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

NBE CME programme for DNB consultantspercussion); Evaluation of surrounding structures eg Trachea, Recurrent laryngeal nerve andCarotids; Neck nodes – complete evaluation; Systemic exam – includes evaluation of thyroidstatus through CVS, CNS and eye signs . Respiratory exam must also be doneInvestigations-Ultrasound;Thyroid function tests (TSH, T3 , T4 ) ; FNAC;If further needed, Thyroidscan ; CT Neck for node evaluation , finding retrosternal extension;X-ray ChestDifferential diagnosis- For Diffuse thyroid enlargement (Physiological;Diffuse colloid; MNG(Endemic); Autoimmune Thyroiditis; Thyrotoxicosis – Primary & Secondary; Malignancy – Papillary,Follicular, MCT, Anaplastic & Lymphoma); STN (Dominant nodule of MNG; Cyst; Adenoma – Follicular& Toxic; Carcinoma; Focal Thyroiditis)Non- surgical treatment- Thyroxine – for suppressing TSH in colloid adenomas ( curative intent ),After Surgery of malignancy for suppressing TSH in Papillary ca. , as replacement after Near Totalthyroidectomy and to prevent recurrence after subtotal excision in MNG; Needle aspiration underUSG guidance for all cyst; Anti – thyroid drugs and Propranolol for thyrotoxic; Lugol’s / Collosaliodine for preparing thyrotoxic for surgerySurgical management— Some kind of thyroid resection for all except Anaplastic and Lymphoma;Either Lobectomy or Subtotal thyroidectomy or Near Total or Total thyroidectomy; If malignancy –Modified (conservative) block dissection depending upon the Lymph node group involvement; Anyother(External Beam Radiation for Anaplastic / Lymphoma;Radio-iodine for select group of Thyrotoxiccases)Cervical lymphadenopathyHistory-(Duration and the pattern of progress of swelling; Fever – details; Constitutional symptoms;H/O respiratory difficulty , dysphagia , any change in voice; Associated symptoms pertaining to Oralcavity/Abdomen/ Chest viz cough , abd. Lump., oral ulcer / salivation etc.; H/O testicular swelling ,Parotid swelling)Clinical examination- General physical exam – Besides routine specially look for jaundice, clubbing,pedal edema etc; Local (Neck) Exam – Complete evaluation of all groups of cervical nodes eg size,consistency, matting , mobility , fluctuations, any evidence of collar-stud abscess etc; If anyassociated thyroid swelling . it’s detailed clinical evaluation; If any Parotid swelling , it’s detailedevaluation; Exam of oral cavity ( lip, tongue , cheek, floor of mouth , gums, palate and inner Waldeyer’sring) including oropharynx; Examination of Head & face for evidence of melanoma, Squamous cellcarcinoma etc; Clinical evaluation of Ear , Nose and Throat; Systemic Examination should include– exam of abdomen for any malignancy, Examination of Testis , Chest for clinical evidence of ca.Lung and Breast ca. and P/R and /or P/V examinationInvestigations - Pertaining to Lymph nodes(Hb, TLC, DLC , ESR; Chest X-ray; FNAC; Excision/Incision biopsy depending upon site if lymphoma); If Primary is obvious-complete evaluation ofprimary by USG/CT/MRI etc & FNAC; If Primary is not obvious-Battery of investigations consisting ofendoscopic evaluation of nasopharynx / laryngopharynx; Plain X-rays and radiocontrast studies;USG/CT/MRI; Upper / Lower GI endoscopy; Exfoliative cytology etc.Differential Diagnosis - Reactive hyperplasia ( to infection ); Tuberculosis; Lymphoma; Secondariesform abdomen, Chest, Breast, Thyroid, oral cavity etc; Rare surgical causes to be enlisted in last(if at all)Non- Surgical Treatment-Antibiotics for infections; Anti-tubercular treatment for tubercular nodes;Chemotherapy for appropriate set of cases of lymphoma / Secondaries.Surgical Treatment - ( Excision/Incision biopsy - has diagnostic role and not therapeutic); Antigravityaspiration for cold abscess; Excision for tubercular sinus; Block dissection / modified blockdissection for secondaries depending upon primary and secondary itself. Any Other-Radiotherapyfor selected set of cases of secondaries and lymphoma.90