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While it may be similar to symptoms 5dp5dt purchase genuine depakote line other compounded products studied symptoms weight loss purchase genuine depakote online, consistent dose and release profiles are not supported by the current literature symptoms gerd depakote 500 mg without a prescription. Page 3 of 58585 Preauthorization requirements are only valid for the month published treatment pneumonia depakote 250mg for sale. In addition, consideration of coverage for any testosterone would require review versus coverage criteria in the Testosterone replacement therapy products medication policy. Testosterone replacement therapy products (including Testopel), Medication Policy Manual, Policy No. Page 4 of 58686 Preauthorization requirements are only valid for the month published. Page 5 of 58787 Preauthorization requirements are only valid for the month published. Description Romiplostim (Nplate) is a provider administered subcutaneous injection that is used to increase platelets. Most contracts require pre-authorization of romiplostim (Nplate) prior to coverage. Patient is at risk of spontaneous bleeding as demonstrated by either one of the following criteria 1 or 2 below: 1. Regence Pharmacy Services does not consider romiplostim (Nplate) to be a self administered medication. When pre-authorization is approved, romiplostim (Nplate) may be initially authorized for a period of 12 weeks. Authorization shall be reviewed at least every six months to confirm that the dose does not exceed 10 mcg/kg and the patient’s recent (within the last 90 days) platelet count is either: 1. Less than 30,000/mm3 but platelet counts have increased from baseline accompanied with a resolution of previous bleeding. Romiplostim (Nplate) is considered investigational when used for all other conditions, including, but not limited to: A. Only rarely should patients be treated when platelet counts are above 30,000, such a preparation of surgery or an invasive procedure. Due to strict monitoring requirement, safety concerns, and lack of data for self-administration, romiplostim is currently required to be administered by a health professional. Corticosteroids should be rapidly tapered and stopped in patients who fail to respond after 4 weeks. Trials of romiplostim were conducted in patients refractory to standard treatments, defined as corticosteroids, immunoglobulins, rituximab, cytotoxic therapies, danazol, and azathioprine. Laboratory measurement Platelet counts are measured per microliter (mcL or µL), which is equivalent to a cubic millimeter (mm3). Clinical studies have not ruled out the possibility that reticulin and other fiber deposition may result in bone marrow fibrosis with cytopenias. Portal vein thrombosis has been reported in patients with chronic liver disease taking romiplostim. Risk for hepatotoxicity is also included in the eltrombopag program, and risk for worsening thrombocytopenia and bleeding after treatment discontinuation is included in the romiplostim program. Maximum weekly dose is 10 mcg/kg and adjusted based on clinical response (platelet count and bleeding). American Society of Hematology: Ten Things Physicians and Patients Should Question. Guidelines for the investigation and management of idiopathic thrombocytopenic purpura in adults, children and in pregnancy. Potential usefulness of thrombopoietin receptor agonists in haemophiliacs with thrombocytopaenia due to chronic liver disease. Results of a randomized, double-blind study of romiplostim versus placebo in patients with low/intermediate-1-risk myelodysplastic syndrome and thrombocytopenia. Safety and efficacy of thrombopoietin-receptor agonists in myelodysplastic syndromes: a systematic review and meta-analysis of randomized controlled trials. Phase 2 study of romiplostim in patients with low or intermediate-risk myelodysplastic syndrome receiving azacitidine therapy. A randomized, double-blind, placebo-controlled phase 2 study evaluating the efficacy and safety of romiplostim treatment of patients with low or intermediate-1 risk myelodysplastic syndrome receiving lenalidomide. A randomized controlled trial of romiplostim in patients with low or intermediate-risk myelodysplastic syndrome receiving decitabine. Medication Policy is not intended to dictate to providers how to practice medicine. Most contracts require pre-authorization approval of canakinumab (Ilaris) prior to coverage. Canakinumab (Ilaris) may be considered medically necessary when there is clinical documentation (including, but not limited to chart notes) showing that one diagnostic criterion A, B, C, D, or E below is met. Prior treatment with both tocilizumab (Actemra) and anakinra (Kineret) has been ineffective, contraindicated, or not tolerated. Regence Pharmacy Services does not consider canakinumab (Ilaris) to be a self administered medication. When prior authorization is approved, canakinumab (Ilaris) may be authorized in quantities as follows: 1. Clinical documentation (including, but not limited to chart notes) must be provided to confirm that current medical necessity criteria are met and that the medication is providing clinical benefit, such as disease stability or improvement of associated symptoms. Canakinumab (Ilaris) is considered investigational when used for all other conditions including, but not limited to: A. Fever and associated symptoms commonly last at least five days and often continue for more than two weeks. Off-label treatment with etanercept for patients with frequent and/or severe recurrences has been reported. Case reports of treatment with etanercept, anakinra, and tocilizumab have been reported in the literature. Patients aged 2 to 76 years were then randomized at flare onset into a 16-week double-blind, placebo-controlled treatment period (part 2) where they received either 150 mg canakinumab (2 mg/kg for patients weighing less than or equal to 40 kg) subcutaneously or placebo every 4 weeks. Additional doses of canakinumab were permitted for patients whose disease flare did not resolve, or who had persistent disease activity. The median time to flare was 236 days in the placebo group and had not yet been reached in the canakinumab group (p = 0. The dose can be increased to 4 mg/kg every 4 weeks if the clinical response is not adequate. The dose can be increased to 300 mg every 4 weeks if the clinical response is not adequate. Other Uses Several studies have evaluated the use of canakinumab (Ilaris) for treating acute gouty arthritis. The results suggest that canakinumab is superior to daily colchicine for prophylaxis against gouty arthritis flares. There are some flaws affecting the validity and generalizability of the results, including that < 5% of the study subjects were from North America, and the dose of colchicine studied was lower than the labeled dose for prophylaxis. The results suggest that canakinumab may provide significant pain and inflammation relief compared to triamcinolone. These studies assessed single doses over a short period of time, so it is unclear if the reported benefit is sustained over time. In a phase 3, randomized, placebo-controlled trial, treatment with canakinumab (Ilaris) 150 mg and 300 reduced the primary composite endpoint of nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. While promising, additional information is needed to clarify the risk-benefit profile of the drug as the magnitude of benefit is relatively small and canakinumab (Ilaris) had a significantly higher risk of serious infection and sepsis compared to placebo. Cross References Arcalyst, rilonacept, Medication Policy Manual, dru159 Drugs for chronic inflammatory diseases, Medication Policy Manual, dru444 © 2019 Regence. Canakinumab for acute gouty arthritis in patients with limited treatment options: results from two randomised, multicentre, active controlled, double-blind trials and their initial extensions. Canakinumab reduces the risk of acute gouty arthritis flares during initiation of allopurinol treatment: results of a double-blind, randomised study. Description Cetuximab (Erbitux) is a monoclonal antibody used to treat specific types of cancer. Most contracts require pre-authorization approval of cetuximab (Erbitux) prior to coverage. Cetuximab (Erbitux) may be considered medically necessary when there is clinical documentation (including, but not limited to chart notes) confirming that criterion A, or B below is met: A.
In cirrhotics medicine allergy purchase depakote 500 mg, losartan in unchanged form with a t of 6–9 hours; action has been found to moroccanoil treatment order depakote discount control portal hypertension symptoms zoning out order depakote overnight delivery. Aliskiren is a nonpeptide which binds mild side effects—mainly dyspepsia symptoms 0f yeast infectiion in women generic 500mg depakote overnight delivery, abdominal selectively to the catalytic site of renin and compe pain, loose motions, headache and dizziness. Aliskiren is contraindicated during of renin in plasma is increased by feed back, pregnancy. Bradykinin can also be generated from kallidin on the removal Plasma kinins are polypeptides split off from a of lysine residue by an aminopeptidase. Plasma and tissues also contain kininogenase inhibitory plasma globulin Kininogen by the action of factors of which complement (C1) esterase inhibitor is the specific enzymes Kallikreins. Moreover, kallikreins are normally present plasma kinins, Kallidin (decapeptide) and Brady in their inactive forms. Thus, physiologically only small amounts of kinins are generated in plasma and tissues. Kinins are also generated by trypsin, proteolytic most veins and vessels with damaged endothe enzymes in snake and wasp venoms and by kallikrein present lium are constricted through direct action on the in kidney, pancreas and other tissues. Smooth muscle Kinin-induced contraction the B receptor is located on the smooth muscle of 1 of intestine is slow (bradys—slow, kinein—to large arteries and veins—mediates contraction of these vessels, move). They cause marked bronchoconstriction but is expressed minimally in normal tissues. Action induces synthesis of B1 receptors, which colocalize with kininase I enzyme, so that the B1 agonistic des-Arg kinins on other smooth muscles is not prominent, some are produced locally. The diuretic effect of furose pain produced by bradykinin, but induced B1 receptors appear mide is reduced by kinin B2 receptor antagonists, to mediate pain of chronic inflammation. Kallikreins may have selective agonists of B2 receptors, while their des-Arg roles in these systems which are independent of kinin metabolites generated by the action of kininase I are selective production. Most of the kinin actions in noninfla med tissues are mediated by B receptors which are 5. Recent evidence indicates that ischaemic preconditioning (iii) Sensory nerves—acute pain. Kinins cause closure of ductus arteriosus, dilatation of Ca2+ mobilization transducer mechanism. Icatibant has been After characterization of B1 and B2 kinin receptors, recently approved in Europe for symptomatic several peptide and nonpeptide kinin antagonists treatment of hereditary angioedema. He had pitting edema of feet, dyspnoea and cough on mild exertion, fatigue, engorged neck veins, soft enlargement of liver, pulmonary congestion and mild cardiac dilatation. He was prescribed— Tab furosemide 40 mg once daily in the morning Tab captopril 25 mg twice daily, morning and evening. After 2 hours of taking the medicines, he started passing increased quantity of urine and in the next few hours he gradually started feeling weakness, nausea, sweating and fainted while walking to the toilet. Thus, All digitalis glycosides have qualitatively similar efficiency of failing heart is increased. In addition, it has vagomimetic action, decoction containing ‘foxglove’ (Digitalis) with other herbals, reflex effects due to alteration in haemodynamics prepared by an old lady, relieved dropsy. He published his classic monograph ‘An account of the Foxglove and some of its medicinal uses: with practical remarks Force of contraction Digitalis causes a dose on dropsy and other diseases’ in 1785 and ascribed the beneficial effect to an action on the kidney. Cushney and dependent increase in force of contraction of Mackenzie, in the beginning of 20th century, established its heart—a positive inotropic action. Digitalis lanata of tension development and higher peak tension is the source of Digoxin, the only glycoside that can be generated. When a normal heart is subjected Digitalis purpurea) and Ouabain (from Strophan to increased impedance to outflow, it generates thus gratus), etc. The digitalized failing heart Chemistry regains some of its capacity to contract more forcefully when subjected to increased resistance the cardiac glycosides consist of an aglycone (genin) to which are attached one or moresugar(glucose or digitoxose) moieties. There is more complete emptying of failing and dilated ventricles—cardiac output is increased and end-diastolic volume is reduced. However, therapeutic doses of digoxin do not increase resting tension (tone) in myocardial fibres. High doses of digitalis of baroreceptors, as well as by stimulation of produce coupled beats by another mechanism: vagal centre. Excitability is the atria to respond at a increased by enhanced at low doses but depressed at toxic higher rate and in an + direct action doses because Na channels are inactivated. This action Increased by direct, vagomimetic A-V node and and antiadrenergic actions; the is most marked in A-V node and bundle of bundle of His maximum rate at which impulses His. This triggers release of larger amount of Ca2+ • Decreased amplitude or inversion of T wave. Ca2+ increases transiently to about 500 nM • Shortening of Q-T interval (reflecting shor (calcium transients) > triggers contraction by tening of systole). A fraction (equal to that which force of cardiac contraction by a direct action entered from outside during depolarization) is extruded mainly by 3Na+/1Ca2+ exchange trans independent of innervation. No diuresis occurs in normal progressively get loaded with more Ca > individuals or in patients with edema due to other subsequent calcium transients are augmented. The relationship of cytosolic [Na ] and [Ca ] is such that a small percentage increase in Na+ concentration leads 2+ 4. Moreover, raised cytosolic Ca2+ induces greater entry of Ca2+ through in therapeutic dose. Still higher It has been shown that 1 mM rise in cytosolic [Na+] results doses produce hyperapnoea, central sympathetic in 20–30% increase in the tension developed by ventricular stimulation, mental confusion, disorientation and fibres. As such, inotropic effect of digitalis takes hours to develop, even after the pharmacokinetic features of digoxin are listed i. Presence of there is depletion of intracellular K+; and digitalis food in stomach delays absorption of digoxin. Time course of action* patients this is more than compensated by the –Onset 15–30 min –Peak 2–5 hr indirect effect of improvement in circulation, i. Route of elimination Renal tension is no contraindication to the use of (predominant) excretion digitalis. About 25% patients deve suppresses the excessive automaticity, but does lop one or other toxic symptom. Extracardiac Anorexia, nausea, vomiting and (c) For supraventricular arrhythmias abdominal pain are usually reported first: are due Propranolol may be given i. Fatigue, malaise, headache, mental confusion, restlessness, hyperapnoea, (d) For A-V block and bradycardia Atropine disorientation, psychosis and visual disturbances 0. Attempts to enhance the elimination of be produced by digitalis: pulsus bigeminus, nodal digoxin by diuretics or haemodialysis are not very effective. Severe bradycardia, atrial extra It is nonimmunogenic because it lacks the Fc fragment. The digoxin-Fab symptoms precede cardiac; in the rest serious complex is rapidly excreted by kidney. Digitalis can increase hypertension, aortic stenosis, congenital heart the chances of reentry by slowing conduction in the normal disease, A-V shunts, hypertrophic cardiomyopathy. Diuretics: cause hypokalemia which increases the risk tomatic relief, primarily in systolic dysfunction. Poor response and more transporter P-glycoprotein > plasma concentration of digoxin toxicity is likely when the myocardium has been is doubled > toxicity can occur. Verapamil, diltiazem, damaged by ischaemia, inflammation or captopril, propafenone and amiodarone also increase plasma concentration of digoxin to variable extents. Adrenergic drugs: can induce arrhythmias in digitalized as well as in high output failure (in anaemia). Absorption of with hypertrophy, cardiac muscle undergoes remodeling which digoxin is increased by atropinic drugs, including tricyclic may involve changes in various functional proteins such antidepressants. Cardiac may additively depress A-V conduction and oppose positive glycosides do not affect remodeling. Reduction in heart rate and relief of heart failure symptoms are the best guide to dosing. Uncertainty exists in the ing Na+ and water are inactivated, diuresis occurs area of maintenance therapy, i.
Avoid careless remarks that may hurt the feelings of your patient and thereby jeopardize the friendly communication you would like to symptoms 0f parkinson disease depakote 500 mg sale establish between your patient and yourself medications pregnancy purchase depakote without prescription. Besides pure keratin treatment 500mg depakote with amex, remember that any emotional upset may change the course of the illness of the patient symptoms 4 dpo cheap depakote 500 mg fast delivery. It is also important to note that the medical and paramedical personnel should respect the professional secrecy so much expected of them. Thus, a medical record is strictly the property of the medical staff looking after the patient and should not be exposed to any one outside the staff, nor should the contents be told to others at any time. Therefore, history taking demands: Tact Patience Tolerance Sympathy and Understanding. Components of Clinical History the conventional health history has several parts each with a specific purpose. Together, they give structure to your data collection and final record but they do not dictate the sequence of the interview 8 Physical Diagnosis Socio-Demographic Data Certain socio-demographic data in the health history typically precede the account of the patient’s history. Patient Identification which includes: the full name the Age and Sex Address Marital status Ethnic origin Religion Occupation, including before retirement and Level of education of the patient. This not only serves to establish who the patient is but also to give you some tentative suggestions as to what kind of person you are talking to and what the likely problems might be. Source of referral this is important especially when patients do not initiate their own visits. It indicates that a written report may be important, and it helps you to understand the patient’s possible motivation. For example, persons seen at the request of the police for medico legal reasons may have different goals than those who come on their own initiative. Source of the history It helps to assess the value and possible bias of the information. The source can be the patient, family, friends, police, a letter of referral, or the past medical record. Previous Admissions: this is a list of hospitalization in the order they occurred. In each case, specify the date, name and location of the health institution, the disease that led to admission and the outcome as briefly as possible. On the other hand, if the previous admission is related to the present illness, it should be described in the appropriate place in the history of the present illness. Chief complaints: these are the major symptoms for which the patient is seeking care or advice. History of present illness: this section is a clear chronological account of the problems for which the patient is seeking care. Though the data comes from the patient, the organization is the duty of the clinician. The problems should be described as follows: • Date of onset: It is usually useful to start the history of the present illness with the phrase “the patient was perfectly or relatively well unit. One should try to find out if the pain radiates to other areas and describe the extent and manner of radiation. For example, a chest pain, which always comes on after a certain amount of exertion or made worse by exertion is almost certainly due to ischemia of the heart (angina). For example, rest usually promptly relieves upper gastro intestinal pains, like duodenal ulcers. For example, in a patient presenting with hemoptysis, statements like “ he denies night sweats, chronic cough, he has not lost weight, he doesn’t have loss of appetite” are as important as “ he suddenly developed fever, chills, rigors, chest pain aggravated by deep breathing, and cough productive of blood streaked sputum two days ago. It comprises: Childhood illnesses like measles, rubella, mumps, whooping cough, chicken pox, etc. Functional Inquiry (Systemic Review): this is a detailed account of signs and symptoms referable to each system of the body. It has at least three purposes: • It gives a clear understanding of the present illness • It is a double check on the history of present illness • It guides the examiner to concentrate on specific systems during the physical examination when he/she is in a hurry. One should know that there is no need to repeat complaints already recorded in the history of present illness. The functional inquiry should be recorded as follows: 12 Physical Diagnosis General: this includes history of recent weight change, weakness, fatigue, fever, etc. Eyes: double vision, blurring, photophobia, itching, pain, redness, excessive tearing, etc. Nose: frequent colds, nasal stuffiness, nasal discharge or itching; nasal bleeding, etc. Mouth and Throat: sore tongue, frequent sore throat, and hoarseness of voice, dry mouth, oral thrush, dental carries, etc. Neck: pain, stiffness, swollen glands,”lumps”, etc Lympho-glandular system: this includes enlarged glands, lumps in the breasts, and discharge from the nipples, goiter with or without heat or cold intolerance. Genitals: Males: history of hernias, discharge from the urethra or sores on the penis, testicular pain or masses, undescended testicles, past history of sexually transmitted diseases. Menstrual history: Age at menarche Regularity Frequency and duration of bleeding Amount of bleeding Last normal menstrual period History of dysmenorrhea Age at menopause History of post-menopausal bleeding. Personal – Social history: In order to have a complete picture of the patient as a person and to interpret his/her disease in the light of his social back ground, the personal and social history is very important. It is recorded as follows; • Early development: place of birth and where the patient lived before, childhood development, health and activities. Family history: the family history of the patient is very important because it provides information about the health status of immediate relatives, hereditary illnesses, and the emotional difficulties which may be the cause of symptoms or maladjustments of the patient. It is recorded as follows: • Siblings: list their ages and current health status (If dead, mention the date and possible cause of death) • Father and Mother: list their ages and current health status (If dead, the date and possible cause of death should be mentioned) • Familial Diseases: diseases like tuberculosis, asthma, diabetes mellitus, hypertensive disorders, migraine, etc should be asked. Overview of Physical examination It is always advisable to follow the points below while examining the patient: Examination should take place with good lighting and in a quite environment. T (head, eye, ear, nose, mouth and throat) Lymph glandular system Respiratory system Cardiovascular system Gastro intestinal system Genito urinary system Integumentary system Mesculo skeletal system Central nervous system. Explain the significance of the important physical findings in the respiratory system. Introduction the respiratory system consists of the lungs, the branching airways, the gaseous exchange membranes, the rib cages, and the respiratory muscles. Diseases of the respiratory system are one of the commonest causes of mortality and morbidity throughout the world. As with every aspect of diagnosis in medicine, thorough examination of the system is very important to properly diagnose any respiratory problem. Respiratory symptoms Cough: It is the commonest symptom of diseases of the lungs and air passages. A person may cough voluntarily, but more typically cough is a reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi. The stimuli include both external agents such as irritating dusts, foreign bodies, and even extremely hot or cold air, and internal substances such as mucus, pus, and blood. Inflammation of the respiratory mucosa, and pressure or tension on the air passages as from a tumor or enlarged peribronchial lymph node may also cause coughing. Assess the qualitatively of cough by asking whether it is dry or productive of sputum. If the cough is productive, try to describe the color, paroxysms, odor and volume of sputum. The amount of sputum produced in 24 hours can be quantified using teaspoon or coffee cup. It is also important to understand that mucoid sputum is translucent, white, or gray; purulent sputum is yellowish or greenish; while muco purulent sputum has both components. The causes of hemoptysis are summarized as follows: Localized causes: Infection (acute or chronic bronchitis, pneumonia, tuberculosis, lung abscess, etc. It is also good to focus on the setting in which the hemoptysis occurred and on other associated symptoms. Dyspnea: this is a non-painful but uncomfortable awareness of breathing that is inappropriate to the circumstances. Dyspnea should be characterized as to whether it occurs at rest or only after certain type of exertion and whether it is persistent or intermittent. It is also important to record some measures of exercise tolerance such as the distance walked before the patient has to stop and rest. Chest Pain: Chest pain, which is defined as pain or discomfort in the chest, can arise from any one of the following thoracic structures: the heart the aorta the trachea and large bronchi the esophagus the chest wall the parietal pleura Chest pains associated with pulmonary diseases usually arise from the pleura. Pleuritic chest pain is sharp and stabbing, and is aggravated by deep breathing or coughing. It occurs when the underlying pleura is inflamed, most commonly by infection in the underlying lung.
A wooden/plastic gag should be placed between the teeth to symptoms nausea discount depakote master card prevent biting of tongue treatment viral pneumonia discount 500mg depakote otc. These instructions should be shared will other family members symptoms nausea dizziness cheap depakote, so that anyone who is closeby may do the needful acute treatment depakote 250mg fast delivery. Because the patient has a history of head trauma and two seizure attacks have occurred within one week, the probability of developing epilepsy is high. As such, antiepileptic medication should be started rightaway without waiting for test reports or further fits to occur. Antiepileptics with proven efficacy in post-head injury tonic-clonic seizures are phenobarbitone, phenytoin, carbamazepine and valproate. Since the patient is a young active lady, phenobarbitone with sedative/cognitive side effects, phenytoin with gum hyperplasia, hirsutism and other cosmetic side effects, and valproate with tremor and weight gain would be less suitable. The parkinson’s disease of this patient appears to have advanced over the last 5 years and he is now experiencing ‘wearing off effect’ of levodopa-carbidopa. At this stage, antiparkinsonian medication cannot be withdrawn, because he will develop marked rigidity, immobility and tremor hampering life activities. He is already experiencing an adverse effect of his medication; therefore, the dose should not be increased further. Since levodopa-carbidopa is the most efficacious and cheapest medication for parkinsonism, it may be prudent to continue it at a reduced dose and supplement it with another longer acting drug to smoothen the therapeutic effect. The options available as supplementary medication are: • A direct dopamine agonist like ropinirole/pramipexole can be gradually added to levodopa carbidopa whose dose should be reduced in steps. It can also be an additional third drug to levodopa-carbidopa + selegiline for greater symptomatic relief. The most likely cause of the motor restlessness exhibited by the patient after 4 weeks of haloperidol therapy is appearance of a common extrapyramidal side effect of the antipsychotic drug called ‘akathisia’. The symptom does not appear to be due to inadequate dose of haloperidol, because the psychotic symptoms have been relieved and the initial psychomotor restlessness had been controlled. The atypical antipsychotics have a low propensity to cause extrapyramidal motor side effects, including akathisia. The choice of drug is correct and the 50 mg twice daily an average dose for initiation of therapy. However, since antidepressant action of any drug (including sertraline) takes 2–4 weeks to manifest, it is too early at 1 week to expect any improvement in depressive symptoms. The dose is not subtherapeutic as indicated by appearance of mild side effects, which nevertheless are quick to appear, but to whom gradual tolerance usually develops. The patient and his family members should be counselled to continue the medication for another 3–4 weeks by which time symptoms should start improving. The choice of drug is appropriate, and at this stage, there is no reason to change the medicine or its dose. Symptoms and signs indicate that the patient is going into neurogenic shock due to the excruciating pain of the crush injury. It will not only lessen the pain and suffering of the patient, but also allay apprehension and counteract neurogenic shock. The primary reason for no improvement in the state of the patient is that all medicines, including donepezil, take weeks and months before any perceptible improvement in Alzheimer’s symptoms become apparent. Moreover, donepezil (or any other drug) is not effective in a significant number of patients. However, one week is too short a time to know whether this patient is going to benefit or not. Since this patient has developed intolerable cholinergic side effects, they are due to donepezil which should be discontinued. Therefore, a drug which acts by a different mechanism could be used in this patient. Memantine is the only other drug, with documented efficacy in moderate to severe Alzheimer’s disease, which is not a cholinergic drug, and which probably acts by blocking glutamate excitotoxicity. However, improvement in memory and cognitive function is less likely, and it may only serve to slow the functional decline. The first measure to be taken in this case is to put the patient in 15° head low position. Digoxin should be prescribed concurrently as it is the most effective drug for restoring compensation by increasing cardiac contractility. Enalapril dose of 5 mg twice a day should be increased by 5 mg/day at 1–2 week intervals till hypotension or other side effects appear or 40 mg/day dose is reached. Since the patient is in a decompensated state, a blocker cannot be added at this stage, because chances of deterioration of cardiac status are high. However, after compensation has been restored by digoxin, diuretic and enalapril and the patient is in a stable condition, a suitable blocker may be started at a very low dose, to be upward titrated later, because blockers afford further morbidity and mortality benefits. Therefore, he has been put on anticoagulant medication with warfarin to prevent thromboembolism. His heart (ventricular) rate can be controlled by a drug which depresses A-V conduction. For this purpose verapamil or diltiazem or propranolol should be given orally and dose adjusted to maintain a heart rate between 60–70/min. This patient is having one or more episodes of angina practically every day; therefore, he should be prescribed regular medication to prevent the episodes. Considering the age of the patient (>55 years), diagnosis of isolated systolic hypertension, history of stroke in the past, absence of diabetes/heart failure/ischaemic heart disease/chronic kidney disease, the most suitable antihypertensive drug for this patient is a thiazide diuretic (hydrochlorothiazide/chlorthalidone) or a long-acting dihydropyridine calcium channel blocker (like amlodipine). Therapy may be initiated with either of these classes of drugs and later modified depending on the response and tolerability. Induction of brisk diuresis with furosemide alone is not the appropriate treatment of cirrhotic edema and ascites. It can be supplemented by furosemide, because spironolactone alone is a weak diuretic. In this patient, use of furosemide alone resulted in further hypokalaemia and alkalosis. Because of secondary hyperaldosteronism, the response to furosemide decreased within few days. At this stage, the patient should be managed by temporarily stopping furosemide and instituting spironolactone (50 mg 6 hourly) therapy along with appropriate i. After restoration of the fluid/electrolyte balance and his mental status, the patient should be put on maintenance therapy with spironolactone (100–400 mg/day) and furosemide (40–160 mg/day) with dose adjustment according to response. If hormonal side effects of spironolactone occur, it may be substituted by the other aldosterone antagonist eplerenone. The potassium sparing non aldosterone antagonist diuretic amiloride is an alternative. There are several reasons which could account for failure of this patient of iron deficiency anaemia to respond to the oral iron medication she has been taking: • Taking 160 mg of ferric ammonium citrate (iron content 20%) would provide just 32 mg of elemental iron/day. This is grossly inadequate to treat iron deficiency, for which 200 mg of elemental iron/day is required to yield optimum response. This patient is taking acid suppressant medication (rabeprazole, a proton pump inhibitor). Since there are obvious factors in this case which can be tackled, it would be inappropriate to abandon oral iron therapy at this stage and jump on to injectable iron. Proper selection of oral iron preparation and its dose, and careful management of therapy may yield a response in this patient. A ferrous salt with high iron content like ferrous sulphate or ferrous fumarate (both having ~33% iron) should be prescribed in a dose of 200 mg 3 times a day (total 600 mg or 200 mg elemental iron/day). However, therapy should be initiated with a low dose to be gradually increased as the gastrointestinal tract adjusts to the medication and tolerance to side effects develops. The doses should preferably be taken in empty stomach, but if gastric discomfort occurs, it may be given with food. Selection of ferrous salt would reduce dependence on gastric acid for absorption of iron. The obvious cause in this patient is the additive hypoprothrombinaemic action of inj ceftriaxone given for treatment of pelvic infection. This complication could have been prevented either by selecting an antibiotic that does not cause hypoprothrombinaemia/interact with warfarin or by reducing the dose of warfarin when ceftriaxone was started.
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