• AFP's Top 20 Articles By Year


    The following lists are the 20 most popular articles from each year according to page views on the website. The articles are listed in order of most views.

    2021

    Hip Pain in Adults: Evaluation and Differential Diagnosis

    Rachel Chamberlain
    Hip pain usually localizes anteriorly, laterally, or posteriorly. A focused history and physical examination can help differentiate the causes of hip pain, which is important for prescribing effective therapy. The history should include personal history of hip problems, sports activities, and injuries; family history of hip problems; and the location and quality of pain, aggravating and alleviating factors, and mechanical symptoms. Physical examination should include evaluation of gait, range of motion, and muscle strength; palpation of the painful area; and special tests as indicated. If imaging is needed, standing radiography of the hip and pelvis should be the initial test. January 15, 2021

    Onychomycosis: Rapid Evidence Review

    Winfred Taylor Frazier, Zuleica M. Santiago-Delgado, and Kenneth C. Stupka II
    Onychomycosis is a chronic fungal infection of the fingernail or toenail bed, causing brittle, discolored, and thickened nails. Confirming the diagnosis with a potassium hydroxide preparation is recommended before initiating treatment, which can include oral or topical therapies. Treatment choice should be based on shared decision-making. October 2021

    Irritable Bowel Syndrome: Questions and Answers for Effective Care

    John M. Wilkinson and Margaret C. Gill
    Irritable bowel syndrome (IBS) is a heterogeneous group of conditions related to specific biologic and cellular abnormalities that are not fully understood. Psychological factors do not cause IBS, but many people with IBS also have an anxious or depressed mood, prior adverse life events, or psychosocial stressors. Physicians should understand the concerns and expectations of patients and the models that patients use to explain their illness and should empathetically respond to psychosocial cues. Anxiety related to the unpredictability of symptoms may have a greater effect on quality of life than the symptoms themselves. Patients who meet symptom-based criteria and have no alarm features may be confidently diagnosed with few tests. Treatments should focus on symptom relief and improved quality of life. June 15, 2021

    Home Blood Pressure Monitoring

    Jeffrey M. Weinfeld, Kathryn M. Hart, and Jose D. Vargas
    Home blood pressure monitoring can confirm the diagnosis of hypertension after an elevated in-office blood pressure measurement. Although ambulatory blood pressure monitoring is the diagnostic standard for measurement, home blood pressure monitoring is more practical and accessible to patients. September 2021

    Topical Corticosteroids: Choice and Application

    Stephen K. Stacey and Mark McEleney
    Topical corticosteroids are an essential tool for treating inflammatory skin conditions. These medications are classified by strength and the risk of adverse effects such as atrophy, striae, rosacea, telangiectasias, purpura, and other cutaneous and systemic reactions. The quantity prescribed depends on the duration of treatment, the frequency of application, the skin location, and the total surface area treated. March 15, 2021

    Hypothyroidism: Diagnosis and Treatment

    Stephen A. Wilson, Leah A. Stem, and Richard D. Bruehlman
    Clinical hypothyroidism is present in one in 300 people in the United States, with a higher prevalence in female and older patients. Symptoms range from minimal to life-threatening. More common symptoms include cold intolerance, fatigue, weight gain, dry skin, constipation, and voice changes. The signs and symptoms that suggest thyroid dysfunction are nonspecific and nondiagnostic. A diagnosis is based on blood levels of thyroid-stimulating hormone and free thyroxine. There is no evidence that population screening is beneficial. Symptom relief and normalized thyroid-stimulating hormone levels are achieved with levothyroxine replacement therapy. May 15, 2021

    Tinnitus: Diagnosis and Management

    Sarah N. Dalrymple, Sarah H. Lewis, and Samantha Philman
    Tinnitus is the perception of sound in the absence of an objective internal or external source. Tinnitus is a symptom, not a disease, and although it is typically not associated with a dangerous condition, it can significantly affect an individual’s quality of life. Guidelines recommend a standard approach to history and physical examination to determine the etiology, followed by audiometric testing and imaging, laboratory studies, and other testing as appropriate. Cognitive behavior therapy is the only treatment that has been shown to improve quality of life in patients with tinnitus. Avoidance of noise exposure may help prevent the development or progression of tinnitus. June 1, 2021

    Recent-Onset Altered Mental Status: Evaluation and Management

    Brian Veauthier, Jaime R. Hornecker, and Tabitha Thrasher
    Potential precipitating factors for the recent onset of altered mental status can be multifactorial and include central nervous system insults, systemic infections, metabolic disturbances, toxin exposure, medications, chronic systemic diseases, and psychiatric conditions. Clinicians must quickly identify and treat reversible causes to avoid poor patient outcomes. November 2021

    Care of the College Student

    Brian K. Unwin, Jeffrey Goodie, Brian V. Reamy, and Jeffrey D. Quinlan
    Although generally healthy, about 20% of students who attend college have special health care needs, including asthma, diabetes mellitus, and learning, mental health, and substance use disorders. Physicians can facilitate the transition of a youth to an adult model of health care by using structured processes to orient the youth to self-care. August 2021

    Eating Disorders in Primary Care: Diagnosis and Management

    David A. Klein, Jillian E. Sylvester, and Natasha A. Schvey
    Eating disorders are potentially life-threatening conditions characterized by disordered eating and weight-control behaviors that impair physical health and psychosocial functioning. Up to 8% of females and 2% of males are affected during their lifetimes. At least one-third of persons with disordered eating develop persistent symptoms that remain 20 years postdiagnosis. Co-occurring mood, anxiety, substance use, personality, or somatic disorders are identified in more than two-thirds of persons with eating disorders. Early intervention with symptom improvement decreases the risk of a protracted course and long-term pathology. January 1, 2021

    Unintentional Weight Loss in Older Adults

    Heidi L. Gaddey and Kathryn K. Holder
    Unintentional weight loss in people older than 65 years is associated with increased morbidity and mortality. Treatment should focus on feeding assistance, addressing contributing medications, providing appealing foods, and social support. July 2021

    The Preparticipation Physical Evaluation

    James MacDonald, Marie Schaefer, and Justin Stumph
    The preparticipation physical evaluation (PPE) is a common primary care medical visit for young athletes. In 2019, the American Academy of Pediatrics published updated PPE recommendations. The general goals outlined in these guidelines include determining general physical and psychological health; evaluating for life-threatening or disabling conditions; and serving as an entry point into the health care system for those without a medical home or primary care physician. The PPE should include a structured physical examination with focus on the cardiovascular, musculoskeletal, and neurologic systems. Screening for depression, anxiety disorders, and attention-deficit/hyperactivity disorder is also recommended. Consideration should be taken to address the needs and concerns of transgender athletes and athletes with physical and intellectual disabilities. May 1, 2021

    Interpreting SARS-CoV-2 Diagnostic Tests: Common Questions and Answers

    William D. Nettleton
    The spectrum of asymptomatic, presymptomatic, and symptomatic SARS-CoV-2 transmission presents challenges for evaluating SARS-CoV-2 test performance for diagnostic or screening purposes and for interpreting test results. Molecular and antigen SARS-CoV-2 tests both have high specificity. However, antigen tests generally have lower sensitivity and thus greater potential for false-negative results, especially when performed more than five days after the onset of symptoms. This article addresses common questions about SARS-CoV-2 testing and presents an approach to interpreting diagnostic test results. April 15, 2021

    Health Maintenance for Women of Reproductive Age

    Heather L. Paladine, Himabindu Ekanadham, and Daniela C. Diaz
    This article focuses on screening and counseling for health conditions that are more prevalent in, or have a unique impact on, women, transgender men, and nonbinary individuals of reproductive age. Health issues including cardiovascular risk factors, obesity, hypertension, cancer, depression, intimate partner violence, sexually transmitted infections, and unhealthy drug and alcohol use should be considered. To have the greatest impact on health, physicians should focus on U.S. Preventive Services Task Force grade A and B recommendations with patients. February 15, 2021

    Bipolar Disorders: Evaluation and Treatment

    Gabrielle Marzani and Amy Price Neff
    Bipolar disorders are common mental health conditions of variable severity that are difficult to diagnose. New diagnostic criteria and specifiers with attention on mixed features and anxious distress aid the physician in recognizing episode severity and prognosis. Early recognition and treatment of bipolar disorders improve outcomes. Physicians should consider bipolar disorder in any patient presenting with depression. Pharmacotherapy with mood stabilizers is a first-line treatment that should be continued indefinitely because of the risk of patient relapse. Active lifestyle approaches include good nutrition, exercise, and sleep hygiene. Monotherapy with antidepressants is contraindicated during episodes with mixed features, manic episodes, and in bipolar I disorder. Psychotherapy is a useful adjunct to pharmacotherapy. Patients and their support systems should be educated about the chronic nature of the illness, possible relapse, suicidality, environmental triggers, and the effectiveness of early intervention. February 15, 2021

    Peripheral Nerve Entrapment and Injury in the Upper Extremity

    Sabrina Silver, Christopher C. Ledford, Kendall J. Vogel, and James J. Arnold
    Peripheral nerves in the upper extremities are at risk of injury and entrapment because of their superficial nature and length. Injury can result from trauma, anatomic abnormalities, systemic disease, and entrapment. Most peripheral nerve injuries seen by family physicians will involve neurapraxia, resulting from entrapment along the anatomic course of the nerve. History and physical examination alone are often enough to identify the injury or entrapment; advanced diagnostic testing with magnetic resonance imaging, ultrasonography, or electrodiagnostic studies helps to confirm the clinical diagnosis and is indicated if conservative management is ineffective. Initial treatment is conservative, with surgical options available for refractory injuries or entrapment caused by anatomic abnormalities. March 1, 2021

    Nutrition Support Therapy

    Mary N. R. Lesser and Lenard I. Lesser
    Nutrition support therapy is the delivery of formulated enteral or parenteral nutrients to maintain or restore nutrition status. Family physicians can provide nutrition support therapy to patients at risk of malnutrition when it would improve clinical outcomes or quality of life. Physicians should initiate a thorough nutrition screening and assessment to determine an individual’s nutrition status and the potential need for nutrition support therapy. December 2021

    Alcohol Withdrawal Syndrome: Outpatient Management

    Samuel M. Tiglao, Erica S. Meisenheimer, and Robert C. Oh
    Approximately one-half of patients with alcohol use disorder who abruptly stop or reduce their alcohol use will develop signs or symptoms of alcohol withdrawal syndrome. Alcohol withdrawal syndrome can lead to tremors, insomnia, nausea and vomiting, hallucinations, anxiety, and agitation. September 2021

    Telemedicine Management of Musculoskeletal Issues

    Nicole T. Yedlinsky and Rebecca L. Peebles
    Telemedicine has become a valuable tool during the coronavirus disease 2019 pandemic. Musculoskeletal issues are a common reason for primary care visits and can often be managed using telemedicine, especially if a standardized approach is used. This article discusses telemedicine methods and techniques, including visit preparation, virtual history collection and physical examination, and initial treatment options. Findings from the virtual history and physical examination usually suggest a likely diagnosis. However, physicians should have a low threshold for proceeding with further evaluation, including in-person visits, if the diagnosis or initial management is unclear. February 1, 2021

    Initiating Hormonal Contraception

    Ruth Lesnewski
    Most patients can safely begin using hormonal contraception at any point during their menstrual cycle. A flexible, patient-centered approach to initiating contraception promotes health and enhances patients’ reproductive autonomy. A recent Papanicolaou test is not necessary before prescribing hormonal contraception. Most patients can begin using progestin-only contraceptives immediately after childbirth. Delaying contraception to wait for the next menses or for an appointment creates unnecessary barriers for patients. Clinicians can facilitate the use of hormonal contraception by providing anticipatory guidance about common side effects, giving comprehensive information about available contraceptive choices, honoring patients’ preferences, and eliminating office-related barriers. March 1, 2021

    2020

    Outpatient Management of Covid-19: Rapid Evidence Review

    Anthony Cheng, Dominic Caruso, and Craig McDougall
    When possible, patients with suspected coronavirus disease 2019 should be triaged via telehealth before they receive in-person care. There are no evidence-based treatments appropriate for use in the outpatient setting; management is supportive and should include education about isolation. In hospitalized patients, remdesivir should be considered to reduce time to recovery, and low-dose dexamethasone should be considered in patients who require supplemental oxygen. October 15, 2020 [Updated March 1, 2021]

    Managing Hypertension Using Combination Therapy

    Dustin K. Smith, Robert P. Lennon, and Peter B. Carlsgaard
    Most adults with primary hypertension will eventually require treatment with at least two antihypertensive agents. This article focuses on combination therapy—when to initiate it, choice of agents, and special populations whose comorbid conditions influence those choices. March 15, 2020

    Acute Chest Pain in Adults: Outpatient Evaluation

    John R. McConaghy, Malvika Sharma, and Hiten Patel
    Approximately 1% of primary care office visits are for chest pain. Initial evaluation is based on determining whether the patient needs to be referred to a higher level of care to rule out acute coronary syndrome (ACS). Age, sex, and type of chest pain can predict the likelihood of coronary artery disease. Patients with suspicion of ACS should be transported to the emergency department. Those with low or intermediate risk can undergo outpatient testing. In those with low suspicion for ACS, consider costochondritis, gastroesophageal reflux disease, and anxiety states. Other less common considerations include acute pericarditis, pneumonia, and heart failure. December 15, 2020

    Functional Dyspepsia: Evaluation and Management

    Anne Mounsey, Amir Barzin, and Ashley Reitz
    Dyspepsia affects up to 30% of the general population in the United States, Canada, and the United Kingdom, with 70% of patients having functional dyspepsia. Symptoms include postprandial fullness, early satiety, and epigastric pain or burning. Perform a dyspepsia endoscopy for patients 60 years or older. For patients younger than 60 years, a test and treat strategy for Helicobacter pylori is recommended before acid suppression therapy. All patients should be advised to limit foods associated with increased symptoms of dyspepsia. January 15, 2020

    Management of Hypertriglyceridemia: Common Questions and Answers

    Robert C. Oh, Evan T. Trivette, and Katie L. Westerfield
    Hypertriglyceridemia is associated with increased risk of cardiovascular disease, and severely elevated triglyceride levels increase the risk of pancreatitis. Common risk factors for hypertriglyceridemia include obesity, metabolic syndrome, and type 2 diabetes mellitus. Management starts with lifestyle modifications such as diet and exercise. Statins can be considered for patients with high triglyceride levels who have borderline or intermediate 10-year risk of atherosclerotic cardiovascular disease. Icosapent can be added in patients at high cardiovascular risk if triglyceride levels remain high despite statin use. Fibrates, omega-3 fatty acids, or niacin may be considered in patients with severe hypertriglyceridemia to reduce the risk of pancreatitis. September 15, 2020

    Neck Pain: Initial Evaluation and Management

    Marc A. Childress and Samantha Jayne Stuek
    The broad differential diagnosis for neck pain requires an efficient but global assessment. Emphasis is typically placed on red flags that can assist in the early recognition and treatment of more concerning diagnoses, such as traumatic injuries, infection, malignancy, vascular emergencies, and other inflammatory conditions. August 1, 2020

    Atopic Dermatitis: Diagnosis and Treatment

    Winfred Frazier and Namita Bhardwaj
    Atopic dermatitis is a chronic relapsing and remitting inflammatory skin disease that causes intensely pruritic skin lesions. Maintenance therapy consists of liberal use of emollients and daily bathing with soap-free cleansers. Use of topical corticosteroids is the first-line treatment for flare-ups, with or without the addition of a calcineurin inhibitor. Ultraviolet phototherapy is a safe and effective second-line treatment for moderate to severe atopic dermatitis. March 15, 2020

    Urinary Tract Infections in Young Children and Infants: Common Questions and Answers

    Brian Veauthier and Michael V. Miller
    The decision to test for urinary tract infection should be based on risk factors and the child’s age. Urinalysis can help rule out infection and inform decisions about when to start antibiotics. However, urine culture is needed for definitive diagnosis. Antibiotic selection should be based on local sensitivity patterns and adjusted once culture results are available. September 1, 2020

    Tickborne Diseases: Diagnosis and Management

    Emma J. Pace and Matthew O'Reilly
    The incidence of tickborne disease is increasing in the United States. Patients presenting with flulike symptoms during the spring and summer months should be evaluated for a tickborne disease. Treatment based on experience and observation is recommended for tickborne diseases that fit the clinical presentation and geographic distribution of the disease. Early treatment with doxycycline has been shown to improve morbidity and mortality. Prophylactic treatment after tick exposure in patients without symptoms is generally not recommended. May 1, 2020

    Management of Fever in Infants and Young Children

    Jennifer L. Hamilton, Susanna G. Evans, and Munish Bakshi
    Febrile illness in children younger than 36 months is a concern with potentially serious consequences. Factors include poor arousability and increased respiratory effort. Urinary tract infections are the most common serious bacterial infections in these children. Antibiotic choice should reflect local patterns of microbial resistance. June 15, 2020

    Short-Term Systemic Corticosteroids: Appropriate Use in Primary Care

    Evan L. Dvorin and Mark H. Ebell
    Short-term systemic corticosteroids are frequently prescribed for adults by primary care physicians; however, short courses of the steroids are associated with adverse effects, including hyperglycemia, elevated blood pressure, mood disturbance, sepsis, and fracture. There is evidence against corticosteroid use in patients with acute bronchitis, acute sinusitis, carpal tunnel, and allergic rhinitis and for its use in patients with Bell palsy and acute gout. There is insufficient evidence supporting its use for patients with pharyngitis, lumbar radiculopathy, and herpes zoster. January 15, 2020

    Frequent Headaches: Evaluation and Management

    Anne Walling
    Repeated headaches can induce central sensitization and transformation to chronic headaches that are intractable and difficult to treat. Learn which red flag features to watch for that could signal serious underlying pathology. April 1, 2020

    Gout: Rapid Evidence Review

    Karl T. Clebak, Ashley Morrison, and Jason R. Croad
    Risk factors of gout include male sex; obesity; hypertension; alcohol intake; and a diet rich in meat, seafood, and fructose-rich food and beverages. Gout is characterized by swelling, pain, or tenderness in a peripheral joint or bursa. Diagnosis is made using several validated clinical prediction rules. Arthrocentesis should be performed when suspicion for an underlying septic joint is present; synovial fluid or tophus analysis should be performed if the diagnosis is uncertain. Colchicine, nonsteroidal anti-inflammatory drugs, and corticosteroids all relieve pain in acute episodes. Indications for chronic urate-lowering therapy include chronic kidney disease, two or more flares per year, urolithiasis, the presence of tophus, chronic gouty arthritis, and joint damage. November 1, 2020

    Chronic Diarrhea in Adults: Evaluation and Differential Diagnosis

    Kristina Burgers, Briana Lindberg, and Zachary J. Bevis
    Common causes of chronic diarrhea include irritable bowel syndrome, inflammatory bowel disease, celiac disease, and microscopic colitis. The differential diagnosis for chronic diarrhea is broad; however, a thorough history and physical examination can narrow the diagnostic evaluation. April 15, 2020

    Basal Cell and Cutaneous Squamous Cell Carcinomas: Diagnosis and Treatment

    Jonathon M. Firnhaber
    Keratinocyte carcinoma is the most common skin cancer malignancy found in humans. It is comprised of basal cell carcinoma and cutaneous squamous cell carcinoma.  The increasing incidence of cutaneous squamous cell carcinoma is primarily in older patients and is attributed to cumulative ultraviolet light exposure. September 15, 2020

    Outpatient Burn Care: Prevention and Treatment

    Jason S. Lanham, Nicole K. Nelson, Bryan Hendren, and Teneisha S. Jordan
    For all types of minor burn injuries, the goal of initial treatment is to minimize the extent of the burn, clean the wound, and address pain. The burn surface should be cooled with running tap water. Although superficial burns do not require dressings, advanced dressings should be used for partial-thickness burns to promote reepithelization and protect the wound. Patients with full-thickness burns should be immediately referred to a burn center. April 15, 2020

    Peripheral Neuropathy: Evaluation and Differential Diagnosis

    Gregory Castelli, Krishna M. Desai, and Rebecca E. Cantone
    Peripheral neuropathy is one of the most common neurologic problems encountered by family physicians. Common identifiable causes include diabetes mellitus, nerve compression or injury, alcohol use, toxin exposure, hereditary diseases, and nutritional deficiencies, although many cases are idiopathic. Diagnosis requires a comprehensive history, physical examination, and judicious laboratory testing. December 15, 2020

    Point-of-Care Ultrasonography

    Michael J. Arnold, Christopher E. Jonas, and Rachel E. Carter
    Point-of-care ultrasonography (POCUS) reduces cost, radiation exposure, and imaging delays, and increases patient satisfaction. POCUS is useful in resource-limited settings, and the use of POCUS in primary care is increasing. March 1, 2020

    Sepsis: Diagnosis and Management

    Robert Gauer, Damon Forbes, and Nathan Boyer
    To improve sepsis diagnosis, which can be challenging, clinicians must obtain historical, clinical, laboratory, and radiographic data supportive of infection and organ dysfunction. After initial airway and respiratory stabilization, the sepsis bundle should be initiated (fluid resuscitation, antibiotics, lactate measurement, and cultures) within three hours of presentation. Vasopressor therapy is needed if fluid resuscitation is ineffective. April 1, 2020

    Chronic Musculoskeletal Pain: Nonpharmacologic, Noninvasive Treatments

    Diane M. Flynn
    Because no individual therapy for chronic musculoskeletal pain has consistent benefit, a multimodal treatment approach is recommended. Many nonpharmacologic, noninvasive treatment approaches yield small to moderate improvement in pain and function. This article summarizes the evidence for these therapies, which can be used with pharmacologic or more invasive modalities. October 15, 2020

    2019

    Treatment of the Common Cold

    Katharine C. DeGeorge, Daniel J. Ring, and Sarah N. Dalrymple
    Acute upper respiratory tract infection, also called the common cold, is the most common acute illness in the United States. Informing patients about the self-limited nature of this illness can help manage expectations, limit antibiotic use, and avoid over-the-counter purchases that are unlikely to help. Treatments with proven effectiveness for cold symptoms in adults include over-the-counter analgesics, zinc, nasal decongestants with or without antihistamines, and intranasal ipratropium. The only safe and effective treatments for children are analgesics, acetylcysteine, honey, nasal saline irrigation, intranasal ipratropium, and menthol rub. September 1, 2019

    Type 2 Diabetes Therapies: A STEPS Approach

    Joshua Steinberg and Lyndsay Carlson
    Several recent large randomized controlled trials have significantly improved physicians’ knowledge about the impact of medications for type 2 diabetes mellitus on patient-oriented outcomes. A concise and organized way to evaluate pharmacotherapy options is to use the five patient-oriented STEPS criteria: safety, tolerability, effectiveness, price, and simplicity. The first-line treatment option, metformin, is safe and fairly well-tolerated, has excellent long-term effectiveness on patient-oriented outcomes, is moderately priced, and has a simple dosing regimen. However, most patients with type 2 diabetes require more than one medication. The STEPS approach can help choose subsequent medications if metformin does not provide adequate glycemic control. February 15, 2019

    Migraine Headache Prophylaxis

    Hien Ha and Annika Gonzalez
    Many patients with episodic migraine headaches would benefit from preventive therapy, which reduces frequency, severity, and distress from migraines; preventive therapy could improve quality of life and prevent chronic migraines. Indications for preventive therapy include four or more headaches a month, eight or more headache days a month, debilitating headaches, and medication-overuse headaches. Several first- and second-line medications are available for treatment; identifying and managing environmental, dietary, and behavioral triggers can also be useful. Relaxation training, thermal biofeedback, electromyographic feedback, and cognitive behavior therapy have good evidence as nonpharma­cologic ways to prevent episodic migraines. January 1, 2019

    Anticoagulation: Updated Guidelines for Outpatient Management

    Patricia Wigle, Brad Hein, and Christopher R. Bernheisel
    Vitamin K antagonists, unfractionated heparin, low-molecular-weight heparin, and direct oral anticoagulants are commonly used for the prevention and treatment of systemic embolism associated with atrial fibrillation, stroke, and venous thromboembolism. Low-molecular-weight heparin and select direct oral anticoagulants can be used for anticoagulation therapy initiation on an outpatient basis. Indications for anticoagulation therapy, direct oral anticoagulant therapy, and recommendations from guidelines are addressed in this article. October 1, 2019

    Patellofemoral Pain Syndrome

    David Y. Gaitonde, Alex Ericksen, and Rachel C. Robbins
    Patellofemoral pain syndrome, a common cause of knee pain in adolescents and adults younger than 60 years, can cause limitations in daily physical activity and ability to exercise if undiagnosed. The cardinal feature of patellofemoral pain syndrome is pain in or around the anterior knee that intensifies when the knee is flexed during weight-bearing activities. The diagnosis is clinical, and pain with squatting is the most sensitive physical examination finding. Treatment includes rest, a short course of nonsteroidal anti-inflammatory drugs, and physical therapy with strengthening exercises. January 15, 2019

    Plantar Fasciitis

    Thomas Trojian and Alicia K. Tucker
    Plantar fasciitis is common in runners but can also affect sedentary people. Risk factors include limited ankle dorsiflexion, increased body mass index, and standing for prolonged periods of time. Symptoms are stabbing, nonradiating pain first thing in the morning in the proximal medioplantar surface of the foot; the pain becomes worse at the end of the day. Treatment should start with stretching of the plantar fascia, ice massage, and nonsteroidal anti-inflammatory drugs. Many conservative treatments have not shown benefit over placebo. Recalcitrant plantar fasciitis can be treated with injections, extracorporeal shock wave therapy, or surgical procedures. June 15, 2019

    Acne Vulgaris: Diagnosis and Treatment

    Linda K. Ogé, Alan Broussard, and Marilyn D. Marshall
    Typical acne lesions involve the pilosebaceous follicles and the inter­related processes of sebum production, Cutibacterium acnes colonization, and inflammation. Treatment is based on severity and usually includes topical agents such as retinoids, benzoyl peroxide, and antibiotics. Oral antibiotics and isotretinoin may be used for severe, recalcitrant acne. Combination oral contraceptives and spironolactone are also used in some patients. Further study is needed to determine the effectiveness of complementary therapies and physical modalities such as laser therapy and light therapy. October 15, 2019

    Current Concepts in Concussion: Initial Evaluation and Management

    Keith A. Scorza and Wesley Cole
    Concussion results from trauma to the head; it affects individuals physically, cognitively, and emotionally/behaviorally and is a major health concern. Headache is the most common symptom. Spine and serious brain injuries should be ruled out before diagnosis. Symptom checklists, neuropsychological tests, balance tests, and sideline assessment tools are used for diagnosis and monitoring recovery. Athletes with suspected concussion should not return to play until medically cleared. Brief cognitive and physical rest is the preferred management. Individuals should gradually return to activities, but those with risk factors, such as more severe symptoms immediately following injury, may require longer recovery periods. April 1, 2019

    Urinary Incontinence in Women: Evaluation and Management

    Jocelyn S. Hu and Elyse Fiore Pierre
    Urinary incontinence (UI) is a common problem in women, resulting in economic burden and decreased quality of life. The Women’s Preventive Services Initiative is the only major organization that recommends annual screening for UI in all women. Initial evaluation should determine whether incontinence is transient or chronic, the subtype of the incontinence, and whether any findings warrant subspecialist referral. Pelvic floor strengthening and lifestyle modifications are first-line recommendations for all UI subtypes. No medications are approved by the U.S. Food and Drug Administration for treatment of stress incontinence; antimuscarinic medications may be prescribed for urge incontinence. Patients with refractory symptoms should be referred for more invasive management. September 15, 2019

    Hand-Foot-and-Mouth Disease: Rapid Evidence Review

    Aaron Saguil, Shawn F. Kane, Rebecca Lauters, and Michael G. Mercado
    Hand-foot-and-mouth disease is most commonly caused by enterovirus 71 and coxsackievirus A16. Clinical diagnosis is based on the presentation of a low-grade fever with a maculopapular or papulovesicular rash on the hands and soles of the feet, and by painful oral ulcerations. The largest incidence of the disease is within the first five years of life, and most cases occur in patients younger than 10 years. Handwashing, specifically after diaper changes and toileting, and before eating, helps stop the spread of the disease. October 1, 2019

    Abnormal Uterine Bleeding in Premenopausal Women

    Noah Wouk and Margaret Helton
    Abnormal uterine bleeding is a common symptom in reproductive-aged women. The acronym PALM-COEIN facilitates the classification of bleeding, with PALM referring to structural etiologies (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia), and COEIN referring to nonstructural etiologies (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified). Evaluation includes a detailed history and pelvic examination, as well as laboratory testing to rule out anemia and pregnancy. Endometrial sampling should be performed in patients 45 years and older, and in younger patients with a significant history of unopposed estrogen exposure. To avoid surgical risks and preserve fertility, medical management is the preferred initial approach for most hemodynamically stable patients. April 1, 2019

    Kidney Stones: Treatment and Prevention

    Leonardo Ferreira Fontenelle and Thiago Dias Sarti
    In patients with suspected kidney stones, the first priority is to rule out conditions requiring immediate referral to an emergency department, then to alleviate pain. The diagnostic workup consists of urinalysis, urine culture, and imaging to confirm the diagnosis and assess for conditions requiring active stone removal. Conservative management consists of pain control, medical expulsive therapy with an alpha blocker, and follow-up imaging to monitor stone position and assess for hydronephrosis. Asymptomatic kidney stones should be followed with serial imaging and should be removed if they become larger or if symptoms, urinary obstruction, or infection occurs. All patients with kidney stones should be screened for risk of stone recurrence. April 15, 2019

    Otitis Media: Rapid Evidence Review

    Heidi L. Gaddey, Matthew Thomas Wright, and Tracy N. Nelson
    Acute otitis media, the most common diagnosis in childhood acute sick visits, can cause ear pain, fever, irritability, otorrhea, anorexia, and sometimes vomiting and lethargy. Acute otitis media is diagnosed in children with moderate to severe bulging of the tympanic membrane or new-onset otorrhea not caused by acute otitis externa, and in children with mild bulging and recent-onset ear pain or intense erythema of the tympanic membrane. Treatment usually consists of pain management and antibiotics. However, observation with deferment of initial antibiotics is an option in some children without severe symptoms. Pneumococcal and influenza vaccines and exclusive breastfeeding until at least six months of age can reduce the risk of acute otitis media. September 15, 2019

    Gastroenteritis in Children

    Scott Hartman, Elizabeth Brown, Elizabeth Loomis, and Holly Ann Russell
    Acute gastroenteritis, defined as a diarrheal disease of rapid onset, with or without nausea, vomiting, fever, or abdominal pain, is not a major cause of death in the United States but leads to significant morbidity. Physical examination is the best way to assess hydration. Mild to moderate dehydration can be treated with oral rehydration therapy. Half-strength apple juice followed by preferred fluids may be used for mild dehydration, and an oral rehydration solution with or without an antiemetic should be used for moderate dehydration. Hospitalization and intravenous rehydration are recommended for children who do not respond to oral rehydration therapy plus an antiemetic and patients with severe dehydration. February 1, 2019

    Influenza: Diagnosis and Treatment

    David Y. Gaitonde, Faith C. Moore, and Mackenzie K. Morgan
    The hallmark of influenza infection is abrupt onset of fever, cough, chills or sweats, myalgias, and malaise. For most patients in the outpatient setting, the diagnosis is made clinically, and laboratory confirmation is not necessary. Laboratory testing may be useful in hospitalized patients with suspected influenza and in patients for whom a confirmed diagnosis will change treatment decisions. Rapid molecular assays are the preferred diagnostic tests. Treatment with one of four approved anti-influenza drugs may be considered if the patient presents within 48 hours of symptom onset. Annual influenza vaccination is recommended for all people six months and older who do not have contraindications. December 15, 2019

    Gas, Bloating, and Belching: Approach to Evaluation and Management

    John M. Wilkinson, Elizabeth W. Cozine, and Conor G. Loftus
    Gas, bloating, and belching are most often caused by functional gastrointestinal disorders. Psychological distress often makes the symptoms worse. Exhaustive testing is not necessary for diagnosis. Most patients are classified as having gastric or small bowel bloating, bloating with constipation, or belching disorders, with functional dyspepsia, irritable bowel syndrome, and chronic idiopathic constipation being the most common causes. Patients with symptoms of irritable bowel syndrome should be tested for celiac disease, and patients with chronic constipation should have a rectal examination to evaluate for dyssynergic defecation. March 1, 2019

    Acute Hand Infections

    Caitlyn M. Rerucha, John T. Ewing, Kathryn E. Oppenlander, and Wesley Charles Cowan
    Any trauma to the hand, particularly a penetrating trauma, may introduce damaging pathogens. Superficial infections occur in the skin and subcutaneous tissues, whereas deep infections can involve the tendon sheaths, adjacent anatomic compartments, deep fascial planes, bursae, joint spaces, and bones. Superficial hand infections are more common than deep infections and are typically managed with elevation, warm soaks, splinting in the position of function, analgesics, and empiric antibiotics when indicated. Clenched-fist bite wounds result from direct contact of the fist on incisor teeth and are associated with polymicrobial infections. Empiric antibiotics and prompt surgical consultation are indicated to reduce long-term morbidity. February 15, 2019

    Erythema Multiforme: Recognition and Management

    Kathryn P. Trayes, Gillian Love, and James S. Studdiford
    Erythema multiforme is an immune-mediated reaction that involves the skin and sometimes the mucosa. Erythema multiforme lesions can be isolated, recurrent, or persistent, and are classically described as target-like with three concentric segments: a dark center, surrounded by a lighter pink ring, both of which are surrounded by a red ring. Infections, especially herpes simplex virus and Mycoplasma pneumonia, and medications constitute most of the causes of erythema multiforme. Management of erythema multiforme depends on the underlying etiology and the disease severity. July 15, 2019

    Health Maintenance in School-Aged Children: Part I. History, Physical Examination, Screening, and Immunizations

    Margaret Riley, Leigh Morrison, and Anna McEvoy
    The goals of the health maintenance visit in school-aged children (five to 12 years) are promoting health, detecting disease, and counseling to prevent injury and future health problems. The visit should include a history (e.g., hospital care since the previous visit, living situation, lifestyle habits, school performance, social determinants of health); physical examination; and appropriate screening, such as depression, dyslipidemia, hypertension, hearing, and vision assessments. Immunizations should be given based on the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices immunization schedule. August 15, 2019

    Toilet Training: Common Questions and Answers

    Drew C. Baird, Michael Bybel, and Adam W. Kowalski
    Most U.S. children achieve the physiologic, cognitive, and emotional development necessary for toilet training by 18 to 30 months of age, although some children require more time. Markers of readiness for toilet training include being able to walk, don and remove clothing, and follow parental instruction; expressive language; awareness of a full bladder or rectum; and demonstrated dissatisfaction with a soiled diaper. Physicians should provide anticipatory guidance to parents beginning at about 18 to 24 months of age, noting the signs of toilet training readiness, and setting realistic expectations for parents. Complications of toilet training include stool toileting refusal, stool withholding, encopresis, hiding to defecate, and enuresis. These problems typically resolve with time. October 15, 2019

    2018

    Type 2 Diabetes Mellitus: Outpatient Insulin Management

    Amanda Howard-Thompson, Muneeza Khan, Morgan Jones, and Chritsa M. George
    In patients with type 2 diabetes mellitus, insulin may be used to augment therapy with oral glycemic medications or as insulin replacement therapy. Insulin regimens should be adjusted every three or four days until self-monitoring of blood glucose targets are reached. Goals should be individualized. January 1, 2018

    Acute Migraine Headache: Treatment Strategies

    Laura Mayans and Anne Walling
    Migraine is a chronic condition characterized by recurrent attacks. Acetaminophen, nonsteroidal anti-inflammatory drugs, triptans, antiemetics, ergot alkaloids, and combination analgesics have evidence supporting their effectiveness. Learn about the three treatment strategies recommended for migraine and when to consider prophylactic therapy. February 15, 2018

    Vitamin D Screening and Supplementation in Community-Dwelling Adults: Common Questions and Answers

    Michael L. LeFevre and Nicholas M. LeFevre
    Measuring vitamin D levels and prescribing oral vitamin D supplementation is common in clinical practice, although the health benefits have not been established. Clinical trials have not found vitamin D to be beneficial for chronic nonskeletal conditions, and screening and supplementation are not recommended in asymptomatic individuals. February 15, 2018

    Knee Pain in Adults and Adolescents: The Initial Evaluation

    Christopher W. Bunt, Christopher E. Jones, and Jennifer G. Chang
    Knee pain affects nearly 25% of adults. This article reviews the initial primary care office evaluation of knee pain and describes systematic approaches to evaluation. It also defines instances in which radiographic imaging, musculoskeletal ultrasound, magnetic resonance imaging, and laboratory tests should be performed. November 1, 2018

    Mechanical Low Back Pain

    Joshua Scott Will, David C. Bury, and John A. Miller
    Repetitive trauma and overuse are common causes of chronic mechanical low back pain. The history and physical examination can point toward a specific etiology, and imaging should generally be used only in the presence of red flags. Evidence-based therapies include nonsteroidal anti-inflammatory drugs, topiramate, and physical therapy. October 1, 2018

    Hemorrhoids: Diagnosis and Treatment Options

    Timothy Mott, Kelly Latimer, and Chad Edwards
    Treatment of hemorrhoids begins with conservative therapies, such as a high-fiber diet, increased water intake, warm water baths, fiber supplementation, stool softeners, and topical preparations. If these are unsuccessful, office-based and surgical procedures are warranted. Office-based procedures are generally more effective for lower-grade hemorrhoids. February 1, 2018

    Heel Pain: Diagnosis and Management

    Priscilla Tu
    The differential diagnosis of heel pain is extensive, but a mechanical etiology is the most common. Learn the most likely causes of heel pain based on the specific anatomic location affected. January 15, 2018

    Diets for Health: Goals and Guidelines

    Amy Locke, Jill Schneiderhan, and Suzanna M. Zick
    Patients and physicians often have difficulty staying abreast of diet trends, many of which focus primarily on weight loss rather than nutrition and health. Find out which dietary approaches have proven benefits for cardiovascular disease, cancer, type 2 diabetes mellitus, and obesity. June 1, 2018

    Well-Child Visits for Infants and Young Children

    Katherine Turner
    Well-child visits involve comprehensive assessment of a child. Complete history, head-to-toe examination, review of immunizations, and screening for postpartum depression in mothers of infants are performed. The physician answers questions and provides age-appropriate guidance. September 15, 2018

    Ear Pain: Diagnosing Common and Uncommon Causes

    John Scott Earwood, Tyler Sherrod Rogers, and Nicholas Alan Rathjen
    When patients present with otalgia, the first step is to determine whether the pain is originating from inside or outside the ear. Review the history and physical examination findings that can help identify the diagnosis, as well as the risk factors that may indicate a more serious condition. January 1, 2018

    Vaginitis: Diagnosis and Treatment

    Heather L. Paladine and Urmi A. Desai
    Review the diagnosis and treatment strategies for the three main causes of vaginitis: bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis. Treatment during pregnancy and treatment of recurrent episodes are also discussed. March 1, 2018

    The Adult Well-Male Examination

    Joel J. Heidelbaugh
    The goal of the adult well male examination is to promote optimal health and well-being, prevent premature morbidity and mortality from chronic diseases, and provide appropriate cancer screening and immunizations. This article summarizes evidence-based guidelines for counseling and screening in men. December 15, 2018

    Geriatric Assessment: An Office-Based Approach

    Paul E. Tatum III, Shaida Talebreza, and Jeanette S. Ross
    The goal of the geriatric assessment is to evaluate factors that influence patients’ overall well-being and to identify problems that impair quality of life. Typical domains to assess include functional status, fall risk, medications, nutrition, vision, hearing, cognition, mood, and toileting. Medicare’s Annual Wellness Visit provides an opportunity to address these elements in a single office visit. June 15, 2018

    Common Running Injuries: Evaluation and Management

    Michael J. Arnold and Aaron L. Moody
    Most running injuries are due to overuse and typically respond to conservative treatment. Learn which tests can help diagnose patellar tendinopathy, patellofemoral pain syndrome, iliotibial band syndrome, Achilles tendinopathy, plantar fasciopathy, and tibial and hamstring injuries, and the recommended treatments for each condition. April 15, 2018

    Rheumatologic Tests: A Primer for Family Physicians

    Yousaf Ali
    Patients with a suspected connective tissue disorder should undergo serologic testing to confirm the diagnosis and in some cases, to monitor disease activity and predict flares. However, many serologic tests are nonspecific, and further testing may be necessary. Physicians should order these tests only when patients have a high pretest probability of a specific connective tissue disorder. August 1, 2018

    Stable Coronary Artery Disease: Treatment

    Michael M. Braun, William A. Stevens, and Craig H. Barstow
    Treatment of stable coronary artery disease involves risk factor management, antiplatelet therapy, and antianginal medications. Treatment of comorbidities should be optimized to reduce cardiovascular risk. This article includes a management algorithm and a stepwise approach for antiplatelet therapy. March 15, 2018

    Acute Appendicitis: Efficient Diagnosis and Management

    Matthew J. Snyder, Marjorie Guthrie, and Stephen Cagle
    Appendicitis is one of the most common causes of acute abdominal pain in adults and children. Find out which clinical decision rules are most useful in specific patient populations, when to use ultrasonography vs. computed tomography or magnetic resonance imaging, and which patients may be safely treated with antibiotics only. July 1, 2018

    Caring for Transgender and Gender-Diverse Persons: What Clinicians Should Know

    David A. Klein, Scott L. Paradise, and Emily T. Goodwin
    Transgender persons often face substantial health care disparities and barriers to care. Find out how to establish a safe and welcoming environment for these patients, and get the information you need to decide whether to take an active role in their care by evaluating for gender dysphoria and managing hormone therapy, or an adjunctive role by monitoring well-being and providing referrals. December 1, 2018

    Top 20 Research Studies of 2017 for Primary Care Physicians

    Mark H. Ebell and Roland Grad
    The latest installment of the top 20 research studies for primary care physicians includes studies on cardiovascular disease and hypertension, infections, diabetes mellitus, musculoskeletal problems, and cancer screening, among other topics. The five highest-rated practice guidelines are also summarized. May 1, 2018

    Evaluation of Suspected Dementia

    Nathan Falk, Ariel Cole and T. Jason Meredith
    Patients with suspected dementia can be screened in the primary care office setting with a brief screening tool. A positive screening result warrants more in-depth screening tests. Evaluation for depression, laboratory studies for possible medical conditions that affect memory, and magnetic resonance imaging of the brain should be performed if cognitive impairment is confirmed. March 15, 2018

    2017

    Dizziness: Approach to Evaluation and Management

    Herbert L. Muncie, Susan M. Sirmans, and Ernest James
    Find out how to distinguish central from peripheral causes, and which patients need urgent evaluation and treatment. February 1, 2017

    Deep Venous Thrombosis and Pulmonary Embolism: Current Therapy

    Jason Wilbur and Brian Shain
    Anticoagulation is the mainstay of therapy for venous thromboembolism. Most patients can be treated in the outpatient setting with low-molecular-weight heparin and a vitamin K antagonist (warfarin) or direct-acting oral anticoagulants. March 1, 2017

    Chronic Obstructive Pulmonary Disease: Diagnosis and Management

    Shari Gentry and Barry Gentry
    Learn about the latest recommendations from the Global Initiative for Chronic Obstructive Lung Disease, the American College of Physicians, and the National Institute for Health and Care Excellence. April 1, 2017

    Severe Asymptomatic Hypertension: Evaluation and Treatment

    Robert Gauer
    Severely elevated blood pressure without symptoms of target organ injury can often be managed in the outpatient setting. A gradual lowering of blood pressure over several days to weeks is recommended over aggressive reduction. April 15, 2017

    Hyperlipidemia: Drugs for Cardiovascular Risk Reduction in Adults

    Allen R. Last, Jonathan D. Ference, and Elizabeth Rollmann Menzel
    Review recommendations from two major guidelines on lipid-lowering drugs for the primary and secondary prevention of atherosclerotic cardiovascular disease events. Statins are preferred, although nonstatins may be appropriate in specific cases. January 15, 2017

    Syncope: Evaluation and Differential Diagnosis

    Lloyd A. Runser, Robert Gauer, and Alex Houser
    Learn how to categorize patients as low- or high-risk, and how risk stratification affects management. March 1, 2017

    Laceration Repair: A Practical Approach

    Randall T. Forsch, Sahoko H. Little, and Christa Williams
    The goals of laceration repair are to achieve hemostasis and optimal cosmetic results without increasing the risk of infection. Learn the best techniques for wound preparation and repair, including suture and other closure options. May 15, 2017

    Insomnia: Pharmacologic Therapy

    Eric Matheson and Barry L. Hainer
    Get the latest evidence to help choose between benzodiazepines, z-drugs, melatonin agonists, tricyclic antidepressants, antihistamines, atypical antipsychotics, suvorexant, and antiepileptics. July 1, 2017

    Acute Coronary Syndrome: Current Treatment

    Timothy L. Switaj, Scott R. Christensen, and Dean M. Brewer
    Management of acute myocardial infarction begins with antiplatelet therapy and anticoagulation therapy, among other medications as appropriate. Learn which reperfusion strategies are recommended for patients with ST elevation myocardial infarction and non–ST elevation acute coronary syndrome. February 15, 2017

    Acute Coronary Syndrome: Diagnostic Evaluation

    Craig H. Barstow, Matthew S. Rice, and Jonathan D. McDivitt
    Although chest pain is common with myocardial infarction, there are many noncardiac causes of chest pain. A diagnosis may not be possible based on initial presentation alone. The initial assessment includes evaluation of risk factors and presenting signs and symptoms, rapid electrocardiography, and serum cardiac troponin measurements. February 1, 2017

    Mildly Elevated Liver Transaminase Levels: Causes and Evaluation

    Robert C. Oh, Thomas R. Hustead, Syed M. Ali, and Matthew W. Pantsari
    Mild, asymptomatic elevations in transaminase levels are common in primary care. Nonalcoholic fatty liver disease is the most common cause and is often benign and treated with lifestyle modification. Learn about this and other less common causes of transaminase elevations. December 1, 2017

    Probiotics for Gastrointestinal Conditions: A Summary of the Evidence

    Thad Wilkins and Jacqueline Sequoia
    Probiotics are useful for treating a variety of gastrointestinal conditions. Review the conditions with the best supporting evidence for probiotic use, as well which probiotic species are most appropriate. August 1, 2017

    Subclinical Hyperthyroidism: When to Consider Treatment

    Ines Donangelo and Se Young Suh
    Learn about new research on the association between subclinical hyperthyroidism and the risk of cardiovascular disease and bone fractures. June 1, 2017

    Heart Failure Due to Reduced Ejection Fraction: Medical Management

    William E. Chavey, Robert V. Hogikyan, R. Van Harrison, John M. Nicklas
    Multiple medication classes have demonstrated mortality benefit in heart failure. Recent data have shown benefit in two new classes—angiotensin blocker/neprilysin inhibitors and sinus node modulator. January 1, 2017

    Vitamin B12 Deficiency: Recognition and Management

    Robert C. Langan, Andrew J. Goodbred
    Find out which patients should be screened, and get the latest evidence on the optimal method of replacement in patients with vitamin B12 deficiency. September 15, 2017

    Pleuritic Chest Pain: Sorting Through the Differential Diagnosis

    Brian V. Reamy, Pamela M. Williams, and Michael Ryan Odom
    Once diagnoses requiring emergent attention are excluded, a virus is a likely causative agent to consider. Some patients must be reexamined with radiography after they receive treatment to ensure complete resolution of illness. September 1, 2017

    Evaluation of Jaundice in Adults

    Matthew V. Fargo, Scott P. Grogan, and Aaron Saguil
    Jaundice can indicate significant underlying disease. Review key components of the history, physical examination, laboratory evaluation, and imaging tests to determine the cause. February 1, 2017

    Secondary Hypertension: Discovering the Underlying Cause

    Lesley Charles, Jean Triscott, and Bonnie Dobbs
    Review common causes of secondary hypertension, including renovascular hypertension, renal disease, primary hyperaldosteronism, and obstructive sleep apnea. October 1, 2017

    End-of-Life Care: Managing Common Symptoms

    Ross H. Albert
    Review the most effective strategies for managing pain, dyspnea, delirium and agitation, nausea and vomiting, constipation, and oropharyngeal secretions in patients approaching the end of life. March 15, 2017

    Chronic Cough: Evaluation and Management

    Charlie Michaudet and John Malaty
    Learn which four conditions are the most likely cause, which imaging tests to order, and when to refer patients with refractory cough to a subspecialist. November 1, 2017