Introduction About Mayo Clinic Mayo Clinic is the first and largest integrated group practice in the world. Doctors from every medical specialty work together to care for patients, joined by common systems and a philosophy of "the needs of the patient come first." More than 2,500 physicians and scientists and 42,000 allied health staff work at the original clinic in Rochester, Minn., and newer clinics in Jacksonville, Fla., and Arizona. Collectively, the three clinics treat more than half a million people each year. The tradition Around the turn of the 20th century, Dr. Charlie and Dr. Will Mayo organized medical professionals in a new way to better care for patients. They created a system that allowed doctors to take the time to thoroughly investigate patient problems and to quickly and easily get help from other specialists. The system was built on the idea that two heads are better than one and five are even better. It also encouraged a continual search for better ways of diagnosis and treatment. Patients flocked to the Mayo’s because of their ability to find answers to their problems. Doctors, too, came to observe and learn at "the Mayo's clinic.” Through growth and change, Mayo remains committed to its heritage: thorough diagnosis, accurate answers and effective treatment through the application of collective wisdom to the problems of each patient. Mayo will provide the best care to every patient every day through integrated clinical practice, education and research. Personal goals for this clerkship During this clerkship I strive to purchase the following goals:
1. Increasing knowledge concerning diagnosing, pathophysiology and treatment
2. Getting better insight in gynecologic and obstetrical surgery concerning
the medical-technical aspects, also by assisting during operations the pre-operative care the post-operative care possible complications and their treatment
3. If allowed, functioning by myself as a ‘clinic’ doctor under supervision at the
inpatient department (concerning admitting patients, policy making, etc.)
4. Doing anamnesis and physical examinations and making policy for patiens at the
5. Good oral presentation of patients to the medical staff 6. Learning about the scientific research Mayo is performing 7. Getting to know the differences between health care in the States/Mayo and in the
The first 3 weeks I worked with dr Wilson, who is a gynecologic surgeon who is specialized in oncology. The last week I worked with dr Gebhart who is an urogynecologist. I also got the chance to be in obstetrics a couple of days. Because of this have seen a lot of different cases and thus have increased my knowledge in a very broad way. I think that the one thing that contributed mostly to this is that there is a lot of time for each patient at Mayo and, moreover, doctors spent a big amount of time in educating patients. Every other day was either a clinic day or a surgical day. Usually we started at 6 am for rounding at the patients. During the rounds I saw and took care of patients on my own. That means that I talked to the patients and their families, did physical examinations and made plans for the patients for that day. Afterwards I presented my patients to the supervisor. In the beginning it took me some time to get used to the different medication names and laboratory references, but after a while that was not a problem anymore. Mayo works with electronic patient charts in which you can find almost everything about a patient. Is was good to see how that works and to become familiar with that. I think it works very well and can be a great aid for giving good medical care. On the surgical days I was able to scrub in at almost every operation. In that way I got a very good view of the procedures. The surgeons involved me as much as they could, for example they let me experience differences of morphology of masses or explained the operation step by step. Also, it was good to be able to practice knotting and stitching. During the ‘clinic’ days I saw patients on my own at the outpatient department and presented them to the gynecologic surgeon with my plan. In addition, I observed a lot of consultations. It was very interesting to see how information is given to patients concerning oncologic matters, and how patients and their families react to that. After observing so many different doctors during my rotations, I hope I will be able to mix all the good characteristics of them to become a good one myself. During these 4 weeks I have been and felt like a member of the gynecologic surgical team. Mayo claims to be a ‘team’ hospital, and I have experienced it really is. The team
did everything they could to make me feel at ease. Mayo is an educational center, so wherever there was something for me to learn I got the chance to do so. For me it was also very good to be able to join the residents for their preparations for the boards. Because of these upcoming exams there were a lot of educational meetings in which we discussed clinical problems. In addition, I liked the journal club where we talked about recent published articles or scientific research. My last goal was about getting to know the differences between healthcare in The Netherlands ans The United States. I think it is better to say ‘Mayo’ in stead of America, as Mayo is a unique center on its self. In my opinion there are a lot of similarities but also differences, and it is too much to write them all down. Next I will give some examples. Here at Mayo the patient comes first, as you van read in the introduction. All hospital staff is trying their best to give the patient the best care possible. The staff wears professional business attire in stead of a white coat during the clinical days. Even after one month that felt a bit unusual to me. The thing that amazed me most was the timing. When a patient is referred to Mayo, he can be diagnosed and operated on within a few days. There are no waiting lists for whatever investigation or operation. I talked to some doctors about the American heath insurance policy. I expected to see much more uninsured people here, but I guess Mayo does not have so many of these patients. But it was surprising to see that a lot of people had to check their policies to know whether their insurance would cover for an operation they really needed. You would probably not see that in Holland. I also talked about the malpractice insurance for doctors. In the States gynecology/obstetrics is not as popular as it is in The Netherlands because of the high rate of law suits. I know that Europe is heading for that same culture, but I really hope it will not get that way… It was also surprising to see that at Mayo everything is specialized. There are different services for almost everything. This is also pronounced within a specialty: if you are a gynecologic surgeon, you will not be in obstetrics when you are on call. During my clerkship I had the chance to spend a few days in obstetrics as well. Here in the States there are three different specialists who assist in labour: family physicians, midwifes or gynecologists. There are almost none home deliveries and the same counts for breech deliveries, who almost all get a caesarian sectio. I was able to assist during a few of these as well. Looking back, I think I have reached all my goals for this visiting clerkship. To end with, I had a great time here in Rochester. It was very special to work at Mayo Clinic. There were also a few other international students with whom I spend my free time at the hotel. It was nice to hear about their medical schools and their life. The cold weather made it even more special. Maybe you can imagine what it would be like to slide down a hill on a plastic bag with students who never had experienced snow before… Not only have I learned a lot professionally, also personally. Thank you for everything, it was great!
Case: 51-year-old woman
Reason for admission: Evaluation and treatment for possible recurrence of poorly differentiated stage IC ovarian cancer.
Past medical/surgical history: 1. Fibroid uterine tumor. 2. Mitral valve prolapse, asymptomatic. 3. Congenital hernia repaired in 1987. 4. Repair of right ankle and leg veins in 1987, chronic venous insufficiency. 5. Deep venous thrombosis and small pulmonary embolism in the right lung in the course of malignancy, vena cava inferior filter was placed and removed after 6 months. Gynecologic history: Ovarian cancer status post debulking (abdominal hysterectomy with bilateral salpingo- oophorectomy, omentectomy, appendectomy, multiple peritoneal biopsies, bilateral pelvic and para-aortic lymphadenectomy) 2004, complicated by a hematoma after initiating coagulation therapy. Adjuvant chemotherapy for 3 months because of malignant cells in ascites. Patient is gravida 2, para 2, both uncomplicated vaginal deliveries. Admission medications: Nexium 40 mg once a day ; Vitamin C, D, K, two once a day.
Subjective: Patient has had a debulking operation and 3 months of adjuvant chemotherapy because of ovarian cancer in 2004. Follow up investigations showed an increased CA-125 level (from 10 to 35) and some lesions involving the liver on CT-scan. Patient was referred to Mayo Clinic to discuss the surgical possibilities of these lesions. At the moment she does not have any complaints. Questions concerning weight changes, abdominal distention, vaginal discharge or blood loss, changed defecation habits or urinating symptoms are all answered negative. Family history: Positive for lung cancer, hyperlipidemia, hypertension, and osteoporosis. There is no history of abnormal clotting or bleeding. Intoxications: Patient has never smoked and does not take alcohol. Allergies: Patient’s skin is sensitive to tape. Social: Patient is married. She has two daughters and is a teacher on a primary school.
Laboratory findings: Hemoglobin 13.8 g/dL (12.0-15.5 g/dL), Hematocrit 40.5 % (34.9-44.5 %), Leukocytes 5.9x10(9)/L (3.5-10.5 x10(9)/L), Platelet Count 280 x10(9)/L (150-450 x10(9)/L) Prothrombin Time 9.9s (8.4-12.0 s), INR 1.0 (5), Sodium 143 mEq/L (135-145 mEq/L) Potassium 4.6 mEq/L (3.6-4.8 mEq/L), Calcium10.0 mg/dL (8.9-10.1 mg/dL), Glucose(P) 83 mg/dL (70-100 mg/dL) Alk Phosphatase 84 U/L (41-108 U/L), AST (GOT) 24 U/L (12-31 U/L), Bilirubin, Total 0.7 mg/dL (0.1-1.0 mg/dL), Bilirubin, Direct 0.1 mg/dL (0.0-0.3 mg/dL) Creatinine0.8 mg/dL (0.7-1.2 mg/dL)
CA 125(S) 34 (<35 U/mL) (9.4 (September), 7.6 (June 2005), 6.0 (March 2005)) CT-scan 12-5-05: CT examination of the chest, abdomen, and pelvis with IV contrast is compared to the previous postoperative CT of 5-18-04. The immediate postoperative changes of cytoreductive surgery have resolved including removal of a right chest tube and Foley catheter. There are two adjacent metastatic peritoneal implants along the dome of the liver measuring 3cm and 2cm in diameter, not apparent on the previous PO examination. No other peritoneal lesions identified. There are several small hypodense lesions within the lower pole of the spleen which are indeterminate. Small bilateral renal cysts. Hysterectomy and BSO. Areas of focal benign-appearing sclerosis in the sacrum. Conclusion:
51-year-old woman, status post debulking operation for a poorly differentiated stage IC ovarian carcinoma, with elevated CA-125 and evidence of disease involving the diaphragm/liver and perhaps also in the spleen seen on CT-scan. History of DVT / PE and post-operative hematoma. Plan: Exploratory laparotomy, splenectomy, excision of possible recurrent ovarian cancer masses. Refer patient to Thrombophilia Clinic for pre-operative analysis because of her history of DVT / PE. Pre-operative advice Thrombophilia Clinic CT of the chest showed no residual thrombosis or no new one either. The patient has signs of chronic venous insufficiency, more right leg than the left. She needs to wear an elastic stocking of 20 to 30 mmHg life-long. The patient does not need to have an IVC filter as peri procedure management of anticoagulation. It is recommended to treat the patient after surgery with a high prophylactic dose of low molecular weight heparin. A dose of 5000 units of dalteparin will be still effective as a prophylaxis, yet associated with a minimal increased risk of bleeding. The low molecular weight heparin needs to be continued for three weeks after surgery. If the patient is dismissed from the hospital, continue anticoagulation treatment with 40 mg injected subcutaneously every day. Operation Report: Abdominal exploration, resection right hemidiaphragm, splenectomy, removal of mass from cul-de-sac. An upper midline incision was made. There was obvious tumor between the liver and right hemidiaphragm. The liver itself was palpably unremarkable. The mass was adherent to the muscularis of the diaphragm and we subsequently perforated the diaphragm entering the pleural space. A full-thickness piece of diaphragm perhaps 4 cm in an anterior-to-posterior direction and 8 to 10 cm in a medial-to-lateral direction was removed. There were several smaller nodules on the diaphragm as well that were directly adjacent to the 3- to 4-cm nodule. The lung and pleura are probably unremarkable, except just medial to our defect in the diaphragm there were two nodules that would probably be less than 1 mm. These were quite near the portal vein, and given their location, rather than removing them, they were cauterized until they were no longer
palpable. The diaphragmatic defect was now closed after insufflating the lung. There was no evidence of a leak with maximum inspiration. The spleen and stomach were unremarkable. However, splenectomy was performed Examination of the kidneys, pancreas, and other peritoneal areas was without abnormality. Examination of the pelvis did reveal a 1- to 1.5-cm nodule worrisome for tumor. First there was a 5-mm plaque on the peritoneum overlying the right kidney, and this was grasped and excised removing the underlying peritoneum submitting it to Pathology. On the left side of the cul-de-sac we had a 1.5-cm nodule with an associated 5-mm nodule directly adjacent to it. These were worrisome for tumor and were excised including the underlying peritoneum and submitted to Pathology. Estimated blood loss was 500 cc. Pathology: Soft tissue, right renal area, biopsy: Metastatic grade 4 (of 4) serous carcinoma. Uterus, cul de sac, biopsy: Metastatic grade 4 (of 4) serous carcinoma. Diaphragm, right, biopsy: Metastatic grade 4 (of 4) serous carcinoma forming a multinodular mass (0.5 cm in greatest dimension). Spleen, splenectomy: Negative for tumor. Cytology: cul de sac wash: Positive for malignancy. Adenocarcinoma. Post-operative course: The patient experienced dyspnea and hypoxia on post-operative day 3. CT scan following PE protocol was negative, although it showed bilateral pleural effusion, greater in right side. Patient underwent thoracocentesis obtaining 500 cc of sanguinous fluid, secondary probably to fluid from abdomen during diaphragm resection. Her pulmonary symptoms improved as well as her saturation within the next couple of days. She was eventually dismissed to home after resuming normal bowel and bladder function, ambulating, and tolerating oral diet. Vaccination against encapsulated organisms was done before dismissal. Conclusion and plan: Recurrent serous ovarian cancer, stage IV. Status post resection of partial right hemidiaphragm and pelvic mass, splenectomy. Post-operative course was complicated by dyspnea and hypoxia because of fluid secondary to the operation for which patient underwent thoracocentesis. Patient will receive at least six cycles of Taxol-carboplatin once again. If she refuses or otherwise does not want this she would be candidate for whole abdominal radiation therapy.
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BOLETÍN OFICIAL DE LA PROVINCIA DE MÁLAGA — 16 de abril de 2003municipal, por el que se comprueba que en Edificio Guetaria, aparta-nación vigente, se acordará la demolición de las obras a costa del inte -mento número 9, sito en la calle Juan Sebastián Elcano, 10, la baran-dilla del balcón ha sido retirada no siendo reemplazada por otra; es2. Incoarse procedimiento sancionador para d