Approach To Suspected Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a functional GI disorder characterized by chronic abdominal pain and altered bowel habits. The prevalence of IBS is approximately 10-15 of the U.S. population and accounts for a large proportion of GI complaints seen both by primary care physicians and gastroenterologists. IBS affects women 2-3 more times often than men and patients typically present in the second or third decades of life, although virtually any age group can be affected. Despite studies to...

Clinical Pearl

A thorough understanding of functional anatomy is important to optimally interpret the physical examination findings. 12. Laboratory Assessment Depends on the Circumstances. a. CBC. or complete blood count, can assess for anemia, leukocytosis (infection), and thrombocytopenia. b. Basic metabolic panel electrolytes, glucose, BUN (blood urea nitrogen), and creatinine (renal function). c. Urinalysis and or urine culture to assess for hematuria, pyuria, or bac-teruria. A pregnancy test is important...

Normal Changes

Immediately following delivery, the uterus begins the process of involution, the return to its nonpregnant size. Contraction of the uterine musculature promotes hemostasis by compressing the uterine blood vessels. An IV infusion of oxytocin (Pitocin) given during or immediately after the third stage of labor will aid in producing increased uterine tone. Early breast-feeding also leads to uterine contraction, further promoting involution. In most cases, the uterus has returned to normal size by...

Development

An assessment of the child's development in the areas of gross motor, fine motor adaptive, language, and social personal skills is an important aspect of each well child visit. Numerous screening tools, such as the Denver II developmental screening test, the Parents' Evaluations of Developmental Status (PEDS), and others, are available to assist with these assessments. These assessments typically involve both responses from the parents regarding the child's behavior at home and observations of...

Other Tests

A 12-lead EKG should be done in all stroke patients in order to detect acute myocardial infarctions, which can both cause strokes or be the result of a stroke. An EKG will also aid in the diagnosis of atrial fibrillation. Echocardiography may also be necessary to adequately assess the heart. Transesophageal echocardiography is particularly useful in detecting cardiac sources of embolism, such as thrombus caused by myocardial infarction, endocarditis, rheumatic heart disease, valvular...

Epidemiology

HIV infection is a chronic infection with a variable course. The HIV pandemic has spread to every country in the world and has infected 59 million persons worldwide. It is estimated that more than 20 million people have died from AIDS and its complications. HIV disease is caused by the human retroviruses. HIV-1 and HIV-2. HIV-1 is more common worldwide, whereas HIV-2 has been reported in western Africa. Europe. South America, and Canada. In the United States, more than I million people are...

Definitions

Angina pectoris Severe pain around the heart caused by a relative deficiency of oxygen supply to the heart muscle. Myocardial infarction (MI) Cardiac muscle death caused by partial or complete occlusion of one or more of the coronary arteries. New York Heart Association Functional Classification of Angina Class I Angina only with unusually strenuous activity Class II Angina with slightly more prolonged or slightly more vigorous activity than usual Class III Angina with usual daily activity...

Approach To Cvatia

There are 700,000 people that suffer from stroke in the United States each year, and the incidence of TIA is approximately 200.000 500.000 per year. Strokes remain the third-leading cause of death in North America. TIA is defined as a focal neurologic deficit lasting less than 24 hours a stroke is diagnosed if the symptoms persist for more than 24 hours. However, with the development of new imaging techniques, a new definition of TIA has been proposed a brief episode of neurologic dysfunction...

Answers To Case 45 HIV and AIDS

Summary A 45-year-old. homeless, IV drug abuser is seen with fever, cough, dyspnea, and fatigue. He is found to be tachypneic, febrile, and hypoxemic. His chest x-ray reveals bilateral interstitial infiltrates. Most likely cause of current illness Pneumocystis jiroved (formerly known as Pneumocystis carinii) pneumonia Most probable underlying illness AIDS Recommended current testing and treatment Complete blood count (CBC), electrolytes, arterial blood gas HIV enzyme-linked immunosorbent assay...

Answers To Case 18 Geriatric Health Maintenance

Summary A 75-year-old man who presents with loss of speech discrimination and complains of difficulty understanding speech and conversation in noisy areas most likely has presbycusis. Presbycusis is age-related sensorineural hearing loss typically associated with both selective high-frequency loss and difficulty with speech discrimination. Physical examination of the ears in patients with presbycusis is normal. Most likely diagnosis Presbycusis. Next step Presbycusis is a diagnosis of...

Approach To Migraine Headaches

Headaches are an extremely common complaint in primary care, urgent care, and emergency settings. The vast majority of adults have at least one headache each year, although most do not present for medical care. The role of the practitioner is to attempt to accurately diagnose the cause of the headache, rule out secondary causes of headaches (red flags) that may signify a serious underlying pathology, provide appropriate acute management, and assist with headache prevention when needed. The...

Comprehension Questions

40.1 A 65-year-old male patient reports a lifelong history of IBS with alternating bouts of constipation and diarrhea. He denies any so-called alarm symptoms, but does report that his symptoms have worsened over the last several months. What is the most important next step A. Esophagogastroduodenoscopy (EGD) B. Begin trial of the 5-HT agonist tegaserod C. Explore possible underlying psychiatric symptoms 40.2 Which of the following agents is clinically indicated as a first-line treatment for...

Objectives

Know a diagnostic approach to anemia in geriatrics. 2. Be familiar with a rational work-up for anemia of different origins. A 65-year-old woman who has developed worsening dyspnea and palpitations over a 1-week period of time needs to be evaluated for cardiac and respiratory problems despite the gradual onset of symptoms. Specifically, in a postmenopausal woman, signs and symptoms of angina or acute myocardial infarction may not always have a typical presentation. That the patient has been...

Clinical Approach

Chronic renal failure is becoming more common in the United States. The most common etiologies are diabetes, hypertension, and glomerulonephritis. Diabetic kidney disease occurs in 30-40 of type I diabetics, in 25 of type II diabetics, and in 24 of hypertensive patients. Within the diabetic patient population. 20-60 have hypertension. Many patients present at a (ater stage of CRF and it is then difficult to determine the etiology. The Kidney Disease Outcomes Quality Initiative (KDOQI) from the...

Clinical Pearls Immunizations 2017

The male latex condom remains the best shield against AIDS and other STDs. Barrier methods, which work by keeping the sperm and egg apart, usually have only minor side effects. Combination oral contraceptives offer significant protection against ovarian cancer, endometrial cancer, iron-deficiency anemia, PID. and fibrocystic breast disease. Methods of hormonal contraception, when used properly, are extremely effective. Surgical sterilization must be considered permanent. Vasectomy is considered...

Clinical Pearls

Alcohol and other drug abuse can significantly impact both physical and mental health. Assess whether the onset of depression or other mental health behavioral problems preceded or followed significant alcohol or other drug abuse or dependence, to determine the primary problem and associated treatment. Alcohol dependence is characterized by tolerance withdrawal drinking larger amounts or for longer periods over time desire or unsuccessful efforts to control use much time spent drinking...

Answers To Case 40 Irritable Bowel Syndrome

Summary A 28-year-old female presents with a several-year history of abdominal pain and constipation. She denies any fever, weight loss, heartburn, or bloody stools. Her past medical history and family history are otherwise unremarkable. The physical examination, including abdominal and pelvic examination, are grossly within normal limits. Most likely diagnosis Irritable bowel syndrome Most appropriate next step In the absence of any GI alarm features, a complete blood count and stool Hemoccult...

Screening for Osteoporosis

Osteoporosis is a condition of decreased bone mineral density associated with an increased risk of fracture. Half of all postmenopausal women will have an osteoporosis related fracture in their lifetime. These include hip fractures. which are associated with higher risks of loss of independence, institutionalization and death. The risk of osteoporosis is increased with advancing age, tobacco use. low body weight. Caucasian or Asian ancestry, family history of osteoporosis, low calcium intake...

Answers To Case 33 Obesity

Summary A 20-year-old obese female presents for a routine examination. Along with her abdominal obesity, she has irregular menstrual cycles, acanthosis nigricans, and hirsutism. Clinical issues to address Obesity and possible polycystic ovarian disease. Next steps in evaluation Calculate a body mass index (BMI), measure waist circumference, repeat blood pressure. Order laboratory tests to measure fasting glucose, lipids, thyroid-stimulating hormone (TSH), and liver enzymes. + Therapeutic...

Deli nit ions

Emancipation Emancipation is a legal process in which a person who is younger than the age of 18 years petitions the court to have herself himself declared a legal adult. Laws for emancipation vary by state. Emancipation ends the parent's legal duty to support the minor, and also ends the parents right to make decisions about the minor's residence, education, healthcare, and to control the minor's conduct. However, this does not include the ability to consume alcohol, use tobacco, or exercise...

Andrea Lazzaretto

Heimlich maneuver Performed by standing or sitting behind the person who is choking and placing the thumb side of one fist between the navel and the xiphoid process. The other hand grasps the fisted hand and a series of upward abdominal thrusts are delivered to create an artificial cough in a choking victim in an effort to dislodge the object blocking the airway. Stridor Wheezing coming from obstruction of the large airway that has a constant pitch and intensity throughout the entire...

Considerations

Acute bronchitis refers to inflammation of the tracheobronchial tree. The inflammatory response to the trigger, whether infectious, allergic, or irritant, leads to increased mucous production and airway hyperresponsiveness. As bronchitis most commonly occurs in the setting of an upper respiratory illness, it is seen more frequently in the winter. Influenza, parainfluenza, adenovirus, rhinovirus. other viruses. Mycoplasma pneumoniae, and Chlamydia pneumoniae have been implicated as causes. As...

Clinical Approach Partner Abuse

Family violence is an abuse of power, in which a more-powerful person exerts control over a less-powerful person or persons. This abuse can take the form of physical violence (battery), sexual violence, intimidation, emotional and psychological abuse, economic control, and isolation from others. Although it is most common to think of this as a man abusing a woman, abuse can occur both in homosexual relationships and in heterosexual relationships with a male victim. It is estimated that more...

Approach To Diseases Of The Breast Palpable Breast Mass

Following a complete history, with an emphasis on factors that may confer an increased risk of cancer, a careful examination of both breasts should be performed. The breast examination should include a visual inspection for skin changes, dimpling, retraction, and asymmetry, and should note the presence and quality of any nipple discharge (color, presence of blood, etc.). Palpatory examination should be performed in a systematic manner to include all quadrants of the breast, as well as the...

Sports Preparticipation Examination

A common reason for healthy adolescents to present to primary care physicians is for a preparticipation examination as a requirement to play a sport in school. The goal of these examinations is to attempt to identify conditions that may place a young athlete at risk during athletic participation. These conditions are primarily cardiac and orthopedic, but are not limited to these systems. A preparticipation examination allows the physician to provide the comprehensive health maintenance,...

Case

A 55-year-old male comes into your office for follow-up of a chronic cough. He also complains of shortness of breath with activity. He reports that this has been getting worse over time. As you are interviewing the patient, you note that he smells of cigarette smoke. Upon further questioning, he reports smoking I pack of cigarettes per day for the past 35 years and denies ever being advised to quit. On examination, he is in no respiratory distress at rest, his vital signs are normal, and he has...

Immunizations

As is the case for well child care, the provision of age- and condition-appropriate immunizations is an important component of well-adult care. Recommendations for immunizations change from time to time and the most up-to-date source of vaccine recommendations is the Advisory Committee on Immunization Practices. Its immunization schedules are widely published and are available at the Centers for Disease Control website (among other places) at www.cdc.gov. A booster vaccination for tetanus and...

Conjunctivitis

Conjunctivitis is an infection of the palpebral and or bulbar conjunctiva. It is the most common eye disease seen in community medicine. Most cases are caused by bacterial or viral infection. Other causes include allergy and chemical irritants. The mode of transmission of infectious conjunctivitis is usually direct contact to the opposite eye or to other persons via fingers, towels, or handkerchiefs. The organisms isolated most commonly in bacterial conjunctivitis are Staphylococci,...

Evaluation

COPD is defined as airway obstruction that is not fully reversible, is usually progressive, and is associated with chronic bronchitis, emphysema, or both. The most common etiology is cigarette smoking, which is associated with approximately 90 of cases of COPD. Other etiologies of COPD include passive exposure to cigarette smoke (second-hand smoke) and occupational exposures to dusts or chemicals. A rare cause of COPD is a genetic deficiency in a.-antitrypsin, which should be considered when...

Treatment

As in every critical patient, the initial survey should assess the ABCs. If hypoxia is detected, supplemental oxygen should be administered to maintain oxygen saturation above 95 and the cause of the hypoxia investigated (partial airway obstruction, aspiration pneumonia, atelectasis). An endotracheal tube should be placed if the airway is threatened. A cardiac monitor should be placed to detect atrial fibrillation or any other arrhythmias. Unless a hypertensive encephalopathy, aortic...

Approach To High Cholesterol Definitions

ATP III The third report of the National Cholesterol Education Program Expert Panel on the Detection. Evaluation and Treatment of High Blood Cholesterol in Adults. HDL cholesterol High-density lipoprotein cholesterol. LDL cholesterol Low-density lipoprotein cholesterol. Statin Medication in the A (HMG-CoA (-reductase inhibitor class. These are the most widely used medications for lowering LDL cholesterol. Clinical Approach Determination of Lipid Goal Numerous studies show that LDL cholesterol...

Etiologies

The symptoms and signs that occur are unique and characteristic of the alterations to the normal physiologic function. Symptoms of right-sided heart failure include venous congestion, nausea vomiting, distension bloating, constipation, abdominal pain, and decreased appetite. Common signs of right-sided heart failure are fluid retention, weight gain, peripheral edema, JVD. hepatojugular reflux, hepatic ascites, and splenomegaly. Left-sided heart failure manifests with pulmonary congestion,...

Clinical Presentation

Fatigue, weakness, and dyspnea are symptoms that are commonly reported by elderly persons with anemia. These vague and nonspecific symptoms are often ignored by both patients and physicians as symptoms of old age. Anemia may result in worsening of symptoms of other underlying conditions. For example, the reduced oxygen-carrying capacity of the blood as a consequence of anemia may exacerbate dyspnea associated with congestive heart failure. Certain signs found on examination may prompt a work-up...

Approach To Diabetes Mellitus Definitions

DCCT Diabetes Control and Complications Trial, a large, prospective, randomized controlled study of the advantages and disadvantages of tight versus loose diabetic control in type 1 diabetes. UKPDS United Kingdom Prospective Diabetes Study, a large, prospective. randomized controlled study of interventions and outcomes in type 2 diabetes. Diabetes mellitus is a general term for several different diseases that result in high blood sugar levels and that eventually lead to microvascular and macro...

Approach To Bites And Stings Insect Stings Local Reactions

Almost all hymenoptera stings will result in a local reaction, which includes redness, swelling, pain, and itching at the site of the injury. These reactions tend to occur almost immediately and last for a few hours. The local tissue response is a consequence of a histaminelike reaction caused by the venom that is released by the sting. Local reactions can be treated with ice and antihistamine for itching. Tetanus prophylaxis should be provided for those who have not been vaccinated. Large...

Urinalysis In Malignant Melanoma

The preventable risk factor common to all skin cancers is sun exposure. Recommend to your at-risk patients limiting exposure to sunlight in the middle of the day, wearing appropriate protective clothing, and using sun screen. Contrary to popular belief, the use of tanning beds is also a risk factor for skin cancer. There is no such thing as a healthy tan. Abbasi NR, Shaw HM. Rigel DS. el al. Early diagnosis of cutaneous melanoma revisiting ihe ABCD criteria. JAMA 2004 292 2771-2776. Fitzpatrick...

Answers To Case 20 Chest Pain

Summary A 56-year-old obese male presents to the emergency department with chest discomfort. He has a pressure sensation in the left substernal area of his chest associated with shortness of breath and diaphoresis. His symptoms began with minimal exertion. The patient is without prior medical care. He has a family history of coronary artery disease (CAD) and a history of tobacco abuse. He is hypertensive and tachycardic. He has a cardiac gallop. Lower extremities have trace edema and a femoral...

Approach To Hematuria

Hematuria is divided into glomerular, renal nonglomerular . and urologic etiologies. Glomerular hematuria typically is associated with significant proteinuria, erythrocyte casts, and dysmorphic RBCs. Renal nonglomerular hematuria is secondary to tubulointerstitial. renovascular, and metabolic disorders. Like glomerular hematuria, it often is associated with significant proteinuria however, there are no associated dysmorphic RBCs or erythrocyte casts. Urologic causes of hematuria include tumors,...

Index

Note Page numbers followed by or t indicate figures or lables. respectively. AAFP. See American Academy of Family Physicians AAP. Sec American Academy of Pediatrics ABCD criteria. for skin lesions, 127 ABCs. See airway, breathing, and circulation abdominal aortic aneurysm. 20 abdominal examination. 6 abdominal pain. 369-371. 415-416. 425-426. See also pediatric abdominal pain abnormal bleeding, regular menstrual cycles and. 452 abscess. 125. 354-355 deep. 364 peritonsillar. 364. 366...

Approach To Jaundice History and Examination

The most important information in the diagnostic evaluation usually comes from the history. In patients presenting with jaundice, the history should be thorough and should include questions focused on identifying the common causes of jaundice. Specific information should include when the jaundice commenced and whether it is of acute or gradual onset. The presence of gastrointestinal symptoms, such as abdominal pain, nausea, vomiting, diarrhea, or changes in stool color can be significant....

Physical Findings

Most patients with depression have no significant physical abnormalities on examination. Those who have more severe symptoms may reveal decline in RISK FACTORS FOR SUICIDE ATTEMPTS AND COMPLETED SUICIDES RISK FACTORS FOR SUICIDE ATTEMPTS AND COMPLETED SUICIDES Social isolation divorced, widowed Data from, American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. 4th cd. Washington. DC American Psychiatric Association Press 1994 and Guck TP. et al. Assessment and...

Functional Assessment

Dementia Functional Assessment

Functional assessment gauges a patient's ability to manage tasks of self-care, household management, and mobility. Impairment in activities of daily living results in an increased risk of falls, hip fracture, depression, and institutionalization. Figure 18-1. Approach to geriatric health maintenance. ADL, activities of dailv living DNAK, do not attempt resuscitation IADL, instrumental activities of daily living. Figure 18-1. Approach to geriatric health maintenance. ADL, activities of dailv...

Acute Bronchitis Clinical Pearl

The main concerns with pharyngitis are to rule out more serious conditions, such as epiglottitis or peritonsillar abscess, and to diagnose group A P-hemolytic streptococcal infections. Hepatosplenomegaly can be found in infectious mononucleosis infection. A tonsillopharyngeal exudate does not differentiate viral and bacterial causes. Tonsillopharyngeal palatal petechiae are seen in GAS infections and infectious mononucleosis. Tierney LM. McPhee SJ. Papadakis MA. Current medical diagnosis and...

Answers To Case 35 Hyperlipidemia

Summary A 56-year-old male with well-controlled hypertension is found to have elevated cholesterol on a screening blood test as part of a physical examination. He has no known history of coronary artery disease or of any coronary artery disease risk equivalent. Goal for LDL-cholesterol lt 130 mg dL Further testing at this time blood glucose, creatinine, liver function tests, thyroid-stimulating hormone Initial management of his elevated cholesterol therapeutic lifestyle changes

Diagnosis and WorkUp

The diagnosis of hypertension relies on accurate measurement of blood pressure. The appropriate technique is to allow the patient to sit quietly in a chair not on the examination table with a supported back and feet on the floor for 5 minutes prior to making the measurement. The blood pressure should be measured at least twice, using a calibrated sphygmomanometer and an appropriately sized cuff for the patient. The blood pressure cuff should encircle at least 80 of the patient's arm a cuff that...

Blenning C.e. 2005 . An Approach To The Postpartum Office Visit. American Family Physician 72 2491-2498.

Many of the important postpartum issues mood problems, contraception. and breast-feeding are best managed by addressing them in the prenatal course first, and then readdressing or reinforcing them in the postpartum period. Most causes of postpartum hemorrhage can be remembered with the four Ts Tone. Trauma. Tissue, and Thrombin. Anderson J. Etches D. Smith D. Postpartum hemorrhage third stage emergency. In Atwood L, Deutchman M. Bailey E. et al. eds . Advanced life support in obstetrics manual....

Nodular Thyroid Disease

Thyroid nodules, both solitary and multiple, are common and are often found incidentally on physical examination, ultrasonography, or computed tomography. They are more prevalent in women and increase in frequency with age. Although their pathogenesis is not clear, nodules are known to be associated with iodine deficiency, higher gravidity, and the ingestion of goitrogens. Further work-up of identified nodules is indicated, as the incidence of malignancy in solitary nodules is estimated at 5-6...

Click To Cure Cancer Clinical Cases

Adolescent healthcare is a complex issue. However, the clinician should attempt to administer confidential healthcare to minors seeking care for sensitive medical issues when it is safe and appropriate to do so. It is very important for clinicians to know the laws regarding consent and confidentiality when treating adolescent patients of the states in which they practice. Boonstra H. Nash E. Minors and the rights to consent to health care. The Guttmacher Report on Public Policy, Volume 3,...

Contributors

Department of Family and Community Medicine The University of Texas-Houston Medical School Houston. Texas Approach to Asthma and Allergies Approach to Respiratory Tract Infections Approach to Depression Department of Family and Community Medicine The University of Texas-Houston Medical School Houston, Texas Approach to HIV AIDS Department of Family and Community Medicine The University of Texas-Houston Medical School Houston. Texas Approach to Arrhythmia Department of Family and Community...