Case study of cyanotic congenital heart disease

Case study of cyanotic congenital heart disease Baby J, a 3-week-old infant, was admitted to Ward 5A since birth due to severe central cyanosis caused by several congenital heart problems. Soon after birth, he suffered from respiratory distress, where his initial SaO2 was only about 70%. He was resuscitated and given 5 nanograms/kg/min of Prostin (Prostaglandin E2). On appearance, he was dusky-looking and his peripheries were cold and cyanosed. He was started on biphasic continuous positive airway pressure (CPAP) via an apnoea mask and also given positive end-expiratory pressure (PEEP) as an adjunct. His CPAP was delivered using nasal cannula the following day after his SaO2 increased to 80% and he remained on CPAP for the first 5 days after birth, which subsequently was weaned off. Antenatal scans found pulmonary atresia, overriding aorta and ventricular septal defect (VSD). Postnatally, cardiac catheterisation confirmed the antenatal findings with extra major aortopulmonary collateral arteries (MAPCAs). He tolerated feeding via TPN and was given 6ml of EBM (expressed breast milk) at intervals of 2 hourly. Bottle feeding was attempted on 28/09/09 and he tolerated the feedings well. Recently, the feedings increased to 44ml 2 hourly. Baby J passed urine normally and his stools were of normal consistency. Past Medical and Surgical History Baby J underwent a cardiac surgery on 1/10/09 through a median sternotomy and a Melbourne shunt was inserted to create an aortopulmonary connection. He was also diagnosed with Alagilles syndrome (an autosomal dominant inherited disorder affecting the heart, liver, spine, kidney and central nervous system). Family History Baby Js father was diagnosed with Alagilles syndrome as a child. He has congenital spinal abnormalities, cardiac defects (atrial septal defect, ASD, pulmonary stenosis and right ventricular dysfunction). Baby Js mother suffered from depression for about 3 years now. She also has asthma and a high BMI of 40. During pregnancy, Baby Js mother was on anti-depressant (Fluoxetine 20 mg OD) and inhalers (Becctide and Ventolin). Drug History NKDA Medication Dosage Frequency Aspirin 15mg OD Frusemide 3mg BD Spironolactone 3mg BD Social History Baby J is the 3rd child in the family. He has one brother and 2 sisters. His brother was also diagnosed with Alagilles and suffers from cardiac anomaly. Baby Js mother is a non-smoker and she did not drink alcohol while conceiving him. Systemic Enquiry Neurological None to note. Cardiovascular See above. Respiratory Cyanotic. Gastrointestinal None to note. Opened bowel normally with normal stools. Genitourinary None to note. Passed urine normally. Haematological None to note. No fevers or rigors Musculoskeletal None to note. Endocrine None to note PHYSICAL EXAMINATION General Inspection Not distressed or in pain. Alert and non-lethargic. Apyrexial (Temperature 37.1 0C) Mild bluish discolouration of lips and tongue. SaO2 83% on room air. Heart rate: 156 bpm RR: 48/min Anterior fontanelle normal. Cardiovascular Examination Examination Findings BP Pulse rate 78/ 45 mmHg 156 bpm (regular, normal volume, character) No radial-radial delay or radio-femoral delay. Normal radial/ brachial/ femoral pulses. Normal carotid pulses. Inspection Hands and nails Face and tongue Precordium Ankle Non-cyanotic fingers. CRT No finger clubbing/ splinter haemorrhages. Non-pallor palmar creases. Deep-set eyes, prominent forehead (features of Alagilles syndrome) Non-pallor conjunctiva Mild central cyanosis (bluish tinge to tongue) Median stenotomy scar. No peripheral oedema (rarely seen in children) Palpation Central trachea. No thrills or left parasternal heave. Auscultation HS=I+Single II (muscular pulmonary atresia) + Ejection click (due to high flow across aortic valve) and continuous murmur. Respiratory Examination Examination Findings Inspection Hands Mouth Eyes Chest wall Not breathless or in distress. Breathing at ease. No peripheral cyanosis. No finger clubbing. Mild bluish tinge to tongue. No jaundice and non-pallor conjunctiva. Normal AP diameter. Symmetrical movement of chest wall with respiration No accessory muscles used in respiration. Trachea Central, no tracheal tug Percussion Generally, resonant to percussion. Auscultation Vesicular breath sounds. Normal air entry. No wheeze or added sounds. Summary of Problems Baby J suffered from severe cyanosis immediately post-delivery due to closure of ductus arteriosus. To maintain the patency of the duct, he was given prostaglandin E2. However, this was just a temporary measure to maintain a duct-dependent pulmonary circulation. A more definitive treatment for Baby J was to establish a direct connection between the aorta and the pulmonary artery by a shunt in order to promote growth of central pulmonary artery. Differential Diagnosis *Most likely differential for Baby J bolded. Differentials of cyanosis:- Primary pulmonary disease Cyanotic congenital heart disease Reduced or duct-dependent pulmonary circulation Tetralogy of Fallot Pulmonary atresia Tricuspid atresia Abnormal mixing Transposition of great arteries Total anomalous pulmonary venous drainage (all draining into right atrium) Single truncus arteriosus Persistent pulmonary hypertension due to persistent fetal circulation Anaemia Asphyxia Sepsis Metabolic disorder Methaemoglobinaemia due to haemolytic anaemia Management Plan Initial management:- Respiratory distress at birth Resuscitation, give CPAP and PEEP to maintain oxygenation to lungs, immediate Prostin (5ng/kg/min) Check breathing Maintain circulation IV fluids Routine bloods and ABG Continuous monitoring oxygen saturation and vitals Cardiology review- echo and CXR Echo findings consistent with Fallot tetralogy with MAPCAs CXR found cardiomegaly Feeding via TPN (6ml/kg/2 hourly) Further management:- Cardiac catherisation to assess for cardiac anomaly Cardiology experts advised surgery to establish connection between aorta and pulmonary artery to increase pulmonary blood flow. Melbourne shunt was inserted via median sternotomy on 1/10/09. Echo post-op showed good flow in small pulmonary arteries and patent central shunt. Continue monitoring oxygen saturation aim to keep above 75% Perform ECG Monitor temperature post-op If pyrexial, culture blood and give vancomycin and gentamicin. Start on aspirin, frusemide, spironolactone and paracetamol PRN. Increase feed to 150ml/kg/day via bottle Relevant Investigations and Results: Bloods results (2/10/09) after cardiac surgery FBC Hb Platelets WBC 15.2 230 10.5 UE Na+ K+ Cl Urea Creatinine 142 4.7 100 3.9 77 LFTs Alk P AST ALT Pro Alb 274 29 31 55 27 CRP 100 Echo Results on 18/09/09 Pulmonary atresia, MAPCAs, VSD, overriding aorta. Results on 2/10/09 Patent central shunt with good flow to small pulmonary arteries. MAPCAs flow demonstrated from joined aortopulmary branches. X-ray of whole spine Single AP view of thoracolumbar spine no abnormality found. Reflective Commentary: Tetralogy of Fallot Tetralogy of Fallot (TOF) is the commonest cause of cyanotic congenital heart disease. It has 4 cardinal anatomical anomalies:- [1] Large outlet VSD Overriding aorta with respect to ventricular septum Right ventricular outflow obstruction (infundibular and valvular pulmonary stenosis) Right ventricular hypertrophy Epidemiology TOF affects 3-6 infants in every 10, 000 births. [1] Aetiology [4] The aetiology is unknown, but evidence suggests a multifactorial cause. Antenatal risk factors are:- Maternal rubella (or other viral infections during pregnancy) Poor antenatal nutrition Maternal alcohol use Maternal age > 40 years Diabetes Children with Down syndrome have a higher risk of TOF. Presentation [4] Symptoms Very few infants present with severe cyanosis in the first few days of life with duct-dependent pulmonary circulation. Most infants are diagnosed by murmur at the age of 1-2 months. Feeding difficulty and failure to thrive. Tet spells episodes of bluish pale skin during crying or feeding. Squatting is classical of infants with TOF. Exertional dyspnoea usually worsens with age. Physical examination Smaller than expected for age. Peripheral cyanosis is normally found at birth, and after 3-6 months, finger clubbing may develop. Cardiac examination:- A thrill at left sternal border. Ejection systolic murmur heard over the pulmonic area and the left sternal border. In babies with aortopulmonary collaterals, continuous murmurs may be detected The S2  is usually single. Diagnosis Diagnosis is through history and clinical examination, supported by chest x-ray and ECG, and confirmed by echocardiography. Bloods Haemoglobin and haematocrit are usually increased in relation to the degree of cyanosis. The arterial oxygen saturation varies from 65-70%. ECG ECG shows right ventricular hypertrophy (+ right axis deviation) and may also show right atrial hypertrophy. Imaging Radiography Classical boot-shaped heart. Echocardiography Used to diagnose ductus arteriosus, VSD, or ASD with Doppler echocardiography. *Comparison of Baby Js presentation to the classical presentation Baby J had severe pulmonary atresia (muscular in origin) due to a severely malrotated infundibular septum. He suffered from life-threatening cyanosis at birth which had to be attended to promptly by maintaining the patency of ductus arteriosis using prostaglandin E2. As he was highly symptomatic, a palliative surgery to increase pulmonary blood flow had to be done where he underwent placement of Melbourne shunt connecting his aorta to MAPCA. This was done hoping to promote the development of main pulmonary artery. Baby J also had another problem which was the 50% possible chance of inheriting Alagilles syndrome (autosomal dominant) from his father. His LFTs were checked for any liver abnormality which is commonly implicated in this syndrome. He also had spine X-ray to exclude spinal deformities. He will be having ophthalmology review soon as well. GMC theme 2: Treatment Acute treatment [4] Neonates with severe cyanosis due to ductal constriction are given an infusion of prostaglandin E2(0.05 to 0.1  ÃƒÅ½Ã‚ ¼g/kg/min IV) to reopen the ductus arteriosus. Tet spells are usually self-limiting and followed by a period of sleep. If prolonged (> 15 mins), treatment consists of:- [4] placing infants in a knee-chest position sedation and pain relief morphine  IM. IV fluids are used for volume expansion. Propanolol  IV acts as peripheral vasoconstrictor. Bicarbonate to correct acidosis. Muscle paralysis and artificial ventilator to reduce oxygen demand. Symptomatic or palliative treatment in first few months Palliative surgery can be performed in patients who are not suitable for complete repair or patients with tet spells. One of the commonly used procedures is the Blalock-Taussig shunt where the subclavian artery is connected to the ipsilateral pulmonary artery with a prosthetic graft. Baby J had a relatively new shunt placement (first developed in Melbourne) which connects the major aortopulmonary collateral artery (MAPCA) to aorta. This has been shown to promote the growth of central pulmonary artery. [2] Melbourne shunt: illustrates the completed shunt with the pulmonary artery anastomosed to the posterior and left lateral aspect of the ascending aorta close to the sinotubular junction. Adapted from Ref [2] Corrective Surgery Since TOF is a progressive disorder, Baby J will require a more definitive corrective surgery. Nowadays, surgery is commonly performed electively at around 6 months of age (or before 1 year). The timing of complete surgical repair on Baby J will depend on numerous factors like further symptoms, severity of lesions (multiple VSDs, pulmonary atresia),etc. Complete repair is achieved by patch closure of VSD and widening of right ventricular outflow tract. Perioperative mortality rate is   Primary repair is beneficial in terms of preventing long-term right ventricular outflow obstruction and the consequential development of right ventricular hypertrophy, prolonged cyanosis, and postnatal angiogenesis. [1] Summary Survival in children with simple forms of TOF is promising and quality of life is good. Studies showed that survivors are in NYHA 1 class with minimal reduction in exercise capacity. However, Baby J has a rather severe form of TOF and it is difficult to predict his prognosis as for now. This will depend on his progress after corrective surgery repair done. He will need life-long cardiac review and this can be quite stressful for the child and the family as well. Baby J is fortunate to have good supportive parents who are both rather anxious about the childs condition during the interview.

Evolution Of Management Essay -- Organization Management Industry

Evolution of Management In this paper I will be explaining the evolution of management from the beginning of the industrial revolution to present which includes Classical School of Management, the Human Relations/ Behavioral School of Management, Theory X and Y, the Scientific Approach, Contingency Approach, and Theory Z. I will also be comparing the classical style and the present style to each other and to my current work environment. The Classical school of thought began during the Industrial Revolution around 1900 and continued into the 1920s when new problems related to the factory system began to appear. Managers were unsure of how to train employees (many of them non-English speaking immigrants) or deal with increased labor dissatisfaction, so they began to test solutions. Traditional or classical management focuses on efficiency and includes scientific, bureaucratic and administrative management. Bureaucratic management needs a rational set of structuring guidelines, such as rules and procedures, hierarchy, and a clear division of labor. Scientific management focuses on the "one best way" to do the job. Administrative management emphasizes the flow of information in the operation of the organization. The first... ...g. Fayol believed that all managers performed these functions and that the functions distinguished management as a separate discipline of study apart from accounting, finance, and production." (Online - http://www.referenceforbusiness.com/management/Log-Mar/Management Thought.html) [3] "McGregor recognized that some people may not have reached the level of maturity assumed by Theory Y and therefore may need tighter controls that can be relaxed as the employee develops." (Online - http://www.envisionsoftware.com/articles/Theory_X.html) [4] "This approach arose out of the observation that the three earlier approaches to management - the Classical, the Behavioral, and the Operations Research - did not always lead to an acceptable solution" (Patrick J. Montana and Bruce H Charnov, Management, Third Edition, page 30)

Organizational Conflict Essay

Conflicts within an organization can be difficult on employees. Some conflicts may be petty and some could end up in violence. They are often started because of the difference of opinions between employees (Shetach, A., 2012). Regardless of the situation; employers cannot afford to have conflicts within their organization. The purpose of this paper is to analyze the reason for the conflict within this organization and to come up with ways to help solve the conflicts. Description of the Conflict The conflict at my place of employment is that there are never enough associates scheduled to perform the duties that are needed to be done. The ICS team is the main team that goes through the inventory in the back room on a daily basis. Their job is to bin every item that comes within this store with a labeling system. The problem that is being cause is that there are not enough associates able to keep up with binning the items after the ICS team finishes scanning and counting their freight. What conflict that has occurred from this is that the unloaders are coming in and they have to help them out. In return the un-loaders are falling behind in their work. When the morning shift associates comes in; mainly department managers they have to work out the items that the ICS team has scanned. When you look at the amount of freight that is needing to be work out, it could be from four to fifteen L-carts. L-carts are the large carts that are used to move large freight to the floor or to the customer’s car. Production was falling behind because there was not a good plan set into place on who, what, and how the receiving area of the store would be operated. There was lack of communication that was going on between upper management and lower management. It seemed as though the associates were the ones that were making the decisions instead of the managers. The ICS team and the un-loaders were constantly arguing with each other, claiming that the other one is not doing their job. The department managers were coming in to work stating that the overnight associates were not putting out freight. It looked as if the same freight was left from the day before was not being worked. Level of Conflict There are four levels of conflict within an organization (Baack, D., 2012). What is going on within this organization is called intragroup conflicts. Intragroup conflicts occur when incidents between members of a team do not have the same mind set concerning goals. They disagree with the way the operations are being handled and the leadership (Baack, D., 2012). If conflicts are left unattended within an organization it could affect the overall goal of the company. The teams may not do what they need to do and the decision that they make in doing their job may not be the right decision (Baack, D., 2012). Propose Steps to Resolve the Conflict There are five steps that must be followed in order to help resolve conflicts within this organization. The first thing is to identify the parties that are involved in the conflict. Determining if the entire team is involved or if there is an individual that is causing the conflict need to be investigated first (Baack, D., 2012). By doing this, it will allow for the managers to help determine what is need to be done in order to resolve the conflict. This conflict can be stopped with the proper communication between team members and management. But they need to have weekly meeting in order to go over their goals and their concerns (Shetach, A., 2012). Having meeting will allow the team members to voice their opinions if they feel they may not be doing ample amount of production that is needed in order to be productive. This can be analyzed by management as soon as it is brought up in the meeting. The management team needs to find out what the real issue is within the team and figure o ut how the problem started. While they are investigating this issue they need to also know what position that each team member have concerning this conflict (Baack, D., 2012). This can help management to understand where each team member stands on this conflict so it could help them come up with a better solution in order to stop the problem. Finding an area in which there can be bargaining is very important in resolving conflicts within an organization (Baack, D., 2012). Management need to stay neutral in making a decision regarding the conflict that is going on between the ICS team, the unloaders, and the department managers. There should be lines in which the managers need to be able to listen to all sides and not show favoritism. Finding the best solution for the organization in what is important. The policies need to be addressed at the time when bargaining process is going on (Montgomery, M., 1995). At the same time, the team members need to be able to work through their conflicts. There need to be a check list that needs to be done on a daily basis in order for each backroom associate to follow. If they are not able to do what they are assigned then they should be able to type in the reason why. For example, I was called to work in the garden center by Assistant Tony. It should have the time, and date on the log so that it can show the reason why a task was not completed. Management should not be able to call an ICS member out of their work area for more than 15 minutes a day. Considering they might be one of four that was assigned to scan in what is coming off of the trucks. Another step that could help resolve the conflict is to schedule people with the department managers that only have one associate. Some department managers do not have more than one associate within th eir area. A department manage usually have five hundred to five thousand prices changes to do on a daily basis. They have to work their bins; bins are the freight that they have to put out on the shelves. If more associates are schedule past 5 pm, it could help the organization to make a better profit; because the shelves will be filled. Not all conflict situations are the same. Some may be resolved if the people that are involved learn the effect that their opinion, attitudes, or behavior have on other team members (Montgomery, M., 1995). Some of the managers need to be more productive by helping the team members to see what they need to improve in or what they have to offer to make the team stronger. Outcomes to the Conflict Resolution By not doing anything and letting the teams argue about what each other are doing it will cause a lack of production within the team. It could affect the entire team as a whole. Agreement is very important in a conflict resolution (Baack, D., 2012). When all of the team members on the ICS, department managers, and the un-loaders believe that their opinions matters that is when agreement is reached. The managers have to let them all know that all of the concerns that were leading up to their conflicts have been met. Everyone will be held accountable for their own job expectation, and no one will be pulled out of their area for more than fifteen minutes a day. The night managers will make sure that they have associates working in areas that have the largest amount of freight in order to keep the department managers from being over whelmed. Stronger relationships may develop between the teams; however, some teams like to work without other teams being involved. Take the ICS team for example; they do not trust anyone to count what is coming in on the truck. If an upper member of management scans what comes in on the truck they do not have much of a choice. If a new employee is in training they have to gain trust within this group before they let them work by themselves. And finally organizational learning can take place among team members. The can learn how to work together by coming up with better ways to find solutions to the problems they may encounter within their team (Baack, D., 2012). They can learn how to deal with each other on a personal level because they may have learned what each team needs. If the meetings continue to be given between these three teams on a weekly basis, this will teach them. In conclusion, there conflicts can make it difficult for team to work together. This paper was to show ways that teams could resolve their conflicts in order to help their organization to run smoothly and put a handle on conflicts. References Baack, D. (2012). Organizational behavior. San Diego, CA: Bridgepoint Education, Inc Montgomery, M., (1995). Five steps to resolves conflicts. Supervisory Management, 40(10), 8 Shetach, A., (2012). Conflict Leadership. Navigating Toward Effective and Efficient Team Outcomes. Journal for Quality & Participation, 35(2), 25-30

Analysis Of Joan Baez s The Voice - 1028 Words

Joan Baez: A Voice Straight To God Joan Baez is an extraordinary American female icon, most notable for her contributions to the folk music scene, as well as her involvement with civil rights and antiwar movements. Baez, still alive today at 75 years old, continues to inspire and lead people along an inclusive and nonviolent way of life, as she knows that â€Å"action is the antidote to despair† (Loder). Joan Chandos Baez was born in Staten Island, New York on January 9th, 1941, to a white mother, Joan, and a Mexican father, Albert (Biography.com). The Baez family were Quakers, who, in addition to Joan, had two other daughters, the eldest Pauline and the youngest Mimi. Due to their biracial heritage, Baez and her sisters had their fair share of experience with discrimination; in an interview with TIME Magazine in 1962, she recounts how, in her childhood, a white neighbor called her the n-word from observing her dark Mexican skin (Rothman). When they lived in Baghdad for a shor t period, Joan was often mistaken for an Arab girl, and was treated very differently than her lighter-skinned sisters (â€Å"Joan Baez: How Sweet the Sound†). In high school, Baez received her fifteen minutes of fame as she protested against an air-raid drill that was to be performed at her school (â€Å"Joan Baez: How Sweet The Sound†). In 1958, Baez enrolled in Boston University for theater but soon flunked out due to boredom of school and a more vested interest in singing folk songs at local coffee shops (Loder).Show MoreRelated The Influence of Protest Music during the 1960’s And Beyond Essay examples3816 Words   |  16 PagesThe 1960’s was one of the most controversial decades in American history because of not only the Vietnam War, but there was an outbreak of protests involving civil and social conditions all across college campuses. These protests have been taken to the extent where people either have died or have been seriously injured. However , during the 1960’s, America saw a popular form of art known as protest music, which responded to the social turmoil of that era, from the civil rights movement to the warRead MoreManaging Information Technology (7th Edition)239873 Words   |  960 Pagesand permission should be obtained from the publisher prior to any prohibited reproduction, storage in a retrieval system, or transmission in any form or by any means, electronic, mechanical, photocopying, recording, or likewise. To obtain permission(s) to use material from this work, please submit a written request to Pearson Education, Inc., Permissions Department, One Lake Street, Upper Saddle River, New Jersey 07458. Many of the designations by manufacturers and sellers to distinguish their