Monday, January 27, 2020

Example Medicolegal Report

Example Medicolegal Report MEDICOLEGAL REPORT Prepared for the Court Claimant:Mrs A Address:Unspecified Date of Birth:1958 Occupation:Housewife Date of Accident:15 February 2005 Examining Doctor:Dr D Consultant Obstetrician and Gynaecologist Statement of Instruction This report is prepared on behalf of the defendant, Dr D in connection with the complications following treatment of Endometriosis on Mrs A started from 23 April 2003. Case Summary Mrs A has suffered complications from foecal peritonitis and pulmonary embolism following the procedures of total abdominal hysterectomy and bilateral salpingo-oophorectomy for the treatment of endometriosis. Case Details Mrs A was referred by her GP and attended the clinic on 23rd April 2003. Mrs A was complaining of constant, severe abdominal pain, per vaginal bleeding with irregular cycles for 2 months with a background history of tubal ligation in 1999. Dr D was unsure of the diagnosis as to whether it was due to endometriosis, polycystic ovarian disease, or tubal infection associated with the previous tubal ligation. Therefore Mrs A was admitted, prescribed with painkiller (Pethidine), and booked for laparoscopy the next day. The result of laparoscopy confirmed active endometriosis with 2 small fibroids and medical treatment of GnRH analogue (Zoladex) was discussed with Mrs A and agreed. Mrs A treatment was then to be reviewed in November 2003. On 5th November 2003, Mrs A attended the clinic and her medication was changed from GnRH analogue to Medroxyprogesterone acetate (Provera). On review in 4th February 2004, Mrs A was not happy with Provera and the prescription was reverted back to Zoladex. On review in 14th July 2004, side effects due to prolonged use of Zoladex were explained and she agreed to start on combined oral contraceptive pills (COCP). On 24th Novemeber 2014, Mrs A came in complaining of severe pain not resolved with COCP and painkiller. Surgical treatment was discussed and she was booked for operation for the removal of uterus, cervix, Fallopian tubes, and ovaries called â€Å"Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy (TAH/BSO)† in February 2005 and for the meanwhile she was also prescribed with non-steroidal anti-inflammatory drug Mefenamic acid (Ponstan) and an opioid analgesics tramadol (Zydol) to relieve the pain. On 15th February 2005, Mrs A was admitted to the hospital for TAH/BSO. On 16th February 2005, Mrs A complained of pleuritic chest pain, shortness of breath, fever, and sweating. On examination she was tachycardic, and on auscultation, there were coarse crackles on the right base of the lung and fine crackles on the left base. She was commenced on antibiiotics without delay – ciprofloxacin and gentamycin together with an anticoagulant low molecular weight heparin – Innohep post-surgery. On 17th February 2005, CT pulmonary angiogram confirmed pulmonary embolism on the right side with possibility on the left side. She was commenced on warfarin and Innohep was continued until INR stabilized. On 18th February 2005, Mrs A complained of non-pleuritic chest pain, numbness going down on the left arm and up into the neck, and tenderness over the left axilla. Cultures showed positive Gram negative coccobacili. Antibiotics treatment was continued and respiratory consult was obtained. On 21st February 2005, cultures showed anaerobic organism that usually comes from the gut – Prevotella loescheii. The antibiotic course was changed to include metronidazole. On 23rd February 2005, radiology report confirmed the diagnosis of foecal peritonitis. Stomatherapy was discussed and anaesthetic consult was obtained. This was day 9 post-TAH/BSO and Hartmann procedure was done to treat the peritonitis. On 24th February 2005, antibiotic treatment of cephalosporin (Cephradine), metronidazole, and gentamycin were continued. The Results of Investigation Mrs A was diagnosed endometriosis through laparoscopy and 2 small fibroids were also found. It was confirmed from the histopathology report. Pulmonary embolism was diagnosed through radiological findings on CTPA and increased in D-dimer while sepsis was identified from the blood culture. Peritonitis was suspected from the finding of anaerobes on culture and clinical signs and symptoms together with CT scan of the abdomen formed the diagnosis of foecal peritonitis. The Nature of Treatments Received by the Claimant Endometriosis When Mrs A first diagnosed with endometriosis, she was treated by medical treatments – GnRH analogue for 6 months, then changed to Medroxyprogesterone for the next 4 months, back to GnRH analogue for another 6 months afterwards, and changed to Combined OCP. Mrs A condition was getting worse and surgical option of TAH/BSO was decided. Pulmonary Embolism (PE) and Sepsis Mrs A was prescribed with antibiotics and anticoagulant when lower respiratory tract infection or PE was suspected. When PE was confirmed, she was already on anticoagulant (Innohep). Warfarin was prescribed after the diagnosis made and antibiotics were continued due to suspected pneumonia or sepsis. The next day, blood culture result was out and confirmed positive. Peritonitis Mrs A was suspected of having sepsis and once culture showed the presence of anaerobes from the gut (Prevatella loescheii), metronidazole was prescribed to cover the anaerobic bacteria. When bowel perforation and foecal peritonitis were confirmed, surgery was carried out to clean up the abdominal cavity. Antibiotics, painkiller, and anticoagulant were continued post-surgery. Opinion on the Patient Management It was a regretful incident that Mrs A suffered complication from peritonitis secondary to bowel perforation, either secondary to adverse event where the operating surgeon unintentionally cut the bowel or due to advanced endometriosis. My review of the managements of this patient from her initial presentation of endometriosis are they are evidence-based, performed in a timely manner, and displayed the knowledge and action of an experienced clinician, and that the complications aroused were less likely due to poor management of the patient. In 1999, Mrs A underwent a laparoscopic tubal ligation and during the operation, there was suspected retrograde menstruation found which may possibly suggest endometriosis. It was in 2003 that the patient was actually diagnosed with endometriosis. However, this could be common where there was delay between the onset of symptoms and the diagnosis of the disease. There is no difference in the delay in diagnosis between mild to moderate and severe endometriosis. In a comparison study conducted in UK and US, the average delay before the diagnosis of endometriosis was 7.5 years and this will likely decreases the women’s capability to cope with the symptoms in which they would present to the formal healthcare [Ruth Hadfield, 1996]. The clinical evaluation of Mrs A was done in a sufficient and timely manner as the diagnosis of endometriosis was suspected in the first presentation since this will usually require high index suspicion due to the wide variety of symptoms and unpredictable course of disease (Lobo, 2007). Video-assisted laparoscopy was also carried out in the second day of admission showing that the clinician involved has a very high suspicion index of endometriosis from the beginning, as laparoscopy is the gold standard to reach a definitive diagnosis of endometriosis. [Bagan et al, 2003] The approach of the management of endometriosis was done properly and the choice of medical treatment as opposed to surgical treatment is wise. Unlike surgery for cancer, Adamson GD (1997) and Sutton et al (1997) said that in the case of endometriosis, surgery is relatively more effective for severe endometriosis rather than in mild cases such as in those with chronic pelvic pain and infertility and because of that, medical treatment is much preferable in the first presentation of endometriosis apart from it being non-invasive. A Canadian study of more than 53 000 admissions showed that 25% patients who had surgical treatment would need another surgery within 4 years and 10% would require hysterectomy and therefore, continual medical management is much preferred over serial surgeries [Weir et al, 2005]. Alifano (2003) mentioned that the prescription of GnRH analogue is recommended as it may have both diagnostic and therapeutic values. The prescription of not more than 6 months in this case was also supported by clinical literatures and Royal College of Obstetrician and Gynaecology (RCOG) guideline as the treatment may result in loss of 6% bone mineral density in the first 6 months [RCOG, 2006]. Extended treatment may result in further loss of bone minerals. Falcone (2011) recommended the commencement of combined oral contraceptive pills (COCP) following the cessation of GnRH analogue and therefore, the choice of COCP after GnRH analogue in this case was also supported by clinical evidence. Shakiba et al (2008) also described the usage of COCP as cost-effective, well tolerated, and clinically effective as danazol and GnRH analogue. The medical treatment is initially acceptable for this patient as earlier laparoscopy in June 2003 showed adhesions between the omentum and uterus with multiple spots of endometriosis and thick, stale, reddish green blood while the later microscopy findings in February 2005 showed well bordered white lesion and occasional white coloured spots that may be suggestive of healed or inactive lesions which should reduce the likelihood of invasive treatment. Brosens (1994) believed that the early and very active lesion would be in red, active and advanced lesion in black, and inactive or healed lesion in white, even though this might be varied from case to case. It is worth to note that there is currently no cure for endometriosis as current treatments aim at symptoms relief such as pain and infertility and organ damage prevention in severe cases. There is no randomized clinical trial comparing medical with surgical treatments; therefore the change of medical to surgical treatment has its own advantages and disadvantages [Sally et al, 2013]. From the record, there was a gap between the patient presentation of severe pain not improving with painkiller and COCP to the last clinic before surgery in November 2004 and the booked surgery in February 2005. This may be justified by non-invasive over invasive management; for example managing the pain by prescribing stronger painkiller such as in this case, tramadol. Since there is no relationship between the severity of pain with the severity of endometriosis, short delay in deciding on hysterectomy or watchful waiting may be an advantage for the patient and the clinician as well to see if there woul d be any improvement. Apart from that, there was no guarantee that surgery may treat the endometriosis. The decision of TAH/BSO was also recommended in this case as the preservation of one or both ovaries in some women may have left the problems with endometriosis behind. Whether the hysterectomy being subtotal or total, it would definitely improve the quality of life of this patient and thus should be considerable decision by the clinician. [Thakar et al, 2004] Even though all precautions and preventive measures have been made, while incidence of internal organ injury is rare, however it does happen especially when the risk is higher in the patient with history of pelvic infection, endometriosis, and adhesive diseases [John, 1997]. However, considerations that need to be taken into account is whether the complications aroused were due to an adverse event such as bowel perforation from the surgery, expected complication arising from the condition such as secondary to adhesions from endometriosis, or the combination of both. The risk of bowel perforation in this open abdominal surgery is much lowered compared to scope-assisted hysterectomy. Bowel injuries happen in about 0.2-1% of cases and primarily due to adhesions involving bowel or cutting within the pouch of Douglas – the space between rectum and uterus. Therefore, it was difficult to expect that this case was to be an addition to the 0.2-1% risk in the study. (Gary et al, 2004) Infection is a common complication following abdominal hysterectomy carrying the risk of 6-25%. Above all, about 33% of patients develop infection after the operation regardless of careful precautions taken [Rice et al, 2006]. Other than infection, severe complications that may occur involve lung collapse, heart attack, stroke, kidney failure, and clotting in the blood vessel (ie pulmonary embolism- clot blockage in the lung) with 4% risk. Greer (1997) mentioned that the risk of developing pulmonary embolism in patient following major general or gynaecologic surgery without clot prevention treatment (thromboprophylaxis) is very low at 0.2-0.9% while in another study, the risk of pulmonary embolism for patient receiving clot prevention treatment of anticoagulants is 0.2%. Therefore, this is a rare severe complication of abdominal hysterectomy that less expected to happen. Despite psychological effects following hysterectomy and prolonged hospitalisation, patient has benefit from the improvement in the quality of life in longer term. And even though multiple complications resulted from the procedure, most women are quite satisfied with the results of the surgery and with the significant symptom relief they experience [Kjerulff et al, 2000]. Conclusion Complications after surgery despite their rareness does happen and this was unexpected incident befall upon Mrs A. However, I believed Dr D, within his capabilities, has managed Mrs A with acceptable, sufficient, and evidence-based methods from the initial treatment until the last resort of hysterectomy to prevent any complications from happening. Duty of an Expert I understand my duty is to the Court; to help the Court on matters within my expertise, and I have complied with that. I understand that this duty over-rides any obligations to those by whom I have been instructed. I believe that the facts I have stated in the report are true and within my own knowledge and that the opinions I have expressed represent my professional opinion. BIBLIOGRAPHY Brosens I. Is mild endometriosis a progressive disease? Human Reproduction 1994; 9: 2209–2211. Adamson GD. Treatment of endometriosis-associated infertility. Seminars in Reproductive Endocrinology 1997; 15: 263–271. Sutton CJG, Pooley AS Ewen SP. Follow-up report on a randomized, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild and moderate endometriosis. Fertility and Sterility 1997; 68: 170–174. AstraZeneca. Zoladex 3.6mg Implant. Summary of Product characteristics. 2012. Brown J, Pan A, Hart RJ. Gonadotrophin-releasing hormone analogues for pain associated with endometriosis. Cochrane Database of Systematic Reviews 2010, Issue 12. Art. No.: CD008475. Falcone T. Lebovic DI. Clinical management of endometriosis. Obstetrics Gynecology. 118(3):691-705, 2011 Sep. RCOG. The investigation and management of endometriosis. Green-top guideline 24. 2006 Lobo R. Endometriosis: Etiology, Pathology, Diagnosis and Management. 5th ed. Katz VL, editor. Comprehensive Gynecology. Philadelphia, PA: Mosby Elsevier; 2007:473–499. Alifano M, Roth T, Broet SC, Schussler O, Magdeleinat P, Regnard JF. Catamenial pneumothorax: a prospective study. Chest. 2003;124:1004–1008. Bagan P, Le Pimpec Barthes F, Assouad J, Souilamas R, Riquet M. Catamenial pneumothorax: retrospective study of surgical treatment. Ann Thorac Surg. 2003;75:378–81; discusssion 81. Weir E, Mustard C, Cohen M, Kung R. Endometriosis: What is the risk of hospital admission, readmission, and major surgical intervention? J Minim Invasive Gynecol 2005;12:486–93. Shakiba K, Bena JF, McGill KM, Minger J, Falcone T. Surgical treatment of endometriosis: a 7-year follow up on the requirement for further surgery. Obstet Gynecol 2008;111: 1285–92. John D Thompson. Operative Injuries to the Ureter: Prevention, Recognition, and Management. In: John A Rock and John D Thompson. Te Lindes Operative Gynecology. Eighth. Philadelphia New York: Lippincott-Raven; 1997:Chapter 40 Pages 1135-1173. Thakar R, Ayers S, Georgakapolou A, Clarkson P, Stanton S, Manyonda I. Hysterectomy improves quality of life and decreases psychiatric symptoms: a prospective and randomised comparison of total versus subtotal hysterectomy. BJOG. Oct 2004;111(10):1115-20. Eskenazi B, Warner ML. Epidemiology of endometriosis. Obstet Gynecol Clin North Am. Jun 1997;24(2):235-258. Wykes CB, Clark TJ, Khan KS. Accuracy of laparoscopy in the diagnosis of endometriosis: a systematic quantitative review. BJOG. Nov 2004;111(11):1204-1212. Ruth H, Helen M, David B, Stephen K. Delay in diagnosis of endometriosis: a survey of women from the USA and the UK. Human Reproduction; 1996: vol.11 no.4 pages 878-880. Kjerulff KH, Langenberg PW, Rhodes JC, et al. Effectiveness of hysterectomy. Obstet Gynecol. 2000;95:319-326. Rice CN, Howard CH. Complications of hysterectomy. US Pharm. 2006; 31(9):HS-16-HS-24. Greer IA. Epidemiology, risk factors and prophylaxis of venous thrombo-embolism in obstetrics and gynaecology. Baillieres Clin Obstet Gynaecol 1997; 11:403. Garry R, Fountain J, Mason S, et al. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ 2004; 328:129. Mà ¤kinen J, Johansson J, Tomà ¡s C, et al. Morbidity of 10 110 hysterectomies by type of approach. Hum Reprod 2001; 16:1473.

Sunday, January 19, 2020

Schneck vs United States :: essays research papers

Schenck vs. United States- 1919 HOLLIES, J. This is an indictment in three counts. The first charges a conspiracy to violate the Espionage Act of June 15, 1917 . . . by causing and attempting to cause insubordination, &c., in the military and naval forces of the United States, and to obstruct the recruiting and enlistment service of the United States, when the United States was at war with the German Empire, to wit, that the defendants willfully conspired to have printed and circulated to men who had been called and accepted for military service under the Act of May 18, 1917, a document set forth and alleged to be calculated to cause such insubordination and obstruction. The count alleges overt acts in pursuance of the conspiracy, ending in the distribution of the document set forth. . . . They set up the First Amendment to the Constitution forbidding Congress to make any law abridging the freedom of speech, or of the press, and bringing the case here on that ground have argued some other points also of which w e must dispose. It is argued that the evidence, if admissible, was not sufficient to prove that the defendant Schenck was concerned in sending the documents. According to the testimony Schenck said he was general secretary of the Socialist party and had charge of the Socialist headquarters from which the documents were sent. He identified a book found there as the minutes of the Executive Committee of the party The book showed a resolution of August 13, 1917, that 15,000 leaflets should be printed on the other side of one of them in use, to be mailed to men who had passed exemption boards, and for distribution. Schenck personally attended to the printing. On August 20 the general secretary's report said, "Obtained new leaflets from printer and started work addressing envelopes" &c.; and there was a resolve that Comrade Schenck be allowed $125 for sending leaflets through the mail. He said that he had about fifteen or sixteen thousand printed. There were files of the circular in questio n in the inner office which he said were printed on the other side of the one sided circular and were there for distribu|tion. Other copies were proved to have been sent through the mails to drafted men. With; out going into confirmatory details that were l proved, no reasonable man could doubt that the defendant Schenck was largely instrumental in sending the circulars about.

Saturday, January 11, 2020

To Be Human Is To Discuss

There were only 100 years without war in the whole history of human civilization! Iraq and Kuwait had had a long standing, but low level, border dispute over a pair of Persian Gulf islands. No preventative diplomacy was employed during this period of escalation, and Kuwait was invaded in August of 1990. more than 200 people lost their lives. In Vietnam war the total amount of casualties is more than 1,800 million people. In Rwanda after April 6, 1994, 800,000 men, women, and children perished in the Rwandan genocide, perhaps as many as three quarters of the Tutsi population.Although the Rwandans are fully responsible for the organization and execution of the genocide, governments and peoples elsewhere all share in the shame of the crime because they failed to prevent and stop this killing campaign. Not only did international leaders reject what was going on, but they also declined for weeks to use their political and moral authority to challenge the legitimacy of the genocidal govern ment. When international leaders finally voiced disapproval, the genocidal authorities listened well enough to change their tactics although not their ultimate goal.Far from cause for satisfaction, this small success only highlights the tragedy: if weak protests produced this result in late April, imagine what might have been the result if in mid-April the entire world had spoken out. Syria now is bogged down in endless killing. Early in the uprising, Western support might have ousted Mr Assad and preserved Syria’s sectarian harmony. , but the West held back. Now, after more than 110,000 people have died during 30 months of violence, it is too late. Like many civil-war leaders Mr Assad prefers to prolong the fighting rather than risk compromise.The rebels, too, battle on in the knowledge that surrender is likely to mean death. Guys,we live in the 21 century and the humans became so developed that we can tell GOOGle what to GOOgle with our voice but we still fight even more ho rribly than centuries ago. why do wars still occur then? Wars occur when negotiations fail or don’t even take place. The talks fail when one or more of the parties refuse to participate in negotiations. There are 4 most common reasons for such refusals- 1) that the refusing party thinks that it can get a better outcome by some other means-usually through force.2)they fear they will be forced to accept unwanted compromises. If parties think they will have to compromise their values, or give up their chance to obtain their fundamental needs, they will refuse to participate in any negotiation. 3)that parties may refuse to negotiate because they make think that the negotiations are a waste of time and are destined to fail. 4)A final reason why parties may refuse to negotiate is that they are so angry with the other group that they are not even willing to sit down at a table , because they do not want to grant them the legitimacy that such an act would imply.These reasons are not sensible enough to risk thousands of human lives. The main reason why the man got ahead of the mammals is thanks to the intensive development and differentiation of the cerebral cortex. But even the mammals don’t kill each other whereas it’s not uncommon for us to do this. We really differ from mammals and need to understand that the power of the word is immense and the only way for us to remain human beings is to discuss. All these bloodstained wars are not the inability to discuss, but just the unwillingness.While war has created more separation between Arab world and the West, negotiations could have improved the relationships and found long-term solution. the only way to stop the continuous fight in Syria is through negotiations. The Economist suggests that The effort is worth it—about 40% of civil wars end through negotiation. And to pave the way for negotiated solutions, parties should have clear understanding of their interests, acknowledge their interdep endence by considering both short-term and long-term interests, and recognize that their interests are not incompatible.The parties should also reject the attempt to frame negotiations as talk with a madman. Negotiations are about finding common ground with the opponent, but not judging personal qualities of the negotiator. And the thing that the parties should understand best of all- is that they are humans and that as leaders they have to protect their people from war. Nothing in this world is more valuable than a human life. Let’s save it by discussion! It began to snow.. lightly at first, but then in large flakes. The wind started to howl,it was a snowstorm.In an instant the dark sky merged into an ocean of snow. Everything disappeared. The epigraph for Bulgacov’s â€Å"White Guardian† seems like a snowy night on December the 9th in Kiev. the protesters have blockaded streets and occupied municipal buildings, riot police have beaten demonstrators and journal ists, agent provocateurs have tried to discredit the crowd and thus to excuse the repression. The violence can get much worse but the both parties answers to the idea of talks are â€Å"we shall push a little bit more and everything will be OK†. Won’t it be only worse?

Friday, January 3, 2020

How Does An Autism Assistance Dog Positively Affect The...

Research Question: How does an autism assistance dog positively affect the autistic child? I decided to research this topic as I have always been interested in animals and want to pursue a career working with animals. After watching a captivating news clip on assistance dogs it was clear this was going to be the topic I would investigate for my research project. I researched autism assistance dogs (AAD), specifically their training, eligible criteria and positive effects on the child. I read websites and books along with watching videos to get secondary information. I contacted an expert in the field - Danielle Mathews, service coordinator of AAD at Guide Dogs SA/NT, to obtain further information to support my findings. My Research Outcome is in report form and features pictures and diagrams. (Word count 130) Evaluation E1 – Evaluation of Research processes I relied heavily on secondary sources as there were limited organisations where I could receive the primary information. All the resources used cross referenced each other and were specific to my topic. The basis of my research was conducted through Guide dogs SA/NT as they are based in Adelaide and have significant information regarding AAD. This process was highly valid in that it included a large amount of relevant in-depth information that contributed to many key findings of my research. Guide dogs provided me with an effective abundance of information desired. As well as having generalShow MoreRelatedSocial Interaction For Children With Autism3206 Words   |  13 PagesSocial interaction for children with autism can be even more difficult (Burrows, 2008). For several of these children having a companion dog can make all the difference. Dogs like any other animal will not judge a child; they do not care how popular a child is or how they look or even how he or she forms sentence s. The continuous companionship and friendship of such a devoted creature can help a child with autism build confidence (Beaumont, 2008). Companion dogs accompany their partner to doctor sRead MoreAutism Spectrum Disorder ( Asd ) Essay2187 Words   |  9 PagesAutism spectrum disorder (ASD) is an intricate brain disorder that can cause difficulties in social skills, communications, and abnormal behavior. Looking at children with ASD, researchers began investigating how to lessen the affects that ASD had on children using animals. More specifically, it was discovered that dogs could be helpful to children. â€Å"Man’s best friend† may be valuable in a way doctors and trained therapeutic professionals are not. How does interacting with a dog affect children withRead MoreThe European Society Of Animal Assisted Therapy7053 Words   |  29 Pagesanimals or are active for animals. Implementation is goal-oriented and based on a clear process and topic orientation taking int o account animal-ethical principles with subsequent documentation and professional well-founded considerations. Therapy dogs undergo extensive training before working with patients (Murphy, Shepard, (2004). There are many different groups of people that have benefited from canine assisted therapy. The following sections will take an in-depth look at a few groups. CanineRead MoreHealing Powers from an Unexpected Source1900 Words   |  8 PagesWhether it be a dog, cat, bird, rabbit, or even a horse, all types of animals can be trained to help the emotional and physical health of many in simple and extraordinary ways. The use of animal therapy with highly trained animals can benefit the emotional and physical health of a variety of people, including children, elderly, and individuals with unique circumstances. Healing can be found in situations of animal presence with a child, throwing a ball for a dog, students petting dogs before a testRead MoreLeadership for Health and Social Care and Children65584 Words   |  263 Pagesand practices in health and social care or children and young people s settings (M1) 62 Working in partnership in health and social care or children and young people s settings (M2c) 66 Understand child and young person s development (MU5.2) 68 Lead practice that supports positive outcomes for child and young person develo pment (MU5.3) 72 Develop and implement policies and procedures to support the safeguarding of children and young people (MU5.4) 75 Lead and manage group living for children (P4)