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देशका विभिन्न भागमा बैशाख १२ र २९ गते आएको 

बिनाशकारी भूकम्पमा परी मिति २०७२ -०२-११ गते 

सोमबार बिहान १०:०० बजेसम्मको प्राप्त जानकारी 

अनुसार ८,६५९ जनाको ज्यान गुमेको छ भने २१,९५२ 

जना घाइते भएका छन् ।

Update till 10:00 hrs, May 25, 2015

Death- 8,659

Injured- 21,952

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"बिनम्र अनुरोध "

समर्पण बारम "आन्मोल "

यहि २०७२ साल बैशाख १२ गते सनिबारको दिन महाभुकम्पमा परि दिबंगत हुनुभएका सम्पूर्ण बरामहरु  प्रति हार्दिक स्रदान्जली तथा उहाहरुको   परिवारप्रति हार्दिक समबेदना ब्यक्त गर्दछु,  साथै उक्त दुखद घटनामा घाइते हुनु भएका बराम बन्दुहरुको सिग्र स्वास्थ्य लाभको कामना गर्दछु, यस अकल्पनीय मानबिय तथा भौतिक क्षेतिबाट माथि उठी आफ्नो दिनचर्यामा बिस्तारै फर्की, आउदो बर्सहरुमा कहिले पनि यस्तो दुखद अवस्था  झेल्न नपरोस यहि शोकाकुल चण्डीपुर्णिमाको  हार्दिक मंगल मया शुभकामान

समर्पण बराम अनमोल

चण्डीपुर्निमलाई फर्केर हेर्दा किरण कुमार बराम , सुमन बराम अनि मेरो साथमा तमाम बराम बन्दुहरु

HISTORY TAKING

Dr. DINESWAR

Importance of History Taking

Importance of History TakingImportance of History Taking

žFirst step in determining the etiology of a patient's problem.

• žA large percentage of the time ) 70%) a diagnosis made based on the history alone.

Basic Ocular Anatomy & Physiology

ASIK PRADHAN

Consultant Optometrist

Introduction

The eye is a paired organ, the organ of vision.

 The eye is made up of various components, which enable it to receive light stimuli from the environment, and deliver this stimuli to the brain in the form of an electrical signal.

The Eyeball

The eyeball 

Cystic structure

An oblate spheriod*

Anterior and posterior pole &  Equator*

Dimensions of Adult Eyeball

Anteroposterior Diameter- 24 mm

Vertical Diameter- 23mm

Volume- 6.5ml

Weight- 7 gms

Coats of the eyeball

1.Fibrous coat (Sclera & Cornea) - Outer Coat- Protection

●

2.Vascular coat (Uveal Tissue) -  Middle coat- Nutrition

●

3.Nervous Coat (Retina)- Inner Coat-  Visual Functions

●

Segments and chambers of the eyeball 

1.Anterior segment

i.Anterior Chamber

ii.Posterior Chamber

●

2.Posterior Segment

Parts of the eyeball

Conjunctiva

Cornea

Sclera

Anterior Chamber

Iris

Ciliary Body

Pupil

Posterior Chamber

Lens

Vitreous

Retina

Choroid

Optic Nerve

  conjunctiva

Mucous membrane (stratified squamous), translucent

Lines posterior surface of the eyelids and anterior aspect of the eyeball

 Contains many goblet cells which secretes mucin that keep the eye moist.

Parts-

 Palpebral

 Bulbar

 Fornix

v Nerve supply- branches of 5th Cranial nerve

conjunctiva

cornea

Transparent, avascular, watch-glass like structure

Forms anterior one-sixth of the outer fibrous coat (Type I collagen)

Functions

To act as a major refracting medium ( Refractive power of cornea is + 45 Ds )

To protect the intraocular contents

Nerve supply

Anterior ciliary nerves (Branch of ophthalmic division of 5th cranial nerve)

CORNEA 

Histologically, it has 5 layers

1.Epithelium

2.Bowman’s membrane

3.Stroma

4.Decemet’s membrane

5.Endothelium

●

●

sclera

vWhite fibrous layer

vForms the posterior opaque five-sixth part of  the outer coat

vThinnest at insersion of rectus and thickest at posterior pole.

vFunctions

vProtect the eye ball

vGive attachment to the extra ocular muscles.

vNerve supply- Long Ciliary nerve

Anterior chamber

vSmall cavity – cornea anteriorly and iris and part of ciliary body posteriorly.

vAbout 2.5mm deep in normal individuals

vShallow in Hypermetropes and Deep in myopes

vContains 0.25ml aqueous humour

vPosterior Chamber

vTraingular space bounded anteriorly by the posterior surface of iris and part of ciliary body, posteriorly by the crystalline lens

vContains about 0.06ml of aqueous humour

Anterior and posterior chamber

Uveal tract

Iris & Pupils

Most anterior part of the uveal tract.

A thin circular disc corresponding to the diaphragm of a camera.

Divides the space between the cornea and lens into anterior and posterior chambers

In its centre is an aperture of about 4mm called “PUPILS”

Regulates the amount of light reaching the retina

Muscles of the iris controls the pupils size

•SPINCHTER PUPILLAE – Parasympathetic supply

•DILATOR PUPILLAE – Sympathetic supply

Ciliary body

vForward continuation of choroid, triangular in shape

vDivided into two parts

vPars plicata: anterior, with finger-like ciliary processes

vPars plana: posterior smooth part

v3 types of Non- striated muscles in the stroma

vLongitudinal – aids in aqueous outflow

vRadial- aids in aqueous outflow

vCircular- help in accomodation

vAqueous produced by ciliary epithelium.

vOptically clear media as it is devoid of protien cells.

Choroid

Posterior most part of the vascular coat of the eyeball

Inner surface is smooth, brown and lies in contact with retina where as outer surface is rough and in contact with the sclera

Function:

Nourishes the retina

Lens

A transparent, biconvex, crystalline structure between iris and vitreous

Suspended by ciliary zonules

Refractive index is 1.39

Dioptric power is 15-16 Diopters

Function

Accomodation 

vitreous

vClear, jelly-like substance that fills the middle of the eye.

vOccupies 4/5th of volume of the globe.

vTotal volume- 4 ml

vFunction:

vMedia for light pass.

vGive shape of globe internally

vPathway for nutrients to reach the retina and the lens

retina

The innermost tunic of the eyeball

Is a thin, delicate and transparent membrane

Is the most highly developed tissue of the eye

Appears purplish-red

Divided into 3 distinct regions

Optic disc

Macula Lutea

Peripheral Retina

retina

Has 10 layers

Function:

Senses light and creates impulses to the brain through optic nerve

Visual pathway

Eyeball acts as a camera; it perceives the images and relays the signals to the brain via visual pathway

orbit

Pyramidal shape bony cavity

Each eyeball is suspended by extraocular muscles and fascial sheaths with cushion of orbital pad of fats

Extraocular muscles

4 Recti

Medial Rectus

Lateral Rectus

Superior Rectus

Inferior Rectus

2 Oblique

Superior Oblique

Inferior Oblique

Innervation

LR6  SO4  Rest3

Appendages of the eye

Beauty of each eye is enhanced by the Eyebrows

Each eye is protected anteriorly by two shutters called Eyelids & Eyelashes

Conjunctiva  joins these eyelids to the eyeball

Appendages of the eye

For smooth functioning, the cornea and conjunctiva are kept moist due to tears produced by Main & Accessory Lacrimal Gland

The tears is drained by Lacrimal passage (Punctum, Canaliculi, Lacrimal sac, Nasolacrimal duct, Inferior Meatus)

Thank you

TRACHEOSTOMY It is an operation in which the windpipe is opened from the front of neck or Surgical creation of an opening into the trachea Indications for tracheostomy 1. Upper airway obstruction: to relieve upper airway obstruction  Infection : laryngeal infection  Neoplasm: carcinoma of larynx and pharynx  Trauma: laryngo-tracheal injuries  Foreign body in larynx  Neurological : B/L vocal cord palsy 2. Respiratory insufficiency : who needs prolong ventilation  Comatose patient without cough reflex: head and chest injuries, poisoning  Neurological condition: myasthenia garvis, poliomyelitis  COPD  Pneumonia 3. Tracheobronchial toileting  Accumulation of secretion in lower respiratory tract prevent proper gas diffusion at alveoli  Tracheostomy allows frequent and adequate pulmonary aspiration  Pulmonary edema  Congestive heart failure  Chronic lung disease and infections Types of Tracheostomy  Depending upon the urgency  Emergency  acute laryngeal obstruction demanding urgent relief.  Elective  Temporary  Permanent Technique  Position / Anaesthesia Tracheostomy Tubes  Metal tubes  Non-metal tubes Types of Tracheostomy Tubes  Portex tube (with cuff)  prevent aspiration  can be used in ventilator  May get blocked- has to be removed  Metal tubes  2 tubes - inner and outer tubes  Advantage - can be used for long period and has and less chance of blockade (if inner tube is blocked, it can be removed and patient breathes through the outer tube) Metallic tube Non metallic tube It has set of outer tube, inner tube and introducer Outer tube is fastened to neck with ribbon strap Inner tube is slipped into outer tube and fused to it by locking device Made of silastic Consists of single tube Advantage Main advantage of metal tube is that , if crusts or mucous plug blocks the inner tube and patient has difficulty in breathing, inner tube can be removed while outer tube remains in trachea and maintains patency of airway allowing the patient to breathe Advantage : Have inflatable cuff and can be connected to ventilator Disadvantage Do not have cuff and cannot produce an airtight seal needed for ventilator If lower end of metal tube do not fit properly, it can cause injury and even erosion of tracheal wall Disadvantage Inflatable cuff itself can cause excess cuff pressure leading to subglottic stenosis if used more than 2-3 weeks Has single tube, so that tube can get blocked due to mucous plug or crust leading to respiratory obstruction Nursing Care of Tracheostomy  Meticulous postoperative care of tracheostomy is necessary to avoid complication  Bed should be close to nursing station  Bedside items - suction machine with sterile suction catheters, 1 extra tracheostomy tube, paper and pen for the patient to communicate  Suction: regular tracheal suction after putting 1-2 ml of sterile saline into trachea to prevent crusting  Humidification : regular humidification( done by inhalation of steam or alternately by electric humidification unit ; nebulizer)  Chest physiotherapy: regular chest physiotherapy  First change of tube The first change of tracheostomy tube is done after 72 hours of surgery . after 72 hours a tract usually form and remains patent . if removed earlier than there is likelihood of soft tissue around tracheostomy collapsing and obstructing the airway Subsequent change of tube  When a metal tube is used –inner tube is removed, cleaned and reinserted without disturbing outer tube, 2 times a day  Outer tube is similarly removed and cleaned and reinserted once a day  When single lumen silastic tube is used – this tube should be removed cleaned and reinserted everyday Deflation of cuffed tube  When a cuffed silastic tube is used, cuff should be deflated every 2 hours for a few seconds or min in order to prevent tracheal injuries- necrosis and subglottic stenosis Principles of Decanulation  Tube size reduced before decanulation  Tube is corked off for increasing periods  Self-ventilating for at least one full night  No further need for tracheal suction  Remove the tube; plug the tracheostomy site

Foreign Body Oesophagus and Differential Diagnosis of Dysphagia: Foreign Body Oesophagus:  One of the commonest emergencies  Most of the time : accidental  Due to negligence  Various objects  If not tackle on time, severe complications  Life threatening. Types of foreign body:  Depends upon age group;  Paediatric : coins, battery, parts of toys  Adult : fish bones, meat bones  Old age: dentures, meat bolus Site of impaction:  Pyriform sinus  Cricopharyngeal junction = 15 cm  Arch of aorta= 23 cm  Left main bronchus= 27 cm Clinical features:  Symptoms : painful swallowing (odynophagia) : Associated symptoms  Signs : tenderness over neck : excessive salivation I/L : pooling of saliva in pyriform sinus Diagnosis:  X-ray soft tissues neck lateral view: : radio-opaque object : increased soft tissues density, prevertebral space  X-ray chest Lateral view:  Ba- swallow  Flexible upper GI-endoscopy  Rigid endoscopy Treatment:  Fresh: rigid oesophagoscopy and removal of foreign body under GA + antibiotic therapy  With infection: IV-Antibiotic therapy for 72 hrs followed by rigid oesophagoscopy  With impaction: thoracotomy and removal of foreign body. Complications:  Trauma : lip------- cardiac sphincter  Perforation of oesophageal wall  Mediastinitis  Haemorrhage  Haemo-pneumothorax  Dislocation of A-O joint. Contraindications:  Severe trismus  Acute oropharyngitis  Acute corrosive burn  Severe cervical spondylosis  Fracture of cervical spine  Secondaries in cervical spine  Aortic aneurism  Vascular tumour Causes of Dysphagia: 1. Congenital: stricture, atresia, web 2. F.B oesophagus 3. Neoplastic : in the lumen: pharynx, oesophagus : outside the wall: thyroid, larynx, bronchus, neck nodes 1. Paralytic: head injury, # base of skull, CVA, encephalitis, myasthenia , LMND, PBP

Foreign Bodies in Air Passages Foreign Bodies in Tracheobronchial Tree Clinical Features 3 stages a. Initial period of chocking, gagging and wheezing → cyanosis a. Brief period b. Cough out, lodge or down to bronchus b. Asymptopatic interval a. Depend on size and nature of FB b. Various sign Vegetable FB – chemical reaction- tracheobronchitis Non vegetable FB – remain silent for long time a. Later symptoms a. Airway obstruction b. Inflammation  Diagnosis a. History & clinical examination b. Chest X-rays a. Signs of collapse, emphysema c. CT-scan d. Diagonostic bronchoscopy  Treatment a. Antibiotics by IV route b. Anti-inflammatory agents – like steroid c. Heimlich’s manoeuvre. d. Cricothyrotomy and Tracheostomy e. Bronchoscopy and FB removal f. Thoracotomy – impacted FB g. Lobectomy

Tonsillitis Most frequently seen in children but is not uncommon in adults Causative organism 1. Viral most common 2. B-hemolytic streptococcus : most common 3. Streptococcus pneumonae 4. Hemophilus influenza 5. Clinical feature 6. Symptoms 7. Sorethroat 8. Odynophagia 9. Fever 10. Earache (referred otalgia) 11. 12. Sign 13. Congested and enlarged tonsil (bilateral) with or without pus point 14. Enlarged tender jugulodiagastric lymphnode Investigations Clinical diagnosis Tonsillar swab- culture sensitivity Complete blood count Treatment adequate fluid intake for first 2-3 days Oral analgesic 1. Paracetamol 500mg *qid *pc 2. Ibuprofen 400mg *tds *pc 3. Nimesulide 100mg *bd *pc Salt water or betadine gargle Antibiotics Oral penicillin: 1. Amoxycillin 250-500mg *tds for7-12 dys (choice of drugs) 2. Ampicillin 250-50mg *qod for 7-10 dys 3. Erythromycin 250-500mg *qid for 7-10 days 4. Cloxacillin 250-500mg *qid for 7-10 dys 5. Cephalexin 250-500mg*qid for 7-10 dys 6. Ciprofloxacin 250-500mg*bd for 7-10 dys I/M antibiotics 1. Inj. Penicillin 10 lakh I/M 6 hrsly or for 24-48hrs 2. Benzathine penicillin 6-12lakh I/M *od for 10 dys If condition is severe and patient unable to swollen due to pain, patient should be hospitalized and antibiotics should be given intravenously Complication 1. Tonsillitis due to B-hemolytic streptococcus group A can cause 2. rheumatic fever and acute glomerulo nephritis CHRONIC TONSILLITIS Person suffering from recurrent attacks of acute tonsillitis are also referred to as having chronic tonsillitis D/D of ulcer & white patch on tonsil Infection 1. Ac tonsillitis 2. Peritonsillar abscess 3. Candidiasis 4. Infectious mononucleosis 5. TB 6. Diptheria 7. Syphilis Neoplasm Blood disease Tonsillectomy Indications 1. 5 or >5 of acute tonsillitis over a period of 2 years 2. Obstructive sleep apnea syndrome (OSAS) along with adenoidectomy 3. Suspected neoplasm of tonsil There is no evidence of any deleterious long term immunological side effects after tonsillectomy Contraindications 1. Bleeding disorder 2. During acute infection Post operative care following tonsillectomy 1. Nursing care should be directed towards early detection of bleeding and to prevent its aspiration pulse examined every 10 minutes and BP every 30 min in early post operative period: a rising pulse rate and falling BP are signs of bleeding 2. In semiconscious patient noisy breathing and frequent swallowing are indirect sign of bleeding 3. Patient is encouraged to have normal food as soon as possible 4. Chewing and swallowing decreases post operative pain by preventing spasm of pharyngeal muscle

ACUTE PHARYNGITIS It is clinical condition characterized by inflammation of lining mucosa of pharyngeal wall and subepithelial lymphoid follicles. Predisposing factors 1. Common cold 2. Influenza 3. Measles 4. Scarlet fever 5. Exposure to air pollutants. Smoking 6. Rhinitis Types of pharyngits 1. Bacterial pharyngitis 2. Viral pharyngitis ACUTE BACTERIAL PHARYNGITIS Acute pharyngitis can occur as an isolated condition Sometimes the pharynx is involved together with the tonsils and it is called pharyngotonsillitis causes of acute pharyngitis 1. Viral a. Rhinoviruses b. Influenza c. Parainfluenza d. Measles, chickenpox e. Coxsackie virus f. Herpes simplex g. Infectious mononucleosis h. Cytomegalovirus 2. Bacterial a. Group A, B -memolytic streptococcus b. Diphtheria c. Conococcus 3. Fungal a. Candida albicans b. Chlamydial trichomatis 4. Miscellaneous a. toxoplasmosis Clinical feature Sorethroat: worse on swallowing Fever:+/- Odynophagia but not dysphagia O/E; congested pharyngeal wall Treatment: 1. Bed rest 2. Plenty of fluid 3. Warm saline gargle Analgesics 1. Paracetamol 2. Aspirin 3. Nimesulide 100mg *bd Lignocaine can be used to reduce pain during swallowing Lacal discomfort in the throat Antibiotics a. Group A, B -memolytic streptococcus a. Penicillin v 200,000-250000 units per oral*qid for 10 dys or b. Benzathine penicillin G i. <30kg data-blogger-escaped-body="" data-blogger-escaped-i="" data-blogger-escaped-ii.="" data-blogger-escaped-once="" data-blogger-escaped-units="" data-blogger-escaped-wt="600,000">30kg body wt =120,000 units once IM (12lacks) b. In penicillin sensitive infividuals a. Erythromycin 20-40mg/kg/day in divided oral dose for 10 dys c. Gonococcal pharyngitis a. Penicillin b. Tetracycline Symptomatic treatment Complication Same as acute tonsillitis

Deviated Nasal Septum Fracture Nasal Bone

Anatomy of Nasal Septum

►    Anatomically 3 parts:

1.       Columellar part

2.       Membranous part

3.       Septum proper

DNS

►    Aetiology:

1.       Traumatic

2.       Developmental

3.       Racial

4.       Hereditary

►    May involve the bony or cartilaginous part

►    Classified as:

1.       Spur

2.       Deviation

3.       Dislocation

►    Classification of Deformity of Septum.

►    Spur.  Sharp angulation  at the junction of vomer below with the septal cartilage  and or ethmoid , due to vertical compression force. # in the septal cartilage produces spur.

2.  Deviation : “C” or “S” , can be on vertical or horizontal  zone, may involve cartilage or bone or both.

3. Dislocation :  lower border of septal cartilage is displaced from its medial position ans projects into one of the nostril.Photo

DNS (spur)

►    Sharp projection at the junction of the cartilage and the bony part

DNS ( Deviation)

►    Bulging of the either the quadrilateral cartilage or bone.

►    ‘C’ or ‘S’ shaped.

DNS ( Dislocation)

1. The dislocation of the lower border of the septal cartilage from the maxillary crest. OR
2. Anterior columellar dislocation
3. Rarely posterior dislocation

Clinical features

1. Usually asymptomatic
2. Nasal obstruction
3. Dry nasal cavity
4. Recurrent rhinosinusitis
5. Headache
6. Epistaxis -rarely

Signs

1. Decrease nasal patency on the side of the DNS.
2. On anterior rhinoscopy

-          deviated septum

-          - maybe assoc. compensatory             hypertrophy of the middle or inferior turbinate on the opposite side.

3.     Maybe assoc. wt external nasal deformity.

4.     Investigations:

5.     Clinical diagnosis

Treatment:

•       Always Surgical

“As the septum goes, so goes the nose” Correct the septum first

1.  Treat the chronic sinusitis – Cap. Doxycyclin
2.  Treat the allergy – antihistamine, steroid spray

Treatment

1. Only for symptomatic DNS cases.
2. Surgical modality: Septoplasty OR Submucous resection of the septum (SMR operation)
3. Inferior turbinate reduction if needed. Collumelloplasty if ant. Collumellar dislocation.
4. Septoplasty:
1. Conservative operation where only the deviated part of the septum is removed.
5. SMR:
1. Radical operation where most of the bony and the cartilaginous part is excised leaving only ‘L’ shaped portion of the cartilage, superiorly and anteriorly.

Complications

Immediate:

1. Bleeding
2. Septal hematoma or abscess
3. Fever

Delayed:

1. Septal perforation
2. Nasal deformity
3. Nasal tip collapse
4. Synechiae
5. Depression of bridge
6. Columellar retraction
7. Papery thin septum
8. Parrot beak deformity

Fracture of the nasal bone

1.     After sports injury, RTA, blow etc.

2.     Maybe simple or complex

3.     Simple:

a.     With or without nasal deformity or septal deformity or septal displacement

1. Complex:
1. Assoc. with other facial skeletal fractures (naso-orbitoethmoid fractures)

Fracture nasal bone-clinical features

1. H/O trauma
2. Assoc. pain and swelling around the nose
3. epistaxis                                         
4. Nasal deformity                            
5. nasal obstruction (rule out septal hematoma)
6. Assoc. c/o facial deformity, diplopia, CSF rhinorrhea, proptosis, occlusal deformity
7. Maybe features of head injury, loss of consciousness

Signs:

1. Crooked nose
2. Tender swelling over the nasal bone
3. Epistaxis
4. Septal hematoma
5. DNS
6. Assoc. features of facial swelling, fracture zygoma, maxilla, orbital fracture, skull fracture etc

Fracture nasal bone-management

►    Investigations:

1.       X-ray of the nasal bone-lateral view

2.       CT scan in complex ones

Nasal injury (septal hematoma)

1. Early surgical drainage to prevent cartilage necrosis  and then packing of nose

Nasal bone fracture

1.Assess other facial injury

2. Pack if epistaxis
3. If grossly swollen fracture cant be assessed so wait for one week
4. If no immediate swelling then assess the grade of fracture

Nasal bone fracture (management)

►    Treatment:

1.       Undisplaced fractures- symptomatic treatment

2.       Simple fractures wt minimal displacement - ext. digital manipulation or intranasal fracture reduction in LA or GA. Either before edema develops or after the edema subsides( in 7-10 days). Delayed ones need rhinoplasty

3.       Complex ones – open surgical procedures. May need involvement of other faculties.