on 08-Feb-2017 (Wed)

5.2 Logical operators 115 Table 5.1 Logical Operators Operator Meaning ~ NOT & AND | O

However, the expression 0<1 is evaluated as 0. This is because the left hand operation (0 < 0.5)isfirst evaluated to 1 (true), followed by 1<1which is false. Inequalities like this should rather be coded as (0<1

In general, if x and v are vectors, where v has n elements, then x(v) means [x(v(1)), x(v(2)), ..., x(v(n))]

The function logical(v) returns a logical vector, with elements which are 1 or 0 according as the elements of v are non-zero or 0

A summary of the rules for the use of a logical vector as a subscript are as follows: A logical vector v may be a subscript of another vector x. Only the elements of x corresponding to 1s in v are returned. x and v mustbethesamesize

Logical vector subscripts provide an elegant way of removing certain elements from a vector, e.g., a=a(a>0) removes all the non-positive elements from a, because a>0returns the log- ical vector [00111].

A probability distribution can refer to probability of measurement values or of parameter values. The probability can be interpreted either as how much a value could be sampled from a generative process, or as how much credibility the value has relative to other values.

When p(θ) represents credibility values of θ, instead of the probability of sampling θ, then the mean of p(θ ) can be thought of as a value of θ that represents a typical credible value

The standard deviation of θ, which measures how wide the distribution is, can be thought of as a measure of uncertainty across candidate values. If the standard deviation is small, then we believe strongly in values of θ near the mean. If the standard deviation is large, then we are not very certain about what value of θ to believe in.

A value represents the central tendency of the distribution if the value is close to the highly probable values of the distribution

Therefore, we define the central tendency of a distribution as whatever value M minimizes the long-run expected distance between it and all the other values of x.

how should we define “distance” between values? One way to define distance is as squared difference: The distance between x and M is (x − M) 2 . One virtue of this definition is that the distance from x to M isthesameasthedistancefromM to x, because (x −M) 2 = (M −x)

The central tendency is, therefore, the value M that minimizes the expected value of (x − M) 2 . Thus, we want the value M that minimizes dxp(x)(x −M) 2

In other words, the mean of the distribution is the value that minimizes the expected squared deviation. In this way, the mean is a central tendency of the distribution

As an aside, if the distance between M and x is defined instead as |x − M|, then the value that minimizes the expected distance is called the median of the distribution. An analogous statement applies to the modes of a distribution, with distance defined as zero for any exact match, and one for any mismatch

The HDI indicates which points of a distribution are most credible, and which cover most of the distribution. Thus, the HDI summarizes the distribution by specifying an interval that spans most of the distribution, say 95% of it, such that every point inside the interval has higher credibility than any point outside the interval

At birth = 50cm (avg)

Doubles height by 4 years

Measure recumbent length until 2 years, then standing height

cont from 4mo

The 95% HDI includes all those values of x for which the density is at least as big as some value W , such that the integral over all those x values is 95%. Formally, the values of x in the 95% HDI are those such that p(x)>W where W satisfies x : p(x)>W dxp(x) = 0.95

When the distribution refers to credibility of values, then the width of the HDI is another way of measuring uncertainty of beliefs. If the HDI is wide, then beliefs are uncertain. If the HDI is narrow, then beliefs are relatively certain.

We denote the conditional probability of hair color given eye color as p(h|e), which is spoken “the probability of h given e

p(h|e) = p(e, h)/p(e). This equation is taken as the definition of conditional probability. Recall that the marginal probability is merely the sum of the cell probabilities, and therefore the definition can be written p(h|e) = p(e, h)/p(e) = p(e, h)/ h p(e, h).

The definition of conditional probability can be written using more general variable names, with r referring to an arbitrary row attribute and c referring to an arbitrary column attribute. Then, for attributes with discrete values, conditional probability is defined as p(c|r) = p(r, c) c ∗ p(r, c ∗ ) = p(r, c) p(r)

When the column attribute is continuous, the sum becomes an integral: p(c|r) = p(r, c) dcp(r, c) = p(r, c) p(r)

It is also important to recognize that there is no temporal order in conditional probabilities. When we say “the probability of x given y”wedonot mean that y has already happened and x has yet to happen. All we mean is that we are restricting our calculations of probability to a particular subset of possible outcomes.

A better gloss of p(x|y) is, “among all joint outcomes with value y, this proportion of them also has value x.”

Among other contexts, independence will come up when we are constructing mathematical descriptions of our beliefs about more than one parameter. We will create a mathematical description of our beliefs about one parameter, and another mathematical description of our beliefs about the other parameter. Then, to describe what we believe about combinations of parameters, we will often assume independence, and simply multiply the separate credibilities to specify the joint credibilities

The five financial statement elements noted previously serve as the inputs for equations that underlie the financial statements.

A statement of retained earnings can be viewed as a component of the statement of stockholders’ equity, which shows all changes to owners’ equity, both changes resulting from retained earnings and changes resulting from share issuance or repurchase.

Other terms are used to denote owners’ equity, including shareholders’ equity, stockholders’ equity, net assets, equity, net worth, net book value, and partners’ capital.

Owners’ equity at a given date can be further classified by its origin: capital contributed by owners, and earnings retained in the business up to that date

Note that net income (loss) is the difference between two of the elements: revenue and expenses.

Revenue and expenses generally relate to providing goods or services in a company’s primary business activities.

Gains (losses) relate to increases (decreases) in resources that are not part of a company’s primary business activities.

Distinguishing a company’s primary business activities from other business activities is important in financial analysis; however, for purposes of the accounting equation, gains are included in revenue and losses are included in expenses.

Balance sheet and Income statements are linked together through the retained earnings component of owners’ equity.

Beginning retained earnings is the balance in this account at the beginning of the accounting period, and ending retained earnings is the balance at the end of the period.

A company’s ending retained earnings is composed of the beginning balance (if any), plus net income, less any distributions to owners (dividends).

Ending retained earnings = Beginning retained earnings + Net income − Dividends

Retained earnings represent the amount not distributed as dividends to owners.

Retained earnings is a component of owners’ equity and links the “as of” balance sheet equation with the “activity” equation of the income statement.

Assets=Liabilities+Contributedcapital+Beginningretainedearnings+Revenue−Expenses−DividendsAssets=Liabilities+Contributedcapital+Beginningretainedearnings+  Revenue−Expenses−Dividends

The basic accounting equation reflected in the balance sheet (Assets = Liabilities + Owners’ equity) implies that every recorded transaction affects at least two accounts in order to keep the equation in balance, hence the term double-entry accounting

Influenza is the most common cause of acute myositis in otherwise healthy children.

CONSULT NOTES
A good consult note contains the following elements, and should be prepared in this order:

HISTORY
ID and RFR (reason for referral)
• ID = Gender and age
• Include occupation and handedness if a hand consult
HPI
• Hand injuries: Mechanism, time of injury, any treatment so far
• Tetanus status if open wounds
PMHx
• Include PSHx (past surgical history)
Medications
• *Blood thinners*
SocHx
• Include smoking, EtOH, and recreational drug use (esp. IVDU)
Allergies
• Clarify the reaction to any stated allergy

PHYSICAL EXAMINATION

INVESTIGATIONS

ASSESSMENT AND PLAN

Example
ID 28M R-handed, works in construction
RFR Query flexor tenosynovitis
HPI 3d ago puncture wound to volar distal phalanx left index finger from drill bit. Reports pain locally and in palm x1 week. Similar episode hand pain 1 year ago without Hx trauma, resolved spontaneously. Denies fevers and chills. Tetanus UTD.
PMHx Healthy. Appendectomy @6yo
Meds None
SocHx Lives with girlfriend. Nonsmoker, no EtOH, no rec drug use
ALL None
O/E Looks well. BP 130/90, HR 75 bpm, RR12, SaO2 99% room air, afebrile.
R hand mildly swollen compared to L, mild palmar erythema. All digits NVI.
R index: swollen with 0.5 mm puncture wound mid DP radially, no purulence. Pain on passive extension but no tenderness over flexor sheath, no fusiform swelling, and digit held in neutral position.
Wound explored and irrigated in sterile conditions under local anaesthesia: maximal wound depth is to subcutaneous tissue only
Ix WBC 6.0
XR R hand: normal
A+P Inconsistent with flexor tenosynovitis as wound not adjacent to flexor sheath and pain began before injury.
Likely tenosynovitis given previous episode with spontaneous recovery.
Rx given for Naproxen x1 week. F/U Dr. X in 1 week, or call office if worsening or becomes unwell.

All progress notes should begin with a line summarizing the patient.
The remainder of the note follows the format “SOAP”:

Subjective
• How is the patient feeling, any concerns
• Pain control, nausea/vomiting
• Ambulating?
• Tolerating diet?
Objective
• Vital signs
• Drain outputs
• Urine output if relevant
• Findings on physical examination
Assessment
• How is the patient doing overall, what are the issues
Plan
• Summarize plan for each issue

Example
55F POD #3 bilateral immediate breast reconstruction with DIEP flaps
S: Patients feels well, pain controlled. Eating well. Ambulating.
O: AVSS. JP output: #1 50cc, #2 60cc – both serosanguinous. Flaps: good colour, cap refill, turgor. Both warm. Small blue discoloration lateral aspect right breast, 2x1 cm. Abdomen soft. Incisions clean, dry and intact.
A/P: Doing well. Continue to monitor flaps as per protocol. Reassess lateral aspect right breast this afternoon.

For this, you can use of the mnemonic AD DAVID.

Admit to (ward/department/nicu), under Dr. Surgeon
Diagnosis: confirmed or suspected (UTI w/ 2ndary dehydration)
Diet: DAT (diet as tolerated), NPO (if surg/procedures), sips only, CF (clear fluids), ff (full fluids), thickened fluids (dysphagia), advancing diet, diabetic diet (indicate calories eg. 1800kcal), cardiac diet, TPN, etc
Include amount, freq, rate if applicable.
Activity: AAT (activity as tolerated), NWB (non-weight bearing), FWB (full weight bearing), BR (bed rest), BR with BRP (bed rest w/ bathroom privileges), ambulation (up in chair tid, ambulate bid)
Vitals: VSR (vital signs routine - HR, RR, BP, O2 sat, Temp q8-12h, q shift), VS q4h (was told this is routine), special parameters (eg postural vitals, neuro vitals)
IVF, Investigations, Ins and outs
-ins & outs: surg/volume status pts
-daily weights: eg renal failure, edematous, infants
-investigations: heme (CBC + diff, PTT/INR), biochem (lytes - Na, K, Cl, HCO; urea, Cr, Ca, Mg, PO4, glu, CSF cell count, CSF protein & glucose) microbio (urine R&M/C&S, blood cultures, CSF from LP for gram stain, C&S; just rmb all the things you can culture - CSF, sputum, urine, feces, pus from wounds, blood), imaging (cxr, ct, mri, ekg, pft, spirometry), consults (sw, neuro, ID)
Drugs
-all meds pt's already on (Past)
-meds pt needs right now (present)
-anticipate what pt might need: prophylaxis, sleep, nausea & pain (future)
-10 patient P's: Problems (specific med issues), Pain (analgesia), Pus (antimicrobials), Puke (anti-emetics, prokinetics, antacids), Pee (IV fluids, diuretics, lytes), Poop (bowel routine), Pillow (sedation), PE (anticoag), Psych (DTs), Prev meds

Example
Admit to Plastic Surgery, under Dr. X
Diagnosis: Flexor tenosynovitis L D3

NPO (patient is pre-op. May be NPO @ midnight if OR not planned until following day)
AAT (activity as tolerated); Splint L hand
Vitals q8h (vitals can be more frequent if patient unstable)
IV RL @ 100cc/hr while NPO (note: maintenance IVF should be based on the 4:2:1rule)
CBC, lytes, BUN, Cr, PTT, INR qAM x2
Monitor ins and outs (for unstable patients)
Group and screen (or type and cross if ++ blood loss probable in OR – check with staff/seniors if this is needed)
EKG (if >40y pre-op)
CXR (if >50y pre-op)
Ancef 1g IV x1 on call to OR (Clindamycin 600mg IV x1 if pen-allergic)
Antibiotics for infection need to be prescribed around the clock: check with your staff/senior which you should prescribe
Gravol 25-50 mg PO/IV q6h PRN
Dressing orders (check with staff/seniors)
Patients home meds
Anaesthesia consult (if patient has other co-morbidities and high risk for surgery)

Please note that all orders should be reviewed and co-signed by a resident. Be mindful of patient’s allergies before ordering medications.

Pre-Operative Dx:
Post-Operative Dx:
Procedure:
Surgeon:
Assistants:
Anaesthesia:
EBL:
Complications:
Disposition:

Example
Pre-Operative Dx: Dupuytren’s contracture
Post-Operative Dx: Same
Procedure: Palmar fasciectomy R D4 + D5
Surgeon: Dr. Martin
Assistants: Willoughbail (R3), Ramjam (R2)
Anaesthesia: Bier block with neurolept anaesthesia, Dr. X
EBL: nil
Complications: None
Disposition: Extubated in OR. Stable to recovery room

For this, you can again use of the mnemonic AD DAVID

Admit to Plastic Surgery, under Dr. Surgeon
Diagnosis

Diet
Activity
Vitals
IVF, Investigations, Ins and outs
Drugs (the 5 P’s)
• Pain (analgesia)
• Puke (anti-emetic)
• Prophylactic (anti-coagulation)
• Pus (antibiotic)
• Precedent medications (restart appropriate home meds)

Example (post-op orders, patient for same day discharge)
Admit to Plastic Surgery, under Dr. Martin
Diagnosis: Flexor tenosynovitis L D3

Sips to DAT
AAT (activity as tolerated)
Splint L hand
Vitals q8h
IV RL @ 100cc/hr; SLIV (Saline lock IV) when drinking well
Tylenol #3 PO 1 -2 tabs q4h PRN
Gravol 25-50 mg PO/IV q6h PRN
*No DVT prophylaxis (patient ambulatory, low risk for DVT/PE)
*No home meds
Discharge home when well
Rx on chart
F/u with Dr. Martin in 2 weeks

Please note that all orders should be reviewed and co-signed by a resident. Be mindful of patient’s allergies before ordering medications.

Date of admission:
Date of discharge:
*start of dictation*

Discharge diagnosis: (1, 2, etc)
Other (non-active) dx:
Follow-up: (appts, pending ix, home care)
Discharge meds: (dose, freq, route, duration)
Summary of presenting illness:
• 1-2 line summary of presenting illness & reason for admission. Refer to separately dictated note for full hx & px of admission. Only if no admission dictation completed, indicate full HPI, PMH, and initial px prior to ‘Course in Hospital’
Course in hospital:
• Describe briefly the events and progression of illness while in hospital including status upon discharge
• If multiple medical issues, this section can be done by system (cardiovascular, respiratory, fluids and nutrition, ID, hematological, CNS, etc)
Operations performed in hospital:
Investigations in hospital:
• Include if any significant findings
Discharge plan:
• Who the patient is following up with
• Any issues the GP needs to follow up on
• Dressings (CCAC)
• Return to ER if..

Example
Date of admission: June 20, 2015
Date of discharge: June 30, 2015
Admission diagnosis:
1. Scald burn to bilateral thighs, TBSA = 15%
Discharge diagnosis:
1. Second degree scald burns to bilateral thighs, TBSA = 15%
2. Hypertension
Operations performed in hospital: Split thickness skin grafting left thigh June 23
History of presenting illness: Ms. X is a 65 yo F admitted to Hamilton General Hospital on June 22 after sustaining scald burns to her thighs from hot tea. She was transferred to our hospital from Brantford due to concerns of full thickness burns of TBSA 15%. She was admitted for monitoring and wound management as we suspected she may require skin grafting.
Course in hospital: It became apparent on the second day of admission that her left thigh burns were deep partial thickness and wound benefit from split thickness skin grafting to expedite healing. This procedure occurred on June 23, 2015. Post-operatively she was stable, though she was hypertensive throughout her admission with systolic pressures in the 180s. She was started on hydrochlorothiazide. The patient was kept in hospital until her dressings were manageable by CCAC on an outpatient basis.
Investigations in hospital: Routine bloodwork was unremarkable.
Discharge medications:
1. Hydrochlorothiazide 12.5 mg PO daily
2. Tylenol #3 x 40 tabs
3. Colace x 20 days
Discharge plan:
1. CCAC will be providing dressing changes q2days.
2. She will return for reassessment at the outpatient burn clinic on X day.
3. We kindly ask her family doctor, Dr. Y, to follow up on her hypertension and adjust her medications as necessary.

1) Umbilical cord falls off
2) Poop changes colour (black tarry to yellow seedy). Red is not normal.
3) BACK TO BED, NO BED SHARING
4) Fever!! (axilla is best, 37.5 bad)

Suppose that truth is a woman – and why not? Aren’t there reasons for suspecting that all philosophers, to the extent that they have been dogma- tists, have not really understood women? That the grotesque seriousness of their approach towards the truth and the clumsy advances they have made so far are unsuitable ways of pressing their suit with a woman? What is certain is that she has spurned them – leaving dogmatism of all types standing sad and discouraged.