notes of JPFerrara http://members/tripod.com/~uncljoedoc/index.html

Notes on ambulatory care issues

	early detection
		hypercholesterolemia
		carcinoma in situ of cervix
		hypertension
		breast cancer
		prostate cancer
		colon cancer


	lead time - the interval of time from when a condition 
		is detected by a screening test to the usual
		time of diagnosis.

	pneumococcal pneumonia high risk over 65 
		(consider pneumococcal vaccine)
	
History taking
	focus on one symptom at a time
		chronology
			date and time of onset
			duration
			frequency and time of day of symptom
			course over time 
			remote history of similar problem
		quality
		aggravating alleviating factors
		associated factors
		description of single episode
		impact of symptoms on activities
		patient's explanatory model

	formulations at the patients level of understanding
		social profile gives a clue
		do not confuse the patient

	spot-check of patient's understanding of diagnoses and plan

Wisdom:                 The patient whom you most wish to avoid 
		is often most in need of your careful attention.
			If nothing else at least ask what exactly
		the patient was doing at the onset of a condition.
			Not sleep versus work, rather study versus
		sleep and work.
			Knowledge is necessary but not sufficient
		to ensure patient change.
			
			
		
non-compliance as a disease

geriatric medicine
	have old medical records, current medications
	speak slowly clearly, not necessarily loudly
	mental status exam
	living will, durable power of attorney for health care
		look for unanimous family consensus in decisions for
		incompetent patients

	activities of daily living
		feeding 
		bathing 
		dressing 
		transferring 
		toiletting 
		continence 
	
	types of urinary incontinence
		urge incontinence -at a certain volume the bladder empties
		stress incontinence -with cough sneeeze or exertion
		overflow -bladder overfills due to inadequate sensory
			perception or outlet obstruction then empties
		functional incontinence due to being bedridden or some meds.
			drugs
				diuretics
				anticholinergics
				sedatives
				neuroleptics
			other
				fecal impaction
				uti's, atrophic vaginitis
			get a bladder record

				
adolescent medicine
	alcohol
	homocide
	suicide
	neoplasia
		acute leukemia
			lymphocytic
			myelogenous
		lymphoma
			Hodgkins
			non hodgkins
		cns tumors
			gliomas (infra and supratentorial)
		bone tumors
			osteogenic sarcoma
			Ewing's sarcoma
		solid organ tumors
			especially genital in origin
		cystic fibrosis
		nephritis
		congenital heart disease


obesity in adolesence
	defined as 20% over ideal body weight
	screen for other cardiovascular risk factors
	modify eating habits and encourage exercise


Five Depressive States of Adolescent (Mattson)

	depressive mood swings
	acute depressive reactions - to loss lasting weeks or months
	depressive neurosis
	masked depressions of adolescence
	psychotic depressions

Approach to Adolescent depression
	uncover recent events precipitating the depressive disorder
	rule out organic brain disease or drug abuse 
	look for thought disorder or other signs of psychosis
	looked for symptoms of masked depressive states


The Common Cold
	nasal discharge and obstruction
	sneezing
	sore throat
	cough
	hoarseness

	adults have two to four colds per year
	children have six to eight

	last from one to two weeks

	topical decongestants are safe for hypertensives
	and may be used up to five days (rebound effect thereafter)



Flu
	significant morbidity and mortality 
	Amantadine for Influenza Type A
	secondary pneumonias especially in COPD CHF and geriatric pop