Items in AFP with MESH term: Medical History Taking
Evaluation of Nausea and Vomiting - Article
ABSTRACT: A comprehensive history and physical examination can often reveal the cause of nausea and vomiting, making further evaluation unnecessary. Acute symptoms generally are the result of infectious, inflammatory, or iatrogenic causes. Most infections are self-limiting and require minimal intervention; iatrogenic causes can be resolved by removing the offending agent. Chronic symptoms are usually a pathologic response to any of a variety of conditions. Gastrointestinal etiologies include obstruction, functional disorders, and organic diseases. Central nervous system etiologies are primarily related to conditions that increase intracranial pressure, and typically cause other neurologic signs. Pregnancy is the most common endocrinologic cause of nausea and must be considered in any woman of childbearing age. Numerous metabolic abnormalities and psychiatric diagnoses also may cause nausea and vomiting. Evaluation should first focus on detecting any emergencies or complications that require hospitalization. Attention should then turn to identifying the underlying cause and providing specific therapies. When the cause cannot be determined, empiric therapy with an antiemetic is appropriate. Initial diagnostic testing should generally be limited to basic laboratory tests and plain radiography. Further testing, such as upper endoscopy or computed tomography of the abdomen, should be determined by clinical suspicion based on a complete history and physical examination.
Second Trimester Pregnancy Loss - Article
ABSTRACT: Second trimester pregnancy loss is uncommon, but it should be regarded as an important event in a woman's obstetric history. Fetal abnormalities, including chromosomal problems, and maternal anatomic factors, immunologic factors, infection, and thrombophilia should be considered; however, a cause-and-effect relationship may be difficult to establish. A thorough history and physical examination should include inquiries about previous pregnancy loss. Laboratory tests may identify treatable etiologies. Although there is limited evidence that specific interventions improve outcomes, management of contributing maternal factors (e.g., smoking, substance abuse) is essential. Preventive measures, including vaccination and folic acid supplementation, are recommended regardless of risk. Management of associated chromosomal factors requires consultation with a genetic counselor or obstetrician. The family physician can play an important role in helping the patient and her family cope with the emotional aspects of pregnancy loss.
ABSTRACT: Testicular cancer is the most common malignancy in men 20 to 35 years of age and has an annual incidence of four per 100,000. If diagnosed early, the cure rate is nearly 99 percent. Risk factors for testicular cancer include cryptorchidism (i.e., undescended testicles), family history, infertility, tobacco use, and white race. Routine self-examination and physician screening have not been shown to improve outcomes, and the U.S. Preventive Services Task Force and American Cancer Society do not recommend them in asymptomatic men. Patients presenting with a painless testicular mass, scrotal heaviness, a dull ache, or acute pain should receive a thorough examination. Testicular masses should be examined with scrotal ultrasonography. If ultrasonography shows an intratesticular mass, the patient should be referred to a urologist for definitive diagnosis, orchiectomy, and further evaluation with abdominal computed tomography and chest radiography. The family physician's role after diagnosis of testicular cancer includes encouraging the patient to bank sperm because of possible infertility and evaluating for recurrence and future complications, especially cardiovascular disease.
ABSTRACT: Primary care physicians are often asked about easy bruising, excessive bleeding, or risk of bleeding before surgery. A thorough history, including a family history, will guide the appropriate work-up, and a physical examination may provide clues to diagnosis. A standardized bleeding score system can help physicians to organize the patient's bleeding history and to avoid overlooking the most common inherited bleeding disorder, von Willebrand's disease. In cases of suspected bleeding disorders, initial laboratory evaluations should include a complete blood count with platelet count, peripheral blood smear, prothrombin time, and partial thromboplastin time. More specialized yet relatively simple tests, such as the Platelet Function Analyzer-100, mixing studies, and inhibitor assays, may also be helpful. These tests can help diagnose platelet function disorders, quantitative platelet disorders, factor deficiencies, and factor inhibitors.
Primary Brain Tumors in Adults - Article
ABSTRACT: Primary malignant brain tumors account for 2 percent of all cancers in U.S. adults. The most common malignant brain tumor is glioblastoma multiforme, and patients with this type of tumor have a poor prognosis. Previous exposure to high-dose ionizing radiation is the only proven environmental risk factor for a brain tumor. Primary brain tumors are classified based on their cellular origin and histologic appearance. Typical symptoms include persistent headache, seizures, nausea, vomiting, neurocognitive symptoms, and personality changes. A tumor can be identified using brain imaging, and the diagnosis is confirmed with histopathology. Any patient with chronic, persistent headache in association with protracted nausea, vomiting, seizures, change in headache pattern, neurologic symptoms, or positional worsening should be evaluated for a brain tumor. Magnetic resonance imaging is the preferred initial imaging study. A comprehensive neurosurgical evaluation is necessary to obtain tissue for diagnosis and for possible resection of the tumor. Primary brain tumors rarely metastasize outside the central nervous system, and there is no standard staging method. Surgical resection of the tumor is the mainstay of therapy. Postoperative radiation and chemotherapy have improved survival in patients with high-grade brain tumors. Recent developments in targeted chemotherapy provide novel treatment options for patients with tumor recurrence. Primary care physicians play an important role in the perioperative and supportive treatment of patients with primary brain tumors, including palliative care and symptom control.
ABSTRACT: Benign prostatic hyperplasia is a common condition affecting older men. Typical presenting symptoms include urinary hesitancy, weak stream, nocturia, incontinence, and recurrent urinary tract infections. Acute urinary retention, which requires urgent bladder catheterization, is relatively uncommon. Irreversible renal damage is rare. The initial evaluation should assess the frequency and severity of symptoms and the impact of symptoms on the patient's quality of life. The American Urological Association Symptom Index is a validated instrument for the objective assessment of symptom severity. The initial evaluation should also include a digital rectal examination and urinalysis. Men with hematuria should be evaluated for bladder cancer. A palpable nodule or induration of the prostate requires referral for assessment to rule out prostate cancer. For men with mild symptoms, watchful waiting with annual reassessment is appropriate. Over the past decade, numerous medical and surgical interventions have been shown to be effective in relieving symptoms of benign prostatic hyperplasia. Alpha blockers improve symptoms relatively quickly. Although 5-alpha reductase inhibitors have a slower onset of action, they may decrease prostate size and alter the disease course. Limited evidence shows that the herbal agents saw palmetto extract, rye grass pollen extract, and pygeum relieve symptoms. Transurethral resection of the prostate often provides permanent relief. Newer laser-based surgical techniques have comparable effectiveness to transurethral resection up to two years after surgery with lower perioperative morbidity. Various outpatient surgical techniques are associated with reduced morbidity, but symptom relief may be less durable.
ABSTRACT: Deviations from a normal age-appropriate gait pattern can be caused by a wide variety of conditions. In most children, limping is caused by a mild, self-limiting event, such as a contusion, strain, or sprain. In some cases, however, a limp can be a sign of a serious or even life-threatening condition. Delays in diagnosis and treatment can result in significant morbidity and mortality. Examination of a limping child should begin with a thorough history, focusing on the presence of pain, any history of trauma, and any associated systemic symptoms. The presence of fever, night sweats, weight loss, and anorexia suggests the possibility of infection, inflammation, or malignancy. Physical examination should focus on identifying the type of limp and localizing the site of pathology by direct palpation and by examining the range of motion of individual joints. Localized tenderness may indicate contusions, fractures, osteomyelitis, or malignancy. A palpable mass raises the concern of malignancy. The child should be carefully examined because non-musculoskeletal conditions can cause limping. Based on the most probable diagnoses suggested by the history and physical examination, the appropriate use of laboratory tests and imaging studies can help confirm the diagnosis.
Maintaining a Medication List in the Chart - Improving Patient Care
Making Decisions at the Point of Care: Sore Throat - Improving Patient Care