Items in FPM with MESH term: Physical Examination
Tension-Type Headache - Article
ABSTRACT: Tension-type headache typically causes pain that radiates in a band-like fashion bilaterally from the forehead to the occiput. Pain often radiates to the neck muscles and is described as tightness, pressure, or dull ache. Migraine-type features (unilateral, throbbing pain, nausea, photophobia) are not present All patients with frequent or severe headaches need careful evaluation to exclude any occult serious condition that may be causing the headache. Neuroimaging is not needed in patients who have no worrisome findings on examination. Treatment of tension-type headache typically involves the use of over-the-counter analgesics. Use of pain relievers more than twice weekly places patients at risk for progression to chronic daily headache. Sedating antihistamines or antiemetics can potentiate the pain-relieving effects of standard analgesics. Analgesics combined with butalbital or opiates are often useful for tension-type pain but have an increased risk of causing chronic daily headache. Amitriptyline is the most widely researched prophylactic agent for frequent headaches. No large trials with rigorous methodologies have been conducted for most non-medication therapies. Among the commonly employed modalities are biofeedback, relaxation training, self-hypnosis, and cognitive therapy.
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.
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.
The Abnormal Fontanel - Article
ABSTRACT: The diagnosis of an abnormal fontanel requires an understanding of the wide variation of normal. At birth, an infant has six fontanels. The anterior fontanel is the largest and most important for clinical evaluation. The average size of the anterior fontanel is 2.1 cm, and the median time of closure is 13.8 months. The most common causes of a large anterior fontanel or delayed fontanel closure are achondroplasia, hypothyroidism, Down syndrome, increased intracranial pressure, and rickets. A bulging anterior fontanel can be a result of increased intracranial pressure or intracranial and extracranial tumors, and a sunken fontanel usually is a sign of dehydration. A physical examination helps the physician determine which imaging modality, such as plain films, ultrasonography, computed tomographic scan, or magnetic resonance imaging, to use for diagnosis.
Acute Abdominal Pain in Children - Article
ABSTRACT: Acute abdominal pain in children presents a diagnostic dilemma. Although many cases of acute abdominal pain are benign, some require rapid diagnosis and treatment to minimize morbidity. Numerous disorders can cause abdominal pain. The most common medical cause is gastroenteritis, and the most common surgical cause is appendicitis. In most instances, abdominal pain can be diagnosed through the history and physical examination. Age is a key factor in evaluating the cause; the incidence and symptoms of different conditions vary greatly over the pediatric age spectrum. In the acute surgical abdomen, pain generally precedes vomiting, while the reverse is true in medical conditions. Diarrhea often is associated with gastroenteritis or food poisoning. Appendicitis should be suspected in any child with pain in the right lower quadrant. Signs that suggest an acute surgical abdomen include involuntary guarding or rigidity, marked abdominal distention, marked abdominal tenderness, and rebound abdominal tenderness. If the diagnosis is not clear after the initial evaluation, repeated physical examination by the same physician often is useful. Selected imaging studies also might be helpful. Surgical consultation is necessary if a surgical cause is suspected or the cause is not obvious after a thorough evaluation.
ABSTRACT: Diabetic neuropathy is a debilitating disorder that occurs in nearly 50 percent of patients with diabetes. It is a late finding in type 1 diabetes but can be an early finding in type 2 diabetes. The primary types of diabetic neuropathy are sensorimotor and autonomic. Patients may present with only one type of diabetic neuropathy or may develop combinations of neuropathies (e.g., distal symmetric polyneuropathy and autonomic neuropathy). Distal symmetric polyneuropathy is the most common form of diabetic neuropathy. Diabetic neuropathy also can cause motor deficits, silent cardiac ischemia, orthostatic hypotension, vasomotor instability, hyperhidrosis, gastroparesis, bladder dysfunction, and sexual dysfunction. Strict glycemic control and good daily foot care are key to preventing complications of diabetic neuropathy.
Diagnostic Approach to Tinnitus - Article
ABSTRACT: Tinnitus is a common disorder with many possible causes. Most cases of tinnitus are subjective, but occasionally the tinnitus can be heard by an examiner. Otologic problems, especially hearing loss, are the most common causes of subjective tinnitus. Common causes of conductive hearing loss include external ear infection, cerumen impaction, and middle ear effusion. Sensorineural hearing loss may be caused by exposure to excessive loud noise, presbycusis, ototoxic medications, or Meniere's disease. Unilateral hearing loss plus tinnitus should increase suspicion for acoustic neuroma. Subjective tinnitus also may be caused by neurologic, metabolic, or psychogenic disorders. Objective tinnitus usually is caused by vascular abnormalities of the carotid artery or jugular venous systems. Initial evaluation of tinnitus should include a thorough history, head and neck examination, and audiometric testing to identify an underlying etiology. Unilateral or pulsatile tinnitus may be caused by more serious pathology and typically merits specialized audiometric testing and radiologic studies. In patients who are discomforted by tinnitus and have no remediable cause, auditory masking may provide some relief.
Obstructive Sleep Apnea in Children - Article
ABSTRACT: Obstructive sleep-disordered breathing is common in children. From 3 percent to 12 percent of children snore, while obstructive sleep apnea syndrome affects 1 percent to 10 percent of children. The majority of these children have mild symptoms, and many outgrow the condition. Consequences of untreated obstructive sleep apnea include failure to thrive, enuresis, attention-deficit disorder, behavior problems, poor academic performance, and cardiopulmonary disease. The most common etiology of obstructive sleep apnea is adenotonsillar hypertrophy. Clinical diagnosis of obstructive sleep apnea is reliable; however, the gold standard evaluation is overnight polysomnography. Treatment includes the use of continuous positive airway pressure and weight loss in obese children. These alternatives are tolerated poorly in children and rarely are considered primary therapy. Adenotonsillectomy is curative in most patients. Children with craniofacial syndromes, neuromuscular diseases, medical comorbidities, or severe obstructive sleep apnea, and those younger than three years are at increased risk of developing postoperative complications and should be monitored overnight in the hospital.
ABSTRACT: Diagnosis of upper extremity injuries depends on knowledge of basic anatomy and biomechanics of the hand and wrist. The wrist is composed of two rows of carpal bones. Flexor and extensor tendons cross the wrist to allow function of the hand and digits. The ulnar, median, and radial nerves provide innervation of the hand and wrist. A systematic primary and secondary examination of the hand and wrist includes assessment of active and passive range of motion of the wrist and digits, and dynamic stability testing. The most commonly fractured bone of the wrist is the scaphoid, and the most common ligamentous instability involves the scaphoid and lunate.
ABSTRACT: Primary care physicians must be able to recognize wrist and hand injuries that require immediate attention. A complete history and physical examination, including assessment of distal limb function, are essential. Hemorrhage control is necessary in patients with vessel lacerations and amputations. Amputations require an understanding of the indications and contraindications in the management of the amputated limb. High-pressure injection injuries and compartment syndromes require a high index of suspicion for early recognition. Infectious entities include "fight bite," open fractures, purulent tenosynovitis, animal bites, and retained foreign bodies. Tendon disruptions should be recognized early to optimize management.