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Case Presentation For Medical Students Template

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Transcript: British Medical Journal Annals of Rheumatoid Disease Synovial membrane inflamed and thickened. Bones and cartilage gradually begin to erode Stratification Change in MRI Erosion Score from baseline to week 24 with the use of Rituximab! Progression of osseous tissue formation, causing fusion of the bones, this reducing mobility and in resulting in pain Other Signs and Symptoms of RA Baseline MRI scan 14 days before 1st infusion. Images scored by 2 independent radiologists In fact, data presents joint improvement! All secondary outcomes lead to development of primary outcome (Joint erosion) van Elteren test Used to determine primary endpoint Percent change from baseline Study did not have true 'normal' Each patient's baseline was their individual 'normal' ANOVA cannot be used Test is considered inferior to others with a true 'normal' What if they're biologically naive? Randomized 1:1:1 Loss of energy Loss of appetite Low fever Dry eyes/mouth (sjorgren's syndrome) Rheumatoid nodules (elbows/hands) To evaluate the effect of Rituximab + MTX in reducing structural damage and joint inflammation vs. MTX alone in patients with active RA. Progression of RA 3. Fibrous Ankylosis MRI assessment of suppression of structural damage in patients with rheumatoid arthritis receiving rituximab: results from the randomised, placebo-controlled, double-blind RA-SCORE study Impact Factor: 10.38 Authors Professor Charles Peterfy MD, PhD 1. DiCarlo J. Julie Camille DiCarlo - Publications. Researchgatenet. 2015. Available at: http://www.researchgate.net/profile/Julie_Dicarlo2/publications. Accessed December 1, 2015. 2. Clinicaltrials.gov. A Study of Rituximab (MabThera®/Rituxan®) in Patients With Rheumatoid Arthritis and Inadequate Response to Methotrexate - Full Text View - ClinicalTrials.gov. 2015. Available at: https://clinicaltrials.gov/ct2/show/NCT00578305?term=00578305&rank=1. Accessed December 1, 2015. 3. Peterfy C, Emery P, Tak P et al. MRI assessment of suppression of structural damage in patients with rheumatoid arthritis receiving rituximab: results from the randomised, placebo-controlled, double-blind RA-SCORE study. Annals of the Rheumatic Diseases. 2014. doi:10.1136/annrheumdis-2014-206015. 4. Vimeo. MabThera (Rituximab) – Mode of action and the role of B cells in rheumatoid arthritis (RA) (1). 2014. Available at: https://vimeo.com/91432523. Accessed December 1, 2015. 5. Netter F, Iannotti J, Parker R. Musculoskeletal System. Philadelphia: Elsevier Saunders; 2013. Significant finding: Rituximab 1000 mg exhibited slower progression of joint erosion. Inclusion Criteria Study Objective American Rheumatology Criteria for ≥3 months and ≤10 years Erosion/signs/symptoms of synovitis in a single joint (MRI) IR to MTX at dose 12.5-25mg/wk ≥ 12wks More Analysis Interactive Voice Response System (IVRS) RA RA! Rituximab Against Rheumatoid Arthritis Discussion History of rheumatic autoimmune disease other than RA or significant systemic involvement secondary to RA Previously on another biologic agent that depletes B-cells. Progression of RA 2. Pannus Formation Founder and CEO of Spire Sciences. Attending radiologist at UCSF for 7 years Director of Arthritis Research for the Osteoporosis and Arthritis Research Group. Developed the WOMRS system and co-developed the RAMRIS (Rheumatoid Arthritis MRI Score) and PsAMRIS (Psoriatic Arthritis MRI Score) methods. - Spire Sciences’ mission is to improve world health by helping bring new and better therapies into clinical use faster. They are focused exclusively on central image analysis. <6 months MTX therapy ≥ 6 months MTX therapy +Bone erosion No bone erosion Primary Outcome Article Post-Hoc Analysis CARLOS TDS TIS week 12, 24, and 52 Health Assessment Questionaire Disability Index (HAQ-DI) Antibody to CD-20, which is found on the surface of B-cells Progression of RA 4. Bony Ankylosis Non-Biologic Hydroxychloroquine Sulfasalazine Leflunomide Methotrexate - Drug of Choice for non-biologic DMARDs Folate antimetabolite (anti-inflammatory and immunosuppressive) Most common type of autoimmune arthritis Progression of RA 1. Synovitis Statistical Analysis for Secondary Outcomes Efficacy Assessment Sponsors & Collaborators: Hoffmann-La Roche Rheumatoid Arthritis Symptoms Clinical significance: Rituximab+MTX prevents joint damage in MTX-IR patients with active RA Reductions in synovitis and osteitis --> reduction in erosion and cartilage loss. Will Rituximab slow the progression of joint erosion in patients with active RA, biologically naive, and failed MTX treatment? 75% of those affected are women Preparation Randomization Rheumatoid Arthritis (RA) Genant-Modified Sharp radiographic scoring Range is too narrow (0-4) Study only used biologically naive patients Possible author bias. He co-developed RAMRIS score Research facility focuses on Central Image Analysis Discrepancies between text, tables, and charts. Insignificant p-value in table, while chart and text indicate statistical significance.

Depression for Medical Students

Transcript: Phenomenology What is it like? Epidemiology risk factors for depression & suicide Etiology Genes and environment Diagnosis DSM-IV criteria for Major depressive episode and Depressive Disorder Pathophysiology Where and how in the brain Depression Diagnosis 3 Mental Status Examination Depression: What you need to learn Depression: Epidemiology 3 Risk Factors Major Depressive Disorder (Single or Recurrent) Dysthymia Bipolar Disorder-depressed Depressive Disorder Due to Medical Condition Substance-induced Depressive Disorder Adjustment Disorder with Depressed Mood Depressive Disorder NOS Self Rating Scales Anatomy of Melancholy Depression Diagnosis 2 SIG: E. CAPS Pervasive, sustained feeling tone Internal experience Influences behavior and perception Like the “climate” Depression: Diagnosis 1 MDD – highest lifetime prevalence of any psychiatric disorder = 16.9% (National Comorbidity Survey) Females 20.2% Males 13.2% Cohort (generations) 18-29 16% 30-44 19.3% 45-59 20.1% 60+ 10.7% MDD – yearly incidence = 1.6% If a transmitter depolarizes the post-synaptic neuron, it is said to be excitatory If a transmitter hyperpolarizes the post-synaptic neuron, it is said to be inhibitory Whether a transmitter is excitatory or inhibitory depends on its receptor Ten leading causes of burden of disease, world, 2004 and 2030 Melancholy by Edward Munch, 1891 Nearly all depressed patients have considerable anxiety Anxiety may lead patients to suicide Patients may drink to calm anxiety Important to treat anxiety Comorbid anxiety disorders common (i.e. social phobia, panic) The Noradrenaline Pathways Types of Depressive Disorders Neurotransmitters Norepinephrine, Serotonin, Dopamine Second messengers Hormonal regulation HPA, Thyroid, GH, Prolactin Immunological disturbances Quote from a patient: “Depression is the worst of all diseases because when you are sick you want to get better; but when you are depressed you want to die…” Epidemiology Origins: Substancia Nigra “Probably more unpleasant than any physical disease except rabies” “There is constant mental pain” Physicians often shy away because it is so difficult to be with these patient’s feelings. Depressed patients make us feel helpless. Post partum depression versus “Baby Blues” DALYs Erick Messias, MD, PhD Phenomenology Excitatory and inhibitory neurotransmitters Differential Diagnosis Origins: Locus Ceruleus Carcinoid tumors Carcinomas (pancreas) Cerebrovascular disease (stroke) Collagen-vascular disease Endocrinopathies (thyroid, adrenal) Cardiac disease (common post MI) Pernicious anemia Neurological – stroke, brain injury, Parkinson’s Disease Grief and Bereavement Depression may be caused by medical treatments Beck Depression Inventory 1 and 2 PHQ 2/9 % Ischaemic heart disease 12.2 Cerebrovascular disease 9.7 Lower respiratory infections 7.1 COPD 5.1 Diarrhoeal diseases 3.7 HIV/AIDS 3.5 Tuberculosis 2.5 Trachea, bronchus, lung cancers 2.3 Road traffic accidents 2.2 Prematurity, low birth weight 2.0 Don’t MISS the DEPRESSION if the patient has physical complaints and/or medical illness Don’t MISS the Medical problems if the patient complaint is DEPRESSION Defining terms 1: Mood vs. Affect Depression: Epidemiology 1 Depression Depression and Medical Comorbidities Hamilton Rating Scale for Depression HAM-D Montgomery-Asberg Depression Rating Scale MADRS What for? For the test For your clerkship For your practice (whatever specialty) For your career in psychiatry For life External expression of mood Observed Like the “weather” Quote from Darkness Visible Appearance – posture, psychomotor retardation, tearfulness, hand wringing Mood- 50% deny depressed mood Speech – decreased rate & volume Delusions, Hallucinations –mood congruent Thoughts- negative, ruminations Memory- 50-75% impaired Insight / Judgment - impaired Antibiotics Antihypertensives Benzodiazepines Barbiturates Corticosteroids Chemotherapeutic agents Cimetidine Interferon Opioid Analgesics Monoamines: Overlapping Functions “Bad Mood” Sadness Grief Demoralization Depressed The Serotonin Pathways Goya’s Dark Paintings 5 or more for at least 2 weeks Essential Symptoms 1. Depressed mood 2. Anhedonia Physical Symptoms (VEGETATIVE SX) 3. Changes in sleep 4. Change in appetite or weight 5. Fatigue 6. Change in psychomotor activity Psychological symptoms 7. Feelings of guilt, worthlessness, hopelessness 8. Difficulty in thinking, concentrating, or making decisions 9. Recurrent thoughts of death and/or suicidal plans or attempts Adapted from DSM-IV History and FH Are there symptoms of a medical condition (cold intolerance, neuro changes?, etc) Medical conditions may mimic some symptoms of depression (energy, weight) Late onset more suggestive of medical cause Check Medication list Thyroid testing, B12 level Urine drug screen Brain imaging? Depression With psychotic features Delusions & Hallucination With catatonic features Mutism, immobility or motor overactivity, posturing, echolalia With Atypical features Increase

Medical Case Presentation

Transcript: Boulanger David medicine student Medical case presentation Identity Identity Name: Johnson Forname: William DOB: 24th September 1979 Occupation: Teacher (school director) Social status: Married Child: 2 (girl: 12 boy: 8) Live in: Grenoble (France) Symptom(s) Symptom(s) - Dizziness - Headache - Muscle aches - Insomnia - Nausea and vomiting - Irritability - Loss of appetite - Swelling of the hands, feet, and face - Rapid heartbeat - shortness of breath with physical exertion - Coughing - Chest congestion - Pale complexion and skin discoloration - Inability to walk or lack of balance - Social withdrawal Family history (FH) Family history (FH) TIME FATHER: myocardial infarction (67) MOTHER: Diabetes (32) Siblings: NAD Past medical history Past medical history TIME appendectomy (14) tonsillectomy (15) withdrawal of wisdom teeth (18) Broken leg (23) Social history (SH) Social history (SH) TIME Walking Trekking Climbing Swimming Skiing Examination (O/E) Examination (O/E) examination (O/E) examination (O/E) Weight: 70 Size: 1.75 Weight: 70 Size: 1.75 BP: 140/80 BP: 140/80 P: 180 P: 180 Respiratory frequency 20 / Min Respiratory frequency 20 / Min P02: 92% P02: 92% T: 37.5°C T: 37.5°C DIAGNOSIS DIAGNOSIS Acute Mountain Sickness (AMS) ? Acute Mountain Sickness (AMS) Treatment Treatment Medications : acetazolamide, to correct breathing problems blood pressure medicine lung inhalers dexamethasone, to decrease brain swelling aspirin, for headache relief Other treatments Lower altitude Lower altitude At rest At rest Water Water

Medical Case Presentation

Transcript: O God, that men should put an enemy in their mouths to steal away their brains! That we should with joy, pleasance, revel, and applause transform ourselves into beasts! William Shakespeare (1564-1616) British poet and playwright. 48 year old Caucasian female "My stomach is really hurting" HPI 48 y/o lady with a PMH of alcoholic liver cirrhosis, and esophageal varices "My stomach really hurts" She's been having abdominal pain for the past 6 days. Describes the pain as dull (constant and diffuse) 8/10 in severity starting from the epigastrium moving to the lower part of the belly. She feels relief when she lies down and worse sitting up. She also mentions that she noticed gradual distention of her belly for the past three weeks. She denies any nausea, vomiting, weight loss, or fever but notices some swelling in her left leg. In addition, she has recently been experiening some shortness of breath. She has dyspnea on exertion but denies orthopnea and paroxysmal nocturnal dyspnea. Of note, she mentions that she had similar belly pain 2 weeks ago which was associated with episodes of bloody vomiting. She went to Eastern Shore Hospital, admitted for upper GI bleed, underwent a panel of tests that included an endoscopy, ultrasound, and ascitic tapping and diagnosed with liver dx. She also mentions that she felt a lot better after that and hoped to get tapping done at SAH. Past Medical History Alcoholic liver cirrhosis Grade one esophageal varices Anemia Hx of thrombocytopenia Anxiety disorder GERD Cholecystitis Alcohol abuse Past Surgical History Rhinoplasty Allergies Acetaminophen (rash) Oxycodone (nausea) Medications Propanolol 10 mg po BID Pantoprazole 40 mg po BID Lactulose 15 mg po Qday Spironolactone 25 mg po Qday Sertraline 100 mg po Qday Clonazepam 1 mg po BID Review of Systems General: Muscle weakness, fatigue, and chills HEENT: No headaches, vision change, hearing changes, sinus troubles, bleeding gums, swollen glands Cardiac: No chest pain, palpitations Resp: Cough (non productive) and wheezing Breasts: No lumps, pain, nipple discharge GI: per HPI GU: No trouble urinating, no pain on urination, no hematuria, LMP was three years ago Extremities: per HPI Skin: No rashes, lesions, or color changes Endocrine: No heat or cold intolerance, excessive thirst or hunger Neuro: No seizures, numbness, or tingling Hematologic: No easy bruising or past transfusions Physical Exam 99.0 T 76 P 18 RR 115/60 BP 97% on 2L nasal cannula Weight: 70.307 kg General: Middle aged lady, in obvious pain but no acute respiratory distress, alert and oriented to person, place, and time. HEENT: Scalp normal, pupils equally round and reactive to light and accomodation. Fundoscopic exam reveals normal vessels, tympanic membranes are normal, oral pharynx is normal, neck is supple, no abnormal adenopathy in cervical or supraclavicular areas, thyroid is normal without any masses. Cardio: No murmurs/rubs, heart sounds S1 and S2 are present. Resp: Decreased air entry over the rt lower lung field, some expiratory wheezing bilaterally. GI: The abdomen is distended and bulging at the flanks but not tense, diffuse tenderness to palpation exquisitely over the epigastrium, Murphy's sign not present, bowel sounds are present, positive for shifting dullness, liver palpable 2 fingers below the subcostal margin, unable to appreciate exact size of liver or any splenomegaly MS: No cyanosis, clubbing, or edema noted. Peripheal pulses in the dorsalis pedis, and radial arms are normal. Skin: Multiple spider angiomas over subclavicular region, face and shoulders Neuro: Alert, oriented x3, CN II-XII intact, power 5/5 all extremities. March 10: Hypoxic requiring 100%FIO2 and PEEP of 12. March 11: Breathing improving requiring PEEP of 5 and FiO2 of 40%. Renal function improving with the CVVHD March 12: Breathing treatment the same, worsening encephalopathy, sedated but arousable, does not follow commands this am, eye opening present. CT of abdmn showed mild ascites, possible ascending colitis. Displaying multiorgan failure. March 13: Family decides to change code to DNI/DNR and request pt to be extubated with pastoral services present. March 14: Pt displays agonal breathing, no longer arousable. On morphine drip for pain. March 15: Worsening agonal breathing, no longer arousable. On morphine drip for pain. March 16: Pt passes away at 6:21pm. SBP Spontaneous bacterial peritonitis (SBP) is an acute bacterial infection in the peritoneum and severe consequence of ascites. Patients with cirrhosis who are in a decompensated state are at the highest risk of developing spontaneous bacterial peritonitis. Patients at greatest risk for spontaneous bacterial peritonitis have decreased hepatic synthetic function with associated low total protein level or prolonged prothrombin time (PT). The diagnosis is established by a positive ascitic fluid bacterial culture and an elevated ascitic fluid PMN count >250 cells/mm3 SBP Fever and chills occur in as many as 80% of patients.

Template for SS8 Students

Transcript: THE CONSTITUTION JUDICIAL EXECUTIVE LEGISLATIVE Constitutionality Outside Forces Legistative What does each of the first ten amendments mean? Why are there two separate parts of Congress? Can Veto laws Disision made in court I Social Consequence How long? Precedent Partisan What powers do the other two branches have over it? City council VIII City Level Most Power to Big States Press The people Rich indaviduals Rellection Other goverments Family members Historic figures Advertising Terrorists Protesters Wall Street Religion Political action commity (PAC) Lobbyists Judicial Branch Legistative What powers does it have over other two branches? How long? Can rule enforsment of laws unconstitutional U.S. Supreme Court 9 Justices--> senate for life The president nominates Senate Confirms Infer part Laws--> senate whether theLaws are (Constitusion) Small States get no power Both parties form commitee toghether. Executive Food inc. Who? over rule veto it 2/3 majority Can rule laws unsonstitutionaly Where? Partisan Politics What? President/ Vice President + Cabinet (Security) Comaner in Chief of the milatary 4 Years term (2 years cabinet) Can impeach justicies Why? VII What does the President swear to do? Why? What are the Bill of Rights and what is its purpose? IX How long? Miranda Rights senate confirms justice What powers does it have over other two branches? nominates justicies Senate 2 from every state 100 toatal 6 years term Politicians need money to advertise Pay to play Campain finance IV Active Liberty State Congress Which amendments define the rights of individuals suspected or accused of crimes? Executive (Carrys out the Laws) V Why? Executive (Mayor) What? Who? Innocent until proven guilty Originalist Judacial county/ court What are the different approaches to deciding on cases before the Supreme Court? II Judicial Restraint Who? Who? Why? Where? What powers does it have over other two branches? Congress State Supreme Court Bi-partisan House What is the Electoral College and why is it important? Where? Where? Prosecutor--> lawyer who tries to preserve guilty National Level Self-Incrimination How does a bill become a law? Tires Impeachment Politics where they vote only to support their party. Democrats and republicans vote against each other. What? Legistative Due Process Can rule laws unconstitutional House of Representatives 435 members chosen by % of population 2 year term 50% Majority passes a bill--> Must go through both The Balance of Power Bipartisan What? III Senate Indrustries/ Corporations buy food/ Control market Regulators (goverment) ex-employees of the corporations Nothing changes when children die (infected meat) Lobbyists: Persuade goverment officials to make laws Meat indrustries pay lobbyists CORUPTION Officials need money to get elected: donations from people or organizations with money Hard money- money given directly to politicians ($5,000) Soft money- give to party/ organizations (PAC) Political Action Commtee Subsidy-Paying money to the indrusty by using taxes Burden of Proof Governor Impeach What powers do the other two branches have over it? VI What powers do the other two branches have over it? State Level What is the main job of the President in regards to armed forces? Hung Jury Due procese Burden of proof Hung jury Self incrimanation Mranda rights What is an amendment? Make Laws What is an article? X Judicial Review

Template For Students

Transcript: Stories & Legends Winter 1. Powerful Central Image with an inquiry question to guide your thinking 2. Three main idea subtopics to refine your thinking: 1) Geography/Topography - 10 pictures (5 for land, 5 for water) relating to geographical terms with definitions for each 2) Natural Resources - Food: What types were available? - Where did they get it from? - How did they get it? - Transportation - What natural resources did they use for travel? - Natural waterways? - Did they make vessels or tools to aid their travel? - Clothing - How did the seasons/climate change what they wore? - What was the clothing made of and why? - Housing: 5 Facts - Did they change/move depending on season? - What were they made of? - How many people/families did they support? 3) Lifestyle & Cultural Practices: At least two of each: - Stories/Legends (2) - Ceremonies (2) - Beliefs (2) 3. At least 3 short video clips (less than 5 minutes; one for each main idea) Transportation/Tools From Resources Picture Hunting From the Land Agriculture What is it made of? Canoes? Snowshoes? Different styles? Using the Land as a Lifeline Spring Summer Fishing How does where one lives, affect how they live? Beliefs Clothing From Resources Picture Hunting How do the seasons/climate change the clothing? Food From Resources Picture Women were usually the ones that gathered the berrys Criteria Ceremonies From the Natural Waterways Geography/Topography Picture of Land Housing From Resources Picture Fall Lifestyle & Culture Natural Waterways Gathering Quoted From: http://www.aitc.sk.ca/saskschools/firstnations/beliefs.html Geography/Topography Using the Land as a Lifeline Picture of Water First Peoples of Canada Prezi What resources helped them travel? Lifestyle & Culture INSERT CENTRAL IMAGE

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