Medicines for Headache

1. Tension-Type Headache (Most Common)

Warning: Avoid taking analgesics more than 10-15 days/month. Overuse of paracetamol, NSAIDs, opioids, or triptans can cause medication overuse (rebound) headache - a chronic daily headache pattern. - Bradley and Daroff's Neurology in Clinical Practice

2. Migraine Headache

Non-Specific (Mild-Moderate Attacks)

Migraine-Specific (Moderate-Severe Attacks)

Triptans are more effective than simple analgesics, especially for disabling migraines. They work best taken early. - Bradley and Daroff's Neurology in Clinical Practice

Contraindications for triptans/DHE: ischemic heart disease, uncontrolled hypertension, basilar or hemiplegic migraine.

For Nausea/Vomiting (Adjuncts)

3. Cluster Headache (Severe, Unilateral, Periorbital)

Key Principle: Stratified vs. Step-Care

Medicines for One-Sided (Migraine) Headache

What Is It?

PART 1 - Medicines to STOP an Attack (Acute/Abortive Treatment)

Step 1 - Mild to Moderate Pain: Simple Analgesics (OTC)

Step 2 - Moderate to Severe Pain: Triptans (Most Effective)

Subcutaneous sumatriptan gives the fastest and strongest relief. Oral forms are cheaper and more convenient.

Contraindications for triptans: ischemic heart disease, uncontrolled high blood pressure, history of stroke, basilar or hemiplegic migraine.

Step 3 - Newer Alternative: Lasmiditan

• Lasmiditan (oral) - a selective 5-HT1F agonist with NO vasoconstrictive properties
• Comparable efficacy to triptans
• Safer for patients with heart disease (unlike triptans)
• Can cause dizziness/drowsiness - do not drive for 8 hours after taking

Step 4 - If Nausea/Vomiting Present (Add These)

Step 5 - Ergotamine (Older Alternative)

Avoid if pregnant, heart disease, or used sumatriptan in the last 24 hours.

PART 2 - Medicines to PREVENT Attacks (Prophylaxis)

Preventive treatment should be continued for at least 6-12 months after stabilization. Full benefit may take up to 6 months to appear. - Bradley and Daroff's Neurology in Clinical Practice

Important Warning: Medication Overuse Headache

Body Shivering + Breathlessness - Why It Happens

Understanding Each Symptom

Shivering (Rigors/Chills)

• The brain's temperature "set point" is raised (as in fever/infection)
• The body is physically cold
• The nervous system is overwhelmed (shock, panic)

Breathlessness (Dyspnea)

• Lungs are infected or inflamed
• The heart is not pumping efficiently
• Blood oxygen drops
• The brain triggers rapid breathing (as in panic or fever)

Common Causes of Both Together

1. Pneumonia (Lung Infection) - Most Common Cause

• Symptoms: Fever + shaking chills (rigors) + cough + breathlessness + chest pain
• Cause: Streptococcus pneumoniae, viral pneumonia, COVID-19, etc.
• "The clinical presentation of pneumonia may include fever; sweats; rigors (chills); cough, sputum production, dyspnea, or pleurisy" - Fishman's Pulmonary Diseases
• "Characterized by abrupt onset of cough and dyspnea accompanied by fever, shaking chills" - Harrison's Principles of Internal Medicine

2. Sepsis (Severe Bloodstream Infection)

• Shivering from high fever or dangerously low temperature
• Breathlessness from lungs filling with fluid (ARDS) or low blood pressure
• Other signs: rapid heart rate, confusion, low blood pressure
• This is a medical emergency - requires urgent hospital treatment

3. Malaria

• The classic malaria attack: periodic shaking chills + high fever + sweating in cycles
• Dyspnea occurs as infection worsens (low red blood cells = less oxygen delivery)
• Caused by Plasmodium parasites transmitted by mosquitoes - Goldman-Cecil Medicine

4. Viral Infections (Flu, COVID-19, etc.)

• Influenza and COVID-19 commonly present with fever, chills/rigors, myalgia, cough, and dyspnea
• "Fever, chills, rigors, cough, dyspnea, tachypnea, pleuritic pain" are listed as typical presentations - Rosen's Emergency Medicine
• COVID-19 specifically can progress to severe breathlessness as it inflames lung tissue

5. Panic Attack / Severe Anxiety

• During intense fear or panic, the nervous system goes into overdrive
• Hyperventilation (rapid breathing) causes breathlessness sensation
• Muscle tremors and shivering occur from adrenaline surge
• Accompanied by: rapid heartbeat, chest tightness, dizziness, feeling of doom
• Usually resolves on its own; no fever

6. Anaphylaxis (Severe Allergic Reaction)

• Triggered by food, medicines, insect stings
• Causes: shivering, breathing difficulty, throat swelling, low blood pressure
• This is a life-threatening emergency - needs immediate adrenaline (epinephrine)

7. Pulmonary Embolism (Blood Clot in Lungs)

• A clot blocks blood flow in the lung arteries
• Causes sudden breathlessness, chest pain, and sometimes chills/fever
• Risk factors: long travel, surgery, immobility, cancer
• Urgent medical emergency

8. Heart Failure (Acute)

• The heart fails to pump properly - fluid backs up into the lungs
• Causes severe breathlessness, sometimes with chills from poor circulation
• Other signs: swollen ankles, pink frothy sputum, lying flat worsens breathing

9. Acute Hemolytic Transfusion Reaction (after blood transfusion)

• "Signs and symptoms include fever, chills/rigors, anxiety, chest and abdominal pain, dyspnea" - Goldman-Cecil Medicine
• Occurs when the body attacks transfused blood cells

Summary Table

When to See a Doctor IMMEDIATELY

• High fever (above 39°C / 102°F)
• Chest pain
• Lips or fingernails turning blue
• Confusion or loss of consciousness
• Rapid worsening of symptoms
• Known heart or lung disease

Body Shivering + Breathlessness: Causes & How to Overcome

PART 1 - WHY IT HAPPENS

The Basic Mechanism

PART 2 - MAIN CAUSES

1. Pneumonia (Lung Infection) - Most Common

• Infection in the lungs causes fever with shaking chills (rigors) and breathlessness from inflamed lung tissue
• Other signs: cough, chest pain, sputum
• "Pneumonia may include fever; sweats; rigors (chills); cough, dyspnea, pleurisy" - Fishman's Pulmonary Diseases

2. Sepsis (Severe Blood Infection)

• Bacteria in the bloodstream triggers a whole-body storm: fever/chills + rapid breathing + fast heart rate
• "Tachycardia, tachypnea, fever, and immune system activation are common manifestations. If the body is unable to overcome this insult, shock and multiorgan failure may ensue." - Rosen's Emergency Medicine
• This is a medical emergency

3. Flu / COVID-19 / Viral Infections

• Virus infects the airways causing fever, chills, body tremors, cough, breathlessness
• Usually self-limiting but can progress to severe pneumonia

4. Malaria

• Classic: periodic shaking chills + fever + sweating in cycles + breathlessness from low red blood cells

5. Panic Attack / Anxiety

• Adrenaline surge causes muscle tremors, hyperventilation (fast shallow breathing), chest tightness
• No fever; resolves without medicine in most cases

6. Asthma Attack

• Airways tighten, causing breathlessness + sometimes trembling from effort and fear
• Triggered by allergens, cold air, exercise, stress

7. Pulmonary Embolism (Blood Clot in Lung)

• Sudden severe breathlessness + chest pain + mild chills - a life-threatening emergency

PART 3 - HOW TO OVERCOME IT

Step 1 - First Aid at Home (Immediate Relief)

• Wrap yourself in a warm blanket
• Drink warm fluids (water, soup, herbal tea)
• Take paracetamol (500-1000 mg) or ibuprofen (400 mg) to bring down fever and reduce shivering
• Rest in a warm, comfortable environment

• Sit upright or lean slightly forward (tripod position) - this opens the airways
• Breathe slowly and deeply through the nose, out through the mouth
• Loosen any tight clothing around the chest
• Stay calm - anxiety worsens breathing difficulty
• Move to fresh air if indoors is stuffy

Step 2 - Treatment by Cause

Pneumonia / Bacterial Infection

"Prompt administration of antibiotics is essential and should be based on the suspected source of infection" - Rosen's Emergency Medicine

Sepsis (Hospital Treatment)

"Early treatment should focus on fluid resuscitation, oxygen, antibiotics, and early identification of infections requiring surgical management" - Rosen's Emergency Medicine

Panic Attack / Anxiety

Asthma Attack

Malaria

Step 3 - Supportive Care for Everyone

When to Go to Hospital IMMEDIATELY

• 🔴 Oxygen level below 94% on pulse oximeter
• 🔴 Fever above 39.5°C (103°F) not coming down with medicine
• 🔴 Lips or fingertips turning blue or grey
• 🔴 Chest pain or pressure
• 🔴 Confusion, difficulty speaking, drowsiness
• 🔴 Symptoms worsening rapidly
• 🔴 Known heart or lung disease

Summary

Medicines for Instant Relief from Constipation

FASTEST RELIEF (15 Minutes to 1 Hour) - Rectal Options

1. Glycerin Suppository

• How it works: Draws water into the rectum (osmotic effect) + mild stimulant
• Dose: 1 adult suppository inserted rectally
• Onset: 15-30 minutes
• Best for: Quick, gentle relief; safe for most people including elderly
• Available: Over the counter (OTC)

2. Bisacodyl Suppository (Dulcolax)

• How it works: Stimulates the rectal wall muscles directly, causing bowel contraction
• Dose: 1 suppository (10 mg) rectally
• Onset: 15-60 minutes
• Best for: Severe or stubborn constipation needing very fast relief
• Available: OTC

3. Enema (Sodium Phosphate / Fleet Enema)

• How it works: Liquid injected into the rectum softens and loosens stool instantly
• Dose: 1 adult enema rectally (118-133 mL)
• Onset: 2-15 minutes (fastest of all options)
• Caution: Avoid in kidney disease (risk of phosphate toxicity)
• Available: OTC

4. Soap Suds / Tap Water Enema

• Used in hospitals for immediate bowel clearance
• Works within minutes

FAST RELIEF (6-12 Hours) - Oral Stimulant Laxatives

5. Bisacodyl Oral (Dulcolax Tablet)

• How it works: Acts on the myenteric nerve plexus of the intestine - increases peristalsis (gut movement) and reduces water absorption from the colon
• Dose: 5-10 mg orally once daily
• Onset: 6-12 hours
• Grade of recommendation: A (strong evidence)
• Available: OTC

6. Senna (Senokot)

• How it works: Anthraquinone stimulant - increases intestinal peristalsis through nerve plexus stimulation
• Dose: 17.6-34.4 mg once daily (or 2 tablets twice daily)
• Onset: 6-12 hours
• Note: Less abdominal cramping compared to bisacodyl
• Available: OTC

7. Sodium Picosulfate

• How it works: Same as senna/bisacodyl - stimulant laxative
• Dose: 5-10 mg orally
• Onset: 6-12 hours

MODERATE RELIEF (1-3 Hours) - Osmotic Laxatives

8. Milk of Magnesia (Magnesium Hydroxide)

• How it works: Osmotic - pulls water into the gut; also stimulates gut hormones
• Dose: 15-30 mL once or twice daily
• Onset: 0.5-3 hours (one of the fastest oral options)
• Caution: Avoid in kidney disease (risk of high magnesium)
• Available: OTC

9. Magnesium Citrate

• Dose: 75-150 mL once daily
• Onset: 30 minutes to 3 hours
• Very effective for quick bowel clearance
• Available: OTC

10. Polyethylene Glycol / PEG (Miralax, Movicol)

• How it works: Osmotic - binds water in the colon, softens stool
• Dose: 17-34 g in water once or twice daily
• Onset: 1-3 days for regular use; 1-4 hours in high doses (bowel prep)
• Tasteless, odorless - mixes with any drink
• Causes less bloating and cramps than other agents
• Grade A evidence - first-line osmotic laxative
• Available: OTC

11. Lactulose

• Dose: 15-30 mL once or twice daily
• Onset: 2-3 days (slowest osmotic option - not ideal for instant relief)
• Side effects: gas and bloating from fermentation

PRESCRIPTION OPTIONS (When OTC Laxatives Fail)

Quick Comparison: Speed of Action

Simple Home Tips Alongside Medicines

• Drink a full glass of warm water as soon as you wake up - stimulates the gastrocolic reflex
• Try squatting position on the toilet (feet raised on a small stool) - straightens the anorectal angle and makes passing stool much easier
• Gentle abdominal massage in a clockwise direction
• Light walking or movement
• Warm prune juice (prunes have both osmotic and fiber-based laxative effects - Grade B evidence)

Important Cautions

• Do not use stimulant laxatives (bisacodyl, senna) daily for more than 1-2 weeks without medical advice - can cause dependence and a "lazy bowel"
• Avoid sodium phosphate enemas in kidney disease, heart failure, or elderly patients
• Avoid magnesium-based laxatives in kidney disease
• If constipation is new, severe, or accompanied by blood in stool, weight loss, or abdominal pain - see a doctor to rule out a serious underlying cause

"Stimulant agents (bisacodyl, senna) should be reserved for patients who do not respond to fiber or osmotic laxatives" - Sleisenger & Fordtran's Gastrointestinal and Liver Disease

How to Get Relief from Varicose Veins

What Are Varicose Veins?

STEP 1 - Conservative (Non-Surgical) Relief at Home

1. Compression Stockings (Most Important)

• Wear graduated elastic compression stockings - they squeeze the legs from ankle upward, pushing blood back up toward the heart
• Compression levels:
  • 20-30 mmHg - mild varicose veins, daily wear
  • 30-40 mmHg - moderate-severe varicose veins or swelling
  • 40-50 mmHg - severe cases, venous ulcers
• Wear from morning (before getting up) to bedtime
• Choose knee-high or thigh-high depending on where the veins are
• "Elastic compression provides sufficient relief of symptoms in many symptomatic patients" - Schwartz's Principles of Surgery
• Guidelines recommend superficial venous intervention over long-term compression stockings for candidates who are fit for procedures (strong recommendation, moderate evidence)

2. Leg Elevation

• Elevate legs above heart level for 15-20 minutes, 3-4 times daily
• Sleep with a pillow under your legs
• This drains pooled blood and reduces swelling and aching immediately

3. Exercise and Movement

• Walking is the best exercise - activates the calf muscle pump which pushes blood upward
• Avoid prolonged standing or sitting in one position
• Take breaks every 30-60 minutes to walk or flex/point your feet
• Swimming and cycling are also excellent - reduce leg pressure while strengthening the pump

4. Weight Management

• Losing excess weight reduces pressure on leg veins significantly

5. Avoid Heat

• Hot baths, saunas, and direct heat cause veins to dilate further and worsen symptoms
• Cool water on the legs can provide temporary relief

6. Posture Changes

• When sitting, avoid crossing your legs - it restricts circulation
• Use a footrest to keep legs slightly elevated at your desk

STEP 2 - Medicines for Symptom Relief

"Treatment of superficial thrombophlebitis consists of compression with a firm elastic support, pain relief with analgesics, and reduction of inflammation by non-steroidal anti-inflammatory agents for 7 days" - Pye's Surgical Handicraft

STEP 3 - Minimally Invasive Medical Procedures

1. Sclerotherapy (Injection Treatment)

• A sclerosant chemical (polidocanol, sodium tetradecyl sulfate, hypertonic saline) is injected directly into the vein
• The chemical destroys the vein's inner lining, causing it to scar shut and disappear
• The leg is firmly bandaged/compressed for 3-5 days after injection
• Foam sclerotherapy (sclerosant mixed with air) is used for larger veins - randomized trials show significant symptom relief and improved cosmetic appearance
• Best for: small-to-medium varicose veins and spider veins (telangiectasias)
• Complications: skin pigmentation, allergic reaction, rare skin necrosis, DVT

2. Endovenous Laser Ablation (EVLA)

• A thin laser fiber is inserted into the vein under ultrasound guidance
• Laser energy heats and closes the vein from inside
• No surgical cut needed; done under local anaesthetic
• Equally effective as surgery but with faster recovery
• Best for: great saphenous vein (GSV) or small saphenous vein (SSV) reflux
• Complications: bruising, DVT, nerve injury (rare)

3. Radiofrequency Ablation (RFA)

• Similar to laser but uses radiofrequency energy (heat) to close the vein
• The RFA catheter (e.g. ClosureFast system) is guided inside the vein by ultrasound and withdrawn as it treats
• "RFA and EVLA techniques have long track records of safety and efficacy" - Current Surgical Therapy
• Both RFA and EVLA are now preferred over open surgery for most patients

4. Cyanoacrylate Glue Injection (VenaSeal)

• A medical-grade adhesive is injected to seal the vein shut
• No heat, no tumescent anaesthetic needed
• Non-thermal, non-sclerosant - promising newer technique
• Very well tolerated; minimal downtime

STEP 4 - Surgical Treatment (For Severe Cases)

1. High Ligation and Stripping

• The great saphenous vein is tied off at the groin (saphenofemoral disconnection) and physically stripped/removed down to the knee
• Done under general or spinal anaesthesia
• "For long saphenous incompetence, a sapheno-femoral disconnection is essential. It is preferable to strip the long saphenous vein down to the knee to remove mid-thigh perforating veins" - Pye's Surgical Handicraft
• Visible surface varicose veins are removed through tiny incisions (avulsion technique)

2. Phlebectomy (Ambulatory/Micro-Phlebectomy)

• Tiny hook instruments remove varicose veins through very small punctures in the skin
• Can be done alongside laser/RFA or alone
• Fast recovery, minimal scarring

Summary: Which Treatment for Which Situation?

When to See a Doctor Urgently

• Leg suddenly becomes very painful, red, and swollen along a vein (thrombophlebitis)
• An open sore or ulcer develops on the leg (venous ulcer)
• A varicose vein bursts and bleeds (apply firm direct pressure and elevate the leg immediately, then go to hospital)
• Leg becomes severely swollen, hot, and tender (may indicate deep vein thrombosis - DVT)

Naproxen + Telmikind (Telmisartan) - Can They Be Taken Together?

What Are These Drugs?

The Answer: Use With Caution - Significant Interaction Exists

Why the Interaction Happens - The Mechanism

Problem 1: NSAIDs Raise Blood Pressure and Reduce Telmisartan's Effect

• NSAIDs like naproxen inhibit prostaglandins (COX-1 and COX-2 enzymes)
• Prostaglandins cause sodium and water excretion from the kidneys
• When prostaglandins are blocked, the kidneys retain more sodium and water
• This raises blood volume and counteracts the blood pressure-lowering effect of Telmisartan
• "NSAIDs are associated with a relatively modest increase in mean blood pressure of 5 mmHg, but the increase can be more pronounced in patients with a history of hypertension controlled with antihypertensive medications" - Frameworks for Internal Medicine

Problem 2: The "Triple Whammy" - Risk of Acute Kidney Injury

1. An ARB (Telmisartan) - blocks angiotensin II, which normally helps maintain kidney blood flow
2. An NSAID (Naproxen) - reduces prostaglandins that also protect kidney blood flow
3. Any diuretic (if also prescribed, e.g. hydrochlorothiazide in combination tablets like Telmikind-H)

• NSAIDs inhibit prostaglandin-mediated renin release, disrupting the renin-angiotensin-aldosterone system (RAAS)
• ARBs already block angiotensin II receptors in the kidney
• Together, both protective mechanisms are removed, leaving the kidney vulnerable

Problem 3: Hyperkalemia (High Potassium)

• NSAIDs inhibit prostaglandin-mediated renin release → less aldosterone → potassium builds up in the blood
• ARBs like Telmisartan also reduce aldosterone → further raise potassium
• Combined use significantly increases the risk of dangerous hyperkalemia (high potassium), especially in patients with kidney disease, diabetes, or older age
• "NSAIDs inhibit prostaglandin-mediated renin release. This effect can predispose to hyperkalemia, particularly in the presence of kidney disease" - Morgan & Mikhail's Clinical Anesthesiology

Summary of Risks

When Is It Relatively Safe?

• Young, otherwise healthy patients with normal kidney function
• When naproxen is used only for a few days (e.g. for acute pain or fever)
• When blood pressure and kidney function are monitored during use

When Should It Be Avoided?

• Chronic kidney disease (CKD)
• Elderly patients (kidneys are more vulnerable)
• Patients also taking a diuretic (thiazide or furosemide) - the "triple whammy" risk
• Heart failure patients
• Dehydrated patients
• Patients with poorly controlled blood pressure

Safer Alternatives to Naproxen in a Telmisartan Patient

What to Do If Both Are Prescribed

1. Tell your doctor you are on both - ensure they are aware
2. Take naproxen only as long as necessary - shortest dose, shortest duration
3. Stay well hydrated - do not take NSAIDs when dehydrated or fasting
4. Monitor blood pressure at home
5. Watch for warning signs of kidney problems: reduced urine output, swelling of ankles, tiredness, dark urine - seek care immediately
6. Avoid adding a diuretic unless closely supervised

Medicines for Bloating and Gas (Stomach)

Why Does It Happen?

• Excess gas accumulates in the stomach or intestines (from swallowed air, bacterial fermentation of food, or poor digestion)
• Slow gastric emptying - food stays in the stomach too long, producing gas
• Acid excess - too much stomach acid causes bloating and discomfort
• Gut sensitivity - the gut feels distended even with normal gas amounts (functional dyspepsia, IBS)
• Food intolerances - lactose or gluten causing fermentation and gas

CATEGORY 1 - Anti-Gas / Antiflatulent Medicines (Fastest Relief)

1. Simethicone (Gas-X, Gelusil Gas, Dimethicone)

• How it works: Breaks up large gas bubbles in the stomach and intestines into smaller ones, making them easier to pass
• Dose: 40-125 mg after meals and at bedtime
• Onset: Within 30 minutes
• Available: OTC - tablets, chewable tablets, drops
• Safety: Very safe - not absorbed into the bloodstream; safe for all ages including infants (infant drops)
• Best for: Immediate gas relief after meals, infant colic

2. Activated Charcoal

• How it works: Adsorbs (binds) gas-producing substances in the gut
• Dose: 500 mg capsules as directed
• Note: Less consistent evidence; may reduce other drug absorption if taken at same time
• Available: OTC

3. Alpha-Galactosidase (Beano)

• How it works: Enzyme that breaks down complex sugars (raffinose, stachyose) in beans, vegetables, and whole grains that bacteria would otherwise ferment into gas
• Dose: Take just before eating gas-producing foods
• Best for: Preventing gas from beans, lentils, broccoli, cabbage

CATEGORY 2 - Antacids (For Gas + Acidity Together)

Many antacid products (like Gelusil MPS, Digene Gas) already contain simethicone combined with antacid - these cover both gas and acidity together and are very popular OTC choices.

CATEGORY 3 - Prokinetics (For Bloating from Slow Stomach Emptying)

1. Domperidone (Motilium, Domstal)

• How it works: Blocks dopamine D2 receptors in the gut, enhancing gastric contractions and speeding up gastric emptying; also reduces nausea
• Dose: 10 mg before meals (3 times daily)
• Best for: Post-meal bloating, fullness, nausea
• Note: Meta-analyses show significant benefit for postprandial fullness and early satiation over placebo - Yamada's Textbook of Gastroenterology
• Caution: Associated with QT interval prolongation - avoid in patients with heart rhythm problems; not available in the USA

2. Metoclopramide (Maxolon, Perinorm)

• How it works: Same as domperidone (D2 antagonist) + 5-HT4 agonist; speeds gastric emptying and reduces nausea
• Dose: 10 mg before meals
• Caution: Can cause neurological side effects (restlessness, drowsiness, dystonia) in 10-20% of patients; long-term use should be avoided - Katzung's Pharmacology; has a black box warning for neurological adverse events
• Best for: Short-term use for acute bloating with nausea

3. Acotiamide (Acogut - available in India and Japan)

• How it works: Newer prokinetic; enhances acetylcholine at gut nerve synapses, improving gastric accommodation and emptying
• Better tolerated than metoclopramide with fewer neurological side effects
• Approved for functional dyspepsia in India (2018) and Japan
• Yamada's Textbook of Gastroenterology

CATEGORY 4 - Acid Reducers (For Bloating from Excess Acid / GERD)

H2 Blockers (Moderate Acid Reduction)

Proton Pump Inhibitors - PPIs (Strongest Acid Reduction)

PPIs are best when bloating is associated with frequent acidity, GERD, or H. pylori infection.

CATEGORY 5 - Enzyme Supplements (For Bloating from Poor Digestion)

CATEGORY 6 - Probiotics (For Chronic / Recurring Bloating)

CATEGORY 7 - Antispasmodics (For Bloating + Cramping, IBS)

Quick Summary: Which Medicine for Which Situation?

Simple Home Measures Alongside Medicine

• Eat slowly and chew food thoroughly (less swallowed air)
• Avoid carbonated drinks, chewing gum, straws
• Reduce gas-producing foods: beans, lentils, broccoli, cabbage, onions, fizzy drinks
• Walk for 10-15 minutes after meals (speeds digestion)
• Warm water or ginger tea can help expel gas naturally
• Avoid lying down immediately after eating

Common temporary reasons

• Not drinking enough water, causing concentrated urine
• Fever or recent infection
• Heavy exercise
• Stress
• Standing for long periods
• Urinary tract infection, especially if burning urine, urgency, fever, or blood is present
• Vaginal discharge or menstrual blood contaminating the sample

When it may need attention

• Diabetes
• High blood pressure
• Kidney disease
• Pregnancy, particularly with high blood pressure, headache, visual symptoms, or swelling
• Autoimmune disease such as lupus

What to do next

1. Repeat a clean-catch early-morning urine test in 1-2 weeks, when you are well hydrated and have not done strenuous exercise for 24-48 hours.
2. If protein is still present, ask for:
   • Urine albumin-to-creatinine ratio, called UACR
   • Blood creatinine and eGFR kidney-function test
   • Blood pressure and blood sugar check
   • Urine microscopy, especially if there is blood or infection symptoms
     A UACR of 30 mg/g or less is generally normal; repeated values above this may indicate kidney disease, per NIDDK CKD testing information.

Seek medical care promptly if

• Swelling of feet, face, or eyelids
• Foamy urine that persists
• Blood in urine
• Reduced urine output
• High blood pressure
• Fever with back pain or painful urination
• You are pregnant and have protein in urine, high BP, headache, visual changes, or upper abdominal pain

• Chest pain or pressure
• Severe breathlessness
• Fainting, dizziness, confusion, marked weakness
• Cold sweating, pale/clammy skin
• Low blood pressure
• Known heart disease, pregnancy, or age over 60

1. Have the patient sit or lie down and rest.
2. Avoid caffeine, nicotine, alcohol, cold medicines/decongestants, and exertion.
3. Check temperature, blood pressure, oxygen saturation, and blood sugar if equipment is available.
4. If they are fully awake, not short of breath, and the fast pulse is regular and sudden in onset, a clinician may advise a Valsalva maneuver: bear down as if passing stool for 10-15 seconds, then relax. Do not do carotid-neck massage yourself.
5. If the patient becomes unconscious or is not breathing normally, start CPR and call emergency services.

1. Take her to fresh air right away. Open doors and windows. Do not let anyone stay in the room to clean it without ventilation.
2. Keep her sitting upright, loosen tight clothing, and keep her calm.
3. Do not give medicines, milk, lemon, or induce vomiting.
4. If phenyl touched the skin, remove contaminated clothing and rinse skin under running water for at least 15 minutes.
   If it went into the eyes, rinse continuously with clean water for 15-20 minutes.
5. Go to an emergency department now / call emergency services if she has any cough that persists, wheezing, throat or chest burning, shortness of breath, vomiting, dizziness, drowsiness, confusion, fainting, or if exposure occurred in a closed room or was more than a brief smell.
6. Take the phenyl bottle/container or a photo of its label to the hospital. “Phenyl” products vary and may contain phenol, cresols, or other chemicals.

• Fever, cough, sputum, shortness of breath, chest pain
• Oxygen saturation, pulse, breathing rate
• Chest examination for focal crackles/consolidation
• The full X-ray report, specifically whether there is an infiltrate, consolidation, pleural effusion, or collapse
• COVID/flu testing where appropriate
• Asthma history, wheeze, smoking/vaping, allergy, TB exposure

What she should do

• Temperature, pulse, breathing rate, oxygen saturation
• Chest examination
• Review of the full X-ray report
• COVID-19 and influenza testing if appropriate
• Pregnancy status and drug-allergy history before any prescription

• Rest and fluids
• Paracetamol for fever/body ache, if safe for her
• Warm fluids and steam for nasal congestion
• Avoid smoking, vaping, and unnecessary antibiotics

What to do for dengue

• Drink frequent oral fluids or ORS, unless a doctor has restricted fluids.
• Use paracetamol/acetaminophen only for fever and pain, within the dose advised by the doctor.
• Avoid aspirin, ibuprofen, naproxen, diclofenac, and other NSAID painkillers because dengue can lower platelets and increase bleeding risk. The WHO dengue advice also recommends paracetamol and avoiding NSAIDs.
• Monitor daily or as advised: platelet count, hematocrit, urine output, blood pressure, and hydration. Falling fever around days 3-7 is sometimes when the critical phase begins, not necessarily recovery.

Go to hospital immediately if there is

• Severe or persistent abdominal pain
• Repeated vomiting or inability to drink
• Nose/gum bleeding, vomiting blood, black stool, or blood in urine
• Extreme weakness, restlessness, drowsiness, fainting
• Cold/clammy hands and feet, reduced urine, severe dizziness
• Breathing difficulty
• Rapidly falling platelets or rising hematocrit