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Social: some alcohol use – “socially”; nonsmoker; denies drugs; sexually active; lives with husband; works in computer programming G generic 200 mg sustiva otc. Extremities: right knee swollen with palpable effusion; very tender to palpation and ranging; nonerythematous; patient unable to walk without extreme pain; hip and ankle both normal; distal pulses normal cheap sustiva 200 mg without prescription, equal bilaterally m safe 200mg sustiva. Patient’s pain is much improved after pain medication and arthrocentesis cheap sustiva 200mg otc, but is still present d. This is a case of septic arthritis involving the right knee; a bacterial infection that can cause severe damage to the joint if left undiagnosed and treated. The patient is otherwise healthy and clinically appears well, so an appropriate work-up for the right knee pain and fever can be done without the concern for starting early sepsis management. Her pain will persist until an appropriate dose of opioid, such as morphine, is given. A diagnostic arthrocentesis (joint aspiration) should be performed before all other studies (x-ray is allowable if done quickly, but should not hold up the arthro- centesis). Most patients with a monoarticular arthritis, even with a history of gout, require an arthrocentesis. Ceftriaxone should be given for gonorrheal infection, nafcillin or vancomycin for Staphylococcus infection. For gram-negative bacilli infection, treat with 3rd or 4th generation cephalo- sporin with antipseudomonal coverage. Patient appears stated age, awake and alert responding to questions but is pale, listless, and uncomfortable. Today, his mother noticed a rash on his hands and wrists that has been steadily spreading to the chest and back. Vomiting and diarrhea (nonbloody, nonbilious) have been intermittent 3 to 4 times each day; nonbloody, nonbilious. Travel history (if asked): last weekend went on camping trip with Boy Scouts, does not remember insect bite G. Eyes: pale conjunctivae, extraocular movement intact, pupils equal, reactive to light d. Abdomen: mild hepatosplenomegaly, nondistended, nontender, soft, no rebound/ guarding, no masses/hernias, no rigidity l. Extremities: full range of motion, no deformity, normal pulses, maculopapular rash over palms, soles, and extremities to the trunk o. Skin: warm and dry, maculopapular rash over complete extremities and front of chest, including palms and soles r. Chloramphenicol (provided risk of myelosupression is considered) 246 Case 57: rash b. Only about 50% of cases involve a history of tick bite, so it is often treated on the basis of a clinical suspicion and exposure history, in this case the recent history of camp- ing. Symptoms can involve multiple organs and can be serious, so a thorough 248 Case 57: rash Case 58: sickle-Cell Disease examination is necessary, including neurological, chest, lungs, and abdomen. Early actions in this case include fuid resuscitation and administration of anti- biotics. If fuids are not given, the patient will continue to have an elevated heart rate until fuids are given. Antibody titers and/or a skin biopsy are acceptable, but the results will not be available and do not affect the case. A chest and/or abdomen x-ray is also acceptable but again will not affect the case. Rash beginning on the palms and soles and spreading to the trunk is pathogno- monic for Rocky Mountain spotted fever. When any single tick-borne illness is encountered, consider the possibil- ity of coinfection with the others (including Lyme disease, ehrlichiosis, and babesiosis) P. Patient appears stated age, awake, and alert responding to questions but appears in severe pain and mildly tachypneic. Today he notes mild shortness of breath; denies diarrhea, vomiting, headache, or neck pain. If asked about previous episodes, the patient will explain that most painful crises are in the hips and legs and this is the frst visit for chest pain. General: alert, oriented × 3, in distress because of pain and mild shortness of breath b. Lungs: diminished breath sounds at left base, + crackles, dull to percussion, normal breath sounds right lung 250 Case 58: sickle-Cell Disease Figure 58. Extremities: no deformity, normal pulses, + pain to range of motion of left shoulder, right upper and bilateral lower extremities with full range of motion n. This is a case of acute chest syndrome in a sickle-cell patient, a condition of unclear etiology thought to be caused by infection or lack of oxygen supply to the lung tissue that can lead to respiratory failure and death. This is a more seri- ous diagnosis than the more common pain crises, and can lead to rapid dete- rioration of respiratory status. Symptoms that identify acute chest syndrome are chest pain, respiratory complaints, fever, or cough. Curveball: the nurse approaches the candidate and states, “This guy is here all the time, and complains about pain here or there until he gets his fx of narcot- ics. Rapid identifcation of painful crises that are not typical of the patient’s usual symptoms should elicit a search for more serious complications of sickle cell including acute chest, aplastic crisis, splenic sequestration, hemolytic crisis, serious infection, stroke, or other end-organ infarct. Patient appears stated age, somewhat lethargic, appears ill, responding slowly to questions. He did not want to come to the hospital, but his roommate insisted when he developed a fever and was “not very awake. Not the worse headache of life but signifcant pain, not sudden onset or thunderclap, no nausea, vomiting, blurry vision; + photophobia, + neck pain. Eyes: extraocular movement intact, pale conjunctivae, + photophobia, equal and reactive pupils, unable to visualize fundus d. Sent for Gram stain, culture, cell count, glucose, protein Case 59: Headache 255 Figure 59. This is a case of bacterial meningitis, a serious infection of the tissues surround- ing the brain and usually fatal if not treated promptly. Classic symptoms are headache, fever, neck stiffness, and a petechial or purpuric rash. If steroids are given, they should be administered Case 59: Headache Case 60: Chest Pain 257 before or with the antibiotic. The candidate should isolate the patient early in the course of the case and get in contact with college heath services regarding prophylaxis of students and staff for meningitis. Petechial/purpuric rash in the setting of headache and fever is suffcient to begin treatment. Kernig’s(contractionofhamstringsinresponsetokneeextension)orBrudzinski’s (fexion of hips/knees in response to neck fexion) signs are often unreliable but may aid in the diagnosis.

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The maxillary branch is sen- sory and innervates the upper eyelid before branching to supply the lower eyelid sustiva 200 mg cheap, palate buy sustiva 200mg, skin of the upper beak order sustiva 200 mg amex, nasal cavity and infraorbital sinus buy sustiva 200mg without a prescription. It innervates the muscles of mastication and the skin and the mucosa at the commissures of the beak. It is not involved in taste as in mammals, but supplies the hyoid and the cutaneous neck muscles. The lingual branch of the glosso- pharyngeal nerve receives sensory input from taste fibers. The pharyngeal branch has fibers that join with the vagus nerve to in- nervate the larynx and trachea. The esophageal branch courses along the neck with the jugular vein, supplying the esophagus. The former has a lingual branch that innervates the tongue muscles and a syringeal branch that courses to the syrinx and tracheal muscles. Spinal Nerves Because birds of different species have varying num- bers of vertebrae, spinal nerves are numbered by the vertebra caudal to it in numerical order regardless of whether it is cervical, thoracic, lumbar, sacral or coccygeal. The ram communicans lateralis and medialis connect the second to the third nerve roots and the fourth to the fifth roots (if pre- sent). The lumbar plexus is composed of three to four nerve roots (the last two lumbar and first sacral roots). The obturator nerve, femoral nerve, cranial gluteal nerve and saphenous nerve arise from this plexus. The ischiatic plexus or sacral plexus is usually made up of six sacral nerve roots, but occasionally four, five or seven roots. The roots combine to form the isch- iatic nerve, which is the largest nerve in body. This nerve should be faintly striated and a loss of stria- tions is suggestive of an inflamma- tory process. The examination should be kidney has been removed to show their relationship with the lumbar plexuses. Neuropa- thies are particularly common secon- ond through fourth roots give off rami musculares to dary to trauma, exposure to toxins innervate the neck muscles. Assessment of segmental There are three nerve plexuses in the lumbosacral reflexes may be difficult in avian patients, making region (lumbar, ischiatic and pudendal). These nerve evaluation of muscle tone, strength and atrophy an roots lie embedded in the foveae of the pelvis sur- essential part of the neurologic examination. A fundic examination may be performed feeding response, menace reflex, use of wings to bal- with the aid of d-tubocurarine. Its action on the avian ance, vocalization, perching ability, pain perception pupil may be to inhibit the iris constrictor muscles and hopping response. Any personality changes Cranial nerve V is responsible for facial sensation, reported by the owner should be noted. The bird’s movement of the mandible and blinking of the eye- ability to perform normal activities and its aware- lids. Diminished beak strength may indicate an ab- ness of its surroundings should be assessed. Abnor- a focal brain lesion (individual nerves involved) or a mal, spontaneous nystagmus may result from ves- generalized encephalopathy (several nerves in- tibular lesions. Bi- Reflexes are evaluated to help determine if a lesion lateral blindness without ocular lesions may indicate is central (upper motor neuron) or peripheral (lower neoplasm, abscess or granuloma formation in the motor neuron). Pain per- stances, the absence of a menace response does not ception in the wing requires intact peripheral nerves always indicate dysfunction of these cranial nerves. The signs of head, wing or leg dysfunction are indicative patellar reflex is difficult to assess in birds; however, of a lumbosacral spinal cord lesion. Because withdrawal of Conscious proprioception requires an intact periph- a stimulated extremity is a segmental reflex and eral and central nervous system. A lesion in either does not require an intact spinal cord for a normal will result in the bird knuckling over. The vent re- response, movement does not indicate the patient is sponse is a segmental reflex, and the sphincter able to feel the stimulus. Some type of conscious should be responsive to stimulation if a spinal cord recognition of the stimulus must be identified (eg, lesion is present and the nerve roots are not affected. A crossed extensor reflex generally indicates a lesion This part of the examination is generally reserved for in the spinal cord with a loss of normal central inhibi- last so that the painful stimulus does not influence tory pathways. With cervical spinal cord lesions, dysfunction of the wings, legs and cloaca may be observed while head function and cranial nerves appear normal (Figure 28. Weakness in the wings and legs with intact leg and wing withdrawal and vent response would be Diagnostic Techniques indicative of a cervical spinal cord lesion. Lesions affecting the thoracolumbar spinal cord will cause leg and cloacal dysfunction without affecting the head, cranial nerves or wings. Cloacal sphincter hyper- The results of the neurologic examination will sug- tonia, incontinence and soiling of the vent without gest which diagnostic tests should be performed. La- paroscopy and organ biopsy may be indicated to further define metabolic neuropathies. Serum for viral dis- eases or chlamydiosis, and blood lev- els for heavy metals are indicated in some cases. Radiographs are indi- cated if spinal trauma or heavy met- al intoxication is suspected. Elec- tromyograms, nerve conduction ve- locities, spinal evoked potentials and nerve or muscle biopsies are helpful in evaluating neuropathies. When avail- recumbent, and a deep pain response could not be elicited from either pelvic limb. Radiographs indicated a puncture wound through the lung (arrow) with an increased soft able, electrodiagnostic techniques tissue density (blood) in portions of the lung parenchyma. The bird was placed on are valuable in avian patients for broad-spectrum antibiotics and steroids. A deep pain response was noted five days after distinguishing between a neuropa- the initial injury, and the bird slowly improved with a complete return to normal function over a three-month period. A nerve stimulator is used to generate an M consists of insertion potentials, motor unit potentials response at two different locations along the course and spontaneous waves, which occur infrequently. The distance between the sites When the electrode is inserted into the muscle, the is divided by the latency difference in the two M intrafascicular nerve branches and muscle fibers are responses to determine the velocity with which the stimulated, creating a brief burst of electrical activ- impulse travels along the nerve (m/s). Where there is ity, which ceases immediately after the electrode a peripheral neuropathy such as demyelination, the stops moving. If the electrode is moved, insertional velocity is slow and the M responses are polyphasic activity will again be recorded.

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How- ever purchase sustiva 200 mg free shipping, a question remains: can pay-for-performance programmes improve health quality and reduce disparities? In fact order sustiva 200 mg otc, despite growing enthusiasm for such programmes in the policy and commercial sectors discount 200mg sustiva amex, the evidence to support their effectiveness is weak [45] discount 200 mg sustiva otc. Generally, studies show that modest improvement can be achieved in measures explicitly incentivised, at least over the short term [46]. However, it is unclear whether the improve- ments are a result of the ¿nancial incentives themselves or simply the increased focus on services resulting from performance measurement and publication data [47]. Another version of pay for performance is more correctly thought of as pay for par- ticipation. Instead of direct individual rewards for individual performance, providers are compensated for participation in larger collaborative activities designed to improve perfor- mance outcome. Providers receive regular feedback on their performance from peers and then work collaboratively to improve ef¿ciency and collective patient morbidity and mor- tality rates: a highly effective programme in interventional cardiology is currently in place, with resultant improvements in mortality and postprocedure complication rates [48]. For surgical procedures, pay for performance presents unique challenges, as surgical outcomes are often more dif¿cult to quantify and compare fairly. In response, a model based on Centres for Excellence has been developed at locations throughout the United States. The model involves identifying and funnelling patients towards hospitals and pro- viders with proven track records of high-quality care. Financial in- centives are most likely to be the most effective means of inÀuencing professional behav- iour when performance-target rewards are aligned to the values of the staff being rewarded [51, 52]. Professional motivation alone may not be suf¿cient to improve quality of patient care, especially when physicians have to make ¿nancial investment in their practices – for example, by employing more staff to achieve gains in quality. Sustained improvement in quality of care – which involves a range of health care providers (e. Ultimately, the most important question is wheth- er pay for performance is actually effective in improving quality and/or ef¿ciency. A more recent analysis of various pay-for-performance plans found mixed results, with no consistent improvement in quality in all plans [55]. Some fundamental problems included the fact that many of these programmes seemed to permit adverse selection by allowing providers or hospitals to exclude the sickest patients. The remaining patients only appeared to have improvements in quality; in reality, many improvements were simply due to improved documentation. Much depends on the details of the plan, as all pay-for-performance plans present structural questions that must be correctly addressed prior to implementation. Several questions remain unsolved: should bene¿ts be given to individual physicians or to organisations that will then distribute the bene¿ts collectively? Who should be rewarded for performance: all high performers or only the top performers [56]? To date, there are no decisive answers as to whether pay-for-performance programmes work de¿nitively respecting professionalism recommendations; the linking of physician reimbursement to measures of clinical performance is growing in popularity among pay- ers, including local health authorities and manager, including national and federal govern- ments. Although a body of literature is developing on the anticipated positive results of such programmes – and we applaud innovations that improve care – little evidence exists on the effectiveness of such programmes [57–59]. Pay for performance focuses attention on ethical conÀicts because it rewards good quality care by improving the physician’s in- come, but conÀict of interest exists with non¿nancial incentives to improve quality – only the incentives differ. Similarly, ¿nancial conÀicts exist in every payment system, such as incentives in fee-for-service payment to increase care or the incentive under capitation to do less rather than more. In all of these conÀict-of-interest situations, the ethical impera- tive is the same: clinicians must ensure that provision of medically appropriate levels of care take precedence over personal considerations [60, 61]. According to Snyder and Neu- bauer, pay for performance programmes and other strong incentives can increase the qual- ity of care if they purposely promote the ethical obligation of the physician to deliver the best-quality care for their patients [59]. Proposed methods for assuring quality processes 30 Professionalism, Quality of Care and Pay-for-Performance Services 359 Table 30. Lagasse and Johnstone – in a thoughtful review – de¿ne pay for performance, or value purchasing, as “the use of incentives to encourage and reinforce the delivery of evidence- based practice and health care systems’ transformation that promotes better outcomes as ef¿ciently possible” [61]. This de¿nition provides some insight into the current status of pay for performance by describing its driving force more clearly than it does any particular incentives. In other words, the driving forces pay for performance are quality improvement and cost reduction. Gullo A (2005) Professionalism, ethics and curricula for the renewal of the health system. Gullo A, Santonocito C, Astuto M (2010) Professionalism as a pendulum to pay for performance in the changing world. World Health Organization (2000) World health report 2000 – Health systems: improving performance. Regional overview of social health insurance in south-east Asia, World Health Organization and overview of health care ¿nancing (2006) Retrieved August 18. Kohn L, Corrigan J, Donaldson M, eds (2000) To Err Is Human: Building a Safer Health System. Commonwealth Fund International survey (2005) Taking the pulse of health care systems. New Zealand Ministry of Health (2001) Adverse events in New Zealand public hospital: principal ¿ndings from a national survey. World Health As- 30 Professionalism, Quality of Care and Pay-for-Performance Services 361 sembly. Agency for Healthcare research and Quality: The National Guidelines Clearing- house http://www. Fiorentini G, Iezzi E, Lippi Bruni M et al (2010) Incentives in primary care and their impact on potentially avoidable hospital admissions. Grumback K, Osmond D, Vranizan K et al (1998) Primary care physicians experi- ences of ¿nancial incentives in managed-care systems. Coleman K, Hamblin R (2007) Can pay-for-performance improve quality and re- 362 A. Spooner A, Chapple A, Roland M (2001) What makes British general practitioners take part in a quality improvement scheme? Campbell A, Steiner A, Robinson J et al (2005) Do personal medical services con- tracts improve quality of care? Peterson L, Woodard L et al (2006) Does pay-for-performance improve the quality of health care? Snyder L, Neubauer R, for the American College of Physicians Ethics, Profession- alism and Human Rights Committee (2007) Pay for performance principles that promote patient-centered care: an ethics manifesto. Ethics in practice: managed care and the changing health care environment medicine as a profession managed care ethics working group statement. American College of Physicians (2007) Linking physicians payment to quality of care. American College of Physicians (2007) The use of performance measurements to improve physician quality of care. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication.

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