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BRONCHITIS, ACUTE

Population

  • –Adults age ≥18 y.

Recommendations

CDC—October 3, 2017

  • –Recommends against a chest x-ray if all the following are present:

    • Heart rate <100 beats/min.

    • Respiratory rate <24 breaths/min.

    • Temperature <100.4°F (38°C).

    • No exam findings consistent with pneumonia (consolidation, egophony, fremitus).

  • –Recommends against routine use of antibiotics regardless of duration of cough.

Source

Comments

  1. Primary clinical goal is to exclude pneumonia.

  2. Consider antitussive agents for short-term relief of coughing.

  3. β2 agonists or mucolytic agents should not be used routinely to alleviate cough.

CATARACT

FIGURE 28-1

Cataract in Adults: Evaluation and Management Algorithm

aBegin evaluation only when patients complain of a vision problem or impairment.

Identifying impairment in visual function during routine history and physical examination constitutes sound medical practice.

bEssential elements of the comprehensive eye and vision exam:

  • Patient history: Consider cataract if acute or gradual onset of vision loss; vision problems under special conditions (eg, low contrast, glare); difficulties performing various visual tasks. Ask about refractive history, previous ocular disease, amblyopia, eye surgery, trauma, general health history, medications, and allergies. It is critical to describe the actual impact of the cataract on the person’s function and quality of life. There are several instruments available for assessing functional impairment related to cataract, including VF-14, Activities of Daily Vision Scale, and Visual Activities Questionnaire.

  • Ocular examination includes Snellen acuity and refraction; measurement of intraocular pressure; assessment of pupillary function; external exam; slit-lamp exam; and dilated exam of fundus.

  • Supplemental testing: May be necessary to assess and document the extent of the functional disability and to determine whether other diseases may limit preoperative or postoperative vision. Most elderly patients presenting with visual problems do not have a cataract that causes functional impairment. Refractive error, macular degeneration, and glaucoma are common alternative etiologies for visual impairment.

cOnce cataract has been identified as the cause of visual disability, patients should be counseled concerning the nature of the problem, its natural history, and the existence of both surgical and nonsurgical approaches to management. The principal factor that should guide decision making with regard to surgery is the extent to which the cataract impairs the ability to function in daily life.

The findings of the physical examination should corroborate that the cataract is the major contributing cause of the functional impairment, and that there is a reasonable expectation that managing the cataract will positively impact the patient’s functional activity. Preoperative visual acuity is a poor predictor of postoperative functional improvement:

The decision to recommend cataract surgery should not be made solely on the basis of visual acuity.

dPatients who complain of mild-to-moderate limitation in activities due ...

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