Protocols@Internal Medicine@2018-2019

PAHS Internal Medicine Guidelines 2018-2019
GUIDELINES FOR SOME COMMON DISEASES
DEPARTMENT
of
INTERNAL MEDICINE
Prepared by Residents of PAHS (Batch 2017 and 2018)

Under the guidance of faculties
Compiled by
Dr Mukesh Kumar Sah
2019
This compilation is made for students of PAHS for academic purpose only.
Table of Content
Disease Page No.

1. Fever……………………………………………………………………………………………………………………………1
2. COPD……………………………………………………………………………………………………………………………6
3. Stroke………………………………………………………………………………………………………………………..10
4. Intravenous thombolysis in acute ischemic stroke…………………………………. ………………….13
5. Chronic Liver Disease ………………………………………………………………………………………………….24
6. Diabetes Mellitus………………………………………………………………………………………………………..30
7. Community-Acquired Pneumonia,…………… …………………………………………………………………37
8. Acute Pancreatitis…………………………………………………………………………………………………….. 39
9. Hypertension ……………………………………………………………………………………………………………..42
10. Seizures ……………………………………………………………………………………………………………………47
FEVER
st
(RR – Dec 2018 – 1 ed.)
Fever is demonstrable rise in temperature > 99.9 F

Acute : fever < 3weeks Chronic : fever> 3 weeks
.Localising
Symptoms localising to a particular system
.Undifferentiated
1.ACUTE FEVER
History: Onset
Duration
Associated features
Travel history
Drug history
Contact history
Time of years: summer , rainy or winter
i. Differentiated Fever
Clinical features localising to organ system:
Respiratory Upper: Running nose ,dry cough , sore throat
Lower: Productive cough, chest pain,
Dyspnea
CNS Headache, seizure, neck stiffness
Urinary Dysuria , burning micturition, hematuria
GIT Abdominal pain, diarrhea
Skin Abscess, furuncles, rash
Clinical features suggesting severity

SIRS qSOFA
Heart rate>90 Altered sensorium
TLC >11,00 or <4000 Hypotension: SBP<100mm of hg
RR> 20 Tachypnea :RR>= 22
temperature> 38 or <36
>=2 out of 4 criteria is SIRS >=2 criteria
Admit in ICU
Admit the patient
Physical examination
Pallor , icterus, lymphadenopathy, dehydration
Skin lesions
GIT: abdominal tenderness, renal angle tenderness, palpable spleen and liver
Nervous system: Neck rigidity
Respiratory: abnormal sounds on lung auscultation
Initial investigations
CBC
Blood C/S (before initiating antibiotics): 10 cc of blood should be drawn
Guidelines in this compilation is prepared by residents of the Department of Internal Medicine, PAHS
Compiled by Dr. Mukesh Kumar Sah, Resident-2018 batch, GP and EM Page 1
Urine RME
Urine C/S (if pus cells significant or bacteria seen)
Chest x-ray
Lumber puncture if headache and vomiting with or without meningism
Initiate management
Antipyretics ( paracetamol ) if T> 101 deg F
Hydration ( oral fluids preferred/ IV fluids if vomiting)
Manage specific syndrome:

URTI
Pneumonia
Upper and lower UTI
Meningoencephalitis
Acute GI infection
Skin soft tissue infection
Empiric Treatment of pharyngitis

• Centor Criteria (presence of each clinical feature scores 1 point)
a.History of fever
b. Tender anterior cervical lymphadenopathy
c. Absence of cough
d. Tonsillar exudate
>=3 treat for Group A Streptococcus
Treat with amoxicillin 500mg PO TDS for 7 days
For management of Pneumonia

Severity Assessment / Site
CRB-65 in OPD settings, CURB-65 in ward
(Confusion, (Urea>40mg%), Respiratory rate > 30/min, Blood pressure < 90/60, Age >65)
CRB-65:
0-1: Home Treatment
2: Admission in hospital (in ward)
3-4: Manage as severe, requires ICU
CURB-65:
0-1: home treatment
[The patient’s social situation should also be considered in disposition.]
Antibiotic as per PAHS CAP protocol
Antibiotic indication in COPD

If any one of these-
1. Fever
2. Sputum purulence
3. CXR showing infiltrates
4. CRP >40
5. Need of mechanical ventilation
Choice-
a. Oral: Co-amoxiclav/ azithromycin/ doxycycline
or
b. Intravenous: Ceftriaxone
‘If proven pneumonia use ceftriaxone and azithromycin
Antibiotics in urinary tract infections
Uncomplicated Complicated
(Male, Diabetic, Sepsis,
Urologic abnormalities,
vomiting)
UPPER Tab. Cefixime 400mg PO BD Inj Amikacin ( according to
or weight and creatinine
Tab. Cotrimoxazole DS 1 tab clearance)
PO BD
LOWER Tab. Nitrofurantoin SR 100mg
PO BD or
Tab. Cotrimoxazole DS 1 tab
PO BD
Pregnant: Tab. Nitrofurantoin 100mg po BD
Fever with jaundice
Viral Hepatitis
Sepsis
Typhus
Leptospirosis
Drug induced
Malaria
Cholangitis
Pneumonia
ii. Acute Undifferentiated Fever

Duration >3 days
Symptoms not localising to any system
Reassess severity criteria
Reassess for localising features
Likely differential diagnosis
Disease Etiology Clinical features
Acute Viremia Arbovirus, paramyxovirus, High grade fever, myalgia, flu
enteroviral infections like symptoms with normal
blood picture
Enteric fever Salmonella sps. Fever, constipation or
diarrhoea , splenomegaly,
relative bradycardia,
leucopenia.
Leptospirosis leptospira Fever, myalgia, jaundice, AKI
Typhus Murine Fever, jaundice, cough,
scrub eschar (rare, pathognomic)
Dengue Dengue virus Fever, flu like symptoms with
or without hemorrhagic
features
Malaria P. Vivax , P. Falciparum Fever with chills and rigor,
jaundice, cerebral malaria
Investigate with
Blood C/S : 10 ml of Blood, 2 blood cultures from separate venipuncture sites
Serology for scrub typhus, brucella and leptospira
NS-1 antigen and IgM antibody for dengue
RDT for malaria and microscopy
Empiric therapy
Initiate empiric antibiotic therapy while waiting for result:
Tab. Azithromycin 1gm po OD / third generation Cephalosporins
Lack of response to Cephalosporins (for 5 days or earlier depending on the condition of the
patient) or fever + multisystem disease like thrombocytopenia, jaundice, AKI, meningitis : Add
Doxycycline 100mg po BD
Positive blood cultures: Diagnose and manage accordingly
Negative blood cultures: Abdominal imaging, repeat Chest xray
2. Approach to chronic fever
If fever > 3 weeks ,and all initial investigations negative then think of:
Tuberculosis
Malignacies
Bacterial endocarditis
Connective tissue disease
Drugs
Brucellosis
Kala azar
HIV
Adult onset still's disease
Investigations
ESR or CRP
Serum LDH
Tuberculin test
HIV immunoassay
Three routine Blood cultures
Rheumatoid factor
ANA
Lumber puncture
Biopsies
Exclude manipulation with thermometer

Stop or replace medication to exclude drug fever
Repeat Detailed history and examination by Senior Doctor: localising features present then
guided diagnostic tests
Consult second senior doctor

Fresh history and physical examination
Bone marrow biopsy if CBC abnormal
If no diagnosis: chest and abdominal CT
temporal artery biopsy(>55 y)
Serum ferritin level: for Adult stills disease

If no diagnosis and
Stable condition: follow up , consider NSAIDs, could also consider Trial of antibiotics, then trial
of ATT
Deteriorates: further diagnostic tests
References
Infectious disease control guideline , Epidemiology and Disease control division, Nepal 2016
Uptodate
Micro data of patan hospital 2073
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

(COPD)
(SA – Jan2018 – 1st ed.)
Stable COPD
1. Diagnostic Approach
When to suspect?
Individual > 40 yrs with history of persistence of following symptoms and signs- chronic cough,
sputum, dyspnea and/or wheezing, in those with previous prolonged exposure to risk factors.
How to diagnose?
a. All suspected COPD patients must have spirometry done at least once
b. Spirometry to be done 15 minutes after bronchodilation with 4 puffs inhalation of salbutamol
c. Post-bronchodilator FEV1/ FVC < 0.7 confirms COPD
2. Severity assessment
3. Diagnostic Testing (Routine, OPD)

a. Chest Xray
b. CBC
c. ECG
d. Echocardiogram if ECG and chest Xray suggestive of cor pulmonale
e. Sputum C/S if purulent sputum or baseline FEV1< 50%
4. Treatment (OPD)
a. Medications
SABA- Short acting beta agonist e.g. salbutamol

SAMA- short acting muscarinic agonist e.g. ipratropium
LABA- Long acting beta agonist e.g. salmeterol, formeterol
LAMA- Long acting muscarinic agonist e.g. tiotropium
ICS- inhaled corticosteroid e.g. beclomethasone, fluticasone,
budesonide
Delivery device
∗ MDI with spacer
∗ DPI
Preference to MDI with spacer as it can effectively be used by all
population group.
b. Use of domiciliary O2
i. Day time resting SpO2 < 88%
ii. OR Those with cor pulmonale/ Hct > 55%
iii. Target SpO2 88- 92%
iv. Use of O2 > 15 hrs/day (at least during sleep, in morning and evening)
v. Cessation of smoking during O2 use
c. Smoking cessation
i. Ask about tobacco use
ii. Assess the status and severity of use
iii. Advise to stop
d. Other OPD treatment

i. Consider montelukast only in those with ACOS, uncontrolled wheeze or family history
of asthma.
ii. Give daily calcium (500 mg) and vitamin D (250 IU)supplementation to all males > 60
years and female > 50 years.
iii. Encourage daily exercise.
iv. Assure adequate calorie/protein intake.
v. Evaluate for depression if suspected.
e. Prevention
i. Pneumococcal and influenza vaccination for all patients.
ii. Give antibiotic course (azithromycin) for one week to use at home on PRN basis (in case
of purulent sputum).
Acute Exacerbation COPD
1. Definition
a. Acute worsening of respiratory symptoms (mMRC grade) in a case of COPD, resulting in
additional therapy.
b. Rule out conditions like ACS, CCF, PE and pneumonia.
2. Investigations
a. CBC, CRP, RFT
b. Chest X-Ray
c. ABG
d. Sputum AFB,G/S, C/S
e. ECG
f. Echocardiogram if features of cor pulmonale
3. Severity assessment / Admission Site
Acute deterioration in mental status + ICU – invasive ventilation
Require > 4 liter/min O2 +
pH < 7.25 and pCO2 > 60
Preserved mental status + ICU – Non-invasive ventilation
Require > 4 liter/min O2 + (BIPAP)
pH < 7.25 and pCO2 > 60
Respiratory distress + Admit to Ward
pH > 7.25 and pCO2 < 60
No respiratory distress + Observe overnight in ER
pH > 7.25 and pCO2 < 60
4. Treatment (Inpatient)
a. Oxygen
i. Supplemental O2 via nasal prong to maintain SpO2 between 88-92%
ii. NIV should be preferred mode of ventilation in case of acute respiratory failure
b. Bronchodilators
i. SABA with SAMA via nebulizer 4-6 hourly as required
ii. Maintenance with LAMA with/out LABA once patient becomes stable
iii. ICS not recommended during exacerbation.
c. Systemic Corticosteroids
i. Prednisolone 40 mg OD for not more than 5-7 days
ii. Intravenous only if unable to take oral
d. Antibiotics
Single antibiotic indications-
If any one of these-
1. Fever
2. Sputum purulence
3. CXR showing infiltrates
4. CRP >40
5. Need of mechanical ventilation
ii. Choice-
a. Oral: Co-amoxiclav/ azithromycin/ doxycycline
or
b. Intravenous: Ceftriaxone
If proven pneumonia: use pneumonia protocol for antibiotics
iii. Duration- 5-7 days for both indications
e. VTE prophylaxis with SC heparin or LMW heparin
f. Consider pneumococcal and influenza vaccination
5. Discharge Advice
a. Emphasize on smoking cessation
b. Assess inhaler technique
c. Assess need for O2 (needed if cor pulmonale/ Hct > 55% or room air SpO2 < 85%)
d. Grade the severity of COPD at discharge and give maintenance treatment accordingly
i. Moderate- LAMA plus LABA inhalation
ii. Severe- LAMA plus LABA plus ICS
iii. In case of pneumonia during exacerbation, ICS use should be de-escalated
e. Ensure early follow up within 1 - 4 weeks.
6. Follow up
a. Emphasize on smoking cessation
b. Reassess inhaler technique
c. Reassess need for long term O2 (as per stable COPD)
d. Document capacity to do daily activities
e. Grade the severity
f. Also measure spirometry in subsequent followup at 12-16 weeks if this has not been done
previously
References
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for
Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org
Gupta D, Agarwal R, Aggarwal AN, Maturu V N, Dhooria S, Prasad K T, Sehgal IS, Yenge LB,
Jindal A, Singh N, Ghoshal A G, Khilnani G C, Samaria J K, Gaur S N, Behera D, S. K. Jindal
for the COPD Guidelines Working Group. Guidelines for diagnosis and management of chronic
obstructive pulmonary disease: Joint ICS/NCCP (I) recommendations. Lung India [serial online]
2013 [cited 2018 Feb 18];30:228-67. Available from:
http://www.lungindia.com/text.asp?2013/30/3/228/116248
st
STROKE
(AG – Feb2018 – 1 ed.)
These guidelines outline the acute management and secondary prevention protocol for patients
presenting with acute ischemic stroke (cerebrovascular accident). This excludes patient stroke
syndromes due to hemorrhage, tumor, or trauma, and does not include intravenous thrombolytic
therapy or thrombectomy.
1. Emergency Evaluation
 NCCT SCAN head for all the suspected patients within 30 mins of arrival
 Other diagnostic evaluations:
 Blood glucose
 CBC
 Creatinine, sodium, potassium
 ECG
 PT/ INR
 Cardiac troponins (only if clinically indicated)
 Chest X-ray (if evidence of acute pulmonary, cardiac, or pulmonary vascular disease)
 Routine scoring by NIH Stroke Scale is not indicated.
2. General Supportive Care and Emergency Treatment

a. Oxygenation:
 Decreased consciousness or bulbar dysfunction compromising airway  Mechanical airway
support and ventilatory assistance.
 Target oxygen saturation >94% (No supplementary oxygen if < 94%)
b. Blood pressure
 Close BP monitoring for first 48 hours
 If BP≥ 220/120 Target to lower BP by 15% in first 24 hours
 If BP< 220/120 No antihypertensive needed for first 48-72hrs
 Antihypertensive to be started after 72 hours (earlier in comorbid condition)
 Stop pre-existing anti-hypertensives for 24 hours
 IV resuscitation if BP is low
c. Temperature
 Antipyretics medications if hyperthermia (temp>100.4F)
 Identification of source of hyperthermia and treatment
 No benefit of induced hypothermia
d. Blood Glucose
 Close blood glucose monitoring for 24 hours
 Target blood glucose levels: 140 - 180 mg/dL; treatment with IV insulin
 Hypoglycemia (blood glucose <60 mg/dL) should be treated
e. Antiplatelet therapy
 Aspirin (300mg )as soon as possible once brain imaging has excluded hemorrhage
 In TIA and minor stroke (ABCD ≥ 4), aspirin (300 mg) and clopidogrel (300 mg) for 21 days
begun within 24 hours and then clopidogrel (75mg) for a period of up to 90 days
f. Anticoagulant therapy
• Anticoagulant therapy is not indicated, except in suspected cardiac embolic CVA
g. Dysphagia Screening
• An abnormal gag reflex, impaired voluntary cough, dysphonia, or cranial nerve palsies are all
important risk indicators.
• 3-ounce water swallow test
• Can feed if no risk indicators and negative water swallow test (begin with semi-solid diet)
h. Nutrition
 NG tube feeding for those with risk factors or who fail 3-ounce swallow test
i. Other
• No routine use of prophylactic antibiotics and urinary catheterization
• No routine use of corticosteroids
• Minimization of skin friction and skin pressure
• Avoidance of excessive moistures
• Regular turning of patients
• Good skin hygiene
3. Management of Complications
a. Brain edema
• Elevation of the head end of the bed to 30°
• Hyperventilation (pCO2 target 30-34mmHg)
• IV mannitol (0.25 to 0.5 g/kg) and/or glycerol or 3% normal saline
• IV frusemide 40 mg
• Avoidance of hyperglycemia
• Minimization of hypoxemia and hypercarbia
• Treatment of hyperthermia
• Avoidance of antihypertensives, particularly those that induce cerebral vasodilatation
• Avoidance of corticosteroids
b. Seizures
• Recurrent seizures after stroke should be treated in a manner similar to when they occur with
other acute neurological conditions
• Prophylactic use of anti-seizure drugs to be avoided
4. Secondary prevention
a. Screening risk factors (within one week of admission):
• BP monitoring
• Fasting and PP glucose, HbA1C
• Lipid profile
• Carotid Doppler
• Echocardiography
(Secondary Prevention – Cont’d.)
b. Antithrombotic therapy
• Aspirin(75mg) to all patients with ischaemic stroke or TIA not on anticoagulation therapy
• In the setting of atrial fibrillation or proven intramural thrombus, oral anticoagulation(warfarin)
within 4 to 14 days after the onset of neurological symptoms
• Dual therapy(antiplatelet and anticoagulant) in unstable angina and coronary artery stenting
c. Statins
• If age ≤ 75 years - Atorvastatin 40daily; age > 75years - Atrovastatin 20mg daily
• To commence immediately on admission
d. Rehabilitation
• Commence mobilization (out of bed activity) within 48 hrs of stroke onset
• Order inpatient physiotherapy
e. DVT prophylaxis
• Heparin 5000 Units s.c. B.D.
• Elastic compression stockings should be avoided
f. Smoking cessation
• Active as well as passive smoking to be avoided
REFERENCES
• 2018 guidelines for the early management of patients with acute Ischemic stroke (America
Heart Assosciation/ American Stroke Assosciation)
• ISA (Indian Stroke Assosciation): Consensus Statement 2015 Recommendations for the
Early Management of Acute Ischemic Stroke
INTRAVENOUS THROMBOLYSIS IN
ACUTE ISCHEMIC STROKE
(AT – May2018 – 1sted.)
These guidelines outline the proposed treatment protocol for intravenous thrombolytic therapy in
acute ischemic stroke in Patan Hospital. Summary statements of drug usage are followed by
working protocols for clinicians in the emergency room, medical on-call, and ICU, then by
troubleshooting protocols and an appendix with a scoring tool.
1. Drug Adminstration
a. Drug Dosage
b. Indications
c. Contraindications and Adjustments
d. Treatment in ICU
2. Entry Algorithms and Checklists
Treatment Goals
a. First Step: ER Triage Team
b. Second Step: ER Doctor
c. Third Step: Medicine On-Call
3. Troubleshooting
a. BP Lowering Agents
b. Intracerebral hemorrhage
c. Orolingual angioedema
4. Addendum
a. NIHSS Scoring Sheet
1. DRUG ADMINISTRATION
1.1 Drug Dosage: IV Alteplase
 Tissue Plasminogen Activator (tPA)
 Doage:IV 0.9 mg/kg, maximum dose 90 mg over 60 min with initial 10% of dose given as
bolus over 1 min.
 Place of administration: Intensive care unit
1.2 Indications
 Clinical diagnosis of ischaemic stroke causing measurable neurologic deficit
 Onset of symptoms <3 hrs before beginning treatment
 Age ≥18 years.
1.3 Contraindications
Absolute:
 Non-contrast CT (NCCT) Head: evidence of hemorrhage.
 NCCT Head: extensive regions of hypodensity consistent with irreversible injury.
 Ischemic stroke or severe head trauma in previous 3 months.
 Previous intracerebral hemorrhage.
 Gastrointestinal malignancy or hemorrhage in previous 21 days.
 Intracranial or intraspinal surgery within prior 3 months.
 Intra-axial or intracranial neoplasm.
 Symptoms suggestive of subarachnoid hemorrhage.
 Persistent BP (- Systolic ≥185 or - diastolic ≥110).
 Active internal bleeding.
 Presentation consistent with infective endocarditis.
 Stroke known or suspected to be associated with aortic arch dissection.
 Therapeutic doses of low molecular weight heparin received within 24 hours.
 Current use of a direct thrombin inhibitor or direct factor Xa
inhibitor(Bivalrudin,Dabigatran,Argatroban, Apixaban, Rivaroxaban).
Relative:
 Minor and isolated neurologic signs or rapidly improving signs.
 Serum glucose< 50 mg/dl.
 Serious trauma in previous 14 days.
 Major surgery in previous 14 days.
 History of gastrointestinal bleeding (remote) or genitourinary bleeding.
 Seizure at the onset of stroke with postictal neurological impairment.
 Pregnancy.
 Arterial puncture at non-compressible sites in previous seven days.
 Untreated intracranial vascular malformation.
(See possible adjustment to contraindications below)
Adjustments in Setting of Possible Contraindications

 BP: IV alteplase is recommended in patients whose BP can be lowered safely (to <185/110)
with antihypertensive agents, with the physician assessing the stability of the BP before
starting IV alteplase.
 Blood glucose: IV alteplase is recommended in otherwise eligible patients with initial glucose
levels >50 mg/dl
 Mild to moderate ischemic changes: IV alteplase administration is recommended in the
setting of early, mild to moderate ischemic changes on NCCT
 Antiplatelet drugs: IV alteplase is recommended for patients taking antiplatelet drug
monotherapy or combined aspirin/clopidogrelbefore this acute stroke.
1.4 Treatment in ICU

 Admit patient in intensive care unit.
 Administer Altplase IV 0.9 mg/kg, maximum dose 90 mg over 60 min with initial 10% of dose
given as bolus over 1 min.
 If the patient develops severe headache, acute hypertension, nausea, or vomiting or has a
worsening neurological examination, discontinue the infusion (if IV alteplase is being
administered) and obtain emergency head CT scan.
 Measure BP and perform neurological assessments every 15 min during and after IV
alteplase infusion for 2 h, then every 30 min for 6 h, then hourly until 24 h after IV alteplase
treatment.
 Increase the frequency of BP measurements if systolic BP is >180 or if diastolic BP is >105;
administer antihypertensive medications to maintain BP at or below these levels .
 Obtain a follow-up CT scan at 24 h after IV alteplase before starting anticoagulants or
antiplatelet agents.
2. ENTRY ALGORITHMS AND CHECKLISTS

Treatment Goals
 Door to ER medical officer ≤ 10 minutes.
 Door to CT initiation ≤ 25 minutes.
 Door to CT interpretation ≤ 45 minutes.
 Door to needle time of ≤ 60 minutes.
 Medicine doctor on duty will attend the patient as soon as possible.
 ICU team will free up ICU bed (if possible) as soon as possible.
2.1 First step: ER Triage Team

 Place : Triage Station ER
 Person: Triage Nurse
 Job: If patient suspected to have stroke arrives within 6 hours of onset of symptoms, then
the nurse immediately (in person) informs Emergency Medical Officer
TRIAGE TEAM Checklist

Look for following symptoms and signs
DURATION OF ONSET OF SYMPTOMS : ____ hours.
IF ANY OF THE SYMPTOMS/SIGNS ARE PRESENT

AND DURATION IS LESS THAN 6 HOURS CALL EMERGENCY MEDICAL OFFICER ASAP.
2.2 Second step: ER Doctor

 Place: Emergency Room
 Person: Emergency Medical Officer
 Job:
2.2.1 Look for following symptoms: (Any)
SN Symptoms Yes No
1 Sudden weakness/numbness of face, arms and legs.
2 Sudden confusion, trouble speaking or understanding language
3 Sudden deteriotration of Vision
4 Sudden trouble walking, co-ordination, loss of balance, dizziness
2.2.2 Look for following signs: (Any)
For speech impairment:

-Look for NEW disturbance in speech. (confirm with companion)
-Look for slurring of speech.
-Look for word finding difficulties.
For Facial palsy:
-Ask the patient to smile or show the teeth.
For arm weakness:
-Ask the patient to raise both hand at 90 while sitting and 45 while supine and hold it for 5
seconds. Look for any drift.
Time of onset of symtoms: _____ hrs. If less than 3 hours, call medicine on call, since the
patient may be eligible for thrombolysis.
2.2.3 Measure Blood Sugar and treat accordingly.
2.2.4 Record Blood pressure and treat accordingly.

If Blood pressure is >185/110 mm of HG,
Administer InjLabetelol 10-20 mg intravenously over 1-2 minutes. Can repeat one time.
2.2.5 Call medicine on call.
2.2.6 Take the patient NCCT scan of head as soon as possible.
2.3 Third Step: Medicine on Call Doctor

Job:
2.3.1 Checks ICU for availability of bed and ventilator facility.
2.3.2 Informs senior (consultant on duty) about the case.
2.3.3 Grabs the checklist and attends the patient.
2.3.4 Takes a brief history about symptoms and duration of onset, examines the patient
according to NIHSS scale, checks for inclusion and exclusion and looks at the CT
SCAN.
2.3.5 If patient eligible, counsels the patient’s family, takes written consent, shifts the patient to
ICU and starts IV alteplase. The on call doctor needs to specifically counsel about the
risk and benefits of thrombolysis and the cost of alteplase.
MEDICINE ON CALL(Overall Checklist)

YES NO
1 Check for the documents
a.NIHSS
a. check list (Appendix 4.1)
b.Inclusion/Contraindications check lists
c.Consent form (Appendix 4.2)
2 Check for ICU bed availability
3 Inform Medicine 2nd ON CALL
4 Presence of hemorrhage in CT-SCAN
(Detail Checklists)
Inclusion criteria (All)
Yes No
1 Clinical diagnosis of ischaemic stroke causing measurable neurologic
deficit
2 Onset of symptoms <3 hrs before beginning treatment
3 Age ≥18 years.
Contraindications (Any)
Yes No
1. Head CT Scan
a. Evidence of hemorrhage
b. Extensive regions of obvious hypodensity consistent with
irreversible injury
2. HISTORY
a. ischemic stroke or severe head trauma in previous 3 months
b. Previous ICH
c. Gastrointestinal malignancy or hemorrhage in previous 21 days
d. Intracranial or intraspinal surgery within prior 3 months
e. Intra-axial intracranial neoplasm
3. CLINICAL
a. Symptoms suggestive of SAH
b. persistent BP (Systolic ≥185 mm of Hg or diastolic ≥110 mm of hg)
c. Active internal bleeding
d. Presentation consistent with infective endocarditis
e. Stroke known or suspected to be associated with aortic arch
dissection.
4. HEMATOLOGICAL
a. Therapeutic doses of low molecular weight heparin received
within 24 hours.
b. Current use of a direct thrombin inhibitor or direct factor Xa
inhibitor (Bivalrudin,Dabigatran,Argatroban, Apixaban, Rivaroxaban)
NOTE: SEND PLATELET COUNT AND PT/INR BEFORE STARTING ALTEPLASE BUT
DONOT WAIT FOR THE RESULT. IF PLATELET COUNT IS <100000/MM3 AND PT IS >15
SECONDS STOP ALTEPLASE.
Relative contraindications: (Any)
S NO YES NO
1 Minor and isolated neurologic signs or rapidly improving.
2 Serum glucose< 50 mg/dl
3 Serious trauma in previous 14 days.
4 Major surgery in previous 14 days.
5 History of gastrointestinal bleeding (remote) or genitourinary
bleeding.
6 Seizure at the onset of stroke with postictal neurological
impairment.
7 Pregnancy
8 Arterial puncture at non-compressible sites in previous seven days.
9 Untreated intracranial vascular malformation.
3. TROUBLE-SHOOTING
3.1Treatment of hypertension before and during reperfusion therapy:
3.1.1 Patient otherwise eligible for acute reperfusion therapy except that BP is >185/110:
 Labetalol 10–20 mg IV over 1–2 min, may repeat 1 time; OR
 Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5–15 min, maximum 15 mg/h; when
desired BP reached, adjust to maintain proper BP limits; OR
 Clevidipine 1–2 mg/h IV, titrate by doubling the dose every 2–5 min until desired BP
reached; maximum 21 mg/h
 Other agents (eg, hydralazine, enalaprilat) may also be considered If BP is not
maintained ≤185/110 mm Hg, do not administer alteplase
3.1.2 Management of BP during and after alteplase or other acute reperfusion therapy to
maintain BP ≤180/105:
 Monitor BP every 15 min for 2 h from the start of alteplase therapy, then every 30 min
for 6 h, and then every hour for 16 h
3.1.3 If systolic BP >180–230 or diastolic BP >105–120:

 Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min; OR
 Nicardipine5 mg/h IV, titrate up to desired effect by 2.5 mg/h every 5–15 min, maximum
15 mg/h; OR
 Clevidipine 1–2 mg/h IV, titrate by doubling the dose every 2–5 min until desired BP
reached; maximum 21 mg/h
 If BP not controlled or diastolic BP >140 , consider IV sodium nitroprusside
3.2 Management of Symptomatic Intracranial Bleeding Occurring Within 24 Hours After

Administration of IV Alteplase
 Stop Alteplase
 infusion CBC, PT (INR), aPTT, fibrinogen level, and type and cross-match
 Emergent nonenhanced head CT
 Cryoprecipitate (includes factor VIII): 10 U infused over 10–30 min (onset in 1 h, peaks
in 12 h); administer additional dose for fibrinogen level of <200 mg/dL
 Tranexamic acid 1000 mg IV infused over 10 min OR ε-aminocaproic acid 4–5 g over 1
h, followed by 1 g IV until bleeding is controlled (peak onset in 3 h)
 Hematology and neurosurgery consultations
 Supportive therapy, including BP management, ICP, CPP, MAP, temperature, and
glucose control
3.3 Management of Orolingual Angioedema Associated With IV Alteplase

 Maintain airway
 Endotracheal intubation may not be necessary if edema is limited to anterior
tongue and lips.
 Edema involving larynx, palate, floor of mouth, or oropharynx with rapid
progression (within 30 min) poses higher risk of requiring intubation
 Discontinue IV alteplase infusion and hold ACEIs
 Administer IV methylprednisolone 125 mg
 Administer IV diphenhydramine 50 mg
 Administer ranitidine 50 mg IV or famotidine 20 mg IV
 If there is further increase in angioedema, administer epinephrine (0.1%) 0.3 mL

subcutaneously or by nebulizer 0.5 mL
 Supportive therapy
4. APPENDICES
4.1 NIHSS CHECKLIST

Before 1 24
hr hr
1 Level of consciousness 0=Alert
1=not alert but arousable with minimal
stimulation
2=Not alert,requires repeated stimulation to
attend
3=responds only with reflex motor or
autonomic effects, totally unresponsive,
flaccid.
2 LOC questions: Month and 0=answers both correctly
own age 1=answers one correctly
2= both incorrect
3 LOC command: opens and 0=obeys both command
closes eyes, grips and 1= obeys 1 correctly
releases non paralytic hand 2=both incorrect
4 Best gaze (only horizontal 0= Normal
eye movement) 1=partial gaze palsy
2=forced deviation
5 Visual field 0= No visual loss
1=partial hemianopia
2=complete hemianopia
3=B/L hemianopia(blind, including cortical
blind)
6 Facial paresis (Ask the 0= Normal symmetrical movement
patient to show teeth, raise 1=Minor paralysis(flattened nasolabial
eyebrows and close eye) fold,asymmetry on smiling)
2=Partial paralysis (total or near total
paralysis of lower face)
3=complete paralysis of one or both face)
7 Motor function of right arm 0=No drift

1=Drift
2=Some effort against gravity
3=no effort against gravity
4=No movement
0=untestable (amputation or joint fusion at
the shoulder)
8 Motor function of left arm 0=No drift
1=Drift
4=No movement
the shoulder)
Before 1 24
hr hrs
9 Motor function of right leg 0=No drift
1=Drift
4=No movement
the shoulder)
10 Motor function of left leg 0=No drift
1=Drift
4=No movement
the shoulder)
11 Limb Ataxia 0=Absent
1=Present in one limb
2=present in two limb
0=Untestable (amputation or joint fusion)
12 Sensory to pinprick or 0= Normal
withdrawal from noxious 1=Mild-moderate sensory loss
stimulus 2=Severe to total sensory loss
13 Language 0=No aphasia
1=mild-moderate aphasia
2=Severe aphasia
3=Mute, global aphasia
14 Dysarthria 0=None
1=mild-moderate dysarthria
2=Severe dysarthria
0=intubated or other physical barrier to
producing speech
15 Extinction and inattention 0=No abnormality
1=Inattention or extinction to bilateral
simultaneous stimulation in one of the
sensory modalities
2=profound inattention or extinction to more
than one modality
TOTAL SCORE
CHRONIC LIVER DISEASE

st
(SA – Jul2018 – 1 ed.)
These guidelines outline the acute management for patients presenting with any of the manifestations
of decompensated chronic liver disease (CLD). This excludes management of specific causes of chronic
liver disease (such as alcohol and viruses).
1. Initial Evaluation
● History
● Physical examination
● Abdominal ultrasound
● Laboratory assessment
○ CBC with PT/INR
○ LFT including protein and albumin
○ Urea, Creatinine
○ Serum Na, K
2. Ascites
● Ascites severity criteria:
○ Mild: only detectable by ultrasound examination
○ Moderate: moderate symmetrical distension of abdomen
○ Gross: marked abdominal distension
● Diagnostic paracentesis is indicated in:
○ All patients with new-onset moderate to gross ascites.
○ Patients hospitalized for worsening ascites or any complication of cirrhosis.
● Ascitic fluid analysis
○ Serum-ascites albumin gradient (SAAG) [>1.1 portal HTN;<1.1 non-portal cause]
○ Neutrophil count [ >250/mm3 Spontaneous bacterial peritonitis - treatment]
○ Protein [<1gm% SBP - prophylaxis]
○ Culture
● Treatment
○ Mild ascites:
 Moderate restriction of sodium intake which is no-added-salt diet with
avoidance of pre-prepared meals.
○ Moderate ascites:
 Salt restriction
 Diuretics
 Start with oral spironolactone 100 mg OD and furosemide 40 mg OD (no
IV furosemide)
 If no adequate response in 5 days, increase by 100 and 40 mg
respectively
 Maximum doses - 400 and 160 mg respectively
 Start with spironolactone monotherapy if hypokalemia is present, add
furosemide once it normalizes, goal K- 3.4 – 5.0 mEq/l
 GI hemorrhage, renal impairment, hepatic encephalopathy,
hyponatremia, or alterations in serum potassium concentration, should
be corrected before starting diuretic therapy

 Recommended maximum weight loss: 0.5 kg/day in patients without
edema, 1 kg/day in patients with edema
 Once ascites has mostly resolved, the dose of diuretics should be
reduced to the lowest effective dose
○ Gross ascites:
 Salt restriction
 Diuretics as above plus large volume paracentesis (LVP)
 > 5 liters with albumin infusion required
 < 5 liters with albumin infusion if patient can afford
 After LVP, patients should receive the minimum dose of diuretics
necessary to prevent re-accumulation of ascites
○ Refractory ascites: persisting or reappearing after at least 1 week of maximum tolerated
diuretic therapy and salt restriction
 Repeated LVP plus albumin (8 g/L of ascites removed) along with diuretics
o When to discontinue diuretics
 Hyponatremia (< 125 mmol/l) - avoid spironolactone
 Rise in creatinine
 Hepatic encephalopathy
 K alteration -
 Furosemide if hypokalemia
 Spironolactone if hyperkalemia
o Drugs contraindicated
 NSAID
 ACEI or ARB
 Aminoglycosides
3. Spontaneous Bacterial Peritonitis

 Diagnosis
o Diagnostic paracentesis should be carried out in patients with cirrhosis and ascites, at
admission, to rule out SBP
o SBP diagnosed by a neutrophil count in ascitic fluid >250/mm
o Ascitic fluid culture positivity is not a prerequisite for SBP diagnosis
 Treatment
o Community-acquired - Cefotaxime 2 gram IV TDS
o Healthcare-associated and nosocomial SBP
 Piperacillin/tazobactam or
 Carbapenem
o De-escalation based on culture/sensitivity
o Second paracentesis at 48 hours from starting treatment to assess response-
 Suspect failure if worsening clinical signs and symptoms and/or increase, or no
marked reduction in leucocyte count (at least 25% drop) in 48 hours
o The duration of treatment should be at least 5–7 days
o Albumin to prevent HRS-AKI and reduce mortality.
 1.5 g/kg at diagnosis and
 1 g/kg on Day 3
o PPI use should be restricted to those with a clear indication.

 SBP Prophylaxis
o History of SBP: Prolonged outpatient Cotrim- DS one tablet OD
o Inpatients with an ascitic protein concentration of less than 1 g/dL who are hospitalized
for a reason other than SBP or gastrointestinal bleeding:
 Inpatient prophylaxis with Cotrim-DS 1 tab OD
o Those admitted for GI Bleed:
 IV Ceftriaxone 1 gm OD initially, followed by Cotrim-DS 1 tab BD once able to
take oral, for a total of 7 days
4. Hyponatremia
● Serum sodium concentration <130 mmol/L
● Removal of the cause and administration of normal saline for hypovolemic hyponatremia
● Fluid restriction to 1,000 ml/day for hypervolemic hyponatremia
5. Variceal Bleeding
 Diagnosis
o All patients with decompensated cirrhosis (Child-Pugh B/C) should have an UGI
endoscopy to screen for varices, unless previously diagnosed and treated.
o In patients without varices in whom an etiological factor persists and/or who remain
decompensated, screening endoscopy should be repeated yearly.
 Primary prophylaxis
o Small varices with red sign marks or Child–Pugh C-
 treat with Non-selective beta blockers (NSBB) - propranolol or carvedilol
o Medium–large varices-
 treat with either NSBB or endoscopic band ligation (EBL)
o Initial NSSB at low dose, target- resting heart rate of 60 bpm
o NSBBs should be discontinued in patients with progressive hypotension or those who
develop an acute intercurrent condition- bleeding, sepsis, SBP or AKI.
 Secondary prophylaxis (to prevent re-bleeding)
o Combination therapy of NSBB + EBL
 Acute Variceal Bleeding
○ Initial resuscitation
○ Immediate start of vasoactive drug- octreotide 50 mcg iv bolus, then 25 mcg/hr.
infusion or terlipressin 2 mg IV every 4 hrs. till hemostasis, then 1 mg every 4 hrs. –
continue for 3-5 days
○ Antibiotic prophylaxis
 Ceftriaxone 1gm IV OD or
 Cotrim-DS 1 tab BD once able to take tablets, for total of 7 days
o Diagnostic endoscopy within 12 hrs. to confirm variceal bleed
o Perform endoscopic band ligation (EBL)
o β-blockers and vasodilators should be avoided during the acute bleeding episode
 Follow-up
o Repeat endoscopy in 1-2 months and repeat EBL if required

6. Renal Impairment
 Definition of AKI
o Increase in sCr ≥ 0.3 mg/dl within 48 hours or
o Increase in sCr ≥ 50% within the prior 7 days
 AKI Management
o Remove risk factors (withdrawal of nephrotoxic drugs, vasodilators, NSAIDs, β-blockers,
treat infections when diagnosed)
o Withdraw diuretics and expand volume with albumin (1 g/kg/day) for 2 days
o If not resolved - Does AKI meet criteria of Hepato-renal Syndrome?:
 AKI in setting of cirrhosis and ascites
 No response after 2 consecutive days of diuretic withdrawal and plasma volume
expansion with albumin 1 g/kg/day
 Absence of shock
 No current or recent use of nephrotoxic drugs (NSAIDs, aminoglycosides,
iodinated contrast media, etc.)
 No macroscopic signs of structural kidney injury; uninjured defined as:
 Absence of protein
 Absence of RBCs
 Normal findings on renal ultrasonography
o AKI + tense ascites- therapeutic paracentesis should be accompanied by albumin
infusion even when a low volume of ascitic fluid is removed
 HRS Management
o Albumin solution (20%) should be used at 20–40 g/day till SCr< 1.5 mg/dl or maximum
of 14 days)
o Terlipressin- 1 mg every 4–6 hours
 In case of non-response (decrease in SCr <25% from the peak value) after 2
days, increase dose to 2 mg every 4 hrs.
o Noradrenaline (0.5-3 mg/h infusion)can be an alternative to terlipressin
 Requires a central venous line, often in the ICU
o ECG prior to starting terlipressin or noradrenaline
o Octreotide can be an option when terlipressin or noradrenaline are unavailable.
7. Hepatic Encephalopathy
● General: Appropriate nutritional support, avoiding dehydration and electrolyte abnormalities,
and providing a safe environment.
● Agitated patient-
○ Use of restraints,
○ Haloperidol (0.5-1.0 mg) if required
● Stop diuretics
● No protein restriction
● Eat small meals throughout the day with a late-night snack of complex carbohydrates
● Correction of (one of ten) precipitating causes if any
○ GI bleed
○ Hypovolemia
○ Infection including SBP
○ Hypoxia
○ Hypokalemia
○ Sedative
○ Metabolic alkalosis
○ Hypoglycemia
○ Renal failure
○ Constipation
● Lowering blood ammonia
○ Lactulose (30 to 45 mL given two to four times per day), titrated to achieve two to three
soft stools per day
○ Rifaximin 550 mg BD
○ Both medications can be continued in outpatient if recurrent HE.
8. Coagulopathy
● Asymptomatic raised INR or low platelet count does not need treatment
● In case of bleeding (non-variceal),
○ Give vitamin K to patients with suspected vitamin K deficiency
■ Vitamin K 10 mg OD oral for 3 days, or 10 mg IV single dose
○ Cryoprecipitate or FFP
○ Transfuse RBC or platelet if required (maintain Hb >7, Platelet> 50,000).
○ Treat infection, uremia if present.
9. Nutrition
● Energy intake of 35 to 40 kcal/kg/day
● Protein - 1.4 gm/kg/day
 No protein restriction, even in HE
● Use Poustik Sanjivani as nutritional supplement.
● Eat small meals throughout the day with a late-night snack of complex carbohydrates.
● Use tube feeding if patients are not able to maintain adequate oral intake.
10. Prognosis
 Inform patient party of prognosis based on Child-Pugh Score.
 Child-Pugh Scoring:
1
Measure 2 points 3 points
point
Prothrombin time, prolongation <4.0 4.0–6.0 > 6.0
or INR <1.7 1.7 – 2.3 >2.3
Serum albumin, g/dL >3.5 2.8–3.5 <2.8
Total bilirubin, mg/dL < 2.0 2.0-3.0 >3.0
Ascites Mild (or suppressed with Moderate to severe (or
None
medication) refractory)
Hepatic encephalopathy None Grade I–II Grade III–IV
Categories can be remembered by the pneumonic
‘Pour Another Beer At Eleven’
 Prognosis based on Class / Score
Child-Pugh Score 1 year 2 year

survival survival
A (well compensated) 5-6 100% 85%
B (significant functional compromise) 7-9 80% 60%
C (decompensated) 10-15 45% 35%
References-
● Angeli, P., Bernardi, M., Villanueva, C., Francoz, C., Mookerjee, R., Trebicka, J., Krag, A., Laleman,
W. and Gines, P. (2018). EASL Clinical Practice Guidelines for the management of patients with
decompensated cirrhosis. Journal of Hepatology, 69(2), pp.406-460. DOI:
10.1016/j.jhep.2018.03.024
● Goldberg, E. and Chopra, S. (2018). Cirrhosis in adults: Overview of complications, general
management, and prognosis. UpToDate. [online] Uptodate.com. Available at:
https://www.uptodate.com/contents/cirrhosis-in-adults-overview-of-complications-general-
management-and-
prognosis?search=cirrhosis%20treatment&source=search_result&selectedTitle=1~150&usage_t
ype=default&display_rank=1 [Accessed 25 Aug. 2018].
DIABETES MELLITUS
(AG – Dec 2018 – 1st ed.)
Contents
1. Diagnosis
a) Criteria for Diabetes
b) Criteria for Pre-diabetes
c) Screening
2. Outpatient management
a) Treatment
b) Diabetic Drugs and Treatment Targets
c) Screening for Complications
d) Comorbidities - Hypertension
e) Supportive Treatment
i) Antiplatelet Therapy
ii) Statin Therapy
3. Inpatient Management
a) Hyperglycemia Management In Hospitalized Patients
b) Diabetic Ketoacidosis / Hyperglycemic Hyperosmolar State
i) Diagnostic Criteria
ii) Investigations
iii) ICU admission
iv) Fluid therapy
v) Insulin Therapy
vi) Potassium therapy
vii) Bicarbonate Therapy
1. Diagnosis
a. Criteria For diagnosis ‘Diabetes Mellitus’

At least two blood sugar levels among the following three (could be repeat of same level):
Fasting blood glucose (FBG) ≥ 126 mg/dl
OR
2hr post-prandial blood glucose ≥ 200 mg/dl (OGTT)
OR
HbA1c ≥ 6.5%
OR
Classic diabetes symptoms
Plus single random blood sugar ≥ 200mg/dl
b. Criteria for diagnosis ‘Prediabetes’

At least two blood sugar levels of:
Fasting blood glucose(FBG) = 100 - 125 mg/dl
OR
2hr plasma glucose = 140 - 199 mg/dl during OGTT
OR
HbA1c = 5.7 - 6.4%
c. Screening for Diabetes Mellitus:
i) Screening for diabetes mellitus should be done in the following patients:

• Individuals presenting to healthcare settings for unrelated illness
• People over the age of 45 years
• Asymptomatic adults with 1 or more following risk factors:
o HbA1c ≥ 5.7% or impaired glucose tolerance or impaired fasting glucose on
previous testing
o First degree relatives of diabetics
o Women who were diagnosed with gestational diabetes mellitus
o History of cardiovascular disease
o Hypertension (BP>140/90 or on therapy)
o HDL cholesterol < 35 mg/dl and/ or triglycerides > 250mg/dl
o Women with polycystic ovarian syndrome
o Physical inactivity
o Conditions associated with insulin resistance (obesity, acanthosis nigricans)
ii) Random blood sugar will be done as the screening test initially.
• If RBS> 140, then FBS, 2 hrs PP and HbA1c should be performed.
• If tests are normal, monitoring of blood sugar at least at 3 yearly intervals or as
advised by physician.
• If tests show pre-diabetes, monitoring of blood sugar annually.
2. Outpatient Management
a. Treatment
i) Type 1 Diabetes Mellitus
• Variable mixed intermediate and short acting insulin

OR
• Basal insulin plus multiple daily injections of prandial insulin
ii) Type 2 Diabetes Mellitus

• Metformin is preferred anti-diabetic if not contraindicated (such as by renal insufficiency)
• Dual therapy with two anti-diabetic drugs is usually needed if HbA1c ≥ 9%
• Initial insulin therapy may be needed in symptomatic patients with any of these: o
HbA1c ≥ 10% or
o FBS > 250 mg/dl or o
PPG > 300 mg/dL or o
Positive ketonuria And
definitely needed in:
o Pregnant or planning pregnancy
b. Diabetic Drugs and Treatment Targets

If glycemic target is not reached after 3 months of therapy, titrate up to next line therapy:
Monotherapy to dual therapy
Dual therapy to either insulin or triple therapy
i) Oral anti-diabetic drugs

st
1 line therapy:
• Metformin
nd
2 line therapy:
• Metformin + sulfonylurea or thiazolidinedione or SGLT2 inhibitor, or DPP-4 inhibitor,
or AGI
rd
3 line therapy:
• Addition of other anti-diabetic drugs to second line or insulin therapy
th
4 line therapy
• Insulin
ii) Insulin Therapy:

Initial therapy:
• Premixed insulin or basal insulin (as per patient preference)
If HbA1c not controlled despite controlling of FPG with basal insulin
• Basal bolus insulin or premixed insulin
• Fasting Blood sugar:80-130mg/dl

• 2 hours Post prandial < 180mg/dl
• HbA1c <7%
• Can be achieved easily without significant hypoglycemia especially in young

Higher Target of HbA1c (<8%) if:
• History of repeated hypoglycemia
• Limited life expectancy
• Associated comorbidities
• Longer duration of disease
c. Screening for Complications
i) Retinopathy Ophthalmologist
examination
• Type 1 Diabetes
o At least within 5 years of diabetes onset or
o If patient reaches puberty
• Type 2 Diabetes
o At the time of diagnosis
Follow up screening to be done at least annually thereafter.
ii) Nephropathy
Urine albumin and serum creatinine (with calculation of creatinine clearance)
• Type 1 Diabetes:
o At least within 5 years of diabetes onset
o At the time of diagnosis
Follow up screening to be done at least annually.
iii) Neuropathy This

comprises:
• History
o Prior history of ulceration, amputation, Charcot foot, angioplasty or vascular
surgery
o Cigarette smoking
o Retinopathy & renal disease
o Symptoms of peripheral arterial disease
• Examination:
o Inspection of the skin
o Assessment of foot deformities
o Neurologic assessment
10g monofilament test
Vibration sensation
Temperature and pin prick sensation
o Vascular assessment including pulses in the legs and feet
o Inspection of foot wear
At least within 5 years of diabetes onset
At the time of diagnosis
Follow up screening to be done annually.
iv) Atherosclerotic cardiovascular disease

• Electrocardiogram
• Baseline and repeated according to suggestive symptoms
d. Co-morbidities
i) Hypertension
• BP should be measured at every routine visit
• If found to be elevated, confirm on separate day
• Target BP < 140/90
• For high risk of cardiovascular disease, target BP <130/80
• For pregnant with chronic hypertension, target BP 120-160/80-105
e. Supportive treatment
i) Antiplatelet therapy
Aspirin 75 mg daily for primary prevention of cardiovascular disease if:
Age ≥50 years and at least one additional major risk factor:
• Family history of premature atherosclerosis cardiovascular disease
• Hypertension
• Smoking
• Dyslipidemia
• Albuminuria
ii) Statin Therapy

Age Risk Factors Statin intensity
<40years 1. None 1. None
2. ASCVD* risk 2. Moderate
3. ASCVD 3. High
40-75 years 1. None 1. Moderate
2. ASCVD risk 2. High
>75 years 1. None 1. Moderate
2. ASCVD risk 2. Moderate to high
3. ASCVD 3. High
Moderate Intensity statin: Atorvastatin 10-20 mg daily or Rosuvastatin 5-10 mg daily

High Intensity statin: Atorvastatin 20-40 mg daily or Rosuvastatin 10-20 mg daily
*ASCVD= Atherosclerotic Cardiovascular Disease
3. Inpatient Management
a) Hyperglycemia Management In Hospitalized Patients

• HbA1c for all patients with diabetes or hyperglycemia (if not done in the prior 3 months)
• Target Blood glucose: 140-180 mg/dl
• More stringent goals (110-140 mg/dL) for selected critically ill patients(ICU patients, MI,
pancreatitis, heart failure)
i) Critical Care settings
Continuous intravenous insulin infusion
ii) Non-Critical Care Settings
For patients with poor oral intake or those who are NPO: continuous intravenous insulin
For patients with good intake: premixed or basal
insulin Use of sliding scale insulin to be avoided
If oral medications are held in the hospital, oral medications to be resumed 1–2 days before
discharge
b) Diabetic Ketoacidosis(DKA) / Hyperglycemic Hyperosmolar State(HHS)

i) Diagnostic Criteria for DKA/HHS
Mild DKA Moderate DKA Severe DKA HHS
Blood >250 >250 >250 >600
glucose(mg/dl)
Arterial pH 7.25-7.3 7-7.24 <7,0 >7.3
Bicarbonate(mEq/L) 15-18 10-14 <10 >15
Urine ketones Positive Positive Positive small
Osmolality(mOsm/k
g) Variable Variable Variable >320
Anion gap >10 >12 >12 variable
Mental Status Alert Alert/drowsy Stupor/coma Stupor/coma
ii) Investigations
• Blood glucose
• Creatinine, Urea, Sodium, Potassium
• Urinalysis with urine ketones
• ABG
• CBC
• ECG
• Bacterial cultures of urine, blood, and throat if infection is suspected
• Chest X-ray (if indicated)
iii) ICU admission if (any of following)
• pH<7.1
• HCO3<10meQ/L
• Altered sensorium/ obtundation
• Associated severe comorbidities
iv) Fluid Therapy
• Initial Fluid therapy:
Isotonic saline (0.9% NaCl) 15–20 ml/kg /hr during the 1st hour (1-1.5L)
• Subsequent fluid depends on hydration status and sodium concentration
If hypovolemia - continue 0.9% NS at same rate of infusion

If not hypovolemia and:
Corrected sodium normal or increased - 0.45% NaCl
Corrected sodium low- 0.9% NS
( at 250-500 mL/hour )
•
If blood sugar reaches 250mg/dl (300mg/dl in HHS): 5% dextrose with 0.45% NaCl
(at 150-250ml/h)
v) Insulin Therapy
• Hold insulin
• Give potassium 10 - 20mEq/h until measured > 3.3mEq/L

If potassium > 3.3mEq/L)
• 0.15 units /kg iv bolus followed by 0.1 units/kg/hour iv infusion

• If patient is able to eat, subcutaneous multiple-dose schedule should be started
• Continue intravenous insulin infusion for 1–2 h after the split-mixed regimen is begun
vi) Potassium Therapy
If serum potassium <3.3meq/L
• Give potassium 20mEq/h until >3.3mEq/L

If potassium-3.3-5.5
• Give potassium 20mEq in each liter of iv fluids
Continue to measure potassium at least twice a day during acute phase

vii) Bicarbonate Therapy

If pH > 7
• No bicarbonate therapy
If pH <7
• NaHCO3 350mmol/L dilute in 200 ml of water
• Infuse at 200ml/h
• Repeat ABG 2hrly until pH >7
References
• American Diabetic Assosciation “Standards of Medical care in Diabetes—2018”
• RSSDI Clinical Practice Recommendations for the Management of type 2 Diabetes

mellitus 2017
• Uptodate 2018
COMMUNITY ACQUIRED PNEUMONIA (CAP)

(AT – Nov2014 – 1st ed.)
Community-acquired pneumonia (CAP) is defined as an acute infection of the pulmonary

parenchyma that is associated with at least some symptoms of acute infection, accompanied by
the presence of an acute infiltrate on a chest radiograph or auscultatory findings consistent with
pneumonia, occurring in a community setting.
1. Diagnostic approach
Clinical Features (Productive cough, fever, chest pain; Auscultation findings)
Chest X ray (Acute lung infiltrates)
2. Severity Assessment / Site

CRB-65 in OPD settings, CURB-65 in ward
(Confusion, (Urea>40mg%), Respiratory rate > 30/min, Blood pressure < 90/60, Age >65)
CRB-65:
0-1: Home Treatment
CURB-65:
0-1: home treatment
[The patient’s social situation should also be considered in disposition.]
3. Diagnostic Testing
Routine diagnostic tests to identify an etiological diagnosis are optional for outpatients.
Blood culture and sputum for gram stain and culture should be performed in hospitalized
patients, especially those admitted to ICU, with previous treatment, or with co-morbid
conditions.
4. Antibiotic treatment
OUTPATIENTS
No comorbid condition or use of antimicrobials A macrolide (Azithromycin 500 mg daily)
within previous 3 months.
Presence of comorbidities such as chronic A b-lactam plus a macrolide (Co-amoxiclav
heart, lung, liver or renal disease; diabetes +azithromycin)
mellitus; alcoholism; malignancies; asplenia;
immunosuppressing conditions or use of
immunosuppressing drugs; or use of
antimicrobials within the previous 3 months .
Avoid flouroquinolones for empiric treatment.
INPATIENT - WARD
Previously healthy and no use of A b-lactam (ceftriaxone, cefotaxime,
antimicrobials or admission within the previous amoxiclav) plus a macrolide (Azithromycin)
3 months.
Hospitalization for ≥ 2 days in past 3 months An anti-pneumococcal, antipseudomonal b-
or received antibiotics in past 3 months lactam (piperacillin-tazobactam) plus a
macrolide.
(Antibiotics – cont’d)
INPATIENT - ICU
An anti-pneumococcal, antipseudomonal b-lactam (piperacillin-
(Options:) tazobactam, cefepime, imipenem, or meropenem) plus an
aminoglycoside (amikacin) plus azithromycin.
OR
An anti-pneumococcal, antipseudomonal b-lactam (piperacillin-
tazobactam, cefepime, imipenem, or meropenem) plus a
fluoroquinolone plus azithromycin.
(Fluoroquinolone and macrolide should be used together with
caution since there is increased risk of QT prolongation with the
combination)
MRSA is a consideration Add vancomycin or linezolid.

(dialysis, home wound care)
Use fluoroquinolones only as a last resort and with simultaneous AFB testing.
5. Switch from Intravenous to Oral Therapy

Patients should be switched from intravenous to oral therapy when they are hemodynamically
stable and improving clinically, are able to ingest medications, and have a normally functioning
gastrointestinal tract.
Patients should be discharged from the hospital as soon as they are clinically stable, have no
other active medical problems, and have a safe environment for continued care. Inpatient
observation while receiving oral therapy is not necessary.
6. Duration of Antibiotic therapy

Outpatients should be treated for a minimum of 5 days.
Inpatients for a minimum of 7 days (including outpatient continuation).
7. Prevention
Inactivated influenza vaccine
Pneumococcal conjugate vaccine
Smoking cessation
References
Infectious Disease Society of America / American Thoracic Society Guidelines for Community Acquired
Pneumonia
https://academic.oup.com/cid/article/44/Supplement_2/S27/372079
Guidelines for diagnosis and management of community-and hospital-acquired pneumonia in adults: Joint
ICS/NCCP(I) recommendations
http://www.lungindia.com/article.asp?issn=0970-
2113;year=2012;volume=29;issue=6;spage=27;epage=62;aulast=Gupta
Adhikari R, Shrestha S. Prevalence and antibiotic sensitivity profiles of bacteria causing community
acquired pneumonia (http://dx.doi.org/10.1016/j.ijid.2016.02.223)
Shrestha R,Paudel N, et al. Etiology and clinical profile of inpatients with Community acquired pneumonia
in Manipal Teaching hospital, Pokhara, Nepal .
(https://www.nepjol.info/index.php/NJMS/article/viewFile/6605/5394)
ACUTE PANCREATITIS
st
(SS – Jan 2019 – 1 ed.)
1. DIAGNOSIS
Diagnosis requires at least 2 of the following features:
 characteristic abdominal pain (acute onset, severe, persistent epigastric pain with radiation to
back)
 biochemical evidence of pancreatitis (amylase or lipase elevated >3 times the upper limit of
normal)
 radiographic evidence of pancreatitis on cross-sectional imaging
2. INITIAL INVESTIGATIONS
 CBC
 RFT
 LFT
 Lipid Profile
 Serum Calcium
 ABG
 Urine Routine Examination
 Ultrasound Abdomen And Pelvis
 Chest X-ray
 Electrocardiogram
3. SEVERITY
• Mild
- Absence of organ failure
- Absence of local complications
• Moderately Severe
- Local complications AND/OR
- Transient organ failure (< 48 h)
• Severe
- Persistent organ failure > 48 h
BISAP SCORE (to be documented in all patients)
(Bedside Inventory of Severity of Acute Pancreatitis – Also acronym first letters)
Each one point:
 Blood Urea Nitrogen > 25 mg/dl (Urea> 50 mg/dl)
 Impaired Mental Status
 SIRS > 2
 Age > 60 yrs
 Pleural Effusion
4. WHERE TO ADMIT
• Mild (No complications/BISAP=0) – Medical Ward
• Mod. Severe (Complications/BISAP≥1) – Consider ICU /Stepdown
• Severe (Established organ failure, not responding to fluids) – ICU

Patients with one or more of the following parameters should also be considered for ICU:
- Serum sodium < 110 mmol/L or > 170 mmol/L
- Serum potassium < 2.0 mmol/L or > 7.0 mmol/L
- PaO2 < 50 mmHg
- pH < 7.1 or > 7.7
- Serum glucose > 800 mg/dL
- Serum calcium >15 mg/dl
- Anuria
5. TREATMENT
a. Fluid Therapy
 Normal Saline or Ringer’s Lacate 60 ml/kg over first 12 hours (60 kg = 3.5 liters)
 In patients in shock, rapid repletion with 20 ml/kg of intravenous fluid given over 30 minutes
followed by 30 ml/kg over next 12 hours
 Ringer’s Lactate not to be used in hypercalcemia
 Fluid resuscitation guided by vital signs and urine output.
 Check haematocrit, Creatinine and Serum Urea every day if abnormal.
 Goal-directed therapy: Tailor fluids to:
HR <120 /minute, MAP (65 to 85 mmHg), urine output (>0.5 to 1 cc/kg/hour) and reduction in
hematocrit (goal 35 to 44 percent) and Serum Urea over 24 hours.
b. Analgesia
 Inj. Tramadol (50mg 8 hourly) and Ondansetron 4mg 8 hourly
(If severe or not relieved:)
 Inj. Pethidine 50mg 6 hourly or Inj. Morphine 5mg 4 hourly as needed and Ondansetron
c. Intake / Nutrition
 Attempt full calorie/ full protein as soon as tolerated
 Mild cases – Start feeding liquid diet from next morning
 Moderate / Severe – Continue NPO until pain begins to subside
 Vomiting – NG Tube insertion
d. Antibiotics
 No prophylactic antibiotics
 Start antibiotics if any of these is present:
- Proven focus of infection
- Fever with no other identifiable cause
- Clinically unstable patient
- Presence of gas within necrosis
 Antibiotic regimens
- Inj. Imipenam 1gm 8 hrly or
- Inj. Meropenem 1gm 8 hrly or
- Inj. Cefepime 2 gm 12 hrly and Inj. Metronidazole 500 mg 8 hrly
6. ROLE OF IMAGING
Contrast-enhanced computed tomographic (CECT) and/or magnetic resonance imaging (MRI) of
the pancreas should be reserved for patients in whom
 the diagnosis is unclear
 who fail to improve clinically within the first 48–72 h after hospital admission
 fluid collection seen in Ultrasound
7. SURGICAL CONSULTATION
• Biliary pancreatitis
• Symptomatic pseudocysts
• rapidly enlarging pseudocysts
• infected pseudocysts/ necrosis that do not improve with medical management
REFERENCES
• American Gastroenterological Association Institute Guideline on Management of Acute
Pancreatitis – June 2013
• UPTODATE 18th jan 2019
st
HYPERTENSION
(AJ – April 2019 - 1 ed.)
1. BP MEASUREMENT
• Seat patient comfortably for 5 min before beginning BP measurements.
• Have patient avoid caffeine, exercise, and smoking for at least 30 min before measurement.
• Ensure patient has emptied his/her bladder.
• Remove all clothing covering the location of cuff placement.
• Position the middle of the cuff on the patient’s upper arm at the level of the right atrium (the
midpoint of the sternum). Rest patient’s arm on the table.
• At the first visit, record BP in both arms. Use the arm that gives the higher reading for
subsequent readings.
• Record three BP measurements, 1–2 min apart and additional measurements only if the first
two readings differ by >10 mmHg. BP is recorded as the average of the last two BP
readings.
• Use an average of ≥2 readings obtained on ≥2 occasions 1 week apart to estimate the
individual’s level of BP.
2. DIAGNOSIS
BP category Systolic BP Diastolic BP
(SBP) (DBP)
Normal <120 mm Hg and <80 mm Hg
Elevated 120-129 mm Hg and <80 mm Hg

Hypertension
Stage 1 130-139 mm Hg or 80-89 mm Hg
Stage 2 ≥ 140 mm Hg or > 90 mm Hg
*Individuals with SBP and DBP in 2 categories should be designated to the higher BP category.
• Diagnosis can be made without further confirmatory readings in the following cases:
1. Hypertensive urgency or emergency (≥180 / ≥120)
2. Initial BP ≥160 / ≥100 with end organ damage (e.g. left ventricular failure, hypertensive
retinopathy, ischemic cardiovascular disease)
3. EVALUATION
a. Investigations
 For all newly diagnosed cases of hypertension order:
• Hemoglobin
• Fasting blood sugar
• Lipid profile
• Creatinine, sodium and potassium
• TSH
• Uric acid
• Urine routine exam
• ECG
• Fundoscopy
• 10-year atherosclerotic cardiovascular disease (ASCVD) risk calculation
b. Secondary hypertension
 Suspect If any of the following is present:
• Onset of hypertension age < 40 years
• Abrupt onset of hypertension
• Exacerbation of previously controlled hypertension
• Drug-resistant hypertension
• Presence of extensive end organ damage
• Onset of diastolic hypertension in age > 65 years
• Unprovoked or excessive hypokalemia
Cause Suggestive features Further evaluation
Renal parenchymal Diabetes; hematuria; proteinuria; Urinary protein:creatinine

disease nocturia; anemia; renal mass; polycystic ratio;
kidney disease renal ultrasound
Obstructive sleep Snoring; obesity; morning headache; Epworth score
apnea daytime somnolence
Atherosclerotic Older; diabetes; smoking; recurrent Duplex renal artery Doppler
renovascular disease flash pulmonary edema; abdominal
bruit
Primary aldosteronism Mostly asymptomatic; muscle Plasma aldosterone/renin
weakness (hypokalemia) ratio
Pheochromocytoma Episodic symptoms (the 5 ‘Ps’): Plasma or 24-hr urinary
paroxysmal hypertension, pounding fractionated
headache, perspiration palpitations, or metanephrine
pallor
Cushing’s syndrome Moon face; central obesity; skin 24-hr urinary-free cortisol
atrophy; striae and bruising; diabetes;
chronic steroid use
Hyperparathyroidism Hypercalcaemia; hypophosphataemia Parathyroid hormone
Coarctation of the Different BP (≥ 20/10 mmHg) between Echocardiogram
aorta upper–lower extremities and/or
between right–left arm and delayed
radial femoral pulsation
Drug or alcohol Sodium-containing antacids; caffeine;
induced smoking; alcohol; NSAIDs; oral
contraceptives; decongestants;
cocaine, antidepressants, atypical
antipsychotics, corticosteroids
4. TREATMENT
a. Targets
 In patients < 65 years: ≤ 130/ 80 mm Hg
 In older patients (aged ≥ 65 years) receiving BP-lowering drugs: SBP should be targeted to
a BP range of 130–139 mmHg.
 A DBP target of < 80 mmHg should be considered for all hypertensive patients,
independent of the level of risk and comorbidities .
b. Non-pharmacological measures
 For all cases of hypertension as well as elevated BP:
• No added salts or high-salt food
• Smoking cessation
• Alcohol cessation
• Increased consumption of vegetables, fresh fruits, fish
• Decreased consumption of red meat and consumption of low-fat dairy products
• Reduction of 1 kg weight decreases BP by 1 mm Hg.
• BMI target = 20 - 23 kg/m2
• Regular exercise of at least 30 min for 5-7 days a week
c. Pharmacological
 When to initiate drug therapy?
• For all patients with Stage 2 hypertension
• For patients with Stage 1 Hypertension with established ASCVD or 10-year ASCVD risk ≥
10 %
 Monotherapy or Combination therapy?
• Monotherapy for patients with
- Stage 1 hypertension or
- Stage 2 hypertension when BP is ≤ 150/90 mm Hg
• Combination therapy in patients with BP > 150/90 mm Hg
 Initial drugs of choice?
• Combination of renin-angiotensin system blocker (ACEI or ARB) plus calcium channel
blocker or diuretic as initial choice in hypertensive patients
• For monotherapy: RAS blocker (except in patients with angina pectoris or atrial fibrillation
where beta blockers are to be used).
 What drugs to add?
• Addition of CCB or diuretics (whichever not used).
• After using all 3 drug types at maximum doses, add spironolactone (not to be used if
GFR<45 or baseline K > 4.5).
 Choice of diuretics
• GFR > 45 - Hydrochlorothiazide
• GFR > 25 - Chlorthalidone
• GFR < 25 - Torsemide
 Stable Ischemic Heart Disease
• Initial choice: Beta blockers or ACE inhibitors/ARBs or combination
• If angina is present, the 3rd drug should be dihydropyridine CCBs (Amlodipine)
• Preferred beta blockers: carvedilol, metoprolol tartarate, metoprolol succinate, nadolol,
bisoprolol, propranolol, or timolol (Note: Not atenolol)
 Secondary Stroke Prevention
• For adults who experience an ischemic stroke or TIA, treatment with a thiazide diuretic, ACE
inhibitor, or ARB, or combination treatment consisting of a thiazide diuretic plus ACE
inhibitor or ARB, is useful.
• In patients > 65 years diuretics not to be used.
5. HYPERTENSIVE CRISES
a. Hypertensive urgencies
 Severe BP elevation (>180/120) in otherwise stable patients without acute or impending
change in target organ damage or dysfunction.
 Don’t need to be admitted.
 Can be managed with usual oral drugs in increased doses.
b. Hypertensive emergencies
 Severe elevations in BP (>180/120) associated with evidence of new or worsening target
organ damage such as:
- hypertensive encephalopathy, intracerebral hemorrhage, or acute ischemic stroke
- acute MI, acute LV failure with pulmonary edema, unstable angina pectoris,
dissecting aortic aneurysm
- acute renal failure
- eclampsia
 BP reduction rates:

 Drugs (Emergency)
• Labetalol
- Initial 10 to 20 mg IV over 2 min; double every 10 min (up to 80 mg / dose) until target
SBP is reached. Total maximum dose: 300 mg.
- Continuous IV infusion: 0.5 to 2 mg/min until target reached; 5-20 mg/hr thereafter
- Contraindicated in reactive airways disease or chronic obstructive pulmonary disease.
May worsen HF and should not be given in patients with second- or third-degree heart
block or bradycardia.
• Nitroglycerin
- Initial 5 mcg / min; increase in increments of 5 mcg / min every 5 min to a maximum of
200 mcg/min.
- Use only in patients with acute coronary syndrome and/or acute pulmonary edema. Do
not use in volume-depleted patients.
• Sodium nitroprusside
- Initial 0.5 mcg/kg / min; increase in increments of 0.5 mcg / kg / min to achieve BP
target; maximum dose 10 mcg/kg/min; duration of treatment as short as possible
- Cyanide toxicity with prolonged use can result in irreversible neurological changes and
cardiac arrest.
• Hydralazine
- Initial 10 mg via slow IV infusion (maximum initial dose 20 mg); repeat every 4–6 hr
as needed.
- Unpredictability of response and prolonged duration of action do not make it a desirable
first-line agent for acute treatment.
- BP begins to decrease within 10–30 min, and the fall lasts 2–4 hr.
(Nifedipine by any route is not recommended for hypertensive emergencies.)
References:
• 2018 European Society of Cardiology/European Society of Hypertension Guidelines for
the management of arterial hypertension.
• 2017 American College of Cardiology /American Heart Association
/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention,
Detection, Evaluation, and Management of High Blood Pressure in Adults.
• 2018 American Heart Association statement on Resistant Hypertension.
• Uptodate 2019.
st
SEIZURES
(PS – May 2019-1 ed.)
3. DEFINITION
• A seizure is a sudden change in behavior caused by electrical hyper-synchronization of
neuronal networks in the cerebral cortex.
4. TYPE OF SEIZURE(Choose two descriptors)

 Provoked:refers to a seizure that occurs at the time of a systemic insult or in close temporal
association with a documented brain insult.
 Unprovoked:refers to a seizure of unknown etiology as well as one that occurs in relation
to a preexisting brain lesion or progressive nervous system disorder
and
 Focal: starting with focal motor or sensory signs/symptoms or focal pathology on imaging.
 Generalized: all others
[Therefore any seizure should be recorded as being

Provoked or Unprovoked + Focal or Generalized]
5. CAUSES OF PROVOKED SEIZURES

a. Intracranial
 CVA
 Subdural/ subarachnoid hemorrhage
 Traumatic brain injury (concussion)
 Hypoxic-brain injury
 Infection : meningitis, encephalitis and brain abscess
b. Extracranial
 Electrolyte: Hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia
and hyperglycemia
 Metabolic: Hypoxia, uremia and porphyria
 Drug and alcohol : Withdrawal, intoxication, cocaine and amphetamine
 Endocrine : Hyperthyroidism
6. EPILEPSY
 At least two unprovoked (or reflex) seizures occurring more than 24 hours apart.
 One unprovoked (or reflex) seizure and a probability of further seizures similar to the general
recurrence risk after two unprovoked seizures (eg, ≥60 percent) occurring over the next 10
years.
 Diagnosis of an epilepsy syndrome.
7. CLASSIFICATION SYSTEM
a. Focal
 Intact/impaired awareness
 Motor/Non-motor
 Focal to bilateral tonic-clonic
b. Generalized
 Motor
 Non-motor
c. Unknown
8. APPROACH TO SEIZURE
a. Classifyas Provoked/Unprovoked + Focal/Generalized
b. Evaluation
i. History (and detailed neuro-examination)
 Clinical event  Past history

 Eye witness/patient  Similar episode
 How it began  Previous illness like
 Awareness TB,diabetes, febrile seizure,  Differential diagnosis
 Incontinence HIV, Alzheimer  Syncope
 Tongue bite  TIA
 Paralysis  Migraine
 Duration  Panic attack
 Time to regain  Psychogenic
consciousness nonepileptic seizure
 Narcolepsy with
 Precipitant  Family history cataplexy
 Emotion  Absence and myoclonic  Paroxsymal movement
 Sleep deprivation disorder
 Alcohol/Withdrawal
 Drugs
ii. Labs iv.Indication of Imaging

 Random blood sugar  Non-contrast CT for all
 CBC new onset seizure
 Renal Function Tests  MRI as per treating physician
 Calcium decision
 Urine R/M/E
 ALT/AST
 Electrocardiogram
v. Indication of EEG
iii. Lumbar puncture  Any unprovoked seizure
 Fever with or without altered  HIV

sensorium.
c. Treatment
 NOTE: CT/fundoscopy must be
considered prior to LP

i. When to start anti-seizure drug therapy
 Any one of these

- Status epilepticus
- Second unprovoked seizure
- Focal neurological sign
- Abnormal neuro-imaging (CT/MRI)
- An EEG with epileptiform abnormality
- Nocturnal seizure
ii. Selection of drugs
Type of seizure Drugs

Tonic-clonic Valproate
Lamotrigine
Focal Lamotrigine
Carbamazepine
Phenytoin
Levetiracetam
Valproate
Focal to bilateral tonic- Same as focal
clonic seizure Valproate if not sure
Typical absence Valpraote
Ethosuximide
Lamotrigine iii. Initiation
 Conf
irm diagnosis and type of seizure
 Start with most appropriate anti-seizure medicine
 If type of seizure couldn’t be made (focal/generalized): start with valproate
 If seizure is controlled and no adverse effect: continue treatment with regular follow-up
 If uncontrolled : increase the dose (dose can be increased to max. tolerable dose or till
adverse effect develop)
 If uncontrolled with single drug then revise the diagnosis and check for compliance
 Add- on therapy with second AED
 If seizure is controlled with added AED : optimize the second AED and taper the first
AED
 Goal should be to maintain on monotherapy whenever possible
 If uncontrolled with 2 drugs
 Further evaluation for focal seizure/ multiple seizure type is needed(MRI/EEG if not done
already)
 Combine first line drugs
 New antieplileptics like zonisamide, brivaracetam, lacosamide, tiagabine or topiramate
may be added
 Neurophysician consultation
iv. Drug Monitoring

 Patient education: Compliance and adverse effects
 Seizure calendar: Record day and time of seizure if any

 At the start of treatment: CBC, ALT
 Follow up visit every 3 month
CBC and ALT every 6 month
Drug level only if sign of toxicity or pregnancy
v. Drug dosing and side effects

Drug Dose range Starting dose Side effects
Valproate 750-2000 mg/day 500 mg BID Ataxia, sedation,
(Rs 760/ month) BID-QID (Immediate Tremor,
For usual starting and delay), daily hepatotoxicity,
dose (extended) Thrombocytopenia
Carbamazepine 600-1800 mg/day 400 mg BID Ataxia, dizziness,
(Rs 400/ month) BID Diplopia,
vertigo,leukopenia
Phenytoin 300-400 mg/day 200-300 mg Ataxia, dizziness,
(Rs 180/ month) QD-TDS OD Diplopia,
Folic acid Gum hyperplasia,
Preconception and hirsuitism
pregnant: 5 mg/day
Children : 0.5mg/day
Adult: not indicated
Lamotrigine 150-500 mg/day 100 mg BID Ataxia,
(Rs 700/ month) BID (Immediate Dizziness,
release) Diplopia,
Daily (extended Skin rash
release)
Levetiracetam 1000-3000 mg/day 500 mg BID Sedation,
(Rs 960/ month) BID Fatigue,
(Immediate Mood change,
release) Anemia,
Daily (extended Leukopenia
release)
vi. When to discontinue therapy

1. Complete medical control of seizure for more than 2 year
2. Single seizure type, with generalized seizures
3. Normal neurological examination
4. No family history
 Who meet all of above criteria:

 Tapering done over 3 month
 Slowly taper the medication via a 25% dose reduction of original dose every 3 weeks
 If seizure recurs during tapering then therapy should be reinitiated and continued
9. SEIZURE IN CHILD-BEARING AGE

a. Treatment approach
i. Drugs / Timing
New Onset Already on AED
Pre-conception Lamotrigine or Delay conception and change to
Levetiracetam lamotrigine / levetiracetam.
Assure full control
During pregnancy Lamotrigine or Continue same AED
Levetiracetam (even Valproate)
(dose increment will be required)
Post-partum Same as non-pregnant state Continue same drug and reduce
the dose to pre-pregnancy state
(taper over 2-3 week)
ii.When to monitor drug level

 When pregnancy is detected (on AED)
 Worsening of seizure/ adverse effect
iii. Other considerations in pregnancy

 Lamotrigine and Levetiracetam have a high clearance and concentrations should
be monitored closely during pregnancy to prevent a decrease by more than 35%
from preconception baseline and seizure deterioration.
 If a woman’s seizures can only be controlled by valproate after all reasonable

AED alternatives have failed, then valproate should be used at the lowest dosage
possible to obtain reasonable seizure control.
10. NEUROCYSTICERCOSIS (NCC)

a. Viable intra-parenchymal disease
 Antiepileptic drugs appear to be effective in controlling seizures in patients with parenchymal
NCC
 Consider tapering off after 2 years if meet criteria for withdrawal as in idiopathic epilepsy.
 Drug: Phenytoin, carbamazepine or levetiracetam
b. Single enhancing lesion

 Antiepileptic drugs can be discontinued after resolution of cystic lesions if no risk factors for
recurrence.
 Seizure free for 6 month
 Risk factors for recurrent seizures include
(1) calcifications on follow-up CT,
(2) breakthrough seizures, and
(3) >2 seizures during the course of the disease
c. Calcified parenchymal neurocysticercosis with or without perilesional edema

 Management guidelines are similar to that in other patients with seizures.
d. Refractory cases
 Surgical removal
11. STATUS EPILEPTICUS (SE)

a. Definition
Generalized convulsive SE in adults and children older than 5 years is operationally defined
as ≥5 min of continuous seizure or two or more discrete seizures between which there is
incomplete recovery of consciousness.
b. Management
i. Stabilization phase
 ABCDE
 Time since onset of seizure and vital monitoring
 Access oxygenation via mask or may need intubation
 Cardiac monitoring
 GRBS IF <60mg/dl : 100mg Thiamine followed by 50% 50 ml dextrose
 IV access and collect blood for investigation
ii. Initial therapy phase

 IV diazepam : 0.15-0.2 mg/kg slowly (max 10 mg at a time) or
 IM/IV midazolam : 0.2mg/kg (max 10 mg) or
 IV lorazepam : 0.1 mg/kg (max 4 mg)
iii. Second therapy phase

 IV Phenytoin : 20 mg/kg (max 1500 mg) at rate of 50 mg per minute in 100 ml of normal saline
iv. Third therapy phase

 IV Midazolam : 0.2-0.6 mg/kg/hr
 IV Propofol : 2- 10 mg/kg/hr
12. REFERENCES
 International league against epilepsy 2017
 American academy of neurology 2018
 Harrison’s 20th edition
 Uptodate
 American epilepsy society 2016
 The management of epilepsy in children and adults 2017 piero perucca1,2, ingrid e
scheffer3,4, michelle kiley5
 Discontinuation of antiepileptic drugs in seizure-free patients – when and how? Morten
i. Lossius, kristin å. Alfstad, kari m. Aaberg, karl o. Nakken
 Clinical use and monitoring of antiepileptic drugs claire e. Knezevic1 and mark a.
Marzinke 2018
 Medscape
 Seizures in pregnancy: diagnosis and management. Beach rl1, kaplan pw
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PAHS Internal Medicine Guidelines 2018-2019

GUIDELINES FOR SOME COMMON DISEASES

Prepared by Residents of PAHS (Batch 2017 and 2018)

Disease Page No.

Fever is demonstrable rise in temperature > 99.9 F

Clinical features suggesting severity

Manage specific syndrome:

Empiric Treatment of pharyngitis

For management of Pneumonia

Antibiotic indication in COPD

‘If proven pneumonia use ceftriaxone and azithromycin

Antibiotics in urinary tract infections

Fever with jaundice

ii. Acute Undifferentiated Fever

2. Approach to chronic fever

Exclude manipulation with thermometer

Consult second senior doctor

Serum ferritin level: for Adult stills disease

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

3. Diagnostic Testing (Routine, OPD)

SABA- Short acting beta agonist e.g. salbutamol

d. Other OPD treatment

e. VTE prophylaxis with SC heparin or LMW heparin

f. Consider pneumococcal and influenza vaccination

2. General Supportive Care and Emergency Treatment

(Secondary Prevention – Cont’d.)

Adjustments in Setting of Possible Contraindications

1.4 Treatment in ICU

2. ENTRY ALGORITHMS AND CHECKLISTS

2.1 First step: ER Triage Team

TRIAGE TEAM Checklist

DURATION OF ONSET OF SYMPTOMS : ____ hours.

IF ANY OF THE SYMPTOMS/SIGNS ARE PRESENT

2.2 Second step: ER Doctor

2.2.2 Look for following signs: (Any)

For speech impairment:

2.2.3 Measure Blood Sugar and treat accordingly.

2.2.4 Record Blood pressure and treat accordingly.

2.2.5 Call medicine on call.

2.2.6 Take the patient NCCT scan of head as soon as possible.

2.3 Third Step: Medicine on Call Doctor

MEDICINE ON CALL(Overall Checklist)

Relative contraindications: (Any)

3.1.3 If systolic BP >180–230 or diastolic BP >105–120:

3.2 Management of Symptomatic Intracranial Bleeding Occurring Within 24 Hours After

3.3 Management of Orolingual Angioedema Associated With IV Alteplase

 If there is further increase in angioedema, administer epinephrine (0.1%) 0.3 mL

4.1 NIHSS CHECKLIST

7 Motor function of right arm 0=No drift

CHRONIC LIVER DISEASE

be corrected before starting diuretic therapy

3. Spontaneous Bacterial Peritonitis

o PPI use should be restricted to those with a clear indication.

o Repeat endoscopy in 1-2 months and repeat EBL if required

 Prognosis based on Class / Score

Child-Pugh Score 1 year 2 year

A (well compensated) 5-6 100% 85%

B (significant functional compromise) 7-9 80% 60%

C (decompensated) 10-15 45% 35%

a. Criteria For diagnosis ‘Diabetes Mellitus’

b. Criteria for diagnosis ‘Prediabetes’

i) Screening for diabetes mellitus should be done in the following patients: