Common cold (coryza)

1. Commonest viral infection
2. Causative agents
1. Rhinovirus
2. Corona virus
3. Influenza / parainfluenza
4. Respiratory syncytial
5. Adenovirus
6. Others
3. Predisposing factors
1. Climate
2. Environment, temperature and humidity
3. Immune status
4. Fitness
5. Nutrition and Vitamin deficiency
4. Mode of transmission
1. Droplet and dust
2. Droplet nuclei
3. contact
5. C/F
1.  burning sensation at back of nose
2. Nasal stuffiness, rhinorrhoea and sneezing
3. Low grade fever , myalgia
4. Self-limiting and resolves in 2-3 weeks.
6. T/t
1. Complete rest
2. Hot bath: Inhalation of menthol or tincture of benzoid
3. Analgesics and antipyretics

                                                               i.      Aspirin 300mg to600mg sos (pc)

                                                             ii.      PCM 500mg sos

4. Antihistaminics

                                                               i.      Cetrizone 10mg to 20 mg BD

1.       Child 2-6yrs 2.5mg BD or 5mg OD

2.       >6yrs 10mg OD

                                                             ii.      Chlorpherarmine 4mg tds

1.       1-2 yrs  1mg BD

2.       2-5yrs  1mg tds (max=6mg/day)

3.       6-12yrs 2mg tds (max=12mg/day)

                                                            iii.      Fexofenadine  60mg BID

1.       >2yrs 0.23mg/kg/day (4-6)hrs

2.       2-6yrs 1mg

3.       6-12yrs 2mg

4.       >12yrs 4mg of 4-6 hrs

5. Nasal decongestant

                                                               i.      Ephederine  nasal drop 2-3 drps

                                                             ii.      Xylomethanzolin nasal drop 2-3drps

6. Antibiotics in complications

                                                               i.      Amoxicillin 250-500mg tds 5-7 days

                                                             ii.      Tetracycline 250-500mg qid 5-7 days

7. Complications
1.  Pharyngitis
2. Sinusitis
3. Otitis media
4. Lymphadenitis
5. Tonsillitis
6. Lower respiratory complications
8. Bacteriology
1. Streptococcus
2. Pneumocccus
3. Haemophilus influenzae
4. Staphylococcus

Whooping cough

Pertusis is an acute highly contagenious respiratory track infection caused bye bordetella perturis.

The dz is characterized by intestine spasmodic cough

Incubation period : 7-14dys

Mode of transmission : aerosol droplet

c/f

The clinical presentation can be divided into three stage

1.       The catarrhal phage for 1-2wks

a.       Most infection period cough, coryza with little nasopharyngeal secretion. The cough doesn’t improve in a few days but becomes more severe and frequent with the passage of time

2.       The paroxysmal stage last for 2-6wks

a.       Cough progress to episodic paroxysms of increasing intensity ending with high pitched this stage occurs inspiration whoop

b.       The whoop is produced bye the air rushing is during inspiration through the half open glotitus. Cough is thick tenacious mucous vomiting.

3.       Convalescent phge

a.       The intensity and paroxysms of cough decrease gradually over 1-4 wks , the vomiting becomes less frequent, appetite, general condition and health gradually improve

Complication

1.       Otitis media

2.       Inguinal hernia

3.       Rectal prolapsed

Diagnosis

Based of clinical features specific diagnosi depends on isolated of the organism from nasopharyngeal swab or cough plate cultured on bordet Gengou medium

Management

1.       Nutrion

2.       Hydration

3.       Antibiotic of choice in Erythromycin  :40-50mg /kg/day in 3 divided dose *14 dys

4.       Nebulization with salbutamol

Poliomyelitis

The polio virus belong in the germ enterovirus in the family picorairidae and comprise there related serotypes.

Type

I, II, III All of which can cause paralysis

Epidemiology: the dz is seasonal , occurring. More commonly in summer and early autumn in temperature climate , some areas experience increase in incidence during rainy session.

Pathogenesis

The mouth is the usual portal of entry the virus is usually present in the pharyranx and stool before the onset of paralytic illness. It invade local lymphoid tissue enters the bld stream to invade certain nerve cells and my damage or destroy these cells.

c/f

1.       Sore throat

2.       Vomiting

3.       Abdominal pain

4.       Low grade fever

5.       Headache

6.       Leg stiffness and paralysis of the trunks, abdominal and thoracic muscles

7.       Difficult in swelling , eating and speaking

8.       Rarely loss of the consciousness and seizure may occurs

9.       Residual flaccid paralysis in usually present after 60 dys

Diagnosis

Based of history and characteristic clinical manifestation of asymptomatic flaccid paralysis stool examination is recommended is every case of acute flaccid paralysis.

I/V

Stool  : c/s

Rx

1.       Isolation

2.       Analgesic

3.       Antipyretic

4.       Refer to higher center may need plasma exchange

Prevention -vaccine

Acute rhematic fever

Rhematic fever is a immune medicated disease which is preceded by Group ‘A’ hemolytic streptococcus infecton of throat. Or

Rheumatic fever is an immunological disorder initiated by Group A beata hemolytic streptococcus.

Clinical feature

Children of (5-15) years present with history of sore throat 2-3 weeks before with in

1.           Fever

2.           Anorexia

3.           Chest pain

4.           Breathlessness

5.           Joint pain

6.           Lethargy

Diagnostic criteria : it has been described as jone’s criteria  2major or 1major+2minor criteria makes the diagnosis of acute rhematic fever

Major criteria

1.           Carditis

2.           Migratory polyarthritis

3.           Erythema  marginatum

4.           Subcutaneous nodules

5.           Syndentamis chorea

Minor criteria

1.           Fever

2.           Arthalgia

3.           Prevoous rhematic fever or rhematic heart disease

4.           Increase  TLC

5.           Increase ESR

6.           Increase CRP(creatine protein)

7.           Increase PI interval

Essential criteria

1.           Increase Antistreptolysin ‘o’ titer >200in adult and >300 in children

2.           Positive throat culture

3.           History of scarlet fever

Investigation

1.           Blood :increase ESR , increase total count , increase  c-protien , increase  ASO (anti streptolysin o )titer

2.           Throat swab :culture and sevsitivity

3.           ECG :evidence of carditis

4.           Echocardiography: valvula lesion , heart function

Treatment

1.           Bed rest : till acute phase reactants (ESR,CRP)

2.           Aspirin :90-120mg/kg/day in a divided dose *10wks then trpperd in the 2wks alternatively

3.           Corticosteroids is used  if inflammation is not controlled by aspirin prednosolune 1-2 mg/kg/day is used thus reduces finlamation and decreasecarditis and arthritis (maximum dose 60mg) is given 3wks than tapered gradually in nxet 9wks.

Treatment of heart failure if needed

1.       Xigoxine

2.       frusemide

4.           Antistreptococcal therapy : drug of choice is penicillin

5.           Single dose of Benzathine penicillin 0.6-1.2million   units alternatively IM once a weeks or procain penicillin 4 lakh units IM *BD or

6. penicillin  V 125-250mg orally QID*10days

7. Erythromycin 250mg QiD*10days

Prevention of rhematic fever

1.                   Primary prevention:prevent Rhematic fever by taking early antibiotic for throat infection

Penicillin 10dys or benzathin penicillin 10dys

2.                   Secondary prevention :prevents further damage of organ ie -heart , joints

Benzathin penicillin every 3-4wks 1200000 unit for >30kg

600000 unit <30kg continue long life

Mumps

Mump is an acute viral infection characterized by painful enlargement of the salivary gland, most characteristically the parotial glands.

Causes

RNA virus of genus Paramyxovirus in the family paramyxoviridae (mumps virus)

Epidemiology: Occurs mainly 5-15 yrs infants are rarely affected due to presence of transplacentally acquired maternal antibodies.

Incidence –Higher in winter and spring

Transmission : The virus is spread from human reservoir by

1.       Direct contact

2.       Air borne

3.       Droplets

4.       Fomites contaminated by saliva and urine

Incubation period : 2-4wks

c/f

1.       Fever

2.       Malaise

3.       Headache

4.       Mumps infection is characterized by unilateral and bilateral parities

5.       Earache

6.       Jaw tenderness

7.       Swelling at the angle of jaw

Diagnosis

1.       Based on clinical examination

2.       ELISA  test for Igm serum amylase

Rx

1.       Symptomatic

a.       Antipyretics

b.       Warm saliva

c.        Bed rest

Prevention

1.The affected pt. should be isolated until the parotid swelling has subsided

2.       Immunization

             
HISTORY TAKING
 Identifying data    
Chief complaint      
History of present illness              
Past medical/surgical history                      
Drug history    
Family history                                  
Social history    
Systemic enquiry
1. Identifying data :
Always record personal details:
Name,
Age,
Address,
Sex,
Occupation,
Religion,
Marital status.
Date of examination
Reliability
2. Chief Complaint
Chief Complaint (CC):
Short/specific in one clear sentence communicating present/major problem/issue. As:
Timing – fever for last two weeks or since Monday
Recurrent –recurring episode of abdominal pain/cough
Note: CC should be put in patient language.

3. History of Present Illness
History of Present Illness - Tips
Elaborate on the chief complaint in detail
Ask relevant associated symptoms
Have differential diagnosis in mind
Lead the conversation & thoughts
Decide & weight the importance of minor complaints
History of Present Illness - Tips
The principal symptoms should be well-characterized, with descriptions of
(1) location,
(2) quality,
(3) quantity or severity,
(4) timing, including onset, duration, and frequency,
(5) the setting in which they occur,
(6) factors that have aggravated or relieved the symptoms,
(7) associated manifestations
(8) treatment
Ask OPQRSTA for each symptom
Pain (OPQRSTA)
Onset of disease
Position/site
Quality, nature, character – burning sharp, stabbing, crushing; also explain depth of pain – superficial or deep.
Relationship to anything or other body function/position.
Radiation: where moved to
Relieving or aggravating factors – any activities or position
Severity – how it affects daily work/physical activities. Wakes him up at night, cannot sleep/do any work.
Timing – mode of onset (abrupt or gradual), progression (continuous or intermittent – if intermittent ask frequency/ nature.)
Treatment received or/and outcome.
Are there any associated symptoms? .
4. Past history
Past Medical /Surgical History
Past medical
            IHD/ Heart Attack/ DM/ Asthma/ RHD, TB/ Jaundice/ Fits

Past surgical/operation history
                  E.g. time/place/ what type of operation.
 
Note any blood transfusion / blood grouping.

H/O dental extractions/circumcision & any exessive bleeding during these procedures.

History of trauma/accidents

Any minor operations or procedures including endoscopies, biopsy


5. Drug History
Drug History
Drug History (DH)
Always use generic name
           Example: Ranitidine 150 mg BD PO
 Note: do not forget to mention: OCT/Vitamins/Traditional /Herbal medicine & acupuncture.
Blood transfusion.
bd (Bis die) - Twice daily (usually morning and night)
tds (ter die sumendus)/tid (ter in die) = Three times a day mainly 8 hourly
qds (quarter die sumendus)/qid (quarter in die) = four times daily mainly 6 hourly
Mane/(om – omni mane) = morning
Nocte/(on – omni nocte) = night
ac (ante cibum) = before food
pc (post cibum) = after food
po (per orum/os) = by mouth
stat – statim = immediately as initial dose
Rx (recipe) = treat with

6. Family History
Any familial disease/running in families e.g. breast cancer, IHD, DM, schizophrenia, Developmental delay, asthma .
Infections running in families as TB, Leprosy.
Cholera, typhoid
7. Social History
Smoking history - amount, duration & type.
             A strong risk factor for IHD
Alcohol history - amount, duration & type.
Occupation
Home conditions as:
              Water supply.
              Sanitation status in his home & surrounding.
               Animals / birds in his/her house.

Don’t forget that healthy alcohol use is associated with less IHD & Ischemic CVA.
Unhealthy alcohol use is associated with cardiomyopathy, CVA, Myopathies, liver cirrhosis .
Other Relevant History
Gyane/Obstetric history if female
Gravida, para, abortions, antenatal care & screens as for Hep B & C.
9. System Review
This is a guide not to miss anything
General
Weakness
Fatigue
Anorexia
Change of weight
Fever/chills
Lumps
Night sweats
System Review
Cardiovascular
Chest pain
Paroxysmal Nocturnal Dyspnoea
Orthopnoea
Short Of Breath(SOB)
Cough/sputum (pinkish/frank blood)
Palpitations
Cyanosis
Gastrointestinal/Alimentary
Appetite (anorexia/weight change)
Diet
Nausea/vomiting
Regurgitation/heart burn/flatulence
Difficulty in swallowing
Abdominal pain/distension
Change of bowel habit
Haematemesis, melaena
Jaundice
Respiratory System
Cough(productive/dry)
Sputum (colour, amount, smell)
Haemoptysis
Chest pain
SOB/Dyspnoea
Tachypnoea
Hoarseness
Wheezing
Urinary System
Frequency
Dysuria
Urgency/strangury (severe pain on base of urethra)
Hesitancy
Terminal dribbling
Nocturia
Back/loin pain
Incontinence
Character of urine:color/ amount (polyuria) & timing
Fever
Nervous System
Visual/Smell/Taste/Hearing/Speech problem
Head ache
Fits/Faints/Black outs/loss of consciousness(LOC)
Muscle weakness/numbness/paralysis
Abnormal sensation
Tremor
Change of behaviour or psyche.
Pariesis.
Genital system
Pain/ discomfort/ itching
Discharge
Unusual bleeding
Sexual history
Menstrual history – menarche/ LMP/ duration & amount of cycle/ Contraception
Obstetric history – Para(no of live born)/ gravida(no of preg.)/abortion
Musculoskeletal System
Pain – muscle, bone, joint
Swelling
Weakness/movement
Deformities
Gait
PHYSICAL  EXAMINATION
1.)  General examination
2.)  Systemic examination
General Examination
Vital Sign (T, P, R, Bp)
Temperature
    Normal axillary T: 36~37?
    Fever:  T>37?
    Hypothermia: T<35?
Pulse
    Frequency: 60~100/min
    Rhythm: Regular
Respiration
    Normal: 14~20/min
Pallor (whitish discolouration)
Look for  mucous membrane in inner aspect of  lips, palm, eye.
Hb < 6 gm/dl --> pale palmar creases
Causes of pallor:
Anemia
Anxiety
Shock
Edema
     Jaundice(Icterus)
Yellowish discolouration of skin and mucous membrane is called jaundice.
Types of jaundice:
         1.) haemolytic jaundice
         2.) hepatocellular jaundice
         3.) post hepatic jaundice
Cyanosis
Bluish discoloration
     -Central ~~~ lateral aspect of under surface
                          of the tongue, lips (warm hands)
     -Peripheral ~~~ extremities  (cold hands)

Lymph nodes1

Size
Consistency
Tenderness
Matting
Mobility
Relation to surrounding structures.      
           Dehydration
It is a state of clinical condition due to decrease amount of water in the body.
Sites of examination:
    Eye: sunken eye
    Tongue: dry and thirsty
     Skin: skin pinch go back slowly or very slowly.
SYSTEMIC  EXAMINATION
Basic Examination Techniques
  inspection
  palpation
  percussion
  auscultation

Inspection
The areas to be inspected should be visible
   
Good lighting is important
   
The angle of the light can be used to advantage
   
Inspection and thinking with knowledge
   
Palpation
Light palpation
Deep palpation

Percussion Notes
Tympany: gas
Hyperresonance: increased gas in lung tissue
Resonance: lung tissue
Dullness: gas and tissue
Flatness: essential organ or fluid
Auscultation

Breath sounds, adventitious sounds
 
Heart sounds, murmurs
   
Bowel sound; bowel tones
Pulmonary Examination
 lung inspection
 
 lung palpation
 
 lung percussion

Lung auscultation
 
The Lung Inspection
Size and shape of thorax: barrel chest, flat chest

Respiratory frequency: normal-14-20, bradypnea<8, tachypnea>24
Depth and rhythm
   
Respiratory movement
             Normal: bilateral Symmetrical movements

   
The Lung Palpation
Chest expansion
 
Tracheal position
 
Vocal (tactile) fremitus
 


       

EPILEPSY Refresher

What is seizure

1. Seizures are episodes of brain malfunction due to abnormal electrical discharges
1. Seizures can be classified as generalized or partial according to the clinical presentation
2. Our focus will be only on GTCS

What is epilepsy

The condition in which people experience recurrent (at least twice), unprovoked seizures

Causes

2.       Complications during childbirth

3.       Head injury

4.       Brain infections

a.       Meningitis, encephalitis, cerebral malaria

5.       Neurocysticercosis (tape worm)

6.       Genetic, only in some cases

7.       Some epilepsy has no known cause

8.       Stroke

Types of Seizure

1. Genearlized Tonic Clonic
2. Partial Serizure
3. Complexpartial
4. Absence
5. Febrile convulsions

Symptoms of GTCS

1.       Preictal Stage/ postictal stage

2.       Loss of counsciousness

3.       Tonic clonic contraction of whole body

4.       Uprolling of eyes

5.       Clinching of teeth/ tounge bite

6.       Loss of bowel/bladder

7.       Injury

Why should we treat epilepsy

1. Epilepsy is common (prevalence is 0.8-1.2%)
2. Epilepsy is life threatening
3. Each seizure causes brain injury
4. People with epilepsy are stigmatized and excluded
1.  Some children with epilepsy are not allowed to go to school
2. People don’t get married
3. Treatment is simple, inexpensive and effective
4.  70% can be seizure-free for life after 2 years of treatment
   
   

Pseudoseizure (PNES)       Seizure

1. Duration:
1. Minutes to hrs                      Seconds to Minutess
2.  Auras:
1. Absent                                  Present
3.  Injury:
1. None or minor                      Serious injury may be present
4.  Always occurs in presence      May occur alone or in presence of  someone else                         of someone else
5. Postictal confusion:
1. Absent                                   Present                        
6. Incontinence of stool and urine

                                                               i.      Absent                                      May be present

7.       Total loss of conciousness:

                                                               i.      May not be present                   Always Present

8.       Frothing/ Tounge bite:

                                                               i.      Not present                                May be present

9.       Possessions/ Asking for water:

                                                               i.      May be present                          Always absent

Management of acute stage

1. Airway
2. Breathing
3. Circulation

DO NOT leave the person alone

Place in recovery position

Make sure NOTHING is in the mouth

Measure and document vitals

1.       Blood Pressure

2.       Temperature

3.       Respiratory rate

a.       These must be measured accurately and documented

b.       In particular, respiratory rate should be counted. You may be using drugs that cause respiratory depression

Rule out other causes

1. Organic:
1. Hypoglycemia
2. Meningitis
3. Head trauma

2.       Substance abuse:

1. Alcohol and Benzodiazepams

3.       Eclampsia

4.       Febrile seizure

Manage Seizure

1. Start intravenous fluids
1.  IV Glucose slowly, 30 drops/minute
2. Adults: Give IV Diazepam 10mg slowly OR IV Lorazepam 4mg  slowly
2. Children: Give diazepam IV 0.2 -0.5 mg/kg slowly (maximum 10 mg) or lorazepam IV 0.1 mg/kg(maximum 4mg), if available

If IV line cannot be made

1. If you cannot place an intravenous cannula
1. DO NOT GIVE IM DIAZEPAM, it is poorly and erratically absorbed
2. Give rectal diazepam

                                                               i.      Use the rectal formulation if available

                                                             ii.      If the rectal formulation is not available, the IV formulation can be used

                                                            iii.      Adults: 10mg

                                                            iv.      Children: 0.2 – 0.5 mg/kg (maximum 10mg)

2. Do not forget to place an IV cannula after the seizure has stopped

If seizure does not stop

1. It could be Status epilepticus
2. Status epilepticus is defined as:
1. More than 30 minutes of continuous seizure activity OR
2. Two or more sequential seizures without full recovery of consciousness between seizures  
3. If the seizure does not stop 10 minutes after the first dose of diazepam, give a second dose of the same amount
4. Refer the person to hospital as this is an emergency
5. Do not give more than 2 doses of diazepam

Starting antiepileptic therapy

1.       Seizure diary

2.       Do not treat single episode of seizure with prophylactic therapy

Carbamazepine

1. MOA: Stablizes Na channels
2. Metabolism:
1. Liver
2. Autoinduction
3. T ½ 25 to 65hrs(initially) 10 to 20 hrs (later)
4. Elimination : Urine

Carbamazepine

1.       In child

1. Starting dose: 5 mg / kg / day in divided dose 12hrly
2. Maintenance dose: 10 – 30 mg / kg / day

2.       In adult

1. Starting dose: 100 -200 mg / day
2. Maintenance dose: 400 – 1200 mg / day

Side Effects:

1. Ataxia
2. Dizziness
3. Nausea and Vomiting
4. Hypersensitivity reactions
5. Aplastic anemia and bone marrow suppression

Phenobarbitone

1. MOA: Acts on GABA
2. Metabolism:
1. Liver
2. Enzyme Inducer
3. T ½  : 50 to 140hr
4. Elimination : Urine 

5.       In child

1. Starting dose: 2 – 3 mg / kg / day
2. Maintenance dose: 2 – 6 mg / kg / day
3. Initiate with 2 mg / kg / day for 2 weeks. If poor response increase the dose to 3 mg / kg / day for 2 months. If seizures persist, increase the dose to maximum of 6 mg / kg / day.

6.       In adult

1. Starting dose: 60 mg / day
2. Maintenance dose: 60 – 180 mg / day
3. Initiate with 1 mg / kg / day (60 mg tablet) for 2 weeks. If poor response, increase to 2 mg / kg / day (120 mg) for 2 months. If seizures persist, increase the dose to 3 mg / kg / day (180 mg)

Side Effects:

1.       Ataxia

2.       Drowsiness

3.       Nausea and Vomiting

4.       Behavioural Problems

5.       Headache

Phenytoin

1. MOA: Acts on Na clannel
2. Metabolism:
1. Liver
2. Enzyme inducer
3. T ½ : 22hrs
4. Elimination : Urine
5. In child
1. Starting dose: 3-4 mg \kg \day
2. Maintenance dose: 3-8 mg \kg\day (maximum 300 mg \daily)
3. In children give twice daily.
6. In adult
1. Starting dose: 150-200mg \day
2. Maintenance dose: 200-400 mg \day

Side Effects

1.       Drowsiness

2.       Gum Hyperplasia

3.       Ataxia/  slurred speech

4.       GI disturbances

5.       Cardiac problems in high doses

6.       Rashes

Key points

1. Taking the medication as prescribed is essential
2. Consult your healthcare provider in case of recurrence of seizures or side-effects
3. Consider stopping treatment if there have been no seizures for two years.
1. Explain that there is a risk of seizure recurrence after stopping the medication (10-20%).
2. It should be done in consultation with family
4.  For women of child bearing age
1. Give folic acid
2. Breastfeeding is safe
5. Missed doses?
6. People with epilepsy can do most jobs but should avoid
1. Heavy machinery
2. High places
3. Collecting water from open bodies of water
4. People with epilepsy should avoid swimming alone and cooking on open fires
7. People with epilepsy should avoid
1. Excessive alcohol
2. Recreational drugs
3. Sleep deprivation
4. Flashing lights
5. Fasting

Follow ups

1. Follow up
1.  once a month for the first 3 months
2.  then once every 3 months
2. Explain that the person can come in whenever needed and that the person should come in immediately if there is another seizure