Clinical Pearls Rgz
The presence of accelerations on a fetal heart tracing is very reassuring and consistent with a fetal pH of gt 7.2. The use of universal, prenatal screening for group B streptococcus and provision of intrapartum antibiotics to women who are colonized can reduce the risk of GBS disease in infants by approximately 50 . Fetal heart rate tracings must be interpreted within the overall clinical situation. Reduction in variability shortly after giving a narcotic pain medication may represent fetal...
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...
Clinical Pearls Tnq
Consider Marfan syndrome in a tall patient with long arms, long fingers, who wears glasses. A 24-72-hour Holter monitor is appropriate in a patient with frequent i.e., daily palpitations a 30-day event monitor is a better test in someone with infrequent episodes. Hypertrophic cardiomyopathy is the most common cause of sudden cardiac death in adolescents. An adolescent with a systolic heart murmur that increases in intensity with Valsalva maneuver should have his her activity restricted until a...
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...
Clinical Pearls Pnn
Anyone with a history of anaphylactic reactions should be given a prescription lor an epinephrine injector kit and instructed in the importance of keeping it at hand. These prescriptions need to be updated often, as the medication expires in 6-12 months. Human bite wounds are not always the result of a bite. A punch to the mouth can cause a serious inoculation and infection to the knuckles of the puncher. Golden DBK. Stinging insect allergy. Am Fam Physician 2003 67 2541-2546. Goldstein EJC....
Comprehension Questions Bhe
34.1 A 28-year-old male presents for evaluation of headaches. He has had several episodes of unilateral throbbing headaches that last 8-12 hours. When they occur, he gets nauseated and just wants to go to bed. Usually they are relieved after he lies down in a dark, quiet room for the remainder of the day. He is missing significant amounts of work because of the headaches. He has a normal examination today. Which of the following statements is true regarding this situation A. He needs a CT scan...
Clinical Pearls Vxb
The pathophysiology of IBS is not clearly elucidated. However, altered gut motility, visceral hypersensitivity, and dysregulation of the brain gut axis, coupled with psychosocial factors, appear to influence IBS symptoms in varying degrees. The symptom complex of altered bowel habits and chronic abdominal pain is the hallmark of IBS. Symptoms typically begin early in life, wax and wane, and occur in the absence of any organic cause. Alarm features may indicate an underlying organic pathology...
Clinical Pearls Fcx
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...
Clinical Pearls Ygs
Lipid levels must always be interpreted in the context of the individual's overall risk factors for CHD. Statins have the best data to support improvement in outcomes that are clinically significant, such as heart attacks, strokes, and death. Except when there is a contraindication, a statin should be the first medication used for cholesterol reduction. Remind patients who are taking lipid-lowering medications that lifestyle modifications are still necessary. Medications are not a substitute...
Pediatric History
For the purposes of routine well child visits, a comprehensive history should be obtained at the initial visit with more focused, interval histories obtained at subsequent encounters. The initial history should include an opportunity for the parent to raise any questions or concerns that the parent may have. New parents, especially first-time parents and young parents, often have many questions or anxieties about their child. The ability to discuss them with the physician will help to engender...
Clinical Pearls Ptv
The presentation of acutely altered mental status delirium should prompt an aggressive work-up for an underlying cause, as treatment may result in correction of the mental status. Alzheimer disease is a disease of the family, not just the individual. It is critical to treat the patient and support the caregivers. Alva G. Potkin SG. Alzheimer disease and other dementias. Clin Geriatr Med 2003 19 763-776. Alzheimer's Association website www.alz.org. American Geriatric Society website...
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
Answers Oza
16.1 B. The cervical dilation beyond 4 cm means active phase. No cervical change for 2 hours is defined as arrest of active phase. 16.2 A. Early decelerations are thought to be caused by fetal head compression. Variable decelerations are caused by cord compression and late decelerations by uteroplacental insufficiency. 16.31 B. A pool of clear fluid with ferning noted on an air-dried microscopic slide is diagnostic of rupture of fetal membranes. In this case, as she is 34 weeks' gestation, it...
Case 1
A 52-year-old man comes to your office for a routine physical examination. He is a new patient to your practice. He has no significant medical history and takes no medications regularly. His father died at the age of 74 of a heart attack. His mother is alive at the age of 80. She has hypertension. He has 2 younger siblings with no known chronic medical conditions. He does not smoke cigarettes, drink alcohol, use any recreational drugs, and does not exercise. On examination, his blood pressure...
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
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....
Clinical Pearls Xuv
Adolescents tend to see physicians irregularly. Take the time at each visit, no matter what the chief complaint is, to review health maintenance issues. True contraindications to participation in all sports are rare. Almost everyone should be able to participate in some form of athletic activity. Universal adolescent vaccination with meningococcal vaccine became a recommendation in 2005 unvaccinated adolescents and teens should be offered vaccination routinely. American Medical Association....
Approach To Hypercalcemia
The diagnostic approach to hypercalcemia begins with a careful history, including the manifestations of elevated calcium levels. When the aforementioned etiologies are taken into consideration, it becomes clear that the history should include family history of calcium disorders, such as renal stones or malignancy. The patient's risk factors for malignancy, such as smoking, should be investigated. A careful review of medications should also take place, to include not only prescription...
History 1
As in all areas of medicine, the history of the presenting illness will guide the diagnostic work-up. In the history of a patient with musculoskeletal complaints, important information to gather includes whether the primary symptom is pain, limited movement, weakness, instability, or a combination of symptoms. The onset of the symptoms whether acute, chronic, or an acute worsening of a chronic problem can be significant. The location, severity, and pattern of radiation of pain should be...
Diagnosis
The test of choice for the determination of the source of lower GI bleeding is colonoscopy. Adequate bowel preparation with an oral sulfate purge to clear the bowel of blood, clots, and stool increases the yield in diagnosing colonic bleeding sites. Angiography and technetium-labeled colloid or red blood cell scans may be of value if colonoscopy cannot be performed or if heavy bleeding prevents adequate visualization of the colon. However, the magnitude of bleeding required to show the bleeding...
Clinical Pearls Jll
Elderly patients often have fewer or less-severe symptoms or atypical presentations of pneumonia. Consider pneumonia in the differential diagnosis of altered mental status in the elderly. Appropriate use of influenza and pneumococcal vaccination reduces the risk of pneumonia in susceptible populations. Consider the diagnosis of empyema in patients with pneumonia and a pleural effusion, especially if the patients continue to have fever despite appropriate antibiotic therapy. American Thoracic...
Case 6
A 35-year-old female with a history of asthma presents to your office with symptoms of nasal itching, sneezing, and rhinorrhea. She states she feels this way most days but her symptoms are worse in the spring and fall. She has had difficulty sleeping because she is always congested. She states she has taken diphenhydramine Benadryl with no relief. She does not smoke cigarettes and does not have exposure to passive smoke but she does have 2 cats at home. On examination, she appears tired but is...
Answers Ylr
21.11 B. The patient has CRF with volume overload as evidenced by symptoms and physical examination. A simple first step is to do a chest x-ray to confirm what you already suspect pulmonary edema. After initiating furosemide Lasix , the chest x-ray may be repeated to see to what degree the diuresis has improved the overload. Cardiac work-up is also indicated but would not be the first test done. 21.2 F. High blood pressure, acidosis, volume depletion, and cholesterol all worsen kidney function...
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...
Clinical Pearls Pxk
If you suspect that a patient's limited active range of motion is primarily a result of pain, you can numb the joint by injecting lido-caine into it and then reexamine the joint. Use the uninjured, contralateral extremity as a comparison for your examination of an injured extremity. An adequate x-ray series must include at least two views at 90 degrees to each other. Hockenberry RT, Sammarco GJ. Evaluation and treatment of ankle sprains. Phys Sports Med 2001 29 2 . Available online at...
Clinical Pearls Qub
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,...
Clinical Pearls Exi
Protein undernutrition is associated with an increased risk of infections, anemia, orthostatic hypotension, and decubitus ulcers. Smoking is associated with osteoporosis. If osteoporotic fractures, such as vertebral compression fractures, occur in conjunction with osteopenia on x-ray, the diagnosis of osteoporosis is almost certain. Hearing loss, and sensory impairments in general, can be confused with cognitive impairment or an affective disorder. Presbyopia, macular degeneration, glaucoma,...
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...