Medi Magazine kauvery A quarterly magazine from VOLUME - 23 | ISSUE 02 APRIL 2018 VOLUME

All that is on the chest is not Necessarily a keloid Atypical presentation Of atypical organism Basi- frontal Arteriovenous Malformation presenting as acute subdural bleed Neonatal scrub Typhus – a rare entity

Total laparoscopic excision Basilar Of choledochal cysts Artery Stroke

tips for Medico-legal Epidural Blood Patch problem for Post Dural Puncture Headache

A case of megaloblastic Anaemia / viral fever /acute renal failure

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01 ATYPICAL PRESENTATION

PATRONS Page Number OF ATYPICAL ORGANISM Dr. S. Chandrakumar Dr. S. Manivannan 07 NEONATAL SCRUB TYPHUS – A RARE ENTITY Page Number

ADVISORY BOARD Pediatric Team Dr Senguttuvan .D , Dr Suresh Chelliah , Dr K. Senthil Kumar, Dr. D. Senguttuvan Dr C.Vignesh, Dr K. Swaminathan , Dr Naresh Kumar N. Dr. Aravindan Selvaraj Dr. Pradeep, Dr. Rubini Dr. T. Senthil Kumar Kauvery Hospital, Trichy

EDITOR Dr. Skanda Shyamsundar 01 EDITOR’S

Page Number DESK 03 ALL THAT IS ON THE CHEST IS NOT EDITORIAL TEAM Page Number NECESSARILY A KELOID Dr. Chokkalingam S Dr. Skanda Shyamsundar Dr. Jos Jasper G Head of the Department, Dept. of Plastic & Micro Surgery Dr. Senthil Kumar S Kauvery Hospital, Trichy Dr. Senthil Kumar K Dr. Velmurugan S

CO-ORDINATOR Mr. Dilip Rajkumar S 04 BASI- FRONTAL ARTERIOVENOUS

Page Number MALFORMATION PRESENTING AS ACUTE SUBDURAL BLEED DESIGN & LAYOUT Dr. Jos Jasper Mr. Vahid Ali N. Head of the Department Mr. Benhar J G Kauvery Brain and Spine centre

05 COME LET’S

Page Number TRAVEL

08 TOTAL LAPAROSCOPIC EXCISION

Page Number OF CHOLEDOCHAL CYSTS Dr.S. VELMURUGAN MS, FRCS(Glas), FRCS(UGI-HPB), CSST(UK) EDITORIAL OFFICE HOD & Senior Consultant-Advanced Laparoscopic/GI/Obesity/HPB/ Kauvery Hospital Liver Transplant Surgeon VI Floor, Administrative Office, Dr. Archana.R DNB(GS) Trainee #6, Royal Road, Cantonment, Kauvery Hospitals, Trichy Tiruchirappalli-620001 Call us at (431) 40 77 777 E: [email protected] W: www. kauveryhospital.com

I • CAPSULE MAGAZINE • APRIL 2018 KAUVERY CAPSULE EDITOR DESK

I’M NOT SURE OF THE CAUSE... I THINK IT COULD 09 HEALTHY BE DUE TO ALCOHOL.

THAT’S OK, Page Number RECIPE I’LL COME BACK WHEN YOU’RE SOBER Chocolate Chai Ice Cream

09 JOKE

Page Number CORNER

10 EPIDURAL BLOOD PATCH 11 BASILAR FOR POST DURAL Page Number Page Number ARTERY STROKE PUNCTURE HEADACHE Dr. Sivarajan Thandeswaran., MBBS, MRCP (London) Dr.K.Senthil Kumar M.D., PGDMLE, Senior consultant Stroke & Neurovascular medicine Sr. Consultant and Head of the Department, Anaesthesiology, Kauvery Hospital, Dr.P.Sasi Kumar M.D., D.A., Dr.M.Rayan M.D., DNB., Dr.S.Vadhan Prasanna M.D., DNB., Department of Anaesthesiology, Kauvery Hospital, Trichy

12 ROAD SAFETY 13 DEALING WITH

Page Number WEEK Page Number MEDICOLEGAL ISSUES Awareness program IN DAY TO DAY PRACTICE

15 NEW PANEL OF 17 WORLD Page Number Page Number CONSULTANTS KIDNEY DAY CELEBRATION Flash Mob

19 TIMES OF INDIA

Page Number AWARDS

APRIL 2018 • CAPSULE MAGAZINE • II KAUVERY CAPSULE EDITOR’S DESK | ATYPICAL PRESENTATION OF ATYPICAL ORGANISM

ATYPICAL PRESENTATION OF ATYPICAL ORGANISM Pediatric Team Dr Senguttuvan .D , Dr Suresh Chelliah , Dr K. Senthil Kumar, Dr C.Vignesh, Dr K. Swaminathan , Dr Naresh Kumar N. Dr. Pradeep, Dr. Rubini Kauvery Hospital, Trichy

Dear colleagues and friends, A six year old girl, presented to our emergency department on day six of It gives me great pleasure to take over from Dr. S. illness, with high grade intermittent fever for six days associated with Senthil Kumar as Editor of Kauvery's Capsule magazine periumblical abdominal pain, non-bilious vomiting and loose stools for henceforth. Over the years, Capsule has become a a day. There was history of mild cough since day three of illness. No visual treat, with good content and has a very wide other associated systemic symptoms were present reach and acceptance among our referral base. I look forward to all your support to taking Capsule to even greater heights and someday, I wish it would be as popular as a "Coffee table book", with content that would interest even the common man. We are proud to have departments that are on par with the best in the CLINICAL FINDINGS AND inotropes. She was given country, and this magazine helps to showcase our INVESTIGATIONS intravenous antibiotics after wonderful work to all of you. Most of us would be This child was febrile and obtaining blood for aerobic surprised that what is described in textbooks is being tachypneic at presentation, with culture. done on a day to day basis in Kauvery, and Capsule signs of compensated shock. In view of Pneumonia with would help to serve as the "all seeing eye" giving a Her abdominal examination hepatitis, anemia, leucopenia, sneak peek into the wonderful world of medicine. revealed mild hepatomegaly. thrombocytopenia and Other systems were normal. coagulopathy, other differentials The magazine is undergoing a slight makeover, shifting Her Q-SOFA score was three, like Sepsis with DIC / Swine flu from purely medical case based content, to a mix of indicating severe illness. (H1N1) / Leptospirosis/ SLE with medical content, interesting cases and information that Peripheral smear revealed mild autoimmune hepatitis were would make for interesting reading, with a little bit of normocytic normochromic considered. She was supported something for everyone. anemia, leucopenia, with adequate antibiotics, thrombocytopenia with other cell antiviral, blood products and We are also working on a revamped online edition with lines in normal limits. adequate hepato-supportive interactive content, and containing videos of post op Liver function tests revealed very measures. Etiological workup follow up, functional recovery, or rare procedures that high liver enzymes with normal was negative for Dengue , will make for interesting viewing overall. bilirubin level, mild leptospirosis, scrub typhus and hypoalbuminemia and bleeding Swine flu. Autoimmune workup We wish to also move to user driven content, and we parameters were deranged. was also negative. would appreciate your valuable feedback and Renal function tests were normal. Secondary Hemophagocytosis suggestions to make Capsule even better in the years CRP was very high suggestive of was considered in view of ahead. severe sepsis. persistent bicytopenia, fever & Chest xray revealed peri-hilar hepatitis, however complete Please do send your suggestions and comments to infiltrates more on right side workup ruled out that diagnosis. [email protected]. We will publish the suggestive of pneumonia. best "Letters to the Editor" in the subsequent issues, and SUBSEQUENT CLINICAL work towards implementing your suggestions for a PROGRESS better Capsule. THE WORKING DIAGNOSIS Her liver enzymes that were AND MANAGEMENT grossly elevated gradually Capsule is what it is thanks to all your support. Looking reduced from day 4 of forward to more active participation from our readers Infectious causes like severe hospitalisation after adequate and your continuing patronage...... sepsis / enteric fever / scrub hepato-supportive measures. Her typhus with features of coagulopathy was corrected compensated shock were gradually. Anemia was corrected Dr. Skanda Shyamsundar considered clinically. She was with packed cell transfusion. HOD, Dept. of Plastic & Micro Surgery resuscitated with intravenous However in view of persistent Kauvery Hospital, Trichy crystalloids, oxygen and thrombocytopenia, persistent

01 • CAPSULE MAGAZINE • APRIL 2018 KAUVERY CAPSULE ATYPICAL PRESENTATION OF ATYPICAL ORGANISM

fever, oxygen dependency and DISCUSSION: humans, M. pneumoniae grows cholecystitis, and pancreatitis poor clinical response to higher Mycoplasma, the smallest relatively slowly, with visible have been reported. Elevated antibiotics, atypical organisms free-living microorganisms are formation of colonies rarely liver enzymes are rarely observed were considered. Anti- ubiquitous in nature. Of this occurring in less than 1 week during M. pneumoniae infection Mycoplasma IgM was strongly group, seventeen have been and possibly taking 3 weeks or in children. Liver involvement was positive. She was then started on identified as human pathogens. more. transitory in these patients, and intravenous azithromycin. Mycoplasma pneumoniae, recovery of liver enzymes to This child’s recovery was Mycoplasma hominis, and M. pneumoniae commonly normal range correlated directly dramatic and she was gradually Ureaplasma urealyticum found to affects the respiratory system . with resolution of mycoplasma weaned off from oxygen. Her cause disease frequently in However numerous pneumonia, as demonstrated in blood counts, liver function and children. It grows under both extra-pulmonary manifestations our patient. bleeding parameters returned to anaerobic and aerobic have been documented. normal shortly. She was conditions, but growth is more Pulmonary and extrapulmonary discharged on day nine of consistent when it is incubated in manifestations are tabulated hospitalisation. She was doing nitrogen and 5 percent carbon below (table-1). Gastrointestinal well on her follow up. dioxide. When compared with manifestations including other mycoplasmas isolated from hepatitis, acute acalculous

CARDO PULMONARY BLOOD GASTRO-INTESINAL CNS MUSCULO- SKELETAL VASCULAR

-Pharyngitis -Pericarditis -Hemolytic anemia -Hepatitis -Aseptic meningitis -Arthritis -Otitis media -Perimyocarditis -Thrombocyto-penia -Cholecystitis -Rye-like illness -Polymyositis -Croup -Secondary heart block -Disseminated -Pancreatitis -Cerebral Infarct -Rhabdomyoly-sis -Bronchitis -Intravascular -Splenic infarct -Psychosis -Leucocytoclastic -Infectious asthma coagulation -Radiculopathy vasculitis -Pneumonia -Secondary -ADEM hemophagocytosis

Mycoplasma can be detected easily by cold agglutinin method, detection of IgM / IgA antibodies by ELISA method and polymerase chain reaction method.

TREATMENT CONCLUSION: REFERENCES Azithromycin and clarithromy- We report a case of Severe 1. Waites KB. New concepts of cin both are approved for mycoplasma pneumonaie Mycoplasma pneumoniae the treatment of community-ac- infection with atypical manifesta- infections in children. Pediatr quired pneumonia and severe tions namely severe pneumonia Pulmonol.2003;36:267–278. disease in children. In more associated with hepatitis, serious illness such as thrombocytopenia and coagu- 2. Kim JH, Chae SA, Lee DK. Stevens-Johnson syndrome and lopathy, who recovered well with Clinical findings of Mycoplasma neurologic disease, case studies adequate intravenous azithromy- pneumonia in children, from have indicated little evidence of cin therapy. Mycoplasma 1998 to 2003.Korean J Pediatr. therapeutic benefit with either infection should be considered 2005;48:969–975 erythromycin or tetracycline as a differential diagnosis when therapy. Corticosteroids have atypical extrapulmonary clinical 3. Feigin and cherry textbook of been used in severe conditions manifestations are encountered. Pediatric infectious disease like steven Johnson, neurological manifestation, severe pneumonia and hemoytic anemia.

APRIL 2018 • CAPSULE MAGAZINE • 02 KAUVERY CAPSULE ALL THAT IS ON THE CHEST IS NOT NECESSARILY A KELOID

ALL THAT IS ON Keloids are one of the most common swellings seen on the chest wall in surgical THE CHEST IS NOT practice. However, a high degree of NECESSARILY A KELOID suspicion is needed in unusual swellings on Dr. Skanda Shyamsundar the chest wall, and an error in diagnosis HOD, Dept. of Plastic & Micro Surgery could have dire consequences. Presenting Kauvery Hospital, Trichy one such case.

CASE HISTORY AN UNPLEASANT SURPRISE IN a 2 year follow up period. taken into mind, and attention A 34 year old male had THE BIOPSY must be paid to cosmesis and presented with the history of a Biopsy in this case threw up an LESSONS TO BE LEARNT functional outcome in such rapidly growing swelling on the unpleasant surprise. This swelling A very valuable lesson to be patients. Here there is no chest wall for three months. He turned out to be a HIGH GRADE learnt is that more often than unevenness at first glance in the had previously visited another CUTANEOUS not, in our practice, The patient position of the chest, with little surgical clinic where the LEIOMYOSARCOMA, a highly is always right. This patient had evidence of the patient having diagnosis of a keloid was made aggressive malignant lesion. repeatedly mentioned to the undergone such a major and treated with intralesional Luckily for the patient, there were previous treating doctor that the reconstruction. kenacort. Even after completion no metastatic lesions or involved swelling was increasing, but he of 4 doses of kenacort, no lymph nodes at the time of was sent away. When in doubt, response was seen and the diagnosis. MRI revealed that the TISSUE DIAGNOSIS IS THE swelling paradoxically increased lesion was situated only at the ONLY TRUE CONFIRMATION. A in size. Following this, the patient cutaneous level and there was confirmatory diagnosis of a visited us for a second opinion no invasion of deeper structures. highly aggressive malignant lesion is life altering for the OUR APPROACH AND THE THE TREATMENT PLAN patient and needs the REASONING The patient was taken up for appropriate multimodality On examination, there was a surgical treatment and wide local approach. In this case, the firm to hard swelling 3x3 cm with excision with 2 cm margins was patient was lucky and the irregular margins on the chest done. There was a large defect diagnosis was spotted relatively wall with bosselated surface. Also in the centre of the chest early and we could go for a the history of rapid growth in the exposing the sternum. This defect curative approach. As swelling suggested a more was covered with a pectoralis practitioners, we must be alert sinister diagnosis. We suspected major myocutaneous flap. The and aware of such problems and a soft tissue sarcoma, most post op period was uneventful must be thorough in our clinical probably and patient was sent for examination. DERMATOFIBROSARCOMA radiotherapy. Margins were An elegant reconstruction is also PROTUBERANS and hence negative in biopsy. The patient important in such cases, where proceeded with a biopsy. has remained recurrence free in the post op radiation plan is

The tumar on the chest wall The defect after excision of tumor Coverage with pectoralis major flap One year follow up showing no recurrence and a near perfect nipple level on the operated side

03 • CAPSULE MAGAZINE • APRIL 2018 KAUVERY CAPSULE BASI- FRONTAL ARTERIOVENOUS MALFORMATION PRESENTING AS ACUTE SUBDURAL BLEED

BASI- FRONTAL Cerebral Arterio Venous Malformations [AVM] are vascular ARTERIOVENOUS abnormalities consisting of fistulous connections of arteries and veins without normal intervening capillary beds. Though perceived MALFORMATION to be congenital, it rarely presents in the younger age group. PRESENTING AS ACUTE Parenchymal / pial AVMs usually present with intraparenchymal SUBDURAL BLEED bleed ( ICH). This write up is about a young girl who had a rare Dr. Jos Jasper presentation of acute sub dural haemorrhage ( SDH ) due to an Head of the Department underlying AVM. Kauvery Brain and Spine centre

CASE HISTORY co-management and intensive that of haemorrhage [30 –70%]. be as high as 30%. Treatment of This eight-year-old girl who was care support from the pediatric This bleed is rarely subdural AVMs include microvascular completely normal the previous department. Cerebral angiogram unless it is a dural AVM. Pial or surgery, radiosurgery and night presented with sudden was done later which revealed a classic cerebral AVM bleeds in to endovascular interventions. onset of vomiting and seizures, left basi- frontal Arterio – venous parenchyma followed by intra Identification of the draining waking the family up early in the malformation with a feeder from ventricular space and presents vein/s is the most crucial step of morning. As her level of middle cerebral artery and rarely as a subarachnoid the surgery. consciousness slowly dropped, draining in to superficial sylvian haemorrhage. Small size, she was brought to the ER by her vein [Fig 2]. Microvascular exclusive deep venous drainage, Prognostication of AVMs in parents. The presenting GCS was surgical excision of the AVM was deep location, posterior fossa literature is mainly using ICH and E1V1M2 with pupillary done and confirmed by location, association with presentation as SDH is rarely asymmetry. Patient was stabilised histopathology. Post-operative aneurysm and venous ectasia are reported. The data of such bleed and intubated. angiogram showed complete radiological risk factors for and AVM is also of a excision of the vascular lesion presentation with haemorrhage. predominantly adult population. INVESTIGATIVE FINDINGS [Fig 3]. After a month, patient’s Other symptoms include Spontaneous SDH in a young Brain imaging revealed a large tracheostomy was closed. With seizures, headache and focal patient raised the suspicion but a left fronto- temporo- parietal some involuntary movements deficits due to micro bleeds, cerebral AVM was a last suspect. SDH with significant midline shift and dysphasia, she is on the mass effect and ‘steal’ of blood Active management from the and mass effect. Coagulation road to recovery now. flow. Overall risk for bleed is 2- paediatric side played a major profile was normal. 4 % per year. Once symptoms part in recovery. The mass effect DISCUSSION start, risk of haemorrhage is of the SDH over the brain and its THE TREATMENT PLAN AND AVMs of the brain have an highest in the first 5 years. In secondary neuronal insult may PROGRESS OF THE PATIENT incidence of 1- 4% as estimated patients with prior history of take some more time to recover, With no history suggestive of by large autopsy series. Patients haemorrhage, the risk for but another bleed could have coagulation disorders, the are typically seen between 20 recurrent haemorrhage is up to been fatal and would have made reason for such a spontaneous and 40 years of age.With the 44%.Furthermore, in these our efforts useless. Proper history SDH could not be decoded increasing use of MRI, the patients, the risk for subsequent taking and a high degree of immediately. Emergency number of asymptomatic, haemorrhage is highest in the curiosity helped in clinching the decompressive craniotomy was incidentally discovered AVMs has first year, and in the first month. diagnosis. performed as a life saving increased. If symptomatic, the The mortality associated with measure, with watchful most common presentation is symptomatic haemorrhage can

Showing spontaneous Post operative well defined CT cerebral angiogram showing well subdural hematoma hyperdense SOL vascular lesion defined AVM in the left basifrontal region.

APRIL 2018 • CAPSULE MAGAZINE • 04 KAUVERY CAPSULE COME LET’S TRAVEL

Come let’s travel The 4th largest town in , Tiruchirappalli is an ancient town with a recorded history that dates back to the 3rd century BC. The city has been ruled by various ancient and historical kingdoms and empires. The Cholas, the Pandya, the Pallava, the Vijaynagar Kingdom, the Carnatic Kingdom and the British have ruled this region and have deeply influenced the city’s culture over the years. As a result of the various cultural influences Tiruchirappalli is famous for its various monuments and temples. Also, due to the city being surrounded by various channels of the Kaveri River is rich in vegetation and natural resources. Here’s the list of the best places you must visit in Tiruchirappalli.

ROCKFORT CITY A BEAUTIFUL CITY

Rockfort Temple: Rockfort Temple refers to an ancient fort and the temple which is situated in the fort’s highest reaches. Rockfort played a major part in the Carnatic wars that was a major battle that helped establish the British Rule in India. The fort also has the famous Ucchi Pillayar Temple which was built in the 7th century and stands 83 meters high atop a rock in the fort complex. The cave temples built by the Pallavas in 508 AD are the oldest structure in the fort and is also a must be seen attraction.

Sri Ranganathaswamy Temple Often listed among the largest functioning Hindu temples in the world, the Sri Ranganathaswamy temple was built between the 6th and the 9th centuries by the Azhwar Saints. The temple is dedicated to Lord Vishnu and is the 1st of the 108 Divya Desams or Kallanai Dam Puliancholai Falls Vishnu Temples in the world. The temple Kallanai Dam is one of the major attractions in The Puliyancholai Falls are one of the complex is spread across 156 acres and Tamil Nadu which was built nearly 2000 years ago. most amazing picnic spot you can visit in is built in the Dravidian style of The Kallanai Dam was built by the Cholas in the the ancient town of Tiruchirappalli. The architecture. The temple gopuram is 72 2nd century AD and is one of the oldest functioning falls are a terrace waterfall located in a meters in height and consists of 72 tiers. water diversion structures in the world which are still very serene and calm environment. The The temple is a must visit and is one of in use. The place is located in peaceful and lush calm scenery which can be encountered the major Hindu temples in the country. green vicinity and is a great picnic spot. during your commute is an amazing

05 • CAPSULE MAGAZINE • APRIL 2018 KAUVERY CAPSULE COME LET’S TRAVEL

experience and will refresh your senses for sure.

The ancient city of Tiruchirappalli is one of the best tourist towns in Tamil Nadu. Owing to its vast history and the culture that the town acquired from the various dynasties and empires that ruled the area, Tiruchirappalli is a must visit.

Our Lady of Lourdes Church The church is decked out in Gallo-Catholic design, from neo-Gothic spires to anguieshed scenes of crucifixion and matrydom painted inside. In a note of cross-religious pollination, icons of Virgin Mary are garlanded in flower necklaces. Constructed in the year 1840 AD. The church is situated near the rock fort. The main tower is 220 feet in height, and the small tower is 120 feet in height. The statues of St. Sacred heart, along with St. Ignatius, St. Francis Xavier, St.britto is placed at the center of the tower. The church bell is set at a height of 90 feet.

APRIL 2018 • CAPSULE MAGAZINE • 06 KAUVERY CAPSULE NEONATAL SCRUB TYPHUS – A RARE ENTITY

NEONATAL SCRUB Scrub typhus, through a rare entity, needs to be considered on an important TYPHUS – A RARE ENTITY differential diagnosis in a cute febile illness of newborn pregnanting the such experience in our insititute. Pediatric Team Dr Senguttuvan .D , Dr Suresh Chelliah , Dr K. Senthil Kumar, Dr C.Vignesh, Dr K. Swaminathan , Dr Naresh Kumar N. Dr. Pradeep, Dr. Rubini Kauvery Hospital, Trichy

A 14 days old term male repeat cultures. Dengue and ranges between 1-30 days. and platelet count mostly normal neonate, in whom Hirschsprung’s scrub typhus were considered as There are 3 possible route of although thrombocytopenia in disease was suspected, presented alternative diagnoses and infection in neonate one quarter to one third patients. with history of vomiting, fever serology for dengue antigen was 1. Transplacental infection, Thrombocytopenia was noted in and abdominal distension for sent and management changed 2. Perinatal blood-born transmis- our case and cases reported. two days. He was delivered by accordingly. sion and Diagnosis mostly based on normal vaginal delivery. There Fever subsided and platelet 3. Postnatal infection. history, clinical features and was with significant antenatal counts were increasing, with Vasculitis is the basic mechanism serological marker. Antibody history or history of maternal clinical improvement of neonate. responsible for skin rash, micro mediated test like indirect fever in peri-partal period. Dengue NS1 Antigen was vascular leakage, edema and hemagglutination, ELISA, weil Examination showed the negative. Scrub typhus IgM done tissue hypo perfusion and felix, immunoassay help in following findings: on day 11 of illness was positive, end-organ ischemic injury. There diagnosing scrub typhus. confirming the diagnosis of scrub is formation of thrombi leading Doxycycline is the drug of choice. • Active baby typhus. Mode of infection for this to tissue infarction and hemor- Long course of tetracycline to • No external anomalies neonate might be from a mite, in rhagic necrosis. newborn and young children • Soft and distended abdomen the mattress purchased from leads teeth related problems. with liver palpable two cm below street vendors and their Most newborn present with Use of quinolones during right costal margin residence in an rural area respiratory distress, fever, neonatal period may cause • Bowel sounds heard corroborating it. The timely decreased oral intake, abdomi- problems related to cartilage and • Other systems were normal. diagnosis and institution of nal distension, hepatospleno- bone. Azithromycin is a safer Investigations done revealed the appropriate antibiotics saved the megaly, seizure and lethargy alternative. Clinical trials show following: infant from life threatening mimicking neonatal septicemia that Azithromycin is equally • Thrombocytopenia with other situation. as seen in our case and also in effective. cell lines in normal limits cases reported. An eschar found • High CRP. DISCUSSION on clinical examination is a CONCLUSION • Blood culture - sterile. Scrub typhus is a vector born hallmark for the diagnosis. It is increasingly evident that disease and has high morbidity However atypical presentations scrub typhus needs to be A preliminary diagnosis of late and mortality if untreated. without eschar as in our neonate, considered in the differential onset sepsis made. This baby Transmission via bite of the larval has also been documented. An diagnosis of acute febrile was treated with intravenous stage (chigger) of trombiculid eschar is present at the site of illnesses/ sepsis in the newborn antibiotics and feeds were mite serves as both vector and chigger bite in 7-68% of cases. It period. Early diagnosis is gradually increased, which were reservoir. Transmission is most affects almost all system. possible only if there is a high tolerated well. commonly trans-ovarial and Neonates may develop compli- index of suspicion for scrub However, there were persistent regurgitation of infected saliva cations such as shock, seizures, typhus. Undue delay in adminis- fever spikes and on examination, during feeding. It is extremely encephalopathy, pleural effusion, tering appropriate antibiotics there was an increasing hepato rare in newborn period. Neona- pneumonitis and respiratory may lead to increased morbidity and splenomegaly with further tal scrub typhus has been failure. and mortality. fall in platelet counts. Antibiotics reported rarely in literature. were therefore escalated after Incubation period of the disease On hemogram, total leukocyte

07 • CAPSULE MAGAZINE • APRIL 2018 KAUVERY CAPSULE TOTAL LAPAROSCOPIC EXCISION OF CHOLEDOCHAL CYSTS

Choledochal cysts (CCs) are cystic dilations of extrahepatic duct, intrahepatic duct, or both that may TOTAL LAPAROSCOPIC result in significant morbidity and mortality, unless EXCISION OF CHOLEDOCHAL identified early and managed appropriately. CYSTS Complications of choledochal cyst include cholangitis, pancreatitis and malignancy. Complete surgical excision Dr.S. VELMURUGAN MS, FRCS(Glas), FRCS(UGI-HPB), CSST(UK) with biliary reconstruction is considered as the treatment HOD & Senior Consultant-Advanced Laparoscopic/GI/Obesity/HPB/Liver Transplant Surgeon Dr. Archana.R DNB(GS) Trainee of choice. Modified Todani classification is the most Kauvery Hospitals, Trichy common classification used for choledochal cysts. We herewith report two cases of choledochal cysts managed by total laparoscopic excision with reconstruction.

CASE REPORT-1 CASE REPORT-2 left in distal end. Distal end to A 22yr old female, known A 50yr old female, known cyst dissected as much as Rheumatic heart disease patient, diabetic and hypertensive, possible without injuring presented with complaints of presented in another hospital pancreatic duct. Distal end of epigastric and right upper with history of obstructive cyst suture ligated and cut. Entire quadrant (RUQ) abdominal pain. jaundice and associated RUQ choledochal cyst excised leaving Patient presented with nausea, abdominal pain. There was no small cuff distal to hepatic ducts vomiting. Examination of the history of fever. She had already confluence. Jejunum divided abdomen revealed slight undergone ERCP & Stenting in 20cm distal to DJ with Echelon MRCP showing type I tenderness in the epigastric and the outside hospital for suspected stapler. Jejuno jejunostomy at choledochal cyst right hypochondrial region. No CBD stricture. 50cm distal to hepatico- mass was palpable. Serum MRCP showed Type I choledoch- jejunostomy site with Echelon Amylase and Liver enzymes were al cyst, with no CBD stone or stapler (side to side). Stapler elevated. Ultrasound abdomen stricture. Patient was referred to entry hole closed with 3-0 vicryl showed grossly dilated common our centre for further manage- in 2 layers. Retrocolic jejunum bile duct ( CBD ). MRCP showed ment. Clinical examination and taken to porta hepatis. Laparo- Todani Type I choledochal cyst LFTs were normal. Total laparo- scopic hepaticojejunostomy done with multiple secondary calculi in scopic excision of choledochal with 5-0 PDS, posterior layer the CBD, acute edematous cyst +Roux-en-Y hepaticojeju- continuous, anterior layer pancreatitis with peripancreatic nostomy +cholecystectomy was interrupted sutures. Mesocolic Todani classification inflammatory changes. Pancreati- done. Postoperative period was and mesenteric windows closed. tis was treated conservatively. uneventful and got discharged Cholecystectomy done. Patient was discharged in stable on POD 5. Histology confirmed Scan this QR Code condition. 2 months later she the diagnosis of choledochal cyst CONCLUSION was readmitted for surgery. Total with no evidence of malignancy. Choledochal cyst in adults laparoscopic excision of usually present with complica- choledochal cyst+Roux-en-Y 5 ports- One 10mm, one tions of longstanding cysts. hepaticojejunostomy +cholecys- 10-12mm, three 5mm ports. Diagnosis is made with the help tectomy was done. Postoperative Calot’s triangle dissected. Cystic of ultrasound, CT or MRCP. Total period was uneventful and the artery and cystic duct clipped cyst excision minimises the patient was discharged on post and cut individually. Choledochal incidence of malignancy and to watch op day 6. Histology confirmed cyst dissected protecting portal prevent complications like THE TOTAL LAPAROSCOPIC the diagnosis of choledochal vein and hepatic artery. Chole- cholangitis and pancreatitis. This EXCISION OF cyst with no evidence of malig- dochotomy performed. All stones complex surgery is done totally CHOLEDOCHAL CYST WITH nancy. and sludge in distal end laparoscopically in our centre RECONSTRUCTION removed. Check choledochosco- and patients had excellent SURGERY PROCEDURE py done to make sure no stones recovery with no morbidity.

APRIL 2018 • CAPSULE MAGAZINE • 08 KAUVERY CAPSULE JOKE CORNER | HEALTHY RECIPE

JOKE CORNER I’M NOT SURE OF THE CAUSE... I THINK IT COULD HIS DOCTOR SAID HE HAS SOMETHING HMM I DON’T KNOW BE DUE TO ALCOHOL. CALLED “PHOLENFROMETRY?” IT SAYS HERE “HE HAS FALLEN FROM A TREE?”

THAT’S OK, I’LL COME BACK WHEN YOU’RE SOBER

HEALTHY RECIPE This chocolate chai ice cream recipe is a home run. It’s sweet, but not too sweet, Chocolate Chai Ice Cream perfectly rich and the blend of chai spices is deliciously complex

INGREDIENTS 2 c. heavy cream 1 c. whole milk 2/3 c. sugar 1/3 c. unsweetened cocoa powder 1 tsp. kosher salt 3 slices peeled ginger, sliced about 1/4- inch thick 1/2 tsp. freshly ground nutmeg 1 tsp. orange zest 7 tsp. loose black tea leaves 1 vanilla bean, scraped 1 cinnamon stick

INSTRUCTION 1. Combine cream and milk in a saucepan and heat over medium heat. 2. Add sugar, cocoa powder and salt and stir until everything is completely dissolved. Bring to a boil, turn down to a simmer and simmer for four minutes. 3. Add the remaining ingredients to the heated mixture. Remove from heat, cover and let steep for 25 minutes. 4. Using a fine mesh sieve, strain out the spices and tea leaves. 5. Chill in the refrigerator for at least two hours, then transfer to ice cream maker and churn according to your machine directions. Transfer to a freezer-safe container and freeze for at least four hours. 6. Optional: Grate a bit of cinnamon on top before serving.

09 • CAPSULE MAGAZINE • APRIL 2018 KAUVERY CAPSULE EPIDURAL BLOOD PATCH FOR POST DURAL PUNCTURE HEADACHE

EPIDURAL BLOOD PATCH FOR POST DURAL PUNCTURE HEADACHE Post dural puncture headche is a common entity Dr.K.Senthil Kumar M.D., PGDMLE, that setter usually with ______presently Senior Consultant and HoD, Anaesthesiology, relief in severe and refractione case Dr.P.Sasi Kumar M.D., D.A., Dr.M.Rayan M.D., DNB., Dr.S.Vadhan Prasanna M.D., DNB., Department of Anaesthesiology, Kauvery Hospital, Trichy

Blood deposited in epidural space

Post Dural Puncture Headache (PDPH) commonly known as ‘Spinal Headache’ was first described by August Bier in 1898. It classically presents as a postural headache following Spinal anaesthesia or an accidental puncture in duramater during an attempt for epidural anaesthesia. This postural headache typically presents between 24 and 72 hours following spinal anaesthesia or after an accidental dural puncture during epidural anaesthesia. Patients experience a typical bilateral fronto occipital headache sometimes radiating to neck with or without nausea and vomiting and is aggravated on sitting and standing position. Relief is obtained by lying down, either in the supine or prone position.

CASE REPORT turn reduction in CSF pressure of choice. Other NSAIDs are and CSF pressure is maintained A 23 year old male who causing traction over cranial used if needed. These conserva- and hence headache is relieved. underwent an abdominal surgery nerves leading on to headache tive measures are tried for 24 CONTRAINDICATIONS under combined spinal epidural and neck pain. In addition, there hours and if there is no further Blood patch is contraindicated if anaesthesia experienced typical is a compensatory intracranial symptomatic improvement, there is associated coagulopathy, PDPH 24 hours after the vasodilatation effect to offset the Epidural blood patch is the sepsis, fever and non-acceptance procedure. He was initially decrease in CSF pressure which treatment of choice. by the patient. treated with adequate fluids, oral also adds up to the headache.- analgesics and Caffeine tablet. This is prevented by the below THE TECHNIQUE CONCLUSION As the headache didn’t settle with mentioned measures 15 to 20 ml of patient’s blood is Epidural blood patch is a these conservative measures a) Using small diameter needles drawn in an aseptic manner and rewarding relief measure for patient was given the option of b) Using atraumatic needles injected epidurally. The patient is patients who have PDPH where epidural blood patch and the (Pencil point Whitacre needles positioned in either of the lateral conservative measures have patient accepted for it. Under are preferred over Quincke’s position in universal flexion. After failed. strict asepsis 15 ml of patient’s needle) strict asepsis epidural needle is blood was drawn from right c) Passing the needle bevel introduced one or two space antecubital fossa and injected parallel to longitudinal fibres below the intersipinous space eipdurally with patient in right of duramater where spinal anaesthesia was lateral position. Blood patch was d) Stylet to be in position during previously administered, ie, the infused epidurally one space introduction and removal of site of accidental dural puncture. below the previous interspinous needle About 15-20 ml is drawn in a space where combined spinal e) Adequate hydration during separate syringe from the cubital epidural anesthesia was given. perioperative period. fossa. Blood is infused through He was observed in recovery epidural needle into epidural Patient’s blood injected epidurally room in supine position for 2 Management of post dural space slowly over 60 to 90 hours and later evaluated for puncture headache seconds. Then patient is made to headache in sitting posture. He In general, post dural puncture lie down supine for 1 to 2 hours. was absolutely pain free and felt headache settles with conserva- 2 hours later, patient becomes very comfortable then on and he tive measures. Nausea and absolutely headache free and was discharged the next day. vomiting are treated appropriate- symptomatic relief is dramatic. DISCUSSION ly. Oral fluid intake is encour- The injected epidural blood clots Dural puncture creates a rent in aged and IV fluids are given in and this blood patch forms a dura, causing leakage of more severe cases. Paracetamol seal over the rent in duramater. Cerebro Spinal Fluid (CSF) in and caffeine are the initial drugs This seal arrests the CSF leak

APRIL 2018 • CAPSULE MAGAZINE • 10 KAUVERY CAPSULE BASILAR ARTERY STROKE

Basilar artery BASILAR ARTERY STROKE Left vertebral artery Dr. Sivarajan Thandeswaran., MBBS, MRCP (London) Senior consultant Stroke & Neurovascular medicine Kauvery Hospital, Chennai

Stroke is a leading cause of Right vertebral artery morbidity and mortality with increasing incidence in younger age group in developing India. Ischemic strokes (80%) are caused by poorly controlled hypertension, diabetes, hypercholesterolemia, lifestyle choices like smoking, excess alcohol and poor exercise. Though majority of risk factors are modifiable, some are not, such as atrial fibrillation, increasing age, genetic causes etc. With increasing longevity we are treating Right subclavian artery increasing number of atrial fibrillation in the community with anticoagulants like acitrom and newer agents like apixaban, dabigatran and rivoroxaban.

Stroke due to AF are often devastating as they tend to block major arteries like internal carotid, middle cerebral and basilar artery. Creating awareness on stroke identification and newer treatments like iv thrombolysis is the need of the hour. 80% of strokes can be reversed if prompt treatments are initiated in the right setting.

CASE REPORT potential thrombectomy as the Door to CT time in this case was symptoms at onset resulting in 78yr old male on Acitrom for recanalisation rates for large 15 mins and Door to Iv delays in diagnosisand uncertain Atrial fibrillation with no other clots are 50%. INR was 1.67 thrombolysis 45 mins. This is best management. Often major co-morbidities presented hence iv thrombolysis was much better than international symptoms range from transient to ER with acute onset giddiness, initiated after family discussion standards and with launch of dizziness, vertigo, diplopia, nausea, aphasia and right and consent. While the patient HASU - Hyperacute Stroke Unit paraesthesia and syncopal hemiplegia. He also had was getting prepared for DSA in at Kauvery, it is envisaged to episodes. Clinical findings like ophthalmoplegia and ocular cathlab for potential have door to needle time less truncal ataxia, nystagmus, bobbing. He was taken to CT thrombectomy, patient started then 20mins for all eligible opthalmoplegias, ocular bobbing Brain within 15 mins of arrival. recovering rapidly with return of patients. Stroke is a truly and unexplained dizziness or Non-contrast CT Brain showed speech and right sided motor multidisciplinary disease which syncope should prompt posterior no evidence of bleed or early functions. Subsequent brain demands good team work circulation stroke investigations. ischemic changes in left imaging next day revealed starting from ER team, lab In this case, particular issue was hemisphere. However Basilar complete recanalisation of right personnel, , related to use of anticoagulation. artery was hyper dense raising vertebral and basilar arteries with and intensive care. Multiple If INR > 1.7, iv thrombolysis suspicion of clot occlusion. small infarcts in right superior departments ultimately would be relatively Angiogram confirmed presence cerebellar artery territory only. He contributed to this patient’s timely contraindicated with potentially of clot in right vertebral artery was mobilised out of bed with recovery. higher bleeding risk. In such and another clot at the apex of physiotherapist. scenarios, direct mechanical clot basilar artery. Ophthalmoplegia completely DISCUSSION removal is ideal. recovered in 4 days and patient Basilar artery stroke carries a Simultaneously blood samples was discharged home on day 5. high mortality (90%) without were despatched for urgent INR Acitrom was converted to rapid diagnostic work up and testing to determine safety for Apixaban for smooth appropriate treatment. Particular iv thrombolysis and interventional anti-coagulation. issues relevant to basilar stroke radiologist was pre-warned for include variable and stuttering

11 • CAPSULE MAGAZINE • APRIL 2018 KAUVERY CAPSULE ROAD SAFETY WEEK AWARENESS SHOW ROAD SAFETY WEEK AWARENESS SHOW Road safety week is celebrated with the great joy and enthusiasm every year in India at many places. People are encouraged about how to drive on roads by organizing variety of programmes related to road safety. During the whole week , a variety of educational banners, safety posters, safety films, pocket guides and leaflets related to the road safety are distributed to the on road travelers. They get motivated about the road safety while travelling on road means having planned, well-organized and professional way traveling. Those who travel in unprofessional way are requested to use road safety measures and follow traffic rules by educating them about consequences without adequate safety measures. Awareness is created on the importance of traffic rules, firstaid and road safety. the below photos were captured during one of our public mock session.

APRIL 2018 • CAPSULE MAGAZINE • 12 KAUVERY CAPSULE DEALING WITH MEDICOLEGAL ISSUES IN DAY TO DAY PRACTICE

QUERY If a patient wants to leave the hospital DEALING WITH on his own without the consent of MEDICOLEGAL treating doctor -LAMA., can he insist ISSUES for discharge and treatment summery IN DAY TO DAY or operative notes. PRACTICE I have noticed, majority of times, this is not done spl in Govt setups.

Answer I have seen that doctors become uncomfortable when patient decide to use his fundamental right whether to accept treatment or not from a particular doctor / hospital. It is usually labeled as LAMA- left against medical advice. Patient is denied treatment papers and discharge slip.

It is wrong. All such patients should be treated as discharge on request. You can record it in case sheet that patient has gone on its own. You should provide discharge summary along with all papers.

LAMA should be primarily used for absconded patient where you can deny papers later on.

13 • CAPSULE MAGAZINE • APRIL 2018 KAUVERY CAPSULE TIPS FOR MEDICO-LEGAL PROBLEM

My query is: "Do we have to prescribe the injection again on our prescription slip for it to be given?" It has already been prescribed by a qualified doctor elsewhere. Can the injection be administered with request & undertaking of the patient as "I XYZ, hereby give my request and consent towards administration of the injection to me/my patient as advised & prescribed by Dr. ABC. I have been explained the side effects & adverse effects of the injection to be QUERY administered by my treating & prescribing doctor. The entire I am working in PSU hospital in a semi-rural location. The responsibility towards the administration of the injection project is close to a big city & patients are frequently taking including adverse effects shall lie on me. This hospital, its treatment for various ailments from the private practitioners. doctors and staff shall not be responsible of any adverse Very frequently they turn up at our hospital demanding reaction or event that may occur subsequent to administration administration of Injectable as advised by their treating of such an injection." doctors. Many times we may not agree to the medication being administered and being a PSU/Govt. hospital, it leads Do such consents carry any validity in case of any adverse to confrontations. reactions? Can the injection be simply given with this consent and original prescription of private practitioner? In case of any adverse reaction, who would be responsible?

In certain cases we may agree to the Injectable to be administered. Is there a boundation on a doctor to prescribe that medicine? The patient has already bypassed our hospital & available specialist services citing various reasons has merely come back for essentially nursing services.

Answer Every medical practitioner is independent to follow his own treatment policy. You may or may not agree with your colleague or another qualified doctor. In your case, if you think, injection is required in this case, you can endorse it on own letter head so that it can be given by nurse. If you think, it is not required, just refuse it. If any reaction / negligence occur, you would be held liable if injection has been prescribed by you. Please remember that your hospital is a PSU hospital which is manned by qualified doctors and patients have no right to treat it as injection facility centre where they can get any injection at will.

Your hospital is well within rights to refuse injections not prescribed by doctors of your hospital. The consent from patient which you mentioned has no legal value.

QUERY QUERY I am working as a gynecologist at government hospital. I am working as an orthopedic surgeon in a corporate hospital. In our unit one baby was delivered with major congenital We get frequent orthopedic emergencies like acute dislocation, anomalies. compound fracture and vascular injuries. These are orthopedic She was not advised anomaly scan as level 2 ultrasound is emergencies as per my knowledge. But we can’t deliver treatment not available in our hospital and we can't advice it from due to financial clearance from hospital. In case of any delay in private center. What are legal implications in present delivering the treatment; who will be responsible- me, hospital or scenario? Who is responsible for negligence? Treating patient himself. And how should I protect myself legally. Kindly doctor or authorities. advice.

Answer Answer Please note that if a doctor is working in a govt setup, it I am surprised that such things are happening in corporate does not mean that proper advice would not be given if hospitals. Please bring it to knowledge of hospital authorities like facilities are not available at that centre. In above mentioned Med Supdt or Director. It is difficult to say who will be responsible case , level 2 ultrasound was must and would have been in case of negligence either hospital or doctor or both as it will recommended. It is patient choice to get it done from private depend on circumstances. if facilities are not available at govt setup. Non advice of If hospital authorities do not respond and correct the system, level 2 ultrasound is a negligence in this case which is done change the hospital. by gynaecologist. Govt authorities are rarely held liable for negligence as govt can say that they cannot provide all Courtesy facilities al all places. Prof ( Dr ) R K Sharma In this case, gynecologist should have sent this case to MBBS (AIIMS) , MD ( AIIMS), FIAMLE , FICFMT , higher centre for level 2 ultrasound. Medico-Legal Consultant President, Indian Association of Medico-Legal Experts , New Delhi

APRIL 2018 • CAPSULE MAGAZINE • 14 KAUVERY CAPSULE PANEL OF NEW CONSULTANTS

Dr. M. Ranjith Kumar, MD, DM ( Pead. ) WARM Pedicatrics Neurologist WELCOME Trichy NEW CREW Dr. Gerard Joseph MEMBER Gonsalvez, MBBS, MD Consultant Intensvisit Trichy

Dr. Srihari MS., MCh Neuro Surgeon Trichy

Dr. Saravana Kumar, Dr.A.J.Lawrence MD, DM ( Critical Care) MD(Radiology)., HOD- Critical Care Consultant Radiologist Trichy Trichy

Dr.K.Arivarasan Dr.Archana Kalaichelvam "MD(Medicine)., MD(Anaes.)., DM().," Critical Care Physician Consultant Medical Trichy Gastroenterologist Trichy

Dr.P.Anandeswari MD (TB & Chest diseases) Pulmonologist Salem Dr.P.Sathya Sudhakar Dr.M.Rajendran MBBS.,DGO.,DRM(Germany) "MD.,(Gen.Medicine), Obstetrics & Gynaecologist DM()" Salem Interventional Cardiologist Salem

Dr. Subha S.S. MD.,D.G.O., Obstetrics & Gynaecologist Salem Dr. Dhanapal P.V. M.S.,(Gen)F.A.I.S General Surgeon & Laparoscopic Surgeon Salem

Dr.S.A.K.Noor Mohammed M.D.(Gen. Med), D.M.(Nephro) Nephrologist Salem Dr.R.Kandasamy B.Sc.,MBBS.,PG Dip.DIAB General Physician Salem

15 • CAPSULE MAGAZINE • APRIL 2018 KAUVERY CAPSULE PANEL OF NEW CONSULTANTS

Dr.S.Ravikumar MS.,M.Ch(Gastro)., Surgical Gastroenterology Salem

Dr. K. Mahendran MBBS.,MS(ENT).,DLO ENT & Endoscopic Surgeon Salem

Dr Ramesh Ramanathan Dr.K.M.Lakshmanarajan MBBS.,PGDHS(Echo)., MBBS.,MD., Dc.CM(Cardiac Medicine)., DNB(ANESTHESIA), Dc.RM(Resp Medicine)., FNB(CARDIAC ANESTHESIA) FSAMS(Gen Sur)., Anaesthesiologist MS., FCGP., FCCP Salem Dr.G.Sivaraman Associate Consultant MS.,M.Ch(Plasitc Surgeon)., Plastic Surgeon Chennai Salem

Dr.Anantha Subramanian MBBS., MD (Pul Med) Senior Resident Dr.K.Rajan Chennai MBBS., DMRD., MD (Radio Diagnosis) Senior Consultant Radiology Chennai

Dr. Vivekanandan Dr.Arunkumar Sengottaiyan MBBS., MRCS., FRCS MBBS M.S(Gen Surgery) Senior Consultant M.Ch() Liver Transplant Surgeon Consultant-Urologist Chennai Hosur Dr.A.M.Shantha Kumar., M.S.Ortho Consultant-Orthopaedician Hosur

Dr.C.P.AmruthuKumar MBBS DA DNB Consultant-Anaesthetist Hosur Dr.Manikandan MBBS., DNB., MCH Junior Consultant Cardio Thoracic Surgery Chennai

Dr.M.RekhaMahesh MBBS MS(OBG) Consultant-Obstetrics Dr.R.Anbuchezhian & Gynaecologist MBBS MS ENT Hosur Fellowship in Implantation Otology. Consultant-ENT Hosur

APRIL 2018 • CAPSULE MAGAZINE • 16 KAUVERY CAPSULE WORLD KIDNEY DAY FLASH MOB (8th Mar) World Kidney Day Awareness-Flash Mob Theme - Kidneys & Women’s Health: Include, Value, Empower Every year in the month of March, Worldwide theme based awareness will be enhanced to commemorate “World Kidney Day” (March 8th), which this year emphasize on kidneys and women’s health and on the same day we had Women’s Day. So we integrated both women’s day and kidney day as the theme is also based on women’s health.

Kauvery Kidney centre, tennur always step forward for social cause. This time, we have initiated various events among general public to commemorate “World Kidney Day” & “World Women’s Day”.

17 • CAPSULE MAGAZINE • APRIL 2018 KAUVERY CAPSULE WORLD KIDNEY DAY, FLASH MOB

APRIL 2018 • CAPSULE MAGAZINE • 18 KAUVERY CAPSULE TOI AWARD

An award for excelling in Human Care! Kauvery Hospital’s zeal for personalized care and innovation has helped win many laurels in the recently held Times Healthcare Awards 2018 (Tamilnadu) on May 5th 2018 at Feathers Hotel, Chennai. The prestigious event was presided by Dr. J. Radhakrishnan, Best Multi Speciality Hospital - ROTN Principal Secreatary to Tamilnadu Government as Chief Guest and Dr. V. Shanta, Chairperson, Adyar Cancer Institute as Special Guest. The event was attended by leading medical fraternity representing the top providers in About Tamilnadu. The Award The Times Healthcare Achievers Chennai 2018 is an endeavor to salute those individuals and institutions who have made outstanding contributions in their respective fields to enhance the quality of medical services and healthcare delivery. It is a roll of honor which aims to recognize doctors and institutions that have played an integral role in developing and diversifying the healthcare landscape in Tamilnadu. The TAMIL NADU previous city editions of the Awards included Hyderabad an.d Delhi NCR.

Legends Award - Dr. P. R. Ramasamy Legends Award - Dr. D. Senguttuvan, E.D (Received by Dr. T. Senthil Kumar)

19 • CAPSULE MAGAZINE • APRIL 2018 KAUVERY CAPSULE TOI AWARD

Best Speciality in a Multi Specialty Hospital - Neurology Best Speciality in a Multi Specialty Hospital Cardiology & Cardiothoracic Surgery

Best Speciality in a Multi Specialty Hospital - Orthopedics Stalwarts - Prof Dr. N. Sekar, Vascular Surgery

Stalwarts - Dr. T. Senthil Kumar Stalwarts - Dr. Kannan D, Gastroenterology Cardiology & Cardiothoracic Surgery

Stalwarts - Dr. P. D. Aravindan, Young Achievers - Dr. T. Rajarajan, General Medicine & Diabetology

APRIL 2018 • CAPSULE MAGAZINE • 20 Catalyst – Series IV

Advanced Laparoscopic Surgical Skills course

Date: 17th, 18th & 19th August 2018 Venue: Hotel Sangam, Trichy

CATALYST (Centre for Academy of Training in Advanced Laparoscopy and Surgical Techniques) To be Accreditated by Tamil Nadu Dr. MGR Medical University

Course Director: Dr. S. Velmurugan

• Previous courses were well appreciated with and excellent feedback from candidates • Plenty of Hands on Training • One to one trainer (Mentor) • One day live advanced Lap surgeries including hernia repair , fundoplication, Bariatric surgery, TLH & Gynaec surgery

Limited to 40 Candidates only , (First come first serve basis allotment)

Register Now...

For registration & queries Dr. S. Vetrivinayakan – 98949 68124 | 97150 91246 Ms. Saraswathy – 73739 61117 | 89407 09624