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

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NBE CME programme for DNB consultantsSystemic examination- Chest; Abdomen – Hepatomegaly; Ascites.Investigations – FNAC; Biopsy if FNAC in not conclusive; If Bemign nodule – Pre operativeinvestigations; If Malignant(X Ray chest; Liver function tests;USG – abdomen – Liver; Ascites;Pelvis; ovaries; X-Ray of bones, if bony pains; Bone scan if suspicion of Secondaries; ER and PRreceptor studyPre operative investigations, if operable - Urine; Hb%; Blood sugar; ECG; Blood urea; Sr. CreatinineDifferential Diagnosis - Fibroadenoma; Carcinoma of Breast; Simple Cyst; Tuberculosis of breast;Chronic breast abscess;Treatment - Depending upon the final diagnosis.Inguino-scrotal swellingHistory-Duration and pattern of progress of swelling; Fever , Chills ( for filarial infection ); H/OTrauma( If swelling present from birth; Any H/O irreducibility of swelling; Gepgraphical area ofresidence; Any H/O increased intra-abdominal pressure viz cough, constipation, urinary difficulty;Constitutional symptoms; Married and No of children ( for varicocele )Clinical Examination - General physical examination – Routine specially pedal edema/edema leg;Local examination - Routine exam of swelling laying emphasis on can or can’t get above swelling;can testis be palpated separately; cough impulse; Transillumination; Fluctuations; Movement ofswelling with traction on cord; Testicular sensation; Feeling of bag of worm; Ring Occlusion testetc; Systemic examination – to evaluate any sec . from testicular tumor into abdomen / renal lumpon left side in varicocele cases; Abdominal muscle tone/ malgagnian bulges ; Neck forsupraclavicular nodes.Investigations - No specific diagnostic investigations for Hernia ( for these case evaluation ofChest by Chest X-ray and USG prostate adv); No specific for hydrocele ( but if non-transilluminantwith positive fluctuations, then a formal ultrasound may be considered ); For testicular swelling -FNAC; Tumor makers; Semen analysis for all cases of varicoceleDifferential Diagnosis - Inguinal Hernia ( Direct & Indirect ); Femoral hernia; Hydrocele; Testiculartumors; Encysted hydrocele of cord; Epididymal cyst / Spermatocele; Lipoma of cord; VaricoceleNon-Surgical Management - Advisable for mild varicocele, mild hydrocele and aymptomaticbubonocele in form of scrotal support; Hetrazone therapy for filarial eradicationSurgical Management - Herniotomy, herniorrhaphy, hernioplasty depending on case; Hydrocele –must know all type of operations with relevant indications; Excision for epididymal cyst,spermatocele, lipoma of cord; Varicocele – Ligation ( Open and laparoscopic ); Testicular tumor –High inguinal orchidectomy followed by Chemotherapy /Radiotherapy/RPLND depending on stageand response; Any other -Follow up and tumor markers for testicular tumorsExternal Genitalia ( Ulcer/nodule)History-Mode of onset and progress pattern; H/O unprotected sexual activity; Bleeding , pain ordischarge from the lesion; Associated diseases eg TB, peripheral neuritis etc; Religion).Clinical examination- Gen physical exam – Apart from routine ,stigmata of syphilis , cachexia; Localexamination – Exam of glans and penile shaft alongwith scrotum and inguinal area looking for;Ulcer / nodule – detailed exam; Exam of external meatus including any discharge;InguinaladenopathyInvestigations - Complete hematology; Urine exam – complete and Culture & Sensitivity; Serology-VDRL, ELISA and CFT; Microscopic examination of discharge;;Swab culture; Wedge biopsy; FNACof lymph nodes / nodule(s)Differential Diagnosis - Trauma; Tumor; Syphilis; Chancroid; Lympho-granuloma Inguinale; Herpes;HIV; Carcinoma Penis; Condyloma; Premalignant lesions eg Leukoplakia, Paget’s disease etc;Non-surgical management; For benign ulcers – antibiotic according to causative agent andsupportive therapy94
NBE CME programme for DNB consultantsSurgical Management - Generally for – malignant disease and consist of partial or completeamputation ; Inguinal block dissection depending upon requirementRadiotherapy - For malignant cases (Proper indication and ways to give radiotherapy must beknown)Soft tissue swellings/ tumorsHistory-Duration and pattern of progress of swelling eg if history of sudden increase recently orbecame more painful; Associated fever; Painful or pain free; Associated edema / motor dysfunction/ sensory loss; Any ulceration of swellingClinical examination - General physical exam – all routine; Local exam – Complete evaluation ofswelling specially anatomical plane of swelling, mobility , consistency, evidence of involvement ofdeeper structures viz muscles , nerves or vessels or even bone; Relevant pulsations; Movement ofjoint (if relevant to location of swelling); Multiplicity of swellings over body; Systemic exam – allroutineInvestigations - Apart from routine; Ultrasonic evaluation of swelling; If deeper infiltration , CT/MRI;Chest X-ray for sarcomas for knowing secondaries; FNAC / Trucut needle biopsyDifferential diagnosis - Sebaceous cyst, Lipoma, Neurofibroma; Ganglion; Parasitic cyst; Papilloma;Hamartomas; Fibrous histiocytomas; Fibrosarcoma; Other rare causes may be mentioned in lastNon- Surgical management - By and large no role; Inj Hyaluronidase for Ganglion if small andsimpleSurgical management - Enucleation/ Excision for swellings like lipoma, Seb cyst etc; Wide excisionfor locally recurrent tumors viz histiocytoma , hamartomas etc; Three dimensional excision /disarticulation for sarcomas, Any other - NilSoft tissue tumors of trunkHistory-Swelling – onset and progress pattern; Any h/o recent rapid increase in size or pain; Previoush/o surgery for same site swelling; Symptoms pertaining to local structures involvement ;Constitutional symptomsClinical examination - General physical examination – Routine; Local examination - Venousprominences; Visible pulsations; Complete examination of swelling specially to know clinically theanatomical plane of origin , consistency, fixity/mobility, pulsatility, surface and margins; Completeexamination of affected surrounding structures viz peripheral nerves / vessels / joint movements ifrelevant to that particular case-Bruit if any audible; Detailed evaluation of regional lymphadenopathyInvestigations - Plain radiography; Chest X-ray for evidence of metastasis; Ultrasonic assessment, if relevant to the site - CT/MRI evaluation for extent and depth / involvement of surrounding structuresor relations with vascular & neural structures; FNAC; Core needle biopsyDifferential Diagnosis - Benign viz Lipoma , Solitary neurofibroma , Nerve sheath tumor; Desmoids;Hamartomas; Fibrous histiocytoma; Dermatofibroma protuberns; Sarcoma like Liposarco.Fibrosarco. etc; Other rare causes at the endNon- Surgical Management - No primary role; Chemotherapy for malignant tumors mostly asadjuvant or sometimes as neo-adjuvantSurgical Management - Wide excision is the mainstay of therapy and that may sometimes involveremoval of muscles from origin to insertion; Followed by primary closure / grafting / use of flaps forclosure depending upon individual case, Any other – Radiotherapy as adjuvantOral ulcer / growthHistory-Pain – local or referred; Excessive salivation; Foul smell; Difficulty in protruding tongue /opening mouth; Alteration of voice; H/O smoking, Tobacco and alcohol; Spicy food consumption;Betalnut chewing; Dental plate / Sharp tooth95
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