Session 1
PATIENT 1
Identification:
- Date: 09/06/19
- Time: 2:30 PM
- Name: EA
- Sex: F
- Race: Nigerian
- Age: 78
- Marital status: Married
- Address: Long Term Care, Gouverner
Informant:
- Source of history: Patient, reliable
Referral Source: Self
Chief Complaint:
- “Trembling and weakness of right arm and hand x 1 day”
Present Illness:
78 year old Nigerian female with PMHx HTN, pre-diabetes, arthritis, and GERD c/o “trembling and weakness of right arm and hand x 1 day.” Patient states that she woke up in the morning and tried to grab her phone when she noticed some trembling and weakness of her right arm and hand. She reports that the trembling and weakness occurs at rest and is worse when moving or holding something. Patient has not tried any treatments yet. She admits to slowed cognition, slowing of speech, and fatigue. Denies any fever, chills, N/V/D, HA, dizziness, LOC, numbness, tingling, vision changes, slurred speech, incontinence, recent falls or trauma.
As per chart review, patient presented to Mount Sinai Queens ER with acute right cerebellar hemorrhage on 07/04/19. According to son, patient woke up on the morning of 07/04/19 with slurred speech and c/o dizziness for one week prior to that morning. Both son and daughter had multiple conversations with the patient without any problems the night before. Upon arrival to the ED, patient was noted to have left sided facial weakness.
Stat head CT revealed right cerebellar hemorrhage with mass effect, no hydrocephalus. Patient was intubated for airway protection, placed on propofol infusion for sedation, and cardene for BP control as systolic BP on arrival to ED was >200. Patient was given DDDAVP given for chronic ASA use, mannitol 100g IV, and transferred for surgical intervention. She was taken to the OR emergently for minimally invasive right cerebellar hemorrhage evacuation and right occipital EVD placement.
Comments
The first line included past medical history and current symptoms, but it does not say where the patient was presenting from. What is missing is the date the patient comes to the LTC facility and and why. I think the story in the second paragraph should be first and the first paragraph should be last. It makes more sense to start off with why she is in the LTC facility rather than her symptoms there right pff the bat. Another vital piece of information is how the patient did post-surgery. A good thing about this HPI is the description of what happened in mount sinai and the interventions that took place. I also think it was off how the sentence “As per chart review, patient presented to Mount Sinai Queens ER with acute right cerebellar hemorrhage on 07/04/19.” Since a dx was made and then the story was given.
PATIENT 2
Name: AS
Race: African American
Date: 9/13/19
Source: pt himself
DOB: 4/02/1950
Referral: self
Reliable
CC: “pain in my right foot” x 15 years
HPI:
69 yo AA Male with PMH of multiple medical problems including HTN, HLD, chronic pain, depression, Cervical spondylosis with myelopathy and hx of multiple falls presents to ADHC for monthly evaluation c/o right foot pain x 15 years. The pt states the pain in his foot is chronic but he has noticed recently, for the past 1-2 weeks, that his foot is more swollen, to the point that his shoe does not fit properly. Pt states that the pain is an 8/10 on the pain scale and that while gabapentin usually relieves his pain, it is not helping at this time. The pain is sharp in character and nonradiating, pt states pain is worse with ambulation and standing. Denies any recent trauma to the foot. Denies fatigue, dizziness, lightheadedness, diaphoresis, night sweats, chills, change in weight, muscle fatigue, arthritis, muscle deformity and redness.
Comments
The pertinent ROS included was good and most of OLD CARTS was included. I would like to know if he has experienced this pain before. There is no baseline of the patient, It states that he has a history of multiple falls, does he have any disabilities? What are his ADLs and IADLs. Is his foot pain preventing him from doing activities? If so, which ones? His home living situation is lacking, does he take stairs to get home? Who does he live with? We don’t know what has been going on with his foot for the past 15 years. Has he seen a podiatrist? Where on the foot does he have the pain? Overall the medical information is there but the patient’s past story needs to be developed more.
Feedback for student
Most of the pertinent medical information was included. What I would suggest is working on formatting so there a better flow of information. Begin with where the patient presents from, what happened there, and why were they sent to an LTC facility. The patient’s story needs to be developed more.
Session 2
Pain management in patients with chronic kidney disease and in elderly patients without diagnosed kidney disease (but perhaps with reduced CrCl)
The choice of analgesic for patients depends partly on the nature of the pain. Pain is usually classified as nociceptive or neuropathic. Nociceptive pain is typically with tissue injury and Neuropathic pain arises from abnormal neural activity secondary to disease, injury or dysfunction of the nervous system. Many analgesics should be avoided or have dose reductions in patients with kidney disease. Since the pharmacokinetics and pharmacodynamics of many analgesics and most opioids are altered among these patients, risk of is toxicity is high. In regars to Nociceptive pain, acetamenophen prescribed in standard full doses, is the first-line analgesic for patients with advanced CKD who have nociceptive pain. Acetaminophen elimination is not significantly reduced among patients with decreased estimated GFR.
Opioids are used for patients who do not respond to acetaminophen alone. The next step would be acetaminophen plus a strong opioid. Preferred opioids include hydromorphone, fentanyl, methadone, or buprenorphine.
A common practice is to start with hydromorphone at 0.5 to 1 mg orally every four to six hours. Some opiods that are not used in patients with CKD are codeine, tramadol, morphine, meperidine/pethidine, or propoxyphene. Oxycodone may be used among patients with CKD but is considered a second-line agent compared with other opioids.
Some examples of neuropathic pain among patients with CKD are carpel tunnel syndrome, and diabetic neuropathy. Fist line therapies for these patients are gabapentin and pregabalin. Common side effects of these medications are dizziness, somnolence, fatigue and weight gain. If that is infective the next step is TCAs(amitriptyline or carbamazapine). If that is ineffective add acetaminophen and then last step would be to add an opioid. Start with a low dose especially with gabapentin since it is cleared by the kidneys.
People who have mixed neuropathic pain and noiceceptive pain recommendation s to use acetamenophen and gabapentin or pregabalin.
Pain management in elderly without a diagnosis of kidney disease:
Non-opioid medications are preferred to opioids for non-cancer pain, due to side effects in older patients. Analgesics should be initiated at the lowest effective dose and titrated to achieve pain control with minimal adverse effects. Therefore, frequent reassessment of patients for pain relief and side effects as doses are adjusted is required. Acetaminophen is the first-line treatment in the management of mild persistent pain in the older adult because it is considered safe particularly compared to nonsteroidal anti-inflammatory drugs (NSAIDs). However, acetaminophen lacks significant anti-inflammatory properties, making acetaminophen less effective for chronic inflammatory pain than NSAIDs.
If NSAIDS are used they should be used only briefly in (1-2 weeks) during episodes of increased nociceptive pain. Low doses should be used and tailored to the patient’s risk factors like GI and cardiovascular disease.
Opiods:
The choice and dose of specific opioid depend upon desired route of administration (eg, oral versus transdermal), onset time, duration of action, interactions with other medications, coexisting medical conditions, and sensitivity to side effects. In general, reasonable choices in older adults include morphine, oxycodone, hydromorphone, fentanyl, and buprenorphine.
The majority of patients with chronic pain will use oral medications. Patients with difficulty swallowing may benefit from medications available in liquid form (eg, hydromorphone, morphine, oxycodone) or as a lozenge (eg, fentanyl). A transdermal patch (eg, fentanyl, buprenorphine) may also be a good alternative for patients who have difficulty swallowing, although absorption from the patch may be compromised in patients with decreased subcutaneous tissue, a potential problem in frail, older adults. As with all long-acting opioids, the patch should be avoided in opioid-naïve patient.
American Geriatrics Society Panel
- What is conventional practice for this type of pain or patient?
- Is there an alternative therapy that is likely to have an equivalent or better therapeutic index for pain control, functional restoration, and improvement in quality of life?
- Does the patient have medical problems that may increase the risk of opioid-related adverse effects?
- Is the patient likely to manage the opioid therapy responsibly (or relevant caregiver likely to responsibly co-manage)?
Session 3
There is an important conversation going on now about racial disparities in COVID-19 incidence and deaths in the US. Summarize the concerns and the findings briefly
Black communities, Latino communities, immigrant communities, Native American communities are bear the impact of this pandemic more than other communities for multiple reasons:
- The myth of Black Immunity
- Camaroonian student
– idea that the genetic make up of African/ Afrian Americans
– melanin in their skin rendered the population immune to COVID 19.
– the news spread across social media
– the consequences of this unproven claim resulted in many disregarding the disease and not taking the proper precautions.
Essential workers
- Staying at home has been the strongest way to prevent contracting COVID-19
- Minority populations disproportionally make up “essential worker”
- Healthcare workers, grocery workers, bus drivers, custodians ect
- They don’t have the privilege of staying home and they are in constant contact with the public. They have higher rates of jobs in service industries where they are less able to work from home.
- Many minority populations are reliant on public transportation which increases their risk of getting infected
- Additionally many of these workers have to make tough decisions between sustaining a living or their personal safety and the safety of their families,
Comorbidities:
- African American communities have higher rates of HIV, obesity, DM, HTN, CAD, respiratory illnesses compared to other communities, which increases their risk of mortality when infected with COVID.
- for example, In New Orleans, where nearly 60 percent of all residents are African American, obesity, hypertension and obesity rates are all higher than the national average, making the population more vulnerable to COVID-19
Government:
- There is a lack in access of care from a government stand point, 14 states refused to accept the Affordable care act expansion, therefore millions of poor sick Americans who could have had health insurance are without access to healthcare during this pandemic
- There are existing racial inequalities. Many undocumented workers don’t have health insurance and aren’t seeking treatment when they have severe symptoms.
New York
Most recent article that I read
- Largest percentage of deaths in New York City is among Hispanics (34%) and African Americans(28%) account for the second largest percentage
- White 27%
- Looking at a map of NY the zip codes with the most cases the the low income areas. They are also the areas with the high minority population.
- Living conditions in this area are cramped and people live in apartments and attached homes. This allows an infectious agent like COVID to spread fast
Post-class assignment
One of the questions you are likely to be asked about by patients and perhaps friends and family is whether masks make a difference and whether they should wear one.
Please look at the evidence for and against and decide what it shows with respect to:
- Usefulness of homemade cloth masks (are different types more/less effective?
A study conducted in 2013 evaluated the rate of transmission of viral and bacterial aerosols with the use of different types of homemade masks. They found that surgical masks had the highest filtration efficacy, all the other masks were made from household items. The mask made from 100% cotton t-shirts and pillowcase were the most suitable improvised materials for a mask, but they were 3 times less effective than surgical masks. Nevertheless, homemade masks are better than no mask and should be used as a last resort to prevent droplet transmission. Thicker material such as a tea towel and doubling up on the material is more effective however, they become uncomfortable to wear. Cloth coverings such as bandanas are less effective than cotton masks.
Sources:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7108646/
- Whether it makes a difference in likelihood of transmission for people to wear a mask when outdoors, in a closed environment (e.g. a subway or bus).
When outdoors in a closed environment wearing a mask does decrease the likelihood of transmission. There was a case of a patient in China who was infected with COVID-19, he used public transportation. He had no mask on in one vehicle and had a mask on in the second vehicle. He had a cough and was unaware that he was infected (did not wear a mask) and took a bus. In the bus, there were 39 others and some were not wearing a mask. Five individuals got infected in that bus. The patient obtains a mask and takes a minibus with 14 other individuals. After screening and testing and a 14-day medical observation, none of the 14 individuals had respiratory symptoms, digestive symptoms, fever, and PCR test results came back negative. This indicates the importance of wearing a face mask in closed environments.
Source: https://onlinelibrary.wiley.com/doi/full/10.1111/irv.12740
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7191274/
- Whether wearing a mask makes transmission in the home less? (infected pt. wearing mask vs. others wearing mask vs. all wearing masks)
The CDC recommends infected patient wearing a mask at home when they are around other people and or animals. They should have a mask or cloth covering on before someone enters the room. Caregivers should wear a mask when they are in contact with and caring for the person that is sick. Additionally, they can prevent getting sick by also washing hands, avoiding touching their mouth and nose, and frequently disinfecting surfaces.
Sources: https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/care-for-someone.html https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.html
- Whether countries where mask use is common have lower transmission rates/R0/fatality rates?
Countries that required face masks early in the pandemic seem to have had some success slowing the disease’s spread. Studies have shown that Asian countries where face masks were widely worn suffered fewer cases of COVID-19. Some of these countries include China, Singapore, Japan, and South Korea have had far fewer infection rates than western countries these even though countries were closer to the source of the pandemic. These countries also have lower mortality rates. “Country-wide coronavirus mortality and use of mask by the public” was an analysis that showed that countries have an increase by 43% per capita mortality where people were not wearing masks and 2.8% in mortality rates in countries that were wearing masks. R0 Determines the rate of growth of the disease and the goal is to get it below 1.0. Interventions of implementing mask usage in a country will affect R0. In regard to wearing masks, the HKBU COVID-19 Modelling Group created a model that found that wearing masks reduces R0 by a factor (1 − epm)2. In this model “e is the efficacy of trapping viral particles inside the mask, and pm is the percentage of the population that wears masks.”(2) Following this model if a large percentage of the population of the country wears a mask the R0 will decrease.
- Who is more protected by a cloth mask – the person wearing it or the contacts of the person wearing it.
The contacts of the person wearing a cloth mask is more protected when the person is wearing the mask. A cloth mask is worn to help protect others in case the wearer has the virus, and it helps prevent spreading the virus to others. It keeps respiratory droplets contained and from reaching other people.
Sources:
https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-mask/art-20485449
This entry is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International license.
