ACKNOWLEDGEMENT

Formal words of acknowledgement will hardly fulfill the end of sentiments while expressing
deep sense of gratitude of many known and unknown hands which pushed me forward, learned
souls put us on the right path and enlightened us with their knowledge and experience. We shall
forever remain grateful to all of them.

We consider it our great privilege to express the long awaited heartfelt gratitude and sincere
thanks to the Chief dietitian Mrs. Ruma Singh, HOD , Department of Dietetics, Christian
Medical College and Hospital, Ludhiana in this study for her keen interest ,erudite guidance,
indispensable support, constructive criticism, constant inspiration and hearty encouragement in
the various phase of planning, initiation and ultimate completion of this study .Her unbounded
sympathy, benignity and doubtless faith bestowed upon us are the prime entities for the present
accomplishment. She will stay as the guiding star in all our future endeavors.

With sincere gratitude, We would like to manifest our utmost reverence to the respected teachers
Ms. Ashish Rani, Mrs. Gurjeet Kaur, Ms. Navneet Kaur, Ms. Zebish Ali , Assistant
Dietitians, CMC&H, Ludhiana for their guidance and valuable suggestion. Without their interest
and deep involvement, our internship could not have been successfully completed. We are also
thankful to Mrs. Elizabeth James for teaching us the table work and co-operating with us.
Sincere thanks to all the teaching and non-teaching staff members of Dietetics Department,
Christian Medical College and Hospital for their kind support.

We avail this opportunity to extend heartfelt thanks , deep respect and cordial thanks to express
our indebtedness to managing director Dr. William Bhatti for permitting us to utilize their
services in the hospital and helping us to gain more knowledge. We owe our gratitude to all the
doctors , sisters, technicians and other staffs for supporting in quest to finish the project.

Above all, walking by our side when He knows what we can handle or carrying us on His
shoulders during the trails of our life, from the core full of scars, We bow our head with tears of
thankfulness to the one who created the things, bright & beautiful, great & small , the wise and
wonderful, ‘the Lord’ who helped us survive doldrums.

Dated – 10 MAY, 2019

Place - Ludhiana
 CONTENTS
1. Introduction to the hospital
2. Dietary department
3. Organization chart
4. Procedures:
I. Echocardiography
II. Hemodialysis
III. Peritoneal dialysis
IV. Endoscopy
V. Nasogastric tube feeding
VI. Angiography

5. Horlicks Promotion Session

6. Biochemistry department
7. Our learning
 INTRODUCTION TO THE HOSPITAL

The Christian Medical College & Hospital, Ludhiana is an educational and research institution of
an all India character established and run by the minority Christian community. Its primary aim
is to educate and train Christian men and women as health professionals, in the spirit of Jesus
Christ for the healing ministry of the Church in India. However, like many other Christian
educational institutions this college also offers educational facilities to other young men and
women irrespective of religion, caste and community.

Through education in this college the Christian Church seeks to make a significant contribution
to the health standards of all communities of our nation with special emphasis on health care in
the rural underserved and unreached areas/communities in India.

The Medical Missionary work was started in Ludhiana in the year 1881 by the Greenfield sisters,
Miss Martha Rose and Miss Kay Greenfield. They were Evangelists and Educationalists from
Scotland. This pioneering medical work of the Greenfield sisters was the precursor of the
Medical Training and Health Care Service Program of the present Christian Medical College,
Ludhiana

The Greenfield sisters and their associates organized the Health Care Educational Services in
which endeavor Dr. Edith Mary Brown joined them in 1893 and in 1894 the North Indian School
of Medicine for Christian Women was started by Dr. Edith Mary Brown and her colleagues with
the object of training Indian nationals particularly the women, to serve in the field of Medical
education and Health Care Services, emphasizing integration of training and health care services.

The period from 1894 to 1952 has been an epoch making era which saw the landmark of
development from its beginning as a School of Medicine for Christian Women to Women’s
Christian Medical College until 1952 when the name was changed to Christian Medical College
to enable it to admit both men and women students for the upgraded MBBS course which came
into effect for its first admission from 1953. The College was affiliated with Punjab University,
Chandigarh. The Medical School granted LSMF diploma till 1952. Since the College was
upgraded to M.B.B.S in 1953, more than 2000 candidates have graduated and are serving in
different parts of India & the world.
The Christian Medical College is situated in a large campus not far from Ludhiana Railway
Station, on both sides of the Brown Road. The Campus has residential quarters for the staff,
hostels for medical, nursing and paramedical students, both men and women. The College
maintains 775 Hospital beds. Our national medical and Para-medical teaching staff and other
staff come from nearly every state in India. The Government of India and Punjab have continued
their interest and support in the work and the development of the college and its hospital.

The Christian Medical College is recognized by the Medical Council of India. Since July 1999
the College is affiliated with Baba Farid University of Health Sciences, Faridkot, Punjab.
Ludhiana, one of the old-established cities of Punjab, with a population that has increased during
recent years to around 20, 00,000 lies 300 km north-west of Delhi and less than 150 km from the
border with Pakistan. It is situated on the Grand Trunk Road running from the border through to
Delhi, and is an important railway junction. Today it is one of the fastest-growing small and
medium industrial centers in India.

SERVICES PROVIDED:
 Adolescent Health Sciences
 Anatomy Anesthesiology & Critical Care
 Blood Bank
 Cardiology Casualty , Trauma & AMARS
 Cardiothoracic & Vascular Surgery
 Clinical Biochemistry
 Clinical Hematology
 Clinical Psychology
 Dietetics
 Dermatology
 Endocrine and Diabetes Unit
 Gastroenterology
 ENT
 Pediatric Medicine
 General Surgery
 Internal Medicine
 Nephrology
 Neurology
 Neurosurgery
 Orthopedic Surgery
 Obstetrics & Gynecology
 Ophthalmology
 Pediatric Surgery
 Pathology
 Pharmacology
 Physical Medicine & Rehabilitation
 Physiotherapy & Occupational Therapy
 Plastic & Micro Vascular Surgery
 Psychiatry
 Pulmonary Medicine
 Radiation & Occupational Surgery
 Radiology
 Medical Records Department
 DIETETICS DEPARTMENT
Dietetics is a field of specialization in therapeutic and clinical nutrition. Dietitians are trained
professionals who have been an inevitable part of the medical treatment in today’s era where
there is a wide range of disease and disease related problems being discovered every day.

Department of Dietetics was established in 50s Mrs. Gwen Forbat and Ms. Maxime Burch were
the pioneer dietitians who gave shape to the department. During that time few patients were
availing the facilities of the department. Teaching to medical students and nursing students was a
part of the dietitian’s responsibility from the very beginning. Department of Dietetics at Christian
Medical College & Hospital was the only food service department in Northern India till late 90s.

During the tenure of Ms. Ruth Pershadi and Mrs. Prem Kaul more patients started availing the
facilities. Staff and student canteen services (one time snack) were introduced apart from the
official caterings. After the retirement of Dr. Molly Joshi in June 2007, Mrs. Ruma Singh is the
Chief Dietitian. Since 1986, Mrs. Ruma Singh has been working at different levels. Ms. Ashish
Rani, Mrs. Gurjeet Kaur, Ms. Navneet Kaur , Ms. Zebish Ali are working as deputy dietitians
and Mrs. Elizabeth James & Mr Arun are working as Clerk.

The department of Dietetics and Nutrition services is progressive & fully committed to provide
the highest quality nutritional care, leading edge nutrition practice, food service & education- to
patients and staff. The Department addresses today’s complex nutrition and health issues found
across the country to enhance the quality of life for people and communities.
 HIERARCHY OF DIETARY DEPARTMENT

DIRECTOR

PRINCIPAL
M.S. G.S. N.S. (CMC,
CDC,IAHS,
CON, COP)
DIETARY
DEPARTMENT

CHIEF DEPUTY
DIETITIAN DIETITIAN

SUPERVISOR CLERK

KITCHEN
HEAD COOK STEWARDS SWEEPERS
HELPERS

ASSISTANT
COOK
 WORK DONE IN THE DIETARY DEPARTMENT
CMC, like many leading institutions, believes that diet plays a major role in the promotion of
health and well-being of an individual. The department provides & promotes optimal nutritional
care & food services to the hospital and community in:

Clinical nutrition

Food service management

Research (Case Study) & Education

CMC strives to attain the highest quality of care & service through effective & efficient
management of resources, systems & changes

CORE AREAS: Clinical Nutrition, Education & Research, Patient Services and Community
Programs

CLINICAL NUTRITION:

 Clinical dietitians are specialists in assessing and addressing nutritional needs of patients
with complex health conditions.
 Offers nutritional assessment and dietary advice to patients who are under hospital care.
 Aim of department is to promote health, prevent disease and aid in the managenment of
illness.
 This facility is available for OPD and IPD

OUTPATIENT SERVICES:

 Dietary department provides outpatient nutrition services within the hospital campus.
 Nutrition experts from the department aids the general public with management of
specific dietary needs in many different areas.

INPATIENT SERVICES:

 Good nutrition is the key component of recovering from surgery or illness.

 Department provides nutritional care, advice and education to patients while they are in
hospital and even after their discharge.
 Dietitians work with medical team providing valueable information regarding appropriate
nutrition care to the patients.
 Educating patients about dietary modifications in their diet.
EDUCATION AND RESEARCH (Case Study)

 Department is dedicated to nutritionist students and dietetic interns.

 Self-directed and inter professional learning opportunities are available through dietetic
internship.

PATIENT FOOD SERVICES:

 This is one of the most important aspects of food system which includes food service
management, nutrition communication and food production.
 Providing diet to patients according to their physiological conditions.
 They are monitored on regular basis and dietary modifications are made.

COMMUNITY PROGRAMS:

Several partnerships with agencies and organizations have enabled the department to
become involved at a community level.
 ECHOCARDIOGRAPHY
Echocardiography is a diagnostic test which uses ultrasound waves to make the images of the
heart chamber, valves and surrounding structures.

It can measure cardiac output and is a sensitive test for fluid around the heart and detect any
abnormal anatomy or infection of the heart valves.

ECHOCARDIOGRAM: Echo= sound + card= heart + gram= drawing (ECG)

ECG is an ultrasound test that can evaluate the structures of the heart as well direction of blood
flow within it. Technicians trained in echocardiography produce the images and videos using a
special probe or transducer that is placed in various places on the chest wall, to view the heart
from different directions. ECG is done to evaluate heart anatomy and functions.

ECG is the most common heart tracing done. Electrodes are placed on the chest wall and collect
information about the electrical activity of the heart. Aside from the heart rate and rhythm of the
heartbeat, it also provides indirect evidence of blood flow within arteries to heart muscles and
thickness of heart muscle.

Cardiac catheterization is an invasive test performed by a cardiologist, where a catheter is

threaded into the coronary arteries through femoral artery in the groin, the radial artery in the
wristor brachial artery in the elbow. Dye is injected into the coronary arteries looking for
blockage. In some instances, the blockage can be corrected by balloon angioplasty where a
balloon is inflated at the level of blockage, re-establishing the blood flow. A stent can be used to
open the artery.

Some heart issues that the echocardiogram can help evaluate include the following:

 Heart valve disorders: stenosis, insufficiency or regurgitation

 Abnormalities of the septum: arterial septal defect, ventricular septal defect
 Wall motion abnormalities
 Disease of pericardium

PROCEDURE:

Echo test are done by trained technicians. Patient lies down and small metal disc (electrodes) is
placed on the chest. The disk has wires that hook to an ECG machine and it keeps the track of
the heartbeat during the test.

 The room is dark so the technicians can better see the video monitor.
 Gel is put on the chest to help sound waves pass through the skin.
 The technician may ask to move or hold the breath briefly to get the better pictures.
  The transducer is passed across the chest. The probe produces sound waves that bounces
off the heart and “echo” back to the probe.
 The sound waves are change into pictures and displayed on a video monitor. The pictures
on the video monitor are recorded so the doctors can look at them later.

The Results of an Echocardiogram Indicate:

The main purpose is to assess the structure and function of the heart. The result will provide
information that can help the health care professional make a diagnosis that involves the heart.
ECG may be repeated over the time, monitoring heart function and the results may help decide
whether the previous treatment has been effective and any changes in the treatment program are
required.
 DIALYSIS
Dialysis is a procedure to remove waste products and excess fluid from the blood when the
kidneys stop functioning properly.it often involves diverting blood to a machine to be cleaned.

Normally, the kidneys filter the blood, removing harmful waste products and excess fluid and
turning these into urine to be passed out of the body. Kidney performs many functions such as
regulating body’s fluid balance which is done by adjusting the amount of urine that is excreted
on a daily basis and when these waste products are not removed adequately, they build upon the
body. An elevation of waste products are measured in the blood is called a s “azotemia”. When
waste products accumulate they cause a sick feeling throughout the body called “uremia’’, which
is due to urea and other nitrogenous compounds.

When kidneys are not working properly and are unable to filter the blood dialysis is performed.
Dialysis is a procedure that filters out the unwanted substances and fluids from the blood and it is
a substitute for many of the kidneys normal function. It helps the body by performing the
functions of failed kidneys.
DIALYSIS

Hemodialysis
CAPD
Peritoneal dialysis
CCPD

HEMODIALYSIS

In hemodialysis, a dialysis machine and a special filter called dialyzer are used to clean the
blood. Firstly, a fistula (arteriovenous or A-V fistula) is created by joining an artery and vein
under the skin of the arm. A –V graphed or central venous catheter can also be used.
During hemodialysis

 The patient sits or lies back on a chair. A technician will place 2 needles in the arm where
the fistula or graft is located.
 A pump in the hemodialysis machine slowly draws out the blood, and then sends it
through another machine called dialyzer which works like an artificial kidney and filters
out extra salts, wastes and fluids and clean blood is sent back into the body through the
second needle in the arm.

DIALYZER

 The dialyzer has two parts, one for the blood and another for the dialysate i.e. the
washing fluid.
 A thin semipermeable membrane separates these two parts
 Blood cells, protein and other important things remain in the blood because they are too
big to pass through the membrane.
 Smaller waste products such as urea, creatinine, potassium and extra fluid pass through
the membrane and excreted out of the body.

HD can be done in a hospital, dialysis center or home. In dialysis center, hemodialysis is usually
done 3 times per week for about 4 hours at a time.
 PERITONEAL DIALYSIS

Peritoneal dialysis is a way to remove waste products from your blood when your kidneys can't
adequately do the job any longer. This procedure filters the blood in a different way than does
the more common blood-filtering procedure called hemodialysis.

During peritoneal dialysis, a cleansing fluid flows through a tube (catheter) into part of your
abdomen. The lining of your abdomen (peritoneum) acts as a filter and removes waste products
from your blood. After a set period of time, the fluid with the filtered waste products flows out of
your abdomen and is discarded.

These treatments can be done at home, at work or while traveling. But peritoneal dialysis isn't an
option for everyone with kidney failure. You need manual dexterity and the ability to care for
yourself at home, or you need a reliable caregiver.

Risks

Complications of peritoneal dialysis can include:

  Infections. An infection of the abdominal lining (peritonitis) is a common complication of
peritoneal dialysis. An infection can also develop at the site where the catheter is inserted
to carry the cleansing fluid (dialysate) into and out of your abdomen. The risk of infection
is greater if the person doing the dialysis isn't adequately trained.

 Weight gain. The dialysate contains sugar (dextrose). Absorbing some of the dialysate
might cause you to take in hundreds of extra calories daily, leading to weight gain. The
extra calories can also cause high blood sugar, especially if one has diabetes.

 Hernia. Holding fluid in your abdomen for long periods may strain your muscles.

 Inadequate dialysis. Peritoneal dialysis can become ineffective after several years. One
might need to switch to hemodialysis.

If one has to undergo peritoneal dialysis, they'll need to avoid:

 Certain prescription and over-the-counter medications that can damage your kidneys,
including nonsteroidal anti-inflammatory drugs.

 Soaking in a bath or hot tub, or swimming in a lake, pond, river or non-chlorinated pool —
which increases the risk of infection. Showers and swimming in a chlorinated pool are
generally acceptable.
How to prepare

an operation to insert the catheter that carries the dialysate in and out of the abdomen. The
insertion might be done under local or general anesthesia. The tube is usually inserted near the
bellybutton.

After the tube is inserted, your doctor will probably recommend waiting up to a month before
starting peritoneal dialysis treatments to give the catheter site time to heal.

One also receives training on how to use the peritoneal dialysis equipment.

What to expect

During peritoneal dialysis:

 The dialysate flows into the abdomen and stays there for a prescribed period of time (dwell
time) — usually four to six hours
  Dextrose in the dialysate helps filter waste, chemicals and extra fluid in your blood from
tiny blood vessels in the lining of the abdominal cavity

 When the dwell time is over, the solution — along with waste products drawn from blood
— drains into a sterile collection bag

The process of filling and then draining your abdomen is called an exchange. Different methods
of peritoneal dialysis have different schedules of exchange. The two main schedules are:

 Continuous ambulatory peritoneal dialysis (CAPD)

 Continuous cycling peritoneal dialysis (CCPD)

Continuous ambulatory peritoneal dialysis (CAPD)

Fill the abdomen with dialysate; let it remain there for a prescribed dwell time, then drain the
fluid. Gravity moves the fluid through the catheter and into and out of the abdomen.

With CAPD:

 You may need three to five exchanges during the day and one with a longer dwell time
while you sleep

 You can do the exchanges at home, work or any clean place

 You're free to go about your normal activities while the dialysate dwells in your abdomen
Continuous cycling peritoneal dialysis (CCPD)

Also known as automated peritoneal dialysis (APD), this method uses a machine (automated
cycler) that performs multiple exchanges at night while you sleep. The cycler automatically fills
your abdomen with dialysate, allows it to dwell there and then drains it to a sterile bag that you
empty in the morning.

With CCPD:

 You must remain attached to the machine for about 10 to 12 hours at night.

 You aren't connected to the machine during the day. But in the morning you begin one
exchange with a dwell time that lasts the entire day.
 ENDOSCOPY

Endoscopy is the insertion of a long, thin tube directly into the body to observe an internal
organ or tissue in detail. It can also be used to carry out other tasks including imaging and
minor surgery. Endoscopes are minimally invasive and can be inserted into the openings of the
body such as the mouth or anus.

Types: Endoscopy is useful for investigating many systems within the human body these areas
include:

 Gastrointestinal tract: esophagus, stomach, and duodenum (esophagogastroduodenoscopy),

small intestine (enteroscopy) , large intestine/colon (colonoscopy, sigmoidoscopy), bile duct,
rectum (rectoscopy), and anus (anoscopy).

 Respiratory tract: Nose (rhinoscopy), lower respiratory tract (bronchoscopy).

 Ear: Otoscopy

 Urinary tract: Cystoscopy

 Female reproductive tract (gynoscopy): Cervix (colposcopy), uterus (hysteroscopy), fallopian

tubes (falloposcopy).

 Through a small incision: Abdominal or pelvic cavity (laparoscopy), interior of a joint

(arthroscopy), organs of the chest (thoracoscopy and mediastinoscopy).

Preparation

The procedure does not require an overnight stay in the hospital and usually only takes around 1
hour to complete. The doctor will provide instructions about the preparation for the procedure.

For many types of endoscopy, the individual needs to fast for around 12 hours, though this varies
based on the type.

For procedures investigating the gut, laxatives may be taken the night before to clear the system.

There are three main reasons for carrying out an endoscopy:

 Investigation: If an individual is experiencing vomiting, abdominal pain, breathing disorders,

stomach ulcers, difficulty swallowing, or gastrointestinal bleeding, for example an endoscope
can be used to search for a cause.
 Confirmation of a diagnosis: Endoscopy can be used to carry out a biopsy to confirm a
diagnosis of cancer or other diseases.

 Treatment: an endoscope can be used to treat an illness directly; for instance, endoscopy can
be used to cauterize (seal using heat) a bleeding vessel or remove a polyp.

Risks and side effects

Endoscopy is a relatively safe procedure, but there are certain risks involved. Risks depend on
the area that is being examined.

Risks of endoscopy may include:

 Over-sedation, although sedation is not always necessary

 Feeling bloated for a short time after the procedure

 Mild cramping

 A numb throat for a few hours due to the use of local anesthetic

 Infection of the area of investigation: this most commonly occurs when additional procedures
are carried out at the same time. The infections are normally minor and treatable with a course
of antibiotics

 Persistent pain in the area of the endoscopy

 Perforation or tear of the lining of the stomach or esophagus occurs in 1 in every 2,500-11,000
cases

 Internal bleeding, usually minor and sometimes treatable by endoscopic cauterization

 Complications related to preexisting conditions

 NASOGASTRIC TUBE FEEDING

A nasogastric (NG) tube is a long polyurethane or silicone tube that is passed through the nasal
passages via the esophagus into the stomach. They are commonly inserted in surgical practice for
various reasons.

Indications

There are only two main indications for NG tube insertion – to empty the upper gastrointestinal
tract or for feeding. Insertion may be for prophylactic or
therapeutic reasons.

Care should be taken in cases where there may be:

 Ear, nose and throat abnormalities or infections;

 Possible strictures of the esophagus;
 Esophageal varices;
 Anatomical abnormalities (esophageal diverticulae);
 Risk of aspiration.

Gaining consent

Practitioners should give patients a reassuring, detailed explanation of the insertion procedure,
together with the reasons why the tube is necessary. Verbal consent should then be obtained.

Sizes

Nasogastric tubes come in various sizes (8, 10, 12, 14, 16 and 18 Fr). Stiff tubes are easier to
insert, and putting them in a refrigerator or filling them with saline helps to stiffen them. Some
fine-bore tubes come with a guide wire to aid placement. The tube has markings and a radio-
opaque marker at the tip to check its position on X-ray.

Preparation
After washing hands, prepare a trolley including gloves, local anaesthetic jelly or spray, a 60ml
syringe, pH strip, kidney tray, sticky tape and a bag to collect secretions. Placing a glass of
drinking water nearby is useful.

Insertion technique

Tubes are usually inserted by nurses or junior doctors by the bedside or by anesthetists in theatre
before or during surgery.

External measurement from the tip of the nose to a point halfway between the xiphoid and the
umbilicus distance gives a rough idea of the required length.

The patient should sit up, without any head tilt (chin up). An appropriately sized tube is chosen
and the tip is lubricated by smearing aqua gel or local anesthetic gel. Anesthetic gel is a drug so
if it is used it must be prescribed, and precautions taken such as checking for allergies.

The wider nostril is chosen and the tube slid down along the floor of the nasal cavity. Patients
often gag when the tube reaches the pharynx. Asking them to swallow their saliva or a small
amount of water may help to direct the tube into the esophagus. Once in the esophagus, it may be
easy to push it down into the stomach.

The correct intragastric position is then verified (see below). The tube is fixed to the nose and
forehead using adhesive tapes. The stomach is decompressed by attaching a 60ml syringe and
aspirating its contents. Blocked tubes can be flushed open with saline or air.

Verifying correct intragastric positioning

The intragastric position of the tube must be confirmed after its initial insertion, and this must be
documented in the patient’s notes. There are two ways of confirming the tube’s position
currently recommended. These are by pH test (Stock et al, 2008; NPSA, 2005a; 2005b) and X-
ray. Other methods can be inaccurate and should not be used.

pH test :The NG tube is aspirated and the contents are checked using pH paper, not litmus paper
(Earley, 2005). The NPSA (2005b) recommended that it is safe to feed patients (infants, children
and adults) if the pH is 5.5 or below. This advice does not apply to neonates (preterm to 28
days). See the NPSA’s (2005b) advice and the update (2007) for more information.

Note that taking proton pump inhibitors or H2 receptor antagonists may alter the pH. Similarly,
intake of milk can neutralize the acid.
 Chest X-ray: When in doubt, it is best practice to use X-ray to check the tube’s location (Stock
et al, 2008). Patients who have swallowing problems, confused patients and those in ICU should
all be given an X-ray to verify the tube’s intragastric position. This involves taking a chest X-ray
including the upper half of the abdomen. The tip of the tube can be seen as a white radio-opaque
line and should be below the diaphragm on the left side.

Syringe test: This test is mentioned here for historic interest only. Also known as the whoosh
test, it has been shown to be an unreliable method of checking tube placement, and the NPSA
(2007; 2005a; 2005b) has said that it must no longer be used.

Confirming position

Correct intragastric positioning should be confirmed:

 Immediately after initial placement;

 Before each feed;
 Following vomiting/coughing and after observing decreased oxygen saturation;
 If the tube is accidentally dislodged or the patient complains of discomfort.
 Never insert the guide wire while the nasogastric tube is in the patient.

Advantages

There are several advantages associated with the use of NG tubes.

They will decompress the stomach by releasing air and liquid contents. This is important for
patients with ileus, intestinal and gastric outlet obstruction. These conditions can cause vomiting,
and patients are at risk of aspirating their stomach contents, which can lead to potentially lethal
pneumonitis.

Nasogastric tubes may also be useful for feeding patients who have dysphagia, for example after
experiencing a stroke, and also for those being who have undergone a tracheostomy. Nasojejunal
tubes are longer versions of NG tubes. They are inserted under endoscopic guidance to lie further
in the jejunum and may be useful in feeding patients with pancreatitis.
 ANGIOGRAPHY
A coronary angiogram is a procedure that uses X-ray imaging to see the heart's blood vessels.
The test is generally done to see if there's a restriction in blood flow going to the heart.

During a coronary angiogram, a type of dye that's visible by an X-ray machine is injected into
the blood vessels of your heart. The X-ray machine rapidly takes a series of images
(angiograms), offering a look at the blood vessels. If necessary, doctor can open clogged heart
arteries (angioplasty) during coronary angiogram.

Why it's done: Doctor may recommend to have a coronary angiogram if one has:

 Symptoms of coronary artery disease, such as chest pain (angina)

 Pain in your chest, jaw, neck or arm that can't be explained by other tests

 New or increasing chest pain (unstable angina)

 A heart defect you were born with (congenital heart disease)

 Abnormal results on a noninvasive heart stress test

 Other blood vessel problems or a chest injury

 A heart valve problem that requires surgery

General guidelines

 Don't eat or drink anything after midnight before angiogram.

 If one has diabetes, ask doctor whether to take insulin or other oral medications before
angiogram.
Before the procedure

Before angiogram procedure starts, health care team will review medical history, including
allergies and medications taken. The team may perform a physical exam and check vital signs —
blood pressure and pulse.

During the procedure

An IV line is inserted into a vein in arm. You may be given a sedative through the IV to help you
relax, as well as other medications and fluids.
Electrodes on chest monitor the heart throughout the procedure. A blood pressure cuff tracks
blood pressure and another device, a pulse oximeter, measures the amount of oxygen in the
blood.

A small incision is made at the entry site, and a short plastic tube (sheath) is inserted into artery.
The catheter is inserted through the sheath into blood vessel and carefully threaded to heart or
coronary arteries.

Dye (contrast material) is injected through the catheter. The dye is easy to see on X-ray images.
As it moves through blood vessels, the doctor can observe its flow and identify any blockages or
constricted areas. Depending on what doctor discovers during angiogram, one may have
additional catheter procedures at the same time, such as a balloon angioplasty or a stent
placement to open up a narrowed artery.

After the procedure

When the angiogram is over, the catheter is removed from the arm or groin and the incision is
closed with manual pressure, a clamp or a small plug.

Results

An angiogram can show doctors what's wrong with blood vessels. It can:

 Show how many of the coronary arteries are blocked or narrowed by fatty plaques
(atherosclerosis)

 Pinpoint where blockages are located in blood vessels

 Show how much blood flow is blocked through blood vessels

 Check the results of previous coronary bypass surgery

 Check the blood flow through heart and blood vessels

RISK FACTORS:

 Bleeding and bruising

 Blood clots
 Injury to an artery or vein
 A small risk of stroke
 Low blood pressure
 HORLICKS PROTEIN PLUS SESSION

A session was conducted on 26th April 2019 in afternoon by a sales executive from Horlicks
(Company) to promote and educate about their new product PROTEIN PLUS .

HORLICKS is a malted milk hot drink developed by founders James& William Horlicks. it was
first sold as ‘Horlicks Infants And Invalids Foods’, soon adding “aged and travellers” to their
labels. In the early 20th century, it was sold as a powdered meal replacement drink mix and now
it is marketed as a nutritional supplement and manufactured by GlaxoSmithKline (Customer
Healthcare) in UK, Australia, New Zealand, Hong Kong, India and Jamacia.

ABOUT PROTEIN PLUS:

Horlicks Protein+ Contains 33% Protein

It Has a Triple Blend Of Proteins

The Science behind Protein

The rate at which proteins breakdown and release Amino Acids into the blood stream will
determine the ability of the body to stimulate Muscle Protein synthesis (the process by which
muscles are rebuilt on a daily basis). For a long time, Whey Protein was considered the best
protein due to its fast release into the blood; however, the science now suggests a blend of
Proteins is better.

1. Whey Protein
Whey Protein is a fast release protein, being digested rapidly and leading to a fast increase in
amino acids into the blood.

2. Soy Protein
Soy Protein is termed an 'intermediate release protein', releasing amino acids into the blood a
little slower than whey but higher as compared to casein.

3. Casein Protein
Casein, the dominant protein in milk, is a slow release protein with a lower peak but a more
gradual and prolonged amino acid release pattern.
The beauty of choosing a blend containing all three of these Protein is that it provides a fast
and sustained release over time to support Muscle Maintenance & Growth.

The Importance of High Quality Protein

To maintain muscle mass, one does not just need the right amount of Protein but also the right
quality. The quality of Protein can be measured by something called PDCAAS.
Whey, Soy and Casein, the Proteins in Horlicks Protein+ all have a PDCAAS score of 1, the
highest score possible on this scale.

It was an interacting session and the promoter explained about how it works, its benefits,
ingredients and why it should be preferred and importance of the 3 components it contains,
Overall, we gained information and knowledge about the product available in the market.
 BIOCHEMISTRY DEPARTMENT VISIT
We had visited the Biochemistry Department in the CMC hospital, which is the integral part of
the hospital. The Department is over 27 years old. During this time it has made rapid progress
both in technology and academics to meet the needs of the growing needs of the clinicians,
patients and students. Routine and special biochemical investigations are carried out in the
biochemistry lab. A large number of special investigations on hormones, drugs, and fertility
panel, Thalassemia and Diabetes are also carried out by Chemilumiscence, ELISA and RIA. On
the academic side regular teaching and training of MBBS, BDS Nursing, DMLT and DMLT.
The department has a research projects for M.D. /M.S. students as well as for ICMR projects for
both UG and PG students.

In general, Clinical Biochemistry is the area of the chemistry that is generally concerned with the
analysis of bodily fluids for diagnostic and therapeutic purposes. The discipline originated in the
late 19th century with the use of simple chemical reaction tests for various components of blood
and urine. Over the decades, other techniques have been applied including the use and
measurement of enzyme activities ,spectrophotometry, electrophoresis and immunoassay.most
current laboratories are now highly automated to accommodate the high workload of hospital.

All biochemical tests come under chemical pathology and these are performed on body fluids,
but mostly on serum or plasma. The large array of tests can be categorized into sub-specialities
of:

 General or routine chemistry- LFT, RFT

 Special chemistry : electrophoresis and manual testing methods
 Clinical endocrinology : study of hormones and diagnosis of endocrine disorders
 Toxicology : drug abuse and chemicals
 Therapeutic drug monitoring : measurement of therapeutic medication levels to optimize
dosages
 Urinalysis and fecal analysis: chemical analysis of urine for wide array of diseases and
detection of gastrointestinal disorders

TESTS:

Common clinical chemistry tests include:

Electrolytes

 Sodium
 Potassium
 Chloride
 Bicarbonates
RENAL FUNCTION TESTS

 Creatinine
 Blood urea nitrogen

LIVER FUNCTION TESTS:

 Total serum protein

 Albumin
 Globulins
 A/G ratio
 Protein electrophoresis
 Urine protein
 Total bilirubin
 Direct bilirubin
 Aspartate transaminase
 Alanine transaminase
 GGT
 Alkaline phosphate

CARDIAC MARKERS:

 H-FABP
 Troponin
 Myoglobin
 CK-MB
 Minerals :
 Calcium
 Magnesium
 Phosphate
 Potassium

BLOOD DISORDERS:

 Iron
 Transferrin
 TIBC
 Vitamin B12
  Vitamin D
 Folic acid

MISCELLANEOUS:

 Glucose
 C reactive protein
 Glycated hemoglobin (HbA1C)
 Uric acid
 Arterial blood gases
 Neuron specific enolase (NSE)

PANEL TESTS:

A set of commonly ordered tests are combined onto a panel

 Basic metabolic panel (BMP) - 8 tests – sodium, potassium, Chloride, bicarbonate,

bklood urea nitrogen , creatinine , glucose , calcium
 Comprehensive metabolic panel (CMP) -14 tests- above BMP plus total protein,
albumin, alkaline phosphatase, alanine amino transferase, aspartate amino transferase ,
bilirubin .

Here in CMC Hospital, Miss Swetha is the head of Biochemistry Department when we visited
the department we were shown different machines and their use in the analysis of different
biochemical parameters. She also gave us an insight into the departmental work culture and the
sample collection procedure. In the end she also gave us a list of normal ranges of different
parameters.

It was truly an amazing opportunity to learn, interact and know the importance of
biochemistry and how advanced biochemistry diagnostic tests can help detect and prevent
a vast multitude of diseases.
 OUR LEARNING
It has been a wonderful opportunity for all of us to be able to pursue the Dietetics internship
here, at CMC&H which has one of the oldest and the best dietary department in northern India.
Not only have we learnt the basis of diet planning but also the complex relationship between the
diseases and diet and how correct diet can play an important role in improving the health
condition of an individual suffering from a combination of complex diseases.

The guides, dietary staff, clerks and, most importantly our Head ma’am have been immensely
supportive throughout our internship which has only helped us in enhancing our knowledge of
the working of the dietary department in a hospital .

We have also been immensely lucky to have a firsthand experience of witnessing live procedures
like angiography, echocardiography, endoscopy etc. .

Most importantly we here at CMC&H have learnt how to interact with the patients and the art
and skills of dietary counseling.

We shall forever be thankful to each and every individual who has been a part of our educational
journey for these 4 months.