clinical vignettes
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2022 ◽  
Vol 12 ◽  
Author(s):  
Michael K. Racke ◽  
Elliot M. Frohman ◽  
Teresa Frohman

Neuropathic pain and other pain syndromes occur in the vast majority of patients with multiple sclerosis at some time during their disease course. Pain can become chronic and paroxysmal. In this review, we will utilize clinical vignettes to describe various pain syndromes associated with multiple sclerosis and their pathophysiology. These syndromes vary from central neuropathic pain or Lhermitte's phenomenon associated with central nervous system lesions to trigeminal neuralgia and optic neuritis pain associated with nerve lesions. Muscular pain can also arise due to spasticity. In addition, we will discuss strategies utilized to help patients manage these symptoms.


Urine drug screens (UDSs) are often performed in the emergency department (ED) as part of a standard ED order set in patients with significant altered mental status, trauma, or seizures usually without the patient’s knowledge or specified informed consent. In the ED the UDS has been included in the standard consent to treatment for routine testing along with blood studies, EKG, urinalysis and radiology. Many technical factors are known to effect UDS results.There is a lack of education among physicians regarding the clinical pitfalls of UDS interpretation. This article discusses the current state and issues associated with the UDS, and presents three clinical vignettes that illustrate the impact of false-positive UDS results on patient care and the potential for a patient becoming unknowingly and unfairly stigmatized. The article also offers suggestions including a requirement for either formal informed consent or an “opt out” screening process, as recommended by the CDC in HIV testing, designed to protect patient autonomy and confidentiality.


Urine drug screens (UDSs) are often performed in the emergency department (ED) as part of a standard ED order set in patients with significant altered mental status, trauma, or seizures usually without the patient’s knowledge or specified informed consent. In the ED the UDS has been included in the standard consent to treatment for routine testing along with blood studies, EKG, urinalysis and radiology. Many technical factors are known to effect UDS results.There is a lack of education among physicians regarding the clinical pitfalls of UDS interpretation. This article discusses the current state and issues associated with the UDS, and presents three clinical vignettes that illustrate the impact of false-positive UDS results on patient care and the potential for a patient becoming unknowingly and unfairly stigmatized. The article also offers suggestions including a requirement for either formal informed consent or an “opt out” screening process, as recommended by the CDC in HIV testing, designed to protect patient autonomy and confidentiality.


2021 ◽  
Vol 3 (2) ◽  
pp. 113-122
Author(s):  
Carine Minne

This article on fuses igniting in the consulting room is entirely based on clinical experiences without reference to any theoretical positions. Three clinical vignettes will be described to illustrate situations when the therapist realised there was a sudden unexpected rise in “temperature” of a patient’s mind and/or in her own mind, and why this may have occurred. A fuse was lit but was it a slow or a quick one? A slow match is a very slow-burning fuse presenting only a small glowing tip whereas a quick match is one, which once ignited, burns at top speed. I will relate this ignition to the possibility of premature interpretations, or a failure to realise how anxious the patient was in the presence of the terrifying object–therapist and also, unexpected situations arising during and outside of sessions. I will describe how these situations unfolded during sessions and how, upon reflection, these could have been diffused differently. The emphasis will be on how best to maintain a psychoanalytic stance but also how to clinically judge when a session must be terminated in order to protect patient and therapist from exploding “bombs” inadvertently ignited by patient, therapist, or external events. The importance of supervision and consultation with colleagues will be stressed.


Author(s):  
Florian Naye ◽  
Simon Décary ◽  
Yannick Tousignant-Laflamme

BACKGROUND: A framework to establish the biopsychosocial patient profile for persons with low back pain has been recently proposed and validated: The Pain and Disability Drivers Management model (PDDM). In order to facilitate its clinical integration, we developed the PDDM rating scale. OBJECTIVES: To determine the inter-rater agreement of the PDDM rating scale. A second objective was to determine if this inter-rater agreement varies according to the complexity of patients’ clinical presentation. METHODS: We recruited physiotherapists during workshops on the PDDM. We asked each participant to assess two clinical vignettes using the rating scale. One vignette presented a typical clinical presentation (moderate level of difficulty) and one presented an atypical presentation (complex level of difficulty). We determined inter-rater agreement with the proportion of participants who gave the same answer for each PDDM domain. RESULTS: For the typical vignette, the inter-rater agreement per domain was moderate to good (between 0.54 and 0.97). For the complex vignette, the inter-rater agreement per domain was poor to good (between 0.49 and 0.81). The comparison between the two vignettes showed a significant difference (p< 0.01) for nociceptive and cognitive-emotional domains. CONCLUSION: Overall performance indicates that the rating scale present adequate agreement for clinical use, but specific domains require further development.


Author(s):  
Rafik Belloum ◽  
Amel Yaddaden ◽  
Maxime Lussier ◽  
Nathalie Bier ◽  
Charles Consel

Older adults often need some level of assistance in performing daily living activities. Even though these activities are common to the vast majority of individuals (e.g., eating, bathing, dressing), the way they are performed varies across individuals. Supporting older people in performing their everyday activities is a major avenue of research in smart homes. However, because of its early stage, this line of work has paid little attention on customizing assistive computing support with respect to the specific needs of each older adult towards improving its effectiveness and acceptability. We propose a tool-based approach to allowing caregivers to define services in the area of home daily living, leveraging their knowledge and expertise on the older adult they care for. This approach consists of two stages: 1) a wizard allows caregivers to define an assistive service, which supports aspects of a daily activity that are specific to an older adult; 2) the wizard-generated service is uploaded in an existing smart home platform and interpreted by a dedicated component, carrying out the caregiver-defined service. Our approach has been implemented. Our wizard has been successfully used to define existing manually-programmed, activity-supporting services. The resulting services have been deployed and executed by an existing assisted living platform deployed in the home of community-dwelling individuals. They have been shown to be equivalent to their manually-programmed counterparts. We also conducted an ergonomics study involving five occupational therapists, who tested our wizard with clinical vignettes describing fictitious patients. Participants were able to successfully define services while revealing an ease of use of our wizard.


2021 ◽  
pp. 1-4
Author(s):  
Gustavo L. Franklin ◽  
Alex T. Meira ◽  
Maira Tonidandel Barbosa ◽  
Hélio A.G. Teive ◽  
Paulo Caramelli

The significant increment in life expectancy, associated to the existence of high-performing older adults, and the appropriate diagnosis of early dementias, lead to an uncommon scenario, of healthy parents accompanying their children with Alzheimer’s disease or another dementia to medical consultations. Here, we reported three peculiar clinical vignettes of patients diagnosed with a dementia, who were accompanied by healthy parents. This is a modern situation that tends to become more frequent, and must be properly discussed, since multidisciplinary care and specific training are necessary.


2021 ◽  
Author(s):  
Gertraud Diem-Wille

When Freud introduced his concept of the death instinct in Beyond the Pleasure Principle (1920) he solved three theoretical problems which could not be explained by the one drive theory: masochism, repetition compulsion and the negative therapeutic reaction. The concept of two inherently opposed instincts remained one of the most controversial parts of Freud’s theory. For Melanie Klein, Freud’s idea of the death instinct was a powerful instrument in solving her greatest problems of integrating her clinical evidence of an earlier, very harsh superego. In Freud’s account, the superego was the manifestation at birth of the death instinct operating in destructiveness towards the person, as he had argued. In this way, Klein put – as Hinshelwood claims – clinical “flesh on the bones of Freud’s theory of the death instinct.” I will describe the development of Freud’s theory and how this was elaborated by Klein and her followers Bion, Esther Bick, Segal and Rosenfeld. With three clinical vignettes--from an Infant Observation, a child analysis and an adult analysis--the clinical use of the concept will be illustrated.


Author(s):  
C Curtis ◽  
A Pauranik

Background: A basic understanding of localization for a given set of focal neurological deficits is essential for accurate acquisition and interpretation of neuroimaging. Relying on often-limited clinical information, neuroradiologists must choose the most appropriate imaging modality and tailor a study to best identify the culprit lesion to allow for accurate interpretation. Methods: A multiple-choice quiz was designed including clinical vignettes localizing to lesions within the central (CNS) and peripheral nervous systems (PNS). The quiz was pilot-tested and refined before distribution as an electronic survey to practicing neuroradiologists and fellows within newsletters from the American Society for Neuroradiology and Canadian Neurological Sciences Federation. Results: The quiz was begun by 45 neuroradiologists and completed in its entirety by 22. Most respondents were working at urban academic/teaching hospitals(81%) in the USA(42%). The majority (90%) report no clinical neurology rotation during their training. Respondents identified a high proportion (88%) of correct answers in questions about brainstem localizations. Fewer correct answers were selected in questions describing seizure semiology (44%) or flaccid weakness (59%). Conclusions: The small size of our study limits interpretation and generalizability of the findings. Identification of a potential gap in neuroradiology education relating to localization of more complex CNS and PNS presentations merits further exploration.


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