NBE CME programme for DNB consultants - National Board Of ...

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NBE CME programme for DNB consultantsInvestigations - Hb, TLC, DLC, ESR, platelet count; Chest X-ray; Blood culture(bacterial infection);Tourniquet test; Viral serology; TORCH screen; LE cell, rheumatoid factor; ECHO(cardiacinvolvement) ; ECG(rheumatic fever) ; Urine analysis(Bacterial endocarditis) ; Lumbar punctureManagement - Maintenance of vitals (oxygenation, BP, blood sugar, temperature, airway, etc.) ;Temperature control; Intravenous fluids; Antibiotics fro bacterial infections (rational antibiotictherapy) ; Blood/blood product transfusion as per requirement; Specific therapy for specific disordersAnemiaHistory- Present — Acute or Chronic - Lethargy; Fatigue; Scholastic backwardness; Frequentinfections; H/o Exertional dyspnoea breathlessness; H/o Bleeding – any site e.g. PR. Past— H/oPallor; H/o bleeding disorders; H/o Malaria; H/o Blood transfusions; H/o Worsening of pallor withinfections; H/o Chronic infections – bronchicetasis, osteomylitis, dactylitis; H/o Connective tissuedisorders – Rhumatoid arthritis, SLE; Chronic renal Diseas; Chronic diarrhea; H/o Surgery –involving stomach/terminal clieum(B12 def). Personal History — H/o Chewing pencil(lead) ; H/oPica-mud, ice cube, etc. ; Hook work – H/o walking barefoot – open defecation. Family History —Anemia; Blood transfusions; Splenectomy; Bleeding disorders. Birth History — Preterm birth; H/o bleeding in the newborn period. Dietetic History — Strict vegan (B12 def.) ; Iron def. Diet; Durationof breast feeding; Time of cow’s milk introduction; Milk protein introlerance; H/o goat’s milkintake(folate def.). Drug History - Phenytoin; Methotrexate; PyrimethamineClinical Examinaton –General -Stunted growth; Thin built, marasmic/obese(rare) ; Pallor-nailsbulbarconjunctiva-tongue, Blue line of gums; Eyes-blue sclera; Tongue-papillae are atrophiedred painful tongue(pernicious anemia) ; Nails-longitudinal-ridges; Koilonychia; Thins, brittlenails; Bony abnormalities; Triphalangeal thumb(Diamond Blackfan anemia)CVS - Tachycardia;Cardiomegaly; Murmurs; Venous hum;Abd - Splenomegaly; (Mother’s Splenomegaly);CNS -Alaxia; Hyporeflexia; Clonus; Babinski positiveInvestigations - Blood —Haemoglobin – low; Red cell indices – MCV, MCH, RDW; Retic count –Decrease in Diamond Blackfan, Increased in hemolytic anemia; TC, DC; Neutropaenia;Hypersegmented(>5 segments) nucleated neutrophils>5% - folic acid def. ; Platelet increased iniron def. Anemia; Blood smear – study morphology of RBC, nucleated RBC, basophilic stippling(leadpoisoning) ; Decrease in c/c infections; Iron binding capacity – increased in iron def., decrease inc/c injections; Serum ferritin – decrease in iron deficiency; Adenosine deaminase activity in RBC,increased in Diamond Blackfan; Lactate dehydrogenase increased in hemolysis; Serum folatelevel; Bore Marrow – Aspiration — Morphology of cells; Erythroid hyperplasia(iron def.) ; Meglablasticprecurcessor; Absent harmodiderin slain; Ring sideroblasts; Culture – reduced no. of erythrocytecolony forming units; Biopsy if indicated; Urine - Methyy malonic acid excretion orotic acid crystal –orotic aciduria; Schelling test - to confirm absence o intrinsic factor in pernicious an anemiaApproach - Anemia alone or other marrow elements involved. In aplastic anemia only anemia isseen; Is there reticulocytosis? Seen in hemolysis and bleeding; Peripheral smear-Spherocytosishereditaryspherocytosis, Wilson disese, Autoimmune hemolytic anemia, Sickle cells-sickle cellanemia, Target cells, Nucleated RBC, Microangiopathy, Bite cells-G6PD deficiency—RBC size-,Microcytic(lead poisoning, thalassemia, irondefeciency),Macrocytic anemia(folate deficiency, B122deficiency, Pearson syndrome , Normocytic-Chronic disease, renal failure, hypothyroidismDifferential Diagnosis-Infancy - Diamond Blackfan; Transient erythro blastopaenia of childhood;Physiological anaemia of infancy; Red cell hypoplasia; Drug induces – eg; ChloramphenicolD/dof Microcytic an anemia - Iron def anemia; Sideroblastic anemia; Lead poisoning; A transferinanimia;D/d of Megaloblastic anemia - Folic acid deficiency; Abnormalities of folate metabolism;Drug induced eg; Methotrexate, Pyrimethamine; Vitamin B12 deficiency ; Orotic aciduria; Thiamnieresponsive anemia;Haemolytic anemias - Membrane defects(spherocytosis, elliptocytosis) ;Enzyme deficiencies, G6PD deficiency; Auto immune haemolytic anemias; Hyper splenism;Hemoglobinopathies(Sickle cell anemia) ; Thalassemias;Pancytopenias - Constitutional/acquiredManagement-Iron def. Oral ferrous iron.(sulphate, gluconate, fumarate) ; Parenteral Iron-only in154
NBE CME programme for DNB consultantscases of malabsorption; Imrove diet-decrease milk ot 500ml/day, Iron rich foods, combinationfoods with Vitamin C; Severe anaemia – blood transfusion packed cells; Frank CCF-Exchangetransfusion with fresh packed cellsSpecial situation - Iron chelating therapy; Steroids in Diamond Blackfan; Vitamin B12supplementaion, Folinic acid supplementation; Folate supplementation in haemolytic anemia;Recombinant human erythropoietin eg- renal failure; Bone marrow transplantation Pancytopenias;Gene therapySurgical management; SplenetomyQuadriplegiaHistory-History of epidemics; History of Recent Viral Infection; Adequate Immunization; History ofcousanguinivity; Fetal movement antenataly; March of evens of paralysis; History of Trauma tospinal cord History suggestive of TB; History of convulsions/altered sensorium; History suggestiveof cranial nerve palsies; History of respiratory difficulty; Bladder/bowel disturbancesClinical Examination-Assessment of higher functions, Cranial nerves, S/o Meningitis, WhetherUMN for LMN type of Paralysis, Tone, Involuntary movement, FundoscopyInvestigations - Apart from routine investigations, NCV studies, Muscle biopsy, CT/MRI of skull andspine, EEGDifferential Diagnosis-Poliomyelitis, G B Syndrome, Spinal dystrophies, Cong. Myopathies, Cerebralpalcies hypo and hypertonic, Cord injuriesNon surgical management - Role IV IG, Role of rest, Role of physiotherapy, Nutritional management,Care of bladder and bowl, Prevention of bed sores,. Role of ATTSurgical Management - Cord decompression, Release of contractures, Selective neurectingSeizure DisorderHistory – Aims- to differentiate Febrile seizure from afebrile seizure and age related childhoodseizure disorder like infantile spasm; To differentiate provoked seizure from unprovoked seizure;To differentiate Seizures from Pseudo seizure- Situation of episode, Any triggering factorm, Detailedeye witness account (eye witness should be asked to imitate the actions which he has seen),Onset , Level of consciousness, Presence of aura,Recovery, Speech, Bowel/bladder incontinence,Any injury sustained, Duration of seizure activity, Presence of fever (whether followed the seizure orpreceded the seizure), Drug treatment history Any antiepileptic drugs, their dosage and history ofdiscontinuation; Potentially epileptogenic drugs like ciprofloxacin, antimalarials; Drugs withimportant interactions; History of provoked seizure e.g. drug intoxication - Meningitis / encephalitis,Head Injury, Intracranial hemorrhage, Interruption in treatment, Metabolic events like hypoglycemia,hypocalcaemia, hypomagnesaemia, dyselectrolytemia, hypoxia etc.;Special attention should begiven to identify — Absence seizure, Myoclonic seizure,Simple partial , Complex partial seizure;History of heart disease, depression, anxiety, head injury, past h/o febrile seizure ;Family History -H/o of febrile seizure; H/O afebrile seizure; H/O sudden unexpected death; H/O syncope;SocialHistory - Education; Employment; Driving Status; Home situations; Sports; Use of alcoholicdrinksClinical Examination-Look for episodes of seizure /Pseudo seizure byhyperventilation;Neurocutaneous markers;Dysmorphic features, micro/ macrocephaly;Asymmetryin body size; Cerebral bruit; Tremor; Hair loss; Weight gain; Gum hypertrophy, Hirsutism; Acne,ataxia; Neonate with neurometabolic disorder, failure to thrive, rash, vomiting etc Absent reflexes,visual field defects; Neurodevelopmental delay, cerebral palsy, other neurologic disorders;Longtract signs, focal neurological deficits, raised intracranial pressure; Mental retardation, hyperactivityetc.CVS exam if syncope is consideredInvestigations -Hemogram to diagnose evidence of infection,Electrolyte estimation,Metabolicparameters like calcium, magnesium, sugar,EEG, Video EEG, Neuroimaging- MRI is better than155
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