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OPD Patient Case Compendium - Multi-Specialty Exam Preparation Guide

How to Use This Guide: Each case follows full SOAP format (Subjective - Objective - Assessment - Plan), with differentials, investigation findings, a model prescription, and a teaching summary. Cases span General Medicine, Cardiology, Respiratory, Gastroenterology, Nephrology/Urology, Dermatology, Pediatrics, ENT, Ophthalmology, and Orthopedics.

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HOW TO WRITE A PROPER OPD CASE NOTE (Template)

Date:                          OPD No.:
Clinic:                        Attending:

PATIENT DETAILS
Name: ___________   Age: ___   Sex: ___   Occupation: ___   Address: ___

CHIEF COMPLAINT (CC): [Main symptom + duration]

HISTORY OF PRESENT ILLNESS (HPI):
  - Onset, Duration, Character, Location, Radiation, Severity (1-10)
  - Aggravating/Relieving factors
  - Associated symptoms
  - Previous episodes / prior treatment

PAST MEDICAL HISTORY (PMH): ___
SURGICAL HISTORY: ___
DRUG HISTORY / ALLERGIES: ___
FAMILY HISTORY: ___
SOCIAL HISTORY (smoking, alcohol, diet, occupation): ___
REVIEW OF SYSTEMS (ROS): ___

EXAMINATION:
  General: Appearance, built, nourishment, pallor, icterus, cyanosis,
           clubbing, lymphadenopathy, edema
  Vitals: BP:    HR:    RR:    Temp:    SpO2:    Weight:    BMI:
  Systemic examination (relevant system)

INVESTIGATIONS: [Results]

DIAGNOSIS (Working + Differential):
  1. Working:
  2. Differentials:

PLAN & PRESCRIPTION:
  Non-pharmacologic:
  Pharmacologic: [Rx written below]
  Follow-up:

PRESCRIPTION:
─────────────────────────────────────────────────
Dr. [Name], MBBS/MD
Registration No.: ___
Date: ___
Patient: ___   Age: ___

Rx

1. Drug name  dose  route  frequency  duration
2. ...

Investigations: ___
Advice: ___
Review: ___
─────────────────────────────────────────────────

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CASE 1 - ESSENTIAL HYPERTENSION (Newly Diagnosed)

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SUBJECTIVE

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OBJECTIVE

• FBC: Normal
• Renal profile: Cr 0.9 mg/dL, eGFR 88, K+ 4.1, Na+ 139
• Fasting glucose: 5.2 mmol/L (94 mg/dL) - normal
• Lipid profile: LDL 3.6 mmol/L (high), HDL 1.1, TG 2.1
• Urinalysis: Protein trace, no casts
• ECG: LVH by voltage criteria (Sokolow-Lyon: SV1 + RV5 = 36 mm)
• Echo (ordered): Pending

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ASSESSMENT

• BP ≥140/90 = Stage 2
• No identifiable secondary cause on initial workup

1. Secondary hypertension - Renal parenchymal (excluded: normal Cr, no casts)
2. Renovascular hypertension (no bruit, but keep in mind if refractory)
3. Primary hyperaldosteronism (check if K+ falls or resistant HTN)
4. White coat hypertension (less likely given bilateral + retinopathy changes)

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PLAN

• DASH diet: reduce sodium to <2g/day, increase fruits/vegetables
• Aerobic exercise 30 min/day, 5 days/week
• Alcohol restriction (<14 units/week)
• Stress management / relaxation techniques
• Weight reduction target BMI <25

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PRESCRIPTION

─────────────────────────────────────────────────────
Dr. A. Sharma, MBBS, MD (Medicine)
Reg. No.: MCI/12345
Date: 31-May-2026
Patient: Mr. Ramesh Kumar, 48M
Wt: 78 kg | BP at visit: 162/98 mmHg | Allergies: NKDA

Rx

1. Tab. Amlodipine 5 mg                 1-0-0     (for 30 days)
   [Calcium channel blocker; first-line for hypertension]

2. Tab. Atorvastatin 20 mg              0-0-1     (for 30 days)
   [Statin for LDL lowering; take at night]

3. Tab. Aspirin 75 mg                   1-0-0     (for 30 days)
   [Low-dose for high CV risk - after stabilization of BP >160 - to start
   once BP controlled to avoid hemorrhagic stroke risk]
   *** DO NOT start aspirin until BP <150/90 ***

Investigations:
- ABPM (Ambulatory Blood Pressure Monitoring) - to confirm white coat HTN excluded
- Renal ultrasound (Doppler) - screen renovascular cause
- Echo - assess LVH
- Fasting lipid profile repeat in 6 weeks (statin monitoring)
- HbA1c (baseline screen)

Advice:
- Low-salt DASH diet. Avoid pickles, processed foods.
- Walk 30 min daily.
- Return immediately if: severe headache, chest pain, visual changes, weakness.

Review: 4 weeks
─────────────────────────────────────────────────────

Teaching Point: For Stage 2 HTN, most guidelines now recommend starting pharmacotherapy alongside lifestyle modification immediately. Amlodipine is preferred over thiazides in patients with LVH (diltiazem/verapamil if angina co-exists). An ACE inhibitor (e.g., Ramipril 5 mg) would be the preferred add-on if the patient develops microalbuminuria or has diabetes. - Harrison's Principles of Internal Medicine, 22e

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CASE 2 - TYPE 2 DIABETES MELLITUS (New Presentation)

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SUBJECTIVE

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OBJECTIVE

• Fasting plasma glucose: 14.2 mmol/L (256 mg/dL) - Markedly elevated
• Random glucose: 18.4 mmol/L
• HbA1c: 9.8% (markedly above target of <7%)
• Urinalysis: Glucose 4+, Protein 1+, Ketones trace
• Renal profile: Normal (Cr 0.8 mg/dL, eGFR 94)
• Lipid profile: LDL 4.1, HDL 0.9, TG 3.8 (dyslipidemia)
• LFTs: Mildly elevated ALT (52 IU/L) - fatty liver
• ECG: Normal sinus rhythm

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ASSESSMENT

• Meets ADA diagnostic criteria: FPG >7.0 mmol/L confirmed, HbA1c >6.5%

1. LADA (Latent Autoimmune Diabetes in Adults) - possible given relatively rapid onset; check anti-GAD antibodies
2. MODY (Maturity Onset Diabetes of the Young) - less likely at age 52
3. Steroid-induced hyperglycemia - no steroid use
4. Cushing's syndrome - not applicable here

• Early peripheral neuropathy
• Microalbuminuria (protein trace on UA)
• Dyslipidemia
• NAFLD (elevated ALT)
• Hypertension (existing)

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PLAN

• Medical nutrition therapy: reduce refined carbohydrates, increase fiber, caloric deficit 500 kcal/day
• Exercise: 150 min/week moderate aerobic + resistance training
• Self-monitoring blood glucose (SMBG): pre-meal target 4-7 mmol/L, post-meal <10 mmol/L
• Diabetes education (foot care, sick day rules, hypoglycemia recognition)

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PRESCRIPTION

─────────────────────────────────────────────────────
Dr. P. Verma, MD (Endocrinology)
Date: 31-May-2026
Patient: Mrs. Sunita Devi, 52F
Wt: 82 kg | HbA1c: 9.8% | eGFR: 94 | Allergies: NKDA

Rx

1. Tab. Metformin 500 mg                1-0-1     (week 1-2)
   Then Tab. Metformin 1000 mg          1-0-1     (week 3 onwards)
   [Take with meals to reduce GI side effects. Contraindicated if eGFR <30]

2. Tab. Empagliflozin (SGLT-2i) 10 mg  1-0-0     (30 days)
   [Additional glucose-lowering + cardioprotective + weight loss benefit]
   [Counsel on genital hygiene - risk of genital mycotic infections]

3. Tab. Atorvastatin 40 mg              0-0-1     (30 days)
   [Diabetic patients = high CV risk; target LDL <1.8 mmol/L]

4. Continue Tab. Amlodipine 5 mg        1-0-0     (30 days)
   [BP target in DM: <130/80 mmHg; may need to add ACEi/ARB]

5. Tab. Pregabalin 75 mg                0-0-1     (30 days)
   [For peripheral neuropathic pain/tingling]

6. Cap. Vitamin B12 (Methylcobalamin) 1500 mcg  0-0-1  (30 days)

Investigations:
- Anti-GAD antibody (exclude LADA)
- C-peptide level
- Urine microalbumin:creatinine ratio
- Ultrasound abdomen (fatty liver assessment)
- Ophthalmology referral: baseline retinal exam
- TSH (screen thyroid)

Advice:
- Glucose monitoring diary (bring readings to next visit)
- Foot care: inspect feet daily, appropriate footwear
- Stay well hydrated on empagliflozin
- Alert: dizziness while standing (postural hypotension)
- Review: 6 weeks (HbA1c recheck at 3 months)
─────────────────────────────────────────────────────

Teaching Point: When HbA1c >9%, ADA guidelines recommend dual therapy from the start. SGLT-2 inhibitors (empagliflozin, dapagliflozin) are preferred in patients with cardiovascular or renal risk. GLP-1 receptor agonists are preferred when weight loss is a priority. - Symptom to Diagnosis, 4th Edition

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CASE 3 - BRONCHIAL ASTHMA (Moderate Persistent)

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SUBJECTIVE

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OBJECTIVE

• Spirometry: FEV1/FVC = 0.62 (obstructive pattern). Post-bronchodilator FEV1 improves by 18% (>12% and >200 mL = significant reversibility - confirms asthma)
• Chest X-ray: Mild hyperinflation. No consolidation, no pneumothorax.
• CBC: Eosinophilia (750 cells/µL, normal <500) - atopic background
• IgE: Total IgE 420 IU/mL (elevated)
• Peak flow diary (given to patient): Variable diurnal pattern >20% variation

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ASSESSMENT

1. COPD - excluded by age, non-smoker, full reversibility on bronchodilator
2. Vocal cord dysfunction - adduction rather than expiratory wheeze; Rx does not help
3. Cardiac asthma (heart failure) - excluded by age, clinical picture
4. ABPA (Allergic Bronchopulmonary Aspergillosis) - check if poorly controlled; IgE >1000 would suggest
5. Eosinophilic bronchitis - no airflow obstruction on spirometry (excluded)

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PLAN

• Identify and avoid triggers (cold air, perfumes, exercise without warm-up)
• HEPA air purifier for bedroom
• Allergen avoidance (dust mite covers, avoid strong perfumes)
• Written Asthma Action Plan
• Influenza vaccination annually
• Inhaler technique education (demonstrate and check back)

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PRESCRIPTION

─────────────────────────────────────────────────────
Dr. R. Menon, MBBS, MD (Respiratory Medicine)
Date: 31-May-2026
Patient: Miss Priya Singh, 24F
Weight: 54 kg | SpO2: 95% | PEFR: 58% predicted | Allergy: Penicillin (rash)

Rx

1. Inhaler: Budesonide/Formoterol 160/4.5 mcg (Symbicort Turbuhaler)
   2 puffs BD (morning and night) - CONTROLLER THERAPY
   [Low-dose ICS + LABA; GINA Step 3 preferred combination]
   [Use MART regimen: also use 1 puff as reliever as needed]

2. Inhaler: Salbutamol 100 mcg MDI (with spacer)
   2 puffs as needed (reliever for acute wheeze)
   [Short-acting β2-agonist; limit use to <3x/week - if more frequent,
   step up treatment]

3. Nasal spray: Fluticasone furoate 27.5 mcg/spray
   2 sprays each nostril OD morning (for allergic rhinitis)
   [Intranasal steroid; treating rhinitis improves asthma control]

4. Tab. Montelukast 10 mg              0-0-1     (30 days)
   [Leukotriene receptor antagonist; adjunct for atopic asthma + rhinitis]

5. Cetirizine 10 mg                    0-0-1     (as needed for rhinitis/itch)

Investigations:
- Spirometry repeat at 6 weeks (assess response to treatment)
- Skin prick test / RAST (specific IgE panel - identify allergens)
- Peak flow diary (monitor daily AM/PM for 2 weeks)

Advice:
- Always use spacer with MDI (improves lung deposition, reduces oral candidiasis)
- Rinse mouth after steroid inhaler
- Avoid beta-blockers, aspirin, NSAIDs (can precipitate bronchospasm)
- Emergency: If reliever ineffective after 2-4 puffs, go to emergency
- Return: 6 weeks (or earlier if worsening)
─────────────────────────────────────────────────────

Teaching Point: Asthma classification guides step-up therapy. Moderate persistent = GINA Step 3. ICS is the cornerstone - never treat asthma with LABA alone (increased mortality risk). MART (Maintenance And Reliever Therapy) using ICS/formoterol as both controller and reliever is a preferred modern strategy. - Symptom to Diagnosis, 4th Edition

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CASE 4 - PEPTIC ULCER DISEASE (H. pylori-related)

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SUBJECTIVE

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OBJECTIVE

• FBC: Hb 13.8 g/dL (normal). MCV normal.
• Urea breath test (UBT): POSITIVE for H. pylori
• Stool H. pylori antigen: Positive (confirmatory)
• LFTs: Normal
• Fasting glucose: Normal

• Age >45 with new dyspepsia (alarming symptom protocol)
• Alarming features: weight loss, dysphagia, GI bleeding, persistent vomiting → URGENT OGD

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ASSESSMENT

• H. pylori positive + classic hunger pain + epigastric tenderness
• NSAID use is a contributory factor

1. GERD (gastroesophageal reflux) - burning can overlap, but relief with eating more suggestive of ulcer
2. Gastric ulcer - pain typically worsens WITH eating (not relieved by it)
3. Functional dyspepsia - diagnosis of exclusion; H. pylori eradication first
4. Gastric carcinoma - less likely at 38, no alarming symptoms; monitor
5. Zollinger-Ellison syndrome - consider if resistant to triple therapy; measure fasting serum gastrin

• H. pylori colonizes gastric antrum → impairs somatostatin-producing D-cells → uninhibited gastrin release → excess acid → ulcer
• NSAID use independently suppresses prostaglandin synthesis (prostaglandins protect mucosa by stimulating mucus and bicarbonate)
• Together = synergistically damaging

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PLAN

• Proton Pump Inhibitor (PPI) + Clarithromycin + Amoxicillin
• Then continue PPI for additional 4 weeks after eradication

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PRESCRIPTION

─────────────────────────────────────────────────────
Dr. S. Iyer, MD (Gastroenterology)
Date: 31-May-2026
Patient: Mr. Suresh Patel, 38M
H. pylori: POSITIVE | Allergy: NKDA

Rx

H. PYLORI ERADICATION - STANDARD TRIPLE THERAPY (14 days):

1. Cap. Omeprazole 20 mg               1 cap BD (before meals)
   [PPI - acid suppression; continue for 4 more weeks after eradication course]

2. Tab. Clarithromycin 500 mg          1 tab BD (with meals)
   [Macrolide antibiotic; take for 14 days only]

3. Cap. Amoxicillin 1000 mg (1g)       1 cap BD (with meals)
   [Penicillin-based; take for 14 days only]

AFTER COMPLETING 14-DAY COURSE:

4. Cap. Omeprazole 20 mg               1 cap OD (for 4 more weeks)
   [Continue PPI for mucosal healing after eradication]

SEPARATELY:

5. Tab. Sucralfate 1g                  1 tab QID (1 hr before meals + bedtime)
   [Mucosal protectant; coats ulcer base; take for 4 weeks]
   [Do NOT take within 30 min of PPI/antacids]

6. STOP Ibuprofen
   Replace with Tab. Paracetamol 500 mg  1-2 tabs TDS PRN for back pain
   [Max 4g/day; safer for GI mucosa]

Investigations:
- Upper GI Endoscopy (OGD) in 6 weeks (confirm ulcer healing, exclude malignancy)
- H. pylori eradication test: Urea breath test 4 weeks AFTER completing all antibiotics
  (not before, as PPI falsely suppresses UBT)

Advice:
- Take all 3 medications together with meals (improves compliance, reduces GI side effects)
- Do NOT stop antibiotics early even if symptoms improve
- Avoid alcohol for 2 weeks (clarithromycin + alcohol = disulfiram-like reaction rare but possible)
- Quit smoking (delays ulcer healing, increases recurrence risk)
- Return immediately if: black tarry stools, vomiting blood, severe abdominal pain

Review: 6 weeks with endoscopy report
─────────────────────────────────────────────────────

Teaching Point: H. pylori eradication is the mainstay of PUD treatment. Confirm eradication with UBT (not stool antigen) at least 4 weeks after completing PPI and antibiotics. Failure to confirm eradication = treatment failure = increased resistance risk. - Robbins & Kumar Basic Pathology

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CASE 5 - URINARY TRACT INFECTION (Uncomplicated Cystitis in Women)

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SUBJECTIVE

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OBJECTIVE

• Urine dipstick: Leukocytes 3+, Nitrites POSITIVE, Blood 1+ - highly suggestive of bacterial UTI
• Urine microscopy: >10 WBCs/HPF (pyuria), numerous gram-negative bacilli
• Urine culture & sensitivity (C&S): Sent (result in 48 hrs) - report: E. coli, sensitive to nitrofurantoin, trimethoprim; resistant to ampicillin

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ASSESSMENT

1. Urethritis (STI - Chlamydia/Gonorrhea) - excluded by no sexual activity, no discharge
2. Interstitial cystitis - recurrent, but dipstick typically negative; chronic course
3. Pyelonephritis - excluded by absence of fever, rigors, loin pain, CVA tenderness
4. Vulvovaginitis - excluded by no vaginal discharge/itch

• Cystitis (lower UTI): fever absent, no loin pain, suprapubic pain, frequency/urgency
• Pyelonephritis (upper UTI): HIGH fever (>38.5°C), rigors, loin pain, CVA tenderness, systemic illness = treat with IV antibiotics, hospital admission

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PRESCRIPTION

─────────────────────────────────────────────────────
Dr. A. Nair, MBBS, MD
Date: 31-May-2026
Patient: Miss Kavya Reddy, 26F
Allergy: SULFONAMIDES (rash) - AVOID TMP-SMX (Cotrimoxazole)

Rx

1. Cap. Nitrofurantoin (Macrocrystals) 100 mg   BD × 5 days
   [First-line for uncomplicated cystitis; take with food to reduce nausea;
   NOT suitable if eGFR <30 - check renal function if elderly]

2. Tab. Phenazopyridine 200 mg                  TDS × 2 days
   [Urinary analgesic/antiseptic - relieves burning quickly;
   WARN patient: urine will turn orange-red - normal, not blood;
   NOT an antibiotic - use only for symptom relief]

3. Oral Rehydration: drink 2-3 litres water/day
   [Flushing mechanism; dilutes bacteria and reduces urinary irritation]

Investigations:
- Urine C&S result review in 48 hours (adjust antibiotic if resistant)
- Renal function test (baseline if recurrent UTIs)

Advice:
- Complete full 5-day course even if symptoms improve in 24 hours
- Void after intercourse (post-coital voiding prevents recurrence)
- Wipe front-to-back (hygiene instruction)
- Cranberry juice (some evidence for reducing recurrence, not for treatment)
- Return immediately if: fever develops, back/flank pain develops, symptoms worsen
  (= pyelonephritis developing → needs escalation to hospital)

Review: 48-72 hours (or sooner if worsening)
─────────────────────────────────────────────────────

Teaching Point: In women with uncomplicated UTI, urine C&S is not mandatory before treating, but is essential in: men, children, pregnant women, recurrent UTIs (>3/year), and clinical features of upper UTI. Avoid fluoroquinolones as first-line for simple cystitis due to resistance pressure. - Campbell-Walsh-Wein Urology

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CASE 6 - ATOPIC DERMATITIS (Moderate Severity)

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SUBJECTIVE

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OBJECTIVE

• Bilateral antecubital fossae: lichenification (skin thickening from chronic scratching), hyperpigmentation, excoriations, minimal weeping
• Popliteal fossae: similar lichenified plaques
• Neck: mild erythematous, dry scaling patches
• No vesicles, no honey-crusting (rules out secondary impetigo)
• Skin dry (xerosis) overall

• Major: Pruritus, typical morphology/distribution, chronic relapsing course, atopic family history
• Minor: Xerosis, IgE reactivity, food intolerance, peri-orbital darkening

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ASSESSMENT

1. Contact dermatitis (allergic) - requires specific allergen exposure, patch testing distinguishes
2. Psoriasis - silver scale, different distribution (extensors, scalp, nails)
3. Scabies - burrows, interdigital, highly contagious, family members affected
4. Seborrheic dermatitis - greasy yellow scale, scalp/face/chest distribution

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PLAN

• Step 1 (mild): Emollients only
• Step 2 (mild-moderate): Low-potency TCS (topical corticosteroid) + emollients
• Step 3 (moderate - this patient): Moderate-potency TCS + emollients + antihistamine at night
• Step 4 (severe): Tacrolimus/pimecrolimus or phototherapy
• Step 5 (refractory): Dupilumab (biologic - anti-IL-4/IL-13)

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PRESCRIPTION

─────────────────────────────────────────────────────
Dr. P. Gupta, MD (Dermatology)
Date: 31-May-2026
Patient: Master Arjun Sharma, 8M, 24 kg
Allergy: Peanuts (EpiPen in use)

Rx

1. Mometasone furoate 0.1% cream
   Apply thin layer to affected areas (NOT face) BD × 2 weeks
   Then taper to OD × 1 week, then every-other-day × 1 week
   [Mid-potency TCS; anti-inflammatory; do NOT use on face/groin/axillae]
   [Apply within 3 min of bathing ("soak and smear" technique)]

2. Hydrocortisone 1% cream
   Apply to FACE and flexures OD × 2 weeks
   [Low-potency TCS - safe for face; use instead of mometasone on delicate skin]

3. White soft paraffin + Liquid paraffin (50:50) emollient
   Apply liberally all over body TDS (especially after bathing)
   [500g jar; reapply frequently; emollient is the mainstay of ALL treatment]
   [Emollient use reduces TCS requirement by 30-40%]

4. Syr. Hydroxyzine 10 mg/5mL
   5 mL at bedtime (0.5 mg/kg/dose = 12 mg for 24 kg child)
   [Sedating antihistamine; improves sleep quality, reduces nocturnal scratching]
   [Non-sedating antihistamines have minimal benefit for eczema itch]

5. Mupirocin 2% ointment
   Apply to excoriated/broken skin areas TDS × 5 days
   [To prevent secondary bacterial infection (Staph aureus) in excoriations]

Investigations:
- Total IgE and specific IgE (RAST) panel (food + environmental allergens)
- Skin swab (if signs of infection appear: honey crusting, warm redness, oozing)
- Patch testing (when older, if contact allergen suspected)

Advice:
- Bathe in lukewarm (not hot) water, max 10 min, use soap-free cleanser (Cetaphil/Dove Sensitive)
- Pat dry (do NOT rub), apply emollient immediately
- Use cotton clothing; avoid wool, synthetic fabrics
- Trim nails short to prevent excoriation trauma
- Avoid known triggers: dust mites (mite-proof mattress covers), pet dander
- Do NOT apply TCS to unaffected skin
- EpiPen: keep accessible (peanut allergy risk at school)
- Return: 4 weeks (SCORAD re-assessment)
─────────────────────────────────────────────────────

Teaching Point: Atopic dermatitis is the first step in the "atopic march" - eczema → food allergy → allergic rhinitis → asthma. Early aggressive emollient therapy may reduce progression. Dupilumab (biologic anti-IL-4/IL-13 antibody) is now approved from age 6 months for moderate-severe AD refractory to topical therapy. - Andrews' Diseases of the Skin

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CASE 7 - IRON DEFICIENCY ANEMIA

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SUBJECTIVE

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OBJECTIVE

• FBC: Hb 6.8 g/dL, MCV 64 fL (microcytic), MCH 18 pg (hypochromic), RDW elevated
• Peripheral blood smear: Microcytic hypochromic red cells, pencil cells, occasional target cells
• Serum Ferritin: 4 ng/mL (severely depleted - confirms iron deficiency)
• Serum Iron: Low. TIBC: HIGH (inverse relationship)
• Transferrin saturation: 8% (normal >20%)
• Reticulocyte count: 0.5% (inappropriately low for degree of anemia = bone marrow cannot compensate)
• B12 and Folate: Normal

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ASSESSMENT

1. Anemia of chronic disease - ferritin is NORMAL or HIGH in ACD (not low); TIBC LOW in ACD
2. Thalassemia trait - MCV low but RDW normal, ferritin normal; Hb electrophoresis distinguishes
3. Sideroblastic anemia - rare, ring sideroblasts on smear, ferritin high
4. B12/Folate deficiency - macrocytic (high MCV), not microcytic; excluded here

• Koilonychia, Angular cheilitis, Glossitis

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PRESCRIPTION

─────────────────────────────────────────────────────
Dr. M. Krishnan, MD
Date: 31-May-2026
Patient: Mrs. Fatima Khan, 32F
Hb: 6.8 g/dL | Ferritin: 4 ng/mL | Allergy: NKDA

Rx

1. Tab. Ferrous Sulphate 200 mg (65 mg elemental iron)   TDS × 3 months
   [Take on empty stomach for maximum absorption if tolerated;
   take with orange juice (Vitamin C increases absorption by 3x);
   do NOT take with tea, milk, antacids (chelate iron)]
   [Expected Hb rise: 1 g/dL every 7-10 days with adequate therapy]
   [Continue for 3 months AFTER Hb normalizes to replenish stores]
   [Common side effects: dark stools, constipation, nausea - reassure]

2. Tab. Vitamin C (Ascorbic Acid) 500 mg                 TDS (with each iron tablet)
   [Enhances non-heme iron absorption from GI tract]

3. Tab. Folic Acid 5 mg                                  OD × 3 months
   [Prevents concurrent folate deficiency from increased RBC production]

4. Refer to Gynecology OPD
   [For investigation and management of menorrhagia - cause of blood loss]
   [Likely options: Tranexamic acid, Mefenamic acid, or Mirena IUS (levonorgestrel)]

Investigations:
- Repeat FBC + Reticulocyte count in 2 weeks (should see reticulocyte surge = "reticulocyte crisis")
- Serum ferritin at 3 months
- Ultrasound pelvis (fibroids as cause of menorrhagia)
- OGD + Colonoscopy if menstrual correction fails to explain full degree of anemia

Dietary Advice:
- Increase iron-rich foods: dark green leafy vegetables (spinach), lentils, beans, tofu, fortified cereals
- Avoid tea/coffee within 1 hour of iron tablet
- Cook in iron pots (increases dietary iron content)

Review: 2 weeks (check reticulocyte response) then 6 weeks (Hb check)
─────────────────────────────────────────────────────

Teaching Point: Serum ferritin is the single best test for iron deficiency - it is low only in iron deficiency (it is an acute-phase reactant, so can be falsely normal in inflammation). Always identify and treat the underlying cause, not just replace iron.

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CASE 8 - ACUTE OTITIS MEDIA (Children)

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SUBJECTIVE

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OBJECTIVE

• RIGHT: Tympanic membrane - erythematous, bulging, absent light reflex, loss of bony landmarks (classic AOM appearance)
• LEFT: Normal TM, no bulging, normal light reflex

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ASSESSMENT

1. Otitis media with effusion (OME / glue ear) - TM retracted but NOT bulging, no fever; manages watchfully
2. Otitis externa - pain with ear canal manipulation, TM usually normal
3. Mastoiditis - postauricular swelling, tenderness, displacement of pinna (complication of AOM - rule out)
4. Teething - referred pain, no TM changes

1. Moderate-to-severe bulging of TM (or new ear discharge)
2. Onset within 48 hrs
3. Ear pain (or intense TM erythema alone in <24 months)

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PRESCRIPTION

─────────────────────────────────────────────────────
Dr. S. Nambiar, MD (Pediatrics)
Date: 31-May-2026
Patient: Master Dev Agarwal, 3M, 14 kg | Allergy: NKDA

Rx

1. Syr. Amoxicillin 250 mg/5 mL
   Give 7.5 mL TDS × 10 days (= 90 mg/kg/day - high dose for AOM)
   [High-dose amoxicillin 80-90 mg/kg/day is first-line for AOM per AAP]
   [14 kg × 90 mg/kg = 1260 mg/day ÷ 3 = 420 mg TDS ≈ 7.5 mL TDS of 250mg/5mL]
   [If penicillin allergy: use Azithromycin or Cefdinir]

2. Syr. Paracetamol 120 mg/5 mL
   Give 7 mL every 4-6 hours as needed for pain/fever
   (= 15 mg/kg/dose for 14 kg = 210 mg = ~7 mL of 120mg/5mL)
   [Maximum 5 doses/24h; fever control + pain relief]

3. Nasal drops: Normal Saline (0.9%) nasal drops
   2 drops each nostril TDS (before feeds)
   [Relieves nasal congestion; improves Eustachian tube drainage]

NOTE: Decongestants and antihistamines are NOT recommended in AOM
(no evidence of benefit; potential harm in <2 years)

Investigations (not required for uncomplicated AOM, but if recurrent):
- Tympanometry (confirms middle ear effusion)
- Audiometry (if hearing loss persists >3 months after AOM)

Advice (to parents):
- Give full antibiotic course even if fever settles in 48 hours
- Return if: no improvement in 72 hours (= antibiotic failure, consider Augmentin),
  ear discharge begins, worsening pain/fever, swelling behind ear develops (mastoiditis emergency)
- Keep child away from passive smoke (major risk factor for recurrent AOM)
- Breastfeeding protective against recurrent AOM (educate for future sibling)
- Pneumococcal vaccination review

Referral: ENT if third episode in 6 months → consider ventilation tube (grommet) insertion for
recurrent AOM or persistent otitis media with effusion

Review: 72 hours (response check)
─────────────────────────────────────────────────────

Teaching Point: High-dose amoxicillin (80-90 mg/kg/day) is now standard for AOM to cover penicillin-resistant S. pneumoniae. Watchful waiting is acceptable for mild AOM in children >2 years with unilateral AOM and mild symptoms. If no improvement at 72 hrs, switch to Amoxicillin-Clavulanate (Augmentin).

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CASE 9 - STABLE ANGINA (Ischemic Heart Disease)

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SUBJECTIVE

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OBJECTIVE

• Troponin I (at rest): Negative (rules out ACS at this visit)
• ECG: Normal at rest (typical of stable angina - changes occur with exertion)
• Exercise stress test (treadmill): Positive at Stage 2 (Bruce protocol) - 1.5 mm horizontal ST depression in leads V4-V6. Patient developed typical chest pain at Stage 2. Test STOPPED.
• Echocardiogram: LVEF 55% (preserved), mild inferior hypokinesia on stress
• Lipid profile: LDL 4.8 mmol/L (very high), HDL 0.9, TG 3.1
• HbA1c: 7.9% (suboptimal)
• Creatinine: 1.0 mg/dL (eGFR 75)

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ASSESSMENT

• Class I: Angina with strenuous activity only
• Class II: Angina with walking >2 blocks or climbing >1 flight - slight limitation
• Class III: Angina with minimal activity - marked limitation
• Class IV: Angina at rest or with minimal exertion

1. GERD (acid reflux) - burning rather than pressure, not consistently exertional
2. Musculoskeletal chest pain - reproducible with palpation, positional
3. Unstable angina (ACS) - rest pain, crescendo pattern, troponin rise → differentiated
4. Vasospastic (Prinzmetal) angina - usually at rest, early morning, ST elevation

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PRESCRIPTION

─────────────────────────────────────────────────────
Dr. A. Gupta, DM (Cardiology)
Date: 31-May-2026
Patient: Mr. Harish Mehta, 56M | Troponin: Neg | LVEF: 55%
CCS Class II Stable Angina | Allergy: NKDA

Rx

ANTI-ANGINAL:

1. Tab. Isosorbide Mononitrate SR 30 mg         1-0-0     (30 days)
   [Long-acting nitrate; give in morning; allow 8-10 hr nitrate-free period
   to prevent tolerance; headache is a common side effect initially]

2. Tab. Metoprolol Succinate ER 25 mg            1-0-0     (30 days)
   [Beta-1-selective blocker; slows HR, reduces myocardial O2 demand;
   target resting HR 55-60 bpm; up-titrate to 50 mg if tolerated]
   [ALSO now replacing amlodipine as this patient has angina + HTN]

SECONDARY PREVENTION (MANDATORY in all IHD patients):

3. Tab. Aspirin 75 mg                            1-0-0     (long-term)
   [Antiplatelet - reduces MI risk; take with food]

4. Tab. Atorvastatin 80 mg                       0-0-1     (long-term)
   [High-intensity statin mandatory in all stable IHD; target LDL <1.8 mmol/L]
   [Current LDL 4.8 = extremely high; 80 mg essential]

5. Tab. Ramipril (ACE inhibitor) 5 mg            0-0-1     (30 days)
   [ACE inhibitors reduce cardiovascular events in IHD + DM + HTN;
   check K+ and Cr in 2 weeks; stop if persistent dry cough → switch to ARB]

6. S/L Glyceryl Trinitrate (GTN) spray 0.4 mg   PRN (acute episode)
   [Use 1-2 puffs sublingually at onset of chest pain;
   sit down first; may repeat once after 5 minutes;
   if pain not gone after 2 doses in 10 min → CALL EMERGENCY (potential MI)]
   [Store below 25°C; replace spray every 12 months]

7. Continue Metformin 1g BD (adjust if Cr rises)
8. Change Amlodipine to Metoprolol as above (unless needed for BP control)

Investigations:
- Coronary Angiography (URGENT REFERRAL) - positive stress test warrants
  angiography to define coronary anatomy and assess for revascularization (PCI/CABG)
- Repeat lipid profile at 6 weeks (target LDL <1.8)
- Renal profile + K+ in 2 weeks (post-ACEi initiation)
- HbA1c at 3 months

Advice:
- HOW TO USE GTN SPRAY: sit down, spray under tongue, do NOT swallow;
  wait 5 min, if no relief repeat once; if still no relief → EMERGENCY
- Avoid Sildenafil (Viagra) / PDE-5 inhibitors: fatal hypotension with nitrates
- Cardiac rehabilitation referral
- Quit smoking (already done) - reinforce
- Regular moderate exercise (walking 30 min/day once medically cleared post-angiography)

URGENT REFERRAL: Interventional Cardiology for Coronary Angiography
Review: 1-2 weeks (with angiography appointment)
─────────────────────────────────────────────────────

Teaching Point: All patients with stable angina need the "ABCDE" secondary prevention approach: Aspirin/Antianginal, Beta-blocker/Blood pressure, Cholesterol (statin)/Cigarettes, Diet/Diabetes, Exercise/Education. A positive stress test at Stage 2 of Bruce protocol warrants coronary angiography.

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CASE 10 - ALLERGIC RHINITIS

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SUBJECTIVE

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OBJECTIVE

• Total IgE: 380 IU/mL (elevated)
• Specific IgE (RAST): Tree pollen +++, House dust mite ++, Grass pollen ++
• Nasal smear: Eosinophils present (confirms allergic basis)
• PEFR: 72% predicted (borderline; check inhaler technique)

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ASSESSMENT

• Intermittent: symptoms <4 days/week OR <4 weeks/year
• Persistent: symptoms >4 days/week AND >4 weeks/year
• Mild / Moderate-Severe (based on impact on sleep/daily activities/work)

1. Acute viral rhinosinusitis - fever, purulent discharge, facial pain, <10 days
2. Non-allergic (vasomotor) rhinitis - triggered by temperature, irritants; RAST negative
3. Nasal polyps - pale masses in nasal cavity; associated with aspirin sensitivity, asthma (Samter's triad)
4. Structural deviation (DNS) - unilateral obstruction; confirmed on nasal endoscopy

---

PRESCRIPTION

─────────────────────────────────────────────────────
Dr. B. Sharma, ENT Specialist
Date: 31-May-2026
Patient: Mr. Anil Kapoor, 31M | Allergy: Tree pollen, HDM | NKDA

Rx

1. Nasal spray: Mometasone furoate 50 mcg/spray
   2 sprays each nostril OD (morning)
   [First-line for persistent AR; intranasal corticosteroid - most effective]
   [Takes 3-7 days to reach full effect; continue even when symptoms improve]
   [Proper technique: tilt head slightly forward, spray laterally away from septum]

2. Tab. Fexofenadine 120 mg              1-0-0     (30 days)
   [Non-sedating second-generation antihistamine; controls sneezing/itch/discharge]
   [Does NOT cause drowsiness; safe for office work, driving]

3. Eye drops: Sodium Cromoglicate 2% (Opticrom)
   1-2 drops both eyes QID (for allergic conjunctivitis)
   [Mast cell stabilizer; use regularly for best effect]
   [Alternative: Azelastine eye drops 0.05% - antihistamine eye drops]

4. Nasal saline irrigation (Neti pot / NeilMed)
   Use BD morning and night
   [Flushes allergens and mucus from nasal cavity; improves mucosal function]

5. Continue Salbutamol MDI 100 mcg      2 puffs PRN (for breakthrough wheeze)

Investigations:
- Consider spirometry (asthma reassessment given borderline PEFR)
- Review skin prick testing (comprehensive allergen panel if considering immunotherapy)

Referral:
- Allergy Clinic for Allergen Immunotherapy (AIT) assessment
  [If symptoms persist despite optimal pharmacotherapy; HDM immunotherapy (subcutaneous
   or sublingual drops) can modify disease course long-term]

Advice:
- Keep windows closed during pollen season (morning 5-10 AM = highest pollen count)
- Wear wraparound sunglasses outdoors
- Shower after coming home from outside (remove pollen from hair/skin)
- Avoid drying clothes outdoors during pollen season
- Air purifier with HEPA filter at home

Review: 4 weeks
─────────────────────────────────────────────────────

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CASE 11 - LOWER BACK PAIN (Mechanical)

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SUBJECTIVE

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OBJECTIVE

• Lumbar spine: Paraspinal muscle spasm bilaterally at L4-L5 level. Midline tenderness at L4-L5 on palpation. Reduced lumbar flexion (can reach to mid-shin only). Straight leg raise (SLR): NEGATIVE bilaterally (no radiculopathy)
• Neurological: Normal power, reflexes, sensation in both lower limbs
• Gait: Antalgic gait (leaning slightly to right to avoid pain)

• X-ray lumbar spine: Mild L4-L5 disc space narrowing (degenerative change), no fracture, no listhesis
• MRI lumbar spine (ordered): To assess disc and nerve roots if not improving at 4 weeks

---

ASSESSMENT

• Cancer: weight loss, night pain, age >50, known malignancy
• Infection: fever, IV drug use, recent infection, raised ESR/CRP
• Cauda equina: bladder/bowel dysfunction, saddle anesthesia, bilateral leg weakness
• Fracture: trauma, osteoporosis, steroid use
• Inflammatory spondyloarthropathy: age <40, morning stiffness >30 min, alternating buttock pain None present in this case → mechanical LBP confirmed.

1. L4-L5 disc herniation with radiculopathy - excluded by negative SLR, no leg symptoms
2. Spinal stenosis - older patients, claudication-type leg pain on walking
3. Vertebral fracture - no trauma, no osteoporosis risk
4. Sacroiliac joint dysfunction - pain at PSIS, positive FABER test (check if not improving)
5. Ankylosing spondylitis - excluded by normal X-ray, age, negative inflammatory markers

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PRESCRIPTION

─────────────────────────────────────────────────────
Dr. K. Singh, MS (Orthopaedics)
Date: 31-May-2026
Patient: Mr. Vijay Bose, 42M | No red flags | Allergy: NKDA

Rx

1. Tab. Etoricoxib 60 mg (COX-2 inhibitor)        1-0-0     (7 days)
   [Selective NSAID; superior GI safety vs. ibuprofen for short-term use]
   [Take with food; avoid if hypertension or renal impairment]
   [Replace ongoing ibuprofen to reduce GI risk]

2. Tab. Paracetamol 500 mg                        2 tabs TDS × 7 days
   [Baseline analgesia; safe adjunct to NSAID]

3. Tab. Thiocolchicoside 4 mg (muscle relaxant)   0-1-1     × 5 days
   [Centrally acting muscle relaxant; reduces paraspinal spasm;
   causes drowsiness - advise NOT to drive; avoid in pregnancy]

4. Tab. Pantoprazole 40 mg                        1-0-0     × 7 days
   [Gastroprotection - patient on NSAIDs; prevents NSAID-induced gastric ulcer]

5. Topical: Diclofenac 1% gel
   Apply to lower back area TDS × 2 weeks
   [Reduces local inflammation; less systemic absorption than oral NSAIDs]

Physiotherapy (REFER):
- Heat therapy to lumbar region (moist heat pack 15 min TDS)
- Core strengthening exercises (started AFTER acute phase settles - 1-2 weeks)
- McKenzie exercises for disc derangement
- Postural training and ergonomic assessment

Investigations:
- MRI lumbar spine (if no improvement at 4 weeks)
- ESR, CRP (if fever or inflammatory features develop)
- DEXA scan (if osteoporosis suspected - older patients)

Advice:
- Stay ACTIVE (bed rest >1-2 days is harmful; gentle walking recommended)
- Ergonomic review of work station (monitor at eye level, lumbar support)
- No heavy lifting for 4 weeks
- Sleep with pillow between knees (reduces lumbar strain)
- RETURN if: leg weakness, bladder/bowel problems, pain worsens at night (red flags)

Review: 2 weeks
─────────────────────────────────────────────────────

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CASE 12 - HYPOTHYROIDISM

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SUBJECTIVE

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OBJECTIVE

• TSH: 78 mIU/L (severely elevated, normal 0.5-4.5)
• Free T4 (FT4): 4.2 pmol/L (severely low, normal 12-22)
• Free T3: Low
• Anti-TPO antibody: 1240 IU/mL (massively elevated - confirms Hashimoto's autoimmune thyroiditis)
• Anti-Thyroglobulin antibody: Positive
• FBC: Normocytic anemia (Hb 10.8 g/dL) - secondary to hypothyroidism
• Lipid profile: High LDL and total cholesterol (hypothyroidism causes dyslipidemia)
• ECG: Sinus bradycardia, low voltage complexes, prolonged QTc
• Echo: Mild pericardial effusion (0.5 cm) - myxedema

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ASSESSMENT

• Severely elevated TSH + low FT4 + anti-TPO positive + goitre = Hashimoto's thyroiditis

1. Atrophic thyroiditis (idiopathic) - no goitre; antibodies may be negative
2. Post-radioiodine/post-surgical hypothyroidism - excluded by history
3. Drug-induced (amiodarone, lithium, interferon) - no such medications
4. Iodine deficiency - unlikely in developed areas; check iodine intake
5. Central (pituitary) hypothyroidism - TSH low with low T4; excluded (TSH very HIGH)

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PRESCRIPTION

─────────────────────────────────────────────────────
Dr. P. Reddy, MD (Endocrinology)
Date: 31-May-2026
Patient: Mrs. Geeta Sinha, 45F | TSH: 78 | FT4: 4.2 | Wt: 78 kg | Allergy: NKDA

Rx

1. Tab. Levothyroxine (L-T4) 50 mcg          OD on empty stomach
   Take 30-60 min before breakfast with water ONLY
   [Do NOT take with: calcium, iron, antacids, coffee - all reduce absorption]
   [Start at LOW dose (50 mcg) and uptitrate to prevent cardiac precipitation]
   [In elderly or known CAD: START at 12.5-25 mcg and uptitrate slowly]
   [Expected dose: 1.6 mcg/kg/day = 78 × 1.6 = ~125 mcg maintenance]
   Uptitrate: 50 mcg → 75 mcg → 100 mcg → 125 mcg (every 4-6 weeks based on TSH)

2. No specific treatment needed for the pericardial effusion
   [Will resolve with thyroid hormone replacement; monitor on Echo]

3. Multivitamin with B12 and B-complex OD
   [General support; B12 deficiency co-exists with Hashimoto's frequently]

Investigations:
- TSH + FT4 repeat at 6 weeks (adjust levothyroxine dose)
- Target TSH: 0.5 - 2.5 mIU/L (aim lower end in symptomatic patients)
- Serum B12 (Hashimoto's associated with pernicious anemia)
- Fasting glucose / HbA1c (Type 1 DM + Hashimoto's - autoimmune clustering)
- Coeliac antibodies (AGA, anti-TTG) - autoimmune thyroid disease clusters with coeliac
- Lipid profile recheck at 3 months (often normalizes with thyroid replacement)
- Echo repeat at 3 months (pericardial effusion)

Advice:
- Strict timing of levothyroxine (same time daily, empty stomach - critical)
- Lifelong therapy (Hashimoto's thyroiditis is permanent)
- Annual TSH monitoring once stable
- Do NOT self-adjust dose
- Symptoms improve slowly over 4-8 weeks - set expectations

Review: 6 weeks
─────────────────────────────────────────────────────

Teaching Point: Levothyroxine must be taken on an empty stomach 30-60 min before breakfast. Absorption is reduced by calcium, iron, antacids, proton pump inhibitors, and even coffee. Drug-drug interactions are clinically significant. TSH is the best monitoring test - FT4 lags behind.

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CASE 13 - ACUTE CONJUNCTIVITIS

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SUBJECTIVE

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OBJECTIVE

• VA: 6/6 bilaterally (vision unaffected - confirms no corneal/deep eye involvement)
• Lids: Bilateral lid edema, eyelid margins matted with mucopurulent discharge
• Conjunctivae: Diffuse conjunctival injection (bulbar and palpebral conjunctiva), no follicles visible
• Cornea: Clear. No staining with fluorescein (no corneal ulcer)
• Anterior chamber: Normal depth, no cells/flare
• Pupil: Reactive to light, no relative afferent pupillary defect (RAPD)
• Fundus: Normal (not examined - not indicated)

• Conjunctival swab C&S (if no response to empirical treatment)
• Common pathogens: Staph. aureus, Staph. epidermidis, H. influenzae, Strep. pneumoniae

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ASSESSMENT

1. Viral conjunctivitis - watery discharge, follicular reaction, pre-auricular lymphadenopathy, associated URTI; self-limiting 1-2 weeks
2. Allergic conjunctivitis - itching (dominant), bilateral, watery/stringy mucous discharge, seasonal
3. Chlamydial conjunctivitis - large follicles on tarsal conjunctiva, sexual history, look for genital symptoms
4. Acute angle-closure glaucoma - RED FLAG: Severe pain, halos, dilated fixed pupil, nausea, very elevated IOP → EMERGENCY
5. Anterior uveitis (Iritis) - photophobia, ciliary flush, small irregular pupil, deep ache → EMERGENCY

---

PRESCRIPTION

─────────────────────────────────────────────────────
Dr. R. Sharma, DOMS, MS (Ophthalmology)
Date: 31-May-2026
Patient: Miss Nisha Thomas, 19F | VA: 6/6 bilaterally | Allergy: NKDA

Rx

1. Eye drops: Moxifloxacin 0.5% (Vigamox)
   1 drop in BOTH eyes hourly × 2 days, then QID × 5 days
   [Broad-spectrum fluoroquinolone; covers Gram-positive and Gram-negative organisms]
   [Continue for 5-7 days total even if symptoms clear]

2. Eye drops: Artificial tears (Carboxy methyl cellulose 0.5%)
   1 drop both eyes QID (for comfort/lubrication)

3. Lid hygiene:
   - Wipe lids with clean cotton ball soaked in cooled boiled water
   - Wipe from inner to outer corner of each eye
   - Use separate piece of cotton for each eye

NOTE: DO NOT patch the eye (increases bacterial multiplication)
NOTE: Topical steroids are CONTRAINDICATED in bacterial conjunctivitis
      (can worsen and cause corneal ulceration)

Investigations:
- Only if no improvement in 3-4 days: Conjunctival swab for C&S
- Chlamydia swab if persistent/refractory or if sexually active young adult

Advice:
- HIGHLY CONTAGIOUS: do not share towels, pillowcases, eye cosmetics
- Wash hands frequently (transmission is hand-to-eye)
- Avoid school/college for 24 hours after starting antibiotics (or until discharge resolves)
- Do not use contact lenses until fully resolved
- Return if: pain develops, vision blurs, photophobia starts → corneal ulcer or iritis (EMERGENCY)

Review: 3-4 days (or sooner if worsening)
─────────────────────────────────────────────────────

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CASE 14 - GOUT (Acute Arthritis)

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SUBJECTIVE

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OBJECTIVE

• Serum uric acid: 9.8 mg/dL (severely elevated; normal <7 mg/dL men)
• FBC: WBC 14.2 × 10⁹/L (neutrophilia - acute inflammatory response)
• CRP: 98 mg/L (elevated)
• ESR: 78 mm/hr (elevated)
• Renal profile: Creatinine 1.2 mg/dL, eGFR 68 (CKD stage 2)
• Joint aspiration (if performed): Negatively birefringent needle-shaped urate crystals under polarizing microscopy (PATHOGNOMONIC) - this is the gold standard for diagnosis
• X-ray foot: No erosions (acute episode; punched-out erosions seen in chronic tophaceous gout)

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ASSESSMENT

1. Pseudogout (calcium pyrophosphate deposition) - wrist/knee more common; positively birefringent rhomboid crystals
2. Septic arthritis - extremely important to exclude! WBC typically higher, fever higher; joint aspiration mandatory if doubt
3. Reactive arthritis - history of recent infection (GI/GU), asymmetric oligoarthritis
4. Rheumatoid arthritis - morning stiffness, symmetrical, MCP/PIP joints

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PRESCRIPTION

─────────────────────────────────────────────────────
Dr. N. Bhat, MD (Rheumatology)
Date: 31-May-2026
Patient: Mr. Rajiv Khanna, 52M | Uric acid: 9.8 | eGFR: 68 | Allergy: NKDA

Rx

ACUTE GOUT TREATMENT:

1. Tab. Etoricoxib 120 mg                 OD × 5 days
   [COX-2 inhibitor; first-line for acute gout; highly effective anti-inflammatory]
   [Use with pantoprazole 40mg OD for gastroprotection; caution in CKD - monitor Cr]

2. Tab. Colchicine 0.5 mg                 TDS × 3 days (low-dose regimen)
   [Anti-inflammatory (inhibits tubulin polymerization, blocks neutrophil migration);
   modern evidence: low-dose (1.5 mg/day) equally effective as high-dose with fewer GI side effects]
   [Main side effect: diarrhea, nausea; reduce dose if eGFR <50]
   [DO NOT USE IF eGFR <10 or severe hepatic impairment]

3. Tab. Prednisolone 30 mg                OD × 5 days (if NSAID + colchicine insufficient
   or if eGFR <50 where NSAID use is limited)
   [Systemic steroid for acute gout - especially in CKD patients where NSAIDs are risky]
   [Alternatively: intra-articular steroid injection if monoarthritis]

4. Tab. Pantoprazole 40 mg                1-0-0     (GI protection while on NSAIDs)

5. Change Hydrochlorothiazide to Losartan 50 mg (ARB for hypertension)
   [Thiazides are URICOSURIC INHIBITORS - they raise uric acid → precipitate gout]
   [Losartan is mildly uricosuric (lowers uric acid) - preferred antihypertensive in gout]

URATE-LOWERING THERAPY (start 2-4 weeks after acute attack resolves):
NOTE: Do NOT start allopurinol during acute attack (can prolong/worsen attack)

6. Tab. Allopurinol 100 mg                OD (to start in 4 weeks)
   [Xanthine oxidase inhibitor; reduces uric acid production]
   [Titrate: 100 mg → 200 mg → 300 mg every 4 weeks]
   [Target serum uric acid: <6 mg/dL (>5 if tophi present)]
   [CAUTION: Check HLA-B*58:01 (allopurinol hypersensitivity) before starting
    in Southeast Asian populations - risk of Stevens-Johnson syndrome]

Continue colchicine 0.5 mg OD for 6 months prophylaxis while initiating allopurinol
(prevents mobilization flares as uric acid starts to fall)

Investigations:
- Repeat uric acid 4 weeks (after acute attack resolves)
- Renal profile monthly for 3 months (allopurinol dose adjusts with eGFR)
- 24-hr urine uric acid (to determine under-excretion vs. over-production)

Dietary/Lifestyle Advice:
- Avoid: organ meats, red meat, shellfish, beer, spirits
- Reduce: fructose (high-fructose corn syrup in soft drinks)
- Increase: low-fat dairy products (uricosuric), cherries (anti-inflammatory)
- Adequate hydration (2-3L/day) - promotes uric acid excretion
- Lose weight (obesity → higher uric acid)

Review: 1 week (acute attack) then 4 weeks (start allopurinol)
─────────────────────────────────────────────────────

Teaching Point: Never start urate-lowering therapy during an acute gout attack - this prolongs the attack. The classic finding is negatively birefringent (blue when parallel to polarizer) needle-shaped crystals in the joint fluid. Allopurinol hypersensitivity (DRESS/SJS) is linked to HLA-B*58:01, especially in Han Chinese, Thai, and Korean populations.

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CASE 15 - CHILDHOOD FEBRILE ILLNESS WITH RASH (Dengue Fever)

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SUBJECTIVE

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OBJECTIVE

• FBC: WBC 2.8 × 10⁹/L (leukopenia - characteristic), Platelets 92,000/µL (thrombocytopenia - WARNING sign), Hct 42%
• NS1 antigen: POSITIVE (dengue-specific antigen, positive from day 1-5)
• Dengue IgM/IgG: IgM positive (acute infection)
• LFTs: Mild elevation (AST/ALT ~3x normal)
• Urea: Normal

• Dengue without warning signs (mild)
• Dengue with warning signs (this patient - thrombocytopenia <100K, hepatomegaly, positive tourniquet)
• Severe dengue (shock, bleeding, organ impairment)

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PLAN & PRESCRIPTION

─────────────────────────────────────────────────────
Dr. M. Nair, MD (Pediatrics)
Date: 31-May-2026
Patient: Master Rohan Pillai, 10M, 32 kg | Platelets: 92,000 | Allergy: NKDA

Rx

1. Tab. Paracetamol 500 mg               TDS-QID PRN for fever/pain (= 15 mg/kg/dose)
   Give if temp > 38.5°C
   [ONLY analgesic/antipyretic to use in dengue]
   [AVOID: Aspirin, Ibuprofen, Diclofenac, Naproxen → ALL NSAIDs]
   [NSAIDs inhibit platelet function → risk of hemorrhage in thrombocytopenic patient]

2. Oral Rehydration Therapy (ORS) + plain water + fruit juices
   Aim: >2L/day (maintain hydration, monitor urine output)
   [Dengue = plasma leakage phase on days 3-6 = risk of dehydration and shock]
   [Adequate oral hydration is the KEY treatment]

3. NO antibiotics (viral illness - dengue is a flavivirus; antibiotics have no role)

IMPORTANT MONITORING:
- Check FBC with platelets DAILY (especially day 4-6 = critical phase for leakage)
- Danger signs requiring IMMEDIATE HOSPITAL ADMISSION:
  - Platelets < 50,000 or rapidly falling
  - Spontaneous bleeding (gums, epistaxis, melena, hematuria)
  - Abdominal pain, persistent vomiting
  - Fluid accumulation (ascites, pleural effusion)
  - Postural hypotension or shock (cold hands/feet, narrow pulse pressure)
  - Altered consciousness, seizures
  - Urine output dropping (<0.5 mL/kg/hr)

Investigations (daily monitoring):
- FBC + Platelet count DAILY
- Hematocrit (Hct) - rising Hct > 20% = plasma leakage = severe dengue warning
- LFTs x2 (every 48 hours)
- Daily weight (fluid accumulation)

Advice (to parents):
- Closely monitor: check child hourly at home for danger signs above
- Maintain fluid intake (ORS every 2-3 hours)
- Rest and avoid strenuous activity
- Keep mosquito net over child (to prevent spreading dengue to others)
- Return to OPD daily for platelet count
- IMMEDIATELY go to Emergency if any danger signs above develop

Review: NEXT DAY (OPD return for platelet count)
─────────────────────────────────────────────────────

Teaching Point: The critical phase of dengue is days 4-6 (even as fever falls - "defervescence"). This is when plasma leakage, thrombocytopenia, and hemorrhage risk peak. A falling platelet count + rising hematocrit = classic "dengue shock" developing. NSAIDs are absolutely contraindicated.

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QUICK REFERENCE TABLE - OPD CASES SUMMARY

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KEY EXAM POINTS - PRESCRIPTIONS

Drug Classes by Condition (Exam Favorites)

"Never Miss" Red Flags on Prescription Writing

1. Asthma: Never prescribe beta-blockers, aspirin, or NSAIDs without checking.
2. Gout: Never start allopurinol during an acute attack.
3. HTN: GTN + Sildenafil = potentially fatal hypotension.
4. Dengue: NSAIDs are absolutely contraindicated.
5. Metformin: Hold before contrast dye (IV contrast nephropathy → lactic acidosis).
6. Warfarin: Multiple interactions; check INR before prescribing.
7. ACE inhibitors: Do not combine with ARBs (dual RAAS blockade) - hyperkalemia, AKI.
8. Levothyroxine: Absorption severely impaired by calcium, iron, PPIs, coffee.
9. TCS (topical steroids) on face: Use only low-potency (1% hydrocortisone); high-potency causes skin atrophy, telangiectasia.
10. Antibiotics in viral illness: No antibiotics for dengue, viral URTI, or viral conjunctivitis.

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PRESCRIPTION WRITING FORMAT (Exam Standard)

1. Date of writing
2. Patient name, age, weight (mandatory for pediatric patients)
3. Drug name (generic preferred; brand in parentheses)
4. Dose (e.g., 500 mg)
5. Route (oral, topical, inhalation, IV, IM, SC)
6. Frequency (OD, BD, TDS, QID, PRN - "as needed")
7. Duration (number of days/weeks)
8. Instructions (take with food / take on empty stomach / use spacer etc.)
9. Allergies noted (top of prescription)
10. Doctor's signature + registration number

• OD = Once daily | BD = Twice daily | TDS = Three times/day | QID = Four times/day
• PRN = As needed | SOS = If necessary (single dose) | AC = Before meals | PC = After meals
• S/L = Sublingual | INH = Inhaled | TOP = Topical | IM = Intramuscular

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