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

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NBE CME programme for DNB consultants(Meningitis, encephalitis, TBM),Demyelintng- Acute Desseminated Encephalo Myelitis(ADEM),Todd’s paralysis also may be considered,ifhemiplegia follows a prolonged seizure, Spaceoccupying lesionsNon-surgical management - Depends on etiology. Measures to reduce cerebral edema, correctionof fluid and electrlytes imbalance, if any has to be done. Long term management like physiotherapy,speech therapy, and rehabilitative measures may be required in some cases. Referral to a childdevelopment center (CDC) is advisable for selective .patients.Surgical management - Surgical management will be required in space occupying lesions .andselective cases of spastic cerebral palsy.Any other - Site of the lesion,(Localisation) must be discussed before considering the differentialdiagnosis..Ear DischargeHistory - Name, Age, Sex, Address, Occupation, Brought by, Reliability , Presenting Complaints-Ear - Ear discharge- duration, Insidious,sudden, Progressive,stable, Intermittent,continuous,Color of discharge, Amount – copious, scanty, Smell - foul smell ,not, Aggravating,relieving factor,H/o FB ears; b. Earache-Site, duration, Sudden,insidious,character, Association withotorrhoea,vomiting,giddiness, Radiation, Periodicity, Aggravating, relieving factors; Hearing Loss– Side,duration, Insidious,sudden, trauma, exposure to sound,H/o drug, ingestion (Ototoxic) ,Progressive,stable, Associated giddiness;itching in ear- -Side / duration, Association withdischarge, HOH, Aggraveting relieving factor; Vertigo- Duration, Periodicity, Associated withnausea,vomiting, Frequency of attack , Aggravated by change in posture, Associated with discharge’HOH;Tinnitus—Side, High pitched,Low pitched;Fever-Associated with headache & chill, Periodicity,With nausea,vomiting;Hyperacusis, Aautophony, Dip!acusis;Diplopia;Facial weakness; Swelling behind ear; H/o trauma;H/o swimming, diving;Nose-Nasal discharge, Side - duration (Intermittent,continuous,Stable,progressive), Nature – watery, mucoid, purulent,blood stained, FouL smelling / or not ,Aggravating, relieving factor; Nasal obstruction- Side, duration, Birth, acquired, Intermittent,persistent, paradoxical- Associated with sneezing, Progressive or not - Aggravating, relievingfactors, Mouth breathing,snoring; Headache-Side, duration(Time of onset, Periodicity), Blurring ofvision, vomiting ( Character – throbbing, piercing, cutting ), Aggravating, relieving factor, Associatedwith ear discharge,bleeding;Anosmia- - Side, duration, Intermittent, Permanent, Associated withsneezing or loss of taste. Sneezing- Duration, With mouth breathing, With rhinorrhea, nasal block,anosmia; Post nasal drip- -Duration, Amount; Allergy- Specific,seasonal ;Throat -Sore Throat-Duration, Recurrent ,not , With fever and dysphagia;Past History - Any prolonged medication forTB, Ototoxic Drugs, Prolonged use of ear drops, nasal drops, Hlo HIV, HIO recurrent URTinfection, Hlo measles, whopping cough, Surgical history- Tonsillectomy, adenoidectomy, DNSsurgery, myringotomy, myringoplasty, Medical History- Use of antibiotics, analgesics,eardrops,antihistamines, H/o native treatment;Family History - Similar Complaints, Deafness,Overcrowding;Contact History - H/o Contact with known case of TB ;Immunization History - DPT,OPV, BCG, Measles, HIB, Pneumococcal, conjugated, polysaccharide;Dietic history - Totalcalories expected, Calories deficit, Protein deficitExamination - General Examination - General Condition WT, HT, Head Circumference, Anemia,BP ,Pulse, Temperature, Nutritional status, Febrile, Cyanosis, Generalized lymph adenopathy,Clubbing, Systemic ExaminationEar - Pinna, Pre auricular and post auricular region, External auditory canal (without speculum,with speculum) , Tympanic membrane (Position, Color, Surface, Mobility) , Middle ear, Mastoid, 3-finger test, Eustation tube, Tragus sign, Fistula test , Tuning fork test (rinne test , weber test,absolute bone conduction) , Ear examination under microscopeNose - External nose, Vestibule, Anterior rhinoscopy(nasal passage, septum, floor, roof, lateral158
NBE CME programme for DNB consultantswall), Posterior rhinoscopy (Choana, Posterior end of turbinate, Discharge in middle meatus,Adenoids, ET opening, tubal tonsils, fossa of rossenmuller ), Examination of paranasal sinus,Maxillary sinus (Frontal sinus, Ethmoidal sinus, Sphenoid sinus)Oral - Lips, Buccal mucosa, teeth, tongue , Hard I soft palate, Tonsils, anterior and posterior,pillar, Posterior pharyngeal wall, Indirect laryngoscopy (IDL Mirror) , CVS,RS,ABDOMEN, CNSexamination , Sensorium, Neck rigidity, Kerning’s sign, Brudzinski sign, CN palsyInvestigation - Cufture swab and sensitivity, gram stain of ear discharge, Blood culture, TC, DC,Hb, Bleeding time, clotting time, blood grouping, X-ray - mastoid, paranasal sinuses, chest, CT -scan - sinuses, skull (to detect fractures of base of skull) , Audiogram, bera (in children), otoacousticemission (OAE) , Mantoux test, Sinus endoscopyDifferential Diagnosis - Otitis extema - Severe pain, Tragus sign positive, Serous discharge;Acutesuppurative otitis media - Sudden onset of discharge, No previous h/o of discharge, Initially bloodtinged but later mucopurulent ;Chronic Supparative otitis media- Safe type - Mucoid discharge,Profuse discharge, Central perforation Unsafe type - Purulent I foul smelling discharge, Scantyamount, Attic or marginal perforation;Tauma - H/o of trauma, Sudden onset, Associated withbleeding;Neoplasia - Glomus jugular, Frank bleedingTreatment - Otitis externa - I.G. Packing, Aural toilet, Eardrops, Systemic antibiotics and analgesics,Incision and drainage if abscess formation occurs (Furuncle)Acute Suppurative otitis media - Aural toilet, Eardrops, Systemic antibiotics and analgesics,Surgical - myringotomyChronic otitis media - Safe type -Aural toilet , Eardrops, Systemic antibiotics, Treatment of thecontributory cause (eg adenoids, tonsils) , Surgical, Aural polyp, snare technique, Myringoplastywith or without ossicle reconstruction. Unsafe type - Surgical - Canal wall down procedure(Atticotomy, Modified radical mastoidectomy, Radical mastoidectomy) ; Canal wall up procedure (Intact canalwall mastoidectomy, Posterior tympanotomy ) ; Reconstructive (Myringoplasty, Tympanoplasty );Conservative treatment (Aural toilet )Respiratory Case (Cough)History - Onset of cough- Sudden- Foreign body/ Aspiration, Gradual- URI/LRI / Asthma; Nature ofcough- Croupy cough, Throat clearing cough- postnasal drip, Dry brassy cough; Cough Timingduringsleep - Tropical Eosinophillia post nasal drip, Bronchospasm, Psychogenic coughdisappears with sleep. On awakening - Productive cough, LRI, Cystic Fibrosis; Cough with Feeding-Gastro esophageal Reflux disease, Aspiration, Discoordinated swallow; Seasonal cough- AllergicRhinitis. Bronchospasm / Asthma; Associated factors- Aggravating factors- Activity, Food intake;Relleving factors- sleep, posture; Associated illness- Cong heart disease, CNS-convulsions ,Renal Uremia, Immunological diseases-OIClinical Examination - General Examination Anthropometry - Height, Weight, Head and chestCircumference, Clubbing Cyanosis, Pallor, examination of sinusitis Allergic RhinitisExamination of Chest - Inspection—Respiratory rate, Chest wall movements, retraction Flaring ofnares, Respatory grunt, Stridor, Inter coastal muscle. Palpation- Chest measurements, Chestexpansion, VF, VRPercussion- Dullness, Hyper resonance, Tidal Percussion. Auscultation- Air entry, Breath Soundsand its character , adventitious sounds-rhonchi,rales,cracklesTan. illumination of chestInvestigations - Radiology- Chest X-Ray/ Fluoroscopy, CT,MRI; Bronchogram, PulmonaryArteriogram, Aortogram ; Hematological - CBC, ESR ; Microbiological- Sputum, gastric or bronchiallavage, Culture a Sensitivity ; Purified Protein Derivative (PPD) ; PuImonary Function Testing;Blood Gas analysis; Endoscopic studies- Laryngoscope, Bronchoscope, Thoracoscopy;Thoracocentesis ; Lung BiopsyI Pleural biopsy; Sweat test159
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