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ABSTRACT: Acute abdominal pain can represent a spectrum of conditions from benign and self-limited disease to surgical emergencies. Evaluating abdominal pain requires an approach that relies on the likelihood of disease, patient history, physical examination, laboratory tests, and imaging studies. The location of pain is a useful starting point and will guide further evaluation. For example, right lower quadrant pain strongly suggests appendicitis. Certain elements of the history and physical examination are helpful (e.g., constipation and abdominal distension strongly suggest bowel obstruction), whereas others are of little value (e.g., anorexia has little predictive value for appendicitis). The American College of Radiology has recommended different imaging studies for assessing abdominal pain based on pain location. Ultrasonography is recommended to assess right upper quadrant pain, and computed tomography is recommended for right and left lower quadrant pain. It is also important to consider special populations such as women, who are at risk of genitourinary disease, which may cause abdominal pain; and the elderly, who may present with atypical symptoms of a disease.
ABSTRACT: The population of adults with congenital heart disease is increasing in North America. Radiologic imaging is critical for the initial assessment and for surveillance in this population. Chest radiography and echocardiography are valuable first-line tools for evaluation. However, magnetic resonance imaging and computed tomography are often necessary, particularly for assessment of extracardiac anatomy or specific vascular connections or relationships, which may be complex in postoperative patients. Although magnetic resonance imaging and computed tomography can provide volumetric data for more comprehensive evaluation of cardiac anatomy and function, magnetic resonance imaging does not require patient exposure to ionizing radiation or nephrotoxic iodinated contrast media. Magnetic resonance imaging also can measure blood flow for quantification of left-to-right shunts, regurgitant fractions, and pressure gradients. Although noninvasive imaging techniques have limitations, they can evaluate most lesions and preclude the need for cardiac catheterization. Noninvasive imaging is particularly useful for serial evaluation of patients with surgically corrected congenital heart disease, because nearly one half of these patients will require two or more surgeries.
ABSTRACT: Solitary pulmonary nodules are common radiologic findings, typically discovered incidentally through chest radiography or computed tomography of the neck, chest, and abdomen. Primary care physicians must decide how to pursue an evaluation of a nodule once it has been identified. The differential diagnosis for pulmonary nodules includes benign and malignant causes. Diameter of 8 mm or more, "ground-glass" density, irregular borders, and doubling time between one month and one year suggest malignancy. The American College of Chest Physicians recently released guidelines for the evaluation of solitary pulmonary nodules, based primarily on nodule size and patient risk factors for cancer. Algorithms for the evaluation of lesions smaller than 8 mm and those 8 mm or greater recommend different imaging follow-up regimens. Fluorodeoxyglucose-positron emission tomography can be used to aid decision making when cancer pretest probability and imaging results are discordant. Any patient with evidence of a nodule with notable growth during follow-up should undergo biopsy for identification. The rationale for closely monitoring an incidentally found pulmonary lesion is that detection and treatment of early lung cancer might lead to decreased morbidity and mortality.
ABSTRACT: Adnexal masses represent a spectrum of conditions from gynecologic and nongynecologic sources. They may be benign or malignant. The initial detection and evaluation of an adnexal mass requires a high index of suspicion, a thorough history and physical examination, and careful attention to subtle historical clues. Timely, appropriate laboratory and radiographic studies are required. The most common symptoms reported by women with ovarian cancer are pelvic or abdominal pain; increased abdominal size; bloating; urinary urgency, frequency, or incontinence; early satiety; difficulty eating; and weight loss. These vague symptoms are present for months in up to 93 percent of patients with ovarian cancer. Any of these symptoms occurring daily for more than two weeks, or with failure to respond to appropriate therapy warrant further evaluation. Transvaginal ultrasonography remains the standard for evaluation of adnexal masses. Findings suggestive of malignancy in an adnexal mass include a solid component, thick septations (greater than 2 to 3 mm), bilaterality, Doppler flow to the solid component of the mass, and presence of ascites. Family physicians can manage many nonmalignant adnexal masses; however, prepubescent girls and postmenopausal women with an adnexal mass should be referred to a gynecologist or gynecologic oncologist for further treatment. All women, regardless of menopausal status, should be referred if they have evidence of metastatic disease, ascites, a complex mass, an adnexal mass greater than 10 cm, or any mass that persists longer than 12 weeks.
Evaluation of Acute Pelvic Pain in Women - Article
ABSTRACT: Diagnosis of pelvic pain in women can be challenging because many symptoms and signs are insensitive and nonspecific. As the first priority, urgent life-threatening conditions (e.g., ectopic pregnancy, appendicitis, ruptured ovarian cyst) and fertility-threatening conditions (e.g., pelvic inflammatory disease, ovarian torsion) must be considered. A careful history focusing on pain characteristics, review of systems, and gynecologic, sexual, and social history, in addition to physical examination helps narrow the differential diagnosis. The most common urgent causes of pelvic pain are pelvic inflammatory disease, ruptured ovarian cyst, and appendicitis; however, many other diagnoses in the differential may mimic these conditions, and imaging is often needed. Transvaginal ultrasonography should be the initial imaging test because of its sensitivities across most etiologies and its lack of radiation exposure. A high index of suspicion should be maintained for pelvic inflammatory disease when other etiologies are ruled out, because the presentation is variable and the prevalence is high. Multiple studies have shown that 20 to 50 percent of women presenting with pelvic pain have pelvic inflammatory disease. Adolescents and pregnant and postpartum women require unique considerations.
ABSTRACT: Pregnant women are at risk of exposure to nonionizing and ionizing radiation resulting from necessary medical procedures, workplace exposure, and diagnostic or therapeutic interventions before the pregnancy is known. Nonionizing radiation includes microwave, ultrasound, radio frequency, and electromagnetic waves. In utero exposure to nonionizing radiation is not associated with significant risks; therefore, ultrasonography is safe to perform during pregnancy. Ionizing radiation includes particles and electromagnetic radiation (e.g., gamma rays, x-rays). In utero exposure to ionizing radiation can be teratogenic, carcinogenic, or mutagenic. The effects are directly related to the level of exposure and stage of fetal development. The fetus is most susceptible to radiation during organogenesis (two to seven weeks after conception) and in the early fetal period (eight to 15 weeks after conception). Noncancer health effects have not been detected at any stage of gestation after exposure to ionizing radiation of less than 0.05 Gy (5 rad). Spontaneous abortion, growth restriction, and mental retardation may occur at higher exposure levels. The risk of cancer is increased regardless of the dose. When an exposure to ionizing radiation occurs, the total fetal radiation dose should be estimated and the mother counseled about the potential risks so that she can make informed decisions about her pregnancy management.
ABSTRACT: Acute intestinal obstruction occurs when there is an interruption in the forward flow of intes- tinal contents. This interruption can occur at any point along the length of the gastrointestinal tract, and clinical symptoms often vary based on the level of obstruction. Intestinal obstruc- tion is most commonly caused by intra-abdominal adhesions, malignancy, or intestinal hernia- tion. The clinical presentation generally includes nausea and emesis, colicky abdominal pain, and a failure to pass flatus or bowel movements. The classic physical examination findings of abdominal distension, tympany to percussion, and high-pitched bowel sounds suggest the diagnosis. Radiologic imaging can confirm the diagnosis, and can also serve as useful adjunc- tive investigations when the diagnosis is less certain. Although radiography is often the initial study, non-contrast computed tomography is recommended if the index of suspicion is high or if suspicion persists despite negative radiography. Management of uncomplicated obstructions includes fluid resuscitation with correction of metabolic derangements, intestinal decompres- sion, and bowel rest. Evidence of vascular compromise or perforation, or failure to resolve with adequate bowel decompression is an indication for surgical intervention.
American Heart Association Issues Guidelines on Imaging in Transient Ischemic Attacks and Stroke - Special Medical Reports
ABSTRACT: Stress fractures are common injuries in athletes and military recruits. These injuries occur more commonly in lower extremities than in upper extremities. Stress fractures should be considered in patients who present with tenderness or edema after a recent increase in activity or repeated activity with limited rest. The differential diagnosis varies based on location, but commonly includes tendinopathy, compartment syndrome, and nerve or artery entrapment syndrome. Medial tibial stress syndrome (shin splints) can be distinguished from tibial stress fractures by diffuse tenderness along the length of the posteromedial tibial shaft and a lack of edema. When stress fracture is suspected, plain radiography should be obtained initially and, if negative, may be repeated after two to three weeks for greater accuracy. If an urgent diagnosis is needed, triple-phase bone scintigraphy or magnetic resonance imaging should be considered. Both modalities have a similar sensitivity, but magnetic resonance imaging has greater specificity. Treatment of stress fractures consists of activity modification, including the use of nonweight-bearing crutches if needed for pain relief. Analgesics are appropriate to relieve pain, and pneumatic bracing can be used to facilitate healing. After the pain is resolved and the examination shows improvement, patients may gradually increase their level of activity. Surgical consultation may be appropriate for patients with stress fractures in high-risk locations, nonunion, or recurrent stress fractures. Prevention of stress fractures has been studied in military personnel, but more research is needed in other populations.
Subacute Management of Ischemic Stroke - Article
ABSTRACT: Ischemic stroke is the third leading cause of death in the United States and a common reason for hospitalization. The subacute period after a stroke refers to the time when the decision to not employ thrombolytics is made up until two weeks after the stroke occurred. Family physicians are often involved in the subacute management of ischemic stroke. All patients with an ischemic stroke should be admitted to the hospital in the subacute period for cardiac and neurologic monitoring. Imaging studies, including magnetic resonance angiography, carotid artery ultrasonography, and/or echocardiography, may be indicated to determine the cause of the stroke. Evaluation for aspiration risk, including a swallowing assessment, should be performed, and nutritional, physical, occupational, and speech therapy should be initiated. Significant causes of morbidity and mortality following ischemic stroke include venous thromboembolism, pressure sores, infection, and delirium, and measures should be taken to prevent these complications. For secondary prevention of future strokes, antiplatelet therapy with aspirin should be initiated within 24 hours of ischemic stroke in all patients without contraindications, and one of several antiplatelet regimens should be continued long-term. Statin therapy should also be given in most situations. Although permissive hypertension is initially warranted, antihypertensive therapy should begin within 24 hours. Diabetes mellitus should be controlled and patients counseled about lifestyle modifications to reduce stroke risk. Rehabilitative therapy following hospitalization improves outcomes and should be considered.