Dear colleagues, The community pharmacist is an essential member of the whole systemized medical services.

Usually he is the first resort of sick people. Not only he dispenses prescriptions, but he always gives advices and decisions to the patients, he is allowed to describe OTC medicines or refer the patients to specialized physicians.

Introduction

It is a honor to the Nahdi Training and Development Department (NTD) to publish this valuable book, which is directed to the community pharmacists everywhere. This book is a good matter of interest; it will guide you with the required knowledge about the most common cases. These cases are classified and arranged according to the general medicine classification. The book describes the symptoms, lines of treatment and patient education for these cases in a simple attractive manner. Dear colleagues, we are proud because you are the most professional community pharmacists in the Middle East and North Africa. Nahdi Training Department May 2011 Regards and best of luck.

Contents

Introduction ......................................................................................................................................................................................1 Contents............................................................................................................................................................................................2 Common Cold & Flu...........................................................................................................................................................................6 Cough ................................................................................................................................................................................................7 Bronchitis ..........................................................................................................................................................................................8 Bronchial Asthma ..............................................................................................................................................................................9 Acute pleurisy ............................................................................................................................................................................10 Pulmonary tuberculosis...................................................................................................................................................................10 Sore throat, Tonsillitis and Pharyngitis ............................................................................................................................................11 Laryngitis.........................................................................................................................................................................................11 Acute Infected Rhinitis ....................................................................................................................................................................12 Allergic Rhinitis ...............................................................................................................................................................................12 Acute sinusitis .................................................................................................................................................................................13 Chronic sinusitis ..............................................................................................................................................................................13 Epistaxis(Nose bleeding) .................................................................................................................................................................15 Otitis Media ................................................................................................................................................................................15 Otitis Externa (Swimmers ear )...................................................................................................................................................16 Otomycosis......................................................................................................................................................................................16 Chronic Suppurative Otitis Media................................................................................................................................................16 Ear Wax ...........................................................................................................................................................................................16 Menieres Disease ...........................................................................................................................................................................17 Motion Sickness ..............................................................................................................................................................................17 Oral Moniliasis ................................................................................................................................................................................18 Oral ulceration ................................................................................................................................................................................18 Ulcerative stomatitis .......................................................................................................................................................................19 Gingivitis : ............................................................................................................................................. Error! Bookmark not defined.

Gastro-enteritis ...............................................................................................................................................................................20 Diarrhea ..........................................................................................................................................................................................21 Rota viral diarrhea ......................................................................................................................................................................21 Dysentery ........................................................................................................................................................................................22 Haematemesis and Melena .............................................................................................................................................................22 Heart Burn (Hyperacidity)................................................................................................................................................................22 Peptic Ulcer .....................................................................................................................................................................................23 Helicobacter Pylori ......................................................................................................................................................................23 Hiatus Hernia with Esophageal Reflux ........................................................................................................................................23 Acute Gastritis.................................................................................................................................................................................24 Acute Cholecystitis & Biliary colic................................................................................................................................................24 Crohns disease (Regional enteritis) ............................................................................................................................................24 Mesenteric Angina ......................................................................................................................................................................25 Intestinal Colic.................................................................................................................................................................................25 Ulcerative Colitis .........................................................................................................................................................................25 Irritable bowel syndrome (Spastic Colon) ........................................................................................................................................26 Malabsorption syndrome ................................................................................................................................................................26 Flatulence........................................................................................................................................................................................27 Dyspepsia ........................................................................................................................................................................................27 Constipation ....................................................................................................................................................................................27 Vomiting..........................................................................................................................................................................................28 Overweight and Obesity..................................................................................................................................................................28 Hiccup 92.................................................................................................................................................................................... Hemorrhoids ...................................................................................................................................................................................29 Urticaria ..........................................................................................................................................................................................31 Eczema ............................................................................................................................................................................................31 Boils (furunculosis) ..........................................................................................................................................................................32 Carbuncle ........................................................................................................................................................................................32

Herpes simplex................................................................................................................................................................................33 Herpes zoster33.............................................................................................................................................................. Chicken Pox .....................................................................................................................................................................................34 Sweat Rash (Miliaria) ......................................................................................................................................................................34 Warts ..............................................................................................................................................................................................35 Callus and Corns ..............................................................................................................................................................................35 Skin Fungal Infection ( Ringworms ).................................................................................................................................................36 Tinea Capitis ....................................................................................................................................................................................36 Tinea Versicolor...............................................................................................................................................................................36 Tinea Cruris .....................................................................................................................................................................................36 Tinea Pedis (Athletes Foot)..............................................................................................................................................................37 Scabies ............................................................................................................................................................................................37 Alopecia Areata ...............................................................................................................................................................................38 Psoriasis ..........................................................................................................................................................................................38 Gonorrhea.......................................................................................................................................................................................39 Syphilis ............................................................................................................................................................................................39 Urinary Tract Infection ....................................................................................................................................................................40 Renal Colic (Pain) ........................................................................................................................................................................40 Acute Retention of Urine.............................................................................................................................................................41 Acute Nephritic syndrome...............................................................................................................................................................41 Acute pyelonephritis .......................................................................................................................................................................41 Cystitis & Urethritis (Acute & Chronic) ............................................................................................................................................42 Nocturnal Enuresis ..........................................................................................................................................................................42 Acute Bacterial prostatitis ...............................................................................................................................................................43 Chronic Prostatitis ...........................................................................................................................................................................43 Senile Enlargement of Prostate .......................................................................................................................................................43 Conjunctivitis ..................................................................................................................................................................................44 Red Eyes (Allergic Conjunctivitis).....................................................................................................................................................44

Red eye with infection.....................................................................................................................................................................45 Inclusion conjunctivitis ....................................................................................................................................................................45 Dry Eye ............................................................................................................................................................................................45 Trachoma 64....................................................................................................................................................................... Blepharitis .......................................................................................................................................................................................46 Corneal Ulcer...................................................................................................................................................................................46 Infantile colic...................................................................................................................................................................................47 Napkin dermatitis............................................................................................................................................................................47 Teething Pain ..................................................................................................................................................................................47 Headache ........................................................................................................................................................................................48 Migraine..........................................................................................................................................................................................49 Facial Palsy (Cranial Mononeuropathy) ...........................................................................................................................................49 Low Back Pain with Tension ............................................................................................................................................................50 References ......................................................................................................................................................................................51

Common Cold & Flu

Lines of Treatment Symptomatic treatment Topical decongestant. Systemic decongestant.

Pulmonology

It is very common respiratory syndrome which may be caused by wide variety of viruses mainly the Influenza & Rhinovirus. Most patients complain malaise (weakness), headache, watery nasal discharge, sneezing , nasal obstruction, then purulent discharge, sore throat ( dryness, pain, hoarseness of voice, may occur mild & moderate congestion of pharynx & tonsils), cervical lymph nodes maybe enlarged & slightly tender, Herpes Labialis is common. Complications: Secondary bacterial infection, purulent sinusitis, otitis media, tonsillitis and bronchitis.

Local treatment of throat soreness (M. Wash, Lozenges, etc.). Antipyretic analgesic. Cough therapy. Inhalation of volatile oils (as vapor of Tincture benzion compound or Breath cure cap.) if the voice is affected. Topical application of antiviral in case of H. labialis. Antibiotics in case of secondary bacterial infection.

Patient Education Rest. Adequate fluid intake. Increased humidification. Nasal irrigation. Avoid close contact with suffering persons , wash hands regularly , clean & disinfect shared surfaces e .g. telephones . Cross-Sales Immune stimulant. Humidifiers if needed. Disinfectants (Antiseptic sprays, hand gels,etc).

N o s e P ro b l e m

C o n g e s tio n is m a in s y m p to m s

N a s a l d is c h a r g e & s n e e z in g a r e m a in s y m p to m s

P o st - n a sa l d is c h a r g e & H e a d a ch e a r e m a in s y m p to m s

B le e d in g is m a in s y m p to m s

C o m m o n c o ld

A lle rg ic R h in it is

S in u s it is

E p is t a x is

Differentiation between Cold & Flu Symptoms Fever cough Aches Stuffy nose chills Tiredness Sneezing Sudden symptoms Headache Sore throat Flu Mostly high fever Non productive (dry ) Sever aches &pains are common Not commonly present with the flu Common with flu about more than 60% Moderate to severe Commonly is not present Flu has rapid onset , within 3- 6 hrs , sudden symptoms high fever aches &pain Is very common 80% of cases Is not commonly Severe Cold Rare with cold Hacking & productive Slight aches &pains Commonly with cold & resolve within 1weak Uncommon Mild tiredness Commonly present Develop over few days Fairly uncommon Commonly accompanied Mild to Moderate

Cough
Chest discomfort

A cough can be classified by its duration, character, quality, and timing. The duration can be either acute (of sudden onset) if it is present less than three weeks, sub acute if it is present between three and eight weeks, and chronic when lasting longer than eight weeks. A cough can be dry or productive, depending on whether sputum is coughed up or not. Productive cough (Moist cough) Also known as chesty cough, it is usually due to a viral or bacterial infection. This type of cough expels the phlegm which has formed in our respiratory passages, so that abnormal mucus and germs are eliminated from the respiratory tract and breathing becomes easier. Lines of Treatment of moist cough (without infection) Mucolytic or muco regulator. Expectorant. Herbal cough syrup (thyme ivy). Bronchodilator or (muco regulator + bronchodilator). Non-productive cough (Dry cough) Non-productive cough is dry, tickling and irritating. This cough can for example be caused by phlegm that is so viscous that it is not loosened and expectorated. It can also have an allergic or neurotic origin or can be caused by other perhaps more severe diseases. Lines of Treatment Cough suppressant (Dextromethorphan). Herbal cough syrup (thyme Ivy honey).

Cough in common cold In the case of a common cold or flu, there are often two phases: first a nonproductive or less productive cough, followed by a productive cough. When viruses invade the lung, the lining of the respiratory tract is attacked and impaired. The normal secretion of mucus changes: mucus becomes stickier and adheres in the lungs. It cannot be expelled yet, and coughing is experienced as very troublesome and exhausting. As the cold progresses, more mucus is usually produced and the cough becomes productive. It is then possible to expel the phlegm by coughing. Most common causes of cough Stimulation of cough receptor by: Inflammation: air ways inflammation ---- bronchitis, Laryngitis, Alveolar inflammation ---- Pneumonia. Mechanical: compression of air passage (external internal). Chemical: inhalation of irritant cases chemical, fumes, - cigarette smoking. Other causes: gastroesophageal reflux disease, ACE inhibitor, air pollution and sychogenic cough.

Bronchitis

Complication of cough Fatigue, anorexia, headache, may occur rib fracture, muscle rupture, emphysema, cough syncope.

Symptoms Cough, low or high degree of fever or without fever, mucous by large amount change from clear to turbid or yellowish. Lines of treatment Systemic antibiotic. Mucolytic or muco regulator. Expectorant. Herbal (thyme Ivy honey). Bronchodilator or (muco regulator + bronchodilator). Systemic anti histamine or/ and corticosteroid by physician. Antipyretic if fever is in the symptoms. Anti tussives are better to be avoided in infants due to fear of pneumonia & bronchopneumonia, if necessary it can be used before sleep only.

Bronchial Asthma

Symptoms Repeated attacks of wheezy chest or night cough. It may be mild, moderate chronic, or severe chronic asthma. Infection, allergen body, exercise, drugs as aspirin, NSAID, psychological & environmental factors are the stimuli of the acute attack in asthmatic patients. Lines of treatment Bronchodilator systemic or/and local (inhaler or turbohaller). Local corticosteroid (as inhaler or turbohaller ). If asthmatic bronchitis is accompanied by infection then systemic antibiotic is very necessary. Systemic anti allergy as H1 blocker or by physician prophylactic anti allergic drugs as Ketotifen or Montelukast for long period. Physician can also prescribe corticosteroid as prednisolone 2mg /kg/day for 3- 5 day. Physician can also prescribe local combination of corticosteroid & bronchodilator (inhaler, turbohaller , discus ) as Symbicort , Seretide. N.B. salbutamole & terbutaline (B2 agonist ) are not used below 18 months due to not effective under this age, therefore can use theophylline but notice that it cause insomnia as a side effect , also the effect of theophylline increases by erythrocin antibiotic. Cough suppressant can be used for severe spasmodic cough, but if there is mucous we can use expectorant or muco regulator or herbal cough syrup. Patient Education . . . . Beta blocker , Aspirin , NSAID

Comparison
Age Duration Fever Distress Obstruction

Bronchiolitis
2 - 3 year 3 - 7day mild or non marked inspiratory& exp.

Bronchial asthma
few month to adult variable no mild- marked Expiratory

Pneumonia
all ages 7-10 day
moderate-high

mild-marked no obst. But tachypnea

Acute pleurisy

Symptoms Sudden stitching pain, with inspiration cough & straining the site of pain depend on the part of pleura affected also may be dry cough & dyspnoea.

Pulmonary tuberculosis
Lines of Treatment

Lines of treatment Antibiotic, analgesic, pethidine 50, may need intercostals nerve block, strapping the chest on the affected side with adhesive tape, also treat other symptoms.

Symptoms Loss of weight, loss of appetite, night sweating, night fever, hemoptysis sputum occurs, investigation by detection of tubercle bacilli, tuberculin test, and blood picture (high E.S.R.)

1st line drugs (standard drugs )

Rifadin 2 Isoniazied 2 Or Rifinah or Ramactazide 2 Vit. B This treatment given for 9- 12 month. Pyrazinamide: 15- 30mg /kg/once daily add to treatment 1st 2 months. Also can use Ethambutol as 2nd line alternative to Rifampicin. Good diet. Fresh air. Bed rest in very ill cases. Duration of treatment 15 months. Follow up: symptoms disappear, Lab. Data E.S.R., C-reactive protein, and improvement of anemia. X- Ray: Repeated film (every 2-3months). Some physicians prescribe corticosteroid: 1-2 mg /kg/day orally 1st 4-6week of therapy.

Other Type of TB Miliary TB. , TB. Meningitis, Pericarditis & TB bronchopneumonia. 2nd line of treatment is Alternative drugs Streptomycin used as 3rd drug with INH + Rifampicin. Other amino glycoside as Amikacin. Ethambutol: 15- 20 mg/kg/day in one dose orally (side effects: skin rashes, reversible optic neuritis). Para amino- salicylic acid is also used as alternative drug when other drugs are not available: 200300mg/kg/day in one or 2 doses (side effects: gastric upset & vomiting).

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Sore throat, Tonsillitis and Pharyngitis

ENT
Symptoms Sore throat Can occurs as a result of inflammation in one or more of 3 sites: Pharynx (pharyngitis). Tonsils (Tonsillitis). Larynx (Laryngitis). Causes: Viral (70%) & bacterial (30%). Tonsillitis & pharyngitis high fever, pain in the form of burning in the throat, dysphagia, & enlarged tonsils with or without streak of pus, but laryngitis cause hoarseness, may cause complete loss of voice. Lines of treatment Antibiotic to overcome the secondary infection (pharyngitis). Anti pyretic or analgesic anti inflammatory. Anti septic mouth wash (gargle). Soothing & anti septic as lozenges or V.O inhalation in case of laryngitis. Immune stimulant as multivitamins at the end of the treatment course. Bed rest, balanced diet & fluid. Advice for patient Tonsillectomy should be postponed for 3 weeks after recovery from acute infection, & not to be done before the age of 4 years. Indication of tonsillectomy: o Chronic tonsillitis. o Recurrent tonsillitis more than 5 per year. o Peritonsillar abscess. o Previous history of rheumatic fever.

Laryngitis

Symptoms Hoarseness is the main symptoms in adult, but stridor (change in the sound) in child due to congestion & oedema of the vocal cord. Lines of treatment Voice rest. Soothing by inhalation of Tincture Benzoin Compound. Systemic antibiotic. Systemic corticosteroid (by physician) as Prednisolone: 1-2 mg /kg /day for 3- 5 days, then decrease gradually or dexamethasone: 0.1-0.2/kg/day, also decreases gradually. Systemic antihistamine. In chronic case, use the same treatment lines except the antibiotic.

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Acute Infected Rhinitis

Symptoms Dryness, sneezing, watery discharge, sever nasal congestion & obstruction, itching of nasal mucosa & conjunctiva, and lacrimation. Also may be accompanied by fever. If 2ndry infection occurs; purulent discharge appears. Lines of treatment Systemic decongestant with anti allergy. Local decongestant for short course to avoid the rebound effect, or use product that is less effective but highly save as normal saline. Antipyretic, analgesic. Antibiotic. Immune stimulant as Vit. C. Rest.

Symptoms In case of nasal allergy (Allergic Rhinitis): the same symptoms of acute rhinitis but recurrent with intermittent nasal obstruction, headache, more watery discharge, more sneezing, seasonal and runs in families. Lines of treatment Try to avoid the cause of allergens (dust, food, fumes, Pollens), that is why allergic rhinitis is called hay fever where it increases during the haying season. Systemic antihistamine. Specific anti allergic local nasal spray (corticosteroid or non corticosteroid). Systemic decongestant for short periods therapy. Systemic analgesic, anti inflammatory if needed. Precaution to Avoid catching allergic Rhinitis Remain indoors when outdoor pollen grains levels are high or use mask. Keep windows closed. Do not dry clothes outdoors. Avoid exposure to environmental irritants as insect sides sprays, tobacco smoke, air pollution and fresh tar or paint. Regular wash of hands & face to remove pollen grains.

Allergic Rhinitis

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Acute sinusitis

Symptoms It is inflammation and infection of Para nasal sinuses leads to fever, headache, nasal obstruction, mucopurulent discharge with bad smell and pain over the affected sinus increases by cough or straining. Lines of treatment Systemic antibiotic. Antipyretic or analgesic, anti inflammatory. Washing or irrigation of the sinus is very important. Mucolytic. Systemic decongestant & antihistamine for short periods therapy. Rest.

Chronic sinusitis

Symptoms The same symptoms but continues for a long time, no fever, also symptoms of descending infection as otitis media, laryngitis, pharyngitis, or arthritis may present. Lines of treatment Antibiotic after culture & sensitivity test. Anti inflammatory drug is necessary (Ambezim is preferable). Washing or irrigation of the sinus is very important (normal saline or sea water). Mucolytic. Also other steps of treatment (as in acute sinusitis). Surgical entrance.

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comparison

Acute sinusitis
Accumulation of fluid in sinus cavity interfere with normal drainage

Chronic sinusitis
Accumulation of fluid in sinus cavity prevent normal mucous drainage From long time Frequent Frequent Mostly postnasal discharge Yellow to greenish , with bad odor , Intermittent headache,aching behind the eye Inadequate treat. Of acute sinusitis Allergic sinusitis

Time of appearance Fever Facial pain Nasal discharge Color of discharge Headache

From short time Mostly Mainly throbbing pain Front & post nasal Watery then with 2ndry infection change to yellow or greenish The main symptoms of sinusitis Acute upper respiratory infection

Causes

Swimming or diving Dental abscess or extraction Bed rest , light diet & fluid Systemic antibiotic

Treatment Antipyretic & analgesic Wash or irrigate the sinus Systemic decongestant & anti allergy

The antibiotic need to culture & sensitivity test Anti inflammatory as ambezim The same + Mucolytics

Precautions to prevent sinuses attacks During cold & allergy attack, patient should keep sinuses clear by using short course of nasal decongestant (Normal saline is preferable). Gently blowing nostril opening. Drinking plenty of fluid. Avoid air travel, if necessary use decongestant N.S. Prevent blockage of the sinuses allows mucus to drain (use mucolytic).

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Epistaxis (Nose bleeding)

Symptoms There are two types: Anterior which is most common and posterior which is less common but more sever. Causes Local predisposing factors: Nasal trauma, rhinitis, dryness of nasal mucosa, foreign bodies, nose picking and deviation of nasal septum). Systematic factors: Alcohol due to vasodilatation, allergies, heart failure due to increase venous pressure, hypertension, infectious diseases and malnutrition. Lines of treatment Specific Measure : treat the cause Local Management Position is sitting position to decrease the venous pressure, may be lean forward to lessen swallowing of blood. Direct pressure on the bleeding site for 5 minutes. Cold compresses on the head may be applied. Using nasal decongestant (spray or gel). Local anesthetic (spray or gel). Anterior nasal pack with gauze wetted by vasoconstrictor. Dicynone tab. or amp. Physician examines the site of bleeding and may apply cautery. Also physician can prescribe antibiotic. Some advises for epistaxis patient: avoid vigorous exercise, hot or spicy food and smoking. Recurrent cases may be due to hereditary factor, or problem in the Para nasal sinuses, blood platelets.

Otitis Media

Symptoms More common in infants & children 3- 6 years. Early deafness, tinnitus, throbbing pain after perforation of drum discharge of pus, fever, symptoms of cold. Lines of treatment Antipyretic or analgesic anti inflammatory. Systemic antibiotic with maximum dose level. Local antibiotic in chronic cases. Nasal decongestant local & systemic. Mucolytic. Systemic antihistamine (may be used). Remove discharge & debris. Reexamination is necessary after one week.

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Otitis Externa (Swimmers ear )

Symptoms Pain on mastication, discharge, deafness, inflammation & swelling external ear. Lines of treatment Remove the purulent debris from the ear canal. Antibiotic Local & systemic. Analgesic Local & systemic. Systemic antihistamine.

Otomycosis

Symptoms Fungal infection of external ear. Itching, deafness when fungal mass obstructs the meatus. Lines of treatment Antifungal drops. 2% salicylic acid in alcohol to remove the infected epithelium. Earplug to protect from water. In some complicated cases can use systemic antibiotic. Advice Ear washing or suction by physician.

Chronic Suppurative Otitis Media Ear Wax

Lines of treatment Regular removal of infected debris. Earplugs to protect from water. Antibiotic from 1 to 6 week some time need antibiotic effective on pseudomonas as pipril or azethromycin. Local antibiotic ear drops. Last stage surgical treatment.

Symptoms Wax (cerumen impaction): deafness, tinnitus when the wax obstruct the meatus, mostly no pain, no tinnitus, no vertigo, but feeling of fullness & impaction. Lines of Treatment Cerumen liquefaction. Then mechanical removal & suction. Washing, cleaning & drying by the ENT physician.

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Menieres Disease

Symptoms Recurrent sudden attacks of deafness, tinnitus, vertigo, nausea and vomiting. The main cause is distention of endolymphatic sac of inner ear, also circulation insufficiency of inner ear N.B no history of travel, high attitude or exit to sea. Lines of treatment Increase the inner ear circulation (Betahistine, Cinnerazine, Ginko bilopa, ). Decrease the endolymphatic pressure by using diuretic. Symptomatic treatment using anti emetic. Also advice by low salt diet.

Motion Sickness
Lines of treatment

Symptoms Dizziness with history of travelling, high attitude, exit or travelling through sea.

Depends mainly on antihistamine that has high central effect as diphenhydramine (dizzinil, Dramamine). Parasympatholytic has also high central effect as Buscopan. Antiemetic hour before travelling, especially that with central effect. In sever vomiting cases we can use sedative as Neurazine supp. or injection or Promethazine. For children sedating antihistamine.

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Oral Moniliasis

GIT

Symptoms Thrush appears as crude milk sheet on the tongue & other sites of the mouth. Lines of treatment Local antiseptic (mouth wash in case of adult). Local antifungal for 2 weeks. Systemic antifungal in complicated cases or cases which are not responding to the local treatment. Analgesic, anti inflammatory if there is pain in the history. Cross-sales Multivitamins or natural source of vitamin B-complex (ex: yeast tablets) or immuno-stimulant (ex: Echinacea).

Oral ulceration
Patient education Symptoms Red patches, necrotic patches.

) (

Lines of treatment Anti septic washes. Astringent as Pyralvex. Local oral anaesthetic as Lidocaine viscous. Local anti inflammatory using corticosteroid as Kenalog in orabase. Systemic analgesic anti inflammatory. Cross-Sales Source of vitamin B-complex as Yeast tablets or capsules.

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Ulcerative stomatitis

Symptoms Shallow mucosal ulcer surrounded by erythema. Numerous Pin point shape and painful. Citrus fruit, chocolate and nuts increase the pain. Lines of treatment Remove the cause ex: dentures, braces, GIT disordersetc. Anti septic by using mouth wash. Astringent as Pyralvex. Local anesthetic as Xylocaine viscous. Local anti inflammatory using corticosteroid as Kenalog in orabase. Systemic analgesic anti inflammatory. Last stage is cautery and systemic steroids.

Gingivitis:
Cross-Sales

Immuno-Stimulants (Propolis Echinacea Black seed).

Symptoms Inflamed, congested and sometimes bleeding gum. Lines of treatment Anti septic solution (mouth wash). Systemic Antibiotic. Analgesic anti inflammatory. Specific tooth paste for gingivitis & gum bleeding as Parodontex, Lacalute aktiv, Arthrodontetc. (Used as normal toothpaste with brush then washed). Specific local preparations for treatment of congestion as Ginvapaste or Parodiumetc. (applied to the gingiva without further washing or removal). Astringent as Pyralvix, Salivex. Intensify the blood vessels using vit C or Rutin etc. Dental care o Toothbrush (soft, ultra-soft and massage brushes are more preferred). o Suitable Intradental devices as flosses, tapesetc. o Oxy-jet. Patient Education .

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Gastro-enteritis
Symptoms Diarrhea, vomiting.

Lines of treatment Mild & moderate cases (home management). I Prevention of dehydration (lemon, apple juice, rice water, light tea. II- Rehydrating solution especially in baby. III-Feeding partial or incomplete breast feeding, carrot, rice, especially in baby. IV- Milupa special formula also can use other formula as Isomil in baby. Symptomatic Ttt as anti colic, antipyretic, anti diarrhea, metabolic acidosis, convulsions. Specific therapy (antibiotic, anti protozaol as Metronidazol: 50/kg /day & after one year old). All sever cases most be referred to physician or hospital. Dehydration signs Dry tongue, sunken eyes, loss of skin elasticity, loss of weight, oliguria. Increase heart rate & tachypnoea, complication of dehydration: shock, arthritis, peritonitis, &pneumonia, bleeding orifices, the main causes of dehydration are fever, diarrhea and/or vomiting. Degree of dehydration according the weight loss Mild loss 3- 5% of the weight. Moderate loss 5 10% of the weight. Severe loss more than 10% of the weight. Deficit replacement: in mild cases need to 50ml /kg /day. In moderate need to 100ml /kg / day but severe cases need to 120ml/kg /day. Initial anti shock: blood, plasma ringers solution, 0.9 % NaCl. Oral rehydrating solution 5 Correction of acidosis use 1/6 sodium lactate solution 20ml/kg. Correction of hypokalemia by giving K solution orally.

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Diarrhea
Acute diarrhea

In infants & children the number of diarrhea per day must be considered, where more than 6 times per day is considered as diarrhea, but in adult; diarrhea is change than the normal & also the number of defecations. Types & causes of diarrhoea Mostly Caused by infective Agent: (Shigella , - Salmonella , - E. Coli , V. Cholera , - Staph , - Cl . wellchii , Entameba histolytica , - Viral due to Reo virus ). Or caused by toxic allergic agent: (food, drugs, etc.). Lines of Treatment Symptomatic treatment. Treatment of the Cause.

Dietary diarrhea due to high lipids food , or high amount of vegetables

Lines of treatment Symptomatic treatment. Remove the cause. May be: Infective (bacterial, viral or amoebic). Non infective. Lines of treatment According the cause: If infective (symptomatic treatment + Doxycycline + other anti infection according to the cause, in case of Amoebic diarrhea we must use Metronidazole), but in non infective cases we use only Imodium, or astringent. Psychogenic as anxiety Ttt (symptomatic + psychotherapy). Chronic: the problem is in the stomach & small intestine as (T.B., parasite, Lactase deficiency, Crohnes disease), or the problem is in the colon as (Irritable Bowel Syndrome, Fecal impaction, Ulcertative colitis, Polyposis). As D.M., some drugs, thyrotoxicosis, pancreatic & biliary disease, other infectious disease).

Traveler diarrhea

Rota viral diarrhea

Other causes of Diarrhea
Lines of treatment Oral rehydrating solution. Astringent. Immune stimulant.

Symptoms Rice watery diarrhea, nausea, vomiting, depression, tired.

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Dysentery

Symptoms Repeated defecation with colic, mucous, blood may be diarrhea. Lines of treatment Amebicidal. Anti infection. Anti spasmodic. Astringent may be used. After treatment course use vitamin B is very necessary.

Haematemesis and Melena Heart Burn (Hyperacidity)

Symptoms Depending on the site of bleeding, its rate & underlying disease: Haematemesis: vomiting of blood. Melena: black, tarry & offensive stools, containing digested blood. Haematochazia: bleeding per rectum. Common & important causes of GIT bleeding esophageal, peptic ulcer, duodenal 33%, gastric 25%, acute erosive gastritis, hiatus hernia.

Symptoms A burning sensation in the chest, just behind the breastbone or in the epigastrium. The pain often rises in the chest and may radiate to the neck, throat, or angle of the jaw. Heartburn is usually associated with regurgitation of gastric acid (gastric reflux) which is the major symptom of gastroesophageal reflux disease (GERD).It however may also be a symptom of ischemic heart disease so concluding that it is gastroesophageal reflux disease prematurely may lead to misdiagnosis. Commonly result from reflux esophagitis, Hiatus hernia, gastritis give feature of hyperacidity postprandial & increase on lying. Lines of Treatment Treat the cause. Antacid. H2 Blocker. Patient Education General Measure: Avoid spicy, fatty meals, pepper, coffee, tea, coca, smoking, alcoholic drinks, snacks between meals. Also avoid aspirin, & NSAIDs. Never lay down after a meal, allow 2 to three hours between eating and bedtime. Maintenance therapy: For patients with frequent relapses more than 3times per year, with no HP infection, previous complications, with high risk to tolerate the operations: use H2 blocker at bed time, or one of long T1/2 of proton pump inhibitor as pantaprazole. Last stage is surgical treatment (failure medical treatment, complications e.g. hemorrhage, perforation, or pyloric obstruction, suspected malignancy.

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Peptic Ulcer

Symptoms Duodenal ulcer: epigastric pain 2hrs after meal commonly relieved by anti acid, & food, patient is anxious; overweight due to food alleviates the case. Gastric ulcer: epigastric pain 10- 30 min. after meal relieved by (vomiting & anti acid) , there is loss of weight due to food lead to pain. Complete diagnosis by X- ray, endoscopy, Gastric analysis, Barium metal studies, cytologic studies for tumor cells in gastric lavage. Lines of treatments Anti acids (neutralization). H2 blockers. Proton pump inhibitor is used in resistant cases (no healing after 12weeks), Severe cases, it causes gastric metaplasia secondary to complete achlorhydria. There for the treatment continues for 6- 8week. Ranitidine is the drug of choice because: no anti androgenic activity, no CNS side effect, and no drug interaction. (Selective M1 receptor antagonist ) Pirenzepine (as Gastrozepin) it is kept for peptic ulcer associated with pylorospasm. Mucosal protective drug as Sucralfate. Prostaglandin analogues (Misoprostol), but contraindicated in pregnant women.

Helicobacter Pylori
Patient Education As mentioned in Heartburn.

Helicobacter pylori (H. pylori) are supposed to be responsible for most ulcers and many cases of stomach inflammation (chronic gastritis). The bacteria can weaken the protective coating of the stomach, allowing digestive juices to irritate the sensitive stomach lining.

Hiatus Hernia with Esophageal Reflux

Lines of treatment The same drugs for Duodenal ulcers in addition to two weeks course of antibiotics ( triple therapy ). Lines of treatment Acid neutralization by antacids + H2 blocker once at bed time. Prokinetic drugs as domperidone or metclopramide. Anti flatulence & digestant. Surgical repair (large paraesophageal type hernia, small sliding hernia).

Symptoms History of flatulent dyspepsia , heart burn , cramping , distress retrosternal chest pain is common complain, the symptoms increase by sleeping , relieved by upright position, X-Ray (barium study ): Herniation of cardio- esophageal junction , Esophagoscopy : hyperemia , exudation & ulceration.

23

Patient Education Weight reduction. Avoid all conditions which increase the intra- abdominal pressure. Avoid lying down after meals, patient can sit & elevate head of bed 20cm. Stop smoking. Avoid alcohol, fatty food and caffeine. Avoid late night meals.

Acute Gastritis

Symptoms No definite symptoms, pain (distress after meal, anorexia, nausea, vomiting), previous stress (major burn, trauma, shock, or surgery), Haematemesis, Hemorrhage, Endoscopy: gastric mucosal erosions. Lines of treatment Remove the cause as shock, trauma, drugs or alcohol. Use of mucosal protective drugs as Sucralfate, also H2blockers can be used. Also can use antibiotic, in severe cases use ice water lavage.

Acute Cholecystitis & Biliary colic

Lines of treatments Bed rest. Relief pain till Pethidine can be given. Systemic antibiotic & Flagyl infusion.

Symptoms Acute upper abdominal pain in the right, to the tip of right shoulder, &to right scapula, it is severe pain & last several hours, nausea, vomiting, past history of biliary colic, moderate fever around 38 C in absence of complications. Tenderness R. subs costal.

Crohns disease (Regional enteritis)

Symptoms Usually encountered before the age of 40 year, & it is equal in both sexes chronic diarrhea, fever, Weight loss, anorexia, steady abdominal colicky pain, abdominal fistula & abscess may develop, peri anal abscess, also stimulate appendicitis, investigation by blood picture, E.S.R., X-ray(Barium meal & Barium enema). Lines of treatments High protein diet, high energy, low fat, milk free diet, parenteral nutrition required in severe cases. Drugs : iron + folic acid, anti diarrhea drugs as lopramide, anti- inflammatory & immunosuppressant as hostacortin , salazopyrin twice daily (ulcerative colitis ) , Immuran 50mg 2mg /kg/day , antimicrobial (as Flagyl infusion twice daily). Surgery.

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Mesenteric Angina Intestinal Colic

Lines of treatments Small frequent meal. Surgery.

Symptoms Abdominal pain localized or diffused, mostly postprandial, epigastric problem may be audible X-ray series show disturbed intestinal motility & narrowing.

May result from overeating, food poisoning, enteritis or cold. Should secure that it is not intestinal obstruction before any treatment. History of improper food may involvement of other family members, colicky pain around the umbilicus, lasting in few mint, nausea, vomiting, and anorexia. Lines of treatment Exclude intestinal obstruction. Spasmolytic. Bed rest, fluids, and light diet. May need to decrease peristalsis if there is diarrhea & use lopramide.

Ulcerative Colitis
Symptoms

Vague lower abdominal discomfort or pain, attack of bloody diarrhea, in severe cases, sudden violent diarrhea, high fever, peritonitis, weight loss & anemia, investigation by laboratory diagnosis. Lines of treatment Rest. Normal diet without raw fruit or milk. Decrease peristalsis movement, sedative. In moderate & severe cases corticosteroid is being used, Salazopyrin, Immuran. Fluid, also potassium source to prevent potassium depletion. Last stage surgery.

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Irritable bowel syndrome (Spastic Colon)

Symptoms Tense anxious which may give dyspnoea, palpitation, and tachycardia. In some cases painless diarrhea with mucous (no blood), in majority cases flatulence, distension, with diarrhea or constipation, tenderness in sigmoid colon, no complete defection. Lines of Treatment Spasmolytic drugs. Digesting & anti acids if hyperacidity is in the symptoms. Ant flatulence & can use intestinal antiseptic. Regulate defecation by using fibers. Probiotic to activate the flora of intestine. Prokinetics. Anxiolytic. Patient Education Treat any depressive reaction, avoid any anxiety, regular physical activity, & normal diet. Avoid much heavy eating, but several small meals with high fibers content are recommended. Avoid rapid eating. Avoid high fatty meals & junk food. Decrease or eliminate fermentable food (gas forming diet). Avoid drinking much fluid with meal. -

Malabsorption syndrome

Symptoms Syndrome of impaired nutritional absorption from the small bowel Lead to diarrhea, abdominal distension, flatulence, bloating, gas production, steatorrhoea. Features of nutritional deficiency due to Malabsorption syndrome : Microcytic or Megaloblastic anemia , Ca++ deficiency lead to bone pain & tetany, thiamine def. lead to paresthesia , Riboflavin def. lead to Sore tongue, angular stomatitis , Hypoproteinaemia lead to edema also severe diarrhea lead to hypokalaemia & muscle wasting, endocrinal disturbance lead to amenorrhoea. More investigations by laboratory for right diagnosis. Lines of treatment Remove the cause. Treat the symptoms: iron, folic acid, vit. B tab. & injection, especially Depovit B12, multivitamins & minerals. Antibiotic to overcome any infection. In severe cases give systemic corticosteroid. Gluten free diet.

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Flatulence

Symptoms This is a state of exaggerated gas production, accumulated in the intestine leading to feel of distension& distress Causes: Aerophagia (air swallow), colonic bacteria, indigestion, GIT disease, Gastro esophageal reflux, acid dyspepsia, cholecystitis, Malabsorption syndrome, irritable bowel syndrome. Lines of treatment Eliminate the cause. Give anti flatulence. Digesting drugs (direct digesting enzyme or indirect using probiotic or vitamin B). Combination of (digesting + anti flatulence). Prokinitics. Anti acids if accompanied in symptoms. Patient education Regular physical activity & normal diet. Avoid much eating, but several small meals. Avoid rapid eating. Decrease high fat food, junk food. Decrease or eliminate fermentable food (gas forming diet). Avoid drinking much fluid with meal.

Dyspepsia
It is indigestion.

Constipation

Lines of treatment The management as in the management of flatulence

Symptoms Causes: may be due to bowel obstruction, a dynamic ileus, head or spinal injury, following general anaesthesia , Bedridden patient, fasting or low amount of food. Causes of chronic constipation: chronic infection, hypothyroidism, Parkinsonism, cerebral thrombosis, psychogenic causes depression or anxiety. Lines of treatment Suitable laxative. Enema. Re establishment of regular evacuation. Diet adequate volume, adequate bulk food with high fiber content. Glass of hot water taken one half hour before breakfast. Vegetables & raw fruit (figs & orange).

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Vomiting

Causes CNS: Migraine, cerebrovascular accident, hypertensive encephalopathy. GIT: Gastritis, peptic ulcer, appendicitis, peritonitis, intestinal or pyloric obstruction, cancer. Pregnancy. Renal: pyelonephritis , stones. Cardiac: CHF, M.I, pericarditis. Endocrine: diabetic acidosis, adrenal insufficiency. Others: toxic causes, drugs, poisons, infection, glaucoma, mismatched blood transfusion.

Overweight and Obesity

Lines of treatment Treat the cause. Use anti emetic.

Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk of serious health problems. A person with a BMI of 30 or more is generally considered obese. Weight management goal is to decrease the total calories input and increase the total calories output. To manage your weight you have to: 1. Modify the diet to be mainly dependent on low carbohydrate and high fibers foods. 2. Increase exercise at least 3 times weekly. 3. Use slimming drugs.

Lines of Treatment Decreasing fat absorption ( orlistat - chitosan - anthocyanidine ). Fats and carbohydrates burners (chromium). Decrease appetite by bulky forming fibers (Psyllium seed husk - bran Mucivital Twinfast ). other lines: o Metformin (increase the burning & utilization of glucose). o Acarbose (decrease the absorption of glucose). o Thyroxine (Increase basal metabolic rate).

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Cross-Sales Slimming tea (Diafah Jamu). Digital scale. Sauna belt. Slimming soap. Sugar replacement (Tropicana Candrel). Patient Education Avoid junk food and soda drinks. Modify your life style: dont eat one meal daily but divide it into 3 meals, dont sleep directly after meals. Walking, Running, Rowing, Swimming or any exercise must be done at least 3 times weekly. Always weigh yourself using the same scale to measure the weight change perfectly. The healthy weight loss is about 3-5 kg/month.

Hiccup

Symptoms Stimulation of diaphragm by any cause e.g. gastric distension, subphrenic abscess, CNS disorder, Idiopathic disorders. Most cases resolve themselves in a short period of time, but if it lasts for more than 3 hours or they disturb you eating or sleeping habits, a medical treatment is recommended. Lines of Treatment Divert the patients attention by sudden blow from behind or introduce soft catheter nasally to stimulate the nasopharynex. Increase Co2 inhalation by breathing in closed bag or take long respiration & still longer time then expiration. Prokinetics drugs specially primperan. Tranquilizer in prolonged hiccup as Largactil (promethazine) 25- 50 mg orally 3 time daily for 2- 3 days. Anti acid may be helpful. Sedation.

Hemorrhoids

Symptoms Hemorrhoids are swollen and inflamed veins around the anus or in the lower rectum. External hemorrhoids are located under the skin around the anus. Internal hemorrhoids develop in the lower rectum. Internal hemorrhoids may protrude, or prolapse through the anus. Bright red blood on stool is often noticeable after a bowel movement. Prolapsed hemorrhoids often cause pain, discomfort, and anal itching. Lines of Treatment Local anesthetic (lidocaiine). Local antiseptic & astringent (Povidone iodine, Pilobath). Local astringent, emollient, anti-inflammatory, local anaethetic (as Proctoglevenol or Neohelar). Phlebotonic and vasculoprotective (Daflon Antistax Horse Chestnut). Laxative in case of constipation. Systemic analgesic NSAID. Stop the bleeding using Dycinone. Antibiotic in case of bleeding.

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Cross sales Sitz bath. Ring cashion. Antiseptic tissues. Patient Education Increase the dietary fibres overcome constipation which is the major cause of haemorrhoids. Dont strain during bowel movement. Dont sit on the toilet for long periods of time.

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Urticaria

DERMATOLOGY

Symptoms Acute condition characterized by formation of wheals & severs itching, the lesions usually subside in few hours & new lesions appear, the lesions of urticaria are subcutaneous or sub mucous. Lines of treatment Systemic antihistamine. Soothing lotion as calamine. Calcium gluconate amp., or Calcium Sandoz amp. Decadron phosphate vial. May give minor anxiolytics drug as Atarax or Buspar. If mouth & larynx are affected, the physician gives Adrenaline amp. s/c after dilution by normal saline.

Eczema

Symptoms Reddened skin that itches or burns. Intense itching is generally the first symptom in most people with eczema. Sometimes, eczema may lead to blisters and oozing lesions, but eczema can also result in dry and scaly skin. Repeated scratching may lead to thickened, crusty skin. Different types Contact dermatitis. Atopic eczema. Seborrhoeic eczema. Varicose eczema. Infective eczematous dermatitis. Discoid eczema. Lines of Treatment Systemic antihistamine. Local corticosteroid or corticosteroid with anti infective agent if required. Calcineurin Inhibitors ex: Pimecrolimus (Elidel) , Tacrolimus (Protopic). Moisturizers and soothing preparations. Locally acute stage use antiseptic solution as potassium permanganate or boric A. Antibiotic for infected type. In severe cases physician use systemic corticosteroid. Anxiolytics. 31

Cross-Sales Soapless and moisturizing cleansers. Cotton gloves. Electric Humidifiers. Patient Education Avoidance of over-bathing. Applying moisturizer frequently, especially after bathing. Bathing in warm, not hot, water and use soapless moisturizing cleansers. Limiting or avoiding contact with known irritants like soaps, perfumes, detergents, jewelry, environmental irritants, etc. Wearing loose-fitting clothing (cotton clothing may be less irritating for many people than wool or synthetic fibers). The use of cool compresses to help control itching. Avoiding foods that cause allergic reactions. Exercise, meditation, or other stress-management techniques can help those for whom stress is a trigger. Wearing protective gloves for activities that require frequent submersion of the hands in water. Avoiding activities that make you hot and sweaty as well as abrupt changes in temperature and humidity. A humidifier should be used in both winter (when the heating dries the atmosphere) and in the summer (if air conditioning is used because it depletes the moisture in the air). Maintaining cool temperatures in sleeping areas, because heat can lead to sweating that worsens itching and irritation. Practicing good skin hygiene even when you are not having symptoms.

Boils (furunculosis)
Lines of Treatment Local antiseptic solution. Local antibiotic. Systemic Antibiotic.

Symptoms Acute painful staphylococcal infection involving hair follicle, sebaceous gland.

Carbuncle

Symptoms Aggregation of adjacent boils. Lines of Treatment Local antiseptic solution. Local antibiotic. Systemic Antibiotic. Surgical drainage (by physician). Cross Sales Normal saline for cleaning. Gauze, otton, bandage, band aid. Vitamins course at the end of treatment. 32

Herpes simplex

Symptoms Small grouped vesicles on erythematous base, the regional lymph node not enlarged unless secondary infection occurs, herpes facials (around the mouth), herpes keratoconjunctivitis; herpes genitalis. Recurrent herpes simplex is stimulated by fever, common cold, influenza, menstruation, exposure to sun, and excessive coitus. Lines of Treatment Gentian violet. Topical antiviral. Topical antibiotic (in case of or to prevent secondary infection). Systemic antibiotic to prevent secondary infection. Systemic Antiviral in severe cases. (by physician). - Corticosteroids are contraindicated.

Herpes zoster
Lines of Treatment Analgesic. Systemic antibiotic. Gentian violet topically. Vit.B12 depot amp. Systemic antiviral.

Symptoms Unilateral grouped vesicles on an erythematous base along the course of sensory nerve neuralgic pain, the regional lymph nodes are usually enlarged and tender. Sometimes, it is wrongly diagnosed as allergy.

H. simplex
Burning Sensation Bilateral Around orifices Healing without Scar Recurrent No enlargement L.N unless 2nry infection

H. Zoster
Neuralgic Pain Unilateral Along sensory nerve Healing Leaving Scar 99 % Not Recurrent Regional L. N. enlarged , Tender

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Chicken Pox

Symptoms Erythematous patches, vesicle containing fluid, opened vesicles In different parts of the body, especially abdominal region, fever in the first stage. The severity of the case in children is less than that in the case of adults. Lines of Treatment Antipyretic. Sedative antihistamine. Systemic antibiotic for secondary infection. Soothing by calamine lotion. Physician can prescribes antiviral in the first stage. Patient Education . . , . Cross-Sales Personal Hygiene products (hand sanitizers). Disinfectants (Dettol sprays,etc). Soft or ultra-soft (sponge) loofah.

Sweat Rash (Miliaria)

Lines of Treatment Soothing lotion (ex: calamine lotion). Systemic antihistamine. Antibiotic if there is secondary infection.

Symptoms More in children, the lesions may be small, clear, thin walled vesicles or minute red papules with pricking sensation. Secondary infection may occur.

Patient Education Avoid excessive clothing. Avoid excessive use of soap (soap-less products are preferred).

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Warts

Symptoms Benign papillomatous of skin or mucous membrane caused by virus (papilloma virus). Lines of Treatment Keratolytic agent. Podophyllin resin25%. Electrical cautery. Surgical. Cross-Sales Petroleum Jelly (as a protector cream). File Immuno-Stimulant. Patient Education : ) (

Callus and Corns

Lines of Treatment Keratolytic agent. Electrical cautery. Surgical.

Symptoms A callus (Tayloms) is an area of skin that thickens after exposure to repetitive forces in order to protect the skin, when a calluse develop a mass of dead cells in its center; it becomes a corn (Heloma).

Cross-Sales Petroleum Jelly (as a protector cream). File Protective cover to be placed over the sore(s) to relief the pressure. Patient Education As mentioned in case of Warts.

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Skin Fungal Infection ( Ringworms ) Tinea Capitis

Symptoms Rounded or oval patch covered with small grayish white scales on the scalp. It may be one or more batches. Lines of Treatment Cleaning with antifungal shampoo. Systemic antifungal as Nizoral 3mg /kg/day for one month. Local antifungal for one month. Patient Education Hair must be cut short. Head covering for infected child. Personal hygiene.

Tinea Versicolor

Symptoms Scaly round or oval macules (patches) the color of lesions varies from whitish to light brown according to skin color, its sites: trunk, part of upper arm & neck (fanela area), itching is absent. Lines of Treatment Cleaning with antifungal shampoo. Local antifungal. Systemic antifungal. Patient Education Personal hygiene. Exposure to the sunlight during the treatment period to accelerate restoring the natural skin color. Ultra violet rays later on for hypo pigmented area.

Tinea Cruris

Symptoms Erythematous patches with active raised edge covered with minute papules, vesicles, & crusts. Itching is present. Site: upper medial side of the thigh, buttocks and the pubic area. Lines of Treatment Local antiseptic wash. Local antifungal with topical corticosteroids for few days and then stop the corticosteroids and continue with the antifungal. Systemic antifungal.

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Patient Education

Tinea Pedis (Athletes Foot)

Lines of Treatment Local antiseptic wash. Local antifungal. Systemic antifungal. Patient Education

Symptoms Cracked flaking peeling between the toes. The affected area is usually reddish or whitish and itchy with burning sensation. Sites: On the feet or between the fingers.

Cross-Sales Finger separators. Shoe and foot fresheners. Perforated Insoles.

Scabies

Symptoms Severe itching mainly at night, lesion consists of burrows, papules, vesicles, scratch marks. Lines of Treatment Anti mite as Eurax , Benzanil , Ectometherin , Scabine , Benzyl benzoate Sedating anti histamine. Local antibiotic. Systemic antibiotic if there is secondary infection. Patient Education

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Alopecia Areata
Cross-Sales Sulpher soap. Hard Loofah.

Symptoms Sudden loss of hair in certain area. The skin of the involved area is completely normal. The cause is unknown. Lines of Treatment Increase the follicular blood flow by topical solution as minoxidil. Topical corticosteroid to induce Hirsutism. Irritation of the scalp in this site by using Rubifaciant gel or alopecia solution containing (Capsicum, Gaporadium & Cantharides). Keratolytic (as salicylic acid) combines with a corticosteroid topically. Systemic supplementation (cystine, cystiene, methionine, zinc, iron, biotin and B-complex).

Psoriasis

Symptoms Red papules and plaques covered with silvery scales on elbow, knees, sacral region and scalp. Nail infection occur (pitting, brittleness, thickening) also in other joints. Psoriasis characterized by remissions & relapses. Lines of Treatment In case of limited cases, the following can prescribed: Potent corticosteroid as immunosuppressive (scalp, palms, soles). Regulate the cell growth using topical Calcipotriol (Daivonex). Decrease the growth of cells using tar. Keratolytic, using salicylic A. to reduce flakes. Emollient or moisturizing cream. Cross-Sales Using moisturizing soap for sensitive skin.

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Gonorrhea Syphilis

STDs

Symptoms In males: thick creamy yellowish discharge. Dysuria complicated by prostatitis, arthritis, iridocyclitis In Females: dysuria, terminal hematuria and cervicitis. Lines of Treatment Systemic antibiotic as Quinolone, or Macrolide, Rocephin injection, Kanamycin. Patient Education Avoid intercourse. Avoid spicy foods. Plenty of fluid to drink.

Symptoms Primary chancre, it is single painless, surface is eroded. Site: Genital chancre 95%, Extra genital chancre 5% in lips, tongue, anus, nipple, finger. Secondary syphilis 1.5 month after appearance of chancre, skin rash, generalized lymphadenopathy. Tertiary syphilis 3-10 year clinical signs of neurosyphilis, cardiovascular affection. Lines of treatment Erythrocin or Tetracycline. Long acting penicillin (after allergy test). In primary & secondary,use 2 injections at once. But tertiary,use 2 injection /week for 3-4 week.

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Urinary Tract Infection

UROLOGY

Symptoms Strong persistent urge to urinate. Burning sensation during urination. Frequent passing, small amount of urine. Urine appears cloudy. Urine may appear pink or cola colored. Strong smelling urine. Pelvic pain in women and erectile pain in men. In children it is better to do urine culture &sensitivity test. Lines of Treatment Systemic antibiotic (mainly Quinolones for adults over 18 years age). Urinary tract antiseptic (Coliurinal eff.). Urinary tract smooth muscle relaxant (ex: spasmourgenin, Genurine, Rowatinex). Cross-Sales Vitamins specially vitamins B.

Renal Colic (Pain)

Patient Education

Symptoms Intermittent attack of severe pain, radiating at the renal angle down to the groin, scrotum, or vulva, may be associated with vomiting, hematuria, frequency of micturition. Lines of Treatment Atropine , glucolynamine, + morphine , spasmocin , if no response can use Stadol or pethidine Rowatinex tab. Coli urinal eff. Apply warmth to the loin. Plenty of fluids & bed rest. Investigation of the case. Causes of persistent Renal colic: impacted stone, infection, allergy & oedema. Cocktail of Renal colic: dextrose5%+ Avil amp. + Glucolynamine +Ca. Sandoz amp. drop by drop.

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Acute Retention of Urine

Symptoms

The Patient has no pass of water, with severe lower abdominal pain, high desire to micturation without urination.
Lines of Treatment Obstructive cause treated by catheterization. Postoperative causes morphine ampoule & apply warmth the suprapubic region. If no obstruction, can use Neostigmine amp. Dont give diuretics to these patients as the case may worsen.

Acute Nephritic syndrome

(Acute post streptococcal glomerulonephritis)

Symptoms It occurs secondary to the infection by nephritic strains of beta haemolytic streptococci, it is more common in children & characterized by Haematuria , proteinuria, oliguria , edema & blood pressure increase. Lines of Treatment Antibiotic as Crystalline Penicillin 21 Or broad spectrum antibiotic as Amoxyclave or Macrolide. Vitamin B complex tab. Patient education Counseling by bed rest till no sign. Decrease protein in the diet. Eat salt free diet. Fluid balance urine volume + 500ml or increase fluid by all method.

Acute pyelonephritis
Urinary tract infection

Symptoms Fever , rigors , sudden pain in one or both loin , which may radiate to the groins , dysuria , Frequency of micturition & turbidity of urine , positive urine culture , in children usually presented by unexplained fever. Lines of Treatment Broad spectrum antibiotic or antibiotic after culture & sensitivity. Garamycin 1mg/kg/8hrs for 21 day or Septazole 2tab. twice daily for 21 day, or Norfloxacin 1tab.twice daily for 21 day are recommended. Complete bed rest, plenty of fluids &light diets.

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Cystitis & Urethritis (Acute & Chronic)

Lines of Treatment Antibiotic, mostly Quinolones. Or Sulphonamide. Antispasmodic as Genurin forte. Plenty of fluid. Treatment of predisposing factor.

Symptoms Dysuria, very increasing in the frequency of micturition, suprapubic tenderness, positive urine culture.

Nocturnal Enuresis

Symptoms Involuntary urination (bed wetting) occurs during sleeping after the age at which bladder control usually occurs (age of 6). Lines of Treatment (Drugs are only used in children above 6 years and adults) Desmopressin (Minirin). Intranasal solution, nasal spray or tabs. 10mcg before sleep 2week then 20mcg & continue for 6 week then decrease for other 6 week. Tricyclic anti-depressants (Tofranil 25 mg) one tab. daily before sleep for 2 month then one tab. every 2 day for one month then one tab. every 3 day for one month. If no response can use: Smooth muscle relaxant drugs as Spasmourginine. One tab. 3 time daily used with any of last 2 drugs. Patient Education (very essential in this case) Psychotherapy & reassurance No fluid intake 2-3 hours before sleep. Interrupt his sleep and ask to urinate. Avoid tea, coffee and spices 2hours before sleep. Through day time must be trained to control himself for some time that increases gradually to increase the urinary bladder capacity. Try to investigate the case by specialist to eliminate any other causes. Cross-Sales Bed Under Pads (lotus, Sanita, Egosan, ..).

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Acute Bacterial prostatitis Chronic Prostatitis

URINOGENITAL

Symptoms Perineal pain radiates to tip of the penis, frequent micturition, dysuria & pain on defecation, acute retention of urine may occur. Lines of treatment Antibiotic, better to do culture & sensitivity test to the prostatic secretion. Analgesic. Antispasmodic. Anti inflammatory as Decongestyl supp. In case of non bacterial prostatitis as Chlamydia in prostate secretion gives Doxacycline every 12hrs for 14 day.

Symptoms Dysuria, frequency micturition, urethral discharge, impotence, arthritis, myositis. Enlarged tender prostate, pus cells in prostatic secretion, enlarged tender prostate. Lines of Treatment Antibiotic, better to do culture & sensitivity test to the prostatic secretion. Analgesic. Antispasmodic. Anti inflammatory as Decongestyl supp. In case of non bacterial prostatitis as Chlamydia in prostate secretion gives Doxacycline every 12hrs for 14 day. Prostatic massage: 12 setting in 6- 8 weeks. Short wave therapy: 12 setting in 6- 8 weeks.

Senile Enlargement of Prostate

Symptoms Frequency of micturition, dysuria, urgency of micturition, haematuria, early symptoms of nocturnal enuresis, urine retention may occur. Lines of treatment Androgen ablation & blockade for benign prostatic hyperplasia by anti androgen drugs (the libido is maintained) or by progestational drugs which produce impotence & loss of libido. Also LHRH antagonist as Leuprolide. Alpha blocking agent as Itrin , Cardura , & more specific alpha 1 blocker as Ominic & Xateral. Anti inflammatory as Prostin, Decongestyl. 5alpha reductaze inhibitor as Proscar & Avodurt. Herbal treatment has dual effect where it has anti inflammatory effect & also decreases the size of benign prostatic hyperplasia (as Sawpalmato & Pepon). Avoid constipation, cold current, sexual excitation & decrease fluid intake at night. Surgery. 43

OPHTHALMOLOGY

Conjunctivitis

Is the most common eye disease and include the following types: Allergic conjunctivitis: Mostly seasonal, discharge is scanty but severs itching. Mucopurulent conjunctivitis: Mostly bilateral, discharge is exudates, no cornea involvement. Viral conjunctivitis: Adenovirus 3,8 & 19. Strong redness, copious watery discharge & scanty exudates. Gonococcal conjunctivitis: Urgent due to corneal involvement & perforation may occur. Inclusion conjunctivitis: Eye is usually involved following accidental contact with genital secretion. Trachoma: Chronic recurrent bilateral conjunctivitis & corneal vascularization also trichiasis in adult.

Red Eyes (Allergic Conjunctivitis)

Symptoms Congestion, watery discharge, and itching. Lines of Treatment Specific local anti allergic (corticosteroids or non corticosteroids). Local decongestant or (combination of decongestant & anti allergic). Local moisturizing. Systemic anti histamine (or anti allergic). Cold compression.

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Red eye with infection

Symptoms Bacterial: Congestion mucopurelent discharge. Viral: profuse watery discharge, gritty pain. Lines of Treatment Cleansing (sodium chloride, boric acid 2% sol.). Local antibiotic (or combination of antibiotic with corticosteroid) drops through the day in viral preferable to use sulphonamide or chloramphenicol to prevent the secondary infection accompanied with the viral infection. Antiviral eye ointment (Zozirax) in case of viral infection. Local antibiotic or combination of antibiotic with corticosteroid ointment at night. Local decongestant. Systemic ant infection. Systemic analgesic anti inflammatory. Worm compression to decrease the discomfort.

Inclusion conjunctivitis Dry Eye

Symptoms Eye is usually involved following accidental contact with genital secretion. Lines of Treatment Antibiotics drops 4-8 time / day for 6 day. Antibiotic oint. Once / daily before bed time. In strong cases systemic antibiotic can be used, also in case of gonococcal conjunctivitis Rocephin 1gm injection for 5 day especially with corneal involvement, also trachoma & inclusion conjunctivitis the drug of choice is Erythrocin or Doxycycline for 4 - 2 week. Boric acid 2% lotion washes for the eye. Also wash for the using normal saline.

Symptoms Eye burns, feel tired, sandy eye, irritated, itchy, or gritty may be the not particularly red. Lines of Treatment Moisturizing (long acting & short acting). Local anti allergic. Systemic anti allergic.

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Trachoma

Symptoms Granular conjunctivitis or chronic inflammation of M.M. of the eye caused by Chlamydia trachomatis (conjunctivitis, swelling for eye lid, corneal involvement). Lines of Treatment Cleansing (Normal saline, 2% boric acid sol.). Systemic antibiotic ( doxycyline 2 cap. Then one cap. Daily for 14 day) or systemic anti infection. Local anti infection (drops &ointment) in day and night. Systemic anti histamine or anti allergic to decrease itching.

Blepharitis

Symptoms Chronic inflammation of lid margin (eye lid inflammation accompanied by eye lashes). Lines of Treatment Eye lid wash (Lid care ). Local antibiotic. Systemic antibiotic if needed. Patient Education A typical lid margin hygiene routine consists of four steps: 1. Softening of lid margin debris and oils: Apply a warm wet compress to the lids - such as a washcloth with hot water - for about two minutes. New, dry, warm compress masks can be conveniently warmed in a micro-wave oven and maintain a comfortable 40C temperature for 10 minutes while the waxy oils blocking the glands are cleared. 2. Mechanical removal of lid margin debris: At the end of a shower routine, wash your face with a wash cloth. Use facial soap or non-burning baby shampoo (make sure to dilute the soap solution 1/10 with water first). Gently and repeatedly rub along the lid margins while eyes are closed. Too much soap or shampoo may remove the essential oily layer of the eyes' own tear film and create further problems with dry eye discomfort. 3. Antibiotic reduction of lid margin bacteria (at the discretion of your physician): After lid margin cleaning, spread small amount of prescription antibiotic ophthalmic ointment with finger tip along lid fissure while eyes closed. Use prior to bed time as opposed to in the morning to avoid blurry vision. 4. Avoid the use of eye make-up until symptoms subside.

Corneal Ulcer

Symptoms Corneal opacity pain, watery discharge. Lines of treatments Atropine or any mydriatic. Antibiotic with corticosteroid, or sulfonamide. Vit. A local &systemic. Eye bandage.

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Infantile colic

PEDIATRICS

Exclude all causes of crying e.g. napkin dermatitis, otitis media, under feeding, tight binder; the colic will disappear gradually by the age till 3 month. Lines of treatment Exclude all causes of crying (Napkin dermatitis, feeding, tight binder, check all organ of the baby,.. ). Gases broken & control as (Infacol, Gripe water, Herbal tea, Simethicone drops, ). Sedating as spasmotal oral drops 2 3- 4 Put the baby in prone position during the attack. Eructate the baby at the middle and at the end of feeding.

Napkin dermatitis Teething Pain

Lines of treatments Protective after change the diaper as zinc oxide, Medo, Seudo cream. Moderate & severe cases: Anti septic drying solution as (Eosin) or using moisturizing. Multi component topical cream as Momenta, Kenacombe, Daktacort . Avoid tight diapers, & irritant soap. Diarrhea increase the napkin dermatitis there for must treat the cause. Frequent change the diaper. Use medical cotton because it is in direct contact with the skin.

Symptoms Red and swollen gums. Sleepless nights. Inconsistent feeding. Biting and grumpiness (bringing his fingers to his mouth). Fever and/or diarrhea may be noticed in some cases. In most babies teething begins from the age of six months. Lines of Treatment Frozen teething ring. Local anesthetic (Pansoral or Dentinox teething gels). Systemic analgesic.

47

Headache

NEUROLOGY

One of the commonest presenting symptoms in the outpatient , taking good history is of extreme importance to reach proper diagnosis. Vascular headache causes: hypertension, arteriosclerosis. Tension headache: (psychogenic) severe continuous headache describe as tightness, related to stress time, other muscle tension, depression, or anxiety. Migranous headache: past &family are important , common in young middle aged females start in adolescence in episodes lasting few hours to 2 day , pain is often unilateral , some time become bilateral , may be increase in premenstrual days. Reffered headache: sinusitis (acute & chronic), Eye disease (Glaucoma severe bursting eye pain & vomiting associated headache), errors of refraction. Others cause lead to headache: meningitis , encephalitis , subarachnoid hemorrhage , otitis , , Extra cranial & subdural hematoma , constipation , fasting ,.

Lines of Treatment Treat the cause. Analgesic. Migraine treatment. Patient Education Diet regulation, Physical & mental rest. Physiotherapy.

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Migraine

Symptoms Paroxysmal hemi cranial headache associated with visual disturbances, aphasia, confusion, polyuria. Types : Classic migraine: with aura , common migraine :without aura , ophthalmoplagic migraine: temporary EOM paralysis , Lower migraine : vertigo ataxia blackout , cluster migranous headache : flushing , sweating, lacrimation in one half of the face. Lines oft reatment Acute, moderate & severe: Bed rest in dark room. Analgesic. Cranial vasoconstriction by Caforgot, Migril, Imigran , Relepax , Partenel. Sedation using drugs as Valinil or using Sebilium cap. 2 caps. /daily. Resistant cases try these drugs: Tegretol tab. 3 times /day, Inderal tab. 3 times /day, Epanutin 3 times /day. Prophylaxis Avoid predisposing factor as (anxiety, exhaustion, and hormonal contraceptive). The drugs used in treatment of migraine are contraindicated in pregnancy, hypertension, coronary heart disease, peripheral vascular disease.

Facial Palsy (Cranial Mononeuropathy)

Disorder of the nerve that controls movement of the muscles of the face. Symptoms Most often start suddenly. They are only in one side only. The face will feel stiff or pulled to one side. Difficult eating and drinking. Lines of Treatment Systemic corticosteroid. Vitamin B complex. Facial massage and physiotherapy. Artificial tears. Pain reliever. Antiviral in case of the cause is virus. Cross sales Massage machine. Eye patch to protect the opened eye especially during sleeping. Heat packs Patient Education

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Low Back Pain with Tension

Lines of Treatment Muscle relaxant. Systemic analgesic, anti inflammatory. Local analgesic anti inflammatory. Cross sales Hot compression. Vitamin B complex (neurotonic). Omega 3. Supporting belt (not to be used for long periods). Patient Education

Orthopedics

Symptoms Pain comes on quickly, stiffness, acute sudden, also no sciatica pain, neurological pain, electrical shock, the low back pain increases by cough & sneezing.

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References

Super guide for diagnosis and treatment. Comprehensive pharmacy review. Comprehensive guide to symptomatic clinical signs investigation. Therapeutic emergency and prescription. Appleton and Langes review of pharmacy. Basic and clinical pharmacology Bertram G. & Katzung. Handbook of nonprescription drugs. Smart chart pharmacology. Physician drugs index Egypt. Egyptian Atlas No.7. Egyptian Atlas No.1. BNF. Martindale.

Authors

Nahdi Training Team

Reviewed by
Dr. Alaa Zaghloul Pediatrics specialist Fairoz polyclinic Jeddeh Email: flyingsoul1@hotmail.com Dr. Gamal G. Elsayed , MD Internal medicine & Nephrologist King Faisal hospital Jeddeh Email: gamalgouda2020@yahoo.com

Edition 3.05.11 Prepared by Nahdi Training Department May 2011

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