PHC MANUAL

version 1.3, updated October 2008.

Dedicated to the God of South-Indian Cinema!

Note: These notes are meant for review before the Phase III PHC / Family Medicine OSCE exam.

1. Malaria Treatment.....................................................................................2
2. Typhoid Treatment....................................................................................3
3. Asthma Classification.................................................................................4
4. Hypertension............................................................................................5
5. Diabetes.................................................................................................13
6. NYHA Classification of Heart Failure............................................................18
7. Tuberculosis...........................................................................................19
8. General Gynae / Obs.................................................................................27
9. General Paediatrics..................................................................................31
10. General Adults.......................................................................................37
11. Drugs and Dosages.................................................................................48

1
MALARIA TREATMENT
Pakistan has Falciparum and Vivax.

Treatment first line:

1. Chloroquine 4 tablets first dose 2 tablets after 6 hrs 2 tablets on 2nd day 2 tablets on 3rd
day.
(150mg tblts) 10 mg/ kg stat 5 mg/kg at 6hrs 5 mg/kg OD for 2 days

2. Chloroquine 150 mg base tablet 1 OD for 3 days followed by Primaquine 15mg OD for 14 days
(Primaquine pediatric dose: 0.3 mg/kg; always check for G-6-PD deficiency)

3. Artimesen plus Leumofentrin (for falciparum)

For a person/adult >35 kg: 4 tablets at 0, 8, 24 and 48 hours
25-34 kg: 3 tablets
14-24 kg: 2 tablets

Treatment for Chloroquine Resistant P. Falciparum:

1. Quinine 600 mg TID for 7 days PLUS:

a. Doxycycline 100mg BID (paediatric 2mg/kg/day) for 7 days
b. Sulfadoxine pyramethamine 3 tablets on the last day
c. Clindamycin 900 mg TID (paediatric 20-40 mg/kg/day) for 5 days

Malaria in Pregnancy:

1st Trimester:
1. Quinine plus Clindamycin
2. ACT can be used if it is the only effective treatment available
2nd and 3rd trimester:-
1. Quinine plus clindamycin for 7 days if clindamycin not available, use monotherapy.
2. Artesunate plus clindamycin for 7 days

2
TYPHOID TREATMENT

Typhoid Drug Daily Dose Course Alternate Effective

Susceptibility Drug

Uncomplicated Fluoroquinolone 15 mg/kg 5-7 days Chloramphenicol 75

mg/kg for 14 days;
sensitive
Amoxil 100 mg/kg for
14 days

Carriers: Ciprofloxacin 500 mg BID 3-4wks 50-60% respond to

pharmatherapy
S .typhi > 1 yr
cholecystectomy

Typhoid vaccine

Paeds Ciprofloxacin 15 mg/kg BID 5-7 days

Chloramphenicol 75 mg/kg in 4 14 days

divided doses

Amoxicillin 100 mg/kg 14 days

TMP-SMX 8-40 mg/kg in 2 14 days

divided doses
or
1 Septran DS BID

MDR Quinolone: day 1-7

Cefixime: day 7-14

Azithromycin 1-7 d 8-10mg

Cefixime 7-14 d 15-20mg

Quinolone Azithromycin 8-10mg/kg 7days

Resistant Ceftriaxone 75mg/kg 10-14days
Cefixime 20mg/kg 7-14days

3
ASTHMA
GINA Guidelines

Levels of Asthma Control

Characteristic CONTROLLED PARTLY UNCONTROLLED
(All of the following) CONTROLLED
(Any measure
present in any week)
Daytime symptoms None ( 2 / week) 2 / week 3 features of partly
controlled asthma
Limitations of None Any
present in any week
activities
Nocturnal symptoms / None Any
awakening
Need for reliever / None ( 2 / week) 2 / week
rescue treatment
Lung function (PEF Normal < 80% predicted or
or FEV1) personal best (if
known)
Exacerbations None 1 / year* One in any week
* Any exacerbation should prompt review of maintenance treatment to ensure that it is
adequate.
By definition, an exacerbation in any week makes that an uncontrolled asthma week.
Lung function is not a reliable test for children 5 years and younger.

Previous Guidelines (for comparison)

Classification of Asthma Severity by Clinical Features Before Treatment
Symptoms < 1 / week Brief exacerbations
INTERMITTENT Nocturnal symptoms 2 / month
FEV1 or PEF 80% predicted
PEF or FEV1 variability < 20%
Symptoms > 1 / week but < 1 / day Exacerbations may affect activity and sleep
MILD PERSISTENT Nocturnal symptoms > 2 / month
FEV1 or PEF 80% predicted
PEF or FEV1 variability < 20 30%
Symptoms daily Exacerbations may affect activity and sleep
MODERATE Nocturnal symptoms > 1 / week
PERSISTENT Daily use of inhaled short-acting 2-agonist
FEV1 or PEF 60-80% predicted
PEF or FEV1 variability > 30%
Symptoms daily Frequent exacerbations
SEVERE PERSISTENT Frequent nocturnal asthma symptoms
Limitation of physical activities
FEV1 or PEF 60% predicted
PEF or FEV1 variability > 30%
*The worst feature determines the severity classification.

4
HYPERTENSION

JNC 7 GUIDELINES

5
6
7
8
DASH Diet (Dietary Approaches to Stop Hypertension)

DASH Diet

The DASH Diet (Dietary Approaches to Stop Hypertension) was tested and established by the National
Heart, Lung and Blood Institute NHLBI. It recommends limiting salt and sodium intake to control blood
pressure; in addition, it also recognizes the roles of another 3 minerals in controlling blood pressure -
calcium, magnesium and potassium.
The DASH diet puts more emphasis on whole grains, fruits and vegetables as well as low-fat dairy and
meat products. Studies showed that the DASH diet has been shown to lower both systolic and diastolic
blood pressure. Furthermore, it worked very quickly usually within 2 weeks! The DASH-sodium study
showed an even better blood pressure results with an intake of 1500 mg daily.
The following DASH diet is based on 2000 kcal a day.

Summary of the DASH Diet

Grains 7-8 servings
Vegetables 4-5 servings
Fruits 4-5 servings
Low-fat or Fat-free Dairy 2-3 servings
Meats, poultry & fish 2 or less servings
Nuts, seeds & dry beans 4-5 per week
Fats & oils 2-3
Sweets 5 per week

Basically, increased fruit, leafy vegetables and whole grain and fiber; restricted sodium (< 1500 or 1 tsp
per day), decreased red meat and use of polyunsaturated fats.

Goals of Therapy
The ultimate public health goal of antihypertensive therapy is the reduction of cardiovascular and renal
morbidity and mortality. Since most persons with hypertension, especially those age >50 years, will
reach the DBP goal once SBP is at goal, the primary focus should be on achieving the SBP goal.
Treating SBP and DBP to targets that are <140/90 mmHg is associated with a decrease in CVD
complications. In patients with hypertension and diabetes or renal disease, the BP goal is <130/80
mmHg.

Lifestyle Modifications
Adoption of healthy lifestyles by all persons is critical for the prevention of high BP and is an
indispensable part of the management of those with hypertension. Major lifestyle modifications shown
to lower BP include weight reduction in those individuals who are overweight or obese, adoption of the
Dietary Approaches to Stop Hypertension (DASH) eating plan which is rich in potassium and calcium,
dietary sodium reduction, physical activity, and moderation of alcohol consumption. (See table 5.)
Lifestyle modifications reduce BP, enhance antihypertensive drug efficacy, and decrease cardiovascular
risk. For example, a 1,600 mg sodium DASH eating plan has effects similar to single drug therapy.
Combinations of two (or more) lifestyle modifications can achieve even better results.

9
Pharmacologic Treatment
There are excellent clinical outcome trial data proving that lowering BP with several classes of drugs,
including angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs),
beta blockers (BBs), calcium channel blockers (CCBs), and thiazide-type diuretics, will all reduce the
complications of hypertension. Tables 6 and 7 provide a list of commonly used antihypertensive agents.
Thiazide-type diuretics have been the basis of antihypertensive therapy in most outcome trials. In these
trials [including the recently published Antihypertensive and Lipid Lowering Treatment to Prevent Heart
Attack Trial (ALLHAT)], diuretics have been virtually unsurpassed in preventing the cardiovascular
complications of hypertension. The exception is the Second Australian National Blood Pressure trial
which reported slightly better outcomes in White men with a regimen that began with an ACEI
compared to one starting with a diuretic.36 Diuretics enhance the antihypertensive efficacy of multidrug
regimens, can be useful in achieving BP control, and are more affordable than other antihypertensive
agents. Despite these findings, diuretics remain underutilized.
Thiazide-type diuretics should be used as initial therapy for most patients with hypertension, either alone
or in combination with one of the other classes (ACEIs, ARBs, BBs, CCBs) demonstrated to be
beneficial in randomized controlled outcome trials. The list of compelling indications requiring the use
of other antihypertensive drugs as initial therapy, are listed in table 8. If a drug is not tolerated or is
contraindicated, then one of the other classes proven to reduce cardiovascular events should be used
instead.

Achieving Blood Pressure Control in Individual Patients

Most patients who are hypertensive will require two or more antihypertensive medications to achieve
their BP goals. Addition of a second drug from a different class should be initiated when use of a single
drug in adequate doses fails to achieve the BP goal. When BP is more than 20/10 mmHg above goal,
consideration should be given to initiating therapy with two drugs, either as separate prescriptions or in
fixed-dose combinations. (See figure 1.) The initiation of drug therapy with more than one agent may
increase the likelihood of achieving the BP goal in a more timely fashion, but particular caution is
advised in those at risk for orthostatic hypotension, such as patients with diabetes, autonomic
dysfunction, and some older persons. Use of generic drugs or combination drugs should be considered to
reduce prescription costs.

10
Followup and Monitoring
Once antihypertensive drug therapy is initiated, most patients should return for followup and adjustment
of medications at approximately monthly intervals until the BP goal is reached. More frequent visits will
be necessary for patients with stage 2 hypertension or with complicating comorbid conditions. Serum
potassium and creatinine should be monitored at least 12 times/year. After BP is at goal and stable,
followup visits can usually be at 3- to 6-month intervals. Comorbidities, such as heart failure, associated
diseases such as diabetes, and the need for laboratory tests influence the frequency of visits. Other
cardiovascular risk factors should be treated to their respective goals, and tobacco avoidance should be
promoted vigorously. Low-dose aspirin therapy should be considered only when BP is controlled,
because the risk of hemorrhagic stroke is increased in patients with uncontrolled hypertension.

11
CCBs in heart failure, post MI, chronic kidney disease and prevention of recurrent stroke.
Post MI BB and ACE-I and aldosterone antagonist have proven to be most beneficial.
Intensive lipid management and aspirin are also recommended.
Heart failure asymptomatic ACE-I and B-blockers.
Symptomatic Loop diuretic with either ACE- I, ARB, BB and aldosterone blockers are
given
Stable angina BB or long acting CCB.
Recurrent stroke prevention ACE-I and Thiazide diuretic.

BHS & WHO HYPERTENSION CLASSIFICATION

BHS Algorithm for Management of Hypertension

12
DIABETES MELLITUS
(American Association of Clinical Endocrinologists 2007 guidelines for DM)

SCREENING AND DIAGNOSIS

Annually screen all individuals 30 years or older who are at risk for having or developing T2DM
(grade B)
Use 1 of the 3 diagnostic criteria presented in Table 2.3 to diagnose diabetes mellitus (grade B)
ACE/AACE does not recommend using HbA1c measurement to diagnose diabetes mellitus (grade C)
Screen all pregnant women for gestational diabetes mellitus (GDM) (grade A); women at low risk
should be screened at 24 to 28 weeks gestation; women at high risk should be screened at 20 weeks
gestation (grade B)

Table 2.1. Risk Factors for Prediabetes and Diabetes Mellitus (1)
Family history of diabetes Hypertension
Cardiovascular disease Increased levels of triglycerides, low
Overweight or obese state concentrations of HDL cholesterol, or both
Sedentary lifestyle History of gestational diabetes
Latino/Hispanic, NonHispanic black, Asian History of delivery of an infant with a birth weight
American, Native American, or Pacific Islander >9 pounds
ethnicity Polycystic ovary syndrome
Previously identified impaired glucose tolerance Psychiatric illness
or impaired fasting glucose

Table 2.2. Clinical Interpretations of Plasma Glucose Concentrations (2)

Fasting
<100 Within the reference range
100-125 Impaired fasting glucose/prediabetes mellitus
126 Overt diabetes mellitus
2-hour postchallenge load (75-g OGTT)
<140 Within the reference range
140-199 Impaired glucose tolerance/prediabetes mellitus
200 Overt diabetes mellitus

Table 2.3. Diagnostic Criteria for Diabetes Mellitusa (3)

Symptoms of diabetes (polyuria, polydipsia, unexplained weight loss) plus casual plasma glucose
concentration 200 mg/dL
or
Fasting plasma glucose concentration 126 mg/dL
or
2-hour postchallenge glucose concentration 200 mg/dL during a 75-g oral glucose tolerance test

One of the 3 criteria listed is sufficient to establish the diagnosis of diabetes mellitus.
These assessments should be confirmed by repeated testing on a subsequent day in the absence of
unequivocal hyperglycemia.

13
Table 2.4. Risk Factors for Gestational Diabetes Mellitus
>25 years of age Latino/Hispanic, nonHispanic black, Asian
Overweight or obese state American, Native American, or Pacific Islander
Family history of diabetes mellitus (ie, in a first- ethnicity
degree relative) Fasting (no energy intake for at least 8 hours)
History of abnormal glucose metabolism plasma glucose concentration >85 mg/dL
History of poor obstetric outcome or
History of delivery of an infant with a birth weight 2-hour postprandial glucose concentration >140
>9 pounds mg/dL (indicates need to perform a 75-g oral
History of polycystic ovary syndrome glucose tolerance test)

Table 2.5. Diagnostic Criteria for Gestational Diabetes Mellitus Using a 75-g Oral Glucose Tolerance Test (2)
Fasting >95
1-hour postglucose administration >180
2-hour postglucose administration >155
Two or more of the listed venous plasma glucose concentrations must be met or exceeded for a positive diagnosis. The test should be
performed after an overnight fast of 8 to 14 hours and after at least 3 days of unrestricted diet (ie, 150 g carbohydrate per day) and
unlimited physical activity.

Table 2.6. Summary of Diabetes Mellitus Classifications (2)

Type 1 Diabetes Mellitus
Accounts for only 5% to 10% of all diabetes mellitus cases.
Caused by an absolute deficiency of insulin secretion due to a cellular-mediated autoimmune destruction of the pancreatic -
cells.
Viruses associated with initiation of -cell destruction include congenital rubella, coxsackievirus B, cytomegalovirus,
adenovirus, and mumps.
Markers of -cell destruction include islet cell autoantibodies, autoantibodies to insulin, autoantibodies to glutamic acid
decarboxylase (GAD65), and autoantibodies to the tyrosine phosphatases IA-2 and IA-2.
Rate of -cell destruction variesinfants and children often experience rapid -cell destruction; rate of destruction is usually
slower in adults.
Individuals at increased risk can often be identified by serological evidence of an autoimmune pathologic process occurring
in the pancreatic islet cells and by genetic markers.

Type 2 Diabetes Mellitus

Accounts for 90% to 95% of all diabetes mellitus cases.
Caused by a combination of complex metabolic disorders that result from coexisting defects of multiple organ sites such as
insulin resistance in muscle and adipose tissue, a progressive decline in pancreatic insulin secretion, unrestrained hepatic
glucose production, and other hormonal deficiencies.
Before the appearance of clinical symptoms, a degree of hyperglycemia may be present, causing pathologic and functional
changes in various target tissues.
Most affected individuals are obese and, therefore, have variable degrees of insulin resistance; affected individuals who are
not obese may have an increased percentage of visceral fat, which can cause insulin resistance.
Other risk factors include increasing age and sedentary lifestyle.
Occurs more frequently in women with previous gestational diabetes and in individuals with hypertension or dyslipidemia.
Associated with a strong genetic predisposition.

Gestational Diabetes Mellitus

Defined as any degree of glucose intolerance identified during pregnancy; definition applies regardless of the therapy used to
treat the condition

14
TREATMENT GUIDELINES FOR DIABETES MELLITUS

15
16
Insulin given as Basal, 2/3rd and 1/3rd; 2/3rd in AM and 1/3rd in PM along with rapid acting insulin before
meals or oral hypoglycaemics.

Table 4.6. Effect of Oral Therapies on Hemoglobin A1c Levels in Patients With Diabetes Mellitus

17
The Stages of Heart Failure NYHA Classification
In order to determine the best course of therapy, physicians often assess the stage of heart failure
according to the New York Heart Association (NYHA) functional classification system. This system
relates symptoms to everyday activities and the patient's quality of life.

Class Patient Symptoms

Class I (Mild) No limitation of physical activity. Ordinary physical activity does not cause
undue fatigue, palpitation, or dyspnea (shortness of breath).
Class II (Mild) Slight limitation of physical activity. Comfortable at rest, but ordinary
physical activity results in fatigue, palpitation, or dyspnea.
Class III (Moderate) Marked limitation of physical activity. Comfortable at rest, but less than
ordinary activity causes fatigue, palpitation, or dyspnea.
Class IV (Severe) Unable to carry out any physical activity without discomfort. Symptoms of
cardiac insufficiency at rest. If any physical activity is undertaken, discomfort
is increased.

18
TUBERCULOSIS
(Guidelines for Diagnosis & Management of Tuberculosis: A National Clinical Guideline;
Pakistan Chest Society Center, 2005)

Tuberculosis is an infectious, systemic, chronic granulomatous disease caused by Mycobacterium

tuberculosis. Mycobacterium bovis and Mycobacterium avium can rarely cause tuberculosis
Infection occurs almost exclusively through the respiratory system by inhalation of tubercle bacilli.
Tuberculosis spreads from the primary lung lesion to other parts of the body via the blood stream and
lymphatics or by direct extension, and in this way may affect any organ.

FORMS OF TUBERCULOSIS
Pulmonary Tuberculosis: Tuberculosis affects the lungs in more than 80% of cases. Pulmonary
tuberculosis in adults is often sputum smear-positive and therefore highly infectious. Cases, which are
sputum smear-negative or positive only on sputum culture, are 7 to 10 times less infectious than those
who are positive on direct microscopic examination of sputum smears.
Extra-Pulmonary Tuberculosis: This affects various organs such as lymph nodes, pleura, pericardium,
intestines and many other parts of the body. Diagnosis is often difficult and should preferably be made
by physicians at referral hospitals. Extra -pulmonary tuberculosis is usually non-infectious.
Tuberculosis in children: Diagnosis of tuberculosis in children depends largely on results of clinical
examination, history of close contact with a case of tuberculosis, X-ray examination and tuberculin
testing. This is because sputum cannot be easily obtained from children. The decision whether to treat
the child or not should be made by an expert.

Sx
Most common Sx of pulmonary TB: persistent cough for three weeks or more, usually with
expectoration.
Associated Sx: fever, loss of appetite, weight loss, tiredness, night sweats, chest pain, shortness of breath
and haemoptysis.
Suspicion of tuberculosis much more likely to be correct in patients with above-mentioned symptoms
and Hx of close contact with a patient having smear positive TB.
For extra-pulmonary TB, symptoms depend on the organ involved, for example:
Cough and shortness of breath in pleural or pericardial effusion.
Swelling, occasionally with pus discharge when lymph nodes are affected.
Pain and swelling when joints are involved.
Headache, fever, neck stiffness and confusion when there is tuberculous meningitis.
Backache with or without loss of function in lower limbs when there is gibbus formation and spinal
involvement.
Abdominal pain, diarrhea or ascites with abdominal involvement.
Infertility when genital organs are affected.

19
DEFINITIONS
Smear Positive Patient at least 2 sputum specimens +ive for AFB by microscopy,
OR radiographic abnormalities of pulmonary TB with 1 sputum
specimen +ive for AFB.

Smear-Negative Patient clinical and radiographic abnormalities consistent with active

pulmonary TB, but at least 3 sputum specimens ive for AFB by
microscopy.

Extra-Pulmonary Tuberculosis 1 bacterial culture +ive specimen from an extra-pulmonary site

OR +ive histological and/or clinical evidence consistent with active
extra pulmonary TB

New Case A patient who has never had treatment for tuberculosis or has taken anti-
tuberculous drugs for less than four weeks.

Relapse A sputum smear positive patient, who was declared cured in the past, after
completing a course of antituberculous drugs.

Failure Case A patient who remains, or becomes, sputum smear positive five months or
more after commencing treatment.

Chronic Case A patient who remains AFB smear-positive even after completing a re-
treatment regimen under supervision.

Treatment after default A patient who returns to treatment after having interrupted treatment for
two months or more, and is sputum smear positive.

COMPLICATIONS OF TUBERCULOSIS
Haemoptysis All severe cases: the patient should be referred to the nearest hospital.
In treated cases, the recurrence of haemoptysis does not always reflect active disease and if in doubt,
sputum examination should be done.
Causes other than tuberculosis may also be considered.
Spontaneous Pneumothorax Refer immediately to nearest hospital
Pleural effusion Massive effusion does not improve with chemotherapy alone. Aspiration may be
necessary for relief of symptoms. Therefore, patients should be referred to the nearest hospital for
further management.
Bronchiectasis / Fibrosis of the lungs Common consequences of tuberculosis responsible for
recurrence of non-TB infections and haemoptysis.
Chronic respiratory insufficiency Tuberculosis may heal with extensive destruction of the lung
tissue or scarring. These patients will continue to complain of shortness of breath, cough and sputum
with haemoptysis etc, and may eventually develop right sided heart failure i.e. cor pulmonale. Such
patients should not be treated with anti-tuberculous drugs.

20
DRUGS AND REGIMENS
Do not start treatment for tuberculosis until a firm diagnosis has been made; confirmed TB patients
should receive a complete course of treatment according to their regimens and specified duration. TB
drugs should not be given as a trial.

TB patients can be categorized into 2 major groups:

1) New Cases
2) Re-Treatment Cases

1. New Cases
Patients who have never received treatment for tuberculosis, or taken it for less than 4 weeks. This
group includes the following:
Smear positive pulmonary tuberculosis.
Smear negative pulmonary tuberculosis.
Extra-pulmonary tuberculosis.
The treatment for this group of patients should be eight months short course chemotherapy (SCC).
(Figure 1)
Initial intensive phase 2 HRZE, i.e. isoniazid, rifampicin, pyrazinamide and ethambutol, administered
under strict observation daily, for 2 months.
Continuation phase 6 HE, i.e. isoniazid and ethambutol, daily for 6 months. Alternatively, RH, i.e.
rifampicin and isoniazid, may be given for 4 months.

2. Re-Treatment Case
Patients who have taken treatment in the past. This group includes the following:
Relapses
Treatment failures
Smear positive patients who have taken antituberculous treatment (ATT) for more than one
month and defaulted.
The treatment recommended for this group of patients is also eight months short course chemotherapy.
(Figure 2)
Initial intensive phase 2 RHZE+S, i.e. rifampicin, isoniazid, pyrazinamide, ethambutol and
streptomycin for 2 months, followed by one month with 4 drugs, i.e. RHZE.
Continuation phase 5 RHE, i.e. rifampicin, isoniazid, and ethambutol for another 5 months.

21
22
23
FIXED DOSE COMBINATIONS (FDCs).
FDCs have the advantage of improving patient compliance. Always calculate dosage according to each patient.
Use of separate drugs is advised in cases of weight-dosage discrepancy with FDCs.

(RHZE) R= 120 mg. H= 60mg. Z=300mg, E=225mg, (HE) H= 100 mg, E= 300mg,
R = Rifampicin H = Isoniazid Z = Pyrazinamide E = Ethambutol
RH for 4 months may be given in the continuation phase.

(RHZE) R = 120mg, H = 60mg, Z = 300mg, E = 225mg (RHE) R = 150mg H = 75mg E = 300mg

R = Rifampicin, H = Isoniazid, Z = Pyrazinamide, E = Ethambutol, S = Streptomycin
24
(HR) = H 100mg, R 150 mg, (HE) = H 100mg, E 150 mg, (Z) = 500mg, (E) = 400mg
R = Rifampicin H = Isoniazid Z = Pyrazinamide E = Ethambutol
RH for 4 months may be given in the continuation phase

(HR) = H 100mg, R 150mg, (HRE) = H 75mg, R 150mg, E 300mg, (Z) = 500mg, (E) = 400mg, (S) = 1 gm
R = Rifampicin H = Isoniazid Z = Pyrazinamide E =Ethambutol S = Streptomycin

(HR) = H100mg. R 150 mg, (Z) = 500mg R = Rifampicin H = Isoniazid Z = Pyrazinamide E = Ethambutol S = Streptomycin
NOTE: Treatment for pre-treatment weight of less than 5 kg must be prescribed by a specialist. Streptomycin should be given in place of
Ethambutol to children under the age of 6 years.
25
POINTS TO REMEMBER
Remember to do sputum smear for AFB on all patients suspected of Pulmonary Tuberculosis.
Try to get histological proof for extra -pulmonary TB (e.g. effusion, lymph node etc) where possible.
Always calculate the dose according to patients body weight.
Patients education regarding correct dosage of drugs, regular treatment and possible side effects is
essential.
Always categorize patients according to the Chest Society Guidelines.
Treatment must be directly observed during the intensive phase of treatment.
Regular follow-up of the patients throughout the treatment period.
Refer patients with suspected MDR-TB for treatment to a chest specialist.
Never add a single drug to a failing regimen.

26
GENERAL GYNAE/OBS

DOWNS SYNDROME SCREENING

First trimester screens (0-13 weeks)
Maternal age and past obstetric history
Pregnancy associated plasma protein (PAPP-A which is low in Downss)
Nuchal translucency 11-14 weeks (measure the collection of fluid behind the neck in fetus).
N.B. If both indicative of downs go for a diagnostic test CVS or amniocentesis.
Second trimester screens (13-26 weeks)
Triple screen 16-20 weeks (measures alpha feto protein decreased, -hCG increased,
unconjugated estriol) is not diagnostic but identifies women who should be offered diagnostic
test such as amniocentesis/CVS. Adding inhibin A to the battery of tests makes it the quadruple
screen.
Chorionic villus sampling or Amniocentesis to identify fetal cells with trisomy 21
N.B. The advantage of identifying downs in the first trimester is that the fetus can be aborted as a
daycare procedure. If identified in 2nd trimester then need to induce labor.

Pregnant woman with LOWER ABDOMINAL PAIN

Abortion Ectopic pregnancy
Ovarian torsion If shock present D/D includes Ectopic,
Ruptured ovarian cyst ruptured hepatic adenoma and ruptured
PID spleen.
Degenerative leiomyoma

MENORRHAGIA
Hx What is the length of the cycle including the longest and the shortest?
For how many days does heavy bleeding occurs
How many sanitary pads are to be used
Do you ever experience flooding
Do you ever pass clot if yes what is the size
Does this affect your functionality
How else is the bleeding affecting you
What contraception is she using (?IUD)
Are there symptoms of anemia
Is there associated pain with the period
Any intermenstrual or post-coital bleeding
Dysparunia
Pelvic pain
Pre-menstrual pain
Rx Tranxemic acid when painless 500 mg TID 5 days
Mefenamic acid when painful 500 mg TID 5 days
OCPs

27
TREATMENT OF PCOS
Give clomiphene citrate 50 mg OD from day 5 to day 10 of the menstrual cycle. Access follicle size on
day 12 and if adequate give HMG on day 14 to induce ovulation.

Aspirin dose in rheumatic fever:

dose of 120 mg/kg/day is given upto a maximum of 8 gm/day for two weeks and then 60 mg/kg is given
for the next 6-9 weeks until symptoms subside.

Woman of reproductive age with hyperthyroidism:

Give Propanolol 100 mg BID
Propylthiouracil 100-200 mg PO QID.
Check FT4 levels after 3-4 weeks and adjust dose accordingly.

VAGINAL DISCHARGE
Hx Duration Any change in sanitary practices/under
Amount garments
Color Marital status
Odor Sexual Hx
Consistency Hx of STDs Or PIDs
Relation to menstrual cycle Contraception
Assoc. symptoms like pain, itching, Co-morbid conditions like DM
burning or post-coital bleeding Drugs (steroids, ABX)
Rx Bacterial Vaginosis Metronidazole 500 mg TID for 1 week
or
Clindamycin 300 mg BID for 1 week
Candidiasis 5% clotrimazole cream for 7-14 days
Clotrimazole vag tab 100 mg for 7 days
Fluconazole 150 mg single dose
Trichomoniasis Treat both partners
Metronidazole 2 g stat

POSTMENOPAUSAL LADY
screen for
Cervical Ca
Breast Ca
IHD
Osteoporosis (both primary and secondary prevention)
Give Calcium 1200 mg and Vit-D 400 I.U per day.

PREGNANT LADY
F.A 5 mg OD
FeSO4 200 mg TID
Calcium lactate 300 mg TID
Calories Add 300 Kcal to the basal requirement
28
APPROPRIATE WEIGHT GAIN
Weight gain during pregnancy is a normal phenomenon. However gaining too much or too little can be
harmful for both the mother and the baby. Following is a rough guide of weight distribution that is
gained during pregnancy.

WHERE THE WEIGHT GOES

7.5 - 8.5 lbs Baby
2 lbs Amniotic Fluid
1.5 - 2 lbs Placenta
1.5 - 2 lbs Breast Tissue
3 lbs Blood Volume
2 - 2.5 lbs Uterine Muscle
4 lbs Water
8 lbs Maternal Stores
Appropriate weight gain is determined by calculating the BMI of the female. Appropriate weight gain
according to BMI from the American College of Obstetricians and Gynecologists guidelines are as
follows:
Underweight 28 to 40 pounds
Normal weight 25 to 35 pounds
Overweight 15 to 25 pounds
Obese At least 15 pounds

A second more accurate

method will be to plot
the exact BMI of the
patient and compare
it with the standard. A
standard graph for BMI
less than 20 is given
below.

According to this a
woman less than 5 feet
2 inches and BMI less
than 20 should follow
the curve below.
Women with BMI less
than 20 and height more
than 5 feet 2 inches
should be following the
curve on the upper side.
Many women are not
able to achieve the first
trimester target because
of excessive nausea and
vomiting. This is not worrisome if she is able to catch up later. Weight gain in the second and third
trimester is very important during which time there must be a gain of one pound per week.

29
Counseling for FAMILY PLANNING GATHER
Greeting
Age (both partners), Parity (ask spacing between children), Gravidity, L.M.P
P/C if any
Detailed menstrual Hx.
Previous contraceptives use Type and level of satisfaction with that.
Co-morbid conditions
Family Hx.
Ask about the methods she knows
Tell her about all the different options
Help her in choosing one
Explains pros and cons of that
Regular F/Up as indicated

SMOKING COUNSELING
Greeting and Introduction
Age, Occupation
Ask question about the cigarette smoking:
How many per day: Kitnay dubay peetay hain
Since how long: Kub se?
Any attempt or previous desire to quit: Pehlay chornay ki koshish ki?
Attitude towards the habit: Is aadat ko kaisa samajhtay hain?
Knowledge about the side effects: Kya app ko iss ke muzar asraat ka pata hai?
Readiness to quit: Ky abb chornay ke liyay tiyaar hain?
Also ask CAGE to see if addiction is present
Now comes our part
Explains the S/E both to the patient and to the family physically, mentally and financially
Tell about the benefits of quitting
If ready to quit
Explain steps towards quitting
Ask the person to choose one day for quitting.
Tell them about the different ways available to help them quit.
Positively re-enforce and be in constant touch to help person stick with the decision.

30
GENERAL PAEDIATRICS

Child presents with runny nose, respiratory distress with a rate of 44/min and stridor
Hx Ask about fever and convulsions, oral intake, F.B.
Rx Give first dose of antibiotic and refer.

Infection after ear piercing

Remove F.B, Give tetanus toxoid if not immunized or more than five years have lapsed since last dose.
Give Cloxacillin 250 mg PO QID for 7 days
In children give 50-100 mg PO QID for 7 days.
Assess dehydration Pulse, general appearance, Ant. fontanelle, Eyes: tears or not, Skin turgor,
Drinking
Also ask about danger signs
Organisms Rotavirus, E.Coli, Salmonella, Shigella, Vibrio. Cholera

NEONATAL JAUNDICE
Bilirubin is the final product of heme degradation. At physiologic pH, bilirubin is insoluble in plasma
and requires protein binding with albumin. After conjugation in the liver, it is excreted in bile.
Newborns produce bilirubin at a rate of approximately 6 to 8 mg per kg per day. This is more than twice
the production rate in adults, primarily because of relative polycythemia and increased red blood cell
turnover in neonates.Bilirubin production typically declines to the adult level within 10 to 14 days after
birth.

Bilirubin Toxicity
"Kernicterus" refers to the neurologic consequences of the deposition of unconjugated bilirubin in
brain tissue. Subsequent damage and scarring of the basal ganglia and brainstem nuclei may occur.
If the serum unconjugated bilirubin level exceeds the binding capacity of albumin, unbound lipid-
soluble bilirubin crosses the blood-brain barrier. Albumin-bound bilirubin may also cross the blood-
brain barrier if damage has occurred because of asphyxia, acidosis, hypoxia, hypoperfusion,
hyperosmolality, or sepsis in the newborn.
The exact bilirubin concentration associated with kernicterus in the healthy term infant is unpredictable.
Toxicity levels may vary; the risk of bilirubin toxicity is probably negligible in a healthy term newborn
without hemolysis, the physician should become concerned if the bilirubin level is above 25 mg per dL,
and in the term newborn with hemolysis, a bilirubin level above 20 mg per dL.

Effects of Bilirubin Toxicity in Newborns

Early Late Chronic
Lethargy Irritability Athetoid cerebral palsy
Poor feeding Opisthotonos High-frequency hearing loss
High-pitched cry Seizures Paralysis of upward gaze
Hypotonia Apnea Dental dysplasia
Oculogyric crisis Mild mental retardation
Hypertonia
Fever

31
Risk Factors for Hyperbilirubinemia in Newborns
Maternal factors Neonatal factors
Blood type ABO or Rh incompatibility Birth trauma: cephalohematoma, cutaneous
Breastfeeding bruising, instrumented delivery
Drugs: diazepam (Valium), oxytocin (Pitocin) Drugs: sulfisoxazole acetyl with erythromycin,
Ethnicity: Asian, Native American ethylsuccinate (Pediazole), chloramphenicol
Maternal illness: gestational diabetes (Chloromycetin)
Excessive weight loss after birth
Infections: TORCH
Infrequent feedings
Male gender
Polycythemia
Prematurity
Previous sibling with hyperbilirubinemia

TORCH = toxoplasmosis, other viruses, rubella, cytomegalovirus, herpes (simplex) viruses.

32
PHYSIOLOGIC JAUNDICE
Physiologic jaundice in healthy term newborns follows a typical pattern. The average total serum bilirubin
level usually peaks at 5 to 6 mg per dL (86 to 103 mol per L) on the third to fourth day of life and then declines
over the first week after birth.Bilirubin elevations of up to 12 mg per dL, with less than 2 mg per dL (34 mol per
L) of the conjugated form, can sometimes occur. Infants with multiple risk factors may develop an exaggerated
form of physiologic jaundice in which the total serum bilirubin level may rise as high as 17 mg per dL (291 mol
per L).
Factors that contribute to the development of physiologic hyperbilirubinemia in the neonate include an
increased bilirubin load because of relative polycythemia, a shortened erythrocyte life span (80 days compared
with the adult 120 days), immature hepatic uptake and conjugation processes, and increased enterohepatic
circulation.

JAUNDICE AND BREASTFEEDING

Early-Onset Breastfeeding Jaundice. Breastfed newborns may be at increased risk for early-onset exaggerated
physiologic jaundice because of relative caloric deprivation in the first few days of life.Decreased volume and
frequency of feedings may result in mild dehydration and the delayed passage of meconium. Compared with
formula-fed newborns, breastfed infants are three to six times more likely to experience moderate jaundice (total
serum bilirubin level above 12 mg per dL) or severe jaundice (total serum bilirubin level above 15 mg per dL
[257 mol per L]).
In a breastfed newborn with early-onset hyperbilirubinemia, the frequency of feedings needs to be increased to
more than 10 per day. If the infant has a decline in weight gain, delayed stooling, and continued poor caloric
intake, formula supplementation may be necessary, but breastfeeding should be continued to maintain breast milk
production. Supplemental water or dextrose-water administration should be avoided, as it decreases breast milk
production and places the newborn at risk for iatrogenic hyponatremia.
Late-Onset Breast Milk Jaundice. Breast milk jaundice occurs later in the newborn period, with the bilirubin
level usually peaking in the sixth to 14th days of life. This late-onset jaundice may develop in up to one third of
healthy breastfed infants. Total serum bilirubin levels vary from 12 to 20 mg per dL (340 mol per L) and are
nonpathologic.
The underlying cause of breast milk jaundice is not entirely understood. Substances in maternal milk, such as
glucuronidases, and nonesterified fatty acids, may inhibit normal bilirubin metabolism. The bilirubin level usually
falls continually after the infant is two weeks old, but it may remain persistently elevated for one to three months.
If the diagnosis of breast milk jaundice is in doubt or the total serum bilirubin level becomes markedly elevated,
breastfeeding may be temporarily interrupted, although the mother should continue to express breast milk to
maintain production.With formula substitution, the total serum bilirubin level should decline rapidly over 48
hours (at a rate of 3 mg per dL [51 mol per L] per day),1 confirming the diagnosis. Breastfeeding may then be
resumed.

PATHOLOGIC JAUNDICE
All etiologies of jaundice beyond physiologic and breastfeeding or breast milk jaundice are considered
pathologic. Features of pathologic jaundice include the appearance of jaundice within 24 hours after birth, a
rapidly rising total serum bilirubin concentration (increase of more than 5 mg per dL per day), and a total serum
bilirubin level higher than 17 mg per dL in a full-term newborn. Other features of concern include prolonged
jaundice, evidence of underlying illness, and elevation of the serum conjugated bilirubin level to greater than 2
mg per dL or more than 20 percent of the total serum bilirubin concentration. Pathologic causes include disorders
such as sepsis, rubella, toxoplasmosis, occult hemorrhage, and erythroblastosis fetalis.

33
PHYSICAL EXAMINATION
The presence of jaundice can be determined by examining the infant in a well-lit room and blanching the skin
with digital pressure to reveal the color of the skin and subcutaneous tissue. Neonatal dermal icterus is not
noticeable at total serum bilirubin levels below 4 mg per dL (68 mol per L).
Increasing total serum bilirubin levels are accompanied by the cephalocaudal progression of dermal icterus,
predictably from the face to the trunk and extremities, and finally to the palms and soles. The total serum bilirubin
level can be estimated clinically by the degree of caudal extension: face, 5 mg per dL; upper chest, 10 mg per dL
(171 mol per L); abdomen, 12 mg per dL; palms and soles, greater than 15 mg per dL.
The only consistently reliable estimation of total serum bilirubin occurs when dermal icterus is confined to
above the nipple line. In this situation, the bilirubin level is invariably below 12 mg per dL.As jaundice extends
below the middle of the chest, the correlation between physical signs and measured bilirubin levels becomes
increasingly unreliable. Differences in skin color among races, delays in dermal deposition with rapidly rising
bilirubin levels, interobserver variability, and other factors contribute to the difficulty of accurately predicting the
total serum bilirubin concentration based on caudal progression alone.
The physical examination should focus on identifying one of the known causes of pathologic jaundice. The
infant should be assessed for pallor, petechiae, extravasated blood, excessive bruising, hepatosplenomegaly,
weight loss, and evidence of dehydration.

34
TREATMENT
Before treatment is initiated, the minimum evaluation should include the infant's age and postnatal course, a
maternal and gestational history, physical examination of the infant, and determination of the total serum bilirubin
level and the rate at which it is rising.
Jaundice in a term newborn fewer than 24 hours old is always pathologic: it should be investigated thoroughly
and treated appropriately. Depending on the rate at which the bilirubin level rises, a newborn's risk of developing
significant hyperbilirubinemia can be classified as low, intermediate, or high. Conjugated hyperbilirubinemia is
never physiologic, and it may indicate the presence of a potentially serious underlying disorder. However,
elevated conjugated bilirubin levels are not directly toxic to brain cells in the neonate.
If jaundice persists for more than two weeks in a formula-fed infant and more than three weeks in a breastfed
infant, further evaluation is warranted. Laboratory studies should include a fractionated bilirubin level, thyroid
studies, evaluations for metabolic disorders or hemolytic disease, and an assessment for intestinal obstruction.
PHOTOTHERAPY
Phototherapy employs blue wavelengths of light to alter unconjugated bilirubin in the skin. The bilirubin is
converted to less toxic water-soluble photoisomers that are excreted in the bile and urine without conjugation. The
decision to initiate phototherapy is based on the newborns age and total serum bilirubin level (Table 4).
To expose the greatest surface area, the newborn should be naked except for eye shields. For double
phototherapy, a fiber optic pad can be placed under the newborn. This method is twice as effective as standard
phototherapy.
The only contraindication to the use of phototherapy is conjugated hyperbilirubinemia, as occurs in patients
with cholestasis and hepatic disease. In this setting, phototherapy may cause a dark grayish-brown discoloration
of the skin (bronze baby syndrome). Potential problems that may occur with phototherapy include burns, retinal
damage, thermoregulatory instability, loose stools, dehydration, skin rash, and tanning of the skin. Because
phototherapy is continuous, treatment also involves significant separation of the infant and parents.
With intensive phototherapy, the total serum bilirubin level should decline by 1 to 2 mg per dL (17 to 34 mol
per L) within four to six hours. The bilirubin level may decline more slowly in breastfed infants (rate of 2 to 3 mg
per dL per day) than in formula-fed infants. Phototherapy usually can be discontinued when the total serum
bilirubin level is below 15 mg per dL. The average rebound bilirubin level after phototherapy is below 1 mg per
dL. Therefore, hospital discharge of most infants does not have to be delayed to monitor for rebound elevation.
If the total serum bilirubin level remains elevated after intensive phototherapy or if the initial bilirubin level is
meets defined critical levels based on the infants age (Table 4),1 preparations should be made for exchange
transfusion.
EXCHANGE TRANSFUSION
Exchange transfusion is the most rapid method for lowering serum bilirubin concentrations. This treatment is
rarely needed when intensive phototherapy is effective. The procedure removes partially hemolyzed and antibody-
coated erythrocytes and replaces them with uncoated donor red blood cells that lack the sensitizing antigen.
In the presence of hemolytic disease, severe anemia, or a rapid rise in the total serum bilirubin level (greater
than 1 mg per dL per hour in less than six hours), exchange transfusion is the recommended treatment. Exchange
transfusion should be considered in a newborn with nonhemolytic jaundice if intensive phototherapy fails to lower
the bilirubin level.
Complications of exchange transfusion can include air embolism, vasospasm, infarction, infection, and even
death. Because of the potential seriousness of these complications, intensive phototherapy efforts should be
exhausted before exchange transfusion is initiated.

35
ENURESIS
Differentiate between primary and secondary (remained dry for 6 months)
Night time only or day time as well
Psychological stressors
Fluid and caffeine intake
Assoc. constipation
No. of times / month (two or more is significant for 4-6 years of age and 1 or more is significant for >6 years of age)
Sleeping habits
Wt. Loss (D.M, hyperthyroidism)
Hx of UTI
Lower limb problem
Causes: Excessive water intake, congenital anomalies, constipation, UTI, psychological, dysfunctional
sphincter control, neurogenic bladder, seizures, pin-worm, and urethral obstruction.
Exam:
General look of the patient Gait Sign of abuse
Lumbo-sacral area Reflexes Mile stones
Genital exam
Abdominal exam Bladder palpation, kidney palpation, any other masses.
DRE
Labs: Urine D/R, U/S
Rx Assess whether the child is motivated or not
Behavioral therapy (bell and pad apparatus, star chart, award system)
Drugs Use only intermittently
Desmopressin 0.2 mg HS for three months

DIARRHEA
Fluids and rehydration
Infectious:
1. Nalidixic Acid 55 mg/kg/day in 4 divided doses (5 ml has 250 mg)
2. Metronidazole 15 mg/kg/day in 3 divided doses for 5 days
3. Septran < 6 months tsp
6m-5yrs 1 tsp
5-12 yrs 2 tsp
4. Cloxacillin 50-100 mg QID for 7 days

36
GENERAL ADULTS
Person treated for malaria, Plasmodium vivax. Recurrence occurs. What to do?
Give Chloroquine + Primaquine (15 mg OD for 14 days)

Person with hypertension:

Labs Urinalysis, Cr, Serum K, Cholesterol, U.A, ECG, CXR, VMA, Renal Artery U/S

COPD
Chest X-Ray findings: Hyperinflated lungs
Decreased vascular markings
Tubular heart
Black lung fields
Flat diaphragm
Mx : Most important for long term Mx is to stop smoking.
Other treatment includes Ipratropium initially PRN then regularly Q6H. Also give a trial of
steroids.

BREAST CA
Risk Factors Family Hx Radiation
Nulliparity Early menarche
Late menopause HRT
First child after 30 years of age
Screening History, clinical exam, self exam is not that effective. Mammography and U/S

Both B-blockers and ACE inhibitors cause cough.

OBESE HYPERTENSIVE PATIENT newly diagnosed with DM and HYPERLIPIDEMIA

Nonpharmacological Mx Diet, Exercise, Stop Smoking, No Alcohol.
Pharmacological Mx Change to ACE-I enalapril 5mg 1+0+0
Give metformin (start at 500 mg 1+0+1)
and Atorvastatin (Lipiget 10 mg OD)

HERPES ZOSTER if patients presents within 72 hrs of vesicle eruption

Acyclovir 800 mg 5 times a day for five days
For pain give NSAIDs + amitryptaline 25 mg OD for 1 week
If post-herpetic neuralgia: give carbamazapine or gabapentin

CHILD WITH T.B CONTACT

Do PPD: if less than 5 vaccinate
if b/w 5-10 no intervention
if >10 start ATT

37
TIA
Labs & Radio: Cr, Electrolytes, Glucose, CBC, LFTs, Tox screen, CT without contrast, carotid
Doppler, clotting profile
For B.P control give ACE-I and thiazide diuretic
Strict control of dyslipidemia
If confirmed TIA give aspirin and clopidogrel

TINEA
on slide ring shaped advancing lesion with raised scaly margins and central clearing, hair loss.
Tinea corporis (trunk, limbs) give topical clotrimazole 1% BID for 2 weeks
Tinea cruris (groin) give topical clotrimazole 1% BID 4 weeks
Tinea pedis (foot) give topical clotrimazole 1% BID for 4 weeks
Tinea capitis (Head) Tab Griseofulvin 0.5g QD PO for 6 weeks
Tinea unguium (finger nails) also called onychomycosis Tab Griseofulvin 1g PO QD for 6 weeks
Tinea unguium (toe nail) Tab Griseofulvin 1g PO QD for 3-4 months
Candidiasis: Clotrimazole cream inserted in to vagina once usually clears infection. A pessary can be
used instead, or if convenience is desired and the patient is not pregnant a single Tab of Clotrimazole
500 mg PO STAT.
Tinea versicolor 1% clotrimazole apply bid for 4-6 weeks.
Griseofulvin is contraindicated in women who might get preganant. Its teratogenic.
Also in case of pedis advice patient to clean the feet, keep them dry and change socks regularly. If there
is recurrent infections send FBS to rule out diabetes.

PROLACTINOMA:
To rule out prolactinoma ask about headaches, visual changes (classically bitemporal hemianopia),
galactorrhea, infertility in males and menstrual problems in females and finally C.N. palsies.
Sar ka dard?
Nazar theek aa raha ha?
Seenay se kuch kharij tou nahee ho raha?
Kya hamal thernay mein mushkil paish aa rahee hai?
Mahwaree theek aarahee hai ya nahee?
Do serum prolactin: >200 is significant, MRI head and visual fields.

Tests for Hep-A: SGPT, anti HAV Ab IgM.

Diet: Explain to the patient that there is no dietary restriction except alcohol.

PNEUMONIA Typical Atypical

Strep. Pneumoniae Mycoplasma
H. Influenzae Chlamydia
Viral
Diagnosis: Sputum gram stain, blood C/S and CXR
Special tests: Serology, Cold agglutinins 1:32, Ab titer for Chlamydia.
Tell patient not to smoke, take rest and drink plenty of fluids.
Treatment: For Community acquired pneumonia
1st choice: Tab Erythromycin 500 mg PO QID for 10 days
2nd choice: Tab Doxycycline 100 mg PO BID for 10 days
38
Red flags in LOWER BACK ACHE
Lower limb weakness/paralysis and paresthesias/sensory loss, Urinary or Stool incontinence,
Neurogenic bladder, Severe unrelenting progressive pain, Fever, Weight loss, Contact with T.B, Clonus,
new onset Erectile dysfunction, Spine tenderness
D/D: Mechanical Disc herniation
Inflammatory Infection
Neoplasm/mets Referred pain
Examination: Inspection for spine curvature. Any tuft of hair or simple in midline.
Palpate spine for tenderness
Range of movements for the spine
Lower limb strength and sensory perception and reflexes
SLR eliciting neuropathic pain before 60 degree is suggestive of nerve root compression. The pain must
radiate below the knee for the test to be positive.
Make the patient get up from squatting: inability or weakness suggestive of L4 lesion.
Sensory loss about the knee with loss of knee jerk
Walking on heels: test for L5 nerve root, pain on side of leg, no reflexes affected,
anesthesia in the interdigital web of big toe, weak dorsiflexion of foot
Walking on toes: test for S1 nerve root, loss of ankle jerk, weak planter plexion of foot

SHOULDER EXAM
Observation, Passive and active range of movements and finally Hawkins and Neeres test for rotator
cuff tendonitis.
Rx Shoulder rest from activities that cause pain. Physiotherapy and hot-fomentation.
Give NSAIDs for pain relief. If still unable to move the shoulder give steroidal injection.

MANAGEMENT OF ROTATOR CUFF TENDONITIS

The injured shoulder should be rested from the activities that caused the problem and from activities that
cause pain. Ice packs applied to the shoulder and NSAIDs (Brufen 200-400 mg TID) will help reduce
inflammation and pain. Physical therapy to strengthen the muscles of the rotator cuff should be started.
If the pain persists or if therapy is not possible because of severe pain, a steroid injection may reduce
pain and inflammation enough to allow effective therapy.
If the rotator cuff has sustained a complete tear, or if the symptoms persist despite conservative therapy,
surgery may be necessary. Arthroscopic surgery can remove bone spurs and inflamed tissue around the
shoulder.

GOOD HEALTHY DIET

CHO should be 50-60 %, proteins should be 12-20 % and fat should be 30-35%.
For calculation of calories: weight in kg x 22 basal
add 5 kCal/kg for sedentary life style,
10 for moderate activity,
15 for active life style,
and 20 kcal/kg for strenuous activity.

39
UTI
Honeymoon cystitis Staph. saprophyticus
Give Tab Septran (SMZ160/TMP800) PO BID for 3 days
For complicated UTI/pyelonephritis
Give Tab Septran (SMZ160/TMP800) PO BID for 10-14 days
Rx of UTI in pregnancy
Nitrofurantoin 100 mg Q6H for 7-10 days
Amoxicillin 500 mg TID for 7-10 days
Nalidixic acid 500 mg Q6H for 7-10 days
Cefspan 250 mg BID for 7-10 days

Treatment of IMPETIGO
Tab. Claxacillin 250 mg Q6H for 10 days
Tab. Augmentin 625 mg Q8H for 10 days

PALLIATIVE TREATMENT:
Symptomatic control (pain, nausea etc)
Nutrition
Bed sores
N-G and Catheter care
Good communication
No unnecessary therapy
Support of relatives
Team work
Continuity of care
Help in bereavement
For constipation give Enema, lactulose or ispaghol as indicated
For pressure sores change position more frequently, apply pads under points of contact and give
antibiotics if necessary.

TYPHOID TREATMENT
Ciprofloxacin 500 mg BID 10 days
Amoxicillin 100 mg /kg /day in three divided doses for 14 days
Amoxicillin 1.5 g three times a day for 14 days.

RICKETS
One test for rickets: X-Ray wrist
Give Vit. D 200,000 I.U and F/Up after 2 weeks with a repeat x-ray. If better give maintenance, if no
changes give another dose of I.M Vit. D 200,000 units and F/Up in 2 weeks. If better give maintenance
dose of Vit. D which is 400 I.U daily. If no change is still present Vit. DResistant Rickets is diagnosed.

Signs of APPENDICITIS
Guarding Rebound tenderness Ilio-psoas sign +ive Rovsings sign

40
PEPTIC ULCER DISEASE (PUD) AND H. PYLORI INFECTION
Treatment of H. pylori Give 14 day treatment of Helezol 20 mg OD
Metronidazole 400 mg TID
Clarithromycin 500 mg BID

Risk Factors for Peptic Ulcer Disease

Helicobacter pylori infection (90% duodenal Excessive intake of Caffeine
ulcers and 70% Gastric ulcers) Gastric acid hypersecretion
Nonsteroidal antiinflammatory drugs and o hypergastrinemia that is H. pylori-
Aspirin ( 15% Gastric ulcers) dependent
Cigarette Smoking o vagal hyperactivity
Gastrinomas (Zollinger Ellison syndrome) Duodenal abnormalities
Malignancy o impaired duodenal bicarbonate secretion
Blood group O Psychological factors (even though
Family history relationship not established so far): Highly
Overuse of Laxatives nervous, emotional, ambitious and
Past history of PUD aggressive individuals are more prone to
Age > 60 yrs ulcers
Corticosteroid and anticoagulant therapy Eating Habits: Eating hurriedly, improper
mastication of food and missing meals
Burns
predispose to ulcer formation.
Head Trauma
Occupation: Doctors and high ranking
Mechanical Ventilation
executives commonly suffer from ulcers.
Alcohol in high concentration

Areas of Concern
Significant weight loss Early satiety
Inappropriate dietary habits: excessive milk Possibility of bleeding from ulcer leading to
stimulates acid secretion due to high anemia
concentration of calcium. Age > 40 years
Prolonged Aspirin use Lack of appropriate response to acid
Continuous dyspepsia suppression

Dietary Advice
Eat 3 small meals and 3 snacks evenly spaced throughout the day. It is important to avoid periods of
hunger or overeating. The quantity of food eaten should be small to avoid overfilling the stomach
and causing distention.
Eat slowly
Avoid eating within 3 hours before bedtime. Bedtime snacks can cause gastric acid secretion during
the night.
Include a good source of protein (milk, meat, egg, cheese, etc.) at each meal
Easily digestible fats like fat of whole milk, egg yolk, cream and butter should be used in moderate
amounts only as they decrease the emptying time of the stomach.
Try to avoid caffeine beverages such as coffee, cola and tea. Also avoid excessive amounts of
alcohol.
Cut down on, or stop smoking cigarettes.
Avoid excessive strong spices
Avoid fibrous nature of cereals, fruits and vegetables.
41
 Avoid frequent use of aspirin
Foods commonly high in sodium including canned soup, potato/corn chips, salted nuts must be
avoided.
Eating more vegetables and fruit, such as carrots, cabbage and apricots for their beta-carotene and
vitamin C content, in order to help protect the lining of the stomach and intestine. Vitamin E from
foods like wheatgerm, hazelnuts, coldpressed sunflower seed oil, soybean oil, should also help, as
should Zinc from seafood and whole grains.
Steps to alleviate stress
Milk and cream feedings should not be used as antacid therapy. Although milk protein has an initial
neutralizing effect on gastric acid, it is also a very potent stimulator. Hourly feedings of milk have
been shown to produce a lower pH than three regular meals.

Management if Endoscopy report not available:

In case endoscopy report is not available, still treat it as peptic ulcer disease based on clinical findings
and high risk profile.
Management would include:
Test for presence of H. pylori infection: if endoscopy is unavailable and there are no alarm symptoms
Serum H. pylori Antibody testing
Stool H. pylori testing
Carbon-labeled urea breath testing
Eradication of H. pylori infection:
H. pylori Infection is the most common cause of duodenal ulcers (DU). In fact in some areas H. pylori is
responsible for more than 90% of DUs. Therefore, if history suggests DU, and investigations are
unfeasible then empirical therapy for H. pylori can be started.
Review after 4 weeks of therapy and confirm eradication.
Refer to gastroenterology if symptoms persist
Dietary management will not change as foods increasing acid production in the stomach will still be
advised to be decreased.

FACIAL NERVE PALSY

Hx ask about the following causes of nerve palsy
Otitis Media, Ramsey Hunt syndrome, Sarcoidosis, Tumor, Guillain-Barre syndrome, Lyme
disease, stroke, Multiple Sclerosis, Trauma, Mumps; and co-morbidities like Hypertension and
Diabetes Mellitus.
Ask about the onset and progression and any other associated problem in the body. Ask about
recent history of rash, fever, arthralgia, history of peripheral nerve palsy, exposure to influenza
vaccine or new medication or exposure to ticks.
Exam careful inspection of the ear canal, tympanic membrane, and oropharynx,
evaluation of peripheral nerve function in the extremities
palpation of the parotid gland.
Rx Reassurance
Eye care
Acyclovir if patient presents within 3 days of paralysis. Dose: 400 mg 5 times / day for 10 days.
Prednisolone 60 mg daily for 5 days, then 40 mg daily for 5 days. In children give 2 mg/kg for
7-10 days.

42
DIARRHEA
Hx Onset Urine output
Duration Ask about the presence of danger signs
Progression Social HxUse tap water or some other
Frequency source?
Consistency Boil water or not?
Any blood or mucus Bottle Vs breast feeding
Assoc. Abdominal pain Weaning
Fever Family Hx
Vomiting Any treatment given
Rx
Bacillary Dysentery (more fever, abd. pain and acute in onset) Nalidixic acid 55 mg/kg/day in four
divided doses for 5 days
Amoebic Dysentery (more blood and insidious onset) Metronidazole 35-50 mg/kg/day in three divided
doses for five days.
Persistent diarrhea: Diarrhea for more than 14 days
Nutritional rehabilitation is the most important part
Add cereals and oils to the food.
Exclude milk
Give yogurt
Give small frequent meals
Micro-nutrients: Zn, Mg, Folic acid, Vitamins A, D and also Iron. Give double the dose of RDA in the
first two weeks.

RED EYE
Hx Onset
Unilateral or bilateral
Pain Timing. On movement?, photophobia?, Deep probing pain?
Discharge Consistency, Amount
Assoc. Symptoms Itching, Family Hx, Swelling, Vision, Flashing lights, Urethritis,
Joint involovment.
Any drug used
Exam General look of the patient
Inspection of Eye and surrounding area
Examine conjunctiva
Pupillary size and reaction
Hypopyon or hyphema
Tonometry
Pre-auricular lymph nodes
Rx Cloxin 1 drop QID for 5 days
Ketrosan 1 drop QID for 5 days
Keep washing eyes and wash hand. Keep towel separate from other family members.
Hyperpurulent discharge means gonorrhea and needs eye referral
Chlamydia (with urethritis, arthritis) Doxycycline 100 mg BID for 14 days
Opthalmia neonatorum IV ceftriaxone
Dacryocystitis give augmentin

43
ANTI TB DRUGS
INH 5 mg/kg (max.300mg, given as 1 OD, available in 100 and 300 mg tablets)
Rifampicin 10 mg/kg (max 600, 150 and 300 mg tablets)
Ethambutol 15 mg/kg (max 1500, 100 and 400mg tablets)
Pyrazinamide 25 mg/kg 9max 2g, 500 mg tablets)
Streptomycin 15 mg/kg
Counseling Nature of the disease
Do not stop drugs even if you feel better
Explain S/E of drugs
Covering mouth while coughing and flushing the sputum
Regular F/UPs
Baseline Lab tests before ATT CBC, BUN, Cr, LFTs, Color vision

LESION IN UPPER LOBE OF LUNG

T.B Collapse Pneumonia Fibrosis Mets
Labs Sputum smear, Sputum culture, Blood C/S, ACE, Bone scan

CHEST PAIN
Onset, Character, Site, Progression, Aggravating (stress, breathing, palpation) and Relieving factor
(Drugs, Leaning forward), Radiation, Level of Functional Impairment, any association with meals and
any associated symptoms, family Hx
For level of functioning ask How much can you walk before experiencing discomfort?
Do you feel discomfort while climbing stairs or doing home activities?
Is discomfort induced by meals? Is it influenced by cold weather?
Baseline tests CBC, ECG, Cardiac enzymes, CXR
Treatment 0.5 mg S/L GTN (glyceryl trinitrate) + Aspirin 500 mg and refer.

EAR PROBLEM
Duration, any discharge, timing and amount of discharge, swelling behind the ear, pain in the ear,
aggravated by pulling the pinna, swallowing, opening jaw, chewing, cold exposure ? any time
association, any loss of hearing, feeding problem, irritability, difficulty sleeping, temperature, nausea
and vomiting, any weight loss
Breast feeding history, does child attend day care, smoking exposure, Hx of ear infection, Hx of ear
surgery, Hx of allergy.
Sample Hx Kaan mein dard:
Kub se dard hai? Shuru kaisay hua tha? Waqt ke saath barha hai ya ghata hai?
Musalsal hota hai ya ruk ruk ke? Kis cheez se dard barhta hai? Chabanay se? iss
karwat laitnay se? cold exposure se?
In kids: kya ye kaan ko khench khench ke rota hai? Kya bukhar hua hai? Feeding? Kaan
se paani ya peep aye hai?
Otosclerosis: Classic Hx of patient in his early thirties comes with the complain of bilateral hearing loss
(30% unilateral) speaking loudly (because bone conduction through skull is > air conduction through
middle ear). Vertigo is uncommon. Tinnitus is not there. There is no otalgia or otorrhea.
On exam no pain of tugging or pressing tragus. Otoscopic exam appears normal. No postauricular
swelling or tenderness.
44
BREATHLESSNESS
Mode of onset, Duration, Progression, Variability, Aggravating and Relieving factors, PND, Dyspnea on
lying flat, associated Sx includes cough, wheeze, sputum, hemoptysis and chest pain; level of Functional
Limitation; Past Hx of allergic, cardiac or respiratory disorder; Occupation; Tobacco consumption: Past
and present; Recent travel abroad.
Sample Hx of Breathlessness:
Shuru kaisay hua tha? Kisi event ke saath association thee kya?
Kitnay arsay se chal raha hai?
Kya waqt ke saath saath barha hai, kum hua hai ya stable raha hai?
24 ghantay mein koi intensity ka pattern hai kya? (asthmatics usually wake up around 3-5 am with a
wheeze. COPD patients have breathlessness bothering them first thing in the morning which gets better
with clearing secretions)
Kis cheez ya kaam se barhta hai e.g. exercise, allergen?
Kis cheez ya kaam se kum hota hai e.g. rest, medication, inhaler, clearing secretions (bulghhum)
Kya laitnay se saans ka masla barh jata hai?
Saath mein aur koi masla jaisay khansi, seenay se seeti ki awaz, bulghhum, seenay mein dard, bulghhum
mein khoon?
Kitna chul saktay hain in one go before u have to rest?
Pehlay koi allergy, dill ki takleef, saan ki takleef (like asthma)?
Kaam kya kartay hain (allergen at work place occupational asthma which gets better on weekends)
Cigarette peetay hain?
No. of pack/day x No. of years = pack years (e.g. 30 cigarettes a day for 20 years would be 1.5 x 20 = 30
pack years * one pack contains 20 cigarettes)

HEADACHE
Main site, Radiation, Character, Severity, Duration, Frequency and Periodicity, Special times of
occurrence, Aggravating factors, Relieving factors and Associated Sx,
Family Hx and Menstrual Hx.
Red flags Patient more than 50 years old.
Neurological symptoms,
Changes in personality,
Worst headache ever,
Headache which awakes from sleep,
Getting worse on cough, sneezing and straining.
Indications for imaging Focal neurological signs,
Altered mental status
Headache > 72 hrs
Papilledema
Trauma
TREATMENT OF MIGRAINE
Paracetamol 1g Q6h
Maxalon 5 mg TID
Sumatriptan 100 mg stat can be given. Dose can be repeated after 2 hrs with a max. dose of 300 mg.
For prophylaxis: TCAs, B-blockers (Propranolol 20 mg OD), CCB, or Valproic acid

45
FATIGUE
Define lethargy, continuous or intermittent, progression, related to day or night, workload/lack of sleep,
is there lack of ambition, any effect on life activities, associated features: Fever, wt. loss, loss of
appetite, mood pattern, sleep pattern, stool and urine, cough, dyspnoea, any pain.
Past Hx: any co-morbids, any episode in the past.
Labs: TSH, FBS, Urine DR.

DIZZINESS
Tell me about your symptoms without using the word dizziness.
Tell me about the last time you had these symptoms and go from start to end.
List of all the medications
Progression
Rule out the dangerous signs and symptoms
Past medical history
Try and categorize the patient.
Functional limitation
Dangerous S/S: Chest discomfort, vertigo with neurological deficits, severe acute vertigo with
imbalance, nausea and vomiting. External ear vesicular eruptions, otalgia, hearing loss or facial
paralysis.
Categorization: Do you feel lightheaded or feel that the room is spinning.
Do you feel that the problem is in your head or legs. Do you feel imbalance.
Have you ever passed out.
Have you ever felt after getting up that you will pass out
Others
O/E: Cardiopulmonary, neuromuscular

SYNCOPE
Does the patient lose consciousness? Injury? Dose the patient move? Incontinence? Convulsions?
Tongue biting? Associated Symptoms? Attack duration? Post-ictal? Sleepy before attack? Warning
symptoms? Triggers? Prevention, Remember about attack? Progression? Clouding, Diplopia / Vertigo?
Causes Vasovagal Hypoglycemia
Epilepsy Arryhthmia
Orthostatic hypotension Anxiety
Narcolepsy Factititious
Exam: CVS, Neurological, B.P
Investigations: EEG, ECG, CBC, FBS, Urea and lytes.

VERTIGO
What do you mean by vertigo? Onset, Duration, Severity, Precipitating factors, Episodic or Continuous,
Accompanying Sx like Nausea/Vomiting (as in travel sickness), Loss of Consciousness, Dysphagia and
Dysphasia, Hx of Trauma (BPPV)
Drugs Hx, Hx of T.B, Hypothyroidism and Diabetes.
O/E: GPE look for anemia, Postural Hypotension, Ear exam, Cerebellar exam, Rombergs and C.N.
exam and CVS exam. Hallpikes if BPPV is suspected
Rx Stemetil 10-15 mg TID for 3-5 days
Maxalon 10 mg PRN
46
SCABIES
Intractable itch, worse at night, common in children and immunocompromised.
In children: classically distributed on face, neck, palm soles.
In adults: extensor surfaces, interdigital webs.
Pruritic papules on penis, scrotum and areola are highly characteristic.
Often whole family affected.
Permethrin (insecticide pyrethroid neurotoxin to mite) application for 8 hours
or Benzyl benzoate for 12 hours (scabicidal agent)
Calamine lotion (Zn Oxide + Fe (III) Oxide antipruritic and mildly antiseptic)
Cholrphenamine (CPM) anti-pruritic, antihistamine
Advice Treat whole family even if not affected, Wash all clothes and bed sheaths, prevent contact,
apply scabicidal agent neck and below also on palms and soles. Let it stay overnight. Take a bath next
morning and dry.
If infected give either Augmentin (90 mg/kg/day in kiddies) and/or cloxacillin

TREATMENT OF DEPRESSION
Tryptanol: Start with 25 mg. Increase 25 mg after every 2 weeks going up to maximum of 150 mg; stay
at this dose for 6-9 months and then taper off 25 mg every 2 weeks till no drug is required; or if
symptoms recur maintain the patient on minimum effective dose for 2 years.

FOOT EXAM
Observation for ulcers on shin, calf, foot and toes. Any unhealed wounds. Hair distribution on
shin. Ischemic changes on toes. Callus formation. Look at interdigital webs for fungal infection.
Abnormal or infected toe nails. Foot shape (clawed toes, rocker bottom feet, bunion, high instep)
Feel for temperature; whether symmetric or not? Compare with upper limb(s)
Palpate posterior tibial and dorsalis pedis pulses bilaterally
Do the monofilament test on ten site. Score out of 10
Proprioception at big toe
Vibration first check toe tip. If absent check at ankle. If absent check shin. If still absent check
at knee.
Rx for Neuropathy Gabapentin around 800 mg at bed time.. (not sure about this Gabapentin is not
approved by FDA for neuropathic pain though is frequently prescribed)

PRESCRIPTION WRITING
Date Patient I.D Name Age Diagnosis
Drug formulation: Name Strength Dose Duration

47
Drugs and Dosing Regimens / PHC Rx

Enteric fever
Amoxicillin 100 mg/kg/day Q8H 14 days
Ciprofloxacin 750 mg BID 14 days
Chloramphenicol 75 mg/kg/day Q8H 14 days
Septran DS 400 mg BID 14 days

Scabies
Benzyl Benzoate 25% suspension OD @ night time 3 days
Sulphur Ointment 2.5% for 24 hrs
Calamine lotion L/A PRN
Chlorphenyramine (CPM) 5 mg (1 tsp) HS

Tinea
Gryseofulvin 1g OD 8 wks
Clotrimazole cream L/A TID 14 days
(Canesten cream)

PUD (H. pylori)

Omeprazole 20 mg HS 14 days
Metronidazole 400 mg BID 14 days
Amoxicillin 1g TID 14 days
or
Clarithromycin 500 mg BID 14 days
If resistant:
Tetracycline 500 mg TID

UTI
Nalidixic Acid 55 mg/kg/day TID 7-10 days
500-1000 mg
Nitrofurantoin 5-7 mg/kg/day QID 7-10 days
100 mg
Septran DS 400 mg BID 5 days
In pregnancy:
Amoxicillin 500 mg TID 10 days
or
Urixin 400 mg BID 10 days

48
Rickets
Vitamin D3 300,000 IU (< 2 yrs) I/M once
600,000 IU (> 2 yrs) I/M once
Vitamin D3 400 IU daily

Candida
Fluconazole 150 mg OD SD
Canesten Pessary 1 tab OD 7 days

Otitis media
Amoxicillin 50 mg/kg/day TID 10 days
Septran 10 mg/kg/day BID 7-10 days
Augmentin 40-50 mg/kg/day TID 10 days

Bacterial Sinusitis
Amoxicillin 50 mg/kg/day TID 10 days
Epinephrine 1% 2 puffs 5 days
Paracetamol 12-15 mg/kg/dose Q6H

Streptococcal Sore Throat

Penicillin V 50 mg/kg/day QID 10 days
or 500 mg * 6
Benzathine Penicillin 600,000 units (< 5 yrs) I/M SD
1,200,000 units (> 5 yrs) I/M

PID
Trichomonas/ Chlamydia/ BV
Amoxycillin 500 mg TID 10-14 days
Metronidazole 400 mg TID 10-14 days
Doxycycline 100 mg BID 10-14 days
Azithromycin 1g single dose
Syphilis
Penicillin 2.5 million units I/M twice
Gonococcal
Ceftriaxone (Rociphen) 250 mg I/M once
Ciprofloxacin 500 mg PO once
Spectinomycin 2g I/M once
Tetracycline 500 mg QID 4 days
*STI empiric treatment: Amoxicillin, metronidazole, doxycycline, ciprofloxacin

49
Malaria
1. Chloroquine phosphate 1 g (4 tabs) STAT or (10 mg/kg)
500 mg (2 tabs) 6 hrs later (5 mg/kg)
500 mg (2 tabs) 12 hrs later (5 mg/kg)
500 mg (2 tabs) 24 hrs later (5 mg/kg)
Primaquine phosphate 15 mg/kg 14 days
2. Quinine sulphate 650 mg TID 10 days
+ Tetracycline 250 mg QID 10 days
3. Mefloquine 750-1250 mg once
4. Fancimef 3 tabs once
Prophylaxis:
Chloroquine phosphate 500 mg (2 tabs) everyday, from 1-2 wks before, till 2
wks after leaving the area
Mefloquine 250 mg once/week same as above

Helminthiasis
Pyrantel palmoate 1 tab (250 mg) SD
20 mg/kg OD 2 days
Mebendazole 1 tab (100 or 500 mg) OD STAT
Albendazole 200 mg BID 3 days
or
400 mg (adults) STAT
200 mg (paeds) STAT
Levamisole (Ketress) 150 mg (adults) single dose
50 mg (paeds) single dose

Misc. Drugs (1 tsp = 5 ml)

Calpol 10 mg/kg/dose (120 mg in 5 ml)
Ventolin 0.1 mg/kg/dose (2 mg in 5 ml)
CPM 1 tsp (5 mg in 5 ml)
Erythromycin 30- 50 mg/kg/day (125 mg in 5 ml)
Amoxicillin 40-50 mg/kg/day (125 mg in 5 ml)
Septran 10 mg/kg/dose (40:200 mg in 5 ml)

Paeds Adults
Brufen 15 mg/kg/day 200-400 mg TID
Cloxacillin 50-100 mg/kg/day 500mg-1gm 4 doses
Metrondazole (giardiasis) 15 mg/kg/day 200-400 mg 3 doses
(amoebic dysentery) 30 mg/kg/day 500mg -1 gm
Nalidixic acid 55 mg/kg/day
Folic acid 5 mg/day
Iron 6-7 mg/kg/day 200mg TID

50
Vitamin B12 100-200 g I/M inj
100 g PO
Pyridoxine 10-20 mg PO OD
Vitamin A 100,000 units I/M daily for 3 days and then
50,000 units I/M for 2 wks

ANTIDIABETES DRUGS
Sulfonylureas Glibenclimide 5-15 mg OD (Daonil 5 mg tablets)
Gliclazide 40-80 mg initially, up to max 320 mg in 2 divided doses
(Diamicron 80 mg, Glimicron 80 mg)
Glimeperide 1 mg to 6 mg increasing the dose at 1 to 2 week intervals
(Amaryl 1,2,3,4 mg tablets)
Biguandies Metformin 500 TID or 850 BID initially, up to max of 3 g daily
(Biguanil, Glucophage and Neodipar all available as 250, 500 and 850
mg tablets; Neodipar also available as 1 g)
Thiazolidinediones Pioglitazone 15-30 mg OD upto max of 45 mg/day
(Piozer 15 mg, 30 mg, 45 mg)
Rosiglitazone 4 mg OD or 2 mg BID up to daily max of 8 mg
(Avandia 2 mg, 4 mg)
Meglitinides Repaglinide 0.5-4 mg per dose with daily max of 16 mg
(Repaglin 1 mg, 2 mg)
Glucosidase Inhibitors Acarbose 50 mg TID up to max of 200 mg TID
(Glucobay 50 mg, 100 mg)

ANTIHYPERTENSIVES
Thiazides Hydrochlorothiazide (available in combination with Amiloride as Moduretic
12.5 mg OD)
ACE -I Captopril 25-100 mg BID (Capoten)
Enalapril 5-40 mg
Lisinopril 10-40 mg OD (Zestril)
ARBs Losartan 25-100 mg OD/BID (Cozaar, Eziday)
(also available in combination with thiazide as Co-eziday)
CCBs Amlodipine 2.5-10 OD (Norvasc, Sofvasc)
K sparing diuretics Amiloride 5-10 mg BID
Beta blocker Atenolol 25-100 mg OD (Tenormin)
Propranolol 40-160 mg OD (Inderol)
Alpha 1 blocker Prazosin 0.5 mg first dose
0.5 mg TID day 2-7
1 g TID day 7 onwards
Centrally acting Clonidine 0.2-0.8 mg BID
Methyldopa 250-2000 mg BID (Aldomet)
51
52