What is the approach to managing common OPD and casualty cases, including history, examination, investigations, and treatment, according to Indian guidelines?

Approach to Common OPD and Casualty Cases

I'll provide you with structured case note templates for the most common presentations you'll encounter as a junior doctor in Indian OPD and casualty settings.

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COPD Exacerbation (Acute)

History

Key Points to Document:

• Baseline exercise tolerance - specifically how independent the patient is normally versus during this exacerbation 1
• Current medications - especially nebulizers and long-term oxygen therapy (LTOT) 1
• Timeline of current exacerbation - when symptoms worsened 1
• Social circumstances - living alone/with support/with family, and suitability of accommodation 1
• Previous admissions - number in past 5 years, including any ICU admissions 1
• Smoking history - pack-years 1

Examination

Critical Signs Indicating Severe Deterioration:

• Infection markers - fever, frankly purulent sputum 1
• Severe airflow obstruction - audible wheeze, tachypnea, use of accessory muscles 1
• Peripheral edema 1
• Cyanosis and/or confusion 1

Investigations

Immediate (within 60 minutes):

• Arterial blood gas - note the inspired oxygen concentration (FiO2) 1
• Chest X-ray 1

Within 24 hours:

• Complete blood count 1
• Urea and electrolytes 1
• ECG 1
• FEV1 and/or peak flow - start serial peak flow chart 1
• Sputum culture - if purulent 1
• Blood cultures - if pneumonia suspected 1

Management

Oxygen Therapy (Critical - Follow This Protocol):

• Start with maximum 28% via Venturi mask or 2 L/min via nasal cannulae until ABG known in patients aged ≥50 years with COPD history 1, 2
• Check ABG within 60 minutes of starting oxygen and within 60 minutes of any change 1, 2
• Target PaO2 ≥6.6 kPa without pH falling below 7.26 1, 2
• If PaO2 improving and pH stable, gradually increase oxygen until PaO2 >7.5 kPa 1, 2
• If pH falls below 7.26, consider ventilatory support 1, 2

Bronchodilators:

• Nebulized beta-agonist or anticholinergic on arrival, then 4-6 hourly 1, 2
• For severe cases or poor response, combine both beta-agonist and anticholinergic 1, 3
• Drive nebulizers with compressed air (not oxygen) if PaCO2 elevated or respiratory acidosis present 3

Antibiotics - Give if ≥2 of the following:

• Increased breathlessness 1, 4
• Increased sputum volume 1, 4
• Development of purulent sputum 1, 4

Corticosteroids:

• Prednisolone 30 mg daily for 7-14 days (or hydrocortisone 100 mg IV if oral not possible) 1, 4, 3
• Do not continue long-term after exacerbation 1, 4

Additional Measures:

• Diuretics - if peripheral edema and raised JVP present 2, 3
• Prophylactic subcutaneous heparin - for acute-on-chronic respiratory failure 2, 3
• Avoid sedatives and hypnotics - may worsen respiratory depression 3

Ventilatory Support Indications:

• pH <7.26 with rising PaCO2 despite controlled oxygen 2, 3
• Consider NIPPV first - reduces need for intubation 2, 3
• Factors favoring ventilation: identifiable reversible cause, first episode of respiratory failure, acceptable quality of life 2

Common Pitfalls:

• Never give high-concentration oxygen without ABG monitoring - may worsen respiratory acidosis 2
• pH <7.26 predicts poor outcome - requires aggressive management 2
• Do not use chest physiotherapy during acute exacerbations 3

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Acute Asthma Exacerbation

History

• Onset and duration of current symptoms
• Trigger factors - infection, allergen exposure, medication non-compliance
• Usual medications - inhaler types, doses, compliance
• Previous severe attacks - ICU admissions, intubations
• Last oral steroid course - when and response

Examination

Severity Assessment:

• Respiratory rate - >25/min suggests severe
• Heart rate - >110/min suggests severe
• Peak flow - <50% predicted suggests severe, <33% life-threatening
• Ability to speak - inability to complete sentences suggests severe
• Use of accessory muscles
• Silent chest - life-threatening sign
• Altered consciousness - life-threatening sign

Investigations

• Peak expiratory flow rate (PEFR) - immediately
• Oxygen saturation - continuous monitoring
• ABG - if SpO2 <92% or severe/life-threatening features
• Chest X-ray - if pneumothorax suspected or not responding
• ECG - if cardiac complications suspected

Management

Immediate Treatment:

• Oxygen - target SpO2 94-98%
• Salbutamol nebulization - 2.5-5 mg, can repeat every 20 minutes
• Ipratropium bromide - 500 mcg nebulized with salbutamol for severe cases
• Hydrocortisone 100 mg IV or prednisolone 40-50 mg oral immediately
• IV magnesium sulfate 2 g over 20 minutes - for severe/life-threatening cases

Monitoring:

• PEFR every 15-30 minutes initially
• Continuous SpO2 monitoring
• Repeat ABG if deteriorating

Admission Criteria:

• PEFR <50% predicted after initial treatment
• Previous severe attacks
• Presenting at night
• Pregnancy
• Inadequate social support

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Acute Gastroenteritis

History

• Duration and frequency of diarrhea and vomiting
• Stool characteristics - watery, bloody, mucoid
• Fever - presence and degree
• Recent food intake - outside food, contaminated water
• Similar illness in contacts
• Urine output - to assess dehydration
• Comorbidities - diabetes, immunosuppression

Examination

Dehydration Assessment:

• Mild - thirst, dry mucous membranes
• Moderate - sunken eyes, reduced skin turgor, tachycardia
• Severe - hypotension, altered consciousness, oliguria

Abdominal examination - tenderness, guarding (to rule out surgical abdomen)

Investigations

• Stool routine and culture - if bloody diarrhea or fever
• Complete blood count
• Renal function tests and electrolytes - if moderate-severe dehydration
• Blood sugar - especially in diabetics

Management

Mild Dehydration (OPD Management):

• ORS solution - 200-400 ml after each loose stool
• Zinc supplementation - 20 mg daily for 14 days (especially children)
• Continue normal diet - avoid only milk products temporarily
• Probiotics - may reduce duration

Moderate-Severe Dehydration (Casualty/Admission):

• IV fluids - Ringer's lactate or normal saline
  • Rapid bolus - 20 ml/kg over 15-30 minutes if severe
  • Maintenance - based on deficit calculation
• Monitor urine output - aim >0.5 ml/kg/hr

Antibiotics - Only if:

• Bloody diarrhea with fever (suspected dysentery)
• Cholera suspected (rice water stools)
• Immunocompromised patients
• Avoid routine antibiotics - most cases are self-limiting

Antiemetics:

• Ondansetron 4-8 mg IV/oral - if severe vomiting

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Acute Febrile Illness (Undifferentiated)

History

• Fever pattern - continuous, intermittent, duration
• Associated symptoms - headache, body ache, rash, bleeding manifestations
• Travel history - malaria endemic area
• Mosquito exposure
• Sick contacts
• Vaccination status

Examination

• Vital signs - temperature, BP, pulse, respiratory rate
• Hydration status
• Rash - petechiae, maculopapular
• Hepatosplenomegaly
• Lymphadenopathy
• Warning signs - bleeding, altered consciousness, severe abdominal pain

Investigations

Day 1-3 of fever:

• Complete blood count with platelet count
• Peripheral smear for malaria - thick and thin films
• Dengue NS1 antigen
• Blood culture - if typhoid suspected
• Urine routine
• Chest X-ray - if respiratory symptoms

Day 4-7 of fever:

• Dengue IgM/IgG antibodies
• Widal test - for typhoid (after 7 days)
• Repeat platelet count daily - if dengue suspected

Management

Supportive Care:

• Paracetamol 500-1000 mg - every 6 hours for fever
• Avoid NSAIDs - especially if dengue suspected (bleeding risk)
• Adequate hydration - oral or IV fluids
• Monitor platelet count daily - if dengue suspected

Specific Treatment:

• Malaria positive - artemisinin-based combination therapy (ACT) or chloroquine based on species
• Dengue - supportive care, monitor for warning signs, platelet transfusion only if active bleeding
• Typhoid suspected - ceftriaxone 2 g IV daily or azithromycin 500 mg oral daily

Admission Criteria:

• Warning signs (severe abdominal pain, persistent vomiting, bleeding)
• Platelet count <20,000/μL
• Hemodynamic instability
• Comorbidities

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Acute Chest Pain

History

• Character - crushing, sharp, burning
• Location and radiation - retrosternal, left arm, jaw
• Duration - seconds, minutes, hours
• Aggravating/relieving factors - exertion, position, food
• Associated symptoms - sweating, breathlessness, palpitations
• Risk factors - diabetes, hypertension, smoking, family history

Examination

• Vital signs - BP both arms, pulse, respiratory rate
• Cardiovascular - heart sounds, murmurs, JVP
• Respiratory - air entry, crepitations
• Chest wall tenderness

Investigations

Immediate:

• ECG - within 10 minutes of presentation
• Oxygen saturation

Within 30 minutes:

• Troponin I or T - at presentation and 3-6 hours later
• Chest X-ray
• Complete blood count
• Renal function tests
• Blood sugar
• Lipid profile

Management

If STEMI (ST elevation MI):

• Aspirin 300 mg - chew immediately
• Clopidogrel 300 mg - loading dose
• Atorvastatin 80 mg
• Morphine 2-4 mg IV - for pain
• Oxygen - only if SpO2 <94%
• Arrange primary PCI - door-to-balloon time <90 minutes
• If PCI not available - thrombolysis with streptokinase/tenecteplase within 12 hours

If NSTEMI/Unstable Angina:

• Aspirin 300 mg
• Clopidogrel 300 mg
• Atorvastatin 80 mg
• Low molecular weight heparin - enoxaparin 1 mg/kg SC twice daily
• Beta-blocker - metoprolol 25-50 mg
• Admit for monitoring and risk stratification

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Acute Breathlessness

History

• Onset - sudden or gradual
• Duration
• Orthopnea, PND - suggests cardiac cause
• Cough, sputum - suggests respiratory cause
• Chest pain
• Leg swelling
• Known cardiac/respiratory disease

Examination

• Respiratory rate - >24/min suggests severe
• Oxygen saturation
• Chest examination - wheeze, crepitations, reduced air entry
• Cardiac examination - gallop rhythm, murmurs
• JVP, pedal edema

Investigations

• Oxygen saturation
• Chest X-ray
• ECG
• ABG - if SpO2 <92%
• Complete blood count
• Renal function tests
• BNP/NT-proBNP - if cardiac cause suspected

Management

Acute Pulmonary Edema:

• Sit patient upright
• Oxygen - high flow to maintain SpO2 >94%
• Furosemide 40-80 mg IV
• Nitroglycerin - sublingual or IV infusion if BP permits
• Morphine 2-4 mg IV - reduces anxiety and preload
• NIPPV/CPAP - if not responding

Acute Asthma: (See above)

Pneumonia:

• Oxygen - target SpO2 94-98%
• Antibiotics - ceftriaxone 1-2 g IV + azithromycin 500 mg
• IV fluids
• Bronchodilators - if wheeze present

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Altered Sensorium/Unconscious Patient

History (from attendants)

• Onset - sudden or gradual
• Preceding symptoms - fever, headache, vomiting, seizures
• Trauma history
• Diabetes - hypoglycemia risk
• Medications - overdose possibility
• Alcohol/substance use

Examination

• Glasgow Coma Scale - document E, V, M scores
• Vital signs - temperature, BP, pulse, respiratory rate
• Pupil size and reaction
• Focal neurological deficits
• Neck stiffness - meningitis
• Signs of trauma
• Breath smell - alcohol, ketones

Investigations

Immediate:

• Blood sugar - finger prick test first
• Oxygen saturation
• ECG

Urgent:

• Complete blood count
• Renal function tests, electrolytes
• Liver function tests
• Arterial blood gas
• CT head - if trauma or stroke suspected
• Lumbar puncture - if meningitis suspected (after ruling out raised ICP)

Management

ABC Approach:

• Airway - secure airway, recovery position
• Breathing - oxygen if SpO2 <94%
• Circulation - IV access, fluids if hypotensive

Specific Treatments:

• Hypoglycemia - 25% dextrose 100 ml IV bolus
• Opioid overdose - naloxone 0.4-2 mg IV
• Seizures - lorazepam 4 mg IV or diazepam 10 mg IV
• Suspected meningitis - ceftriaxone 2 g IV immediately (don't wait for LP)
• Stroke - aspirin 300 mg (after CT rules out hemorrhage)

Monitoring:

• GCS every 15-30 minutes
• Vital signs
• Urine output

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Key Principles Across All Cases:

• Document vital signs in every patient 1
• Never delay life-saving treatment for investigations
• Reassess frequently - clinical condition can change rapidly 5
• Communicate with seniors early if uncertain 6
• Ensure proper handover if admitting patient