ITEMS IN AFP WITH MESH TERM:
ABSTRACT: Heart murmurs are common in healthy infants, children, and adolescents. Although most are not pathologic, a murmur may be the sole manifestation of serious heart disease. Historical elements that suggest pathology include family history of sudden cardiac death or congenital heart disease, in utero exposure to certain medications or alcohol, maternal diabetes mellitus, history of rheumatic fever or Kawasaki disease, and certain genetic disorders. Physical examination should focus on vital signs; age-appropriate exercise capacity; respiratory or gastrointestinal manifestations of congestive heart failure; and a thorough cardiovascular examination, including features of the murmur, assessment of peripheral perfusion, and auscultation over the heart valves. Red flags that increase the likelihood of a pathologic murmur include a holosystolic or diastolic murmur, grade 3 or higher murmur, harsh quality, an abnormal S2, maximal murmur intensity at the upper left sternal border, a systolic click, or increased intensity when the patient stands. Electrocardiography and chest radiography rarely assist in the diagnosis. Referral to a pediatric cardiologist is recommended for patients with any other abnormal physical examination findings, a history of conditions that increase the likelihood of structural heart disease, symptoms suggesting underlying cardiac disease, or when a specific innocent murmur cannot be identified by the family physician. Echocardiography provides a definitive diagnosis and is recommended for evaluation of any potentially pathologic murmur, and for evaluation of neonatal heart murmurs because these are more likely to be manifestations of structural heart disease.
Evaluation of Suspected Dementia - Article
ABSTRACT: As the proportion of persons in the United States older than 65 years increases, the prevalence of dementia will increase as well. Risk factors for dementia include age, family history of dementia, apolipoprotein E4 genotype, cardiovascular comorbidities, chronic anticholinergic use, and lower educational level. Patient history, physical examination, functional assessment, cognitive testing, laboratory studies, and imaging studies are used to assess a patient with suspected dementia. A two-visit approach is time-effective for primary care physicians in a busy outpatient setting. During the first visit, the physician should administer a screening test such as the verbal fluency test, the Mini-Cognitive Assessment Instrument, or the Sweet 16. These tests have high sensitivity and specificity for detecting dementia, and can be completed in as little as 60 seconds. If the screening test result is abnormal or clinical suspicion of another disease is present, appropriate laboratory and imaging tests should be ordered, and the patient should return for additional cognitive testing. A second visit should include a Mini-Mental State Examination, Geriatric Depression Scale, and verbal fluency and clock drawing tests, if not previously completed.
ABSTRACT: Initial evaluation of the patient with chronic cough (i.e., of more than eight weeks’ duration) should include a focused history and physical examination, and in most patients, chest radiography. Patients who are taking an angiotensin-converting enzyme inhibitor should switch to a medication from another drug class. The most common causes of chronic cough in adults are upper airway cough syndrome, asthma, and gastroesophageal reflux disease, alone or in combination. If upper airway cough syndrome is suspected, a trial of a decongestant and a first-generation antihistamine is warranted. The diagnosis of asthma should be confirmed based on clinical response to empiric therapy with inhaled bronchodilators or corticosteroids. Empiric treatment for gastroesophageal reflux disease should be initiated in lieu of testing for patients with chronic cough and reflux symptoms. Patients should avoid exposure to cough-evoking irritants, such as cigarette smoke. Further testing, such as high-resolution computed tomography, and referral to a pulmonologist may be indicated if the cause of chronic cough is not identified. In children, a cough lasting longer than four weeks is considered chronic. The most common causes in children are respiratory tract infections, asthma, and gastroesophageal reflux disease. Evaluation of children with chronic cough should include chest radiography and spirometry.
Evaluation of Chronic Diarrhea - Article
ABSTRACT: Chronic diarrhea, defined as a decrease in stool consistency for more than four weeks, is a common but challenging clinical scenario. It can be divided into three basic categories: watery, fatty (malabsorption), and inflammatory. Watery diarrhea may be subdivided into osmotic, secretory, and functional types. Watery diarrhea includes irritable bowel syndrome, which is the most common cause of functional diarrhea. Another example of watery diarrhea is microscopic colitis, which is a secretory diarrhea affecting older persons. Laxative-induced diarrhea is often osmotic. Malabsorptive diarrhea is characterized by excess gas, steatorrhea, or weight loss; giardiasis is a classic infectious example. Celiac disease (gluten-sensitive enteropathy) is also malabsorptive, and typically results in weight loss and iron deficiency anemia. Inflammatory diarrhea, such as ulcerative colitis or Crohn disease, is characterized by blood and pus in the stool and an elevated fecal calprotectin level. Invasive bacteria and parasites also produce inflammation. Infections caused by Clostridium difficile subsequent to antibiotic use have become increasingly common and virulent. Not all chronic diarrhea is strictly watery, malabsorptive, or inflammatory, because some categories overlap. Still, the most practical diagnostic approach is to attempt to categorize the diarrhea by type before testing and treating. This narrows the list of diagnostic possibilities and reduces unnecessary testing. Empiric therapy is justified when a specific diagnosis is strongly suspected and follow-up is available.
Arcuate, Red Plaques with Pustules on the Trunk - Photo Quiz
Persistent Cough - Photo Quiz
Osteoarthritis: Diagnosis and Treatment - Article
ABSTRACT: Osteoarthritis is a common degenerative disorder of the articular cartilage associated with hypertrophic bone changes. Risk factors include genetics, female sex, past trauma, advancing age, and obesity. The diagnosis is based on a history of joint pain worsened by movement, which can lead to disability in activities of daily living. Plain radiography may help in the diagnosis, but laboratory testing usually does not. Pharmacologic treatment should begin with acetaminophen and step up to nonsteroidal anti-inflammatory drugs. Exercise is a useful adjunct to treatment and has been shown to reduce pain and disability. The supplements glucosamine and chondroitin can be used for moderate to severe osteoarthritis when taken in combination. Corticosteroid injections provide inexpensive, short-term (four to eight weeks) relief of osteoarthritic flare-ups of the knee, whereas hyaluronic acid injections are more expensive but can maintain symptom improvement for longer periods. Total joint replacement of the hip, knee, or shoulder is recommended for patients with chronic pain and disability despite maximal medical therapy.
Generalized Red Rash - Photo Quiz
ABSTRACT: Although historical findings have some value in diagnosing internal derangement of the knee, a thorough physical examination can often rule out fracture and ligamentous and meniscal injuries. The Ottawa Knee Rule can help physicians determine which patients require radiography. Positive physical examination tests and findings of acute effusion suggest internal derangement. An abnormal McMurray or Thessaly test strongly suggests meniscal injury, whereas a normal Thessaly test may rule out meniscal injury. Absence of evidence of joint effusion significantly decreases the probability of internal derangement. Magnetic resonance imaging should be reserved for ruling out internal derangement in patients with suggestive historical and physical examination findings.