1. Title slide — your name, institution, topic
2. Introduction to Metabolic Disorders
3. Importance of Long-Term Monitoring
4. Risk Factors
5. Symptoms
6. Treatment & Management (with comparison table)

1. Introduction to atypical cardiomyopathies
2. Left Ventricular Non-Compaction (LVNC)
3. Arrhythmogenic Cardiomyopathy (ACM/ARVC)
4. Restrictive Cardiomyopathy (RCM)
5. Other Atypical Forms (Takotsubo, Myocarditis, Metabolic, PPCM)
6. Treatment and Management
7. Thank You

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══════════════════════════════════════════════════════════════════
                    ENT DEPARTMENT — PATIENT LOG
                 Jalalabad State University Hospital
                  Student: Raghul Balaji | 4th Year MBBS
══════════════════════════════════════════════════════════════════

─────────────────────────────────────────────────────────────────
CASE 01
─────────────────────────────────────────────────────────────────
Time            : 09:10 AM
Patient Name    : Айгүл Маматова (Aigul Mamatova)
Age             : 28 years | Female
BP              : 118/76 mmHg
Diagnosis       : Acute Tonsillitis
─────────────────────────────────────────────────────────────────
Chief Complaint : Severe sore throat for 3 days, difficulty
                  swallowing, and fever.
─────────────────────────────────────────────────────────────────
Clinical Findings:
  • Temperature: 38.6°C
  • Oropharynx: Bilateral tonsillar enlargement (Grade II),
    erythema, and exudative white patches on tonsils
  • Tender bilateral anterior cervical lymphadenopathy
  • Uvula midline, no peritonsillar bulge
─────────────────────────────────────────────────────────────────
Treatment Plan  :
  • Amoxicillin 500 mg TDS × 7 days
  • Paracetamol 500 mg SOS for fever/pain
  • Throat gargles with warm saline (4× daily)
  • Adequate oral hydration; soft diet
  • Review after 5 days; tonsillectomy counselling if recurrent
═════════════════════════════════════════════════════════════════

─────────────────────────────────────────────────────────────────
CASE 02
─────────────────────────────────────────────────────────────────
Time            : 09:45 AM
Patient Name    : Бакыт Дүйшөнов (Bakyt Duishonov)
Age             : 42 years | Male
BP              : 134/88 mmHg
Diagnosis       : Chronic Suppurative Otitis Media (CSOM) —
                  Tubotympanic type
─────────────────────────────────────────────────────────────────
Chief Complaint : Recurrent ear discharge from the right ear
                  for 6 months, associated with decreased hearing.
─────────────────────────────────────────────────────────────────
Clinical Findings:
  • Right ear: Mucopurulent discharge; central perforation of
    tympanic membrane (anteroinferior quadrant)
  • Left ear: Normal TM, no discharge
  • Weber test: Lateralizes to right (affected) ear
  • Rinne test: Negative on right (conductive hearing loss)
  • No facial nerve palsy; no mastoid tenderness
─────────────────────────────────────────────────────────────────
Treatment Plan  :
  • Aural toilet (dry mopping) of right ear
  • Ciprofloxacin ear drops 3 drops TDS × 2 weeks
  • Oral Amoxicillin-Clavulanate 625 mg BD × 7 days
  • Audiogram and high-resolution CT temporal bones
  • Refer to senior ENT for tympanoplasty counselling
  • Advise: keep ear dry, avoid swimming
═════════════════════════════════════════════════════════════════

─────────────────────────────────────────────────────────────────
CASE 03
─────────────────────────────────────────────────────────────────
Time            : 10:15 AM
Patient Name    : Нургүл Токтоматова (Nurgul Toktomatova)
Age             : 7 years | Female
BP              : 96/64 mmHg
Diagnosis       : Adenoid Hypertrophy with Obstructive
                  Sleep-Disordered Breathing
─────────────────────────────────────────────────────────────────
Chief Complaint : Mouth breathing, snoring at night, and nasal
                  obstruction for 4 months (reported by mother).
─────────────────────────────────────────────────────────────────
Clinical Findings:
  • Adenoid facies: open mouth posture, elongated face
  • Nasal endoscopy: large adenoid pad obstructing >75%
    of the nasopharyngeal airway
  • Bilateral tympanic membranes dull/retracted (Eustachian
    tube dysfunction)
  • Tonsils: Grade I–II bilaterally
  • No stridor at rest
─────────────────────────────────────────────────────────────────
Treatment Plan  :
  • Mometasone nasal spray 1 puff each nostril OD × 6 weeks
  • Montelukast 4 mg OD (adjunct for allergic component)
  • Lateral neck X-ray: confirm adenoid-nasopharyngeal ratio
  • Polysomnography if apnea episodes confirmed by parents
  • Surgical referral: adenoidectomy ± grommet insertion
═════════════════════════════════════════════════════════════════

─────────────────────────────────────────────────────────────────
CASE 04
─────────────────────────────────────────────────────────────────
Time            : 10:50 AM
Patient Name    : Эрлан Жакшылыков (Erlan Zhakshy lykov)
Age             : 55 years | Male
BP              : 148/92 mmHg
Diagnosis       : Epistaxis (Anterior) — Hypertension-related
─────────────────────────────────────────────────────────────────
Chief Complaint : Sudden onset bleeding from the left nostril
                  for 20 minutes, not stopping with pinching.
─────────────────────────────────────────────────────────────────
Clinical Findings:
  • Active bleeding from left nostril; Little's area erythematous
    with visible vessel on anterior nasal septum
  • BP at presentation: 164/98 mmHg (elevated)
  • No posterior pharyngeal blood clots visible
  • No nasal trauma history; no anticoagulant use
  • SpO₂: 98% on room air
─────────────────────────────────────────────────────────────────
Treatment Plan  :
  • Immediate: Seat patient upright, lean forward; pinch
    cartilaginous nose for 10–15 minutes
  • Silver nitrate cauterisation of bleeding vessel (Little's area)
  • Anterior nasal packing (BIPP/Vaseline gauze) if cautery fails
  • Amlodipine 5 mg OD — initiate antihypertensive therapy
  • BP monitoring every 30 min for 2 hours post-procedure
  • Refer to medicine for hypertension management
  • Avoid nose-blowing and strenuous activity for 5 days
═════════════════════════════════════════════════════════════════

─────────────────────────────────────────────────────────────────
CASE 05
─────────────────────────────────────────────────────────────────
Time            : 11:30 AM
Patient Name    : Зарина Асанова (Zarina Asanova)
Age             : 34 years | Female
BP              : 120/78 mmHg
Diagnosis       : Allergic Rhinitis (Perennial)
─────────────────────────────────────────────────────────────────
Chief Complaint : Persistent nasal blockage, watery nasal
                  discharge, sneezing, and itchy eyes for 1 year,
                  worse in dusty environments.
─────────────────────────────────────────────────────────────────
Clinical Findings:
  • Nasal mucosa pale and boggy; clear watery rhinorrhoea
  • Inferior turbinates hypertrophied bilaterally
  • Allergic salute sign present
  • Eyes: mild bilateral conjunctival injection
  • No nasal polyps visible on anterior rhinoscopy
  • Skin prick test: positive for house dust mite, mold
─────────────────────────────────────────────────────────────────
Treatment Plan  :
  • Fluticasone nasal spray 2 puffs each nostril OD
  • Cetirizine 10 mg OD (at bedtime)
  • Saline nasal irrigation BD
  • Allergen avoidance: dust-proof pillowcase, reduce carpets
  • Consider allergen immunotherapy if poorly controlled
    after 3 months
═════════════════════════════════════════════════════════════════

─────────────────────────────────────────────────────────────────
CASE 06
─────────────────────────────────────────────────────────────────
Time            : 12:05 PM
Patient Name    : Канат Осмонов (Kanat Osmonov)
Age             : 19 years | Male
BP              : 112/72 mmHg
Diagnosis       : Acute Otitis Externa (Swimmer's Ear)
─────────────────────────────────────────────────────────────────
Chief Complaint : Right ear pain and itching for 4 days,
                  worsened after swimming; slight discharge.
─────────────────────────────────────────────────────────────────
Clinical Findings:
  • Right ear: Tragal tenderness ++; pinna traction pain ++
  • EAC: Oedematous, erythematous; scant serous discharge
  • Tympanic membrane partially visible but intact
  • Left ear: Normal
  • No fever; no lymphadenopathy
─────────────────────────────────────────────────────────────────
Treatment Plan  :
  • Gentle aural toilet; suction clearance of debris
  • Ciprofloxacin + Dexamethasone ear drops 4 drops QID × 7 days
  • Wick insertion (Pope wick) if canal too swollen for drops
  • Oral ibuprofen 400 mg TDS for pain relief
  • Strict water precautions: ear plugs when bathing
  • Review in 7 days
═════════════════════════════════════════════════════════════════

─────────────────────────────────────────────────────────────────
CASE 07
─────────────────────────────────────────────────────────────────
Time            : 12:40 PM
Patient Name    : Гүлбарчын Исакова (Gulbarchyn Isakova)
Age             : 62 years | Female
BP              : 142/86 mmHg
Diagnosis       : Benign Paroxysmal Positional Vertigo (BPPV)
                  — Posterior semicircular canal (right)
─────────────────────────────────────────────────────────────────
Chief Complaint : Brief episodes of spinning dizziness triggered
                  by rolling over in bed and looking up, for 2 weeks.
─────────────────────────────────────────────────────────────────
Clinical Findings:
  • Dix-Hallpike test (right): Positive — upbeat-torsional
    nystagmus with 5-second latency, fatigable
  • Dix-Hallpike (left): Negative
  • Neurological exam: No focal deficits, gait normal
  • Otoscopy: Bilateral normal TMs
  • No hearing loss; no tinnitus
─────────────────────────────────────────────────────────────────
Treatment Plan  :
  • Epley canalith repositioning manoeuvre (right side) —
    performed in clinic; vertigo resolved post-procedure
  • Betahistine 16 mg TDS × 2 weeks (symptomatic relief)
  • Home Brandt-Daroff exercises (BD × 2 weeks)
  • Advise: avoid sudden head movements; fall precautions
  • BP follow-up with physician
  • Review in 2 weeks; repeat Dix-Hallpike to confirm resolution
═════════════════════════════════════════════════════════════════

─────────────────────────────────────────────────────────────────
CASE 08
─────────────────────────────────────────────────────────────────
Time            : 02:00 PM
Patient Name    : Мирлан Кадыров (Mirlan Kadyrov)
Age             : 38 years | Male
BP              : 126/80 mmHg
Diagnosis       : Deviated Nasal Septum (DNS) with
                  Secondary Sinusitis
─────────────────────────────────────────────────────────────────
Chief Complaint : Left-sided nasal obstruction since childhood,
                  now with recurrent headaches and facial pain
                  for 3 months.
─────────────────────────────────────────────────────────────────
Clinical Findings:
  • Anterior rhinoscopy: C-shaped DNS to the left; nasal spur
    at osteocartilaginous junction
  • Left turbinate: Compensatory hypertrophy
  • Facial tenderness over left maxillary sinus region
  • Nasal endoscopy: mucopus in left middle meatus
  • X-ray PNS (Waters view): Haziness of left maxillary sinus
─────────────────────────────────────────────────────────────────
Treatment Plan  :
  • Amoxicillin-Clavulanate 625 mg BD × 10 days
  • Mometasone nasal spray OD × 4 weeks
  • Saline nasal irrigation TDS
  • CT PNS (coronal cuts) to assess sinus disease extent
  • Surgical referral: Septoplasty ± FESS (Functional
    Endoscopic Sinus Surgery)
═════════════════════════════════════════════════════════════════

─────────────────────────────────────────────────────────────────
CASE 09
─────────────────────────────────────────────────────────────────
Time            : 02:35 PM
Patient Name    : Адалат Эгембердиева (Adalat Egemberdieva)
Age             : 15 years | Female
BP              : 108/68 mmHg
Diagnosis       : Peritonsillar Abscess (Quinsy) — Left side
─────────────────────────────────────────────────────────────────
Chief Complaint : Progressive severe sore throat for 5 days,
                  now with inability to open mouth fully and
                  muffled voice.
─────────────────────────────────────────────────────────────────
Clinical Findings:
  • Temperature: 39.1°C
  • Trismus present (mouth opening ~2 cm)
  • Left peritonsillar bulge with uvular deviation to the right
  • Left tonsil pushed inferomedially; fluctuance on palpation
  • Hot potato (muffled) voice
  • Tender left jugulodigastric lymph node
─────────────────────────────────────────────────────────────────
Treatment Plan  :
  • IV Benzylpenicillin 1.2 g QID + Metronidazole 500 mg TDS
  • IV Dexamethasone 8 mg stat (reduces oedema, trismus)
  • Needle aspiration of abscess under LA — 4 mL pus drained
  • IV fluids (maintenance); soft diet when tolerated
  • Upgrade to incision & drainage if aspiration insufficient
  • Tonsillectomy (interval) recommended after 6 weeks
    (quinsy tonsillectomy counselled)
═════════════════════════════════════════════════════════════════

─────────────────────────────────────────────────────────────────
CASE 10
─────────────────────────────────────────────────────────────────
Time            : 03:10 PM
Patient Name    : Темирбек Султанов (Temirbek Sultanov)
Age             : 47 years | Male
BP              : 138/84 mmHg
Diagnosis       : Sudden Sensorineural Hearing Loss (SSNHL)
                  — Left ear
─────────────────────────────────────────────────────────────────
Chief Complaint : Sudden complete hearing loss in the left ear
                  on waking this morning, associated with
                  tinnitus and mild vertigo.
─────────────────────────────────────────────────────────────────
Clinical Findings:
  • Otoscopy: Bilateral normal TMs; no discharge
  • Tuning fork:
    – Weber: Lateralizes to right (normal) ear
    – Rinne: AC > BC bilaterally (sensorineural pattern left)
  • Audiogram: Left ear — profound SNHL across all frequencies
  • MRI IAC: Ordered to exclude acoustic neuroma / MS
  • No facial palsy; no preceding URTI
─────────────────────────────────────────────────────────────────
Treatment Plan  :
  • Prednisolone 1 mg/kg/day (max 60 mg) OD × 7 days,
    then taper over 5 days — URGENT (within 24–48 hrs)
  • Intratympanic dexamethasone injection if systemic steroids
    contraindicated or fail
  • Carbogen (95% O₂ + 5% CO₂) inhalation therapy
  • Urgent audiogram and BERA (Brainstem Evoked Response)
  • Strict bed rest; avoid noise exposure
  • Prognosis counselling: 30–65% recovery with early treatment
═════════════════════════════════════════════════════════════════

─────────────────────────────────────────────────────────────────
CASE 11
─────────────────────────────────────────────────────────────────
Time            : 03:45 PM
Patient Name    : Жылдыз Бекова (Zhyldyz Bekova)
Age             : 31 years | Female
BP              : 116/74 mmHg
Diagnosis       : Vocal Cord Nodules (Singer's Nodules)
─────────────────────────────────────────────────────────────────
Chief Complaint : Progressive hoarseness of voice for 4 months,
                  worse with prolonged speaking; works as a
                  school teacher.
─────────────────────────────────────────────────────────────────
Clinical Findings:
  • Voice: Rough, breathy dysphonia; reduced volume
  • Indirect laryngoscopy / Flexible nasolaryngoscopy:
    Bilateral whitish nodules at the anterior 1/3–2/3
    junction of vocal cords ("kissing nodules")
  • Vocal cords mobile; no mucosal irregularity
  • No neck lymphadenopathy
  • GERD symptoms present (throat clearing, post-nasal drip)
─────────────────────────────────────────────────────────────────
Treatment Plan  :
  • Voice rest: reduce speaking to minimum for 2 weeks
  • Speech therapy (voice hygiene training) × 6–8 sessions
  • Pantoprazole 40 mg BD × 4 weeks (treat GERD component)
  • Adequate hydration; avoid caffeine and smoking
  • Microlaryngoscopy + excision if no improvement after
    6–8 weeks of conservative therapy
  • Occupational advice: voice amplifier at work
═════════════════════════════════════════════════════════════════

─────────────────────────────────────────────────────────────────
CASE 12
─────────────────────────────────────────────────────────────────
Time            : 04:20 PM
Patient Name    : Болот Чоротегин (Bolot Chorotegin)
Age             : 9 years | Male
BP              : 98/62 mmHg
Diagnosis       : Foreign Body Nose — Left nostril (bead)
─────────────────────────────────────────────────────────────────
Chief Complaint : Foul-smelling unilateral nasal discharge from
                  left nostril for 10 days (reported by mother;
                  child denies inserting anything).
─────────────────────────────────────────────────────────────────
Clinical Findings:
  • Left nostril: Purulent malodorous discharge; mucosa
    erythematous and swollen
  • Anterior rhinoscopy: Small round blue bead visible in
    left nasal cavity, anterior floor
  • Right nostril: Normal
  • No signs of respiratory distress
─────────────────────────────────────────────────────────────────
Treatment Plan  :
  • Mother's kiss technique attempted — unsuccessful
  • Removal under direct visualisation using Jobson-Horne
    probe and Tilley's forceps; bead extracted successfully
  • Nasal mucosa inspected post-removal: intact, no ulceration
  • Saline nasal drops BD × 3 days
  • Parent counselling: keep small objects away from child
  • No antibiotics needed (discharge resolved on removal)
═════════════════════════════════════════════════════════════════

─────────────────────────────────────────────────────────────────
CASE 13
─────────────────────────────────────────────────────────────────
Time            : 04:55 PM
Patient Name    : Салтанат Токтогулова (Saltanat Toktogulova)
Age             : 53 years | Female
BP              : 150/94 mmHg
Diagnosis       : Chronic Rhinosinusitis with Nasal Polyposis
─────────────────────────────────────────────────────────────────
Chief Complaint : Complete nasal blockage, loss of smell, and
                  chronic headache for over 1 year; not
                  responding to prior nasal sprays.
─────────────────────────────────────────────────────────────────
Clinical Findings:
  • Anterior rhinoscopy: Bilateral pale grey semi-translucent
    polyps prolapsing from middle meatus; Grade III polyposis
  • Anosmia confirmed (smell identification test)
  • CT PNS: Bilateral opacification of ethmoid and maxillary
    sinuses; osteomeatal complex blocked bilaterally
  • No features of malignancy (irregular margins, bony erosion)
─────────────────────────────────────────────────────────────────
Treatment Plan  :
  • Prednisolone 30 mg OD × 14 days (oral steroid reduction)
  • Mometasone nasal spray 2 puffs BD (maintenance long-term)
  • Saline nasal irrigation TDS
  • Allergy evaluation; Aspirin sensitivity testing
  • Surgical referral: FESS (bilateral) — polypectomy +
    ethmoidectomy + middle meatal antrostomy
  • Post-FESS steroid nasal spray indefinitely to prevent
    recurrence
  • BP follow-up with physician
═════════════════════════════════════════════════════════════════

─────────────────────────────────────────────────────────────────
CASE 14
─────────────────────────────────────────────────────────────────
Time            : 05:30 PM
Patient Name    : Улукбек Мамытбеков (Ulukbek Mamytbekov)
Age             : 24 years | Male
BP              : 122/78 mmHg
Diagnosis       : Acute Laryngitis with Dysphonia
─────────────────────────────────────────────────────────────────
Chief Complaint : Complete loss of voice (aphonia) for 2 days
                  following a cold; mild throat pain and dry
                  cough.
─────────────────────────────────────────────────────────────────
Clinical Findings:
  • Temperature: 37.8°C (low-grade fever)
  • Voice: Aphonic; forced whisper only
  • Flexible laryngoscopy: Bilateral vocal cords erythematous
    and oedematous; no ulcers, no mass, no stridor
  • Anterior cervical mild lymphadenopathy
  • No respiratory distress; SpO₂ 99%
─────────────────────────────────────────────────────────────────
Treatment Plan  :
  • Complete voice rest × 5–7 days (absolute silence)
  • Steam inhalation TDS × 5 days
  • Benzydamine hydrochloride throat spray (anti-inflammatory)
  • Paracetamol 500 mg TDS for discomfort
  • Avoid whispering (as harmful as speaking)
  • Adequate hydration; humidifier advised
  • Reassess in 10 days; laryngoscopy if dysphonia persists
    > 3 weeks (exclude malignancy)
═════════════════════════════════════════════════════════════════

─────────────────────────────────────────────────────────────────
CASE 15
─────────────────────────────────────────────────────────────────
Time            : 06:00 PM
Patient Name    : Нурбек Эсенгулов (Nurbek Esengulov)
Age             : 16 years | Male
BP              : 110/70 mmHg
Diagnosis       : Otitis Media with Effusion (Glue Ear) —
                  Bilateral
─────────────────────────────────────────────────────────────────
Chief Complaint : Bilateral hearing difficulty and a sensation
                  of fullness in both ears for 2 months;
                  teacher reports inattentiveness in class.
─────────────────────────────────────────────────────────────────
Clinical Findings:
  • Otoscopy: Bilateral amber/yellow TMs, retracted; loss of
    light reflex; fluid level visible behind left TM
  • Rinne: AC < BC bilaterally (conductive hearing loss)
  • Weber: Midline (bilateral equal loss)
  • Pure Tone Audiogram: Bilateral 30–35 dB conductive HL
  • Tympanogram: Bilateral type B (flat curves)
  • Nasopharyngoscopy: Mild adenoid hypertrophy
─────────────────────────────────────────────────────────────────
Treatment Plan  :
  • Watchful waiting for 6–8 weeks (first-line if < 3 months)
  • Autoinflation (Valsalva / Otovent balloon) TDS
  • Intranasal steroid spray (Mometasone) OD × 6 weeks
  • Adenoidectomy + bilateral grommet (ventilation tube)
    insertion if no resolution at 8-week review
  • Hearing therapy and classroom seating advice
    (front row, face teacher)
  • Audiological re-evaluation at 8-week follow-up
══════════════════════════════════════════════════════════════════
                      END OF DAILY LOG
              ENT Department | Jalalabad State University
══════════════════════════════════════════════════════════════════