M A N UA L

FOR
INTERNS ORIENTATION
PROGRAMME
ON
QUALITY CARE

NATIONAL TEACHER TRAINING CENTRE

(Department of Medical Education)
JAWAHARLAL INSTITUTE OF POSTGRADUATE
MEDICAL EDUCATION & RESEARCH,
PUDUCHERRY-605006
 CONTENTS
PREFACE

1. ETHICS IN MEDICINE....................................................... 3

2. DOCTOR-PATIENT COMMUNICATION

(A) ORAL COMMUNICATION................................. 5

i) Personality type of patients and ways of
dealing with them (Tactics)................................ 6
ii) Do's and Don'ts during doctor-patient dyad....... 8

(B) WRITTEN COMMUNICATION............................ 9

i) How to write a progress record............................ 10
ii) How to write doctor's orders................................ 11
iii) How to write a cross reference form.................... 11
iv) How to write a discharge summary...................... 12

3. RATIONAL MANAGEMENT

(A) Rational use of diagnostics..................................... 13

(B) Rational drug therapy.............................................. 18
(C) P-drug concept ....................................................... 21
(D) Choosing drugs in special situations....................... 23

4. HOW TO DEAL WITH MEDICAL REPRESENTATIVES...... 28

5. PRECAUTIONS TO BE TAKEN IN OPERATION

THEATRE FOR HIV / HEPATITIS-C CASES........................ 30

6. GUIDELINES FOR LABORATORY INVESTIGATIONS

(A) Pathology.............................................................. 32
(B) Microbiology......................................................... 35
(C) Biochemistry........................................................ 37
(D) Pharmacology...................................................... 48
(E) Radiotherapy........................................................ 50
(F) Physiology............................................................ 50
(G) Nuclear Medicine.................................................. 51
(H) Emergency Medical Services ................................ 53

7. LABORATORY REFERENCE RANGES

(A) Haematology......................................................... 54
(B) Microbiology.......................................................... 55

8. SPECIAL INVESTIGATIONS (Obst. & Gyn.)....................... 56

9. APPENDIX I ................................................................. 57

1
 PREFACE

It is the privilege of NTTC to bring out this manual in a handy

pocket-book format. This manual has a fairly long history since the
late 80's when it was brought out by the department of Pharmacolo-
gy covering various aspects of essential drugs and rational drug ther-
apy.

Over the years, other disciplines joined in orientating interns

on rational therapy. Since 1993, the whole programme was re-
designed and focussed on quality care concept. This included orien-
tation to communication skills (oral and written), rational use of diag-
nostic tests and therapies, essential and personal drug concepts and
critical appraisal of medical promotion. These are not the only com-
ponents of quality care though they are the most important.

The reduction in size has been made to create a "handy carry-

around manual". The faculty of the IOP will be satisfied if the interns
make the best use of this manual.

The support and encouragement given by the Director, the

Dean, the Medical Superintendent and all the Heads of Departments
of JIPMER are gratefully acknowledged.

Suggestions from all quarters on how to improve this manual is

welcome.

Head, Dept. of Medical Education

& Project Officer
National Teacher Training Centre
JIPMER, Pondicherry

2
 1. ETHICS IN MEDICINE

The edifice of Medicine stands on three pillars - Knowledge, Practice and Eth-
ics. The propriety and moral rightness of all the acts of a medical professional, be it a
matter of statistics, public health or individual care, constitute medical ethics. Ethics
deal with professional values, Morals deal with personal values and the Law deals
with societal values and mores.
One aspect of medical ethics is bedside manners and professional courtesy.
Another aspect deals with legal issues related to newer developments in medicine
like euthanasia, MTP, in-vitro fertilisation, etc. Yet another area is social justice and
equality in health care in the current milieu of free market forces. The important
areas can be classified as follows:

1.Death and dying 2. Doctor-patient relationship

3.Patient's rights 4. Informed consent
5.Professional conduct 6. Confidentiality
7.Birth control and MTP 8. Assisted reproduction
9.Organ transplantation 10. Gift and sponsorship
Though the issues may seem widely spread out and covering different areas,
the fundamental principles of Medical Ethics are only three:

1. Beneficence and Non-Maleficence

(Do good or at least do no harm - "primum non nocere")
2. Justice and Equality
(Consider all human beings equal in providing care, regardless of socio-
economic, literacy level, religion and other factors)
3. Patient Autonomy or Freedom of Choice
(Patient should be free to choose the type of health care - Physician should be
a guide, not a parent). Paternalism is the anti-thesis of this.

All the ethical issues could be reduced to one or more of these three princi-
ples. At times, two or more principles may operate and result in ethical dilemma.
Group decision making helps in resolving the dilemma and in reducing personal bias.

3
 PRECAUTIONS AGAINST MEDICAL NEGLIGENCE CLAIMS

Do’s Don'ts
1. Develop a good doctor- 1. Do not promise a cure or 100% safety
patient relationship and
maintain effective communi- 2. Do not base an important diagnosis
cation with the patient. on a clinical impression alone, if reli-
able diagnostic aids are available.
2. Secure a full and informed
However, use these aids judiciously.
consent for any invasive or
operative procedure and be-
3. Do not, in the absence of an emer-
fore starting any chemother-
gency, perform any additional opera-
apy drugs.
tive procedure not expressly author-
3. Advise an X-ray examination ized..
whenever a patient present
with a real or suspected bone 4. Do not do elective pelvic surgery
or joint injury. during child bearing age unless it is
4. Exercise care in selection of definitely established that the pa-
your assistants and delega- tient is not pregnant.
tion of duties to them.
5. Do not leave your patient unattended
5. Cover your risk by adequate during labour, during any procedure
insurance for medical negli- or in the immediate post-operative
gence claims period
6. Make a medico-legal case in
all suspicious circumstances. 6. Do not fail to advise immunization
and precautions to patients and their
attendants where indicated

7. Do not criticize another doctor.

4
 2. DOCTOR-PATIENT COMMUNICATION
(A) ORAL COMMUNICATION

Introduction

A common notion is that "communication is the process of transfer-

ring thoughts and ideas from one person to another." This implies that
communication is similar to pouring a liquid from A to B! Communication
is not so simple or straight forward.

Communication is the process of sharing thoughts, ideas and feel-

ings with each other in commonly understandable ways.

Communication is hardly ever 100% successful in the sharing pro-

cess. An effective communicator anticipates and plans for such deficien-
cies.

Coding of Ideas and Thoughts

Code Amount of meaning conveyed

Language (verbal, Written) 7%

Para-Language (tone, Pitch, accent, etc.) 38%

Non-verbal or Body-language (face and 55%

eye movements, other gestures, body (It explains how children are
space, dress and appearance, time, etc. able to communicate so well
despite poor literacy)

5
 (i) PERSONALITY TYPES OF PATIENTS AND TACTICS IN
HANDLING THEM
Personality type Tactics
Superior : 1. Acknowledge patients worth in his/her own
field of expertise.
Arrogant, snobbish; feels 2. Maintain adult to adult type of conversation
invulnerable and often denies and transaction.
that disease can harm; feels 3. Strongly affirm your own expertise especially
important about self. when challenged or accosted by the patient.
4. Avoid `Parent-Child' transactions.
Dramatising / Hysterical: 1. Be generous in reassurance, support and
compliments.
Dramatises symptoms; may 2. But at the same time discourage any emotional
deny or repress facts (or involvement.
diseases); filtrations and 1. Allow patient to discuss his/her fears freely.
seductive; has underlying 2. Help distinguish facts from fantasies.
insecurity and needs 3. Guard against any untoward response to
reassurance. filtrations or seductive appeal.
Impulsive: 1. Set firm limits - Do not permit undue
expectations.
Demands quick and easy 2. Hold the patient responsible for impulsive
solutions to problems; has low actions.
threshold for frustration; often 3. Avoid open confrontations as it may lead to
appears childish in outlook and unpleasantness and angry words.
aggressive in behaviour. 4. Avoid humour, jokes, etc.
Silent, reclusive: a. Respect need for privacy.
b. Be friendly and empathetic but do not expect
Shy, aloof, reticent and him/her to respond - it is against their
detached. character to do so.
c. Play `nurturing-parent' role and see if it
works.
Masochistic: a. Do not avoid them - it aggravates sickness
and suffering.
Long-suffering by own b. Avoid reinforcing the sick-role! Use humour.
admission; sees the present c. Set limits of care and responsibility or they
illness as one more episode of may end up dependent on you.
life-long occurrences of d. Support and guide family members who must
unpleasant events. deal with masochism all the time.
e. Maintain an adult to adult type transaction.
`Nurturing parent' role may worsen the illness
related behaviour.

6
 Personality type Tactics

Suspicious: a. Be friendly and open.

b. Maintain an adult to adult relationship
Paranoid about being harmed, in all transactions.
exploited or taken for a ride; c. Avoid humour and cryptic comments.
generally blames others for their d. Inform all options fully.
illness and other problems. e. Acknowledge the need for circumspec-
tion and critical analysis. But Be Firm in
Your Rebuttal and Reputation (based on
facts).
Dependent:
a. Show readiness and willingness to
Insatiable needs, overly depend- care for them.
ent on their doctors to solve all b. Interact in a direct and open way. Try
their problems, tax their doctors to avoid `parent-child' transactions as
to the point of creating genuine it aggravates dependency.
anger or frustration c. Set limits (time, availability, areas of
health care, etc.)
d. Avoid direct confrontation but turn
responsibility for their behaviour back
to them.
e. Persuade them to be more autono-
mous and independent.

Orderly, Controlling:
a. Inform methodically the nature of
Overriding need for control of illness; treatment options, etc.
their problems by them-selves; b. Include the patient in decision mak-
see their body parts and bodily ing.
functions as `objects' to be under c. Encourage patient's strengths to
their control. make them responsible for self-care.
d. Make them feel they are in control of
their illness or disability.
e. Clearly inform of events or functions
that cannot be controlled by volition.

7
(ii) DO's AND DON’Ts DURING DOCTOR-PATIENT DYAD

1. Avoid cynical talk. "Cynic is one who knows the cost of every-
thing but the value of nothing!"

2. Do not give misleadingly false hope; at the same time.

3. Do not give "hopeless" outlook - it may backfire at times or

cause a "hex-death" situation.

4. Anticipate problems and be one step ahead - after all you

know more than the patient about diseases!

5. Do not pass value judgement or create guilt complex.

6. Be aware of psycho-social pressures operating on the patient

and his or her relatives.

7. When indicated, lose temper judiciously and in the best inter-

est of your patients.

Attempted Persuasion
The factors influencing attempted per-
suasion by a doctor are: (1) Doctor’s credibility,
(2) Patient’s felt need, (3) Other’s opinion and
(4) Evidence and Logic. If all the four elements
are in mutual agreement, then persuasion is
likely to succeed.

8
 (B) WRITTEN COMMUNICATION
* Medical Records +

The importance of maintenance of medical records has been

acknowledged from ancient times. The physicians of ancient Greece, Egypt
and India have recorded in paintings and carvings the details of diseases and
remedies prevalent in their civilizations. In present day practice, the
significance of proper maintenance of records is well understood. The main
purposes of these records are that:

1. It forms a means of communication between the physician and other

members of the health care team.
2. It provides a basis for planning individual patient care.
3. It serves as a basis for evaluation of quality of patient care.
4 It assists in protecting the legal interests of the patient, hospital and
physician
5. It provides clinical data for medical education and research.

Good medical records generally reflect good medical care and vice
versa. The skills of medical and allied health care professionals are required
for comprehensive patient management. The team interact with each other
through their entries in the record. It is essential that the medical record
should contain necessary information to identify the patient, to establish the
diagnosis and to give details of the treatment and progress of the patient. This
holds good for both out-patient and in-patient records.
The In-patient Record begins with the admission of the patient. The
Admission Record contains details of the patient's complaints, medical history,
physical examination details and plan of treatment.
The In-patient Case Sheet contains the following:
1. Progress Notes
2. Doctor's Orders
3. Reports of Investigations
4. Consent Forms
5. Special Forms, e.g., Labour record, operation notes,
cross reference forms
6. Discharge Summary

9
 (i) HOW TO WRITE A PROGRESS RECORD

1. When you write a progress sheet, always think of what information

can be gathered from your records by some other doctor. Imagine
what information you can get after six months or one year from
your records. In writing a record you must be accurate, brief and
clear.
2. Always mention the date and time of your progress report, and sign
legibly underneath. This is important because in case of later
enquiry or investigation, the identity of the treating doctor is to be
established. This is especially true in medico-legal cases.
3. Irrespective of whatever notes you have written earlier in Casualty
or out-patients, always start the progress report as if it were a new
case.
4. When a patient gets admitted to the ward, write a brief note about
the case. If it is a diagnostic problem, mention the prominent
clinical findings and say what the problem is.
5. If it is a known case admitted for a therapeutic procedure, mention
what therapeutic procedure you are going to perform and why you
are doing it now.
6. In case of emergency admission, mention what the emergency is,
what has been done till now and what you are going to do.
7. If you are planning an emergency operation, mention specifically
the indication and justification for the operation.
8. In all cases, it is better to write a plan of investigations and manage-
ment which can be suitably modified by your seniors.
9. If you have consulted a senior person, mention his name and
designation and time of consultation.
10. On subsequent days, make a mention of whatever change has
occurred in the patient's conditions. If there is no change, say so.
Don't write, "G.C. Fair temperature N" ad nauseum. Parameters for
daily monitoring have to be individualised, e.g., BP in a hypertensive
and wheezes in an asthmatic.
11. If patient has undergone some investigations or operative
procedure, mention this in your progress record. You must also
indicate whether this has changed the diagnosis and general
conditions of the patient.
12. When the patient gets discharge, you must mention his condition at
the time of discharge and also your recommendations and when
you want him to come back.

10
 (ii) HOW TO WRITE DOCTOR'S ORDERS

The written medical orders constitute the physician's directions to the Nursing
and other staff covering all medications and other treatment given to the pa-
tient.

1. All orders must be signed by the attending doctor.

2. When repeating the orders, each item should be repeated separately

and no terms like "repeat all" should be used.

3. When starting a fresh sheet, all the orders should be repeated fully and
not as repeat (1), (2), (3), etc.

iii) HOW TO WRITE A CROSS REFERENCE FORM

Cross Referenc Form is sent in order to get:
(a) assistance in diagnosis or therapy
(b) a specific procedure
(c) a second opinion
1. Make sure that the identification and characteristics of the patient,
viz., name, hospital number, age, ward and bed number are properly
written.
2. Mention the referring unit and the unit to which the reference is being
made.
3. Classify carefully whether the reference is of routine nature or of ur-
gent nature. Do not make a reference urgent because the routine
reference was forgotten.
4. Precisely and briefly mention the findings in the patient in the appro-
priate column.
5. Try to be as precise as possible in communicating what is your expec-
tation from the referred unit. Do not be ambiguous.
6. Sign legibly and write your designation.
7. Remember you are referring to a Unit Head on behalf of your Unit
Head.
8. Do not suggest any treatment. For example:
1. Not "Please extract the tooth", but "Please attend to this patient's
dental problem.
2. Not "Do lymph node biopsy", but "For favour of tissue diagnosis".
9. Always mention the date and time of reference.

11
 (iv) HOW TO WRITE A DISCHARGE SUMMARY

A Discharge Summary (or Clinical Resume) is required for:

(a) Continuity of medical care to the patient on a subsequent re-

admission, or for treatment at another hospital.

(b) To facilitate review by medical staff regarding patient care and for
office records.

The Discharge Summary should be concise and written promptly after the
patient's discharge. It should contain information about:

1. Why did the patient enter hospital? - chief complaint and history of
present illness.

2. What were the physical findings and laboratory findings?

3. What was the medical and/or surgical treatment including patient's

response, complications and consultations.

4. What was the patient's condition on discharge?

5. What instructions were given regarding continuing care and follow up ?

medication, diet, physical activity and date of next appointment.

6. Always give an outside prescription for all the medications that the
patient needs to take in case he/she is not able to keep his/her
next appointment.

Discharge Summary, even if written by a resident staff, is best counter-

signed by the attending Physician. The summary carries the "image" of the
unit and the hospital.

12
 3. RATIONAL MANAGEMENT
(A) RATIONAL USE OF DIAGNOSTICS

Using WHO definition of irrational drug therapy as the basis, irrational use
of diagnostics may be defined thus: "a diagnostic test is irrationally used when
the expected benefit is negligible or nil or when it is not worth the potential harm
or the cost."
It is indeed strange that while so much has been written about irrational
drug usage, not enough attention has been focused on irrational use of diagnos-
tics. If one realises that an irrational CT-Scan is equivalent to about 100 bottles of
an irrational `tonic', then the importance of rational use of diagnostics will be
apparent.
Due to the practice of `defensive medicine', excessive use of diagnostics
has become the norm rather than the exception. This has lead to expensive, irra-
tional and wasteful hi-tech medical practice. Unless curbed, individual and na-
tional economies may face hardships as is evident in USA in the 90's.

WHY INVESTIGATE - AN INTROSPECTION

Before requesting an investigation, the clinician should ask himself/herself

the following queries:

1) Will the test result help me to -

a) confirm/establish diagnosis, b) rule out a diagnosis,
c) monitor therapy, d) estimate prognosis, or
e) screen for and detect a disease?

2) Can the abnormality I seek in this case -

a) exist without any clinical evidence of it?
b) even if present, be in any way harmful to the patient?
c) be treated or controlled? and
d) be worth the cost and the risk for this patient?
e) Is there no safer and more economical alternative?

If , after careful thought, the answer to all these questions is a clear `No',
then there is no need to do the test. If the answer to any one of them is `Yes',
the test may need to be performed depending on its availability, predictive values
and patient's affordability.

13
 COMMON PITFALLS
(`Why Not Investigate' Syndrome)

A prudent clinician should be wary of the following state-

ments which promote irrational use of investigations:

1. "It would be nice to know"

Ask yourself `nice for whom?' - will it really help the
patient or is it merely to satisfy your academic curiosi-
ty?
2. "We would like to document it fully" - Will this extra
documentation make any difference to the patient?
3. "Everyone else does it" - They all may be right, but
are you aware of the reasons? Perhaps, they too do it
because `every one does it'! Medical practice is full of
examples of transient fashions that do not stand the
test of Time. Do not accept and adopt such `medical
fashions' uncritically.

HOW OFTEN SHOULD I INVESTIGATE?

This depends on the following factors:

1. How quickly are measurable and significant changes likely to occur? For
example, plasma protein does not change in less than a week unless infused.
2. Whether a change, even if numerically significant, will alter management?
For example, serum transaminase levels change rapidly during acute hepati-
tis. But once the diagnosis is made, this change is unlikely to affect manage-
ment.

WHEN IS AN INVESTIGATION ‘URGENT’

The only justification for urgency is when an earlier result will alter
management. This situation is very rare.

14
 WHAT TO DO WITH THE LABORATORY REPORT?

1. When it is consistent with the clinical situation, follow up the case with
treatment.

2. When it is (a) unexpected or (b) incompatible, as in the examples given

below, repeat the test to rule out a mix up. For example:

(a) Cervix apparently looks healthy but cytology report is positive for malig-
nant cells.

(b) Previous cervical smear done two weeks ago was negative, But the pre-
sent smear is positive for invasive carcinoma.

In any case, record the report with reference number and date in the case sheet
and case summary with a note on the uncertainty.

HOW TO GET THE MAXIMUM OUT OF THE

LABORATORY SERVICES ?

1. Order for the minimum number of tests warranted by the clinical situation.

2. Await the results of preliminary screening tests before ordering a complete

list. For example:

A. Check the reticulocyte count before ordering for a full work up on haemo-
lytic anaemia.

B Check the peripheral smear report in cases of hepatosplenomegaly before

ordering a bone marrow aspiration or a liver biopsy.

3. For special tests, make sure that the concerned department/ section has
been informed and kept ready. For example: Frozen section, Immuno-
fluorescence study for renal or skin biopsy, Coagulation studies, etc.

15
 CHECK THE FOLLOWING BEFORE DESPATCHING
A LABORATORY REQUISITION

1. Have you checked whether the test you are ordering now has not
been done already? (Report may have been misplaced or may be on
the way).

2. Have you used the correct form? Have you entered the patient ID
correctly?

3. Have you specified the nature of test required?

4. Have you indicated the urgency (if needed)?

5. Have you provided the relevant clinical details/X-ray findings and cross
reference (Example: Previous biopsy number, peripheral blood pic-
ture)?

6. Have you used the correct container, sample, anti-coagulant?

7. Does the ID label on the container match the patient ID?

8. Have you made a note in the case record after ordering?

HOW TO GET REPORTS FROM THE LABORATORY IN URGENT CASES ?

1. Contact the section concerned on phone or appraise directly the

officer concerned on the nature of emergency such as blood transfu-
sion or frozen section.

2. Personally ensure the despatch of the correct sample and quantity in

the recommended containers to the correct section of the laboratory.
Confirm the receipt of the sample in the laboratory and find out when
the report would be ready.

16
 FACTORS WHICH MAY CAUSE DELAY IN
PROCESSING URGENT REPORTS
a. Overload of work.
b. Over-utilisation of the label `urgent’ leading to a disregard for
the label - the “cry wolf syndrome”.
c. Frequent interruption of routine work.

FACTORS RESPONSIBLE FOR NON-RECEIPT OF

LABORATORY REPORTS

1. Wrong entry or non-entry of patient ID.

2. Sample is kept pending in the laboratory for want of:

a) Essential data like name, hospital number, ward.
b) mention on the nature of test ordered.
c) reagents not available in the laboratory.
d) batch processing of kit based tests.

3. The specimen reaching the wrong laboratory or not reaching

there at all.

OTHER REASONS FOR A DELAYED REPORT

FROM THE LABORATORY

1. Lack of relevant details on the requisition which have a bearing

on this investigation.

Example:
Cytohormonal study, histopathology of bone marrow and lymph
node, histopathology of bone tumours, renal and
dermatopathology.

2. Time consumed (few days) in doing certain special staining

procedures and in decalcifying bone.

17
 (B) RATIONAL DRUG THERAPY

REASONS FOR IRRATIONAL PRESCRIBING

1. Lack of training in clinical pharmacology and in basic principles

underlying rational drug use.
2. Lack of continuing education, supervision and critical review of
prescribing practices.
3. Promotional activities by pharmaceutical companies.
4. Desire for prestige.
5. Too many patients.
6. Uncertain diagnosis.
7. Reliance on their own limited favourable experience with a drug
regardless of scientific merit.

TYPES OF IRRATIONAL PRESCRIBING

Irrational drug prescribing can occur when the medication prescribed

is incorrect, inappropriate, excessive, unnecessary or inadequate
(WHO Draft, 1985). Accordingly, the types of Irrational Prescribing
are:

1. Incorrect prescribing
2. Inappropriate prescribing
3. Over prescribing
4. Multiple prescribing
5. Under prescribing

18
 INCORRECT PRESCRIBING

It can result when the wrong medication is prescribed for the patient,
e.g., an erroneous diagnosis or inadequate knowledge of the drug.

It can also happen when clinical laboratories or other diagnostic facilities

are limited or the patient's history is inadequate.

Ignorance of drug's actual therapeutic indications or the availability of

alternatives that are clearly safer and/or more effective, e.g., selection of
a newer non-steroid anti-inflammatory drug or a glucocorticoid rather
than aspirin for the treatment of rheumatoid arthritis exposes the pa-
tient to more expensive medication and may lead to severe side effects.

INAPPROPRIATE PRESCRIBING
This results when:
1. The most appropriate medication is not selected, e.g., an expensive
unusual or rarely stocked drug is prescribed in preference to a less
expensive or readily available drug.
2. Prescribing a drug that cannot readily or safely be
administered such as IV preparation of amphotericin B.

OVER-PRESCRIBING
Over prescribing includes prescription of a drug that is not needed.
A drug given in excessive dose or for too long period of time often
in an attempt to reduce the frequency of patient's visits.

19
 MULTIPLE PRESCRIBING

It is the use of:

1. An unnecessary number of drugs when fewer drugs will produce an

equivalent beneficial effect, e.g., prescribing two or more drugs or a
multi-drug combination products when only one or two drugs are
needed.

2. A drug to counteract adverse effects produced by the primary drug

when selection of an alternative primary drug can reduce or elimi-
nate such side effects, e.g., ampicillin produces diarrhoea for which
anti-diarrhoeals are used.

UNDER-PRESCRIBING

1. Giving inadequate amounts of medication or failure to prescribe a

needed drug, e.g., withholding medications like morphine in termi-
nally ill patients because of an unreasonable fear of producing opi-
oid dependence.

2. Prescribing inadequate drug dosage or using medication for an in-

sufficient period of time to treat the patient, e.g., sub-therapeutic
doses of antibiotics promote the development of bacterial re-
sistance.

Under prescribing is often employed in an attempt to conserve medica-

tion for very sick patients or using lower doses to treat more people.

20
 WHAT DO WE NEED TO KNOW FOR
RATIONAL PRESCRIBING

1. Basic pharmacology of a drug.

2. Indications for this drug's use.
3. Contra-indications to this drug's use.
4. Side effects of this drug.
5. Drug interactions.
6. Cost to the patient and community.
7. Dosage schedule.
8. What is the quality of the evidence provided about the risk/ benefit ratio of
this new drug compared to existing therapy?
9. What conclusions have independent experts reached about the role of this

(C) P-DRUG CONCEPT

Introduction to P-drugs
P-drugs are `Personal' drugs you have chosen to prescribe regularly, and with
which you have become familiar. They are your priority choice for given indications.
The P-drug concept is more than just the name of a pharmacological substance, it also
includes the dosage form, dosage schedule and duration of treatment. P-drugs will
differ from country to country, and between doctors. As you use your P-drugs regular-
ly, you will get to know their effects and side effects thoroughly, with obvious benefits
to the patient.
In general, the list of drugs registered for use in the country and the national
list of essential drugs contain many more drugs than you are likely to use regularly.
Most doctors use only 40-60 drugs routinely. It is, therefore, useful to make your own
selection from these lists, and to make this selection in a rational way. In fact, in doing
so, you are preparing your own essential drugs list. You should compile your own list
of P-drugs instead of just copying it from clinical teachers, or from existing national or
local treatment guidelines or formularies.

WHY SHOULD YOU COMPILE YOUR OWN LIST OF P-DRUGS?

1. You have final responsibility for your patient's well-being and you cannot pass this
on to others. While you can and should draw on expert opinion and consensus
guidelines, you should always think for yourself.
2. You will learn how to handle pharmacological concepts and data.
3. You will know the alternatives when your P-drug choice cannot be used.
4. You will regularly receive information on new drugs, new side effects, new indica-
tions, etc. However, the latest and the most expensive drug is not necessarily the
best, the safest or the most cost-effective.

21
 STEPS IN CHOOSING A P-DRUG
1. Define the diagnosis.
2. Specify the therapeutic objective.
3. Make an inventory of effective groups of drugs.
4. Choose an effective group according to criteria:
a) The pharmacological action of this group needs further comparison. During
this process, three other criteria should be used: safety, suitability and cost of
treatment.
b) Efficacy is not based on pharmaco-dynamics alone. The therapeutic objective
is that the drug should work as soon as possible. Pharmaco-kinetics are there-
fore important as well.
c) Safety: All drug groups have side effects, most of which are a direct conse-
quence of the working mechanism of the drug.
d) Suitability: This is usually linked to an individual patient and so not considered
when you make your list of P-drugs. However, you need to keep some practi-
cal aspects in mind.
e) Cost of treatment: Prices differ between countries, and are more linked to
individual drug products than to drug groups.
5. Choose a P-drug:
a) Choose an active substance and a dosage form.
b) Choose a standard dosage schedule.
c) Choose a standard duration of the treatment.

Summary

HOW TO SELECT A P-DRUG

1. Define the diagnosis (patho-physiology)
2. Specify the therapeutic objective
3. Make an inventory of effective groups
4. Choose a group according to criteria
Efficacy Safety Suitability Cost
Group 1
Group 2
Group 3
5. Choose a P-drug
Efficacy Safety Suitability Cost
Drug 1
Drug 2
Drug 3
Conclusion:
Active substance, dosage form :
Standard dosage schedule :
Standard duration :

22
 (D) CHOOSING DRUGS IN SPECIAL SITUATIONS

Drugs with Possible Risk of Haemolysis

In Some G6PD-deficient Subjects

Dapsone and other sulphones (higher doses for dermatitis herpetiformis more
likely to cause problems)
Methylene blue
Niridazole
Nitrofurantoin
Pamaquin
Primaquine (30 mg weekly for 8 weeks has been found to be without undue
harmful effects in Afro and Asian people)
4-Quinolones (including ciprofloxacin and nalidixic acid)
Sulphonamides (including co-trimoxazole; some sulphonamides, e.g., sulphadia-
zine, have been tested and found not to be haemolytic in many
G6PD-deficient subjects)

Drugs with Possible Risk of Haemolysis

In Some G6PD-deficient Subjects
Aspirin (acceptable in a dose of at least 1 g daily in most G6PD-deficient subjects
Chloroquine (acceptable in acute malaria)
Menadione, water-soluble derivatives (e.g., menadiol sodium phosphate)
Probenecid
Quinidine (acceptable in acute malaria)
Quinine (acceptable in acute malaria)

Note: Mothballs may contain naphthalene which also causes haemolysis in subjects
with G6PD-deficiency.

DRUGS IN PREGNANCY OR LACTATION

General Rules for Drug Use in Pregnancy or Lactation

1. Avoid any drug as far as possible.

2. If life saving, use the drug.
3. Drugs in general are excreted in small amounts in breast milk.
4. Consider “Risk” Versus “Benefit”
5. Confirmed teratogens increase the natural risk of 3% by 1-2% or at the most
the risk doubles or triples.
6. Some untreated diseases pose a more serious risk to mother and foetus than
drugs used in their treatment

23
 Drugs that may be commonly used
Drugs that may be commonly used
1. Analgesics:
Aspirin –?- First trimester abortion
Paracetamol – Safe
Brufen, Indomethacin – Reversible effects
Morphine, Codeine, Pethidine - Non-Teratogenic

2. Anaesthetics:
Thiopentone, N2O, Ketamine, Halothane,
Scoline, Curare, Xylocaine - Non Teratogenic

3. Antiemetics:
Doxylamine, Pyridoxine, Meclizine,
Promethazine, Prochlorperazine, - Non Teratogenic
Chlorpromazine, Metoclopramide

4. Antihypertensives:
Alphamethyldopa, Hydralazine, Beta Blockers, Calcium Blockers,
Clonidine, Nitroprusside

5. Diuretics:
Hydrochlorthiazide, Furosemide, Spironolactone

6. Antimicrobials:
Penicillins, Macrolides, Cephalosporins, Nitrofurantoin, Spiramycin

7. Anti T B:
Rifampicin,, INH, Ethambutol

8. Antifungal:
Clotrimazole, Nystatin, Miconazole

9. Antivirals:
Acyclovir, Reverse Transcriptase Inhibitors, Protease Inhibitors,
Interferons

10. Antiparasitic Agents:

Metronidazole, Antimalarials, Mebendazole, Pyrantel Pamoate,
Thiabendazole

11. Antiasthmatics:
24
 Adrenaline, Terbutaline, Aminophylline, Cromolyn, Steroids

12. Cardiac drugs:

Digoxin, Quinidine

13. Hormones:
Oral contraceptives

Hospital policy on the number of days for which drugs can be prescribed for:
1. Non-clinic OPD patient: FOUR days ; Antibiotics – FIVE days
2. Clinic OPD patient : SEVEN days
3. Hospital discharged patient: FOUR days
4. EMS patient: ONE day
5. TB patient: THIRTY days (with signature of consultant)
6. Insulin: ONE month
7. Analgesics, antihistaminics – upto TEN doses
8. Antiepileptic drugs for paediatric patients – ONE MONTH
Working hours of hospital pharmacy:
Monday to Friday: 9.00 A.M. to 6 P.M.
Saturday: 9 A.M. to 4 P.M.
Sunday: 9 A.M. to 12 noon.
If any drug is needed urgently at night - Pharmacist is on call.

While prescribing for OPD patients:

1. Do not prescribe double dose unless essential
2. Do not use abbreviations for the names of drugs
3. If there is a stamp – strike out the drugs, which are not to be dispensed, indi-
cate duration of treatment, dose
4. Check the dose – especially for children
5. Minimize prescribing for hospital staff by proxy
6. Check the list of drugs available in the OPD (displayed outside the pharmacy)
7. Record the prescription in the case sheet
8. Limit the number of drugs per prescription
9. Write down the dosage form, name of drug, dose and the number of days for
which the drug has to be taken legibly
10. Write the name and hospital number of the patient on the prescription slip.
11. Sign your name clearly

25
 LIST OF DRUGS AVAILABLE FOR OPD PATIENTS

Acetazolamide 250 mg Frusemide 40mg

Aminophylline IP100 mg Glibenclamide 5 mg
Amitriptyline IP 25mg Griseofulvin 250mg (skin OPD)
Amlodipine besylate 5mg Haloperidol 5mg
Aspirin 300mg Isoniazid 100/300 mg
Atenolol 25 mg Isosorbide dinitrate 10mg
Beclomethasone Rotacaps200mg Isosorbide Mononitrate 10 mg
B. Complex Lithium carbonate 300mg
Benzhexol 2 mg Mebendazole 100mg
Bisacodyl 10 mg Medroxyprogesterone acetate 10 mg
Calcium with Vit.D Metoclopramide 10 mg
Ciproflaxacin 500 mg Metronidazole 200 mg
Clotrimazole (vaginal) Omeprazole 20 mg
Carbamazepine 200mg Paracetamol 500 mg
Carbimazole 5 mg Penicillamine 250 mg
Chloroquine 150 mg Phenobarbitone 60 mg
Chloramphenicol Eye applicaps Phenoxymethyl Penicillin 125mg/250mg
Chlorpromazine 100/200mg Phenytoin sodium 100mg
Chlorpheniramine maleate 4mg Prednisolone 5 mg
Clofazimine100mg (Skin OPD) Primaquine Phosphate 7.5 mg
Clonazepam 0.5mg Propranolol 40 mg
Co-trimoxazole SS/DS Pyrazinamide 500mg
Dapsone 100mg (Skin OPD) Pyridostigimine 60mg
Deriphylline Retard 300 mg Pyridoxine 10mg
Dexamethasone 0.5mg (Skin OPD) Rifampicin 150mg/ 300mg
Diclofenac Sodium 50mg Risperidone 2mg
Dicyclomine 20 mg Salbutamol 4mg
Diethylcarbamazine 100mg/50mg Salbutamol Rotacaps 200 mg
Digoxin 0.25mg Spiranolactone 25 mg
Doxycycline 100mg Thyroxine sod.0.1mg
Enalapril 5 mg Vitamin A 50,000IU
Ethambutol 800 mg INH 300mg+Rifampicin 450mg
Famotidine 20 mg Sodium valproate 200 mg
Ferrous sulphate 200mg Triamterene 50mg+Benzthiazide 25mg
Folic Acid 5 mg Vitamic C 100 mg
Fluoxetine 20mg

PAEDIATRIC FORMULATIONS
Oral Rehydration Powder Promethazine Syrup 5mg/5ml
Paracetamol syrup 125mg/5ml Multimineral Soln. for PICU patients
Amoxycillin Trihydrate Dt 125 mg
Co-trimoxazole suspension 40+200mg/5ml

26
 PREPARATION ROOM ITEMS

Acetic acid 2% ear drops I.G.paint \

Acriflavine lotion 1000/10000 Joulie’s Solution
Acriflavine glycerin Lugol’s solution
Aluminium acetate 1% Lint.Turpentine
Benzyl benzoate emulsion Linctus codeine
Boric acid ear drops Listerine Mouth wash
Boroglycerine Mandl’s throat paint
Calamine lotion Oral Glycerol
Cough syrup Oint. Salicylic acid 3.3%
Condy’s lotion Oint. Salicylic acid 10%
Ephedrine Nasal drops 0.5% / 1% Oint. Salicylic acid 20%
Eusol Oint. Salicylic acid 40%
25% Glucose glycerin nasal drops Oint. Sulphur
15% Glycerin eye drops Oint. Vaseline
Glycerine Mag. Sulph Oint. Whitfield
Glycerine tannic acid Piles Injection
G.V. Paint Salicylic Ointment
Homotropine eye drops Shohl’s Solution
Hypertonic saline Spirit salicylic ear drops 2%
Hypo Solution Silver nitrate 1%
Ichthammol Glycerine Sodium bicarbonate eardrops
Sulphur calamine lotion
Zinc cream

INJECTIONS AVAILABLE FOR OPD PATIENTS

Adrenaline
Ampicillin Gentamicin
Aminophylline Insulin lente & plain
Atropine sulphate Metoclopramide
Chlorpheniramine maleate Paracetamol
Deriphylline Ranitidine
Dexamethasone Tetanus Toxoid
Diazepam Vit.K3
Diclofenac Sodium Promethazine HCl
Frusemide Streptomycin
Xylocaine 2%

27
 HOW TO DEAL WITH MEDICAL
REPRESENTATIVES
Some doctors exercise their right not to see drug representatives at all.
If you do choose to see a medical representative:

1. See him only by appointment.

2. Be clear regarding the time you have available.

3. Take control at the beginning of the meeting.

4. Ask what products he is detailing and discuss only those that interest
you.

5. Don't be afraid to interrupt.

6. Ask what is the role of his drug in relation to currently accepted ther-
apy (e.g., peer-consensus guideline recommendations).

7. Specifically ask about contra-indications, adverse effects and costs

(use MIMS, etc., as a check).

8. Request independent published evidence ( review articles, editorials,

etc).

9. Evaluate the evidence critically (see "CRAP Detection").

10. Take time to summarise the prescribing information you have learnt.

11. Decline the offer to evaluate the product on a few patients using sam-
ple packs or promotional research.

12. Before accepting hospitality, gifts and gimmicks remember there is no

such thing as a free lunch in the business world, only the expectation
that you will provide a favour in return. It is our patients who pay.

13. If you are in a teaching or group practice, request permission to rec-

ord some interviews for subsequent group evaluation ( after all drug
reps record information about you).
14. Be familiar with the codes of conduct and if the promotion seems
questionable refer it to the Medical Lobby for Appropriate Marketing
(MaLAM).

28
 CRAP DETECTION

Crap detection refers to applying your critical mental fac-

ulties to detect logical fallacies and other tricks used during
medical promotion.

1. Absolute Risk versus Relative Risk

2. Absolute Cost versus Relative Cost

3. Efficacy versus Potency

4. Surrogate versus Real end point in treatment

5. Cause and Effect Fallacy (Causal or Casual?)

6. Wrong or Unequal Comparisons (Clinical equipoise)

7. Unwarranted extrapolation with mischievous intent leading

to mistaken belief s

8. Bypassing rational queries by smoothing, ignoring, denying

or telling half truths.

To learn more about these, discuss with your seniors during In-
ternship.

29
 5. PRECAUTIONS TO BE TAKEN IN OPERATION
THEATRE FOR HIV/HEPATITIS-B/HEPATITIS-C CASES

1. Such patients should be taken up last for operation, on the day of the operation.
2. If possible, he/she should be operated in isolated operating theatre, which can be
easily cleaned at the end of the operation without disturbing the routine operation of
the next day.
3. Minimum necessary staff should remain in the operation theatre while the operation is
being carried out.
4. Nobody should be allowed to move out of the operation theatre till the operation is
over, and soiled linen and plastic covers, etc., are discarded inside the same operation
theatre.
5. All the staff must wear gloves while handling such patients.
6. Special precautions for `HIV' positive case is to wear plastic caps, water resistant
aprons, leggings and goggles.
7. As far as possible, disposable equipments and instruments should be used.
8. All unnecessary equipments must be cleared from the operating room prior to use.
9. Operating table to be covered with a single sheet of polythene which is to be
incinerated at the end of surgery.
10. Used disposable items must be burnt without washing.
11. All soiled linen must be dipped in Hydrochloride solution overnight and then packed in
a plastic bag and sent to Laundry for autoclaving. Instruments should be dipped in
Cidex followed by autoclaving before they are washed.
12. Blood specimens must be handled very carefully and must be packed and labelled
`Infection Risk'
13. Staff who have `open wound' must not enter the operation theatre.
14. Staff working in the theatre must take all precautions to avoid open injury to
themselves.
15. No touch technique to be employed as far as possible.
16. If blood of the patient comes in contact with the body of the staff, it should be gently
rinsed with water immediately.
17. Use of scissors or diathermy to cut in preference to knife.
18. No hand-held needle to be used. All needles must be held in needle holders.
19. Sharp instruments should not be handed over from nurses to surgeons and vice versa,
but must be kept in a bowl.
20. Patients should not be taken to post operative ward, but from OT directly to his/her
bed.
21. Skin to be closed as far as possible by clips and not sutures.
22. All staff exposed to risk due to a breach in technique must be given AZT, if possible.
23. HIV infection is transmitted by blood and blood products; HIV infection can spread by
direct entry of virus by infected needles. Contaminated articles, e.g., linen, should be
placed directly into a puncture resistant disposable container and labelled `Infection
Risk'.
24. There is no need for fumigation of OT for HIV and HBV/HCV +ve cases. However, a
thorough washing by soap is adequate.

30
 POST EXPOSURE PROPHYLAXIS FOR HIV
(PEP-HIV)

Risk of HIV transmission in the health care setting is quite low and is estimated to
be 0.3% for needle stick injury and 0.09% for mucous membrane exposure.

Risk for HIV transmission depends on (a) gravity of the accident (depth, inocula-
tion of blood/body fluids, quality of needle-hollow bore/surgical, and (b) infection
status of the source patient (viral load).

Transmission is likely to occur only on exposure to the following:

Blood, CSF, Peritoneal fluid, pericardial fluid, synovial fluid, amniotic fluid,
saliva in association with dentistry, unfixed organ or tissues.
Vaginal secretions, semen.
What to do after exposure?
DO NOT PANIC
Wash the would/site in contact with body fluids with soap and water.

Mucous membranes should be flushed with water.

Use of antiseptics or expressing fluid by squeezing is NOT recommended.

Chemotherapy for PEP reduces the risk of transmission by nearly 80% if started
with 2 hours. PEP not effective after 48 hours.

PEP drugs are stocked in the Medical Intensive Care Unit (MICU) and accessible
round the clock

Consult medical specialists for counselling regarding PEP.

HIV infection is NOT transmitted by:

Blood falling on the skin, by coughing and sneezing, through sweat, tears
or insect bites, by air or by living or working with patients suffering from
HIV infection and through food, urine and faeces.

31
 6. GUIDELINES FOR LABORATORY INVESTIGATIONS

(A) PATHOLOGY
TIME SCHEDULE FOR RECEIVING SAMPLES FOR INVESTIGATIONS:

 Working hours: Monday to Friday: 9:00 am to 4:30 pm *lunch break 1:00 to 2:00
pm.+
 OPD lab specimen collection: 8:30 am to 12:00 pm
 Haematology, Cytology, Histopathology specimen reception: 9:00 am to 12:00 noon
 Emergency samples: 24 hrs X 7 days *duty resident to be informed+

COLLECTION OF SAMPLES FOR

HAEMATOLOGICAL EXAMINATION

General instructions:
 All requisition forms must be properly filled and signed.
 Ensure proper labelling of samples.
 Send the samples to the lab as early as possible. If any delay, refrigerate the
sample at 4-10 deg.C. Do not freeze.
 Samples for peripheral smear should not be collected from I.V lines.
 While collecting blood ensure free flow of blood. Do not eject the blood
from the syringe through the needle. This will cause hemolysis and make the
sample useless.
 Ambulant patients may be sent to the respective labs.

Investigation Sample Required Instructions

COMPLETE 2 ml venous blood in EDTA Requisition forms to be
HAEMOGRAM: vial. signed by the haemat.
Tests include Hb, RBC, Resident/ consultant.
WBC, Platelet, DLC, RBC EDTA
indices, PCV, P/S. vials, *lavender capped
non-vacuum tubes for
routine & ’E’ labeled
vials for
emergency duty+ to be
collected from the lab
only.

32
Reticulocyte count, AEC, “ “
ESR
LE cell test 5 ml clotted blood “
COAGULATION Ambulatory patients may be Requisition forms to
PROFILE: sent to the lab. be signed by the
Tests include BT, CT, PT, Otherwise sample to be col- consultant and date
APTT, TT, Mixing studies, lected in citrated tube. *0.5 ml to the fixed. For BT
Factor assay, Fibrinogen citrate + 4.5 ml blood+ patient has to be
estimation, Clot retraction sent to the lab. FDP
test, Platelet aggregation sample should al-
tests, d-dimmer test, para- ways be accompa-
coagulation test for FDP. nied with a haemo-
gram sample and a
control sample

HAEMOLYTIC ANEMIA 5 ml heparinised sample for Requisition forms to

STUDIES G6PD and OFT. 8 ml EDTA sam- be signed by the
Tests include OFT, ple for Hb consultant and sate
Alkali denaturation test for electophoresis, alkali to be fixed. Sample
Hb F, Kleihaur’s test for denaturation test. Fresh finger collection vials to be
Hbf, Haemoglobin electro- prick sample for sickling test. collected from the
phoresis, Hams test, Sick- Ambulatory patients may be lab only. Gentle
ling tes, G6PD deficiency sent to the lab. mixing of the sam-
test, ple with anticoagu-
Autohaemolysis test, Su- lant avoids haemol-
crose lysis test. ysis. Kindly do not
send the patient to
fix dates. Come per-
sonally to the lab.
Ensure baseline
investigations are
done prior to fixing
a date.
BONE MARROW Usually done in bed-side. A Requisition form to
ASPIRATION AND technician from the be signed by the
BIOPSY: laboratory usually attends to consultant and date
the procedure. to be fixed. Kindly
ensure baseline
investigations are
done prior to fixing
a date.

33
33
EMERGENCY HAEMATOLOGY SAMPLES

The hematology laboratory runs 24 hours on all days. Emergency samples are accepted
for cases of fever look for parasites and for cases of bleeding like DIC and HUS for
platelet counting. Paracoagulation tests for FDP are also done on emergency basis.
Kindly inform the resident on call, if samples have to be sent after working hours or on
holidays. The resident duty roster is available with the casualty medical officer. Kindly
do not leave the samples outside the laboratory in the corridor. Ensure that the indica-
tion for performing emergency hemograms is strictly adhere to.

COLLECTION OF SAMPLES FOR CYTOLOGY:

Cervical and Vaginal smears: Smears to be fixed immediately in the fixative *95% etha-
nol+, supplied from the cytology lab.
Body Fluids: Samples should be sent fresh. If there is any delay refrigerate the sample.
Urine: Freshly voided *5-10ml+ sample is ideal and should be sent on three consecutive
days.
Buccal Smear: Patient to be sent to the cytology lab.
Sputum: Sample to be collected in a clean vial and sent to cytology lab.
FNAC: Requisition form to be duly filled and the patient should be sent to the lab *OPD
block+
Guided FNAC: Residents to be informed and fixative jars to be collected from the cytol-
ogy lab.

COLLECTION OF SAMPLES FOR HISTOPATHOLOGY:

 Biopsy tissue/organ to be fixed immediately in 10% formalin atleast 7 to 10

times the volume of the specimen.
 For frozen section requests, the tissue/organ to be sent immediately to the his-
topathology lab. Prior intimation should be given to the lab. The resident must
accompany the specimen. Frozen sections will be accepted from 9 am to 3.30
pm.
 Immunofluroscent specimen to be sent in NORMAL SALINE along with H&E sam-
ple sent in NEUTRAL BUFFERED FORMALINE.
DIF specimen should not frozen. On Saturday Frozen specimen will be accepted
from 9 am to 11.30 am.
 Avoid sending specimens for Frozen during lunch time 1pm to 2 pm.
 Outside block, slide and specimen should be sent along with outside
report and concerned Faculty in charge signature with seal.

34
 (B) MICROBIOLOGY
Bacteriology Section
1. Culture of exudates (pus, sputum, peritoneal fluid, pleural fluid, ascetic fluid,
synovial fluid, CSF, throat swab, wound swab, tissue bits, ophthalmological
specimens, any aspirates)
2. Urine culture - Semiquantitative method.
3. Stool culture for common enteric pathogens like Salmonella, shigella and
Vibrio
4. Blood culture.
5. Antibiotic susceptibility testing for all pathogenic isolates.
6. Anaerobic culture
7. Bacteriological testing of water.
8. Sterility checking of intravenous fluids, blood collection bags.
9. Culture of hospital specimens from environment and others for monitoring
nosocomial infections.

HIV Section
1. Flow cytometry - to estimate CD4 count.
2. ELISA and rapid detection of anti-HIV antibodies.

Immunology section
1. Widal test
2. VDRL test - Qualitative and Quantitative for serum and CSF samples
3. Weil Felix test
4. Brucella agglutination test
5. Paul Bunnel test
6. Latex agglutination test & Nephelometry – RA factor, CRP, ALSO
7. AntiLeptospira antibody by ELISA
8. ANA – IFA
9. dsDNA – ELISA
10. Cold agglutination test

Mycobacteriology section
1. Z.N. staining, Auramine O Staining
2. Culture for AFB from all specimens by conventional method
3. Culture for AFB by BacT/ALERT system

Molecular biology section

1. PCR for Entamoeba histolytica (stool & liver abscess pus)
2. PCR for Mycobacterium tuberculosis
3. PCR for Leptospira

35
Mycology section
1. Direct and KOH mount
2. Culture of all types of specimen for fungal infections.
3. Antifungal susceptibility of Candida spp.
4. Speciation of Candida isolates

Parasitology section
Stool examination by concentration for ova and cysts
1. Acid fast staining for coccidian parasites
2. Stool / aspirates for culture for Entamoeba histolytica
3. Indirect Haemagglutination test for diagnosis of:
a. Amoebiasis
b. Filariasis
c. Hydatid disease
5. ELISA
a. (IgM ELISA) for diagnosis of Toxoplasmosis
b. (IgG ELISA) for diagnosis of Cysticercosis
c. (IgG ELISA) for diagnosis of Hydatid disease
6. Wet mount examination and culture of CSF / Corneal scrapings for Acan-
thamoeba
7. Peripheral blood smear examination for malarial parasites, microfilaria and
L.D. bodies
8. QBC for malaria parasite
9. Para F test for malarial parasite
10. Cysticercus cellulosae antigen detection by Co-agglutination test Western
blot – Cysticercosis, Hydatid disease.
Regional Influenza laboratory
Realtime PCR – H1N1 Influenza virus detection.

Virology section
1. ELISA
HBsAg
Anti-HBsAg antibodies
Anti-HCV antibodies
Anti-Dengue-IgM, IgG antibodies
Anti-HSV antibodies
Anti-CMV IgM antibodies
EBV – anti VCA IgM antibodies
Anti-Rubella IgM antibodies
Anti-JE IgM antibodies

36
 (C) BIOCHEMISTRY

TIME SCHEDULE FOR RECEIVING SAMPLES

1. On working days : From wards : 9.00 a.m. – 10.30 a.m.

From OPD : 9.00 a.m. – 12.00 Noon
From SSB : 9.00 a.m. – 04.30 p.m.

2. Emergency samples: Round the clock on all days of the week inclusive of
Sundays and other holidays for notified investigations only.

PARTICULARS OF INVESTIGATIONS AND PROCEDURES

GENERAL INSTRUCTIONS

The following factors that affect composition of body fluids should be

duly considered while interpreting the biological values.

Controllable Factors

Posture, hospitalisation, immobilisation, exercise, physical training,

circadian variation, blindness, travel, food ingestion, beverages, smoking,
alcohol, drugs, fever, shock, trauma, transfusion, etc.

Uncontrollable Factors

Age, gender, race, environment, geographical location, seasons, menstrual

cycle, habits, dietary habits, etc.

1. The clinician should use the laboratory selectively and judiciously in

the best interests of patients. In interpreting the results, the
following facts should be borne in mind, in addition to what had been
said earlier.

37
2. The relationship of a result to a reference range only indicates the
probability that it is normal or abnormal.
3. There are physiological differences in normal ranges and physiological
variations from day to day.
4. There are small day to day variations in results due to technical fac-
tors and reference ranges may vary from laboratory to laboratory and
with the technique employed.
5. Changes in a given constituent may be non-specific and unrelated to a
primary defect in the metabolism of that constituents.

SPECIAL INSTRUCTIONS

1. The reverse page of the requisition form should be ticked for appro-
priate investigations requested for.
2. Any specific instruction or information required should be clearly indi-
cated.
3. The clinical information about the patient should be mentioned.
4. Samples sent for biochemical analysis with incomplete information
will not be processed for analysis.
5. Samples collected for biochemical investigations should be sent to the
laboratory within 30 minutes of collection.
6. In case of delay, samples must be refrigerated and sent as soon as
possible, but this information should be intimated.
7. Requisition form should be countersigned by a Unit Consultant for
all special investigations.

SAMPLE REQUIREMENTS FOR AUTOANALYSER

ASSAYS

Most of the investigations are done in autoanalyser. For that, 3 ml of blood

has to be sent (in plain bottle) for 4 investigations and 5 ml for more than 4
investigations.

38
 ROUTINE INVESTIGATIONS (3 ml of blood in plain bottle)

BLOOD GLUCOSE LIPID PROFILE MYOCARDIAL

PROFILE
 Total Cholesterol
RENAL PROFILE  LDH(Total)
 Blood urea  Triglycerides  CK total
 Serum creatinine  HDL Cholesterol  CK – 2
 Uric acid
 LDL Cholesterol
OTHERS
SERUM ELECTROLYTES  VLDL Cholesterol  Serum Amylase
 Na+  Serum Acid
 K+ HEPATOBILIARY PRO- Phosphatase
 Cl- FILE  Plasma Fibrinogen
 Li+ (Therapeutic)  Total Bilirubin (3.6 ml blood in
 Ca2+ ( Ionic)  Direct Bilirubin citrated tubes
 Ca2+ (Total)  Indirect Bilirubin collected from Resi-
 Inorganic phosphorus  Total Protein dents’ Room)
 Magnesium  Albumin  Prothrombin time
 Globulin (1.8 ml blood in
 AST citrated tubes
 ALT collected from Clini-
 GGT cal
 Alkaline Biochemistry Lab)
phosphatase
Body Fluids (1 ml in
plain bottle)
 Protein
 Glucose
 Chloride

39
SPECIAL INVESTIGATIONS (on prior fixation / after consultation)
(3 ml of clotted blood in plain bottle can be sent for each of the investigations given be-
low except for Glycated Hemoglobin for which 1 ml of blood in EDTA
bottle is needed )
1. OGTT
2. Electrophoresis of serum proteins
3. Ceruloplasmin
4. Glycated Hemoglobin (HbA1C)
5. Iron
6. Ferritin
7. Osmolality

URINALYSIS (20 ml urine for each test)

(The department has to be contacted either for obtaining the preservatives or some oth-
er requirements regarding the 24 hour collection of urine; volume of 24 hour urine to be
measured and noted)
QUANTITATIVE
1. 24 hour urine protein
2. 24 hour urine creatinine
3. Creatinine clearance (blood and urine samples as per protocol)
4. Protein-creatinine ratio
5. Microalbumin
6. Glucose
7. Calcium (24 hour collection preferred)
8. Phosphate (24 hour collection preferred)
9. Electrolytes
10. Specific gravity
11. pH
12. Alkaline tide
QUALITATIVE
1. Reducing sugars
2. Ketone bodies
3. Amino acids
4. Hemoglobin & Myoglobin
5. Bile salts & bile pigments
6. Bence-Jones protein
7. Urobilinogen
8. Porphobilinogen
9. Acid Mucopolysaccharides
40
OTHERS
1. Adenosine deaminase activity (ADA) in body fluids
2. Stone Analysis
3. Sweat Chloride test
4. Hemoglobin Spectroscopy

HORMONAL ASSAY , TUMOUR MARKERS , VITAMINS AND OTHERS

(3 ml of clotted blood in plain bottle can be sent for each of the
investigations given below except for homocysteine for which 2 ml of blood in
EDTA bottle is needed )

1. Hormonal Assays (For Cortisol, collect the sample between 6 to 8 a.m. For
female sex hormones, specify the day of menstrual cycle.)
a. Thyroid profile(TSH, free T3 and free T4 )
b. assay related to pregnancy (LH, FSH, testosterone, estradiol, proges-
terone, prolactin)
c. cortisol
d. parathormone
2. Tumor markers
a. CA-125
b. Carcinoembryonic Antigen,
c.  fetoprotein
d. Prostate specific antigen
3. Vitamins
a. B 12
b. Folate
4. Homocysteine

EMERGENCY INVESTIGATIONS : ROUND THE CLOCK

1. Blood Glucose
2. Blood Urea
3. Blood Gas Analysis (pH, pCO2, pO2, Bicarbonate)
4. Serum Electrolytes
5. Serum Bilirubin (for neonatal cases only)
6. Serum Creatinine (for life saving conditions only)
7. Serum Calcium (for tetany cases only)
8. Serum Amylase
9. Creatine Kinase
10. Creatine Kinase-2
11. Prothrombin Time
41
 LABORATORY REFERENCE RANGES
CLINICAL BIOCHEMISTRY
ROUTINE INVESTIGATIONS
BLOOD GLUCOSE
Fasting 70 – 100 mg/dl
Random 70 – 140 mg/dl
2 hour postprandial < 140 mg/dl
OGTT
Fasting <95 mg/dl
1 hour <180 mg/dl
2 hour <155 mg/dl
3 hour <140 mg/dl
RENAL PROFILE
 Blood urea 15 – 40 mg/dl
 Serum creatinine 0.7 – 1.2 mg/dl
 Uric acid 2.5 – 7 mg/dl (Males)
1.5 – 6 mg/dl (Females)
SERUM ELECTROLYTES
 Na+ 135 – 145 mmol/L
 K+ 3.5 – 5 mmol/L

 Cl- 96 – 106 mmol/L

 Li+ (Therapeutic) 0.6 – 1.2 mmol/L
 Ca2+ ( Ionic) 4.5 – 5.6 mg/dl
 Ca2+ (Total) 9 – 11 mg/dl
 Inorganic phosphorus 2.5 -4.5 mg/dl
 Magnesium 1.8 – 3 mg/dl
LIPID PROFILE
 Total Cholesterol <200 mg/dl
 Triglycerides <150 mg/dl
 HDL Cholesterol >40 mg/dl
 LDL Cholesterol <100 mg/dl
 VLDL Cholesterol <30 mg/dl
HEPATOBILIARY PROFILE
 Total Bilirubin 0.4 – 1.2 mg/dl
 Direct Bilirubin 0.1 – 0.4 mg/dl
 Indirect Bilirubin 0.3 – 0.8 mg/dl

42
  Total Protein 6.3 – 8.3 g/dl
 Albumin 3.5 – 5.5 g/dl
 Globulin 2.5 – 3.5 g/dl
 AST 0 – 40 IU/L
 ALT 0 – 45 IU/L
 GGT 1 – 50 IU/L
 Alkaline phosphatase 30 – 125 IU/L
MYOCARDIAL PROFILE
 LDH 60 – 200 IU/L
 CK total 20 – 170 IU/L
 CK - 2 < 6 g/L
CSF
 Protein 15 – 40 mg/dl
 Glucose 40 – 70 mg/dl
 Chloride 116 – 130 mmol/L
OTHERS
 Serum Amylase 28 – 100 IU/L
 Serum Acid 1.5 – 4.5 IU/L
Phosphatase
 Plasma Fibrinogen 200 – 400 mg/dl
 Prothrombin time
SPECIAL INVESTIGATIONS
12 – 18 Sec ( INR: 1 – 1.2)

THYROID PROFILE
 Total T4 Adults:4.5 – 10.9 g/dl
Children:
1 – 3 days:11.8 – 22.6 g/dl
1 – 2 weeks : 9.9 -16.6 g/dl
1 – 4 months: 7.2 - 14.4 g/dl
4 -12 months:7.8 -16.5 g/dl
1 -5 years: 7.3 – 15 g/dl
5 – 10 years:6.4 – 13.3 g/dl
11 – 15 years:5.6 – 11.7 g/dl
 Free T4 Adults:0.89 – 1.76 ng/dl
Children:
1 – 4 days:2.2 – 5.3 ng/dl
2 weeks – 20 years :0.8 – 2 ng/dl

43
  Total T3 Adults:0.6 – 1.81 ng/ml
Children :
1 – 3 days :1 – 7 ng/ml
1 – 11 months :1.05 – 2.45 ng/ml
1 – 5 years:1.05 – 2.69 ng/ml
6 – 10 years:0.94 – 2.41 ng/ml
11 – 15 years : 0.82 – 2.13 ng/ml
 Free T3 Adults:2.3 – 4.2 pg/ml
 TSH Adults <55 years:0.35 – 5.5 IU/ml
Adults >55 years:0.5- 8.95 IU/ml
Children :
1 – 4 days:1 – 39 IU/ml
2 – 20 weeks :1.7 – 9.1 IU/ml
21 weeks – 20 years: 0.7 – 6.4
IU/ml
ASSAYS RELATED TO PREGNANCY
PRENATAL SCREEHING & INFERTILITY
 Testosterone 241 – 827 ng/dl (Males)
14 – 76 ng/dl (Females )
 LH Males:
23 -70 years :1.5 – 9.3 mIU/ml
>70 years :3.1 – 34.6 mIU/ml
Females:
Follicular phase: 1.9 – 12.5 mIU/ml
Mid cycle Peak :8.7 – 76.3 mIU/ml
Luteal phase : 0.5 – 16.9 mIU/ml
Pregnant : <0.1 – 1.5 mIU/ml
Post menopausal : 15.9 – 54 mIU/ml
Contraceptives: 0.7- 5.6 mIU/ml
 FSH Males:
23 – 70 years: 1.4 – 18.1 mIU/ml
Females:
Follicular phase: 2.5 -10.2 mIU/ml
Mid cycle peak :3.4 -33.4 mIU/ml
Luteal phase : 1.5 – 9.1 mIU/ml
Pregnant : <0.3 mIU/ml
Post menopausal : 23 – 116.3 mIU/ml

44
 Estradiol Pre pubertal child: 3 – 10 pg/ml
Males : 10 - 50 pg/ml
Females:
Follicular Phase:20 – 250 pg/ml
Midcycle:35 – 570 pg/ml
Luteal phase:23 – 256 pg/ml
Post menopausal: <21 pg/ml
 Progesterone Prepubertal child : 7 - 52 ng/dl
Males : 13 - 97 ng/dl
Females :
Follicular phase : 15 – 70 ng/dl
Luteal phase : 200 – 2500 ng/dl
Pregnant Female
First trimester : 725 – 4400 ng/dl
Second trimester : 1950 – 8250 ng/dl
Third trimester : 6500 -22,900 ng/dl
 Prolactin Males:2.1 – 17.7 ng/ml
Females:
Non pregnant:2.8 – 29.2 ng/ml
Pregnant: 9.7 -208.5 ng/ml
Post menopausal : 1.8 – 20.3 ng/ml
 Total human Males : <5 IU/L
chorionic Females:
gonadotropin Non pregnant : <5 IU/L
Pregnant :
4 weeks : 5 – 100 IU/L
5 weeks : 200 – 3000 IU/L
6 weeks : 10,000 – 80,000 IU/L
7-14 weeks : 90,000 – 5,00,000 IU/L
15-26 weeks : 5000 – 80,000 IU/L
27-40 weeks : 3000 – 15,000 IU/L

Trophoblastic disease : >1,00,000 IU/L

45
TUMOR MARKERS
 Alpha feto protein Gestational age:
15 weeks : 31.3 ng/ml
16 weeks: 36.3 ng/ml
17 weeks: 42 ng/ml
18 weeks :48.7 ng/ml
19 weeks:56.5 ng/ml
20 weeks:65.4 ng/ml
(-For screening of Down syndrome, values less
than above are abnormal.
-For screening of neural tube defects,
values more than twice the above are
abnormal)
 Prostate specific antigen < 4 ng/ml
 CA 125 < 35 U/ml
 Carcinoembryonic antigen < 3 ng/ml
OTHERS
 Serum Cortisol 4.3 – 22.4 g/dl
 Serum PTH 10 – 65 pg/ml
 Serum Iron 60 - 160 g/dl (Males)
35 – 145 g/dl (Females)
 Serum Ferritin 20 – 250 ng/ml ( Males)
10 – 120 ng/ml (Females)
 Plasma Homocysteine 3.7 – 14 mol/l
 Serum Vitamin B12 >201 pg/ml
 Serum Folic acid >5.38 ng/ml
 ADA CSF:< 10 U/L
Other fluids : < 30 U/L
 Glycated haemoglobin 4 -6 %
(Whole Blood)
 Serum ceruloplasmin 20- 60 mg/dl
 Troponin T 0 – 0.1 ng/ml
 Troponin I 0 – 0.4 ng/ml
 Sweat chloride 5 – 35 mmol/l

46
URINE INVESTIGATIONS
 24 Hour Protein <150 mg/dl
 Spot Protein creatinine ratio <0.2 mg/mg
 pH 4.6 - 8
 Specific gravity 1.016 – 1.022
 Sodium 40 – 220 mmol/day (Males)
27 – 287 mmol/day (Females)
 Potassium 25 – 125 mmol/day
 Chloride 110 – 250 mmol/day
 Osmolality 60 – 1200 mOsm/kg
 Magnesium 6 – 10 mmol/L
 Phosphorus 400 – 1300 mg/day
 Calcium 100 – 300 mg/day
 Uric Acid 250 – 750 mg/day
 Creatinine 1 – 2 g/day
 Creatinine clearance 85 – 125 ml/min ( Males)
80 – 115 ml/min (Females)
 Microalbuminuria 30 – 300 mg/day

47
 (D) PHARMACOLOGY
COLLECTION PROCEDURES

Name Sample Value Time of collection

Drugs: 8 ml of whole blood in a For suspected therapeutic failure:

Phenobarbitone plain bottle Just before the next dose
Phenytoin
Carbamazepine For suspected drug toxicity:
Theophylline 2 hours after the last dose
Paracetamol
Salicylic acid
Digoxin

Hormones: 10 ml of whole blood in a For Cortisol - between 4 am and 8

FSH plain bottle am.
LH Other hormones - prefe-rably in the
Oestradiol morning.
Testosterone Female sex hormones - day of men-
Prolactin strual cycle needs to be recorded.

Others: Collect the urine for 24 Patient should abstain from banana,
hours using 10 ml of 6 ice-cream, chocolate, tea, coffee,
VMA N Hcl as preservative. foods containing vanilla, citrus
The specimen should be fruits, and drugs such as aspirin and
refrigerated during col- anti-hypertensive agents, at least 2
lection. days before the collection period.
Measure the total vol-
ume and send an ali-
quot of 50 ml for inves-
tigation.

Note:
1. Prior appointment has to be made with HPLC Laboratory for all
estimations.
2. Special requisition form issued by HPLC Laboratory, duly filled and signed
by the Head of the Unit, must accompany all the samples.
3. Samples should be sent to HPLC Laboratory before noon.

48
How to write Adverse drug reaction reporting (ADR) form?
An Adverse drug reaction is a “response to a drug which is noxious
and unintended which occurs at doses normally used in man for prophy-
laxis, diagnosis or therapy of disease or for the modification of physiologic
function.

An ADR form is required for:

(i) Reporting adverse experiences with one medication.
(ii) Generating incidence of ADR for a particular drug in Indian context.
(iii) To prevent future ADRs for your patients and others.
The ADR form should contain information about:
(a) Patient details.
(b) Suspected adverse reaction.
(c) Suspected medications.
(d) Name and address of the reporting person.
(e) Date of report.

The ADR can be reported by any health care professional including

Doctors, Dentists, Nurses and Pharmacists.

49
 (E) RADIOTHERAPY
Investigations offered: Thyroid Scan using Radio Iodine-131
Contra-indications:
1. Pregnancy (especially in 1st trimester) - ask for history of amenorrhoea.
2. Lactation - Advise avoidance of breast-feeding for 7 days after iodine
administration.
Preparation:
1. Patient should be fasting on the date of the investigation.
2. Patient should stop all iodine containing drugs/anti-thyroid drugs for at
least 10 days prior to the investigation.

(F) PHYSIOLOGY

Tests conducted:
1. Motor and sensory conduction tests
2. Electromyogram (EMG): ( HIV, HBs Ag & HCV has to be ruled out before
sending request)
3. Somato-sensory evoked potentials
4. Visual evoked potentials
5. Auditory evoked potential (BERA)
6. Pulmonary function tests (FVC, FEV1 & PEFR)
7. Autonomic function test
8. Tilt table test

Date and time:

Routine cases: Tests done on all working days

Date and time to be fixed in advance.

50
 (G) Nuclear Medicine
Nuclear medicine refers to the constantly evolving medical specialty that in-
volves the use of radioactive isotopes in the diagnosis and treatment of disease.
Nuclear imaging detects functional properties of human tissues either by Gam-
ma camera (for 99mTc, 131-Iodine, 123-Iodine) or by PET scanner (18-F FDG). The
imaging is done by tracing the distribution of radiopharmaceuticals within the body.
A radiopharmaceutical consists of a radioactive isotope bound to a chemical agent
specific for the organ to be imaged. Normally patient presents to the department
where radiopharmaceutical is injected intravenously (given orally in case of 131-
Iodine) and imaging is done by gamma camera/PET scanner. Different imaging proto-
cols are followed for various studies to obtain the physiological information. There
are no adverse effects of radiopharmaceutical as these are given in micromolar quan-
tities.
The department at JIPMER is equipped with state of the art one SPECT.CT gam-
ma camera with which we can obtain functional as well as anatomical information.
Isotope and radiopharmaceuticals (cold kits) are imported from BRIT Mumbai. The
labelling of the particular radiopharmaceuticals required for the studies planned for
the day is done in the department daily. Planning for nuclear studies is subject to
availability of isotopes, radiopharmaceuticals and number of cases available for eco-
nomic & appropriate utilization of cold kits. Once the studies are done the results are
made available as soon as possible for ward patients and within 72 hours for OPD
patients.
Precaution to be taken are-
1. Pregnancy or breast feeding status should be revealed prior to study.
2. Prior appointment and instructions for the studies are necessary.
3. Certain medication can interfere with the results of the scan e.g. antithyroid
drugs in thyroid scan so these have to be stopped temporarily.
4. Any nuclear medicine study or any contrast study done in recent past should be
known as it might interfere with some nuclear studies.

51
 The various diagnostic studies and therapy done in the department are given
below:

DIAGNOSTIC STUDIES#:
Skeletal system: (Monday & Tuesday) Cardiac & Other studies (Wedensday)
Stress Myocardial Perfusion SPECT
Whole body Bone Scan (Single and three
Myocardial Viability assessment
phase)
MUGA for LVEF.
Bone SPECT.CT
Scintimammography (MIBI)
Iodine-131 Whole Body Scan for ca thyroid
Sestamibi Brain SPECT for tumors
patients
Hepatobiliary & others (Friday)
I-131 MIBG scan (Once in a month)
Tc-99m Thyroid Scan
Parathyroid Scan for adenoma
Meckel's Study
Urinary system & Brain SPECT: (Thursday) *Hepatobiliary Study (HIDA)
Renal dynamic scan by LLEC/ MAG3. *Cisternography.
DTPA renal scan for GFR *Ventilation perfusion study for P.E
Captopril Renal Study *RBC labelled study for GI bleed
Renal Transplant Evaluation
Miscellaneous studies: (Saturday)
DMSA Renal cortical scan
Lymphoscintigraphy
DRCG for Vesicoureteric reflux
Lacrimal Study.
HMPAO / ECD Brain SPECT
Esophageal transit study
Therapy: (Monday) Gastroesophageal study
Gastric emptying study
I-131 therapy for hyperthyroidism

# Schedule can change depending on the availability of isotopes, radiophar-

maceuticals and patients load.
*studies can be planned on other days also depending on the emergency and
isotope availability.

52
The department has protocols to perform other radionuclide therapy
involving residual and metastatic ablation in case of ca thyroid patients,
Iodine-131 MIBG therapy in neuroendocrine tumors preferably pheo-
chromocytoma, neuroblastoma and paraganglioma, radiosynovectomy
for various chronic active arthritis patients.

(H) EMS LABORATORY

For patients attending EMS during 2 pm to 7 am, following
tests are done in EMS lab:

1. Pl. Glucose 7. Blood Gas

2. Sr. Amylase 8. CSF Sugar
3. Serum Bilirubin 9. BT,CT,Hn,TLC,DLC
4. Serum Na+& K+ 10. Bacterial Inoculatin
5. Serum Creatinine & Protein
6. Serum Urea

53
 7. LABORATORY REFERENCE RANGES

(A) HAEMATOLOGY

S.I. Units Conventional Units

12
RBC count Males 5.5 ± 1.0 x 10 /1 5.5 ± 1.0 million/cumm
Females 4.8 ± 1.0 x 1012/1 4.8 ± 1.0 million/cumm

Haemoglobin Males 155 ± 25 g/l 15.5 ± 2.5 g/dl

Females 140 ± 25 g/l 14.0 ± 2.5 g/dl
Haematocrit Males 0.47 ± 0.07
Females 0.42 ± 0.05

MCV 86 ± 10 fl
Adults 29.5 ± 2.5 pg
MCH Adults 325 ± 25 g/l 32.5 ± 2.5 g/dl
MCHC Adults
Reticulocytes 0.2 - 2%

Total leucocyte count 7.5 ± 3.5 x 109/l 4000 - 11000/cumm

Platelet count 150 - 400 x 109/l 1.5 lakhs - 4 lakhs/ cumm

Bleeding time (Ivy's) 2 - 7 mins.

Clotting time (Lee & 4 - 11 min.

White's 37E)

PT 10 - 14 secs. >2 secs of control taken as

abnormal.

APTT 35 - 43 secs. >6 secs of control taken as

abnormal.

ESR (Westergren) M 1-10 mm/hr

F 1-15 mm/hr

ESR (Wintrobe) M 1-10 mm/hr

F 1-20 mm/hr

54
 (B) MICROBIOLOGY

Section Investigation Reference Range

Immunology VDRL Reactive / Non-reactive

Cut off titre: 8

Widal: TO 80 (equivocal)
160 (indicative of infection)

TH 80 (equivocal)
160 (indicative of infection)

AH > 160 (indicative of infection)

BH > 160 (indicative of infection

Brucella Aggluti-nation Titre: 80-160 (indicative)

Test > 320 (conclusive, even in
single specimen)
Rheumatoid factor detec-
tion by Latex Agglutination Positive or Negative

ASLO titre
(Latex Agglutination)
Cut off titre: >200 IU/ml

Virology RPHA FPR Hbs Ag. Postitive or Negative

HIV Lab ELISA for HIV Reactive (+ve)

Non-reactive (-ve)

Parasitology IgM ELISA for Toxoplasmo- Negative / Equivocal / Positive

sis

IHA for Amoebiasis Cut off titre: >128

IHA for Filariasis Cut off titre: >128
IHA for Hydatidosis Cut off titre: >128

55
 SPECIAL INVESTIGATIONS – OBST. & GYN

I. ULTRASOUND
Obstetric
I Trimester – Transvaginal (with empty bladder)
II & III Trimester – Abdominal (with full bladder)

Gynaecological
1) Abdominal masses – Abdominal (with full bladder)
2) Ascites
3) Pelvis – Vaginal scan (with empty bladder)
4) Sonal guided aspiration / FNAC – Empty bladder

II NON-STRESS TEST
After 32-34 weeks of pregnancy in high risk patients after a meal

III HYSTEROSALPINGOGRAPHY
- To be done postmenstrually after date fixation with Dept. of
Radiodiagnosis
- To be done in Radiodiagnosis Dept. by a Senior / Junior
Resident

IV. LAPAROSCOPY CHROMOTUBATION

a) With endometrial biopsy – Premenstrual
b) Without endometrial biopsy – Postmenstrual

V. DIAGNOSTIC LAPAROSCOPY
For ectopic, endometriosis (without regard to menstrual
cycle)

VI. COLPOSCOPY
- Done on Wednesday afternoons
- Not during menstruation
56
 Appendix

Grading of quality of available evidence: Category of evidence

Ia- meta-analysis of randomized controlled trials
Ib- at least one randomized controlled trial
IIa- at least one controlled study without randomization
IIb- at least one other type of quasi-experimental study
III- non-experimental, descriptive studies, such as comparative
studies, correlation studies, and case studies
IV- expert committee reports or the opinions or clinical experi-
ence of respected authorities, or both
Strength of recommendation
Grade A (levels Ia and Ib)- at least one randomized controlled
trial as part of the body of literature of overall good quality and
consistency addressing specific recommendations
Grade B (levels IIA, IIb, and III)- availability of well conducted
clinical studies, but no randomized clinical trials on the topic of
recommendation
Grade C (level IV)- evidence obtained from expert committee
reports or the opinions or clinical experience of respected au-
thorities, or both. Indicates absence of directly applicable clini-
cal studies of good quality
Source: US Department of Health and Human Services. (AHCPR
publication No 92-0023).

57