Sneak peek 4 handbook of family medicine volume 1

                                Lactational breast abscess (acute bacterial mastitis)

           

Etiology:

Ø  Most common in lactating mothers.

Ø  Due to cracked nipples fissure in nipples.

Ø  Retracted nipples.

Ø  Oral cavity infection of neonate.

Pathology:

Ø  Common organism staphylococcus aureus which enters through nipple proliferate intraductually and leads to stage of cellulitis if not treated form a breast abscess. Non lactating abscess can be due to  duct ectasia or periductal mastitis. When they rupture, they form mammary duct fistula.

Clinical features:

Ø  Sever throbbing pain in breast due to inflammation.

Ø  Swollen, tense, tender, warm to touch breast-stage of  cellulitis.

Ø  High grade  fever with chills and rigors.

Ø  If both breast involved milk to express boil and then to give to infant.

Ø  Deep seated abscess difficult to elicit fluctuation sign.

Treatment:

Conservative:

Ø  Not to feed on affected side.

Ø  Cloxacillin 500m g 6 hourly or amoxicillin clavulanic acid combination orally or IV  as per genera l condition.

Ø  Anti-inflammatory drugs.

Ø  Good supporting bras to use.

Ø  If suspecting anaerobic organism then can add metronidazole.

 Surgical:

Ø  Incision and drainage is treatment of choice. Semicircular incision is preferred.

Ø  Pus should be aspirated and sent for culture and sensitivity.

Complication:

Ø  abscess ,Toxemia, Skin necrosis.

Ø  Antibioma-when abscess is not drained and antibiotics are given abscess cavity becomes fibrous and it results in firm to hard lump in breast. It requires excision.

Sneak peek 3 handbook family medicine vol 1

                                               Phlyctenular  conjunctivitis

Ø  Phlyctenular keratoconjunctivitis is characterised by nodule formation which occur as an allergic response by the conjunctival and corneal epithelium to some endogenous allergens  which they have become sensitized.

Aetiology:

Ø  More common in females of age group 3-15 years than males.

Ø  Malnutrition.

Ø  Type IV hypersensitivity to microbial protein.

Ø  Overcrowding.

Ø  Poor hygiene.

Ø  Common in spring and summer.

Pathology:

1. Stage of nodule formation:

Ø  The phlycten commences as a localised infiltration with round cells which produces a grey nodule usually situated at limbus .The epithelium is rubbed off and infection supervenes.

Ø  The commonest organism concerned is staphylococcus .

2. Stage of ulceration:

Ø  The ulcer become s covered with polymorphnuclear leucocytes and looks yellow.

Ø  Leash of conjuctival vessels converges on ulcer.

Ø  When phlycten actually starts in the cornea, the cellular infiltration lies deep to Bowmen’s membrane as this is tightly bound and cannot be lifted up the corneal phlycten is much less prominent than the conjuctival or limbal one.

Ø  Later bowman’s membrane and the epithelium break down to form an ulcer.

Types of ulcer formation:

a) The fascicular ulcer:

Ø  It starts at the limbus and creeps steadily over the cornea towards the centre.It is followed by a leash of vessels. The head of the ulcer is the infiltrated crescent which marks the conjunctiva. This  type of  ulcer do not perforate but leaves permanent opacity.

b) Ring  ulcer:

Ø  This  type may break down to form a large ulcer and perforate. Multiple small ulcers at limbus looks like grains of sand. A ring ulcer is formed by densely packed phlycten at the limbus breaking down and becoming confluent.

Ø  The nutrition of cornea is cut off and a large perforating ulcer or even necrosis of the whole cornea may result.

Ø  Phlyctenular pannus is like trachomatous pannus but any part of the cornea may be affected. It is thin and not very vascular.

Ø   It usually go under complete resolution with  the vessels  deep to bowmen’s membrane.

3. Stage of granulation:

Ø  Granulation tissue formed on healing ulcer.

4. Stage of healing:

Ø  Once granulation formation completes ulcer heals but can leave a scar.

Clinical presentation:

Ø  Discomfort  & irritation in eye.

Ø  Reflex watering.

Ø  Pinkish white nodule surrounded by hyperaemia on bulbar conjunctiva near limbus.

Ø  Ocular pain.

Ø  Swelling of lids and conjunctiva with redness.

Ø  Foreign body sensation.

Treatment:

Ø  Local antibiotic drops three times a day should be given till ulcer heals and infection is under control. Then start local steroids ointments or drops till ulcer subsides.

Ø  Lubricating eye drops prescribed to prevent dryness of conjunctiva.

Ø  If any specific focus for infection is found then it should be treated accordingly along with improvement in general condition.

Sneak peek 2 Integrated handbook of family medicine

                     Approach to case of   Stridor

Ø Harsh & high pitched sound produced by turbulent airflow through a partially obstructed airway is called as stridor.

Ø It can be inspiratory, expiratory or biphasic.

1. Inspiratory stridor:

It occurs due to  obstruction at the level of supraglottis.

E.g. laryngeal, nasal, pharyngeal.

2. Expiratory stridor:

It occurs at level of obstruction is below the sub glottis i.e. at trachea/bronchi.

3. Biphasic stridor:

This type has obstruction at the level of glottis and sub glottis.

Causes of stridor:

Larynx	Glottis	Sub glottis	Trachea & Bronchi	others
Supraglottis Laryngomalacia Webs Saccular cysts Laryngocoele Diphtheria Tetanus Prolonged intubation	Webs VC Paralysis	Webs Stenosis Haemangioma	Webs Stenosis Tracheomalacia Vascular compression Cysts Mediastinal tumours Foreign body tracheobronchitis	Choanal atresia Macroglossia Tracheo osophageal fistula

Evaluation:

This helps to determine the Level of obstruction and type of lesion.

History:

Ø Age of onset.( congenital /acquired).

Ø Onset and progression.

ü Sudden- Forign body,edema.

ü Gradual & progressive- laryngomalacia,juvenile papilloma.

Ø Nature of the sound and timing of the sound.

Ø Severity.

Physical Examination:

Ø Maintain a calm, quiet, reassuring attitude.

Ø It need to be fast yet detail.

Ø It should not be overdone.

Ø Make the patient comfortable & use Minimum instruments.

Ø Check for lesion at larynx or trachea.

Ø Look for respiratory distress, recession in suprasternal notch, sternum.

Ø Note the character of the stridor.

ü Snoring indicates nasopharyngeal origin.

ü Gurging & muffled sound suggest pharyngeal origin.

ü Hoarse voice suggest laryngeal cause.

Ø Fever suggestive of infection or inflammation.

Ø Sequential auscultation with unaided ear and with stethoscope over nose, open mouth, neck and chest helps to localize probable site of origin.

Ø Stridor of laryngomalacia, micrognathia, macroglossia disappears when baby lies in prone position.

Investigations:

Ø X-ray like lateral view of the neck  is helpful for above the glottis lesion.

Ø PA View of the chest helps t o find the sub glottis and the central airway lesion.

Ø CT and MRI has limited role because of Motion artifacts and Lack of fat plane in the region especially in children.

Ø Echo cardiography helps to rule out vascular compression, congenital cardiac disease.

Ø Flexible endoscopy: Good optics, paediatric sizes tubes are  available.

This is excellent for dynamic lesions like Laryngomalacia, Vocal Cord  Palsy .Sub glottis structures are poorly visualised.

Ø Laryngoscopy

Ø Bronchoscopy

Treatment:

Medical treatment:

Ø Oxygen inhalation with 40 – 60% concentration can help.

Ø Steroids therapy like IV Dexamethasone (0.15 – 0.6 mg/kg) or nebulised Budesonide (2 mg) may relive spasm. It helps to decreases the inflammation and oedema.

Ø Epinephrine inhalation helpful in mucosal oedema reduction as they act as topical decongestants.

Ø However the effect is temporary and definitive management is required. Rebound effect may be dangerous.

Ø Oropharyngeal airway mainatainace with endotracheal intubation require in severe stridor cases.

Surgical Treatment:

1.     Cricothyroidotomy.

2.     Tracheostomy.

MCQ memory based by June 2015 students

Dear friends ,
With help of Dr. Parag Patil, Dr.Sumana  & Dr.Subha here I am sharing memory based mcqs for you all.Hope that this will help you in your further preparation.

1. 3-4 mcqs on Apgar score like infant with pink colour,respiration irregular,flexion,H.R.100
options 4/5/6.
2. TB prophylaxis to child 10 mg INH 6 Months
3. Exposure to cotton dust cause.....
4.Prevalence detect by which study case control/cross section /cohort.
5.Casseines disease caused by heat/cold /noise /air.
6.Iodine deficiency found by investigation.
7.Relative risk 1 suggestive of....
8.Suggest oil for house use veg oil/veg +animal /mix of more than 2 veg oil.
9.English teacher classify as sedentary life style moderate / severe.
10.Obesity for Indians/asians  BMI of 23/ 27.5 /30.
11.At  12 th weeks pregnancy  uterus not palpable/palpable between pelvic & umbilicus.
12.IUD absolutely contraindicated in menorrhagia/unmotivated patient /abdominal pain.
13. 3 mcqs on zinc supplementation in diarrhoea.
14. White,thick ,foul smelling discharge vaginal diagnosis /investigation /treatment.
15. Peripheral most health delivery system anaganwadi/sub centre/PHC.
16. 2 disaster management.
17.Husband  MDR TB wife sputum smear positive which regimen to prefer in her?
18.abstinence after vasectomy.
19.Virulence, pathogenicity, infectivity 2 qs.
20. Puerperal sepsis within 3/7/21/42 days.
21.At risk infants
22.Curdy  discharge,fishy odour ,flakes,adherent,itching  per vagina gonorrhoea bacterial vaginosis/gonorrhea/candida/trichomonas vaginalis.
23.Ophthalmia neonatorum.
24.Contraindications of epidural anaesthesia.
25.Amino acid deficiency in cereals
26.Entry ,change of stage but no multiplication inside vector termed as Cyclodevelopment propagative /cyclopropagative.
27.Good calcium content in ragi /bajara.
28.Leprosy eradication definition  1/10000 1/1000 1/100000
29.HIV transmission can not occur in tranplacental /universal /breast feeding/perinatal
30. IMNCI colour coding
31.Plastic cover of syringe is disposed in
32.Human waste management
33.Predictor of ASHA work IMR/maternal weight gain
34.Commonest cause of maternal mortality
35.Death registration to be done within
36.Maternal mortality rate 2010 -2012 SRS
37.Vaccine contraindicated in HIV
38.Kalaazar PHC investigation
39.Malaria prophylaxis for 4 weeks stay
40.Primaquine in  pregnancy with falcifarum no dose/1 dose/14 days /2 days
41.Distribution of blood sugar measurement of women 45-60 age group in a village best depicted by bar diagram,composite bar,histogram
42.Farmer's lung.
43.Etiology asbestosis.
44.Age of buying cigarettes.
45. Definition  XDR rifampicin /isoniazid /amikacin/ capreomycin.
46.Local infection in neonate
47.Umbilical discharge 4-5 pustules
48.Cause of acid fastness mycolic acid
49.Why BCG given above left deltoid
50.Insecticide for spraying in Kitchen
51.Insecticide for residual spray
52.Eradication definition for leprosy
53.Indicator of  environmental iodine deficiency
54.PEP in HIV given within 6/12/24 hours preferable
55. Anaesthetic patches 1 nerve involvement....
56.Norethisterone enantate is repeated within ...
57.MAC  11-12/12-13/13-14/14-15.
58.Soft uterus bigger than the period of amenorrhoea molar/fibroid/ectopic/gestational trophoblastic tumour.
59.5 cleans of delivery
60.Subjective well being-living standards PQI/HDI.
61.Couple planning for pregnancy which is beneficial folic acid /Hb%
62.Minimal antenatal check-up
63.ASHA workers immunisation /health information/meeting with ANM/delivery at home
64.Severe malnutrition with effect W/H/ W/A/H/A(W/H wasting /stunting both /none)
65.Preterm < 259 days /< 2500 gms/ both.
66.Essential drugs can serve 80/50 /90/95 % of the diseases
67.Sickle cell anaemia -phenylalanine hydroxylase deficiency /autosomal recessive
68.Selling of counterfeit medicines increased due to high cost/private hospitals/delivery chain
69.A screening test can measure validity /reliability/accuracy.
70.Sullage does not contain  human excreta/?/?
71.Highest quantity of protein in soya bean/egg.
72,Less amount of calcium in spinach /rice
73.Angular stomatitis caused due to riboflavin /thiamine
74.Fe mostly absorbed from duodenum /stomach/distal small intestine
75.Fe absorption better with ascorbic acid ./pantothenic acid
76.Overhead tank water cleaning can be prevented dengue /malaria/filaria
77.Water collection removal of the home surroundings can prevent anopheles /ades/ culex mosquitoes.
78.International health regulation cholera /plague/ polio.
79.Traige most imp red /green/ black
80.Cows milk v/s human milk  vitamin  less A/C/D
81.Two cotton cloth can filter hookworm /ring worm/guinea worm infestation.
82.Single drug given in neonate to prevent MTCT nevirapine /lamivudine /zidovudine
83.Age of marriage in India for men 18/21/25
84.Eligibility for MTP at 18 weeks
85.Which type of E.Coli causes diarrhea in children EPEC/ETEC/EHEC
86.Phylosophy of DOTS plus
87.Define TB failure
88.TB New case no tretment/tretment < 4 weeks
89.Baby friendly hospital initiative.
90.Rooming in concept baby's craddle beside mother/baby & mother in secure place /mother in secure place/baby in secure place.
91.Parameter for sense of well being
92.Sentinel surveillance use
93.Risk from a disease of short duration best denoted by case fatality rate/....
94.AFP measured for antenatal screening of neural tube defect
95.Most important fatty acid to human
96.Nalgonda technique for fluoride removal
97.Dental caries factor
98.Epidemic dropsy sanguinarine
99.Permissible hardness of water
100.Spastic paralysis for which toxin
101.Addition of little quantity of nutrient to food termed as food addition/enrichment/fortification/adulteration
102.child with charge of theft should be sent to remand homes/borstal /prison
103.Child with naughtiness to be send to
104. Rog kalyan samiti
105. Vaccine contraindicated in HIV mother
106.Iron plus initiative
107. Paucibacillary leprosy treatment in child
108.Most important indicator for air pollution
109.Sick child acute respiratory infection/diarrhoea/suspected local and systemic bacterial infections
110.First vaccine to be developed for STI HPV/HEP B /Syphilis/Gonorrhea.
111.Skin fold thickness measured in all areas except suprailiac/suprascapular/subscapular/triceps
112.Screening of diabetes to be started after whic hage 40/45/30/18
113.Emergency contraception 4 OCP od 30 mcg estrogen
114.Progesterone content in yasmin
115.Which mosquito larva floats horizontally under water surface
116.Types of pesticide to kill birds/tick/ mites/rodent mouds
117.Ability of a test to find out correctly which are not present positive predictive value/sensitivity/specificity
118.Comparison of prevalance of a disease in two places done by which test chi square,anova,student t test,paired student test
119.Effectiveness of MDG done by which indicator neonatal mortality/maternal mortality/under 5 mortality
120.White patch after giving aceto acetic acid denotes which malignancy cervix/skin

Feed back from q bank users post theory exam

1.Easy and all expected.your book definitely helped mam. thank you - Dr.krishna.
2.Thanks again mam.The collection of the short subject questions helped a lot and made a huge difference.Your book saved our nearly 2 weeks time and also prevent missing important topics specially short subjects.- Dr.Subha,Kolkata.
3.Q bank was helpful mam.Thanks-Dr Meghna,Pune.
4.Nice book mam.Almost all the questions are covered in the paper by your book -Dr.Rajat,Pondecherry.
5.Thanks a lot mam. We are very thankful to you for your q bank .-Dr.Mahima,Pune.
6.Thanks smruti mam for q bank.Ihope volume also helpful.-Dr.Parag Patil,Nagpur.
7.Dr.Smruti your question bank is awesome ..to be posessed by every DNB from first day of PG only.Your book was absolute guidance.I must admit .-Dr.Sumana,Kolkata.
8.Your book was a real help mam  for theory preparation.It helped me in focused study.Dr.Sadhana,Hydrabad.
9.Books made study of family medicine exams much easy.Very helpful.Will try to contribute i n revised editions of book.- Dr.Paul.
10.Books really helped me in clearing my theory exam.Worth reading. - Dr. Afzal.

How to manage family medicine training:Postings

Dear friends,
            Many of us have under gone various permutations and combinations of postings during our 3 years training.Ideally DNB does have a training session table .But hardly few institutes follow them.Majority of us are posted in casualty,ICU or medicine for most of the time and rarely get other rotations like psychiatry dermat or anaesthesia which are equally vital.Every time you cant fight with management .So what's  the solution to this?
          One  is contact NBE,note down your problems & other is adjust with what ever they are allotting you.But make sure you won't compromise your integrated family medicine approach.Learn every day as much you can.Every single day bring new lessons and teach you something new.While doing major rotations do visit near by PHC or UHC  to see new GOI programmes,vaccines etc.Its ok even you don't get to work in PHC. Learn from higher centre and bring that advance knowledge close to community in your practice time when you  actually serve the community.Also make a habit to visit wards to see interesting cases. e.g .your there in surgery and few interesting cases are there in medicine /pads & visa versa.Go examine them & present.
           Make sure minimum you attend 2 months OBG,2 months surgery,4 months pads ,1 month ortho. anaesthesia you can cover in surgery posting while your in O.T. & E.N.T.,psychiatry & ophthalm at least 10-15 days rotation you request and take.
           As a doctor we have  to remain student and receptive whole life.No matter how they train you,what matters is how you allow them to train you.Preserve your core as family physician and  I am sure your training will be very interesting .all the best.Take care.


Ideal schedule by NBE:

(l) CLINICAL AREAS

24 months of rotating residencies in approved hospital wards in the areas of

-Internal Medicine including mental health : 10 months

-Paediatrics: 4 months

-General Surgery including orthopaedics : 3 months

-Obstetrics and Gynecology : 2 months

-Emergency services : 1 month

-Elective training includes any one or more from the areas of dermatology,ophthalmology, otorhinolaryngology,geriatrics, physical medicine,rehabilitation and anaesthesia. Other relatively lesser known areas for elective training include school health,sports medicine, long term care and occupational/industrial medicine:4 months

(II)FIELD AREAS

12 months of rotating field postings in the following areas identified by the accredited hospitals :

Family Practice Centre (or a primary health centre or a rural/urban health clinic) 6 Month

Practice area of a senior general practitioner 3 months

Nursing homes and other sites for 3 months

Posting at each of these sites should be equally distributed into 50% of time for assistantship with the tutor’s practice where he also participates in group discussions and in planned programmes to carry out short projects such as detection and follow up of some risk factors under tutor’s supervision and another 50% of time for independent work with the trainee’s own allotted practice population.

Sneak peek in handbook of family medicine vol 1

Dear friends,
 Here I am sharing sneak peek of my next book.This is just a sample representation and not the actual image.Hope it will inspire you for booking starting from 20 June.good day.

                          Fracture of clavicle

Ø  Fracture of clavicle is very common type of fracture due to fall on outstretched hand or road traffic accidents.

Ø  It can also occur due to violence or direct fall on shoulder joint.

Types:

1.       Junction of middle and outer third of clavicle.

2.       Outer third of clavicle.

3.       Inner third of clavicle.

4.       In children, green stick type.

Mechanism:

Ø  If it occurs with greater force on clavicle or direct violence there can be separation of bone into two pieces.

Ø  Medial end get pull due to underlying sternomastoid muscle & becomes elevated.

Ø  Lateral fragment sags below & forward due to weight of the arm.

Ø  It gets displaced medially by pectoralis major & forward due to pull with forward rotation of scapula.

Ø  Rare cases both bones can get separated and are not in contact.

Ø  If outer third is involved, there is minimal displacement of bony ends as both fragments are attached to scapula by coracoclavicular ligament.

Clinical features:

Ø  Patient often enters clinic supporting elbow of the injured side with other hand and bending slightly towards injured side.

Ø  A careful documentation of history is important to understand mechanism and force which cause injury.

Ø  Patient complaints of difficulty in using arm of injured side.

Ø  They also complaint of pain around shoulder and difficulty is raising arm.

Ø  There is distinct tenderness at site of fracture be it in middle third or lateral third or medial third.

Ø  X-ray gives clear idea a about type of fracture.

Treatment:

Ø  In children with green stick fracture, clavicular collar cuff or broad arm sling is used to keep hand elevated and relive the pain.

Ø  In adults, middle third clavicle type of fracture with displacement, reduction is required by pulling patients shoulder firmly backwards to align bone fragments.

Ø  Displaced fragments should be kept aligned well if not maintained mal union can occur.

Ø  Few methods can be used to keep them in alignment like Figure of 8 bandages, clavicular ring.

Ø  If fracture is at lateral end & fragments are not displaced, a simple  clavicular collar with cuff or broad arm sling (triangular sling) can be used for 3 weeks .

Ø  If fragments are displaced, they may require surgical fixation or plaster to keep in alignment.

Ø  Any type of clavicular fracture requires periodic inspection.

Ø  If bandages are used they require tightening once a day for first week and every 2-3 days for next 2-3 weeks.

Ø  If slings are used they should be changed after 2 weeks.

Ø  A clavicular collar and cuff or broad arm sling is use to support shoulder.

Ø  As soon as pain relives patient should be encouraged to move hand.

Ø  Elbow, wrist, fingers must get exercise from beginning.

Ø  Once pain subsides, patient can do gradual shoulder movements.

Ø  Sling can be stopped once pain subsides and fracture aligns.

Ø  Surgical open reduction required when there is neurovascular deficit or cosmetic deformity with demand of correction by patient.

Ø  It can be fixed by using plates internally.

Complication:

Ø  Mal-union.

Ø  Nonunion.

Ø  Subclavian vessel injury or brachial plexus injury.

Ø  Stiffness of shoulder.