American family physician
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American family physician · Jan 1995
ReviewAnalgesia, sedation and paralysis in the intensive care unit.
Patients admitted to the intensive care unit often experience some degree of pain and frequently are anxious, confused or delirious. Relief of pain, anxiety and agitation is important for effective patient care. ⋯ Opioids are the cornerstone of analgesia, while benzodiazepines and haloperidol are commonly used for sedation and relief of agitation. When sedative agents fail to control agitation and effective ventilation of the patient is compromised, it may be appropriate to pharmacologically paralyze the patient.
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Clinical questions often arise suddenly and at odd hours during the intrapartum period. Many questions can be answered immediately by making use of readily available diagnostic ultrasonography. ⋯ Sonographic skills facilitate the performance of certain procedures, including external version of the breech fetus, intrapartum twin management and amniocentesis for lung-maturity testing or culture in cases of suspected chorioamnionitis. Sonography can be helpful in the evaluation of possible placental abruption, but management of this condition remains clinical and should not be affected by a negative sonographic scan.
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Trauma and compression along the course of the median, ulnar or radial nerve from the brachial plexus to the fingers may cause pain, weakness, numbness or tingling of the upper extremity. Diabetes, smoking, alcohol consumption, rheumatoid arthritis and hypothyroidism are risk factors for nerve entrapment, although these disorders typically produce bilateral symptoms. Carpal tunnel syndrome, the most common nerve entrapment condition, results from median nerve compression at the wrist. ⋯ Electromyography and radiography may help differentiate these conditions. Radial tunnel syndrome occasionally accompanies inflammation of the common wrist extensors and lateral epicondylitis ("tennis elbow"). A radial nerve block can help exclude concomitant radial tunnel syndrome in patients with symptoms of lateral epicondylitis.
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Delirium is characterized by a sudden deterioration in cognitive function and an inability to sustain attention. It is a medical emergency that occurs in more than 20 percent of hospitalized elderly patients. Misdiagnosis is common and contributes to high morbidity and mortality. ⋯ Effective management requires prompt treatment of the underlying pathology and maintenance of a supportive environment. It is often necessary to control agitation and prevent the complications of immobility in elderly patients with delirium. Although the long-term prognosis is guarded in elderly patients with delirium, sound geriatric care and a high index of suspicion can minimize the impact of delirium.
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Clinically apparent thyroid nodules occur in about 5 percent of the population. Because most patients with thyroid nodules present initially to their primary care physician, family physicians should have a thorough understanding of the diagnosis and treatment of thyroid nodules. ⋯ In most cases, fine-needle aspiration biopsy can accurately identify malignant thyroid nodules. Fine-needle aspiration biopsy is safe and can be performed in an office setting.