ppt by mukhtar alam

1. DIRECTED BY:DIRECTED BY: COMPLETEDBY:COMPLETEDBY:
DR.B.S.SHARMA MUKHTAR ALAMDR.B.S.SHARMA MUKHTAR ALAM
DR.ARTIMAL BAMS FINAL PROF.DR.ARTIMAL BAMS FINAL PROF.
ROLL.NO.74411ROLL.NO.74411
2014-20152014-2015
..
Project on:
Pneumonia

2. PneumoniaPneumonia
Pneumonia is an inflammatory process which involves the lungPneumonia is an inflammatory process which involves the lung
parenchyma.parenchyma.
Pathogenesis:Pathogenesis:
1.Anatomical defense mechanism1.Anatomical defense mechanism
Length of airways include nose,trachea,pharynxLength of airways include nose,trachea,pharynx
2.Mechanical defense mechanism2.Mechanical defense mechanism
Cough,sneezingCough,sneezing
3.Chemical defense mechanism
-Alfa 1 antitrypsin
-Lactoferron
-Lysozymes
-Interferon

3. 4.Immunological defense mechanism
Phagocytosis,Cell mediated and humoral
Entry of microorganismEntry of microorganism
VasodilationVasodilation
Leads to outpouring of exudates or fluidsLeads to outpouring of exudates or fluids
InflammationInflammation
(proliferation of bacteria .toxins released which cause inflammation )(proliferation of bacteria .toxins released which cause inflammation )
PhagocytosisPhagocytosis
MacrophagesMacrophages
Clearance of bacteria debrisClearance of bacteria debris

4. Four stagesFour stages::
1.Stage of congestion1.Stage of congestion
Entry of bacteriaEntry of bacteria
VasodilationVasodilation
OutpouringOutpouring
ProliferationProliferation
1-2 days upto onset1-2 days upto onset
2.Stage of Red hepatisation2.Stage of Red hepatisation
Infilteration of polymorph,RBC,fibrinInfilteration of polymorph,RBC,fibrin
2-4 days after onset2-4 days after onset
3.Stage of Grey hepatisation3.Stage of Grey hepatisation
Consolidation stageConsolidation stage
Active phagocytosisActive phagocytosis
4-8 days4-8 days

5. 4.Stage of resolution4.Stage of resolution
Activation of macrophagesActivation of macrophages
Inflammation subsideInflammation subside
Bacterial debris wash outBacterial debris wash out
Estabilishing normal parenchyma of lungEstabilishing normal parenchyma of lung
8-9 days8-9 days
Pneumonia results from-Pneumonia results from-
1.1. AspirationAspiration
2.2. Contiguous spread of virulent agents from upper airways.Contiguous spread of virulent agents from upper airways.
3.3. Secondary infection when there is disruption of protectiveSecondary infection when there is disruption of protective
mechanism.mechanism.
4.4. Haematogenous spreadHaematogenous spread

6. ClassificationClassification
A. AnatomicalA. Anatomical
1. Lobar or lobular pneumonia-1. Lobar or lobular pneumonia- Characterized by replacementCharacterized by replacement
of alveolar air with cellular exudates.of alveolar air with cellular exudates.
2. Interstitial pneumonia-2. Interstitial pneumonia- Characterized by massive proliferationCharacterized by massive proliferation andand
desquamation of alveolar cells.desquamation of alveolar cells.
3. Bronchopneumonia-3. Bronchopneumonia- Characterized by spreading inflammation ofCharacterized by spreading inflammation of
the terminal bronchioles.the terminal bronchioles.
4. Multi lobar Pneumonia4. Multi lobar Pneumonia
B. Based on duration of symptomsB. Based on duration of symptoms
1. Persistent pneumonia-1. Persistent pneumonia- persistence of symptoms andpersistence of symptoms and xx--
abnormalities for more than 4 weeks.abnormalities for more than 4 weeks.
2. Recurrent pneumonia-2. Recurrent pneumonia- two episodes of pneumonia in 1 year ortwo episodes of pneumonia in 1 year or
more than three episodes at any time withmore than three episodes at any time with xx-ray clearance between two-ray clearance between two
episodes of illness.episodes of illness.
C. Based f Etiological factorsC. Based f Etiological factors
1.1. Infective-Infective- Pneumonia occurs as a result of invasion of lungs due toPneumonia occurs as a result of invasion of lungs due to
micro-organisms such as bacteria and ruses.micro-organisms such as bacteria and ruses.
2.2. Non-infective-Non-infective- ChemicalChemical

7. Causative Agents in PneumoniaCausative Agents in Pneumonia
Infective Pneumonia
Bacterial
Atypical Pneumonia
Viral Pneumonia
Etiological Agents
Streptococcus pneumonia
H. influenza
Staphylococcus aureus
M. Tuberculosis
Chlamydia
Mycoplasma
Legionella
Respiratory syncytial virus
Para influenza virus
Influenza virus
Rhinovirus
Adenovirus

8. Difference between viral and bacterial pneumonia
Features Bacterial Pneumonia Viral Pneumonia
Onset Abrupt Gradual
Epidemic Not Seen Common
Associated Conditions Infectionate other sites, Associated with URI, coryza
septicemia
Fever High grade May be absent
Toxemia Common Absent
Respiratory Distress Common Common in infants
Lung signs Crackles ++ Wheeze ++
Chest x-ray Confluent infiltrates Diffuse in Peripheral areas
Pleural involvement May be seen Not common
Prognosis Complications such as Self-limiting, usually resolve in
empyema, pneumatoidal about a week. Hyperinflation
septicemia may be seen seen in RSV infection.

9. D.D. Based of ImmunityBased of Immunity
1. Primary Pneumonia-1. Primary Pneumonia- It is caused by organisms of high purulent andIt is caused by organisms of high purulent and
as such, it even affects those with good immunity.as such, it even affects those with good immunity.
2. Secondary Pneumonia-2. Secondary Pneumonia- this occurs with organisms of lowthis occurs with organisms of low
virulence. Either the immunity of host is diminished or somevirulence. Either the immunity of host is diminished or some
predisposing factor is present such as aspiration.predisposing factor is present such as aspiration.
E.E. Based on Source of InfectionBased on Source of Infection
1.1. Community acquired pneumonia-Community acquired pneumonia- is caused by organisms presentis caused by organisms present
in the community in children who have not been hospitalized in thein the community in children who have not been hospitalized in the
recent past.recent past.
2.2. Hospital acquired pneumonia-Hospital acquired pneumonia- is caused by organisms present inis caused by organisms present in
hospital. It occurs after at least 48-72 hours of being admitted in thehospital. It occurs after at least 48-72 hours of being admitted in the
hospital.hospital.
3.3. Opportunistic pneumonia-Opportunistic pneumonia- is seen in children with decreasedis seen in children with decreased
immunity and is caused by organisms which usually do not causeimmunity and is caused by organisms which usually do not cause
pneumonia.pneumonia.

10. Types of Pneumonia Causative Agent
Community Acquired
- Typical
Atypical
S. Pneumoniae
H. Infleunzae
S. Aureus
Mycoplasma
Chlamydia
Legionella
Hospital Acquired E. coli
Proteins
Klebsiella
S. aureus
Pseudomonas
Opportunistic P. Carinii
Cytomegalouirus (CMV)
Varicella Zoster

11. Organisms Neonates 1 month to 5years Above 5 years
Bacteria Group B
Streptococci
E. Coli
Listeria
S. Aureus
S. pneumoniae
S. aureus
H. influenza
Group A
Streptococus
Klebsiella
Pseudomonas
M. Tuberculosis
S. Pneumonia
S. Aureus
H. Influenzae
M. Tuberculosis
Viruses CMV
Herpes
CMV
RSV
Influenza virus
Adenovirus
Influenza Virus
Varicella
Atypical Organisms Chlamydia Mycoplasma Mycoplasma
Legionella
Chlamydia

12. AETIOLOGYAETIOLOGY
The causative organism depends on the following factors-The causative organism depends on the following factors-
1. Age1. Age
2. Congenital anomalies2. Congenital anomalies such as cleft palate and tracheo-such as cleft palate and tracheo-
oesophageal fistula predispose to aspiration pneumonia by organismsoesophageal fistula predispose to aspiration pneumonia by organisms
present in oral cavity.present in oral cavity.
3. Immunity status-3. Immunity status- Klabsiella infection is common isKlabsiella infection is common is
immunocompromised children.immunocompromised children.
4. Underlying lung disease-4. Underlying lung disease- S. auceus, H. influenzae and P.S. auceus, H. influenzae and P.
aeruginosa are the three most common organisms causing lungaeruginosa are the three most common organisms causing lung
infections in cystic fibrosis patients.infections in cystic fibrosis patients.
5. H/o exposure to infection-5. H/o exposure to infection- When one of the family member isWhen one of the family member is
infected with an organism, the possibility of the same infection in otherinfected with an organism, the possibility of the same infection in other
child become more.child become more.

13. Common Organisms causing Pneumonia in ImmunoCommon Organisms causing Pneumonia in Immuno
compromised Children.compromised Children.
Protozoa Bacteria Viral Fungal
P. Carinii Gram + ve
- S.
Pneumoniae
- S. Aureus
Gram – Ve
- Klebsiella
- Pseudomonas
- H. influenza
- Legionella
CMV
Varicella zoster
Measles giant
cell pneumonia
RSV
Hespes simplex
HIV
Candidiasis
Aspergillus

14. Pre-Disposing FactorsPre-Disposing Factors
1.1. Age-below 6 monthsAge-below 6 months
2.2. Neonatal factors – preterm, low birth weight babies.Neonatal factors – preterm, low birth weight babies.
3.3. Congenital defects (may predispose to aspiration)- cleft palate, toCongenital defects (may predispose to aspiration)- cleft palate, to
Fistula, ciliary dyskinesia.Fistula, ciliary dyskinesia.
4.4. Bad child hearing practices- bottles feeding, lack of breast-feeding.Bad child hearing practices- bottles feeding, lack of breast-feeding.
5.5. Nutritional factors- protein energy malnutrition vit. A deficiency (severe),Nutritional factors- protein energy malnutrition vit. A deficiency (severe),
iron deficiency anemia, zinc deficiency and so on.iron deficiency anemia, zinc deficiency and so on.
Systemic factorsSystemic factors
Cardiovascular causes- congenital heart diseases, left to right shunts.
Chronic lung diseases- asthma, cystic fibrosis
Others- measles, diarrhoea, sinusitis, otitis media
7. Immunological status- immunosuppressed states
8. Malignancy
9. Iatrogenic – anesthesia
10. Trauma

15. Environmental FactorsEnvironmental Factors
1.1. OvercrowdingOvercrowding
2.2. Number of siblings (order of birth)Number of siblings (order of birth)
3.3. Indoor air pollutionIndoor air pollution
4.4. SanitationSanitation
5.5. Passive smokingPassive smoking
6.6. Educational statusEducational status
Clinical FeaturesClinical Features
SymptomsSymptoms
1.1. Fever with chillsFever with chills
2.2. Fast and difficult breathingFast and difficult breathing
3.3. CoughCough
4.4. Chest painChest pain
5.5. Abdominal painAbdominal pain
6.6. Poor feedingPoor feeding
7.7. IrritabilityIrritability
8.8. Excessive sleepinessExcessive sleepiness

16. SignsSigns
1.1. TachypnoeaTachypnoea
2.2. Chest retractionChest retraction
3.3. Grunting and stridorGrunting and stridor
4.4. Nasal flaringNasal flaring
5.5. CyanosisCyanosis
6.6. Dullness on percussionDullness on percussion
7.7. Diminished breath sounds, wheeze and crackles onDiminished breath sounds, wheeze and crackles on
auscultationauscultation
8.8. May be associated with meningismus, paralytic ileus.May be associated with meningismus, paralytic ileus.
9.9. Right lower lobe pneumonia causes diaphragmatic irritationRight lower lobe pneumonia causes diaphragmatic irritation
which may present as hiccoughswhich may present as hiccoughs

17. InvestigationsInvestigations
1.Chest radiography- PA and lateral view1.Chest radiography- PA and lateral view
2.Total and differential blood count, haemoglobin2.Total and differential blood count, haemoglobin
3.3. Tests to identify organismsTests to identify organisms
(a)(a) Microscopic examination – gMicroscopic examination – g
ram staining and AFB stainingram staining and AFB staining
(b)(b) Serological tests for bacteria and virusesSerological tests for bacteria and viruses
(c)(c) Urinary antigen tests for bacterial and viral antigensUrinary antigen tests for bacterial and viral antigens
(d)(d) Rapid antigen detection tests such as direct fluorescent antibody testRapid antigen detection tests such as direct fluorescent antibody test
(e)(e) Polymerase chain reaction for mycobacteriumPolymerase chain reaction for mycobacterium
(f)(f) Culture studies in sputum and blood.Culture studies in sputum and blood.
Specimens to identify the organisms are taken from nasopharyngealSpecimens to identify the organisms are taken from nasopharyngeal
aspirate, the oat swab, bronchoalveolar lavage and lung aspirates.aspirate, the oat swab, bronchoalveolar lavage and lung aspirates.

18. Indications for AdmissionIndications for Admission
1.1. Severe malnutritionSevere malnutrition
2.2. ImmunodeficiencyImmunodeficiency
3.3. Severe anaemiaSevere anaemia
4.4. disseminated infection, septicemia and shockdisseminated infection, septicemia and shock
5.5. Drowsiness and altered senosoriumDrowsiness and altered senosorium
6.6. Decreased ODecreased O22 saturationsaturation
7.7. Leucopenia or leucocytosisLeucopenia or leucocytosis
8.8. Culture and sensitivity tests- result growth of staphylococcusCulture and sensitivity tests- result growth of staphylococcus
aureusaureus

19. Supportive TreatmentSupportive Treatment
In mild cases it should be givenIn mild cases it should be given
AntihistaminicAntihistaminic
AntipyreticAntipyretic
Anti allergicAnti allergic
There is no role in antibiotic in viralThere is no role in antibiotic in viral
1.1. OxygenOxygen
2.2. Intra venous fluidIntra venous fluid
3.3. Good nutritionGood nutrition
4.4. If fever is present then tepid sponging should be given ParacetamolIf fever is present then tepid sponging should be given Paracetamol
will also be helpfulwill also be helpful
5.5. Predisposing factors should be avoidedPredisposing factors should be avoided
6.6. PhysiotherapyPhysiotherapy

20. Management:Management:
1.Severe pneumonia1.Severe pneumonia
O2 inhalation ,Maintain good hydration, good nutrition with antibioticO2 inhalation ,Maintain good hydration, good nutrition with antibiotic
therapytherapy
2.Viral pneumonia2.Viral pneumonia
-vomiting (no antiemetics)-vomiting (no antiemetics)
-loose motion (no intervention)-loose motion (no intervention)
lathouh-lathouh- in case of feverin case of fever
Anand bherav rasaAnand bherav rasa-in-in cace of loose motioncace of loose motion
Laxmivilas rasaLaxmivilas rasa ––acute corhyzaacute corhyza
Kafketu rasaKafketu rasa--productive corhyzaproductive corhyza
RoutinelyRoutinely
1.Laxmivilas rasa ,Kafketu rasa1.Laxmivilas rasa ,Kafketu rasa
2.Vishan bhasm and shring bhasm –in2.Vishan bhasm and shring bhasm –in parshv shoolparshv shool
3.Kwath3.Kwath-Gojihvvadi,Panchkoiladi,Laookqe Sapista-Gojihvvadi,Panchkoiladi,Laookqe Sapista
4.Nasal decongestant4.Nasal decongestant-Ajvain fumes inhalation-Ajvain fumes inhalation
55..Talishadi churnaTalishadi churna

21. General Protocol:General Protocol:
1.Luke warm water-shunthi/aadrak sidhh1.Luke warm water-shunthi/aadrak sidhh
2.Haldi,aadrak,tulsi ptra,kalimirch-tea/kwath2.Haldi,aadrak,tulsi ptra,kalimirch-tea/kwath
3.Pind khajoor,adrak,pipli-chhir paka3.Pind khajoor,adrak,pipli-chhir paka
4.Local fomentation4.Local fomentation
3.Bacterial pneumonia3.Bacterial pneumonia
1.Makardhavaj/Rasasindoor1.Makardhavaj/Rasasindoor
2.Trilokya chintamani swaras not used in shirap awastha2.Trilokya chintamani swaras not used in shirap awastha
3.vrihat kasturi bherav rasa3.vrihat kasturi bherav rasa
4.bramhmi vati4.bramhmi vati
4.Severe stage convulsions4.Severe stage convulsions
Mukta pishti,godanti-protect vital partsMukta pishti,godanti-protect vital parts
Sitopladi churna-brinhan hetuSitopladi churna-brinhan hetu
Balchaturbhadra churna-if diarrheaBalchaturbhadra churna-if diarrhea
Kshir pak-Kshir pak-
MunakkaMunakka
Anjir,Kesar ,Shunthi,pipaliAnjir,Kesar ,Shunthi,pipali

22. PreventionPrevention
1.Immunization1.Immunization
2.Health education to mother2.Health education to mother
3.Proper implementation of ART Control programme3.Proper implementation of ART Control programme
4.High risk factors should be avoided4.High risk factors should be avoided
Recurrent and Persistent PneumoniaRecurrent and Persistent Pneumonia
Etiology of recurrent and persistent PneumoniaEtiology of recurrent and persistent Pneumonia
Causes Conditions
Congenital
Infections
CMV
Non-infections Cleft palate
To fistula
Gastro-oesophageal reflux
Sickle cell anaemia
Acquired Infections Otitis media, sinusitis, bronchietasis,
CMV infection
Non-infections Recurrent aspiration foreign body
aspiration Asthma

23. Typical PneumoniaTypical Pneumonia
It is also known as 'walking pneumonia'. The children with theseIt is also known as 'walking pneumonia'. The children with these
infections present with atypical symptoms.infections present with atypical symptoms.
Features Typical pneumonia A typical pneumonia
Causative organisms S. Pneumoniae
S. dureus
H. influenza
M. Pneumonae
Chlmyadia Pneumoniae
Legionella
Onset Sudden Gradual
Age Any age Usually > 5 years, except
chlamyetia which
commonly occurs without
first 6 months.
Fever common may be present
cough productive dry
symptoms pulmonary systemic
x-ray chest findings localised diffuse

24. Radiological findings in various types of pneumoniaRadiological findings in various types of pneumonia
Radiological Changes Type of Pneumonia
1. Lobar involvement Pneumococcal pneumonia
2. Right middle lobe
pneumonia
Aspiration pneumonia
3. Upper lobe pneumonia,
cavitations, bronchopneumonia
with hilar lymphadenopathy
Tuberculosis pneumonia
4. Lower lobe pneumonia Chemical pneumonia
5. Multiple abscesses staphylococcal / klebsiella
pneumonia
6. Bilateral interstitial
pneumonia
Viral pneumonia
7. B/L interstitial pneumonia Pneumocystic carinric

25. Classification of Pneumonia according WHOClassification of Pneumonia according WHO
Classification Clinical Features
No proumonia Cough & No fast breathing
No chest indrawing & Feeding well
Pneumonia Cough & No chest in drawing & Able to
drink Fast breathing
Severe pneumonia Lower chest in drawing present & Able to
drink
Fast breathing & Other signs may be
present – nasal flaring, grunting, cyanosis
Very severe pneumonia Not able to drink & Cyanosis
Striders in calm child
severe respiratory distress or grunting
lethargy, excessive drowsiness
convulsions

26. ComplicationsComplications
System Complications
1. Respiratory
Pulmonary Suppurative lung diseases & Collapse
Bronchiectasis
Pleural Parapneumonic effusion & empyema
Pneum othorax & Pyopneumothorax
2. Cardiovascular Acute circulatory failure due to
bacteraemia
Pericarditis & Endocarditis
Miscellaneous Meningism & Shock due to bacteriaemia
Multiorgan failure

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31. BIBLIOGRAPHYBIBLIOGRAPHY
1.Kaumarbhritya –Prof.Devendranath Mishra1.Kaumarbhritya –Prof.Devendranath Mishra
Chowkhamba publicationChowkhamba publication
2.Bailey and Love – A short text book of Surgery2.Bailey and Love – A short text book of Surgery
3.Human Anatomy – B.D.Chaurasia3.Human Anatomy – B.D.Chaurasia
4.Human Physiology – Prof.A.K.Jain4.Human Physiology – Prof.A.K.Jain
5.Hutchison’s Clinical Methods5.Hutchison’s Clinical Methods
6.A Text Book Of pathology – William Boyd6.A Text Book Of pathology – William Boyd
7.WWW.GOOGLE.COM7.WWW.GOOGLE.COM
8.Meharban Singh paediatrics8.Meharban Singh paediatrics
9. OP Ghai Textbook of pediatrics9. OP Ghai Textbook of pediatrics
10.Medsape10.Medsape
11.11. ¼;ks-j-ck-jks-fp-i`- 456½¼;ks-j-ck-jks-fp-i`- 456½
12.12. ¼p-fp- 3@53&54½¼p-fp- 3@53&54½

32. THANKSTHANKS