Cause Of Consultation Research Articles

Estado actual de las especialidades médicas en Chile: realidad en el sistema público no municipalizado

To adequately plan the post graduate training of physicians, we need to know the needs for specialists in the country and the most prevalent diseases and causes of consultations. In 2004, the National System of Health Services assessed the number of hours and types of specialties available, their regional distribution and calculated an approximate number of physicians in charge of those specialties, determining an equivalent per 44 weekly hours of physician. This number of hours is the maximum that a physician is allowed to work per week. Fifty six percent of specialists correspond to basic specialties (3,688 physicians equivalent to 44 hours, 33% to primary specialties (2,205 physicians) and 10% to subspecialties (666 physicians). The regional distribution of basic specialties is proportional to the population of each region. However, there are gaps in the distribution of primary specialties and subspecialties. The demand for specialists, assessed measuring the yield in minutes of each hired hour, determined that 54% of specialist hours are dedicated to the new health program that guarantees the access to certain specialties in a predefined lapse, to all beneficiaries (AUGE). Moreover the demand for attentions to cover this health system has a gap of 30% in hours or 800 specialists. This motivated the creation of new posts for specialties during 2005 and 2006, equivalent to 250 physicians hired for 44 hours per week.

Depressão na Atenção Primária à Saúde

Dos pacientes assistidos em ambulatórios gerais, 10% a 25% são portadores depressão1, representando a segunda causa de consulta, ainda que freqüentemente ignorada ou subdiagnosticada. Médicos generalistas, e não psiquiatras, tratam a maioria dos pacientes com sintomas depressivos2. A depressão ocupa o segundo lugar entre as doenças mais incapacitantes nos países ocidentais3. Na maioria dos países em desenvolvimento, a deficiência na saúde mental é ainda inaceitável, sendo meta da OMS aprimorar o diagnóstico e o tratamento da depressão em ambulatórios gerais em todo o mundo. Várias estratégias comprovam ser custo-efetivas, sendo as principais: educação médica continuada, maior participação da enfermagem e melhor integração entre atenção primária e secundária (especialista psiquiatra)4. Para depressão leve a moderada, estudos de meta-análise mostraram que há pouca diferença de efetividade entre as modalidades terapêuticas e entre antidepressivos, sendo a continuação da terapia o mais importante fator de escolha. Os melhores resultados são obtidos quando há aliança terapêutica entre o profissional de saúde e o paciente e um tratamento adequado é mantido por período suficiente5. Este estudo vem discorrer sobre a importância, diagnóstico e tratamento da depressão na atenção primária e propor estratégias para implementar uma rede efetiva de atendimento, articulada com a atenção secundária.

Tumor del cuerpo carotídeo: A propósito de 10 casos tratados

Carotid body tumors arise from a cellular conglomerate located at the carotid bifurcation. Progressive enlargement can involve the arterial wall and neighbor cranial nerves.To report a series of 10 patients treated of carotid body tumors and review national experience.Between 1984 and 2006, we operated 8 women and 2 men, aged 19 to 75 years, with this type of tumor.The most common cause for consultation was a cervical mass in 90%, with a mean evolution lapse of 13.2 months (range 3 to 126). In all cases, diagnosis was confirmed with angiographic imaging and histopathology. Ten tumors were surgically removed with no complications. Eighty percent of tumors were in stage II according to Shamblin classification. During long term follow up all patients have remained asymptomatic. Only 31 carotid body tumors have been reported in Chilean medical literature during a 43 year period.Paragangliomas of the carotid body can be diagnosed in clinical grounds, requiring vascular imaging. These infrequent lesions are generally benign, early surgical removal by surgeons with vascular expertise avoids neurological and or vascular complications.

Tratamiento de la crisis asmática en pediatría

Despite the significant advances that have been produced in the management of asthma in the last few decades, crises, attacks, or asthma exacerbations (acute asthma) continue to be the most common cause of consultation in pediatric emergency units. Visits to these units and hospital admissions due to acute asthma represent three quarters of the direct costs due to this disease. Acute asthma is a medical emergency that should be rapidly diagnosed and treated. Evaluation of children with acute asthma exacerbations should consist of two phases: a static phase (determination of the severity of the crisis on admission) and a dynamic phase (treatment response). The present article provides an in-depth review and analysis of current pharmacological and nonpharmacological treatments (oxygen, bronchodilators, corticosteroids - inhaled and systemic - aminophylline, magnesium sulfate, etc.) of acute asthma exacerbations and proposes management protocols for use in both primary care and emergency units.

Enigmas y confusiones en el diagnóstico y tratamiento de la plagiocefalia posicional. Protocolo asistencial

Positional plagiocephaly is currently the most frequent cause of consultation at pediatric neurosurgical departments in Spain and other western countries. There is considerable confusion in the literature on the terminology and physiopathology of this deformity, as well as its differential diagnosis with true synostosis and treatment recommendations. To clarify these concepts and present a protocol for the management of positional plagiocephaly, which was recently requested by the Health Administration of the Community of Madrid. The protocol aims to achieve coordination among pediatricians and neurosurgeons, as well as to provide precise information on this deformity for parents, pediatricians and neurosurgeons. Previous consensus was reached on a series of data. Infants were classified into three categories of deformity (mild, moderate, severe) according to measurements on digital photographs. Diagnosis and treatment follows two phases: a pediatric phase (up to 5 months of age) and a neurosurgical phase (from 5 months onwards). Infants are referred to neurosurgical consultation only after being treated with postural changes and physiotherapy and only after reaching the age of 5 months. The reasons for this approach are explained in the protocol, which also defines the functions and responsibilities of each specialty. The treatment proposed in the protocol is staged, starting with postural changes and physiotherapy, followed by orthotic cranial devices and finally surgical treatment.

Características clínico-epidemiológicas de la neumonía adquirida en la comunidad en niños menores de 6 años

Acute respiratory infections are an important cause of consultations in primary care and hospitals. Most published epidemiological studies have analyzed pneumonia in hospitals and very few include information on primary care. We performed a multicenter, prospective, epidemiological study in 17 primary care centers and four hospital pediatric emergency rooms. All children under 6 years of age with a clinical diagnosis of pneumonia were included. There were 311 patients with a mean age of 32.2 months. The incidence of community-acquired pneumonia was 3,600 cases/100,000 children/year under 6 years old in primary care centers. Of these, 136 were diagnosed in hospitals (43.7 %). The most common clinical signs and symptoms were fever (95.4 %), cough (94.4 %), tachypnea (58.2 %), and auscultation abnormalities (90.2 %). Antibiotic therapy was started in 298 patients (98 %). The most frequent antibiotic was amoxicillin-clavulanate (39.5 %), followed by cefuroxime (32.7 %) and clarithromycin (8.3 %). The most frequently isolated microorganism was respiratory syncytial virus followed by Streptococcus pneumoniae. Hospital admission was required in 15.6 % of patients. Only 24.6 % of the patients had been vaccinated with the heptavalent pneumococcal conjugate vaccine and 12.7 % of the children with underlying respiratory diseases had been vaccinated with the influenza virus vaccine. In our milieu, the diagnosis and treatment of community-acquired pneumonia is usually carried out in primary care and the incidence is high. Although most patients do not require hospitalization, etiological diagnosis of community-acquired pneumonia and optimal antibiotic therapy remain difficult goals to achieve.

Astrocitoma de vías ópticas: una causa infrecuente de retraso ponderal en el lactante

Failure to thrive is a frequent cause of consultation in pediatric services. The main objective in these patients is the early detection of an organic cause, if present. We report a case of low-grade astrocytoma of the optic pathway in a 2-month-old child whose main symptoms at diagnosis were failure to thrive and anorexia. Unfortunately, despite therapeutic efforts, the tumor showed local and metastatic progression refractory to chemotherapy. The patient died 3 months after diagnosis. We conclude that diencephalic tumors must be considered in the differential diagnosis of failure to thrive during the first year of life, especially when, after initial investigations, a cause is not found.

Consejería a adolescentes: descripción epidemiológica y motivos de consulta

Teenager counseling to recognize risks and reinforce strengths is carried out in a primary care outpatient clinic since 2003. To describe the epidemiology and causes for consultation in this teenage counseling program. Retrospective review of the records of 116 teenagers (median age 13 years, 67% females) that received teenager counseling. Seventy percent of women and 50% of men came from nuclear families. More than two thirds were primogenital. Most adolescents were accompanied by their mother, that were the main adult raw model. Fifty percent had dysfunctional families. All were attending school regularly and 21% of women and 29% of men had repeated a school level. Sixty eight percent of women and 62% of men declared to have a life project. Twenty percent were worried about their physical appearance. Seventy seven percent of women and 62% of men considered themselves as happy. Thirty six percent of women and 14% of men smoked. The figures for alcohol consumption were 21% and 14%, respectively. The causes for consultation were obesity, overweight, unspecific symptoms, behavioral problems, bad school achievement, communication problems or pregnancy. Reasons for counseling were family dysfunction, low self esteem, bad school achievement and information about sexuality. The information obtained could help to improve the interdisciplinary work and to coordinate counseling with the family and schools.

Malformaciones gastrointestinales: causa de dolor torácico

Chest pain is an uncommon cause of consultation in childhood and is even less frequent if resulting from digestive causes. We present the cases of two patients with gastrointestinal tract malformations (diverticulum and esophageal duplication cyst) diagnosed after investigation of chest pain. A potential etiology of diverticulum could be a traction effect caused by fibrous adenopathy of tuberculous primary infection. Duplication cysts are inborn defects. Although these malformations are uncommon, clinicians should take them into account in patients with chest pain.

Dietetic fiber in 22 children from the Hospital Infantil Club Noel of Cali, Colombia.

Introduction: Functional chronic constipation is an important cause of consultation in pediatric gastroenterology. The role of the dietetic fiber in children is controversial as a cause of the constipation. Objective: To report the dietetic fiber consumption in 22 children of the Hospital Infantil Club Noel (HICN) of Cali. Report of cases: Were included 22 children (3-13 years), both gender, from the HICN of Cali with digestive diagnoses for the first time. A medical clinical history was made, and one interviews nutritional by reminder of 24 hours. Acute undernourishment was defined when the deficit for weight/height (W/H) was >10% and overweight when the excess for W/H was >10%. The chemical analysis of the dietetic fiber was made following the Content of Dietetic Fiber and Resistant Starch in Foods and Latin American Products of the CYTED. The patients were divided according to gender, intestinal habit, signs and symptoms; in children with constipation (n=9) and without constipation (n=13) (p=0.865, 95% IC -6.71 to 7.91). Conclusion: The 22 children of the HICN of Cali, independent of the constipation presence, consume 12.8±7.8 grams of dietetic fiber to the day, an amount that is the recommended one by almost all of the consulted studies.

CONSULTATION PATTERNS IN FUNCTIONAL ABDOMINAL PAIN

Background: Functional abdominal pain (AP) is a common cause of consultation in children. Adult and pediatric studies have shown a higher prevalence of irritable bowel syndrome in females. There are no studies on consulting behavior for AP in South American children. Aims: To analyze the pattern of AP consultations in children in Uruguay. Methods: An observational study of outpatient consultations. We reviewed all records of house call visits of the largest institution in Uruguay exclusively providing outpatient care. Study period: 2002-2005. Sample size: 21,145 children (girls 49%), 4-14 years old, 7.2 % of age appropriate children of Montevideo (largest city). Statistical analysis: Two tailed chi-square test to determine significance. Age and gender difference calculations were related to number of subjects in each category. Results: 125,945 house calls (girls 46%). There was a significant predominance of boys in GI and girls in AP consultations. GI consultations: 18,103: girls 8,973, boys 9,130 (P < 0.05). AP consultations: 4,760 (26%) girls 2,501, boys 2,259 (P < 0.01). In children group 4-8 there was a significant predominance of GI consultations in boys (girls 3,899, boys 5,460) P < 0.001, but no difference in AP consultations: girls 1,247, boys 1,215 (P < 1). In children 9-14, there was a significant predominance of AP consultations in girls (girls 1,254, boys 1,044) P < 0.001. An analysis by age group revealed a peak rate of consultations for AP in patients 7-9 years of age. The pattern of consultation for AP reveals a female predominance in older children similar to what is found in adults. No gender predominance was found in younger children. Peak age for consultation was 7-9 years. Age-related hormonal or behavioral changes could explain our findings. Conclusions: There is a higher rate of consultation for AP in females particularly in children older than 9 years in South American children.

Priapismo: diagnóstico y tratamiento

Priapism, prolonged and painful erection, is an exceptional cause of consultation in the pediatric population. High- and low-flow priapism and recurrent prolonged erection must be differentiated, as the prognosis and treatment of these entities differ. Assessment of patients with priapism begins with a detailed history, physical examination, and complete blood cell count. The definitive diagnosis is given by penile Doppler ultrasonography, corpora cavernosa blood gas analysis, and pelvic arteriography. We present two patients who attended our emergency service in the last year and propose an algorithm for the diagnosis and treatment of this entity.

Talla baja idiopática: definición y tratamiento

Short stature is the leading cause of consultation in Pediatric Endocrinology. Decreased growth velocity and abnormally short height are characteristic of several different nosologic entities. Some are well characterized, while others correspond to what is known as idiopathic short stature (ISS). ISS includes children who grow less than 2 SD of the mean height values corresponding to their peers of similar age and the same sex, in whom the known causes of short stature have been ruled out. The diagnosis of ISS does not include children who only present a constitutional delay in growth and development. Several clinical trials have demonstrated the efficacy of growth hormone (rhGH) treatment in achieving catch-up growth in these children. Therefore, ISS should be kept in mind in the diagnosis of patients with short stature and abnormal growth patterns, who may benefit from rhGH treatment.

Proyecto de acción interdisciplinaria en salud (PAIS): un modelo de atención centrado en el hogar hace la diferencia

To propose an interdisciplinary approach in Community Health through a model based on Home Health Care. A prospective study programmed in two periods: a cross sectional study for data collection followed by home assistance for the health problems detected. 100 families (570 inhabitants) were randomly submitted to a clinical, nutritional and laboratory examination in order to detect major health problems. Afterwards the same professional team took care of 10 families in health promotion counseling and illness treatment. This study shows that 84% of the patients in whom a health abnormality was detected were not aware of their illness. The population was mainly affected by hypertension, hypercholesterolemia, hypertrigliceridemia, and anemia. None of these problems were listed as the main causes of consultation in a local center belonging to the traditional health services. Almost 70% of the inhabitants consumed a daily diet with less nutrients and calories than recommended. The project included health care for all family members and free drugs provision for all illnesses detected. Ninety-eight percent of patients had a proper and continuous follow up of their illness for a 3 year period, compared with a 31% follow up provided by the traditional health care organization. This work shows an integrated effort by the University, health centers, and all health care disciplines to propose an alternative program that personalizes attention and moves health care from Institutions to people's own homes. This model improved community health conditions, had a high impact on illness follow up and increased health care accessibility.

Illnesses in Travelers Returning from the Tropics: A Prospective Study of 622 Patients

Although between 8 and 19% of travelers consult a doctor after returning from the tropics, the full spectrum of health complaints is unknown. We analyzed the relative frequency of travel-associated health complaints in all travelers (immigrants returning from visiting their home countries, expatriates, business travelers, and tourists) consulting our department between November 2002 and May 2003. A total of 622 patients were studied (256 women, 366 men; median age 38 yr; 45.3% tourists, 33.8% immigrants, 14.1% expatriates, 6.7% business travelers). The median duration of travel was 36.9 days. The main destinations were Africa (57.6%) and Asia (26.4%). A total of 637 diseases were diagnosed, distributed as follows: skin diseases (23.4%), gastrointestinal infections (19.1%), respiratory tract infections (11.5%), malaria (8.8%), schistosomiasis (7.2%), viral hepatitis (4.1%), urinary tract infections (3.5%), sexually transmitted infections (3.5%), tuberculosis (2.7%), dengue fever (2.5%), and others (13.8%). Malaria and intestinal tract infections accounted for 21% and 23% of diagnoses in the 257 febrile travelers, respectively. Overall, 230 diagnoses (36.1%) corresponded to imported tropical diseases, the main imported diseases being malaria, schistosomiasis, amebiasis, gastrointestinal disorders caused by intestinal nematodes, and dengue fever. Tropical diseases are not the leading cause of consultation in travelers returning from the tropics. Immigrants are the travelers most at risk of common tropical diseases, with the noteworthy exceptions of dengue fever and invasive schistosomiasis.

Medical Conditions Affecting Well-Accommodated Travelers in Lebanon

There are no data on the prevalence of common diseases affecting travelers to Lebanon. Between 2001 and 2002, one among nine physicians was consulted on guests who needed medical attention in a five-star Beirut hotel. Physicians were consulted 114 times. The mean age of the patients was 36.6 years. Gastroenteritis (50.9%) followed by respiratory problems (25.4%) were the leading causes for consultation.

Allergies: Our Reality

RATIONALE: Epidemiological study in a rural medical office, located in the humid tropics, October 2003 to September 2004.METHODS: A retrospective study comprised of 471 patients; diagnosed with allergic disease, based on daily registry, their individual files, the guidelines of WAO, GINA, ARIA, the medical interview, the medical examination, and the clinical diagnosis. The frequency per month was compared against historical average weather data and viral prevalence data.RESULTS: During this study year, in our office, 17% of the total patients were observed with some Allergic Disease; the month of greatest incidence was September. The patients with Perennial Allergic Rhinitis prevailed: 46.92%, patients with Asthma: 43.5% and 23.37% suffer Asthma and Allergic Rhinitis (ADCA). The most common cause of consultation was the Exacerbations; followed by Bacterial Infections in the Upper Airway and Acute Viral Respiratory Infection. In our Series, 15% did not know they had Allergies; 98% came seeking medical attendance by exacerbations or co-morbidities. The weather played an important role; the relative humidity and precipitation increased the incidence of allergy exacerbations and co-morbidity, and viruses are linked with exacerbations and may increase cases of bacterial infection in the airway.CONCLUSIONS: Allergies are a major health problem in our tropical community; the patients do not have suitable information about their allergic diseases. RATIONALE: Epidemiological study in a rural medical office, located in the humid tropics, October 2003 to September 2004. METHODS: A retrospective study comprised of 471 patients; diagnosed with allergic disease, based on daily registry, their individual files, the guidelines of WAO, GINA, ARIA, the medical interview, the medical examination, and the clinical diagnosis. The frequency per month was compared against historical average weather data and viral prevalence data. RESULTS: During this study year, in our office, 17% of the total patients were observed with some Allergic Disease; the month of greatest incidence was September. The patients with Perennial Allergic Rhinitis prevailed: 46.92%, patients with Asthma: 43.5% and 23.37% suffer Asthma and Allergic Rhinitis (ADCA). The most common cause of consultation was the Exacerbations; followed by Bacterial Infections in the Upper Airway and Acute Viral Respiratory Infection. In our Series, 15% did not know they had Allergies; 98% came seeking medical attendance by exacerbations or co-morbidities. The weather played an important role; the relative humidity and precipitation increased the incidence of allergy exacerbations and co-morbidity, and viruses are linked with exacerbations and may increase cases of bacterial infection in the airway. CONCLUSIONS: Allergies are a major health problem in our tropical community; the patients do not have suitable information about their allergic diseases.

Atención farmacéutica en pacientes con nutrición enteral

To detect potential complications and interactions between drugs and enteral nutrition (EN) as to describe the interventions carried out by the pharmacist in those circumstances and to propose strategies of improvement. Prospective assessment of patients admitted to hospital candidates to receive EN. The pharmacist worked as part of the team of Endocrinology and Nutrition for one month. A data collection form was designed for the study in which the following information had to be recorded: NE indications, nutrition characteristics (type, route of administration, infusion rate), pharmacological therapy, drug/EN interaction and complications. The study included 14 patients (mean age of 50 +/- 13 years) in which digestive (35.7%) and neurological (28.6%) complications were the most frequent indications for EN. Eleven patients (78.57%) reported complications associated to EN, mostly digestive (57.14%). The main cause for consultation was related to the administration of drugs via NGT (nasogastric tube). A total of 77 drugs were prescribed, 23 of which were administered in this way, so a guidelines for the administration of drugs via nasogastric tube was prepared. The hospital pharmacist can actively cooperate with nutritional support units, given the need to assess the nutritional support administered and to manage potential complications and interactions between nutritional status, drugs and artificial nutrition. The pharmacist also plays a significant role in the prevention and identification of problems related to the administration of drugs via NGT.

An Audit of Inpatient Consultations to a Hematology Department over Two-Year Period.

Background:Inpatient consultation to hematologist increased in incidence and the role of hematologist as consultant continues to expand. But the resons for, frequency, and the result of inpatient hematologic consultation are largely unstudied. The aim of this study was investigation for the profiles of inpatients and their hematologic problems evaluated and managed by the hematology consultation of tertiary hospital.Methods:In this report, we evaluatded 354 consecutive patients with abnormal hematologic manifestation consulted for hematology department from March 2003 to Februery 2005. We prospectively recorded the demographics of the patients for whom consultation was requested, the reason of consultation, provisional diagnosis of the referring service, the final diagnosis and outcome of the patients in each case.Results:The consulted patients were 354 among 55,704 inpatients (0.6%). Approximately half the patients were female (54%). The median age was 55 years (range: 16–85) and the most frequent age group was the 6th decade. The median length of hospitalization was 26 days (range: 4–188) and the median interval from admission to initial consultation was 6 days (range: 1–76). In a third cases of consultations, the hematologic abnormalities were found newly after admission. The departments requesting consultation frequently were neurosurgery (24%), general surgery (11%), divisions of internal medicine (11%), orthopedic surgery (9%), and neurology (9%). The common causes of consultation were as follows: anemia (29%), thrombocytopenia (21%), pancytopenia/bicytopenia (16%), coagulation abnormality (15%) and thrombocytosis (7%). While anemia was the most common reason of consultations from medical services (internal medicine, neurology, psychology, rehabilitation medicine, etc), thrombocytopenia and coagulopathy were the frequent reasons of consultations from surgical services (general surgery, orthopedic surgery, plastic surgery, neurosurgery, etc.). The best part of anemia were IDA (43%) and anemia of chronic disease (33%). Drugs made up 38% of the cause of thrombocytopenia and the suspected drugs were anticonvulsants and antibiotics. A half of pan/bicytopenia were caused by drug-related or vitB12/folate deficiency. 40% of coagulopathy resulted from nonspecific or undefined cause. Bone marrow examination was required in 30 cases (8%). Careful evaluation of patients with hematologic problem sometimes revealed occult bleeding, liver disease or hematologic disease such as myelodysplastic syndrome, immune thrombocytopenic purpura or chronic myeloproliperative disorder. Almost physicians avoided making presumptive diagnoses and requested consultation for abnormal laboratory findings, leaving it to the hematologist to determine the cause.Conclusion:Although It provides a small cross-sectional findings of the types of patients and problems seen by hematologist during inpatient consultation, these informations may be helpful to provide optimal inpatients care for hematologist and to improve the quality of the consultation process by the referring service.

Syndromes coronariens aigus sans sus-décalage du segment ST en médecine d'urgence

Non ST segment elevation acute coronary syndromes (NSTE ACS) are a frequent cause of consultation in emergency departments, and hospitalisation in intensive care units. NSTE ACS are generally related to the rupture of an unstable atheromatous plaque located in a coronary artery and the development of a thrombus. The obstruction of the artery is usually incomplete. This broad pathophysiological context explains the great variability of both the clinical expression and the prognosis of NSTE ACS, and determines their treatment. The commonest initial presentation is a thoracic pain which has regressed at the time of consultation. Specific electrocardiographic signs are rare. Despite such relative benignity in the presentation, the risk of death or severe myocardial infarction is quite similar to that of patients with ST segment elevation ACS. Evaluating the level of risk for death and severe infarction in a patient is based on the rigorous collection of clinical and electrocardiographic signs and repeated measurement of troponin serum concentration. This stratification of the risk determines the management. For all patients, the treatment is based on aspirin, heparin or low molecular weight heparin, a beta-blocking agent and a statin. For patients at higher risk, particularly the diabetics and those with a measurable troponin, the treatment combines an anti GPIIb/IIIa agent and a coronarography aiming at a revascularisation. Secondary prevention begins together with the initial phase of management.