American family physician
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A complete urinalysis includes physical, chemical, and microscopic examinations. Midstream clean collection is acceptable in most situations, but the specimen should be examined within two hours of collection. Cloudy urine often is a result of precipitated phosphate crystals in alkaline urine, but pyuria also can be the cause. ⋯ Glomerular, renal, and urologic causes of microhematuria often can be differentiated by other elements of the urinalysis. Although transient proteinuria typically is a benign condition, persistent proteinuria requires further work-up. Uncomplicated urinary tract infections diagnosed by positive leukocyte esterase and nitrite tests can be treated without culture.
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American family physician · Mar 2005
ReviewAntiplatelet therapy and anticoagulation in patients with hypertension.
Elevated systemic blood pressure results in high intravascular pressure. The main complications, coronary heart disease, ischemic strokes, and peripheral vascular disease, are related to thrombosis rather than hemorrhage. Some complications related to elevated blood pressure, heart failure, and atrial fibrillation are associated with stroke and thromboembolism. It seems plausible that antithrombotic therapy may be particularly useful in preventing thrombosis-related complications of elevated blood pressure. ⋯ Antiplatelet therapy with ASA cannot be recommended for primary prevention of vascular events in patients with elevated blood pressure, because the magnitude of benefit--a reduction in rates of MI--is negated by a harm of similar magnitude, an increase in rates of major hemorrhage. Antiplatelet therapy is recommended for secondary prevention in patients with elevated blood pressure because the magnitude of the absolute benefit is many times greater. Warfarin therapy alone or in combination with aspirin in patients with elevated blood pressure cannot be recommended because of lack of demonstrated benefit. Glycoprotein IIb/IIIa inhibitors, as well as ticlopidine and clopidogrel, have not been evaluated sufficiently in patients with elevated blood pressure. Further trials of antithrombotic therapy with complete documentation of all benefits and harms are needed in patients with elevated blood pressure.
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American family physician · Mar 2005
ReviewDiagnosis and management of acute pyelonephritis in adults.
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. ⋯ 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.
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Physicians most often recommend or prescribe oral medication for relief of acute pain. This review of the available evidence supports the use of acetaminophen in doses up to 1,000 mg as the initial choice for mild to moderate acute pain. In some cases, modest improvements in analgesic efficacy can be achieved by adding or changing to a nonsteroidal anti-inflammatory drug (NSAID). ⋯ Cyclooxygenase-2 inhibitors provide equivalent efficacy to traditional NSAIDs but lack a demonstrable safety advantage for the treatment of acute pain. For more severe acute pain, the evidence supports the addition of oral narcotic medications such as hydrocodone, morphine, or oxycodone. Specific oral analgesics that have shown poor efficacy and side effects include codeine, propoxyphene, and tramadol.