Katutura State Hospital Internal MED PDF

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INTERMEDIATE HOSPITAL KATUTURA

INTERNAL MEDICINE GUIDELINES

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1.

GENERAL

2.

POISONING

3.

CVS IHD

Angina Pectoris MI Cardiac failure Acute Pulmonary Edema CCF Infective endocarditis Hypertension ECG Arrhythmias Rheumatic fever Mitral and aortic valve disease cardiomyopathies

3.

RESPIRATORY DISEASE Asthma Pneumonia Pleural effusions Haemoptysis COPD Pulmonary embolus Cor-pulmonale

4.

NEUROLOGY Depressed consciousness Meningitis Stroke (CVA) Seizures Bells palsy

5. 6. 7. 8. 9. 10. 11.

DKA HYPERTHYROIDISM ANEMIA DIABETES MELLITUS LIVER FAILURE RENAL FAILURE NEPHROTIC SYNDROME 2

GENERAL ANAPHYLAXIS Ask about allergies, previous anaphylaxis, and check medic alerts. Rx:

Place patient in recumbent position Administer 1) 1mℓ adrenaline 1:1000 solution im into deltoid or put up drip and give adrenaline slowly iv 2) Antihistamine 50 mg iv slowly and diluted 3) Hydrocortisone 100 mg iv 4) Aminophylline 250 mg slowly iv if bronchospasm Aminophyline should be put in 200 ml normal saline

CPR:

Call for help Give a hard thump with the fist to the midsternal area place patient on firm surface ABC: A= Airway- clear the airway of vomitis, remove loose dentures and correct positioning of head and neck B= Breathing- initiate ventilation (mouth to mouth, mask bag) C= Circulation- external cardiac massages, ventilation to cardiac massage ratio 1:5. Aim to massage 60 x per min. D= Definite therapy

Phase 1:

Secure iv line Sodium bicarbonate 4.2% solution . Give 200mℓ immediately, then 100mℓ Every 10 min. Connect ECG (to assess cardiac rhythm)

Phase 2:

Correct arrhthymias 1. VT, VF Defibrillate start with 200J if unsuccessful Give 200J again then 360J shocks Fine ventricular fibrillation may be made coarser by giving adrenaline I.V. and then attempting defibrillation Then give lignocaine 2.5-5mℓ 2% solution(50-100 mg) iv bolus and continue with infusion of 4mℓ lignocaine 10% solution in 200mℓ N/S Use 15d/mℓ administration set and commence with 30 drops/mℓ

2. Asystole

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Give adrenaline 0.5 – 1mℓ intravenously, transtracheally, or by intra-cardiac route. This precipitates VF which can then be defibrillated or use isoprenaline 0.2 mg iv 3.

+Bradycardia Atropine 0.6 mg iv Isoprenaline infusion 5 amp (1 mg) in 200mℓ, 5% dextrose Titrate to desired effect Cardiac pacemaker

Phase 3:

One stable effective cardio-respiratory state achieved, admit to ICU Neurology exam

POISONING Assess the patient and get a history from the family. Clear the airway and support the vital functions Call poison centre for information Ventilate if necessary-that is a respiratory rate 3.5 at < 72 hours ( must measure INR every 12 hours) Renal failure Blood pH < 7.2 ( lactic acidosis) Systolic BP < 80mmHg

Ecstasy poisoning (hallucinogenic amphetamine) Patient present with nausea, blurred vision, muscle pain, ataxia, confusion, dehydration, tachyarrhythmias, hyperthermia, and convulsions. Give activated charcoal and monitor the vitals, and ECG, for 12 hours. Monitor the urine output and U&E (renal function) Give diazepam for anxiety and seizures Always call the poison centre for help Tricyclics Monitor the heart rate, BP, RR, and ECG. Correct acidosis and enhance urinary excretion with sodium bicarbonate infusion to maintain arterial pH at 7.45-7.50 Monitor and treat the arrhythmias and give diazepam for convulsions. Methyalcohol Treat with ethyl alcohol. Give 50% alcohol e.g. Whisky or brandy (1mℓ/kg 2 hourly) Methylated spirits does not contain methyl alcohol. Cannabis Needs supportive treatment. Give diazepam 5-10 mg stat If psychosis present then give haloperidol 5-20 mg stat then 1-5 mg 12 hourly. Cocaine It is a very potent stimulant. Features of overdose are respiratory depression, tachyarrhythmias, convulsions and hypertension. They can present with acute myocardial infarct. Treatment haloperidol 5-10 mg daily if psychotic Diazepam for seizures Nitrates for chest pain Ascorbic acid to acidify urine to enhance excretion

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B-blockers for tachyarrhythmias Antidotes Benzodiazepines B-blockers Heavy metals Iron Oral anticoagulants Opiates Phenothiazines

flumazenil 300-600ug iv over 3-5 min. atropine 0.3 mg iv or glucagon 5-10 mg iv bolus if atropine fails dimercaprol desferrioxamine lavage with 50 mℓ 8% NaHCO3 IN 1ℓ water + 2g Desferrioxamine vitamin K (if not bleeding) FFP (if bleeding) naloxone 0.4 -1.2 mg iv every 2 min. until breathing is adequate if severe dystonia or extra-pyramidal effects give biperidin 5 mg iv stat

RESPIRATORY DISEASE ASTHMA Classical triad—wheeze, breathlessness, cough (Pleuritic pain due to diaphragmatic stretch) Precipitants

exposure to allergens / irritant Upper respiratory infections Chest infections (viral/bacterial) Neglect of medications Cold air or exercise induced asthma Emotional stress (Patients with marked ‘morning-dips’ in PEFR are at risk of sudden severe attacks)

Investigations FBC, ESR, ABG pulse oximetry CXR ECG, Pulmonary function test, peak flow rate Management 1) Sit patient up in bed, keep saturation >90% 2) Give oxygen 15 ℓ/min, obtain iv access, adequate hydration 3) Salbutomol Nebulization hourly (give 5- 15ℓ/min)measure PEFR 4) Ipratropium bromide can be added to nebulizer 5) Hydrocortisone 200 mg iv 4 to 6 hourly Celestone soluspan 2mℓ im Adrenaline may be given s.c 0.1mg, this can be repeated at 30 min intervals 2-3 times Adrenaline can also be given by nebulization (0.1-0.3 mg)

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Antibiotics if chest infection, purulent sputum or fever

Good response PEFR >200ℓ/min

and

Poor response and Pulse >100/min Pulses paradoxus>15 mmHg PEFR 130/min with pulses paradoxus Confused, drowsy, exhausted coma CXR – pneumothorax Failure to improve despite maximum therapy If no improvement after 2 hours measure blood gases Ventilate if pCO2 >6 kpa or increase pCO2 over 2 hours pox 75%

50-75%

Severe/life treating 60 Confusion Atrial fibrillation

wcc < 4 or > 20 x 109 bacteraemia s-urea > 7 mmol/ℓ multilobar-pneumonia

Treatment Blind treatment is started as soon as possible when appropriate cultures have been sent. Then once you get the result you can modify treatment Start iv antibiotics for 48 hours and 9

adjust to clinical condition and response. Consider treatment with salbutamol (2.5 mg nebulization every 6 hours) and maybe aminophylline to relieve bronchospasm, loosen secretions and improve mucocillary action. Give iv fluids to keep patient hydrated. Monitor response to treatment with FBC,CRP, pulse oximetry, and CXR at 3-5 days if patient deteriorating. Follow up CXR 4-6 weeks after discharge to exclude endobronchial lesion. Community acquired pneumonia

Cefuroxime 1.5g iv stat then 750 mg iv t.d.s plus Erythromycin 500 mg p.o q.i.d OR Amoxyl 1g iv t d.s plus erythromycin

Hospital acquired pneumonia Cefotaxime plus metronidazole Aspiration pneumonia

Cefuroxime plus metronidazole plus OR Benzyl penicillin plus gentamycin plus Metronidazole

Post influenza pneumonia

Cefuroxime plus erythromycin plus cloxicillin (staph. Aureas possible)

HIV patient

Cefuroxime plus co-trimoxazole

ASPIRATION PNEUMONIA Always admit It is usually seen in epileptic patients, comatosed patients, dsyphagia, GERD, stroke patients. Clinical picture –wheeze, frothy non-purulent sputum tachypnoea, cyanosis and respiratory distress. Gastric acid destroys alveoli resulting in increase capliiary permeability and pulmonary oedema. Heamorrage is common and severe necrotizing pneumonia may result. HOSPITALIZED PNEUMONIA Mostly enteric gram negative and anaerobes Pseudomonas aerginosa if patient is ventilated If intubated for > 48 hours use antipseudomonal antibiotics( ceftazidime 2g tds) PNEUMONIA IN IMMUNOCOMPROMISED All routine pathogens are possible Also consider TB and atypical mycobacteria(common)

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In AI+DS –PCP most common. Desaturation in presence of normal CXR or one with diffuse interstial shadowing is highly suggestive of PCP. A CXR can be abnormal secondary to Kaposi sarcoma or lymphoma. Recipients of organ transplants have depressed cell-mediated immunity due to antiimmunosuppresive treatment and they are susceptible to PCP, viruse(CMV,influenza and parainfluenza,adenoviruses) and fungi(aspergillus spp.,candida spp.) RECURRENT PNEUMONIA Wrong diagnosis( ?pumlonary emboli,pulmonary oedema,pulmonary vasculitis,alveolar haemorrhage,cavitation) Wrong antibiotic/weak antibiotic ?occupation ?interstial lung fibrosis ?connective tissue disease CAVITATION OR LUNG ABSCESS Any severe pneumonia may cavitate esp. Staph. aureas, Klebsiella, TB, aspiration pneumonia,bronchial obstruction(foreign body or tumour) Treatment triple antibiotic regime Cefuroxime+gentamycin+metronidazole( treat 4-6 weeks) Surgical drainage or CT guided percutanoues aspiration COAD Present with progressive dyspnoea, morning cough, wheeze Respiratory failure without dyspnoea ( blue bloater) Wheeze not relieved by inhalers Positive smoking history( or late onset asthma) Confusion/decrease LOC (exhaustion, CO2 retetntion) Causes infective exacerbations S.pnuemoniae, S.viridans, H.influenzae, Mycplasma, legionella,branhamella catarrhalis Exposure to allergens Sputum retention LVF Neglect of usual medications Management treat hypoxia and respiratory failure Relieve bronchial obstruction and bronchospasm Determine and treat the cause Give oxygen If pink puffer (thin not cyanosed, pursed lip breathing, no sign of CO2 retention)

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++give 30-40% oxygen If blue bloater (sign of CO2 retention ,obsese,cyanosed) give 28% oxygen

Check ABG If patient is not retaining CO2 PaCO2...