AN EXCEPTIONAL

WORKSHOP FOR
GP.

DR.ABDUR RAHMAN
(BIJOY)
MBBS(SSMC),BCS(HEALTH)
FCPS,MEDICINE(Final part)
MD,RESIDENT (Nephrology)
CCD(BIRDEM).
GP PRACTITIONER.
ENDOCRINOLOGY
 1.DM

 DIAGNOSTIC CLUE:
S/S:
 POLYURIA,POLYDIPSIA,POLYPHAGIA,
 PREDILECTION FOR SWEET FOODS
 MOOD CHANGE,IRRITABILITY
 DIFFICULTY IN CONCENTRATING
 WEIGT CHANGE.
 BLURRING OF VISION
 CHEST PAIN
 DELAYED HEALING
 RECURRENT ABCESS
 RECURRENT MYALGIA,H/O COMMON COLD
 PRURITUS VULVAE.
 TINGLING,NUMBNESS OF BOTH UPPER & LOWE LIMBS.
 THEN GO FOR GENERAL EXAMINATION(MUST)
 THEN DO SPOT RBS.
 H/O HEPATIC/RENAL IMPAIRMENT.
 NOW,
 INVESTIGATION:
 FBS,2 HOUR ABF,HBA1C
 URINE R/E
 FASTING LIPID PROFILE.
 S.CREATININE
 SGPT
 ECG
 FUNDOSCOPY(IF U THINK)
 CBC& THYROID FUNCTION TEST(IF PATIENT IS RICH ENOUGH)
TREATMENT:
1.DIET----SEE DIET LIST (PLATE THERAPY)

2.DISCIPLINE---NO SMOKING,NO ALCOHOL,NO BETEL NUT,AVOID LIFT,AVOID

EXCESSIVE LEISURE,AVOID CAR,DO HARD WORK,FREE MORNING
WALKING,EXERCISE,DAILY 30 MIN WALKING FOR AT LEAST 5 DAYS.

3.DRUG-----WHEN?
 STARTING OF DRUG THERAPY:
1.HbA1C <9% OR FBS < 11.1 mmol/l------LIFESTYLE+METFORMIN(TAB.COMET 500 mg
BD,After meal)

2.HbA1C 9-10% or FBS 11.1-16.7 mmol/l---LIFESTYLE+METFORMIN/METFORMIN

COMBINATION(DPP4 Inhibitor)+add 2nd DRUG (SULPHONYLUREA).e.g

Tab.Comet/Tab .vildapin plus /Tab.Sitagil M/Linaglip M--1+0+1---(A/M)

+
Tab.comprid / Tab Amaryl-----1+0+0---Before meal----continue.
3.HbA1C >10 or FBS > 16.7 mmol/l----START INSULIN (PREFERABLY COMBINATION)
START INSULIN 0.3-0.5 IU/KG/DAY. e.g.

 Inj .MIXTARD/MIXTARD Penfill 30/70 100 IU----2/3rd +0+1/3rd-----S/C before meal.

+/-
TAB. METFORMIN(COMET)
+/-
DPP4 Inhibitor
+/-
DAPAGLIFLOZIN/EMPFAGLIFLOZIN

OR
 Inj Novo Rapid Penfill (Insulin aspart) 100 IU---8+8+4 +/-2 (with meal)-------
CONTINUE.

 IF FASTING IS NOT CONTROLLED THEN ADD LONG ACTING INSULIN AT NIGHT.e.g.

 Inj. Lantus (insulin glargine) 100 IU /ml.---0+0+10-----B/M----Continue.

 If post prandial blood glucose is not controlled ,type 2 DM,Rich people---then

 Inj.liraglutide (GLP-1 RECEPTOR AGONIST) e.g. Inj. Victoza 3ml----0.6
mg/day(highest 1.8 mg/day) can be used BD.
N.B.
 IF FASTING BLOOD GLUCOSE IS HIGH -----INCREASE THE BASAL INSULIN.
 IF POST PRANDIAL BLOOD GLUCOSE IS HIGH---INCREASE SHORT/ULTRA SHORT
ACTING INSULIN.

IF HEPATIC OR RENAL IMPAIRMENT PRESENT

 USE LINAGLIPTIN (TAB.LINAGLIP 5/10 MG)

 USE INSULIN
 USE DAPAGLIFLOZIN 5/10 MG/ EMPAGLIFLOZIN 10/25 (DAPAGLIP/EMPAGLIF)—
1+0+0----WITH OR WITHOUT FOOD.

 TARGET OF TREATMENT:
 FBS: < 6 mmol/l
 Post prandial: < 8 mmol/l
 HbA1C : < 7%
 Lipid profile : LDL < 100 mg/dl, HDL > 40 mg/dl,TG < 150 mg/dl.
 BP: < 130/80 mmof Hg
 BMI : < 23 Kg/m2
 Waist Circumference : < 90 cm in male,< 80 cm in female.
 Indication of insulin
 Type 1 DM
 Severe acute illness.
 Pregnancy
 Major surgery
 Very high blood glucose
 OAD failure
 Adverse effect with OAD.

 FOLLOW UP:

 Follow up after 4 weeks in case of oral drug & after 2 weeks in case of INSULINE.
 2.HYPOTHYROIDISM

 DIAGNOSTIC CLUE
 FATIGUE,WEAKNESS
 WEIGHT GAIN
 COLD INTOLERANCE
 MENORRAGIA
 DRY SKIN,DRY HAIR

 THEN GO FOR GENERAL EXAMINATION(MUST)

 PULSE—BRADYCARDIA.
 EDEMA—NONPITTING.
 ANKLE JERK—DELAYED RELAXATION.

 THEN ,INVESTIGATE:

 S.TSH,S.FT4,S.FT3
 ECG----SINUS BRADYCARDIA,LOW VOLTAGE ECG.
 IF RICH----ADVICE FOR THYROID SCAN,THYROID PEROXIDASE ANTIBODY.
TREATMENT:
 TAB.THYROX 50 mcg----1+0+0---in early empty stomach-----3 wks.
then,2+0+0-----------for another 3 wks.

 Increase the dose in every 3 wks until TSH,FT4 are within normal limit.

 IN Younger patient: start at 100 mcg/day.

 If associated with IHD-----start at very low dose 25 mcg/day
 If pregnancy----Add 25 mcg with previous dose.

ADVICE:
 IT,S A LIFELONG TREATMENT.
 DON’T ALTER THE DOSE WITHOUT CONSULTING THE PHYSICIAN.
 CONSULT WITH ME AFTER 6 WKS with TSH & FT4 REPORT.
 3.SUBCLINICAL HYPOTHYROIDISM
DIGNOSTIC CLUE:
 S.TSH----- MILDLY ELEVATED (5-20 mIU/L)
 S.FT4-----NORMAL.
 S.FT3-----NORMAL.

 TREATMENT:
 IF PATIENT IS CLINICALLY ASYMPTOMATIC----NO TREATMENT IS
REQUIRED.EXPLANATION,REASSURANCE & COUNSELLING,REGULAR FOLLOW UP.

 CRITERIA FOR INITIATION OF TREATMENT:

• IF TSH > 10 mIU/L
• AUTO Ab POSITIVE
• TSH 6-10 mIU/L+ C/F OF HYPOTHYROIDISM
• INFERTILITY
• DYSLIPIDEMIA.

SO ,START LOW DOSE LEVOTHYROXINE e.g. Tab.Thyrox 25-50 mcg/day until the srum
TSH goes to normal range.
 4.HYPERTHYROIDISM
DIAGNOSTIC CLUE:
 WEIGHT LOSS DESPITE NORMAL/INCREASD APPETITE
 PALPITATIONS,TREMOR
 HEAT INTOLERANCE
 IRRITABILITY,EMOTIONAL LABILITY
 HYPERDEFECATION.

THEN GO FOR GENERAL EXAMINATION:(MUST)

 TREMOR,SWEATING
 PALMER ERYTHEMA
 SINUS TACHYCARDIA
 LID LAG,LID RETRACTION,EXOPTHALMOSE
 TERROR FACE,ANXIOUS LOOK.

INVESTIGATION:
1.S.TSH,S.FT4
2.ECG----TACHYCARDIA,ATRAIAL FIBRILATION.
IF GRAVE’S DISEASE SUSPECTED ----THEN REFER TO ENDOCRINOLOGY DEPT.FOR
FURTHER EVALUATION.(THYROID Ab,& Radio isotope scan).
 TREATMENT:
 Tab .Indever (Propanolol) 40 mg-----1/2+0+1/2------6 wks.
 Tab .Carbizol (Carbimazole) 5 mg----2+2+2------------6 wks.
 Tab. Rivotril (clonazepam ) 0.5 mg ----0+0+1----------6 wks.

 FOLLOW UP: DO S.TSH & FT4 After 6 wks.If within normal limit,then
Tab.Carbizol 5 mg--------1+0+1------18 months.

 If Toxic multinodular goiter:Refer to SURGERY after being EUTHYROID.

 SUBCLINICAL THYROTOXICOSIS: When TSH is undetected & FT4,FT3 are within the
normal range.usually treatment is not required.assurance,counselling & follow up.

Indication of treatment:
 Atrial fibrillation
 Osteoporosis .
 5.HYPER-HYDROSIS

 DIAGNOSTIC CLUE:

 SWEATING OF PALM & SOLE,AXILLA –Maximum time of the day.

 Problem during writing & doing important task.

 TREATMENT:

 Dricare 20% solution( Aluminium Chloride hexahydrate 20%)-----at night----3-4

wks.
 Tab .prokind 15 mg (propantheline bromide)-----0+0+1/1+0+1------1 month.

 Follow up after 2 wks.

NEUROLOGY
 6.MIGRAINE
 DIAGNOSTIC CLUE:
 Severe & throbbing headache with photophobia,phonophobia & nausea,vomiting
lasting from 4-72 hours.
 Pain worse on movement.
 Patient prefers to lie in a quiet,dark room.

 Do general examination for patient’s satisfaction.But nothing significant.

 Investigation not necessary.

 TREATMENT:
In case of acute attack:
Tab.Tufnil (Tolfenamic acid)200 mg 1 tab stat----may be repeated 10-15 min later.

OR
Tab.Napro A Plus 375/500 (Naproxen+Esomeprazole) 1 tab stat.
 If Attacks are frequent (more than two per month):

Tab.Norium (flunarizine) 10 mg-----0+0+1------continued.

or
Tab.Pizofen TS (Pizotifen) 1.5 mg----0+0+1------continued.

or
Tab.Topmate ( topiramet) 50 mg----0+0+1------continued.

or
Tab.Indever (Propanolol) 40 mg----0+0+1-------continued.

or
Tab.Amilin ( Amitriptyline) 25 mg----0+0+1-----continued.

 ADVICE:Avoidance of Triggers or Exacerbating factors.(AVOID→ Tea,coffe,cold

drinks,ice cream,fasting,exposure to sharp light,exposure to loud noise,exposure
to air conditioner,exposure to hot/cold climate)

 Came for follow up after 2 weeks.

 7.BELL’S PALSY
 DIAGNOSTIC CLUE:
 Deviation of mouth.
 Unilateral weakness
 Pain around the ear
 Diminished salivation & tear secretion.

 Ask He/She has any H/O ---DM,HTN,IMMUNOSUPPRESSION,URTI.

 Now,After seeing vital sign ,Do the facial nerve examination (what we do in our
ward) to diff.between UMN type/LMN type.

 Usually it is LMN type.But if it is UMN type----Refer to Neurologist by suggesting CT

scan/MRI of the brain.

 TREATMENT:
 If < 72 hour after onset of symptoms:
Tab. Precodil (prednisolone)20 mg----1+0+1----7-10 days.

 No role but prescribed ususally:

Tab. Virux (Acyclovir ) 400 mg ----1+1+1+1+1----7-10 days.
 Tearon fresh (Carboxymethylcellulose sodium) 10 mg/ml Eye drop----1-2 drop in
affected eye if feeling drying sensation.

 ADVICE:
1.Use glasses in the day.
2.Protect eye---Tape lid shut & pad at night.

 When REFER:
1.If recovery is not starting after 3 week.
2.If long standing palsy---for tarsorraphy.
3.If UMN type.
 8.PARKINSON’S DISEASE
 DIAGNOSTIC CLUE:
 Older patient
 Insidious onset of Resting Tremor.
 Slowing of movement.
 Rigidity
 Parkinsonian gait.

 Then Go for General Examination.

 Examine the wrist & ankle joint ---to see cogwheel & led pipe rigidity.
 See the jerks & planter response & Cerebellar sign.

 TREATMENT:
 For Tremor:
Tab. Hexinor 5 mg -----1/2+0+1/2----continued.

 For Rigidity & bradykinesia-:

Tab.Syndopa (carbidopa+levodopa)110 mg---1/2+0+1/2-----continued.

 Refer all patient to a specialist:

1.For confirmation of diagnosis.

2.Access a multidisciplinary specialist rehabilitation team.
 9.VERTIGO(ACUTE VESTIBULAR FAILURE)

 DIAGNOSTIC CLUE:
 Abrupt onset of vertigo & nausea, vomiting for----- days.

 Do general examination for patient’s satisfaction.( Anemia,Nystagmus may be

present)

 INVESTIGATION:
1.CBC
2.S.Electrolytes.

 TREATMENT:
Tab.Emenil plus (Meclizine Hydrochloride+pyridoxine HCL)---1+0+1---3-4 wks.

+/-
Tab.Menaril ( Betahistine Dihydrochloride) 8/16 mg---1+0+1----3-4 wks.
or
Tab.Cinaron plus (Cinnarizine +dimenhydrinate)-------1+0+1------3-4 wks.

 Came for follow up after 2 wks.

 10.Motion sickness
 DIAGNOSTIC CLUE:
 Nausea,vertigo,vomiting during travelling/riding into bus,car/during shopping
outside.

 Do general examination.
 No need to investigate.

 TREATMENT:
Tab.Efodio/Domin (Domperidone) 10 mg ----1+1+1----before
meal/travelling.
+
Tab.Vertina plus (Meclizine HCL+Pyridoxine HCL)—1+1+1—In whole day
staying outside.

 ADVICE:Explanation & reassurance.

 11.STROKE
 DIAGNOSTIC CLUE:FAST.
 Facial Asymmetry
 Arm/unilateral weakness.
 Speech difficulty
 Timing:sudden onset.

 Short history about---HTN,DM,IHD,Valvular heart disease,smoking,alcohol,drug

misuse.

 Do general examination.
 Neurological examination: see the jerks & planter response.
 Put your stethoscope into the chest of the patient---any evidence of valvular heart
disease.(murmur).

 ADVICE:
1. CT SCAN of the brain.
2. RBS
3. S.Creatinine
4. Lipid profile
5. ECG
6.URINE R/E
7.CBC

8. If Patient is young:
 Echocardiography ---for detection of VHD.
 ANA—SLE.
 ANCA—Vasculitis.
 Protein s,protein c,Antithrombin ∏T
 CBC with ESR
 S.Homocysteine.
 Anticardiolipin Ab.

 TREATMENT: Immediate Hospitalization after giving following medication.

Tab.Rosuva (Rosuvastatin) 10 mg----stat & 0+0+1
Tab.pantonix (Pantoprazole) 20 mg---1+0+1----B/M.
 12.PLID
 DIAGNOSTIC CLUE:
1.Sudden/gradual/repeated episodes of low back pain for months to years.

2.Constant aching pain is felt in the lumber region & may radiate to the buttock
,thigh,calf & foot.

3.Pain is exacerbated by coughing or straining but may be relieved by lying flat.

 Do The General examination.

 Next ---SLR Test(positive).

 INVESTIGATION:
1.MRI of L/S Spine---choice of investigation if patient can afford.
2.X-RAY L/S Spine both view---(little value).
3.S.Creatinine,SGPT,RBS.

 ADVICE:
 Early morning Exercise,Backstrengthening exercise.don’t liftv the weight more
than 1 kg.
 TREATMENT:
Tab.Napro A PLUS(Naproxen+Esomeprazole) 500 mg----1+0+1------2-3 wks.
or
Tab.Reservix SR ( Aceclofenac )200 mg----------------1+0+1------ 2-3 wks.
plus

Cap.pregaba (pregabalin) 50/75 mg------------------1+0+1--------2 month

+/-

Tab.Gabapen (Gabapentine) 300 mg----------------1+0+1--------2 month.

+/-
Tab.Emenil plus/Tab.Emistat(ONDANSETRON) 8 MG---------1+0+1-----1
month.

 ADVICE:
 Refer to Neurosurgery If no response to conservative mx./progressive neurological
deficit/disturbance of sphincter function.
 13.GBS
DIAGNOSTIC CLUE:
1.Ascending paralysis which is progressive & symmetrical.
2.No sensory disturbance.
3.No bowel & bladder involvement.
4.Ask past H/O diarrohoea/URTI.

EXAMINATION:
 Respiratory counting test.
 Vital signs.
 Reflexes :All reflexes are absent.
 SENSORY---Intact.

Investigation : Just do a URGENT Serum electrolyte level to exclude hypokalemia.

Treatment : Immediate hospitalization.

PSYCHIATRY
 14. SCHIZOPHRENIA
 DIAGNOSTIC CLUE:

 Laughing,smiling,crying without any obvious reason.

 Talking to self/imaginary figures.
 Socially disorganaized behavior---aggressive/violent/abusing/roaming aimlessly.
 Suspiciousness
 Talking irrelevantly
 Fearfullness
 Thoughts of being harmed or controlled by some external agencies.
 Neglecting personal care
 DISTURBED SLEEP
 Remaining quiet.

 Go for G/E---BP Must.

 INVESTIGATION:Repeat yearly.
 CBC,ECG,LIPID PROFILE,RBS/HBA1C,SGPT.
 TREATMENT:
Tab.Deprex (olanzapine) 5/10 mg -----0+0+1----continued.
or
Tab. Rispolux/Frenia (Risperidone) 1/ 2 /4 mg---0+0+1----continued.
or
Tab.Opsonil (chlorpromazine) 25/ 50/100 mg-------0+0+1-----continued.
or
Tab. Halopid (haloperidol) 5 mg -------0+0+1----------continued.

+/-
Tab. Queit ( Queitepine) 100 mg-------0+0+1----------continued.

 When Refer To Psychiatrist??

 Increase in Risk to self /others.

 Poor response to medication.
 Patient is new to your practice.
 15.DEPRESSION
 DIAGNOSTIC CLUE:

 Loss of pleasure in activities(enjoyed earlier).

 Sadness of mood
 Lack of interest in daily activities
 Decreased concentration
 Feeling of guilt.
 Death wishes
 Disruption of social & occupational functioning.
 Lack of sleep,appetite,libido,energy.

 Go for G/E.

 ADVICE:
 Counselling+ reassurance.
 Psychological support.
 TREATMENT:
Tab.Setra (Sertraline) 50 mg/25mg/100 mg----0+0+1------continued.
or
Tab. Esita (Escitalopram) 5 mg---------------------0+0+1------continued.
or
Tab. Pramin (Imipramin) 25 mg-------------------0+0+1------continued.
or
Tab.Amit (Amitriptyline) 25 mg------------------1+0+1-------continued.

 Duration of TX:

 If first episode ----6-9 months.(Tapering over a period of 6-8 wks).if symptoms recur
during this period –treatment needs to be continued for another 3-4 months.

 In case multiple episode ---to be continued.

 If sudden switch to mania----stop Antidepressant immediately.

 WHEN REFER?----High suicidal tendency.

 16.ANXIETY DISORDER/PANIC
DISORDER/OCD.
 DIAGNOSTIC CLUE:

 ANXIETY DISORDER:
 Symptoms of sympathetic overactivity (palpitation,sweating,dry mouth,increased frequency
of micturition.)
 Worrying too much,forgetfulness.
 Sleep disturbance.
 Worries about future
 Restlessness ,generalized ache.

 PANIC DISORDER:(Attack last for minutes)

 Sudden onset of palpitations ,chest pain,choking sensations.
 Fear of dying
 Persistent fear of going alone abroad.
 Diagnosis is made when several attacks occurred in previous month.

 OCD:
 Repeated same behavior & usually anxiety provoking—Thoughts of contamination,repeated
hand wash etc.
 INVESTIGATION:
• CBC,ECG,Thyroid function test.—To Exclude Systemic disease.

 TREATMENT:
Tab.Frenxit (Flupenthixol+melitracen) 10 mg-----0+0+1----continued.
or
Tab.Setra (Sertraline) 50/100 mg------0+0+1--------------continued.
or
Tab.parotin/Oxat (paroxetine) 10/20 mg---------0+0+1-----continued.
or
Tab.Esita (escitalopram) 10 mg---------------------0+0+1------continued.
+/-
Tab.Rivotril /disopan (0.5 mg)---------------------0+0+1-------continued.

 FOR OCD----Cap.Nodep/Modipran (fluoxetine) 20 mg ----0+0+1----continued.

or
Tab.Frenxit /Setra/esita-----can be prescribed.

 DURATION OF TREATMENT:8-12 months.then taper slowly over a minimum period

of 6-8 weeks.
 Response may take 2-3 weeks to begin & 8-12 weeks to stabilize.
 17.NOCTURNAL EMISSION
DIAGNOSTIC CLUE:
 Hearing the history.

 Then go for G/E.& investigation not necessary.

 TREATMENT.
Reassure the patient.
+
Tab. Nexcital (Escitalopram ) 10 mg------0+0+1--------1 month.
or
Tab. Depram ( Imipramin HCL) 25 mg/75 mg----0+0+1-----1 month.
DERMATOLOGY
 18.SCABIES
DIAGNOSTIC CLUE:
 Nocturnal itching at typical site.
 Contact history of similar complaints invariably present.

 INVESTIGATION:Not necessary.

 ADVICE: Improve personal hygiene of all family members.

disinfection of bedding & clothing by laundering.

 TREATMENT:
Lotion Lorix ( 5% permethrin)/Lorix plus (Crotamiton 10%)---Apply after
bath/at bed tym into the whole body except face,keep it in 12-24 hours.then washed
off.May be repeated----after 7 days./SCABEX 5% cream.
+
Tab.fexo (fexofenadine ) 120 mg-------0+0+1-------2 wks.
0r
Tab.Alarex/Atrizin (cetirizine dihydrochloride)-------0+0+1----2 wks.

If secondary infection:Tab. Zithrin (azithromycin) 500 mg/cap .cefixim 200 mg is added.

If heavy infestation---Tab.Ivera (Ivermectin) 3 mg or 6 mg-----stat & repeat after 2 wks.
 19. TINEA
CORPORIS/CRURIS/CAPITIS/PEDIS.
 DIAGNOSTIC CLUE:
 Ring shaped lesion in the body with itching.
 Itching in groin region.
 Itchy rash between toes,with peeling,fissuring,heperkeratotic plaque.
 Patches of partial alopecia+hair follicle discharging pus,thick crusting.

 See the Vital sign,

 investigation is not performed usually.

 CORPORIS/CRURIS/PEDIS:
 Aristoderm cream(betamethasone+clotrimazole+gentamicin)----twice daily---2-4
wks. Or
Fungidal HC CREAM (Hydrocortisone 1 % + Miconazole nitrate 2%)---same.
+
Tab.Terbifine ( Terbinafine) 250 mg--------1+0+0---------2-3 wks.
or
Cap.Nispore/ Flugal (fluconazole)150 mg thrice weekly for 4-6 wks.
+
Tab.Fexo 120 mg/Tab. Deslor 5 mg-----------0+0+1-------2 wks.
 FOR CAPITIS:
CAP.Flugal ( fluconazole) 50/150 mg-----once weekly ------6-8 wks.
or
Tab. Terbifine 1+0+0-------------------------1+0+0---------------3-4 wks.
+
Dancel/Nizoder 2% (ketoconazole shampoo)----use 3 times weekly—6-8 wks.
+/-
Tab.Fenadine 120 mg/Tab.Mastel MR (Mizolastine)10 mg---0+0+1---2-4 weeks.

 Advice:
 Avoid soap & detergent.
 Wear loose undergarments & clean regularly
 Avoid oil application to scalp in case of capitis.
 Use personal towel & footwear.
 Becareful at saloon.
 20.PITYRIASIS
VERSICOLOR
 DIAGNOSIS:
 Usually by visual impression.
 Hypopigmentation is more obvious after sun exposure.

 TREATMENT:
Neosten 1% cream(clotrimazole 1%)-----twice daily ------6-8 wks.
+
Dancel /Nizoder 2% ( ketoconazole shampoo)----TRICE weekly----6-8 wks.
+
cap. Flugal 150 mg------2 cap on each Friday-------6 weeks.
+/-
Tab. Fenadin 120 mg----0+0+1----------------4 wks.(if itching/allergy).

 Advice:
 Avoid soap application at affected area.
 Avoid oil application.
 21.PARONYCHIA/BOILS/FOLLICULITIS

 DIAGNOSTIC CLUE:
 Redness,swelling,pus formation,pain in paronychial area.
 Tender ,red nodule with pus formation surrounding a hair follicle,+/- fever—boils.
 Same---but occured in hair bearing areas(scalp,beared area,legs)---folliculitis.

 Do RBS ---PLUS Exclude DM.

 Treatment :
Drain the Pus by simple incision.
+
Cap. Fluclox ( flucloxacillin) 500 mg----1+1+1+1-------7 days
or
cap .Clidacin (Clindamycin ) 300 mg----1+1+1---------7 days.

If pain--Add Tab.Rolac 10 mg / Tab. Lindac (sulindac) 200 mg---1+0+1---5 days.(A/M)

+
cap.omep 20 mg --------------1+0+1-------5 DAYS.(B/M).

ADVICE:keep the affected area dry & clean.

 22.MELASMA

 DIAGNOSTIC CLUE:
 During pregnancy.
 OCP USERS.

 TREATMENT:

TRIMELA Cream (Fluocinolone+hydroquinone 4%+tretinoin 0.05%)---continue 1-2

month-------------twice daily.
or
Depiquin Forte cream (dioxybenzone+hydroquinone+octyldimet p
aminobenzoate+oxybenzone)----------------------twice daily-----1-2 month.
+
Clean & Clear facewash------------------twice daily.

 Advice :
 Don’t use soap.
 23.ACNE
 Diagnostic clue:
 Spots on face (visual impression)+/- back and chest.

 TREATMENT:(Mild cases)
Eromycin 3% lotion ------once/twice daily--------6-8 wks.
or
clindacin lotion 1% -------ONCE/TWICE DAILY------6-8 wks.
OR
Betnox / Caress (Benzoyl peroxide) 2.5%----initially once daily—then twice
daily for 6-8 wks.
+/-
Cap.Roaccutane (Isotretinoin) 10 mg--------1+0+1---------4-6 wks.

In case ( severe caseas):

Above treatment
+
Cap. Servidoxyne/Doxycap (doxycycline) 100 mg-----0+0+1---4-12 wks.
 ADVICE:
 Avoid excessive cosmetics/take more & more drinking water/regular washing and
cleaning of face,regular shampooing.
 Picking at Acne doesnot improve it and can cause scarring.
 24. ECZEMA
 DIAGNOSTIC CLUE:
 Itching & vesicular eruption.
 Exudation in acute cases.
 Skin markings.
 Fissuring with pigmentation.

Treatment :
Aristoderm Ointment-----apply twice daily-------1 month.
or
Topicort 1 % (Hydrocortisone 1%) cream---------apply twice daily------1 month.
+
Tab. Seasonix (levocitarizine) 5 mg---0+0+1------1 month.

If secondary infection---Add Tab.Zithrin( azithromycin) 500 mg---0+0+1---7 days.

 ADVICE:
 Avoid wool,wear loose cotton clothing.
 Avoid excessive heat,keep nails short.
 25.PSORIASIS

 DIAGNOSTIC CLUE:
 Erythematous,well defined,dry scaly papules & plaque of various sizes(extensor
surface usually)
 Scales can be removed in layers.
 When the scales are compleyely scraped off,multiple bleeding points are seen.
 Lesion produced at trauma sites.

 INVESTIGSTION:skin biopsy.

 Treatment :
Clobesol SA /Dermasol cream (clobetasol proprionate+salicylic acid)---at night---
3-4 weeks. +/-
Tacrolim 0.1 % ointment ( tacrolimus)--------apply once daily------3-4 weeks.
+/-
Tab.Avil ( pheniramine maleate) 22.7 mg----0+0+1------------continued.
+
Cap. A VIT 1 (Retinol) 1 lac unit------1+0+0--------------------3 weeks.
+/-
cap.Moxacil (Amoxicillin) 500 mg ----------1+0+1------------1 week(if secondary
infection).
 In face & flexural psoriasis:
Use Topicort 1 %( hydrocortisone 1%) cream----same BD------1 MONTH.

 IN SCALP PSORIASIS:/dandruff:
Soritar scalp ointment (coal tar+precipitated sulpher+salicylic acid)---apply
daily/thrice weekly-----1-2 month.apply to wet hair & rinse well.

 When to REFER???

 Pustular psoriasis
 Acutely unstable
 Widespread
 Associated with arthritis
 Failure to respond with primary MX.
 26. GONORRHOEA.

 DIAGNOSTIC CLUE:

 Purulent urethral discharge usually 2-5 days after sexual exposure.

 Dysura.

 TREATMENT:
Inj. Ceftron (ceftriaxone ) 500 mg----1 vial I/M stat.
or
Tab.ZIMAX ( azithromycin ) 500 mg----2 Tab stat.

Investigation :C/S of urethral discharge can be done.

HAEMATOLOGY
 27.IRON DEFICIENCY ANEMIA
DIAGNOSTIC CLUE:
 Tiredeness,lightheadedness,breathlessness,worsening of angina.
 Seeing the CBC report.

DO G/E----anemia,koilonychias,pulse,BP,JVP,edema.

INVESTIGATION:
 Cbc with PBF
 IRON PROFILE
 Stool for ova/stool R/E
 IF RICH:Renal function test,upper GI Endoscopy,Colonoscopy.

 TREATMENT:
 Diet rich in red meat,liver,kochu shak,banana.
 Tab.Ipec plus/Hemofix FZ (ferrous ascorbate+folic acid+zinc)----1+0+1-----3-6
month.
 BLOOD TRANSFUSION:If Heart failure,Angina,Evidence of cerebral hypoxia(so,adv
for hospitalization).
 Parenteral iron :If malabsorption,chronic gut disease,inability to tolerate oral iron.

ADVICE: Do CBC after 3-4 week & come for follow up.
 28.MEGALOBLASTIC ANEMIA
 DIAGNOSTIC CLUE:
 Strict vegetarian
 Sore mouth,raw tongue,weight loss
 Angular cheilosis,vitiligo
 Usually a diagnosed case/ came with report.

 DO G/E.

 INVESTIGATION:
 CBC with PBF
 VIT-B12 assay & folate Assay.
 Serum ferritin,LDH.

 TREATMENT:
Inj.Cynomin H (Hydroxycobalamin) 1 mg/ml----1 amp. I/M stat & every 3 DAYS
apart ----total 6 doses-----then, 1 amp I/M every 3 month---for life long.
+
Tab. Folison (folic acid ) 5 mg-----0+0+1------3 months----then 1 tab every
Friday for life long.
PAEDIATRICS
 29.ACUTE BRONCHIOLITIS
 DIAGNOSTIC CLUE:
 TREATMENT:(mild cases)
SYP.Pedeamin (diphenhydramine hydrochloride) 10 mg/5 ml----6.25 mg bd—2-6
yrs.but less than 2 years ½ tsf bd/2.5 ml bd.----7-14days.

+
NORSOL/HAPPYSOL nasal drop----1-2 deops in each nostril 8 hourly.----2 wks
+/-
Syp. Zithrin (200 MG/5 ml)-----10 mg/kg/day---------------once daily.
+/-
Syp .precodil (prednisolone) 15 mg/5 ml----o.5-1 mg/kg/day----bd---7 days.
+/-
Nebulization with (Ventolin+IPREX+Normal saline)-----------stat & sos.

In severe cases/recurrent cases:

Syp.Thenglate ( 120 mg/ 5 ml)-----5-10 mg/kg/day----mixed with honey.---2 wks.
 Hospitalization:
 Poor feeding
 Cyanosis
 Convulsion
 If there is no improvement.
 30.ORAL CANDIDIASIS
 DIAGNOSTIC CLUE:
 Thick white patches on an erythematous base in the oral mucosa.

 TREATMENT:
Nystat/Candex (nystatin) drops----10-15 drops applied to each side of the -
mouth----8 hourly-----7-10 days.
or
Gelora Oral Gel(miconazol 2%)-----apply locally 3 times/day---7 days.
 31.COMMON COLD
 DIAGNOSTIC CLUUE:sore throat,nasal congestion,rhinorrhea,cough.

 Treatment:
Syp.Pedeamin/Syp.Adryl/Syp.Fexo(30 mg/5 ml)------bd--------7-14 days.
+/-
Syp. Moxacil (125 mg/5ml)-----40-45 mg/kg/day-----Tds--------7 days.
+
Norsol nasal drop--------same as before.
+
Syp.Honeybas-------1 tsf BD---------2 WKS.

 ADV: CXR P/A View.came for F/U.

 32.CONSTIPATION
 TREATMENT:

SYP.Avolac(lactulose)-----2.5-10 ml/day(may increased)----bd/tds---stop when

stool becomes nomal consistency.
or
Syp. Magfin (liquid paraffin+magnesium hydroxide)----5-10 ml at bedtime/bd.
+/-
Suppository Glysup 1.15gm----2/3 into the rectum stat & sos.
 33.EXCESSIVE CRYING & Abdominal
distention & INSOMNIA
 Treatment:
Tab.Barbit (phenobarbitone) 30 mg-----3-5 mg/kg/day--------1 month.
+
Gasnil/lefoam paed.drop(simethicone)67 mg/ml
< 2 years-----0.3-.5 ml 4 times daily
2-12 years----0.6 ml 4 times daily
>12 years----0.6-1.2 ml 4 times daily

 Came for F/U After 1 wks.

 34.CHICKEN
POX/MUMPS
 DIAGNOSTIC CLUE:
Vesicular Eruption
Fever
New lesion—every 2-4 days.

 TREATMENT:
Syp.Napa ----1 tsf 4 times daily/Tab.Napa------1+1+1+1-----7 days.
+
Syp.Cefaclav (cefuroxime+clavulanic acid) ---20-30 mg/kg/day bd.—7 days
or
Syp.Cef-3 (cefixime)----8 mg/kg/day-----------7 days.
+
syp. Fenadin/Pedeamin-------1 tsf bd-----------2 wks.

+
Calamine lotion (calamine 15%+ Zinc oxide 5%)----apply bd----1-2 wks.

 IN CASE OF MUMPS-----Same treatment except Calamine lotion.

 35.DYSENTRY
 TREATMENT:

SYP.Ciprocin (250 mg/5 ml)– 20-40 mg/kg/day------12 hourly-----5 days.

+/-
Syp.Amodis (200 mg/5 ml)----15-30 mg/kg/day----tds---------3 days.
+/-
syp. Zofra (ondansetron)(4 mg/5 ml)----- 8 mg/day-----1/2 ot 1 tsf tds B/M-----5 days
 36.SEVERE DIARRHOEA
 TREATMENT:
Same to dysentery
+
syp. Xinc (10 mg/5ml)
2-6 month-------10 mg—once daily---14 days.
>6 month-------10 mg--------bd--------14 days.
+/-
ORS
 Ensure Exclusive breast feeding.
 Avoid artificial feeding.
 37.HOOKWORM
INFESTATION.
TREATMENT:

SYP.ALMEX ( Albendazole) 200 mg/ 5 ml---15 mg/kg/day----repeat after 7 days.

or
syp.SOLAS (mebendazole) 100 mg/5 ml----1 TSF ---BD----3 days.may be
repeated after 1 month if not controlled.

Advice :Don’t prescribe before 2 years of age.

 38.DOG BITE
 TREATMENT:
INJ. Rabix-VC 2.5 IU------I amp I/M on- –day 0, 3,7,14,& 28 days.---post exposure.

pre exposure----- day---0 , 7 ,21 , 28 followed by booster I year later.

 39.LOSS OF APPETITE+ DECREASED GROWTH

 TREATMENT:

COUNSELLING+ REASSURANCE
+
SYP.Vitagrow (multivitamin with cod liver oil)—1 tsf bd/tds---1 month.
+/-
Tab.Folison 5 mg-----0+0+1----------1 month.
+/-
Cora –DX-Vita------1 tab mixed in 1 glasses of water--------1 month.
+/-
syp./tab.solas 100 mg---------bd--------------3 days.
 40.ENTERIC FEVER
 Diagnostic clue:
 High grade fever > 7 days.
 Malaise,headache,vomiting,cough,bodyache
 Coated tongue
 Bradycardia---+/-
 CBC and BLOOD C/S evidence.

 TREATMENT(:In Children)
inj. Ceftron (ceftron) 1 gm----100 mg/kg/day------10-14 days.
+/-
syp. Paracetamol
+/-
syp. Emistat (4 mg/5 ml)----4-8 mg
+
Syp. Xinc (10 mg/5 ml)
< 6 month---- 1 TSF for 14 days.
>6 month----1 TSF for 14 days.
In case of Adult----inj. Ceftron 2 gm ----bd--------------------------14 days with paracetamol
+/-
Tab. Revital 32 ----1+0+1------------1 month.
 41.SEVERE DIARRHOEA NOT RESPONSIVE TO
CONVENTIONAL TREATMENT
 TREATMENT:
Cap.Tetrax ( Tetracycline) 500 mg----1+1+1+1------7 days.
+/-
ORS,Coconut water.

 Better to refer---hospitalization.
RESPIRATORY SYSTEM
 42 .COUGH & COMMON COLD

 TREATMENT:
Tab. X Pa XR 665 MG-------1+1+1------7-10 days.
+
Afrin nasal drop .o5% (oxymetazoline)---1-2 drops at each nostril---bd---7 days.
+
Tab.Sardin 120 mg-------0+0+1--------------7 days.
+
Tab.Sinecod SR 50 mg(butamirate citrate)-----1+0+1-----------7 days.(DRY)
0R
Cap.Lytex SR 75 mg (Ambroxol HCL)----------bd/tds------------7 days.
or
Syp.DEXPOTEN PLUS (dextromethorphan+phenylephrine+triprolidine HCL)
2-3 tsf----tds----7 days.
or
Tab/ syp MUCOLYT(bromohexine HCL)/SYP. Mirakof ------2 TSF—TDS---7 days.

 ADVICE: Take plenty of luke warm water+lemon tea/tulsee tea/gingiver Tea.

 VACCINATION.
 43.Sinusitis
 DIAGNOSTIC CLUE:
 Nasal congestion
 Facial pain—sinusoidal area
 Fever+/-
 Loss of smell.

 INVESTIGATION:
 CBC
 X-RAY PNS OM View.

 TREATMENT:
Tab.Longpara 665 mg-----------1+1+1--------------2 wks.
+
Afrin Nasal DROP/Antazol Nasal dro---------------2 wks
+
Tab. Fenadin 120 mg---------------0+0+1-----------2 wks.
+
Tab.Tyclav 625 mg(Amoxycillin+ clavulanic acid)---bd/tds-----7 days(if
symptoms persist for more than 5 days)
or Tab.Trevox 500 mg( levofloxacin)---1+0+0--------7 days.
 44.ASTHMA/COPD
 DIAGNOSTIC CLUE:
 Chest Tightness
 Wheeze
 Breathlessness
 Cogh,ronchi positive
 Vesicular with prolonged expiration

 Investigation:
1.CBC
2.CXR P/A View
3.ECG
4.PEFR+SPIROMETRY IF POSSIBLE.

 TREATMENT:
Tab.BRODIL (salbutamol)-----1+1+1--------4-wks/when required
or
windel DPI ---1 capsule to be inhaled with Bexihaler SOD-----to be continued.
+/-
Ticamet 250 cozycap (salmeterol+fluticasone)----same------to be continued.
 +/-
Tab.Monas( montelucast) 10 mg/Tab.Contine (Theophyline)400 mg-------0+0+1---
----continued.
+/-
Tab.Fexo 120 mg-----0+0+1----------1 month.
+/-
Tab.Cortan (prednisolone) 20 mg------2+0+0----7 days.

 U Can use INHALER----AZMASOL (salbutamol)---2 puff tds—sos/continue depending

on the severity. +
Inhaler ----Bexitrol F 25/250----------2 Puff BD----Continue(gurgle with water
after 10 min).

 IN COPD: (see the signs of Respiratory failure)

INHALER/Iprasol DPI (Salbutamol+ipratropium bromide)—SOS/To be continued.
+
Tioriva Bexicap 18 mcg(Tiotropium) DPI-----BD----Continued.
+
Tab. Docopa (Doxyphylline) 200 mg----1+0+1---Continue.
+/-
Tab.CORTAN 20 mg/Tab.Monas 10 mg+Anti ulcerant.
 45.CAP
 Diagnostic clue:
 Fever
 Unilateral chest pain
 Braethlessness,cough,sputum production.
 Past H/O TB,COPD,Asthma

 Do the G/E & Respiratory system Examination.(Bronchial breath sound),Creps

present in Resolution phase.

 Investigation:Baseline+Exclude TB.+CURB-65.

 TREATMENT:
Tab. Moxaclav 625 mg----1+1+1--------10-14 days.
or
Tab.Cefotil Plus 5oo mg---1+0+1-------10-14 days.
+/-
Tab.Clarin (Clarithromycin) 500 mg-----1+0+1----2 wks.
+
Tab.napa 500 mg tds+Anti ulcerant.
 46.HTN
 TARGET:
Age < 80 years-----< 140/90 mmof Hg
Age > 80 years------ < 150/90 mmof Hg
With CKD/DM---------< 130/80 mmof Hg

 TREATMENT:(AGE < 55 YEARS).

Start with Tab.Losart 50 mg (ARB)---0+0+1-------continue
next
Tab.Bizoran 5/20 or 5/40 (ARB+ Ca Channel Blocker)0+0+1----continue.
next
Tab. Angilock 50 /100plus(ARB+DIURETICS)+Tab.Amdocal(ca channel-) 5/10 mg1+0+0-
--continued.
next
Refer to specialist.

IF AGE > 55 YEARS----Start with Ca Channel blocker+otherwise ok.

 INVESTIGATION:Renal function test+Thyroid function test+ECG+ECHO+RBS+LIPID

PROFILE+Urine R/E.
 HTN with special situations:
 HTN+Heart failure-----ARB+DIURETICS.
Tab. Olmecar plus (olmesartan+hydrochlorothiazide) 20/12.5—1+0+1----
continued.
 HTN+Angina-----Tab. Cardinor 2.5/5 mg(bisoprolol)/Tab.Amdocal 5/10 mg—
1+0+0—cont.
 HTN+DM--------ACE Inhibitor/ARB.
 HTN+CKD--------ACE Inhibitor/ARB.
 HTN+BPH--------Tab. Alphapress (prazosin)1 mg/2 mg------1+0+1----continued,
 HTN+Asthma-----Avoid Beta blocker,Ca Channel blocker.

 Isolated systolic HTN:(Systolic BP > 160 mmof Hg)—Drug of Choice in order.

1.diuretics .
2.Beta blocker.
3.diuretic+beta blocker.
4.diuretic+CCB
5.ACE inhibitor+CCB.
 47.CHRONIC STABLE ANGINA
 DIAGNOSTIC CLUE:
 Occasional central chest pain
 Chest discomfort,breathlessness
 Past H/O—HTN,DM,IHD.

 DO baseline investigation(ALL) +ETT.

 TREATMENT:
Tab. Ecosprin 75 mg-----0+1+0-----A/M-----continued.
+
Tab.Rosuva (Rosuvastatin) 5/10 mg----0+0+1-----B/M----continued.
+
Tab.Nitrin SR(GTN) 2.6 mg----1+1+0--------------------continue.
+
Tab. Betaloc (Metoprolol) 25/50 mg----1+0+1--------continue.
+
Cap.Sergel (Esomeprazole) 20 mg------1+0+1--------B/M—Continue.

 ADVICE;as usual.Refer---if unstable angina/Rapidly progressive symptoms.

 48.Acute viral hepatitis
 Treatment :

Full bed rest+Drink boiled/filter water+Avoid Constipated Food.

+
Tab.Efodio (Domperidone) 10 mg----1+1+1---b/m-----2 wks.
+
syp.Avolac (lactulose) –15-30 ml TDS--------7 DAYS.

If There is deep jaundice----Inj.Konakion (Vit-k)---1 amp I/M stat and daily for 5 days.
+
if-itching----Tab.Ursocol (Ursodeoxycholic acid) 150 mg----1+0+1----2-3 wks.

 INVESTIGATION:

Liver function test+viral markers.

 49.FATTY LIVER
 TREATMENT:
Tab.Heplol 150 mg (L-ornithine+L-Aspartate)---1+0+1--------1 month.
or
Hepagurd Powder--- 1-2 sachet in large amount of water---1 month
+/-
Cap.Omesoft 1gm----1+0+1--------3 month.
+/-
Tab. Uliv (Ursodeoxycholic acid) 150 mg----0+0+1-------3 month.

 Advice:
 Lifestyle modification.+Fibroscan+LFT+RBS+LIPID profile.
 50.PUD
 DIAGNOSTIC CLUE:
 Recurrent Upper Abdominal/Epigastric pain
 Relationship with food.
 Episodic occurrence.

 H/O SMOKING,Alcohol intake,NSAIDs,Steroid.

 INVESTIGATION:UPPER GI ENDOSCOPY.

 TREATMENT:
Tab.Helicon Kit (Amoxicillin+Clarithromycin+lansoprazole )—1 strip BD—14 days.
then
Cap.Eprazol 40 mg ----1+0+1-----b/m------2-3 month.
+/-
Tab. Domiren 10 mg-----1+1+1-----B/M-----2 WKS.

 ADVICE:
 Regular meal
 Stop smoking
 Avoid fast food.
 51.NUD
 DIAGNOSTIC CLUE:
 Discomfort,bloating,nausea
 H/O –NSAIDs,Steroid,Potassium,Digoxin,alcohol,smoking.

 INVESTIGATION:Upper GI Endoscopy.(If alarm features.)

 TREATMENT:
TAB. DOMIN 10 mg-----tds---b/m----15 days.
+
Tab. Rabe-20 mg-------bd------b/m---15 days.
+/-
Tab. Triptin 10 mg----0+0+1-----------15 days.
 52.HICCUP
 TREATMENT:

Tab.Beklo 5-10 mg------1+1+1----------2 days.

+/-
Tab.Motilon (metoclopramide)10 mg----1+1+1------2 days.
+/-
Tab.Largactil(Chlorpromazine) 25/50 mg-----1+1+1---3-5 days.

 Reassure the Patient.

 53.APTHOUS ULCER
 TREATMENT:

Kenalogue in orabase cream 0.1%( Triamcenolone)----apply locally TDS----7 DAYS.

0R
Trialon 0.1% cream--------same.
+/-
Oralon (Chlorohexidine) 0.2% mouth wash -----mixed with water gurgling---tds—7 days.
 54.IBS
 DIAGNOSTIC CLUE:
 Recurrent upper abdominal pain
 Improved with defecation
 Change in form & frequency of stool

 Investigation: CBC,CRP,RBS,SGPT,CREATININE,USG W/A,TSH,COLONOSCOPY—IF

>40 YRS.

 TREATMENT:(For pain+bloating)
Tab.Mave/Rostil SR(Mebeverine HCL) (200 mg)----1+0+1------b/m---continue.
+
Tab.Leanxit (Flupenthixol+Melitracen)----------0+0+1/1+0+0------------continue.

 If diarrhea predominant: Tab.Rifagut (Rifaximine) 550 mg---1+0+1-----2-3 wks.

+
Tab. Amit 25 mg-------0+0+1-------continue.
 if Constipation predominant:
syrup. Avolac/ cap.lubilax 8 mcg/16 mcg-----bd/tds----till constipation
persist.
 DIETARY ADVICE: Mainstay of Treatment.
 55.GERD
 DIAGNOSTIC CLUE:
 Heartburn
 Waterbrash---mouth fills with saliva.
 Reflux to acid into the mouth.
 Nausea,vomiting
 Nocturnal cough.

 Endoscopy of Upper GIT----If required.

 TREATMENT:
SUSP. Gaviscon (Na Alginate+sodium Bicarbonate+calcium carbonate)---2 TSF
TDS----15 Days. +
Tab.Efodio 10 mg -------------1+1+1------b/m----------15 days.
+/-
PPI (20 mg)-----bd----------15 days.

If esophagitis at endoscopy----Double dose of PPI.

IF QUALITY OF LIFY---impaired----Referred to surgery----for laparoscopic anti reflux

surgery.
 56. ANAL FISSURE
 Diagnostic Clue:
 Severe pain on defecation-sharp/cutting/tearing.
 Bleeding is usually small
 Pruritus.

 INVESTIGATION: CBC,RBS.
 TREATMENT:
Tab. Torax (ketorolac) 10 mg---1+1+1-----a/m------5-7 days with PPI—BD.
+
CAP.Traxyl (Tranexamic acid) 500 mg---1+1+1-----5-7 days if bleeding.
+
cap.Lubilax 24 mcg------1+0+1-----15 days.
+
Erian ointment (cinchocaine+hydrocortisone+framycetin sulphate+esculin)
apply locally before defecation./RECTOCARE ointment(GTN 0.4%)
+
HIP Bath with POVIDONE IODINE solution---daily for 30 min –30 days.

 Take plenty of water+dietary fiber.

 57.PILES
 DIAGNOSTIC CLUE:
 TREATMENT:
Same as anal fissure
+
Tab. Normanal ( diosmin+Hesperidin)
2+2+2-----4 days,2+0+2----3 days,1+0+1------3 month
+
Cap.Cefixime 400 mg---1+0+1----7 days.
+
Tab. Metro 400 mg-----1+1+1-----5 days(after meal).

 IF SERIOUS-----REFERRED TO SURGERY.
 58.HERPES ZOSTER
 DIAGNOSTIC CLUE:
 Burning discomfort in affected dermatome.
 Discrete vesicles appearing 3-4 days later.
 Past H/O ---Chicken pox.

 TREATMENT:
Tab.Revira (Valacyclovir) 1 gm---1+1+1--------7 days.
+
Tab. Amilin 25 mg----------0+0+1---------------7 days.
+
Tab.Gabapen 300 mg-----1+0+1-------------3-4 wks.
+/-
cap. Pregaba 75 mg ------1+0+1-------------3-4 wks.
+/-
voltaline suppository (Diclofenac sodium)----SOS.
+/-
Cap.Cefixime 200 mg ----1+0+1--------------7 days.
 59.UTI
 DIAGNOSTIC CLUE:
 Dysuria
 Suprapubic pain
 Intense desire to pass urine during & after voiding
 Cloudy/red urine.
 H/O DM.

 INVESTIGATION:URINE R/E,Urine C/S,USG of KUB, CBC with ESR.

 TREATMENT:
TAB.Rutix ( Ofloxacin) 400 mg----1+0+1------7-10 days.
or
Tab. Nintoin SR (Nitrofurantoin) 100 mg----1+0+1----3 days in female/10 days in male.
or
Tab.Roxilab plus (cefuroxime+clavulanic acid)---1+0+1------7 days.

 ADVICE.
60.CKD

DISCUSSION.
 61.BEP
 DIAGNOSTIC CLUE:
 Sensation of incomplete voiding
 Frequency,urgency,hesitancy,urge incontinency.

 Inv :USG of KUB with PVR,S.Creatinine.

 TREATMENT:
PROSTATE< 30 gm----Cap. Uromax 400 mcg---0+0+1---may be increased upto
800 mcg if response is inadequate.-----continued.

PROSTATE > 30 gm----Cap. Uromax D (tamsulosin+Dutasteride)----0+0+1---

continued.

 ADVICE:
 Reduction of evening fluid intake.
 Reduction of caffeine intake.
 Bladder retraining & prevention of constipation.
 62. MECHANICAL BACK PAIN
 DIAGNOSTIC CLUE:
 Pain improved with rest.
 No clear cut nerve distribution.
 No systemic features.

 INVESTIGATION:PLAIN X –RAY of the affected region .

 TREATMENT:
Tab.Naprosyn( Naproxen) 500 mg----1+0+1------7-10 days.
+
Antiulcerant.

 Advice for physiotherapy.

 63.OSTEOARTRITIS

 DIAGNOSTIC CLUE:
 Usually old age
 Pain in knee/hip joint
 Insidious,Intermittent
 Mainly related to movement & weight bearing.

 Examination :
 Joint line tenderness.
 Creps.
 Restricted movement of the affected joint.

 INVESTIGATION:
 X-RAY Of the involved joint.

 Advice :see the page.

 TREATMENT:
Tab.Naprosyn 500 mg-----1+0+1---2 wks—A/M---with Antiulcerant.
+
Tab. Calcium +vit-D (Calbo-D)---1+0+1------3 -6 month.
+/-
Tab. Cartilage plus (Chondroitin+glucosamine)----1+0+1-----1-2 month.
+/-
Intra-Articular inj.Triamcenolome 0.1% mixed with 2% lidocaine.---(if severe)

 Regular Exercise.
 64. RA
 DIAGNOSTIC CLUE:
 Pain & swelling of small joints of the hand.
 Morning stiffness.
 Deformity +/-
 Anorexia ,weight loss ,fatigue.

 INVESTIGATION:CBC with ESR,CRP,RA.Anti CCP Ab,SGPT,RBS,S.creatinine,ECG,X-

RAY of the affected joint.

 TREATMENT:
Tab. MTX (methotrexate) 10 mg ---1.5 tab every Friday ---continued.
(can be increasd 5 mg in every 2-3 wks upto 25 mg/week)
+
Tab. Folison (folic acid) 5 mg----1 tab.every Saturday---continue.
+
Tab.Precodil 10 mg ----3+0+0---2 weeks,2.5+0+0------2 weeks,2+0+0-----2
weeks,1.5+0+0-----2 weeks,1+0+0------2 weeks,0.5+0+0-----2 weeks.

IF PAIN IS SEVERE---Tab.Indomet SR ---1+0+1-----(A/M)---3-4 WKS can be added.

 Came for follow up after 1 month with ---CBC,SGPT,S.Creatinine report.
 65.SORE THROAT
 DIAGNOSTIC CLUE:
 Pain/discomfort in throat.
 Difficulty in swallowing
 Fever
 Dry cough
 Hoarse/less voice

 TREATMENT:
 Cap. Cefotil plus 250/500 mg----1+0+1------7 days.
or
Tab.Levoxin (levofloxacin) 500 mg-----0+0+1----7 days.
+

Tab. NAPA EXTEND 665 mg----1+1+1------3-5 days if pain/fever.

 ADVICE:Gurgle with luke warm water.

 66.ACUTE TONSILITIS
 DIAGNOSTIC CLUE:
 Pain in the throat aggravated on swallowing
 Fever & malaise.
 Enlarged tonsils.
 Enlarged & tender jugulodigastric lymph nodes.

 TREATMENT:
Tab. Moxaclav 625 mg----1+0+1------7 days.
+
tab. Fenadin 120 mg-----0+0+1------7 days.
+
Tab.X PA XR 665 mg-----1+1+1------if pain/fever.

 RECURRENT: TONSILLECTOMY.
 67.ACUTE CONJUCTIVITIS
 TREATMENT:
Dextrobac eye drop(Tobramycin +dexamethason)---1 drop in affected 4 times
daily----10 days.
or
A Phenicol eye drop( chloramphenicol)-------same as before.
OR
Eyemox-D Eye drop (moxifloxacin+dexamethasone)-----same.
+
Tobracin eye ointment----apply on the eye at night.----10 days.
+
Tab.Atrizin (Cetirizine HCL)------0+0+1----------10 days.

 ADVICE: wear sun glasse,clear eye with water before application of drug.
 68.EXCESSIVE LACRIMATION
 TREATMENT:

Lopadin 0.1% eye drop(olopatadin)----1-2 drops in each eye---4 hourly----15 days.

+
Tab. Avil 22.7 mg ( pheniramin maleate)----0+0+1---15 days.

 ADVICE.
 69.STY/INFECTED CHALAZION

 TREATMENT:
Remove eye lashes from the affected side.
+
Cap.Flux (flucloxacillin)500 mg---1+1+1+1------7 days.
+
Tobracin (Tobramycin )eye ointment----before sleep—15 days.
+
Tab.X PA XR 665 mg-----1+1+1-----if pain.

 ADVICE.
GYNAECOLOGY
 70.LEUCORRHOEA
 DIAGNOSTIC CLUE:
 P/V Discharge---Non irritating,Non foul smelling,Usually increases before & or after
menstruation.

 INVESTIGATION:
 VIA----If < 30 years.
 RBS----If > 30 years.

 TREATMENT:
Tab.Opsovit-Z (Vitamin B complex+zn)----0+0+1-----3 month
+
Tab. Secnid DS (Secnidazole) 1 gm-------1+0+1--------1 day.
+
Cap. Flugal (fluconazole)150 mg-----1 tab weekly ------for 6 wks.

 ADVICE:
1.Take plenty of water.
2.Maintain good personal hygiene.
3.Use cotton undergarments.
4.Wash private parts with luke warm water.
5.Assure that it’s a normal physiology.
 71.VAGINAL CANDIDIASIS
 DIAGNOSTIC CLUE:
 P/V Discharge ----irritating & Foul smelling.

 INVESTIGATION:sss
 VIA
 URINE R/E,FBS,2 Hour ABF.
 TREATMENT:
Gynomix Vaginal suppository(metronidazole+neomycin sulphate+Nystatin+polymixin B )-
------------1 Stick P/V at night------12 nights.
+
Tab.Neofloxin 500 mg---1+0+1------7 days.
+
Tab. Secnid DS 1 gm-----1+0+1-------1 day.
+
Cap.Nispore 150 mg-----1 tab weekly-----6-8 wks.
+
Tab.sardin 120 mg -----0+0+1------------1 month.
+/-
Topicazole plus/Unigal HC (Hydrocortisone 1%+Miconazole 2%)------apply locally for 14
days if irritation persist.
 ADVICE:Same as leucorrhoea.
 72.PID
 DIAGNOSTIC CLUE:
 Lower abdominal pain
 Fever
 P/V discharge

 INVESTIGATION:
 URINE R/E
 USG of W/A
 FBS,2 Hour ABFs
 VIA if > 30 years.

 TREATMENT: Cap.Doxycap (Doxycycline) 100 mg---1+0+1----14 days

+
Tab.Ornid(ornidazole) 500 mg-------1+0+1-----5 days.(A/M)
+
Tab.Tynium/Viset (Tiemonium Methylsulphate) 50 mg---1+1+1---B/M---If pain
persist. +
Tab.X-PA XR 665 mg---1+1+1+1------if fever.
+
Tab.Pantonix 20 mg ------1+0+1---------14 days.
 73.ANTENATAL VISIT
 DIAGNOSTIC CLUE:
 Amenorrhoea/Pregnancy for ----weeks.

 Investigation at 1st Visit:

 CBC
 Thyroid function test.
 Blood grouping & Rh typing.
 HBsAg,VDRL,RBS.
 Urine R/E.
 USG of lower Abdomen.
 Then U can Refer The patient to a Gynaecologist.

 TREATMENT:(Before 12 weeks of pregnancy)

Tab.Zifolet (Zinc+folic acid)-----0+0+1--------continue.

 After 12 weeks of pregnancy:

Tab.Ipec plus (Iron+folic acid+zinc)----1+0+0------continue.
+
Tab.V-PLEX (B-complex)---1+1+1-----continue.
+
Tab.Calborate (calcium orotate) 740 mg---0+1+0 ---------continue.
 +
Tab. Pantonix 20 mg ------1+0+1----if acidity occurs.

 ADVICE:

1.Avoid travel,heavy exercise,coitus in first & last trimester.

2.Eat fresh fruits & vegetables.
3.Follow up after 2-3 months or at 24 weeks.
4.At least 4 visits----1st within 16 weeks.
2nd within 24-28 weeks.
3rd at 32 weeks.
4 th at 36 weeks.

5.In Every visit----Do, Urine R/E,HB%,RBS,USG of the lower Abdomen.

 74.UTI IN PREGNANCY
 DIAGNOSTIC CLUE:
 Seeing the urine report.
 Burning sensation of micturition+/-renal angle tenderness+/-suprapubic
tenderness.

 INVESTIGATION: URINE R/E,URINE C/S, USG OF KUB,CBC with ESR.

 TREATMENT:
Tab. Clavucef (cefuroxime+clavulenic acid) 500 mg-------1+0+1------7 days.
or
Tab. Nintoin(Nitrofurantoin) SR (100 mg)------------------1+0+1-------7 days.

 ADVICE.
 75.PG with LOWER ABDOMINAL PAIN

 DIAGNOSTIC CLUE:
 Hearing the history.

 Just do a USG of lower abdomen for patient satisfaction.

 TREATMENT:
Tab.Algin 50 mg------1+1+1------B/M------3 days.

If not improved within the 3 days-----referred to a gynaecologist.

 76.PG with ANAEMIA
 DIAGNOSTIC CLUE:
 CBC Report.
 Slight PV bleeding.

 TREATMENT:
 IF Hb < 6 gm/dl--------blood transfusion.
 If Hb 6-8 gm/dl---------inj. Xenofer (Iron sucrose) 100 mg/5ml---2 amp IV 15
Drops/min stat & repeat after 1 week.

 If Hb > 8 gm /dl --------Tab. Ipec plus ( iron+folic+zinc)----1+0+0-----continue.

+
Tab. Bicozin (Vitamin B complex+zn)---1+0+1------continue.
+
Tab.Mom vit plus (multivitamin+multimineral)---0+0+1-----continue.

 ADVICE:
 Eat iron containing food.
 Eat fresh meat,milk.
 Repeat Hb% after 2 wks.
 77.PG with DIARRHOEA
 TREATMENT:

Tab.Zimax (Azithromycin )500 mg-----0+1+0-----7 days.

+
ORS (after each purging)
 78.PG with Nausea & Vertigo
 TREATMENT:

Tab. Vertina plus (Meclizine+pyridoxine)----1+0+1-----7 days.

+
Cap.Omep -20 mg-----1+0+1-----B/M-------7 days.

 ADVICE:
 Take Adequate rest.
 Reassurance.
 79.PG with Common COLD
 DIAGNOSTIC CLUE:
 Runny nose,Sneezing,cough.

 TREATMENT:
Tab. Fenadin 120/Rupa 10 mg-------0+0+1-----10 days.
+
Tab. Montela 10 mg/Trilock 10 mg-----0+0+1-----10 days.

 ADVICE:
 Avoid exposure to cold,dust.
 Wearing sandle in tiles floor.
 Avoid cold water.
 Avoid shower at the end of the day.
 80.PRURITUS VALVAE
 TREATMENT:

A-Fun cream (clotrimazole)------apply at affected area twice daily----7 days.

+
Syp.Alben ---1 TSF ----bd----3 days.
+
Syp.PEP-2 (Zinc sulphate monohydrate)----1 TSF -----Once daily ---1 month.
 81.PG with HTN
 DIAGNOSTIC CLUE:
 HTN after 20 wks----G.HTN.
 BP > 140/90 mmof Hg.

 INVESTIGATION: Urine R/E.

 TREATMENT:
Tab.Sardopa (Methyldopa) 250 mg------1+0+1-----continue.

IF not Controlled within 1 week---

Tab. Sardopa 250 mg---------2+2+2----------continue.

IF not controlled,
Add---Tab.Nifedipine 20 mg-----1+0+1-----continue.

If not controlled----referred to the Gynaecologist/hospital.

 82.DYSPAREUNIA
 TREATMENT:

KY jelly------before each coital act.

 ADVICE:
 USG of W/A
 VIA.
 83.POST PONDING MENSTRUATION
 DIAGNOSTIC CLUE:
 PT.wants to post-pond her menstruation for certain period of time.

 TREATMENT:
Tab.Norestin (Norethisterone) 5 mg------1+1+1----start from 3 days before
estimated date of nenstruation & continue till desired period.

or
Tab. ROSEN 28 ------0+0+1------Continue without iron pill till desired period.
 84.IRREGULAR MENSTRUATION
 DIAGNOSTIC CLUE:
 Taking the History
 Weight gain/loss.

 TREATMENT:
Tab.Normens(Norethisterone) 5 mg ----1+1+1----21 days----then stop for 7 days
then again same cycle for 3 month.
+
Cap.Zeefol CI (Carbonyl iron+folic acid+zn)----0+1+0-------3 month.
+/-
Tab. Comet ( Metformin HCL)---------1+0+1---------continued.(for weight reduction)

 PV BLEEDING FOR 10 DAYS :

Same Treatment+cap.Traxyl 500 mg 1+1+1----5-7 days.

85.THANK YOU ALL