Initial evaluation and management of wide-complex tachycardia: A simplified and practical approach

The evaluation and treatment of wide QRS-complex tachycardia remains a challenge, and mismanagement is quite common. Diagnostic aids such as wide-complex tachycardia algorithms perform poorly in the real-life setting. The purpose of this review is to offer a simple clinical-electrocardiographic approach for the initial evaluation and management of the adult patient with stable wide-complex tachycardia that does not require recollection of complex guidelines or algorithms.     

UTI: a practical approach to management

Most patients with cystitis can be managed without investigation. There is no evidence that recurrent infection in women leads to a rise in blood pressure, serum urea concentration or kidney scarring. However, children require an entirely different approach because of the risk of renal scarring.     

Vasculitis. A practical approach to management.

Vasculitis encompasses a wide variety of diseases. Because diagnosis may be difficult, a careful evaluation is essential, including a detailed patient history, thorough physical examination, and appropriate laboratory studies. Diagnosis is based on clinicopathologic features that permit identification of the condition. Biopsies are often necessary to confirm a diagnosis. It is important to accurately categorize the vasculitic disorders, since prompt, aggressive therapy with potentially toxic drugs is necessary to avoid irreversible organ system dysfunction.     

Premenstrual syndrome. A practical approach to management

Management of premenstrual syndrome (PMS) includes psychosocial as well as medical therapy. Nonmedical treatment involves patient education, physician and family support, stress reduction, and dietary changes. If these methods do not alleviate symptoms, drug therapy may be necessary. Because the exact cause of PMS is unknown, treatment is largely empirical. More research is imperative to improve therapy for patients with PMS.     

The dizzy patient. A practical approach to management

Dizziness can generally be divided into true vertigo and pseudovertigo (giddiness or light-headedness). The most common causes of pseudovertigo are hyperventilation, orthostatic hypotension, and multisensory deficits of older patients. Of the many types of true vertigo, only a few are caused by serious structural disorders of the brainstem, and these can usually be recognized by their temporal profile and concomitant symptoms and signs. Most cases of vertigo are caused by peripheral vestibular disorders that are self-limiting. Treatment is directed toward control of the acute autonomic symptoms and labyrinthine suppression until physiologic compensation takes place. Patients with vertigo that is prolonged, chronic, and recurrent may be helped by exercises designed to hasten or assist recovery of compensatory mechanisms.     

A practical approach to instrument selection, evaluation, basic financial management and implementation in pathology and research

Abstract In response to increasingly complex demands in terms of productivity and budgets, there is a critical need to avoid mistakes during instrument selection that will be financially costly, and adversely affect customers, staff, productivity and test turnaround time. As there is no "one size fits all", guidelines must be appropriate to permit informed decision making. A Medline search was conducted to assess background knowledge in this area, using the terms "laboratory instrument selection" and "laboratory instrument evaluation". Searches returned over 800 articles, of which only seven were directly related to the topic of the search, with most outdated, and suggesting a paucity of appropriate information. Additional resources used included the American Association of Clinical Chemistry (AACC) website and the Internet. Appropriate criteria for instrument selection were established in the current report based on subjective and objective (technical) evaluations. Additionally, a sound and simple financial approach is also suggested to help in making informed decisions and avoid costly mistakes. We propose that such a process as outlined in our report will protect laboratories from making costly and avoidable mistakes in the acquisition of major equipment. Clin Chem Lab Med 2008;46:1223-9.     

A practical approach to neurologic evaluation in the intensive care unit

Delirium and neurologic impairment are extremely common in the intensive care setting, and their delayed identification is an important contributor to patient morbidity. Even in comatose patients, the clinical neurologic examination remains the most accurate and effective tool in assessing nervous system function. Rapid identification of neurologic deficits with a practical and easily reproducible neurologic examination is a core skill for effectively caring for critically ill patients. The purpose of this tutorial is to discuss techniques of neurologic examination and localization with an emphasis on comatose patients. Commonly encountered cases of encephalopathy and coma along with clinical pearls are presented.     

Pain management: a practical approach to nursing education

This article describes a program that provides a practical approach to educating staff nurses in pain management. The content is appropriate for adult patients across all clinical specialties. Pain assessment and commonly used analgesic and adjuvant medications are provided in nine educational sessions lasting 10 to 20 minute. Each presentation topic is prepared in Microsoft Power Point in three versions: slides, notes, and handouts.     

A practical approach to the echocardiographic evaluation of diastolic function.

A number of recent community-based epidemiologic studies suggest that 40% to 50% of the cases of heart failure have preserved left ventricular systolic function. Although diastolic heart failure is often not well clinically recognized, it is associated with marked increases in morbidity and all-cause mortality. Doppler echocardiography has emerged as the principal clinical tool for the assessment of left ventricular diastolic function. Doppler mitral inflow velocity-derived variables remain the cornerstone of the evaluation of diastolic function. Pulmonary venous Doppler flow indices and mitral inflow measurements with Valsalva's maneuver are important adjuncts for differentiating normal and pseudonormal mitral inflow patterns. Unfortunately, these Doppler flow variables are significantly influenced by loading conditions and, therefore, the results from these standard techniques can be inconclusive. Recently, color M-mode and Doppler tissue imaging have emerged as new modalities that are less affected by preload and, thus, provide a strong complementary role in the assessment of diastolic function. This review will discuss the diastolic properties of the left ventricle, Doppler echocardiographic evaluation, and grading of diastolic dysfunction.     

A practical approach to hypercalcemia

Hypercalcemia is a disorder commonly encountered by primary care physicians. The diagnosis often is made incidentally in asymptomatic patients. Clinical manifestations affect the neuromuscular, gastrointestinal, renal, skeletal, and cardiovascular systems. The most common causes of hypercalcemia are primary hyperparathyroidism and malignancy. Some other important causes of hypercalcemia are medications and familial hypocalciuric hypercalcemia. An initial diagnostic work-up should include measurement of intact parathyroid hormone, and any medications that are likely to be causative should be discontinued. Parathyroid hormone is suppressed in malignancy-associated hypercalcemia and elevated in primary hyperparathyroidism. It is essential to exclude other causes before considering parathyroid surgery, and patients should be referred for parathyroidectomy only if they meet certain criteria. Many patients with primary hyperparathyroidism have a benign course and do not need surgery. Hypercalcemic crisis is a life-threatening emergency. Aggressive intravenous rehydration is the mainstay of management in severe hypercalcemia, and antiresorptive agents, such as calcitonin and bisphosphonates, frequently can alleviate the clinical manifestations of hypercalcemic disorders.     

A practical approach to evidence-based medicine: lessons learned from developing ventilator management protocols

Development of robust clinical protocols is a time-consuming process that requires allocation of sufficient time and resources. As outlined for the mechanical-ventilation protocol, the goals of the protocol must be clear before embarking on this journey. Critical appraisal of existing evidence is an essential first step to developing a draft protocol. The inclusion of a multidisciplinary team of clinicians, including nurses and respiratory therapists, is required to refine the logic and to ensure protocol acceptance. Extensive bedside testing of the protocol across the spectrum of patients in which it will be applied is essential for ensuring that the protocol works as intended. An effective, ongoing training program must be implemented to ensure protocol success. The final protocol should be carefully monitored in 50 to 100 patients to ensure that clinicians are complying with the protocol rules and that adverse events related to the protocol are not occurring. Finally, protocols must be tended to and updated when new evidence becomes available.     

A practical approach to intersex

The realm of intersex presents a challenge to the family as well the health care provider. As the physical aspects of diagnosis and management have become better understood, it has become apparent that there are psychological and social aspects that we have only begun to understand. A general overview of intersex issues that may confront the urologic practitioner, and the current concepts of diagnosis and management, are provided.     

Metastatic acetabular fractures: evaluation and approach to management

Although bone metastasis to the acetabulum can cause significant disability from pain and immobility, little has been written about the diagnosis and management of a pathologic acetabular fracture. We present three patients with metastatic acetabular fractures and discuss an approach to evaluation and management. When a high index of suspicion of fracture exists, further radiographic workup is warranted. Management requires a multidisciplinary approach. Factors such as age, associated comorbidities, natural history of the underlying primary cancer, general health status, prognosis, acetabular fracture characteristics, and quality of bone should be considered. We briefly discuss the options available to nonoperative candidates.     

Community-acquired pneumonia in the emergency department: a practical approach to diagnosis and management

Pneumonia is one of the most common conditions for which patients seek emergency care. It is a challenging infection in that the spectrum of illness ranges from the nontoxic patient appropriate for outpatient antibiotics to the critically ill patient requiring intensive care hospitalization. Current data and diagnostic technology provide the emergency physician with the tools for an appropriately rapid evaluation and consideration of the differential diagnosis. Key critical thinking and application of published findings allow for intelligent empirical antibiotic treatment and risk stratification for the best disposition. Although antibiotic-resistant organisms increasingly are being identified, patients continue to benefit from early institution of standard ED treatment. Coverage for atypical organisms improves patient response and outcome. Finally, identification and treatment of the complications of pneumonia and accompanying sepsis must be considered by the ED physician when evaluating critically ill patients.     

A practical approach to the management of patients with chronic renal failure

The number of patients with significant chronic renal failure is expanding rapidly in the United States. All physicians and medical-care providers will have an increasingly important role in the detection and management of renal failure in patients who are not undergoing dialysis. Patients with diabetes or hypertension should be carefully monitored for the development of renal insufficiency by using screening tools such as blood pressure measurement, determination of serum creatinine, urinalysis, and determination of 24-hour urinary microalbuminuria. In order to slow the progression of renal disease, attenuate uremic complications, and prepare patients with renal failure for renal replacement therapy, all medical-care providers should "take care of the BEANS." Blood pressure should be maintained in a target range lower than 130/85 mm Hg, and in many patients, angiotensin-converting enzyme inhibitors may be beneficial. Erythropoietin should be used to maintain the hemoglobin level at 10 to 12 g/dL. Access for long-term dialysis should be created when the serum creatinine value increases above 4.0 mg/dL or the glomerular filtration rate declines below 20 mL/min. Nutritional status must be closely monitored in order to avoid protein malnutrition and to initiate dialysis before the patient's nutritional status has deteriorated. Nutritional care also involves correction of acidosis, prevention and treatment of hyperphosphatemia, and administration of vitamin supplements to provide folic acid. Specialty referral to nephrology should occur when the creatinine level increases above 3.0 mg/dL or when the involvement of a nephrologist would be beneficial for ongoing management of the patient.     

Opioids and psychological issues: A practical, patient-centered approach to a risk evaluation and mitigation strategy

The use of long-term opioid therapy for the management of chronic pain remains controversial. The highlighted consequences of long-term opioid therapy are aberrant drug-taking behaviors, abuse, and dependence. However, the limitations of this treatment modality usually can be attributed to a lack of efficacy and adverse events. Patients that remain refractory to long-term opioid therapy for chronic pain often have a psychiatric disorder that is acting as a barrier to effectiveness. While standardized approaches to the evaluation of a patient to receive long-term opioid therapy are established, little data exists to document their ability to limit opioid abuse or enhance their efficacy. Screening questionnaires and other attempts at predicting or detecting opioid-related substance use disorders fail to determine the presence of comorbid psychiatric disorders. A comprehensive approach for the psychiatric evaluation of patients with chronic pain will address specific barriers to successful chronic pain management and optimize the chances for success with long-term opioid therapy.     

A practical approach to catheter-associated problems

This article examines some commonly found catheter-related problems and discusses approaches to managing and preventing them.