澳大利亚John Murtagh全科病案研究(三十九)——突然出现的眩晕

译者按:头晕是全科医生诊所里最常见的病人主诉之一.头晕属于"不适"(discomfort)的范畴,是一种卫生服务需要.有很多躯体疾病、心理状态、环境影响都可以产生头晕症状.从生物医学角度看,头晕可以是脑源性的(如脑动脉硬化或颈椎关节病引起脑血管循环障碍)、心源性的(如心脏功能障碍导致的脑供血不足)、血管抑制性的(如紧张、疲劳、情绪波动、空腹、恶劣天气等引发的植物神经紊乱)、药物中毒性的(如某些抗生素的不良反应)、神经系统感染(如前庭神经的病毒感染)、耳鼻喉科情况(如化脓性中耳乳突炎)等.Murtagh教授指出,"病人是带着症状来的",而且病人呈现给医生的头晕主诉并没有带着特定的生物医学标签.因此全科医生应根据症状特点进行初步判断,并给予合理的治疗和病人管理.     

澳大利亚John Murtagh全科病案研究(三十四)——对糖尿病患者的连续诊治过程(1)

1 病史 13年前,金42岁,到全科医学诊所来体检.他是一位警察,以前身体一直很健康,不过近几个月来感到很劳累,很容易疲倦.特别是锻炼身体后,常感到疲惫不堪.最近他晋升为警督,工作更加繁忙了,而且要花更多的时间处理公务,疲劳感也就更为严重.他说感到自己力不从心,而且体重也增加了不少.他倒是没有什么其他的症状,特别是没有泌尿系统的症状.     

澳大利亚John Murtagh全科病案研究(十六) 全科医学服务中的警戒故事——致命的家族病史

1案例1 贝蒂是68岁的家庭妇女,以前是护士,现已退休,住在舒适的乡村地区.她来找我只是做一个普通的身体检查.她自述身体很好,但是一年来她发现大便有点不成形,而且有一种说不清的腹部不适.     

Methodological considerations for end-of-life research in patients with chronic kidney disease

Good quality information is lacking about how patients die. This is particularly true for chronic kidney disease (CKD) patients who have extensive and unique end-of-life care considerations and needs. Research specific to CKD is required to develop systematic and comprehensive information on the end-of-life care needs and the quality of end-of-life care for patients with CKD, to describe the effectiveness of existing end-of-life care strategies in CKD (including cost-effectiveness), to identify areas that should be priorities for improvement and ultimately to develop innovative strategies for improving the end-of-life care for patients dying with CKD. This paper will highlight the challenges and limitations of the current approaches to end-of-life care research and will outline what is required, both in content and methodology, to move the field of renal palliative care forward.     

Magnetic Resonance Angiography of a Posterior Cerebral Artery Occlusion

A 45-year-old woman suddenly had severe pain in the right eye and blurred vision. Physical findings were normal except for left homonymous hemianopia. Laboratory test results were normal. However, magnetic resonance images showed evidence of cerebral infarctions in the right posterior cerebral artery distribution. In addition, magnetic resonance angiography was consistent with absent flow of that vessel.     

Variability of the Doppler gradient in pulmonary valve stenosis before and after balloon dilatation.

The variability of the valve gradient measured by Doppler in pulmonary stenosis was compared with the variability of the gradient measured at catheterisation in 42 infants and children undergoing catheterisation with a view to balloon dilatation of the pulmonary valve. The maximum value measured by Doppler when the patient was unsedated was significantly higher than that measured when the patient was sedated for catheterisation, and the maximum gradient was significantly higher shortly after than several days later. In a patient with pronounced infundibular obstruction after dilatation the Doppler signal clearly showed that the obstruction was dynamic, with a superimposed lower fixed signal that correctly predicted the final low gradient. The Doppler gradient in an alert and unsedated patient may be a better measure of the true physiological value. The highest Doppler value so obtained is a more appropriate indicator of the need for balloon dilatation than a single catheter measurement. The result of dilatation is best assessed by Doppler measurement at least a day after the procedure.     

The use of opioid analgesia in end-stage renal disease patients managed without dialysis: recommendations for practice

The numbers of patients dying with end-stage renal disease (ESRD), particularly those managed conservatively (without dialysis) or withdrawing from dialysis is increasing rapidly in developed countries. There is growing awareness of the extensive symptom control needs of these patients. Pain is a common problem, and has been both under-recognized and under-treated. It is challenging to manage, largely because of the constraints very poor renal function places on use of medication. Although pharmacological reviews of opioid use in renal failure have been published, there is a need for clinical recommendations to aid palliative and renal specialists in providing effective pain control. This review describes the pharmacological evidence for and against the use of the different opioid medications, and translates this into clinical recommendations for ESRD patients managed conservatively, not for those on dialysis for whom there are different pharmacological considerations. Acetaminophen (paracetamol) is recommended at Step 1 of the World Health Organization ladder. Of the Step 2 analgesics, tramadol is the least problematic, although dose reduction and increased dosing interval are required, and caution should be exercised. Of the Step 3 analgesics, fentanyl, alfentanil and methadone are recommended. There is limited evidence for buprenorphine, although theoretical reasons why it may be a good choice for these patients. Hydromorphone and oxycodone cannot be recommended because of extremely limited evidence, although each is likely a better choice than morphine or diamorphine. Morphine and diamorphine themselves are not recommended because of known accumulation of potentially toxic metabolites.     

Progressive necrotizing myelopathy associated with leukemia: clinical, pathologic, and MRI correlation

We describe a patient with progressive, irreversible, necrotizing myelopathy associated with myelomonocytic leukemia. The neuropathologic lesions consisted of diffuse necrosis, most pronounced in the cervical cord and affecting both the gray and white matter. These areas corresponded to areas of increased T2 on magnetic resonance imaging scans of the patient. We felt that there was no causal relationship of these lesions to any single antileukemic agent the patient received, and no other local or systemic causes were found to explain the lesions at necropsy. It is suggested that our case is an example of paraneoplastic necrotizing myelopathy. To our knowledge, this is the third case of necrotizing myelopathy associated with leukemia reported in the English medical literature, and the first one demonstrating usefulness of magnetic resonance imaging in diagnosis of necrotizing myelopathy.