all recommendations are level ‘c’: “expert opinion” when preparing to give bad news, assess...

All Recommendations are level ‘C’: “Expert opinion”

When preparing to give bad news, assess patient’s level of understanding about disease and future expectations

When preparing to give bad news, assess how much info the pt wants to know.

PCP should remain involved with the pt during all stages of cancer

Initiate discussions ref availability of svcs like palliative care early. As dz progresses, transition from curative to palliative care

Avoid phrases & words that can be misconstrued & lead to misconceptions such as abandonment & failure

Assess and be sensitive to pt’s cultural & individual preferences

Prioritize Practice & Prepare Assess Patient Understanding Determine Patient Preferences Present Info Provide Emotional Support Discuss Future Options Offer Additional Spt Consider individual Preferences

Breaking bad news Communicating Prognosis Discuss Disease transitions Coordinate Care Provide Support

Physician Frankness Family Involvement Decision-Making Advance Care planning Social, educational and family factors Religious & spiritual factors

Algorithm for what to do w.r.t. pt preference on knowing about prognosis

Commonly Misconstrued Physician phrases

What is the difference between a hunter & a fisherman?

A hunter lies in wait. A fisherman waits & lies.

Glucosamine Sulfate may be used for reducing SX and possibly slowing Dz progression in DJD of knee: ‘B’

Not Glucosamine hydrochloride Patients may need additional SX relief

from analgesics 1500 mg Qday or 500 TID Cost: $9-35 per month

Chondroitin may provide modest benefit in some patients; but has no advantage over glucosamine: ‘B’

Research is not of high quality REC: Try Glucosamine first May Interact with Warfarin Cost : $10-25 per month

S-adenosylmethionine may reduce DJD pain, but is a less appropriate option for most patients : ‘B’

Probably takes several weeks to be effective

Reports of hypomania with it; SSRIs Unstable shelf life Cost: $60-120 per month

May Work BUT Research is inadequate to support any

recommendation for usage

Devil’s Claw : May work; BUT need more study on safety

Turmeric : Anecdote only Ginger : Maybe; BUT not enough

evidence to make recommendation

The great tragedy of Canada is that They could have had

› French cuisine› British Culture &› American technology

Instead they have› British cuisine› American culture &› French technology

Interpersonal or CBT should be offered to pts with bulimia nervosa (BN) & binge-eating disorder (BED): ‘A’

A self-help program may be considered the 1st step in RX BN & BED : ‘B’

Most Pts with anorexia nervosa (AN) should be treated as outpatients in a tertiary care setting by a multidisciplinary team : ‘C’

Antidepressant trial may be offered as primary RX or in combo with psychotherapy in Pts with BN

Diagnostic criteria Level of Care guidelines, outpt vs inpt Medical Complications of Eating

Disorders Components of Guided Self-Help Practical Questions & Statements

during interview

While heading into the jungle, she thought that she would impress her boyfriend with her knowledge, so she turned to the safari guide and said, “I know that carrying a torch will keep lions away.”

The guide replied, “That depends on how fast you carry the torch.”

Abscess formation outside tonsillar capsule

Signs and symptoms:› Fever› Sore throat› Dysphagia/odynophagia› Drooling› Trismus› Unilateral swelling of soft palate/pharynx with

uvula deviation

Paired, sit in tonsillar sinus Limited anteriorly by palatoglossal arch,

posteriorly by palatopharyngeal arch, laterally by superior pharyngeal constrictor

Enclosed in a fibrous capsule Blood supply from tonsillar and ascending

palatine branches of facial artery, ascending pharyngeal artery, dorsal lingual branch of the lingual artery and the palatine branch of maxillary artery

Part of secondary immune system No afferent lymphatics Exposed to ingested or inspired antigens

passed through the epithelial layer Immunologic structure is divided into 4

compartments: reticular crypt epithelium, extra follicular area, mantle zone of the lymphoid follicle, and the germinal center of the lymphoid follicle

Group A beta-hemolytic is most recognized pathogen

Associated with a risk of rheumatic fever and glomerulonephritis

Many other organisms are involved

Signs and symptoms:› Fever› Sore throat› Tender cervical lymphadenopathy› Dysphagia› Erythematous tonsils with exudates

Thought to be extension of tonsillitis to involve surrounding tissue with abscess formation

Recently described to be an infection of small salivary glands in the supratonsillar fossa called Weber’s glands

Would explain superior pole involvement and the usual absence of tonsillar erythema/exudates

Airway Obstruction Aspiration Pneumonitis or Abscess Death from carotid erosion Beep tissue extension Poststreptococcal sequelae

Aerobic› Grp A Strep› Staph A› H. InFLU

Anaerobic› Fusobacterium› Peptostreptococcus› Pigmented Prevotella

Drainage

Antibiotics

Supportive care

Needle aspiration I & D

IV:› Unasyn 3 gr Q 6 hrs› Pcn G 10 million Q 6 hrs PLUS Flagyl

500mg q 6› PCN allergy? Clindamycin 900 mg q 8 hrs

Oral :› Augmentin 875 mg BID› PCN VK 500 mg QID PLUS Flagyl 500 QID› Cleocin 600 mg BID

Most Outpt If aspirate, watch for 3-4 hrs to ensure

PO ABX & analgesics F/U 24 hrs ABX x 10 days

Steroid MAY help speed recovery If not competent/confident, refer to

ENT

42 yo nonhealing ulcer x 6 weeks Painless, 2 CM, superficial, Firm base, Indurated edges No buboes

What is it? Why?

Evidence favors Late cord clamping (> 2 minutes):anemia risk & iron stores; no clinical adverse problems

Less Anticoagulation Needed after DVT or PE : 3 months as good as 6 months with less hemmorhage. Caveats

Q Day ICS (with salmeterol) OK for step-down RX in pts with mild, persistent Asthma

Pulmonary Rehab works in COPD :› Endurance and weight training› Inspiratory muscle trng: NO› CPT : NO› Nutritional supplements: NO› Longer & higher intensity are better

Premature Rupture of Membranes:› What to do at what EGA› Nothing new?

Ngo-Metzger Q. et al. End-of-Life Care: Guidelines for Patient-Centered Communication. AFP. January 15, 2008. Vol 77. No 2.

Gregory P. et al. Dietary Supplements for Osteoarthritis. AFP. January 15, 2008. Vol 77. No 2.

Galiato N. Peritonsillar Abscess. AFP. January 15, 2008. Vol 77. No 2.