Items in FPM with MESH term: Family Practice
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: Family physicians must proactively address the sexual health of their patients. Effective sexual health care should address wellness considerations in addition to infections, contraception, and sexual dysfunction. However, physicians consistently underestimate the prevalence of sexual concerns in their patients. By allocating time to discuss sexual health during office visits, high-risk sexual behaviors that can cause sexually transmitted diseases, unintended pregnancies, and unhealthy sexual decisions may be reduced. Developing a routine way to elicit the patient's sexual history that avoids judgmental attitudes and asks the patient for permission to discuss sexual function will make it easier to gather the necessary information. Successful integration of sexual health care into family practice can decrease morbidity and mortality, and enhance well-being and longevity in the patient.
ABSTRACT: As many as 30 million Americans have migraine headaches. The impact on patients and their families can be tremendous, and treatment of migraines can present diagnostic and therapeutic challenges for family physicians. Abortive treatment options include nonspecific and migraine-specific therapy. Nonspecific therapies include analgesics (aspirin, nonsteroidal anti-inflammatory drugs, and opiates), adjunctive therapies (antiemetics and sedatives), and other nonspecific medications (intranasal lidocaine or steroids). Migraine-specific abortive therapies include ergotamine and its derivatives, and triptans. Complementary and alternative therapies can also be used to abort the headache or enhance the efficacy of another therapeutic modality. Treatment choices for acute migraine should be based on headache severity, migraine frequency, associated symptoms, and comorbidities.
ABSTRACT: Vaccines have turned many childhood diseases into distant memories in industrialized countries. However, questions have been raised about the safety of some vaccines because of rare but serious adverse effects that have been attributed to them. Pain, swelling, and redness at the injection site are common local reactions to vaccines. Fever and irritability may occur after some immunizations. Currently, no substantial evidence links measles-mumps-rubella vaccine to autism, or hepatitis B vaccine to multiple sclerosis. Thimerosal is being eliminated from routine childhood vaccines because of concerns that multiple immunizations with vaccines containing this preservative could exceed recommended mercury exposures. Family physicians should be knowledgeable about vaccines so that they can inform their patients of the benefits of immunization and any proven risks. If immunization rates fall, the incidence of vaccine-preventable illnesses may rise.
Lymphadenopathy and Malignancy - Article
ABSTRACT: The majority of patients presenting with peripheral lymphadenopathy have easily identifiable causes that are benign or self-limited. Among primary care patients presenting with lymphadenopathy, the prevalence of malignancy has been estimated to be as low as 1.1 percent. The critical challenge for the primary care physician is to identify which cases are secondary to malignancies or other serious conditions. Key risk factors for malignancy include older age, firm, fixed nodal character, duration of greater than two weeks, and supraclavicular location. Knowledge of these risk factors is critical to determining the management of unexplained lymphadenopathy. In addition, a complete exposure history, review of associated symptoms, and a thorough regional examination help determine whether lymphadenopathy is of benign or malignant origin. Unexplained lymphadenopathy without signs or symptoms of serious disease or malignancy can be observed for one month, after which specific testing or biopsy should be performed. While modern hematopathologic technologies have improved the diagnostic yields of fine-needle aspiration, excisional biopsy remains the initial diagnostic procedure of choice. The overall evaluation of lymphadenopathy, with a focus on findings suggestive of malignancy, as well as an approach to the patient with unexplained lymphadenopathy, will be reviewed.
ABSTRACT: Joint injection of the elbow is a useful diagnostic and therapeutic tool for the family physician. In this article, the injection procedures for the elbow joint, medial and lateral epicondylitis, and olecranon bursitis are reviewed. Persistent pain related to inflammatory conditions responds well to injection in the region. Indications for elbow joint injection include osteoarthritis and rheumatoid arthritis. Corticosteroid injection is an accepted treatment option for medial and lateral epicondylitis. Olecranon bursa aspiration and injection are useful when that bursa is inflamed. The proper techniques, choice and quantity of pharmaceuticals, and appropriate follow-up essential for effective outcomes are discussed.
ABSTRACT: West Nile virus is a mosquito-borne flavivirus and human neuropathogen. Since the virus was recognized in New York City in 1999, it has spread rapidly across the United States, with human disease documented in 39 states and the District of Columbia. West Nile virus can cause a broad range of clinical syndromes, including fever, meningitis, encephalitis, and a flaccid paralysis characteristic of a poliomyelitis-like syndrome. Approximately one in 150 infections results in severe neurologic illness. Advanced age is the greatest risk factor for severe neurologic disease, long-term sequelae, and death. Physicians should consider West Nile virus infection when evaluating febrile patients who have unexplained neurologic symptoms, muscle weakness, or erythematous rash during late spring through early fall, or throughout the year in warm climates. West Nile virus infection has no characteristic findings on routine laboratory tests, although anemia, leukocytosis, or lymphopenia may be present. Testing for IgM antibody to West Nile virus in serum or cerebrospinal fluid (samples from the acute and convalescent phases, submitted at least two weeks apart) is the most common diagnostic method. Local or state health departments usually can perform the test within 24 to 36 hours of submission. Treatment is supportive. Prevention relies on comprehensive mosquito-control programs and measures to avoid mosquito bites, including the use of mosquito repellents containing N,N-diethyl-m-toluamide.
Acute Dyspnea in the Office - Article
ABSTRACT: Respiratory difficulty is a common presenting complaint in the outpatient primary care setting. Because patients may first seek care by calling their physician's office, telephone triage plays a role in the early management of dyspnea. Once the patient is in the office, the initial goal of assessment is to determine the severity of the dyspnea with respect to the need for oxygenation and intubation. Unstable patients typically present with abnormal vital signs, altered mental status, hypoxia, or unstable arrhythmia, and require supplemental oxygen, intravenous access and, possibly, intubation. Subsequent management depends on the differential diagnosis established by a proper history, physical examination, and ancillary studies. Dyspnea is most commonly caused by respiratory and cardiac disorders. Other causes may be upper airway obstruction, metabolic acidosis, a psychogenic disorder, or a neuromuscular condition. Differential diagnoses in children include bronchiolitis, croup, epiglottitis, and foreign body aspiration. Pertinent history findings include cough, sore throat, chest pain, edema, and orthopnea. The physical examination should focus on vital signs and the heart, lungs, neck, and lower extremities. Significant physical signs are fever, rales, wheezing, cyanosis, stridor, or absent breath sounds. Diagnostic work-up includes pulse oximetry, complete blood count, electrocardiography, and chest radiography. If the patient is admitted to the emergency department or hospital, blood gases, ventilation-perfusion scan, D-dimer tests, and spiral computed tomography can help clarify the diagnosis. In a stable patient, management depends on the underlying etiology of the dyspnea.
Breast Cyst Aspiration - Article
ABSTRACT: The breast mass is a clinical problem commonly encountered by family physicians. Fine-needle and core biopsy techniques require training and cytopathologist support. In contrast, breast cyst aspiration using a 21- or 22-gauge needle is a simple, cost-effective, minimally invasive procedure. The technique is easy to learn and can be practiced on a breast model. Breast cyst aspiration may be attempted in many women who present with a palpable, dominant breast mass. If clear fluid is aspirated and the mass resolves, malignancy is unlikely, and breast cyst is the probable diagnosis. In this situation, reevaluation in four to six weeks is appropriate; if the cyst has not recurred, only routine mammographic surveillance is required. Referral for fine-needle or excisional biopsy is indicated if the aspirate is bloody or extremely tenacious, if no fluid can be aspirated, or if there is residual mass after aspiration. Complications such as local discomfort, bruising, and infection are uncommon.
ABSTRACT: Chemical dependency is a common, chronic disease that affects up to 25 percent of patients seen in primary care practices. The treatment goal for patients recovering from chemical dependency should be to avoid relapse. This requires physicians to have an open, nonjudgmental attitude and specific expertise about the implications of addiction for other health problems. First-line treatment for chemical dependency should be nonpharmacologic, but when medication is necessary, physicians should avoid drugs that have the potential for abuse or addiction. Medications that sedate or otherwise impair judgment also should be avoided in the recovering patient. Psychiatric illnesses should be aggressively treated, because untreated symptoms increase the risk of relapse into chemical dependency. Selective serotonin reuptake inhibitors may help to lower alcohol consumption in depressed patients, and desipramine may help to facilitate abstinence in persons addicted to cocaine. If insomnia extends beyond the acute or postacute withdrawal period, trazodone may be an effective treatment. If nonpharmacologic management of pain is not possible, nonaddictive medications should be used. However, if non-addictive medications fail, long-acting opiates used under strict supervision may be considered. Uncontrolled pain in itself is a relapse risk.