Issuing Medical Certificate

As an ENT Surgeon,I issue post operative off work certificate to patients.However in the outpatients,we should be careful in issuing certificates.
On personal ground,I disagree taking off work for small cough colds.Most of the people who ask such certificate are people who are bored of their work and have already taken off before consulting me.When they visit the clinic,they will argue that they were not well previous day and now they have paid my consultation fees.Well! consultation was done for your medical ailments and if it was told by patient that they are visiting me for a certificate-I would have refused to see them in the first place.

Another group who come for certificates are parents of school going kids.The family would have gone on holidays or to attend family functions and then appear to the doctors for a certificate.I blindly refuse to give such certificates.

I was once called for an enquiry where I had written date of resuming as 2/2/13 and the patient made it 12/12/13.This is true and I was so very overwhelmed that after that I never gave certificates for about 2 years .For operated ones,I used to ask ward secretary to type.Handwritten can easily be played around!Also in below article it has mentioned that take the signature of patient and an unrelated witness on the certificate which we occasionally follow in practice.

Here I share a well written article on docplus by DR Professor Prabhakar.Also the comments following it are informative
https://www.docplexus.in/#/app/posts/8fcb924f-a49b-494f-8c40-ff5874088220?utm_term=Email-Digest-0-eve&utm_campaign=Email-Digest&utm_medium=Email&utm_source=Docplexus.in&utm_content=CTA

Criteria For Issuance Of Medical Certificate

What kind of legal precautions can we take against violent incidents of non-issue of medical certificates? Patients seek medical certificates (MC) even for cold and cough these days to remain absent from work since they are bored with the same routine and mechanical working conditions. The purpose of seeking medical certificate documentation by any kind of patients is most important whether for the government or private sector. If for government purpose, patient is informed that certificate issued by a private physician will be invalid in such a condition so that the patient should at once convince of regarding this legal statement. Even then patient forces and insists for MC, certificates may be issued mentioning and confirming that the genuine purpose of MC whether it is true to patients knowledge free of cost. God alone knows how these so called certificates are accepted in working places whether government or private industries that are issued by government or private doctors and vice-versa. It is very well known that authorization should be mandatory to issue such medical certificates; however there is paucity of this issue in government protocols because MC issued by the private doctor is also valid in some companies. In such conditions it is always worth to ask the patient convincingly what is the purpose of MC and what he/she is going to do with that and whether MC granted by private doctor is valid or not valid in her/his company etc. These are the preliminary questions that may help to gain the confidence of any patient more so with poor and pity psychiatric patients. Once the purpose is revealed we will have to ask is it true and what for- very soothingly. Why all this in-patients will come deciding everything about MC issuing problems and even ready for fight and assault if the same is not issued, so much fixed in their minds, and prejudiced and preplanned, that’s how our mind works for the future consequences management, of course. Nicely we will have to solace the patients regarding invalidity and unacceptability of these so called MC stories issued by private firms. Repeatedly confirm whether patient is asking for medical treatment certificate or medical consultation fees certification if so we will have to issue both. When so called law protectors exhibit such irrelevance and carelessness towards such type of incidents, then God alone is the ultimate protector and destroyer of this material world. In the first instance police stayed away from this incidence because they thought they are dealing with a psychiatric patient and why to give trouble this is mercy and kindness always shown towards any patient suffering from disease of mind. Therefore prophylactic cautions that work are important than so-called these legal precautions. These are very few precautions not amounting to cautions only, when private doctor issuing MC to adamant patients who insist upon and force doctors to grant MC. Only we can take these simple cordial precautionary steps to prevent further legal mishaps-so enough of this violation. 

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Nasal Polyps in Children

Nasal Polyps are common nasal swellings or masses seen in children.

The paranasal sinuses (“the sinuses”) are air-filled cavities located within the bones of the face and around the nasal cavity and eyes. 

Each sinus is named for the bone in which it is located:

Maxillary sinus- one sinus located within the bone of each cheek  

Ethmoid sinus- located under the bone of the inside corner of each eye, although this is often shown as a single sinus in diagrams   this is really a honeycomb-like structure of 6-12 small sinuses that is better appreciated on CT scan images through the face  

Frontal- one sinus per side, located within the bone of the forehead above the level of the eyes and nasal bridge  

Sphenoid- one sinus per side, located behind the ethmoid sinuses; the sphenoid is not seen in a head-on view but is better appreciated looking at a side view

However in children sinuses are still developing and when we refer to sinuses in children;it is mainly maxillary and ethmoids.

Nasal polyps in children can be inflamatory (bacterial),allergic or associated with cystic fibrosis. 

The nasal polyps are of two kinds mainly : Antrochoanal or Sinonasal.

Antrochoanal are ususally single polyps aising from the maxillay antrum and going towards the choana (posterior opening of nostrils).They are usually one sided.

Sinonasal usually arise from the sinus lining of both sides of sinuses.

The common symptoms of polyps are 

nasal block

obstructive sleep apnoea or snoring in children

sometimes nose bleed

Usually the ENT surgeon will ask for CT scan to know the extend of disease.

The nasal polyps require surgical removal.Nowadays in children it is usually endoscopic approach.Sometimes transoral and other approaches are require for complete removal.

As a surgeon,I always consider the growing anatomy of sinuses,unerupted teeth and concern for facial growth in children while deciding the surgery.

Sinusitis in children

Sinusitis is the inflammation of the sinuses.Though an adult has four pairs of sinuses,in children it is usually the maxillary and ethmoid sinuses are involved as the sphenoid and frontal sinuses are still developing.

In children,common cold or viral infection is the commonest cause of sinusitis.
Other common cause is foreign body in the nostrils or untreated allergic rhinitis leading to sinusitis.

Common symptoms the child will have are
Nasal discharge: green or yellow
fever
cough
headache
facial pain or pressure over face
swelling or redness over face or cheeks
swelling around the eyes

Child should be immediately seen by their physician who will decide the treatment starting from decongestion of the nose to allergy treatment or antibiotics depending on diagnosis.
Ocassionally scans are ordered:CT scan of sinuses especially if eye is involved.

Meditation: A state of mind

Often people think meditation means sitting quiet,closing the eyes and breathing- this activity is prānāyāmā.
No ,meditation is a state of mind,not sitting alone in a room.
Real meditation is in day to day life,in normal existing condition.Meditation is a mental state,You have a problem,you meditate.Take a wholesome view,this is the problem,these are the consequences,keep an ideal before-what is to be done.Hold on to the ideal,examine,do the right thing,say the right thing.
Unfortunately,we are traditionally brought up- as if prayer means to sit before a shrine.
No, prayer is an attitude of mind, a prayerful attitude.

Meditate wherever you are,whatever you may be doing,with a prayerful attitude.

Above is taken from "Raja Yoga Lectures by Swami Sarvagatananda"

Is Yoga a way of life or an exercise as publicized?

As majority of humans who are engrossed in their fields and usually blindly believe religious stuff   around,I thought Yoga was some kind of exercise.
It had to be easy since everyone is doing it.I see all these Baba's demonstrating on television or filmstars coming out with videos of yoga.
Anyway I had no time for it (so did I think)  or the right time had to come.
Now I am aware of my ignorance and my miseries lead me to realisation,I am ready to know "What is Yoga?"

Let me tell you I have just made a beginning but so impatient to share with all!just shows I have a long way to go!
We are confusing Yoga with Asana.
For those who are spiritually inclined,Patanjali lists eight steps-

• Yama,niyama deals with moral excellence
• asana,pranayama deals with the physical  
• Pratyahara,dharana deals with mental
• dyana,samadhi deals with spiritual

So even before we reach physical i.e. asanas ,we need to be morally sound.

Yoga is not something which if attained will lead us to Heaven,it teaches us how to cope and live now..here.

Sharing some excerpts from Books and Lectures of Swami Vivekananda.
"Yoga means Union.Yoga is purposeful living.
Following are the unities you gain from yoga 1. First is within yourself 2. Is within the society and 3. By gradually evolving you gain the Ground.
Yoga touches the mainstream of our life,our way of thinking,feeling and functioning.We need Yoga in our day to day living."
Yoga does not take us beyond this life and existence,
It helps us to conduct ourselves properly in day to day life.
It is not for post-mortem bliss or something somewhere in heaven.

Yoga is purposeful living and realising.Knowing the pain but not being miserable.knowing the facts.

Reflect not react!
Oh!with all the past memories in my subconscious and the samskaras ingrained,it's not an easy task.
How do we resolve the subconscious mental contents (Samakaras) ?
Either we have a strong mind or strong will to be absolutely unaffected- Buddha Method or we Surrender completely to the divine like a child runs towards its mother for protection.
There are 3 things necessary for the practice of yoga -
1.Austerity,self control
2.Knowledge, study, ability to think
3.Surrendering to the divine. As Jung said "God is a psychological necessity ".

We are ignorant,lost,helpless and confused; And then there is nobody to blame -no society,no parents or environment.For we are humans and have a chance to correct our ignorance.
It is never too late ,No case is hopeless "

An introduction on Yoga from Complete Works of Swami Vivekananda Volume VI  is worth a read.

And really do not get caught in so called Power Yoga,popularised by the west.
I personally believe,we Indians should claim the right on the use of the word Yoga in the right sense.
It is the duty of each one of us to stand for our precious teachings and culture.

Dare to be Deaf!

Vertigo in Children

Vertigo in children is uncommon.The attacks of vertigo in children may be less dramatic than adults,however they cause severe anxiety if a diagnosis is not reached and appropriately explained.

The clinical diagnosis involves accurate history which many adults are not capable of giving.The reason I say so is that the terms "Vertigo" "Dizziness""Giddiness" and "Imbalance" are very commonly used without proper understanding by adult patients,let alone poor child!
When a child presents with vertigo, we also need to keep in mind their distractibility,coordination capabilities and behavioral problems.Also the compliance in pediatric population to perform otoneurological examinations is limited

Let us go through various terms commonly used by patients or parents.
Dizziness can be used to explain different sensations like lightheadedness, Fainting or Syncope, Giddiness (when engaging in activities like spinning) or Vertigo.

Vertigo is a sensation of spinning (either we feel spinning or the surrounding is spinning).It can be associated with nausea,jerky eye movements,headache,sweating and ringing in the ears or hearing loss.

Vertigo is an uncommon complaint in children and adolescents.Despite the most significant technological achievements in the development of diagnostic tools like scans and audiology, diagnosis is still based mainly upon the patient’s history and physical examination.There could be history of migraine or vertigo in the family.

The child's pediatrician may refer to Pediatric ENT for further otologic and audiologic evaluation.If required, the child may be seen by neurologist for evaluation.

There have been various scientific studies about the etiologies or causes of vertigo in children.The common causes of vertigo or the differential diagnosis includes Migraine associated vertigo or variants,Benign Paroxysmal Vertigo, Otitis Media and rarely other inner ear pathologies.

It is worth mentioning about "Motion Sickness" here.
It is a clinical phenomenon provoked by passive locomotion or movement of the visual environment only.It consists of pallor,tiredness,weakness,hypersalivation,nausea and emesis.

Diagnosis should be followed by adequate symptomatic treatment and management of underlying etiologies.The success of treatment of vertigo lies in regular follow up.