The American journal of medicine
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Many musculoskeletal complaints are accompanied by classic signs and symptoms that can be readily diagnosed by the primary care physician. Others are much less obvious and present a diagnostic challenge. In the office evaluation of patients with musculoskeletal complaints, the history is the most informative element. ⋯ Patients who present with the "algias" may have no physical signs but manifest extensive musculoskeletal pain. Fibromyalgia occurs typically in younger women; polymyalgia rheumatica rarely occurs in patients < 50 years of age and is usually accompanied by a strikingly high ESR. Age and gender should be noted in the office evaluation because they can provide clues not only to these "algias," but other rheumatic diseases seen more frequently in one age or gender group than another.
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Hyponatremia is the most common electrolyte abnormality among hospitalized patients. Death or brain damage associated with hyponatremia has been described since 1935, and it is now evident that hyponatremia can lead to death in otherwise healthy individuals. In the past, it had been assumed that the likelihood of brain damage from hyponatremia was directly related to either a rapid decline in plasma sodium or a particularly low level of plasma sodium. ⋯ If the patient is symptomatic, active therapy to increase the plasma sodium with hypertonic NaCl is usually indicated. Although inappropriate therapy of hyponatremia can lead to brain damage, such an occurrence is rare. Thus, the risk of not treating a symptomatic patient for exceeds that of improper therapy.
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Review
How safe are serotonin reuptake inhibitors for depression in patients with coronary heart disease?
Depression occurs frequently in patients with coronary heart disease (CHD), and confers significant risk for additional morbidity and mortality. The cardiac effects of the tricyclic antidepressants (TCAs) have been well characterized. ⋯ In addition, potential drug interactions, reports of side effects, and efficacy studies in the elderly are reviewed. Finally, recommendations are made considering the risk/benefit ratio.
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In patients with coronary artery disease (CAD), left ventricular (LV) function, the number of diseased vessels, and the severity of myocardial ischemia are important determinants of survival. These factors can be used to identify subsets of high-risk patients who are candidates for aggressive intervention. Among patients with LV dysfunction, those with left main CAD, three-vessel disease, and one- or two-vessel disease with inducible ischemia are at highest risk. ⋯ The risk in this population is exacerbated by the abnormalities in lipid metabolism associated with the diabetic state. CAD mortality increases with aging, but it is recommended that elderly patients with CAD also receive risk factor intervention, such as cholesterol-lowering therapy. Consideration of the impact of such therapy on quality of life is especially important in initiating such interventions in the older population.