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NIMS(Nepal Index Of Medical Specialities) has been design to provide information on drugs that are marketed in Nepal by Pharma company from around the world .


NIMS(Nepal Index Of Medical Specialities) has been design to provide information on drugs that are marketed in Nepal by Pharma company from around the world .


NIMS(Nepal Index Of Medical Specialities) has been design to provide information on drugs that are marketed in Nepal by Pharma company from around the world .


NIMS(Nepal Index Of Medical Specialities) has been design to provide information on drugs that are marketed in Nepal by Pharma company from around the world .


NIMS(Nepal Index Of Medical Specialities) has been design to provide information on drugs that are marketed in Nepal by Pharma company from around the world .

Tuesday, July 28, 2015

Patients taking which of the following drugs should be advised to avoid drinking grapefruit juice?

Patients taking which of the following drugs should be advised to avoid drinking grapefruit juice?

drug interaction with grape juice 

A. Amoxicillin
B. Aspirin
C. Atorvastatin
D. Prevacid
E. Sildenafil

The answer is C.  Grapefruit juice inhibits CYP3A4 in the liver, particularly at
high doses. This can cause decreased drug elimination via hepatic metabolism and increase
potential drug toxicities. Atorvastatin is metabolized via this pathway. Drugs that may
enhance atorvastatin toxicity via this mechanism include phenytoin, ritonavir, clarithromycin,
and azole antifungals. Aspirin is cleared via renal mechanisms. Prevacid can cause
impaired absorption of other drugs via its effect on gastric pH. Sildenafil is a phosphodiesterase
inhibitor that may enhance the effect of nitrate medications and cause hypotension.

Sunday, July 26, 2015

Chemical Eye Exposure

Chemical Eye Exposure

Case presentation:

A 34 - year - old female is seen in the emergency department after having an unknown chemical
splashed in her face and eyes. She is complaining of burning, tearing, decreased vision, and light sensitivity.

Gross inspection reveals first - degree burns to the periorbital skin and lids. The globes are intact.
On physical examination, the visual acuity is 20/200 in each eye.

The bulbar and palpebral conjunctiva is markedly injected with a watery mucous discharge (illustrated).
chemical eye exposure
The corneas are hazy with blurred iris detail.
There is a 6 mm oval area of blanched bulbar conjunctiva inferiorly near the limbus. The anterior chambers are deep, and the pupils are round.

Question: What emergent action should be initiated prior to completing the ophthalmic examination?

A. Emergent ophthalmology consultation
B. Litmus test
C. Irrigation of the eye with copious fluids such as saline or lactated Ringer ’ s solution
D. Tetanus prophylaxis
E. Neutralization with a weak acid or base for a base - or acid - offending agent, respectively

Answer: C
Diagnosis: Chemical injury to the eye
Discussion: Chemical injuries to the eye range from mild irritation to devastating destruction of the ocular surface resulting in visual impairment or even loss of the eye. Most chemical injuries affect young patients, with exposure occurring at home, in industrial or agricultural accidents, or in criminal assault. The offending chemical may be in the form of a solid, liquid, powder, or vapor. The severity of the injury depends on the offending agent, the  surface area of contact, and the degree of penetration. The most important step in the initial management of chemical injuries is immediate and copious irrigation of the ocular surface with lactated Ringer ’ s solution or normal saline solution, even before testing vision. This may be facilitated using a topical anesthetic and handheld intravenous tubing or a Morgan lens. Irrigation should be continued for a minimum of 30 minutes until the conjunctival sac pH is neutral. The conjunctival pH can be easily checked with a urinary pH strip. Sweeping the conjunctival fornices with a moistened cotton - tipped applicator
for solid particles should be performed for a persistently elevated pH.

Alkali injuries occur most frequently and are the most devastating. These agents elevate the pH and
readily penetrate the ocular tissues. Blanching of the conjunctiva indicates penetration, vascular ischemia, and necrosis, which are often the result of severe alkali injuries. On the other hand, acid injuries tend to remain confined to the surface of the eye and produce superficial damage.

Wednesday, July 22, 2015

Confluent Rash on a Child

Confluent Rash on a Child

Case presentation: A 2-year-old boy with no medical history presents to the emergency department with complaints of a diffuse rash over his bilateral lower extremities for the past 2 days that is now progressing to his trunk and upper extremities. He otherwise appears playful and well with no complaint of itching or fever. His parents deny new detergents, creams, or drug exposures. They do, however, report mild upper respiratory symptoms 1 week ago. 

On physical examination, he has multiple confluent lesions with central clearing diffusely. The lesions are present on his palms and soles but are most prominent on his bilateral lower extremities. There is no conjunctival injection, and there are no sores in or around his mouth or genital area.

Question: What is the next most appropriate management
strategy at this time?

A. Obtain a complete blood count (CBC) and blood culture, administer ceftriaxone, and admit for
B. Obtain a CBC and blood culture, but do not treat with antibiotics
C. Discharge to home with diphenhydramine as needed for itching
D. Consult dermatology emergently
E. Administer subcutaneous epinephrine immediately

confluent rash whole over the body 

Answer: C
Diagnosis: Erythema multiforme (minor)
Discussion: Erythema multiforme (EM) is an acute and typically self - limited hypersensitivity reaction that manifests as a diffuse eruption with characteristic lesions. The  lesions are usually symmetric, involve the palms of the hands and the soles of the feet, and predominate on the
extensor surfaces of the upper and lower extremities.
Although these are characteristic locations, lesions can be found anywhere on the body. The rash of EM can look macular, urticarial, or vesicobullous, but the prototypical  lesion is a target lesion with a dusky center. Often the rash changes from one form of lesion to another as the disease progresses. The rash itself generally lasts for at least 1 week, but can last up to 6 weeks. Patients are often otherwise asymptomatic, although they can also have itching associated with the lesions or involvement of the oral mucosa.  The causes of EM in children are most commonly infectious,
whereas in adults the condition is much more frequently related to drug reaction or malignancy. The most common infectious agent attributed to EM is herpes simplex virus. The differential diagnosis of EM includes pemphigus, bullous pemphigoid, urticaria, or other viral exanthems. Treatment for EM minor may involve cessation of inciting agents but is mainly supportive, including antihistamines and/or nonsteroidal anti - infl ammatory drugs. Systemic glucocorticoids are sometimes used, although there are no randomized trials showing clear  benefi t. Recurrent cases may be treated with antiviral medications including acyclovir, valacyclovir, or  famciclovir.

 Classically, EM has been thought to be part of continuum of more serious illness such as Stevens – Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), but increasingly EM is being considered a distinct diagnosis, albeit with a similar pathophysiology to that of the more  severe syndromes. It is important on physical examination to evaluate mucosal surfaces to differentiate between EM and SJS or TEN. EM involves the skin and only one other mucosal surface, usually the mouth. In contrast, SJS involves the eye, oral cavity, genital mucosa, upper airway, or esophagus. SJS and TEN are much more serious conditions with signifi cantly higher mortality rates. 

Treatment for these conditions is frequently compared to burn care, and hospital admission is required. It is important to keep these other entities in mind even in cases of EM because patients and their families should be discharged with clear instructions about signs to look for that may indicate progression to more serious disease.

Sunday, July 12, 2015

Anorexia, Hair Loss, and Fingernail Bands

Anorexia, Hair Loss, and Fingernail Bands

Case presentation: A 62-year-old man has been hospitalized 10 times during the previous 5 years. He has been  treated for gastrointestinal disturbances, cardiomyopathy, leucopenia, and paresthesias. He presents again after several days of uncontrollable diarrhea and vomiting. His “glove and sock” paresthesias have rapidly progressed.

He is having significant hair loss and is experiencing weakness of the upper and lower extremities. A picture of his nails is noted below.

Question: What substance is most likely responsible for
his signs and symptoms?
A. Arsenic
B. Barium
C. Aluminum
D. Chromium
E. Bismuth

Answer: A

Diagnosis: Arsenic toxicity
Discussion: Numerous reports of acute intoxication following criminal poisoning have been published (in the  case presented, the patient ’ s wife was placing it into his food). Clinical effects may appear minutes, hours, or days after exposure depending on the dose and type of arsenic consumed. The earliest manifestations of acute poisoning are severe gastrointestinal symptoms of nausea, vomiting, abdominal pain, and diarrhea. The diarrhea may resemble that seen with cholera and can appear as “ rice water. ” These symptoms occur within minutes to several hours
after ingestion. The patient often complains of muscle cramps and thirst. Cardiovascular and respiratory symptoms include hypotension, shock, pulmonary edema, acute respiratory distress syndrome, and heart failure.
Prolonged or additional symptoms may occur for days to weeks after an acute exposure. Neurologic symptoms such as headache, confusion, personality change, irritability, hallucinations, delirium, and seizures may develop or persist. Peripheral neuropathy commonly occurs 1 – 3 weeks after an acute poisoning.

The peripheral neuropathy may last for years. Progressive neuropathy may be misdiagnosed as Guillain – Barr é syndrome. Sensory symptoms may include numbness, tingling, lightheadedness, delirium, encephalopathy, muscle weakness, and severe pain following superfi cial touch of the limbs.  An accumulation of arsenic in the skin, hair, and nails causes clinical effects such as hyperpigmentation, keratoses o f the palms and soles, melanosis, and hair loss. Mees ’ lines may be seen and correspond with signifi cant poisonings that have occurred previously.    

Mees’ lines highlighted by arrows.

A metallic taste and garlic odor of the breath and sweat may be noted. Definitive diagnosis is made by an elevated urinary arsenic level. 

Friday, July 10, 2015

What laboratory test is most appropriate for this patient?

3. Calcitonin

This patient had multiple flesh-colored papules on the eyelids, lips, and tongue. This phenotype is suggestive of multiple endocrine neoplasia (MEN) type 2B (MEN-2B), an autosomal dominant condition characterized by medullary thyroid cancer among other features. Serum calcitonin can be used to screen for medullary thyroid cancer. 

A 16-year-old boy presented with multiple flesh-colored papules and dermal nodules on his eyelids, lips, and tongue (Panels A, B, and C, respectively). Six years earlier, his mother had received a diagnosis of metastatic medullary thyroid cancer, at the age of 38 years. At that time, both of her sons were found to have markedly elevated serum calcitonin levels but no biochemical evidence of pheochromocytoma. Both boys subsequently underwent total thyroidectomy. 

On pathological examination, a medullary thyroid tumor measuring 0.5 cm by 0.5 cm had been discovered in the thyroid gland of this patient. This clinical history is suggestive of the multiple endocrine neoplasia type 2B syndrome, an autosomal dominant condition characterized by medullary thyroid cancer, pheochromocytoma, mucosal neuromas, intestinal ganglioneuromas, and marfanoid body habitus. Although comprehensive genotyping of the RET proto-oncogene was not available at the time of this family's presentation, such analysis now allows for highly specific screening of family members and subsequent initiation of genetic counseling, pheochromocytoma screening, and prophylactic thyroidectomy. The boy continues to receive levothyroxine replacement therapy and appropriate screening investigations.

Wednesday, July 8, 2015




Zinc supplements are used for the treatment of zinc deficiency, severe diarrhoea, liver cirrhosis, alcoholism and Wilson’s disease.
Do not take zinc supplements more than 100 mg/day. It can increase the risk of developing prostate cancer.

Zinc supplements are contraindicated in HIV/AIDS patients.
Other Drug Interactions
Zinc may interact with cisplatin, quinolone antibiotics, tetracycline, amiloride and penicillamine
For treatment of common cold (Adults):
Consider administration zinc gluconate or acetate lozenge equivalent to 9-24 mg of elemental zinc, every two hours.

For treatment of diarrhoea and malnourishment (Adults):
Consider administration of 10-40 mg of zinc, daily
Prevention of pneumonia among malnourished children:
Consider administration of 10-70 mg/day.

For treatment of abnormal taste changes (Adults):
Consider administration of 25-100 mg/day.

For treatment of anorexia nervosa (Adults):
Consider administration of 100 mg of zinc gluconate, daily.

For treatment of peptic ulcers (Adults):
Consider administration of 200mg of zinc, thrice daily.

For treatment of muscle cramps in hepatic patients with zinc deficiency (Adults):
Consider administration of 220mg of zinc, twice daily.

For treatment of osteoporosis (Adults):
Consider 15 mg of zinc with other supplements including copper, manganese and calcium.

For treatment of sickle cell anemia (Adults):
Consider administration of 220mg of zinc, thrice daily.
For treatment of ADHD (Children):
Consider administration of 15-40mg of elemental zinc

For treatment of AMD (Adults):
Consider administration of 80 mg of elemental zinc with vitamins.

For treatment of acne (Adults)
Consider administration of 30-135 mg of elemental zinc, every day.
Zinc supplements can be taken before or after food intake

List of Contraindications

Zinc and Pregnancy
Zinc supplements are not classified under USFDA Pregnancy Category. In recommended dietary allowances (RDA), zinc supplements are likely safe for pregnant women. Consult a physician before taking Zinc supplements.
Zinc and Lactation
In recommended dietary allowances (RDA), zinc supplements are likely safe for lactating mothers. Consult a physician before taking Zinc supplements.

Zinc and Children
Do not give Zinc supplements to children unless prescribed by a pediatrician

Tuesday, July 7, 2015

“My Eyes Are Yellow!”

“My Eyes Are Yellow!”

Case presentation: 
A 48-year-old female presents to the emergency department with the chief complaint: “My
eyes are yellow!” 
Yellow Eye , Icterus 

She denies other clinical symptoms. Her physical examination is remarkable only for scleral icterus and jaundice (illustrated). No abdominal tenderness or hepatomegaly is detected

Question: Which of the following statements is true?

A. Her scleral icterus effectively rules out hemolysis as a cause of her condition
B. Normal to mildly elevated transaminases with an elevated alkaline phosphatase and conjugated
bilirubin would suggest extrinsic bile duct compression in this patient
C. The presence of Courviosier’s sign suggests an infectious etiology in this patient
D. The lack of abdominal pain effectively rules out pancreatic cancer as a cause of her condition
E. Excessive beta-carotene ingestion is a potential cause of this patient’s condition

note the lower bulbar conjunctiva is yellow 

Answer: B
Jaundice secondary to hyperbilirubinemia
Discussion: Jaundice is the yellowish discoloration of the skin, mucous membranes, and sclerae caused by hyperbilirubinemia. Jaundice is not usually clinically apparent unless the serum bilirubin is above 3 mg/dL. It can be sign of many medical conditions ranging from the benign to the potentially fatal.
Jaundice results from a dysfunction in bilirubin metabolism at either the prehepatic, intrahepatic, or posthepatic phase. Bilirubin itself is produced from the metabolism of heme, which largely comes from breakdown of red blood cells.
The fi rst step in the diagnosis of jaundice is determining the type of hyperbilirubinemia. Blood should be analyzed for levels of conjugated and unconjugated bilirubin.
If the hyperbilirubinemia is primarily unconjugated, a disorder of bilirubin metabolism should be suspected. Increased bilirubin production that occurs from hemolysis, ineffective erythropoiesis, massive transfusion, or the resorption of a large hematoma can exceed the liver ’ s conjugation process. Decreased hepatocellular uptake can be caused by drugs such as rifampin. Decreased conjugation is responsible for Gilbert ’ s or Crigler – Najjar syndrome and is the cause of physiologic jaundice of the newborn.

If the hyperbilirubinemia is predominantly conjugated, the etiology is likely to be secondary to liver disease, cholestasis, extrinsic bile duct compression, Dubin – Johnson or Rotor ’ s syndrome. Alanine aminotranferase and aspartate aminotransferase elevation suggests intrinsic liver disease or a cholestatic process. Normal to mildly elevated transaminases with an elevated alkaline phosphatase
and gamma - glutamyltransferase suggests extrinsic bile duct compression. Etiologies of intrinsic
liver disease include hepatitis, cirrhosis, hepatotoxins, metabolic disorders of the liver such as Wilson ’ s disease, HELLP syndrome, and infi ltrative diseases such as amyloidosis and metastatic carcinoma. Cholestatic diseases include graft-versus-host disease, primary biliary cirrhosis, and drugs such as erythromycin and chlorpromazine.

Extrinsic obstruction of the bile ducts can be caused by cholelithiasis and cholecystitis, primary sclerosing cholangitis, postsurgical strictures, neoplasms of the pancreatic head and biliary tract, and pancreatitis. Initial imaging of the right upper quadrant can be done with either computed tomography or ultrasound scanning. Further work-up should be directed by the outcome of initial
laboratory values and abdominal imaging. Scleral icterus is more sensitive than jaundice for the
detection of hyperbilirubinemia because of the high concentration of elastin in the sclera, which has a high affinity for bilirubin. Courvoisier’s sign is painless enlargement of the gallbladder that represents extrinsic compression of the biliary tree; however, it is present in less than a third of patients with biliary obstruction. The classic diagnosis associated with painless jaundice is pancreatic carcinoma. Excessive beta-carotene ingestion does not cause scleral icterus. Lack of scleral icterus can clinically differentiate pseudo-jaundice caused by beta-carotene from jaundice. Cholestatic jaundice can also present with generalized pruritis as the primary complaint. 


Sunday, July 5, 2015

new medication and notes that his breasts have become enlarged

A male patient is placed on a new medication and notes that his breasts have become enlarged and tender to the touch. 

breast enlargement in male 

Which medication is he most likely taking?

A. Chlorthalidone.
B. Furosemide.
C. Hydrochlorothiazide.

D. Spironolactone.

E. Triamterene.

Correct answer = D. An adverse drug reaction to spironolactone is gynecomastia due to its effects on androgens and progesterone in the body. Eplerenone may be a suitable alternative if the patient is in need of an aldosterone antagonist but has a history of gynecomastia.

Spironolactone [spy-ro-no-LAC-tone] is a direct antagonist of aldosterone, thereby preventing salt retention, myocardial hypertrophy, and hypokalemia.

40-year-old male has recently been diagnosed with hypertension

A 40-year-old male has recently been diagnosed with hypertension due to pressure readings of 163/102 and 165/100 mm Hg. He also has diabetes that is well controlled with oral hypoglycemic medications.

BP monitoring 
Which is the best initial treatment regimen for treatment of hypertension in this patient?A. Felodipine.
B. Furosemide.
C. Lisinopril.
D. Lisinopril and hydrochlorothiazide.E. Metoprolol

Correct answer = D. Because the systolic blood pressure is more than 20 mm Hg above goal (10 mm Hg above goal diastolic), treatment with two different medications is preferred. Because the patient is diabetic, he also has a compelling indication for an ACE inhibitor or ARB.