Items in FPM with MESH term: Disease Management
Do-It-Yourself Disease Management - Feature
Subacute Management of Ischemic Stroke - Article
ABSTRACT: Ischemic stroke is the third leading cause of death in the United States and a common reason for hospitalization. The subacute period after a stroke refers to the time when the decision to not employ thrombolytics is made up until two weeks after the stroke occurred. Family physicians are often involved in the subacute management of ischemic stroke. All patients with an ischemic stroke should be admitted to the hospital in the subacute period for cardiac and neurologic monitoring. Imaging studies, including magnetic resonance angiography, carotid artery ultrasonography, and/or echocardiography, may be indicated to determine the cause of the stroke. Evaluation for aspiration risk, including a swallowing assessment, should be performed, and nutritional, physical, occupational, and speech therapy should be initiated. Significant causes of morbidity and mortality following ischemic stroke include venous thromboembolism, pressure sores, infection, and delirium, and measures should be taken to prevent these complications. For secondary prevention of future strokes, antiplatelet therapy with aspirin should be initiated within 24 hours of ischemic stroke in all patients without contraindications, and one of several antiplatelet regimens should be continued long-term. Statin therapy should also be given in most situations. Although permissive hypertension is initially warranted, antihypertensive therapy should begin within 24 hours. Diabetes mellitus should be controlled and patients counseled about lifestyle modifications to reduce stroke risk. Rehabilitative therapy following hospitalization improves outcomes and should be considered.
ABSTRACT: Crohn’s disease is a chronic inflammatory condition affecting the gastrointestinal tract at any point from the mouth to the rectum. Patients may experience diarrhea, abdominal pain, fever, weight loss, abdominal masses, and anemia. Extraintestinal manifestations of Crohn’s disease include osteoporosis, inflammatory arthropathies, scleritis, nephrolithiasis, cholelithiasis, and erythema nodosum. Acute phase reactants, such as C-reactive protein level and erythrocyte sedimentation rate, are often increased with inflammation and may correlate with disease activity. Levels of vitamin B12, folate, albumin, prealbumin, and vitamin D can help assess nutritional status. Colonoscopy with ileoscopy, capsule endoscopy, computed tomography enterography, and small bowel follow-through are often used to diagnose Crohn’s disease. Ultrasonography, computed axial tomography, scintigraphy, and magnetic resonance imaging can assess for extraintestinal manifestations or complications (e.g., abscess, perforation). Mesalamine products are often used for the medical management of mild to moderate colonic Crohn’s disease. Antibiotics (e.g., metronidazole, fluoroquinolones) are often used for treatment. Patients with moderate to severe Crohn’s disease are treated with corticosteroids, azathioprine, 6-mercaptopurine, or anti–tumor necrosis factor agents (e.g., infliximab, adalimumab). Severe disease may require emergent hospitalization and a multidisciplinary approach with a family physician, gastroenterologist, and surgeon.
ABSTRACT: Cirrhosis is the 12th leading cause of death in the United States. It accounted for 29,165 deaths in 2007, with a mortality rate of 9.7 per 100,000 persons. Alcohol abuse and viral hepatitis are the most common causes of cirrhosis, although nonalcoholic fatty liver disease is emerging as an increasingly important cause. Primary care physicians share responsibility with specialists in managing the most common complications of the disease, screening for hepatocellular carcinoma, and preparing patients for referral to a transplant center. Patients with cirrhosis should be screened for hepatocellular carcinoma with imaging studies every six to 12 months. Causes of hepatic encephalopathy include constipation, infection, gastrointestinal bleeding, certain medications, electrolyte imbalances, and noncompliance with medical therapy. These should be sought and managed before instituting the use of lactulose or rifaximin, which is aimed at reducing serum ammonia levels. Ascites should be treated initially with salt restriction and diuresis. Patients with acute episodes of gastrointestinal bleeding should be monitored in an intensive care unit, and should have endoscopy performed within 24 hours. Physicians should also be vigilant for spontaneous bacterial peritonitis. Treating alcohol abuse, screening for viral hepatitis, and controlling risk factors for nonalcoholic fatty liver disease are mechanisms by which the primary care physician can reduce the incidence of cirrhosis.
ABSTRACT: Attention-deficit/hyperactivity disorder in childhood can persist into adulthood in at least 30 percent of patients, with 3 to 4 percent of adults meeting the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., diagnostic criteria. A number of conditions, such as thyroid disease, mood disorders, and substance use disorders, have symptoms similar to those of attention-deficit/hyperactivity disorder and should be considered in the differential diagnosis. Steroids, antihistamines, anticonvulsants, caffeine, and nicotine also can have adverse effects that mimic attention-deficit/hyperactivity disorder symptoms. Proper diagnosis and treatment can improve daily functioning. Diagnosis relies on a thorough clinical history, supported by a number of rating scales that take five to 20 minutes to complete, depending on the scale. Clinical guidelines recommend stimulants and the nonstimulant atomoxetine as first-line treatments, followed by antidepressants. Cognitive behavior therapy has also been shown to be helpful as adjunctive treatment with medication. For adults with coexisting depression, the combination of an antidepressant and stimulants has been shown to be safe and effective. To monitor for misuse or diversion of stimulants, family physicians should consider using a controlled substances agreement and random urine drug screening in addition to regular follow-up visits.
AAN/AHS Update Recommendations for Migraine Prevention in Adults - Practice Guidelines