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Morning Presentation

Transcript: 295-04-28 55 year old female presents with a four month history of dysphagia History and Physical History of presenting illness History of presenting illness In her usual state of health until January 2017 when she noticed occasional difficulty swallowing her PPI tablets In her usual state of health until January 2017 when she noticed occasional difficul... Gradually developed dysphagia for solids, such as rice, roti and meat Gradually developed dysphagia for solids, such as rice, roti and meat Initially able to maintain her appetite, and did not lose any weight. Did take longer to chew and swallow meals. Initially able to maintain her appetite, and did not lose any weight. Did take long... Dysphagia progressed to liquids approximately 3 months later, and she started complaining of difficulty drinking tea Dysphagia progressed to liquids approximately 3 months later, and she started complaining ... During this time, she reported: bloating; belching; odynophagia, rarely During this time, she reported: bloating; belchi... Denied any: vomiting or regurgitation; vocal changes or hoarseness; dry or productive cough; chest pain; or dyspnea Denied any: vomiting or regurgitation; vocal changes ... Had a 15 year history of intermittent GERD, requiring PPI use. Complained of generalized myalgias of late Negative for: Fever Diarrhea Constipation Melena Hematochezia Hematemesis Urinary habitus changes Review of Systems Review of Systems S/P Total Abdominal Hysterectomy - 2004 No other hospitalizations or history of transfusions DM - 5 years - managed conservatively Past Medical and Surgical History Past Medical and Surgical History Brother recently diagnosed with lung cancer Family history negative for cancer prior to this No history of DM, HTN or CHD Family History Family History Resident of Sanghar Married, with four children Lives with her son who is a cardiologist No addictions Passive smoking - husband had a 20 pack year history of smoking Personal History Personal History Middle aged, overweight lady lying comfortably in bed General Physical: Unremarkable except for enlarged thyroid, visibly and on palpation. No proptosis or tremors. Chest: CTAB Cardiovascular: S1 + S2 + 0 Abdomen: Previous surgical scar visible. Soft, non tender, no organomegaly or shifting dullness. Bowel sounds positive. Physical Examination Physical Examination Differential Diagnoses and Investigations DDx and Investigations Differentials? Differentials? 1. Esophageal Carcinoma 2. Benign esophageal neoplasm 3. Chronic GERD 4. Achalasia 5. Diffuse esophageal spasm 6. Esophageal strictures 1. Esophageal Carcinoma 2. Benign esophage... EGD: Fungating growth seen at 25-28 cms from incisors, biopsy taken Biopsy: Moderately differentiating squamous cell carcinoma CT Chest with contrast: Enhancing mural thickening involving mid dorsal esophagus. Measures 6cm in length, 1.3 cm in mural thickness, from D5-7 vertebra. Distal esophagus also shows smooth mural thickening measuring 6cm extending along GE Junction. Few prominent lymph nodes. Investigations Investigations Advised preoperative neoadjuvant chemoradiotherapy Underwent 5 cycles of chemotherapy with Carboplatin and Taxol, as well as 25 sessions of radiotherapy Returned after 6 weeks of both with PET CT, which showed no evidence of skeletal, pulmonary or hepatic metastasis Admitted for a two stage esophagectomy Further management and disease course Further management and disease course Esophageal Carcinomas Esophageal Carcinomas Two main types: Adenocarcinoma most commonly at the GE junction SCC in most of the esophagus Most common histology worldwide is SCC Most common in sixth decade of life, with men predominating Basics Basics Tobacco Alcohol GE Reflux Barrett's Esophagus Radiation Risk Factors Risk Factors CROSS Trial The role of neoadjuvant chemoradiotherapy in the treatment of patients with esophageal or esophagogastric-junction cancer is not well established. We compared chemoradiotherapy followed by surgery with surgery alone in this patient population. Background Background We randomly assigned patients with resectable tumors to receive surgery alone or weekly administration of carboplatin and paclitaxel for 5 weeks and concurrent radiotherapy (in 23 fractions, 5 days per week), followed by surgery. Methods Methods Complete resection with no tumor within 1 mm of the resection margins (R0) was achieved in 92% of patients in the chemoradiotherapy–surgery group versus 69% in the surgery group (P<0.001). Postoperative complications were similar in the two treatment groups, and in-hospital mortality was 4% in both. Median overall survival was 49.4 months in the chemoradiotherapy– surgery group versus 24.0 months in the surgery group. Overall survival was significantly better in the chemoradiotherapy–surgery group (95% confidence interval, 0.495 to 0.871; P=0.003). Results Results Post-operatively Post Operative Remained vitally stable and did not develop any fever or arrhythmias. Had occasional

Rounds Presentation

Transcript: Team - SLP, OT, TA 4-5 sessions/client Ax 2-3 Tx sessions with TA Follow up/Prescription Waitlist management 12 clients Phone History prior to Ax Plan: 3 Goals “The goal is to connect these children and youth to the services they need as early as possible and improve the service experience of families in three key areas: 1. Identifying kids earlier and getting them the right help sooner Trained providers ...will screen for potential risks to the child’s development as early as possible. 2. Coordinating service planning New service planning coordinators ... will connect families to the right services and supports. 3. Making supports and service delivery seamless Integrating the delivery of rehabilitation services...Services will be easier to access and seamless from birth through the school years.” ( Barriers and Reflections Barriers Identifying and Meeting Our Client Needs 1. Increasing awareness amongst first responder community.  2. Offering resources and training , e.g., CDAC for frontline workers, and possibly sharing information via catchment agencies’ web sites.  3. Review role of signifier/arm band (with or without CAN symbol). The client and family may make use of aid (if their preference) in order to help first responder. 1. Kingston ACS Screening Clinic Screening Assessment Existing Screening Measures 2. Early AAC Intervention. Triaging select clients on waitlist. Prospective clients may not benefit from high tech intervention. Offered recommendations and treatment. Placement on wait list removed or adjusted accordingly. Minimizing/mitigating service gaps, i.e., more seamless service.  9 clients seen across 3 clinics: Language Express (PSL Smiths Falls); Pathways for Children & Youth (IBI); and Early Expressions (PSL Kingston)  5/9 referrals, i.e., 4 potentially inappropriate referrals not received. *Community providers rated quality of service and benefit of recommendations 5/5. Satisfaction and meeting clients' needs 4/5. Liked specific activity examples and strategies most. Results Preliminary Planning Stage Tyler Levee, M.Cl.Sc, S-LP (C), Reg.CASLPO Problem 6/12 clients seen Purpose and rationale  Community partners promote use of high tech systems for face-to-face communication. Sometimes inappropriate suggestions for system and/or implementation made. Opportunity to offer recommendations, suggest system or resource. Occasionally inappropriate referrals received, e.g., a client has functional speech or he/she is preintentional or not a symbol user. Meeting needs across large catchment and narrows/shortens wait list. 3. Identification of Communication Needs to First Responders Jessica Whynot, RECE,CDA, Therapy Assistant Long waitlist Complex cases Not necessarily appropriate for high tech Proposed initiatives to meet these needs: Concerns, Barriers, and Benefits Clients not appropriate for high tech - sent with low tech goals to work on One-to-one Tx - clinic is consultative Integrated services with other teams (Special Needs Strategy)  Composite checklist of essential AAC skills, e.g., intentional communication attempts, recognition and discrimination of symbols  Obtain additional valuable information inc. ability to match item to category, access needs, etc. Serves as guideline  Communication and Symbolic Behaviour Scales – Developmental Profile (CSBS-DP)  Augmentative Communication Interaction Checklist (Church & Glennen, 1992)  Meaningful Use of Speech Scale (MUSS) (Robbins & Osberger, 1992)  Augmentative and Alternative Communication Information and Needs Assessment (Beukelman & Mirenda, 1992)  Communication Matrix (Rowland, 2004)  Interactive Checklist for Augmentative Communication (INCH) (Bolton & Dashiell, 1991) Greater sensitivity than specificity? I.e., based on items alone, it is not great at identifying those who meet criteria but would not be eligible for prescription (emerging speech, unintelligible speech, DAS).  Poor reliability? Recognition and discrimination for novel symbols. Some clients were able to demonstrate skills only after multiple teaching trials. Others were able to demonstrate skills with own device, symbols. Inconsistent intake (coordinator vs. community ACS clinician) and misunderstanding amongst community providers. Resource intensive. Assessment Overview Special Needs Strategy Scheduling/time of the year Referral information was outdated SLP only available one day per week  Avoid stigmatization. Are clients visibly labeled by wearing signal and/or arm band? Do specific goals outweigh this concern?  Client needs may/may not be visible. Benefit for first responders to seek out system/device, seek contact information, ask family or guardians about need for system.  Nil traction with regional EMS. A number of contacts made. Possible to collaborate at provincial level?  Soliciting honest feedback re. the proposal, contacts and coordination process. Please see

Morning Rounds

Transcript: Morning Rounds This is a 56 year old African American woman who presented to the ED with 3 days of nausea and vomiting. What questios do you have about this patient's HPI,PMH,PE? What is the first step in therapy? Work Up the Acid/Base Disturbance! Stepwise approach to interpreting the arterial blood gas. 1. H&P. The most clinical useful information comes from the clinical description of the patient by the history and physical examination. The H&P usually gives an idea of what acid base disorder might be present even before collecting the ABG sample 2. Look at the pH. Is there an acid base disorder present? - If pH < 7.35, then acidemia - if pH > 7.45, then alkalemia - If pH within normal range, then acid base disorder not likely present. - pH may be normal in the presence of a mixed acid base disorder, particularly if other parameters of the ABG are abnormal. 3. Look at PCO2, HCO3-. What is the acid base process (alkalosis vs acidosis) leading to the abnormal pH? Are both values normal or abnormal? - In simple acid base disorders, both values are abnormal and direction of the abnormal change is the same for both parameters. - One abnormal value will be the initial change and the other will be the compensatory response. 3a. Distinguish the initial change from the compensatory response. - The initial change will be the abnormal value that correlates with the abnormal pH. - If Alkalosis, then PCO2 low or HCO3- high - If Acidosis, then PCO2 high or HCO3- low. Once the initial change is identified, then the other abnormal parameter is the compensatory response if the direction of the change is the same. If not, suspect a mixed disorder. 3b. Once the initial chemical change and the compensatory response is distinguished, then identify the specific disorder. See table below. - If PCO2 is the initial chemical change, then process is respiratory. - if HCO3- is the initial chemical change, then process is metabolic. Acid Base Disorder Initial Chemical Change Compensatory Response Respiratory Acidosis ↑ PCO2 ↑HCO3- Respiratory Alkalosis ↓ PCO2 ↓ HCO3- Metabolic Acidosis ↓ HCO3- ↓ PCO2 Metabolic Alkalosis ↑ HCO3- ↑ PCO2 4. If respiratory process, is it acute or chronic? - An acute respiratory process will produce a compensatory response that is due primarily to rapid intracellular buffering. - A chronic respiratory process will produce a more significant compensatory response that is due primarily to renal adaptation, which takes a longer time to develop. - To assess if acute or chronic, determine the extent of compensation. See table. 5. If metabolic acidosis, then look at the Anion Gap. - If elevated (> than 16), then acidosis due to KULT. (Ketoacidosis, Uremia, Lactic acidosis, Toxins). See table. - If anion gap is normal, then acidosis likely due to diarrhea, RTA. 6. If metabolic process, is degree of compensation adequate? - Calculate the estimated PCO2, this will help to determine if a seperate respiratory disorder is present. See table. 7. If anion gap is elevated, then calculate the Delta-Ratio (∆/∆) to assess for other simultaneous disorders. - ∆/∆ compares the change in the anion gap to the change in bicarbonate. - If ratio between 1 and 2, then pure elevated anion gap acidosis - If < 1, then there is a simultaneous normal anion gap acidosis present. - if > 2, then there is a simultaneous metabolic alkalosis present or a compensated chronic respiratory acidosis. 8. If normal anion gap and cause is unknown, then calculate the Urine Anion Gap (UAG). This will help to differentiate RTAs from other causes of non elevated anion gap acidosis. - In RTA, UAG is positive. - In diarrhea and other causes of metabolic acidosis, the UAG is negative. (neGUTive in diarrhea Electrolytes Potassium If a patient is hyperkalemic, it is best to hold potassium. Low potassium is a sign of more serious disease and should be replaced. Sodium Typically, low sodium itself does not cause many clinical promlems in this context. Phosphate Bicarbonate Should bicarbonate be replaced? No. Has not been proven to be useful and is associated with a four fold increase in the incidence of cerbral edema. Treatment? Insulin at .1 units/kg/hr Why not faster? Low phosphate can lead to muscle weakness, confusion and rhabdomyolysis from depleted ATP stores. Phosphate repletion has not been shown to be of benefit in patients with DVT. Click anywhere & add an idea Treatment Louie Hendricks Protocol for the management of adult patients with DKA Insulin at .1 units/kg/hr

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