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Grand Rounds Presentation

Transcript: Grand Rounds Joanna Davenport Anna Heller Introduction Introduction Joanna Davenport is an 18 year old caucasion woman who was self reffered with support from her mother and school teacher. Joanna is experiencing anger, anxiety, social withdrawl, and has a difficult time expressing and understanding her emotions. Referral Question- How can Joanna learn to control her anger? Background Background Medical Hisory- no serious illnesses, accidents or surgeries. No medications Developmental History- Uncomplicated birth, reached developmental milestones on time. She began having tantrums at the age of 3. An articulation disorder (lisp) also began at the age of 3 which persisted until she began speech therapy classes in the 8th grade. Family and Social History- Raised by bilogical mother and father whom had a conflictual relationship. She is close with her mother who is supportive of her. Her father has trouble understanding her and impliments a lot of tough love and punishment. Background Continued She fights with her two older sisters often. Hitting and throwing things at them in earlier years but now just gets in verbal altercations with them. She was often bullied for her lisp growing up which would trigger tantrums. She had a hard time making friends. She has one close friend who she is able to confide in and would stick up for her in school but she recently moved to a different town and now they rarely talk or see each other. She is also feels close to her school teacher. She is not involved in any clubs, social activities, or church. Background Continued Background Continued Abuse History- Her father paddled her on the bottom as a child as a form of discipline. Occupational Hisory- employed through Dairy Queen. She is not satisfied as she does not get along with her coworkers and has a hard time controlling her anger with customers. Mental Helth History- Her mother is diagnosed with anxiety. Joanna has never sought mental health services before this time. Substance use History- No history of substance abuse. Educational History- Senior at St. Clairsville HIghschool. No learning problems, usually averaging C's. Has trouble focusing in class because a lack of sence of belonging socially. Background Continued Mental Status On time Neetly groomed Dressed appropriately Cooperative and eager to participate Appropriate eye contact Some psychomotor agitation, playing with her hair and shirt Mental Status Kaufman Brief Intelligence Test, Second Edition (KBIT-2): Interpretation of Tests Verbal Intelligence Standard Score- 126 (above average) Nonverbal Intelligence Standard Score- 108 (average) IQ- 120 (above average) Minnesota Multiphasic Personality Inventory- Third Edition (MMPI-3) Interpretation of Tests She read items carefully and responded in a consistent and thoughtful manner, neither overstaing or understating. Should be assessed for: Internalizing disorders, depression related disorders, anxiety related disorders including PTSD, anger related disorders, personality disorders involving detachment such as avoidant and schizoid, attention related disorders, externalizing disorders, impulse control disorders, disorders associated with interpersonal aggression, personality disorders involving mistrust of and/ or hostility toward others and acting out behaviors personality disorders involving disinhibited behavior such as antisocial and borderline disorders, disorders involving excessively assertive or domineering behavior, personality disorders involving antagonistic behavior such as narcissistic and antisocial Conceptualization Conceptualization Presentation- anger, anxiety, socially avoidant. Precipitant- Lisp, best friend moving, socially avidant, not expressing her emotions accurately, parents conflictual relationship Bilogical predisposition- anxiety Pattern- acting out aggressively (yelling); maintained by having a small support system Highly acculturated, no evidence of prejudice or conflicting cultural expectations Personality structure- avoidant Self schemas- Nobody understands me or likes me Other schemas- my parents fight because of me Skill Defecits- emotional regulation, expressing emotions, social skills Conceptualization Contunued Social- (current) small support system, mother and teacher are supportive, bullied and outcasted by classmates for anger outbursts. (past) best friend moved away recently. Challenges- ambivalent resistence, may not take well to any constructive criticism may benefit from having a female therapist Conceptualization Continued Diagnosis Intermittent Explosive Disorder Meets all criteria- 1. A. verbal aggression (tantrums verbal arguments). B. aggression is out of proportion to precipitating stressors. C. aggressive outbursts are not premeditated (impulsive/ anger based). D. Aggressive outbursts cause disress in the individual and impairment in occupational and interpersonal functioning. E. At least 6 years old. F. Not better explained by another mental disorder Diagnosis

Grand Rounds Presentation

Transcript: Balance Pt responded very well to treatment. Frequent breaks. Comfortable with stairs. Very comfortable with the rollator walker. ~The End~ Group 12: Sam Seratelli, Sarah Sergeant, Mike Stasik Intervention What else could we have done? Goal Interventions Stair training COPD Spontaneous pneumothorax (2) Any Questions? Grand Rounds Presentation Pt will be able to ambulate 100ft independently with a rollator walker and oxygen by increasing his strength and respiratory endurance in 2 weeks so that he can be a community ambulator. Assessment Gait training Patient Description Any Ideas?! 82 year old male Focus of our treatment? Take aways: Communication Style Adaptation

Grand Rounds Presentation

Transcript: Patient, Mr. I.P, week 6 clinical placement Admitted to Medical Floor after undergoing a frontal twist drill craniostomy to relieve a subdural hematoma caused by fall-related injury with direct impact to the head. NURSING INTERVENTIONS INTERCONNECTIONS Place pt. bed in lowest possible position and use a floor pad at side of bed. (Doenges et al., 2016) R/T insufficient fluid intake, dysuria, incontinence AEB urinary retention, urinary tract infection, catheterization Provide pt. with frequent teaching of the consequences of falling, and importance of safety. measures red blood cell, count, white blood cell count, and platelet count. A low red blood cell count indicates significant blood loss. captures image of the brain and depicts bleeding around the brain, confirms the presence of the subdural hematoma. b | Twist drill craniostomy showing a single twist drill hole created over the thickest portion of the hematoma with a minimally invasive hollow screw in place. a | Burr hole craniostomy with subdural drain. Figure shows two burr holes created with a perforator. GRIEVING ACUTE CONFUSION Medications List Visual impairment R/T macular degeneration Has eye glasses- often forgets to put on No hearing impairment Cognition fluctuates throughout the day Disoriented to date/time; oriented to person/event 'Pleasantly confused' Some word-finding difficulties Dx dementia 2010 Risk for Falls CT Image of Chronic Subdural Hematoma Reduce clutter in pt. room by putting shoes under bed, and ensuring clear path from bed to door/commode. Foley catheter (emptied: 0700hr 800cc, 1900hr 500cc) with 'leg bag' Often forgets about catheter and complains of having to urinate Small type 1 BM found in bed 0730hr Urinary retention prior to hospitalization Wears incontinence briefs at all times Typically uses commode for bowel movements Priority problem: Using proper mobility device will improve balance and gait reducing likelihood of falling. Lowering the bed and providing a floor pad will decreass the severity of injury if pt. were to fall out of bed. Sex: Male Age group: 80-90 Diagnoses: Chronic subdural hematoma, benign prostatic hyperplasia, dementia, urinary retention, COPD, UTI (ESBL E. Coli) Vitals (2/13/17 0800hr): BP 114/60 T 36.6 C R 18/min R.A HR 88 bpm O2 Sat 96% Concept Map RISK FOR FALLS Health Perception- Management c | Minicraniotomy with subdural drain. This procedure is usually reserved for recurrent CSDH with extensive organization and membrane formation, or primary evacuation of a CSDH that has a substantial acute component. tests the patients' mental status by observing quality of speech, level of consciousness, Glasgow Coma Scale score, orientation to time, place and person, memory, and attention span as well as nerve functioning. DIAGNOSTIC TESTS Advair Diskus (fluticasone, salmeterol)- inhaled corticosteroid and bronchodilator; opens airways for gas exchange Allopurinol (Zyloprim)- xanthine oxidase inhibitor decreases high uric acid levels to treat gout and kidney stones Clotrimazole (Canesten)- anti-fungal cream to treat candidiasis yeast infection Dutasteride (Avodart)- to treat benign prostatic hyperplasia (enlarged protate) PEG 3350 prn- osmotic laxative draws large amount of water into to colon to evacuate stool Risperidone prn- antipsychotic medication administered prn to manage behaviours such as aggression Tamsulosin- for urinary retention- relaxes muscles of the bladder neck to ease passage of urine Tiotropium Bromide (Spiriva)- anticholinergic bronchodilator Regular diet- requires set up and cuing to eat a meal or will not eat Allergy to Codeine Upper and lower full dentures Insufficient fluid consumption- 400 mL over 12 hours Urinary Tract Infection (ESBL+) History of GI Bleeds Abdominal assessment findings: audible normal bowel sounds in all 4 quadrants (02/13/17 1140hr) April 10, 2017 Amanda Hill, SPN2 Common treatment options for Subdural Hematoma http://emedicine.medscape.com/article/344482-overview#a2 R/T loss of spouse, anticipatory loss of friends, anticipatory loss of current home, movement to LTC AEB altered sleep pattern, pt. expression of distress regarding moving and loss of spouse Living at retirement home in Arthur, ON prior to hospitalization Verbalized he is sad to be leaving his friends at the home and moving to LTC post hospital discharge Reports his family lives within 10 minutes of him Married for over 50 years to his late wife One biological son with wife, and two step-children from wife's previous marriage Six granddaughters, two grandsons, 18 great-grandchildren Career Hx of truck driving and volunteer fire fighting Recovering from twist drill craniostomy, on contact isolation precautions Proud to discuss his large family, especially his two granddaughters that are nurses Social, talkative, and enjoys reminiscing about Hx of travel with wife and family Expresses loneliness resulting from current loss of wife and current hospitalization and isolation Expressed feelings of sadness

Grand Rounds Presentation

Transcript: Physical Assessment History of Present Illness Last visit with Ms. "E" VS Stable Labs: patient refuses phlebotomy sticks for lab values Discharge to boyfriend's home per pt. request Continue Methadone outpatient in Watts Abscess D/C IV Vanco Rx: PO Bactrim UTI Urine Culture + E. Coli D/C IV Vancomycin Rx: PO Cipro Wound care education Fu in clinic 3-4 days for symptoms check and to establish primary care Abscess Management Active Diagnoses Abscess of right hip PICC line Surgery Consult for I & D Vancomycin IV Thorazine PO Drug abuse Methadone Acute UTI Bactrim PO Repeat UA Urine Cx Gentamicin IV Acute pain Norco PO only NO IV pain meds Morphine sulfate sub Q Acute hypokalemia Potassium PO Acute hyponatremia NS Bolus IVFs Cardiovascular BP 103 Respiratory Clubbing of nails Integumentary R hip: 20 x 15 erythematous lesion blanching warmer fluctuant mass No necrosis No crepitus L hip: multiple older lesions Thank You! HPI Continued Report Labs Blood Cultures Lactate Renal Function CK to rule out Rhabdomyolysis Diagnostics Ultrasound distinguishes cellulitis vs abscess Lymph node enlargement and lymphatic streaking confirm cellulitis Dx Management Antibiotics **MRSA** PO Bactrim, doxycycline, Linezolid IV Vanco, Daptomycin, Linezolid, Clindamycin IVFs I&D surgery Ellipitical incision Loop drainage technique O2 CVP monitoring Loose packing Past Medical History Taj Price-Gibson California State University, Los Angeles Ms. "E" 37 y.o. Caucasian Female English Speaking Single No children Admitted to WMMC ED CC: Right hip abscess Admission date: 4/16/17 CC: Abscess LOS: 3 days Day 1: April 16 Day 2: April 17 Day 3: April 18 April 16, 2017 CC: R hip Abscess x 1 week w/ non radiating pain To WMMC ED Constitutional + Diffuse body aches x 1 week + Fatigue x 1 week + Subjective fever x 1 week + Chills + Diaphoresis + weakness + diffuse pain + throbbing pain to abscess site non radiating 8/10 - no exudate or leakage + Severe withdrawal + heroin use 2 hours ago ENT + Nasal congestion + Sore throat Respiratory + Sputum production + Cough Pus accumulation within tissue of body Furuncle or Carbuncle Cellulitis Signs & Symptoms Warmth Redness Pain Swelling Fluctuant fluid Purulent odor or pus drainage Sub Q Air Associated Cellulitis Etiology Staph Aureus Chronic: E. Coli** Risk factors IVDA& Chemical irritants PMH IVDA heroin & methadone 40 cc/day or 2 “packs”/ day Methadone clinic last time 3 mos ago Endocarditis ECHO ORDERED PSH Appendectomy Cholcystectomy Hysterectomy Allergies Penicillin Toradol Home Medications: None Cardiovascular + Palpitations Gastrointestinal + Nausea GU + Dysuria + Polyuria Lymphatics + Swollen lymph glands MS + Joint pain + Muscle pain + Claudication + Decreased ROM Integumentary + Rashes + Needle tracks in bilateral upper extremities + L hip multiple old abscesses or indurations non infected + R hip multiple abscesses redness, warmth Psychiatric +Anxiety +Depression What is an Abscess? Continuity of Care History The Patient CC: Abscess Surgery Consult Ruled out Necortizing fasciitis, DVT & osteomylitis Recommendation: I&D R hip & bilateral buttocks Rx: PO Doxycycline CV EKG - Endocarditis hx ECHO - Ruled out Endocarditis GU Dysuria & pyuria UA Orange color Turbid appearance Moderate leukocyte esterase Blood Rx: PO Bactrim Blood Cx’s Lab Values WBC 15.3 Hct 29.8 Na 128 K 3.0 Day 2 Grand Rounds Presentation Abscess Day 1 Day 3 Med Surge Awaiting Urine Cx Continue IV Vanco & Gent Increase Methadone to 80 Discharge Planning Case Management Consult Wound care 62 ECG bpm

Grand Rounds Presentation

Transcript: Alfred Mathew Grand Rounds Presentation James Zhao MD HPI HPI The patient is a 30 year old male with no relevant past medical history, presenting after a motor vehicular accident with an emergent cricothyrotomy placed. He presents with several severe lacerations to the face. The patient is stabilized in the utmb OR. More recently, the patient is recovering and is able to shake yes or no to questions. The patient is a welder was past ocular history of far sightedness and early signs of cataracts. Other past medical history, ocular history, family history, and social history is currently unknown. Only a brief history was taken due to patient's mental status. History History Medications taken for severe automobile injuries include: -Albuterol 20-100 mcg -Esomeprazole 40 mg -Fentanyl 250 mL -Levetiracetam 100mg/mL -Lidocaine 1% -Piperacillin 3.375 gram/50 mL The patient has no known allergies. Medications Meds/Allergies Pupils: OD: dark: 3 mm light: 1 mm rAPD: no OS: dark: 3mm light: 1 mm rAPD: no Intraocular Pressure: soft to palpation, low pressure Motility OD: full OS: -2 restriction to left gaze Forced adduction OS with restriction to left gaze Negative oculocardiac reflex during EOM and forced abductions Anterior Exam and Fundus Exam was could not be conducted Visual EXAM Visual Exam Ocular Movements Normal Ocular Movements TIME Doctor's Name Patient CT Differential Differential A tumor in the orbit of a 62-year-old man compresses a structure that runs through both the superior orbital fissure and the common tendinous ring. Which of the following structures is most likely damaged? A-Frontal Nerve B-Lacrimal Nerve C-Trochlear Nerve D-Abducens Nerve E-Ophthalmic Vein OKAP Question OKAP D Answer Is this a nerve or a muscular issue? How can you tell? Differential Differential List -Muscle entrapment (Lateral Rectus) -Cranial Nerve VI Defect -Cranial Nerve III Defect -Duane Syndrome Type 1 -Duane Radial Ray Syndrome -Blowout Fracture Differential List List History History/Pathophysiology NOW 1957 1844 2015 Orbital floor fractures Originally described in 1844 by Dr. MacKenzie in Paris The term blow-out fracture was coined around 1957 by Dr. Smith The lateral rectus muscle is innervated by the abducens nerve and controls movement of eye away from the midline (abduction) An entrapment of the muscle would prevent the leftward or rightward gaze of the left or right eye respectively. Very commonly seen in trauma patients Treatments Treatments Conservative Treatments -Smoothing of bony contour -Reduction in Orbital Content Herniation -Spontaneous Improvement Surgical Repair Research Article Young et al -Compares conservative treatment with surgical repair in patient cohort -Conclusions showed the treatments were equally as effective, with reduced side effects from the conservative approach -Possible issues include the small sample size

Grand Rounds Presentation

Transcript: Clarkson University Class of 2019 Christina Vogel-Rosbrook, PA-S2 Life Is Like a Box of Chocolates Patient Info 69 y/o CM presents to ER CC: "constipated for three days" Differential Differential Diagnosis Appendicitis Abdominal Hernia Diverticulitis Crohn Disease Ulcerative Colitis Perforation Ileus Irritable Bowel Syndrome Large Bowel Obstruction Spontaneous Bacterial Peritonitis Toxic Megacolon Volvulus Ogilvie Syndrome Multiple Sclerosis Lupus Scleroderma Amyloidosis Spinal Cord Injury Parkinson Disease Neuropathy Hypothyroidism Colon Cancer Medication-Induced Hypercalcemia Anal Fissure Fecal Impaction Renal Insufficiency Achalasia Portal Hypertension Cholelithiasis Cholecystitis Celiac Disease Liver Cirrhosis Alcoholic Fatty Liver Disease Non-Alcoholic Fatty Liver Disease Hyperparathyroidism Uremia HPI HPI: Pt reported to ER after 3 days of constipation. Insidious onset of abdominal distention beginning last fall worsened over the past 3-4 days. Associated symptoms include SOB, decreased appetite, severe abdominal distention, and weight fluctuation. He reported first time occurrence. Sxs worsened with time; nothing improved sxs. Medications Medications Neurontin (Gabapentin) - 300 mg PO TID Lipitor (Atorvastatin Calcium) - 40 mg PO daily Synthroid (Levothyroxine) - 175 mcg PO daily Flomax (Tamsulosin) - 0.4 mg PO daily Medical marijuana - for PTSD Intolerance/ Allergies Simvastatin - Headache Pollen Allergy - Congestion. PMH & PSH Past Medical History Frozen Shoulder - Hypertension Hyperlipidemia Type 2 Diabetes Mellitus Post Traumatic Stress Disorder Past Surgical History FH & SH Family History Father 50's y/o. Helicopter accident. Mother 60's. Alcoholism. Brother HTN. Sister Unknown. Sister Alive and well. Sister Alive and well. Daughter 37 y/o. Alive and well. Daughter 34 y/o. Alive and well. Daughter 32 y/o. Alive and well. Daughter 28y/o. Alive and well. Denies family history of liver cancer, cirrhosis, hepatitis, pancreatic cancer, crohn's disease, ulcerative colitis, congestive heart failure. Vietnam Veteran and Retired plumber. Married. Lives with wife, two wolves. Former tobacco and alcohol use. Stopped smoking and drinking about 10 years ago. Registered NYS medicinal marijuana. Denies cocaine or heroin use. Diet: Regular. Exercise: Active with projects around house. Leisure: Enjoys cooking, fixing motorcycles, spending time with family. Safety: Drives with seatbelt. Social History Review of Systems ROS General: +poor appetite, fatigue. No fever, chills. Skin: No open wounds, rashes, lesions, ecchymosis. Head: No headache, trauma, pain. Eyes: No vision changes, blurred vision, photophobia. Ears: No hearing changes, vertigo, tinnitus. Nose: No rhinorrhea, changes in smell, epistaxis. Throat: No dysphagia, sore throat, hoarseness. Neck: No nuchal rigidity, stiffness, lumps. Cardiovascular: No palpitations, chest pain, chest wall pain, orthopnea. Pulmonary: +Dyspnea. No cough, hemoptysis, pleuritic chest pain. Gastrointestinal: +Abdominal distention, diffuse abdominal pain, constipation, early satiety, passing flatus. No nausea, vomiting, diarrhea, hematochezia, melena. Genitourinary: +Rentention. No dysuria, hematuria, frequency, incontinence. Musculoskeletal: +Left leg pain. No arthralgia, muscle atrophy, myalgia. Neuro: No weakness, numbness, confusion, change in speech. Vascular: +Mild leg edema bilaterally. No increased vascularity, claudication. Endocrine: No heat/ cold intolerance, diaphoresis, polyuria, polydipsia. Psychiatric: No feeling of depression, anxiety, memory loss, harmful thoughts. ROS Physical Exam Exam Vital Signs Blood Pressure - 135/67 Pulse - 72 Temperature - 97.7 degrees Farenheit Respirations - 18 Oxygen Saturation - 96% Room Air Vital Signs Physical Exam Physical Exam General: Skin: Head: Eyes: Ears: Nose: Throat: Neck: Pulmonary: Cardio: Abdomen: Extremities: Msculoskeletal: Neuro: Endocrine: Psych: Tests Labs CBC, CMP, other chemistries Blood Cultures Urinalysis Coagulation Serology Labs CBC, CMP CBC, CMP 13.2 16.2 38.7 285 129 4.6 94 4 113 0.6 29 MCV - 83.2 MCH - 28.4 MCHC - 34.1 RDW - 13.7 MPV - 8.4 Neutorphil% - 84 Lymph% - 7.7 Mono% - 6.8 Eos% - 0.6 Baso% - 0.3 Lactic Acid - 1.0 Calcium Adj for Alb - 11.7 Mag - 1.70 Total Bili - 0.5 AST - 31 ALT - 25 Alk Phos - 89 LDH - 164 Total PRO - 6.8 Albumin - 3.8 Lipase - 57 C-Reactive Protein - 9.11 Other CHEM Other CHEM Lipase - 57 TSH - 24.700 T4 - 10.8 TBG Color - Yellow Clarity - Clear pH - 8.0 Specific Gravity - 1.028 Ketones - Negative Blood - Negative Nitrite - Negative Bilirubin - Negative Urobilinogen - 1.0 Leukocyte Esterase - Negative Total PRO - Negative Urinalysis UA Serology Serology Imaging Imaging EKG EKG Chest X-Ray No Acute Disease. Abdominal CT with contrast "Large 10 cm liver lesion with subhepatic space extension into the small bowel mesentery with changes of perotineal carcinomatosis identified with omental caking and studding as well as ascites. I am concerned about primary cholangiocarcinoma of the

Grand Rounds Presentation

Transcript: Past Medical History: Hx of smoking (1 pack a day) no known cardiovascular disease no known respiratory disease no Hx can be gathered on scene no fall earlier no slurred speech no new activities low probability of drugs or ETOH intox A - alcohol, acidosis, arrythmia E - electrolytes, encephalopathy, endocrine I - infection O - oxygen, overdose U - UTI, uremia T - trauma, temperature, thrombus, toxins, tumor I - insulin P - psychiatric, poison S - sepsis, stroke, seizue, syncope Trauma Assessment: head & neck patient grimaces and says "pain" when you palpate behind his head and down his neck no deformities, discolouration chest equal bilateral chest wall movement equal clear lung sounds apices to bases abdomen patient grimaces and says "pain" upon palpation of the upper and lower left quadrats pelvis & extremities unremarkable pedal pulses present Patient Presentation: sitting on the ground outside the transport van eyes closed, visibly in pain GSC 9 eye - open to pain verbal - words motor - localizes pain patent airway shallow respirations palpable pulses no bleeding or incontinence no smell of alcohol no facial droop Call Info: code 4 ottawa carleton detention centre patient altered "not acting himself" History of Present Illness: Elgin Toole patient transported by OPP from courthouse to innes detention centre patients mentation and LOA begins to decline during transportation begins complaining of head/neck pain becomes confused and then unresponsive detention centre staff say he is typically very chatty, likes to go out for smokes, social guy patient goes from GSC 15 to GSC 9 in 30 mins paramedics called shortly after Vital Signs & 12-Lead: Grand Rounds - Altered Patient Skin - PWD Pupils - left 2mm right 4 mm, sluggish Temp - 36.5 C RR - 18, shallow BP - 112/86 HR - 98 bpm, NSR SPO2 - 96% RA, 98% 4 lpm ETCO2 - 40 mmHg BGL - 5 mmol Treatment & Transport: oxygen therapy, NC, 4lpm supine, head elevated 45 degrees Code 4, CTAS 2 Ottawa Hopsital General Campus QUESTIONS??

Grand rounds presentation

Transcript: Sling support for first few days until balance is gained. Exercise restrictions- no vigorous activity for at least 4 weeks post-surgery Weight control to minimize damage to weight bearing joints A follow up phone call was made 4 days post-splint application. The owner stated that "Xena" was doing well. Several days later the owner noticed a laceration on the leg just above the splint and applied a bandage. The homemade bandage was taped too tightly and it tourniqueted the hock just proximal to the hock joint. After several more days the owner noticed a bad smell and brought "Xena" in to have the leg rechecked. "Xena" 2 y/o FS German Shepherd Mix Day 3 pm Amputation of the metatarsals- digits 4 and 5 Example of hind leg splint Treatments: Daily TPR,monitoring input and output-eating, drinking, urination and defecation, administration of oral medications- Clindamycin, Carprofen, IV medication- Cefazolin. Buprenex IM for pain control and Enrofloxacin IM. Continued IV Fluids. Monitored for fluid overload and IV catheter complications and patency. Removal of bandage, hydrotherapy of wounds and reapplication of wet/dry bandage every 12 hours. "Xena" Dorsoplantar View of Left pelvic limb Grand Rounds Presentation Heather Stitzel Summer 2015 *Bandages must be kept clean and dry- place a moisture resistant wrapping over the bandage before going outside or bathing pet *Check bandage frequently for tissue swelling above or below bandage *Bandages must be rechecked by veterinarian if swelling develops, unusual smell is present or if the bandage slips or gets wet History References Day 4 Questions? Kahn, Cynthia M. The Merck Veterinary Manual. Whitehouse Station, NJ: Merck, 2005. Print. Hospitalization Hydrotherapy and Lavage progression Possible complications Treatments: Daily TPR,monitoring input and output-eating, drinking, urination and defecation, administration of oral medications- Clindamycin, Carprofen, IV medication- Cefazolin. Buprenex IM for pain control and Enrofloxacin IM were added to drug regimen. IV Fluids were continued. Patient monitored for fluid overload and IV catheter complications and patency. Removal of bandage, hydrotherapy of wounds and reapplication of wet/dry bandage every 12 hours. Hot spot developing on chin and neck Daily TPR. Monitored input and output- eating, drinking, urination and defecation. Administered oral medications- Carprofen, Clindamycin, Enrofloxacin and Gabapentin, injectable medication- Hydromorophone and topical medication to chin/neck- Betagen Spray. Monitored incision site and cold packed area to reduce swelling. Encouraged patient to eat by offering variety of enticing foods. "Xena" Left lateral Day 2 Lavage and hydrotherapy Post-op care Amputation of Canine Pelvic Limb. Online Surgical Videos for Healthcare Professionals. N.p., n.d. Web. 11 July 2015. <http://www.surgerytheater.com/users/ShinkisMovies/> Treatments: IV catheter placed , IV Fluids administered @ 85 ml/hr (2x maintenance), Hydromorphone IM, Cefazolin IV, Convenia SQ, hydrotherapy of wound, chlorhexidine soak, Carprofen and Clindamycin PO. A wet/dry bandage was placed, with orders to change every 12 hours. Long term care Reason for Visit "OrthoVetSuperSite." OrthoVetSuperSite. N.p., n.d. Web. 11 July 2015. <http://www.orthovetsupersite.org/> Day 1 Client Education Temperature was increased 102.5, pain tolerance has decreased, replaced catheter pre-surgically, cleaned and dried chin and neck due to irritation from e-collar PE: The patient was QAR and inappetent. A necrotic smell was coming from the bandage. "Xena" had a weight loss of 6.4# in 2 weeks. The bandage and splint were removed- bandage exhibited staining at distal end, the rolled cotton was hardened and stained, tissue edema noted proximal to hock, skin discoloration and skin sloughing observed on the dorsal aspect of the left hind foot as well as necrotic tissue on the plantar aspect at the metatarsal pad and digital pad #5. T-99.3 P-100 R- 40 Weight- 37.4# Plumb, Donald C. Plumb's Veterinary Drug Handbook. Stockholm, WI: PharmaVet, 2005. Print. Day 3 am "CHAPTER 48 AMPUTATION." N.p., n.d. Web. 21 July 2015. <http://cal.vet.upenn.edu/projects/saortho/chapter_48/48mast.htm>. 2 weeks prior the patient was presented to the clinic for limping on the left pelvic limb. PE was performed and radiographs were taken to determine the cause. Soft tissue swelling and a fracture of metatarsal #2 was discovered. A spoon splint, 2 layers of rolled cotton, 1 layer of conforming gauze and vetwrap were applied extending from the phalanges to the hock. Elasticon was placed at the top of splint to prevent slippage and a small amount of elasticon placed on the bottom of the foot for traction. Carprofen was prescribed to control pain and inflammation. The patient was fitted for an e-collar. Optional treatments Non-adherent foam dressing Vacuum assisted wound closure Mid shaft amputation with prosthetic limb Skin grafting Sugar/honey dressing The patient has a good

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