Primary care
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Social services to assist in improving nutritional status in older adults are reviewed. The social service interventions are placed in three broad categories of risk for older people to include poverty, social isolation, and dependency/disability. Each social service is identified and described to include eligibility and local resources. A social services intervention contact guide is provided as well as a state-by-stage aging services and resources directory.
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Nutrition risk can be assessed in elderly populations by evaluating such factors as food intake, income, functional status, socialization, acute and chronic illness, and use of medications. Nutrition screening must become an integral component of the health care services provided for all older Americans. Nutrition screening and early intervention are primary steps in the development of a system of health care that is affordable and accessible to all.
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Recent position statements by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists and the emergence of legal and ethical analyses on the nature of compelled cesarean section have instigated much discussion on how the primary care physician should respond when a pregnant woman refuses to consent to surgery. This article clarifies the ethical obligations of the physician and mother and the nature of their relationships to the fetus. The formulation of an agreement, the physician-mother-fetal contract, is discussed as a teaching tool for helping to clarify the roles of all parties. Also, the function of the primary care physician as proactive educator is highlighted.
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A number of analgesic and anesthetic options are available for patients during the intrapartum period. Appropriate attention in the prenatal period to patient education regarding these options is imperative. If pharmacologic anesthesia is required, risks and benefits both to the mother and neonate must be considered. ⋯ This discussion should begin during the prenatal period to ensure that the woman has an opportunity to make an informed choice. When the woman presents in labor, the anesthetic plan may again need to be revised. Continued patient-doctor communication throughout labor is essential with the woman's preferences, tempered by sound medical judgment, guiding optimal pain control.
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Clearly, there are numerous troubling variations in the medical diagnosis of child sexual abuse. These variations include delays in disclosure; rapid healing; maturational changes; variations in normal congenital findings; the technique of the examiner; patient position, relaxation, and cooperation; and additional medical conditions that mimic abuse. ⋯ Emphasis on the child's history in documenting the abuse is increasing. As physicians, we must develop interviewing techniques that will assist in child protection, and we must listen and believe the comments made by our patients.