حالات الاستقبال ج4

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Bronchial asthma



During attacks:

1- VD 2- ABG if severly distressed 3- Start by Nebulizer → 1 amp.lasix + 2cc saline +1 amp Atrovent {Ibratropium Bromide** + 1cm Ventoline {B2 agonist >>> # if tachycardia** 1-if ...severe ( distressed or not responding) >> give Cocktail → 500 cc saline or Glu + 2 amp. Solucortef + 1 amp. Aminophilline ± Mg Sulphate {Smooth ms relaxant** >>> # in hypotension & renal impairment**

N.B.:

* In case of cocktail if the pt is diabetic give saline & if the pt is hypertensive gives glucose. *If the pt has HF or CRF give minimal fluids 100cc or 200cc



Home ttt:

R/- ttt of ppt factor e.g. infection - Spray e.g. Clenil (salbutamol+ Beclomethasone) وبخه ﻋﻨﺩ اللزومساعات 6کل ۲بخه

- Uniphilline (Theophylline) ½ tab. Every 12 hrs



± B2 agonist: Ventoline tab. 1*3 Bricanyl tab. 1*3
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حالات الاستقبال ج3

Fever




...

Management:

1-Cold fomentation 2-Cold saline enema (# in diarrhea) 3-NSAIDs: - Paracetamol (R/ Cetal or Pyral Brufen or Novalgen
كنت سامع من الأستقبال والحضور أن البارسيتامول مش بيشتغل إلا عند درجة حرارة 38 ) 4Aspegic: - ?? thrombocytopenia - ?? Reye $ 5- Search for the cause: sore throat, chest infection, ear infection, UTI……………

* if u don’t find a cause for fever & fever is prolonged > 2 wks >>>>>> FUO

Investigations:( For FUO)

1-CBC 2-ESR 3-Blood culture , urine culture , sputum analysis + ZN stain 4-Collagen markers 5-Malaria & Toxoplasmosis 6-Widal & Brucella 7- X- ray chest

UTI:

C/O: dysuria, frequency, urgency, hematuria…………. Ask for urine analysis: if pus cells > 100 / hpf (N=0 /hpf) >>>> ask for urine culture ttt: Give the best antibiotics which is sulfa or Quinolones e.g. -Sutrim tab. 2*2*5 -Chemotrim fort 1*2*5 -Septrin 1*2*5 OR Quinolones if there is hypersensitivity to sulfa or resistance to it -Tarivid 200mg (ofloxacin) 1*2*5 -Oflicin 200mg (ofloxacin) 1*2*5 ·if pylonephritis: IV AB is required (hospital admission)



Tonsillitis or oropharingitis:

TTT: 1- Antibiotics for 1 wk:

the best is – penicillin e.g. Ampiclox 1*4 - 1st generation cephalosporin’s e.g. Velosef or Duricef - Sulfa e.g. Sutrim 2- Antipyretic 3- mouth wash

Otitis Media:

As above + nasal decongestant e.g. Afrin drops 1*3*7

Bronchitis:

As above + expectorants & mucolytics e.g. Mucosol syrup 1*3
Mucophylline Bronchophene Bisolvon 1*3 Trisolven

* if pneumonia >>>>> it is indication of admission for IV AB ( penicillin & 3rd generation Cephalosporins)

Gastroentritis:

SI → C/O: Watery diarrhea (no blood, no mucous, no tenesmus)

. >>>> this is viral infection >>>> give antiseptic e.g. streptomycin 1*3
LI → C/O: Diarrhea + blood + mucous + tenesmus + fever



Renal Colic: (loin pain radiating to the groin)

Give Glucolynamine IV >>>>> # IM (may cause abscess)

Papaverine IM >>>>>>>> # IV (cause hypotension)



* if no response give {Ca+ atropine + Buscopan + Papaverine + Brufen** كباب
*Ask for urine analysis, pelviabd. U/S
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حالات الاستقبال ج2



Tense ascitis ( TTT)

1-Rest in bed.


... 2-Salt restriction ( salt free diet )


3-Diuretics:


a) Start with Spironolactone (Aldactone) 100 mg قرص بعد الغداء


And increase gradually up to 4 tablets \day


Value : K sparing diuretic, Aldosterone antagonist.


b) Lasix 40 mg daily up to 4 tablets ( 160 mg\d)


N.B.: Diuretics esp. Lasix stopped if there is hyopkalemia or precoma


4-Follow up pt. with fluid chart


(body wtàtarget: decrease B.wt by 1\2 kg \day.)


5-If resistant à Tapping or paracentesis should be done if tense ascitis cause significant discomfort or resp. distress ( Therapeutic purpose of tapping )




6-Tapping:





a-Exclude encephalopathy.


b-Palpation of abdomen to avoid injury to any organ during tapping .


c-Sterilization of (Macburny's point) or mid way bet. Costal margin


& ASIS( most dependant area)


***Sterilization is done in circular manner from in into out by


betadine then alcohol.




d-introduce canula + IV line. - Replacement with albumin if tapping > 3L (one bottle contain 10gm)


- Stop if : hypotension , bleeding of tapping ,, disturbed conc. Level.




N.B.:-

* Diagnostic purpose of tapping : if suspicion of malignant ascitis or SBP or new onset ascitis.
* Fluid obtained from tapping : 3 samples for : culture & sensitivity, chemistry, pathological exam.
* Indication of Albumin in CLD Pt.:

- Tapping > 3 L of ascitis fluid.


- Infection


- Surgery


- SBP


- Hepatorenal $







SBP ( spontinous bacterial peritonitis ):




Infectious complication of portal HTN related ascitis in absence of


cause for peritonitis . most commen org : E-coli….




C\P : Pt with CLD with [ marked deterioration precipitate hepatic


encephalopathy],, [ fever, abd.pain , tenderness ] ,, [ silent]




D.D : leucocytosis may be present


Diagnostic paracentesisàcell count [WBC >500\ m3\HPF with


out sympt.,,PNL >250 \m3\HPF with symptoms ]




TTT: - Antipyretic.


- Antibioticà3rd generation cephalosporin E.g. : cefotaxime


"claforan" 1 gm \ 8 h for 5 days unless there is


renal failure ((dose adjustment))


- Anticoma measures ( previousely mentioned )


- Albumin.





Hepatic encephalopathy :-




It's neuropsychiatric complex in pts with acute or chronic LCF or portosystemic shunting(i.e.: disorderd conciousness, abnormal behavior…)




Ask about ppt factors in Ch. Liver disease pts :


-Diuretics


- High dietary prot.


- Haematemsis, melena


- Fever (infection)


- SBP


- Severe vomiting or diarrhea, excess tapping of ascitis.


- Hepatotoxicity ( alcohol ,drugs e.g. : sedative, opiod…)




Management :


1-Vital data ((fever. Haematemsis ))


2-Canula à sample for metabolic profile. ( Na, K, Creat, RBS)


3-Ryle &wash to exclude haematemsis.


4-Chest x ray à ( chest infection. . Rt sided P.effustion.


5-ECG






TTT:


1- To avoid prot. In diet.


2- Eradicate bact. Flora by: - Neomycin 500 mg 2*4*5


– Flagyl 250 mg 1*3*7


- Lactulose 30 ml \8 h. (osmotic purgative )


- Enema \4h


3- Hepamerz"L-Arnithine – L-aspanate (2 amp +200cc glucose 10% \12 h.)


à if creat > 3


4-Aminolesan 500ml\12h (AA infusion


5-TTT of the cause :


E.g. : Haematemsis àDicynon ,konakion, cyclokapron ,zantac…….



Infectionà TTT
SBPà Antipyretic, Antibiotic, Anticoma, Albumin……
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حالات الأستقبال

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وسأنقل لكم المتبع لدينا فى أستقبال الباطنة

والأدوية المتاحة
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والله الموفق نبدأ بأكثر الحالات شائعة فى الأستقبال



Haematemsis & melena.









1st aid measures :-

1-Vital data : pulse .. ... Bl.pr.


2-Canula & give : ((haematemsis cocktail )) ...............> Dicynon"hemostatic" , Konakion "vit.k ", Cyclokabron " antifibrinolytic" ,and Zantac " H2 blocker"



3-Ryle ---------------à Never before canula

*Values : -Ensure no bleeding

-To wash by cold water with or without adrenaline to cause
local VC.



*Continue wash till it become clear to prepare pt. For endoscopy .

N.B.: Pt. Fit for endoscope means :-

- Ryle wash becomes clear .

- Pt. is not shocked.
- Pt is not in encephalopathy.



4- 3 blood samples ((obtained from the canula before giving cocktail ))

- One for CBC -----à baseline Hbe

-----àPlat. ((decrease in HCV +ve pt. ))

- One for metabolic profile ----àRoutine ..
- One for blood preparation.


5- ECG ....to exclude ISHD.





** If bleeding severe or pt not fit for endoscope or not available
endoscope *

* We may use Sangstakin ---àinflate gastric ballon with 250-300 cc saline
** sangstakin should not be left more than 48 hours to prevent necrosis .







** Also in case of severe bleeding we can give :-

-Somatostatin:- [Octeriotide = antigrowth hormone] 25-50 ug\h..."one

ampoule contain 100 ug"

- 400 saline or Ringer أميول واحد على مدى 4 ساعات +

Value : VC.

- Glypressin "One ampoule contain 1mg "
2 أميول الآن ثم 1 واحد أميول كل 6 ساعات



$$. Take care :

It cause coronary VC, so give nitroderm patches if blood

pr. Allows.

Glypressin is # in IHD, old age…..

Blood is given if pt. chocked.

Plasma is given if pt INR >1.5

Plat. Is given if pt plat. >50,000

Till blood --àgive Colloid which last in intravascular space more than crystalloids. E.g. : Dextran,haemgel….
If Colloid not available -----à give crystalloids E.g.: Saline, Ringer.





II- History taking :
History of :- chronic liver dis., Gu or Du, Drug Intake : aspirin, NSAID, anticoagulant.


III-Examination : HSM , ascites , flapping tremors….



IV:-Upper GIT endoscope àshould be done when Pt. becomes fit for it .
Value :

1- Diagnostic for cause of bleeding

2- Therapeutic ( as mentioned before).



TTT of bleeding Oesophageal varices:









I ) 1st aid measures .

II) Injection sclerotherapy.
III) Anticoma…to avoid encephalopathy..

*Enema \4 h.

* protein restriction 20gm\d.

* Lactulose 30 cm\3 times\d àstopped if diarrhea

*Eradicate bact. Flora :

- Flagyl 250 mg (1*3*7)esp with renal impairment

- Neomycin 500 mg (2*4*5) #with renal impairment.

Side effect : ototoxicity so not given >5days

IV)Guard against SBP by Noroxin (Norfloxacin ) 1*2 .
V) Give (Dicynon ,konakion, Cyclocapron, Zantac) à 2 amp\8h.{ Zantac is # with thrombocytopenia.)



.If bleeding persist we give :-
Sandostatin, Glypressin



After bleeding stopped :

1- follow up GI for injection

.( ميعاد المنظار والحقن )

2Drug to decrease portal hypertensionàIndral 10mg à1*4

(If Indral can't be given as in case of DM\BAor PVD or CHF)

Give Effox 40 mg à1*2

3- Vit. K (1*3)

4- Liver support Eg: Legalon 1*3

5- Diuretics àdepend on pt is compensated or not à i.e. pt has
ascites.







TTT OF PU

a)1st aid measures

b)Upper GIT endoscopy for D.D.-à if active bleeding à injection with adrenaline

c) Losec ( Omeprazole) vial + 200 cc Ringer over 2 hours.

d) If anteral gastritis or Duà Tripple therapy to eradicate h.pylori

It includes :- PPI e.g. : Gastrazole 1*2*15 days

- Clarithromycin 2*2*15 days
- Amoxicilin 2*2*15 days.



Discharge Pt. when :-

Melena stopped

Hb = 8 or more.
Avoid spicy food , smoking , NSAID


NB: If pt. with PU with severe haematemsisà consult à Surgery.



Indication of admission of pt:

Haematemsis, melena

Tense ascitis

SBP

Hepatic encephalopathy

Recommended pt