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multiple drugs that lower BP In patients with low-output states particularly when hypotension is present positive inotropic agents are indicated These approaches to treatment have been discussed previously Bronchospasm may occur in response to pulmonary edema and may itself exacerbate hypoxemia and dyspnea Treatment with inhaled -adrenergic agonists or intravenous aminophylline may be helpful, but both may also provoke tachycardia and supraventricular arrhythmias In most cases, pulmonary edema responds rapidly to therapy When the patient has improved, the cause or precipitating factor should be ascertained In patients without prior heart failure, evaluation should include echocardiography and in many cases cardiac catheterization and coronary angiography Patients with acute decompensation of chronic heart failure should be treated to achieve a euvolemic state and have their medical regimen optimized Generally, an oral diuretic and an ACE inhibitor should be initiated, with efficacy and tolerability confirmed prior to discharge In selected patients, early but careful initiation of -blockers in low doses should be considered

Cotter G et al Pulmonary edema: new insight on pathogenesis and treatment Curr Opin Cardiol 2001 May;16(3):159 63 [PMID: 11357010] Fonarow GC Pharmacologic therapies for acutely decompensated heart failure Rev Cardiovasc Med 2002;3 Suppl 4:S18 27 [PMID: 12439427] Gandhi SK et al The pathogenesis of acute pulmonary edema associated with hypertension N Engl J Med 2001 Jan 4;344 (1):17 22 [PMID: 11136955] Jain P et al Current medical treatment for the exacerbation of chronic heart failure resulting in hospitalization Am Heart J 2003 Feb;145(2 Suppl):S3 17 [PMID: 12594447] Young JB et al Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive heart failure: a randomized controlled trial JAMA 2002 Mar 27;287(12):1531 40 [PMID: 11911755]

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Well-designed cohort studies have shown that some women can be reliably diagnosed with uncomplicated cystitis without a physical examination or urinalysis, and randomized controlled trials show that telephone management of uncomplicated cystitis is safe and effective An increased likelihood of cystitis is present when women report multiple irritative voiding symptoms (dysuria, urgency, frequency), fever, or back pain (likelihood ratios = 16 20) Inquiring about symptoms of vulvovaginitis is imperative, since the presence of vaginal discharge or itching substantially decreases the likelihood of cystitis (likelihood ratios = 02 03) When women report dysuria and urinary frequency, and deny vaginal discharge and irritation, the likelihood ratio for culture-confirmed cystitis is 245 In contrast, when vaginal discharge or irritation is present, as well as dysuria or urinary frequency, the likelihood ratio is 07 Gross hematuria in women with voiding symptoms usually represents hemorrhagic cystitis, but can also be a sign of bladder cancer (particularly in older patients) or upper tract disease Failure of hematuria to resolve with antibiotic treatment should prompt further evaluation of the bladder and kidneys Finally, chlamydial infection should be strongly considered among women age 25 years or younger who are sexually active and who are seeking medical attention for a suspected urinary tract infection for the first time

Urine culture should be considered for all women with upper tract symptoms (prior to initiating antibiotic therapy), as well as those with dysuria and a negative urine dipstick test In symptomatic women, a clean-catch urine culture is considered positive when 102 103 colony-forming units/mL of a uropathogenic organism is detected

When severe flank or back pain is present, the possibility of complicated kidney infection (perinephric abscess, nephrolithiasis) or of hydronephrosis should be considered Depending on local availability, acceptable imaging options to assess

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