Treatment of Cardiac Arrhythmias

An organized approach to the treatment of cardiac arrhythmias is paramount. Initial steps include identification and verification of the arrhythmia type and an assessment of potential harm to the patient. Box 27-9 outlines various rhythms categorized by their cardiac chamber of origin. As previously described, inpatient evaluation is recommended in some patients. When pharmacologic therapy is recommended, the side-effects and proarrhythmia potential must be known. Table 27-16 outlines...

Mind Body Medicine

The area of CAM with perhaps the most extensive research base is mind-body medicine, which encompasses a diverse array of practices that overlap many traditions and whole systems of care. Astin and colleagues (2003) concluded, There is now considerable evidence that an array of mind-body therapies can be used as effective adjuncts to conventional medical treatment for a number of common clinical conditions. They found strong evidence to support mind-body approaches in the treatment of low back...

Difficult Patients Personality Disorders and Somatoform Complaints

Feinstein and Frank Verloin deGruy III Personality Style vs. Personality Disorder Discussing Defense Mechanisms and Coping Styles Management Algorithm for Somatization Unexplained Physical Symptoms vs. Somatoform Disorders Pharmacotherapy and Psychotherapy for Somatoform Disorders Patient Core Beliefs, Irrational Thoughts, and Fears Interventions for Specific Personality Disorders Patient Behaviors, Adherence, and Use of Medical Services Physician Reactions to Difficult Patients...

Key Treatment

Give oral griseofulvin daily for 6 to 8 weeks to treat tinea capitis (Fleece et al., 2004) (SOR B). Consider 4 weeks of oral terbinafine daily (Caceres-Rios et al., 2000) (SOR B). Consider oral fluconazole (available as liquid) as an option to treat tinea capitis (Foster et al., 2005) (SOR B). Figure 33-48 Inverse psoriasis that resembles tinea cruris. Note nail pitting of psoriasis. Richard P. Usatine.) Figure 33-48 Inverse psoriasis that resembles tinea cruris. Note nail pitting of psoriasis....

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

In seasonal allergic rhinitis, exposure is followed by complaints of paroxysmal sneezing, a watery nasal discharge with congestion, and nasal pruritus. Conjunctival and pharyngeal itching often occurs. Less specific symptoms are postnasal drainage or fullness or aching in the frontal areas. The patient might exhibit an allergic salute, an upward thrust of the palm against the nares to relieve itching and open the nasal airways and a gaping expression from mouth breathing. Allergic shiners or...

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...

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...

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...

Nasal Obstruction

The sensation of unilateral or bilateral nasal obstruction is relatively common and can range from mildly annoying to extremely frustrating to the patient. Nasal obstruction may be associated with other symptoms such as rhinorrhea, lost or altered sense of smell, or facial discomfort. Nasal obstruction may result from pathology of the nasal cavity or nasopharynx. (eTable 19-4 online summarizes the most common causes, associated signs and symptoms, and treatment for nasal obstruction). See the...

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...

Neoplastic

Anaplastic carcinoma Follicular carcinoma Lymphoma Medullary carcinoma Papillary carcinoma of hyperthyroidism and is more common in women age 20 to 50. Treatment modalities include antithyroid medications, radioactive iodine ablation, or surgical excision when medical treatment fails. Thyroiditis can cause nodular enlargement of the thyroid gland. Subacute thyroiditis may be a cause of intermittent hyperthyroidism from the release of stored thyroid hormone. Chronic lymphocytic (Hashimoto's)...

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...

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...

Nodules and Cysts

Thyroid nodules come in a variety of sizes and types. The incidence of malignancy in nodules less than 1.0 cm, which are found incidentally during nonthyroid-related diagnostic procedures (e.g., head and neck ultrasonography), is less than 0.5 . Current recommendations for evaluation of inci-dentalomas include a sTSH and FT4 and careful palpation of the thyroid gland (Cooper et al., 2009). If tests and palpation are normal, only annual follow-up with palpation by the physician is recommended....

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.,...

Nursing Home

As dementia progresses, most patients develop severe functional deficits or behavior problems that make living at home impossible, even with the most dedicated family caregivers supported by home health care workers. Nursing home admission is a traumatic experience for the patient and family even in the best of circumstances. The trauma is reduced if the admission can be anticipated and the patient and family have meaningful involvement in the decision-making process. The physician's role in...

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

Opiates Nonmedical Use of Prescription Drugs

Hydrocodone (Vicodin) is the most frequently prescribed opioid in the United States. Oxycodone (Oxycontin) and hydrocodone are prescribed in the treatment of acute and chronic pain. Abusers of hydrocodone and oxycodone experience euphoria, relaxation, and sedation. Long-term use can result in tolerance. Abusers may overdose as they take increasing doses of the medication while pursuing euphoric sensations that they previously experienced. Overdoses may result in severe respiratory depression,...

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

See online text for other forms of hyperthyroidism (ficti-tious iatrogenic thyrotoxicosis). Two courses of action can be followed for long-term treatment of Graves' disease. The goal is to maintain a euthyroid state. This can be accomplished with continued use of anti-thyroid medication, adjusting dose to maintain sTSH in a normal range. The alternative treatment is ablation of the thyroid gland using 131I, usually requiring postradiation thyroid hormone replacement. Either is appropriate, and...

Other Causes of Strabismus

Acute strabismus may be brought on by a viral upper respiratory tract infection, which can cause acute cranial nerve VI palsy. With the advent of antibiotics, middle ear infections with associated petrositis and cranial nerve VI palsies are relatively uncommon. Sudden-onset strabismus may also indicate underlying neurologic disease. Another cause is spasm of the near reflex. A hallmark of spasm of convergence is a constricted pupil. Paralytic or mechanical causes of strabismus occur with trauma...

Other Drugs

Table 51-6 lists the signs and symptoms of intoxication and withdrawal of other drugs. There are no specific antidotes or reversal agents for the remaining drug classes. Care of the overdose patient is largely supportive and aimed at treating the medical effects of the particular overdose, such as treatment of myocardial ischemia resulting from cocaine overdose. Currently, no FDA-approved medications are available for stimulant (including cocaine and methamphetamine), marijuana, hallucinogen...

Other Pulmonary Diseases of the Pulmonary Vasculature

Wegener's granulomatosis is a vasculitis (inflammatory condition) of the vascular bed that can manifest either with shortness of breath or hemoptysis or with progressive pulmonary fibrosis caused by repeated small hemorrhages at the alveolar level. It is now categorized as a systemic antineutrophil cytoplasmic antibody (ANCA)-associated small-vessel vasculitis, and it usually combines pulmonary features with glomeru-lonephritis. Tissue biopsy of either the lung or the kidney may be diagnostic....

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...

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...

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...

Pregnant Women

Approximately 5.1 of pregnant women age 15 to 44 were current users of illicit substances in 2008. Compared with nonpregnant women, the rate of drug use is significantly lower for all age groups, with the exception of adolescent women 15 to 17 years old. The rate of illicit substance use was higher among pregnant adolescents age 15 to 17 compared to same-age nonpregnant adolescents (21.6 vs. 12.9 ). Use of cocaine, heroin, methamphetamine, marijuana, MDMA, inhalants, and nicotine during...

Prenatal Genetic Diagnostic Testing

If specific risk factors for fetal abnormalities are identified in the mother, appropriate counseling and specific diagnostic testing should be offered. The most common reason to offer prenatal genetic diagnosis is advanced maternal age a somewhat linear increase in nondisjunction in meiosis increases the risk of a conception with aneuploidy (abnormal chromosome number). This is one reason why older women have a higher rate of spontaneous first-trimester miscarriage. It is also why older women...

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...

Preventive Services for Older Adults

An emphasis on a shared decision-making approach is especially important when considering preventive services for older adults. Family physicians and their older patients should consider issues that contribute to the complexity of prevention in older adults, including unique goals of prevention, life expectancy, comorbidities, potential for harm, and patient values and preferences (Harris et al., 2001). The patient's values and preferences are always important, and shared decision making should...

Procedure Room

Evert Skin Edges

A clean procedure room with a table that elevates and an overhead surgical light that can be adjusted and focused gives the provider the best environment to carry out procedures. An adjustable and mobile mayo stand allows the most comfortable access to sterile trays and instruments during a procedure. Surgical instruments should be stored in sterile packs, ideally set up for specific procedures. Extra equipment may be in individual sterile packs and should be readily available. Check sterility...

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...

Quality of Care

Primary care provided by physicians specifically trained to care for the problems presenting to personal physicians, who know their patients over time, is of higher quality than care provided by other physicians. This has been confirmed by a variety of studies comparing the care given by physicians in different specialties. When hospitalized patients with pneumonia are cared for by family physicians or full-time specialist hospitalists, the quality of care is comparable, but the hospitalists...

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...

Referral to the Rheumatologist

As for all types of disease conditions, referral to the subspe-cialist largely depends on the family physician's knowledge, interest level, and logistical ability to provide state-of-the-art care to a given patient for a given disease entity at a given time in the disease course. Specific conditions, such as suspected septic arthritis, acute myelopathy or mononeuritis multiplex, suspected acute tendon or muscle rupture, or acute internal derangement, should probably be referred. In addition,...

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...

Rheumatoid Arthritis

Rheumatoid arthritis affects women 3 1 over men, with 70 having an insidious onset. Symmetric synovitis with morning stiffness longer than 1 hour is the hallmark of RA. Constitutional symptoms are common in patients with RA. Rheumatoid arthritis is a chronic inflammatory systemic disease in which cellular and autoimmune mechanisms result in destruction of tissues, primarily the synovium. Genetic predisposition appears to be important, but a specific inciting infectious agent or other cause has...

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 for Lead Toxicity

Lead is neurotoxic and affects both intellectual and behavioral function, even below the 10 dL level established by the U.S. Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) (Canfield et al., 2003). Federal Medicaid law has required lead screening of young children eligible for Medicaid at ages 12 months and 24 months, and for children ages 36 to 72 months not previously tested. However, 1999-2004 NHANES data demonstrate that the percentage of children with...

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...

Second Line Medications

Clonidine and nortriptyline are listed in the PHS guidelines as second-line drugs, and both have been shown to have significant effects on cessation compared with placebo (Fiore et al., 2008). Nortriptyline is generally titrated up to 75 to 100 mg day and used for 8 to 12 weeks. It has the advantage of being quite inexpensive, but drug levels may be needed to avoid toxicity. Clonidine patches, 0.2 mg day, are recommended for up to 10 weeks and should be started 1 week before the quit date....

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...

Shoulder Dystocia

Shoulder dystocia is defined as the impaction of the anterior shoulder against the pubic symphysis after the delivery of the head and occurs when the breadth of the shoulder is greater than the biparietal diameter of the head (Fig. 21-8). It is a life-threatening event associated with significant morbidity and mortality that needs to be recognized early and managed promptly. The overall incidence of shoulder dystocia is 0.3 to 1 but increases to 5 to 7 for newborns with macrosomia (birth weight...

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...

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...

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...

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...

Thyroid Masses

Careful examination for thyroid abnormalities should be performed on each patient in routine office visits. Thyroid nodules occur in about 5 to 10 of the population of these, approximately 10 are malignant. Differential diagnosis of thyroid masses is presented in Box 19-9. Risk factors for malignancy include exposure to radiation and family history of medullary carcinoma. Factors that increase the possibility of carcinoma include hoarseness age younger than 20 years or older than 45 years male...

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...

Treatment Nonspecific Measures

Removing known allergens is of prime importance because it can eliminate symptoms. When exposure is unavoidable, environmental control should reduce symptoms and prevent exacerbations. The patient or the family must assume responsibility for environmental control, so an understanding of allergens is helpful. Commonly inhaled allergens include pollens, which can produce symptoms of seasonal allergic rhinitis, conjunctivitis, and asthma. Allergenic pollens come from trees, grasses, and weeds....

Twelve Step Facilitation

Twelve-step facilitation (TSF) is a modality that seeks to increase the SUD patient's attendance and active involvement in 12-step self-help groups such as Cocaine Anonymous (CA) and Narcotics Anonymous (NA). TSF is used in residential treatment programs as well as outpatient settings. Sessions are highly structured, often workbook guided, and cast the counselor in the role of facilitator of change, with patient involvement the true agent of change. The underlying 12-step principles are the...

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 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....

Web Resources

Ira Byock's website, includes resources on end-of-life care, grief and healing, and frequently asked questions about end-of-life experience and care. www.hospicefoundation.org Hospice Foundation of America. How to locate and choose a hospice, paying for hospice care, tools for caregivers, etc. www.nahc.org National Association for Home Care. Trade association representing interests and concerns of home care agencies and hospices, including regulatory, legislative, and...

Who Is More Likely to Use CAM and

Consistent with data from the 2002 NHIS study, CAM use by adults in 2007 was more prevalent among women adults age 30 to 69 those with higher education level, not poor, or living in the West former smokers and those hospitalized in the prior year (Barnes, 2008). CAM use was positively associated with number of health conditions and number of physician visits in the previous year. When concerned about cost or inability to pay for conventional care, adults were more likely to use CAM. For...

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...