Volume 97, Issue 5

The diagnosis of stroke, which is diagnosis-related group (DRG) 014, is the fourth most frequent discharge DRG at Macomb Hospital Center, Warren, Michigan. The length of stay for stroke was 7.52 days before intervention. Quality improvement techniques identified areas of delay that presented opportunities for improvement. After the initiation of a critical pathway that begins its interventions in the Emergency Department, the length of stay decreased to 6.33 days. Quality of care was also improved in delivery time of carotid artery ultrasound examinations, as well as in timeliness of obtaining head computed tomography scans and reports. This article describes the development, implementation, and results of a stroke critical pathway that was implemented to address excessive length of stay.

With vertigo, the symptom of unsteadiness is a common presenting complaint and the etiology protean. However, the specific subset of this patient population with benign paroxysmal positional vertigo (BPPV) is more defined. Cupololithiasis and canalithiasis are perhaps the best known and best described pathologic conditions resulting in vertigo. This condition occurs when otoconia from the utricle are displaced into the Posterior semicircular canal-cupula. The abnormal position of the otoconia often results in a pathological condition. The location of displacement is most often in the posterior semicircular canal. A better understanding of the etiology of BPPV has led to a simple and effective particle repositioning maneuver that allows the practitioner to alleviate vertigo symptoms for most patients using a simple manipulation.

Childhood and adolescent depression is probably more common in the primary care setting than most physicians realize. Because depression can result in suicide, it must be differentially diagnosed from the more common complaints seen in pediatric and adolescent patients. The cause of depression is usually multifactorial and may include psychodynamic, cognitive, behavioral, life stress/socioenvironmental, biologiclbiochemical, and genetic components. Depending on the patient's age, depression can present as mood disturbances, and eating and sleeping disturbances, as well as somatic complaints. With no laboratory tests currently available to diagnose depression, physicians must rely on the history and physical examination as the best diagnostic tool. To aid family practitioners, the authors present criteria for diagnosing depression from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition along with treatment that includes psychotherapy and pharmacotherapy for the best possible outcome.

Review of current medical literature reveals little understanding of the physiology underlying the complex signs and symptoms that accompany reflex sympathetic dystrophy (RSD). The author surveyed the osteopathic medical literature and found a significant body of research documenting the physiology of somatic dysfunction. The manifestations of upper thoracic somatic dysfunction are strikingly similar to those of RSD and may offer insight into its heretofore unexplained physiology of this disorder.

A 7-year-old boy had a left-sided cerebrovascular accident 48 hours after beginning intranasal desmopressin acetate (DDAVP) therapy for persistent secondary nocturnal enuresis and approximately 2 weeks after varicella infection. A possible connection between desmopressin therapy or varicella infection (or both) and the patient's neurologic symptoms is discussed, as is the relationship of desmopressin with hypercoagulability. Suggestions for patient/parent education, medical history taking, and patient surveillance are offered to prescribing physicians.

Hydatidifonn mole is a gestational trophoblastic disease that arises from fetal rather than maternal tissue and can become metastatic. Most signs and symptoms occur late in the first trimester and are often confused with symptoms of a nonnal pregnancy and, thus, are often disregarded. The two most important diagnostic tools to detect this disease are the ultrasound and the quantitative f3-human chorionic gonadotropin assay. Treatment includes dilation and evacuation of the uterus and strict follow-up of quantitative f3-human chorionic gonadotropin levels. It is also important that the patient be placed on a reliable form of birth control during her follow-up period.