Evidence-based diagnosis in primary care : a practical approach to common problems


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Symptoms of MDS are often vague and nonspecific, and the diagnosis is often made during a workup for anemia, thrombocytopenia, or neutropenia discovered on a CBC. If present, signs and symptoms depend on the blood and bone marrow cell types that are affected. When erythrocytes are affected the most common situation , patients present with signs of anemia, including pallor, pale conjunctiva, tachycardia, hypotension, fatigue, headache, and exercise intolerance, or with signs and symptoms of a worsening underlying condition such as angina pectoris, heart failure, or emphysema.

When platelets or neutrophils are affected. Splenomegaly and lymphadenopathy are uncommon in MDS and, if detected, should raise suspicion of a myeloproliferative or lymphoproliferative neoplasm.

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Skip to main content. Myelodysplastic syndromes: A practical approach to diagnosis and treatment. Cleveland Clinic Journal of Medicine. Sekeres, MD, MS. Factors that make MDS more difficult to manage and that worsen the prognosis are older age at diagnosis and comorbidities such as coronary artery disease, chronic obstructive pulmonary disease, and chronic kidney disease.

Patients with lower-risk disease can continue followup with their primary care provider once the treatment goals and plans are established.

How to make a clinical diagnosis: a step by step guide

MDS are currently diagnosed in an estimated 3. Next Article: A judgment call. Hematology Oncology. Menu Close. The diagnostic criteria for surveillance of HCAI in traditional hospital settings generally address acute admissions services One of the essential criteria for determining whether an infectious process is a HCAI is that the disease was not present at the time of treatment. However, chronicity in patients and recurrences are limiting factors for determining when an infection was acquired 12 because, although care is continuous over time, each contact is brief.

Furthermore, asymptomatic infectious processes may already exist at the time of care. In addition, comorbidities, such as HIV, that are prone to opportunistic infections hinder the clear definition of the disease as HCAI among this group. A reliable standardised denominator and indicators to facilitate process monitoring have yet to be produced The denominator person-time at risk , or alternatively, the number of cases per person may be used, while the use of the denominator people at risk apparently does not take into account this type of healthcare.

This not only reduces the accuracy of the epidemiological and clinical diagnosis, but also leads to the excessive use of antibiotics, increasing selective pressure in a population of bacteria and potentially contributing towards resistance to antimicrobial agents. As a result, surveillance systems involving patients not admitted to hospital are often time consuming or lack sensitivity and specificity The implementation of a sensitive, specific and efficient HCAI surveillance system is therefore a major challenge.

Such a system should be simple and pragmatic and focus on the most likely preventable infections associated with the most common care procedures The education and training of these professionals does not necessarily include the control and prevention of HCAIs, and therefore certain professionals may not consider HCAIs a potential problem.

There is also a tendency towards detached care practices, in which professionals apply prevention measures based on individual knowledge rather than on standardised treatments.

Apart from problems related to immunisation, little is known about the risks involved with the most common care procedures in PHC. Procedures with a relatively significant level of invasiveness and which may result in adverse effects commonly performed in PHC include colpocitological tests, insertion of intrauterine devices, cervical cauterization, measurement of capillary blood glucose, inhalation, dressings, and injections.

However, estimates regarding the adverse effects caused by such procedures do not exist.

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With respect to dental procedures, while there is a recognised risk associated with the acquisition of viruses such as hepatitis B and HIV, reports of HCAIs caused by bacteria are rare. The current literature provides little or no information regarding the potential risk of infection associated with physiotherapy, except in cases of hydrotherapy As a general rule, it is assumed that the risk associated with psychologists, nutritionists, social workers, and other professionals that do not use invasive procedures is minimal.

However, the use of toys, special items of furniture and other devices may act as a reservoir for pathogens if they are not made with easily cleanable and disinfectable material. In PHC healthcare facilities and settings it is rare to find trained professionals who are formally responsible for creating and implementing policy and provide training, supervision and guidance regarding HCAI control and prevention measures. With regard to humanitarian disasters and disease outbreaks, it is vital that the health system is prepared to provide a rapid response.

To effectively react to a problem and provide adequate individual care and appropriate guidance to the population regarding prevention, PHC services must be staffed with properly trained and experienced professionals. The national literature gives no clear indication on how a HCAI prevention and control programme for PHC should be structured and implemented, and few recommendations are provided regarding out-of-hospital care in general 12 , 17 - The main objective is to protect the patient, health workers and all other individuals in the physical healthcare environment and the public sector should provide the necessary financial resources for the implementation, maintenance and supervision of effective HCAI prevention in PHC settings.

Eight key components can be highlighted and should be part of any set of measures implemented within the PHC sphere. Standard precautions SPs : SPs are a set of best practices for prevention that should be adopted with all patients, regardless of suspected diagnosis or confirmed infection The following procedures relevant to PHC are worth highlighting:. Hand hygiene: this is considered the most effective measure for preventing infections since it prevents the propagation of microorganisms in all care settings Currently, the use of alcohol-based hand sanitizers on clean hands is preferred and these should be readily available in the care facility.

The use of alcohol based products to clean the hands as opposed to washing with soap and water is preferred for a number of reasons: a alcohol is more effective as a germicide; b the antimicrobial action of alcohol is quicker; c alcohol-based products dry the skin less. Alcohol gel dispensers are recommended in the reception of the health facility to promote hand hygiene among service users on arrival and during waiting.

Hand hygiene should be performed during home visits and professionals should always carry alcohol-based hand gel with them. Care with health products: there are two categories of health products: reusable and disposable The latter, for example syringes, needles and plastic vaginal speculum, should be disposed of and their reuse is unacceptable from a safety perspective and is not justifiable from a cost-benefit point of view.


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With regard to reusable items, the relevant recommendations and norms regarding their use and reuse should be complied with 23 - PHC procedures that present the greatest risk are those that involve the invasion of normally sterile tissues such as injections, venipuncture, vesical probing and certain dental procedures. The items used during these procedures should therefore be sterile. Procedures involving contact with mucous dental procedures in general, colpocitological tests, dressings, and inhalation present lesser risk, because mucous membranes provide certain protection against pathogenic invasion.

In such cases, high level disinfection is required to ensure that microorganisms which are not part of the local microbiota do not penetrate this tissue and that pathogens are not transferred from one patient to the other. Respiratory etiquette: patients should be advised to cover their nose and mouth when coughing or sneezing and perform subsequent hand hygiene. To facilitate this behaviour, paper tissues and hand hygiene products should be provided in treatment and waiting areas All furniture, equipment and toys should be made of cleanable and disinfectable materials.

Decreased fetal movements: a practical approach in a primary care setting

Mattresses and mats used for physiotherapy, relaxation or other physical activities should be cleaned between each use. Waste management: infectious waste requires specific treatment in accordance with relevant legislation. The healthcare team should be fully aware of what constitutes infectious waste 21 and special attention should be given to sharps waste.

Activities which frequently generate devices or objects used to puncture or lacerate the skin include vaccinations, dressings, blood and bodily fluid sampling, testing for blood glucose levels, and administration of medications. The areas where these activities are carried out should obligatorily contain special disposal units in accordance with relevant regulations: improvised bins to dispose of these items are unacceptable.

Healthcare waste management related to home care is the responsibility of the health professional that provides care and waste items should be returned to the health facility for correct disposal and devices or objects used to puncture or lacerate the skin should be placed in a hard container carried by the professional. Specific precautions: these comprise additional recommendations that should be followed when SPs do not suffice to interrupt transmission of pathogens There are three categories of specific precautions: contact precautions; droplet precautions; and airborne precautions Health conditions treated in PHC settings that most commonly require the adoption of specific precautions include: pulmonary tuberculosis, varicella airborne , influenza droplets , and scabies and multiresistant microorganisms contact.

Although treatment of these cases may be brief, it is vital to define specific procedures to prevent the transmission of these pathogens. Patients suspected to have such diseases should not wait for treatment in waiting areas and should be given priority treatment using the personal protective equipment recommended for each specific precaution During the contagious period, patients should be advised to use personal items and should not handle items that are for general use. Cardboard boxes should be disposed of since they are not hygienic and attract insects. Specific items should be stored in a temperature-controlled refrigerator specifically used for these products.

Nonrelated items food stuffs, organic material, etc Hand hygiene products should be readily available in the storage and distribution area. Injections should be given safely with rigorous application of the aseptic technique. Hyperventilation and photic stimulation also may induce true epileptic seizures, but their clinical features usually are distinctive Findings on the interictal EEG in patients with pseudoseizures are normal and remain normal during the clinical episode, demonstrating no evidence of a cerebral dysrhythmia.

With the introduction of long-term ambulatory EEG monitoring, correlating the episodic behavior of a patient with the EEG tracing is possible, and psychogenic seizures are distinguishable from true epileptic seizures plasma prolactin concentrations may provide additional supportive data. Plasma prolactin concentrations frequently are elevated after tonic-clonic seizures, peaking in 15 to 20 minutes, and less frequently after complex partial seizures.

Serum prolactin levels almost invariably are normal after psychogenic seizures, although such a finding does not exclude the diagnosis of true epileptic seizures EEG-video monitoring is the most reliable procedure which remains the standard diagnostic method for distinguishing between epileptic and psychogenic seizures. Cognitive symptoms are common among patients with functional neurological symptoms. They may be attributable to fatigue, anxiety, or low. In someone who is usually not absentminded, forgetting why they went upstairs, losing their keys, or losing track of conversation may be interpreted as abnormal.

The patient reports variability in their memory problems and episodes when they forgot familiar information such as their own address and then remembered it again Word-finding difficulty is a common symptom among patients with other functional neurological symptoms.

These are very simple tests that even patients with severe dementia or head injury should be able to perform well. For example, the coin-in-the-hand test involves 10 trials of showing a patient which hand a coin is held in, asking them to close their eyes for 10 seconds and then choose the hand with the coin. Therefore, an abnormal VEP is not always diagnostic of an organic visual disturbance Double vision.

Binocular diplopia is usually due to convergence spasm asymmetrical overactivity of the normal convergence response This can be demonstrated by testing convergence movements but holding the finger at a close distance for longer than usual. When persistent, convergence spasm can resemble a sixth nerve palsy Monocular diplopia is usually functional but can be due to ocular pathology Triplopia is surprisingly usually related to an organic eye movement abnormality but can be functional.

Functional dysarthria usually takes the form of intermittent slurred speech or stuttering speech with difficulty starting words. Speech may be slow and with hesitations noticeably occurring in the middle of sentences Dysphonia Functional dysphonia is a common presenting symptom to otolaryngologists but may be seen by neurologists in combination with other functional symptoms.

There is controversy regarding how often this symptom can be explained by gastroesophageal reflux disease and appropriate levels of investigation. Clues to functional weakness include the following: 1. Improvement in strength with coaching 2.

UCSD's Practical Guide to Clinical Medicine

Inconsistencies in examination—for example, inability to extend the foot but able to walk on toes 3. Hoover sign 4. Paralysis in the absence of other signs of motor system dysfunction, including tone and reflex changes 5. Pattern of weakness: In functional weakness, the limb is usually globally weak or often demonstrates the inverse of pyramidal weakness, with the flexors weaker in the arms and the extensors weaker in the legs 6.

Hip abductor sign. This is a pattern of weakness in which the patient transiently has normal power but then the limb gives way Weakness as a functional symptom is more common in females and typically presents in the mid-thirties Comorbidity with other functional symptoms, especially fatigue and pain, is almost invariable The most common presentation is unilateral weakness with no good evidence for left-sided or nondominant preponderance, followed by monoparesis and paraparesis.

In the acute presentation, there are often symptoms of a panic attack, dissociative seizure, or an immediate trigger such as a physical injury, acute pain, migraine, a general anesthetic, or an episode of sleep paralysis When the onset is more gradual, there is typically a history of fatigue, pain, or immobility on which the weakness becomes superimposed gradually over time.

Evidence-based diagnosis in primary care : a practical approach to common problems Evidence-based diagnosis in primary care : a practical approach to common problems
Evidence-based diagnosis in primary care : a practical approach to common problems Evidence-based diagnosis in primary care : a practical approach to common problems
Evidence-based diagnosis in primary care : a practical approach to common problems Evidence-based diagnosis in primary care : a practical approach to common problems
Evidence-based diagnosis in primary care : a practical approach to common problems Evidence-based diagnosis in primary care : a practical approach to common problems
Evidence-based diagnosis in primary care : a practical approach to common problems Evidence-based diagnosis in primary care : a practical approach to common problems
Evidence-based diagnosis in primary care : a practical approach to common problems Evidence-based diagnosis in primary care : a practical approach to common problems
Evidence-based diagnosis in primary care : a practical approach to common problems Evidence-based diagnosis in primary care : a practical approach to common problems
Evidence-based diagnosis in primary care : a practical approach to common problems Evidence-based diagnosis in primary care : a practical approach to common problems
Evidence-based diagnosis in primary care : a practical approach to common problems

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