Items in FPM with MESH term: Physical Examination
Prevention of Falls in Older Patients - Article
ABSTRACT: Falls are one of the most common geriatric syndromes threatening the independence of older persons. Between 30 and 40 percent of community-dwelling adults older than 65 years fall each year, and the rates are higher for nursing home residents. Falls are associated with increased morbidity, mortality, and nursing home placement. Most falls have multiple causes. Risk factors for falls include muscle weakness, a history of falls, use of four or more prescription medications, use of an assistive device, arthritis, depression, age older than 80 years, and impairments in gait, balance, cognition, vision, and activities of daily living. Physicians caring for older patients should ask about any falls that have occurred in the past year. Assessment should include evaluating the circumstances of the fall and a complete history and physical examination, looking for potential risk factors. The most effective fall prevention strategies are multifactorial interventions targeting identified risk factors, exercises for muscle strengthening combined with balance training, and withdrawal of psychotropic medication. Home hazard assessment and modification by a health professional also is helpful.
ABSTRACT: Although only 32,000 new cases of adenocarcinoma of the pancreas occur in the United States each year, it is the fourth leading cause of cancer deaths in this country. The overall five-year survival rate is 4 percent, and localized, resectable disease has only a 17 percent survival rate. Risk factors include smoking, certain familial cancer syndromes, and familial chronic pancreatitis. The link between risk of pancreatic cancer and other factors (e.g., diabetes, obesity) is less clear. Most patients present with obstructive jaundice caused by compression of the bile duct in the head of the pancreas. Epigastric or back pain, vague abdominal symptoms, and weight loss also are characteristic of pancreatic cancer. More than one half of cases have distant metastasis at diagnosis. Computed tomography is the most useful diagnostic and staging tool. Ultrasonography, magnetic resonance imaging, and endoscopic retrograde cholangiopancreatography may provide additional information. The majority of tumors are not surgically resectable because of metastasis and invasion of the major vessels posterior to the pancreas. Resectable tumors are treated with the Whipple procedure or the pylorus-preserving Whipple procedure. Adjuvant fluorouracil-based chemotherapy may prolong survival. For nonresectable tumors, chemotherapy with gemcitabine prolongs survival. Other agents are being studied. Radiation combined with chemotherapy has slowed progression in locally advanced cancers. Throughout the illness and during end-of-life care, patients need comprehensive symptom control.
Developmental Dysplasia of the Hip - Article
ABSTRACT: Developmental dysplasia of the hip refers to a continuum of abnormalities in the immature hip that can range from subtle dysplasia to dislocation. The identification of risk factors, including breech presentation and family history, should heighten a physician's suspicion of developmental dysplasia of the hip. Diagnosis is made by physical examination. Palpable hip instability, unequal leg lengths, and asymmetric thigh skinfolds may be present in newborns with a hip dislocation, whereas gait abnormalities and limited hip abduction are more common in older children. The role of ultrasonography is controversial, but it generally is used to confirm diagnosis and assess hip development once treatment is initiated. Bracing is first-line treatment in children younger than six months. Surgery is an option for children in whom nonoperative treatment has failed and in children diagnosed after six months of age. It is important to diagnose developmental dysplasia of the hip early to improve treatment results and to decrease the risk of complications.
ABSTRACT: Constipation in children usually is functional and the result of stool retention. However, family physicians must be alert for red flags that may indicate the presence of an uncommon but serious organic cause of constipation, such as Hirschsprung's disease (congenital aganglionic megacolon), pseudo-obstruction, spinal cord abnormality, hypothyroidism, diabetes insipidus, cystic fibrosis, gluten enteropathy, or congenital anorectal malformation. Treatment of functional constipation involves disimpaction using oral or rectal medication. Polyethylene glycol is effective and well tolerated, but a number of alternatives are available. After disimpaction, a maintenance program may be required for months to years because relapse of functional constipation is common. Maintenance medications include mineral oil, lactulose, milk of magnesia, polyethylene glycol powder, and sorbitol. Education of the family and, when possible, the child is instrumental in improving functional constipation. Behavioral education improves response to treatment; biofeedback training does not. Because cow's milk may promote constipation in some children, a trial of withholding milk may be considered. Adding fiber to the diet may improve constipation. Despite treatment, only 50 to 70 percent of children with functional constipation demonstrate long-term improvement.
ABSTRACT: Preterm premature rupture of membranes is the rupture of membranes during pregnancy before 37 weeks' gestation. It occurs in 3 percent of pregnancies and is the cause of approximately one third of preterm deliveries. It can lead to significant perinatal morbidity, including respiratory distress syndrome, neonatal sepsis, umbilical cord prolapse, placental abruption, and fetal death. Appropriate evaluation and management are important for improving neonatal outcomes. Speculum examination to determine cervical dilation is preferred because digital examination is associated with a decreased latent period and with the potential for adverse sequelae. Treatment varies depending on gestational age and includes consideration of delivery when rupture of membranes occurs at or after 34 weeks' gestation. Corticosteroids can reduce many neonatal complications, particularly intraventricular hemorrhage and respiratory distress syndrome, and antibiotics are effective for increasing the latency period.
ABSTRACT: Ectopic pregnancy is a high-risk condition that occurs in 1.9 percent of reported pregnancies. The condition is the leading cause of pregnancy-related death in the first trimester. If a woman of reproductive age presents with abdominal pain, vaginal bleeding, syncope, or hypotension, the physician should perform a pregnancy test. If the patient is pregnant, the physician should perform a work-up to detect possible ectopic or ruptured ectopic pregnancy. Prompt ultrasound evaluation is key in diagnosing ectopic pregnancy. Equivocal ultrasound results should be combined with quantitative beta subunit of human chorionic gonadotropin levels. If a patient has a beta subunit of human chorionic gonadotropin level of 1,500 mIU per mL or greater, but the transvaginal ultrasonography does not show an intrauterine gestational sac, ectopic pregnancy should be suspected. Diagnostic uterine curettage may be appropriate in patients who are hemodynamically stable and whose beta subunit of human chorionic gonadotropin levels are not increasing as expected. Appropriate treatment for patients with nonruptured ectopic pregnancy may include expectant management, medical management with methotrexate, or surgery. Expectant management is appropriate only when beta subunit of human chorionic gonadotropin levels are low and declining. Initial levels determine the success of medical treatment. Surgical treatment is appropriate if ruptured ectopic pregnancy is suspected and if the patient is hemodynamically unstable.
Diagnosing the Cause of Chest Pain - Article
ABSTRACT: Chest pain presents a diagnostic challenge in outpatient family medicine. Noncardiac causes are common, but it is important not to overlook serious conditions such as an acute coronary syndrome, pulmonary embolism, or pneumonia. In addition to a thorough history and physical examination, most patients should have a chest radiograph and an electrocardiogram. Patients with chest pain that is predictably exertional, with electrocardiogram abnormalities, or with cardiac risk factors should be evaluated further with measurement of troponin levels and cardiac stress testing. Risk of pulmonary embolism can be determined with a simple prediction rule, and a D-dimer assay can help determine whether further evaluation with helical computed tomography or venous ultrasound is needed. Fever, egophony, and dullness to percussion suggest pneumonia, which can be confirmed with chest radiograph. Although some patients with chest pain have heart failure, this is unlikely in the absence of dyspnea; a brain natriuretic peptide level measurement can clarify the diagnosis. Pain reproducible by palpation is more likely to be musculoskeletal than ischemic. Chest pain also may be associated with panic disorder, for which patients can be screened with a two-item questionnaire. Clinical prediction rules can help clarify many of these diagnoses.
ABSTRACT: Musculoskeletal pain can be difficult for children to characterize. Primary care physicians must determine whether the pain may be caused by a systemic disease. Change in activity, constitutional symptoms such as fevers and fatigue, or abnormal examination findings without obvious etiology should raise suspicion for rheumatic disease. A complete physical examination should be performed to look for extra-articular signs of rheumatic disease, focusing on but not limited to the affected areas. A logical and consistent approach to diagnosis is recommended, with judicious use of laboratory and radiologic testing. Complete blood count and erythrocyte sedimentation rate measurement are useful if rheumatic disease is suspected. Other rheumatologic tests (e.g., antinuclear antibody) have a low pretest probability in the primary care setting and must be interpreted cautiously. Plain radiography can exclude fractures or malignancy; computed tomography and magnetic resonance imaging are more sensitive in detecting joint inflammation. Family physicians should refer children to a subspecialist when the diagnosis is in question or subspecialty treatment is required. Part II of this series discusses rheumatic diseases that present primarily with musculoskeletal pain in children, including juvenile arthritis, the spondyloarthropathies, acute rheumatic fever, Henoch-SchÃ¶nlein purpura, and systemic lupus erythematosus.
Second Trimester Pregnancy Loss - Article
ABSTRACT: Second trimester pregnancy loss is uncommon, but it should be regarded as an important event in a woman's obstetric history. Fetal abnormalities, including chromosomal problems, and maternal anatomic factors, immunologic factors, infection, and thrombophilia should be considered; however, a cause-and-effect relationship may be difficult to establish. A thorough history and physical examination should include inquiries about previous pregnancy loss. Laboratory tests may identify treatable etiologies. Although there is limited evidence that specific interventions improve outcomes, management of contributing maternal factors (e.g., smoking, substance abuse) is essential. Preventive measures, including vaccination and folic acid supplementation, are recommended regardless of risk. Management of associated chromosomal factors requires consultation with a genetic counselor or obstetrician. The family physician can play an important role in helping the patient and her family cope with the emotional aspects of pregnancy loss.
Initiating Hormonal Contraception - Article
ABSTRACT: Most women can safely begin taking hormonal birth control products immediately after an office visit, at any point in the menstrual cycle. Because hormonal contraceptives do not accelerate cervical neoplasia or interfere with cervical cytology, women who have not had a recent Papanicolaou smear can begin using hormonal contraceptives before the test is performed. After childbirth, most women can begin using progestin-only contraceptives immediately. Estrogen-containing methods can safely be initiated six weeks to six months postpartum for women who are breastfeeding their infants and three weeks postpartum for women who are not breastfeeding. Women can begin any appropriate contraceptive method immediately following an early abortion. Delaying contraception may decrease adherence. Physicians can help patients improve their use of birth control by providing anticipatory guidance about the most common side effects, giving comprehensive information about available choices, and honoring women's preferences. An evidence-based, flexible, patient-centered approach to initiating contraception may help to lower the high rate of unintended pregnancy in the United States.