Items in AFP with MESH term: Referral and Consultation
ABSTRACT: Several large clinical trials conducted over the past decade have shown that pharmacologic interventions can dramatically reduce the morbidity and mortality associated with heart failure. These trials have modified and enhanced the therapeutic paradigm for heart failure and extended treatment goals beyond limiting congestive symptoms of volume overload. Part II of this two-part article presents treatment recommendations for patients with left ventricular systolic dysfunction. The authors recommend that, if tolerated and not contraindicated, the following agents be used in patients with left ventricular systolic dysfunction: an angiotensin-converting enzyme inhibitor in all patients; a beta blocker in all patients except those who have symptoms at rest; and spironolactone in patients who have symptoms at rest or who have had such symptoms within the past six months. Diuretics and digoxin should be reserved, as needed, for symptomatic management of heart failure. Other treatments or treatment programs may be necessary in individual patients.
Depression in Children and Adolescents - Article
ABSTRACT: Depression among children and adolescents is common but frequently unrecognized. It affects 2 percent of prepubertal children and 5 to 8 percent of adolescents. The clinical spectrum of the disease can range from simple sadness to a major depressive or bipolar disorder. Risk factors include a family history of depression and poor school performance. Evaluation should include a complete medical assessment to rule out underlying medical causes. A structured clinical interview and various rating scales such as the Pediatric Symptom Checklist are helpful in determining whether a child or adolescent is depressed. Evidence-based treatment guidelines from the literature are limited. Psychotherapy appears to be useful in most children and adolescents with mild to moderate depression. Tricyclic antidepressants and selective serotonin reuptake inhibitors are medical therapies that have been studied on a limited basis. The latter agents are better tolerated but not necessarily more efficacious. Because the risk of school failure and suicide is quite high in depressed children and adolescents, prompt referral or close collaboration with a mental health professional is often necessary.
Evaluation and Treatment of ADHD - Article
ABSTRACT: Symptoms of attention-deficit/hyperactivity disorder (ADHD) are present in as many as 9 percent of school-age children. ADHD-specific questionnaires can help determine whether children meet diagnostic criteria for the disorder. The recommended evaluation also includes documenting the type and severity of ADHD symptoms, verifying the presence of normal vision and hearing, screening for comorbid psychologic conditions, reviewing the child's developmental history and school performance, and applying objective measures of cognitive function. The stimulants methylphenidate and dextroamphetamine remain the pharmacologic agents of first choice for the management of ADHD. These agents are equally effective in improving the core symptoms of the disorder, but individual children may respond better to one stimulant medication than to another. Achievement of maximal benefit may require titration of the initial dosage and dosing before breakfast, before lunch and in the afternoon. The family physician should tailor the treatment plan to meet the unique needs of the child and family. Psychosocial, behavioral and educational strategies that enhance specific behaviors may improve educational and social functioning in the child with ADHD.
ABSTRACT: Adolescent idiopathic scoliosis is present in 2 to 4 percent of children between 10 and 16 years of age. It is defined as a lateral curvature of the spine greater than 10 degrees accompanied by vertebral rotation. It is thought to be a multigene dominant condition with variable phenotypic expression. Scoliosis can be identified by the Adam's forward bend test during physical examination. Severe pain, a left thoracic curve or an abnormal neurologic examination are red flags that point to a secondary cause for spinal deformity. Specialty consultation and magnetic resonance imaging are needed if red flags are present. Of adolescents diagnosed with scoliosis, only 10 percent have curves that progress and require medical intervention. The main risk factors for curve progression are a large curve magnitude, skeletal immaturity and female gender. The likelihood of curve progression can be estimated by measuring the curve magnitude using the Cobb method on radiographs and by assessing skeletal growth potential using Tanner staging and Risser grading.
ABSTRACT: Sports have become increasingly popular and account for numerous eye injuries each year. The sports that most commonly cause eye injuries, in order of decreasing frequency, are basketball, water sports, baseball, and racquet sports. Sports are classified as low risk, high risk, and very high risk. Sports-related eye injuries are blunt, penetrating, and radiation injuries. The use of eye protection has helped to reduce the number and severity of eye injuries. The American Society for Testing and Materials has established performance standards for selected eyewear. Consultation with an eye care professional is recommended for fitting protective eyewear. The functionally one-eyed, or monocular, athlete should take extra precautions. A preparticipation eye examination is helpful in identifying persons who may be at increased risk for eye injury. Sports-related eye injuries should be evaluated on site with an adequate examination of the eye and adnexa. Minor eye injuries may be treated on site. The team physician must know which injuries require immediate referral to an ophthalmologist and the guidelines for returning an athlete to competition.
Electrosurgery for the Skin - Article
ABSTRACT: The purposes of electrosurgery are to destroy benign and malignant lesions, control bleeding, and cut or excise tissue. The major modalities in electrosurgery are electrodesiccation, fulguration, electrocoagulation, and electrosection. Electrosurgery can be used for incisional techniques that produce full-thickness excision of nevi, for shave techniques that produce partial-thickness removal of superficial lesions, and for removing vascular lesions such as hemangiomas or pyogenic granulomas. The correct output power can be determined by starting low and increasing the power until the desired outcome is attained (destruction, coagulation, or cutting). Smaller cherry angiomas can be electrocoagulated lightly. Larger cherry angiomas may be easier to treat by shaving them first, then electrocoagulating or desiccating the base. The elevated portion of pyogenic granulomas can be shaved off with a scalpel or a loop electrode using a cutting/coagulation current. The base of the lesion is curetted to remove the remaining tissue and then electrodesiccated. Complications such as burns, shocks, and transmission of infection can be prevented by careful use of the electrosurgical equipment.
ABSTRACT: Sinusitis is one of the most common diseases treated by primary care physicians. Uncomplicated sinusitis does not require radiologic imagery. However, when symptoms are recurrent or refractory despite adequate treatment, further diagnostic evaluations may be indicated. Plain radiography has a limited role in the management of sinusitis. Although air-fluid levels and complete opacification of a sinus are more specific for sinusitis, they are only seen in 60 percent of cases. Noncontrast coronal computed tomographic (CT) images can define the nasal anatomy much more precisely. Mucosal thickening, polyps, and other sinus abnormalities can be seen in 40 percent of symptomatic adults; however, clinical correlation is needed to avoid overdiagnosis of sinusitis because of nonspecific CT findings. Use of CT is typically reserved for difficult cases or to define anatomy prior to sinus surgery. Magnetic resonance imaging (MRI) cannot define bony anatomy as well as CT. MRI is only used to differentiate soft-tissue structures, such as in cases of suspected fungal infection or neoplasm. Referral will occasionally be needed in unusual or complicated cases. Immunocompromised persons and smokers are at increased risk for serious sinusitis complications.
Failure to Thrive - Article
ABSTRACT: Failure to thrive is a condition commonly seen by primary care physicians. Prompt diagnosis and intervention are important for preventing malnutrition and developmental sequelae. Medical and social factors often contribute to failure to thrive. Either extreme of parental attention (neglect or hypervigilance) can lead to failure to thrive. About 25 percent of normal infants will shift to a lower growth percentile in the first two years of life and then follow that percentile; this should not be diagnosed as failure to thrive. Infants with Down syndrome, intrauterine growth retardation, or premature birth follow different growth patterns than normal infants. Many infants with failure to thrive are not identified unless careful attention is paid to plotting growth parameters at routine checkups. A thorough history is the best guide to establishing the etiology of the failure to thrive and directing further evaluation and management. All children with failure to thrive need additional calories for catch-up growth (typically 150 percent of the caloric requirement for their expected, not actual, weight). Few need laboratory evaluation. Hospitalization is rarely required and is indicated only for severe failure to thrive and for those whose safety is a concern. A multidisciplinary approach is recommended when failure to thrive persists despite intervention or when it is severe.
Common Dental Emergencies - Article
ABSTRACT: Dental caries, a bacterial disease of teeth characterized by destruction of enamel and dentine, is often the underlying cause of dental pain. When a carious lesion impinges on the dental pulp, pulpitis follows and, ultimately, necrosis of the pulp occurs. Untreated necrosis may lead to a localized abscess or a spreading infection into the surrounding soft tissue that results in cellulitis. Immediate treatment involves antibiotic therapy for cellulitis, perhaps with drainage of abscesses, while definitive treatment requires root canal therapy or extraction of the involved tooth. Pericoronitis is an inflammation of the soft tissue overlying a partially erupted tooth. Localized cases respond to irrigation. Secondary cellulitis can develop. Definitive treatment may require surgical extraction of the underlying tooth or excision of the gum flap. Avulsion of a permanent tooth secondary to trauma is a true dental emergency. The tooth should be reimplanted on the spot, and the patient should be seen immediately by a dentist for splinting and antibiotic prophylaxis. Most dental problems can be prevented with regular dental care and steps to minimize risks of oral trauma.
ABSTRACT: Acute monoarthritis can be the initial manifestation of many joint disorders. The first step in diagnosis is to verify that the source of pain is the joint, not the surrounding soft tissues. The most common causes of monoarthritis are crystals (i.e., gout and pseudogout), trauma, and infection. A careful history and physical examination are important because diagnostic studies frequently are only supportive. Examination of joint fluid often is essential in making a definitive diagnosis. Leukocyte counts vary widely in septic and sterile synovial fluids and should be interpreted cautiously. If the history and diagnostic studies suggest an infection, aggressive treatment can prevent rapid joint destruction. When an infection is suspected, culture and Gram staining should be performed and antibiotics should be started. Light microscopy may be useful to identify gout crystals, but polarized microscopy is preferred. Blood tests alone never confirm a diagnosis, and radiographic studies are diagnostic only in selected conditions. Referral is indicated when patients have septic arthritis or when the initial evaluation does not determine the etiology.