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Vaginismus Rounds Presentation

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

Medical Rounds Presentation

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

Laboratory Testing - Surgery Rounds

Transcript: Surgery Rounds December 11, 2018 Dr. Victor Leung, Dr. Janet Simons, Dr. Karen Dallas Too Much Information -- Choosing the Right Laboratory Services for your Patients Topic Too much information? Why it matters Physical harms Psychological consequences Treatment burden Social consequences Financial consequences Consequences of inappropriate testing Testing Cycle Analytic Pre analytic Post analytic Decision to perform test Test ordered Specimen collected and transported Specimen analyzed Result reported Data interpreted Clinical action Post-test probability Pre-test probability Diagnostic Stewardship Modifying the process of ordering, performing and reporting diagnostic tests to improve patient outcomes Topic Topic Subtopic One or more of the following: Dysuria New urgency New frequency New incontinence Suprapubic pain Costovertebral angle tenderness Checklist BEFORE Urine Culture Collection Cloudy or malodorous urine is insufficient to consider UTI Mental status change alone is insufficient to consider UTI Urine cultures at SPH Urine cultures at SPH Downstream effects: Unnecessary antibiotic use in > 30% of asymptomatic bacteriuria ~$10,000 wasted in laboratory costs Topic Daily Bloodwork 45 days of unnecessary bloodwork 45 pokes (no line, on apixaban) IV team had to draw near end of stay >8 hours of phlebotomy time 90 tubes >200 tests 300 mL of blood "CBC, lytes, Cr, BUN daily " Lauren “In the inpatient setting, don’t order repeated CBC and chemistry testing in the face of clinical and lab stability.” — Canadian Society of Internal Medicine, Choosing Wisely Canada recommendation #4 “Avoid standing orders for repeat CBC on inpatients who are clinically stable.” — Canadian Association of Pathologists, Choosing Wisely Canada Recommendation #4 “Don’t order repeat laboratory investigations on inpatients who are clinically stable.” — Resident Doctors of Canada, Choosing Wisely Canada Recommendation #2 What was the longest unbroken run of daily bloodwork? How much is too much? Inpatient data for St Paul’s Hospital, 2016-2018 202 days How many patients have had over 30 straight days of daily bloodwork? How much is too much? Inpatient data for St Paul’s Hospital, 2016-2018 270 patients Just surgical patients? 48 patients >30 days 327 patients 10-30 days Opportunity costs Happier patients More thoughtful ordering Less iatrogenic anemia Fewer morning collections Morning bloodwork done sooner Time and cost savings Better, more patient centred care Reducing ‘routine’ bloodwork could mean: Daily = x 3 days, then reassess Time limit on frequency (q4h, BID) orders – TBD Exceptions for ex. IV heparin Automatic Stop on ‘Daily’ Bloodwork Orders What you can do today Write orders for bloodwork 'in AM' or daily x2 or 3 days Review 'standing' bloodwork orders on your patients New Policy Proposal Topic Why give TWO when ONE will do? Don’t transfuse more than one red cell unit at a time when transfusion is required in stable, non-bleeding patients. Canadian Society for Transfusion Medicine Don’t transfuse patients based solely on an arbitrary hemoglobin threshold. Canadian Hematology Society Don’t transfuse red blood cells for arbitrary hemoglobin or hematocrit thresholds in the absence of symptoms, active coronary disease, heart failure or stroke. Canadian Society of Internal Medicine We are ready for change INR / PTT Hematology consult multiple tests hematopathology consult INR developed in 1930’s for Warfarin monitoring PTT developed in 1940’s for high-risk hemophilia screening & later validated for heparin monitoring INR & PTT Do these tests “predict” a patient’s propensity for bleeding? Emergency Department 81%  INR and PTT ordered together 18.2%  only INR 0.8%  only PTT In just one year @ SPH  ~20 patients each who had >10 days in a row normal INR or PTT What are we doing at PHC? REFLECT on your own practice - what could you question? COMMIT to one thing you will start doing differently or thinking about differently DISCUSS with your colleagues, trainees, supervisors, and patients Call to Action Topic providencelaboratory.comOnline Test Directory We're here to help! Contact Us janet.simons@providencehealth.bc.ca vleung@providencehealth.bc.ca kdallas@providencehealth.bc.ca Data Science for Doctors Free for PHC physicians course all day Feb 1/2 pass@providencehealth.bc.ca Come Visit Us!

Grand Rounds Presentation

Transcript: Physical Assessment History of Present Illness Last visit with Ms. "E" VS Stable Labs: patient refuses phlebotomy sticks for lab values Discharge to boyfriend's home per pt. request Continue Methadone outpatient in Watts Abscess D/C IV Vanco Rx: PO Bactrim UTI Urine Culture + E. Coli D/C IV Vancomycin Rx: PO Cipro Wound care education Fu in clinic 3-4 days for symptoms check and to establish primary care Abscess Management Active Diagnoses Abscess of right hip PICC line Surgery Consult for I & D Vancomycin IV Thorazine PO Drug abuse Methadone Acute UTI Bactrim PO Repeat UA Urine Cx Gentamicin IV Acute pain Norco PO only NO IV pain meds Morphine sulfate sub Q Acute hypokalemia Potassium PO Acute hyponatremia NS Bolus IVFs Cardiovascular BP 103 Respiratory Clubbing of nails Integumentary R hip: 20 x 15 erythematous lesion blanching warmer fluctuant mass No necrosis No crepitus L hip: multiple older lesions Thank You! HPI Continued Report Labs Blood Cultures Lactate Renal Function CK to rule out Rhabdomyolysis Diagnostics Ultrasound distinguishes cellulitis vs abscess Lymph node enlargement and lymphatic streaking confirm cellulitis Dx Management Antibiotics **MRSA** PO Bactrim, doxycycline, Linezolid IV Vanco, Daptomycin, Linezolid, Clindamycin IVFs I&D surgery Ellipitical incision Loop drainage technique O2 CVP monitoring Loose packing Past Medical History Taj Price-Gibson California State University, Los Angeles Ms. "E" 37 y.o. Caucasian Female English Speaking Single No children Admitted to WMMC ED CC: Right hip abscess Admission date: 4/16/17 CC: Abscess LOS: 3 days Day 1: April 16 Day 2: April 17 Day 3: April 18 April 16, 2017 CC: R hip Abscess x 1 week w/ non radiating pain To WMMC ED Constitutional + Diffuse body aches x 1 week + Fatigue x 1 week + Subjective fever x 1 week + Chills + Diaphoresis + weakness + diffuse pain + throbbing pain to abscess site non radiating 8/10 - no exudate or leakage + Severe withdrawal + heroin use 2 hours ago ENT + Nasal congestion + Sore throat Respiratory + Sputum production + Cough Pus accumulation within tissue of body Furuncle or Carbuncle Cellulitis Signs & Symptoms Warmth Redness Pain Swelling Fluctuant fluid Purulent odor or pus drainage Sub Q Air Associated Cellulitis Etiology Staph Aureus Chronic: E. Coli** Risk factors IVDA& Chemical irritants PMH IVDA heroin & methadone 40 cc/day or 2 “packs”/ day Methadone clinic last time 3 mos ago Endocarditis ECHO ORDERED PSH Appendectomy Cholcystectomy Hysterectomy Allergies Penicillin Toradol Home Medications: None Cardiovascular + Palpitations Gastrointestinal + Nausea GU + Dysuria + Polyuria Lymphatics + Swollen lymph glands MS + Joint pain + Muscle pain + Claudication + Decreased ROM Integumentary + Rashes + Needle tracks in bilateral upper extremities + L hip multiple old abscesses or indurations non infected + R hip multiple abscesses redness, warmth Psychiatric +Anxiety +Depression What is an Abscess? Continuity of Care History The Patient CC: Abscess Surgery Consult Ruled out Necortizing fasciitis, DVT & osteomylitis Recommendation: I&D R hip & bilateral buttocks Rx: PO Doxycycline CV EKG - Endocarditis hx ECHO - Ruled out Endocarditis GU Dysuria & pyuria UA Orange color Turbid appearance Moderate leukocyte esterase Blood Rx: PO Bactrim Blood Cx’s Lab Values WBC 15.3 Hct 29.8 Na 128 K 3.0 Day 2 Grand Rounds Presentation Abscess Day 1 Day 3 Med Surge Awaiting Urine Cx Continue IV Vanco & Gent Increase Methadone to 80 Discharge Planning Case Management Consult Wound care 62 ECG bpm

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.” (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

Surgery Presentation

Transcript: Surgery: ET's presentation to hopsital Renee Duvenage 25/06/2013 Past Medical History: * 4 months Post partum- vaginal birth * L Carpal tunnel release Family history: * Father: AMI (3rd decade) Medications: * nil * NKDA Social History: * Non Smoker * Non Drinker * Lives at home with husband and child Differentials Provisional Diagnosis: GORD Peptic Ulcer Differential Diagnosis: Pancreatitis Cholecystitis AAA Investigations Management Biliary Colic Acute Cholangitis Chronic Cholangitis Anatomy: Can you name all the structures Management: Categories: 1: Incidental : requires no managment 2: Biliary symptoms, Gallstones (U/S), no complications 3: Atypical Symptoms, Gallstones (U/S) 4: Biliary symptoms without Gallstones (U/S) Complications Outcome Definitions and Classification Examination Further History Findings Thank you Imaging U/S: multiple small mobile calculi, mildly distended, positive sonographraphic Murphy's sign. CBD was not dilated (4.6 mm). Fatty liver changes identified. http://www.sonoguide.com/GB_Video13.html Presentation FBC: Leukocytosis LFT: All mildly elevated Abdominal pain S: Epigastric O: 2/7 C: Crescendo-descrendo, Never fully remitting R: Radiating to back and up to jaw. A: Alleviated by vomiting, associated with nausea, anorexia, T: At night, after dinner E: Exacerbated by food S: ranging from 3-8/10 Observation: appears comfortable at rest, bandages over laprascopic incisions present, IV cannula in situ, and is obese. Palpation: demonstrated a tender RUQ, and Positive Murphy's sign, AA difficult to palpate Auscultation: Bowel sounds present, no respiratory findings, HSDNM Percussion: Liver 14cm, no acites Blood Work Vital Signs: * Heart Rate: 74 bpm * Blood Pressure: 131/88 mmHg * Respiratory Rate: 22 bpm * Temperature: 37.7 C PC

Surgery Grand Rounds

Transcript: CC: shortness of breath 9 Make a lateral skin incision overlying the rib that is below the desired intercostal level of entry Indications: - Denies: Nausea, vomiting, diarrhea, HA, sore throat, urinary symptoms -Admits to: fevers, weakness, fatigue, unintentional weight loss 50lb/6 months, shortness of breath, cough, congestion, pleuritic chest pain Opportunistic Infections in AIDS Specimen: left lung, fresh Persistent air leak Bleeding from pulmonary vessels Intercostal nerve damage due to insertion of instruments through ports Complications from single lung ventilation, including respiratory insufficiency or post-operative re-expansion pulmonary edema Tumor implantation following VATS C Per notes – based on presence of oral thrush, his presentation is consistent with HIV, likely his CD4 lymphocyte count is <200. Pathology Report CXR suspicious for Pneumocystis pneumonia. Treatment of choice is TMP-SMX for 3 weeks. Corticosteriods have been shown to improve the course of patients with moderate to severe PCP with oxygen saturation <90% or PaO2 <65mmHg Surgery Grand Rounds Absolute: need for emergent thoracotomy Relative: coagulopathy, pulmonary bullae, pulmonary, pleural or thoracic adhesions, loculated pleural effusion or empyema, skin infection over the chest tube insertion site What labs and imaging do you want to order? Literature Review: Continued 6 POD #0: VATS with pleurodesis & placement of L chest tube POD #1: CXR, suction on chest tube d/c’d POD #2: CXR shows worsening L pneumothorax likely 2/2 airleak, restart suctionPOD #3: CXR shows some improvement POD#4: CXR shows small increase in small L residual apical pneumothorax, +AFB from 2/14, started on RIPE tx for TB, 1-3 beta glucan fungal test positive, Pathology report returns POD #5: CXR shows trace pneumothorax POD #6: CXR stable, Mycobacterium TB complex PCR negative POD #7: CXR shows increased pneumothorax POD #8: CXR stable, must be cleared by the health department POD #9: CXR stable POD #10: CXR stable, no airleak noted POD #11: CXR shows decreasing pneumothorax POD #12: CXR stable, AFB grew M.avium complex x1 POD #13: CXR cleared by Epidemiology department for d/c home with Heimlich valve (one-way valve) Q: You are taking care of 40M with a history of HIV (diagnosed 2 years ago) and has been on therapy without disease progression. You order a PPD. What amount of induration would he be positive for TB? a) Any induration indicates a positive b) 3 mm c) 5 mm d) 10 mm e) 15 mm Heimlich Valve 1. Markedly unstable or shocked patient 2. Extensive adhesions obliterating the pleural space 3. Prior talc pleurodesis Deflated lung Contraindications: Anesthesia: General with selective single lung ventilation using a double-lumen endobronchial tube Positioning: lateral decubitus Steps: 1-4 incisions are used in thorascopic procedures, at least 5cm apart so instruments do not cross “baseball diamond” Endoscope along with instruments are used to manipulate the lung, staple lung biopsy retrieved with endocatch bag through trochar ports. Single stitch or few subcuticular stitches placed if needed. Chest tube placed in normal fashion THANKS, THAT'S IT!!!! Absolute Lymphocyte Count = WBC x Lymphocyte% x10 Vitals Signs: HR 110, RR 20, BP 132/77, T 100.6, O2 saturation 98% RA, wt 165lbs HEENT: NCAT, PERRL, EOMI b/l, no scleral icterus +mild to moderate oral thrush involving the roof of the mouth, no anterior cervical lymph node tenderness but +mildly enlarged lymph node palpated CV: regular rhythm, tachycardic, no murmurs Resp: Right lung – some rhonchi, Left lung – reduced breath sounds Abdomen: soft, ND, no TTP, bowel sounds normoactive x4, no HSM, no jaundice Ext: no edema, no clubbing, pulses strong Neuro: A&Ox4, neurologically intact OMM: b/l suboccipital hypertonicity, b/l hypertonicity with bogginess in b/l upper thoracics, L thoracic diaphragm restricted, L lower rib restriction (Ribs 7-12) Minkes (whale) & Deere 1 Treatments: Suboccipital release Thoracic diaphragm release Paraspinal inhibition MFR of thoracic paraspinal muscles Osteopathic Manipulative Medicine Objectives: To discuss the case presentation of surgical patient To describe the surgical management of the case To discuss the medical management of the patient subsequently To relate this patient to OP&P To provide board-study questions Look for respiration-related swing in the fluid level of the water seal device to confirm correct intrathoracic placement C Pneumothorax (open or closed) (simple or tension) Hemothorax Hemopneumothorax Hydrothorax Chylothorax Empyema Pleural effusion Patients with penetrating chest wall injuries (intentional/unintentional) "Sections show consolidated lung tissue containing alveolar spaces filled with pink foamy amorphous material and numerous macrophages..." "An AFB stain is negative for mycobacteria..." "A GMS stain on specimens A and B highlights numerous organisms consistent with Pneumocystis jiroveci." 7 Recurrent Pneumothorax Left Pneumothorax s/p chest

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