ITEMS IN FPM WITH MESH TERM:
Viral Croup - Article
ABSTRACT: Viral croup is the most common form of airway obstruction in children six months to six years of age. The frightening nature of croup often prompts parents and caregivers to seek physician consultation. For children with mild croup, symptomatic care and mist therapy may be all that is necessary. Epinephrine has been used for decades to treat more severe cases of croup, but recent meta-analyses have found that glucocorticoid use is associated with shorter hospital stays, improvement in croup scores, and less use of epinephrine. Studies have shown that treatment with 0.6 mg per kg of oral dexamethasone is as effective as intramuscular dexamethasone or 2 mg of nebulized budesonide. Oral dexamethasone in dosages as low as 0.15 mg per kg also may be effective. While more studies are needed to establish guidelines, oral dexamethasone can be used to treat mild to moderate croup with close follow-up and instructions for further care, if needed.
Alcohol Withdrawal Syndrome - Article
ABSTRACT: The spectrum of alcohol withdrawal symptoms ranges from such minor symptoms as insomnia and tremulousness to severe complications such as withdrawal seizures and delirium tremens. Although the history and physical examination usually are sufficient to diagnose alcohol withdrawal syndrome, other conditions may present with similar symptoms. Most patients undergoing alcohol withdrawal can be treated safely and effectively as outpatients. Pharmacologic treatment involves the use of medications that are cross-tolerant with alcohol. Benzodiazepines, the agents of choice, may be administered on a fixed or symptom-triggered schedule. Carbamazepine is an appropriate alternative to a benzodiazepine in the outpatient treatment of patients with mild to moderate alcohol withdrawal symptoms. Medications such as haloperidol, beta blockers, clonidine, and phenytoin may be used as adjuncts to a benzodiazepine in the treatment of complications of withdrawal. Treatment of alcohol withdrawal should be followed by treatment for alcohol dependence.
ABSTRACT: Vitamin D deficiency among hospitalized patients may be more widespread than realized. Vague musculoskeletal complaints in these chronically ill patients may be attributed to multiple underlying disease processes rather than a deficiency in vitamin D. However, the failure to diagnose an underlying deficiency places the patient at risk for continued pain, weakness, secondary hyperparathyroidism, osteomalacia, and fractures. The causes of hypocalcemia and hypophosphatemia in the chronically ill patient are many, and the patient may respond to simple replacement therapy. Elderly hospitalized patients with ionized hypocalcemia and hypophosphatemia, with or without an elevated parathyroid hormone level, are most likely deficient in vitamin D. Initiating treatment during hospitalization is reasonable once the diagnosis has been confirmed by finding a low 25-hydroxyvitamin D level. Treatment with high doses of vitamin D is safe. Unfortunately, some hospital formularies continue to provide multivitamin supplements that contain less vitamin D than currently is recommended.
ABSTRACT: There are approximately 250,000 cases of acute pyelonephritis each year, resulting in more than 100,000 hospitalizations. The most common etiologic cause is infection with Escherichia coli. The combination of the leukocyte esterase test and the nitrite test (with either test proving positive) has a sensitivity of 75 to 84 percent and a specificity of 82 to 98 percent for urinary tract infection. Urine cultures are positive in 90 percent of patients with acute pyelonephritis, and cultures should be obtained before antibiotic therapy is initiated. The use of blood cultures should be reserved for patients with an uncertain diagnosis, those who are immunocompromised, and those who are suspected of having hematogenous infections. Outpatient oral antibiotic therapy with a fluoroquinolone is successful in most patients with mild uncomplicated pyelonephritis. Other effective alternatives include extended-spectrum penicillins, amoxicillin-clavulanate potassium, cephalosporins, and trimethoprim-sulfamethoxazole. Indications for inpatient treatment include complicated infections, sepsis, persistent vomiting, failed outpatient treatment, or extremes of age. In hospitalized patients, intravenous treatment is recommended with a fluoroquinolone, aminoglycoside with or without ampicillin, or a third-generation cephalosporin. The standard duration of therapy is seven to 14 days. Urine culture should be repeated one to two weeks after completion of antibiotic therapy. Treatment failure may be caused by resistant organisms, underlying anatomic/functional abnormalities, or immunosuppressed states. Lack of response should prompt repeat blood and urine cultures and, possibly, imaging studies. A change in antibiotics or surgical intervention may be required.
ABSTRACT: Binge-eating disorder, bulimia nervosa, and anorexia nervosa are potentially life-threatening disorders that involve complex psychosocial issues. A strong therapeutic relationship between the physician and patient is necessary for assessing the psychosocial and medical factors used to determine the appropriate level of care. Most patients can be effectively treated in the outpatient setting by a health care team that includes a physician, a registered dietitian, and a therapist. Psychiatric consultation may be beneficial. Patients may require inpatient care if they are suicidal or have life-threatening medical complications, such as marked bradycardia, hypotension, hypothermia, severe electrolyte disturbances, end-organ compromise, or weight below 85 percent of their healthy body weight. For the treatment of binge-eating disorder and bulimia nervosa, good evidence supports the use of interpersonal and cognitive behavior therapies, as well as antidepressants. Limited evidence supports the use of guided self-help programs as a first step in a stepped-care approach to these disorders. For patients with anorexia nervosa, the effectiveness of behavioral or pharmacologic treatments remains unclear.
ABSTRACT: Subopitmal glycemic control in hospitalized patients with type 2 (non-insulin-dependent) diabetes mellitus can have adverse consequences, including increased neurologic ischemia, delayed wound healing and an increased infection rate. Poor glycemic control can also affect the outcome of the primary illness. If possible, hospitalized diabetic patients should continue their previous antihyperglycemic treatment regimen. Decreased physical activity and the stress of illness often lead to hyperglycemia in hospitalized patients with type 2 diabetes. When indicated, insulin is given either as a supplement to usual therapy or as a temporary substitute. The overall benefit of the traditional sliding-scale insulin regimen has been questioned. Insulin supplementation given according to an algorithm may be a logical alternative. Any antihyperglycemic regimen should be administered and monitored in a manner coincident with the intake of food or other sources of calories. Factors that can alter glycemic control acutely, including specific medical conditions and medications, should be identified and anticipated.
ABSTRACT: Pneumonia is an important cause of morbidity and mortality in nursing home residents, with 30-day mortality rates ranging from 10 to 30 percent. Streptococcus pneumoniae is the most common cause of nursing home-acquired pneumonia, although Staphylococcus aureus and gram-negative organisms may be more common in severe cases. Antibiotic therapy for nursing home-acquired pneumonia should target a broad range of organisms, and drug-resistant microbes should be considered when making treatment decisions. In the nursing home setting, treatment should consist of an antipneumococcal fluoroquinolone alone or either a high-dose beta-lactam/beta-lactamase inhibitor or a second- or third-generation cephalosporin, in combination with azithromycin. Treatment of hospitalized patients with nursing home-acquired pneumonia requires broad-spectrum antibiotics with coverage of many gram-negative and gram-positive organisms, including methicillin-resistant S. aureus. Appropriate dosing of antibiotics for nursing home-acquired pneumonia is important to optimize effectiveness and avoid adverse effects. Because many nursing home residents take multiple medications, it is important to consider possible drug interactions.
30 Standardized Hospital Admission Orders - Improving Patient Care