ITEMS IN AFP WITH MESH TERM:
ABSTRACT: Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. The leading causes of involuntary weight loss are depression (especially in residents of long-term care facilities), cancer (lung and gastrointestinal malignancies), cardiac disorders and benign gastrointestinal diseases. Medications that may cause nausea and vomiting, dysphagia, dysgeusia and anorexia have been implicated. Polypharmacy can cause unintended weight loss, as can psychotropic medication reduction (i.e., by unmasking problems such as anxiety). A specific cause is not identified in approximately one quarter of elderly patients with unintentional weight loss. A reasonable work-up includes tests dictated by the history and physical examination, a fecal occult blood test, a complete blood count, a chemistry panel, an ultrasensitive thyroid-stimulating hormone test and a urinalysis. Upper gastrointestinal studies have a reasonably high yield in selected patients. Management is directed at treating underlying causes and providing nutritional support. Consideration should be given to the patient's environment and interest in and ability to eat food, the amelioration of symptoms and the provision of adequate nutrition. The U.S. Food and Drug Administration has labeled no appetite stimulants for the treatment of weight loss in the elderly.
ABSTRACT: HAIR-AN syndrome is an acronym for an unusual multisystem disorder in women that consists of hyperandrogenism (HA), insulin resistance (IR) and acanthosis nigricans (AN). The precipitating abnormality is thought to be insulin resistance, with a secondary increase in insulin levels and subsequent overproduction of androgens in the ovaries. Long periods of hyperinsulinism and, some suspect, hyperandrogenism can result in the cutaneous manifestation of acanthosis nigricans. Patients are often concerned about the physical manifestations of this disorder, including virilization and acanthosis nigricans, and may be less aware of systemic problems. Physicians should assess women with these problems for an underlying endocrine abnormality. Although a treatment regimen for the HAIR-AN syndrome has not been established, antiandrogen therapy and weight loss are useful.
Evaluating the Child for Sexual Abuse - Article
ABSTRACT: Child victims of sexual abuse may present with physical findings that can include anogenital problems, enuresis or encopresis. Behavioral changes may involve sexual acting out, aggression, depression, eating disturbances and regression. Because the examination findings of most child victims of sexual abuse are within normal limits or are nonspecific, the child's statements are extremely important. The child's history as obtained by the physician may be admitted as evidence in court trials; therefore, complete documentation of questions and answers is critical. A careful history should be obtained and a thorough physical examination should be performed with documentation of all findings. When examining the child's genitalia, it is important that the physician be familiar with normal variants, non-specific changes and diagnostic signs of sexual abuse. Judicious use of laboratory tests, along with appropriate therapy, should be individually tailored. Forensic evidence collection is indicated in certain cases. Referral for psychologic services is important because victims of abuse are more likely to have depression, anxiety disorders, behavioral problems and post-traumatic stress disorder.
ABSTRACT: Chronic obstructive pulmonary disease affects more than 26 million adults in the United States. Family physicians provide care for most of these patients. Cigarette smoking is the leading risk factor for chronic obstructive pulmonary disease, although other risk factors, including occupational and environmental exposures, account for up to one in six cases. Patients presenting with chronic cough, increased sputum production, or progressive dyspnea should be evaluated for the disease. Asthma is the disease most often confused with chronic obstructive pulmonary disease. The diagnosis of chronic obstructive pulmonary disease is based on clinical suspicion and spirometry confirmation. A forced expiratory volume in one second/forced vital capacity ratio that is less than 70 percent, and that is incompletely reversible with the administration of an inhaled bronchodilator, suggests chronic obstructive pulmonary disease. Disease severity is classified by symptomatology and spirometry. Joint guidelines from the American Thoracic Society and the European Respiratory Society recommend a single quantitative test for alpha1-antitrypsin deficiency in patients diagnosed with chronic obstructive pulmonary disease who remain symptomatic despite bronchodilator therapy. Other advanced testing is usually not necessary.
Chronic Pelvic Pain in Women - Article
ABSTRACT: The etiology of chronic pelvic pain in women is poorly understood. Although a specific diagnosis is not found in the majority of cases, some common diagnoses include endometriosis, adhesions, irritable bowel syndrome, and interstitial cystitis. The initial history and physical examination can narrow the diagnostic possibilities, guide any subsequent evaluation, and rule out malignancy or significant systemic disease. If the initial evaluation does not reveal a specific diagnosis, a limited laboratory and ultrasound evaluation can clarify the diagnosis, as well as rule out serious disease and reassure the patient. Few treatment modalities have demonstrated benefit for the symptoms of chronic pelvic pain. The evidence supports the use of oral medroxyprogesterone, goserelin, adhesiolysis for severe adhesions, and a multidisciplinary treatment approach for patients without a specific diagnosis. Less supporting evidence is available for oral analgesics, combined oral contraceptive pills, gonadotropin-releasing hormone agonists, intramuscular medroxyprogesterone, trigger point and botulinum A toxin injections, neuromodulative therapies, and hysterectomy.
Diagnosis of Appendicitis: Part I. History and Physical Examination - Point-of-Care Guides
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.
ABSTRACT: Chronic low back pain is a common problem in primary care. A history and physical examination should place patients into one of several categories: (1) nonspecific low back pain; (2) back pain associated with radiculopathy or spinal stenosis; (3) back pain referred from a nonspinal source; or (4) back pain associated with another specific spinal cause. For patients who have back pain associated with radiculopathy, spinal stenosis, or another specific spinal cause, magnetic resonance imaging or computed tomography may establish the diagnosis and guide management. Because evidence of improved outcomes is lacking, lumbar spine radiography should be delayed for at least one to two months in patients with nonspecific pain. Acetaminophen and nonsteroidal anti-inflammatory drugs are first-line medications for chronic low back pain. Tramadol, opioids, and other adjunctive medications may benefit some patients who do not respond to nonsteroidal anti-inflammatory drugs. Acupuncture, exercise therapy, multidisciplinary rehabilitation programs, massage, behavior therapy, and spinal manipulation are effective in certain clinical situations. Patients with radicular symptoms may benefit from epidural steroid injections, but studies have produced mixed results. Most patients with chronic low back pain will not benefit from surgery. A surgical evaluation may be considered for select patients with functional disabilities or refractory pain despite multiple nonsurgical treatments.
Hoarseness in Adults - Article
ABSTRACT: Numerous conditions can cause hoarseness, ranging from simple inflammatory processes to more serious systemic, neurologic, or cancerous conditions involving the larynx. Evaluation of a patient with hoarseness includes a careful history, physical examination, and in many cases, laryngoscopy. Any patient with hoarseness lasting longer than two weeks in the absence of an apparent benign cause requires a thorough evaluation of the larynx by direct or indirect laryngoscopy. The management of hoarseness includes identification and treatment of any underlying conditions, vocal hygiene, voice therapy, and specific treatment of vocal cord lesions. Vocal hygiene education is an integral aspect of the treatment of hoarseness in most cases. Referral to a speech-language pathologist for voice therapy may be particularly helpful for patients whose occupation depends on singing or talking loudly or for prolonged periods. Voice therapy is an effective method for improving voice quality and vocal performance in patients with nonorganic dysphonia and for treating many benign pathologic vocal cord lesions. Referral for surgical or other targeted interventions is indicated when conservative management of vocal cord pathology is unsuccessful, when dysplasia or carcinoma is suspected, or when significant airway obstruction is present.
ABSTRACT: Adnexal masses represent a spectrum of conditions from gynecologic and nongynecologic sources. They may be benign or malignant. The initial detection and evaluation of an adnexal mass requires a high index of suspicion, a thorough history and physical examination, and careful attention to subtle historical clues. Timely, appropriate laboratory and radiographic studies are required. The most common symptoms reported by women with ovarian cancer are pelvic or abdominal pain; increased abdominal size; bloating; urinary urgency, frequency, or incontinence; early satiety; difficulty eating; and weight loss. These vague symptoms are present for months in up to 93 percent of patients with ovarian cancer. Any of these symptoms occurring daily for more than two weeks, or with failure to respond to appropriate therapy warrant further evaluation. Transvaginal ultrasonography remains the standard for evaluation of adnexal masses. Findings suggestive of malignancy in an adnexal mass include a solid component, thick septations (greater than 2 to 3 mm), bilaterality, Doppler flow to the solid component of the mass, and presence of ascites. Family physicians can manage many nonmalignant adnexal masses; however, prepubescent girls and postmenopausal women with an adnexal mass should be referred to a gynecologist or gynecologic oncologist for further treatment. All women, regardless of menopausal status, should be referred if they have evidence of metastatic disease, ascites, a complex mass, an adnexal mass greater than 10 cm, or any mass that persists longer than 12 weeks.