Clinics in geriatric medicine
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Clin. Geriatr. Med. · Nov 1999
Development of clinical pathways for stroke management: an example from Saint Luke's Hospital, Kansas City.
Clinical pathways for stroke are important tools for improved case management and outcome assessment. The clinical path created at St. Luke's Hospital in Kansas City is described here. ⋯ Ideally, a clinical path should be used as a guide rather than a standard of care, which is to be individualized for each patient. This article describes the methods for writing the pathways and how they are used for documentation. It also summarizes how the pathway data support stroke outcome assessment.
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A physician should have a better appreciation of diseases that can cause significant ocular morbidity and, in some cases, death. This article describes some of the painful eye syndromes associated with ocular, orbital, and intracranial disease. Differential diagnosis, clinical findings, laboratory investigation, and treatment are reviewed.
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Sudden painless visual loss occurs in retinal disorders that reflect primary ocular disease, as well as systemic disease. This article reviews vitreous and retinal detachment and macular degeneration as ocular causes of sudden visual loss. Retinal changes that are caused by systemic disease, including infectious retinitis, occlusion of retinal vessels, and proliferative new vessel formation, are reviewed. In each instance, the retinal examination should provide the ocular or systemic diagnosis or lead to the diagnosis.
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Delirium is a common, serious problem for hospitalized older patients. Recognition of delirium poses challenges requiring cognitive assessment and knowledge of the clinical course. ⋯ Nonpharmacologic approaches for delirium management are recommended; pharmacologic management should be reserved for patients who pose a danger to themselves or others. Importantly, delirium and its complications may be preventable through a targeted risk factor approach.
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Physicians are increasingly challenged by issues surrounding medical decision-making for hospitalized patients. Advance directives express a patient's preferences regarding end-of-life care; when available, they should be used to guide medical treatment. ⋯ An ethics committee consultation may be especially helpful to resolve conflicts that may arise regarding medical treatments. Physicians play a vital role in promoting earlier patient-physician discussions about end-of-life care preferences, increased completion of advance directives, and ongoing education for physicians to improve communication skills.