1/9. Managing cancer and noncancer chronic pain in critical care settings. knowledge and skills every nurse needs to know.nurses and physicians caring for people with all types of pain are responsible for providing effective pain management in all clinical settings. Although the principles for managing all types of pain are similar, people with chronic pain have special needs to sustain optimal analgesia in critical care settings. nursing practice must be guided by national standards, guidelines, and recommendations for managing chronic and acute pain. Pain assessment, reassessment, and follow-up; titration of medications to individual responses; aggressive management of side effects; prevention of pain; and routine evaluation of the effectiveness of the plan are basic skills for all health professionals. Every person's baseline level of pain must be determined, and preexisting interventions for pain relief must be maintained to assure continuity of care. chronic pain complicates clinical problems and could have a profound effect on patient outcome. Managing chronic pain improves function, outcome, and quality of life. The knowledge, skills, medications, nondrug interventions, and technology are available to manage nearly all types of pain. Pain relief is a responsibility of all health care professionals. Our patients deserve our best efforts to optimize their comfort, and we must be accountable.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/9. Prevention for the older woman. Mobility: a practical guide to managing osteoarthritis and falls. Part 6.By anticipating issues of mobility, physicians can help older women lead more independent and satisfying lives. osteoarthritis is a major cause of physical disability in older women. Aerobic exercise, resistance training, and judicious analgesic use can be well-tolerated interventions that reduce pain and disability. Reducing the risk of injurious falls is paramount given the prevalence of osteoporosis. Interventions that may reduce fall risk include minimizing the use of sedative-hypnotic agents, providing training in transfer skills (balance and gait training), and adapting the home environment.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/9. NSAID induced avascular necrosis and arthropathy of femoral head.The authors present the case of an 81-year-old woman with pain in her left hip. X-ray showed moderate osteoarthritic changes. The patient was prescribed diclofenal sodium (Voltaren), a nonsteroidal anti-inflammatory drug (NSAID). The patient continued use of the drug and returned 18 months later complaining of severe hip pain and difficulty in walking. X-ray, at that time, showed necrosis of the femoral head with subluxation and formation of a pseudoacetabulum. Total hip replacement was performed and the patient resumed normal daily activity. The authors point out that avascular necrosis of the femoral head, a known complication of steroid therapy, can also be caused by NSAID therapy and urge physicians to be aware of this complication.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/9. osteoarthritis as a misdiagnosis in elderly patients.Musculoskeletal disorders are very common in the elderly, and x-ray evidence of irreversible damage due to osteoarthritis is found in probably all older people. Thus, when confronted by various pain symptoms in an older patient, the physician must always include osteoarthritis in the differential diagnosis. However, potentially reversible causes for the problem are too often ignored, and a misdiagnosis of osteoarthritis prevents or delays effective treatment of the actual underlying problem, with potentially serious consequences. Six case studies are offered illustrating this problem and pointers in differential diagnosis are suggested.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/9. Spontaneous osteonecrosis of the knee.Spontaneous osteonecrosis is a common cause of knee pain in older patients, but the diagnosis is often overlooked. Sudden knee pain in older women, with marked joint line tenderness and a decreased range of motion, should alert the physician to the diagnosis. Two to three weeks after the onset of symptoms, plain radiographs will usually be normal but bone scan will be markedly positive. Treatment is initially conservative. Surgical intervention (either osteotomy or arthroplasty) is reserved for patients who develop a large radiolucent lesion in the subchondral femoral condyle.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/9. Ruptured abdominal aortic aneurysm: the internist as diagnostician.PURPOSE: To define the clinical features and assess the frequency and causes of missed diagnoses of ruptured abdominal aortic aneurysm (AAA) in patients initially presenting to internists. patients: All identified patients with ruptured AAA presenting to internists during a 7 1/2-year period at a large academic medical center. METHOD: Chart review. RESULTS: We identified 23 patients with a ruptured AAA presenting to internists. Most had abdominal pain and tenderness, back or flank pain, and leukocytosis, whereas anemia and profound hypotension (systolic blood pressure below 90 mm Hg) were uncommon at presentation. In 14 cases (61%), the diagnosis of ruptured AAA was initially missed. Nine patients had an interval of 24 hours or more between presentation to the internist and surgery or death. The diagnosis was not made until after shock developed in nine patients who were hemodynamically stable at presentation. Of 17 patients who underwent surgery, 7 of 8 with preoperative shock died, compared with 2 deaths in 9 patients (p < .02) without shock. All six patients who did not have surgery died, yielding an overall mortality of 65% for the series. Ruptured AAAs were most frequently misdiagnosed as urinary tract obstruction or infection, spinal disease, and diverticulitis. Chart review revealed a general lack of physician awareness of the syndromes of contained rupture of AAA and symptomatic unruptured AAA. CONCLUSIONS: In patients with ruptured AAA who present to internists, the diagnosis is often delayed or missed and this appears to adversely effect survival. Internists should familiarize themselves with the presentation and management of ruptured AAA.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/9. diclofenac-associated thrombocytopenia and neutropenia.OBJECTIVE: To report a case of thrombocytopenia and a case of neutropenia, both associated with the use of diclofenac. CASE SUMMARIES: A 63-year-old woman was receiving diclofenac for osteoarthritis. During a hospital admission for pneumonia, she was found to have severe thrombocytopenia. diclofenac therapy was stopped and the thrombocytopenia resolved. Several months later she was inadvertently treated with diclofenac by another physician and again experienced thrombocytopenia, which again resolved on discontinuation of the drug and has not recurred since. A 72-year-old man was receiving diclofenac for 9 months for osteoarthritis. He was then found to have asymptomatic neutropenia. diclofenac therapy was stopped and the neutropenia resolved with no other intervention. He was not rechallenged. DISCUSSION: Severe thrombocytopenia and neutropenia are extremely rare adverse reactions to diclofenac. To date, there is only 1 case of each that is well documented and supported in the literature. CONCLUSIONS: Severe thrombocytopenia and neutropenia are potential serious adverse effects of the use of diclofenac. patients who are receiving diclofenac and develop symptoms of either thrombocytopenia or neutropenia should have a complete blood count, and if this diagnosis is confirmed, the drug therapy should be stopped.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/9. Therapeutic approaches of German and Turkish physicians to rheumatoid arthritis and to osteoarthritis of the knee.Our objective was to compare the therapeutic approaches of German and Turkish physicians to rheumatoid arthritis (RA) and to osteoarthritis (OA) of the knee, by means of a mailed survey. The survey contained four case histories representing a mild, a moderate and a severe case of RA and a case of OA of the knee. One hundred and thirty-two physicians from germany (internal medicine based (IR) and orthopaedics based (OR) rheumatologists) and thirty-three from turkey (rheumatologists and physical medicine and rehabilitation specialists (PT)) participated in the study. German respondents would give more disease-modifying drugs (DMARD) in early RA (48.7% vs 18.2%, p < 0.05), whereas their Turkish colleagues would prescribe more analgesics, ultrasound and kryotherapy in OA of the knee (63.6% vs 22.1%, 30.3% vs 6.5% and 24.2% vs 0.0% respectively p < 0.05). German physicians chose more exercise, physical and occupational therapy, radiation synovectomy and surgery in all cases. In OA of the knee German OR's would recommend less analgesics, but more local steroids, chondroprotective agents and surgery than the other groups. We may conclude that clinical practice of RA and OA of the knee differs considerably in germany and turkey. Cultural, social, educational and economic factors could influence the decisions of the physicians.- - - - - - - - - - ranking = 8keywords = physician (Clic here for more details about this article) |
9/9. Unnecessary prescribing of NSAIDs and the management of NSAID-related gastropathy in medical practice.BACKGROUND: Use of nonsteroidal anti-inflammatory drugs (NSAIDs) increases the risk for hospitalization and death from gastrointestinal bleeding and perforation. OBJECTIVES: To 1) estimate the extent to which NSAIDs are prescribed unnecessarily and NSAID-related side effects are inaccurately diagnosed and inappropriately managed and 2) identify the physician and visit characteristics associated with suboptimal use of NSAIDs. DESIGN: Prospective cohort study. SETTING: Montreal, canada. PARTICIPANTS: 112 physicians representing academically affilliated general practitioners, community-based general practitioners, and residents in family medicine and internal medicine. INTERVENTIONS: Blinded, office-based assessment of the management of two clinical cases (chronic hip pain due to early osteoarthritis and NSAID-related gastropathy) using elderly standardized patients. MEASUREMENTS: Quality of drug management and potential predictors of suboptimal drug management. RESULTS: Unnecessary prescriptions for NSAIDs or other drugs were written during 41.7% of visits. Gastropathy related to NSAID use was correctly diagnosed in 93.4% of visits and was acceptably managed in 77.4% of visits. The risk for an unnecessary NSAID prescription was greater when the contraindications to NSAID therapy were incompletely assessed (odds ratio, 2.3 [95% CI, 1.0 to 5.2]) and when the case was managed by residents in internal medicine (odds ratio, 4.1 [CI, 1.2 to 14.7]). The risk for suboptimal management of NSAID-related side effects was increased by incorrect diagnosis (odds ratio, 16.6 [CI, 3.6 to 76.5]) and shorter visits. CONCLUSIONS: Unnecessary NSAID prescribing and suboptimal management of NSAID-related side effects were sufficiently common to raise questions about the appropriateness of NSAID use in the general population. If these results reflect current practice, prescribing patterns may contribute to avoidable gastrointestinal morbidity in elderly persons.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |