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Picking up the Missed Opportunities: Topics to teach for geriatrics and the ACGME core competencies 1. 43 year-old female. Acute pancreatitis with a fever. Geriatric Topics Pain management Systems Based Practice Transition Trigger Surgical service to medicine service Topic Trigger Pancreatitis Failure Trigger CT scan cancelled Practice Based Learning Review of appropriate use of medical imaging 2. 80 year old male with mental status changes and falls for nursing home placement. Geriatric Topics Delirium Unmasked dementia Decision Making Capacity Polypharmacy Deconditioning Falls Systems Based Practice Transition Trigger Home to NH Topic Trigger Delirium—risk stratification and prevention Failure Trigger Admission for NHP—unrecognized dementia as an outpatient Professionalism & Communication Family crisis intervention—discussing the dementia diagnosis and need for 24 hour supervision Practice Based Learning Geriatric discharge case audit Johnson, Podrazik, and Whelan 1 3. 62 year-old male. Transfer from the MICU after 8 day ARDS/sepsis stay Geriatric Topics Transitions of care Functional Assessment and Decline Systems Based Practice Transition Trigger Topic Trigger ARDS SEPSIS Failure Trigger Doc to Doc Communication Practice Based Learning Stress ulcer prophylaxis census audit Foley catheter census audit DVT prophylaxis census audit 4. 28 year-old male. Pneumonia in what may be a newly diagnosed HIV patient Geriatric Topics Chronic disease model Systems Based Practice Transition Trigger Move from health to chronic disease state Initiation into health care system Topic Trigger HIV and societal costs Failure Trigger Inability to get AFB smears Practice Based Learning Immunizations in the inpatient setting Review of education provided Professionalism and Communication: HIV test counseling Educating and counseling a newly diagnosed HIV patient about the disease Johnson, Podrazik, and Whelan 2 5. 67 year-old female. ESRD with fevers, possible line infection. Geriatric Topics Sepsis Delirium Drugs and the aging kidney Dialysis utilization and advancing age Systems Based Practice Transition Trigger Transition back to outpatient dialysis Topic Trigger Dialysis utilization and cost Failure Trigger Nosocomial infections 6. 90 year-old female. Elderly patient from NH with urosepsis, stable. Geriatric Topics Nosocomial infections Foley catheter indications Skin exam and pressure ulcers Apathetic delirium Delirium prevention, risk stratification Systems Based Practice Transition Trigger Transition back to the NH—trouble shooting the weekend transfer Topic Trigger NH—the structure, cost and oversight of NH care in the U.S. Failure Trigger NH patients and the need for acute hospitalization --balancing NH oversight, patient wishes, resources and systems issues in U. S. medicare/medicaid NHs. ________________________________________________________________________ Johnson, Podrazik, and Whelan 3 7. 31 year-old male. Acute asthma exacerbation, looks ok Geriatric Topics Acute on chronic model Systems Based Practice Transition Trigger Facilitation to county health system Topic Trigger Asthma outcome in the Chicago Metro area Practice Based Learning Review of adherence to guidelines/pathways Timeliness of nebulizer treatment and monitoring ________________________________________________________________________ 8. 84 year-old female. Transfer from neurosurgery service with a subdural hematoma, fever, mental status changes. Geriatric Topics Delirium Falls Prognostication End-of-life issues/care Systems Based Practice Transition trigger Transferring a patient from the surgical service to the medical service Shifting care to the palliative mode Topic trigger Catastrophic injury at advanced age Cost of hospital care at end-of-life in the U.S. Patient wishes and end-of-life care in the U.S. Failure trigger Determining patient wishes and health care proxy for end-of-life decisions Practice Based Learning Review how to give bad news, discuss end-of-life issues Professionalism & Communication When surgery requests a medicine consult Addressing end-of-life issues with family ____________________________________________________________________ Johnson, Podrazik, and Whelan 4 9. 76 year-old female. Admitted with pneumonia, chest x-ray with cavitary lesions. Geriatric Topics Pneumonia and the aging patient TB and the aging patient Functional assessment Delirium prevention for the patient in isolation Systems Based Practice Transition Trigger Assuring appropriate follow-up for high-risk infection like TB Topic trigger Demographics of TB in the U.S. aging population State of the Public Health System in the US Failure trigger Making the diagnosis of TB in the community Professionalism & Communication Infectious disease consult ______________________________________________________________________ 10. 41 year-old female. Sickle crisis and chest pain Geriatric Topics Acute on chronic disease model Pain management Systems Based Practice Transition Trigger Lack of sickle cell center Topic Trigger Effect of small percentage of high volume in-hospital users on the sickle cell population at large Failure Trigger Difficulty with initiation and monitoring of pain management Practice Based Learning Pain management review Professionalism and Communication: Team approach to pain management Approaches to developing a pain management plan with joint decision making Recognizing personal and system biases towards the treatment of certain disease populations Johnson, Podrazik, and Whelan 5
