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

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NBE CME programme for DNB consultantsHypothyroidismIncreased sensitivity to depressant drugs; Hypodynamic cardiovascular system; Decreasedcardiac output; Slowed drug metabolism; Unresponsive baroreceptor reflexes; Impairedventilatory responses to arterial hypoxemia or hypercarbia ; Hypovolemia; Delayed gastricemptying time; Hyponatremia, anaemia, hypoglycemia; Adrenal insufficiency; Anaestheticmanagement including pre operative medication, choice of drugs for induction and maintenanceof anaesthesia, monitoring with emphasis on temperature monitoring, concerns about recoveryfrom anaesthesia; Role of regional anaesthesia.Obstructive JaundiceHistory-Onset, duration, progress of jaundice; Relevant history to elicit features of hepatic failureClinical signs-General physical examination and detailed examination of GIT to elicit signs ofhepatocellular failure; To demonstrate sites of eliciting jaundice; Features of portal hypertensionDifferential diagnosis-To be able to differentiate on the basis of history/examination/availableinvestigations the etiologies of obstructive jaundice examples Malignancy, CBD stone, CongenitalInvestigations-Relevance of each component of liver function tests; Risk stratification scoresManagement-To be able to discuss special consideration for Whipple’s procedure, hepaticresection- Major/minor, CBD exploration; To prevent hepatorenal syndrome; Pain managementstrategiesPortal HypertensionHistory-Presenting complaint with duration ( Haematmesis), malena, ascitis; Weight loss, Nausea,vomiting, anorexia, malaise, abdominal discomfort; Arthralgia ,myalgia- acute viral hepatitis; H/odrug exposure-CCl 4,vinyl chloride, acetaminophen ingestion, INH, methyldopa; H/o contact withjaundiced patient, blood transfusion, injections; H/o Alcohol consumption, variceal bleeds, flappingtremors, ascites, weight loss, loss of libido, menstrual disturbances—-suggestive of cirrhosis;H/o travel to hepatitis endemic area; JaundiceClinical signs-Pallor, dry papery skin, scratch marks; Cachexia, clubbing – Biliary cirrhosis; Pedaledema- bilateral in cirrhosis; Lymphadenopathy- Supraclavicular fossa- malignancy; Stigmata ofChronic liver disease; Abdominal Examination; Ascites (distended abdomen, bulging flanks),Umbilicus stretched – transversely in ascites and vertically in ovarian cyst. Skin over abdomentense,shiny and transparent; Hepatomegaly, splenomegaly, pleural effusion; Right upper quadranttenderness, palpable gall bladder; Signs of liver cell failure- parotid swelling, Dupuytrens contracture,gynaecomastia, fetor hepaticus, asterixis, testicular atrophy etc.; Cardiovascular system-Signs ofhyperdynamic circulations may be present; Respiratory System- Signs of Hepatopulmonarysyndrome; Central Nervous System- Look for signs of Hepatic encephalopathy.Investigations-Basic- Haematological, Liver function test, kidney function testsManagement- Medical management of varices; Surgical management- Shunt; Liver failure- livertransplantChronic Renal FailureHistory-Pertaining to precipitating etiological factor, duration of disease, renal replacement therapyif any; History pertaining to renal status i.e., urine output, swelling of the body, breathlessness,activity level; History of antihypertensive, hypoglycemic agents, history of haematocrit improvingmeasures (erythropoietin, blood transfusion); Past surgery/ dialysis schedule; History ofimmunization (hepatitis B)Clinical signs-General physical examination – pallor, blood pressure, oedema, nutritional states,presence of fistula; Respiratory system – infections/ effusion; Cardiovascular systemcardiomyopathy,effusionDifferential Diagnosis-To differentiate between acute/chronic renal failures and end stage renaldisease.58
NBE CME programme for DNB consultantsInvestigations-Haematocrit, urea, creatinine, electrolytes, total proteins, chest x-ray, ECG,Echocardiography, DPTA scan and their implicationsManagement-Implications of CRF on various body systems and their interactions with anaestheticagents; Perioperative management of a patient for live related renal transplant/cadaveric transplant;Management of a patient with CRF for incidental surgery.Severe AnaemiaHistory-Depend upon age, severity and speed with which it appears; Mild anaemia (8-10gm/dL)-loss of stamina, shortness of breath with exercise, palpitation; Moderate anaemia (6-8gm/dL)-Exercise capacity markedly reduced, exertion associated with headache, rapid exhaustion,dyspnoea, palpitation; Worsening of angina, claudication, heart failure; For type of anaemia-Soremouth, difficulty in swallowing, craving for ice/dirt (pica) – Iron deficiency anemia;Life long h/operiodic severe bone and joint pain – sickle cell anemia ;Jaundice, leg ulcers, gall stones –suggestions of hemolytic anemia; H/o prior transfusion; Drug/alcohol intake, Nutritional habits;Family h/o anemia, Racial background; H/o increased or acute blood loss from GIT, female genitaltract (menorrhagia); Worms in stool; H/o chronic disease which may be associated with anemiai.e CRF, connective tissue disorders, infections, malignancy, diabetes, AIDS, alcoholic liver diseaseand even pregnancy; H/o conditions which will worsen O 2delivery to tissues i.e. COPD, restrictivelung disease; H/o conditions which will predispose patients to increased risk from anemia. Eg.IHDClinical signs-Pallor, koilonychias; Apical impulse forceful; Strong peripheral pulses with widepulse pressure; Mild systolic/ holosystolic murmur secondary to increased blood flow andturbulence; Paresthesia, spleenomegalyInvestigations-Hb, blood count, reticulocyte count, Haematocrit, MCV, MCHC, Platelet count,peripheral blood smear ( Cell Morphology- cell size, Hb content, Anisocytosis, Poikilocytosis,Polychromasia); Reticulocyte count; Iron supply studies; Serum Iron; Total iron binding capacity;Serum ferritin; Marrow iron stain; Bone marrow examination; Aspirate; Erythroid/granulocyteprecursor ratio; Cell Morphology; Iron stain; Biopsy; Cellularity; MorphologyManagement-Blood transfusion; Iron- oral or intravenous; Vitamin B12Benign Hypertrophy of Prostate for TURPHistory-To bring out feature of obstructive uropathy; As these patients are usually elderly to bringout associated fractures and co-morbidities; Drug historyClinical signs-General physical examination including examination of spine; To bring out featuresof associated co-morbiditiesDifferential diagnosis-Benign and malignant conditionsInvestigations-Haematocrit; Pertaining to co-morbiditiesManagement-Type of anesthesia- advantages and disadvantages; TURP syndrome- diagnosisand treatment; Bladder perforation; Pacemaker and TURP; Radical prostectomy- Robotic surgery.Paraplegia/GBS/Motor Neuron DiseaseHistory-Evolution of the disease highlighting the main relevant complaint; History of any associatedmedical diseases; Past history- Similar problem at any time and what was done? Any previousanaesthesia exposure? Any member in the family had complication because of anaesthesia.Clinical Examination- Whether the concerned organ system has been focused on candidate. Hemust examine the cases from head to toe. Hemust examine all the systems as a routine followedby specific system examination.Investigation- Must mention the basic investigations and should be able to Recognize abnormalityand normal range .No battery of unnecessary tests since cost factor is also important. Special andadvanced investigations must be mentioned by the candidate to arrive at a diagnosis.59
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