ITEMS IN FPM WITH MESH TERM:
ABSTRACT: This article provides answers to many of the questions medical students ask about the specialty of family practice. It is the fourth update of a previous article and was developed in response to feedback from medical students at the 1997 National Congress of Student Members held by the American Academy of Family Physicians. Students at the 1998 Congress also identified areas of interest and concern. This article discusses the hours and income of the family physician, the scope of medical practice in the specialty, required continuing medical education and board certification, family practice residency training and combined-specialty training.
ABSTRACT: Social phobia is a highly prevalent yet often overlooked psychiatric disorder that can cause severe disability but fortunately has shown responsiveness to specific pharmacotherapy and psychotherapy. Recognition of its essential clinical features and the use of brief, targeted screening questions can improve detection within family practice settings. Cognitive behavioral therapy, with or without specific antidepressant therapy, is the evidence-based treatment of choice for most patients. Adjunctive use of benzodiazepines can facilitate the treatment response of patients who need initial symptom relief. The use of beta blockers as needed has been found to be helpful in the treatment of circumscribed social and performance phobias. Treatment planning should consider the patient's preference, the severity of presenting symptoms, the degree of functional impairment, psychiatric and substance-related comorbidity, and long-term treatment goals.
ABSTRACT: Knee effusions may be the result of trauma, overuse or systemic disease. An understanding of knee pathoanatomy is an invaluable part of making the correct diagnosis and formulating a treatment plan. Taking a thorough medical history is the key component of the evaluation. The most common traumatic causes of knee effusion are ligamentous, osseous and meniscal injuries, and overuse syndromes. Atraumatic etiologies include arthritis, infection, crystal deposition and tumor. It is essential to compare the affected knee with the unaffected knee. Systematic physical examination of the knee, using specific maneuvers, and the appropriate use of diagnostic imaging studies and arthrocentesis establish the correct diagnosis and treatment.
ABSTRACT: Helping patients change behavior is an important role for family physicians. Change interventions are especially useful in addressing lifestyle modification for disease prevention, long-term disease management and addictions. The concepts of "patient noncompliance" and motivation often focus on patient failure. Understanding patient readiness to make change, appreciating barriers to change and helping patients anticipate relapse can improve patient satisfaction and lower physician frustration during the change process. In this article, we review the Transtheoretical Model of Change, also known as the Stages of Change model, and discuss its application to the family practice setting. The Readiness to Change Ruler and the Agenda-Setting Chart are two simple tools that can be used in the office to promote discussion.
ABSTRACT: The differential diagnosis for febrile patients with a rash is extensive. Diseases that present with fever and rash are usually classified according to the morphology of the primary lesion. Rashes can be categorized as maculopapular (centrally and peripherally distributed), petechial, diffusely erythematous with desquamation, vesiculobullous-pustular and nodular. Potential causes include viruses, bacteria, spirochetes, rickettsiae, medications and rheumatologic diseases. A thorough history and a careful physical examination are essential to making a correct diagnosis. Although laboratory studies can be useful in confirming the diagnosis, test results often are not available immediately. Because the severity of these illnesses can vary from minor (roseola) to life-threatening (meningococcemia), the family physician must make prompt management decisions regarding empiric therapy. Hospitalization, isolation and antimicrobial therapy often must be considered when a patient presents with fever and a rash.
Assessing Nicotine Dependence - Article
ABSTRACT: Family physicians can assess the smoking behavior of their patients in a few minutes, using carefully chosen questions. The CAGE questionnaire for smoking (modified from the familiar CAGE questionnaire for alcoholism), the "four Cs" test and the FagerstrÃ¶m Test for Nicotine Dependence help make the diagnosis of nicotine dependence based on standard criteria. Additional questions can be used to determine the patient's readiness to change and the nature of the reinforcement the patient receives from smoking. These tools can assist family physicians in guiding patients to quit smoking-the single most important thing smokers can do to improve their health.
ABSTRACT: The American Academy of Family Physicians now recommends that all persons 50 years of age and older receive an annual influenza vaccination, because the rates of morbidity and mortality associated with influenza are high and vaccination is cost-effective. Reasons for lowering the recommended age for routine vaccination from 65 to 50 years of age include reductions in office visits, hospitalizations, time taken off work and associated costs. In working adults 18 to 64 years of age, the cost savings were estimated at $46.85 per person vaccinated. Furthermore, the fatality rate from influenza begins to rise at age 45 and is highest in persons with multiple chronic medical conditions. As in the past, recommendations target persons at high risk for complications, such as those with cardiac disease, lung disease and diabetes, as well as health care workers and residents of nursing homes. Severe allergy to eggs is a contraindication to influenza vaccination.
ABSTRACT: The incidence of malignant melanoma has increased in recent years more than that of any other cancer in the United States. About one in 70 people will develop melanoma during their lifetime. Family physicians should be aware that a patient with a changing mole, an atypical mole or multiple nevi is at considerable risk for developing melanoma. Any mole that is suggestive of melanoma requires an excisional biopsy, primarily because prognosis and treatment are based on tumor thickness. Staging is based on tumor thickness (Breslow's measurement) and histologic level of invasion (Clark level). The current recommendations for excisional removal of confirmed melanomas include 1-cm margins for lesions measuring 1.0 mm or less in thickness and 2-cm margins for lesions from 1.0 mm to 4.0 mm in thickness or Clark's level IV of any thickness. No evidence currently shows that wider margins improve survival in patients with lesions more than 4.0 mm thick. Clinically positive nodes are typically managed by completely removing lymph nodes in the area. Elective lymph node dissection is recommended only for patients who are younger than 60 years with lesions between 1.5 mm and 4.0 mm in thickness. In the Eastern Cooperative Oncology Group Trial, interferon alfa-2b was shown to improve disease-free and overall survival, but in many other trials it has not been shown to be effective at prolonging overall survival. Vaccine therapy is currently being used to stimulate the immune system of melanoma patients with metastatic disease.
ABSTRACT: Patients who provide care to family members or friends with dementia are likely to be in a family physician's practice. The caregiver role can be stressful, and identifying these patients can give the family physician opportunities to help patients cope with the challenges of the caregiver role. Family physicians have a systematic approach for assessing the degree of caregiver burden in these patients. Because caregivers are at increased risk for depression and anxiety, screening should be done to exclude the presence of either disorder. The caregiver's skill in managing behavioral problems in the family member with dementia should be assessed. If there are problems, family physicians should provide practical counseling about common caregiving stresses and about resources that benefit caregivers. Helping the caregiver learn strategies for coping with difficulties may help reduce some of the stress the caregiver is experiencing.
Prevention and Treatment of Dog Bites - Article
ABSTRACT: Almost one half of all dog bites involve an animal owned by the victim's family or neighbors. A large percentage of dog bite victims are children. Although some breeds of dogs have been identified as being more aggressive than other breeds, any dog may attack when threatened. All dog bites carry a risk of infection, but immediate copious irrigation can significantly decrease that risk. Assessment for the risk of tetanus and rabies virus infection, and subsequent selection of prophylactic antibiotics, are essential in the management of dog bites. The dog bite injury should be documented with photographs and diagrams when appropriate. Family physicians should educate parents and children on ways to prevent dog bites.