Practical Prescriber PDF

Practical Standard
Prescriber
Practical Standard
Prescriber
Seventh Edition
LC Gupta MD FAMS DSc (Hon)

Kusum Gupta PhD (Hon)
Abhitabh Gupta MD DMRE
New Delhi, India
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Practical Standard Prescriber

© 2009, LC Gupta, Kusum Gupta, Abhitabh Gupta
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in
any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written
permission of the editors and the publisher.
This book has been published in good faith that the material provided by contributors is original. Every effort
is made to ensure accuracy of material, but the publisher, printer and editors will not be held responsible for
any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition: 1984

Sixth Edition: 2001
Reprint : 2002, 2004, 2005, 2007
Seventh Edition: 2009
ISBN 978-81-8448-550-9
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd. NOIDA
To
Revered Sh RC Lahoti
Ex-Chief Justice of India
who helped and guided us
at every turning point of life
Contributors
• Abhishek Gupta MD DRM DNB MNAMS
DIFI Centre, New Delhi
• Jawahar Jain MBBS MBA DSc (Hon)
Delhi University
• Lakhpat Lodha MD
Medical College, Jodhpur
• PK Pande MD
LNPPI, Gwalior
• Parul Gupta MBBS
Jhansi
• Preeti Gupta MBBS DGO
Gwalior
• Priya Verma MDS
New Delhi
• Puneet Rastogi MD DM
Medical College, Gwalior
• Sekhar Jaiswal MBBS
Srinagar
• Sheevi Rastogi MBBS DGO
Gwalior
• Sujata MS Mch DNB
Safdarjung Hospital, New Delhi
• Vandna Mangal MD
Medical College, Jaipur
Preface to the Seventh Edition
This revised seventh edition of Practical Standard

Prescriber, owes to the popular demand of students,
residents and general practitioners. Jaypee Brothers
Medical Publishers (P) Ltd. is proud to present this in its
continuing efforts to serve the medical profession.
Treatment part has been totally revised and updated.
Certain new diseases have also been included.
LC Gupta
Kusum Gupta
Abhitabh Gupta
Preface to the First Edition
The drug world is expanding at a very fast pace. New

drugs are continuously being added and obsolete ones
are withdrawn. Age old regimens which once enjoyed
mass acceptance and reputation are being replaced with
newer concepts. A busy practitioner or a new incumbent
to the profession should keep himself abreast of these
developments and reorient himself to the changing
circumstances. Drug resistance is frequently being
encountered and is the main cause of treatment failure.
In this small work, attempt has been made to enumerate
the standard drugs to be prescribed for a particular
disease. In case of intolerance or drugs resistance,
alternative regimens are also inserted. However, the
choice of drugs depends upon the treating physician.
Over prescription is certainly to be avoided and drug
abuse is to be kept at minimum.
Doctor shopping is a common feature of the present
time. Readymade prescription is available across the
counter from mini modified doctors and there is no
need to present the patient before the doctor. Such a
trend is certainly hazardous.
Correct dosage, duration of therapy, contrain-
dications, adverse reactions, drug interactions, side
effects and toxicity should be kept in mind while writing
a prescription. The economic status of the patient and
xii Practical Standard Prescriber
his occupation should be given due consideration.

Ailments which are otherwise innocuous and self-
limiting should be handled tactfully. For reaching at a
correct diagnosis, the cardinal symptoms, signs,
pathologic and laboratory findings are also incorporated
in this book. However, correct diagnosis is left to
ingenuity of the prescriber.
In a developing country where many people are
below poverty line with high illiteracy rate, one may
find it extremely difficult to afford costly medicines for
miraculous cure, or discriminate between safe and
dangerous drugs. They wholly and fully depend upon
the prescriber who may be a doctor, a quack or a friend.
Under such circumstances the cheap, effective and
harmless medicines are to be tried first rather than
jumping to the newer and less known products.
Aggressive marketing and unabated advertising
through mass media by some drug manufacturers to
push their product creates confusion and dilemma in
the minds of innocent consumers. Some products
without a rational basis become the household remedy
and every home possess them. Such practice is certainly
detrimental to the ethics of medical profession.
LC Gupta
Contents xiii
Contents
GASTROINTESTINAL DISEASES
1. Achalasia Cardia ..................................................... 1
2. Acute Cholecystitis ................................................ 2
3. Acute Gastritis ........................................................ 3
4. Acute Mesenteric Lymphadenitis ....................... 4
5. Acute Mesenteric Vascular Occlusion ................. 5
6. Acute Organic Small Bowel Obstruction ............ 6
7. Acute Pancreatitis .................................................. 7
8. Alcoholic Hepatitis ................................................. 8
9. Amoebiasis ............................................................ 10
10. Anal Fissure .......................................................... 11
11. Aphthous Stomatitis ............................................ 12
12. Appendicitis .......................................................... 13
13. Bacillary Dysentery ............................................. 15
14. Botulism ................................................................. 16
15. Cancer Colon ........................................................ 17
16. Cancer Oesophagus ............................................ 17
17. Candidiasis (Thrush) ........................................... 18
18. Carcinoma of Liver ............................................. 19
19. Carcinoma of Stomach ....................................... 20
20. Choledocholithiasis ............................................. 21
21. Cholera .................................................................. 22
22. Chronic Cholecystitis .......................................... 23
23. Chronic Gastritis .................................................. 24
24. Constipation ......................................................... 25
xiv Practical Standard Prescriber
25. Diverticular Disease of Colon (Diverticulosis) 26

26. Dumping Syndrome
(Post-Gastrectomy Syndrome) .......................... 27
27. Duodenal Ulcer ..................................................... 28
28. Gastric Ulcer .......................................................... 30
29. Haemorrhoids ...................................................... 31
30. Herpetic Stomatitis .............................................. 32
31. Hiccup .................................................................... 33
32. Intestinal Tuberculosis ........................................ 34
33. Irritable Bowel Syndrome .................................. 35
34. Nausea and Vomiting ......................................... 37
35. Nodular Cirrhosis ................................................ 39
36. Non-Specific Ulcerative Colitis .......................... 41
37. Paralytic Ileus (Functional Obstruction) .......... 44
38. Peptic Oesophagitis ............................................. 45
39. Primary Biliary Cirrhosis .................................... 46
40. Rectal Polyp .......................................................... 47
41. Regional Enteritis (Crohn’s Disease) ................ 48
42. Secondary Biliary Cirrhosis ................................ 49
43. Sprue Syndrome (Tropical Sprue) .................... 50
44. Typhoid Fever ...................................................... 51
45. Upper Gastrointestinal Haemorrhage ............. 52
46. Vincent’s Stomatitis ............................................. 53
47. Viral Hepatitis (Infectious Hepatitis) ................ 54
48. Wilson’s Disease ................................................... 55
49. Zollinger-Ellison Syndrome ............................... 56
Contents xv
RESPIRATORY DISEASES
50. Acute Bronchitis ................................................... 58
51. Adult Respiratory Distress Syndrome ............. 59
52. Atelectasis .............................................................. 60
53. Atypical Pneumonia
(Mycoplasma Pneumonia) ................................. 62
54. Bronchial Adenoma ............................................. 63
55. Bronchial Asthma ................................................. 63
56. Bronchiectasis ....................................................... 67
57. Bronchiolar Carcinoma ....................................... 69
58. Broncho-Pneumonia ........................................... 70
59. Chronic Bronchitis ............................................... 71
60. Emphysema .......................................................... 73
61. Empyema .............................................................. 75
62. Haemoptysis ......................................................... 76
63. Haemothorax ....................................................... 77
64. Hydrothorax ......................................................... 78
65. Lobar Pneumonia ................................................ 78
66. Lung Abscess ........................................................ 80
67. Mediastinal Tumour ............................................ 82
68. Pleural Effusion .................................................... 83
69. Pulmonary Oedema ............................................ 85
70. Pulmonary Thromboembolism ........................ 86
71. Pulmonary Tuberculosis ..................................... 89
72. Sarcoidosis ............................................................. 94
73. Spontaneous Pneumothorax ............................. 95
74. Tension Pneumothorax ...................................... 96
xvi Practical Standard Prescriber
75. Traumatic Pneumothorax .................................. 97

76. Viral Penumonia .................................................. 97
HEART DISEASES
77. Angina Pectoris ..................................................... 99
78. Heart Disease ...................................................... 102
79. Hypertension ...................................................... 104
80. Myocardial Infarction ........................................ 109
81. Rheumatic Fever ................................................ 114
82. Sub-Acute Bacterial Endocarditis ..................... 117
SKIN DISEASES
83. Acne Vulgaris ...................................................... 121
84. Allergic Contact Dermatitis .............................. 122
85. Bed Sores ............................................................. 123
86. Boil ........................................................................ 124
87. Contact Dermatitis ............................................. 125
88. Dermatophytosis ................................................ 126
89. Discoid Lupus Erythematosus .......................... 127
90. Eczema ................................................................. 127
91. Erythema Multiforme ........................................ 129
92. Erythema Nodosum .......................................... 130
93. Exfoliative Dermatitis ........................................ 130
94. Folliculitis ............................................................. 131
95. Gonorrhoea ......................................................... 132
96. Herpes Simplex ................................................... 133
Contents xvii
97. Herpes Zoster ..................................................... 134

98. Impetigo .............................................................. 135
99. Infantile Eczema ................................................. 136
100. Lichen Planus ...................................................... 136
101. Malignant Melanoma ......................................... 137
102. Miliaria ................................................................. 138
103. Pediculosis ........................................................... 138
104. Pemphigus ........................................................... 139
105. Psoriasis ............................................................... 140
106. Ringworm ........................................................... 142
107. Scabies .................................................................. 143
108. Seborrhoeic Dermatitis ...................................... 144
109. Syphilis ................................................................. 145
110. Tinea Versicolor .................................................. 146
111. Urticaria ............................................................... 147
112. Venous Insufficiency Leg Ulcer ........................ 148
113. Warts .................................................................... 149
PSYCHIATRIC DISEASES
114. Anxiety ................................................................. 151
115. Depression ........................................................... 152
116. Hysteria ............................................................... 154
117. Phobic Reaction .................................................. 155
118. Psychopath .......................................................... 155
119. Psychosis .............................................................. 156
120. Schizophrenia ...................................................... 158
xviii Practical Standard Prescriber
GYNAECOLOGICAL DISORDERS
121. Amenorrhoea ..................................................... 161
122. Cancer Cervix ..................................................... 162
123. Carcinoma of Body of Uterus .......................... 163
124. Cervicitis .............................................................. 164
125. Delaying Menstruation ...................................... 165
126. Dysfunctional Uterine Bleeding ....................... 166
127. Dysmenorrhoea ................................................. 167
128. Habitual Abortion .............................................. 168
129. Hypermesis Gravidarum .................................. 169
130. Incomplete Abortion ......................................... 170
131. Inevitable Abortion ............................................ 170
132. Leucorrhoea ........................................................ 171
133. Menopause .......................................................... 172
134. Monilial Vaginitis ................................................ 173
135. Premenstrual Tension ........................................ 174
136. Senile Vaginitis .................................................... 175
137. Threatened Abortion ......................................... 176
138. Trichomonas Vaginitis ....................................... 177
139. Vaginitis ............................................................... 178
EAR AND NOSE DISEASES

140. Acoustic Neuroma ............................................. 179
141. Acute Otitis Media ............................................. 180
142. Cholesteatoma ................................................... 181
143. Chronic Simple Otitis Media ............................ 182
Contents xix
144. Deafness .............................................................. 183

145. Deviated Nasal Septum .................................... 184
146. Diseases of Nose ................................................ 185
147. Ear Diseases ........................................................ 186
148. Epistaxis ............................................................... 187
149. Localized Otitis Externa .................................... 188
150. Secondary Otitis Media ..................................... 189
151. Vertigo ................................................................. 189
152. Vertigo Due to Meniere’s Disease .................. 189
EYE DISORDERS
153. Acute Glaucoma ................................................. 191
154. Cataract ............................................................... 192
155. Conjunctival Discharge ..................................... 193
156. Conjunctivitis ...................................................... 195
157. Corneal Ulcer ...................................................... 196
158. Detachment of Retina ....................................... 197
159. Iritis ....................................................................... 198
160. Redness of Eye ................................................... 199
DISEASES OF CHILDREN
161. Acute Rheumatic Fever .................................... 201
162. Anaemia .............................................................. 203
163. Aortic Stenosis .................................................... 204
164. Aortic Regurgitation ......................................... 204
165. Bronchopneumonia ........................................... 205
xx Practical Standard Prescriber
166. Chicken Pox ........................................................ 206

167. Congenital Syphilis ............................................ 208
168. Dengue ................................................................. 208
169. Diphtheria ........................................................... 209
170. Indian Childhood Cirrhosis ............................. 211
171. Infantile Diarrhoea ............................................ 212
172. Kwashiorkor ....................................................... 213
173. Marasmus ............................................................ 214
174. Measles ................................................................ 215
175. Mitral Regurgitation .......................................... 217
176. Mitral Stenosis .................................................... 217
177. Mumps ................................................................. 218
178. Poliomyelitis ....................................................... 219
179. Rickets .................................................................. 221
180. Scurvy .................................................................. 222
181. Whooping Cough .............................................. 222
MEDICAL EMERGENCIES
182. Acute Alcohol Intoxication ............................... 224
183. Acute Morphine Poisoning .............................. 225
184. Acute Respiratory Failure ................................ 226
185. Acute Retention of Urine .................................. 228
186. Agranulocytosis ................................................. 229
187. Anaphylactic Shock ........................................... 230
188. Arsenic Poisoning .............................................. 230
189. Barbiturate Poisoning ....................................... 231
190. Bee Sting .............................................................. 233
Contents xxi
191. Burns .................................................................... 234

192. Cardiac Arrest .................................................... 235
193. Cardiogenic Shock ............................................. 237
194. Dehydration ........................................................ 237
195. Dhatura Poisoning ............................................. 238
196. Drowning ............................................................ 239
197. Ectopic Pregnancy ............................................. 240
198. Frost Bite ............................................................. 241
199. Hypoglycemia .................................................... 241
200. Hypothermia ...................................................... 243
201. Injuries to Vulva, Vagina .................................. 243
202. Poisoning ............................................................. 244
203. Profuse Vaginal Haemorrhage ....................... 245
204. Renal Colic .......................................................... 246
205. Snake Bite ............................................................ 247
206. Spontaneous Pneumothorax ........................... 249
207. Suicidal Behaviour ............................................. 250
208. Transfusion Reactions ....................................... 251
MISCELLANEOUS
209. Acute Leukemia ................................................. 252
210. Addison’s Disease .............................................. 255
211. AIDS ..................................................................... 256
212. Chronic Lymphatic Leukemia ......................... 257
213. Chronic Myeloid Leukemia ............................. 258
214. Congestive Cardiac Failure .............................. 259
xxii Practical Standard Prescriber
215. Diabetes Insipidus .............................................. 260

216. Diabtetes Mellitus .............................................. 261
217. Diabetic Ketoacidosis ........................................ 263
218. Filaria ................................................................... 264
219. Heatstroke .......................................................... 265
220. Hodgkin’s Disease ............................................. 266
221. Hookworm Infestation ..................................... 267
222. Hyperkalemia ..................................................... 268
223. Lactic Acidosis ..................................................... 269
224. Left Ventricular Failure ..................................... 270
225. Malaria ................................................................. 271
226. Multiple Myeloma .............................................. 272
227. Myasthenia Gravis ............................................. 273
228. Nephrotic Syndrome ........................................ 274
229. Non Hodgkin’s Lymphoma ............................ 275
230. Obesity ................................................................. 276
231. Organophosphorus Poisoning ........................ 277
232. Roundworm ....................................................... 278
233. Tapeworm Infestation ...................................... 279
234. Threadworm ....................................................... 280
GENERAL INFORMATION
235. Immunisation ...................................................... 282
236. Weights and Measures ...................................... 282
Contents xxiii
DIET THERAPY
237. Diabetes Mellitus ................................................ 288
238. Diarrhoea and Dysentery ................................. 292
239. Gout ...................................................................... 293
240. Hypertension ...................................................... 294
241. Infective Hepatitis .............................................. 295
242. Ischemic Heart Disease ..................................... 297
243. Kwashiorkor and Marasmus ........................... 298
244. Nephrotic Syndrome ........................................ 300
245. Obesity ................................................................. 301
246. Peptic Ulcer ......................................................... 303
247. Some of Available Drugs .................................. 304
248. Underweight ....................................................... 330
BLOOD COUNT
249. Normal Blood Count ......................................... 332
250. Red Cell Morphology ........................................ 339
BLOOD BIOCHEMISTRY
251. Blood Biochemistry ............................................ 354
CEREBROSPINAL FLUID
252. Cerebrospinal Fluid ........................................... 380

xxiv Practical Standard Prescriber
GLUCOSE TOLERANCE TEST
253. Glucose Tolerance Test ...................................... 390
BONE MARROW ASPIRATION
254. Bone Marrow Aspiration .................................. 393
RENAL FUNCTION TESTS
255. Renal Function Tests .......................................... 398
LIVER FUNCTION TESTS
256. Liver Function Tests ........................................... 400
FUNDUS EXAMINATION
257. Changes of Fundus in Different Diseases ....... 416
RENAL SYSTEM
258. Acute Giomerulonephritis ................................ 422

259. Acute Nephritic Syndrome ............................... 423
260. Acute Pyleonephritis .......................................... 424
261. Acute Renal Failure ............................................ 425
262. Benign Prostatic Hyperplasia ........................... 426
263. Chronic Renal Failure ........................................ 427
Contents xxv
264. Neurogenic Bladder ........................................... 428

265. Obstructive Uropathy ........................................ 429
266. Uraemia ............................................................... 430
NEUROLOGICAL DISEASES
267. Bell’s Palsy ........................................................... 432
268. Brachial Neuralgia .............................................. 433
269. Broadman’s Areas of Brain ............................... 433
270. Cerebral Stroke .................................................. 434
271. Cervical Rib Syndrome ..................................... 435
272. Cluster Headache ............................................... 436
273. Common Headache ........................................... 437
274. Epilepsy ................................................................ 437
275. Infective Polyneuritis ......................................... 440
276. Intracerebral Haemorrhage ............................. 441
277. Intracranial Tumours ......................................... 442
278. Meningitis ............................................................ 443
279. Migraine ............................................................... 444
280. Multiple Sclerosis ................................................ 445
281. Parkinson’s Disease ............................................ 445
282. Polyneuropathy .................................................. 446
283. Raised Intracranial Tension ............................... 447
284. Sciatica .................................................................. 448
285. Subarachnoid Haemorrhage ............................ 449
286. Stroke ................................................................... 449
287. Tension Headache .............................................. 451
xxvi Practical Standard Prescriber
288. Transient Ischaemic Attacks ............................. 451

289. Trigeminal Neuralgia ......................................... 452
HAEMATOLOGY
290. Acquired Aplastic Anaemia .............................. 454
291. Constitutional Aplastic Anaemia ..................... 455
292. Haemophilia-A ................................................... 455
293. Hodgkin’s Disease .............................................. 456
294. Thalassemias ....................................................... 457
295. Polycythemia Rubravera .................................. 458
ORAL DISEASES
296. Acute Necrotizing Ulcerative Gingivitis ......... 460
297. Bad Breath (Halithosis) ...................................... 461
298. Dental Caries ....................................................... 461
299. Hand, Foot and Mouth Disease ....................... 462
300. Recurrent Aphthous Stomatitis ........................ 463
301. Sharp Stabbing Pain ........................................... 464
302. Xerostomia .......................................................... 465
DISEASES OF BONES AND JOINTS

303. Acute Osteomyelitis ........................................... 466
304. Ankylosing Spondylitis ..................................... 467
305. Goutyarthritis ..................................................... 468
306. Osteoartheritis .................................................... 469
Contents xxvii
307. Psoriatic Arthritis ................................................ 471

308. Rheumatoid Arthritis ......................................... 472
309. Tuberculosis of Bone Joints ............................... 474
APPENDIX
310. Expenditure of Calories/Hour ........................ 476
311. Food and Nutrition ........................................... 476
312. Important Sources of Cholesterol mg/100 gm ... 478
313. Important Sources of Fat .................................. 478
314. Important Sources of Iron mg/100 gm ......... 479
315. Important Sources of Proteins gm/100 gm .. 479
316. Showing Approximate Values ......................... 480
317. Table of Food Value/100 gm ........................... 480
GASTROINTESTINAL DISEASES
ACHALASIA CARDIA
Essentials of Diagnosis
• Dysphagia, initially intermittent with food appar-
ently sticking at the level of xiphoid cartilage, asso-
ciated with retrosternal discomfort.
• Regurgitation immediately following ingestion and
delayed regurgitation in chronic cases.
• Cough and dyspnoea due to pressure of dilated
oesophagus on trachea and bronchi.
• Aspiration of material to tracheobronchial tree may
cause bronchiectasis, lung abscess or pulmonary
fibrosis.
• X-ray shows conical tapering of distal oesophagus
and fluoroscopy shows ineffectual and purposeless
peristalsis with dilatation.
Treatment
 Anticholinergics to relieve spasm of oesophagus.
Tab Probanthine or Buscopan, one tablet thrice
daily ½ hour before meals.
 Nifedipine 10 mg thrice daily is beneficial.
2 Practical Standard Prescriber
 To avoid irritant substances like salicylates.

NSAIDs. Alcohol, spicy food, gulping of food and
swallowing unchewed food particles should be
avoided.
 Avoid lying down for 2-3 hours after taking food.
 Oesophageal dilatation using pneumatic bag
under fluoroscopic guidance.
 Oesophago-cardio-myotomy may be required in a
few cases.
ACUTE CHOLECYSTITIS
• Constant, severe pain and tenderness in right hypo-
chondrium or epigastrium.
• Nausea, vomiting, fever, chills.
• Jaundice.
• Leucocytosis.
• Positive Murphy’s sign.
• Plain X-ray shows gallstones in 15 per cent cases.
Treatment
 Rest in bed.
 Nothing to be taken orally.
 IV fluids 5 per cent Dextrose/ringer solution.
Gastrointestinal Diseases 3
 Analgesics/sedatives like Fortwin 30 mg slow IV

or IM or Phenargan (Morphine is contraindicated
as it causes spasm of sphincter of oddi).
 Antibiotics are needed.
Injection Ampicillin 500 mg, 6 hourly IV or IM
and injection Gentamycin 60 mg 12 hourly IV
or IM
and injection Metrogyl 100 mg 8 hourly IV
 Injection B complex 2 ml IM or IV on alternate day
 Once acute attack subsides allow fat free liquid diet
and later on fat free soft diet may be taken.
Surgery is indicated if
• Patient develops peritonitis.
• Failure of medical treatment for 48 hours.
Operative
If conservative treatment fails to bring relief or the pain,
tenderness and systemic sysmptoms are aggravated
indicating perforation/gangrene-immediate chole-
cystectomy is advised. Elective cholecystectomy is per-
formed in those who respond to conservative treatment.
ACUTE GASTRITIS
• Anorexia, epigastric fullness, nausea.
• Diarrhoea, colic, haematemesis, fever, chills, head-

ache and malaise are common when caused due to
toxins or infections.
• Epigastric tenderness present.
• Endoscopy differentiates acute simple gastritis from
erosive gastritis, peptic ulcer or a mucosal laceration
(Mallory-Weiss syndrome).
Treatment
 Bed rest.
 Bland soft diet.
 Mucaine gel or digene gel 2 tsf thrice daily after
meals.
 Tab Ranitidine 150 mg twice daily or Ramotidine
20 mg twice daily.
 Tab Probanthine twice daily.
 Tab Sucralfate 1 gm tds if NSAIDs induced
erosions.
 Specific antidotes for corrosive poisons.
 Treat infective cause if any.
ACUTE MESENTERIC
LYMPHADENITIS
• Acute pain around umbilicus or right iliac fossa in a
child.
• Anorexia, nausea, vomiting, fever.

• Tenderness in right iliac fossa without any signs of
peritoneal irritation.
• Marked leucocytosis.
• History of recent or current upper respiratory
infection.
Treatment
 Rest and soft nutritious diet.
 Broad spectrum antibiotic preferably Amoxicillin
1 tds for 7 days.
ACUTE MESENTERIC
VASCULAR OCCLUSION
• Severe abdominal pain, nausea, fecal vomiting and
bloody diarrhoea.
• Severe prostration and shock.
• Abdominal distention, tenderness, rigidity.
• Leucocytosis and haemoconcentration.
Treatment
1. Restoration of fluid, electrolyte and colloid balance.
2. Decompression of the bowel.
3. Heavy doses of broad spectrum antibiotics to
prevent sepsis.
Laparotomy should be done as soon as possible and

gangrenous bowel is to be resected. Embolectomy
and thrombectomy may be possible if there is isolated
thrombus/embolus in a major artery. Anticoagulants
are not indicated.
ACUTE ORGANIC SMALL

BOWEL OBSTRUCTION
• Colicky abdominal pain, vomiting, constipation
borborygmus.
• Tender distended abdomen.
• Audible peristalsis.
• X-ray evidence of gas or multiple gas and fluid
levels without movement of gas.
• Little or no leucocytosis.
Treatment
Supportive measures
a. Decompression by nasogastric suction.
b. Correction of fluid, electrolyte and colloid deficit.
c. Broad spectrum antibiotic if strangulation is
suspected (i.e. Gentamicin/Ampicillin IM/IV
Metrogyl)
Surgical measures are indicated in

 Fever, leucocytosis, abdominal rigidity/ascites,
blood in the faeces means strangulation and
immediate surgery is essential.
 If in an uncomplicated case with adequate decom-
pression pain does not subside and flatus does not
pass, operation is inevitable. Surgery consists of
relieving the obstruction and removal of gan-
grenous bowel with reanastomosis.
ACUTE PANCREATITIS
• Sudden, severe epigastric pain with radiation to back
in an alcoholic or in those with known biliary disease.
• Fainting attacks, sweating, vomiting.
• Fever, leucocytosis, paralytic ileus in some patients.
• Elevated serum and urinary amylase and lipase.
• History of previous episodes specially after dietary
excesses.
Treatment
 Nil orally. Fluid and electrolyte balance to be
maintained.
 Several litres of IV fluid replacement as patient is
invariably dehydrated.
 Continuous gastric suction to reduce vomiting and

distension of gut.
 For pain, injection Pethidine 100 mg IM or
Morphine 15 mg IM.
 Injection Atropine 0.6 mg IM or injection Proban-
theline 15-30 mg six hourly to reduce gastric, duo-
denal and pancreatic secretion and to relieve spasm
of sphincter of oddi.
 Antibiotics for secondary infection—Injection
Ampicillin 500 mg 6 hourly and Gentamycin 60-80
mg eight hourly.
 Calcium gluconate 10 per cent as 10 ml slow IV
twice or thrice if serum calcium is low.
 Liquid Gelucil or Divol or Siloxagen one table
spoonful hourly through Ryle’s tube.
 If respiratory distress then oxygen.
ALCOHOLIC HEPATITIS
• Anorexia, nausea, abdominal discomfort in a
patient after a recent period of heavy drinking.
• Tender hepatomegaly and often jaundice.
• Fever, splenomegaly, ascites, encephalopathy, abdo-

minal pain and tenderness when present, further
support the diagnosis.
• Elevated serum alkaline phosphatase. (Rarely more
than three times of normal value). Increased SGOT,
serum bilirubin, elevated serum globulin and
depressed albumin.
• Liver biopsy is confirmatory.
Treatment
 Avoid alcohol.
 Hydration is to be maintained by oral fluids or IV
supplementation.
 Vitamin K for elevated prothrombin time as 10 mg
IM.
 Vitamin B supplementation especially thiamine
and folic acid.
 Low dose steroids to be used only if everything
else fails.
 If patient has severe dehydration elevated proth-
rombin time (> 1.5 times of normal), intractable
nausea or vomiting, marked rise of bilirubin, hepa-
tic encephalopathy, azotemia person may require
hospitalisation.
AMOEBIASIS
Intestinal Amoebiasis
• Frequent passage of loose offensive stool, often
mixed with blood and mucus.
• Abdominal cramps.
• Gaseous distention, vague abdominal pain often
with insomnia and depression.
• A sensation of incomplete clearance of bowel even
after frequent stool.
• Frequent stools with offensive gangrenous sloughs,
dark blood, pus, prostration and dehydration in ful-
minant cases.
• Constipation alternating with diarrhoea, tender pal-
pable descending and sigmoid colon in chronic cases.
• Haematophagous amoebas in stool are diagnostic,
cysts in the stool are evidence of quiescent infection.
• Sigmoidoscopy shows flask shaped ulcers, raised
button like ulcers or mouse eaten appearance.
Treatment
Acute
 Tab Metrogyl 800 mg tds for 5 days (children 50
mg/kg/day in three divided doses).
or
Tinidazole 2 gm/day for 5 days.

or
Tab Secnidazole 2 gm as single dose.
or
Diloxamide furoate 500 mg plus Metrogyl 400 mg
tds for 5 days
or
Tab Furamide 500 mg tds for 10 days.
 For abdominal pain Tab Buscopan or Capsule Spas-
moproxyvon bd or tds.
 In dehydration IV fluids may be given.
Chronic Amoebiasis
 Tab Diloxamide Furoate 500 mg tds × 10 days.
or
Tab Furamide 500 mg tds × 10 days.
or
Dependal-M 1 tds × 10 days.
In amoebic hepatitis and liver abscess same
treatment is to be given.
ANAL FISSURE
1. Acute pain during and after defecation.
2. Bright red blood with stool.
3. Tendency for constipation due to fear of pain.
Treatment
 Mineral oil and stool softners daily. Mild laxative-
Syp Cremaffin 2-3 tea spoon hs.
 Anal suppositories twice daily.
 Local application of Gentian violet 1 per cent Xylo-
caine 4 percent jelly locally 1/2 hour before passing
stools or sos.
 Anal dilatation.
 Surgical excision if all above measures fail or
recurrence occurs.
APHTHOUS STOMATITIS
• Shallow ulcers with erythematous base, covered with
pseudomembrane (greyish exudate).
• Often painful and usually recurrent.
• May be associated with inflammatory bowel disease,
prolonged fevers, infectious mononucleosis history
of emotional stress.
Treatment
 Avoid spices, tobacco, hot food.
 Bland diet.
 Good oral hygiene.
 Aqueous Chlorhexidine 0.2 per cent mouth wash.
 Efcorlin pellets (glaxo) allow pellet to dissolve in

close proximity to ulcer 3-4 times daily.
or
Trimonalone 0.1 per cent in dental paste apply as
thin coating to ulcer thrice a day.
 Tetracycline or Mystecline capsule 250 mg, dissolve
one capsule in water and rinse mouth 3 times a
day.
 Glycerine or Zytee for topical application.
 If pain tablet Paracetamol 1 tds.
 Patient to be reviewed within 3 weeks to ensure
healing has occured otherwise ulcer must be
biopsied.
APPENDICITIS
• Pain and tenderness in right iliac fossa with signs of
peritoneal irritation (muscle guard and +ve
Rovsing’s sign).
• Low grade fever, vomiting, constipation.
• Polymorphonuclear leucocytosis.
• Rectal tenderness is common in pelvic appendicitis;
psoas and obturator signs are positive. X-ray abdo-
men shows radiopaque shadow consistent with
faecolith in the appendix area.
• In infants and aged the prodromal symptoms as well

as localised signs are minimum until perforation
occurs.
• Tender mass in the iliac fossa with continuous
fever, malaise, toxicity and marked leucocytosis
indicate appendicular abscess. Pelvic abscess tends
to protrude into vagina/rectum.
• Septic fever, chills, hepatomegaly and jaundice with
appendicitis indicate appendicular perforation,
pyelophlebitis.
Treatment
 Complete bed rest.
 Nothing orally.
 Laxatives and narcotics are absolutely contrain-
dicated.
 IV glucose saline.
 Nasogastric intubation with gastric lavage.
 Inj Ampicillin 500 mg 6 hourly IV, Inj Gentamycin
80 mg IM 8 hourly, Inj Metrogyl 1 g 8 hourly IV.
 Appendicectomy within 48 hrs.
Surgical
In uncomplicated cases appendicectomy is performed
as soon as fluid imbalance and systemic disturbances
are controlled.
Appendicular Mass
Conservative
• Bed rest.
• Fluid diet.
• Record temperature, pulse and size of mass.
• If mass enlarges and pyrexia continues then drain
the abscess.
• Appendicectomy after 3 months of resolution of
mass.
BACILLARY DYSENTERY
• Frequent stools with blood and mucous (Red currant
jelly).
• Abdominal cramps.
• Fever, malaise and prostration.
• Pus in stool.
• Organisms isolated on stool culture.
Treatment
 Correct dehydration IV fluids or Electral powder
orally.
 Ampicillin 500 mg 6 hourly.
or
Septran DS 1 tablet twice daily.
or
Nalidixic acid 1 gm 6 hourly.

or
Tetracycline 500 mg 6 hourly.
 Antispasmodics if needed.
BOTULISM
• Sudden onset of diplopia, dry mouth, dysphagia,
dyspnoea, cranial nerve paralysis, muscle weakness
progressing to respiratory paralysis.
• History of recent ingestion of home canned or unus-
ual foods.
• Toxin demonstrated in the food by mouse innocu-
lation and identified with specific antisera.
Treatment
 Stomach wash if diagnosed early.
 ABC botulinus anti-toxin.
 Maintenance of oxygenation and ventilation by
good respiratory drainage (elevation of foot end)
aspiration or tracheostomy and mechanical
respiration if necessary.
 Parenteral fluids.
 Antibiotics if pneumonitis develops.
CANCER COLON
• Blood in the faeces, anaemia, asthenia.
• Palpable colonic mass (especially in ascending
colon).
• Altered bowel function, i.e. progressively increasing
constipation (left colon) or diarrhoea.
• Sigmoidoscopic and X-ray evidence of the
neoplasm.
Treatment
 Surgical resection of the lesion and its regional
lymphatics after adequate bowel preparation in
early cases.
 In late cases with invasion or obstruction palliative
resection.
 Preoperative irradiation 2000 to 2500 R, in 10 sitt-
ings over 12 days increases resectability and impro-
ves survival.
CANCER OESOPHAGUS
• Progressive dysphagia even to liquids.
• Anaemia, weight loss.
• Chest pain—Unrelated to eating implies local exten-

sion of tumour.
• Barium swallow shows irregular, frequently annular
space occupying lesions.
Treatment
 Irradiation is best, if upper half of oesophagus is
involved.
 In absence of metastasis, tumours of lower half may
be treated by resection and oesophago-gastrostomy
or jejunal or colonic interposition. Gastrostomy for
palliation in hopeless cases may be done to improve
nutrition. Cure rate in best hands is only 5 to 10
per cent.
CANDIDIASIS (THRUSH)
• Creamy-white curd like patches surrounded by
erythema.
• Pain, fever and lymphadenopathy in some cases.
Treatment
 Saturated solution of sodabicarb for mouth wash.
 One per cent gentian violet to be painted three times
daily on the patches.
 Nystatin tablet or Mycostatin tablet dissolved in

Glycerine and applied locally and oral Nystatin
500,000 units three times daily or Nystatin mouth
wash.
or
Tab Ketoconazole 200 mg tds.
Chronic candiasis
 Oral lesions may respond only to IV Amphotericin
with or without Fluconazole or Ketoconazole.
CARCINOMA OF LIVER
1. Hard, enlarged, tender liver with or without palpable
nodules.
2. Symptoms of long-standing cirrhosis with sudden
deterioration in the condition of the patient.
3. Bloody ascites.
• Anaemia, cachexia, hepatic bruit or friction rub.
• Primary site of malignancy (stomach), colon or
other parts of GI tract.
• Alfa-foetoprotein positive in 50 per cent case of
hepatoma.
• Ultrasound and CT scan.
• Liver scanning with 99mTc. Sulfur colloid and liver
biopsy are confirmatory.
Treatment
 Cytotoxic drugs, irradiation or surgery have not
proved effective.
 When benign or malignant hepatic neoplasms are
encountered in ladies taking oral contraceptives,
discontinuation of contraceptives may cause
regression of benign tumours (i.e. focal nodular
hyperplasia).
 Alcohol injection into tumour.
CARCINOMA OF STOMACH
• Anaemia, asthenia and anorexia in patients over 40
years of age.
• Palpable abdominal mass.
• Occult blood in stool.
• Gastroscopic and X-ray abnormality with positive
cytological examination.
• The less common manifestations include post-
prandial distress simulating peptic ulcer and
diarrhoea due to associated achlorhydria. Enlarged
Virchow’s (left supraclavicular) nodes, Krukenberg’s
tumour in female, enlarged hard nodular liver,
ascites, pelvic mass and pathological fractures denote
metastasis.
• Radiological findings vary according to the type of

lesion, i.e. ulcerative, polypoid, infiltrating or combi-
nations. The findings can be summarised as:
– Ulcer more than 1 cm in diameter.
– Annular narrowing near pylorus or in fundus.
– Pyloric elongation, narrowing or rigidity.
– Diffuse fibrosis (linitis Plastica).
– Hyper rugosity.
Treatment
 If distant metastasis is present palliation with radia-
tion therapy, with 5 fluorouracil, gastroentero-
stomy or palliative resection can prolong life.
 If the tumour is localised to stomach sub-total
gastrectomy is the standard treatment.
CHOLEDOCHOLITHIASIS
• Sudden, severe, right upper quadrant abdominal
pain radiating to scapula.
• Nausea, vomiting, fever, jaundice, leucocytosis.
• History of such recurrent attacks persisting for hours.
• Chills with gram-ve shock in cases of acute suppura-
tive cholangitis.
• Enlarged tender liver in some cases.
• Laboratory investigations show features of obstruc-
tive jaundice with hypoprothrombinemia.
Treatment
 Cholecystectomy and choledochostomy.
 Basketting and ECSWL.
CHOLERA
• Sudden onset of explosive diarrhoea.
• Stool if grey, turbid without any faecal odour, blood
or pus (rice water stool).
• Rapid development of dehydration, acidosis, hypo-
kalaemia, hypotension.
• Positive stool culture and agglutination of vibrios
with specific sera.
• Fever is absent but vomiting may coexist.
Treatment
Oral solution consists of
Pot chloride 1.5 gram
Glucose 20 mg
Water up to 1 litre
or
Sodium chloride 5 gram
Glucose 20 gram
Water up to 1 litre
Antibiotics
Tetracycline 500 mg 6 hourly for 5 days.
or
Chloramphenicol 500 mg 6 hourly.
or
Doxycycline 100 mg daily.
or
Ofloxacin 200 mg 12 hourly, Dehydration is to be
compensated.
CHRONIC CHOLECYSTITIS
• History of frequent attacks of biliary colic (i.e. right
upper quadrant abdominal pain referred to right
scapula).
• Flatulant dyspepsia with fatty food intolerance.
• Non-functioning gall bladder on IV cholecysto-
graphy or presence of gallstones.
Treatment
 Cholecystectomy.
CHRONIC GASTRITIS
• Asymptomatic or vague non-descriptive upper
abdominal distress.
• Mild epigastric tenderness or no physical findings
whatsover.
• Ulcer or cancer like syndrome, often with gross hae-
matemesis.
• Gastroscopy shows mucosal atrophy as evidenced
by visualisation of blood vessels through mucosa.
• Biopsy shows varying degrees of atrophy and infil-
tration of lamina propria with lymphocytes and
plasma cells.
Treatment
For atrophic gastritis causing B12 malabsorption and
pernicious anaemia Injection vitamin B12
 Anti-ulcer regimen, i.e. antacid, anticholinergic, H2
receptor blockers and mild tranquilizer.
 For achlorhydria 1 to 2 tsf of dilute HCl in fruit
juice sipped with meals.
 Avoidance of alcohol, tobacco, spices and hot foods.
CONSTIPATION
Patient should be considered to be constipated only if

defaecation is explainably delayed for days or if stools
are unusually hard, dry, and difficult to expel. Causes
of constipation are:
• Dietary factors-highly refined or low fibre foods,
inadequate fluids.
• Physical inactivity, inadequate exercise and prolon-
ged bed rest.
• Pregnancy.
• Advanced age.
• Drugs—Anaesthesia, antacids, ganglion blocking
agents, iron salts, opiates.
Treatment
 Cathartics and enema should not be used.
 Foods with high fibre content such as bran and raw
fruits and vegetables may be helpful.
 8 to 10 glasses of fluids daily are to be taken.
 Dulcolax 10-15 mg acts within 6-12 hours.
 Glycerine suppository, a potent rectal agent for
lubricating hard faecal matter; 3 gm acts in 30
minutes.
Naturolax or Igol or Ispaghula one tsf with water

at night daily
or
Tab Dulcolax 1-2 tablet at bed time.
or
Cremaffin 2-3 teaspoonful after dinner.
For chronic constipation—Tablet Cisapride 10 mg
twice a day.
DIVERTICULAR DISEASE OF COLON

(Diverticulosis)
• Intermittent cramping and left lower abdominal
pain.
• Constipation or constipation alternating with
diarrhoea.
• Tenderness in left lower quadrant.
• X-ray evidence of diverticula, thickened interhau-
stral folds, narrowed lumen on Barium enema.
Treatment
Capsule Ampicillin 500 mg 6 hourly or capsule
Tetracycline 500 mg 6 hourly.
 Clear liquid diet.
 If severe disease patient may be hospitalised with

bowel rest IV fluids and antibiotics. Combination
of Ampicillin and Aminoglycosides with additional
amoebic coverage with Metronidazole or Clina-
mycin is given.
 Surgery is indicated if patient does not respond to
therapy or develop peritonitis.
 Recurrent diverticulitis may lead to stricture perfo-
ration and can be an indication for elective
hemicolectomy.
DUMPING SYNDROME
(Post-gastrectomy Syndrome)
• Sweating, tachycardia, pallor, abdominal cramps,
weakness and in severe cases syncope within 20
minutes of meal.
Treatment
 Frequent small feeds with high protein, moderately
high fat and low carbohydrate.
 Fluids should be taken in between meals but not
soon after the meals.
 Sedatives and anticholinergics.
DUODENAL ULCER
• Epigastric pain 1/2 to 1 hour after meals or noctur-
nal pain, both relieved by food, antacid or
vomiting.
• Chronic and periodic symptoms.
• Epigastric tenderness, often with guarding and unila-
teral spasm of rectus over duodenal bulb.
• Ulcer crater or deformity of bulb noted in Barium
meal.
• Pylorospasm, gastric hypermotility and irritability
of the bulb with difficulty in retaining the barium are
indirect evidences of duodenal ulcer.
• Gastric analysis shows acid in all cases and hyper-
secretion in some cases.
• Few patients may present with vague dyspepsia or
typical symptoms due to anxiety.
• Direct visualisation by endoscopy.
Treatment
 2 to 3 weeks of rest.
 Nutritious diet taken at regular intervals; restriction
of coffee, tea, cola, beverages, alcohol and smok-
ing. First few days with bland liquid diet with gradual
change over to soft solid diet in 4 to 8 weeks time.
 Antacids—Digene tablet or Get 2 tab or 2 teaspoon
2-3 hrs after meals.
 Aluminium hydroxide in tablet form being inert is

not very useful. Magnesium oxide and Calcium
carbonate combinations are best. Magnesium is
contraindicated in renal impairment and calcium
salts may cause hypercalcaemia (polyuria, poly-
dypsia, anorexia, constipation, etc.). Liquid forms
are preferable. Initially given hourly then changed
to 1 and 3 hours after each meal and at bed time.
Antacids may cause phosphate depletion especially
the aluminium salts.
 Omeprazole 20 mg od for 1 month.
 Parasympatholytics
These are of questionable value as the dose required
to produce significant gastric antisecretory effect may
cause blurring of vision, urinary retention and
constipation. They are helpful in relief of refractory
pain and are given 1/2 hour before meal and at bed
time. They are contraindicated in glaucoma, gastric
ulcer, pyloric stenosis, hiatus hernia, bladder neck
obstruction, etc.
H2 Receptor Antagonist
Famotidine 20 mg twice daily.
Rantidine 300-600 mg daily for 6 weeks.
Therapy continued for 4 to 6 weeks and then
maintenance dose of 300 (Ranitidine)/40(Famotidine)
mg at bed time given for six months.
Look for gynaecomastia, galactorrhoea, gout as adverse

effects
• Phenylbutazone, Reserpine, Indomethacin and
analgesics should be discontinued if possible as they
aggravate the condition. To eliminate H.pylori from
gastric mucosa-Metrogyl 400 mg tds plus Amoxicillin
250 mg tds for one week.
GASTRIC ULCER
• Epigastric distress, relieved by vomiting, antacid.
• Epigastric tenderness and muscle guarding.
• Ulcer demonstrated by Barium meal and X-ray or
gastroscopy (Oedema, spasm, convergence of gast-
ric mucosal folds).
• 90 per cent heal in 12 weeks on medical therapy.
Gastric ulcer Chronic duodenal ulcer
Pain onset 2.5 to 4 hours 15 minutes to 2 hours
after meals after meals
Sequence Comfort - food Pain - food - comfort
- pain - comfort
Site Epigastrium Right half of gastrium
Radiation to Common Rare
back
Relief Taking alkalis After food
Hydrochloric Normal ++
acid
Ba meal Stomach Empties fast
empties slowly
Treatment
 Avoid spicy food, alcohol and smoking.
 Intensive antacid therapy and H2 receptor blockers:
H2 receptor antagonists are more effective than
antacids in healing gastric ulcer.
 Sucralfate and bismuth salts 1 g qid on empty
stomach.
 If no response or unsatisfactory improvement is
seen with antacid and Cimetidine or Ranitidine
surgical resection is the answer.
Recurrence, perforation, obstruction or
uncontrollable haemorrhage require surgical
intervention.
HAEMORRHOIDS
• Rectal bleeding and discomfort following defaeca-
tion. Protrusion and pain around anus.
• Haemorrhoids visible on anal inspection or ano-
scopic examination.
Treatment
1. Lower roughage diet.
2. Regulation of bowel habit with mineral oil or stool
softeners.
3. Warm sitz bath (hip bath) for 15 min, 2-3 times a
day.
4. Soothing anal suppository 2 to 3 times daily.

5. Xylocaine 2 per cent topical ointment before and
after defaecation.
6. Diasomin (150 mg) (Daflon) 2 cap twice daily to
tds for 1 week.
7. Antibiotics preferably Ampicillin for 5 to 7 days to
combat any infection if present.
8. The use of heparin containing oint. (Hirudoid) or
Hydrocortisone ointment (Proctosedyl) are of value
once acute pain and bleeding are controlled.
9. Control other precipitating/aggravating factors
like obesity, chronic cough, portal hypertension, etc.
Surgical Treatment
 Injection of sclerosing agents but recurrence occurs
in 5 per cent cases.
 Band ligation.
 Excision.
HERPETIC STOMATITIS
• Common in children below 10 years.
• Severe ulceration of oral mucous membrane asso-
ciated with systemic signs, i.e. fever, lymphadeno-
pathy (cervical) and malaise.
• Cytologic smear showing pathognomonic pseudo-

giant cells is confirmatory.
Treatment
 Local Idoxuridine application or 5 per cent Acyclo-
vir cream (Zovirax).
 Oral Acyclovir 400-1000 mg/day for 12 months if
frequent cold sores.
HICCUP
It is a transient phenomenon and may occur as manifes-

tation of many diseases such as neuroses, CNS
disorders, GIT disorders, etc. It may be only symptom
of peptic oesophagitis.
Treatment
 Slow deep breathing.
 Neooctinum 30 drops in a glass of water every 4
hourly.
or
Neooctinum dragees 1 tds.
 Tab Valium 2 mg tds.
If no response then
Injection Largactil (Chlorpromazine) 25 mg IM
or 50 mg orally.
 Antispasmodics, i.e. Atropine sulphate 0.3-0.6 mg

subcutaneously.
 Amylnitrate inhalation may be effective.
 Antacids-Gelucil/Digene tab after each meal.
If it still persist
 Gastric lavage with ice cold saline or 1 per cent soda
bicarb solution.
INTESTINAL TUBERCULOSIS
• Fever, anorexia, nausea, flatulence, food intolerance
and distension after food.
• Chronic abdominal pain varying from mild to
severe cramps.
• Mild to severe diarrhoea.
• Doughy feelings of abdomen on palpation.
• X-ray findings according to type of lesion, i.e. irrita-
bility and spasm particularly in caecal region, irre-
gular hypermotility of the intestinal tract, irregular
filing defects (hypertrophic type of lesion) are noted.
Persistent narrow beam of barium in small bowel
(string sign) is seen. Biopsy and animal innoculation
are confirmatory. The presence of tubercle bacilli in
stool does not correlate with intestinal involvement.
Treatment
 INH 300 mg od
 Rifampicin 450 mg/day if body weight is 55 kg.
Above 55 kg body weight 600 mg daily should be
given in a single dose before breakfast.
 Pyrazinamide.
< 50 kg 1.5 gm
50-75 kg 2 gm
> 75 kg 2.5 gm
It may be given in single dose or in 2 divided doses.
 Ethambutol 25 mg/kg body weight as single dose.
 Supplementary multivitamins and Pyridoxin
40 mg daily.
 Low residue high protein diet.
Surgical Treatment
Indications
1. Localised hypertrophic lesion.
2. Stenosis of bowel.
3. Perforation of tuberculous ulcer.
IRRITABLE BOWEL SYNDROME
• Abdominal pain.
• Altered bowel function, constipation or diarrhoea.

• Hypersecretion of colonic mucosa.
• Flatulence, nausea and anorexia.
• Varying degree of anxiety of depression.
Treatment
 Reassure and explain nature of illness to patient.
 Avoid stress.
 Avoid fried foods, alcohol, tea and coffee.
 Regular meals and adequate sleep is essential.
If pain and distension
Tab Mebenerine (Colospa) 100 mg tds
Tab Spasril 1 tds
or
Tab Librax 1 tds
Tab Ispaghula or Isogel 1 tsf once or twice day.
If main complaint is of frequent, loose stools with
urgency then
 Tab Lopramide (Imosec) 2 mg once or twice daily.
or
Tab Codeine phosphate 30 mg once or twice daily.
or
Tab Diphenoxylate (Lomotil) 2.5 mg once or twice
a day.
NAUSEA AND VOMITING
Simple causes of vomiting are:

• Alimentary disorders, irritation, inflammation or
mechanical disturbances at any level of GI tract.
• Central nervous system—Increased intracranial
pressure, stroke, migraine, infection, toxins and
radiation sickness.
• Endocrine disorders—Diabetic acidosis, adreno-
cortical crisis, pregnancy, starvation, lactic acidosis.
• Drugs—Morphine, Meperidine, Codeine, anticancer
drugs.
• Psychological disorders—Reaction to pain, fear or
displeasure, chronic anxiety reaction, anorexia
nervosa, psychosis.
Treatment
i Simple acute vomiting following dietary or alco-
holic indiscretion or during morning sickness of
early pregnancy do not require much of treatment.
 Withhold foods temporarily and give 5 to 10 per
cent Dextrose saline solution IV.
 Avoid lukewarm beverages.
 Antiemetics, i.e. Perinorm, Emidoxyn, Avomin are
better for preventing vomiting.
 Sedatives alone or with anticholinergic may be

helpful with psychogenic vomiting.
 Domperidone is better as it has no parkinsonian
side effects.
ii. If symptomatic
Injection Perinorm IM.
or
Injection Stemetil 12.5 mg IM.
or
Injection Metachlorpramide (Reglan) 10 mg IV or
IM.
or
Tablet Perinorm or Domperidone one tds
or
Tablet Eskazine 1 mg tds.
Withhold food temporarily and start IV fluids
5 per cent Dextrose or Ringer’s lactate or Glucose
saline to correct dehydration.
iii. Eradicate the cause
 If psychogenic vomiting sedatives alone or with
anticholinergics. Injection Phenargan IM.
 If vomiting is following chemotherapy or
radiotherapy then tab Oncoden 4-8 mg tds Injection
2 mg/ml.
NODULAR CIRRHOSIS
• Anorexia, weight loss, anaemia, nausea, vomiting,
abdominal pain, diarrhoea.
• Palpable, firm liver with blunt edges.
• Ascites.
• Amenorrhoea, impotence, sterility.
• Spider naevi, palmar erythema.
• Splenomegaly, jaundice in some cases.
• Gynaecomastia, testicular atrophy, axillary and
pectoral alopecia are additional findings.
• Pleural effusion, ankle oedema, haematemesis are
late findings.
• Flapping tremor, dysarthria, delirium and
drowsiness are present in pre-coma state.
• Laboratory findings include bromosulphthalein
retention, elevated LDH, SGOT, alkaline phos-
phatase, bilirubin, decreased albumin, and elevated
gamma globulin.
• Liver biopsy shows diffuse fibrosis and nodular
regeneration throughout the liver.
Treatment
Salt upto 500 mg and fluid restriction
 Diuretic like Frusemide.
 Stop alcohol completely.
 High protein diet (100 gm), if required injection

Albumin 5 per cent or 20 per cent IV.
 Iron and folic acid for correction of anaemia.
 Vitamin K injection 10 mg IM.
 Tab Propanolol 20 mg twice to reduce portal
pressure.
If ascites is present
 Tab Spironolactone (Aldactone) 100-200 mg/day
increasing by 100 mg every 3 days if no
improvement (suggested by 1 kg weight loss in 3
days)
 If no response add Frusemide 20 mg increased to a
maximum of 120 mg.
 Check for electrolyte imbalance especially
hypokalaemia and alkalosis.
If ascites persists—Human Serum Albumin 5-20 per
cent 50-100 ml IV.
 In large ascites panacentesis is done.
If hematemesis is present
 Injection Vitamin K, 10 mg IV for 3 days.
 Injection Pitressin 20 CC diluted in 100 ml 5 per
cent Glucose over 10 minute.
or
 Injection Glypressin 2 mg IV 6 hourly for maximum
4 dose.
or
 Injection Somatostatin 250 mg bolus followed by

250 mg/hour.
 Balloon tamponade under vigilant supervision
endoscopic sclerotherapy may be done on emer-
gency basis since risk of rebleeding is high.
 For long-term endoscopic sclerotherapy-injection
of Varcies is done at the interval of 1-2 weeks.
 Propanolol is given in increasing daily dosage to
achieve a pulse rate of 60/minute to check rebleed-
ing. Shunt surgery and liver transplantation in
suitable cases.
If precoma is suspected
 Restrict protein.
 Neomycin 1 gm 6 hourly orally or through naso-
gastric tube, or
Streptomycin 1 gram six hourly by tube, or
Ampicillin 500 mg 6 hourly, or
Lactulose 30 ml tds, or
Metrogyl 800 mg/day.
NON-SPECIFIC
ULCERATIVE COLITIS
• Frequent passage of blood mixed stool (bloody
diarrhoea).
• Spontaneous remissions and exacerbations.

• Lower abdominal cramps with mild abdominal
tenderness usually on rectosigmoid area.
• Anaemia, no stool pathogens.
• Barium enema and X-ray shows irritability and fuzzy
margins to pseudopolyps, shortening of colon,
narrowing of lumen, loss of haustral markings.
• Sigmoidoscopic findings include hyperaemia,
petechiae and minimum granularity in mild cases
to ulceration and polypoid changes in severe cases.
Mucosa is friable and bleeds easily.
• Victims are adolescents or young adults.
Treatment
Severe fulminant disease

i. Immediate hospitalisation as there lies chance of
haemorrhage, perforation, toxic megacolon,
sepsis, etc. endangering life.
ii. Stoppage of oral intake, IV fluids and electro-
lytes, nasogastric suction if colon is dilated.
iii. Broad spectrum antibiotic singly or in
combination as a prophylaxis against sepsis
(Ampicillin, Chloramphenicol and Gentamicin).
iv. Prednisolone 300 mg IV daily at 6 hourly
interval.
v. Surgery: If patient remains toxic and colonic

dilatation does not improve within 8 to 12 hrs
colonic resection is indicated. Selective colectomy
may be performed in those who fail to improve
in the long run.
Moderate disease (Patient is not toxic but

diarrhoea, anaemia, asthenia are present)
 Hospitalisation and only cooked foods devoid of
milk and mild products to be taken.
 Prednisolone 20 to 40 mg daily, then reduced to
5 mg per week. Hydrocortisone 100 mg retention
enema each night.
 Sulfasalazine 2 to 4 gm daily in divided doses. If
patient is sensitive to sulphadrugs—Ampicillin,
Cephalosporin are the alternatives.
Mild disease (No systemic signs, only

painless bleeding)
 Diet devoid of milk and milk products.
 Sulfasalazine 2 to 4 gm orally daily in divided doses
as prolonged maintenance therapy.
 Hydrocortisone enema 100 mg every night until
lesion heals.
Surgery is indicated for patients with refractory
disease. Widespread involvement of colon, massive
haemorrhage or extracolonic complications (growth

suppression) or perirectal disease. Total colectomy
with permanent ileostomy is the surgery of choice.
 In severe cases retention enema of steroid at night
daily for 6 days. Injection Efcorline 100 mg or tablet
Betnesol 8 tablets dissolved in 100 ml normal saline
and given as slow rectal drip with patient in left
lateral position. Effort is made to retain enema
overnight.
Important—Broad spectrum antibiotics should
never be given orally as they may cause or wosen
diarrhoea.
PARALYTIC ILEUS
(Functional Obstruction)
• Continuous abdominal pain, distension, vomiting
and constipation.
• History of precipitating factors, i.e. after surgery,
peritonitis.
• Minimal abdominal tenderness and decreased or
absent bowel sounds.
• X-ray evidence of gas and fluid in the bowel.
Treatment
 Postoperative ileus responds to restriction of oral
fluid intake. Severe and prolonged ileus requires
nasogastric suction and IV fluids with complete
restriction on oral intake. Potassium depletion in
postoperative cases is often a cause for prolonged
ileus and needs potassium supplement under
proper ECG control.
 When conservative treatment fails surgical
decompression with enterostomy or caecostomy
may be done. If ileus is secondary to electrolyte
imbalance, severe infection, pneumonitis, intra-
abdominal/back injury, the ileus is managed as
above plus treatment of the primary disease.
PEPTIC OESOPHAGITIS
• Retrosternal burning, pain and heaviness.
• Symptoms aggravated by recumbency or increased
abdominal pressure, relieved by upright position.
• Nocturnal regurgitation with cough and dyspnea in
some case.
• Hiatus hernia on X-ray.
• Common in middle aged obese females or with
patients of increased intra-abdominal pressure.
• Oesophagoscopy showing hyperaemia and

ulceration.
• Erosion when seen is confirmatory. Biopsy is manda-
tory to exclude malignancy.
Treatment
 Advise patient not to lie down immediately after
food and to sleep with head end of bed being raised
9" to 10".
 Weight reduction if obese and avoidance of tight
belts/corsets.
 Antacid 2 tab to be chewed 1 hr after each meal
and at bed time.
 Large hiatus hernia or paraoesophageal ones
requires surgical correction.
 Ranitidine 150 mg twice daily for 4 to 6 weeks.
PRIMARY BILLIARY CIRRHOSIS
• Insidious onset.
• Pruritus followed by jaundice.
• Hepatosplenomegaly.
• Xanthomatous lesions around eyelids.
• Serological tests reflect cholestasis with elevated

alkaline phosphatase, 5 nucleotidase, cholesterol,
bilirubin.
• Serum is positive for antimitochondrial antibodies.
• Mainly in ladies of age group 40 to 60 years.
Treatment
 Cholestyramine to relieve pruritus.
 Vitamin A, K and D for steatorrhoea (Parenteral
administration).
 Corticosteroids and Azathioprine in selected cases.
 Portal hypertension (enlarged spleen, ascites, oeso-
phageal varices) to be treated as discussed under
nodular cirrhosis.
 Liver transplantation.
RECTAL POLYP
• Painless rectal bleeding in a child.
Treatment
 Simple polypectomy by avulsion.
REGIONAL ENTERITIS
(Crohn’s Disease)
• Insidious onset.
• Intermittent bouts of diarrhoea, low grade fever.
• Pain, tenderness and often mass in right iliac fossa.
• Symptoms due to bowel perforation, i.e. localised
abscess, internal/external fistula, peritonitis.
• Extra-intestinal manifestations like:
a. Arthritis, subacute migratory, asymmetrical,
polyarthritis lasting for one to two weeks princi-
pally involving knees and ankles.
b. Erythema nodosum.
c. Uveitis.
Treatment
General measures
 Diet should be high in calories and vitamins and
low in fat and roughage.
 For diarrhoea.
Tab Diaphenoxylate or Loperamide.
 For general malaise—Iron vitamin B12 and supple-
ments of potassium and magnesium.
 Tab Salazopyrine 500 mg thrice daily.

 Tab Prednisolone 0.25-0.75/k/day for 3-4 months.
 If seriously ill-injection Hydrocortisone 100 mg 8
hourly or IV Dexamethasone 8 mg 8 hourly.
If above therapy fails then
 Azathioprine 2.5 mg/kg/day
or
Mercaptopurine 1.5/kg/day
 If acute suppuration indicated by fever,
leucocytosis and tender mass then
 Injection Ampicillin 4-8 gm IV daily followed by
2-4 gm orally.
SECONDARY BILIARY
CIRRHOSIS
• Symptoms of long standing cholestasis either due
to carcinoma head of pancreas or choledo-
cholithiasis.
• Serum is negative for mitochondrial antibodies.
Treatment
 Removal of causative factors are symptomatic
treatment.
SPRUE SYNDROME
(Tropical Sprue)
• Pale, bulky, greasy, frothy, foul smelling stool with
increased faecal fat on chemical analysis.
• Weight loss and multiple vitamin deficiency.
• Impaired intestinal absorption of glucose, vitamins
and fat.
• Hypochromic or megaloblastic anaemia. X-ray-her-
ring bone appearance.
• Skin pigmentation.
Treatment
 Complete rest in severe cases and restriction of
activity in mild case.
 Diet: High protein, low carbohydrate and low fat
diet.
 Folic acid 10 to 20 mg daily orally or intramus-
cularly for a few weeks corrects diarrhoea, ano-
rexia, weight loss, glossitis and anaemia. Once
acute symptoms subside patient can be maintained
on Folic acid 5 mg daily.
 Antibiotics: Broad spectrum antibiotic 250 mg
6 hourly for few days.
 Cap Minicycline 100 mg twice daily.
 Prednisolone: 50 mg daily for first few days and

then maintained on 15 mg daily. It increases absorp-
tion of nitrogen, fat and has a nonspecific effect in
producing euphoria and increase appetite. For
malabsorption and steatorrhoea-Pancreatic enzy-
mes-Merckenzyme tabs 2 with meals.
TYPHOID FEVER
• Gradual onset of malaise, headache, sore throat,
cough and finally pea-soup diarrhoea or consti-
pation.
• Slow rise (Step-ladder) of fever to maximum and
then gradual lowering down of fever is common
with maximum temperature at evening hours
(variation less than 2F). Temperature never becomes
normal.
• Relative bradycardia, splenomegaly, abdominal
tenderness and distention, with rose spots.
• Leucopenia, positive blood culture in first week and
positive stool and urine culture.
• Positive widal test with increasing titre.
Treatment
Drug of choice
 Ciprofloxacin 500 mg bd × 10 days or Tefloxacin
400 mg bd or Norflox 400 mg bd or Ofloxacin 200
mg bd or Cefuraxime 500 mg bd × 7 days.
 Hydrocortisone 100 mg IV 8 hourly in severely
toxic patients, the danger of perforation should be
weighed carefully.
 Parenteral fluid and vitamins control fever.
 High calorie and low residue diet.
 Perforation needs immediate surgery.
UPPER GASTROINTESTINAL
HAEMORRHAGE
There may be rapid loss of sufficient blood to cause
hypovolaemic shock.
• There is usually history of sudden weakness or
fainting associated with or followed by black tarry
stools or vomiting.
• Malena occurs in all patients and haemataemesis in
50 per cent patients.
• There is usually no pain and the pain of peptic
ulcer often stops with the onset of bleeding.
• There may be a history of peptic ulcer, chronic liver
disease, alcohol excess or severe vomiting.
Treatment
 Complete bed rest. Ice cold saline gastric lavage
through Ryle’s tube till returning fluid is clear.
 Reassure the patient.
 Inj Calmpose or Valium 10 mg IM. Repeat after
8 hours if necessary.
 Inj Stemetil 12.5 mg IM.
If state of shock:
 Inj Plasma IV drip.
or Inj Lomodex 500 ml.
 Inj Glucose saline 500 ml.
Indications for blood transfusion are:
 Pulse rate more than 130/minute.
 Systolic BP less than 90 mm Hg.
 Hb less than 60 per cent.
 O2 inhalation may be required.
VINCENT’S STOMATITIS
• Ulcer surface covered with grey pseudomembrane
surrounded by erythema.
• Fever, gingival bleeding, lymphadenopathy.
Treatment
 Metronidazole 200 mg tds × 5 days.
 Cap Becosule 1 daily.
 Alkaline mouth wash.
VIRAL HEPATITIS
(Infectious Hepatitis)
• Anorexia, nausea, vomiting influenza like syndrome.
• Fever, soft enlarged tender liver, jaundice.
• Abnormal liver function tests with elevation of
SGOT, SGPT and LDH.
• Liver biopsy is characteristic.
Treatment
 Bed rest at the initial stage of the disease with gra-
dual return to normal activity in convalescence.
 Plenty of oral Glucose or IV Glucose 10 per cent if
oral intake is hampered due to nausea/vomiting.
 A palatable diet with less fat. If patient shows any
signs of impending coma, protein should be
withheld.
 Plenty of vitamin B-Complex and vitamin ‘K’.
 Liv-52 can be given empirically at the dose of 2 tab
tds for 1 to 2 months.
 If jaundice is progressive, Corticotropin or

Prednisolone. Prednisolone is given for 20 days at
the dose of 2 tab (5 mg tab) tds for 5 days, 1 tab tds
× 5 days, 1 tab bd × 5 days and 1 tab od × 5 days.
 Phenobarbitone if restlessness occurs.
 1 per cent Phenol with Calamine lotion or Choles-
tyramine 4 gm daily to reduce itching.
Neomycin/Paramomycin only when precoma
occurs. Serum hepatitis is transmitted by infected
blood or blood products. Its incubation period is
long (6 weeks to 6 months) and its onset is more
insidious. The clinical picture is similar to that of
infectious hepatitis. The blood of the patient is
positive for Australia antigen.
Prophylaxis
Hepatitis A—Human normal immunoglobulin 0.002
ml/kg IM soon after exposure.
Hepatitis B—Vaccine Engerix B given IM in deltoid
muscle. Same dose for all ages in 3 doses. Second dose
1 month after first dose and third dose 6 months after
1st dose.
WILSON’S DISEASE
• Symptoms of cirrhosis (jaundice, portal hypertension,
splenomegaly) or chronic atypical hepatitis.
• Basal ganglion dysfunction like rigidity, Parkinsonian

tremor.
• Kayser-Fleischer rings are pathognomonic (fine
pigmented granular deposits in membrane of the
cornea).
• Low serum ceruloplasmin (less than 20 mg), increa-
sed urinary copper excretion.
Treatment
 Oral Penicillamine 1 to 1.5 gm daily in divided
doses is the drug of choice, to be continued
indefinitely.
 If patient is intolerant to Penicillamine, Triethylene
teramine may be tried.
ZOLLINGER-ELLISON
SYNDROME
• Severe uncontrollable peptic ulcer syndrome.
• Gastric hypersecretion.
• Elevated serum gastrin more than 300 pg/ml.
• Gastrinoma of pancreas, duodenum or at other
ectopic site.
Treatment
 For prolonged period/Famotidine/Ranitidine/
Omeprazole may be given in higher doses.
 Omeprazole 40-80 mg od.
 If unresponsive to drugs surgical resection is
advised.
RESPIRATORY DISEASES
ACUTE BRONCHITIS
• Productive cough (mucoid to mucopurulent).
• Fever.
• Rhonchi and crepitation in the chest with occasional
wheeze.
• Absence of X-ray findings.
Treatment
 Bed rest with complete prohibition of smoking.
 Hot drinks such as tea, coffee to help expectoration.
 Steam or tincture benzoin co-inhalation to relieve
cough.
 If non-productive cough is exhausting then give
Linctus codein one teaspoonful thrice daily.
 If cough is productive Benadryl expectorant or Zeet
expectorant 1 teaspoonful thrice daily.
 Antibiotics to be prescribed only in severe or
complicated cases to prevent secondary infection
Respiratory Diseases 59
and in children. Ampicillin or Amoxycillin 250-500

mg four times daily.
 Antipyretics (Crocin) or analgesics (Dispirin) to
relieve fever and pain.
ADULT RESPIRATORY
DISTRESS SYNDROME
This term describes the non-cardiogenic pulmonary
oedema occurring in association with massive trauma,
hypotension of any cause, cardiopulmonary bypass
procedures, severe infections, septicaemia, narcotic over
dose, etc. There is damage to pulmonary capillary endo-
thelium producing increased permeability, interstitial
and alveolar haemorrhage and oedema.
• Dyspnoea, tachypnoea, anxiety, altered sensorium.
• Arterial hypoxaemia with hypocapnoea.
• Diffuse alveolar and interstitial infiltrates on chest X-
ray.
• Decreased pulmonary compliance, i.e. arterial
oxygen saturation does not increase inspite of
increasingly high concentration of inspired oxygen.
Treatment
 Hospitalise the patient.
 Treat underlying cause.
 High flow oxygen via mask or endotracheal tube.
If despite this PaO2 is not maintained, or If res-
piratory failure then.
 Mechanical ventilation with large tidal volume (15
ml/kg) or positive end expiratory pressure
method.
 Fluid balance by Saline or Ringer’s lactate 20-25
ml/kg/day IV.
 Broad spectrum antibiotics for suspected site of
sepsis.
 Injection Lasix 40-80 mg IV. Low dosage Dopamine
to maintain satisfactory urine output.
ATELECTASIS
• Acute cases: Dyspnoea, tachycardia, cyanosis, chest
pain, fever and hypoxaemia.
• Chronic cases: No symptoms, only diagnosed on X-
ray.
• Important signs include retraction and immobility
of chest on one side, displacement of mediastinum
towards affected side, impaired percussion note on
affected side with hyper resonance on healthy side,

diminished to absent breath sounds on affected side.
• Radiological findings consistent with atelectasis are
lobar or segmental density, often homogeneous with
reduction in the size of the affected lobe. Tracheal
deviation to affected side with elevation of dia-
phragm in massive atelectasis.
Treatment
 Oxygen inhalation.
 Relief of pain with low doses of Morphine or
Pethidine.
 Relief of obstruction:
i. Removal of foreign body by bronchoscopic
manoeuvre.
ii. Removal of secretion by mucolytics (Brom-
hexine), bronchodilators, postural drainage.
iii. Tracheal suction.
 Antibiotics to prevent infection in atelectic lung.
Ampicillin 250-500 mg four times.
 Assisted ventilation: Tracheostomy may be
performed for the purpose of reducing the dead
space and to facilitate aspiration of secretions. Inter-
mittent positive pressure breathing greatly helps
the seriously ill patient.
 In postoperative atelectasis the main treatment is
induction of hyperventilation and stimulation of
coughing.
ATYPICAL PNEUMONIA
(Mycoplasma Pneumonia)
• Increasing intensity of cough with scanty sputum.
• Minimal signs on chest examination, i.e. rales and
other signs of consolidation.
• X-ray shows pulmonary infiltration often extensive,
disproportionate to physical findings.
• Normal WBC count.
• Fever is constant, low grade without chill and patient
does not appear seriously ill inspite of extensive chest
lesions and continued fever.
Treatment
 Bed rest.
 General supportive treatment as for pneumococcal
pneumonia.
 Antibiotics only in severe cases.
 Ampicillin or Erythromycin 500 mg 6 hourly for
2 weeks are preferable.
 Analgesic + antipyretics to control pain and fever.
BRONCHIAL ADENOMA
• Insidious onset of dry cough with localised wheeze.
• Haemoptysis in 25 to 30 per cent cases.
• Evidence of bronchial obstruction leading to collapse,
bronchiectasis.
• Bronchoscopy and biopsy or exploratory thoraco-
tomy confirms the diagnosis. As the tumour does
not exfoliate, sputum examination is not helpful.
Treatment
The ideal treatment is lobectomy. Fewer noninvasive
pedunculated adenomas may be removed by
bronchoscopy but serious bleeding may occur.
BRONCHIAL ASTHMA
• Recurrent attacks of dyspnoea, cough with mucoid
tenacious sputum and wheezing.
• Expiratory rhonchi all over chest.
• Symptoms promptly reversible with broncho-
dilators.
• X-ray chest—normal in early cases. Emphysematous
changes with pneumothorax in late cases.
Treatment
Acute attack
 Get out of bed.
 Take extra puff of aerosol inhaler.
 Take some hot tea or beverage or sips of warm
water.
 Injection of Adrenaline 0.5 ml subcutaneously.
 If aerosol is ineffective, prolonged repeated attacks
at night causes immobilisation then start course of
Prednisolone 5 mg tablet, 2 tablets tds. Then
reduce dose gradually.
 Asthaline inhalation—Take deep breath for 5-10
seconds. Two puffs to be inhaled at the interval of
5 minutes. Alternative is Terbutaline inhalation.
If no relief—hospitalise
Severe acute asthma—Diagnostic features are:
 Lack of response to normal medication.
 Inability to talk or complete a sentence.
 Increasing tachycardia and respiratory rate.
 Pulsus paradoxus.
 Hypotension.
 Silent chest.
 Cynosis.
Increasing distress and exhaustion.
 Hospitalise.
 Arterial blood gas estimation.

 X-ray chest to rule out pneumothorax.
 Oxygen at high flow rate 6-8 litre per minute by
nasal prongs or mask.
 Injection Aminophylline 250 mg IV or 6 mg/kg IV
slowly over 30 minutes followed by 0.6 mg/kg/
hr.
 Injection Hydrocortisone 5 mg/kg IV six hourly.
Double dose if no improvement in 8 hours.
 Nebulisation by Salbutamol or Terbutaline 2.5 mg,
2-4 hourly.
If improvement is seen, reduce nebulisation to
6 hourly.
If no response
 Injection Salbutamol 200 mg/IM or 100 mg IV.
or
 Injection Terbutaline 0.25-0.5 mg SC or IV over 10
minute followed by maintenance dose of 12.5 mg/
minute.
 Antibiotics if evidence of infection-fever, purulent
sputum.
After attack subsides
 Tab Tedral SA or Asthalin SA twice a day.
or
Tablet Terbutaline 2.5-5 mg tds.
 Phensedyl linctus 1 tsf hs.
Chronic asthma
 Avoid known allergens.
 Stop smoking.
 Drugs.
Preventives—Beclate inhalation, metered dose
inhaler 50 mg per metered dose, 2 inhalations 3-4 times
daily.
or
Rotacaps 200 mg inhaled in rotahaler 3-4 times
daily.
or
Oral Prednisolone or Betamethasone at minimum
effective dose.
 Sodium Cromoglycate inhalation by metered dose
inhaler 2 puffs 4 times daily.
 Ketofen 1 mg tab, 1-2 tablets with food.
Relievers
Salbutamol 2-4 mg bd or Theophylline SR 200 mg bd
Exercise induced asthma.
Inhalations of Salbutamol.
or
Terbutaline prior to exercise or Sodium chromo-
glycate inhalation.
BRONCHIECTASIS
• Chronic cough with profuse, purulent sputum.
• Bilateral basal coarse crepitations with rhonchi.
• Clubbing of fingers, haemoptysis.
• Signs of general toxaemia, e.g. anaemia, anorexia,
weight loss, etc.
• Pulmonary osteoarthropathy, varying degree of
dyspnoea.
• Sputum production is more during change of
posture. Sputum often separates into three layers,
i.e. sediment, fluid and foam on standing.
• Plain X-ray chest shows increased pulmonary
markings at bases with multiple radiolucencies.
• Bronchogram shows saccular, cylindrical or fusiform
dilatations with loss of normal “tree in full bloom
pattern” of the terminal bronchi.
Treatment
 Bed rest.
 Avoid exposure to smoke, dust, fumes.
 Warm, dry climate is preferable.
 Mucolytic agents, i.e. acetylcysteine by aerosol to
liquify thick sputum.
 A hot drink before postural drainage may help to
liquify sputum. Attempts to dislodge the secretions
should be made by coughing and by percussing

the affected part of the chest. Drainage should be
done for 10 minutes.
 Ampicillin 500 mg four times daily or Septran DS
twice daily.
 Adequate nutrition.
Indications for surgical resection are:

 Unilateral bronchiectasis with more than 1 ounce
of sputum in 24 hours.
 Repeated major infections in bronchiectatic area.
 Young adults.
Contraindications of surgery are:

 Old age.
 Poor cardiorespiratory reserve.
 Bilateral extensive disease.
Other antibiotics
 Ciprofloxacin 500 mg twice daily.
or
Pefloxacin 400 mg twice daily.
To be continued till sputum becomes mucoid.
If acute infection does not subside or recurs quickly
culture sputum and prescribe antibiotic as per
sensitivity.
BRONCHIOLAR CARCINOMA
• Patients are in the age group of 50 to 60 years.
• Chest pain with copious watery or mucoid sputum.
• Bilateral involvement is very common.
• Dyspnoea, cyanosis, dullness on percussion, clubb-
ing, cor pulmonale, etc.
• Chest X-ray shows bilateral, discrete or diffuse
lesions.
• Sputum cytology is diagnostic.
If the lesion is unilateral, localised without extrapul-
monary metastasis surgical removal is indicated.
• Sputum cytology, bronchoscopy, biopsy of palpable
nodes, mediastinoscopy, tomography and scanning
procedures determine the exact location, extent and
spread of the disease.
Treatment
 Early detection and surgical removal before meta-
stasis occurs.
 Small doses of cytotoxic drugs with radiotherapy
offer some hope of improved palliation.
As a precautionary measure chest X-ray once a
year for smokers above 40 years of age is recom-
mended.
BRONCHO-PNEUMONIA
• Fever, cough, dyspnoea.
• Greenish-yellow expectoration with mixed bacterial
flora on culture.
• Leucocytosis.
• Patchy infiltration in X-ray.
• Varied signs of rhonchi, fine crepitation and bronchial
breathing.
Treatment
 In case of infants and young children disease has to
be treated on emergency basis.
 Good nursing is essential to conserve child’s
energy.
 Sedatives may be given if child is restless and
distressing.
 High concentration of O2 will relieve distress.
 Crystalline Penicillin 5 lacs units IM 6 hourly or
Amoxycillin 25 mg/kg/day in divided doses 6-8
hourly.
 In dry cough, linctus may be given.
 Collapse—Stimultants like Coramine or Micoren.
 Fever—Crocin/Mejoral may be used.
CHRONIC BRONCHITIS
• Productive cough of longer duration (at least 2 years)
getting worse in winter or on exposure to cold.
• Dyspnoea in advanced cases.
• Fever is absent except during acute exacerbations.
• Widespread rhonchi, basal crepitations and prolon-
ged expiration.
• X-ray shows prominent broncho-vascular markings.
Treatment
 Sources of possible chronic irritation should be avoi-
ded, i.e. smoking, allergenic agents, fumes, dust
and other irritants.
 For non-productive cough—Codein phosphate 15
to 30 mg every 4 hours.
 For thick sputum.
1. Inhalation, and expectorants.
2. Mucolytic agents, i.e. Bromhexine.
 For bronchial spasm. Terbutaline 2.5 to 5 mg 4
hourly.
or
Salbutamol 4 mg 6 hourly.
 Antihistamines and short-term Prednisolone in case
of allergy, i.e. Prednisolone 5 mg 4 times daily for 3
to 4 days and then gradually reduced and elimi-

nated over next 7 days.
 Antibiotics preferably Ampicillin or Ciprobid if
sputum is purulent. Use of maintenance dose of
antibiotics at half the dose to reduce severity and
duration (but not frequency) is advisable in deser-
ving cases. Long acting Penicillin are preferable if
patient is not sensitive to Penicillin.
No response
Capsule Cephalexine 500 mg qid.
or Cefaclor 250 mg twice daily.
or Cefuroxine 250 mg twice daily.
or Azithromycin 250 mg daily.
or Lomofloxacin 400 mg daily.
For bronchospasm
 Injection Aminophylline 500 mg IV slowly or
Salbutamol-Theophylline 2 tds.
For persistent spasm
 Tab Prednisolone 400 mg daily × 7 days. Followed
by maintenance of 10 mg daily.
 Treatment of acute/chronic respiratory failure is
discussed separately.
EMPHYSEMA
• Insidious onset of exertional dyspnoea gradually
progressing to dyspnoea at rest.
• Prolonged expiration with wheezing.
• Barrel shaped chest, accessory muscles of respiration
are acting.
• Often ineffective productive cough.
• Old history of asthma, bronchitis, fibrotic pulmonary
disease or a familial predilection.
• Over aerated lung fields with flattened diaphragm
on chest X-ray.
• Varying signs and symptoms of respiratory acidosis,
i.e. tetany, headache, tremor, etc.
• Percussion note is hyper-resonant, with diminished
breath sounds, prolonged high pitch expiratory
phase.
• Signs of anoxia, i.e. clubbing, cynosis.
• Right heart failure with depressed/enlarged liver in
terminal stages.
• Pulmonary function tests confirm respiratory
obstruction. The simplest outdoor tests being the
inability in putting out a burning match stick at a
distance of 1 foot or exhaling the total vital capacity
in more than 5 seconds.
Treatment
 Mild physical activity.
 Avoid pulmonary irritants, i.e. smoking, exposure
to dust, humid or cold air.
 Control of bronchial secretion—Mucous liquifica-
tion by giving plenty of fluids, Bromhexine and
facilitation of expectoration by giving expectorants.
 Control of respiratory infection by giving the
appropriate antibiotic. When mixed organisms are
likely, long course of Tetracycline is preferable.
 Relief of respiratory obstruction by use of broncho-
dilators, preferably in the aerosol form. Salbutamol
or Ventolin are preferred.
 Breathing exercises to improve alveolar ventilation,
i.e.
a. To exhale through closed lips gradually and as
completely as possible.
b. Rapid inhalation.
c. To contract abdominal muscles gently during
expiration.
 Intermittent positive pressure breathing for patients
of advanced respiratory acidosis.
 Corticosteroids in lowest doses especially to
patients of chronic bronchitis.
 Phlebotomy especially if polycythemia is trouble-
some.
EMPYEMA
• Signs of pleural effusion.
• Fever, toxicity, pleural pain.
• Frankly purulent exudate on thoracocentesis. Lack
of bacterial growth suggests tuberculosis.
Treatment
 Aspiration of pus every second or third day.
 Antibiotics preferably according to culture and
sensitivity test. Pending culture report, crystalline
Penicillin 10 lacs IM 6 hourly is started. So also intra-
pleural instillation with 5 lacs units diluted in 5 to 10
ml of saline is done.
 Intercostal drainage if there is no improvement
with antibiotic and aspiration.
 Breathing exercises as soon as signs of general toxi-
city disappear.
In chronic empyema there are recurrent attacks of
fever and chest pain. Anaemia, weight loss, clubbing
of fingers, chest wall deformity, bronchopleural
fistula or sinus tract to skin may occur. The treatment
consists of decortication of pleura and evacuation of
pus combined with proper chemotherapy.
HAEMOPTYSIS
• Signs and symptom of pulmonary or cardiac
diseases.
• Blood is coughed up.
• Blood is bright red, frothy and mixed up with
sputum.
• Reaction alkaline.
• Sputum becomes rusty next day.
Common Causes
• Pulmonary tuberculosis.
• Mitral stenosis.
• Lung diseases, i.e. bronchiectasis, acute pneumonia,
infarct, fibrosis.
• Ulceration of larynx or trachea.
Haemoptysis Haematemesis
Blood is coughed up Blood is vomited
Blood is alkaline and Blood is acidic, brown
bright red in colour
Part of body is frothy Blood not frothy
Blood is mixed with sputum No mixed sputum
Previous history of Previous history of gastric
respiratory disease illness
Normal stools Stools are black and tarry
Episode lasts for days Brief episode
Treatment
 Inj Calmpose or Valium 10 mg IM. If small haemo-
ptysis. Tab Calmpose 1 stat.
 In severe cases inj 100 mg Pethidine.
 Bed rest in semi-reclining position and leaning on
the elbow on affected side to minimise aspiration
of blood.
 Blood transfusion if profuse bleeding.
 Antitussive if cough is exhaustive or troublesome.
Small doses of Codein or other cough suppressive
may be given.
 Antibiotics are of preventive use to avoid
secondary infection.
Note—Haemostatic agents are of no value in control
of haemoptysis.
HAEMOTHORAX
The common causes are trauma, tumours, tuberculosis
and pulmonary infarction. The pleural sac is to be evacua-
ted at the earliest with thoracocentesis and water seal
drainage. If bleeding continues thoracotomy is indi-
cated. Surgical removal of blood clots may be neces-
sary.
HYDROTHORAX
In hydrothorax the effusion fluid is serous or transudate
with specific gravity less than 1015 and protein content
less than 3 gm per cent. It is commonly associated with
congestive heart failure, obstruction of superior vena
cava, cirrhosis, hypoproteinemia, etc. Thoracocentesis
should be done to relieve dyspnoea and the treatment
is for the underlying causes.
LOBAR PNEUMONIA
• Chest pain, fever, chills, cough with rusty sputum
toxaemia and tachypnoea.
• Chest X-ray shows pulmonary infiltration often lobar
in distribution.
• Examination shows classical signs of consolidation,
i.e. dullness, inspiratory crepitation, absent breath
sounds to bronchial breathing VF and VR increased.
• Pneumococci present in sputum, identified on culture.
• Leucocytosis.
Treatment
 Inj Procaine Penicillin 6 lacs IM twice daily in mild
cases and Inj Crystalline Penicillin 10 lacs IM six
hourly in severe cases. If patient is sensitive to Peni-

cillin start Cephalexin or Erythromycin. Treatment
should continue for 3 days after defervescence.
or injection Ampicillin 500 mg 6 hourly.
or cap Synthromycin 500 mg 6 hourly.
If patient is sensitive to Penicillin capsule Cephalexin
500 mg 6 hourly.
or injection Cephaloridine 500 mg 6 hourly.
Antibiotics according to causative organism
(pneumococcal is a common causative organism).
 Ampicillin 500 mg cap 6 hourly.
or Ciprofloxacin 500 mg twice daily.
or Pefloxacin 400 mg twice daily.
or Ciforclor 500 mg twice daily.
 Staphylococcal (Abscess formation is common).
 Cloxacillin 500 mg 6 hourly.
For amoebic organism.
 Injection Metrogyl 400 mg tds.
 Injection Gentamicin 80 mg 8 hourly.
Klebsiella
 Chloramphenicol 500 mg six hourly.
 Injection Gentamicin 80 mg 8 hourly.
Pseudomonas
Injection Gentamicin 80 mg 8 hourly.
or injection Cabelin 8 gm IM in 24 hours.
or Ticarcillin 15-20 gm/day IM for 10 days.
 O2 inhalation (humidified).
 Treat shock and pulmonary oedema if present.
 Manage toxic Delirium with Diazepam or Pheno-
barbitone.
 Pleuritic pain can be relieved with Codein phos or
by spray of Ethylchloride over the skin.
 Abdominal distension can be relieved with naso-
gastric suction, Inj Neostigmine methyl sulphate
or by passage of flatus tube.
 Congestive cardiac failure and cardiac arrhythmia
need proper treatment.
If marked improvement does not occur after 72
hours of effective treatment, consider these 3 main
possibilities.
1. Presence of empyema, lung abscess, endocarditis,
meningitis.
2. Infection by organisms other than pneumococcus
and resistant to the drug.
3. Possible drug fever or any associated disease.
LUNG ABSCESS
• Septic fever and sweats, sudden expectoration of
large amounts of purulent, foul smelling or rusty
sputum, occasional haemoptysis.
• The above symptoms appear 1 to 2 weeks after possi-

ble aspiration, bronchial obstruction (carcinoma) or
previous pneumonia.
• Signs of consolidation with cavernous breathing on
physical examination.
• X-ray shows cavity with fluid level.
• Weight loss, anaemia and pulmonary osteo-
arthropathy in chronic abscesses of 8 to 12 weeks
duration.
Treatment
 Injection Chloramphenicol 500 mg 6 hourly.
or Injection Cefotaxine 1 gm twice daily.
or Injection Gentamicin 80 mg 8 hourly.
or Cap Cephalexin 500 mg 6 hourly.
or Anaerobic organism Tab Metronidazole 400 mg
tds.
 Inj Cryst Penicillin 6 lacs IM 6 hourly or Erythro-
mycin 500 mg 6 hourly (in patients allergic to Peni-
cillin) for 2 weeks. If the patient improves continue
treatment for 1 to 2 months. If fever does not
subside even 2 weeks after therapy or abscess dia-
meter is more than 6 cm in diameter or with very
thick cavity wall consider surgical resection.
 Drainage of the cavity either by:
a. Postural drainage with clapping over the
abscess site.
b. Bronchoscopic drainage if possible.
 100 per cent oxygen inhalation to check growth of

anaerobic organisms.
 Supportive therapy as rest, high protein diet,
vitamin supplements, etc.
MEDIASTINAL TUMOUR
• Substernal pain, occasionally radiating to shoulder,
neck, arm mimicking cardiac pain.
• Tracheal/bronchial compression may cause sterto-
rous breathing, cough, dyspnoea and pulmonary
infections.
• Hoarseness due to compression of left recurrent
laryngeal nerve.
• Mild to severe dysphagia due to external compres-
sion of oesophagus.
• Superior vena cava syndrome, i.e. dilated neck veins,
collateral veins on thoracic wall, fullness of neck and
face.
• Horner’s syndrome, i.e. miosis, ptosis, and enoph-
thalmos due to compression of sympathetic outflow.
• Many tumours are asymptomatic and are only disco-
vered on routine X-ray.
• X-ray of chest after barium swallow, lymph node
biopsy of supraclavicular/cervical nodes, media-
stinoscopy confirms the diagnosis.
Treatment
Depends upon the primary disease and histologic
characteristic of the mass.
PLEURAL EFFUSION
• Dyspnoea if effusion is large or of rapid onset,
asymptomatic in minimal effusion of gradual onset.
• Pleuritic pain often precedes the effusion.
• Stony dullness on percussion, decreased breath
sounds, decreased to absent vocal fremitus, shifting
away of mediastinum.
• The underlying pulmonary/cardiac disease may be
a source of major symptoms, e.g. pulmonary tuber-
culosis, bronchogenic carcinoma, infarction, thoracic
duct obstruction (chylous effusion).
• X-ray evidence: Obliteration of costophrenic angle is
the earliest sign. Triangular homogenous shadow of
the fluid with apex in the axilla is noted in later cases.
Distribution of fluid in the interlobar fissures or in
loculated form may be noted as also shifting of
mediastinum.
• Thoracocentesis is the definitive diagnostic proce-
dure.
Treatment
 Rest in bed till fluid gets absorbed, nourishing diet,
vitamins.
 Fluid should be removed otherwise.
i. Fibrin is deposited.
ii. Pleura becomes thickened.
iii. Re-expansion of lung is hampered.
iv. Frozen chest may develop.
 Indications for aspiration of fluid are:
i. Large effusion up to clavicle.
ii. Bilateral effusion.
iii. Fluid is haemorrhagic or has high content of
protein.
 If effusion is tuberculous anti-tuberculous
treatment is to be given.
 Corticosteroids should be given in large effusions
who are acutely ill or if loculation of fluid has
occurred.
 Effusion due to malignant tumours.
 Pleural aspiration—Choose an intercostal space
over the area of maximum dullness. Infiltrate local
anaesthetic to parietal pleura after cleaning the area.
Put in the needle through the space and aspirate
through syringe.
 If malignant, i.e. rapid accumulation after repeated
aspiration then inject Tetracycline.
 Drain the effusion over night by intercostal tube.
 Tetracycline HCl 500 mg dissolved in 20 ml saline is

injected into pleural space via the intercostal tube
followed by further 20 ml saline. The tube is then
clamped for 6 hours during which time the patient’s
position is changed frequently. The tube is then
unclamped and free drainage allowed till no further
fluid escapes. The tube is then removed.
Effusion tends to reaccumulate rapidly and requires
frequent removal. An attempt should be made to
control the reformation of fluid by irradiation of
hemithorax or intrapleural cytotoxic drugs.
PULMONARY OEDEMA
• Chest pain, dyspnoea, orthopnoea.
• Presistent cough with copious frothy expectoration
often blood tinged.
• Bubling rales over lower lobes then spreading all
over chest.
• Sweating, hypothermia.
Treatment
 O2 inhalation by continuous or intermittent posi-
tive pressure method.
 Tracheal suction.
 IV Frusemide 40 mg.
 IV Aminophylline 500 mg.
 Correction of metabolic/respiratory acidosis by
administration of Soda-bicarb.
 Hydrocortisone upto 1 gm IV daily.
 Treatment of specific condition precipitating the
attack, i.e. treatment of left heart failure with
Digoxin, etc. Treatment of circulatory overload by
venesection or trapping of blood in lower limbs by
application of sphygmomanometer cuffs to thighs
and inflating them half way between systolic and
diastolic pressure.
PULMONARY
THROMBOEMBOLISM
• Sudden onset of dyspnoea, anxiety (with or without
substernal pain), signs of acute right heart
failure and circulatory collapse in large pulmonary
emboli.
• Pleuritic pain, cough, haemoptysis, pleuritic friction
rub, fever with signs of consolidation and in some
cases of pleurisy develop 12-24 hours later due to
pulmonary infarction.
• Gradually developing unexplained dyspnoea with

or without X-ray densities may indicate repeated
minor embolisation to the lungs.
• History of thrombophlebitis is commonly present.
• Recent myocardial infarction, infective endocarditis,
mitral stenosis may be discovered as the cause of
discharge of embolus to the lungs.
• X-ray may show: (a) density signifying congestive
atelectasis or pulmonary infarction, (b) small pleural
effusion, (c) raised poorly mobile diaphragm.
• Cardiovascular signs include tachycardia, accen-
tuation of P2, wide splitting of aortic and pulmonary
valve sounds, diastolic gallop. Shock, cyanosis and
elevated central venous pressure.
• Lung scanning and pulmonary angiography are
confirmatory.
• Transient ECG changes in 10 to 20 per cent cases
showing deep S wave in lead I, prominent Q wave,
inverted T in lead III and right axis deviation.
Treatment
 100 per cent oxygen therapy.
 Heparin 1000 IU IV followed by 5000 IU every 4
hourly for 5 to 7 days or 1000 IU IV by infusion
every hour. Heparin administration is monitored
by partial thromboplastin time, prothrombin time
which would be 1½-2 times of the normal.
 For pain give Morphine 15 mg IM or 5 mg IV.

Avoid these agents if there is shock. IM route should
not be used in heparinised patients.
 Treatment of shock with Dopamine and Nor-
adrenaline.
 Antibiotics to prevent secondary infection.
 Aminophyline and digitalis to control dyspnoea
and heart failure.
 Pulmonary embolectomy for massive emboli not
responding to therapy.
Follow-up treatment
 Recurrence of emboli inspite of adequate anti-
coagulants may require venacaval interruption.
 Warfarin should be continued for a period of 3 to 6
months in patients with risk factor (prior history of
thromboembolism).
Prevention
Patients over age of 40 who are to undergo surgery
may be given 5000 IU of heparin subcutaneously 12
hourly from the day of operation till fully ambulatory.
No laboratory monitoring is required with this mini
dose therapy. Patients with deep vein thrombosis or
postpartum pelvic thrombophlebitis should
receive adequate anticoagulant therapy. Phlebography
and 125 fibrinogen procedures greatly facilitate
diagnosis of deep vein thrombosis. Colour Doppler
ultrasonography also helps in this.
PULMONARY TUBERCULOSIS
• Malaise, easy fatigability, anorexia, weight loss
evening rise of temperature, night sweat.
• Cough, haemoptysis, apical crepitations.
• Signs of consolidation, cavity, bronchitis.
• Positive tuberculin skin test, especially a recent
conversion from negative to positive.
• Sputum positive for AFB, bacilli discovered in
tracheal/gastric washings.
• X-ray chest shows apical or sub-apical infiltration
often with cavities. Hilar lymph node enlargement
with small parenchymal calcification denotes primary
infection. Fibrotic disease with dense, well delineated
streaks may dominate the picture. Solitary nodules,
miliary lesions, lobar consolidation (acute caseous
pneumonia) may be seen and present difficult
problems in differential diagnosis. Serial films,
lordotic views are essential in establishing tubercular
activity and evaluating response to therapy.
Treatment
Drug therapy
 Bed rest for few days during the acute stage, i.e.
with fever, severe cough, haemoptysis.
Fresh case
Initial phase of 2 months-4 drugs regime.
 Capsule Rifampicin 450 mg/day if body weight is
< 55 kg and 600 mg if body weight is > 55 kg to be
given ½ hour before breakfast.
 Tab INH 300 mg/day.
Pyrazinamide in single or two divided doses
< 50 kg 1.5 gram
50-70 kg 2 gram
> 75 2.5 gram
Tablet Ethambutol 25 mg/kg single dose next 4
months—continuation phase Rifampicin + INH
In 3 drug regime Rifampicin and INH is given with
Streptomycin for 3 months after which Streptomycin
is discontinued and INH + Rifampicin continued for
another 6 months.
Streptomycin
1 gm IM daily or twice weekly. Vestibular damage with
vertigo may limit its use.
INH
5 to 10 mg/kg daily orally. Pyridoxine 25 to 50 mg daily
orally be supplemented during INH therapy to counter
act peripheral neuropathy seen in patients taking INH,
look for toxic hepatitis due to INH.
PAS
4 to 5 gm three times daily orally after food. Gastric
irritation, dermatitis, drug fever, hepatitis may limit its
use.
Ethambutol
15 mg/kg orally daily as a single dose. Monitor visual
acuity during therapy and discontinue and replace with
PAS if there is decreased visual acuity (retrobulbar
neuritis). Do not prescribe it to children in whom visual
acuity cannot be monitored.
Rifampicin
10 to 20 mg/kg daily orally on empty stomach to the
maximum of 600 mg. It can replace INH. When added
to INH it may increase hepatotoxicity of the latter.
Itching with or without rash, orange discolouration of
urine and offensive odour of sweat may occur. Drug
interaction with Rifampicin are frequent. It makes oral
contraceptives, Tolbutamide and Warfarin less effective.
Thiacetazone
150 mg daily orally. It can be combined with INH. There
is no advantage of giving it with PAS.
Second Line Drugs
Pyrazinamide: 20 to 30 mg/kg weight to a
maximum 1 gm daily orally in two
divided doses.
Morphazinamide: Taken after food. Look for Hepa-

tocellular dysfunction during
therapy.
Ethionamide and Prothionamide
1 gm daily orally in two divided doses after food; gastric
side effects are quite common and drug should be
avoided during pregnancy, in diabetics, alcoholics and
in epileptics.
Cycloserine
250 mg twice daily in adults and 100 mg/kg weight in
children. It is best combined with Ethionamide.
Capreomycin
1 gm IM daily. Dose not to exceed 20 mg/kg/day. After
3 months frequency of injection is better reduced to
three weekly. It is very costly and is prescribed in
Streptomycin resistant cases.
Viomycin and Kanamycin
1 gm IM daily. Renal and ototoxicity limit their use.
They have cross resistance with Streptomycin.
Drug regimens for newly diagnosed cases.
1. Streptomycin 1 gm + INH 30 mg + PAS 10 gm.
2. Streptomycin 1 gm + INH 300 + Ethambutol
800 mg.
3. Streptomycin 1 gm + INH 300 + Rifampicin
600 mg.
4. INH 300 mg + Ethambutol 800 + Rifampicin

600 mg.
Any of the above regimen can be continued for 3
months for initial intensive chemotherapy. It is then
followed by any one of the following regimen for rest
15 months:
INH 300 mg + PAS + Thiacetazone 150 mg.
INH 300 mg + Ethambutol 800 mg.
INH 300 mg + Rifampicin 600 mg.
9 months and 6 months regimens are also under
trial but with higher relapse rates.
Resistant Cases
The duration of chemotherapy is for one year after two
consecutive sputum cultures are shown to be –ve.
Regimens. Two second line drug regimens:
i. INH + Ethambutol + Pyrazinamide.
ii. INH + Ethionamide + Pyrazinamide.
iii. INH + Ethambutol + Rifampicin.
iv. INH +Pyrazinamide + Rifampicin.
Three second line drug regimens:
i. INH + Ethionamide + Cycloserine + Pyrazi-
namide.
ii. INH + Ethambutol + Ethionamide + Pyrazi-
namide.
iii. INH + Ethambutol + Pyrazinamide + Rifam-
picin.
iv. INH + Capreomycin or Kanamycin + Pyrazi-
namide + Rifampicin.
INH is continued in these regimens even if culture

shows resistance to INH.
Corticosteroids. Low dose Corticosteroid for short-
term may be beneficial in extensive disease with severe
toxic symptoms. To be given in addition to anti-tuber-
culous drugs.
Surgery
Pulmonary resection is indicated in any of the following
circumstances:
i. When there is localised pulmonary nodule and
the possibility of cancer cannot be excluded.
ii. For bronchial stenosis.
iii. For any localised chronic focus that has not
improved substantially after 3 to 6 months of
adequate drug therapy with persistence of AFB
in sputum.
Thoracoplasty may occassionally be used to reduce
pleural dead space after a large pulmonary resection
thus minimizing distention of healthy lung or to close a
chronic empyema space.
SARCOIDOSIS
• It is a rare disease.
• X-ray chest shows hilar adenopathy, nodular or
fibrous infiltration of both lungs.
• AFB negative so also Mantoux test.

• Occasionally skin, bone, uveal tract, salivary glands
and myocardium are also involved.
• Biopsy of lymph nodes and skin shows noncasea-
ting epithelioid cell granuloma.
• Often asymptomatic inspite of gross pulmonary
changes.
Treatment
 Spontaneous resolution is common. Asympto-
matic, non-progressive cases do not need treat-
ment.
 For progressive symptomatic cases.
 Prednisolone 40 mg daily for 1 month. If there is
improvement reduce the dose gradually to 20 mg
and continue till clearance occurs.
If there is no improvement with 40 mg daily oral
dose for 1 month then gradually reduce and discon-
tinue the drug.
SPONTANEOUS
PNEUMOTHORAX
• Sudden onset of chest pain referred to the shoulder
or arm on the involved side, associated with
dyspnoea, cyanosis.
• Decreased chest movement, hyper resonance,

decreased breath sounds, mediastinal shift away
from the involved side, obliteration of liver and
cardiac dullness depending upon the side involved.
Coin sound or bell sound test positive.
• X-ray shows retraction of the lung from parietal
pleura.
Treatment
 Bed rest till air leak is stopped.
 Inj Pethidine 100 mg or Morphine 15 mg for pain.
 Codein sulphate 15 mg 4 hourly to suppress the
annoying dry cough.
 O2 inhalation if there is dyspnoea.
 Aspiration or intubation with under water seal.
TENSION PNEUMOTHORAX
It is a medical emergency. A trocar is introduced into
the 2nd space anteriorly and once the tension has been
relieved a Foley’s catheter is introduced into pleural
space either through the trocar or by direct incision and
attached to a water trap with the end of the tube 1 to
2 cm below water. A suction pump with a maximum
vacuum of 30 cm of water may be attached to the water
trap.
TRAUMATIC PNEUMOTHORAX
This is an emergency. Open chest wounds (sucking
wounds) must be made air tight immediately by any
available means (e.g. bandage, handkerchief) and closed
surgically as soon as possible.
Traumatic pneumothorax due to lung puncture or
laceration is managed as spontaneous pneumothorax.
VIRAL PNEUMONIA
• Constitutional symptoms more prominent, i.e.
fever, dyspnoea, malaise.
• Cough is less troublesome and mucoid with scanty
sputum.
• Few physical signs inconsistent with X-ray findings.
• Depressed leucocyte count.
• X-ray shows homogeneous shadows with ill-defined
edges or ground glass appearance with finely nodu-
lar opacities not corresponding to anatomical lobes
or segments.
• Failure of resolution with antibiotic.
Treatment
 Symptomatic for cough, pleural pain.
 A broad spectrum antibiotic either Ampicillin
250-500 mg 6 hourly to avoid bacterial super
infection.
 Tab Crocin to control fever and pain.
 In cyanosis and dyspnoea O2 is to be given.
Heart Diseases 99
HEART DISEASES
ANGINA PECTORIS
• Retrosternal transient pain, squeezing or pressure
like appearing during exertion: radiating to neck,
left shoulder or left arm, relieved completely with
rest.
• Exercise stress test with ECG shows ST depression
by 2 mm but 35 per cent of cases may have normal
ECG (those only with single artery involvement).
• Coronary angiography shows stenosis of coronary
arteries.
• Radio-isotope studies with thallium 201 are
supportive.
Angina pectoris Coronary thrombosis
Attack comes on exercise. At anytime
With cold and emotions
Pain soon goes off Patient becomes restless,
collapsed sweating
flushed
Contd...
Contd...
Angina pectoris Coronary thrombosis
Attack lasts a few minutes Attack lasts for hours
BP++ BP Falls
ESR normal ESR Raised
Heart sound audible Feeble
Transaminase test negative Test is positive
Treatment
During attack
 Nitroglycerine under the tongue, acts in 1 to 2
minutes.
 Amyl nitrate pearls, crushed and inhaled acts in 10
seconds.
 Sorbitrate 10 mg or Monosorbitrate tab 20 mg three
times daily orally or sublingually. Peritrate 1 tab
daily.
 Calmpose 1 tab twice daily.
 Inderal 40 mg tab three times daily or Metoprolol
50-100 mg bd Propranolol (Inderal) is avoided if
there is left ventricular failure and bronchial asthma,
heart block or low blood pressure.
Supporting measures
 Cut down smoking.
Heart Diseases 101
 Reduce obesity with diet and exercise.

 Control hyperlipidemia with Gemifibrozil 300
mg 2 caps bd before meals or Lovastatin 20-40 mg
od with dinner.
 To have regular graded exercise.
 Avoid stress, treat anaemia and control hyper-
tension, diabetes.
Respiratory angina
 Isoptin 1 tab three times a day, Sorbitrate 1 qid.
 Nifedipine 20 mg tds.
 Diltiazem 40-120 mg daily as 30 or 60 mg tds.
 Apply Nitrobid oint 2 percent on 2" to 3" of skin
surface and cover with a plastic wrap during sleep.
 Tab Aspirin 75-150 mg/day.
Nocturnal angina
 Hypnotex or Valium at bed time.
 Rule out early cardiac decompensation and if so
start digoxin and diuretic.
Balloon angioplasty for proximal stenosis
(excluding left main) or Nitroglycerine.
Coronary by pass surgery
 Disabling angina not responding to drugs.
 Unstable angina with repeated infarctions.
 Major stenosis (50-70%) of the proximal segment
with a healthy distal segment.
Unstable angina
 Hospitalise in CCU.
 Rule out myocardial infarction.
 Bed rest.
 Oxygen inhalation.
 Tablet Sorbitrate one tab 3 hourly.
 Nifedipine 10 mg tds.
or Tablet Diltiazem 30-60 mg tds.
 Tab Propanolol 40 mg 1-2 tds.
 Tablet Aspirin 1 od.
If no response
Injection Nitroglycerine (nitro-bid) 5 ml IV infusion
in 5 per cent Dextrose or normal saline at the rate of
2.5-5 mg/minute and gradually increase it.
Monitor heart rate and BP.
HEART DISEASES
In developed countries cardiovascular diseases are

responsible for approximately 50 per cent of deaths of
which coronary heart disease (25%), hypertension (20%,
especially in Japan), rheumatic heart diseases (2%),
congenital heart disease (1%) and pulmonary heart dis-
eases are the important ones. Pulmonary heart disease
is common in communities consuming excess cigarettes
and exposed to severe atmospheric pollution. Under
Heart Diseases 103
age of fifteen congenital heart disease is the major prob-

lem. Over this age coronary disease and hypertension
are likely, pulmonary heart disease is largely confined
to men over 45.
Manifestations of Heart Diseases
The most common symptoms are dyspnoea, fatigue,
chest pain, palpitation and oedema. Dyspnoea or
paroxysmal nocturnal dyspnoea (the first symptom of
left ventricular failure or tight mitral stenosis). Anxiety
states, cardiac neuroses can produce any form of
dyspnoea. Fatigue is common in low output states and
heart failure. It is often the chief complaint in congenital
heart disease, cor pulmonale, and mitral stenosis. Chest
pain occurs in angina pectoris (intermittent myocardial
ischaemia), myocardial infarction, myopericarditis,
pericardial effusion or tamponade, aortic dissection or
aneurysm, pulmonary infarction. Palpitation is the
consciousness of irregular forceful or rapid beating of
the heart and is common with sinus tachycardia or
premature ventricular systoles.
The valuable signs of the heart disease are:
1. Oedema of dependent parts due to right heart
failure associated with engorged neck veins.
2. Cyanosis: (a) Central cyanosis is seen on warm
parts like insides of the lips, cheeks, tongue,
conjunctiva and is caused by right to left shunts,
pulmonary arteriovenous fistulas, chronic lung
diseases and pneumonia. Administration of 100

per cent oxygen decreases cyanosis due to par-
enchymal lung disease whereas that due to shunt
remains unaffected. (b) Peripheral cyanosis occurs
in presence of normal oxygen saturation and is
caused by slowed circulation through peripheral
vascular beds. Reduced cardiac output due to heart
failure, pulmonary/mitral stenosis are the
common causes.
3. Murmurs: A soft short systolic murmur at any
valve area is innocent if there are no other abnor-
malities and if it changes markedly with respira-
tion and position. The louder a systolic murmur
the more likely it is to be of organic origin.
Diastolic murmurs are always organic and may be
due to dilatation of the heart, i.e. myocarditis and anae-
mia, dilatation of aortic ring (marked hypertension),
deformity of a valve, rapid diastolic flow or intracardiac
shunts.
HYPERTENSION
• Persistently raised BP above 160/100 mmHg in a
person above 60 years or 140/90 in persons
below 50 years. If the mean BP is less than 107 mmHg
Heart Diseases 105
or the increase is purely systolic as in old people due

to loss of elasticity in their major arteries, do not
label them as hypertensive.
• Occipital headache worse in morning, light headed-
ness, tinnitus, palpitation.
• Retinal changes:
Grade I—Minimal arteriolar narrowing.
Grade II—Marked narrowing, arteriovenous
thickening.
Grade III—Cotton-wool exudates and flame shaped
haemorrhages.
Grade IV—Any of above + papilloedema, i.e. oblite-
ration of physiological cup, blurring of disc margin.
• Loud aortic second sound and early systolic ejection
click.
• Left ventricular enlargement with heave.
• Symptom of left ventricular failurein advanced cases,
aldosteronism, pheochromocytoma, coarctation of
aorta, acute nephritis or chronic nephritis, pre-
eclampsia, increased intracranial pressure of any
cause and collagen diseases.
• Signs of Cushing’s syndrome.
• Malignant hypertension means sustained elevation
of diastolic pressure above 130 mmHg causing
widespread arteriolar necrosis with ischaemic atro-
phy of nephrons. The important symptoms are, head-
ache, visual disturbances, somnolescence, signs of
acute hypertension, encephalopathy or pulmonary
oedema.
• Laboratory findings depend upon the cause of hyper-

tension; routine examination for specific gravity, pus
cells, RBC casts, blood urea/nitrogen, serum
creatinine, serum potassium, urinary excretion of
17-hydroxy corticosteroids should be done.
• X-ray chest may show an enlarged left ventricle or
rib notching due to coarctation of aorta. IVP may be
required for diagnosing polycystic kidney and
chronic pyelonephritis.
• ECG shows left ventricular hypertrophy with signs
of coronary artery disease. Prolonged QT interval
(hypokalaemia) is an indication of Cushing’s disease
or aldosteronism.
• Blood pressure should be recorded in the both arms
and legs. Major vessels including abdominal aorta,
iliac vessels and renal vessels should be auscultated
for bruits (narrowing).
• Quantitative repeated urine culture may prove
chronic pyelonephritis. In this disease pyuria is fre-
quently absent and bacilluria is intermittent.
Demonstrable bacilluria in a clean fresh urine sample
suggests chronic pyelonephritis.
• More specialised studies like selective angiography,
renal vein renin determinations, radio-isotope ex-
cretion studies and differential urinary function stud-
ies on each kidney may be required for establishing
renal artery stenosis.
Heart Diseases 107
Treatment
The principle is to initiate treatment with a single drug
and then to add agents with a different mode of
action till BP is controlled.
First line drugs
Diuretics-Thiazides or Lasix (Frusemide) or combi-
nation of Lasix with Spironolactone or β-blockers
cardioselective (Atenolol, Metaprolol, Acetabutolol)
or noncardioselective (Propranolol). They are prefer-
red in patients with concomitant ischaemic heart
disease.
Calcium antagonist: Nifedipine 10-20 mg
ACE inhibitors: Captopril, Enalapril Lirinopril or
Amlodipine can be used the above three drugs cannot
be used.
Second line drugs
Combination of drugs to be used if single drug does
not reduce BP to within a target range.
 Calcium antagonist plus β blockers.
 ACE inhibitor plus Thiazide diuretic.
 β-blocker plus Thiazide diuretic.
Hypertension emergency
 Nifedipine 5 mg sublingually every 10 minutes till
diastolic BP < 110 mmHg. Then 5-10 mg 6 hourly
up to total dose of 60 mg in 24 hours.
 Hospitalise patient.
 If response inadequate—Injection Lasix 80 mg IV.
 If still response inadequate—Injection Diazoxide
150 mg IV rapidly. Repeat as needed at 5 mm
interval till total of 600 mg.
 If response inadequate—Injection Nitroprusside-
dissolve 50 mg vial in 2 ml glucose water and further
diluted in 500 ml 5 per cent Glucose.
 Start with 0.5 mcg/kg/minute and adjust dose till
BP reaches at desired level.
or Hydralazine 5 to 20 mg IM 2-4 hourly.
Mild Hypertension (Diastolic 90-110)

• Thiazides (e.g. Esidrex) or Lasix for one week, if not
controlled add Reserpin, Hydralazine, Methyldopa,
Clonidine or Propranolol.
Moderate Hypertension (Diastolic 110-130)

Treat with a diuretic (Thiazide) + any of the second line
drugs from beginning. Combination of Hydralazine +
Propranolol (Corbetazine) is best as betablocker Propra-
nolol counteracts the sympathetic stimulation caused
by Hydralazine and consequently the combination has
fewer side effects.
If there is associated renal failure then Hydralazine,
Methyldopa, Clonidine are preferred. Guanethidine
should replace rather than be added to other agents.
Heart Diseases 109
Caution
MAO inhibitors if combined with antihypertensive
drugs may precipitate hypertensive crisis.
Remember Minoxidil is the most powerful oral
hypotensive vasodilator agent.
Severe Hypertension (Diastolic above 130)
Prompt and immediate treatment with rapid acting
drugs preferable in injectable form.
• Reduce weight if obese.
• Low salt diet.
MYOCARDIAL INFARCTION
• Sudden, prolonged, constricting anterior chest pain
referred to neck, left shoulder, inner side of left arm
with sweating, not relieved by rest or Nitroglycerine
often having symptoms of shock, cardiac failure.
• Rarely painless presenting as acute congestive heart
failure, syncope, cerebral thrombosis or unexplained
shock.
• Fever, leucocytosis, raised ESR, raised CPK-MB,
SGOT and LDH.
• ECG shows elevated ST, abnormal Q waves and later

on symmetric inversion of T waves.
• Radio-isotope imaging with Technetium 99 pyro-
phosphate confirms the infarction as well localised
‘hotspots’.
Treatment
Relieve pain first with.
 Fortwin 30 mg IM for mild pain.
 Pethidine 100 mg IM or severe pain.
or
 Morphine 15 mg IM.
If patient is still restless add 25 mg of Phenergan.
Morphine 2.5 mg slow IV every 15 minutes if pain
is uncontrolled and severe. Morphine is contrain-
dicated if respiration is below 12/min or PCO2, is above
45 mmHg. Patients on Morphine be advised not to sit-
up or stand as it may cause fainting due to venous
pooling leading to decreased cardiac output.
 Oxygen inhalation. Positive pressure breathing is
better avoided as it often decreases venous return
and aggravates myocardial ischaemia.
 Complete bed rest for 2 days and then permitted
to sit-up in bed or bed side chair, to go for
bathroom, to shave, to feed, etc. If there is no
complication patients can return to work after 3
months. For reperfusion-Thrombolytic therapy.
Heart Diseases 111
Injection Streptokinase (Streptase) 1,500,000 units

in 100 ml saline, over 60 minutes IV or 750,000 units as
slow IV repeated after 30 minutes.
or Injection Urokinase 250,000 units in 10 ml 5 per
cent Dextrose as bolus IV over 5-10 minutes followed
by 250,000 units in 50-100 ml drip over 30 minutes.
or Injection Apteplase (TPA) 10 mg bolus followed
by 50 mg over 1 hour and 40 mg over second hour.
This may be preceded by injection Phenargan 10 mg
and injection Hydrocortisone 100 mg in 100 ml 5 per
cent Dextrose to suppress allergic reaction.
 If in severe shock or CCF, previous thrombotic or
embolic episodes or severe lung disease is evident
then anticoagulants.
Anticoagulant therapy.
Heparin 5,000 IU IV 8 hourly 1st day.
Dindevan 50 mg or Warfarin 5 mg 2 tab tds 1st day.
2nd day Warfarin/Dindevan 1 tab tds.
3rd day onwards: 1 or 2 tab to keep prothrombin
time 2½ times of normal.
Disprin and Sorbitrate to continue for 3-5 years.
 Diet: Liquid diet 1st day, salt restricted semi-solid
diet from 2nd day onwards. Full diet only after
1 week.
 Bowels: If constipated Cremaffin or Agarol 1 to 2 tsf
at night or mild enema may be given.
 Thrombolytic therapy and angioplasty in suitable
cases.
Complications
Shock: Continuous oxygen.
• Sodabicarb 7.5 per cent 100 ml IV.
• Noradrenaline 4 mg/500 ml Dextrose slow IV drip
so as to maintain systolic BP around 100 mgHg.
or
• Mephentine 300 mg in 500 ml Dextrose drip.
or
• Dopamine 1 to 2 mcg/kg/min IV drip.
• Intra-aortic balloon counter pulsation technique in
protracted cases.
Cardiac Failure
• Lasix 40 mg daily.
• Lanoxin 0.5 mg IM/IV then 0.25 mg tab twice a day
till failure is controlled.
Arrhythmias
Start 5 per cent Dextrose IV drip.
Ventricular Premature Beats
• Gesicard or Xylocard (2%) 50 mg IV in one minute as
bolus and then 2 mg/minute with IV drip for next 24
to 48 hours.
If ineffective
Inj Pronestyl 750 mg IV drip over 30 to 60 minutes.
or
Heart Diseases 113
Inj Norpace 200 mg loading dose followed by

100 mg 6 hourly.
or
Inj Mexitil 100 mg IV bolus followed by 100 mg
infused over 1 hour, 250 mg over next 2 hours and 0.5
mg/min thereafter or Amiodarone 400-800 mg pd.
Prophylaxis Against Recurrence

Pronestyl 250 mg 4 times daily.
or
Quinidine 200 mg 4 times daily.
or
Inderal 20 mg 4 times daily.
or
Regubeat 100 mg 4 times daily.
or
Mexitil 200 mg three times daily continued for 4 weeks.
For ventricular tachycardia—institute above
treatment or electric cardioversion.
For ventricular fibrillation: Immediate DC shock.
Ventricular Tachycardia
Rapid ventricular rate > 120/minute.
Tab Mexiletine 150 mg tds.
or
Tab Metoprolol 25-50 mg twice daily correct
hypokalaemia and hypomagnesaemia. If rate < 120/min
usually self limiting.
Ventricular Fibrillation
DC shock (220) If this fails then.
DC shock (360J).
Adrenaline 1 ml 1:1000 IV.
10 sequences of 5:1 compression ventilation.
Sinus Bradycardia
Atropine 0.3 mg IV or Isoprenaline 2 mg in 500 ml 5 per
cent Dextrose IV drip, finally cardiac pacemaker.
RHEUMATIC FEVER
Major criteria
1. Carditis.
2. Sydenham’s chorea.
3. Subcutaneous nodules.
4. Erythema marginatum.
5. Fleeting polyarthritis.
Minor criteria
1. Fever
2. Polyarthralgia.
3. Prolongation of PR interval.
4. Increased ESR.
5. Increased antistreptolysin-O titre.
Heart Diseases 115
With two or more major criteria diagnosis of rheu-

matic fever is certain. The minor criteria are only the
non-specific manifestations and are of diagnostic help
when associated with more specific features.
Carditis
May manifest as: (a) fibrinous pericarditis or with
effusion, (b) frank congestive failure due to dilatation
of weak inflamed myocardium and (c) mitral or aortic
diastolic murmurs due to dilatation of valve rings.
Prevention of Recurrent Attacks

a. Avoid contact with patients having streptococcal
throat infections.
b. Drug prophylaxis with Penidure LA-12 every 4 weeks
or oral Penicillin 2.5 lac units daily before breakfast.
Oral Penicillin is less reliable. Adult should receive
prophylaxis for 5 years after an attack whereas
children should be given throughout the school going
years continued up to age of 25. Alternatively give
Sulphadiazine 1 gm daily if patient is sensitive to
Penicillin or Erythrocin 250 mg 12 hourly.
c. Prompt therapy of streptococcal sore throat with
24 hours will prevent most attacks of rheumatic
fever.
Treatment
 Bed rest till fever subsides, ESR is normal and rest-
ing pulse rate is normal, maintain good nutrition
and gradual return to normal activities over
months.
 Salicylates.
Sodium salicylate is preferred but is contrain-
dicated if there is associated cardiac failure. Aspirin
can be substituted for Salicylate in same doses, i.e.
4 to 5 gm or 100 mg/kg weight daily in divided
dose. Add any conventional antacid with each dose
of Aspirin to reduce gastric irritation. Salicylates do
not alter the course of the disease but only
reduce fever, relieve pain and joint swelling. Early
toxic symptoms due to Salicylates are tinnitus,
nausea and vomiting.
 Inj Procaine Penicillin 4 lacs IM daily × 10 days to
eradicate any existing streptococci in throat.
 If allergic to Penicillin, Erythromycin 50 mg/kg/
day in 4 divided doses.
 In severe cases and Prednisolone 1-2 mg/kg/day
in 4 divided doses for 3 weeks and then gradually
reduce, first omit the night then evening and
finally the day doses in another 3 weeks. Cortico-
steroids do not prevent cardiac damage or mini-
mize it, and only act as potent anti-inflammatory
Heart Diseases 117
drug superior to Salicylates and are of special values

if there is carditis.
In treatment of congestive failure of carditis, digitalis
is not very effective and may rather further irritate
the myocardium producing arrhythmia. Hence it
should be used with extreme caution.
Rheumatic echorea
Phenobarbitone 6 mg/kg/day and/or Largactil
2 mg/kg/day
Taper as symptoms improve
 Serenace (Haloperidole) 0.25 mg tab 1-3 day
 Tab Diazepam 2 mg tds.
SUB-ACUTE BACTERIAL
ENDOCARDITIS
• Continued fever, weight loss, anaemia, arthralgia.
• Petechiae, splenomegaly.
• Heart murmurs or evidence of congenital heart
disease.
• Haematuria.
• Blood culture positive for Streptococcus viridans or
faecal streptococci.
• Embolic phenomena to brain, lungs, intestine, spleen

and kidney.
• Splinter haemorrhages beneath nails, clubbing.
Treatment
 Penicillin G 5 to 10 million units daily in divided
dose for 3 to 4 weeks.
 Add Probenecid 0.5 gm orally tds to enhance blood
levels of Penicillin.
For Streptococcus faecalis
In addition to Penicillin G add one Aminoglycoside
preferably Gentamicin 5 mg/kg/day. Penicillin by
weakening the cell wall facilitate entry of Aminoglyco-
cides into the organism. Continue treatment for 5 to 6
weeks.
If recurrence occurs a second course of properly
selected drugs often for longer duration is recom-
mended.
 If there is embolism, anticoagulants may be added.
 If there is associated myocarditis with congestive
failure add digitalis and diuretic. Use Potassium salts
of Penicillin. If aortic insufficiency develops and
progresses refer the patient for early prosthesis
after 2 weeks of intensive antimicrobial therapy.
Inspite of bacteriologic cure 50 per cent cases prog-
ress to cardiac failure in 5 to 10 years principally
due to valvular deformity.
Heart Diseases 119
 Hospitalise.
 Take blood culture before starting treatment
(preferably and sets of cultures over 1½ hours).
Streptococcus viridans—It is the commonest orga-
nism.
Injection Benzyl penicillin 2 million units 4 hourly
for 4 weeks plus injection Gentamicin 3 mg/kg/day
IV 8 hourly for 2 weeks followed by:
 Capsule Amoxycillin 6 gm/day for 2 weeks. If
allergy to penicillin then injection Erythromycin
lactobionate 4 gm/24 hours plus Rifampicin 10 mg/
kg/day.
 or Injection Vancomycin or injection Cephalothine
are other alternatives.
If Staph. aureus
 Injection Methiathin 10 gm IV daily.
 Injection Cephalothin 12 gm IV daily for 4 weeks.
Pyocyaneus
Injection Colistin 1.5 million units IM 8 hourly for 2
weeks.
If fungal
Injection Amphotericin IV test dose 5 mg over 2 hours
gradually increasing at the end of one week to 1 mg/
kg/day.
Plus Flucytosine 100-200 mg/kg/day in 4 divided

doses.
Follow-up
 Tab Pentids 800 mg bd for years together.
 Record daily temperature twice for 3 months after
stopping therapy.
 Blood cultures should be done at 2, 4 and 6 weeks.
 Treatment of dental sepsis if any.
Skin Diseases 121
SKIN DISEASES
ACNE VULGARIS
• Starts as papules at puberty and common sites are
cheeks, chin, nose, back and shoulders.
• Permanent scars on skin if left untreated and
uncared.
• Clinical picture is of black heads, inflammatory
papules, pustules or cyst.
• It is often familial and found in oily skin.
Treatment
 Local area to be washed properly with soap 2-3
times a day.
 Oxytetracyclin 250 mg bd is often adequate for 10
days.
 Minocycline 100 mg daily
 Vitamin ‘A’ and ‘C’ in high doses.
 Oral Retinoids or local Isotretinoin ointment.
 Local application of Eskamel/Clearacil ointment
after wash.
 Capsule Doxycycline 100 mg twice day for 10 days

then 1 daily for 20 days.
 Locally Pernox or Persol gel 2.5 or 5 percent apply
at night for 2-3 months use Lyramycin or Eryth-
romycin cream or solution if there develops inflam-
matory and pustular lesions.
 Retino-A cream or Eudyna cream applied 2-3 times
a week only at night for 3-4 months.
ALLERGIC CONTACT DERMATITIS
• Itching.
• Erythema is often followed by vesicles/bullae.
• There may be secondary infection.
• There will be a history of previous episode of
itching.
• History of repetitive exposure to causative factors.
• Patch test with agent is positive.
• In acute phase there will be tiny vesicles weepy and
crusted lesions.
• Affected area is hot and swollen.
• Gram’s stain and culture will rule out impetigo/sec-
ondary infection.
Skin Diseases 123
Treatment
 Localised involvement can be managed by topical
agents.
 In acute weeping dermatitis compresses are used.
 Calamine lotions may be used in dried cases.
 Mild potency triomcinolone 0.1 % to high potency
steroids are useful.
 In acute cases one may give prednisone 60 mg for
4-7 days.
BED SORES
• Special type of ulcers due to impaired blood supply
and tissue nutrition due to prolonged pressure.
• Skin overlying sacrum and hips is commonly in-
volved.
• Patient is old, paralyzed or unconscious patient.
Treatment
 Good nursing care is needed.
 Early treatment requires antibiotic powders and
absorbent bandage.
 Established lesion requires surgery for debridement
and dressing.
 Spongy foam may be put under the pressure points

of body.
BOIL
It is a deep seated infection involving hair follicle and
adjacent subcutaneous tissue.
• Pain and tenderness may be prominent.
• Abcess is round or conical.
• It enlarges, becomes fluctuant and then softens and
bursts automatically within a few days.
• Coagulase positive Staphylococcus aureus is the caus-
ative organism.
• Carbuncle consists of joining hair follicles with mul-
tiple drainage point.
Treatment
 Aspirin controls fever and pain
 Systemic corticosteroids help.
 Be careful of diabetes.
 Cyclosporine in doses of 3-5 mg/kg per day is use-
ful.
Skin Diseases 125
CONTACT DERMATITIS
• The erruption begins at the contact with the causative
agent.
• Site gives a clue to the probable allergen, i.e. at wrist
due to watch, in axilla due to deodorant, at dorsum
of foot due to nylon socks, at lips due to lipstick, etc.
Treatment
 All suspected allergens should be avoided. The use
of soap should be prohibited.
 Patient should be instructed not to scratch. Scratch-
ing may spread the erruption.
 Hydrocortisone in lotion is effective both as an anti-
pruritic and as an anti-inflammatory agent.
 Antihistaminics should be given orally 1 tab bd for
2-3 weeks.
 After recovery patient may be advised not to get
himself exposed to the allergen again.
Acute weeping dermatitis
Lactocalamine lotion or Flucort H cream to be applied
twice a day for 7 days.
Subacute lesions
Zovate or Beclate cream twice a day for 7 days.
Chronic lesions
Cortilate or Dermozyme ointment twice daily for 2
weeks.
If marked lichenification
Dipsalic or Reziderms ointment. If extensive and
chronic.
Tab Prednisolone 2 bd for 10 days then 1 bd × 10
days.
DERMATOPHYTOSIS
• It is fungal infection of the feet and hands.
• Disease starts on the sides of the toes and webs as
interdigital maceration and scaling.
• May be erythema, vesiculation and soreness
followed by fissuring.
Treatment
 3% Salicylic acid in alcohol at bed time and 10%
Boric acid foot powder in the morning.
 1% Gentian violet in water may be applied.
 Miconazole or Cotrimazole 2% local application.
 Griseofulvin 1 qid for 21 days or Ketoconazole 200-
400 mg daily.
Skin Diseases 127
DISCOID LUPUS ERYTHEMATOSUS

• On face there will be localised red plaques.
• Scaling and follicular plugging.
• Dyspigmentation.
• Arms are mostly involved.
• Permanent hair loss and loss of pigmentation.
• Lesions may be covered by dry, horny adherent
scales.
Treatment
 Protect body from sun light
 Use sun blocker with high SPF > 30
 High potency corticoid creams to be applied each
night
 Chloroquine sulfate 250 mg daily may be effective
 Thalidomide is a potent teratogen but is very effec-
tive in refractory cases
 Disease is persistent but life does not remain in
danger.
ECZEMA
• It is a non-contagious inflammatory disease.
• Stimuli may be exogenous.

• Erythema, oedema, vesiculation, oozing, weeping
and crusting in acute stage.
• After healing up of eruption there is a residual
pigmentation of the skin.
• In chronic stage there is a lichenification.
Treatment
 Non-irritating detergent should be used instead of
soap.
 For secondary infection Neomycin ointment is
useful.
 Antibiotics may be given orally, i.e. Ampicillin
250 mg 4 times daily.
 Hydrocortisone ointment, cream, lotion applied
once, or twice daily will relieve pruritus, i.e.
Betnovate or Flucort-N.
 Antihistaminics orally are helpful.
 Avil Tab 1 thrice daily.
 In acute oozing eczema without secondary
infection.
Tab Prednisolone 5 mg 2 tab bd × 5 days. Then
2 tab 1 bd × 4 days followed by 1 tablet daily × 4
days.
 Zovate M cream twice a day.
 In chronic lichenified lesion locally inject hydro-
cortisone or Kenacort intralesionally.
Skin Diseases 129
ERYTHEMA MULTIFORME
• It is an acute inflammatory skin disease.
• It may follow outbreak of herpes simplex.
• It may present as recurring oral ulceration.
• There is sudden onset of symmatic erythematous
skin lesions with history of recurrence.
• Lesion may be macular, papular, urticarial or purpu-
ric.
• Centre of lesion is clear with concentric erythema-
tous rings.
• In erythema multiforme major multiple lacerations
are present at two or more sites making eating food
difficult.
• Skin biopsy is diagnostic.
• Tracheobronchial mucosa and conjunctiva may be
involved.
Treatment
 Corticosteroids are usually given although a few
patients don’t respond to it.
 Oral acyclovir prophylaxis may be effective.
 Antistreptophylococcal antibiotics are used in
secondary infection.
 Tropical therapy is not effective.
ERYTHEMA NODOSUM
• It is a symptom complex of tender, erythematous
nodules on extensor surface of lower legs.
• It lasts for six weeks and may reoccur.
• Slow regression over several weeks.
• Lesions of 1 -10 cm are pink to red.
Treatment
 Treat the underlying cause.
 Primary therapy is with nonsteroidal anti-inflam-
matory agents.
 Standard solution of Potassium iodide 5-15 drops
three times daily.
 In painful lesions complete bed rest is advised.
 Systemic corticosteroids may be given.
EXFOLIATIVE DERMATITIS
• Patchy erythema spreading rapidly.
• Fever, shivering and malaise.
• Scales may be large or fine.
• Whole skin becomes red, warm to touch and is
thickened.
• Hair become brittle and fall.
Skin Diseases 131
Management
 Bed rest.
 Keep the patient comfortable in cool temperature.
 Daily bath followed by oily application.
 Antiallergic, i.e. Avil tab 1 tds
 Steroids 30-40 mg, Prednisolone daily till improve-
ment. Then patient is kept on maintenance dose.
FOLLICULITIS
• It is caused by staphylococcal infection especially in
diabetics
• When lesion is deep seated in head and neck it is
called sycosis.
• Gram-negative folliculitis develops during antibiotic
treatment.
• Steroid acne is a type of folliculitis seen in systemic
corticosteroid therapy.
• Eosinophilic folliculitis shows urticarial papules with
eosinophilic infiltration in AIDS.
• Pseudo folliculitis is seen as in growing hair in beared
area.
• There may be burning to internse itching
• There will be pustules of hair follicules.
Treatment
 Proper control of diabetes.
 Anhydrous ethyl alcohol containing 6.25% alu-
minium chloride may be applied locally.
 Systemic antibiotics may be applied.
 Eosinophilic folliculitis may be treated with 2.5%
selenium sulfide 15 minutes daily for 3 weeks.
GONORRHOEA
In females
• Discharge, dysuria, frequency and urgency.
• Difficulty in walking, soreness around parts, burning
while passing urine
• Vulva is swollen and reddened.
In males
• Thick creamy, greenish yellow purulent discharge.
• Severe pain during micturition with frequency and
urgency.
• Symptoms are more marked in posterior urethritis.
Skin Diseases 133
Management
 Penicillin is the drug of choice.
 In uncomplicated gonorrhoea. Procaine penicillin
G 2,400,000 units/Norfloxacin 800 mg/Ampicillin
3 gm/Ciprofloxacin 500 mg/Azithromycin 1000
mg stat.
 Tetracyclines, Erythromycin and Chloramphenicol
500 mg 6 hourly upto 2-4 grams; Spectinomycin
for resistant case.
HERPES SIMPLEX
• It involves orolabial and genital areas.
• There develops small grouped vesicles on an
erythematous base.
• Regional lymph glands become swollen and tender.
• Tzanck smear is positive for multinucleated giant
cells.
• Main symptom is burning and stinging.
• Neuralgia is severe.
• Lesions heal with in a week.
• It is the main cause of genital ulceration.
Treatment
 Acyclovir is very effective. It may even be given
IV dose is 200 mg five times daily for 7-10 days.
 In recurrent cases 400 mg twice daily of Acyclovir
for many days is advised.
HERPES ZOSTER
• Pain and hyperaesthesia along the nerves.
• Fever 102-103° F.
• Small vesicles occur in crops, content becomes
purulent.
• Regional glands are painful and tender.
• Each crop dries in a week.
• Rash is usually unilateral.
Management
 Calamine lotion for local use.
 Aspirin or Novalgin 1 thrice daily × 5 days.
 Antibiotics in case of infection: Ampicillin cap 1 qid
× 5 days.
 Corticosteroids for anti-inflammatory effect to cut
down course of disease, severity and to prevent
neuralgia.
Skin Diseases 135
 Large doses of B1, B6, B12, Neurobion inj daily × 5 to

7 days.
 Tab Diazepam (Valium) 1 at bed time.
 Acyclovir orally and Idoxyuridine oint locally.
 Tab Zonirax or Herpes 800 mg 5 times a day for 7
days. It is effective only if started within 2 days.
 Injection Kenacort 40 mg/ml 1 ml weekly.
IMPETIGO
• These are weeping or encrusted lesions.
• There are superficial blisters full of purulent mate-
rial.
• Positive Gram’s stain.
• Bacteria may be cultured.
• Itching ++
• Face and other exposed parts are commonly
involved.
Treatment
 Local antibiotics are not effective
 Systemic antibiotics work well. Doxycycline 100 mg
twice daily for 5 days may be given.
 Crusts and weepy areas may be treated by com-
presses.
INFANTILE ECZEMA
• Eczema occurring in infants upto the age of 2 years.

• Acute inflammation with erythema, oedema,
scaliness with vesicles and scratching.
• There may be automatic recovery after the age of
two.
Treatment
 Soap substitute or mineral oil may be used to clean
the skin.
 If a contact aetiology is suspected the causative
agent should be searched for and to be eliminated
from the environment.
 Antihistaminic therapy will be useful.
 Under no consideration X-ray therapy should be
given, ultraviolet rays usually do more harm.
 Hydrocortisone cream or ointment (1%) is a
valuable preparation. Oral Corticosteroids should
be avoided.
LICHEN PLANUS
• It is an inflammatory pruritic disease of skin and
mucous membrane.
Skin Diseases 137
• These are flat topped papules with fine white streaks.

• Distribution is symmetrical.
• Stitching is mild to severe
• Papules are 1-4 mm in diameter.
Treatment
 Topical corticosteroids applied twice daily helps.
 Topical tacrolimus appears effective in oral and vagi-
nal erosive lichen planus.
 Oral corticosteroids may be required but disease in
general persists for months.
MALIGNANT MELANOMA
• Pigmented skin lesion with recent change in appear-
ance.
• Colour may range from red, black and bluish.
• Border is irregular.
• Lesion may be flat or raised and from macules to
papules.
Treatment
 After histological diagnosis excision is the line of
therapy.
MILIARIA
• Heat rash generally develops on trunk due to hot
moist environment causing plugging of sweet ducts.
• There will be burning, itching small papules.
• Pustules may cause prostration.
• A lesion consists of small, superficial red, thin walled
aggregated papules.
Treatment
 Prevention includes antibacterial preparation prior
to exposure.
 Triamcinolone acetonide lotion is useful.
 Doxycycline one tab twice daily is useful for five
days in secondary infection.
PEDICULOSIS
• It is a parasitic infestation of skin of scalp, trunk and
pubic area.
• There will be pruritus with excoriation.
• Nits on skin and hair shafts.
• Occasionally a sky blue macule.
Skin Diseases 139
• Itching may be intense

• A few patients may develop pyoderma.
Treatment
 Affected clothes should be washed in Luke warm
water.
 For pubic lice lindane lotion or cream is applied.
 Sexual contacts should be treated.
 Nits are removed maticulously with a fine tooth
comb.
PEMPHIGUS
• Bullous skin disorder of poor prognosis.
• First lesion may occur in any part of the body.
• There is an offensive, characteristic odour.
• Later on eruptions may become generalised along
with itching, loss of weight and anaemia.
• Bullae arise from a normal skin with erythema
around.
• Bullae tends to be tense due to contained serum.
• Rupture of bullae leaves a raw, exuding surface which
becomes crusted.
• When crusts are shed, pigmentation remains for
many weeks/months.
Treatment
 Hospitalise the patient.
 High calorie, high protein diet.
 1% aqueous Gentian violet is soothing and reduces
bacterial infection or dress with Sofratulle and
Neosporin ointment.
 Cap Ampicillin 250-500 mg 1 qid × 7 days to
overcome secondary infection or Cap Doxycycline
100 mg bd for 10-20 days.
 Tab Prednisolone 120-150 mg in divided doses.
Reduce slowly to maintenance dose of 10-20 mg/
daily.
 Betnovate-N ointment apply twice daily.
 Betnesol-N eyedrops 6 hourly for 7 days at least.
 Cyclophosphamide + Methotrexate.
 Cyclophosphamide 200 mg daily then reduced to
50 mg od Tab vit C 500 mg 1 bd for 20 days.
PSORIASIS
It is a familial, chronic, recurrent disease of unknown
origin.
• Well circumscribed erythematous dry plaques of
various size covered with mica like silvery scales.
Skin Diseases 141
• Removal of scales may expose a thin membrane

giving rise to pinpoint bleeding points.
• Extensor aspect of extremities especially elbows,
knees, occiput are the commonly affected sites.
Treatment
 Removal of precipitating cause if known.
 Warm climate helps to check relapse.
 Coal tar local application.
 Vitamin B1, B6, B12 IM may be helpful.
 PUVA therapy.
 Steroid ointment under occulsive dressing is helpful,
i.e. Betnovate-N or Flucort-N.
 Methotrexate orally in resistant cases.
Acute psoriasis: Cap Doxycycline 100 mg bd × 10
days. Tennovate or Excel cream twice a day for 14
days.
Chronic psoriasis:
Salicylic acid 3 parts.
Benzoic acid 5 parts.
Imulsifying ointment to 100.
To be applied on lesions twice a day.
 Whitfield’s ointment or Pragmatar cream at night.
 Diprovate or Cortilate cream or Elocon ointment
locally once a day for a month.
RINGWORM
• Superficial fungal disease of smooth skin, tinea
corporis is known as ringworm.
• Lesions are asymmetrically distributed and are of
various sizes.
• These are erythematous, scaly plaques, circinate with
a central clear area.
• At times several concentric rings may develop.
• There is always a definite border often vesicular in
character.
• Itching often during night hours.
Treatment
 Avoid soap and keep the part dry. Change the
under garments frequently.
 Whitfield’s ointment is useful.
 Antifungal ointment; Dermoquinol oint to be
applied three times a day or Canesten cream or
Imidil cream.
 Tab Griseofulvin 500 mg daily for 3 to 5 weeks.
 Tab ketoconazole 200 mg twice daily or Tab
Fluconagole 50-100 mg/day for 2-4 weeks.
Skin Diseases 143
SCABIES
• It is a contagious disease caused by Sarcoptes scabiei.
• Severe itching which becomes worse at night
especially in children.
• Burrow is a elevated greyish tortuous or dotted line
in the skin.
• Black spots in inter digital folds, around nipple,
genitalia, buttocks, medial aspects of thighs.
Treatment
 All the family members should be treated at a time.
 The clothes, bed linen, towels should be boiled,
ironed and changed frequently.
 If there is secondary infection it should be treated
first.
 Septran 1 bd × 5 days.
 After proper bath, patient’s body should be allowed
to dry and Ascabiol or Benzyl benzoate 25%
solution should be applied from the toe to neck for
3 consecutive days (12½% in children).
or
 Scaboma lotion 1% or Crotorax ointment or
lotion.
or
 Sulphur ointment 10% for adults, 5% for children
and 2.5% for infants is to be applied below neck on
4 consecutive nights.
or
 Mitigal, Dimethyl diphenyl disulphide is used as a
10% solution in liquid paraffin for 3 nights.
or
 Gamabenzene hydrochloride used as cream or
lotion after bath for 3 days.
 Tab Avil 1 bd × 3 days if itching is more.
SEBORRHOEIC DERMATITIS
• Excessive oiliness.
• Greasy scaling of scalp is accompanied by discomfort
and pruritus leading to scratching.
• With superadded pyogenic infection disease may
spread to the sides of the nose, eyebrows, margins
of eyelids.
• There may be dry scaling of scalp resulting in loss of
hair.
Treatment
Savlon or Cetavalon concentrate 4 tsf to a glass of
water to be used as shampoo twice a week.
 Medicated shampoo once or twice weekly (Selsun).
 Proper hygiene, low fat diet and increased vitamins.
Skin Diseases 145
 Antibacterial measures in pyogenic superadded

infections. Ampicillin Cap 250 to 500 mg qid for
5 days.
 Psychiatric help may be advisable.
 Avoid using oil on scalp.
SYPHILIS
• Chancre is the initial evidence.
• Chancre is single in the form of erosion of an ulcer,
painless and not tender.
• Base is indurated, floor is clean with serous
discharge.
• Usually found over genitals, lips, tongue and
fingers.
• Chancre heals with atrophic scar even without any
treatment.
• Regional lymph nodes are bilaterally enlarged,
discrete, rubbery in consistency and not tender.
• Headache, fever, malaise and arthralgia which is
worst at night.
Management
Early syphilis
 Benzathine penicillin 2.4 mega units.
or
 Procaine penicillin G in oil, 4.8 mega units at one
time and 1.2 mega units for 2 injections three days
apart.
or
 Procaine penicillin G 6 lacs units daily for 8 days.
Late syphilis
 Benzathine penicillin 6-9 mega units in divided
doses.
 If patient is allergic to Penicillin. Erythromycin 500
mg qid for 3 to 4 weeks.
 Tetracycline is another alternative 30 to 40 gm over
10 to 15 days.
TINEA VERSICOLOR
• Upper trunk is mostly involved.
• Velvety, pink/brown macules. These can be scraped
easily.
• Hyperpigmented form is not uncommon.
• Mostly asymptomatic, only a few develop itching.
• Macules are 4-5 mm in diameter.
• Thick walled budding spores may be seen under
microscope.
Skin Diseases 147
Treatment
 Selenium sulphide lotion may be applied from neck
to waist from 5 to 15 minutes.
 Ketoconazole shampoo over chest and back for 5
minutes.
 Ketoconazole 200 mg daily for 1 week gives short-
term cure.
 Single dose of 400 mg.
Ketoconazole may not work in hot humid
wheather.
 Imidazole creams, solutions and lotions are useful.
URTICARIA
• Spontaneous development of wheals produced by a
transudate through the injured walls of arterioles
and capillaries, may be due to ingested food or drug,
bite of insects or parasites.
• Circumscribed areas of oedema may be slightly pink
in colour.
• Trunk is the common site.
• In children papules and vesicles may develop
instead of wheals.
Treatment
 Careful history may give indication if it is due to
ingested food or drugs.
 Antihistamine therapy is useful. Citrazine tab daily
× 5 days.
 Corticosteroids should be given in acute attack but
may not be very useful in chronic patients.
 Soothing lotions or creams with 2% Phenol,
Menthol or Camphor may be used.
 Deworming may be done.
VENOUS INSUFFICIENCY
LEG ULCER
• History of venous insufficiency like thrombophle-
bitis.
• There may be immobility of calf muscles as in
paraplegia.
• There will be irregular ulceration often on medical
aspects of lower leg above medial malleolus.
• Oedema and hyperpigmentation.
• Skin breaks down and eventually sclerosis of skin
takes place.
Skin Diseases 149
Treatment
 Compression stockings reduce oedema.
 Compression should achieve a pressure of 50 mm
Hg below knee and 40 mmHg at the ankle.
 Ulcer is treated with metronidazole gel to reduce
bacterial growth and odour.
 Red dermatitis skin is treated with corticosteroid
ointment.
 Ulcer is then covered with an exclusive hydro
active dressing.
 Complete healing of ulcer may take 4-6 months.
 Some ulcers may require grafting.
 Cultured epidermal cell grafts are very useful al-
though costlier.
 Ciprofloxacin 500 mg twice daily is useful.
 Zinc supplementation is beneficial.
WARTS
• These are caused by human papilloma viruses.
• There are no symptoms.
• Anogenital warts may produce itching.
• These are verrucous papules on skin or mucous
membrane not larger than 1 cm in diameter.
• Incubation period is 2-18 months and spontaneous

cures are noted.
• Recurrences in 50% cases develop.
• Flat warts are better seen under oblique illumina-
tion.
• Subungual warts may be dry and fissured.
• Plantar warts look like corns.
• In AIDS wart like lesions may be caused by varicella
zoster virus.
Treatment
 Liquid nitrogen is applied to achieve a thaw time of
20-45 seconds.
 Liquid nitrogen may result in depigmentation.
 Any salicylic acid products may be used.
 5% cream of Imiquimod helps in clearing external
genital warts.
 Anogenital warts may be treated carefully every
2-3 weeks with 25% podophyllum resin.
 Plantar warts may be removed by blunt dissec-
tion.
 CO2 laser is effective for treating recurrent warts.
 Bleomycin diluted to 1 unit /ml may be injected
into warts.
Psychiatric Diseases 151
PSYCHIATRIC DISEASES
ANXIETY
• Excessive perspiration.
• Skeletal muscle tension—Tension headache, back-
ache.
• Sighing respiration.
• Hyperventilation syndrome—Dyspnoea, dizziness,
paresthesia.
• Functional gastrointestinal disorders—Abdominal
pain, diarrhoea, constipation.
• Cardiovascular irritability—Transient systolic hyper-
tension, tachycardia, fainting.
• Genitourinary dysfunction—Urinary frequency,
dysuria, impotence, frigidity.
• Patient feels very sick/frightened during a short
period.
Treatment
 Give attention to the root problem of the patient.
 Reassure him.
 Tab Diazepam (Valium or Calmpose) 5 mg tds.

or Tab Lorazepam (Larpose, Ativan, Trapex) 1 mg
tds.
or Tab Chlordiazepoxide (Librium) 10 mg tds.
or Tab Alprazolam (Alprax, Alzolam) 0.25 mg
1 mg daily.
or Tab Oxazepam (Serepax) 15 mg tds.
or Tab Buspirone (Buscalm) 5 mg tds.
 Antipsychotic agents, effective against anxiety asso-
ciated with high distractibility.
 Tab Melleril 10 mg tds.
 In anxiety associated with depression tricyclic anti-
depressants are effective.
Tab Imipramine 25 mg tds.
or Tab Amitryptiline 10 mg tds.
or Tab Doxepin 10 mg tds.
or Tab Chlomipramine 10 mg tds.
 Antidepressants are effective in anxiety associated
with depression. Tab Tryptomer 10 mg thrice daily.
DEPRESSION
• Loss of pleasurable interest.
• Spontaneity is gone.
• Realistic worries and bodily discomforts are pro-

minent in awareness.
• Mild depressive patient feels physically fit and does
his usual work.
• Severely depressive, seems gloomy, hopeless and
loss of self-esteem.
• Thinking, speech and movements are slowed.
• Agitated depressed patient complains endlessly
about aches, pains, fatigues, feeling of unworthiness
or guilty fears.
• Restless sleep/insomnia are prominent symptoms.
• Anorexia and weight loss.
• Sexual disinterest and incapacity.
Treatment
 Give kind attention and reassurance.
 Suicide risk is to be evaluated.
 Antidepressant drugs, Tryptomer 1 tds 25 mg.
Doxepin, Trazodone.
Tricyclic antidepressants
 Tab Imipramine (Depsol, Antidip) 25 mg tds, daily
dose is 75-300 mg).
or Tab Amitryptiline (Tryptomer, Serotena) 10 mg
tds daily.
or Tab Doxepin (Spectra, Doxetar) 10 mg tds.
or Tab Clomipramine (Anafranil, Clonil) 10 mg tds.
HYSTERIA
• Somatic and/or psychological symptoms without
any organic basis.
• Symptoms serve the primary or secondary gain.
• Symptoms cannot be explained in term of known
organic diseases.
• They have no anatomical basis.
• Symptoms seldom occur when the patient is alone
and are exaggerated in presence of a sympathetic
audience.
• Symptoms change qualitatively and quantitatively
with different examiners.
Treatment
 Isolation of the patient from the pathogenic envi-
ronment. Reassurance and sympathetic attention.
 Placebo therapy—Some iron preparations or intra-
muscular injections of distilled water.
 Chlorpromazine 50 mg tds for 2 to 3 days or
Diazepam 10 mg IM relieves psychological tension.
 Hypnosis helps in relieving the symptom by its
value of suggestibility.
 Psychotherapy.
PHOBIC REACTION
• It is a persistent excessive fear attached to an object
or a situation which in reality is not significant source
of danger.
• Perspiration, tremors, pallor, tachycardia, rapid
breathing, diarrhoea, vomiting and tightness in the
chest.
• Attack to panic lasts as long as patients face the pho-
bic subject or situation.
• Common phobic situations are darkness, brightness,
depth and heights.
Treatment
 Psychoanalysis, deconditioning, hypnosis, reassur-
ance, group therapy, environmental manipulations.
 Mild tranquillizers may be helpful like Calmpose 5
mg tds.
 Tab Depsonil 25 mg thrice daily.
 Tab Librium 10 mg thrice daily.
PSYCHOPATH
• Persistent disorder of mind resulting in abnormally
aggressive and seriously irresponsible conduct.
• Antisocial behaviour.
• Unexplained failures in love and job.
• Irresponsibility and inability to distinguish between
truth, and falsehood, good and bad, moral and
immoral.
• Shallow and impersonal response to sex life.
• Inability to sex life.
• Inability to accept blame.
Treatment
 Very difficult and unsatisfactory. No drug seems
to help in correcting them in behaviour.
PSYCHOSIS
Manic type
• Elated, unstable mood. The mood is one of excess
gaiety, euphoria, disinhibition and may be ecstasy.
• Transitory brief moments of depression.
• There may be boisterous joking, unrestrained good
humour.
• His thinking demonstrates flight of ideas, easy
distractability, absence of self criticism, little true self
awareness, tendency to blame others and at times
poor judgement.
• Excessive speech may result in hoarseness of voice.

• There is difficulty in falling asleep and when asleep
awakens early.
• Little increase in sexual drive and potency.
Depressed type
• Depressed, difficulty in thinking, psychomotor
retardation.
• Patient feels extremely inadequate, no confidence
and may feel that he is a worthless person.
• Attraction of life seems meaningless and without
value.
• Memory and orientation are intact.
• Develops suicidal tendencies.
• Frightening dreams are common.
Treatment
Hospitalisation
Manic states
Tab Haloperidol 10 mg tds.
If extrapyramidal symptoms develop as a side
effect then give.
Tab Pacitane 2 mg tds.
or Tab Phenargan 25 mg one twice a day.
Prophylaxis of mania.
Tab Lithium one tablet thrice a day.
or Tab Tegretol 200 mg one twice a day. The dose

of Tegretol may be increased upto 1000-1200 mg daily
till optimum response is obtained.
or Tab Valparin (Sodium valporate) 200 mg one
thrice a day.
Depressive state
Although ECT is more effective but drug therapy is
usually tried first.
Tricycles (Treptomer) 25 mg tds.
or Tab Doxepin (Spectra) 25 mg tds.
or Tab Clomipramine (Clonil) 25 mg tds.
or Tab Amoxapine (Demolox) 50 mg tds.
or Tab Alphrazolam (Alprax) 0.5 mg tds.
or Tab Trazodone (Trazonil) 50 mg 2 hs.
 Chlordiazepoxide 10 mg (Librium) + Diazepam
(Valium) 5-10 mg qid.
 ECT is treatment of choice in acutely suicidal
patient or in patient refractory to drugs 6-8
treatments are sufficient.
SCHIZOPHRENIA
• Thinking appears bizarre, illogical and chaotic.
• Preoccupation with ideas derived from day dreams
and fantasies, hallucinations and delusions.
• Mood is inconsistent or exaggerated. There may be

indifference, shallowness, constriction, flatness.
• Develops contradictory feelings, attitudes, wishes or
ideas towards a given object, person or situation.
• False, troubling impression that others are talking
about him.
• Delusion that ‘CBI is after me’.
Treatment
Acute stage
In an emergency when patient is aggressive and
excited.
 Injection Chlorpromazine (Largactil) 50 mg IM 12
hourly or injection Haloperidol (Serenace) 5 mg
IM every hour till adequately sedated.
If mildly agitated patient
Injection Eskazine 1 mg IM 8 hourly and tab
Pacitane 2 mg tds.
For out patient treatment
Tab Chlorpromazine 50 mg tds.
Tab Trifluoperazine 5 mg tds.
Tab Trihexyphenidyl 2 mg tds.
or Tab Loxapine 25 mg 1 tds.
Tab Procyclidine 2.5 mg tds.
or Tab Pimozide 2 mg bd.
Tab Procyclidine 2.5 mg thrice a day.
For chronic schizophrenic patients.
Injection Fluphenazine deconate (Anatensol) 12.5

mg IM every 2 weeks.
or Tab Haloperidol deconate (Depidol LA) 50-100
mg every 2-4 weeks.
or Fluanxol depot 20 mg IM every 2 weeks 20-40
mg every 2-3 weeks.
For resistant schizophrenia
Tab Clozapine (Lozapin) 25 mg ½-1 bd.
Gynaecological Disorders 161
GYNAECOLOGICAL DISORDERS
AMENORRHOEA
• Unphysiological absence or cessation of mens-

truation due to local, constitutional, psychogenic and
endocrinal factors.
• Physiological amenorrhoea is found in pregnancy,
before puberty, after menopause and during lacta-
tion (lactation amenorrhoea).
• Primary amenorrhoea may be due to psychic shock,
anorexia nervosa, psychosis, depression, ovarian
dysgenesis, infantile or hypoplastic uterus.
• Secondary amenorrhoea may be due to chronic ill-
ness, i.e. tuberculosis, malnutrition/anaemia and
obesity.
Treatment
Progesterone withdrawal test

Tab Farlutal 10 mg 1 daily × 10 days. If withdrawal
results it indicates anovulation. Induce ovulation if
patient desires child bearing.
If withdrawal negative.
Oestrogen + Progesterone withdrawal.
Tab Premarin (1.25 mg) for 25 days.
or Tab Lynoral (0.05 mg) for 25 days followed by
Tab Farlutal (10 mg) od from 16th to 25th day.
or Tab Orgametril (5 mg) two daily 16th to 25th
day.
 If oestrogen + progesterone withdrawal negative.
Ref to gynaecologist for outflow tract evaluation.
 If positive evaluate for hypothalamopituitary. If
FSH, LH low or normal and hormone withdrawal
with progesterone positive give.
Tab Serophene (Clomiphene citrate) 50 mg daily
from 2nd day for 5 days. Next cycle 100 mg daily for 5
days.
or Clomiphene + hCG 10,000 IU on 12th or 13th
day. If no response then hMG/hCG therapy.
 If prolactin elevated.
Tab Proctinol initially 2.5 mg for 5-7 days in 2
divided doses after weeks increase the dose to 5 mg
for 25 days.
CANCER CERVIX
• Cervix may appear normal, eroded or chronically
infected.
• Cervix is hard to touch and bleeds on examination.

It is friable and fixed.
• Loss of appetite, loss of weight and anaemia is noted.
Pain is a late feature.
Treatment
 High protein and vitamin diet to correct anaemia.
 Treat sepsis by douches, antibiotics and urinary
antiseptics.
 Surgery in stage I and II, Radical abdominal hyste-
rectomy with lymphadenectomy-Wertheim’s
hysterectomy.
 Postoperative radiotherapy. In stage III and IV-
palliative treatment.
CARCINOMA OF
BODY OF UTERUS
• Irregular continuous postmenopausal bleeding.
• Leucorrhoea in fungating polypoidal mass in late
stage.
• Pyometra and abdominal lump.
• Abdominal pain, cachexia, loss of weight, anaemia,
etc.
Treatment
 General improvement of health, correction of
anaemia.
 Total hysterectomy with bilateral oophorectomy.
 Surgery and irradiation.
 Radiotherapy in advanced stages.
 Large doses of progesterone in advanced cases
offers palliation.
CERVICITIS
ACUTE CERVICITIS
• Mainly gonococcal or perpueral in origin.
• Cervix is congested, enlarged, swollen, mucous
membrane pouting at the external OS.
• Cervix is tender with profuse purulent discharge.
CHRONIC CERVICITIS
• It is a histological diagnosis.
• Mucopurulent discharge.
• Low backache partly relieved by rest.
• Aching in low abdomen and pelvis.
• Deep seated dyspareunia.

• Contact bleeding, menorrhagia and congestive
dysmenorrhoea.
• May result in infertility.
Treatment
 Tetracycline in full doses 500 mg 6 hourly for 10
days to overcome gonorrhoea.
 Douching only to remove discharge and odour
temporarily.
 Electric or diathermy cauterisation to destroy
diseased area.
 When endocervix and external OS are badly affec-
ted, remove the whole area by doing one excision.
 Clotrimazole and Econazole vaginal cream/tab.
DELAYING MENSTRUATION
Due to certain unavoidable circumstances, exami-

nations, sports competition, etc. one may desire to delay
the menstruation for her convenience.
• Primulor-N one tablet thrice daily.
or
• Primovlar/any oral contraceptive once daily at bed
time.
or
• Tab Orgametril 2 tablets daily until bleeding is desi-
red. The first dose should not be later than day 22.
DYSFUNCTIONAL
UTERINE BLEEDING
• Bleeding from a non-inflammatory non-neoplastic
uterus.
• There may be history of amenorrhoea for 1 to 2
months followed by irregular bleeding.
• 75 per cent patients are of paramenopausal age
group.
• Psychic or emotional disturbances.
Treatment
Mid cycle spotting
Tab Lynoral 0.01-0.05 mg from 12th-16th day of cycle.
Menorrhagia
i. If patient desires pregnancy ovulation induction
with Clomiphene citrate.
ii. If pregnancy not desired.
Tab Regestrone 10 mg.
or
Tab Primolut N 10 mg
or
Tab Duphaston 10 mg bd for 21 days.
It may continue for 3 cycles. If no improvement
diagnostic curettage may be done.
Continuous prolonged bleeding per vagina Tab Premarin

1.5-2.5 mg/day till bleeding stops. Then 1.25 mg daily
for 20 days. Tab Farlutal 10 mg/day to start after 15
days of above tablet for 10 days.
Premenstrual spotting.
Tab Farlutal 10 mg.
or Tab Regestrone 10 mg.
or Tab Duphaston 10 mg from 16th to 25th day.
DYSMENORRHOEA
• Painful menstruation.
• Fear of sex, unsatisfied sex urge, anxiety and worry
may cause dysmenorrhoea.
• Pain sensation arises in uterus and is related to muscle
contraction.
• It starts just before and after menstruation and lasts
about 12 hours.
• Pain is colicky in nature starting in hypogastrium
and radiates to inner thighs and never goes below
knee.
Treatment
 Teach young girls to have a proper outlook of
menstruation, sex and health.
 Tab Baralgan or Cap Spasmoproxyvon 1 bd during

menstrual period.
 Tab Stilboestrol 1 mg daily from 5th to 12th day of
the cycle.
 Tab Mestranol 5 mg daily from 13th to 25th day.
 Practice exercises for dysmenorrhoea.
HABITUAL ABORTION
• Three consecutive pregnancies ending is spontan-
eous abortion.
• Rh incompatibility test, VDRL positive for syphilis,
thyroid function test for hypothyroidism, blood
sugar estimation for diabetes and study of the
chromosome patterns of wife and husband are to be
done.
Treatment
 Injection Gestone 50 mg daily until 10-12 weeks of
gestation till foetal movements are seen on
ultrasound.
 Tab Fertugard 5 mg tds continue for 1 week after
pains have subsided.
or Injection Puberogen (HCG) 1000 I units daily till

threat is over. Then 5000 units once a week till foetal
heart sounds are heard.
 Tab Folic acid 5 mg twice daily.
HYPEREMESIS GRAVIDARUM
• Morning sickness starting around sixth week and
abates around 12th week.
• Vomiting is persistent and follows every meal or
drink.
• Weakness, giddiness, exhaustion, passes scanty
urine.
• Symptoms of dehydration in severe cases.
Treatment
 Isolation and reassurance.
 Correct dehydration by parentral fluids.
 Vitamins B 1 and B2 in sufficient quantity.
 Antihistaminics help in sedation and control vomit-
ing.
 Plenty of carbohydrates to combat hypoglycaemia.
INCOMPLETE ABORTION
• After incomplete abortion, bleeding does not stop
but varies from day-to-day and heavy from time-
to-time.
• Uterus is soft and enlarged.
• Internal OS remains open.
Treatment
 Dilatation of cervix and exploration of uterus
under general anaesthesia.
 Expelled material should be examined for placenta.
INEVITABLE ABORTION
• Bleeding per vagina.
• Painful uterine contractions.
• Dilatation of cervix.
• Ballooning of the upper vagina, tenderness of uterus
and pyrexia.
Treatment
 Confine the patient to bed until abortion is
complete.
 Pethidine 100 mg to relieve pain and anxiety.

 Packing of uterus is avoided because it may hide
haemorrhage resulting in shock.
 If bleeding is profuse, continuously or inter-
mittently give 5 units of Oxytocin or 0.5 mg of
Ergometrine.
 In severe anaemia blood transfusion may be given.
 In favourable circumstances removal of any
remaining placenta by means of finger, sponge
forceps or curette.
 Bimanual massage of uterus or Oxytocin IV helps
in uterine retraction.
 Hot intrauterine douche of water may be helpful
after curettage.
LEUCORRHOEA
• Excessive normal discharge, white or cream when
fresh but leaves brown yellow stain on clothing.
• It may cause excoriation and soreness of vulva but
no pruritus and is never offensive.
• Microscopically it contains mucus, epithelial debris
and organisms of various kinds.
• If pus is not found then only it is a true leucorrhoea.
Treatment
 Cleanliness is to be ensured by bathing and regular
change of under clothings.
 Finding of non-specific bacteria on culture from
vagina without pus does not justify administration
of antiseptics, suplhonamides and antibiotics.
 Imidil vaginal tab to be kept in vagina at bed time
for 6 days.
 Cauterisation of cervical erosion helps in repeated
leucorrhoea. Improve her general health.
MENOPAUSE
• Gradual cessation of menses because ovaries stop
reacting to the stimulus of the anterior pituitary gland
as an ageing effect.
• Profuse irregular bleeding is never a symptom of
menopause.
• There may be depression, excitability, nervousness,
irritability and inability to concentrate.
• Palpitation, night sweats, hot flushes and precordial
pains are common.
• Atrophy, dryness of vagina may cause dyspareunia.

• Tender breasts, osteoporosis, menopausal hyper-
tension is common.
Treatment
 Tab Librium three times daily.
 Inj Mixogen one amp IM once a month.
 Ethinyl oestradiol 0.05 mg/day.
 Dienestrol cream to be used locally in vagina.
Hormone replacement therapy
 Tab Premarin 0.625-1.25 mg/day for 25 days every
month.
Or Tab Synoral 0.02-0.05 mg/day for 25 days
every month followed by Tab Farutal 10 mg 10-12
days each month to prevent endometrial hyperplasia
HRT can also be given in the form of transdermal
route via dermal patches which release 50-100 μg of β-
estradiol daily.
MONILIAL VAGINITIS
• Vaginal thrush is caused by yeast like organism,
Candida albicans.
• Discharge is typically thick, white, cheesy tending to

form plaques which are highly adherent to vaginal
wall. Vaginal wall becomes diffusely reddened and
oedematous.
• Vulval pruritus is associated with discharge.
Treatment
 Candid or Canesten vaginal tablet 1-2 inserted daily
for 6 nights.
 Betadine vaginal pessaries 2 pessaries at bed time
for 14 days.
 Gentian violet 2 per cent aqueous solution.
PREMENSTRUAL TENSION
• Period of premenstrual tension varies from 3 to 10
days before menstrual period.
• Heaviness of breasts due to congestion and fluid
retention.
• Heaviness of lower abdomen.
• Migraine and ocular disturbances.
• Tachycardia and hot flushes.
• Psychogenic imbalance, i.e. irritability, anxiety,
depression, fear, impulses of aggression and
destruction.
Treatment
 Educate and reassure the patient and divert the
attention from menstrual cycle problem.
 Avoid salt.
 Tab Larpose 1 mg twice daily.
 Tab Ethisterone 5 mg daily.
 Tab Lasix 1 daily starting from one day before
expected period for 2-3 days.
SENILE VAGINITIS
• Small multiple reddened areas seen in vault and
around urethral orifice.
• Postmenopausal yellowish discharge, may be with
excoriation and soreness of vulva.
• Cervical cytology or biopsy is essential to rule out
malignancy.
Treatment
 To restore vaginal resistance oestrogen
preparations in full doses for 3 weeks. May be
repeated after a gap of one week.
 Local antiseptics are of no use.
 Local oestrogens combined with lactic acid may be
of some use.
THREATENED ABORTION
• Uterine bleeding during early pregnancy.
• Fresh blood is bright red. Dark brown blood means
that active bleeding has ceased.
• Cervix is not dilated but there is slight bleeding.
• Passage of blood clots and fever shows that abortion
is inevitable.
• There may be backache and slight lower abdominal
discomfort due to uterine contractions.
Treatment
 Bed rest.
 Gestanin tablet 1 tds.
If βhCG titre is low gestenon or Uniprogesterone
50 mg daily till fetal heart movement seen on
ultrasound.
Or
Injection Profasi (hCG) 1000 IU daily till threat
is over then 1000 IU once a week till fetal heart
movements seen.
Or
Tab Fertugard 2-4 tablets daily initially follo-
wed by 3 tablets daily till 5th month of pregnancy.
Or
Injection Puberogen 1st day 2000 units
3rd day 2000 units
5th day 2000 units

9th day 1000 units
14th day 1000 units
TRICHOMONAS VAGINITIS
• It is not common in virgins, children and old women.
• Cream coloured, frothy, purulent vaginal discharge
of sudden onset.
• Pruritus and itching being felt around and within
introitus.
• Vaginal tenderness and congestion results in
dyspareunia.
Treatment
 Metronidazole 200 mg thrice daily for one week
orally or Tinidazole 2 g stat or 300 mg tds for 7
days for both husband and wife.
 Husband may be treated simultaneously because
90% of them harbour the parasites on urethra
beneath the prepuce.
 Coitus should be avoided during course of treat-
ment. Pimafucin 100, one od for 10 days in
vagina.
VAGINITIS
INFANTILE VAGINITIS
• Pain and soreness of the vulva.
• Vulva may become reddened, oedematous or
excoriated.
• Discharge may be blood stained if some foreign body
or polyp is there.
Treatment
 If due to any foreign body then it should be
removed.
 Antibiotics/Sulphonamides or fungicides should be
given.
 If infection does not clear, Ethinyloestradiol (0.01
mg) is given orally thrice daily for a month.
 Local instillation of 0.5% aqueous solution of
mercurochrome is helpful.
Ear and Nose Diseases 179
EAR AND NOSE DISEASES
ACOUSTIC NEUROMA
• Slowly progressive perceptive unilateral deafness.
• Unsteady gait.
• Symptoms of raised intracranial pressure, i.e.
headache, vomiting.
• Associated with horizontal nystagmus, facial nerve
paresis, loss of corneal sensation.
• Lumbar puncture shows increased CSF pressure and
raised protein.
Treatment
It is only surgical and depends on site and size of the
tumour. Large tumour growing into cerebellopontine
angle needs immediate removal by a skilled neuro-
surgeon while small tumours in the canal are removed
by opening through the mastoid and approaching the
canal by removing the semicircular canals.
ACUTE OTITIS MEDIA
• Severe earache in an young baby or school going
child who screams in agony or bangs his head or
pulls the affected ear.
• Fever, vomiting, even convulsions.
• Conductive deafness.
• Instant relief of pain after discharge of mucopus from
affected ear.
• Ear drum shows congestion of handle of malleus,
margin of tympanic membrane inflamed, bulging
of tympanic membrane or perforation that dischar-
ges mucopus to external ear. The discharge may be
seen to be pulsating, reflecting light intermittently
(light house sign).
• Mastoid tenderness, often oedema.
• Signs of facial nerve paralysis, meningitis, even brain
abscess may be seen in fulminating cases.
• Associated with it are chronic sinusitis, adenoids,
measles, scarlet fever, etc.
Treatment
 Bed rest and plenty of fluids.
 Analgesics to relieve pain.
 Oral Penicillin or perferably injectible form for a
minimum 7 days or until tympanic membrane
looks normal and deafness disappears.
 Capsule Ampicillin 250-500 mg qid.

or Cap Amoxycillin 250-500 mg tds.
or Cap Cephalexin 250-500 mg qid.
or Tab Erythromycin 250 mg qid.
or Tab Norflox 400 mg bd.
or Tab Ciprofloxacin 500 mg bd.
or Tab Roxithromycin 150 mg bd.
 Aural toilet—Removal of mucopus from canal by
Hydrogen peroxide instillation.
 Myringotomy—To be performed when there is
persistent collection of mucopus in middle ear
causing continued deafness and recurrence.
CHOLESTEATOMA
• Foul recurrent aural discharge.
• Deafness often severe.
• Earache and vertigo.
• On examination, attic perforation often discharging
white scales, or with pedunculated aural polyp
bleeding on touch and causing vertigo on pressure.
• Audiogram shows conductive deafness.
• X-ray shows non-pneumatised mastoid and bony
erosion by cholesteatoma.
Treatment
 Removal of cholesteatoma under general anaes-
thesia with the help of aural microscope and daily
aural toilet thereafter.
 Mastoidectomy—Simple, modified or radical
mastoidectomy according to degree of destruction
of middle ear by cholesteatoma.
Treatment of Complications
Labyrinth is infected either through a fistula in the late-
ral semi-circular canal or through oval window by
erosion of cholesteatoma. Ultimately the infection passes
to membranous labyrinth with destruction of cells in
cochlear and vestibular organs.
CHRONIC SIMPLE OTITIS MEDIA
• Gradually increasing deafness.
• Recurrent discharge from the ear.
• Occasional earache.
• On examination a central perforation exposing
promontory, round and oval windows, often
opening of the eustachian tube is visible.
• Audiogram shows conductive deafness.
• X-ray shows pneumatic mastoid.
• X-ray PNS may show sinusitis or DNS.
Treatment
 Aural toilet if there is discharge and protective
dressing, e.g. Silicone eardrops.
 Control of infection of PNS and nose and throat.
 Proper antibiotic in full course to control residual
middle ear infection. Ciprobid 500 mg bd for 5 days.
 Tympanoplasty and reconstruction of ossicular
chain.
 All such patients are advised not to have head bath,
to plug their ears during bath and to use a pro-
phylactic decongestant nasal drop.
Clear and dry the ear.
Use ear drops—Nebasulf drops, Chloromycetin
drops, or Gentamicin drops 3-5 drops thrice daily till
ear becomes dry.
DEAFNESS
Deafness is of two types conductive and sensory

neural.
Conductive Deafness
The common causes are wax, chronic otitis externa, acute
suppurative and secretory otitis media, cholesteatoma,
otosclerosis and perforation.
Sensory Neural Deafness

The common causes are:
• Presbyacusis or degeneration of hair cells in old age
causing deafness.
• Ménière’s disease.
• Trauma by high pitched loud noises, e.g. artillery
men, pop groups, noisy machine or fractures of
petrous temporal bone.
• Infection and destruction of labyrinth by cholestea-
toma or mumps virus.
• Disease of auditory nerve, i.e. neurofibroma.
DEVIATED NASAL SEPTUM
• Nasal obstruction.
• Occasional headache and pain around the eye.
• Smell unimpaired.
• Deviation visualised after the mucous membrane is
shrinked with application of adrenaline 1:1000.
Treatment
Operation either submucous resection or septal
repositioning.
Indications for Operation

Deviation of the septum is extremely common and few
selected cases only, as listed below, need surgical
correction.
1. Total or sub-total obstruction of one nasal cavity by
a bony or cartilaginous deflection.
2. Obstruction to the drainage of one of PNS.
3. As an operation of access to a bleeding point in
epistaxis.
4. As an operation of access to the ethmoidal and
sphenoidal sinuses.
DISEASES OF NOSE
The common symptoms of nasal disease are:

• Nasal obstruction leading to nasal voice, mouth
breathing, crowding of teeth, high arched palate,
shortness of nose especially if obstruction originates
in childhood and is unrelieved.
• Nasal discharge may be mucopus, mucous, blood or
CSF (fracture cribriform plate of ethmoid).
• Sneezing especially in allergic rhinitis.
• Loss of sense of smell.
• Headache and facial discomfort if there is associated
sinus disease or osteomyelitis.
EAR DISEASES
The main symptoms of ear diseases are:
Pain in ear
This is generally due to otitis media, boil or impacted
wax. There may be referred pain from posterior third
of tongue, tonsil or a carious molar tooth.
Discharge from ear
• A watery discharge is due to diffuse otitis externa
and often results in crusting at the orifice.
• A purulent discharge comes from a boil in the canal.
• A mucopurulent discharge comes from middle ear
during acute or benign chronic suppurative otitis
media. It is pale yellow and odourless.
• A foul smelling discharge is an evidence of attic
cholesteatoma or marginal granulations.
• Blood stained discharge is due to an aural polyp or
acute otitis media, with bleeding into the middle ear.
Tinnitus
• Noise in ear causes lot of distress specially at night
when patient is sleeping. There may be no
abnormality in their ears or upper respiratory tract
but it may occur in otosclerosis and in chronic otitis
media.
EPISTAXIS
Examine the patient and ascertain the site of bleeding. If

bleeding is from Little’s area, insert a cotton wool soaked
with 4 per cent lignocaine and 1 in 1000 solution of
adrenaline and squeeze the end of the nose for few
minutes. If bleeding recurs, bleeding points should be
sealed by application of chemical or electrical cautery.
When bleeding is from nasal mucosa, e.g. hypertension,
pressure can be put by passing an inflatable bag into
the nasal cavity and by filling it with air or water.
Nasal pack is the other alternative easily available and
commonly practised. For this purpose 1/2" wide gauze
of about 1.2 meters is sufficient for one side. The gauze
is impregnated with vaseline or an anti-infective agent
like Bismuth iodoform paraffin paste, and is introduced
using Tilley’s nasal dressing forceps.
An antibiotic cover is essential. If blood flows down
the nasopharynx a post-nasal pack may be necessary.
In uncontrolled epistaxis disruption of some arterial
supply should be considered.
Patient should be put on bed rest, nursed in propped
up position, should be given sufficient fluid to drink
and phenobarbitone to allay his anxiety.
Once bleeding has stopped the cause should be searc-
hed for. The commonest causes are hypertension, acute
exanthemata, bleeding and coagulation disorders,
intranasal polyps, malignancy, leukaemia, haeman-

gioma of nose, telangiectasis and injury to nasal
structures.
LOCALIZED OTITIS EXTERNA
• Due to infection of hair follicle in the cartilaginous
external canal by Staphylococus aureus.
• Earache made worse by moving or touching pinna.
• Orifice is red and swollen.
Treatment
 Wicks soaked in Glycerine and MagSulph paste are
generally placed in canal each day.
 Inj Crystalline Penicillin IM 5 lacs qid is to be given.
 Soluble Aspirin to relieve pain.
Sofradex cream
or Betnovate-N cream
or Millicortin vioform cream
If associated furunculosis capsule Ampicillin 250 mg
qid or Doxycycline 100 mg bd
SECONDARY OTITIS MEDIA

It is a common cause of deafness in childhood as a
result of obstruction of eustachian tube.
• Deafness in children without pain but may be dullness
of ear.
• Tuning fork tests and audiometry test may show
deafness to be conductive type.
• No ear discharge.
• There may be symptoms of enlarged adenoids and
chronic sinusitis.
VERTIGO
The following ear disorders may cause vertigo:

• Ménière’s disease.
• Injury to ear.
• Positional vertigo.
• Labyrinthine.
• Diseases of acoustic nerve, cerebellum and cardio-
vascular system.
VERTIGO DUE TO MÉNIÈRE’S DISEASE
• Sudden onset of vertigo, nausea and vomiting in
middle aged.
• Tinnitus prior to and during attack.

• Progressive sensory neural deafness.
• Frequent remissions and exacerbations.
Treatment
 Bed rest in dark, quiet room.
 Avomine 25 mg 6 hourly by mouth.
 In severe cases with vomiting Phenergan 25 mg
with Largactil every 6 hourly.
 Restriction on fluid intake to 3 cups a day.
 Complete salt restriction.
 Abstinence from smoking.
 To avoid undue mental stress and overwork.
 Decompression of saccus endolymphaticus to
reduce pressure on membranous labyrinth.
 When the ear is severely deaf with troublesome
vertigo: the best method for relief of vertigo is
destruction of labyrinth.
Injection Luminal 30 mg IM twice daily.
or Injection Calmpose 10 mg IM twice daily.
Tab Stemetil 12.5 mg.
or Tab Marzine or tab Dramamin 1 bd.
or Tab Diligan 1 tds.
or Tab Vertin 1 tds.
Eye Disorders 191
EYE DISORDERS
ACUTE GLAUCOMA
• Severe pain and tenderness of eye.
• Pain is along trigeminal nerve to produce severe
hemicrania.
• Within few hours patient may complain of misty
vision and seeing of rainbows or halos around bright
lights.
• Progressive loss of vision.
• Congestion of eye is more prominent.
• Cornea becomes cloudy.
• Pupil becomes irregularly dilated and is frequently
oval or vertical in shape.
• Pupils fail to react to light and accommodation.
Treatment
 Advise to consult ophthalmic surgeon to avoid risk
of irreparable blindness.
 Keep the pupil presistently contracted by putting

Pilocarpine 4% very frequently every 5 min for 1
hour, then every hour for 6 hours and then 2 hourly.
 Tab Diamox (Acetazolamide) 500 mg stat and 250
mg 6 hourly to reduce intraocular tension in all
cases of glaucoma.
 IV Mannitol 350 ml at rate of 40 drops/minute/
oral glycerol.
 Oral Potklor 1 tsf tds
 Timolol 0.25-0.5% eyedrops for chronic cases.
CATARACT
• Generally in an old age.
• Gradual painless loss of vision.
• During development of cataract diplopia, polyopia
may develop.
• Usually the lens of one eye is first affected.
• Later on both eyes may develop complete opacity
and become greyish white in colour.
Management
 No effective medical treatment is known.
 Operation is the only choice when cataract is
matured.
 Intraocular lens implantation is advisable.
Eye Disorders 193
CONJUNCTIVAL DISCHARGE
Purulent Bacterial infection
Conjunctivitis
Corneal infection
Watery discharge Viral conjunctivitis
Keratitis
Tearing + ropy Allergic conjunctivitis
Discharge
Ocular Discomfort
• Watering is due to inadequate tear drainage and
obstruction of lacrimal drainage.
• Itching is due to allergic eye disease.
• Burning is due to dryness of eye, atropine drug or
ocular disease.
• Photophobia is due to corneal disease
• Foreign body sensation is due to corneal or conjuncti-
val foreign body
• Ocular pain is due to trauma, infection or raised
intraocular pressure.
Pupils
Pupils are commonly examined for size, reaction to light
and accommodation.
i. Large poorly reactive pupil.
• Third nerve palsy

• Iris damage due to acute glaucoma
• Pharmacological mydriasis
ii. Small poorly reacting pupil
• Horner’s syndrome
• Neurosyphilis
Extraocular Foreign Bodies
Most of foreign bodies are small coal, dust, steel, wings
of insect.
Essentials of diagnosis
• Sudden discomfort in eye
• Reflex blinking
• Irritation if the foreign body is in sulcus subtarsalis
or embedded in cornea.
• Lacrimation
• Blepharospasm.
Treatment
 Wash the eye with plenty of clean water or saline.
Most of the foreign bodies will be washed out by
this.
 If foreign body is sticking it should be removed
after proper aseptic precautions by a specialist.
 Industry worker should use goggles while at work
as a preventive tool.
Eye Disorders 195
Injury by Chemicals and Burns

Burn injury can be caused by hot water, steam, explo-
sive powder, acid/alkalis.
Essentials of diagnosis
• Red eye with swelling of lids/conjunctiva.
• Marked blephrospasm.
• Photophobia.
• Marks of burns on surrounding skin.
• Marked congestion and chemosis.
• In severe cases cornea appears dull and opaque.
Treatment
 Wash the eye thoroughly with plenty of water
immediately
 If corneal erosion is there treat it like an ulcer.
 If cornea is not involved steroids may be used
locally to prevent formation of symblepharon.
CONJUNCTIVITIS
• Eye is uncomfortable but not painful.
• Photophobia is present.
• Discharge may be purulent, mucopurulent or
watery.
• Hyperaema is superficial.
• Intraocular tension, size and reaction of the pupils
remain unaffected.
Treatment
 Avoid dust and sunshine. Purulent exudates should
be washed with preboiled water before instillation
of antibiotic drops.
 Frequent instillation of broad spectrum antibiotic
drops depending on the severity of the disease such
as Soframycin, Garamycin, Chloramphenicol or
Neosporin eye ointment.
 Decongestant drops such as Tetrahydrozoline eye-
drops (Visine) Naphazoline (Clearine eyedrops).
These drops are instilled three or four times a day.
 Antibiotic ointment at bed time, i.e. Neosporine or
Soframycin. In severe cases—Cap Ampicillin 500
mg qid.
CORNEAL ULCER
• Eye is severely painful.
• Photophobia and blepharospasm are marked.
• Free running of water from eyes.
• Floor of ulcer readily stains with Fluoroscein eye-
drops.
Eye Disorders 197
• Infiltration around the margin of ulcers by dye.

• There is a tendency to perforate.
Treatment
 Protection of eyeball by applying pad and bandage.
 Two hourly Soframycin and Neosporin drops or
ointment.
 Atropine eyedrops or ointment three times a day.
 Ridinox eyedrops in cases of viral ulcer, i.e.
Herpes simplex.
 Sometimes local cauterisation is needed.
 Systemic antibiotics and anti-inflammatory drugs
like, Peelox and Ibuprofen may be given. If large
ulcer fortified Soframycin 15 mg/ml every hour
alternately with fortified Cefazolin 50 mg/ml
every hour.
DETACHMENT OF RETINA
• Sudden rapid diminution or loss of vision in the
affected eye.
• Flashes of light, transient attacks of decreased
vision.
• Floating specks in front of eyes.

• Crescentic tear is most frequent.
• Greyish red colour at the fundus.
Management
 No effective medical treatment.
 Produce aseptic choroiditis around the hole by
means of laser coagulation or perforation
diathermy/electrolysis.
IRITIS
• Severe pain.
• Circumcorneal congestion.
• Photophobia and lacrimation.
• Affected pupil is smaller and reacts sluggishly to light.
• Visual acuity is not necessarily diminished.
Treatment
 Eyes need protection.
 Pain can be relieved by giving Disprin/Analgin
group of drugs thrice daily.
 Local treatment.
 Atropine 1% eyedrops three to four times daily.
or
Eye Disorders 199
 Atropine 1% eye ointment three times daily

(Atropine hypersensitivity is more common with
Atropine ointment than drops).
 Corticosteroid eyedrops 4-6 times a day. Dexame-
thasone (Decadron). Betamethasone (Betnesol).
Hydrocortisone drops (Allucort).
 Cortisone eye ointment at bed time, i.e. Betnesol,
Cambisone and Kenalog-S ointment.
 Hot fomentation.
 Sub conjunctival injection of Corticosteroids like
Betamethasone 1/2 cc mixed with injection
Mydricaine (combination of Atropine, Adrenaline
and Xylocaine) 0.3 cc can be repeated after 12 hours.
 Systemic treatment
 Anti-inflammatory drugs like Ibuprofen, Oxy-
phenylbutazone one thrice daily.
 Antibacterial or antibiotic drug like Septran DS
twice daily.
REDNESS OF EYE
• It is due to hyperaemia of conjunctiva, episcleral or
Ciliary’s vessels
• Subconjunctival haemorrhage
Common Causes
200
Acute Acute Trauma

conjunctivitis uveitis infection
Pain Mild Moderate ++
Discharge + to ++ None Watery or purulent
Vision No effect Blurred Blurred
Cornea Clear Clear Clarity changes
Pupil size Normal Small Normal
Smear Organism No organism Organism in
corneal ulcer
Conjunctival Diffuse Circumcorneal Mainly
Treatment
redness circumcorneal
 According to the causative factor.

Diseases of Children 201
DISEASES OF CHILDREN
ACUTE RHEUMATIC FEVER
• Migratory or flitting signs of joint inflammation and
pain.
• Single cycle of fever for 10 to 15 days, each joint
inflamed for 4-6 days, recovers and is not again
affected.
• Fever may rise to 101-103°F. Shows daily variation
of 1-3°F. Fever may last from few days to weeks.
• Systolic murmur of mitral regurgitation is the early
sign. Basal diastolic murmur of AR is heard.
• Mitral stenotic murmur develops only some years
after acute episode of rheumatic fever.
• ESR is elevated with leukocytosis. PR interval is
prolonged on ECG.
Management
 Rest and nursing care.
 Patients with carditis should be kept in bed till
a. Intensity of heart murmur has diminished,

b. Sleeping pulse rate is below 100 per minute,
c. Patient starts gaining weight.
 High protein and high calorie diet.
 Oral Penicillin 200,000 units qds for 10 days.
or
If allergy to Penicillin.
 Erythrocin 250 mg qds for days (50 mg/kg/day).
 Aspirin 60 mg/pound per day in 6 divided doses
with milk or after meals for one week and then
doses are to be reduced.
 Steroids are to be given when there is cardiac
enlargement or cardiac failure. Prednisolone 2 mg/
kg/day for 3-6 weeks.
 Symptomatic treatment.
 Cardiac failure— Digitalis in small dose, oral
diuretics and oxygen.
 Pain and restlessness— Codein for dry cough and
pain or Morphine if needed.
Rheumatic Chorea
• Prophylaxis of rheumatic fever.
• Phenobarb 6 mg/kg/day and or Largactil 2 mg/
kg/day taper as symptoms improve.
• Serenace 0.25 mg tab 1-3 days or Calmpose 2 mg
tds.
• Treat every attack of sore throat vigorously.

• Injection Penidura LA 12 lacs units once in 3 weeks at
least up to 20 years of age or 5 years after last attack
whichever period is longer.
or
If allergic to Penicillin, Erythromycin 250 mg bd.
ANAEMIA
• Lemon yellow tint of body.
• Breathlessness, palpitation, fatiguability.
• Headache, vertigo, irritability.
• Anorexia, haemic murmur.
• Splenomegaly, Koilonychia.
• Oedema of feet.
• Hb percent will be low, ESR may be raised.
Management
 Iron, oral or IM for iron deficiency anaemia.
 Mebex in cases of hookworm infestation.
 B12 or Folic acid for megaloblastic anaemia.
 Testosterone or anabolic steroid for aplastic anae-
mia.
 Corticosteroid, i.e. Prednisolone 40-60 mg daily for
autoimmune haemolytic anaemia.
AORTIC STENOSIS
• Dyspnoea on effort is often the first symptom, ortho-
pnoea and paroxysmal dyspnoea follow as a result
of left ventricular failure.
• Dizziness is most frequent when standing.
• Syncopal speels begin after onset of left ventricular
failure.
• Systolic thrill in second right interspace. Ejection sys-
tolic murmur.
• Interval between apex beat and radial pulse pro-
longed.
• Low systolic BP with narrowed pulse pressure.
Management
1. Always recommend surgical valve replacement
even though the symptoms are slight or absent.
AORTIC REGURGITATION
• Dyspnoea on exertion.
• Angina pectoris on heavy exertion.
• Palpitation due to forceful heart beat.
• Syncopal attacks may be due to cerebral anoxia.

• Diastolic murmur—High pitched murmur maximal
in early diastole.
• Water hammer or collapsing pulse.
• Visible arterial pulsations in neck.
• Wide pulse pressure.
• ECG shows left ventricular hypertrophy.
Management
1. Left ventricular failure of chronic aortic regur-
gitation.
• Digitalis (Digoxin).
• Salt restriction.
• Diuretics.
2. Nitroglycerine and long acting nitrates—If chest
pain and AR.
3. Arrhythmia—Treated vigorously.
4. Syphilitic aortitis—Penicillin 5 lacs 6 hourly × 10
days.
5. Valve replacement.
BRONCHOPNEUMONIA
• Onset is acute with fever which rises rapidly up to
103° F.
• Dyspnoea is constant, cough is dry and painful.

• Child looks exhausted with half open eyes. There
may be diarrhoea and vomiting.
• Restlessness, delirium, insomnia, apathy and con-
vulsions may occur.
• Hyperventilation may lead to dehydration.
• Coarse crepitation heard all over chest.
Management
 Good nursing and frequent feeds of dilute milk.
 Sedatives may be given if restlessness is dis-
tressing.
 Crystalline Penicillin 5 lacs IM 6 hourly.
or
 Ampicillin 100 mg/kg/day.
or
 Amoxycillin 50 mg/kg/day.
 Sedative cough linctus, oxygen in cyanosis.
 In collapse stimulants to be given.
 Fever to be controlled by sponging or with Para-
cetamol.
CHICKENPOX
Causative agent is varicella zoster virus and transmis-
sion is through drouplets. Incubation period is 14-15
days. Period of infectevity is 7 days before eruption.
• Headache, sore throat and fever for 24 hours.
• Earliest lesions on buccal and pharyngeal mucosa.
• Rashes develop in crops at first on back then chest,
abdomen, face and limbs.
• At first macules, in a few hours become pink papule
which soon turns into vesicle. Vesicle turns into pus-
tules in 24 hours. Scabs in 2 to 5 days.
• Distribution is centripetal, more on upper arms and
thighs, upper part of face and in concavities.
• Crops mature very quickly and spots dry up in 48
hours then new crops appear.
• Itching may develop.
• Generalised lymphadenopathy may be seen.
• Complications include pneumonia and post-varicella
encephalitis.
Treatment
 Isolation and bed rest.
 For pruritus calamine lotion.
 Antihistaminics by mouth.
 For pneumonia a course of erythromycin + B com-
plex.
 For encephalitis – oxygen and corticosteroids.
CONGENITAL SYPHILIS
• Anaemia, wasting, fever, fretfulness.
• Infant undersized, marasmic, wrinkled face and
wizened appearance.
• Eyebrows disappear.
• Hoarseness of voice due to laryngitis.
• Liver is enlarged, firm, smooth, non-tender.
• Periosteitis of shafts of long bones.
• There may be maculopapular, circular, slightly eleva-
ted skin rashes which do not itch.
• Iritis or choroiditis.
• Hutchinson’s teeth.
Management
 Penicillin is the drug of choice. Total dose of 200,000
units per pound given as 20,000 units per pound
daily of PAM.
DENGUE
It is caused by group B arbovirus, transmitted by bite of
Aedes mosquito a domestic habitat, a day biter.
• Incubation is 2-7 days.
• Sudden onset of high fever.

• Sore throat, conjunctival injection and facial flush-
ing.
• After 2-3 days of fever rashes appear on dorsum of
hand and feet and spreading centrally.
• Some patients develop petechial rashes and GIT
haemorrhages
• Leucopenia is a hall mark of disease.
• Thrombocytopenia occurs.
• Complications include pneumonia, orchitis and
iritis.
Treatment
 Treatment is symptomatic.
 Patient dies due to circulatory failure within 1-2
days.
 Antibiotics are given to check chest complications.
DIPHTHERIA
• Maximum age incidence between 2-5 years. Mode
of infection is by droplet. Incubation period 2-6 days.
• Insidious onset with excessive salivation.
• Thin and glistening membrane white in early stage
and becomes thick and opaque later on.
• Membrane is adherent and bleeds on forcible

removal.
• Edge of membrane is well demarcated and shows
inflammation.
• Low grade pyrexia, pallor and listlessness.
• Difficulty in breathing.
Management
• Complete bed rest. Admit in hospital.
• Liquid diet.
• IV Glucose.
• Antitoxin by IV drip or IM injection as a single
dose.
If Tonsillar involvement is unilateral—20,000 IU.
If Tonsillar involvement is bilateral—40,000 IU.
If Tonsillar and pharyngeal involvement—60,000
IU.
If Laryngeal and nasopharyngeal involvement—
80,000 IU.
• Antibiotics Penicillin 250,000 units IM every 6
hours/Erythromycin 250 mg 6 hourly for 5 to 7
days.
• O2 inhalation. If respiration remains distressed
tracheostomy may be done.
INDIAN CHILDHOOD
CIRRHOSIS
Early stage
• There may be infective hepatitis.
• Child becomes irritable, is off colour and does not
play.
• Diarrhoea, low grade fever, flatulence.
• Liver is just palpable and firm with sharp margins.
Late stage
• Child looks ill and frankly jaundiced.
• Abdomen becomes prominent with superficial veins.
• Liver is palpable with spleen too.
• Oedema of ankles, puffiness of face and ascites.
• Child may die of hepatic coma, intercurrent infection
or bleeding episode.
Management
 Full diet rich in protein. Extra butter or ghee to be
avoided.
 Methionine and choline in the form of syrups.
 Neomycin 50-100 mg/kg/day orally.
 Steroids in cases of marked anorexia or persistent
jaundice.
 Penicillamine may be tried.

 Diuretics for oedema and ascites—Lasix 2 mg/kg/
day.
INFANTILE DIARRHOEA
Dietic diarrhoea
• Excess of fat—Loose, curdled and foul smelling stools.
• Excess of carbohydrates— Loose, green fronthy, acid
stools.
Infective diarrhoea
• Onset with loose diarrhoea type of stools, greenish
slightly offensive with mucus and curd. Number of
stool varies from 2 to 10 with slight fever. In severe
cases rapid dehydration may set in.
Parenteral diarrhoea
• Due to acute otitis media, mastoiditis, meningitis and
tooth eruption.
Management
Acute diarrhoea
Electral or Prolyte powder 2 tsf in 100 ml water
ORS NaCl 3.5 gm

NaHCO3 2.5 gm
KCl 1.5 gm
Glucose 20 gm
To be dissolved in 1 litre of water.
Don’t stop breastfeeding.
 If moderate to severe dehydration when oral fluids
are not tolerated then IV fluids 200-250 ml/kg in
24 hours.
 If signs of hypopotassemia—Add KCl 1 ml or 2
mEq in 100 ml glucose.
 If infant is toxic—Colistine sulphate 1-2 tsf qid.
or Furoxone ½ tsf qid.
or Gramoneg 50 mg/kg in 2-3 divided doses.
or syrup Metrogyl 15-20 mg/kg/day in 3 divided
doses is amoebic dysentery.
If above drugs fail then
Injection Gentamicin 4 mg/kg IM in 2-3 divided
doses
Neutrolin B syrup ½-1 tsf tds.
KWASHIORKOR
• Generalised oedema. Extremities often cold, hands
and feet may be dusky.
• Child appears apathetic but resents attention.

• Oedema appears on feet and face and often spreads
to involve all parts of the body.
• Skin erythema soon changes into pigmented patches.
• Hair becomes discoloured and brittle. Many of the
hair can be pulled out easily.
• Diarrhoea is a prominent feature with watery
offensive stools.
Management
 Use of adequate proteins and impart education to
mothers about diet for such children.
 3 to 5 gm of proteins per kilogram of expected
body weight, low sugar diet, palatable and
digestible with small frequent feeds.
 Skimmed milks and milk proteins are most satis-
factory source of proteins.
 Multivitamin drops/syrup may be given. B comp-
lex syp 1 tsf daily.
 If concurrent respiratory or urinary infection to be
treated with systemic antibiotics.
 Vitamin AD capsule 1 daily.
MARASMUS
• Child is irritable and cries excessively.
• Sharp features with monkey face. Progressive loss

of subcutaneous fat.
• Sunken and lustreless eyes with sunken anterior
fontanelle.
• Apathy and lack of playful movements.
• Delayed milestones, delay in learning to sit, stand
and walk.
• Failure to gain weight and height.
• Abdomen may be sunken and any reveal the
outlines of the intestines beneath.
Management
Diet
 Adequate intake of calories, fats, vitamins and
carbohydrates.
 Frequent feeds are to be given.
 Groundnuts and soya bean preparations are to be
given.
 Educate the parents about the requirement of diet
as 50 calories per pound. Multi-vitamins may be
given.
 Correct infection and infestation like roundworms.
MEASLES
It is a systemic viral disease transmitted by infected
droplet. Incubation period is 10-12 days.
• Prodromal symptoms are like that of flu.
• Non-productive cough, watering redness of eyes and
fever.
• Koplick’s spots appear as tiny table salt crystals on
cheek’s mucous membrane.
• After 3-4 days rash appear on face.
• Fever rises abruptly but subsides once eruption of
rashes is complete.
• To start rashes are pin head papules and coalesce to
form brick red morbiliform rash.
• Rash fades after 4 days in order of appearance.
• Eyes and pharynx becomes congested.
• Lymph nodes of angle of jaw and posterior cervical
region are enlarged.
• Complications include encephalitis, otitis and myo-
carditis.
Treatment
 Isolation. Communicability is more in pre-erup-
tive stage till rashes remains.
 Bed rest
 Cough suppressant.
 Saline eye sponge and nasal drops.
 Erythromycin/antibiotic to prevent respiratory in-
fection.
 Gammaglobulin 0.25 ml/kg can modify the course
of disease.
 Live attenuated virus disease prevents the disease.
MITRAL REGURGITATION
• Effort dyspnoea progressing to orthopnoea and
paroxysmal cardiac dyspnoea.
• Dramatic onset of pulmonary oedema.
• Pansystolic murmur, high pitched blowing starts
immediately after the first sound.
• Soft first heart sound.
• Third heart sound usually audible at apex due to
rapid filling of LV.
• X-ray shows LA and LV enlargement.
Management
1. If valve disease predominant and symptoms
severe—Mitral valve replacement/valvoplasty.
2. Infective endocarditis should be brought under
control before surgery.
MITRAL STENOSIS
• May be congenital or rheumatic in origin.
• Undue dyspnoea on exertion.
• Blood stained sputum.
• Palpitation with regular or irregular rhythm.
• Cyanosis usually peripheral due to low cardiac

output and central cyanosis due to pulmonary
congestion.
• Highly coloured cool cyanotic patches over cheeks.
• Presystolic and mid diastolic thrill may be felt.
• On X-ray, double contour of right heart border,
elevation of left main bronchus, posterior
displacement of barium filled oesophagus, Kerley’s
B lines and straightening of left heart border.
Management
 Prevention of recurrence of rheumatic fever by
giving Benzathine penicillin G 1.2 million IM once a
month.
 To check atrial fibrillation digitalis may be given.
 To prevent pulmonary oedema diuretics are
necessary.
Surgical mitral valvotomy. Indications are:
 Uncontrolled atrial fibrillation.
 Pulmonary oedema.
 Following embolism.
MUMPS
• It is a virus disease of children and portal of entry is
upper respiratory tract. Incubation period is 16-21
days.
• There will be moderate fever, sore throat.

• Swelling of face on the affected side.
• Pain or tenderness beneath angle of lower jaw.
• Swelling of parotid gland reaches its maximum on
3rd day, remains at peak for 2 days and then sub-
sides.
• Lobe of ear is centre of swelling and is tender.
• Skin over parotid gland is red, shiny and tender.
• Fever may be 103° – 104°F, remittent or intermittent
and falls by lysis in 3 days.
• Orchitis, epididymitis and otitis media are its compli-
cations.
Treatment
 Rest and isolation in bed for 10 days
 Liquid or semisolid food
 Mouth wash
 Aspirin/ combiflame for 3-5 days
 Prednisolone 15 mg qds if swelling is severe.
POLIOMYELITIS
It is caused by RNA virus which replicates in GI tract.
Virus is stable having three types 1, 2 and 3.
• Prodromal stage— Coryza, sore throat or cough. Fe-
ver, drowsiness and sweating. Fever touches nor-
mal in 36-48 hours and rises again.
• Pre paralytic stage — Fever up to 39°C with pain stiff-

ness in back. Hyperesthesia of skin develops. Kerning
sign is positive.
– Flickering movements in muscles may be seen.
Patient remains active.
• Paralytic stage — There is still fever. Paralysis deve-
lops within five days of onset of disease. It progresses
for 1-3 days.
– Lower limbs are mostly affected especially quadri-
ceps, tibialis anterior and paroneal group. In upper
limb deltoid is affected.
– Diaphragm and intercostals muscles may be
affected.
• Convalescence – Initial paralysis diminishes to some
extent. Paralysis is flaccid type and often contraction
persists.
Treatment
 Rest in bed.
 Sedation and moist heat.
 Splints to paralysed muscles.
 Lastly gentle massage together with active and
passive movements.
 To prevent the disease best is vaccination.
RICKETS
• Head is larger with frontal bossing. Anterior
frontanelle is larger and there is delayed closure.
• Beading of ribs specially 4th, 5th, and 6th. Lateral
spinal curvature is common.
• Epiphyseal enlargement of wrists and ankles, knock
knee and bow legs.
• Pot belly due to weakness of abdominal muscles
restlessness at night with rolling of head over
pillows.
• Delay in dentition.
• On X-ray, fraying and cupping of distal ends of radius
and ulna.
Management
 Proper exposure of body to sun light.
 Vitamin D 1200 units daily.
 Massive doses of vitamin D 600,000 iu in oil
solution.
 Compound of calcium and phosphorus preferable.
 Ostocalcium tab 2 bd may be given.
SCURVY
• More common in artificial fed children.
• Child becomes fretful, pallor or tenderness of legs
cause child to cry whenever touched. Digestive
disturbances and loss of weight.
• Gums may swell up into large purple fleshy masses
which bleed on touch, teeth become loose.
• X-ray shows increased density of long bones as white
lines. Signet ring appearance of epiphysis. Ground
glass appearance of shaft of diaphysis and pencil
lining of cortex.
Management
 Child should be disturbed as little as possible. The
cot may be lined with cotton.
 Inj. Redoxon forte 500 mg IM stat or vit C drops 20
drops tds.
 Vitamin C 100 mg twice daily.
 3 to 4 ounces of fresh orange juice or tomato juice
daily.
WHOOPING COUGH
It is caused by gram-negative cocobacillus Bordetella
pertussis. Incubation period is 7-16 days. Infectivity is
greatest during catarrhal stage. Symptoms are of

upper respiratory catarrh.
• Cough becomes paroxysmal.
• Each paroxysm consists 15-20 short coughs followed
by deep inspiration.
• Closed glottis produces “whoop”.
• Episodes of chocking and apnoea may be a major
manifestation.
• There may be engorged conjuctiva periorbital edema
and petechial haemorrhage.
• Scattered ronchi heared in chest.
• X-Ray chest may show enlarged mediastinal nodes
and patchy atelectasis.
Treatment
 Erythromycin 50 mg per kg of body weight in
4 divided doses is drug of choice.
 A short course of steroid may shorten the clinical
course.
 Prevention includes three injections of pertuses
vaccine. Pertuses suspension is incorporated in triple
vaccine with alum, precipitated diphtheria and teta-
nus toxoid. Booster injections are called for one
and five years after the initial course.
MEDICAL EMERGENCIES
ACUTE ALCOHOL
INTOXICATION
• Smell or alcohol is characteristic.
• Gastric irritation, nausea and vomiting.
• Irrelevant talks, incoordination.
• Hypotonia, depressed jerks.
• Pupils normal or slightly dilated.
In severe intoxication
• Loss of jerks.
• Extensor plantar response.
• Dilated pupils.
• Irregular breathing.
• Coma.
• Death may occur due to medullary paralysis.
Management
 Removal of unabsorbed poison by gastric lavage.
 Correct hypoglycaemia by 50 per cent Glucose, 50
ml IV.
Medical Emergencies 225
 If patient is still drowsy give 5 per cent Glucose

drip for 4 to 6 hours with Inj Vitamin B complex 2 ml.
 If patient still does not improve give Mannitol diure-
sis by IV infusion fo 350 ml of 20 per cent Mannitol.
For irritable retching and acute alcoholic excitation
give 10 mg Diazepam.
Haemodialysis if blood ethanol concentration > 7500
mg/L or if metabolic acidosis.
ACUTE MORPHINE POISONING
• Pin point pupil.
• Respiratory depression.
• Cyanosis.
• Hypothermia.
• Hypotension.
• Coma.
Treatment
 0.6-12 mg of Atropine sulphate is injected as
physiological antidote.
 Apomorphine hydrochloride 6 mg is also given.
 Stomach wash first with plain water for chemical
examination then with 0.2 per cent KMNO4.
 Nalorphine or Naltrexone for respiratory depres-

sion.
 Hot coffee or strong tea.
 2 gm of Sodabicarb with 250 ml of tea helps in
preventing acidosis.
 Shock is treated with IV 5 per cent Glucose with
Noradrenaline if the blood pressure is very low.
 O2 inhalation if cyanosis is present.
Position patient correctly to avoid risk of aspiration
of vomitus. Naloxone 0.4-1.2 mg IV dose may be
repeated if pupillary constriction and respiratory
depression are not reversed within 1-2 minutes.
If Naloxone is not available—Injection Lethidrone
(Nalorphine) 10 mg IV stat. Watch for dilatation of
pupils and acceleration of respiratory rate. Repeat
10 mg after 1 hour if respiration slows. Total dose not
to exceed 40 mg.
ACUTE RESPIRATORY
FAILURE
• Sudden inability of the respiratory apparatus and
heart to maintain adequate arterial oxygen.
• Important causes are chronic airway obstruction,
chronic bronchitis, emphysema, asthma.
• Restlessness, headache.
• Confusion, tachycardia.
• Central cyanosis, hypotension.
• Depressed respiration.
Management
 Type I respiratory failure (acute failure—cyanosis
is a presenting feature). High concentration of O2
at 6 L/minute.
 Type II respiratory failure (chronic failure, cor
pulmonale) Treat cause, i.e. infection, massive
pleural effusion, drug overdose, etc).
 Oxygen by nasal prongs 24 per cent or ventimask
28 per cent. Repeat ABG to ensure that PO2 is main-
tained at over 50 mm Hg. If this cannot be achieved
use respiratory stimulant or mechanical ventilation.
 Ampicillin injection 500 mg 6 hourly. or
 Injection Benzyl penicillin 2 mega units IM 12
hourly. After 48 hours if sputum culture report is
available give antibiotics according to sensitivity.
 Injection Aminophylline 500 mg IV slowly in
5 per cent Dextrose over 6 hours.
 Tab Salbutamol 4 mg 6 hourly.
If patient is drowsy or unable to cough give
 Injection Doxaprem by continuous IV infusion 1-3
mg/minute. If level of conciousness deteriorates
or patient is exhausted—Put on mechanical
ventilation to restore pH between 7.38-7.42.
ACUTE RETENTION OF URINE
• Obstruction distal to bladder leads to retention of
urine, i.e. prostatic enlargement, bladder neck
obstruction. Vesical diverticulum, calculi or growth
in pelvic cavity, neurogenic bladder.
• To start there will be hesitancy, poor stream and
terminal dribbling.
• Bladder may be distended.
• If not attended promptly may cause minimal hydro-
nephrosis and renal failure.
Management
If patient is in bed, make him sit or stand and pass
urine. Hot water bag alternating with cold water bag
to lower abdomen may help.
 If not relieved, catheterize bladder with strict
asepsis, use 12 or 14 F guage catheter for females
and 16 or 18 F for males.
 If cather cannot to passed do a suprapubic cysto-
stomy with a 10 to 14 F catheter.
 Urinary antiseptics like Tab Septran DS 1 bd or
Norflox/Uroflox 400 mg twice daily.
Definitive treatment
 If hypotonic bladder—Tab Urecholine 25-30 mg
tds or use self intermittent catheterisation.
 If stricture urethra—Endoscopic urethrotomy or

open urethroplasty or dilatation.
 If enlarged prostate—Prostectomy.
 If obstructive calculus—Endoscopic extraction of
calculus.
AGRANULOCYTOSIS
Chloramphenicol, Phenylbutazones, Chlorpromazine,

Barbiturates may cause it.
• History of taking offending drugs.
• Sore throat followed by chills.
• Increasing fever and dysphagia.
• Areas of necrosis seen in tonsillar region.
• Enlarged cervical lymph nodes.
Management
 Withdrawal of offending drugs.
 Isolation of patient in sterile room.
 Gentamicin 60 mg 8 hourly IM or Inj Ampicillin 500
mg 6 hrly or Inj Cephalosporin 500 mg 6 hrly or Inj
Cefotaxime 1 g bd.
ANAPHYLACTIC SHOCK
• Rapid onset of urticaria.
• History of taking Penicillin injection or any other
injection capable of causing anaphylactic shock.
• Choking of throat.
• Difficulty in breathing.
• Nausea/vomiting.
Management
 IV Adrenaline 0.5 ml, 1:1000 in 10 ml saline slowly
over a period of 5 minutes. It may be given SC
also.
 IV or IM Hydrocortisone Hemisuccinate 100 mg
or 8 mg Dexamethasone may be repeated after 4
hours.
 Inj Avil 20 mg stat.
 Clear the airway and give O2.
ARSENIC POISONING
• Patient complains of sensation of heart and burning
pain in throat.
• Violent purging with distressing tenesmus and

burning sensation at rectum.
• Stool resembles rice water stool of cholera but mixed
up with blood.
• Urine is suppressed, scanty.
• Distressing cramp in calf muscles and severe
restlessness.
• Painful cutaneous eruptions.
• Mind remains clear but there may be delirium,
convulsions and lockjaw.
• Clonic or tonic spasms preceding death.
Treatment
 Vomiting should be encouraged and copious drinks
of warm water are given. Emetics may be given.
 Stomach wash with KMNO 4 is to be done.
 BAL 3 mg/kg/body weight every 4-6 hours for
2 days, then every 6-8 hours.
 Butter is useful as it prevents absorption of arsenic.
 Massage to relieve cramps.
 IV drip 5 per cent Glucose to combat shock.
BARBITURATE POISONING
• Drowsiness to deep coma.
• Hypotonia of limbs.
• Depression of deep reflexes. Plantars may be
extensors.
• Hypotension.
• Hypothermia, shock and anuria.
• Bullous rash on skin.
• Dilated and non-reacting pupil.
• Hyporeflexia.
Treatment
Forced alkaline diuretics to be started unless contraindi-
cated by presence of organic heart disease or renal
failure or severe hypotension, shock or anemia or
respiratory paralysis. IV line to be sarted and patient
catheterised. Each cycle consist of 5 per cent Dextrose
saline 500 ml +10 ml Kesol 15 per cent with 7.5 per cent
Sodabicarb 150 ml and Mannitol 25 per cent 350 ml.
Fluids to be given at the rate of 350-400 ml/hour. The
number of cycles and duration of treatment depends
on severity of poisoning and response to treatment.
 Stomach is washed with warm water and activated
charcoal or tannic acid, 10-15 gm of sodium sulphate
is left after wash.
 In severe cases O 2 inhalation and artificial
respiration are started.
 Best antidotes are Bemegride or Megimide and
Leptazol. These are given in 5 per cent Glucose
drip in a dose of 15 mg of Leptazol and 50 mg of

bemegride every 5 minutes till pharyngeal and
laryngeal reflexes return.
 Amphetamine sulphate 10 mg may be given to
shorten the duration of coma.
 Noradrenaline may be given if blood pressure is
too low.
BEE STING
• History of bee bite.
• Local pain, swelling.
• Itching, erythema and wheal formation.
• In severe bite, urticaria, oedema of glottis,
bronchospasm, etc.
Management
Remove sting by scraping with blade or finger nail.
Do not grasp with forceps to avoid squeezing more
venom from sac into skin.
 Local application of antihistaminic cream.
 Analgesics like Novalgin.
 Oral antihistamine, i.e. Avil 1 tds.
 In severe analphylactic reaction, Adrenaline

injection 0.5 ml subcutaneous and Corticosteroid—
Prednisolone 20 mg single dose.
BURNS
• History of burn.
• Blisters/ulcer.
• Severe pain.
• Symptoms of shock.
Management
 Put off the fire by:
a. Falling and rolling on the floor in a blanket to
put out the flames.
b. Water is an effective and comfortable agent to
put off the flames.
c. Immersion in cold water relieves pain and
minimises thermal damage.
 Wound should be covered with sterile dressings.
 Chemical burns should be washed off with plenty
of water.
 All burns except minor ones need hospitalisation.
 Relief of pain by analgesics. Tab Novalgin sos.

 Clean the parts by soap water or 1 per cent Savlon,
put vaseline gauze and change dressing on 3rd day
only.
 Fluid balance is to be maintained by giving IV
Ringer’s lactate.
 Antibiotics to prevent secondary infections.
 Skin grafting for raw areas.
CARDIAC ARREST
• Important causes are—Myocardial infarction, rapid
over dose of anaesthesia, sudden obstruction of
airways, digitalis, electric shock, anaphylaxis.
• Sudden collapse.
• Unconsciousness.
• Cyanosis/cessation of heart sounds and respiration.
• Dilated pupils.
Management
 Put the patient in supine position.
 Establish an open airway.
 Hyperextend the neck.
 Remove obstructing substances, i.e. dentures, food,

mucus, blood from pharynx with fingers.
 Chest thump—Strong blow to midsternal area may
terminate asystole and ventricular tachycardia.
 Mouth-to-mouth respiration.
 Cardiac massage—Place heel of palm of left hand
over xiphoid covering it crosswise with right hand.
Give firm compression with weight of body to push
sternum an inch or more. Do this 60 times per
minute.
 Injection Sodabicarb 50 ml 7.5 per cent. Repeat
after 10 minutes.
 Injection Adrenaline (1:1000) dilute 1 ml in 20 ml
saline and inject 1 ml IV or intracardiac every 10
minutes. If above measures fail heart action to be
checked by ECG.
 If asystole—Rule out fine ventricular fibrillation by
ECG.
or
 Injection Isoprenaline 1-2 mg IV.
 Injection Decadron 8 mg IV.
 If ventricular fibrillation—External DC defibrillation
given.
 If refractory ventricular fibrillation—Injection
Bretylium torylate 100 mg IV.
 Effective external cardiac massage.
 If BP is low then 30 mg Mephentermine in 500 ml
of 5 percent Glucose at the rate of 20-30 drops/
minute.
CARDIOGENIC SHOCK
• Important causes are myocardial infarction, acute
cardiac arrhythmias, embolism, etc.
• Cold and clammy skin.
• Peripheral cyanosis.
• Rapid thready pulse.
• BP persistently less than 50 mm Hg.
• Oliguria.
• Restlessness.
Management
 Oxygen by nasal catheter 4-6 L/min.
 Noradrenaline 2 mg in 500 ml of 5 per cent Glucose
or Dopamine dobutamine drip.
 IV Digoxin 0.25 mg diluted with 5 per cent Glucose.
 Inj furosemide 50-80 mg IV.
 Inj Aminophylline 250 mg in 20 ml of 20 per cent
Glucose.
 Dexamethasone 8 mg 4-6 hourly.
DEHYDRATION
• Isotonic loss of salt and water seen in diarrhoea,
vomiting, gastric and intestinal suction.
• Nausea, anorexia, vomiting, apathy, weakness,

orthostatic syncope.
• Poor skin turgor.
• Dry shrunken tongue, sunken eyes.
• Postural hypotension.
• Weak thready pulse, low BP.
Management
 Accurate intake and output chart.
 IV isotonic saline in vomiting and diarrhoea.
 IV Ringer’s lactate solution in comatose patients,
palsma/blood loss or in burns, etc.
 Meet potassium loss in vomiting, diarrhoea.
DHATURA POISONING
• There is feeling of impending suffocation with a
change in the voice. Vomiting often occurs.
• Giddiness and staggering gait. Face is flushed, pupils
widely dialated. Diplopia or photophobia may
develop. Light reflex is lost.
• Skin is hot and dry with rise of temperature, may be
upto 106°F.
• Sensation of itching and burning all over the body.
• Patient becomes restless with peculiar behaviour.

He develops pill rolling movement.
• Death occurs due to heart failure or respiratory
paralysis.
Treatment
 Stomach is washed with weak solution of KMNO 4
or 2-4 per cent tannic acid.
 Emetic-apomorphine hydrochloride is given.
 Strong tea is a useful antidote.
 Stimulants like coramine or cardiazol may be given.
 Pilocarpine nitrate (6-15 mg) subcutaneous, is
physiological antidote of atropine.
 Artificial respiration and O 2 inhalation.
 Paraldehyde is given to loosen excitement.
 Diuretics and purgatives may be given to eliminate
poison.
DROWNING
• History.
• Long submersion in water may lead to cerebral
anoxia.
• Loss of consciousness.
• Cardiac arrest and it may cause death.
Management
 Establish an airway and maintain it.
 Maintain circulation with external cardiac massage.
 Sodabicarb solution 7.5 per cent IV.
 Aminophylline 0.2 gm IV if there bronchospasm.
 Ringer’s lactate solution IV.
ECTOPIC PREGNANCY
• Acute, severe abdominal pain.
• Fainting attacks.
• Amenorrhoea of short duration.
• Feeling of something bursting in abdomen.
• Bleeding per vagina is scanty.
• Low BP, fast pulse, cold and clammy skin, air hunger
and thirst.
• Marked tenderness in iliac fossa. No rigidity.
• PV findings—Fullness of fornices more on affected
side.
Management
 100 mg Inj Pethidine IM.
 Start IV fluids or plasma expanders if blood is not
available.
 Confirm the diagnosis by colpopuncture.
 Perform exploratory laparotomy.
FROST BITE
• History of constant exposure to cold.
• Numbness, tingling and burning sensation in the
extremities.
• Skin may be white or yellow in colour.
• Associated oedema.
• Blisters, necrosis and gangrene.
Management
 Warm the patient with blankets and give hot soup/
coffee.
 Remove all coverings from injured parts.
 Gradual rewarming with water or air.
 Analgesics for pain, i.e. Novalgin.
 Give Tetanus toxoid 1 cc. stat.
 Antibiotics in open wounds, Septran DS 1 bd × 5
days.
 No dressings to be applied.
HYPOGLYCEMIA
It is caused by excessive dose of insulin or oral

hypoglycaemic agents or a missed meal or vigorous
physical excercise by a diabetic.
• Palpitation, sweating, mental confusion and
drowsiness.
• Coma with or without neurological deficit.
• Cool sweaty skin, full bounding pulse and suggestive
history.
Hyperglycaemic Hypoglycaemic
coma coma
History Missed insulin Missed meals
Onset Slow Rapid
Skin Dry Moist
Tongue Dry Moist
Pulse Small volume Normal
BP Reduced Normal
Breath Acetone smell Normal
Urine Sugar ++ ketone ++ Absent. No. Ketone
Blood sugar 400 mg% 60 mg%
Management
 Collect blood and send for sugar estimation.
 50 ml of 50% Glucose IV stat—Dramatic recovery
usually occurs. Give oral Glucose or food too.
 If hypoglycaemia is due to long acting sulphony-
lurea or long acting insulin it can recur after few
hours. Give Corticosteroids and observe the patient
for 48 hours.
HYPOTHERMIA
• History of exposure to cold, drowning or swimming
in cold water, myxoedema, morphine poisoning, etc.
• Body temperature below 35°C.
• Bradycardia, lowering of blood pressure and slow
respiration.
• Uncontrolled rigors, clouding of consciousness.
• Cause of death is respiratory arrest and ventricular
fibrillation.
Management
 Remove the person from cold environment.
 Use of blankets, use of heater or immerse in warm
Water if core temperature > 32°C. If temp < 32°C—
gastric or rectal lavage with warm saline, warm
IV fluids.
 Artificial respiration.
 Correction of metabolic acidosis.
INJURIES TO VULVA, VAGINA

• Common causes are postcoital virgin young girls,
postabortal or after operations.
• Direct/indirect trauma.
• Profuse bleeding.
• Swelling.
• Signs of shock and collapse.
• Retention of urine in case of periurethral avulsion.
• Vaginal tear or haematoma.
Treatment
 Resuscitation of patient.
 Suturing of laceration under anaesthesia.
 Cold compresses in haematoma.
 Prophylactic antibiotic therapy.
POISONING
General Principle of Management

i. Removal of unabsorbed poison.
ii. Removal of absorbed poison.
iii. Maintenance of vital functions and general care.
iv. Administration of antidotes.
v. Symptomatic treatment.
vi. Medicolegal responsibilities.
PROFUSE VAGINAL
HAEMORRHAGE
• Common causes are complications of pregnancy
abortion, fibroid, carcinoma, IUD, etc.
• Pain lower abdomen.
• Anaemia, weakness, fatigue.
• Attacks of giddiness, fainting.
• Palpitation, breathlessness.
• Per speculum-profuse bleeding through OS and clots
in vagina.
Management
 Complete bed rest.
 Inj Pethidine 100 mg stat and if required may be
repeated after four hours.
 Inj Vit K IV, vit C and Calcium gluconate IV slowly.
 Dilatation and curettage may be done, except in
unmarried girls.
 Oestrogens are effective and cheaper in young
girls—Ethinyl oestradiol 0.05 mg tab, 1 mg every
two to three hourly till bleeding stops, later on one
daily for 21 days.
 Progesterone (Primolut N 5 mg) may be given
during last 10 days to reduce withdrawal bleeding.
RENAL COLIC
• It may be caused by stones, pus, blood, papillae or
tumour.
• Constant nagging pain in loin between 12th rib and
iliac crest.
• Pain generally radiates towards urethra.
• There may be tenderness over renal angle.
• Fever may be moderate to high with rigors in
pyelonephritis.
• There may be associated nausea and vomiting and
suppression of urine. Patient may complain of
haematuria.
• Urine examination, X-ray KUB/IVP may be helpful.
Management
 Control of pain by use of parenteral antispasmodics
like Buscopan 2 ml or analgesics like Fortwin 30
mg or Pethidine 100 mg or Diclofenac 3 ml or
Ketorolac 30 mg.
 If pain is not relieved treat the patient like that of
acute abdomen, i.e.
• Nil orally.
• IV fluids.
• IV/IM antispasmodics, i.e. Inj Baralgan or Inj
Fortwin.
• Investigate by X-ray abdomen, ultrasound

abdomen.
 If associated infection send urine culture and start
antibiotics accordingly.
SNAKE BITE
• There may be fang marks.
• Local features—Severe local pain, numbness,
tingling, local oedema, redness, warmth, bleeding
from site.
• General—Nausea, vomiting, headache, fever,
urticaria.
• CNS—Muscular paralysis, ptosis, squint, facial
weakness, respiratory paralysis.
• CVS—Cardiotoxin causes cardiac dysfunction, i.e.
tachycardia, hypotension, shock, cardiac failure,
cardiac arrhythmias.
• Cobra and krait causes constitutional symptoms
more than local symptoms. Neurotoxicity is more.
• Russel and scaled vipers cause severe local symptoms
and haemorrhagic tendency.
Management
Local
 Apply tourniquet 2" proximal to bite. It should be
tight enough to stop lymphatic flow, the route of
absorption.
In late cases
 Elevation of the limb.
 Mag sulph compresses.
 Heparinoid ointment.
 Some antibiotic.
 Freeze dried antisnake venom is reconstituted by
adding distilled water. After intradermal test give
20 ml IV slowly in 15 minutes.
 It can be repeated after 2 hours.
General
 Tetanus toxoid 1 ml IM.
 Antihistaminics—Inj Avil 1 amp stat may be given.
 Analgesics—Inj Voveran 1-3 ml IM stat followed
by Tab Ibuprofen 1 tds may be given.
 Corticosteroids in cases of severe shock and allergic
reactions. Inj Efcorlin 100 mg or Inj Decadron 4 mg
IV stat and repeat 6 hourly.
 In acute renal failure, Mannitol diuresis—Mannitol
20 per cent, 350 ml slow IV.
 In respiratory failure, Oxygen inhalation or IPPV.
If bleeding—Transfuse fresh blood or platelet.
— Fibrinogen 300-600 gm IV.
SPONTANEOUS
PNEUMOTHORAX
• Important causes are trauma, subpleural tuber-
culosis, emphysematous bulla, post-pneumonic cyst.
• Sudden onset of pleuritic chest pain.
• Dyspnoea.
• Vomiting and sweating.
• Cyanosis, low BP, fast pulse.
• Hyperresonance and reduced breath sounds.
• X-ray will show sharpened contrast between air and
relaxed lung.
Management
 Closed and mild case needs no treatment, except
sedatives and cough linctus.
In severe cases
 100 mg Pethidine or Inj Pentazocine 30 mg or Inj
Ketorolac 30 mg.
 Propped up position.
 O2 inhalation.
 Drainage of air by introduction of needle in 4th/
5th intercostal space, just posterior to anterior
axillary line connected to an under water seal.
 Cough linctus Codein 1 tsf tds.

 Broad spectrum antibiotics.
Surgery needed if lung fails to re-expand or if there
is persistent air leak due to bronchopleural fistula.
SUICIDAL BEHAVIOUR
It may be self destruction, escape from difficulties,

aggression directed at others and appeal for help.
• Repeated statements expressing suicidal wish or a
history of previous attempt.
• Depression or schizophrenia.
• Suicidal note.
• Presence of long illness-cancer or paralysis, etc.
• Personality disorder, hysterical, drug dependence,
etc.
Management
 Hospitalise the patient in a protected ward.
 Electroconvulsive therapy.
 Tricyclic group of antidepressants, i.e. Depsonil or
sedation with major/minor tranquillizers.
 Assurance and psychotherapy.
TRANSFUSION REACTIONS
Allergic reactions
• Urticaria.
• Sore throat, joints pain, fever.
• Angioneurotic oedema.
• Lymphadenopathy.
Management
 Antihistaminics—Inj Avil 2 cc stat IV.
 Corticosteroids—Inj Decadron 2 cc stat IV or Inj
Efcorlin 100-200 mg IV stat.
Febrile reactions
• May occur 1-24 hours after transfusion due to
improper sterilisation.
• Patient gets chills, fever, headache, nausea and
vomiting.
Management
 Symptomatic treatment.
 Inj Penicillin for throat infection.
MISCELLANEOUS
ACUTE LEUKAEMIA
• Abrupt or insidious onset, common in children.
• Tiredness, weakness, fatigability, marked pallor.
• Spleen slight to moderately enlarged.
• Lymphadenopathy specially in lymphatic leukaemia.
• Tenderness over sternum and other bones.
• Liver is enlarged may be with jaundice.
• Fever, malaise and prostration.
Acute myeloid leukaemia
• Total white cell count over 50,000/cu mm.
• Peripheral blood film shows increased number of
typical or atypical myeloblast.
• Bone marrow shows more than 20 per cent blast
cells.
• Daunorubicin IV alternate days × 3 doses.
• Ara-C IV twice daily × 10 days.
More than one course may be required to induce
remission.
Miscellaneous 253
Consolidation
• Ara-C IV twice daily × 10 days.
• Daunorubicin IV alternate days × 3 doses.
• Etopside IV daily × 5 days.
• Amisacrine daily IV for 5 days.
• 3 courses given at 4-6 weeks interval. Once remission
is achieved, patient must undergo bone marrow
transplantation if HLA matched sibling donor is
available and patient is < 45 days.
Before specific treatment is given following
supportive treatment is to be given:
i. If hyperuricaemia Plenty of fluids alkaline
is present Citrate 2 tsf tds with water
Tab Zyloric 100 mg tds.
ii. Thrombocytopenia Platelet transfusion
iii. Anemia Packed cell transfusion
iv. If fever 38°C.
• Injection Ceftazidime (Fortum) 1-2 g 8 hourly.
or Injection Gentamicin 80 mg 8 hourly.
or Injection Carbenecillin 5 gm IV 6 hourly.
If these fail then
• Injection Amikacin 500 mg 12 hourly IV.
or Injection Ciprofloxacin 200 mg IV bd.
or Injection Ceftazidime 1-2 gm 8 hourly IV.
Acute lymphatic leukaemia
• Total white cell count, more than 500,000 predomi-
nantly lymphoblasts.
• In leukaemic leukaemia less than 1000 white cells.

• Bone marrow—Hypercellular marrow with
depression of erythropoeisis, granulopoeisis and
thrombopoeisis.
Management
AML
 Cyclophosphamide and Prednisolone until marrow
is hypoplastic.
 Transfusion of packed red cells from stored blood.
 Treatment of infection with broad spectrum
antibiotic.
ALL
 Oncovin 1 mg IV weekly with Prednisolone 40 mg
daily, along with supportive therapy.
Induction (4 weeks)
 Vincristine IV weekly for 4 weeks.
 Oral Prednisolone daily × 4 weeks.
 α-asparaginase IM weekly × 3 weeks.
 Daunorubicin IV daily × 2 days.
Intensification (1 week)
 Vincristine IV one dose.
 Daunorubicin IV daily × 2 days.
 Prednisolone oral daily × 2 days.
Miscellaneous 255
 Etoposide IV daily × 5 days.

 Cystosine arabinocide IV daily × 5 days.
 Thioguanine oral daily × 5 days.
CNS prophylaxis (3 weeks)

Cranial radiation 24 GY fractionated. Intrathecal
methotrexate weekly × 3 also given twice during
induction and once with each intensification course.
Maintenance therapy (2 years)
 Methotrexate oral weekly × 2 years.
 6-Mercaptopurine oral daily × 2 years.
 Prednisolone oral 5 days each month × 2 years.
 Vincristine IV one dose monthly × 2 years.
ADDISON’S DISEASE
• Weakness, weight loss.
• Pigmentation of skin and mucous membrane.
• Hypotension.
• Hyponatraemia and hyperkalaemia.
• Diminished urinary Cortisol, 17 Hydroxy corticoids
and 17 Ketosteroids.
Treatment
 Increased salt intake. Take 1 tsf salt daily in addition
to what is used in cooking.
 Prednisolone 5 mg morning and 2.5 mg in evening
as replacement.
 0.05 mg of Fluorohydrocortisone in selected
patients.
AIDS
Transmission of HIV is mostly through sex and sharing
needles/blood transfusion. Breastfeeding, Kissing,
casual contact sharing towel/bed sheet don’t transmit
the disease.
Immune Abnormalities
• Depletion of T4 lymphocytes.
• Impaired lymphocyte proliferation.
• Impaired NK cell activity.
When to Suspect AIDS
• Kaposi sarcoma.
• Unexplained lymphadenopathy.
• Prolonged fever of unknown origin.
• Primary CNS lymphoma.
• Early dementia.
• Unexplained weight loss.
• Repeated Herpes zoster.
• Opportunistic infections.
Miscellaneous 257
Standard ELISA test has a sensitivity of 99.5% but with
low specificity of 13%. Hence positive western blot gives
definite diagnosis. Antibodies appear 1-3 months after
infection. Patients with CD4 cell count below 200cumm
are at high-risk.
Treatment
Antiretroviral therapy for HIV disease
 AZT 100 mg 5 times daily
 Abacavir 300 mg bid.
 Adefovir 60 mg qid.
 Indinavir 800 mg tds
 Ritonavir 600mg bd.
 Delaviridme 400 mg tds
CHRONIC LYMPHATIC LEUKAEMIA

• Absolute lymphocytosis and leucocytosis.
• Lymph node enlargement usually non-tender and
generalised.
• Anaemia, hepatosplenomegaly.
Treatment
 Tab Chlorambucil 0.1-0.2 mg/kg daily.
or Tab Cyclophosphamide (Endoxan) 50-100 mg.
1-3 times daily. Give in cycles upto 2 weeks.
 Corticosteroids 40 mg daily. Prednisolone—If
severe marrow failure or autoimmune pheno-
menon supportive—Regular blood transfusion and
infections.
CHRONIC MYELOID LEUKAEMIA
• Unexplained fever, splenomegaly.
• Leucocytosis with blast cells, promyelocytes,
myelocytes appearing in peripheral blood.
• Bone marrow aspiration shows dominant promy-
elocytes and myelocytic series with blast cells less
than 30 per cent. Marrow is hypercellular.
• Philadelphia chromosome is positive and leucocyte
alkaline phosphatase is negative.
Treatment
 Hydroxyurea 1.5-2 g/day PC within 1-2 wks TLC
starts to fall. Thereafter continue with maintenance
dose 0.5-2 g/day indefinitely. If not tolerated then.
 Busulfan 2-4 mg orally daily.
 or A interferon daily subcutaneous injection 3-9
MU.
 600 rads to spleen or low dose total body irradia-
tion.
 Radioactive phosphorus 1-2 mci every 1-2 weeks.
 DAT regime if patient goes to blast crisis.
Miscellaneous 259
CONGESTIVE CARDIAC FAILURE
• Dyspnoea on exertion often progressing to ortho-
pnoea.
• Crepitations at lung bases.
• Tender hepatomegaly, dependent oedema, enlarged
neck veins.
• Prolonged arm to tongue circulation time.
• Evident heart lesion or dilatation.
Treatment
 Bed rest, salt restriction, small feeds.
 Tab Lanoxin (or Cardioxin) 2 tablets every six hours
for 4 doses. Then one or two tablets daily (to keep
pulse about 80/minute) for six days a week.
 Tab Lasix 40 mg or Esidrex 50 mg-1 every morning
for 3 days. Then one on alternate day for 3 doses
and then one once a week.
 Potassium supplement—Syrup Potklor 1 tsf bd.
 Low dose Heparin 5000 units in selected cases.
 Add Verapamil 80-120 mg/day for tachycardia.
 Preload and after load reduction in refractory heart
failure with oral Sorbitrate and Hydralazine.
 If excess dyspnoea-O2 inhalation.
Injection Aminophyline 0.025 mg IV twice a day
for 3 days then once a day for 3 days.
 Tab Deriphylline retard 1 bd.

 For severe failure add vasodilators Salbutamol
4-12 mg tds.
or Captopril—Initial dose 6.25 mg.
or Enalapril—Initial dose 1.5-2.5 mg.
or Lisinopril—Initial dose 2.5 mg.
DIABETES INSIPIDUS
• Inability to concentrate urine.
• Large and dilute urine rarely less than 3 litres daily.
• Excessive thirst and resulting disturbance of sleep.
• Deficiency of ADH secretion.
• Inability of distal tubules and collecting ducts of
nephrons to respond to ADH (Nephrogenic diabetes
insipidus).
Treatment
 Pitressin IM 10-20 units of aqueous solution twice
daily or 5-10 units Pitressin tannate in oil every
2 to 3 days.
 Chlorpropamide 250 mg daily.
 Chlorthiazide 500 mg in Vasopressin resistant cases
to reduce urine volume.
Miscellaneous 261
DIABETES MELLITUS
• Usually gradual in adults but acute in children.
• Polyuria, intense thirst.
• Nocturia.
• Polyphagia.
• Weight loss, weakness and lassitude.
• Pruritus vulvae in females and balanitis in males.
• Leg cramps, crops of boils, loss of libido and
impotence in middle age.
• Blurring of vision may develop.
• High fasting blood sugar content > 120 mg%.
• Urine may be positive for sugar.
Treatment
 Low calorie diet.
 Low carbohydrate, high protein diet.
 Lots of green vegetables to be consumed.
 Sulphonylureas stimulate production of Insulin +
extrapancreatic hypoglycaemic effect. These are
given to maturity onset diabetes of average weight
not controlled by diet.
 Diabetic of normal weight stabilised on Insulin not
more than 30 units daily without developing ketosis
any time.
Obese patient
 DBI-TD one with breakfast if not controlled after
2 weeks.
 Diabinese tab 250 mg.
or Daonil or Euglucon 5 mg one tablet with
breakfast.
 DBI-TD one after dinner.
If not controlled.
 Inj Insulin.
Non-obese patient
 1/2 Tab Daonil or Euglucon with breakfast. It may
be increased to 1 tablet.
If not controlled.
 Diabinese 500 mg with breakfast watch for 2 weeks.
Even if not controlled.
 Euglucon or Daonil
2 tab with breakfast, one after dinner.
If still not controlled.
Inj. Lente insulin 15 units subcutaneous before
breakfast.
Dose may be increased according to urine sugar.
If dose of Lente insulin exceeds 50 units/day.
 Inj soluble Insulin 20 units once before breakfast
with.
 Inj NPH or Lente insulin 20 units.
Miscellaneous 263
If urine sugar ++ before lunch increase soluble

insulin by 2 units before breakfast.
 If urine sugar ++ before dinner increase NPH Or
Lente insulin by 2 units before breakfast.
If control is still difficult.
Inj Plain insulin:
20 units before breakfast
20 units before lunch
15 units before dinner.
Adjust dose according to urine sugar.
DIABETIC KETOACIDOSIS
• Polyuria, thirst, vomiting, lethargy.
• Abdominal pain, anorexia.
• Kussmaul breathing, rapid thready pulse.
• Elevated blood sugar, Plasma ketone and low
bicarbonate.
• Urine is positive for ketone bodies.
Treatment
 Rapid rehydration with 4-6 litres of isotonic saline
within 12 hrs.
 Low dose Insulin 6-8 units per hour by IV infusion.
 Bicarbonate IV if plasma pH is below 7.2.

 IV Potassium, 1 ampoule to each bottle of saline
infusion from 3rd bottle onwards under ECG
control.
 Insuline infusion is to be continued till ketosis clears
up. Once blood sugar reaches around 250 mg
percent NaCl is replaced by 5 per cent Dextrose
saline.
FILARIA
• Usually high fever with rigors.
• Nausea and vomiting during attacks.
• Tender inflamed lymphatics are seen as red streaks.
• Itching, irregular erythematous swelling of skin
scattered over the body.
• Lymph glands swollen, firm and tender, generally
of groins.
• Secondary gram-positive bacterial infection in breast
may develop.
• Microfilariae in peripheral blood collected about mid-
night.
• Gland biopsy to identify adult worm.
Miscellaneous 265
Management
Acute lymphangitis
 Tab Banocide forte, 100 mg thrice daily for 3 weeks.
 Inj Terramycin 100 mg bd IM.
 Tab Paracetamol 1 sos.
 Tab Brufen 1 thrice daily.
 Tab Sugarnil 1 tds.
Post-lymphangitic oedema
 Elevation of the extremity at night.
 Elastocrepe bandage during day time.
 Cough sedative.
 Tab Betnesol may be given.
1 tds × 5 days.
1 bd × 5 days.
1 daily × 5 days.
In Chyluria complete rest. Omit fat from diet.
Saline purge.
HEATSTROKE
• Skin dry and hot, often hyperpyrexia.
• Confusion, disorientation and coma.
• History of exposure to hot environment.
Treatment
 Inj Novalgin 3 ml IM stat.
 Tab Paracetamol 1 qid.
 Immediate cooling of body by ice packs or
immersion in cold water.
 100 per cent oxygen.
 IV 50 per cent Dextrose Saline Infusion 2500 ml/
day.
 Small doses of Chlorpromazine to control shivering
during cooling in conscious patient 50-100 mg IM
every 4-6 hrs.
 Support of peripheral circulation with Dopamine
infusion.
HODGKIN’S DISEASE
• Firm, non-tender, rubbery lymph node enlargement.
• Irregular fever, weight loss, pruritus, sweating.
• Exacerbations and remissions.
• Lymph node biopsy shows Sternberg-Reed giant
cells.
Treatment
Chemotherapy
 MOPP regime.
Miscellaneous 267
 Mechlorethamine 6 mg/m2 IV day 1 and 8.

 Vincristine 1.4 mg/m2 IV day 1 and 8.
 Procarbazine 100 mg/m2 orally for 14 days.
 Prednisolone 40 mg/m2 orally for 14 days in cycle
1 and 4.
 Total duration of therapy is 6 cycles with 2 weeks
of drug free period in between two cycles. Cyclo-
phosphamide may be substituted for Mechlo-
rethamine.
HOOKWORM INFESTATION
Infective larva penetrate human skin and reach blood

stream-lung capillaries-alveoli-oesophagus-jejunum
where they attach to mucosa.
• At the point of entry, generally in between toes
develops a ground itch.
• Skin becomes dry and anaemic.
• Hair becomes dry and scanty, oedema of feet
develops.
• Epigastric discomfort, tenderness and diarrhoea. It
may contain blood and mucus.
• Palpitation, functional murmurs, fast pulse, low BP

and little cardiac enlargement.
• Hypochromic microcytic anaemia.
• Physical and mental tiredness.
• Detection of ova in stools or worms after drugs or
otherwise.
Management
If Hb% is below 5 gm per cent it is advisable to raise
the Hb% before giving deworming drugs like
Mebendazole, Albendazole or Pyrantel.
Deworming with Mebendazole 100 mg bid ×
3 days.
Albendazole 400 mg hs or Pyrantel palmoate
500 mg (10 mg/kg) hs.
HYPERKALAEMIA
• Features of acidosis like dehydration, twitching,
tremors, muscle weakness, lethargy.
• Associated renal failure, adrenal hypofunction.
• ECG changes like tall T waves, dysrrhythmia.
• Raised serum potassium.
Miscellaneous 269
Treatment
 10 per cent Glucose, 200 ml IV in 20 minutes with
10 units of soluble Insulin.
 Calcium gluconate 10 cc, 10 per cent slow IV.
 Sodium bicarbonate 2 ampoules (20 mEq) IV.
 Cation exchange resins like Sodium Polystyrene
Sulfonate 20 gm orally 4 times daily along with
sorbitol.
 Dialysis when situation is more demanding or
previous methods fail.
LACTIC ACIDOSIS
• Features of acidosis like lethargy, dehydration.
• Wide “anion gap”.
• Evidence of precipitating factors like shock, drugs
intake.
• Raised plasma lactate.
Treatment
 Rapid bicarbonate infusion to raise the pH to 7.2.
 Treatment of primary disorder like shock.
 Trial of dichloracetate and dichlorpropionate.
LEFT
VENTRICULAR FAILURE
• Dyspnoea, orthopnoea, paroxysmal nocturnal
dyspnoea.
• Frothy blood tinged sputum.
• Batwing appearance to floppy opacities in lung fields.
• Evident primary heart disease or hypertension.
Treatment
 Prop up position.
 Frusemide 40-80 mg IV.
 Digoxin 0.25-0.5 mg IV.
 Morphine 15 mg IM or Inj Pethidine 100 mg IM.
 Inj Siquil 10 mg IM or Stemetil 25 mg IM.
 Inj Nitrogylcerine 20-25 mg/min IV (Titrate
according to systolic BP).
 Sorbitrate 10 mg 6 hourly.
 Aminophylline 500 mg slow IV.
 Rotating tourniquet or phelbotomy to reduce
venous return to heart.
 Treatment of precipitating/primary disease.
Miscellaneous 271
MALARIA
• Lassitude, loss of appetite, headache, chilliness.
• Cold stage lasts for 1/2 hour. Patient feels cold and
shivers; may chatter his teeth and covers himself
with blanket.
• He develops severe headache and vomiting.
Temperature goes on rising.
• Hot stage lasts for 1-6 hours. He may be burning hot
and may be delirious, vomit continues. The face is
flushed, skin becomes dry and burning. Temperature
may rise to 41°C.
• Sweating stage: Develops perspiration. Temperature
drops, patient becomes comfortable and falls asleep.
Usually spleen is enlarged and in children liver may
become tender.
• Classical bouts of fever appear at regular intervals.
Management
 Bed rest.
 Get blood tested for MP.
 Tab Chloroquine 600 mg (4 tab) stat with food or
milk 2 Tablets after 8 hour. then 2 tab daily for
3 days.
 Tab Primaquine 7.5 mg bd × 5 days.

 Control fever with Paracetamol.
For chloroquine resistant cases

 Tab Metakelfin 2 stat, Quinine 2 × 350 mg tid for
14 days.
 Prophylaxis-Tab Resochin/Camoquin 2 at bed time
once a week.
 Tab Crocin sos.
MULTIPLE MYELOMA
• Bone pain, bone fracture on trivial trauma.
• Recurrent infection, weight loss.
• Raised ESR and serum globulin.
• Bence Jones proteinuria.
• Immature and atypical plasma cells in bone
marrow.
• Monoclonal bands in serum immunoelectro-
phoresis.
Treatment
High fluid in take (about 3 L/day) and prompt
treatment of infections with antibiotics.
Miscellaneous 273
 Pulse therapy consisting of: (1) Vincrystine 1 mg

IV. (2) Cyclophosphamide 100 mg/m2 for 4 days.
(3) Prednisolone 60 mg/m2 for 4 days.
This course is repeated every 4 weeks, once acute
symptoms are controlled maintenance therapy is with
intermittent.
 Melphelan 7 mg/m2 for 4 days.
 Prednisolone 60 mg/m2 for 4 days.
 Plasmapheresis when myeloma protein is too high
with hyperviscosity syndrome.
 Treat hypercalcaemia.
 Dialysis if oliguric renal failure.
MYASTHENIA GRAVIS
• Drooping or eyelids towards evening.
• Diplopia, weakness in chewing, swallowing and
speaking.
• Muscle weakness progressively increases as muscles
are used.
• Pupils are never affected and muscle involvement is
bilateral.
• Common in females in third decade.
• Decremental response more than 10 per cent on EMG.
• Positive edrophonium and neostigmin tests.
Treatment
 Neostigmine 15 mg 4 hourly along with atropine
derivatives.
 Thymectomy and irradiation to thymus.
 Corticosteroids when response to Neostigmine is
inadequate.
 Plasmapheresis.
 Immunosuppressants like Azathioprine 2 mg/kg
daily.
NEPHROTIC SYNDROME
• Proteinuria, specially albuminuria.
• Hypoproteinaemia with reversal of normal albumin
globulin ratio.
• Hypercholesterolaemia.
• Lipiduria with oval fat bodies and lipid crystals in
urine.
• Oedema in the form of anasarca and effusion.
Management
 The patient should be confined to bed.
 Protein intake of 100 gm daily with restriction of
salt.
Miscellaneous 275
 Diuretic, i.e. Esidrex 25 mg thrice daily orally.

 Corticosteroid 0.5 mg per kg thrice daily for 15
days and later on should be tapered gradually
(Prednisolone). In steroid resistant cases-
Cyclophosphamide 2-3 mg/kg for 3-6 weeks. Lasix
2 mg/kg/day. Potklor 1 tsf bd.
NON-HODGKIN’S LYMPHOMA
• Painless, discrete, firm to hard lymph node enlarge-
ment.
• Unlike Hodgkin’s lymphoma skin, bones, eyes,
breast, testes are involved.
• Absence of Sternberg-Reed giant cells in lymph node
biopsy.
Treatment
 Radiotherapy as in Hodgkin’s lymphoma.
 Chemotherapy with either MOPP regime or COPP
regime. The latter consists of Cyclophosphamide,
Oncovin, Procarbazine and Prednisolone given in
the same manner as in Hodgkin’s disease.
 Combination of chemotherapy and radiotherapy
in selected cases.
OBESITY
Obesity is when person weighs more than 20% of
expected weight. Obesity is defined as an excess of adi-
pose tissue.
• Body mass index more than 30%.
• Upper body obesity is more harmful than lower body
obesity.
• Normal BMI is 18.5-24.9, overweight is BMI = 25-
29.9, Class I obesity 30 – 34.9, class II obesity is 35-
39.9 and class III obesity is BMI >40.
• High waist hip ratio > 1.0 in men and >0.85 in women
have a greater risk of diabetes, stroke and coronary
heart disease.
• There is a genetic influence causing obesity.
• Hypothyroidism and Cushing’s syndrome may also
result in obesity.
Treatment
 It requires a greatest will power to loose weight.
 Consume less of calories. Avoid fats, sweets, pine-
apple, banana and mangoes.
 Consume lot of salads and green vegetables which
contains minimum of calories.
 Start walking at least 3-4 km daily and indulge in
exercises.
Miscellaneous 277
 Don’t miss any meals but consume lesser quantity

of preparation of your choice.
 No drug has been found of great success.
Activity Expenditure Activity Expenditure

of calories of calories
Dressing and 33 Mental work 7
undressing
Sitting at rest 15 Sawing wood 420
Walking 130-200 Cycling 180-300
Running 500-900 Climbing 200-900
Reading 20 Wrestling 900
Sweeping 120 Scrubbing floor 260
ORGANOPHOSPHORUS
POISONING
• Myosis, red eyes and red tears.
• Sweating, salivation, diarrhoea, dyspnoea and
blurred vision.
• Muscle twitchings and convulsions.
• History of exposure to pesticides.
Treatment
 Removal of unabsorbed poison from skin and GI
tract by gastric lavage.
 Atropine sulphate 2 mg IM/IV every 5 minutes till
pupils are dilated and maintenance of atropinisation.
 Pralidoxime 1 gm IV after full atropinisation
(30 mg/kg).
 Inj Diazepam 10-15 mg IM.
 Respiratory support and oxygen inhalation.
 Inj Ampicillin 500 mg 6 hrly if respiratory infection.
ROUNDWORM
Man acquires the infection by swallowing the larvae
with contaminated food.
Larval phase
• Cough severe dyspnoea may also occur.
• Fever with eosinophilia may also occur.
• Ill-defined abdominal pain.
Adult worm phase
• Intestinal colic and passage of worms in stool.
• Malabsorption, malnutrition and distension of
abdomen.
• Ocassionally worms are vomitted out.
Miscellaneous 279
Management
 Levamisole 2.5 mg/kg in single dose.
or
 Piperazine derivative 75 mg/kg body weight in
two divided doses on successive days.
or
 Mebendazole 100 mg twice daily for 3 days.
TAPEWORM INFESTATION
• Passage of segments of the worm in the stool.
• Vague abdominal pain, occasionally diarrhoea.
• Characteristic eggs in the stool.
• Brain cysticercosis manifests as seizure, mental
deterioration and hydrocephalus.
Treatment
 Niclosamide 2 gm single dose for T. solium, T. sagi-
nata and D. latum and for 5-7 days for H. Nana.
 Paromomycin 75 mg/kg (max 4 gm) single dose.
 Dichlorophen 6 gm single dose.
 Mebendazole 200 mg twice daily for 3 days.
 Albendazole 400 mg single dose.
 Praziquintel for cysticercosis.
THREADWORM
Adult worms in the colon and rectum. Gravid female
emerges from the anus to deposit the eggs on the
perianal skin. These eggs if swallowed liberate the larvae
which mature in intestines.
• Anal and perianal itching.
• Loss of appetite, abdominal discomfort.
• Girls may develop vulvovaginitis.
• Under microscope ova can be seen.
Management
 Proper sanitation and hygiene.
 Piperazine compound 75 mg/kg body weight daily
for one week.
 Vanquin 5 mg/kg body weight in single dose. Can
be repeated after one week.
or
 Mebendazole single oral dose of 100 mg may be
repeated after a week.
 All infected members of the family should be
treated simultaneously.
General Information 281
GENERAL INFORMATION
Latin Terms used in Prescriptions

QS (Quantum sufficient) As much as is sufficient
Aq (Aqua destillata) Distilled water
Ss (Semis) Half
Ad Sufficient to produce
Mist A mixture
Gargarisma A gargle
Misce Mix
Fiat Make
Ac (anti-cibcus) Before meals
bd (bis in dies) Twice a day
tds (ter in dies sumendus) To be taken thrice a day
c (cum) With
Cm (cras mane) Next morning
HS (Hora Somni) Every night
Om Noct (Omni nocte) Every morning
PC (Post Cibus) After meals
Rept Repeat
State (Statim) Immediately
IMMUNISATION
1st week • BCG vaccination.
{
6 weeks to 3rd month • DPT (Diphtheria.
4th month Tetanus toxoid.
5th month Pertussis vaccine).
Oral polio (Three doses).
9 months • Measles.
2 years • Typhoid vaccine.
3 years • Booster dose Triple
antigen and polio.
5 years • Another booster dose of
Triple antigen and polio.
Because smallpox has been eradicated from the
world there is no need of smallpox vaccination.
WEIGHTS AND MEASURES
Metric System
Measure of mass
1 microgram 0.001 milligram
1 milligram (mg) 0.001 gram
1 kilogram (kg) 1000 grams
Measure of capacity
1 Litre 1000 cc
1 Millilitre 1 cc
Imperial Systems
Measure of mass
16 Ounces 1 pound (lb)
60 Grains (grs) 1 drachm
8 Drachms (437.5 grs) 1 ounce (oz)
Measure of capacity
60 Minims (Mins) 1 fl. drachm
8 fl. dr or (480 Mins) 1 fl. ounce
16 fl. ounce 1 pound
20 fl. ounce 1 pint
1 Gallon 10 pounds
Relation of Imperial and Metric Measures
1 kilogram (kg) 15432 grains or 35.27 ounces
or 2.2046 pounds
1 Gram (G) 15.432 grains
1 Milligram 1/60 grains
1 Gm 15 grains
4 Gm or 4 cc 1 drachm
30 gm or 30 cc 1 ounce
460 gm 1 pound
Capacity
1 Litre 1.7598 pints or 35.19 fl ozs
1 millilitre (ml) 16.894 minims
1 Pint 568.25 ml or 0.568 litre
1 fl ounce 28.412 ml
1 fl drachm 3.5515 ml
1 minim (min) 0.059192 ml
Domestic Measures and Weights
The equivalents are only approximates
1 Drop 3/4 minim 1/20 cc
1 Tea spoon 1 drachm 4 cc
1 Dessert spoon 2 drachm 8 cc
1 Table spoon 4 drachm 15 cc
1 Wine glass 2 ounces 60 cc
1 Cup 5 to 6 ounces
1 Glass 8 ounces
1 Tumbler 10 ounces
Table of Proportionate Doses for Different Ages
The adult dose being represented by one, the dose for
different age groups, should be as mentioned below:
Age Dose Age Dose
under 1 year 1/12 under 7 years 1/3
under 2 years 1/8 under 14 years 1/2
under 3 years 1/6 under 20 years 2/3
under 4 years 1/4 From 21 to 64 1
years
Under 12 years the proportionate dose may be calcu-

lated by the Young’s formula:
Age
= × Adult dose
Age + 12
Inhalations
Menthol inhalation
Menthol grs 10
Rectified spirit Oz i
20 drops to 1 pint of steaming water. It is used in
cases of throat congestion, tracheitis and laryngitis.
Tincture Benzoin with Menthol
Menthol grs 30
Eucalyptus oil min 30
Oil of cinnamon min 10
Compound of Tr Oz i
Benzoin add
20 drops to 1 pint of steaming hot water. It is used in
cases of throat infections, tracheitis and laryngitis.
Enemas
Glycerine enema
Glycerine 2 drachm to 2 ounces with or without warm
water.
Soap enema
Soft soap Oz i
Warm water upto Oz 20
Starch enema
Starch gr 120
Water upto Oz 5
Rub the starch to a smooth paste with a little water
add boiling water to obtain a suitable consistency.
Glucose and Saline Enema

Glucose gr 438
Sodium chloride gr 81
Warm water upto Oz 20
Glucose saline enema is given slowly at body
temperature about 5 to 19 Ozs to adults and 2 to 4 Ozs
to Children.
Golden Rules for Prescribing Medicines
Prescription should be short simple and to the point. It
is important to mention the hour of the day when
medicines are to be given:
1. Gastric sedatives as bismuth salts are best given on
empty stomach for their local action.
2. Cod liver oil preparations are to be given after
meals.
3. Mineral acids are given after meals.

4. Alkalies when used to neutralise acid secretion
should be given after food, when given as a syste-
mic alkaliser should be given between meals.
5. Takadiastase and pepsin should be given in an
empty stomach for local action.
6. All stomachic and bitter tonics are to be given
quarter to half an hour before food.
7. Morphine should not be given to head injury cases.
8. Hypnotics should be taken after meals half an hour
before going to bed.
9. Antacids to be given after meals and anticholiner-
gic during or before meals.
10. Castor oil and saline purgatives should be given
early morning as they take only a few hours to act.
Slow acting pills should be given at bed time.
DIET THERAPY
DIABETES MELLITUS
Proteins Protein content should be normal—
1 gram/kg. In children it may be
increased.
Fats Fats should be moderate. Excessive
fat is forbidden.
Carbohydrates Carbohydrate intake must be mini-
mised in order to reduce blood sugar.
Calories Total calories should be adequate for
the growing children and under-
weight persons. In obese patients it
might be necessary to reduce calories.
Minerals Adequate amounts should be
supplied.
Vitamin Vitamin B complex group should be
taken to prevent and treat poly-
neuritis.
What to be Sweet drinks and carbonated drinks
avoided are to be avoided.
Diet Therapy 289
Cakes, Pastries, cream, dried and

caned fruits, sweet pickles, jaggeries,
sweet meats are to be avoided.
Soups Thin vegetable soups supply less
calories. Obese persons are encour-
aged to take large quantities which
would fill up their stomach and give
them a sense of satiety.
Green vegetables Diabetics should consume lot of
green vegetables which are poor
source of calories. While 100 gm of
potato will give about 100 calories.
Brinjals, spinach, tomatoes can be
consumed in plenty. Salads with lime
or vinegar is useful.
Fruits Dried fruits and nuts are avoided
being very rich in calories. Since bana-
nas and mangoes have a high caloric
content they are best avoided.
Orange, sweet lime or apple can be
taken.
Dessert Sweets and ice-creams or custard is
not allowed but small quantity of jelly
can be taken on occasions.
Sugar, honey or Obese diabetic is not allowed any of
jaggery these. One tea spoon of each of these
gives 20 calories. Instead of these
aspartame a sweetening agent can be

used. Brand name ‘Sugar free’ is
available in India.
Egg, fish, Diabetic is allowed one egg or a
chicken single helping of meat, chicken or
fish.
Cooking media Ghee, oil, butter, all are rich in calo-
ries. An obese diabetic is allowed 1
tea spoon full per meal while thin
diabetic can have one table spoon.
Tea, coffee Tea and coffee are permitted but milk
and sugar are to be regulated at
minimum.
Unsweetened drinks like soda are not
restricted.
Diet Sheet (for an obese diabetic)
Early morning Light tea without sugar.
Breakfast Tonned milk 1 cup.
Papaya 2 slices.
Lunch Fulka 2.
Or rice 1 medium bowl.
Dal thin 1/2 medium bowl.
Leafy vegetable 1 medium bowl .
Salad at plenty.
Afternoon Light tea 1 cup without sugar.
Bread 1 thin slice.
Diet Therapy 291
Dinner Fulka 2 small.

Or rice 1 medium bowl.
Vegetable 3/4 bowl.
Oil for cooking 1 tea spoonful.
Diet provides 1000 calories, 40 gram proteins.
Diet Sheet (for an underweight diabetic)
Early morning Light tea with little sugar.
Breakfast Bread 2 slices.
Fruit one.
Lunch Fulka 4.
Rice 1 medium bowl.
Dal 3/4 medium bowl thick.
Or fish 2 pieces.
Or lean meat 2 pieces.
Leafy vegetables 1 medium bowl.
Salad 1 medium bowl.
Oil for cooking 1 teaspoonful.
Afternoon Light tea 1 cup.
Bread 1 slice.
1 biscuit.
Rice 1 medium bowl.
Dal 1 medium bowl.
Vegetable 1 medium bowl.
10 PM Milk 1 glass.
Diet will provide 2000 calories, 65 gram protein and
350 gram carbohydrate.
DIARRHOEA AND DYSENTERY

Proteins Skimmed milk and curd, khichri
should be given.
Fats These may aggravate the diarrhoea
and are best avoided.
Carbohydrates Fruit juices and Electral powder, etc.
may be given.
Calories Adequate calories are required. For
undernourished surplus calories are
needed.
Minerals and Diarrhoea may result in loss of
fluids fluids and electrolytes. Fluid must be
replaced promptly.
If vomiting exists intravenous fluids should be given.
Spices, condiments, pickles and sweets are to be avoided.
Diet Sheet
Early morning Light tea.
Breakfast One cup butter milk.
Lunch Well cooked rice 2 bowl or 3 fulka
Curd medium bowl.
1/2 bowl vegetable.
Banana 1.
5 PM Light tea.
2 salted biscuits.
Diet Therapy 293
Dinner Fulka 2.
Dal 3/4 bowl.
Vegetable 1/2 bowl.
Diet will provide about 1500 calories, 35 gm
proteins and 350 gm of carbohydrate.
GOUT
Persons suffering from gout can have normal diet
except that they must avoid substances rich in purine.
Substances rich in purine are:
Vegetarian food Beans, peas, brinjals, cauliflower,
spinach, pulses, mushroom.
Non-vegetarian Liver, kidney, meat extracts fish
food Milk, egg, sweets, cereals contain-
negligible purine content.
Proteins 50 to 60 gram of proteins preferably
of vegetable origin.
Fats Fats are to be restricted to avoid
obesity and fats cause urate retention.
Carbohydrates Carbohydrates should be the main
source of calories supply.
Calories Extra calories may precipitate gout.
Vitamins Adequate supplements are required.
Fluids Increased intake of fluids will facili-
tate excretion of uric acid in urine.
Tea and coffee. A few cups are
permitted as they contain methyl

purines which are not converted to
uric acid. Alcohol should be avoided
as it may precipitate an acute attack
of gout.
HYPERTENSION
Proteins In mild hypertension 50-60 gram of

proteins may be consumed but in
severe hypertension protein should
be cut down to 20 gram because it is
difficult to achieve salt restriction
without protein restriction.
Fats High intake of animal fats and hydro-
genated oils should be discouraged
because saturated fats results in
atherosclerosis. Saffola oil or kardi oil
should be used.
Carbohydrate It should make the major bulk of
calories required for daily activities.
In case of obesity calories should be
cut.
Minerals Sodium must be restricted in
majority of hypertensives because it
causes water retention.
Diet Therapy 295
Fluid restriction is necessary.

Articles like pickles, chutney, pastries, salted biscuit,
egg and tinned foods should be avoided.
Drugs containing sodium like Aspirin, Cortico-
steroid should be ideally avoided. Extra salt and baking
powder may not be used.
Diet Sheet
Early morning One cup light tea.
Breakfast One cup milk with minimum sugar
and cream.
Lunch Fulka 4 small
Dal 1 medium bowl thin
Green vegetable 1 bowl
Oil for cooking 2 tsf only
Curd 3/4 bowl without salt and sugar.
Afternoon Light tea with minimum sugar.
Evening One orange.
Dinner Fulka 3 small thin.
Green vegetables 3/4 bowl.
Diet provides about 2000 calories, 40 gram fat.
INFECTIVE HEPATITIS
Proteins With mild jaundice 50-60 gram of

proteins are allowed but in severe
jaundice with bilirubin more than 10

to 15 mg per cent the protein intake
should be reduced to 40 gm per day.
Fats In jaundice fats are little restricted.
Carbohydrates Large quantities of fluid carbohy-
drates are given as they provide
major source of calories. In cases of
nausea and vomiting intravenous
Glucose should be given.
Calories 2000-2500 calories/day.
Vitamins Supplements of vitamin B complex
with vitamin C are believed to be
useful.
Diet Sheet
Early morning Milk half cup (fat free).
Breakfast Sugarcane juice 150 ml.
Jam 1 tea spoon.
10 AM Sugarcane juice/orange juice,
1 glass.
Lunch 3 fulka.
1/2 bowl rice.
Thin dal 1/2 medium bowl.
Butter milk 1 cup.
3 PM Sago pudding.
Milk 1/2 cup or light tea.
6 PM Fruit juice 1 cup.
Banana one.
Diet Therapy 297
Dinner Roti medium size 2.

Well cooked dal 1/2 bowl.
Mixed fruits.
Diet provides 2400 calories, 40 gram proteins,
25 gram fats and 500 gram carbohydrate.
ISCHAEMIC HEART DISEASE

Proteins Normal intake of 50 to 60 gram.
Fats Cholesterol is to be kept in low
limits.
Following fats have higher amount
of saturated fatty acid.
Animal fats. Pork, beaf, meat
Fats. Dairy products like cream
butter, ghee.
Oils. Groundnut oil.
Carbohydrates Carbohydrates are responsible for
endogenous synthesis of cholesterol
and triglycerides hence excess is to
be avoided.
Calories Obesity burdens the heart. Reduction
of calories help to lose weight.
Vitamins Nicotinic acid reduces lipids in blood.
Adequate potassium and calcium in
blood is required to prevent arrhyth-
mias.
Miscellaneous Smoking and alcohol are to be restric-

ted.
Diet Sheet
Early morning Light tea 1 cup with minimum sugar
and milk.
11 AM Bread 2 slices with butter milk
without fat.
Lunch Chapatis 4 thin without ghee.
Rice 1 medium bowl
Pulses 1 medium bowl
Salad as desired
Green leafy vegetables 1 bowl
4 PM Light tea without sugar
6 PM Any fruit, orange, papaya
Dinner 3 Fulka
3/4 bowl dal
More of salad.
3/4 bowl green vegetables.
Diet will provide about 1600 calories.
KWASHIORKOR AND MARASMUS

Proteins 20 per cent of total calories should be
supplied by proteins. This amounts
to 3 to 5 gram per kg of the expected
body weight. Best source of protein
Diet Therapy 299
is milk and Bengal gram. National

Institute of Nutrition has formulated
an energy-protein rich mixture to
treat PEM.
Whole wheat (roasted) 40 gram
Bengal gram 16 gram
Groundnut 10 gram
Jaggery 20 gram
86 gram
Total energy 330 calories
Protein 11.3 gram.
Fats 15 to 20 per cent calories can be
derived from fats.
Calories Daily requirement for the child is
90-100 calories per kg of expected
body weight.
Vitamins Multivitamins are helpful as patients
of malnutrition develops vitamin
deficiency.
Minerals Serum potassium level is markedly
low. Calcium supplements as Calcium
lactate is useful. Iron therapy is
advisable.
Diet Sheet
Early morning Milk 1 cup with sugar.
Banana 1.
Egg 1.
Lunch Rice 1/2 bowl.

Dal 1/2 bowl.
Curd 1/2 medium bowl.
5 PM Milk 1 cup.
Biscuits sweet-2.
7.30 PM Dal 1/2 cup/bowl.
Fulka 1.
Mixed vegetable 1/2 bowl.
9 PM 1 cup milk.
Diet provides about 1200 calories.
NEPHROTIC SYNDROME
Proteins High protein diet containing 100-140
gram of protein is advised as there is
massive loss of protein in urine.
Groundnut, dal and chana are rich in
proteins. Soya bean and skimmed
milk powder are good source of
proteins.
Fats 1 gm/kg of body weight.
Calories 2500-3000 calories/day.
Minerals During the stage of water logging or
oliguria low sodium is usually advi-
sed. Butter, salted biscuits, preserved
fish, papad, chutney are to be avoided.
When oedema subsides salt restriction is not needed.
Diet Therapy 301
Diet Sheet
Early morning Light tea.
Breakfast Milk 1 glass.
Egg one, 2 bread slices.
10 AM Roasted groudnut 15 gram
Chana 15 gram.
Lunch Chapaties 2 with ghee.
Rice bowl 1.
Dal 1 medium bowl.
Meat—4/5 pieces.
or
Paneer.
Curd 3/4 bowl.
Evening 2 Biscuits.
1 Glass milk.
Groundnut cake or besan ladoo.
Dinner Chapaties 3 with ghee.
Rajmah 1 bowl.
Potato + Nutrinuget 1 medium bowl
Milk made sweet dish or ice-cream,
etc.
Diet will provide about 2600 calories, 100 gram.
OBESITY
Proteins About 1 gram/kg of body weight.
Fats These should be restricted as they are
concentrated source of energy.
Carbohydrates Substances rich in carbohydrates like

potatoes, sweets, icecreams. Bulk
substances such as fruits and green
vegetables are not restricted.
Vitamins and Fat and water soluble vitamins both
minerals are necessary. An excess in salt restric-
tion is helpful in weight reduction.
Miscellaneous Liberal water intake before food may
reduce the intake of food.
Avoid snacks, biscuits, etc.
Regular exercise will burn extra-
calories
Avoid fatty fried articles.
Alcohol has to be omitted.
Diet Sheet
Early morning Light tea one cup.
Breakfast Butter milk 1 cup without sugar
Papaya 2-3 slices.
Lunch Fulka 2-3 small and thin.
Rice 1/2 medium bowl.
Dal 1 medium bowl.
Thin Butter milk 1 glass.
4 PM Light tea.
1 biscuit.
Pulses 1/2 medium bowl.
Diet Therapy 303
Green vegetables 1 bowl.

Salad at liberty.
Diet will provide about 1200 calories..
PEPTIC ULCER
It is one disease where proper dietary management is
more beneficial than pure drug therapy.
Proteins Normal 1 gram per kilogram of body
weight. Milk proteins are best because
these will not irritate gastric mucosa
unlike meat.
Fat Fat consumption is better because it
forms a protective layer over mucosa.
Fats stimulate enterogastrone which
inhibits gastric secretion. Visible fats
like butter, ghee and cream are helpful
but fried hard articles may aggravate
the symptoms.
Carbohydrates Potatoes and cereals are useful. Raw
vegetables and cooked vegetables are
harmful.
Sufficient calories should be provided to maintain
health.
Frequent feeding to neutralize HCl is needed. It
should be soft, smooth and preferably cold.
All the fruits with edible seeds should be avoided.

Salty, spicy or acidic food should be avoided.
Coffee, tea, alcohol and smoking should be stopped.
Diet Sheet
Early morning Milk 1 cup
Breakfast Bread 2 slices with 2 tea spoon butter
Boiled egg one.
Lunch Fulka 3 small with little ghee. Rice one
medium bowl, well cooked dal 3/4
medium bowl.
Well cooked vegetable 1 bowl.
2 PM Milk 1 cup.
5 PM Banana 1.
Rice 1 medium bowl.
Well cooked dal 3/4 bowl.
Bed time 1 cup milk.
Diet will provide about 2300 calories, 60 gram
proteins, 20 gram fat and 300 gram carbohydrate.
SOME OF AVAILABLE DRUGS
Antacids
Agre antacids Tablet Duphar
Alma carb Tablet Glaxo
Diet Therapy 305
Alucinol Tablet Franco-Indian

Aludrox-MH Tablet/Suspension Wyeth
Famocid Tab Sun Pharma
Digene Tablet/Suspension Boots
Diovol Tablet/Suspension Carter Wallace
Gelusil Tab/Liquid Warner
Mucaine Suspension Wyeth
Polycrol forte gel Suspension Nicholas
Magacone Tablet Shalak
Ranitidine Tablet 150 mg Torrent
Ocid Cap Cadila
Laxative, Purgative and Lubricant
Agarol Emulsion Warner
Cremaffin Emulsion Boots
Dulcolax Tablet German Remedies
Evacuol Granules Griffon
Glaxenna Tablet Glaxo
Pursennid-IN Tablet Sandoz
Laxatin Tablet Alembic
Milk of Magnesia Liquid Alembic
Antidiarrhoeals
Dependal-M Tablet SK and F
Furoxone Tab/Suspension SK and F
Kaltin with Suspension Abbott
neomycin
Tinidazole Tab Aristo
+ Ciprofloxacin
(Citizol)
Meganeg Tab Dabur
Tinibal-N Tab Zydus cadila
Tindiflox Tab Kontest
Antiemetics
Ancoloxin Tablet Allenburys
Avomine Tablet May and Baker
Emidoxyn Tablet Rallis
Marzine Tablet Wellcome
Pregnidoxin Tablet Unichem
Reglan Tab/Inj/Syrup Cosme Farma
Reggi Tab/Syrup Shalaks
Domstal Tab Torrent
Perinorm Tab/Inj IPCA
Decongestants
(For common cold)
Actifed plus Tablet Wellcome
Bodryl Tablet Parke Davis
Capramin Tablet Glaxo
Cinaryl Syrup/Tab Themis
Cosavil Tablet Hoechst
Dristan Tab/Syrup Manners
Eskold Tab/Syrup SK and F
Vikoryl Tab/Suspension Alembic
Diet Therapy 307
Analgesics and Antipyretics

Apidin Tablet IDPL
Calpol Tab/Syrup Wellcome
Crocin Tab/Syrup Duphar
Disprin Tablet Reckitt and
Colman
Fortwin Tablet/Inj Ranbaxy
Mejoral Tablet Cosme Farma
Micropyrin Tablet Nicholas
Novalgin Tab/Inj Hoechst
Ultragin Tab/Inj/Syrup Manners
Pyremol Tablet Alembic
Proxyvon Cap Wockhardt
Non-steroid Anti-inflammatory Drugs
Algestin Tab/Inj Alembic
Brufen Tab 200/400/ Boots
600 mg
Brufamol Tab Shalaks
Dolocap Capsule Unique
Esgipyrin Inj/Tab SG Chemicals
Reducin/ Tablet Unique
Reducin-A
Sugarnil Tablet SG Chemicals
Idicin Capsule IDPL
Oxalgin Tablet Cadila
Meftal Capsule Blue Cross
Toldin 10/20 mg Tablet Torrent

Flurbiprofen Tablet FDC
Rubefacient
Algipan Cream Wyeth
Medicreme Cream Rallis
Relaxyl Cream Franco Indian
Rubriment Liniment German remedies
Anti-diabetics
DBI Tablet USV and P
Daonil Tablet Hoechst
Diamicron Tab Serdia
Diabinese Tab Pfizer
Euglucon Tablet Bohringer-Knoll
Glyciphage Franco Indian
Insulins Soluble Zinc boots
suspension lentae
Isophane (NPH)
Diuretics
Aldactone Tablet Searle
Diamox Tablet Cyanamid
Diural Tab/Inj Alembic
Dytide Tablet SK and F
Hythalton Tablet SG Chemicals
Lasix Tab/Inj Hoechst
Navidrex Tablet Ciba Geigy
Diet Therapy 309
Nephril Tablet Pfizer

Xipamid Tablet German Remedies
Urinary Anti-infective and Anti-spasmodic
Campicilin Cap/Syrup Cadila
Genticyn Injection Nicholas
Gramoneg Tablet Ranbaxy
Pyridacil Tablet Ethnor
Pyridium Tablet Warner
Septran DS Tab/Ped Susp/ Wellcome
Ped Tab
Fortwin Inj Ranbaxy
Uroflox Tab Torrent
Reflobid Tab Cadila
Norflox Tab Cipla
Supristol Tab/Ped Tab/Susp German
Urobiotic Capsule Pfizer
Urolucosil Liq Tab Warner
Ultrox Tablet Ethnor
Corticosteroids and Related Drugs
Bletacortril Tab/Forte Tab Pfizer
Betnelan Tablet Glaxo
Betnesol Tab/Inj Oral Glaxo
Drops
Decadron Tab/Inj MSD
Deltacortril Tab/Forte Pfizer
Tab/Inj
Dexona Inj/Tab Cadila

Hostacortin-H Tablet Hoechst
Kenacort Tab/Inj Sarabhai
Ledercort Tablet Cynamid
Lycortin-S Tablet Lyka
Walcort Tablet Carter Wallace
Wycort Injection Wyeth
Wymesone Tablet Wyeth
Wysolone Tablet Wyeth
Butapred Tablet Biochem
Corthist Tablet Inga
Dexabolin Tablet Organon
Docabolin Tablet Organon
Perideca Tab/Susp MSD
Anticancer Drug
Ledoxan Tab/Inj Dabur
Leukeran Tab Wellcome
Zexate Tab Dabur
Intaxel Tab Dabur
Tamofen Tab Torrent
Anti-hypertensive
Adelphane Tablet Ciba Geigy
Aldephane Tablet Ciba Geigy
Esidrex
Aldomet Tablet MSD
Arkamin Tablet Unichem
Diet Therapy 311
Ciplar Tab/Forte Cipla

Tab/Inj
Emdopa Tablet IDPL
Inderal Tab 10/40/80 mg ACCI
Ismelin Tab 10/25 mg Ciba Geigy
Nephril-R Tablet Pfizer
Nepresol Tablet Ciba Geigy
Serpasil Tab/Inj Ciba Geigy
Betacard Tablet Torrent
Pinadol Tablet Ranbaxy
Aceten Tablet 25 mg Wockhardt
Betaloc Tablet Astra
Atenol Tab NPIL
Lorvas Tablet Torrent
Nepresol Tablet Ciba
Vasoconstrictors
(For migraine)
Cafergot Tablet Sandoz
Migranil Tablet Inga
Migril Tablet Wellcome
Vasograin Tablet Cadila
Sulphonamides
Bactrim Tab/Pediatric Tab Rosche
Ciplin Tab/Susp Cipla
Fortrim Tab/Paed Tab Bombay drug
Septran DS Tab/Susp Wellcome

Synastat Tab/Susp Roussel
Antituberculous Drugs
Albutol Tablet Alkem
Ambistryn-S Injection Sarabhai
Bi-Teben Tablet Bayer
Erbazide Tablet Mac
Etibi Tab 200/400 mg Pharmed
Eufacin Capsules Euphoric
Inapas Tab/Granules Neopharma
Isokin Tab 300 mg Warner
Isokin-T Tablet Warner
Isonex Tab 50/100 mg Pfizer
Myambutol Tablet Cyanamid
Pas dumex Granules Pfizer
Rifamycin Cap 150/300 mg Biochem
Rimpacin Cap 100 mg Cadila
Themibutol Tab 200/400 mg Themis
Tibitol Tab 200/400 mg PCI
Antifungals
Fungivin Tab 125 mg Eurphoric
Grifungin PG Tablet Reno
Grisovin FP Tablet Glaxo
Grivin FP Tablet Cosme farma
Indifulvin Tablet IDPL
Diet Therapy 313
Mycostatin Tablet Sarabhai

Walavin-FP Tablet Carter Wallace
Calcium Preparations
Calcima ACD Tablet Cipla
Calcinol F Syrup Raptakos
Calcinol Tablet Raptakos
Calcium Sandoz Injection Sandoz
With Vit C and D
and B12
Kalzana Tab/Syrup Sandoz
Malcavit Syrup/Inj Sandoz
Ostocalcium Tab/Syrup Glaxo
Vitamin A Preparations
Adexolin Cap/Liquid Glaxo
Adiplon-12 Drops Khandelwal
Aquasol-A Capsule USV and P
Aquasol A-D Liquid USV and P
drops
Aquasol A-E Capsule USV and P
Arovit Tab/Inj/Drops Roche
Nasal Drops
Betnesol-N-nasal Drops Glaxo
Catazol Drops Bengal Chemicals
Dristan nasal Drops Manners
drops
Efcorlin nasal Drops Allenburys

drops
Endrine Drops Wyeth
Nasivion Drops/Paed Merck
Otrivin Drops/Paed Ciba Geigy
Aural Preparations
Chloromycetin Drops Parke Davis
eardrops
Genticyn Drops Nicholas
Eye/Ear
Hamycin Drops HAL
Otek Drops FDC
Neosporin-H Drops Wellcome
Paraxin eardrops Drops Boehringer-K
Terramycin ear Drops Pfizer
Tyotocin Drops MSD
Eyedrops
Albucid 10% 20% 30% Nicholas
Drops
Alcycline Ointment Alembic
Chloromycetin Aplicaps Parke Davis
aplicaps
Genticyn Drops Nicholas
Locula 10% 20% 30% East India
Drops
Diet Therapy 315
Soframycin Oint Mac

ophthalmic oint
Vanmycetin Drops FDC
Zinco sulfa Drops BELL
Anti-allergic Drugs
Actidil Tablet Wellcome
Avil 22.5/45 mg Tab/ Hoechst
Syrup/Inj
Benadryl Cap/Syrup Parke Davis
Dilosyn Tab/Syrup Allenburys
Foristal Tablet Ciba Geigy
Foristal Lon tab Tablet Ciba Geigy
Histacort Tablet SINS
Incidal Tablet Bayer
Longifene Tab/Syrup Nni UCB
Practin Tab/Syrup MSD
Astelong Tab Torrent
Cetzine Cap/Tab Glaxo
Zadine Tab/Syrup Schering
Anti-scabies Drugs
Ascabiol Emulsion May and Baker
Benhex Cream Searle
Benzoscab Ointment UNILOIDS
Crotorax Cream/Lotion SG Chemicals
Dermoscab Ointment Chowgule
Emscab Lotion MM Lab
Gamaderm Lotion Vilco

Tetmosol SOL Solution/Soap SK and F
Topical Antifungal Drugs
Bradex Vioform Cream Ciba Geigy
Dermoquinol 4% and 8% tube East India
Multifungin Power/Soln/Oint Boehringer
Multifungin-H Ointment Boehringer Knoll
Mycoderm Dusting powder FDC
Tinaderm Soln Fulford
Tineafax Ointment Wellcome
Daktar in 2% Oint Ethnor
Surfaz Oint Franco Indian
Econazole Oint Sarabhai
Hamycin Susp HAL
Topical Anti-Infective Preparation
Achromycin oint Ointment Cyanamid
Burnol Cream Boots
Cetavlex cream Cream ACCI
Cetavlon conc ACCI
Chloromycetin Soln Parke Davis
topical
Dettol antiseptic Cream Rickett and
cream Colman
Furacin Powder/Cream SK and F
Genticyn topical Cream Nicholas
Ledermycin oint Ointment Cyanamid
Diet Therapy 317
Nabasulf Ointment/Powder Pfizer

Neosporin Powder/Oint Wellcome
Savlon Cream/Liquid ACCI
Soframycin skin Ointment Roussel
Betadine Oint/Lot Wockhardt
Fucidin-Leo Oint Wallace
Genticyn topical Oint Nicholas
Topical Steroid Preparation
Betnovate Cream and Oint Glaxo
Betnovate-N Cream/Oint Glaxo
Betnovate-C Cream/Oint Glaxo
Cambison oint Ointment Hoechst
Cortoquinol Cream East India
Decadron cream Cream MSD
Furacin-S Cream SK and F
Flucort Cream Lyka
Flucort-C Cream Lyka
Flucort-N Cream Lyka
Flucort Sol Cream Lyka
Kenalog-S skin Ointment Sarabhai
Ledercort Cream Cyanamid
Nebacortril skin Ointment Pfizer
Neosporin-H Ointment Wellcome
Sofradex cream Cream Roussel
Wycort oint Ointment Wyeth
Plasma Expanders
Dextran 70 Rallis-Fison
Dextraven Rallis
Dextrose 2.5% Mc Gaw
Dextrose 5% Duphar/Mc Gaw/Flexflac
Dextrose 10% Mc Gaw/Flexflac
Dextrose 20% Mount Mettur/Mc Gaw
Dextrose 25% Mount Mettur
and 50%
Dextrose and Sodium Chloride
Dextrose (2.5%) Mount Mettur/Mc Gaw
Sodium chloride
(0.45%)
Dextrose (5%) Duphar/Mc
Gaw/Flexflac
Sodium chloride (0.9%)
Dextrose Mount Mettur/
Mc Gaw/Flexflac
Sodium chloride
Haemaccel Fluid Hoechst
Lomodex Fluid Rallis-Fison
Mannitol 5% Fluid 500 ml Mc Gaw
10% and 20%
Mannitol 350 ml Unichem
Molar lactate sol Mount Mettur/
Mc Gaw
Diet Therapy 319
Ringer’s lactate 540 ml Mount Mettur/

500 ml Mc Gaw
Sodium Chloride
Sodium chloride 540 ml Mc Gaw/Mount
0.45% Mettur
Sodium chloride 540 ml Duphar/Mc Gaw
0.9%
Vitamin B and Vitamin C
Preparations/Multivitamin
Becosule Cap/Syrup Pfizer
Becozym forte Tablet Roche
Bejectal Injection Abbott
Beneuron Capsule Franco Indian
Beplex forte Tab/Inj Anglo French
Berin Tablet Glaxo
Bevidox Tablet Abbott
Bivinal forte Capsule Alembic
Vit C
Cebexin Tablet IDPL
Cecon-500 Tab/Drops Abbott
Celin Tablet Glaxo
50/100/500 mg
Chewcee Tablet Cyanamid
Cobadex forte Tablet Glaxo
Dolo neurobion Tablet Merck
Hexavit (M vit) Tablet IDPL

Multivitaplex Cap/Elixir/Drops Pfizer
forte
Neurobion Tab/Forte Merck
Tab/Inj
Neuroxin-12 Inj/Forte Inj Cadila
Polybion Tab/Inj/Syrup Merck
Redoxon Tab/Inj Roche
Surbex Tablet/Syrup Abbott
Surbex-T Tablet Abbott
Vidaylin Drops/Syrup Abbott
Visyneral Drops/Syrup USV and P
Vitneurin Ampoule Glaxo
Food Products
Alprovit Liquid Alkem
Procasenol Granules MSD
Protinex Granules Pfizer
Protinules Powder Alembic
SYU Granules AFD
Anti-helminthics
Alcopar Granules Wellcome
Antepar Elixir Wellcome
Decaris Tab 150/50 mg Ethnor
Helmacid Granules Glaxo
Mebex Tablet Cipla
Diet Therapy 321
Mintezol Tablet MSD

Nilcaris Tab 150 /50 mg Bombay Drug
Vanpar Suspension Parke Davis
Wormin Tablet Cadila
Vermisol Tablet Khandelwal
Alminth Tablet Torrent
Bronchospasm Relaxants
Alupent Tab/Inj/Syrup German Remedies
Asmapax depot Tablet Nicholas
Asthalin Tab/Syrup Cipla
Broncordil Elixir Neo Pharma
Cortasmyl Tablet Roussel
Deriphyllin Tab/Inj German Remedies
Sedonol Tablet East India
Tedral Tab/Liquid Warner
Tedral SA Tablet Warner
Terbutaline Tablet Astra
Bricanyl Inhaler Astra
Asthalin Inhaler Cipla
Autohaler Inhaler Cipla
Beclate Inhaler Cipla
Cough Expectorants/Sedatives
Avil Expectorant Syrup Hoechst
Benadryl Syrup Parke Davis
Expectorant
Corex Syrup Pfizer
Dilosyn Exp Soln Allenburys

Dristan Exp Tab/Syrup Manners
Piriton Exp Liquid Glaxo
Soventol Exp Liquid Boehringer
Knolls
Tixylix Liquid May and Baker
Zeet Exp Syrup Alembic
Phensedyl Linctus May and Baker
Iron Preparations
Autrin Capsule Cyanamid
Dexorange Syrup Franco Indian
Dumasules Capsule Pfizer
Erythrotone Cap/Syrup Nicholas
Fefol spansule Capsule SK and F
Folinate B-12 Cap/Liquid Alembic
Folvron-F Cap/Liquid Cyanamid
Hematrine Capsule Sandoz
Livogen Capsule Allenburys
Neoferilex S Liquid Rallis
Plastules B-12 Capsule Wyeth
Rarical Tablet Ethnor
Rubration Elixir Sarabhai
Tonoferon Syrup/Drops East India
Antibiotics
Alcyclin Cap/Paed drops Alembic
Althrocin Tab/Granules Alembic
Diet Therapy 323
Bacipen Capsule Alembic

Campicillin Dry Syrup/Inj Cadila
Combiotic Injection Pfizer
Doxycaps Capsule Reno
Emycin Tablet Themis
Erythrocin Tablet Abbott
Garamycin Injection Fulford
Olymox Cap Shalaks
Ampiclox Cap Biochem
Alcephin Cap Alembic
Cifran Tab Ranbaxy
Minicyclin Cap Plethico
Genticyn Injection Nicholas
Hostacyclin 500 Dragees Hoechst
Kaypen Tab/Granules HAL
Klox Cap/Syrup Lyka
Ciprobid Tab Zydus cadila
Althrox Tab Alembic
Norflox Tab Cipla
Ledermycin Cap/drops/ Cyanamid
Syrup
Paraxin Cap/Dry Syrup B Knoll
Penidura LA 6, Injection Wyeth
LA 12, LA 24
Synthocilin Cap/Inj/Drops PCI
250/500 mg
Thromycin Tablet IDPL
Veripen Tab/Forte Alembic

Penglobe Tablet Astra
Alcizon Injection Alembic
Alcephin Capsule Alembic
Carbelin Injection Lyka
Ceflad Injection Biochem
Cephaxin Cap/Syrup/Inj Biochem
Flemipen Capsule FDC
Sisocin Injection Biochem
Ciprofloxacin Tab Sarabhai
Enzymes and Digestives
Bestozyme Tab/Syrup Biological Evans
Combizyme Dragees Neo Pharma
Digiplex Syrup Rallis
Dispeptal Tablet B Knoll
Panzynorm Tablet German Remedies
Unienzyme Tablet Unichem
Vitazyme Liquid East India
Local and Systemic Drugs for

Vaginal and Urethral Conditions
Compeba Tablet IDPL
Dienoestrol Cream Ethnor
Flagyl Tab 200/400 mg May and Baker
Giardyl Tab/Susp IPCA
Kemicetine Suppositories SG Chemicals
vaginal
Diet Therapy 325
Metrogyl Tab 200/400 mg Unique

Mycostatin Vaginal Tab Sarabhai
Vaginal
Talsutin Vaginal Vaginal Tab Sarabhai
Vaginal Preparations
Betadine Pessary Wockhardt
Floraquin Pessary Searle
Hamycin Vaginal Tablet HAL
Gynodaktarin Vaginal Tablet Ethnor
Natamycin Vaginal Tablet Martel-Hammer
Anti-spasmodics and Anti-cholinergics
Buscopan Tab/Inj German
compositum Remedies
Antrenyl Tab/Drops Ciba
Antrenyl duplex Tablet Ciba
Bardase Tab/Liquid Parke Davis
Belladenal IN Tablet Sandoz
Belladenal IF Tablet Sandoz
Retard
Daricon Tablet Ciba
Cibalgin Tablet Ciba
Piptal Drops Chem pharma
Spasmindon Tab/Inj Indo pharma
Spasmo-Proxyvon Injection Wockhardt
Antimalarials
Chloroquin Tablet Bengal
immunity
Cadiquin Injection Cadila
Nivaquin Injection M and B
Camoquin Tablet Parke Davis
Daraprim Tablet Wellcome
Lariago Syrup/Tab/Inj IPCA
Metakelfin Tablet Water Brushel
Quinarsol Tablet Cipla
Anginal Drugs and Coronary Vasodilator
Cardilate Tablet Wellcome
Ciplar Tablet Cipla
Inderal Tablet ACCI
Isoptin Dragees/Inj B Knoll
Isorpil Tab/Sulingual Manners
Neocor Tablet Warner
Peritrate Tablet Warner
Peritrate SA Tablet Warner
Segontin Tablet Hoechst
Sorbitrate Sublingual Tab Nicholas
Anti-anginal
Angised Tablet Wellcome
Calcigard Tablet Torrent
Clinium Tablet Ethnor
Diet Therapy 327
Ildamen Tablet German Remedies

Isomack Tablet Biochem
Peripheral Vasodilator
Arlidin Tablet USV and P
Complamina Tab/Amp German Remedies
Duvadilan Tab/Inj Duphar
Cyclospasmol Tablet Martin Haris
Nicidal Tablet Cipla
Repaverine Tablet Retort
Xanthomina Tablet Cipla
Tranquilizers
Atarax Drops/Inj/Syrup UCL
Ifibrium Tablet Unique
Larpose Tablet Cipla
Meprindon Tablet Indo Pharma
Equanil Tablet Wyeth
Calmpose Tab/Syrup/Inj Ranbaxy
Librium Tablet Roche
Valium Tablet Roche
Hypnotics and Sedatives
Non-barbiturates
Calcibronat Tab/Inj/Syrup Sandoz
Barbiturate Plain
Luminol Tab/Inj Bayers
Phenobarbitone Tablet Deys/IDPL
Gardenal Tab/Inj May and Baker

Barbiturate Combination
Vesparax Tablet UCB
Sympathomimetics and Analeptics
Nikethamide Injection Bengal Immunity
Strychnine Injection Bengal Immunity
Cardiazol Inj/Tab B Knoll
Veritol Injection B Knoll
Coramine Tab/Inj/Drops Ciba
Levophed Injection Deys
Mephentine Injection Wyeth
Sex Hormones/Hormonal Contraceptives
Voldays 21 Tablet Glaxo
Norcyclin Tablet Ciba
Ovral Tablet Wyeth
Lyndiol Tablet Organon
Norlestrin Tablet P. Davis
Orlest Tablet P. Davis
Anovlar-21 Tablet Schering
Gynovlar-21 Tablet Schering
Primovlar-30 Tablet Schering
Ovulen Tablet Searle
Androgens and Combinations
Testosterone Injection Bengal Immunity
Triolandern Injection Ciba
Diet Therapy 329
Aquaviron Injection Ind Schering

Aquaviron B-12 Injection Ind Schering
Sustanon Injection Organon
Testoviron Injection Ind Schering
Uni-testron depotInjection Unichem Lab
For Acne
Acnelak Soap Shalaks
Acnelak Cream Shalaks
Acnebenz Shalaks
Oestrogen and Combinations
Ethisterone Tablet BPL
Clinestrol Injection Glaxo
Ovucyclin Injection Ciba
Honvan Tablet Khandel Lab
Lynoral Tablet Organon
Progestogens and Combinations
Progesterone Injection Bengal
Immunity
Lutocyclin Inj/Tab Ciba
Progesterone Tablet PCI
Gestanin Tablet Organon
Prolution Injection Schering
UNI progestin Injection UCB
Antioxidant
Zemin Cap Shalaks
Anxiolytic
Zollpam Tab Shalaks
Alprax Tab Torrent
Alzolam Tab Sun Pharma
Zolax Tab Intas
Sun Screens
UV Dew Cream 10, SPF Shalaks
UV Dew Plus SPF 18+ Shalaks
UV AVO SPF 25+ Shalaks
UNDERWEIGHT
Proteins 1.5 gm/kg or more.
Fats These are encouraged to increase
weight. However, care should be
taken because excessive fats produce
diarrhoea.
Produce flatulance and gastro-
intestinal disorder.
If taken before actual meals may
decrease the appetite.
Carbohydrates Sweet potatoes, potatoes, finger
chips, biscuits, soya bean prepara-
Diet Therapy 331
tions, groundnuts will help in gain-

ing weight.
Vitamin Should be supplemented in sufficient
quantity.
Sweetened juices, cheese, butter,
bread, jam, dried nuts and fruits, eggs
and meat with gravy are encour-
aged.
BLOOD COUNT
NORMAL BLOOD COUNT
RBC COUNT
Men
4.5 to 5.6 million/cu mm.
Women
3.9 to 5.6 million/cu mm.
Total leucocyte count–4000 to 11000/cu mm of blood.
Differential leucocytes (in adults)
Polymorphs (neutrophils) 55-65%
Lymphocytes 20-35%
Monocytes 3-10%
Eosinophils 1-6%
Basophils (0-1%).
LEUCOCYTOSIS
An absolute increase in leucocytes is referred to as leuco-
cytosis, i.e., above 11000 cells per cu mm of blood.
Blood Count 333
Neutrophilia
Physiological
• In muscular activity
• Infants during first few days
• During last week of pregnancy
• Emotional disturbances
• Extreme heat and cold.
Pathological
• Acute infections due to staphylococcus, streptoco-
ccus, pneumococcus, gonococci and septicaemia,
acute appendicitis, osteomyelitis, etc.
• In intoxications
• Gout, diabetic coma, cirrhosis of liver, intestinal
obstruction, uraemia.
• Myeloid leukaemia
• After acute haemorrhage
• In malignant tumours
• Poisons like carbon monoxide, chloroform, ether
• Myocardial infarction
• Serum sickness.
LEUCOPENIA
A reduction in the number of leucocytes below
4000/cu mm.
Infections
Bacterial
• Typhoid fever, paratyphoid fever, brucellosis, miliary
tuberculosis.
Viral
• Influenza, measles, infective hepatitis.
Protozoal
• Malaria, kala azar, relapsing fever.
Defective Bone Marrow Function
• Aplastic anaemia
• Megaloblastic anaemia.
Bone Marrow Involvement
• Secondary carcinoma
• Malignant lymphoma
• Myelosclerosis
• Multiple myeloma.
Sensitivity to Drugs (Agranulocytosis)
• Sulphonamides
• Thiouracil
• Amidopyrine
• Phenylbutazone
• Chloramphenicol.
Blood Count 335
Shock
• Traumatic
• Anaphylactic.
Irradiation
• Exposure to X-ray and radioactive substances.
LYMPHOCYTOSIS
Relative lymphocytosis occurs in conditions showing
polymorphonuclear leucopenia. Absolute lympho-
cytosis occurs in:
• Pertussis
• Infectious mononucleosis
• Chronic lymphatic leukaemia
• Chronic infections–tuberculosis, syphilis, infective
hepatitis
• Mumps, measles, chickenpox
• Thyrotoxicosis.
LYMPHOPENIA
• Administration of ACTH
• In conditions of stress and carcinomatosis
• Excessive radiation.
MONOCYTOSIS
Bacterial infections
• Tuberculosis, typhoid, brucellosis
• Subacute bacterial endocarditis.
Protozoal
• Malaria, kala-azar, amoebiasis
• Monocytic leukaemia
• Hodgkin’s disease.
EOSINOPHILIA
Allergic Disorders
• Asthma, drug allergy
• Serum sickness
• Urticaria.
Parasitic Infestations
• Intestinal worms
• Hydatid cyst
• Bilharziasis.
Drug Administration
(with or without drug allergy)
• Liver extract, penicillin
• Chlorpromazine
• Streptomycin.
Skin Diseases (Allergy Type)
• Eczema
• Exfoliative dermatitis.
Pulmonary Eosinophilia
• Tropical eosinophilia
• Loeffler’s syndrome.
Blood Count 337
Blood Dyscrasias
• Eosinophilic leukaemia
• Chronic myeloid leukaemia
• Following irradiation
• Hodgkin’s disease.
EOSINOPENIA
• Administration of ACTH, adrenaline and ephedrine
• Response to stress: Traumatic shock, surgical opera-
tions, burns, acute emotional stress, exposure to cold.
• Endocrine disorders: Cushing’s disease and
acromegaly.
• Aplastic anaemia, SLE.
BASOPHILIA
• Polycythemia vera
• Cirrhosis of liver
• Early stages of Hodgkin’s disease
• Lead poisoning (punctuate basophilia).
PLASMA CELLS
These are normally not present in peripheral blood, but
may be found in:
• Measles, chickenpox (plasmacytoid lymphocytes)
• Multiple myeloma with spillover
• Plasma cell leukaemia.
PLATELETS
Normal value: 150,000-450,000/cu mm.
THROMBOCYTOPENIA
(Below 150,000/cu mm)
• Idiopathic thrombocytopenic purpura
• Leukaemia (usually acute leukaemias)
• Multiple myeloma
• Hypersplenism
• Drug reactions
• Megaloblastic anaemia.
THROMBOCYTOSIS
(Count above 450,000/cu mm)
• Polycythemia vera, essential thrombocythemia
• After splenectomy
• After haemorrhage
• After parturition
• After severe injuries, major surgical operations.
PANCYTOPENIA
When all the three elements of blood are reduced:
• Subleukaemic leukaemia
• Bone marrow infiltration, i.e. Hodgkin’s, multiple
myeloma or secondary carcinoma deposit.
• Hypersplenism.
Blood Count 339
• Megaloblastic anaemia
• Disseminated sclerosis.
RED CELL MORPHOLOGY
HYPOCHROMIA (Increase in central pallor)

• Iron deficiency anaemia
• Thalassaemia
• Sideroblastic anaemia
• Anaemias of chronic diseases.
MACROCYTES
(Larger than small lymphocytes)
• Myeloblastic anaemia
• Hepatic disease
• B deficiency
• Congenital dyserythropoietic anaemia
• Pure red cell aplasia.
TARGET CELLS
• Obstructive liver disease
• Thalassaemia
• Haemoglobin ‘C’ disease
• Haemoglobin ‘D’ disease.
SPHEROCYTES
• Hereditary spherocytes
• Autoimmune haemolytic anaemia
• Cl. welchii infection
• Post-burn patients.
LEUCOERYTHROBLASTIC PICTURE
(Immature myeloid and erythroid cells
appearing in peripheral blood)
• Myeloproliferative disorders:
– Polycythemia vera
– Myelofibrosis
• Haemolytic anaemias
• Leukaemias
• Bone marrow involvement with Hodgkin’s
carcinoma or lymphoma
• Leukaemoid reactions.
RETICULOCYTE COUNT
Stained with brilliant cresyl blue appears as bluish
strands in cytoplasm due to precipitation of ribosomes
and RNA.
(Normal 0.1-2%).
Increased
• Haemolytic anaemia
• Nutritional anaemia on therapy.
Blood Count 341
Reduced
• PNH.
INCREASED PLASMA HAEMOGLOBIN
(Normal 0.4 mg/100 ml)
• G6 PD deficiency
• PNH
• Black water fever
• Cold haemoglobinuria
• Autoimmune haemolytic anaemia.
LEUCOCYTE ALKALINE
PHOSPHATASE SCORE
Increased
• Infection
• Leukaemoid reaction
• Myelofibrosis
• Polycythemia vera.
Decreased
• Paroxysmal nocturnal haemoglobinuria.
COOMB’S TEST
It is positive in autoimmune haemolytic anaemia
i. Idiopathic.
ii. Secondary to
• Lymphoma
• Mycoplasma pneumonia
• Cold agglutinin disease.
LUPUS ERYTHEMATOSUS (LE) CELLS
Positive LE Cells in Blood
• Systemic lupus erythematosus (70-80%)
• Rheumatoid arthritis (10%)
• Occasionally other collagen diseases
• Active chronic lupoid hepatitis (10%)
• Malaria
• Drugs-Hydralazine, Procainamide.
ERYTHROCYTE SEDIMENTATION RATE (ESR)
Two methods are employed commonly:
Westergren Method
• 0-5 mm in men
• 0-7 mm in women.
Wintrobe Method
• 0-9 mm in men
• 0-20 mm in women.
ESR not raised
• In relatively inactive infections, i.e., influenza
• Chronic focal dental infection.
Blood Count 343
• In benign tumour and early sarcoma

• Ectopic pregnancy
• Psychoneurotic diseases.
ESR raised
• Pregnancy from 4th month
• Anaemia (except sickle cell)
• Acute myocardial infarction
• Carcinomatosis
• Pulmonary tuberculosis
• Acute gout
• Extensive tissue damage-burns
• Acute infections
• After fracture and operation.
ESR decreased
• Polycythaemia vera
• Congestive cardiac failure
• Whooping cough, dehydration.
ESR very rapid increase
• Temporal arteritis
• Kala-azar
• Some cases of multiple myeloma
• Rheumatoid arthritis
• Leukaemia
• Chronic renal disease
• Sarcoidosis.
ESR in diagnosis
• To distinguish functional from organic disease.
• In active rheumatoid arthritis, acute gout and infec-
tive arthritis, it is markedly raised while in osteo-
arthritis it remains practically normal.
• In myocardial infarction it is raised while in angina it
is not.
• It differentiates cancer of stomach from peptic ulcer.
• It is raised in pelvic inflammation and not in unrup-
tured ectopic gestation.
ESR in prognosis and treatment
• In fevers, a rising ESR suggests progress of the
disease.
• In rheumatic fever it is a specially sensitive index of
persistent rheumatic infection.
• In coronary thrombosis repeated determination
serves as a guide of healing and in management of
patient’s activities.
• In acute nephritis, the rate remains high in patients
passing into chronic stage.
Fragility of erythrocytes
Normal: Begins in 0.45-0.30% NaCl
Completes in 0.33-0.30% NaCl.
Increased
• Hereditary spherocytosis
• Congenital haemolytic jaundice.
Blood Count 345
Decreased
• Pernicious anaemia
• Hypochromic anaemia
• Obstructive jaundice
• After splenectomy.
BLEEDING TIME
Normal is 2-10 minutes, but in some individuals it may
extend upto 11 minutes.
Bleeding Time is Prolonged
• In thrombocytopenia.
• Hereditary functional platelet defects.
• In acute haemorrhagic exanthemata.
• In atrophy of bone marrow as in aplastic anaemia.
• In excessive destruction of platelets by spleen as in
Gaucher’s disease and Banti’s spleen.
• von Willebrand’s disease.
Functional Platelet Defects
Platelets are adequate in number but defective in
function leading to increase in bleeding time.
• Glanzmann’s thrombasthenia
• Storage pool disease
• Bernard-Soulier’s disease
• Cyclooxygenase deficiency
• Thromboxane synthetase deficiency.
COAGULATION TIME
Normal values for clotting time are 9-15 minutes.
Reduced
• After meals
• In typhoid
• After haemorrhage and general anaesthesia
• In endocarditis
• After splenectomy.
Prolonged
• In haemophilia A, B, and Factor XI deficiency
• Chloroform and phosphorus poisoning. Here the
fibrinogen forming function of liver in hampered
• Excessive CO2 in blood
• Occasionally in leukaemia.
COAGULANT FACTOR DEFECTS
Haemophilia A
(Factor VIII pro-coagulant activity deficiency)
Mild–5.25% of normal
Moderate–1.5% of normal
Severe– < 1% of normal.
Blood Count 347
Haemophilia B
(Christmas disease)
Due to factor IX deficiency.
Both haemophilia A and B are ‘X’ linked diseases
transmitted by female carriers.
von Willebrand’s Disease

It is due to deficiency of factor VIII related antigen
deficiency.
PACKED CELL VOLUME (PCV)

Normal value Male: 47% (47-54).
Female: 42% (36-47).
MEAN CORPUSCULAR HAEMOGLOBIN (MCH)

Hb in gm/1,000 ml of blood
in micro-
MCH = microgram
RBC in millon/C mm
Normal value 27 to 32.
Raised
• Macrocytic anaemia.
Low
• Hypochromic anaemia.
MEAN CORPUSCULAR HAEMOGLOBULIN

CONCENTRATION(MCHC)
Hb in gm/100 ml blood
MCV = ______________________________________
× 100
PCV%
Normal 32 to 38%.
Raised
• Not possible. Red cell stroma cannot hold greater
than normal cancentration of Hb.
Low
• Iron deficiency.
MEAN CORPUSCULAR VOLUME (MCV)
PCV I in ml/100 ml of blood in cubic microns

MCV = _______________________________________________________________
RBC in million/cu mm
Normal value 78 to 94 cubic microns.
Raised
• Macrocytic anaemia.
Low
• Microcytic hypochromic anaemia.
COLOUR INDEX (CI)
Hb expressed as a %age of normal
Blood Count 349
14.5 gm Hb as 100%)
CI = _____________________________________________________
RBC expressed as %age of normal)
Normal values 0.9 to 1.1.

Raised
• Pernicious anaemia.
Low
• Iron deficiency anaemia.
HAEMATOLOGICAL DIAGNOSIS OF LEUKAEMIA

Myeloblasts 10-25 m in diameter, round to oval nucleus
2/3 of cell size, chromatin strands with 2 or more
nucleoli, auter rods present. Lymphoblasts–10-20 m in
diameter, 1-2 nucleoli more compact chromatin with
less cytoplasm.
Cytochemical Characteristics
Acute myeloblastic leukaemia
• Myeloperoxidase positive
• Siedor black positive
• Chloroacetate elastase positive.
Acute monoblastic leukaemia

• Non-specific esterase positive.
ALL
• Periodic acid schiff (PAS) positive.
Hairy cell leukaemia
• Tartrate resistant acid phosphatase positive.
Acute megakaryoblastic leukaemia
• Platelet peroxidase positive.
Leukaemoid reaction
The total leukocyte count is often in the range of 50,000
cu/mm mimicking leukaemia.
i. Infections
a. Myelocytic or myeloblastic
• Pneumonia
• Meningitis
• Diphtheria
• Tuberculosis.
b. Lymphocytic
• Whooping cough
• Chicken pox
• Tuberculosis
• Benign lymphocytosis.
ii. Intoxications
• Eclampsia
• Burns
• Mercury poisoning.
Blood Count 351
iii. Malignant diseases with bone marrow metastasis

• Myelofibrosis
• Hodgkin’s disease
iv. Following severe haemorrhage, sudden haemo-
lysis.
HAEMOGLOBIN ELECTROPHORESIS
It is done for diagnosis of abnormal haemoglobins like
Hb, S, C, D, E, H, Barts.
In alkaline pH electrophoresis (pH 8-9):
Slowest moving Hb-HbA2 C, E
Fastest moving Hb-HbH, Barts.
Haemoglobin A2
Normal 2.0-2.9%.
Increase
• Beta-thalassaemia trait
• Myeloblastic anaemia
• Haemoglobinopathies.
Decrease
Haemoglobin-F
Normal 0.1%.
Increase
Physiological • Foetal life
Pathological • Thalassaemia
• Haemoglobinopathies
• Hereditary persistent haemoglobin
• Juvenile CML
• Fanconi’s anaemia.
IMMUNOGLOBULIN ESTIMATION
IgG 1200 mg/dl
IgA 280 mg/dl
IgM 100 mg/dl
IgD 3 mg/dl
IgE 10-20 mgm/dl
IgG1 70%, IgG2 18%, IgG3 8%
IgG4 4%, IgA1 75%, IgA2 25%.
All immunoglobulins are decreased in:
• Severe combined immune deficiency
• Thymic aplasia
• Ataxia telangiectasia
• X-linked agammaglobulinaemia
• Transient hypogammaglobulinaemia of infancy
• Common varied immunodeficiency.
IgA Deficiency
• Bronchiectasis and chronic lung infections
Blood Count 353
• Giardiasis
• SLE and rheumatoid arthritis.
IgM Deficiency
• Wiskott-Aldrich syndrome
IHA: Iso haemaglutination
ELISA: Enzyme linked immunosorbent assay
BFT: Bintolite flocculation test.
BLOOD BIOCHEMISTRY
SERUM MAGNESIUM
Elevated
• Renal insufficiency.
Decreased
• Acute fluid loss from GI tract
• Chronic alcoholism
• Chronic hepatitis
• Chronic renal loss
• Hypervitaminosis D.
SERUM PHOSPHORUS: INORGANIC
Normal
Children – 4 to 7 mg/100 ml
Adults – 3 to 4 mg/100 ml.
Elevated
• Renal insufficiency
• Hypoparathyroidism
• Hypervitaminosis D.
Blood Biochemistry 355
Decreased
• Hyperparathyroidism
• Rickets and osteomalacia
• Steatorrhoea
• Antacid ingestion.
SERUM TRIGLYCERIDES
Normal
• Below 165 mg/100 ml.
Elevated
• Primary hyperlipoproteinemias
• Hypothyroidism, diabetes mellitus
• Nephrotic syndrome, use of contraceptive pills
• Biliary obstruction.
Decreased
• Primary hypolipoproteinemias
• Malabsorption
• Malnutrition.
SERUM BILIRUBIN
Normal total 0.3 to 1.1 mg/100 ml.
Direct
0.1 to 0.4 mg/100 ml.
Indirect
0.2 to 0.7 mg/100 ml.
Rise of Indirect Serum Bilirubin
• In haemolytic disease or reactions.
• Gilbert’s disease.
Rise of Total Serum Bilirubin
• Acute and chronic hepatitis
• Biliary tract obstruction–gallstones or due to
cancer head of pancreas.
SERUM CALCIUM
Normal 9.6 to 10.9 mg/100 ml.
Raised
• Hyperparathyroidism (20 mg%)
• Hypervitaminosis D (17 mg%)
• Cushing’s syndrome.
Decreased
• Hypoparathyroidism
• Osteomalacia, rickets
• Malabsorption syndrome
• Acute pancreatitis.
CHLORIDES
Normal 350 to 275 mg/100 ml.
Increased
• Excessive salt in diet
• Over treatment with saline solution
• Decreased excretion in urinary tract obstruction
• Acute and chronic nephritis with low intake of
proteins
• Decompensated heart disease.
Decreased
• Abnormal loss such as in severe diarrhoea and vomi-
ting excessive sweating
• Overtreatment with diuretics
• Renal failure.
SODIUM
Normal 136 to 145 mEq/L.
Low
• Severe diarrhoea and vomiting
• Failure of sodium retention in Addison’s disease
• Excess of water in take or inappropriate ADH
secretion.
High
• Excessive replacement of sodium-oral or IV
• Excessive replacement of sodium-hyper-aldo-
steronism
• Failure of water retention
• Diabetes insipidus.
SERUM CHOLESTEROL
Normal 150 to 250 mg/100 ml, 60-75% as esterified.
Raised
• Xanthomatosis
• Physiological in pregnancy
• Alcohol and fatty diet consumption
• Myxoedema
• Diabetes mellitus
• Obesity
• Nephrotic syndrome
• Amyloid disease of kidney
• Familial hyperlipoproteinemias.
Low
• Hyperthyroidism
• Acute infections
• Anaemia with malnutrition.
PLASMA PROTEINS
Total proteins 6 to 8 gm/100 ml.
SERUM ALBUMIN
Normal 3.5 to 5.5 gm/100 ml.
Raised
• Haemoconcentration
• Shock
• Dehydration.
Low
• Malnutrition
• Starvation
• Glomerulonephritis
• Hepatic insufficiency
• Leukaemia and other malignancies.
SERUM GLOBULIN
Normal 1.5 to 3 gm/130 m.
Raised
• Hepatic diseases, e.g. infective hepatitis
• Some bacterial and viral infections
• Typhus, leishmaniasis and malaria.
Low
• Starvation with malnutrition
• Agammaglobulinemia
• Lymphatic leukaemia.
SERUM FIBRINOGEN
Raised
• Rheumatic fever
• Arthritis
• Glomerulonephritis.
Decreased
• Eclampsia of pregnancy
• Severe anaemia
• Typhoid
• Primary and secondary fibrinolysis
• Acute and chronic hepatic insufficiency
• Disseminated intravascular coagulation
• Hypofibrinogenemia
• Metastatic carcinoma of prostate.
NITROGEN COMPOUNDS
Normal Values
Nonprotein nitrogen (NPN) 15 to 35 mg/100 ml
Blood urea nitrogen (BUN) 10 to 40 mg/100 ml
Serum creatinine 0.7 to 1.5 mg/100 ml.
Increased
Renal insufficiency
• Nephritis, acute renal failure
• Urinary tract obstruction.
Increased nitrogen metabolism with decreased
renal blood flow.
• Dehydration, gastrointestinal bleeding
• Decreased renal flow
• Shock, adrenal insufficiency
• Congestive cardiac failure.
Decreased
• Hepatic failure
• Nephrosis
• Low protein diet.
UREA/CREATININE RATIO
Increased
• High protein diet
• Increased catabolism
• Fever, burns, steroid therapy
• Wasting in severe illness
• Urinary stasis with urea reabsorption.
Decreased
• Protein restriction
• Excessive vomiting
• Liver disease with impaired urea production.
SERUM URIC ACID

Raised
• Due to increased purine synthesis and decreased uric
acid excretion, i.e. gout
• Overproduction of uric acid chronic haemolytic
anaemias, psoriasis
• Reduction in renal excretion of uric acid diuretics,
Ethambutol, chronic renal disease
• Starvation ketosis.
Low
• Aspirin therapy.
SERUM CREATINE
Raised
• Rheumatoid arthritis
• Heart failure.
SERUM ALKALINE PHOSPHATASE
Normal 5 to 13 KA or 2 to 5 Bodansky units per 100 ml.
Raised
• Osteoblastic bone disease (Severe osteomalacia,
osteogenic sarcoma, metastatic carcinoma bones).
• Hepatic duct obstruction (due to stone, stricture or

neoplasm).
• Hepatic disease resulting from drugs (Chlorpro-
mazine and Methyltestosterone).
• Boeck’s sarcoid
• Paget’s disease
• Myeloid leukaemia
• Physiological (Pregnancy, alimentary hyperglycae-
mia, exposure to ultraviolet rays, in children).
Low
• Hypothyroidism
• Growth retardation in children.
ACID PHOSPHATASE
Normal 1-5 KA units or 0.5 to 2 Bodansky units/
100 ml.
Raised
• Carcinoma prostate with secondary bone metastasis
and occasionally in acute myelocytic leukaemia.
SERUM AMYLASE
Normal 0.5 to 2 Bodansky units (80-180 Somogyi Units/
100 ml).
Raised
• Acute pancreatitis
• Carcinoma of pancreas
• Certain cases of perforated peptic ulcer
• Acute cholecystitis
• Cirrhosis liver
• Mumps
• Renal failure.
Low
• Necrotising hepatitis
• Severe burns
• Toxaemia of pregnancy.
SERUM LIPASE
Normal 0.2 to 1.5 units.
Raised
• Acute pancreatitis
• Cholelithiasis with jaundice
• Liver cirrhosis
• Intestinal obstruction
• Duodenal ulcer.
SERUM POTASSIUM
Normal 14 to 20 mg per 100 ml (2.5-5.0 mEq/L).
Raised
• Addison’s disease
• Renal insufficiency
• Intestinal obstruction with vomiting.
Low
Inadequate intake
• Starvation.
Inadequate absorption
• Vomiting, diarrhoea, malabsorption syndrome.
Increased renal loss
• Diuretics
• Steroid therapy and hyper-aldosteronism.
Renal diseases
• Chronic pyelonephritis
• Acute renal failure
• Renal ischaemia
• De Toni-Fanconi syndrome.
SERUM IRON
Normal 75 to 175 mcg/100 ml.
Raised
• Haemochromatosis.
• Haemosiderosis
• Haemolytic disease
Low
• Iron deficiency anaemia
• Anaemia of chronic diseases
• Nephrosis
• Chronic renal insufficiency
• Paroxysmal nocturnal haemoglobinuria.
IODINE
Normal 3.5 to 8 mcg/100 ml.
Raised
• Pregnancy
• Hyperthyroidism
• Active stage of thyroiditis.
Low
• Hypothyroidism
• After Reserpine.
SERUM FERRITIN
Normal – 10-200 µg/ml.
Increased
• Chronic infection
• Malignancy
• Collagen vascular disease.
Reduced
RHEUMATOID FACTOR
Positive Rheumatoid Factor
• Rheumatoid arthritis (80%)
• Connective tissue disease—Scleroderma
• Chronic infection–Syphilis, leprosy, tuberculosis
• After drugs–Procainamide, Isoniazid
• Other diseases–Primary biliary cirrhosis
• Acute/chronic hepatitis
• Sarcoidosis
• Lymphoma.
CHEMICAL CONSTITUENTS OF BLOOD
For some procedures, the reference values may vary
depending upon the method used.
Conventional units
Acetoacetate, plasma < 0.3 mmol per litre
Aldolase 0-8 units/litre
α-Amino nitrogen, plasma 3.5-5.5 mg/dl
Ammonia, while blood 80-110 μg/dl
venous
Amylase, serum 60-180 Somogyi units per
decilitre; 0.8-3.2 units per litre
Contd...
Contd...
Conventional units
Ascorbic acid, serum 0.4-1.0 mg/dl
Leukocytes 25-40 mg/dl
Base, total serum 145-155 mmol/litre
Bicarbonate, serum 23-29 mmol/litre
Bilirubin, total serum 0.3-1.0 mg/dl
(Millory Evelyn)
Direct, serum 0.1-0.3 mg/dl
Indirect, serum 0.2-0.7 mg/dl
Bromsulphalein BSP 5% or less retention
(5 mg per kg of body after 45 minutes
weight intravenously)
Calcium, serum 2.2-2.7 mmol/litre;
9-11 mg/dl
Calcium, ionised 1.1-1.4 mmol/litre
4.5-5.6 mg/dl
Carbon dioxide content 21-30 mmol/litre; 50-70
Plasma (sea level) volume % per litre
Carbon dioxide tension 35-45 mm Hg
arterial blood (sea level)
Carotenoids, serum 50-300 μg/dl
Ceruloplasmin, serum 27-37 mg/dl
Chlorides, serum (as Cl) 98-106 monol/litre
Cholesterol, serum total 150-250 mg/100 mg
Esters 68-76% of total
cholesterol
Contd...
Contd...
Conventional units
Cholinesterase
Serum 0.5-1.3 pH unit
Erythrocytes 0.5-1.0 pH unit
Copper serum
(mean ± ISD) 114 ± 14 μg/dl
Cortisol (competitive 5-20 μg/dl
protein binding) at 8.00 AM
Creatine phosphokinase
Serum (Total)
Females 10-70 units/millilitre
Males 25-90 units/millilitre
Isoenzymes, serum fraction 2 (MB)
< 5% of total
Creatinine, serum < 1.5 mg/dl
Cryoglobulins, serum 0
Fatty acids, free
(nonesterified) plasma 0.7 mmol/litre
Fibrinogen, plasma 160 to 415 mg/dl
Folic acid, serum 6-15 ng/ml
Gamma glutamyl transferase
(transpeptidase), serum 4-60 units/litre
Gastrin, serum 40-200 mg/dl
Glucose (fasting), plasma
Normal 75-105 mg/dl
Diabetes mellitus > 140 mg/dl
Contd...
Contd...
Conventional units
Haptoglobin, serum 128 ± 25 mg/dl
(mean ± 1 SD)
Hydroxybutyric 0-180 milli units/ml
dehydrogenase, serum (IU)
(30°) (Rosalki-
Wilkinson) 114-290
units/ml
(Wroblewski)
17-Hydroxycorticosteroids
Immunoglobulins, serum 2-10 mg/day
IgG 800-1500 mg/dl
IgA 90-325 mg/dl
IgM 45-150 mg/dl
Insulin, serum or plasma,
fasting 6-26 μU/ml
Iodine protein bound, serum 3.5-8.0 mcg/100 ml
Iron, serum
Males and females
(mean ± 1SD) 105 ± 35 mg/dl
Iron binding capacity
serum (mean ± SD) 305 ± 32 μg/dl
Saturation 20-45%
17-Ketosteroids
Men 7-25 μg/day
Contd...
Contd...
Conventional units
Women 4-15 mg/day
Lactic acid, blood < 1.2 mmol/litre
Lactate dehydrogenase
isoenzymes, serum
LDH1 22-37% of total

LDH4 5-11% of total
LDH5 2-11% of total
Leucine aminopeptidase, 14-40 milli units/ml
serum (IU) (30°)
Lipase, serum 1.5 units (Charry-
Crandall)
Lipids, total, serum 450-850 mg/100 ml
Magnesium, serum 0.8-1.3 mmol/litre
5-Nucleotidase, serum 0.3-2.6 Bodansky units
per decilitre
Nitrogen, nonprotein, serum 15-35 mg/dl
Osmolality, serum 280-300 mOsmol/kg of
serum water
Oxygen, content
Arterial blood (sea level) 17-21 volume %
Venous blood, arm
(sea level) 10-16 volume %
Contd...
Contd...
Conventional units
Oxygen % saturation
(sea level)
Arterial blood 97%
Venous blood, arm 60-85%
Oxygen tension, blood 80-100 mmHg
P50, blood 26.27 mmHg
pH, blood 7.38-7.44
Phenylalanine, serum Less than 3 mg/100 ml
Phosphatase, acid, serum 0.10-0.63 unit (Bessey-
lowry method)
0.5-2.0 units (Bodansky’s
method)
< 0.6 unit per decilitre
(Fishman lerner; tartrate
sensitive)
0.5-2.0 units (Gutman’s
method)
0.2-1.8 international
units
1.0-5.0 units (King-
Armstrong method)
0.0-1.1 units (Shinowara
method)
Phosphatase, alkaline, serum 0.8-2.3 units (Bessey-
Lowry method)
Contd...
Contd...
Conventional units
2.0-4.5 units (Bodansky
method)
2.0-4.5 units (Gutman
method)
21-91 international units
per litre at 37°C
4.0-13.0 units (King-
Armstrong method)
2.2-8.6 units (Shinowara
method)
Phosphorus, inorganic, 1-1.4 mmol/litre

serum
Phospholipids, serum 150-250 mg/dl
Potassium, serum 3.5-5.0 mmol/litre
Proteins, total, serum 5.5-8.0 g/dl
Protein fractions, serum
Albumin 3.5-5.5 g/dl
Globulin 2.0-3.5 g/dl
Alpha1 0.2-0.4 g/dl
Alpha2 0.5-0.9 g/dl
Beta 0.6-1.1 g/dl
Gamma 0.7-1.7 g/dl
Protoporphyrin, free 16-36 mg/dl red blood
erythrocyte (EP) cells
Contd...
Contd...
Conventional units
Pyruvic acid, blood < 0.15 mmol/litre
Sodium, serum 136-145 mmol/litre
Sulphate, inorganic, serum 0.8-1.2 mg/100 ml
Testosterone
Women < 100 ng/dl
Men 300-1000 ng/dl
Prepubertal boys and girls 5-20 ng/dl
Thyroid stimulating < 5 μU/ml
hormone (TSH)
Thyroxine, free serum 1.0-2.1 nano gm/100 ml
Thyroxine (T4), serum 4-12 ng/dl
radioimmunoassay
Thyroxine binding globulin 10-26/100 ml
(TBG) serum, (as thyroxine)
Triiodothyronine (T3), serum 80-100 ng/dl
by radioimmunoassay
Thyroxine iodine, serum 2.9-64 mcg/100 ml
Transaminase, serum 10-40 karmen units per
millilitre
Glutamic oxaloacetic 6-18 units per litre
(SGOT, AST)
Transaminase, serum 10-40 karmen units per
millilitre
Glutamate, Pyruvate (SGPT, 3-26 units per litre
ALT)
Contd...
Contd...
Conventional units
Triglycerides, serum 40-150 mg/100 ml
Uric acid, serum
Males 2.5-8.0 mg/dl
Females 1.5-6.0 mg/dl
Urea
Blood 21-43 mg/100 ml
Plasma or serum 24-49 mg/100 ml
Urea nitrogen, whole blood 10-20 mg/dl
Vitamin A, serum 20-100 μg/dl
Vitamin B12, serum 200-600 pg/ml
REFERENCE VALUES FOR URINE

For some procedures, the reference values may vary
depending upon the method used.
Conventional units
Acetone and acetoacetate, Negative
qualitative
Addis count
Erythrocytes 0-130,000/24 hrs
Leukocytes 0-650,000/24 hrs
Casts (hyaline) 0-2000/24 hrs
Albumin
Qualitative Negative
Quantitative 10-100 mg/24 hrs
Contd...
Contd...
Conventional units
Aldosterone 2-10 μg/day
Alpha amino nitrogen 0.4-1.0 g in 24 hrs
Amylase 35-260 Somogyi units
per hour
Bilirubin, qualitative Negative
Calcium (10 mEq or 200 mg < 3.8 mmol in 24 hrs
calcium diet) < 150 mg in 24 hrs
Catecholamines < 100 μ in 24 hrs
Chloride 100-250 mmol/24 hrs
(varies with intake)
Chorionic gonadotrophin 0
Copper 0-25 μg in 24 hrs
Creatine, as creatinine
Adult males < 50 mg in 24 hrs
Adult females < 100 mg in 24 hrs
Creatinine 1.0-1.6 g in 24 hrs
Creatinine clearance
Males 140-150 ml/min
Females 105-132 ml/min (1.73
sq metre surface area)
Cystine or cysteine, Negative
qualitative
Dehydroepiandrosterone Less than 15% of total
17 ketosteroids
Delta aminolevulinic acid 1.3-7.0 mg/24 hrs
Estrogens
Contd...
Contd...
Conventional units
Males
Estrone 3-8 μg/24 hrs
Estradiol 0-6 μg/24 hrs
Estriol 1-11 μg/24 hrs
Total 4-25 μg/24 hrs
Females
Estrone 4-31 μg/24 hrs
Estradiol 0-14 μg/24 hrs
Estriol 0-72 μg/24 hrs
Total 5-100 μg/24 hrs
(Markedly increased
during pregnancy)
Glucose, true(oxidase, 50-300 mg in 24 hrs
method)
Gonadotropins, pituitary 10-50 mouse units/24
hrs
Hemoglobin and myoglobin Negative
qualitative
Hemogentisic acid Negative
qualitative
17-Hydroxycorticosteroids 2-10 mg/day
5-Hydroxyindoleacetic 2-9 mg in 24 hrs
acid (5-HIAA)
17-Ketosteroids
Men 7-25 mg/day
Women 4-15 mg/day
Contd...
Contd...
Conventional units
Magnesium 6.0-8.5 mEq/24 hrs
Metanephrines < 1.3 mg/day
Osmolality 38-1400 mOsm/kg
water
pH 4.6-8.0 average 6.0
(Depends on diet)
Phenolsulfonphthalein 25% or more in 15 min
excretion (PSP) 40% or more in 30 min
55% or more in 2 hrs
(After injection of 1 ml
PSP intravenously)
Phenylpyruvic acid, Negative
qualitative
Phosphorus 0.9-1.3 gm/24 hrs
Porphobilinogen None
Porphyrins
Coproporphyrin 50-250 mcg/24 hrs
Uroporphyrin 10-30 mcg/24 hrs
Potassium 25-100 mmol in 24 hrs
(Varies with intake)
Pregnanediol
Males 0.4-1.4 mg/24 hrs
Females
Proliferative 0.5-1.5 mg/24 hrs
Luteal phase 2.0-7.0 mg/24 hrs
Contd...
Contd...
Conventional units
Postmenopausal phase 0.2-1.0 mg/24 hrs
Pregnant 16 weeks 5-21 mg/24 hrs
Pregnanetriol Less than 2.5 mg/24
hrs in adults
Protein < 150 mg in 24 hrs
Sodium 100 to 260 mmol in 24
hrs
Specific gravity 1.003-1.030
Titratable acidity 20-40 mmol/24 hrs
Urate 200-500 mg/24 hrs
(with normal diet)
Urobilinogen 1-3.5 mg in 24 hrs
Vanillylmandelic acid < 8 mg/day
(VMA)
CEREBROSPINAL FLUID
Normal cerebrospinal fluid is clear, colourless and faintly

alkaline. It has specific gravity from 1.006 to 1.008. In
normal adult total volume of CSF is 100 to 150 ml.
Normal daily production is 100 ml. So there is practically
complete turnover daily.
PRESSURE
Normal in horizontal position 60 to 150 mm of water.
Sitting Position
• 200 to 250 mm of water.
Increased tension
• Intracranial tumour
• Meningitis
• Intracranial haemorrhage
• Hydrocephalus
• Benign intracranial hypertension, encephalitis.
Decreased tension
• Subdural haematoma
• Spinal subarachnoid block
Cerebrospinal Fluid 381
• Block in the region of foramen magnum

• Repeated lumbar punctures.
APPEARANCE
Clear Fluid
• Normal
• Syphilis
• Maningism
• Hydrocephalus
• Uraemia
• Poliomyelitis
• Tuberculous meningitis.
Turbidity
• Presence of excess cells
(Erythrocytes, White cells, microorganisms)
• Meningitis.
Fine Spider Web Clot
Massive Coagulation
• Polyneuritis
• Spinal block.
Blood Stained
• Trauma due to needle
• Spinal cord trauma
• Intracerebral haemorrhage.
Xanthochromia (Yellow/Colouration)
• Following haemorrhage into CSF (old)
• High Proteinous fluid
• Subdural haematoma.
PROTEIN
Normal, CSF contains 15 to 45 mg% of protein. The
ratio of albumin to globulin is 3:1. In most cases albu-
min increases more than globulin.
Increase of albumin
• Cerebral tumour
• Encephalitis.
Increase of globulin
• Complete spinal subarachnoid block due to cord
tumour
• Caries of spine
• Cerebrospinal syphilitic meningitis.
GLUCOSE
The level in CSF depends on the blood glucose level at
the time fluid is withdrawn and the presence of pyogenic
organisms or inflammatory cells in the CSF that use up
sugar in their metabolism. CSF glucose is 20-30% less
than the corresponding blood glucose level.
Normal 50 to 80 mg%.
Remains Normal in
• Aseptic meningeal reaction
• Syphilitic meningitis.
Increased
• Uraemia
• Encephalitis.
Decreased
• Tuberculous meningitis
• Insulin shock
• Pyogenic meningitis.
CHLORIDES
• Normal values.
Children
• 625 to 670 mg%.
Adults
• 720 to 760 mg%.
No Change in Level
• Tumours
• Encephalitis
• Brain abscess
• Chronic degenerative disease.
Increased
• Uraemia.
Decreased (below 620 mg%)
CALCIUM
• Normal 5.7 to 6.8 mg%.
Increased
• Froin’s syndrome.
Decreased
• Tetany.
ACID-BASE EQUILIBRIUM
• Normal pH 7.4 to 7.6.
Remains Unaltered
• Hydrocephalus
• Serous meningitis
• Cerebral tumours.
Acidosis
• Acute meningitis
• Uraemia
CYTOLOGICAL LEUCOCYTE COUNT

• It is done within first half hour after withdrawal
because on longer standing cells begin to disintegrate.
Normal:
Adults 0 to 10 cells/cu mm
Children 0 to 20 cells/cu mm
Cell Count:
Between 13 to 100 Cell/cu mm
• Neurosyphilis
• Encephalitis
• Disseminated sclerosis
• Tuberculous meningitis
• Cerebral tumour.
Polymorphonuclear Leucocytosis
• Pyogenic meningitis
• Acute syphilitic meningitis
• Early poliomyelitis.
Malignant Cells
• Malignant growth of brain or spinal cord.
Eosinophils
• Pathognomonic of cerebral or spinal cysticercosis.
Plasma Cells
• In neurosyphilis.
Cerebrospinal Fluid Picture in Some Diseases
386
MENINGITIS
Test Normal Pyogenic TB Virus Brain Syphilis Subara- Spinal
abscess meningo chnoid tumour
vascular haemorr-
hage
Appearance Clear Turbid Clear or Usually Clear Clear Turbid Yellowish
and col- slightly clear and or fro- if com-
ourless opales- colour- thy plete
cent less blood block,
slightly
yellow or
clear if in-
complet
Pressure 60-150 Raised Raised Raised Raised Usually Raised Dimi-
mm normal nished
water
Total 15-30 Marke- Marke- Increa- Increa- Increa- Greatly Greatly
protein mg% dly inc- dly inc- sed sed sed increa- increa-
100 ml reased reased sed sed
Cont...
Cont...
MENINGITIS
Test Normal Pyogenic T.B. Virus Brain Syphilis Subara- Spinal
vascular haemorr-
hage
Sugar 50-70 Marke- Redu- Normal Normal Normal Normal Normal
mg% dly red- ced
100 ml uced or
absent
Chlorides 720-750 Redu- Redu- Normal Normal Normal Normal Normal
mg% ced ced
100 ml
Cells 0-5 lym- Large 50-500 Lympo- 100-200 Lym- Large Usually
phocy- number per c. cytes per c. pho’s number normal
tes per of poly- mm increa- mm increa- of red
c. mm morphs lympho-sed many sed cells
cytes lympho-
Cerebrospinal Fluid
predo- cytes
minant
387
Cont....
Cont.
388
MENINGITIS
Test Normal Pyogenic T.B. Virus Brain Syphilis Subara- Spinal
vascular haemorr-
hage
Bacteria Sterile Causal Myco. Sterile Sterile Sterile Sterile Sterile
orga- tuber- W.R.*
nism culosis usually
isola- positive
ted
* Wasserman reaction.
BACTERIA AND PARASITES

• Pyogenic organisms on smear and culture in purulent
meningitis.
• Tubercle bacilli in tuberculous meningitis (culture and
guinea pig inoculation).
• Flagellated trypanosomes in sleeping sickness more
easily seen in CSF than in blood.
SEROLOGICAL
Wasserman reaction is positive in neurosyphilis.
Normal Curve
Fasting blood sugar 80 to 120 mg% and peak of curve
not more than 180 mg%. After 2 hours of taking glucose-
blood sugar returns to normal fasting level or a little
lower.
Diabetic Curve
• Fasting blood sugar above 120 mg
• A value above 180 mg is recorded at some time
during the test.
• The blood sugar does not return to normal within
2 hours.
• A positive urine test for sugar is obtained.
Lag Curve
• Normal fasting blood glucose level
• Blood sugar rises above 180 mg during test
• After 2 hours blood sugar level falls at or below
normal fasting level.
• Urine sample may be positive when blood sugar
level is higher than 180 mg%.
Glucose Tolerance Test 391
OTHER CAUSES OF LOWERED GLUCOSE

TOLERANCE
• Sepsis
• Cushing’s syndrome
• Acromegaly
• Hyperthyroidism
• Severe liver damage
• After steroid therapy.
INTRAVENOUS GLUCOSE TOLERANCE TEST
Indications
Inadequate absorption of glucose from intestines as in:
• Steatorrhoea
• Pancreatic islet cell tumours
• Addison’s disease
• Hypopituitary stage.
Give 20 to 30 gm of glucose IV.
Normal
• Never rises more than 180 mg%
• Returns to normal in about one hour.
Diabetes
• Rises above 180 mg% during one hour
• Does not return to normal.
CORTISONE GLUCOSE TOLERANCE TEST

Cortisone increases gluconeogenesis by the liver and
leads to a higher blood sugar level with a glucose load.
This is a test for latent diabetes and for uncovering non-
diabetic carriers of the diabetic trait. 50 mg Cortisone
acetate is given by mouth 8 and 2 hours before the
standard 100 mg GTT.
Result:Test is positive when 2 hours blood sugar value
is higher than 140 mg/100 ml.
Bone Marrow Aspiration 393
BONE MARROW ASPIRATION
BONE MARROW EXAMINATION

It is done for the diagnosis of following conditions:
• Acute leukaemias
• Kala-azar
• Niemann-Pick disease
• Gaucher’s disease
• Sideroblastic anaemia
• Congenital dyserythropoietic anaemia
• Pure-red cell aplasia.
BONE MARROW BIOPSY
It is done for diagnosis of:
• Myelofibrosis
• Staging of lymphoma
• Diagnosis of carcinoma metastasis to bone
• Therapeutic assessment in acute leukaemia therapy.
ACTIVITY OF ERYTHROPOIESIS
Normoblastic
• Normally
• Haemolytic anaemia.
Micronormoblastic
Megaloblastic
• Nutritional B12, folic acid deficiency
• Steatorrhoea
• Anaemia of pregnancy
MYELOID/ERYTHROID RATIO
Normal 2:1 to 8:1.
High
• Leukaemia
Low
• Anaemia
OTHER ABNORMALITIES
Aleukaemic Leukaemia
• Abnormal cells are absent in peripheral blood but
present in large numbers in bone marrow.
Multiple Myeloma
• Bone marrow infiltration with plasma cell/myeloma
cells.
Bone Marrow Biopsy
Feature Normal Tropical macro- Iron deficiency Chronic myeloid

cytic anaemia microcytic leukaemia
anaemia
Cellularity Normal Increased Normal/Increa- Increased
sed
Predominant Neutrophils and Megaloblasts Micronormo- Granulocytes
cells metamyelocyte and normo- blasts
blast in varying
proportions
Myeloid cells All types but Few giant meta- All types, but All forms, many
few early forms myelocytes and few early forms. myelocytes,
hypersegmented Cell often small basophils
Neutrophils increased
Erythroid cells Intermediate Megaloblasts Normoblast in Normoblast in all
and late normo- and normo- all stages and stages
blast blasts in all with irregular
stages scanty cyto-
plasms, cell size
small
Cont....
Cont....
396
Feature Normal Tropical macro- Iron deficiency Chronic myeloid

cytic anaemia microcytic leukaemia
anaemia
Lymphocytes Few, mature Few, mature Few, mature Very few
Plasma cells Few, mature Increased often Few, mature Very few
Monocytes Few, mature Few, mature Few, mature Few, mature
(sometime more)
Megakaryocyte Present Present Present Megakaryocytes
increased
Myeloid 2:1 to 8:1 1:5 to 1:7 1:1 to 1:4 3:1 to 7:1
erythroid ratio
Secondary Carcinoma
• Carcinoma cells in groups.
Gaucher’s Disease
• Reticulum cells stuffed with lipid (Glucocerebroside).
Malaria
• Parasites inside RBC.
Kala-azar
• L D bodies in monocytes.
Aplastic Anaemia
• Bone marrow hypocellular
• Megakaryocytes not seen
• Granulopoiesis/erythropoiesis depressed.
Agranulocytosis
• Granulocytic series of cells decreased.
RENAL FUNCTION TESTS
CONCENTRATION TEST (SPECIFIC

GRAVITY TEST)
The patient is not allowed water after 5 PM
Normal specific gravity–1.025.
Failure to concentrate urine above 1.020 is
suggestive of renal impairment. Specific gravity only to
1.010 is suggestive of severe damage.
Results are unreliable if:
• Severe water or electrolyte imbalance
• Pregnancy
• Shock
• Chronic liver disease
• Adrenal cortical insufficiency.
UREA CLEARANCE TEST

Normal 75 mg/minute.
40 to 60% of normal–Mild impairment
20 to 40% of normal–Moderate impairment
Below 20%–Severe impairment of renal function.
Renal Function Tests 399
UREA/CREATININE RATIO
Increased
• High protein diet
• Increased catabolism
• Fever, burns, steroid therapy
• Wasting in severe illness
• Urinary stasis with urea reabsorption.
Decreased
• Protein restriction
• Excessive vomiting
• Liver disease with impaired urea production.
LIVER FUNCTION TEST
Indications
• Detection of liver damage in absence of jaundice.
• Differential diagnosis of jaundice.
• Differential diagnosis of hepatic enlargement.
• As a parameter of response to medical treatment.
BILIRUBIN METABOLISM
Normal Up to 1 mg%
Free bilirubin (Indirect) 0.8 mg%
Conjugated bilirubin (Direct) 0.2 mg%
Latent jaundice up to 2 mgm%
Visible jaundice 2.5 mgm% or
more
Direct Van Den Bergh’s Reaction
Add 1 ml of reagent to 1 ml of serum. Three types of
reactions are noted.
Immediate
• A violet colour due to formation of diazobilirubin in
10 to 30 seconds.
Liver Function Test 401
Delayed
• No change in appearance for 5 to 15 minutes, then
reddish colour appears which turns into violet.
Biphasic
• Red colour appears immediately and takes a longer
time to become violet.
Indirect Reaction
It determines serum bilirubin quantitatively. 1 ml of
serum is mixed with 2 ml of 95% alcohol. After centri-
fuging to 1 ml of fluid and 0.25 ml of reagent, add 0.5 ml
of alcohol. A reddish violet colour develops immediately.
Prompt direct reaction–Obstructive jaundice.
Indirect/delayed direct reaction–Haemolytic
jaundice.
Direct reaction–Jaundice due to liver damage.
DIFFERENTIAL DIAGNOSIS OF JAUNDICE
Haemolytic (Prephatic jaundice)
It is due to excessive destruction of red blood cells and
liver is unable to conjugate all the bilirubin so there is
rise in serum free bilirubin.
Jaundice due to liver diseases (Hepatic)
Direct bilirubin is increased. In hepatic disease there is
increase in direct reacting bilirubin fraction. With
bilirubin in urine, liver diseases causing this are viral

hepatitis, cirrhosis of liver and toxic hepatitis.
Post-hepatic (Obstructive jaundice)
It may be due to carcinoma of head of pancreas, bile
duct obstruction, pancreatitis and gallstones in bile duct.
CAUSES OF PREDOMINANTLY UNCONJUGATED
HYPERBILIRUBINEMIA
• Prolonged fasting
• Sepsis
• Neonatal jaundice
• Hepatitis
• Cirrhosis liver.
After Drugs
• Pregnandiol
• Chloramphenicol.
CAUSES OF PREDOMINANTLY CONJUGATED
HYPERBILIRUBINEMIA
• Recurrent intrahepatic cholestasis
• Cholestatic jaundice of pregnancy
• Viral hepatitis
• Oral contraceptives
• Methyl testosterone
• Sepsis and stones
• Stricture and tumour of bile ducts.
Lab Hemolytic Obstructive Hepatocellular

investigation (Pre-hepatic) (Post-hepatic) (Hepatic)
Serum Indirect Direct Biphasic
bilirubin
Urine Absent Present Present
bilirubin
Urine urobili- Increased Absent or Increased
nogen decreased
Stool colour Dark colour Clay colour Pale
Flocculation Negative Negative Positive
Turbidity test
Serum alka- Normal Increased Slightly
line phospha- increased
tase
Serum total Normal Increased Decreased
cholesterol
URINE UROBILINOGEN
Normal 0.2 to 1.2 units.
Absent
• Complete obstruction to bile flow may be due to
stone/tumour
Decreased
• Post-hepatitis
• Early phase of hepatic jaundice
Increased
• Haemolytic jaundice
• Metastatic carcinoma
• Congestive cardiac failure
• Pulmonary infarct.
FAECAL STERCOBILINOGEN
Normal Value 50 to 300 Ehrlich units in 130 gm of faeces.
Causes are same as for urine urobilinogen.
CARBOHYDRATE METABOLIC TEST

Galactose Tolerance Test
A single dose of 40 gm of galactose is given by mouth.
If more than 3 gm appears in 5 hours, then liver function
is impaired.
Positive
• In infective and toxic jaundice.
Negative
• Chronic liver disease
• Carcinoma of liver
• Early extrahepatic biliary obstruction.

In liver diseases fasting blood sugar level is normal or
low and the occurrence of subnormal values by the 5th
hour after taking glucose is a distinguishing feature
between diabetes mellitus and liver diseases.
EPINEPHRINE TOLERANCE TEST
A high carbohydrate diet is given for 3 days. Fourth
day fasting blood sugar level is done and patient is given
0.01 mg of epinephrine per kg/body weight. The blood
sugar is determined 30-60 minutes after the epinephrine
is given.
Normal–Individuals show rise of 40 to 60 mg%.
Subnormal Response
• Cirrhosis
• Hepatitis
• Glycogen storage disease (genetic deficiency of glyco-
genolytic enzyme).
PLASMA PROTEINS
Serum albumin normal value 3.5 to 5 gm/100 ml.
Decreased
• Cirrhosis
• Active hepatitis
• Prolonged cholestasis.
The degree of hypoalbuminaemia correlates with

the severity of chronic liver diseases. It is the best indica-
tor of successful medical treatment in cirrhosis of liver.
SERUM GAMMAGLOBULIN
Increased
• Acute hepatitis (slight hyperglobulinaemia).
• Cirrhosis (marked hyperglobulinaemia).
Serum globulin if 7 gm/100 ml or more is prognos-
tically a bad omen.
ALPHA GLOBULIN
Normal level 0.8 to 1.1 gm/100 ml.
Increased
• Inflammatory disease of liver
• Injury to liver.
BETA GLOBULIN
Reduced
• Cirrhosis.
Increased
• Bile duct obstruction
• Xanthomatous biliary cirrhosis.
ALBUMIN/GLOBULIN RATIO
Normal 1.7:1.
Reduced
• Cirrhosis with jaundice.
Increased
• Xanthomatous biliary cirrhosis.
SERUM ENZYMES
Alkaline Phosphatase
Normal value 1.5 to 4.5-Bodansky units
4 to 13-King Armstrong units.
Slight to Moderate Increase
• Hepatitis
• Cirrhosis.
Striking Increase
• Extrahepatic biliary obstruction
• Primary biliary cirrhosis
• Carcinoma of liver
• Liver abscess
• Bony metastasis and fractures.
TRANSAMINASES
i. Serum glutamic oxaloacetic transaminase (SGOT)
Normal 6 to 40 international units/L.
Increased
50 to 200 units
• Subclinical or aniecteric viral hepatitis
• Laennec’s cirrhosis
• Tumour invasion.
200 to 500 units
• Less severe liver necrosis.
1000 to 3000 units
• Severe viral hepatitis.
Other Causes
• CO2 poisoning
• Myocardial necrosis
• Skeletal muscle necrosis.
ii. Serum glutamic pyruvic transaminase (SGPT)
Normal 6 to 36 Karmen units/L.
Increased
• Hepatocellular damage
• Myocardial and skeletal muscle necrosis.
LACTIC DEHYDROGENASE
Normal 60 to 230 international units per litre.
Moderate increase
• Damage to heart, liver, skeletal muscles and brain.
High increase
• Leukaemias and lymphomas.
Decreased
• Impaired hepatic protein synthesis.
5-NUCLEOTIDASE
In hepatic disease both 5-nucleotidase and alkaline
phosphatase are elevated while in primary bone dis-
eases the alkaline phosphate only is elevated.
Other enzymes: GGT and OCT are elevated is serum in
hepatobiliary diseases.
SERUM AMMONIA
Normal 100 micro gm%.
Increased
• Cirrhosis
• Severe hepatitis
• Severe heart failure
• Cor pulmonale.
SERUM CHOLESTEROL
Normal cholesterol 150 to 250 mg%.
Esterified Cholesterol
• 60 to 70% of total.
Increased
• Intrahepatic obstruction
• Atherosclerosis
• Obesity
• Diabetes mellitus.
SERUM IRON
Normal 80 to 180 micro gm%.
Increased
• Haemochromatosis
• Viral hepatitis
• Hepatic necrosis.
TURBIDITY AND FLOCCULATION TEST
1. Cephaline cholesterol flocculation test.
Positive Test
• Acute/Chronic hepatic disease
• Hepatitis
• Fatty liver with jaundice
2. Thymol turbidity test.
Positive Test
• Liver diseases
• Kala-azar
• Malaria
• Sarcoidosis
• Collagen disorders.
SERUM ALDOLASE
Normal –Males: below 33 units (W and C)
–Females: below 19 units (W and C).
Elevated
• Myocardial infarction
• Muscular dystrophy
• Metastatic prostatic carcinoma
• Leukaemia
• Acute pancreatitis and hepatitis.
SERUM BICARBONATE
Normal 22 to 28 mg/litre.
Elevated
Metabolic alkalosis
• Protracted vomiting
• Potassium deficiency
• Consumption of soda-bicarbonate.
Respiratory Acidosis
Due to:
• Pulmonary emphysema
• Heart failure
• Respiratory depression.
Decreased
• Metabolic Acidosis
– Diabetic ketosis
– Persistent diarrhoea
– Renal insufficiency
– Ingestion of acidifying salts
– Salicylate poisoning
– Starvation.
• Respiratory Alkalosis
– Hyperventilation.
CERULOPLASMIN AND COPPER
Normal.
Ceruloplasmin
• 25 to 43 mg/100 ml.
Copper
• 70 to 200 micro gm/100 ml
95% of copper is bound to ceruloplasmin.
Elevated
• Hyperthyroidism
• Infection
• Acute leukaemia
• Hodgkin’s disease
• Cirrhosis liver
• Pregnancy.
Decreased
• Wilson’s disease
• Nephrosis
• Malabsorption syndrome.
Creatine-Phosphokinase (CPK)
Normal 10 to 50 IU/litre.
Elevated in injury to heart muscle. Polymyositis,
dermatomyositis hypothyroidism, cerebral infarction.
In myocardial infarction CPK rises rapidly within
3 to 5 hours.
FUNDUS EXAMINATION
During fundoscopy examination it is usually possible to

examine the optic disc, surrounding retina, vitreous and
the choroid. Normal fundus is bright red in colour.
OPTIC DISC
Normal shape • Round or oval
Normal diameter • About 1.5 mm in diameter
Normal colour • Pale pink
Blurred Margin
• Papillitis
• Papilloedema
• Secondary optic atrophy following papillitis/
papilloedema.
Colour
Pale/Greyish White
• Optic atrophy.
Hyperemic with Swollen Disc
• High hypermetropia.
Fundus Examination 415
Deep Pink
• Oedema of head of the optic nerve due to raised
intracranial pressure.
• Papillitis due to any cause.
PHYSIOLOGICAL CUP
In central part of the disc there is usually a depression
known as physiological cup. Cup is paler than surround-
ing disc and through it retinal vessels enter and leave
the eye. Normal cup and disc ratio is 1:3.
RETINAL BLOOD VESSELS
These radiate dichotomously into many branches as
they run towards periphery to retina. Normal ratio of
diameter of vein and artery is 3:2. Arteries are lighter
red in colour, narrower than vein and have a bright
salivary longitudinal streak at the centre where light is
reflected from their convex walls. Normally artery
crosses the vein.
Spontaneous retinal artery pulsation is always
pathological and is noted in:
• Glaucoma
• Aortic regurgitation
• Exophthalmic goitre
• Orbital tumour
• Syncope.
Spontaneous venous pulsation is present normally
in 10 to 20% of the cases.
MACULAR MARGIN
It is usually as a small circular area of deep red colour
situated about 2 disc diameter, i.e. 3 mm from temporal
border of the optic disc. It is supplied by twigs from the
superior temporal arteries and a few branches direct
from the disc. At the centre of the macular region there
is a small depression known as ‘fovea’ which is lighter
on colour and often shines. There are no retinal blood
vessels at the fovea itself.
CHANGES OF FUNDUS IN
DIFFERENT DISEASES
GLAUCOMA
• Cup and disc ratio alters
• Position of cup becomes vertical
• Blood vessels appear to be broken off at the disc
margin.
PAPILLOEDEMA
• Disc swelling is more than 2 to 3 dioptres.
• Increased redness of the disc with blurring of its
margin.
• Physiological cup becomes filled in and cannot be
seen clearly.
• Retinal veins become slightly distended and con-
gested.
• Even on pressure, venous pulsation remains absent.

• It occurs in cases of brain tumour.
OPTIC NEURITIS
• Loss of vision, either central scotoma or complete
blindness.
• Hyperaemic disc.
• Swelling of disc is usually less, i.e. about 2 to 3 diop-
tres.
• Distention of retinal veins less marked than papill-
oedema.
• Sign of inflammation, i.e. hazy viterous and retinal
exudate.
• In retrobulbar neuritis disc appears normal in acute
stage.
OPTIC ATROPHY
• Optic disc is paler than normal and may even be
white.
• There is reduction of the disc capillaries.
• Number of capillaries that cross the disc margin is
reduced from 10 to 7.
• In primary atrophy disc is flat and white with clear
cut margins.
• In secondary atrophy disc is greyish white, slightly
swollen and its edges are rough.
Optic atrophy may result from:

• Interference with the blood supply of the optic nerve.
• Pressure on the nerve may be intraocular, intraorbital
or intracranial.
• Following optic neuritis or trauma.
• Due to toxicity of tobacco or alcohol.
RETINAL ARTERIOSCLEROSIS
It occurs either as an exaggeration of the general ageing
process or in association with hypertension.
• Broadening of the arterial light reflex, producing a
‘copper wire’ or ‘silver wire’ appearance.
• Tortuosity of the vessels.
• Nipping, indentation or deflection of the veins where
they are crossed by the arteries.
• White plaques on the arteries.
• ‘Flame shaped’ haemorrhages and ‘Cotton-wool’
exudates in the region of macula.
HYPERTENSIVE RETINOPATHY
Grade I
• Only mild narrowing or sclerosis of the retinal blood
vessels.
Grade II
• Changes in retinal vessels are more marked and
characterised by signs of sclerosis at the arterio-
venous crossing and generalised or localised narrow-
ing of the arterioles. Retinopathy is still not present.
Grade III
• Retinal wool spots with haemorrhages with marked
sclerotic changes in the arterioles
• Oedema of the disc not present.
Grade IV
• Papilloedema with diffuse retinopathy
• Spastic and organic narrowing of the arterioles.
DIABETIC RETINOPATHY
• Formation of microaneurysms as tiny red spots
around macula.
• Minute haemorrhages and punctate exudate
(microlesions).
• Retinal haemorrhages are punctate or round and
the exudates as waxy yellow white in appearance.
• Haemorrhages extended to vitreous result in retinitis
proliferans.
• Covering of macula or retinal detachment may cause
blindness.
• May or may not be associated with hypertension.
• Arteriovenous ratio becomes 2:4.
SEVERE ANAEMIA
• Fundus may be paler.
• Few small flame shaped haemorrhages with wooly
exudate.
• Retinal veins are more tortuous and dilated than

arteries.
POLYCYTHEMIA
• Retinal vessels are dark, tortuous and dilated.
• Cyanotic background of the fundus.
• Oedema of the optic disc.
• Retinal haemorrhages may be present.
LEUKAEMIA
• Retinal veins are dilated and tortuous.
• Arteries and veins may be yellowish in colour.
• Fundus becomes paler.
• Retinal haemorrhages of various types are noted
specially round with pale centre.
OCCLUSION OF CENTRAL ARTERY OF RETINA
• Optic disc and surrounding retina are pale.
• Presence of ‘Cherry red spot’ at the macula in
contrast to milky pallor of adjacent area.
• Retinal arteries become narrow similar to thread.
OCCLUSION OF CENTRAL VEIN
• Intense swelling of the optic disc with gross venous
dilatation.
• Numerous retinal haemorrhages extending from
disc in all directions.
CHOROIDITIS
Acute
• One or more, round or oval, yellowish whitish
patches deeper to retinal vessels.
• Patches have ill-defined edges and vitreous may be
hazy.
Chronic
• Yellowish areas become flat, white scars with
pigment around their edges are seen.
TOXAEMIA OF PREGNANCY
Usually occurs in ninth month and rarely before the
sixth month.
• Nasal branches of retinal arteries become narrow
• It is followed by spasmodic contraction
• Exudative retinal detachment may be present
• Other signs of hypertensive retinopathy may be
noted.
RENAL SYSTEM
ACUTE GLOMERULONEPHRITIS
• Fullness of face.
• Low urinary output.
• Fever 101° to 103°F at the onset and becomes normal
in 7-10 days.
• BP is raised.
• Malaise, anorexia, vomiting and headache.
• Urine volume diminished to 300-600 ml, specific
gravity raised, hyaline, blood and epithelial casts,
culture is sterile.
• ESR is raised.
Management
 Bed rest for 2-4 weeks till gross haematuria subsides.
 Fluids should be restricted to 1/2 litre plus the
volume of previous day urinary output till oedema
subsides.
 Protein consumption should be controlled. Salt
intake should be low.
Renal System 423
 Suitable antibiotic for primary infection.

 Septran 2 bd × 5 days to be given.
For moderate hypertension—Tab Nepresol 1/2 to
1 tds or Tab Alphadopa 10-65 mg/kg 1 day and Tab
Lasix 2 mg/kg.
ACUTE NEPHRITIC SYNDROME
• Haematuria and Proteinuria are hallmarks.
• Some degree of azotemia.
• Low serum C3 complement.
• Raised antibody titre to streptococcal antigen like
ASO anti-streptokinase and anti-DNA titres.
Treatment
 Treatment is supportive.
 Bed rest till haematuria subsides.
 Fluid and salt retention.
 Loop diuretics to promote diuresis.
 Protein restriction if there is azotemia.
 Course of erythromycin 7-10 days to eradicate
streptococci.
ACUTE PYELONEPHRITIS
It is due to acute inflammation of parenchyma and pelvis
of kidney. It may be unilateral or bilateral.
• Onset sudden with pain in one or both loins, radiating
to iliac fossa or suprapubic area.
• Dysuria, vomiting.
• Body temperature 100° to 104°F with rigors.
• Tenderness and gurgling in the lumbar region.
• Urine is dark due to blood and pus. Reaction acidic.
• Polymorphonuclear leucocytosis.
Management
 Bed rest with tepid sponging.
 Plenty of fluids in diet.
 Alkaline mixture, i.e. Alkacitrone 1 tsf tds.
 Ampicillin 250 mg six hourly or Septran (80 mg) 1
tab twice daily for 5 to 7 days.
 Norfloxacin 400 mg bd × 7-10 days.
 Tab Nalidixic acid 1 gm qid.
or
 Injection Gentamicin 60-80 mg 8 hourly alone or
with Ampicillin or Cephalexin 500 mg 6 hourly.
or
 Injection Ciprofloxocin 200 mg bd IV.
 Tab Pyuridium 100 mg tds for dysuria.
Renal System 425
ACUTE RENAL FAILURE
Pre-oliguric stage
• Lethargy, headache, nausea and vomiting.
Oliguric stage
• Lasts for 4-10 days. Complete anuria is rare.
Uraemic symptoms
• Nausea, vomiting, diarrhoea, hiccough.
Hyperkalaemia shows
• Paraesthesias, depressed reflexes, general weakness,
flaccid paralysis.
Diuretic stage
• Urinary output is increased to 1000 ml in 24 hours.
Management
 Rule out renal obstruction or retention by catheteri-
zation, KUB and USG.
 Correct fluid imbalance if any and restore BP. Res-
trict fluid intake if anuria. It should be output plus
500 ml plus 200 ml per degree of fever if any.
 Treat infection.
 If ATN—Injection Lasix 200-250 mg slow IV repeat
upto 1-2 gm/day.
or Injection Mannitol 20 percent 250 ml IV over 30

minutes.
If hyperkalemia (weakness, drowsiness, brady-
cardia, tall peaked T waves serum K > 6 mEq/L).
 Injection Calcium gluconate 10 percent 10-20 ml
IV.
 If acidosis use IV NaHCo3 (mEq/L = body weight
× 0.3 × base deficit).
 If hyponatraemia—Restrict fluids or dialysis.
 Restrict protein intake—Give carbohydrate 100-150
gm daily.
Indications for dialysis
 If serum K > 6.5 mEq/L.
 Severe acidosis.
 Pulmonary oedema, fluid over load.
 Encephalopathy, pericarditis.
 Steadily increasing serum creatinine > 10 mg%.
BENIGN PROSTATIC HYPERPLASIA
• Urinary frequency.
• Urinary urgency and nocturia due to incomplete
emptying.
• Sensation of incomplete emptying and terminal drib-
bling.
Renal System 427
• On rectal examination prostate is usually enlarged

with a rubbery consistency and frequently loss of
median furrow.
• Chills and fever indicates infection.
• Indurated and tender prostate suggests prostatitis
• Stony hard, nodular prostate indicates carcinoma.
• Prostatic specific antigen is moderately enlarged.
Treatment
 Prazocin, doxazosin and Adrenergic blockers may
improve voiding in some patients.
 The 50° C reductase inhibitor finasteride 5 mg daily
may reduce size of prostate.
 Larger benign prostate needs suprapubic approach
of prostectomy.
CHRONIC RENAL FAILURE
• Irreversible damage to nephron leads to chronic
renal failure.
• Commonly implicated diseases are glomerulone-
phritis, diabetes mellitus, chronic pyelonephritis
hypertension and polycystic disease.
• By products of proteins and amino acids metabo-

lism instead being excreted are retained in body.
• Many small molecular weight substances are also
retained
• GFR falls to 10 to 20%.
Treatment
 40 gram of proteins is permitted. If blood urea
exceeds 60 mg proteins are restricted to 20 gram
daily.
 Water intake should be adjusted
 Potassium containing food and fruits are to be
restricted.
 Aluminum hydroxide 400 mg four times daily
controls hyperphosphataemia.
 Supplement of vitamin B complex and regular in-
jection of anabolic steroids minimize catabolism
thus reducing urea load.
 Dialysis prepares patients for renal transplantation.
 For renal transplantation HLA matched sibling
donors are preferred.
NEUROGENIC BLADDER
It is caused by vesical dysfunction due to congenital
abnormality, injury and myelomeningocele. Syphilis,
diabetes mellitus, brain or spinal cord tumor may result
it.
Renal System 429
• Partial or complete urinary retention.
• Inadequate emptying.
• In spinal cord injury shock bladder is atonic and dis-
tended with continuous overflow dribbling.
• With lower spinal cord lesion bladder becomes flac-
cid.
• Upper cord lesion produces an automatic or spastic
reflex bladder which empties spontaneously.
• Cystourethroscopic evaluation determines the
degree of bladder outlet obstruction.
Treatment
 Continuous catheter drainage in flaccid paralysis
of bladder due to spinal cord injury.
 In automatic bladder condom catheter drainage.
 Oxybutynin chloride 5 mg reduces detrusor spas-
ticity and involuntary contractions.
 Sphincter dysynergia respond to doxazocin
mesylate 1 mg or terazocin 1 mg twice daily.
OBSTRUCTIVE UROPATHY
Chronic urine obstruction results in hydronephrosis,
renal atrophy and chronic renal failure. Urinary infec-
tion and stone formation may take place.
• Flank pain with micturition.
• Renal colic although pain is constant with fluctuation
in intensity.
• Distension of collecting system.
• Hypertension especially in unilateral obstruction.
• Urine examination shows pyuria, crystalluria and
haematuria.
• KUB X-ray may show radiopaque stone.
Treatment
 Depends on the causative factor.
 Any spasmodic tablet/injection gives temporary
relief.
URAEMIA
• Headache, vertigo, muscular weakness and
twitching.
• Apathy and inability to concentrate, restlessness
neuralgic pains.
• Reflexes exaggerated.
• Dryness of mouth, tongue coated brown or grey.
• Anorexia, polydipsia, nausea and vomiting.
Renal System 431
• Ammonical odour of breath.

• Uraemic frost—Deposition of greyish white crystals
mostly on the face, neck and chest.
Laboratory findings
• Elevation of non protein nitrogen in blood.
• Oliguria with low specific gravity.
• Blood uric acid elevated.
• Serum creatinine elevated and chlorides diminished.
Management
 Low protein diet with adequate salt.
 Increased fluid intake. In dehydration IV 5 per cent
Glucose saline.
 Sodium lactate 5-10 gm thrice daily to combat
acidosis.
 Antibiotics to combat infection. Septran 2 bd × 5
days.
 Treatment of hypertension and heart failure.
 Dialysis.
 Ampicillin 2 gm daily to reduce urea production.
NEUROLOGICAL DISEASES
BELL’S PALSY
• Sudden onset of lower motor facial paralysis
manifesting as inability to close the eye, sagging angle
of mouth and poor buccinator tone.
• Pain behind the angle of jaw and history of exposure
to cold.
Treatment
 Tab Prednisolone 40-60 mg daily for 5-10 days.
 Tab Aspirin 325 mg tds.
 Neostigmine 15 mg daily for 5-10 days.
 Faradic stimulation of facial nerve.
 Prophylactic antibiotic eyedrops and tarsorrhaphy
to prevent exposure keratitis.
 Plastic surgery in selected cases.
 Decompression of facial canal if deemed necessary.
 Infrared rays treatment and massage of facial
muscles of paralyzed side.
Neurological Diseases 433
BRACHIAL NEURALGIA
• Pain and paresthesia in upper limb and shoulder area.
• Neck becomes rigid and flexed towards the side of
lesion.
• Tendon reflexes diminish.
• Acute disc protrusion may develop severe pain, mus-
cular spasm and rigidity of neck muscles.
• Occipital headache worse in early morning hours.
• Vertebro-basilar ischaemia – Flexion may cause a
brief attack of giddiness or drop attack.
• X-ray may show endophytes.
Treatment
 Bed rest.
 Analgesics in acute pain.
 Cervical collar may be used day and night.
 Exercises for neck and shoulder.
 Head traction with or without manipulation.
BROADMAN’S AREAS OF BRAIN
Occipital Lobe
Area 17 Visual cortex
Area 18, 19 Visual association areas
Parietal Lobe
Area 3, 1, 2 Principal sensory areas
Area 5, 7 Sensory association area
Area 41 Primary auditory cortex
Area 42 Associate auditory cortex
Area 38, 40,20,21,22 Association areas.
Frontal Lobe
Area 4 Principal motor area
Area 6 Part of extrapyramidal
circuit
Area 8 Eye movement
Area 44 Motor speech area.
CEREBRAL STROKE
• Sudden onset of neurological deficit.
• Patient has history of hypertension, diabetes, and
atherosclerosis.
• Distinctive neurological signs reflect the area of brain
affected.
• Middle cerebral artery occlusion leads to contralat-
eral hemiplegia, hemi-sensory loss and homony-
mous hemianopia.
• Anterior cerebral artery occlusion causes weakness,

cortical sensory loss and homonymous hemianopia.
• Occlusion of posterior cerebral artery may develop
contralateral hemisensory disturbances, spontane-
ous pain and hyperpathia.
• Vertebral artery occlusion may be clinically silent.
• Occlusion of major cerebellar artery produces ver-
tigo, nausea, and ataxia.
• Massive carebellar infarction may lead to coma, ton-
sillar herniation and death.
Treatment
 Intravenous thrombolytic therapy within first 3
hours.
 In acute stage cortisone IV is given to reduce brain
oedema. Dexamethasone 16 mg/daily may be
given.
 MR angiography should be got done.
CERVICAL RIB SYNDROME
• Compression of 8th cervical and first dorsal root by
enlarged transverse rib or a small rib or fibrous band
from 7th cervical vertebra.
• Pain and paresthesia along inner border of fore arm

and hand. Pain increases by raising the arm above
head.
• Attacks of recurrent coldness in arms and digits with
pallor or cyanosis.
• Nerve becomes tender on pressure.
Management
 Surgical intervention may be required.
 Injections of B1, B 6 and B 12 on alternate days may
help.
CLUSTER HEADACHE
It is also known as Horton’s headache Hair’s syndrome,
histamine cephalgia and migrainous neuralgia.
• It can be confused with trigeminal neuralgia.
• It is an unilateral headache.
• Pain starts 2-3 hours after falling asleep during the
phase of REM sleep.
• Headache is intense, non-throbbing around orbit.
• Eyes become red with lacrimation and rhinorrhoea.
• Attack lasts for 2-3 hours and returns every night.
• On lying down pain increases.
Treatment
 Prednisolone 60-80 mg daily or triamicilone 80 mg
daily
 Verapamil 40-80 mg daily.
COMMON HEADACHE
Migrain Cluster Psychogenic
headache headache
Quality of Throbbing Boring Dull
Location Unilateral Unilateral Diffuse
Duration 6-40 hours 2-3 hours Anu
duration
Frequency Sporadic Sporadic Often
Other symptoms Nausea Visual aura Depression
vomiting
EPILEPSY
Grand mal type

• Tonic spasm of all muscles with sudden onset.
• Aura may be present but generally patient looses
consciousness without any warning.
• Tonic spasms are followed by clonic phase involving

face, arms and legs.
• There is typical epileptic cry due to spasm of respi-
ratory and laryngeal muscles.
• BP falls, pupils are dilated and there may be
incontinence of urine.
• Patient may bite his tongue with fronthing from
mouth.
• After regaining consciousness patient goes for sound
sleep.
Petit mal type
• It is common below 14 years of age.
• There may be momentary loss of consciousness with
or without falling.
• Staring look or eyes are tilted up.
• Attack may appear several times a day.
• Myoclonic jerks—Some time simple twitching of
individual muscle may be noted.
Psychomotor type
• Emotional state of mind either with fear, horror or
outrage.
• Feeling of epigastric sensation.
• Hallucinations of smell, taste and vision.
• Disturbances of memory are present.
Focal Fits
• In focal fits symptoms depend on location of lesion
in the brain.
Management
Generalised seizures
 Keep patient in quiet room.
 Give O2 if required.
 Protect from external injury.
 Injection Diazepam 10 mg or Lorazepam 4 mg IV.
 Tab Phenytoin 100 mg tds after meals.
If not Controlled Add
Tab Carbamazapine 200 mg thrice a day.
or Tab Mysoline (Primidone) 250 mg, ½ od increase
by ½ every week till 1 tds or Sodium valproate 200
mg bd.
These are to be given for 5 years after last attack
without break.
Status epilepticus
 Injection Diazepam 0.2-0.4 mg/kg IV over 5 minu-
tes. Repeat after ½ hour if attack recurs. Can also
be given 0.5 mg/kg followed by injection Pheny-
toin 15-20 mg IV slowly over ½ hour and repeat
every hour for 4 doses.
 Injection Paraldehyde 10 ml deep IM (5 ml in each
buttock).
If seizures persist
 Injection Thiopentone 1 gm in 500 ml 5 percent
Dextrose slow IV.
Myoclonic Seizures
 Sodium valproate 200-300 mg bd.
If not controlled
 Clonazepam 1-6 mg/day.
or
 Nitrazepam 10 mg tds.
INFECTIVE POLYNEURITIS
• Ascending lower motor neuron palsy usually
preceded by upper respiratory infection.
• Sensory involvement is minimal to nil.
• CSF shows albumino-cytological dissociation.
Treatment
 Inj Ampicillin 500 mg 6 hrly.
 ACTH 80 mg IV or Prednisolone 40 mg daily for a
short period.
 Hot packs and splinting of paralysed parts.
 Physiotherapy to paralysed muscles once muscle
power returns.
 Supportive therapy with vitamins and analgesics.

Plasma exchange or IV immunoglobulin therapy
of short duration improve prognosis of ventilation.
INTRACEREBRAL
HAEMORRHAGE
Capsular haemorrhage
• Unconsciousness.
• Face usually flushed, cyanosed and sweating.
• Breathing stertorous.
• Superficial and deep reflexes lost.
• Retention of urine and faeces.
• BP raised, Blood in CSF.
Cortical haemorrhage
• Patient generally remains conscious.
• Convulsions.
• Paralysis of one or more limbs.
• Aphasia or hemianopia.
Pontine haemorrhage
• Patient comatose.
• Convulsions of legs.
• Vomiting.
• Pin point pupil.
• Contralateral hemiplegia.
• Hyperpyrexia.
Management
 Patient should be propped up in bed.
 Airway is maintained, O2 and ventilation if hypoxic
cyanosis.
 Nasal feeding, catheterization.
 Coramine subcutaneously.
 Controlled lowering of BP.
 Crystalline penicillin 0.5 mega unit 4-6 hourly.
 Treatment of brain edema.
 Surgical removal of clot.
INTRACRANIAL TUMOURS
• Generally early morning and night headaches.
• Projectile vomiting without hyperacidity symptoms.
• Giddiness, mental dullness and apathy.
• Convulsions.
• Double vision.
• Paroxysms of yawning or hiccough specially with
growth in posterior fossa.
Management
 Investigate fully.
 Symptomatic relief by antiedema measures.
 Surgical removal easier with meningiomas and
acoustic neuromas.
 For invasive growth, partial removal, decompres-
sion or radiotherapy.
MENINGITIS
It may be bacterial/viral/spirochaetal or parasitic.
• Generally young children are affected.
• Incubation period is 1-5 days.
• There will be abrupt onset with severe headache.
• Fever, pain in neck and back.
• Rigors and convulsions.
• In meningeal stage headache will be severe.
• Kernig’s sign will be positive.
• Exaggeration of deep jerks.
• Leucocytosis between 20,000 – 30,000 per cu/mm.
• CSF will be turbid/purulent. Pressure will be
increased.
Treatment
 High doses of antibiotics.
 Sedatives to lumbar puncture to lower down the
CSF pressure.
 8 mg dexamethasone IV every 8 hourly.
 Mannitol 25 gm in 250 ml. over a period of 1-2
hours.
MIGRAINE
• May have familial history.
• It develops generally before the age of 15.
• Nausea, vomiting scintillating scotomas, photo-
phobia, hemianopia.
• Blurred vision.
Management
 Analgesics like Aspirin and Codein if attack is mild.
 Ergotamine tartrate 0.25 to 0.5 mg IM or 1-2 mg
tablet or Tab Migranil 2 tab stat.
 Propranolol has been found useful in some
patients 20 mg bd or qid if needed. For in between
attacks Amitryptiline/Clonidine 25 mg bd or tds.
If no response Librium 5 mg or Larpose 2 mg bd.
MULTIPLE SCLEROSIS
• Weakness, numbness, tingling and unsteadiness in
limb.
• Retrobulbar neuritis.
• Diplopia.
• Urinary sphincter disturbance.
• Relapses are more common in 2-3 months.
• MRI is a better tool to diagnose it. It is a multifocal
white matter disease.
Treatment
 60 to 80 mg of prednisone is given daily for one
week and taper it slowly. Long-term corticoster-
oids don’t help much in preventing relapse.
 Immunosuppressive therapy with methotrexate/
cyclophosphamide may help.
PARKINSON’S DISEASE
• Rigidity, akinesia.
• Pill rolling action tremors.
• Previous history of encephalitis, drug intake.
Treatment
 Levodopa 500 mg 2-10 tab daily starting from a
low dose with gradual increment every 4th day till
optimal response.
 Amantidine 100-200 mg daily.
 Atropine like drugs.
• Benzhexol 2-10 mg in divided doses.
• Procyclidine 10-30 mg in divided doses.
• Orphenadrine 400 mg daily.
 Bromocryptine 1.25 mg to 10 mg daily.
POLYNEUROPATHY
There may be simultaneous impairment of many
peripheral nerves. Alcohol, isoniazid, lead, arsenic,
deficiency of vitamin B1, B12, etc. may cause it.
• Numbness, tingling, burning sensation pain in calf
muscles.
• Extensors area affected more than flexors.
• Atrophy of muscles and flaccidity.
• Dryness and excessive sweating of extremities
• Postural hypotension and impotence.
• Tendon reflex absent or reduced.
Treatment
 Rich, high protein diet.
 Hot packs and analgesics.
 Vitamin B1 and B12.
 Corticosteroids in relapsing cases.
 Demyelinating neuropathies.
RAISED INTRACRANIAL TENSION
• Generalised headache, projectile vomiting without
nausea.
• Deterioration of consciousness and mental function.
• Feature of brain herniations.
• Evident primary cause like tumour, haemorrhage,
massive infarction or infection.
• CT scan shows hypodense diffuse areas.
Management
 Decadron 4 mg 4 times daily IM/IV.
 Mannitol 1.5 mg/kg rapid IV over 1/2-1 hour 2-3
times daily.
 Frusemide 40 mg IM bd.
 Acetazolamide 100 mg tds.
 High dose of barbiturates in hopeless cases.
 Emergency ventricular/cisternal puncture or

ventriculo-atrial/thecoperitoneal shunt surgery.
 Treatment of primary cause.
SCIATICA
• Pain in the distribution of sciatic nerve or its branches.
• True sciatic neuritis due to nerve injury and post-
herpetic neuralgia.
• Mechanical pressure on nerve- Protruded lumbar
disc, arachnoiditis haemorrhage or infection.
• Sacroilitis, arthritis may result it.
• Sciatica may be the first sign of spinal caries.
• Restriction of straight leg raising.
• Intensification of pain back and leg during rotatory
extension of lumbar spine suggesting ruptured disc.
• Spondylolisthesis may develop backache after pro-
longed standing or bilateral sciatica.
• Sacroiliac arthritis causes alteration of pain. First in
one buttock and posterior thigh then pain transfers
to other side.
• Benign spinal tumour causes progressive severe neu-
rological signs.
• Intermittent claudicating is caused by affection of
internal iliac artery.
Treatment
 Rest in bed with hard boards to support back.
 Analgesics as required
 Heat and massage
 Lumbar corset worn at all times
 In last surgical intervention may be required
according to causative factor.
SUBARACHNOID HAEMORRHAGE
• Sudden severe headache never experienced before.
• There may be nausea, vomiting or loss of conscious-
ness.
• Patient is confused and irritable.
• Nuchal rigidity.
• Other signs of meningeal irritation.
Treatment
 CT is more useful in first 24 hours.
 Surgical intervention is needed.
STROKE
• Sudden onset of neurological deficit.
• Prolonged coma is uncommon unless there is

cerebral haemorrhage or massive brain oedema.
• Convulsions may occur at outset.
• Advanced atherosclerosis, hypertension or a source
of embolus are evident.
• Prior history of transient ischaemic attacks, or
reversible ischaemic neurological deficit.
• The neurological deficit may be in the form of
aphasia, hemiplegia, hemianaesthesia, cranial nerve
deficit, deaf-mutism or a movement disorder
depending upon the area of brain involved, CT scan
shows the infarction or haemorrhage.
Treatment
 Anticoagulants during the stage of stroke in evolu-
tion or embolic stroke. Inj Heparin 5000 IU intra-
venous every 8 hrs for 24 hours.
 Antihypertensive agents to control hypertension
and insulin for diabetes mellitus.
 Physiotherapy to paralysed muscles.
 Antiplatelet drugs to reduce platelet stickness like
Aspirin 325 mg daily alone or in combination with
Dipyridamole 150-300 mg daily.
 Vasopressors when there is diffuse cerebral arterial
spasm.
 Measures to control brain oedema—Inj Mannitol
350 ml (20%) IV in ½ hr on Glycerol 1 oz by Ryles
tube tds or Inj Decadron 8 mg 6 hrly for 48 hrs and
then taper.
 Treatment of the primary cause like heart lesion,

atherosclerosis.
 Revascularisation of brain by transcranial external
to internal carotic anastomosis.
TENSION HEADACHE
• Headache is bilateral and diffuse.
• Sense of tightness and pressure in head.
• Onset is gradual and persistent for a few days
• Patient is able to sleep but whenever he gets up
develops pain.
• It is worst during worry, anxiety, tension and excite-
ment.
Treatment
 Analgesics don’t help
 Anxiolytics and antideppressants help.
TRANSIENT ISCHAEMIC ATTACKS
• It may be caused by embolization.
• Onset is abrupt without warning.
• Recovery occurs within a few minutes.

• There may be weakness and heaviness of contralat-
eral arm, leg, face.
• There may be slowness of movement, dysphagia or
mono-ocular visual loss on opposite side.
• During attack there may be flaccid weakness, sen-
sory change, hyperflexia or extensor plantar response
on the affected side.
• Vertebrobasilar ischaemic attacks may develop ver-
tigo, ataxia, diplopia, blurring of vision, weakness
on one or both sides.
• Attacks may occur frequently in some cases.
• When frank stroke occur it develops during first 48
hours.
Treatment
 Medical treatment is to prevent further attacks.
 In embolization of heart treatment may be initi-
ated with 5000-10000 units of heparin.
 325 mg of aspirin reduces the frequency of TIA
 Patient needs close watch.
TRIGEMINAL NEURALGIA
• Brief episodes of stabbing facial pain.
• It is unilateral. Pain shoots towards one side of ear.

• Eating, touching and movements trigger the pain.
• Spontaneous remissions for several months or longer
may occur.
• As disorder progresses pain becomes more frequent.
• Symptoms remained confined to the distribution of
trigeminal branch/nerve.
• Neurological examination shows no abnormality.
Treatment
 Tegretol 200-400 mg. thrice a day. Ataxia and gin-
givitis are side effects.
 Baclofen 10-20 mg. thrice daily.
 Gabapentine another anticonvulsant may be added
upto 2400 mg in 3 divided doses.
 Surgery may not show any abnormality.
HAEMATOLOGY
ACQUIRED APLASTIC ANAEMIA

It may be idiopathic, secondary to hepatitis B, and
chloramphenicol. There is no family history.
• History of aspirin, chlorthiazide, Chloropromazine,
chloromycetin, diethyl stilboestrol, isoniazid, qui-
nine, tetracycline.
• Whole body irradiation 300-500 reds can result in
complete loss of hemopoietic activity.
Treatment
 Blood transfusion.
 Early bone marrow transplantation in case of reticu-
locytes count < 1%, platelet count 20,000/cumm,
Bone marrow lymphoid element 7%.
 Androgens have limited role.
Haematology 455
CONSTITUTIONAL APLASTIC ANAEMIA
• Pancytopenia, reticulopenia.
• Hypoplastic marrow.
• Skeletal anomalies.
• Chromosomal breaks.
• Elevated serum iron.
• Increased AML in these patients.
Treatment
 Prednisone 1 mg /kg /day + oxymethalone 5 mg/
kg/day till Hb reaches 12 gm %. Then give mainte-
nance dose.
 Bone marrow transplantation.
HAEMOPHILIA – A
It is an X-linked recessive disease due to deficiency of
factor VIII.
• Positive family history. Females are carriers.
• Bleeding in joints causing deformities and contrac-
tures.
• Normal bleeding time and prothrombin time.
• Platelet count normal.

• 5 – 30 % of normal factor VIII in mild disease
• 3 – 5 % of normal fctor VIII moderate disease
• < 3% of normal in severe cases.
Treatment
 Fresh frozen plasma.
 Lyophilized factor VIII.
 Haemarthrosis needs immobilisation by splinting.
 Bleeding into skin and muscle requires single dose
of 20 units/kg of factor VIII.
 Epsilon aminocaproic acid gm/m2 PO every
6 hours is hlpful in minor dental surgery.
 Plasma alone is inadequate to increase factor VIII
level for safe surgery.
 Small skin wounds and epistaxis may respond to
ice packs and pressure or desmopressin which
temporarily raises factors VIIIC.
HODGKIN’S DISEASE
• Superficial lymph node in neck enlarges first.
• Glands are painless, leathery to feel and discrete.
• In 70% splenomegaly is marked.
• In 50% cases liver is enlarged.
Haematology 457
• There will be cachexia and loss of weight.

• Mild fever and night sweats.
• Anaemia due to haemolysis.
• Pain at the site of disease after drinking alcohol.
Metastatic Growth
• Localised pain in bones. Sclerotic deposits on X-ray.
• CNS – Paresthesia and pains.
• Mediastinal pressure – Dyspnoea, stride and dysph-
agia.
• Respiratory – laryngeal paralysis, collapse of lungs,
pleural effusion.
• GIT – Ascites and jaundice.
• Genitourinary – Haematuria, pyuria and flank pain.
Treatment
 Radiation therapy is useful in early phase of dis-
ease.
 Advanced disease is treated with combination
chemotherapy of adriamycin, bleomycin and
decarbonizers.
THALASSEMIAS
It is a hereditary defect in globin chain synthesis trans-
mitted by autosomal recessive traits.
• Normal to increased serum iron and iron binding
capacity.
• Target cells, basophilic stippling, microcytosis more
marked than hypochromia.
• Serum ferritin and serum unconjugated billirubin
levels are increased.
• Marked erythroid hyperplasia
• X ray shows sunray experience of skull, widening of
tables and expansion of medullary cavity of metac-
arpals.
Treatment
 Frequent red cell transfusion to keep Hb around
10 gram %
 Folic acid supplement but no iron.
 Splenectomy if hypersplanism
 Bone marrow transplantation
 Gene therapy is a distinct possibility
 Deferoxamine 2-6 g, /day by infusion pump.
 Vitamin C to chelate the excess of stored iron.
POLYCYTHEMIA RUBRA VERA

There is an excessive red cell production by a hyper-
plastic bone narrow.
Haematology 459
• Onset is insidious with cerebral symptoms.
• Cyanosis of distal portion of extremities with swell-
ing and pain.
• Red colour of mucous membrane.
• Epistaxis and blood shot eyes.
• Duodenal ulcer may develop.
• Dyspnoea and massive haemoptysis.
• Fundus congested and tortuous vessel.
• Weakness, lassitude, fatigue and pruritus.
• Raised haematocrit with leucocytosis and increased
platelet count.
• Leucocyte alkaline phosphatase raised.
• Hyperplasia of bone narrow.
Treatment
 Avoidance of strain. Low iron and low animal
proteins.
 Venesection – if haematocrit is above 55% daily
venesection of 500 ml to reduce PCV below 52%.
 Busulphan – If 32p is not available daily dose of it is
4-6 mg. Maintenance dose is 1-2 mg daily.
ORAL DISEASES
ACUTE NECROTIZING
ULCERATIVE GINGIVITIS
It is an infective disease with progressive ulceration of
inter dental papillae.
• Anaerobic gram-negative organisms are involved.
• Moderate to severe gingival tenderness causing pain
when eating/brushing.
• Pain is dull boring in character.
• Bad breath (halitosis) and unpleasant metallic taste
• Gums bleed spontaneously.
• A grey pseudomembrane lies over gingival tissues.
Profuse bleeding on removal of membrane is noted.
• Pyrexia, malaise and cervical lymphadenopathy are
common features.
Treatment
 Irrigate the tissues.
 Chlorhexidine mouth rinse.
Oral Diseases 461
 Metronidazole 200 mg TDS for five days.

 Scale / polish after acute phase.
 Advise patient to avoid smoking.
BAD BREATH (HALITOSIS)

Most important causes are:
• Smoking
• Alcoholism
• Sepsis.
Drugs causing bad breath are:
• Disulfiram
• Chloral hydrate
• Dimethyl sulphoxide
Psychological diseases:
• Depression
• Hypochondria
Diabetic ketoacidosis
Constipation.
Treatment depends on the causative factor.
DENTAL CARIES
• Pits, fissures and interproximal surfaces are the most
susceptible areas of tooth decay.
• Enamel caries does not give rise to symptoms. So is

early caries of dentine.
• Extensive lesions often cause discomfort to patients
when eating food.
• White areas of enamel hypocalcification
• More advanced lesions cause grey / black spots.
• Active caries of dentine is soft.
• X-ray of interproximal or occlusal caries helps.
Treatment
 Prevention — Diet and improve oral hygiene. Use
of fluorides helps.
 Monitor at regular intervals.
 Antibiotics and anti-inflammatory analgesic drugs.
 Restoration.
 Extraction.
HAND, FOOT AND

MOUTH DISEASE
It is caused by virus coxsackie A 16. It affects young
children.
• Low grade fever, coryza
• Lymphadenopathy
Oral Diseases 463
• Sore mouth with refusal to eat.

• Small, multiple vesicular and ulcerative oral lesions
on tongue and buccal mucosa.
Treatment
 It is a self limiting disease.
 No specific treatment is needed.
RECURRENT APHTHOUS STOMATITIS
• These are painful recurrent ulcers of mouth.
• There will be prodromal tingling sensation.
• Eating, swallowing will increase pain and discom-
fort.
• Cervical lymph nodes may be enlarged.
• Buccal mucosa, floor of mouth are involved.
• Size is 2-5 mm shape is round or elliptical. Edges are
inflamed with red margins.
• Major aphthous ulcers are larger one to ten in num-
ber on lips, cheeks tongue and soft palate.
Treatment
 There is no specific treatment.
 Tetracycline mouth wash for 5-7 days is helpful.
 1.5% cortisone acetate applied locally is effective.
 Chemical cautery reduces pain.
SHARP STABBING PAIN
Poor Response to Analgesic

• Exposed dentine.
• Caries, cracked tooth.
• Early pulpitis.
• Trigeminal neuralgia.
Dull/throbbing boring pain is associated with - (Re-
sponse to analgesics).
• Apical and lateral peridontitis
• Dry socket
• Tumors
• Atypical odontalgia
• Atypical facial pain
Burning pain is noted in
• Burning mouth syndrome
• Post-herpetic neuralgia
 Pain on biting/touching indicates acute periodonti-
tis/pericoronitis.
 Pain on hot/cold suggests
– Exposure of root
– Caries
– Defective restoration
– Pulpitis.
 Pain with sweet foods suggests
– Exposure of caries
– Dentinal hypersensitivity.
Oral Diseases 465
 Pain related to meals indicate

– Salivary gland obstruction
– TM joint disorder.
XEROSTOMIA
Dryness of mouth is a clinical manifestation of salivary
gland dysfunction.
• Dry and burning sensation.
• Mucosa appears normal but poor oral hygiene is
noted.
• Tricyclic antidepressant drugs may develop xeros-
tomia Excessive use of diuretics may also cause it.
• Mucosa in severe cases may appear dry and atro-
phic, sometimes inflamed or more often pale and
translucent.
• Tongue papillae may be atrophied.
• Riboflavin and nicotinic acid deficiency may be seen.
Treatment
 Only symptomatic relief is possible.
DISEASES OF
BONES AND JOINTS
ACUTE OSTEOMYELITIS
Mostly it has haemategonous spread.
• Metaphysis of long bones in children is involved.
• Symptoms of acute inflammation are seen, swelling
and redness are prominent.
• Pain is localised and child may limp.
• Fever and chill may be present.
• ESR will be raised.
• After 1-2 weeks X- ray will show radiolucent lesion
and periosteal elevation. Reactive sclerosis will be
absent.
Treatment
 Six weeks of antibiotic therapy is advised.
 If patient does not improve surgical intervention
will be needed.
Diseases of Bones and Joints 467
ANKYLOSING SPONDYLITIS
It is a chronic inflammatory disease resulting in pain
and stiffening of spine.
• Onset is gradual with intermittent bouts of back pain
radiating down the thigh.
• Symptoms progress in cephaloid direction.
• Back motion becomes limited.
• In chronic stage entire spine becomes fused allow-
ing no motion.
• In 50% cases permanent changes in peripheral joints
may develop.
• In 20-25% cases anterior uveitis may develop.
• Pulmonary fibrosis of upper lobes.
• ESR is raised and test is negative for rheumatoid
factor.
• Mild anaemia is present.
• Erosion and sclerosis of SI joint may be seen.
• X-ray will show ‘Bamboo spine’.
Treatment
 Postural and breathing exercise
 Indomethacin is well effective but toxic if used for
long-term.
 Sulfasalazine 1000 mg twice daily is sometimes use-
ful.
 Infliximab 5 mg /kg every other month is useful.
 Physiotherapy may be useful.
GOUTY ARTHRITIS
It is a metabolic disease, often familial.
• Acute onset with single joint involvement.
• Often first metatarsophalangeal joint is involved.
• There is over production or under excretion of uric
acid noted.
• Identification of urate crystals in joint fluid or tophi
is diagnostic.
• Alcohol ingestion promotes hyperuricaemia.
• In 5 to 10% cases kidney stones are present.
• More than one joint may occasionally be affected.
• Tophi may be seen in external ears, hands, feet, ole-
cranon process and prepatellar bursa.
Treatment
 High purine containing foods are to be avoided
such as meats, sea foods and alcohols.
 Consumption of beans, peas, lentils, spinach, cauli-
flower and mushrooms are to be minimized.
 Nonsteroidal anti-inflammatory drugs are useful.
One should take care of acidity.
 Thiazide and loop diuretics which inhibit excretion
of uric acid are to be avoided. Aspirin < 3 gm daily
aggravate hyperuricaemia.
 Colchicine is less favoured due to its side effects.

 Corticosteroids often give dramatic symptomatic
relief in acute episodes of gout.
 Bed rest in acute phase.
 Allopurinol lowers plasma urate and urinary uric
acid concentration and facilitates tophus mobilisa-
tion.
OSTEOARTHRITIS
It is a degenerative disease of old age which runs in
families.
• After the age of 50 weight bearing knee joints are
involved.
• Usually one or a few joints are involved.
• Pain is relieved by rest
• X-ray will show narrowed joint space, osteophytes,
increased density of subchondral bone and bony
cysts.
• Articular cartilage is first roughened and finally worn
away. Spur formation and lipping at the edge of
joint surface seen. Joint is narrowed.
Treatment
 Weight reduction.
Ankylosing spondylitis Osteoarthritis
470
Age of onset 15-25 years After 50 years

Hereditary Sometimes Often familial
Causative factor Rheumatoid Degenerative
Number of joints Multiple Usually one or two
involved
Types of joints Spinal joints Knee/Hip
Constitutional Weakness, malaise Usually none
symptoms
Joint pain Mild to agoinising Mild

 Walking programme improves clinical picture.

 Non-steroid anti-inflammatory drugs are effective
although toxic.
 In mild disease acetaminophen 2 to 4 gm daily will
help.
 Glutamine and chondrotin are also effective in knee
joint.
 Intra-articular injection of triamcilone 20-40 mg
gives relief.
 Capsaicin cream 0.025% applied twice may help.
 In late case arthroscopic knee surgery helps
PSORIATIC ARTHRITIS
• In 80% of cases psoriasis precedes.
• Arthritis usually asymmetric with savage appear-
ance of fingers and toes.
• Sacroiliac joint is commonly involved. Ankylosis of
this joint may occur.
• Rheumatoid factor is negative.
• X-ray may show osteolysis, bony ankylosis and
atypical syndesmophytes. Fluffy periosteal new bone
++.
• ESR will be raised.
Treatment
 Non-steroidal anti-inflammatory drugs are helpful.
 Corticosteroids are less effective in psoriatic arthri-
tis.
 In resistant cases methotrexate may be helpful.
RHEUMATOID ARTHRITIS
It is a systemic connective tissue disorder affecting syn-
ovial joints.
• Malaise, fever, morning stiffness.
• Onset is insidious in small joint.
• Rheumatoid factor present.
• Pericarditis/pleural effusion.
• Stiffness persist for 30 minutes and subsides during
day hours.
• To start monoarticular disease is seen.
• 20% patients will have subcutaneous nodules.
• In late stage fibrous ankylosis is seen.
• Spindling of proximal interphalangeal joints and
swelling of metacarpophalangeal joints and dorsum
of wrist.
• ‘Z’ deformity of thumbs and ulnar deviation of fin-
gers.
• There may be splenomegaly and lymph node

enlargement.
• Anorexia and weight loss.
• Generalised osteoporosis especially of vertebra.
• Eyes may develop keratoconjunctivitis sicca.
• Peripheral neuropathy.
Treatment
 Mental and physical rest.
 Nutritious diet.
 Avoid cold and damp climate.
 Non-steroidal anti-inflammatory drugs. High doses
of aspirin helps.
 Ibuprofen 400 mg QID/Mefonic acid 500 mg QID.
 Piroxicam 20 mg daily.
 Antimalarials – 25 to 40% patients respond to
hydroxychloroquine 200 – 400 mg daily in 3-6
months of therapy side effect includes pigmentary
retinitis causing visual loss.
 Corticosteroids produce dramatic anti-inflamma-
tory effect.
 Sulfasalazine is a second line agent. Dose is 0.5 gm
twice daily. Side effects include Neutrogenia and
thrombocytopenia.
 Minocycline – 200 mg of it is useful in first year of
disease.
 Azathioprine is an anti-metabolite which is effec-

tive for severe rheumatoid arthritis where gold or
anti malarials have failed.
TUBERCULOSIS OF BONE / JOINTS

Causative factor is Mycobacterium tuberculosis. It spreads
through blood.
• Onset is insidious.
• Pain is mild and is worst at night.
• Joint may become stiff.
• Limitation of joint movement.
• Joint may be tender with soft tissue swelling and
effusion. Local area may be hot.
• Without treatment muscle atrophies becomes promi-
nent.
• Progressive destruction in spine may cause gibbus.
• ESR is raised.
• Biopsy of bony lesion, synovium, regional lymph
node may show caseating necrosis and giant cells.
• X-ray will show soft tissue swelling. Bone atrophy
may cause thinning of trabecular pattern, narrow-
ing of cortex and enlargement of medullary canal.
In later stage there may be focal erosion of articular
surface.
• Paraplegia is the commonest complication of spinal

tuberculosis.
Treatment
 Rich diet + Vitamins
 Because of rise of resistant organisms treatment is
to begin with four drugs –(i) isoniazid 300 mg /
daily (ii) pyrazinamide 25 mg/kg/daily (iii) rifampin
600 mg/daily and (iv) ethambutol 15 mg/kg/
daily.
 Lastly surgical intervention has to be done.
APPENDIX
EXPENDITURE OF
CALORIES/HOUR
Activity Calories Activity Calories

Dressing 33 Mental work 7-10
Sitting at rest 15 Sawing wood 420
Standing 20 Cycling 180-300
Running 500-900 Climbing 200-900
Sewing 25-30 Wrestling 980
Reading 20 Rifle cleaning 50
Sweeping 110 Brick laying 240
Knitting 31 Scrubbing floor 260
FOOD AND NUTRITION
• Water soluble vitamins B complex and vitamin C

cannot be stored in body, hence excessive
consumption is a waste. It puts load on kidneys to
filter these out.
Appendix 477
• Milk is a poor source of vitamin C and iron, but

provides class-I proteins.
• Hard boiled egg and salad provides negative calories.
• Each gram of whisky gives 7 empty calories. Every
time you drink, it damages your brain cells which
are never regenerated.
• Pure ghee, dalda or refined oil provides same amount
of 9 calories per gram. Pure ghee increases serum
cholesterol level, a predisposing factor of heart
attack.
• Cashewnuts, pista, badam and groundnuts all are
having more or less same nutritional values hence it
is better to consume groundnuts instead of spending
much more money on sophisticated nuts.
• Pressure cooked foods are light, fluffy and easily
digestible. Loss of heat labile nutrients is also
minimized.
• Certain enzymes are inactivated by cold freezing
and refrigeration.
• Soda water contains only 5 calories while Fanta,
Limca, Thums up contain about 90 calories.
• Liver can store large amounts, i.e. 100,000 inter-
national units of vit. A. These reserves may last for 6
months. Excessive consumption of vit. A may result
in headache, irritability, nausea, vomiting and ano-
rexia.
• None of the vitamins yields energy.
IMPORTANT SOURCES OF
CHOLESTEROL MG/100 GM
Food Cholesterol Food Cholesterol

Butter 280 Egg white 0
Cheese 145 Egg yolk 1330
Cream 140 Chicken 40
Milk 11 Liver 250
Egg hen 498 Fish 50
IMPORTANT SOURCES OF FAT
Food % Fat Food % Fat

Ghee 100 Soya bean 19.5
Butter 81 Cow’s milk 3.5
Almond 58 Egg 13.3
Cashewnut 46 Mutton 13.3
Groundnut 40 Fish 3.2
Appendix 479
IRON MG/100 GM
Food Iron (mg) Food Iron (mg)

Bajra 8.8 Jaggery 11.4
Wheat whole 5.3 Betel leaves 5.7
Bengal gram 8.9 Coriander 1.0
Peas dry 4.4 Methi 16.9
Soya bean 11.3 Mint 15.6
Bitter gau 9.4 Tomato 2.4
Egg 2.1 Mutton 2.5
PROTEINS GM/100 GM
Food Protein Food Protein

Wheat 11.8 Egg hen 13.3
Rice 7.0 Fish 21.5
Maize 11.1 Mutton 18.3
Bengal gram 17.1 Milk (cow) 3.5
Lentil 25.1 Milk (human) 1.2
Peas dried 19.7 Groundnut 26.7
Green gram dal 24.0 Almond 20
Soya bean 42.0 Gingelly seeds 18.2
SHOWING APPROXIMATE VALUES

Food Quantity Wt Calo- Prot- Fats
(gm) ries eins (gm)
Chapaties 2 57 193 5 5.5
Rice 1 plate 100 110 6 0.2
Pulse 1 cup 150 284 16 9
Omelette 1 39 77 5.8 5.7
Bread 2 slice 46 120 4.0 1.0
Biscuits 2 16 64 1.6 2.0
Milk 1 cup 703 300 9.0 6.0
Banana 1 100 99 1.2 0.2
Apple 1 66 42 0.2 0.3
Butter Table spoon 20 58 0.1 0.1
Ghee Table spoon 15 1345 - 15
Sugar 1 teaspoon 5 20 - -
Groundnut 30 gm - 165 8 14
TABLE OF FOOD VALUE/100 GM

Food Pro- Fat Cal- Iron Vit Vit Cal-
tein gm cium mg “C” “A” ories
gm mg mcg
Cereals Rice
Raw milled 6.8 0.5 10 3.1 0 0 345
Par boiled 6.4 0.4 9 4.0 0 0 346
Contd...
Appendix 481
Contd...
gm mg mcg
Flakes 6.6 1.2 20 20.0 0 0 346
Puffed 7.5 0.1 20 7.6 0 0 325
Wheat
Whole flour 12.1 1.7 48 11.5 0 29 341
Flour 11.0 0.9 23 2.5 0 25 348
refined
Suji 10.4 0.8 16 1.6 0 — 348
Bread white 7.8 0.7 11 1.1 0 0 245
Millets
Bajra 11.6 5.0 42 5.0 0 132 361
Jowar 10.4 1.9 25 5.8 0 47 349
Maize 11.1 3.6 10 2.0 0 90 342
Ragi 7.3 1.3 344 6.4 0 42 328
Pulses Dals
Bengal gram 20.8 5.6 56 9.1 1 129 372
Black gram 24.0 1.4 154 9.1 0 38 347
Green gram 24.5 1.2 75 8.5 0 49 348
Red gram 22.3 1.7 73 5.8 0 132 335
Whole Dal
Bengal gram 17.1 5.3 202 10.2 3 189 360
Green gram 24.0 1.3 127 7.3 0 92 334
Lentil
(Masur) 25.0 0.7 69 4.8 0 294 343
Peas dry 19.7 1.1 75 5.1 0 39 315
Contd...
Contd...
gm mg mcg
Rajmah 22.9 1.3 260 5.8 0 — 346
Moth beans 23.6 1.1 202 9.5 0 9 330
Soya bean 43.2 19.5 240 11.5 0 426 432
Nuts and Seeds
Groundnut 25.3 40.1 90 2.8 0 37 567
Til 18.3 43.0 1450 10.5 0 60 563
Poppy seeds 21.7 19 1584 — — — 408
Cashewnut 21.2 47 50 5.0 — — 596
Almond 20.8 59 230 4.5 — — 655
Dry coconut 6.8 62 40 2.7 7 — 662
Milk and Milk Products
Milk cow 3.2 4.1 120 0.2 2 174 67
Milk buffalo 4.3 8.8 210 0.2 1 160 117
Milk goat 3.3 4.5 170 0.3 1 182 72
Curd 3.1 4.0 149 0.2 1 102 60
Butter milk 0.8 1.1 30 0.8 — 0 30
Cheese 24.1 25.1 790 2.1 — — 348
Khoa 14.6 31.2 650 5.8 — — 421
Whole milk
powder 25.8 26.7 950 0.6 4 1400 496
Skimmed
milk powder 38.0 0.1 1370 1.4 5 0 357
Contd...
Appendix 483
Contd...
gm mg mcg
Egg and Meal
Egg hen 13.3 13.3 60 2.1 0 600 173
Mutton 18.5 13.3 150 2.5 — 0 194
Goat meat 21.4 3.6 12 — — — 118
Chicken 26.0 0.6 25 — — — 109
Beef 22.6 2.6 10 0.8 2 0 114
Pork 18.7 4.4 30 2.2 2 0 114
Liver sheep 19.3 7.5 10 6.3 20 0 150
Fish
Pomfrets 17.0 1.3 200 0.9 — — 87
Hilsa 21.8 19.4 180 2.1 24 — 273
Prawn fresh 19.1 1.0 323 5.3 — — 89
Fish fresh
high fat 11.2 5.8 240 2.3 — — 138
Fish dry 5.5 2.7 315 3.5 — — 255
Crab 8.9 1.1 1370 21.2 — — 59
Green Leafy Vegetables
Amranth 4.0 0.5 397 25.5 99 5520 45
Bathua 3.7 0.4 150 4.2 35 1700 30
Cabbage 1.8 0.1 39 0.8 124 1200 27
Colocasia
green leaves 3.9 1.5 227 10.0 12 10270 56
Contd...
Contd...
gm mg mcg
Cariander 3.3 0.6 184 18.5 135 6918 44
Drumstick
leaves 6.7 1.7 440 7.0 220 6780 92
Methi 4.4 0.9 395 16.5 52 2300 49
Lettuce 2.1 0.3 50 2.4 10 990 21
Raddish
leaves 3.8 0.4 265 3.6 81 5300 28
Palak 2.0 0.7 73 10.9 28 5580 26
Bulbs and Tubers
Beet root 1.7 0.1 18 1.0 10 0 43
Carrot 0.9 0.2 80 2.2 3 1890 48
Raddish 0.7 0.1 35 0.4 15 0 17
Onion 1.2 0.1 47 0.7 2 0 50
Potato 1.6 0.1 10 0.7 17 0 97
Colocacia 3.0 0.1 40 1.7 0 — 97
Yam 1.2 0.1 50 0.6 0 260 79
Other Vegetables
Drum stick 2.5 0.1 30 5.3 120 110 26
Capsicum 1.2 0.3 10 1.0 137 420 24
Karela 1.6 0.2 20 1.8 88 125 25
Beans french 1.7 0.1 50 1.7 24 130 26
Beans cluster 3.2 0.4 130 4.5 49 200 60
Peas 7.2 0.3 20 1.5 9 80 93
Contd...
Appendix 485
Contd...
gm mg mcg
Fruits
Amla 0.5 0.1 50 1.2 600 9 58
Guava 0.9 0.3 10 1.4 212 0 51
Grape 0.7 0.1 20 0.2 31 0 32
Lemon 1.0 0.9 70 2.3 39 0 57
Mosambi 0.8 0.3 40 0.7 50 0 43
Orange 0.7 0.2 26 0.3 30 1104 65
Juice 0.2 0.1 5 0.7 64 15 48
Lichi 1.1 0.2 10 0.7 31 0 61
Melon 0.3 0.2 32 1.4 26 170 17
Papaya 0.6 0.1 17 0.5 57 665 32
Pineapple 0.4 0.1 20 1.2 39 ++ 46
Sitaphal 1.6 0.4 17 1.5 37 0 104
Strawberry 0.7 0.2 30 1.8 52 15 44
Tomato 0.9 0.2 48 0.4 27 350 20
Apple 0.2 0.5 10 1.0 1 0 59
Bael fruit 1.8 0.3 85 0.6 3 55 137
Banana 1.2 0.3 17 0.9 7 78 116
Cherries 1.1 0.5 24 1.3 7 — 64
Figs 1.3 0.2 80 1.0 5 162 37
Jack fruit 1.9 0.1 20 0.5 7 175 88
Mango 0.6 0.4 14 1.3 16 2740 74
Chiku 0.7 0.1 28 2.0 6 95 98
Contd...
Contd...
gm mg mcg
Fats and Oil
Butter — 81.0 — — — 960 730
Ghee (cow) — 100.0 — — — 600 900
Ghee
(buffalo) — 100.0 — — — 240 900
Vanaspati — 100.0 — — — 750 900
Refined oil — 100.0 — — — 750 900
Miscellaneous
Dates 2.5 0.4 120 7.3 3 25 317
Coriander
seeds 14.1 16.1 630 18.0 0 940 288
Methi 26.2 5.8 160 14.1 0 95 335
Chillies
green 2.9 0.6 30 1.2 111 175 29
Betel leaves 3.1 0.8 230 7.0 5 5760 44
Biscuits
salted 4.5 6.6 — — — — 534
Biscuits
sweet 5.4 6.4 — — — — 450
Fish liver
oil — 100 — — — — 900
Honey 0.3 0 5 0.9 4 — 320
Contd...
Appendix 487
Contd...
gm mg mcg
Jaggery 0.4 0.1 80 11.4 — 165 383
Mushroom 4.6 0.8 6 1.5 12 0 43
Papad 18.8 0.3 80 17.2 — — 288
Sago 0.2 0.2 10 1.3 — — 351
Sugarcane
juice 0.1 0.2 10 1.1 — — 39

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Practical Standard

LC Gupta MD FAMS DSc (Hon)

Practical Standard Prescriber

First Edition: 1984

This revised seventh edition of Practical Standard

The drug world is expanding at a very fast pace. New

his occupation should be given due consideration.

25. Diverticular Disease of Colon (Diverticulosis) 26

75. Traumatic Pneumothorax .................................. 97

97. Herpes Zoster ..................................................... 134

EAR AND NOSE DISEASES

144. Deafness .............................................................. 183

166. Chicken Pox ........................................................ 206

191. Burns .................................................................... 234

215. Diabetes Insipidus .............................................. 260

252. Cerebrospinal Fluid ........................................... 380

GLUCOSE TOLERANCE TEST

253. Glucose Tolerance Test ...................................... 390

BONE MARROW ASPIRATION

254. Bone Marrow Aspiration .................................. 393

RENAL FUNCTION TESTS

255. Renal Function Tests .......................................... 398

LIVER FUNCTION TESTS

256. Liver Function Tests ........................................... 400

257. Changes of Fundus in Different Diseases ....... 416

258. Acute Giomerulonephritis ................................ 422

264. Neurogenic Bladder ........................................... 428

288. Transient Ischaemic Attacks ............................. 451

DISEASES OF BONES AND JOINTS

307. Psoriatic Arthritis ................................................ 471

 To avoid irritant substances like salicylates.

 Analgesics/sedatives like Fortwin 30 mg slow IV

• Diarrhoea, colic, haematemesis, fever, chills, head-

• Anorexia, nausea, vomiting, fever.

Laparotomy should be done as soon as possible and

ACUTE ORGANIC SMALL

Surgical measures are indicated in

 Continuous gastric suction to reduce vomiting and

• Fever, splenomegaly, ascites, encephalopathy, abdo-

Tinidazole 2 gm/day for 5 days.

 Efcorlin pellets (glaxo) allow pellet to dissolve in

• In infants and aged the prodromal symptoms as well

Nalidixic acid 1 gm 6 hourly.

• Chest pain—Unrelated to eating implies local exten-

 Nystatin tablet or Mycostatin tablet dissolved in

• Radiological findings vary according to the type of

Patient should be considered to be constipated only if

Naturolax or Igol or Ispaghula one tsf with water

DIVERTICULAR DISEASE OF COLON

 If severe disease patient may be hospitalised with

 Aluminium hydroxide in tablet form being inert is

Look for gynaecomastia, galactorrhoea, gout as adverse

4. Soothing anal suppository 2 to 3 times daily.

• Cytologic smear showing pathognomonic pseudo-

It is a transient phenomenon and may occur as manifes-

 Antispasmodics, i.e. Atropine sulphate 0.3-0.6 mg

IRRITABLE BOWEL SYNDROME

• Altered bowel function, constipation or diarrhoea.

NAUSEA AND VOMITING