Items in AFP with MESH term: Medical History Taking
ABSTRACT: Family physicians must proactively address the sexual health of their patients. Effective sexual health care should address wellness considerations in addition to infections, contraception, and sexual dysfunction. However, physicians consistently underestimate the prevalence of sexual concerns in their patients. By allocating time to discuss sexual health during office visits, high-risk sexual behaviors that can cause sexually transmitted diseases, unintended pregnancies, and unhealthy sexual decisions may be reduced. Developing a routine way to elicit the patient's sexual history that avoids judgmental attitudes and asks the patient for permission to discuss sexual function will make it easier to gather the necessary information. Successful integration of sexual health care into family practice can decrease morbidity and mortality, and enhance well-being and longevity in the patient.
ABSTRACT: Family physicians frequently encounter patients with knee pain. Accurate diagnosis requires a knowledge of knee anatomy, common pain patterns in knee injuries, and features of frequently encountered causes of knee pain, as well as specific physical examination skills. The history should include characteristics of the patient's pain, mechanical symptoms (locking, popping, giving way), joint effusion (timing, amount, recurrence), and mechanism of injury. The physical examination should include careful inspection of the knee, palpation for point tenderness, assessment of joint effusion, range-of-motion testing, evaluation of ligaments for injury or laxity, and assessment of the menisci. Radiographs should be obtained in patients with isolated patellar tenderness or tenderness at the head of the fibula, inability to bear weight or flex the knee to 90 degrees, or age greater than 55 years.
Fever in the Returned Traveler - Article
ABSTRACT: With the rising popularity of international travel to exotic locations, family physicians are encountering more febrile patients who recently have visited tropical countries. In the majority of cases, the fever is caused by a common illness such as tracheobronchitis, pneumonia, or urinary tract infection. However, fever in returned travelers always should raise suspicion for a severe or potentially life-threatening tropical infection. In addition to the usual medical history, physicians should obtain a careful travel history, a description of accommodations, information about pretravel immunizations or chemoprophylaxis during travel, a sexual history, and a list of exposures and risk factors. The extent and type of lymphadenopathy are important diagnostic clues. Altered mental status with fever is an alarm symptom and requires urgent evaluation and treatment. Malaria must be considered in patients who traveled even briefly within an endemic area. Enteric fever is treated with fluoroquinolones, dengue fever with supportive measures only, leptospirosis with penicillin or doxycycline, and rickettsial infections with doxycycline.
Acute Dyspnea in the Office - Article
ABSTRACT: Respiratory difficulty is a common presenting complaint in the outpatient primary care setting. Because patients may first seek care by calling their physician's office, telephone triage plays a role in the early management of dyspnea. Once the patient is in the office, the initial goal of assessment is to determine the severity of the dyspnea with respect to the need for oxygenation and intubation. Unstable patients typically present with abnormal vital signs, altered mental status, hypoxia, or unstable arrhythmia, and require supplemental oxygen, intravenous access and, possibly, intubation. Subsequent management depends on the differential diagnosis established by a proper history, physical examination, and ancillary studies. Dyspnea is most commonly caused by respiratory and cardiac disorders. Other causes may be upper airway obstruction, metabolic acidosis, a psychogenic disorder, or a neuromuscular condition. Differential diagnoses in children include bronchiolitis, croup, epiglottitis, and foreign body aspiration. Pertinent history findings include cough, sore throat, chest pain, edema, and orthopnea. The physical examination should focus on vital signs and the heart, lungs, neck, and lower extremities. Significant physical signs are fever, rales, wheezing, cyanosis, stridor, or absent breath sounds. Diagnostic work-up includes pulse oximetry, complete blood count, electrocardiography, and chest radiography. If the patient is admitted to the emergency department or hospital, blood gases, ventilation-perfusion scan, D-dimer tests, and spiral computed tomography can help clarify the diagnosis. In a stable patient, management depends on the underlying etiology of the dyspnea.
Diagnostic Approach to Tinnitus - Article
ABSTRACT: Tinnitus is a common disorder with many possible causes. Most cases of tinnitus are subjective, but occasionally the tinnitus can be heard by an examiner. Otologic problems, especially hearing loss, are the most common causes of subjective tinnitus. Common causes of conductive hearing loss include external ear infection, cerumen impaction, and middle ear effusion. Sensorineural hearing loss may be caused by exposure to excessive loud noise, presbycusis, ototoxic medications, or Meniere's disease. Unilateral hearing loss plus tinnitus should increase suspicion for acoustic neuroma. Subjective tinnitus also may be caused by neurologic, metabolic, or psychogenic disorders. Objective tinnitus usually is caused by vascular abnormalities of the carotid artery or jugular venous systems. Initial evaluation of tinnitus should include a thorough history, head and neck examination, and audiometric testing to identify an underlying etiology. Unilateral or pulsatile tinnitus may be caused by more serious pathology and typically merits specialized audiometric testing and radiologic studies. In patients who are discomforted by tinnitus and have no remediable cause, auditory masking may provide some relief.
ABSTRACT: Men who have sex with men often do not reveal their sexual practices or sexual orientation to their physician. Lack of disclosure from the patient, discomfort or inadequate training of the physician, perceived or real hostility from medical staff, and insufficient screening guidelines limit preventive care. Because of greater societal stresses, lack of emotional support, and practice of unsafe sex, men who have sex with men are at increased risk for sexually transmitted diseases (including human immunodeficiency virus infection), anal cancer, psychologic and behavioral disorders, drug abuse, and eating disorders. Recent trends indicate an increasing rate of sexual risk-taking among these men, particularly if they are young. Periodic screening should include a yearly health risk and physical assessment as well as a thorough sexual and psychologic history. The physician should ask questions about sexual orientation in a nonjudgmental manner; furthermore, confidentiality should be addressed and maintained. Office practices and staff should be similarly nonjudgmental, with confidentiality maintained. Targeted screening for sexually transmitted diseases, depression, substance abuse, and other disorders should be performed routinely. Screening guidelines, while inconsistent and subject to change, offer some useful suggestions for the care of men who have sex with men.
Diagnosing Heel Pain in Adults - Article
ABSTRACT: Heel pain is a common condition in adults that may cause significant discomfort and disability. A variety of soft tissue, osseous, and systemic disorders can cause heel pain. Narrowing the differential diagnosis begins with a history and physical examination of the lower extremity to pinpoint the anatomic origin of the heel pain. The most common cause of heel pain in adults is plantar fasciitis. Patients with plantar fasciitis report increased heel pain with their first steps in the morning or when they stand up after prolonged sitting. Tenderness at the calcaneal tuberosity usually is apparent on examination and is increased with passive dorsiflexion of the toes. Tendonitis also may cause heel pain. Achilles tendonitis is associated with posterior heel pain. Bursae adjacent to the Achilles tendon insertion may become inflamed and cause pain. Calcaneal stress fractures are more likely to occur in athletes who participate in sports that require running and jumping. Patients with plantar heel pain accompanied by tingling, burning, or numbness may have tarsal tunnel syndrome. Heel pad atrophy may present with diffuse plantar heel pain, especially in patients who are older and obese. Less common causes of heel pain, which should be considered when symptoms are prolonged or unexplained, include osteomyelitis, bony abnormalities (such as calcaneal stress fracture), or tumor. Heel pain rarely is a presenting symptom in patients with systemic illnesses, but the latter may be a factor in persons with bilateral heel pain, pain in other joints, or known inflammatory arthritis conditions.
The Patient with Daily Headaches - Article
ABSTRACT: The term 'chronic daily headache' (CDH) describes a variety of headache types, of which chronic migraine is the most common. Daily headaches often are disabling and may be challenging to diagnose and treat. Medication overuse, or drug rebound headache, is the most treatable cause of refractory daily headache. A pathologic underlying cause should be considered in patients with recent-onset daily headache, a change from a previous headache pattern, or associated neurologic or systemic symptoms. Treatment of CDH focuses on reduction of headache triggers and use of preventive medication, most commonly anti-depressants, antiepileptic drugs, and beta blockers. Medication overuse must be treated with discontinuation of symptomatic medicines, a transitional therapy, and long-term prophylaxis. Anxiety and depression are common in patients with CDH and should be identified and treated. Although the condition is challenging, appropriate treatment of patients with CDH can bring about significant improvement in the patient's quality-of-life.
Evaluation of Chronic Dyspnea - Article
ABSTRACT: Chronic dyspnea is defined as dyspnea lasting more than one month. In approximately two thirds of patients presenting with dyspnea, the underlying cause is cardiopulmonary disease. Establishing an accurate diagnosis is essential because treatment differs depending on the underlying condition. Asthma, congestive heart failure, chronic obstructive pulmonary disease, pneumonia, cardiac ischemia, interstitial lung disease, and psychogenic causes account for 85 percent of patients with this principal symptom. The history and physical examination should guide selection of initial diagnostic tests such as electrocardiogram, chest radiograph, pulse oximetry, spirometry, complete blood count, and metabolic panel. If these are inconclusive, additional testing is indicated. Formal pulmonary function testing may be needed to establish a diagnosis of asthma, chronic obstructive pulmonary disease, or interstitial lung disease. High-resolution computed tomography is particularly useful for diagnosing interstitial lung disease, idiopathic pulmonary fibrosis, bronchiectasis, or pulmonary embolism. Echocardiography and brain natriuretic peptide levels help establish a diagnosis of congestive heart failure. If the diagnosis remains unclear, additional tests may be required. These include ventilation perfusion scans, Holter monitoring, cardiac catheterization, esophageal pH monitoring, lung biopsy, and cardiopulmonary exercise testing.
ABSTRACT: Dementia is a common disorder among older persons, and projections indicate that the number of patients with dementia in the United States will continue to grow. Alzheimer's disease and vascular dementia account for the majority of cases of dementia. After a thorough history and physical examination, including a discussion with other family members, a baseline measurement of cognitive function should be obtained. The Mini-Mental State Examination is the most commonly used instrument to document cognitive impairment. Initial laboratory evaluation includes tests for thyroid-stimulating hormone and vitamin B12 levels. Structural neuroimaging with noncontrast computed tomography or magnetic resonance imaging also is recommended. Other testing should be guided by the history and physical examination. Neuropsychologic testing can help determine the extent of cognitive impairment, but it is not recommended on a routine basis. Neuropsychologic testing may be most helpful in situations where screening tests are normal or equivocal, but there remains a high level of concern that the person may be cognitively impaired.