–6.9 mmol/L)
>126 (7.0 m/L)
HbA1c
< 5.7
5.7–6.4
>6.5%
PPBS
>200 (11.1 mmol/L)
75 g oral glucose tolerance test (OGTT) (2 h plasma glucose)
< 140 (7.8 mmol/L)
140–199 [impaired glucose tolerance (IGT)] (7.8–11 mmol/L)
>200 (11.1 mmol/L)
Fasting blood sugar (FBS)
Needs 8 hours fasting (one can drink water during fast). FBS > 126 is DM. Repeat FBS, if >126 the next day to confirm diagnosis of DM. FBS is the best test, since it is easy and convenient
Random blood sugar (RBS)
RBS > 200 with symptoms of polyuria, polyphagia and unexplained weight loss is DM
HbA1c
Glycosylated hemoglobin, (HbA1c) > 6.5 is diagnostic of DM. HbA1c gives an indication of average blood sugar level over the last 3 months (false positives can be seen in anemia, severe hepatic and renal diseases). HbA1c should not be used for diagnosis of gestational diabetes in pregnant woman or for diagnosis of diabetes in people who have had recent severe bleeding or BT, those with chronic kidney or liver disease or anemia Correlation of HbA1c with average glucose:
HbA1c (%)
Mean plasma glucose
mg/dL
mmol/L
6
126
7.0
7
154
8.6
8
183
10.2
9
212
11.8
10
240
13.4
11
269
14.9
12
298
16.532
Oral glucose tolerance test
For all pregnant women:
Perform 75 g OGTT, with plasma glucose measurement fasting and at 1 and 2 hours, at 24–28 weeks of gestation in women not previously diagnosed with overt diabetes. OGTT should be performed in the morning after an overnight fast of at least 8 hours. Diagnosis of GDM is made when any of the following plasma glucose values are:
Fasting: ≥92 mg/dL (5.1 mmol/L)
1 hour: ≥180 mg/dL (10.0 mmol/L)
2 hours: ≥153 mg/L (8.5 mmol/L)
Self-monitored blood glucose (SMBG) level by glucometer
Glucometer readings are likely to be 20 mg% < (simultaneous) laboratory blood sugar levels
Impaired glucose tolerance/impaired fasting glucose
Prediabetic patients are those who have IFG or IGT. Do not label these patients as diabetics. Advice to prediabetic patients:
About 1,500 calorie diabetic diet (diet advise)
Walk for 30 minutes daily (increased physical activity to decrease weight, if overweight)
Consider Metformin, if HbA1c > 6.5
Check FBS every 6 months, since 5% of prediabetics can become diabetics
Educate patient about complications of DM
Screening diabetes (asymptomatic adult individuals):
Testing should be considered in all adults who are overweight (BMI ≥ 25 kg/m2) and have additional risk factors:
  • Physical inactivity
  • First-degree relative with diabetes
  • High-risk race/ethnicity (e.g., African, American, Latino, Asian, American, and Pacific Islander)
  • Women who delivered a baby weight > 9 lb or were diagnosed with GDM
  • Hypertension (≥ 140/90 mm Hg or on therapy for hypertension)
  • High-density lipoprotein (HDL) cholesterol level < 35 mg/dL (0.90 mmol/L) and/or a triglyceride level > 250 mg/dL (2.82 mmol/L)
  • Women with polycystic ovary syndrome (PCOS)
  • HbA1c ≥ 5.7% IGT or IFG on previous testing
  • Other clinical conditions associated with insulin resistance (e.g., severe obesity and acanthosis nigricans)
  • History of CVD
 
Metabolic Syndrome or Insulin Resistance Syndrome or Syndrome X
Patient who has more than three criteria listed below:
1. Waist > 90 cm (men), > 80 cm (women) (Asians)
2. Triglycerides > 150 mg/dL
3. HDL < 40 mg/dL
4. FBS > 100 mg/dL
5. BP > 130/85 mm Hg or being treated for hypertension
Suspect insulin resistance if obesity, PCOS, nonalcoholic fatty liver disease (NAFLD), CKD, sleepiness after a meal, craving carbohydrate rich foods, brain fog, male pattern hair loss in women swollen ankles, and increased triglyceride levels and depression. Insulin resistance increases risk of developing T2DM and prediabetes. Insulin resistance is a condition in which body produces insulin but does not use it effectively. When people have insulin resistance, glucose builds up in body instead of being absorbed by cells, leading to T2DM or prediabetes. Insulin resistance patient or prediabetic patient can decrease the risk of getting diabetes by eating healthy diet, reaching and maintaining a healthy weight, increasing physical activity, stop smoking, and taking medication (Metformin) in some cases.
ABCD [Abdominal obesity, Blood pressure (high), Cholesterol (high), Diabetes (FBS >100 mg/dL), increase risk of IHD, stroke, and Diabetes mellitus].
 
Symptoms of Diabetics
Asymptomatic
Common
UTI, fungal infection, dry itchy skin, numbness or tingling in extremities, and fatigue
Occasional
Increased urination, thirsty, increased appetite, nocturia, and unexplained weight loss
 
Glucose (Sugar) and HbA1c Levels: How Good is Your Control
Glucose level (mg/dL)
FBS (fasting)
PPBS (2 hours postprandial)
HbA1c
Excellent
70–120
100–140
<6.5
Good
121–140
141–160
<7 (Target)
7–7.5 (in elderly > 65 years)33
Fair
141–160
161–200
<7.5
Poor
>160
>200
>7.5
 
Comparison of Dextrometer and Laboratory Glucose Levels
Timing of test for glucose
SMBG* (Dextrometer and glucometer)
Laboratory
FBS (premeal)
<120 mg/dL
< 100 ~_ 140
PPBS (postmeal 2 hours)
<160 mg/dL (<180 elderly)
<180
Bedtime
<120 mg/dL
~_ 140
Critically ill
RBS 160–200 mg/dL
RBS 140–180 mg/dL
*SMBG: self-monitored blood glucose level by glucometer. Glucometer readings are likely to be 20 mg% < (simultaneous) laboratory blood sugar.
 
Target Values for Diabetics to Precent Cardiovascular Outcome in Diabetic Patients
Diabetic on treatment
Goal/Target
Glucose (sugar)
FBS 70–120 mg/dL, PPBS 100–140 mg/dL, HbA1c 6.5
BP
<130/80 mm Hg
Lipids
Total cholesterol (< 180 mg/dL) LDL < 100 mg/dL (< 70 in CVD)
HDL > 40 men, > 50 women
Triglycerides < 150 mg/dL
BMI
18–22.9
 
Complications
Acute
Long-term
Other complications
Diabetic ketoacidosis
Hyperosmolar coma
Hypoglycemia
Microvascular:
Retinopathy
Nephropathy
Peripheral/Autonomic neuropathy
Macrovascular:
Coronary heart disease
Cerebrovascular disease
Peripheral arterial disease (PAD)
Decreased resistance to infection
Skin changes
Poor wound healing
Cataracts
Glaucoma
Nonalcoholic steatosis/steatohepatitis
Medical history
Physical examination
  • Onset of diabetes (e.g., DKA, asymptomatic laboratory finding)
  • Eating patterns, physical activity habits, nutritional status, and weight history; growth and development in children and adolescents
  • Review of previous treatment regimens and response to therapy (HbA1c)
  • Current treatment of diabetes including medications, medication adherence and barriers, meal plan, and physical activity
  • Results of glucose monitoring and patient use of data
  • DKA frequency, severity, and cause
  • Hypoglycemic episodes:
    • Hypoglycemia awareness
    • Any severe hypoglycemia, its frequency and cause
  • History of diabetes-related complications:
    • Microvascular: Retinopathy, nephropathy, neuropathy (sensory, including history of foot lesions; autonomic, including sexual dysfunction, and gastroparesis)
    • Macrovascular: CHD, cerebrovascular disease and PAD
  • Other: Psychosocial problems and dental disease
  • Height, weight, and BMI
  • Blood pressure (including orthostatic measurements)
  • Fundoscopic examination
  • Thyroid palpation
  • Skin examination (for acanthosis nigricans and insulin injection sites)
  • Comprehensive foot examination:
    • Inspection
    • Palpation of dorsalis pedis and posterior tibial pulses
    • Presence/absence of patellar and Achilles reflexes
    • Determination of proprioception, vibration, and monofilament sensation34
 
Investigations (Choices Include)
CBC
FBS
PPBS
Urine routine
24 hours or spot urine protein-to-creatinine ratio (UPCT)
Urea and creatinine
Lipid profile
LFT (AST and ALT)
TSH, TPO antibodies
HbA1c
OGTT
 
Treatment (Choices Include)
Choice of any antidiabetic agent should take account patients general health status and associated medical disorders. This patient centric approach may be referred to as ABCDEFGH approach for diabetes management.
A.
Age (elderly > 65 years)
Dipeptidyl peptidase-4 (DPP-4) inhibitor + metformin
Sulfonylurea
B.
BMI
Glucagon-like peptide 1 (GLP-1) agonist
Sodium-glucose cotransporter-2 (SGLT-2) inhibitor
DPP-4 inhibitor
Alpha-glucosidase inhibitor (AGI)
C.
Chronic kidney disease (diabetic kidney disease)
DPP-4 inhibitor
Sulfonylurea
Injectables
D.
Duration of diabetes
(long-standing)
Insulin
GLP-1 agonist
SGLT-2 inhibitor
E.
Established CVD
GLPI analog
SGLT-2 inhibitor
Sulfonylurea
F.
Financial
Sulfonylurea + metformin
G.
Glycemic reduction
Order of glucose lowering agents to efficacy of HPLC reduction r insulin, GLP-1 agonists, metformin, SGLT-2 inhibitors, pioglitazone, DDPP-4 inhibitors, sulfonylurea, glynides, and AGIs
H.
Hypoglycemia or postprandial hypoglycemia
In patients with history of hypoglycemia or dose at high risk of hypoglycemia, GLP-1 agonists/SGLT-2 inhibitors/DPP-4 inhibitors or AGIs/pioglitazone should be considered as first choice with metformin
Diet
Calories prescription is an important element in nutritional management. Calorie needs vary with age, sex, and activity level. Recommended calorie level is based on individual's desired weight.
Ideal body weight (IBW) in kilograms: (Height in cm – 100 × 0.9)
Calorie intake based on activity is as follows:
Sedentary: 20–25 cal/kg IBW
Moderate: 26–30 cal/kg IBW
Strenuous: 31–35 cal/kg IBW
An energy deficit of 500 kcal/day will help to reduce 500 g of weight every week. A hypocaloric diet independent of weight loss is associated with increased sensitivity to insulin and improvement in blood glucose level. Moderate weight loss is shown to reduce hyperglycemia, dyslipidemia, and hypertension (three meals a day with a gap of 5 hours, breakfast 6 to 8 am, lunch 12 to 2 pm, dinner 6 to 8 pm)
Risk factor identification and treatment
HT
Dyslipidemia
Insulin resistance
Obesity
Avoid certain drugs, e.g., phenytoin, steroids, thiazides, and beta blockers (BB)35
Exercise weight control
Increase physical activities, e.g., walk 30 minutes 5 days a week
Drugs
OHA/insulin
Surgery
Bariatric procedures like sleeve gastrectomy, etc.
 
Treatment Choices based on FBS or HbA1c
FBS/HbA1c
Treatment options
Drug/Combination drugs
FBS 126–160 or HbA1c < 7.5
OHA (monotherapy)
Metformin/DPP4i, insulin
FBS 160–240 or HbA1c > 7.5
OHA (dual therapy)
Or
Metformin + sulfonylurea
Metformin + glitazones (not used now)
Metformin + AG-1
Metformin + DPP-4 inhibitors
Metformin + GLP-1A
OHA
(triple therapy)
Metformin + sulfonylurea + voglibose
Metformin + sulfonylurea + DPP -4 inhibitor
Metformin + sulfonylurea + glitazone (not used now)
FBS > 240 or HbA1c > 9 or FBS > 160 on OHA
Insulin
Insulin (multidose therapy is preferred)
 
Oral Hypoglycemic Agents
Class/Type
Frequency
Maximum dose
Cost in rupees per month
Good for
Side effects
1. Biguanides:
Metformin (GLYCIPHAGE 500 mg, GLYCOMET 500 mg, GLUCONORM 500 mg)
Extended release metformin: GLYCIPHAGE SR 500/1,000 mg, DIBETA SR 500/1,000 mg, GLUCONORM SR 500/1,000 mg
od/bd/tds (5–10 minutes before meal)
2 g
100
Type 2 diabetes mellitus
Dyslipidemia
High FBS
Anorexia
Bloating
Lactic acidosis (avoid metformin in renal insufficiency LVF and in patients aged > 80 years, serum creatinine > 1.5 in males or > 1.4 in females)
2. Sulfonylurea:
Glibenclamide 2.5 mg, 5 mg (DAONIL)
bd
(5–10 minutes before meals)
20 mg
50
Postmeal hyperglycemia
Lean patient
Hypoglycemia
Weight gain
Glipizide 2.5 mg, 5 mg (GLIDE/GLYNASE)
od/bd
(5–10 minutes before meals)
10 mg
80
Glimepiride 1 mg, 2 mg (AMARYL/AZULIX/GLIM, GLIMCARE)
od/bd
(5–10 minutes before meals)
8 mg
450
3. Thiazolidinediones:
Pioglitazone 15 mg, 30 mg
od/bd
(5–10 minutes before meals)
45
Obese
Dyslipidemia
Edema
Weight gain
CCF
Bone fracture
Bladder cancer
4. α-glucosidase inhibitor:
Voglibose 0.2/0.3 mg (REBOSE/VOLIX/VOGLET)
Acarbose (MIGLITOL)
tds
(eat 2 mouth full of food and then take the tablet)
0.9 mg
700
Postmeal hypoglycemia
Flatulence
Bloating
Dyspepsia
5. Mitiglinide:
Repaglinide
Nateglinide
tds
(5–10 minutes before meals)
0.5–4 mg
Renal insufficiency
Same as per pioglitazone36
6. DPP-4 inhibitor
Sitagliptin (JANUVIA/ZITA/ISTAVEL)
Vildagliptin (JALRA)
od
(5–10 minutes before meals)
od/bd
(5–10 minutes before meals)
100 mg
50–100 mg
1,200
Postmeal hyperglycemia
7. SGLT-2
Dapagliflozin (Dapa)
10 mg
8. GLP-1 agonist/analog
Exenatide (EXAPRIDE)
Liraglutide (VICTOZA)
5 mg SC bd
(0.6 mg SC od just before meals)
Very costly
Injectable pen Weight loss
No hypoglycemia
Nausea
 
Insulin
Indications:
Patients on OHA with poor control (e.g., FBS >160, PPBS > 200, and HbA1c > 9)
Newly detected patient with high blood sugar (FBS > 250 and PPBS > 300)
Infection, MI, DKA, pregnancy, or patients undergoing major surgery
Patients with target organ damage, e.g., IHD, CVD, PAD, retinopathy, neuropathy, or nephropathy.
Name
Brand
Onset
Peak action (hour)
Duration (hour)
Route
Doses
1. Prandial insulin:
Rapid acting analogs:
Lispro(HUMALOG)
Aspart (NOVOLOG)
Glycine (APIDRA)
10–20 minutes
1–3 hours
4-6
Short acting:
Actrapid
Huminsulin R
Insuman R
Lilly
Abbot
30 minutes
45 minutes
1.5–3.5 hours
8
8
SC/IV
SC/IV
3
3
2. Basal insulin:
Intermediate acting:
Monotard
Huminsulin N
Human NPH
Insuman basal
Abbott
Lilly
1-2 hours
8–16
4–6
10–12
10–12
18
18–24
SC
SC
SC
SC
Very long analogs (basal)
Glargine
Detmer
Degludec
No peak
3–9
No peak
24
 
SC
SC
SC
1
3. Premixed products:
MIXTARD 30/70
MIXTARD 50/50
HUMINSULIN 30/70
HUMINSULIN 50/50
INSUMAN combo (25/75)
Abbott
Abbott
Lilly
Lilly
Sanofi
1 hour
45 minutes
1 hour
45 minutes
40 minutes
2
2
2
2
2
12–16
12–16
12–16
12–16
14–16
SC
SC
SC
SC
SC
2
2
2
2
2
Insulin should be taken 1–2 minutes before meals. Once daily dose should be administered with the evening meal or at bedtime. With twice-daily dosing, the second dose can be administered with the evening meal, at bedtime or 12 hours after the morning dose.
Strength: In mixtures, 30% or 50% is regular insulin and 50% or 70% is NPH insulin.
For example, ACTRAPID (40 or 100 IU/mL in 10 mL vial) and MIXTARD (30/70, 40 or 100 IU/mL in 10 mL vial)37
Calculation for dose of insulin required per day—“start low, go slow”
0.5–1.0 unit/kg/day
For example, MIXTARD 30/70, weight of the patient = 60 kg
0.5 × 60 = 30 units = (2/3 dose, am = 20 units; 1/3 dose, pm = 10 units)
Rough guide for administering ACTRAPID in emergency cases:
GRBS (mg/dL)
Insulin
150–175
2 units of Actrapid SC
175–225
4 units Actrapid SC
225–300
6 units Actrapid SC
< 100 or > 300
Inform consultant
Side Effects of Insulin
Hypoglycemia, weight gain, edema, insulin antibodies with animal insulin, and lipodystrophy at injection sites.
Delivery Devices for Insulin
Ordinary glass syringe, disposable insulin syringe, insulin pen (NovoPen, NovoLet), and insulin pumps.
 
Follow-up/Referrals
Daily
2 weekly
Monthly
Every 3 months
Every 1 year
  • SMBG
  • Foot care
  • FBS
  • PPBS (if not well controlled)
  • FBS
  • PPBS (if well controlled)
  • Visit doctor
  • HbA1c
  • Medication review
  • Weight check
  • Smoking cessation
  • Depression screening
  • Aspirin therapy (if indicated)
  • Creatinine
  • Urine microscopy
  • Albuminuria
  • Lipid profile
  • Eye check
  • Neuropathy check
  • Dental check-up
 
Checklist for Patients with Uncontrolled Sugars
Causes
Actions
1.
Dietary noncompliance
Education and motivation
2.
Failure to increase levels of physical activity
Regular exercise schedule and motivation
3.
Intercurrent illness
Diagnose and treat
4.
Treatment noncompliance
Reinforcement, education, and motivation
5.
Medications, which interfere with OHA or cause glucose intolerance
Shift to noninterfering drug, if possible
6.
Progressive beta-cell failure
Consider insulin therapy
 
Key Points
  • Prediabetes is a toxic state and risk factor for diabetes and its associated with pathological changes in several tissues and organs
  • Insulin resistance and impaired insulin secretion are important in pathophysiology of T2DM
  • Long-term complications include macrovascular and microvascular complications
  • Diabetes is also associated with several comorbidities which make diabetes management more difficult
  • Weight loss combined with low carbohydrate diet is a safe and effective way of reversing diabetes
  • Emphasis on patient centric approach is given while considering individualized therapy
  • SGLT-2i and DPP-4i are drugs which should be used alone, or in combination with metformin to achieve glycemic targets
 
1.16.1 DIABETIC FOOT
 
Red Flags
  • Inability to walk and bear weight
  • Bruising
  • Trauma
  • Hot and swollen joint38
  • Constitutional features such as fever and malaise
  • Pain
  • Numbness and paresthesia
 
Etiology
Etiology
Comments
Neuropathy
Can be sensory, motor, autonomic or mixed
Infection
Usually polymicrobial
Ischemia
Is due to microangiopathy, atherosclerosis or PAD
 
Symptoms/Signs/Complications
Ulcer
Infection (cellulitis/fasciitis and gangrene/osteomyelitis)
Intermittent claudication or rest pain
Neuropathic foot
Charcot's joint
 
Investigations
Investigations (choices include)
Comments
Routine blood and urine
CBC, blood sugar, urine ketone bodies, and urea creatinine
Imaging:
X-ray foot
Doppler studies (assess perfusion):
MRI
Nuclear scan [fluorodeoxyglucose, positron emission tomography-computed tomography (18FDG, PET-CT scan)
Angiography (DSA/MRA)
Foreign bodies, gas shadows or bone involvement—osteomyelitis
Tissue healing is likely to occur on conservative measures with a TcPO2 > 50 mm Hg (revascularization warranted for TcPO2 < 30 mm Hg)
Results are misleading
Best test
Useful to assess soft tissues (e.g., infections)
Useful to assess soft tissues (e.g., infections)
Gold standard prior to any intervention
Microbiology
Deep tissue culture/sensitivity (bacterial and fungus)
 
Treatment (Multidisciplinary Team Approach) (Choices Include)
Antibiotics
Antibiotic choices for limb threatening or life-threatening infections:
Clindamycin or vancomycin or fluoroquinolones + metronidazole or
Cefixime + linezolid or
Cefoperazone sulbactam +, metronidazole or
Piperacillin + aminoglycoside or
Imipenem or meropenem or linezolid + aztreonam
Postoperatively follow with deep tissue CS report with antibiotics and antifungals (refer also Chapters 12.2 and 14.9)
Insulin
Insulin is ideal for patients with infection to control diabetic and treat associated risk factors (e.g., hypertension, dyslipidemia, and smoking)
Surgery
Surgical debridement is the most effective method (Other procedures include skin graft, flap surgery or amputation)
Other methods for debridement:
Autolytic: Use of occlusive dressing (hydrogels and calcium alginates). Hydrogels are effective for dry to minimally draining wounds and alginates (Sorbsan) for heavy exudative wounds
Enzymatic: Topical collagenase and papain
Biological: Use of maggots larvae of green blow fly (Lucilia sericata and Phaenicia sericata) removes necrotic tissue and their antimicrobial secretion has antibacterial action against Staphylococcus, Streptococcus, and methicillin-resistant Staphylococcus aureus (MRSA).
Mechanical: Nonselective, painful, e.g., wet-to-dry gauze dressing (dry gauze dressing may damage healthy granulation tissue and nerve epithelium)39
Treat ischemia
Revascularization (vascular reconstructive surgery is useful in select cases) (choices are listed below):
Endovascular procedure: Percutaneous transluminal angioplasty (PTA) (balloon)
Surgery: Bypass surgery
Combined approach
Moist wound care
Moist dressing soaked in NS is ideal
Povidone-iodine, acetic acid (white vinegar), hydrogen peroxide, and Dakin's solution (sodium hypochlorite) for topical treatment, may destroy surface bacteria; they are cytotoxic to granulation tissue and may delay wound healing
Adjunctive treatments for wound care
When standard wound care fails to heal diabetic foot ulcer, consider:
Negative pressure wound therapy (NPWT): Applying controlled negative pressure via suction to a chronic and exudating wound helps to remove excessive fluid; cells are stimulated to proliferate angiogenesis is accelerated and the sustained contraction helps to draw the wound margins close. It requires less frequent dressings
Topical growth factors: Recombinant human platelet-derived growth factor (rhPDGF 0.01% gel), stimulates fibroblasts and other connective tissues, located in skin and accelerates healing of neuropathic ulcers. It is FDA approved. Stored at 2–8°C. It is applied once daily and covered with moist saline gauze
Hyperbaric oxygen (HBO2): It can be used in select cases, which have reasonable vascularity.
Living skin equivalents (LSE): These are cultured human dermis (derived from neonatal skin fibroblasts) grown on a synthetic mesh (e.g., Apligraf, Dermagraft, and Theraskin). Need to be kept at –80°C and thawed and meshed prior to application on wound. Useful in venous stasis and diabetic foot ulcers
Future therapies: Stem cell therapy, ESWL, laser, and topical lactoferrin
Pressure offloading
It is an essential part of diabetic wound care. Remove or redistribute force on pressure areas with walker/crutches/wheel chair/total contact cast (TCC)
Bedrest or total contact plaster cast (TCC) can be used to accelerate healing
TCC should not be used in patients with active deep foot infection causing marked swelling or with fluctuating edema (e.g., in nephropathy patients)
Foot care advice
Never walk barefoot, do not wear tight footwear, cut nails carefully. If there is any pain, swelling or discoloration, see surgeon immediately. You only have one pair of feet, take care of them
Do's
Don'ts
  • Check your feet every day for cuts, cracks, bruises, blisters, sores, infections or unusual markings, and report to surgeon, immediately
  • Check the color of your legs and feet. If there is swelling, warmth, or redness or if you have pain, see your doctor or foot specialist right away
  • Clean a cut or scratch with a mild soap and water, and cover with dry dressing for sensitive skin and report to doctor
  • Use a mirror to see the bottom or your feet, if you cannot lift them up
  • Trim your nails straight across
  • Wash and dry your feet every day, especially between toes
  • Change socks every day
  • Always wear professionally fitted shoes from a reputable store. Professionally fitted orthotics may help
  • Choose shoes with low heels (under 5 cm high)
  • Buy shoes in the late afternoon (since your feet swell slightly by then)
  • Exercise regularly
  • Cut your own corns or calluses
  • Treat your own in-growing toe nails or slivers with a razor or scissors. See your doctor or foot care specialist
  • Use over-the-counter medications to treat corns and warts. They are dangerous for people with diabetes
  • Apply heat to your feet with a hot water bottle or electric blanket. You could burn your feet without realizing it
  • Soak your feet
  • Walk barefoot inside or outside
  • Wear tight socks, garters or elastics or knee highs
  • Wear over-the-counter insoles—they can cause blisters, if they are not right for your feet
  • Smoke40
 
Treatment for Diabetic Foot Infection: Summary
zoom view
 
Charcot Arthropathy = Neuropathic Joint Disease/Arthropathy
It is destructive arthritis secondary to peripheral neuropathy and loss of pain sensation. Affected joint is subjected to repeated stress unrecognized by the patient.
High Index of suspicion
Diabetic Long-standing
Loss of sensation
Hot/red/swelling
Trauma—minor/major
Architectural disruption (laxity or instability of joint)
Pain or ulcer +/–
 
Treatment
No weight bearing of extremity, casting/immobilization for 6–12 months
Bisphosphonates
Elevation decreases edema
Surgery is reserved for severe cases
 
1.16.2 DIABETIC NEUROPATHY/DIABETIC SENSORIMOTOR NEUROPATHY
 
Treatment (Choices Include)
Drug/Method
Indications
Contraindications/Comments
Insulin
Ideal for all patients with neuropathy
Lidocaine patch 5%
(1–3 patches every 12 hours)
Localized pain
Topical nitroglycerin spray
Alpha-lipoic acid (ALA)
ALA 100/ALADIN 100 mg bd for 5 weeks
Sensory symptoms
ALA prevents protein glycosylation and inhibits enzyme aldose reductase. It is a potent antioxidant
Tricyclic antidepressants (TCA):
Amitriptyline (tryptomer/amiline) 25–75 mg hs Imipramine (ANTIDEP) 25–75 mg hs
First-line drug
<50 years age
Cardiac conduction defects
Unable to tolerate side effects such as dry mouth, constipation, increased sweating, and tachycardia41
Serotonin-norepinephrine reuptake inhibitor (SNRI):
Venlafaxine (VENLA) 37.5–75 mg hs (maximum 450 mg)
Duloxetine (SYMPATA) 30 mg od (maximum 60 mg)
TCAs are contraindicated
Unable to tolerate TCAs
Patients also have comorbid depression
Dizziness, peripheral edema, angioedema, hypersensitivity, and somnolence
Anticonvulsants:
Pregabalin (PREGAB) 50–150 mg hs (max 600 mg/day)
Gabapentin (GABAPENTAN) 300–600 mg tds
TCAs are contraindicated
Not responding to TCAs or SNRI tried at least for 8 weeks
Opioids:
Tramadol (TRAMAZAC) 50–100 mg q6h Morphine 5–20 mg q6h
Anodyne therapy
Deep penetrating infrared rays releases nitric oxide from cells and helps to improve nerve vascularity and nerve regeneration. Also helps wound healing
Capsaicin (CAPSITOP O GEL), DUBINOR ointment
 
1.17 DYSLIPIDEMIA
 
Symptoms and Signs
Asymptomatic
Coronary artery disease (CAD) (MI), stroke, PVD (atherosclerosis)
Abdominal pain (pancreatitis)
Xanthomas (painless nodules near eyelids, tendons, elbow, and buttocks)
Corneal arcus
 
When to Check Lipid Profile
Age > 20 years: Since serum lipids vary from day to day, 2–3 measurements should be done days or weeks apart before initiating therapy. Fasting (12 hours, but one can drink water during fasting) is important—mainly for triglycerides (LDL, HDL, and cholesterol values remain unaffected during eating or fasting!).
On treatment for hyperlipidemia, check lipid profile 3 months after treatment and once a year.
 
Goal Values for Lipids
Lipid profile
Goal value
Comment(s)
LDL
<100 mg/dL
Patients with ACS including diabetics, treatment target should be <100 mg/dL and achieving the goal might require high dose, high potency statin
In very high-risk patients, those with CAD, diabetes or both LDL goal of < 70 mg/dL is optional
HDL
>40 mg/dL
Cholesterol42
<200 mg/dL
If cholesterol is high, avoid egg yolks, organ meat, shrimps (prawns), seafood, palm and coconut oil
Triglycerides
<150 mg/dL
Triglycerides > 400 mg/dL is a risk factor for CAD and pancreatitis
 
Risk Factor Assessment (Personal and Family) Two or More = Moderate Risk
Risk factor
CAD
PAD
STROKE
Family history
MI, angioplasty, or sudden death
CAD
Hypertension
SBP > 140 mm Hg or
DBP > 90 mm Hg or
On treatment for hypertension
Yes
Yes
Diabetes mellitus
Yes
Yes
Yes
Cholesterol
TC > 200 mg/dL
LDL >120 mg/dL
Yes
Yes
Cigarette smoking
Currently smoking or quit 6 months ago
Yes
Yes
Sedentary life or physical inactivity
No exercise of 30 min/day
Yes
Yes
Obesity
Yes
BMI > 25
 
Secondary Causes of Lipid Abnormalities
Enquire about these conditions directly during history. Treating underlying secondary causes may obviate need to treat an apparent lipid disorder.
Secondary cause
Increased LDL
Increased triglycerides
Diet
Saturated fat
Transfat
Weight gain
Anorexia
Weight gain
Low-fat diet
High-carbohydrate diet
Increase alcohol intake
Drugs
Diuretics, steroids, and cyclosporine
Estrogens, steroids, bile acid suppressants, beta blockers (except carvedilol, raloxifene, tamoxifen, and retinoic acid)
Diseases:
Thyroid
Liver
Kidney
Hypothyroidism
Biliary obstruction
Nephrotic syndrome
Hypothyroidism
Nephrotic syndrome
CRF
 
Investigations and Treatment Options
Hypercholesterolemia
Hypertriglyceridemia
Evaluation and investigations
Lipoprotein profile (cholesterol, TG, HDL, and LDL)
Risk factor assessment (family and personal)
Glucose, TSH, RFT, LFT (if LDL > 130 mg/dL to rule as secondary cause)
Lipoprotein profile (cholesterol, TG, HDL, and LDL) Glucose, TSH, RFT, and LFT
Risk factor assessment of family and personal (refer table above)
History of eruptive xanthomas or abdominal pain
Exercise, weight gain, estrogen treatment, alcohol intake, and diabetes
Treatment (choices include)
High risk (existing CVD or atherosclerosis > 2 factors or DM): LDL > 100 mg/dL treat with diet and drugs
Moderate risk (two risk factors): LDL > 130 treat with diet and drugs
Low risk (0 or 1 risk factor): Refer table below
Diet Exercise
Alcohol intake to be reduced
Treat secondary causes
Drugs
 
Treatment (Choices Include)
 
Diet and Exercise
In most patients, diet is implemented before initiating drug therapy. However, in high-risk patients, drug therapy may be initiated simultaneously with diet.
ADA recommendations for diet in lipid disorders
Components
Recommendations
Total fat
Polyunsaturated fatty acid (PUFA) approximately 10% total calories monounsaturated fatty acids (MUFA) approximately 20% total calories saturated fatty acids (SFA) < 7% total calories
Dietary cholesterol
<200 mg/day
Carbohydrates (CHO)
“Complex” whole grains, fruits, and vegetables (50–60% total calories)
Protein
Approximately 15% of total calorie
Plant stanols/sterols
Soybean oil, rice bran oil, olive, canola, peanut, and sunflower oil43
Dietary fiber
Viscous (soluble) fiber (20–30 g/day)
NATUROLAX (one tablespoon twice daily), oats, barley, pectin fruits, vegetables, legumes, and nuts
Total calories
Sufficient calories to be consumed to maintain desirable body weight
Physical activity
Moderate exercise (walk daily for 30 minutes, 5 days a week)
Miscellaneous agents, which help to reduce cholesterol
Omega-3 fatty acids
Sardines, salmon, mackerels (nonvegetarian), soybean oil, almonds, walnuts, flaxseeds
Phytochemicals
Garlic/garlic pearls (400–600 mg/day)
Antioxidants
Vitamin A (carotenoids), vitamin C, vitamin E, green tea
Phytoestrogens
Red wine
Folic acid and vitamin B6
Green leafy vegetables, oats, barley, legumes, whole grains, and fruits
Anti-inflammatory agent
One teaspoon turmeric in water before meals
 
Drugs (Choices Include)
Subclass
Dose
Side effects
Statins:
Atorvastatin (ATOR) (STORVAS); rosuvastatin (ROSUVAS, ROZAVEL) (useful for MI, PAD, primary and secondary prevention of hyperlipidemia, pravastatin, and lovastatin—similar to atorvastatin, but less efficacious)
10–80 mg, hs
Myopathy
Hepatic dysfunction
Fibrate:
Fenofibrate (LIPICARD) (FIBRATE)
Gemfibrozil (NORMOLIP) (useful for hyperglyceridemia and low LDL)
200–400 mg
Myopathy
Hepatic dysfunction
Cholesterol absorption inhibitor (CAI):
Ezetimibe (ZETIA) do not combine CAI with resins/fibrates)
10 mg once daily, hs
Angioedema
Headache
Niacin (NIALIP) (useful for high LDL and low HDL)
375–500 mg, hs
Flushing Hyperglycemia
Bile acid sequestrants (colestipol) (cholestyramine, colesevelam are similar to colestipol)
5 mg, maximum 30 mg
Constipation
Bloating
Miscellaneous:
Omega-3 fatty acids:
Soya bean oil, nuts, flaxseeds (vegetarian)
Fish oil 3–6 g qid (nonvegetarian)
Dyspepsia, diarrhea, fishy breath
Drug
High-intensity treatment
Moderate intensity treatment
Low-intensity treatment
Atorvastatin
40–80 mg
10–20 mg
Simvastatin
20–40 mg
10 mg
 
Summary of Treatment Choices
1.
High LDL or all diabetics even with LDL < 100 mg/dL (monotherapy)
Atorvastatin 10–80 mg (20 mg od) or
Simvastatin 5–80 mg (10 mg od)
2.
High LDL, low HDL, high triglyceride (combination therapy) (statin + CAI or fibrates)
Atorvastatin + ezetimibe (ATORLIP-EZ) (EZESTAT) atorvastatin + fenofibrate (ATORLIP-F) (FIBATOR) rosuvastatin 10 mg + fenofibrate (GLIVAS-F)
3.
High triglyceride (TG) 200–500 or > 500 mg/dL
If TG 200–500 mg/dL with > two risk factors or CHD give high dose statin + ezetimibe or niacin or fibrate
If TG > 500 mg/dL fish oil or fibric acid. Add niacin if needed
4.
High triglycerides + low LDL + Low HDL
Fibrate
5.
Smoking cessation
6.
Aspirin (ECOSPRIN) (in high-risk diabetics over 40)
7.
Blood pressure control
8.
Identify and treat secondary causes of dyslipidemias44
 
Key Points
  • Rule out secondary causes of dyslipidemias
  • Every 1% reduction of total cholesterol lowers risk of CAD by 2%
  • Most common side effects of statin therapy are headache, nausea, sleep disturbance, GI discomfort, and muscle ache. Statins are well tolerated by most patients, but carry a small but definite risk of myopathy.
  • In all patients with ACS, including diabetics, treatment target should be <100 mg/dL and achieving the goal might require a high dose, high potency statin.
  • In very high-risk patients, those with CVD, diabetes or both, a LDL goal of < 70 mg/dL is optional.
  • All diabetics, even those with LDL <100 mg/dL, should be on a statin (for primary or secondary CVD prevention).
 
1.18 EDEMA
Soft tissue swelling is due to abnormal expansion of interstitial fluid volume. Edema fluid is a plasma transudate that accumulates when movement of fluid from vascular to interstitial space is favored.
Lymphedema is the result of an inability of the existing lymphatic system to accommodate protein and fluid entering the interstitial compartment.
 
Etiology
Localized edema (leg or arm or face, abdomen, or thorax)
Generalized edema/Bilateral leg edema
Unilateral leg edema:
Bilateral leg edema:
Upper limb edema:
Facial edema:
Ascites (abdominal)
Hydrothorax
 
Clues from History
Features
Diagnosis/Comments
Face edema
Suspect renal disease, hypothyroidism, or patient is on steroids
Periorbital edema noted on awakening
Renal disease, impaired sodium excretion
Bilateral lower leg edema more pronounced after prolonged standing for several hours
Chronic venous insufficiency (CVI), cardiac problem
Ascites, pedal edema, and scrotal edema
Cirrhosis, nephrotic syndrome, or CHF
Hypoalbuminemia without proteinuria
Requires investigations for malnutrition or protein loosing enteropathy, provided liver disease is excluded
Idiopathic cyclical edema is based on
Appropriate clinical setting
All other causes are excluded
Positive water loading test
Ascites more than pedal edema
Tuberculosis, carcinomatosis, and mesothelial malignancy
Ascites + palpable spleen
Portal hypertension
 
Investigations for Unilateral Leg/Arm Edema (Choices Include)
Investigation
Comments/Useful for
CBC, peripheral smear, and microfilaria (mf)
D-dimer
DVT
Doppler US (color)
DVT, varicose veins, and AV malformation
Lymphoscintigram (radioisotopic-labeled colloid)
US/CT/MRI
Abdominal masses
Fine needle aspiration cytology (FNAC)/LN biopsy
Mass lesion or lymph nodes
 
Etiology and Treatment of Acute Unilateral Painful Edema
Etiology
Investigations and treatment
DVT
Cellulitis
 
Treatment of Chronic Unilateral Lymphedema (Choices Include)
Comments
Compression therapy
Elastocrepe or stockings
Pneumatic compression in home/hospital once a day for 30–60 minutes
Elevation (keep affected part elevated)
Helps to decrease edema
Massage
Walk or continue to exercise
Prevents stagnation
Drugs (select appropriately)
DAFLON 1 bd
LYMHEDIN 1 bd
LASILACTONE 1 od
HETRAZAN (DEC) 100 mg PO, tds for 21 days (for filariasis)
PENICILLIN or CEFAZOLIN or LEVOFLOXACIN or AUGMENTIN (for cellulitis)
Foot care advice
Do not walk bare foot, cut nails carefully, report to doctor immediately if any injury, infection, or pain
Surgery
Excisional surgery (debulking) or bypass procedures, e.g., in filariasis
 
Investigations for Generalized Edema/Bilateral Edema (Choices Include)
Investigation
Comments/Useful for
CBC
Anemia46
Urine analysis
Active urine sediment suggests renal failure, glomerulonephritis, and nephrotic syndrome
Creatinine, urea
Renal failure
LFT, PT
Albumin <2.5 g/dL suggests severe malnutrition, cirrhosis, or nephrotic syndrome
TSH, T4, TPO
Hypothyroidism
CXR, ECG, ECHO
Heart failure
Drug history
NSAIDS
Amlodipine, nifedipine, hydralazine, clonidine, methyldopa, and minoxidil thiazolidines
Glucocorticoids, anabolic steroids, estrogens, and progestins
US/CT/MRI
For abdominal mass/pathology
 
Treatment of Generalized Edema (Choices Include)
Comments
Identify and treat the cause whenever possible
Dietary sodium restriction (<500 mg/day)
May prevent further edema formation
Supportive stockings
Elevation of legs
Diuretics
DYTIDE or BIDURET or LASILACTONE (potassium sparing diuretic) or furosemide (LASIX), hydrochlorothiazide (AQUAZIDE) loop diuretics may be used for marked peripheral edema, pulmonary edema, CHF, and inadequate dietary salt restriction
 
Key Points
  • Rule out common causes such as anemia, cardiac, hepatic, or renal causes.
  • Cellulitis and DVT are common causes of painful unilateral edema.
  • If you suspect DVT and D-dimer test is positive, it shows a high probability of DVT.
  • Fracture or strain: As incompetence of lymphatics occurs, edema takes a long time to settle; therefore affected part should be kept elevated.
 
1.19 FATIGUE/GENERAL WEAKNESS/FEELING TIRED
 
Red Flags
Feeling tired or fatigue
  • Weight loss, loss of appetite, fever, night sweats, and lymphadenopathy
  • Localizing/local neurological signs
  • Polyuria and polydipsia (diabetes)
  • Significant lymph node enlargement
  • Disabling tiredness
  • Symptoms and signs of arthritis or CTD
  • Pain anywhere in the body
  • Symptoms and signs of cardiorespiratory disease
  • Abnormal physical examination
  • Weight loss/weight gain
  • Depression
  • Sleep apnea
Fatigue has three components:
  1. Lack of ability/motivation to start an activity.
  2. Tiring quickly after starting the activity.
  3. Difficulty with concentration and memory to start or complete an activity.
Feeling tired/dead tired should not be confused with drowsiness/need to sleep/shortness of breath after stressful work or muscle weakness.47
 
Etiology and Investigations
Etiology
Investigation(s) (choices include)
1. Psychogenic causes (80%)
  • Anxiety
  • Depression
History
(refer Chapters 6.14.1 and 6.14.2)
2. Organic causes (20%)
  • Anemia
CBC, peripheral smear, CSR, ferritin, serum iron, and TIBC (refer Chapter 1.1)
  • Infections:
Influenza, infectious mononucleosis, TB, HIV, hepatitis B, C
Mantoux test, ESR, CXR, sputum acid-fast bacilli (AFB), etc. (refer Chapter 1.48), serological tests for hepatitis B, C, HIV, Lyme borreliosis, EB virus, cytomegalovirus, and toxoplasmosis
  • Cancer:
Lymphoma and leukemia
CBC, peripheral blood smear, imaging procedures (US, CT, and PET-CT), biopsy
  • Endocrine:
Diabetes hypo- /hyperthyroidism, hyperparathyroidism, hypo or hyperaldosteronism
FBS, PPBS, HbA1c, TSH, TPO, calcium, cortisol, aldosterone, ARR
  • Liver disease
LFT, PT, serological test for hepatitis A, B, and C
  • Renal disease
Urine analysis, creatinine, and urea
  • Cardiovascular
CXR and ECHO, ECG
  • Respiratory
CXR, CT, SpO2
  • CTD/Musculoskeletal
RF, ANA, anti-CPP, and LE cell (CTD workup), ENA, CPK
  • Meditations
Check medications
  • Substance abuse
Alcohol, LSD, etc.
 
Fatigue Questionnaire
Fatigue questionnaire
Clue/Diagnosis
Improves with rest
Organic cause
Does not improve with rest
Psychogenic cause
Anorexia, breathlessness on exertion, palpitations, and body pain
Anemia
Increased thirst and frequent urination, itching
Diabetes mellitus
Low grade fever, cough, and lymph node enlargement
Tuberculosis
Weight gain, cold intolerance, constipation, very dry skin, slow thinking, depressed mood, and muscle cramps (especially if the symptoms are new or persistent)
Hypothyroidism
History of alcohol, drugs, and medications
Medication/substance abuse
Elderly patient
Cancer
Erectile dysfunction
History
Anxiety/depression:
Anxiety: Three or more features listed below indicate generalized anxiety disorder
  • Restlessness or feeling tense (on edge), or feeling of fear or impending disaster
  • Fatigue, i.e., getting tired
  • Difficulty in concentrating
  • Irritable
  • Muscle tension, increased pulse rate, increased heart rate, or increased frequency of urination or defecation
  • Sleep disturbance
Depression: 6 symptoms: 2 major + any 4 minor for > 2 weeks = Depression
  • Major criteria
    • Little interest or pleasure in doing things
    • Feeling down, depressed, or hopeless
  • Minor criteria: Plus any 4 features listed below:
    • Trouble falling or staying asleep or sleeping too much
    • Feeling tired or having little energy, i.e., fatigue out of proportion to energy expended
    • Poor appetite or overeating48
  • Feeling bad about yourself or that you are a failure or have let yourself or your family down, i.e., guilt
  • Trouble concentrating on things, such as reading the newspaper or watching television
  • Moving or speaking so slowly that other people could have noticed? Fidgety or restlessly you have been moving around a lot more than usual? Or irritable or withdrawn, i.e., psychomotor
  • Thoughts that you would be better off dead or of hurting yourself in some way, i.e., suicidal
 
Treatment (Choices Include)
Identity and treat the cause whenever possible
MULTIVITE FM/SUPRADYN tablet (multivitamins and minerals) twice daily for 30 days
EVION LC (vitamin E + levocarnitine) (bd for 10 days)
AUTRIN or LIVOGEN once daily
BETONIN/POLYBION tonic 15 mL bd
NEUROBION injection 2 mL IM on alternate days (5–10 injections)
Levothyroxine (ELTROXIN)
FLUDEP (fluoxetine) 20 mg od
 
Key Points
  • Rule out common causes such as anemia, diabetes, TB, renal, and liver disease. Other causes include HIV, myxedema, malignancy, addiction, and sexual weakness. In elderly patients, rule out carcinoma, e.g., stomach and liver.
  • Fatigue may be due to anxiety, anger, or chronic conflict.
  • Fatigue caused by physical illness is relieved by decreasing activity, by rest or by sleeping.
  • Make sure/ask a direct question about erectile dysfunction in males and this could be a clue for diagnosis of fatigue!
  • Careful neurologic examination/investigation is indicated in all cases.
  • After pregnancy (in postpartum), give iron for 60 days and 1 g of calcium daily for 1 year or till she weans, whichever in longer.
  • Avoid anabolic steroids
  • After initial work up, patient should be kept under observation.
 
1.20 FEVER/FEVER OF UNKNOWN ORIGIN (FUO)
Red flags
Risk factors
  • Septicemia
  • Altered mental state
  • Severe headache
  • Immunosuppression
  • Neutropenia
  • Diabetes mellitus
  • Malignancy
  • Immunosuppression including HIV
  • Steroid treatment
  • Neutropenia
  • Exposure to tropical disease
  • Intravenous drug use
  • Old age and young children
 
Viral Fever
Etiology
Influenza, parainfluenza, adeno, rhino, respiratory syncytial virus (RSV), COVID-19, mumps, measles, rubella, hepatitis, herpes group; enteroviruses such as polio, coxsackie A, B and echo; arboviruses such as encephalitis, dengue, and Kyasanur forest disease (KFD)
Symptoms
Body ache, headache, backache, coryza, rashes, diarrhea, conjunctival suffusion, pharyngitis, palatal hemorrhages, lymphadenopathy, hepatosplenomegaly, etc.
Treatment and course
Most viral infections are self-limiting. Reassurance and supportive treatment are enough. In some patients with infections such as herpes, antiviral agents, e.g., acyclovir can be used. Anticipate complications in patients with hemorrhagic rashes, muscle tenderness, severe prostration, etc.49
 
Influenza/Common Cold
History
Differential diagnosis
Chills/runny nose or congestion
Viral fever, UTI, malaria, abscess, and cellulitis
Throat pain
Viral pharyngitis, tonsillitis
Cough, fever
Viral upper respiratory infection
Headache
Viral fever, sinusitis, typhoid, and malaria
Examination
Check temperature with thermometer
Check eyes (jaundice/anemia)
Torch light examination of throat
Examine the neck for neck nodes (particularly tonsillar nodes)
Auscultation of chest
Palpate abdomen for liver and spleen
Treatment
SINAREST/WIKORYL (combination of paracetamol and antihistamine) tds for 3 days
Influenza needs to be treated with antivirals (oseltamivir) in specific groups of patients
How to prevent spread of common cold? Wash hands frequently; sneeze/cough in your elbow and not in your hands
 
Dengue, Leptospirosis, Rickettsiosis, and Chikungunya: Clinical Features, Investigations and Treatment
Dengue
Leptospirosis
Rickettsiosis
Chikungunya
Flavivirus
Spirochete-infected animal contact or indirect contact with water or soil with rat /dogs/farm animals urine
Bacteria
Virus
High-grade fever for 2–7 days (two or more listed features below):
Dengue fever
Headache
Retro-orbital pain
Myalgia, arthralgia
Rash
Petechiae, positive tourniquet test
Leukopenia
Dehydration
Shock, bleeding or organ failure
Flu-like illness
Weil's syndrome (jaundice, renal failure, hemorrhage, myocarditis)
Meningitis
Pulmonary hemorrhage
Respiratory failure
Fever, rashes
Headache
Myalgia
Lymph node enlargement
Eschar
Headache, chills, fever, arthralgia or arthritis, conjunctival suffusion, nausea, and vomiting
NSI dengue card test positive (+)
IgM, IgG ELISA are positive (+)
Progressive decrease in WBC
Tourniquet test is positive (monitor for severe signs, edema, ascites, pleural effusion, severe thrombocytopenia)
Leptospira card test is positive (+)
IgM ELISA is positive (+)
Hepatic enzymes, CK are increased
IgM ELISA scrub positive (+)
Hepatic transaminases elevated
Leukocytosis
Chikungunya, IgM ELISA positive (+)
IV fluids
Fresh blood/packed cells
Paracetamol
Avoid IM injections, Aspirin, NSAID, steroids and antibiotics
Doxycycline 100 mg PO bd or ceftriaxone 1 g IV od
Doxycycline 100 mg PO bd
Rest, fluids, NSAIDs, Paracetamol Chloroquine phosphate 200 mg od
Avoid Aspirin
 
Etiology of Fever (1)
Infection
Bacterial (UTI, cellulitis, pelvic inflammatory disease, abscess, TB, endocarditis, syphilis, or osteomyelitis)
Viral (herpes, EBV, CMV, and HIV)
Fungal (antibiotics, intravascular devices) Parasitic (toxoplasmosis, tropical infections)
Malignancy
Lymphoma, leukemia, cancer of kidney, colon, liver, breast or pancreas, etc.
Connective tissue disease/immunological disorders, e.g., RA, SLE, Crohn's disease, and sarcoidosis
Severe trauma and muscle damage
Road traffic accident, work and sport injuries (e.g., large hematoma)
Drug induced
Isoniazid (INH), β-lactam antibiotics, and procainamide50
 
Etiology of Fever (2)
Fever
Classic Pyrexia of unknown origin (PUO)
Nosocomial
Neutropenic
HIV associated
Patient situation
Fever > 101°C or 38.5°C more than one occasion
Duration > 3 weeks
No diagnosis despite 1 week of intensive evaluation
Hospitalized
Acute case
No infection when admitted
Neutrophil count < 500 μL or expected to fall to that level in 1–2 days
Confirmed HIV case
Examples
Infections (30%): Tuberculosis, malaria, amebiasis, EBV, Lyme, endocarditis, intra-abdominal abscess, osteomyelitis, dental abscess, and sinusitis
CTD (30%): Rheumatic fever, PAN, RA, giant cell arteritis, and temporal arteritis
Neoplasms (30%): Lymphoma, leukemia, cancer (hepatocellular, colon, pancreas, liver, and secondaries)
Miscellaneous (20%): Drugs, hematoma, thyroid, or adrenal insufficiency
Thrombophlebitis
UTI
Sinusitis
Drugs
Clostridium difficile colitis
Virus, bacteria, and parasites
Drugs
Aspergillosis
Perianal infection
Empiric antibiotics indicated in neutropenic patient:
For fever of unknown origin: monotherapy with piper/Tazo, Ticar/Clav, imipenem or ceftazidime or ceftriaxone
For sepsis or pneumonia, or pseudomonas infection, combination therapy with antipseudomonal β-lactam, i.e. any of the above drug used in monotherapy with aminoglycoside or fluoroquinolone
For mucositis, catheter site infection: Any drug used above in monotherapy with vancomycin
Tuberculosis, mycobacterium avium-intracellulare infection
 
History
Duration
2–5 days
Viral COVID-19 (dengue and chikungunya)
Protozoal (malaria)
Bacterial (leptospirosis and scrub)
Upper respiratory tract infection (URTI), lower respiratory tract infection (LRTI), UTI, and others
5–7 days
All of the above + enteric (typhoid) fever
>3 weeks
Infections, neoplasms, and CTD
Questions for symptoms and signs/clues
Possible diagnosis
Anorexia
Hepatitis
Dark color urine
Jaundice and hepatitis
Chills
Malaria, filaria, UTI, cellulitis, abscess, biliary tract obstruction, pyelonephritis, septicemia, pneumonia, and viral infections
Cough, chest pain, breathlessness
Pneumonia
Dysuria, pyuria
UTI
Diarrhea
Enteric fever, colitis, and drug-induced diarrhea
Delirium
Meningitis, encephalitis, typhoid, and pneumonia
Epidemic
Dengue and influenza
Headache
Sinusitis, otitis media, typhoid, malaria, and viral fevers
Pain, body ache
Viral fever
Ear
Otitis
Throat
Tonsillitis51
Joints
CTD/rheumatic fever/chikungunya
Muscles
Viral fever
Jaundice
Hepatitis A, B, C, malaria, leptospirosis, dengue, and cholangitis
Exanthems/blisters— sepsis
Rash (apart from exanthems)
Chickenpox (day 1), measles (day 4)
Drug allergy
Ampicillin
Erythema nodosum
Tuberculosis, leprosy, fungal infections, and streptococcal infection
Erythema multiforme
Herpes simplex, mycoplasma, and drugs
Butterfly rash
SLE
Septicemia
Meningococcal, gonococcal, Gram-negative sepsis, and staphylococcal toxic epidermolysis
Ecthyma gangrenosum
Pseudomonas infection
Nutrition
Type and source of food. Is food poisoning a possibility?
Sexual history
Any exposure to sexually transmitted infections
Work
Exposed to pathogens or unusual chemicals at work? Consider work-related exposures to infectious diseases if patients work in sewers, laboratories or with live animals (e.g., leptospirosis)
Travel
Recently traveled to a hot climate with increased prevalence of tropical infections (e.g., malaria and typhoid fever)?
Hobbies
Any contact with animals and birds (e.g., psittacosis) or spirochete-infected animal contact, or indirect contact with water or soil with rat urine (e.g., leptospirosis). Have there been any recent tick bites?
Past and current medical problems
Recent infections: Consider abscess formation and recurrence
Operations: Recent surgery raises the possibility of postoperative infection or deep venous thrombosis
Trauma: Ask about any recent trauma with extensive muscle damage. A resolving hematoma may also cause fever
Immunization: Check details about the patient's immunization status
Medication
Drugs causing fever: Is patient taking any drugs (INH, β-lactam antibiotics, procainamide, and phenytoin)? Check prescription and over-the-counter medication as well as illicit substances (e.g., doping body building)
Antipyretics: Have these been taken? Are they effective in reducing the fever and alleviating symptoms? Antipyretics may also mask the fever and its diurnal pattern
Antibiotics: Has the patient taken any antibiotics already, such as those prescribed by another practitioner or leftover?
Steroids: Long-term oral steroids increase the risk of infection and may mask symptoms
Chemotherapy and drugs causing neutropenia: Consider neutropenia, if the patient has recently undergone chemotherapy or is taking drugs that may cause blood dyscrasias (e.g., carbimazole)
Allergies
Ask about allergies to any antibiotics needed to be prescribed for treatment of infection
Home
How has home life been affected by the symptoms? Do other people who live in the same accommodation also suffer from fever or other symptoms?
 
Patient Examination and Clues for Diagnosis of Fever
Region
Look for
Possible cause of fever
1.
Eyes
Jaundice
Hepatitis
2.
Sinuses
Tenderness
Sinusitis
3.
Teeth
Caries
Dental
4.
Ear
Ear discharge, tenderness
Acute suppurative otitis media (ASOM) and chronic suppurative otitis media (CSOM)52
5.
Throat
Redness, any membrane
Tonsillitis and pharyngitis
6.
Lymph nodes
In neck, axilla, and groin
TB, lymphoma, EBV, and cancer
7.
Skin
Blisters and rash
Chickenpox and measles
8.
Respiratory system
Tachypnea, diminished breath sounds, bronchial breathing, crepitation, rhonchi, rub, and dullness
Pneumonia, bronchitis, cavities, pleurisy, effusion, and empyema
9.
Cardiovascular system
Heart rate, murmurs, and pericardial rub
Endo-/Peri-/myocarditis
10a.
Abdomen
Tenderness, hepatosplenomegaly, free fluid, mass, right-sided chest wall/intercostal tenderness is liver abscess
Hepatitis, splenomegaly in various infections, intra-abdominal abscesses peritonitis
b.
Genitalia
Scrotum, testes, vagina, and cervix
Orchitis, pyocele, balanoposthitis, and STDs abscess
c.
Per rectal
Perianal abscess, prostate, and seminal vesicles
Perianal abscess, prostatitis, and seminal vesiculitis
d.
Pelvic examination
Tenderness, discharge
PID
11.
Musculoskeletal
Muscle tenderness in shoulders, gluteal region, calf; joint pain, swelling, tenderness; spine tenderness
Dengue, leptospirosis, arthritis, myositis, DVT, etc.
12.
Central nervous system
Altered sensorium, neck stiffness, ocular fundi, and neurological deficits
Meningitis, encephalitis, and brain abscess
 
Investigations (Part 1) (Choices Include)
Duration
Probable cause for fever
Investigations (choices include)
2–5 days
Viral fever, malaria, URTI, LRTI, UTI, and COVID 19
CBC, MP, QBC, reverse transcription polymerase chain reaction (RT-PCR) dengue, NS1, LFT
Urine routine
5–7 days
All the above and enteric (typhoid) fever
CBC and peripheral smear
Urine routine
LFT
Malarial parasite in blood and malarial card test
Culture sensitivity (blood, urine, and stool)
Serological tests (card tests/ELISA):
Typhi point (typhoid)
IgM ELISA for leptospirosis, dengue—NS1, IgM, chikungunya
CXR, US, and CT
7–15 days
Headache
Sinusitis, otitis, dental sepsis, malaria, meningitis, and migraine
Refer investigations (Part 2) on Page 68
Cough
Tonsillitis, pneumonia, bronchitis, malaria, and TB
Chest pain
Pleural effusion/empyema, pericarditis, liver abscess, root pain, emphysematous bullae, and costochondritis
Duration
Probable cause for fever
Diarrhea
Enteric fever, colitis, and drug induced
Pain abdomen
Hepatitis, liver abscess, appendicitis, PID, and other intra-abdominal sepsis
Consider: Prolonged viral fevers (e.g., COVID-19, infectious mononucleosis, CMV, and HIV), malaria, enteric fever or TB (partially treated or resistant)53
 
Approach to Patient with Neutropenic FUO
zoom view
 
Investigations (Part 2) to Consider in FUO (Pyrexia of Unknown Origin) (Choices Include)
Investigation
Comments
1. Blood test
CBC
Leukopenia with relative lymphocytosis = Viral
Leukopenia = Typhoid
Platelets may be decreased in dengue, leptospirosis, and typhoid
ESR
May be elevated in infection, CTD
CRP
May be elevated in infection, CTD
Blood picture
May show malarial parasite
LFT
May be abnormal in liver abscess, dengue, and leptospirosis
D-dimer
Increased levels may suggest DVT/PE
Antinuclear antibodies
ACCP, ANA, and RF may be positive in CTD54
Serological tests (CARD/ELISA IgG/IgM test)
Viral infections: Dengue, leptospira, chikungunya, and HIV
Bacterial infections: Typhoid, infectious mononucleosis, brucellosis, scrub, and syphilis
Protozoal infections: Malaria and amebiasis
Serum electrophoresis
Creatinine, electrolytes, and calcium
Serum iron, transferrin, TIBC, and vitamin B12
2. Urine test
Urine routine, urine CS
3. Imaging
CXR
US (abdomen, lungs)
CT/MRI (abdomen, chest, CNS) Color Doppler (limbs for DVT)
4. Microbiology
CS of blood, urine, sputum, stool, CSF, tissue, or pus
5. Biopsy
Needle biopsy of liver or other tissue indicated by potentially diagnostic clues
 
Recommendations for Transmission-based Precautions of Select Cases
Precaution type
Selected case
Specifications
Standard
All patients
Hand hygiene before and after patient contact, gloves, eye protection, safe disposal, cleaning of equipment or linen, and cough etiquette
Contact
Pathogens implicated to spread via environmental contamination
Wash hands with soap and water. Private room preferred, gown on upon entering room. Consider gowning patient during transport. Noncritical items should be dedicated to use for single patient
Droplet
Pathogens spread through respiratory or mucous membrane contact with respiratory secretions
Private room preferred, wear surgical mask when within six feet of patient. Mask patient during transport
Airborne
Pathogens that remain infectious over long distances in the air, e.g., measles, small pox, varicella, Covid-19
Place patient in the negative pressure room, wear certified respirator N 95. Mask patient during transport
Complete
High mortality rate lack, of treatment or incompletely defined transmission modes, e.g., hemorrhagic fever, Ebola, Marburg MARS, Covid-19
Follow standard, contact, and airborne precautions. Complete skin coverage and eye protection required for provider. Use a trained observer for all PPE
 
Key Points for Clinical Practice
  • Simple viral fevers do not need antibiotics. No investigations are needed.
  • Before labeling a fever as viral, look for pallor, jaundice, and neck stiffness. Auscultate chest and examine the abdomen for liver/spleen enlargement.
  • If fever is not subsiding in 3–4 days of empirical treatment, investigate the patient thoroughly or refer to higher center.
 
1.21 FIRST AID
Allergic reaction
Carry epinephrine injection (EPIPEN). It makes heart pump, improves breathing, and gives you about 20 minutes to get to a hospital
Keep a few antihistamine tablets (AVIL or LEVOCET) into your wallet. These tablets will begin to fight an allergic reaction, while you proceed to the hospital55
Amputated FINGER/ TOE
Amputated part should be wrapped in moist (saline) gauze and placed in a sealed plastic bag
This sealed bag is placed in a container containing an ice saline bath to maintain a temperature of 4°C (cold ischemia). The amputated part should never be placed directly onto the ice or into a hyper- or hypotonic solution
1 hour of warm ischemia is equivalent to approximately 6 hours of cold ischemia. Hence, cooling can markedly prolong the window of opportunity for replantation
Animal bites
Wash with soap and plenty of water. Dogs, cats, ferrets, bats, foxes, coyotes, raccoon need rabies vaccine mice, rodents, rabbits, squirrels, guinea pigs, cattle, horse, and goats bites do not need rabies vaccine
Avulsed tooth
Tooth should be brought to the dentist within 1 hour of avulsion by keeping it in the buccal vestibule, under the tongue or placing the tooth in cold milk or plain cold water
No chemicals, medicaments, and disinfectants should be applied to the tooth surface
Teeth can be avulsed from their sockets due to traumatic injury. They can be reimplanted into their sockets and their function restored
Bee sting
Do not press the bag of the sting. Use forceps to remove the sting apply cold or weak ammonia
Bleeding
Apply direct or indirect pressure with hand or clean cloth, paper towel, scarf or any fabric you can grab and push down on the wound until the bleeding stops (this is known as packing the wound). Cover with a dressing pad and apply firm bandage. Elevate affected part above level of heart (the only time to use a tourniquet is when you know everything distal to the wound is beyond repair; say, the accident has amputated finger, arm, or leg)
Burns
Burn wounds are immersed in cold water for about 30 minutes (just splashing some water on the burn wound dissipates little heat from the wounds)
Chemical burns
Wash/irrigate the area with lots of water for a long period (over an hour). This helps to remove or dilute the chemical agent
Choking
Hit the top of the chair or edge of the counter against the upper abdomen, in the soft part below the bony upside-down V of the ribs. Thrust up and inward. This helps to send the stuck piece of food flying out helping you to breathe. If you still cannot breathe after six tries, repeatedly phone a neighbor or friend living nearby even if you cannot talk
Electric shock
Switch off the mains whenever possible
Detach the person with a dry wooden stick/log or use a loop of dry cotton fabric or plastic to pull the person away
Ensure airway, breathing, and circulation
Fainting
Place the person on the ground flat. Loosen clothing around chest and waist. Turn head to one side. Raising legs up above the level of heart helps to restore circulation
Do not give any solids or liquids to drink immediately
Finger injury
Use compression bandage and elevate the finger above the level of heart for 5 minutes
Fracture
Immobilize with a well-padded stiff support reaching the joints on either side. Apply bandages on either side of the site and near the joints on either side
Heart attack
If you are experiencing crushing chest pain with or without pain in your left arm, or you are short of breath, or have a sense of impending doom, you may be having a heart attack (women have atypical symptoms such as severe fatigue, nausea, heartburn, and profuse sweating)
Chew 325 mg uncoated aspirin (ECOSPRIN 325 mg), to get it into your bloodstream fast. This will thin your blood, often stopping a heart attack in its tracks
Lie down so your heart does not have to work as hard
Try forcing yourself to cough deeply (if you think you are going to die). It changes the pressure in your chest and can have the same effect as the thump given in CPR. Sometimes, it can jolt the heart into a normal rhythm
Impalement
Do not remove any embedded object/foreign body, e.g., knife, foreign bodies, and tree branch in any body part or eye
Leave it in the same position and transfer to hospital
Lightning
A large, enclosed building is safest, but a car is also good, as long as you close the doors and windows and do not touch any metal surfaces. Stay there for 30 minutes after the last rumble of thunder
Avoid tall trees, partially enclosed buildings, fences, poles, or any metal objects. It you are with a group, do not huddle near other people; stay at least 5 meters from one another. That way, if one of you is hit, the lightning would not travel between you
Nose bleeding
Sit up. Tightly pinch both nostrils for 5 minutes. Ask to breathe through mouth (not nose). Discourage to swallow blood as it may dislodge the clot56
Snakebite
Keep patient calm, stay cool. 50% are dry bites!! Wash the wound gently with soap and water Immobilize the part/area
Do not apply tourniquet
Do not massage
Do not incise, cut or attempt to suck the wound
Try to identify the snake
If patient is brought with tourniquet, start anti-snake venom (ASV), IV fluids and then release the tourniquet
Sprain/strain/muscle injury/ligament injury
PRICE method:
P: Protect the injured part (with POP or fiber cast, if needed). Each joint is immobilized in its own functional position
R: Rest or reduced activity
I: Ice or cold packs for 20 minutes every 2 hours (within 48 hours of injury)
C: Compress the area with support such as Elastocrepe or stockings
E: Elevate the injured area above the level of heart
After 48 hours or after swelling subsides, one can use hot compress or heating pads for 20 minutes at a time
Swimming emergencies
While swimming if a strong current takes inside the sea, you float for a while and swim parallel to the beach along the shore. Do not head toward the shore!
Trapped in a burning building
Close yourself in a smoke-free room and place a wet towel underneath the door to prevent any smoke from entering. Then get low to the ground, where you can breathe and see better, until help arrives
If you are in a house, get as low as you can and crawl outside as fast as possible. Do not stop until you are well away from the fire. Do not look through window. Lie down and look through mirror or plate
 
1.22 FOREIGN BODIES
 
Swallowed Foreign Bodies
Most will pass spontaneously, nearly 20% will require endoscopy and 1% will require surgical removal. Esophagus narrows naturally down at three places upper esophageal sphincter, aortic arch, and diaphragm.
Investigations (choices include):
1.
X-ray: Plane, coronal view/multiple views
Negative radiograph does not exclude a foreign body (fish bones, pills, and meat bolus)
2.
CT scan
Treatment (choices include):
ABC
Endoscopy (inability to handle secretions, fever, crepitus, is free air on radiograph, disk battery, sharp object, magnet, large objects, inability to tolerate oral solids or liquids, and foreign bodies in esophagus longer than 24 hours
Watchful waiting and serial radiographs
 
Foreign Bodies in Wounds
Glass, wood, bone, teeth, bullets metal, gravel, shell, rock, and plastic are examples.
Investigations (choices include):
1.
X-ray
Plain, multiple views around the wound, may be helpful
2.
US
It is done when foreign body is suspected but not seen in X-ray, or foreign body is deep or close to anatomical structures or when surgery is planned. When wood, glass or metal is suspected, local application of lidocaine may enhance appearance of foreign body. Use of water bath can improve sound wave conduction and can help identify soft issue foreign bodies
3.
CT scan
4.
MRI
MRI sensitivity is less due to artifact created by foreign body
 
Key Points
  • Wood splinters unless painted, fish bones, pills, drug packets, and meat bolus are not radiopaque.
  • X-ray with multiple views should be ordered when there is a concern for retained foreign body. X-rays can identify glass fragments if >2 mm57
  • Ultrasound and CT scan are other imaging choices for foreign bodies.
  • Foreign bodies may migrate and later cause problems such as nerve damage injury to tendons or blood vessels. Therefore, most foreign bodies should be explored. A tourniquet may be useful sometimes specially in extremities.
 
1.23 HEADACHE
 
Red Flags/Alarm Symptoms/Warning Signs
  • Make sure you ask direct questions as listed below (if red flags/flags are present, urgent neuroimaging CT or MRI should be done):
    • Worst headache ever/severe headache, started suddenly over seconds (suggests bleed)
    • Sudden change in previously stable headache
    • Headache worsening or progressive over the days
    • Early morning headache (although also common with migraine)
    • “Thunderclap” headache—rapid time to speak headache intensity
    • Nausea and vomiting (also common with migraine)
    • Vomiting precedes headache (increase ICT)
    • Is headache precipitated by bending, lifting and coughing (increase ICT)?
    • Is it worse when lying down (postural headache)?
    • Fever or unexplained systemic signs
    • Night-time awakening
    • Nonblanching rash (meningitis)
    • Head trauma
    • Retro-orbital pain
    • Neck stiffness
    • ↑BP + ↓pulse rate (=↑ICT)
    • Neurological findings such as papilledema, hemiparesis, cranial nerve abnormalities or hemianesthesia, and drowsiness
    • Jaw claudication (temporal arteritis)
    • HIV infection
    • History of cancer
  • Let them tell/unfold the story. Do not take history immediately.
  • Other questions:
    • Band-like headache = Tension
    • Unilateral or bilateral throbbing headache increases as exposure to loud sounds or bright light with visual aura = Migraine
    • Unilateral headache with watering from eye, nasal congestion or conjunctival chemosis = Cluster headache
    • Worse in the morning and decreases by evening = Increased ICT
    • Discharge, sinus pain or headache increase on bending, fever = Sinusitis
    • Headache after reading a book or seeing a movie = Refractive error
    • Nausea, altered vision, tinnitus, drowsiness, and fever = Migraine/meningitis
    • Headache while eating hot, cold or sweet foods or increase during eating/talking = Trigeminal neuralgia
    • Facial pain = Dental cause
    • Amenorrhea, galactorrhea, and history of cancer = Polycystic syndrome, pituitary adenoma, and cancer
    • History of quinolones, nalidixic acid, and vitamin A and D can cause pseudotumor cerebri.
 
Examination
  • General: BP, pulse, RR, check teeth, and paranasal sinus tenderness
  • CVS: Heart sounds, murmur
  • Central nervous system: Mental status, pupil response, motor strength, DTR, gait testing, signs of meningeal irritation (neck stiffness), signs of increased ICP (↑BP, ↓pulse rate), and papilledema.58
 
Primary Headache
Type
Duration
Features
Tension (also known as anxiety/ chronic daily headache)
Half an hour–7 days
Episodic or chronic
Bilateral tight band like constricting/pressure/squeezing pain. Not aggravated by movement. No nausea or vomiting. Some relief if pressure is applied
Migraine
15 minutes–3 hours
Repeated attacks of headache lasting 4–72 hours in patients with normal physical examination and no other cause for headache, and has at least two of the following features:
+
At least one of the following features:
Cluster
Half an–1 hour
1–8 hours od/day,
2–12 weeks periodic attacks
Five attack of severe unilateral or orbital, or temporal pain plus at least one features such as eye redness/lacrimation/edema of eye/sweating/meiosis or ptosis. Restless or agitated
 
Secondary Headache
Site
Etiology
Intracranial:
Extracranial
Eyes: Refractory error
Sinuses:
 
Investigations (Choices Include)
Erythrocyte sedimentation rate
CT brain/MRI brain [do a CT at least once in all patients with chronic daily headache (consider with contrast unless only looking for bleeding)].
Paranasal sinus (PNS) X-ray, cervical spine X-ray
Eye check-up
Dental check-up
Temporal artery biopsy
Headache
First-line (abortive) treatment
Preventive prophylactic treatment
Patient education
Tension
CALPOL (paracetamol) 500–1,000 mg PO BRUFUN (ibuprofen) 400–800 mg PO
TRYPTOMER/AMILINE
(amitriptyline)
10–75 mg PO, at night
Migraine
CALPOL (paracetamol) 500–1,000 mg
or
MICROPYRIN (aspirin + caffeine)
or
BRUFEN (IBUPROFEN) 400–800 mg PO stat
Plus
ACUVERT 5 mg PO/STEMETIL
(prochlorperazine) 12.5 mg IM or 10 mg PO stat
or
PERINORM (metoclopramide) 10 mg PO
or IM/IV
SUMITREX (sumatriptan) 100 mg PO (take within 20 minutes of attack)
(side effects are in chest, drowsiness and dizziness)
or
MIGRIL (2 mg ergot + caffeine + cyclizine) 1 tablet PO within 1–1½ hour of attack (side effects are nausea, vomiting, and muscle cramps; maximum dose of 2 tablets in 24 hour, contraindicated in IHD, CAD, and peptic ulcer)
>2 episodes/month/debilitating headache consider: Inderal (propranolol) 40–80 mg PO, bd
or
TRYPTOMER/AMILINE
(amitriptyline) 25–75 mg PO, hs
or
TOPAMAX (topiramate) 25–200 mg PO, hs
or
FLUGRAINE (flunarizine) calcium antagonist 10 mg, PO, hs (try one drug for 2 months and if patient is not better, change to another drug)
or
Riboflavin (vitamin B12)
400 mg PO Qid for 12 weeks
or
Fremanezumab antibody therapy
Avoid triggers:
Cluster
O2 12–15 L/min for 5 minutes
SUMITREX (sumatriptan) 6 mg SC stat; maximum 12 mg
LIDOCAINE 4% drops: Place 15 drops in ipsilateral nostril with head raised up by 45° angle. Repeat dose after 15 minutes, if necessary
Zolmitriptan intranasal spray
Verapamil (CALAPTIN) 80 mg PO, tds
or
TOPAMAX (topiramate) 25 mg hs PO, increase by 25 mg every 5th day; maximum dose 200 mg
or
GABANTIN (gabapentin)
900 mg/day
 
Key Points
  • Make one correct diagnosis of primary headache syndromes (i.e., is it tension, migraine, or cluster?)
  • Tension headache is the most common headache. Patient with tension headache feels relieved by pressing over the temporal region.
  • A child or a young patient complaining of frontal headache may have refractory error. Refer patient to ophthalmologist.
  • Simple analgesics such as paracetamol control symptoms in most people. Explain risks of dependency on analgesics.
  • Identify and alleviate precipitating stresses. Relaxation techniques may help.
  • Tricyclic antidepressants (amitriptyline, sertraline) or BB (propranolol) may be useful in some cases of tension headache.
  • Obtain CT scan at least once in patients with chronic daily headaches.
  • Consider possibility of space-occupying lesion in patients with new onset of symptoms, specially headache and vomiting.
 
1.24 HEEL PAIN: PLANTAR FASCIITIS
Plantar fascia is a layer of tough fibrous tissue, which runs along the bottom of foot to support the arch. This is one of the longest and strongest ligaments in the body. There is inflammation of the plantar fascia on the heel bone. As the plantar fascia pulls on the heel, body responds by laying down more bone in the area. This can be seen on an X-ray and is known as a heel spur.60
 
Symptoms
Heel pain is severe usually in the morning and decreases after few hours.
 
Treatment (Choices Include)
Treatment
Procedure/Comments
Soak
Soak feet in warm concentrated salt water solution, for ½ hour (do this as the first thing in morning as soon as you get up from the bed)
Ice massage
The plantar aspect of foot with hand or ice ball
Stretching exercises
Help lengthening the plantar fascia, calf muscles. Tightness in calf muscles can cause excess pronation (arch drop), which may contribute to plantar fasciitis
Anti-inflammatory drugs (NSAIDs)
Anti-inflammatory drugs may provide temporary relief
Ultrasound (extracorporeal short wave)
Can be helpful
Acupuncture
Limited benefit
Acupressure
Can be helpful
Corticosteroid injections
Are reserved for intractable or difficult cases (steroids may provide more relief than oral anti-inflammatory medications)
Change footwear/silicone or rubber heel cup
With foot solutions, custom biomechanical arch supports, i.e., specialized footwear; one can expect 50–70% relief for the 1st month, 70–90% relief for the 2nd month and 90–100% relief for the 3rd month depending on how consistently the support is used. Consistent arch support use can ensure that the problem does not recur
Reduce weight
If BMI > 25
Physiotherapy
Stretching exercises, toe curls, toe towel curls, simple forced dorsiflexion of foot and toes
 
Natural History and Prognosis
If left alone, plantar fasciitis may take 6–18 months to resolve. This condition is clinically diagnosed and 80% patients see self-limiting resolution within 1 year. There is no strong evidence that any particular treatment is beneficial.
 
1.25 HERPES ZOSTER (SHINGLES)
Herpes zoster is reactivation of varicella zoster virus (VZV).
Chest wall (most common site)
Face (trigeminal nerve area)
Geniculate ganglion (facial palsy, loss of taste, buccal ulceration and rash in external auditory canal = Ramsay Hunt syndrome)
 
Clinical Features
Burning discomfort in affected dermatome, which progresses to frank neuralgia discrete vesicles in the dermatome, 3–5 days later often coalesce.
Severe, multiple dermatomal involvement, or recurrence may suggest underlying immunodeficiency rule out DM, CKD, and HIV.
 
Complications
Postherpetic neuralgia (PHN) (persistence of pain for 1–6 months or more following healing of rash)
Secondary infection
Persistent visceral dysfunction (particularly in the absence of a rash)
Loss of sight with corneal scarring (particularly secondary to ophthalmic herpes)
Ramsay Hunt syndrome
Transverse myelitis
Meningoencephalitis
Pneumonitis
Atypical trigeminal neuralgia (ATN)61
Cranial and peripheral nerve palsies (Bell's palsy)
Transient ischemic attack (TIA), stroke from viral vasculitis
Deafness
 
Treatment (Choices Include)
Subset
Drugs
Acute pain
Acyclovir (CYCLOVIR) 800 mg five times a day for 7 days or valacyclovir 1 g tid for 7 days; start within 3 days
+
Tramadol (ULTRACET) for 5 days
+
Amitriptyline (TRYPTOMER) 25 mg hs or
Carbamazepine (TEGRETOL) 200 mg tds for 5 days
Postherpetic neuralgia (PHN)
Amitriptyline (TRYPTOMER) 25–100 mg hs or carbamazepine (TEGRETOL) 200 mg tds or gabapentin (GABENTIN) 300 mg od/bd
 
Key Points
  • Pain may precede rash.
  • Any rash, which stops in midline, suspects herpes zoster (i.e., involving single dermatome)
  • If skin is so hypersensitive that even touch of clothes is intolerable, it could be the start of herpes zoster!
  • Start treatment with acyclovir early (at the onset of burning pain/appearance of rash) (PO or IV if severe) + carbamazepine (TEGRETOL) 200 mg tds.
  • For pain relief, opioid analgesics are better than NSAIDs.
  • Chickenpox can be contracted from a case of herpes zoster and not the reverse.
  • While writing diagnosis, mention dermatome nerve root involved.
 
1.25.1 human immunodeficiency virus (HIV)
 
Red Flags
  • Reduced CD4 count
  • New neurological symptoms and signs including dementia
  • Persistent fever
  • Unexplained weight loss
  • Recurrent/severe shingles
  • Unexplained high plasma viscosity
  • Development of cancer
  • Significant psychological problems
 
Clinical Features of Acute Seroconversion Illness
Fever (present in 80–90%)
Rash, often erythematous and maculopapular
Fatigue
Pharyngitis (with or without exudate)
Generalized lymphadenopathy
Urticaria
Myalgia/arthralgia
Anorexia
Mucocutaneous ulceration
Headache, retro-orbital pain
Neurologic symptoms (e.g. aseptic meningitis, myelitis, and cranial nerve palsies)
 
Clinical Features of Early Symptomatic HIV Detection
Thrush
Persistent vaginal candidiasis that is difficult to manage
Oral hairy leukoplakia
Herpes zoster involving two episodes or more than one dermatome
Peripheral neuropathy
Bacillary angioplasia
Cervical carcinoma in situ62
Constitutional symptoms such as fever (38.5°C) or diarrhea for >1 month
Idiopathic thrombocytopenic purpura
Pelvic inflammatory disease, especially if complicated by a turbo-ovarian abscess
Listeriosis
 
Indicator Conditions in Case Definition
Candidiasis of esophagus, trachea, bronchi, or lungs
Cervical cancer, invasive
Coccidioidomycosis extrapulmonary
Cryptococcosis extrapulmonary
Cryptosporidiosis with diarrhea for > 1 month
Cytomegalovirus affecting any organ other than liver, spleen, or lymph nodes
Herpes simplex with mucocutaneous ulcer for > 1 month or bronchitis, pneumonitis, and esophagitis
Histoplasmosis, extrapulmonary
HIV-associated dementia: Disabling cognitive and/or motor dysfunction interfering with occupation or activities of daily living
HIV-associated wasting: Involuntary weight loss of > 10% of baseline plus chronic diarrhea (≥ 2 loose stools/day for ≥ 30 days) or chronic weakness and documented enigmatic fever for ≥ 30 days
Isosporiasis with diarrhea for >1 month
Kaposi's sarcoma in patient younger than age 60 (or older than age 60)
Lymphoma of brain in patient younger than age 60 (or older than age 60)
Lymphoma, non-Hodgkin's of B cell or unknown immunologic phenotype and histology showing small, non-cleaved lymphoma or immunoblastic sarcoma or Mycobacterium kansasii, disseminated
Mycobacterium avium, Mycobacterium tuberculosis (M. tuberculosis)
M. tuberculosis, pulmonary
Nocardiosis (disseminated nocardiosis)
Pneumocystis jirovecii (P. jirovecii), Pneumonia (formerly known as Pneumocystis carinii)
Pneumonia (recurrent bacterial)
Progressive multifocal leukoencephalopathy (PML)
Salmonella septicemia (nontyphoid), recurrent
Strongyloidiasis, extraintestinal
Toxoplasmosis of internal organ
 
Clinical Indicator Diseases for Adult HIV Infection
Clinical specialty
AIDS-defining condition
Other conditions where HIV testing should be offered
Dermatology
Kaposi's sarcoma
Severe/Recalcitrant seborrheic dermatitis or psoriasis
ENT
Lymphadenopathy of unknown cause63
Chronic parotitis
Gastroenterology
Persistent cryptosporidiosis
Oral candidiasis
Oral hairy leukoplakia
Chronic diarrhea of unknown cause
Weight loss of unknown cause
Gynecology
Cervical cancer
Vaginal intraepithelial neoplasia of grade 2 or above
Hematology
Any unexplained blood dyscrasia including neutropenia, lymphopenia, and thrombocytopenia
Neurology
Cerebral toxoplasmosis
Primary cerebral lymphoma
Cryptococcal meningitis
Aseptic meningitis/encephalitis
Cerebral abscess
Space-occupying lesion of unknown cause
Oncology
Non-Hodgkin's lymphoma (NHL)
Anal cancer or anal intraepithelial dysplasia
Lung cancer
Hodgkin's lymphoma (HL)
Respiratory
Tuberculosis
Pneumocystis
Bacterial pneumonia
Aspergillosis
Other
Mononucleosis-like syndrome (consider primary HIV infection)
Pyrexia of unknown origin
Any lymphadenopathy of unknown cause
 
Diagnosis of HIV Infection
Antibody detection
ELISA (at least 3 months from exposure)
Rapid spot tests
Western blot tests
Antigen detection
P24 antigen test (at least 2 weeks from exposure)
Molecular diagnostics
Qualitative and quantitative viral load test
Viral cultures
 
Factors Affecting CD4 Cell Counts
Factors affecting CD4 counts
Factors affecting CD4 counts
Bone marrow suppressive medicine
Splenectomy
Acute infections
Coinfections with human
T-lymphotropic virus type 1
α-interferon therapy
Target population
WHO recommendation
Severe or advanced HIV infection (clinical stage III and IV)
Start ART irrespective of CD4 counts
HIV infection (clinical stage I and II)
Start ART when CD4 count falls below 500 cells/mm3 (priority in case it falls below 350 cells/mm3)
Tuberculosis
Start ART regardless of CD4 count
Hepatitis B Co infection
Start ART in all individuals with CD4 count <500 cells/mm3
In case of severe chronic liver disease, initiate ART regardless of CD4 count
HIV-serodiscordant couples (one partner is HIV positive and the other is HIV negative)
Initiate ART for infected partner, regardless of CD4 count
 
National AIDS Control Organization (NACO) Guidelines on Initiation of ART (2010)
WHO clinical stage
Start of treatment
I and II
Start treatment when CD4 count below 250 cells/mm3
III
Start treatment when CD4 count below 350 cells/mm3
IV
Start treatment irrespective of CD4 count
 
Available Antiretroviral Drugs for HIV Infections
NRTI
NNRTI
PI
Others
Zidovudine (ZDV)
Stavudine (d4)
Lamivudine (3TC)
Didanosine (ddi)
Abacavir (ABC)
Tenofovir (TDF)
Nevirapine (NVP)
Efavirenz (EFV)
Etravirine (ETR)
Rilpivirine (RLP)
Atazanavir (ATV)
Indinavir (IDV)
Lopinavir (LPV)
Ritonavir (RTV)
Nelfinavir (NFV)
Darunavir (DRV)
Tipranavir (TPV)
Fosamprenavir
Fusion inhibitor: T20
Integrase inhibitor: Raltegravir (RAL)
CCR5 antagonist: Maraviroc
The antiretroviral medications to manage HIV/AIDS are divided into five major types.
Reverse transcriptase (RT) inhibitors
The RT inhibitors hinder the process of reverse transcription during the HIV life cycle. Two major forms of RT inhibitors are available:
1. Nucleoside/nucleotide RT inhibitors: Obstruct the functioning of HIV from replicating in a cell
2. Non-nucleoside RT inhibitors: Interferes with the ability of HIV to convert the RNA into DNA
Protease inhibitors
The protease inhibitors obstruct the protease enzyme that aids the HIV to generate infectious viral particles
Fusion/Entry inhibitors
The fusion inhibitors block the ability of HIV to merge with the cellular membrane to the host, consequently impeding its entry into the host cell64
Integrase inhibitors
The integrase inhibitors block the activity of integrates enzyme that incorporates the genetic material of HIV into the host cell
Multidrug combination products
Since patient with HIV infection can become resistant to one therapeutic agent, highly active antiretroviral therapy (HAART) containing a combination of 3 antiretroviral medications has been recommended
 
Key Points
  • Two distinct species of HIV (HIV-1 and HIV-2) exist.
  • HIV-1 is more virulent, easily transmissible, and accounts for majority of cases.
  • Sexual transmission, IV drug abuse, BT, and vertical transmission are major routes of acquisition.
  • High-risk group includes those with multiple sex partners, partner of HIV-infected patients, and IV drug abusers.
  • Acute infections resemble other acute infections.
  • Suspect HIV-infected patient with constitutional symptoms, recurrent fever, recurrent diarrhea, oral candidiasis, vaginal candidiasis, herpes zoster, and lymphadenopathy are the symptoms of early HIV infections.
  • Tuberculosis is one of the most common opportunistic infections with more extrapulmonary involvement and lower lobe involvement.
  • Pneumocystis jiroveci pneumonia (PCP), esophageal candidiasis, nocardiosis, PML, cryptococcal meningitis, HIV dementia, and wasting are other AIDS- defining conditions in our region.
  • Diagnosis of HIV is arrived by antibody-based tests.
  • ELISA/Rapid screening test in suspected cases.
  • Confirm diagnosis with Western blot test.
  • Screen for coinfections such as HBsAg, HCV, and syphilis.
  • CD4 is an important marker of immune system.
  • Viral load is important for monitoring the therapy.
  • Treat opportunistic infections before starting therapy.
  • Starting ART is not an emergency except in PEP and in prevention of mother-to-child transmission.
  • Combination ART should be used for management.
  • Therapy is life long without interruptions.
  • Monitor patient for acute and long-term side effects.
  • Three-drug combination of ART is preferred.
 
1.26 HICCUPS
 
Etiology and Investigations
Etiology
Investigations (choices include)
Metabolic (uremia, hyponatremia, DKA, hypoglycemia, and hypokalemia)
Creatinine, urea, Na+, K+, RBS, and CBC
Respiratory (pleurisy, Hodgkin's, metastatic cancer), sarcoidosis
CXR, US, and CT
Abdominal (subdiaphragmatic collections/abscess, abdominal distension)
CXR, US, and CT
Infections (sepsis)
CBC, culture, and sensitivity
Trauma
Drugs (dexamethasone, benzodiazepines, opioids, and methyldopa)
Substance abuse, e.g., alcohol
CNS (CVA, MS, lateral medullary syndrome)
Idiopathic
 
Treatment (Choices Include)
LARGACTIL (chlorpromazine)
50 mg stat PO/IM/q8 h
SERENACE (haloperidol)
2.5–5 mg IM/IV65
PERINORM (metoclopramide)
10 mg IV q8 h
BUSCOPAN (hyoscine butylbromide)
10 mg PO/IV q8 h
ALPRAX (alprazolam)
0.25 mg q8 h (if anxiety)
MUCAINE Gel
15 mL q4 h
LIOFEN XL (baclofen)
10 mg q12 h
 
Other Home Remedies
Swallowing granulated sugar
Gargling
Breathe into a plastic bag and rebreathe the same air
 
Key Points
  • Identify and treat the cause whenever possible.
  • Suspect hysteria in a young female patient with hiccups.
  • Suspect BPH/uremia in elderly male patients.
 
1.27 HYPERTENSION
 
Red Flags
  • Features suggesting a secondary cause
  • Accelerated hypertension (BP > 180/110 mm Hg with signs of papilledema and/or retinal hemorrhage)
  • Proteinuria
  • Visual symptoms (e.g., pituitary tumor)
  • Lack of response to treatment
  • Age < 30 years
In most cases, persistently raised BP is due to primary (essential) hypertension. Consider secondary hypertension in young people if there are additional symptoms or treatment resistance.
 
Etiology
1. Primary (essential) (95% cases)
Investigations/Comments
Genetic and environmental factors
Please refer investigations/comments listed in the next page
2. Secondary causes of hypertension (5% cases)
Investigations/Comments
(i) Renal:
Renal disease (PSK, CKD, obstruction)
Creatinine and urea, electrolytes, US abdomen
Renal vascular hypertension (renal artery stenosis)
Kidney US (Doppler), CT, and renal angiogram
(ii) Endocrine:
Primary aldosteronism (adrenal adenoma or bilateral adrenal hyperplasia)
Plasma aldosterone concentration increased, plasma renin activity increased, CT, or MRI of adrenal
Cushing's syndrome
Serum cortisol is increased, urinary free cortisol is increased
Dexamethasone suppression test
Pheochromocytoma
Urine or plasma metanephrine level
Hyperparathyroidism, hypercalcemia
Serum calcium
Hyperthyroidism, hypothyroidism
TSH, free T3, and free T4
(iii) Vascular:
CoA, vasculitis, connective tissue disease
66
(iv) CNS cause brain tumor, intracranial hypertension, sleep apnea
CT brain
(v) Drug induced or drug related or toxins or substance abuse (alcohol, cocaine, nicotine)
Nonadherence/Inadequate dose
Inappropriate combinations
Nonsteroidal anti-inflammatory drugs (NASIDs) (indomethacin and piroxicam); cyclooxygenase-2 (COX-2) inhibitors (celecoxib), antidepressants (venlafaxine), cocaine, amphetamines, other substance abuse drugs, sympathomimetic (decongestants, e.g., phenylephrine), oral contraceptives, steroids, cyclosporine, erythropoietin, and licorice
(vi) Miscellaneous causes
Improper BP measurement
Volume overload and pseudotolerance
Excess sodium intake
 
Complications
For each increase of 20 mm Hg SBP or 10 mm Hg DBP, there is two-fold increase in cardiovascular complications.
Cardiac
CAD, LVH, and CHF
Vascular
Aortic dissection, aortic aneurysm, and PAD
Neurologic
TIA/CVA, rupture of aneurysms
Renal, Genital
Proteinuria, renal failure, and erectile dysfunction
 
How to Check Blood Pressure?
  1. After 5 minutes of rest, patient seated in a chair, feet resting on floor, back supported and arm bare and at heart level, and place BP cuff (a large adult-sized cuff should be used to measure BP in overweight adults because standard size cuff can spuriously elevate readings).
  2. Tobacco and caffeine should be avoided for at least 30 minutes
  3. BP should be measured in both arms to exclude coarctation of aorta (CoA).
  4. BP should also be measured after 3 minutes of standing to exclude a significant postural fall in BP (≥ 20 mm Hg) (Systolic fall in BP = Orthostatic hypotension). Orthostatic hypotension may be a marker of early atherosclerosis and is associated with elevated risk of heart failure.
  5. On average BP readings are 5–10 mm Hg lower than with digital, unattended or out of office methods of measurement than with routine or standard methods of office measurement
  6. Less aggressive goals presented in table may be appropriate for specific group of patients including those with postural hypotension. frail older adult patient. and those with side effects to multiple antihypertensive medications home BP readings should not be used to manage BP unless it is performed adequately and in conjunction with office BP or ambulatory BP.
 
Goal Blood Pressure in Different Clinical Situations
Category
Blood pressure (mm Hg)
125–130/ < 80
125–130/ < 80
125–130/ < 80
125–130/ < 80
125–130/ < 80
125–130/ < 80
130–139/ <9067
 
When and Whom to Check Blood Pressure?
  • All patients as routine examination
  • Patients > 40 years
  • Diabetes mellitus
  • Obese
  • Headache
  • Giddiness
  • Chest pain
  • Epistaxis
  • Direct relatives of hypertension patients
 
Staging of Blood Pressure
Staging of blood pressure
Recommended treatment option(s)
Blood pressure (stage)
Systolic BP (mm Hg)
Diastolic BP (mm Hg)
Normal
< 120
<80
Nil
Elevated
120–129
<80
Lifestyle modification
Hypertension
130–139
80–89
A + C + D
Hypertension
140 or higher
90 or higher
A + C or A + D or A + C + D or A + C + D + B
Isolated systolic HT (elderly > 50 years)
>130
> 80
Isolated diastolic HT
<130
>80
Hypertensive crisis
>180
>120
Note: A stands for ACE inhibitors (ACEIs) or angiotensin-II receptor blockers (ARBs), B for beta blockers, C for calcium channel blockers (CCBs) and D for diuretics.
 
Investigations (Choices Include)
Test
Comments
Creatinine and urea
For renal disease
RFT needs to be checked before starting ACEI
K+ and Na+
FBS
For DM
Lipid profile
For hypercholesterolemia
TFT
Hyperthyroidism may be associated with HT and hypothyroidism is linked to diabetes and hyperlipidemias
Uric acid
Urine routine and microalbuminuria
ECG
May show LVH
ECHO
Renal Doppler
APBI
Carotid Doppler
Investigations to be done when secondary cause is suspected:
Note: ABPI, carotid Doppler studies and microalbuminuria can pick up silent end-organ damage early.68
 
Treatment (Choices Include)
  1. Lifestyle Modifications
    Modification
    Recommendation
    Approximate systolic blood pressure reduction
    Weight reduction
    Maintain normal body weight [body mass index (BMI) (18.5–24.9 kg/m2)]
    5–20 mm Hg/10 kg
    Adopt DASH eating plan
    Consume a diet rich in fruits, vegetables, low carbohydrate, low salt, low-fat dairy products with a reduced content of saturated and total fat
    8–14 mm Hg
    Dietary sodium reduction
    Reduce dietary sodium intake to no > 100 mmol/day (2.4 g sodium or 6 g sodium chloride)
    2–8 mm Hg
    Physical activity
    Engage in regular aerobic physical activity such as brisk walking (at least 30 min/day for at least 5 days/week)
    4–9 mm Hg
    Moderation of alcohol consumption
    For men, limit consumption to no more than two drinks [1 oz or 30 mL ethanol; 24 oz beer (720 mL), 10 oz wine (300 mL), or 2 oz (60 mL) 80% proof whiskey] per day
    For women and lighter weight person, not more than one drink per day
    2.5–4 mm Hg
    DASH highlights (table listed below is based on a 2,000 calorie plan):
    Food groups
    Daily servings
    Serving size
    Grains and grain products
    7–8
    1 slice bread (preferably whole wheat) or
    1 cup dry cereal or
    ½ cup cooked rice
    Vegetables
    4–5
    1 cup raw leafy vegetables or
    ½ cup cooked vegetables or
    ½ glass vegetable juice
    Fruits
    4–5
    1 medium fruit or
    200 mL fresh fruit juice
    Fat-free or low-fat milk and milk products
    2–3
    250 milk or
    1 cup yogurt
    Lean meat poultry and fish or pulses
    2 or less
    ½ cup cooked lean meat, skinless poultry or
    fish, or
    1 small bowl of pulses
    Nuts, seeds, and legumes
    4–5 per week
    7–8 count of dry fruits or
    1 small cup of legumes two to three times a day
    Fats and oils
    2–3
    1 teaspoon vegetable oil
    Sweets
    5 or less per week
    1 teaspoon sugar
  2. Antihypertensive Drugs
    Drugs group
    Trade name
    Starting dose (mg)
    Maximum dose (mg)
    (i) ACE inhibitors (ACEI)
    Enalapril
    ENVAS
    2.5
    4069
    Ramipril
    RAMACE, CARDACE
    2.5
    10
    (ii) Angiotensin-II receptor blockers
    Losartan
    LOSAR
    25
    100
    Telmisartan
    TELMA and TAZOLAC
    40
    80
    Olmesartan
    OLMARK
    20
    40
    Side effects are dry cough and hyperkalemia
    (iii) Beta blockers
    Atenolol
    ATEN
    25
    100
    Bisoprolol
    CONCOR
    2.5
    10
    Carvedilol
    CARVIL
    12.5
    25
    Metoprolol
    BETALOC
    25
    450
    Side effects are bronchospasm, lethargy and erectile dysfunction
    Bisoprolol and carvedilol are used in CHF and resistant hypertension
    (iv) Calcium channel blockers
    Amlodipine
    AMLOVAS, AMLODAC
    2.5
    20
    Nifedipine
    NICARDIA RETARD
    10
    120
    Cilnidipine
    CILACAR
    5–10
    20
    Diltiazem
    DILZEM
    30/60/90
    240
    Verapamil
    CALOPTIN
    80 tds
    120–360
    Side effects are edema and flushing of head
    Diltiazem and verapamil are used when BB are contraindicated or patient has cardiac problems such as SVT
    (v) Diuretics
    Hydrochlorothiazide
    AQUAZIDE
    12.5
    25
    Chlorthalidone
    CTD/LUPICLOR
    12.5
    25
    Torsemide
    DYTOR
    5
    10
    Furosemide
    LASIX
    Indapamide
    LOZOL
    1.25
    5
    Metolazone
    METENIX, ZYTANIX
    2.5
    10
    Side effects are hypokalemia and erectile dysfunction
    (vi) Alpha blockers
    Prazosin
    MINIPRESS XL PRAZOPRESS
    2.5/5
    20
    Terazosin
    TETRAPRESS, HYTRIN
    1/2/4
    20
    Side effects are orthostatic, hypotension, syncope and nasal congestion.
After counseling about lifestyle interventions to lower BP:
If systolic BP is more than 20 mm Hg above goal or diastolic pressure is more than 10 mm Hg above goal, start ACE inhibitor or ARB. If BP uncontrolled, add CCB, and BP remains still uncontrolled add thiazide like diuretic and even after that if BP remains uncontrolled it is a case of apparent resistant hypertension.
If systolic BP more than 20 mm Hg above goal or diastolic pressure is more than 10 mm Hg is not above goal, is not there do albumin to creatinine ratio (ACR) and if ACR is > 300 mg/g initiate ACE inhibitor/ARB. If albumin to creatinine ratio (ACR) is <300 mg/g initiate ACE inhibitor/ARB/a CCB, if BP remains uncontrolled combine ACE inhibitor/ARB with a CCB, and if BP still remains uncontrolled add thiazide like diuretic and even after this if the BP remains uncontrolled it is resistant hypertension.
If BP 130–139/80–89, with elevated cardiovascular risk one can attain goal BP with lifestyle interventions alone for a period of 3–6 months. Drug therapy should be initiated in such patients if lifestyle interventions are not sufficient to achieve goal BP.
Some experts suggest that initial drug therapy should include two drugs combination therapy if systolic pressure is more than 20 mm Hg above goal, or diastolic > 10 mm Hg above goal, how other experts suggest that combination therapy should be used in patients where systolic pressure is > 10 mm Hg above the goal. Both approaches are reasonable.
Using single pill combinations rather than prescribing two separate pills is preferred because it can improve adherence and control.70
Use of thiazide like diuretic (chlorthalidone and indapamide) is a reasonable alternative for monotherapy or in combination with ACE inhibitor or ARB instead of using a dihydropyridine CCB like amlodipine felodipine nifedipine. In addition, thiazide like diuretics, but not thiazide type diuretics have been shown to reduce cardiovascular outcomes.
“AB/CD” algorithm:
“A” stands for ACE inhibitors or angiotensin-II receptor antagonists
“B” stands for beta blockers
“C” stands for CCBs
“D” stands for diuretics
Algorithm is based on the idea that hypertension is best treated by one of the two categories of antihypertensives:
Those that inhibit the renin-angiotensin system (A or B) and those that do not (C or D)
A + D are best and more effective for young patients < 55 years
C + D group drugs are best for elderly people
Most people usually need 3–4 drug combinations to attain and maintain target BP levels. Combination drugs are used for hypertension (usually for stage II BP, i.e., >160/100 mm Hg)
Some combination drugs:
ACE inhibitors + CCB
ACE inhibitors + Diuretics
ACE inhibitors + Diuretics + CCB
Beta blockers + Diuretics
CCB + Diuretics
 
Antihypertensive Drug Choices in Specific Situations
Clinical situation
Recommended drugs (ü)