ITEMS IN AFP WITH MESH TERM:
ABSTRACT: Ten percent of the population abuses drugs or alcohol, and 20 percent of patients seen by family physicians have substance-abuse problems, excluding tobacco use. These patients can be identified by relying on regular screening or a high index of suspicion based on "red flags" that can be noted in various clinical situations. The modified CAGE questionnaire is an excellent screening instrument, but several alternatives are available. The best screening test is one that the physician will routinely use well. Laboratory indicators such as gamma-glutamyl transpeptidase, mean corpuscular volume, and carbohydrate-deficient transferrin are nonspecific but can add to the evidence of alcohol abuse. If problem alcohol use is diagnosed, even brief physician advice can be helpful. If the problem has progressed to addiction, referral to an addiction specialist or treatment center is recommended. Special issues arise in dealing with substance abuse in adolescents, elderly patients, and patients with mental illness, but the family physician can play an important role in recognizing this common problem.
ABSTRACT: Family physicians must decide how to screen for depression or dementia and which patients to screen. Mental health questionnaires can be helpful. In practice-based screening, questionnaires are administered to all patients, regardless of risk status. In case-finding screening, questionnaires are administered only when depression or dementia is suspected. The 2002 U.S. Preventive Services Task Force report recommends screening adults for depression to improve detection and patient outcomes but does not suggest the use of any particular screening instrument. Serial or sequential testing with the Patient Health Questionnaire-2 and the Patient Health Questionnaire-9 is a good strategy for detecting major depressive episodes in primary care settings. The Patient Health Questionnaire-2 consists of two questions that assess the presence of anhedonia and dysphoria. If a patient answers "yes" to either question, the more specific Patient Health Questionnaire-9 is administered to assess the severity of depressive symptoms and to ascertain the presence of major depressive episode. The Patient Health Questionnaire-9 also can be used to monitor symptom severity and treatment response. The 2003 U.S. Preventive Services Task Force report does not recommend for or against routine screening for dementia in older adults. However, the report does assert that cognitive function should be assessed when impairment is suspected. The Folstein Mini-Mental State Examination and the Functional Activities Questionnaire are suggested tools. The Clock Drawing Test also has been shown to be useful in primary care settings.
ABSTRACT: Physicians face several barriers to counseling their patients about nutrition, including conflicting evidence of the benefit of counseling, limited training and understanding of the topic, and imperfect and varied guidelines to follow. Because cardiovascular disease remains the leading cause of death in industrialized nations, family physicians should provide more than pharmacologic interventions. They must identify the patient's dietary habits and attitudes and provide appropriate counseling. Tools are available to help, and a seven-step approach to nutritional therapy for the dyslipidemic patient may be useful. These steps include recommending increased intake of plant proteins; increased intake of omega-3 fatty acids; modification of the types of oils used in food preparation; decreased intake of saturated and trans-fatty acids; increased intake of whole grains and dietary fiber (especially soluble fiber) and decreased intake of refined grains; modification of alcohol intake, if needed; and regular exercise. Recommendations should be accompanied by patient information handouts presenting acceptable substitutions for currently identified detrimental food choices.
ABSTRACT: Substance abuse in adolescents is undertreated in the United States. Family physicians are well positioned to recognize substance use in their patients and to take steps to address the issue before use escalates. Comorbid mental disorders among adolescents with substance abuse include depression, anxiety, conduct disorder, and attention-deficit/ hyperactivity disorder. Office-, home-, and school-based drug testing is not routinely recommended. Screening tools for adolescent substance abuse include the CRAFFT questionnaire. Family therapy is crucial in the management of adolescent substance use disorders. Although family physicians may be able to treat adolescents with substance use disorders in the office setting, it is often necessary and prudent to refer patients to one or more appropriate consultants who specialize specifically in substance use disorders, psychology, or psychiatry. Treatment options include anticipatory guidance, brief therapeutic counseling, school-based drug-counseling programs, outpatient substance abuse clinics, day treatment programs, and inpatient and residential programs. Working within community and family contexts, family physicians can activate and oversee the system of professionals and treatment components necessary for optimal management of substance misuse in adolescents.
Fatigue: An Overview - Article
ABSTRACT: Fatigue, a common presenting symptom in primary care, negatively impacts work performance, family life, and social relationships. The differential diagnosis of fatigue includes lifestyle issues, physical conditions, mental disorders, and treatment side effects. Fatigue can be classified as secondary to other medical conditions, physiologic, or chronic. The history and physical examination should focus on identifying common secondary causes (e.g., medications, anemia, pregnancy) and life-threatening problems, such as cancer. Results of laboratory studies affect management in only 5 percent of patients, and if initial results are normal, repeat testing is generally not indicated. Treatment of all types of fatigue should include a structured plan for regular physical activity that consists of stretching and aerobic exercise, such as walking. Caffeine and modafinil may be useful for episodic situations requiring alertness. Short naps are proven performance enhancers. Selective serotonin reuptake inhibitors, such as fluoxetine, paroxetine, or sertraline, may improve energy in patients with depression. Patients with chronic fatigue may respond to cognitive behavior therapy. Scheduling regular follow-up visits, rather than sporadic urgent appointments, is recommended for effective long-term management.
Does Health Habit Advice Affect Patient Satisfaction? - Improving Patient Care
Focusing on Today's Visit - Improving Patient Care