Items in FPM with MESH term: Office Visits
ABSTRACT: The simple request for a sick note can disguise important medical, psychologic or social issues. Disability may be influenced by social and cultural factors as well as by patient expectations. Assessment of impairment and subsequent disability is best made on the basis of objective data by use of a biopsychosocial model to ensure that the expression of disability does not mask other unaddressed psychologic or social issues. Enabling prolonged disability in such a situation can be a dysfunctional physician response to a maladaptive process. The physician's role is to treat the condition, to fulfill the appropriate role of patient advocate, to facilitate health (including resumption of activity), to offer proactive advice on the basis of prognosis, to be familiar with the patient's social obligations and resources and to provide education about the therapeutic benefits of returning to optimal function. This factual, medical-based approach offers an effective preventive strategy that will save many patients from unnecessary disability and morbidity.
ABSTRACT: The presence of family members at an office visit creates unique opportunities and challenges for the physician while interviewing the patient. The physician must address issues of confidentiality, privacy, and agency. Special skills are required to respectfully and efficiently involve family members, while keeping the patient at the center of the visit. A core set of interviewing skills exists for office visit interviews with family members present. These skills include building rapport with each participant by identifying their individual issues and perspectives, and encouraging participation by listening to and addressing the concerns of all persons. Physicians should also avoid triangulation, maintain confidentiality, and verify agreement with the plan. It may be necessary to use more advanced family interviewing skills, including providing direction despite problematic communications; managing conflict; negotiating common ground; and referring members to family therapy.
An Approach to Interpreting Spirometry - Article
ABSTRACT: Spirometry is a powerful tool that can be used to detect, follow, and manage patients with lung disorders. Technology advancements have made spirometry much more reliable and relatively simple to incorporate into a routine office visit. However, interpreting spirometry results can be challenging because the quality of the test is largely dependent on patient effort and cooperation, and the interpreter's knowledge of appropriate reference values. A simplified and stepwise method is key to interpreting spirometry. The first step is determining the validity of the test. Next, the determination of an obstructive or restrictive ventilatory patten is made. If a ventilatory pattern is identified, its severity is graded. In some patients, additional tests such as static lung volumes, diffusing capacity of the lung for carbon monoxide, and bronchodilator challenge testing are needed. These tests can further define lung processes but require more sophisticated equipment and expertise available only in a pulmonary function laboratory.
ABSTRACT: The postpartum period (typically the first six weeks after delivery) may underscore physical and emotional health issues in new mothers. A structured approach to the postpartum office visit ensures that relevant conditions and concerns are discussed and appropriately addressed. Common medical complications during this period include persistent postpartum bleeding, endometritis, urinary incontinence, and thyroid disorders. Breastfeeding education and behavioral counseling may increase breastfeeding continuance. Postpartum depression can cause significant morbidity for the mother and baby; a postnatal depression screening tool may assist in diagnosing depression-related conditions. Decreased libido can affect sexual functioning after a woman gives birth. Physicians should also discuss contraception with postpartum patients, even those who are breastfeeding. Progestin-only contraceptives are recommended for breastfeeding women. The lactational amenorrhea method may be a birth control option but requires strict criteria for effectiveness.
ABSTRACT: Medical problems associated with prematurity are frequently complex, and a multidisciplinary approach is often required. Some common problems include the following: (1) anemia, which can be reduced by iron supplementation, (2) cerebral palsy or mental retardation as a result of intraventricular hemorrhage or periventricular leukomalacia, (3) respiratory problems, including bronchopulmonary dysplasia and apnea, (4) visual problems, such as those associated with retinopathy of prematurity, (5) gastroesophageal reflux and (6) surgical problems, including inguinal or umbilical hernia and cryptorchidism. Monitoring of growth and development includes recording the infant's head circumference, weight and length on a growth chart for premature infants. Nutritional status should be assessed at each visit, watching for hyperosmolar problems in infants receiving high-calorie formulas. Consultation with other specialists may be required if abnormalities are identified during follow-up care in the office.
ABSTRACT: Chronic cough is a common problem in patients who visit family physicians. The three most common causes of chronic cough in those who are referred to pulmonary specialists are postnasal drip, asthma and gastroesophageal reflux. The initial treatment of patients with cough is often empiric and may involve a trial of decongestants, bronchodilators or histamine H2 antagonists, as monotherapy or in combination. If a therapeutic trial is not successful, sequential diagnostic testing including chest radiograph, purified protein derivative test for tuberculosis, computed tomography of the sinuses, methacholine challenge test or barium swallow may be indicated. By using a standard protocol for diagnosis and treatment, 90 percent of patients with chronic cough can be managed successfully in the family physician's office. However, in some cases it may take three to five months to determine a diagnosis and effective treatment. For the minority of patients in whom this diagnostic approach is unsuccessful, consultation with a pulmonary specialist is appropriate.
Treatment of Type 2 Diabetes Mellitus - Article
ABSTRACT: Type 2 diabetes mellitus (formerly called non-insulin-dependent diabetes) causes abnormal carbohydrate, lipid and protein metabolism associated with insulin resistance and impaired insulin secretion. Insulin resistance is a major contributor to progression of the disease and to complications of diabetes. Type 2 diabetes is a common and underdiagnosed condition that poses treatment challenges to family practitioners. The introduction of new oral agents within the past three years has expanded the range of possible combination regimens available for treating type 2 diabetes. Despite the choice of pharmacologic agents, physicians must stress the nonpharmacologic approaches of diet modification, weight control and regular exercise. Pharmacologic approaches must be based on patient characteristics, level of glucose control and cost considerations. Combinations of different oral agents may be useful for controlling hyperglycemia before insulin therapy becomes necessary. A stepped-care approach to drug therapy may provide the most rational, cost-efficient approach to management of this disease. Pharmaco-economic analyses of clinical trials are needed to determine cost-effective treatment strategies for management of type 2 diabetes.
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.
ABSTRACT: Although it is often unrecognized, family physicians provide a significant amount of mental health care in the United States. Time is one of the major obstacles to providing counseling in primary care. Counseling approaches developed specifically for ambulatory patients and traditional psychotherapies modified for primary care are efficient first-line treatments. For some clinical conditions, providing individualized feedback alone leads to improvement. The five A's (ask, advise, assess, assist, arrange) and FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of strategies, empathetic style, promote self-efficacy) techniques are stepwise protocols that are effective for smoking cessation and reducing excessive alcohol consumption. These models can be adapted to address other problems, such as treatment nonadherence. Although both approaches are helpful to patients who are ready to change, they are less likely to be successful in patients who are ambivalent or who have broader psychosocial problems. For patients who are less committed to changing health risk behavior or increasing healthy behavior, the stages-of-change approach and motivational interviewing address barriers. Patients with psychiatric conditions and acute psychosocial stressors will likely respond to problem-solving therapy or the BATHE (background, affect, troubles, handling, empathy) technique. Although brief primary care counseling has been effective, patients who do not fully respond to the initial intervention should receive multimodal therapy or be referred to a mental health professional.
Making Diabetes Checkups More Fruitful - Improving Patient Care