🏥 Adult OPD Clinical Cases - Practice & Education Reference

Disclaimer: All prescriptions are for educational purposes only. Drug doses, combinations, and duration must be individualized based on patient comorbidities, renal/hepatic function, allergies, local antibiogram, and clinical judgment. Always follow your institution's formulary and current guidelines.

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Format for Each Case

• Chief Complaint / History
• Examination Findings
• Diagnosis
• Investigations to Order
• Sample Prescription (Rx)
• Key Teaching Points

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CARDIOVASCULAR CASES

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Case 1: Essential Hypertension (Newly Diagnosed, Stage 1)

• Headache is occipital, worse in the morning
• No chest pain, no shortness of breath, no visual disturbance
• Desk job, sedentary lifestyle, smokes 5 cigarettes/day
• Family history: father had "BP problem"

• BP: 148/94 mmHg (repeated x2, both arms)
• HR: 82 bpm, regular
• BMI: 27 kg/m²
• No papilledema, no S3/S4, no renal bruit
• Fundus: Grade I hypertensive retinopathy (mild AV nicking)

• FBC, Urea, Creatinine, Electrolytes
• Fasting glucose, HbA1c
• Lipid profile
• Urinalysis (proteinuria, casts)
• ECG (LVH)
• Thyroid function (if clinically indicated)

Rx
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1. Tab. Amlodipine 5 mg — OD (morning)         #30
   ↳ CCB: first-line for uncomplicated HTN

2. Tab. Aspirin 75 mg — OD (after food)         #30
   ↳ Only if Framingham CVD risk >10%

3. Cap. Omega-3 1000 mg — OD (after dinner)     #30
   ↳ Adjunct for dyslipidemia / cardioprotection

Advice:
- DASH diet: ↓ salt (<2g Na/day), ↑ fruits/vegetables
- 30 min brisk walk 5 days/week
- Stop smoking
- Target BP: <130/80 mmHg (ACC/AHA 2017)

Follow-up: 4 weeks
────────────────────────────────────────────────────

• Stage 1 HTN (130–139/80–89): lifestyle modification + drug therapy if CVD risk ≥10%
• Amlodipine is preferred in elderly, Black patients, isolated systolic HTN
• ACE inhibitors (e.g., Enalapril 5 mg OD) preferred in diabetics and CKD
• ARBs (e.g., Losartan 50 mg OD) if ACE inhibitor cough develops

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Case 2: Hypertension with Diabetes (Dual Management)

• DM type 2 for 6 years, on Metformin 500 mg BD
• BP readings at home: 150–160/90–100 mmHg
• Mild ankle swelling, no chest pain
• No urinary symptoms

• BP: 158/96 mmHg | HR: 78 | Weight: 74 kg
• Mild bilateral pedal edema (+1)
• No crackles, no murmurs

• HbA1c, Fasting blood glucose
• Spot urine albumin:creatinine ratio (ACR) - microalbuminuria?
• Serum creatinine, GFR
• Lipid profile
• ECG

Rx
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1. Tab. Enalapril 5 mg — OD (morning)          #30
   ↳ ACE inhibitor: renoprotective in DM

2. Tab. Amlodipine 5 mg — OD (morning)         #30
   ↳ Add if BP not controlled on ACEi alone

3. Tab. Metformin 500 mg — BD (after meals)     #60
   ↳ Continue existing antidiabetic

4. Tab. Empagliflozin 10 mg — OD (morning)     #30
   ↳ SGLT2-i: cardio/renoprotective in DM+HTN

5. Tab. Atorvastatin 20 mg — OD (night)        #30
   ↳ CVD risk reduction

Advice:
- BP target: <130/80 mmHg
- HbA1c target: <7%
- Low-sodium, low-glycemic diet
- Foot care, ophthalmology referral

Follow-up: 4 weeks
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• ACE inhibitors/ARBs are first-line in DM+HTN due to renoprotection
• SGLT2 inhibitors (empagliflozin, dapagliflozin) have proven CV and renal outcomes
• ACR >30 mg/g = microalbuminuria - treat aggressively
• Avoid NSAIDs in CKD/HTN patients

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Case 3: Stable Angina (Chronic Coronary Syndrome)

• Dull, pressing chest pain (central), radiating to left arm
• Occurs on exertion (climbing 2 flights of stairs), relieved by rest within 5 minutes
• No pain at rest
• Smoker, hypertensive on Amlodipine 5 mg

• BP: 138/86 | HR: 80 | O2 Sat: 98%
• Normal heart sounds, no murmur
• No signs of heart failure

• ECG (may show ST depression during pain)
• Stress ECG (treadmill test)
• Echo (wall motion abnormalities)
• Fasting lipids, HbA1c
• FBC (exclude anemia as cause)

Rx
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1. Tab. Aspirin 75 mg — OD (after food)         #30
   ↳ Antiplatelet

2. Tab. Atorvastatin 40 mg — OD (night)        #30
   ↳ High-intensity statin; plaque stabilization

3. Tab. Bisoprolol 2.5 mg — OD (morning)       #30
   ↳ Beta-blocker: ↓ HR, ↓ O2 demand, antianginal

4. Tab. Isosorbide Mononitrate 30 mg SR — OD   #30
   ↳ Long-acting nitrate for angina prophylaxis

5. GTN Spray (Sublingual) — PRN during chest pain
   ↳ 1–2 puffs under tongue; repeat after 5 min (max 3x)
   ↳ If no relief after 3 doses → EMERGENCY ROOM

Advice:
- Refer for coronary angiography assessment
- Avoid sudden exertion
- Carry GTN at all times

Follow-up: 2 weeks
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• Beta-blockers are first-line for angina prophylaxis (reduce HR and O2 demand)
• GTN spray provides rapid relief - teach patient proper use
• High-intensity statin (Atorvastatin 40-80 mg) recommended for all CAD patients
• Dual antiplatelet therapy if post-PCI (add Clopidogrel 75 mg)

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ENDOCRINE / METABOLIC CASES

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Case 4: Type 2 Diabetes Mellitus (Newly Diagnosed)

• Polyuria (waking 3x/night), polydipsia, polyphagia
• 5 kg weight loss in 2 months
• Family history: mother has DM
• No foot ulcers, no visual changes

• BMI: 30 kg/m² | BP: 130/82 | FBG done today: 11.2 mmol/L
• No diabetic foot changes
• No retinopathy on fundoscopy

• HbA1c (confirm diagnosis + baseline)
• FBG, OGTT if borderline
• Lipid profile
• Urine ACR
• Creatinine, eGFR
• Thyroid function
• ECG

Rx
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1. Tab. Metformin 500 mg — BD (after meals)     #60
   ↳ Titrate to 1000 mg BD over 4 weeks
   ↳ First-line: weight-neutral, cardioprotective

2. Tab. Sitagliptin 100 mg — OD (morning)      #30
   ↳ DPP-4 inhibitor: add if HbA1c >8% on Metformin
   ↳ OR substitute Empagliflozin 10 mg OD (if CV risk)

3. Tab. Atorvastatin 20 mg — OD (night)        #30
   ↳ CVD risk reduction (most DM patients benefit)

4. Tab. Folic acid 5 mg — OD                   #30
   ↳ If on Metformin (B12 monitoring yearly)

Advice:
- HbA1c target: <7% (individualize: <8% in elderly)
- Carbohydrate counting, low-GI diet
- Daily foot inspection
- SMBG: fasting and 2h post-meal

Follow-up: 8 weeks (with HbA1c result)
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• Metformin is still first-line unless eGFR <30 mL/min
• If HbA1c >9%: start dual therapy immediately
• If HbA1c >10%: consider early insulin
• SGLT2 inhibitors preferred in patients with heart failure or CKD

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Case 5: Hypothyroidism

• Gradual weight gain 6 kg over 1 year
• Always feeling cold, hair thinning, dry skin
• Menstrual irregularity (heavy periods)
• No neck swelling noticed

• HR: 58 bpm | BP: 110/70
• BMI: 29 | Puffy face, periorbital edema
• Dry coarse skin, slow relaxing ankle reflexes (hung reflex)
• Diffuse goiter - Grade 1 on palpation

• TSH (elevated), Free T4 (low)
• Anti-TPO antibodies (Hashimoto's confirmation)
• FBC (macrocytic anemia possible)
• Lipid profile (hyperlipidemia common)
• Blood glucose

Rx
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1. Tab. Levothyroxine 50 mcg — OD               #30
   ↳ 30 min before breakfast, empty stomach
   ↳ Titrate up by 25 mcg every 6–8 weeks
   ↳ Target: TSH 0.5–2.5 mIU/L (or 1–3 mIU/L in elderly)

Advice:
- Take Levothyroxine AWAY from calcium, iron, antacids (4h gap)
- Do not take double dose if missed
- Thyroid function check: 6–8 weeks after dose change
- Pregnancy: TSH target <2.5 in first trimester

Follow-up: 6–8 weeks with TSH/T4
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• Start low in elderly/cardiac patients (12.5–25 mcg) to avoid precipitating angina
• Subclinical hypothyroidism (↑TSH, normal T4): treat if TSH >10 or symptomatic
• Anti-TPO positivity predicts progression to overt hypothyroidism

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Case 6: Hyperthyroidism (Graves' Disease)

• 8 kg unintentional weight loss in 3 months despite increased appetite
• Racing heart (palpitations), tremors
• Excessive sweating, heat intolerance
• Prominent eyes noticed by family

• HR: 112 bpm, irregular | BP: 140/70
• Exophthalmos (proptosis), lid lag, lid retraction
• Diffuse smooth goiter, bruit audible over thyroid
• Fine tremor of outstretched hands
• Warm, moist skin; brisk reflexes

• TSH (suppressed), Free T4/T3 (elevated)
• TSH receptor antibodies (TRAb) - confirmatory
• Thyroid ultrasound (diffuse enlargement)
• ECG (AF/sinus tachycardia)

Rx
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1. Tab. Carbimazole 20–40 mg — OD (divided doses)  #30
   ↳ Titrate down based on thyroid function
   ↳ Monitor: FBC (agranulocytosis - rare but serious)

2. Tab. Propranolol 40 mg — TDS                    #90
   ↳ Beta-blocker: controls palpitations, tremor, anxiety
   ↳ Taper once euthyroid state achieved

3. Tab. Prednisolone 10 mg — OD (if eye disease)   #30
   ↳ Only if active thyroid eye disease present

Advice:
- Report sore throat/fever immediately (agranulocytosis)
- Ophthalmology referral for Graves' orbitopathy
- Discuss radioiodine (I-131) or surgery for definitive Rx
- Avoid iodine-containing foods/contrast dye

Follow-up: 4–6 weeks with TFTs
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RESPIRATORY CASES

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Case 7: Bronchial Asthma (Adult, Moderate Persistent)

• Wheeze 4–5 days/week
• Nocturnal symptoms 2x/week (waking from sleep)
• Activity limitation: can't play football anymore
• Triggers: dust, cold air, exercise
• Using salbutamol inhaler 4–5x/week (over-reliance)
• Family history: sister has eczema

• RR: 18 | O2 Sat: 97% (at rest)
• Bilateral expiratory wheeze on auscultation
• No signs of acute severe asthma currently
• Eczematous patches on arm (atopic background)

• Spirometry: FEV1/FVC <0.70, FEV1 % predicted (obstructive pattern)
• Bronchodilator reversibility test (>12% improvement = asthma)
• Peak flow diary
• Skin prick test / IgE (allergy workup)
• CXR (hyperinflation, exclude pneumonia)

Rx
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1. Fluticasone 250 mcg + Salmeterol 25 mcg MDI
   (Seretide 250/25 or equivalent)
   — 2 puffs BD (with spacer)                   #1 inhaler
   ↳ ICS/LABA combination: GINA Step 3 controller
   ↳ Rinse mouth after use (prevent oral candidiasis)

2. Salbutamol 100 mcg MDI (Reliever)
   — 1–2 puffs PRN (max 4x/day)                 #1 inhaler
   ↳ "Blue inhaler" - use for acute symptoms only

3. Tab. Montelukast 10 mg — OD (night)          #30
   ↳ Leukotriene modifier: add-on therapy for atopic asthma

Advice:
- Inhaler technique demonstration essential
- Avoid triggers (dust mites, pets, smoke)
- Written Asthma Action Plan provided
- Step down if controlled for 3 months

Follow-up: 4 weeks (review symptom diary)
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• "Brown/purple = preventer, Blue = reliever"
• ICS is the cornerstone of asthma management
• If salbutamol needed >2x/week: step UP treatment
• GINA 2024: ICS-formoterol as MART (maintenance AND reliever)

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Case 8: COPD (Stable, Moderate)

• Cough for 8 years, productive (white/yellow sputum in mornings)
• Increasing dyspnea: now breathless walking on flat ground (mMRC Grade 2)
• 2 exacerbations last year requiring antibiotics
• Ex-smoker (quit 1 year ago)

• RR: 20 | O2 Sat: 93% | HR: 88
• Barrel chest, ↑ AP diameter
• Hyperresonant percussion, ↓ breath sounds bilaterally
• Prolonged expiration, scattered wheeze

• Spirometry: FEV1/FVC <0.70 post-bronchodilator; FEV1 40–59% = GOLD 2 (Moderate)
• CXR (hyperinflation, flat diaphragm, bullae)
• ABG (if O2 Sat <92%)
• FBC (polycythemia), ECG
• Sputum culture (during exacerbation)
• Echo (if cor pulmonale suspected)

Rx
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1. Tiotropium 18 mcg Handihaler — 1 capsule OD   #30
   ↳ Long-acting muscarinic antagonist (LAMA)
   ↳ Core bronchodilator for COPD

2. Formoterol 12 mcg Turbuhaler — 1 puff BD      #1
   ↳ LABA: second bronchodilator for GOLD B

3. Budesonide/Formoterol 160/4.5 mcg — 2 puffs BD #1
   ↳ ICS/LABA: if frequent exacerbations (≥2/year)

4. Salbutamol MDI — 1–2 puffs PRN (rescue)       #1

5. Tab. Mucinac (N-acetylcysteine) 600 mg — BD    #60
   ↳ Mucolytic: reduces exacerbation frequency

6. Tab. Azithromycin 250 mg — OD (Mon/Wed/Fri)    #3 months
   ↳ Only if frequent exacerbations, non-smoker, after sputum culture

Advice:
- Smoking cessation (most important intervention)
- Pulmonary rehabilitation referral
- Annual influenza + pneumococcal vaccine
- Supplemental O2 if PaO2 <55 mmHg at rest

Follow-up: 3 months
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Case 9: Pulmonary Tuberculosis (PTB - New Case)

• Cough 6 weeks, productive (occasionally blood-streaked)
• Fever (low-grade, evenings), drenching night sweats
• 7 kg weight loss in 2 months
• Works in crowded garment factory
• Contact: colleague had TB last year

• Temperature: 37.9°C | RR: 22 | O2 Sat: 96%
• Dull on percussion (right upper zone)
• Bronchial breath sounds (right apex)
• Cervical lymphadenopathy (mild)

• Sputum AFB smear x 3 (morning specimens)
• GeneXpert MTB/RIF (preferred - rapid + drug resistance)
• CXR: upper lobe infiltrates, cavitation (classic)
• Mantoux test / IGRA
• HIV test (mandatory)
• LFTs (baseline before DOTS therapy)

Rx
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INTENSIVE PHASE (2 months):
H-R-Z-E (HRZE Fixed-Dose Combination)
Based on weight 60 kg:
- Isoniazid 300 mg + Rifampicin 600 mg
  + Pyrazinamide 1500 mg + Ethambutol 1200 mg
  — OD (before breakfast) x 60 days

+ Tab. Pyridoxine (Vit B6) 25 mg — OD
  ↳ Prevents Isoniazid-induced peripheral neuropathy

CONTINUATION PHASE (4 months):
H-R:
- Isoniazid 300 mg + Rifampicin 600 mg — OD x 4 months

Advice:
- DOTS program: supervised treatment
- Notify local public health authority
- Household contacts: screen + prophylaxis (INH 300 mg x 6 months)
- Rifampicin: warn about red/orange urine, ↓ OCP efficacy
- No alcohol (↑ hepatotoxicity)
- LFTs at 2 weeks if symptomatic
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• GeneXpert is now preferred over AFB smear alone (detects resistance)
• Total treatment: 6 months (2HRZE + 4HR) for new pulmonary TB
• Drug-resistant TB (MDR/XDR) requires longer regimens - refer specialist
• HIV co-infection: start ART within 2-8 weeks of TB treatment

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GASTROENTEROLOGY CASES

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Case 10: Peptic Ulcer Disease / GERD

• Burning/gnawing epigastric pain for 3 months
• Worse 1–3 hours after meals, partially relieved by food/antacids
• Sour regurgitation, occasional heartburn
• NSAID use: takes Diclofenac for back pain
• No vomiting blood, no black stools

• Mild epigastric tenderness on deep palpation
• No rebound, no guarding
• No organomegaly

• H. pylori: Rapid Urease Test (endoscopy) OR H. pylori stool antigen OR urea breath test
• Upper GI endoscopy (if >45 years, alarm features, or treatment failure)
• Alarm features requiring urgent scope: dysphagia, weight loss, vomiting, anemia, mass

Rx
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1. Tab. Pantoprazole 40 mg — OD (30 min before breakfast)   #28
   ↳ PPI: gold standard for acid suppression/ulcer healing
   ↳ Continue 4–8 weeks (ulcer) or 4 weeks (GERD)

IF H. PYLORI POSITIVE - Triple Therapy (14 days):
2. Tab. Amoxicillin 1 g — BD (after food)       #28
3. Tab. Clarithromycin 500 mg — BD (after food)  #28
   + Continue Pantoprazole as above

   OR (if Clarithromycin resistance suspected):
   Bismuth Quadruple Therapy:
   Bismuth Subcitrate 240 mg + Metronidazole 400 mg
   + Tetracycline 500 mg — QID + Pantoprazole 40 mg BD x 14 days

4. Tab. Metoclopramide 10 mg — TDS (before meals)   #90
   ↳ PRN for nausea/vomiting

5. Antacid Suspension (Aluminum + Magnesium Hydroxide)
   — 10 mL PRN (between meals and at bedtime)

Advice:
- STOP NSAIDs; switch to Paracetamol for pain
- Eat small, frequent meals; avoid spicy food
- No coffee, alcohol, smoking
- Sleep with head of bed elevated (for GERD)
- Verify H. pylori eradication: urea breath test 4 weeks after treatment

Follow-up: 4 weeks
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• H. pylori eradication is the definitive treatment for H. pylori-positive ulcers
• All PPIs have similar efficacy; choice based on cost/availability
• "Test and treat" for H. pylori in patients <45 years with dyspepsia (no alarm features)
• NSAID users: add PPI for gastroprotection (especially if elderly, on steroids/anticoagulants)

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Case 11: Irritable Bowel Syndrome (IBS-D)

• Abdominal pain (periumbilical/LIF) for 2 years
• Predominantly loose stools (4–6x/day during flares)
• Pain relieved by defecation
• Mucus in stool, bloating, incomplete evacuation
• Worse with stress (exams, work deadlines)
• No blood in stool, no weight loss, no fever

• Mild LIF tenderness, no mass
• Normal bowel sounds
• No organomegaly

• FBC, ESR, CRP (exclude IBD)
• Stool for calprotectin (elevated in IBD, normal in IBS)
• Celiac serology (anti-tTG IgA)
• Colonoscopy: only if alarm features (blood, weight loss, >50 years, family hx of colon cancer)

Rx
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1. Tab. Mebeverine 135 mg — TDS (20 min before meals)  #90
   ↳ Antispasmodic: first-line for abdominal cramps

2. Tab. Loperamide 2 mg — OD/BD (for diarrhea days)    PRN
   ↳ Antimotility agent; do NOT use if constipation

3. Tab. Buscopan (Hyoscine) 10 mg — TDS PRN            #30
   ↳ Alternative antispasmodic for acute cramps

4. Sachet Probiotics (Lactobacillus rhamnosus)
   — 1 sachet OD after food                             #30
   ↳ Evidence for symptom reduction in IBS

5. Tab. Amitriptyline 10 mg — OD (night)               #30
   ↳ Low-dose TCA: central pain modulation
   ↳ Especially useful if IBS with anxiety/depression

Advice:
- Low-FODMAP diet trial (4–6 weeks)
- Identify and avoid food triggers
- Stress management, CBT referral if anxiety prominent
- Increase soluble fiber (IBS-C type)
- Regular sleep and exercise pattern

Follow-up: 6 weeks
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Case 12: Acute Gastroenteritis

• 8–10 loose watery stools/day, no blood
• Projectile vomiting x 5 times today
• Ate at roadside stall yesterday (suspect food)
• Crampy periumbilical pain
• Dizziness on standing (orthostatic symptoms)

• Temp: 37.8°C | HR: 102 | BP: 110/70 (sitting), 95/60 (standing)
• Dry mucous membranes, skin turgor ↓
• Mild diffuse abdominal tenderness, hyperactive bowel sounds

• Stool routine + culture (if bloody or prolonged)
• FBC (leukocytosis in bacterial)
• Serum electrolytes (hyponatremia, hypokalemia)
• Urea/Creatinine (if severe dehydration)

Rx
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1. ORS (Oral Rehydration Salts)
   — 200 mL after every loose stool              x10 sachets
   ↳ Primary treatment for dehydration

2. Tab. Ondansetron 4 mg — BD/TDS (for vomiting) #6
   ↳ 5-HT3 antagonist antiemetic

3. Tab. Loperamide 2 mg — after each loose stool  #6
   ↳ Max 16 mg/day; do NOT use if fever/bloody stool

4. Tab. Ciprofloxacin 500 mg — BD x 5 days        #10
   ↳ ONLY if:
   ↳ - Bloody diarrhea / Traveler's diarrhea
   ↳ - Severe illness (fever, systemic symptoms)
   ↳ NOT routine for viral gastroenteritis

5. Tab. Domperidone 10 mg — TDS (before meals)    #9
   ↳ Alternative antiemetic (prokinetic)

6. Zinc 20 mg — OD x 10–14 days                   #14
   ↳ Reduces duration and severity

Advice:
- Drink ORS, clear liquids, coconut water
- BRAT diet (Banana, Rice, Applesauce, Toast)
- Hand hygiene; isolate if infectious
- Return if: high fever, blood in stool, cannot keep fluids down, confusion

Follow-up: 3 days or sooner if deteriorating
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NEUROLOGICAL CASES

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Case 13: Migraine (Episodic, Moderate-Severe)

• Pulsating left-sided headache, 4/10 episodes per month
• Severity: 7–8/10, lasting 8–24 hours
• Associated: photophobia, phonophobia, nausea, vomiting
• Aura: visual zig-zag lines (scintillating scotoma) 20–30 min before headache (WITH aura)
• Aggravated by: menstruation, stress, skipping meals
• Partially relieved by lying in dark, quiet room
• Family history: mother has migraines

• Normal neurological examination between episodes
• No papilledema, no focal deficits

• MRI Brain (first attack in adults, atypical features, thunderclap, progressive)
• Not routinely needed if classic presentation with normal neuro exam

Rx
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ACUTE ATTACK TREATMENT:
1. Tab. Sumatriptan 50 mg — at onset of migraine   #6
   ↳ Triptan: most effective specific abortive therapy
   ↳ Take early (at aura onset); repeat after 2h if partial relief
   ↳ Max: 200 mg/day; NOT for basilar/hemiplegic migraine

2. Tab. Domperidone 10 mg — with Sumatriptan       #6
   ↳ Antiemetic + enhances triptan absorption

3. Tab. Naproxen 500 mg — OD/BD during attack      #6
   ↳ NSAID alternative if triptans unavailable

PREVENTIVE TREATMENT (≥4 attacks/month):
4. Tab. Propranolol 40 mg — BD                    #60
   ↳ First-line migraine prophylaxis
   ↳ Avoid if asthma, Raynaud's

   OR Tab. Amitriptyline 10–25 mg — OD (night)    #30
   ↳ Alternative prophylaxis; helpful if insomnia/depression

   OR Tab. Topiramate 25–100 mg — OD (night)      #30
   ↳ Weight loss benefit; avoid in pregnancy

Advice:
- Headache diary (triggers, frequency, severity)
- Regular sleep schedule, meals, hydration
- Avoid triggers: cheese, red wine, bright lights
- AVOID COMBINED OCP (migraine with aura = stroke risk)
- Limit acute medications ≤10 days/month (prevent medication overuse headache)

Follow-up: 8 weeks with headache diary
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• Migraine with aura + combined OCP = CONTRAINDICATED (thrombotic stroke risk - WHO Category 4)
• Medication overuse headache (analgesic rebound): treat >10 days/month
• Triptans work best when taken early in the attack

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Case 14: Tension-Type Headache

• Bilateral pressure/tightening, non-pulsating headache ("like a tight band")
• Mild-moderate severity, not aggravated by routine physical activity
• No nausea, no vomiting, mild photophobia
• Works at computer 10 hours/day
• 3–4 cups of coffee daily (sometimes misses morning coffee)

• Normal neurological exam
• Tenderness in neck/suboccipital muscles, pericranial muscles
• Normal fundoscopy

Rx
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ACUTE:
1. Tab. Ibuprofen 400 mg — with food (max 3x/week)  #9
   ↳ Most effective NSAID for TTH
   ↳ Do NOT use daily (MOH risk)

2. Tab. Paracetamol 1 g — TDS PRN                   #9
   ↳ Alternative analgesic

PREVENTIVE (if >15 headache days/month):
3. Tab. Amitriptyline 10–25 mg — OD (night)         #30
   ↳ Evidence-based TTH prophylaxis

Advice:
- Neck stretching exercises, physiotherapy
- Ergonomic workstation correction
- Gradual caffeine reduction (not abrupt)
- Regular sleep schedule
- Stress management techniques

Follow-up: 6 weeks
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MUSCULOSKELETAL CASES

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Case 15: Osteoarthritis (Knee)

• Bilateral knee pain, R > L
• Worse in the morning (stiffness <30 min), after prolonged sitting ("start-up pain")
• Joint swelling, crepitus on movement
• Difficulty climbing stairs, no fever, no rash
• BMI: 32 (obese)

• Crepitus bilateral knee joints on flexion/extension
• Joint line tenderness, mild bony enlargement
• Bony swelling (osteophytes) over medial compartment
• No warmth, minimal effusion
• Varus deformity, limited range of motion

• X-ray knee (weight-bearing AP + lateral): joint space narrowing, osteophytes, subchondral sclerosis
• FBC, ESR, uric acid (exclude gout/inflammatory arthritis)

Rx
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1. Tab. Paracetamol 500 mg — BD/TDS                  #60
   ↳ First-line analgesic; safer than NSAIDs in elderly

2. Tab. Ibuprofen 400 mg — BD (after food)           #30
   ↳ If Paracetamol alone insufficient
   ↳ ADD: Tab. Pantoprazole 20 mg OD (gastroprotection)

3. Diclofenac Gel 1% — Apply TDS to affected knee    #1 tube
   ↳ Topical NSAID: local effect, less systemic SE

4. Tab. Glucosamine Sulfate 1500 mg — OD             #30
   ↳ + Chondroitin 1200 mg OD (cartilage support)
   ↳ 3-month trial; evidence mixed but safe

5. Cap. Celecoxib 200 mg — OD (after food)           #30
   ↳ COX-2 inhibitor: if CV risk acceptable
   ↳ Use if GI intolerance to non-selective NSAIDs

6. Inj. Triamcinolone 40 mg — Intra-articular        #1
   ↳ For moderate-severe effusion / flare
   ↳ Refer orthopedics if recurrent (max 3–4/year)

Advice:
- Weight loss (most effective intervention: each 1 kg ↓ = 4 kg less knee load)
- Quadriceps strengthening exercises
- Swimming, cycling (low-impact activities)
- Walking aids (knee brace, walking stick)
- Orthopedics referral for total knee replacement if Grade IV

Follow-up: 4 weeks
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Case 16: Gout (Acute Attack)

• Woke at 3 AM with excruciating pain in right first metatarsophalangeal joint
• Joint: red, hot, swollen, extremely tender (cannot bear sheet touching it)
• Ate red meat and drank beer at party last night
• Previous similar episode 6 months ago
• Taking Hydrochlorothiazide for BP

• Temperature: 37.6°C
• Right MTP joint: red, hot, swollen, extremely tender
• Tophi: none
• BP: 138/88

• Serum uric acid (may be normal during acute attack)
• Joint aspiration + microscopy: needle-shaped negatively birefringent crystals (MSU)
• FBC (leukocytosis), CRP, ESR
• Renal function, urine for uric acid
• X-ray (punched-out erosions with overhanging edge - chronic gout)

Rx
────────────────────────────────────────────────────
ACUTE ATTACK TREATMENT (choose ONE):

Option A - Colchicine (preferred if <24h of attack):
1. Tab. Colchicine 1 mg — at onset                  #5
   ↳ Then 0.5 mg after 1h (low-dose protocol)
   ↳ Then 0.5 mg BD for 5–7 days
   ↳ STOP if diarrhea, vomiting (dose-limiting SE)

Option B - NSAIDs:
2. Tab. Indomethacin 50 mg — TDS (after food) x 5 days  #15
   ↳ Or Naproxen 500 mg BD x 5 days
   ↳ Avoid if renal impairment, peptic ulcer, anticoagulation
   ↳ ADD Pantoprazole 40 mg OD (GI protection)

Option C - Prednisolone (if NSAIDs/Colchicine contraindicated):
3. Tab. Prednisolone 30–35 mg — OD x 5 days        #5
   ↳ Then taper over next 5 days

URATE-LOWERING THERAPY (start 2–4 weeks AFTER acute attack settles):
4. Tab. Allopurinol 100 mg — OD                    #30
   ↳ Titrate to 300 mg OD (target serum uric acid <360 μmol/L)
   ↳ Start WITH Colchicine 0.5 mg OD cover (prevents flare)
   ↳ Avoid thiazide diuretics if possible

Advice:
- Avoid: red meat, organ meat, shellfish, alcohol (especially beer)
- Increase water intake
- Change Hydrochlorothiazide to Losartan (uricosuric BP drug)
- Rest affected joint; ice packs

Follow-up: 2 weeks
────────────────────────────────────────────────────

---

Case 17: Rheumatoid Arthritis (Early)

• Bilateral small joint swelling (MCP, PIP joints), wrists
• Morning stiffness lasting 1.5–2 hours
• Fatigue, mild fever, weight loss
• Symmetric involvement
• Duration: 6 weeks (Early RA)

• Boggy synovial swelling: bilateral MCP 2-3-4, PIP, wrists
• Warmth and tenderness over affected joints
• No nodules, no deformity yet

• RF (Rheumatoid Factor) - 60–80% positive in RA
• Anti-CCP antibodies (more specific than RF)
• ESR, CRP, FBC (anemia of chronic disease)
• X-ray hands/wrists (periarticular osteopenia, marginal erosions - early signs)
• Ultrasound joints (synovitis, Power Doppler)
• LFTs, RFTs (before DMARD therapy)

Rx
────────────────────────────────────────────────────
1. Tab. Methotrexate (MTX) 7.5 mg — once weekly    #4/month
   ↳ Anchor DMARD for RA; start low, titrate to 15–25 mg/week
   ↳ Take on SAME day every week (e.g., every Monday)
   ↳ Monitor: LFTs, FBC every 3 months

2. Tab. Folic Acid 5 mg — once weekly (day AFTER MTX)  #4/month
   ↳ Reduces MTX side effects (mucositis, nausea)

3. Tab. Hydroxychloroquine 200 mg — BD              #60
   ↳ Antimalarial DMARD: combination with MTX
   ↳ Annual ophthalmology check (macular toxicity)

4. Tab. Prednisolone 10 mg — OD (bridging therapy)  #30
   ↳ Bridge until DMARD takes effect (2–4 months)
   ↳ Taper and STOP as soon as DMARDs are effective
   ↳ Add calcium + Vit D if prolonged steroid use

5. Tab. Diclofenac SR 75 mg — BD (after food)       #60
   ↳ NSAID for symptom control (not disease modification)
   ↳ Add Pantoprazole 40 mg OD gastroprotection

Advice:
- Rheumatology referral (DMARD management)
- Treat-to-Target (T2T): DAS28 <2.6 = remission
- Physiotherapy: joint protection, exercise
- NO live vaccines while on MTX/biologics

Follow-up: 4 weeks
────────────────────────────────────────────────────

---

---

INFECTIOUS DISEASE CASES

---

Case 18: Community-Acquired Pneumonia (Mild-Moderate)

• High-grade fever (39.2°C), rigors
• Cough with rusty/yellow-green sputum
• Right-sided pleuritic chest pain (sharp, worse on breathing)
• Mild breathlessness on exertion

• Temp: 39.1°C | RR: 24 | HR: 102 | O2 Sat: 94%
• Dullness to percussion (right lower zone)
• Bronchial breath sounds + crepitations (right base)
• Pleural friction rub (right)

• CXR: right lower lobe consolidation
• FBC: leukocytosis (neutrophilia)
• CRP elevated
• Sputum culture + sensitivity (ideally before antibiotics)
• Blood cultures x2 (if febrile/septic)
• Urine Legionella antigen (if severe/epidemic)

Rx
────────────────────────────────────────────────────
OUTPATIENT CAP (CURB-65 0-1):
1. Tab. Amoxicillin 1 g — TDS x 5–7 days             #21
   ↳ First-line: covers Streptococcus pneumoniae

   + Tab. Azithromycin 500 mg — OD x 5 days           #5
   ↳ Covers atypicals (Mycoplasma, Chlamydophila, Legionella)

   OR
   Tab. Doxycycline 100 mg — BD x 5–7 days            #14
   ↳ Alternative single agent for atypicals + typical bacteria

   OR (if allergic to penicillin):
   Tab. Clarithromycin 500 mg — BD x 5–7 days         #14

2. Tab. Paracetamol 1 g — TDS PRN (fever/pain)        #21

3. Tab. N-Acetylcysteine 600 mg — BD                  #14
   ↳ Mucolytic: helps expectorate sputum

Advice:
- Rest, adequate hydration
- Deep breathing exercises
- ADMIT if: O2 Sat <92%, RR >30, BP <90/60, confusion, or CURB-65 ≥3
- Follow-up CXR at 6–8 weeks (exclude underlying malignancy)
- Pneumococcal vaccine (prevent recurrence)

Follow-up: 3 days if no improvement
────────────────────────────────────────────────────

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Case 19: Urinary Tract Infection (Uncomplicated, Female)

• Dysuria (burning on urination) for 3 days
• Urinary frequency (every 30–60 minutes)
• Suprapubic discomfort
• No fever, no loin pain (no upper UTI features)
• Sexually active (recent new partner)
• No pregnancy

• Temperature: 37.2°C (afebrile)
• Mild suprapubic tenderness
• No CVA (costovertebral angle) tenderness - no pyelonephritis signs

• Urine dipstick: leukocytes ++ (WBC), nitrites + (bacteria)
• Urine routine + microscopy + culture/sensitivity (midstream urine)
• Pregnancy test (urine hCG) - before prescribing antibiotics

Rx
────────────────────────────────────────────────────
1. Tab. Nitrofurantoin 100 mg MR — BD x 5 days        #10
   ↳ First-line for uncomplicated cystitis (low resistance)
   ↳ Avoid if eGFR <45 mL/min

   OR Tab. Trimethoprim 200 mg — BD x 7 days          #14
   ↳ Alternative first-line (check local resistance patterns)

   OR Tab. Cefalexin 500 mg — TDS x 5 days            #15
   ↳ If above unavailable

   AVOID Ciprofloxacin for uncomplicated UTI
   (Reserve fluoroquinolones; resistance stewardship)

2. Tab. Phenazopyridine 200 mg — TDS x 2 days         PRN
   ↳ Urinary analgesic (dyes urine orange - warn patient)

3. Tab. Paracetamol 500 mg — TDS PRN                  #9
   ↳ For suprapubic discomfort

Advice:
- Drink 2–3 L water/day
- Urinate after intercourse
- Avoid bubble baths, scented products
- Return if: fever, loin pain, vomiting (pyelonephritis)
- Recurrent UTI (≥3/year): discuss prophylactic options

Follow-up: 5–7 days if not improving
────────────────────────────────────────────────────

---

Case 20: Malaria (Uncomplicated, P. vivax)

• Fever with rigors for 6 days
• Classic periodicity: every 48h (tertian pattern)
• Rigors → high fever → drenching sweats → relative well-being
• Headache, myalgia, malaise
• Travel: visited malaria-endemic area 10 days ago

• Temp: 40.1°C (during fever) | HR: 104 | BP: 110/70
• Pallor, mild jaundice (hemolysis)
• Splenomegaly (soft, tender) - 4 cm below costal margin
• No neck stiffness, no altered consciousness

• Peripheral blood thick and thin film (malaria parasites, species identification)
• Rapid Diagnostic Test (RDT) for Plasmodium antigen
• FBC: anemia, thrombocytopenia, leukopenia
• LFTs (elevated bilirubin), RFTs
• Blood glucose (hypoglycemia in severe malaria)
• G6PD assay BEFORE starting Primaquine

Rx
────────────────────────────────────────────────────
P. VIVAX (Chloroquine-sensitive areas):
1. Tab. Chloroquine 250 mg base:
   Day 1: 600 mg base (4 tabs)
   Day 2: 300 mg base (2 tabs)
   Day 3: 300 mg base (2 tabs)
   ↳ Total: 1500 mg base over 3 days

2. Tab. Primaquine 15 mg — OD x 14 days            #14
   ↳ Eliminates hypnozoites (prevents relapse in P. vivax)
   ↳ CHECK G6PD STATUS FIRST (causes hemolysis in G6PD deficiency)
   ↳ CONTRAINDICATED in pregnancy

P. FALCIPARUM (or uncertain species):
   Tab. Artemether-Lumefantrine (Coartem 20/120 mg)
   — 4 tabs at 0, 8, 24, 36, 48, 60 hours (weight 35+ kg)
   ↳ ACT: first-line for P. falciparum

3. Tab. Paracetamol 1 g — TDS PRN (fever)          #9
4. ORS/adequate hydration

Advice:
- ADMIT if: Hb <7, altered consciousness, respiratory distress, severe vomiting
- Mosquito net, repellent (DEET), long-sleeved clothing
- Notify health authority (notifiable disease)

Follow-up: 48–72 hours
────────────────────────────────────────────────────

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---

DERMATOLOGY CASES

---

Case 21: Fungal Skin Infection (Tinea Corporis / Ringworm)

• Annular (ring-shaped) scaly patch, trunk and inner thigh
• Intense pruritus, worse with sweating
• Skin-to-skin contact with affected family member possible
• No fever, no joint pain

• Annular scaly plaques with raised active edge and central clearing
• 3–4 lesions on trunk, inner thigh
• Wood's lamp: may not fluoresce (Trichophyton species)
• KOH test: branching hyphae (positive)

Rx
────────────────────────────────────────────────────
TOPICAL (mild/localized):
1. Clotrimazole 1% Cream — Apply BD x 4 weeks      #1 tube
   ↳ Apply 2 cm beyond visible lesion edge
   ↳ Continue 2 weeks after lesions clear

   OR Terbinafine 1% Cream — Apply OD x 2 weeks    #1 tube
   ↳ Faster response; shorter course

ORAL (extensive/resistant/tinea capitis):
2. Tab. Terbinafine 250 mg — OD x 2–4 weeks        #28
   ↳ First-line systemic antifungal for tinea
   ↳ LFTs baseline if prolonged course

   OR Tab. Fluconazole 150 mg — once weekly x 4 weeks  #4
   ↳ Alternative oral agent

3. Antifungal Powder (Clotrimazole) — Dusting powder #1
   ↳ Apply to skin folds to keep dry

Advice:
- Keep skin dry; avoid tight clothing
- Treat all household contacts
- Do not share towels, clothing
- Wash clothes in hot water
- Complete full course (even if rash clears)

Follow-up: 4 weeks
────────────────────────────────────────────────────

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Case 22: Atopic Dermatitis (Eczema) - Adult Flare

• Chronic dry itchy skin since childhood (atopic)
• Current flare: antecubital fossa, neck, popliteal fossa
• Worse in winter, with stress, after bathing with hot water
• History of asthma and allergic rhinitis (atopic triad)
• Using soap (fragranced) - likely trigger

• Lichenification (thickened skin), excoriations, hyperpigmented patches
• Antecubital fossa bilateral, popliteal fossa
• No secondary bacterial infection signs (no crusting/pustules)

Rx
────────────────────────────────────────────────────
1. Hydrocortisone 1% Cream — Apply BD x 2 weeks    #1 tube
   ↳ Low-potency TCS for face and flexures
   ↳ (for trunk/limbs: Betamethasone 0.05% BD x 1–2 weeks)

2. Emollient/Moisturizer (Aqueous Cream or Cetaphil)
   — Apply TDS (after bathing, before sleep)        Large tub
   ↳ Cornerstone of eczema management
   ↳ Apply within 3 min of bathing ("soak and seal")

3. Tab. Cetirizine 10 mg — OD (night)              #30
   ↳ Antihistamine: ↓ pruritus, especially nocturnal

4. Tacrolimus 0.1% Ointment — Apply BD             #1 tube
   ↳ Topical calcineurin inhibitor
   ↳ Use for face/eyelids where TCS risky
   ↳ Steroid-sparing agent for maintenance

5. Tab. Prednisolone 20 mg — OD x 5 days (if severe flare)  #5
   ↳ Short course oral steroid for severe flares only
   ↳ Taper not needed for short courses

Advice:
- Use fragrance-free soap, Dove or Cetaphil wash
- Lukewarm (not hot) baths; pat dry (don't rub)
- Wear cotton clothing (avoid wool/synthetic)
- Wet wrap therapy for severe flares
- Avoid known triggers (sweat, stress, dust mites)

Follow-up: 2–4 weeks
────────────────────────────────────────────────────

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---

MENTAL HEALTH CASES

---

Case 23: Major Depressive Disorder (Moderate)

• Persistent low mood daily for 6 weeks
• Loss of interest in activities she previously enjoyed
• Sleep: early morning awakening, insomnia
• Poor appetite, 4 kg weight loss
• Fatigue, difficulty concentrating
• Feelings of worthlessness, guilt
• No suicidal ideation (must always screen)
• Recent stressor: divorce

• PHQ-9 score: 17/27 (Moderately Severe Depression)
• Slow speech, tearful
• Alert, oriented; no psychotic features
• Exclude hypothyroidism, anemia (TFTs, FBC ordered)

• TFTs (exclude hypothyroidism)
• FBC (anemia)
• Blood glucose (DM)
• Consider: Urea/Creatinine (before starting medication)
• Suicide risk assessment: always screen with "Columbia Protocol"

Rx
────────────────────────────────────────────────────
1. Tab. Sertraline 50 mg — OD (morning)             #30
   ↳ SSRI: first-line antidepressant
   ↳ Increase to 100 mg after 2 weeks if tolerated
   ↳ Full effect: 4–6 weeks; continue min 6 months
   ↳ SE: initial nausea, insomnia (transient)
   ↳ WARNING: Monitor for increased suicidality in first 2 weeks

   OR Escitalopram 10 mg — OD (morning)            #30
   ↳ SSRI: better tolerated, fewer drug interactions

2. Tab. Mirtazapine 15 mg — OD (night)             #30
   ↳ Add if prominent insomnia/anxiety/poor appetite
   ↳ Weight gain is common (may be useful here)

3. Tab. Clonazepam 0.5 mg — OD (night) x 2 weeks   #14
   ↳ Short-term only for severe insomnia/anxiety
   ↳ Risk of dependence; do NOT prescribe long-term

Advice:
- Psychotherapy referral (CBT is evidence-based)
- Regular exercise (proven antidepressant effect)
- Social support activation
- Crisis line number given
- Return IMMEDIATELY if suicidal thoughts
- Do NOT stop medication suddenly

Follow-up: 2 weeks (early follow-up for safety)
────────────────────────────────────────────────────

• Always screen for bipolar disorder before starting antidepressant (antidepressants can trigger mania)
• Minimum 6-9 months treatment after first episode; longer for recurrent depression
• SSRIs can transiently increase anxiety and suicidal ideation in the first 2 weeks - critical safety net

---

Case 24: Anxiety Disorder / Panic Disorder

• Recurrent sudden episodes lasting 10–30 minutes
• During episodes: palpitations, sweating, trembling, shortness of breath, chest tightness, dizziness, fear of dying or "going crazy"
• 4–5 episodes in last month
• No trigger; can occur at rest
• Between attacks: persistent worry about having another attack ("anticipatory anxiety")
• Multiple ER visits - all cardiac tests normal

• All systems normal during consultation
• ECG: normal sinus rhythm
• No thyrotoxicosis signs

• ECG (arrhythmia)
• TFTs (hyperthyroidism)
• Blood glucose (hypoglycemia)
• 24h Holter monitor if frequent palpitations
• Urine catecholamines (if pheochromocytoma suspected)

Rx
────────────────────────────────────────────────────
LONG-TERM TREATMENT:
1. Tab. Escitalopram 10 mg — OD (morning)           #30
   ↳ SSRI: first-line for panic disorder
   ↳ Start at 5 mg x 1 week (avoids initial anxiety worsening)
   ↳ Continue 12 months minimum

   OR Tab. Paroxetine 20 mg — OD                    #30

BRIDGING (short-term only, <4 weeks):
2. Tab. Clonazepam 0.5 mg — BD                      #28
   ↳ Benzodiazepine: rapid symptom relief
   ↳ Bridge until SSRI takes effect
   ↳ MUST taper before stopping; risk of dependence

3. Tab. Propranolol 20–40 mg — PRN                  #10
   ↳ For situational anxiety/anticipatory anxiety
   ↳ Controls somatic symptoms (palpitations, tremor)

Advice:
- Psychoeducation: panic attacks are NOT life-threatening
- Diaphragmatic breathing technique (demonstrated)
- Cognitive Behavioral Therapy (CBT) referral - MOST effective long-term
- Avoid caffeine, alcohol, stimulants
- Regular aerobic exercise

Follow-up: 2 weeks
────────────────────────────────────────────────────

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---

HEMATOLOGY CASES

---

Case 25: Iron Deficiency Anemia

• Progressive fatigue for 3 months
• Dyspnea on climbing stairs
• Heavy menstrual bleeding (menorrhagia) for 1 year
• Pica: craving ice and clay (pagophagia)
• Diet: vegetarian, low red meat intake

• Pallor (conjunctival, palmar)
• HR: 96, BP: 110/70
• Koilonychia (spoon-shaped nails)
• Glossitis (smooth red tongue)
• Angular cheilitis (mouth corners)
• No organomegaly

• FBC: Hb ↓, MCV ↓ (microcytic), MCH ↓, MCHC ↓
• Peripheral blood film: microcytic hypochromic picture, pencil cells, target cells
• Serum ferritin (LOW - most sensitive for iron stores)
• Serum iron (↓), TIBC (↑)
• Reticulocyte count
• Stool for occult blood (exclude GI bleeding)
• Gynecology referral for menorrhagia

Rx
────────────────────────────────────────────────────
1. Tab. Ferrous Sulfate 200 mg — TDS (between meals)  #90
   ↳ 65 mg elemental iron per 200 mg tablet
   ↳ Take with Vitamin C (orange juice) to enhance absorption
   ↳ Avoid with tea, calcium, antacids (1–2h gap)
   ↳ SE: constipation, black stools (warn patient)
   ↳ Alternative: Ferrous Gluconate 300 mg BD (better tolerated)

2. Tab. Vitamin C 500 mg — TDS (with iron tablet)     #90
   ↳ Enhances non-heme iron absorption significantly

3. Tab. Folic Acid 5 mg — OD                          #30
   ↳ Common co-deficiency

4. Mefenamic Acid 500 mg — TDS during menstruation    PRN
   ↳ For dysmenorrhea / reduces menstrual blood loss
   ↳ Refer gynecology for definitive menorrhagia management

Advice:
- Iron-rich foods: dark leafy greens, legumes, fortified cereals
- Cook in cast iron pan
- Hemoglobin check at 4 weeks (expect 1–2 g/dL rise/month)
- Continue iron 3 months AFTER Hb normalizes (replenish stores)
- Explore cause: always rule out GI blood loss in older patients

Follow-up: 4 weeks with CBC
────────────────────────────────────────────────────

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---

ADDITIONAL SPECIALTY CASES

---

Case 26: Chronic Kidney Disease (CKD Stage 3)

• Known DM type 2 (10 years) and HTN
• Recent labs: Creatinine 200 μmol/L, eGFR 38 mL/min/1.73m²
• Pedal edema, nocturia
• No hematuria, no frothy urine (patient not checked)
• Medications: Metformin (currently taking), Amlodipine

• BP: 152/94 | Bilateral pedal edema (+2)
• Pallor, no asterixis
• Fundoscopy: Grade II hypertensive retinopathy

• Urine ACR (albumin:creatinine ratio)
• Urine R/E/M/C (casts, proteinuria)
• Serum electrolytes (hyperkalemia)
• CBC (normocytic anemia of CKD)
• PTH, Calcium, Phosphate, Vit D (mineral bone disease)
• Renal ultrasound (size, echogenicity, obstruction)
• Referral: nephrology

Rx
────────────────────────────────────────────────────
1. Tab. Losartan 50 mg — OD (morning)               #30
   ↳ ARB: renoprotective in DM; ↓ proteinuria
   ↳ Monitor K+, creatinine at 2 weeks after starting
   ↳ Accept up to 30% creatinine rise (expected with ARB)

2. Tab. Amlodipine 5 mg — OD                        #30
   ↳ BP target: <130/80 mmHg in CKD

3. STOP Metformin (eGFR <30 contraindicated; at eGFR 38: use with caution)
   ↳ Switch to: Sitagliptin 50 mg OD (dose-adjusted for CKD)
   ↳ OR Linagliptin 5 mg OD (no renal dose adjustment)

4. Tab. Frusemide 40 mg — OD (for edema)            #30
   ↳ Loop diuretic: more effective than thiazide in CKD

5. Tab. Ferrous Sulfate 200 mg — BD                  #60
   ↳ Treat IDA (anemia of CKD)
   ↳ Refer nephrology if ESA (erythropoietin) needed

6. Tab. Calcium Carbonate 500 mg — TDS with meals    #90
   ↳ Phosphate binder + calcium supplement
   ↳ Also: Calcitriol 0.25 mcg OD (active Vit D - if low)

Advice:
- Low-protein diet (0.8 g/kg/day)
- Low-potassium diet (avoid banana, potato, tomato)
- Restrict phosphate (avoid processed foods, cola)
- AVOID NSAIDs, contrast dye, aminoglycosides
- Nephrology referral for CKD management planning

Follow-up: 4 weeks with labs
────────────────────────────────────────────────────

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Case 27: Dyslipidemia

• Asymptomatic; found high cholesterol on routine screening
• Diet: high in saturated fats, processed food
• Sedentary, desk job, non-smoker
• No personal/family history of premature CVD
• BP normal; no DM

• BMI: 28 | BP: 126/80 | HR: 74
• No xanthelasma, no corneal arcus (suggest familial hypercholesterolemia if present)
• No tendon xanthomas

• Fasting lipid profile (repeat to confirm)
• Calculate 10-year CVD risk (Framingham / SCORE)
• HbA1c, FBG (exclude DM)
• TFTs (hypothyroidism causes dyslipidemia)
• LFTs (before statin therapy)

Rx
────────────────────────────────────────────────────
1. Tab. Atorvastatin 20 mg — OD (night)             #30
   ↳ High/moderate-intensity statin
   ↳ First-line for elevated LDL
   ↳ Monitor: CK (if myalgia), LFTs at 3 months
   ↳ Increase to 40–80 mg if LDL target not reached
   ↳ LDL target: <2.6 mmol/L (low risk); <1.8 (high CVD risk)

2. Cap. Omega-3 1000 mg — BD (after meals)          #60
   ↳ For hypertriglyceridemia (TG > 5.6: add Fenofibrate)
   ↳ Tab. Fenofibrate 145 mg OD - if TG very high

3. Tab. Ezetimibe 10 mg — OD (morning)              #30
   ↳ Add if LDL target not achieved on statin alone

Advice:
- Mediterranean diet (key lifestyle intervention)
- Exercise 150 min/week
- Reduce alcohol, saturated fat, sugar
- Target LDL <2.6 mmol/L (low-intermediate risk)
- Stop statins if CK >5x normal or AST/ALT >3x normal

Follow-up: 6–12 weeks with lipid profile
────────────────────────────────────────────────────

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Case 28: Allergic Rhinitis

• Persistent nasal congestion, rhinorrhea (clear watery)
• Sneezing (10–20 episodes in morning)
• Bilateral watery, itchy eyes
• Postnasal drip, throat clearing
• Year-round symptoms (perennial) + worse April-June (seasonal)
• History of asthma, atopic eczema

• "Allergic salute" (transverse nasal crease)
• Pale bluish inferior turbinate hypertrophy
• Clear nasal discharge
• Cobblestone appearance of posterior pharynx (lymphoid hyperplasia)
• Mild conjunctival injection, periorbital puffiness

• Skin prick test / Specific IgE (allergen identification)
• Nasal smear (eosinophils)
• Total IgE
• Consider spirometry (co-existing asthma)

Rx
────────────────────────────────────────────────────
1. Mometasone Furoate 50 mcg Nasal Spray
   — 2 sprays each nostril OD                       #1 bottle
   ↳ Intranasal corticosteroid: MOST EFFECTIVE Rx
   ↳ Onset: 1–2 weeks; continue 4+ weeks
   ↳ Correct technique: spray away from nasal septum

2. Tab. Loratadine 10 mg — OD                       #30
   ↳ Non-sedating antihistamine (H1 antagonist)
   ↳ Alternative: Cetirizine 10 mg OD
   ↳ Fexofenadine 180 mg OD (truly non-sedating)

3. Xylometazoline 0.1% Nasal Spray — BD x MAX 5 days  PRN
   ↳ Decongestant: only for acute severe blockage
   ↳ Do NOT use >5 days (rhinitis medicamentosa)

4. Sodium Cromoglicate 2% Eye Drops
   — 1 drop each eye QID                            #1 bottle
   ↳ For allergic conjunctivitis

Advice:
- Allergen avoidance (HEPA filter, dust mite covers)
- Allergen immunotherapy (subcutaneous/sublingual) if inadequate control
- Nasal saline irrigation (Neti pot) BD

Follow-up: 4 weeks
────────────────────────────────────────────────────

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Case 29: Insomnia (Primary/Chronic)

• Difficulty initiating sleep (lying awake 1–2 hours)
• Multiple awakenings at night, unable to return to sleep
• Early morning wakening
• Total sleep: 4–5 hours/night
• Daytime fatigue, mood irritability, cognitive impairment
• No sleep apnea symptoms (no snoring, no witnessed apneas)
• Alcohol: occasionally uses alcohol to sleep (warn about dependence)

• Clinically normal
• Epworth Sleepiness Scale: 10/24
• Exclude: depression (PHQ-9), anxiety (GAD-7), thyroid disease

Rx
────────────────────────────────────────────────────
FIRST LINE:
1. Cognitive Behavioral Therapy for Insomnia (CBT-I)
   ↳ Most effective long-term treatment
   ↳ Refer to psychologist or CBT-I app (Sleepio, Somryst)

SHORT-TERM PHARMACOLOGICAL (max 4 weeks):
2. Tab. Melatonin 2–5 mg — OD (30 min before bedtime)  #28
   ↳ Resets circadian rhythm; safe, minimal dependence
   ↳ Best for delayed sleep phase

3. Tab. Zolpidem 5–10 mg — OD (before bed) PRN         #14
   ↳ Only short-term (max 4 weeks)
   ↳ Risk: dependence, falls in elderly, next-day sedation

   OR Tab. Mirtazapine 7.5–15 mg — OD (night)          #30
   ↳ Sedating antidepressant; good if co-morbid depression/anxiety

   OR Tab. Doxepin 3–6 mg — OD (night)                 #30
   ↳ Approved specifically for sleep maintenance insomnia

AVOID: Benzodiazepines long-term (dependency, cognitive impairment)

Advice:
- Sleep Hygiene: fixed wake time, no screens 1h before bed
- No caffeine after 2 PM; no alcohol as sleep aid
- Cool, dark, quiet bedroom
- "Stimulus control": bed only for sleep and sex
- Sleep restriction therapy (under CBT-I guidance)

Follow-up: 4 weeks
────────────────────────────────────────────────────

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Case 30: Vitamin D Deficiency

• Diffuse musculoskeletal pain, lower back, legs
• Fatigue, muscle weakness (proximal - difficulty climbing stairs)
• Minimal sun exposure (office worker, covers skin for religious reasons)
• Postpartum (breastfeeding - 6 months)
• Mild hair loss

• Proximal muscle weakness
• Bone tenderness over sternum, tibia
• No tetany, no Chvostek/Trousseau sign

• 25-OH Vitamin D level (goal: >50 nmol/L)
  • Deficiency: <25 nmol/L
  • Insufficiency: 25–50 nmol/L
• Serum calcium, phosphate (hypocalcemia in severe deficiency)
• Alkaline phosphatase (elevated in osteomalacia)
• PTH (secondary hyperparathyroidism)
• FBC (exclude other causes of fatigue)
• TSH (co-existing hypothyroidism)

Rx
────────────────────────────────────────────────────
LOADING/REPLETION (for deficiency <25 nmol/L):
1. Cap. Cholecalciferol (Vit D3) 50,000 IU
   — Once weekly x 8 weeks                          #8
   ↳ Loading dose regimen

   THEN maintenance:
   Cap. Cholecalciferol 1000–2000 IU — OD ongoing  #90

   OR Stoss Therapy (single dose):
   300,000 IU IM injection once (if compliance concern)

2. Tab. Calcium Carbonate 500 mg — BD (with meals)  #60
   ↳ Especially if dietary calcium intake is low
   ↳ Not needed if dietary calcium is adequate

3. Sachet Calcium + Vitamin D3 (e.g., Shelcal)
   — 1 sachet BD (combines both)                    #60
   ↳ Convenient combination for compliance

Advice:
- 15–30 min sun exposure (face + arms) 3–4x/week (morning)
- Dietary sources: fatty fish, egg yolks, fortified milk
- Recheck 25-OH Vit D in 3 months
- If calcium low: treat simultaneously

Follow-up: 3 months with repeat Vit D level
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QUICK REFERENCE TABLE - 30 Adult OPD Cases Summary

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CLINICAL PRESCRIBING PRINCIPLES (Key for OPD Practice)

The 5 Rights of Prescribing

1. Right Drug - Based on diagnosis, evidence, guidelines
2. Right Dose - Check renal/hepatic function, weight, age
3. Right Route - Oral first; IV only when necessary
4. Right Time/Frequency - OD for better adherence over TDS
5. Right Duration - Complete the course; avoid indefinite prescribing

Common OPD Drug Safety Points

Antibiotic Stewardship Reminders

• Viral URTI / Common cold: No antibiotics (self-limiting)
• Uncomplicated UTI: Nitrofurantoin / Trimethoprim (NOT fluoroquinolones)
• Community pneumonia: Amoxicillin ± Azithromycin (NOT broad-spectrum unless severe)
• Acute pharyngitis (Strep): Amoxicillin 500 mg TDS x 10 days (if Group A Strep confirmed)
• Skin infections (non-purulent): Amoxicillin-Clavulanate / Cefalexin

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Educational Disclaimer: All prescriptions and dosages presented are for educational and training purposes only. Clinical prescribing must always be individualized to the patient's specific clinical situation, laboratory values, comorbidities, drug allergies, pregnancy status, local antibiograms, and current institutional guidelines. Never administer medications based solely on educational material without a proper clinical evaluation.

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What's Covered (30 Cases Across 8 Specialties)

Cardiovascular (3 cases)

• Essential Hypertension (Stage 1)
• HTN with Diabetes (dual management)
• Stable Angina (Chronic Coronary Syndrome)

Endocrine / Metabolic (4 cases)

• Type 2 DM (newly diagnosed)
• Hypothyroidism (Hashimoto's)
• Hyperthyroidism (Graves' Disease)
• Dyslipidemia (mixed)

Respiratory (3 cases)

• Bronchial Asthma (Moderate Persistent, GINA Step 3)
• COPD (Moderate, GOLD B)
• Pulmonary Tuberculosis (DOTS regimen)

Gastroenterology (3 cases)

• Peptic Ulcer Disease / GERD (with H. pylori eradication)
• IBS - Diarrhea Predominant
• Acute Gastroenteritis

Neurology (2 cases)

• Migraine with Aura
• Tension-Type Headache

Musculoskeletal / Rheumatology (3 cases)

• Osteoarthritis (Knee)
• Acute Gout + Urate-lowering therapy
• Early Rheumatoid Arthritis (DMARD therapy)

Infectious Disease (3 cases)

• Community-Acquired Pneumonia
• Uncomplicated UTI (Female)
• Uncomplicated Malaria (P. vivax)

Dermatology (2 cases)

• Tinea Corporis
• Atopic Dermatitis

Mental Health (2 cases)

• Major Depressive Disorder (Moderate)
• Panic Disorder

Other (3 cases)

• Iron Deficiency Anemia
• CKD Stage 3
• Vitamin D Deficiency / Allergic Rhinitis / Insomnia

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• Detailed history and clinical presentation
• Examination findings
• Working diagnosis with classification
• Investigations to order
• Sample prescription with dosing rationale and warnings
• Key teaching points and safety alerts