Primary care
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Shoulder injuries result from acute or repetitive over-use mechanisms. An outline for a careful history and physical examination is presented along with recommendations for radiographic imaging of shoulder injuries dependent on the suspected diagnosis and injury mechanism. Descriptions of the more common shoulder problems are presented with recommendations for non-surgical treatment. Indications for surgical treatment that will allow the primary practitioner to best manage these injuries are presented.
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One important role for the primary care provider is to be familiar with all available treatment options for HIV disease. Because only a few treatments are approved, unapproved therapy becomes important for many patients. As a result, clinicians have had systems developed that create access to promising investigational drugs. In addition, because of the urgent need to increase the number of proven treatments, some clinicians have chosen to become more directly involved in the evaluation of new treatments for HIV disease by becoming community based "clinician-researchers."
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The HIV virus and the associated worldwide pandemic pose enormous biomedical, clinical, and social dilemmas for health care providers, biomedical researchers, policy analysts, and the public at large 10 years after its discovery. Many of these dilemmas and challenges are captured in the difficult ethical issues the HIV epidemic has highlighted for primary care physicians. Given the vanishingly small risk to primary care providers of acquiring HIV infection in office practice and the rapidly increasing prevalence of the virus, a clear ethical obligation to care for HIV-infected patients exists for primary care physicians. ⋯ Primary care providers should also model responsible shared decision making and goal setting with HIV-infected patients early in the course of the disease, laying the foundation for subsequent decision making later in the course of the illness. Finally, considerable controversy exists about the responsibilities of HIV-infected providers to inform patients of their status; professional and public policy in this area is in rapid flux. Undoubtedly, the HIV epidemic will continue to challenge us and force careful examination of many of the critical dilemmas in modern biomedical ethics.
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The care of HIV-infected patients is demanding, raising concerns among health care workers regarding safety, competence, and emotional endurance. Many health care workers are reluctant to undertake this challenging work. For many professions within health care, for example nursing, there is a clearly articulated responsibility to treat all ill individuals. ⋯ A supportive working environment, characterized by some meaningful element of control by all health care workers not just the medical staff, nonauthoritarian management, explicit and responsive processes for approaching the inevitable ethical dilemmas that arise in the care of HIV-infected patients, and a recognition of the emotional, psychological, and technical aspects of medical care are essential. In such an environment, health care providers will be able to develop and institute programs that address their particular needs. Strategies that have been helpful are diverse and include support groups, rotation of clinical assignments, part-time work, social activities away from the workplace, and collective spiritual activities.
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The major differences that have been recognized between black and white hypertensives are primarily epidemiologic, with hypertension being more prevalent, having an earlier onset, and having more severe sequelae in the black population. The cause of the problem in both black and white people remains obscure, but it appears that a difference in sodium handling may contribute to the particular hemodynamic and hormonal profile of black hypertensives. ⋯ Complications such as stroke and left ventricular hypertrophy remain the major sequelae of this disease in blacks. Finally, a current study confirmed the improved efficacy of antihypertensive therapy in blacks to diuretics and calcium channel blockers and a somewhat lower efficacy profile to angiotensin converting enzyme inhibitors and beta blockers, although the latter classes of agents have shown better response in blacks than previously thought.