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 All Recommendations are level ‘C’: “Expert opinion”  When preparing to give bad news, assess patient’s level of understanding about disease and future.

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Presentation on theme: " All Recommendations are level ‘C’: “Expert opinion”  When preparing to give bad news, assess patient’s level of understanding about disease and future."— Presentation transcript:

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2  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.

3  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

4  Avoid phrases & words that can be misconstrued & lead to misconceptions such as abandonment & failure  Assess and be sensitive to pt’s cultural & individual preferences

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

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

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

8  Algorithm for what to do w.r.t. pt preference on knowing about prognosis  Commonly Misconstrued Physician phrases

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10  What is the difference between a hunter & a fisherman?  A hunter lies in wait.  A fisherman waits & lies.

11  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

12  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

13  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: $ per month

14  May Work BUT  Research is inadequate to support any recommendation for usage

15  Devil’s Claw : May work; BUT need more study on safety  Turmeric : Anecdote only  Ginger : Maybe; BUT not enough evidence to make recommendation

16  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

17  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 1 st step in RX BN & BED : ‘B’

18  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

19  Diagnostic criteria  Level of Care guidelines, outpt vs inpt  Medical Complications of Eating Disorders  Components of Guided Self-Help  Practical Questions & Statements during interview

20  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.”

21  Abscess formation outside tonsillar capsule  Signs and symptoms: › Fever › Sore throat › Dysphagia/odynophagia › Drooling › Trismus › Unilateral swelling of soft palate/pharynx with uvula deviation

22  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

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24  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

25  Group A beta-hemolytic is most recognized pathogen  Associated with a risk of rheumatic fever and glomerulonephritis  Many other organisms are involved

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

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28  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

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

33  Aerobic › Grp A Strep › Staph A › H. InFLU  Anaerobic › Fusobacterium › Peptostreptococcus › Pigmented Prevotella

34  Drainage  Antibiotics  Supportive care

35  Needle aspiration  I & D

36  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

37  Most Outpt  If aspirate, watch for 3-4 hrs to ensure PO ABX & analgesics  F/U 24 hrs  ABX x 10 days

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

39  42 yo nonhealing ulcer x 6 weeks  Painless, 2 CM, superficial,  Firm base, Indurated edges  No buboes  What is it?  Why?

40  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

41  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?

42  Ngo-Metzger Q. et al. End-of-Life Care: Guidelines for Patient- Centered Communication. AFP. January 15, Vol 77. No 2.  Gregory P. et al. Dietary Supplements for Osteoarthritis. AFP. January 15, Vol 77. No 2.  Galiato N. Peritonsillar Abscess. AFP. January 15, Vol 77. No 2.


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