Transcript: WHat? WHEn a visual assessment Di'Ovion Smith client information Gave verbal consent on 2.17.20 and 4.15.20. Important Dates Date of Birth (of client): 09/18/1998 Date of Examination: 2/17/2020 1:15:35 secs Duration PRESENTING PROBLEM/REASON FOR REPORT Why? More Information Available Here. More information.. Ms. S. Volunteered to do the interview to help the examiner complete their assignment. However,the client did express concerns about having depression symptoms and feelings of being overwhelmed with classes and certain aspects of her life. Family BACKGROUND family Born in St. Paul, MN and raised in Chicago, IL. Adopted by Aunt after mother's death. Their Relationship was less than perfect. Met biological father at 15 y.o. along with that side of family. Credits paternal siblings for "giving purpose" to her life. Counseling background history Previous history of counseling. Cause of counseling for her was feelings of depression and anger problems brought on by upbringing. Sent to facility after family incident. Counseling had a very positive outcome, loves therapist. medical history Ms. S claims to not have any major medical problems. however, she has taken medication for depression and anger. substance use and/or abuse Claims to be "social drinker". Has experienced with marijuana in lifetime. Denies any legal consequences due to alcohol use. Educational background Began in Catholic school then switched to public school once she began middle school. After high school, Ms. S. began her college career at a private institution in Jackson, MS. Her intended degree is in Mass Communications. vocational history vocational history Works at Chicago Park District. Job title is Recreational Leader. Job duties are to watch the kids, assist them when they need help, and basically be a mentor to the children that she works with. She has held that position since she was 14. She began as a member before becoming a leader nd claims to love job. behavioral observations Ms. S. overall behavior did not raise any concerns during the assessment process. she was very open and honest with the examiner. However, Ms. S. did get emotional an begin to cry when discussing a certain aspect of her life. test results results results for the mmse mmse Ms . S scored within the _24-30_ range on global cognitive measures achieving a _29_/30 on the Mini-Mental Status Exam results emotional screening Ms. S was administered a screening test for depression. She scored in the _0-5_ range, endorsing _7_/15 items results personality screening Received the ISFJ personality type. "The Nurturer" ISFJ stands for Introverted, Sensing. Feeling, and Judging. results vocational screening Ms. S score on the RIASEC Test came out with the highest numbers being for the letter R.A.S. R are often good at mechanical jobs. S are people who like to work with other people rather than with things. A type people are those who like to work in unstructured situations where they can use creativity. . An example of a good major for people who score high with S is communications. Coincidentally, Ms. S is currently studying to get her degree in communications. diagnostic impression Minor Depressive Disorder, Mild, Recurrent additional info Summary Ms. S is a 21 years old college student who presented with depressive symptoms and minor signs of anxiety. The results of today’s evaluation reveal Ms. S has mild symptoms indicative of depression summary recommendations recommendations 1) continue to see current counselor and participating in sessions as seen necessary. 2) Consult with a counselor for further evaluation. 3) Re-evaluation is suggested within a year if symptoms worsen. the end
Transcript: Andro: a boy with Autism with Developmental delay Andro was a full-term baby delivered with no complications. He was born on May 18, 2002 via caesarian. At birth he weighed 6.3 lbs which is average for a newborn. His parents reported that as a baby and toddler, he was healthy but his motor development was poor within the normal limits for the milestones of sitting, standing and walking. Also, he is very quiet and he develops difficulties in sleeping and extreme tantrums. His communication development was also delayed. At the age of 1 they noticed that Andro couldn’t say a single word compared to his elder brother who could say “Mama” and “Papa” when he was 1. They thought Andro could be deaf and it appeared that Andro is” in his own little world” and his mother was blaming herself for that because she didn’t even communicate with Andro when he is still a baby. She let Andro have his own little world while she drowns herself in reading pocket books. At the time of his diagnosis, shortly after they thought he is deaf, Andro has no speech and was neither pointing nor gesturing to indicate his needs. His parents would hold things up for him to try and determine what he needed or what’s bothering him. Andro would not imitate actions of people around him nor did he engage in pretend play or play with other children. Play is very aspect of a child’s life that promotes language, social and cognitive skills. Andro responds when the doctor rings the bell that confirmed that he is not deaf. The doctor recommends them to place him in a therapy center. He began intervention right away to address speech, language, socio-emotional and cognitive delay. Andro Ray is a 12 year-old boy who was diagnosed with Autism Spectrum Disorder with developmental delay at the age of 1. He lives with his parents, an older brother and a younger brother. According to parental report, they have relatives with same case as Andro, 4 on father’s side and 2 on mother’s side. His other brothers were normal and no problems growing up. Case Report Andro improved a lot. When you greeted him he would respond to you immediately. He’s now on his 4th grade and his teachers reported that he’s a smart boy and he can easily pick up the lessons but he gets home whenever he likes. He’s now interacting with others. He draws beautifully and he learned how to read. He also learned to use computer and he got addicted to it. He’s communication is slightly poor because his family talks to him like his a 1 year old boy that’s why his speaking skill didn’t improved a lot. He can understand you but he can answer you properly because his chose of words were inappropriate especially in Tagalog. He has a sharp memory: what he reads retain to his head. He also has a mannerism where he will draw something in the air using his fingers. His parents reported that he stops going to his therapists when he starts going to school because they cannot financially support Ando and right now they don’t what level of Autism he is in now. Shortly after the diagnosis, he began participating in physical therapy to address his walking difficulty. It only takes him a moth to be able to walk alone. Together with it, he also participates in occupational therapy to address sensory issue to adaptive skills and decrease tantrums behavior. They also look for a Speech Therapist for him to speak and improve his communication skills. That time they couldn’t find one because the there are few of them here in our country and if there’s one it is fully booked. It takes them a year to find one. His OT requests them to help Andro by daily living skills like doing chores. It takes him 8 years to have a session with his therapist. Those 8 years were and off. At age of 9 he started going to a regular school as request by his OT. Attending to school will help him to improve his social and cognitive skills. Treatment Background Current Status
Transcript: Chief Complaint Basic Information Wang Xuejun Female 49 years old Born in Taojiang, Yi Yang County Right-handed Admitted in 5th, Dec, 2013 Headache for 1 month Alternate ptosis diplopia for 15 days Present History Case report
Transcript: Day 2 Had not used any alternative or complementary medicines DD - Abdominal Pain Extra - abdominal (4) Acute abdomen with ileus cholecystitis Diverticulitis Pancreatitis Acute hepatitis- viral? Alcohol?... Mesenteric event Thank you Lead Poisoning Temperature 37.3 BP 110/68 Weight 81.8, BMI 25.8. Pitting edema of ankles and varicosities Day 4 Pain worsens with eating Intermittent constant Constipation- 2 days Causes of Dysgeusia The following day, 2 days after presentation outpatient clinic His partner did not drink from that set of mugs or use the spoon. Our paitient worked from a home office Incomplete RNA degradation and abnormal ribosomal structure Reflects impaired hemoglobin synthesis or impaired iron incorporation into heme Causes: Sideroblastic anemia (MDS, alcohol-induced sideroblastic anemia…) lead poisoning Arsenic poisoning Some thalassemias TTP DD Source of lead poisoning? What's next ? 59 y Epigastric distress, no weight loss ,no use of NSAIDs Ankle edema Personal stress, difficulty sleeping, dysgeusia and nausea. Anemia , normocytic (Hb-9.9), RDW ALT, AST Examination… Treatment Day 2 Oxycodone and ondansetron were administered. Avoid acetaminophen and alcohol Acute porphyria Generally Inherited Deficiency in enzymes required for heme synthesis. Categorized according to clinical presentation - neurovisceral or cutaneous principal source of overproduction of porphyrins and porphyrin precursors (typically, the bone marrow or the liver) Can be triggered by starvation, drugs or alcohol, smoking, infections, and other forms of stress. Day 3 DD Causes of Bashophilic stippling Because of the inhibition of ALA dehydratase and the overproduction of ALA- patients with lead poisoning present with features that are similar to those of patients with acute porphyria. Indeed, plumboporphyria, a porphyria that is caused by a deficiency of ALA dehydratase, is named for “plumbum” (Latin for “lead”) because symptoms of the condition mimic those of lead poisoning, but plumboporphyria is rare and is generally reported in children. Confirmed by measuring the blood lead level: 10 μg per deciliter or higher is considered elevated in adults The level may be higher than 100 μg per deciliter in patients with acute lead poisoning, which is much less common than chronic lead poisoning Diagnosis of lead poisoning DD Abdominal Pain +Elevated LFT (3) Diagnosis : gastroenteritis, possible peptic-ulcer disease and a bleeding ulcer. Omeprazole and sucralfate Tests for : Blood in the stool Antibodies to Helicobacter pylori in the blood Upper endoscopy - scheduled Follow up in 3 days, or sooner if condition worsened. What's next ? The next day , 5 days after initial presentation outpatient clinic Abdominal pain (“lead colic”), nausea, dysgeusia, constipation, colonic pseudo-obstruction, joint and muscle pain, behavioral and cognitive changes, acute anemia, basophilic stippling, SIADH, and decline in level of phosphorus (renal phosphate wasting) Lead lines- are not a reliable indicator of acute lead poisoning; absent in this patient. Deposition of lead in bones may be seen with long-term exposure, as may hypertension and neuropsychiatric effects Lead poisoning vs. acute porphyria The next day…. Day 2 Diagnosis must explain: Colonic pseudo-obstruction Acute anemia without apparent GI bleeding Acute hyponatremia, m/p SIADH The next day…. At the same night… ER Lead poisoning vs. acute porphyria Drank wine frequently, but from standard wine glasses, not special leaded glasses He used antique Russian cloisonné spoon to stir his coffee each morning for the past year and drank his coffee from an Italian glazed mug . Back to work...:) Upper endoscopic examination : Hiatal hernia Nodularity in the duodenal bulb. Interior designer and stated that he was never in a building during the renovation process, making exposure to lead from paint dust unlikely. Day 4 Chemotherapeutic agents Other drugs, such as albuterol, histamine H1-receptor antagonists, penicillamine, metronidazole, pirbuterol Exposure to pesticides and other toxins, such as lead poisoning Zinc deficiency Calls his doc. Pain in both legs Stool became looser, with out hematochezia or melena. Radiography of the abdomen – dilated colon, with findings suggestive of stool in the right and transverse colon to a transition point in the proximal descending colon. CT of the abdomen and pelvis, after the administration of contrast material- large amount of stool in the cecum and no evidence of obstruction. He was admitted to this hospital. Day 5 Chelation treatment with calcium disodium EDTA for 4 days, followed by treatment with 2,3-dimercaptosuccinic acid (succimer) for an additional 14 days. Abdominal pain, constipation, and mental-status changes all completely resolved within 2 days after the initiation of chelation treatment. After the patient completed the treatment, the liver-enzyme abnormalities and anemia resolved. Lead level has steadily declined but has not yet normalized (?)
Transcript: huddle Mrs. Rossi huddle to crowd together crowd huddle separate
Transcript: Boxes which need to be modified: -Professor/a: Depending on the gender modify it and just add your name. Watch out! There are two boxes!! -Nivell ( level) : Write down the level they are doing. -Participant: You have to write down name and surnames. -Terms: Fill in the correspondent term. It is really easy, you just have to follow certain steps. If you do not follow them, we will send back your student's reports for you to modify them. -There are two main parts: Term evaluation and comments. Every term you will have to fill in with their marks, leaving the previous ones. - Interacció ( interaction): if the participant interacts / participates . There are 4 possibilites: Ok, Good, Very Good or Excellent. -Writings: Pass or Not pass. -There is no average mark! Therefore, participants will see how they are doing in each skill. They are adults. In the comments section is where you have to write down your opinion. Report templates Acadèmia Formate -Reports have to be sent to the language school in advance. We have to check for spelling mistakes, appropiate comments and translation. - Send a whole group in a file. -Every year , we have to modify reports and Ferran and myself have to rush up because teachers do not pay attention. That is why, we will send back anything not been appropiately filled. - Translations have to be done for minors. So, their feedback must be in English and Catalan/ Spanish. -First / advanced students do not have reports! -Write down as well when we are coming back in the comment!!! At the bottom of the sheet, modify: Professor o professora (depending on the gender) and date. -Once we print the reports, you will have to sign them. -Exams have to be handed in in reception as well. Children's template: The format is different. -You grade your pupils according to their abilities and evolution throughout the term.
Transcript: Nobody knows babies like we do! Quality products . Good Customer service. Every Kid really loves this store.. BABYLOU ABOUT US About Us BabyLou was established in 2004. It has been more than a decade since we started, where we have ensured to take care of every need and want of every child and infant under one roof, true to the caption “NO BODY KNOWS BABIES LIKE WE DO”. Our benchmark is to provide 100% customer service and satisfaction and continue to deliver the same with a wide range of toys, garments and Baby Products. Play and Create We Are Best 01 02 03 Block games Building Blocks help Kids to use their brain. PLAY TO LEARN in Crusing Adventures Our Discoveries Enjoy a sunny vacation aboard a luxury yacht with the LEGO® Creator 3in1 31083 Cruising Adventures set. This ship has all the comforts you need, including a well-equipped cabin and a toilet. Sail away to a sunny bay and take the cool water scooter to the beach. Build a sandcastle, enjoy a picnic, go surfing or check out the cute sea creatures before you head back to the yacht for a spot of fishing. Escape into the mountains Disney Little Princes in Also available for your Babies..... Also... Out of The World… Our reponsibility BABYLOU…. Our Responsibility All children have the right to fun, creative and engaging play experiences. Play is essential because when children play, they learn. As a provider of play experiences, we must ensure that our behaviour and actions are responsible towards all children and towards our stakeholders, society and the environment. We are committed to continue earning the trust our stakeholders place in us, and we are always inspired by children to be the best we can be. Innovate for children We aim to inspire children through our unique playful learning experiences and to play an active role in making a global difference on product safety while being dedicated promoters of responsibility towards children.
Transcript: 11/29 hospital-acquired intraabdominal infections 患者SPUTUM細菌培養結果為Staphylococcus aureus (ORSA) (+)，考量有可能是插管的汙染，但近日患者出現發燒的情形，且肺部浸潤狀況變嚴重，若非插管汙染，ORSA的治療建議加上Vancomycin 較缺乏效力 Thank you! amphotericinB ~peritonitis~ Assessment peritonitis PUS/WOUND PMN:>25/LPF Ep. cell:10-25/LPF G(+) Cocci:(+) G(+) Bacilli:(+) G(-) Bacilli:(+) 11/20.22 Candida glabrata 要注意患者的心臟狀況、 血鉀、血鎂是否太低 Doripenem500mgIVQ8H Google Search(illustration) Candida grabrata additional considerations recommended empiric IV antibiotics for ADULTS with mild-to- moderate community-acquired complicated intra-abdominal infection secondary peritonitis ~Follow up~ 第一線: 冊 WHOLE BLOOD Imipenem500mgIVQ6H±Vancomycin1.5gmIV Q12H Objective 第二線 原發性腹膜炎 第一線: Tapimycin ~peritonitis~ 患者為69歲男性，今天早上抱怨腹痛更嚴重。他被送往急診尋求協助，檢查發現腹部有壓痛與反彈疼痛的現象。 腹部和骨盆CT檢查顯示: 1.腹腔有氣體→疑似穿孔性消化潰瘍 2.腹水與輕度脂肪肝 3.一個左腎囊腫 4.動脈粥樣硬化 5.左髖關節有半髖關節成形術 6.脊椎退化 7.肛門周圍有積液→疑似膿瘍 ceftriaxone 2gmIVq24h No growth of aerobic and anaerobic pathogens in 7 days. No growth of anaerobic microorganism. Medications 12/7 quinolones should not be used unless hospital surveys indicate > 90% susceptibility of E. coli to quinolones aminoglycosides not routinely recommended CASE 腹水細菌培養檢查: lung abscess 11/19 Candida grabrata Candida krusei 理學檢查: 腹部硬且膨脹、壓痛、 反彈疼痛、腹水 11/21 enterococci Anaerobes-Bacteroides fragilis CXR peritonitis hospital-acquire pneumonia 11/29 No growth of aerobic and anaerobic pathogens in 7 days. 臨床使用抗生素手冊 amoxicillin-clavulanate oxfloxacin 400mg orally twice daily 11/19 根據DynaMed較嚴重的繼發性腹膜炎可使用 常見致病菌: 臨床使用抗生素手冊 recommended empiric IV antibiotics for ADULTS with community-acquired complicated intra-abdominal infection and high severity or high risk due to severe physiologic disturbance, advanced age, or immunocompromised state 繼續注意患者發燒狀況、CXR肺炎浸潤情形是否改善 並留意患者腎功能狀況，調整藥物頻次 肺炎:考慮是否為ORSA，加上Vancomycin DynaMed 早上開始有瀰漫性腹痛 為甚麼為甚麼要把 腹腔內臟器的炎症、穿孔、外傷、或醫源性創傷等所引致的腹膜急性化膿性炎症 最可能的致病菌: Escherichia coli Klebsiella pneumoniae Streptococcus pneumoniae Viridans streptococci Ceftazidime2gmIVQ8H Plan 第一線: Cefuroxime1.5gmIV Q8H+Metronidazole1gm IV Q12H peritonitis SOAP 腎功能不全: conclusion metronidazole 500 mg every 8-12 hours or 1,500 mg every 24 hours + ciprofloxacin 400 mg every 12 hours problem 第二線: 11/28 Ciproxin 400mg IVD q12h+ Tapimycin 4.5gm q6h IVD 第一線經驗性療法: Moderate sputum noted third-generation cephalosporins echinocandins PMN:10-25/LPF Ep. cell:<10/LPF G(-) Cocci:(+) G(-) Bacilli:(+) 3rd generation cephalosporin cefotaxime ≥ 2 g IV every 8 hours preferred agent 11/28 腎功能正常: 有心臟毒性，可能導致 Tigecycline100mgIVQ12H+ Fever(since11/29) Tapimycin Case Report Dose Adjustments Subjective Prolonged QT interval & Torsades de pointes Antibiotic Meropenem1gmIVQ8H 第三線 Objective Candida spp. Cefotaxime Ofloxacin: Amoxicillin/Clavulanate potassium 換成 pneumonia SOAP 腹膜炎是腹腔壁層腹膜和 臟層腹膜的炎症， 可由細菌、化學、物理損傷等引起。 根據 Tapimycin 11/28 手術介入 69歲男性 pneumonia Ciproxin 400mg ivd q12h +SABS 500mg ivd q6h 繼發性腹膜炎 PLAN Piperacillin-tazobactam3.375gmIVQ8H Suspected or known spontaneous bacterial peritonitis 患者腎功能狀況不佳，因此要密切監控腎功能狀況 若CrCl<30 ciprofloxacin建議調整為Q24H Tapimycin建議調整為Q8H 若CrCl<20 Tapimycin建議調整為Q12H 第二線: 判斷可能為腹膜炎 外科治療 Micromedex 第一線 viridan streptococci COPD with secondary infection Diffuse abdominal pain 繼續觀察患者發燒情形: 病程進展 但患者敏感性試驗Ciprofloxacin的結果為R，因此要觀察患者情形是否改善，如果沒有改善可以考慮其他治療選擇如 Carbapenem類抗生素 腹水PMN> 250 cells/mL No growth of anaerobic microorganism. 經驗性療法 由於患者手術後腹部感染情形得到控制，且Tapimycin除了可治療腹膜炎外，也可治療患者肺炎的部分 Assessment 11/19 Diflucan 400 mg IVD QD 經驗性抗生素 Fluconazole: Candida albicans, Candida tropicalis,Candida parapsilosis fluconazole Ceftriaxone 2gmIV Q24H+Metronidazole1gm IV Q12H Nofloxacin Ofloxacin Ceftriaxone 11/19 Ciprofloxacin 繼發性腹膜炎 Secondary peritonitis 替代療法: Candida glabrata Ciproxin 400mg IVD q12h+ Tapimycin 4.5gm q6h IVD SBP V.S secondary peritonitis spontaneous bacterial peritonitis (SBP) Subjective GRAMSTAIN PMN:>25/LPF Ep. cell:<10/LPF echinocandins COMMON AEROBIC CULTURE Rare of normal flora isolated. Reference quinolones should not be used unless hospital surveys indicate > 90% susceptibility of Escherichia coli to quinolones 現病史HPI Candida glabrata:(++) 過去病史PMH Communiy-acquired pneumonia 沒有腸胃道或臟器破裂、膿瘍或局部感染存在 的情況下，產生了腹膜或腹膜液的感染。 肝膽腸胃系統:酒精性肝炎、胃潰瘍、胃食道逆流、 膽結石 內分泌系統:Type 2 糖尿病，藥物控制5年以上 住院史: 肛門廔管合併膿腫→住院9次 伴有咳血的支氣管肺炎→住院1次 胃潰瘍、胃食道逆流、痛風性關節炎、菌血症、酒精性肝炎、糖尿病→住院1次 疝氣→住院1次 Problem List 腹膜感染: 考慮更換ciprofloxacin成Carbapenem類抗生素 Imipenem500mgIVQ6H SPUTUM 新感染 胸腹部CT顯示: 腹腔有氣體→疑似穿孔性消化潰瘍 按發病機制可分為 原發性腹膜炎spontaneous bacterial peritonitis candidemia Cefepime2gmIVQ8H+Metronidazole1gmIVQ12H 11/20.21.23 ~pneumonia~ Ciproxin 400mg IVD q12h +SABS 500mg IVD q6h Outline OR problem list patient background Hsiang-Chi,Huang Doripenem500mgIVQ8H±Vancomycin1.5gmIV Q12H piperacillin-tazobactam 3.375 g every 6 hours Problem 11/21 conclusion PMN:<10/LPF Ep. cell:<10/LPF Ciprofloxacin secondary peritonitis Short-term prophylaxis against spontaneous bacterial peritonitis in patients with cirrhosis, with or without ascites, and gastrointestinal hemorrhage Aspiration pneumonia E.coli 繼發性腹膜炎 ER
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