Mononucleosis Epstein Barr Virus Infection

Mononucleosis is a common viral infection, particularly in adolescents and young adults, and has an incubation period of 30 to 45 days and a prodrome of 7 to 14 days. Typically, mononucleosis is associated with an infection by the Epstein-Barr virus (EBV), which is a herpesvirus. Laboratory findings include leukocytosis, with more than half the leukocytes being lymphocytes. Approximately 10 to 15 of the mononuclear cells are atypical lymphocytes. Thrombocytopenia may develop with infectious...

Treatment

Special equipment is necessary to deal with anaphylactic events that occur in the office (Box 20-7). An algorithm for the management of the acute episode is shown in Figure 20-5. On suspicion that an anaphylactic event has occurred, therapy should be initiated immediately (Box 20-8). The airway, circulation, and level of consciousness should immediately be assessed. Oxygen should be started and the patient placed in the recumbent position with feet elevated. The recumbent position is important...

Indications and Contraindications

Routine immunizations are essential for the control and prevention of previously common childhood infectious diseases. During 2008, more than 76 of U.S. children age 19 to 35 months received 4 or more doses of diphtheria, tetanus toxoids, and pertussis vaccines (DTP DT DTaP) 3 or more doses of poliovirus vaccine 1 or more doses of any measles-containing vaccine at least 3 doses of Haemophilus influenzae type b (Hib) vaccine at least 3 doses of hepatitis B vaccine and at least 1 dose of...

Tinea Corporis

Tinea corporis is a superficial dermatophyte infection of the cornified layers of skin on the trunk and extremities. Lesions are typically annular with central clearing and a scaling border and may be pruritic (Fig. 33-42). Infection may be transmitted from person to person, by animals such as household pets or farm animals, and through fomites. Because the cornified layer of skin is involved, topical therapy is usually sufficient for localized cases. A topical antifungal should be applied to...

Manifestations

Almost all patients with anaphylaxis express cutaneous symptoms, the most common of which are urticaria and angioedema. However, anaphylactic events can occur without any cutaneous manifestation. The most common cause is probably the rapid onset of hypotension and shock, which diverts blood flow from the skin. Anaphylaxis can clearly be the cause of syncope without any other manifestation and therefore must be considered as a cause of any syncopal episode. Table 20-5 lists signs and symptoms of...

Maternal Biochemical Screening

Low-risk women can be offered screening for genetic abnormalities of the fetus by biochemical testing in the first or second trimester and ultrasound nuchal translucency screening (first trimester) and targeted ultrasound evaluation of fetal anatomy, best done at 18 to 20 weeks' gestation. The general consensus is that women of any age should have access to any screening or diagnostic testing (as previously described) if they choose to accept the underlying risks. Biochemical testing is the...

Measles Rubeola and Rubella

Rubeola presents as maculopapular (morbilliform) eruption. It starts on the face and spreads centrifugally. It is associated with cough, coryza, conjunctivitis, fever, and Koplik spots (red-white-blue macules in mouth). As with varicella, rubeola is now uncommon because of vaccinations. The exanthem of rubeola (measles) begins around the fourth febrile day, with discrete lesions that become confluent as they spread from the hairline downward, sparing the palms and soles. The exanthem typically...

Medications for Acute Relapses

Glucocorticoids are still widely used for the treatment of acute exacerbations of MS. The principal effects of cortico-steroids appear to be related to their anti-inflammatory and The complete reference list is available online at www.expertconsult.com. Washington University Neuromuscular Disease Center comprehensive resource for disorders affecting peripheral nerve, muscle, and neuromuscular junction. Centers for Disease Control and Prevention recommended immunization schedule. www.aan.com...

Methamphetamine

Methamphetamine is a highly addictive stimulant that can cause increased alertness and increased physical activity with small doses by causing the release of high levels of the neu-rotransmitter dopamine in the brain. Abusers of metham-phetamine experience a brief rush by smoking or injecting methamphetamine. Oral ingestion or snorting methamphet-amine can produce a high that can last approximately half a day. Due to tolerance, chronic users of methamphetamine may take higher doses of the drug...

Mitral Valve Prolapse

Mitral valve prolapse (MVP) is described as bulging of one or more of the mitral leaflets into the left atrium in systole (see Fig. 27-21). Although the most common cause of significant MR (Cheng and Barlow., 1989), it can be isolated without valvular insufficiency. MVP with MR is a strong indication for prophylaxis against bacterial endocarditis during dental, GI, and genitourinary procedures. MVP carries a benign course (Freed et al., 2002). On rare occasions it may be associated with...

Naltrexone

The euphoric effect of alcohol is mediated through the endogenous opioid system, with activation of the prefrontal cortex (Tuhonen et al., 1994). Naltrexone, an opioid antagonist, has documented beneficial effect in reducing relapse and craving in alcoholic patients (O'Malley et al., 1992 Swift et al., 1994 Volpicelli et al., 1992). Alcoholics taking nal-trexone report a less pleasurable effect or high from alcohol consumption and do not escalate their drinking as rapidly as control groups...

Narcissistic Personality Disorder

The family physician's reactions to the narcissistic patient are often difficult to manage. The superior, entitled, self-loving, arrogant attitude of these patients can be intimidating. They may elicit feelings of being devalued and inferior. The physician may have concerns about the patient's anger and criticism. Alternatively, the lack of empathy and interpersonal exploitation of these patients can readily provoke the physician to anger, a wish to retaliate with harsh criticism, or a desire...

Narcolepsy

Although rare, narcolepsy is an important cause of daytime sleepiness because it can affect personal safety and school performance but is readily treatable. Normally, REM sleep only occurs when a person has been asleep for 60 to 90 minutes and follows all four stages of non-REM sleep. Narcolep-tic patients, on the other hand, experience sudden episodes of REM sleep in the middle of a wakeful state or immediately after falling asleep. The key feature of narcolepsy is recurrent sleep attacks...

Neonatal Resuscitation

The successful transition to extrauterine life depends heavily on the ability of the neonatal pulmonary system to adapt quickly and provide oxygen to the infant. Any illness or injury Box 22-2 Neonatal Resuscitation Supplies and Equipment for Delivery of a Term Infant Mechanical suction and tubing Suction catheters 8-F feeding tube and 20-mL syringe Meconium aspirator Neonatal resuscitation bag with a pressure-release valve or pressure manometer Face masks, newborn and premature sizes Oxygen...

Neurochemical Hypothesis

Cholinergic transmission in the CNS has a major role in cognition and attention, and an acute cholinergic deficit exists in delirium. Dopaminergic transmission is increased in delirium, and this or the imbalance between cholinergic and dopaminergic systems may be etiologic. Disturbances in other neurotransmitters are hypothesized, perhaps explaining subtypes or variations in presentations of delirium. Serotonin may be increased in delirium associated with serotonin syndrome and in hepatic...

Neurologic Examination and Newborn Reflexes

The neurologic examination of the newborn begins with the general appearance of the infant. The newborn should have a strong cry and exhibit symmetric movements a high-pitched or weak cry can be associated with current illness or neurologic deficits. Asymmetric movements can indicate musculoskeletal or focal neurologic injury. Complete absence or asymmetry of any newborn reflex can indicate neurologic deficit or injury. The following developmental reflexes are present at birth in the normal...

Neutropenia

Neutropenia is defined as ANC less than 1800 cells L, approximately 2 SD below the mean, and includes both mature PMN and band forms. Some ethnic populations, such as those of African descent or Yemenite Jews, may have a lower total WBC count and ANC that can be normal at 1000 neutrophils . The primary concern with neutropenia is the risk of infection. Severe infection does not usually occur unless ANC is less than 500 cells L (Table 39-5). When severe neutropenia occurs, patients are at risk...

Nocturia

Nocturia describes waking at night to urinate. It is more common in older adults, but no population data define a normal range for any group therefore the complaint implies a deviation from a perceived norm. Furthermore, the primary complaint often centers on the sleep disturbance rather than on urination. It may represent frequent nocturnal urination or excessive nocturnal urine production (nocturnal polyuria). Although often thought of as a prostatic symptom, it is common in both men and...

Nontraditional Therapy

Interest in complementary and alternative medicine (CAM) for health disorders has been growing steadily in the last several decades. As a result, a greater number of alternative or complementary agents are being tested in more methodologically rigorous ways, allowing greater scientific assessment of such treatments. Survey evidence suggests that as many as 40 to 60 of patients may be taking CAM therapies, although patients often do not disclose such use to their physicians (Elkins et al.,...

Normal Equilibrium State and Stressors

Under normal circumstances, a person has a sense of internal psychological equilibrium and environmental support that generally permits activities of daily living (ADLs), working, and experiencing pleasure. A delicate balance among the person's internal wishes and fears, skills and capacities, and values and ideals determines psychological equilibrium. Environmental equilibrium refers to a stable balance among basic needs for food, water, shelter, physical comfort, and the integrity of...

Nutrition

Although uncontrolled pain is the principal complaint of many patients, the family's primary concern is often the patient not eating well. The causes of cancer cachexia are still poorly understood. Because patients seem to stop eating, lose weight, and eventually die, the natural assumption has been that even if physicians cannot effectively treat the cancer, they can at least treat malnutrition and thereby delay death. The problem is that more harm than good can come from tube feedings or...

Obstetrics

Williams and Gabriella Pridjian Placenta Accreta, Increta, and Percreta Drug and Chemical Exposures in Pregnancy Influenza and Novel Influenza A (H1N1) Virus Secondary Arrest of Cervical Dilation Abnormalities of the Second Stage of Labor Interpretation of Fetal Heart Rate Recordings

Operative Vaginal Deliveries

Indications for operative vaginal delivery in a low-risk mother are nonreassuring FHR, maternal exhaustion, and prolonged second stage, which is generally 3 hours for a nul-liparous woman and 2 hours for a parous woman. Essential for safe operative vaginal delivery is optimal readiness. The laboring woman should understand the reasons why operative delivery has been chosen, with documentation in the chart. She should then be placed in a position in which her legs are maximally open, preferably...

Opportunities

Education of the patient or the family can make a contribution to every medical interaction. Every recent medical school graduate is familiar with the SOAP note format (i.e., subjective data, objective data, assessment, and plan) for documenting a medical encounter. Adding education (E) to the plan by using a SOAPE note serves as a reminder to educate patients and to document the education. All excellent family physicians are also excellent teachers of patients. Such physicians typically...

Optic Neuritis

Optic neuritis is localized inflammation of the optic nerve sheath, resulting in reduced neuronal transmission and decreased visual acuity. Generally, there is a loss of color vision and red desaturation noticed by the patients. The symptoms generally worsen during the first few days and progressively improve over several weeks. In children, optic neuritis has various causes, typically associated with viral infections. In young adults, optic neuritis has a high association with multiple...

Orthopedic Disorders

Overweight children have an increased risk of slipped femoral capital epiphysis, genu valga, pes planus, and scoliosis (Speiser et al., 2005). In adults, an association between obesity and degenerative joint disease (DJD), particularly of the knee, is related in part to mechanical factors resulting in increased compressive forces on the knee. Obesity-related cytokine production has been associated with a chronic inflammatory state promoting osteoarthritis. Obesity is associated with knee...

Other Syndromes

Syndromes involving chromosomes (Down, Klinefelter's), fat and muscle metabolism (Prader-Willi, myotonic dystrophy), and autoimmune mechanisms (stiff man syndrome) can affect insulin secretion or sensitivity. Aging, 1 IR or 2 excess nutrient storage Figure 34-1 How normal or genetically impaired beta cells can be affected by inflammation and overnutrition, resulting in absolute or relative loss of insulin secretory reserve and the activation of the common mechanism leading to diabetic crisis. 1...

Pancreas

An equally dismal picture occurs with cancer of the pancreas, for which the 5-year survival rate is only 2 . Because of the nonspecific nature of the initial symptoms and the difficulty in making a diagnosis, the mean survival time after diagnosis of pancreatic cancer is less than 6 months. Smokers have two to three times the risk of pancreatic cancer as nonsmokers, and the risk is proportional to the amount smoked. Increased risk persists at least 10 years after quitting. More than one fourth...

Partial Lens Opacities

The evaluation of partial lens opacities is related to the location of the cataract. Anterior cataracts include anterior lenticonus, polar cataracts, persistent pupillary membrane opacities, and those occurring with anterior segment dys-genesis. Posterior cataracts include posterior polar, posterior lenticonus, persistent hyperplastic primary vitreous, and posterior subcapsular lens opacities. Posterior subcapsular cataracts are typically associated with corticosteroid use, atopic dermatitis,...

Pattern Recognition of Arrhythmias Atrial Rhythms

Treatment of asymptomatic or minimally symptomatic, non-life-threatening atrial rhythms should be less risky than no treatment at all. The proarrhythmic side effects of drug therapy, including ventricular fibrillation, should be carefully weighed before initiation of drug therapy. Sinus rhythm is a regular, organized atrial rhythm between 60 and 100 beats min at rest in healthy individuals. Slower rates as low as 40 to 50 beats min may be normal in some individuals. Originating high in the...

Pediatric Cataracts

Approximately 40 of acquired pediatric cataracts are secondary to trauma, and as many as approximately one third of pediatric cataracts are inherited. The basic approach to the patient with pediatric cataracts is to determine whether the cataract is an isolated finding, part of a systemic abnormality, or associated with ocular disease. When several members of the same family are affected by congenital cataracts, a hereditary origin may be assumed. Autosomal dominant hereditary patterns are the...

Peritonsillar Abscess

A peritonsillar abscess is the accumulation of pus in the peritonsillar space that surrounds the tonsil. The same organisms responsible for common tonsillar infections Streptococcus and Staphylococcus species and anaerobes are also found in peritonsillar abscesses. The typical signs and symptoms of peritonsillar abscess include fever, sore throat for 3 to 5 days, dysphagia, odynophagia, and a muffled, hot potato voice. Trismus is extremely common. Examination confirms asymmetric tonsils and...

Personal Control

An individual's perception of the extent of his or her control in a stressful circumstance is a critical component of the appraisal process in coping. This includes control over the stressor or circumstances as well as control over one's responses, whether problem focused or emotion focused. How a person deals with the loss of control precipitated by stressful life events can affect health outcomes. Personal control can be defined as the feeling that one can make decisions and take effective...

Pharmacologic Therapies

Various medications have been used to treat the different forms of urinary incontinence. However, most current medications are used for urge or mixed incontinence, because there is little evidence that adrenergic agonists help stress incontinence (Alhasso et al., 2005) (Table 4-18). The anti-cholinergic, antimuscarinic medications prescribed for urge incontinence work by blocking cholinergic receptors in the bladder, which in turn diminishes bladder contractility. This class of medications is...

Pharmacologic Therapy

Published studies to date overwhelmingly support the ability of aspirin to reduce stroke incidence and death in patients who present with TIA or CVA. Aspirin and other agents that affect platelet function are frequently used for long-term secondary stroke prevention. It therefore seems reasonable, after hemorrhage has been excluded by CT, to begin aspirin therapy in the setting of acute stroke, provided the patient does not have a contraindication to aspirin therapy. Aspirin doses between 50...

Physical Examination

The neck examination includes inspection for any neck lesions, masses, or scars as well as posture and normal cervical lordosis, characterized by a slight anterior curvature (Fig. 31-5). The neck is palpated for points of tenderness. Figure 31-1 Typical cervical vertebra. S, Spinous process L, lamina A, articular facet P, pedicle T, transverse process B, body. (Redrawn from MercierL. Practical Orthopedics, 5th ed. St Louis, Mosby, 2000, p 27) Figure 31-3 Ligaments of the cervical spine. A,...

Platelet Function Disorders

Impaired platelet function may be acquired or inherited. Certain drugs are designed to interfere with platelet function and have proved useful in preventing recurrent strokes or other cardiovascular events, such as transient ischemic attacks (TIAs), in patients with established vascular disease. Particularly useful are drugs such as aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). An important distinction between aspirin and NSAIDs is that aspirin irreversibly inactivates...

Platelet Functions

The primary role of the platelet is to maintain the integrity of the endothelial lining of small vessels. This process is not completely understood but most likely indicates that platelets are constantly being recruited to repair submicroscopic rents between endothelial lining cells in small arterioles and venules. Thus, when the platelet count falls below a certain level, petechiae begin to appear, particularly in the dependent portions of the body such as the ankles and lower legs. Minor...

Polycythemia

Polycythemia (or erythrocytosis) is the overproduction of red blood cells (erythrocytes). The mechanism of action resulting in polycythemia may be primary or secondary. Primary polycythemia indicates that the disorder arises at the level of the hematopoietic stem cells (see later), whereas secondary polycythemia represents the overproduction of RBCs caused by the increased stimulation of the bone marrow by EPO. Polycythemia is typically identified initially in the laboratory by Hb and Hct...

Posterior Pituitary Disorders

Arginine vasopressin (AVP) and oxytocin are the principal hormones secreted from the posterior pituitary. The two major stimuli of oxytocin secretion are suckling during lactation and dilation of the cervix during labor. Although not essential for initiation of labor, oxytocin can be used pharmacologically to initiate labor or control postpartum hemorrhage and uterine atony. Rarely, it has been used to induce milk ejection. The physiologic role of oxytocin in males is not known. AVP differs...

Postoperative Care

Intensive insulinization should be maintained in the postoperative ICU, especially in patients with increased risk of ketoacidosis. Problems can occur when ICU patients transfer to step-down units, where tight control to achieve 120 to 180 mg dL values depends on SC insulin delivery, which is inherently more unstable. The principles of adequate basal coverage and reactive bolus insulin apply, although frequent adjustments remain necessary because of altered insulin pharmacokinetics associated...

Postpartum Hemorrhage

Traditionally, postpartum hemorrhage (PPH) was defined as blood loss greater than 500 mL in a vaginal delivery and greater than 1000 mL in a cesarean delivery. However, studies have revealed that an uncomplicated delivery often results in blood loss of more than 500 mL without any compromise of the mother's condition (Pritchard et al., 1962). Clinically, these findings led some authors to adopt a broader definition for PPH. Any bleeding that results in signs and symptoms of hemodynamic...

Precipitating Factors

All patients suspected of having asthma should be questioned about early warning signs and precipitating factors. Early warning signs of an attack include symptoms such as cough, scratchy throat, and nasal stuffiness, especially if an attack follows an upper respiratory tract infection. Many other precipitating factors can provoke asthma symptoms or an acute attack (Box 20-3). Identification of these precipitating factors can help patients manage their asthma by learning their early warning...

Prevalence

Prevalence of diabetes has increased worldwide. In 1990 the prevalence of self-reported diabetes was 2.9 in the United States, increasing to almost 8 in the first decade of the 21st century. Because self-report misses persons with undiagnosed diabetes, the Centers for Disease Control and Prevention (CDC) estimates total prevalence of diabetes in adults 20 or older approaches 11 of the U.S. population, and those with impaired fasting glucose (prediabetes), about 26 (2003-2006). In both men and...

Prevention

The USPSTF recommends high-intensity behavioral counseling to at-risk adults and adolescents to prevent STIs. High-intensity counseling involves multiple sessions and often is delivered to groups of patients. Unfortunately, this type of intervention has limitations in its practicality for population-based delivery. No risk of harm was discovered in the delivery of counseling for STI prevention. Vaccination is the most important form of primary prevention of common infectious diseases. Two...

Prevention from the Disease Oriented Perspective A Focus on Heart Disease

To be effective, family physicians need to reduce mortality from all causes, not just heart disease or stroke for all their patients. Using the total number of deaths is the relevant measure of effectiveness for two reasons. First, it is simple, cleaner, and easier to measure a person is either alive or dead. Second, the count is not affected by diagnostic error. The literature reviewed here focuses especially on all-cause mortality as a relevant measure of a healthy lifestyle. In the United...

Preventive Health Care

Janelle Guirguis-Blake, Tracy Wolff, Renee Crichlow, Jane E. Wilson, and David Meyers Key Concepts in Evidence-Based Prevention Preventive Services for Pregnant Women Preventive Services for Older Adults Theories and Models of Behavior Change Family Physicians within the Health Care System Rethinking the Periodic Health Examination Metabolic, Nutritional, and Endocrine Conditions

Principles of Healing

Wound healing begins immediately after the initial trauma or cut. Traditional descriptions of wound healing use three distinct but overlapping phases (inflammatory, proliferative, remodeling), whereas others use four phases to better describe the healing process. Surgical technique and smoking are modifiable risk factors for poor wound healing. Other factors affecting wound healing include anemia, diabetes, malnutrition, HIV infection, and cancer. Trauma to surrounding tissue by the injury and...

Prostatitis

A common complication of UTI in men is prostatitis. Bacterial prostatitis is usually caused by the same gram-negative bacilli that cause UTI in female patients 80 or more of such infections are caused by Escherichia coli. The pathogenesis of this condition is poorly understood. Antibacterial substances in prostatic secretions probably protect against such infections. A National Institutes of Health (NIH) expert consensus panel has recommended classifying prostatitis into three syndromes acute...

Recommendation

The USPSTF recommends that clinicians routinely screen all sexually active women age 24 or younger (including pregnant women) and older asymptomatic women at increased risk for chlamydial infection. They recommend against routine screening in asymptomatic women age 25 and older (including pregnant women) who are not at increased risk. Although USPSTF found insufficient evidence to recommend for or against routine screening of men, they counsel clinicians and health care systems to focus on...

Recurrent Urinary Tract Infection

Recurrence of uncomplicated cystitis in reproductive-age women is common, and some form of preventive strategy is indicated if three or more symptomatic episodes occur in 1 year. However, risk factors specific to women with recurrent cystitis have received little study (Sen, 2008). Several antimicrobial strategies are available, but before initiating therapy, the patient should try such simple interventions as voiding immediately after sexual intercourse and using a contraceptive method other...

Reflux Laryngitis

Reflux laryngitis, also known as laryngopharyngeal reflux (LPR), is a relatively common condition. Many patients do not have the classic symptoms of GERD, including heartburn, and the correct diagnosis is often initially overlooked. Constant throat clearing may be the only presenting symptom. Other manifestations include a feeling of a lump in the throat with a choking sensation (globus pharyngeus), odynophagia, dysphagia, chronic cough, and hoarseness. The patient may also complain of...

Renal Protection

Renal protection, achieved with BP and glucose control, is a primary objective in diabetic care. The urine should be checked for microalbuminuria yearly. Finding marginal elevations indicates that control should be tightened and an ACE inhibitor or angiotensin receptor blocker (ARB) prescribed or increased. However, if BP is normal, pharmacotherapy can be difficult because of potential orthostasis. Another measure that could affect microalbuminuria is weight, which relates to the total-body...

Resuscitation of the Infant Born through Meconium Stained Amniotic Fluid

Meconium staining of the amniotic fluid is a common complication during delivery of term infants, and approximately 5 to 12 of these infants develop meconium aspiration Reflex irritability to tactile stimulation *Apgar scoring should be completed at 1 and 5 minutes. The normal Apgar score at 5 minutes is 7 or higher. If the 5-minute Apgar is less than 7, continue resuscitative efforts and assign additional scores every 5 minutes for up to 20 minutes after birth. Modified from Kattwinkel J (ed)....

Rocky Mountain Spotted Fever

Rocky Mountain spotted fever (RMSF) is the most severe and most often reported rickettsial illness in the United States. It is caused by Rickettsia rickettsii, a species of bacteria that is spread to humans by ixodid (hard) ticks (Figure 16-6). Initial signs and symptoms include sudden onset of fever, headache, and muscle pain, followed by development of rash. The disease can be difficult to diagnose in the early stage. RMSF is most common among males and children. Risk factors are frequent...

Sarcoidosis

Sarcoidosis is a systemic granulomatous disease of unknown etiology that most often involves the lungs (90 ). The skin is involved in about one third of patients with systemic sar-coidosis. In the United States, women and African Americans are more frequently affected. As with syphilis, sarcoidosis is considered a great imitator because it has widely variable presentations and may involve almost any organ system. Classic skin lesions of sarcoidosis are red-brown, nonscaly papules and plaques...

Screening

Screening, brief intervention, and referral to treatment (SBIRT) for alcohol use disorders in primary care has been well studied and is recommended for incorporation into routine primary care by the U.S. Preventive Services Task Force (USP-STF, SOR B). However, SBIRT in primary care for drug use has been less studied to date, and USPSTF states that there is currently insufficient evidence to recommend for or against routine screening for drug use in primary care. With the recent increase in...

Setting Goals

Discussing expectations for weight loss is important as the process begins. If a target goal is too difficult, the patient may quit in frustration. Studies show that a 5 to 10 body weight reduction is achievable through lifestyle approaches, and that this amount of weight loss will benefit health. If this goal is achieved and weight is still above the desired weight, a lower target can be set. Randomized trials demonstrate that weekly weight loss of 1 to 2 lb can be achieved with a daily...

Sick Euthyroid Syndrome Thyroid Hormone Adaptation Syndrome

Thyroid function can be suppressed during severe illness and may not represent abnormal thyroid function. Serious illness has been shown to affect laboratory tests of thyroid function (sTSH, T4, thyroglobulin), but there is no clear evidence this reflects a disease state (Chopra, 1997). Because these changes appear to have no direct adverse effect on the patient's overall clinical state, this condition is labeled sick euthyroid syndrome. In broad terms, sick euthyroid syndrome is more of...

Sickle Cell Anemia

Sickle cell anemia is an inherited autosomal condition in which glutamic acid in the sixth position on the p-globin chain is replaced by a valine (Glu6Val). This results in hemoglobin SS in the homozygous state. Sickle cell trait, or hemoglobin AS, is found in 8 to 10 of African Americans in the United States, and sickle cell anemia occurs in about 1 in 400, or about 70,000 individuals. The gene for HbS is prevalent in sub-Saharan Africa. Persons of Mediterranean descent from India or Saudi...

Skin

Examination of the skin should identify signs of systemic illness, signs of trauma from delivery, and birthmarks. Pallor, mottling, and central cyanosis can be signs of infection or respiratory distress. Petechiae on the face, scalp, and upper chest can occur as a result of a compressed nuchal cord during delivery. Bruising on the face and molding of the cranium are common in vaginal deliveries and often resolve in the first few days of life. Several common benign skin conditions in the newborn...

Special Clinical ECG Syndromes

Sick sinus syndrome (SSS) is a group of electrocardiographic and clinical findings. Patients often have symptoms of fatigue, palpitations, and heart racing and may suffer from dizzy spells or even syncope. The findings of paroxysmal atrial tachycardia, atrial fibrillation (AF), or atrial flutter result in tachypalpitations and heart racing. Excessive SA node suppression often occurs with drugs used to slow AV conduction or reduce atrial arrhythmias. Figure 27-51 demonstrates typical ECG...

Specific Immunotherapy

When skin tests identify sensitivity to an unavoidable inhalant allergen, immunotherapy may be indicated for treating allergic rhinitis. Its efficacy has been shown to be 80 for controlling pollen symptoms and 60 for controlling mold and house dust symptoms. Immunotherapy is therefore more effective in seasonal allergic rhinitis than perennial allergic rhinitis. When considering immunotherapy, the ease of control of other therapies should be weighed against the frequency and severity of...

Spondyloarthropathies

The spondyloarthropathies are a group of multisystem inflammatory disorders that affect predominantly the spine but also other joints and extra-articular tissues. Most are linked to the HLA-B27 gene, but HLA-B27 by itself does not explain the development of these diseases pathogenesis of these conditions is still unknown. They include ankylos-ing spondylitis, reactive arthritis (Reiter's syndrome), pso-riatic arthropathy, enteropathic arthropathy, juvenile-onset arthropathy, and...

Squamous Cell Carcinoma

Cutaneous squamous cell carcinoma is the second most common form of skin cancer, also arising primarily on sun-exposed skin of middle-aged and older adults. Most SCCs arise from sun-induced precancerous lesions (actinic keratoses). As in BD, there is a higher risk of SCC in patients with radiation dermatitis (x-ray damage), leukoplakia or erythro-plakia (in oral or genital mucosa), burn scars, and chronic skin ulcers. It is important to note that organ transplant recipients have a 40 to 250...

Stages of Change

The purpose of patient education efforts often is to inform and to change behavior. Typically, the goal is to improve adherence to therapeutic regimens, encourage new lifestyles, or help the patient adopt other behaviors that prevent disease and disability. One of the most useful ways to understand the process of behavior change is the transtheoretical model, often called the stages of change model (Zimmerman et al., 2000). This model proposes stages called pre-contemplation, contemplation,...

Stasis Dermatitis

Stasis dermatitis occurs on the lower extremities in patients with chronic venous insufficiency (Fig. 33-32). Impaired function of the venous valves permits backflow of the blood from the deep venous system to the superficial system, causing increased venous hydrostatic pressure and increased permeability of dermal capillaries. The condition typically affects middle-aged and older-adult patients, except for patients with acquired venous insufficiency resulting from surgery, trauma, or...

Subarachnoid Hemorrhage

A recent systematic review of the risk factors for subarachnoid hemorrhage (SAH) shows that smoking doubles the risk for SAH (Feigin et al., 2005). About one third of all SAH was found to be attributable to smoking in a smaller case-control study, and, although the risk dropped within a few years after quitting, it may remain increased for up to 15 years in the heaviest women smokers (Anderson et al., 2004). Older studies involving high-dose estrogen OCs showed a significant interaction with...

Summary

The epidemic of obesity has major implications for health care now and in the future. Family physicians are in a unique position to affect this epidemic through primary as well as secondary prevention. This strategy should start in childhood but must also continue as a lifelong process. Over a lifetime, gradual restriction in caloric intake and continued participation in physical activity are necessary to maintain weight and health. Weight management should be addressed with patients and...

Syphilis

Syphilis is a spirochetal infection that has resurged since 2001, the nadir year since 1996. Syphilis infection rates are highest in men who have sex with men. Syphilis is much less common than the other STIs, with an infection rate of 5.6 per 100,000 population in the United States (vs. 496 per 100,000 for Chlamydia). Syphilis presents in several stages. The primary phase of syphilis is a painless ulcer called a chancre (Figure 16-4). The chancre may be visible on the genitals, although it can...

Systemic Sclerosis Key Points

CREST syndrome and diffuse cutaneous systemic sclerosis are the primary manifestations of systemic sclerosis. Female male predominance is 8 1 for sclerosis. The major ACR criterion for systemic sclerosis is skin thickening proximal to the MCP and MTP joints. Scleroderma, or hardening of the skin, is now recognized to be a disorder involving almost every organ system in the body and is therefore more appropriately referred to as systemic sclerosis. Systemic sclerosis is characterized by a...

Terminology

The term substance use disorder (SUD) implies a continuum of use from abstinence to at-risk use to abuse and dependence (Fig. 51-1). The majority of the general population, as well as family medicine patients, are abstainers. The majority of users of illicit substances do not meet criteria for the diagnosis of abuse and dependency. This model of substance use is important for family medicine physicians to keep in mind as they talk with their patients about substance use issues. It highlights...

Testing for Strabismus

The corneal light reflex test, cover test, red reflex, and extra-ocular rotations are four basic tests for strabismus. To perform the corneal light test, project a penlight onto the cornea of both eyes simultaneously while the child looks straight ahead. Compare the placement of the two corneal reflections. When the eyes are straight, the light appears at the same point on each cornea. If a muscle deviation is present, the reflected light appears slightly off center in one eye. Figure 41-13...

The Biopsychosocial Model

As previously noted, the biopsychosocial model was proposed as a scientific paradigm by Engel (1977), who encouraged the clinician to observe biochemical and morphologic changes in relation to a patient's emotional patterns, life goals, attitudes toward illness, and social environment. Engel proposed that the brain and peripheral organs were linked in complex, mutually adjusting relationships, affected by changes in social as well as physical stimuli. Within this model, environmental and...

The Chronic Care Model

The chronic care model (CCM) has been proposed as a useful framework for considering the system changes necessary to construct a health care system that proactively promotes healthy behaviors and trains clinician and patients to work as partners in a collaborative care process (Glasgow et al., 2001) (Figure 6-3). The CCM identifies six essential elements of a health care system that together foster interactions between an informed, activated patient and a prepared, proactive health care team....

The Listening Environment

An important element in the listening environment is the physician's sense of attention with the patient, and whether the patient feels the physician is listening to his or her concerns (Table 14-1). If the physician is running behind schedule, has had several difficult encounters during the day, or is tired from lack of rest, the patient will often pick up on various subtleties in the physician's behavior that communicate a lack of presence to the patient (i.e., countertransference). Some...

The Physicians Attitude

Less than 10 of people die suddenly, whereas more than 90 experience a protracted life-threatening illness (Emanuel et al., 2003). Terminal illness is more taxing on the physician than sudden and unexpected death. Not surprisingly, an empathic family physician with a long patient relationship may be uncomfortable in dealing with the patient's impending death. Physicians are most uncomfortable when they feel helpless. Unfortunately, this leads to withdrawal from the patient who is terminally...

The Process in Your Clinical Practice

The encounter for lifestyle change opens with the establishment of rapport and trust with your patient. You are assisting the patient to be in control of the encounter and trying to establish a partnership for what needs to be done, which only the patient can decide. Your role is to assess the patient's level of healthy lifestyle activity, educational needs, emotional state, and readiness to embark on change, and to reflect these back to the patient as they become clear. A good way to open the...

Thirdhand Smoke

Thirdhand smoke occurs when cigarette smoke reacts with nitrous acid on surfaces to form tobacco-specific nitrosamines (TSNAs). Nitrous acid is a common indoor pollutant and, when combined with cigarette smoke, forms a carcinogen that becomes more potent over time. Thus, nicotine is converted to a dangerous carcinogen after it is absorbed on indoor surfaces in automobiles and furniture. This can be especially hazardous to infants and children who live close to the floor because the TSNAs are...

Transitioning

When clinically appropriate, usually at 6 to 12 hours, the patient should be offered oral fluids to determine GI function. When the diet is advanced to solid food, the patient should be started on subcutaneous (SC) insulin, basal and reactive therapy, while still maintaining the insulin infusion. A common error at this phase is discontinuation of the insulin infusion before SC insulin achieves an adequate steady state to prevent recurrent ketosis. This takes 4 to 6 hours if the correct basal...

Traumatic Tympanic Membrane Perforations

Traumatic perforation of the tympanic membrane may result from barotrauma (water skiing diving injuries, blast injuries, blows to side of head), ear canal instrumentation (cotton-tipped applicators, bobby pins, paper clips, cerumen curettes), or otitis media (see earlier discussion). The patient usually complains of acute pain that subsides quickly, associated with bloody otorrhea. Severe vertigo can occur but is transient in most cases. Persistent vertigo suggests inner ear involvement...

Trichomonas vaginalis

Trichomonas vaginalis causes vaginitis in women, who may have a stereotypic frothy, green, and foul-smelling discharge. Many women are asymptomatic with trichomoniasis. In addition to causing asymptomatic infection in men, T. vaginalis may cause urethritis. This organism may be suspected in men when patients have repeated treatment failures and no other explanation for symptoms. Microscopic examination of vaginal discharge is 60 to 70 sensitive in women. A first voided urine specimen or...

Urgent Situations

Urgent situations include those for which therapy should be instituted within minutes or a few hours. They include penetrating injuries of the globe, acute angle-closure glaucoma, Figure 41-10 Central retinal artery occlusion of left eye with Hollenhorst plaque in right eye. Patient has a characteristic cherry-red spot involving the macula of left eye (left). Hollenhorst plaque with a retinal arcade in right eye suggests bilateral carotid disease and cardiovascular disease (right). Figure 41-10...

Urinary Tract Disorders

Charles Carter, James Stallworth, and Robert Holleman Benign Neoplasia Benign Prostatic Hyperplasia Urogenital health care concerns account for 4.4 of all ambulatory patient visits in the United States, more than half with primary care physicians (Schappert and Rechtsteiner, 2008). Disease in the urogenital system can be categorized as anatomic, functional, infectious, and neoplastic disorders. Although there is inevitable overlap between these categories, as in benign prostatic hyperplasia...

Urinary Tract Infection in Pregnancy

Although the most common bacterial infection during pregnancy, the incidence of UTI in pregnancy is similar to that reported in sexually active nonpregnant women of childbearing age. Up to 40 of pregnant women with untreated bacteriuria in the first trimester develop acute pyelonephritis later in pregnancy. Premature births and perinatal mortality are increased in pregnancies complicated by UTI. Therefore, in pregnant women, asymptomatic bacteriuria should be actively sought and aggressively...

Uveitis

A red painful eye with photophobia and increased tearing often occurs with the presentation of anterior uveitis. In addition, the patient may have decreased vision. Vascular injection, a circumcorneal injection involving the deep vessels of the sclera, is one of the primary signs of anterior uve-itis. Generally, uveitis patients are moderately light sensitive. In addition, the inflammatory process may hinder aqueous production and reduce intraocular pressure. Patients suspected of an anterior...

Vascular Dementia

Vascular dementia vies with LBD as the second most common type of dementia in the United States. The rate is higher in areas with higher rates of hypertension. Conceptually, VaD refers to cases in which vascular disease produces cerebral injury severe enough to result in dementia. This fairly simple concept is made clinically challenging by the multiple types of vascular disease and the varying location and degree of the resulting cerebral injury. Cerebral damage may be hem-orrhagic, hypoxic,...

Vision Screening and Ocular Examination

Appropriate vision screening is one of the most important factors in pediatric eye care. Because focused visual stimuli are critical to normal development, early detection and correction of visual problems reduce serious vision impairment or blindness. The American Academy of Ophthalmology (AAO), American Academy of Pediatrics (AAP), and American Association of Pediatric Ophthalmology and Strabismus (AAPOS) strongly support the goal of early detection and treatment of eye problems in children....

Vitamin D

Vitamin D is now recognized not only for its importance in preventing rickets, but also in preventing osteopenia, osteoporosis, muscle weakness, and falls. Testing levels ofvitamin D can be considered in patients at increased risk of vitamin D deficiency, including elderly patients and those with osteoporosis, osteopenia, fat malabsorption, chronic kidney disease, and increased skin pigmentation. The term vitamin D includes vitamin D2 and vitamin D3. Vitamin D2 (calciferol) is manufactured from...

Web Resources

American College of Allergy, Asthma and Immunology for information on the diagnosis and treatment of allergic diseases. www.cdc.gov nchs fastats asthma.htm www.cdc.gov ASTHMA healthcare.html Center for Disease Control and Prevention Statistics. National Heart, Lung and Blood Institute and National Asthma Education and Prevention Panel Expert Panel Report 3 Guidelines for the Diagnosis and Management of Asthma, 2007. www.thoracic.org pft5 .html American Thoracic Society information for...

Who Will Be Involved

Formal studies and anecdotal reports have consistently indicated that involvement of all of the office staff in patient education increases the total impact and saves the physician time. The physician always needs to be involved in defining the educational goals, delivering brief messages about the importance of goals, prescribing an educational process, and following up regularly to assess progress. Depending on the physician's interest and the nature of the problem, the education can be given...

Woman and Child Health

The health of a nation is often reflected in the health of its mothers and newborns. The World Health Organization (WHO) often uses a nation's maternity and neonatal morbidity and mortality statistics as a proxy for the health status of its population. It is an important summary reflecting social, political, health care delivery, and medical outcomes in a geographic area. The United States, despite its economic wealth and medical resources, consistently ranks poorly in such measures as maternal...

Diagnosis and Staging

By the time many patients present for treatment, the diagnosis of COPD is apparent. In addition to symptoms of dyspnea, chronic productive cough, and functional limitations, patients can show physical findings of lung hyperexpansion (increased lung span on percussion, increased thoracic AP diameter, and use of accessory muscles of respiration). Extra-thoracic signs include peripheral or central cyanosis, nail clubbing, and signs of increased central venous pressure or even right-sided heart...

Epidemiology and Risk Factors

Secondary causes of pulmonary hypertension include chronic lung disease (COPD and chronic bronchitis), cardiac disease (congenital defects, mitral stenosis, left atrial myxoma), autoimmune or inflammatory conditions such as scleroderma and SLE (Paolini et al., 2004), and granulomatous disease such as sarcoidosis. Certain drugs (fenfluramine) can also cause the condition, as can chronic liver disease with portal hypertension. Some patients experience pulmonary hypertension as a complication of...

Laboratory Evaluation

There is no specific laboratory study or serum marker for the diagnosis of peripheral neuropathy. Information from the history and physical examination may direct specific laboratory tests (e.g., testing for specific toxins, infections, or inflammatory disorders). If the cause of neuropathy is not obvious, some screening laboratory studies should be considered ESR, CBC, LFTs, and determination of fasting blood glucose, glycosylated hemoglobin, BUN, creatinine, serum vitamin B12, and TSH levels....

Sinusitis

Symptoms of rhinitis and sinusitis are often very similar and even difficult to differentiate in many cases. Sinusitis implies inflammation of the mucosa of one or more of the paranasal sinuses. This usually coexists with rhinitis and is actually more accurately referred to as rhinosinusitis. Studies have shown that CT scans of patients with uncomplicated viral upper respiratory infections (URIs) have mucosal thickening and opacification of the sinuses. For this reason, most URIs are...

Laboratory Studies

A complete cell count (CBC) with differential, urinalysis, and renal and liver function tests should be performed if asymptomatic rheumatic disease is suspected. Importantly, the frequency of abnormal laboratory results increases with increasing age in the normal population, even in the absence of disease, including common tests such as erythrocyte sedimentation rate (ESR), uric acid, antinuclear antibodies (ANAs), and rheumatoid factor (RF). Thus, arthritis panels can confuse the situation and...

Erythema Nodosum

Erythema nodosum is an acute inflammatory process involving the fatty tissue layer underlying the skin (pan-niculitis). The condition is more frequently seen in women, and although often idiopathic, many cases are associated with streptococcal infections of the upper respiratory tract, drugs such as estrogens oral contraceptives, sarcoidosis, and inflammatory bowel disease. Other, less frequent bacterial causes include tuberculosis, brucellosis, mycoplasma, and chlamydia. Fungal infections such...

Sudden Sensorineural Hearing Loss

Although most types of hearing loss are nonurgent problems, sudden sensorineural hearing loss (SSNHL) deserves special note because it is considered otologic emergency. Any patient complaining of sudden hearing loss requires prompt evaluation. An obvious cause such as cerumen impaction or middle ear fluid can be treated appropriately and routinely. If a cause is not identified, sudden sensorineural hearing loss should be suspected and prompt ENT referral arranged. SSNHL is thought to be...

Sensorineural Hearing Loss

Hereditary (congenital) loss Idiopathic loss Meniere's disease Multiple sclerosis Noise-induced loss Ototoxicity Perilymphatic fistula Presbycusis Syphilis ally decreasing hearing acuity, especially for higher-pitch tones (women's and children's voices) and in certain situations (with background noise). Tinnitus is common. The cause of presbycusis is likely multifactorial, but ultimately the loss of cochlear hair cell function is thought to be the cause in most cases. Hair cell damage or loss...