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First & foremost I towards

would like to thank God completion of this

almighty for his kindness & blessing extended successful Assignment. I am extremely thankful to Dr. Sunil M. Jain to offering me a platform to under take this project. I am especially grateful to PROJECT HOPE S TEAM for them encouragement & constructive criticism. I consider aprevilage to express a deep sense of gratitude of all the my friends who gave me encouragement suggestion and supervision.

Above all I am deeply and most profoundly thankful to my parents for their un-ending support and understanding.







Bhopal Memorial Hospital Trust
The mission of Bhopal Memorial Trust is to provide medical and other available facilities ( including facilities for medical surveillance by periodic medical check up) for the benefit in the first instance of the victims of the Bhopal Gas Tragedy of 1984 and their dependents and subject thereto for the people of Bhopal and the public at large.

Bhopal Memorial Hospital & Research Centre

The mission of Bhopal Memorial and Research Centre is to provide the patients with the medical treatment of a highly specialized nature in defined areas. It will promote medical research and continuous education programmes including post graduates education training

Mini Units

The missions of mini units, affiliated to Bhopal Memorial Hospital and Research Centre, is to provide primary healthcare to the gas victims and to guide them to get proper & proper & specialized medical services, Whenever it is necessary. Min Units shall also contribute to the prevention, rehabilitation & health awareness programmes.

1. To provide state-of-the-art Super-specialty medical to all registered gas victims and their entitles dependents. 2. To carry our basic, clinical and epidemiological research in all disciplines in the hospital . 3. TO determine long term effect by Methyl Isocynate (MIC) on human and to plan treatment modalities based on the findings. 4. To utilize the existing infrastructure to train doctors, nurse and paramedical personnel

The OPD remains open from 9 O clock in the morning to 2 O clock in the afternoon from Monday to Saturday.

WARD BED Pulmonary Medicine Cardiology Cardiothoracic Surgery Neurology & Psychiatry Neurology Surgery Gastro Enterolgy Medicine Ophthalmology Nephrology : : : : : : : : 30 Beds 30 Beds 30 Beds 30 Beds 30 Beds 30 Beds 30 Beds 30 Beds

Urology Intensive Care Unit (ICU)

: :

30 Beds 11 Beds 10 Beds 05 Beds 24 Beds 350 Beds

Intensive Coronary Care Unit (ICCU): Neuro ICU Paying Wards Total : : :

Cancer is a term used to refer malignant neoplasm or tumors Neoplasia means cell in tissue proliferate without the normal control of growth. In malignant neoplasm the cell spread to adjacent tissue and interfere with the function and often has undesirable systemic effects. Benign tumors represent the occumulatoin of cell which have been transformed to reproduce in abnormal numbers but under circumstances where they remain with in the tissue origin. Cancer is caused by mutation or abnormal activation of cellular genes that control cell growth and cell mitosis. The abnormal genes are called oncogenes .

The development of cancer is a complex multi stage process which can be summarized as: 1) INITIATION 2) PROMOTION 3) PROGRESSION

Carcinoma cancer Sarcoma cancer Lymphomas cancer Leukemia cancer Melanoma cancer

Glidmas cancer

RISK FACTOR OF CANCER Heredity Lonizing radiation Chemical substance Dietary factor Meat

Energy balance Fat Protein Alcohol Nitrates

DIET : ENERGY : High calorie 3000 to 4000 PROTEIN : High protein 80 to 100gm. FAT : Moderate fat VITAMIN : & MINERALS : FLUIDS :

Patient with pancreatic disease are particularly likely to have nutrition related problem and be nutritionally depleted under nutrition is a high results of poor dietary intake. Due to anorexia some times compound by alcohol abuse. Malabsorptoin caused by pancreatic exocrine insufficiency. ACUTE PANCREATITIS :- A.P. develops when activate pancreatic enzyme and liberated with in the pancreatic system. Resulting in the auto digestion of tissue. Acute pancreatitis is a serious disorder

CAUSE : A biliary tract disease (especially calculai in the common bile duct) Alcohol abuse Trauma or major abdominal surgery It can also be associated with under condition such as hyperlipidaemia, hypercalcaemia, and stage renal

Failure & viral infection & in about 10% of cases may idiopathic Some systematic complication include shock renal failure & respiratory insufficiency SYMPTOMS : Pain in upper left quadrant of the abdomen Nausea & vomiting Appetite decrease Weight loss


SBS Refers to the Malabsorptoin of fluid nutrients associated with significant resection of the small intestine, which results in only 3to5 feet of intact small bowel remaining. But resection of 40-60% may lead to several consequence of SBS, depending on the site of the resection and other factor. Resection of the distal ileum has the most significant impact on risk of SBS, but the risk of dehydration, electrolyte disorder malnutrition is increased after distal small bowel resection or colonic removal. The most common reasons for major resection of the intestine in adults include crohn,s disease, radiation entritis, mesenteric infract, malignant disease and volvulus. Obvious complications of SBS include malabsoption of micronutrients and macronutrients, fluid and electrolyte inbalances, weight loss and growth failure. Gastric hypersecretin, oxalate renal stone, cholesterol, gall stone and rarely D-lactic acidosis may also occur severity of malabsorption, the extent of complication and degree of dependence on parental nutritional support reflect the length and the location of the resection, the age of the patients at the time of he operation, and the health of remaining GI tract. NUTRITIONAL THERAPY :-

Most patient present who, have significant bowel resection require TPN initially to restore and maintain nutritional status. The duration of TPN and subsequent nutrition therapy is based on the extent of the bowel resection, the health of the patient, and the condition of the femaining GI tract. Some may require life supplementation with P.N. to maintain adequate fluid and nutritional status. The 2 general principles for resuming E.N. after small bowel resection are 1) TO start enteral feeding early 2) TO increase feeding early concentration and volume gradualy over time Patients with jejunal resections and an interact ileum and colon with likely adapt quickly to normal diets. A normal balance of protein, fat & CHO sources is satisfactory 6 small feeding, with avoidance of lactose large amount of concentrated sweet, and caffine may help to reduce the risk of blotin, abdominal pain and diarrhea.


ANTHROPOMETRIC MEASUREMENT :HEIGHT (cm):WEIGHT (kg) :B.M.I. :182 100 (Admission ) 75 (Discharge ) 30 (Admission ) 23 (Discharge)

Diagnosis :- Acute Necrotizing Pancretitis SKIN EYE HAIR NAIL Drugs Tab Motitium Inj amikacine BD Inj Tiniba OD Inj Omez BD Inj Heparine BD NORMAL NORMAL NORMAL NORMAL

Normal Volve Hemoglobin 13/18 gm/dl TLC 400011000cm Blood Urea 10/50 mg /dl S. 0.6-1.4 Creatinine mg/dl Sodium 135-155 m mol/l Potassium 3.5-5.5 m mal/l SGOT Up to 46 U/L SGPT UP to 49 U/L AIK PO4 72 WBS 4-11 X 109 /L Date 11/08/08 11.2 11,700 23 0.67 137 3.21 34 14 25/09/08 10.7 13 0.65 131 3.92 25 14 19400 24200 18800 5/10/08 9.7 25 0.75 124 4.11 12/10/08 9.0


BP Pulse Rate

5/10/08 110/70mm Hg 90/min

12/10/08 120/70mmHg 94/min


TIME 6:00 AM 7:00AM 8:00AM 9:00AM 10:00AM 11:00 AM 12:00 1:00 PM 2:00PM 3:00 PM 4:00PM 5:00 PM 6:00PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 12:00 PM FOOD ITEM Tea Dhal water Soup Papaya Shake Butter milk Milk Soup Dhal water Milk AMOUNT (gm) 75ml 150ml 100ml 150ml 150ml 100ml 100ml 150ml 100ml


: : : :

900 Kcal 16 gm 22 gm 146

Principle of Diet Food Habits Early morning Break Fast : : : : Low Fat, High Protein, Low CHO Veg/Non-Veg 1 cup tea/coffee/milk +biscuit (without sugar) 1 cup milk + (any one snack_ Upma/Poha /sprouts 1 bow /Paranthas 1/bowl /Idili 2+ sambhar 1 bow 1 Mid Morning Lunch Evening Mid Evening Dinner Bed Time : : : : : : Buttermilk/Veg.soup 1 bowl1/any fruits1 Phulkas 2/Bread 1 Slices, Rice 1, Dhal 1 bowl, thin, Vegatables 1 bowl, Salad, Curd 1 bowl 1 cup Tea/Milk +2 Biscuits Murmura 1 bow/ any fruit Phulka 2, Rice 1, Vegetables 1 bowl, 1 cup milk + without sugar.


: :

1330 cal 29 gram

Included Avoided

: :

Cereals Pulses skimmed milk, fruits , vegetables Cake, patereis, deep fried food, pickles, papad bakery products, butter cheese


This may be caused by a variety of agents including alcohol infection such as viral hepatitis and autoimmune disease. Chronic liver disease may give rose to cirrhosis. Which reflects state of irreversible liver damage characterized by fibrosis nodular regeneration and disturbance of normal hepatic architecture. The severity of cirrhosis graded using pughs modification of child classification. Cirrhosis does not always cause symptoms in which case. It is said to be well compensated. I.E. Although the liver is damaged. It is still able to function adequately and he patient condition stable. However

further to the liver for example infection. Gastrointestinal bleeding, dehydration, or continues alcohol abuse may lead to decomposition and a number complications including fluid retention and encephalopathy.

Personal Information Patients Name Age Date of Admission Date of Discharge Hospital I D No. Economical Status Food Habits :::::::Manju SINGH 47 17/05/11 27/05/11 12013542 Educated MIG Veg/Non-Veg

Educational Status :-

Anthropometric measurement Height (cm) Weight (kg) ::170 59 (Admission )

51 (after 16 days) BMI Diagnosis Clinical Information Skin Eye Hair Nail Drug T. Ecosprin 100 1OD T. Enam 2 Int BD Inj Supacet 1sgm BD Int Amikacin 500mg BD Inj Tinibs 500 mg OD Inj Tradmadol lamp Tbs Inj Heparin 5000 ug BD ::::Rough Normal Rough Normal ::20 Ca Cecall

Normal Value Heamoglobin WBC. Total Loun Platelet Count Blood Urea Creations Billirubin Total Direct Indirect S No Potassium 13-18 gm /dl 4 -11 X 10 /L 1.5 4 X10M /L 10-50 mg /dl 0.6 1.4 mg /dl 0.2 1.2 mg /dl 0.0 0.2 mg/dl 0.1 1.0 mg /dl 135- 155 mmol/d 3.5 5.5 mmol/l 27 1.07 0.34 0.14 0.20 136 3.82 138 3.67 Date 29/9/08 13.6 6400 11/10/08 12.9 13000 1.66 27 0.99 12/10/08 13.9 12000 1.48 18 1.02 0.83 0.16 0.67 136 4.18

27/09/08 Pulse Rate BP Intake Output 78/min 140 /90 mm Hg 1750 ml 1400ml 12/10/08 74/min 130/90 mmHg 2500ml 3250ml


TIME 6:00 AM 7:00 AM 8: 00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 1:00 PM 2 :00 PM 3 :00 PM 4 :00 5 : 00 PM 6 : 00 PM FOOD ITEM Tea Marie Gold Biscuit Upma Phulka Dal Rice Veg Curd Tea Marie Gold AMOUNT (gm) 70 ml 2 30 gram 3 30 gm 30 gm 30 gm 100 ml 70 ml 4 No

7 : 00 PM 8 : 00 PM 9 : 00 PM 10 : 00 PM 11 : 00 PM 12 :00 PM

Phulka Dal Rice Veg Milk

4 No 30 gm 30 gm 30 gm 100 ml


: : :

1771 Kcal 62 gm 45 gm 240 gm


Principles of Diet Food Habits Early Morning Break Fast : : : : Low Fat, Moderate Protein, Low Salt Veg/Non-veg 1 cup tea/ coffee/milk + biscuits Threptine 1 Cup milk sugar 1 tsp. + ( any one snack) Upma/poha/sprouts 1 bow1 Phulkas 2/ Bread Slices 2 + 1 egg Cornflakes 1 bow1/Idli 2 + sambar 1 bow1 Mid Morning Lunch : : Butter milk/veg.soup 1 bowl any fruit. Phulkas 2/ Bread 1 Slices, Rice 1 bow1 Dal 1 bowl, Vegetables 1 bowl, Salad 1 plate Curd 1 bowl. Evening Mid Evening Dinner : : 1 cup Tea/Milk + Biscuits. Murmura 1 bowl/any fruit : phulkas 2/ Rice 1 bowl/ Vegetables 1 bowl Salad 1 plate

Bed time

1 cup milk + sugar 1 tsp

ENERGY : 1732 Kcal PROTEINS : 42 gm Food included : Green Leafy vegetable, ripe yellow fruits & vegetables papaya, milk, melon, mango Pumpkine, carrots Guava, Orange, sweet lime cereals, oil seeds, Nuts, meats, liver, seafoods, mushroom, chocolates, pulses. Food to be Avoided : Whole milk, Cream, Buter, Deep Fried Food Pickles, chutney, papad

Cirrhosis is condition in which there destruction of the liver cell due to necrosis, fatty infiltration fibrosis and nodular regenerations . it is a serious and irreversible disease. The cirrhosis process may commence many years before it becomes clinically obvious and usually the patients when first seen is at a very late stage with complication such as ascitis, ruptured oesophageal varies or hepatic coma. Almost 80-90% of liver damage also do not produce symptoms. The initial change in cirrhosis is wide spread liver cell necrosis due to viral hepatitis alcohol etc. Cirrhosis of liver is the structural and functional and results of nutritional, infective of toxic change in the liver. A ETIOLOGY : Viral infection Alcohol Nutrition Toxins of food

SYMPTOMS The one set of cirrhosis my be gradual with gastrointestinal disturbance such as : Anorexia Nausea Vomiting Pain and distension Weakness Hypertension


Personal Information Patients Name AGE SEX DATE OF ADMISSION DATE OF DISCHARGE HOSPITAL ID NO. ::::::90037741 UNEDUCATED MIG Veg/Non veg Mrs. SUDHA SAXENA 65 FEMALE 10/03/11


Anthropometric measurement :HEIGHT (cm) WEIGHT B.M.I. :::40 17 157

DIAGNOSIS :- ASCITTS AND CID (Chronic Liver disease ) HISTORY :C/o abdominal ID

CLINICAL INFORMATION SKIN EYE HAIR NAIL DRUG Inj meghex 1 gm Inj rejlox Inj Isom + Kcol 150ml C. cylolac inj Dopmin smac/en Normal Normal R Normal


Time 6:00 AM 7:00 AM 12:00 1: 00PM 2:00PM 3:00PM 4:00PM 6:00 PM 7:00 PM 9:00 PM 10:00 PM Food Item Tea Biscuits Phulkas Dal Rice Vege Curd Tea Biscuit Rice Dal Amount (gm) 75ml 2 Nos 2 Nos 30gm 30 gm 30gm 30gm 75ml 2 Nos 30 gm 30gm


1030 Kcal


27 gm 30 gm 161 gm

Principle of Diet Food Habits Early morning Break Fast : : : : Low Fat, Moderate Protein, Low Salts Veg/ Non-Veg 1 cup tea/ milk + biscuit (Thriptine) 1 glass milk sugar 1 tsp. + (any one Snack Upma/poha 1bowl (without ground nut ) Bread Slices 2 +1 egg/Cornflakes 1 bowl/ Idli 2 + sambar 1 bowl Mid Morning Lunch : : Any Fruits (Soft ) Bread 2 Slice/soft Rice 1 bowl OR Bread 2 slices + soft rice 1 bowl/soft cooked veg./fish 2 psc./Curd 1 bowl. Evening Mid Evening Dinner : : : 1 cup Tea /Milk +2 Biscuits Plain custard 1 bowl/any fruit (soft)/fruit Shake 1 cup Daliya/ Khichri 1 bowl,Soft cooked vegetables 1 bowl,Curd 1 bowl

Bed Time ENERGY PROTEINS Food included

: : : :

1 cup tea/milk +biscuits 2 Nos 1260 Kcal 34 gram Cereals, Pulse, Milk, and milk product, Vegetables puree, egg, fruits.

Food to be Avoided

Deep fried foods, cake pastries, whole milk Cream, juices, soups , all fluids.

SAMPLE MENU (Cirrhosis)

Principle of diet : high calorie, high protein, high carbohydrate moderate or restricted fate Food habits Early morning Break Fast : : : Veg Non- veg milk + Biscuits/ Coffee /Tea Poha/ Upma /Suji Halwa/OMellte / fruits salad/ sprouted Salad Mid Morning : Anar Juice/ Papaya Shake/ Musami Juice /Orange Juice/ apple 1 glass Lunch : Phulkas 2 / vegetables 1 bowl salad 1 plate, Rice dal 1 bowl, curd 1 bowl Evening Mid Evening : : Tea/ 1 cup /Biscuits + Milk / Tost/Mumura /Dhokla 1 bowl


2 phulkas, Rice 1 bowl, Dal 1 bowl, vegetable, 1 bowl/ Salad 1 plate


: : :

1 cup Milk + Sugar 1650 55 gm


It is characterized by slowly progressive obstruction of the airways COPD A) Emphysema B) Chronic bronchitis

Tobacco smoking over whelmingly os the most important causative fator. All though environment air pollution and genetic susceptibility are other etiologic possibilities. Decrease food intake is common Morning headache and confusion from hypercapina must be identifying because these symptoms may interfere with food preparation or intake. Other assessment focus on blood oxygen saturation, fatigue anorexia, difficulty chewing and swallowing from dyspnea, constipation from low fibre food selection or diarrhea fro impaired peristalsis secondary to lack of oxygen to the G I track. Sufficient protein 1.2 1.7kg body weight is necessary to maintain or restore lungs and muscles strength as well as to promote immune functions.

A balance ratio of proteins ( 15-20 % of calories) with fat (30-40 % of calories ) and CHO (40-55 % of calories ) is important to preserve a satisfactory RQ from substrate utilization some patient with corplmenatle and fluid retention require sodium and fluid restriction depending on the diuretics prescribed, Increased dietary intake of potassium may be required .

Tuberculosis is an infections disease caused by the bacillius mycobacterium. It affects the lungs most often but may also be localized in other organs such as the lymphndes or kidneys or it may be generalized. Tuber bacilli gain entry in the body usually by inhalation of ingestion. Rarely they may gain entry through skin. Tonsilsls,conjuctiva Source of tubercle bacilli. A single cough expels up to 40, 000 tubercle bacilli. Droplets of sputum containing the bacilli may be inhaled directly by those in the vicinity or they may fall on the ground and mix with dust. When the ground is swept the bacilli rise with the dust may be inhaled. Clinical feature :

Fevers brief period, which is often passed off as influenza . Anorexia and weight loss. Cough and wheeze to due to pressure of lymph on bronchi. Local areas of rates or bronchi. General ability: a thin pale fretful child with loss of skin elasticity and less glassy hairs .


TIME 6 : 00AM 7: 00AM 8: 00AM 9: 00AM 10: 00AM 11: 00AM 12 : 00 1 :00PM 2:00PM 3:00PM 4:00PM 5:00PM 6:00PM 7:00PM 8:00PM 9:00PM 10:00PM 11:00PM FOOD ITEM Tea Biscuits Idli Sambhar Papaya Phulka Dal Veg AMOUNT (gm) 75 ml 2 No 2 Nos 30gm 130 ml 2 20 gm 30 gm

Tea Biscuits Phulka Veg Milk

75 ml 2 2 20 gm 150 ml

12 :00


: : :

1060 Kcal 37 gm 19.3 gm 173 gm


Principle of Diet Food Habits Early Morning Break Fast : : : : Low Fat, High Proteins, Salts Veg/Non- Veg 1 cup tea/coffee/milk + biscuit Nos 1 Cup milk sugar 1 tsp. + (any one snack) Upma/poha/sprouts 1 bowl Paranthas 1/phulkas 1 Bread Slices + 1 egg (white part ), Cornflakes 1 bowl Idli 2 + Sambar 1 bowl Mid Morning Lunch Evening Mid Morning : : : : Veg. Soup 1 bowl any fruits (Apple) Phulkas 2 /Bread 2 slices, Dal bowl, Vegetables 1 bowl 1 cup Tea /Milk + 2 Biscuits Murmura 1 any/fruit

Dinner Bed Time ENERGY PROTEINS Food included Food to be Avoided

: : : : : :

Phulkas 1/ Vegetables 1 bowl 1 cup milk + sugar 1 tsp. 1400 Kcal 35 gram all Cereals, pulses whole milk, Panner, Cheese Nuts . Potato, Roots and tuber, Banana, Curs Milk fruits Milk, Fat, Citrus fruits

CASE STUDY (pulmonary ward )

Personal information Patient Name Age Sex Date of Admission Date of Discharge Hospital ID No. Economical Status Food habits : : : : : : : : 17028626 Educated MIG (middle income group) Veg/Non- veg Md. Akbar 56 Male 30/04/11

Educational Status :

Anthropometric Measurement Height Weight BMI : : : 55 (164 cm ) (Admission) 78 kg Discharge 72kg 29 (Admission , 27 (Discharge )


COPD (chronic obstructive pulmonary disorder)

Clinical information Skin Eye Hair Nail : : : : Normal Normal Normal Normal

Drugs : T Clopidqrel T Opphylhin Syp AMbroual T lasiluctoss

Normal value Hemoglobin TLC Blood Urea S. Creatinine SE 13-18 mg /dl 4000-11000cm 10-50 mg /dl 0.6-1.4 mg /dl Date 30/4/2011 13.6 27500 74 1.86 129/3.23 Date 4/5/2011 Date 21/5/2011 13.4 9600

12.7 10,700 21 0.71 135/273


Date 30/4/2011



BP Pulse

110/70 mm Hg 90 /min

120/78mm Hg 98 /min

120/70 mm Hg 97/ min

Personal information Patient Name Age Sex Date of Admission Date of Discharge Hospital ID No. Economical Status Food habits : : : : : : : : Kamla Bai 50 Female 5/02/11 24/03/11 10016267 I lletarate Middle income group Veg/Non-veg

Educational Status :

Anthropometric Measurement : Height (cm) : Weight (kg) : Admission : 145 35 35 30 (after 2 months )

BMI Diagnosis History

: : :

18 (Admission) 15 (after 2 months) Chronic obstructive pulmonary Disorder C lod PTD (Tuberculosis) weakness, loss of appet. Br. Asthma C old healed PTB

Clinical Information : Skin Eye Hair Nail : : : : Normal Normal Normal Normal

Drugs : T Theoday 400 mg R/C Sroflow 500 mg BD Cap Omez 20 mg BD T Motium 10 mg TDS Syp. Sucral 1/1/2 tsp TD

Normal Value Hemoglobin TLC Blood Urea Creatinine RBS WBC Polymorps Lymphocytes Eosinophils Monocytes 13-18 mg /dl 4000- 11000cm 10-50 mg /dl 0.6 1.4 mg/dl 70-140 mg /dl 4-11 X 109/L 40-75 % 20-45% 1-6 % 2-10 % Date 5/2/2011 13.6 20,800 18 0.75 97 mg/dl 14,200/mm3 73% 20% 01.% 0.6 11 0.65 Date 26/3/2011 18.9


TIME 6:00AM 7:00AM 8:00AM 9:00AM 10:00AM 11:00AM 12 :00 1 :00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8: 00 PM 9: 00 PM 10: 00 PM 11: 00 PM 12: 00 FOOD ITEM Tea (without sugar) Biscuits (Marie) AMOUNT(gm) 75 ml 2 Nos

Phulkas Dal Rice Veg. Curd (skimmed) Tea (without sugar) Biscuits (Marie Choice) Phulkas Dal

2 Nos 30 gm 30 gm 30 gm 30 gm 75 ml 2 Nos 1 Nos 30 gm


1030 Kcal 28 cm



: :

25 gm 160 gm

Principle of Diet Food Habits Early morning Bread Fast : : : : Low Fat, Moderate Protein, Complex CHO Low Salts Veg/Non-veg 1 cup tea/coffee/milk + biscuits 1 Cup milk (without sugar) 1 tsp+ (any one snack) Upma/poha/ sprouts 1 bowl/Paranthas 1/Phulka / Bread Slices 2 + 1 egg (white part ) Cornflakes 1 bowl Idli 2 + sambar 1 bowl Mid morning Lunch : : Buttermilk/Veg. soup 1 bowl any fruits 1 Phulkas 2/ Bread 2 Slices/Dal 1 bowl/ Vegetables 1 bowl, Salad 1 plate, Curd 1 bowl Evening Mid Evening Dinner : : : 1 cup Tea/Milk + 2 Biscuits Murmura 1/any fruit/Chicken1 bowl Phulka 2, Bread1 Slices, Rice 1 bowl Dal 1 bowl Vegetable 1 bowl/Salad 1 plate Bed Time ENERGY PROTEINS Food to be Included : : : : : 1 cup milk + without sugar. 1500 Kcal 44 gram Cereals, pulses, Egg, milk, milk product, curd, Paneer, buttermilk , sprouted fruits, apple Papaya.

Food to be Avoided

Fruits and fruit juices, sweets, cake pastery Butter, Ghee, Low Salt spcies, and Deep Freid food.

The kidneys, organs with several functions, serve essential regulatory roles in most animals, including vertebrates and some invertebrates. They are essential in the urinary system and also serve homeostatic functions such as the regulation of electrolytes, maintenance of acid-base balance, and regulation of blood pressure (via maintaining salt and water balance). They serve the body as a natural filter of the blood, and remove wastes which are diverted to the urinary bladder. In producing urine, the kidneys excrete wastes such as urea and ammonium; the kidneys also are responsible for the reabsorption of water, glucose, and amino acids. The kidneys also produce hormones including calcitriol, renin, and erythropoietin. Located at the rear of the abdominal cavity in the retroperitoneum, the kidneys receive blood from the paired renal arteries, and drain into the paired renal veins. Each kidney excretes urine into a ureter, itself a paired structure that empties into the urinary bladder.

Renal physiology is the study of kidney function, while nephrology is the medical specialty concerned with kidney diseases Common clinical conditions involving the kidney include the nephritic and nephrotic syndromes, renal cysts, acute kidney injury, chronic kidney disease, urinary tract infection, nephrolithiasis, and urinary tract obstruction.[1] Various cancers of the kidney exist; the most common adult renal cancer is renal cell carcinoma. Cancers, cysts, and some other renal conditions can be managed with removal of the kidney, or nephrectomy. When renal function, measured by glomerular filtration rate, is persistently poor, dialysis and kidney transplantation may be treatment options. Although they are not severely harmful, kidney stones can be a pain and a nuisance. The removal of kidney stones includes sound wave treatment, which breaks up the stones into smaller pieces which are then passed through the urinary tract. One common symptom of kidney stones is a sharp pain in the medial/lateral segments of the lower back.

The kidney participates in whole-body homeostasis, regulating acid-base balance, electrolyte concentrations, extracellular fluid volume, and regulation of blood pressure. The kidney accomplishes these homeostatic functions both independently and in concert with other organs, particularly those of the endocrine system. Various endocrine hormones coordinate these endocrine functions; these include renin, angiotensin II, aldosterone, antidiuretic hormone, and atrial natriuretic peptide, among others.

Many of the kidney's functions are accomplished by relatively simple mechanisms of filtration, reabsorption, and secretion, which take place in the nephron. Filtration, which takes place at the renal corpuscle, is the process by which cells and large proteins are filtered from the blood to make an ultrafiltrate that will eventually become urine. The kidney generates 180 liters of filtrate a day, while reabsorbing a large percentage, allowing for only the generation of approximately 2 liters of urine. Reabsorption is the transport of molecules from this ultrafiltrate and into the blood. Secretion is the reverse process, in which molecules are transported in the opposite direction, from the blood into the urine.

Excretion of wastes
The kidneys excrete a variety of waste products produced by metabolism. These include the nitrogenous wastes urea, from protein catabolism, and uric acid, from nucleic acid metabolism.

Acid-base homeostasis
Main article: Acid-base homeostasis Two organ systems, the kidneys and lungs, maintain acid-base homeostasis, which is the maintenance of pH around a relatively stable value. The lungs contribute to acid-base homeostasis by regulating bicarbonate (HCO3-) concentration. The kidneys have two important roles in the maintaining of the acid-base balance: to reabsorb bicarbonate from and to excrete hydrogen ions into urine

Osmolality regulation
Any significant rise in plasma osmolality is detected by the hypothalamus, which communicates directly with the posterior pituitary gland. An increase in osmolality causes the gland to secrete antidiuretic hormone (ADH), resulting in water reabsorption by the kidney and an increase in urine concentration. The two factors work together to return the plasma osmolality to its normal levels. ADH binds to principal cells in the collecting duct that translocate aquaporins to the membrane allowing water to leave the normally impermeable membrane and be reabsorbed into the body by the vasa recta, thus increasing the plasma volume of the body. There are two systems that create a hyperosmotic medulla and thus increase the body plasma volume: Urea recycling and the 'single effect.' Urea is usually excreted as a waste product from the kidneys. However, when plasma blood volume is low and ADH is released the aquaporins that are opened are also permeable to urea. This allows urea to leave the collecting duct into the medulla creating a hyperosmotic solution that 'attracts' water. Urea can then re-enter the nephron and be excreted or recycled again depending on whether ADH is still present or not. The 'Single effect' describes the fact that the ascending thick limb of the loop of Henle is not permeable to water but is permeable to NaCl. This means that a countercurrent system is created whereby the medulla becomes increasingly concentrated setting up an osmotic gradient for water to follow should the aquaporins of the collecting duct be opened by ADH.

Blood pressure regulation Blood pressure regulation and Renin-angiotensin system

Long-term regulation of blood pressure predominantly depends upon the kidney. This primarily occurs through maintenance of the extracellular fluid compartment, the size of which depends on the plasma sodium concentration. Although the kidney cannot directly sense blood pressure, changes in the delivery of sodium and chloride to the distal part of the nephron alter the kidney's secretion of the enzyme renin. When the extracellular fluid compartment is expanded and blood pressure is high, the delivery of these ions is increased and renin secretion is decreased. Similarly, when the extracellular fluid compartment is contracted and blood pressure is low, sodium and chloride delivery is decreased and renin secretion is increased in response. Renin is the first in a series of important chemical messengers that comprise the renin-angiotensin system. Changes in renin ultimately alter the output of this system, principally the hormones angiotensin II and aldosterone. Each hormone acts via multiple mechanisms, but both increase the kidney's absorption of sodium chloride, thereby expanding the extracellular fluid compartment and raising blood pressure. When renin levels are elevated, the concentrations of angiotensin II and aldosterone increase, leading to increased sodium chloride reabsorption, expansion of the extracellular fluid compartment, and an increase in blood pressure. Conversely, when renin levels are low, angiotensin II and aldosterone levels decrease, contracting the extracellular fluid compartment, and decreasing blood pressure.

Hormone secretion
The kidneys secrete a variety of hormones, including erythropoietin, and the enzyme renin. Erythropoietin is released in response to hypoxia (low levels of oxygen at tissue level) in the renal circulation. It stimulates erythropoiesis (production of red blood cells) in the bone marrow. Calcitriol, the activated form of vitamin D, promotes intestinal absorption of calcium and the renal reabsorption of phosphate. Part of the renin-angiotensin-aldosterone system, renin is an enzyme involved in the regulation of aldosterone levels.

The mammalian kidney develops from intermediate mesoderm. Kidney development, also called nephrogenesis, proceeds through a series of three successive phases, each marked by the development of a more advanced pair of kidneys: the pronephros, mesonephros, and metanephros.

Diseases and disorders


Congenital hydronephrosis Congenital obstruction of urinary tract Duplex kidneys, or double kidneys, occur in approximately 1% of the population. This occurence normally causes no complications but can occasionally cause urine infections.[11]

Duplicated ureter occurs in approximately one in 100 live births Horseshoe kidney occurs in approximately one in 400 live births Polycystic kidney disease

Autosomal dominant polycystic kidney disease afflicts patients later in life. Approximately one in 1000 people will develop this condition o Autosomal recessive polycystic kidney disease is far less common, but more severe, than the dominant condition. It is apparent in utero or at birth. Renal agenesis. Failure of one kidney to form occurs in approximately one in 750 live births. Failure of both kidneys to form is invariably fatal. Renal dysplasia Unilateral small kidney Multicystic dysplastic kidney occurs in approximately one in every 2400 live births Ureteropelvic Junction Obstruction or UPJO; although most cases appear congenital, some appear to be an acquired condition[13]


Diabetic nephropathy Glomerulonephritis Hydronephrosis is the enlargement of one or both of the kidneys caused by obstruction of the flow of urine. Interstitial nephritis Kidney stones (nephrolithiasis) are a relatively common and particularly painful disorder. Kidney tumors o Wilms tumor o Renal cell carcinoma Lupus nephritis Minimal change disease In nephrotic syndrome, the glomerulus has been damaged so that a large amount of protein in the blood enters the urine. Other frequent features of the nephrotic syndrome include swelling, low serum albumin, and high cholesterol. Pyelonephritis is infection of the kidneys and is frequently caused by complication of a urinary tract infection. Renal failure o Acute renal failure o Stage 5 Chronic Kidney Disease

Kidney Failure Main article: Renal failure Generally, humans can live normally with just one kidney, as one has more functioning renal tissue than is needed to survive. Only when the amount of functioning kidney tissue is greatly diminished does one develop chronic kidney disease. Renal replacement therapy, in the form of dialysis or kidney transplantation, is indicated when the glomerular filtration rate has fallen very low or if the renal dysfunction leads to severe symptoms.

Chronic kidney disease

Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss in renal function over a period of months or years. The symptoms of worsening kidney function are unspecific, and might include feeling generally unwell and experiencing a reduced appetite. Often, chronic kidney disease is diagnosed as a result of screening of people known to be at risk of kidney problems, such as those with high blood pressure or diabetes and those with a blood relative with chronic kidney disease. Chronic kidney disease may also be identified when it leads to one of its recognized complications, such as cardiovascular disease, anemia or pericarditis

Chronic kidney disease is identified by a blood test for creatinine. Higher levels of creatinine indicate a falling glomerular filtration rate and as a result a decreased capability of the kidneys to excrete waste products. Creatinine levels may be normal in the early stages of CKD, and the condition is discovered if urinalysis (testing of a urine sample) shows that the kidney is allowing the loss of protein or red blood cells into the urine. To fully investigate the underlying cause of kidney damage, various forms of medical imaging, blood tests and often renal biopsy (removing a small sample of kidney tissue) are employed to find out if there is a reversible cause for the kidney malfunction.[1] Recent professional guidelines classify the severity of chronic kidney disease in five stages, with stage 1 being the mildest and usually causing few symptoms and stage 5 being a severe illness with poor life expectancy if untreated. Stage 5 CKD is also called established chronic kidney disease and is synonymous with the now outdated terms end-stage renal disease (ESRD), chronic kidney failure (CKF) or chronic renal failure (CRF).[1]

Signs and symptoms

Blood pressure is increased due to fluid overload and production of vasoactive hormones created by the kidney via the RAS (renin-angiotensin system), increasing one's risk of developing hypertension and/or suffering from congestive heart failure Urea accumulates, leading to azotemia and ultimately uremia (symptoms ranging from lethargy to pericarditis and encephalopathy). Urea is excreted by sweating and crystallizes on skin ("uremic frost"). Potassium accumulates in the blood (known as hyperkalemia with a range of symptoms including malaise and potentially fatal cardiac arrhythmias) Erythropoietin synthesis is decreased (potentially leading to anemia, which causes fatigue)

Fluid volume overload - symptoms may range from mild edema to life-threatening pulmonary edema Hyperphosphatemia -

Diet is an important consideration for those with impaired kidney function. Consultation with a dietician may be helpful to understand what foods may or may not be appropriate. Since the kidneys cannot easily remove excess water, salt, or potassium, these may need to be consumed in limited quantities. Foods high in potassium include bananas, apricots, and salt substitutes. Phosphorus is a forgotten chemical that is associated with calcium metabolism and may be elevated in the body in kidney failure. Too much phosphorus can leech calcium from the bones and cause osteoporosis and fractures. Foods with high phosphorus content include milk, cheese, nuts, and cola drinks.

Medications may be used to help control some of the issues associated with kidney failure.

Phosphorus-lowering medications (calcium carbonate [Caltrate], calcitriol [Rocaltrol], sevelamer [Renagel]) Red blood cell production stimulation (erythropoietin, darbepoetin [Aranesp]) Red blood cell production (iron supplements) Blood pressure medications

Dialysis cleanses the body of waste products in the body by use of filter systems. There are two types of dialysis; 1) hemodialysis, and 2) peritoneal dialysis.

Hemodialysis uses a machine filter called a dialyzer or artificial kidney to remove excess water and salt, to balance the other electrolytes in the body, and to remove waste products of metabolism. Blood is removed from the body and flows through tubing into the machine, where it passes next to a filter membrane. A specialized chemical solution (dialysate) flows on the other side of the membrane. The dialysate is formulated to draw impurities from the blood through the filter membrane. Blood and dialysate never touch in the artificial kidney machine. For this type of dialysis, access to the blood vessels needs to be surgically created so that large amounts of blood can flow into the machine and back to the body. Surgeons can build a fistula, a

connection between a large artery and vein in the body, usually in the arm, that causes a large amount of blood flow into the vein. This makes the vein larger and its walls thicker so that it can tolerate repeated needle sticks to attach tubing from the body to the machine. Since it takes many weeks for a fistula to mature enough to be used, significant planning is required if hemodialysis is to be considered as an option.

Peritoneal dialysis
Peritoneal dialysis uses the lining of the abdominal cavity as the dialysis filter to rid the body of waste and to balance electrolyte levels. A catheter is placed in the abdominal cavity through the abdominal wall by a surgeon and is expected to remain there for the long-term. The dialysis solution is then dripped in through the catheter and left in the abdominal cavity for a few hours and then is drained out. In that time, waste products leech from the blood normally flowing through the lining of the abdomen (peritoneum). There are benefits and complications for each type of dialysis. Not every patient can choose which type he or she would prefer. The treatment decision depends on the patient's illness and their past medical history along with other issues. Usually, the nephrologist (kidney specialist) will have a long discussion with the patient and family to decide what will be the best option available. Dialysis is life saving. Without it, patients whose kidneys no longer function would die relatively quickly due to electrolyte abnormalities and the buildup of toxins in the blood stream. Patients may live many years with dialysis but other underlying and associated illnesses often are the cause of death.

Personal information Patient Name Age Sex Date of Admission Date of Discharge Hospital ID No. Economical Status Food habits : : : : : : : : Sita Jain 50 Female 5/02/11 24/03/11 17003450 I lletarate Middle income group Veg/

Educational Status :

Anthropometric Measurement : Height (cm) : Weight (kg) : 145 73

BMI Diagnosis

: :

18 Chronic Renal Failure (CRF)

Clinical Information : Skin Eye Hair Nail : : : : Normal Normal Normal Normal

Drugs : T Nifidopin R/C Sroflow 500 mg BD Cap Omez 20 mg BD T Motium 10 mg TDS Syp. Sucral 1/1/2 tsp TD Inj Sudopen 500 mg OD Inj Clindomentin 600 mg

Normal Value Hemoglobin TLC Blood Urea Creatinine RBS WBC Polymorps Lymphocytes Eosinophils Monocytes 13-18 mg /dl 4000- 11000cm 10-50 mg /dl 0.6 1.4 mg/dl 70-140 mg /dl 4-11 X 10 /L 40-75 % 20-45% 1-6 % 2-10 %

Date 5/2/2011 7.5 20,800 90 3.3 160mg/dl

Date 26/3/2011 13 11 0.65 110 mg/ dl 14,200/mm3 73% 20% 01.% 0.6

5/2/2011 Pulse Rage BP 106/min 110/60 mm Hg 22/2/2011 90/min 110/70 mm Hg 17/3/2011 90/ min 140/80 mm Hg 22/3/2011 90/min 110/70 mm Hg

Principle of Diet Food Habits Early morning : : : Low Fat, Moderate Protein, Low CHO Veg/Non-Veg 1 cup tea/coffee/milk +biscuit (without sugar)

Break Fast

1 cup milk + (any one snack_ Upma/Poha /sprouts 1 bow /Paranthas 1/bowl /Idili 2+ sambhar 1 bow 1

Mid Morning Lunch Evening Mid Evening Dinner Bed Time

: : : : : :

Buttermilk/Veg.soup 1 bowl1/any fruits1 Phulkas 2/Bread 1 Slices, Rice 1, Dhal 1 bowl, thin, Vegatables 1 bowl, Salad, Curd 1 bowl 1 cup Tea/Milk +2 Biscuits Murmura 1 bow/ any fruit Phulka 2, Rice 1, Vegetables 1 bowl, 1 cup milk + without sugar.


: :

1330 cal 55 gram

Included Avoided

: :

Cereals Pulses skimmed milk, fruits , vegetables Cake, patereis, deep fried food, pickles, papad bakery products, butter cheese


Hydrocephalus is a term derived from the Greek words "hydro" meaning water, and "cephalus" meaning head, and this condition is sometimes known as "water on the brain". People with hydrocephalus have abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles, or cavities, of the brain. This may cause increased intracranial pressure inside the skull and progressive enlargement of the head, convulsion, and mental disability.

Hydrocephalus is usually due to blockage of CSF outflow in the ventricles or in the subarachnoid space over the brain. In a person without hydrocephalus, CSF continuously circulates through the brain, its ventricles and the spinal cord and is continuously drained away into the circulatory system. Alternatively, the condition may result from an overproduction of the CSF fluid, from a congenital malformation blocking normal drainage of the fluid, or from complications of head injuries or infections Regardless of cause, the fluid accumulates in the ventricles. Compression of the brain by the accumulating fluid eventually may cause convulsions and mental retardation. These signs occur sooner in adults, whose skulls no longer are able to expand to accommodate the increasing fluid volume within. Fetuses, infants, and young children with hydrocephalus typically have an abnormally large head, excluding the face, because the pressure of the fluid causes the individual skull bones which have yet to fuse to bulge outward at their juncture points. Another medical sign, in infants, is a characteristic fixed downward gaze with whites of the eyes showing above the iris, as though the infant were trying to examine its own lower eyelids.[2] Hydrocephalus occurs in about one out of every 500 live births[3] and was routinely fatal until surgical techniques for shunting the excess fluid out of the central nervous system and into the blood or abdomen were developed. Hydrocephalus is detectable during prenatal ultrasound examinations. Usually, hydrocephalus does not cause any intellectual disability if recognized and properly treated. A massive degree of hydrocephalus rarely exists in typically functioning people, though such a rarity may occur if onset is gradual rather than sudden. There is no cure for hydrocephalus. Hydrocephalus affects one in every 500 live births, making it one of the most common developmental disabilities, more common than Down syndrome or deafness Symptoms Symptoms of increased intracranial pressure may include headaches, vomiting, nausea, papilledema, sleepiness, or coma. Elevated intracranial pressure may result in uncal and/or cerebellar tonsill herniation, with resulting life threatening brain stem compression. For details on other manifestations of increased intracrani Hydrocephalus

Treatment Hydrocephalus treatment is surgical. It involves the placement of a ventricular catheter (a tube made of silastic), into the cerebral ventricles to bypass the flow obstruction/malfunctioning arachnoidal granulations and drain the excess fluid into other body cavities, from where it can be resorbed. Most shunts drain the fluid into the peritoneal cavity (ventriculo-peritoneal shunt), but alternative sites include the right atrium (ventriculo-atrial shunt), pleural cavity (ventriculo-pleural shunt), and gallbladder. A shunt system can also be placed in the lumbar space of the spine and have the CSF redirected to the peritoneal cavity (ventriculo-pleural shunt). An alternative treatment for obstructive hydrocephalus in selected patients is the endoscopic third ventriculostomy (ETV), whereby a surgically created opening in the floor of the third ventricle allows the CSF to flow directly to the basal cisterns, thereby shortcutting any obstruction, as in aqueductal stenosis Hemiparesis Hemiparesis is weakness on one side of the body. Contrast with Hemiplegia, which is total paralysis of the arm, leg, and trunk on the same side of the body. Hemiparesis is generally caused by lesions of the corticospinal tract, which runs down from the cortical neurons of the frontal lobe to the motor neurons of the spinal cord (see the second paragraph of Amyotrophic lateral sclerosis) and is responsible for the movements of the muscles of the body and its limbs. On its way the tract passes through several parts of the brain stem; namely the midbrain, pons and medulla, respectively. The tract crosses to the opposite side (or decussates) on the lowest portion of the medulla (forming an anatomical structure named as the pyramids) and goes down along the opposite side of the spinal cord to meet the contralateral motor neurons. For this reason, one side of the brain controls the muscle movements of the opposite side of the body, and thus the disruption of the right corticospinal tract on brain stem or upper brain structures causes a hemiparesis on the left side of the body and vice versa. On the other hand, the lesions of the tract on the spinal cord lead to a hemiparesis on the same side of the body. The facial muscles are also controlled by the same tract. The tract activates the facial nuclei (see ganglion) and the facial nerve emerging from these nuclei activate the facial muscles during voluntary facial muscle contraction. Since the facial nuclei are located in the pons above the decussation, the lesions of the tract on the pons or upper structures give rise to a hemiparesis on the opposite side of the body and a paresis on the same side of the face and that is called a crossed hemiparesis. If the patient's face is not involved, this is highly suggestive of a lesion of the tract on lower parts of the brain stem or spinal cord. Since the spinal cord is a very small structure, it is very unusual for only one side to be affected by a lesion and usually both tracts are affected. Therefore, the spinal cord lesions usually present with the paralysis of both arms and legs (quadriparesis) or both legs (paraparesis). Hemiplegia is similar to hemiparesis, but hemiparesis is considered less severe.

Brain tumor
A brain tumor (or brain tumour) is an intracranial solid neoplasm, a tumor (defined as an abnormal growth of cells) within the brain or the central spinal canal.

Brain tumors include all tumors inside the cranium or in the central spinal canal. They are created by an abnormal and uncontrolled cell division, normally either in the brain itself (neurons, glial cells (astrocytes, oligodendrocytes, ependymal cells, myelin-producing Schwann cells), lymphatic tissue, blood vessels), in the cranial nerves, in the brain envelopes (meninges), skull, pituitary and pineal gland, or spread from cancers primarily located in other organs (metastatic tumors). Any brain tumor is inherently serious and life-threatening because of its invasive and infiltrative character in the limited space of the intracranial cavity. However, brain tumors (even malignant ones) are not invariably fatal. Brain tumors or intracranial neoplasms can be cancerous (malignant) or non-cancerous (benign); however, the definitions of malignant or benign neoplasms differs from those commonly used in other types of cancerous or non-cancerous neoplasms in the body. Its threat level depends on the combination of factors like the type of tumor, its location, its size and its state of development. Because the brain is well protected by the skull, the early detection of a brain tumor only occurs when diagnostic tools are directed at the intracranial cavity. Usually detection occurs in advanced stages when the presence of the tumor has caused unexplained symptoms. Primary (true) brain tumors are commonly located in the posterior cranial fossa in children and in the anterior two-thirds of the cerebral hemispheres in adults, although they can affect any part of the brain. Signs and symptoms The visibility of signs and symptoms of brain tumors mainly depends on two factors: tumor size (volume) and tumor location. The moment that symptoms will become apparent, either to the person or people around him (symptom onset) is an important milestone in the course of the diagnosis and treatment of the tumor. The symptom onset - in the timeline of the development of the neoplasm - depends in many cases on the nature of the tumor but in many cases is also related to the change of the neoplasm from "benign" (i.e. slow-growing/late symptom onset) to more malignant (fast growing/early symptom onset). Symptoms of solid neoplasms of the brain (primary brain tumors and secondary tumors alike) can be divided in 3 main categories :

Consequences of intracranial hypertension : The symptoms that often occur first are those that are the consequences of increased intracranial pressure: Large tumors or tumors with extensive perifocal swelling (edema) inevitably lead to elevated intracranial pressure (intracranial hypertension), which translates clinically into headaches, vomiting (sometimes without nausea), altered state of consciousness (somnolence, coma), dilatation of the pupil on the side of the lesion (anisocoria), papilledema (prominent optic disc at the funduscopic eye examination). However, even small tumors obstructing the passage of cerebrospinal fluid (CSF) may cause early signs of increased intracranial pressure. Increased intracranial pressure may result in herniation (i.e. displacement) of certain parts of the brain, such as the cerebellar tonsils or the temporal uncus, resulting in lethal brainstem compression. In very young children, elevated intracranial pressure may cause an increase in the diameter of the skull and bulging of the fontanelles. Dysfunction : depending on the tumor location and the damage it may have caused to surrounding brain structures, either through compression or infiltration, any type of focal neurologic symptoms may occur, such as cognitive and behavioral impairment (including impaired judgment, memory loss, lack of recognition, spatial orientation disorders), personality or emotional changes, hemiparesis, hypoesthesia, aphasia, ataxia, visual field impairment, impaired sense of smell, impaired hearing, facial paralysis, double vision,

dizziness, but more severe symptoms might occur too such as: paralysis on one side of the body hemiplegia or impairment to swallow . These symptoms are not specific for brain tumors they may be caused by a large variety of neurologic conditions (e.g. stroke, traumatic brain injury). What counts, however, is the location of the lesion and the functional systems (e.g. motor, sensory, visual, etc.) it affects. A bilateral temporal visual field defect (bitemporal hemianopiadue to compression of the optic chiasm), often associated with endocrine disfunctioneither hypopituitarism or hyperproduction of pituitary hormones and hyperprolactinemia is suggestive of a pituitary tumor. Irritation : abnormal fatigue, weariness, absences and tremors, but also epileptic seizures.

When a person suffering from a metastasized cancer is diagnosed, a scan of the skull frequently reveals secondary tumors. : Alarm Signals first headache complaint from patient over 50 first migraine attack in patient over 40 headache from patient under 6 senior patient with pain at temples pregnancy with unknown headache increased headaches after trauma high-pitched headaches with high blood pressure acute high pitched headache headache and fever (with reduced consciousness) Stiffness of the neck/neurological dysfunction headache with signs of elevated intracranial pressure focal neurological dysfunction early morning vomiting or vomiting unrelated to headache or other illness behavioral changes or rapid decline in school results aura migraine always at one side Possible Cause to be investigated arteritis temporalis] brain tumor brain tumor, hydrocephalus arteritis temporalis pre-eclampsia sub/epidural hematoma malign hypertension meningitis, CVA (Cerebrovascular accident or stroke), subarachnoidal hemorrhage meningitis meningitis, brain tumor brain tumor brain tumor brain tumor brain tumor brain tumor

A craniotomy is a surgical operation in which a bone flap is (temporarily) removed from the skull, to access the brain. Craniotomies are often a critical operation performed on patients suffering from brain lesions or traumatic brain injury (TBI), and can also allow doctors to surgically implant deep brain stimulators for the treatment of Parkinson's disease, epilepsy and cerebellar tremor. The procedure is also widely used in neuroscience for extracellular recording, brain imaging, and for neurological manipulations such as electrical stimulation and chemical titration. Human craniotomy is usually performed under general anesthesia but can be also done with the patient awake using a local anaesthetic; the procedure generally does not involve significant discomfort for the patient. In general, a craniotomy will be preceded by an MRI scan which

provides a picture of the brain that the surgeon uses to plan the precise location for bone removal and the appropriate angle of access to the relevant brain areas. The amount of skull that needs to be removed depends to a large extent on the type of surgery being performed. The bone flap is then replaced using titanium plates and screws or another form of fixation (wire, suture, ...etc). Craniotomy is distinguished from craniectomy (in which the skull flap is not immediately replaced, allowing the brain to swell, thus reducing intracranial pressure) and from trepanation, the creation of a burr hole through the cranium in to the dura mater.

Case Study Patient Name Babulal

Age/Sex Date of Admission Date of Discharge Hospital ID No. Economical Status Food Habits 65/M 21/12/2010 28/1/2011 90052475 LIG Non-vegetarian

Anthropometric Measurements Height (cm) Weight (kg) Diagnosis Clinical Information Skin Eye Hair Nail Drugs: Inj. Augimenin 1 2 gm. TDS Inj. Ceftoianone 1 gm. TDS Inj. Cyetoogyl 100 mg. TDS Tab. Epsarin 100 mg. TDS Tab. Rantac 150 mg. BD Tab. Shelcal BD Tab. Phenobarb 90 mg. 10 A.m. S/C Detaparin 0.25 ml. OD Tab, Amlodipine10 Mg Tab, Aten 25 Mg Tab Cardiovas 6.25 Mg Dull Pale yellow colour Normal Pale yellow colour 54 65 HYDROCEPHALUS with LEFT HAMIPARESIS

S. Streptomycin 0.75 mg. I/M Inj. MVI 10 daily Biochemical Investigation Parameter Analysed Hb. TLC DLC At the Time of Admission 14.6 7300 At the Time of Discharge 13.7 8300 Normal Range 13 18 gm/dl 4000 11000 cm 40 75 %

neutrophill Urea Creatinine Sodium Potessium

85 16 0.65 129 2.70

87 18 0.62 126 3.3

10 50 mg/dl 0.6 1.4 mg/dl 130 150 mmol 3.5 5.5

PHYSICAL PARAMETERS Pulse Rate BP Input Output 68/m 142/113mmhg 2600 1925

Case Study Patient Name ABIDA BEE

Age/Sex Date of Admission Date of Discharge Hospital ID No. Economical Status Food Habits 70/F 21/12/2010 28/1/2011 90052475 LIG Non-vegetarian

Anthropometric Measurements Height (cm) Weight (kg) Diagnosis Clinical Information Skin Eye Hair Nail Drugs: Inj. Augimenin 1 2 gm. TDS Inj. Ceftoianone 1 gm. TDS Inj. Cyetoogyl 100 mg. TDS Tab. Epsarin 100 mg. TDS Tab. Rantac 150 mg. BD Tab. Shelcal BD Tab. Phenobarb 90 mg. 10 A.m. S/C Detaparin 0.25 ml. OD Tab, Amlodipine10 Mg Tab, Aten 25 Mg Tab Cardiovas 6.25 Mg Dull Pale yellow colour Normal Pale yellow colour 54 65 HYDROCEPHALUS with LEFT HAMIPARESIS

S. Streptomycin 0.75 mg. I/M Inj. MVI 10 daily Biochemical Investigation Parameter Analysed Hb. TLC DLC At the Time of Admission 14.6 7300 At the Time of Discharge 13.7 8300 Normal Range 13 18 gm/dl 4000 11000 cm 40 75 %

neutrophill Urea Creatinine Sodium Potessium

85 16 0.65 129 2.70

87 18 0.62 126 3.3

10 50 mg/dl 0.6 1.4 mg/dl 130 150 mmol 3.5 5.5

PHYSICAL PARAMETERS Pulse Rate BP Input Output 68/m 142/113mmhg 2600 1925

Nutrition plays an important role in the prevention and management of many diseases. None today would challenge the concept that nutritional support is an integral and essential element in the care of the patient who is critically ill nutritionally, depleted or both. Patients unable to consume necessary nutrients orally require alternative form of nutritional support. Chronic illness is associated with many complications such as anorexia, hypermetabolism, malabsorption, atrophy of muscles, liver, kidney, gastrointestinal tract heart,

impaired cell mediated immunity, susceptibility to infection, poor wound healing, anemia, death. Hence it is important to correct caloric and nutrient deficiencies whenever possible. By definition the term enteral means "within or by the way of the gastrointestinal (GI) tract." In common practice however, commercially available liquid nutritional supplements are generally referred to as " oral supplements and " enteral feeding" and "tube feeding" are used interchangeably. History of enteral feeding dates back to 18th century. In 1790 John Hunter cured a case of paralysis for which had fed through a tube made of whalebone. Stengel and Ravdin used Nesoenteric route for the first time in 1939. The feeding was introduced through the nose and advanced into the jejunum for Post-operative nutritional support. There are primarily two routes of access for aggressive nutritional support i.e. enteral and parenteral. The majority of patients are given oral diets to provide for nutrient needs. When patient does not consume adequate nutrients it is supplied by increasing the amount of food or by giving snacks in between meals. Liquid supplementation is often useful, because food is easier to drink than to eat. Psychologically liquid seem to be less filling, and they are much easier to digest for debilitated patients to handle. Selection of feeding can be done stepwise. First step regular or modified diet, 2.Regular or modified diet and supplements. 3. Tube feeding.

The choice of nutritional supplement depends on the degree of inability to meet nutritional needs by diet alone, presence or absence of dysphagia, taste preference or sensitivity to taste fatigue, availability of labor and resource for preparation or presence of other safety and cost concern, degree of tolerance to lactose, sucrose or glucose or other dietary modifications In-patients where the gastrointestinal tract (GI) cannot be used, nutrition should be provided by the parenterally. The enteral route partly or wholly must feed patients with a gastrointestinal tract functional. Frequently it is quoted "when the gut works and can be used safely use it". Enteral feeding is the method of nutrient solutions fed into gastrointestinal (GI) tract through a tube. Enteral nutrition is the optimal method for meeting nutritional needs of a child who has a functioning gut and is unable or unwilling to achieve oral intake.

The use of enteral feeding is increasing because of

a. The development of simple and low risk procedures for placement of tubes in GI tract particularly percutaneous endoscopic gastrostomies and jejunostomies. b. The availability of wide variety of commercial enteral feeding formulas. c. Enteral nutrition is generally less expensive than parenteral nutrition.

It is important to realize that enteral and parenteral nutritional supports should not be viewed, as substitutes for each other as both these methods are complementary rather than competitive.

Goals of feeding

A. Selection of an appropriate formula B. Formula delivery C. Indications of nutritional status


Signs of feeding intolerance

Indications Specific conditions for which nutrition indicated for adults and children shown in table 1 Table 1. Indications for nasoenteric Tube feeding for adults Neurological indications: 1. 2. 3. 4. 5. Severe Head injuries Cerebrovascular accidents Coma due to any cause Neoplasms: Advanced primary and secondary intracranial tumors Dysphagia associated with neurological disorders

Hypermetabolism: 1. Postoperative major surgery 2. Sepsis 3. Trauma Burns Organ transplant acquired immune deficiency syndrome Surgical indications: 1. 2. 3. 4. 5. 6. 7. Facial and jaw surgeries Head & Neck surgeries Oropharyngeal surgeries Pharyngoesophageal surgeries Polytrauma associated with extensive abdominal surgeries Patients with burns for surgeries unable to take oral nutrition Surgery complicated with sepsis

Gastrointestinal (GI) disease 1. Short-bowel syndrome (if absorptive capacity of remaining bowel is sufficient e.g. approximately a minimum of 100 cm jejunal and 150 cm of ileal length of functioning small bowel with ileocecal value intact. 2. Inflammatory bowel disease 3. Minimal GI tract fistula output ( less than 500mL/d) 4. Pancreatitis 5. Esophageal obstruction 6. Malabsorption 7. Fistulas Cancer

1. 2. 3. 4. 5. 6. 7. 8.

Oral malignancies Oropharyngeal malignancies Nasopharyngeal malignancies Head and neck malignancies Esophageal malignancies Gastric malignancies Chemotherapy Radiotherapy

Resistance to oral intake 1. Anorexia 2. Dysphagia 3. Severe depression Malnutrition 1. 2. 3. 4. Protein energy malnutrition with inadequate oral intake for at least 5 days Malnutrition preoperatively and postoperatively Malnutrition in cancer patients Malnutrition in-patients with Acquired Immune Deficiency Syndrome (AIDS) unable to take oral nutrition. 5. Malnutrition in debilitated aged patients Organ system failure: 1. 2. 3. 4. 5. 6. Respiratory failure Renal failure Cardiac failure Central nervous system failure Hepatic failure Multiple organ system failure

Transition from parenteral nutrition For children 1. 2. 3. 4. 5. 6. Malnutrition Malabsorption Hypermetabolism Failure to thrive Prematurity Disorders of absorption, digestion, excretion, utilization, or storage of nutrients Contraindications: 1. Malfunctioning of GI tract or conditions requiring extended bowel rest
o o o

Insufficient absorptive capacity of intestinal tract e.g. short-bowel syndrome ( intestinal span suggested for sufficient absorption of nutrients) Mechanical obstruction of GI tract Prolonged ileus

o o o o o

Severe GI hemorrhage Severe diarrhea Intractable vomiting High output GI tract fistula (> 500 ml/ day) Severe enterocolitis

1. Harm may exceed benefit for incompetent patients with end-stage illness, minimal levels of consciousness, and lack of advance directives, whose anticipated benefits may be uncertain or short-term; is likely against the patients best interests. Advantages of enteral feeding 1. Provides good nutritional care plan 2. Nourishing child who can not take adequate nutrients orally 3. Helps family and health care professionals to see enteral alimentation as positive and optimal way rather than a punitive and optimal way of nourishing the malnourished child. Nutritional requirements 1. The recommended dietary allowances serve as initial guidelines in the selection and modification of a formula All nutrients of the final formula should be calculated and compared with RDA for age or for the developmentally delayed child for height age o Vitamin mineral supplementation may be needed

1. The disease process itself indicates whether the requirements are changed 2. Drug induced nutritional deficiencies may develop from long-term use of medication that affects
o o

nutrient function and metabolism decrease nutrient absorption or synthesis

1. Feeding tube The small-caliber tubing requires a finely dispersed product with low viscosity whereas the gastrostomy tube can accommodate blenderized feed 2. Fluid requirement Enteral formulas Selection of an appropriate enteral formula requires assessment of patients digestive and absorptive capacity as well as the knowledge of the substrate source and form. 1. Protein components:

Components of protein are intact protein (larger molecular weight protein), partially hydrolyzed protein (protein enzymatically hydrolyzed into shorter polypeptide fragments such as oligopeptide), dipeptides and tripeptides (type of partially hydrolyzed proteins to di and tri-peptide fragment. a. Protein quality attributed to amino acid profile: an amino acids of at least 40% amino acids as essential amino acids is suggested for anabolism. b. Predominant sources of protein include soy and casein. 1. Carbohydrate components Components of carbohydrate are starch, glucose polymers (derived from partially hydrolyzed corn starch), disaccharide (sucrose: glucose fructose; maltose (glucose glucose; lactose: glucose galactose), monosaccharides (glucose: dextrose; fructose) a. Primary differences in carbohydrate components are related to the form and concentration of carbohydrate b. The most predominant form of carbohydrate found in enteral formula is hydrolyzed cornstarch or maltodextrin 1. Fat components Components of fat are polyunsaturated fatty acids (PUFA), medium chain triglycerides (MCT) and saturated fatty acids (SFA) a. b. c. d. Fat enhances palatability and flavor of formula Vegetable oil contains variable amount of essential fatty acids (EFA). Suggested EFA intake specially linoleic acid is 3% to 4% total calorie needs. Sources of fat commonly found in formulas include a variety of vegetable oils

1. Fiber components Component of fiber is insoluble (cellulose, noncellulose: hemicellulose), or soluble fiber (pectin, mucilage, algal polysaccharide, gum). a. Content of fiber-supplemented formula ranges from 5 to 14 g of fiber per liter. b. Recommended intake of dietary fiber is approximately 20 to25 g / day c. Preliminary studies have shown that fiber intake of less than 30 g / day did not seem to impair vitamin, mineral or drug bioavailability in the gut. d. Most predominantly used from of fiber in enteral formulas is soy polysaccharide. 1. Water a. Quantity water in the enteral formulas is often described as water content or moisture content b. Quantity of water ( frequently reported in milliliters of water per 1000 ml of formula or milliliters of water per liter of formula)

c. Most of enteral formulas contain water in the general range of 690 to 860 ml per 1000ml of enteral formula. Standard infant formulas are 0.67 calories/cc. Whereas adult formulas are either 1 calorie/cc or 1.5 to 2.0 calories/cc

1. Vitamin and minerals a. Most nutritionally complete commercial formulas contain adequate vitamin and minerals when a sufficient volume of formula to meet energy and macronutrient needs is provided. b. Some disease specific formulas are nutritionally incomplete in relation to vitamin and mineral content c. Liquid vitamins and mineral supplements may be indicated for patients receiving nutritionally incomplete or diluted formulas for prolonged periods d. Fat-soluble vitamins such as vitamin K may be indicated for patients with fat absorption or for patients with vitamin K deficiency; vitamin K deficiency is rare in as much as vitamin K is synthesized by intestinal flora, and most commercial formulas includes vitamin K. Classification of formulas 1. Polymeric formulas: a. Most of patients who are critically ill may be enterally fed with polymeric formulas. b. Nitrogen balance has been reported to be similar for patient with normal digestive and absorptive capacity who were fed intact protein, partially hydrolyzed protein, and amino acids with approximately the same amino acid profiles. c. Intrajejunal digestion, nutrient absorption, and nitrogen balance have been reported to be similar between intact protein and polymeric formulas compared with partially hydrolyzed (small peptides and amino acids) formulas in jejunal feedings in under nourished patients. 1. Partially hydrolyzed formulas: a. Characteristics:
o o o

Macro-nutrients may be partially or completely hydrolyzed via enzymatic activity into smaller components (e.g., free amino acids and peptides) Some formulas may have unpleasant odors and taste, Most of the formulas are expensive.

a. Composition may vary in free amino acids and peptides, type and quantity of fat, content of carbohydrate content. b. Indicated for patients with partial digestive and absorptive capacity; patients with resolved acute illness might be capable of transition form partially hydrolyzed formulas to polymeric formulas. 1. Disease-specific formulas: some formulas are designed for specific organ dysfunction and some are for metabolic stress. Efficacy of the disease specific formulas is controversial

2. Modular formulas: a. One purpose for using modular formulas is supplemental use

May add calorie or protein density Tailor tube feeding to individual nutritional needs as a supplement to commercial enteral formulas.

a. Another advantage is that it can be de novo formulated for individualized designed of nutrient formula to meet specific nutrient needs of an individual. b. Advantages of de novo enteral formulation include
o o

Customizing the formula to meet specific nutrient composition of the patient Select cases using de novo formulas have reported cost savings.

a. Disadvantages of de novo formula include


o o o o

Complexity of ordering specific nutrient composition as well as the method and rate of tube feeding administration unless a standardized orders form is used. Increased cost of labor Complexity of calculating nutrient composition Potential risk of bacterial contamination from excessive handling of formulas Potential physical incompatibilities with insoluble components.

Guidelines for selection of product: Substrate source individual requirements and ability to tolerate various sources of intact or elemental carbohydrate protein and fiber. Calorie concentration The calorie-to volume ratio will affect the volume required to meet nutritional requirements. Increasing the calorie-to-volume ratio will affect the osmolality of the solution. Available feeding equipment The size of the feeding tube, drip chamber, and availability of pumps may affect the choice of solution. Blenderized feeding and those containing soy polysaccharide fiber usually require pumps for the infusion through smaller bore tubes due to higher viscosity. 1. Determine total volume for adult man per day a] Continuous feedings: example- formula to run at 75 cc/hr. 75 cc/hr X 24hrs = 1800 cc or 1.8 liters b] Intermittent feeding: Example formula to be given in volume of 400cc 5 times a day i.e. 400cc X 5 = 2liters. 1. Determine the calorie content of the formula by multiplying the total volume (cc) calorie/cc of the formula.

Example 1800 cc X 1.06 kcal/cc = 1908 2. Determine the protein content either per cc or per liter. This can be calculated by multiplying the total volume in liters by protein per liters or per cc. Example 1.8 liters X 37 g protein per liter = 67 g protein. Or 1.8 liters X 0.037 g protein per cc = 67 g protein 3. Determine the actual calories and protein provided by multiplying the calories and protein per liter by the strength of formula. 1 /4 strength = 0.25 1/2 strength = 0.5 3 /4 strength = 0.75 1/3 strength = 0.33 2/3 strength = 0.67 full strength = 1.0 2. Method of estimating fluid needs for children 100 cc / kg for the first 10 kg 50 cc / kg for the next 10 kg over 10 kg 20 cc / kg for the number of kg over 20 kg Example: child weighing 35 kg First 10 kg = 100 X 10 =1000 Next 10 kg = 50 X 10 = 500 Remaining 15 kg = 15 X 20 = 300 Total fluid requirement = 1800 cc (Final fluid requirement will be depend upon disease condition) Initiation of feeding a. Prior to initiating enteral feeds, tube placement must be verified. b. Placement can be confirmed by the aspiration of gastric contents. 1. It is recommended that a small syringe (10 to 30 cc) be used when checking small bore tubes to prevent exerting negative pressure and collapsing the tube. 2. If gastric content can not be aspirated through the tube, then radiographic confirmation of tube location should be done. a. Isotonic solution can be initiated full strength at a rate of 25 to 50 cc per hour and advanced every 12 to 24 hours until the desired rate is achieved. b. If intolerance develops at any time appropriate adjustment should be made.

c. Rate of the feeding is advanced to desired volume and then strength of the formula is gradually increased until calorie and protein needs are achieved. d. Strength and rate should not be advanced concurrently. Determining the method for the tube feeding administration 1. The method selected depend upon a. b. c. d. e. f. g. h. Central access route Stability of the patient (whether patient is critically ill or not.) Gastric emptying rate GI tolerance of tube feeding Type of formula use Calorie and protein needs Ease of administration Patients mobility.

1. The Feeds are given either by continuous drip, intermittent infusions, and bolus feed. a. Continuous drip- Tube feedings are administered at constant, steady rate usually over 24 hrs of period. Use of an infusion pump is recommended, as accuracy of volume delivered is assured. However most enteral feeding is administered by gravity of force. b. Intermittent infusions- Tube feeds are administered at specific intervals through out the day. The volume of desired feeding is divided into equal portion and been fed 4 to 6 hourly per day. The feedings are usually given by gravity drip over period of 30 min. to 1 hour. c. Bolus feed Rapid installation of feeding into GI tract by syringe or funnel. The majority of patients tolerate this method of feed. For optimal results of enteral feeding the following points to be considered: Temperature:
o o

Solution can be administered chilled if they are infused by continuous drip Decreased incidence of GI side effects may occur if intermittent and bolus feedings are allowed to reach room temperature prior to administration.

Bacterial contamination:
o o o o o

Use close feeding containers to decrease risk of organism contamination. Extension tubing administration set and bag should be changed daily. Never add new formula to old formula. Prepared formulas should be refrigerated if not used immediately. Feeding solutions should not be allowed to hang for longer than 8 to 12 hrs.

Prevention of aspiration:
o o

Placement of tube should be checked prior to feeds. Head of bed should be elevated at least 30 to45 degrees.

Few drops of food color may be added to enteral formulas. This will help in detection of aspirated of tube feeding from pulmonary secretions but does not protect against aspiration. The technique of aspirating gastric residuals via the feeding tube is common practice although not based on scientific studies. Tube position or mechanical difficulty may give inaccurate assessment. In general the practice is limited to larger bore feeding tubes. The smaller tubes collapse when aspiration is attempted. Generally feeds are held if aspirate is between 75 to 150 cc.

o o o o

Feeding tube should be irrigated every shift washed with 40 to 50 cc of warm water after its use. Even after each feed stopped, tube should be flushed with 40 50 cc of warm water. In case of clogging flush the tube, using a syringe containing 30 to 50 cc of warm water. Medicine should be liquid if it has to pass through tube. The tube should be flushed with 20cc water before and after administration of medication.

Monitoring: A. Complications associated with enteral tube feeding may be prevented and managed with appropriate monitoring. 1. Monitoring schedules are diversified because of patients stability, institutional protocol, and feeding duration.
o o o o o o o o o

Tube position confirmation prior to initiation of feeding or prior to intermittent feeding Daily weight Daily intake and output of urine fractionals every six hours until maximal tube feeding rate is established. Patients with history of diabetes mellitus should have urine fractionals daily until therapy terminated. Record of gastric residuals every four hours when feeding intragastric. Record of bowel movements/consistency Weekly serum electrolytes and blood count Weekly profile of liver function tests, phosphorus, calcium, and magnesium, total protein albumin, nitrogen balance. Weekly reassessment of nutritional indices with appropriate readjustment in energy and protein provisions needed.

A. Prevention of mechanical, GI, and infectious complications of tube feeding B. Total quality care of tube feeding patients requires interdisciplinary team management. Home blend formulas Occasionally patient requests or is required to prepare tube feeding at home. Though this is possible and does have some benefits, there are

some significant points to be consider when home blend formulas are prescribe to the patient. The table no will show the advantages and disadvantages of home blend formulas. Advantages and Disadvantages of home blenderized tube feeding Advantages Family can take an active part in food preparation for patient Less costly Commercially prepared products can be 10% to 50% more expensive Cost of commercial products is not always reimbursable. Payment is depend upon necessity of use as dictated by disease process Increased amount of fiber can be provided Sense of " being different " is lessened since the patient can enjoy the same table food as his or her family Disadvantages Blenderized feeding require more time and energy to prepare than commercial products Special equipment is needed i.e. blender or food processor, measuring utensils, access to refrigeration etc

Special care must be taken to liquefy the contents of the blender completely, as food particles can clog the feeding tube

Feeding must be prepared daily Daily ingredient selection should be carefully made to ensure nutrition adequacy of diet. May need vitamin and mineral supplementation Extra amount of blenderized feed must be kept refrigerated and must slightly warmed before feeding.

Manipulation of individual nutrients is easier in blenderized feedings than with commercial products Unpleasant taste from eructations is less likely to occur

Higher incidence of bacterial contamination may occur. Clean food preparation technique must be emphasized

Blenderized feeding are difficult to sue if the patient is away from home The home tube feeding recipes is a teaching tool for use by either the patient or the primary caretaker. The content of feeding are determined by the dietician to provide the requirement of the nutrients such as protein, calories, carbohydrate fat, vitamins, minerals and water. The feeding can be prepared either by blender or using hand mixer.

Directions: 1. Measure all ingredients accurately. Pour into large mixing bowl and stir contents to combine.

Blender method; add three cups of mixture to blender. Set at medium speed for three minutes. Pour into separate large bowl. Repeat above procedure until formulas have been thoroughly mixed. Mixer method: using an electric mixer, blend at medium speed five minutes or until thoroughly mixed

1. If mixture is thick, thin with water until the desire consistency is achieved. 2. Pour formula into individual jars. Cover and refrigerate immediately. Discard any unused formula within 24 hours 3. Take individual serving out one hour before needed and allow it to warm to room temperature before use. Always keep it covered. 4. The patient/caretaker should follow the direction given to him regarding feeding

Parenteral Nutrition
Parenteral nutrition (PN) is feeding a person intravenously, bypassing the usual process of eating and digestion. The person receives nutritional formulas that contain nutrients such as salts,

glucose, amino acids, lipids and added vitamins. It is called total parenteral nutrition (TPN) or total nutrient admixture (TNA) when no food is given by other routes. Indications

Total parenteral nutrition (TPN) is provided when the gastrointestinal tract is nonfunctional because of an interruption in its continuity or because its absorptive capacity is impaired.[1] It has been used for comatose patients, although enteral feeding is usually preferable, and less prone to complications. Parenteral nutrition is indicated to prevent the adverse effects of malnutrition in patients who are unable to obtain adequate nutrients by oral or enteral routes. Gastrointestinal disorders TPN may be the only feasible option for nutrition patients who do not have a functioning gastrointestinal tract or who have disorders requiring complete bowel rest, including bowel obstruction, short bowel syndrome, prolonged diarrhoea regardless of its cause, high-output fistula, some stages of Crohn's disease or ulcerative colitis, and certain pediatric GI disorders including congenital GI anomalies.

Use in cancer
The benefit of TPN to cancer patients is largely debated, and studies to date have generally showed minimal long term benefit. Weight loss with advanced disease is significantly more complicated than simply replacing calories as cancer produces a multitude of chemicals that also lead to weight loss. 50% of cancer patients started on TPN die in 6 months; only about 10% are alive at 2 years

Short-term PN may be used if a person's digestive system has shut down (for instance by peritonitis), and they are at a low enough weight to cause concerns about nutrition during an extended hospital stay. Long-term PN is occasionally used to treat people suffering the extended consequences of an accident, surgery, or digestive disorder. PN has extended the life of children born with nonexistent or severely deformed organs. People have survived on total parenteral nutrition for more than 35 years, though the majority of patients die within a year of TPN being started

TPN is an artificial method of feeding, fully passing the GI tract. As advanced as science is, this unnatural way of feeding the body is far from perfect and comes with several significant complications

TPN requires a chronic IV access for the solution to run though, and the most common complication is infection of this catheter. Infection is a common cause of death in these patients, with a mortality rate of approximately 15% per infection, and death usually results from septic shock. Fungal blood infections from TPN are especially common in patients getting TPN

Blood clots
Chronic IV access leaves a foreign body in the vascular system, and blood clots on this IV line are common. Death can result from a clot that starts on the IV line but breaks off and goes into the lungs. This process is called a pulmonary embolism

Fatty liver and liver failure

Fatty liver is usually a more long term complication of TPN, though over a long enough course it is fairly common. The pathogenesis is still unknown.

Other complications
Total parenteral nutrition increases the risk of acute cholecystitis due to complete unusage of gastrointestinal tract, which may result in bile stasis in the gallbladder. Other potential hepatobiliary dysfunctions include steatosis, steatohepatitis, cholestasis, and cholelithiasis.

he nutrient solution consists of water and electrolytes; glucose, amino acids, and lipids; essential vitamins, minerals and trace elements are added or given separately. Previously lipid emulsions were given separately but it is becoming more common for a "three-in-one" solution of glucose, proteins, and lipids to be administered.[11][12] In most US hospitals, clinical pharmacists or Registered Dietitians evaluate the patient's individual data and decide what PN formula to use. For energy only, intravenous sugar solutions with dextrose or glucose are generally used.

[edit] Total parenteral nutrition

Solutions for total parenteral nutrition may be customized to individual patient requirements, or standardized solutions may be used. The use of standardized parenteral nutrition solutions is cost effective and may provide better control of serum electrolytes.[13] Standardized solutions may also differ between developers. Following are some examples of what compositions they may have. The solution for normal patients may be given both centrally and peripherally.

Examples of total parenteral nutrition solutions[13] Substance Normal patient High stress Fluid-restricted

Amino acids Dextrose Lipids Na+ K+ Ca2+ Mg2+ Acetate ClP MVI-12 Trace elements

85 g 250 g 100 g 150 mEq 80 mEq 360 mg 240 mg 72 mEq 143 mEq 310 mg 10 mL 5 mL

128 g 350 g 100 g 155 mEq 80 mEq 360 mg 240 mg 226 mEq 145 mEq 465 mg 10 mL 5 mL

75 g 250 g 50 g 80 mEq 40 mEq 180 mg 120 mg 134 mEq 70 mEq 233 mg 10 mL 5 mL

Infusion procedure
The preferred method of delivering PN is with a medical infusion pump. A sterile bag of nutrient solution, between 500 mL and 4 L, is provided. The pump infuses a small amount (0.1 to 10 mL/hr) continuously in order to keep the vein open. Feeding schedules vary, but one common regimen ramps up the nutrition over one hour, levels off the rate for a few hours, and then ramps it down over a final hour, in order to simulate a normal metabolic response resembling meal time. This should be done over 12 to 24 hours rather than intermittently during the day. Chronic PN is performed through a central intravenous catheter, usually through the subclavian or jugular vein with the tip of the catheter at the superior vena cava without entering the right atrium. Another common practice is to use a PICC line, which originates in the arm, and extends to one of the central veins, such as the subclavian with the tip in the superior vena cava. In infants, sometimes the umbilical vein is used. Battery-powered ambulatory infusion pumps can be used with chronic PN patients. Usually the pump and a small (100 ml) bag of nutrient (to keep the vein open) are carried in a small bag around the waist or on the shoulder. Outpatient TPN practices are still being refined but have been used for years. Patients can receive the majority of their infusions while they sleep and instill heparin in their catheters when they are done to simulate a more "normal" life style off the pump

Bariatric surgery
also known as weight loss surgery, refers to the various surgical procedures performed to treat obesity by modification of the gastrointestinal tract to reduce nutrient intake and/or absorption. The term does not include procedures for surgical removal of body fat such as liposuction or abdominoplasty. For individuals who have been unable to achieve significant weight loss through diet modifications and exercise programs alone, bariatric surgery may help to attain a more healthy body weight. There are a number of surgical options available to treat obesity, each with its advantages and pitfalls. In general, bariatric surgery is successful in producing (often substantial) weight loss, though one must consider operative risk (including mortality) and side effects before making the decision to pursue this treatment option. Usually, these procedures can be carried out safely


"Surgery should be considered as a treatment option for patients with a BMI of 40 kg/m 2 or greater who instituted but failed an adequate exercise and diet program (with or without adjunctive drug therapy) and who present with obesity-related comorbid conditions, such as hypertension, impaired glucose tolerance, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea. A doctorpatient discussion of surgical options should include the long-term side effects, such as possible need for reoperation, gallbladder disease, and malabsorption." "Patients should be referred to high-volume centers with surgeons experienced in bariatric surgery


Obesity means having too much body fat (adipose tissue). Obesity generally is determined by calculating body mass index (BMI), which measures weight for height and is stated in numbers. BMI is calculated by the weight in kilograms divided by height in meters squared. Weight (inKgs,) --------------------------------------Height (in meters) Status Underweight Normal Overweight Obese Severe Obesity Morbid Obesity Super morbid Obesity


BMI Below 18.5 18.5 24.9 25 29.9 30 34.9 35 39.9 > 40 > 50


Severe obesity damages the body by its mechanical, metabolic and physiological adverse effects on normal bodily function. These "co-morbidities" affect nearly every organ in the body in some way, and produce serious secondary illnesses, which may also be life-threatening. The cumulative effect of these co-morbidities can interfere with a normal and productive life and can seriously shorten life, as well. The risk of developing these medical problems is proportional to the degree of obesity.

People who are obese do not live as long as those who are not obese and the earlier a person become obese; the more years of life are lost. Heart Disease Severely obese persons are approximately 6 times as likely to develop heart disease as those who are normal-weighted. Heart disease is the leading cause of death today and obese persons tend to develop it earlier in life and it shortens their lives. High Blood Pressure Hypertension is much more common in obese persons and leads to development of heart disease, and damage to the blood vessels throughout the body, causing susceptibility to strokes, kidney damage, and hardening of the arteries. High Blood Cholesterol. Diabetes Mellitus Overweight persons are40 times as likely to develop Type-2, AdultOnset, diabetes. Once Diabetes occurs, it becomes even harder to lose weight, because of hormone changes which cause the body to store fat even more than before. Sleep Apnea Syndrome Sleep apnea - the stoppage of breathing during sleep -- is commonly caused in the obese, by compression of the neck, closing the air passage to the lungs. Respiratory Insufficiency Heartburn - Reflux Disease and Reflux Nocturnal Aspiration Asthma and Bronchitis Gallbladder Disease Gallbladder disease occurs several times as frequently in the obese, in part due to repeated efforts at dieting, which predispose to this problem. Stress Urinary Incontinence. Degenerative Disease of Lumbo-Sacral Spine (Backbone). Degenerative Arthritis of Weight-Bearing Joints like knee, hip. Venous Stasis Disease in the lower extremities. Emotional / Psychological Illness Seriously overweight persons face constant challenges to their emotions: repeated failure with dieting, disapproval from family and friends and remarks from strangers. They often experience discrimination at work Stereotypes of obese people such as that they are lazy may result in lower self esteem and poor body image. There is no wonder that anxiety and depression might accompany years of suffering from the effects of a genetic condition -- one which skinny people all believe should be controlled easily by will power. Social Effects Severely obese persons suffer inability to qualify for many types of employment and tend to have higher rates of unemployment, There is a general societal belief that obesity is a consequence of a lack of self-discipline, or moral weakness. People who are obese do not live as long as those who are not obese and the earlier a person become obese; the more years of life are lost. Heart Disease Severely obese persons are approximately 6 times as likely to develop heart disease as those who are normal-weighted. Heart disease is the leading cause of death today and obese persons tend to develop it earlier in life and it shortens their lives.

High Blood Pressure Hypertension is much more common in obese persons and leads to development of heart disease, and damage to the blood vessels throughout the body, causing susceptibility to strokes, kidney damage, and hardening of the arteries. High Blood Cholesterol.

Diabetes Mellitus Overweight persons are40 times as likely to develop Type-2, Adult-Onset, diabetes. Once Diabetes occurs, it becomes even harder to lose weight, because of hormone


Medical conditions that may be greatly improved after surgery include:

High Blood pressure About 60 percent of patients with high blood pressure are able to stop all medications and have a normal blood pressure, usually within two to three months after surgery.

High Cholesterol More than 70 percent of patients will develop normal cholesterol levels within wo to three months. Diabetes More than 80 percent of Type-2 diabetics obtain excellent results, usually within a few weeks after surgery.. There is no medical treatment for diabetes that can achieve as complete and profound an effect as surgery. Asthma According to IFSO, successful bariatric surgery reduces the number and severity of asthma attacks. Respiratory Insufficiency Improvement of exercise tolerance and breathing ability usually occurs within the first few months after surgery. Often, patients who have barely been able to walk find that they are able to participate in family activities, and even sports. Sleep Apnea Syndrome Dramatic relief of sleep apnea occurs as patients lose weight. Many report that within a year of surgery, their symptoms were completely gone, and they had even stopped snoring completely-and their spouses agree. Sleep apnea is cured in about 75 percent of patients after surgery Gastro-Esophageal Reflux Disease Relief of symptoms of reflux usually occurs within a few weeks of surgery for many patients Gallbladder Disease When gallbladder disease is present at the time of the surgery, it is "cured" by removing the gallbladder during the operation.

Stress Urinary Incontinence This condition responds dramatically to weight loss and usually significant improvement in the control occurs.

Low Back Pain, Degenerative Disk Disease, & Degenerative Joint Disease Patients usually experience considerable relief of pain and disability from degenerative arthritis and disc disease and from pain in the weight-bearing joints

Classification of surgical procedures

Diagram of an adjustable gastric banding.

Adjustable gastric band

The same effect can be created using a silicone band, which can be adjusted by addition or removal of saline through a port placed just under the skin. This operation can be performed laparoscopically, and is commonly referred to as a "lap band." The first gastric band was patented in 1985 by Obtech Medical of Sweden (now owned by J&J/Ethicon) and is known as the Swedish Adjustable Gastric Band (SAGB). An American company, INAMED Health, later designed the BioEnterics LAP-BAND Adjustable Gastric Banding System. The LAP-BAND System was introduced in Europe in 1993. Neither of these bands was initially designed for use with keyhole surgery. The LAP-BAND System received U.S. Food and Drug Administration (FDA) approval for use in the United States in June 2001. In 2000, the first lower pressure, wider, one-piece adjustable gastric band called the MIDband was introduced in Lyon France by Medical Innovation Development.[5] In 2002, the first lower pressure, wider, one-piece adjustable gastric band called the Bioring was introduced in France by Cousin-Biotech.[6] Unlike many of the early bands this was designed specifically for laparoscopic insertion. It has swiftly become one of the leading bands placed in France. There are now many band manufacturers (approx 7-8 in total). Mixed procedures Mixed procedures apply both techniques simultaneously.

Roux-en-Y gastric bypass.

Gastric Bypass Surgery

The most common form of gastric bypass surgery is Roux-en-Y gastric bypass surgery. Here, a small stomach pouch is created with a stapler device, and connected to the distal small intestine. The upper part of the small intestine is then reattached in a Y-shaped configuration. Effectiveness of surgery Weight loss In general, the malabsorptive procedures lead to more weight loss than the restrictive procedures. A meta-analysis from University of California, Los Angeles reports the following weight loss at 36 months:[3] Biliopancreatic diversion - 53 kg

Roux-en-Y gastric bypass (RYGB) - 41 kg o Open - 42 kg o Laparoscopic - 38 kg Adjustable gastric banding - 35 kg

Adverse effects Complications from weight loss surgery are frequent. A study of insurance claims of 2522 who had undergone bariatric surgery showed 21.9% complications during the initial hospital stay and a total of 40% risk of complications in the subsequent six months. This was more common in those over 40 and led to increased health care expenditure. Common problems were gastric dumping syndrome in about 20% (bloatedness and diarrhoea after eating, necessitating small meals or medication), leaks at the surgical site (12%), incisional hernia (7%), infections (6%) and pneumonia (4%). Mortality was 0.2%.[13] As the rate of complications appears to be reduced when the procedure is performed by an experienced surgeon, guidelines recommend that surgery is performed in dedicated or experienced units.[2]

Sleeve gastrectomy
Sleeve gastrectomy is a surgical weight-loss procedure in which the stomach is reduced to about 25% of its original size, by surgical removal of a large portion of the stomach, following the major curve. The open edges are then attached together (often with surgical staples) to form a sleeve or tube with a banana shape. The procedure permanently reduces the size of the stomach. The procedure is performed laparoscopically and is not reversible.

The Sleeve Gastrectomy is a new procedure that induces weight loss by restricting food intake. With this procedure, approximately 80-85 percent of the stomach is removed laparoscopically so that the stomach takes the shape of a tube or "sleeve." This procedure is usually performed on superobese (BMI >60 or high risk patients with the intention of performing another surgery at a later time. This surgery may also be done on regular patients (BMI of 30+) who desire a lower risk procedure than the RNY Bypass while getting similar results. The second procedure a gastric bypass can then be done if necessary for the superobese to reach goal.

Advantages of the Vertical Gastrectomy Weight Loss Surgery

The stomach is reduced in volume but tends to function normally so most food items can be consumed, albeit in small amounts. Eliminates the portion of the stomach that produces the hormones that stimulates hunger (Ghrelin). No dumping syndrome because the pylorus is preserved. Minimizes the chance of an ulcer occurring. By avoiding the intestinal bypass, the chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are almost eliminated. Very effective as a first stage procedure for high BMI patients (BMI>55 kg/m2). Limited results appear promising as a single stage procedure for low BMI patients (BMI 30-45 kg/m2). Appealing option for people with existing anemia, Crohn's disease and numerous other conditions that make them too high risk for intestinal bypass procedures. Can be done laparoscopically in patients weighing over 500 pounds.

Disadvantages of the Vertical Gastrectomy Weight Loss Surgery

Potential for inadequate weight loss or weight regain. While this is true for all procedures, it is theoretically more possible with procedures that do not have an intestinal bypass. Higher BMI patients will most likely need to have a second stage procedure later to help lose the rest of the weight. Two stages may ultimately be safer and more effective than one operation for high BMI patients. This is an active point of discussion for Bariatric surgeons. Soft calories such as ice cream, milk shakes, etc can be absorbed and may slow weight loss. This procedure does involve stomach stapling and therefore leaks and other complications related to stapling may occur. Because the stomach is removed, it is not reversible. It can be converted to almost any other weight loss procedure. Considered investigational by some surgeons and insurance companies.

Personal information Patient Name Age Sex Date of Admission Date of Operation Hospital ID No. Educational Status : Economical Status Food habits : : Middle income group Veg/ Non veg : Mr JAI KUMAR MALI : 35 : Male :5/4/2011 : 6/4/2011

Anthropometric Measurement : Height (cm) : Weight (kg) : BMI Diagnosis HISTORY : : ; 145 73 45 MORBID OBESITY HTN No H/o TB / DM / Asthama Clinical Information : Skin Eye Hair Nail : : : : Normal Normal Normal Normal

INTRODUCTION OF INDIAN HOSPITALS In INDIA, hospitals have existed from ancient times. During the time of BUDDHA (6thcentury) there were a number of hospitals to look after the crippled and the poor. More such hospitals were started by devotees of BUDDHA in various parts of India and outside the country. The outstanding hospitals in India at the time were those build by king ASHOKA (274-332 BC).The Upakalpaniyam Adyayam of Charka Suthrasthanam gives specification for hospital buildings, lab our rooms and children wards. The qualifications for hospital attendants and nurses as well as specifications for hospital equipment, utensils, instruments and diets have also been given. The re is evidence to show that there were may hospitals in South India in olden days, as observed in the Chola and Malakapuram edicts. MEANING OF HOSPITAL:The English word hospital originates from the word HOSPILEand also some viewed that it comes from the French word hospital as do the words hostel and hotel. The three words hospital, hostel ,hotel, all are derived from same source ,are used in different sense, but basically the meaning of the word will be the same .Likewise all these three institutions are meant for treating their clients, but style of treatment will be different. INTRODUCTION HOSPITAL INFORMATION Definition: Philosophy is an abstract system of thought or belief that is concerned with the conduct Of mans endeavors. Since hospital organization is an essential part of the medical care, it should have its own philosophy .No statement of philosophy of an institution is permanent document, it may change according to changing needs and circumstance of the society at large.

HOSPITAL HISRTORY REVIEW B.M.H.R.C:The Bhopal gas tragedy is a catastrophe that has no parallel in industrial history. In the early morning hours of December 3, 1984 a rolling wind carried a poisonous grey cloud of Methyl Iso Cynate (MIC) from the Union Carbide Corporation(UCC) USA, causing one of the worlds worst & most horrendous disaster. Forty tons of toxic gas were released from carbides Bhopal Plant & spread throughout the city. The result was a nightmare that still has no end. An estimated 10,000or more people died, people whose hope &dream were ironically bound with the technology & affluence that plant symbolized. About 500,000 or more suffered agonizing injuries from the disastrous effects of the massive poisoning, while none can say, if future generations would not be affected. TRUST:Pursuant to the order passed by the Supreme Court Of India (SCI), UCC established a charitable in London on 20th march 1992 called The Bhopal Hospital Trust was established in the order of accordance with Sir Ian Pereival As its sole trustee. Following the unfortunate death of Sir Ian Percival ,a trust called The Bhopal Memorial Hospital Trust Was established in accordance with the order of SCI in 1998. The Trust is chaired by the Shri Justice A.M .Ahmadi, Former chief justice of India. BHOPAL MEMORIAL HOSPITAL TRUST The mission of Bhopal Memorial Hospital Trust is to provide medical & other available facilities for the benefit in the first instance of the victims of the Bhopal Gas Tragedy of 1984 & their dependents & subject there to for the people of Bhopal & public at large. LOCATION:

The Government of Madhya Pradesh granted 87 acres of land free of cost for the construction of hospital. The hospital is located on the Raisen Bypass Road near Karond square. The hospital is easily accessible to visitors & patients By Air, Rail or Road. BMHRC is 350 bedded super specialty hospitals.

MINI UNITS The Trust has developed a network of 10 mini units out of which 8 mini units are functional & they are scattered all over the gas affected areas of Bhopal. They are as follows:1. kainchi Chola . 2. Station Bajaria. 3. Chandbarh. 4. Teela Jamalpura. 5. Ginnouri. 6. Jehangirabad. 7. Karond. 8. Bal vihar. Two more mini units are in pipeline. These mini units has got well equipped pathology lab, diagnostic ophthalmic wing & X- ray machines ect. The mission of mini is to provide primary healthcare to the gas victims & to guide them to get proper & specializes medical services, & whenever it is necessary. Mini units also contribute to the prevention, rehabilitation, & health awareness programmes. Mission: The mission of Bhopal Memorial Hospital & Research Center is to provide the patients with the medical treatment of a highly specialized nature in defined areas. It will promote research & continuous education programmes including post graduate education training. OBJECTIVEST To provide state of the art super specialty medical facilities to all registered gas victims & their entitled dependents. To carry out basic, clinical, & epidemiological research in all disciplines in the hospital. To determine long term effects of Methyl Iso Cynate (MIC) on human tissue & to plan treatment modalities based on the findings.

To utilize the existing infrastructure to train doctors, nurses, & paramedical personnel.

PHYSICAL WARD DESINGN: - The primary object of ward design is to ensure the nurse to react to emergencies with maximum efficiency & minimum physical & emotional stress. PRIMARY 1. Bed accommodation: The size of a hospital bed is 6 6 x33. The minimum distance between the centers of two beds should be .25m. The are per bed in a ward is 70-90 sq. ft. The area per bed in a acute ward is 100- 120 sq .ft. The space between two rows of beds is 5 ft. 2. a. b. c. d. e. Nursing station. Nerve center of ward should be located centrally. Should be of minimum 20x20 size with following components. Sisters room with attached bath & WC+ cupboards. A large worktable in open space with stool / chair for nurses. Built in cupboard for medicines, dangerous drugs & refrigerator, communication system (computer).

2. Treatment room I) II) For physical examination, dressing & certain procedure. It should be equipped with examination table, spotlight, cabinets& a dressing Trolley + hand washing facilities.

Auxiliary 1) Doctors duty room:-

In this room doctors can work during the day & rest during the night duty it should be equipped with a bed, chair & table, wash basin & have an attached toilet. 2) Nurses :In nurses room nurses can work & have food and so many work can performs by nurse in it. 3) Stores :Store room is a place where all materials (drugs, medicine, equipment etc.) those come from main store then issue to patient from the ward store. Sanitary A. Toilet block. B. It is divided into male/ female toilet. Ancillary A) Ward pantry. 1. It is a small area for the dietary services. 2. It should be equipped with arrangement for hot water, refrigerator, crockery & plate stroge & hot case. B) Day room :Place for sitting, relaxing & meeting visitors. C) Conference room:For clinico pathological conference, provided in teaching hospital. D) Stretcher, Trolley , Wheel chair bay:Usually one for the ward floor.








1. ANAESTHESIOLOGY- CRITICAL CARE AND PAIN MANAGEMENT: 1. Pre- anesthesia / anesthetic check- up clinic. 2. pre operative anesthesia services. 3. Intensive care unit services. 4. Emergency resuscitative services. 5. Pain clinic out patient services. 3.CARDILOGY:A) An immediate response, 24 hr emergency team with a mobile intensive care unit. B) The department of cardiology is a 30 bed unit with a 10 baded coronary care unit (CCU). ELECTIVE SERVICES:Exercise stress test and electrocardiogram. Primary angioplasty, coronary angiography, coronary angioplasty, balloon mitral vulvulopasty. 4. CARDIOVASCULAR THORACIC SURGERY:Treatment for heart disease by operation. 1. Coronary artery diseases. 2. Rheumatic valvular heart diseases. 3. Congenital disorder. 4. Pulmonary and there thoracic disorder.


Endoscopy services ERCP, GI physiology, variceal hemorrhage, liver disease, peptic ulcer.

7. NEPHROLOGY:* Dialysis unit, continuous ambulatory peritoneal dialysis. * vascular access services. * Kidney biopsy.

8. NEUROLOGY:* OPD *IPD dedicated 30 beds in ward facility . * Emergency. *Physiotherapy and rehabilitation. * Investigation available. EEG, NERVE CONDUTION STUDY , ELECTO MYOGRAPHY, TRANS CRANIAL DOPPLER. 9. NEURO SURGERY:General cranial and spinal surgery. * Skull base neurosurgery , pediatrics neurosurgery transphenoidal surgery.

10. OPHTHALMOLOGY :All types of medical and operative treatment available , cataract , glaucoma, sclera conjunctiva. 11.PULMONARY MEDICINE:*Salient disorders investigation carried out. * Flexible bronchoscopes for adult and pediatric patents.

12.PATHOLOGY:* Hematology anemia profile , leukemia and cytochemistry, bone marrow. * Bio chemistry special test like serum ferritin serum iron TIBC and glycosylated, hemoglobin etc.

* Cytology and Histopathology. * Automated and semi automated analyzers.

13. PSYCHIATRY:*Outpatient services, inpatient services. *Psychometric testing battery of tests available for intelligence personality. *Psychotherapy including relaxation therapy. *Electro-convulsive therapy. *Investigations psychometric testing , EEG,CT-scan, MRI.

14. RADIOLOGY:* Non- invasive services, plain, x-rays, paleography. *Specialized services ultrasound color Doppler ct scan. * Invasive services USG, guided, biopsy. * Angioplasty.

15. TRANSFUSION MEDICEN BLOOD BANK:*24 hr blood transfusion services. * Modern antibody screening and cross matching techniques. * Plasma pheresis and single donor blood products. * Blood donation . * 100% Blood component preparation.

16. SURGICAL GASTRO ENTROLOGY:*Comprehensive care for disease of the gastrointestinal tract, 30 bedded ward which includes a 6 bedded HDU.