Introduction:-
The heart is roughly cone – shaped hollow muscular organ. It is about 10 cm long & is about the size of the owner’s fist. Its weighs about 225g in women and is heavier in men about 310 g.
Position:- The heart lies in the thoracic cavity in the mediastinum . It lies obliquely, a little more to the left than the right and presents a base above, and an apex below. The apex is about 9 cm to the left of the midline at the level of the 5th intercostal space, i.e a little below the nipple and slightly nearer the midline. The base extends to the level of the 2ndrib.
Organs associated with the heart:-
(1) Inferiorly –the apex rests on the central tendon of the diaphragm
(2) Superiorly –the great blood vessels , i.e the aorta, superior vena cava , pulmonary artery and pulmonary veins
(3) Posteriorly-the oesophagus , trachea , left and right bronchus, descending aorta, inferior vena cava and thoracic vertebrae
(4) Laterally –the lungs
(5) Anteriorly:- the sternum , ribs and intercostal muscles .
Structure:- The heart is composed of three layers of tissue-
–Pericardium
— Myocardium
— Endocardium
(1) Pericardium:- It is outer layer of heart . It is made up of two sacs. The outer sac consists of fibrous tissue and the inner of a continuous double layer of serous membrane.
The two layers of pericardium are-
– Outer layer (parietal pericardium)
– Inner layer (visceral pericardium)
(2) Myocardium:- The myocardium is composed of specialised cardiac muscle found only in the heart. It is not under voluntary control but, like skeletal muscle, cross –stripes are seen on microscopic examination.
(3) Endocardium:- It is inner most layer of heart. This lines the chambers and valves of the heart. It is a thin, smooth, glistening membrane that permits smooth flow of blood inside the heart. It consists of flattened epithelial cells, and it is continuous with the endothelium lining the blood vessels.

INTRODUCTION:– Hyperthyroidism, also known as overactive thyroid and hyperthyreosis, is the condition that occurs due to excessive production of thyroid hormone by the thyroid gland. Thyrotoxicosis is the condition that occurs due to excessive thyroid hormone of any cause and therefore includes hyperthyroidism
Sign & symptoms:-
Hyperthyroidism may be asymptomatic or present with significant symptoms. Some of the symptoms of hyperthyroidism include
1) nervousness, irritability,
2) increased perspiration,
3) heart racing,
4) hand tremors
5) , anxiety, difficulty sleeping,
6) thinning of the skin,
7) fine brittle hair,
8) Muscular weakness—especially in the upper arms and thighs.
9) More frequent bowel movements may occur, and diarrhea is common.
10) Weight loss, sometimes significant, may occur despite a good appetite

CAUSE:-
The major causes in humans are:
• Graves’ disease. An autoimmune disease
• Toxic thyroid adenoma
• Toxic multinodular goiter
High blood levels of thyroid hormones (most accurately termed hyperthyroxinemia) can occur for a number of other reasons:
• Inflammation of the thyroid is called thyroiditis. There are several different kinds of thyroiditis including Hashimoto’s thyroiditis (Hypothyroidism immune-mediated), and subacute thyroiditis . These may be initially associated with secretion of excess thyroid hormone, but usually progress to gland dysfunction and, thus, to hormone deficiency and hypothyroidism.
• Oral consumption of excess thyroid hormone tablets is possible (surreptitious use of thyroid hormone),
• Amiodarone, an anti-arrhythmic drug, is structurally similar to thyroxin and may cause either under- or over activity of the thyroid.
• Postpartum thyroiditis (PPT) occurs in about 7% of women during the year after they give birth.
• A Struma ovarian is a rare form of monodermal teratoma that contains mostly thyroid tissue, which leads to hyperthyroidism.
• Excess iodine consumption notably from algae such as kelp
DIAGNOSIS:- Measuring the level of thyroid-stimulating hormone (TSH), produced by the pituitary gland (which in turn is also regulated by the hypothalamus’s TSH Releasing Hormone) in the blood is typically the initial test for suspected hyperthyroidism. A low TSH level typically indicates that the pituitary gland is being inhibited or “instructed” by the brain to cut back on stimulating the thyroid gland, having sensed increased levels of T4 and/or T3 in the blood. In rare circumstances, a low TSH indicates primary failure of the pituitary, or temporary inhibition of the pituitary due to another illness (euthyroid sick syndrome) and so checking the T4 and T3 is still clinically useful.
TREATMENT:-
Anti thyroid drugs
Hydrostatics (ant thyroid drugs) are drugs that inhibit the production of thyroid hormones, such as carbimazole (used in UK) and methimazole (used in US), and propylthiouracil.
Beta-blockers
Many of the common symptoms of hyperthyroidism such as palpitations, trembling, and anxiety are mediated by increases in beta adrenergic receptors on cell surfaces.
Diet
People with autoimmune hyperthyroidism should not eat foods high in iodine, such as edible seaweed and kelps.

INTRODUCTION:
The heart is a muscular organ in humans and other animals, which pumps blood through the blood vessels of the circulatory system. Blood provides the body with oxygen and nutrients, and also assists in the removal of metabolic wastes. The heart is located in the middle compartment of the mediastinum in the chest.
STRUCTURE
The heart is situated in the middle mediastinum behind the breastbone in the chest, at the level of thoracic vertebrae T5-T8. The right side of the heart is deflected forwards, and the left deflected to the back.
CARDIAC OUTPUT
The x-axis reflects time with a recording of the heart sounds. The y-axis represents pressure.
Cardiac output (CO) is a measurement of the amount of blood pumped by each ventricle (stroke volume) in one minute. This is calculated by multiplying the stroke volume (SV) by the beats per minute of the heart rate (HR). So that: CO = SV x HR. The cardiac output is normalized to body size through body surface area and is called the cardiac index.
The average cardiac output, using an average SV of about 70mL, is 5.25 L/min, with a range of 4.0–8.0 L/min.The stroke volume is normally measured using an echocardiogram and can be influenced by the size of the heart, physical and mental condition of the individual, sex, contractility, duration of contraction, preload and afterload. Preload refers to the filling pressure of the atria at the end of diastole, when they are at their fullest. A main factor is how long it takes the ventricles to fill—if the ventricles contract faster, then there is less time to fill and the preload will be less. Preload can also be affected by a person’s hydration status. The force of each contraction of the heart muscle is proportional to the preload, described as the Frank-Starling mechanism. This states that the force of contraction is directly proportional to the initial length of muscle fiber, meaning a ventricle will contract more forcefully, the more it is stretched. Afterload, or how much pressure the heart must generate to eject blood at systole, is influenced by vascular resistance. It can be influenced by narrowing of the heart valves (stenosis) or contraction or relaxation of the peripheral blood vessels.

INTRODUCTION
Salivary glands release there secretions into ducts that leads to the mouth. There are three main pairs:
The parotid glands
The submandibular glands
The sublingual glands

The parotid glands:
These are situated one on each side of the face just below the external acoustic meatus. Each gland has a parotid duct opening in the mouth at the level of the second upper molar teeth.
The submandibular glands:
These lie on one on each side of the face under the angle of the jaw. The two submandibular ducts open on the floor of the mouth, one on each side of the frenulum of the tongue.
The sublingual glands:
These glands lie under the mucus membrane of the floor of the mouth in front of the submandibular glands. They have numerous small ducts that open into the floor of the mouth.
HISTOLOGY
The gland is internally divided into lobules. Blood vessels and nerves enter the glands at the hilum and gradually branch out into the lobules.
Acini
Secretory cells are found in a group, or acinus (plural, acini). Each acinus is located at the terminal part of the gland connected to the ductal system, with many acini within each lobule of the gland. Each acinus consists of a single layer of cuboidal epithelial cells surrounding a lumen, a central opening where the saliva is deposited after being produced by the secretory cells. The three forms of acini are classified in terms of the type of epithelial cell present and the secretory product being produced: serous, mucoserous and mucous.
Ducts
In the duct system, the lumina are formed by intercalated ducts, which in turn join to form striated ducts. These drain into ducts situated between the lobes of the gland (called interlobar ducts or secretory ducts). These are found on most major and minor glands (exception may be the sublingual gland
All of the human salivary glands terminate in the mouth, where the saliva proceeds to aid in digestion. The saliva that salivary glands release is quickly inactivated in the stomach by the acid that is present there but the saliva also contains enzymes that are actually activated by the acid.

Introduction: – Most People Who Are Exposed To Tb Never Develop Symptoms Because The Bacteria Can Live In An Inactive Form In The Body. But If The Immune System Weakens, Such As In People With HIV Or Elderly Adults, Tb Bacteria Can Become Active. In Their Active State, Tb Bacteria Cause Death Of Tissue In The Organs They Infect.
Tb Affects All Age Groups And All Parts Of The World. However, The Disease Mostly Affects Young Adults, And People Living In Developing Countries.
Definition: – Tb Is A Bacterial Infection That Can Spread Through The Lymph Nodes And Bloodstream To Any Organ In Your Body. It Is Most Often Found In The Lungs.

Causes: – The Mycobacterium Tuberculosis Bacterium Causes Tb. It Is Spread Through the Air When A Person With Tb (Whose Lungs Are Affected) Coughs, Sneezes, Spits, Laughs Or Talks.
Sign &Symptoms:-
• Coughing, Sometimes With Mucus Or Blood
• Chills
• Fatigue
• Fever
• Loss Of Weight
• Loss Of Appetite
• Night Sweats.
Tb Can Spread To Other Parts Of The Body Through The Bloodstream:
• Tb Infecting The Bones Can Lead To Spinal Pain And Joint Destruction
• Tb Infecting The Brain Can Cause Meningitis
• Tb Infecting The Liver And Kidneys Can Impair Their Waste Filtration Functions And Lead To Blood In The Urine
• Tb Infecting The Heart Can Impair The Heart’s Ability To Pump Blood, Resulting In A Condition Called Cardiac Tamponade That Can Be Fatal.
Diagnosis:-
The Mantoux Tuberculin Skin Test, Or Tst, Is Performed By Placing An Intradermal Injection Of 0.1 Ml Of Purified Protein Derivative Containing 5 Tuberculin Units Into The Volar Surface Of The Forearm. The Injection Should Be Made With A Disposable 27-Gauge Tuberculin Syringe, Just Beneath The Surface Of The Skin, With The Needle Bevel Facing Upward. This Should Produce A Wheal 6 Mm To 10 Mm In Diameter.

Administering The Mantoux Tuberculin Skin Test
The Reaction Is Read By Measuring In Millimeters The Diameter Of Induration (Palpable Raised Hardened Area) Across The Forearm. If There Is No Induration, The Result Should Be Recorded As 0 Mm. The Area Of Erythema Should Not Be Measured, Just The Induration.

Reading The Mantoux Tuberculin Skin Test: (Left, Correct) Only The Induration Is Being Measured; (Right, Incorrect) The Erythema Is Being Measured.
Reactions ≥5 Mm. A Tst Reaction Greater Than Or Equal To 5 Mm Of Induration Is Interpreted As A Positive
Reactions ≥10 Mm. A Tst Reaction Greater Than Or Equal To10 Mm Of Induration Is Interpreted As A Positive Result In Individuals Who Do Not Meet The Preceding Criteria But Who Have Other Risk Factors For Tb.
Reactions ≥15 Mm. A Tst Reaction Greater Than Or Equal To 15 Mm Of Induration Is Interpreted As A Positive Result In All Cases.

Confirmation Is Done By Sputum Test.
Blood Test
Chest X-Ray etc.
Medical Management:-
DIRECTLY OBSERVED THERAPY (Dot)
Dot Means That A Nurse Or Another Designated Individual Watches The Patient Swallow Each Dose Of Tb Medication. Dot Can Significantly Reduce The Development Of Drug Resistance, Treatment Failure, Or Relapse After Treatment Ends. Establishing A Relationship With The Patient And Addressing Barriers To Adherence Is The Core Of A Successful Dot Program.
Therapy May Be Directly Observed In A Medical Office Or Clinic Setting But Can Also Be Observed By An Outreach Worker In The Field.
Dot Is Recommended For All Children And Adolescents With Tb. Even When Drugs Are Given Under Dot, Tolerance To The Medications Must Be Monitored Closely. It Is Not Advised To Rely On Parents Alone To Supervise Dot
Recommended Regimen

• Isoniazid (Inh), 300 Mg, Daily For At Least 6 Months, And Preferably For 9 Months
• Isoniazid (Inh), 900 Mg, Plus Rifapentine (Priftin), 900 Mg, Weekly For 3 Months (Dot)
• Rifampin (Rifadin), 600 Mg, Daily For 4 Months
• Isoniazid (Inh), 300 Mg, Plus Rifampin (Rifadin), 600 Mg, Daily For 3 Months
• Isoniazid (Inh), 900 Mg, Plus Rifampin (Rifadin), 600 Mg, Twice Weekly For 3 Months

Introduction
Blepharitis is a common eye condition characterized by chronic inflammation of the eyelid, usually where eyelashes grow, resulting in inflamed, irritated, itchy, and reddened eyelids. A number of diseases and conditions can lead to blepharitis. It can be caused by the oil glands at the base of the eyelashes becoming clogged, a bacterial infection, allergies, or other conditions.
The severity and course can vary. Onset can be acute, resolving without treatment within 2–4 weeks (this can be greatly reduced with lid hygiene), but more generally is a long-standing chronic inflammation of varying severity.
It may be classified as seborrhea, staphylococcal, mixed, posterior or meibomitis, or parasitic. It usually does not cause permanent damage.
SYMPTOMS: – Symptoms associated with blepharitis include:
• Watery eye
• Red eyes
• Red/swollen eyelids
• Crusting at the eyelid margins/base of the eyelashes/medial cantus, generally worse on waking
• Eyelid sticking
• Eyelid itching
• Flaking of skin on eyelids
• Gritty/burning sensation in the eye, or foreign-body sensation
• Eyelids appear greasy
• Frequent blinking
• Light sensitivity/photophobia
• Misdirected eyelashes that grow abnormally
• Eyelash loss
• Infection of the eyelash follicle/sebaceous gland (hordeolum)
• Debris in the tear film, seen under magnification (improved contrast with use of fluorescein drops)

DIAGNOSIS: – The doctor typically diagnoses the condition on physical examination of the area. A specimen of material is occasionally collected for bacterial or fungal testing

PREVENTION:- Careful daily washing of the eyelids seems to prevent blepharitis. A simple routine is to wash each eyelid for 30 seconds twice a day, using a clean face flannel with a single drop of nonirritant soap (e.g. baby shampoo) and ample water.

TREATMENT: – Blepharitis does not often disappear entirely, and even successful treatment is often followed by relapses.
A Cochrane Systematic Review of topical antibiotics was shown to be effective in providing symptomatic relief and clearing bacteria for individuals with anterior blepharitis. Topical steroids provided some symptomatic relief but were ineffective in clearing bacteria from the eyelids. Lid hygiene measures such as warm compresses and lid scrubs were found to be effective in providing symptomatic relief for participants with anterior and posterior blepharitis
HOME CARE:-
• Soften lid margin debris and oils: Place a very warm wet compress such as a warm wet washcloth over the closed eyelids for five minutes Re-wet and reapply it as it cools. This warms, softens, and loosens crusty and oily eyelid gland deposits
• Remove lid margin debris: Immediately after, gently wash the eyelids with a warm, wet, soapy washcloth to remove accumulated debris. Use diluted non-burning baby shampoo. Gently and repeatedly rub along the lid margins while eyes are closed.
• Antibiotics (if prescribed): To reduce lid margin bacteria to help control blepharitis caused by a bacterial infection, antibiotics such as erythromycin or sulfacetamide may be used via eye drops, cream, or ointment on the eyelid margin.
• Steroid eye drops/ointments. Eye drops or ointments containing corticosteroids, sometimes combined with antibiotics, can help control eye and eyelid inflammation.
• Treat underlying conditions. Blepharitis caused by seborrhea dermatitis, rosacea, or other diseases may be controlled by treating the underlying disease.
• Eye make-up should be discontinued while inflammation is present
• Dandruff shampoo. If dandruff is contributing to the blepharitis, using a dandruff-controlling shampoo may relieve blepharitis symptoms.

DESCRIPTION-
Patients with respiratory dysfunction are treated with oxygen inhalation to relieve anoxemia or hypoxemia(deficiency of oxygen in blood).The normal amount of oxygen in the arterial blood should be in the range of 80 to 100 mm of hg. If it falls below 60 mm of hg, irreversible physiologic effects may occur.
METHODS-
1. Nasal canula: the two canula about 1.5cm long protrude from the centre of a disposable tube and are inserted and. Oxygen is delivered via canula with a flow rate of up to 4 liter/minute.
2. Nasal catheter: most common method of administering oxygen to the patients in hospital wards, the nasal catheter is inserted into the nostrils reaching up to the uvula and is held in place by adhesive tape. Flow of 1 to 4 liters of oxygen will be sufficient to maintain the concentration of 22 to 30% oxygen.
3. Oxygen by mask:. It is shaped to fit snugly over the mouth and nose and is secured in place with a strap. There are 2 primary types of mask, high and low concentration. It is used to deliver oxygen concentration of 24% to28%, 30%, 35%, with oxygen flow rates of 2 to 3, 4, 6liter/minute respectively.
4. Oxygen tent: an oxygen tent consists of canopy over the patient’s bed that may cover the patient fully or partially and is connected to a supply of oxygen.
NURSE RESPONSIBILITY IN THE ADMINISTRATION OF OXYGEN
 Check the name, bed no. and other identifications of the patient.
 Check doctors order for specific precautions regarding the movement and positioning of the patient.
 Assess the patient for any signs of clinical anoxia.
 Assess the patients vital signs and breathing pattern carefully.
 Check the result of ABG analysis.
 Note any signs of pulmonary dysfunction.
STEPS OF PROCEDURE
 Wash hands
 Measure the length of the nasal catheter to be introduced into the nostrils.
 Lubricate the tip of the catheter sparingly with water soluble jelly and then check the flow by immersing it in the water.
 Introduce catheter slowly to one of the nostrils to the previously marked distance. If any obstruction is encountered withdraw the catheter a little, rotate it and introduce it again.

Description:
INTRODUCTION-It is a coronargry heart disease may lead to development of heart failure. Heart failure is not a disease but group of manifestation inwhich inadequate pump performance of heart that leads to pulmonary & systemic congestion.
Definition-Heart failure is a physiological state inwhich the heart can not pump enough blood to meet the metabolic demand of the body. It is also known as heart failure.
Etiology-
1. Abnormal loading condition
– Hypervolemia
-Congenital heart disease
-Pulmonary hypertension
– Valvular stenosis [Narrowing of valve]
– Valvular regurgitation [In complete closure of valve]
– Valvular prolapse [Protrusion of valvular leaflet into the atrium]
2.Malfuncton of myocardium-
– coronary artery disease
– cardiomyopathy [Abnormality of myocardium muscles]
– Pericarditis
– Myocarditis
– Endocarditis
3. Condition which precipitate heart failure –
– Pregnancy
– Anemia
– Hypertension
– Renal disease
– Smoking, tobacoo, & alcohol
– Excess administration of fluid
– High intake sodium
PATHOPHYSIOLOGY
Due to etiological factor

Left ventricular hypertrophy

Ventricular hypertrophy leads to increase muscles fibers diameter

Increase contractile function of cardiac muscle fibers

Increase heart work load

When heart fail then compensatory mechanism of heart is do act (States)

If it is fail then Increase residual volume of left ventricles.

Receiving capacity of heart

Pulmonary edema

Pressure Increase on right ventricles

Right ventricles fail

Systemic congestion
Clinical manifestation:-
(1) RHF/RVF:-
• Oedema of ankle, knee & extremities
• Juglar vein distension
• Weight gain
• Hepatomegaly
• Spleeno megaly
• Ascites(Bowel sound absent)
• A, N, V & constipation
(2) LHF/LVF:-
• Dyspnoea
• Pulmonary oedema
• Crackle sound in lungs
• Coughing
• Wheezing
• Tachypnoea
• Cyanosis
• Paroxysmal nocturnal dyspnoea
Diagnostic Measures:-
• History taking
• Physical examination
• E.C.G (QRS-Large)
• Echo cardiography( Hypertrophy & dilataion Ejection Fraction)
• X-ray, USG, Lipid profile,CBC, BNP,CT-Scan, MRI
Treatement:-
• Digitalis/Digoxin/cardiac glucosides
Action:- Increase the force of myocardial contraction, increase cardiac output.
• Diuretics:- ex. Furosemide, thiazide
• Angiotensin coverting enzyme inhibitors ex. Captopril, Analapril

Surgical Management:– Heart transplantation

INTRODUCTION
Lactation is a complex physiologic process under neuroendocrine control. It is the biologic completion of the reproductive cycle. Starting at about 16 week’s gestation the breasts develop and prepare for full lactation. In the first few postpartal hours and days the breast respond to hormones and the stimulation of the infants suck to produce and release milk.
PHYSIOLOGY OF LACTATION
The physiological basis of lactation is divided into four phases:
Mammogenesis or preparation of breasts
Lactogenesis or initiation of milk sectetion
Galactokinesis or ejection of milk and
Galectopoiesis or maintenance of established milk secretion.
MAMMOGENESIS
Pregnancy is associated with a remarkable growth of both buctal and lobulo-alveolar system. During lactation the breast tissue is characterized by large numbers of alveoli. After lactation when, milk is no longer removed from the breast by the infant the alveoli gradually collapse and adipose tissue increases.
LACTOGENESIS
Complex nervous and endocrine factors are involved in the establishment of milk production in the first 2 to 5 days postpartum. Child birth results in a rapid decrease in oestrogen and progestron and an increase in prolactin secretion. Prolactin from the pituitary gland triggers milk production by stimulating the alveolar cells of the breast. Prolactin levels increase in responsible to tactile stimulation of the breast and sucking by the infant.
GALACTOKINESIS
Discharge of milk from mammary glands depends not only on the suction exerted by the baby during sucking, but also on the contractile mechanism which expresses the milk from the alveoli into the ducts. The milk ejection is inhibited by factors such as pain, breast engorgement or adverse psychic condition.
GALECTOPOIESIS
Prolactin is the most important galactopoietics – hormone. For maintenance of effective and continuous lactation, suckling is essential as it causes release of porlactin. Milk pressure reduces the rate of production and hence periodic breast feeding is necessary to relieve the pressure which in term maintains the secretion.

Percentage Composition of colostrums and breast milk
PROTEIN FAT CARBOHYDRATES WATER
COLOSTRUM 8.6 2.3 3.2 86
BREAST MIKL 1.2 3.2 7.5 87

INTRODUCTION
Amniocentesis is a prenatal test that allows healthcare practitioner to gather information about baby’s health from a sample of amniotic fluid. This is the fluid that surrounds baby in the uterus.
The most common reason to have an “amnio” is to determine whether a baby has certain genetic disorders or a chromosomal abnormality, such as Down syndrome.
Amniocentesis is usually done when a woman is between 14 and 16 weeks pregnant. The test is invasive and carries a small risk of miscarriage.

PROCEDURE

Amniocentesis.
Before the start of the procedure, a local anesthetic can be given to the mother in order to relieve the pain felt during the insertion of the needle used to withdraw the fluid. After the local anesthetic is in effect, a needle is usually inserted through the mother’s abdominal wall, then through the wall of the uterus, and finally into the amniotic sac. With the aid of ultrasound-guidance, a physician punctures the sac in an area away from the fetus and extracts approximately 20ml of amniotic fluid. If used for prenatal genetic diagnosis, fetal cells are separated from the extracted sample. The cells are grown in a culture medium, then fixed and stained. Under a microscope the chromosomes are examined for abnormalities. The most common abnormalities detected are Down syndrome (trisomy 21), Edwards syndrome (trisomy 18), and Turner syndrome (monosomy X). In regard to the fetus, the puncture seals and the amniotic sac replenishes the liquid over the next 24–48 hours.
INDICATIONS AND RESULT
Genetic diagnosis
Early in pregnancy, amniocentesis is used for diagnosis of chromosomal and other fetal problems such as:
• Down syndrome (trisomy 21)
• Trisomy 13
• Trisomy 18
• Fragile X
• Rare, inherited metabolic disorders
• Neural tube defects (anencephaly and spina bifida) by alpha-fetoprotein levels.
Lung maturity
Amniocentesis can predict fetal lung maturity, which is inversely correlated to the risk of infant respiratory distress syndrome.
Other
Amniocentesis can also be used to detect problems such as:
• Infection, in which amniocentesis can detect a decreased glucose level, a Gram stain showing bacteria or an abnormal differential count of white blood cells.[6]
• Rh incompatibility
• Decompression of polyhydramnios