Diabetes Mellitus

1. Diagnostic criteria

Impaired Glucose Fasting <126 mg/dl

Tolerance 2-h plasma glucose 140 mg/dl to200 mg/dl
Impaired Fasting Fasting 110 mg/dl to 125 mg/dl
Prediabetes
Glucose 2-h plasma glucose < 140 mg/dl
Fasting ≥126 mg/dl
Diabetes
2-h plasma glucose >200 mg/dl
HbA1c ≥ 6.5%

2. Modifiable and Non-Modifiable risk factors of Diabetes

Modifiable risk factors Non-Modifiable risk factors

Obesity Age
Sedentary life-style Sex
Diet Genetic Factors
Dietary fibre Immune mechanisms
Malnutrition in early infancy Maternal diabetes
Alcohol
Stress

3. Role of Diet in Diabetes

Decreased Risk Increased Risk

High unsaturated & Polyunsaturated fat intake High saturated fat intake
High Dietary fibre intake (Non-starch Polysaccharides) Trans fatty acids
η-3 fatty acids

4. Glycaemic Index (GI) of a food is defined by area under the 2-hour blood glucose response curve (AUC) following
the ingestion of a fixed portion of test carbohydrate (usually 50 g) as a proportion (%) of the AUC of the standard
(glucose or white bread)

Classification GI Range Examples

Low GI: slow release 55 or less Most Fruit & vegetables (Except: Potatoes, Watermelon, sweet corn), Whole grains, pasta
of sugar foods, beans, lentils
Medium GI 56-69 Sucrose, Basmati rice, Brown rice
High GI: readily 70 or Corn flakes, Baked potato, White bread, Candy bar, Syrupy foods
digestible & more
absorbable sugar

5a) Symptoms & signs of Diabetes

Polyuria, Polyphagia, Polydipsia
5b) Complications of Diabetes

Macro-Vascular Micro-Vascular
Transient Ischemic Attacks, Stroke Diabetic Retinopathy
Myocardial Infarction Diabetic Nephropathy
Peripheral Vascular disease Diabetic Neuropathy

6. Metabolic Syndrome or Syndrome X:

Genetic Defect leads to insulin resistance predisposes to Hyperglycaemia, hyperinsulinaemia, dyslipidemia,
Hypertension resulting in Obesity and Type 2 DM

7. Anthropometric Indices:
 Classification BMI (kg/m2) (Asian)
Underweight <18.5
Normal Range 18.5 – 22.9
Overweight 23 – 24.9
Obese ≥25

Waist Circumference: Measured at Mid-point between lower border of rib-cage and the iliac crest. Index of intra-
abdominal fat mass and total body fat.
Increases risk of metabolic complications if ≥ 102 cm (males), ≥ 88 cm (females)

Waist Hip Ratio (WHR)

High WHR for Males > 1.0, for Females > 0.85 indicate abdominal fat accumulation

8. Opportunistic Screening:
Screening of individuals more than 30 years for Non-Communicable diseases.

9. Self-care in DM
Element of secondary prevention
Adherence to diet & drug regimens
Self-monitoring of urine & blood glucose
Self-administration of insulin
Abstinence from alcohol
Maintenance of optimum weight
Attending periodic Check-ups
Recognition of symptoms of glycosuria and hypoglycemia

10. IDRS –Indian Diabetes Risk Score

Categorized Risk Factors Score
< 35 years 0
Age 35 – 49 years 20
≥ 50 years 30
Waist circumference Female <80 cm, Male <90 cm 0
Abdominal
Female 80-89 cm, Male 90-99 cm 10
Obesity
Female ≥90 cm, Male ≥100 cm 20
Vigorous exercise or strenuous at work 0
Physical Moderate exercise at home/office 10
Activity Mild exercise at home/office 20
No exercise or sedentary life style 30
Both non-diabetic 0
Family History One parent diabetic 10
Both parents diabetic 20
Maximum Score = 100
≥60 High risk
30-50 Medium risk
<30 Low risk

Hypertension
1. Diagnostic Criteria

Category SBP & DBP DBP

 Normal < 120 < 80
Pre-hypertension 120-139 80-89
Stage I 140-159 90-99
Hypertension
Stage II >160 ≥ 100

2. Modifiable and Non-Modifiable risk factors

Modifiable Non-Modifiable
Obesity Age
Salt Intake, Saturated fat, Dietary fibre Sex
Alcohol Genetic factors
Heart rate Ethnicity (Black Americans have high BP levels)
Physical activity
Environment stress

3. Rule of Halves: Hypertension is an ice-berg disease

Only about half of the hypertensive subjects in general population in developed countries were aware of the
condition, only about half the problem were being treated, and only about half of those treated were considered
adequately treated

4. DASH (Dietary Approaches to Stop Hypertension) Diet:

Diet rich in fruits, vegetables and low-fat dairy products with reduced content of saturated fat and total fat
Food group Daily servings Daily servings Servings
(1600 K Cal) (2000 K Cal)
Grains 6 6-8 - 1 slice whole wheat bread
- 1 oz dry cereal
- ½ cup cooked cereal
Lean meats, 3-6 6 or less - 1 oz. cooked lean meat, skinless poultry,
poultry & fish fish
- 1 egg (no more than 4 a week)
- 2 egg whites
Vegetables 3-4 4-5 - 1 cup raw leafy green vegetable
- ½ cup cut-up raw or cooked vegetables
- ½ cup (4 fluid oz) low-sodium vegetable
juice
Fruits 4 4-5 - 1 medium fruit
- ¼ cup dried fruit
- ½ cup fresh, frozen or canned fruit
- ½ cup (4 fluid oz) 100% fruit juice
Low fat or dairy 2-3 2-3 - 1 cup (8 fluid oz) milk
products - 1 cup yogurt
- 1½ oz. cheese
Fats & oils 2 2-3 - 1 tsp soft margarine
- 1 tsp vegetable oil
- 1 tablespoon mayonnaise
- 2 tablespoons salad dressing
Sodium 2300 mg 2300 mg - 1 slice whole wheat bread
- 1 oz dry cereal
- ½ cup cooked cereal
Food group Weekly serving Weekly serving
Nuts, seeds, dry 3 4-5 - 1/3 cup (1.5 oz) nuts
beans & peas - 2 tablespoons peanut butter
- 2 tablespoons ( ½ oz) seeds
- ½ cup cooked legumes
Sweets 0 5 or less - 1 tablespoon sugar
- 1 tablespoon jelly or jam
- ½ cup sorbet
 - 1 cup (8 fluid oz) sweetened lemonade

5. Tracking of BP:
BP of individuals when followed up from early childhood to adult life, those individuals with high in
distribution, would probably continue in the same “track” as adults. Phenomenon of persistence rank order of BP is
described as “Tracking”. Helps in identifying children and adolescents “at risk” of developing HTN in future.

6a) Malignant Hypertension: High BP associated with Retinal hemorrhages, exudates and Papilledema
6b) Hypertensive Urgency: Elevated BP without acute end organ damage
6c) Hypertensive Emergency: Elevated BP with acute end organ damage

7. Korotkoff’s Sounds:

8. Complications of HTN
Cerebrovascular Accidents
Hypertensive retinopathy
Myocardial Infarction
Hypertensive Cardiomyopathy
Hypertensive Nephropathy

9. Self-Care in HTN
Adherence to DASH diet & drug regimens
Self-Monitoring of BP
Abstinence from alcohol & Smoking
Maintenance of optimum weight
Attending periodic Check-ups
Avoidance of Stress
Yoga, Meditation

10. ISH (WHO) Risk prediction chart:

The WHO/ISH risk prediction charts indicate 10-year risk of a fatal or nonfatal major cardiovascular event
(myocardial infarction or stroke), according to age, sex, blood pressure, smoking status, total blood cholesterol and
presence or absence of diabetes mellitus
 Tuberculosis
1. Case Definitions
a) Classification based on Anatomical site
Pulmonary TB
Extrapulmonary Tb: other than lungs. Eg. Pleura, lymph nodes, abdomen, genitourinary tract, skin, joints,
bones, meninges
b) Based on H/o previous TB
New patients: never been treated before for TB or have taken ATT for less than a month
Previously treated: who received 1 month or more of ATT in the past. Further classified into:
a) Relapse: Previously treated for TB, were declared cured, or treatment completed and now
diagnosed with a recurrent episode of TB (true relapse or new TB by re-infection)
b) Treatment after failure: who have previously been treated for TB and whose treatment failed at
the end of their most recent course of treatment
 c) Treatment after lost to follow up: Previously treated for TB & were declared lost to follow up at
the end of their recent course of treatment
d) Other previously treated: Previously been treated for TB whose outcome of the recent course of
treatment is unknown or undocumented
e) Patients with unknown previous TB treatment history: not fit into any of the above categories.
1c) Based on Drug resistance
Monoresistance: Resistant to 1 first line ATT only
Polydrug Resistance: resistant to >1 first line ATT (other than INH and Rifampicin)
MDR: Resistant to at least both INH and Rifampicin
XDR: Resistant to any Fluoroquinolone and at least one of the three second line injectable drugs
(capreomycin, kanamycin, amikacin), in addition to MDR
Rifampicin Resistance: resistance to rifampicin detected using phenotypic or genotypic methods, with or
without resistance to other anti-TB drugs (includes any resistance to any rifampicin MDR, XDR, monoresistance)
1d) Based on HIV-status
HIV positive TB patient: Bacteriological or Clinical confirmed TB patient who has positive result of HIV
HIV negative TB patient: Bacteriological or Clinical confirmed TB patient who has negative result of HIV
HIV status Unknown TB patient: HIV positive TB patient: Bacteriological or Clinical confirmed TB patient who
has no result of HIV testing

2. Treatment Outcome Definitions:

a) TB Patients (excluding RR-TB, MDR-TB)
Cured: Bacteriologically confirmed TB patient – smear or culture negative in the last month of treatment and
on at least one previous occasion.
Treatment completed: TB patient completed treatment, without evidence of failure but no record to show
smear or culture results in the last month of treatment and or at least one previous occasion
Treatment Failure: TB patient smear or culture positive at 5 month or later during treatment
Died: TB patient dies for any reason before starting or during the course of treatment
Lost to Follow up: TB patient who did not start treatment or treatment interrupted for 2 consecutive
months or more
Not evaluated: TB patient for whom no treatment outcome is assigned. Also includes “transferred out” to
another unit
Treatment success: Sum of cured and treatment completed
b) TB patients (RR-TB / MDR-TB / XDR-TB )
Cured: Treatment completed as recommended by national policy without evidence of failure and 3 or more
consecutive cultures taken at least 30 days apart are negative after IP.
Treatment completed: Treatment completed as recommended by national policy without evidence of failure
but no record that 3 or more consecutive cultures taken at least 30 days apart are negative after IP
Treatment Failure: Treatment terminated or need for change of at least 2 anti-TB drugs due to
-lack of conversion by end of IP
-Bacteriological reversion in the CP after conversion to negative
-evidence of acquired resistance to FQs or Injectable drugs
-adverse drug reactions
Died: TB patient dies for any reason before starting or during the course of treatment
Lost to Follow up: TB patient who did not start treatment or treatment interrupted for 2 consecutive
months or more
Not evaluated: TB patient for whom no treatment outcome is assigned. Also includes “transferred out” to
another unit
Treatment success: Sum of cured and treatment completed

2. ZN staining and Interpretation

2 samples: Day 1 “on the spot” sample under supervision
Day 2 early morning sample

- Fix the smear

- Cover with carbolfuchsin, steam gently for 5 minutes
- Wash with deionized water
- Decolorize with 3% acid-alcohol
 - Wash with water
- Counter stain for 1 minute with methylene blue
- Wash with deionized water and let it dry
No. of bacilli Reporting
0 AFB per 100 oil immersion fields 0
1-9 AFB per 100 oil immersion fields Scanty
10-99 AFB per 100 oil immersion fields 1+
1-10 AFB per oil immersion field 2+
>10 AFB per oil immersion field 3+

3. CBNAAT indications
- Paediatric TB diagnosis
- TB/HIV co-infection
- Smear negative but CXR suggestive of TB

4. Treatment Regimes

Type IP CP
New 2 HRZE 4 HRE
Previously treated 2 HRZES + 1 HRZE 5 HRE

FDC for Adults

No. of tablets (FDCs)
Weight IP CP Inj. Streptomycin
category (kg) HRZE HRE (g)
75/150/400/275 75/150/275
25-39 2 2 0.5
40-54 3 3 0.75
55-69 4 4 1
≥70 5 5 1

FDC for Paediatric TB

No. of tablets (FDCs)
Weight IP CP Inj. Streptomycin
category (kg) HRZ E HRE (mg)
50/75/150 100 50/175/100
4-7 1 1 1 100
8-11 2 2 2 150
12-15 3 3 3 200
16-24 4 4 4 300
25-29 3 + 1A* 3 3 + 1A* 400
30-39 2 + 2A* 2 2 + 2A* 500
*A = adult FDC

5. Tuberculin Test:
Tuberculin test only means of estimating the prevalence of infection in population. Two have been accepted
as standard by WHO, PPD-S and PPD-RT 23.
Tuberculin reactions are erythema and induration.
Induration >10mm: Positive
<6mm: Negative
6-9mm: Doubtful
>20mm: greater chances of developing TB

6. TB drugs MOA

Bactericidal Bacteriostatic
 Rifampicin Ethambutol
INH Fluoroquinolones
Streptomycin Ethionamide
Pyrazinamide Capreomycin
Cycloserine Kanamycin &Amikacin
Thioacetazone
Bedaquiline

7. Newer Anti-Tb drugs

Bedaquiline – Mycobacterial ATP synthase inhibitor, oral drug
Contraindicated in Pregnancy, Cardiac arrhythmia
Delamanid

8.BCG Vaccine:
Live attenuated vaccine, Danish 1331 strain, Administered: Intra-dermal route, left upper-arm
Dose: <4weeks: 0.05 ml, >4weeks: 0.1 ml
Contra-indications: Eczema, infective dermatosis, Hypogammaglobulinemia, Leukemia, lymphoma,
pregnancy, patients on immune-suppressive therapy

9. End TB Strategy:
Components:
- Integrated patient centred care and prevention
- Bold policies and supportive system
- Intensified research and innovation

Indicators for END TB 2035 are

- Reduction in TB deaths by 95% by 2035 compared with 2015
- Reduction in TB incidence by 90% by 2035 compared with 2015
- Ensure no families face catastrophic costs due to TB

10. Cough Hygiene

Cough covering the mouth
Dispose the sputum in a coconut shell and bury it or put it in a container with disinfectant (5% phenol)

ANC
1a) Ideal ANC Visits
Once a month in first 7 months
Twice a month during next month; and thereafter, once a week if everything is normal
1b) Minimum required visits -4
1- within 12 weeks, as soon as pregnancy is suspected
2- between 14 and 26 weeks
3- between 28 and 34 weeks
4- between 36 weeks and term

2. Anemia in pregnancy

g/dl
Adult Males 13
Adult Female, non-pregnant 12
Adult Female, pregnant 11
Children, 6months – 6 years 11
Children, 6 – 14 years 12
 Anemia Classification HB level (g/dl)
Very severe <4
Severe 4-6.9
Moderate 7-9.9
Mild 10-10.9

3. Iron Folic acid Supplementation (100 mg of elemental iron and 500mcg of FA)
Prophylaxis: 1 tablet per day 6 months antenatal and 6 months postnatal
Therapeutic dose: 2 tablets per day

4. Risk Approach: to identify “high risk” cases as early as possible

- Elderly primi (30years and over)
- Short statured primi (140 cm and below)
- Malpresentations (breech, transverse lie)
- Antepartum haemorrhage, threatened abortion
- Pre-eclampsia and eclampsia
- Anaemia
- Twins, Hydramnios
- Previous still-birth, intrauterine death, manual removal of placenta
- Elderly grandmultiparas
- Prolonged pregnancy (14 days past EDD)
- H/o previous LSCS, instrumental delivery
- Pregnancy associated with other diseases, Cardiovascular, renal, DM, TB, HIV, RTI, STI, Malaria, convulsions,
asthma, liver disease
- Treatment for infertility
- 3 or more consecutive abortions

5. Warning signs of Pregnancy

- Swelling of the feet,Fits, Headache, blurring of vision, Bleeding or discharge from vagina

6. GDM Diagnosis
Single step test recommended by WHO for diagnosis of GDM using 75 g of glucose, through OGTT
irrespective of the last meal with a threshold value of 2-hour Blood sugar > 140 mg/dl

7. Immunisation in Pregnancy (previously TT, now Td)

2doses: 1st: at 16 – 20 weeks
2nd: at 20 – 24 weeks, with minimum interval of 1 month between 2 doses
If next pregnancy is within 3 years, one booster is enough

8. Essential Obstetric Care:

Early registration of pregnancy
Provision of minimum 3 antenatal visits
Institutional delivery
Skilled attendance at delivery
Provision of 3 postnatal check-ups to monitor postnatal recovery

9. Dietary Recommendations:
Additional Calorie requirements
Pregnancy 350 K Cal
Lactation 1st 6 months 600 K Cal
Next 6 months 520 K Cal
Normal weight gain: 6-10kg

10. First Referral unit

- 24 hours delivery services including normal and assisted deliveries,
 - Emergency obstetric care including surgical interventions like LSCS
- New-born care
- Emergency care of sick-new born
- Full range of family planning services including laparoscopic services
- Safe abortion services
- Treatment of STI/RTI
- Blood storage facility
- Essential laboratory services
- Referral services

Gravida: Total no. of pregnancies including the current pregnancy

Para: No. of pregnancies that have crossed the viability period (28 weeks)
Still birth: Death of a fetus weighing 1000g (equivalent to 28 weeks) at birth
Perinatal Death: Late fetal death (still-births) + Early neonatal deaths (birth to 7 days)

Maternal mortality ratio

= Total no. of female deaths due to complications of pregnancy, childbirth
or within 42days of delivery from puerperal causes in a area during a year x 100,000
______________________________________________________________________
Total no. of live births in the same area and year

Perinatal mortality rate

=Late fetal deaths (28 weeks gestation and more) + early neonatal deaths (birth to 7days) in a year x 1000
________________________________________________________________________________________
Live births + late fetal deaths in same year

Neonatal Mortality rate

= No. of deaths of children under 28 days of age in a year x 1000
___________________________________________________________
Total live births in a year

Infant Mortality Rate

= No. of deaths of children less than 1year of age in a year x 1000
___________________________________________________________
No. of live births in a year

PNC
1. Complications of Post-partum period
- Puerperal sepsis: infections of genital tract within 3 weeks of delivery
- Thrombophlebitis
- Secondary Haemorrhage: bleeding from vagina anytime after 6 hours after delivery to the end of
puerperium (6weeks)
- Urinary tract infection, Mastitis

2. Exclusive Breast feeding: Feeding of infants exclusively with Breast milk for first 6 months of life without any Pre-
lacteal or supplementary feeds.
Foremilk: thin, watery, proteins, lactose, High carbohydrate & Low fat
Hind-milk: High Fat & Low carbohydrate, released after 10-20 min of initiation of feeding

3. Postnatal visits: 3, 7, 14, 42 days

4. Low birth weight = 1.5 kg - 2.5 kg Very low birth weight <1.5 kg

5. Term 37 completed weeks; Preterm < 37 weeks; Post-term > 42 weeks of gestation

6. Small for date: Baby born at term or preterm and weighing less than the 10 th percentile for the gestational age

7. Kangaroo mother care:

KMC for LBW babies. Four components include skin to skin positioning of a baby on the mother’s chest;
adequate nutrition through breast feeding; ambulatory care as a result of earlier discharge from hospital; and
support for the mother and her family in caring for the baby.

8. Weaning: Gradual process starting around the age of 6 months, because the mother’s milk alone is not sufficient
to sustain growth beyond 6 months. It should be rich in protein and other nutrients. AKA Supplementary foods,
usually are cow’s milk, fruit juice, soft cooked rice, suji, dhal and vegetables.

Under 5
1.Growth chart monitoring:

Below -2SD in Chart Interpretation

Weight for age Underweight
Height/Length for age Stunting
Weight for Height Wasting
2.
Marasmus Kwashiorkar
Inadequate intake of both protein& energy Severe under nutrition; diets with low protein/energy ratio
Little or no edema Oedema+
Severe wasting Wasting+
Minimal subcutaneous fat Liver enlargement+
Non-Normal S.albumin Hypoalbuminemia, Steatosis
Depigmentation of skin & hair
3. Severe Acute Malnutrition
Very low weight-for-height/length (Z-scores below -3SD of the median WHO child growth standards), a mid-
upper arm circumference <115cm, or presence of nutritional oedema.

4. Mid Arm circumference interpretation:

MUAC Interpretation
>13.5cm Normal
12.5-13.5cm Mild-moderate malnutrition
<12.5cm Severe malnutrition

5. Assessment of Dehydration

Character No dehydration Some Dehydration Severe dehydration

GC Active, alert Restless, irritable Lethargic or unconscious
Thirst Drinks normally Thirsty, drinks eagerly Poor drinking
Eyes Normal Sunken Sunken
Skin pinch Goes back normally Goes back slowly Goes back very slowly

6. IMNCI
3 Components:
Improvement in case management skills of health staff by provision of locally adapted guidelines
Improvement in health system required for effective management of childhood illness
Improvement in family and community practices
Elements include:
Assessment of child
Classify child’s illness
Identify specific treatments for child
Provide practical treatment instructions
Counsel to solve any feeding problems
Give follow-up care
 Vaccine Due Age Max Age Dose Diluent Route Site
For Pregnant Women
Td-1 Early Pregnancy 0.5ml NO Intra-muscular Upper arm
Td-2 4weeks after TT-1 0.5ml NO Intra-muscular Upper arm
If received TT
doses in a
Td-Booster 0.5ml NO Intra-muscular Upper arm
Pregnancy within
last 3 years
For Infants
<1month:
Till 1 year of 0.05ml Sodium Upper arm -
BCG At birth Intra-dermal
age >1month: chloride LEFT
0.1ml
Antero-
lateral side of
Hepatitis B (Birth dose) At birth <24 hours 0.5ml NO Intra-muscular
mid- thigh –
LEFT
bOPV-0 At birth <first 15 days 2drops - Oral Oral
<5 years of
bOPV-1,2,3 6,10,14 weeks 2drops - Oral Oral
age
Pentavalent1,2,3 Antero-
(Diphtheria+Pertusis+ lateral side of
6,10,14 weeks 1 year of age 0.5ml NO Intra-muscular
Tetanus+HepatitisB+Hi mid- thigh –
b) LEFT
Fractional IPV
Upper arm-
(Inactivated Polio 6,14 weeks 1 year of age 0.1ml NO Intra-dermal
RIGHT
Vaccine)
Rotavirus* (Where
6,10,14 weeks 1 year of age 5drops Oral Oral
Applicable)
Pneumococcal Antero-
6 & 14 weeks
Conjugate Vaccine lateral side of
At 9 completed 1 year of age 0.5ml NO Intra-muscular
(PCV) (Where mid- thigh –
months Booster
applicable) RIGHT
At 9 completed
Measles/Rubella 1st Sub- Upper arm-
months – 12 5 years of age 0.5ml Sterile water
Dose Cutaneous RIGHT
months
Japanese Encephalitis-1 At 9 months – 12 15 years of Phosphate Sub- Upper arm-
0.5ml
(Where applicable) months age buffer solution Cutaneous LEFT
5years of age
Vitamin-A (1st dose) At 9 months 1ml - Oral Oral
(1lakh IU)
For Children
Antero-
lateral side of
DPT booster-1 16 – 24 months 7years of age 0.5ml NO Intra-muscular
mid- thigh –
LEFT
Measles/Rubella 2nd Sub- Upper arm-
16 – 24 months 5years of age 0.5ml Sterile water
dose Cutaneous RIGHT
bOPV Booster 16 – 24 months 5years 2drops NO Oral Oral
16 – 24 months (3
Japanese Encephalitis-2 Till 15years of Phosphate Sub- Upper arm-
months gap b/w 2 0.5ml
(Where applicable) age buffer solution Cutaneous LEFT
JE doses)
At 16months.
Vitamin A (2nd to 9th 2ml (2lakh
Then 1 dose every Up to 5years - Oral Oral
dose) IU)
6months
DPT Booster-2 5 – 6 years 7years 0.5ml NO Intra-muscular Upper arm
10 years & 16
Td 16years 0.5ml NO Intra-muscular Upper arm
years