The Medical clinics of North America
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Med. Clin. North Am. · Sep 1995
ReviewA stepwise strategy for coronary risk assessment for noncardiac surgery.
Physicians should adapt a systematic approach to cardiac risk stratification for patients being considered for noncardiac surgery, involving clinical evaluation, functional assessment, and surgical risk assessment for all patients and then deciding which patient needs to undergo noninvasive testing, coronary angiography and revascularization, perioperative monitoring, and aggressive postoperative care.
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Syncope accounts for approximately 1% to 6% of hospital admissions and 3% of emergency room visits. Syncope is defined as a sudden transient loss of consciousness associated with a loss of postural tone with spontaneous recovery. Patients should not require electrical or chemical cardioversion to regain consciousness. Syncope must be clinically differentiated from other states of altered consciousness, such as dizziness, vertigo, seizures, coma, and nacrolepsy.
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This article addresses controversial issues in the field of intra-abdominal sepsis with particular attention to major changes in management that have evolved during the past decade. In the area of diagnostics, scanning techniques have revolutionized the ability to detect loculated collections, although many of these techniques are of limited value in the early stages of inflammation. The greatest debate concerns the relative merits of scanning techniques; the author's choice is CT scans with contrast, although ultrasonography is preferred in patients who cannot be transported and is probably preferred for pelvic infections. ⋯ Nevertheless, surveys of practicing surgeons indicate that most actually combine this oral preparation with parenteral agents as well. The final controversy concerns percutaneous drainage, which has now become a standard technique for dealing with intra-abdominal abscesses in 50% to 90% of cases. This controversy has sometimes been seen as a territorial battle between surgeons and radiologists, and most cases are clearly the prerogative of one discipline or the other, but many are in a gray zone in which clearly defined indications are not readily available.
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Concerns about abnormal menstrual bleeding are a common reason for women to consult a primary care physician. The first step in the evaluation is to determine the patient's ovulatory status. Women with heavy bleeding but normal ovulatory cycles should be evaluated for coagulopathies, structural lesions, and hypothyroidism. ⋯ Obesity, polycystic ovary syndrome, stress, crash diets, and vigorous exercise can all disrupt normal ovulatory function. Treatment options for dysfunctional uterine bleeding include oral contraceptives, cyclic progesterone, or hormone replacement with estrogen and progesterone. Patients with structural lesions or those who do not resume normal withdrawal bleeding patterns on hormone therapy should be referred to a gynecologist for further evaluation and treatment.
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Med. Clin. North Am. · Mar 1995
Review Case ReportsOffice management of common sleep-wake disorders.
The prevalence of sleep disorders manifest as insomnia and fatigue of excessive daytime sleepiness in the general population; office practice is high. Poor quality sleep may pose a significant health risk for not only the patient but society in general. ⋯ Differentiation of the principal complaint into insomnia versus hypersomnia and determination of duration are the key elements. Office-based management of the most common sleep-wake disorders and current diagnostic testing standards are discussed.