volume :1 issue : 2 april-june 2020 2020.pdf · 2020-03-30 · sps hospitals medcentre : new model...

Volume :1 Issue : 2April-June 2020

24X7 EMERGENCY & PHARMACY

82 83 83 83 92LUDHIANA

75 04 61 23 45SIRSA

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SPS Hospitals Medcentre : New Model Town, Ludhiana, Punjab 141001 0161 500 1210SPS Hospitals Medcentre : Omaxe Royal Residency, Pakhowal Road, Ludhiana - 141012

0161-4659549

Editorial Disclaimer Content: All content found on this publication - MedTalk, including: text, images or other formats were created for informational and scientific purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment.Contents and any information provided by Contributors in this publication, are provided on an "as is" basis. The Contributors are solely responsible for the respective content and it's authenticity and MedTalk is not responsible for any such content.Images: The images used are either provided by Contributors (all photos of patients used in the articles have been obtained after "written informed consent" from the patient to be used only for scientific research purpose.) or are royalty free images or are legally procured stock images. The scientific articles that are included in the news letter are already published in scientific journals. The authors of the articles are clinicians in SPS Hospitals and consent has been taken from them to publish these articles in our newsletter with proper citation of the article giving due diligence to give credit to the journal in which original article was published.

Meet the Medtalk Team

Executive Board

Mr. Jai Singh: Managing DirectorDr. Jatinder Arora: COODr. Rajiv Kundra: Medical SuperintendentDr. Annie Mattu: Deputy Medical Superintendent

Contributors

Dr. H.R.S. GirnDr. Gurpreet SinghDr. Vikas SikriDr. Rajeev KapilaDr. Ashish Gupta

Dr. Sundeep KaurDr. Jastinder GillDr. Promila JindalDr. Sandeep Goyal

Dr. Annie Mattu (Editor in Chief)

Dr. H.R.S. Girn

Dr. Gurpreet Singh

Dr. Vikas Sikri

Dr. Rajeev Kapila

Dr. Ashish Gupta

Dr. Sundeep Kaur

Dr. Jastinder Gill

Dr. Promila Jindal

Dr. Sandeep Goyal

Dr. Akriti Gupta

2

• Complex liver resections: Cirrhotic resections-

Awareness and preview of development

of a sub specialty. - Dr. H.R.S Girn 04

• Look Good, Feel Good!!! - Dr. Jastinder Gill 07

• Tracheal Tumor: an unusual cause of severe

dyspnoea treated as severe asthma

- Dr. Gurpreet Singh, 08

- Dr. Vikas Sikri &

- Dr. Rajeev Kapila

• Who needs IVF and when? - Dr. Promila Jindal 11

• Hand Re-Vascularization at SPS Hospital

- Dr. Ashish Gupta & 13

- Dr. Sundeep Kaur 14

• Book Launch - Dr. Sandeep Goyal 16

• Preventive Healthcare Packages 18

3

Mobilization of the right lobe of the liver

An adult liver is the largest organ in the body accounting for 2% – 3% of the total body mass. Liver also has a unique potential of regeneration. When it began, liver surgery used nothing but the instruments of general surgery. Today, with the exploitation of special technology and instrumentation such as operative ultrasound, ultrasonic dissectors, argon coagulators, cryotherapy, radiofrequency, and extracorporeal circulation, liver surgery has become a subspecialty of gastro surgery, or more precisely, a hyper-specialty; just like cardiac surgery is to cardio-thoracic surgery. This concept although well established in the west and the east and even in Indian metropolis, has taken a very large span of time to percolate down to second and third tier cities in India, but is rapidly catching up mainly lead by the increased awareness of the educated patient populous rather than by the medical establishments themselves. There is still a big grey line in liver surgery in Indian peripheral sector as to what is palliation, what is bridging and what is curative; and again this territory distinction is dissipating by the patient themselves seeking multiple referrals rather than an organized protocol referral stream. Liver surgery in peripheral India at best can be compared to cardiac surgery in 1980’s in India and is undergoing the same learning curves with some centers ahead of the others.Having done the first successful cholecystectomy in 1882, the German surgeon Carl Johann August Langenbuch performed the first successful hepatic resection in 1888. However liver surgery really took off after the success of first liver transplants done by Thomas Starzl in 1958. Thomas Starzl also

did a significant body of work on describing the initial liver segmental liver resections and these techniques were further refined by Henri Bismuth from France and liver surgery began to take off in all major liver transplant centers across the globe. India somehow remained isolated to these developments in the 20th century and finally liver surgery came to light again with the establishment of successful liver transplant centers in the first decade of 21st century in India. Hepatology (sub specialty) of gastroenterology actually became established on the background of liver transplantation in India rather than the other way around as has been the case for other major sub specialties where development of medical super specialties precedes the surgical super specialties. Another important factor in the development in the liver surgery in India was the concept of cadaveric and live donor liver transplantation. One might think what cadaveric donation has got to do with development of liver surgery. Initially all liver transplant centers in the west were dependant on cadaveric supply of liver organs, and these centers were the training grounds for liver surgeons in the world. When these liver surgeons travelled to their native countries for establishing the liver units the cultural differences between the west and east in terms of attitude of government and public towards organ donation became the single dominant factor determining the future of liver surgery. In south East Asia, Japan, Korea and India the organ donation rates were abysmal. The proportion of liver cancer and liver cirrhosis disease load was at an astronomical proportion comparatively. So live donor liver transplantation became the key to cure cirrhosis in this part of the

world compared to the west, but majority of the text books were still written by western authors and this lead to a mismatch of advice given by the medical doctors and lack of organs became and isolated problem of the surgeons pursuing this specialty; this is still true for north India where patients are regularly counseled for cadaveric transplant rather than live donor liver transplant which is the actual realistic option here. One may ask what that has got to do with development of liver surgery. These two factors are actually inter-related. Liver resection surgery really developed in the east – South Korea, Japan, Taiwan, Hong Kong and now even India where liver surgeons began to regularly undertake complex resections instead of transplantation for patients with hepatocellular carcinoma (HCC) and this was based on the development of skill sets harnessed by performing live donor hepatectomies as there was shortage of cadaveric donor pools in these countries. Initially western world stuck to transplantation as the key treatment for HCC, but with increasing body of work from South east Asia, liver resections started to be an acceptable modality of treatment even in well worked up and selected cirrhotic patients. All the latest guidelines from American Society of Study of Liver Disease, European Liver study groups started to reflect liver resections as an option in HCC, something that the Asia pacific societies had

been saying for some time. This concept has still not caught up with the gastroenterology community in India thus far but the concepts are changing as the evidence in favor is building up and shortage of cadaveric organs is a reality for all of us. Further developments between interventional radiology and liver surgical groups have helped refine the results in the favor of the patient and these specialties are actually emerging as complementary specialties rather than competitive ones.The above background serves as the preamble to our policy here at SPS Liver and Pancreas Institute of offering liver resections to both non cirrhotic and highly selected non cirrhotic patients for HCC, sometimes directly, sometimes in combination with Transarterial chemoembolization (TACE), sometimes with liver augmentation techniques like portal vein embolization; all above protocols dictated by the stage of cirrhosis, portal pressure measurements and volumetry and working in very close association with gastroenterologists with special interest in liver diseases, with purist hepatologists and with our radiology and interventional radiology colleagues. Majority of our patients come directly to seek specialized liver treatments and few of the examples out of a subset of over 100 complex liver resections are provided below:

Patient 1- 74 year female with HCC of right lobe of the liver

On the background of Childs A Cirrhosis with mild splemomegaly, borderline platelets at 120 and prominent esophageal veins rather than varices.

This patient underwent resection of posterior sector of her liver and is tumour free at 4 years follow up.

4 5

Complex liver resections: Cirrhotic resections- Awareness and preview of development of a sub specialty.

Look Good, Feel Good!!!

6 7

Patient 2 – 60 year old male

HCC right lobe of liver on the background of child cirrhosis

Intraoperative view of the tumour

Complete mobilization of right lobe of tumour

Complete right hemihepatectomy specimen with removal

of the tumourPatient 3- 35 year old female with large hepatic epithelioid haemangioendothelioma (HEHE)

Large HEHE of the right lobe of liver

Resected extended right hemihepatectomy specimen on HEHE

Summary:1. Significant developments have been made in the field of liver sectional surgery where in up to 75 percent of the liver can be removed safely

2. Early referral, multidisciplinary team approach and setting up of specialized centers doing complex liver resectional work is the key to success

BEFORE AFTER

In today's world when the mantra is look good, feel good, everyone wants a blemish-face and wrinkle-free skin. And with the advance of science and technology it has become possible to reverse the sign of ageing and have an ever youthful skin. We have 2 major procedures being done in the department of skin and cosmetology, which I shall discuss here.

1) Chemical PeelsIt's a lunch time procedure, where the client comes into the clinic and goes back to work. There are different peels with different chemicals and concentration for different skin conditions and problems. Chemical peels give excellent results in case of blemishes, open pores and post acne scars.

The only thing to take care is sun protection after the peel. Around 6 sittings are done at an interval of 4 weeks. The chemical peels, rejuvenate the skin and help to build up collagen and elastin which brings in a glow to the skin, reduces the open pores and pigmentation.

2) Fractional Laser/Laser FacialWe have the fractional laser, which help to reduce and prevent the wrinkles, fine lines, tightens up the skin. It brings back the glow and the ever youthful look to the face. It also gets rid of the acne scars and open pores. Around 2-3 sittings are needed at an interval of 6-12 weeks depending upon your skin condition and problem.

Tracheal Tumor: An unusual cause of severe dyspnoea treated as severe asthma : (Indian J chest dis allied SCI 2019;61;101-102)

1 1 1Gurpreet Singh , Rajwinder Kaur , Vikas Sikri ,

2 3 4Rajeev Kapila , Gurpreet Singh , N.C. Kajal and 4

Srijna RanaDepartments of Pulmonary Medicine and Critical

1 2Care , and ENT , Satguru Partap Singh Hospitals, Ludhiana, Department of Cardiothoracic and

3Vascular Surgery , Fortis Hospital, Mohali and

4Department of Chest and TB ,Government Medical College, Amritsar (Punjab), IndiaAbstract Inflammatory myofibroblastic tumours (IMTs) are rare neoplasm with benign clinical course. Although the aetiology is unclear, it is believed that IMTs are true neoplasm rather than a reactive or inflammatory lesion. We present the case of a 43-year-old female who presented to us with respiratory symptoms. She was being treated for bronchial asthma for the preceding nine months. Diagnostic testing revealed pedunculated tracheal tumour on computed tomography of the chest. Tracheostomy and tumour coblation was performed under general anesthesia and histopathology revealed IMT. [Indian J chest dis allied SCI 2019;61;101-102]Key words: Inflammatory myofibroblastic

tumours, Benign, Pedunculated, Coblation.IntroductionPrimary tracheal tumours are relatively rare and

1are usually malignant (80%–90%) in adults and 2

benign (60%–70%) in children. these make up only about 2% of all tumours that arise from the upper airways. Most of the tracheal tumours are squamous cell carcinomas or adenoid cystic carcinomas. Inflammatory myofibroblastic tumour (IMT) is rare constituting 0.04%–0.07% of all respiratory tract tumours and usually presents in children under 16 years of age.3 As patients with tracheal tumours initially present with non- specific respiratory symptoms, definitive diagnosis is often delayed. Chest computed tomography is an important imaging modality to diagnose and stage patients with suspected tracheal neoplasm. Bronchoscopy is essential to make histopathological diagnosis. Persistent or progressive local disease can cause complications, like hemorrhage, tracheal stenosis, or esophageal-tracheal fistula.Case reportA 43-year-old female with no known co-morbidities, presented with dyspnoea and episodes of haemoptysis since preceding 8-9

months. She was being treated symptomatically before reporting to us. At presentation, strider was the only abnormal finding on physical examination. She was unable to perform pulmonary function testing because of respiratory distress. Laboratory investigations were normal. Chest radiograph was normal. Thereafter, computed tomography (CT) of the chest was done which revealed endotracheal mass obliterating the lumen of the trachea (Figures 1A & B).Flexible fibreoptic Bronchoscopy showed a smooth- surfaced, pedunculated mass arising from the posterior tracheal wall in the lower third of the trachea (Figure 2A).The bronchoscope could not be negotiated beyond the tumour. Tracheostomy followed by tumour excision with coblation was done under general anesthesia. On histopathological examination (Figure 2 B), diagnosis of IMT was made. Immunohistochemistry demonstrated positivity for (SMA), caldesmon and anaplastic lymphoma kinase-1 (ALK-1) which confirmed IMT. The patient’s symptoms resolved completely and subsequently tracheostomy tube was removed on third post-operative day. Check Bronchoscopy was done before discharge which was essentially normal.DiscussionPrimary tracheal tumours account for 0.1%-0.4% of all malignant diseases.4 IMTs, a rare variant constitute 20% of all primary lung tumours and 57% of all benign lung tumours.[Received: March 23, 2018; accepted after revision: January 14, 2019]correspondence and reprint requests: Dr Gurpreet Singh, House No. 160, Kidwainagar, Ludhiana (Punjab), India The various other name of this entity include inflammatory pseudotumour, histiocytoma, fibroushistiocytoma, xanthoma, xanthofibroma,

5 xantogranuloma and plasma cell granuloma.

Although the lung is the most common site for these tumours, IMTs may also develop in other sites, such as stomach, orbit, mesentery, heart, gastrointestinal tract, adrenal gland and central nervous system.The symptoms of IMTs are usually non-specific and depend on the site and size of the lesion. Patients usually present with respiratory symptoms, such as dyspnoea, strider, chronic cough, haemoptysis and pleuritic chest pain. In the small subset of patients with endobronchial lesions, the presentation may be acute due to post- obstructive pneumonia or symptoms associated with airway obstruction. Some cases have been

6mis-diagnosed and treated as asthma as in our case.Radiographic investigations with chest radiograph, CT and endoscopy are the used in the diagnostic

7work- up of obstructive tracheal lesions. Average diameter of tumour ranges from 5cm to 10cm, although tumours up to 20cm have also been

8,9 reported. Macroscopically, these appear lobular, multinodular and hard masses. In our case, the tumour was pedunculated, round, mooth surfaced, about 1.5 centimeters and above the carina. Histological, the tumour is composed of myofibroblastic spindle cells infiltrated by plasma cells, lymphocytes and eosinophils. IMTs are locally invasive tumours with a recurrence rate of 18% to 40% and have metastatic potential.Diagnosis is usually delayed as symptoms are non- specific. Management includes interventional endoscopy, surgery, and radiotherapy and endoluminal brachytherapy. However, complete surgical resection is the gold standard.10 this is preferable modality to endoscopic resection particularly when the tumour is not pedunculated or seems to grow deep into the wall. Tumour resection can be done either bronchoscopically with biopsy forceps, carbon dioxide laser or open surgical intervention with segmental tracheal resection. Adjuvant radiotherapy and

8 9

Dr. Gurpreet Singh

chemotherapy are reserved for the aggressive variants. The prognosis after radical resection is excellent. Radiotherapy alone is a possible treatment option in inoperable cases. Endo-bronchial brachytherapy may be used for tracheal tumours, especially if the tumour is small in size. The overall prognosis remains good but patient needs regular follow-up to detect early recurrence.In conclusion, inflammatory myofibroblastic tumour is a rare variant involving the airways and should be considered as differential diagnosis in cases presenting with respiratory distress due to upper airway obstruction. Complete surgical resection is the gold standard. Radiotherapy and chemotherapy should be considered after surgery in case of metastasis or recurrence or in cases where tumour is not amendable to resection. It is only through vigilant observation, knowledge and clinical skills, a physician can diagnose and treat timely with certainty, as our patient was mis-diagnosed initially requiring frequent hospital visits and compromising her quality of life.References1. Grillo HC. Primary tracheal tumours. In Grillo

HC, editor, Surgery of the Trachea and Bronchi, 4th edition. London: BC Decker; 2004:pp208–47.

2. Gilbert JB, Mazzarella LA, FeitL J. Primary tracheal tumours in infants and children. J Pediatr 1949;35:63–69.

3. Wenig BM, Devaney K, Bisceglia M. Inflammatory myofibroblastic tumor of the larynx: a clinicopathologic study of eight

cases simulating a malignant spindle cell neoplasm. Cancer 1995;76:2217–29.

4. Cerfolio RJ, Allen MS, Nascimento AG, Deschamps C, Trastek VF, Miller DL, et al. Inflammatory pseudotumors of the lung. Ann Thorac Surg 1999;67:933–6.

5. De Palma A, Loizzi D, Sollitto F, Loizzi M. Surgical treatment of a rare case of tracheal inflammatory pseudotumor in pediatric age. Interact Cardiovasc Thorac Surg 2009;9:1035–37.

6. Andrade FM, Abou-Mourad OM, Judice LF, Bento CA, Schau B, Carvalho AC, et al. Endotracheal inflammatory pseudotumor: the role of interventional bronchoscopy. Ann Thorac Surg 2010;90:e36–7.

7. Bumber Z, Jurlina M, Manojlovic S, Jakić-Razumović J. Inflammatory pseudotumor of the trachea. J Pediatr Surg 2001;36:631–4.

8. Fletcher CDM. Tumors of soft tissue. In: Diagnostic Histopathology of Tumors; 4th edition. USA: Elsevier Saunders; 2013:pp 1823–4.

9. Weiss SW, Goldblum JR. Fibrous tumors of infancy and childhood. In: Weiss SW and Goldblum JR, editors. Enzinger and Weiss’s Soft Tissue Tumors; 5th edition. USAP: Mosby Elsevier; 2008:pp 284–9.

Fabre D, Fadel E, Singhal S, Montpreville VD, Mussot S, Mercier O, et al. Complete resection of pulmonary inflammatory pseudotumors has excellent long term prognosis. J Thorac Cardiovasc Surg 2009;137:435–40.

Figure 1. computed tomography of the chest (coronal and axial view) showing tracheal

tumour obliterating >95% of its lumen.

Figure 2. (a) Bronchoscopic view of the tracheal tumour and (B) Photomicrograph of the excised tracheal

tumour showing Inflammatory myoblastic tumour (Haematoxylin and eosin, X 400).

Who needs IVF and when?

A couple is said to be infertile when it fails to conceive within one year of unprotected vaginal sexual intercourse. That is the time when the couple should consult an Infertility Specialist. For males, basic semen analysis will rule out almost all male causes of infertility. For females, basic investigations for infections, ovulation, tube testing; hormonal and systemic causes like thyroid and diabetes mellitus will be done. If there is some abnormality in any of the male or female tests, treatment will be given to correct that abnormality. Then the couple can try for normal conception for approximately one year.If all these test reports are normal, then there is nothing to worry. The couple can wait for another one year by observing fertile period and making dietary changes or reducing stress (if present).It has been observed that in one year of cohabitation nearly 50-60 % of couple conceive, in another 6monthsfurther of 10-20 % conceive and in the next 6 months nearly 10 % more couples conceive. Still, there are 15-20% couples who fail to achieve pregnancy. For these couples, some advanced tests like Hysteroscopy or Laparoscopy will be required to diagnose endometriosis or uterine abnormalities. If found, appropriate treatment and correction of abnormality will help couple to conceive.If still, pregnancy does not occur, one may need to take Ovulation Inducing Agents &Intra-Uterine Insemination of semen (IUI) which will increase the chances of conception by making more sperms available when egg is released from ovary. But this process should be tried for maximum 6 ovulatory cycles and not indefinitely as every cycle of

ovulation inducing agent will decrease more than normal eggs from ovaries ultimately decreasing ovarian reserve. If the couple fails to get pregnant after IUI then is the time to seek help of infertility specialist to be more specific IVF specialist because in spite of ovulation being present and semen analysis being normal there may be problem in quality and fertilization capacity of egg and sperm that may be preventing pregnancy or repeated abortions after conception. All these defects can only be diagnosed during IVF procedure of ovarian stimulation, ovum pick up and embryo formation and watching embryo development for 3-5 days.If during course of treatment Fallopian tubes are found to be blocked or diseased (hydrosalpinx) or frozen pelvis is found, then one should opt for IVF at early stage without any further wastage of time in hope of natural conception As now average marriage age has increased so if female age is 35yrs then the couple should not wait for one year and rather seek advice after 6months of marriage as after 30yrs ovarian reserve decreases and chances of conception with abnormal child increases.In males after semen analysis if there is no sperm ( Azoospermia), less sperms (Oligospermia),more abnormal (Teratospermia) less motile sperms (Asthenospermia) persisting after treatment, then all these abnormalities can be easily dealt in various IVF procedures e.g. either by picking up normal sperm and doing ICSI (Intracytoplasmic Sperm Insemination) or getting sperms from healthy donor as last resort .

10 11

Dr. Promila Jindal

Similarly, if in a female, ovarian reserve is low (AMH) or egg quality is poor, eggs from a young healthy female donor can be taken to form healthy embryo then this healthy embryo will be transferred in female partner of couple and she will deliver the child.Uterus of donor (surrogacy) can be offered, if uterus of female partner is diseased to this extent that it cannot bear pregnancy at all somehow repeatedly embryo fails to get implanted if after successful implantation abortions are taking place repeatedly IVF (test tube baby) is a well-accepted modality of

infertility treatment. It is cheaper, affordable and becoming within reach of middle even lower middle class of society and has good success rate in good hands and good laboratoryDepartment of Reproductive Medicine, SPS Hospitals Ludhiana is fully equipped with all IVF facilities. Under the guidance of team of expert doctors, embryologist & dedicated, compassionate staff, state-of-the-art ..................embryology laboratory is ready to serve these women with all fertility solutions.

Hand Re-Vascularization at SPS Hospital :Dr. Ashish Gupta ; Dr. Sundeep Kaur

CASE 1:-

12 13

Dr. Ashish Gupta

Dr. Sundeep Kaur

A 36yrs male presented to in our Emergency Department after accidental industrial injury at his work place. Patient was taken to the nearest primary health care facility for first aid and was referred to a tertiary center. He reached our emergency 8hrs after injury. He was resuscitated, stabilized and investigated and radiogram was done. On examination he had near total amputation of hand at the wrist level. There was circumferential crush injury, with hand attached to the wrist with only a few tendons. It was cold to touch with no pulsations present at the wrist. He was immediately taken for surgery under anesthesia. Bony fixation was done by the orthopedic team. Micro vascular, nerve, tendon repair was done by Plastic surgery team. Post operatively his hand was successfully vascularised, salvaged and patient was discharged. He followed in OPD for regular dressings, his cast was removed and proper physiotherapy started.Discussion:- SPS hospital is a tertiary center which provides high quality skillful micro surgical services round the clock in Department of plastic surgery. There are many challenges faced in dealing with such cases. Increasing the awareness of the potential of these microsurgical services among medical personal and public has to be addressed and is now days the need of the hour. The outcome in the management of any injury depends on the interplay of 3 variables. These are the nature of injury (Crush/Contaminated injuries are more challenging to handle), factors related to the patient (time taken to reach the tertiary center- results improved if patient arrives within 6

hrs of injury, method of transfer of amputated part) and factors related to the surgical team(good

1micro vascular technique used).So for a good outcome, a patient having such an injury must be transferred to a tertiary center as early as possible. His amputated part must be properly transferred for better results. It should be washed with running tap water. Ice placed in plastic bags should be placed in the vicinity of the distal part to reduce warm ischemia time. When the distal part is connected with a small bit of tissue, it may be better to cut it off and the severed part should then be transported carefully. The severed part is to be covered with gauze moistened with saline, kept in a plastic bag and then placed in ice. Direct contact with ice is to be avoided as it may cause frostbite injury. Bleeding vessels in the stump should not be clamped and should be managed by compressive dressings and

2limb elevation.A coordinated multidisciplinary team approach is the key for a successful re-implantation which involves plastic surgeon, anesthesia team, and orthopedic team. Proper post surgical care and rehabilitation by physiotherapist is crucial for an optimal outcome.References:-1. Sabapathy SR, Satbhai NG. Microsurgery in the

urgent and emergent management of the hand. Curr Rev Musculoskelet Med. 2014;7(1):40–46.

2. Nanda V, Alsafy T, Jacob J, Mohan L. Successful revascularization of near total amputation of the upper limb at the sultan qaboos hospital, salalah. Oman Med J. 2009; 24(1):44–48.

CASE 2:-

14 15

SPS is honoured to announce that one of our consultants Dr. Sandeep Kumar Goyal has published a book on identification and management of common mental disorders. SPS has always encouraged and fostered a culture of continuing medical education and academics.In recent years, Psychiatry as a branch of Medicine has become increasingly relevant and important. The social stigma attached to psychiatric illness is fast disappearing and the number of people visiting psychiatry clinics is increasing by the day.

Number of Psychiatry patients is more than that which can be handled by psychiatrist alone. So it is the need of the hour to increase the knowledge of the Indian Medical Graduate about various psychiatric disorders, the book is written mainly for the undergraduate medical students but it will also be useful to MSC psychiatric nursing students and psychology students. Students pursuing DNB in medicine can also be benefitted by this book. Practicing doctors can also refresh their knowledge of psychiatry by reading this book.

BOOK LAUNCH Let Our Family Take Care Of Your Family...

ADDING LIFE TO YEARS & YEARS TO LIFE

16 17

Dr. Sandeep Goyal

INR 5050

6PROMOTIONAL OFFER

Parameters

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Lipid Profile CBC Liver Profile Urine routine Stool routine TFT (Thyriod Profile) HBA1C HBSAG PAP Smear Vit D 25-Hydroxy Renal Profile (Creatinine, Sodium,Urea,Potassium & Chloride) ECG Stress Test

7PROMOTIONAL OFFERCOMPLETE HEALTH PLAN - 2

X-Ray chest USG Abdomen Cardiologist Consultation Physician Consultation Dietician Consultation Gynecology Consultation

If your answer is yes to any two questions. You must consult a Gastroenterologist.

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18 19

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Do you have a family history of Heart Disease ?

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If your answer is yes to any two questions. You must consult a Cardiologist


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If your answer is yes to any two questions. You must consult a Gynaecologist

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If your answer is yes to any two questions. You must consult a orthopedician .

CBC Urine routine Lipid profile HBA1C Serum Creatnine Serum Bilirubin Fundus Examination Thyroid Profile ECG Endocrinologist Consultation

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20 21

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Haemoglobin and PCV Platelet Count ESR TLC DLC MCHC MCV MCH Blood grouping RH Typing HBA1C Lipid Profile Urine Routine HBsAG

Anti HCV Rapid Plasma Reagin(RPR) HIV Semen Analysis for Male Ultrasound Screening ( Whole abdomen) Gynaecology consultation( For females) U rology consultation( For Male)

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RHEUMATOLOGY PACKAGE


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Uric Acid ESR CRP Rheumatoid Factor Serum Calcium Vitamin-D 25 SGOT SGPT C BC X-Ray Single View Dietician consultation Physiotherapist consultation Rheumatoligist Consultation


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If your answer is yes to any two questions. You must consult a orthopedician .

Parameters Blood Grouping and Rh Typing CBC Urine Routine, Stool routine Chest X ray Ophthalmology Consultation Paediatrician Consultation

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Parameters CBC RFT RBS SGOT SGPT PT/INR for young only Lipid Profile ECG ECHO Carotid Doppler Brain Angiography(CT Angio Cerebral) MRI Brain Neurology Consultation


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22 23

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Pain with chewing or biting.

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24 25

volume :1 issue : 2 april-june 2020 2020.pdf · 2020-03-30 · sps hospitals medcentre : new model...

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