Nephrology Case No 3.Renal Stone.

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Nephrology Case No 3.Renal Stone.

একটা renal stone এর পেশেন্টের

চিকিৎসা করবেন কিভাবে :

প্রথমে

general management :

1.bed rest দিবো

2.pain releive করতে

-anti spasmodic -hyoscine N butyl bromide দিবো

Tablet 1:-Hysomide 20mg (AS A Hyoscine Butylbromide AS A Anticholinergics (antimuscarinics)/ Anti-spasmodics) Khabar age khali pete khete hobe.

Indications of Tablet :-Hysomide 20mg (AS A Hyoscine Butylbromide AS A Anticholinergics (antimuscarinics)/ Anti-spasmodics) Khabar age khali pete khete hobe.

হায়োসিন বিউটাইলব্রোমাইড একটি এন্টিকোলিনার্জিক ওষুধ, এবডোমিনাল ক্যাভিটির বিভিন্ন অংশের নরম মাংসপেশীর (smooth muscle) উপর যার খিঁচুনিবিরোধী (antispasmodic) ক্রিয়া রয়েছে। হায়োসিন বিউটাইলব্রোমাইড ট্যাবলেট গ্যাসট্রো ইন্টেসটিনাল ট্র্যাক্টে অথবা জেনিটো-ইউরিনারী ট্র্যাক্টের ভিসেরাল খিঁচুনি জনিত লক্ষণসমূহে নির্দেশিত। স্পাসমোডিক ডিসমেনোরিয়াতেও এটি নির্দেশিত। হায়োসিন বিউটাইলব্রোমাইড ইনজেকশন গ্যাসট্রো-ইন্টেসটিনাল খিঁচুনি এবং রেনাল অথবা পিত্তের (billary) তীব্র ব্যথাতেও নির্দেশিত। রেডিওলজীতে প্রতিবন্ধকতার পার্থক্যমূলক রোগ নির্ণয়ে, পাইলোগ্রাফীতে খিঁচুনি ও ব্যথা কমাতে এবং গ্যাসট্রো-ডিওডেনাল এনডোস্কোপীর মত রোগ নির্ণয়ের অন্যান্য পদ্ধতিতেও খিঁচুনির সমস্যা দূর করার জন্য হায়োসিন বিউটাইলব্রোমাইড ইনজেকশন ব্যবহার করা হয়।

Dosage & Administration of Tablet :-Hysomide 20mg (AS A Hyoscine Butylbromide AS A Anticholinergics (antimuscarinics)/ Anti-spasmodics) Khabar age khali pete khete hobe

খাওয়ার জন্য-

প্রাপ্ত বয়স্ক: ২০ মিগ্রা দিনে চার বার। স্পাসমোডিক ডিসমেনোরিয়ার ক্ষেত্রে ঋতুস্রাব (menstruation) শুরুর সম্ভাব্য তারিখের কমপক্ষে দুদিন আগে থেকে চিকিৎসা শুরু করতে হবে এবং স্রাব শুরুর তিনদিন পরে পর্যন্ত তা অব্যাহত রাখতে হবে।
শিশু ৬ থেকে ১২ বৎসর পর্যন্ত: ১০ মিগ্রা দিনে তিনবার অথবা চিকিৎসকের নির্দেশ অনুযায়ী।

ইনজেকশন হিসেবে-

প্রাপ্তবয়স্ক: মাংসপেশীতে বা শিরাপথে প্রয়োগের জন্য সাধারণ মাত্রা হচ্ছে ২০ মিগ্রা (১টি এ্যাম্পুল), প্রয়োজনে যা কিনা ৩০ মিনিট পর পুনরায় প্রয়োগ করতে হবে। এনডোস্কোপীর ক্ষেত্রে এই মাত্রা আরো ঘন ঘন প্রয়োগ করতে হবে।

Contraindications of Tablet :-Hysomide 20mg (AS A Hyoscine Butylbromide AS A Anticholinergics (antimuscarinics)/ Anti-spasmodics) Khabar age khali pete khete hobe

যে সব রোগীর প্রস্টেটিক বৃদ্ধি ঘটেছে তাদের ক্ষেত্রে এর ব্যবহার নিষিদ্ধ এবং বৃদ্ধদের ক্ষেত্রে এটি সতর্কতার সাথে ব্যবহার করতে হবে। যে সব রোগী প্যারালাইটিক ইলিয়াস অথবা পাইলোরিক ষ্টেনোসিসে ভুগছেন তাদের ক্ষেত্রেও ওষুধটির ব্যবহার নিষিদ্ধ। সম্ভাব্য মাইড্রিয়াটিক ক্ষতির কারণে যে সব রোগীর গ্লুকোমা রয়েছে তাদের ক্ষেত্রেও এটির ব্যবহার নিষিদ্ধ ।

Side Effects of Tablet :-Hysomide 20mg (AS A Hyoscine Butylbromide AS A Anticholinergics (antimuscarinics)/ Anti-spasmodics) Khabar age khali pete khete hobe

হায়োসিন বিউটাইলব্রোমাইড এর পার্শ্ব-প্রতিক্রিয়ার মধ্যে রয়েছে মুখ শুকিয়ে যাওয়া, পিউপিল এর প্রসরণ (dilatation), ইন্ট্রা-অকিউলার প্রেসার বৃদ্ধি, ফ্লাসিং, ত্বক শুকিয়ে যাওয়া, ব্র্যাডিকার্ডিয়া এবং তারপরেই ট্যাকিকার্ডিয়া ও এরিমিয়া। কখনো কখনো ক্লান্তি, বমি, মাথা ঝিমঝিম (giddiness) এবং ষ্ট্যাগারিং হতে পারে।

Pregnancy & Lactation of Tablet :-Hysomide 20mg (AS A Hyoscine Butylbromide AS A Anticholinergics (antimuscarinics)/ Anti-spasmodics) Khabar age khali pete khete hobe

গর্ভাবস্থার প্রথম তিন মাসে অন্যান্য ওষুধের মতো একেও সতর্কতার সাথে ব্যবহার করতে হবে।

Therapeutic Class of Tablet :-Hysomide 20mg (AS A Hyoscine Butylbromide AS A Anticholinergics (antimuscarinics)/ Anti-spasmodics) Khabar age khali pete khete hobe

Anticholinergics (antimuscarinics)/ Anti-spasmodics

-Analgesic (ketorolac)

Tablet 2:-Etorac 10mg AS A (ketorolac Tromethamine) (AS A Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Indications of Tablet :-Etorac 10mg AS A (ketorolac Tromethamine) (AS A Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Etorac is indicated for the short-term management of moderate to severe acute post-operative pain. Etorac ophthalmic solution helps relieve pain, inflammation, and light sensitivity after ocular surgery. It may also be used to decrease eye inflammation or redness caused by seasonal allergies.

Pharmacology of Tablet :-Etorac 10mg AS A (ketorolac Tromethamine) (AS A Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Ketorolac Tromethamine is a potent analgesic of the non-steroidal anti-inflammatory drugs (NSAIDs). It acts by inhibiting the cyclooxygenase enzyme system and hence inhibits the prostaglandin synthesis. It demonstrates a minimal anti-inflammatory effect at its analgesic dose.

Dosage & Administration of Tablet :-Etorac 10mg AS A (ketorolac Tromethamine) (AS A Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Tablet: Recommended dose is 10 mg every 4-6 hours. It should be used short-term only (up to 7 days) and are not recommended for chronic use. Doses exceeding 40 mg/day is not recommended.

Injection: Ketorolac injection may be used as a single or multiple doses, on a regular or when necessary schedule for the management of moderately severe, acute pain that requires analgesia at the opioid level, usually in a postoperative setting. When administering Ketorolac injection, the IV bolus must be given over no less than 15 seconds. The IM administration should be given slowly and deeply into the muscle. The analgesic effect begins within 30 minutes with maximum effect in 1 to 2 hours after dosing IV or IM. Duration of analgesic effect is usually 4 to 6 hours.

Single-Dose Treatment-
IM Dosing (Adult):

Patients <65 years of age: One dose of 60 mg.
Patients >65 years of age, renally impaired and/or less than 50 kg of body weight: One dose of 30 mg.

IV Dosing (Adult):

Patients <65 years of age: One dose of 30 mg.
Patients >65 years of age, renally impaired and/or less than 50 kg of body weight: One dose of 15 mg.

IV or IM Dosing (2 to 16 years of age):

IM Dosing: One dose of 1 mg/kg up to a maximum of 30 mg.
IV Dosing: One dose of 0.5 mg/kg up to a maximum of 15 mg.

Multiple-Dose Treatment (IV or IM)-

Patients <65 years of age: The recommended dose is 30 mg Ketorolac injection every 6 hours. The maximum daily dose should not exceed 120 mg. Patients >65 years of age, renally impaired patients and patients less than 50 kg: The recommended dose is 15 mg Ketorolac injection every 6 hours. The maximum daily dose for these populations should not exceed 60 mg. For breakthrough pain, do not increase the dose or the frequency of Ketorolac Tromethamine.
Conversion from Parenteral to Oral Therapy: Ketorolac tablets may be used either as monotherapy or as follow-on therapy to parenteral Ketorolac. When Ketorolac tablets are used as a follow-on therapy to parenteral Ketorolac, the total combined daily dose of ketorolac (oral + parenteral) should not exceed 120 mg in younger adult patients or 60 mg in elderly patients on the day the change of formulation is made. On subsequent days, oral dosing should not exceed the recommended daily maximum of 40 mg. Ketorolac IM should be replaced by Ketorolac tablet as soon as feasible. The total duration of combined parenteral and oral treatment should not exceed 5 days.

Eye Drops: Adults: 1 drop in each eye 4 times daily.

Interaction of Tablet :-Etorac 10mg AS A (ketorolac Tromethamine) (AS A Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Other NSAIDs or aspirin: Increase the side effects of Etorac.
Anti-coagulants: Enhance anti-coagulant effect.
Beta Blocker: Reduce the anti-hypertensive effect .
ACE Inhibitors: Increase the risk of renal impairment.
Methotrexate: Enhance the toxicity of methotrexate.

Contraindications of Tablet :-Etorac 10mg AS A (ketorolac Tromethamine) (AS A Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Ketorolac is contraindicated in patients having hypersensitivity to this drug or other NSAIDs. It should not be used in children under 16 years of age. lt is also contraindicated as prophylactic analgesic before surgery.

Side Effects of Tablet :-Etorac 10mg AS A (ketorolac Tromethamine) (AS A Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Commonly occurring side effects are nausea, vomiting, gastro-intestinal bleeding, melana, peptic ulcer, pancreatitis, anxiety, drowsiness, headache, excessive thirst, fatigue, bradycardia, hypertension, palpitation, chest pain, infertility in female and pulmonary edema.

Pregnancy & Lactation of Tablet :-Etorac 10mg AS A (ketorolac Tromethamine) (AS A Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

US FDA Pregnancy category of Ketorolac Tromethamine is C. So, Ketorolac Tromethamine should be avoided in pregnancy and lactation unless the potential benefits to the other outweigh the possible risks to the fetus.

Therapeutic Class of Tablet :-Etorac 10mg AS A (ketorolac Tromethamine) (AS A Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics

3.sedative

Tablet 3.Rivotril 0.5mg (AS A Clonazepam Adjunct anti-epileptic drugs, Benzodiazepine hypnotics AS A Sedative Drug).

Indications of Tablet:-Rivotril 0.5mg (AS A Clonazepam Adjunct anti-epileptic drugs, Benzodiazepine hypnotics AS A Sedative Drug).

Rivotril is indicated for the treatment of panic disorder, with or without agoraphobia. Panic disorder is characterized by the occurrence of unexpected panic attacks and associated concern about having additional attacks, worry about the implications or consequences of the attacks.

Rivotril is also indicated alone or as an adjunct in the treatment of the Lennox-Gastaut Syndrome (petit mal variant), akinetic and myoclonic seizures. It may be indicated in patients with absence seizures (petit mal) who have failed to respond to succinimides.

The effectiveness of Rivotril in long-term use, that is, for more than 9 weeks, has not been systematically studied in controlled clinical trials. The physician who elects to use Rivotril for extended periods should periodically reevaluate the long-term usefulness of the drug for the individual patient.

Pharmacology of Tablet:-Rivotril 0.5mg (AS A Clonazepam Adjunct anti-epileptic drugs, Benzodiazepine hypnotics AS A Sedative Drug).

Clonazepam exhibits pharmacological properties which are common to benzodiazepines and include anticonvulsive, sedative, muscle relaxing and anxiolytic effects. The central actions of benzodiazepines are mediated through an enhancement of the GABAergic neurotransmission at inhibitory synapses. In the presence of benzodiazepines the affinity of the GABA receptor for the neurotransmitter is enhanced through positive allosteric modulation resulting in an increased action of released GABA on the postsynaptic transmembrane chloride ion flux.

There are also animal data showing an effect of clonazepam on serotonin. Animal data and electroencephalographic investigations in man have shown that clonazepam rapidly suppresses many types of paroxysmal activity including the spike and wave discharge in absences seizures (petit mal), slow spike wave, generalized spike wave, spikes with temporal or other locations as well as irregular spikes and waves. Generalized EEG abnormalities are more regularly suppressed than focal abnormalities. According to these findings clonazepam has beneficial effects in generalized and focal epilepsies.

Dosage & Administration of Tablet:-Rivotril 0.5mg (AS A Clonazepam Adjunct anti-epileptic drugs, Benzodiazepine hypnotics AS A Sedative Drug).

Oral:

Adults: The initial dose for adults with seizure disorders should not exceed 1.5 mg/day divided into three doses. Dosage may be increased in increments of 0.5 to 1 mg every 3 days until seizures are adequately controlled or until side effects preclude any further increase. Maintenance dosage must be individualized for each patient depending upon response. Maximum recommended daily dose is 20 mg.

The initial dose for adults with panic disorder is 0.25 mg given in two divided dose. An increase to the target dose for most patients of 1 mg/day may be made after 3 days.
Pediatric Patients: In order to minimize drowsiness, the initial dose for infants and children (up to 10 years of age or 30 kg of body weight) should be between 0.01 and 0.03 mg/kg/day but not to exceed 0.05 mg/kg/day given in two or three divided doses.

Injection:

Infants and children: half of a vial (0.5 mg) by slow IV injection or by IV infusion.
Adults: 1 vial (1 mg) by slow IV injection or by IV infusion. This dose can be repeated as required (1-4 mg are usually sufficient to reverse the status). In adults, the rate of injection must not exceed 0.25 – 0.5 mg per minute (0.5-1.0 ml of the prepared solution) and a total dose of 10 mg should not be exceeded.

Interaction of Tablet:-Rivotril 0.5mg (AS A Clonazepam Adjunct anti-epileptic drugs, Benzodiazepine hypnotics AS A Sedative Drug).

Rivotril does not appear to alter the pharmacokinetics of phenytoin, carbamazepine or phenobarbital. The effect of Rivotril on the metabolism of other drugs has not been investigated.

Contraindications of Tablet:-Rivotril 0.5mg (AS A Clonazepam Adjunct anti-epileptic drugs, Benzodiazepine hypnotics AS A Sedative Drug).

It should not be used in patients with a history of hypersensitivity to benzodiazepines, nor in patients with clinical or biochemical evidence of significant liver disease. It may be used in patients with open angle glaucoma who are receiving appropriate therapy but is contraindicated in acute narrow angle glaucoma.

Side Effects of Tablet:-Rivotril 0.5mg (AS A Clonazepam Adjunct anti-epileptic drugs, Benzodiazepine hypnotics AS A Sedative Drug).

The most frequently occurring side effects of Rivotril are referable to CNS depression. Experience in treatment of seizures has shown that drowsiness has occurred in approximately 50% of patients and ataxia in approximately 30%. In some cases, these may diminish with time; behavior problems have been noted in approximately 25% of patients. Abnormal eye movements, aphonia, coma, tremor, vertigo, confusion, depression, amnesia, hallucinations, hysteria, increased libido, insomnia, psychosis & palpitations may also occur.

Pregnancy & Lactation of Tablet:-Rivotril 0.5mg (AS A Clonazepam Adjunct anti-epileptic drugs, Benzodiazepine hypnotics AS A Sedative Drug).

Pregnancy: From preclinical studies it cannot be excluded that clonazepam possesses the possibility of producing congenital malformations. From epidemiological evaluations there is

evidence that anticonvulsant drugs act as teratogens. However, it is difficult to determine from published epidemiological reports which drug or combination of drugs is responsible for defects in the newborn. The possibility also exists that other factors e.g. genetic factors or the epileptic condition itself may be more important than drug therapy in leading to birth defects. Under these circumstances, the drug should only be administered to pregnant women if the potential benefits outweigh the risk to the foetus. During pregnancy, Clonazepam may be administered only if there is a compelling indication. Administration of high doses in the last trimester of pregnancy or during labour can cause irregularities in the heartbeat of the unborn child and hypothermia, hypotonia, mild respiratory depression and poor feeding in the neonate. It should be borne in mind that both pregnancy itself and abrupt discontinuation of the medication can cause exacerbation of epilepsy. Withdrawal symptoms in newborn infants have occasionally been reported with benzodiazepines.

Nursing Mothers: Although the active ingredient of Clonazepam has been found to pass into the maternal milk in small amounts only, mothers undergoing treatment with this drug should not breastfeed. If there is a compelling indication for Clonazepam, breastfeeding should be discontinued.

Therapeutic Class of Tablet:-Rivotril 0.5mg (AS A Clonazepam Adjunct anti-epileptic drugs, Benzodiazepine hypnotics AS A Sedative Drug).

Adjunct anti-epileptic drugs, Benzodiazepine hypnotics

4.plenty of fluid ,iv fluid and electrolyte

5.antibiotics -if urinary infection (according to culture )

স্পেসিফিক ট্রিটমেন্ট :

১.যদি স্টোন 0.5cm অর্থাৎ 5mm এর কম হয় তাহলে আশা করা যায় এটা spontaneously pass হয়ে যাবে।আমরা সিরিয়াল xray করে (প্রতি ৬-৮ সপ্তাহে)এটা ফলোআপ করতে পারি

২.যদি এর থেকে বড় হয় তাহলে আমাদের intervention এ যেতে হবে।

যেমন Endoscopic surgery আছে:rac

-PCNL(percutaneous nephrolithotomy)

-ESWL(extracorporeal shockwave lithotripsy )

-staghorn calculi এর ক্ষেত্রে :PCNL+ESWL

Open surgery এর ও অপশন আছে:

-percutaneous nephrostomy

-pyelolithotomy(extra renal pelvis এ স্টোন থাকলে)

-extended pyelolithotomy(intra renal pelvis এ স্টোন থাকলে)

-nephrolithotomy( stone calyces এ থাকলে)

-partial nephrectomy(stone in lowermost calyx)

-nephrectomy

Raiyyan Tahsan Date:20-01-2025 Monday Time:10-47-45 Pm

Raiyyan Tahsan

Raiyyan Tahsan