1.1 ANEMIA
Red Flags
Iron deficiency anemia | Pernicious anemia and B12 deficiency |
|---|---|
Iron deficiency anemia in men | Systemic features (e.g., weight loss, fever, night sweats, malaise, and fatigue) |
Iron deficiency in postmenopausal women | Psychiatric symptoms (e.g., depression, delirium, and dementia) |
Failure to respond with oral iron therapy | Neurological problems (e.g., peripheral neuropathy and subacute degeneration of spinal cord) |
Weight loss, malaise, fever, and night sweats | Cardiac symptoms (e.g., chest pain and heart failure) |
Worsening or new symptoms | |
Gastrointestinal (GI) symptoms (especially GI bleeding) |
WHO definition of anemia | Adult male | Adult female |
|---|---|---|
Hemoglobin concentration | <13 g/dL | <12 g/dL (<11 g/dL in pregnancy) |
Hematocrit (HCT) | <39% | <36% |
Anemias arise because red blood cell (RBC) production is inadequate or RBC lifespan (normally 120 days) is shortened through loss from circulation or destruction.
Etiology
Iron deficiency anemia
Anemia of chronic disease (ACD) [infections, connective tissue disease (CTD), and malignancy]
Chronic kidney disease (CKD) and chronic renal failure (CRF)
Blood loss (hemorrhage)
Hemolysis
Drugs (e.g., chemotherapy and drugs)
Etiology may be determined on the basis of mean corpuscular volume (MCV) [when complete blood count (CBC) or hemogram is done], but if there is associated leukocyte abnormality or platelet abnormality, or patient is not responding to treatment in 4 weeks despite treating an apparent cause, consider bone marrow biopsy or bone marrow aspiration.2
Etiology of Anemia (Based on MCV) and Investigations
Low MCV: < 80 = Microcytic anemia | Normal MCV: 80–100 = Normocytic anemia | High MCV: >100 = Macrocytic anemia |
|---|---|---|
Etiology | ||
|
|
|
Investigations (choices include) | ||
Peripheral smear Stool occult blood Iron profile: 1. Serum iron 2. Transferrin 3. Ferritin 4. Total iron-binding capacity (TIBC) Gastrointestinal workup may include: Endoscopy Colonoscopy Capsule enteroscopy Tc-labeled Meckel's scan Bleeding scan (Tc-labeled with RBC) Angiography Perioperative enteroscopy Hb electrophoresis (Hb variant analysis) HbA, HbA2, HbF helps to diagnose thalassemia | Peripheral smear Serum ferritin, serum iron and TIBC (may be normal or increased) Renal function test (RFT) Chest X-ray (CXR), Mantoux test CTD workup Neoplasm workup [ultrasound (US), CT, MRI, and biopsy] Bone marrow biopsy | Peripheral smear Serum folic acid level Serum B12 level Liver function test (LFT) (increased indirect bilirubin + increased reticulocyte count suggests hemolysis) Thyroid-stimulating hormone (TSH) Reticulocyte count |
Parameters | Normal values | Iron deficiency | Thalassemia | Sideroblastic | Inflammation | Renal disease |
|---|---|---|---|---|---|---|
Peripheral smear | Normochromic normocytic | Microcytic hypochromic | Microcytic/hypochromia with targeting | Variable | Microcytic/hypochromic/normocytic | Normocytic |
MCV (fL) | 80–100 | 60–90 | <80 | – | 80–90 | 90 |
Serum iron (SI) (µg/L) | 50–150 | <30 (low) | Normal or high | Normal or high | <50 | Normal |
Serum ferritin (µg/L) | 50–200 | <15 (low) | 50–300 | 50–300 | 30–200 | 115–150 |
TIBC (µg/L) | 300–360 | >360 (high) | Normal | Normal | <300 | Normal |
Marrow iron stores | 1–3+ | – | – | 2–4+ | 1–4+ | |
Saturation (%) | 30–50 | <10 | – | – | 10–20 | Normal |
Treatment of Anemia
Treatment for iron deficiency anemia (choices include) | Treatment of anemia of chronic disease (e.g., CKD) (choices include) | Treatment of macrocytic anemia (choices include) |
Iron replacement Oral iron: LIVOGEN or AUTRIN or DEXORANGE or 1 capsule/tablet once daily with food for 6 weeks and reassess. May add vitamin C to augment absorption. Avoid taking with antacids Compliance may be checked by asking color of stool (if stool is dark or black, it means patient is taking medicine regularly) Hemoglobin should increase by 2 g/dL by the end of 3 weeks and if it is not increasing, it may be due to noncompliance, continued blood loss, or incorrect diagnosis Continue for 3 months after hemoglobin has returned to normal | Treat the cause | |
Parenteral iron: HEMFER (iron sucrose) 2 ampules in 1 bottle of normal saline (NS) over 4 hours; give twice weekly till hemoglobin increases to 10–12 g FERINJECT (ferric carboxymaltose): Up to 1,000 mg iron bolus over 15 min/week Blood transfusion (BT), packed red blood cells (PRBC), 300 mL gives 200 mg iron (i.e. ↑Hb by 1 g/dL) | ||
Deworm: ZENTEL (albendazole) 1 tablet immediate dose and repeat after 10 days or MEBEX (mebendazole) 1 bd for 3 days and repeat after 10 days | Erythropoietin* (EPOX/EPREX/HEMAX) 2,000–4,000 U/mL; SC once a week | Tablet folate 5 mg od |
Gastrointestinal workup/investigation (consider occult GI malignancy in older people), e.g., endoscopy, colonoscopy, etc. and treat the cause | HEMFER IV (iron sucrose); give twice weekly till hemoglobin increases to 10–12 g | Neurobion forte IM daily for 1 week, once a week for 1 month and then once a month |
* Erythropoietin (SC EPO) 50–100 units/kg SC once a week to maintain a hematocrit >30%.
Blood Transfusion in Anemia
Anemia itself is not an indication for BT. A second trigger factor listed below must be present for BT. At least two units of PRBCs should be given. Single unit transfusion is not advised.
Anemia/Hb level | Second trigger | Blood transfusion (BT) |
|---|---|---|
<7 g/dL | Symptoms such as hypotension, tachycardia | Indicated |
<8 g/dL | Elderly > 65 year, LVD, PVD, history of stroke, and chronic obstructive pulmonary disease (COPD) | Indicated |
Acute blood loss > 1,500 mL | Trauma patient | Indicated |
7–8 g/dL | Needs minor surgery, and patient is young and healthy | Not indicated |
Hemolytic Anemia
Causes of hemolytic anemia by mechanism | |||
|---|---|---|---|
Location | Mechanism | Examples | Mode |
Red blood cells Intrinsic deficiency | Enzyme defects | Glucose-6-phosphate dehydrogenase (G6PD) or pyruvate deficiency | Hereditary |
Hemoglobinopathies | Sickle cell anemia | ||
Membrane abnormalities | Hereditary spherocytosis paroxysmal nocturnal hemoglobinuria (PNH) | ||
Extrinsic | Immune-mediated | Autoimmune, drug induced (lead, copper, and oxidizing agents) | Acquired |
Hemolysis | Prosthesis, transfusion reactions | ||
Infections | Malaria, Bartonella, Babesia, and Clostridia | ||
Organ dependent | Liver failure and hypersplenism | ||
Microangiopathic | Thrombotic thrombocytopenic purpura and prosthetic valve leak | ||
Investigations and Clues for Hemolytic Anemias
Blood picture may show spherocytes.
Increased reticulocyte count (RI > 2%), increased lactate dehydrogenase (LDH), increased indirect bilirubin, decreased haptoglobin, and positive urinary hemosiderin (suggest hemolytic anemia)
Autoimmune hemolysis: Coombs test = Direct antiglobulin test (DAT) is positive (if agglutination occurs when antisera against immunoglobulins or C3 are applied to patient RBCs)
Intravascular: Increased LDH, decreased haptoglobin, hemoglobinemia, hemoglobinuria, and hemosiderinuria
Extravascular: Splenomegaly
Family history of anemia, personal or family history of cholelithiasis4
Key Points
Palate is the best place to look for anemia (tongue and eye can be misleading).
Initial investigation should be a hemogram or CBC with MCV and blood picture; then select appropriate investigation(s) depending on MCV. MCV helps to diagnose type of anemia.
Iron deficiency anemia: Serum ferritin level is <15 µg/mL (microgram per milliliter), caused by bleeding unless proved otherwise, and responds to iron therapy. In microcytic hypochromic anemia, consider GI malignancy in elderly, deworming children and menorrhagia in young females of reproductive age group.
Anemia of chronic disease [CKD, infections, rheumatoid arthritis (RA), inflammatory bowel disease (IBD), and malignancy] may have mild-to-moderate normocytic anemia or microcytic anemia. Treat the underlying cause.
In thalassemia, microcytosis is disproportionate to degree of anemia. There is a family history or lifelong personal history of microcytic anemia. Microsites, hypochromic target cells, and acanthosis are seen in peripheral blood smear.
If patient is very pale, liver or spleen is enlarged, has bleeding tendencies or not responding to treatment, they need further evaluation and referral.
1.2 ANOREXIA AND WEIGHT LOSS
Red Flags
Unexplained and/or rapid weight loss (>10% in 6 months)
Symptoms suggestive of malignancy
Eating disorder
Depression
Night sweats
Fever
Lymphadenopathy [especially left supraclavicular scalene node enlargement (Virchow's node)]
Past history of cancer
Abnormal blood tests
Abnormal physical examination
Etiology and Investigations
Etiology | Investigations (choices include), and clues from history |
|---|---|
Anemia | CBC (refer Chapter 1.1) |
Infections (fever) | CBC, CXR, LFT, Hepatitis A, B, C, HIV [HBsAg, HBcAb, HAV (IgM, IgG), HIV] |
Metabolic: Diabetes Hyperthyroidism | Fasting blood sugar (FBS), postprandial blood sugar (PPBS), HbA1c TSH, FT3, FT4 |
Cancer, lymphoma, and leukemia | CBC, endoscopy, colonoscopy, US, CT/MRI, and biopsy |
Renal disease | Creatinine, urea, urine examination, US |
Liver disease | LFT, PT, and US |
Drugs | History of metformin, antimalarial, antibiotics |
Psychogenic | Anxiety and depression |
Miscellaneous tricky situations: Child | Psychological or study related |
Female | Pregnancy, family problems with spouse or child |
Male | Alcoholic, malignancy |
History and Diagnosis
History | Clues/Diagnosis |
|---|---|
Fever, hepatitis, jaundice | Fever and jaundice |
Cough, low-grade fever | Tuberculosis (TB) |
Fatigue, breathlessness on exertion, palpitation, leg pain, nausea, vomiting, loss of appetite, blood in vomit or stool, postprandial, and dark color urine, does not feel as looking at food, postprandial fullness, change in bowel habits | |
Diet and eating habits | |
Current medications (antibiotics, metformin, and antimalarial) | Drug induced |
Addictions | Alcohol, paan, and cigarettes |
Psychiatric history | Anxiety or depression |
Checklist
Check for anemia, jaundice, and lymph nodes
Auscultate chest (for TB, etc.)
Palpate abdomen for spleen or liver enlargement (systemic illness)
Check for lumps/masses to rule out cancer (carcinoma, e.g., stomach/liver)
Treatment (Choices Include)
Rule out organic/psychogenic causes at the starting of treatment | |
|---|---|
Deworming | Mebendazole (MEBEX) 1 bd for 3 days, repeat after 1 week albendazole (ZENTEL) 400 mg immediately, repeat after 1 week |
Appetizing tonics | ZINCOVIT/BETONIN/NEOGADINE ELIXIR |
Protein supplements | THREPTIN DISKETTES three biscuits thrice daily or three scoops of protein powder (B-protein) |
B-complex injections | NEUROBION injection |
Key Points
Rule out anemia, infections (e.g., hepatitis and TB), malignancy (e.g., stomach carcinoma), side effects of drugs (metformin, antibiotics, and antimalarial), and substance abuse (alcohol, paan/betel nut, etc.)
Anorexia is a common phenomenon during and after most fevers.
Weight loss with increased appetite could be due to diabetes mellitus (DM), hyperthyroidism, worms, parasites, malabsorption, or Addison's disease.
1.3 BELL'S PALSY (IDIOPATHIC FACIAL NERVE PALSY)
Etiology
Reactivation of latent herpes simplex virus-1 (HSV-1)
Clinical Features
Unilateral weakness of facial muscles. Unable to close eye or smile properly on affected side, may be associated with ipsilateral hearing loss.
Diagnosis can be made clinically in patients with:
Typical presentation
No risk factors or preexisting symptoms for other causes of facial paralysis
No lesions of herpes zoster in external ear canal
Normal neurological examination with exception of facial nerve involvement
Investigations (Choices Include)
In uncertain cases, investigations may include erythrocyte sedimentation rate (ESR), fasting blood sugar (FBS) for DM, Lyme titer, angiotensin-converting enzyme level, abdomen and chest imaging for possible sarcoidosis, lumbar puncture for possible Guillain–Barré syndrome, or MRI scanning.
Treatment (Choices Include)
Combination treatment with Valacyclovir (VALCIVIR) 500 mg twice a day for 5 days and prednisolone (WYSOLONE) 60–80 mg/day for 5 days, speeds up recovery. Physiotherapy including electrical nerve stimulation may be tried in selected cases.6
Key Points
Self-limiting in most cases, although full recovery of affected facial muscle may take up to 3 months.
Patient should protect eye with a patch and artificial tears [MOISOL (methylcellulose) eye drops].
Refer urgently for ophthalmological assessment, if eyelid does not fully cover cornea when closure is attempted.
Incomplete paralysis in 1st week is favorable sign. Recovery is possible.
Search for underlying cause, if recovery has not started within 6 weeks of onset of symptoms.
Aberrant reinnervation may occur during course of recovery, giving rise to unwanted facial movements (e.g., eye closure when mouth is moved) or crocodile tears (tears in eyes during salivation).
1.4 BITES (MAMMALS, ANIMALS AND FIGHT BITES)
A. Animal/mammalian Bite
Dog, cat, bat, ferret, monkey, horse, sheep, goat, mongoose, jackal, and hyena bite or scratch or lick on abraded skin need rabies vaccine
(Rat, rodent rabbit, hare, squirrel, guinea pig, hamster, gerbil, and chipmunk bite wounds do not need rabies vaccine.)
Treatment of Animal Bite Wound
Wound care:
Wash with soap and water for 5–10 minutes. Irrigate wound for 5–10 minutes. Use 19G needle with 20 mL syringe or 35 mL piston to produce a pressure of 8 psi. Disinfect/Clean wound with betadine. Deride if necessary.
Avoid suturing the wound. Delayed primary closure is recommended (i.e., suture the wound after 3–5 days of dressing).
Puncture wounds should be left unsutured.
Elevate affected part
Antibiotics: Select appropriate antibiotics listed below (3–5 days as prophylaxis or 10–15 days for established infections). If patient is allergic to amoxicillin, use levofloxacin or ciprofloxacin. Consider adding metronidazole, if necessary.
Bite
Pathogens
Antibiotic choices
Dog
Eikenella corrodens, Staphylococcus aureus (S. aureus), Streptococcus, Pasteurella multocida (P. multocida) + anaerobes
Amoxicillin/clavulanic acid (AUGMENTIN or CLAVAM)
Cat
P. multocida, S. aureus + anaerobes
Amoxicillin/clavulanic acid (AUGMENTIN or CLAVAM)
Human
Streptococcus viridans (S. viridans), S. aureus + anaerobes
Amoxicillin/clavulanic acid (AUGMENTIN or CLAVAM)
Monkey
Eikenella corrodens, S. viridans
Amoxicillin + clavulanic acid (AUGMENTIN or CLAVAM)
Rat
Streptobacillus moniliformis, Leptospira
Amoxicillin/clavulanic acid) (AUGMENTIN or CLAVAM)
Snake
Pseudomonas, Enterobacteriaceae
Amoxicillin + clavulanic acid (AUGMENTIN or CLAVAM)
Shellfish
E. risopath
Doxycycline 100 mg IV bd
Meat bone
E. risopath
Doxycycline 100 mg IV bd
Poultry sting
Aeromonas
Cloxacillin + gentamicin
Leech
Aeromonas hydrophila
Ciprofloxacin (CIFRAN)
Tetanus toxoid (TT) booster
Vaccinations/Immunoglobulins
Post-exposure prophylaxis (PEP)
All or as much of the full dose of HRIG should be injected into the wound and the remaining vaccine should be injected IM into the deltoid. Do not give HRIG at the same site or through the same syringe with other rabies vaccine.
Administer in deltoid for adults; anterolateral thigh may be used for children (to avoid sciatic nerve injury and reduce adipose tissue depot delivery, the gluteus is not used).
Pre-exposure prophylaxis (PrEP): Primary vaccine is given for people who work as laboratory staff in research laboratories, animal handlers, wildlife officers, children, and travelers in rabies-affected areas. Vaccine is given on day 0, 7, 21, or 28 and a booster may be required every 6 months to 2 years
B. Fight Bites
Fight bites [tooth injuries to metacarpophalangeal (MCP) joints] should be treated more aggressively than human bites. These injuries occur when patient strikes another person in the mouth with a closed fist. Inoculation of sheath of tendon occurs as closed fist has extensor tendons at maximal length. Damaged contaminated sheet retracts up carrying saliva and bacteria. A small metacarpophalangeal skin laceration may appear innocuous but significant infection may be evolving. History suggesting a small skin laceration metacarpophalangeal joint should prompt thorough evaluation. Fight bites have an infection rate up to 75% and approximately 60% have deep structure involvement including tendon injury, joint involvement, and fractures. These injuries should be washed out in emergency department or in operating room and should be seen by a surgeon immediately.
C. Snakes/Scorpion Bite/Sting
Refer Chapters 3.5.2 and 3.5.3.
Key Points
The more complex the wound, the more it should be irrigated.
All lacerations of the metacarpophalangeal joint are to be considered as a fight bite.
Consider rabies prophylaxis in all mammalian bites
Proper antibiotic coverage for mammalian bites, fight bites should include antibiotics to cover beta lactamase producing bacteria.
1.5 BLEEDING
Red Flags
Bruising over face, neck, and trunk
Petechiae and/or purpura on extremities and trunk
Bleeding from multiple sites
Sepsis
Fever
Systemic symptoms (e.g., weight loss, malaise, fatigue, fever, and night sweats)
Etiology
Hematological causes | General causes |
|---|---|
Inherited coagulation disorders [e.g., Hemophilia A, Christmas disease, and von Willebrand's disease (vWD)] | |
Idiopathic thrombocytopenic purpura (ITP) | Liver disease |
Leukemia | Drugs (e.g., anticoagulants, antiplatelet therapy, and steroids) |
Myelodysplasia | Renal failure |
Myelofibrosis with splenomegaly | Shock |
Meningococcal septicemia and other sepsis, disseminated intravascular coagulation (DIC) | |
Systemic lupus erythematosus (SLE) | |
Antiphospholipid syndrome | |
Nutritional (e.g., vitamin C deficiency) |
History
Subset | Inference | Examples |
|---|---|---|
Site of bleeding: | Suspect defect in platelet or Vessel coagulation disorder | Nonsteroidal anti-inflammatory drugs (NSAIDs), ITP, leukemia, aplastic anemia Hemophilia, liver failure, DIC, and anticoagulants |
Age: | Inherited cause Acquired or milder inherited causes | |
Family history: | Acquired defect or no defect in hemostasis Hemophilia A or B, vWD | |
Clinical scenario: | Rule out extrinsic anticoagulation vWD, HELLP syndrome Rule out bleeding from arteries and veins |
Examination (Checklist)
Pallor, gum hypertrophy, jaundice, lymphadenopathy, hepatosplenomegaly, and bony or sternal tenderness
Hematological and general conditions may cause bruising and bleeding (refer table above)
Coagulopathies, abnormal platelet function, or abnormal blood vessel walls are important causes.
Methods/Drugs to Stop Bleeding (Choices include)
Apply local pressure or pack or ligate the bleeder
Adrenaline (with NS or local anesthesia, e.g., xylocaine to pack a wound)
BOTROCLOT (use for nasal bleeding, e.g., hemocoagulase)
Vitamin K 5–10 mg PO or IV (liver disease)
Tranexamic acid (TXA) (TRANFIB) (for major trauma) 500–1,000 mg PO or IV thrice daily
Epsilon-aminocaproic acid (EACA) (HEMOSTAT) 5 mg tds PO for capillary bleeding
Fibrin sealant/gel foam (e.g., liver tear)
Ultrasound (harmonic scalpel)
Diathermy
Vasopressin, octreotide, somatostatin, and desmopressin (e.g., duodenal ulcer and variceal bleed)
When to Stop, Restart Antiplatelet, Anticoagulant, Fibrinolytic Medicines before Surgery and Choice of Reversal Agents
Drug | Stop before surgery | Restart after surgery | Reversal agent (choices include) |
|---|---|---|---|
1. Antiplatelets | |||
Aspirin/NSAIDs | No need to stop for local anesthesia cases or spinal anesthesia. Stop 3 days before surgery for epidural anesthesia | 12 hours after surgery | |
Clopidogrel | 5–7 days before surgery | 12–24 hours after surgery | Platelet transfusion Desmopressin |
Prasugrel | 7 days before surgery | ||
Ticlopidine | 14 days before surgery | ||
2. Anticoagulants | |||
Heparin | 6 hours before surgery | 6 hours after surgery | Protamine |
Warfarin | 4–5 days before surgery | 12–24 hours after surgery | Vitamin K 10 mg IV FFP |
LMWH like Enoxaparin | 12 hours before surgery if on prophylactic treatment or 24 hours if on treatment for DVT | None | |
Dabigatran | 7 days before surgery | 24 hours after surgery | None |
Fondaparinux | 3 days before surgery | 12 hours after surgery | None |
Rivaroxaban, apixaban | 3 days before surgery | 6 hours after surgery | None |
3. Fibrinolytics | |||
Streptokinase, Urokinase | No clear data available | No clear data available | Tranexamic acid EACA |
Investigations (Choices Include)
Complete blood count with peripheral smear
Clotting screen:
Platelet count: Normal = 150,000–450,000
Prothrombin time (PT): A difference of more than 4 seconds between control and test is significant (normal = 6.5–11.9)
Activated partial thromboplastin time (aPTT): A ratio of >1.5 times between control and test is significant [International Normalized Ratio (INR): > 1.3 is significant](normal = 0.7–1.2)
Bleeding time (BT): Normal = 2–7 minutes
Clotting time (CT): Normal = 3–8 minutes
Liver function test
Urea and electrolytes
Human immunodeficiency virus (HIV), hepatitis B and C [blood borne infection (BBI) screen]
Interpretation of Investigations
Platelet | PT | aPTT | Diagnosis |
|---|---|---|---|
↓ | Normal | Normal | ITP, aplastic anemia |
↓ | ↑ | ↑ | Treatment with anticoagulants, liver failure, and vitamin K deficiency |
Normal | Normal | Abnormal | Hemophilia (factor X, factor VII, and factor XI), heparin treatment and vWD |
Normal | Normal | Normal | Factor XIII deficiency and renal failure |
Normal | ↑ | Normal | Vitamin K deficiency |
Normal | ↑ | Abnormal | Liver cell failure |
↓ | Normal | Normal | Dengue, leptospirosis, aspirin, and NSAIDs |
General Instructions for Patients with Bleeding Diathesis or Bleeding Tendency
Avoid intramuscular (IM) injections
Avoid NSAIDs, as it interferes with platelet function
Consult a hematologist prior to any surgical procedure
Persistent or profuse bleeding should always be shown to a local physician/hematologist.
Gum bleed from tooth socket:
One tablet of TXA (TRANFIB, CYKLOKAPRON) 500 mg to be made as fine powder and mix with one teaspoon of water to make a paste. This is applied at local site of bleed (at least 10–15 minutes), can be swallowed later.
In case of generalized bleed, dissolve tablet in 15 mL water. Keep in mouth for 5 minutes and then swallow.
If bleeding does not stop by local measures, tablet/capsule can be taken orally.
Dose 500 mg tid for an adult initially and can be increased to 1 g every 6 hours (dose in children is 50–100 mg/kg/day). This may be continued till the bleeding stops. Systemic TXA (oral/intravenous) is contraindicated in patients with hematuria.10
Epistaxis:
Tranexamic acid injection 500 mg (TRANFIB 1 mL = 10.0 mg) can be drawn in and instilled into the nose drop by drop and pinch nose.
Once a vial is opened and drawn in a syringe, it may be kept in refrigerator (4–8°C) for a maximum of 24 hours.
If injection is not available, one tablet may be finely powdered and mixed with 5 mL of water and the above instruction may be followed.
Girls who have achieved menarche: In case of heavy menstrual bleeds, tablet Ovral L one tablet three times a day for 2–3 days followed by one tablet twice a day for 2 days and then once a day for a total of 28 days (in case of normal menses, hormonal control of bleed is not required).
1.6 BLOOD AND BLOOD TRANSFUSION
Blood Composition (Total Volume is 5 Liters)
Constituents | Function | |
|---|---|---|
RBC | Carry oxygen to body organs and tissues. | |
WBC | Neutrophils, lymphocytes, monocytes, eosinophils, and basophils | Defense |
Platelets | Platelets + fibrin = clot | |
Plasma | (Water, salts, proteins and clotting factors) Albumin, immunoglobulins, clotting factors, and fibrinogen | Immune function and clotting |
Blood Components/Blood Fractions
Procedure of splitting whole blood to blood components is called cytapheresis. Eight blood components or flood fractions are obtained from whole blood
Blood Groups (Two Major Groups are ABO and Rh)
ABO Group (Karl Landsteiner Discovered Blood Groups)
Blood group is classification of blood based on presence or absence of certain substances (proteins) on blood cell surface. Like eye color, blood group is determined from genes.
Blood group | Antigens on RBC membrane | Antibodies in plasma |
|---|---|---|
A | A | Anti-B |
B | B | Anti-A |
AB (Universal receiver) | A and B | No antibody |
O (Universal donor) | No antigen |
Blood transfusions—who can receive blood from whom?
People with blood group O are called “Universal donors”.
People with blood group AB are called “Universal recipients”.
Rh (Rhesus) Group
In addition to ABO group, another antigen is present on the RBC is called Rh factor.
If Rh D antigen is present, it is Rh + and if not present, it Rh –
Importance of Rh group:
During pregnancy, if mother is Rh negative, and father is Rh positive, baby's blood group will be Rh positive as it is dominant and if not treated, baby can have serious complications.
Rhesus disease is a condition where antibodies in pregnant women's blood (Rh negative) destroy her baby's blood cells (this is known as hemolytic disease of new born) and is diagnosed by indirect Coombs test in mother.
All Rh negative women during pregnancy get anti–D injection at 28 weeks and 34 weeks.
Check cord blood:
If baby is Rh+, give another injection of anti–D to mother.
If cord blood of baby is Rh-, there is no need to give anti–D injection to mother.
Blood Grouping and Cross Match
Blood grouping | Cross match | |
|---|---|---|
How to do | A, B, and Rh D agglutinins are added to donated blood | Donors RBC are mixed with recipient's serum |
Time taken | 5 minutes | 15 minutes |
Uses | Blood transfusion Pregnancy (Rh incompatibility) Investigating cases of paternity dispute | Done before blood transfusion to give the right blood group |
Blood Components/Fractions
Component | Amount (mL) | Storage | Shelf life | Indications | Transfusion time |
|---|---|---|---|---|---|
Packed red blood cell (PRBC) | 300 | 4°C | 40 days | <4 hours | |
Leukocytes | |||||
Platelet concentrate | 50 mL = 1 unit | 22°C | 5 days | <20 minutes | |
Fresh frozen plasma | 1 unit = 200 mL (usually 3–4 unit are given) (5–10 mL/kg) | −18°C | 365 days | Within 2 hours | |
Cryoprecipitate (from cooling plasma to 4° C and collecting the precipitate) | 1 bag = 20 mL (usually 10 bags are given) Contains VII, Fibrinogen and VWF | −18°C | 365 days | <20 minutes | |
Albumin (5% and 25%) | |||||
Immunoglobulins (IgG, IgM, IgA, IgD and IgE) | |||||
Coagulation factor 8 and 9 | |||||
Whole blood (not used now a days) | 400 mL | 4°C | 35 days | <4 hours |
Indications for Blood Component Transfusion (Mnemonic = ABCT)
Anemia |
Bleeding (trauma, intraoperative, postoperative) |
Coagulopathy (congenital/acquired bleeding disorders) |
Thrombocytopenia (decreased production/chemotherapy/tumor infiltration) |
Blood Transfusion Complications
Immediate/Acute (<24 hours) | Delayed (>24 hours) |
|---|---|
Transfusion reactions: Allergic Febrile Hemolytic | Infections: HIV, hepatitis C, and hepatitis B Others: Hepatitis A, malaria, brucellosis, and trypanosomiasis |
Transfusion-related acute lung injury (TRALI) | Iron overload |
Septic shock | Post-transfusion purpura (PTP) |
Transfusion associated cardiac overload (TACO) | Graft versus host disease (GVHD) |
Hypothermia | |
Hyperkalemia | |
Hypocalcemia | |
Air embolism |
Treatment of Blood Transfusion Reactions
Acute hemolytic transfusion reaction (AHTR) (Mismatched blood transfusion) | |
|---|---|
Etiology | ABO incompatibility |
Site of hemolysis | Intravascular |
Pathophysiology | Hemoglobin released is bound by serum haptoglobin. Hemoglobin is filtered in kidney. Hemoglobinuria and renal failure |
Symptoms and signs | Fever, dyspnea, headache, loin pain, hypotension acute renal failure, jaundice, DIC, hypotension, and bleeding |
Treatment | ICU admission, cardiac monitor, and pulse oximetry: Stop transfusion Send blood samples Donor and recipient for cross match and group, blood coagulation screen, LFT, creatinine, urea Normal saline infusion (maintain urine output >100 mL/h). Insert Foley catheter. Diuretics (mannitol or furosemide) Maintain BP Intubation and ventilation serious cases Anuria: Treat as acute renal failure (ARF) Disseminated intravascular coagulation: Treat with appropriate blood components |
Allergic reaction (mild) (urticaria and itching) | Slow or stop transfusion Chlorpheniramine 10 mg IV Restart transfusion at a slow rate Observe more frequently |
Anaphylaxis | Stop transfusion Oxygen IV fluids NS (as fast as possible). Adrenaline IM. Chlorpheniramine |
Nonhemolytic febrile transfusion reaction (NHFTR) | Slow or stop transfusion Temperature > 1.5°C (patient stable). Give paracetamol. Restart transfusion at a slower rate Observe more frequently |
TRALI (clinical features of left ventricular hypertrophy (LVH) fever, chills) | Stop transfusion Oxygen, endotracheal intubation, and ventilate if necessary |
Bacterial contamination/septic shock | Stop transfusion Antibiotics |
Transfusion associated cardiac overload (TACO) | Slow or stop transfusion Give oxygen and diuretic, e.g., furosemide |
Prevention of Blood Transfusion Complications
Safety check list for Laboratory staff, Nurses, and doctors | Use blood transfusion only if needed Give to right patient Check group and cross match compatibility. Check expiry date. Check for signs of hemolysis/leakage If any acute complication is noted, stop transfusion and review |
Methods to Reduce Blood Transfusion (i.e., Blood Conservation)
History | Enquire about bleeding history (past, present, family, and drug history) This helps to detect patients with coagulation/bleeding disorder Perform coagulation screen, platelets, PT, APTT, TT, LFT, and correct before surgery whenever possible | ||||||
Drugs | Stop drugs like aspirin, clopidogrel, heparin, warfarin 5–7 days before surgery Treat anemia with Iron supplements/B12/erythropoietin Tranexamic acid 1 g half hour before surgery for major cases/trauma-associated shock | ||||||
Procedures | Temporary measures to control bleeding (pressing/lacking) Tourniquets, vasoconstrictors (e.g., LA with adrenaline) Electrocautery, lasers, and embolization Fibrin sealants (e.g., liver surgery and cardiac surgery) | ||||||
Auto transfusion (use your own blood) |
|
Massive Blood Transfusion
Massive transfusion causes a lethal triad of coagulopathy, hypothermia, and acidosis.
Hemophilia
Introduction | Hemophilia A is deficiency of factor 8 Hemophilia B is deficiency of factor 9 (Christmas disease) Affects males, females are carriers. Severity of disease depends on level of clotting factors |
Signs and symptoms | Frequent spontaneous bleeding into joints, muscles, and soft tissue (pain precedes bleeding) Epistaxis, bleeding gums, hematuria, and central nervous system (CNS) bleeding |
Investigations | Factor 8 or 9 (reduced levels) APPT (prolonged) Platelets normal, prothrombin time normal |
Treatment choices | Hemophilia A:
Hemophilia B:
|
Artificial Blood/Oxygen Therapeutic Agents (OTAs)/Blood Substitutes
Types | 1. Hemoglobin based oxygen carriers (HBOCs). Artificial blood is designed for sole purpose of transporting oxygen throughout body. HBOCs (0.08–0.1 μ) vaguely resemble blood. They are very dark red or burgundy and are made from sterilized hemoglobin and are extremely good at carrying dissolved gases 2. Perfluorocarbons |
Advantages | No compatibility testing Free from blood borne infections Prolonged shelf life and requires no refrigeration |
Disadvantages | Still under research and development Not approved by FDA |
Key Points
Avoid unwanted blood transfusion.
Lab data is not sufficient especially in acute and ongoing bleeding
PRBC transfusion is indicated in:
Acute and ongoing bleeding even if Hb is in normal limits
Chronic anemia if patient is symptomatic and Hb is <7 g/dL
Platelet transfusion is indicated if there:
Thrombocytopenia or platelet dysfunction
If platelet count is <50,000/mL for minor surgical procedures
1.7 CELLULITIS
Definition
Spreading subcutaneous infection by β-hemolytic Streptococcus (Streptococcus releases hyaluronidase and streptokinase).
Clinical Features
Swollen, warm, red, painful, and fever
Lymphangitis (lymphatic draining affected areas become inflamed and are seen as red streaks)
Lymphadenitis (lymph nodes swollen and tender)
Complications
Abscess
Septicemia
Precipitating factor for diabetic ketoacidosis (DKA)15
Differential Diagnosis
Erysipelas
Stasis dermatitis
Lipodermatosclerosis or sclerosing panniculitis
Contact dermatitis
Popular urticaria
Investigations (Choices Include)
WBC count, RBS/FBS/PPBS
Blood culture and sensitivity (C/S)
Microscopy, C/S of fluid (aspiration from point of maximum inflammation, leading edge or most intense area of induration)
X-ray/CT/MRI
Treatment (Choices Include)
Antibiotics: Penicillin/cefazolin/cefadroxil/levoflox/amoxiclav
Analgesics
Anti-inflammatory drugs
Rest (immobilization)
Elevation (helps to reduce edema)
Note: Refer Chapters 1.4, 12.2.14.9 for more details.
Key Points
Cellulitis most often presents unilaterally.
Stasis dermatitis is a common mimic of cellulitis and results from long-standing history of chronic venous stasis and decreased tissue perfusion
Pain out of proportion to exam should prompt physician to consider necrotizing soft tissue infections.
Observation and serial examination will aid in treatment and evaluation for alternate diagnosis.
History and physical exam will direct physician in differentiating cellulitis from its mimics.
Double incision fasciotomy for severe cellulitis and lymphangitis decreases the incidence of persistent lymphedema.
Note for Readers:
1.8. CHANGE IN MENTAL STATUS (CONFUSION, AGITATION, DELIRIUM, DROWSINESS, STUPOR, AND COMA) (REFER CHAPTERS 1.10, 1.14 AND 1.15)
1.9 SOME COMMON DISEASES OF KIDNEY AND CHRONIC KIDNEY DISEASE
1. Common Kidney Diseases
Kidney disease occurs when the kidneys are damaged and cannot function properly. Numerous conditions and diseases can result in damage to the kidneys, thus affecting their ability to filter waste from the blood while reabsorbing important substances. Generally, kidney disease may present or develop in a few different ways.
Acute kidney injury (AKI)—rapid loss (over a few hours or days) of kidney function. It may be recognized when a person suddenly produces urine much less frequently and/or has a dramatic increase in the level of waste products in the blood that the kidneys normally filter out. AKI is often the result of trauma, illness, or a medication that damages the kidneys. It is most common in people who are already hospitalized such as those who are critically ill and in intensive care unit. If damage caused by AKI persists, it can eventually progress to CKD.
Chronic kidney disease occurs over time lasting over 3 months and common causes are diabetes and high BP (hypertension).
Nephrotic syndrome: It is characterized by the loss of too much protein in the urine and caused by damage to glomeruli. A primary disorder of the kidney or secondary to an illness or other condition, such as cancer or lupus can cause nephrotic syndrome. Along with high amount of protein in urine, signs and symptoms of nephrotic syndrome include a low albumin in blood, higher than normal lipid levels in blood, and swelling (edema) in levels of legs, feet, and ankles.16
Kidney failure, also called end-stage renal disease or ESRD, is the total or near total loss of kidney function and is permanent. Treatment with hemodialysis or kidney transplant is the only option at this stage of kidney disease to sustain life.
Risk factors for kidney disease are:
Diabetes: A sustained high level of blood glucose from uncontrolled diabetes can over time damage the nephrons in the kidneys. This can be avoided by maintaining a good glucose control.
Family history of kidney disease : Polycystic kidney disease (PKD)
Glomerulonephritis (chronic nephritis or nephritic syndrome)
Obstruction: Kidney stone or tumor
Autoimmune disease: Systemic lupus erythematosis or Goodpasture's syndrome
Infections: Strep infections of throat or skin, skin infection impetigo, endocarditis, or a viral infection.
Toxins : Contrast dyes used for imaging procedures and certain medication
Prerenal azotemia: Severe burns, severe dehydration, or septic shock
Tests Commonly Used For Screening and Diagnosis
The National Kidney Foundation and the National Kidney Disease Education Program (NKDEP) recommend that people who are at high risk be screened for kidney disease to detect it in its earliest. Risk factors include diabetes, high BP, heart disease, or a family history of these or kidney disease.
Tests | Comments |
|---|---|
Urine albumin | This test may be done on a 24-hour urine sample or both urine albumin and creatinine can be measured in a random urine sample and the albumin/creatinine ratio (ACR) can be calculated. The American Diabetes Association recommends ACR as a preferred test for screening for albumin the urine (microalbuminuria) |
Urine analysis | This is a routine test that can detect protein in the urine as well as RBCs and white blood cells. These are not normally found in the urine and if present, may indicate kidney disease |
Urine total protein or urine to creatinine ratio (UP/CR) | Detects not just albumin but all types of proteins that may be present in the urine |
Estimated glomerular filtration rate (eGFR) | A blood creatinine test or possibly a cystatin C test is performed in order to calculate the eGFR. The GFR refers to the amount of blood that is filtered by the glomeruli per minute. As a person's kidney function declines due to damage or disease, the filtration rate decreases and waste products begin to accumulate in the blood |
Urea (urea nitrogen or BUN) | Level of this waste product in blood increases as kidney filtration declines. Increased BUN levels suggest impaired kidney function, although they can also be elevated due condition that results in decreased blood flow to the kidneys, such as congestive heart failure (CHF), heart attack, or shock |
Creatinine clearance | Measures creatinine levels in both a sample of blood and a sample of urine from a 24-hour urine collection. Results are used to calculate the amount of creatinine that has been cleared from the blood and passed in to the urine. This calculation allows for a general evaluation of amount of blood that is being filtered by kidneys in a 24-hour time period |
Tests to Monitor Kidney Function
If a person has been diagnosed with a kidney disease, several laboratory tests may be ordered to help monitor kidney function. Some of these include:
Tests to Help Determine the Cause/Guide Treatment
Tests | Comments |
|---|---|
Urine analysis with a urine culture | May be done when someone has symptoms suggesting infections to confirm the presence of a bacterial infection |
Hepatitis B or C testing | To detect a hepatitis viral infection associated with some types of kidney disease |
Antinuclear antibody (ANA) | To help identify an autoimmune condition such as lupus that may be affecting the kidneys |
Kidney stone risk panel | Evaluates a person's risk of developing a kidney stone to help guide and monitor treatment and prevention |
Kidney stone analysis | Determines composition of a kidney stone passed or removed from the urinary tract and may be done to help determine the cause of its formation, to guide treatment, and prevent recurrence |
Complement tests (C3 and C4) | May be tested and monitored |
Urine protein electrophoresis | To determine the source of a high level of protein in the urine |
Myoglobin | In people who have had extensive damage to skeletal muscles (rhabdomyolysis), a urine myoglobin test may be ordered to determine the risk of kidney damage. With severe muscle injury, blood and urine levels of myoglobin can rise very quickly |
2. Chronic Kidney Disease
Etiology
Diabetes
Hypertension
Glomerulonephritis
Polycystic kidney disease
Reflux nephropathy and other congenital renal diseases
Interstitial nephritis, including analgesic nephropathy
Stages of Chronic Kidney Disease
Chronic kidney disease is present if any features listed below are present for >3 months.
Pathologic damage: Biopsy shows glomerulosclerosis, tubular atrophy, and interstitial fibrosis.
Abnormalities in blood: Elevation of BUN and serum creatinine over at least 3 months, anemia, hypocalcemia, and hyperphosphatemia.
Abnormalities in urine test: Urine sediments/proteinuria can be a forerunner of CKD.18
Abnormalities in albumin excretion | |
|---|---|
Test | Spot microalbumin collection (µg/mg creatinine) |
Normal | <30 mg/dL |
Increased urinary albumin excretion | >30 mg/dL |
Historically, ratios between 30 and 299 have been called microalbuminuria and those 300 mg/dL or greater have been called macroalbuminuria (clinical albuminuria = albumin in urine) | |
Imaging: Findings of small echogenic kidneys bilaterally < 9–10 cm by ultrasonography support a diagnosis of CKD (normal or even large kidneys with CKD can be seen with adult PKD, diabetic nephropathy, HIV-associated nephropathy, multiple myeloma, amyloidosis, and obstructive uropathy).
History of kidney transplantation
GFR < 60 mL/min/1. 73 m2
Symptoms and Signs of Uremia
Organ system | Symptoms | Signs |
|---|---|---|
General | Fatigue and weakness | Chronically ill |
Skin | Pruritus, easy bruisability | Pallor, ecchymosis, excoriations, edema, and xerosis |
ENT | Metallic taste in mouth, epistaxis | Urinous breath |
Eye | – | Pale conjunctiva, retinopathy |
Pulmonary | Shortness of breath | Rales, pleural effusion |
Cardiovascular | Dyspnea on exertion, retrosternal pain on inspiration (pericarditis) | Hypertension, cardiomegaly, and friction rubs |
Gastrointestinal | Anorexia, nausea, vomiting, and hiccups | |
Genitourinary | Nocturia, erectile dysfunction | Isosthenuria |
Neuromuscular | Restless legs, numbness, and cramps in legs | |
Neurologic | Generalized irritability and inability to concentrate, decreased libido | Stupor, asterixis, myoclonus, and peripheral neuropathy |
Treatment of Chronic Kidney Disease
Correct reversible causes of kidney injury causing CKD:
Reversible factors
Diagnostic clues
Infection
Urine culture and sensitivity tests
Obstruction
Bladder catheterization and renal US
Extracellular fluid volume depletion
Orthostatic BP and pulse (decreased BP and increased pulse upon sitting up or standing from a supine position)
Hypokalemia, hypercalcemia and hyperuricemia
Serum electrolytes, calcium, phosphate, and uric acid
Nephrotoxic agents
Drug history
Hypertension
BP, chest radiograph
Congestive heart failure
Physical examination, chest radiograph, and echocardiogram
Anemia
Iron deficiency/B12 deficiency/EPO deficiency
Diet:
Protein restriction
0.6 g/kg body weight for patients with stage 4 and 5 CKD
At least 50% protein intake should consist of high biological value protein
Salt restriction
80–120 mmol/day (NaCl) = 1 teaspoon salt
Water restriction
In fluid overloaded patients, daily intake should be < 800–1,000 mL/day
Potassium restriction
Avoid potassium-rich foods such as tender coconut water, banana, citrus fruit, and dates (when GFR falls below 10–20 mL/min or if patient is hyperkalemic)
Phosphorus restriction
Avoid eggs, beans, dairy products, cola beverages (when pH is high)
Magnesium restriction
Treatment of complications or comorbidities:
Hypertension
Maintain BP < 130/80 mm Hg
Proteinuria
Angiotensin receptor blockers (ARBs)/ACE inhibitors are drugs that have proven effect in decreasing proteinuria and prevent progression of diseases
Diabetes
Maintain FBS 90–130 mg/dL, HbA1c < 7
Short-acting insulin preferred (e.g., plain insulin)
If oral hypoglycemic agents (OHA) are to be used, short-acting sulfonylureas (e.g., gliclazide/glipizide) are preferred
Anemia
When Hb is < 10 g/dL:
Erythropoietin (WEPOX, EPOTRUST) 4,000 units twice weekly SC (80–20 units/kg body/week)
Check transferrin saturation and ferritin. If transferrin saturation < 20% or ferritin < 200 mg/mL, give iron sucrose 200 mg in 100 mL NS over 1 hour weekly once for 5 weeks followed once monthly; parenteral iron (FERINJECT and QRON) (iron sucrose) (refer Chapter 1.1)
Target Hb should be 11–12 g/dL
Bone disease—renal osteodystrophy (hyperphosphatemia, hypocalcemia and hypovitaminosis D) (↑ PTH)
Hyperphosphatemia:
Phosphate binders, calcium-containing binder: Ca acetate (LANUM 667 mg tds/PHOSTAT tds)
Noncalcium-containing binder: Sevelamer (REVYLAMER 400 mg tds)
Hypocalcemia:
Calcium carbonate (SHELCAL)
Hypovitaminosis D:
1,25(OH2), calcitriol, i.e., active form of vitamin D3 (LARETOL/ONE-ALPH)
High uric acid
If uric acid is > 8 mg/dL, febuxostat (FEBUGET/FEBUTAZ 40 mg od, morning) or [allopurinol (ZYLORIC 100 mg tds), dose should be decreased in azotemia]
Dialysis (indications):
Type
Indications
Hemodialysis or peritoneal dialysis (PD)
Anuria > 24 hours
Fluid overload unresponsive to diuretics
Refractory hyperkalemia
Severe metabolic acidosis
Uremic symptoms (encephalopathy, gastritis, and pericarditis)
Potassium and Chronic Kidney Disease Diet
What is potassium and why is it important?
Potassium is a mineral found in many foods. It plays a role in keeping heartbeat regular and muscles working right. It is the job of healthy kidneys to keep right amount of potassium in body. However, when kidneys are not healthy, one needs to limit certain foods that can increase the potassium in blood to a dangerous level. If potassium level is high, one may experience weakness, numbness and tingling or irregular heartbeat, deteriorating, VT or VF, and cardiac arrest.
What is a safe level of potassium in blood?
If it is 3.5–5.0 | Safe zone |
If it is 5.1–6.0 | Caution zone |
If it is higher than 6.0 | Danger zone |
How to keep potassium level from getting too high?
One should limit foods that are high in potassium; renal dietician will help to plan the diet.
Eat a variety of foods, but in moderation
Leach potassium-rich vegetables before using (leaching is a process by which some potassium can be pulled out of the vegetable)
Do not drink or use the liquid from canned fruits and vegetables or juices from cooked meat.
Almost all foods have some potassium, size of the serving is very important.
A large amount of a low-potassium food can turn into a high-potassium food.
What foods are high in potassium (>200 mg per portion)?
Following table lists foods that are high in potassium. The portion size is ½ cup unless otherwise stated. Check portion sizes. While all the foods on this list are high in potassium, some are higher than others.20
High-potassium foods | ||
|---|---|---|
Fruits | Vegetables | Other foods |
Apricot, raw (2 medium) and dried (5 halves) Avocado (¼ whole) Banana (½ whole) Dates (5 whole) Dried fruits Figs, dried Grapefruit juice Kiwi (1 medium) Mango (1 medium) Orange(1 medium) Orange juice Papaya (½ whole) Pomegranate (1 whole) Pomegranate juice Prunes Fruits Prune juice Raisins | Artichoke Bamboo shoots Baked beans Butternut squash Refried beans Beets, fresh and then boiled Black beans Broccoli, cooked Brussels sprouts Chinese cabbage Carrots, raw Dried beans and peas Greens Lentils Legumes Vegetables Mushrooms, canned Parsnips Potatoes, white and sweet Pumpkin | Bran/Bran products Chocolate (1.5–2 ounces) Granola Milk, all types (1 cup) Molasses (1 tablespoon) Nuts and seeds (1 ounce) Peanut butter (2 tablespoon) Salt substitutes/low salt Salt-free broth Yogurt Nutritional supplements: Use only under the direction of doctor or dietician |
What foods are low in potassium?
Following table lists foods that are low in potassium. The portion is ½ cup unless otherwise noted. Eating more than one portion can make a low-potassium food into a high-potassium food.
Low-potassium foods | ||
|---|---|---|
Fruits | Vegetables | Other foods |
Apple (1 medium) Apple Juice Apple sauce Apricots, canned in juice Blackberries Blueberries Cherries Cranberries Fruit cocktail Grapes Grape juice Grape fruit (½ whole) Mandarin oranges Peaches, fresh (1 small), canned (½ cup) Pears, fresh (1 small), canned (½ cup) Pineapple Pineapple juice Plums (1 whole) Raspberries Strawberries Tangerine (1 whole) Watermelon (limit to 1 cup) | Asparagus (6 spears) Beans, green or wax Cabbage, green and red carrots, cooked Cauliflower Celery (1 stalk) Corn, fresh (½ spear) and frozen (½ cup) Cucumber Eggplant Kale Lettuce Mixed vegetables Mushrooms, fresh Okra Onions Parsley Peas, green Peppers Radish Watercress Yellow squash Zucchini squash | Rice Noodles Pasta Bread and bread products (not whole grains) Cake (angel, yellow) Coffee (limit to 8 ounces) Pies without chocolate or high-potassium fruit Cookies without nuts or chocolate Tea (limit to 16 ounces) |
Sodium and Chronic Kidney Disease Diet
What is sodium?
Sodium is a mineral found naturally in foods and is a major part of table salt.21
What are the effects of eating too much sodium?
Some salt or sodium is needed for maintaining water balance in the body. But, when kidneys lose the ability to control sodium and water balance, one may experience the following:
Thirst
Fluid gain (swollen ankles, pedal edema, and puffiness of face)
High BP especially in salt sensitive people
Limit the amount | Food to limit because of their high-sodium content | Acceptable substitutes |
|---|---|---|
Salt and salt seasonings | Table salt, seasoning salt, garlic salt, onion salt, celery salt, meat tenderizer, and flavor enhancers | Fresh garlic, fresh onion, garlic powder, onion powder, black pepper, lemon juice, low sodium/salt-free seasoning blends, and vinegar |
Salty foods | High sodium sauces such as barbecue sauce, steak sauce, soy sauce, teriyaki sauce, oyster sauce salted snacks such as crackers, potato chips, corn chips, pretzels, tortilla chips, nuts, popcorn, and sunflower seeds | Homemade or low-sodium sauces and salad dressings (vinegar, dry mustard) unsalted popcorn, pretzels, tortilla, or corn chips |
Cured foods | Ham, salt pork, bacon, sauerkraut, pickles, pickle relish, and olives | Fresh beef, veal, pork, poultry, fish, and eggs |
Luncheon meats | Hot dogs, cold cuts, deli meats, sausage, and spam | Low-salt meats |
Processed foods | Buttermilk, cheese, soups, tomato products, vegetable juices, canned vegetables, macaroni and cheese, spaghetti, commercial mixes, frozen prepared foods, and fast foods | Natural cheese (1–2 oz per week) Homemade or low-sodium soups, canned food without added salt Homemade casseroles without added salt, made with fresh or raw vegetables, fresh meat, rice, pasta, or unsalted canned vegetables |
Hints to Keep Sodium Intake Down
Cook with herbs and spices instead of salt, read food labels, and choose those foods low in sodium.
Avoid salt substitutes and specially low-sodium foods made with salt substitutes because they are high in potassium.
When eating out, ask for meat or fish without salt, ask for gravy or sauce on the side; these may contain large amounts of salt, and should be used in small amounts.
Limit use of canned, processed, and frozen foods.
Understanding Information about Food Labels
Understanding the terms:
Sodium free: Only a trivial amount of sodium per serving
Very low sodium: 35 mg or less per serving
Low sodium: 140 mg or less per serving
Reduced sodium: Foods in which level of sodium is reduced by 25%
Light or lite in sodium: Foods in which sodium is reduced by at least 50%.
Simple rule of thumb: If salt is listed in first five ingredients, the item is probably too high in sodium to use.
All food labels now have milligram (mg) of sodium listed. Follow these steps when reading sodium information on the label:
Know how much sodium is allowed each day: Remember that there are 1,000 mg in 1 g. For example, if the diet prescription is 2 g of sodium, limit is 2,000 mg/day. Consider sodium value or other food to be eaten during the day.
Look at package label and check serving size: Nutrition values are expressed per serving. How does this compare to the total daily allowance? If sodium level is 500 mg or more per serving, item is not a good choice.
Compare labels of similar products: Select lowest sodium level for same serving size.
1.10 COMA
A coma patient is unarousable and unable to respond to external events or inner needs (although reflex posturing may be present). Coma is a major complication of serious CNS disorders. It can result from seizures, hypothermia, metabolic disturbances or structural lesions causing bilateral cerebral hemispheric dysfunction, or a disturbance of the brainstem reticular activating system. Mass lesion involving one cerebral hemisphere may cause coma by compression of the brainstem. All comatose patients should be admitted to hospital and referred to a neurologist or neurosurgeon.22
Physical examination | Immediate treatment (choices include) (“GOT-FAN MD” mnemonic) | |
|---|---|---|
| Glucose 50% | 50 mL, IV |
Oxygen | 8 L/min | |
Thiamine | 100 mg, IV | |
Flumazenil | 2 mL (0.2 mg) IV (max 10 mL = 1 mg)(benzodiazepine overdose) | |
Atropine | 0.3–0.6 mg (organophosphorus poisoning) | |
Naloxone | 400 mg, SC/IM (for opioid overdose) | |
Mannitol 20% | 0.25–1 g, IV over 10 min [for increased intracranial pressure (ICP)] | |
Dexamethasone | 16 mg IV stat + 8 mg, IV 8 hourly (if suspecting adrenal insufficiency) | |
Etiology and Investigations
Etiology (mnemonic “MIND”) | Investigations (choices include, select appropriately) |
|---|---|
Metabolic | CBC, RBS, Na, K, Ca LFT, RFT |
Infections | CBC Widal and malarial parasite in febrile patient Urine analyses Culture and sensitivity (C/S) of blood, urine, pus, tissue LP (CSF fluid analysis) CT (brain) |
Neurological | CT (trauma) MRI (stroke, seizure, infection, and neoplasm) |
Drugs | Toxic substance screening, e.g., drugs and poison |
Take a Good History from Attendants
History | Probable diagnoses |
|---|---|
Diabetes on (OHA/insulin, diabetic untreated or diabetic missed drugs or on irregular treatment) | Hypoglycemia, DKA, or hyperosmolar coma or cerebrovascular accidents (CVA)—thrombosis |
Hypertension, hypertensive encephalopathy | Stroke, hemorrhage, or SAH |
Epilepsy | Postictal state |
Drug history | Drug overdose |
COPD, bronchial asthma | Carbon dioxide narcosis, hypoxia |
Ischemic heart diseases (IHD), heart disease | Acute myocardial infarction (MI), embolic stroke, and brady- or tachyarrhythmia |
Renal disease | Uremic encephalopathy |
Metabolic acidosis | – |
Liver disease | Hepatic encephalopathy |
On diuretics | Hyponatremia (diuretics) |
Hypokalemia | – |
Other electrolyte imbalance | – |
Bleeding tendency or anticoagulation | Intracerebral hemorrhage |
Metabolic Coma
Etiology | Specific neurologic signs | Investigations |
|---|---|---|
Etiology | Specific neurologic signs | Investigations |
Hypoxia | Respiratory problem, cardiac problem, polytrauma resuscitation, and attempted suicide | Oxygen saturation, CXR, and ECG |
Hyperosmolar diabetic coma | Coma, seizures, and focal signs | |
Diabetic ketoacidosis | Clouding of consciousness, but rarely coma | Ketonuria Blood glucose > 250 mg% |
Hypoglycemia | High variability, including coma, seizure, and focal signs | Blood glucose < 60 mg% |
Hepatic encephalopathy | Tremor, asterixis (wing beating); final stage, severe clouding of consciousness | LFT, PT |
Uremia | Delirium, seizures, myoclonus, asterixis; final stage, and clouding of consciousness | Serum creatinine, urea, and potassium |
Disequilibrium syndrome | Muscle cramps, seizures, coma | Postdialysis, urea, sodium, and osmolarity |
Hyponatremia | Clouding of consciousness; seizures and coma only in case of rapid change of serum sodium level | Serum sodium < 126 mg |
Hypernatremia | Delirium, muscle weakness, and coma only in case of rapid change | Serum sodium >156 mg |
Hypocalcemia | Delirium, headache, and muscle weakness | Calcium and phosphate in serum and urine, parathormone |
Hypercalcemia | Bone/Joint pain, delirium, pseudopsychotic behavior, seizures | Calcium and phosphate in serum and urine, and parathormone |
Thiamine deficiency | Wernicke's encephalopathy; rarely coma (suspect in alcoholics) | Vitamin B level |
Prevention of Secondary Brain Damage
Secondary brain injury is commonly due to increased ICP.
It is a physiologic response, which occurs hours or even after days after primary brain injury due to hypotension or decreased cerebral blood flow (from local edema/bleeding/increased ICP).
Cause | Prevention/Treatment choices | ||||
Hypoxia (if SpO2 is <93%) | Supplement with oxygen 8 L/min and maintain SpO2 >94% Intubate and ventilate | ||||
Hypotension | Maintain SBP around > 90 mm Hg [mean arterial pressure (MAP) > 70 mm Hg] Maintain normotension | ||||
Raised ICP Hypoxia and hypotension are main causes of increased ICP Clinical features may include agitation, lethargy, focal neurological deficit, nonreactive pupils or Cushing's Triad Bradycardia, hypertension, or irregular respiration | Neutral head and neck position
| ||||
Hypercapnia (increased CO2 levels) | Ventilation to achieve normocapnia | ||||
Hypoglycemia/hyperglycemia | Maintain RBS around 150 mg/dL (normoglycemia), avoid dextrose containing solutions | ||||
Infection | Start appropriate antibiotics | ||||
Convulsions/seizures | Phenytoin, Levipill (PO/IV) |
Care of Unconscious Patient (Checklist)
Pass Ryle's tube (stomach wash, if poisoning/GI bleed is suspected)
Catheterize bladder. If urinary retention. (Connect condom drainage, if incontinent).
Nutrition and hydration: Start Ryle's tube feeding at the earliest, if there are no contraindications, as IV fluids alone will not give enough calories and nutrients. Total parenteral nutrition is expensive. Enteral nutrition is started with either premixed preparations or locally available freshly prepared (using items such as rice, dal, oil, egg, etc.).
Care of eyes to prevent exposure keratitis. Use eye shields to keep eyes closed.
Care of back to prevent bedsores. Frequent change of position (every 2 hours) to keep skin dry by using talcum powder. Use water/air bed.
Chest physiotherapy and intermittent throat suction to clear secretions.24
Maintain oral hygiene by wash/suction.
Nurse in lateral position to avoid aspiration.
Care of endotracheal tube. Periodic sterile suction and transient cuff deflation.
Care of IV access line, look for evidence of infection.
Follow aseptic precautions. Change cannula, if there is evidence of cellulitis or thrombophlebitis.
Avoid hypertonic solutions. Avoid extravasation of hypertonic solution, contrast material and drugs.
Prevent DVT.
Stabilize the neck with rigid collar, in cervical spine injury is ruled out.
Avoid supine position.
Do not place pillow.
Key Points
Coma is defined as persistent loss of consciousness.
Remember the mnemonic MIND for etiology of coma:
M: Metabolic
I: Infection
N: Neurological
D: Drugs
In an unconscious patient, if pupils are reacting well and equally, and no neurological deficit is present, coma etiology may be metabolic (diabetes or uremia) or intoxication (alcohol or sedatives).
Evaluate CNS, pupils, eye position, and focal deficits (lateralizing signs and meningeal irritation)
Consider antidotes (GOT-FAN) (Glucose, Oxygen, Thiamine, Flumazenil, Atropine, Naloxone)
In elderly patients, consider hyponatremia, treat with 3% saline infusion, aim for Na of 125–130 mg/dL and correct slowly.
Consider endotracheal intubation, if patient has apnea or SpO2 < 90% or Glasgow coma scale (GCS) < 8.
CT study may still be normal in bilateral hemispheric infarction, small brainstem lesions, encephalitis, meningitis, closed head trauma, sagittal sinus thrombosis, and subdural hematomas that are isodense to adjacent tissue.
Note for Readers:
1.11 COMMON COLD (REFER CHAPTER 1.20)
1.12 COUGH (REFER CHAPTER 6.15.2)
1.13 CRACKS ON SOLES
Etiology
Medical conditions | Diabetes mellitus (DM), leprosy, fungal infection, and hypothyroidism |
Acquired | Excessive sweating, aging, deficiency of vitamin A, and zinc |
Genetic/dermatological | Palmoplantar keratosis, hyperhidrosis, and psoriasis |
Treatment (Choices Include)
Soak feet in warm water for 20 minutes to soften feet. Use pumice stone for scrubbing feet if needed.
SALICA (salicylic acid 20%)—apply and cover with cling film.
COTARYL (urea and salicylic acid)
DK gel (miconazole) or CANDID (clotrimazole) ointment
SEBIFIN (terbinafine) tablets 250 mg od for 2 weeks
ZOCON (fluconazole) 150 mg one tablet twice weekly for 6 weeks
RETINO-A 0.05%
SUPER GLUE (apply locally after thorough cleaning to seal cracks)
Vaseline + lemon juice (mix in equal volumes and apply)
Ripe banana mash application
DALDA or VANASPATI (apply and cover with cling film and wear a pair of socks)25
Patient Education
Wear soft MCR footwear (chappals/slippers)
Avoid standing in stagnant blue detergent soap water, while washing clothes
Avoid steroid ointments for sole of feet
Wear kitchen gloves and rubber shoes
Avoid pouring detergent water on feet
1.14 CRITICALLY ILL PATIENT (IN ICU) (Refer also Chapters 1.10, 1.14, 1.15 and 3)
1.14.1 CHECKLIST FOR EVALUATION OF CRITICALLY ILL PATIENT
A Framework—Think Head to Foot
Critically Ill Patient Assessment
Airway | Obstruction? Clear obstruction → Intubate if necessary and maintain airway |
Breathing | No spontaneous respiration or noisy breathing → Ventilate |
Circulation | No palpable pulse → Start cardiopulmonary resuscitation (CPR) |
Vital signs | Temperature, pulse (heart rate), respiration (TPR), BP, SpO2, and GCS |
Laboratory tests/ICU profile | CBC, RBS, SpO2, urea, creatinine, electrolytes (Na+, K+), LFT, CXR, ECG, blood gas, and urine analysis |
Consider | “GOT FAN”—Glucose, Oxygen, Thiamine, Flumazenil, Atropine, and Naloxone. However, in an alcoholic, consider giving “T” before “G” |
Treatment (Choices Include)
Give specific therapy whenever possible.
Ensure oxygen saturation (SpO2) is compatible with survival, i.e., usually > 80% and preferably > 90–95%.
Mechanical ventilation if any respiratory failure.
1.14.2 CHECKLIST FOR PATIENT ON VENTILATOR SUPPORT (FAST HUGS BID)
FAST HUG should be done at least once a day for ICU patient on ventilator support.
F: Feeding
A: Analgesia
S: Sedation
T: Thromboprophylaxis
H: Head up position
U: Ulcer prophylaxis
G: Glycemic control
S: Spontaneous breathing trial
B: Bowel
I: Indwelling catheter
D: De-escalation of antimicrobial and other pharmacotherapies
1.14.3 EMERGENCIES IN ICU
Respiratory | Cardiovascular | Neurological |
Hypoxia:
| Hypotension:
| Depressed sensorium:
|
Dyspnea/tachypnea:
| Bradycardia:
| Seizures:
|
Tachycardia:
|
Problem | How to diagnose | What to do |
|---|---|---|
Acidosis | Arterial blood gas | Treat cause Consider need for dialysis |
Anaphylaxis | Check for medications in past hour | Adrenaline, ensure airway and oxygen |
Alveolar problem | Chest X-ray (infection, ARDS, and edema) | Increase positive end-expiratory pressure (PEEP), physiotherapy, negative fluid balance, and antibiotics |
Circuit problems Leak (including cuff leak, tube displacement), block | Run hand over circuit, place hand on trachea, chest movement, note airway pressures, resistance to manual ventilation, CXR | Use Ambu bag, localize leak Inflate ET/TRACH cuff to appropriate pressure Reposition/suction ET/TRACH tube, if needed Pull back ET tube, if endobronchial intubation |
High CO2 | Arterial blood gas | |
Hyperkalemia | K+ level | Calcium IV, followed by glucose/bicarbonate, β2 agent; dialysis |
Hypocalcemia | Ca level | Calcium IV |
Hypoglycemia | RBS | Glucose IV |
Hyponatremia | Measure on blood sample | Depends on etiology |
Hypotension | BP | Fluid/inotropes |
Hypoxia | SpO2, ABG | Increase fraction of inspired oxygen (FiO2) If unconscious and unintubated, intubate |
Myocardial infarction | ECG, CK-MB, Troponin I | Aspirin, β-blocker, LMW heparin; thrombolysis/percutaneous transluminal coronary angioplasty (PTCA) |
Organophosphorus poisoning | History | High-dose atropine bolus (up to 60–100 mg in 15 minutes) and infusion |
Pneumothorax | Percuss, auscultate, needle test, and CXR | Chest tube |
Primary neurological problems | Asymmetrical movement/pupils/plantar response; CT scan | As appropriate |
Pulmonary embolism | Lower limp swelling, D-dimer, ECG, CXR, color Doppler, and ECHO | Anticoagulation, thrombosis |
Seizures | Clinical | Lorazepam IV, phenytoin slow IV, correct glucose, calcium Continuing seizures—give propofol and intubate, start midazolam infusion, consider encephalitis, cerebral venous thrombosis, etc. |
Sepsis | White cell count, cultures, procalcitonin, imaging | Line changes, appropriate antibiotics |
Tachyarrhythmia | ECG | If BP low, electrical Rx If BP normal, consider whether physiological or pathological rhythm |
Investigations in ICU CBC, creatinine, urea, Na+, K+, LFT, CXR, ECG, SpO2, blood gas analysis | ||
1.15 DELIRIUM (Restlessness, Acute Confusional State, Acute Brain Attack)
Definition
Confusion is lack of clarity in thinking and delirium is used to describe an acute confusional state.
Red Flags
Sodium < 125 mmol/L or >145 mmol/L
Raised calcium (>11 mg/dL)
Severe headache
Sudden onset of symptoms such as dysphasia
Rapid deterioration
Fever or hypothermia
Seizure
Features of raised ICP (bradycardia + hypertension, papilledema)
Introduction of new medication (e.g., overdose or adverse effects)
Alcohol misuse
Etiology and Investigation
Etiology (‘MIND ATE' is the mnemonic for delirium) | Investigations (select appropriately, choices include) |
Metabolic (acute): | Electrolytes (Na+, K+), RBS, Ca+, P, Mg, ABG RBS SpO2, ECG, CXR, ABG LFT, ammonia RFT (creatinine, urea, urine analysis) |
Infection | Infection screen: CBC, urine analysis, C/S of blood, urine, pus, tissue; widal and quantitative buffy coat (QBC) in febrile patients, CXR, US abdomen |
Neurologic: | MRI/CT ECG/MRI CT MRI, CSF fluid analysis MRI CT, MRI |
Drugs/substance abuse: Narcotics, benzodiazepines, digoxin, OHA, insulin, alcohol withdrawal, lysergic acid diethylamide (LSD), cocaine | Check drug/medications of patient, urine and blood toxicology screening |
Autoimmune disease: For example, lupus | CBC, autoimmune serology (ANA, ANA profile if ANA is positive) |
Toxins: Organophosphorus poisons, e.g., pesticides | Toxic substance screening (cholinesterase levels) |
Endocrine: | FBS, RBS, K+ TSH, free T4 TSH, free T4 Calcium, parathyroid level Cortisol B12, folate, thiamine |
Miscellaneous: | Check if patient is in pain Check if bladder is palpable Check temperature |
History and Clues
History of diabetes, jaundice, and alcohol | Suggests metabolic problem |
History of fever, headache, and vomiting | Suggests infection |
History of fever, headache, vomiting, blurred vision, ↑BP, ↓pulse, convulsions, and trauma | Suggests neurological problem |
Current medications | Narcotics, benzodiazepines |
Substance abuse | Alcohol, opium, LSD, and cocaine |
Poisons | Pesticides |
Checklist
Temperature, pulse, respiration rate, BP, SpO2 (oxygen saturation) | Airway, breathing, and circulation |
General examination | Trauma, stigmata of liver disease, neck stiffness, and smell of breath (clue to diagnosis) |
Neurological examination | ↑BP, ↓pulse, focal deficit = (ICT), pupil size, reflexes: Babinski, asterixis (liver flap) |
Systemic examination | CVS, RS, and abdomen |
Treatment (Choices Include)
Try to identify the cause and treat the cause.
SERENACE (Haloperidol) 2.5–5 mg IM/IV stat and every 4 hours, in elderly patient start with 2.5 mg. Add PHENERGAN (promethazine) 15–25 mg IM or IV with Serenace to prevent extrapyramidal side effects. This drug combination helps to sedate restless or agitation people, but can make them more confused due to anticholinergic effects of Phenergan.
Consider antidotes “GOT FAN” (if needed) (refer Chapter 1.10 for more details):
Glucose
Oxygen
Thiamine
Flumazenil
Atropine
Naloxone
When there is increased ICP (signs of meningism: ↑BP, ↓pulse, headache, vomiting, seizures, papilledema, or ↓RR) (refer Chapter 1.10 for treatment choices).
1.16 DIABETES MELLITUS
Red Flags
Hypertension
Cardiovascular disease (CVD), cerebrovascular disease, and peripheral vascular disease
End organ damage (diabetic retinopathy and nephropathy)
Skin and soft tissue infections
Recurrent urinary tract infection (UTI)
Peripheral neuropathy
Foot ulcers
Diabetic ketoacidosis
Types of Diabetes Mellitus
Type 1 | Beta cell destruction deficiency and includes latent autoimmune diabetes of adulthood |
Type 2 | Insulin resistance progressive loss of beta cells |
Specific causes | Maturity-onset of diabetes in young (MODY) |
Gestational | Diagnosed usually in the second-and-third-trimester |
Diagnosis of Diabetes Mellitus: Blood Sugar Levels (Venous Plasma/Serum Glucose)
Test | Normal | Prediabetic/Impaired glucose tolerance | Diabetes mellitus |
|---|---|---|---|
FBS | 70–99 (3.9–5.5 mmol/L) | 101–125 [impaired fasting glucose (IFG)] (5.6–6.9 mmol/L) | >126 (7.0 m/L) |
HbA1c | < 5.7 | 5.7–6.4 | >6.5% |
PPBS | >200 (11.1 mmol/L) | ||
75 g oral glucose tolerance test (OGTT) (2 h plasma glucose) | < 140 (7.8 mmol/L) | 140–199 [impaired glucose tolerance (IGT)] (7.8–11 mmol/L) | >200 (11.1 mmol/L) |
Fasting blood sugar (FBS) | Needs 8 hours fasting (one can drink water during fast). FBS > 126 is DM. Repeat FBS, if >126 the next day to confirm diagnosis of DM. FBS is the best test, since it is easy and convenient | ||||||||||||||||||||||||||
Random blood sugar (RBS) | RBS > 200 with symptoms of polyuria, polyphagia and unexplained weight loss is DM | ||||||||||||||||||||||||||
HbA1c | Glycosylated hemoglobin, (HbA1c) > 6.5 is diagnostic of DM. HbA1c gives an indication of average blood sugar level over the last 3 months (false positives can be seen in anemia, severe hepatic and renal diseases). HbA1c should not be used for diagnosis of gestational diabetes in pregnant woman or for diagnosis of diabetes in people who have had recent severe bleeding or BT, those with chronic kidney or liver disease or anemia Correlation of HbA1c with average glucose:
| ||||||||||||||||||||||||||
Oral glucose tolerance test | For all pregnant women: Perform 75 g OGTT, with plasma glucose measurement fasting and at 1 and 2 hours, at 24–28 weeks of gestation in women not previously diagnosed with overt diabetes. OGTT should be performed in the morning after an overnight fast of at least 8 hours. Diagnosis of GDM is made when any of the following plasma glucose values are: Fasting: ≥92 mg/dL (5.1 mmol/L) 1 hour: ≥180 mg/dL (10.0 mmol/L) 2 hours: ≥153 mg/L (8.5 mmol/L) | ||||||||||||||||||||||||||
Self-monitored blood glucose (SMBG) level by glucometer | Glucometer readings are likely to be 20 mg% < (simultaneous) laboratory blood sugar levels | ||||||||||||||||||||||||||
Impaired glucose tolerance/impaired fasting glucose | Prediabetic patients are those who have IFG or IGT. Do not label these patients as diabetics. Advice to prediabetic patients: About 1,500 calorie diabetic diet (diet advise) Walk for 30 minutes daily (increased physical activity to decrease weight, if overweight) Consider Metformin, if HbA1c > 6.5 Check FBS every 6 months, since 5% of prediabetics can become diabetics Educate patient about complications of DM | ||||||||||||||||||||||||||
Screening diabetes (asymptomatic adult individuals):
Testing should be considered in all adults who are overweight (BMI ≥ 25 kg/m2) and have additional risk factors:
Physical inactivity
First-degree relative with diabetes
High-risk race/ethnicity (e.g., African, American, Latino, Asian, American, and Pacific Islander)
Women who delivered a baby weight > 9 lb or were diagnosed with GDM
Hypertension (≥ 140/90 mm Hg or on therapy for hypertension)
High-density lipoprotein (HDL) cholesterol level < 35 mg/dL (0.90 mmol/L) and/or a triglyceride level > 250 mg/dL (2.82 mmol/L)
Women with polycystic ovary syndrome (PCOS)
HbA1c ≥ 5.7% IGT or IFG on previous testing
Other clinical conditions associated with insulin resistance (e.g., severe obesity and acanthosis nigricans)
History of CVD
Metabolic Syndrome or Insulin Resistance Syndrome or Syndrome X
Patient who has more than three criteria listed below:
1. Waist > 90 cm (men), > 80 cm (women) (Asians)
2. Triglycerides > 150 mg/dL
3. HDL < 40 mg/dL
4. FBS > 100 mg/dL
5. BP > 130/85 mm Hg or being treated for hypertension
Suspect insulin resistance if obesity, PCOS, nonalcoholic fatty liver disease (NAFLD), CKD, sleepiness after a meal, craving carbohydrate rich foods, brain fog, male pattern hair loss in women swollen ankles, and increased triglyceride levels and depression. Insulin resistance increases risk of developing T2DM and prediabetes. Insulin resistance is a condition in which body produces insulin but does not use it effectively. When people have insulin resistance, glucose builds up in body instead of being absorbed by cells, leading to T2DM or prediabetes. Insulin resistance patient or prediabetic patient can decrease the risk of getting diabetes by eating healthy diet, reaching and maintaining a healthy weight, increasing physical activity, stop smoking, and taking medication (Metformin) in some cases.
ABCD [Abdominal obesity, Blood pressure (high), Cholesterol (high), Diabetes (FBS >100 mg/dL), increase risk of IHD, stroke, and Diabetes mellitus].
Symptoms of Diabetics
Asymptomatic | |
Common | UTI, fungal infection, dry itchy skin, numbness or tingling in extremities, and fatigue |
Occasional | Increased urination, thirsty, increased appetite, nocturia, and unexplained weight loss |
Glucose (Sugar) and HbA1c Levels: How Good is Your Control
Glucose level (mg/dL) | FBS (fasting) | PPBS (2 hours postprandial) | HbA1c |
|---|---|---|---|
Excellent | 70–120 | 100–140 | <6.5 |
Good | 121–140 | 141–160 | <7 (Target) |
Fair | 141–160 | 161–200 | <7.5 |
Poor | >160 | >200 | >7.5 |
Comparison of Dextrometer and Laboratory Glucose Levels
Timing of test for glucose | SMBG* (Dextrometer and glucometer) | Laboratory |
|---|---|---|
FBS (premeal) | <120 mg/dL | < 100 ~_ 140 |
PPBS (postmeal 2 hours) | <160 mg/dL (<180 elderly) | <180 |
Bedtime | <120 mg/dL | ~_ 140 |
Critically ill | RBS 160–200 mg/dL | RBS 140–180 mg/dL |
*SMBG: self-monitored blood glucose level by glucometer. Glucometer readings are likely to be 20 mg% < (simultaneous) laboratory blood sugar. | ||
Target Values for Diabetics to Precent Cardiovascular Outcome in Diabetic Patients
Diabetic on treatment | Goal/Target |
|---|---|
Glucose (sugar) | FBS 70–120 mg/dL, PPBS 100–140 mg/dL, HbA1c 6.5 |
BP | <130/80 mm Hg |
Lipids | Total cholesterol (< 180 mg/dL) LDL < 100 mg/dL (< 70 in CVD) HDL > 40 men, > 50 women Triglycerides < 150 mg/dL |
BMI | 18–22.9 |
Complications
Acute | Long-term | Other complications |
|---|---|---|
Diabetic ketoacidosis Hyperosmolar coma Hypoglycemia | Microvascular: Retinopathy Nephropathy Peripheral/Autonomic neuropathy Macrovascular: Coronary heart disease Cerebrovascular disease Peripheral arterial disease (PAD) | Decreased resistance to infection Skin changes Poor wound healing Cataracts Glaucoma Nonalcoholic steatosis/steatohepatitis |
Medical history | Physical examination |
|---|---|
|
|
Investigations (Choices Include)
CBC
FBS
PPBS
Urine routine
24 hours or spot urine protein-to-creatinine ratio (UPCT)
Urea and creatinine
Lipid profile
LFT (AST and ALT)
TSH, TPO antibodies
HbA1c
OGTT
Treatment (Choices Include)
Choice of any antidiabetic agent should take account patients general health status and associated medical disorders. This patient centric approach may be referred to as ABCDEFGH approach for diabetes management.
A. | Age (elderly > 65 years) | Dipeptidyl peptidase-4 (DPP-4) inhibitor + metformin |
Sulfonylurea | ||
B. | BMI | Glucagon-like peptide 1 (GLP-1) agonist |
Sodium-glucose cotransporter-2 (SGLT-2) inhibitor | ||
DPP-4 inhibitor | ||
Alpha-glucosidase inhibitor (AGI) | ||
C. | Chronic kidney disease (diabetic kidney disease) | DPP-4 inhibitor |
Sulfonylurea | ||
Injectables | ||
D. | Duration of diabetes (long-standing) | Insulin |
GLP-1 agonist | ||
SGLT-2 inhibitor | ||
E. | Established CVD | GLPI analog |
SGLT-2 inhibitor | ||
Sulfonylurea | ||
F. | Financial | Sulfonylurea + metformin |
G. | Glycemic reduction | Order of glucose lowering agents to efficacy of HPLC reduction r insulin, GLP-1 agonists, metformin, SGLT-2 inhibitors, pioglitazone, DDPP-4 inhibitors, sulfonylurea, glynides, and AGIs |
H. | Hypoglycemia or postprandial hypoglycemia | In patients with history of hypoglycemia or dose at high risk of hypoglycemia, GLP-1 agonists/SGLT-2 inhibitors/DPP-4 inhibitors or AGIs/pioglitazone should be considered as first choice with metformin |
Treatment Choices based on FBS or HbA1c
FBS/HbA1c | Treatment options | Drug/Combination drugs |
FBS 126–160 or HbA1c < 7.5 | OHA (monotherapy) | Metformin/DPP4i, insulin |
FBS 160–240 or HbA1c > 7.5 | ↓ OHA (dual therapy) ↓ Or | Metformin + sulfonylurea Metformin + glitazones (not used now) Metformin + AG-1 Metformin + DPP-4 inhibitors Metformin + GLP-1A |
OHA (triple therapy) | Metformin + sulfonylurea + voglibose Metformin + sulfonylurea + DPP -4 inhibitor Metformin + sulfonylurea + glitazone (not used now) | |
FBS > 240 or HbA1c > 9 or FBS > 160 on OHA | Insulin | Insulin (multidose therapy is preferred) |
Oral Hypoglycemic Agents
Class/Type | Frequency | Maximum dose | Cost in rupees per month | Good for | Side effects |
|---|---|---|---|---|---|
1. Biguanides: Metformin (GLYCIPHAGE 500 mg, GLYCOMET 500 mg, GLUCONORM 500 mg) Extended release metformin: GLYCIPHAGE SR 500/1,000 mg, DIBETA SR 500/1,000 mg, GLUCONORM SR 500/1,000 mg | od/bd/tds (5–10 minutes before meal) | 2 g | 100 | Type 2 diabetes mellitus Dyslipidemia High FBS | Anorexia Bloating Lactic acidosis (avoid metformin in renal insufficiency LVF and in patients aged > 80 years, serum creatinine > 1.5 in males or > 1.4 in females) |
2. Sulfonylurea: Glibenclamide 2.5 mg, 5 mg (DAONIL) | bd (5–10 minutes before meals) | 20 mg | 50 | Postmeal hyperglycemia Lean patient | Hypoglycemia Weight gain |
Glipizide 2.5 mg, 5 mg (GLIDE/GLYNASE) | od/bd (5–10 minutes before meals) | 10 mg | 80 | ||
Glimepiride 1 mg, 2 mg (AMARYL/AZULIX/GLIM, GLIMCARE) | od/bd (5–10 minutes before meals) | 8 mg | 450 | ||
3. Thiazolidinediones: Pioglitazone 15 mg, 30 mg | od/bd (5–10 minutes before meals) | 45 | Obese Dyslipidemia | Edema Weight gain CCF Bone fracture Bladder cancer | |
4. α-glucosidase inhibitor: Voglibose 0.2/0.3 mg (REBOSE/VOLIX/VOGLET) Acarbose (MIGLITOL) | tds (eat 2 mouth full of food and then take the tablet) | 0.9 mg | 700 | Postmeal hypoglycemia | Flatulence Bloating Dyspepsia |
5. Mitiglinide: Repaglinide Nateglinide | tds (5–10 minutes before meals) | 0.5–4 mg | Renal insufficiency | ||
6. DPP-4 inhibitor Sitagliptin (JANUVIA/ZITA/ISTAVEL) Vildagliptin (JALRA) | od (5–10 minutes before meals) od/bd (5–10 minutes before meals) | 100 mg 50–100 mg | 1,200 | Postmeal hyperglycemia | |
7. SGLT-2 Dapagliflozin (Dapa) | 10 mg | ||||
8. GLP-1 agonist/analog Exenatide (EXAPRIDE) Liraglutide (VICTOZA) | 5 mg SC bd (0.6 mg SC od just before meals) | Very costly | Injectable pen Weight loss No hypoglycemia | Nausea |
Insulin
Indications:
Patients on OHA with poor control (e.g., FBS >160, PPBS > 200, and HbA1c > 9)
Newly detected patient with high blood sugar (FBS > 250 and PPBS > 300)
Infection, MI, DKA, pregnancy, or patients undergoing major surgery
Patients with target organ damage, e.g., IHD, CVD, PAD, retinopathy, neuropathy, or nephropathy.
Name | Brand | Onset | Peak action (hour) | Duration (hour) | Route | Doses |
1. Prandial insulin: Rapid acting analogs: Lispro(HUMALOG) Aspart (NOVOLOG) Glycine (APIDRA) | 10–20 minutes | 1–3 hours | 4-6 | |||
Short acting: Actrapid Huminsulin R Insuman R | Lilly Abbot | 30 minutes 45 minutes | 1.5–3.5 hours | 8 8 | SC/IV SC/IV | 3 3 |
2. Basal insulin: Intermediate acting: Monotard Huminsulin N Human NPH Insuman basal | Abbott Lilly | 1-2 hours | 8–16 4–6 | 10–12 10–12 18 18–24 | SC SC SC SC | |
Very long analogs (basal) Glargine Detmer Degludec | No peak 3–9 No peak | 24 | SC SC SC | 1 | ||
3. Premixed products: MIXTARD 30/70 MIXTARD 50/50 HUMINSULIN 30/70 HUMINSULIN 50/50 INSUMAN combo (25/75) | Abbott Abbott Lilly Lilly Sanofi | 1 hour 45 minutes 1 hour 45 minutes 40 minutes | 2 2 2 2 2 | 12–16 12–16 12–16 12–16 14–16 | SC SC SC SC SC | 2 2 2 2 2 |
Insulin should be taken 1–2 minutes before meals. Once daily dose should be administered with the evening meal or at bedtime. With twice-daily dosing, the second dose can be administered with the evening meal, at bedtime or 12 hours after the morning dose.
Strength: In mixtures, 30% or 50% is regular insulin and 50% or 70% is NPH insulin.
For example, ACTRAPID (40 or 100 IU/mL in 10 mL vial) and MIXTARD (30/70, 40 or 100 IU/mL in 10 mL vial)37
Calculation for dose of insulin required per day—“start low, go slow”
0.5–1.0 unit/kg/day
For example, MIXTARD 30/70, weight of the patient = 60 kg
0.5 × 60 = 30 units = (2/3 dose, am = 20 units; 1/3 dose, pm = 10 units)
Rough guide for administering ACTRAPID in emergency cases:
GRBS (mg/dL) | Insulin |
|---|---|
150–175 | 2 units of Actrapid SC |
175–225 | 4 units Actrapid SC |
225–300 | 6 units Actrapid SC |
< 100 or > 300 | Inform consultant |
Side Effects of Insulin
Hypoglycemia, weight gain, edema, insulin antibodies with animal insulin, and lipodystrophy at injection sites.
Delivery Devices for Insulin
Ordinary glass syringe, disposable insulin syringe, insulin pen (NovoPen, NovoLet), and insulin pumps.
Follow-up/Referrals
Daily | 2 weekly | Monthly | Every 3 months | Every 1 year |
|---|---|---|---|---|
|
|
|
|
|
Checklist for Patients with Uncontrolled Sugars
Causes | Actions | |
|---|---|---|
1. | Dietary noncompliance | Education and motivation |
2. | Failure to increase levels of physical activity | Regular exercise schedule and motivation |
3. | Intercurrent illness | Diagnose and treat |
4. | Treatment noncompliance | Reinforcement, education, and motivation |
5. | Medications, which interfere with OHA or cause glucose intolerance | Shift to noninterfering drug, if possible |
6. | Progressive beta-cell failure | Consider insulin therapy |
Key Points
Prediabetes is a toxic state and risk factor for diabetes and its associated with pathological changes in several tissues and organs
Insulin resistance and impaired insulin secretion are important in pathophysiology of T2DM
Long-term complications include macrovascular and microvascular complications
Diabetes is also associated with several comorbidities which make diabetes management more difficult
Weight loss combined with low carbohydrate diet is a safe and effective way of reversing diabetes
Emphasis on patient centric approach is given while considering individualized therapy
SGLT-2i and DPP-4i are drugs which should be used alone, or in combination with metformin to achieve glycemic targets
1.16.1 DIABETIC FOOT
Red Flags
Inability to walk and bear weight
Bruising
Trauma
Constitutional features such as fever and malaise
Pain
Numbness and paresthesia
Etiology
Etiology | Comments |
|---|---|
Neuropathy | Can be sensory, motor, autonomic or mixed |
Infection | Usually polymicrobial |
Ischemia | Is due to microangiopathy, atherosclerosis or PAD |
Symptoms/Signs/Complications
Ulcer
Infection (cellulitis/fasciitis and gangrene/osteomyelitis)
Intermittent claudication or rest pain
Neuropathic foot
Charcot's joint
Investigations
Investigations (choices include) | Comments |
|---|---|
Routine blood and urine | CBC, blood sugar, urine ketone bodies, and urea creatinine |
Imaging: X-ray foot Doppler studies (assess perfusion): MRI Nuclear scan [fluorodeoxyglucose, positron emission tomography-computed tomography (18FDG, PET-CT scan) Angiography (DSA/MRA) | Foreign bodies, gas shadows or bone involvement—osteomyelitis Tissue healing is likely to occur on conservative measures with a TcPO2 > 50 mm Hg (revascularization warranted for TcPO2 < 30 mm Hg) Results are misleading Best test Useful to assess soft tissues (e.g., infections) Useful to assess soft tissues (e.g., infections) Gold standard prior to any intervention |
Microbiology | Deep tissue culture/sensitivity (bacterial and fungus) |
Treatment (Multidisciplinary Team Approach) (Choices Include)
Treatment for Diabetic Foot Infection: Summary
Charcot Arthropathy = Neuropathic Joint Disease/Arthropathy
It is destructive arthritis secondary to peripheral neuropathy and loss of pain sensation. Affected joint is subjected to repeated stress unrecognized by the patient.
High Index of suspicion
Diabetic Long-standing
Loss of sensation
Hot/red/swelling
Trauma—minor/major
Architectural disruption (laxity or instability of joint)
Pain or ulcer +/–
Treatment
No weight bearing of extremity, casting/immobilization for 6–12 months
Bisphosphonates
Elevation decreases edema
Surgery is reserved for severe cases
1.16.2 DIABETIC NEUROPATHY/DIABETIC SENSORIMOTOR NEUROPATHY
Treatment (Choices Include)
1.17 DYSLIPIDEMIA
Symptoms and Signs
Asymptomatic
Coronary artery disease (CAD) (MI), stroke, PVD (atherosclerosis)
Abdominal pain (pancreatitis)
Xanthomas (painless nodules near eyelids, tendons, elbow, and buttocks)
Corneal arcus
When to Check Lipid Profile
Age > 20 years: Since serum lipids vary from day to day, 2–3 measurements should be done days or weeks apart before initiating therapy. Fasting (12 hours, but one can drink water during fasting) is important—mainly for triglycerides (LDL, HDL, and cholesterol values remain unaffected during eating or fasting!).
On treatment for hyperlipidemia, check lipid profile 3 months after treatment and once a year.
Goal Values for Lipids
Lipid profile | Goal value | Comment(s) |
LDL | <100 mg/dL | Patients with ACS including diabetics, treatment target should be <100 mg/dL and achieving the goal might require high dose, high potency statin In very high-risk patients, those with CAD, diabetes or both LDL goal of < 70 mg/dL is optional |
HDL | >40 mg/dL | – |
<200 mg/dL | If cholesterol is high, avoid egg yolks, organ meat, shrimps (prawns), seafood, palm and coconut oil | |
Triglycerides | <150 mg/dL | Triglycerides > 400 mg/dL is a risk factor for CAD and pancreatitis |
Risk Factor Assessment (Personal and Family) Two or More = Moderate Risk
Risk factor | CAD | PAD | STROKE |
|---|---|---|---|
Family history | MI, angioplasty, or sudden death | – | CAD |
Hypertension | SBP > 140 mm Hg or DBP > 90 mm Hg or On treatment for hypertension | Yes | Yes |
Diabetes mellitus | Yes | Yes | Yes |
Cholesterol | TC > 200 mg/dL LDL >120 mg/dL | Yes | Yes |
Cigarette smoking | Currently smoking or quit 6 months ago | Yes | Yes |
Sedentary life or physical inactivity | No exercise of 30 min/day | Yes | Yes |
Obesity | Yes | BMI > 25 | – |
Secondary Causes of Lipid Abnormalities
Enquire about these conditions directly during history. Treating underlying secondary causes may obviate need to treat an apparent lipid disorder.
Secondary cause | Increased LDL | Increased triglycerides |
|---|---|---|
Diet | Saturated fat Transfat Weight gain Anorexia | Weight gain Low-fat diet High-carbohydrate diet Increase alcohol intake |
Drugs | Diuretics, steroids, and cyclosporine | Estrogens, steroids, bile acid suppressants, beta blockers (except carvedilol, raloxifene, tamoxifen, and retinoic acid) |
Diseases: Thyroid Liver Kidney | Hypothyroidism Biliary obstruction Nephrotic syndrome | Hypothyroidism Nephrotic syndrome CRF |
Investigations and Treatment Options
Hypercholesterolemia | Hypertriglyceridemia | |
|---|---|---|
Evaluation and investigations | Lipoprotein profile (cholesterol, TG, HDL, and LDL) Risk factor assessment (family and personal) Glucose, TSH, RFT, LFT (if LDL > 130 mg/dL to rule as secondary cause) | Lipoprotein profile (cholesterol, TG, HDL, and LDL) Glucose, TSH, RFT, and LFT Risk factor assessment of family and personal (refer table above) History of eruptive xanthomas or abdominal pain Exercise, weight gain, estrogen treatment, alcohol intake, and diabetes |
Treatment (choices include) | High risk (existing CVD or atherosclerosis > 2 factors or DM): LDL > 100 mg/dL treat with diet and drugs Moderate risk (two risk factors): LDL > 130 treat with diet and drugs Low risk (0 or 1 risk factor): Refer table below | Diet Exercise Alcohol intake to be reduced Treat secondary causes Drugs |
Treatment (Choices Include)
Diet and Exercise
In most patients, diet is implemented before initiating drug therapy. However, in high-risk patients, drug therapy may be initiated simultaneously with diet.
Drugs (Choices Include)
Subclass | Dose | Side effects |
|---|---|---|
Statins: Atorvastatin (ATOR) (STORVAS); rosuvastatin (ROSUVAS, ROZAVEL) (useful for MI, PAD, primary and secondary prevention of hyperlipidemia, pravastatin, and lovastatin—similar to atorvastatin, but less efficacious) | 10–80 mg, hs | Myopathy Hepatic dysfunction |
Fibrate: Fenofibrate (LIPICARD) (FIBRATE) Gemfibrozil (NORMOLIP) (useful for hyperglyceridemia and low LDL) | 200–400 mg | Myopathy Hepatic dysfunction |
Cholesterol absorption inhibitor (CAI): Ezetimibe (ZETIA) do not combine CAI with resins/fibrates) | 10 mg once daily, hs | Angioedema Headache |
Niacin (NIALIP) (useful for high LDL and low HDL) | 375–500 mg, hs | Flushing Hyperglycemia |
Bile acid sequestrants (colestipol) (cholestyramine, colesevelam are similar to colestipol) | 5 mg, maximum 30 mg | Constipation Bloating |
Miscellaneous: Omega-3 fatty acids: Soya bean oil, nuts, flaxseeds (vegetarian) Fish oil 3–6 g qid (nonvegetarian) | – | Dyspepsia, diarrhea, fishy breath |
Drug | High-intensity treatment | Moderate intensity treatment | Low-intensity treatment |
|---|---|---|---|
Atorvastatin | 40–80 mg | 10–20 mg | – |
Simvastatin | – | 20–40 mg | 10 mg |
Summary of Treatment Choices
1. | High LDL or all diabetics even with LDL < 100 mg/dL (monotherapy) | Atorvastatin 10–80 mg (20 mg od) or Simvastatin 5–80 mg (10 mg od) |
2. | High LDL, low HDL, high triglyceride (combination therapy) (statin + CAI or fibrates) | Atorvastatin + ezetimibe (ATORLIP-EZ) (EZESTAT) atorvastatin + fenofibrate (ATORLIP-F) (FIBATOR) rosuvastatin 10 mg + fenofibrate (GLIVAS-F) |
3. | High triglyceride (TG) 200–500 or > 500 mg/dL | If TG 200–500 mg/dL with > two risk factors or CHD give high dose statin + ezetimibe or niacin or fibrate If TG > 500 mg/dL fish oil or fibric acid. Add niacin if needed |
4. | High triglycerides + low LDL + Low HDL | Fibrate |
5. | Smoking cessation | |
6. | Aspirin (ECOSPRIN) (in high-risk diabetics over 40) | |
7. | Blood pressure control | |
8. | ||
Key Points
Rule out secondary causes of dyslipidemias
Every 1% reduction of total cholesterol lowers risk of CAD by 2%
Most common side effects of statin therapy are headache, nausea, sleep disturbance, GI discomfort, and muscle ache. Statins are well tolerated by most patients, but carry a small but definite risk of myopathy.
In all patients with ACS, including diabetics, treatment target should be <100 mg/dL and achieving the goal might require a high dose, high potency statin.
In very high-risk patients, those with CVD, diabetes or both, a LDL goal of < 70 mg/dL is optional.
All diabetics, even those with LDL <100 mg/dL, should be on a statin (for primary or secondary CVD prevention).
1.18 EDEMA
Soft tissue swelling is due to abnormal expansion of interstitial fluid volume. Edema fluid is a plasma transudate that accumulates when movement of fluid from vascular to interstitial space is favored.
Lymphedema is the result of an inability of the existing lymphatic system to accommodate protein and fluid entering the interstitial compartment.
Etiology
Localized edema (leg or arm or face, abdomen, or thorax) | Generalized edema/Bilateral leg edema |
|---|---|
Unilateral leg edema: | |
Bilateral leg edema: | |
Upper limb edema: | |
Facial edema: | |
Ascites (abdominal) | |
Hydrothorax |
Clues from History
Features | Diagnosis/Comments |
|---|---|
Face edema | Suspect renal disease, hypothyroidism, or patient is on steroids |
Periorbital edema noted on awakening | Renal disease, impaired sodium excretion |
Bilateral lower leg edema more pronounced after prolonged standing for several hours | Chronic venous insufficiency (CVI), cardiac problem |
Ascites, pedal edema, and scrotal edema | Cirrhosis, nephrotic syndrome, or CHF |
Hypoalbuminemia without proteinuria | Requires investigations for malnutrition or protein loosing enteropathy, provided liver disease is excluded |
Idiopathic cyclical edema is based on | Appropriate clinical setting All other causes are excluded Positive water loading test |
Ascites more than pedal edema | Tuberculosis, carcinomatosis, and mesothelial malignancy |
Ascites + palpable spleen | Portal hypertension |
Investigations for Unilateral Leg/Arm Edema (Choices Include)
Investigation | Comments/Useful for |
|---|---|
CBC, peripheral smear, and microfilaria (mf) | – |
D-dimer | DVT |
Doppler US (color) | DVT, varicose veins, and AV malformation |
Lymphoscintigram (radioisotopic-labeled colloid) | – |
US/CT/MRI | Abdominal masses |
Fine needle aspiration cytology (FNAC)/LN biopsy | Mass lesion or lymph nodes |
Etiology and Treatment of Acute Unilateral Painful Edema
Etiology | Investigations and treatment |
|---|---|
DVT | Refer Chapter 6.17.9 |
Cellulitis | Refer Chapter 1.7 |
Treatment of Chronic Unilateral Lymphedema (Choices Include)
Comments | |
|---|---|
Compression therapy | Elastocrepe or stockings Pneumatic compression in home/hospital once a day for 30–60 minutes |
Elevation (keep affected part elevated) | Helps to decrease edema |
Massage | – |
Walk or continue to exercise | Prevents stagnation |
Drugs (select appropriately) | DAFLON 1 bd LYMHEDIN 1 bd LASILACTONE 1 od HETRAZAN (DEC) 100 mg PO, tds for 21 days (for filariasis) PENICILLIN or CEFAZOLIN or LEVOFLOXACIN or AUGMENTIN (for cellulitis) |
Foot care advice | Do not walk bare foot, cut nails carefully, report to doctor immediately if any injury, infection, or pain |
Surgery | Excisional surgery (debulking) or bypass procedures, e.g., in filariasis |
Investigations for Generalized Edema/Bilateral Edema (Choices Include)
Investigation | Comments/Useful for |
|---|---|
CBC | |
Urine analysis | Active urine sediment suggests renal failure, glomerulonephritis, and nephrotic syndrome |
Creatinine, urea | Renal failure |
LFT, PT | Albumin <2.5 g/dL suggests severe malnutrition, cirrhosis, or nephrotic syndrome |
TSH, T4, TPO | Hypothyroidism |
CXR, ECG, ECHO | Heart failure |
Drug history | NSAIDS Amlodipine, nifedipine, hydralazine, clonidine, methyldopa, and minoxidil thiazolidines Glucocorticoids, anabolic steroids, estrogens, and progestins |
US/CT/MRI | For abdominal mass/pathology |
Treatment of Generalized Edema (Choices Include)
Comments | |
|---|---|
Identify and treat the cause whenever possible | – |
Dietary sodium restriction (<500 mg/day) | May prevent further edema formation |
Supportive stockings | – |
Elevation of legs | – |
Diuretics | DYTIDE or BIDURET or LASILACTONE (potassium sparing diuretic) or furosemide (LASIX), hydrochlorothiazide (AQUAZIDE) loop diuretics may be used for marked peripheral edema, pulmonary edema, CHF, and inadequate dietary salt restriction |
Key Points
Rule out common causes such as anemia, cardiac, hepatic, or renal causes.
Cellulitis and DVT are common causes of painful unilateral edema.
If you suspect DVT and D-dimer test is positive, it shows a high probability of DVT.
Fracture or strain: As incompetence of lymphatics occurs, edema takes a long time to settle; therefore affected part should be kept elevated.
1.19 FATIGUE/GENERAL WEAKNESS/FEELING TIRED
Red Flags
Feeling tired or fatigue | |
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Fatigue has three components:
Lack of ability/motivation to start an activity.
Tiring quickly after starting the activity.
Difficulty with concentration and memory to start or complete an activity.
Feeling tired/dead tired should not be confused with drowsiness/need to sleep/shortness of breath after stressful work or muscle weakness.47
Etiology and Investigations
Etiology | Investigation(s) (choices include) |
1. Psychogenic causes (80%)
| History (refer Chapters 6.14.1 and 6.14.2) |
2. Organic causes (20%)
| CBC, peripheral smear, CSR, ferritin, serum iron, and TIBC (refer Chapter 1.1) |
Influenza, infectious mononucleosis, TB, HIV, hepatitis B, C | Mantoux test, ESR, CXR, sputum acid-fast bacilli (AFB), etc. (refer Chapter 1.48), serological tests for hepatitis B, C, HIV, Lyme borreliosis, EB virus, cytomegalovirus, and toxoplasmosis |
Lymphoma and leukemia | CBC, peripheral blood smear, imaging procedures (US, CT, and PET-CT), biopsy |
Diabetes hypo- /hyperthyroidism, hyperparathyroidism, hypo or hyperaldosteronism | FBS, PPBS, HbA1c, TSH, TPO, calcium, cortisol, aldosterone, ARR |
| LFT, PT, serological test for hepatitis A, B, and C |
| Urine analysis, creatinine, and urea |
| CXR and ECHO, ECG |
| CXR, CT, SpO2 |
| RF, ANA, anti-CPP, and LE cell (CTD workup), ENA, CPK |
| Check medications |
| Alcohol, LSD, etc. |
Fatigue Questionnaire
Fatigue questionnaire | Clue/Diagnosis |
Improves with rest | Organic cause |
Does not improve with rest | Psychogenic cause |
Anorexia, breathlessness on exertion, palpitations, and body pain | Anemia |
Increased thirst and frequent urination, itching | Diabetes mellitus |
Low grade fever, cough, and lymph node enlargement | Tuberculosis |
Weight gain, cold intolerance, constipation, very dry skin, slow thinking, depressed mood, and muscle cramps (especially if the symptoms are new or persistent) | Hypothyroidism |
History of alcohol, drugs, and medications | Medication/substance abuse |
Elderly patient | Cancer |
Erectile dysfunction | History |
Anxiety/depression: Anxiety: Three or more features listed below indicate generalized anxiety disorder
Depression: 6 symptoms: 2 major + any 4 minor for > 2 weeks = Depression
| |
| |
Treatment (Choices Include)
Identity and treat the cause whenever possible
MULTIVITE FM/SUPRADYN tablet (multivitamins and minerals) twice daily for 30 days
EVION LC (vitamin E + levocarnitine) (bd for 10 days)
AUTRIN or LIVOGEN once daily
BETONIN/POLYBION tonic 15 mL bd
NEUROBION injection 2 mL IM on alternate days (5–10 injections)
Levothyroxine (ELTROXIN)
FLUDEP (fluoxetine) 20 mg od
Key Points
Rule out common causes such as anemia, diabetes, TB, renal, and liver disease. Other causes include HIV, myxedema, malignancy, addiction, and sexual weakness. In elderly patients, rule out carcinoma, e.g., stomach and liver.
Fatigue may be due to anxiety, anger, or chronic conflict.
Fatigue caused by physical illness is relieved by decreasing activity, by rest or by sleeping.
Make sure/ask a direct question about erectile dysfunction in males and this could be a clue for diagnosis of fatigue!
Careful neurologic examination/investigation is indicated in all cases.
After pregnancy (in postpartum), give iron for 60 days and 1 g of calcium daily for 1 year or till she weans, whichever in longer.
Avoid anabolic steroids
After initial work up, patient should be kept under observation.
1.20 FEVER/FEVER OF UNKNOWN ORIGIN (FUO)
Red flags | Risk factors |
|---|---|
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Viral Fever
Influenza/Common Cold
History | Differential diagnosis |
|---|---|
Chills/runny nose or congestion | Viral fever, UTI, malaria, abscess, and cellulitis |
Throat pain | Viral pharyngitis, tonsillitis |
Cough, fever | Viral upper respiratory infection |
Headache | Viral fever, sinusitis, typhoid, and malaria |
Examination | Check temperature with thermometer Check eyes (jaundice/anemia) Torch light examination of throat Examine the neck for neck nodes (particularly tonsillar nodes) Auscultation of chest Palpate abdomen for liver and spleen |
Treatment | SINAREST/WIKORYL (combination of paracetamol and antihistamine) tds for 3 days Influenza needs to be treated with antivirals (oseltamivir) in specific groups of patients How to prevent spread of common cold? Wash hands frequently; sneeze/cough in your elbow and not in your hands |
Dengue, Leptospirosis, Rickettsiosis, and Chikungunya: Clinical Features, Investigations and Treatment
Dengue | Leptospirosis | Rickettsiosis | Chikungunya |
|---|---|---|---|
Flavivirus | Spirochete-infected animal contact or indirect contact with water or soil with rat /dogs/farm animals urine | Bacteria | Virus |
High-grade fever for 2–7 days (two or more listed features below): Dengue fever Headache Retro-orbital pain Myalgia, arthralgia Rash Petechiae, positive tourniquet test Leukopenia Dehydration Shock, bleeding or organ failure | Flu-like illness Weil's syndrome (jaundice, renal failure, hemorrhage, myocarditis) Meningitis Pulmonary hemorrhage Respiratory failure | Fever, rashes Headache Myalgia Lymph node enlargement Eschar | Headache, chills, fever, arthralgia or arthritis, conjunctival suffusion, nausea, and vomiting |
NSI dengue card test positive (+) IgM, IgG ELISA are positive (+) Progressive decrease in WBC Tourniquet test is positive (monitor for severe signs, edema, ascites, pleural effusion, severe thrombocytopenia) | Leptospira card test is positive (+) IgM ELISA is positive (+) Hepatic enzymes, CK are increased | IgM ELISA scrub positive (+) Hepatic transaminases elevated Leukocytosis | Chikungunya, IgM ELISA positive (+) |
IV fluids Fresh blood/packed cells Paracetamol Avoid IM injections, Aspirin, NSAID, steroids and antibiotics | Doxycycline 100 mg PO bd or ceftriaxone 1 g IV od | Doxycycline 100 mg PO bd | Rest, fluids, NSAIDs, Paracetamol Chloroquine phosphate 200 mg od Avoid Aspirin |
Etiology of Fever (1)
Infection | Bacterial (UTI, cellulitis, pelvic inflammatory disease, abscess, TB, endocarditis, syphilis, or osteomyelitis) Viral (herpes, EBV, CMV, and HIV) Fungal (antibiotics, intravascular devices) Parasitic (toxoplasmosis, tropical infections) |
Malignancy | Lymphoma, leukemia, cancer of kidney, colon, liver, breast or pancreas, etc. Connective tissue disease/immunological disorders, e.g., RA, SLE, Crohn's disease, and sarcoidosis |
Severe trauma and muscle damage | Road traffic accident, work and sport injuries (e.g., large hematoma) |
Drug induced |
Etiology of Fever (2)
Fever | Classic Pyrexia of unknown origin (PUO) | Nosocomial | Neutropenic | HIV associated |
|---|---|---|---|---|
Patient situation | Fever > 101°C or 38.5°C more than one occasion Duration > 3 weeks No diagnosis despite 1 week of intensive evaluation | Hospitalized Acute case No infection when admitted | Neutrophil count < 500 μL or expected to fall to that level in 1–2 days | Confirmed HIV case |
Examples | Infections (30%): Tuberculosis, malaria, amebiasis, EBV, Lyme, endocarditis, intra-abdominal abscess, osteomyelitis, dental abscess, and sinusitis CTD (30%): Rheumatic fever, PAN, RA, giant cell arteritis, and temporal arteritis Neoplasms (30%): Lymphoma, leukemia, cancer (hepatocellular, colon, pancreas, liver, and secondaries) Miscellaneous (20%): Drugs, hematoma, thyroid, or adrenal insufficiency | Thrombophlebitis UTI Sinusitis Drugs Clostridium difficile colitis | Virus, bacteria, and parasites Drugs Aspergillosis Perianal infection Empiric antibiotics indicated in neutropenic patient: For fever of unknown origin: monotherapy with piper/Tazo, Ticar/Clav, imipenem or ceftazidime or ceftriaxone For sepsis or pneumonia, or pseudomonas infection, combination therapy with antipseudomonal β-lactam, i.e. any of the above drug used in monotherapy with aminoglycoside or fluoroquinolone For mucositis, catheter site infection: Any drug used above in monotherapy with vancomycin | Tuberculosis, mycobacterium avium-intracellulare infection |
History
Duration | |
|---|---|
2–5 days | Viral COVID-19 (dengue and chikungunya) Protozoal (malaria) Bacterial (leptospirosis and scrub) Upper respiratory tract infection (URTI), lower respiratory tract infection (LRTI), UTI, and others |
5–7 days | All of the above + enteric (typhoid) fever |
>3 weeks | Infections, neoplasms, and CTD |
Questions for symptoms and signs/clues | Possible diagnosis |
|---|---|
Anorexia | Hepatitis |
Dark color urine | Jaundice and hepatitis |
Chills | Malaria, filaria, UTI, cellulitis, abscess, biliary tract obstruction, pyelonephritis, septicemia, pneumonia, and viral infections |
Cough, chest pain, breathlessness | Pneumonia |
Dysuria, pyuria | UTI |
Diarrhea | Enteric fever, colitis, and drug-induced diarrhea |
Delirium | Meningitis, encephalitis, typhoid, and pneumonia |
Epidemic | Dengue and influenza |
Headache | Sinusitis, otitis media, typhoid, malaria, and viral fevers |
Pain, body ache | Viral fever |
Ear | Otitis |
Throat | |
Joints | CTD/rheumatic fever/chikungunya |
Muscles | Viral fever |
Jaundice | Hepatitis A, B, C, malaria, leptospirosis, dengue, and cholangitis |
Exanthems/blisters— sepsis Rash (apart from exanthems) | Chickenpox (day 1), measles (day 4) |
Drug allergy | Ampicillin |
Erythema nodosum | Tuberculosis, leprosy, fungal infections, and streptococcal infection |
Erythema multiforme | Herpes simplex, mycoplasma, and drugs |
Butterfly rash | SLE |
Septicemia | Meningococcal, gonococcal, Gram-negative sepsis, and staphylococcal toxic epidermolysis |
Ecthyma gangrenosum | Pseudomonas infection |
Nutrition | Type and source of food. Is food poisoning a possibility? |
Sexual history | Any exposure to sexually transmitted infections |
Work | Exposed to pathogens or unusual chemicals at work? Consider work-related exposures to infectious diseases if patients work in sewers, laboratories or with live animals (e.g., leptospirosis) |
Travel | Recently traveled to a hot climate with increased prevalence of tropical infections (e.g., malaria and typhoid fever)? |
Hobbies | Any contact with animals and birds (e.g., psittacosis) or spirochete-infected animal contact, or indirect contact with water or soil with rat urine (e.g., leptospirosis). Have there been any recent tick bites? |
Past and current medical problems | Recent infections: Consider abscess formation and recurrence Operations: Recent surgery raises the possibility of postoperative infection or deep venous thrombosis Trauma: Ask about any recent trauma with extensive muscle damage. A resolving hematoma may also cause fever Immunization: Check details about the patient's immunization status |
Medication | Drugs causing fever: Is patient taking any drugs (INH, β-lactam antibiotics, procainamide, and phenytoin)? Check prescription and over-the-counter medication as well as illicit substances (e.g., doping body building) Antipyretics: Have these been taken? Are they effective in reducing the fever and alleviating symptoms? Antipyretics may also mask the fever and its diurnal pattern Antibiotics: Has the patient taken any antibiotics already, such as those prescribed by another practitioner or leftover? Steroids: Long-term oral steroids increase the risk of infection and may mask symptoms Chemotherapy and drugs causing neutropenia: Consider neutropenia, if the patient has recently undergone chemotherapy or is taking drugs that may cause blood dyscrasias (e.g., carbimazole) |
Allergies | Ask about allergies to any antibiotics needed to be prescribed for treatment of infection |
Home | How has home life been affected by the symptoms? Do other people who live in the same accommodation also suffer from fever or other symptoms? |
Patient Examination and Clues for Diagnosis of Fever
Investigations (Part 1) (Choices Include)
Duration | Probable cause for fever | Investigations (choices include) | |
|---|---|---|---|
2–5 days | Viral fever, malaria, URTI, LRTI, UTI, and COVID 19 | CBC, MP, QBC, reverse transcription polymerase chain reaction (RT-PCR) dengue, NS1, LFT Urine routine | |
5–7 days | All the above and enteric (typhoid) fever | CBC and peripheral smear Urine routine LFT Malarial parasite in blood and malarial card test Culture sensitivity (blood, urine, and stool) Serological tests (card tests/ELISA): Typhi point (typhoid) IgM ELISA for leptospirosis, dengue—NS1, IgM, chikungunya CXR, US, and CT | |
7–15 days | Headache | Sinusitis, otitis, dental sepsis, malaria, meningitis, and migraine | Refer investigations (Part 2) on Page 68 |
Cough | Tonsillitis, pneumonia, bronchitis, malaria, and TB | ||
Chest pain | Pleural effusion/empyema, pericarditis, liver abscess, root pain, emphysematous bullae, and costochondritis | ||
Approach to Patient with Neutropenic FUO
Investigations (Part 2) to Consider in FUO (Pyrexia of Unknown Origin) (Choices Include)
Investigation | Comments |
|---|---|
1. Blood test | |
CBC | Leukopenia with relative lymphocytosis = Viral Leukopenia = Typhoid Platelets may be decreased in dengue, leptospirosis, and typhoid |
ESR | May be elevated in infection, CTD |
CRP | May be elevated in infection, CTD |
Blood picture | May show malarial parasite |
LFT | May be abnormal in liver abscess, dengue, and leptospirosis |
D-dimer | Increased levels may suggest DVT/PE |
Antinuclear antibodies | |
Serological tests (CARD/ELISA IgG/IgM test) | Viral infections: Dengue, leptospira, chikungunya, and HIV Bacterial infections: Typhoid, infectious mononucleosis, brucellosis, scrub, and syphilis Protozoal infections: Malaria and amebiasis |
Serum electrophoresis | |
Creatinine, electrolytes, and calcium | |
Serum iron, transferrin, TIBC, and vitamin B12 | |
2. Urine test | |
Urine routine, urine CS | |
3. Imaging | |
CXR US (abdomen, lungs) CT/MRI (abdomen, chest, CNS) Color Doppler (limbs for DVT) | |
4. Microbiology | |
CS of blood, urine, sputum, stool, CSF, tissue, or pus | |
5. Biopsy | Needle biopsy of liver or other tissue indicated by potentially diagnostic clues |
Recommendations for Transmission-based Precautions of Select Cases
Precaution type | Selected case | Specifications |
|---|---|---|
Standard | All patients | Hand hygiene before and after patient contact, gloves, eye protection, safe disposal, cleaning of equipment or linen, and cough etiquette |
Contact | Pathogens implicated to spread via environmental contamination | Wash hands with soap and water. Private room preferred, gown on upon entering room. Consider gowning patient during transport. Noncritical items should be dedicated to use for single patient |
Droplet | Pathogens spread through respiratory or mucous membrane contact with respiratory secretions | Private room preferred, wear surgical mask when within six feet of patient. Mask patient during transport |
Airborne | Pathogens that remain infectious over long distances in the air, e.g., measles, small pox, varicella, Covid-19 | Place patient in the negative pressure room, wear certified respirator N 95. Mask patient during transport |
Complete | High mortality rate lack, of treatment or incompletely defined transmission modes, e.g., hemorrhagic fever, Ebola, Marburg MARS, Covid-19 | Follow standard, contact, and airborne precautions. Complete skin coverage and eye protection required for provider. Use a trained observer for all PPE |
Key Points for Clinical Practice
Simple viral fevers do not need antibiotics. No investigations are needed.
Before labeling a fever as viral, look for pallor, jaundice, and neck stiffness. Auscultate chest and examine the abdomen for liver/spleen enlargement.
If fever is not subsiding in 3–4 days of empirical treatment, investigate the patient thoroughly or refer to higher center.
1.21 FIRST AID
1.22 FOREIGN BODIES
Swallowed Foreign Bodies
Most will pass spontaneously, nearly 20% will require endoscopy and 1% will require surgical removal. Esophagus narrows naturally down at three places upper esophageal sphincter, aortic arch, and diaphragm.
Investigations (choices include):
1. | X-ray: Plane, coronal view/multiple views | Negative radiograph does not exclude a foreign body (fish bones, pills, and meat bolus) |
2. | CT scan |
Treatment (choices include):
ABC
Endoscopy (inability to handle secretions, fever, crepitus, is free air on radiograph, disk battery, sharp object, magnet, large objects, inability to tolerate oral solids or liquids, and foreign bodies in esophagus longer than 24 hours
Watchful waiting and serial radiographs
Foreign Bodies in Wounds
Glass, wood, bone, teeth, bullets metal, gravel, shell, rock, and plastic are examples.
Investigations (choices include):
1. | X-ray | Plain, multiple views around the wound, may be helpful |
2. | US | It is done when foreign body is suspected but not seen in X-ray, or foreign body is deep or close to anatomical structures or when surgery is planned. When wood, glass or metal is suspected, local application of lidocaine may enhance appearance of foreign body. Use of water bath can improve sound wave conduction and can help identify soft issue foreign bodies |
3. | CT scan | |
4. | MRI | MRI sensitivity is less due to artifact created by foreign body |
Key Points
Wood splinters unless painted, fish bones, pills, drug packets, and meat bolus are not radiopaque.
X-ray with multiple views should be ordered when there is a concern for retained foreign body. X-rays can identify glass fragments if >2 mm57
Ultrasound and CT scan are other imaging choices for foreign bodies.
Foreign bodies may migrate and later cause problems such as nerve damage injury to tendons or blood vessels. Therefore, most foreign bodies should be explored. A tourniquet may be useful sometimes specially in extremities.
1.23 HEADACHE
Red Flags/Alarm Symptoms/Warning Signs
Make sure you ask direct questions as listed below (if red flags/flags are present, urgent neuroimaging CT or MRI should be done):
Worst headache ever/severe headache, started suddenly over seconds (suggests bleed)
Sudden change in previously stable headache
Headache worsening or progressive over the days
Early morning headache (although also common with migraine)
“Thunderclap” headache—rapid time to speak headache intensity
Nausea and vomiting (also common with migraine)
Vomiting precedes headache (increase ICT)
Is headache precipitated by bending, lifting and coughing (increase ICT)?
Is it worse when lying down (postural headache)?
Fever or unexplained systemic signs
Night-time awakening
Nonblanching rash (meningitis)
Head trauma
Retro-orbital pain
Neck stiffness
↑BP + ↓pulse rate (=↑ICT)
Neurological findings such as papilledema, hemiparesis, cranial nerve abnormalities or hemianesthesia, and drowsiness
Jaw claudication (temporal arteritis)
HIV infection
History of cancer
Let them tell/unfold the story. Do not take history immediately.
Other questions:
Band-like headache = Tension
Unilateral or bilateral throbbing headache increases as exposure to loud sounds or bright light with visual aura = Migraine
Unilateral headache with watering from eye, nasal congestion or conjunctival chemosis = Cluster headache
Worse in the morning and decreases by evening = Increased ICT
Discharge, sinus pain or headache increase on bending, fever = Sinusitis
Headache after reading a book or seeing a movie = Refractive error
Nausea, altered vision, tinnitus, drowsiness, and fever = Migraine/meningitis
Headache while eating hot, cold or sweet foods or increase during eating/talking = Trigeminal neuralgia
Facial pain = Dental cause
Amenorrhea, galactorrhea, and history of cancer = Polycystic syndrome, pituitary adenoma, and cancer
History of quinolones, nalidixic acid, and vitamin A and D can cause pseudotumor cerebri.
Examination
General: BP, pulse, RR, check teeth, and paranasal sinus tenderness
CVS: Heart sounds, murmur
Central nervous system: Mental status, pupil response, motor strength, DTR, gait testing, signs of meningeal irritation (neck stiffness), signs of increased ICP (↑BP, ↓pulse rate), and papilledema.58
Primary Headache
Type | Duration | Features |
|---|---|---|
Tension (also known as anxiety/ chronic daily headache) | Half an hour–7 days Episodic or chronic | Bilateral tight band like constricting/pressure/squeezing pain. Not aggravated by movement. No nausea or vomiting. Some relief if pressure is applied |
Migraine | 15 minutes–3 hours | Repeated attacks of headache lasting 4–72 hours in patients with normal physical examination and no other cause for headache, and has at least two of the following features: + At least one of the following features: |
Cluster | Half an–1 hour 1–8 hours od/day, 2–12 weeks periodic attacks | Five attack of severe unilateral or orbital, or temporal pain plus at least one features such as eye redness/lacrimation/edema of eye/sweating/meiosis or ptosis. Restless or agitated |
Secondary Headache
Site | Etiology |
Intracranial: | |
Extracranial | Eyes: Refractory error Sinuses: |
Investigations (Choices Include)
Erythrocyte sedimentation rate
CT brain/MRI brain [do a CT at least once in all patients with chronic daily headache (consider with contrast unless only looking for bleeding)].
Paranasal sinus (PNS) X-ray, cervical spine X-ray
Eye check-up
Dental check-up
Temporal artery biopsy
Headache | First-line (abortive) treatment | Preventive prophylactic treatment | Patient education |
|---|---|---|---|
Tension | CALPOL (paracetamol) 500–1,000 mg PO BRUFUN (ibuprofen) 400–800 mg PO | TRYPTOMER/AMILINE (amitriptyline) 10–75 mg PO, at night | |
Migraine | CALPOL (paracetamol) 500–1,000 mg or MICROPYRIN (aspirin + caffeine) or BRUFEN (IBUPROFEN) 400–800 mg PO stat Plus ACUVERT 5 mg PO/STEMETIL (prochlorperazine) 12.5 mg IM or 10 mg PO stat or PERINORM (metoclopramide) 10 mg PO or IM/IV SUMITREX (sumatriptan) 100 mg PO (take within 20 minutes of attack) (side effects are in chest, drowsiness and dizziness) or MIGRIL (2 mg ergot + caffeine + cyclizine) 1 tablet PO within 1–1½ hour of attack (side effects are nausea, vomiting, and muscle cramps; maximum dose of 2 tablets in 24 hour, contraindicated in IHD, CAD, and peptic ulcer) | >2 episodes/month/debilitating headache consider: Inderal (propranolol) 40–80 mg PO, bd or TRYPTOMER/AMILINE (amitriptyline) 25–75 mg PO, hs or TOPAMAX (topiramate) 25–200 mg PO, hs or FLUGRAINE (flunarizine) calcium antagonist 10 mg, PO, hs (try one drug for 2 months and if patient is not better, change to another drug) or Riboflavin (vitamin B12) 400 mg PO Qid for 12 weeks or Fremanezumab antibody therapy | Avoid triggers: |
Cluster | O2 12–15 L/min for 5 minutes SUMITREX (sumatriptan) 6 mg SC stat; maximum 12 mg LIDOCAINE 4% drops: Place 15 drops in ipsilateral nostril with head raised up by 45° angle. Repeat dose after 15 minutes, if necessary Zolmitriptan intranasal spray | Verapamil (CALAPTIN) 80 mg PO, tds or TOPAMAX (topiramate) 25 mg hs PO, increase by 25 mg every 5th day; maximum dose 200 mg or GABANTIN (gabapentin) 900 mg/day |
Key Points
Make one correct diagnosis of primary headache syndromes (i.e., is it tension, migraine, or cluster?)
Tension headache is the most common headache. Patient with tension headache feels relieved by pressing over the temporal region.
A child or a young patient complaining of frontal headache may have refractory error. Refer patient to ophthalmologist.
Simple analgesics such as paracetamol control symptoms in most people. Explain risks of dependency on analgesics.
Identify and alleviate precipitating stresses. Relaxation techniques may help.
Tricyclic antidepressants (amitriptyline, sertraline) or BB (propranolol) may be useful in some cases of tension headache.
Obtain CT scan at least once in patients with chronic daily headaches.
Consider possibility of space-occupying lesion in patients with new onset of symptoms, specially headache and vomiting.
1.24 HEEL PAIN: PLANTAR FASCIITIS
Plantar fascia is a layer of tough fibrous tissue, which runs along the bottom of foot to support the arch. This is one of the longest and strongest ligaments in the body. There is inflammation of the plantar fascia on the heel bone. As the plantar fascia pulls on the heel, body responds by laying down more bone in the area. This can be seen on an X-ray and is known as a heel spur.60
Symptoms
Heel pain is severe usually in the morning and decreases after few hours.
Treatment (Choices Include)
Treatment | Procedure/Comments |
Soak | Soak feet in warm concentrated salt water solution, for ½ hour (do this as the first thing in morning as soon as you get up from the bed) |
Ice massage | The plantar aspect of foot with hand or ice ball |
Stretching exercises | Help lengthening the plantar fascia, calf muscles. Tightness in calf muscles can cause excess pronation (arch drop), which may contribute to plantar fasciitis |
Anti-inflammatory drugs (NSAIDs) | Anti-inflammatory drugs may provide temporary relief |
Ultrasound (extracorporeal short wave) | Can be helpful |
Acupuncture | Limited benefit |
Acupressure | Can be helpful |
Corticosteroid injections | Are reserved for intractable or difficult cases (steroids may provide more relief than oral anti-inflammatory medications) |
Change footwear/silicone or rubber heel cup | With foot solutions, custom biomechanical arch supports, i.e., specialized footwear; one can expect 50–70% relief for the 1st month, 70–90% relief for the 2nd month and 90–100% relief for the 3rd month depending on how consistently the support is used. Consistent arch support use can ensure that the problem does not recur |
Reduce weight | If BMI > 25 |
Physiotherapy | Stretching exercises, toe curls, toe towel curls, simple forced dorsiflexion of foot and toes |
Natural History and Prognosis
If left alone, plantar fasciitis may take 6–18 months to resolve. This condition is clinically diagnosed and 80% patients see self-limiting resolution within 1 year. There is no strong evidence that any particular treatment is beneficial.
1.25 HERPES ZOSTER (SHINGLES)
Herpes zoster is reactivation of varicella zoster virus (VZV).
Chest wall (most common site)
Face (trigeminal nerve area)
Geniculate ganglion (facial palsy, loss of taste, buccal ulceration and rash in external auditory canal = Ramsay Hunt syndrome)
Clinical Features
Burning discomfort in affected dermatome, which progresses to frank neuralgia discrete vesicles in the dermatome, 3–5 days later often coalesce.
Severe, multiple dermatomal involvement, or recurrence may suggest underlying immunodeficiency rule out DM, CKD, and HIV.
Complications
Postherpetic neuralgia (PHN) (persistence of pain for 1–6 months or more following healing of rash)
Secondary infection
Persistent visceral dysfunction (particularly in the absence of a rash)
Loss of sight with corneal scarring (particularly secondary to ophthalmic herpes)
Ramsay Hunt syndrome
Transverse myelitis
Meningoencephalitis
Pneumonitis
Atypical trigeminal neuralgia (ATN)61
Cranial and peripheral nerve palsies (Bell's palsy)
Transient ischemic attack (TIA), stroke from viral vasculitis
Deafness
Treatment (Choices Include)
Subset | Drugs |
Acute pain | Acyclovir (CYCLOVIR) 800 mg five times a day for 7 days or valacyclovir 1 g tid for 7 days; start within 3 days + Tramadol (ULTRACET) for 5 days + Amitriptyline (TRYPTOMER) 25 mg hs or Carbamazepine (TEGRETOL) 200 mg tds for 5 days |
Postherpetic neuralgia (PHN) | Amitriptyline (TRYPTOMER) 25–100 mg hs or carbamazepine (TEGRETOL) 200 mg tds or gabapentin (GABENTIN) 300 mg od/bd |
Key Points
Pain may precede rash.
Any rash, which stops in midline, suspects herpes zoster (i.e., involving single dermatome)
If skin is so hypersensitive that even touch of clothes is intolerable, it could be the start of herpes zoster!
Start treatment with acyclovir early (at the onset of burning pain/appearance of rash) (PO or IV if severe) + carbamazepine (TEGRETOL) 200 mg tds.
For pain relief, opioid analgesics are better than NSAIDs.
Chickenpox can be contracted from a case of herpes zoster and not the reverse.
While writing diagnosis, mention dermatome nerve root involved.
1.25.1 human immunodeficiency virus (HIV)
Red Flags
Reduced CD4 count
New neurological symptoms and signs including dementia
Persistent fever
Unexplained weight loss
Recurrent/severe shingles
Unexplained high plasma viscosity
Development of cancer
Significant psychological problems
Clinical Features of Acute Seroconversion Illness
Fever (present in 80–90%)
Rash, often erythematous and maculopapular
Fatigue
Pharyngitis (with or without exudate)
Generalized lymphadenopathy
Urticaria
Myalgia/arthralgia
Anorexia
Mucocutaneous ulceration
Headache, retro-orbital pain
Neurologic symptoms (e.g. aseptic meningitis, myelitis, and cranial nerve palsies)
Clinical Features of Early Symptomatic HIV Detection
Thrush
Persistent vaginal candidiasis that is difficult to manage
Oral hairy leukoplakia
Herpes zoster involving two episodes or more than one dermatome
Peripheral neuropathy
Bacillary angioplasia
Constitutional symptoms such as fever (38.5°C) or diarrhea for >1 month
Idiopathic thrombocytopenic purpura
Pelvic inflammatory disease, especially if complicated by a turbo-ovarian abscess
Listeriosis
Indicator Conditions in Case Definition
Candidiasis of esophagus, trachea, bronchi, or lungs
Cervical cancer, invasive
Coccidioidomycosis extrapulmonary
Cryptococcosis extrapulmonary
Cryptosporidiosis with diarrhea for > 1 month
Cytomegalovirus affecting any organ other than liver, spleen, or lymph nodes
Herpes simplex with mucocutaneous ulcer for > 1 month or bronchitis, pneumonitis, and esophagitis
Histoplasmosis, extrapulmonary
HIV-associated dementia: Disabling cognitive and/or motor dysfunction interfering with occupation or activities of daily living
HIV-associated wasting: Involuntary weight loss of > 10% of baseline plus chronic diarrhea (≥ 2 loose stools/day for ≥ 30 days) or chronic weakness and documented enigmatic fever for ≥ 30 days
Isosporiasis with diarrhea for >1 month
Kaposi's sarcoma in patient younger than age 60 (or older than age 60)
Lymphoma of brain in patient younger than age 60 (or older than age 60)
Lymphoma, non-Hodgkin's of B cell or unknown immunologic phenotype and histology showing small, non-cleaved lymphoma or immunoblastic sarcoma or Mycobacterium kansasii, disseminated
Mycobacterium avium, Mycobacterium tuberculosis (M. tuberculosis)
M. tuberculosis, pulmonary
Nocardiosis (disseminated nocardiosis)
Pneumocystis jirovecii (P. jirovecii), Pneumonia (formerly known as Pneumocystis carinii)
Pneumonia (recurrent bacterial)
Progressive multifocal leukoencephalopathy (PML)
Salmonella septicemia (nontyphoid), recurrent
Strongyloidiasis, extraintestinal
Toxoplasmosis of internal organ
Clinical Indicator Diseases for Adult HIV Infection
Diagnosis of HIV Infection
Antibody detection | ELISA (at least 3 months from exposure) Rapid spot tests Western blot tests |
Antigen detection | P24 antigen test (at least 2 weeks from exposure) |
Molecular diagnostics | Qualitative and quantitative viral load test |
Viral cultures | – |
Factors Affecting CD4 Cell Counts
Factors affecting CD4 counts | Factors affecting CD4 counts |
Bone marrow suppressive medicine | Splenectomy |
Acute infections | Coinfections with human T-lymphotropic virus type 1 |
α-interferon therapy | – |
Target population | WHO recommendation |
Severe or advanced HIV infection (clinical stage III and IV) | Start ART irrespective of CD4 counts |
HIV infection (clinical stage I and II) | Start ART when CD4 count falls below 500 cells/mm3 (priority in case it falls below 350 cells/mm3) |
Tuberculosis | Start ART regardless of CD4 count |
Hepatitis B Co infection | Start ART in all individuals with CD4 count <500 cells/mm3 In case of severe chronic liver disease, initiate ART regardless of CD4 count |
HIV-serodiscordant couples (one partner is HIV positive and the other is HIV negative) | Initiate ART for infected partner, regardless of CD4 count |
National AIDS Control Organization (NACO) Guidelines on Initiation of ART (2010)
WHO clinical stage | Start of treatment |
I and II | Start treatment when CD4 count below 250 cells/mm3 |
III | Start treatment when CD4 count below 350 cells/mm3 |
IV | Start treatment irrespective of CD4 count |
Available Antiretroviral Drugs for HIV Infections
NRTI | NNRTI | PI | Others |
Zidovudine (ZDV) Stavudine (d4) Lamivudine (3TC) Didanosine (ddi) Abacavir (ABC) Tenofovir (TDF) | Nevirapine (NVP) Efavirenz (EFV) Etravirine (ETR) Rilpivirine (RLP) | Atazanavir (ATV) Indinavir (IDV) Lopinavir (LPV) Ritonavir (RTV) Nelfinavir (NFV) Darunavir (DRV) Tipranavir (TPV) Fosamprenavir | Fusion inhibitor: T20 Integrase inhibitor: Raltegravir (RAL) CCR5 antagonist: Maraviroc |
The antiretroviral medications to manage HIV/AIDS are divided into five major types.
Key Points
Two distinct species of HIV (HIV-1 and HIV-2) exist.
HIV-1 is more virulent, easily transmissible, and accounts for majority of cases.
Sexual transmission, IV drug abuse, BT, and vertical transmission are major routes of acquisition.
High-risk group includes those with multiple sex partners, partner of HIV-infected patients, and IV drug abusers.
Acute infections resemble other acute infections.
Suspect HIV-infected patient with constitutional symptoms, recurrent fever, recurrent diarrhea, oral candidiasis, vaginal candidiasis, herpes zoster, and lymphadenopathy are the symptoms of early HIV infections.
Tuberculosis is one of the most common opportunistic infections with more extrapulmonary involvement and lower lobe involvement.
Pneumocystis jiroveci pneumonia (PCP), esophageal candidiasis, nocardiosis, PML, cryptococcal meningitis, HIV dementia, and wasting are other AIDS- defining conditions in our region.
Diagnosis of HIV is arrived by antibody-based tests.
ELISA/Rapid screening test in suspected cases.
Confirm diagnosis with Western blot test.
Screen for coinfections such as HBsAg, HCV, and syphilis.
CD4 is an important marker of immune system.
Viral load is important for monitoring the therapy.
Treat opportunistic infections before starting therapy.
Starting ART is not an emergency except in PEP and in prevention of mother-to-child transmission.
Combination ART should be used for management.
Therapy is life long without interruptions.
Monitor patient for acute and long-term side effects.
Three-drug combination of ART is preferred.
1.26 HICCUPS
Etiology and Investigations
Etiology | Investigations (choices include) |
|---|---|
Metabolic (uremia, hyponatremia, DKA, hypoglycemia, and hypokalemia) | Creatinine, urea, Na+, K+, RBS, and CBC |
Respiratory (pleurisy, Hodgkin's, metastatic cancer), sarcoidosis | CXR, US, and CT |
Abdominal (subdiaphragmatic collections/abscess, abdominal distension) | CXR, US, and CT |
Infections (sepsis) | CBC, culture, and sensitivity |
Trauma | – |
Drugs (dexamethasone, benzodiazepines, opioids, and methyldopa) | – |
Substance abuse, e.g., alcohol | – |
CNS (CVA, MS, lateral medullary syndrome) | |
Idiopathic | – |
Treatment (Choices Include)
LARGACTIL (chlorpromazine) | 50 mg stat PO/IM/q8 h |
SERENACE (haloperidol) | |
PERINORM (metoclopramide) | 10 mg IV q8 h |
BUSCOPAN (hyoscine butylbromide) | 10 mg PO/IV q8 h |
ALPRAX (alprazolam) | 0.25 mg q8 h (if anxiety) |
MUCAINE Gel | 15 mL q4 h |
LIOFEN XL (baclofen) | 10 mg q12 h |
Other Home Remedies
Swallowing granulated sugar
Gargling
Breathe into a plastic bag and rebreathe the same air
Key Points
Identify and treat the cause whenever possible.
Suspect hysteria in a young female patient with hiccups.
Suspect BPH/uremia in elderly male patients.
1.27 HYPERTENSION
Red Flags
Features suggesting a secondary cause
Accelerated hypertension (BP > 180/110 mm Hg with signs of papilledema and/or retinal hemorrhage)
Proteinuria
Visual symptoms (e.g., pituitary tumor)
Lack of response to treatment
Age < 30 years
In most cases, persistently raised BP is due to primary (essential) hypertension. Consider secondary hypertension in young people if there are additional symptoms or treatment resistance.
Etiology
1. Primary (essential) (95% cases) | Investigations/Comments |
Genetic and environmental factors | Please refer investigations/comments listed in the next page |
2. Secondary causes of hypertension (5% cases) | Investigations/Comments |
|---|---|
(i) Renal: Renal disease (PSK, CKD, obstruction) | Creatinine and urea, electrolytes, US abdomen |
Renal vascular hypertension (renal artery stenosis) | Kidney US (Doppler), CT, and renal angiogram |
(ii) Endocrine: Primary aldosteronism (adrenal adenoma or bilateral adrenal hyperplasia) | Plasma aldosterone concentration increased, plasma renin activity increased, CT, or MRI of adrenal |
Cushing's syndrome | Serum cortisol is increased, urinary free cortisol is increased Dexamethasone suppression test |
Pheochromocytoma | Urine or plasma metanephrine level |
Hyperparathyroidism, hypercalcemia | Serum calcium |
Hyperthyroidism, hypothyroidism | TSH, free T3, and free T4 |
(iii) Vascular: CoA, vasculitis, connective tissue disease | |
(iv) CNS cause brain tumor, intracranial hypertension, sleep apnea | CT brain |
(v) Drug induced or drug related or toxins or substance abuse (alcohol, cocaine, nicotine) | Nonadherence/Inadequate dose Inappropriate combinations Nonsteroidal anti-inflammatory drugs (NASIDs) (indomethacin and piroxicam); cyclooxygenase-2 (COX-2) inhibitors (celecoxib), antidepressants (venlafaxine), cocaine, amphetamines, other substance abuse drugs, sympathomimetic (decongestants, e.g., phenylephrine), oral contraceptives, steroids, cyclosporine, erythropoietin, and licorice |
(vi) Miscellaneous causes | Improper BP measurement Volume overload and pseudotolerance Excess sodium intake |
Complications
For each increase of 20 mm Hg SBP or 10 mm Hg DBP, there is two-fold increase in cardiovascular complications.
Cardiac | CAD, LVH, and CHF |
Vascular | Aortic dissection, aortic aneurysm, and PAD |
Neurologic | TIA/CVA, rupture of aneurysms |
Renal, Genital | Proteinuria, renal failure, and erectile dysfunction |
How to Check Blood Pressure?
After 5 minutes of rest, patient seated in a chair, feet resting on floor, back supported and arm bare and at heart level, and place BP cuff (a large adult-sized cuff should be used to measure BP in overweight adults because standard size cuff can spuriously elevate readings).
Tobacco and caffeine should be avoided for at least 30 minutes
BP should be measured in both arms to exclude coarctation of aorta (CoA).
BP should also be measured after 3 minutes of standing to exclude a significant postural fall in BP (≥ 20 mm Hg) (Systolic fall in BP = Orthostatic hypotension). Orthostatic hypotension may be a marker of early atherosclerosis and is associated with elevated risk of heart failure.
On average BP readings are 5–10 mm Hg lower than with digital, unattended or out of office methods of measurement than with routine or standard methods of office measurement
Less aggressive goals presented in table may be appropriate for specific group of patients including those with postural hypotension. frail older adult patient. and those with side effects to multiple antihypertensive medications home BP readings should not be used to manage BP unless it is performed adequately and in conjunction with office BP or ambulatory BP.
Goal Blood Pressure in Different Clinical Situations
Category | Blood pressure (mm Hg) |
125–130/ < 80 125–130/ < 80 125–130/ < 80 125–130/ < 80 125–130/ < 80 125–130/ < 80 |
When and Whom to Check Blood Pressure?
All patients as routine examination
Patients > 40 years
Diabetes mellitus
Obese
Headache
Giddiness
Chest pain
Epistaxis
Direct relatives of hypertension patients
Staging of Blood Pressure
Staging of blood pressure | Recommended treatment option(s) | ||
|---|---|---|---|
Blood pressure (stage) | Systolic BP (mm Hg) | Diastolic BP (mm Hg) | |
Normal | < 120 | <80 | Nil |
Elevated | 120–129 | <80 | Lifestyle modification |
Hypertension | 130–139 | 80–89 | A + C + D |
Hypertension | 140 or higher | 90 or higher | A + C or A + D or A + C + D or A + C + D + B |
Isolated systolic HT (elderly > 50 years) | >130 | > 80 | |
Isolated diastolic HT | <130 | >80 | |
Hypertensive crisis | >180 | >120 | |
Note: A stands for ACE inhibitors (ACEIs) or angiotensin-II receptor blockers (ARBs), B for beta blockers, C for calcium channel blockers (CCBs) and D for diuretics.
Investigations (Choices Include)
Test | Comments |
|---|---|
Creatinine and urea | For renal disease RFT needs to be checked before starting ACEI |
K+ and Na+ | |
FBS | For DM |
Lipid profile | For hypercholesterolemia |
TFT | Hyperthyroidism may be associated with HT and hypothyroidism is linked to diabetes and hyperlipidemias |
Uric acid | |
Urine routine and microalbuminuria | |
ECG | May show LVH |
ECHO | |
Renal Doppler | |
APBI | |
Carotid Doppler | |
Investigations to be done when secondary cause is suspected: |
Note: ABPI, carotid Doppler studies and microalbuminuria can pick up silent end-organ damage early.68
Treatment (Choices Include)
Lifestyle Modifications
Modification
Recommendation
Approximate systolic blood pressure reduction
Weight reduction
Maintain normal body weight [body mass index (BMI) (18.5–24.9 kg/m2)]
5–20 mm Hg/10 kg
Adopt DASH eating plan
Consume a diet rich in fruits, vegetables, low carbohydrate, low salt, low-fat dairy products with a reduced content of saturated and total fat
8–14 mm Hg
Dietary sodium reduction
Reduce dietary sodium intake to no > 100 mmol/day (2.4 g sodium or 6 g sodium chloride)
2–8 mm Hg
Physical activity
Engage in regular aerobic physical activity such as brisk walking (at least 30 min/day for at least 5 days/week)
4–9 mm Hg
Moderation of alcohol consumption
For men, limit consumption to no more than two drinks [1 oz or 30 mL ethanol; 24 oz beer (720 mL), 10 oz wine (300 mL), or 2 oz (60 mL) 80% proof whiskey] per day
For women and lighter weight person, not more than one drink per day
2.5–4 mm Hg
DASH highlights (table listed below is based on a 2,000 calorie plan):
Food groups
Daily servings
Serving size
Grains and grain products
7–8
1 slice bread (preferably whole wheat) or
1 cup dry cereal or
½ cup cooked rice
Vegetables
4–5
1 cup raw leafy vegetables or
½ cup cooked vegetables or
½ glass vegetable juice
Fruits
4–5
1 medium fruit or
200 mL fresh fruit juice
Fat-free or low-fat milk and milk products
2–3
250 milk or
1 cup yogurt
Lean meat poultry and fish or pulses
2 or less
½ cup cooked lean meat, skinless poultry or
fish, or
1 small bowl of pulses
Nuts, seeds, and legumes
4–5 per week
7–8 count of dry fruits or
1 small cup of legumes two to three times a day
Fats and oils
2–3
1 teaspoon vegetable oil
Sweets
5 or less per week
1 teaspoon sugar
Antihypertensive Drugs
Drugs group
Trade name
Starting dose (mg)
Maximum dose (mg)
(i) ACE inhibitors (ACEI)
Enalapril
ENVAS
2.5
Ramipril
RAMACE, CARDACE
2.5
10
(ii) Angiotensin-II receptor blockers
Losartan
LOSAR
25
100
Telmisartan
TELMA and TAZOLAC
40
80
Olmesartan
OLMARK
20
40
Side effects are dry cough and hyperkalemia
(iii) Beta blockers
Atenolol
ATEN
25
100
Bisoprolol
CONCOR
2.5
10
Carvedilol
CARVIL
12.5
25
Metoprolol
BETALOC
25
450
Side effects are bronchospasm, lethargy and erectile dysfunction
Bisoprolol and carvedilol are used in CHF and resistant hypertension
(iv) Calcium channel blockers
Amlodipine
AMLOVAS, AMLODAC
2.5
20
Nifedipine
NICARDIA RETARD
10
120
Cilnidipine
CILACAR
5–10
20
Diltiazem
DILZEM
30/60/90
240
Verapamil
CALOPTIN
80 tds
120–360
Side effects are edema and flushing of head
Diltiazem and verapamil are used when BB are contraindicated or patient has cardiac problems such as SVT
(v) Diuretics
Hydrochlorothiazide
AQUAZIDE
12.5
25
Chlorthalidone
CTD/LUPICLOR
12.5
25
Torsemide
DYTOR
5
10
Furosemide
LASIX
Indapamide
LOZOL
1.25
5
Metolazone
METENIX, ZYTANIX
2.5
10
Side effects are hypokalemia and erectile dysfunction
(vi) Alpha blockers
Prazosin
MINIPRESS XL PRAZOPRESS
2.5/5
20
Terazosin
TETRAPRESS, HYTRIN
1/2/4
20
Side effects are orthostatic, hypotension, syncope and nasal congestion.
After counseling about lifestyle interventions to lower BP:
If systolic BP is more than 20 mm Hg above goal or diastolic pressure is more than 10 mm Hg above goal, start ACE inhibitor or ARB. If BP uncontrolled, add CCB, and BP remains still uncontrolled add thiazide like diuretic and even after that if BP remains uncontrolled it is a case of apparent resistant hypertension.
If systolic BP more than 20 mm Hg above goal or diastolic pressure is more than 10 mm Hg is not above goal, is not there do albumin to creatinine ratio (ACR) and if ACR is > 300 mg/g initiate ACE inhibitor/ARB. If albumin to creatinine ratio (ACR) is <300 mg/g initiate ACE inhibitor/ARB/a CCB, if BP remains uncontrolled combine ACE inhibitor/ARB with a CCB, and if BP still remains uncontrolled add thiazide like diuretic and even after this if the BP remains uncontrolled it is resistant hypertension.
If BP 130–139/80–89, with elevated cardiovascular risk one can attain goal BP with lifestyle interventions alone for a period of 3–6 months. Drug therapy should be initiated in such patients if lifestyle interventions are not sufficient to achieve goal BP.
Some experts suggest that initial drug therapy should include two drugs combination therapy if systolic pressure is more than 20 mm Hg above goal, or diastolic > 10 mm Hg above goal, how other experts suggest that combination therapy should be used in patients where systolic pressure is > 10 mm Hg above the goal. Both approaches are reasonable.
Using single pill combinations rather than prescribing two separate pills is preferred because it can improve adherence and control.70
Use of thiazide like diuretic (chlorthalidone and indapamide) is a reasonable alternative for monotherapy or in combination with ACE inhibitor or ARB instead of using a dihydropyridine CCB like amlodipine felodipine nifedipine. In addition, thiazide like diuretics, but not thiazide type diuretics have been shown to reduce cardiovascular outcomes.
“AB/CD” algorithm:
“A” stands for ACE inhibitors or angiotensin-II receptor antagonists
“B” stands for beta blockers
“C” stands for CCBs
“D” stands for diuretics
Algorithm is based on the idea that hypertension is best treated by one of the two categories of antihypertensives:
Those that inhibit the renin-angiotensin system (A or B) and those that do not (C or D)
A + D are best and more effective for young patients < 55 years
C + D group drugs are best for elderly people
Most people usually need 3–4 drug combinations to attain and maintain target BP levels. Combination drugs are used for hypertension (usually for stage II BP, i.e., >160/100 mm Hg)
Some combination drugs:
ACE inhibitors + CCB
ACE inhibitors + Diuretics
ACE inhibitors + Diuretics + CCB
Beta blockers + Diuretics
CCB + Diuretics
Antihypertensive Drug Choices in Specific Situations
Clinical situation | Recommended drugs (ü) | Avoid (×) | |||||
|---|---|---|---|---|---|---|---|
Diuretic | BB | ACEI | ARB | CCB | Aldosterone antagonist | ||
Diabetes mellitus | ✓✓ | ✓✓ | ✓ | ||||
Renal disease (CKD) | ✓✓ | ✓✓ | |||||
Congestive heart failure | ✓✓ | ✓ | ✓✓✓ | ✓ | ✓ | ||
Myocardial infarction | ✓ | ✓ | ✓✓ | ||||
Angina pectoris (CAD) | ✓✓ | ✓✓ | |||||
Heart block | CCB, BB | ||||||
Recurrent stroke prevention | ✓ | ✓ | |||||
Renal artery stenosis | Alpha blocker | ARBS, ACEI | |||||
Hyperlipidemias | ✓✓ | ✓ | D, BB | ||||
Asthma, COPD (bronchospastic disease) | ✓ | ✓ | BB | ||||
Young | ✓ | ✓ | ✓ | D, BB | |||
Elderly | ✓ | ✓ | |||||
Peripheral vascular disease | ✓ | BB, ACEI Alpha blocker | |||||
Erectile dysfunction | BB, D | ||||||
BPH | |||||||
Gout | D | ||||||
Pregnancy | Methyldopa (best choice) | ✓ | D, ACEI, ARB | ||||
Essential tremor | ✓✓ | ||||||
Migraine | ✓✓ | ✓✓ | |||||
Osteoporosis | ✓✓ | ||||||
Raynaud's syndrome | ✓✓ | ||||||
Perioperative hypertension | ✓✓ | ||||||
(D: diuretic; BB: beta blocker; ACEI: ACE inhibitors; CCB,: calcium channel blockers; ARB: angiotensin receptor blockers)
[CAD, MI, CCF, DM, renal diseases are main compelling indications (you can give), (× = avoid)].71
Adverse Drug Reactions of Antihypertensive Drugs
Common side effects | Diuretic | Beta blocker | ACE inhibitor | Calcium channel blocker | Alpha blocker |
|---|---|---|---|---|---|
Bronchospasm | – | + | – | – | – |
Lethargy | – | + | – | – | – |
Impotence | + | + | – | – | – |
Hypokalemia | + | – | – | – | – |
CCF | – | + | – | – | – |
Cold hands and feet | – | + | – | – | – |
Heart block | – | + | – | – | – |
Hyperkalemia | – | – | + | – | – |
Dry cough | – | – | – | – | |
Edema | – | – | – | + | – |
Flushing | – | – | – | + | – |
Headache | – | – | – | + | – |
Postural hypotension | – | – | – | – | + |
Dizziness | + |
3. Access Cardiovascular Risk Factors and Treat Them
Risk factor | Goal or suggested activity |
|---|---|
DM | FBS < 130, PPBS < 160, HbA1c < 6.5 |
Dyslipidemia | LDL < 100 |
Obesity | BMI < 23 |
Physical inactivity | 30 minutes of exercise 5 day a week |
Smoking | Quit |
Key Points
Diuretic, CCB, angiotensin converting enzyme inhibitor, or angiotensin receptor blocker is considered as initial therapy for most patients.
Many patients with hypertension need more than one drug to control BP. If first drug does not achieve BP goal, add second drug with different mechanism.
If ACE inhibitor or ARB was used initially it is reasonable to add like diuretic or a CCB. 2 renin angiotensin inhibitors should not be used together.
When baseline BP is more than 20 by 10 mm Hg above goal BP, begin therapy with 2 drugs
For black patients, diuretic or CCB is recommended as initial therapy except for those with CKD or heart failure who should have ACE inhibitor or ARB.
Beta blockers are recommended as initial therapy for patients with other indication for a beta blocker such as coronary heart disease or left ventricular dysfunction.
Angiotensin-converting enzyme (ACE) inhibitor or ARB is used for initial treatment of hypertension with diabetes. In absence is albuminuria, diuretic or CCB will be a reasonable choice.
1.28 HYPOTENSION (SYSTOLIC BLOOD PRESSURE < 90 MM HG)
Normal BP = 120/80 mm Hg
Normal CVP = 6–10 cm of water
Hypotension with low CVP:
Hypovolemic shock (hemorrhagic and nonhemorrhagic)
Distributive shock (septic, anaphylactic, vasovagal, neurogenic, and hypoadrenal).
Etiology and Investigations
Etiology | Volume problem (hypovolemic shock) | Cardiac problem (pump problem) | Pulmonary problem (lung problem) |
|---|---|---|---|
|
|
| |
Investigations (choices include) | CBC, HCT Na+, K+, creatinine, RBS Blood group and crossmatch Coagulation profile C/S of pus, tissue, blood Serum lactate CXR, US, CT (abdomen chest) | ECG CXR ECHO Troponins CKMB | CXR ECG CT angiogram CT (helical) |
Treatment of Hypotension
1. First aid: Foot end elevation | Raise legs straight to 45° and elevate for 4 minutes, while maintaining trunk supine around 600 mL of blood, which is pooled in the legs get pushed into the circulation Foot end elevation, as first aid is ideal in vasovagal shock, anaphylactic shock, and hypovolemic shock (foot end elevation is contraindicated in cardiogenic shock) |
2. Circulation: Restore volume: | In hemorrhagic shock (fluid challenge): 250 mL of NS over 5 minutes and recheck BP, if improving, one can repeat bolus or NS or RL 20 mL/kg or 1,000 mL in 1 hour or as fast as possible to keep BP around 90 mm Hg |
Hematocele or gelofusine or volulyte or hetastarch | |
3. Drugs: | Dopamine: 5–20 µg/kg/mm Dobutamine: 5–20 µg/kg/mm (for cardiogenic shock) |
Norepinephrine (noradrenaline) 5–10 µg/kg/mm | |
Tranexamic acid 1 g (for hemorrhagic shock) (trauma or major surgeries) It minimizes blood loss by inhibiting lysine-binding sites on plasminogen thereby preventing the conversion of plasminogen to plasmin This inhibits fibrinolysis and reduces clot breakdown resulting in reduction of bleeding | |
For vasovagal shock with bradycardia | |
4. Stop blood loss or control bleeding | Pressure, packing of wound, suture ligation, antishock garments, endoscopic procedures to stop blood loss, e.g., embolization/laparoscopy |
5. Airway | Oxygen 100% |
6. Breathing | Endotracheal intubation and ventilation may be needed in some cases |
Goals of Resuscitation in Trauma Patients with Hypotension
Early goal | Final goal | |
SBP | > 80 mm Hg | > 100 mm Hg |
HR | < 120/mL | < 100/min |
Hb | > 9 g/dL | > 9 g/dL |
Urine output | > 0.5 mL/kg/mm | 2 mL/kg/min |
Mentation | Clear |
Refractory Shock
When shock does not respond to usual treatment, IV fluids, etc. It is termed as refractory or unresponsive shock, consider the following.
Etiology | Treatment/Comments |
|---|---|
Acidosis | 50 mL of 8.4% sodium bicarbonate IV |
Hypocalcemia | 10 mL of calcium gluconate IV |
Cardiac tamponade | CXR, ECHO, and pericardiocentesis |
Adrenocortical insufficiency | Suspect if patient is on steroids, has disseminated TB or AIDS |
Septic focus/septic shock | Drain septic focus, and antibiotics |
1.29 HYPOXIA (DESATURATED PATIENT WITH SpO2 < 90)
Investigations (Choices Include)
Pulse oximetry: It measures oxygenation in blood. Normal value is 96–99%; oximetry < 90% indicates significant hypoxia and calls for immediate attention. Pulse oximeter has been shown to be accurate in a wide range of clinical settings and is a valuable tool for monitoring. Skin pigmentation and jaundice do not interfere with readings.
Uses:
In acute respiratory illness, e.g., emphysema and asthma
Fluid overload, e.g., pulmonary edema
Trauma (before, during and after operation)
Operation theater
Limitations:
Anemia
Carboxyhemoglobin
Fingernail polish
Methemoglobinemia
Movement artifact, especially in restless patients
Severe vasoconstriction from hypothermia or shock
Venous congestion
Inadequate perfusion
ECG
Chest X-ray
CT scan (head, thorax, and abdomen)
MRI brain
ECHO
Treatment
Oxygen:
8 L/min 100% (by mask)
Ensure SpO2 is preferably between 90% and 95% (SpO2 > 80 is compatible with survival)
Ventilation (indications):
Respiratory failure
RR > 30 bpm
Hypercapnia (elevated CO2 on blood gas)
Bronchospasm
Laryngeal edema/obstruction
Altered mental status/neurological deterioration or GCS scale < 8
Shock
Inability to protect airway, e.g., trauma
Hypoxemia
Coma
Endotracheal intubation (dictum is when in doubt, intubate):
Preoxygenate with resuscitator, Ambu bag, and mask
Check suction, laryngoscope, endotracheal tube, and use appropriate size
Carefully inspect stylet, it must not protrude beyond the tube or through the Murphy's eye.
Position patient's head on a folded sheet without extending the neck. This will be more comfortable during intubation.
Ensure adequate cricoid pressure, this facilitates intubation and prevents aspiration.
After adequate preoxygenation, attempt intubation. If patient resists, continue preoxygenation, prepare for pharmacological assistance, such as fentanyl 2 mg/kg IV or morphine 0.1–0.2 mg/kg plus propofol 1–2 mg IV.
Intubate
Inflate the cuff adequately, so that there is no air leak. This is confirmed by auscultating the neck during expiration.
Auscultate lung fields for equal air entry
Insert an oropharyngeal airway and secure endotracheal tube with adhesive tape
Paralysis can be extended with pancuronium (PAVULON) 0.1 mg/kg (avoid repeat dose of succinylcholine, as it causes bradycardia, this side effect is effectively handled by administering injection atropine 1.2 mg IV).
Laryngeal mask anesthesia (LMA) or I gel
Ventilator support: Methods and appropriate oxygen supply:
Nasal prongs: 2 L/min (24–30% oxygen)
Mask: 6–8 L/min (up to 60% oxygen)
Mask with reservoir bag (up to 80%)
Continuous positive airway pressure (CPAP)/PEEP (up to 100% oxygen)
Mechanical ventilation is warranted in patients who are intubated. Since medical gases are dry, humidification through ventilators is desirable to prevent dehydration of respiratory passage.
Standard ventilator settings:
Synchronized intermittent mandatory ventilation (SIMV) with pressure support
Fraction of inspired oxygen (FiO2): 100%
Positive end-expiratory pressure: 5 cm H2O
Tidal volume support: 6–10 mL/kg body weight and maintain a peak pressure of 35 cm H2O
If the pressure is higher, reduce tidal volume to 6 mL/kg and maintain required minute volume by increasing the respiratory rate per minute
Perform baseline ABG analysis
Repeat ABG after 1 hour for readjustment of settings.
3. Treat the cause for hypoxia75
1.30 INSOMNIA
Red Flags
Physical symptoms and signs
Depression
Suicidal thoughts
Alcohol or substance abuse
Etiology
Etiology (mnemonic = D2ART) | History |
|---|---|
Depression | Depressed mood or decreased interest + any two of these features listed below: Decreased appetite, decreased sleep, fatigue, decreased concentration, and suicidal thoughts (refer Chapter 6.14.2) |
Anxiety | Any three of the features listed below: Restlessness/feeling of impending disaster or fear, or fatigue or sleep disturbance, irritable, difficulty in concentrating, and muscle tension (refer Chapter 6.14.1) |
Restless leg syndrome | Involuntary leg movements or jerking leg movements |
Drugs | Theophylline, BB, corticosteroids, thyroxine, alcohol withdrawal, and substance abuse |
Travel | Jet lag |
Treatment (Choices Include)
Drug | Brand name | Dose | Comments |
|---|---|---|---|
Zolpidem | Nitrest | 10 mg hs | Use only for short periods of 2–3 weeks, these drugs have risk of dependence |
Temazepam | Restoril | 15–30 mg hs | |
Alprazolam | Alprax | 0.25–0.5 mg hs | |
Doxepin | Doxetar Amiline | 25–75 mg hs | Tricyclic antidepressants can have side effects, ideal for chronic pain and insomnia |
Amitriptyline | 25–50 mg hs | ||
Miscellaneous: Trazodone | Trazalon | 50–100 mg hs | Melatonin is a new entry for insomnia 3 mg 1 hour before bedtime |
Ramelteon | Rozerem | 8 mg hs | |
Melatonin | Meloset 3 mg | 1–6 mg |
Parasomnias (Abnormal Behaviors During Sleep)
Classification | Features | Treatment |
|---|---|---|
Sleep terror | Abrupt terrifying arousal from sleep (preadolescent boys and adults) | Diazepam 5–20 mg at bedtime |
Nightmares | – | Diazepam 5–20 mg at bedtime |
Sleepwalking (somnambulism) | Walking while sleeping (children of 6–12 years and in adults due to drugs or complex seizures) | Diazepam 5–20 mg at bedtime |
Enuresis | Involuntary bedwetting (more common in children) | Imipramine (imipramine/antidep) or desmopressin nasal spray |
Patient Education Regarding Good Sleep Hygiene/Tips for Good Sleep
Go to bed only when sleepy.
Use bed and bedroom only for sleep and sex. Dim lights by 6 pm double panel windows, heavy curtains can reduce sound and light.76
Room should be cool, dark, and quiet (no lights/LED clocks/noisy clocks). Decrease other noises, e.g., snoring, household tension/noises.
Ideal temperature of room should be 23–25 degree in India. Hot weather or cold weather can affect sleep.
Do not watch TV/computer/mobile phone 2 hours before bedtime.
Create a worry box and drop your worries.
Avoid nap or sleep during daytime.
Avoid coffee, late night snacks and alcohol 6 hours before sleep.
Establish daily exercise program.
Invest in a good mattress.
Establish bedtime ritual (30 minutes to wind down) and a routine time for going to sleep.
Deep breathing, diaphragmatic breathing, meditation, yoga, gratitude practice, and prayer can help induce sleep.
Warm compress for spine. Warm temperature of fomentation causes a sedative effect.
Supplies and directions for spine fomentation: Two towels, 1–2 hot water bottles (flat rubber bottles are best)—
Wet one towel with warm water and wring as much as possible
Fill water bottle(s) with hot water and place one or two bottles length wise over the spine with patient lying on their abdomen.
Cover with a dry towel or with blanket from bed. Fomentation can be removed once heat fades away.
Change to another room if not able to sleep in one room after 20 minutes or pursue a restful activity (such as a bath or meditation) and return only when sleepy.
Purchase ear buds (sleep buds) if partner is snoring.
Key Points
Sleeping pills are addictive; they might promise sleep, but end up making a person anxious.
Best sleep is of 6 hours or more.
Taking too much time to fall off to sleep is a sign of stress. Easiest way to overcome this is to stop brooding about things.
If nap is taken in afternoon, it should not last more than an hour.
Lack of sleep affects the way one ages and appears.
Heavy meal at night activates the stomach, thus keeping the brain active. Anything that keeps the brain in overdrive affects sleep.
People believe alcohol is a stimulant, but it is actually a depressant that affects sleep pattern.
Lack of sleep is linked to weight gain, hypertension, reduced immunity, depression, and a feeling of being unwell and lack of concentration during the day.
1.31 LYMPHADENOPATHY and LYMPHEDEMA (refer chapter 6.18)
Around 800 lymph nodes in the body and this includes 300 which are in neck.
Location | Site | Number of nodes |
|---|---|---|
There are four main locations of lymph nodes in body | 1. Neck 2. Armpit 3. Abdomen 4. Groin | 500 |
Neck | Superficial nodes at junction of head and neck Deep inner ring (Waldeyer's ring) Deep nodes: |
Arrangement of Lymph Nodes of Head and Neck
Superficial nodes in ring form at the junction of neck and head (also known as outer Waldeyer's Ring) or Outer horizontal circular chain) | Submental Submandibular Facial Parotid Pre-auricular Occipital Mastoid | ||||||||||||
Deep inner ring (Waldeyer's Ring) | Clumps of mucosa-associated lymphoid tissue (MALT) in nasopharynx and oropharynx (beginning of air and food passages) are listed below: One adenoid (pharyngeal tonsil) Two tubal tonsils Two palatine tonsils and Two lingual tonsils Function of Waldeyer's Ring: Filter breathing and trap bacteria and virus Produce lymphocytes to send to other nodes | ||||||||||||
Deep nodes Level system for describing location of lymph nodes in neck | Receive all lymph directly nor indirectly from superficial nodes and are organized into a vertical chain near internal jugular vein within the carotid sheath (upper, middle, and lower deep cervical nodes). The efferent vessels from deep nodes converge to form the jugular trunk, left trunk joins the left subclavian vein and the right trunk joins the right subclavian vein Termination of neck nodes: Terminate and drain into right lymphatic duct or thoracic duct left side
|
Significance of Levels of Lymph Nodes I to VI (Sloan Memorial Kettering Levels of Nodes in Neck)
There is a high risk of metastasis in cancer in select level of lymph nodes, or if cancer has already spread to a select level node, the surgeon will do an appropriate Block Dissection to remove only affected levels of lymph nodes.
High risk of involvement in oral cancer | Level I, II, and III |
High risk of involvement in oropharyngeal cancer | Level III, IV, and V |
High risk of involvement in thyroid cancer | Level VI |
Drainage Area of Cervical Nodes
Cervical nodes drain head, neck, face, oral cavity, PNS, pharynx, larynx, and thyroid (left supraclavicular nodes also drain from left upper limb, left chest wall, left breast, abdomen, and testes).
1.31.1 Lymphadenopathy (Etiology of Lymph Node Enlargement)
Cause | Examples |
Infections | Acute infections (tonsillitis) Chronic infections (TB) Reactive nodes (nonspecific hyperplasia) |
Noninfective | Connective tissue disease, sarcoidosis, and drugs |
Malignancy | Primary (HL/NHL) Secondary (metastatic carcinoma) Hematological malignancy, e.g., chronic lymphatic leukemia (CLL) |
1.31.2 Cold Abscess
Cold abscess is an abscess that lacks intense inflammation; it is a localized collection of pus without signs of inflammation. TB is the most common cause of cold abscess.
Etiology | Tuberculosis (caseating lymph nodes, TB of spine, ribs, and joint) Madura mycosis Actinomycosis Leprosy |
Site | Neck, paraspinal, intercostal, psoas, groin, and skin (often travel along facial/neurovascular bundle) |
Stages of formation of TB | Lymphadenitis Matting Caseating necrosis and cold abscess Collar stud abscess Sinus |
Investigations (Choices Include)
Blood | CBC, ESR, FBS, creatinine, and blood borne infection screen (HIV, HBS, and HCV) |
Imaging | US neck Chest X-ray CT (neck and chest abdomen) |
Microbiology | AFB smear and AFB C/S |
Biopsy | Lymph node or curetting's from abscess wall cavity |
Molecular diagnostic tests | Expert TB RIF assay, e.g., RT-PCR [detects genetic material (genes, proteins] |
Stage | Confirmatory investigations (microbiology/biopsy/molecular tests) | |
|---|---|---|
1. | Lymphadenitis | FNA/lymph node excision biopsy or Expert TB RIF assay |
2. | Matting of nodes | FNA/lymph node excision biopsy or Expert TB RIF assay |
3. | Cold abscess | I and D and curettage of abscess wall cavity for biopsy or Expert TB RIF assay |
4. | Collar stud abscess | I and D and curettage of abscess wall cavity for biopsy or Expert TB RIF assay |
5. | Sinus |
Treatment of Tuberculosis Abscess
Anti-TB drugs are mandatory for 6 months.
Sometimes are given for 9–12 months in select cases, e.g., Tb meningitis.
Rifampicin + INH + ethambutol + pyrazinamide (four drugs for 2 months) and rifampicin + INH (two drugs for 4 months)
1.31.3 Lymphedema
Classification of Lymphedema
Primary | Secondary | |
Etiology | No definite cause (hypoplasia/aplasia of lymphatic channels) | Definite cause (blocked/destroyed lymphatic channels) |
Examples | Congenital, familial | Surgery, infection, malignancy, postradiation, trauma to groin/axilla |
Complications
Skin thickening
Cellulitis (recurrent)
Lymphangitis
Lymphangiosarcoma
Investigations
Blood and urine | CBC, peripheral Smear, microfilaria (Mf), LFT, RFT, and TFT |
Imaging | Color Doppler ultrasound Isotope lymphoscintigram (technetium labelloid colloid particles, is the best test) US (for abdominal masses) CT/MRI |
Biopsy | Lymph node |
Treatment of Lymphedema (Choices Include)
Medical | Elevation: Foot end of bed is elevated by 15–20° degree (8–10 inch blocks at foot end of bed) Compression stockings Exercise Massage pneumatic compression helps to decrease edema Foot care advice Drugs: Flavonoid (DAFLON 1 bd), coumarin (LYMPHEDIN 1 bd), diuretics, antifilarial drugs (DIETHYLCARBAMAZIPINE CITRATE), antibiotics for cellulitis |
Surgical | Excisional surgery (Debulking): Aim is to remove subcutaneous tissue from limb Bypass procedures are very difficult and rarely done procedures |
1.31.4 Lymphoma
Malignant proliferation of lymphocytes in lymph glands or in bone marrow or in organs like liver and spleen. Histologically divided into HL and NHL
Symptoms
Painless lymph node swelling in neck/axilla/groin
Recurrent fever
Sweating during night
Weight loss
Investigations
Blood tests | CBC, LFT, RFT, ESR, blood borne infection screen (HIV, HBS, and HCV) |
To confirm diagnosis | Lymph node biopsy (core/excisional) |
Staging evaluation (investigations to see extent/spread of tumor) | CT (thorax, abdomen, and pelvis) or PET-CT scan (whole body) + bone marrow biopsy (iliac crest) |
Ann Arbor Classification
It is used for staging of lymphoma (for prognosis, extent and treatment plan of disease).
Stage | |
I | Single lymph node region |
II | Two or more lymph node areas on the same side of diaphragm |
III | Nodes above and below diaphragm |
IV | Lymph nodes + extralymphatic spread like liver, bone marrow, or lungs |
A = No systemic symptoms other than pruritus
B = Weight loss, fever, and sweating
Comparison of Hodgkin's and Non-Hodgkin's Lymphoma
Hodgkin's lymphoma | Non-Hodgkin's lymphoma (more common) | |
|---|---|---|
Clinical features | Young and older adults (20–50 Years) Lymph nodes are enlarged Pyrexia of unknown origin Chest X-ray may show mediastinal lymphadenopathy | Middle and elderly (30–80 years) Immunodeficiency (HIV) Infection (H. Pylori) Toxins |
Site | Nodal: Cervical, supraclavicular, axillary, inguinal | Nodal (75%) Extra nodal (25%) [Skin, GIT, bone, CNS, oropharyngeal lymphoid tissue (Waldeyer's Ring)] |
Fever, weight loss, and sweating | Common | Uncommon |
Splenomegaly | Common | Uncommon |
Diagnosis is by biopsy and immunohistochemistry | Reid Sternberg (RS) cells + (mirror image of nucleus) | RS Cells absent |
Classification | Rye's classification based on cell type: Lymphocyte predominant 2% (excellent prognosis) Lymphocyte depleted 2% (poor prognosis) Mixed cellularity 20% (poor prognosis) Nodular sclerosis 75 (good prognosis) | B cell (fast growing most common type of NHL one-third of cases) T cell Follicular (slow growing in one-fourth cases of NHL, indolent lymphoma, relapses can be seen) Malt Burkitt's |
Ann Arbor staging 1, 2, 3, and 4 | PET-CT and bone marrow biopsy | PET-CT and bone marrow biopsy |
Treatment (choices include, select appropriately) | Stage 1 and 2 (localized disease): Chemotherapy ABVD +RT to lymph nodes after 4 courses of ABVD Stage 3 and 4 (advanced disease): For recurrent/resistant cases, stem cell transplant: Platelet rich concentrate or bone marrow aspirate | All stages: Chemotherapy + targeted chemotherapy is mainstay treatment (R-CHOP) R: Rituximab is a monoclonal antibody C: Cyclophosphamide H: Hydroxydaunorubicin O: Oncovin P: Prednisolone Other choices: Stem cell transplant (platelet rich concentrate /bone marrow aspirate) RT For low grade/indolent disease |
Radiotherapy in Lymphoma
It is given for localized Hodgkin's disease. Main treatment is involved site radiation therapy (ISRT). Involved field RT and extended field RT (mantle field, inverted field, and TANI) are not given now a days.81
1.31.5 Occult Primary/Cancers of Unknown Primary Site
Lymph node in neck has carcinoma but primary site is apparently unknown (routine evaluation fails to identify a primary tumor). CUP = 10% of all cancers. Prognosis= 3–12 months
Features of secondary in neck | Hard Cystic (papillary cancer thyroid) Pressure effects: Fungate/ulcerate/infiltrate Symptoms of primary: Sore throat, hoarseness, dysphagia, nonhealing ulcer, cough, and hemoptysis |
Occult primary sites which can cause secondary in neck | Fossa of Rosen M✓ller, lateral wall of pharynx, posterior third of the tongue, tonsil, thyroid, paranasal sinuses, bronchus, and esophagus |
Type | From | Comments |
Squamous cell CA | Oral cavity, pharynx (40%) | Commonest secondary in neck: Oropharynx 15%, nasopharynx 15%, hypopharynx 10% (40%) Thyroid 20% (papillary cancer) Lung 20% (squamous cell cancer) |
Adenocarcinoma | GIT | |
Melanoma | Skin |
Investigations (Choices Include)
Blood tests | CBC, LFT, RFT, ESR, blood borne infection screen (HIV, HBS, and HCV) |
To confirm cancer | FNAC/biopsy of lymph node and immunohistochemistry |
To find primary source of cancer | Imaging: Pan endoscopy: Gastroscopy, bronchoscopy, and colonoscopy triple endoscopy is nasopharyngoscopy, esophagoscopy, and bronchoscopy) Biopsy of six occult sites taken (random/blind/guided) are from: Rosen mullers fossa |
Treatment of Occult Primary (Choices Include, Select Appropriately)
Option 1 | Radiotherapy head and neck and then radical neck dissection for persistent nodes Wait and watch for the primary cancer to appear |
Option 2 | Radical neck dissection and wait for primary cancer to appear |
Option 3 | Chemotherapy for advanced head and neck cancers. CIS platinum, 5 FU paclitaxel, and cetuximab |
Key Points
There are about 800 lymph nodes in the body (300 in neck and 500 in rest of the body).
New onset lymphadenopathy <7 days duration is unlikely to be malignant.
Enlarged head and neck nodes also need ENT evaluation.
Supraclavicular lymph nodes are enlarged in TB, breast cancer, lymphoma, lung, GIT cancers, and testicular cancer.
Axillary lymph nodes may be enlarged in TB, breast, or lung cancer.
Inguinal lymph nodes may be enlarged in anorectal, perineum, vulva penis and scrotum pathology, most commonly it is enlarged due to local trauma.82
Fine needle aspiration is not recommended in acute lymphadenitis.
Excision biopsy is preferred when lymphoma is suspected.
Fine needle aspiration is best when secondaries (metastasis) in nodes are suspected.
Nondiagnostic biopsies or FNA reports especially with atypical or reactive hyperplasia need follow-up; can also perform a biopsy from another site, because patients may develop/have lymphoproliferative disorder.
Bilateral inguinal nodes are palpable in barefoot walkers.
Note for Readers:
1.32 MIGRAINE (REFER CHAPTER 1.23)
1.33 MUMPS
It is caused by mumps virus, incubation is 12–28 days.
Peak incidence in children aged 5–7 years and during puberty.
Infections period: 3 days before the swelling develops and until 7 days after it resolves.
Clinical Features
Mild prodromal illness
Swelling of salivary glands; parotid glands are affected (unilateral parotid gland swell may occur, may also affect submandibular glands).
Involved glands painful/tender, ear ache may coexist.
Complications
Orchitis and oophoritis are rare before puberty; typically unilateral
Pancreatitis and encephalitis (very rare)
Deafness
Treatment (Choices Include)
Analgesics
Wysolone (prednisolone) 10–20 mg tds for 3–5 days
Key Points
Mumps, orchitis, and oophoritis rarely occur in small children before puberty and these do not cause infertility.
If mumps, orchitis, and oophoritis occur during adolescence/puberty, these may rarely cause infertility.
1.34 MUSCLE CRAMPS
Muscle cramp is due to imbalance of minerals that govern muscle contraction and relaxation.
Etiology | History and investigations | Treatment |
Diabetes | Diabetic (AC, PC) | |
Electrolyte imbalance | Na+, K+ | |
Drugs | Diuretics, e.g., indapamide and gravitor | Change the drug |
Intermittent claudication | History of smoking Check pulses Doppler study | Refer Chapter 6.17.7 |
Muscle fatigue and overuse | ||
Dehydration |
Treatment (Choices Include)
Heat pack
Stretch and massage the area and hold it in stretched position.
Identify cause and treat the specific cause if possible: Some drugs listed below can be helpful:
EVION (vitamin E) : 400 mg od
SANDOCAL/OSTOCALCIUM (calcium): 1 tablet od
CARNITOR (L-carnitine): 330 mg tds
SUPRADYN (vitamin): 1 tablet od
PARACETAMOL (acetaminophen)
PROXYVON (NSAID)
VALIUM (diazepam) for nocturnal pain (5–10 mg po)
CALCIUM Gluconate injection 10 mg slow IV once daily for 3 days
NEUROBION Injection 2 cc IM for 5 days
Increase salt intake
Stop intake of offending drugs, e.g., diuretics, etc.
For muscle cramps, which occur with exercise:
Drink lot of fluids before, during and after exercise
Warm up before exercise and stretch afterward to help muscles relax
If pain is severe, apply ice to reduce inflammation.
Key Points
Rule out diabetes, salt (sodium) deficiency, and calcium deficiency.
Stop intake of offending drugs, e.g., diuretics.
In cases of leg muscle cramps, check peripheral pulses: If pulses are absent or decreased pain or cramp-like feeling may be intermittent claudication (refer Chapters 6.17.3, 6.17.4 and 6.17.7).
1.35 NAUSEA AND VOMITING
Red Flags
Prolonged or severe vomiting
Hematemesis
Head injury
Papilledema
Rash and fever (meningitis)
Dehydration
Systemic symptoms (e.g., weight loss, malaise, fatigue, sweats, and fever)
Eating disorder
Etiology
Treatment (Choices Include)
Drug | Dose | Indication(s) | Comments |
EMESET (ondansetron) (2 mL = 10 mg = 1 ampule) GRANISETRON | 4–8 mg po/IM/IV 1 mg po q12h | PONV Chemotherapy Pregnancy | Headache, constipation, and dizziness Can be used for children |
STEMETIL (prochlorperazine) (1 mL = 12.5 mg = 1 ampule) | 10–20 mg po or 12.5 mg IM | Metabolic causes Drugs (especially opiates) PONV | Extrapyramidal side effects ↓BP, ↑prolactin |
PERINORM (metoclopramide) (2 mL = 10 mg = 1 ampule) | 5–20 mg po/IM/IV | Gastrointestinal causes Migraine Drugs (especially opiates) | Extrapyramidal side effects Avoid in children and pregnancy Avoid long-term use |
PHENERGAN (promethazine) (2 mL = 50 mg = 1 ampule) | 1 mg/kg/dose in children 25–75 mg po/IV in adults | PONV | Ideal for children Do not use IV unless in central vein |
DOMSTAL (domperidone) | 10–20 mg po q8h | Dyspeptic symptoms, motility disorders | Safe drug, less incidence of extrapyramidal side effects No IV route available |
DEXAMETHASONE | 16 mg IV stat, 8 mg IV q8h | CNS-related causes, PONV | – |
AVOMINE (promethazine) | 2 mg | Motion/Travel sickness | Take half an hour before travel |
GRAVOL (dimenhydrinate) | 50 mg po q8h | Pregnancy, PONV | – |
PYRIDOXINE | Pregnancy | ||
PREGNIDOXIN (meclizine) | 1–2 tablets at bedtime | Ménière's syndrome | – |
Amitriptyline, bupropion, and buspirone | For refractory nausea and vomiting |
Investigations
Blood tests | CBC, sodium, potassium, urea, creatinine, LFT, lipase, and amylase |
Urine analysis | Routine and urine ketones |
Endoscopy | Esophagogastroduodenoscopy |
Imaging | Plain X-ray abdomen, CT abdomen, upper GI barium contrast study, nuclear medicine gastric emptying study, and capsule endoscopy |
Complications
Metabolic and electrolyte alterations
Nutritional deficiencies and weight loss
Dental erosions
Esophagitis
Mallory–Weiss syndrome
Boerhaave syndrome
Treatment
Treatment is aimed at correcting the specific cause
Reassess causes every time
Start IV/IM (switch on to oral, whenever necessary)
Do not stop treatment unless cause is removed
Key Points
Initial choice should fall between prochlorperazine (STEMETIL) and metoclopramide (PERINORM).
Vomiting related to drugs and metabolic cause: STEMETIL
Vomiting related to GI cause: PERINORM, DOMSTAL, or ONDANSETRON
Vomiting related to labyrinthine cause: STEMETIL and PHENERGAN
Vomiting related to travel (motion sickness): STUGERON and AVOMINE
Vomiting related to CNS cause: Steroids and MANNITOL
Postoperative nausea and vomiting: ONDANSETRON, PHENERGAN, or STEMETIL
Metoclopramide and prochlorperazine dosage should be reduced in renal and hepatic failure.
Ondansetron dosage should be reduced in hepatic failure.
1.36 OBESITY
Red Flags
Morbid obesity
Severely reduced mobility
Suicidal ideation
Poor self-image
Diabetes
Cardiovascular complications
Etiology
Primary | Genetic factors Environmental factors (food, eating and physical activity) (metabolic disorders) |
Secondary | Hypothyroidism, PCOS, Cushing's syndrome, hypogonadism, insulinoma, and hypothalamic disorders (Frolic's, Laurence–Moon syndrome) Drug induced: |
Complications
Mechanical | Flat feet, osteoarthritis (OA), varicose veins, hernia, and dyspnea |
Metabolic | Insulin resistance, NIDDM, hyperlipidemia, gallstones, hyperuricemia, and gout |
CVS | Coronary artery disease |
Respiratory | Hypoventilation syndrome, snoring, and sleep apnea |
Psychological | Depression and anxiety |
General | High-anesthetic risk, shortened life span |
Investigations (Choices Include)
HbA1c, lipid profile, TFT, LFT, ECG, echo, sleep study, US abdomen for fatty liver, gall stone, or transvaginal US for ovarian cysts.
Treatment (Choices Include)
1. Diet
Avoid total starvation. Low calorie diet: 800–900 cal/day (sample diet)
Early morning | Light tea: 1 cup (2 tsp milk, no sugar) |
Breakfast | Milk (skimmed or toned) ¾ glass (150 mL without sugar) Bread 2 slices |
10 am | One fruit serving: Apple, papaya, orange, watermelon, etc. |
Lunch | One large bowl of thin vegetable soup without butter or ghee One bowl salad: Cabbage, cucumber, onion, carrot, and tomato 1 roti or chapati, or 3 phulkas without oil and ½ bowl rice or 1 bowl rice and 1 phulka or ½ roti or paratha One bowl cooked vegetables 1 bowl thin dal |
4 pm | Light tea: Without sugar 1 cup Bread 1 slice or one idli or a fruit |
Dinner | Thin soup and fresh salad or boiled vegetables 2 thin phulkas 1 bowl vegetable 1 bowl thin dal or pulses Thin buttermilk |
Bedtime | Skimmed milk, ½ glass (75 mL) |
Note:
1 bowl = 150 mL/g
Do not eat: Cereals, potatoes, root vegetables, sugar, all sweets, chocolates, puddings, dried or tinned fruits, butter, ghee, oil, and fried foods
Eat: Green vegetables, fruits, soup, salad vegetables, lean meat, and fish
Use minimum salt or low-sodium salt
Use sugar substitutes
Use skimmed milk
What is diet control and weight management?
Dieting is a lifetime commitment and is not to be done on a crash basis.
For weight loss, total calorie intake should not exceed 1,500 cal/day and should not go below 1,000 cal/day.
You are what you eat!!
Calories in “must balance” calories out. Total calorie intake should be less than total calorie expenditure per day to lose weight and in order to do this, one should exercise lightly at least once every day.
Concept of diet control is very simple. Think of your body as your bank balance. Whatever you eat gets deposited there in the form of calories. Whatever you spend on metabolism and physical exercise would reduce the balance. If your calorie intake is more than what you spend, the surplus will accumulate as fat! The solution is to reduce the intake. If there is still more, do some exercise to reduce it.
Weight loss cannot be achieved by just avoiding oily foods or skipping meals, or simply working out a sweat. You must combine a nutritious, restricted calorie diet with exercise.
A simple way to lose ½ kilo weight every week is to reduce intake of 500 cal/day:
Any exercises for 15 minutes, three times daily (you will burn 300 cal/day)
Avoid a can of coke or two vadas or one samosa. Or whatever you snack regularly (you will consume 200 calories less per day).
Instead of taking six spoons of sugar for tea/coffee daily, take six tablets/pellets of sugar free/equal aspartame (you will consume daily 5 calories only, instead of 120 calories).
How to eat? What to eat? Where to eat?
All meals including breakfast should be taken.
Maintain meal timings.
No snacks should be taken in between.
If hungry in between, drink water or eat “free foods”.
A glass of milk/soup/fresh juice prior to the meal may reduce appetite.
Have a light dinner, medium lunch, and heavy breakfast.
Use a small plate and avoid second helpings (blue color helps to decrease appetite).
Get up from the dining table while you are still feeling a little more hungry (i.e., do not eat up to your neck).
Do not eat when you are not hungry and do not eat when you are not sitting at the dining table.
Eat slowly and chew food well.
It is the bites that matter!!
In the bite diet plan, you can chew a variety of foods spread out in two or three regular and one small meal per day with <18 bites per meal.
Avoid eating in restaurants/hotels; those foods are loaded with calories!
Time | 4 pm | 8 pm | 8 am | 1 pm |
|---|---|---|---|---|
Food taken | Chocolate cake | |||
Table rating | Good | |||
Amount | 3 slices | |||
Calories | 500 cal | |||
Where eaten | Kitchen | |||
With whom eaten | With children | |||
Mood | Fed up | |||
Hungry or not | No | |||
Associated activity | Giving children | |||
Why eaten | Irritated |
Low glycemic index (GI) foods are digested more slowly than those with a high GI. Glycemic index of foods cannot be used in isolation and has some consistency. The glycemic load (GL) solves the GI inconsistency (GL), which is a calculation based on the amount of carbohydrates in the food and it's GI. Choose low GL foods over high GL foods.
Low GL foods are good to eat | Avoid high GL foods |
|---|---|
4 small cans of tomato juice 2 slices of whole gram bread 2 small apples A large bowl of peanuts | Bowl of cornflakes Slice of bread Dates Packet of chips Glass of coke |
What to eat for a balanced diet daily?
Type of food | Servings per day |
|---|---|
Protein and dairy foods (lentils, legumes, peas, meat, fish, egg, milk, curd, nuts and seeds, etc.) | 2–3 |
Vegetables and fruits | 5 |
Starchy foods, cereals, and grains | 5 |
Fats and oils | 1–2 teaspoons |
Sugar | Use sparingly |
Cereals: Rice, wheat, jowar, maize, dals (pulses) can be eaten and they provide at least 50–60% of total calories. When you take lots of these, you are in fact replacing saturated fatty foods/oils with carbohydrates.
Vegetables and fruits:
Eat plenty of vegetables and fruits; they have fiber and this helps to decrease cholesterol.
Vegetables qualify as a miracle diet food; eat plenty of vegetables and go more for the colored ones; such as:
Tomatoes, carrots, green peppers, apples, cherries, grapes, and onion (flavonoids)
Soya flour, soya tofu, cereals, and pulses (phytoestrogens)
Red, orange, yellow vegetables and fruits, and green leafy vegetables (carotenes)
Cabbage, broccoli, and sprouts (glucosinolates)
Garlic, onion, leek, and chives (allium compound)
Green leaves (spinach, lettuce, etc.): 100 g ≤ 20 calories
Solid vegetables (cucumber, marrow, and gourd): 150 g = 40 calories
Nonstarchy root vegetables (radish, onion, carrot): ½ cup (75 g) = 35 calories
Starchy root vegetables (potatoes, yam, etc.): ½ cup (75 g) = 75 calories
Vegetarian diet provides less calories and more of fiber, vitamins, etc.
Dairy products: Nonfat milk or skimmed milk or nonfat yogurt can be eaten. Cottage cheese (paneer) and tofu (soya) are preferred to other types of cheese.
Nonvegetarian foods: Fish is the healthiest nonvegetarian diet, as it has omega-3 fatty acids and these help to decrease cholesterol. Mackerel, tuna, sardines, have high omega-3 fatty acids!! Chicken (without skin and fat) can be eaten in moderation and occasionally. Mutton, beef, and pork are best avoided and in case you still want to eat, choose lean meat and trim off all the visible fat.
Oil: An ideal oil should have:
More of MUFAs, less than PUFAs and least SFAs
Omega-3 content of oil should be more than omega-6 content:
WHO recommends W6/W3 ratio of 5–10. Most of our oil are rich in W6 fatty acids and are deficient in W3 fatty acids. W6 fatty acids promote the synthesis of proinflammatory prostaglandin. These mediate inflammation and clot formation. Oils rich in W6 fatty acids (e.g., sunflower oil) must be curtailed. So when you buy cooking oil, check out the W6/W3 ratio.
Antioxidants such as tocopherol, vitamin E, tocotrienol, and oryzanol:
Soyabean, mustard, and rice bran oils comply to an ideal oil.
Groundnut, gingelly, corn or sunflower oil, or a mixture of these oils with the above oils can be used; do not use sunflower oil alone as the sole cooking medium, it can be used in combination or mixed with other oils like soya bean or rice bran or olive oil.
“Sundrop” brand of oil is the best oil. It is a healthy oil with the right combination of oils. Sundrop heart (rice bran 80% and sunflower 20%), Sundrop Nutrilite (soy 80% and sunflower 20%), Saffola Gold (70% rice bran and 30% kardi oil) with Losorb technology makes oil more stable and foods fried in this oil take less oil. Peanut oil is also good for deep frying, as it has a high smoking point.
Water, drinks, and alcohol: Think before you drink!!
Pepsi/Mirinda/Coke/Fanta | 200 mL | 80 cal |
Tea | 60 mL of milk and sugar | 80 cal |
Fresh fruit juices | 100 mL | 40–60 cal |
One big bottle of beer | 640 mL | 400 cal |
Whisky/Brandy/Gin/Vodka | 60 mL | 160 cal |
Wine | 60 mL | 200 cal |
Drink plenty of water, i.e., 4–6 L/day
Fresh fruit juices are the best and ideal drink.
Avoid coffee/tea with milk and sugar; black tea and coffee, lemon tea or lemon juice with sugar-free tablets (equal/sugar free is an excellent substitute and you will only consume 8 calories!! Instead of 40–80 calories per drink)
It is best to avoid alcohol, but if you follow the safe limits; the recommended maximum amount is 2 drinks per day or 14 drinks per week.
Alcohol contains a significant amount of calories and if you are trying to lose weight, you should restrict yourself to 7 drinks a week.
Note: If you drink spirits, choose a low-calorie mixer.
Make 2 days of your week alcohol free.
“At-risk drinking” is a level of alcohol consumption that is directly harmful or is correlated with a greater risk of health problems. It is defined as more than 14 standard drinks in a week or 5 more drinks per occasion for men and for women; it is >10 g of ethanol.
One standard drink is 30 mL of spirits (whisky, rum, gin, brandy) (80 calories); or ½ bottle of beer is 320 mL beer (200 calories); or 60 mL wine (200 calories), or one-third of a sachet (100 mL) of arrack.
Calorie calculation of common alcohol drinks:
Alcohol type | Unit/Drink/mL | Calorie |
|---|---|---|
Spirits (whisky, rum, brandy, gin or vodka) (roughly 1 mL has 2.3 calories) | 30 mL = 1 unit = 1 drink (30 mL = one standard drink) 60 mL 100 mL 180 mL 200 mL 230 mL 260 mL | 80 160 250 450 500 580 660 |
Beer (roughly 1 mL has 0.9 calories) | 284 mL = 1 unit = 1 drink (284 mL = one standard drink) 640 mL (1 bottle) 1,280 mL (2 bottles) 1 can (356 mL) 2 cans | 177 280 560 154 |
Wine (sweet) (roughly 1 mL has 1.3 calories) Wine (dry) | 60 mL = 1 unit = 1 drink (60 mL = one standard drink) 100 mL 150 mL 200 mL 60 mL 100 mL 150 mL 200 mL | 78 130 200 260 54 90 135 180 |
Unit of alcohol is:
Spirit: 30 mL = 1 unit = 1 drink
Beer: 284 mL = 1 unit = 1 drink
Wine: 60 mL = 1 unit = 1 drink
Sugar, sweets, and desserts:
Two teaspoons of sugar have 40 calories. For every two spoons of sugar, substitute with two pellets or two tablets of equal/sugar free (aspartame). You will be consuming only 0.8 calorie instead of 40 calories!
Substitute fresh/frozen fruits for all or part of your desserts.
How to cook?
Boiled, broiled, grilled, and tandoor methods of cooking are preferred to deep frying. Nonstick pans/vessels are ideal, as they require less oil and while using these vessels, cook on a low flame, or small fire.
Avoid these foods:
Ghee, butter, margarine, vanaspati, coconut oil, and palm oil, which are all saturated fatty oils.
Whole fat milk and dairy products such as cheese, cream, and ice cream
Salad dressings and mayonnaise
Egg yolks
Cakes, sweets, muffins, pastries, and biscuits, unless made at home with polyunsaturated oils such as soy, rice bran, and sunflower oil
Fatty meat, organ meat such as liver, kidney, spleen and skin, and sausages
Ideal snacks:
Apple/pear/slice of melon
Five almonds or a spoon of pumpkin seed
1 square inch of chikki (peanut candy)
Bread or chapati with protein-based topping with paneer, peanut butter or dals
Fresh/frozen fruit instead of dessert
Free foods: When the urge to eat is too strong, try eating “free foods”. Free foods are items of food that have <20 calories per serving. All items must be sugar free and low fat. Below is a list of some sugar-free foods.
Drinks | Diet sodas, diet club soda, diet tonic, and water |
Fruits | ½ cup cranberries, ½ cup rhubarb |
Vegetables/greens | Cabbage, celery, cucumber, green onion, mushrooms, radish, zucchini, lettuce, and spinach |
Sweet substitutes | Sugar-free candy, gelatin, sugar-free gum, sugar-free jam, and sugar-free jelly |
Condiments | Mustard, taco sauce, vinegar, green pepper, and mustard |
Standard Height and Weight (IBW) for Indian Men and Women and Number of Calories Required per Day!
Height | Men | Women | |||
|---|---|---|---|---|---|
Cm | Feet | Kg | Calories | Kg | Calories |
150 | 5' | 50–54 | 1,300 | ||
152 | 5' 1” | 51–55 | 1,325 | ||
154 | 5' 2” | 53–56 | 1,365 | ||
157 | 5' 3” | 54–58 | |||
159 | 5' 4” | 57–61 | 1,770 | 56–59 | 1,438 |
162 | 5' 5” | 59–63 | 1,830 | 57–60 | 1,450 |
165 | 5' 6” | 61–65 | 1,890 | 58–62 | 1,500 |
167 | 5' 7” | 62–67 | 1,950 | 59–64 | 1,550 |
170 | 5' 8” | 64–68 | 1,980 | 61–65 | 1,575 |
172 | 5' 9” | 66–71 | 2,040 | ||
175 | 5' 10” | 68–73 | 2,130 | ||
177 | 5' 11” | 69–74 | 2,160 | ||
180 | 6' | 71–76 | 2,190 | ||
Ideal Body Weight
Height in cm – 100 × 0.9 = IBW
WHO Classification of Body Mass Index
BMI (Asians) | Body weight | BMI (Europeans) |
|---|---|---|
<17.5 | Underweight | > 18.5 |
17.5–22.9 | Normal weight | 18.5–24.9 |
23–27.9 | Overweight | 25–29.9 |
28–32 | Obese | >30 |
>32 | Morbidly obese | >35 |
Calculation of Body Mass Index
Weight in kilogram/height per meter square = (kg/m2)
Calorie Requirements
Sedentary (i.e., < 10,000 step/day): 20–25 cal/kg/IBW
Moderate work: 26–30 cal/kg/IBW
Heavy work: 31–35 cal/kg/IBW
For persons with normal weight, daily calorie intake (DCI) has been calculated at average 30 cal/kg body weight for men and 25 cal/kg for women; ideally, the calorie intake should not exceed 2,000 cal/day.
Ideally your maximum calorie intake should not exceed current weight in kilogram × 25 cal/kg body weight (a person's calorie intake should not exceed 2,000 cal/day).
Do not reduce calorie intake by >500 calories daily from your maximum intake. If you are overweight or obese your DCI should be reduced by 5 cal/kg body weight. For example, for a 80 kg man, maximum calorie intake = 80 × 25 = 2,000 calories, i.e., to lose weight you need 20 cal/kg body weight, i.e., 80 × 20 cal = 1,600 calories or maximum calorie intake – 500 = 1,500 calories
Do not reduce your calorie intake by >500 calorie daily from your maximum intake and whether you are normal weight or overweight or obese, do not eat <1,000 cal/day as your body will figure out what you are doing and it will slow down metabolism and you will not lose weight.
An energy deficit of 500 cal/day will help to reduce 500 g of weight every week and when you achieve your correct weight, your consumption of calories should be your correct weight in kg × 24.
2. Exercise
Physical activity is an important predictor of weight maintenance and will help the body to burn more calories even at the end of an exercise period. Being physically active can substantially reduce one's risk for all-cause mortality. Aim for minimum of 30 minutes of moderate exercise on all days of the week and look to spend 300–500 kilocalories per session and 1,000–2,000 kcal/week. Obese patients should start with moderate levels of physical activity (e.g., brisk walking) for 30– 45 minutes, 3–5 day/week.91
Calories Intake and Activity Needed to Burn
Item | Amount | Calories | Walk/Bicycle/Dance | Run/Climb stairs | Gardening |
|---|---|---|---|---|---|
Beer (1 bottle) | 640 mL | 400 | 1 hour 20 minutes | 40 minutes | 2 hours |
Beer (2 bottles) | 1,280 mL | 800 | 3 hours | 1 hour 20 minutes | 4 hours |
Beer (3 bottles) | 1,920 mL | 1,200 | 4 hours | 2 hours | 7 hours |
Biscuits (arrowroot) | 5 no. | 120 | 24 minutes | 12 minutes | 30 minutes |
Biscuits (cream) | 4 no. | 200 | 40 minutes | 20 minutes | 1 hour |
Butter milk | 200 mL | 60 | 12 minutes | 6 minutes | 20 minutes |
Cake | 1 no. 50 g | 175 | 35 minutes | 18 minutes | 1 hour |
Chips | 100 g | 960 | 3 hours | 1 hour 30 minutes | 5 hours |
Curd (1 cup) | 100 mL | 60 | 12 minutes | 6 minutes | 20 minutes |
Curd (2 cups) | 200 mL | 120 | 24 minutes | 12 minutes | 30 minutes |
Dairy milk | 45 g | 360 | 1 hour 10 minutes | 30 minutes | 2 hours |
Five star | 33 g | 260 | 1 hour | 30 minutes | 1 hour 20 minutes |
French fries (jumbo) | 300 g | 1,000 | 3 hours | 1 hour 30 min | 5 hours |
French fries (large) | 150 g | 500 | 1 hour 30 minutes | 1 hour | 3 hours |
French fries (medium) | 120 g | 380 | 1 hour 15 minutes | 30 minutes | 2 hours |
French fries (small) | 70 g | 230 | 46 minutes | 30 minutes | 1 hour |
Fresh juice | 200 mL | 120 | 24 minutes | 12 minutes | 30 minutes |
Halwa | 50 g | 325 | 1 hour | 30 minutes | 30 minutes |
Ice cream | 1 cup | 300 | 1 hour | 30 minutes | 1 hour 30 minutes |
Jalebi/Rasgulla | 4 no. (80 g) | 320 | 1 hour | 30 minutes | 1 hour 30 minutes |
Kachori | 50 g | 150 | 30 minutes | 15 minutes | 1 hour |
Milk | 200 mL | 140 | 30 minutes | 15 minutes | 45 minutes |
Milk shake | 200 mL | 400 | 1 hour 20 minutes | 30 minutes | 2 hours |
Mixture/Namkein | 50 g | 400 | 1 hour 20 minutes | 30 minutes | 2 hours |
Mixture/Namkein | 100 g | 800 | 2 hours 40 minutes | 1 hour 30 minutes | 4 hours |
Mixture/Namkein | 200 g | 1,200 | 4 hours | 2 hours | 6 hours |
Movie theater popcorn | Small | 225 | 45 minutes | 22 minutes | 1 hour 15 minutes |
Movie theater popcorn | Medium | 370 | 1 hour 14 minutes | 30 minutes | 2 hours |
Movie theater popcorn | Large | 664 | 2 hour 12 minutes | 1 hour | 3 hours |
Cadbury | 20 g | 160 | 32 minutes | 15 minutes | 1 hour |
Murukku | 5 no. | 200 | 40 minutes | 20 minutes | 1 hour |
Mysore pak | 1 no. (30 g) | 240 | 48 minutes | 25 minutes | 1 hour 20 minutes |
Mysore pak | 2 no. (6o g) | 480 | 1 hour 36 minutes | 48 minutes | 2 hours 40 minutes |
Nuts | 5 cashew/ 10 almonds/ 30 peanuts | 60 | 12 minutes | 6 minutes | 20 minutes |
Nuts | 50 g | 300 | 1 hour | 30 minutes | 1 hour 40 minutes |
Nuts | 100 g | 600 | 2 hours | 1 hour | 3 hours 20 minutes |
Payasam | 150 mL | 330 | 1 hour 6 minutes | 30 minutes | 1 hour 50 minutes |
Pepsi/Coke/Fanta | 600 mL | 240 | 48 minutes | 24 minutes | 1 hour 20 minutes |
Pepsi/Coke/Fanta | 200 mL | 80 | 16 minutes | 8 minutes | 30 minutes |
Pattie | 1 no. | 250 | 50 minutes | 30 minutes | 1 hour 20 minutes |
Pattie | 2 no. | 500 | 100 minutes | 1 hour | 2 hours 40 minutes |
Samosa | 1–65 g | 210 | 42 minutes | 20 minutes | 1 hour 10 minutes |
Samosa | 2 no. | 420 | 1 hour 24 minutes | 30 minutes | |
Snickers | Small (15) | 160 | 32 minutes | 15 minutes | 1 hour |
Snickers | Big (30) | 500 | 1 hour 40 minutes | 1 hour | 2 h 40 minutes |
Soup | 200 mL | 40 | 8 minutes | 4 minutes | 15 minutes |
Squash | 200 mL | 330 | 1 hour 6 minutes | 30 minutes | 1 hour 50 minutes |
Vada | 2 no. (50 g) | 140 | 28 minutes | 15 minutes | 1 hour |
Whisky | 180 mL | 300 | 60 minutes | 30 minutes | 1 hour 40 minutes |
Whisky | 240 mL | 400 | 80 minutes | 30 minutes | 2 hours |
Whisky | 300 mL | 500 | 1 hour 40 minutes | 1 hour | 2 hours 40 minutes |
Wine | 120 mL | 160 | 32 minutes | 15 minutes | 1 hour |
Wine | 240 mL | 380 | 1 hour 16 minutes | 30 minutes | 2 hours |
3. Behavior Therapy
Self-monitoring | Food diaries to record total food intake, type of food consumed, calories consumed, food groups consumed, and conditions or situations when overeating is common, e.g., binge eating or snacking in front of TV Physical activity records to understand frequency, duration, and intensity of exercise during a given period. Weight scales or body composition measures to record changes in weight, body fat, or lean body mass Motivation is often the key ingredient for success of any weight loss program. Self-monitoring is associated with improved treatment outcomes. Attitude matters most! NIH guidelines suggest that people, who desire to lose weight, should reduce their calorie intake by 500–1,000 kcal/day, which will produce a weight loss of 0.45–0.90 kg/week. Women may choose a diet of 1,000–1,200 kcal/day and men may choose a diet of 1,200–1,500 kcal/day |
Stimulus control | Suggestions for patients to control stimulus: Eating only at kitchen table without watching TV. Keep no snack food in home. Keep exercise clothes ready the night before as a reminder to walk or jog in the morning |
Cognitive restructuring | Patients need to look within themselves and motivate themselves continuously to lose weight. Cognitive restructuring is important because many obese patients have poor self-esteem and a distorted body image |
Stress management | Stress is a primary predictor of relapse and overeating. Methods for reducing stress and tension include diaphragmatic breathing, progressive muscle relaxation, meditation, yoga, etc. Managing stress can also help avoid binge eating, which can undo a lot of good efforts put in by the patient |
4. Drugs
OBELIT (orlistat) 120 mg thrice daily, an inhibitor of intestinal lipase causes modest loss due to drug-induced fat malabsorption. Metformin, exenatide, and liraglutide tend to decrease body weight in patients with obesity and type 2 diabetes mellitus, but they are not indicated for patients without diabetes. Other drugs are phentermine, lorcaserin, naltrexone, and bupropion.
5. Surgery (Bariatric Procedures)
Laparoscopic (sleeve gastrectomy/roux-en-Y gastric bypass/biliopancreatic diversion with duodenal switch/biliopancreatic diversion) or endoscopic procedures intragastric balloon, endoscopic sleeve gastroplasty.
Key Points
Starvation produces dramatic weight reduction, but weight springs back equally quickly when regular diet is resumed.
Mainstay of treatment is diet and exercise; eating 100 kcal/day less for a year should cause a 5 kg weight loss and a deficit of 1,000 kcal/day should cause a weight loss of approximately 1 kg/week. A deficit of 7,500 kcal will produce a weight loss of 5–7 kg.
If patient falls in high-risk category, i.e., with diabetes, hypertension, angina, family history of infarct, etc., stress the importance of weight reduction, explain the risks, and advice patient to reduce weight.
Drugs are recommended only for severe obesity (all drugs have their side effects).
Laparoscopic (bariatric): Sleeve gastrectomy banding or bypass
Endoscopic: Intragastric balloon, endoscopic stapling
1.37 PALPITATIONS
Red Flags
Previous MI
Abnormal ECG
Chest pain
Shortness of breath
Syncope
Signs of heart failure
Heart rate over 140 beats per minute
Abnormal physical examination
Etiology
Cardiac | Ectopic beats, atrial fibrillation (AF), supraventricular tachycardia (SVT), and ventricular tachycardia (VT) |
Metabolic | Hypoglycemia (diabetes), hyperthyroidism, hypokalemia, and hypomagnesemia |
Anemia | |
Medications | Decongestants, salbutamol, thyroid tablets, terbutaline, and CCBs |
Stimulant | Coffee and smoking |
Substance abuse/Drug withdrawal | Withdrawal symptoms of BB, benzodiazepines, alcohol, and narcotics |
Psychiatric | Anxiety and depression |
If heart beat is | Probable diagnosis is |
Irregular | Ectopic beats, AF |
Regular without discrete attacks of tachycardia (<120/min) | Sinus tachycardia, high stroke volume (e.g., anemia, anxiety, and valve disease) |
Regular with discrete attacks of tachycardia (>120/min) | SVT and VT |
Important Questions
Is heartbeat regular/irregular?
Is palpitation frequent/infrequent?
Ask patient to mimic with rhythm on his/her thigh.
Any associated symptoms (e.g., chest pain, light headedness, polyuria, etc.).
Current medications, which are being used (decongestants, salbutamol, thyroid tablets, terbutaline, and CCBs).
Any precipitating factors (e.g., tobacco, coffee, tea, exercise, and alcohol)
Any history of structural heart disease (CAD, valvular heart disease/lung disease)
Ask the patient to tap the rhythm and auscultate simultaneously.
Physical Examination
Pallor
Check for thyroid nodule or thyroid swelling
Pulse rate
Heaving apex of heartbeat = Aortic stenosis
Heart murmur
ECG during attack
Investigations (Choices Include)
Investigations | Comments |
|---|---|
Review of medications | Decongestants, salbutamol, thyroid tablets, terbutaline, and CCBs Withdrawal symptoms of BB, benzodiazepines, alcohol, and narcotics (substance abuse) Coffee and smoking (stimulants) |
CBC | Anemia |
RBS, FBS, PPBS, and HbA1c | |
TSH | Hyperthyroidism |
ECG, ambulatory ECG (Holter, loop, or implantable loop) | Cardiac problem |
Treatment (Choices Include)
Identify and treat the cause.
Avoid excess coffee, tea, alcohol, and smoking.
ALPRAX (alprazolam) 0.25 mg q8–12 hours
CIPLAR (propranolol) 10 mg q6–12 hours or ATENOLOL 25–50 mg (can start 1 day before, if going for examination/ interview)
AUTRIN capsule 1 od for 2 months, if patient is anemic.
Rule out arrhythmia: SVT, VT, and VPC's
Referral to cardiologist
Key Points
History and physical examination should reveal any reversible cause for palpitations.
Review of medications is important. It includes decongestants, salbutamol, thyroid tablets, terbutaline and CCBs, withdrawal symptoms of BB, benzodiazepines, alcohol, and narcotics [substance abuse, coffee, and smoking (stimulants)].
Metabolic, cardiac, and psychiatric causes should be considered.
First rule out anemia, hyperthyroidism, LVF, and arrhythmias; if patient is diabetic, rule out hypoglycemia.
Anxiety (e.g., examinations)? Pregnancy in young girls is the most common cause for palpitations.
If pulse is normal and heart is normal, palpitations are due to anxiety and patient will respond to sedatives/BB.
1.38 PERIPHERAL NEUROPATHY (Numbness/Tingling)
Red Flags
Features suggesting cancer
Signs of cord compression
Abnormal perianal sensation
Urinary or bowel symptoms
Etiology
Etiology | Examples |
|---|---|
Metabolic | Diabetes mellitus Hypothyroidism Hepatic failure Renal failure Hypocalcemia/Hypercalcemia |
Vitamin deficiencies | B12 deficiency |
Drugs | Steroids, phenytoin, nitrofurantoin, INH, excess B6/pyridoxine, and anticancer drugs |
Substance abuse | Alcohol |
Nerve entrapment (compression) | Trauma Surgery (e.g., posthernia repair) Cervical spondylitis Sciatica |
Connective tissue disease (autoimmune disorders) | Rheumatoid arthritis |
Infection | Herpes (PHN) Human immunodeficiency virus |
Vascular | Trigeminal neuralgia Vasculitis |
Neoplasms | Primary, secondary, paraneoplastic, or hematologic neoplasms |
History of Presenting Complaint
Quality of life: How have symptoms affected quality of life and activities of daily living? Neuropathies can be very distressing and disabling.
Description of symptoms: Find out whether the main problem is disturbed sensation (suggesting sensory loss) or a feeling of weakness (implying a motor lesion). People with sensory loss usually described a perception of “numbness” or complete loss of feeling, whereas positive symptoms may include itching, prickling, buzzing, or burning sensations. Tingling and buzzing paresthesia may be due to dorsal column lesions.
Onset and progression: Remitting symptoms point toward multiple sclerosis (MS), whereas gradual deterioration can be found in mononeuropathies. Peripheral neuropathy tends to start distally and then moves proximally with time. Carpal tunnel syndrome tends to be more at night and may disturb sleep. It improves with handshaking and symptoms tend to be less severe during the day. Focal migraines, epilepsy, and TIAs often present with symptoms of sudden onset and quick resolution. Prolonged paresthesia suggests stroke or space-occupying lesion.
Site and extent: Does the area of paresthesia follow a particular nerve distribution? Has there been any recent injury to the nerve that could explain the symptoms? Spinal problems usually cause patterns that are less well localized. In cord compression, symptoms are present below level of lesion. In disk prolapse, symptoms tend to be confined to a nerve root (dermatome). Glove and stocking distribution can be found in polyneuropathy. Symmetrical peripheral neuropathy due to Guillain–Barré syndrome is rare, but is important since it is potentially life-threatening as respiratory muscles are affected.
Exacerbating and relieving factors: Changes in posture and neck movement may exacerbate symptoms caused by pressure on nerve roots due to cervical spondylosis, injury, or spinal tumor. Wrist flexion and extension tend to exacerbate symptoms in carpal tunnel syndrome.
Trigger factors: Ask about any preceding trauma (e.g., as neck or spinal injury). Repetitive activity and peripheral nerve compression may precipitate symptoms.
Other neurological symptoms: Symptoms such as bowel or bladder problems, muscles weakness, pain and loss of balance or coordination may indicate a CNS lesion. Consider cauda equina syndrome, if there is leg pain, unsteadiness, urinary urgency and frequency, bowel dysfunction, or loss of perianal sensation.
Systemic illness: Check for feature of systemic illness (e.g., metabolic, vasculitic, or connective tissue conditions). Enquire about weight change, musculoskeletal symptoms, tiredness, fever, and rashes. Polydipsia and polyuria together with tiredness may suggest DM.
Past and Current Medical Problems
Significant past illnesses: Ask history of systemic diseases (e.g., diabetes, stroke, inflammatory conditions, or MS).
Trauma: Old fractures may lead to hyperostosis or reactive neuroma, which may cause symptoms after some delay.
Operations: Nerves may get damaged during surgery.
Anxiety: Panic attacks and anxiety may lead to hyperventilation, which is a common cause of paresthesia.
Family History
Hereditary disease: Problems that have been present since childhood may represent a hereditary neuropathy.
Medication
Drug history: Metronidazole, phenytoin, INH or nitrofurantoin, and anticancer drugs may cause peripheral neuropathy.
Treatment: Has any treatment with antidepressants tried for symptomatic relief (e.g., paresthesia)?
Social History
Home: Are activities of daily living affected in any way?
Work: Ask about any problems at work.
Alcohol: Its misuse can lead to neurotoxicity.
Smoking: It is a risk factor for lung cancer, which can lead to isolated neuritis or secondary neuropathy (paraneoplastic syndrome).
Drugs: Drug misuse can cause neuropathic pain and sensory disturbances.96
Examination
General condition: Cachexia and poor general health may be due to underlying cancer, renal failure, infection, diabetes, or a CTD.
Gait: Check balance, a foot drop gait or the inability to stand on heels, or tiptoes suggests distal weakness. Balance problems on eye closure (Romberg's test) point toward vibration and proprioceptive sensory problems in the spinal cord or peripheral nerves.
Main area of paresthesia: Carefully outline the area(s) involved by testing pinprick and light touch/pain sensation and position/vibration sense (dissociated sensory loss). Dissociated sensory loss occurs in spinal cord or occasionally in midbrain lesions.
Other paresthetic areas: Test other areas for any sensory changes. Mononeuritis multiplex may suggest DM, malignancy, or amyloidosis.
Wasting: Inspect relevant muscles for evidence of wasting, particularly around the area of paresthesia. Is there any fasciculation?
Power: Test individual muscle groups for signs of weakness.
Reflexes: Will be reduced or absent in lower motor neurons lesions.
Joints: Joint swelling and deformity suggest rheumatoid disease or systemic lupus erythematosus.
Investigations (Choices Include)
Investigation | Interpretation/Comments |
Complete blood count | Macrocytosis = Alcoholic liver disease, hypothyroidism, vitamin B12, or folate deficiency Normocytic normochromic = Chronic disease |
C-reactive protein (CRP) | Increased in CTD, infection, and paraproteinemia |
Blood urea, serum creatinine, RFT, Na+, K+ (electrolytes) | Renal failure |
Fasting blood sugar, PPBS (PPBS), and HbA1c | Diabetes mellitus |
Liver function tests and gamma-glutamyl transferase | Alcoholic liver disease |
Thyroid function tests (TFTs) | Hypothyroidism or hyperthyroidism |
Blood folate/B12 levels | Nutritional deficiency |
Protein electrophoresis | Paraproteinemias, multiple myeloma |
Nerve conduction studies | Neuropathy |
Imaging: Chest X-ray MRI (brain and spinal cord) | Sarcoidosis, neoplasm Brain and spinal lesions |
Biopsy | Nerve, muscle, or skin |
Treatment (Choices Include)
Treat the cause
Medications (pregabalin, gabapentin, duloxetine, amitriptyline, tramadol, menthol, lidocaine patches, topical capsaicin, and topical gabapentin)
Transcutaneous nerve stimulation (TENS)
1.39 SHOCK
Definition
Shock is acute circulatory failure due to imbalance in tissue oxygen supply and demand (ineffective perfusion) resulting in tissue hypoxia and organ dysfunction.
Classification (MNEMONIC is HOD C) (Head of Department Chemistry)
Type | Pathophysiology | Problem | Example |
|---|---|---|---|
Hypovolemic (the most common cause) | Loss of circulating volume (blood/fluid) | Tank (blood volume) | |
Distributive | Vasodilatation (reduction in systemic vascular resistance) | Tank (blood vessels) | |
Cardiogenic | Pump failure | Pump | |
Obstructive | Obstruction to flow (mechanical/vascular) | Block (lungs or heart) |
Symptoms of shock (ineffective perfusion) | Organ dysfunction | Complications of shock |
Hypotension SBP < 90 mm Hg or MAP < 70 mm Hg Heart rate >100/min Altered mental status Urine output < 0.5 mL/kg/h Skin temperature cold clammy with poor capillary refill | Renal Lungs Cardiac Intestine Brain Heart Skin | Acute renal failure Adult respiratory distress syndrome (ARDS) Myocardial infarction GI ulceration (stress ulceration) Disseminated intravascular coagulation Multiple organ dysfunction syndrome (MODS) |
1.39.1 HYPOVOLEMIC SHOCK
Pathophysiology
Decreased circulating blood/fluid, decreases venous return, cardiac output, blood flow, and supply of oxygen. This causes anoxia and leads to shock. The most common cause of shock is hypovolemic shock.
Etiology
Hemorrhage | Nonhemorrhage |
Trauma GI bleed Ectopic pregnancy Ruptured abdominal aortic aneurysm (AAA) | Gastrointestinal (vomiting and diarrhea) Burns Third space plasma loss (pancreatitis, bowel obstruction) |
Hemorrhage Classification
Based on blood volume loss, origin of bleed, whether bleeding is internal or external, duration of bleed and postoperative bleed.
Blood Volume Loss
Advanced trauma life support classification (ALTS) for hemorrhagic shock:
Class | I (minimal blood loss) | II (mild blood loss) | III (moderate blood loss) | IV (severe blood loss) |
Blood loss (mL) | (500 mL) 0–15% | (1,000 mL) 15–30% | (1,500 mL) 30–40% | (>2,000 mL) >40% |
Pulse rate/min | <100 | >100 | >120 | >140 |
Blood pressure (mm Hg) | Normal | Normal | Decreased | Decreased |
Respiratory rate/min | 14–20 | 20–30 | 30–40 | >40 |
Urine output mL/h | 30–60 | 20–30 | 5–15 | Nil |
Symptoms | Patient is cold Sweating Anxious | Confused | Anxious and Confused | Lethargy/coma |
Need for blood products/IV fluids | Monitor | Crystalloids (NS/ringer lactate) | Crystalloids + Blood |
Drawbacks of ALTS classification for shock:
Vital signs changes are inaccurate in estimating blood loss in acute bleeding.
Elderly, patients on BB and patients with intra-abdominal hemorrhage may present without tachycardia in severe acute hemorrhage/sepsis.
Duration
Acute | Trauma (blood loss) |
Chronic | Ulcer |
Origin of Bleed (Arterial/Venous/Capillary)
Arterial | Forceful, pulsating flow of bright red blood |
Venous | Steady, slow flow dark red blood |
Capillary | Slow even flow |
External or Internal (Place of Bleeding)
Revealed hemorrhage (external bleeding) | Concealed hemorrhage (internal bleeding) |
Deep lacerations Hematemesis from a peptic ulcer Continued blood loss from a surgical wound drain Placenta previa Genital trauma | Intra-abdominal bleeding from a ruptured spleen or portal hypertension Hemorrhage from stomach or duodenal ulcer into the small intestine Intramuscular hematoma from fractures Abruption placenta |
Postoperative Bleeding (Primary/Reactionary/Secondary Bleed)
Types | Time | Etiology | Treatment (Choices include) |
Primary | During surgery | IV Fluids, pressure, packing, diathermy, ligate the bleeder, BBT | |
Reactionary | 4–24 hours after surgery | Loss of vasospasm: Knot slips | Resuscitation with IV fluids Identify site and control bleeding |
Secondary | 7–10 days after surgery | Sloughing of artery or vein due to infection | Antibiotics |
Investigations and Monitoring of Hemorrhagic Shock
Investigations: FBC, RBS, urea, and electrolytes Chest X-ray, ECG, US, and abdomen CT Cardiac enzymes, amylase Cross match and Coagulation studies | Monitoring: Blood Pressure ECG Pulse oximetry Urine output CVP |
Treatment of Hemorrhagic Shock
ABCDE (airway, breathing, circulation, disability and exposure of patient to assess completely) | |
Oxygen | 100%, 8 L with mask |
IV fluids | IV access two wide bore needles. Cross match and coagulation screen IV fluids: NS 30 mL/kg as fast as possible. Titrate against BP, CVP, and Urine output |
Blood products | Packed red blood cells for patients who require >1–2 L of N In MT PRBC, FFP and platelets given in a ratio of 1:1:1 |
Stop blood loss (arrest source of bleeding) | Nonoperative: Pressure to external bleeding points, packing, endoscopic procedures |
Drugs | Tranexamic acid 1 g IV over 10 minutes followed by 1 g over 8 hours. Give TXA within first 3 hours of injury Inotropes: Dopamine and dobutamine Vasopressors: Adrenaline, noradrenaline, and vasopressin |
Supportive therapy | Intubation and Ventilation: If airway is compromised or secondary to hypoxemia, hypercarbia or respiratory rate > 30 breaths/min or altered mental status Blood glucose concentration: Maintain blood glucose concentration around 150 mg (use insulin if necessary) Renal replacement therapy: Dialysis Nutritional support: Start enteral feeds as soon as possible DVT prophylaxis: LMWH |
Postdental Extraction Bleeding
Postextraction bleeding is common. Most cases of bleeding stop with local measures.
Local causes | Gingival tear Gingiva not so closely adapted to bone Failure to have compressed the extraction socket From the socket due to retained roots in raw bony socket |
Systemic causes | Hypertension Bleeding/coagulation disorders |
Methods to Arrest or Control Bleeding (Hemostasis)
Method | Comments |
|---|---|
Manual | Pressure (for 5 minutes) packing needs patience and perseverance |
Suture ligation | Sutures or clips |
Diathermy | Monopolar/bipolar |
Ultrasound | Harmonic scalpel vibration generates heat |
Drugs (Hemostatic) (Antihemorrhagic drugs) | Vitamin K 10 mg IV/IM Tranexamic acid 500 mg, orally thrice daily or 1–1.5 g IV stat Hemocoagulase (BOTROCLOT) drops Ethamsylate (HEMOSTAT/DICYNENE) 500 mg, orally, thrice daily Somatostatin Vasopressin |
Blood products | FFP/platelets (e.g., in dengue fever) |
Embolization | Radiologically guided (e.g., solid organ trauma and postpartum hemorrhage) |
SIRS, Sepsis, MODS, and ARDS
Systemic Inflammatory Response Syndrome (SIRS): Any two of the four features following listed below:
| SIRS is initiated by events such as:
|
Multiple Organ Dysfunction Syndrome (MODS)
It is an effect that SIRS causes systemically. MODS is progressive but reversible dysfunction of two or more systems (lungs—ARDS, hepatic, kidney—AKI, intestinal, clotting—coagulopathy, and cardiac—cardiovascular failure)
Etiology |
| ||||
Pathogenesis | Neutrophil activation and cytokine release and shock and ischemia | ||||
Treatment | ICU admission, ventilator support, antibiotics/antiviral drugs, BT, dialysis, and total parenteral nutrition In MODS, sequence of failure of individual organ often follows a predictable pattern with pulmonary failure occurring first, followed by hepatic, intestinal, renal, and finally cardiac failure. Mortality of MODS is directly related to the number of organs that fail Two organs: >60%, Three organs: >90% Multiple system organ failure (MSOF) is the end stage of uncontrolled MODS |
Acute Respiratory Distress Syndrome ARDS (Wet Lung)
Definition | Onset within 1 week of clinical insult or onset of respiratory failure Chest X-ray shows bilateral unexplained opacities Origin of edema (not explained by cardiac failure or fluid overload) Severity based on continuous 5 cm of CPAP |
Etiology | Indirect lung injury: Infections/injury to head/chest/abdomen Direct lung injury: Pneumonia |
Pathophysiology | Hypoxia and shock cause neutrophil, platelet, macrophage activation which release mediators. These are toxic and cause widespread endothelial damage which results in cell destruction and death. This causes ARDS and MODS |
Treatment | Treat precipitating cause Intubation and ventilation in prone position Fluid restriction Antibiotics/antivirals Steroids Extracorporeal membrane oxygenation (ECMO) |
1.39.2 SEPTIC SHOCK
Definition
Infection (proven or suspected) with persisting hypotension
Systolic BP < 90 mm Hg despite 30 mL/kg IV NS fluid bolus.
Requires vasopressors (e.g., noradrenaline) to maintain a MAP > 65 mm Hg.
Serum lactate is >2 mmol/L (18 mg/dL) despite adequate resuscitation101
Measurement of qSOFA (Sepsis-related organ failure) | Sepsis red flags |
|
Causes of Septic Shock
Surgical causes | Medical causes |
Investigations (Should be Done Immediately) (Choices Include)
Blood | Lactate, procalcitonin, CRP, CBC, urea, creatinine, and RBS Blood C/S (from two different sites, at least 20 mL from each site) (mandatory tests before starting antibiotics) |
Microbiology | Blood, sputum, urine, wound, or pus C/S |
Imaging | Chest X-ray, US, CT (chest, abdomen, or place of suspected infection) |
Goal-directed Early Resuscitation within First 6 Hours
Target values for goal directed therapy
CVP 8–12 mm/Hg, MAP > 65 mm Hg, urine output > 0.5 mL/kg/h
Treatment of Septic Shock (Surviving Sepsis Guidelines) (1 Hour Bundle)
Oxygen | 8 L/min |
IV fluids | 1–2 L NS (30 mL/kg fast bolus) over 1–2 hours, often several liters of fluid are needed |
Antibiotics/antiviral/antifungal drugs | Start within first hour after drawing blood for CS Give maximum doses and do not wait for culture and sensitivity Piper-tazobactam 4.5 g IVq8h or imipenem/cefepime 2g IVq12 h + gentamycin or tobramycin 5 mg/kg q24h in three doses or amikacin 15 mg/kg IV bolus |
Remove source of Infection | Drainage, debridement, and device removal Imaging helps to search for occult site infection (CXR/US/CT/MRI) |
Drugs | Vasopressors: Noradrenaline (to be started if above goals are not met with IV fluids) Inotropes: Dobutamine infusion (in presence of myocardial dysfunction) Steroids: Dexamethasone 4 mg IV and hydrocortisone up to 300 mg/day is indicated in refractory shock, i.e., patients not responding to IV fluids or pressor support (e.g., stress, disseminated TB, AIDS, meningococcal bacteremia, and prior glucocorticoid use) |
Supportive therapy | Intubation and Ventilation: If airway is compromised or secondary to hypoxemia, hypercarbia or respiratory rate > 30 breaths/min or altered mental status Blood glucose concentration: Maintain blood glucose concentration around 150 mg (use insulin if necessary) Renal replacement therapy: Dialysis Nutritional support: Start enteral feeds as soon as possible |
1.39.3 ANAPHYLACTIC SHOCK
National Institutes of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network (NIAID/FAAN) Criteria
Clinical diagnosis of anaphylaxis is considered likely if any one of the three criteria given below are present within minutes to hours.
Acute symptoms involving skin or mucosal surface with at least one of the following: Hypotension, respiratory compromise, or end organ dysfunction |
Two or more occur after exposure to allergen: Skin or mucosal surface, hypotension. respiratory compromise, or persistent GI symptoms |
Hypotension develops after exposure to an allergen: age specific low BP or systolic BP of >30% compared to baseline |
An acute hypersensitivity reaction, mediated by IgE and resulting in release of multiple mediators, mainly histamine.
Patient on beta blockers or ischemic heart disease, or asthma may have severe features anaphylactic shock.
Etiology (Mnemonic is FIDO)
Food | Peanuts, fish, egg, and milk preservatives |
Insect sting and bites | Ants, bees, and wasps |
Drugs | Antibiotics, NSAIDS, IV contrast agents, any drug |
Others | Latex (gloves) |
Clinical Features
System | Symptoms | Signs |
|---|---|---|
Cutaneous | Itching and burning | Urticaria (hives), flushing, periorbital edema, and perioral edema |
Respiratory | Dyspnea, chest tightness | Coughing, sneezing, wheezing, laryngeal edema, pulmonary edema, and bronchospasm |
Cardiovascular | Dizziness, malaise, and chest pain | Disorientation, diaphoresis, loss of consciousness, Hypotension, tachycardia, dysrhythmias, and cardiovascular collapse |
Gastrointestinal (GI) | Nausea, vomiting, diarrhea, and abdominal pain |
Treatment
Oxygen | 100% oxygen (high flow 8 L/min) establish patient airway (open and maintain airway) |
Adrenaline (first-line drug) Antihistamines Corticosteroids Bronchodilators (second line-drugs and have slow action) | 1 mL (1 mg) IM lateral thigh/gluteus/deltoid or subcutaneous/endotracheal/sublingual route every 3–5 minutes Pheniramine maleate (AVIL) 1–2 mL (22–44 mg) IV/IM stat (H1 receptor blocker) Ranitidine 1 mg/kg IV (50 mg IV) (H2 receptor blocker) Hydrocortisone 200mg IV/IM stat and q6h Salbutamol 5 mg nebulization (if wheeze persists) Ipratropium (if patient is on beta blockers) |
Fluids | NS 1–2 L in ½–1 hour |
Intubation and Ventilation | Emergency intubation (Laryngeal edema/obstruction, bronchospasm, shock/coma, hypoxemia, hypercarbia, altered mental status, respiratory failure, respiratory rate 30 breaths/min or respiratory difficulty) |
Monitoring | For 4–24 hours |
Discharge advise | EPIPEN training and referral to allergy specialist |
Note: Angioedema is often asymmetrically distributed in areas that are not gravity dependent. Patients may present with hallmark lip and lingual swelling or with more vague symptoms. Angioedema and anaphylaxis are not same but happen to present similarly. Immediate management should include ABCs, removal of inciting agent, IM epinephrine, supplemental oxygen, and volume resuscitation. Adjunctive medicines like H1/H2 receptors have not found to be useful for immediate systemic treatment of anaphylaxis, they provide symptomatic relief of for itching or wheezing. Glucocorticoids may be given for 3 days at discharge, as most cases of biphasic reactions will occur within 3 days, and should be never used as first-line therapy.103
1.39.4 VASOVAGAL SHOCK/SYNCOPE
It is due to reflex bradycardia +/– peripheral vasodilation provoked by emotion, pain or fear, or standing too long. Onset is over seconds and is often preceded by nausea, pallor, sweating, and closing in of visual fields (presyncope). It cannot occur if lying down.
Problems | Treatment choices/comments |
|---|---|
Hypotension |
|
Bradycardia | Atropine (1 ampoule =1 mL = 0.6 mg). 1 mL IV in every 3–5 minutes (maximum 3 mg) |
Asystole and cardiac arrest |
|
1.39.5 CARDIOGENIC SHOCK
Type and clinical features | Etiology | Investigations | Comments |
|---|---|---|---|
|
|
|
|
|
|
| Chest tube drainage in tension pneumothorax, thrombolysis/surgical removal of clot in pulmonary embolism or pericardial window in cardiac tamponade |
1.39.6 HYPOADRENAL SHOCK/ADRENAL CRISIS/ACUTE ADRENAL INSUFFICIENCY
Etiology |
|
Clinical features | Hypotension, nausea, vomiting, fever, low sodium, and raised potassium |
Investigations |
|
Treatment |
|
1.40 SMOKING CESSATION
Fagerstrom Test for Smoking
How soon do you smoke your first cigarette after you wake up?
Within 5 minutes : 3
6–30 minutes : 2
31–60 minutes : 1
After 60 minutes : 0
Do you find it difficult to refrain from smoking in places where it is forbidden?
Yes : 1
No : 2
Which cigarette would you hate to give up most?
How many cigarettes do you smoke per day?
10 or less : 0
11–20 : 1
21–30 : 2
31 or more : 3
Do you smoke more frequently in the 1st hour after waking up than during the rest of the day?
Yes : 1
No : 0
Do you smoke when you are so ill that you are in bed most of the day?
Yes : 1
No : 0
Total score: Sum total of above 6 items.
Treatment
Drug | Dosage and duration | Side effects | Contraindications |
|---|---|---|---|
Nicotine gum (NICOGUM, NICOTEX) | For 1–24 cigarettes/bidis—2 mg gum (up to 24 piece/day) for 12 weeks. For > 25 cigarettes/bidis—4 mg gum (up to 24 piece/day) for 12 weeks. Chewers need about half or a quarter of dose as prescribed for smoker. | Mouth soreness, burning in the mouth, throat irritation, dyspepsia, nausea, vomiting, hiccups, and excess salivation | Gastric ulcers, MI, or stroke in past 2 weeks or poorly controlled CVD. |
Bupropion (BUPRON, BUPRON SR, EFFION 150 mg) (a monocyclic antidepressant that inhibits the reuptake of both norepinephrine and dopamine) | 150 mg once daily for 3 days followed by 150 mg twice daily for 7–12 weeks. Bupropion is started, while person is still using tobacco; person can completely quit 2 weeks after initiating bupropion. | Agitation, restlessness, insomnia, GI upset, anorexia, weight loss, headache, and lowering of seizure threshold (at doses above 600 mg/day); rarely allergic reactions can occur including skin rashes, fever, muscle, and joint pain | History of allergy, tumors of CNS, severe liver disease, undergoing unsupervised withdrawal of alcohol or benzodiazepines, uncontrolled seizures, pregnant and lactating women, those below 18 years and persons on monoamine oxidase inhibitors, children or people with mental illness |
Varenicline (a partial nicotine agonist/antagonist that selectively binds to the 482 nicotinic acetylcholine receptor) | Initially 0.5 mg once daily for the first 3 days, increased to 0.5 mg twice daily for the next 4 days, and then increased to 1 mg twice daily for 12 weeks; person can quit 1 week after initiating Varenicline | Agitation, depression restlessness, insomnia, bad dreams, suicide ideas, gastrointestinal upset, headache and allergy | History of allergy |
Key Points
Tobacco use is a risk factor for coronary heart disease, cerebrovascular disease, PAD, lung cancer, cervical cancer, leukemia, bladder cancer, oral cancer, bronchial asthma, COPD, coal workers pneumoconiosis, DM, osteoporosis, and CKD.
In order to help a patient quit smoking, look at this task in terms of three fundamental behavior change objectives:
Abstinence from smoking
Development of alternatives to smoking
Development of relaxation skills to cope with stress
National Cancer Institute (NCI) has suggested “3A Program”. The first “A is to ASK” each and every patient systematically about the smoking habit. The second “A is to ASSIST”. In this stage, help the patient with a quit plan. The final “A is to ARRANGE”. In this step, schedule at least three follow-up contacts—one right after the quit date, second one at 1 month after the quit date, and the third one at 6 months of the quit date.
Use nicotine replacement therapy (NRT) or bupropion therapy as needed. NRT and bupropion help in reducing withdrawal from nicotine and decrease craving.
Self-efficacy refers to confidence that a person has in his/her, the ability to pursue a given behavior. Build self-efficacy of patient to quit by demonstrating small steps, using credible role models, persuasion, and reducing stress.
Spend at least 5 minutes on every smoker patient and provide tailored health education for tobacco cessation.105
1.41 SKIN AND SOFT TISSUE INFECTIONS—SUPERFICIAL AND DEEP (PYODERMA, CELLULITIS, NECROTIZING FASCIITIS, AND GANGRENE)
Refer Chapter 12.2.14.9 for more details.
Primary pyodermas arise on normal skin | Organisms |
|---|---|
Impetigo: Bullous impetigo Non-bullous impetigo | S. aureus Group A streptococci |
Ecthyma | Group A streptococci |
Folliculitis: Superficial Deep | S. aureus, Pseudomonas aeruginosa (P. aeruginosa) S. aureus |
Furuncles and carbuncles | S. aureus |
Erysipelas | Group A streptococci |
Cellulitis | Group A streptococci S. aureus |
Paronychia | S. aureus Group A streptococci P. aeruginosa (chronic form) |
Erythrasma | Corynebacterium minutissimum (C. minutissimum) |
Secondary pyodermas arise on diseased skin | Organisms |
Insect bites, eczema, scabies, ulcers, dermatophytic infections, and trauma | Any of the above mentioned organisms |
Depth of Infection
Superficial skin infections | They are more common and characterized by pustules, seropurulent discharge, crusting, and erosions |
Deep infections | Manifest as skin lesions with induration, tenderness, regional lymphadenitis, and ulcers, which may heal with scarring, they are usually associated with additional constitutional symptoms such as fever and malaise |
Investigations (Choices Include)
Investigation | Comments |
CBC, RBS, FBS, HbA1c | |
Gram stain, culture, and sensitivity | Superficial skin cultures may be misleading. Aspiration of the leading edge or of the most intense areas of induration or even a punch biopsy of the cellulitis yields positive cultures in 2–40% of the cases Blood cultures are positive in <5%. Fluids from bullae in streptococcal cellulitis are usually negative, but fluid from bullae in streptococcal necrotizing fasciitis is usually positive on culture. Staphylococcal cellulitis-associated abscesses are also usually culture positive |
Imaging: X-ray, CT, or MRI | Can localize osteomyelitis, deep, or occult infections |
Treatment (Choices Include)
Antibiotics | Topical: Mupirocin (TBACT), fusidic acid (FUCIDIN), and retapamulin (RETAREL) are more effective because of their penetration and large coverage of different bacterial species. Neomycin has a higher sensitizing potential and can cause contact dermatitis (avoid Neosporin) Systemic: Antibiotic therapy is initially empiric followed by culture-based therapy. Antibiotics used must cover relevant organisms. Clindamycin has the added advantage of inhibiting protein synthesis and hereby decreasing toxin production. Choice of antibiotic depends on: |
In superficial infections, oral antibiotics are sufficient. In deeper infections, e.g., cellulitis and SSSS, or for widespread infections, parenteral antibiotics have to be administered. S. aureus and streptococci are common pathogens; antibiotics targeting them are most effective. However, when indicated, a pus swab for culture and antibiotic sensitivity should be done to choose the appropriate antibiotic. Cotrimoxazole, cephalosporins, macrolides, cloxacillins, dicloxacillins, and amoxicillin with clavulanic acid are commonly used drugs. Newer antibiotics such as linezolid, tazobactam, and third- or fourth-generation cephalosporins are found to have better efficacy. Penicillins (because of penicillinase production by bacteria and risk of severe drug reactions) are no longer commonly used | |
Surgery | Deep-seated skin and soft tissue infections need early surgical debridement, and delay in débridement will increase mortality. Consider early surgical intervention, e.g., debridement or fasciotomy: For all deep infections Or if symptoms persist in spite of treatment for 48 hours. |
Organism | Depth of infection/disease | Treatment (choices include) |
|---|---|---|
MSSA (methicillin-sensitive S. aureus) | Superficial (cellulitis/erysipelas of extremities) | Cloxacillin or cefadroxil or cefazolin or levofloxacin or amoxclav (azithromycin or clarithromycin, if allergic to β-lactams) |
Deep (polymyositis, necrotizing abscess) | Clindamycin (DALACIN-C) 600 mg IV q8h or Linezolid (LINOSPAN/LIZOLID) 600 mg IV q12h | |
MRSA (methicillin-resistant S. aureus) | Superficial | Clindamycin or linezolid or vancomycin |
Deep | Clindamycin or linezolid or vancomycin | |
Streptococcus | Superficial (cellulitis) | Cefadrox or amoxclav or penicillin or levofloxacin |
Necrotizing (cellulitis) | Clindamycin or Linezolid | |
Necrotizing fasciitis type II (beta-hemolytic streptococci) | Clindamycin or Linezolid | |
Polymicrobic: Anaerobes: Gram negative Gram positive: | Necrotizing fasciitis type I (polymicrobial) | Antibiotics: Injection TT, 5 cc IM stat Gram stain + Culture is mandatory to determine the organism Prompt surgical debridement is necessary Vacuum assisted closure (VAC) Skin graft Hyperbaric oxygen IV immunoglobulins |
Clostridium perfringens (C. perfringens) | Gas gangrene | Clindamycin + penicillin + debridement or amputation |
Haemophilus influenzae (H. influenzae) | Face cellulitis | Ceftriaxone (MONOCEF) 1 g IV od/bd |
Polymicrobial | Orbital cellulitis | Ceftriaxone + metronidazole + vancomycin |
Other organisms | Bite wounds, e.g., dog, cat, human, and snake | Refer chapters 1.4, 3.5.2 and 3.5.3 |
1.42 SPRAIN/STRAIN (MUSCLE/LIGAMENT INJURY)
“PRICER” method is the best treatment:
P | Protect | Injured area (use splint/pop cast/fiber cast) |
R | Rest | |
I | Ice | The painful area; apply ice for 20 min q2h within the first 48 hours of injury (role of heat—use only after 48 hours of injury or before starting any activity, 20 minutes at a time. Heat should be mild to moderate and not scalding) |
C | Compress | The injured area (use elastocrepe/stockings) |
E | Elevate | The injured area above the level of heart (approximately 14 inch above ground level when lying) |
R | Referral | To doctor/specialist |
Drugs (Choices Include)
MOBIZOX (chlorzoxazone 500 mg + diclofenac 50 mg + paracetamol) 1 bd
MYOSPAZ FORTE (chlorzoxazone 500 mg + diclofenac 50 mg + paracetamol) 1 bd
MOBISWIFT D (metaxalone + diclofenac) 1 bd
ACENAC-MR (thiocolchicoside + aceclofenac + paracetamol) 1 bd
ZERODOL-MR (aceclofenac + paracetamol + tizanidine) 1 bd
BRUZEN-MR (tizanidine + brufen) 1 bd
TIZAN-MR (tizanidine) 1 bd
RELMUS (thiocolchicoside) 4–8 mg bd
BRUFEN (ibuprofen) 600–800 q8h po
ACECLAN (aceclofenac) 100 mg q12h po
DOLONEX (piroxicam) 20 mg po/IM q12h IM
DIAZEPAM (valium) 5–10 mg po q6h
ULTRACET/CALPOL-T (paracetamol + tramadol)
Note: Avoid combining muscle relaxants with antihypertensive drugs.
1.43 SUTURES
Characteristics of Suture Material
Absorbability
Structure (monofilament/multifilament (braided)
Origin
Strength
Biologic behavior (scale of tissue reaction)
Tensile behavior (elasticity, plasticity, and memory)
Size: 1–0 to 10–0 (thickness decreases 2–0 is thicker than 3–0)
Classification of Sutures
Based on Absorbability
Absorbable | Nonabsorbable | |
|---|---|---|
Absorption | Get absorbed often. They do their job and subsequently there is no foreign body. Degradation is by digestion with enzymes/hydrolysis | Do not deteriorate immediately after surgery. Get encapsulated/walled off by fibroblasts |
Strength | Limited for few days | Retain their strength indefinitely |
Type of tissue | Quick healing tissues (muscle, colon, bladder) | Slow healing tissues (fascia and tendon) |
Used for | Urinary bladder and biliary tract so that it does not allow stone formation Female genital tract Bowel anastomoses | Abdominal closure Tendon repair Hernia repair Vascular anastomoses |
Examples | Catgut Polydioxanone (PDS) Polyglactin (VICRYL) Polyglycolic acid (DEXON) | Silk Linen Polyester |
Based on Number of Filaments
Monofilament | Multifilament (Braided) | |
|---|---|---|
Composition | Single strand | Several filaments twisted/braided together |
Memory and handling qualities | Crystalline structure increases memory (it retains its curled structure) | Have no memory, easier to handle |
Knot tying and Security of knot | Smooth tissue passage but not easy to tie. Less secure | Easy to tie Secure knots |
Tissue reaction and predisposition to wound infection | Minimal (bacteria cannot harbor in a single strand) | May harbor bacteria as they are multifilament Bacteria may be present in interstices of multifilament material. Can cause infection and should not be used in contaminated/infected cases |
Examples | Polydioxanone Polyamide (NYLON) Polypropylene (PROLINE) Polyglecaprone 25 (MONOCRYL) Stainless steel | Catgut, silk, and linen Polyester Polyglactin (VICRYL) Polyglycolic acid (DEXON) |
Based on Origin
Natural | Synthetic | |
|---|---|---|
Nature | Amine/protein | Synthetic/carbohydrate |
Mode of absorption | Undergoes proteolysis | Undergoes hydrolysis |
Tissue reaction | Intense | Less/minimal tissue reaction |
Period of wound support | Short | Long |
Examples | Gut (sheep submucosa, or beef serosa) Silk (silk cocoon) Linen (flax) Cotton (cotton plants | Polydioxanone Polyglactin |
Nomenclature Based on Thickness
Thickness is 1/10 of diameter of mm. 0, 1–0, 2–0, 3–0, 4–0, 5–0, 6–0, 7–0, 8–0
Surgical Gut (Catgut)
Surgical gut consists mainly of collagen and is made from the dried small bowel submucosa of sheep or mucosa of beef cattle.
Material | Absorbability | Structure | Tissue reaction | Period of wound support | Tensile strength |
|---|---|---|---|---|---|
Protein | Absorption is by cellular response | Multifilament | Severe ++++ | Short term (3–5 days) | Weak |
Plain catgut | Chromic catgut | |
|---|---|---|
Period of wound support | 3 days | 5 days |
Tissue reaction | Elicits an early lymphocytic and intense reaction within 24 hours | Produces a much slower polymorph reaction taking up to 3 days |
Indications | For ligating bleeders in subcutaneous tissue as well as for approximation of wound | Whenever an absorbable suture is indicated |
Advantages | Easy to handle and knots well Not recommended for use in deeper to subcutaneous tissue | Safe in potentially infected cases, since the material will absorb rather than form a sinus and be extruded |
Uses | Wounds in lips and oral cavity. Circumcision | Approximations of muscles, bowel anastomoses, closure of peritoneum, obstetrical, and gynecological procedures109 |
Summary of Classification of Sutures
Monofilament or multifilament
Absorbable or Non-absorbable
Natural (N) or synthetic (S)
Nomenclature based on thickness
Absorbable | N/S | Non-absorbable | N/S | |
|---|---|---|---|---|
Monofilament | Polyglecaprone (MONOCRYL) | S | Polyamide (NYLON) | S |
Polydioxanone (PDS) | S | Polypropylene (PROLINE) | S | |
Polytetrafluoroethylene (GORTEX) | S | |||
Steel | S | |||
Multifilament | Polyglactin (VICRYL) | S | Silk | N |
Polyglycolic acid (DEXON) | S | Linen | N | |
Lactomer 9–1 (POLYSORB) | Polyester (DACRON) | S | ||
Catgut | N |
Size for Skin Suture
Face, neck, hands, digits | 5–0, 6–0 |
Rest of the body | 3–0, 4–0 |
Subcuticular skin closure | 4–0 |
Suture Removal Day
Scalp | 5–7 days |
Gum sockets near teeth | 10 days |
Face, neck | 5–7 days |
Abdomen (trunk) | 10 days |
Upper extremities | 10–14 days |
Lower extremities and Feet | 14–21days |
Patients on steroids or patients with malignancy, infection, cachexia, elderly, or smokers | 14 days or longer |
Suture Line Care
Remove dressing after 24 hours or as instructed by doctor |
Wash with soap and water only after 48 hours depending on wound and doctors instructions |
Apply a thin layer of antimicrobial cream (betadine or mupirocin ointment) |
If patient has tendency to form scars, some procedures listed below may be helpful: Injection of triamcinolone into wound at time of suturing Pressure garments Silicone gel sheets |
Uses of Sutures
Skin closure | Nylon, Vicryl, Monocryl |
Repair of organs (hollow/solid viscera), anastomoses, etc. | Vicryl, Proline |
To stop bleeding | Vicryl |
Complications of Sutures
Infection |
Foreign body: Sinus |
Scar |
Technical/mechanical problems: Bleeding (due to a loose tie) Wound dehiscence (due to Inadequate bites/absorbable sutures) |
Alternatives to Sutures
Adhesives (glue) 2-octyl-cyanoacrylate (DERMA BOND) |
Staples: Non-absorbable (Stainless steel/titanium) Absorbable [polylactic acid (INSORB)] |
Skin grafts |
Flaps |
1.44 SWEATING
Causes and Treatment
Etiology | Treatment (choices include) | |
Generalized sweating | Pathological causes: Fever Myocardial infarction Diabetes (hypoglycemia) Hyperthyroidism Malignant diseases (leukemia) Pheochromocytoma Shock Anemia Hyperthyroidism Drugs Decongestants, novalgin, paracetamol Substance abuse/stimulants Coffee, tea, smoking, alcohol Increased intake of salt Physiological causes: Anxiety Physical exertion Menopause High environmental temperature | Treat the cause |
Localized sweating of palms and soles | Idiopathic (primary palmar hyperhidrosis) | OSTOCALCIUM 1 tablet twice daily for 2 months LARPOSE (lorazepam) 1–2 mg po, bd Soak palms and soles in FORMALIN 10% for 5 minutes daily CIDEX 2% (glutaraldehyde) apply solution thrice a week and reduce to once a week Or Keep dry/all dry (aluminum chloride hexahydrate) in absolute alcohol—apply for 3 nights daily and later on once in 5 days Iontophoresis Cervical sympathectomy |
Underarm sweating | Dove men + care (aluminum zirconium tetrachlorohydrex) Candid active spray Qbrexza (medicated cloth, apply daily, helps to block sweat glands)111 |
1.45 SYNCOPE/BLACKOUT/SUDDEN COLLAPSE
Refer Chapter 3.19 for more details.
Definition
Transient self-limited loss of consciousness and postural tone due to reduced cerebral blood flow. Recovery of consciousness is prompt, if patient is maintained in horizontal position and cerebral perfusion is restored.
Red Flags
Chest pain
Shortness of breath
Blood around the mouth
Known drug misuse
Animal bite
Positive pregnancy test
Headache
Vomiting
Etiology
Subset | Examples |
Neurocardiogenic (vasovagal, reflex situational syncope) | History of cough, micturition or defecation Hot or crowded environment, fatigue, pain, hunger, stress, and prolonged standing |
Cardiac (cardiac syncope) | Arrhythmias, MI, AS, MS, tamponade, and PE |
Orthostatic (postural) | Sudden rising from recumbent position or standing Antihypertensive and antidepressant drugs Autonomic nervous disorders: |
Medications/Drugs | Antihypertensive and antidepressant drugs (alpha blockers, nitrates, ACEI, CCB, hydralazine, diuretics, BB, benzodiazepines, antipsychotics, and TCA), Phenothiazines, barbiturates, and alcohol |
Psychogenic | Anxiety |
First Consider Serious Causes for Syncope/Collapse
Cardiovascular | Syncope, MI, ruptured AAA, and heat exhaustion |
Respiratory | Pulmonary embolism |
Neurological | Stroke, epilepsy, and subarachnoid hemorrhage |
Gastrointestinal | Gastrointestinal bleed, pancreatitis, infarction, or ischemia of intestine |
Metabolic | Hypoglycemia, alcohol intoxication |
Other | Anaphylaxis, ruptured ectopic pregnancy, testicular torsion, trauma, exposure to toxins, and electric shock |
Examination
Check pulse for 1 minute | Observe missed beats or irregular beats |
Check BP supine and standing | Orthostatic hypotension: SBP falls by 20 mm Hg or DBP falls by 10 mm Hg, or heart rate increases by 20 beats or if patient has symptoms when standing |
CVS | JVP, S4, LV heave, and cardiac murmurs |
CNS |
Investigations (Choices Include)
Situation | Comments |
|---|---|
History of situations or stimuli that provoke attack and physical examination is normal | Reflex syncope (tilt testing if severe or recurrent) |
History, physical examination, and ECG suggest cardiac disease | Cardiac syncope (ECG, 24-hour Holter monitor, stress test, other cardiac testing as indicated) |
Examination reveals orthostatic hypotension | Orthostatic or postural hypotension: Normal neurological examination: Abnormal neurological examination: |
Review medications | Antihypertensive and antidepressant drugs (alpha blockers, nitrates, ACEI, CCB, hydralazine, diuretics, BB, benzodiazepines, antipsychotics (TCA) phenothiazines, barbiturates, and alcohol |
Treatment
Cardiac/Neurologic syncope | Orthostatic hypotension | Vasovagal syncope |
|---|---|---|
Treat underlying disorder | Discontinue vasoactive medications Educate patient to get up from supine to upright slowly Increase fluid intake and salt in diet, if necessary Occasionally fludrocortisone acetate, midodrine, or pseudoephedrine may be helpful | Avoid situations or stimuli that provoke attacks |
Key Points
History should include careful analyses of events preceding the attacks.
Common causes of syncope are vasovagal syncope (cough, micturition, or defecation), orthostatic (postural hypotension), and cardiac arrhythmias.
It is important to rule out cardiac or neurological causes.
Recovery may be prolonged with persistent symptoms, but there should be no neurological deficit or confusion.
In elderly, sudden faint without obvious cause may be due to complete heart block or tachyarrhythmia.
In elderly, syncope may also be due to sick sinus syndrome (SSS). Cardiology consultation required.
1-minute pulse rate (manual/digital) can help in diagnosis.
High-risk features (usually warrant admission and further testing):
Age > 60 years history of CAD, CMP, valvular disease, congenital heart disease, and arrhythmias
Syncope consistent with cardiac cause (lack of prodrome, exertional, and resultant trauma)
Abnormal cardiac examination
Abnormal ECG
Differential diagnosis for syncope:
Massive internal hemorrhage, MI, and cardiac arrhythmias can cause fainting and may need emergency treatment.
Undiagnosed seizures
Confusional states due to hypoglycemia, hypoxemia, stroke, and substance abuse (alcohol).
1.46 TREMOR
Red Flags
Disabling effect on daily life
Suspected Parkinson's disease
Alcohol or drug misuse
Systemic features (weight loss, malaise, fever, night sweats, and anorexia)
Signs of raised ICP
Etiology, Investigations, and Treatment
Etiology | Investigation | Treatment (choices include) |
Young Tense, excited | INDERAL/CIPLAR (propranolol) 10 mg q8h or 40 mg od | |
Alcoholic | NEUROBION injection 2 mL IM od for 10 days NEUROBION tablet 1 bd LIBRIUM tablet (chlordiazepoxide) 10 mg, 25 mg tablets: | |
Thyrotoxic | T3, T4, and TSH | THYROCAB (neomercazole) 5–10 mg q8h INDERAL (propranolol) 10 mg q8h |
Drugs | Check if patient is on salbutamol, amitriptyline, and imipramine | |
Hysterical | Alprazolam or diazepam Refer to psychiatrist | |
Elderly Senile | BECOSULE 1 od for 30 days NEUROCETAM (piracetam) 800 mg q8h | |
Parkinsonism | SYNDOPA (levodopa and carbidopa) 1–2 tablets q8h PACITANE (trihexyphenidyl) 2–4 mg q8h for rigidity Refer to neurologist |
Key Points
Enquire directly if patient has history of alcohol (ethanol) abuse.
Common causes of tremor in young are anxiety and alcoholism, and in elderly parkinsonism.
Note for Readers:
1.47 TIREDNESS (REFER CHAPTER 1.19)
1.48 TUBERCULOSIS (TB)
Red Flags
Hemoptysis
Productive cough
Night sweats
Considerable unintentional weight loss
Cachexia
Back pain
Neurological symptoms
Chest wall pain
Tuberculosis spreads by droplet infection (cough or sneeze) where suspended aerosol droplets containing TB bacilli, when inhaled reach lung. Major reasons for TB are malnutrition and under nutrition, contact with active TB patient, and low immunity (DM, HIV, smoking, alcoholism, CKD, cancer, and old age). Symptoms may be cough, anorexia, fever, and swelling of glands.
Investigations (Choices Include)
Blood | CBC, ESR, RBS, LFT, and HIV |
Microbiology | Sputum AFB X 3 samples Sputum AFB C/S |
Imaging | Chest X-ray US (neck, abdomen, and pelvis) CT (neck, brain, thorax abdomen, pelvis, and soft tissue)114 |
Biopsy | Lymph nodes, tissue curetting, peritoneum, bone or synovial tissue endometrial tissue, and skin |
Molecular tests | TB NAAT Xpert MTB/ RIF assay (lymph node, sputum, tissues, and body fluids (CSF/pleural/gastric/bronchial) |
Ophthalmology evaluation | For baseline retinal evaluation before starting ethambutol |
Specimen Type is Decided by the Site of Disease or Purpose of Testing
Site | Specimen of choice | Comments |
|---|---|---|
Active, pulmonary TB | Sputum | Early morning sputum. Two sputum samples must be collected (saliva is not acceptable) Bronchoscopy and bronchoalveolar lavage |
Latent TB (seen in people exposed to TB) | No | Tuberculin skin test (TST) Interferon gamma release assay (IGRA) |
Extrapulmonary TB | +/– | Lymph nodes, abdomen, brain bone and joint, genitourinary, and skin |
TB lymphadenitis | Lymph node aspirate/pus for FNAC Lymph node biopsy | Requires needle aspiration and/or excision biopsy Samples are sent for smears for AFB, culture, and biopsy |
Pleural effusion (TB pleuritis) | Pleural fluid Pleural biopsy | Requires pleural tap and/or biopsy Samples are then sent for pleural fluid analysis, smears for AFB, culture, molecular (PCR) tests, and biopsy; pleural fluid adenosine deaminase (ADA) or interferon-gamma is often helpful |
Ascites (abdominal TB) | Ascitic fluid Peritoneal biopsy | Requires ascitic tap and/or biopsy Samples are then sent for smears for AFB, ascitic fluid analysis, culture, molecular (PCR) tests, and biopsy; ascitic fluid ADA or interferon-gamma is often helpful |
TB meningitis | Cerebrospinal fluid (CSF) | Requires spinal tap for CSF collection Samples are then sent for smears for AFB, CSF analysis, culture, and molecular (PCR) tests |
Bone and joint TB | Bone or synovial tissue biopsy | Biopsy and culture |
Urinary tract and kidneys TB | Urine Tissue via biopsy | Biopsy and culture |
Genitourinary tract TB | Tissue biopsy (e.g., endometrial tissue in women) | Biopsy and culture |
Childhood TB | Sputum in older (younger children; gastric aspirates) |
Xpert MTB/RIF assay (RT-PCR) is a cartridge-based nucleic acid amplification test (NAAT), for EPTB should be used along with other investigations such as microscopy, cultures and histopathology (biopsy) to arrive at final diagnosis. Xpert is particularly useful in CSF samples and in lymph node and other tissues.
Sample | Sensitivity (compared to culture) | Specificity (compared to culture) | WHO recommendations on the use of Xpert |
|---|---|---|---|
Cerebrospinal fluid | 81% | 98% | Xpert is recommended as an initial diagnostic test in CSF specimens for TB meningitis (strong recommendation has given the urgency of rapid diagnosis) |
Lymph nodes | 83% | 94% | Xpert is recommended as a replacement test for usual practice in specific nonrespiratory specimens (lymph nodes and other tissues) for EPTB (conditional recommendation) |
Pleural fluid | 46% | 99% | Pleural fluid is a suboptimal sample and pleural biopsy is preferred; while a positive Xpert result in pleural fluid can be treated as TB, a negative result should be followed by other tests |
Gastric lavage and aspirations | 84% | 98% | Xpert is recommended as a replacement test for usual practice in specific nonrespiratory specimens (including gastric specimens) for EPTB (conditional recommendation)115 |
Drugs Used in Treatment of Tuberculosis
Groups | Drugs | Adverse effects |
|---|---|---|
Group 1 (oral first-line drugs) | INH | Hepatotoxicity, rash, and peripheral neuropathy |
Rifampicin | Hepatitis, rash, and discoloration of urine | |
Ethambutol | Color blindness | |
Pyrazinamide | Hepatitis, increased uric acid | |
Group 2 (injectable) | Kanamycin | Ototoxicity (starts with high-frequency hearing loss and may continue after stopping culprit drug) |
Amikacin Capreomycin | Nephrotoxicity (renal failure and severe hypokalemia) | |
Group 3 (fluoroquinolones) | Ofloxacin | Gastrointestinal disturbances, insomnia, and arthralgia |
Levofloxacin | ||
Moxifloxacin | ||
Group 4 | Ethionamide/prothionamide | GI disturbance (nausea, vomiting, abdominal pain, and anorexia), hepatotoxicity, and hypothyroidism |
Cycloserine | Psychosis, convulsions, paresthesia, and depression | |
P-aminosalicylic acid (acid salt) | GI disturbance (mainly diarrhea) and hypothyroidism | |
Group 5 | Clofazimine | Photosensitivity |
Amoxicillin with clavulanate | ||
Linezolid | Myelosuppression, lactic acidosis, peripheral neuropathy, and pancreatitis | |
Imipenem | ||
Clarithromycin | GI intolerance, rash, hepatitis, prolonged QT syndrome, and ventricular arrhythmias | |
High-dose INH | Hepatitis and peripheral neuropathy | |
Thioacetazone | GI intolerance, hepatitis, and skin reactions |
Revised National Tuberculosis Control; Program Treatment Regimens
Directly Observed Treatment Short Course
Category of treatment | Type of patients | Intensive phase | Continuous phase |
|---|---|---|---|
New cases | New sputum smear (positive) New sputum smear (negative) New extrapulmonary TB Others | 2R3H3Z3E3 | 4R3H3 |
Previously treated cause | Sputum smear (positive relapse) Sputum smear (positive failure) Sputum smear (positive treatment after default) Others | 2S3R3H3Z3E3+ 1R3H3Z3E3 | 5R3H3E3 |
6 months treatment is needed for all cases of TB except for:
Cases with evidence of treatment failure, or
Complications, e.g., bone and joint, spinal TB with neurological involvement, and CNS TB where treatment is longer for 1–1½ years
How can one protect oneself from tuberculosis?
Patient should cover mouth with kerchief while coughing/sneezing. Hands need to be washed regularly. Caretakers also need to be counseled.
1.49 ULCER, SINUS, AND FISTULA
Definition
Ulcer is a break in continuity of skin or mucus membrane or epithelium due to molecular/cell death, e.g., leg ulcer, oral ulcer, and duodenal ulcer116
Classification
Pathological classification (etiology) |
| |||||||||
Clinical classification |
|
Factors Affecting Ulcer Healing (Mnemonic = FRIEND IN MAID)
Local causes | Regional causes | Systemic causes |
|---|---|---|
Foreign bodies Radiation Infection/Interference by patient/Inappropriate dressings/Improper surgical technique (not securing good hemostasis, not removing all dead tissue, not obliterating dead space or closing the wound with tension are faulty surgical techniques) Excessive movement Neoplasia Dead tissue FRIEND! | Ischemia Neuropathy IN | Malnutrition Vitamin deficiencies (A, C and Zinc) Anemia Immunosuppression: Metabolic: MAID |
Investigations (Choices Include, Select Appropriately)
Blood and urine | CBC, FBS, creatinine, and urea blood borne infection screen (HIV, HBS, and HCV) Connective tissue disease work up ANA, RF Vasculitis profile (ANCA, compliment, and ESR) Syphilis: VDRL and FTA |
Microbiology | Grams stain, pus/tissue for C/S (bacteria, fungus, or TB) |
Imaging | X-ray of affected part (to rule out osteomyelitis) Color Doppler/duplex US(CDU) (for venous or arterial disease) MR venography/MR angiography (done sometimes when surgery is planned) Nerve conduction studies (NCS) |
Biopsy | Wedge biopsy |
Treatment (Choices Include, Select Appropriately)
Treat underlying cause | Ulcer due to infection: Antibiotics Malignant ulcer: For example, SQUAMOUS CELL CARCINOMA (WIDE EXCISION with a margin of 1 cm) |
Ulcer wound treatment (choices include) | Dressings (moist wound care, i.e., saline dressings are best in most cases) Debridement Skin graft |
Trophic Ulcer/Chronic Ulcer
Trophic means nutrition (nutrition may be impaired by many causes).
Etiology | Examples | Investigations (choices include) |
|---|---|---|
Neurogenic | Diabetes Leprosy and other neurogenic causes | FBS, HbA1c, Nerve conduction studies. Skin smear and nerve biopsy |
Venous | Chronic venous insufficiency (varicose veins/DVT) | Color Doppler US |
Arterial | Peripheral arterial disease | ABPI, Color Doppler US CT/MR angiogram |
Systemic causes or malnutrition | Anemia Connective tissue disease Vasculitis | CBC, ESR, blood picture, CTD work up (ANA), and vasculitis work-up |
Malignancy | Skin cancers | Biopsy |
Pressure Sore/Bed Sore/Decubitus Ulcer
Where are pressure sores seen? (pressure > 30 mm Hg) | Commonly seen in bedridden patients Ischium Greater trochanter Sacrum Heel Malleolus Occiput |
Treatment choices | Use air bed. Keep area dry Change position of patient every 2 hours Antibiotics Debridement Dressings Vacuum assisted closure or NPWC (negative pressure wound closure, generates 125 mm Hg pressure). Sucks exudate and boosts wound healing. Helps to decrease edema, remove interstitial fluid, increases blood flow, decrease bacterial count and increases cell proliferation Flap/skin graft |
Cushing's/Curling's
Features | Treatment | |
|---|---|---|
Curling's ulcer | Duodenum ulcer seen in patients with severe burns It can cause complications like bleeding and perforation | Proton-pump inhibitors (PPI), e.g., pantoprazole Antacids, e.g., DIGENE gel Cytoprotective agents, e.g., SUCRALFIL |
Cushing's ulcer | Acute stress gastric ulcer It can cause complications like bleeding and perforation | Proton-pump inhibitors, e.g., pantoprazole Antacids, e.g., DIGENE gel Cytoprotective agents, e.g., SUCRALFIL |
Sinus
Definition and etiology | Sinus is a blind epithelial tract, from exterior surface into tissue lined by granulation tissue or epithelial tissue Congenital:
Thyroglossal Bronchial Traumatic (foreign body) Inflammatory (TB, actinomycosis, osteomyelitis, and median mental sinus) | ||||||||||||
Sinus In head and neck |
| ||||||||||||
Causes of persistent sinus/fistula (i.e., nonclosure of fistula) (Mnemonic = FRIEND) | Foreign body (suture/dead bone) Radiation Inadequate drainage Infection (Tb, actinomycosis) Inflammation (Crohn's disease) Epithelialization of tract Neoplasia Distal obstruction | ||||||||||||
Investigations for sinus |
| ||||||||||||
Treatment of sinus | Excision of sinus |
Fistula
Definition | Is an abnormal connection between two epithelial surfaces usually lined by granulation tissue and colonized by bacteria Like a sinus the granulation tissue may get epithelialized: Hollow organ to exterior = external fistula Hollow organs or internal organs = internal fistula | ||||||||||||
Etiology | Congenital (bronchial, tracheoesophageal, and AV fistula) Traumatic Inflammatory (fistula-in-ano) Neoplastic | ||||||||||||
Causes of persistent sinus/fistula (i.e., nonclosure of fistula) (Mnemonic= FRIEND) | Foreign body (suture/dead bone) Radiation Inadequate drainage Infection (TB and actinomycosis) Inflammation (Crohn's disease) Epithelialization of tract Neoplasia Distal obstruction | ||||||||||||
Investigations |
| ||||||||||||
Treatment |
Note for Readers:
1.50 ULCER LEG
1.51 ULCER-ORAL (REFER CHAPTER 6.4.12)
1.52 VACCINATION/IMMUNIZATION
Pediatric Immunization Schedule
Bacillus–Calmette–Guérin (BCG)+ oral polio vaccine (OPV 1) | 0–1 month |
Oral polio vaccine (OPV 2)+ DPT1+ Haemophilus influenzae B1 + HBV1 | 6 weeks |
Oral polio vaccine (OPV 3)+ DPT2 + Haemophilus influenzae B2 + HBV2 | 10 weeks |
Oral polio vaccine (OPV 4)+ DPT3 + Haemophilus influenzae B +HBV3 | Birth, 1 and 6 months or birth, 6 and 14 weeks or 6, 10, and 14 weeks Catch up: 0, 1, and 6 month schedule |
Measles vaccine/OPV | 9 months |
Varicella (chickenpox vaccine) | 1year |
Injection MMR | 15 months |
DPT + HIB + OPV | 18–24 months as first booster dose |
DPT + OPV | 5 years as second booster dose |
TT | 10 years as booster |
TT | 15 years as booster |
Add on Vaccines
Rotavirus | RV1 (ROTARIX): 6 and 10 weeks or RV5 (ROTATEQ): 6, 10, and 14 weeks |
Human papillomavirus (HPV) | 11–12 years. HPV4 (GARDASIL)—0, 2, and 6 months, HPV2 (CERVARIX)—0, 1, and 6 months |
Meningococcal vaccine | Quadrivalent conjugate and polysaccharide above 2 years. Monovalent group a conjugate above 1 year for high-risk group during outbreak, international travel, etc. |
Cholera vaccine | >1 year (killed whole cell Vibrio cholera) two doses 2 weeks apart |
Japanese encephalitis SA-14-14-2 live-attenuated cell culture derived | >8 months—two doses at 9 months and 16–18 months respectively. Inactivated cell culture derived SA14-14-2 for 2 years. 1–3 years—two doses (0.25 mL) 4 weeks apart. >3 years—two doses (0.5 mL) 4 weeks apart. Inactivated cell culture-derived Kolar strain >1 year two doses 4 weeks apart |
Vaccination for Adults (Choice Include)
Vaccine | Dose | Route | Site | Needle size |
|---|---|---|---|---|
Tetanus, diphtheria (td) with pertussis (Tdap) | 0.5 mL | IM | Deltoid muscle | 22–25 G, 1–1½ |
Hepatitis A | ≤18 years: 0.5 mL ≥19 years: 1.0 mL | IM | Deltoid | |
Hepatitis B | ≤19 years: 0.5 mL ≥20 years: 1.0 mL | IM | Deltoid muscle | 22–25 G, 1–1½ |
Hepatitis A + Hepatitis B (Twinrix) | ≤18 years: 1.0 mL | IM | Deltoid muscle | 22–25 G, 1–1½ |
Human papillomavirus | 0.5 mL | IM | Deltoid muscle | 22–25 G, 1–1½” |
Influenza, trivalent inactivated (TIV) | 0.5 mL 0.5 mL | IM IM | Deltoid muscle Deltoid muscle | 22–25 G, 1–1½” 22–25 G, 1–1½” |
Pneumococcal polysaccharide (PPSV23) or pneumococcal vaccine (PCV13) | SC | Fatty tissue over triceps | ||
Meningococcal conjugated (MCV) | 0.5 mL | IM | Deltoid muscle | 22–25 G, 1–1½” |
Meningococcal polysaccharide (MPSV) | 0.5 mL | SC | Fatty tissue over triceps | 23–25 G, 5/8” |
Measles, mumps, rubella (MMR) | 0.5 mL | SC | Fatty tissue over triceps | 23–25 G, 5/8” |
Zoster (ZOS) | 0.65 mL | SC | Fatty tissue over triceps | 23–25 G, 5/8” |
Varicella (VAR) | 0.5 mL | SC | Fatty tissue over triceps | 23–25 G, 5/8” |
Influenza live attenuated (LAIV) | 0.2 mL (0.1 mL into each nostril) | Intranasal spray | Intranasal | NA |
Tetanus toxoid | 0.5 mL | IM | Deltoid | |
Japanese encephalitis vaccine | ||||
Yellow fever vaccine | ||||
Typhoid | ||||
Cholera | ||||
Rabies |
Routes of Vaccination
Name | Size needle and entry | Site | Example |
|---|---|---|---|
IM | 23 G entry 90° | Anterolateral aspect of thighs (vastus lateralis) or mid deltoid | TT |
SC | 26 G entry 45° just pinch skin give SC | Mid triceps | Measles, mumps, and varicella |
Intradermal | 26 G | Flexor aspect of forearm or deltoid | BCG, Mantoux test for drug allergy |
Tetanus Toxoid
Tetanus toxoid is used to prevent tetanus.
Primary Immunization (Roughly Total of 10 Injections from Intrauterine to Adult)
Pregnancy | TT two doses. First dose early in pregnancy and second dose after 4 weeks |
Infants and children | 6, 10, and 14 weeks, then at 15–18 months and 5 years; booster every 5 years |
Adults | 0.5 mL TT, IM repeated twice at monthly intervals |
Secondary Prevention (Tetanus Prophylaxis in Wound Trauma)
All penetrating wounds and bite wounds regardless of severity or etiology are tetanus prone and patient's immunization must be considered. Provide PEP as indicated below.
Tetanus immunization history | Tetanus toxoid (0.5 mL in deltoid IM) | Tetanus immune globulin (TIG) (50% into deltoid muscle and 50% into wound site) |
|---|---|---|
Unknown | Yes | Yes |
>10 years since last booster dose | Yes | Yes |
>5–<10 years since last booster dose | Yes | No |
<5 years since last booster dose | Yes | No |
1.53 VARICELLA ZOSTER (CHICKENPOX)
Highly contagious crops of pruritic vesicles on skin and mucous membrane
Chickenpox spreads by respiratory (airborne) droplets, direct contact with varicella vesicles or zoster lesions. Incubation period is 14–16 days.
Patients are infectious approximately 48 hours before appearance of rash till final lesions have crusted.
Treatment (Choices Include)
Antipyretics for fever
Calamine lotion (OXILAMINE lotion)
Acyclovir (HERPERAX, ACIVIR-DT) 800 mg five times a days for 7 days for adults and children 12 mg/kg po q6h
Famciclovir (VIROVIR) 500 mg tds for 7 days
Valacyclovir (VALCIVIR) 1,000 mg tds for 7 days
Prevention/Prophylaxis
Exposed, susceptible people should be considered at risk and potentially infectious till last vesicle crusts for 21 days.
Time | Drug | Indications |
|---|---|---|
Preexposure vaccination (active immunization) | 0.5 mL varicella virus vaccine SC 2 doses 4–8 weeks apart | All children, seronegative adults Patients > 60 years irrespective of serologic status |
Postexposure (passive immunization) | Varicella zoster immune globulin (VZIG) | Give within 3 days of significant exposure, if risk of complications from varicella are high, for example: Immunocompromised patients Pregnant women Premature infants, neonates whose mothers had chickenpox onset within 5 days before or 2 days after delivery |
Antiviral prophylaxis | Acyclovir (HERPERAX, ACIVIR-DT) 800 mg five times daily | For patients whom 4 days direct contact has passed For high-risk patients who had intense exposure and are ineligible for vaccine |
1.54 VERTIGO/DIZZINESS
Red Flags
Ear discharge
Acute trauma
Suspected cancer
Progressive symptoms
Disability and loss of confidence
Neurological problems
Dizziness or vertigo is a multisensory syndrome. It is not a single disease entity.
There is a mismatch three sensory systems—(1) vestibular, (2) visual, and (3) somatosensory systems.
Symptom | Definition | Provocative tests to reproduce symptoms when meaning of dizziness is uncertain |
|---|---|---|
Dizziness | Variety of head sensations or gait unsteadiness | |
Faintness (presyncope) | Lightheadedness followed by visual blurring or postural swaying along with feeling of warmth, diaphoresis, and nausea | Valsalva maneuver, hyperventilation, or postural changes |
Vertigo(true) | Illusory or hallucinatory sense of movement of the body or the environment, most often a feeling of spinning. Sensation of movement, i.e., room is spinning | Rapid rotation in swivel chair |
Syncope | Transient self-limited loss of consciousness and postural tone due to reduced cerebral blood flow. Recovery of consciousness is prompt, if patient is maintained in horizontal position and cerebral perfusion is restored |
Etiology
Infection: Acute viral infection and severe systemic infections
Intoxication: Alcohol and drug misuse
ENT: Benign paroxysmal vertigo, vestibular neuronitis, Ménière's disease, middle ear disease, and ototoxic drugs
Psychogenic: Hyperventilation (anxiety and depression)
Drugs: Diuretics and SSRIs
Cardiovascular: Postural hypotension (pregnancy and elderly), arrhythmias, and aortic stenosis
Endocrine/metabolic: Hypoglycemia, hypernatremia, and Addison's disease
Neurological: Vertebrobasilar insufficiency, migraine, MS, and epilepsy
Space-occupying lesion: Acoustic neuroma and CNS tumors
Trauma: Head injury, surgical
Other: Systemic disease, carbon monoxide poisoning122
Classification of Vertigo
Classification | Examples | Investigations |
|---|---|---|
Physiologic vertigo | Sea sickness, travel by boat, car, or spaceship | |
Peripheral vertigo (peripheral lesion, i.e., ear labyrinth or eighth nerve) | Benign paroxysmal positional vertigo BPPV, acute labyrinthitis, vestibular neuronitis, Ménière's disease, and wax in ears Patients may have nausea, vomiting, tinnitus or deafness, and unidirectional nystagmus There are no other neurological signs | ENT check-up Dix-Hallpike maneuver (for BPPV) |
Central vertigo (central lesion, i.e., brainstem or cerebellum) | Hemorrhage, ischemia, demyelination, and neoplasm Patients may have associated central nervous abnormalities such as diplopia, hiccups, cranial neuropathies, and dysarthria | MRI brain Doppler study of carotids |
Medications | Antibiotics, aminoglycosides, macrolides, diuretics antihypertensive drugs, mucolytics, anti-inflammatory, antidepressants, cholesterol lowering drugs, antifungals, antimalarials, heavy metals, antipsychotics and antiparkinsonism drugs—bad boy | Check patient's drug(s) |
Substance abuse | History of alcohol |
Differences between Peripheral Vertigo and Central Vertigo
Peripheral vertigo | Central vertigo | |
|---|---|---|
Start | Sudden | Insidious |
Timing | Paroxysmal | Continuous |
Intensity | Initially maximum | Mild |
Duration | Minutes or hours | Days or weeks |
Vertical nystagmus | Absent | Commonly present |
Moments can precipitate | Yes | No |
Tinnitus and deafness | Common | Not present |
Symptoms and other findings to help diagnosis | Possible causes |
Episodes of vertigo lasting around 1 minute that are brought on by rapid head movement in a nonaxial plane | Benign positional vertigo |
Episodes of vertigo lasting for hours, fluctuating and progressive sensorineural hearing loss and tinnitus | Ménière's disease |
Acute onset of vertigo that lasts days to weeks, nausea, and vomiting, without hearing loss | Vestibular neuronitis |
Vertigo episodes lasting for minutes to hours with no significant auditory symptoms; personal or strong family history of migraine | Vestibular migraine |
Vertigo and hearing loss following bacterial or viral infection | Labyrinthitis |
Vertigo accompanied by diplopia, dysarthria, dysphagia, drop attacks, paresthesia, and loss of motor function | Brainstem ischemia Infarction Sclerosis |
Vertigo and dysdiadochokinesia | Cerebellar stroke |
Hearing loss and vertigo following injury to the ear for barotraumas (such as from recent air travel or diving) | Perilymph fistula |
Treatment (Choices Include)
STUGERON (cinnarizine) 25–50 mg tds or
VERTIN (betahistine) 8–16 mg tds or 32 mg od or acuvert 5 mg od for 3 days
STEMETIL (prochlorperazine) 5–10 mg tds or
STUGERON or STEMETIL + VERTIN for 1 week ± NEUROBION FORTE for 3 weeks
Reduce salt intake in Ménière's disease (can also use hydrochlorothiazide).
Key Points
Presyncope in older adults is from dysautonomia associated with antihypertensive or antiarrhythmic therapy. Lying and standing BP measurement (with a postural drop of 20 mm Hg systolic and/or 10 mm Hg diastolic) may confirm orthostatic hypotension; however, lack of this finding should not rule out the diagnosis if patient's history is highly suggestive.123
Vague sensations of lightheadedness and imbalance are associated with panic, phobic and chronic anxiety disorders. Full neurologic history and physical examination are warranted to rule out organic disease.
Diagnosis of benign positional vertigo can be confirmed by Dix-Hallpike (or Barany) maneuver. This consists of moving patient from a sitting to supine position with head turned and hanging over the head of bed or table, so that affected ear faces the floor. Elicitation of vertigo and nystagmus with patient in this position confirms diagnosis.
Episodes of vertigo which last for hours, accompanied by fluctuating and progressive sensorineural hearing loss and tinnitus, strongly suggest Ménière's disease. Vertigo that lasts for hours, but is not associated with significant auditory symptoms is usually migrainous in origin.
Vestibular neuronitis is characterized by an acute onset of vertigo associated with nausea and vomiting, but there are no symptoms of auditory or CNS dysfunction.
Note for Readers:
1.55 WEAKNESS (REFER CHAPTER 1.19)
1.56 WEIGHT LOSS (REFER CHAPTER 1.2)
