Professor, University of Miami Leonard M. Miller School of Medicine
Patients with benign sexual headaches tended to have multiple episodes of the headache arrhythmia young nebivolol 2.5mg amex. Treatment is challenging because these headaches are short-lived and very intermittent blood pressure lab buy nebivolol cheap. Alternative Diagnosis: Intracerebral Hemorrhage Textbook Presentation Intracerebral hemorrhage (hemorrhagic stroke) generally presents in older blood pressure monitor amazon buy nebivolol 5 mg without prescription, hypertensive patients with acute-onset headache and focal neurologic symptoms and signs blood pressure 70 over 30 discount 2.5 mg nebivolol mastercard. Intracerebral hemorrhage accounts for about 10% of strokes, being less common than embolic and thrombotic strokes. Hypertension is the most common cause, followed by amyloid angiopathy, saccular aneurysm rupture, and arteriovenous malformation rupture. Among patients with hypertension, Asians and blacks have the highest risk of hemorrhagic cerebrovascular accidents. The incidence of hypertension-related intracerebral hemorrhage has declined over the last 3 decades with better control of hypertension. In young patients without hypertension, diseases such as arteriovenous malformation, aneurysm rupture, and drug use should be considered. About 50% of patients with arteriovenous malformation present with a hemorrhagic event. Patients with hypertension or a previous hemorrhage have the highest rate of bleeding. Patients with intracerebral hemorrhage usually have headache and focal neurologic signs. Vomiting is present in about 50% of patients, and seizures are present in about 10%. Treatment See the Treatment section under Cerebellar Hemorrhage in Chapter 14, Dizziness. Accurate diagnosis of these patients is highly desirable as they potentially have the best outcomes. This an 80-year-old woman who comes to your office complaining of headaches for the past 3 months. She reports always having had mild headaches that never troubled her enough to see a doctor. At her present visit, she reports no visual changes, no recent head trauma, and no neurologic deficits. She does report fatigue and says that she has lost about 15 lbs over the last month. Her past medical history is notable for hypertension for which she takes losartan, morbid obesity, and a breast mass noted 2 years before. The mass was thought to be low suspicion for malignancy and the patient declined work-up. The differential diagnosis must take into account these pivotal points of age, subacute onset, and constitutional symptoms. The persistence of the headache probably excludes diagnoses such as intracerebral hemorrhage or infections. The throbbing nature of the pain and weight loss could certainly be consistent with either of these types of headache. Subdural hematoma is possible, but the lack of a history of head trauma or use of anticoagulation medications makes this less likely. Although a diagnosis of tension headaches should be given with extreme caution in an elderly person with new headaches, the persistent band-like description raises this possibility. A new headache in a woman with obesity also raises the possibility of idiopathic intracranial hypertension. Soon after the headache began (3 months prior to her current presentation), she went to an emergency department and cervical osteoarthritis was diagnosed. Leading Hypothesis: Temporal Arteritis Textbook Presentation Temporal arteritis classically presents in white women over age 50 as a bilateral, throbbing headache. There may be a history of polymyalgia rheumatica or consistent symptoms (shoulder and hip girdle pain) and the physical exam can reveal beading and tenderness of the temporal arteries. Temporal (or giant cell) arteritis is a corticosteroid-responsive vasculitis of large arteries. Primarily involves the vessels of the aortic arch, particularly the external carotid. Although the most common presentation is a new headache, temporal arteritis can present with nonspecific manifestations of a chronic inflammatory disorder. Rapid diagnosis and treatment are critical to prevent vasculitis-associated thrombosis in the effected vessels. Two systematic reviews presented test characteristics for many of the commonly cited findings. Because the clinical signs and symptoms of temporal arteritis are not highly predictive, temporal artery biopsy should be used in any patient in whom the clinical suspicion is even moderate. Most studies have found this finding to be insensitive and not specific enough to avoid biopsy. Given the difficulty of clinically diagnosing temporal arteritis and the common side effects of the treatment, temporal artery biopsy is always recommended to establish the diagnosis of temporal arteritis. Although biopsy should be done as quickly as possible once the disease is suspected, a short delay after beginning treatment (7 days) probably does not affect the results. Treatment of temporal arteritis should not be delayed to perform a biopsy in a patient in whom temporal arteritis is suspected. One much quoted study gave the following test characteristics for temporal artery biopsy: a.
It is germane to ask whether lay jurors can properly digest technical details in cases that involve pathologists or other professional defendants hypertension kidney specialist order nebivolol 5mg. The process of teaching the intricacies of pathology to residentsin-training takes several years beyond medical school pulmonary hypertension 50 mmhg nebivolol 5 mg cheap. Nevertheless arrhythmia alliance order 2.5 mg nebivolol mastercard, most lawyers continue to aver that "expert" testimony can be assimilated successfully by lay jurors arrhythmia originating in the upper chambers of the heart purchase genuine nebivolol line. It would be relatively easy to convene "mock" juries, give them conflicting "expert" medical opinions, and test them to see how much scientific information had been absorbed correctly. Nonetheless, because the legal system lacks even the rudimentary features of an objective, evidence-based mechanism, such tests of procedural validity have never been performed. The effects of professional inertia and self-interest are probably also operative in this problem [35]. Sporadic assertions have been made in the legal literature that a "statistically significant" correlation exists between jury verdicts and "expert" opinions [14]. Foucar improve "expert" testimony in the courtroom by publicly challenging the opinions of professional mavericks are in danger of being sued for offenses such as "defamation of character" [36]. Sadly, most physicians and medical specialty organizations have ignored this problem altogether [37]. With that fact as a background, one might assume that the tort system could be a valuable asset in preventing iatrogenic harm to patients. That situation stifles any meaningful input from the courts in estimating the relative weight of those elements as causes of adverse clinical outcome. In contrast to medical error, which has been studied assiduously over the past decade, departure from "the standard of [medical] care" is a vestigial legalism that has only weak links to medical error analysis. For example, in the Law, it does not matter whether a misdiagnosis stemmed from ambient disturbances in the laboratory, technical problems in the histology laboratory, transposition of specimens before receipt in the pathology suite, or misinterpretation of the disease process by a pathologist. Laboratory directors and practicing pathologists are held personally and globally responsible for all of those factors; they are all subsumed by the phrase "standard of care. No expert can be found to assert that a diagnosis or interpretation fell below the "standard of care," and the plaintiff has no case 2. The mistake is blatantly the result of substandard practices or professional incompetence, as judged by unbiased peer-evaluators, and no expert can be found who will testify in favor of the pathologist. The particular details of the error are important only in regard to the award Two Cultures: Lawyers and Doctors Lawyers and judges control the legal system, and it would seem rational for physicians to work with these individuals to reduce jury error. Unfortunately, the two parties typically adhere to irreconcilable paradigms in their evaluation of the Law. Each group has its own modes of training, specialized terminologies, professional objectives, ways of evaluating the results of their work, and forums for publication and discussion of professional thought. Consequently, several observers have noted a "rawness" of physicianbased antipathy toward attorneys, as well as a "searing distrust" of the courts [41]. Physicians may consider it to be simply unacceptable to ever allow the delivery of misinformation to jurors. In contrast, a critical mass of lawyers believes that the opportunity for cross examination of "experts," truthful opposing testimony, and the option to appeal unfavorable verdicts effectively compensates for f laws in "expert" testimony [43, 44]. Physicians are free to consider the latter opinion overtly wrong, but that does not prove that physicians are correct. The jury will have to decide which expert opinion reflects practice reality, and then how to integrate this conclusion into a final verdict. The most valuable information on medical error coming from the courts has been collected by insurance companies, not lawyers, and analyzed by other physicians [45]. However, such data are very incomplete, because many malpractice cases are settled under private terms [46], and details of jury deliberations are not often made available as public information. Nonetheless, no credible objective proof has appeared showing that this approach does produce improvement in medical practice or patient welfare. Undeniably, however, it does measurably discourage doctors from practicing in geographic locales where torts are rife. In addition, it has been proven beyond doubt that perceived malpractice risks prompt physicians to over-order tests, medications, and procedures in a defensive posture, elevating the cost and complexity of medical care [48]. The vacuous concept called "standard of care" leads doctors to think increasingly about how lay jurors might respond to each of the many professional decisions that comprise patient care [49]. Typically, that type of rumination is scientifically unproductive, expensive for the medical system, and inefficient. One can attempt to resolve this confusion by consulting a legal dictionary, which says that the "standard of [professional] care" is "the average degree of skill, care, and diligence exercised by members of the same profession, practicing in the same or a similar locality, in light of the present state of. Data would have to be gathered on the performance of a representative sample of qualified "local" professionals in a given vocation, regarding the type of case under discussion, plus 2. A reproducible and logical threshold would need to be established to separate "ordinary" from "non-ordinary" performance. With this information in hand, one could attempt to identify professional conclusions that were "substandard. That is particularly true if the recommended treatment attached to the latter interpretation did not differ substantially from that used for the preeminent diagnosis. Another challenge to "average" or "ordinary" skill is its unclear relationship to subspecialty training or certification. Indeed, when the latter is required, the advanced certificate-holder would, by definition, be "special" and not "ordinary! In the existing legal system, "ordinary" and "non-ordinary" are completely changeable terms, definitions of which could be Is the Professional "Standard of Care" a Valid Concept
For example young women with diurnal storage symptoms in whom urinary infection has been excluded are usually diagnosed as having an idiopathic overactive bladder arteria princeps pollicis discount 2.5mg nebivolol. Elderly men with voiding symptoms and prostate enlargement on digital rectal examination are likely to have bladder outflow obstruction secondary to benign prostatic hyperplasia pulmonary venous hypertension xray discount 5 mg nebivolol otc. Getting up to void once at night might be seen as normal by some individuals but unacceptable by others blood pressure 200120 buy nebivolol australia. The impact of urinary symptoms on quality of life has been quantified by a number of validated instruments including the International Prostatic Symptom Score questionnaire normal pulse pressure 60 year old order nebivolol without a prescription. It is a highly compliant organ and can accommodate increasing volumes of urine without large increases in intravesical pressure. During the voiding phase, the detrusor contracts while the urethral sphincter relaxes in a coordinated fashion, resulting in a normal voiding pattern. The patient is asked to record his or her daily fluid consumption, frequency of micturition and voided volume on a pre-printed chart, ideally for 1 week. This yields a wealth of information about bladder function, including maximum functional capacity, and the relationship of nocturia to fluid intake. Investigation Clinical diagnostic indicators Storage phase symptoms Urgency: a sudden compelling desire to void which is difficult to defer. Increased daytime frequency: the complaint by the patient who considers that he or she voids too often during the day. The patient is asked to void into a funnel-shaped receptacle which is linked to a measurement device. In men there is a gradual decline in flow rate with increasing age, and characteristic flow rates in men with bladder outflow obstruction are likely to be below 10 mL/second. A poor flow may be caused by either obstruction or poor contractility of the detrusor. Conversely, a normal flow rate does not exclude obstruction, as the initial response to bladder outflow obstruction may be the detrusor generating higher pressures to maintain flow rate. However, as a quick, non-invasive and cheap test of voiding function, uroflowmetry is useful, especially when combined with a post-micturition ultrasound scan of residual bladder volume. This simple ultrasound scan estimates the post-void residual urine volume, which should normally be less than 50 mL. Intravesical pressure is a composite of detrusor pressure and the intraabdominal pressure measured by means of a monitoring device inserted into the rectum. The true detrusor pressure is obtained by subtracting the intra-abdominal pressure from the total intravesical pressure. During the filling phase, warm saline is instilled into the bladder at a constant rate. In a normal bladder, the detrusor pressure should change very little as the bladder fills until the maximal capacity is reached, when the pressure rises slightly. Unstable contractions may be observed in an overactive bladder and may be associated with urinary leakage. The patient is asked to report the first sensation of filling and then when discomfort is felt. Once maximal bladder capacity has been reached, the patient is asked to void and pressure flow plots are obtained. These data allow differentiation between poor flow resulting from obstruction, when the detrusor pressure is usually high, and poor flow caused by a hypocontractile detrusor. However, it is an anatomical as opposed to a functional diagnosis, so it is entirely possible to have a hydronephrotic kidney which is not obstructed. Antenatal and infantile hydronephrosis constitute an important and extensive topic and will not be discussed further in this text. Cystoscopy Cystoscopy may be valuable in patients in whom storage symptoms predominate in order to rule out an intravesical lesion. Urodynamic studies Urodynamics is the study of detrusor pressure during bladder filling (cystometrogram) and voiding phases. It is an invasive test requiring placement of a small urethral filling catheter and pressure Investigation Clinical diagnostic indicators the main and often only symptom is renal pain but this can occur with many other conditions. Long-standing hydronephrosis may result in loss of renal parenchymal tissue and this can be seen clearly on ultrasound images. In cases of severe obstruction, pelvicalyceal anatomy may only be demonstrated on delayed films obtained many hours after contrast injection. Retrograde ureteropyelography involves direct retrograde instillation of contrast through a ureteric catheter placed inside the ureteric orifice via a cystoscope. This technique gives very clear anatomical information and is not dependent on renal function. Furosemide is usually administered with the radioisotope to stimulate a brisk diuresis. A normal renogram has a triphasic curve: an initial rapid uptake followed by a short plateau and then rapid elimination as the pelvicalyceal system empties of radioisotope. In the presence of obstruction, the second and third phases of the curve continue to rise as the radioisotope accumulates within the dilated renal pelvis. As well as giving an indication of the presence of obstruction, renography allows an estimate of the relative contribution of each kidney to the overall renal function. In cases of long-standing obstructive hydronephrosis, there may be very little residual renal function. Management the management of hydronephrosis resulting from upper tract obstruction is dependent on the severity of obstruction, clinical symptoms and signs, renal function, and the underlying cause of the obstruction. The left (purple line) kidney displays the normal triphasic pattern of uptake and rapid excretion, especially following furosemide administration at 10 minutes. The right (yellow line) kidney shows uptake but no excretion, signifying obstruction.
C is a 35-year-old man who comes to your outpatient office complaining of 1 day of diarrhea blood pressure medication buy discount nebivolol on line. Infectious diarrhea that presents with large volume (often watery) stool hypertension treatment guidelines 2014 order nebivolol 5 mg fast delivery, constitutional symptoms blood pressure of 80/50 buy generic nebivolol from india, nausea and vomiting blood pressure and heart rate best purchase for nebivolol, and often abdominal cramps can be categorized as gastroenteritis. Infectious colitis presents with fever, tenesmus, and dysentery (stools with blood and mucus). This structure is easy to remember, focuses history taking, allows prognosticating, and is also a good framework on which to consider therapy. Klebsiella oxytoca the first symptom the patient noted was loss of appetite while eating breakfast. Upon arriving at work he developed low-grade fever, abdominal cramping, and vomiting. The low-grade fever and absence of dysentery make it likely that the diagnosis is in the category of gastroenteritis. There have been no recent changes in his diet and he has eaten only food prepared at home for the last week. Leading Hypothesis: Norovirus Textbook Presentation Acute vomiting is usually the presenting symptom. Calciviruses, of which Norovirus and closely related viruses such as Sapovirus are the most common, account for about 80% of adult viral gastroenteritis. Norovirus is easily transmissible via the fecal-oral route, in air-borne droplets, via food, and through fomites. Evidence-Based Diagnosis There are no diagnostic tests for norovirus available for routine clinical use; diagnosis is made by clinical presentation. For patients with mild diarrhea and little volume depletion, any oral fluids are appropriate rehydration. The World Health Organization oral rehydration solution has the following composition: (1) Sodium: 75 mmol/L (2) Chloride: 65 mmol/L (3) Glucose: 75 mmol/L (4) Potassium: 20 mmol/L (5) Citrate: 10 mmol/L d. If this solution is not available, patients can be instructed to mix the following in 1 L of water (1) One-half teaspoon of salt (2) One-quarter teaspoon of baking soda (3) 8 teaspoons of sugar. Antidiarrheals (such as loperamide) are safe and effective for patients without dysentery. Using antidiarrheals in a patient with dysentery is not considered safe because evidence suggests they can: a. Treatment other than supportive care is not necessary for norovirus-like illnesses. Empiric antimicrobial therapy is recommended for diarrheal infections only in limited circumstances. These circumstances never occur in patients with noninfectious diarrhea and almost never in patients with gastroenteritis. Specific circumstances are discussed throughout the chapter; general circumstances include the following: a. Severe disease (profuse diarrhea with hypovolemia, high fever, severe abdominal pain, high band count) c. Most patients with acute diarrhea do not need diagnostic testing as the illness usually resolves without treatment and work up is usually unrewarding. Patients with bloody diarrhea (tests should include assay for Shiga toxin and C difficile toxin). Patients with severe disease (dehydration, toxic appearance) or risk factors for poor outcome (immunosuppression, severe comorbid illnesses). Patients with prolonged diarrhea (> 7 days) should be tested for parasitic causes (stool for ova and parasites). C present is presenting with a clinical syndrome that is consistent with viral gastroenteritis. Even if a diagnostic test for norovirus were available for routine use, the usefulness would be low because treatment is only supportive. In most patients with an acute diarrheal illness, diagnostic testing is not helpful to the patient but may be important from a public health standpoint. Alternative Diagnosis: Toxin-Mediated Gastroenteritis Textbook Presentation the presentation of this syndrome, most commonly caused by S aureus or C perfringens, usually includes acute-onset vomiting and crampy abdominal pain. Vomiting is the predominant symptom with diarrhea being mild and watery and fever being low grade. Although these organisms are the most common causes of food poisoning, they account for only about 1% of food-borne diarrheal illnesses. Salmonella, Campylobacter, and E coli are the most common bacterial causes of food-borne infections. S aureus, C perfringens, and B cereus can often be recognized by the clinical and exposure history.
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