Monday, 25 March 2019

Rule of 2 - Tuberculosis

Rule of two

1.      2 out of 10 word cases of TB are in India
2.      Tuberculosis has 2 words T and B = TB
3.      TB can be pulmonary or extra pulmonary.
4.      Resistant TB can be MDR or XDR Tb.
5.      MDR TB is seen in 2% of new TB cases.
6.      2 patients of every 10 patients are extra pulmonary RB cases
7.      One can treat both sputum positive of sputum negative cases
8.      Sputum negative cases confirm by GeneXpert or LPA test

9.      Don’t ignore fever and cough.

10.  Don’t ignore fever of more than 2 weeks duration.

11.  Don’t ignore cough of more than 2 weeks duration.

12.  Get 2 sputum examination to rule out TB (stat and nearly morning).

13.  Collect 2 ML of sputum for examination.

14.  Sputum can be tested by Z N Stain or fluorescent microscopy.

15.  2 tests for TB to remember: Sputum AFB and Molecular tests.

16.  Molecular tests can be GeneXpert TB test or LPA (line probe assay) test.

17.  GeneXpert TB tests is for rifampicin resistance (2R)

18.  GeneXpert TB test in private sector costs 2 thousand rupees.

19.  LPA for 2 drug resistances: INH and Rifampicin

20.  GeneXpert TB test results are available in 2 hours

21.  LPA test takes more than 2 days for the results

22.  In retreatment cases do both sputum AFB and molecular test

23.  In retreatment cases before labelling as a resistant case do the GeneXpert test 2 times.

24.  2 advanced investigations to remember: HRCT Chest and Bronchoscopy

25.  MDR TB means resistance to Rifampicin and INH. (2 drugs)

26.  XDR Tb means resistance to 2+2 drugs (Rifampicin and INH + quinolone and one injectable) or to 2 group of drugs

27.  Take 2 weeks precautions if AFB is positive.

28.  Rule out HIV and Diabetes Mellitus in case of TB.

29.  Use 2 type of masks, N 95 (for doctor) and surgical mask (for patients).

30.  Notify TB and screen the contacts.

31.  Not notifying TB is a crime under 2 clauses of MCI (5.2 and 7.14).

32.  Municipal Corporation and West Bengal CEA can take action if one fails to notify TB or fails to screen the contacts.

33.  Spreading infection is punishable under IPC Sections IPC 269/270.

34.  Patients of TB can be new cases or retreatment cases.

35.  There are 2 spells of treatment Intensive phase and continuation phase.

36.  For treatment TB can be sputum conformed TB or clinical TB.

37.  Give four drugs for 2 months.

38.  When we give 5 drugs we add SM injection for 2 months.

39.  At 2 months get 2 sputum tests done to confirm if AFB is negative or not.

40.  At 2 months if sputum AFB is positive think of GeneXpert TB tests or LPA test.

41.   In health care setting masks should be available at the reception and laboratory.

42.  Avoid split ACs at 2 places - in cars and at home.

43.  Use burial method or phenol to destroy the sputum.

44.  Skin and GI are the major organs affected by ATT.

45.  Vit B 6 and Vit D should be added to ATT.

46.  Brain and bone TB involvement require long treatment.

47.  MDR TB requires 2 years treatment.

48.  In MDR TB 2 out of 10 cases will die.

49.  In MDR cases 2 out of 10 will default.

50.  Patient rights: To get free diagnostics and free drugs from the government.

51.  Acid-fast bacteria visualized on a slide may represent M. tuberculosis or nontuberculous mycobacteria (NTM).

52.  Notify both confirmed and suspected case.

53.  Collect sputum: Spontaneously (by coughing) or induced by inhalation of aerosolized hypertonic saline generated by a nebulizer.

54.  Two most common presentation of Extra pulmonary TB are TB Lymph Nodes or pleural effusion.

55.  Common test for pleural effusion are proteins and presence of lymphocytes.

56.  Tow thigs to remember in pleural effusion: GeneXpert is negative and ADA test is positive.

57.  Paradoxical reaction in TB lymph nodes occurs at 2 months.

58.   MDR TB can be both pulmonary and extra pulmonary TB.

59.  Think before you order two tests: ELIESA and Gold Interferon.

60.  All biopsy samples should be taken in saline (for IRL) and formalin.

(with inputs from Dr Ashwani Khanna)

Saturday, 29 December 2018

Tuesday, 11 September 2018

Bio Medical Waste

Type of Waste
(a) Human Anatomical Waste : Human tissues, organs, body parts and fetus below the viability period
(as per the Medical Termination of Pregnancy Act 1971, amended from time to time).
(b) Animal Anatomical Waste : Experimental animal carcasses, body parts, organs, tissues, including
the waste generated from animals used in experiments or testing in veterinary hospitals or colleges
or animal houses
(c) Soiled Waste: Items contaminated with blood, body fluids like dressings, plaster casts, cotton
swabs and
(d) Expired or Discarded Medicines: Pharmaceutical waste like antibiotics, cytotoxic drugs including
all items contaminated with cytotoxic drugs along with glass or plastic ampoules, vials etc.
(f) Chemical Liquid waste : Liquid waste generated due to use of chemicals in production of
biological and used or discarded disinfectants, Silver X-ray film developing liquid, discarded Formalin,
infected secretions, aspirated body fluids, liquid from laboratories and floor washings, cleaning,
house-keeping and disinfecting activities etc.
(g) Discarded linen, mattresses, beddings contaminated with blood or body fluid.
(h) Microbiology, Biotechnology and other clinical laboratory waste: Blood bags, Laboratory cultures,
stocks or specimens of microorganisms, live or attenuated vaccines, human and animal cell
cultures used in research, industrial laboratories, production of biological, residual toxins, dishes
and devices used for cultures.

Type of Bag or Container to be used :Yellow coloured non-chlorinated plastic bags
Treatment and Disposal options :Incineration or Plasma Pyrolysis or deep burial

Type of Waste
(a) Wastes generated from disposable items such as tubing, bottles, intravenous tubes and sets,
catheters, urine bags, syringes (without needles and fixed needle syringes) and vaccutainers with
their needles cut) and gloves.
Type of Bag or Container to be used :Red coloured non-chlorinated plastic bags or containers

Treatment and Disposal options: Autoclaving or micro-waving/ hydroclaving followed by shredding
or mutilation or combination of sterilization and shredding. Treated waste to be sent to registered
or authorized recyclers or for energy recovery or plastics to diesel or fuel oil or for road making,
whichever is possible. Plastic waste should not be sent to landfill sites

White (Translucent)
Type of Waste
Waste sharps including Metals: Needles, syringes with fixed needles, needles from needle tip cutter
or burner, scalpels, blades, or any other contaminated sharp object that may cause puncture and
cuts. This includes both used, discarded and contaminated metal shar

Type of Bag or Container to be used :Puncture proof, Leak proof, tamper proof containers

Treatment and Disposal options : Autoclaving or Dry Heat Sterilization followed by shredding
or mutilation or encapsulation in metal container or cement concrete; combination of shredding
cum autoclaving; and sent for final disposal to iron foundries (having consent to operate from
the State Pollution Control Boards or Pollution Control Committees) or sanitary landfill or
designated concrete waste sharp pit

Type of Waste
(a) Glassware: Broken or discarded and contaminated glass including medicine vials and ampoules
except those contaminated with cytotoxic wastes. Cardboard boxes with blue colored marking
Disinfection (by soaking the washed glass waste after cleaning with detergent and Sodium
Hypochlorite treatment) or through autoclaving or microwaving or hydroclaving and then sent for

(b) Metallic Body Implants

Type of Bag or Container to be used :Cardboard boxes with blue colored marking

Treatment and Disposal options :Disinfection (by soaking the washed glass waste after cleaning
with detergent and Sodium Hypochlorite treatment) or through autoclaving or microwaving or
hydroclaving and then sent for recycling.

Wednesday, 5 September 2018

Some poisons & their specific antidotes

1. Anticholinergics --> Cholinergics.
2. Atropine and/or scopolamine --> Physostigmine.
3. benzodiazepines and barbiturates --> flumazenil.
4. Calcium Channel Blockers (Verapamil, Diltiazem) --> Calcium Gluconate.
5. Isoniazid --> Pyridoxine.
6. Magnesium --> Calcium Gluconate.
7. opioids --> naloxone.
8. paracetamol (acetaminophen) --> N-acetylcysteine.
9. Thallium --> Prussian blue.
10. Nicotine --> Bupropion and other ganglion blockers.
11. ethylene glycol --> ethanol or fomepizole, and thiamine.
12. methanol --> ethanol or fomepizole, and folinic acid.

Tuesday, 10 July 2018


Dementia + sensory Ataxia + PNP(polyneuropathy) + UMN(babinski's sign) = B12 deficiency

Dementia + cerebellar ataxia + ophtalmoplegia = B1 def (Wernicke's syndrome)

Dementia + high cholesterol = hypothyroidism

Dementia + myoclonus = Creutzfeldt-Jakob disease

Dementia + gait apraxia + urinary incontinence = NPH (non-pressure hydrocephalus)

Dementia with stepwise progression + pseudobulbar palsy(PBP) = Binswanger's disease (vascular dementia)

Dementia + PBP + gaze abnormality + torticollis = PSP (progressive supranuclear palsy)

Dementia + chorea= Huntington's disease

Dementia + Parkinsonism + syncopal attack = Shy-Drager syndrome (multiple system atrophy)

Dementia that is fluctuating + Parkinsonism= Lewy body dementia

Dementia with sparing visuospatial skills + personality change = Frontotemporal dementia


A wound occurs when the integrity of any tissue is compromised (e.g. skin breaks, muscle tears, burns, or bone fractures). A wound may be caused by an act, such as a gunshot, fall, or surgical procedure; by an infectious disease; or by an underlying condition.

Surgical Wound classification

Class I
An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tract is not entered. In addition, clean wounds are primarily closed and, if necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria.

Class II
An operative wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered.

Class III
Open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique (e.g., open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered are included in this category.

Class IV
Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.

Friday, 22 June 2018

Signs in ENT

BATTLE SIGN- Bruising behind earat mastoid region, due to petroustemporal bone# (middle fossa #).

BOCCA'S SIGN - Absence of postcricoid crackle(Muir's crackle) inCarcinoma post. cricoid.

BROWN SIGN - blanching of rednesson increasing pressure more thansystemic pressure see in glomusjugulare.

BOYCE SIGN - Laryngocoele-Gurgling sound on compression ofexternal laryngocoele with reductionof swelling.

DODD’S SIGN/CRESCENT SIGN - X-ray finding-Crescent of air betweenthe mass and posterior pharyngealwall. positive in AC ployp. Negativein Angiofibroma

FURSTENBERGERSSIGN-This is seenwhen nasopharyngeal cyst is communicating intracranially,there isenlargement of the cyst on crying and upon compression of jugularvein.

HITSELBERGER'SSIGN - In Acousticneuroma- loss of sensation in theear canal suppllied by Arnold'snerve( branch of Vagus nerve to ear )

HOLMAN MILLER SIGN, ANTRALSIGN-it is seen in angiofibroma,thetumor pushes forward on theposterior wall of the maxillarysinus..

HONDOUSA SIGN--X-ray finding inAngiofibroma, indicatinginfratemporal fossa involvementcharacterised by widening of gapbetween ramus of mandible andmaxillary body.

HENNEBERT SIGN- false fistula sign( cong.syphilis, Meniere's,)

IRWIN MOORE’S SIGN-------- positivesqueeze test in chronic tonsillitis

LIGHT HOUSE SIGN--- seeping outof secretions in acute OTITIS media

LYRE'S SIGN - splaying of carotidvessels in carotid body tumor

MILIAN’S EAR SIGN- Erysipelas canspread to pinna(cuticularaffection),where as cellulitis cannot.

PHELP'S SIGN - loss of crust of bonebetween carotid canal and jugularcanal in glomus jugulare

RACOON SIGN-Indicate subgalealhemorrhage,and not necessarly baseof skull #

STEEPLE SIGN- X-ray finding inAcute Laryngo tracheo bronchitis

STANKIEWICK'S SIGN - indicateorbital injury during FESS. fatprotrudes into nasal cavity oncompression of eye ball from ouside

THUMB SIGN --X-ray finding A/cepiglottitis

TRAGUS SIGN- EXTERNAL OTITIS ,Pain on pressing Tragus

TEA POT SIGN is seen in CSFrhinorrhoea..

WOODS SIGN----- palpable jugulodigastric lymphnode