Items in AFP with MESH term: Primary Health Care
ABSTRACT: Family physicians commonly care for patients with serious mental illness. Patients with psychotic and bipolar disorders have more comorbid medical conditions and higher mortality rates than patients without serious mental illness. Many medications prescribed for serious mental illness have significant metabolic and cardiovascular adverse effects. Patients treated with second-generation antipsychotics should receive preventive counseling and treatment for obesity, hyperglycemia, diabetes, and hyperlipidemia. First- and second-generation antipsychotics have been associated with QT prolongation. Many common medications can interact with antipsychotics, increasing the risk of cardiac arrhythmias and sudden death. Drug interactions can also lead to increased adverse effects, increased or decreased drug levels, toxicity, or treatment failure. Physicians should carefully consider the risks and benefits of second-generation antipsychotic medications, and patient care should be coordinated between primary care physicians and mental health professionals to prevent serious adverse effects.
ABSTRACT: Binge-eating disorder, bulimia nervosa, and anorexia nervosa are potentially life-threatening disorders that involve complex psychosocial issues. A strong therapeutic relationship between the physician and patient is necessary for assessing the psychosocial and medical factors used to determine the appropriate level of care. Most patients can be effectively treated in the outpatient setting by a health care team that includes a physician, a registered dietitian, and a therapist. Psychiatric consultation may be beneficial. Patients may require inpatient care if they are suicidal or have life-threatening medical complications, such as marked bradycardia, hypotension, hypothermia, severe electrolyte disturbances, end-organ compromise, or weight below 85 percent of their healthy body weight. For the treatment of binge-eating disorder and bulimia nervosa, good evidence supports the use of interpersonal and cognitive behavior therapies, as well as antidepressants. Limited evidence supports the use of guided self-help programs as a first step in a stepped-care approach to these disorders. For patients with anorexia nervosa, the effectiveness of behavioral or pharmacologic treatments remains unclear.
ABSTRACT: Family physicians commonly encounter patients with dental infections, such as dental caries and periodontal disease. Dental caries is caused by bacteria that destroy the enamel and dentin; it can be detected by an oral examination that shows stained pits or fissures on the tooth surface. Use of fluoride is the most effective prevention measure for dental caries. Untreated caries may progress to pulpitis and, eventually, to necrosis of the pulp. In irreversible pulpitis, the tooth dies and the patient may have a localized abscess that can spread to surrounding tissue. Periodontal infections are caused by bacteria in the subgingival dental plaque. In gingivitis, the inflamed gums bleed easily with brushing or flossing; the condition can be controlled with good oral hygiene. Periodontitis is characterized by a loss of supportive bone structure caused by chronic gingivitis; it is also associated with some systemic diseases. Localized periodontitis is treated with mechanical debridement and good oral hygiene, whereas generalized periodontitis requires adjunct antibiotic therapy. Pericoronitis results when food particles become trapped under the gum of an impacted tooth. This condition can be controlled by removal of food debris and good oral hygiene. For patients in whom dental infections are disseminated and have invaded the deeper oral spaces, antibiotic treatment should be initiated at the time of referral.
ABSTRACT: The prevalence of patients with psychiatric disorders in primary care settings indicates that family physicians have a need for a diagnostic manual suited to the realities of their practice. This article reviews the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., primary care version (DSM-IV-PC) and highlights the ways it accommodates the clinical needs of family physicians. DSM-IV-PC emphasizes the use of nine diagnostic algorithms for the most prevalent psychiatric disorders in primary care. The authors review the conceptual similarities between DSM-IV and DSM-IV-PC and the diagnostic features that are unique to DSM-IV-PC, and offer an illustrative case that incorporates a DSM-IV-PC approach to diagnosis. The authors also outline clinical and technical issues that remain unresolved in DSM-IV-PC.
ABSTRACT: The family physician occupies a front-line position in the detection and treatment of emotional problems and psychiatric illnesses. The practice pattern of the family physician necessitates an efficient, effective model of psychotherapy The BATHE technique is a brief psychotherapeutic method that addresses the patient's background issues, affect and most troubling problem. The emphasis of the interview then shifts to how the patient is handling the problem and a demonstration of empathy by the physician. Some of the challenges in psychotherapy are presented, and cases in which the BATHE technique was used are described.
ABSTRACT: Immunotherapy has been used for over 80 years. It is a safe and effective therapeutic intervention for allergic rhinitis, but its use in the treatment of asthma is more controversial. Patients with unstable asthma are at increased risk of adverse effects from immunotherapy; therefore, if immunotherapy is used in such patients, it should be instituted cautiously. Indications for immunotherapy include evidence of IgE-mediated disease and positive results on skin tests or radioallergosorbent test (RAST). In addition, before immunotherapy is considered, measures to avoid exposure to offending agents and drug therapy should have failed to provide relief of symptoms. Before administering immunotherapy in the office, physicians should be knowledgeable about the use of immunotherapy and the treatment of anaphylaxis, and should have ready access to the equipment needed to avert anaphylaxis.
ABSTRACT: Down syndrome is caused by triplicate material of chromosome 21. The syndrome has a variable physical expression, but congenital cardiac defects, transient myelodysplasia of the newborn and duodenal atresia are highly specific for this chromosomal disorder. Routine health maintenance is important because infants and children with Down syndrome are more likely to have otitis media, thyroid disease, congenital cataracts, leukemoid reactions, dental problems and feeding difficulties. Since infants with this syndrome are prone to respiratory infections, immunization recommendations should be followed closely. Motor, language, social and adaptive skills should be assessed at each office visit. The psychosocial aspects of care should be discussed with the parents of an infant with Down syndrome. If necessary, the parents should be referred to family support and specialty resources. Institutionalization of infants with Down syndrome is now unlikely. With newer surgical techniques, early therapy to minimize developmental delay and proper health supervision, the functional prognosis for infants with Down syndrome is considerably improved.
Sarcoidosis: A Primary Care Review - Article
ABSTRACT: Sarcoidosis is a multisystemic disorder of unknown etiology that most commonly affects adults between 20 and 40 years of age. Patients with sarcoidosis frequently present with bilateral hilar lymphadenopathy and pulmonary infiltration, and often with ocular and skin lesions. The diagnosis is established when clinical and radiographic findings are supported by histologic evidence of non-caseating epithelioid cell granulomas found on tissue biopsy. Diagnosis of sarcoidosis requires exclusion of other causes of granuloma formation. Sarcoidosis is also characterized by distinctive laboratory abnormalities, including hyperglobulinemia, an elevated serum angiotensin converting enzyme level, evidence of depressed cellular immunity manifested by cutaneous anergy and, occasionally, hypercalcemia and hypercalciuria. Glucocorticoids remain the mainstay of therapy when treatment is required, although other anti-inflammatory agents are being used increasingly often.
Primary Care of International Adoptees - Article
ABSTRACT: International adoptees are presenting to family physicians with increasing frequency. U.S. citizens have adopted over 100,000 international children since 1979. Prospective parents may seek advice from their physician during the adoptive process. If available at all, medical information on the child is often scanty. History and physical examination alone are often insufficient for diagnosis of common problems in this population. Adoptive parents may have concerns about growth and development, and appropriate immunizations. In addition, bacterial, viral and parasitic infections endemic in countries of origin create unusual challenges for the U.S. primary care physician. A basic understanding of the process of international adoption, a skillful evaluation of the child and selected laboratory studies enable the family physician to support the prospective parents and assist in a smooth transition of the child into a new family.
ABSTRACT: Patients with insomnia may experience one or more of the following problems: difficulty falling asleep, difficulty maintaining sleep, waking up too early in the morning and nonrefreshing sleep. In addition, daytime consequences such as fatigue, lack of energy, difficulty concentrating and irritability are often present. Approximately 10 percent of adults experience persistent insomnia, although most patients do not mention it during routine office visits. Asking sleep-related questions during the general review of systems and asking patients with sleep complaints to keep a sleep diary are helpful approaches in detecting insomnia. Behavior and pharmacologic therapies are used in treating insomnia. Behavior approaches take a few weeks to improve sleep but continue to provide relief even after training sessions have ended. Hypnotic medications are safe and effective in inducing, maintaining and consolidating sleep. Effective treatment of insomnia may improve the quality of life for many patients.