Treating Based on Stage

Many illnesses are stratified according to severity because prognosis and treatment often vary based on the severity. If neither the prognosis nor the treatment was influenced by the stage of the disease process, there would be no reason to subcategorize a disease as mild or severe. As an example, a pregnant woman at 32 weeks' gestation with mild preeclampsia is at less risk from the disease than if she developed severe preeclampsia (particularly if the severe preeclampsia were pulmonary edema or eclampsia). Accordingly, with mild preeclampsia, the management may be expectant, letting the pregnancy continue while watching for any danger signs (severe disease). In contrast, if severe preeclampsia complicated this same 32-week pregnancy, the treatment would be magnesium sulfate to prevent seizures (eclampsia) and, most importantly, delivery. It is primarily delivery that "cures" the preeclampsia. In this disease, severe preeclampsia means both maternal and fetal risks are increased. As another example, urinary tract infections may be subdivided into lower-tract infections (cystitis), which are treated by oral antibiotics on an outpatient basis, versus upper-tract infections (pyelonephritis), which generally require hospitalization and intravenous antibiotics.

Bacterial vaginosis (BV). which has been associated with preterm delivery, endometritis, and vaginal cuff cellulitis (following hysterectomy), does not have a severe or mild substaging. The presence of BV may slightly increase the risk of problems, but neither the prognosis nor the treatment is affected by "more" B V or "less" B V. Hence, the student should approach a new disease by learning the mechanism, clinical presentation, staging, and treatment based on stage.

CLINICAL PEARL

The third step is. for most conditions, tailoring the treatment to the extent or "stage" of the disease.

Following the Response to Treatment

The final step in the approach to disease is following the patient's response to the therapy. The "measure" of response should be recorded and monitored. Some responses are clinical, such as improvement (or lack of improvement) in a patient's abdominal pain, temperature, or pulmonary examination. Obviously, the student must work on gaining more skill in eliciting the data in an unbiased and standardized manner. Other responses may be followed by imaging tests, such as CT scan to establish retroperitoneal node size in a patient receiving chemotherapy, or a tumor marker, such as CA-125 level in a woman receiving chemotherapy for ovarian cancer. For syphilis, it may be the results of the nonspecific treponemal antibody test RPR titer over time. The student must be prepared to know what to do if the measured marker does not respond as expected. Is the next step to retreat, to reconsider the diagnosis, to repeat the metastatic workup, or to follow up with another more specific test?

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