Case Scenarios

1. TB
Prevalence 2/1000
A. Diagnosis, Clinical features?
Sputum microscopy, Chest xray, Sputum culture, Mantoux test, BACTEC 460 tb, MGIT 960,
PCR, CBNAAT, Gene Xpert
Clinical features :
Fever, productive cough, night sweats, weakness, chest pain, weight loss
B. Treatment categories:

Isoniazid 5 mg/kg

Rifampicin 10 mg/kg

Pyrazinamide 25 mg/kg

Streptomycin 15 mg/kg

Ethambutol 15 mg/kg

Regimens Intensive phase Continuation

phase

Cat I New cases 2(HRZE) 4(HRE) 6 months

Cat II Previously treated 2(HRZES) + 5(HRE) 8 months

cases 1(HRZE)

Regimens IP CP

H Mono/Poly DR-TB 3-6 (LKREZ) 6 (LREZ)

Shorter MDR-TB regimen 4-6 (MhKEtCzZHE) or (KOCZEE) 5 (MhCzZE) or (COZE)

MDR/ RR-TB regimen 6-9 (LKEtCsZE) 18 (LEtCsE)

C. Types of families : Nuclear, Joint, 3 generation

D. Socioeconomic status : Kuppuswamy, BG prasad, Uday parekh
E. Govt schemes and programmes :
Nikshay Poshan Yojana,
National Tuberculosis Elimination Programme (NTEP) - DOTS

F. Methods to prevent spread of TB in family

BCG vaccine, Mask, Social distancing, Handwashing, Chemotherapy INH
G. Advice to family and community:
- Cough etiquette
- INH prophylaxis
- No social participation
- Health education
- Proper sanitation
- Rapid diagnosis and treat
- Adherence to treatment
- Safe sputum collection
- Improve room air ventilation
- Protection of health care workers
- Capacity building
2. Leprosy
Eliminated, <1/10000 cases - 2005
A. Classification, Diagnosis
Ridley Jopling classification - TT, BT, BB, BL, LL (B- Borderline, T - tuberculoid, L - leprosy)
Indian classification - Indeterminate, Tuberculoid, Borderline, Lepromatous, Pure neuritic
Clinical classification - Paucibacillary (1-5 skin lesions) & Multibacillary (>6 skin lesions)
Diagnosis -
i. Clinical examination - thickened nerves (ulnar), hypoanaesthetic patches, paresis of
muscles of hands and feet —> disabilities/ deformities.
ii. Bacteriological examination - skin smears, nasal smears, nasal scrapings
iii. Footpad culture
iv. Histamine test
v. Biopsy
vi. Lepromin test
vii. ELISA
B. Management :
MB PB

Rifampicin 600 mg (monthly) 600 mg (monthly)

Dapsone 100 mg (daily) 100 mg (daily)

Clofazimine 300 mg (monthly) -

50 mg (daily)

C. Skin tests :
Lepromin test - Intradermal injection of 0.1 ml of lepromin into forearm. Reaction is read at 48 h
and 21 d.
a. Early reaction - Fernandez - 24-48 h… 3-4d - redness, induration
Red area >10 mm at end of 48 h — (+)
Due to delayed hypersensitivity
b. Late reaction - Mitsuda - 7-10 d…3-4 w- nodule
Nodule >5 mm - (+)
Evaluate immune status (CMI) of leprosy patients.
Strongly (+) in tuberculoid cases, (-) towards lepromatous cases.
D. Probable social problems
Patient needs social assistance and social support.
- assistance to the patient to travel to & from the clinic.
- help to needy families in terms of food grains, clothes, care of children, and their education
and job replacement.
- slum improvement
- care should be provided through voluntary agencies and dept of social welfare.
E. National programme
National Leprosy Eradication Programme (NLEP) :
Components —
i. Decentralized integrated services
ii. Capacity building
iii. IEC
iv. Prevention of disability and medical rehabilitation
v. Intensified monitoring and supervision
Sub centre - Self care advice, advice to reconstructive surgery, monitoring
PHC - Mx - reactions, Id/ refer pts req RCS, footwear
District hospital - Mx- complicated ulcers
District nucleus - Supply foot wear
RCS centre - RCS
3. HIV/AIDS
A. Diagnosis : ELISA, Western blot, CBC, Virus isolation, Antibody tests, CD4 counts
B. Management : ART (Anti retroviral therapy)
2NRTIs + NNRTI
TEL 300;600;300 mg. [Tenofovir, Efavirenz, Lamivudine]
C. How to protect family members
Advice to wear gloves
Frequent hand washing
Any cuts on patient or caregiver should be covered with bandages,
Do not share razors, toothbrushes, nail scissors, pierced jewellery
D. Advice to community
Condom promotion, Health education, Avoid sharing of needles, Safe sex practices
E. Govt. schemes - Link the people living with HIV to Aadhar card scheme
F. National Programme
National AIDS Control Programme
Link worker scheme; ICTC; PPTCT; STI/RTI Mx; Lab services; Blood safety; Care, Support &
Treatment; IEC; Condom promotion; Suraksha clinic

4. COVID 19
A. Diagnosis :
- Molecular tests — RT- PCR
Lower respiratory tract : Bronchoalveolar lavage, tracheal aspirate, sputum
Upper respiratory tract : Nasopharyngeal & oropharyngeal swab
- NAAT
- Rapid Antigen testing
- Chest X Ray
- Chest CT
- Lung ultrasound
- LDH, CRP, D dimer
B. Quarantine or Isolation
Quarantine - limitation of freedom of movement of such well person exposed to communicable
disease for a ling time not longer than the longest usual incubation period of disease in such
manner as to prevent effective contact with those not so exposed
Isolation - separation, for the period of communicability, of infected persons from others in such
conditions so as to prevent or limit direct or indirect transmission of the infectious agent from
the infected to those who are susceptible
C. Advice to roommate :
Social distancing, mask, frequent handwashing, separate fomites, personal hygiene
D. Preventive measures in hostel :
Advice to maintain social distancing, masks, sanitising, personal hygiene, avoid touching of
fingers on face
Temperature screening
E. Currently recommended management :
Mild disease - URTI symptoms only - Home isolation - Contact precautions, strict hand
hygiene , symptomatic Mx
Moderate disease - RR >24/min, SpO2 <94% - Oxygen support, Remdesivir, HCQ, Steroids,
Anti coagulants, Monitoring; Follow CRP, D dimer, ferretin every 72 sly
Severe disease - RR >30/min, SpO2 >90% - Oxygen support, Anti viral, Steroids, Tocilizumab,
Anti coagulants, use sedation and nutrition therapy

5. Rabies
A. Classification of wounds:
I - touching/ feeding animals - licks on intact skin - none
II - nibbling of uncovered skin, minor scratches/abrasions, no bleeding - immediate vaccine and
local treatment
III - >1 transdermal bites/ scratches, licks on broken skin, contamination of mucous membrane
with saliva and licks, contact with bats - immediate vaccination, immunoglobulin, local
treatment
B. Management of wound:
Local treatment + Post exposure prophylaxis
Immediate flushing and washing wound with soap and water for 15 minutes,
Irrigating the wound site with virucidal agents like alcohol/ tincture/ povidone iodine/ detail
Wound should not be sutured
If unavoidable, suture can be done after 24-48 h observation under the cover of anti Rabies
serum.
Administer antibiotics and anti tetanus measures
Vaccine : cell culture
C. Post exposure prophylaxis:
Medical emergency
Ig + vaccine + local treatment of wound
Immunization
D. Vaccines? Routes of administration
Cell culture and Egg based vaccines

Vaccine Day 0 3 7 14 21 28 Route

IPC 2 2 2 ID

Thai Red 2 2 2 0 0 2 ID
Cross

Essen 1 1 1 1 1 IM

Zagreb 2 0 1 0 1 IM
E. Advice to be given to family and community
Vaccination to pets, Careful from stray animals, First aid measures, Health education
F. Prevention

6. Diarrhoea
A. Causative agents :
Bacteria — E.coli, Shigella, Salmonella, C. jejuni, V.cholerae, V.parahemolyticus
Viruses — Rota, Adeno, Astro, Corona, Calici
Others — E. histolytic, Giardia
B. Degrees of dehydration as per program guidelines

Mild Severe

Patient’s appearance Thirst, alert, restless Drowsy, cold, sweaty

Pulse Normal rate Rapid, feeble

BP Normal <80 mmHg

Skin elasticity Pinch retracts immediately Pinch retracts very slowly (>2 sec)

Tongue Moist Very dry

Anterior fontanelle Normal Very sunken

Urine flow Normal Little or none

% body weight loss 4-5% >10%

Estimated fluid loss 40-50 ml/kg 100-110 ml/kg

C. Management :
Oral Rehydration (75 ml/kg) - ORS
Intravenous Rehydration - Ringer lactate, Diarrhea treatment solution
Appropriate feeding,
 Chemotherapy,
Zinc supplementation
D. ORS
(mmol/l)
Na 75

Cl 65

Glucose 75

K 20

Citrate 10

Total 245
E. WHO DTS and Ringer lactate
RL - supplies adequate sodium & potassium, lactate —> bicarbonate (corrects acidosis)
DTS - contains NaCl, Na acetate, KCl, glucose
F. Advice to mother and community :
- Maternal nutrition : improve pre natal nutrition
- Child nutrition : breast feeding, appropriate weaning, vitamin A supplementation
- Sanitation : water supply, excreta disposal, food hygiene
- Health education
- Immunisation (Measles, Rota)
- Fly control
G. National guidelines
H. Immunisation :
Measles vaccine
Rotavirus vaccine - Oral, live, attenuated; Rotarix 2 doses at 6w,12w; RotaTeq 3 doses 2,4,6m
I. Prevention & Control :
Better MCH services,
Maternal - Prenatal nutrition,
Breast feeding,
Child - Appropriate weaning,
Supplementary feeding
Sanitation
Safe water
Excreta disposal
Disinfection
Personal hygiene
Fly control

7. Pneumonia
A. Classification of respiratory tract infections :
URTI - common cold, pharyngitis, otitis media - sneezing, headache, sore throat
LRTI - epiglottitis, laryngitis, laryngotracheitis, bronchitis, bronchiolitis, pneumonia - Cough*
B. Clinical features : Running nose, cough, sore throat, difficult breathing and ear problem
C. Causative agents :
Bacteria — B. pertussis, C. diphtheriae, H.influenza, K.pneumoniae, Staph, Strep
Viruses — Adeno, Entero, Influenza, Para influenza, Measles, RSV, Rhino, Corona
Others — Chlamydia, Mycoplasma
Signs Chest indrawing No chest indrawing and No chest indrawing and
fast breathing no fast breathing

Classify as SEVERE PNEUMONIA PNEUMONIA NO PNEUMONIA

Treatment Treat fever, wheezing, if Advice mother to give Cough >30 days - Refer
present home care Assess and treat ear
Refer / Give antibiotic problem/ sore throat.
treat with antibiotic & Treat fever, wheezing Advice mother to give
follow up Re assess after 2 days home care
Treat fever, wheezing

If 1. Worse — Refer urgently

2. The same — Change antibiotic / Refer
3. Improving — Finish antibiotics for 5 days

D. Classification
E. Severe pneumonia?
Stopped feeding well, cyanosis, convulsions, difficult to wake, stridor, wheezing, fever or
hypothermia
F. Management at home and health centre
At home :
Provide symptomatic treatment for fever and wheezing
Monitor fluid and food intake
Advise mother on home management on discharge
At health centre :
Benzyl Pencillin or 50,000 IU 6 hourly IM

Ampicillin or 50 mg/kg 6 hourly IM

Chloramphenicol 25 mg/kg/dose 6 hourly IM

If condition improves : If no improvement >48 h,

Continue antibiotics for change antibiotic
next 3 days

G. Prevention of pneumonia in the community :

Primary prevention - Improve living conditions, better nutrition, reduce smoke pollution, better
MCH care, Immunization (Measles, Hib, pneumococcal)
Community support, increase awareness
H. ARI control programme
Improving health care services, early diagnosis, treatment, prevention
Education of mothers
To reduce Under 5 mortality rate due to pneumonia

8. HIV/AIDS

9. Blood transfusion

10. Antenatal Case

A. Antenatal care : Care of woman during pregnancy
Aim : to have healthy mother and baby at the end of pregnancy
Objectives : - To promote, protect and maintain the health of mother during pregnancy
- To detect high risk cases and give them special attention
- To foresee complications and prevent them
- To remove anxiety, dreadness associated with delivery
 - To decrease maternal, infant morbidity and mortality
- To teach mother the elements of child care, nutrition, personal hygiene,
environmental hygiene
- To sensitize the mother of need for family planning, including advice to cases
seeking medical advice

B. Risk approach :
- Teen pregnancy
- Elderly primi (>30 y)
- Short stature (>140 cm)
- Elderly grand multipara
- Anaemia
- Twins
- Hydramnios
- Previous IUD
- Malpresentation
- Still births
- Previous C sec
- Antepartum haemorrhage
- Pregnancy induced hypertension
- Pregnancy assc. General disease
C. Antenatal advice :
Diet,
Exercise,
Hygiene,
No smoking,
Avoid alcohol,
Avoid drugs,
Avoid radiation
Specific protection against anaemia, nutritional deficiency, toxaemia, syphilis, german measles,
Rh incompatibility, Hiv
D. Additional calories
Pregnancy - +350 kcal (extra)
Lactation - +550 kcal
E. National programmes :
National Health mission,
NRHM,
RCH - II,
JSY, JSSK,
UIP,
ICDS

11. Postnatal Case

A. Care after delivery to mother and baby (1st 6 weeks after delivery)
B. Objectives : - To prevent complications
- To provide care for rapid restoration
- Adequate breast feeding
- Family planning
- Health education
C. Complications : Puerperal sepsis, secondary hemorrhage, UTI, Mastitis, Thrombophlebitis
D. Suggestions :
Individual —
- Diet
- Pelvic exercise
- Breast feeding
- Immunisation
- Regular health check ups
- Family planning
Family —
- Proper care of mother and child
 - Nutrition supplement
- Psychological support
Community —
- Screening for nutritional deficiency
- Health education - Anaemia, Immunization
- Family planning
E. Programmes :
JSSK,
RBSK,
ICDS,
RCH,
UIP
12. MTP
13. ICTC
Integrated Counselling and Testing Centre
- Early detection
- Provision of basic information on modes of transmission and prevention of HIV
- Behavourial change
- GATHER approach (Greet, Ask,Tell,Help,Explain,Return)
Types : Fixed facility — Standalone, Facility integrated
Mobile
Consists of Counselling room, Blood collection & testing room, CD4 count room
Diagnosis by SD Bioline HIV test, Trispot, Immunodot test

14. PPTCT
A. By NACO (national aids control organisation)
4 strategies : i. Primary prevention of HIV among women of child bearing age
ii. Preventing unintended pregnancies among women living with HIV
iii. Preventing transmission from woman living with HIV to her infant
iv. Providing care, support and treatment to women and their children with HIV
B. Risk factors : High viral load, Hiv subtype, Advanced stage, resistant strains, recent infection,
malnourishment; uterine manipulation, prolonged rupture of membranes, intrapartum haemorrhage
Preterm baby, LBW, breast pathologies
C. Management :
Safe obstetrics practices -minimise vaginal examinations, avoid prolonged labour, avoid
premature rupture of membranes, avoid trauma during delivery
 Observe newborn for signs and symptoms, all infants exposed to hiv should receive
Cotrimoxazole at 4-6 w of age, routine visits to hospital, DNA PCR,
Exclusive breast feeding, breast hygiene,
D. NEVIRAPINE
Mother - single dose 200 mg - onset of labour
Baby - syrup 2 mg/kg - <72 h of delivery

15. PEM
A. Prevalence - India - Under 5 - 48% ; wasting - 19.8% ; underweight - 42.5%
B. Diagnosis -
i. History taking
ii. Physical examination
Anthropometry : Weight, Length, Weight for age, Mid arm circumference (<12.5 cm),
Chest circumference, Head circumference, Skin fold measurement
BMI
iii. Laboratory tests
C. Signs & symptoms -
Reduced body weight,
Muscle wasting & decreased strength,
Wasting - acute malnutrition - Weight for age - [> - 2 SD]
Stunting - chronic malnutrition - Height for age - [>- 2 SD]
Severe acute malnutrition - >-3 SD

Kwashiorkor Marasmus

Protein deficiency Protein energy malnutrition

Edema, hepatomegaly Cachexia, wasting

Decreased albumin Normal albumin

D. Preventive measures :
Health promotion — care of pregnant, lactating women, breast feeding, low cost weaning foods,
Improve family diet, nutrition education, home economics, family planning, family environment
Specific protection — protein & energy rich foods, immunisation, food fortification
Early diagnosis and treatment — periodic surveillance, early diagnosis and treatment,
development of programmes for early rehydration of children with diarrhoea, supplementary
feeding during epidemics, deworming
Rehabilitation — Nutritional rehab services, hospital treatment, follow up

16. Diabetes mellitus

Prevalence - 15%
A. Clinical features -
Polydipsia, Polyphagia, Polyuria, Glycosuria, Lethargy, Stupor, Blurred vision, Smell of acetone
Complications -
Diabetic retinopathy,
Diabetic nephropathy,
Diabetic neuropathy,
Foot ulcers,
Poor wound healing,
Silent MI
B. Classification - Type 1 DM (Insulin dependent), Non Insulin dependent, Gestational, Malnutrition
related, Impaired glucose tolerance
C. Risk factors -
Host - Age, Sex, Genetics, Obesity, Maternal diabetes,
Environment - Sedentary lifestyle, Dietary fibre,
Malnutrition, Alcohol, Viral infections, Drugs
D. Diagnosis -
 Fasting blood sugar <126 mg/dl
Post prandial blood sugar - 140 - 200 mg/ dl
Glycemic index - <6.5mg%
Oral glucose tolerance test
E. Treatment - Insulin, Oral hypoglycaemic agents
F. Control
Primary and secondary prevention
- Health education : about self care, regular treatment, exercise, diet, regular check up, avoiding
smoking & alcohol, adopting yoga & medication, home glucose monitoring
- Advice correct diet : small meals at frequent intervals, avoid saturated fat, fibre atlas 20 g/ day
Tertiary prevention
- Rehabilition diabetic clinics
- Free services should be made available at PHCs and government hospitals
G. National program : NPCDCS

17. Hypertension
A. Prevalence?
11- 14%
B. Rule of halves?
Half of the hypertensives were aware of the condition,
about half of those aware were treated,
And half of those who treated were adequately treated.
C. Risk factors?
Non modifiable : Age, Gender, Genetic, Ethnicity
Modifiable : Obesity, Salt, Saturated fats, Fibre, Alcohol, Environmental stress, heart rate,
Physical activity, socioeconomic status.
D. Diagnosis?
- Sphygmomanometer
Classification -
Category SBP DBP

Optimal <120 <80

Normal 120-129 80-84

High Normal 130-139 85-89

Grade 1 140-159 90-99

Grade 2 160-179 100-109

Grade 3 >180 >110

Isolated systolic >140 <90

- Blood cell count
- Urine analysis
- ECG
- Total cholesterol levels
E. Complications?
Stroke, HTN encephalopathy, HTN retinopathy, MI, HTN cardiomyopathy, Heart failure,
HTN nephropathy, Chronic renal failure
F. Prevention?
Primary prevention :
Population strategy
— Nutrition (reduce salt intake, moderate fat intake, avoid alcohol, restriction of energy intake
appropriate to body needs
— Weight reduction
— Exercise
 — Behavioural changes - reduce stress, adopt yoga
— Health education
— Self care
High risk strategy
— Family history
— Tracking of BP (those who have initially high would probably continue in the same track as
adults; low bp tend to remain low; high levels tend to become higher as individuals grow
older)
Secondary prevention :
— Early case detection
— Treatment
— Patient compliance
Tertiary prevention :
— Treatment of complications
G. Advice :
Eat more whole grain foods, fruits, fish and nuts
Limit sodium, sweets, sugary drinks, red meat
Cut high levels of saturated fat, cholesterol and trans fat

18. PIH

19. Malaria

20. Dengue