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Patients who are receiving treatment under the auspices of third-party payers 20mg vasodilan with mastercard, the crim- inal justice system order vasodilan 20 mg amex, or as part of occupational health must be educated about the dual roles of the providers involved and the restrictions on confidentiality [67 buy generic vasodilan 20 mg line, 75] discount vasodilan 20mg fast delivery. Clinicians may be faced with difficult decisions such as whether to report drug diversion or prescription forgery to the authorities. Family members may be allies in the patient’s treatment and yet physicians cannot speak to them without the patient’s explicit permission except in emergency situations. They must be careful to protect both the family member and the patient if they choose to act on the information. Suicidal and homicidal impulses, child abuse, domes- tic violence, and driving under the influence are not uncommon in chronic pain and SUD and physicians must inform themselves and patients of the legal and ethical mandates allowing breaches of confidentiality and privacy in such cases [76, 77]. The ethic of autonomy and respect for persons are operationalized in the doctrine of informed consent. Informed consent encompasses the capacity to understand the risks, benefits, and alternatives of a treatment, to communicate a choice regarding therapy, to deliberate and reason about the consequences of the proposed medication, and to appreciate how the treatment will affect life and values. Finally decisions must be made in the absence of strong internal or external coercion. Informed consent is the premise behind the widely used opioid contract which is a valuable aid in maintaining patients with a history or current problem with chemical dependency in chronic pain treatment. The degree to which addiction is voluntary is a very old debate recently revived. Evidence from basic science studies of the pathophysiology and pharmacology of both chronic pain and addiction, and from neuroimaging and molecular genetics suggests that both the cognitive and volitional capacities required for informed consent are diminished in patients with addiction and chronic pain to varying degrees. The behavioral phenomena that characterize SUD, To Help and Not to Harm 163 compulsion, obsession, loss of control, craving, and the continuation of sub- stance use despite negative, medical, psychological, and social consequences are understood from this perspective as symptoms of a brain disease [57, 80]. The neuropsychiatric correlates of these behaviors, neuroadaptation and sensi- tization, appear to diminish the authentic freedom and decisional capacity of the addicted individual as they pertain to informed consent. It is widely recognized that stress, sleep deprivation, anxiety, trauma, and depression or other psychological factors that often accompany pain and SUD may both lower the pain threshold and diminish decisional capacity and autonomy [1, 82]. The practical implication of these theoretical findings is that patients with a history of substance abuse or an active problem may enter into opioid con- tracts with good intentions but diminished capacity for informed consent. If aware of these limitations in the patient’s voluntarism, physicians can provide additional safeguards to protect the patient against relapse or development of addiction such as involving partners and family in treatment, dispensing only small amounts of medication, early and consistent collaboration with substance abuse experts, and most importantly establishing an open and trusting relation- ship in which patients feel safe expressing cravings, lapses, and temptations. Regarding minor infractions of the opioid contract as slips expected in a chronic and relapsing disease rather than intentional undermining of treatment allows both physician and patient to arrive at more constructive solutions. Physicians must also be vigilant about diagnosing and treating the common psychiatric conditions associated with chronic pain that can further reduce deci- sional capacity such as depression, anxiety and psychosis. A Harm Reduction Approach Physicians involved in the care of patients with active or historical SUD and chronic pain are confronted with a number of ethical dilemmas. The fol- lowing recommendations constitute a harm reduction approach to the care of patients with addiction and chronic pain. Harm reduction is a philosophy and a practice utilized in some segments of the addiction medicine community. It offers a means of managing many of the dilemmas patients with chronic pain and addiction present [86, 87]. None of these have been subjected to controlled clinical trials and can substitute for the casuistry of the independent clinical judgment. Notwithstanding their limita- tions, failure to explore, document and address these risk factors would not meet the standard of care for treating chronic pain patients with addiction [88, 89]. Warning signs [adapted from 88] Mild misuse Increasing dose without permission occasionally1 Occasional loss of prescription Preference for a specific pain formulation Moderate misuse Use of the drug to treat symptoms other than chronic pain2 Use of alcohol or other illicit drugs2 Stockpiling drug1 Occasional request for early refill without purported loss of medication1 Purchasing drugs on the street once or twice1, 2 Seeking prescriptions from other providers or the emergency room infrequently but informing primary clinician1 Complaints of adverse effects with any but preferred pain medication Seeking the psychoactive rather than analgesic effects of medication2 Nonadherence to psychosocial dimensions of pain program Inordinate amount of time and energy spent in assuring adequate supply and dosage of pain medication1 Decline in functioning from pretreatment baseline Severe misuses Injecting oral formulations Stealing drugs Forging prescriptions Continual escalation of dosage Diversion of medications Consistent pattern of purchasing drugs on the street Seeking prescriptions from other providers or the emergency room frequently Either hiding behavior or lying to primary clinician about sources and frequency of obtaining medications from other sources Refusal to participate in any psychosocial aspects of pain program Refusing addiction treatment Dysfunctional behavior or gross decline in functioning in multiple spheres of life 1 Behaviors that may also be associated with pseudoaddiction. Researchers disagree on the classification, significance and gravity of the var- ious factors, particularly those on the less pathological end of the spectrum. Table 3 lists some of the most common factors according to whether they rep- resent mild, moderate or severe misuse of controlled substances. Mild misuse is an occasional patient-initiated adjustment in prescribed regimen; moderate misuse is a more frequent and severe misuse of prescriptions contrary to the physician’s intentions and instructions; pathological use involves exploitation of the physician and often criminal behavior. The frequency, To Help and Not to Harm 165 contextual features, intentionality of the patient, and severity of the factors must all be considered when formulating an appropriate therapeutic response to problematic behavior.
Other neurologists may have mostly elderly patients with Alzheimer’s and Parkinson’s discount vasodilan 20 mg without prescription. While this is considerably less than what neurosurgeons earn vasodilan 20mg with mastercard, liability insurance premiums are much lower for neurologists since their work is less invasive generic 20 mg vasodilan free shipping. In 2002 there were 1 generic 20mg vasodilan visa,291 residents in 119 accredited training programs for neurologists. Pathology The medical specialty of pathology deals with the causes, mani- festations, and diagnoses of diseases. One is in a hospital, investigating the effects of disease on the human body. These pathologists perform autopsies and examine tissues removed from patients in biopsies or surgical procedures. Now more than ever, pathologists can make significant contributions to medicine. Pathology is a laboratory-oriented discipline, and there is little patient contact. Pathology is diverse, since it spans all medical special- 78 Opportunities in Physician Careers ties. There is a need for manage- ment skills in pathology because some pathologists run large labs. Average salaries in this field range from $167,000 to $294,500 and liability insurance premiums are low. In 2002 there were 2,289 residents in 153 accredited programs in pathology. The American Board of Pathology offers certification in either anatomic or clinical pathology or both. Subspecialties of pathology include the following fields: Blood banking. A physician specializing in blood banking is responsible for the maintenance of an adequate blood supply, blood donor and patient-recipient safety, and appropriate blood utiliza- tion. The blood-banking specialist directs the preparation and safe use of specially prepared blood components, including red blood cells, white blood cells, platelets, and plasma constituents. This specialty deals with the biochem- istry of the body as it applies to the cause and progress of disease. This specialty includes the application of biochemical data to the detection, confirmation, or monitoring of a disease. The chemical pathologist often serves as a consultant in the diagnosis and treat- ment of disease. The dermopathologist often serves as a clini- cal consultant and must have in-depth knowledge of dermatology, microbiology, parasitology, new technology, and laboratory management. This specialty investigates cases of sudden, unexpected, suspicious, or violent death as well as other specific classes of death defined by law. The forensic pathologist Other Specialties 79 sometimes serves the public by becoming a coroner or medical examiner. This specialty deals with diseases that affect the bone marrow, blood cells, blood clotting mecha- nisms, and lymph nodes. This specialty is concerned with the sci- entific study of the causes, the diagnosis, and prognosis of disease using the application of immunological principles to the analysis of tissues, cells, and body fluids. The practitioner in medical microbi- ology isolates and identifies microbial agents that cause infectious diseases. He or she serves as a consultant to primary care physicians when they are dealing with patients with infectious diseases. This specialty deals with the diagnoses of diseases of the nervous system and muscles. Neuropathologists often serve as consultants to neurologists and neurosurgeons. Physical Medicine and Rehabilitation Physical medicine and rehabilitation, also called physiatry, deals with diagnosing, evaluating, and treating patients with impairments and disabilities that involve musculoskeletal, neurologic, cardio- vascular, and other body systems.
There is complete mixing of unoxygenated and oxygenated blood in the left side of the heart purchase 20 mg vasodilan mastercard, resulting in sys- temic desaturation and varying amounts of pul- monary obstruction discount vasodilan 20mg on line. A secondary complication is tricuspid regurgitation buy 20mg vasodilan with mastercard, which is associated with carcinoid syndrome generic vasodilan 20 mg overnight delivery, SLE, infective endocarditis, and in the presence of mitral valve disease. Formerly known as consumption, TB is an infectious, inflammatory systemic disease that affects the lungs and may disseminate to involve lymph nodes and other organs. It is caused by infection with Mycobacterium tuberculosis and is characterized by granulomas, caseous (resembling cheese) necrosis, and subsequent cavity formation. It is associated with mild to severe abdominal pain; chronic, severe diarrhea; bloody stools; mild to moderate anorexia; and mild to moderate joint pain. There are 5 categories of urinary incontinence: stress incontinence is the loss of urine during activ- ities that increase the intra-abdominal pressure, such as coughing, laughing, lifting; urge inconti- nence is the uncontrolled loss of urine that is pre- ceded by an unexpected, strong urge to void; mixed or total incontinence is a combination of stress and urge incontinence; overflow inconti- nence is the uncontrolled loss of urine when intrav- esicular pressure exceeds outlet resistance, usually the result of a obstruction (eg, tumor) or neurolog- ic symptoms; and functional incontinence, which is the functional inability to get to the bathroom or manage the clothing required to go to the bath- room. An example of urinary tract infection involving the upper urinary tract (ie, kidneys) is pyelonephritis (see pyelo- nephritis). Diseases, Pathologies, and Syndromes Defined 447 Elderly individuals have a higher risk for this due to inactivity or immobility, which causes impaired bladder emptying; bladder ischemia resulting from urine retention; urinary overflow obstruction from renal calculi and prostatic hyperplasia; senile vaginitis; constipation; and diminished bactericidal activity of prostatic secretions. UTI is a bacterial infection with a bacteria count of greater than 100,000 organisms per mL of urine. An occlusion of the vertebral artery lead- ing to a medial medullary infarction of the pyramid can result in contralateral hemiparesis of the arm and leg, sparing the face. If the medial lemniscus and the hypoglossal nerve fibers are involved, loss of joint position sense and ipsilateral tongue weak- ness can occur. The edema associated with cerebel- lar infarction can cause sudden respiratory arrest due to raised intracranial pressure in the posterior fossa. Gait unsteadiness, dizziness, nausea, and vomiting may be the only early symptoms. Lesions of the vestibular system can be broadly categorized into 5 anatomic sites: the vestibular end organ and vestibular nerve terminals, the vestibular ganglia and nerve within the internal auditory canal, the cerebellopontine angle, the brainstem and cerebellum, and the vestibular pro- jections to the cerebral cortex. The causes are varied and include bacterial infection, viral infection, vas- cular disease, neoplasia, trauma, metabolic disor- ders, and toxic drugs. Symptoms may be completely absent or may be those of pain due to pressure on spinal cord and nerves. Wallenberg’s syndrome: See posterior inferior cere- bellar artery syndrome. Weber’s syndrome: When a third cranial nerve palsy occurs with contralateral hemiplegia. Paralysis of oculomotor nerve on one side with contralateral spastic hemiplegia is referred to as Weber’s paralysis. Diseases, Pathologies, and Syndromes Defined 449 Wernicke’s aphasia: Infarct to a specific area of the brain that severely affects the person’s level of com- prehension. Williams syndrome: Syndrome caused by a genetic defect, characterized by cardiovascular problems, high blood calcium levels, mental retardation, developmental delays, and a “little pixie face” with puffy eyes and a turned-up nose. Wilms’ tumor: Wilms’ tumor is a nephroblastoma and is the most common malignant neoplasm in chil- dren. The tumor appears to be fleshy but may have areas of necrosis that lead to cavity formation. The most common presenting feature is a large abdom- inal mass and abdominal pain. Hematuria may occur, as well as hypertension, anorexia, nausea, and vomiting. Wilson’s disease: Also known as hepatolenticular degeneration, it is a progressive disease inherited as an autosomal recessive trait that produces a defect in the metabolism of copper, with accumulation of copper in the liver, brain, kidney, cornea, and other tissues. The disease is characterized by the pres- ence of Kayser-Fleischer rings around the iris of the eye (from copper deposition), cirrhosis of the liver, and degenerative changes in the brain, particularly the basal ganglia. Physical Medicine and Rehabilitation: Diagnostics, Therapeutics, and Basic Problems.
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