Tuesday, 29 September 2015
SYNDROMES IN PSYCHIATRY
Saturday, 26 September 2015
Cardioselective betablockers
cardioselective betablockers mnemonic...
"Betablockers Acting Exclusively At Myocardium"
Cardioselective betablockers are:
Betaxolol
Acebutelol
Esmolol
Atenolol
Metoprolol
Thursday, 24 September 2015
Ulcer Edges
Five common types of ulcer edge are seen in surgical practice.
i. Undermined edge-is mostly seen in tuberculosis.
ii. Punched out edge-is mostly seen in a gummatous ulcer or in a deep trophic ulcer.
iii. Sloping edge is seen mostly in healing traumatic or venous ulcer.
iv. Raised and pearly-white beaded edge-is a feature of rodent ulcer.
v. Rolled out (Everted) edge-is a characteristic feature of squamous cell carcinoma.
Hernia
Bergerg's hernia - hernia in Pouch of Douglas
Grynfelt/s hernia- Upper lumbar triangle hernia
Petit's hernia - Lower lumbar triangle hernia
Cloquet's hernia- hernia through pecteineal fascia
Narath's hernia - behind femoral artery
Hesselbach's hernia - lateral to femoral artery
Serofini's hernia - behind femoral vessels
Laugier's hernia - through lacunar ligament
Tealse's hernia - in front of femoral vessels
Richter's hernia - part of circumference of bowel wall is gangrenous
Littre's hernia - hernia with Meckels's Diverticulum
Sliding hernia - Posterior wall of sac is formed by colon or bladder
Maydl's hernia - 'w' hernia
Phantom hernia - Localised muscle buldge following muscular paralysis
Spigelian hernia - through spegelian fascia
Obturator hernia - through obturator foramen
Femoral hernia - hernia medial to femoral vein
Beclard's hernia - femoral hernia through saphenour opening
Pharma High yield
Mechanism of Action
Wednesday, 23 September 2015
Artery
Completely occluded artery – T1M1 0
Marked occluded artery – T1M1 1
Mild occluded artery – T1M1 2
Normal coronary flow – T1 M1 3
Anatomy lengths
Female urethra
Anal canal
Auditory tube
Cystic duct
Optic nerve
Prostatic urethra
Left principle bronchus
Left main bronchus
Parotid duct
Submandibular duct
Lateral lobe of thyroid gland
Testis
First part of duodenum
Neck of femur
Medial wall of bony orbit
Lateral wall of bony orbit
Virgin uterus
Second part of duodenum
Bile duct
Multiparous uterus
Posterior wall of vagina
Kidney
Uterine tube
Third part of duodenum
Rectum
Spleen
Ascending colon
Pancreas
Root of mesentry
Duodenum
Ureter
Descending colon
Thoracic duct
Vas deferens
Sartorius
Femur
Transverse colon
Parasitology
C.neoformis
U LIP3
Urease positive
Lack of fermentation
Inositol positive
Phenol oxidase positive
Pigment- niger seed agar (black)
Positive gram stain
Clonorchis sinesis
C7
Chinese liver fluke
Cholangio ca
Ca pancreas
Calculi
Cirrhosis
Cholangitis
Cypriloid fish(intermediate host)
Autoinfection
CHEST
Capillaria philiphianses
H.nana
E.vermicularis
S.stercoralis
T.solium
-from class notes
Monday, 21 September 2015
Radiotherapy
Radiation dose (for 5 years) safe for occupational workers?
100 mSievert
Maximum dose for an year for occupational worker can be 30 mS
Radiation dose (for 5 years) safe for general public?
5 mSievert
🔹Maximum dose in a year for this can be 1 mS
Radiation dose (for whole pregnancy) safe for pregnant occupational workers?
2 mSievert
🔹Maximum exposure to lower abdomen of female is 2 mS which is same as 1 mS to the fetus.
Abscopal Effect
Splenectomy is an effective secondary or tertiary treatment for two chronic B cell leukemias, hairy cell leukemia and prolymphocytic leukemia, and for the very rare splenic mantle cell or marginal zone lymphoma.
Splenectomy in these diseases may be associated with significant tumor regression in bone marrow and other sites of disease.
Similar regressions of systemic disease have been noted after splenic irradiation in some types of lymphoid tumors, especially chronic lymphocytic leukemia and prolymphocytic leukemia.
This has been termed the abscopal effect. Such systemic tumor responses to local therapy directed at the spleen suggest that some hormone or growth factor produced by the spleen may affect tumor cell proliferation.
Optic Nerve Drussen
Optic Nerve Drusen:
These are refractile deposits within the substance of the optic nerve head.
They are unrelated to drusen of the retina, which occur in age-related macular degeneration. Optic disc drusen are most common in people of northern European descent.
Their diagnosis is obvious when they are visible as glittering particles upon the surface of the optic disc. However, in many patients they are hidden beneath the surface, producing pseudo-papilledema.
It is important to recognize optic disc drusen to avoid an unneccessary evaluation for papilledema.
Ultrasound or computed tomography (CT) scanning is sensitive for detection of buried optic disc drusen because they contain calcium.
In most patients, optic disc drusen are an incidental, innocuous finding, but they can produce visual obscurations.
On perimetry they give rise to enlarged blind spots and arcuate scotomas from damage to the optic disc. With increasing age, drusen tend to become more exposed on the disc surface as optic atrophy develops. Hemorrhage, choroidal neovascular membrane, and aion are more likely to occur in patients with optic disc drusen. No treatment is available.
Newborn Electrolytes
Hypoglycemia in new born:-
Operational threshold fr hypoglycemia-<40mg/dl
WHO definatn of hypoglycemia-<45mg/dl
Hyperglycemia in newborn->125mg/dl
Mx of asymptomatic hypoglycemia-Trial of oral feed-5g glucose/100ml
Symptomatic hypoglycemia(<20mg/dl)
IV 10% dextrose
2ml/kg bolus then 6mg/kg/min infusion
Never use glucose>12.5% to peripheral veins
Hypocalcemia:-
Total sr ca <7mg/dl
Ionised ca <4mg/dl
Rx-IV calcium glucobate 10%
Precaution-causes bradycardia n arrythmias
Therefore slowly given
Diluted with 5%dextrose 1:1
Vitamin D levels
Based on serum levels of Vitamin D, classified into;
Deficient: less than 10ng/ml
Insufficient: 10-20
Optimal: 20-60
High: 60-90
Toxic: greater than 90
(Ref:O.P Ghai 8th edition page 114)
NRTI Revision
NRTI revision:
Max pancreatitis? Didanosine✅
Max peripheral Neuropathy? Stavudine✅
Max lipodistrophy? Stavudine✅
Best tolerated NRTI? Lamivudine emtricitabine✅
Causes fulminant hepatic failure? Didanosine✅
Causes Nail hyperpigmentation? Zidovudine✅
Among NRTI Diarrhea more common with? Didanosine✅
Apthous ulcers caused by? Zalcitabine✅
Least effective NRTI? Zalcitabine✅
NRTI with ↑ risk for M.I ?abacavir✅
Non renal metabolism among NRTI? Abacavir✅
Also useful against Hep B? Lamivudine , emtricitabine, tenofovir✅
Dermatology Questions
MCQs
1) Most common organism causing tinea- Trichophyton rubrum
2) Most common organism causing tinea capitis- Trichophyton violaceum
3) Most common cranial nerve involved in Hansens- facial
4) Most common nerve taken for nerve biopsy in Hansens- radial cutaneous (upper limb), sural (lower limb)5
) Most common cause of mononeuritis multiplex - Hansen (India), DM (world)
6) Most common cause of ENL- LL> BL7) Most common cause of a negative Slit skin smear in Hansen- neural leprosy
8) Cause of Type 1 reaction- BB> BT> BL
9) DOC for type 1 and type 2 reaction- steroids
10) DOC for chronic, recurrent ENL- thalidomide
11) Most common side effect of dapsone- hemolytic anemia
12) Most common side effect of clofazimine- pigmentation
13) Most common cause of inverted saucer lesion- borderline leprosy
14) Most common cause of leonine facies- LL
15) Earliest sensation lost- temperature
16) Most common Hansen- Borderline Tuberculoid
17) Commonest site for Fixed drug eruption (FDE)- lips
18) DOC for tinea - terbinafine
19) DOC for tinea capitis- griseofulvin
20) Most common type of onychomycosis – Distal and lateral onychomycosis (In HIV, the most common type is proximal subungual onychomycosis and superficial whiteonychomycosis)
21) DOC for sporotrichosis- itraconazole> potassium iodide
22) Most common cause of reactive arthritis- Chlamydia> Shigella
23) Most common Psoriatic arthritis- oligoarticular, asymmetric.
24) DOC for psoriatic arthritis- Methotrexate
25) DOC for arthritis mutilans- etanercept
26) DOC for guttate ps- antibiotics
27) DOC for erythrodermic psoriasis- Methotrexate
28) DOC for pustular psoarisis- Acitretin
29) DOC for early mycosis fungoides- Electron beam therapy > Phototherapy
30) Most common type of pemphigus- pemphigus vulgaris
31) Rarest type of pemphigus- pemphigus vegetans
32) DOC for Dermatiis herpetiformis- Dapsone
33) Most classical joint involved in Psoriatic Arthritis- DIP
34) Most common cause of non bullous impetigo- strepto> staph
35) Most common cause of bullous impetigo- staph
36) Most common underlying disease in kaposis varicelliform eruption - atopic dermatitis
37) Most common site of adult atopic dermatitis- ante cubital fossa
38) Most common site of pediatric atopic dermatitis- cheek
39) Most common cause of cumulative Irritant contact dermatitis- detergents, Wet work
40) Most commonest cause of Allergic contact dermatitis-nickel
41) Most common cause of air borne contact dermatitis- parthenium
42) DOC for air borne contact dermatitis - azathioprine
43) Most common layer of epidermis for lamellar body presence- granular layer
44) Most common layer for synthesis of vitamin D ( Also same answer for presence of langerhans cells)- spinous layer
45) Thickest layer of epidermis- corneum
46) Thinnest layer of epidermis- granular
47) Most common cause of acute paronychia- staph
48) Most common cause of chronic paronychia-candida
49) Most common syphilis transmitted by sexual route- primary
50) Most common syphilis transmitted from infected mother- secondary
51) Most infectious lesion in syphilis- mucous patches
52) Most sensitive test in syphilis- Enzyme Immunoassay> TPPA > FTA-abs
53) Most specific test in syphilis- TPPA> TPHA
54) DOC for chancroid- azithro
55) DOC for LGV and donovanosis- doxy
56) DOC for syphilis in pregnancy- penicillin
57) DOC for urethral discharge and cervical discharge (syndromic management)- azithro+ cefixime
58) DOC for vaginal disch (syndromic management)- fluconazole + secnidazole/metro/tinidazole
59) DOC for bubo (syndromic management)- azithro+ doxy
60) DOC for genital ulcer (syndromic management)- if vesicle - acyclovir, if not azithro+ benzathine penicillin
61) DOC for neurosyphilis- crystalline aqueous penicillin
62) DOC for penicillin allergy in syphilis- doxy
63) DOC for penicillin allergy in syphilis in pregnancy- desensitization
64) DOC for penicillin allergy in neurosyphilis- desensitization
65) DOC for Impetigo herpetiformis- steroids
66) Investigation of choice in primary syphilis- dark ground illumination
67) Most common cutaneous TB- lupus vulgaris (In children, it is Scrofuloderma)
68) Test of choice for lupus vulgaris- biopsy
69) Most common organism for p versicolor now in India- Malassezia globosa
70) Most common internal organ inv in leprosy- testis
71) Organ never inv in leprosy- uterus> CNS72) Sensation never lost in hansens- propioception, vibration
73) DOC for Post herpetic neuralgia- Gabapentin
74) Most characteristic of LP on histopathology- basal cell degeneration
75) Best time to read patch test- 4 days
76) Commonest drug for FDE- sulphonamides
77) Commonest cause of Erythema Multiforme- HSV
78) Commonest cause of SJS/TEN- drugs (NSAIDS, anti epileptic, sulphonamides, penicillin)
79) DOC for scabies- 5% permethrin
80) DOC for scabies in pregnancy- 5% permethrin
81) DOC for nodular scabies- permethrin+ steroids
82) DOC for nerve abscess- I and D
83) DOC for nodulocystic acne- oral isotretinoin
84) DOC for hormonal acne- OCP with drosperinone+ estrogens
85) DOC for pediculosis corporis- disinfection of clothes
86) DOC for head louse- 1% permethrin
87) DOC for norwegian scabies- ivermectin
88) Most common shape of burrow in scabies- S-shaped
89) Most common and earliest manifestation of tuberous sclerosis- ash leaf macule> adenoma sebaceum
90) Earliest manifestation of congenital syphilis- snuffles
91) Best blood test for congenital syphilis- FTA-ABS IgM
92) Most common site for morphoea- limbs
93) Most common cause for salt and pepper skin pigmentation- scleroderma
94) Most common cause of acanthosis nigricans- obesity
95) Most severe form of psoriasis- Von zumbusch
96) Most common melanoma- superficial spreading melanoma
97) Poorest prognosis in melanoma- nodular
98) Most common type of BCC- noduloulcerative
99) Most common cause of hypopigmented, scaly patches on cheek of children- Pityriasis alba
100) Most common cause of hypopigmented, nonscaly, atrophic patches on cheek of endemic area children- indeterminate hansens
101) Investigation of choice for neurosyphilis- CSF-VDRL
102) Most common type of oral LP- reticulate / white lacy pattern
103) DOC for localised alopecia areata- intralesional steroids
104) Most effective drug in alopecia areata- contact sensitizers
105) commonest autoimmune association in vitiligo- thyroid
106) Commonest agent for leucoderma- paratertiary butyl phenol (PTBP)
107) Commonest agent for hair dye allergic contact dermatitis- paraphenylene diamine (PPD)
108) Commonest agent for footwear allergic contact dermatitis- Mercaptobenzothiazole (MBT)
109) Investigation of choice for Air borne contact dermatitis- photo patch test
110) Commonest extra genital site for primary chancre- lips
111) Commonest cause of recurrent blisters on genitals (healing with hyperpigmentation- FDE) ( if not then herpes genitalis)
112) Commonest vitiligo- Vitiligo vulgaris
113) Most common cause of erythema nodosum- Strepococcus.
114) Most common cause of patchy alopecia- Alopecia areata
115) DOC for rosacea- Metronidazole (topical), Doxy (Oral)
116) Commonest site for primary syphilis chancre- Coronal sulcus
117) First test to become positive in primary syphilis- FTA-Abs
118) Characteristic nail change in LP- Pterygium
119) Commonest cause of apple jelly nodules- Lupus vulgaris
120) Commonest cause of hypopigmented, minimally scaly macules and patches on chest and back of young adults- P. versicolor
Ribs
True ribs 1 to 7
False ribs 8 to 12
Floating ribs 11, 12
Typical ribs 3 to 9
Atypical ribs 1,2,10,11,12
Atypical intercostal space- only 1st (arrangement of VAN is not followed). Rest all are typical
Typical intercostal nerve- 3 to 6 ICN
7 th rib is the longest
1st rib is the shortest, widest, and most curved
9th rib is the most oblique
Vitamins
(Coenz. Q) K1, B2
Folic acid is Pteroyl Glutamic acid
Folinic Acid is Citrovorum factor
Erythrocyte Maturation Factor B 12
Vitamin Stored in fat D
Vitamin E Halibut Liver oil
P.E. T and Achalasia are expected to be due to deficiency of Thiamine
Red Crystalline Substance B 12
White Crystalline Substance Ascorbic Acid
Heat Labile Vitamins Vitamin C and Folic acid
Vitamins That are synthesised in Gut
(Flora) B2, B12 ( Not useful) and Vitamin K
In body (Skin) Vitamin D
F.I.G.L.U excretion is secreted in deficiency of B 12
Methylmalonic acid Excretion is increased in deficiency of B 12
Worm infestation causing B 12 deficiency Diphyllobothrium Latum
Vitamin useful in the treatment of methemoglobinemia Vitamin C ( Methylene Blue also useful)
Vitamins with which Hypervitaminosis occurs A and D
Vitamin deficiency which leads to convulsions Pyridoxine
Vitamin useful in treatment of Homocystinuria Pyridoxine
Vitamin useful in treatment of Alcaptonuria Vitamin C
Vitamin that is used peripheral vascular disease Vitamin E. ( For intermittent Claudication)
Vitamins that causes Hemolysis Vitamin K
Vitamin that causes Neonatal Jaundice Vitamin K
Vitamin that causes sensory polyneuropathy in megavitamin doses Pyridoxine
Vitamin deficiency that causes pseudo paralysis Vitamin C, Vitamin D
Vitamin for wound healing Vitamin C
Raw beef tongue is due to deficiency of Niacin
Cataract formation and Corneal
vascularisation are due to deficiency of Riboflavine
Vitamin that does not cross placenta Vitamin D
Vitamin Destroyed by Ultra – Violet Light
HOME BASED NEWBORN CARE
- Main worker - ASHA
- Institutional delivery - 6 visits (day 3,7,14,21,28,42)
- Home deliveries - 7 visits (day 1,3,7,14,28,42)
- LBW babies, Special newborn care unit (SNCU) babies to be followed for one year
- Incentive for ASHA on 45th day if
Immunization with BCG, OPV1, DPT1 entry in card
Registration of birth done
Both baby n mother safe till 42nd day of delivery
Sunday, 20 September 2015
Tyrosine Metabolic Disorders
Tyrosine Metab Disorders :-
Tyrosinemia type-1
Enzyme Defect - Fumaryl AcetoAcetate
hydrolase
Inheritence AR
Tyrosinemia type-2
Enzyme Defect - Tyrosine Transaminase
Inheritence - AR
Tyrosinemia type-3
Enzyme Defect - 4 Hydroxyphenylpyruvate
dioxygenase
Inheritence - AR
Hawkinsinuria - 4 HydroxyPhenylPyruvate
dioxygenase
Inheritence - AD
Alkaptonuria
Enzyme Defect- Homogentisic Acid oxidase
Inheritence - AR
Albinism
Enzyme Defect - Tyrosinase
Inheritence - AR
Disorders of PhenylAlanine Metab :-
PKU Type 1
Enzyme Def :- PhenylAlanine Hydroxylase
Inheritence AR
PKU Type 2
Enzyme Def :- Dihydropteridine reductase
Inheritence :- AR
Criteria and Classification
Criteria & classifications
A
Agatson score : CAD
Austin - kartush classification - middle ear risk index ( MERI)
Alanzolej classification : chloledochal cyst
Amsel's criteria: bacterial vaginosis
Ann Arbours staging: Hodgkin's lymphoma & Non Hodgkin's lymphoma
Ashbury criteria : GBS
Astler collar:colorectal cancer
B
Belthazar scoring : acute pancreatitis
Bent criteria : allergic fungal sinusitis
Butcher's criteria: Mesothelioma
Berlin's criteria : ARDS
Bismuth classification: tumors of hepatic ductal system
Bosniak classification : renal cyst
Broca's index : Ht in cms-100
Boreman classification : Gastric carcinoma
C
Child's Turcott pug score/MELD/PELD- Cirrhosis of liver
Chang staging: Medulloblastoma
cierney & millar classification : chronic osteomyelitis
Corpulence index : Actual wt/desired wt
Cottle's classification --> nasal septum
D
De meester criteria : GERD
Duke staging : colorectal cancer
Duke's criteria: Endocarditis/Heart failure
Durie salmon system of staging: Multiple myeloma
E
Epworth's criteria : Sleep apnea
Enneking's staging : Bone tumors
Evan's stagng: Neuroblastoma
F
Forrest classification: peptic ulcer bleed
Framminghams criteria/Boston's criteria: CHF
FAB: Leukemias
Fisch - glomus tumor
G
Glisson's staging: Prostrate
Gartland's classification: Supracondylar # Humerus
Glasgow Blatch ford score : Upper GI bleed for medical intervention
GOLD's criteria :COPD
Glassgow scale/Ransons criteria/APACHE score: Pancreatitis
H
Hess & Hunt Scale: subarachnoid hemorrhage
Hall's criteria : Down's syndrome
Harvard criteria : brainstem death
J
Jackson's staging:Penile Carcinoma
jones criteria.- Rheumatic fever
K
killip classification-MI with HF
L
LEEFORDT's classification : facial #
Light's criteria: pleural effusion
Lauren's classification: Gastric Ca
Levenson's criteria :- also in congenital cholesteatoma and malignant otitis externa
M
Mac afee protocol : Placenta previa
Mallampati scoring: for intubation
Milan's crjteria: for liver transplant in HCC
Mantrles criteria/Alvarado score: Appendicitis
Mayers n cottons grading system: Subglottic stenosis
Manson's classification: Radial head #
MASAOKA -Thymoma
MELD Criteria- model for end stage liver disease
Mc Donald's criteria: Multiple Sclerosis
MIDAS score : migraine
morry & peterson criteria -acute osteomyelitis
N
Neer's classification: supracondylar# femur
NADA's criteria: ASD assesment of child for heart disease
Nazer's Index: Wilsons disz
O
OKUDA staging : HCC
Oschner sherren regime : Appendicular Mass
P
Paget's Index : Abruptio placentae
paalman criteria : Ectopic pregnancy
Pretext -Hepatoblastoma
Ponderal Index: ht in cm/cube root of body wt in kgs
Q
Quetlet index: BMI -wt in kg/ht in meter square
Quintero staging -TTTS
Quebeck's grading: severity of reflex
R
Richertson bloom scoring : Breast ca.
Include
1.tubule formation
2.Mitotic index
3.Cell size(nuclear pleomorphism)
Robson's staging : RCC
Rye classification: Hodgkin's lymphoma
Rotterdam's criteria : Polycystic ovarian syndrome
Rockall scoring: adverse out come after GI bleed
Rule of wallace/Rule of 9: Burns
S
Seddon's classification: Nerve injury n regeneration
sernath staging -Hypoxic ischaemic encephalopathy
Stanford classification: Aortic dissection
SPIGELBREG criteria= OVARIAN ectopic
STUDDIFORD criteria= ABDOMINAL ectopic (pain)
Spalding's criteria: abdominal pregnancy
T
Todeni classification : chloledochal cyst
V
Van Nuys prognostic index : DCIS
W
Waterson criteria : TEF
Well's criteria: pulmonary embolism
wright & moll classification - psoriatic arthritis
Saturday, 19 September 2015
ASD
Atrial Septal Defect (ASD)
MC- Secundum (Center)✅
Primum (big on medial side)✅
Sinus Venosus (at insertion of SVC, IVC)✅
Seen in
Down's Syndrome✅
Lutembacher's syndrome ( ASD + MS/MR)✅
Ellis van creveld syndrome ( ASD + Polydactyly)✅
Holt oram syndrome ( Autosomal Dominant )✅
🍀Holt Oram Syndrome = Hand heart syndrome :
🌱Familial ASD syndrome
🌱With - VSD , Primary heart block , Atrial fibrillation, Bony Abnormality ( Thumb - absent / rudimentary)
🌱Pleiotropy - Multiple effects due to defect in single gene ( here TBX5)
🌱Can have absent radius.
🍀ASD Secundum :
1. Asymptomatic
2. S2 - Wide and fixed split
3. Grows up -
Adult -
CHF
Arrhythmias
Stroke
Eisenmenger syndrome
🌱ECG : Right axis deviation.
Treatment : Closure at 3-5yrs age by Dacron Patch
🍀ASD Primum :
1. Big cleft on the medial side
2. Also has MR (always)
Pansystolic at Apex
Radiate to axila and back
3. S2 - Wide and fixed split
4. It is severe ASD
therefore
Clinical features at 6 - 10 wks
Failure to thrive
Recurrent infections
Feeding difficulties
CHF
ECG : Left axis deviation.
Treatment : Early surgery.
Friday, 18 September 2015
Half lives
Half life
Rbc. Adults?120 days✔
Newborn? 100 days✔
Fetus? 80 days✔
Half life eryrhopoitin? 1 hour✔
Digitalis?36 hrs✔
I131? 8 days✔
I123? 13 hours✔
I132?2.3 hours✔
Tuesday, 15 September 2015
Jones
?JONES COMPILATION:
1⃣Jones Criteria▶Diagnosis of Rheumatic Fever
2⃣Bence Jones Proteinuria▶Occurs in myeloma, leukemia, and Hodgkin’s disease. They can be detected by positive Bradshaw’s test, heat test and electrophoresis
3⃣Jones Mote Reaction▶Cutaneous Basophilic Hypersensitivity-Type IV HSR
4⃣Jones Surgery in OBG▶Unification of Septate Uterus
5⃣Jones Surgery in Opht▶Bloodless repair of Senile Entropion by plication of inferior retractors
6⃣Jones Surgery in Ortho▶Claw hallux deformity
7⃣Watson Jones Approach▶Hip replacement
8⃣Watson Jones Procedure▶Chronic lateral ankle instability
9⃣Jones Compression▶Posterior Lower leg Splint for Knee and Calf injuries
1⃣0⃣Jones Tendon Transfer▶Radial nerve palsy
1⃣1⃣Jones #▶Base of 5th Metatarsal # due to pull of Peroneus brevis during inversion
1⃣2⃣Maxwell Jones▶Concept of Therapeutic Community
1⃣3⃣Jones Dye Test▶Lacrimal pump failure
Sunday, 13 September 2015
Dead End Infections
When a pathogen infects a species that it does not normally infect, it is often unable to spread effectively from that host, this situation is known as dead end infection or dead end transmission.
Dead end infections are,
Leptospirosis
Legionella
Endemic typhus
Tetanus
Human rabies
Japanese Encephalitis
T.solium
Echinococcus granulosus and Trichinella spiralis
Saturday, 12 September 2015
Bioenergetics
Calculation For Energy (Atp ) Generated By Fatty Acid Oxidation , Tca Cycle , Glycolysis & Pdh System
I) Basic Rules-
A) Energetics Of Glycolysis-
1. Energy Production Steps-
2nadh2= 2× 2.5 Atp (New) & 2× 3 Atp (Old)= 5 Atp (New) & 6 Atp (Old) - For Aerobic Glycolysis
Substrate Level Phosphorylation = 2× 2atp = 4 Atp
Total= 9 Atp (New) & 10 Atp (Old)-aerobic Glycolysis
= 4 Atp - Anerobic Glycolysis
2. Energy Utilizing Steps-
2× 1atp = 2atp
3. Net Atp Produced-
For Aerobic Glycolysis- 9 Atp (New) & 10 Atp (Old) - 2atp= 7 Atp (New) & 8 Atp (Old)
For Anerobic Glycolysis - 4 Atp - 2atp = 2atp
B) Energetics Of Pyruvate Dehydrogenase Complex-
Energy From Conversion Of 2 Moles Of Pyruvate To Acetyl Coa (Aerobic Respiration) = 2× 1nadh2= 2nadh2
Net Energy Yield= 2nadh2 = 2× 2.5 Atp (New) & 2 × 3 Atp (Old) = 5 Atp (New) & 6 Atp (Old)
C. Energetics Of Tca Cycle-each Cycle With 1acetyl Coa Metabolism Produces-
3nadh2 = 3 × 2.5 Atp (New) & 3×3 Atp (Old) = 7.5 Atp (New) & 9 Atp (Old)
1fadh2 = 1× 1.5 Atp (New) & 1×2 Atp (Old) = 1.5 Atp (New) & 2 Atp (Old)
Substrate Level Phosphorylation- 1 Gtp Formed Which Is Converted To Atp Via Adp
Gtp + Adp = Atp + Gdp
Thus 1atp
Net Yield Of Atp Per Turn ( 1mol Of Acetyl Coa) = 10 Atp (New) & 12 Atp (Old)
Thus Total Atp In Tca Cycle Per Molecule Of Glucose = 2 Acetyl Coa =2× 10/12= 20 Atp (New) & 24 Atp (Old)
D) Thus Net Yield Of Atp When 1molecule Of Glucose Is Completely Oxidised Aerobically-
1. From Aerobic Glycolysis= 7 Atp (New) & 8 Atp (Old)
2. From Pdh Complex= 5 Atp (New) & 6 Atp (Old)
3. From Tca Cycle= 20 Atp (New) & 24 Atp (Old)
Net Atp Produced= 32 Atp (New) & 38 Atp (Old)
E) Energetics Of Fatty Acid Oxidation-
1. Initial Activation Req 2 Atp= (-2atp)
2. Each Cycle Removes 1acetyl Coa & Produces-
1fadh2=1.5 Atp (New) & 2 Atp (Old)
1 Nadh2= 2.5 Atp (New) & 3 Atp (Old)
Total = 4 Atp (New) & 5 Atp (Old)
3. Thus Each Cycle Produces 4 Atp (New) & 5 Atp (Old) & 1 Acetyl Coa
4. Each Mole Of Acetyl Coa Produces 10 Atp (New) & 12 Atp (Old) In Tca Cycle
5. Now Taking Example Of Say Palmitic Acid- (C16) Saturated Fatty Acid
It Undergoes 7 Cycles Of Beta Oxidation To Produce 8 Moles Of Acetyl Coa
Thus Atp From 7 Cycles = 7× 4 Atp (New) & 5 Atp (Old)= 28 Atp (New) & 35 Atp (Old)
And Atp From 8 Acetyl Coa Via Tca Cycle= 8× 10 Atp (New) & 12 Atp (Old)= 80 Atp (New) & 96 Atp (Old)
★★★finally Net Atp From 1 Palmitic Acid=
28 Atp (New) & 35 Atp (Old) + 80 Atp (New) & 96 Atp (Old) - 2atp (For Initial Activation)= 106 Atp (New) & 129 Atp (Old) ★★★
Friday, 11 September 2015
Myelodisplastic Syndrome
MC cytogenetic change in Myelodysplastic Syndrome in adult - 5q deletion
Megaloblastoids are seen in - Myelodysplasia
Ringed sideroblast - Mitochondria encrusted iron
Treatment of MDS with 5q deletion - Lenalidomide
Splints
🌴IMPORTANT SPLINTS:
🌴 Thomas splint is for?-# FEMUR
🌴Dennis brown splint?-CTEV
🌴 cock up splint?- RADIAL NERVE PALSY
🌴 knuckle bender splint?-ULNAR N PALSY
🌴 aeroplane splint?-BRACHIAL PLEXUS INJ
🌴63 von Rosen splint?- cdh 🌴Minerva cast for?-CERVICAL SPINE DISEASE
🌴turn buckle cast. ?-SCOLIOS
🌴 Rissers cast?-SCOLIOSIS
🌴milwaukees brace?-SCOLIOSIS
🌴 BOSTON BRACE -SCOLIOSIS
🌴frog leg cast?-CDH
🌴cylinder cast?#PATELLA
🌴 hip Spica?-FEMUR #
🌴 hanging cast?- HUMERUS #
🌴tube cast?- KNEE
Triads
Triads:
Reiter syndrome triad :
Urethritis
Conjuctivitis
Arthritis
Triad of Alports Syndrome
Sensorineural deafness
Progressive renal failure
Ocular anomalies
Triad of Behcet’s Syndrome
Recurrent oral ulcers
Genital ulcers
Iridocyclitis
Beck’s Triad of Cardiac Tamponade
Muffled heart sound
Distended neck veins
Hypotension
Charcot’s Triad For Cholangitis
Fever with rigors
Right hypochondriac pain
Jaundice
Charcots triad of Multiple sclerosis
Nystagmus
Intention tremor
Stacato or scanning speech
Wilms tumor Triad –hematuria+ fever+ abd mass
Wilsons disease ( Neuro manifestation )Triad-Dystonia, inco-ordination, tremor
Triad of Hypernephroma (Renal Cell Ca)
Pain + hematuria + renal mass
Hutchinson’s Triad Of Congenital syphillis
Hutchison’s teeth
Interstitial keratitis
Nerve deafness
Triad of Kwashiorkar
Growth retardation
Mental changes
Edema
Saint’s Triad
Gall stones
Diverticulosis
Hiatus hernia
Trotter’s Triad Of Nasopharyngeal Carcinoma
Conductive deafness (blockade of Eustachian tube)
Immobility of homolateral soft palate (X th CN nerve involved)
Trigeminal neuralgia (V th CN nerve involved)
Virchow’s Triad
Stasis
Hypercoagulabilty
Vessel injury
Hemolytic Uremic Syndrome Triad
Anaemia
Thrombocytopenia
Renal failure
Pentad of TTP
Microangiopathic haemolytic anaemia
Fever
Disturbed neurological function
Renal failure
Thrombocytopenia
Fanconi Syndrome Triad
Aminoaciduria
Proteinuria
Phosphaturia
Tetany in Children – Triad
Stridor
Carpopedal spasm
Convulsions
Pentalogy of Fallot
Fallot’s tetralogy with, in addition, a patent foramen ovale or
Atrial septal defect
Vogt’s triad of Congenital Toxoplasmosis (3C)
Choroidoretinitis.
Cerebral calcification.
Convulsions
Vogt’s triad of Post congestive glaucoma –
Glaucoma flecken,
Pigments on endothelium
Iris atrophy
VOGT triad of tuberous sclerosis
Facial nevus (Adenoma sebaceum)
Seizures
Mental retardation
Vogt’s triad of Buphthalmos: (BPL) = Lacrimation, photophobia, Blepharospam
Triad of sandblom (for Hemobilia)-(MOB)
M: Melena
O: Obstructive Jaundice
B: Biliary colic.
Samters triad:
Aspirin intolerance
Asthma
Nasal polyp
Carney triad
Pulmonary chondroma
Paraganglioma (Extra adrenal)
GIST
Anderson Triad
Bronchiectasis
Cystic fibrosis
Vitamin A deficiency
Beck’s triad of Para pharyngeal Abscess
External cervical swelling (at the submandibular region which is tender)
Trismus due to spasm of the medial pterygoid
Internal swelling: of the lateral pharyngeal wall,pushing the tonsil medially
Beck’s cognitive triad (negative thought in depression)
Negative thought of self
Negative thought of environment
Negative thought of future
Cushing’s triad is a late sign of increase intra-cranial tension
Hypertension
Respiratory depression
Bradycardia
Ecological triad of disease
Causative Agent
Host
Environment
Gradenigo’s triad of Petrositis
Persistent otorrhea
Ipsilateral retro-orbital pain due to irritation of the nearby trigeminal ganglion(CN-V)
Ipsilateral squint and diplopia due to paralysis of the 6th nerve•
Trotter’s triad is diagnostic for nasopharyngeal carcinoma
Unilateral conductive hearing loss(secretory otitis media)
Ipsilateral earache and facial pain(trigeminal nerve)
Ipsilateral paralysis of the soft palate
Atta’s triad of bilharzia dysentery
Bleeding per rectum
Polyposis
Clubbing of fingers
VOGT triad of tuberous sclerosis
Facial nevus (Adenoma sebaceum)
Seizures
Mental retardation
WHIPPLE’S triad of insulinoma
Signs &symptoms of Hypoglycemia
Serum glucose < 2.5 m moles/lit
Relief of symptoms on administration of glucose
O’ Donoghue Triad:Twisting force in a weight bearing knee joint causes injury to
Medial collateral ligament
Anterior cruciate ligament
Medial meniscus
Triad of Mercury poisoning
Excessive salivation and Gingivitis
Danbury tremors (very severe= Concussio mercurialis)
Neuropsychiatric illness (Erethism)
Triad of Meig’s syndrome
Benign tumor of ovary (fibroma)
Ascites
Pleural effusion
Thursday, 10 September 2015
Influenza
Asked Points :
Malaria Epidemiology
Malaria Epidemiology
• MC species of Plasmodium in India- P.falciparum>P.vivax
• MC species of Plasmodium in world- P.vivax
• P.malariae found in which place in India- Tumkur (Karnataka)
• P.ovale found in which place in India- Delhi, Orissa,Gujrat, Assam, Kolkatta
• Most endemic state in India- Orissa
Life cycle of Plasmodium-
1. Definitive host- Female anapheles
2. Intermediate host-man
3. Modes of transmission other than mosquito bite- blood transfusion, vertical
4. Infective form -sporozoite
5. Infective form if transmitted by other than mosquito bite- merozoites
6. Infective form to mosquito-Gametocyte
7. Minimum gametocyte need to transit the infection to mosquito- 12/cmm
Placenta
Placenta 10 points [MRP=must remember points]
1. Weighs 500gm, 20 cms, 3cm thick. Placenta is from both maternal and fetal tissue; at term 80% is fetal origin
2. Maternal placenta:
1. 20% of placenta weight
2. Made of decidua basalis, margins of spongy decidua, cotyledons
3. Fetal portion placenta
1. Made of villi
2. Fetal surface is covered by amnion
4. Circumvillete:
1. circum marginate
2. Predispose to premature marginal seperation, IInd TM APH
5. Succenturate lobe:
1. Accessory cotyledon
2. Cause for PPH
6. placenta previa
1. Implanted lower than normal, in lower uterine segment, near zone of effacement
2. Mostly in parous females
3. Present as sudden painless profuse bleeding in IIIrd TM
7. Battledore placenta
1. Umbilical cord inserted in margins
2. Cord entanglement is risky
8. Membraneacea placenta
1. Decidua capsularis is vascularised, chorion does not show atrophy
9. Bi partite placenta
1. Divided placenta
2. Retention may lead to PPH, sepsis
10. Placenta accreta
1. Abnormal adherence to uterine muscle, decidua deficiency
2. Seen in Placenta previa, prev CS, prev DC, grand multi para
3. Placenta increta: invade myometrium
4. Placenta percreta: perforate myometrium
Larynx
1.vocal cord post 1/3rd cartilaginous. n ant 2/3rd membranous part.
2.angle. between 2 lamina of thyroid cartilage : male. 90degree. female : 120 degree.
3.lenghth of. vocal cord in male : 24-25 mm. n in female 16-17 mm.
4.length of larynx : vocal cord + 12 mm
5.distance. between 2 vocal cord : 19 mm.
6. focal. lenght of objective lens. ear : 200-250 nm. nose. 300 nm. throat. 400 nm
7. position of larynx in child. c2-c3. n. in adult. c3-c6.
8. size. of subglottic in preterm is less than 3 mm n. full term 4. mm. you can remember from latter itself pre. 3. n. full 4.
9. ca larynx. male. female ratio : 10:1.
10.tracheotomy. reduced the dead space. upto. : 50 percent.
Monday, 7 September 2015
TRALI
Pathogenesis - two hit hypothesis.
First hit is the priming event like endothelial activation which leads to increased sequestration and
sensitisation of neutrophils in the micro vasculature of lung. Second hit can be the antibodies in
the transfused blood product that recognise antigens expressed on neutrophils. Most common
antibodies can be those that bind MHC antigens.
2. TRALI can occur with all plasma containing products but more common with transfusion of FFP and platelets.
3. Clinically - dyspnea, tachypnea, fever, hypotension.
4. Chest X Ray - bilateral pulmonary infiltrates or white out lung. That is why most important differential diagnosis is ARDS.
Friday, 4 September 2015
Myelodysplastic Syndrome
Asked Points :
MC cytogenetic change in Myelodysplastic Syndrome in adult - 5q deletion
Cytogenetic change in Myelodysplastic Syndrome in children - Monosomy 7
Common age group affected by Myelodysplastic syndrome - >50
Ringed sideroblast characteristically seen in - Myelodysplastic syndrome
Pawn ball megakaryocytes is characteristic of - Myelodysplastic syndrome
NOT true about Myelodysplastic syndrome - Hypocellular bone marrow
Act by hypomethylation - Decitabine
Megaloblastoids are seen in - Myelodysplasia
Ringed sideroblast - Mitochondria encrusted iron
International prognostic scoring system for -
Myelodysplasia
Drug used for myelodysplastic syndrome -
Lenalidomide
Additional Points :
Treatment of MDS with 5q deletion - Lenalidomide
Malaria
Malaria:
Urban- Stephensi
Rural- Culicifacies
Brackish water- Sundaicus
Moving water- Fluviatilis
Most efficient- Fluviatilis
Overhead tanks- Stephensi
Anthrophilic- Fluviatilis
Isolation period
Isolation period of some infectious diseases-
👌🏾Chicken pox Until all lesions crusted,
usually 6 days after onset of rash
👌🏾Measles-From onset of catarrhal stage to the
3rd day of rash
👌🏾German measles/rubella None
👌🏾Hepatitis A 3 wks
👌🏾Influenza 3 days onset
👌🏾Polio 2 weeks adult, 6 wks pediatric
👌🏾Tuberculosis Until 3 wks of effective
chemotherapy
👌🏾Herpes zoster 6 days after onset of rash
👌🏾Mumps Until swelling subsides
👌🏾Meningococcal meningitis Until 1st 6 hrs of
effective antibiotic therapy
Functional and Non Functional enzymes
Functional enzymes -enzy which have specific function in plasma.
Examples of functional enzyme-
🔺coagulation enzyme
🔺lipoprotein lipase
Non -functional enzymes-
🔺have nonsoecific function in serum.
🔺Comes out from tissue as a result of normal wear n tear.
🔺There level is very low in serum
🔺level rises during tissue injury
🔺hence help to diagonse the site of tissue injury
examples
🔺LDH
🔺Creatine kinase
🔺Alakline phosphatase
Coombs Test
A) DIRECT COOMBS TEST:-
(also known as the direct antiglobulin test or DAT)
● detect antibodies or complement bound to RBC surface antigens in vivo.
●used for:-
1) immune-mediated hemolytic anemia
2) Hemolytic disease of the newborn
3) Rh D hemolytic disease of the newborn
4) ABO hemolytic disease of the newborn
5) Drug-induced immune-mediated hemolysis
6) Transfusion reaction, such as one due to improperly matched units of blood
B) INDIRECT COOMBS TEST :-
(also known as the indirect antiglobulin test or IAT)
●detect in-vitro antibody-antigen reactions
●used for:-
1) detection of very low concentrations of antibodies present in a patient's plasma/serum prior to a blood transfusion
2) in antenatal care, the IAT is used to screen pregnant women for antibodies that may cause hemolytic disease of the newborn
3) compatibility testing
4) antibody identification
5) RBC phenotyping
6) titration studies.
?☺: Tumor Lysis Syndrome
* Most commonly seen with acute leukemias, Burkitt lymphoma and other lympho-reticular malignancies (uncommon in solid tumors).
* Chemotherapy results in death of large quantities of cells, which leads to release of massive amounts of potassium, uric acid and other breakdown products into the blood.
* It develops within hours to few days of initiation of chemotherapy.
* Features:
- hypocalcemia
- renal failure due to precipitation of uric acid crystals or calcium phosphate crystals in the kidney
- hyperkalemia leading to arrhythmias
- hyperphosphatemia
* Management
- vigorous IV hydration with half normal saline
- correction of metabolic abnormalities
- hemodialysis in severe cases
Thursday, 3 September 2015
Eggs in Medicine
ALL EGGS YOU HAVE TO KNOW IN MEDICINE:: - ALL EGGS YOU HAVE TO KNOW IN MEDICINE::
• Oligodendroglial components are characterized
histologically by a moderately cellular collection of cells
with round nuclei and perinuclear halos ("fried egg"
appearance)
• The mycoplasmas are typically slow growers with a
generation time of 1-6 hours. They produce small
colonies typically described as a fried-egg appearance.
• Diphtheria 'Intermedius colonies' are small, 2 mm in size,
lustreless with domed centre and irregular margin with
'frog egg' appearance.
• Crumbled egg---> Hydatid Liver Cyst
• Scrambled egg---> Pancreatic cancer; Best Disease
• Egg in cup appearance Constrictive pericarditis
• Egg on side appearance TGV ( transportation of great
vessels )
• Egg on a string : Appearance of the heart that may be
seen with transposition of great arteries.
• Odour in poisoning: H2S--> Rotten egg
• Egg cell calcification of the hilar node: Silicosis >
sarcoidosis
• Schistosome Eggs::
Egg with
Terminal spine--> S.Hemotabium (TSH)
Lateral Spine---> S.Mansoni (LSM)
Lateral Knob--> S.Japonicum (LKJ)
• Non-bile stained egg:
"NEHA"
Necator americanus
Enterobius vermicularis
H.nana
Ancylostoma duodenale
Zoonosis
ZOONOSES
Definition: Diseases and infections which are naturally transmitted between vertebrate animals and man.
Types:
Anthropozoonoses: Diseases in animals that can be transmitted to man (eg. rabies).
Zooanthroponoses: Diseases in humans that can be transmitted to animals (eg. tuberculosis in cats, monkeys).
Amphixenoses: Diseases affecting humans and animals that can be occasionally transmitted from one to another (eg. staphyloccocal infection).
Euzoonoses: Diseases in which humans are an obligatory host of the agent (eg. Taenia solium or T. saginata)
Examples:
Some Major Bacterial Etiologic Agents of New Zoonoses
E. coli O157:H7
Borrelia burgdorferi (Lyme disease)
Helicobacter pylori and other spp.
Ehrlichia chaffeensis (HME)
Bartonella henselae (Cat scratch Disease)
Rickettsia felis (Murine typhus like)
E. Equi/A. phagocytophila (HGE)
Some Major Viral Etiologic Agents of New Zoonoses
Guanarito virus (Venezuelan hemor. fever)Sin nombre virus (Hantavirus Pulm.Syndr.)Sabia virus (Brazilian hemorrhagic fever)Hendra virus (Equine morbillivirus)Australian bat Lyssavirus (Rhabdovirus)Menangle virus (paramyxovirus)Influenza virus H5N1 (Hong Kong)Nipah virus (Paramyxovirus)Influenza virus H9N2 (Hong Kong)SARS (Coronavirus)
Types on the basis of Epidemiological cycle/Modes of transmission:
Orthozoonoses: Disease transmission cycle can be completed with only one vertebrate reservoir (eg. rabies).
Cyclozoonoses: Diseases whose maintenance cycle requires more than one vertebrate species, but no invertebrate host (eg., hydatid disease, taeniasis).
Pherozoonoses (or Metazoonoses): Diseases whose maintenance cycle requires both vertebrates and invertebrates to complete their transmission cycle (eg. arboviruses).
Saprozoonoses: Diseases that depend upon inanimate reservoirs or development sites, as well as upon vertebrate hosts (eg. listeriosis)
Depending on Clinical manifestations:
Phanerozoonoses: Zoonoses for which symptoms are observed in animals and humans. They may be Iso-symptomatic (Symptoms are the same in humans and animals eg. Rabies, tuberculosis) or Aniso-symptomatic (Symptoms are different in humans and animals eg. Q fever, anthrax)
Cryptozoonoses: Zoonoses for which there is only infection without symptoms in animals and/or humans. eg.Infection in animals/disease in humans: ornithosisInfection in humans/disease in animals: Ebola
Tuesday, 1 September 2015
Spm
SPM
Vit. A prophylaxis program --ministry of health and family
welfare,mohfw
Prophylaxis against nut.anrmia--mohfw
Iodine deficiency disorder Ctrl program.-mohfw
Special nutrition prog--ministry of social welfare,mosw
Balwadis nutrition prog--mosw
Icds--mosw
Mid meal programme--ministry f education
Mid meal scheme--ministry f HRD
A.water born dises--
diarrhoea,cholera,typhoid,dysentery,polio,hepatitis A and e
B.water based disease--snails--schistosomiasi,cyclops--
dracunculiasi
C.water related vector di--malaria,filaria,he,sleep in sickness
D. water source/washed di-
trachoma,scabies,conjuntuvitis,bacillary and amoebic dysentry,skin
sepsis,lice,salmonellosis,worm infestation
��Hardness of Water
--soap destroying power of water
A.temporary h.--d/t bicarbonates of Ca and Mg
B. permanent h.--d/t sulphate,chloride,nitrate of Ca and Mg
��Hardness of Water
Classification of hard water ( as mg/l of caco3)__
Soft--0-50 mg/ l (<1 meq/l)
Mod hard--51-150(1-3)
Hard--151-300(3-6)
��Very hard-->300(>6)
����WASTES
A.sewage--wasts water + excreta
B.sullage--waste water not contaminated with excreta e.g
kitchen,bathroom waste
C.scum--after prim sedimntn f sewage ,organic matter settle
down as sludge and fatty layer float know as scum
D.dry weather flow--avg amount f sewage which flows through sewerage system in 24 hr
����INSTRUMENTS
A.anemometer-fr low air velocity
B.kata thermometer-cooling power f air
C.assman sling psychrometer--humidity f air
D.Symons rain gauze--measurs ppt. f rain,snow,hail,dew,frost
E.dial thermometer-cold chain temp monitoring
F.salter scale--measure b. at
G.Winchester quart bottle--asses physical and chemical quality f
drinking water
H.chloroscope--measur residual cl in water
I.colorimeter--determine colour f water
J.chloronome--mixing cl in water
����Family cycle
��A.formation--marriage to birth f 1 st child
��B.extension--birth f 1 st child to birth f last child
��C.complete extension--birt f last child to 1 st child leave home
��D.contraction--1 st child leave home to last child left home
��E.completed contraction-last child left home to 1 st spouse dies
��F.dissolution--1 st spouse dies to death f survivor
Comfort Zones
��A.pleasant and cool--20
B.comfortable and cool --20-25
C.comfortable--25-27
D.hot and uncomfortable--27-28
E.extremely hot--28+
��F.intolerable hot--30+
����Overcrowding and Accepted standards
��FLOOR SPACE--accepted standards r--
>=110 sq ft.--2 persons
90-100 sq ft--1 and 1/2 person
70-90 sq ft--1 person
50-70 sq ft--1/2 person
<50 sq ft--nil
---baby < 12 month is not counted.children b/w 1-10 yr as half
����Persons per room--accepted standards r--
1 room--2 persons
2 room--3 persons
3 rooms--5 persons
>5 rooms--10 persons( addnl 2 fr each further room)