Arvind Kumar Purohit S/O Late Narendra ... vs Fortis Healthcare Limited on 13 July, 2020

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State Consumer Disputes Redressal Commission

Arvind Kumar Purohit S/O Late Narendra ... vs Fortis Healthcare Limited on 13 July, 2020

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01. Arvind Kumar Purohit S/o Late Shri Narendra Nath Purohit, aged 65 Years, by caste Brahmin, r/o Flat No. 3, Ground Floor, Pooja II Apartments, 117, Vishveshvarya Nagar, Gopalpura Bypass, Jaipur 302018, Rajasthan (India)

02. Smt. Tapasya Bharat Khurana, w/o Shri Bharat Khurana, aged 38 years, by caste Brahmin, r/o 59B, 2nd Floor, Anjali Kiran Socienty, near Vakola Bridge, Santa Cruz (East), Mumbai, Maharashtra (India)

03. Smt. Shradha Vyas, w/o Shri Punarvasu Vyas, aged 35 Years, by caste Brahmin, r/o A-404. Triveni Nagar, Gopalpura Bypass, Jaipur 302018, Rajasthan (India) ifjoknhx.k cuke

01. Fortis Healthcare Limited, CIN: L85110DL1996PLC076704, Registered Office: Escorts Heart Institute and Research Centre, Okhla Road, New Delhi 110025 (India), through its Executive Chairman. Managing Director

02. Fortis Hospitals Limited, CIN: U93000DL2009PLC222166, Registered Office: Escorts Heart Institute and Research Centre, Okhla Road, New Delhi 110025 (India), through its Managing Director

03. Fortis Escorts Hospital (a unit of Fortis Hospitals Limited) Jawahar Lal Nehru Marg, Malviya Nagar, Jaipur 302017, Rajasthan (India) through its Medical Superintendent

04. Dr. Rajeev Bhargava, M.S. (Orthopaedics), Senior Consultant and Head of Department (Bone & Joint), Forits Escorts Hospital, 2 Jawahar Lal Nehru Marg, Malviya Nagar, Jaipur 302017, Rajasthan (India)

05. Dr. Sushil Kalara, M.D. (Medicine), Senior Consultant Physician and Specialist - Internal Medicine, Fortis Escorts Hospital, Jawahar Lal Nehru Marg, Malviya Nagar, Jaipur 302017, Rajasthan ((India) foi{khx.k le{k % ekuuh; Jh dey dqekj ckxMh] lnL; ¼U;kf;d½ ekuuh; Jh 'kSysUnz HkÍ] lnL;

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mifLFkr %& ifjoknhx.k dh vksj ls Jh foTth vxzoky vf/koDrk foi{khx.k dh vksj ls Jh nso's k caly vf/koDrk fu.kZ; fnukad%&13 tqykbZ] 2020 jkT; vk;ksx jktLFkku t;iqj ¼}kjk Jh dey dqekj ckxM+h] lnL;] ¼U;kf;d½ ;g ifjokn Arvind Kumar Purohit & ors. dh vksj ls Fortis Healthcare Limited & ors. ds fo:) bl vk;ksx esa fnukad 09-04-2015 dks is'k fd;kA izdj.k ds rF; bl izdkj gS fd Jherh t;Urh iqjksfgr ifjoknh la[;k 1 dh iRuh Fkh o ifjoknh la[;k 2 o 3 dh ekrk Fkh] ftldh yEckbZ 5-4 bap Fkh rFkk mldk otu 120 fdyks FkkA Jherh t;Urh iqjksfgr dks fnukad 30-07-2013 dks foi{kh gkWfLiVy esa Bone & Joint foHkkx esa fn[kk;k x;k mlds nkfgus Knee esa rdyhQ Fkh og gk;ijVsa'ku o Hypothyroidism dh ejht FkhA foi{kh la[;k 4 MkW- jktho HkkxZo ls tkWap djok;h Right Knee esa tenderness over joint Line 3 with Range of Motion (in short ROM) to be 5 fMxzh ls 90 fMxzh rd Fkk rFkk Left Knee 0 fMxzh ls 100 fMxzh Motion Fkk] tkWap ds ckn nkfgus Knee ds fjIysalesaV dh lykg nh x;hA ,Mfe'ku ds le; u rks Jherh t;Urh iqjksfgr dh yEckbZ fy[kh x;h u gh otu fy[kk x;k Jherh t;Urh iqjksfgr ls fizUVsM dUlsV QkeZ ij gLrk{kj djus dk dgk tks dj fn;s MkWa0 HkkxZo dks ltZjh djuh FkhA fnukad 31-07-2013 dks izh vkWijsfVo pSdfyLV cuk;h x;h tks uflZax LVkWQ us cuk;h mlesa osV ,oa gkbZV dk ftdz fd;k x;kA Jherh t;Urh iqjksfgr dk BMI 45.42 Kg FkkA 30 fdyks ls Åij BMI dk O;fDr Obese dk f'kdkj gksrk gSA fnukad 31-07-2013 dks Jherh t;Urh iqjksfgr dh Right Knee dh TKR dh x;hA Msyh izksxszl uksV~l esa fnukad 03-08-2013 dks MkWa0 jktho HkkxZo ds uksV esa vk;k fd ejht comfortable gS rFkk og VkW;ysV rd tk ldrh gSA fnukad 04- 08-2013 dks Msyh izksxzsl uksV~l esa vafdr fd;k fd ys¶V Knee esa nnZ dh f'kdk;r gS rFkk fjIysalesVa pkgrh gS] fnukad 06-08-2013 dks izh&vkWijsfVo pSd fyLV cuk;h x;h Nis Nik;s QkeZ ij Jherh t;Urh iqjksfgr ds gLrk{kj djok;s x;s gksus okys dkEiyhds'ku ds ckjs esa ugha crk;k x;k mlds ckn nwljh dUlsaV ij gLrk{kj djok;s x;s ml le; MkWa0 jktho HkkxZo mifLFkr ugha Fks vU; MkDVj mifLFkr Fks] fnukad 07-08-2013 dks Left Knee dh TKR dh x;hA Jherh t;Urh iqjksfgr us ltZjh ,fj;k esa nnZ dh f'kdk;r dh ijUrq mls Evaluate djus dh dksf'k'k ugha dh og cSM ij Hkh fgyus dh fLFkfr esa ugha FkhA foi{kh la[;k 3 o 4 us fnukad 11-08-2013 dks NqV~Vh ns nh rFkk ;g vafdr dj fn;k fd dqN Step pyus dh fLFkfr esa gS] tc fd Jherh t;Urh iqjksfgr fMLpktZ dh fLFkfr esa ugha Fkh mls ,Ecqysal esa ?kj ys tk;k x;k] mlds i'pkr~ dbZ eghuksa rd fQft;ksFksjsih djok;h x;h fQft;ksFksjsfiLV foi{kh gkWfLiVy dk gh Fkk Jherh t;Urh iqjksfgr Morbidly Obese dh f'kdkj Fkh] 4]08]105@&:- dk Hkqxrku fd;k x;k] 800@&:- ,Ecqysal dk Hkqxrku fd;k x;k gkWfLiVy ls fQft;ksFksjsfiLV vkrk Fkk mlds 116 ls'kUl fd;s rFkk 400@&:- izfr ls'ku ds fglkc ls 46]400@&:- dk Hkqxrku fd;k x;kA Jherh t;Urh iqjksfgr MksesfLVd gSYi ds fy, t;iqj lfoZl lsUVj ls lsok,Wa yh x;h mls 21]000@&:- Hkqxrku fd;k x;kA foi{kh dh vksj ls uflZax LVkWQ ulZ tkrh Fkh ftlus Stitches [kksys rFkk Mªsflax dh ftlds 4300@&&:- Hkqxrku fd;k] vkWijs'ku ds ?kko esa il vkus yxh ftl ij MkWa0 jktho HkkxZo }kjk nqckjk VkWads yxk;s x;sA Jherh t;Urh iqjksfgr vius 'kjhj dk Hkkj mBkus esa vlEkFkZ jgh fcLrj ij gh jgus ls Bed 4 Sor gks x;s rFkk ,fufed Hkh gks x;h Air Bed 7139@&:- dk [kjhnk x;k dEikm.Mj ewypUn /kkdM+ Bed Sores ij 01-10-2013 ls 19-01-2014 rd Mªsflax dh ftlds 10]900@&&:- olwy fd;s x;s] ,MokUl ,;j eSVªsl fdjk;s ij yh x;h mlds 28]665@&&:- vnk fd;s x;sA Jherh t;Urh iqjksfgr dks MkWa0 jktho HkkxZo dks 21-09-2013] 05-12-2013] o 08-01-2014 dks MkWa- ,l0 vkj0 'kqDyk dks 07-11-2013 dks] MkWa0 lq'khy dkyjk dks 05-12-2013] 19-12-2013 ,oa 02-01-2014 dks MkWa0 lanhi eqdqy dks 05-12-2013 dks] vkSj MkWa0 t;Ur 'kekZ dks 19-12-2013] 02-01-2014] 04-01-2014 rFkk 08-01-2014 dks fn[kk;k ;g lHkh foi{kh la[;k 3 gkWfLiVy esa dk;Zjr Fks buds fcy Hkh cuk;s x;s gkWfLiVy dh ,Ecqysal Hkh cqyk;h mldk Hkqxrku Hkh fd;k x;k esfMflu Hkh yh x;hA Jherh t;Urh iqjksfgr dh fLFkfr [kjkc gksrh x;h] fnukad 20-01-2014 dks bUVjuy esfMflu okMZ esa MkW0 lq'khy dkyjk ds okMZ esa HkrhZ djok;k x;k Jherh t;Urh iqjksfgr cSM ij Fkh rFkk 3 fMxzh izs'kj vYlj Fks] ifjokn esa Msyh esMhdy uksV vafdr fd;k x;k gS ftldk fooj.k vkxs fn;k tk;sxk] fnukad 27-01-2014 dks Jherh t;Urh iqjksfgr dks dejs ls pksFkh eafty ij SICU III jkf= 11-55 ij ys tk;k x;k rFkk lsUVªy ykbZu Mkyus ds fy, dgk rks ejht us euk dj fn;k rFkk ejht ds ifr us Hkh euk dj fn;k lsUVªy ykbZu ugha Mkyh x;h blds ckn refusal ds ckotwn lsUVªy ykbZu Mky nh x;h lsUVªy ykbZu vkSj blds ckn Jherh t;Urh iqjksfgr dh fLFkfr [kjkc gks x;h tc fd ,Mfe'ku ds le; 20-01-2014 ls 28-01-2014 dh lqcg rd mldh fLFkfr Li"V Fkh mlds 'okal esa rdyhQ gksus yxh mls Sinus bradycardia vk x;k rFkk gkVZjV s 58 gks x;h vkSj lsfIll gks x;k vkWDlhtu ekLd yxk;k x;k fQj osUVhysVj ij fy;k x;kA fnukad 29-01-2014 dks Jherh t;Urh iqjksfgr dh fLFkfr vkSj [kjkc gks x;h mldks SICU III ls MICU esa f'k¶V fd;k x;k ml le; Jherh t;Urh iqjksfgr lsfIll o lsfIll 'kksd ,oa Qaxy baQDs 'ku B/L Axilla rFkk lkekU; fLFkfr detksj crk;h x;h mlds Endotracheal Tube Mkyh x;h jkr dks 10-30 cts Right Radial Artery Cannulation fd;k x;k] fnukad 30-01-2014 dks jkf= 1-40 ij Jherh t;Urh iqjksfgr dks Bradycardia vk;k rFkk mldh e`R;q gks x;h e`R;q dk dkj.k e`R;q izek.k&i= esa crk;k x;k gSA 1]52]010@&:- dk fcy cuk ftldk Hkqxrku fd;k x;kA vr% ifjokn esa pkgs x;s vuqrks"k fnyok;s tk;saA 5 ifjoknh dh vksj ls ifjokn ,oa lk{; ds leFkZu esa ifjoknh dk 'kiFk&i= ,oa izn'kZ&C/1 yxk;r izn'kZ&C/83 nLrkost izLrqr fd;sA foi{kh la[;k 4 dh vksj ls tokc esa dFku fd;k x;k fd Jherh t;Urh iqjksfgr lhfo;j vkFkZjkbZfVl dh ejht Fkh mldk 120 fdyks otu Fkk rFkk 5QhV 4bap yEckbZ Fkh og viuh ukseZy ykbZQ ugha th jgh Fkh blls mlds ekufld ruko Fkk fMizs'ku esa FkhA nksuksa ?kqVuks dk fjIysalesaV vPNk ifj.kke ns ldrk FkkA Jherh t;Urh iqjksfgr ds iwoZ dh History ;k bZykt ds nLrkost miyC/k ugha djok;s x;s ifjoknhx.k Lo;a usxyhtsUlh ds fy, ftEesnkj gS mldks nsjh ls gkWfLiVy esa fn[kk;k x;k ftlls mldh chekjh c< x;hA foi{kh ds fo:) dksbZ okn vk/kkj ugha cuk;k x;k gSA ek= vPNk ifj.kke ugha vkus ls fpfdRlh; vlko/kkuh ugha dgha tk ldrh dksbZ fo'ks"kK lk{; is'k ugha dh x;h ifjoknhx.k LoPNk gkFkksa ls ugha vk;s rFkk rF; fNikdj vk;s gS ltZjh ds ckn ?kj ij mldk /;ku ugha j[kk x;k ejht ds ;g fpfdRlh; vlko/kkuh dk dsl ugha gS] ejht tc fMLpktZ fd;k x;k rc mldh fLFkfr Bhd Fkh py ldrh Fkh] foi{kh vLirky ds fpfdRld blds ftEesnkj ugha gSA esMhdy izkslhtj fjLd esa vkrk gS esMhdy usxyhtsUlh dsls gqbZ ;g ugha crk;k x;k gSA ifjokn lhfj;l Disputed Facts ls lacaf/kr gS bldk nhokuh U;k;ky; }kjk fu.kZ; fd;k tkuk pkfg,] vk/kkjghu >wWaBk nqHkkZoukiwoZd ifjokn is'k fd;k x;k gSA fnukad 30-07- 2013 dks ejht ds rst nnZ Fkk MkWa0 ls feyus ls igys ;g fooknkLin ugha gS rFkk ejht Hypertension Hypothyroidism and other ailments along with depression FksA ejht Jherh t;Urh iqjksfgr dh izh vkWijsfVo pSd fyLV fooknkLin ugha gS fnukad jkbZV Knee dk TKR fd;k x;k is'ksUV 'kq: ls gh nksuksa Knee dk fjIysl a esVa pkgrk Fkk rFkk nksuksa Knee esa nks"k Fkk ,Dljs fy;s x;s Fks vkFkZjkbZfVl nksuksa Knee esa Fkk fnukad 06-08-2013 dks izh pSd fyLV cuk;h x;h] lgefr yh x;h fnukad 07-08-2013 dks lSfd.M Knee fjIysal dh x;h] fnukad 11-08-2013 dks fMLPkktZ djus rd rks lc dqN Bhd Fkk] blfy, fMLpktZ fd;k x;k rFkk ejht dks ,DljlkbZt vkfn dh lykg nh x;h fMLpktZ lejh esa dksbZ ifjorZu ugha fd;k x;k gS ejht ds ifjtuksa us ejht dh ds;j ugha dh gkseds;j ugha dh ftlls Bedsores gks x;s] fnukad 20-01-2014 dks iqu% HkrhZ gqbZ fnukad 20-01-2014 ls 27-01-2014 rd dqN bEiqzesaV fn[k jgk Fkk ijUrq eqWag ls [kkus dh fLFkfr ukseZy ugha FkhA fnukad 27-01-2014 dks lsUVªy ykbZu Mkyus dh dksf'k'k dh ijUrq ejht ds ifjtuksa us euk dj fn;k fnukad 28-01- 6 2014 dks lsUVªy ykbZu Mkyh x;h ejht dh fLFkfr [kjkc gksrh tk jgh Fkh blfy, lsUVªy ykbZu yxkuh t:jh Fkk ifjokn Manipulation is'k fd;k x;k gS nksuksa Knee dh ltZjh esMhdy uksElZ ds vuqlkj dh x;h gSA ifjokn esa cukoVh dgkuh is'k dh x;h gS ;g dguk xyr gS fd lSfd.M Knee ds TKR ds ckn izksij lqijokbZt ugha fd;k x;k ;g izdj.k ifjoknhx.k ds lQkbZ lko/kkuh RkFkk ltZjh ds ckn ds;j ugha djus dk gS ejht dh ds;j iksLV ltZjh ugha dh x;h rFkk fu;fer :i ls fLFkfr ij utj ugha j[kh x;h iksLV lftZdy ds;j ugha dh x;h gSA vr% foi{khx.k ds fo:) ifjokn pyus ;ksX; ugha gS vuko';d :i ls ifjokn is'k fd;k gSA ifjoknhx.k ls 1]50]000@&:- i{kdkjku O;; ds fnyok;s tkus pkfg,A ifjokn [kkfjt djus dk fuosnu fd;kA ,slk gh tokc foi{kh la[;k 5 dh vksj ls is'k fd;k x;k gSA foi{kh dh vksj ls tokc ,oa lk{; ds leFkZu esa foi{khx.k ds 'kiFk&i= ,oa izn'kZ&NA/1 yxk;r izn'kZ&NA/3 nLrkost izLrqr fd;sA i{kdkjku vf/koDrkx.k dh cgl lquh ,oa i=koyh dk voyksdu fd;kA fo)ku vf/koDrk ifjoknh us ifjokn esa vafdr rF;ksa dks nksgjkrs gq, ifjokn Lohdkj djus dk fuosnu fd;k rFkk blds leFkZu esa esMhdy fyVªspj dh vksj /;ku fnyk;kA foi{kh dh vksj ls tokc ds rF;ksa dks nksgjkrs gq, esMhdy fyVªspj dh vksj /;ku fnyk;k rFkk ifjokn [kkfjt djus dk fuosnu fd;kA ;gkWa ;g mYysf[kr djuk mfpr gksxk fd foi{kh la[;k 1 ls 3 ds fo:) ,d rjQk dk;Zokgh gS ijUrq foi{kh la[;k 1 ls 3 dh vksj ls MkWa0 JhdkUr Lokeh tks esMhdy lqifjVsUMsV gS mldk odkyr ukek is'k gqvk gS rFkk mldk lk{; esa 'kiFk&i= is'k gqvk gS bu rhuksa foi{khx.k dh vksj ls ,d rjQk dk;Zokgh lekIr djus dk izkFkZuk&i= is'k fd;k Fkk ijUrq bl deh'ku dks fjO;w dk {ks=kf/kdkj ugha gksus dh otg ls [kkfjt dj fn;k x;k bldh pkjktksgh ekuuh; jk"Vªh; vk;ksx esa dh gks ,slk dksbZ nLrkost i=koyh ij ugha gSA 7 foi{kh us vius tokc esa fo'ks"kKk lk{; ugha gksus dh vkifRr mBk;h gS A JACOB MATHEW Vs STATE OF PUNJAB AND AN OTHER esa ekuuh; loksZPp U;k;ky; ds rhu ekuuh; U;k;k/kh'kksa dh cSap us bls vko';d ugha ekuk chp esa MARTIN F. D'SOUZA V/S MOHD. ISHFAQ dk fu.kZ; vk;k ;g nks ekuuh; U;k;kf/kifrx.k dk Fkk blesa fo'ks"kK lk{; dks vko';d ekuk ijUrq mlds ckn ds0,l0 jkWo ds fu.kZ; esa tks fd nks ekuuh; U;k;kf/kifrx.k dk Fkk fo'ks"kK lk{; dks vfuok;Z ugha ekuk rFkk MARTIN F. D'SOUZA V/S MOHD. ISHFAQ ds fu.kZ; dks izh ,Dosfj;e ekuk foi{khx.k dh vksj ls lkjh dkuwuh fLFkfr Li"V gksus ds ckotwn MARTIN F. D'SOUZA ds fu.kZ; dk lgkjk fy;k tkrk gS tks mfpr ugha gSA ;gh ugha foi{khx.k us ,d izkFkZuk&i= esMhdy cksMZ cukus dk is'k fd;k tks fnukad 17 vDVwcj 2019 dks [kkfjt dj fn;k x;k mDr vkns'k esa lkjh dkuwuh fLFkfr fMLdl dj nh x;h rFkk bl vkns'k dh ekuuh; jk"Vªh; vk;ksx esa dksbZ pkjktksgh dh gks bldk dksbZ nLrkost i=koyh ij ugha gSA ;g izdj.k fpfdRlh; vlko/kkuh dk gS ifjokn ds vuqlkj ejht Jherh t;Urh iqjksfgr 5fQV 4 bap yEckbZ dh Fkh rFkk 120 fdyks otu dh efgyk Fkh og Morbid Obese dh f'kdkj Fkh rFkk vU; chekfj;kWa Hkh FkhA ifjoknh i{k ds vuqlkj ,d Knee dk fjIysalesaV djuk Fkk tks djok fn;k x;k rFkk ejht igys VkW;ysV rd tkus yx x;h fQj dksfjMksj esa ?kqeus yx x;h mlds ckn nwljs Knee dh ltZjh ds fy, dgk x;k Knee dss lac/a k esa tc tkWap igys gqbZ Fkh rc nwljh Knee esa rdyhQ dk dksbZ fooj.k ugha gS blds ckotwn nwljk Knee fjIysl dj fn;k x;k mlds ckn Jherh t;Urh iqjksfgr dHkh py fQj ugha ik;h mlds fuokl LFkku ij 116 fQft;ksFksjsih ds ls'kUl Hkh fd;s x;s MksesfLVd losZV Hkh lgk;rk ds fy, fdjk;s ij j[kk x;k ?kj ij dEikm.Mj Mªsflax ds fy, vk;k ijUrq og dHkh pyus fQjus ds fy, l{ke ugha gqbZA ;gkWa rd fd cSM ij fgyus dh fLFkfr esa ugha Fkh mlds izs'kj vYlj gks x;s le; le; ij gkWfLiVy esa fofHkUu MkDVjksa dks fn[kk;k tkrk jgk] vUr esa fnukad 20-01-2014 dks foi{kh gkWfLiVy esa HkrhZ djok;h x;hA fnukad 20-01-2014 ls 27-01-2014 rd ejht dh fLFkfr lkekU; Fkh rFkk bEizqesaV gks jgh Fkh flQZ eqWag ls [kkus esa leL;k Fkh mlds lsUVªy ykbZu Mkyus dh dksf'k'k dh ifjtuksa ds dgus ij ugha Mkyh x;h mlds 10 ?kaVs ckn gh lsUVªy ykbZu Mky nh x;h] mlds ckn ejht dh fLFkfr [kjkc gksus yxh mlds Sinus bradycardia lsfIVflfe;k o lsfIVd 'kksd gks x;k ejht dh fLFkfr xaHkhj gksrh x;h rFkk vUrr% 30-01-2014 dks ejht dh e`R;q gks x;h 8 ;g lc rF; ifjoknhx.k us u dsoy ifjokn&i= cfYd mlds leFkZu esa is'k fd;s x;s 'kiFk&i= o nLrkost ls lkfcr fd;s gSA vc Hkkj vkrk gS foi{khx.k dk bl laca/k esa ekuuh; loksZPp U;k;ky; us fuEu fu/kkZfjr fd;k gSA bl laca/k esa II (2009) CPJ 61 SC NIZAM INSTITUTE OF MEDICAL SCIENCES Vs. PRASANTH S. DHANANKA esa ekuuh; loksZPp U;k;ky; us fuEu fu/kkZfjr fd;k gS %&

(ii) Medical Negligence--Burden of Proof -- Initial burden to prove medical negligence discharged by complainant - Burden shifts on hospital/attending doctors to satisfy Court that there was no lack of care or deligence.

(2004) 8 SCC page 56 SAVITA GARG (SMT) Vs. DIRECTOR, NATIONAL HEART INSTITUTE esa ekuuh; loksZPp U;k;ky; us fuEu fu/kkZfjr fd;k gS %& D. Consumer Protection Act, 1986 - Ss. 22, 18, 12 and 13 -Mecical negligence -- Burden of proof -Held, once aclaim petition is filed and the complainant has successfully discharged the initial burden that the hospital/clinic/doctor was negligent, and that as a result of such negligence the patient died, then in that case the burden lies on the hospital and the doctor concened who Streatedthe patient to show that there was no negligence involved in the treatment - Reasons for, given - Torts - Medical negligence--Burden of proof ekuuh; loksZPp U;k;ky; ds mDr fu.k;ksa ds ifjizs{; esa foi{khx.k dks ;g fl) djuk gS fd muds }kjk ejht dk iwjh Skill and Care ls bZykt fd;k x;kA pwfa d foi{kh dkWjiksjsV gkWfLiVy gS rFkk eYVhijit Lis'kfyVh gkWfLiVy gS Hkkjh Qhl ysdj bZykt djrk gS blfy, foi{khx.k dh ;g M~;wVh cu tkrh gS fd og High Skill and Care ls bZykt djsAa ;g izdj.k esMhdy usxyhtsUlh dk gS rFkk bl laca/k esa ekuuh; loksZPp U;k;ky; us JACOB MATHEW ,oa Kusum sharma okys izdj.kksa esa fuEu fu/kkZfjr fd;k gSA 9 bl lac/a k esa (2005) 6 Supreme Court Cases 1 JACOB MATHEW Vs STATE OF PUNJAB AND AN OTHER esa ekuuh; loksZPp U;k;ky; us fuEu fu/kkZfjr fd;k gS %& J. Tort -Negligence - Medical Negligence -When actionable - Test for Approach to be taken in dealing with cases of - Rationable for differential treatment of medical profession, discussed in extenso - Duties undertaken by doctors enumerated - Held, in a claim of medical negligence, it is enough for defendant to show that standard of care and skill attained was that of the ordinary competent medical practitioner exercising an ordinary degree of professional skill - Test for medical negligence laid down in Balam case, (1957) 2 All ER 118, 121 D-F [set out in para 19 herein], held, applicable in india -Further explained in detail when deviation from normal medical practice would amount to evidence of medical negligence - various issues clarified as to (1) state of knowledge by which standard of care is to be determined, (2) Standard of care in case of charge of failure (a) to use some particular equipment, or (b) to take some precaution, (3) enquiry to be made when alleged negligence is (a) due to an accident, or (b) due to an error of judgment in choice of a procedure or its execution--Considerations to be kept in mind by any forum trying issue of medical negligence, specified - Medical Practitioners K. Tort -Negligence - Professional negligence--when actionable--Test for--Held, a professional may be held liable for negligence either (1) wnen he was not possessed of the requisite skill which he professed to have possessed, or (2) when he did not exercise, with reasonable competence in the given case, the skill which he did possess--Standard to be applied would be that of an ordinary competent person exercising ordinary skill in that profession--Test for professional negligence laid down in Bolam case, (1957) 2 All ER 118, 121 D-F [set out in para 19 herein], held, applicable in India - Professional negligence distinguished from occupational negligence.

N. Tort -Negligence-Definition and meaning (jurisprudential and forensic), discussed in estenso -Words and phrases The jurisprudential concept of negligence defies any precise definition. In current forensic speech, negligence has three meanings. They are: (i) a state of mind, in which it is apposed to intention; (ii) careless conduct; and (iii) the breach of a duty to take care that is imposed by either common or stature law. All three meanings are aplicable in different circumstances but any one of them does not necessarily exclude the other meanings. (Paras 10 and 11) Negligence is the breach of a duty caused by omission to do domething which a reasonable man guided by those considerations which ordinarily regulate the conduct of human affairs would do, or doing something which a prudent and reasonable man would not do. Negligence becomes actionable on account of injury resulting from the act or omission amounting to negligence attributable to the person sued. The essential components of negligence, as recognised, are three:

"duty", "breach" and "resulting damage", that is to say:

(1)the existence of a duty to take care, which is owed by the defendant to the complainant;

(2)the failure to attain that standard of care, prescribed by the law, thereby committing a breach of such duty; and (3)Damage, which is both causally connected with such breach and recognised by the law, has been suffered by the complainant.

(4) If the Claimant satisfies the court on the evidence that these three ingredients are made out, the defendant should be held liable in negligence.

2010 (I) RLW 722 (SC) Kusum sharma & ors. Vs. Batra Hospital & Medical Research Centre & ors. esa fpfdRlh; ykijokgh ds laca/k esa ekuuh; loksZPp U;k;ky; us fuEu fn'kk&funsZ'k fn;s gS%& "On scrutiny of the leading cases of medical negligence both in our country and other countries specially the United Kingdom, some basic principles 11 emerge in dealing with the cases of medical negligence. While deciding whether the medical professional is guilty of medical negligence following well known principles must be kept in view:

I. Negligence is the breach of a duty exercised by ommission to do somethingwhich a reasonable man, guided by those considerations which ordinarily regulate the conduct of human affairs, would do, or doing something which a prudent and reasonable man would not do.

II. Negligence is an essential ingredient of the offence. The negligence to be established by the prosecution must be culpable or gross and not the negligence merely based upon an error of judgment.

III. The medical professional is ecpected to bring a reasonable degree of skill and knowledge and must exercise a reasonable degree of care. Neither the very highest nor a very low degree of care and competence judged in the light of the particular circumstances of each case is what the law requires.

IV. A medical practitioner would be liable only where his conduct fell below that of the standards of a reasonable competent practitioner in his field.

V. In the realm of diagnosis and treatment there is scope for genuine difference of opinion and one professional doctor is clearly not negligent merely because his conclusion differs from that of other professional doctor.

VI. The medical professional is often called upon to adopt a procedure which involves higher element of risk, but which he honestly believes as providing greater chances of success for the patient rather than a procedure involving lesser risk but highest chances of failure. Just because a professional looking to the gravity of illness has taken higher element of risk to redeem the patient out of his/her suffering which did not yield the disired result may not amount to negligence.

VII. Negligence cannot be attributed to a doctor so long as he performs his duties with reasonable skill and 12 competence. Merely because the doctor chooses one course of action in preference to the other one available, he would not be liable if the course of action chosen by him was acceptable to the medical profession. VIII. It would not be conducive to the effciency of the medical profession if no doctor could administer medicine without a halter round his neck.

IX. It is our bounden duty and obligation of the civil society to ensure that the medical professionals are not unnecessarily harassed or humiliated so that they can perform their professional duties without fear and apprehension.

X. The medical practitioners at times also have to be saved from such a class of complainants who use criminal process as a tool for pressurising the medical professionals/hospitals, particularly private hospitals or clinics for extractine uncalled for compensation. Such malicious proceedings deserve to be discarded against the medical practitoners.

XI. The medical professionals are entitled to get protection so long as they perform their duties with reasonable skill and competence and in the interest of the patients. The interest and welfare of the patients have to be paramount for the medical professionals.

ekuuh; loksZPp U;k;ky; ds Åij of.kZr fu.kZ;ksa ds ifjizs{; esa ;g ns[kuk gS fd D;k ejht dk bZykt iw.kZr;k Skill and Care ls fd;k x;kA foi{khx.k dh vksj ls vafre ekSf[kd cgl gksus ds ckn fyf[kr cgl ds lkFk Medical, Factual & Legal Note is'k fd;s blds lkFk nLrkost Hkh is'k fd;sA ftlesa ,d 23-07-2013 dk dkmUlfyax QkeZ is'k fd;k ;g nLrkost u rks tokc ds lkFk is'k fd;k x;k u gh bldk tokc esa ftdz gS u gh 'kiFk&i=ksa esa ftdz gS] ;gkWa rd fd cgl vafre ds ckn ;g is'k fd;k x;k gSA ;g nLrkost fuEu izdkj gS%& 13 bl nLrkost esa Admission Date 30.07.2013 Expected date of Disc... 05.08.2013, Room Category Single, Package name TKR -BK, Payment cash, Package Charges 1,64,700, Room Rent ---, Drugs && Consumables As per ----, Implant Cost ----, Investigations ----, Doctor Fees----- Total Estimated Espense ---

Expected date of Disc ij dfVax o vksojjkbZfVax gS bl nLrkost esa izkslhtj o iSdst use esa TKR ls BK vafdr gS] bldk eryc Both Knee dh 14 TKR gksuh FkhA bl nLrkost esa iSdst pktsZt 1]64]700@&&:- crk;s x;s gS rFkk Implant Cost 1,10,000/- crk;s x;s gSA tc fd ifjoknh ls 7]22]008@&:-

olwy fd;s x;s gS] blls ;g izrhr gksrk gS fd nLrkost QthZ gS ckn esa rS;kj fd;k gqvk gS rFkk i<+us ;ksX; ugha gSA blds vfrfjDr MkWa0 MkWa0 lanhi eqdqy dh iphZ] MkWa0 lq'khy dkyjk dh iphZ] tujy dUlsV dh iphZ] MkWa0 va'kq dksfV;k dk foi{kh gkWfLiVy esa gksuk] Daily Progress Notes, Central Line Procedural Checklist, Consent for Intervention Procedure, Consent for operation/ Procedure, ;g lc nLrkost fopkj.k ds ckn is'k ugha fd;k x;k gS u rks tokc ifjokn ds lkFk is'k fd;k u 'kiFk&i= esa gksuk ftdz fd;k x;k] ;gkWa rd fd bu ij izn'kZ Hkh ugha Mkys x;s rFkk ekSf[kd cgl vafre ds le; ;g nLrkost ugha Fks ftlls fd ifjoknh budk tokc ns ldsa ;g nLrkost okLrfod gksus dk 'kiFk&i= Hkh is'k ugha gqvk gSA ;g ,d izdkj ls fyf[kr cgl csdMksj rkjh[k ls is'k fd;k x;k gS tks fuUnuh; gSA foi{kh us vius tokc essa ejht ds vkFkZjkbZfVl gksuk crk;k gS tks Illustrated Medical Dioctionary ds ist uacj 51 ij fuEu izdkj crk;k x;k gS %& Arthritis inflammation of one or more joints with pain, swelling and stiffness. There are several different types of arthritis. The most common form is osteoarthritis which most often involves the knees, hips and hands and usually affects middle aged and older people. Cervicalosteoarthritis is a form of osteorthritis that affects the joints in the neck. Rheumatoid arthritis is a damaging condition that causes inflammation in the joints and other body tissues such as the membranous heart covering, blood vessels, lungs and eyes. The disorder has different effects in children (see juvenile chronic arthritis. Ankylosing spondylitis is another persistent form of arthritis that initially affects the spine and the joints between the base of the spine and the pelvis. Other tissues such as the eyes may also be affected. Eventually the disorder may cause the vertebrae (bones of the spine ) to fuse. Reactive arthritis typically develops in susceptible people following an infection, most commonly of the genital tract or intestines. Gout and pseudogout are types of arthritis in which crystals are deposited in a joint, causing swelling and pain. Septic arthritis is a 15 relatively rare condition that can develop when infection enters a joint, either through a would or from the bloodstream. Diagnosis of particular types of arthritis is by blood tests and in some cases microscopic examination of a fluid sample from the affected joint. X-rays or MRI can indicate the type and extent of joint damage.

Physiotherapy and exercises can help to minimize the effects of arthritis and there are specific treatments for some types such as antibiotic drugs for septic arthritis. Analgesic drugs nonsteroidal anti-inflmmatory drugs, disease-modifying antriheumatic drugs, biological therapies and corticosteroids may be used to relieve the symptoms and/or affect the course of the arthritis. In severe cases one or more joints may need arthroplasty (replacement with an artificial substitute) or arthrodesis (fusion of the bones).

bl izdkj vkFkZjkbZfVl dbZ izdkj ds gksrs gS ejht ds dksulk vkFkZjkbZfVl Fkk ;g dgha Hkh Li"V ugha fd;k x;k gS vkFkZjkbZfVl ds ckjs esa irk yxkus ds fy, fuEu rjhdk gS%& How Is Arthritis Diagnosed?

A diagnosis of arthritis is the first step toward successful treatment. To diagnose arthritis, your doctor will consider your symptoms, perform a physical exam to check for swollen joints or loss of motion, and use blood tests and X-rays to confirm the diagnosis. X-rays and blood tests also help distinguish the type of arthritis you have.

For example, most people with rheumatoid arthritis have antibodies called rheumatoid factors (RF) in their blood, although RF may also be present in other disorders.

X-rays are used to diagnose osteoarthritis, typically revealing a loss of cartilage, bone spurs, and in extreme cases, bone rubbing against bone. Sometimes, joint aspiration (using a needle to draw a small sample of fluid from the joint for testing) is used to rule out other types of arthritis. If your doctor suspects infectious arthritis as a complication of some other disease, testing a sample of fluid from the affected joint will usually 16 confirm the diagnosis and determine how it will be treated.

ejht dk ,Dljs djuk crk;k x;k gS ijUrq ,Dljs fjiksVZ is'k ugha dh x;h gS ejht dh CyM VsLV djok;k x;k ,slk dksbZ nLrkost i=koyh ij miyC/k ugha gS fd bldh lcls cM+h tkWap Arthroscopy gS tks Illustrated Medical Dioctionary ds ist uacj 51 ij fuEu izdkj crk;k x;k gS %& Arthroscopy Inspection through an endoscope (viewing tube) of the interior of a joint. Arthroscopy is most often used to diagnose disorders of the knee joint but can also be used in other joints such as the shoulder, hip or wrist. It allows the surgeon to see the surface of the bones the ligaments, the cartilages and the synovial membrane. Specimens can be taken for examination. Some surgical procedures such as removal of damaged cartilage, repair of ligaments and shaving of the patella (kneecap) are usually performed arthroscopically.

ijUrq ;g tkWap dh ugha x;h gSA bl izdkj ejht ds ?kqVus gh fjIysl yk;d Fks bldh tkWap dk u rks dksbZ fjdkMZ gS rFkk flok; ,Dljs djkus ds ftdz ds vykok ftldh Hkh fjiksVZ i=koyh ij ugha gSA vU; dksbZ tkWp djkus ds nLrkost ugha gSA bl izdkj foi{khx.k us tks Knee fjIyslesaV 'kq: fd;k og fcuk tkWap ds fd;k x;kA ejht Morbid Obesity dh f'kdkj Fkh tks fuEu izdkj gS%& Morbid obesity is a condition in which you have a body mass index (BMI) higher than 35. BMI is used to estimate body fat and can help determine if you are at a healthy body weight for your size. BMI is not a perfect measurement but it does help give a general idea of ideal weight ranges for height.

bl izdkj Morbid Obesity dk Hkh /;ku ugha j[kk x;k rFkk nksuksa Knee dk 7 fnu ds xsi esa vkWijs'ku dj fn;k x;k Knee D;k gS bls Black Medical Dictionary ds ist 345 esa fuEu izdkj crk;k x;k gS%& Knee The joint 17 formed by the femur, tibia and patella (knee cap) It belongs to the class of hinge joints, although movements are much more complex than the simple motion of a hinge, the condyles of the femur partly rolling, partly sliding over the flat surfaces on the upper end of the tibia and the acts of straightening and of bending the limb being finished and begun, respectively by a certain amount of rotation. The cavity of the joint is very intricate:it consists really of three joints fused into one, but separated in part by ligaments and folds of the synovial membrane. The ligaments which bind the bones together are extremely strong and include the popliteal and the collateral ligaments a very strong patellar ligament uniting the patella to the front of the tibia, two cruciate ligaments in the interior of the joint and two fibro cartilages which are interposed between the surfaces of tibia and femur at their edge. All these stuctures give to the knee joint great strength so that it is seldom dislocated. The cruciate ligaments though strong sometimes rupture or stretch under severe physical stress such as contact sports or athletics. Surgical repair may be required followed by prolonged physiotherapy.

A troublesome condition ofter found in the knee-and common among athletes, footballers and other energetic sports people- consists of the loosening of one of the fibro-cartilages lying at the head of the tibia especially of that on the inner side of the joint. The cartilage may either be loosened from its attachment and tend to slip beyong the edges of the bones or it may become folded on itself. In either case it tends to cause locking of the joint when sudden movements are made. This causes temporary inability to use the joint until the cartilage is replaced by forcible straighening and the accident is apt to be followed by an attack of synovitis which may last some weeks causing lameness with pain and tenderness especially felt at a point on the inner side of the knee. This condition can be relieved by an operation-sometimes by keyhole surgery (see minimally invasive surgery) -to remove the loose portion of the cartilage. Patients whose knees are severely affected by osteoarthritis or rheumatoid arthritis which cause pain and stiffness can now have the joint replaced with an artificial one.

TKR ;kfu Total Knee Replacement D;k gS og Morbidly obese patients esa crk;k x;k gS tks fuEu izdkj gS%& Total knee replacement in morbidly obese patients RESULTS OF A PROSPECTIVE, MATCHED STUDY Discussion This study shows that in a subgroup of patients who are morbidly obese, TKR is associated with inferior clinical outcome scores, a higher rate of complications and inferior five- year survivorship, when compared with a matched, control group of non-obese patients.

The BMI is a predictor of morbidity and mortality from several chronic diseases, including diabetes mellitus, coronary artery disease and stroke. Health risks increase as the BMI rises from normal (BMI 15 kg/m2 to 25 kg/m2) to overweight (BMI 25 kg/m2 to 30 kg/m2), to obese (BMI 30 kg/m2 to 40 kg/m2) and to morbidly obese (BMI > 40 kg/m2).16-18 It also correlates with 15 years.2,4-10 The rate of peri-operative complications, where reported, has been found to be similar for obese and non-obese patients,6,8-10 although infection may be significantly higher for patients with a BMI > 35 kg/m2.21 With the exception of one retrospective study,8 none could demonstrate a significant difference between obese and non-

obese patients when the results were compared using patient- based or disease-specific formal outcome scoring measures.2,4-7,9,10 Survivorship of the implant is more difficult to compare because varying end-points have been used. Using revision as the end-point, none showed significant differences between obese and non-obese patients following TKR.2,4,5,8-10 Using revision, clinical failure and radiological failure as end-points however, inferior survivorship has been noted in obese patients in retrospective studies.8,9 We have reported observations suggesting that the results of TKR in obese and non-obese patients are comparable, at least in the mid-term.10 However, until results from larger, 19 prospective, long-term studies become available, opinions regarding the results of TKR in patients with a BMI > 30 kg/m2 are likely to remain divided.

All published comparative studies using the BMI to divide patients into obese and non-obese groups2,4-10 have included morbidly obese patients within the obese category. An analysis of results in the subgroup of obese patients who are morbidly obese2,8,11 has consistently demonstrated worse results in the morbidly obese patients when compared with non- morbidly obese and non-obese patients.

In our study, while the post-operative function score component of the KSS was significantly inferior in the morbidly obese group, the difference in the post-operative knee score component was not. This suggests that while morbidly obese patients may achieve similar pain relief, range of movement and stability, they are likely to remain more functionally impaired following TKR, with limitation of walking distance, ability to climb stairs and greater dependence on walking aids.

At five years, six TKRs in five patients were revised, awaiting revision for aseptic loosening (loosening/osteolysis without infection) or were radiologically loose in the morbidly obese patients (Table IV), and nearly a third of TKRs demonstrated linear radiolucent lines on the postoperative radiographs. Increased body-weight results in increased loading across a TKR and the surrounding bone.22 This does not appear to produce high rates of failure in obese patients who have total knee replacements, probably because of the lower activity levels in these patients compared with non-obese patients.23 It is possible however, that in the patients who are morbidly obese, lower activity levels may not compensate for the higher stresses across the tibial component. This may explain the high rate of radiolucent lines and aseptic loosening observed in morbidly obese patients in the study.

There were revisions in two patients for deep infection in the morbidly obese group (Table IV) and another seven developed superficial wound infections. A high rate of infective 20 control group.27 As the risk of infection is inversely related to tissue oxygen partial pressure,28,29 a lower peri-operative tissue oxygenation may explain the high rate of wound complications noted in morbidly obese patients.

This study has certain limitations. A joint-specific outcome scoring system was used in the study, but use of a more patient-based outcome score may have provided more information regarding the clinical outcome.These morbidly obese patients represent only a small proportion of patients selected for TKR since between 1995 and 2004, over 1700 TKRs were performed at our institution, with only 41 (2.4%) in the morbidly obese. Similar numbers have been reported in other series.2,11 With the current rapid rise in average body- weight and prevalence of obesity,12 it is likely that clinicians will encounter an increasing number of patients who are morbidly obese requiring TKR.30 It is therefore imperative that we define the results of TKR in these patients early, and identify any pitfalls in the criteria for selection for an operation which has otherwise proved to be extremely successful in alleviating pain and improving mobility for a large number of patients.31- 36 The two groups were not matched for medical co-morbidity or disease in the adjacent hip or knee and we do not know if these factors may have confounded the overall results.

The present evidence suggests that the results of TKR in patients with a BMI between 30 kg/m2 and 40 kg/m2 are probably comparable with the results of the procedure in non- obese patients. Morbidly obese patients may expect improvement in pain and function following TKR, although the overall results are inferior when compared with non-obese patients. Patients with a BMI > 40 kg/m2 should therefore be advised to lose weight prior to surgery or be counselled regarding the inferior results before proceeding with surgery.

Total Knee Replacement Exential Orthopaedicas 6Th Edition (Maheshwari & Mhaskar ) ds ist uacj 340 ij fuEu gS%& 21 Total knee replacement :- This is a relatively newer operation. In true sense the term total knee replacement is a misnomer, since unlike the hip replacement where a part of the head and neck are actually removed and replaced with similar shaped artificial components in the knee only the damaged articular surface is sliced off to prepare the bone ends to take the artificial components which 'cap' the ends of the bones. In a way this could be more appropriately called a knee resurfacing operation.

Overview Arthritis is an inflammation of the joints. The condition can affect one joint or multiple joints, causing pain and stiffness in the affected area. When these symptoms occur in one or both knees, it usually indicates that the cartilage in the joints has worn away. Knee replacement surgery may be done to replace the damaged joints and to relieve symptoms.

During knee replacement surgery, a surgeon replaces the damaged areas of the knee joint with an artificial knee called a prosthesis. A prosthesis is made of metal, plastic, and ceramic. It can help restore nearly all function of the damaged knee and relieve arthritis pain.

A doctor will usually recommend knee replacement surgery if the pain in your knee is interfering with your daily activities and negatively affecting your quality of life. In most cases, this type of surgery is performed in people over age 60, as younger people tend to wear out their artificial knees more quickly.

When severe arthritis affects both knees, a doctor may suggest double knee replacement surgery. However, more risk is involved with this type of surgery, so it's typically only recommended to those who are:

            physically fit

            in overall good health
                22

 motivated to undergo physical therapy and rehabilitation after surgery to regain their mobility Types of double knee replacement surgery Double knee replacement surgery may involve one surgery or two surgeries.

When both knees are replaced at the same time, the surgery is known as a simultaneous bilateral knee replacement.

When each knee is replaced at a different time, it's called a staged bilateral knee replacement.

Either surgery may involve any combination of total knee replacement or partial knee replacement.

Simultaneous bilateral knee replacement With simultaneous bilateral knee replacement, both of your knees will be replaced during the same surgery. The primary advantage of a simultaneous procedure is that there is only one hospital stay and one rehabilitation period to heal both knees.

However, rehabilitation may be slower, as it's more difficult to use both knees at the same time. In fact, many people who undergo simultaneous bilateral knee surgery need assistance at home as they're recovering.

Simultaneous bilateral knee replacement also takes longer to perform. This procedure typically takes three to four hours to complete, while staged bilateral knee replacement only takes two hours.

Since simultaneous bilateral knee replacement requires more time and heavier doses of anesthesia, there is an increased risk of complications. The surgery 23 isn't recommended for those with heart conditions or lung disease. These high-risk groups may experience heart problems or excessive blood loss during and after surgery.

Staged bilateral knee replacement In staged bilateral knee replacement, both knees are replaced in two separate surgeries. These surgeries are done a few months apart. Each surgery lasts about two hours. This staged approach allows one knee to recover before the second knee undergoes surgery.

The main advantage of a staged procedure is the reduced risk of complications. It also requires a shorter hospital stay.

However, since this procedure requires two surgeries, the overall rehabilitation period can be much longer. This may delay your return to some of your daily activities.

Risks of double knee replacement The risks associated with both simultaneous and staged bilateral knee replacement surgeries include:

 infection  blood clots  heart attack  stroke  nerve damage  failure of the artificial joint  potential necessity for blood transfusion People over age 65 are more likely to experience complications from double knee replacement surgery.

Men are also at a greater risk for complications than women.

Total Knee Replacement Essential Orthopaedics 6th Edition (Mahaeshwari & Mhaskar) ds ist uacj 340 ij dkEiyhds'ku fuEu gS%& Complications: Following complications can occur:

1. Infection: Infection could be minor in the form of wound breakdown or a major infection necessitating another operation to clean up the joint. Sometimes the infection may not be controlled and removal of the prosthesis and fusion of the joing may become necessary.

2. Deep Venous Thrombosis (DVT): It occurs as a result of immobility. Treatment is on lines as discussed in hip section.

3. Nerve palsy: Common peroneal nerve palsy sometimes occurs in cases requiring dissection on the lateral side of the knee. Spontaneous recovery occurs in most cases.

4. Fractures: Fractures may occur while performing the operation, particularly in osteoporotic bones of a bedridden rheumatiod patient. Fractures may occur late through the bones near the prosthesis due to stress concentration in that area.

5. Extensor mechanism complications: Handling of extensor mechanism is required during the course of the operation. These may occur due to avulsion of the patellar tendon, inadvertent curring of the tendon etc.

6. Knee stiffness: The patient may not be able to regain range of motion due to heterotropic bone formation or intra-

articular adhesions.

ejht Morbid Obesity dh f'kdkj Fkh rFkk vU; chekfj;kWa Fkh ftudk T;knkrj VsLV ugha fd;s x;s rFkk izFke Knee Replacement dj fn;k x;k ejht igys VkW;ysV rd tkus yxh rFkk mlds ckn dksfjMksj esa Hkh tkus yxh izn'kZ&C/1 ds vuqlkj Right Knee esa fiNys 1 o"kZ ls rdyhQ Fkh rFkk blds vkWijs'ku ds igys uflZx ,Mfe'ku vlslesaV VsLV fd;k x;k ftlesa ejht dh 25 Bathing, Dressing, Eating, Mobility, Climbing Stairs, Toilet Use, Walking Lo;a dj ldrh Fkh flQZ vdsys lh<+h ugha p<+ ldrh FkhA fnukad 30-07-2013 dks Lower Limb Examination fd;k x;k ftlesa Right Knee 5 & 90 fMxzh] Varus 20 fMxzh] Neurologically No DNVC n'kkZ;k x;k gS rFkk Left Knee esa fdlh izdkj dk nks"k ugha crk;k x;k gSA ejht us flQZ fnukad 04-08-2013 dks nnZ dh f'kdk;r crk;h blds vykok ijs'kkuh ugha FkhA ejht ds laca/k esa izn'kZ&C/1 nLrkost gS mlds VªhVesaV esa flQZ Right Knee esa TKR crk;k x;k gS Left Knee ds TKR ds ckjs esa dqN ugha crk;k x;k gSA izFke Knee ds vkWijs'ku dk uksV fuEu izdkj gS tks izn'kZ& C/6 gS%& Operative Notes TKR Right Side.

Soft tissue Releases. (For Verus)-

.Removal of medical Osteophyte.

.Semimembranosus .MCL Pie -Crusting.

.Down sizing Tibia.

.Popliteus release.

Augmentation of Tibia Cement/Screw.

.Bone graft.

.Rod.

Soft Tissue Releases (For Valgus).

Postlat Capsule.

.Lateral Release.

.IT Band.

.Popliteus Soft Tissue Balancing done.

Final Implants Cemented.

fnukad 04-08-2013 dks ;g esa'ku fd;k x;k fd ejht ds Left Knee esa Hkh nnZ gS rFkk og Left Knee dk TKR djkuk pkgrh gS tc fd Åij of.kZr nLrkost esa Left Knee dk dksbZ nks"k gksuk Hkh vafdr ugha gS] blds ckotwn Left Knee dh ltZjh dh x;hA bl lac/a k esa (2019) 6 Supreme Court Cases 512 NAND KISHORE PRASAD V/S MOHIB HAMIDI AND OTHERS esa ekuuh; loksZPp U;k;ky; us izfrikfnr fd;k gS fd%& 26 Consumer Protection - Services - Medical practitioners/services - Varying approaches to treatment available - Choice amongst - Medical negligence - Test for - Unreasonableness of decision as to course of treatment adopted, as the criterion - In present case, since decision to operating patient concerned was unreasonable, finding of negligence against Operating Surgeon affirmed

- Held, while adopting a course of treatment, the medical professional must ensure that it is not unreasonable - The threshold to prove unreasonableness is set with due regard to the risks associated with medical treatment and the conditions under which medical professionals function - This is to avoid a situation where doctors resort to "defensive medicine" to avoid claims of negligence, often to the detriment of the patient - Hence, in a specific case where unreasonableness in professional conduct has been proven with regard to the circumstances of that case, a professional cannot escape liability for medical evidence merely by relying on a body of professional opinion B. Consumer Protection - Services - Medical practitioners/services - Medical negligence - Decision to perform surgery - If unreasonable, thus amounting to medical negligence - Determination of - Surgery if was of immediate necessity to save life of patient who had critical platelet count

- Held, at admission, recorded history of patient was to complain about pain in abdomen, fever and hemorrhage in both eyes for five days - No evidence of critical condition of patient to be operated upon even with low platelet count - Surgery to remove roundworms not proved to be of immediate necessity to save life of patient who had critical platelet count - In absence of any evidence that surgery was only option even with low blood platelets, finding of negligence of Operating Surgeon cannot be ignored - Thus, it is a case if unreasonable decision of Operating Surgeon to operate and not a case of "bit negligent" so as to absolve surgeon from allegation of medical negligence- Consequently, finding of NCDRC to that extent set aside.

(2019) 7 Supreme Court Cases 401 ARUN KUMAR MANGLIK V/S CHIRAYU HEALTH AND MEDICARE PRIVATE LIMITED AND ANOTHER ds iSjk 45 esa ekuuh; loksZPp U;k;ky; us izfrikfnr fd;k gS fd%& In the practice of medicine, there could be varying approaches to treatment. There can be a genuine difference of opinion. However, while adopting a course of treatment, the medical professional must ensure that it is not unreasonable. The threshold to prove unreasonableness is set with due regard to the risks associated with medical treatment and the conditions under which medical professionals function. This is to avoid a situation where doctors resort to "defensive medicine" to avoid claims of negligence, often to the detriment of the patient. Hence, in a specific case where unreasonableness in professional conduct has been proven with regard to the circumstances of that case, a professional cannot escape liability for medical evidence merely by relying on a body of professional opinion.

ekuuh; loksZPp U;k;ky; }kjk izfrikfnr fl)kUrksa ds vuqlkj ;|fi ejht ds bZykt ds ekeys esa MkDVj ,dy tt gS ijUrq bldk eryc ;g ugha fd vufjtuscy gksA ejht dk jhtuscy bZykt o vkWijs'ku fd;k tkuk pkfg,A ejht dh blds ckotwn nwljh Knee dh TKR dj nh x;h ftldk vkWijs'ku uksV fuEu izdkj izn'kZ& 12 gS%& Soft tissue Releases. (For Verus)-

.Removal of medical Osteophyte.

.Semimembranosus .MCL Pie -Crusting.

.Down sizing Tibia.

.Popliteus release.

Augmentation of Tibia Cement/Screw.

.Bone graft.

.Rod.

Soft Tissue Releases (For Valgus).

Postlat Capsule.

.Lateral Release.

.IT Band.

.Popliteus Soft Tissue Balancing done.

Final Implants Cemented.

Knee ds ckjs esa Short Practice of Surgery 27th Edition ds ist uacj 518 ij fuEu crk;k x;k gS %& The knee applied anatomy The knee joint is a synovial hinge joint. It consists of two condyloid tibiofemoral joints and a seller ( or saddle shaped) patellofemoral joint. The shape makes the joint inherently unstable but stability is achieved by a combination of static (ligaments) and dynamic (muscles) stabilisers acting across the joint.

Interposed between the tibial and femoral condyles are the medial and lateral menisci. These fibrocartilaginous structures aid shock absorption increase the area over which load is dissipated and have a role in anteroposterior stability. Medial meniscal tears are three times more common than those in the more mobile lateral meniscus. The outer third of the meniscus is vascular and so tears can be repaired with the prospect of healing.

The medial and lateral collateral ligaments are the primary restraints to valgus and varus stress respectively. The medial collateral ligament is a broad, flat ligament composed of a superficial and a deep layer. The deep layer is attached to the medial meniscus. The lateral collateral ligament is a simple cord like structure.

The cruciate ligaments are vital for anteroposterior stability. Each cruciate ligament comprises two bundles. The anterior cruciate ligament (AC is composed of an anteromedial bundle that is tight in flexion and a posterolateral bundle that is tight in extension. The posterior cruciate ligament (PCL) has an anterolateral bundle (tight in flexion) and a posteromedial portion (tight in extension). The ACL and PCL prevent anterior and posterior translation of the tibia on the femur respectively.

The knee has burtsae surrounding it that can become inflammed and infected.

bl izdkj igys nwljs Left Knee dh TKR dk dksbZ Iyku gh ugha Fkk u gh dksbZ Mk;Xuksl fd;k x;k rFkk lSfd.M TKR dj nh x;h Mcy Knee fjIyslesaV ltZjh ds ckjs esa fuEu crk;k x;k gS%& Abstract The purpose of this study was to determine if there was a safe time frame for performing the second total knee arthroplasty (TKA) in staged bilateral TKAs. Retrospectively, 589 TKAs were studied at a single institution from January 2000 to June 2012. Patients were excluded if they underwent simultaneous or staggered bilateral TKA during the same hospitalization. Patients were included if they underwent bilateral staged TKA during a different hospitalization within 21 to 90, 91 to 180, 181 to 270, and 271 to 360 days after the first TKA. In-hospital complications were determined using International Classification of Diseases, Ninth Revision codes for cardiac, pulmonary, urinary, deep vein thrombosis, wound complications, mechanical complications, and wound infections. Periprosthetic joint infection (PJI) was determined by hospital readmission records. There were 29 postoperative complication events (4.9%) and there was no difference between time groups and complications. The highest rates of PJI occurred when the second TKA was performed after 271 to 360 days (3.6%), followed by the early postoperative period after 21 to 90 days (2.7%). We could not identify a time frame for performing the second TKA in staged bilateral TKAs to reduce complications. A signal from the study suggests that complications, particularly PJI, may be lower if the second TKA is performed more than 90 days and less than 270 days after the first TKA, although this finding was not significant ejht ds ;k rks nksuksa Knee ds vkWijs'ku lkFk lkFk pyus pkfg, ;fn lkFk lkFk ugha fd;s tkrs gS ejht Morbid Obesity dh f'kdkj gks rks blds ifj.kke ds lac/a k esa fuEu crk;k x;k gS%& 30 What Causes Morbid Obesity?

When you eat, your body uses the calories you consume to run your body. Even at rest, the body needs calories to pump your heart or digest food. If those calories are not used, the body stores them as fat. Your body will build up fat stores if you continue to eat more calories than your body can use during daily activities and exercise. Obesity and morbid Who Is at Risk for Morbid Obesity?

Anyone can gain weight and become obese if they eat more calories than their bodies can use.

Some studies have shown that genetic factors can play a role in how your body stores energy. More research is being done to further explore the relationship between genes and weight.

Many behavioral factors play a role in obesity as well, including your eating habits and daily activity level. Many people develop their eating habits as children and have trouble refining them to maintain proper body weight as they age. As an adult, you may be inactive at your job and have less time for exercise, meal planning, and physical activity.

Other factors, such as stress, anxiety, and lack of sleep, can lead to weight gain. People who quit smoking often experience temporary weight gain. Women may also have trouble losing the weight they gain during pregnancy, or may gain additional weight during menopause. These factors do not necessarily lead to morbid obesity but can certainly contribute to its onset.

Calculating BMI BMI is calculated when your weight in kilograms is divided by your height in meters squared. You can calculate your BMI by using a calculator provided by the Centers for Disease Control and Prevention.

Here are BMI ranges and their corresponding categories of obesity:

under weight under 18.5 percent normal:

18.5 to 24.9 percent overweight: 25.0 to 29.9 31 obese (class 1): 30.0 and 34.9 morbid obesity (class 2): 35-39.9 Using BMI as a diagnosis tool for obesity has limitations. Your BMI is only an estimate of your body fat. For example, athletes may have a high weight because of their higher muscle mass.

They could fall into the obese or morbidly obese BMI range, but actually have a small amount of body fat. Because of this, your doctor might use other tests to get an exact reading of your body fat percentage.

Calculating Body Fat Percentage A skinfold test may also be done to check your body fat percentage. In this test, a doctor measures the thickness of a fold of skin from the arm, abdomen, or thigh with a caliper. Another way to test body fat percentage includes bioelectrical impedance, which is often done using a special type of scale. Finally, body fat can be more accurately measured using special equipment to calculate water or air displacement Complications of Morbid Obesity Obesity is a health concern. Without proper treatment, obesity can lead to other serious health problems, such as:

 osteoarthritis  heart disease and blood lipid abnormalities  Stroke  Type 2 diabetes  Sleep apnea (when you periodically stop breathing during sleep  Reproductive problems  galistones  certain cancers blls ;g izrhr gksrk gS fd ;fn ,d Knee dk TKR fd;k tkrk gS rks nwljs Knee dk vkWijs'ku 90 fnu ls de ij ugha fd;k tkuk pkfg, ijUrq bl 32 izdj.k esa 90 fnu ds LFkku ij 7 fnu esa gh dj fn;k x;k nwljs vkWijs'ku ds ckn ejht flQZ Fyoo Step pyus dh fLFkfr esa crk;h x;h og u rks VkW;ysV rd tkus dh fLFkfr esa gqbZ u gh dksfjMksj esa tkus dh fLFkfr esa gqbZA tc fd izFke vkWijs'ku ds 3 fnu ckn gh og bl fLFkfr esa vk x;h Fkh blds ckotwn ejht dks fnukad 11-08-2013 dks fMLpktZ dj fn;k x;k fMLpktZ fVfdV izn'kZ&C/14 gS tks fuEu izdkj gS%& Patient was admitted with complains of pain swelling and deformity in both knees since about year, difficulty in walking and standing since last 6 months complaints gradually increased in severity patint was admitted for definitive treatment of the complanints a - hypothyroidism and htn-on regular treatment local examination Rt- knee Ffd -o degrees Rom 0 degree to 100 degree Varus 10 degree fixed No dnv deficit Lt- Knee Ffd 0 degrees Rom 0 degree to 100 degree Varus 10 Degree fixed Joint Line Tender Medially No Dnv Deficit Course in the Hospital:

Patient with above mentioned complants was admitted for rurther evaluation and management and found to have osteoarthritis of both knees for which patient was planned for total knee replacement both side but as patient is excessive obese so one by one total knee replacements were done. 2013 under cseat rt side total knee replacement was done using implants of followint size Right Side 1 Singma femoral posterior stabilized cemented component size 2 2 Pfc sigma tibial tray fixed bearingmodular cocr size 2 3 Pfc Sigma tibial Insert fixed bearing stablized size 2*10 mm 4 Patella was kept unsurfaced And on 07/06/2013 Under cseart side total knee peplacement was done using implants of following size 33 Left side:

1 Sigma femoral posterior stabilized cemented component size -2 2 Pfc Sigma tibial tray fixed bearingmodular cocr size -2 3 Pfc Sigma tibial insert fixed bearing stabilized size 2*10 mm 4 Patella was kept unsurfaced.

bl izdkj 30-07-2013 ls 11-08-2013 rd fd Daily Progress Notes fuEu izdkj gS%& Patient Name: Mrs. Jayanti Purohit Age : 55 Yrs.

Sex     :       Female
UHID :          599640
IPID :          23408
DOA :           30/07/2013
DAILY PROGRESS NOTES

30/07/2013 4pm - patient posted for surgery coming morning. Follow pre-op orders. NBM & IVF NS @ 80ml/hr. send patient to OT on call. Give antibiotic dose in night. CRP- <24, <48 ESR - 42 Hb - 12.9 TLC - 7.9 01/08/13 7:50am- Case seen by Ortho resident. POD-1 Right TKR. Patient conscious, oriented, no fresh complaints general condition fair and better. B.P - 107/53 Pulse -72 Resp - 12 Temp. - Normal l/O - 2400/1450 SpO2 - 96% Case seen by Dr. Bhargav Hb - 10.7 TLC -6.5 Pts - 186 Na-135 K - 4.16 Advise- remove drain, Clamb and remove folley's shift to ward. Antihypertensive and control B.P. 02/08/2013 7am- Case seen by Ortho resident. Patient stable, general condition fare, conscious, oriented, no fresh complaints, advise-start oral medication, Rest C.S.T. Case seen by Dr. Bhargav. Advised full diet.

3/08/13 8am- Case seen by Ortho resident. Patient conscious, oriented, communicating properly. No fresh complaints, Advised-dressing. X-ray right lung AP/Lateral. Epidural removal. CST 3/08/13 - Anesthesia notes, epidural removed + all ASP. Tip intact, no blood/pus. 3/08/13 - case seen by Dr. Bhargav. Patient conscious, able to walk upto toilet. Continue same.

4/08/13 - Case seen by Ortho resident, 4th post-operative day right TKR.

Patient conscious and stable. Communication properly. Well movements. No fresh complaints.

Advise - CST, Infain SOS Patient conscious, walking upto corridor, knee wound good, patient complaint of pain in left knee and wants TKR for left side now.

05/08/2013 - case seen by Ortho resident, patient stable, general condition fair, conscious oriented, no fresh complaints. Advise- C.S.T. left TKR Plan, stop ecosprin. 9:30am - send CBC, PT (INR) 5/08/13 - patient plan on 07/08/2013 for left TKR. 6/08/13 8am - Patient planned for surgery tomorrow. Patient oriented, conscious, communicating properly.

CBC - 10.9 TLC - 7.2 PT - 15.7 INR - 1.23 Arrange 1 unit PRBC. CST.

10:30am - 04/08/2013- case seen by Dr. Bhargav. Advise-follow pre-op orders for surgery.

7/08/13 evening - case seen by Ortho resident, patient conscious, oriented, communicating properly, planned for surgery today. Vitals stable. Follow pre-op orders.

8/08/13 7am - case seen by ortho resident. Patient stable. General condition fair, conscious oriented, no fresh complaint. Advised - remove drain, clamp catheter and remove it.

Physiotherapy, rest C.S.T. B.P. - 193/86 Pulse - 100 Resp - 20 Temp - normal I/O - 2750/1540 8/08/13 - case seen by dr. bhargav, patient stable, continue same. 8/08/13 - cannulation done on left hand.

8/08/13 4:30pm - case seen by Ortho resident, patient conscious and alert stable, communicating well drain removed catheter. 9/08/13 morning- case seen by ortho resident Patient conscious alert and communicating well, no fresh complaints. Advise - taper epidural. Rest continue same. 11am - patient stable, complaints of pain at surgical side. Walking with walker. Advised oral medications today.

10/08/13- case seen by Ortho resident, patient conscious, oriented, communicating properly, no fresh complaints, advised dressing, X-ray left knee-AP, LATERAL, epidural removal. APPIH stockings.

CST and discharge coming morning.

11/08/13 - patient stable, wound healing, able to walk few steps, may be discharge.

mlds ckn ejht dks ,Ecqysl a esa ?kj ys tk;k x;k vkSj foi{kh gkWfLiVy ds gh fQft;ksFksjsfiLV us 116 ls'kUl fd;s MksesfLVd losZV Hkh j[kk rFkk ejht 35 dh Msªflax vkfn ds fy, dEikm.Mj vkfn Hkh vkrk Fkk] ysfdu ejht dh fLFkfr Bhd ugha jgh og dHkh pyus fQjus yk;d ugha gqbZ Bed Sores gks x;s bl lac/a k esa foi{kh gkWfLiVy ds fofHkUu fpfdRldksa dks fn[kk;k tkrk jgk rFkk muds crk;s vuqlkj bZykt pyrk jgk ijUrq ejht dh fLFkfr xaHkhj gksrh x;hA vUrr% 20- 01-2014 dks ejht dks iqu% foi{kh gkWfLiVy esa HkrhZ djok;k x;k 20 rkjh[k ls 27 rkjh[k rd ejht dk bZykt pyrk jgk rFkk dqN izksxzsl fn[kkbZ nh] blds ckotwn ejht ds 27&28-01-2014 dh njfe;kuh lsUVªy ykbZu Mkyus ds fy, ys tk;k x;k ijUrq muds ifjtuksa blls badkj dj fn;k rFkk ejht us dkWijsV ugha fd;k blfy,m lsUVªy ykbZu Mkyuk jn~n fd;k x;k ijUrq mlds 10 ?kUVs ckn gh 28-01-2014 dks lqcg lsUVªy ykbZy Mkyh x;h ftlls lsUVªy ykbZu Mkyh x;h ftls RT. Subclavian Line Insertion Hkh dgrs gS Oxford Handbook of Operative Surgery ds ist 332 ij Central Venous Catheter insertion ds ckjs esa fuEu crk;k x;k gS%& Central venous catheter insertion Indications For <4 weeks use, peripherally inserted central catheter (PICC) is used. Long term catheter for:

Parenteral nutrition, chemoetherapy, haemodialysis, antibiotic therapy, regular transfusions, intensive blood smpling or where other peripheral sites have been used.

Options include a tunnelled catheter (Broviac or hickman line) or implantable device (portacath ) Surgical anatomy Internal jugular vein (IJV) subciavian vein (SCV), externaljugular vein (EJV) are commonly used.

Femoral vein (or even aygos vein) are last resorts.

Preoperative preparation If multiple previous catheters have been placed, preoperative vein mapping with doppler ultrasound or MR (magnetic resonance) venography to ensure vein patency Blood tests-platelet count coagulation.

Position Supine, shoulder roll to extend neck tilt head away from intended neck site.

Procedure Percutaneous insertion is preferred.

Percutaneous access Internal jugular vein Position patient with head down. Portable ultrasound (probe placed in sterile cover ) to demonstrate IJV. Needle/syringe inserted into IJV whilst aspirating venous blood. Guidewire passed into right atrium (RA) or IVC confirmed with image intensifier. Small incision is made lateral to needle insertion site. Line is tunnelled from lateral chest to neck incision and cut to that tip will lie in mid right atrium. Dilator/sheath passed over wire into IJV. Dilator removed and line inserted into sheath. Sheath split while advancing line into RA. Line secured and position confirmed as for open technique.

Subclavian vein Palpate midpoint of clavicle, insert needle/syringe just proximal to this point under calvicle into SCV whilst aspirating. Insert guidewire into RA or IVC. Rest of procedure as for percutaneous access (IJV).

Open technique (jugular veins) Transverse neck incision > one finger breadth above clavicle.

Divide platysma, split sternomastoid and expose IJV which is fully mobilized.

Right angled instrument around IJV and two slings placed.

Chlorhexidine soaked swabs around operative field.

Line tunnelled antegradely from lateral chest wall to neck incision; insure cuff is well clear of chest incision.

Lime cut so that tip will lie in mid right atrium.

Slings elevated by assistant,venotomy made with fine scissors and line inserted.

Position checked with image intensifier. Check like aspirates blood and flushes freely.

Line secured at chest site with two non absorbable sutures and dressing.

Sternomastoid re-approximated with absorbable suture.

Neck incision closed with absorbable suture.

Postoperative care Line is ready to use when position is checked with image intensifier.

Line should only be accessed by staff trained/experienced in aseptic technique.

Complications Bleeding, pneumothorax/haemothorax, guidewire slips into vein and passes distally, trauma to vein.

Medium term- infection, blockage/ fracture, line- dislodgement.

Tips and tricks Repeat image intensifier use at each step of percutaneous access to ensure wire remains in situ. Only advance dilator/sheath into IJV/SVC while checking wire slides in/out to avoid trauma e.g. to right ventricle.

A vein pick can be placed into a small vein venotomy (open insertion) to facilitate line insertion.

Radio opaque contrast will be required for small (2.7Fr) catheters to visualize on image intensifier.

Smaller access kits (eg. 4,4.5. 5 Fr) are more user friendly to place needle then wire into small veins.

ejht ds Bed Sores gks x;s blds ckjs esa Short Practice of Surgery 27th Edition esa ist uacj 29 ij Pressure Sores ds ckjs esa fuEu crk;k x;k gS%& Pressure sores :- These can be defined as tissue necrosis with ulceration due to prolonged pressure. Less preferable terms are bed sores, pressure ulcers and decubitus ulcers. They should be regarded as preventable but occur in approximately 5% of all hospitalised patients (range 3-12% in published literature). There is a higher incidence in paraplegic patients in the elderly and in the severely ill patient. The most common sites are listed in summary box 3.5.

A staging system for description of pressure sores devised by the Americal National Pressure Ulcer Advisory Panel is shown in Table 3.2.

If external pressure exceed the capillary occlusive pressure (over 30 mmHg) blood flow to the skin ceases, leading to tissue anoxia , necrosis and ulceration. Prevention is obviously the best treatment with good skin care, special pressure dispersion cushions or foams the use of low air loss and air fluidised beds and urinary or faecal diversion in selected cases. Pressure sore awareness is vital and the bed bound patient should be turned atleast every 2 hours with the wheel chair bound patient being taught to lift themselves off their seat for 10 seconds every 10 minutes. It should be stressed that the most important treatment is to treat the cause of the pressure sore and that surgical treatment is a last resort often deemed to failure if the cause persists.

Sergical management of pressure sores follows the same principles involved in acute wound treatment. The patient must be well motivated, clinically stable with good nutrition and adhere to the preventative measures advised postoperatively. Preoperative management of the pressure sore involves adequate debridement and the use of would for surgical closure. The aim is to fill the dead space and to provide durable sensate skin. Large skin flaps that include muscle are best and occasionally an intact sensory innervated area can be included (e.g. extensor fascia lata flap with lateral cutaneous nerve of the thigh).If possibel use a flap that can be advanced further if there is recurrence and that does not interfere with the planning of neighbouring flaps that may be used in the future.

Short Practice of Surgery 27th Edition esa ist uacj 297 ij Pressure Sores ds ckjs vkSj fuEu crk;k x;k gS%& Pressure sores :- Patients undergoing surgery for a prolonged period of time are vulnerable to the development of a pressure sore or to worsening of a pre-existing sore. Careful positioning and padding of the patient is standard practice intraoperatively to reduce risk. Pressure sores occur as a result of friction or persisting pressure on soft tissues. They particularly affect the pressure points of a recumbent patient 39 including the sacrum, greater trochanter and heels. Risk factors are poor nutritional staus dehydration and lack of mobility and nerve block anaesthesia technique. Early mobilisation prevents pressure sores. High risk patients may be nursed on an air mattress hich automatically relieves the pressure areas.

Short Practice of Surgery 27th Edition esa ist uacj 615 ij Acquired Pressure Sores ds ckjs esa fuEu crk;k x;k gS%& Acquired - Pressure sores : These begin with tissue necrosis at a pressure point and develop into a cone shaped volume of necrotic loss. As many as 10% of acute hospital in- patients will suffer some degree of pressure sore. The majority affect the elderly and patients with spinal injury or decreased sensibility; 80% of paraplegics will get a pressure sore and 8% die as a result.

The pathogenesis of pressure sores revolves around unrelieved pressure; an increase in local tissue pressure above that of perfusion pressure produes ischaemic necrosis that is directly proportional to the duration and degree of pressure and inversely proportional to the area over which it is applied. Muscle and fat are more susceptible to pressure than skin.

In a patient who has no predisposing factors management is aimed at debridement and repair of the defect on the assumption that recurrence will not occur once normal function and sensibility returns. In the paraplegic patient recurrence is likely so management should involve a multidisciplinary approach. Primary treatment involves relieving pressure (special mattress; nursing care; relief of muscle spasm and contractures ); optimising nutrition; correcting anaemia; and preventing infection and dressings. Surgery involves thorough debridement to promote healing and plastic surgery to reconstruct the defect.

Short Practice of Surgery 27th Edition esa ist uacj 953 ij Bed Sores ds ckjs fuEu crk;k x;k gS%& Bedsores A bedsore is gangrene caused by local pressure. Bedsores are predisposed to by five factors; pressure, injury, anaemia, malnutrition and moisture. They can appear 40 and extend rapidly in immobile patients and in those with debilitating illness. Prophylactic measures must be taken including the avoidance of pressure over bony prominences by the use of foam blocks or similar, regular turning and nursing on specially designed beds that reduce the pressure to the skin. A waterbed or a ripple bed is sometimes desirable. Skilled nutsing and the use of appropriate dressings must prevent maceration of the skin by sweat, urine, faeces or pus.

A bedsore can be expected if erythema appears that does not change colour on pressure. Once pressure sores develop they are difficult to heal. They should be kept clean and debrided if necessary. Advice from a plastic surgeon should be sought for major lesions; vacuum dressings and rotation flaps can be effective.

ejht ds lsUVªy ykbZu Mkyus ls dkEiyhds'ku gqbZ ejht ds Hkkjh Bed Sores gks x;s Fks ;kfu Pressure vYlj Fks rFkk og baQDs 'ku dh f'kdkj Fkh blds ckotwn lsUVªy ykbZu Mky nh x;hA fnukad 29-01-2014 dks ejht dks esMhdy ICU esa f'k¶V fd;k x;k mlesa ;g vafdr fd;k x;k fd ejht ds Morbid Obesity Fkh iksLV vkWijsfVo TKR Bed Sores lsfIll] lsfIVd 'kkWd] Qaxy baQDs 'ku Fkk rFkk mldh lkekU; fLFkfr ugha Fkh Morbid Obesity ds ckjs esa iwoZ esa crk;k tk pqdk gS Illustrated Medical Dictionary ds ist 241 esa Fungal infections ds ckjs esa fuEu crk;k x;k gS%& fungal infections Diseases that are caused by the multiplication and spread of fungi. Some fungi are harmlessly present all the time in areas of the body such as the mouth, skin, intestines and vagina. However, they are prevented from multiplying by competition from bacteria. Other fungi are dealt with by the body's immune system.

Fungal infections are therefore more common and serious in people taking long term antibiotic drugs (which destroy the bacterial competition) and in those whose immune systems are suppressed by immunosuppressant drugs, corticosteriod drugs or by a disorder such as AIDS. Sch serious fungal infections are described as opportunistic infections.

Some funfal infections are more common in people with diabetes mellitus.

Fungal infections can be classified into superficial (affecting skin hair nails, inside of the mouth and genital organs) subcutaneous (beneath the skin) and deep (affecting intgernal organs).

The main superficial infections are tinea (including ringworm and athlete's foot) and candidiasis (thrush) both of which are common. Subcutaneous infections which are rare, include sporotrichosis and mycetoma. Deep infections are uncommon but can be serious and include aspergillosis, histoplasmosis, cryptococcosis and blastomycosis. The fungal spores enter the body by inhalation.

Treatment of fungal infections is with antifungal drugs either used topically on the infected area or given by mouth for generalized infections.

lsfIVflfe;k ds ckjs esa Illustrated medical Dictionary ds ist 504 esa fuEu crk;k x;k gS%& septicaemia A potentially life threatening condition in which there is rapid multiplication of bacteria and in which bacterial toxins are present in the blood.

Septicaemia usually arises through escape of bacteria from a focus of infection such as an abscess and is more likely to occue in people with an immunodeficiency disorder, cancer or diabetes mellitus. In those who take immunosuppressant drugs and in drug addicts who inject.

Symptoms include a fever, chills, rapid breathing, headache and clouding of consciousness. There may be multiple organ failure and the sufferer may go into life threatening septic shock.

Glucose and/or saline are given by intraveous infusion and antibiotics by injection or infusion. Surgery may be necessary to remove the original infection. If treatment is given before septic shock develops the outlood is good.

Sapraemia ds ckjs esa Oxford Concise Colour Medical Dictionary ds ist uacj 674 esa fuEu crk;k x;k 42 gS %& Sapraemia - blood poisoning by toxins of saprophytic bacteria ( bacteria living on dead or decaying matter). Compate PYAEMIA , SEPTICAEMIA, TOXAEMIA.

Toxaemia ds ckjs esa Oxford Concise Colour Medical Dictionary ds ist uacj 763 esa fuEu crk;k x;k gS %& Toxaemia blood poisoning that is caused by toxins formed by bacteria growing in a localsite of infection. It produces generalized symptoms including fever, diarrhoea and vomitting. Compare Pyaemia, saparaemia, septicaemia.

Shock ds ckjs esa Oxford Concise Colour Medical Dictionary ds ist uacj 690 ij fuEu crk;k x;k gS %& Shock- the condition associated with circulatory collapse, when the arterial blood pressure is too low to maintain an adequate supply of blooc to the tissues. The patient has a cold sweaty pallid skin, a weak rapid pulse, irregular breathing, dry mouth, dilated pupils, a decreased level of consciousness and a reduced flow of urine.

Shock may be due to a decrease in the volume of blood (hypovolaemic shock) as occurs after internal or external haemorrhage, burns, dehydration or severe vomitting or diarrhoea. It may be caused by reduced activity of the heart (cardiuogenic shock) as in coronary thrombosis, myocardial infarction or pulmonary embolism. It may also be due to widespread dilation of the blood vessels so that there is Insufficient blood to fill themn. This may be caused by severe sepsis (septic, bacteraemic or toxic shock) with a resultant systemic inflammatory resonse associated with disseminated intravascular coagulation and multiple organ failure. It may also be caused by a severe allergiv reaction (anaphylactic shock: see ANAPHYLAZIS) overdosage with such drugs as opioids or barbiturates or the emotional shock due to a personal tragedy or disaster (neurogenic shock). Sometimes shok may result from a combination or any of these causes, as 43 in peritonitis. The treatment of shock is determined by the cause.

Sepsis ds ckjs esa Salient Features Standard Treatment Guidelines A Manual for Medical therapautics ds ist uacj 119 ij crk;k x;k gS %& SALIENT FEATURES Sepsis is life threatening organ dysfunction caused by a dysregulated host response to infection.

Infection: A suspected or proven infection caused by any pathogen or a clinical syndrome associated with a high probabiity of infection. Evidence of infection includes positive findings on clinical examination, imaging or laboratory tests (e.g. leucocytes in a normally sterile body fluid, perforated viscus, chest radiograph consistent with penumonia, petechial or purpuric rash or purpura fulminans) or a positive culture, tissue stain or polymerase chain reaction test.

Sepsis- Organ dysfunction can be identified as an increase in the Sequential Organ Failure Assessment (SOFA) score >2 points consequent to the infection. The baseline SOFA score can be assumed to be zero in patients not known to have preexisting organ dysfunction. A SOFA score > 2 is associated with an in hospital mortality greater than 10%. In out of hospital, emergency department or general hospital ward settings, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical or spesis if they have atleast 2 of the following clinical criteria:

alteration in mental status, systolic blood pressure < 100 mmHg, or respiratory rate > 22/min. Neither bedside quick Sequential Organ Failure Assessment (qSOFA) nor SOFA is intended to be a stand-alone definition or sepsis. It is crucial, however that failure to meet 2 or more qSOFA of SOFA criteria should not lead to a deferral of investigation or treatment of infection or to a delay in any other aspect of care deemed necessary. The new definition abandoned useof host inflammatory response syndrome criteria (SIRS) in identification of sepsis and eliminated the term severe sepsis.

Septic shock is a subset of sepsis in which particularly profound circulatory,cellular and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a persisting hypotension requiring vasopressors to maintain MAP > 65 mmHg and having a serum lactate level > 2 mmol/L (18 mg/dl) despite adequate volume resuscitation. Sepsis with cardiovascular dysfunction persisting after atleast 40 ml/kg of fluid resuscitation in 1 hour.

Refractory septic shock- Fluid refractory septic shock- Shock persisting after > 60 ml/kg of fluid resuscitation. Catecholamine-resistant septic shock - Shock persists despite treatment with catecholamines (i.e. dopamine or adrenaline (epinephrine) infusion or both or noradrenaline (norepinephrine) infusion).

The initial clinical presentation of sepsis in children may be non-specific (especially in younger age groups.) blds lkFk tks 'kCn tqM+s gS mlesa pyaemia ftldk Oxford Concise Colour Medical Dictionary ds ist uacj 634 ij crk;k x;k gS %& pyaemia n. blood poisoning by pus-forming bacteria released from an abscess. The wide-spread formation of abscesses may develop, with fatal results. Compare SAPRAEMIA, SEPTICAEMIA, TOXAEMIA.

Septic Shock ds ckjs esa Black's Medical Dictionary Edited by Gordon Macpherson MB,BS ds ist uacj 557 ij crk;k x;k gS %& Septic Shock- A dangerous disorder characterized by a severe fall in blood pressure and damage to the body tissues as a result of SEPTICAEMIA. The toxins from the septicaemia cause widespread damage to tissue, provoke clotting in small blood vessels and seriously disturb the circulation. The kidneys, lungs and heart are particularly affected. The condition occurs most commonly in people who already have a chronic disease such as cancer, cirrhosis of the liver or diabetes mellitus. Septic shock may also develop in patients with immunodeficiency 45 illnesses such as AIDS. The symptoms are those of septicaemia coupled with those of shock, cold, cyanotic limbs, fast thready pulse and a lowered blood pressure. Septic shock requires urgent treatment with antibiotics, intravenous fluids and oxygen.

lsfIVflfe;k dk eq[; dkj.k csfDVfj;k gksrk gS ftlls cpus dh vko';drk gksrh gSA blds ckjs esa Illustrated Medical Dictionary ds ist uacj 63 ij crk;k x;k gS %& Bactereria- Single-celled microorganisms that are invisible to the naked eye. The singular form of the term is bacertium. Abundant in the air, soil, and water, most bacteria are harmless to humans. Some bacteria such as those that live in the intestine are beneficial and help to break down food for digestion. Bacteria that cause disease are known as pathogens and are classified by shape into three main groups: cocci (spherical) ; bacilli (rod shaped) and spirochaetes or spirilla (spiral shaped). Many bacteria have whiplike threads called flagella, which enable them to move in fluids and pili which anchor them to other cells.

Aerobic bacteria require oxygen to grow and multiply in the body these are most commonly found on the skin or in the respiratory system. Anaerobic bacteria thrive where there is no oxygen deep within tissue or wounds. They reproduce by simple division which can take place every 20 minutes. Some bacteria also produce spores that can survive high temperatures, dry conditions and lack of nourishment and some produce poisons (either endotoxis or exotoxins) that are harmful to human cells.

The body's immune system attacks invading bacteria but in some cases treatment with antibiotic drugs is necessary and will speed recovery. Superficial inflammation and infected wounds may be treated with antiseptics. Immunity to invading bacterial diseases such as some types of meningitis can be acquired by active immunization (See also infecious disease) 46 bl izdkj tc MICU esa HkrhZ dh x;h rc ejht dh fLFkfr xaHkhj gks pqdh Fkh ejht dk Sinus bradycardia tks Davidson's Principles and Practices of Medicines ds ist uacj 469 ij fuEu izdkj crk;k x;k gS%& Sinus bradycardia This may occur in healthy people atrest and is a common finding in atheletes. Some pathological causes are listed in Box 16.19. If sinus bradycardia is asymptomatic then no treatment is required. Symptomatic sinus bardycardia may occur acutely during an MI and can be treated with intravenous atropine (0.6-1.2 mg). Patients with recurrent or persistent symptomatic sinus bradycardia should be considered for p- acemaker implantation.

;gkWa rd fd ejht dk fdzVfs uu 31 ls Åij igqWp a x;k Fkk tc fd 10 ls Åij igqWapus ij Mk;fyfll djuk iM+kA bldk ifj.kke fdMuh Qsy gks ldrk gSA ejht dh 20-01-2014 ls 30-01-2014 dks 1-40 rd dh izksxzsl 'khV fuEu izdkj gS%& 20/01/14- patient come in to emergency with pressur ulcersin back side, morbid obesity, protein deficiency for period of 6 months. Patient is bed ridden since 6 months. Post op TKR developed bed stores and motility decreased and came to our hospital for further treatment. Patient has a past history of anti-depressants and cholecystectomy in 2010. 20/01/14 - case seen by Dr. Kalra, mrs. jayanti purohit, 60yrs old female known case of hypothyroidism, gross obesity, B/L TKR, bed ridden, developed bed stores. Now advised admission for further management. Patient conscious and oriented, afebrile, oedema feet ++ intertrigo ++ B/L axillary region spreading to chest wall and back. Large bed sore on back. Reference to skin specialist for inter trigo and to Dr. Sandeepan mukul for bed sores. 21/01/14 morning- case seen by Dr. Kalra, bed sores + hypoproteinemia, advised - skin reference to dr. Shukla, dr. Sandeepan mukul, protein rich diet, PC enema stat. 21/01/14 - case seen by dr. S.S. Shukla, advised- keep the parts apart, mommate-F cream, Tab Ebaine-20 OD, MFe cream on dry areas, continue antibiotics. 21/01/14 - multiple pressure ulcers, dehydrated, concentrated urine, aphthous ulcers, inter trigo, BD dressing in hydroheal AMGEL, 2 hourly turning, air mattress, check albumin levels and albumin given in case of hypoproteinemia. 21/04/14 evening- case seen by Dr. Kalra, pain+obesity, bed sores, immobile, hypoproteinemia, CBC, SR. Creatinine, Sr. electrolytes coming morning, inj methyl cable 1amp I.M.OD, inj. in drip, bed sore dressing.

22/01/14 - RBC-3.52, Hb-10.21, creatinine - 31.8, RDW 16.3, R 08, L 11, Cl 110, B.P. 130/70, P-80, R-20, motion passed.

22/1/14 morning - case seen by Dr. Kalra, patient not able to move, oral ulcers+pain+morbid obesity advised bed sore dressing, rest CST.

22/01/14 - patient doing well, ads tab folvite, tab nebagn 23/01/14 - patient stable afebrile, B.P. 130/8, Pulse- 30, RR-20, slight pain in leg. 23/01/14 morning- - case seen by Dr. Kalra, hypoproteinemia, bed sores improving, no fever, no breathlessness, hemodynamically stable, motion passed, advised- bed sore dressing rest CST.

23/01/14 evening - case seen by Dr. Kalra, condition improving, no pus no bleeding, symptomatically better. Advised-CST.

24/01/14 - case seen by Dr. Shukla, no fever, no breathlessness, no fresh complaints, I.V. line access not available because f obesity and can be shifted to oral treatments. 24/01/14 evening - case seen by Dr. Kalra, bed sores, obesity, post op TKR, doing well, improving, Lasix, I.V stat, record urine output, advised- CBC, Sr. electrolyte, Sr. creatinine.

25/01/14 - seen by medicine resident, patient stable and vitals normal, symptomatically better, urine output 50 ml (after 7 pm last night) doing well, CST. Advised- CBC, Sr. electrolyte, Sr. creatinine. 25/01/14 11:30 am - case seen by Dr. Bhargav, advised - continue physiotherapy. 25/01/14 morning - case seen by Dr. Kalra, no fever, no breathlessness, improving Hb- 9.5, TLC-11.2, Na- 136, K- 4.56, Creatinine - 1.8,CST.

25/01/14 evening - case seen by Dr. Kalra, doing well, comfortable, symptomatically better, no fever, no breathlessness. Advised - CST, CBC, Sr. electrolyte, Sr. creatinine, Sr. cortisol level.

26/01/14 - case seen by Dr. Kalra, T. Laxis 40 mg BD, patient doing well, no fever, edema++ oral, intake is poor, improve oral intake. 27/01/14 morning- case seen by Dr. Kalra, comfortable, doing well, hypoproteinemia, no fever, no breathlessness. No fresh complaint, symptomatically better, S. cortisol- 18.2, CST, CBC, coming morning.

27/01/14 evening - case seen by Dr. Kalra, symptomatically better, doing well, no fever, no breathlessness, hypoproteinemia. Advised- CBC coming morning, rest CST, central line insertion.

27/01/14 11:55 pm - patient is brought in to SICU3 for central line insertion but patient is non-cooperative so its discussed with dr. kalra and central line insertion is cancelled as patient's husband refused for the same.

28/01/17 - patient shifted from ward due to decrease in saturation. B.P. 120/50, Pulse- 120/min, Resp-25/min.

Sr. electrolyte, cardiac reference, ortho reference, Sr. creatinine, PT/INR, IV cannulation done.

ABG, SpO2-99% on O2 mask, dull looking, oedema+B/L axilla fungal infection with bed sores on back, loss of appetite, B/L Chest clear, Rest CST. 28/01/14 morning - case seen by Dr. Kalra, TLC- 8.9, PLT- 120, AB- 7.4, referred for CVL, oedema feet + Advised- m IV fluids, RT feeding 100ml/2hr 28/01/14 - case seen by Dr. Kapil Kumawat, rhythm disturbance, sinus bradycardia on monitor, presently HR - 65-70, BP - 120/80, Advised- repeat Echo. CT pulmonary Anglo should be considered.

28/01/14 - case seen by psychiatrist, decreased responses, advise- T. Serton (50) rest continue same.

28/01/14 - SICU 4-2D ECHO-echo done in supine position, poor echo window sibradycadia, normal LV sign with fair LV function, LVF-50%, Trivial MR, Mild TR, 48 RVSP 23+RAP, diastolic line, all cardiac chambers normal, IVC 1.8 with <50% collapse, no V/C chest /meg/BE, bradycardia. AO 2.7, LA 3.2, IVS 1.1. LVID 4.3, PW 1.1, P4L2 50, Ao 92. 28/01/14 - SICU 3- case seen by dr. anshu, dr. kalra Rt. Subclavian line insertion done, all aseptic precautions by dr. anshu back flew check in all 3 ports. Advised- X-ray.

29/01/14 8:30am - case seen by SICU 3 resident, dr. anshu. B.P- 112/60, Pulse- 69, resp - 20, temp - afebrile, I/O - 1560/150, RBS- 168. CNS - patient is conscious oriented slight response to verbal commands, GCS - E4V3M6 CVS - S1S2M0 peripheral pulse RS - B/L basal line faint crepts Abd - soft non tender non distended.

Advise - start norad infusion @20/h, CBC, Sr. electrolyte, Sr. creatinine, cover patient with green sterile, Inj. lasix 4 ampule IV stat (If BP over 120 systolic) Infusion @ 20mg/h. keep BP over 120 nsystolic, inform SOS, DVT pump. 29/01/14 10:30am - case seen by Dr. Bhargav, knee okay. Physiotherapy and as advised by dr kalra.

29/01/14 morning - case seen by Dr. Kalra, patient afebrile, dull, BP 150/60 urine output reduced, inj. laxis 100mg IV, CBC, X-ray chest, nephron reference. 29/01/14 evening - case seen by Dr. Kalra, patient dull and drowsy, respiratory distress, extremities cold, electrolyte imbalance, septic shock, prognosis poor explained to family, RT Feed 100 ml/2 hrly with increased protein, Na 137, K 4.06, Creatinine 2.1, Hb 8.39, Ret 60, TLC 9.3, I/O 660/70 Change of treatment plan-

Inj maronam 1gm iv, inj targocid 40mg iv, inj hydrocortisone 50mg iv 6 hrly, inj pantocid 40mg iv, norad infusion, inj atrixa 2.5mg, iv flvid 40+40 ml, ventilator support, thyroxin 150mg, inj albumin 100ml iv. 6:00pm - patient drowsy saturation not measurable, BP not revivable despite high dose, patient intubated with 7.5 ET tube, cuffs inflated and fixed, bilateral air entry checked, put on VCV mode, inj norad 5 amp@15ml/hrs continue VCV mode, urine output 30 ml in 24 hrs. 29/01/14 8:00pm - fungal infection bilateral axilla, general condition poor, BP 118/60, SPO2 92%, LVEF 50%, IVC <56%, FiO2 100%, I:E - 1:2, output 30ml, advised chest x-ray 29/01/14 8:30pm - On ventilation CMW, BP 60/40, Pulse 93 irregular, resp 22, I/O 150ml Forthy ET secretions +, scope ECC broad complexes QRS, hyperkalemia, 60ml/hr, inj norad (10/50), inj lizolid, inj fortum. Advised ABG urgent, arterial line anti K+ measures, start inj vasopressin at 2.4 ml/hr. 29/01/14 10:30pm - all aseptic precautions right radial artery cannulated, back checked, sutured and dressed, refered to Dr. Prateek Tripathi, avoid nephrotoxic drugs including NSAIDS, maintain hemodynamically, high risk consent taken, inserted ICA with full aseptic precautions, no complications noted, check and outflow noted. 30/01/14 1:40am - patient want into bradycardia asystole On inj norad at 20ml/hrs, inj vasopressin at 2.4 ml/hr, inj SBC at 50ml/hr CPR started, inj atropine 1amp iv stat, inj adrenaline 1amp iv stat.

HR - 30/min, Pulse- febrile, BP- 40 systole spo2? Unconscious, unresponsive, CPR continued. inj atropine 1amp iv stat, inj adrenaline 1amp iv stat HR 24/min pulse non- palpable, bp- non recordable, spo2?

CPR continued inj atropine 1amp iv stat, HR-o/min pulse-palpable, BP non recordable, pupils B/L dilated and fixed, reflexes absent, scope ECG shows flat line, inspite of all measures, patient could not be revived and declared dead on 30/01/14 at 2AM. Informed dr kalra and dr shabbar.

Cause of death - Bilateral TKR/ Bed sore/hypoproteinemia/septicemia/septic shock/multirogan failure.

rFkk ejht dh e`R;q gks x;h ejht dk e`R;q izek.k&i= tkjh fd;k x;k ftlesa Hypoproteinaemia e`R;q dk dkj.k crk;k x;k gSA ejht Hypothroidism dh Hkh f'kdkj Fkh ftlds ckjs esa Illustrated Medical Dictionary ds ist uacj 296 ij crk;k x;k gS %& Hypothroidism The underproduction of thyroid hormones by an underactive thyroid gland. Most cases are caused by an autoimmune disorder such as hashimoto's thyroiditis or by certain drugs such as amiodarone. Hypothyroidism may also result from removal of part of the thyroid gland to treat hyperthyroidism. In rare cases babies are born with an underactive thyroid gland (congenital hypothyroidism).

In adults symptoms include tiredness, lethargy, muscle weakness, cramps, slow heart rate, dry skin, hair loss, a deep and husky voice and weight gain. A syndrome called myxoedema in which the skin and other tissues thicken may develop. Enlargement of the thyroid gland may also occur. Babies with congenital hypothyroidism may have feeding difficulties, constipation, jaundice and excessive sleepiness. If the condition is not diagnosed and treated early it may retard mental development in childhood.

Hypothyroidism is diagnosed by measuring the level of thyroid hormones in the blood. Babies are screened for the condition shortly after birth. In all cases treatment consists of replacement therapy with the thyroid hormone thyroxine usually for life.

'ks"k ds ckjs esa Åij foospu fd;k tk pqdk gS bl izdkj ejht Bed Sores ds dkj.k HkrhZ gqbZ vkSj fnukad 20-01-2014 ls 27-01-2014 rd mldh fLFkfr Bhd jgh rFkk izksxzsl gks jgh Fkh vpkud lsUVªy ykbZu Mkyh x;h mlds ckn fLFkfr fcxM+rh x;h] baQsD'ku c<+rk x;k CyM esa baQDs 'ku vkus ls lsfIll ;k lsfIVflfe;k gks x;k mlds ckn Shock esa vk x;h [kwu esa tgj Qsy x;k fdzVfs uu igys gh c<+ pqdk Fkk Sinus bradycardia Hkh gks x;k fQj Hkh dkfMZ;ksyksftLV dks ugha fn[kk;k x;k fQj vUrr% ejht dh e`R;q gks x;hA tks bl ckr dks lkfcr djrh gS fd ejht dk Skill and Care ls bZykt ugha fd;k x;k] ejht ds igys Knee fjIyslesaV ls iwoZ tks tkWap gksuh Fkh] og ugha djok;h x;h igys Knee fjIyslesaV dj fn;k x;k ejht pyus Hkh yx x;h fQj nwljk Knee fjIyslesaV MkWa0 HkkxZo us izHkko Mkydj djok fn;k] ftldh vko';drk gh ugha Fkh rFkk vxj djuk Hkh Fkk rks] de ls de 90 fnu ds dk xsi fn;k tkuk pkfg,A nwljs Knee fjIyslesaV ds ckn u rks ejht gkWfLiVy esa py ik;h tc fd mlds 4 fnu HkrhZ jgh rFkk mlds ckn fQft;ksFkSjsih djkus ds ckotwn og dHkh py fQj ugha ik;hA ;gkWa rd fd Bed ij f[kldus dh fLFkfr esa ugha Fkh Bed Sores gks x;s Fks fQj gkWfLiVy esa HkrhZ djok;h x;h] ejht ds flQZ Bed Sores gh ugha Fks cfYd Knee dkEiyhds'ku Fkh rFkk vU; ,slh dksbZ chekfj;kWa ugha Fkh tks izk.k?kkrd gks ijUrq ejht ds lsUVªy ykbZu Mkyh x;h ftlls ejht dk baQDs 'ku c<+rk x;k vkSj lsfIVd 'kksd esa vk x;h rFkk vUr esa mldh e`R;q gks x;hA foi{kh la[;k 1 ls 5 blds fy, ftEesnkj gSA vc iz'u mRiUu gksrk gS DokVae dk ejht 59 lky dh efgyk Fkh ejht dk ftl rkjh[k ls bZykt fd;k x;k mldk o.kZu Åij fd;k tk pqdk gSA ifjoknh i{k ds 7]22]008@&:- [kpZ gq, gS] ejht ifjoknh la[;k 1 dh iRuh rFkk ifjoknh la[;k 2 o 3 dh ekrk Fkh og lsokfuo`Rr Fkh ijUrq mldk ?kj esa Roll de ugha FkkA bl laca/k es III (2009) CPJ 17 (SC) MALAY KUMAR GANGULY V/S SUKUMAR MUKHERJEE (DR.) ORS. esa ekuuh; loksZPp U;k;ky; us iSjk 173 esa fuEu fu/kkZfjr fd;k gS %& The standard of duty to care in medical services may also be inferred after factoring in the position and stature of the doctors concerned as also the hospital; the premium stature of services available to the patient certainly raises a legitimate 51 expectation. We are not oblivious that the source of the said doctrine is in administrative law. A little expansion of the said doctrine having regard to an implied nature of service which is to be rendered, in our opinion, would not be quite out of place.

fLFkfr esa efgyk gksus ds ukrs ejht dh fLFkfr de ugha vkadh tk ldrhA vr% rhuksa ifjoknhx.k dks ekufld vk?kkr o {kfriwfrZ ds :i esa 50]00]000@&:-

¼v{kjs ipkl yk[k :-½ fnyok;k tkuk mfpr gSA bl izdkj ifjoknhx.k 50]00]000@&:- o 7]22]008@&:- ¼ v{kjs lkr yk[k ckbZl gtkj vkB :i;s ½ bl izdkj dqy 57]22]008@&&:- ¼ lRrkou yk[k ckbZl gtkj vkB :i;s ½ izkIr djus ds vf/kdkjh gSA blesa ls 10]00]000@&&:-¼ v{kjs nl yk[k :-½ MkWa0 jktho HkkxZo 5]00]000@&:- ¼ v{kjs ikWap yk[k :-½ MkWa0 lquhy dkyjk rFkk 'ks"k foi{kh la[;k 1 ls 3 Hkqxrku djsx]sa rFkk bl jkf'k esa ls 10]00]000@&:-¼ v{kjs nl yk[k :½ & 10]00]000@&:-¼ v{kjs nl yk[k :-½ ifjoknh la[;k 2 o 3 izkIr djus ds vf/kdkjh gksxsa rFkk 'ks"k jkf'k ifjoknh la[;k 1 izkIr djus dk vf/kdkjh gksxkA bl jkf'k ij ifjokn nk;j djus dh fnukad 09 vizSy] 2015 ls 9 izfr'kr okf"kZd dh nj ls C;kt Hkh izkIr djus dk vf/kdkjh gksxsAa foi{khx.k ;fn 2 eghus esa Hkqxrku dj nsxsa rks ifjoknhx.k bl vuqlkj jkf'k izkIr djsxsa ;fn 2 eghus esa Hkqxrku ugha djrs gS] rks] Åij of.kZr ewy jkf'k esa vkt fu.kZ; fnukad 13 tqykbZ] 2020 rd dk C;kt ewy jkf'k esa tksM+ fn;k tk;sxk rFkk ml dqy jkf'k ij 9 izfr'kr okf"kZd dh nj ls olwyh rd izkIr djus ds vf/kdkjh gksxsAa foi{khx.k us fcuk tkWap ds igys Nee fjIysl fd;k fQj nwljs Nee esa dksbZ [kjkch ugha Fkh ijUrq izsfjr djds nwljs Nee fjIysl fd;k x;kA ejht dHkh py fQj ugha ldh mlds Bedsores o vU; chekfj;kWa gks x;h fQj gkWfLiVy esa HkrhZ djok;k x;k] fcuk vko';drk ds lsUVªy ykbZu Mky nh x;h ftlls ejht dh gkyr uktqd gksrs gksrs e`R;q gks x;hA bl izdkj foi{kh la[;k 1 ls 3 dh ;g vuQs;j VªsM izsfDVl gSA blfy, foi{kh la[;k 1 ls 3 ij punitive costs yxk;k tkuk mfpr gSA vr% foi{kh la[;k 1 ls 3 ij 10]00]000@&:- ¼ v{kjs nl yk[k :- ½ punitive costs yxk;h tkrh gSA bl ij Hkh ifjokn nk;j djus dh fnukad 09 vizsy] 2015 ls 9 izfr'kr okf"kZd dh nj ls C;kt vnk djuk gksxk] rFkk ;g 52 jkf'k **jktLFkku eq[;ea=h dksfoM&19 jkgr dks"k (RAJ. CMRF COVID-19 MITIGATION FUND)** esa tek gksxhA lkekU;r% fpfdRlh; vlko/kkuh ds izdj.kksa esa fpfdRlh; fjdkMZ dh QksVks izfr is'k gksrh gS tks ;k rks i<+us esa ugha vkrh ;k mldks i<us o le>us esa dkQh dfBukbZ gksrh gSA fpfdRlh; 'kCn ,sls gS fd mlesa ,d 'kCn b/kj ls m/kj gks tk;s ;k ifjofrZr gks tk;s rks] mldk vFkZ cny tkrk gS] ,sl h fLFkfr esa ;g funsZ'k fn;k tkrk gS fd vk;Unk ls tc Hkh fpfdRlh; vlko/kkuh dk izdj.k is'k gks rks esMhdy fjdkMZ dh ewy QksVks dksih ds lkFk VkbZi ;k dEI;wVj }kjk VkbZi dksih nh tkosa] pkgs dksbZ i{kdkj is'k djsa esMhdy fjdkMZ dh VkbZi izfr is'k dh tkosaA jftLVªh izdj.k ysus ls igys bl ckr dks ns[k ysa] ;fn VkbZi dksih ugha yxk;h tkrh gS rks ml izdj.k dks ntZ ugha fd;k tkosa] vkifRr yxkdj vf/koDrk@i{kdkj dks VkbZi izfr is'k djus dk le; ns fn;k tkosa rFkk VkbZi izfr is'k gksus ds i'pkr~ gh izdj.k ntZ djsa vkSj U;k;ky; esa yxk;k tkosaA bl vkns'k dh izfr jftLVªkj] jkT; miHkksDrk fookn izfrrks"k vk;ksx] jktLFkku] t;iqj dks nh tkosaA tks bldh ikyuk lqfuf'pr djsa rFkk jftLVªkj dks ;g Hkh funsZ'k fn;k tkrk gS fd] bl vkns'k dh izfr leLr ftyk miHkksDrk fookn izfrrks "k eapksa esa Hksth tkosa rFkk mudks Hkh Åij of.kZr funsZ'k fn;s tkosaA vkns'k vr% ifjoknhx.k dk ifjokn Lohdkj dj foi{khx.k dks vkns'k fn;k tkrk gS fd os bl vkns'k dh rkjh[k ls nks ekg esa ifjoknhx.k dks ekufld vk?kkr o {kfriwfrZ ds :i esa 50]00]000@&:- ¼v{kjs ipkl yk[k :-½ o [kpsZ ds 7]22]008@&:- ¼ v{kjs lkr yk[k ckbZl gtkj vkB :i;s ½ bl izdkj dqy 57]22]008@&&:- ¼ lRrkou yk[k ckbZl gtkj vkB :i;s ½ ifjokn nk;j djus dh fnukad 09 vizSy] 2015 ls 9 izfr'kr okf"kZd dh nj ls C;kt lfgr vnk djsaA blesa ls 10]00]000@&:-¼ v{kjs nl yk[k :-½ MkWa0 jktho HkkxZo o 5]00]000@&:- ¼ v{kjs ikWap yk[k :-½ MkWa0 lquhy dkyjk rFkk 'ks"k foi{kh la[;k 1 yxk;r 3 Hkqxrku djsx]sa rFkk bl jkf'k esa ls 10]00]000@&:-¼ v{kjs nl yk[k :½ & 10]00]000@&:- ¼ v{kjs nl yk[k :-½ ifjoknh la[;k 2 o 3 izkIr djus ds vf/kdkjh gksxsa rFkk 'ks"k jkf'k ifjoknh la[;k 1 izkIr djus dk vf/kdkjh gksxkA 53 foi{khx.k] ;fn 2 eghus esa Hkqxrku ugha djrs gS] rks] Åij of.kZr ewy jkf'k esa vkt fu.kZ; fnukad 13 tqykbZ] 2020 rd dk C;kt ewy jkf'k esa tksM+ fn;k tk;sxk rFkk ml dqy jkf'k ij 9 izfr'kr okf"kZd dh nj ls olwyh rd izkIr djus ds vf/kdkjh gksxAsa foi{kh la[;k 1 yxk;r 3 }kjk dh x;h vuQs;j VªsM izsfDVl ds dkj.k foi{kh la[;k 1 ls 3 ij punitive costs yxk;k tkuk mfpr gSA vr% foi{kh la[;k 1 ls 3 ij 10]00]000@&:- ¼ v{kjs nl yk[k :- ½ punitive costs yxk;h tkrh gSA bl ij Hkh ifjokn nk;j djus dh fnukad 09 vizsy] 2015 ls 9 izfr'kr okf"kZd dh nj ls C;kt vnk djuk gksxk] rFkk ;g jkf'k **jktLFkku eq[;ea=h dksfoM&19 jkgr dks"k (RAJ. CMRF COVID-19 MITIGATION FUND)** esa tek gksxhA ¼ 'kksHkk flag ½ ¼ 'kSysUnz HkÍ ½ ¼ dey dqekj ckxMh ½ lnL; lnL; lnL; ¼U;kf;d½ @ikBd@ 54 55

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