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Z. Yespas. Russell Sage College.

While trying to work at the library discount 5 mg proscar with amex, she had to contend with uncontrollable involuntary movements generic 5 mg proscar free shipping, slurred speech discount 5 mg proscar with mastercard, and the fear that her supervisor would stop by and see her at her worst, which was in the afternoon. She was embarrassed because her condition made her seem drunk—as people with Parkinson’s are often thought to be when they lose their balance and stagger. After six months, when she had become very lightheaded and dizzy and exhibited extreme shaking, her doctor grew concerned and put her in the hospital for observation. Feldman educated her about Parkinson’s disease and encouraged her to undergo a drug holiday at the hospital, for she was obviously overmedicated. Faylene agreed and spent three weeks at the Boston Medical Center under close supervision of the Par- kinson’s team, as the Sinemet was gradually withdrawn. Although she experienced mobility problems during the withdrawal and afterward, her mobility was restored with the help of physical ther- apy and determination. When Faylene left the hospital, she was taking one-half of a 25/250 pill four times daily—a total of 50 mg of carbidopa and 200 mg of levodopa—approximately one-ninth of her previous dose. Her speech was no longer slurred, her balance was greatly improved, her tremor was diminished, and she felt much better. Faylene is the kind of person who doesn’t just sit back and wait for something good to happen. If she were, she would proba- bly be an invalid today instead of a traveler planning to visit rela- tives in Texas. She was not unhappy with her first doctor, but she didn’t hesitate to consult another when she realized that the treat- ment wasn’t working for her. As a Parkinson’s patient, you should expect to receive appro- priate medication, in dosages adjusted for you, that will result in productive living. Unfortunately, there are a number of look-alike diseases with symptoms similar to those of Parkinson’s. Diagnosis of these look-alikes may be very difficult, despite new technology such as the PET scan, which can measure dopamine content and dopamine receptor activity in the living brain, and the MRI scan (magnetic resonance imaging), which may help to distinguish between different types of parkinsonism. One condition of the elderly that may be mistaken for Parkin- son’s is benign essential tremor. Unlike the resting tremor of Parkinson’s, benign essential tremor increases when the patient reaches out for something or moves his or her hands. Certain drugs help to control this tremor, but they are different from the drugs that treat the tremor of Parkinson’s. Patients with benign essential tremor may wish to contact ITF (International Tremor Foundation), a national foundation devoted to their needs. You can reach ITF at the ad- dress of the United Parkinson Foundation (see appendix A). Shy-Drager syndrome is a Parkinson’s look-alike that starts with dizziness on standing, bladder difficulty (ranging from inconti- nence to difficulty voiding), and impotence, which are only later followed by the primary symptoms of Parkinson’s. An unusual look-alike is normal pressure hydrocephalus, in which fluid cavities in the brain become enlarged. The pressure that is exerted on several brain centers causes difficulty in walking, prob- lems of urinary incontinence, and symptoms of senility. However, in this disease, most of the damage is in the striatum, not in the sub- stantia nigra. Patients do not develop tremor, but they do develop rigidity, slowness of movement, and problems with walking and 98 living well with parkinson’s balance. Arteriosclerotic palsy (pseudobulbar palsy), the result of many small strokes in patients with high blood pressure or diabetes, is another look-alike. Patients may be unaware of these small strokes, but the damage caused to the brain affects balance and walking. Progressive supranuclear palsy is a look-alike that causes paralysis of the movements of the eyes, speech problems, rigidity, and symp- toms of senility. Wilson’s disease, which causes copper to accumulate in the liver and the brain, appears in patients under forty years of age.

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Using rapid MR rather than radi- ographs buy discount proscar 5 mg, fewer than one new case of cancer was detected per 1000 patients imaged proscar 5 mg online. What Is the Role of Imaging in Patients with Back Pain Suspected of Having Infection? Summary of Evidence: When infection is suspected order 5mg proscar amex, MR is the imaging modality of choice. Its sensitivity and specificity are superior to the alter- natives, and the images obtained provide the anatomic information needed for surgical planning. Plain Radiographs In contrast to metastatic disease, radiographic changes in infection are gen- erally nonspecific. Findings of infection after several weeks include poor cortical definition of the involved end plate with subsequent bony lysis and decreased disk height. In one study, the overall sensitivity of radiographs for osteo- myelitis was 82%, and the specificity was 57% (strong evidence) (68). Computed Tomography We found no adequate data on the accuracy of CT for infection in the lumbar spine. Magnetic Resonance In the single best-designed study, the sensitivity of MR for infection was 96% and the specificity was 92%, making MR more accurate than radi- ographs or bone scans (68) (strong evidence). Perhaps more importantly, MR delineates the extent of infection better than other modalities, which is critical to surgical planning. The characteristic MR appearance of pyogenic spondylitis is diffuse low marrow signal on T1-weighted images and high signal on T2-weighted images (Fig. Although classically two vertebral bodies are involved along with their intervening disk, the early imaging is more variable, occasionally with only one vertebral body being involved (69). Gadolinium may increase the specificity of MR, with enhancement of an infected disk and end plates, although rigorous evidence is lacking (70). Sagittal MR of the thoracic spine demonstrating characteristic findings of diskitis and osteomyelitis, with virtual obliteration of the intervertebral disk, low signal on T1-weighted (A) and high signal on T2-weighted (B) images adjacent to the destroyed disk. Note the posterior extension of the process into the spinal canal and epidural space, causing compression of the cord (arrows). We found no studies quantifying the accuracy of MR for epidural abscesses, but because of greater soft tissue contrast, MR should be better able to characterize the extent of an epidural process than CT. Bone Scanning and Single Photon Emission Computed Tomography In one study investigating bone scanning and infection, the sensitivity was moderately high at 82%, but specificity poor; only 23% (71) (moderate evi- dence). What Is the Role of Imaging in Patients with Low Back Pain Suspected of Having Compression Fractures? Summary of Evidence: There are no good estimates on which imaging modality is best for compression fracture imaging. When differentiation between metastatic and osteoporotic collapse is sought, MR is currently the method of choice. Chapter 16 Imaging of Adults with Low Back Pain in the Primary Care Setting 309 Supporting Evidence A. Plain Radiographs Various biases (diagnosis review bias, test review bias, and selective use of reference standards) make it difficult to provide a summary estimate of the radiographic sensitivity and specificity for acute compression fractures. While radiographs are likely reasonably sensitive, they probably cannot distinguish between acute and chronic compression fractures. Clues that a fracture is old include the presence of osteophytes or vertebral body fusion. Because MR identifies marrow edema or an associated hematoma, and because bone scan evaluates metabolic activity, they provide more useful information regarding fracture acuity (limited evidence) (72). Computed Tomography We found no adequate data on the accuracy of CT for compression fractures. Magnetic Resonance We were unable to identify accurate sensitivity and specificity esti- mates for MR imaging in compression fractures. While there is an abun- dance of literature on MR and compression fractures, the overwhelming majority of articles focus on differentiating malignant from osteoporotic etiologies.

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Comprehensive multidisciplinary programs for as quickly modify or cancel programs buy discount proscar 5mg online, if necessary buy discount proscar 5 mg online. Rich MW generic proscar 5mg visa, Beckham V,Wittenberg C, Leven CL, Freedland grams in the traditional system, this discrepancy will KE, Carney RM. Cline CM, Israelsson BY, Willenheimer RB, Broms K, ating chronic disease management programs, significant Erhardt LR. Cost effective management programme for barriers to success exist even within managed care. Prolonged beneficial effects of a home-based intervention physicians to participate in or support programs, and the on unplanned readmissions and mortality among patients difficulty in measuring any dollar savings. Mittelman MS, Ferris SH, Shulman E, Steinberg G, Levin has programs in both diabetes and congestive heart fail- B. A family intervention to delay nursing home placement ure, which program will be primarily responsible for a of patients with Alzheimer disease. A multifactorial in the older adult population hold promise for better intervention to reduce the risk of falling among elderly quality care and decreased costs. Home visits by not just individual patients, has the possibility to im- an occupational therapist for assessment and modification prove overall health care status. It is, however, still a rela- of environmental hazards: a randomized trial of falls pre- tively new and very heterogeneous field that will require vention. Evidence suggest- ally in the nonmanaged care arena where most Medicare ing that a chronic disease self-management program can beneficiaries are still insured, before it can be accepted as improve health status while reducing hospitalization: a a standard of treatment for chronic diseases. Bloom Disease prevention and health promotion are important Papanicolaou smears to detect early cervical cancer, on aspects of health for older individuals. Between 40% and the other hand, are recommended after age 65 mainly for 70% of all diseases are partially or totally preventable women with high-risk sexual behavior or those without through lifestyle modification, risk factor management, a previous Pap smear. Additionally, life expectancy and 1–3 and primary or secondary preventive practices. Despite quality of life are especially important considerations for a lack of definitive data regarding preventive interven- older individuals when deciding upon preventive inter- tions for a number of diseases and occasional disagree- ventions. The disease must have a significant effect on the recommended preventive services remains a major quality and quantity of a patient’s life. Offering and in- Discovering a potentially serious condition at an early corporating such services at worksites, schools, senior stage via screening is only useful if there is a treatment centers, and churches could significantly help improve the available to cure or significantly decrease morbidity from numbers of older people receiving preventive care. If effective treatment does not exist or if nonphysician assistants, nurses, technicians, and others any individual is unable to access treatment after screen- can also greatly facilitate the delivery of preventive ing, screening is not indicated. Early treatment should yield a therapeutic result Primary, secondary, and tertiary prevention are all superior to that obtained by delaying treatment. Primary prevention is the avoidance of a treatment does not lead to a better outcome, detecting a disease before it can begin. The disease must have an asymptomatic period of a disease before it becomes symptomatic and then during which detection and treatment significantly reduce intervening early enough to positively affect outcomes. By definition, screening is per- Tertiary prevention emphasizes rigorously treating estab- formed on individuals asymptomatic for the condition. If lished disease to prevent adverse outcomes and compli- symptoms are present, any testing is diagnostic. This criterion is tions for the general population of older adults as more of an administrative or policy consideration. Indi- opposed to a high-risk group within that population is viduals may be willing to pay for a screening test that also important. Life expectancy, United States, 1997: additional influenza vaccination compared to those receiving a years of life. Hyattsville, Maryland: least 80% should be met to establish herd immunity in National Center for Health Statistic; 1999. More recently, some groups have advocated patients and in two RCTs was associated with a 40% reduction in relative risk for patient mortality. The test is costly, and to date During institutional influenza outbreaks, chemopro- there is only limited evidence of its efficacy as a screen- phylaxis in combination with timely annual influenza ing tool.

Containers for transporting lab specimens To relieve time constraints and improve efficiency proscar 5mg with amex, visits Basic wound care supplies: 2 ¥ 2 gauze buy discount proscar 5 mg line, 4 ¥ 4 gauze proscar 5 mg without a prescription, tape, iodine, Kerlix, gloves can be carefully planned and clustered geographically. In Wound debridement supplies: disposable scalpel, debridement kits the Boston University practice, patients or their families Suture removal kit are phoned 1 day in advance, and a time for the visit is Measuring tape planned so that family members can be present, which Shears is especially useful in the case of non-English-speaking Stool guaiac materials and lubricant Sharps container patients. Practices that employ physician assistants or Urinary catheter supplies including catheterization kit, catheters, nurse practitioners can integrate them into the home care specimen containers team as another way to improve efficiency. Physicians can Prescription pad enhance their safety by traveling with students or other Tongue depressor members of the team, scheduling visits early in the day, Culture swab Medications: steroid for joint injections, local anesthetic, intravenous and carrying cellular telephones. For instance, Medicare reimbursement in Massa- Note: In the summer, it is wise to have a cooler for laboratory chusetts for the lowest level of care for an established specimens. The highest level of care for a new home care patient was reimbursed at $205 per visit versus $135. This approach also allows continuous and it provides important evidence in case of a malprac- assessment of outcomes over time so that the plan can be tice suit, although such lawsuits are rare. The collaborative nature of this practice requires com- munication among the varied disciplines that provide What Is in the Doctor’s Bag services in the home. In addition, there may be overlap The old-time doctor’s "black bag" is probably not large of shared tasks. In the case of a patient undergoing enough to accommodate the items that most home care poststroke rehabilitation, for example, a speech-and- physicians might need on a routine or emergent home swallowing specialist might work closely with a nutri- visit. In the Boston University practice, we use a light- tionist and visiting nurse in providing a patient with a safe weight diaper bag with multiple pockets. A bag on wheels might also family, patient, home health aide, and visiting nurse on a be appropriate in the case of a long walk from the car to plan for safe transfers. If communication is adequate, the entire team should be apprised of current and future plans. In small Interdisciplinary Teams practices where the physician does not have the luxury The home is the ideal location to identify the elder’s of an interdisciplinary team, the physician must act as strengths, abilities, and supports, both formal and infor- the case manager in concert with a visiting nurse. These factors are important in developing a care Although most patients receiving home care services do plan that can be put into operation realistically and that not receive house calls from physicians, the physician 128 S. Possible members of a home care interdisciplinary The initial home visit to a medically and socially com- team. It may take Licensed nurse several home visits for the physician or team to gather all Physical therapist the information in a comprehensive geriatric assessment. Occupational therapist Basic elements of the house call should include the Speech therapist Home health aide history and physical exam, social interaction that Homemaker solidifies the doctor–patient relationship, assessment of Physician assistant caregivers and their burden, environmental safety assess- Social worker ment, psychosocial assessment, nutritional assessment, Pharmacist financial assessment, cognitive assessment, a medication Dentist Podiatrist review (including prescribed and over-the-counter Audiologist medications), functional assessment, an introduction to a Chore aide discussion of advance directives and personal prefer- Optometrist ences, an exploration of spiritual needs, and a discussion Nutritionist of the care management plan. Dietician Friendly visitor The physician may have to take into account various Volunteer environmental barriers when taking the history in the Psychologist home setting. Families may need to be asked to leave the Personal care assistant room for private conversations, and the television or Laboratory assistant radio may need to be turned off. The physical examina- Home repairman Rehabilitation personnel tion poses its own problems. If lighting is poor, the physician should have a light source available; to avoid Source: Adapted from the American Medical Association, with self-injury, the physician should use caution when exam- permission. The physician may need to bring disposal remains an important member of the team and must containers for needles, syringes, and other instruments. Situations in which a visit by the physician subsequent exams can be focused on the patient’s par- may be required include discrepancies in reports of the ticular needs. For instance, a look at the feet of a diabetic patient’s status, acute declines in health or function in patient with neuropathy may be more important than frail patients, unexplained failure to thrive, unexplained weighing the patient. The home environment patient/family meeting to make an important decision, alters the traditional doctor–patient relationship in that and routine medical care for the patient who cannot leave the patient is on his or her own "turf" and therefore has home.

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