Dung Thi Le, M.D.

• Associate Professor of Oncology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0016139/dung-le

A bicuspid aortic valve is not usually considered hereditary medicine to help you sleep order meloset visa, and symptoms jock itch purchase meloset 3 mg overnight delivery, at the age of 24 years counterfeit medications 60 minutes meloset 3 mg low cost, it would be unlikely to present with severe calcification (E) medicine look up drugs 3 mg meloset order with visa. Fibrosis in the left ventricular outflow tract corresponding to the anterior leaflet of the mitral valve is characteristic of hypertrophic cardiomyopathy symptoms 2015 flu buy meloset 3mg without prescription. In hypertrophic cardiomyopathy the main gross feature is the thickened interventricular septum (B). Correct: -myosin heavy chain gene (B) the most common mutation associated with hypertrophic cardiomyopathy is that of the -myosin heavy chain gene (B). Correct: Recent switch from paroxetine to buproprion for his depression (A) the microscopic appearance, eosinophils in a perivascular location, is characteristic of hypersensitivity myocarditis. Hypersensitivity myocarditis most commonly occurs because of a reaction to a medication or a change in the therapeutic regimen of an already prescribed medication (A). A coxsackievirus B infection would have lymphocytes (B), a mutation of the myosin heavy chain gene would be associated with myocardial disarray (C), and recent heavy alcohol use does not produce a characteristic change in the myocardium (E). Although eosinophils are present, release of major basic protein is not the cause of the microscopic changes (D). Correct: A past coxsackievirus B infection (A) Given the fact that she does not have a history of sudden cardiac death in her family, a genetic mutation is less likely (D, E). The morphologic appearance of her heart is consistent with a dilated cardiomyopathy, and her symptoms correlate. A dilated cardiomyopathy can have a variety of underlying causes, but one is a past coxsackievirus B infection, which caused a lymphocytic myocarditis (A). Correct: A mural thrombus in the left ventricle (B) the gross and microscopic features of the heart are those of a dilated cardiomyopathy, a condition that is commonly associated with chronic alcoholics. Of the choices, mural thrombi are most frequently associated with dilated cardiomyopathy (B), as the enlarged heart, with poor contractility, can cause abnormal blood flow and resultant thrombi. The remainder of the conditions listed are not associated with a dilated cardiomyopathy (A, C-E), although a viral myocarditis (E) can ultimately lead to a dilated cardiomyopathy; however, the lymphocytic infiltrate would not still be present. Microscopic examination of the heart in this condition will reveal myocyte disarray (E). Correct: Rupture with bleeding (C) Varicose veins can rupture and bleed, and they have even been a cause of death in this fashion (C); however, they are not associated with the other complications (A-B, D-E). Correct: A pulmonary thromboembolus (D) Given the recent trauma and resultant relative immobility, this patient is a setup for a pulmonary thromboembolus. The episode of sharp chest pain and dyspnea was likely from a small thrombus that reached the periphery of the lung, whereas his death was caused by a saddle pulmonary thromboembolus (D). Although the other conditions (A-C, E) can cause sudden death, he has no risk factors for them. Correct: Tumor in the pancreas (C) Pancreatic tumors are a known risk factor for thrombosis, which can be a precursor to pulmonary thromboembolus (C). The other conditions listed, other than being a source of immobility, are not direct risk factors for pulmonary thromboembolus (A-B, D-E). Correct: A patent foramen ovale (B) Deep venous thrombi usually embolize to the lungs, since they arise in the venous circulation; however, with a patent foramen ovale the emboli can cross over to the systemic circulation and can cause a cerebral infarct, which is referred to as a paradoxical embolus (B). Although all of the other conditions listed could cause an acute cerebral infarct, none are the result of deep venous thrombi (A, C-E). Correct: Embolic occlusion of the pulmonary artery (A) the patient has clinical features consistent with a deep venous thrombus: swelling and erythema of the lower extremity and palpable cord in the lower extremity. A deep venous thrombus is a risk for a pulmonary thromboembolus, which can cause an embolic occlusion of a pulmonary artery (A). None of the other answers, without a patent foramen ovale, would result from a deep venous thrombus (B-E). Correct: History of recent long-distance travel by car (D) In a young adult, the findings of sharp chest pain, dyspnea, and a cough with occasional blood are consistent with small pulmonary thromboemboli. As a saddle pulmonary thromboembolus could cause sudden death, it is very important to rule this diagnosis out, and thus, determine whether the patient has any risk factors for deep venous thrombi (D). Correct: Accentuation of the pulmonic component of the second heart sound (C) With the history of recent immobility, the history of dyspnea and sharp chest pain with a cough is most consistent with a pulmonary thromboembolus. Of the physical examination findings, only (C) is associated with a pulmonary thromboembolus. Pitting edema is associated with congestive heart failure; the edema associated with deep venous thrombi is not typically pitting (A). Neither a murmur nor retinal hemorrhages are usually associated with a pulmonary thromboembolus (B, D). Correct: Glomus tumor (C) A glomus tumor is known for causing pain and commonly is found underneath the fingernail (C). The other conditions listed are not usually painful and do not have a predilection for the subungual region (A-B, D-E). Correct: Rhabdomyoma (C) Cardiac rhabdomyomas are associated with tuberous sclerosis (C), as are hypopigmented macules, Shagreen patch, cortical tubers, subependymal giant cell astrocytomas, lymphangiomyomatosis, and renal angiomyolipomas. Patients with tuberous sclerosis can get fibromas, but these are not typically cardiac in location, usually periungual (B). A myxoma would not produce a nodule in the myocardium (A), and metastatic melanoma and angiosarcoma (D-E) are not usually associated with tuberous sclerosis. Correct: Myxoma (B) the description and location is classic for a cardiac myxoma, which is the most common primary tumor of the heart. Both papillary fibroelastoma and endocarditis could possibly occur at this location but would have a different texture, and their incidence would be rare (A, E). An angiosarcoma and lipoma would be most likely within the myocardium and have a different appearance (C, D). Correct: Healed endocarditis of the aortic valve, with a gaping defect in one leaflet (D) There are two forms of hypertrophy of the heart: concentric and eccentric. Concentric hypertrophy is due to pressure overload, while eccentric hypertrophy is due to volume overload. A perforation of an aortic valve leaflet would lead to insufficiency, which would cause volume overload and eccentric hypertrophy (D). An aldosterone-secreting adenoma of the adrenal gland and coarctation of the aorta would both cause hypertension and lead to concentric hypertrophy (A, B). Aortic stenosis due to a calcified bicuspid valve would also lead to concentric hypertrophy (C). Mitral stenosis should not lead to hypertrophy of the left ventricle, unless there is regurgitation as well (E). Of the listed tests, d-dimer is the most useful when diagnosing a pulmonary thromboembolus (C). Testing for Factor V Leiden would help determine whether the patient was at risk for a thrombus, but it would not help diagnosis the pulmonary thromboembolus, only the reason for the formation of the deep venous thrombus that preceded it (B). Correct: A lung tumor (C) the symptoms are consistent with superior vena cava syndrome, which results from compression of the superior vena cava by an apical pulmonary neoplasm. Given her smoking history, she is at risk for lung cancer, and her history of coughing up blood is consistent with a pulmonary tumor (C). The other conditions listed (A-B, D-E) are not typically associated with obstruction of the superior vena cava. Correct: Angiosarcoma (D) Chronic lymphedema, as could occur following mastectomy and lymph node dissection, is a risk factor for development of angiosarcoma (D). Correct: Acute lymphangiitis (C) 100 the clinical features are consistent with acute lymphangiitis (C), and none of the other choices (A-B, D-E). Correct: Pulmonary fibrosis (D) the patient has signs and symptoms of right-sided heart failure. In pure right-sided heart failure, the underlying cause is within the lungs; the pulmonary fibrosis could lead to right-sided heart failure (D). Correct: Pleural effusions (E) the description is that of chronic passive congestion of the lungs, with the hemosiderin-laden macrophages being heart-failure cells. Of the choices, only pleural effusions are associated with left-sided heart failure (E). Correct: Right ventricular hypertrophy (D) With emphysema, there is a loss of vasculature in the heart, as the number of alveolar septa is decreased, which puts strain on the heart. This strain can lead to right ventricular hypertrophy (D), although most people with emphysema will not have right ventricular hypertrophy. Describe the effects of the parvovirus infection on individuals with a predisposition to anemia. Describe the clinical presentation, epidemiology, and laboratory abnormalities associated with Fanconi anemia. Given the laboratory tests, distinguish between intravascular and extravascular hemolysis. Given the laboratory findings, diagnose microcytic anemia, and list the forms of microcytic anemia and describe how to distinguish between them using laboratory testing. Given the signs and symptoms, diagnose acute pancreatitis, and list and describe the complications of acute pancreatitis. Discuss the clinical evaluation of a microcytic anemia to determine its underlying cause. Describe the laboratory evaluation of microcytic anemia and iron deficiency anemia. Given laboratory testing, distinguish between the various types of microcytic anemia. Given a red blood cell morphology, identify diseases causing it and determine how to distinguish among them. Given signs, symptoms, and laboratory evaluation, diagnosis and determine the underlying cause of anemia. Describe the approach to diagnose iron deficiency in a patient over the age of 50 years old and the association with colon cancer. Distinguish between folic acid deficiency and vitamin B12 deficiency and list the common causes of each. Given the clinical scenario, diagnose paroxysmal nocturnal hemoglobinuria and list its common complications. Diagnose glucose-6-phosphate dehydrogenase deficiency and recognize common precipitants. List the genetic abnormalities associated with each form of acute and chronic myeloid and acute and chronic lymphoid neoplasms. Describe the physical examination, laboratory, and genetic findings of chronic lymphocytic leukemia. Given signs, symptoms, and laboratory testing, diagnose acute leukemia in children, and list the relative frequency of precursor B-cell lymphoblastic leukemia and precursor T-cell lymphoblastic leukemia. Given the clinical scenario, imaging, and laboratory evaluation, diagnose multiple myeloma. Given the pathologic description and clinical scenario, diagnose a Burkitt lymphoma. A 37-year-old white female presents to her family physician with complaints of fatigue and dizziness. Physical examination is unremarkable other than slight pallor of the conjunctivae. She has no family history of cancer, does not drink alcohol excessively, and eats a regular balanced diet. A 53-year-old male presents to his family physician with complaints of fatigue and dizziness. A 64-year-old male presents to his family physician with fatigue and dizziness, which started three months ago. Of the following, which test is most likely to help identify the source of the laboratory results Of the following tests, which is most useful for distinguishing between the two conditions A 36-year-old male, originally from Greece, emigrated to the United States with his family when he was a child. He presents to an acute care clinic after falling from a chair and hitting his head, producing a laceration of the scalp. On physical examination, his blood pressure is 112/68 mm Hg, his pulse is 109 bpm, and his temperature is 98. A complete blood count reveals a white blood cell count of 7,100 cells/µL, hemoglobin of 11 g/dL, and Hct of 34%. Given the previous clinical scenario, of the following, if laboratory testing is performed, which would be identified A 47-year-old female with a 26-year history of systemic lupus erythematosus is being seen by her family physician for a routine examination and refill of medications. She does relate that recently she has felt more fatigued and occasionally becomes short of breath when exercising at the gym. Laboratory testing reveals a white blood cell count of 3,700 cells/µL, a hemoglobin of 10. Her physician is concerned about the possibility of iron deficiency anemia or anemia of chronic disease. A 41-year-old female with a 17-year history of systemic lupus erythematosus is being seen by her family physician for a routine examination and refill of medication. Laboratory testing reveals a white blood cell count of 3,800/µL, a hemoglobin of 10. A medical technologist is examining a blood smear and notes many red blood cells that are decreased in size, are hyperchromatic, and lack a central pallor. The laboratory requisition form indicates that the patient was seen in the clinic and was diagnosed with infectious mononucleosis.

Once the syringe is filled symptoms 8 days past ovulation meloset 3 mg buy amex, the needle is removed from the puncture site and the needle safety device is activated symptoms liver disease order meloset cheap. The needle must be removed and the syringe opening sealed with a special rubber stopper treatment 8th feb cheap meloset line. All needles must be removed from samples before they are transported to the laboratory An alternate method to draw the arterial sample is to use a butterfly needle to puncture the artery treatment 101 meloset 3mg buy fast delivery. The needle of the butterfly is inserted into the artery using the same method as the syringe technique medications dialyzed out meloset 3 mg buy lowest price. Once the butterfly needle is in the artery, the tubing attached to the needle starts filling with blood with a pulsating action. After all the air is forced out of the tubing, a prepared heparin syringe is attached and the arterial blood obtained. The needle is removed from the patient, and the butterfly tubing is detached from the syringe and replaced with a special rubber stopper. Any air bubbles that enter the syringe must be expelled before the syringe is stoppered. Before you leave the patient, check that the artery has not started bleeding again. Handling of the blood gas sample after collection is critical for accurate results. Indicate either on the label or on the test requisition the amount of oxygen the patient is on. If the sample is to be analyzed within 20 minutes, the use of a plastic syringe is recommended and the sample should be transported to the laboratory at room temperature. Samples that will not be tested within 20 minutes are best collected in glass syringes. The sample should be immersed in coolant immediately after collection, labeling, and sealing of the sample. The coolant is a mixture of crushed ice and water large enough to 45 degree angle. Relocate the artery by placing the index or middle finger over the artery to palpate for its size, depth, and direction. Puncture the skin about 5 to 10 ml down the length of the artery (toward the palm) from the point the finger is feeling the pulsating artery. The bevel of the needle should face the direction of the blood flow (toward the elbow). After collection of the proper amount of arterial blood, the syringe and needle are gently pulled from the puncture site. All needles must be removed from syringes before they are transported to the laboratory. The removal of the needle will create an opening for air to infiltrate the sample. The opening must be sealed with a special rubber stopper before the sample is sent to the lab. Immerse the sample in an ice/water solution if it cannot be immediately delivered to the laboratory. The artery is then relocated by placing the index or middle finger over the artery to palpate for its size, depth, and direction. The area of the artery that you are going to puncture can no longer be touched except with sterile gloves or fingers that have also been cleaned with the povidone-iodine (Betadine). The blood gas syringe from a kit will have the proper amount of heparin in the arterial syringe. Place your finger over the location in the artery where you want the tip of the needle to be after it has entered the artery Puncture the skin about 5 to 10 millimeters down the length of the artery (toward the palm) from the point the finger is feeling the pulsating artery. The patient can be breathing spontaneously or breathing through artificial ventilation. The amount of oxygen the patient is receiving and expiring must be recorded before the blood gases are drawn. Procedure 6-6 details the process of drawing arterial blood gases from the radial artery. The site for the draw of the radial artery is located by feeling with the middle or index finger for a pulsing action. Before using iodine, make sure that the patient does not have any allergies to iodine or shellfish Paint the skin with the solution. Work from the puncture site to the outside in concentric circles, and then let it air dry the povidone-iodine (Betadine) is not fully effective until it has dried. The skin is infiltrated on top of the puncture site to produce a small blister with a few drops of 1 percent epinephrine-free lidocaine anesthetic solution using a 25-gauge needle and 1-mL syringe. If the patient is unconscious or an adult patient who is not apprehensive about the arterial puncture, the anesthetic solution may be omitted. Materials: Sterile prepackaged arterial blood gas kit containing preheparinized syringe, safety needle, and caps One 1-ml syringe and 22-gauge safety needle 1 percent epinephrine-free lidocaine 70 percent isopropyl alcohol swab Povidone-iodine (Betadine) Gauze or cotton balls Adhesive bandage or tape Disposable gloves Biohazard sharps container Mixture of crushed ice and water Procedure: 1. Follow standard operating procedures to perform a competent and effective capillary puncture on a patient. Some patients are children; some are elderly or are resistant to having blood collected. Each of these types of patients presents a new and different challenge to the phlebotomist. Chapter 7 looks at each of these patients and offers methods and procedures to provide caring, competent phlebotomy to all types of individuals. Before drawing blood from a child, the phlebotomist must establish rapport with both the child and parent. The child will not cooperate with the phlebotomist if the parent is apprehensive and does not show trust in the phlebotomist. Greet the parent and child calmly and professionally with a soft, understanding voice. Remember, this is a strange world to the child, and everything is very frightening. The phlebotomist may say blood is going to be drawn, but the child may liken the phlebotomist to the monster in a horror movie. Children should never be told the process does not hurt, but rather that it will hurt a little bit and to make it easier they need to hold still. Make this a game, and tell the child that he or she can yell as loud as he or she wants, but just hold still. Children get so involved with seeing how loud they can yell, they do not even notice the needlestick. This distraction technique may hurt your ears, but you get excellent cooperation from the child. Caring for the pediatric patient and restraint of pediatric patients are covered in more detail in Chapter 8. Holding still is one of the most critical factors in obtaining an accurate blood sample from children, because fighting and crying will change blood values. Explain to a child that to make this venipuncture hurt less he or she must hold very still and that these people are here to help him or her hold still. Then while you are working with the child, each person will in sequence help hold the child until everyone is holding. This leaves the child with the feeling that he or she is being helped rather than ganged up on. Explain the importance of communication with and reassurance of parents and child. Explain the importance of proper holding techniques on children during venipuncture. Describe the capillary puncture collection sites and when each site should be used. Describe the step-by-step procedure for drawing blood by fingerstick and heelstick. Explain what to do after drawing blood from a patient receiving anticoagulant therapy. Describe what the phlebotomist must do before a sample from an isolation patient is drawn. Why is the first tube discarded when you are drawing from an indwelling arterial line Pressure must be applied to the site of an arterial puncture and maintained for at least 13. Using your best interpersonal skills, how would you respond to a patient who says she does not want her blood drawn because all phlebotomists hurt her When you go into that room, the patient identifies herself as Jane Smith but the identification bracelet indicates the patient is Jane Smiley. You come back to the laboratory with a tube of blood and notice that the tube does not have a label. The room number and the name on the door agree with the request form and the patient identification bracelet. Assign a name to the patient, such as John Doe, and use that name for identification be identified b. Use a three-part identification system that uses a temporary identification bracelet and labels for samples and blood to be transfused 5. When drawing multiple samples in evacuated tubes, it is important to fill which of the following color-stoppered tubes first:> a. The doctor orders tests requiring a light-blue- stoppered tube for coagulation studies, a lavender-stoppered tube, a red-stoppered tube, and a set of blood cultures. As a general rule, you should not stick a patient more than in an attempt to obtain blood. When you cannot perform a venipuncture successfully after two attempts, you should Copyright 2018 Cengage Learning. Firmly position the lancet device on the finger in a position to cut across the fingerprint lines. Gentle, continuous pressure on the finger below the incision site ensures a free flow of blood. If all fingers are cold, warm the hand 3 minutes with a warm washcloth or heel warmer. Massage the lower portion of the finger while avoiding the puncture site to stimulate blood flow. Hold gauze or have the patient hold gauze to the puncture site until bleeding has stopped. Do not use a bandage on infants and small children, because they could swallow it and choke. After the puncture, the blood drips downward and gravity helps the blood flow into the collector. Before the blood sample is collected, the first drop of blood needs to be wiped away. As the finger is punctured, tissue cells are damaged, and interstitial fluid is released into the first drop. As the drop of blood forms, touch the tip of the microcollection device to the drop of blood. Blood flow can be further enhanced by gently applying continuous pressure to the surrounding tissue. Excess pressure may cause hemolysis or contamination of the sample with tissue fluid. Collection of the Sample A free flow of blood imo the collection device will optimize the amoum of blood obtained. Scraping of the blood from the surface of the skin does not allow the blood to flow into the microcollection device. This action will spread the blood over the surface of the skin and not allow a free flow of blood. The blood will therefore not flow into the device when you collect the blood, resulting in a clot before it is mixed with the anticoagulant. The microcollection device needs to be held so the drops of blood can flow into the tip of the microcollection device and then down its walls. Rotate the tube after every drop so the blood entering the tube contacts the anticoagulant coating the sides. Anticoagulant samples should be mixed by inverting 8 to 10 times once they are capped. Procedure 7-1 explains a detailed procedure of the fingerstick capillary puncture of an adult using a retractable puncture device called a Genie lancet, manufactured by the Becton Dickinson Company. Sample: Capillary blood volume dependent on the test(s) Materials: Disposable sterile puncture device of the proper depth for the amount of blood needed Sterile gauze sq uares 70 percent isopropyl alcohol swabs Gloves Collection containers, as required by test(s): a. Calibrated pipettes Safety glasses and mask if there is a chance of splatter Biohazard sharps container continues Copyright 2018 Cengage Learning. Site Selection for Capillary Puncture Helpful Hint Immediately after using the puncture device, drop it into the sharps container. The earlobe is not recommended except in extreme cases, such as a severely burned patient, when no other location is available. Capillary puncture in an adult is on the palmar surface of the distal phalanx of either the ring finger or great (middle) finger. The side or tip of the finger should not be punctured, because the tissue is about half as thick as the tissue in the center of the finger. The puncture site must be warm or have been warmed, and the finger must not be swollen from the buildup of fluids (edematous). This technique delivers the best possible blood flow and facilitates the formation of drops of blood.

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One trial found no substantial differences in rates of malreduction or functional outcomes at a 2-year follow-up medications used for migraines meloset 3 mg with visa. The first biomechanical studies found that flexible fixation could not maintain reduction under external rotation loads symptoms nicotine withdrawal order meloset american express. The different nature of tibial plafond fractures is related to the energy and direction of the mechanism of injury symptoms non hodgkins lymphoma 3 mg meloset order amex. Tibial plafond fractures typically result from a higher energy mechanism with an axial load weight-bearing cone treatment models meloset 3mg order online, are surrounded by a more extensively compromised soft-tissue envelope medicine on airplanes meloset 3 mg purchase on line, and historically have a high complication rate after surgical treatment. The treatment of tibial plafond fractures should be based on an understanding of the small margin of error involved and a great respect for the complication profile. The common classification systems differentiate among pilon fractures based on the extent of metaphyseal and articular comminution, but they do not encompass the commonly encountered articular fracture lines. Complete articular fractures have a typical pattern of fragments and fracture lines, despite individual variations. The primary fracture line begins at the anterolateral portion of the articular surface at the level of the distal tibiofibular joint, extends medially, splits near the central portion of the plafond, and exits anteriorly and posteriorly. This creates three typical fragments in a complete articular fracture: a medial malleolar frag- ment, a posterior malleolar Volkmann fragment, and an anterolateral joint Chaput fragment. Variability in the size of these fragments and further articular comminution are created by secondary fracture lines. Analyses of posterior partial articular patterns described the challenge of differentiating between posterior pilon fractures and trimalleolar ankle fracture variants. The rationale for this timing is that ligamentotaxis makes surgical planning more effective by improving the understanding of the fracture morphology and clarifying where indirect reduction maneuvers are most likely to be effective. An open pilon fracture requires irrigation and debridement at the initial treatment stage, and it is useful to understand the fracture pattern beforehand. When deciding how to extend an open wound or Posterior impaction must be evaluated in addition to the size and Schematic drawing showing an axial view digital compilation of fracture lines blue lines] and zones of comminution green lines] in 33 complete articular pilon fractures. Surgical Treatment the classic surgical exposure for second-stage pilon fracture treatment is anteromedial. The anteromedial approach provides excellent access to the entire articular block as well as the diaphyseal extension of fracture lines. The disadvantages of the anteromedial approach include the difficulty of treating anterolateral gutter comminution. In addition, wound breakdown can be problematic because skin grafting often is not possible, and more complex soft-tissue coverage is required. The anterolateral surgical approach and current reduction strategies using it have been well described Entrapment of posteromedial structures occurs in approximately 10% of fractures; the posterior tibial tendon is the most commonly involved structure. The posterolatetal surgical exposure allows excellent access to a lateral malleolar fracture and the posterolateral corner of the tibia a Volkmann fragment. A conventional nonlocking anteromedial plate is the classic mechanical construct for a pilon fracture. The plate was designed to serve both as a buttress and a substitute for a deficient medial cortex. The advantages of an anterolateral plate have become more apparent over time as the definitions of fracture patterns and vectors of displacement have improved. Although the surgical exposure required to achieve a reduction may not he the ideal location for placing a plate, the first priority in choosing a surgical exposure should be to achieve the reduction. Often the implant mechanics can be empowered if the exposure precludes implant placement on the optimal bone surface. Nonetheless, there should be a mechanical reason for empowering fixation, and the routine use of locked plating for all pilon fractures should be questioned. The subtalar joint is the site of weight transference from the talus and usually is involved in a calcaneus fracture. The patient may have subtalar arthritis and chronic hindfoot pain even after successful near-anatomic alignment. A randomised study found no substantial improvement in anatomic restoration, although surgical time was decreased, when contralateral radiographs were used in restoring the Btihler angle and calcaneal length. All fractures with displacement of the posterior facet should be considered for reduction and fixation. Most contraindications to surgical treatment of a displaced fracture involve the presence of a comorbid condition that would inhibit healing of the surgical wound, such as a poor soft-tissue envelope, uncontrolled diabetes mel- litus, severe peripheral vascular disease, or neuropathic disease. Many surgeons believe that tobacco smoking is a relative, if not absolute, contraindication to surgery. A patient who is minimally ambulatory or may be unable to comply with postoperative restrictions also can be treated nonsurgically. In return for limiting the risk of soft-tissue complications, a less than perfect articular reduction must be allowed. For some patients this trade-off is acceptable or even preferable to the higher risk of open surgery. Pins placed in the talar neck penetrate the capsule and risk contiguous spread of infection, however, and external fixation of the calcaneus carries the risk that a pin tract infection will become a source for a septic joint. Extensile Versus Limited Approach for Open Reduction and Internal Fixation the lateral extensile approach is the standard for open reduction and internal fixation of the calcaneus, but it is not without complications. Revision of the approach based on the vascular supply to the lateral hindfoot was found to decrease the incidence of flap necrosis but did not eliminate incisional complications, which were reported to occur at rates as high as 30%. Wound-healing complications that have occurred after the use of an extensile approach in the calcaneus or another surgical area such as the tibial plafond have increased interest in minimally invasive procedures. Minimally invasive procedures typically use a limited open approach or percutaneous reduction with radiologic reduction control to view specific portions of the reduca tion. It is important to remember that a tongue-type fracture may represent a surgical emergency because superior fragment pressure on the posterior soft tissue creates a risk of skin necrosis. Typically, the patient has a poor soft-tissue envelope [as a result of recent trauma or preexisting unhealthy skin] or a comorbid condition that would inhibit wound healing. A purely percutaneous method is even less invasive than the limited sinus tarsi approach, and combining external fixation of the calcaneus with Drthopaedic Knowledge Update 12. Chondral damage from the initial injury predisposes the patient to subtalar arthritis, even after an anatomic initial open reduction. The likelihood of a poor functional outcome combined with a damaged soft-tissue envelope has led some surgeons to prefer initial nonsurgical treatment followed by late distraction arthrodesis, as needed. The goals of care in these challenging fractures continue to be focused on restoration of anatomy with a healthy respect for the soft-tissue envelope. I the risk of wound-healing complications with an extensile surgical exposure has led to the develop- ment of alternative surgical exposures, as well as and calcaneus fractures. I the primary fracture lines in complete articular pilon fractures generate three main fracture fragments: an anterolateral, an anteromedial, and a posterior fragment. These primary fracture lines form a Y, with the stem of the Y entering the tibiafibular joint. I Minimally invasive approaches to the calcaneus have been able to reliably restore the radiographic bony anatomy and have substantially lower wound complication profiles. High-energy pilon fractures, rotational ankle fractures, and calcaneal fractures are difficult injuries to treat successfully in an often tenuous soft-tissue envelope. Maximising patient outcomes continues to drive innovation in this challenging anatomic location. Surgical indications and predictors of ankle mortise stability in rotational ankle fractures continue to be refined, and an understanding of the optimal reduction and fixation method of the distal tibiofibular syndesmosis continues to evolve. Staged management of tibial pilon fractures remains the standard treatment in these complex fractures in patients with compromised soft-tissue envelopes. Positive findings on stress radiographs correlated with increasing injury to the deltoid ligament. Schock H], Pinrur M, Manion L, Stover M: the use of gravity or manual-stress radiographs in the assessment of supination-external rotation fractures of the ankle. Haraguchi N, Haruyama H, Tags H, Kato F: Pathoanatomy of posterior malleolar fractures of the ankle. This effect was seen most notably in trimalleolar fracand in cases in which plain radiographs were obscured by plaster. Alioto R], Furia]P, Marquardt]D: Hematoma block for ankle fractures: A safe and efficacious technique for manipulations. Ninety-six percent of the patients treated with immediate postoperative weight hearing as tolerated eventually experienced healing without loss of reduction. Ewart E, Eerhani H, Greisberg], Vosseller]T: How long should patients he kept non-weight bearing after ankle fracture fixation There is substantial variation among surgeons regarding recommendations concerning the duration of the non-weight-bearing period after ankle fracture fixation. Increased injury severity and substantial medical comorbidity were predictors of longer recommended periods of not hearing weight. There were no significant differences in complication rates in groups treated with immobilization versus exercise or early versus late weight bearing. Phisitkul P, Ebinger T, Goets], Vaseenon T, Marsh]L: Forceps reduction of the syndesmosis in rotational ankle fractures: A cadaveric study. The suture-button group displayed some natural correction with less residual displacement compared with the screw-fixation group. Un average, the syndesmosis was overcompressed fibular medialisation by 1 mm compared with the uninjured side. This measurement had high intraobserver reliability, and there were no substantial differences between right and left ankle mea- surements in the study participants. Marmor M, Kandemir U, Matityahu A, Jergesen H, McClellan T, Moi-shed S: A method for detection of lateral malle- olar rnalrotation using conventional fluoroscopy. Welck M], Ray P: Tibialis anterior tendon entrapment after ankle tightrope insertion for acute syndesmosis injury. Kortekangas T, Savola U, Flinkkilii T, et al: A prospective randomised study comparing TightRope and syndesmotic screw fixation for accuracy and maintenance of syndesmotic reduction assessed with bilateral computed tomography. The authors of this study reported that each group had similar immediate postoperative malreduction rates. External rotation malreduction was associated with narrowing of the tibiofibular space, a "pointed-blade" shaped fibula, and-for divergence of Shenton Lines. American Academy of Urtbopaedic Surgeons Chapter 40: Ankle and I-Iiudfoot Fractures had a false positive malreduction finding in one-third of the patients, which corrected with the ankle in neutral position. There were no differences in functional outcome or radiographic arthrosis at a followuup of at least 2 years after surgery. This finding was noted by the attending radiologist in 20% of cases, so surgeon vigilance is important. This prospective randomized trial compared screw fixation to dynamic TightRope fixation for unstable syndesmotic injuries. It was reported that patients treated with dynamic fixation had better functional outcomes and lower rates of implant failure and loss of reduction. The relative frequency of this variant was 20%, and the relative frequency of posterior malleolar fracture was 50%. Ulder patients and females were more likely to have either posterior malleolar or posterior pilon variant fracture components. Weber M: Trimalleolar fractures with impaction of the posteromedial tibial plafond: Implications for talar stability. Medline this prospective randomized trial of 60 consecutive patients with pilon fractures compared locked and noniocked plates. There were no substantial differences between the groups in complications, including nonunion, malunion, infection, stantial differences in functional outcomes between the groups. There were no sub- caneal fractures that evaluated the use of a contralateral calcaneal template reported no difference in radiographic restoration of the Btihler angle and calcaneal length; however, surgical time in the template group was decreased. Ketz J, Sanders R: Staged posterior tibial plating for the treatment of Urthopaedic Trauma Association 43C2 and 43C3 tibial pilon fractures. Medline ooI A retrospective review of displaced intra-articular calcaneal fractures treated with percutaneous reduction and fixation demonstrated similar functional outcomes to open treatment and very low wound complication and infection rates. Medline intra-articular calcaneal fractures with combined transatticular external fixation and minimal internal fixation. Foot wound complication rate, and better functional outcomes in the minimally invasive group. Acceptable restoration of bony anatomy and relatively few complications were reported. Nosewica T, Knupp M, Barg A, et al: Mini-open sinus tarsi approach with percutaneous screw fixation of displaced calcaneal fractures: A prospective computed tomography-based study. No significant differences in clinical outcome or approach group had significantly higher wound complication and revision rates. Delay of definitive fixation via the lateral extensile approach did not this retrospective review of patients with displaced intra-articular calcaneal fractures at a single center compared nonsurgical treatment, percutaneous treatment, and open treatment. There were no significant differences in outcomes between the two groups based on any of the four outcome measurement tools used. Potensa V, Caterini R, Farsetti P, Bisicchia S, Ippolito E: Primary subtalar arthrodesis for the treatment of comminuted intra-articular calcaneal fractures. Delay of more than 2 weeks to definitive fixation when using a minimally invasive technique increased the wound complication rate compared with earlier intervention. Xia 5, Lu Y, Wang H, Wu Z, Wang Z: Upen reduction and internal fixation with conventional plate via L-shaped lateral approach versus internal fixation with percutaneous plate via a sinus tarsi approach for calcaneal fractures: A randomized controlled trial. American Academy of Urthopacdic Surgeons Chapter 41 Bone Grafting in Spinal Surger Peter G.

Phlebotomy Technician I- this technician performs skin punctures and venipunctures medicine zanaflex buy 3 mg meloset overnight delivery. The technician must perform 50 venipunctures and 10 skin punctures (fingersticks) and pass an approved national certifying organizations exam medicine 666 colds buy meloset discount. The technician must perform 20 arterial punctures and meet the requirements of the Certified Phlebotomy Technician I treatment meaning meloset 3mg buy with amex. Laboratories often employ an individual with a high school education and laboratory experience to work as a laboratory assistant symptoms ketosis cheap generic meloset uk. A phlebotomist who has shown exceptional abilities and attitude is often considered for such a program symptoms 38 weeks pregnant purchase meloset 3 mg overnight delivery. The technical positions are either 4-year degree positions or 2-year associate degree positions. A technician has a 2-year associate degree in medical technology and a certification. Both roles are needed to make a laboratory run smoothly and efficiently the secretarial or clerical positions in the office areas of the laboratory require a high school education and some secretarial/ clerical training. They are interacting with many different people and must be able to appropriately interrelate with everyone. The phlebotomist needs a high school education and specialized training in phlebotomy: a minimum of 40 hours of classroom training and 100 hours of clinical or practical training is the standard set by the American Society for Clinical Pathology Individuals with this minimum amount of training may have to work in a clinic, outpatient setting, or small hospital. Many hospitals and clinics are willing to hire a phlebotomist who has completed only classroom training. The hospital or clinic may offer practical on-the-job training with the hope that the phlebotomist-in-training will learn rapidly and be willing to remain at the institution. Many hospitals have established such training programs to fill phlebotomy positions. Phlebotomists may now take certification exams to prove their knowledge in phlebotomy Various certification and registry exams accredit the person as a phlebotomy technician. Some states require that phlebotomists obtain a state license before they can work as a phlebotomist. Certification is a voluntary process and controlled and run by a professional organization; licensure is a requirement run by the state. This provides a faster result for the physician to respond to with treatment, and the patient is released sooner. This in turn benefits the patient because he or she is back to a normal lifestyle sooner. Consolidation and reengineering of the laboratory are an attempt to make this happen. Laboratories were originally organized around the need to perform inpatient testing. With the emphasis on outpatient surgery and shorter lengths of stay in the hospital, there is an increased demand for outpatient services and presurgery testing. Patients can even have presurgery work done at the service center and then go to the hospital for surgery. Each of these service centers needs to be staffed with a multiskilled phlebotomist. In the hospital the nursing staff might draw the blood, but in the service center the multiskilled phlebotomist collects the samples. This in turn reduces the costs to the hospital for patient care, resulting in the hospital avoiding a monetary loss in the care of the patient. Competing hospitals are now forming joint laboratory ventures but still compete vigorously against each other in all other areas. The hospitals join to form a new laboratory company with each hospital as a part owner; sometimes a commercial reference laboratory is another part owner in this joint venture. The employees of the laboratory become employees of the new company and no longer work for the hospital or commercial laboratory. This regional laboratory is usually at an off-site location, central to all the hospitals involved. The advantage is that only one test instrument must be purchased instead of one instrument for each hospital. This also increases the volume of testing done, and more instrument automation can be implemented Lo reduce labor costs. With the testing coming in from multiple locations, certain tests that are not very common, called esoteric tests, can be performed at the regional laboratory. Before the joint venture, no one hospital would have enough volume to do certain tests. This provides the physician the ability to order tests and get results back faster than when the testing had to be sent to an out-of-state commercial laboratory. Hospital laboratories reduce the variety of tests that are completed and concentrate on the tests needed for the immediate care of the inpatient and emergency department patient. The key to making all this work is an efficient courier and sample tracking system. Instead of samples being walked to another area of the hospital, they have to be transported to another area of the city. The phlebotomist can do venipuncture in any of the sites or can become multiskilled and rotate to any of the areas, taking on tasks from processing samples to being a courier. The opportunities become endless for the individual who is willing to learn and rotate to a variety of locations. Many people could not afford to pay for the insurance plan if they were unemployed or their employer did not provide subsidized insurance. These patients had no choice in an emergency but to receive services at a hospital but would be unable to pay. This would cause those patients to go into default on the bill, and the hospitals had to raise pri. The insurance companies realized that they were paying out considerable money to organizations without restrictions or guarantees. As health care costs continued to rise, the insurance companies tried to find ways to lower costs and control the cost of the premium to the patient or employer. Managed care was developed as a complex system to coordinate the provision of health services and health benefits. Most of these systems were put in place to control the use of health services and control costs. This was an unusual concept to the United States even though many other countries had national health insurance that controlled many health services. What developed out of this policy were managed care organizations that would contract with health care providers to provide health care services on a capitated (per-member per-month) basis. To become one of the contracted physicians or hospitals, the physician or hospital would offer to provide services at a discount. The Affordable Healthcare Act has been enacted to help those that could not afford insurance. The theory is that if everyone has insurance, there will be fewer people defaulting on health care bills. There is continued pressure on laboratories to produce quality testing in less time for less cost. These pressures are a result of the managed care programs that are in all areas of health care. Emphasis is on increasing outpatient services and decreasing length of stay for inpatients. This puts pressure on the laboratory to do the testing faster and more frequently so that there is no delay in the health care practitioner getting results and being able to treat the patient. The sooner the diagnosis and treatment are determined, the sooner the patient can be on the road to recovery. Two methods are being used to treat patients faster with less of a wait on the test results. This method of blood testing is usually more expensive than the traditional laboratory test, but often the total cost of care is reduced. The sooner the patient can be released from the hospital, the less it costs the hospital to care for the patient. Here is an example of how this system works: the managed care provider pays the hospital $1,000 per day for a total of 5 days to care for a patient. If the patient takes 7 days to be well enough to be released, the costs are $7,000, but the hospital will be paid only $5,000 by the managed care provider, for a loss of $2,000. The processes that are done to perform the test on the sample to achieve a result include the following: · Sample testing · Maintaining testing equipment and reagents Postexamination- the process whereby the results of the testing are communicated to the physician. These consists of the following: · Reporting of results · Ensuring accuracy and reliability of delivery of results · Follow-up to repeat testing or address physician concerns · Storage of samples after the examination the phlebotomist is mainly involved in the preexamination phase of sample testing. The primary duty of the phlebotomist is to collect venous blood samples from patients. Once the sample is collected, it is prepared by the phlebotomist through centrifugation and processing of the sample to make it stable until testing can occur. The first step of patient identification in the preexamination process is the most important step in th e process. Correct patient identification is critical to ensure that the remaining phases produce accurate results. Improperly identifying the patient is a common administrative (clerical) error in the process. If proper identification is not on the patient, wait for the patient to be properly identified before collecting the blood sample. Fill in the Blanks Areas of Nursing and Type of Care Directions: Identify the correct department of the hospital or nursing specialty. A patient comes out of surgery and must take time to determine if they are progressing well enough to go to a hospital room. The car accident patient is recovered enough to go home but still needs some medical attention daily. The patient has the righ t to expect reasonable continuity of care when appropriate and to be informed by physicians and other caregivers of available and realistic patient care options when hospital care is no longer appropriate. The patient has the righ t to be informed of hospital policies and practices that relate to patient care, treatment, and responsibilities. The patient has the right to be informed of available resources for resolving disputes, grievances, and conflicts, such as ethics committees, patient representatives, or other mechanisms available in the institution. The patient has the right to be informed of the hospitals charges fo r services and available payment methods. Hospitals have many functions to perform, including the enhancement of health status, health promotion, and the prevention and treatment of injury and disease; the immediate and ongoing care and rehabilitation of patients; the education of health professionals, patients, and the community; and research. All these activities must be conducted with an overriding concern for the values and dignity of patients. The collaborative nature of health care requires that patients, or their families or surrogates, participate in their care. The effectiveness of care and patient satisfaction with the course of treatment depends, in part, on the patient fulfilling certain responsibilities. Patients are responsible for providing information about past illnesses, h ospitalizations, medications, and other matters related to health status. To participate effectively in decision making, patients must be encouraged to take responsibility for requesting additional information or clarification about their health status or treatment when they do not fully understand information and instructions. Patients are also responsible for ensuring that the health care institution has a copy of their written advance directive if they have one. Patients are responsible for informing their physicians and other caregivers if they anticipate problems in following prescribed treatment. Patients should also be aware of the hospitals obligation to be reasonably efficient and equitable in providing care to other patients and the community the hospitals rules and regulations are designed to help the hospital meet this obligation. Patients and their families are responsible for making reasonable accommodations to the needs of the hospital, other patients, medical staff, and hospital employees. Patients are responsible for providing necessary information for insurance claims and for working wi. Patients are responsible for recognizing the impact of their lifestyle on their personal health. Most of these rights and responsib ilities can be directly applied to duties as a ph lebotomist: 1. The phlebotomist also must face the realization of mortality ln the United States, 85 percent of the population dies in the hospital. The phlebotomist may question the need for the test to be drawn or realize there was an error on a previous sample, and now the patient has to be redrawn. Questions and concerns should not be discussed with the patient but with the phlebotomists supervisor or the nurse, outside the presence of the patient. The phlebotomist may need to explain briefly how the venipuncture is performed and that these are tests the physician has ordered. The patients act of extending his or her arm for the procedure is taken as an act of consent. Patients have the right to know the identity of physicians, nurses, and others involved in their care as well as when those involved are students, residents, or other trainees. The patient also has the right to know the immediate and long-term financial implications of treatment choices, insofar as they are known. The patient has the right to make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and hospital policy and to be informed of the medical consequences of this action. In case of such refusal, the patient is entitled to other appropriate care and services that the hospital provides or to transfer to another hospital. The hospital should notify patients of any policy that might affect patient choice within the institution. The patient has the right to have an advance directive (such as a living will, health care proxy, or durable power of attorney for health care) concerning treatment or designating a surrogate decision maker with the expectation that the hospital will honor the intent of that directive to the extent permitted by law and hospital policy. Health care institutions must advise patients of their rights under state law and hospital policy to make informed medical choices, ask if the patient has an advance directive, and include that information in patient records.

References

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