Transcript: Morning Rounds: A Simulation Experience for Second Year Med Students Dr. Grzegorz Plochocki, MD; Teri Boese, DNP, RN 2017 SUMMARY BACKGROUND SWOT SWOT S W O T STRENGTHS STRENGTHS WEAKNESSES WEAKNESSES OPPORTUNITIES OPPORTUNITIES THREATS THREATS SUMMARY OF WORK FOCUS AREA 1 THE PROBLEM THE PROBLEM JAN FEB MAR $ #1 #2 #3 2017 PLAN PLAN TIMELINE #1 #2 #3 TIMELINE FOCUS AREA 2 SUMMARY OF RESULTS THE PROBLEM THE PROBLEM $ JAN FEB MAR #1 #2 #3 2017 PLAN PLAN TIMELINE #1 #2 #3 TIMELINE CONCLUSIONS FOCUS AREA 3 THE PROBLEM THE PROBLEM $ JAN FEB MAR #1 #2 #3 2017 PLAN PLAN TIMELINE #1 #2 #3 TIMELINE DISCUSSIONS DISCUSSIONS
Transcript: ter Kuile et al. 2013 (JCCP) Efficacy trial of therapist-aided exposure for lifelong vaginismus N = 70; randomized wait-list group tx group Graded exposure tx (3, 2h sessions within 1 week) to feared penetration "objects" (fingers, dilators) Sessions were guided by a therapist and partner Exposure homework (2-3x/day) Results? Differing Severity of Vaginismus Sexual Response Described healthy level of sexual desire Unsure if she has reached orgasm Not interested in giving or receiving oral sex and does not masturbate or watch erotica due to religious reasons Results Education & Employment Post-secondary degree Currently working in government No evidence of the effectiveness of these treatments is available from controlled studies (e.g., van Lankveld et al., 2010) Assigned Homework: Sensate with Joe Daily relaxation exercises Dilator 1 (30-minutes in duration) Symptoms Overview Often paired with some form of relaxation exercise Teaches how to gain control over & relax muscles Time of insertion varies 10 min- sleeping with dilator every second night Finger penetration has been found helpful to initiate dilation Logging dilation Helpful for accountability and allows for clinician support Assigned Homework Relaxation training prior to and following exposures Exposure: insert Q-tip and finger (5-7x week) for 10-minutes Medical Treatment Primary (lifelong) Vaginismus: Never experienced pain-free sexual intercourse Reissing, 2009; ter Kuile, Both & van Lankveld, 2010 Importance of understanding vaginismus as both a physical and psychological condition (Rosenbaum, 2011) Clinical Interview childhood & family hx relational hx psycho-social hx messages about sex religious orientation penetration hx amount of pain (1-10) anxiety associated with various types of penetration (tampon, Q-tip, finger, gynecological exam, dilator, intercourse) history and inability to tolerate a gynecological exam Validated Measures: Female Sexual Function Index (FSFI; Rosen et al., 2000) Vaginal Penetration Cognition Questionnaire (VPCQ; Klaassen & TerKuile, 2009) Extremely supportive Described a normal level of sexual desire No difficulties with erections or ejaculation Denied engaging in masturbation or viewing erotica Due to religious faith Lamont's Classification (1979) DSM 5 (2013) Sessions 3-4 A history of intercourse feeling like "Hitting a brick wall" or "There is no hole down there" The ability to successfully treat vaginismus is related to the severity of the condition (Pacik, 2014) influenced by both amount of vaginal spasm and degree of fear/anxiety Relationships & Sexual Response Medical History No significant health concerns No drug or alcohol use Interested in starting a family Vaginismus: A Review of the Literature and a Case Study Future Treatment Plans Personal History Vaginismus patients often require more than botox to achieve a successful outcome Botox does not cure associated difficulties such as unrelenting fear of penile penetration; self-image concerns (Pacik, 2011) Questions? Under-reported difficulty discussing with family/friends, docs Difficulties tolerating gynecological examinations Misdiagnosed minimal education in med-schools, residencies, medical meetings Burning or stinging with tightness during sex Difficult or impossible penetration, entry pain Ongoing sexual pain of unknown origin Difficulty inserting tampons or undergoing a pelvic/gynecological exam Spasms in other body muscle groups (legs, lower back, etc.) and/or halted breathing during attempts at intercourse Avoidance of sex due to pain and/or failure Fear and anxiety The etiology of vaginismus is unknown Dilator Therapy Progressively larger dilators are used to help the woman to become comfortable with vaginal penetration Homework Adherence: Daily PMR Success with dilator 1; dilator 2 (tip) noted easier to complete when Joe is away Uncomfortable with fantasy novels Suzie presented with an extreme case of vaginismus and generalized anxiety She was highly motivated for tx Therapy addressed and worked to overcome unhelpful sex-related thoughts and debunk sexual myths Religious views prevented particular exercises A significant obstacle was her extreme vaginal spasms ("vagina to toe") PT referral "Hitting a Brick Wall" Homework Daily relaxation Exposure: Dilators 1-2 Joe's finger Consider fantasy novels Thought record Etiology of Vaginismus Case Study:"Suzie" Evidence-based treatment van Lankveld et al., 2006 first RCT N = 117 with lifelong vaginismus WLC Group CBT CBT bibliotherapy format Treatment: 3-months Challenges Challenges with consistency of dilator 1 Evidence for CBT Mark Kim Malan, Vern Bullough (2005) Conducted a literature review and reported that church members are divided on their moral views about masturbation Bi-weekly to weekly sessions CBT focus with graded exposure exercises Time limited by Resident's contract ongoing "recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with
Transcript: Introduction Community Based Program 5/5/5 Six Physician Faculty ULR Run the Service for two weeks There is a PGY 1 on the servise for two weeks Why Integrated Rounds Not enough time Reinforce Behavioral Medicine Point service learning Team Teach Rules It is medical rounds Only teach three things Remeber residents devlopmental stage Awareness of the size of the service Who is the patient Resident Experience Physician Faculty Expereince
Transcript: Family History - using Fiona’s family and medical history, a physical exam, and the results from diagnostic blood tests and procedures I determine that she had cancer-related IDA Treatment Options - treatment will depend on factors such as age, health, and cause. - To treat Fiona’s cancer related iron deficiency anemia, I recommend two things: ● take iron supplements along with an iron-rich diet to improve overall well being ● treat the underlying cause, the breast cancer. Fiona is now in remission, but the IDA will worsen as her cancer does. - mother also suffered from breast cancer, which can lead to cancer-related IDA Refrences Medical Rounds Presentation Organs/ Organ Systems Related to/ Impacted Iron Deficiency Anemia - name: Fiona - age: 41 - sex: female - a working mom and breast cancer survivor - fatigue - decreased work/ school performance - difficulty maintaining body temperature (always feeling cold) - decreased immune system - laboured breathing and headaches - the first step in being tested for IDA is blood tests. There are two initial types: ● Hemoglobin test (a test that measures hemoglobin which is a protein in the blood that carries oxygen) ● Hematocrit test (the percentage of red blood cells in your blood by volume) - these tests show how much iron is in your blood, and more importantly your body. Hemoglobin and hematocrit levels usually aren't decreased until the later stages of iron deficiency, i.e., anemia. - the next step is more blood tests used to confirm that anemia is due to iron deficiency. These might include: ● complete blood count (to look at the number and volume of the red blood cells) ● serum ferritin (a measure of a stored form of iron) ● serum iron (a measure of the iron in your blood) ● transferrin saturation (a measure of the transported form of iron) ● transferrin receptor (a measure of increased red blood cell production) http://www.medicinenet.com/iron_and_iron_deficiency/article.htm http:// www.ironmatters.com/?gclid=CLKw9oak9LkCFY87MgodYCkAUw http://www.rightdiagnosis.com/i/iron_deficiency_anemia/basics.htm the article on http://www.ironmatters.com/blog/patient-voices/don%E2%80%99t-suffer-unnecessarily - Anemia is a condition in which you do not have enough healthy red blood cells to deliver enough oxygen throughout your body. - When your body does not have enough iron, it will make fewer red blood cells or red blood cells that are too small. This is called iron deficiency anemia. Tests Used in Diagnosis - blood - circulatory system - Severe anemia may cause a condition called high-output heart failure, where the heart must work harder to provide enough oxygen to the brain and other internal organs. The heart beats faster and increases the amount of blood that is delivered per minute. Signs and Symptoms Patient Information Description of Diagnosis
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.” (http://www.children.gov.on.ca/htdocs/English/topics/specialneeds/strategy/index.aspx) 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
Transcript: This is a motivational Alligator Duck. It will help you along your path to glory. Don't be afraid to hop on that treadmill and just get active. You could also try to do some interactive workout videos, which can be found on YouTube. Endurance Exercise Eating healthy is a very big influence on your lifestyle and your internal health. If you eat healthy, you feel good. Not too much I once heard a very nice quote from a dear friend that I love. "A bad attitude is like a flat tire. You're not going anywhere until you change it." This is a great quote because it is true. You have to have a good attitude to be able to accomplish your goal. One very important step in losing Healthy a How To by Curtis Rounds 1-800-lose-lbs Attitude For Help with your journey, Call Don't give up! Keeping your weight off will do you lots of good. weight is that you don't eat more than you are supposed to. Eat a meal, then you're done. How to Lose Weight
Transcript: Grand Rounds Presentation surgeries left buttock tissues have extensive soft tissue density likely reflecting acute inflammation. Day One HCT – 42.3 HGB – 14.0 WBC – 4.36L PLT – 285 NA – 135 K – 3.7 CL – 100 CO2 – 27 Research articles: Current data suggest that most abscesses can be treated successfully with incision and drainage alone. Antibiotic choice is more crucial for management of cellulitis. With increasing resistance to antibiotics, it is important to figure out which cases can be treated without antibiotics. discharge planning Plans for discharge were not yet being arranged for R.G. during my time at clinical, though I knew his destination would be at home with his girlfriend and two children. R.G.’s support system consists of his girlfriend and his best friend. Patient was not in need of any specific equipment before discharge. pathophysiology Banasik, J. and Copstead, L. (2009). Pathophysiology. Published by W.B. Sanders Co. Deglin, J.H., Vallerand, A.H., Sanoski, C.A. (2011). Davis drug guide for nurses: 12th edition. F.A. Davis Company. Fitch, M.T., Manthey, D.E., McGinnis H.D., Nicks, B.A., and Pariyadat, M. (2008). A skin abscess model for teaching incision and drainage procedure. BMC Medical Education 2008, 8:38. Odell, C.A. (2010). Community-associated methicillin-resistant staphylococcus aureus (CA-MRSA) skin infection. Current Opinion in Pediatrics 2010, 22:273–277. Mayo Clinic. (2011). Mrsa infection. http://www.mayoclinic.com/health/mrsa/DS00196. WebMD. (2011). Skin abscess: treatment and symptoms. http://www.emedicinehealth.com/abscess. admitting diagnosis: left gluteal abscess; MRSA Patient Teaching phsyical assessment Use verbal and nonverbal therapeutic communication approaches such as empathy, active listening, and confrontation to encourage the client and family to express emotions as sadness, guilt, and anger (within appropriate limits); verbalize fears and concerns, and set goals. Be supportive of coping behaviors; allow the client time to relax. Inicision & drainage X2 (+) MRSA acute pain r/t injury agents [incision @ peri-rectal area] treatments full code nkda NPO "What is this medication & why I am taking it?" Day Two HCT – 38.2 L HGB – 12.5 L WBC – 18.3 H PLT - 358 wound culture - L.gluteal abscess REFERENCES interventions: Assess pt pain level by using a valid & reliable self-report pain tool such as the 0-10 numerical rating scale Administer opiods orally or intravenously, provide PCA when appropriate & available. Nursing diagnoses medications vancomycin 1250mg q8hrs IV Dilaudid PCA 30mg IV PRN Pelvic CT scan - Meet R. G. - physical assessment All findings WNL except Skin - incision @ L. peri-rectal area from surgery, painful & swollen w/ serosanguinous drainage diagnostics Abscesses are caused by an obstruction of oil or sweat glands, inflammation of hair follicles, or from minor breaks in the skin. Bacteria enter the breaks in the skin or the gland, which initiates your body's inflammatory response. The middle of the abscess liquefiies, and contains dead cells, bacteria & other debris. This area begins to grow, creating tension under the skin & further inflammation of the surrounding tissues. IV - R. forearm LR @ 75ml/hr Foley catheter Penrose drain X 4 dressing change @ wound site daily by Nicole Roldan Ineffective coping related to inadequate social support. current illness Laboratory Findings "What are you looking for?" Medications - Heparin
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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