Evaluating the child for sexual abuse

Child victims of sexual abuse may present with physical findings that can include anogenital problems, enuresis or encopresis. Behavioral changes may involve sexual acting out, aggression, depression, eating disturbances and regression. Because the examination findings of most child victims of sexual abuse are within normal limits or are nonspecific, the child's statements are extremely important. The child's history as obtained by the physician may be admitted as evidence in court trials; therefore, complete documentation of questions and answers is critical. A careful history should be obtained and a thorough physical examination should be performed with documentation of all findings. When examining the child's genitalia, it is important that the physician be familiar with normal variants, non-specific changes and diagnostic signs of sexual abuse. Judicious use of laboratory tests, along with appropriate therapy, should be individually tailored. Forensic evidence collection is indicated in certain cases. Referral for psychologic services is important because victims of abuse are more likely to have depression, anxiety disorders, behavioral problems and post-traumatic stress disorder.     

Sudden sensorineural hearing loss

Hearing is one of our most important senses and its sudden loss can be frightening and frustrating for the patient and his or her physician. Despite multiple reports of sudden SNHL over the years, we still do not have a universally accepted definition. This has led to further confusion in reporting and evaluating the treatment and prognosis of this disease. We generally define any SNHL occurring over 3 days as sudden SNHL. The overall incidence of this disease appears to be low. However, the true incidence may be higher, because those patients who spontaneously recover may never seek medical attention. The etiology is often difficult to identify, leaving a large population of patients labeled as idiopathic SNHL. Before accepting the idiopathic label, the physician must maintain a high level of suspicion to be sure that the SNHL is not a symptom of a larger underlying systemic disorder. Several theories have been proposed to try to explain SNHL. These include the infectious theory, vascular theory, and rupture theory. In addition to these, metabolic imbalances, drug toxicity, and various disease entities may contribute to sudden SNHL. Over the years, many treatment protocols have appeared in the literature, each claiming various rates of success. Unfortunately, they are often based on emotional and empiric considerations, because an exact etiology is unknown. Drugs have been chosen from several categories including the following: vasodilators, diuretics, anticoagulants, plasma expanders, corticosteroids, and contrast material. These medications have been used singly or in combination therapies. One must always be aware of the potential side effects. One factor that appears to be constant in each reported therapy is that those patients who seek medical attention early do better. The type of hearing loss also seems to play a role in the outcome of sudden SNHL; patients with low-frequency hearing losses or upward-sloping audiograms have a better prognosis. The patient must take the first step in seeking medical attention. Once the problem has been recognized, prompt attention by the physician to the medical workup and timely initiation of therapy will offer the patient the best possible chance for recovery. Time is often the greatest factor in the overall recovery, and the physician should reassure the patient that everything is being done to speed this along. However, patience may be the greatest healer of all.     

Management of Alzheimer's disease. A family affair

The various approaches to the patient with Alzheimer's disease are receiving much attention, but relatively little has been written about the important role physicians can serve in helping the patient's family deal with the disease. In managing Alzheimer's disease, the physician's relationship with family members may be as important as or even more important than his or her relationship with the patient. Establishing and maintaining a successful relationship involve early assessment of family function, periodic home visits, coordination of available community resources, regular assessment of caregivers' coping skills, and regular discussions about the limits of home care and the possibility of placement in a nursing home. When nursing home care is chosen, the physician can, by continuing his or her involvement, help assure provision of the highest quality care possible.     

Diabetic retinopathy

It is hoped that this article has given the family physician an understanding of diabetic retinopathy and the recent advances in its treatment. It is crucial that both the family physician and an ophthalmologist follow diabetic patients closely, especially once they develop preproliferative or proliferative retinopathy. Too many patients lose their sight because they are first seen for treatment too late in the course of their disease. This is indeed a tragedy because laser treatment is effective in most patients.     

Alcoholism and other drug dependencies

The disease of addiction is upon us and it is obvious that the elderly are not immune. There is every reason to believe from early reports that the elderly respond favorably to treatment, perhaps more so than their younger counterparts. It is believed that treating chemical dependency as a primary disease rather than as a symptom of something else has been a great boon in terms of improving recovery rates. Furthermore, group therapy is the main component of treatment in rehabilitation, as it affords the greatest opportunity to shift the dependence on chemical to a dependence on human beings. The physician is in a key position to help the elderly, because so many elderly need and use medical care. Intervention is highly recommended if the doctor is knowledgeable and skilled in this area and is willing to kindly confront the patient with a somewhat undesirable diagnosis. Rehabilitation regimens are becoming more plentiful throughout the country. If services are unavailable, however, there is always AA to fall back on or to recommend initially. Remember, fully one third of all AA members are older than 50 and that it is a source of acceptance, support, and an opportunity to depend on human beings instead of psychoactive chemicals. Remember too that few patients with addiction recover by themselves. It is worth remembering that this is an incurable disease in that once addicted, it is unlikely that anyone can ever use socially psychoactive chemical substances again. Use of psychoactive chemicals is fraught with danger for the physician and the patient and indeed may place the physician at risk for malpractice. There is great satisfaction to be gained from helping those afflicted with alcoholism and other drug dependencies. The gratitude displayed by those receiving help for this affliction is truly remarkable and one that will leave the clinician with a sense of "a job well done."     

Decision making in the critically ill patient

In the preceding discussion we have attempted to set forth some realistic guidelines for the primary care physician in the critical care area. We feel that he is of utmost importance in setting the tone for his patient's care. He is the first physician to be called when his patient becomes critically ill. He decides whether or not consultation is needed immediately. He should choose appropriate consultants, trying to provide required expertise and compatible personalities to relate with his patient and the patient's family. His work does not end with establishing roles and delivering care. He is the single most important physician when difficult ethical and medicolegal decisions must be made. He is the physician who knows the patient and the patient's family best. They look to him for guidance and decision making about their health care. He is best able to discuss the wishes and desires of the patient if the patient becomes unable to decide for himself. The primary care physician can be extremely helpful when the appropriate medical decision is to withhold therapy. He can comfort and console the family and help them realize that the proper decisions have been made. His previous close relationship with the patient and family makes difficult decisions much easier to accept. He is also of primary importance when trying to provide care to a patient who ostensibly refuses such care. The trust he has earned in the past because of the care he was provided allows him to be much more forceful than the subspecialist who may have been on the case for 1 or 2 days. He can be the difference between survival and death merely by his presence and advice. Other difficult decisions are always made easier by a primary physician who can relate to the consultants as well as the patient and his family. In conclusion, we feel that the technologic advances of the past 30 years have tended to drive the primary care physician away from the critical care unit. This is mostly because of a need for particular expertise to run the machines of medicine. One cannot be expected to become or remain an expert in primary care and critical care medicine. The primary care physician should not feel or be excluded from the critical care area. His knowledge of general medicine and his expertise in interpersonal and family relationships allow him to provide the much needed "high touch" component of "high tech" critical care medicine.     

Die psychische Dimension des Krebsschmerzes

The perception and expression of pain are primarily psychological phenomena and are not directly correlated with the intensity of the nociceptive stimulus. They are often influenced by earlier experiences of pain, and also by current expectations and fears. The cancer patient interprets pain as a sign of the continued existence and of the progression of the malignant disease: if the pain can be controlled the patient will take this as an indication that the underlying disease can be cured. Inappropriately treated pain, on the other hand, can initiate a vicious circle leading to really excruciating pain and functional destabilization of the patient. Conversely, the personality and the psychological condition of the patient can have a profound effect on how pain is experienced. Fear, for example, is known to exacerbate pain, and fear is often due to a less than ideal doctor-patient relationship, e.g. one in which the patient does not receive adequate information about the disease. Pain can be interpreted as a message that has to be understood before an adequate therapeutic response is possible. For desperate patients who are socially isolated after a long period of illness, pain may be the only way of communicating their unhappiness to other people and of feeling alive at all. Patients with intractable pain are sometimes given placebo therapy, particularly if the pain is interpreted as "only" psychogenic in character or if traditional methods of treatment have failed. Confrontation with terminally ill patients is an especially difficult and frustrating experience for health professionals. The fact that the disease cannot be cured and that a patient is in constant pain reminds the physician of the limitations of curative medicine. This can trigger defense mechanisms in the physician, which may in turn cause insecurity and fear in the patient. In the course of treatment for pain, cancer patients derive most psychological support from the emotional empathy of the therapist, whose availability for the patient is the most important means of preventing the patient's with-drawal into depression. If cancer pain is accompanied by an emotional, psychic and vegetative imbalance, psychotropic drugs are beneficial. In particular, antidepressants and neuroleptics have become an important component of the treatment of chronic pain in cancer patients. Due consideration of the emotional and motivational status of the patient will make it possible to choose between the different effect profiles of these drugs. However, the use of psychotropic drugs should complement, and cannot replace, empathic care from the physician.     

Cardiac resynchronization therapy for the treatment of heart failure

Traditionally, patients with exercise-induced lower extremity ischemia (claudicants) have been treated conservatively. It is important to remember that this is not because the pain of claudication is less important than pain due to other problems, but because the only ‘cure’, operative bypass, has been judged too invasive by both patient and physician. Recent data suggest that endovascular treatment of atherosclerotic disease below the inguinal ligament yields good short-term results, with low periprocedural morbidity and does not compromise future surgical alternatives in the long-term. If this approach is to be used as nonoperative treatment for the pain of claudication, however, the authors suggest that long-term success may be less important than the absolute minimization of short-term and periprocedural risk. The authors believe that given the results of modern endovascular therapy it is increasingly less acceptable to tell claudicants to live with their pain if conservative therapy fails. The option of endovascular treatment for infrainguinal atherosclerotic disease should be discussed with every patient whose claudication is significant, and considered as a treatment option in place of continued pain. This approach should be judged against conservative therapy for claudication, not against surgical bypass for limb threat.     

Can endovascular therapy of infrainguinal disease for claudication be justified?

Traditionally, patients with exercise-induced lower extremity ischemia (claudicants) have been treated conservatively. It is important to remember that this is not because the pain of claudication is less important than pain due to other problems, but because the only 'cure', operative bypass, has been judged too invasive by both patient and physician. Recent data suggest that endovascular treatment of atherosclerotic disease below the inguinal ligament yields good short-term results, with low periprocedural morbidity and does not compromise future surgical alternatives in the long-term. If this approach is to be used as nonoperative treatment for the pain of claudication, however, the authors suggest that long-term success may be less important than the absolute minimization of short-term and periprocedural risk. The authors believe that given the results of modern endovascular therapy it is increasingly less acceptable to tell claudicants to live with their pain if conservative therapy fails. The option of endovascular treatment for infrainguinal atherosclerotic disease should be discussed with every patient whose claudication is significant, and considered as a treatment option in place of continued pain. This approach should be judged against conservative therapy for claudication, not against surgical bypass for limb threat.     

Gedanken zur Betreuung terminal Kranker mit Krebsschmerz

When treating a cancer patient with severe pain it is not sufficient to treat the cancer and the pain. Effective therapy must adhere to the principles of psychosomatic medicine, i.e., the disease, cancer, isnot treated, but instead a human being who is suffering from this disease, has severe, ongoing pain as a result, and is going to die. Irrespective of the question of whether the patient has been told his diagnosis or not, he will be in an extreme situation psychologically, as he instinctively suspects what is wrong with him. Pain indicates that the cancer is advanced; this can be compared with a death sentence, the execution of which has not yet been definitely scheduled. In these cases continuing care is more important than formal therapies. Above all, a cancer patient fears "intractable" pain, the prospect of being helpless because of physical deterioration, and imminent death which is no longer hypothetical. In order to assure adequate pain therapy, the pain medication must be continuous and sufficient, administered on a regular basis and given irrespective of whether there might be side effects or not. This requires that there be a relationship of confidence between the physician and patient in order to ensure compliance of treatment. As morphine is the most powerful analgesic drug, it can and must be given at an early stage. The fear of impending helplessness can be reduced by the physician "accompanying" the patient providing loving care, and assuring the patient that he will have somebody to rely on when he needs it. The most important way to solve such problems is to have a dialogue addressing the problems. Verbalization of fears can resolve them; even fear of death can be reduced when it is addressed in a dialogue. Advanced cancer patients are mostly remote from everyday life; they no longer take part in it. If, however, they receive the proper guidance, they will live more consciously and more intensively. In the awareness of imminent death they can experience every day of their life as a gift. Care of terminally ill cancer patients with severe pain thus also must include a guided approach to death.     

Postmenopausal bleeding: etiology, evaluation, and management

Postmenopausal bleeding can be an alarming symptom for both the patient and the physician because, although in a majority of these cases no pathology is present, the risk of malignancy must be considered. It is important for the physician to fully understand the pathophysiology, differential diagnosis, and the methods of evaluating and treating this disorder in order to ensure the health and comfort of the patient.     

Asthma

Asthma is an extremely common disease that the emergency physician handles on a daily basis. Accurate clinical assessment from the history and physical examination is very important to assess the severity of the disease. Some measure of airway resistance of either FEV1 or PEFR should be done in every patient initially, at repeated intervals, and at discharge, to have a parameter to follow in therapy as well as a tool to use to warn the physician of a severe amount of airway obstruction. The inhaled beta agonists are the first line of therapy in acute asthma and can be delivered by either the nebulizer or the MDI with or without a spacer. Aminophylline will be continued to be used acutely even though it appears there is no improvement in bronchospasm in the first few hours of treatment when aminophylline is added to therapy. Anticholinergic agents will gain a wider role in acute asthma, especially when used in combination with a beta agonist. Corticosteroids continue to have a role in severe attacks of asthma, and earlier use may prevent relapse. Fatal asthma still occurs, however, and the emergency physician must use strict criteria to recognize status asthmaticus or the patient who is not doing well and admit them to the hospital. Using a stepwise, logical approach to the treatment of the asthmatic patient will lead to better patient satisfaction and fewer errors on part of the emergency physician.     

Sudden death.

The alert physician can identify and probably alter the risk of sudden death for certain patients (see Table 5). It appears preferable to study the patient who has already been identified as having coronary artery disease because of clinical symptoms such as R/O MI, which has been shown to have a high risk for subsequent sudden death. In addition, the physician must be sensitive to the middle-aged man with multiple coronary artery disease risk factors who suddenly decides to have a routine check or develops nonspecific complaints. Once identified, patients can be educated to minimize delay time in seeking medical help with crescendo or prolonged angina. Ambulatory ECG monitoring for detection and characterization of ventricular arrhythmias, and exercise stress testing to detect severe ST depression, can facilitate an estimation of the patient's prognosis. A therapeutic plan, including attack on the patient's coronary artery disease risk factors, patient education, and specific medical or surgical therapies may alter the risk of sudden death. Once an infarction has occurred, rapid transport to a coronary care unit or monitoring facility, and administration of intramuscular lidocaine by medical or paramedical personnel when feasible, appear to lessen out-of-hospital mortality.     

Sudden death during exercise. A cruel turn of events.

The causes of sudden death in exercisers age 35 and younger are generally not preventable because they are typically structural and difficult to detect. The best a physician can do is be alert to important information in the family and patient history and to the occasional sign or symptom that may warrant further evaluation. For the over-35 exerciser, screening tests may be appropriate, especially if the person is just beginning an exercise program, although this remains an area of controversy. The screening tests available are far from perfect. If exercise testing is performed, the asymptomatic patient must be apprised of the possibility of a false-positive result and the consequences and attendant risks of overdiagnosis or additional testing (coronary angiography). Physicians should be alert to suspicious symptoms in physically active patients, but they should avoid the tendency to have these patients stop their exercise program. Instead, after appropriate diagnostic testing, they should advise a modified exercise program that is safely within the limits of the disease process involved. It is important to realize that physical activity can be a preventer of cardiac disease but also a provoker of sudden death. Even so, the benefits of regular exercise clearly outweigh the risk.     

Primary care for depression

Depressive patients often visit a primary care physician due to various physical symptoms. Though it is necessary to differentiate organic diseases, it is also important to approach from a viewpoint of psychosocial background and psychiatric disorders. Especially, as mild depression is seen widely in general practice, early diagnosis and early treatment is essential for its good prognosis and medical economics. So, primary care physician is expected to understand its symptomatology and treat depressive patients appropriately. Finally, I want to say that the cooperation between primary physician and psychiatrist is important, because typical bipolar disorders and severe depressive patients should be refer to psychiatry clinic.     

Evaluation of the optimal oral antihistamine for patients with allergic rhinitis

Because of its bothersome symptoms, allergic rhinitis (AR) is 1 of the top 10 reasons for patient visits to primary care physicians. This highly prevalent disease also results in loss of productivity, both at work and in school. Oral antihistamines are one of the most frequently prescribed medications for the management of AR and, with several agents available, it is important to discern the specific benefits and detriments of each. To assess the differences in efficacy and safety factors among antihistamines, the Individual therapeutic window of each agent can be used as a comparative reference tool because it defines the dose range over which an antihistamine is efficacious and free of adverse effects. As such, the therapeutic window includes both undesired effects, such as sedation, and desired properties, such as rapid onset of action, long duration of efficacy, broad age range of applicability, and potential to Improve quality of life. Therefore, agents with broad therapeutic windows, based on both efficacy and safety, are expected to be more favorable; this therapeutic window should be understood by the primary care physician when prescribing a medication.     

Neuro-ophthalmology

Ocular symptoms may indicate the presence of systemic or neurologic disease rather than simply local eye disease. Patients with such symptoms often present initially to the family physician. This article discusses important aspects of the neuro-ophthalmic examination that can aid the physician in identifying common neuro-ophthalmic disorders.     

Air travel for the chronically ill and the elderly

The cabin altitude during airline flights is usually 1,500 m (5,000 ft). Medically important factors include the decreased bioavailability of oxygen, the dryness of the air and the properties of gases within the body as stated in Boyle's law. Passengers who are physically compromised by chronic disease, advanced age or mobility impairment can usually have their special requirements met through the cooperation of the family physician and the airline. Special diets, supplemental oxygen, locomotive aids and communication services are provided on advanced request.     

Cardiovascular evaluation of adolescents and young adults. Salient aspects of the examination

Cardiac findings in adolescents and young adults are usually normal, and most murmurs and other abnormalities that are found are benign. However, the primary care physician needs to obtain a complete personal and family history and perform a thorough physical examination to rule out cardiovascular disease and its precursors. Of primary concern are a personal or family history of syncope, family history of sudden death, and several pathologic murmurs such as those caused by mitral valve prolapse and hypertrophic cardiomyopathy. The physician may need to reassure the patient until a definitive diagnosis is made and can also provide accurate information on cardiac disease prevention.     

Ventilation-perfusion scintigraphy

Ventilation-perfusion scintigraphy remains an important diagnostic tool in the evaluation of patients suspected of having PE. It is important for the emergency physician to be able to use the information from a lung scan appropriately in the diagnostic management of this elusive and life-threatening disorder. This requires a clear knowledge of how these scans are interpreted as well as a consultative approach between the physician ordering the lung scan and the nuclear medicine physician interpreting it. Each can ultimately contribute to the development of an effective management plan. It is important for the clinician to understand that a low-probability lung scan does not rule out PE, but in fact can have up to a 40% probability of PE when clinical suspicion is high.