Feedback from readers and buyers of handbook of family medicine volume 1

1.Its a nice concise book with point wise description which will help in last minute revision.The physiotherapy protocols and other chapters are nice,very practical and useful in daily practice.A good book for viva revision too.All the best.- Dr.Wilma Carvalho,M.B.B.S.D.C.H. M. MED. Family Medicine (CMC Vellore),Belgaum.
2.Congrats smruti.Went through few pages.It is really very nice.Really good work.Its very simple,easy to follow and handy for our practice.-Dr.Yasmin,Coimbatore.
3.Its a very good,easy to understand even by non medicos,well composed book.My best wishes.-Mr.Nandkishor Kalbhor,Pune.
4.Its a very awesome and good book.Also its very useful .Hope it turn out to be awesome service to all D.N.B.Family Medicine pgs.-Dr.Shrihari,Andhra pradesh.
5.Its a really good book.Hard work of authors is commendable.Font size is small but content is good.-Dr.Ajit Jangale,Pune.
6.Book is easy to understand.It covers all important topics in short subject series and no need to read separate book for short subject.Font size is small but my request is to increase it in your next book.Also add few more figures,pictures and flow charts.It will be easy to understand.Good efforts.Kindly publish your next volume as early as possible.Thank you.-Dr.Bijay raj,Delhi.
7.Your book is good Dr.Smruti.Easy to understand.-Dr.Gourab,Kolkata.
8.Madam I have seen your handbook.. Its simply amazing..Thanks alot.You made exam preparation easy.Hope you will bring next volume soon.-Dr.RamaRao, Hydrabad.
9.Mam book is really nice.Hope you will publish next volume soon.-Dr.Mayuri,Hydrabad.
10.Book is very good and useful for us.-Dr. Sakshi,Delhi.
11.The book is really nice and useful.Thank yo umam.-Dr.Dhanya,Trivendrum.
12.The book is awesome & helpful.I like the presentation of the book of each and every topic.You almost cover all the topics.Waiting for second one. -Dr.Varun,Delhi NCR.
13.Very comprehensive book.-Dr.Aditya,Banglore.
14.Nice book.If one reads the book can say surgery and short subjects done. - Dr. Shweta sadhawani,Gurgaon.
15. It is very nice book and I was in need of this kind of book before my june exam.-Dr.Ishan,Pondecherry
16.Very nice and exam preparation oriented book. - Dr.Pradeep,Delhi.
17.Your books are really helping our students in exam preparation - Dr.Bhuvana,Faculty ,D.N.B. Family Medicine, Sri Sathya Sai Super speciality Hospitals, Puttaparthi,Andhra Pradesh.
18.Very nice book.this book is hope for us to read hard. - Dr.Naveen,Assam.
19.Its a very helpful book.Point wise presentation is nice.I am using this book only in my posting preparation as revision.- Dr.Nadiya,USM-KLE IMP,Belgavi.
20.Books made study of family medicine exams much easy.Very helpful.Will try to contribute i n revised editions of book.- Dr.Paul.
21.Books really helped me in clearing my theory exam.Worth reading. - Dr. Afzal.

Sneak peek 5 handbook of family medicine vol 1

5. LOCAL ANAESTHESIA

Dr. Pritam Haval Dr. Smruti Haval

Local anaesthetic (LA) drugs are most commonly used in primary care practice for various procedures. They are classified on basis of their chemical structure and duration of action. Chemically LA consists of a benzene ring separated from tertiary amide either by ester or amide ring linkage. Hence based on that they are classified as aminoesters and aminoamides.

Based on chemical structure

Amino esters	Amino amides
Procaine Chloropracaine Benzocaine Cocaine	Lignocaine Mepivacaine Prilocaine Bupivacaine
Metabolized by psudocholinesterase (except cocaine which use liver for metabolism)	Metabolized primarily in liver
High incidence allergic reaction	Low incidence allergic reaction
Unstable solution	Stable solution
Have shorter duration of action	Have longer duration of action

Mechanism of action

·         Drug with non-ionized form penetrates axonal membrane and inside it gets ionized.

·         This ionized form binds to receptor situated in sodium channel in inactivated state from inner side, blocking the channel and preventing depolarization and action potential.

·         LA enters at node of Ranvier.

·         Potency of LA depends upon lipid solubility.

·         Onset of action depends on pH & pKa.

·         Local anesthetic drugs are weak bases, agents with pKa closer to physiological pH will have more drugs in non-ionized form which can diffuse through axonal membrane and so onset will be rapid. That is why soda bicarbonate is added to LA which increases pH and more drugs is available to use in non-ionized form.

·         Type of fiber decides susceptibility to block. Small diameter axons are more susceptible to block than large diameter fibers.

·         However myelinated fibers are more sensitive than non myelinated fibers. Based on the diameter of fiber they are classified as type A, B, C.

·         HENCE SEQENCE OF BLOCAKGE IS TYPE B> type C >type A.

·         Functionally system wise autonomic>sensory>motor and in recovery motor>sensory>autonomic.

·        Among sensory fibers sequence of blockage temperature (cold>hot) >pain>touch >deep pressure>proprioception

·         Duration of action depends upon dose, plasma protein binding capacity and vasoconstrictor ability.

·     Systematic absorption depends on site if injection and additional vasoconstriction. Additional vasoconstriction increases margin of safety by decreasing systematic absorption.

Systemic effects and toxicity

Cardiovascular system:

Negative inotropic effect myocardium; depression of conduction system; Ventricular arrthmias at high dose; hypotension, cardiac arrest, bradycardia.

Central nervous system:

This is the first to get involved and affected system. Depression of cerebral tissues (inhibitory more than excitatory);Symptoms and signs are dizziness, circumoral numbness, tongue parasthesia, visual & auditory disturbances, muscle twitching, tremors, convulsions and coma.

Respiratory system:

Lignocaine depressed hypoxic drive; Direct depression of medullary respiratory center can occur at high dose.

Immunological:

Allergic reactions are common with esters than amides; Cross sensitivity does not exist between amides and esters but do exist between drugs of same class.

Local toxicity:

When injected directly into nerve, LA can damage nerve. When directly injected into muscle they are myotoxic.

LA and other drugs

Adrenaline

In concentration of 1:200000 duration of both sensory and motor blockade is increased by addition of epinephrine to lignocaine. But only sensory block is prolonged if epinephrine is added to bupivacaine with no effect on motor blockade.

Xylocaine with adrenaline should not be used for Ring block (for fingers, toe, penis, pinna [absolute contraindications]); with inhalational agent (especially halothane which sensitizes myocardium to adrenaline is used); myocardial ischemia; hyperthyroid; severe hypertensive and intravenous regional anesthesia.

Soda bicarbonate

1 ml of 8.4% to 10 ml of lignocaine enhances onset of action,duration of action and improve quality off block, decrease pain of injection.

Modes of administration of LA

·         Topical application at skin: Prilocaine 5% and lignocaine 5% equal amount (1:1 ratio)

·         At mucous membrane of mouth, pharynx, larynx in form of xylocaine sprays 4% or benzocaine lozenges.

·         For catheterization and proctoscopy, lignocaine jelly 2%.

·         Eye drops tetracaine ointments and cocaine drops.

·         For anal canal & rectum like piles, fissures lignocaine 4%,dibucaine 1%,benzocaine 5% ointment.

·         For gastritis oxethazaine 0.2%.

·         Infiltration at operation site & nerve block by injecting around nerve.

·         Central neuraxial blocks like spinal & epidural.

·         Beir’s block by intravenous regional anaesthesia.

·         Intravenous preservative free lignocaine (xylocard 2%) used dosage 2 mg/kg .Its use blunts cardiovascular response to laryngoscopy and intubation.

Further reading

Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s clinical anesthesiology. 5^th ed., McGraw Hill; 2013

Classification Based on duration of action and potency

Drug	Duration	Potency	Duration of action		Max safe dose (mg/kg)	Comment
			Without adrenaline	With adrenaline
Chloroprocaine	Shortest	Low	15-25 min	30-90 min	12 mg/kg	Shortest acting
Procaine	Short	Low	15-30 min	30-90 min	12 mg/kg
Lignocaine	Intermediate	Intermediate	45-60 min	2-3 hour	3 mg/kg without adrenaline 7 mg/kg with adrenaline	Not to be used in patients with h/o malignant hyerthermia,can cause cauda eqina syndrome after continuous spinal. doc ventricular a tachycardia
Mepivaccaine	Intermediate	Intermediate	45-60 min	2-3 hour	4.5 mg/kg
Cocaine	Intermediate	Intermediate			3 mg/kg	Potent vasoconstrictor
Prilocaine	Intermediate	Intermediate	45-60 min	2-3 hour	8 mg/kg	Can cause methhaemoglobinemia
Bupivacaine	Long	High	2-3 hour	3-5 hour	2 mg/kg	Very commonly used LA
Dibucaine	Longest	High	2.5-3.5hour	3.5-5.5 hour	1 mg/kg	Longest acting, most potent, most toxic

How to study geriatric medicine?

Dear friends,
           Many students asked us what is geriatric medicine,how different it is from routine medicine,do we need to prepare separately for it  in our D.N.B.preparation?
          Well geriatrics is a developing discipline as due to better health services elderly population is on rise.Also changed family structure to nuclear family old age homes are increasing.So a family medicine person should know well about geriatric population medicine.
            Its a special age group hence require few modification in your routine treatment protocol due to there altered physiological body status.In  D.N.B. no special preparation is required as you daily work with many old age patients in your ward,ICU,OPD rotation.What simple thing  you need to follow is observe carefully  modifications are required in there treatment,your half battle is over there only.
             You can also read publications by geriatric society India and books like CMDT geriatrics.
post D.N.B. you can do some good course in geriatrics to enhance your knowledge further in subject.
while preparing for exam do follow qs in q bank by us.These will save your lot of time.You must have noticed that each year paper 1/2  have  approach based geriatric qs.So all the best and prepare well,fearlessly.Almighty blessed us all.good day.

Team of contributors handbook of family medicine volume 1

                                                                 

Dear friends,

please welcome my able contributors of integrated handbook of family medicine volume 1 .Without their support to complete this task was impossible.Hope you will like our efforts.good day.

                                                          Contributors

Ophthalmology Section

Dr. Usha Subhash Nikumbh _{MS (Ophthalmology), PHACO, Glaucoma, LASIK, Viteoretinal Surgeon (Fellow USA)}

Consultant Ophthalmologist,

Nikumbh Hospital, Chalisgaon,

Dist. Jalgaon, Maharashtra

Anesthesia Section

Dr. Pritam Nandkumar Haval _DA

Consultant Anesthesiologist,

Rukmini Multispeciality Hospital,

Sankeshwar,dist: Belgaum,

Karnataka

Surgery Section

Dr. Pradeep P. Sharma _{MS, MNAMS, DNB, FICS, FAIS, FACRSI, FIAGES (Hon), FALS (Hon), FIMAS (Hon), FISCP (Hon), Fellow (Israel)}

Ex. Professor in Surgery, Bharati Vidyapeeth Deemed University Medical College and Hospital, Pune,

Head of Surgical Services & Senior Consultant, Noble Hospital and Research Hospital, Pune,

Consultant Surgeon, Jehangir Hospital and Research Centre, Ruby Hall Clinic, Pune, Maharashtra

Dr. Prajakta Y. Thakur _MBBS

General Physician,

Panvel, Navi Mumbai,

Maharashtra

Dr. Suraj J. Panjwani _MBBS

Grant Govt. Medical College & Sir J.J. Group of Hospitals,

Mumbai

Orthopedic Section

Dr. Sampat S. Dumbre Patil _{D. Ortho, DNB (Ortho), MNAMS}

Director and Head,

Orthopaedic Department,

Noble Hospital, Magarpatta,

Pune, Maharashtra

Dr. Suyog Nandkishor Kalbhor _{MD, D. Ortho}

Consultant Orthopedic Surgeon,

Pune, Maharashtra

Dr. Mudmala Vijaya Ram Reddy, _{MPT-Ortho & Sports medicine, MIAP}

Consultant Senior Physiotherapist and CEO

AIM (Access Innovative Medicine),

Bangalore,Karnataka

  

Dr. Ajit Jangale _{MS (Ortho)}

Sancheti Hospital,

Pune, Maharashtra

Otorhinolaryngology Section

Dr. Shweta (Pawar) Khadabadi _{MS, DNB (ENT) Fellow in Laryngology (Bombay hospital)}

Assistant Professor, Department of USM-KLE-IMP Belgaum,

Consultant, KLE Centenary Charitable Hospital, Yellur, Belgaum,Karnataka

Dr. Koustubh Dilip Khandke _{DNB (ENT)}

Deenanath Mangeshkar Hospital,

Pune

Dr. Tanvi Kaustubh Patil _{MS (ENT)}

Dr. K. T. Patil ENT Hospital,

Chalisgaon, Dist: Jalgaon,

Maharashtra

Printer: Satguru Printing Press, Chalisgaon,Dist. Jalgaon, Maharashtra .Pin-424101.

Type Set: Surffers Nook, Belgaum, Karnataka.

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