SECTION 3

CASE MANAGEMENT

CONTENTS:
Disease profiles Cases Viva questions

Disease profiles
Angina Common cold and cough Constipation Diarrhea Edema Fever Hypertension Hypoglycemia Malaria Migraine Mouth ulcer Piles Throat infection Urinary tract infection Warts

PAIN
Abdominal pain Backache Earache Eye pain Headache Jaw pain Muscle pain Neck stiffness Toothache

MOUTH ULCER
DEFINITION:
It is an open sore inside the mouth, or rarely a break in the mucous membrane or the epithelium on the lips or surrounding the mouth.

EPIDEMIOLOGY:
Mouth ulcer is a very common oral lesion. Epidemiological studies show an average prevalence between 15% and 30%. Mouth ulcers tend to be more common in women and those under 45.

ETIOLOGY:
Physical abrasion Chewing tobacco Braces Trauma Cancerous or no specific processes Infection or medication Viral, fungal or bacterial infection

PATHOPHYSIOLOGY:
Any cause Abrasion of mucous membrane Sore formation Release of inflammatory mediators Inflammatory response Ulcer

SIGNS AND SYMPTOMS:

Difficulty in chewing, eating, swallowing Pain Redness Mild fever Severe condition may also lead to bleeding ulcer. Mouth ulcers are easily identifiable by their appearance. A mouth ulcer will be: Round or oval in shape

 White,yellow or grey in colour Inflamed around the edge

DIAGNOSIS:
Physical examination: A health care provider or dentist usually diagnoses the mouth ulcer, based on its appearance and location. Blood tests or a biopsy of the ulcer may be needed to confirm the cause.

TREATMENT:.
Somogel (Lidocaine) Bonjela Rinsing the mouth out with brine (warm salted water)

COUNSELLING:
Rinsing the mouth out with brine (warm salted water) Apply Somogel to sore area. Repeat application every 3 hours as necessary. Avoid spicy food

MIGRAINE
DEFINITION:
Repeated attacks of headache characterized by sharp pain and often accompanied by nausea, vomiting, and visual disturbances

EPIDEMIOLOGY:
35% of people in Pakistan are affected by migraine. Females are more prone to migraine.

ETIOLOGY:
Allergies or allergic reactions, bright lights, loud noise, certain odours or perfumes, physical & emotional stress, changes in sleep patterns or irregular sleep, skipping meals, fasting, alcohol, menstrual cycle fluctuations.

PATHOPHYSIOLOGY:
Stimulus Serotonin levels decrease in brain Vasoconstriction Decrease blood flow (decrease nutrient supply, decrease glucose, decrease blood pressure) Pain

SIGNS AND SYMPTOMS:

Photophobia Blurred vision Blind spot Eye pain
Zig zag lines

GI disturbances

DIAGNOSIS:
There is no specific diagnostic test, but can be diagnosed on the basis of signs and symptoms.

DIFFRENTIAL DIAGNOSIS:
Tension headache: two sided, muscular strain and pressure on eyes are its distinguishing features. Cluster headache: it is usually one sided headache and is episodic in nature.
Migraine: it can be unilateral or bilateral and is associated with visual disturbance, nausea and vomiting.

TREATMENT:
Paracetamol (Acetaminophen) 500mg 1tab tid Naproxen (Anaprox) 500mg 1tab tid

COUNSELLING:.
Take sweets and chocolates as they restore glucose level and increase serotonin level. Avoid migraine triggers. Take proper rest and complete your sleep. Avoid anxiolytics as they decrease serotonin levels in brain.

PILES
DEFINITION:
Hemorrhoids are vascular structures in the anal canal which help with stool control. When they become pathological, this condition is called piles.

ETIOLOGY:
A number of factors may lead to piles, including irregular bowel habits (constipation or diarrhea), exercise, nutrition (low-fiber diet), increased intraabdominal pressure (prolonged straining), pregnancy, genetics, absence of valves within the hemorrhoidal veins, and aging. Other factors that can increase the rectal vein pressure resulting in hemorrhoids include obesity and sitting for long periods of time.

EPIDEMIOLOGY:
Symptomatic hemorrhoids affect at least 50% of the population at some time during their lives and both sexes experiencing the same incidence of the condition.

SIGNS AND SYMPTOMS:

Hemorrhoids usually are present with itching, rectal pain, or rectal bleeding. In most cases, symptoms will resolve within a few days. External hemorrhoids are painful, while internal hemorrhoids usually are not unless they become thrombosed or necrotic. The most common symptom of internal hemorrhoids is bright red blood covering the stool, a condition known as hematochezia,. They may protrude through the anus. Symptoms of external hemorrhoids include painful swelling or lump around the anus.

PATHOPHISOLOGY:
Hemorrhoids tissue anal canal abnormal change piles

DIAGNOSIS:
A visual examination of the anus and surrounding area may be able to diagnose hemorrhoids Visual confirmation of internal hemorrhoids is via anoscopy or proctoscopy. This device is basically a hollow tube with a light attached at one end that allows one to see the internal hemorrhoids. Differential diagnosis: piles may be confused with anal fissure, in which there is break or tear in the skin of anal canal and bright red anal bleeding is observed along with pain after defication.

TREATMENT:
Conservative treatment typically consists of increasing dietary fiber, oral fluids to maintain hydration. Increased fiber intake has been shown to improve outcomes and may be achieved by dietary alterations or the consumption of fiber supplements Non-steroidal anti-inflammatory drugs (NSAID)s and rest. Skin protectants such as petroleum jelly or zinc oxide cream may potentially reduce injury and itching. Surgery

PREVENTION:
The best way to prevent hemorrhoids is to: Keep stools soft so they pass easily, thus decreasing pressure and straining. To empty bowels as soon as possible after the urge occurs.

 Exercise, including walking, and increased fiber in the diet help reduce constipation and straining by producing stools that are softer and easier to pass.

URINARY TRACT INFECTION

DEFINITION:
A urinary tract infection (UTI) is a bacterial infection that affects any part of the urinary tract

ETIOLOGY:
The most common organism implicated in UTIs (8085%) is E.coli, whiles Staphylococcus species are the cause in 510%.

EPIDEMIOLOGY:
Bladder infections are most common in young women, with 10% of women getting an infection yearly and 60% having an infection at some point in their life.

SIGNS AND SYMPTOMS:

The most common symptoms of a bladder infection are burning with urination, frequency of urination, an urge to urinate and no significant pain. An upper urinary tract infection or pylonephritis may also present with flank (abdominal) pain and a fever.

DIAGNOSIS:
Urinary microscopy; Multiple bacilli (rod-shaped bacteria, here shown as black and bean-shaped) shown between white cells at urinary microscopy. This is called bacteriuria and pyuria, respectively. These changes are indicative of a urinary tract infection.

 Urine culture; showing a quantitative count of greater than or equal to 103 colony-forming units (CFU) per mL of a typical urinary tract organism along with antibiotic sensitivities is useful to guide antibiotic choice. However, women with negative cultures may still improve with antibiotic treatment.

TREATMENT:
Antibiotic therapy: for 7-10 days Amoxicillin 250-500 mg. three times a day (shows resistance to E.coli) Ciprofloxacin 250-500 mg. three times a day (reserve for severe cases) Urine alkalinizing agents: Sodium citrate but along with antibiotics not alone Fluid intake: Fluid intake should be enhanced.

COUNSELLING:
Complete the course of antibiotic therapy. Fluid intake should be enhanced. Proper hygiene should be maintained.

WARTS
DEFINITION:
A wart is generally a small, rough growth, typically on a humans hands or feet but often other locations, that can resemble a solid blister and are mostly harmless.

EPIDEMIOLOGY: 2-20% of the population. ETIOLOGY:

They are caused by a viral infection, specifically by human papilomavirus. HPV infects the squamous epithelium, usually of the skin or genitals

PATHOPHYSIOLOGY:
Bacteria/virus Penetrate into skin Toxin release Stratum bacilium abnormal mitotic division warts

SIGNS AND SYMPTOMS:

Wart is generally a small, rough growth, typically on a humans hands or feet but often other locations, that can resemble a cauliflower or a solid blister They typically disappear after a few months but can last for years and can recur.

DIAGNOSIS:
On the basis of general appearance. AND Histopathology; Common warts have a characteristic appearance under the microscope. They have thickening of the stratum corneum (hyperkeratosis), thickening of the stratum spinosum (acanthosis), thickening of thestratum

granulosum, rete ridge elongation, and large blood vessels at the dermalepidermal junction

DIFFRENTIAL DIAGNOSIS: Warts

May be due to bacteria or HPV Mostly affected areas are face hand & feet Solid mass in the form of outgrowth. Can lead to pain & itching

Hives
Occurs due to insect bite Mostly occurs at lower abdominal region Spots are like wheel & flares with redness Itching with mild pain

Clauses
Due to increased pressure Occur in foot region Redness & Cluster of boils Very painful

Moles
Due to increased secretion of melanin In hands & feet Appears like pigmentation & black spots No pain or itching

TYPES:
A range of types of wart have been identified, varying in shape and site affected, as well as the type of human papillomavirus involved. These include:

Common wart (Verruca vulgaris), a raised wart with roughened surface, most common on hands, but can grow anywhere on the body; Flat wart (Verruca plana), a small, smooth flattened wart, flesh-coloured, which can occur in large numbers; most common on the face, neck, hands, wrists and knees; Filiform or digitate wart, a thread- or finger-like wart, most common on the face, especially near the eyelids and lips; Genital wart (venereal wart, Condyloma acuminatum, Verruca acuminata), a wart that occurs on the genitalia. Mosaic wart, a group of tightly clustered plantar-type warts, commonly on the hands or soles of the feet;

Periungual wart, a cauliflower-like cluster of warts that occurs around the nails. Plantar wart (verruca, Verruca pedis), a hard sometimes painful lump, often with multiple black specks in the center; usually only found on pressure points on the soles of the feet;

TREATMENT:
Surgical curettage of the wart Laser treatment. salicylic acid products are readily available at drugstores and supermarkets. There are typically two types of products: adhesive pads treated with salicylic acid or a bottle of concentrated salicylic acid solution. Vaccine against HPV can be used for prevention in some cases.

COUNSELLING:
Do not let wart moisturize with water as it increases infection. Maintain good hygienic condition. Do not scratch warts.

COMMON COLD AND COUGH

DEFINITION:
The common cold (also known as nasopharyngitis, acute viral rhinopharyngitis, acute coryza, or a cold) is a viral infectious disease of the upper respiratory system.Common symptoms includes a cough, sore throat, runny nose, and fever.

ETIOLOGY:
Common cold is a viral infectious disease, caused primarily by rhinoviruses and coronaviruses. Viruses: The common cold is a viral infection of the upper respiratory tract. The most commonly implicated virus is a rhinovirus (3050%), a type of picornavirus with 99 known serotypes. Others include: coronavirus (1015%), influenza (515%), human parainfluenza viruses, human respiratory syncytial virus, adenoviruses, enteroviruses, and metapneumovirus.

EPIDEMIOLOGY:
The common cold is the most frequent infectious disease in humans with the average adult contracting two to four infections a year and the average child contracting between 612 infections a year.

SIGNS AND SYMPTOMS:

Symptoms are cough, sore throat, runny nose, and nasal congestion; sometimes this may be accompanied by conjunctivitis (pink eye), muscle aches, fatigue, headaches, shivering, and loss of appetite. Fever is often present thus creating a symptom picture which overlaps with influenza. The symptoms of influenza however are usually more severe.

DIFFIRENTTIAL DIAGNOSIS:
COMMON COLD AND COUGH
It is causedby rhinovirus, picornavirus, coronavirus, influenza & human parainfluenza viruses,

PHYRANGYTIS/ COMMUNITY ACQUIRED TONSILITIS PNEUMONIA CAUSITIVE AGENTS The cause is usually Most common cause is strep. viral, e.g Epstein barr Pneumonia. Other causes are, virus (90% of cases) non capsulate srains of or bacterial e.g H.influenzae. Legionella S.pyogenes besides pneumophilia, mycoplasma

PULMONARY TUBERCLOSIS It is caused by M tuberculosis

human respiratory syncytial virus, adenoviruses, enteroviruses, and metapneumovirus.

other uncommon species such as Neisseria gonorrhoeae, mycoplasmas etc

pneumonia etc. Viral infections are important as a primary viral infection such as chicken pox may b complicated by a secondary bacterial (variclla pneuminia) infection causing influenza SIGNS AND SYMPTOMS
Sudden onset of symptoms and rapid illness progression are associated with bacterial pneumonias. Chest pain, dyspnea, hemoptysis (when clearly delineated from hematemesis), decreased exercise tolerance, and abdominal pain from pleuritis

The infections are milder then influenza and are self limiting and require no antiviral therapy, antibacterial drugs are not effective. Symptoms are cough, sore throat, runny nose, and nasal congestion; sometimes this may be accompanied by conjunctivitis (pink eye), muscle aches, fatigue, headaches, shivering, and loss of appetite. Fever is often present thus creating a symptom picture which overlaps with influenza. The symptoms of influenza however are usually more severe.

The presenting complains are hoarseness of voice, sore throat, difficulty in swallowing, usually, but not always, accompanied by runny nose. There is a marked inflammation of phyranx with whitish exudate on tonsils, plus large tender cervical nodes. May also be accompanied by sinusitis or otitis. Fever is rare and low grade fever occurs in case of less common bacterial infection.

Slow developing infection Typical symptoms of pulmonary TB include a productive cough with pink colored sputum, fever, and weight loss. Patients with pulmonary TB occasionally present with hemoptysis or chest pain. Other systemic symptoms include anorexia, fatigue, and night sweats. Fever is low grade fever and occurs in episodes i.e. not persistent.

Hyperthermia (fever, typically

>38C) or hypothermia (< 35C) Tachypnea (>18 respirations/min) Use of accessory respiratory muscles Tachycardia (>100 bpm) or bradycardia (< 60 bpm) Central cyanosis Altered mental status

DIAGNOSTIC TEST Blood testing for virus specific bodies may be performed for confirmation, Swab test for culturing causative bacteria, If negative, go for non specific monospot test of atypical lymphocytes or
Bronchoalveolar lavage fluid can be used for culture analysis. Sputum Gram stain and culture should be performed before initiating antibiotic therapy A single predominant microbe should be noted at Gram staining, although mixed flora may be observed with anaerobic infections. Chest radiography is considered the criterion standard for diagnosing the presence of pneumonia: The presence of an infiltrate is required for the diagnosis.

Tuberculin reaction test (Heaf test and Mantoux test) Chest radiography Microbial confirmation via sputum culture. PCR characterization.

specific tests for antibodies to EBV

TREATMENT:
There is currently no known treatment that shortens the duration; however, symptoms usually resolve spontaneously in 7 to 10 days, with some symptoms possibly lasting for up to three weeks. There are currently no medications or herbal remedies which have been conclusively demonstrated to shorten the duration of infection in all people with cold symptoms. Treatment comprises symptomatic support usually via analgesics for fever, headache, sore muscles, and sore throat. Usually antiviral drugs are not prescribed. Panadol CF: contain (Pseudoephedrine (HCl):60mg, Chlorpheniramine (Maleate):4mg, Paracetamol:500mg),2 tablets, B.I.D.

COUNSELLING:
Prevention: Regular hand washing is recommended to reduce transmission of cold viruses and other pathogens via direct contact. Take steam and vicks massage on chest and back for symptomatic relief. Drink hot tea etc, it provides a soothing effect to the throat.

MALARIA
DEFINITION:
Malaria is an acute infectious disease caused by four species of the protozoal genus Plasmodium. The parasite is transmitted to humans through the bite of a female Anopheles mosquito, which thrives in humid, swampy areas.

ETIOLOGY:
Malaria could be caused by any one of four plasmodium sp. 1. 2. 3. 4. Plasmodium falciparum Plasmodium vivax Plasmodium ovale Plasmodium malariae

EPIDEMIOLOGY:
According to a survey 5 million people around the world are attacked by malaria each year and in developing countries it is one of the leading cause of death. In Pakistan its prevalence is quite high and a latest survey estimated its percentage in provinces to be: Punjab 21% , Sindh 36% , Baluchistan and Khaber pakhtoon khwa 43%.

SIGNS AND SYMPTOMS:

The symptoms characteristic of malaria include; Flulike illness with fever, chills, cycles of chills, fever, and sweating that repeat every one, two, or three days are typical. Muscle aches, and headache. Some patients develop nausea, vomiting, cough, diarrhea, yellowing (jaundice) of the skin and whites of the eyes due to destruction of red blood cells and liver cells. Fever pattern associated with malaria caused by P. falciparum can have recurrent fever (up to 105 F)every 3648 hours.

DIFFIRENTIAL DIAGNOSIS:
MALARIA Its a flu like illness with muscle aches. In most cases, nausea vomiting diarrhea may b observed. TYPHOID FEVER Patient has; Poor appetite, abdominal pain, headache and generalized aches. DENGUE FEVER
Headache is usually generalized. Nausea and vomiting. Patients typically describe a maculopapular or macular confluent rash

UTI Common symptoms include frequent urge to urinate even when urine volume is small, a painful or burning

SIGN AND SYMPTOMS

Often intestinal bleeding and perforation may occur after 2-3 weeks of disease, leading to brownish red blood in stools.

over the face, thorax, and flexor surfaces, with islands of skin sparing. Hemorrhagic manifestations may range from small amounts of bleeding from the nose or gums to melena, menorrhagia, or hematemesis. Patients report fatigue and malaise. Patients may report conjunctival injection, sore throat, and cough. Abdominal pain is reported.

sensation during urination, and cloudy or reddish born urine.

The fever is usually high grade fever, upto 105 F. Paroxysm of fever, shaking chills, and sweats (every 48 or 72 h, depending on species) The classic paroxysm begins with a period of shivering and chills, which lasts for approximately 1-2 hours and is followed by a high fever. Finally, the patient experiences excessive diaphoresis, and the body temperature of the patient drops to normal or below normal. Many patients, particularly early in infection, do not present the classic paroxysm but may have several small fever spikes a day. Immunochromatographi c Test (Antigen Test, Rapid Diagnostic Test) Blood Films

FEVER PATTERN Fever in persons with The patient has a persistent high grade symptomatic dengue fever upto 104 F. it is fever may be as high as a 4 stage disease with 41C. The fever typically begins on the fever having a step third day and lasts 5-7 ladder type pattern. days, abating with the Disease duration is cessation of viremia. upto 6 weeks with Fever is often preceded initial incubation by chills, erythematous period upto 2 weeks mottling of the skin, and followed by 4 weeks facial flushing (a sensitive and specific of active disease.

Fever is common in children with UTI infections, however adults manifest fever only if the infection is severe and has progressed to kidneys. Fever is persistent low grade fever. 99 to 101 F.

indicator of dengue fever). Occasionally, and more commonly in children, the fever abates for a day and then returns, a pattern that has been called saddleback fever.

DIAGNOSTIC TESTS
Blood, stool culture tests Specific test is Widal test A positive result from the tourniquet test Petechiae, ecchymoses, or purpura Bleeding from the mucosa, gastrointestinal tract, injection sites, or other sites Hematemesis or melena and thrombocytopenia (< OTC dipstick test Urine culture test Urinalysis ( examined for presence of WBCs and urine proteins)

Blood CP (reveals decreased RBCs e.g Anemia)

Assay kits are available

for identification of plasmodium sp. that caused malaria

100,000 cells/L)

TREATMENT:
World Health Organisation (WHO) has given the standard treatment guidelines regarding Malaria therapy.

DRUG THERAPY:
Chloroquine: Drug of choice (for p.vivax). Strength is prescribed on the base of body weight usually 150-500 mg is initial dose strength. Dosage form: Tablet Dose: 4(stat) +2+1+1. Frequency: Weekly (for 4 weeks approximately). Sulphadoxin: usually in combination with Pyrimethamine (500mg : 25mg). Recommended for prophylaxis for p.falciparum infection. Dosage form: Tablet Dose: 3 (stat) Frequency: Initially when symptoms become relevant and pre diagnosis stage. Artemether+Lumefantrine: Recommended in the areas with higher prevalence rate of Chloroquin-resistant p.falciparum malaria. Strength: Available in two strengths.(80mg:480mg) and (40mg:240mg) Dosage form: Tablet Dose: 2+2+2+2 Frequency: B.I.D ( For 4 days) Quinine: It is 3rd drug of choice for p.falciparum and usually not preferred because of severity of its side effects i.e Cinchonism ( a condition that presents the symptoms like tinnitus, nausea, dizziness, flushing and visual disturbances), auditory abnormalities, angioedema, hematological abnormalities, and Black water fever. A daily dose of 325 mg is effective but not recommended for chemoprophylaxis and usually is preferred when there is no other choice to improve patients condition. Atovaquone+Proguanil: Areas with Chloroquin-resistant p.falciparum infection could have this combination as a better choice. Strength:Atovaquone 250mg:Proguanil 100mg ( Brand: Malarone)

Dosage form: Tablet Dose: 1 tablet Frequency : Daily ( for 3 weeks)

COUNSELLING:
Patient should be informed with the following important points: Mosquitoes that transmit malaria breed in stagnant water. Draining the stagnant water and building houses at least 2 Km away from water sources, such as rivers and lakes reduces mosquitoes and their contact with people respectively. Malaria is best prevented by sleeping under LLINs (Long lasting insecticidal mosquito nets) every night to avoid mosquito bites. Anopheles mosquitoes generally bite in evenings. Malaria is also prevented by spraying of internal walls of houses with residual insecticides particularly in epidemic prone areas.

FEVER
DEFINITION:
Fever (also known as pyrexia) is a common medical sign characterized by an elevation of temperature above the normal range of 36.537.5 C (98100 F) due to an increase in the body temperature regulatory set-point.

ETIOLOGY:
Fever is a common symptom of many medical conditions: Viral or Bacterial infection. Various skin inflammations i.e boils and abcesses Immunolgical disorders i.e inflammatory bowel disease, Kawasaki disease Tissue destruction, which can occur in hemolysis, surgery, infarction, crush syndrome, rhabdomyolysis, cerebral hemorrhage, etc. Reaction to incompatible blood products Cancers, most commonly kidney cancer and leukemia and lymphomas Metabolic disorders, e.g., gout or porphyria Thrombo-embolic processes, e.g., pulmonary embolism or deep venous thrombosis.

EPIDEMIOLOGY:
Fever being one of the most common symptoms of many diseases experienced by each person in life however, etiology and pattern could vary according to underlying cause.

SIGNS AND SYMPTOMS:

A fever is usually accompanied by sickness behavior, which consists of lethargy, depression, anorexia, sleepiness, hyperalgesia, and the inability to concentrate.

DIAGNOSIS:
Fever can be diagnosed empirically by checking body temperature with physical examination or by use of thermometer. A wide range for normal temperatures has been found. Fever is generally agreed to be present if the elevated temperature is caused by a raised set point and: Temperature in the anus (rectum/rectal) is at or over 37.538.3 C (99.5 100.9 F) Temperature in the mouth (oral) is at or over 37.7 C (99.9 F)

Temperature under the arm (axillary) or in the ear (otic) is at or over 37.2 C (99.0 F)

In healthy adult men and women, the range of normal, healthy temperatures for oral temperature is 33.238.2 C (91.8100.8 F), for rectal it is 34.437.8 C (93.9100 F), for tympanic membrane (the ear drum) it is 35.437.8 C (95.7100 F), and for axillary (the armpit) it is 35.537.0 C (95.998.6 F).

DIFFIRENTIAL DIAGNOSIS:
MALARIA
The fever is usually high grade fever, upto 105 F. Paroxysm of fever, shaking chills, and sweats (every 48 or 72 h, depending on species) The classic paroxysm begins with a period of shivering and chills, which lasts for approximately 1-2 hours and is followed by a high fever. Finally, the patient experiences excessive diaphoresis, and the body temperature of the patient drops to normal or below normal. Many patients, particularly early in infection, do not present the classic paroxysm but may have several small fever spikes a day.

TYPHOID The patient has a persistent high grade fever upto 104 F. it is a 4 stage disease with fever having a step ladder type pattern. Disease duration is upto 6 weeks with initial incubation period upto 2 weeks followed by 4 weeks of active disease.

DENGUE Fever in persons with symptomatic dengue fever may be as high as 41C. The fever typically begins on the third day and lasts 5-7 days, abating with the cessation of viremia. Fever is often preceded by chills, erythematous mottling of the skin, and facial flushing (a sensitive and specific indicator of dengue fever). Occasionally, and more commonly in children, the fever abates for a day and then returns, a pattern that has been called saddleback fever.

UTI Fever is common in children with UTI infections, however adults manifest fever only if the infection is severe and has progressed to kidneys. Fever is persistent low grade fever. 99 to 101 F.

TREATMENT:
Paracetamol ( Acetoaminophen): Dosage form:Tablet, suspension. Dose strength: 500mg (tablet) 120mg/5ml (suspension) Dose: 2+2+2 (tablets), 2+2+2 (tablespoon suspension) Frequency: T.I.D

COUNSELLING:
Patient or his/her attendants should be counseled about following points: Take rest. Adhere to prescribed regimen.

In case of high grade fevers Reduce body temperature with conventional methods i.e. cold sponging, bath, and refer to a physician.

CONSTIPATION
DEFINITION:
It Refers to Bowel movements that are infrequent and/or hard to pass.

EPIDEMIOLOGY:
It is the most common digestive Complaint in the US as per survey. It occurs in 2% to 20% of population. It is more common in women the elderly and Children. The reason it occurs more frequently in the elderly is felt to be an increasing number of health problems as human eye & decreased physical activity.

SIGN & SYMPTOMS:

Abdominal pain Abdominal Cramp Difficulty in defecation

ETIOLOGY:
Low Fiber Diet Lack of Physical activity Less intake of water Drugs : 1. Narcotic pain medications such as codeine (for example, Tylenol #3),
oxycodone (for example, Percocet), and hydromorphone (Dilaudid);

2. Antidepressants such as amitriptyline (Elavil) and imipramine (Tofranil) 3. Anticonvulsants such as phenytoin (Dilantin) and carbamazepine (Tegretol)
4. Iron supplements

5. Calcium channel blocking drugs such as diltiazem (Cardizem) and nifedipine

(Procardia)

6. Aluminum-containing antacids such as Amphojel and Basaljel

DIAGNOSIS:
Colonoscopy Anorectal manometry ( measure the co-ordination of the muscle you use to move your Bowels) Scintigraphy (Measure the rate at which material travels through GIT)

DIFFIRENTIAL DIAGNOSIS:
Constipation can be caused by several different factors. To aid diagnosis, effective questioning is required to help determine one of following cause:

CAUSE Poor diet Irritable bowel syndrome Poor bowel habit Laxative abuse Travel Hormone disturbances Pregnancy Fissures and hemorrhoids Underlying diseases Nerve damage Medications

COMMENT
Diets high in animal fats e.g. meats, dairy products, eggs, and refined sugar, e.g. sweets, but low in fiber predispose constipation Spasm of colon delays transit of intestinal contents. Patients have a history of alternating constipation and diarrhea Ignoring and suppressing the urge to have a bowel movement will contribute to constipation Habitual consumption of laxatives necessitates increase in dose over time until intestine becomes atonic and unable to function without laxative stimulation Changes in lifestyle, daily routine, diet and drinking water may all contribute to constipation e.g. hypothyroidism , diabetes,

Mechanical pressure of womb on intestine and hormonal changes e.g. high levels of progesterone. Painful disorder of the anus often leads patients to suppress defecation, leading to constipation.

Such as scleradema, lupus, multiple sclerosis, depression, Parkinsons disease etc Spinal cord injuries and tumors pressing on the spinal cord affect nerves that lead to inestine. Alpha blockers, antacids, anticholenergics, antidepressants, antiemetics, antiepiliptics, antidiarrheal, beta blockers, CNS stimulants, calcium channel blockers, dopamenergic, growth

hormone antagonists, immunosuppressants, lipid lowering drugs, iron, metabolic disorders, muscle relaxant, NSAID, smoking cessation, opiod analgesics, proton pump inhibitors etc

Immobility Electrolyte imbalances

Prolonged bed rest, or general lack of exercise. Hypocalcaemia, hypokalemia

TREATMENT:
1 teaspoon Castor oil B.i.D ( In children) Olive oil in Milk Antacid : Milk of magnesia , Mucaine (lexative ) Syrup 5mL T.i.D Lilac (lactose) Syrup 5mL T.i.d Ispaghol in warm water

COUNSELING:
Intake of Fiber (either dietary or as supplements) Increased intake of water 2 bananas daily Increase physical activity exercise etc Increae intake of juice & fruits

HYPOGLYCEMIA
DEFINITION:
Hypoglycaemia is the condition when body's blood sugar level is abnormally low (below 70md/dL). The term insulin shock is used to describe severe hypoglycaemia that result in unconsciousness.

EPIDEMIOLOGY:
29.3% is the prevalence rate in Pakistan. Type II diabetic patient who are using oral hypoglycaemic agents are more prone toward hyperglycemias.

PATHOGENESIS:
Hepatic glucose output fall due to

Inhibition of hepatic glycogenolysis & gluconeogenesis by insulin Impaired gluconeogeneis (e.g following alcohol ingestion) Depletion of hepatic glycogen Malnutrition Fasting Exercise Advanced liver disease

Glucagon is ineffective

Glycogen is not broken down & release in blood stream

Hypoglycaemia

CAUSATIVE AGENT:
Administration of excessive insulin Ingestion of alcohol Liver disease Delayed meal or skipped a meal Hormonal deficiency (e.g. glucagon, cortisol) , insulinoma (insulin-secreting tumour)

SIGN & SYMPTOMS:

Fatigue Weakness Nervousness Sweating Headache Anxiety Mental confusion Insomnia

DIAGNOSIS:
Blood glucose test by glucometer

DIFFERENTIAL DIAGNOSIS:
Many physicians may fail to recognize hypoglycaemia in affected patients, either initially or over the long term. Clinical symptoms of hypoglycaemia may be subtle or overt, but they are not specific to hypoglycaemia and are frequently attributed to other disorders. This is particularly true if the patient has had another neurologic insult, such as head trauma or hypoxia. Plasma glucose levels should be tested in any patient who presents with neurologic deficits at the time the deficits are present. This may prevent prolonged, inappropriate, ineffective anticonvulsant therapy in children who initially present with seizures. Failure to recognize hypoglycaemia can lead to permanent impairments or death if the condition is not treated. Hypoglycaemia has been reported in individuals who were thought to be comatose secondary to head trauma. Conditions to consider in the differential diagnosis of hypoglycemia include the following: Addison disease: Addison's disease is a disorder that occurs when the adrenal glands do not produce enough of their hormones. The adrenal glands are small hormonesecreting organs located on top of each kidney. They consist of the outer portion

(called the cortex) and the inner portion (called the medulla).The cortex produces three types of hormones: The glucocorticoid hormones (such as cortisol) maintain sugar (glucose) control, decrease (suppress) immune response, , and help the body respond to stress. The mineralocorticoid hormones (such as aldosterone) regulate sodium and potassium balance. The sex hormones, androgens (male) and estrogens (female), affect sexual development and sex drive. Adrenal crisis: Acute adrenal crisis is a life-threatening condition that occurs when there is not enough cortisol, a hormone produced by the adrenal glands. Adrenal crisis occurs when the adrenal gland is damaged (Addison disease primary adrenal insufficiency), the pituitary gland is injured (secondary adrenal insufficiency) , adrenal insufficiency is not properly treated. Symptom include abdominal pain , confusion, dizziness, fatigue, weakness, chills, vomiting, weight loss. Epilepsy: It is a chronic disorder of cerebral function. Causes are hypoxia, genetic metabolic defects, developmental brain defects, vit B6 deficiency etc. Symptoms include seizures, light flashes, tingling, sweating, buzzing, flushing etc. It usually occurs at night time & patient normalizes after 15-20 min. BP & Pulse rate normal.

TREAMENT:
If patient is conscious: 1 -2 table spoon of table sugar 3-4 glucose tablets 1/2 cup or 4 ounces of any fruit juice 1 cup or 8 ounces of milk 5-6 pieces of hard candy If patient is unconscious: Dextrose infusion Glucose 20-50mL of 50% glucose solution by IV infusion over a period of 2-3 minutes Glucagon 1mg S/C or I/M

If hypoglycaemia is because of insulinoma then surgery to remove the tumour is the best treatment.

COUNSELING:
Take proper meals that small meals after short time intervals. Do not skip or delay a meal. Correctly measure her daily insulin dose.

Take additional snacks if any physical activity is done. Always place some sweet thing so that glucose level not fluctuates. Take daily 5 portions of fruits and vegetables. Administer insulin half an hour before meal.

THROAT INFECTION
A sore throat or throat infection (also known as pharyngitis ortonsilitis) is a symptom of a disease affecting the pharynx or the area around the tonsils. It can be the result of an infection by a virus or bacteria.

EPIDEMIOLOGY:
Age group (5 to 15) has the peak incidence of strep throat infection. In adults, 5% to 10% of cases of pharyngitis are estimated to be caused by strep bacteria. Some reports suggest that over 600 million cases of strep throat occur annually worldwide.

PATHOGENESIS:
Virus

Mucosal cell lining of nasopharynx

Replicate in the cells

Pharyngitis

CAUSATIVE AGENT:
Viruses are the most common cause of throat infection in children and in adults. Many types of viruses are known to cause throat infection, and their symptoms may be difficult to distinguish from those of a bacterial infection. E.g. rhinovirus, picornavirus. Bacterial causes of throat infections (tonsillopharyngitis) require further attention from individuals (and their parents or caregiver if the sick person is a child) and physicians. Streptococcus, or strep, is the most frequently found bacterial cause of sore throat. Streptococcus pyogenes, . Mycoplasma, Neisseria, Corynebacterium, are the important bacteria among streptococcus family to cause throat infection.

SIGN & SYMPTOMS

Discomfort, pain, scratchiness, swelling in throat or tonsils, difficulty and/pain while swallowing, difficulty speaking, yellow or white coating on the tonsils, redness of tonsils or throat, fever, swollen lymph glands in the neck, red, swollen soft palate ,bad breath, cough, headache, poor appetite, yellow or white spots on tonsils.

Some of the general and constitutional symptoms of strep throat infection may vary quite a bit depending on the patient's age.

Infants primarily experience a thick "colorful" (yellow or green) drainage from the nose and possibly a low-grade fever, with fussiness, irritability, and a decrease in appetite. Children aged one to three ("toddlers") may complain of a sore throat, trouble swallowing, poor appetite, crankiness, and swollen glands (lymph nodes) beneath the jaws. Older children and adolescents generally look and feel awful with strep throat. They can have high fevers, very painful throats, often severe difficulty swallowing, and pus, which can sometimes be seen covering the tonsils.

DIAGNOSIS:
Throat culture Rapid strep tests (also called the Rapid Antigen Detection Test or (RADT) are available that can give result in minutes. Blood test for strep throat infection

DIFFERENTIAL DIAGNOSIS:
On the basis of sign and symptom we can differentiate between viral and bacterial throat infection:

Bacterial High grade fever Productive cough (sputum color is green) Severe infection Treatment by anti-biotic Wheezing sounds No hoarseness of voice Typically occur in the winter months months.

Viral Low grade fever Dry cough Mild infection Self limiting No wheezing sounds Hoarseness of voice Usually occur in non-winter

COMMON COLD AND COUGH: It is causedby rhinovirus, picornavirus, coronavirus, influenza & human parainfluenza viruses, human respiratory syncytial virus, adenoviruses, enteroviruses, and metapneumovirus. The infections are milder then
influenza and are self limiting and require no antiviral therapy, antibacterial drugs are not effective. Symptoms are cough, sore throat, runny nose, and nasal congestion; sometimes this may be accompanied by conjunctivitis (pink eye), muscle aches, fatigue, headaches, shivering, and loss of appetite. Fever is often present thus creating a symptom picture which overlaps with influenza. The symptoms of influenza however are usually more severe. Blood testing for

virus specific bodies may be performed for confirmation. PHYRANGYTIS/ TONSILITIS: The cause is usually viral, e.g Epstein barr virus (90% of cases) or bacterial e.g S.pyogenes besides other uncommon species such as Neisseria gonorrhoeae, mycoplasmas etc. The presenting complains are hoarseness of voice, sore throat, difficulty in swallowing, usually, but not always, accompanied by runny nose.there is a marked inflammation of pyranx with whitish exudate on onsils, plus large tender cervical nodes. May also be accompanied by sinusitis or otitis. Fever is rare and low grade fever occurs in case of less common bacterial infection. Swab test for culturing causative bacteria. If negative, go for non specific monospot test of atypical lymphocytes or specific tests for antibodies to EBV

TREATMENT:
Empirical therapy: Gargle of warm Salty water Lozenges to smoothen throat

Amoxil 500mb 1 tab t.i.d

And recommended for the culture test to accurately diagnosed bacterial or viral infection. Definitive therapy: If culture test is positive then bacterial infection. Amoxil (clavulanic acid and amoxicillin) 500mb 1 tab t.i.d if not treated then Cephalosporins Azomycin (azithromycin) 250mg BID or 500 mg O.D for 3-5 days. Viral infection : Self limiting after 5-7 days

For prophylactic treatment for ones further.

Gargles of Aspirin. Panadol or Ibuprofen for lowering fever. Lozenges for curing sore throat & for soothing effect

COUNSELING:
Azithromycin: Take empty stomach 1 hour before or 2 hours after a meal. The adult dose is 500-2000 mg in multiple or single doses. Take once daily for 5 days. Gargling with warm salt water can help relieve a sore throat. Using throat lozenges every couple of hours can help relieve sore throat and cough

DIARRHEA
DEFINITION:
Diarrhea can be described as an abnormal increase in the frequency, volume or liquidity of stools. The condition usually lasts a few hours to a couple of days. Diarrhea is typically associated with abdominal cramps Broadly classified in to: ACUTE DIARRHEA Acute diarrhea Sudden onset in a previously healthy person Lasts from 3 days to 2 weeks Self-limiting Resolves without sequel CHRONIC DIARRHEA Chronic diarrhea Lasts for more than 3 weeks Associated with recurring passage of diarrheal stools, fever, and loss of appetite, nausea, vomiting, weight loss, and chronic weakness. May be a sign of an underlying disease, i.e. Inflammatory Bowel Syndrome, Chrohns disease etc.

ETIOLOGY:
ACUTE DIARRHEA CHRONIC DIARRHEA

 Bacterial (Salmonella, shigella, campylobacter, clostridium, E. coli) Viral (Rotavirus, Influenza, Hepatitis A, Drug induced (Cholinergics, Prokinetics, Prostaglandins, Histamine agonists etc.) Nutritional Protozoal

Tumors Diabetes Addisons disease Hyperthyroidism Irritable bowel syndrome

EPIDEMIOLOGY:
In epidemiologic study, 961 (51%) had diarrhea in PAKISTAN .The prevalence of diarrhea was marginally higher among girls than boys (53% versus 49%, odds ratio 1.18, 95% Cl 0.98, 1.41).

SYMPTOMS:
Frequent loose or watery stools, mild, cramping abdominal pain, abdominal distress, and overactive bowl sounds, low grade fever.

DIAGNOSIS:
Carry out examination of a small volume of stool under microscope. If antibiotics are taken within previous 2 weeks, stools should be tested for toxins of C.difficle. There are also immunological tests that can be performed. Chronic diarrhea may require Xray of intestine or endoscopy with biopsies. Fat malabsorption can be diagnosed by measuring fat in a 72h Collection of stools. Hydrogen breath tests may also be carried out, depending on suspected cause.

DIFFRENTIAL DIAGNOSIS:
FOOD POISONING CHOLERA DYSENTRY IRRRITANT BOWL SYNDROME

Causes: Botulism (clostridium botulinum) Campylobacter enteritis Cholera E. coli Fish poisoning Shigella Salmonella listeria

Causes: bacterium (Vibrio cholera)

Causes: Bacterial infections (shigella, Campylobacter, E.coli, Salmonella) Intestinal amoebiasis protozoans parasite (entamoeba histolytica) Symptoms: sever diarrhea with mucus or blood in feces fever abdominal pain

Causes: Exact cause is unknown.it is suspected that a disturbance in the serotonin levels of GIT leads to IBS

Symptoms: Symptoms: Acute onset: 2-6 profuse painless hours diarrhea Delayed onset: 24-72 vomiting of hours (after ingestion clear fluid of contaminated food) fishy odor of Abdominal feces cramps hypotension Diarrhea( may dehydration be bloody) Fever and chills Headache Nausea and vomiting weakness Diagnosis: Diagnosis: Culture test on Dip stick test blood, stools, Stool and swab vomit samples are the most useful specimens for laboratory diagnosis

Symptoms: chronic diarrhea alternating with constipation chronic abdominal pain

Diagnosis: Culture of stool Microscopy of stool

Diagnosis: Diagnosed on the basis of medical historywith complete description of symptoms Physical examination No specific test for IBS exists

TRAVELER'S DIARRHEA

Cause: Travelers diarrhea has been defined as the passage of at least three unformed stools in a 24-hour period during travel or during the first seven to ten days after returning home. Symptoms: Associated symptoms may include nausea, vomiting, abdominal pain, fecal urgency, tenesmus, and bloody or mucoid stools. Individuals at highest risk include young children, adults ages 15-29 years, and those with high gastric pH (achlorhydria, postgastrectomy, and proton-pump inhibitor use).

TREATMENT:
1. The first objective is to rehydrate the patient by administering ORS and if required, with IV fluids. 2. Administer antimotility agents such as Bismuth subsalicylate 44 mg every 4 hours if chronic Loperamide 4 mg (2 capsules) as a first dose, followed by 2 mg (1 capsule) after each unformed stool for symptomatic relief. 3. Administer metronidazole 400mg, 1tab BiD.

COUNSELING:
1. Antimicrobial therapy is not usually indicated in children. 2. Loperamide is not recommended for use in children < 2 years. Significant abdominal pain suggests inflammatory diarrhea (this is a contraindication for loperamide use). 3. In children who are in hemodynamic shock or with abdominal ileus, oral rehydration therapy may be contraindicated 4. Metronidazole is contraindicated with alcohol, phenytoin, phenolbarbitol, busulfan, disulfiram, & anti-coagulants. 5. Patients should be advised not to take alcohol, (or drugs containing alcohol) during Metronidazole therapy and for at least 48 hours afterwards because of a disulfiram like (antabuse effect) reaction (flushing, vomiting, tachycardia). 6. Phenytoin or Phenobarbital: increased elimination of metronidazole resulting in reduced plasma levels. A similar effect may occur with other drugs which induce hepatic microsomal enzymes. 7. Busulfan: Plasma levels of busulfan may be increased by metronidazole, which may lead to severe busulfan toxicity. 8. Disulfiram: psychotic reactions have been reported in patients who were using metronidazole and disulfiram concurrently. 9. Potentiation of the anticoagulant effect and increased hemorrhagic risk caused by decreased hepatic catabolism. In case of coadministration, prothrombin time should be more frequently monitored and anticoagulant therapy adjusted during treatment with metronidazole.

Cases

Includes cases on:

Angina Common cold and cough Constipation Diarrhea Edema Fever Hypertension Hypoglycemia Malaria Migraine Mouth ulcer Piles Throat infection Urinary tract infection Warts

PAIN
Abdominal pain Backache Earache Eye pain Headache Jaw pain Muscle pain Neck stiffness Toothache

Urinary Tract Infection

A boy aged 2 is admitted to hospital with vomiting and abdominal pain. His mother reports that he was treated for urinary

tract infection 6months previously, but was not investigated further at the time. A clean catch urine sample shows over 50 white cells/mm3 and bacteria are seen on microscopy. What action should be taken?
Presenting complaint: a 2 year old boy presenting with vomiting and abdominal pain, Past medical history: he was treated for UTI 6months previously, but was not investigated further at the time. Diagnostic tests: a clean catch urine sample shows over 50 white cells/mm3 and bacteria are seen on microscopy. Differential diagnosis: the patient has a past medical history of UTI which was not investigated and now when the urine sample was investigated a high WCC was observed, along with vomiting and abdominal pain, which makes a significant diagnosis of a relapse or recurrent UTI (acute pyelonephritis). Treatment: cefuroxime 1.5g/8h I.V.

Urinary Tract Infection

An elderly lady is catheterized because of incontinence. She is afebrile but has been confused since her hip replacement 5days earlier, and remains on cefuroxime, which was started as prophylaxis at time of operation. The urine in her catheter bag is cloudy, and has a high white cell count.
Presenting complaint: an elderly lady catheterized because of incontinence. She is afebrile but has been confused. History of presenting complaint: complaining since her hip replacement 5days earlier. Medications: remains on cefuroxime, which was started as prophylaxis at time of operation. Findings: cloudy urine with high WCC and urinary incontinence. Differential diagnosis: Cloudy urine: vaginal discharge, STDs, dehydration, infections and inflammation of urinary tract. High WCC: infection Urinary incontinence: constipation, bladder irritation aging, UTI, B.P. medication Diagnosis: cloudy urine, high WCC and incontinence are significant signs of UTI. Treatment: sulfamethoxazole-trimethoprim 800/160mg 12hourly for 14days.

Urinary Tract Infection

A patient comes to you who is having irritation in urethra and burning urination. He is also having abdominal pain from the last two days along with the fore mentioned symptoms. He is not showing hyperthermia and is apparently in good health. He is asking the treatment for his condition.

SIGNS AND SYMPTOMS: irritation in urethra burning urination abdominal pain DIFFRENTIAL DIAGNOSIS: Although the patient is showing abdominal pain but as he is afebrile so the possibility of typhoid fever has been out ruled His symptoms indicate him to be suffering from urinary tract infection. TREATMENT: Antibiotic therapy: for 7-10 days Amoxicillin 250-500 mg. three times a day (shows resistance to E.coli) Ciprofloxacin 250-500 mg. three times a day (reserve for severe cases) Urine alkalinizing agents: Sodium citrate but along with antibiotics not alone Fluid intake: Fluid intake should be enhanced. C condition; urinary tract infection O objective; pharmacological treatment of urinary tract infection R regimen; Antibiotic therapy/ Fluid intake E evaluation; by follow up and identification of cause

MALARIA
A male person X is planning to visit his seriously ill mother in inner Sindh with high prevalence of malaria along with his 16weeks

pregnant wife and 4years old daughter. What prophylactic medication for malaria should be given to each member of family? Malaria prophylaxis Person Drug + dose
Mr. X Pregnant wife Daughter mefloquine 250mg/week proguanil 200mg/24hours PO + folate supplement mefloquine 125mg/ week

MALARIA
A 29year old male student, presents to ED with complaints of malaise, myalgia, headache, fever and chills. How will you diagnose and treat his problem?
Presenting complaint: 29year old male complaining of malaise, myalgia, headache, fever and chills, Diagnosis: the presenting complaints of the patient suggest that hes suffering from malaria. Treatment: artemether + lumefantrine 20mg/ 120mg a 6-dose regimen over a 3-day period given twice a day for 3 days.

FEVER

A 3year old child is suffering from chickenpox and fever. How fever should be treated and what are the possible complications associated with antipyretic use in patients with chickenpox?
Presenting complaint: 3years old child suffering from fever and chickenpox, Treatment for fever: acetaminophen Tylenol suspension liquid 160mg/ 5ml, 1tsp, tds Possible complications associated: dont give anyone with chickenpox-child or adult- any medicine containing aspirin because this combination has been associated with a condition called Reyes syndrome.

COUGH

A 12year girl is suffering from productive cough. How her cough should be treated?
Presenting complaint: 12year old girl complaining of productive cough, Treatment: a productive cough may be caused by an illness that requires no treatment and will usually go away by itself, like the common cold or flu. It is best not to suppress a cough that brings up mucus because coughing helps remove irritants from your lungs and air passages, so in this case expectorants are useful. Vick 44E (detromethorphan + guaifenesin), 2tsp/ 4hours

COUGH
A 50years old hypertensive male taking Ascard, Capoten, Lipiget is suffering from cough. How will you treat him?
Presenting complaint: 50years old hypertensive male, suffering from cough, Medication history: taking ascard, capoten, lipiget Diagnosis: as the patient is taking capoten; an ACEi, he will definitely suffer from cough. Treatment: replace capoten with Ca channel blocker to get rid of cough. Norvasc (amlodipine) 10mg O.D

DIARRHEA

A 7 year old boy in a previous good health was admitted to hospital with bloody diarrhea &dehydration 4 days after attending a childrens birthday party. He was treated with intravenous fluids &given nothing by mouth. On 5th day his diarrhea seemed to b improving but patient presented to be hypertensive & an emergency laboratory report revealed, hyponatremia & hyperkalemia.
1. What is the likely diagnosis in this child? 2. What specific therapy is required? HISTORY: Bloody diarrhea and dehydration after 4 days of attending a party. Treated with I.V fluid. On 5th day diarrhea seemed to be improving but patient presented to be hypertensive and an emergency laboratory report revealed, hyponatremia and hyperkalemia.

1 .DIFFERENTIAL DIAGNOSIS:
Irritable bowel syndrome Irritable bowel syndrome (IBS) is one of the most common causes of chronic diarrhea. IBS can cause crampy abdominal pain and changes in bowel habits (diarrhea, constipation, or both). IBS can develop after having an infection. Inflammatory bowel disease there are several types of inflammatory bowel disease, two of the most common of which are Crohn's disease and ulcerative colitis. These conditions may develop when the body's immune system attacks parts of the digestive tract. Infections Intestinal infections are a cause of chronic diarrhea. Infections that cause chronic diarrhea can be seen in people who travel or live in tropical or developing countries. Intestinal infections can also develop after eating contaminated food or drinking contaminated water or unpasteurized ("raw") milk. E.coli associated food poisoning can also have diarrhea as a major symptom which begins 12-18 hours after intake of contaminated food. Food allergy or sensitivity Food allergies and hypersensitivity can cause chronic diarrhea. People with celiac disease often have diarrhea and weight loss. Medicines Medicines (prescription and nonprescription), herbs, and dietary supplements can cause diarrhea as a side effect. To determine if a medicine could be the cause of your diarrhea, review your list of medicines with your doctor, nurse, or pharmacist. This information may also be available on the medicine bottle or paperwork that comes with most prescriptions.

DIAGNOSIS: Our patient is not suffering with chronic diarrhea because his condition began to improve after rehydration therapy .Furthermore; he has not being reported with the complaints that could lead to diagnose IBS or IBD. So, patient might be suffering with some sort of food allergy by eating an unsuitable food item or drinking contaminated water. Hypertension could be a complication due to excessive

fluid loss and electrolytes imbalance because his laboratory report revealed hyponatremia and hyperkalemia and both these factors indicate hypertension.

2. SPECIFIC THERAPY:
REHYDRATION THERAPY: In most of the fluid loss disorders rehydration therapy is 1st line of treatment, in this case we will also recommend our patient to take ORS frequently until his condition markedly began to improve. Antidiarrhea medicines, such as loperamide; 2mg tablet, T.I.D (sold as Imodium, available without a prescription) or prescription medicines, such as diphenoxylate (Lomotil) can be suggested. Antibiotic therapy should not be started until stool culture tests are not conducted but for general management of diarrhea Metronidazole (Flagyl) 400mg,b.d and Ciprofloxacin 500mg b.d are in common practice.

PILES

Mr.X is a busy 45 years old executive who works for a large multinational company. He has noted blood in his stools over the past 2 weeks & for a 3 days has had continuous abdominal discomfort .He has discussed his symptoms with his wife & suspect hemorrhoids are the cause, Mr X is going on business in 6 days &seeks your advice on a suitable treatment. 1. How will you differently diagnose hemorrhoids? 2. What advice should be given to Mr X?
HISTORY: Blood in stool for last 2 weeks. Abdominal discomfort for last 3 days. 1. How will you differently diagnose hemorrhoids? Blood in stools could be a symptom of some infection or Ulcers (gastric or peptic ulcer) in GIT, hemorrhages in the lower gastrointestinal tract i.e ulcerative colitis, dysentery, hemorrhoids etc. . Characteristic of blood are quite helpful in detecting the underlying cause: Fresh blood: Light red and pale colored indicates lower gastrointestinal tract infection or hemorrhages such as in hemorrhoids. Dark blood: Dark colored (dark red to reddish black) and thick blood indicates an upper gi tract infection i.e ulcers. Streaks in faces: Indicates dysentery.

Abdominal discomfort could be due to disturbance in normal defecation and diarrhea, constipation and dysentery can have abdominal discomfort as a common symptom.

DIAGNOSIS: Patient is not suffering with diarrhea as frequency of stool is not increased neither constipation is reported. But abdominal discomfort indicates improper defecation due to sedentary lifestyle. Patient has not reported with itching on ano-rectal area but bleeding in stool indicate a possible hemorrhage and patient suspect himself to be suffering with hemorrhoids. 2. What advice should be given to Mr. X? Patient is first of all should be advised for a stool test to evaluate the underlying cause and should visit his physician to discuss his problem. Empirically a person suffering hemorrhoids should be counseled about: To increase fibrous diet. Maintain hygiene Increase water intake. Exercise and proper walk to improve digestion. Avoid constipation.

PILES
Mr. X , is a 45 year old accountant his dietary habits are very poor. He takes unbalanced food &drinks hardly 2-3glasses of water daily. For the last 4 months he is suffering from constipation which is relieved wherever he takes medicine. For last 3 days he is suffering from pain in defecation. One day before he felt red spots of blood with stool. 1. What is likely diagnosis in Mr X (Differential)? 2. What advice should be given to him?
HISTORY: Low water intake and poor dietary habits Had constipation off and on since last 4 months, relived with medication. Since last 3 days he is suffering from itching and pain on defecation. One day before he observed blood in stool. 1. What is likely diagnosis in Mr X (Differential)? No fever, diarrhea or abdominal discomfort is reported along with blood in stool ( streaks in feces ) so Dysentery cannot be diagnosed. Blood in stool along with fever, chronic diarrhea and abdominal distension, frequently nausea and vomiting can indicate Ulcerative colitis, but no such symptoms reported. DIAGNOSIS: Itching and pain upon defecation and blood in stools is an indicator of Piles and chronic constipation being the underlying cause. 2. What advice should be given to him?

Non-pharmacological advise: Maintain hygiene. Increase water intake. Take fibrous diet. Pass stool on urge. Exercise or walk to improve digestion. Drug therapy: Hydrocortisone gel (1% w/w).Apply topically 2 3 times daily. Laxative i.e Lilac. Benzocaine ointment (Auralgen) Apply topically 2 3 times daily.

PILES
A patient comes to you with the symptoms of rectal pain and rectal bleeding along with difficulty in passing stool. He is not having vomiting. He tells that he has a kind of job with prolonged sittings and eats more fast food in his meals. He asks u for your advice.
SIGNS AND SYMPTOMS: Rectal pain Rectal bleeding and Difficulty in defecation. DIFFRENTIAL DIAGNOSIS: Although the patient is showing rectal bleeding but as he is having difficulty in defecation rather than diarrhea so the possibility of dysentery has been out ruled His symptoms indicate him to be suffering from piles. TREATMENT: A thorough physical examination is required for the decision of surgical removal of his hemorrhides He should be advised to increase fibre content in his diet and decrease fast food consumption. Apply petroleum jelly to the rectal region.

C condition; piles O objective; pharmacological treatment of piles and pain releaf R regimen; surgical removal /Topical application of petroleum jelly / increase fibre content in diet. E evaluation; by follow up and identification of cause.

CONSTIPATION
MR. As mother has recently moved in with his family following death of his father 4 months ago. Although she was formerly a sprightly 78 year old she is now withdrawn, eats little of the meals prepared for her & no l0onger goes for her daily walks. Mr. A knows she is taking medicine for a long-standing heart complaint and has recently started taking anti-depressant. She is complaining of constipation. 1. What are causes of her constipation? 2. Mr. A would like to know if there is any medicine suitable to help his mother?
HISTORY: Stressed due to husbands death few months ago. Poor dietary habits. Taking antidepressants and medicines for long standing heart complaints. Complaints of constipation. 1. CAUSES OF CONSTIPATION IN THIS CASE : Mr.A s mother is depressed due to her husbands death few months ago. She is recently moved with her sons family so change of environment is effecting her psychological state and eating habits. Dietary habits are changed due to depression or withdrawn behavior. She is not doing any exercise or walk to improve digestion. Constipation could be a side effect of her medication. 2. MEDICATION TO HELP HER CONDITION: First of all she must be treated psychologically to improve her will-power for continuation of normal routine life. Proper diet and exercise would be helpful in relieving her constipation. Home remedies such as psyllium husk ( ispaghol) is beneficial. Laxative i.e Lilac 3.35 mg /5ml (1 tablespoon) T.I.D.

CONSTIPATION
Mr G is planning to travel to Mexico on business .He was last there 6 months ago but was incapacitated with constipation in a busy work schedule. He doesnot want a repeat experience on his forthcoming visit &seeks advice. He is taking Ferrous sulphate for iron deficiency & dantrolene for muscle stiffness. 1 What are possible reasons for his problem? 2. What is general management for Mr.G disease? 3. What is non drug treatment available for constipation?
HISTORY: Had constipation 6 months ago while on visit to mexico. Want to avoid it now. Taking ferrous sulphate as a supplement and Dantrolene for muscle stiffness. 1. Possible reasons for his problem: Change of environment. Poor dietary habits due to sedentary lifestyle. Improper digestion due to limited physical movement. May be a side effect of ferrous sulfate or muscle relaxant. 2.General management of his disease: Mr. G currently is not suffering with constipation but he want to avoid it therefore no medication could be prescribed and his disease will be managed by taking preventive measures. Improve dietary habits and exercise daily to facilitate digestion. Take fibrous food. He is taking ferrous sulphate as a supplement which could have constipation as a prominent side effect as it is a supplement and its use can be skipped for few days. Dantrolene is a muscle relaxant but does not reported to have constipation as a side effect.so dantrolene should be continued during his visit. 3.Non- pharmacological treatment: Increase dietary fiber intake. Increase water intake. Take ispaghol with water in the morning. Exercise to improve digestion. Pass stool on urge.

VOMITING
A 30 years old man presents seeking remedy for vomiting which had an acute onset, 12 hours previously. What questions should be asked to determine the nature, causes and seriousness of these symptoms.
History: Vomiting from 12 hours previously Chief Complaints: Vomiting Physical examination: Vital signs are not mentioned so assumed to be normal. Differential Diagnosis: Vomiting may be caused by Migraine A migraine is a common type of headache that may occur with symptoms such as nausea, vomiting (yellow in colour and more watery in nature usually do not contain bowel contents) , or sensitivity to light and GIT disturbance. Motion sickness Dizziness, fatigue, and nausea, vomiting are the most common symptoms of motion sickness. Meningitis The most common causes of meningitis are viral infections that usually get better without treatment. However, bacterial meningitis infections ( by Cryptococcal meningitis and H. influenza meningitis) are extremely serious, and may result in death or brain damage, even if treated. Symptoms include fever and chills, mental status changes ,nausea and vomiting, sensitivity to light (photophobia), severe headache , stiff neck . Food poisoning 1-24 hours after ingestion of meal along with frequent stool, headache, nausea, vomiting (that contain bowel contents) and abdominal cramps. Typhoid Typhoid fever is usually caused by Salmonella typhi. Its symptoms include poor appetite headaches, nausea, fever, diarrhea and vomiting. Cholera Cholera is caused by gram negative stain bacterium Vibrio Cholerae and its symptoms include diarrhea that is describes as rice water in nature and fishy odour, vomiting of clear fluid ultimately leading toward dehydration and low B.P.

Core plan: The core of the therapy is to prevent dehydration for this purpose :

ORS is recommended

If mild dehydration occurs due to vomiting then give 50 ml/kg of body weight if severe condition then gives 100 ml/kg of body weight. Then to treat vomiting: Gravinate ( Dimenhydrinate) 50_100mg/kg T.I.D First we will ask patient about frequency and characteristic of vomiting 1. Does it contain blood, bile or small bowel content? If he is taking any medications we will ask about the details. 2. Have you taken any medicine like digitalis , or any chemotherapeutic agents? Because digitalis has narrow TI due to which if dose increases causes emesis. Opiates (activate CTZ) or any chemotherapeutic agent. He may also experience vomiting in diseases like Migraine (along with headache, visual and GIT disturbance) Meningitis (along with high grade fever, neck pain & neck stiffness) Food poisoning (1-24 hours after ingestion of meal along with frequent stool, headache and abdominal cramps) Typhoid (fever, nausea, vomiting and abdominal pain) Cholera (along with vomiting, dehydration and loose stool)

MIGRANE
A 29 years old woman present to clinic with a 5 month history of left sided pulsatile head pain recurring on a weekly basis. Her headaches are usually preceded by unformed flashes of light bilaterally and a sensation of light headedness. The ensuing pain is always unilateral and is associated with nausea, vomiting and photophobia. The headache is not relieved by two tablets of either ASPIRIN 325mg or IBUPROFEN 200mg and generally lasts all day unless she is able to lie in a dark room and sleep. The headache usually interferes with her ability to work. She is unable to identify any external factors that precipitate a migraine attack. Both her mother and grandmother also were affected by migraine headache .Current medication involves OTC analgesics for headache and contraceptives. General physical and neurological examinations are within normal limits. Q1. What subjective and objective signs from above description are consistent with diagnosis of migraine with aura? Q2. What should be the general approach to the treatment of her headache attack? Q3. Is her contraceptive use is a contributing factor to her migraine? Why?
History: 5 month history of head pain, light headedness, nausea, vomiting and photophobia. Her mother and grandmother were also affected by migraine. Past Medication history include Aspirin 325 mg 2 tablets Ibuprofen 200 mg 1 tablet

Current Medication include OTC analgesics and contraceptives Chief Complaints: Sensation of light headedness, nausea, vomiting and photophobia. Physical examination: Vital signs like B.P , pulse rate and respiratory rate are not mentioned hence assumed to be normal. Differential diagnosis: Cluster headaches: are so named because they typically occur in clusters over a period of weeks or months. This is followed by a headache-free period until another cluster of headaches begins. The headache is usually sudden and severe, lasting a few minutes up to 2 hours, and mostly affects the temple or the area around one eye, and on one side of the head (unilateral). Symptoms include forehead sweating, tearing, or runny nose, all occurring on the same side as the headache.

Meningitis: The most common causes of meningitis are viral infections that usually get better without treatment. However, bacterial meningitis infections ( by Cryptococcal meningitis and H. influenza meningitis) are extremely serious, and may result in death or brain damage, even if treated. Symptoms include fever and chills, mental status changes, nausea and vomiting, sensitivity to light (photophobia), severe headache , stiff neck . Sinusitis: is inflammation of the mucosal lining of one or more sinuses that connect to the nasal passageway. Individuals may report nasal congestion, presence of thick yellow/green discharge from the nose, toothache, sore throat, loss of smell, poor response to nasal decongestants, recent history of a cold or allergic rhinitis, headache (especially upon awakening), and/or facial pain. Opioid Type Dependence: Opioid-type dependence is defined as dependence upon the class of natural or synthetic drugs that includes morphine, codeine, and heroin. Withdrawal symptoms include depression, nausea, vomiting, diarrhea, muscle aches, headache, excessive tearing of the eye or nose, pupillary dilation, yawning, fever, or insomnia. Core plan: The main therapeutic objective is to relief pain so for this purpose: Panadol (Acetaminophen) 500 mg 1 tablets T.I.D Anaprox (Naproxen) 550 mg 1 tablet T.I.D Counseling: Take sweets and chocolates as they restore glucose level. Avoid migraine triggers. Drink plenty of water to avoid dehydration, especially if the patient has vomited. Rest in a quite darkened room. Caffeine and chocolates can increase serotonin levels so can be taken. Head massage Aroma therapy can be done by using essential oils. Proper sleep patterns should be followed.

1. What subjective and objective sign form above description that diagnosis of migraine with aura?

Subjective signs: Sign that are perceived only by the patient. e.g. pain, vertigo etc. Following subjective signs are present: Left side palatable pain. Light headedness

Nausea and vomiting Phobias ( photophobia) Inability to concentrate all are the major signs of migraine that are consistent with diagnosis of migraine.

Objective signs: Sign which can be detectable by someone other than the patient e.g. B.P, pulse rate. No objective signs are present in patient.

2. What should be the general approach to the treatment of her headache attack ?

Aromatherapy can be done by using essential oils. Proper sleep patterns should be followed. Rest in a quite darkened room. Caffeine and chocolates can increase serotonin levels so can be taken. Avoid triggering factors (like smell, noise etc.) Head massage Do not take anxiolytics Panadol Naproxen 500mg 500mg 1tab T.I.D

1tab T.I.D

3. Is her contraceptives is contributing factor to her migraine? Why?

Contraceptive increase levels of estrogen. Whenever there are high levels of estrogen there may be two types of changes:

i)

Physiological changes (headache and migraine )

ii)

Physiological changes ( mood swings and depression)

Contraceptives lead to decrease in progesterone

Increased estrogen Contraction of blood vessels

Decreased blood and nutritional supply to brain

Pain

Increase risk of stroke

SORE THROAT
A 28 years old male presents with complains of sore throat fever and usual symptoms of common cold. Q1. How will you differentially diagnose viral and bacterial sore throat? Q2.In case, if it is a viral infection what treatment options are available?
History: Sore throat, fever and common cold symptoms Chief Complaints: Sore throat, fever and common cold Diagnosis: Physical examination

Culture Test Swab Test

Differential Diagnosis: On the basis of sign and symptom we can differentiate between viral and bacterial infection

Bacterial High grade fever productive cough Severe infection Treatment by anti-biotic Wheezing sounds No hoarseness of voice

Viral Low grade fever Dry cough Mild infection Self limiting No wheezing sounds Hoarseness of voice

Core plan: The main therapeutic objective is to treat throat infection. For this purpose: Use aspirin gargles Use lozenges like Stepsils

And recommend culture test to identify viral or bacterial infection. If culture test is positive it indicates bacterial infection and its treatment is: Amoxil (clavulanic acid and amoxicillin) 500mb 1 tab t.i.d if not treated then Azomycin (azithromycin) 250mg BID or 500 mg O.D for 3-5 days. If culture test is negative it shows viral infection which will self treated after its incubation period of 5-7 days. For prophylactic treatment: Gargles of Aspirin. Panadol or Ibuprofen for lowering fever. Lozenges for curing sore throat & for soothing effect

Counseling: Do not drink cold water. Do not eat sour food.

Avoid spicy foods.

1. How will you differentially diagnose viral and bacterial core throat?

On the basis of sign and symptom we can differentiate between viral and bacterial infection

Bacterial High grade fever productive cough Severe infection Treatment by anti-biotic Wheezing sounds No hoarseness of voice

Viral Low grade fever Dry cough Mild infection Self limiting No wheezing sounds Hoarseness of voice

Diagnosis:
If we cannot differentially diagnose the bacterial and viral infection on the basis of sign and symptoms then we will advice patient for culture test. If bacteria grows then infection is bacterial otherwise viral. 2. In case if it is viral infection what is possible treatment? As patient has viral infection then we will not go for any treatment because it will self treated after its incubation period of 5-7 days. For prophylactic treatment for ones further.

Gargles of Aspirin. Panadol or Ibuprofen for lowering fever. Lozenges for curing sore throat & for soothing effect

SORE THROAT
A 12 years child presents with complains of fever and flu like symptoms. Physical examination reveals exudates on tonsils, plus enlarged and tender cervical lymph nodes.

Q1. How will you differentially diagnose his present illness? Q2. What will be the empirical and definitive therapy for this child?
History: Fever and flu like symptoms. Chief complaints: Fever, flu like symptoms, inflamed pharynx with whitish exudates on tonsils and enlarged cervical lymph nodes. Diagnosis: Physical examination Culture Test Swab Test

Differential Diagnosis: On the basis of sign and symptom we can differentiate between : Pharyngitis: or sore throat is discomfort, pain, or scratchiness in the throat. It often makes it painful to swallow. Laryngitis is swelling and irritation (inflammation) of the voice box (larynx) that is usually associated with hoarseness or loss of voice. Tonsillitis is inflammation (swelling) of the tonsils. ARI the common cold is a viral infection of the upper respiratory system, including the nose, throat, sinuses, Eustachian tubes, trachea, larynx, and bronchial tubes

Core plan: The main therapeutic objective is to treat throat infection. For this purpose: Use aspirin gargles Use lozenges like Stepsils

And recommend culture test to identify viral or bacterial infection. If culture test is positive it indicates bacterial infection and its treatment is: Amoxil (clavulanic acid and amoxicillin) 500mb 1 tab t.i.d if not treated then Azomycin (azithromycin) 250mg BID or 500 mg O.D for 3-5 days. If culture test is negative it shows viral infection which will self treated after its incubation period of 5-7 days. For prophylactic treatment: Gargles of Aspirin.

Panadol or Ibuprofen for lowering fever. Lozenges for curing sore throat & for soothing effect

Counseling: Do not drink cold water. Do not eat sour food. Avoid spicy foods.

1. How will you differentially diagnose his present illness? Pharyngitis: or sore throat, is discomfort, pain, or scratchiness in the throat. It often makes it painful to swallow. Laryngitis is swelling and irritation (inflammation) of the voice box (larynx) that is usually associated with hoarseness or loss of voice. Tonsillitis is inflammation (swelling) of the tonsils. ARI the common cold is a viral infection of the upper respiratory system, including the nose, throat, sinuses, Eustachian tube111s, trachea, larynx, and bronchial tubes

On the basis of above mentioned symptoms the child may be suffering from pharyngitis. What will be the Empirical and definitive therapy for this child? Empirical therapy: Gargle of warm Salty water Lozenges to smoothen throat Amoxil 500mb 1 tab t.i.d

And recommended for the culture test to accurately diagnosed bacterial or viral infection. Definitive therapy: If culture test is positive then bacterial infection. Amoxil (clavulanic acid and amoxicillin) 500mb 1 tab t.i.d if not treated then Azomycin (azithromycin) 250mg BID or 500 mg O.D for 3-5 days. Viral infection : Self limiting after 5-7 days

SORE THROAT
Mr. Ali delivered eight lectures back to back in school and came back via local transport through a highly polluted environment. On arrival he felt that he is unable to produce high pitch sound along with pain in throat and he was painful while eating meal. How would you treat him? History:
Name: Mr. Ali (Probably a school teacher)

Physical examinations:
Mr.Ali has hoarseness in voice and have painful throat.

Differential Diagnosis:
On the basis of sign and symptom we can differentiate between viral and bacterial infection

Bacterial High grade fever productive cough Severe infection Treatment by anti-biotic Wheezing sounds No hoarseness of voice

Viral Low grade fever Dry cough Mild infection Self limiting No wheezing sounds Hoarseness of voice

Diagnosis:
Based on history i-e (teacher and has to speak a lot) and physical examination, It has been diagnosis that patient is suffering from pharyngitis (sore throat)

Treatment:
The main therapeutic objective is to treat throat infection. For this purpose: Use aspirin gargles Use lozenges like Stepsils

And recommend culture test to identify viral or bacterial infection. If culture test is positive it indicates bacterial infection and its treatment is: Amoxil (clavulanic acid and amoxicillin) 500mb 1 tab t.i.d if not treated then Azomycin (azithromycin) 250mg BID or 500 mg O.D for 3-5 days.

If culture test is negative it shows viral infection which will self treated after its incubation period of 5-7 days. For prophylactic treatment: Gargles of Aspirin. Panadol or Ibuprofen for lowering fever. Lozenges for curing sore throat & for soothing effect

Counselling:
Avoid loud speaking.. Do not over-burden your throat. Stick to the medicines as prescribed.

HYPOGLYCEMIA
Mr. X an 86 years old patient with type 2 diabetes, who is brought to accident and emergency department by his granddaughter. He normally takes GLIBENCLAMIDE 2.5mg each morning for his diabetes. However today he took glibenclamide but did not eat his supper. His granddaughter gave him some glucose powder at home, which appeared to revive him, however he become drowsy again after 30min.On examination at hospital he was still drowsy bit responsive, confused and looked sweat. His blood sugar measured 3mmol/L. Q1. What factors most commonly predispose a a patient to drug induced hypoglycemia? Q2. How should his hypoglycemia be treated if he becomes unconscious?
History: Diabetes type 2, accident Chief complaints: Accident drowsy but still responsive, confused and look sweaty. Blood sugar was 3mmol/L. Medication history Glibenclamide 2.5 mg each morning. Diagnosis: Physical examination Blood glucose level is checked. Differential Diagnosis: Epilepsy: It is a chronic disorder of cerebral function. Causes are hypoxia, genetic metabolic defects, developmental brain defects, vit B6 deficiency etc. Symptoms include seizures, light flashes, tingling, sweating, buzzing, flushing etc. It usually occurs at night time & patient normalizes after 15-20 min.

BP & Pulse rate normal. Hypoglycemia:

It is the condition of LOW blood glucose.

Causes include decrease glucose intake, improper meals, over dose of ant diabetic agents. Symptoms include weakness, lethargy, hunger, low BP, unconsciousness.

It usually lasts for 10 minutes and patient regains upon administration of sweets. Pulse rate is low & low BP.

Core plan: The core of the treatment is to normalize blood glucose levels as soon as possible for this purpose patient should administer:

1 -2 table spoon of table sugar 3-4 glucose tablets and glucose drink cup or 4 ounces of any fruit juice 1 cup or 8 ounces of milk 5-6 pieces of hard candy If patient is unconscious: Dextrose infusion Glucose 20-50mL of 50% glucose solution by IV infusion over a period of 2-3 minutes Glucagon 1mg S/C or I/M

If hypoglycaemia is because of insulinoma then surgery to remove the tumour is the best treatment.

Counseling: Take proper meals that small meals after short time intervals. Do not skip or delay a meal. Correctly measure her daily insulin dose. Take additional snacks if any physical activity is done.

Always place some sweet thing so that glucose level not fluctuates. Take daily 5 portions of fruits and vegetables. Administer insulin half an hour before meal.

1. What factors most commonly predispose a patient to drug induced hypoglycemia?

Poor Dietary habits including: Delayed meal Skip a meal Not eating the usual amount of CHO.

As hypoglycemia is the major side effects of Glibenclamide (sulphonylureas) and patient is taking Glibenclamide 2.5mg daily. So he should take this half an before meal but he didnt do so before meal but take medicine after which also skips a meal that ultimately leads towards hypoglycemia.

1. How should his hypoglycemia be treated if he becomes Un-conscious?

Dextrose infusion Glucose 20-50mL of 50% glucose solution by IV infusion over a period of 2-3 minutes Glucagon 1mg S/C or I/M

HYPOGLYCEMIA
A 60 years old woman is a patient of diabetes type 1, hypertension and osteoporosis. She feels unconscious following her daily insulin

intake, Q1. How should hypoglycemia be initially treated at home to avoid emergency situation? Q2. What precautionary measures should be adopted to avoid such incidence in future?
History: Diabetes type 1, hypertension, osteoporosis Chief Complaints: She felt unconscious following her daily insulin intake. Diagnosis: Physical examination Blood glucose level is checked. Differential Diagnosis: Epilepsy: It is a chronic disorder of cerebral function. Causes are hypoxia, genetic metabolic defects, developmental brain defects, vit B6 deficiency etc. Symptoms include seizures, light flashes, tingling, sweating, buzzing, flushing etc. It usually occurs at night time & patient normalizes after 15-20 min. BP & Pulse rate normal. Hypoglycemia: It is the condition of LOW blood glucose.

Causes include decrease glucose intake, improper meals, over dose of ant diabetic agents. Symptoms include weakness, lethargy, hunger, low BP, unconsciousness.

It usually lasts for 10 minutes if proper management (giving any sweet) is given. Pulse rate is low.

Core plan: The core of the treatment is to normalize blood glucose levels as soon as possible for this purpose patient should administer:

 1 -2 table spoon of table sugar 3-4 glucose tablets and glucose drink cup or 4 ounces of any fruit juice 1 cup or 8 ounces of milk 5-6 pieces of hard candy If patient is unconscious: Dextrose infusion Glucose 20-50mL of 50% glucose solution by IV infusion over a period of 2-3 minutes Glucagon 1mg S/C or I/M

If hypoglycemia is because of insulinoma then surgery to remove the tumor is the best treatment.

Counseling: Take proper meals that small meals after short time intervals. Do not skip or delay a meal. Correctly measure her daily insulin dose. Take additional snacks if any physical activity is done. Always place some sweet thing so that glucose level not fluctuates. Take daily 5 portions of fruits and vegetables. Administer insulin half an hour before meal.

How should hypoglycemia be initially treated at home avoiding emergency situation?

In Blood glucose level is below 70mg/dL then quickly gives food that raise Blood glucose level. 1 -2 table spoon of table sugar 3-4 glucose tablets and glucose drink cup or 4 ounces of any fruit juice 1 cup or 8 ounces of milk

5-6 pieces of hard candy

What precautionary measures should be adopted to avoid such incidence in future?

Take proper meals. Small meals after short time intervals. Do not skip or delay a meal. Correctly measure her daily insulin dose. Take additional snacks if any physical activity is done. Always place some sweet thing so that glucose level not fluctuates. Take daily 5 portions of fruits and vegetables. Administer insulin half an hour before meal.

HYPOGLYCEMIA
52 year old women with obesity and poorly controlled diabetes-II from last 10 years is using GLIBENCLAMIDE 2.5mg each morning and insulin therapy for her diabetes. She presents with complains of fatigue, weakness, nausea and vomiting and marked decreased in her energy level. How will you justify and manage the situation. History:
Type-II diabetes from 10 years

Chief complaints:
Fatigue Nausea and vomiting Weakness

Physical examination:
Vital signs are not mentioned so assumed to be normal.

Diagnosis:
As patient is on insulin and sulfonylureas therapy and hypoglycaemia is the major side effect of both of these drugs. Fatigue, nausea, vomiting and weakness are major symptoms of hypoglycaemia so patient is suffering from drug induced hypoglycaemia. Similarly patient is obese and may wants to reduce her weight due to which my skip the meal leading to hypoglycaemia.

Treatment and management:

For diabetes: As patient is obese and her diabetes is not controlled by sulfonylureas and insulin then we need to switch to Metformin which is safer for obese patients as it do not increase the weight but helps in weight reduction. On the other hand it do not cause hypoglycaemia. Glucophage (Metformin) - 500 mg 1tab O.D For hypoglycaemia: If BGL is below 70mg/dL then quick fix foods should be consumed to raise blood glucose. 3-4 glucose tablets and glucose drink cup or 4 ounces of any fruit juice 1 cup or 8 ounces of milk 5-6 pieces of hard candy

Counselling:

Take proper meals that small meals after short time intervals.

Do not skip or delay a meal. Correctly measure her daily insulin dose. Take additional snacks if any physical activity is done. Always place some sweet thing so that glucose level not fluctuates. Take daily 5 portions of fruits and vegetables.

Administer insulin half an hour before meal.

WARTS
45 years old female presents with complain of a hard mass on her foot soul. On examination a hard dead mass is found which hinders her in normal walk and is painful. Q1. How will you differentially diagnose her disease? Q2. What treatment options are available? Q3 what is the role of liquid nitrogen for this disease?

History: Presence of hard mass on her foot sole. Chief Complaints: Hard mass which hinders her normal walk and is painful. Diagnosis: Physical examination

Differential Diagnosis:

Warts
May be due to bacteria or HPV Mostly affected areas are face hand & feet Solid mass in the form of outgrowth. Can lead to pain & itching

Hives
Occurs due to insect bite Mostly occurs at lower abdominal region Spots are like wheel & flares with redness Itching with mild

Clauses
Due to increased pressure Occur in foot region Redness & Cluster of boils Very painful

Moles
Due to increased secretion of melanin In hands & feet Appears like pigmentation & black spots No pain or itching

pain

Treatment:

Salicylic acid paints (duofilm) apply 2-3 times on warts avoiding normal skin and cover with plaster. NO home remedy is generally preferred because it can lead towards cancer hence recommended surgical removal.

Counseling: Do not let wart moisturize with water as it increases infection. Maintain good hygienic condition. Do not scratch warts. Do not try to remove them yourself. After touching warts wash your hands carefully.

1. How will you differentially diagnose her disease?

Warts:

May be due to bacteria or HPV Mostly affected areas are face hand & feet Solid mass in the form of outgrowth. Can lead to pain & itching

Hives:

Occurs due to insect bite Mostly occurs at lower abdominal region

Spots are like wheel & flares with redness Itching with mild pain

Clauses:

Due to increased pressure Occur in foot region Redness & Cluster of boils Very painful

Moles:
Due to increased secretion of melanin In hands & feet Appears like pigmentation & black spots No pain or itching

On the basis of symptoms of patients warts is diagnosed.

2. What treatment Options are available?

Salicylic acid (duofilm) applies 2-3 times on warts avoiding normal skin and cover with plaster. NO home remedy is generally preferred because it can lead towards cancer hence recommended surgical removal. 3. What is role of liquid nitrogen for these diseases? Nitrogen provides cooling effect leading to shrinkage and applied on wart which removes the warts. This is not forever therapy. The wart may reoccur after sometime so this therapy is repeated after 3 weeks.

WARTS
A patient comes to you who is having a small, rough outgrowth, on his hand. Which he says has developed over one month. He is not having any ulceration or erosion in that outgrowth. It is also not painful. He asks for the treatment of his condition.
SIGNS AND SYMPTOMS: Small, rough growth, on hand No erosion No pain DIAGNOSIS: His symptoms indicate his outgrowth to be a wart. Histopathological examination can be done for confirmation TREATMENT: Surgical curettage of the wart Laser treatment. Salicylic acid products are readily available at drugstores and supermarkets. There are typically two types of products: adhesive pads treated with salicylic acid or a bottle of concentrated salicylic acid solution. C condition; a non painful wart O objective; pharmacological treatment of wart R regimen; salicylate cream, lotion or paint OR surgery E evaluation; by follow up to prevent re-growth of the wart.

MOUTH ULCER

A male of age 50 years with known history of smoking for last 20-25 years is presented in OPD with complaint of irregular reddish lesion on the buccal mucosa with associated difficulty in chewing and pain. What will be the treatment protocols. By studying the patients history and symptoms of redness, erosion of buccal mucosa it is concluded that he is having mouth ulcer.
DEMOGRAPHICS: GENDER: Male CHIEF COMPLAINTS: Redness on the oral mucosa Difficulty in chewing Pain while chewing HISTORY: History of smoking with no medication TREATMENT: Immediately stop smoking as it is the main cause of mouth ulcers and sores. Analgesics for relieving pain. Panadol tablets depending upon the severity of pain. Topical application of somogel for relieving pain and redness. COUNSELING: Spicy food should be avoided. Do avoid any such food or chemical which causes allergy Maintain oral hygiene. C condition; erosion of buccal mucosa (mouth ulcer) O objective; pharmacological treatment of mouth ulcer R regimen; Topical application of somogel for relieving pain and redness E evaluation; by follow up and identification of cause. AGE: 50 years

MOUTH ULCER
A 78 years old man presented to his physician with diarrhea illness of 1 days duration. His illness began with vomiting followed by abdominal pain. He has a decreased shin turgor & dry mucous membrane. He complains of oral ulcers. 1. What are reasons for oral ulcers? 2. What is specific drug therapy for oral ulcers?
HISTORY: Diarrheal illness began with vomiting followed by abdominal pain of one day duration. Oral ulcers. 1. Reasons for ORAL ULCERS: Trauma Physical abrasions. Smoking cessation. Viral infection i.e Herpes simplex virus infection. Bacterial infection i.e Mycobacterium tuberculosis ( TB), or Traponema pallidum (Syphillus). Fungal infection i.e Coccidioides immitis (valley fever), Cryptococcus neoformans (cryptococcosis), Blastomyces dermatitidis ("North American Blastomycosis") and Candida species are some of the fungal processes causing oral ulceration. Protozoans i.e Entamoeba histolytica, a parasitic protozoan, is sometimes known to cause mouth ulcers through formation of cysts. Immunodeficiency: Repeat episodes of mouth ulcers can be indicative of an immunodeficiency, signaling low levels of immunoglobulin in the oral mucous membranes. Chemotherapy, HIV, and mononucleosis are all causes of immunodeficiency with which oral ulcers become a common manifestation. Dietary: Vitamin C deficiencies may lead to scurvy which impairs wound healing, which can contribute to ulcer formation. Similarly deficiencies in iron, vitamin B12, zinc have been linked to oral ulceration. Acidic food such as citrus fruit may cause mouth ulcers. Crohns disease. 2. Drug therapy for Oral ulcers: Local anaesthetics i.e SOMOGEL ( Lignocaine(0.6%),cetylpyridinium chloride(0.02%),menthol(0.06%),euclyptol(0.1%) and ethanol(33%). Massage gently on sores, 3-4 hourly. ENZICLOR: ( Benzydamine HCl 1%, Cetylpyridinium chloride 0.1%) Gel to be applied every 2-3 hours to a maximum of 12 times/day.

VIVA QUESTIONS

QUESTION 1 What is the difference between the fever pattern of malaria typhoid and UTI?
Malaria It includes three stages viz. Cold stage, hot stage and sweating stage. The febrile episode starts with shaking chills, usually at mid-day between 11 a.m. to 12 noon, and this lasts from 15 minutes to 1 hour (the cold stage), followed by high grade fever, even reaching above 1060 F, which lasts 2 to 6 hours (the hot stage). This is followed by profuse sweating and the fever gradually subsides over 2-4 hours. In vivax malaria, this typical pattern of fever recurs once every 48 hours and this is called as Benign Tertian malaria. Similar pattern may be seen in ovale malaria too (Ovale tertian malaria). In falciparum infection (Malignant tertian malaria), this pattern may not be seen often and the paroxysms tend to be more frequent (Sub-tertian). In P. malariae infection, the relapses occur once every 72 hours and it is called Quartan malaria. Typhoid fever Typhoid fever begins 7-14 days after ingestion of S typhi. The fever pattern is stepwise, characterized by a rising temperature over the course of each day that drops by the subsequent morning. The peaks and troughs rise progressively over time. At approximately the end of the first week of illness, the fever plateaus at 103-104F (39-40C). The patient develops rose spots. The stepladder fever pattern that was once the hallmark of typhoid fever now occurs in as few as 12% of cases. In most contemporary presentations of typhoid fever, the fever has a steady insidious onset. Urinary tract infections Lower urinary tract infection (cystitis) Mild fever (less than 101F), chills, and "just not feeling well" (malaise) Upper urinary tract infection (pyelonephritis) Fairly high fever (higher than 101F) Newborns - Fever or hypothermia (low temperature). Infants fever Children -unexplained fever that doesn't go away. Elderly people - Fever or hypothermia.

QUESTION 2 What are the diagnostic tests conducted for malaria, typhoid and UTI?
Tests Used to Make a Malaria Diagnosis The doctor may suspect malaria based on the patient's symptoms, and the physical findings at examination; however, to make a definitive diagnosis of

malaria, laboratory tests must demonstrate the malaria parasites, or their components. The best test available to diagnose malaria is called a blood smear. In this test, malaria parasites can be identified by examining a drop of the patient's blood under the microscope, spread out as a "blood smear" on a microscope slide. Prior to examination, the specimen (blood) is stained to give to the parasites a distinctive appearance. Tests Used to Reach a Typhoid Fever Diagnosis If the doctor thinks a person is at risk for typhoid fever, he or she can order certain blood, bone marrow, and/or stool tests that look for the presence of the bacteria that cause typhoid fever (Salmonella typhi). This is the only way to know for sure if an illness is typhoid fever. Tests Used to Reach a UTI Diagnosis Urine Sample To diagnose a urinary tract infection (UTI), your doctor will test a sample of urine for pus and bacteria. You will be asked to give a "clean catch" urine sample by washing the genital area and collecting a "midstream" sample of urine in a sterile container. This method of collecting urine will help prevent bacteria around the genital area from getting into the sample and affecting the test results. The urine will also be examined for white and red blood cells and bacteria. The bacteria will be allowed to grow in a culture so that it can be tested against different antibiotics to see which drug best destroys the bacteria. This last step is called a sensitivity test. Additional Tests and Procedures When an infection does not clear up with treatment, doctors May order tests to determine if your system is normal. These tests may include:

An intravenous pyelogram An ultrasound A cystoscopy. Intravenous Pyelogram: An intravenous pyelogram is an x-ray image of the bladder, kidneys, and ureters. Doctors will inject an opaque dye, which is visible on x-ray film, into a vein and then take a series of x-rays. The film will show an outline of the urinary tract and reveal even the small changes in the structure of the tract. Ultrasound: If you have chronic urinary tract infections, your doctor also may recommend an ultrasound exam. An ultrasound is a method of obtaining images from inside the human body through the use of high-frequency sound waves. The reflected sound wave echoes are recorded and displayed as a realtime visual image. Cystoscopy: Another useful test in diagnosing a urinary tract infection is a cystoscopy. A cystoscope is an instrument made out of a hollow tube with several lenses and a light source. A cystoscope allows the doctor to see inside the bladder from the urethra.

QUESTION 3 How a patient of cough and cold be diagnosed for viral or bacterial infection?

Coughs occur with bacterial and viral respiratory infections. A cough is only a symptom, not a disease, and often the importance of your cough can be determined only when other symptoms are evaluated. Viral illnesses are the most common cause of upper respiratory symptoms. Symptoms of a viral illness often appear over several hours without prior illness. Common viral illnesses include colds and the flu (influenza). Sputum and nasal discharges are clear. Bacterial respiratory tract infections are less common than viral infections. Bacterial infections may develop after a viral illness such as a cold or the flu. Bacterial infections may affect the upper or lower respiratory system, and symptoms tend to localize to one area. Sputum and nasal discharges are thick and opaque. The most common sites of bacterial infections in the upper respiratory system are the sinuses and throat. Pneumonia is the most common bacterial infection of the lower respiratory system.

QUESTION 4 Which diseases can be diagnosed on the basis of fever?

Almost any infection can cause a fever. Some common infections are:

Fever
Typhoid fever
Flu (influenza) Common cold Malaria Pneumonia

Range
Fever over 104F Fever over 102F Fever up to 102F Fever up to 106F Fever 101.5*F to 103.5*F
A low grade fever ranges from 100.4oF to 102.2oF.

Mumps Chickenpox Wound Infection

Scarlet Fever Hepatitis Pelvic Inflammatory Disease (PID) Mononucleosis Leukemia Rheumatoid Arthritis Sinusitis Allergies HIV/AIDS Chronic Abscess Tuberculosis Dengue fever

QUESTION 5 How will you distinguish between malaria and dengue patient w.r.t. signs and symptoms, diagnostic tests and treatment?

Dengue Signs and High fever, up to 105 F symptoms (40.6 C) A rash over most of your body, which may subside after a couple of days and then reappear Severe headache, backache or both Pain behind your eyes Severe joint and muscle pain Nausea and vomiting Sign and symptoms usually begin about four to seven days after being bitten by a mosquito carrying a dengue virus. Diagnostic Serologic testing, tests hemagglutination inhibition (HI) assay, IgG or IgM enzyme immunoassays Treatmen Paracetamol 1tab t 250mg not more than 4times in 24hours. Oral fluids and electrolyte therapy.

Malaria A malaria infection is generally characterized by recurrent attacks with the following signs and symptoms: Moderate to severe shaking chills High fever Profuse sweating as body temperature falls Headache Nausea Vomiting Diarrhea Malaria signs and symptoms typically begin within a few weeks after a bite from an infected mosquito. However, some types of malaria parasites can lie dormant in your body for months, or evsen year. Thick and thin blood smears Liver function tests Complete blood count (CBC) Blood glucose test Treatment of uncomplicated P. falciParum malaria Artemether + lumefantrine 20mg/120mg, a 6-dose regimen over a 3-day period given twice a day for 3 days.

Treatment of malaria caused by P. vivax, P. ovale and P. malariae: Chloroquine 25 mg base/kg body weight divided over 3 days, combined with Primaquine 0.25 mg base/kg body weight, taken with food once daily for 14 days. In areas of multidrug resistance (East Asia), artesunate plus mefloquine, or artemether plus lumefantrine or dihydroartemisinin plus piperaquine are recommended

QUESTION 6 How will you differentiate between a patient of food poisoning and irritable bowel syndrome (IBS)?
DEFINITION: Food poisoning is a general term for health problems arising from eating contaminated food. While IBS is a common gastrointestinal disorder involving an abnormal condition of gut contractions. CAUSATIVE AGENTS: Food poisoning may be caused by: bacteria (Salmonella, Staphylococcus aureus, E. coli, Shigella, Clostridium botulinum), virus (Hepatitis A and E), environmental toxins (Heavy metals), toxins present in any food (mushrooms, sea food) .The exact cause of IBS is currently unknown but IBS is thought to result from : Abnormal GI tract movements , a change in the nervous system communication between the brain and the GI tract, abnormal movements of the colon, whether too fast or too slow, are seen in some patients. SIGNS & SYMPTOMS: The symptoms of food poisoning include: Abdominal cramps, nausea, vomiting, diarrhea, and fever. While symptoms of IBS include: Central or lower abdominal cramps, diarrhea, constipation, change in the stool frequency or consistency, gassiness (flatulence), passing mucus from the rectum, bloating, and abdominal distension. DIAGNOSIS: Food poisoning is diagnosed by: Stool test: Test stool for presence of WBCs with methylene blue. WBCs will tell about invasive pathogen but not distinguish specific type of pathogen. Stool culture test determine specific type of pathogen. IBS is diagnosed by: Urine analysis and Colonoscopy. TREATMENT: In case of food poisoning: Administer ORS If the causative organism is campylobacter then we must give erythromycin If it is due to giardia then give Flagyl (Metronidazole) 500 mg 1tab TID If it is due to cryptosporidium then control the underlying HIV with anti-retro viral drugs. In case of IBD: If food intolerance then proper diet is planed If constipation then increase fiber intake. Isbaghola can also be used. If diarrhea then water intake should be increased. Lopramide could also be administered. If it is due to bloating then anti-spasmodics of fluroglucinol can be given.

QUESTION 7 Give effective counseling of migraine. Which medicines are to be given in migraine and which are avoided?
MIGRAINE COUNSELLING: Take sweets and chocolates as they restore glucose level. Avoid migraine triggers. Drink plenty of water to avoid dehydration, especially if the patient has vomited. Rest in a quite darkened room. Caffeine and chocolates can increase serotonin levels so can be taken. Head massage Aromatherapy can be done by using essential oils. Proper sleep patterns should be followed.

MEDICINES TO BE GIVEN: Paracetamol (Acetaminophen) 500mg 1tab t.i.d Naproxen (Anaprox) 500mg 1 tab t.i.d

MEDICINES NOT TO BE GIVEN: Never give anxiolytics like Xanax (Diazepam) as it decreases the serotonin levels in brain. MIGRAINE PATTERNS: Appearance of shimmering light dazzlingly bright, almost as bright as the sun and become enormous shimmering semicircle, with sharp zigzagg borders and brilliant blue and orange colors. After the brightness, came a blindness, an emptiness in field of vision. One-sided, pulsating pain that tends to get worse with physical exertion duration from four hours to three days Accompanied by nausea and vomiting May be followed by a period of mental confusion and sensory sensitivity

QUESTION 8 How will you differentiate between a patient of hypoglycemia and epilepsy?
HYPOGLYCEMIA DEFINITION: A condition in which there is low glucose levels in blood. CAUSATIVE AGENT: Excessive insulin Skipping meals Hepatic impairment Hormonal deficiency SIGNS & SYMPTOMS: Weakness Anxiety Tremors Sweating Palpitation Headache Vertigo Loss of consciousness Drowsiness Fatigue VITAL SIGNS: Low pulse rate Low blood pressure Patient get normalize on administration of some sweet thing. EPILEPSY DEFINITION: A neurological disorder characterized by fits. CAUSATIVE AGANT: CNS disorder

SIGNS & SYMPTOMS: Fits Convulsions Hearing ends in last. Abnormal body movements. Biting on the sides of tongue.

VITAL SIGNS: Normal pulse rate Normal blood pressure Patient regains itself after 20-25 minutes.

QUESTION 9 Give first aid management for:

1. ACID CONSUMPTION:

Do not make the patient vomit. Give plenty of water to dilute the acid. Add if possible 2 table spoon of chalk, milk of magnesia, plaster of paris or white wash to the pint of water for administration.

2. BASE CONSUMPTION:

Vomit should not be induced. Give plenty of water to dilute alkali. Add 2 table spoon of vinegar, orange, lemon or lime juice in a pint of water for administration.

3. SNAKE BITE: Wash the wound with soap and water. Immobilize the affected area. Keep the affected area slightly elevated. Apply a wide elastic crepe bandage tightly to: Prevent venom from spreading Take care of any bleeding Alkaloids like black tea decoction can be given, it act as absorbent.

4. WASP BITE: (basic) Place ice packs on the site of bite. Wash with and water.

Apply vinegar to neutralize. Place sliced lemon to neutralize the effect of bite.

5. HONEY BEE BITE: (acidic)

Remove any stingers remaining in the skin immediately. Wash the sting site with soap and water. Apply an ice cube or ice pack to reduce pain & swelling. Apply calamine lotion. Try not to squeeze the stinger as more venom will be released into the skin .

6. ACID IN EYE: Immediate and thorough irrigation of eye with tap water for 10 minutes to prevent damage to cornea. Wash eye with 0.9% normal saline.

7.

BASE IN EYE: Immediate and thorough irrigation of eye with tap water for 20 minutes to prevent damage to cornea. Wash eye with 0.9% normal saline.

8.

OBJECT IN NOSE: If you cant see the object then try to blow your nose while pinching the other nostril closed. If you can see the object then grab it with tweezers & gently pull it out.

9. OBJECT IN EAR: Do not use oil. Tilt the head towards the side with the foreign object. Gently shake the head towards floor to try to get the object out. Gently pull the ear up & back.

10. FOREIGN PARTICLES IN THE EYE Blow to eye. Remove particle with the help of cotton bud. Take OTC (panadol) for pain. Dont touch eye with dirty hands. Rinse with warm water.

QUESTION 10 Differentiate between upper respiratory tract infection & lower respiratory tract infection.
UPPER RESPIRATORY TRACT INFECTION In URTI person may have red eyes and pressure in ear due to otitis media. Low grade fever Dry cough Mild infection LOWER RESPIRATORY TRACT INFECTION In LRTI there is progression of lower throat infection towards lower side & patient suffers from wheezing sounds. High grade fever Sputum is produced Severe infection Can be treated by Antibiotics No hoarseness Wheezing sounds

It is self limiting Hoarseness of voice due to inflammation of vocal cord No wheezing sounds CAUSES: Most commonly viruses like Adino virus.

CAUSES: Mostly bacterial infections by:H. influenza, Streptococcus pneumonia, M. tubercle

DIAGNOSIS: Swab test Culture test e.g. phyringitis, lyringitis

DIAGNOSIS: Sputum test e.g. asthma, tuberculosis.