Lung Manifestations of Autoimmune Connective Tissue Disorders and Other Systemic Diseases

Many connective tissue diseases can have an impact on the lungs and pleura or on pulmonary function. Rheumatoid arthritis, for example, can cause interstitial lung disease because of a fibronodular inflammatory response or even larger rheumatoid nodules. Inflammation can also lead to pleural effusion or scarring, and pleural biopsy can reveal rheumatic nodules. Patients with RA can also develop one of several varieties of inflammatory interstitial pneumonia. Systemic lupus erythematosus can...

Impetigo

Impetigo is a bacterial infection of the epidermis caused by Staphylococcus aureus and group A beta-hemolytic streptococci (GABHS). Both organisms may be present at the same time in the affected site. Community-acquired methicillin-resistant S. aureus (CA-MRSA) may cause impetigo. Impetigo is highly infectious and easily transmitted by hand contact. Various types of dermatitis can become secondarily infected with bacteria, and the skin is then called impetiginized. About 30 of people are...

Melanoma

Melanoma is the most lethal of the cutaneous malignancies, causing more than 77 of skin cancer deaths. In the United States, more than 62,000 new cases of invasive melanoma and almost 50,000 new cases of melanoma in situ were diagnosed in 2008. Melanoma arises from the pigment-producing cells (melanocytes) located predominantly in the skin, but it also found in the eyes, ears, GI tract, leptomeninges, and oral and genital mucous membranes. Early detection and treatment of melanoma are the best...

Sodium

Abnormal serum sodium levels are markers for impaired water balance. The reference range for serum sodium concentration is 135 to 145 mmol L. In the evaluation of abnormal Table 15-24 Classification of Hypernatremia Table 15-23 Classification of Hyponatremia Table 15-23 Classification of Hyponatremia Urine sodium < 10 mEq L Urine osmolarity high Gastrointestinal losses vomiting, diarrhea Renal losses diuretics, chronic renal failure, salt-wasting nephropathies Congestive heart failure,...

Models of Human Sexual Response

Masters and Johnson first described the physiology of human sexual response cycle in 1966. Based on the physical components of sexual functioning, they described four phases of the sexual response cycle excitement, plateau, orgasm, and resolution (Fig. 43-1). Helen Singer Kaplan subsequently described a more subjective, psychologically oriented sexual responsiveness model with three phases desire, excitement, and orgasm. Recently, however, nonlinear alternative models have been suggested,...

Rosacea

Rosacea, sometimes called acne rosacea, is an inflammatory disease with unknown etiology. Various facial manifestations occur, and symptoms differ from patient to patient. The four types of rosacea are erythematotelangiectatic, papu-lopustular, phymatous, and ocular. Patients may have overlapping features of more than one type. The predominant manifesting complaints of erythematotelangiectatic rosacea are intermittent central facial flushing and erythema. Itching is often absent however, many...

Stridor

Stridor is a symptom, not a definitive diagnosis. It results from turbulent airflow and results from some degree of airway obstruction, usually at the level of the laryngopharynx or trachea. Stridor can affect both adults and children, but children present special diagnostic and therapeutic challenges because the antecedent history may be limited, physical examination is more challenging, and their small airways are more susceptible to critical obstruction. Because...

Rhinitis

Seasonal allergic rhinitis affects 10 to 30 of adults and up to 40 of children in the United States. Although half the patients with allergic rhinitis have symptoms for only 4 months per year, 20 experience symptoms more than 9 months per year. Direct medical costs of treating this condition plus indirect costs of lost productivity and absences from work or school are estimated at up to 2.4 billion per year in the United States. Unfortunately, seasonal allergic rhinitis is not self-limiting and...

Sinonasal Tumors

Intranasal and sinus tumors often manifest with symptoms identical to those of more benign sinonasal conditions. Nasal obstruction, facial pressure or pain, and bloody rhi-norrhea are common symptoms of a neoplastic process within the nasal cavity or sinuses. Because these symptoms are also common with sinusitis, a high index of suspicion is required, and diagnosis is often delayed. Tumors of the external nose are usually related to prolonged exposure to the sun. Basal cell and squamous cell...

Esophagus

Barrett's Esophagus and Esophageal Adenocarcinoma Barrett's esophagus is a premalignant condition related to chronic GERD. The hallmark is a change in the mucosal lining of the distal esophagus from the normal squamous epithelium to columnar-appearing mucosa resembling that of the stomach and small intestines, referred to as intestinal metaplasia (Fig. 38-4). The estimated risk of progression to adenocarcinoma of the esophagus with Barrett's esophagus is approximately 0.5 per year, whereas...

Endocrine and Metabolic Factors

Specific identifiable endocrine or metabolic disorders known to cause obesity account for less than 1 of the obese population, contrary to what is commonly believed (see also Chapter 34). Although rarely found in children, hypothyroidism is associated with slow statural growth and developmental delay. More common among adults and more often seen in women, hypothyroidism is a relatively rare cause of obesity. If undiagnosed, it is typically accompanied by other symptoms of thyroid deficiency,...

Infantile Regurgitation

In the infant with recurrent vomiting, a thorough history and physical examination are often sufficient to establish a diagnosis of uncomplicated gastroesophageal reflux disease (GERD), labeling the infant as the happy spitter. Diagnostic evaluation is indicated if there are signs of poor weight gain, GI obstruction, excessive crying and irritability, disturbed sleep, or feeding or respiratory problems suggesting suspected asthma or recurrent pneumonia. In the infant with uncomplicated GERD,...

Male Hypogonadism

Male hypogonadism is defined as inadequate gonadal function manifested by deficiency in gametogenesis or secretion of gonadal hormones. Primary hypogonadism is caused by dysfunction in the testes from either chromosomal or acquired disorders (Box 35-8). Secondary hypogonadism is caused by an abnormality of the hypothalamic-pituitary axis. Males may present with infertility, decreased testicular size, changes in libido, impotency, gynecomastia, delayed puberty, or a combination of these...

Nutrition and Family Medicine

Mary Barth Noel, Margaret Thompson, William C. Wadland, and Jodi Summers Holtrop Nutrition Decisions in the Hospitalized Patient Deterioration of Nutritional Status and Need for Support Patient Counseling on Dietary Changes Diet in Prevention and Management of Major Disease

N

Nail plate avulsion, for onychomycosis, 565 Narcissistic personality disorder, 1041t-1047t, 1057 Narcolepsy, 445 Narcotics, for pain control, 61t Nasal obstruction, 320-321 Nasal packing, 304 Nasal polyps, 321-322, 329, 346 perennial allergic rhinitis associated with, 346 Nasal spray, nicotine, 1119b, 1120 Nasal trauma, 329-330 Nasal vestibulitis, 321 Nasogastric feeding, 838 Nasolacrimal duct obstruction, 932 Natalizumab, 999 National Center for Complementary and Alternative Medicine (NCCAm),...

Skin Tension Orientation

Surgeons searching for an ideal guide for elective incisions have developed 36 named guidelines. Karl Langer (1819-1887) studied and drew skin lines of cleavage after noting that round punctures in cadaveric skin produced ellipses. The topographic orientation of these lines coincides with the dominant axis of mechanical tension in the skin. Langer lines were developed by studying skin tension in cadavers with rigor mortis and therefore may not be representative of a living human's skin tension...

Pyogenic Granuloma

Pyogenic granulomas (lobulated capillary hemangiomas) are benign vascular lesions that occur most often in young adults and children (Fig. 33-75). These rapidly growing hemangiomas may start at sites of trauma. Treatment is surgical removal. Pyogenic granulomas do not have malignant Figure 33-74 Seborrheic keratosis with horn cysts (comedo-like openings). Figure 33-74 Seborrheic keratosis with horn cysts (comedo-like openings). Figure 33-75 Pyogenic granuloma. (e Richard P. Usatine.) Figure...

Tinea Versicolor

Tinea versicolor presents with hypopigmented, pink brown macules and patches on the trunk with fine scale. Versicolor means varied colors, and this tinea tends to be white, pink, and brown (Fig. 33-51). Tinea versicolor is found on the back, chest, abdomen, and upper arms, often in a capelike distribution. Tinea versicolor is caused by Malassezia furfur (Pityrosporum), a lipophilic yeast that can be normal human cutaneous flora. Tinea versicolor is also called pityriasis versicolor after the...

Chronic Nonbacterial Prostatitis

The term prostatitis means prostate inflammation but often also implies infection (infectious causes are discussed later). However, prostatitis encompasses many different clinical entities (Table 40-7). Chronic nonbacterial prostatitis, also Table 40-6 Serum Creatinine Levels and Chronic Kidney Disease* Table 40-6 Serum Creatinine Levels and Chronic Kidney Disease* Serum Creatinine (mg dL) MDRD Study Equation Modified from Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice...

Tinea Capitis

Tinea capitis, the most common dermatophytosis in children, is an infection of the scalp and hair follicle. Transmission is fostered by poor hygiene and overcrowding and can occur through contaminated hats, brushes, and pillowcases. After being shed, affected hairs can harbor viable organisms for more than 1 year. Tinea capitis is characterized by irregular or well-demarcated alopecia and scaling (Fig. 33-49). Cervical and occipital lymphadenopathy may be prominent. When hairs fracture a few...

Seborrheic Keratosis

Seborrheic keratoses (SKs) are hyperkeratotic lesions of the epidermis that often appear to be stuck on the surface of the skin (Fig. 33-74). SKs usually have a discrete border and vary in color from white or tan to dark brown and even black. Most lesions have a rough surface and usually range from 2 mm to 3 cm in diameter, but can be larger. Seborrheic keratosis may start as a hyperpigmented macule and progress to the characteristic plaque. The trunk is the most common site, but the lesions...

Unipolar Depression vs Bipolar Depression

Distinguishing unipolar from bipolar depression remains a critical distinction and poses one of the greatest clinical challenges for professionals who treat mood disorders. Misdiag-nosis of bipolar disorder can lead to mistreatment (typically with antidepressants alone), worsening of mood, switches into mania or mixed states (i.e., presence of both manic and depressive symptoms), rapid mood swings, worsening psychosocial impairment, greater suicide attempts, and higher mortality (Goldberg and...

Normal Sexual Development

Sexual differentiation in humans is controlled by genetics (presence of Y chromosome determines development of testis and absence determines development of ovary with additional X chromosome), environment (e.g., nutrition), and hormones (MacLaughlin and Donahoe, 2004). Congenital conditions associated with aberrations of chromosomal, gonadal, or anatomic sexual development are called disorders of sex development (DSD) (Houk et al., 2006). In the postgonadal phase, hormones control external...

Synovial Fluid Analysis

Synovial fluid analysis can be helpful in evaluating a febrile patient with an acute joint to rule out septic arthritis or acute monoarthritis. Synovial fluid should be analyzed for white blood cell (WBC) count differential, cultured, and tested with polarized light microscopy for crystals. Purulent synovial fluid with greater than 90 polymorphonuclear leukocytes (PMNs), low viscosity, and turbid clarity can be caused by infection or crystal arthropathy (gout or pseudogout). Urate crystals are...

Helicobacter pylori

A spiral, urease-producing bacterium, Helicobacter pylori is associated with almost 90 of duodenal ulcers. Testing is indicated in patients with either active or previously documented peptic ulcer disease, in the evaluation of dyspepsia who have no alarm features, and for patients with a history of gastric MALT (mucosa-associated lymphoid tissue) lymphoma (MALToma) (Chey and Wong, 2007). Several tests can be performed during endoscopy. Rapid urease testing of a biopsy specimen has sensitivity...

Pharmacotherapy and Psychotherapy for Somatoform Disorders

In a review of 34 randomized clinical trials of treatments for somatoform disorders, two thirds involved somatization disorder or one of its less severe variants (Kroenke, 2007). CBT was effective in 11 of these 13 studies. Antidepressants were effective in four of five pharmacotherapy trials. The consultation letter was effective in 8 of 16 studies. Effective treatments for conversion disorder and pain disorder have not yet been demonstrated. Short-term group therapy has been shown in at least...

Thrombocytosis

Thrombocytosis can be a primary marrow-related disorder or secondary reactive to a surgical or medical condition and is defined as a platelet count greater than 500,000 uL. Primary marrow related thrombocytosis may occur in the face of a chronic myeloproliferative or myelodysplastic disorder such as polycythemia vera (PV), primary myelofibrosis (MF), chronic myelogenous leukemia (CML) and essential thrombocythemia (ET). ET can be diagnosed by eliminating secondary causes and the other...

Ovarian Cysts and Carcinoma

As mentioned, the initial evaluation of an ovarian cyst includes a transvaginal ultrasound. Premenopausal women should have pregnancy testing, and postmenopausal women should have CA-125 testing. Simple cysts are more likely to be benign, whereas complex cysts (with thick walls, irregularity, papillations, septa, and echogenicity) have a higher risk of Table 25-2 Differential Diagnosis of Pelvic Mass Table 25-2 Differential Diagnosis of Pelvic Mass Pelvic pressure, heavy vaginal bleeding...

Polycystic Ovary Syndrome

Polycystic ovary syndrome is the clinical condition seen most frequently with androgen excess. Women with PCOS present with complaints of abnormal menses, infertility, hirsutism, acne, and obesity, all of which are related to excess androgen. PCOS is the single most common endocrine abnormality of women of reproductive age and affects 6 to 8 of women worldwide. The definition of PCOS is constantly being revised. The Task Force on the Phenotype of the Poly-cystic Ovary Syndrome from the Androgen...

Transient Ischemic Attacks in Carotid Artery Disease

Transient ischemic attacks are neurologic deficits lasting less than 24 hours and are reversible. The most common ophthalmologic TIA is amaurosis fugax, which is a fleeting monocular blindness caused by an embolic event. There is a sudden graying or reduction of vision, often moving from the peripheral vision to the center to cover the entire visual field within a few seconds. After 1 to 5 minutes, the central vision Figure 41-36 Bilateral glaucoma in 60-year-old man. Patient also had history...

Evaluation of Joint and Other Musculoskeletal Symptoms

Musculoskeletal Scleroderma

Precise anatomic localization of pain is the first task of the physician caring for a patient presenting with joint pain, while also evaluating stiffness, redness, warmth, or swelling in the absence of trauma. It is important to distinguish pain that is truly articular from periarticular pain. Causes of localized periarticular pain include bursitis, tendonitis, and carpal tunnel syndrome, whereas fibromyalgia, polymyalgia rheumat-ica, and polymyositis all can cause diffuse periarticular pain....

Interventions Using Psychosocial Data

A comprehensive review of interventions addressing psychosocial influences in health is beyond the scope of this chapter and would require discussions of clinical psychology, social work, nursing, occupational therapy, and public health. Even in optimal circumstances, competency can be achieved only within a limited range. Realistically, family physicians should achieve basic proficiency in selected interventional strategies and pursue additional training in areas of interest relevant to their...

Psoriasis

Psoriasis is a common skin disorder that most often appears as inflamed plaques covered with a thickened, silvery-white scale. Psoriasis is divided into the following nine categories, although a patient can have more than one type at the same time 1. Plaque psoriasis accounts for 80 to 90 of patients with psoriasis (Fig. 33-18). 2. Scalp psoriasis causes plaques on the scalp (Fig. 33-19). 3. Guttate psoriasis appears as small, round plaques that resemble water drops (Fig. 33-20). 4. Inverse...

Pubertal Growth and Development

All children grow at a different tempo, with some maturing earlier than others and some later. This difference is most apparent during puberty. The NCHS growth charts now extend to age 20 years. Tanner and Davies (1985) took the Table 23-2 Sexual Maturity Stages in Boys and Girls 1985)u Because fh f two a Mond years of prepuberta1 growth and a peak height velocity greater than that of girls, their ultimate height is usually taller. Head, hands, and feet are first to reach their adult size,...

Exercise Induced Bronchospasm

Exercise-induced bronchospasm is a bronchospastic event that usually occurs during or minutes after vigorous activity. The peak of the bronchospasm occurs 5 to 10 minutes after stopping the activity and usually resolves by 30 minutes. The goal of management is to allow patients to participate in any activity they choose without being hindered by asthma symptoms. Beta-2 agonists used shortly before exercise help prevent exercise-induced bronchospasm in more than 80 of patients. Cromolyn or...

Dry Eye Keratitis Sicca

Tears, because of their lubricating and bacteriostatic properties, are essential for maintaining a healthy cornea and conjunctiva. A deficiency in tear production may result in a dry eye, also known as keratitis sicca. Keratoconjunctivitis sicca is an acquired disorder seen frequently during the fifth decade of life that occurs more often in women. Initial symptoms include a foreign body sensation, dryness, and burning, which often worsens as this condition progresses. Paradoxical tearing from...

Diagnostic Tools in Pulmonary Medicine History and Physical Examination

Diagnosis starts with the patient history and physical examination. Pulmonary symptoms may be evaluated by traditional history-of-present-illness questions, such as character and quality of the symptoms, duration, onset, timing, exacerbating and alleviating factors, efforts at self-treatment, and the patient's own understanding of what is causing the symptoms. For example, the symptoms of asthma may be variously described by patients as shortness of breath, wheezing, whistling, wheezling, chest...

Polymotor Sensory Neuropathy

In the early phase of diabetic neuropathy, physical examination may be uninformative. Assessing the adequacy of perfusion is critical and easily accomplished by inspecting the toenails for capillary perfusion and palpating the tibialis posterior and dorsalis pedis arteries. As noted, a dry, cool foot with thickened or thin subcutaneous tissue and nonelastic skin is demonstrating microangiopathy, despite a palpable dorsalis pedis, indicating a likely positive result in decreased deep tendon...

Bullous Myringitis

Bullous myringitis refers to painful inflammatory bullae on the tympanic membrane. The blebs appear hemorrhagic. It was formerly thought that bullous myringitis was caused by Mycoplasma pneumoniae infection. Roberts (1980), however, summarized six studies involving 858 patients with bullous myringitis, and M. pneumoniae was isolated from only one. The cause is usually viral but can be bacterial in some cases. Studies have confirmed that bacterial cultures from bullous fluid are similar to...

Mitral Stenosis

Mitral stenosis is defined as the reduced ability of the blood to move from the left atrium to the left ventricle in diastole. It is mostly caused by dysfunction in the mitral valve, which lacks the ability to open its leaflets in diastole (Fig. 27-19). Mitral valve stenosis (MS) is predominantly caused by rheumatic carditis and is more prevalent in female patients (Bonow et al., 1998). Acute rheumatic carditis leads to valvular disease in approximately 50 of affected patients. The mitral valve...

Miscellaneous Headaches

Episodic and chronic paroxysmal hemicrania is an unusual headache that tends to occur in women. The attacks are short, and the pain is similar to that of a cluster headache. These headaches respond to indomethacin, with a maximum of 150 mg day in divided doses. Posttraumatic headaches can follow a head injury, with presentation similar to migraine headache. No clear correlation appears to exist between intensity of the head trauma and development of headache. These headaches may be associated...

Objective

Vascular abnormalities Arteriovenous malformation, glomus tumors, stenotic carotid artery, vascular loops, persistent stapedial artery, dehiscent jugular bulb, hypertension Tympanic muscle disorders Palatomyoclonus, idiopathic stapedial Central nervous system anomalies Congenital stenosis of the sylvian aqueduct, type 1 Arnold-Chiari malformation From Lucente FE, Har-El G Essentials of Otolaryngology. Philadelphia, LippincottWilliams & Wilkins, 1999, p 110. heard by the patient and the...

Turners Syndrome

See the discussion online at www.expertconsult.com. Female Infertility Infertility is defined as failure of conception after 1 year of unprotected intercourse. From 15 to 20 of all couples are infertile. In women, fertility peaks between ages 20 and 24. After this, there is progressive decline in fertility until about age 32, followed by a steep decline after 40. Causes of infertility in couples tend to be one-third male factors, one-third female factors, and one-third combination. Female...

Other Forms of Vaginitis

Image Dried Seminal Stain

Aerobic vaginitis is characterized by purulent vaginal discharge with a dominant abnormal aerobic flora. Patients experience a foul-smelling nonfishy discharge, and examination may reveal erythema, inflammation, and ulcers of the posterior fornix. Although culture is the gold standard, the diagnosis is usually one of exclusion, with pH greater than 6.0, white blood cells (WBCs) on microscopy, and absence Figure 25-3 Trichomoniasis. Trichomonads are seen under high-power magnification in a wet...

Cirrhosis

Cirrhosis and chronic liver failure rank as the 12th leading cause of death in the United States, accounting for 27,555 deaths (9.2 per 100,000 population) in 2006, with a slight male predominance (NCHS, 2009). The vast majority of cirrhosis-related morbidity and mortality is secondary to excessive alcohol consumption, hepatitis B and C, and obesity (nonalcoholic fatty liver disease NAFLD ), and is theoretically preventable. The term cirrhosis refers to a progressive diffuse, fibrosing, and...

Candidal Vaginitis

Candidal Vaginitis

Vulvovaginal candidiasis (VVC) is the second most common cause of vaginitis after BV, with a lifetime prevalence in women of 70 to 75 (Spence, 2007). Candida albicans is the most common etiology (80 -90 ). Type 1 diabetes All symptomatic women with BV should be treated (BAASH, 2006). Asymptomatic women undergoing abortion or hysterectomy should be treated to decrease the risk for infectious complications (BAASH, 2006). Oral or vaginal metronidazole (BAASH, 2006) and vaginal clindamycin are...

Examples of Genetic Testing Preconception and Prenatal Screening

Genetic screening or testing can occur either before conception or during the pregnancy. When possible, screening or testing before a pregnancy is ideal, because this provides the broadest range of choices if increased risk of a genetic defect is detected. Preimplantation genetic testing is available for Table 44-3 Types of Genetic Genomic Testing Table 44-3 Types of Genetic Genomic Testing Fluorescent in situ hybridization, karyotype, array comparative genomic hybridization Down syndrome,...

Varicella and Herpes Zoster

Varicella is one of the classic viral exanthems of childhood. Before routine vaccination, having chickenpox was one of childhood's rites of passage. The virus, a herpesvirus (human herpesvirus 3), is effectively transmitted, causing outbreaks in schools and households. Patients with primary varicella present with fever, headache, and sore throat. Generally within 1 to 2 days of onset of symptoms, a papulovesicular rash erupts diffusely. The classic description of the chickenpox lesion is a...

Menieres Disease

Meniere's disease is characterized by episodic severe vertigo lasting hours, with associated symptoms of unilateral roaring tinnitus, fluctuating low-frequency hearing loss, and aural fullness. Typical onset is in the fifth decade of life. The cause is uncertain but is speculated to result from allergic, infectious, or autoimmune injury. The histopathologic finding includes endolymphatic hydrops, which is thought to be caused by either overproduction or underresorption of endo-lymph in the...

Acute Bronchitis

A frequently diagnosed infection in children and adults, acute bronchitis is typically a viral respiratory infection with lower tract symptoms, such as cough, phlegm, hoarseness, or wheezing. This syndrome should be distinguished from acute exacerbations in patients with chronic bronchitis, who are more vulnerable, who might be colonized with different bacterial flora in the respiratory tract, and who might require more aggressive treatment. In acute bronchitis in otherwise healthy patients,...

Acute Pharyngitis and Tonsillitis

Viral agents cause the majority of sore throats. Even when exudates are present, less than 15 of children and 10 of adults have documented group A beta-hemolytic streptococci (GABHS) as the cause. In children younger than 3 years, the predominance of a viral cause is even higher than in school-age children. Pharyngitis caused by GABHS (Streptococcus pyogenes) has its peak incidence in late winter and early spring. The incubation phase is 2 to 5 days and leads to sudden onset of sore throat,...

Burden of Disease

Alcohol abuse and alcohol dependence are associated with repeated negative physical, psychological, and social effects, and the effectiveness of interventions for alcohol dependence are well established. Alcohol misuse, such as risky or hazardous and harmful drinking, does not meet criteria for dependence but place individuals at risk for future problems. Across various primary care populations, the prevalence rates for risky drinking are 4 to 29 for harmful drinking, 0.3 to 10 and for alcohol...

Core Elements of Integrative Medicine

Nutrition, mind-body medicine, and spirituality are considered core elements of an integrative medicine approach and often are applied during patient consultation. These elements also tend to be cost-effective and patient empowering. Considered the foundation of good health and enhanced healing, nutritional principles are key elements in most treatment plans. The adage food is medicine is becoming ever more important as the United States faces impending epidemics of diabetes and obesity. When...

Phimosis and Paraphimosis

Phimosis (inability to retract foreskin over glans) and paraphimosis (inability to return retracted foreskin over glans) are possible complications seen in the uncircumcised male (Fig. 40-11). About 50 of boys typically are able to retract their foreskin by 1 year of age and 80 by age 3 (Anderson and Anderson, 1999). Topical estrogen therapy has been reported as successful, but no randomized trials support its use (Yanagisawa et al., 2000). However, low-potency topical corticosteroid therapy...

The Importance of Self Care

To care deeply for others, we must know how to care for ourselves. As Cassell (2004) says, . . . virtually all the doctor's healing power flows from the doctor's self-mastery. True primary care, therefore, also includes what we do for ourselves. Up to 60 of practicing physicians report symptoms of burnout (Shanafelt et al., 2003 Spickard et al., 2002). This is associated with emotional exhaustion, depersonaliza-tion (seeing patients as objects), reduced empathy, and the loss of meaning in work....

Thrombocytopenia

Thrombocytopenia is a platelet count below the lower normal limit of 150,000 cells L and has two major causes, reduced platelet production and accelerated platelet removal. Bleeding does not generally occur until the platelet count falls below 20,000 cells L or the patient is an older adult, has coexistent diseases such as liver dysfunction or a connective tissue disorder, or is taking a drug that impairs platelet function. Figure 39-6 Increased number of platelets seen on a peripheral blood...

Epstein Barr Virus and Cytomegalovirus

Clinical infectious mononucleosis is a common infection in adolescents and early adults. The clinical syndrome is most often caused by Epstein-Barr virus (EBV), although cytomegalovirus (CMV) may also be the source in this clinical syndrome, which includes fever, exudative tonsillitis, adenopathy (often including posterior cervical or occipital nodes), and fatigue. EBV is transmitted in oral secretions and may be transmitted sexually as well. B cells are infected with EBV either directly or...

Cholelithiasis and Cholecystitis

Gallstones are exceedingly common among women and men of all ages, affecting approximately 20 of Americans during their lifetime. Population-based studies reveal a prevalence of gallbladder disease in women age 20 to 55 of 5 to 20 , increasing to 25 to 30 after age 50. By age 75, an estimated 35 of women and 20 of men will develop either symptomatic or asymptomatic gallstones (Attili et al., 1995). The prevalence for men is approximately one-third to one-half that for women in any given age...

Uterine Aspiration for Biopsy or Miscarriage Management

Manual vacuum aspiration (MVA) can be used in the office setting for easy sampling of the uterine endometrium with a 4-mm or 5-mm cannula when a small endometrial biopsy catheter is insufficient (Fig. 28-19). The MVA can also be used in the office for removal of retained products of conception after an incomplete or missed miscarriage up to 12 weeks without the added cost of an emergency room visit, surgical suite, and general anesthesia. The MVA device is a handheld plastic aspirator syringe...

Antisocial Personality Disorder Malingering and Factitious Disorders

Common physician reactions to a patient with antisocial personality disorder are feelings of being used, exploited, or deceived. This can lead to physician anger and wishes to be free of the patient, uncover lies, and punish or imprison the patient. These patients fear that they will become vulnerable, lose respect or admiration from others, and become easy prey to manipulation when they become ill. They expect to be exploited, demeaned, or humiliated. Like the narcissistic patient, they often...

Bladder and Kidney

Forty percent of bladder cancers are smoking-related, and higher rates of kidney cancers are also noted in smokers. Smokers have two to four times the risk of bladder cancer as those who never smoked. The risk for kidney cancer is strongly dose dependent. Even one to nine cigarettes per day creates a 60 excess risk of renal cell cancer in men, and the risk doubles for men smoking more than a pack a day. Overall, the relative risk (RR) for women smokers is about 1.38, and for men 1.54 (Hunt et...

Lifestyle Interventions and Behavior Change

Prevention from the Disease-Oriented Perspective A Focus on Heart Disease Crux of the Lifestyle Dilemma Do Physicians Believe in Primary Prevention Primary Prevention A Focus on Lifestyle After the Evidence Motivational Interviewing The Process in Your Clinical Practice The two highest-yield strategies for prevention of chronic disease and death are (1) a routine annual cardiac risk assessment strategy for all adults, with intervention graded to level of risk, and (2) a strategy of primary...

Classification of Hematopoietic and Lymphoid Tissue Tumors

The World Health Organization (WHO) updated its classification of blood and lymphoid tissue tumors in 2008 by utilizing more molecular characteristics or markers instead of primarily morphologic changes seen in malignant cells. It includes genetic, morphologic, immunophenotypic, and clinical characteristics to formulate a diagnosis. Tumors of heme and lymphoid cells are divided into three main cell types (1) myeloid cell neoplasms, originating in leukocytes and RBCs found in the marrow (2)...

Key Treatment

Hemorrhoids Band Instrument

Patients over the age of 40 who have hemorrhoidal bleeding cannot be assumed to have no other colorectal pathology and should have further colorectal evaluation. (Chong and Bartolo, 2008) (SOR B). Dietary management of symptomatic hemorrhoids consists of adequate fluid and fiber intake (Alonso-Coello et al., 2005) (SOR B). Rubber band ligation is known to be highly effective outpatient treatment for first-, second-, and some third-degree hemorrhoids (Reese et al., 2009) (SOR B). A nonpainful or...

Physiologic Classification

The physiologic classification of anemia is based on response of the bone marrow. The three major categories are hypop-roliferative anemia, maturation disorders (ineffective eryth-ropoiesis), and hemolytic-hemorrhagic anemia (Box 39-2). In hypoproliferative anemias the response of the bone marrow is impaired by one of three general mechanisms. The first is marrow damage, which results from an injury to the bone marrow and makes it impossible for the marrow to respond to adequate EPO...

Special Clinical Situations

Children who are immunocompromised or infected with HIV usually should not be given live-virus vaccines. However, measles can cause severe disease and death in symptomatic HIV-infected patients. MMR (but not MMRV) is recommended at age 12 months for HIV-infected children with CD4+ T-lymphocyte counts of 15 or greater. The second dose can be given 28 days later to improve the immune response. Children with age-specific low CD4+ counts should not be given measles virus-containing vaccine (AAP Red...

Recommendations

In response to recent epidemiologic and clinical trial data, JNC-7 made a series of new recommendations for addressing the HTN epidemic, which now includes more than 73.6 million patients in the U.S. alone. Patients with SBP of 120 to 139 mm Hg and DBP of 80 to 89 mm Hg are defined as prehypertensive and warrant aggressive lifestyle modification to prevent progression to HTN. It must be assumed that even in this BP range, changes in vessel wall histology and physiology are inducing elevations...

Initial Evaluation

Although medical school teaches students to perform the history before doing the physical examination, this is not the most efficient way to approach the diagnosis of a skin condition. When the patient has a skin complaint, immediately look at the skin while asking your questions. Look carefully at the lesions and determine the lesion morphology. Table 33-1 provides definitions for the terms used to describe primary and secondary morphology. A magnifying glass and good lighting help to...

Nocturnal Enuresis

Enuresis is a common childhood complaint. Distinguishing primary enuresis (children who have never achieved a satisfactory period of nighttime dryness) from secondary enure-sis (return of nighttime wetting after 6 months of nighttime dryness) is important secondary enuresis indicates possible dysfunctional voiding or other pathologic condition. A child needs to be 5 years old to be considered enuretic, and children younger than 7 years may not exhibit the commitment necessary for treatment to...

Labyrinthitis

As with vestibular neuronitis, labyrinthitis causes sudden and severe vertigo. In contrast to vestibular neuronitis, the patient also has tinnitus and hearing loss. The hearing loss is sensorineural, is often severe, and can be permanent. Laby-rinthitis is caused by inflammation within the inner ear. The cause is most often a viral infection but can be bacterial. Bacterial labyrinthitis usually results from extension of a bacterial otitis media into the inner ear. A noninfectious serous...

Lateral Elbow Tendinopathy

Lateral elbow tendinopathy or lateral epicondylitis, commonly called tennis elbow, is caused by repetitive overuse of the wrist extensor and forearm supinator muscles that originate at the lateral epicondyle of the humerus more specifically, the extensor carpi radialis brevis tendon. Once thought to result from inflammation, lateral elbow tendinosis is probably caused more by chronic changes in the musculotendinous matrix (Nirschl, 1992), with minimal inflammation present, particularly with...

Conspiracy of Silence

Honesty with the terminal patient will provide the greatest benefits. However, the physician frequently is torn between patient and family, with the patient saying, Don't tell my wife because she can't handle it, while the wife is saying, Don't tell my husband because he can't handle it. Although the wishes and desires of the family must be considered when deciding how to care for a dying patient, the physician's primary obligation is to the patient. The method of management must be based on...

Web Resources

Age-related macular degeneration handout for patients. Pediatric Eye Disease Investigator Group list of current publications on amblyopia and strabismus. American Academy of Pediatrics Perinatal Guidelines. American Academy of Pediatrics (AAP) red reflex policy statement. Summary of optic neuritis treatment. Orbis Cyber-Sight Telemedicine Learning of Ophthalmology. AAP perinatal guidelines. 50fb-39a3-439c-9225-5fbb013cf472 AAO Preferred Practice Patterns for managing conjunctivitis. AAO...

Parallel Diagnostic Inquiry

Although most clinicians regard patients with somatization as difficult, effective and rewarding approaches exist for recognizing and managing these patients. We first present a general approach to the diagnostic strategy with somatic patients, then describe a more specific diagnostic algorithm that has proved useful in managing patients with somatization. In the course of a normal clinical encounter, a clinician (1) hears a complaint, (2) asks questions to elicit related symptoms and to...

Verbal Communication

Much of the communication process in the clinical interview centers on verbal interchange. Symptoms, past medical history, family medical history, and psychosocial data are transmitted primarily by verbal means. The chief complaint is extremely important because it explains why patients believe they need the physician's help. Patients who do not mention a concern and who withhold requests are less satisfied with their care and experience less improvement in their symptoms. Bell and colleagues...

Jaundice

Jaundice is the most common condition requiring medical attention in the term newborn. Hyperbilirubinemia is one of the primary reasons for hospital readmission during the first week of life (Brown et al., 1999). Visible jaundice refers to a yellow coloration of the skin and sclera in infants with elevated levels of bilirubin and may be difficult to detect in infants with darker skin. Visible jaundice occurs in more than 50 of healthy term newborns. Although rare, high levels of bilirubin...

Causes

Hypopituitarism may result from a genetic disorder or deficiency in hypothalamic releasing factor but more often is the result of pituitary tissue destruction secondary to mass expansion, infiltrative process, autoimmune or infectious disease, vascular accidents, radiation injury, or trauma. In some patients the etiology of hypopituitarism cannot be identified and is considered idiopathic. Most idiopathic cases are sporadic, although there are well-described familial causes of hypopituitarism....

Lymphadenopathy

Enlarged lymph nodes, single or multiple, are a common problem seen by family physicians in ambulatory practice. Nodes may be enlarged as a reactive phenomenon to infection, inflammation, malignancy, or systemic generalized disease (Box 39-7). Most enlarged lymph nodes seen in younger patients are benign. Table 39-6 summarizes the four major determinants of significant lymphadenopathy Bacterial Streptococci, staphylococci, cat-scratch fever, mycobacteria, tularemia Viral Infectious...

Atherosclerosis

Atherosclerosis is a complex, multifactorial disease highly prevalent throughout the world. Atherosclerotic disease is etio-logic for acute coronary syndromes such as myocardial infarction (MI) and unstable angina, ischemic stroke, renal arterial stenosis, and peripheral vascular disease (Libby, 2001). The development and progression of atherosclerosis is driven by a variety of risk factors, including dyslipidemia, hypertension, impairments in glycemic control, age, family history, cigarette...

Followup Prenatal Visits

Leopold Maneuver

According to the report of the Expert Panel on Prenatal Care (Rosen et al., 1991), low-risk primigravid women should have at least 10 prenatal visits low-risk multiparous women should have at least eight visits. Again, however, data suggest that antenatal visits could be reduced without adverse effect to the mother and child (Carroli et al., 2001). Women with psychosocial issues or pregnancy complications should be seen more frequently. In the first two trimesters, prenatal visits may be 5 to 6...

Shoulder Instability

Bony anatomy provides minimal stability to the gleno-humeral joint therefore the primary stability depends on both static and dynamic soft tissue structures. The static soft tissue structures include the fibrocartilaginous labrum, Figure 30-10 Lift-off test is used to assess subscapularis muscle function. Patients are asked to lift their hand off their back against resistance. Weakness or pain indicates subscapularis pathology. Figure 30-10 Lift-off test is used to assess subscapularis muscle...

Erythrocyte Sedimentation Rate

The ESR is one of the oldest laboratory tests still in clinical use. The test measures the distance that erythrocytes (RBCs) fall in a column of anticoagulated blood in 1 hour. Plasma Table 15-15 Causes of Thrombocytopenia Table 15-16 Factors Affecting the Erythrocyte Sedimentation Disseminated intravascular coagulation (DIC) Hemolysis, liver dysfunction, and low platelets (HELLP syndrome) Low room temperature Clotted blood sample NSADs, Nonsteroidal anti-inflammatory drugs. proteins known as...

Osteomyelitis

Osteomyelitis is defined as progressive, inflammation leading to destruction of the bone, usually secondary to an infectious agent. Bacteria can enter bone through hematogenous seeding or a contiguous focus after trauma, implantation of a foreign device, or a local soft tissue infection. Acute osteomyelitis is defined as infection that evolves over a few weeks. Chronic osteomyelitis implies persistent infection of several weeks to months. Hematogenous osteomyelitis occurs primarily in children...

Stomach and Duodenum Dyspepsia

Management Peptic Ulcer Images

Dyspepsia (bad digestion) accounts for approximately 5 of all visits to family practitioners and is the most common reason for referral to a gastroenterologist in the United States, accounting for 20 to 40 of consultations (Jones and Lacy, 2004). The term dyspepsia refers to episodic or recurrent pain or discomfort arising from the proximal GI tract related to meals and is associated with heartburn, reflux, regurgitation, indigestion, bloating, early satiety, and weight loss. The lack of a...

Acupuncture Yoga and Homeopathic Remedies

Three areas of CAM are most likely to be encountered in the family physician's office acupuncture, yoga, and homeopathic remedies (see Chapter 52 online for herbs and supplements). As shown in Table 11-9, these three areas are components of whole systems or nonallopathic medical systems of care acupuncture within traditional Chinese medicine (TCM), yoga as a part of Ayurveda, and homeopathic remedies as the mainstay of homeopathy. Many Table 11-9 Nonallopathic Medical Systems Philosophy Qi and...

Prevention of Tick Borne Disease

Physicians should advise patients who walk or hike in tick-infested areas to tuck long pants into socks to protect the legs and wear shoes and long-sleeved shirts. Ticks show up on white or light colors better than dark colors, making them easier to remove from clothing. If attached, ticks should be removed immediately by using a tweezers, pulling carefully and steadily. Insect repellents such as DEET, alone or in combination with permethrin, may be helpful. Appropriate antibiotic therapy...

Common Pulmonary Symptoms Shortness of Breath

A common presenting symptom in pulmonary disease is shortness of breath. The fundamental question in patients presenting with recent-onset or episodic shortness of breath is this Is it a lung problem, a heart problem, or something else The most common pulmonary causes of chronic or repeated episodes of shortness of breath include asthma, smoking-related COPD, chronic lung infections (TB and HIV-related infections), and occupational pneumoconio-sis. Acute-onset shortness of breath can be caused...

Subacute Presentation of Type 1 Diabetes

The management of type 1 diabetes will depend on the patient's age and the acuity of the diabetes at presentation. Since there is usually no family history of diabetes, or diabetic experience at home, and given the fragility of the new-onset diabetic state, many children or adolescents presenting with type 1 diabetes require hospitalization to initiate and teach glucose monitoring techniques and to begin insulin treatment. The indication for hospitalizing a newly diagnosed child who is not...

Stable Angina

Angina pectoris can manifest as chest pain, chest pressure, or a heavy feeling or squeezing sensation. Angina is a symptom of myocardial ischemia. Stable angina is caused by a mismatch between coronary blood supply and myocardial oxygen demand. The latter is determined by several factors, including heart rate and left ventricular wall stress and contractility (Braunwald, 2000). Coronary supply is determined by oxygen transport capacity and delivery and conditions that regulate the coronary...

Disorders of Neutrophils Neutrophilia

Neutrophilia is defined as a WBC count higher than 10,000 cells L plus an absolute neutrophil count more than 2 SD above the mean, or higher than 7000 cells L. The absolute neutrophil count (ANC) can be calculated by multiplying the total WBC count by the percentage of polymorphonuclear neutrophil (PMN) leukocytes and bands (PMNs + bands) Table 39-4 Normal White Blood Cell (WBC) Counts in Peripheral Blood Table 39-4 Normal White Blood Cell (WBC) Counts in Peripheral Blood in the WBC...

Facial Nerve Paralysis

Facial paralysis occurs for various reasons. Possible causes are listed in Table 19-4. The eponym Bell's palsy is reserved for cases of idiopathic facial paralysis. It has been shown, however, that many if not most cases of idiopathic facial paralysis are actually caused by reactivation of latent herpesvirus living in the facial nerve or geniculate ganglion. Although the most common cause of facial paralysis is indeed Bell's palsy, it is incumbent to rule out other potentially serious causes of...

Cervical Radiculopathy

Radiculopathy occurs when nerve root compression at the neck or spine results in pain, tingling, and numbness, with or without loss of function in the area supplied by the affected nerve. Common causes of cervical radiculopathy are neural foramen narrowing, usually caused by cervical arthritis in older adults, and cervical disk lesion caused by disk degeneration or herniation. Disk degeneration results in loss of disk space, with closer approximation of the vertebrae on either side of the...

Pathogenesis of Rheumatic and Other Musculoskeletal Diseases

As with most disease, research into the causes of rheumato-logic and musculoskeletal diseases shows that the cause for each disease is actually multifactorial. Further identification Figure 32-2 Evaluation of polyarticular symptoms. ANA, Antinuclear antibodies CBC, complete blood cell count ESR, erythrocyte sedimentation rate RF, rheumatoid factor. (From American College of Rheumatology Ad Hoc Committee on Clinical Guidelines Guidelines for the initial evaluation of the adult patient with acute...

Herpes Simplex

Hsv Recurrence

Herpes simplex virus types 1 and 2 (HSV-1 and HSV-2) are very common pathogens that cause orolabial and genital blisters or erosions. Seroprevalence of HSV-1 is estimated at 80 to 90 worldwide and is the most common cause of oral herpes infection (80 ). HSV-2 is the primary pathogen in genital herpes (70 -90 ) and is one of the most common sexually transmitted diseases (STDs). Approximately 50 million Americans have genital herpes, and an estimated 1 million new cases occur each year. Herpes...

Incision and Drainage of Cutaneous Abscess

A cutaneous abscess is identified by a fluctuance or compressible softness in skin surrounded by induration, inflammation, warmth, and tenderness. Furuncles are superficial and result from abscess formation in a sweat gland or hair follicle. Carbuncles are deeper and extend into the subcutaneous tissue. Offending bacteria include Staphylococcus aureus, streptococci, and occasionally gram-negative rods. These infections can be severe in patients with diabetes or vascular disease. Primary...

Male Orgasmic Disorder

Men who can sustain a full erection for a reasonable duration of sexual activity will usually be able to reach orgasm. When this is not the case, a more complete evaluation should be undertaken, evaluating the central and peripheral nervous systems, use of medications and substances, and relationship issues. SSRI antidepressants are well known to interfere with orgasm. Alcohol use can cause difficulty with sustaining arousal or with orgasm. Many contextual and partner issues discussed with...

Alcohol Abuse and Pregnancy

The Institute of Medicine recognizes alcohol-related birth defects (ARBDs) and alcohol-related neurodevelopmen-tal disorder (ARND) in addition to fetal alcohol syndrome (FAS) as potential effects of alcohol use in pregnancy and the periconception period (Warren and Foudin 2001 Muchowski and Paladine, 2004). A diagnosis of FAS requires characteristic facial anomalies, growth retardation, and neurodevelopmental abnormalities. In partial FAS, affected children have some of these characteristics,...

Comorbidity of Personality and Somatoform Disorders

Personality and somatoform disorders have significant comorbidity, and clinical management of these disorders frequently overlaps. According to the DSM IV-TR, 1 to 5 of primary care patients meet the criteria for somatization disorder (APA, 2000). Prevalence rates for personality disorders are reported to be 4 to 13 in the general population and up to 24 of patients in primary care settings (Gross et al., 2002 Moran et al., 2000). A meta-analysis of 18 studies demonstrated that significant...

Pharmacologic Interventions Statins

Knee Plica Exercises

The statins are reversible, competitive 3-hydroxy-3-meth-ylglutaryl coenzyme A (HMG-CoA) reductase inhibitors. HMG-CoA reductase is the rate-limiting step for cholesterol biosynthesis in the liver and systemic tissues. Statins are the most potent agents for reducing serum levels of LDL-C. The statins augment the elimination of atherogenic apoB100-con-taining lipoproteins (VLDL, VLDL remnants, and LDL) from plasma by upregulating the LDL receptor on the surface of hepatocytes. The statins also...

Chlamydia trachomatis

Donovan Bodies

The majority of women with Chlamydia infection are without symptoms. Many men are asymptomatic as well. Regular screening for Chlamydia, as recommended by the USPSTF, can significantly reduce the incidence of pelvic inflammatory disease (PID), one of the most serious sequelae of untreated infection. In women with untreated Chlamydia infection, in addition to PID, tubo-ovarian abscess, tubal scarring and ectopic pregnancy, and infertility can all result. As previously mentioned, regular...