ITEMS IN FPM WITH MESH TERM:
Evaluating the Child for Sexual Abuse - Article
ABSTRACT: Child victims of sexual abuse may present with physical findings that can include anogenital problems, enuresis or encopresis. Behavioral changes may involve sexual acting out, aggression, depression, eating disturbances and regression. Because the examination findings of most child victims of sexual abuse are within normal limits or are nonspecific, the child's statements are extremely important. The child's history as obtained by the physician may be admitted as evidence in court trials; therefore, complete documentation of questions and answers is critical. A careful history should be obtained and a thorough physical examination should be performed with documentation of all findings. When examining the child's genitalia, it is important that the physician be familiar with normal variants, non-specific changes and diagnostic signs of sexual abuse. Judicious use of laboratory tests, along with appropriate therapy, should be individually tailored. Forensic evidence collection is indicated in certain cases. Referral for psychologic services is important because victims of abuse are more likely to have depression, anxiety disorders, behavioral problems and post-traumatic stress disorder.
ABSTRACT: People with valvular heart disease are living longer, with less morbidity, than ever before. Advances in surgical techniques and a better understanding of timing for surgical intervention account for increased rates of survival. Echocardiography remains the gold standard for diagnosis and periodic assessment of patients with valvular heart disease. Generally, patients with stenotic valvular lesions can be monitored clinically until symptoms appear. In contrast, patients with regurgitant valvular lesions require careful echocardiographic monitoring for left ventricular function and may require surgery even if no symptoms are present. Aside from antibiotic prophylaxis, very little medical therapy is available for patients with valvular heart disease; surgery is the treatment for most symptomatic lesions or for lesions causing left ventricular dysfunction even in the absence of symptoms.
ABSTRACT: HAIR-AN syndrome is an acronym for an unusual multisystem disorder in women that consists of hyperandrogenism (HA), insulin resistance (IR) and acanthosis nigricans (AN). The precipitating abnormality is thought to be insulin resistance, with a secondary increase in insulin levels and subsequent overproduction of androgens in the ovaries. Long periods of hyperinsulinism and, some suspect, hyperandrogenism can result in the cutaneous manifestation of acanthosis nigricans. Patients are often concerned about the physical manifestations of this disorder, including virilization and acanthosis nigricans, and may be less aware of systemic problems. Physicians should assess women with these problems for an underlying endocrine abnormality. Although a treatment regimen for the HAIR-AN syndrome has not been established, antiandrogen therapy and weight loss are useful.
ABSTRACT: The routine newborn assessment should include an examination for size, macrocephaly or microcephaly, changes in skin color, signs of birth trauma, malformations, evidence of respiratory distress, level of arousal, posture, tone, presence of spontaneous movements, and symmetry of movements. A newborn with one anatomic malformation should be evaluated for associated anomalies. Total and direct bilirubin levels should be measured in newborns with jaundice, and a complete blood count should be obtained in those with pallor or a ruddy complexion. Neurosurgical consultation is necessary in infants with craniosynostosis accompanied by restricted brain growth or hydrocephalus, cephaloceles, or exophytic scalp nodules. Neck masses can be identified by their location and include vascular malformations, abnormal lymphatic tissue, teratomas, and dermoid cysts. Most facial nerve palsies resolve spontaneously. Conjunctivitis is relatively common in newborns. Infants with chest abnormalities may need to be evaluated for Poland's syndrome or Turner's syndrome. Murmurs in the immediate newborn period are usually innocent and represent a transition from fetal to neonatal circulation. Because cyanosis is primarily secondary to respiratory or cardiac causes, affected newborns should be evaluated expeditiously, with the involvement of a cardiologist or neonatologist.
ABSTRACT: Careful examination of the neonate at delivery can detect anomalies, birth injuries, and disorders that may compromise successful adaptation to extrauterine life. A newborn with one anatomic malformation should be evaluated for associated anomalies. If a newborn is found to have an abdominal wall defect, management includes the application of a warm, moist, and sterile dressing over the defect, decompression of the gastrointestinal tract, aggressive fluid resuscitation, antibiotic therapy, and prompt surgical consultation. Hydroceles are managed conservatively, but inguinal hernias require surgical repair. A newborn with developmental hip dysplasia should be evaluated by an orthopedist, and treatment may require use of a Pavlik harness. The presence of ambiguous genitalia is a medical emergency, and pituitary and adrenal integrity must be established. Early diagnosis of spinal lesions is imperative because surgical correction can prevent irreversible neurologic damage.
ABSTRACT: Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. The leading causes of involuntary weight loss are depression (especially in residents of long-term care facilities), cancer (lung and gastrointestinal malignancies), cardiac disorders and benign gastrointestinal diseases. Medications that may cause nausea and vomiting, dysphagia, dysgeusia and anorexia have been implicated. Polypharmacy can cause unintended weight loss, as can psychotropic medication reduction (i.e., by unmasking problems such as anxiety). A specific cause is not identified in approximately one quarter of elderly patients with unintentional weight loss. A reasonable work-up includes tests dictated by the history and physical examination, a fecal occult blood test, a complete blood count, a chemistry panel, an ultrasensitive thyroid-stimulating hormone test and a urinalysis. Upper gastrointestinal studies have a reasonably high yield in selected patients. Management is directed at treating underlying causes and providing nutritional support. Consideration should be given to the patient's environment and interest in and ability to eat food, the amelioration of symptoms and the provision of adequate nutrition. The U.S. Food and Drug Administration has labeled no appetite stimulants for the treatment of weight loss in the elderly.
Headaches in Children and Adolescents - Article
ABSTRACT: Headaches are common during childhood and become more common and increase in frequency during adolescence. The rational, cost-effective evaluation of children with headache begins with a careful history. The first step is to identify the temporal pattern of the headache--acute, acute-recurrent, chronic-progressive, chronic-nonprogressive, or mixed. The next step is a physical and neurologic examination focusing on the optic disc, eye movements, motor asymmetry, coordination, and reflexes. Neuroimaging is not routinely warranted in the evaluation of childhood headache and should be reserved for use in children with chronic-progressive patterns or abnormalities on neurologic examination. Once the headache diagnosis is established, management must be based on the frequency and severity of headache and the impact on the patient's lifestyle. Treatment of childhood migraine includes the intermittent use of oral analgesics and antiemetics and, occasionally, daily prophylactic agents. Often, the most important therapeutic intervention is confident reassurance about the absence of serious underlying neurologic disease.
Assessing Oral Malignancies - Article
ABSTRACT: Oral cancers account for approximately 3 percent of all cases of cancer in the United States. An estimated 30,000 people will be diagnosed with oral cancer this year, and about one half of them will eventually die of the disease. The most common type of oral cancer is squamous cell carcinoma. Sixty percent of oral cancers are well advanced by the time they are detected, even though physicians and dentists frequently examine the oral cavity. The two most important risk factors for oral cancer are tobacco use and heavy alcohol consumption. The keys to reducing mortality are prevention and control. The earlier any intraoral or extraoral abnormalities or lesions are detected and biopsied, the more lives can be saved. Controversy exists whether screening programs effectively reduce the mortality rate. Specific step-by-step guidelines should be followed to perform an adequate examination of the head and neck.
Evaluation of Dysuria in Adults - Article
ABSTRACT: Dysuria, defined as pain, burning, or discomfort on urination, is more common in women than in men. Although urinary tract infection is the most frequent cause of dysuria, empiric treatment with antibiotics is not always appropriate. Dysuria occurs more often in younger women, probably because of their greater frequency of sexual activity. Older men are more likely to have dysuria because of an increased incidence of prostatic hyperplasia with accompanying inflammation and infection. A comprehensive history and physical examination can often reveal the cause of dysuria. Urinalysis may not be needed in healthier patients who have uncomplicated medical histories and symptoms. In most patients, however, urinalysis can help to determine the presence of infection and confirm a suspected diagnosis. Urine cultures and both urethral and vaginal smears and cultures can help to identify sites of infection and causative agents. Coliform organisms, notably Escherichia coli, are the most common pathogens in urinary tract infection. Dysuria can also be caused by noninfectious inflammation or trauma, neoplasm, calculi, hypoestrogenism, interstitial cystitis, or psychogenic disorders. Although radiography and other forms of imaging are rarely needed, these studies may identify abnormalities in the upper urinary tract when symptoms are more complex.
Evaluation of Constipation - Article
ABSTRACT: Constipation is the reason for 2.5 million physician visits per year in the United States, with more than one half of these visits to primary care physicians. Patients and physicians frequently define constipation differently. To determine the underlying cause of constipation, it is important to evaluate the patient's general health, psychosocial status, medical illnesses, dietary fiber intake, and use of constipating medications. The differential diagnosis of constipation and the approach to its evaluation differ in adults and children. Tests of physiologic function are usually reserved for constipation that does not respond to conventional therapy. Family physicians can effectively manage most patients who have constipation.