ITEMS IN AFP WITH MESH TERM:
Amenorrhea: Evaluation and Treatment - Article
ABSTRACT: A thorough history and physical examination as well as laboratory testing can help narrow the differential diagnosis of amenorrhea. In patients with primary amenorrhea, the presence or absence of sexual development should direct the evaluation. Constitutional delay of growth and puberty commonly causes primary amenorrhea in patients with no sexual development. If the patient has normal pubertal development and a uterus, the most common etiology is congenital outflow tract obstruction with a transverse vaginal septum or imperforate hymen. If the patient has abnormal uterine development, mÃ¼llerian agenesis is the likely cause and a karyotype analysis should confirm that the patient is 46,XX. If a patient has secondary amenorrhea, pregnancy should be ruled out. The treatment of primary and secondary amenorrhea is based on the causative factor. Treatment goals include prevention of complications such as osteoporosis, endometrial hyperplasia, and heart disease; preservation of fertility; and, in primary amenorrhea, progression of normal pubertal development.
ABSTRACT: Thousands of young athletes receive preparticipation evaluations each year in the United States. One objective of these evaluations is to detect underlying cardiovascular abnormalities that may predispose an athlete to sudden death. The leading cardiovascular causes of sudden death in young athletes include hypertrophic cardiomyopathy, congenital coronary artery anomalies, repolarization abnormalities, and Marfan syndrome. Because these abnormalities are rare and difficult to detect clinically, it is recommended that family physicians use standardized history questions and examination techniques. Athletes, accompanied by their parents, if possible, should be asked about family history of cardiac disease and sudden death; personal cardiac history; and exercise-related symptoms, specifically syncope, chest pain, and palpitations. The physical examination should include blood pressure measurement, palpation of radial and femoral pulses, dynamic cardiac auscultation, and evaluation for Marfan syndrome. Athletes with "red flag" signs or symptoms may need activity restriction, special testing, and referral if the diagnosis is unclear.
ABSTRACT: Most children will have been evaluated for a febrile illness by 36 months of age. Although the majority will have a self-limited viral illness, studies done before the use of Haemophilus influenzae type b and Streptococcus pneumoniae vaccines showed that approximately 10 percent of children younger than 36 months without evident sources of fever had occult bacteremia and serious bacterial infection. More recent studies have found lower rates of bacterial infection (1.6 to 1.8 percent). Any infant younger than 29 days and any child that appears toxic should undergo a complete sepsis work-up. However, nontoxic-appearing children one to 36 months of age, who have a fever with no apparent source and who have received the appropriate vaccinations, could undergo screening laboratory analysis and be sent home with close follow-up. Empiric intramuscular antibiotics are suggested for some children; however, cerebrospinal fluid studies should be obtained first. Because immunizations have recently decreased infection rates for S. pneumoniae and H. influenzae type b, the recommendations for evaluation and treatment of febrile children are evolving and could involve fewer tests and less-presumptive treatment in the future. A cautious approach should still be taken based on the potential for adverse consequences of unrecognized and untreated serious bacterial infection.
ABSTRACT: Breast cancer is one of the most significant health concerns in the United States. Recent reviews have questioned the value of traditional breast cancer screening methods. Breast self-examination has been shown not to improve cancer-specific or all-cause mortality in large studies, but it is commonly advocated as a noninvasive screen. Patients who choose to perform self-examination should be trained in appropriate technique and follow-up. The contribution of the clinical breast examination to early detection is difficult to determine, but studies show that sensitivity is highly dependent on time taken to do the examination. Up to 10 percent of cancers are mammographically silent but evident on clinical breast examination. The U.S. Preventive Services Task Force recommends mammography for women older than 40 years who are in good health, but physicians should consider that sensitivity is lower for younger women. Digital mammography is somewhat more sensitive in younger women and women with dense breasts, but outcome studies are lacking. Although magnetic resonance imaging shows promise as a screening tool in some high-risk women, it is not currently recommended for general screening because of high false-positive rates and cost. The American Cancer Society recommends annual magnetic resonance imaging as an adjunct to screening mammography in high-risk women 30 years and older.
ABSTRACT: Shoulder pain is defined as chronic when it has been present for longer than six months. Common conditions that can result in chronic shoulder pain include rotator cuff disorders, adhesive capsulitis, shoulder instability, and shoulder arthritis. Rotator cuff disorders include tendinopathy, partial tears, and complete tears. A clinical decision rule that is helpful in the diagnosis of rotator cuff tears includes pain with overhead activity, weakness on empty can and external rotation tests, and a positive impingement sign. Adhesive capsulitis can be associated with diabetes and thyroid disorders. Clinical presentation includes diffuse shoulder pain with restricted passive range of motion on examination. Acromioclavicular osteoarthritis presents with superior shoulder pain, acromioclavicular joint tenderness, and a painful cross-body adduction test. In patients who are older than 50 years, glenohumeral osteoarthritis usually presents as gradual pain and loss of motion. In patients younger than 40 years, glenohumeral instability generally presents with a history of dislocation or subluxation events. Positive apprehension and relocation are consistent with the diagnosis. Imaging studies, indicated when diagnosis remains unclear or management would be altered, include plain radiographs, magnetic resonance imaging, ultrasonography, and computed tomography scans. Plain radiographs may help diagnose massive rotator cuff tears, shoulder instability, and shoulder arthritis. Magnetic resonance imaging and ultrasonography are preferred for rotator cuff disorders. For shoulder instability, magnetic resonance imaging arthrogram is preferred over magnetic resonance imaging.
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.
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.
The Diagnosis of Wheezing in Children - Article
ABSTRACT: Wheezing in children is a common problem encountered by family physicians. Approximately 25 to 30 percent of infants will have at least one wheezing episode, and nearly one half of children have a history of wheezing by six years of age. The most common causes of wheezing in children include asthma, allergies, infections, gastroesophageal reflux disease, and obstructive sleep apnea. Less common causes include congenital abnormalities, foreign body aspiration, and cystic fibrosis. Historical data that help in the diagnosis include family history, age at onset, pattern of wheezing, seasonality, suddenness of onset, and association with feeding, cough, respiratory illnesses, and positional changes. A focused examination and targeted diagnostic testing guided by clinical suspicion also provide useful information. Children with recurrent wheezing or a single episode of unexplained wheezing that does not respond to bronchodilators should undergo chest radiography. Children whose history or physical examination findings suggest asthma should undergo diagnostic pulmonary function testing.
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.
Trigeminal Neuralgia - Article
ABSTRACT: Trigeminal neuralgia is an uncommon disorder characterized by recurrent attacks of lancinating pain in the trigeminal nerve distribution. Typically, brief attacks are triggered by talking, chewing, teeth brushing, shaving, a light touch, or even a cool breeze. The pain is nearly always unilateral, and it may occur repeatedly throughout the day. The diagnosis is typically determined clinically, although imaging studies or referral for specialized testing may be necessary to rule out other diseases. Accurate and prompt diagnosis is important because the pain of trigeminal neuralgia can be severe. Carbamazepine is the drug of choice for the initial treatment of trigeminal neuralgia; however, baclofen, gabapentin, and other drugs may provide relief in refractory cases. Neurosurgical treatments may help patients in whom medical therapy is unsuccessful or poorly tolerated.