Items in AFP with MESH term: Primary Health Care
ABSTRACT: Approximately 1 percent of primary care office visits are for chest pain, and 1.5 percent of these patients will have unstable angina or acute myocardial infarction. The initial goal in patients presenting with chest pain is to determine if the patient needs to be referred for further testing to rule in or out acute coronary syndrome and myocardial infarction. The physician should consider patient characteristics and risk factors to help determine initial risk. Twelve-lead electrocardiography is typically the test of choice when looking for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new-onset T wave inversions. For persons in whom the suspicion for ischemia is lower, other diagnoses to consider include chest wall pain/costochondritis (localized pain reproducible by palpation), gastroesophageal reflux disease (burning retrosternal pain, acid regurgitation, and a sour or bitter taste in the mouth), and panic disorder/anxiety state. Other less common but important diagnostic considerations include pneumonia (fever, egophony, and dullness to percussion), heart failure, pulmonary embolism (consider using the Wells criteria), acute pericarditis, and acute thoracic aortic dissection (acute chest or back pain with a pulse differential in the upper extremities). Persons with a higher likelihood of acute coronary syndrome should be referred to the emergency department or hospital.
ABSTRACT: Family physicians commonly find themselves in difficult clinical encounters. These encounters often leave the physician feeling frustrated. The patient may also be dissatisfied with these encounters because of unmet needs, unfulfilled expectations, and unresolved medical issues. Difficult encounters may be attributable to factors associated with the physician, patient, situation, or a combination. Common physician factors include negative bias toward specific health conditions, poor communication skills, and situational stressors. Patient factors may include personality disorders, multiple and poorly defined symptoms, nonadherence to medical advice, and self-destructive behaviors. Situational factors include time pressures during visits, patient and staff conflicts, or complex social issues. To better manage difficult clinical encounters, the physician needs to identify all contributing factors, starting with his or her personal frame of reference for the situation. During the encounter, the physician should use empathetic listening skills and a nonjudgmental, caring attitude; evaluate the challenging patient for underlying psychological and medical disorders and previous or current physical or mental abuse; set boundaries; and use patient-centered communication to reach a mutually agreed upon plan. The timing and duration of visits, as well as expected conduct, may need to be specifically negotiated. Understanding and managing the factors contributing to a difficult encounter will lead to a more effective and satisfactory experience for the physician and the patient.
ABSTRACT: Substance misuse is common among patients in primary care settings. Although it has a substantial health impact, physicians report low levels of preparedness to identify and assist patients with substance use disorders. An effective approach to office-based treatment includes a coherent framework for identifying and managing substance use disorders and specific strategies to promote behavior change. Brief validated screening tools allow rapid and efficient identification of problematic drug use, including prescription medication misuse. After a positive screening, a brief assessment should be performed to stratify patients into three categories: hazardous use, substance abuse, or substance dependence. Patients with hazardous use benefit from brief counseling by a physician. For patients with substance abuse, brief counseling is also indicated, with the addition of more intensive ongoing follow-up and reevaluation. In patients with substance dependence, best practices include a combination of counseling, referral to specialty treatment, and pharmacotherapy (e.g., drug tapering, naltrexone, buprenorphine, methadone). Comorbid mental illness and intimate partner violence are common in patients with substance use disorders. The use of a motivational rather than a confrontational communication style during screening, counseling, and treatment is important to improve patient outcomes.
Relying on NPs and PAs Does Not Avoid the Need for Policy Solutions for Primary Care - Graham Center Policy One-Pagers
Unequal Distribution of the U.S. Primary Care Workforce - Graham Center Policy One-Pagers
Behavioral Counseling Interventions to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults - Putting Prevention into Practice
Historic Growth Rates Vary Widely Across the Primary Care Physician Disciplines - Graham Center Policy One-Pagers
Evaluation of the Patient with Hip Pain - Article
ABSTRACT: Hip pain is a common and disabling condition that affects patients of all ages. The differential diagnosis of hip pain is broad, presenting a diagnostic challenge. Patients often express that their hip pain is localized to one of three anatomic regions: the anterior hip and groin, the posterior hip and buttock, or the lateral hip. Anterior hip and groin pain is commonly associated with intra-articular pathology, such as osteoarthritis and hip labral tears. Posterior hip pain is associated with piriformis syndrome, sacroiliac joint dysfunction, lumbar radiculopathy, and less commonly ischiofemoral impingement and vascular claudication. Lateral hip pain occurs with greater trochanteric pain syndrome. Clinical examination tests, although helpful, are not highly sensitive or specific for most diagnoses; however, a rational approach to the hip examination can be used. Radiography should be performed if acute fracture, dislocations, or stress fractures are suspected. Initial plain radiography of the hip should include an anteroposterior view of the pelvis and frog-leg lateral view of the symptomatic hip. Magnetic resonance imaging should be performed if the history and plain radiograph results are not diagnostic. Magnetic resonance imaging is valuable for the detection of occult traumatic fractures, stress fractures, and osteonecrosis of the femoral head. Magnetic resonance arthrography is the diagnostic test of choice for labral tears.