Vocal cord palsy

All muscles supplied by RLN except cricothyroid

SLN :External
Internal
Cough reflex impaired
Posterior cricoarytenoid:

ILN ELN SLN RLN COMPLETE

Thyroplasty
1-
2-
3- Shortening/ relaxation
4- Lengthening/ tightening
HIGH-YIELD
Tonsillectomy: Position (MC): 2-3rd ring
Primary- High:
Secondary- Low:
Reactionary- Block: Partial -
Complete-
Surgical landmarks of facial nerve in parotid surgery Subglottic stenosis
1.Cartilaginous pointer –Tragus Staging:
2.Tympanomastoid suture Treatment:
3.Styloid process
4.Posterior belly of digastric

FISTULA TEST
Erosion of horizontal SCC
Fenestration surgery
Post-stapedectomy fistula
A false negative fistula :

A false positive fistula :

 *Sublingual gland retained

Saccule of inner ear develops from:

Surgery
Nerve Injuries
-Breast surgery axilla clearance- T2 Apex of axilla
-Thyroid surgery- T4 Nipples
T6 Xiphoid process
-Parotid surgery- a) Deviation of angle-
T10 Umbilicus
b) Anaesthesia at angle-
T12 Inguinal ligament
c) Frey-
-Submandibular surgery-
-Hernia surgery-
a) Loss of sensation over lateral thigh
b) Loss of sensation over suprapubic region
c) Loss of sensation over root of penis
d) Loss of Cremasteric reflex
-Thymectomy
JENKIN’S RULE:
Length Of Suture Should Be Times The Length Of The Wound
Angle Of Entry Of Suture Needle:
Verees Needle Angle:
Best for subcuticular suture:
SIRS –2 or more +:
Core Temperature ˂36oC or ˃ 38oC
HR >90bpm
RR ˃20/min or Pco2 ˂32 mmHg
WBC count ˃12,000 /μL, <4000/μL, 10% bands
 SPLIT/ FULL / WOLFE
THIERSCH
Site:

Contracture

Cosmesis:

Open cardiac massage:

TRAUMA
 Parameter Class I Class II Class III Class IV
CO SVR CVP (Mild) (Moderate) (Severe)
Blood loss ˂15% 15-30% 31-40% ˃40%
Cardiogenic
Heart rate ↔ ↑ ↑ ↑↑
Hypovolemic
Blood pressure ↔ ↔ ↓ ↓
Obstructive Pulse pressure ↔ ↓ ↓ ↓
Respiratory rate ↔ ↔ ↑ ↑
Distributive
Urine output ↔ ↔ ↓ ↓↓
Neurogenic Glasgow coma ↔ ↔ ↓ ↓
scale score
SHOCK + WARM EXTREMITIES + Base deficit* 0 to -2mEq/L -2 to -6mEq/L -6 to -10 m Eq/L -10mEq/L or
MV02 >70%: less
Shock index- Need for blood Monitor Possible Yes Massive
Modified shock index- products Transfusion

Mx of hypovolemic patients in shock (ATLS):

Min Cannula- Fluid type- Fluid volume-

-Best clinical indicator of adequacy of resuscitation:

-Best indicator to estimate fluid required for resuscitation:
-Best lab parameter to monitor tissue perfusion:
 ABDOMINAL TRAUMA

Subxiphoid: pericardial effusion Splenorenal pouch

Hepatorenal/ Morrison pouch Pelvis

eFAST:
Sensitivity:
LIMITATIONS:
WHOLE BODY CT:
BURNS:
Latest ATLS:
Adults:
<14yr:
Electrical injury:
Fluid of choice in adults-
Fluid of choice in children-
Time:

Frostbite rewarming:
URETHRAL AND BLADDER TRAUMA
C/F:

IOC:

Q. A 14 year old boy presents to the ED after a

straddle injury and rupture of bulbar urethra.
Extravasated urine can be seen in:
a) Scrotum
b) Thigh
c) Ischiorectal fossa
d) Deep perineal space

IOC:
Alcoholic-fall H/o RTA H/o RTA Sudden right hemiplegia H/o RTA, GCS-9

• Bridging veins • Artery • Trauma> Aneurysm • MC R/F: • NCCT Normal/

• Trivial trauma • RTA • MC site: • MC site: petechial
• Sutures: • Sutures: hemorrheages
• Midline • Midline • IOC:
THYROID
-MC associated with RT, TGC:
-Most common, Best prognosis:
-Lymphatic mets:
-Hematogenous mets:
-MC in iodine deficient areas, MNG:
-MC in MEN2:
-RET point mutation:
-Worst prognosis:
-Wolf chaikoff:
-Jod Basedow:
-Post-viral painful thyroid swelling:

MC location:
Management:
COMPLICATIONS OF THYROID SURGERY
MCC-
C/F time-

Inability to extubate-

MCC of intra-op thyroid storm:

MIAMI CRITERIA:
Intra-op LN removed >50% decline in 10minutes
GB C R eST
 Inheritance Gene Manifestations

MEN 1 =
Wermer

MEN2a=
Sipple

MEN2b=3

Prophylactic thyroidectomy:
BREAST
Screening- Intralobular stroma -MED12 mutation
High-risk/ BRCA +/ RT :
Diagnosis of lump in young / lactating female:
MC gene mutation in sporadic/TNBC:
MC gene in familial breast ca:
IOC for breast implants-
Most sensitive for DCIS-
Most sensitive for microcalcifications-
Staging CA breast
 Luminal HER2 TNBC
(ER+, PR+) (HER2+) (ER-, HER2-)
Allred score
Ki67:Low Ki67: High Ki67: High Ki67: High
HER2 - HER 2 -/ +

Chemotherapy:
LABC or LN +
Most important prognostic factor:
TNBC
FLAPS: DIEP:
Her2neu +:
Radiotherapy: TRAP:
LABC or LN + Van Nuys: Age, grade, margins, size
BCS
>5cm Smoking:
Hormonal treatment: Mondor’s disease
Premenopausal: Duct ectasia
Postmenopausal: Ca breast
Vascular surgery
ABI INTERPRETATION
Pain on 1st step:
>1.4
C/F:
0.9-1.3 Aorto-iliac-
0.5-0.9
SYNDROME:
Iliac-
0.3-0.5 Femoral-
Popliteal-
<0.3

NORMAL DVT
VEIN

COMPRESSIBILITY
Brodie tredelenburg
Morrissey FLOW
Fegan:
 C1 Telangiectasias or reticular veins
APPROACH TO ULCERS:
C2 Varicose veins
C2r Recurrent varicose veins Tip of toes, lateral malleolus, thin and shiny skin
C3 Edema
C4
Gaiters area-medial malleolus, sloping edge
Changes in skin and subcutaneous
tissue Bisgaard regimen
C4a Pigmentation or eczema
Ischium/GT, Pressure >30mm
C4b Lipodermatosclerosis or atrophie
blanche Plantar aspect of foot, loss of sensation
C4c Corona phlebectatica
C5 Healed
C6 Active venous ulcer
C6r Recurrent active venous ulcer

Numbness along medial aspect of leg:

SSV:
RENAL CALCULI
IVP:
RENAL MASSES

RENAL score:

BOSNIAK grade:

Seizures, adenoma sebaceum

Cerebellar
hemangioblastoma, Lung cysts, RP hemorrhage:
Pheochromocytoma fibrofolliculomas
 UROLOGY
TZ: TURP
PZ: DISTAL LIMIT-
MC complication-
TURP syndrome-
Monopolar cautery:
Bipolar cautery:

Painless testicular mass

MC-
Initial- Tumor markers-
Biopsy/FNAC?
IOC for T staging-
IOC for RP LN-
HERNIA

Int oblique + Transversus abdo: Roof Due to weakness of

conjoint tendon
External oblique: LIP

Femoral: Below and lateral to PT

Inguinal: Above and medial to PT
Appropriate mesh for hernia:
Material for mesh:
HEAD AND NECK
GI

Sign: Sign:
• Elderly with Diagnosis: Diagnosis:
regurgitation and IOC: Absence of:
halitosis IOC:
• Pulsion Finding:
• False
• TOC:
Classification:
 Pain abdomen + Distension + Vomiting
Pain abdomen + guarding
1st organ to see intra-op:
Diagnosis:
CI:
Diagnosis: Central Peripheral
Mx:
Markers: Complete folds: Incomplete folds:

Stepladder MCC:
Carney triad: Mx:
MCC:
Fletcher grading Mx:
 RECTAL PROLAPSE
Perineal-
Hinchey Classification Thiersche cerclage
1a Pericolonic Phlegmon and inflammation Altemier’s procedure
1b Pericolonic abscess ＜4cm Delorme procedure
2 Pelvic or inter-loop abscess
Abdominal-
or abscess ＞4cm Ripstein rectopexy
3 Purulent peritonitis Wells
4 Feculent peritonitis
HEPATOBILIARY SURGERY

Obstructive jaundice
Initial Investigation-
IOC-
Gold standard-
Residual vs recurrent stones:
Double duct sign, waxing-waning jaundice:
GB stone + Pneumobilia + SBO:
SCORES
ASEPSIS score
Definition:
A Additional Treatment
S Serous discharge
E Erythema
P Purulent exudates
S Separation of deep tissues
I Isolation of bacteria
S Stay in hospital prolonged over 14
days

Complication of surgery: NOT part

of thoracoscore

King’s college: Jaundice <7d of

encephalopathy NOT included
Model For End Stage Liver Pediatric End-Stage Liver Disease (PELD)
Disease (MELD) -Total bilirubin
Creatinine (mg/dL) -Albumin
Bilirubin (mg/dL) -Age (˂ 1 Y)
INR -Growth failure
-INR
Revised:

Clinical and Lab Points

Criteria 1 2 3
Encephalopathy None Mild to moderate Severe
(grade 1 or 2) (grade 3 or 4)
Ascites None Mild to moderate Severe
(diuretic responsive) (diuretic refractory)
Bilirubin (mg/dL) ˂2 2-3 ˃3
Albumin (g/dL) ˃3.5 2.8 – 3.5 ˂2.8
PT ˂4 4-6 ˃6
INR ˂1.7 1.7-2.3 ˃2.3
Class A= 5 to 6 points (least severe liver disease)
Class B = 7 to 9 points (moderately severe liver diseases)
Class C = 10 to 15 points (most severe liver disease)
BIOCHEMISTRY
Substrates
FED (2hr) FASTING (12-18hr) STARVATION (1-3d)

Liver

Muscle

Adipose

Brain

RBC

Heart
Glucose transporters
SGLT: Primary active transport :
Secondary Active Transport
Unilateral
SGLT-1: Secondary active transport :
SGLT-2:

Transporter Location Function

GLUT-1 Brain, kidney, placenta, erythrocytes Basal uptake of glucose, high affinity

GLUT-2 Liver, pancreatic cell, small intestine Fed state

GLUT-3 Brain, kidney, placenta Glucose uptake, maximum affinity for glucose
GLUT-4 Heart and skeletal muscle, adipose tissue Insulin-stimulated glucose uptake
GLUT-5 Small intestine, sperms Fructose
BASICS
FED FASTING BOTH-
INSULIN GLUCAGON
CYCLES SUMMARY
ENERGETICS:
Aerobic glycolysis-
Anaerobic glycolysis-
RBC- RL shunt
HMP

Amphibolic:
Anaplerotic reaction:

OROTIC
ACIDURIA Transamination:
SGPT/ALT:

SGOT/AST:

Gluconeogenesis Substrates:
NaF
B-oxidation- 1) Alanine (Cahill)
Acetyl CoA 2) Lactate (Cori)
3) Gycerol (TG)
4) Propionyl CoA (Odd-chain FA)
NOT ACETYL CoA

CPS-1: Urea cycle

Co2 + NH3
N-acetyl
Glutamate: CPS-2: Pyrimidine synthesis
Co2 + Glutamine
CPS-1
ETC
1 NADH:
1 FADH2:

Atractyloside: ATP
MALONATE transporter

Dinitrophenol,
Thyroxine, Bilirubin,
Phenobarbitone
Brown fat, Aspirin
overdose H2S

Electron transport +
ATP -
Glycogen metabolism

Coenzyme glycogen phosphorylase:

Lysosomal Storage Disorders

My Fabrite Oh my Gauch! He Pick Zebra’s

activity is Crab glob is out of A Gang of six
this galaxy! broke the bones- big nose with
Ceramics. We small Jews
We need to glu it! your sphinger
made A GalaXy eating onions
with foam
Hyperlipoproteinemias
Type Inherita Pathogenesis ↑Blood level Clinical
nce
I-Hyper- AR Lipoprotein lipase or Chylomicrons, TG, Pancreatitis, eruptive/pruritic xanthomas
chylomicronemia ApoC-II deficiency cholesterol

II- Familial hyper AD Absent LDL receptors, IIa: LDL, Accelerated atherosclerosis, tendon
cholesterolemia or ApoB-100 cholesterol (Achilles) xanthomas, and corneal arcus.

III-Dysbeta- AR Defective ApoE Chylomicrons, Premature atherosclerosis,

lipoproteinemia VLDL tuberoeruptive and palmar xanthoma,
Broad beta band

IV-Hyper- AD Hepatic overproduction VLDL, TG Acute pancreatitis

triglyceridemia of VLDL
Fatty Acid Oxidation Defects
Non-ketotic Retinitis NORMAL HDL LOW HDL
ABSENT LDL / VLDL LOW HDL
hypoglycemia pigmentosa HIGH VLDL

Dicarboxylic Phytanic acid

aciduria raised

VLCFA+ Phytanic
acid Accumulation

Absent peroxisomes
Amino acids
Basic: Glycine+ arginine + methionine:
Acidic: Glycine + cysteine + glutamate:
Imino acid:
Ketogenic only: Glycine + Glutamine + Aspartate:
Aromatic / UV light maximum: Glutamine + aspartate:
Universal methyl donor:
Serine
Purines NO
Heme Creatinine
Creatinine
Glutathione
Collagen MC (every 3rd) GABA

Thyroxine Niacin Histamine

Dopamine Melatonin
Catecholamines Serotonin
Melanin
 Type I Bone, Tendon, Skin,Dentin, Cornea, Late wound repair, Type I: Absent in:
(mc) Fibrocartilage
Type II Hyaline Cartilage, nucleus pulposus
Type III Reticulin, blood vessels, uterus, fetal tissue, early wound Type III: Deficient in:
Type IV Basement membrane (glomerulus), cochlea, lens Type IV: Defective in:

Highest thermic effect: Metal Metalloenzymes

RQ carbohydrates: Zn Carbonic anhydrase, Glutamate dehydrogenase, LDH, ALA
dehydratase
Deficiency:
Cu Tyrosinase, Cytoplasmic SOD, Ceruloplasmin, Lysyl oxidase
Se Glutathione peroxidase, Deiodinase, Thioredoxin reductase
Deficiency:
Alkali disease of livestock
Mo Xanthine Oxidase, Sulfite Oxidase
Enzymes
VITAMINS

Golden rice

Vit A: Day 0,1,14

<1yr: 1lakh each
>1yr: 2lakh each
 Assay: Assay: Assay:

Branch chain ketoDeH:

Alpha ketoglutarate DeH

PDH
Transketolase

Beri-beri
Wet-
Dry-
Wernicke:
Hartnup
Korsakoff: Carcinoid
Maize
INH
Lactic acidosis
 Assay: Assay: Assay:

SACD: Dorsal
columns + UMN

Decarboxylases
ALA synthase
Glycogen phosphorylase

Hypoglycemia
Convulsions, Neuropathy
Sideroblastic anemia

Carboxylation except:

Thromboembolism, Marfanoid habitus,

Ectopia lentis:
Cyanide nitroprusside test
EPIGENETICS
EPIGENETICS
GENE KNOCK IN
Chemical changes in DNA
Transmissible?
GENE KNOCK OUT
Reversible?
Sequence change?
GENE KNOCK DOWN=
RNA INTERFERENCE=PTGS
DNA methylation
(si/miRNA)- 3’UTR
Histone acetylation
Histone deacetylation
RNA EDITING
STOP Codons:

Nucleotide excision :
Base excision: Q. The base sequence of the strand of DNA
Mismatch repair: used as the template for transcription has the
base sequence GATCTAC. What is the base
NHEJ:
sequence of RNA product?
HEJ: A. CUAGAUG
Lamin A gene:
B. GTAGATC
C. GTAGATC
D. GUAGAUC
Molecular Biology Techniques
1. Denaturation-95°C
2. Annealing- 55°C
3. Elongation-72° C

DNA template, DNA primers, a heat stable DNA polymerase,

and deoxynucleotide triphosphates (dNTPs)

Real-time PCR-Quantitative (Ph chromosome, viral load) DNA SEQUENCING

RT PCR-RNA SANGER’S
Digital droplet PCR 3 billion bp/ 19.5k genes
NGS
BLOTTING
“SNOW DROP”

SOUTHERN-
NORTHEN-
WESTERN-
SOUTHWESTERN-
DNA footprinting
Best for ANEUPLOIDY
METAPHASE
CARNOY FIXATIVE
Dicentric chromosomes staining:
MICRODELETION
TRANSLOCATION
AMPLIFICATION
Not-point mutation

Ion-exchange chromatography best for HBA1C

PSM
CONCEPT OF HEALTH

First case in community:

First observed case:
Time between primary and secondary case:
Time between entry of organism and symptom:
Time between entry of organism and max communicability:
Isolation:
Quarantine: QP of Yellow fever:
Health indicators:
Virulence of disease-
Communicability of disease-
Human Development Index Physical Quality of Life The Global Hunger Index
(HDI) Index (PQLI) (GHI)

Knowledge: (Mean & expected Literacy rate Proportion of the population that
years of schooling) is undernourished

Income: real GNI per capita Infant Mortality Rate Prevalence of underweight in
children under five (in %)

Life expectancy at birth Life expectancy at one year Proportion of children dying
before the age of five (in %)

DALY: YLD + YLL

Measures disease burden

QALY: Measures cost effectiveness of intervention

Time distribution of disease
SHORT TERM LONG TERM PERIODIC
FLUCTUATION FLUCTUATION FLUCTUATION

Father of epidemiology:

Definition of epidemiology:
Levels of Prevention

Primordial Primary Secondary Tertiary

Health Education Health Promotion Early Diagnosis Disability limitation

Rehabilitation

Specific Protection Treatment

Vaccines-
Post-exposure prophylaxis-
BCG for CA UB-
Contraceptives-
OCP for PCOD-
Screening-
Physiotherapy for polio-
Chemoprophylaxis in contacts-
Mosquito repellants / Nets / DDT-
IFA in pregnancy-
Seat belts/ helmets-
Types of Epidemiological studies
DESCRIPTIVE:
ANALYTICAL:
EXPERIMENTAL:

Observational Experimental
Studies studies

Population-Based RCT Non-randomized

Individual CONSORT
Analytical:
Based Field trial
Clinical trials Community Trial
Descriptive: Analytical:
Cross over trial
Case reports
Case series Cross-sectional study
or prevalence study

Case-control study or
case-reference

Cohort study or
follow-up study
Best for multiple exposures:
Best for multiple outcomes:
Best for rare diseases:
Best for rare / expensive investigations:

Incidence study:
Prevalence study / snapshot study:
Unit of study in ecological study:
Intention to treat:

Recall bias
Selection bias
Berkesonian bias

Attrition
Hawthorne bias
Best to eliminate known confounders:
Known + Unknown:
• Randomization
• Restriction
• Stratification
• Stratified randomization
• Multivariate analysis/ Statistical modelling
Overall best for confounders:
Bias:
Formula
INCIDENCE PREVALANCE
P= I X D Increased survival
Increased mortality
Faster recovery

Odds ratio Vaccination

Primordial prevention
Relative risk:

Attributable risk:

proportion of disease attributed to R/F

Population attributable risk:

proportional reduction in population disease if risk factor were eliminated

 Screening
Disease
+ -

+
Test

Prospective screening:
Prescriptive screening:
Pre-test probability:
Post-test probability:
External validity of a study is an indicator of generalizability
Clinical trials
Drug Typical Study Sample Purpose
Trials
Phase I Small number of healthy “Is it Safe?”
volunteers Assesses safety, toxicity, pharmacokinetics, and
pharmacodynamics
Phase II Moderate number of patients with “Doses it work?”
disease of interest Assesses treatment efficacy, optimal dosing, and
adverse effects.
Max failure
Phase III Large number of patients “Is it an Improvement over existing drug?”
randomly assigned either to the Compares the new treatment to the current
treatment under investigation or standard of care (any improvement?).
to the standard of care
Phase IV Post marketing surveillance of “Can it stay?”
patients after treatment Detects rare or long-term adverse effects
(e.g., black box warnings)

Phase 0:
BIOSTATISTICS

Most affected by skewed data:

Not affect by skewed data:

Coefficient of variation

Variance

SAMPLE SIZE
No randomization
in meta-analysis

Probability distribution that is used

to show how many times an event
is likely to occur over a specified
period:
Tests of significance

Variables to be Compared

Quantitative / Parametric Qualitative / Non-parametric

(Means and SD) (proportions)

2 Groups ≥3 Groups
Small sample size Large sample size

ANOVA
t-test Fisher exact test Chi-square test
Friedman test
Paired Unpaired
t-test t-test
Q. A study was conducted to test the efficacy of a new vaccine in
preventing a particular disease in a population. The incidence of
the disease before and after the introduction of vaccine were
compared for the same. Which of the following tests would you use
for statistical analysis?

A. Chi-square test

B. Unpaired test

C. Paired t test

D. Regression analysis
Alpha and beta errors
More dangerous error:
Ho true H0 false ALPHA ERROR / p value:
Type I Correct Confidence level : 1-p
Reject Ho
error decision
Power of study:
Correct Type II
Accept Ho Higher Power: Increase sample size, precision
decision error
False positive: False negative:
Confidence interval:
Standard error of mean:
Biomedical waste management
Urine bag-
Blood bag-
Soiled gauze-
Culture plate-
Live vaccine vials-
Cytotoxic drugs-
Vacutainer-
Gloves-
Expired drug-
Syringe-
Syringe with needle-
Pacemaker-
Orthopedic implant-
Foley’s-
Plastic wrapper of foley’s-
Mercury spill -
Blood spills-
Demography
Total fertility rate (TFR) :
The sum of the ASFR for all reproductive age groups for a particular
period

Gross Reproduction Rate (GRR):

Sum of the ASFR (births of daughters), for all reproductive age groups for
a particular period

Net reproduction rate (NRR):

Average number of daughters that would be borne, according to specified
rates of mortality and ASFR, by a new-born female

Maternal mortality ratio:

IMR:

Perinatal mortality ratio:

Complete family size: Target TFR:

Best measure of growth of population: Target NRR: CPR:
Most important indicator of Health status of country:
Quality of heath care delivery services:
Combined Pediatrics + Obstetrics care:
VACCINES
DELAYED OPEN VIAL POLICY: 28days P-Toluene sulphate
IMMUNISATION: Not applicable:
BCG MBJ / COVID/ YF
HEP B
IPV
ROTA
PENTA Day carrier:
PCV Vaccine carrier:
Small ILR:
MR Without electricity?
VIT A
Immunodeficiency:
OPV
SA-14-14-2: Live attenuated
TSS adverse effect:
Hib

DTP

JE

dT/TT
PEP
All wound receive surgical toilet

Wounds less then 6 hours old, Other wounds

clean, non-penetrating,
& with negligible tissue damage Immunity category
A: Nothing more required
B:Toxoid 1 dose
C: Toxoid 1 dose + human tetanus Ig.
Immunity category D:Toxoid complete course + human tetanus Ig
A: Nothing more required
B: Toxoid 1 dose
C: Toxoid 1 dose
D: Toxoid complete course
HRIG:
Equine IG:
 Efficiency/Ri
sk HIV + Pregnant female:
Newborn of mother on ART:
Sexual 0.01-1%
transmission High-risk newborn:
Blood 90%
Needles 0.3% HIV sentinel surveillance:
Vertical 30%

Tenofovir 300 mg+ All in initiative

Lamivudine 300 mg + Nirantar scheme
Dolutegravir 50 mg SUNRISE project

High-priority TB-HIV district: Ford foundation:

SIDA:
DANIDA:
Colombo plan:
Applied nutrition program:
MMR target by 2030:

Luminous intensity: Candela

FLUX: Lumen
Rifabutin Illuminance: Lux
NUTRITION

Indicator Parameter Interpretation

Stunting Low height for age

Wasting Low weight for height

Under weight Low weight for age

Severe acute malnutrition (SAM): 6-59 months of age

A. Weight-for-height below – 3 SD of the median
B. Visible severe wasting
C. Presence of bipedal edema
D. Mid-upper arm circumference below 11.5cm
Food adulterants
• Spastic paralysis of lower limbs in adults
• Toxin: BOAA (Beta oxalyl amino alanine)
• Adulterant: Khesari Dal (Lathyrus Sativus)
• Rx: Steeping /parboiling, Vit C

• Non-inflammatory, bilateral swelling of legs, with

diarrhoea, cardiac failure
• Toxin: Sanguinarine
• Adulterant: Argemone Mexicana (oil) in Mustard oil

• Ascites and jaundice

• Toxin: Pyrrolizidine alkaloids (Hepatotoxins)
• Adulterant: Crotalaria Seeds (Jhunjhunu) in Millets

• Aspergillus flavus
• Aflatoxin in groundnuts, cereal, maize
 ANC VISITS
Ideal WHO:
Min GOI:
Ideal GOI:

Rule of halves:
Tracking:
MONICA:

RDA: 97% population daily

dietary requirement

Growth Charts: WHO Multicenter Infectious diseases: Conditioning factor for malnutrition
Growth Reference Study (MGRS)
Talks series by experts with Q and A:
Iodine in lactation: 4-8 experts in front of audience with Q and A:
6-12 ppl discussing:
Kuppuswamy: Practical skills teaching:
Income, Occupation, Step by step enactment (teaching community):
Education of HOF
 HEALTH PROGRAMS

Fe Folate Frequency
6-59m
5-9y
10-19y
20-49 Females
Postnatal care till 6months Pregnant
Calories: 1/3
Protein: 1/2 Lactating
 Nishchay:

Nikshay:

Nikushth:

SPARSH
SAPNA
MEENA

Screening:
Confirmatory:

Blindness: <3/60 for better eye

VI: <6/18
Environment

Water collection during outbreak for examination: Gentle stream to avoid

Disinfecting action: splashing
Contact period- Best Air pollution indicator:
Residual level : Secondary pollutant:
Drinking water- Best biological air pollution indicator:
Post-disaster- Green house effect max:
Swimming pool- Temporary (camping) sewage disposal:
Cyclops- Area per 10k population for sanitary landfill:
 Hilly/ Plains Beds
tribal Cost-benefit analysis:
Cost-effectiveness analysis:
Sub-centre Network analysis: Program management review
(HWC) technique (PMRT), CPM
A-
B- SCHOOL HEALTH:
PHC Minimum area of 10 sq ft per child should be allocated
A- Less than 40 students per classroom
B- Desk:
School health 1 urinal per 60 students
1/150: 1 teacher -> <6/9 referred to PHC
U-CHC
Metro:
Village level
staff: Factories Act –1948:
• except Defense, Mining, Railways and Eateries.
• Per capita space: > 500 ft3
• One Safety officer per 1000 workers.
VILLAGE HEALTH SANITIATION AND NUTRITION
COMMITTEE: • 14-18 years : 6 AM-7PM-Max 4.5 hours per day.
• MAX: 48hrs per week or less than 9hrs per day.
• OVERTIME: < 60 hours per week.
ORTHO
Important tests
O’Donogue triad:
MCL
ACL
Medial meniscus
 Origin-FDP tendon
1,2: Unipennate
3,4: Bipennate
Function:

ROTATOR CUFF TENDONS:

S
I
T
S
Empty can test
Forgotten tendon, Lift off test:
Painful arc syndrome:
Nerve Injuries
Nerve Injuries and Compression
• Shoulder dislocation, Neck of humerus:
Deltoid
• Quadrangular space: T.Minor
• Holstein Lewis #: Lat arm
• Monteggia #:
• Supracondylar #:
• Elbow dislocation:
• Cubital tunnel, Guyon’s canal (hook of hamate #):
• Wrist dislocation:
• Carpal tunnel, Pronator syndrome:
• Supinator syndrome:
• Cheralgia paraesthetica / Wartenberg syndrome:
• Meralgia paraesthetica:
• Piriformis syndrome:
• Tarsal tunnel :
• Neck of fibula fracture:
Important hands and fingers
Fractures
NONUNION: DEFORMITIES:
• Gunstock deformity:
• Dinner-fork:
MALUNION: • Garden-spade:
• Fish-tail:
• Haglund
• Madelung
IOC for AVN: Type Characteristics
I Puncture wound < 1 cm + Minimal soft tissue damage
Sites for AVN:
II Laceration >1 cm but <10 cm + Moderate soft tissue damage

Keinboch: III A Laceration > 10 cm + Extensive soft tissue damage /

Kohler: contamination
Segmental/ comminuted fractures
Aviator fracture III B Periosteal stripping and bone exposure
Classification: III C Vascular injury requiring repair
Superior ulna Inferior radius
# + radial head # + radio-ulnar
dislocation dislocation

Terrible triad of elbow:

Elbow dislocation Intra-articular:
Radial head # Radial styloid:
Coronoid #
 More age
More trauma
More pain
FABER:
More shortening
FADIR: TB Synovitis
More ER >45 degrees
TB hip arthritis Septic arthritis
MALUNION: Coxa vara
Posterior dislocation Iliotibial band contracture
Anterior dislocation
Bone tumors

Nocturnal pain Onion-peel Codman triangle IOC:

relieved on NSAIDS Most chemo-and Sunburst reaction Cap:
IOC: Radiosensitive Most Radio- Chondrosarcoma
TOC: resistant
MC malignant BT

EPIPHYSEAL DIAPHYSEAL METAPHYSEAL

METAPHYSEAL
SPINE XRAYS-APPROACH

Elderly male Young male with

ALP: Postmenopausal female inflammatory backache
D/D: Sign: HLA:
IOC: Signs:
T-score:
Ca/ Po4/ ALP/PTH: Uveitis
B/L heel pain

PEDICAL SCREWS
Miscellaneous
Coxa vara-
Fairbank triangle

Kite:
Bohler:
Gissane:
Alpha angle:
Beta angle:
Anesthesia
HAND:
INSERT:
PRESSURE:
MC injury:
 Mc nerve:
MC vein for central line: 2nd mc nerve:
MC vein for TPN: Extubation TOF:
Refeeding syndrome: Tetanic stimulation:
Max risk of pneumothorax:
Max risk of infection:
Max risk of thrombosis:
Max flow rate: 5l/min Max flow rate: 10l/min Max flow rate: 15l/min
Max saturation: 40% Max saturation: 60% Max saturation: 60%

Max flow rate: 15l/min Max flow rate: 60l/min

Max saturation: 85-90% Max saturation: 100%
MC circuit in spontaneous:
MC circuit in controlled:
Colour Code
Orange Green 14fr
Gray Orange 16Fr
White
Red 18Fr
Green
Pink Yellow 20Fr
Blue
Purple 22Fr
Yellow
Violet Blue 24Fr
IV anesthetic agents:
DOC for day care/ liver/ kidney/ neuroSx/TIVA/malignant hyperthermia, porphyria
Dissociative anesthesia, DOC in asthma, Cyanotic HD, Shock
CI in hypertension / epilepsy/ glaucoma
DOC in cardiac surgery, S/E Adrenal suppressant
DOC in hyperthyroidism, seizures

LA: MOA-
Causing Hypertension:
Most cardiotoxic:
Max dose of lignocaine:
DOC for LAST:
MethHb:

MR
Depolarising, Hyperkalemia, Bradycardia RSI-
Most cardiostable-
Hoffman elimination(safe in RF/LF)-
Byproduct-
Reversal-
Sugammadex-
Compound A Coronary steal Min MAC Tec-6 vaporizer
Fruity odour AI hepatitis Best for Renal Surgery, Obese
OPIOIDS
Full agonist: Morphine, Pethidine, Heroin, Meperidine, Methadone,
Codeine, Fentanyl
Partial agonist: Buprenorphine
Mixed agonist/antagonist: Nalbuphine, Pentazocine, Butorphanol
Antagonist:

AVOID IN:
Mydriasis:
Pruritus:
No tolerance to:
Serotonin syndrome:
Wooden chest syndrome:
Prolonged QTc:
FEVER + AMS + TACHYCARDIA
RIGIDITY
NORMAL PUPILS
Earliest-
Late-
RYR/DHPR (Chr 19)
DOC-
 PUSH HARD-PUSH FAST

No
breathing,
pulse felt Rate of breathing in CPR
Adults:
Children:
Neonates:
 OT?
Pffanelstein?
LSCS?

• ADRENALINE DOSES
• Anaphylactic shock / status asthmaticus:
• Cardiac arrest:
• Vasoconstriction:
• With LA for VC:
• Labour epidural:
Q. BMV Q. Order of suction:
-Start within:
-Saturation term: Q. Temp of room:
-Saturation <35wks:
-RR:
-CI:

Q. CC
Q. Vascular access of -2 thumb
choice: -Lower 1/3 body sternum
-Midline
-1/3rd depth of AP
CC:PPV-
Psychiatry
General Psychiatry
Delusion is a disorder of thought-
Obsession is a disorder of thought-
Hallucination is a disorder of-
Derailment is a disorder of-
MC delusion: ORIENTATION ATTENTION CONCENTRATION

Capgras- Digit span test Serial 7 subtraction

Fregoli -
Othello syndrome-
Cotard syndrome-
Ganser syndrome-
Transference
MC obsession:
MC compulsion:
Association of OCD, anorexia: Short term memory:
Giving clues:
Distractibility
Irresponsibility
Grandiosity
Flight of ideas
Activity increased
Sleep decreased
Talkativeness
GOOD PROGNOSTIC FACTORS BAD PROGNOSTIC FACTORS
Acute onset or abrupt onset Insidious onset
Advanced age at onset (>35 yrs) Early onset (<20 yrs)
Catatonic, paranoid subtype Simple, disorganised, hebephrenic
Female sex Male sex
Prominent positive symptoms Prominent negative symptoms
Presence of affective symptoms Absence of affective symptoms
Family history of mood disorders Family history of schizophrenia

CAGE: AUTISM SPECTRUM DISORDER

SCOFF: -Social interaction impaired
PANSS: -Repetitive behaviors
Confusion assessment method (CAM): +/- Language delay
SPIKES:
Transtheoretical model of change: Regression in girl >6mon:
Precontemplation -> Contemplation -> Preparation Gene:
-> Action -> Maintainence -> Relapse Drug:
Regression in any gender >2yrs:
 Personality disorders
Cluster A personality disorders
Pervasive distrust, suspiciousness
Voluntary social withdrawal, content with social isolation (vs avoidant)
Odd beliefs or magical thinking

Cluster B personality disorders

Criminality, impulsivity, hostility ≥18 years old
Unstable interpersonal relationships, impulsivity, suicidality. Females > males.
Splitting , Dialectical BT
Attention-seeking, dramatic speech and emotions
Grandiosity, sense of entitlement, requires excessive admiration

Cluster C personality disorders

Hypersensitive to rejection and criticism, socially inhibited
Preoccupation with order, perfectionism, and control; ego-syntonic
Excessive need for support, low self-confidence
 Other disorders
Anorexia Bulimia Reduced REM latency
Hypnagogic/ pompic hallucinations, Cataplexy
BMI
Hypocretin / orexin
Distorted body image DOC:

Amenorrhea, Osteoporosis
Parotitis, Tooth decay
Hypo Cl, K Metabolic alkalosis
Russel sign

UNINTENTIONAL
INTENTIONAL
Secondary Stressor
gain
• Preoccupation of • Excessive • Unexplainable + -
having DIAGNOSIS of preoccupation with 1 neurological
serious illness or more symptoms disorder
• No/ mild symptoms • Stressor + • Stressor + - -
• Consistently negative Ix • > 6months • La Belle
• >6 months Indifference
Antipsychotics
-Max EPS :
-Min EPS, DOC for refractory psychoses:
-Max metabolic s/e, Sialorrhea, Seizure, Myocarditis, Agranulocytosis:
-QT prolongation:
-PD induced psychosis DOC:
-Longest acting:
-Technique for depot injections:
-Catatonia DOC:
-Catatonia TOC/ Depression + suicide / stupor :
Anesthetic agent of choice:
-D2 partial agonist:

Extrapyramidal symptoms Treatment

• Sudden, sustained contraction
• Torticollis, trismus, oculogyric crisis
restlessness, inability to sit still

• Gradual-onset tremor, rigidity, bradykinesia

• Dyskinesia of the mouth, face, trunk,

extremities: Rabbit syndrome
Antidepressants:
-Mc side effect of SSRI:
-SIADH, vivid dreams, dry mouth, sweating:
-DOC for severe depression
-S/e: Hypertension, Discontinuation syndrome
-Min sexual s/e:
-Min wt gain, sedation, Seizures in bulimic, Anti-smoking:
-Priapism:
TCA MOA:
-TCA toxicity DOC: Hemodialysis:
--Drugs with anti-suicide ability:
-Antidepressant of choice in pregnancy:
-Approved for Postpartum depression:
-Black box warning for anti-depressants:
-Novel antidepressant: Agonist at 5HT1a, antagonist at 5HT3:
-Clonus, diarrhea, altered mental status on antidepressants:
Mood Stabilizers Levels:
Prophylaxis-
DOC in acute mania/BPD- Acute Mania-
DOC in prophylaxis of BPD- Toxicity-
DOC in rapid cyclers- Dialysis-
DOC in pregnancy- T1/2:
Measurement:
Adverse Effects of Lithium
• Tremors
• Nephrogenic diabetes insipidus
• DOC: R/F: Volume loss/ AKI, ACE inhibitors, thiazide
• Thyroid dysfunction diuretics, NSAIDs
• Hyperparathyroidism Nausea, vomiting, slurred speech, hyperreflexia,
• Acne, Psoriasis seizures, ataxia
• Weight gain
• Leukocytosis
• Teratogenic:
Pediatrics
APGAR Score Score 2 Score 1 Score 0 Prognostic score
A Timing:

Severe:

Pink Extremities Blue Pale or Blue

P ˃100 bpm ˂100 bpm No pulse
G Cries and pulls Grimaces or weak No response to
away cry stimulation
A

Active movement Arms, legs flexed No movement

R Strong cry Slow, irregular No breathing
Neonatology

1.Kangaroo position (skin to skin)

2.Kangaroo nutrition
3.Kangaroo support
4.Kangaroo discharge

UNCONJUGATED CONJUGATED

BREAST MILK BREASTFEEDING

JAUNDICE JAUNDICE

UDP-GT UDP-GT MRP-2 No black Periductal Absent

severely mildly Black liver fibrosis and periductal
deficient deficient liver proliferation fibrosis
IOC:
Neonatal respiratory distress:
H/o sibling death
PRETERM TERM / LSCS POST-TERM Scaphoid abdomen
SP-B

Lecithin: Sphingomyelin ratio

 TORCH infections
Hydrocephalus Cicatricial skin rash
Chorioretinitis Limb hypoplasia
Parenchymal calcification VZIG: 5d before/ 2d after delivery

Microcephaly Skin and eye lesions

Periventricular calcification Encephalitis

Microcephaly SNHL
Contractures Cataract
GM-WM calcification MC eye C/F:
PDA > PS

Non-immune hydrops
PRCA
Acute Diarrhea
Parameters No Dehydration Some Dehydration Severe Dehydration
Appearance Well, alert Restless, irritable Lethargic, unconscious

Eyes Normal Sunken Very sunken

Thirst Drinks normally, Thirsty, drinks eagerly Drinks poorly or not able to drink
not thirsty
Skin pinch Goes back quickly Goes back slowly Goes back very slowly
(˂1 second ) (1 second) (2 seconds)

ZINC: 14days 75ml/kg over 4 hours

100ml/kg
<6mon: 10mg 30ml/kg 70ml/kg
>6mon: 20mg
GI emergencies
Cystic fibrosis
Cystic Fibrosis Finding Biochemical Evidence of
CFTR Dysfunction
≥1 Phenotypical finding Positive sweat chloride
Or >60meq/l on 2 separate days
Positive neonatal screening Pilocarpine iontophoresis
Or Or
Positive family history Positive Nasal potential
difference
Or
2 mutations in CFTR

CF: Chromosome:
-MC mutation:
-Trikafta: Elexacaftor + Tezacaftor + Ivacaftor
 Congenital Heart Diseases-Approach

-MC overall:
-MC to be affected by IE:
-MC cyanotic HD:
-MC cyanotic HD in neonates:
-MC cause of death in first week:
 High-Yield
CAH MC Testosterone SHORT STATURE:
21- hydroxylase deficiency
Bone Age ˂ Chronological Age

11- hydroxylase deficiency Bone = Chronological Age

Weight with age: Height with age: US:LS :

17- hydroxylase deficiency Birth Birth Birth
5mon 3mon 3yr
1yr 1yr 7yr
2yr 2yr
3yr 4yr
5yr
7yr Anterior fontanelle:
10yr Posterior fontanelle:
Puberty:
FEMALES: MALES:

Breast milk deficient in:

Developmental milestones

Palmar grasp disappears

Recognize mother
Cooing Bidextrous reach
Neck holding Binocular vision
Mouthing
ROFL
Pulls to sit; no head lag
Mirror play Immature princer grasp Pivots and cruises Mature princer grasp
Unidextrous, transfers Object permanence Diagonal localization of Mouthing disappears
Monosyllables Bye-bye sound Comes when called
Tripod “Bye”-syllables Stands with support Stand without support
Stranger anxiety Sits without support Creeps Throw ball
Listens to no Crawling Peek-a-boo Casting
1-2 words
Walk alone Domestic mimicry 2 steps up and down Circle
Jargon Explores drawer 2 word sentences 1 step upwards
Imitates scribbling Unzips 2 objects Handedness
2 blocks tower Runs and kicks ball Draw 2 lines 1-2 colours
Feeds with spoon Parallel play
Dry during day 9 tower
8-10 words Tower-6 blocks
Tower of 3 cubes Asks for food and drink Dress + undress except
Names body parts buttons
Undresses completely Name, gender, age
Unscrew, door knobs
1 step downstairs Triangle draw
Square, Cross 3 step command
Scissor Tie shoelaces
Bridge with blocks Ask meaning of words
Poem Recognise 5 colours
R-L discrimination Gate with blocks
Toilet alone
Age Gross motor Milestone Age Fine motor milestone

Neck holding Bidextrous approach

Rolls over Unidextrous approach

Immature pincer grasp
Sits in tripod position
Mature pincer grasp
Sits without support
Imitates scribbling, tower of 2 blocks,
Stands without support drinks from cup

Walks alone Scribbles, tower of 3 blocks, feeds with

spoon
Runs
Tower of 6 blocks, verticular and
Walks up and downstairs, 2 feet step circular strokes, undresses

Rides tricycle, alternate feet going Tower of 9 blocks, copies circle,

upstairs dresses
Hops on one foot, alternate feet going Copies cross, bridge with blocks
downstairs
Copies triangle, gate with blocks
Age Social Milestone Age Language milestone

Social smile Alerts to sound

Recognizes mother Coos

Stranger anxiety, inhibits to no Laugh loud

Waves bye-bye, repeats activity when Monosyllables

appreciated
Bisyllabes
Comes when called, plays simple ball
game 1-2 words with meaning
Jargon, points to objects of interest 8–10-word vocabulary
Copies parents in task
2-3 word sentences, uses pronouns
Asks for food, drink, toilet Asks question
Shares toys, knows full name and
Sings song, tell stories
gender
Plays cooperatively in group, goes to Asks meaning of words
toilet alone
Helps in household tasks