This document discusses a case where a patient's do not resuscitate (DNR) status was unclear, leading to cardiopulmonary resuscitation being performed against her initial wishes. It provides tips for improving discussions around advanced care planning and DNR status, including using simple language, assessing patient understanding, distinguishing reversible from irreversible conditions, and revisiting goals of care regularly. The case highlights challenges around documenting and communicating patient preferences, as well as ensuring informed consent around life-sustaining treatments.
Fibromyalgia Over-Diagnosed 97% of the timeNelson Hendler
97% of patients told they have fibromyalgia do not meet the diagnostic criteria for this diagnosis, and have treatable disorders, such as nerve entrapments, thoracic outlet syndrome, discs which do not show on MRI, facet syndromes, etc.
Fibromyalgia Over-Diagnosed 97% of the timeNelson Hendler
97% of patients told they have fibromyalgia do not meet the diagnostic criteria for this diagnosis, and have treatable disorders, such as nerve entrapments, thoracic outlet syndrome, discs which do not show on MRI, facet syndromes, etc.
Subarachnoid Block With Low Dose Bupivacaine And Fentanyl In Elderly Hyperten...lgmitra01
read value of mg Fentanyl as mcg- printing error- posted as not available online anymore -
Subarachnoid Block With Low Dose Bupivacaine And
Fentanyl In Elderly Hypertensive Female Patients Undergoing Vaginal Hysterectomy
1Dr. Lalita Gouri Mitra, 2Dr.Suman Chattopadhyay, 3Dr. B. N.Biswas, 4Dr. Manjushree Ray, 5Dr.Pinaki
Mazumder.
INDPAIN FALL Vol. 20 No. 2, 2006
BASIC CASE HISTORY CONTAINING, INTRODUCTION,CLINICAL EXAMINATION- GENERAL, SOFT TISSUE EXAMINATION, HARD TISSUE EXAMINATION, PROVISIONAL DIAGNOSIS, DIFFERENTIAL DIAGNOSIS, SPECIAL INVESTIGATIONS, FINAL DIAGNOSIS, PROGNOSIS, PHASES OF TREATMENT PLANNING
Isolated Cerebellar Stroke Masquerades as DepressionZahiruddin Othman
There are numerous reports on neurological conditions masquerading as psychiatric disorders. However, cerebellar
stroke is not established as one of it. The 2 case reports will highlight that this masquerade is possible and the physician's
high index of suspicion is the key to accurate diagnosis.
EMGuideWire's Radiology Reading Room: PneumoniaSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Pneumonia and is brought to you by Elissabeth Hagler, MD and Tom Shuman, MD. Guest Editor is Michael Leonard, MD, Infectious Disease specialist.
EMGuideWire's Radiology Reading Room: Peripartum CardiomyopathySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Peripartum Cardiomyopathy and is brought to you by Kaley El-Arab, MD, Blaire Langa, NP, Claire Lawson, NP, and Ashley Moore Gibbs, DNP. It is has the special guest editors: Richard Musialowski, MD and Laszlo Littmann, MD.
Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery: April CasesSean M. Fox
Drs. Potter and Richardson are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Dr. Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology Topics including:
• VP Shunt Disconnection
• E-cigarette Vaping Associated Lung Injury
• Apical Lung Mass
• Pulmonary Metastasis
• Vascular Ring
Subarachnoid Block With Low Dose Bupivacaine And Fentanyl In Elderly Hyperten...lgmitra01
read value of mg Fentanyl as mcg- printing error- posted as not available online anymore -
Subarachnoid Block With Low Dose Bupivacaine And
Fentanyl In Elderly Hypertensive Female Patients Undergoing Vaginal Hysterectomy
1Dr. Lalita Gouri Mitra, 2Dr.Suman Chattopadhyay, 3Dr. B. N.Biswas, 4Dr. Manjushree Ray, 5Dr.Pinaki
Mazumder.
INDPAIN FALL Vol. 20 No. 2, 2006
BASIC CASE HISTORY CONTAINING, INTRODUCTION,CLINICAL EXAMINATION- GENERAL, SOFT TISSUE EXAMINATION, HARD TISSUE EXAMINATION, PROVISIONAL DIAGNOSIS, DIFFERENTIAL DIAGNOSIS, SPECIAL INVESTIGATIONS, FINAL DIAGNOSIS, PROGNOSIS, PHASES OF TREATMENT PLANNING
Isolated Cerebellar Stroke Masquerades as DepressionZahiruddin Othman
There are numerous reports on neurological conditions masquerading as psychiatric disorders. However, cerebellar
stroke is not established as one of it. The 2 case reports will highlight that this masquerade is possible and the physician's
high index of suspicion is the key to accurate diagnosis.
EMGuideWire's Radiology Reading Room: PneumoniaSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Pneumonia and is brought to you by Elissabeth Hagler, MD and Tom Shuman, MD. Guest Editor is Michael Leonard, MD, Infectious Disease specialist.
EMGuideWire's Radiology Reading Room: Peripartum CardiomyopathySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Peripartum Cardiomyopathy and is brought to you by Kaley El-Arab, MD, Blaire Langa, NP, Claire Lawson, NP, and Ashley Moore Gibbs, DNP. It is has the special guest editors: Richard Musialowski, MD and Laszlo Littmann, MD.
Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery: April CasesSean M. Fox
Drs. Potter and Richardson are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Dr. Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology Topics including:
• VP Shunt Disconnection
• E-cigarette Vaping Associated Lung Injury
• Apical Lung Mass
• Pulmonary Metastasis
• Vascular Ring
Do Not Resuscitate Orders : What They Mean ?SMSRAZA
Most doctors working in Acute areas know when and how to do CPR. However, most get stuck when it comes to ' When not to do CPR' due to cultural, social, ethical and legal issues attached.
GEMC - Conquering the Sign-Out Challenge Open.Michigan
This is a lecture by Dr. Pamela Fry and Dr. Alison Haddock from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC: Conquering the Sign-Out Challenge: Resident Training Open.Michigan
This is a lecture by Dr. Pamela Fry and Dr. Alison Haddock from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
Approach to internship (mbbs in bangladesh perspective)Pritom Das
Some slides are taken from different textbooks of medicine like Davidson, Kumar and Clark and Oxford, and some from other presentations made by respected tutors. These resources are free for use, and I do not claim any copyright. Hoping knowledge remains free for all, forever.
The practice of anesthesia and sedation continues to expand beyond the operating room and now includes the gastroenterology suite, magnetic resonance imaging suites, and the cardiac catheterization laboratory. Non-anesthesiologists frequently administer sedation, in part because of a lack of available anesthesiologists and economic aspect, which emphasizes the safety of sedation. The Joint Commission International (JCI) set a standard responding to this issue indicating that qualified individuals who have drug and monitoring knowledge as well as airway management skills can only administer sedating agents.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
2. Source and Credits
• This presentation is based on the July 2003
AHRQ WebM&M Spotlight Case
• See the full article at http://webmm.ahrq.gov
2
3. Objectives
At the conclusion of this educational activity,
participants should be able to:
• Appreciate challenges of determining goals of care in
hospitalized patients
• Understand common misconceptions about CPR
• List typical mistakes physicians make when
discussing advanced care planning
• Recognize steps physicians and health care systems
can take to improve advanced care discussions
3
4. Case: NFR Status Confusion
A 60-year-old woman with a history of severe
asthma without prior intubations presented to
the ED with shortness of breath. On physical
examination, her BP was 145/85, HR 85,O2 sat
94% with a respiratory rate of 22. Her lung
exam revealed diffuse-end expiratory wheezes
and decreased breath sounds at the bases.
Despite a long-standing relationship with health
care professionals, the patient had not
completed a living will prior to admission.
4
5. Advanced Directives
• 75% of patients who present to the ED do not
have advanced directives
– Even fewer in absence of terminal diagnosis
• When completed, advanced directives are
often unavailable upon hospitalization or are
difficult to interpret
• Hospital-based physicians often discuss NFR
status with patients they have not met
previously
5 Ishihara KK, et al. Acad Emerg Med. 1996;3:50-3.
6. Patients’ Preferences Regarding CPR
• 30% of patients with serious underlying
illness do not want resuscitation
• Physicians cannot accurately predict
patients’ preferences without asking them
6 Hofmann JC, et al. Ann Intern Med. 1997; 127:1-12.
7. Case (cont.): NFR Status Confusion
Upon admission, the H/S spoke with the patient about
NFR status. The patient stated that she “would not want
to be on a tube to breathe.” About CPR, she did not
want “shocks to the heart or pressing on my heart.” She
said if her breathing continued to be this difficult and
she could not live independently, she would rather not
survive. The H/S interpreted these statements as
indicating the patient’s desire for NFR status, and called
the resident to discuss it, but a NFR form was not
completed at that time.
7
8. Common Features of
NFR Status Discussions
• Use of vague language
– “Would you want your life prolonged?”
• Use of dire scenarios
– Only 50% of Dr’s present scenarios with
reversible conditions
• Failure to elicit patient concerns and discuss
goals of care
– Rarely clarify “small chance” recovery, poor
quality of life
8 Tulsky JA, et al. Ann Intern Med. 1998;129:441-449.
9. Common Features of
NFR Status Discussions
• Domination of discussion by physician
– Physicians speak nearly three-fourths of the time
• Use of medical jargon
– Without confirming patients understanding
9 Tulsky JA, et al. J Gen Intern Med. 1995;10:436-442.
10. Do Patients Understand CPR?
• Survey results: patients have misconceptions
even after discussions:
– CPR survival estimated to be 70% (in reality is
10%-15%)
– 26% could not identify features of CPR
– 37% thought ventilated patients could talk
– 20% thought ventilators were O2 tanks
– 20% thought people on ventilators were in a coma
10 Fischer GS, et al. J Gen Intern Med. 1998;13:447-454.
11. Case (cont.): NFR Status Confusion
A few hours after admission, the patient had
sudden respiratory failure leading to pulseless
electrical activity (PEA) arrest. As there was no
NFR form in the chart, the nurse called a resus
team and CPR was initiated. The resus team
found the H/S’s initial assessment, which
stated the patient’s preference for no
resuscitation or intubation efforts.
11
12. Case (cont.): Code Status Confusion
The registrar had discussed the case briefly
with the H/S (including her interpretation that
the patient wished to be a NFR), but neither
the registrar nor the H/S had discussed NFR
status with the patient. At this time, the
patient’s blood pressure was 90/palpable,
heart rate was 40 and an O2 saturation was
92% with assisted bag-mask ventilation.
12
13. The NFR Status Dilemma
• Documentation—No NFR status documented in
chart; therefore, resus initiated
• Autonomy—Patient had expressed wish to be NFR
to H/S on admission
• Beneficence—Team knew prognosis of witnessed
arrest from asthma exacerbation was good
• Informed decision making—Team concerned patient
was not fully informed when she requested to be
NFR on admission
– This is the only ethical justification for overriding a
NFR order
13 Lo B. Promoting the patient’s best interests. In: Resolving ethical
dilemmas: A guide for clinicians (2nd ed.). 2000:30-41.
14. Case (cont.): NFR Status Confusion
The patient did receive cardiopulmonary
resuscitation, including medications and chest
compressions. In an effort to respect her
preference to avoid invasive ventilation, she
was started on noninvasive bi-level positive
airway pressure (BIPAP) ventilation.
Spontaneous respirations returned with
BIPAP, and the patient was stabilized.
14
15. Case (cont.): NFR Status Confusion
The next day, the patient was alert and able to
express her thoughts about the events of the
previous night. She had not realized that
intubation could be a temporizing measure—
she thought it meant permanent respiratory
support. She had thought the discussion was
about whether she would want to be kept alive
if she was “a vegetable.”
15
16. Case (cont.): NFR Status Confusion
Furthermore, the patient said that she had
not realized that resuscitation attempts could
be successful. After her experience, she
stated that she did want aggressive
interventions for reversible causes.
Her NFR status was changed to full resus.
16
17. Tips for Discussing Advanced Directives
• Do more listening and less talking
• Elicit patients’ values and overall goals of
care—match interventions with these goals
• Use simple language
• Make clear the alternative to CPR is death,
and express the likely survival after CPR.
– Distinguish situations where outcomes are better,
such as in the OT or during conscious sedation
for procedures
17
18. Tips for Discussing Advanced Directives
• Ask about preferences in scenarios with
uncertain outcomes
– i.e., successful cardiac resuscitation with resultant
severe anoxic brain injury
• Assess the patient’s understanding
– Especially if decision is contrary to what would be
expected in similar patients
• Reassess the patient’s goals of care at every
hospitalization
18
19. Recommendations for Hospitals
and Educators
• Standardize the NFR order sheet
– Separate authorization for CPR, intubation, and
vasopressors
– Consider including other life-prolonging
interventions (i.e., tube feeds, antibiotics, dialysis)
that may be instituted in patients who will not
receive CPR
19