This document summarizes the care of a 73-year-old woman with stage 3 ovarian cancer who presented with worsening shortness of breath. Initial treatment for congestive cardiac failure in the emergency department provided some relief. However, she deteriorated with multi-organ failure and increasing oxygen needs. A discussion was had about her poor prognosis with multi-organ failure in the context of advanced cancer. It was decided that further critical care would not be beneficial and she was made comfortable with best supportive care.
Dr Ashling Lillis, National Director's Clinical Fellow Macmillan Support, final year trainee in Acute Oncology
Dr Clare Philliskirk, Trainee in Acute Medicine, West Midlands
Dr Sarbit Clare, Acute Medical Consultant, Sandwell and West Birmingham Hospitals
Palliative Care and Acute Oncology IntegrationRecoveryPackage
Dr Catherine O'Doherty, Consultant in Palliative Medicine, Trust Acute Oncology Lead and Lead Cancer Clinician, Basildon and Thurrock University Hospitals NHS Foundation Trust
Karen Andrews, Head of Nursing for Macmillan/Acute Oncology and EOL services, Basildon and Thurrock University Hospitals NHS Foundation Trust
Dr Ashling Lillis, National Director's Clinical Fellow Macmillan Support, final year trainee in Acute Oncology
Dr Clare Philliskirk, Trainee in Acute Medicine, West Midlands
Dr Sarbit Clare, Acute Medical Consultant, Sandwell and West Birmingham Hospitals
Palliative Care and Acute Oncology IntegrationRecoveryPackage
Dr Catherine O'Doherty, Consultant in Palliative Medicine, Trust Acute Oncology Lead and Lead Cancer Clinician, Basildon and Thurrock University Hospitals NHS Foundation Trust
Karen Andrews, Head of Nursing for Macmillan/Acute Oncology and EOL services, Basildon and Thurrock University Hospitals NHS Foundation Trust
Hyperprolactinemia Quiz - Case PresentationUsama Ragab
Hyperprolactinemia Quiz - Hyperprolactinemia Workshop
In light of 3rd Annual Endo-ISMA Conference 2021
By Dr. Usama Ragab Youssif
Importance of History Taking and Hypothyroidism as a cause of hyperprolactinemia
Kidney transplantation, if not contraindicated, is the most preferred renal replacement therapy for patients with end stage renal disease. Generally, live related transplantation is associated with longer term survival of the transplantated kidney as well as the patient. However, it is associated with great physical and psychological challenges for the donor. Therefore, an exhaustive physical workup as well comprehensive psychological counselling go a long way for a happy donor as well as recipient. Laparoscopic donor surgery has helped reduce surgical morbidity and improve acceptance. Moreover, to avoid medicolegal issues, exhaustive documentation is necessary.
'Clinical governance is the system through which NHS organisations are accountable for continuously monitoring and improving the quality of their care and services, and safeguarding high standards of care and services'
1.The APRN is giving a pathophysiology lecture to APRN students on .docxtrippettjettie
1. The APRN is giving a pathophysiology lecture to APRN students on renal blood flow, glomerular filtration rate, autoregulation, and related hormone factors regulating renal blood flow
Question:
What would be the most important concept of hormonal regulation that the APRN should address?
2. The APRN is giving a pathophysiology lecture to APRN students on renal blood flow, related hormones, and glomerular filtration rate.
Question:
What would be the most important concept of glomerular filtration rate that the APRN should address?
A 46-year-old Caucasian female presents to the PCP’s office with a chief complaint of severe, intermittent right upper quadrant pain for the last 3 days. The pain is described as sharp and has occurred after eating french fries and cheeseburgers and radiates to her right shoulder. She has had a few episodes of vomiting “green stuff”. States had fever and chills last night which precipitated her trip to the office. She also had some dark orange urine, but she thought she was dehydrated.
Physical exam: slightly obese female with icteric sclera as well as generalized jaundice. Temp 101˚F, pulse 108, respirations 18. Abdominal exam revealed rounded abdomen with slightly hypoactive bowel sounds. + rebound tenderness on palpation of right upper quadrant. No tenderness or rebound in epigastrium or other quadrants. Labs demonstrate elevated WBC, elevated serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. Serum bilirubin (indirect) 2.5 mg/dl. Abdominal ultrasound demonstrated enlarged gall bladder, dilated common bile duct and multiple stones in the bile duct. The APRN diagnoses the patient with acute cholecystitis and refers her to the ED for further treatment.
Question 1 of 2:
Describe how gallstones are formed and why they caused the symptoms that the patient presented with.
Question 2 of 2:
Explain how the patient became jaundiced
3. Ruth is a 49-year-old office worker who presents to the clinic with a chief complaint of abdominal pain x 2 days. The pain has significantly increased over the past 6 hours and is now accompanied by nausea and vomiting. The pain is described as “sharp and boring” in mid epigastrum and radiates to the back. Ruth admits to a long history of alcohol use, and often drinks up to a fifth of vodka every day.
Physical Exam: Temp 102.2F, BP 90/60, respirations 22. Pulse Oximetry 92% on room air.
General: thin, pale white female in obvious pain and leaning forward. Moving around on exam table and unable to sit quietly.
CV-tachycardic. RRR without gallops, rubs, clicks or murmurs
Resp-decreased breath sounds in both bases with poor inspiratory effort
Abd- epigastric guarding with tenderness. No rebound tenderness. Negative Cullen’s and + Turner’s signs observed. Hypoactive bowel sounds x 2 upper quadrants, and no bowel sounds heard in both lower quadrants.
The APRN makes a tentative diagnosis of acute pancreatitis based on history and ph.
Hyperprolactinemia Quiz - Case PresentationUsama Ragab
Hyperprolactinemia Quiz - Hyperprolactinemia Workshop
In light of 3rd Annual Endo-ISMA Conference 2021
By Dr. Usama Ragab Youssif
Importance of History Taking and Hypothyroidism as a cause of hyperprolactinemia
Kidney transplantation, if not contraindicated, is the most preferred renal replacement therapy for patients with end stage renal disease. Generally, live related transplantation is associated with longer term survival of the transplantated kidney as well as the patient. However, it is associated with great physical and psychological challenges for the donor. Therefore, an exhaustive physical workup as well comprehensive psychological counselling go a long way for a happy donor as well as recipient. Laparoscopic donor surgery has helped reduce surgical morbidity and improve acceptance. Moreover, to avoid medicolegal issues, exhaustive documentation is necessary.
'Clinical governance is the system through which NHS organisations are accountable for continuously monitoring and improving the quality of their care and services, and safeguarding high standards of care and services'
1.The APRN is giving a pathophysiology lecture to APRN students on .docxtrippettjettie
1. The APRN is giving a pathophysiology lecture to APRN students on renal blood flow, glomerular filtration rate, autoregulation, and related hormone factors regulating renal blood flow
Question:
What would be the most important concept of hormonal regulation that the APRN should address?
2. The APRN is giving a pathophysiology lecture to APRN students on renal blood flow, related hormones, and glomerular filtration rate.
Question:
What would be the most important concept of glomerular filtration rate that the APRN should address?
A 46-year-old Caucasian female presents to the PCP’s office with a chief complaint of severe, intermittent right upper quadrant pain for the last 3 days. The pain is described as sharp and has occurred after eating french fries and cheeseburgers and radiates to her right shoulder. She has had a few episodes of vomiting “green stuff”. States had fever and chills last night which precipitated her trip to the office. She also had some dark orange urine, but she thought she was dehydrated.
Physical exam: slightly obese female with icteric sclera as well as generalized jaundice. Temp 101˚F, pulse 108, respirations 18. Abdominal exam revealed rounded abdomen with slightly hypoactive bowel sounds. + rebound tenderness on palpation of right upper quadrant. No tenderness or rebound in epigastrium or other quadrants. Labs demonstrate elevated WBC, elevated serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. Serum bilirubin (indirect) 2.5 mg/dl. Abdominal ultrasound demonstrated enlarged gall bladder, dilated common bile duct and multiple stones in the bile duct. The APRN diagnoses the patient with acute cholecystitis and refers her to the ED for further treatment.
Question 1 of 2:
Describe how gallstones are formed and why they caused the symptoms that the patient presented with.
Question 2 of 2:
Explain how the patient became jaundiced
3. Ruth is a 49-year-old office worker who presents to the clinic with a chief complaint of abdominal pain x 2 days. The pain has significantly increased over the past 6 hours and is now accompanied by nausea and vomiting. The pain is described as “sharp and boring” in mid epigastrum and radiates to the back. Ruth admits to a long history of alcohol use, and often drinks up to a fifth of vodka every day.
Physical Exam: Temp 102.2F, BP 90/60, respirations 22. Pulse Oximetry 92% on room air.
General: thin, pale white female in obvious pain and leaning forward. Moving around on exam table and unable to sit quietly.
CV-tachycardic. RRR without gallops, rubs, clicks or murmurs
Resp-decreased breath sounds in both bases with poor inspiratory effort
Abd- epigastric guarding with tenderness. No rebound tenderness. Negative Cullen’s and + Turner’s signs observed. Hypoactive bowel sounds x 2 upper quadrants, and no bowel sounds heard in both lower quadrants.
The APRN makes a tentative diagnosis of acute pancreatitis based on history and ph.
Clinical ScenarioREASON FOR CONSULTATION Desaturation to 64.docxbartholomeocoombs
Clinical Scenario:
REASON FOR CONSULTATION:
Desaturation to 64% on room air 1 hours ago with associated shortness of breath.
HISTORY OF PRESENT ILLNESS:
Mrs. X is 73-year-old Caucasian female who was admitted to the general surgery service 3 days ago for a leaking j-tube which was surgically replaced 2 days ago and is now working properly. This morning at 07:30, the RN reported that the patient was sleeping and doing fine, then the CNA made rounds at 0900 and Mrs. X was found be mildly dyspneic. Vital signs were checked at that time and were; temperature 38.6, pulse 120, respirations 22, blood pressure 138/38. O2 sat was 64% on room air. The general surgeon was notified by the nursing staff of the hypoxia, an order for a chest x-ray and oxygen therapy were given to the RN. The O2 sat is maintaining at 91% on 4L NC. The patient was seen and examined at 10:10 a.m. She reports that she has been having mild dyspnea for 2 days that has progressively gotten worse. She does not use oxygen at home. Her respiratory rate at the time of visit was 22 and she feels short of breath. She has felt this way in the past when she had pneumonia. She is currently undergoing radiation treatment for laryngeal cancer and her last treatment was 1 to 2 weeks ago. She reports that she has 2 to 3 treatments left. She denies any chest pain at this time and denies any previous history of CHF. Review of her vital signs show that she has been having intermittent fevers since yesterday morning. Of note, she was admitted to the hospital 3 weeks ago for an atrial fibrillation with RVR for which she was cardioverted and has not had any further problems. The cardiologist at that time said that she did not need any anticoagulation unless she reverted back into A-fib.
REVIEW OF SYSTEMS:
Constitutional:
Negative for diaphoresis and chills.
Positive for fever and fatigue.
HEENT:
Negative for hearing loss, ear pain, nose bleeds, tinnitus.
Positive for throat pain secondary to her laryngeal cancer.
Eyes:
Negative for blurred vision, double vision, photophobia, discharge or redness.
Respiratory:
Positive for cough and shortness of breath
. Negative for hemoptysis and wheezing.
Cardiovascular:
Negative for chest pain, palpitations, orthopnea, leg swelling or PND.
Gastrointestinal:
Negative for heartburn, nausea, vomiting, abdominal pain, diarrhea, constipation, blood in stool or melena.
Genitourinary:
Negative for dysuria, urgency, frequency, hematuria and flank pain.
Musculoskeletal:
Negative for myalgias, back pain and falls.
Skin:
Negative for itching and rash.
Neurological:
Negative for dizziness, tingling, tremors, sensory changes, speech changes.
Endocrine/hematologic/allergies:
Negative for environmental allergies or polydipsia. Does not bruise or bleed easily.
Psychiatric:
Negative for depression, hallucinations and memory loss.
PAST MEDICAL HISTORY:
Diabetes mellitus that was diagnosed 12 years ago with neuropathy. This resolved after gastric.
It is to allow the therapist to formulate an accurate assessment of the clinical status of the patient
Severity of the disease
Stability of the symptoms
Presence of other co-morbidities other than
the primary diagnosis
Dr Neerav Goyal discusses the various aspects of acute liver failure that includes the criteria, pre transplant issues, critical care management, overall survival.
PMR and GCA: A GP Update - Dr Toby Helliwell pcsciences
Dr Toby Helliwell is a practising GP and Researcher at the Research Institute for Primary Care and Health Sciences. As part of the 2017 Musculoskeletal Education Day, he provides an update of the diagnosis on treatment of Polymyalgia Rheumatica and Giant cell Arteritis from a GP's perspective
Nusing Management of CAD Symposia (French) presented at Hôpital Sacré Coeur in Milot, Haiti.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
Dr Alison Young, Consultant Medical Oncology, Leeds Teaching Hospitals Trust
Dr Andrew Stewart, Haematologist and Lead for Acute Oncology, University Hospitals of the North Midlands
Ceri Stubbs, Clinical Lead, Velindre NHS Trust
Dr Sinead Clarke, Macmillan GP Advisor, Clinical Director for Performance, IT, Finance, Cancer and End of Life, South Cheshire and Vale Royal CCGs, Medical Lead for Cheshire end of Life Partnership
Dr Jackie Dominey, GP and Macmillan GP Advisor, Clinical Lead End of Life, Solihull CCG
Dr Ricky Fraser, Acute Oncology Fellow, South West Wales Cancer Centre
Joanne Upton, Skin Cancer Advanced Nurse Practitioner, The Clatterbridge Cancer Centre
Dr Chris Jenkins, Consultant Haematologist, University Hospital of the North Midlands
Dr Andrew Stewart, Consultant Haematologist, The Royal Gwent Hospital
Dr Andrew Stewart, Consultant Haematologist, The Royal Gwent Hospital
Dr Chris Jenkins, Consultant Haematologist, University Hospital of the North Midlands
Acorn Recovery: Restore IT infra within minutesIP ServerOne
Introducing Acorn Recovery as a Service, a simple, fast, and secure managed disaster recovery (DRaaS) by IP ServerOne. A DR solution that helps restore your IT infra within minutes.
This presentation by Morris Kleiner (University of Minnesota), was made during the discussion “Competition and Regulation in Professions and Occupations” held at the Working Party No. 2 on Competition and Regulation on 10 June 2024. More papers and presentations on the topic can be found out at oe.cd/crps.
This presentation was uploaded with the author’s consent.
0x01 - Newton's Third Law: Static vs. Dynamic AbusersOWASP Beja
f you offer a service on the web, odds are that someone will abuse it. Be it an API, a SaaS, a PaaS, or even a static website, someone somewhere will try to figure out a way to use it to their own needs. In this talk we'll compare measures that are effective against static attackers and how to battle a dynamic attacker who adapts to your counter-measures.
About the Speaker
===============
Diogo Sousa, Engineering Manager @ Canonical
An opinionated individual with an interest in cryptography and its intersection with secure software development.
Sharpen existing tools or get a new toolbox? Contemporary cluster initiatives...Orkestra
UIIN Conference, Madrid, 27-29 May 2024
James Wilson, Orkestra and Deusto Business School
Emily Wise, Lund University
Madeline Smith, The Glasgow School of Art
Have you ever wondered how search works while visiting an e-commerce site, internal website, or searching through other types of online resources? Look no further than this informative session on the ways that taxonomies help end-users navigate the internet! Hear from taxonomists and other information professionals who have first-hand experience creating and working with taxonomies that aid in navigation, search, and discovery across a range of disciplines.
2. Carmel, 63 year old female
Recent diagnosis of Stage 3c Endometrial Cancer
Previously fit and well, was working as a carer until 1
month ago
Phone call to her specialist nurse from her family
• General decline over the past few weeks
- Decreased mobility, not got out of bed for 3 days
- Confused and agitated
- Not eating and drinking
Advised to bring her into AMU for assessment
3. Medical Clerking
History confirmed
• Decreased mobility
• Poor oral intake
• Confused
PMH – hypertension
DH - Amlodipine
Examination
• Dehydrated
• Normal cardiovascular/resp/abdo
examination
• No obvious focal neurology
(difficult)
Observations
Temp 36.5
BP 145/80
HR 78
Sats 96% RA
RR 18
12. 48hrs after that…..
Bloods
Ca 3.6
Ur 24
Cr318
K 5.4
Na 161
Clinically
Remains confused, drowsy
mostly but agitated at times
Difficult maintaining IV
access
Minimal oral intake
Urine output <10ml/hr
13. What should we do next?
A. Continue aggressive treatment on the ward with
fluids/NG feeding/further bisphosphonates
B. Accept that she is deteriorating despite our best efforts
and aim for best supportive care
C. Refer to ITU
D. Refer to renal for haemodialysis
14. What can Level 2 Care add?
Access – fluids, blood sampling
NG feeding + NG water
Higher intensity nursing care
Haemofiltration
15. Progress
5 day admission to Critical Care
• Central line and Arterial line
• NG feeding
• Reversal of AKI
• Confusion improved
Transfer to Gynae ward
• On-going hypercalcaemia – denosumab being
considered
• Having physio/rehab with aim for surgery
18. Patient 3
73 year old
Previous Ischaemic Heart disease (Myocardial infarction
2004),Type 2 diabetes, hypertension and rheumatoid
arthritis
Worked in a shop and retired 12 years ago
Ex-smoker
Limited exercise tolerance due to pain in hip & knees prior
to cancer diagnosis
19. Diagnosed with ovarian cancer 6
months ago.
• Stage 3 at diagnosis (abdomenal deposits, no distant
metastases, BRCA negative)
• Treated with de-bulking surgery
• Slow Post Operative recovery
• Now on 3rd cycle of chemo (1x sepsis admission)
20. Presentation
Breathless on exertion
Worse at night when trying to sleep, some ankle swelling
no fever, mild non-productive cough, no chest pain
Much worse today so called her CNS and as breathless at
rest said go to local ED
Triage Obs- RR 24, Spo2 89% on air, BP 111/65, P92
(regular), GCS 15, CPR 2s, Temp 37.4
21. Stabilise and assess
ED get the ball rolling
ABC approach- sit up, high flow oxygen
ECG- Sinus Rhythm, Left BBB (old) poor r wave
progression, non specific changes
Labs- mild acute kidney injury, high WCC, elevated LFTs,
troponin and BNP requested but not yet available
ABG
26. Initial Treatment of
CCF
High flow oxygen
Immediate treatment- GTN
(IV or sublingual)
Furosemide 40-80mg IV
Continuous Positive Airways
Pressure (CPAP)
Coronary care bed
Assess for ischaemia,
sepsis, progressive disease
Continuous Positive Airways Pressure
Coronary care bed
Assess for ischaemia, sepsis, progressive disease
Initial Treatment of
Congestive Cardiac
Failure (CCF)
27.
28. The big questions
What will we do if this doesn’t work?
What is the prognosis from her underlying
disease?
What does she know about her prognosis?
What discussions have been had around
escalation of care and end of life wishes?
What are we going to say to her and her
family?
30. What next?
Possibilities include
• Intubation and ventilation & Renal Replacement therapy
on ITU
• CVC and inotropes on HDU
• Increase CPAP and give more furosemide
• Best supportive care
31. Multi organ failure-
an acute medic approach
• Patient, What do you know, what do you want?
• How many organs have failed?
• Can we reverse the underlying cause?
• Prognosis of multi organ failure?
• Prognosis of multi-organ failure in advanced cancer?
32. Consideration of critical care in cancer
‘I want you to do everything for her doctor’
• Honest discussions are key
• Reversibility of issues are key
• Critical care ‘Is like running a marathon every day’
• Severe functional limitation at baseline is associated to
mortality in ICU
• Treatment escalation planning (TEP) offers an
opportunity to explore expectations about prognosis,
outcomes, CPR and advance care planning
33. ICU and Cancer
• Adult oncology ICU patients who don’t require ventilation
have a ~25% in-hospital mortality, similar to that of non
oncology ICU patients
• Multiple organ dysfunction syndrome has the worst
prognosis, >60% when 2 or more organs fail and near
100% when 4 or more organs fail.
• Disease-related factors that are associated with worse
prognosis in the critically-ill cancer patients:
• poor response to chemotherapy,
• cancer relapse or progressive disease
• progressive or recurrent disease,
34. Progress
Discussion with critical care, oncology and family
Further invasive treatment not likely to be successful
Best supportive care in hospital, died with family present
that night