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Prescription for Acute Watery Diarrhea (Adult)

Important disclaimer: This is for educational/clinical reference only. Always tailor treatment to individual patient factors, local antibiogram, and clinical severity.

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Step 1 - Assess Severity & Dehydration

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Step 2 - Rehydration (FIRST AND MOST IMPORTANT)

• Give 200-400 mL after each loose stool
• Avoid high-sugar drinks (sports drinks, juices) - they worsen fluid losses
• IV fluids (Normal Saline 0.9% or Ringer's Lactate): indicated for severe dehydration, vomiting preventing oral intake, or hemodynamic instability

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Step 3 - Symptomatic (Antidiarrheal) Medications

Avoid loperamide/antimotility agents if: bloody diarrhea, high fever, or suspected Shiga toxin-producing E. coli (risk of HUS, especially in elderly).

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Step 4 - Empiric Antibiotic Therapy

Caution: Antibiotics increase risk of HUS with E. coli O157:H7 - do NOT use if Shiga toxin-producing E. coli is suspected (no fever, bloody diarrhea, outbreak setting, raw meat exposure).

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Step 5 - Adjuncts & Supportive Care

• Zinc supplementation (20 mg/day x 10-14 days) - reduces severity and duration, especially in resource-limited settings
• Probiotics (Lactobacillus spp., Saccharomyces boulardii) - may reduce duration by 1 day; evidence is modest
• Diet: Continue eating; BRAT diet (Banana, Rice, Applesauce, Toast) reduces osmotic load; avoid fatty/spicy foods temporarily
• Bile acid-binding resins (cholestyramine): useful if bile acid-induced diarrhea suspected (post-cholecystectomy)
• Octreotide 50-100 mcg SC TID: reserved for hormone-mediated secretory diarrhea (VIPoma, carcinoid) or refractory diarrhea

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Sample Outpatient Prescription (Uncomplicated Acute Watery Diarrhea)

Rx:
1. ORS sachets - dissolve 1 sachet in 1L clean water; 200-400 mL after each loose stool
2. Tab. Loperamide 2 mg - take 2 tabs stat, then 1 tab after each loose stool; max 8 tabs/day x 2 days
3. Tab. Racecadotril 100 mg TID before meals x 3 days (optional)
4. Tab. Metronidazole 400 mg TID x 5 days (if parasitic etiology suspected)
   OR
   Tab. Ciprofloxacin 500 mg BID x 3 days (only if moderate-severe with systemic features)

Advice:
- Drink plenty of fluids
- Return if: blood in stool, high fever, no improvement in 48-72 hrs, signs of dehydration
- Avoid loperamide if fever or bloody diarrhea develops

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When to Refer/Admit

• Signs of severe dehydration (decreased urine output, dry mucous membranes, hypotension)
• Bloody diarrhea with high fever
• Immunocompromised or elderly patients
• Suspected C. difficile with systemic toxicity
• No improvement after 48-72 hours of outpatient therapy

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Medical Management of Back Pain

Disclaimer: This is educational/clinical reference content. Treatment must be individualized based on cause, severity, duration, and patient comorbidities. Always rule out "red flag" causes before initiating empiric therapy.

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Step 1 - Rule Out Red Flags First

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Step 2 - Classify the Pain

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Step 3 - Pharmacological Prescription

A. First-Line: NSAIDs (for all types of back pain)

Add a PPI (omeprazole 20 mg OD) with NSAIDs in patients >60 yrs, h/o peptic ulcer, or on corticosteroids.

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B. Analgesics / Paracetamol (when NSAIDs contraindicated)

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C. Muscle Relaxants (for acute LBP with muscle spasm)

Muscle relaxants are most effective combined with NSAIDs. Use short-term only (2-3 weeks).

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D. Neuropathic Agents (for radiculopathy / nerve root pain)

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E. Topical Agents (adjuncts, minimal systemic effects)

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F. Short-Course Corticosteroids (for acute radiculopathy)

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Step 4 - Sample Outpatient Prescriptions

Rx:
1. Tab. Ibuprofen 400 mg PO TID with food x 7 days
2. Tab. Omeprazole 20 mg OD (gastric protection)
3. Tab. Cyclobenzaprine 5 mg PO TID x 7 days (take at bedtime if sedating)
4. Diclofenac 1% gel - apply to lower back TID PRN

Advice:
- Stay active; avoid bed rest
- Heat application to lower back 15-20 mins TID
- Physiotherapy referral after acute phase

Rx:
1. Tab. Naproxen 500 mg PO BID with food x 14 days
2. Tab. Omeprazole 20 mg OD
3. Tab. Gabapentin 300 mg OD (night) → 300 mg BID after 3 days → 300 mg TID as tolerated
4. Tab. Prednisolone 40 mg OD x 3 days, then 20 mg OD x 3 days, then 10 mg OD x 3 days (9-day taper)
5. Tab. Cyclobenzaprine 5 mg OD (night, for sleep and spasm)

Advice:
- Avoid heavy lifting and prolonged sitting
- MRI lumbar spine if not improving in 4-6 weeks
- Referral to pain specialist for epidural steroid injection if no improvement after 6 weeks
- Surgery if: progressive neurological deficit, bowel/bladder involvement, or intractable pain >3 months

Rx:
1. Tab. Duloxetine 30 mg OD x 1 week, then 60 mg OD
2. Tab. Naproxen 250 mg BID with food (use lowest effective dose long-term)
3. Tab. Omeprazole 20 mg OD
4. Cap. Pregabalin 75 mg BID if neuropathic features present
5. Physiotherapy + cognitive behavioral therapy referral

Advice:
- Regular aerobic exercise (walking, swimming)
- Weight management
- Avoid prolonged bed rest - it worsens chronic pain

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Step 5 - Non-Pharmacological (Always Co-prescribe)

• Physiotherapy - core strengthening, McKenzie exercises, manual therapy
• Heat/cold therapy - local heat for muscle spasm, ice for acute inflammation
• Activity modification - stay active; avoid bed rest (prolonged bed rest is harmful)
• Posture correction - ergonomic workplace adjustments
• Acupuncture - evidence supports benefit for chronic LBP
• Cognitive-Behavioral Therapy (CBT) - for chronic LBP with psychosocial component
• Weight loss - reduces axial load on lumbar spine

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When to Escalate

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