The Western journal of medicine
-
The presence of pleural effusion enables a physician to obtain a specimen of a body cavity fluid easily. With a systematic analysis of the pleural fluid, in conjunction with the clinical features and ancillary laboratory data, a clinician should be able to arrive at either a presumptive or definitive diagnosis in approximately 90 percent of cases. Selectivity should be exercised in ordering analyses on pleural fluid. ⋯ The differential diagnosis of a transudate is relatively limited and usually easily discernible from the clinical presentation. The differential diagnosis of exudate poses a more difficult challenge for clinicians. The use of certain pleural fluid tests such as leukocyte count and differential, glucose, pH and, when indicated, pleural fluid amylase determinations, helps to narrow the differential diagnosis of an exudative pleural effusion.
-
One of the most challenging situations encountered by primary care physicians is the diagnostic workup of a febrile child. Several studies have shown the surprisingly high incidence of clinically unsuspected, potentially major illness in febrile children. ⋯ An examination of the literature regarding febrile children under two years of age is necessary in order to synthesize the relevant information. Although there are large gaps in our knowledge, it is possible to make specific recommendations for a treatment plan, keeping in mind that areas of controversy and other reasonable approaches exist.
-
The success of efforts at cost containment in medical intensive care units of community hospitals will ultimately depend on accurate assessments of their use by practitioners. This study analyzes 167 consecutive admissions to such a facility, 81 percent of which were supervised by physicians in practice in the community. The results suggest that a significant number of patients are admitted only for observation or conventional medical care, that a substantial proportion of resources is spent on the care of patients who die immediately and that there are few practitioners with enough experience in the daily operation of this facility to develop broad perspectives of its use. Physicians with specific training or more experience in intensive care medicine, such as full-time directors of medical intensive care units, should participate in the decisions about the allocation of the limited resources available to the critically III.
-
The treatment of foreign body obstruction of the upper airway has been the subject of considerable attention and controversy. Current recommendations from the National Academy of Sciences, the American Red Cross and the American Heart Association include the use of back blows, abdominal thrusts (Heimlich maneuver) or chest thrusts (or both) and finger probes, until definitive therapy by trained medical and paramedical personnel becomes available. Nevertheless, a number of authorities on this subject have claimed that these approaches are dangerous, and that abdominal thrusts should be the first and only first-aid technique used in this situation. ⋯ The data that are available suggest that a combination of maneuvers is in fact preferable to any single maneuver. Experimental physiologic data on both humans and animals tend to support this concept and suggest that back blows, which generate high initial pressures, may dislodge objects from the larynx enough to allow subsequent thrust maneuvers, which generate more sustained increases in intrathoracic pressure, to move the object out of the larynx. At this time, in the absence of definitive data, it seems reasonable to teach as many lay citizens as possible to recognize upper airway obstruction due to foreign body and to perform any and all of these techniques (preferably in combination), as well as external cardiopulmonary resuscitation (CPR) where appropriate, on choking victims.