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Transcript: CHMC FAMILY MEDICINE MORTALITY AND MORBIDITY EVIDENCE BASED MEDICINE EBM DISCUSSION DISCUSSION TO UNDERSTAND THE EFFECTS OF HYPERGLYCEMIA ON THE FETUS, IT SHOULD BE REMEMBERED THAT GLUCOSE CROSSES THE PLACENTA FREELY BUT MATERNAL INSULIN DOES NOT, THUS, MATERNAL HYPERGLYCEMIA IMPORTANT FACTS IMPORTANT FACTS EFFECTS OF HYPERGLYCEMIA ON THE FETUS GLUCOSE CROSSES THE PLACENTA FREELY BUT MATERNAL INSULIN DOES NOT PREGNANCY STATE OF INSULIN RESISTANCE IMPT BEC EACH DIAGNOSIS IMPARTS DIFFERENT CLINICAL SIGNIFICANCE DIFFERENCE OF PREGESTATIONAL AND GESTATIONAL DM DIFFERENCE OF PREGESTATIONAL AND GESTATION... CLINICAL COURSE CLINICAL COURSE AT THE ER > VS every four hours > Diet small but frequent feedings > Labs Serum K: 4.03 > IVF PNSS 1L, fast drip 200 cc then regulate to 6 hours > IVF to ff: PNSS 1l x 8 S> 9 hospital days Persistent vomiting HOSPITAL STAY HOSPITAL STAY S > vomiting of more than 10 episodes (+) vaginal spotting this morning O> VITAL SIGNS : BP 120-130/70-80, PR 102-112, RR 21-26, T 36.5- 37.2, O2 SAT 99% FIRST HOSPITAL DAY FIRST HOSPITAL DAY LABORATORY LABORATORY hyponatremia hyponatremia IVF : PNSS 1l x 8 hours Medications: Nacl one tab 3x a day Duvadilan 1 tab 3x a day THERAPUETICS THERAPUETICS S> persistence of vomiting more than 10 episodes O)> BP 100-110/60-70 PR 90-104 RR 20-21 T 36.6 2ND HOSPITAL DAY 2ND HOSPITAL DAY No New Diagnostics No New Diagnostics CONTINUE MEDICATIONS CONTINUE MEDICATIONS 3RD HOSPITAL DAY 3RD HOSPITAL DAY S> persistence of vomiting more than 10 episodes O)> BP 110/80 PR 105 RR 20 T 36.6 No new laboratory work ups done No new laboratory work ups done IVF PNSS 1L x 8 Maintain on CBR without bathroom privilege Therapuetics Therapuetics 10:00 am S> Vomiting of 4 episodes with no vaginal spotting, able to tolerate the food O> BP 100/60 PR 118 RR 20 T 36.0 MGH ORDERS THM: Vitamin B complex OD FOLLOW UP AFTER ONE WEEK 4th HOSPITAL DAY 4th HOSPITAL DAY S> patient complained of chest pain, palpitation, DOB one hour after patient had vomiting O> BP 110/70 rr 30s cr 140s O2 sat 99-100 (+) tachycardia 6:00 PM 6:00 PM DIAGNOSTICS DIAGNOSTICS IVF: PNSS 1L x 8 Oxygen inhalation via nasal cannula 2-3 lpm Moderate back rest Monitor Vital signs hourly un til stable THERAPUETICS THERAPUETICS S> still with shortness of breath O> awake, coherent dry skin, cold clammy extremeties BP 100/60 PR 1 RR 31 T 36.5 O2 sat 99 8:20 PM 8:20 PM Diagnostics Diagnostics REGULAR INSULIN 5 units UIV Refer to diabetologist and secure Consent Therapeutics Therapeutics S> STILL DYSPNEIC O> BP 90/7- CR 138 9:00 PM 9:00 PM DIAGNOSTICS DIAGNOSTICS IVF PNSS 1l x 125 cc/hr Regular insulin 5 units SC now Lanoxin 0. 25 IV now Repeat ABG after 6 hours Therapuetics Therapuetics O> awake, acidotic breathing ph 6.9, PCO2 8.6, PO2 148 HCO32.0 10:00 PM 10:00 PM CBG stat- 378 then CBG monitoring q2 Diagnostics Diagnostics NPO temporarily Monitor urine output hourly NaHCO3 50 meq SIV 1st dose then after 15 mins NaHCO3 50 meqs Incorporate 100 meq HCO3 to present IVF x 12 Therapeutics Therapeutics s> O> 11:59 PM 11:59 PM CBG- now and increase CBG monitoring to hourly HBA1c- now Diagnostics Diagnostics Another NaHCO3 50 meqs SIV was given Apidra drip started 100 units Apidra + 100 cc of PNSS to run at 10 units/hour Therapuetics Therapuetics 5TH HOSPITAL STAY 5TH HOSPITAL STAY S> decrease SOB by 50 % as aclaimed O> BP 110/70 CR 140a RR 30 Input and Output (-) 634 Urine ketone and urinalysis monitoring Repeat ABG, Na, K, BUN, Crea Diagnostics Diagnostics Repeat ABG Repeat ABG > Sliding scale Apidra >Anothere dose Lanoxin 0.25IV >NaHCO3 drip decrease to 60 cc/hr then dc > Amsulvex 750 mg IV q8 as drip (8am)OB then was shifted to Ceftriaxone 1 gram IV q8 (11:50 am) ENDO > Digoxin 0.25 half amp now then 1 tab OD PO > Dulcolax 2 supp per rectum Therapuetics Therapuetics Transfer to private room > revise DIet to 18- cal diabetic diet 3 meals/ 3 snacks, no salt restriction, increase oral fluid intake Transfer to private room > revise DIet to 18- c... 40 meqs KCL incorporated to present IVF to run the same rate, if tolerated, may titrate and start KCL drip 90 ml D5NSS + 20 meqs KCL run for 5 hours x 2 cycles, repeat Na, K after 2nd cycle 40 meqs KCL incorporated to present IVF to run t... S> Persistent episode of vomiting more than 10 O> CR 119 BP 100/70 6th HOSPITAL STAY 6th HOSPITAL STAY urine ketone monitoring Diagnostics Diagnostics hyponatremia and hypokalemia hyponatremia and hypokalemia ICeftriaxone was increased to 2 gram IV OD Apidra drip was maintained 1 cc/hr KCL drip was discontinued, KCL tab one tab PO TID stated Therapuetics Therapuetics S> decrease episod of vomiting to one episode, with vaginal spotting O> CR 120 min 7th Hospital Day 7th Hospital Day CBG monitoring every six hours CBG monitoring every six hours IV Ceftriaxone was shfted to Tergecef 200 mg one cap twice a day Maintain on CBR Polynerve one tab OD PO Another KCL drip (PNSS 90 ml+ 20 meqsKCL) x 5 for 2 cycles but dc, Mixtard 20 units/16 units SQ pre meals

Morbidity and Mortality

Transcript: Guidewire is then withdrawn The trocar is withdrawn. What happened next? 8/8 Started on azithromycin, DuoNebs every 6 hours Solu-Medrol 40 mg every 12 hours, supp O2 as needed NW is a 68 yo female Medical Hx: COPD, GERD, HTN Family Hx: DM and HF in mother Surgical Hx: Tubal ligation (1984) Social Hx: Married, lives at home with husband who takes care of her medications. Tobacco: Former smoker 1 ppd for 50 years, quit in 2005 Allergies: none Medications: Xanax, Paxil, zocor Daliresp (PDE4), Tudorza (LAMA), Pulmicort (steroid), Brovana (LABA), Albuterol (SABA) 8/19 - Nurse Navigator phone encounter Reports that patient will NOT use NIV. Informed that Apria has ordered Nasal Aire NIV appliance that is more like a nasal cannula than a mask which is being shipped directly to patient's home Prior Hospitalizations 4/13/15 - COPD 7/6/15 - COPD 4/22/16 - GI BLEED 5/9/16 - COPD 7/10/16 - COPD Transfer After central line and intubation in ED Pt was transferred to the ICU ABG 8/21 showed acidosis pH 7.22, pCO2 79.5, pO2 302, HCO3 32. Levophed through CVC Titrate per target MAP>65 The Seldinger technique - Sven Ivar Seldinger, was a radiologist from Mora Municipality, Sweden. In 1953, he introduced the Seldinger technique to obtain safe access to blood vessels and other hollow organs. Attempted extubation on 8/26 and reintubated for respiratory distress several hours later despite BIPAP On and off bipap for days Finally extubated on 8/30, placed on bipap A "sheath" or blunt cannula can now be passed over the guidewire into the cavity or vessel. Line was then sutured and dressing applied. It was noted that blood returned from white port, all 3 flush easily. Pressures remained hypotensive during this integral period Pulmonology appointment on 7/20/16 Noted to have advanced COPD and recent admissions for chronic Hypoxemic respiratory failure due to COPD Baseline FEV1 around 26% of predicted. Uses four liter/min oxygen all the time. Patient uses Tudorza , and takes Albuterol as necessary.Patient also uses Advair one inhalation twice a day. Today, she thinks her breathing is back to baseline. Plan Discussed importance of compliance. Continue Tudorza, Pulmicort, Brovana inhalations twice daily Albuterol inhaler six times daily Daliresp once daily Having been in use for a few hours, the patient had received ativan and approx 200cc of Levophed directly into the mediastinum Had some new HF, frequent multifocal PVC's and at one point went to A-FIB for short period of time then went back to SR on her own. Was followed by cardiology 8/11 through 8/17 MSSA growing on sputum cx Remained weak while working with PT Waxing and waning respiratory course Pt continued to refuse BIPAP at night 8/18 - Discharged home w/ home health Prednisone 40 qam x 7 days Pulmicort, Brovana, Turdorza daily Continue round the clock O2 A round-tipped guidewire is then advanced through the lumen of the trocar. A sheath can be used to introduce catheters or other devices to perform endoluminal procedures A case presentation by Mark Haggerty, DO PGY3 Portsmouth Family Medicine The desired vessel or cavity is punctured with a sharp hollow needle called a trocar, with ultrasound guidance if necessary. CT surgery reviewed the images and recommended that it was safe to pull the line Potential areas of improvement and remaining questions Barriers to care Financial - high co-pay on inhalers Unable to tolerate NIV therapy Unwilling to address advanced directives Apparent low motivation, discouraged. Let's get some more background on our patient NW SBT failed on 8/23, 8/24, 8/25 Agitated, pulled out OGT Diarrhea required fecal management system Radiologist talked to ICU regarding CT finding of misplaced CVL Post insertion: All the lumens of the line are aspirated (to ensure that they are all positioned inside the vein) and flushed with either saline or heparin. A chest X-ray may be performed afterwards to confirm that the line is positioned inside the superior vena cava and no pneumothorax was caused inadvertently. Electromagnetic tracking can be used to verify tip placement and provide guidance during insertion, obviating the need for the X-ray afterwards. Sunny day Per pallitaive who had been following; Patient verbalized wanting to shift gears from aggressive measures and focus on comfort. Patient was aware of risk that should she eat by mouth, that it may hasten her death, yet she opted to eat. Comfort care measures initiated by Palliative 9/2 - on prn ativan, fentanyl, robinul, morphine for comfort NW passed away on 9/8/2016 It was noted by nursing that no blood could be aspirated from the ports, and that when the CT finding was noted, the levophed was stopped and no change in blood pressure resulted ED 8/21 Per Medic: alert initially, given solumedrol 125 mg IV, duoneb. Enroute to hospital, patient became more unresponsive, on CPAP Per Husband: She has been SOB since being discharged on 8/18. Per ED nurse: Grayish discoloration of the skin, agonal breathing

Mortality and Morbidity

Transcript: What is MELD? T 98.2, HR 70-80, BP 120/70, RR 20, SaO2 low 80s HFNC 85% 50 L General: A+Ox3, comfortable PEERLA: EOMI, PEERLA CV: systolic murmur, JVD to the angle of the jaw Resp: bibasilar crackles Abd: soft NT ND no organomegaly 11/09: O2 sat dropped to 70-75%, recovered with increased PEEP. He continues on Flolan. IR => risks outweigh the benefits. 11/10: continuing diuresis. 11/11: O2 desat to 60s, failed recruitment maneuvre, started bagging him briefly, ETT chanmged for cuff leak. BP dropped after increased sedation and paralysis => PEA arrest 11/12: worsenign renal failure => CVVHD started, Worsening pressor requirement, and lactic acidosis o/n 11/13: made CMO, and passed away BW 1/03:Improved O2 saturations. MSSA in sputum at OSH, ID recs stop vanco/zosyn, start cefazolin. 1/04: Cards consult: Later worsening MS, and O2sat => intubated January 2016 Hala El Chami PGY 5 Gin et al., Am Heart Journal,1993 Autopsy Results NS 79 yo M, h/o Cor triatriatum, 4 V CABG, HFpEF who is transferred from OSH on 01/02 for worsening hypoxia. Admission at OSH from ID clinic with fever, cough, and weight loss on 12/30. Initially, saturation was 95%, he was given IV fluids and broad spectrum antibiotics. He then developed severe hypoxia after volume resuscitation with saturation in the 60s. Valid and reliable for risk stratification and survival projection after emergent TIPS Clinical Course Stable RR, O2 sat, looked ok, no need for emergent intubation. However, 3 "occasions" to intubate 1. CT 2. VT 3. increased WOB. Clinical course Effectiveness of TIPS in treating portal hypertension. Found that MELD score was an independent predictor of post-TIPS mortality. 68 year old man with hx CHF s/p ICD, ESRD on HD, Afib on Coumadin, CAD s/p recent LAD stent, COPD on 2L home O2, transferred from OSH for seizure, found to be septic ( infected HD cath vs. pna. Labs GD 68 LM 67 DP 63 DA 56 YK 82 SK 47 NS79 JJ 58 WB 68 Exam significant for labored breathing,accessory muscle use. Noticed to not move his right arm =>neuro consult for possible LMCA stroke Overnight, tried scoop mask, high flow, NRB, then BiPAP = Clinical Course JJ 58 yo M, h/o cirrhosis 2/2 HCV, HBV, esophageal and gastric varices, HIV, Parkinson's disease, bipolar disorder and dementia who initially presented to OSH with pancreatitis, complicated with massive hematemesis requiring large volume transfusion (reported 10u PRBC, 8u FFP, 12u platelets). An EGD at the OSH, showed both esophageal and gastric varices with a large amount of blood making visualization difficult and no overt bleeding source was identified. A Blackmore was placed, and he was sent to TMC for evaluation of TIPS procedure. Upon arrival, started on pressors. 11/05: inhaled flolan for worsneing hypoxia with some improvement, increased pressor requiirements => broad abx started 11/06: RHC revealed no step up. Oxygenation continuing to improve, plan to d/c flolan 11/07: Episode of desat, increased sedation and PEEP. Increased pressor requirements=>abx boradenet. TEE attempted but stopped due to UA bleeding. 11/08: TEE Negative for intracardiac shunt but possible intrapulmonary shunts, continued Flolan and diuresis. Discussion with family about further evaluation with angiography for possible embolization. prospectively developed and validated chronic liver disease severity scoring system that uses lab values (T-Bili, crea, INR) to predict three-month survival. Given its accuracy in predicting short-term survival among patients with cirrhosis, MELD was adopted by the United Network for Organ Sharing in 2002 for prioritization of patients awaiting transplantation. Mortality and Morbidity Physical Exam

Mortality and Morbidity

Transcript: Suicide Mental Health Mortality & Morbidity Evidence has consistently shown that patients with mental illness have greater physical health morbidity and mortality compared to the general population. Many factors have been implicated and include a generally unhealthy lifestyle, side effects of medication, and inadequate physical healthcare. Introduction Diabetes Patients suffering from depression are twice as likely to develop type 2 diabetes mellitus, and the prevalence of stroke and myocardial infarction is three- and five-fold respectively higher than people without depression. Diabetes Mellitus Type 2 There is a significant higher prevalence of cigarette smoking in those with mental illness. 56-88% of those with a mental disorder smoke cigarettes. The overall U.S. prevalence is only 25%. 44% of all cigarettes in US are smoked by persons with mental illness Smoking Respiratory Disease The rate of suicides in those with mental illness is stagering; 1,365 people in 2014. Men had a suicide rate four times greater than that of women. The suicide rates among adults were similar across age groups, although the highest rates were among those age 45 to 64. American Indian and Alaska Native youth and middle-aged persons have the highest rate of suicide, followed by non-Hispanic White middle-aged and older adult males. African Americans have the lowest suicide rate, while Hispanics have the second lowest rate. Suicide Those with mental disorders have a significant higher chance of developing eating disorders. Eating disorders are associated with a high mortality because of the physical disorders caused by anorexia/bulimia nervosa affecting other organ systems. Eating Disorders Eating Disorders Cardiovascular disease is yet another risk factor for those with poor mental health. Out of the 88,241 Medicare patients that were hospitalized for MI, their mortality increased by 19% with any mental disorder and 34% with schizophrenia. Psychotropic medication is associated with impaired glucose tolerance and diabetes, metabolic syndrome, dyslipidemia, cardiovascular complications, extrapyramidal side effects and sexual dysfunction. Cardiovascular Disease Cardiovacular Disease To make matters worse, those with mental illness are less likely to be screened or treated for dyslipidemia, hyperglycemia, and hypertension. They are less likely to receive an angioplasty or CABG or to receive drug therapies of proven benefit (thrombolytics, aspirin, beta-blockers, ACE inhibitors) post myocardial infarction. Even Bigger Problems Prpoper Health Care There is a great need for a more active role of healthcare providers to not only treat those with mental illness equaily but to treat the whole person and not just the mind. Information. (2019). Retrieved from https:// Physical morbidity and mortality in people with mental illness. (2014). Retrieved from Suicide in America: Frequently Asked Questions. (2019). Retrieved from References References

Morbidity and Mortality

Transcript: Decadron 40 mg daily Ergocalciferol 50,000 units weekly Norco 10/325 Q6H PRN Synthroid 75 mcg Disposition 9/14 - 9/22/2016: Patient admitted for grade 3 diarrhea. 9/17/2016: Colonoscopy - The entire colon had severe pan colitis. Tissue was ulcerated and friable. Biopsies were taken - mild architectural distortion with expansion of the lamina propria due to inflammation with minimal crypt distortion. There is diffuse lymphoplasmacytic inflammation admixed with neutrophils and eosinophils. Scattered cryptitis and crypt abscesses are present. The differential diagnosis includes drug reaction (immunotherapy), inflammatory bowel disease, and infectious colitis, correlate clinically. 9/19/2016: Started on hydrocortisone > tapering doses of prednisone. Since no improvement with prednisone, patient restarted on tapering doses of decadron ACGME Core Competencies Allergies Thoughts / Orders? Hospital presentation "lactic acid improved with IVF" Patient continues to complain of weakness and decreased appetite. Now he starts to complain of abdominal pain for the first time. Abdominal perforation highly suspected. Patient refused surgical options. He enrolled into hospice and passed away on day #3. Blood cultures grew 2/2 e coli Here are some extra assets : Surgical Assessment & Plan Father - cancer Mother - heart disease Sister - cancer OT: requires max assist for dressing/bathing/toileting SETUP for grooming and eating and MOD assist for transfers with RW. Pt demonstrated 3/5 for RUE strength and 2+/5 for L shoulder strength. Strong grasps bilaterally. Pt required max assist for supine<>sit and mod assist for sit<>stand. Constitutional: He is oriented x4. He appears malnourished and cachectic. No distress. Head: Normocephalic and atraumatic. Right Ear: External ear normal. Left Ear: External ear normal. Nose: Nose normal. Mouth/Throat: Oropharynx is clear and moist. No oropharyngeal exudate. Eyes: Conjunctivae are normal. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus. Neck: Neck supple. No JVD present. No thyromegaly present. Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no gallop and no friction rub. No murmur heard. Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. He has no wheezes. He has no rales. He exhibits no tenderness. Abdominal: Soft. Bowel sounds are normal. He exhibits no distension and no mass. There is no tenderness. There is no rebound and no guarding. Musculoskeletal: He exhibits no edema or tenderness. Lymphadenopathy: He has no cervical adenopathy. Neurological: He is alert and oriented to person, place, and time. He is not disoriented. He displays weakness. He displays no atrophy and no tremor. No cranial nerve deficit or sensory deficit. He exhibits normal muscle tone. Coordination normal. 3/5 proximal LE strength bil 4/5 distal extensor and flexor strength bilaterally. Skin: Skin is warm and dry. No rash noted. He is not diaphoretic. No erythema. No pallor. Psychiatric: Mood, memory, affect and judgment normal. ROS Exam none Nursing documentation: pt assisted to bedside commode for BM; only dark blood noted in commode with 4 quarter sized clots. Amber urine noted as well. Patient assisted back to bed. DR notified. VSS. HGB stable. GI consulted for GI bleed PET SCAN Past history Medical Obs day #1 FEEL FREE TO COPY & PASTE THEM! Jeff Valice PGY-3 12/19/2016 former PPD smoker x 12 years, quit 1980 denies alcohol denies illicit drugs Additional information PT: mod assist for bed mobility, transfer and gait training. Family CABG in 2003 Tonsillectomy 2007 with chemo, radiation and PEG Medications Mild asymmetric focal uptake is seen in the lateral aspect of the right globe with maximum SUV of 6.4. There are numerous small and large hypodense lesions seen throughout the liver with intense uptake. Maximum SUV in right hepatic lobe measures 15.1. Maximum SUV in caudate lobe lesion measures 14.5. Review of skeletal structures demonstrates lytic lesions in the left iliac crest with maximum SUV of 23.7 as well as in the left acetabulum with maximum SUV of 42. BP 113/52 HR82 T 36.6 RR 20, 97% RA, BMI 20 Went for routine eye exam 4 months prior, sent to retinal specialist who diagnosed him with choroid malignant melanoma. Constitutional: Positive for malaise/fatigue and weight loss. Negative for chills, diaphoresis and fever. HENT: Negative for congestion and sore throat. Eyes: Negative for blurred vision and double vision. Respiratory: Negative for cough, shortness of breath and wheezing. Cardiovascular: Positive for leg swelling. Negative for chest pain, palpitations, orthopnea, claudication and PND. Gastrointestinal: Negative for abdominal pain, blood in stool, constipation, diarrhea, heartburn, melena, nausea and vomiting. Genitourinary: Positive for hematuria. Negative for dysuria and urgency. Musculoskeletal: Negative for back pain, joint pain, myalgias and neck pain. Skin:

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