1) A 70-year-old woman presented with acute respiratory failure and shock. POCUS revealed bilateral B-lines and a large mitral regurgitation jet, suggesting acute pulmonary edema from mitral regurgitation as the cause.
2) While the initial CXR showed opacity only in the left lung, POCUS found bilateral B-lines, indicating it can detect pulmonary edema earlier.
3) POCUS is useful for quickly identifying significant abnormalities like a large mitral regurgitation jet, but has limitations for comprehensive evaluation of mitral regurgitation.
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
International Lung Symposium on Pleural Diseases, Manila 2019.
Practice changing clinical trials in pleural diseases from 2017 to 2019 by Dr. Gary Lee.
a very concise , palatable guide to clinical practice in patients with cardiovascular disease in no more than 37 slide with each slide taking no more than half minute reading , surely you well like it , please leave us your impressions bellow this will encourage us .
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
International Lung Symposium on Pleural Diseases, Manila 2019.
Practice changing clinical trials in pleural diseases from 2017 to 2019 by Dr. Gary Lee.
a very concise , palatable guide to clinical practice in patients with cardiovascular disease in no more than 37 slide with each slide taking no more than half minute reading , surely you well like it , please leave us your impressions bellow this will encourage us .
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
Deep Leg Vein Thrombosis occurs when a blood clot forms in one or more of the deep veins in the legs. These clots can impede blood flow, leading to severe complications.
Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
1. Shock, Respiratory Failure, and a
Chest X-ray
A Case Discussion of Clinical Reasoning and POCUS
Free Open-Access Medical Education in Point of Care
Ultrasound
Produced by Pitt IM POCUS
2. Overview
Case information
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
Images
• What is your interpretation?
• Limitations of images? How could they be improved?
Diagnostic and management discussion
• What are the next steps in diagnosis and management?
Hospital Course/Learning Points
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?
3. Case info
70s f with ischemic CM, EF 30% p/w with acute resp failure and shock
Pt was well until 12 hrs ago when she began to feel short of breath with exertion. Progressed
to severe dyspnea at rest, with left sided chest pain, productive cough (pinkish sputum),
nausea/vomiting. She has been adherent to lasix and she is near her dry weight.
T 37.1 HR 140 BP 80/60 SpO2 84% RR 40 on BIPAP.
Crackles left lung. JVP not seen. 1+ LE edema b/l. Systolic murmur heard, hard to characterize
due to loud breathing. Intubated due to resp failure/hemodynamic instability. Requiring high
dose pressors. CXR shown in next slide.
Tn was 0.1. Unfortunately with intubation/induction, pt became pulseless (PEA). Was
successfully resuscitated with CPR and epi. The ultrasound machine then became helpful for
access and for quick diagnostics.
5. Case info
70s f with ischemic CM, EF 30% p/w with acute resp failure and shock
Pt was well until 12 hrs ago when she began to feel short of breath with exertion. Progressed
to severe dyspnea at rest, with left sided chest pain, productive cough (pinkish sputum),
nausea/vomiting. She has been adherent to lasix and she is near her dry weight.
T 37.1 HR 140 BP 80/60 SpO2 84% RR 40 on BIPAP.
Crackles left lung. JVP not seen. 1+ LE edema b/l. Systolic murmur heard, hard to characterize
due to loud breathing. Intubated due to resp failure/hemodynamic instability. Requiring high
dose pressors. CXR shown
Tn was 0.1. Unfortunately with intubation/induction, pt became pulseless (PEA). Was
successfully resuscitated with CPR and epi. The ultrasound machine then became helpful for
access and for quick diagnostics.
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
6. Pause before POCUS
Let’s pause before obtaining POCUS images to think…
Pt is sick. With unilateral lung opacity. First thought ie Type 1 reasoning - PNA
But there's some discordance with PNA (no fever, unusual CXR appearance).
Type 2 reasoning kicks in
What about xray appearance?
1) Neither the heart border nor diaphragm is obscured
2) Seems to have "batwing" appearance, but just one side
3) Center appears dense/"alveolar" but periphery appears interstitial
4) R lung seems to have slight interstitial pattern
7. Pause before POCUS
What about xray appearance?
1) Neither the heart border nor diaphragm is obscured
2) Seems to have "batwing" appearance, but just one side
3) Center appears dense/"alveolar" but periphery appears interstitial
4) R lung seems to have slight interstitial pattern
9. Pause before POCUS
POCUS questions
Lung: are there B lines (and where)? Is there consolidation?
Heart: is there MR? (note limited use in POCUS, and not useful as negative - see
article. Is the RV dilated? (Note: EF expected to be reduced. IVC expected to be
dilated.)
DVT: are femoral veins compressible?
10. Pause before POCUS
You have decided to perform POCUS to answer your specific questions.
How will you approach the exam?
a) Take your time and do a good, thorough POCUS exam
b) Take a quick look to try to gather what data you can to answer your
questions
11. Overview
Case information
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
Images
• What is your interpretation?
• Limitations of images? How could they be improved?
Diagnostic and management discussion
• What are the next steps in diagnosis and management?
Hospital Course/Learning Points
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?
12. Left Lung (L1)
• Interpretation?
• Limitations/Feedback on image quality
Right Lung (R1)
17. POCUS interpretation
Here is a repeat CXR 1 hour later, to help understand the process by assessing radiographic
evolution
18. Overview
Case information
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
Images
• What is your interpretation?
• Limitations of images? How could they be improved?
Diagnostic and management discussion
• What are the next steps in diagnosis and management?
Hospital Course/Learning Points
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?
19. Diagnostic and Management Discussion
What is going on?
What are the next steps in diagnosis and management?
20. Overview
Case information
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
Images
• What is your interpretation?
• Limitations of images? How could they be improved?
Diagnostic and management discussion
• What are the next steps in diagnosis and management?
Hospital Course/Learning Points
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?
21. Hospital Course
• Initially seemed most likely PNA (vs MR).
• POCUS did reveal a very large MR jet (note: classifying severity is nuanced)
• In pt with already fair prob of acute MR, the POCUS findings further raised
that probability.
• The dx was felt to be acute MR, possibly due to papillary muscle rupture
• Hard to say for sure there is not PNA but seems less likely the primary process.
22. Questions/Learning Points
1) How can acute MR cause a unilateral lung opacity?
2) Why did POCUS reveal b/l pulmonary edema, while CXR only left sided
3) How useful is POCUS for mitral regurgitation?
23. 1) How can acute MR cause a unilateral lung opacity?
MR jet usually affects R upper
PV —> increase in PCWP on
the right side --> larger degree
of right-sided edema.
But in 11% of cases, affects L
lung only
http://www.radiologyassistant.nl/en/p4c132f36513d4/chest-x-
ray-heart-failure.html
24. 2) Bilateral B-lines, but unilateral CXR opacity?
B-lines appear earlier than CXR opacities
A systematic review of diagnostic modalities for dx of acute heart failure
in ED sheds light on this...
Lung US has higher sensitivity vs CXR for identifying pulm edema
https://www.ncbi.nlm.nih.gov/pubmed/26910112
25. 2) Bilateral B-lines, but unilateral CXR opacity?
https://www.ncbi.nlm.nih.gov/pubmed/26910112
26. 2) Bilateral B-lines, but unilateral CXR opacity?
A study of IM/EM/Radiology residents also found better accuracy of Lung
US vs CXR for identifying pulmonary edema. Interestingly, confidence
was higher with CXR, though accuracy was higher with US
https://www.ncbi.nlm.nih.gov/pubmed/23263648
27. 2) Bilateral B-lines, but unilateral CXR opacity?
https://www.ncbi.nlm.nih.gov/pubmed/23263648
28. Note that POCUS (and even TTE) can underdiagnose MR, especially if the jet is
eccentric.
Don't be falsely reassured by a negative study. A markedly positive study, as in
this case, may be very helpful.
No data on POCUS for MR
3) POCUS and Mitral Regurgitation
29. Case wrap-up
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?
30. Take home points
• Ultrasound detects pulmonary edema sooner (i.e. at lower PCWP) than CXR
• When encountering a unilateral lung opacity on CXR, consider acute MR as a
possible etiology
• POCUS may not be very sensitive for detecting MR, but may be useful to
quickly identify a significant abnormality
• Some cases may call for a very quick and focused POCUS exam rather than
an extensive, thorough one
31. Want to dive deeper into this case, or see more cases?
This case was presented by Pitt IM POCUS on twitter in May 2019. Follow this
link to see the full thread, including comments and discussion from the POCUS
MedTwitter community. We thank the MedTwitter community for
contributions to this thread.
Please follow us at @PittIMPOCUS
Follow this link for other case presentations
Any questions, please contact
Michelle Fleshner – mfleshner301@gmail.com
Steve Fox – stevefox00@gmail.com
32. This is free, open access medical education. You may download, share, modify,
and use freely when used for medical education.
Patient confidentiality is the priority in these cases, so details may be left out
or modified to prevent identification. An effort is made to maintain the
educational quality.
33. References/Additional Reading
• CXR findings at varying PCWP thresholds (Radiology Assistant)
• Diagnosing Acute Heart Failure in the ED (Martindale, SAEM 2015)
• Diagnosing Pulmonary Edema: Lung US vs CXR (Martindale, EJEM 2013)
