Items in FPM with MESH term: Continuity of Patient Care
ABSTRACT: Detoxification from alcohol can be undertaken in ambulatory settings with patients who are alcohol-dependent and show signs of mild to moderate withdrawal when they are not drinking. An appropriate candidate for outpatient detoxification should have arrangements to start an alcohol treatment program and a responsible support person who can monitor progress, and should not have significant, acute, comorbid conditions or risk factors for severe withdrawal. Long-acting benzodiazepines, the preferred medications for alcohol detoxification, can be given on a fixed schedule or through "front-loading" or "symptom-triggered" regimens. Adjuvant sympatholytics can be used to treat hyperadrenergic symptoms that persist despite adequate sedation. Progress can be monitored with the use of a standard withdrawal-assessment scale and daily physician contact. Detoxification is not a stand-alone treatment but should serve as a bridge to a formal treatment program for alcohol dependence.
Care of Cancer Survivors - Article
ABSTRACT: Cancer survivors are at increased risk for recurrence of their original malignancy; development of second primary malignancies; and medical, developmental, and psychologic problems resulting from cancer therapy, genetic predisposition to cancer, and other risk factors. Surveillance following curative cancer treatment generally includes interval history and physical examinations every six months for five years. Thereafter, histories and examinations are recommended annually for breast cancer; every three months for two years, then every six months for three to five years for colorectal cancer; and every six months for five years, then annually for prostate cancer. Recommended laboratory tests and ancillary procedures include annual mammography of preserved breast tissue in breast cancer survivors, carcinoembryonic antigen level monitoring in conjunction with annual colonoscopy in colorectal cancer patients, and prostate-specific antigen measurements every six months for five years and then annually in prostate cancer survivors. In addition, family physicians should be attentive to concerns about altered body image or sexuality issues following curative surgical procedures. Continued emphasis on preventive health practices is encouraged. Physicians should remain alert to nonspecific symptoms or physical findings (e.g., mass, adenopathy) that can indicate cancer recurrence. In childhood cancer survivors, periodic evaluation that includes a plan for surveillance and prevention, incorporating risks based on previous cancer, therapy, genetic predispositions, personal behaviors, and comorbid health conditions, is recommended.
ABSTRACT: Bariatric surgery leads to sustainable long-term weight loss and may be curative for such obesity-related comorbidities as diabetes and obstructive sleep apnea in severely obese patients. The Roux-en-Y gastric bypass has become the most common procedure for patients undergoing bariatric surgery. The procedure carries a mortality risk of up to 1 percent and a serious complication risk of up to 10 percent. Indications include body mass index of 40 kg per m2 or greater, or 35 kg per m2 or greater with serious obesity-related comorbidities (e.g., diabetes, obstructive sleep apnea, coronary artery disease, debilitating arthritis). Pulmonary emboli, anastomotic leaks, and respiratory failure account for 80 percent of all deaths 30 days after bariatric surgery; therefore, appropriate prophylaxis for venous thrombo-embolism (including, in most cases, low-molecular-weight heparin) and awareness of the symptoms of common complications are important. Some of the common short-term complications of bariatric surgery are wound infection, stomal stenosis, marginal ulceration, and constipation. Symptomatic cholelithiasis, dumping syndrome, persistent vomiting, and nutritional deficiencies may present as long-term complications.
Home Health Care - Article
ABSTRACT: Home health care is the fastest-growing expense in the Medicare program because of the aging population, the increasing prevalence of chronic disease and increasing hospital costs. Patients and families are choosing the option of home care more frequently. Medicare's regulations are often considered the standard of care for all home health agency interactions, even when a patient does not have Medicare insurance. These regulations require patients who receive home health care services to be under the care of a physician and to be homebound. The patient must have a documented need for skilled nursing care or physical, occupational or speech therapy. The care must be part time (28 hours or less per week, eight hours or less per day) and occur at least every 60 days except in special cases. A detailed referral and specific care plan maximize the care to the patient and the reimbursement received by the physician.
Essentials of Skin Laceration Repair - Article
ABSTRACT: Skin laceration repair is an important skill in family medicine. Sutures, tissue adhesives, staples, and skin-closure tapes are options in the outpatient setting. Physicians should be familiar with various suturing techniques, including simple, running, and half-buried mattress (corner) sutures. Although suturing is the preferred method for laceration repair, tissue adhesives are similar in patient satisfaction, infection rates, and scarring risk in low skin-tension areas and may be more cost-effective. The tissue adhesive hair apposition technique also is effective in repairing scalp lacerations. The sting of local anesthesia injections can be lessened by using smaller gauge needles, administering the injection slowly, and warming or buffering the solution. Studies have shown that tap water is safe to use for irrigation, that white petrolatum ointment is as effective as antibiotic ointment in postprocedure care, and that wetting the wound as early as 12 hours after repair does not increase the risk of infection. Patient education and appropriate procedural coding are important after the repair.
ABSTRACT: As death approaches, a gradual shift in emphasis from curative and life prolonging therapies toward palliative therapies can relieve significant medical burdens and maintain a patient's dignity and comfort. Pain and dyspnea are treated based on severity, with stepped interventions, primarily opioids. Common adverse effects of opioids, such as constipation, must be treated proactively; other adverse effects, such as nausea and mental status changes, usually dissipate with time. Parenteral methylnaltrexone can be considered for intractable cases of opioid bowel dysfunction. Tumor-related bowel obstruction can be managed with corticosteroids and octreotide. Therapy for nausea and vomiting should be targeted to the underlying cause; low-dose haloperidol is often effective. Delirium should be prevented with normalization of environment or managed medically. Excessive respiratory secretions can be treated with reassurance and, if necessary, drying of secretions to prevent the phenomenon called the "death rattle." There is always something more that can be done for comfort, no matter how dire a situation appears to be. Good management of physical symptoms allows patients and loved ones the space to work out unfinished emotional, psychological, and spiritual issues, and, thereby, the opportunity to find affirmation at life's end.
A Job-Share Model for the New Millenium - Feature
Coding Hospital Admissions From Other Sites of Service - Getting Paid