Items in AFP with MESH term: Physical Examination
ABSTRACT: Diagnosis of upper extremity injuries depends on knowledge of basic anatomy and biomechanics of the hand and wrist. The wrist is composed of two rows of carpal bones. Flexor and extensor tendons cross the wrist to allow function of the hand and digits. The ulnar, median, and radial nerves provide innervation of the hand and wrist. A systematic primary and secondary examination of the hand and wrist includes assessment of active and passive range of motion of the wrist and digits, and dynamic stability testing. The most commonly fractured bone of the wrist is the scaphoid, and the most common ligamentous instability involves the scaphoid and lunate.
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.
Hemolytic Anemia - Article
ABSTRACT: Hemolysis presents as acute or chronic anemia, reticulocytosis, or jaundice. The diagnosis is established by reticulocytosis, increased unconjugated bilirubin and lactate dehydrogenase, decreased haptoglobin, and peripheral blood smear findings. Premature destruction of erythrocytes occurs intravascularly or extravascularly. The etiologies of hemolysis often are categorized as acquired or hereditary. Common acquired causes of hemolytic anemia are autoimmunity, microangiopathy, and infection. Immune-mediated hemolysis, caused by antierythrocyte antibodies, can be secondary to malignancies, autoimmune disorders, drugs, and transfusion reactions. Microangiopathic hemolytic anemia occurs when the red cell membrane is damaged in circulation, leading to intravascular hemolysis and the appearance of schistocytes. Infectious agents such as malaria and babesiosis invade red blood cells. Disorders of red blood cell enzymes, membranes, and hemoglobin cause hereditary hemolytic anemias. Glucose-6-phosphate dehydrogenase deficiency leads to hemolysis in the presence of oxidative stress. Hereditary spherocytosis is characterized by spherocytes, a family history, and a negative direct antiglobulin test. Sickle cell anemia and thalassemia are hemoglobinopathies characterized by chronic hemolysis.
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.
Diagnosis and Management of Galactorrhea - Article
ABSTRACT: After infancy, galactorrhea usually is medication-induced. The most common pathologic cause of galactorrhea is a pituitary tumor. Other causes include hypothalamic and pituitary stalk lesions, neurogenic stimulation, thyroid disorders, and chronic renal failure. Patients with the latter conditions may have irregular menses, infertility, and osteopenia or osteoporosis if they have associated hyperprolactinemia. Tests for pregnancy, serum prolactin level and serum thyroid-stimulating hormone level, and magnetic resonance imaging are important diagnostic tools that should be employed when clinically indicated. The underlying cause of galactorrhea should be treated when possible. The decision to treat patients with galactorrhea is based on the serum prolactin level, the severity of galactorrhea, and the patient's fertility desires. Dopamine agonists are the treatment of choice in most patients with hyperprolactinemic disorders. Bromocriptine is the preferred agent for treatment of hyperprolactin-induced anovulatory infertility. Although cabergoline is more effective and better tolerated than bromocriptine, it is more expensive, and treatment must be discontinued one month before conception is attempted. Surgical resection rarely is required for prolactinomas.
Tympanometry - Article
ABSTRACT: Tympanometry provides useful quantitative information about the presence of fluid in the middle ear, mobility of the middle ear system, and ear canal volume. Its use has been recommended in conjunction with more qualitative information (e.g., history, appearance, and mobility of the tympanic membrane) in the evaluation of otitis media with effusion and to a lesser extent in acute otitis media. It also can provide useful information about the patency of tympanostomy tubes. Tympanometry is not reliable in infants younger than seven months because of the highly compliant ear canals of infants. Tympanogram tracings are classified as type A (normal), type B (flat, clearly abnormal), and type C (indicating a significantly negative pressure in the middle ear, possibly indicative of pathology). According to the Agency for Healthcare Research and Quality guidelines on otitis media with effusion, the positive predictive value of an abnormal (flat, type B) tympanogram is between 49 and 99 percent. A type C curve may be useful when correlated with other findings, but by itself it is an imprecise estimate of middle ear pressure and does not have high sensitivity or specificity for middle ear disorders.
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.
ABSTRACT: Muscle weakness is a common complaint among patients presenting to family physicians. Diagnosis begins with a patient history distinguishing weakness from fatigue or asthenia, separate conditions with different etiologies that can coexist with, or be confused for, weakness. The pattern and severity of weakness, associated symptoms, medication use, and family history help the physician determine whether the cause of a patient's weakness is infectious, neurologic, endocrine, inflammatory, rheumatologic, genetic, metabolic, electrolyte-induced, or drug-induced. In the physical examination, the physician should objectively document the patient's loss of strength, conduct a neurologic survey, and search for patterns of weakness and extramuscular involvement. If a specific cause of weakness is suspected, the appropriate laboratory or radiologic studies should be performed. Otherwise, electromyography is indicated to confirm the presence of a myopathy or to evaluate for a neuropathy or a disease of the neuromuscular junction. If the diagnosis remains unclear, the examiner should pursue a tiered progression of laboratory studies. Physicians should begin with blood chemistries and a thyroid-stimulating hormone assay to evaluate for electrolyte and endocrine causes, then progress to creatine kinase level, erythrocyte sedimentation rate, and antinuclear antibody assays to evaluate for rheumatologic, inflammatory, genetic, and metabolic causes. Finally, many myopathies require a biopsy for diagnosis. Pathologic evaluation of the muscle tissue specimen focuses on histologic, histochemical, electron microscopic, biochemical, and genetic analyses; advances in technique have made a definitive diagnosis possible for many myopathies.
ABSTRACT: Iliotibial band syndrome is a common knee injury. The most common symptom is lateral knee pain caused by inflammation of the distal portion of the iliotibial band. The iliotibial band is a thick band of fascia that crosses the hip joint and extends distally to insert on the patella, tibia, and biceps femoris tendon. In some athletes, repetitive flexion and extension of the knee causes the distal iliotibial band to become irritated and inflamed resulting in diffuse lateral knee pain. Iliotibial band syndrome can cause significant morbidity and lead to cessation of exercise. Although iliotibial band syndrome is easily diagnosed clinically, it can be extremely challenging to treat. Treatment requires active patient participation and compliance with activity modification. Most patients respond to conservative treatment involving stretching of the iliotibial band, strengthening of the gluteus medius, and altering training regimens. Corticosteroid injections should be considered if visible swelling or pain with ambulation persists for more than three days after initiating treatment. A small percentage of patients are refractory to conservative treatment and may require surgical release of the iliotibial band.
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.