A Synopsis of AFP's "Prolonged Febrile Illness and Fever of Unknown Origin in Adults"

A synopsis of:
Prolonged Febrile Illness and Fever of Unknown Origin in Adults
ELIZABETH C. HERSCH, COL, MC, USA, General Leonard Wood Army Community Hospital, Fort Leonard Wood, Missouri ROBERT C. OH, LTC, MC, USA, Fort Belvoir Community Hospital, Fort Belvoir, Virginia
Am Fam Physician. 2014 Jul 15;90(2):91-96.

     Fever of unknown origin is diagnosed as a temperature above 101°F for three more weeks without and establish course, although the definition has changed throughout history. The differential diagnosis is broad but the most common categories are infection ,malignancy or an inflammatory disease. Some medications that can cause FUO include barbiturates, antihistamines, antimicrobials, cardiovascular drugs, and NSAIDs. If a cause cannot be found after a comprehensive history and physical exam, then the minimum diagnostic workup should include CBC, chest x-ray, urinalysis, urine culture, ESR, CRP, electrolytes, LDH, creatinine, blood cultures, rheumatoid factor, serology, ultrasound and CT. Additional workup includes ferritin, cryoglobulins, ANCA, thyroid labs, complement studies, blood smear, serum plasmapheresis, PET CT and possible tissue biopsy.
     An elevated ESR May reveal an abdominal or pelvic infection, osteomyelitis or endocarditis. Procalcitonin maybe elevated in bacterial infection. Elevated LDH may be due to malaria, lymphoma, or leukemia. Ferritin may be elevated in lupus, stills disease or temporal arteritis. Cryoglobulins may be elevated in endocarditis, lupus, leukemia and lymphoma. A venous Doppler ultrasound may be helpful if the suggested cause of the fever is thromboembolism. If the origin still cannot be found, an 18F fluorodeoxyglucose positron emission tomography plus CT may help locate an area for biopsy. Areas that are commonly biopsied are lymph nodes, liver, bone marrow and temporal artery. Therapy has not been shown to be helpful. Consultation with the specialist is preferred whenever necessary.
   

A Synopsis of AFP's "Evaluation and Treatment of Constipation in Children and Adolescents"

A synopsis of:
Evaluation and Treatment of Constipation in Children and Adolescents
SAMUEL NURKO, MD, and LORI A. ZIMMERMAN, MD, Boston Children's Hospital, Boston, Massachusetts Am Fam Physician. 2014 Jul 15;90(2):82-90.

     An infant will have 3-4 stools per day for the first week of life. In infancy and and as a toddler, it will occur about twice a day,  and will eventually progress to once every 1-2 days. Infants who are breastfed may not stool for several days. Parents will worry regardless.
    Diagnosing constipation in a child is best done using the Rome III criteria found here. For childen younger than four years old, at least two of the following should be present; two or less bowel movements per week, history of excessive retention, history of painful or hard bowel movements, one or more episodes of incontinence per week, feces present in rectum, and history of large caliber stools. Patients above 4 year old may additionally have history of retentive posturing of excessive voluntary stool retention.
     Childhood constipation is often functional, meaning that the patient will voluntarily hold in stool to avoid a painful bowel movement. Ironically, this will only cause to stool to become dryer and harder to pass. The rectum will eventually stretch out and lose the sensation of having a full vault, will will perpetuate incontinence.  The full pathophysiology of fecal incontinence is poorly understood. It is common for patients who are constipated to have fluid leak from the anus, often being mistaken for diarrhea. Organic causes include hirschsprung disease, CF, anorectal malformation, and spinal cord abnormality.
   

A synopsis of AFP's "Chronic Daily Headache: Diagnosis and Management"

A synopsis of:
Chronic Daily Headache: Diagnosis and Management
JOSEPH R. YANCEY, MAJ, MC, USA, Fort Belvoir Community Hospital, Fort Belvoir, Virginia RICHARD SHERIDAN, CPT, MC, USA, 1/25 Stryker Brigade Combat Team, Fort Wainwright, Alaska KELLY G. KOREN, LT, MC, USN, Fort Belvoir Community Hospital, Fort Belvoir, Virginia Am Fam Physician. 2014 Apr 15;89(8):642-648.

     A headache is considered chronic when it occurs for at least 15 days a month for 3 consecutive months. They are further classified by either long or short duration, depending on if each individual headache lasts for more, or less, than four hours. Risk factors include obesity, medications, stress, snoring, caffeine use, and chronic pain. Lab work is not helpful in the diagnosis. Important illnesses in the differential include intracranial hemorrhage, arnold-chiari malformation, subarachnoid hemorrhage, neoplasm, ICP, hemorrhagic stroke, meningitis, encephalitis, and GCA. MRI or CT can help when ruling out these red flags.
     Short duration chronic daily headaches include brief headache syndromes and trigeminal autonomic cephalalgias. Brief headache syndromes include hypnic (during sleep), primary cough (from coughing or valsalva), primary emotional (pulsating pain from exertion), and primary stabbing (transient and localized). Trigeminal autonomic cephalalgias include chronic cluster headaches (stabbing pain behind the eye), paroxysmal hemicrania (severe unilateral orbital/ temporal pain), and SUNA/SUNCT (unilateral stabbing/ pulsating pain). Long duration chronic daily headaches include hemicrania continua (unilateral pain with injection, lacrimation, rhinorrhea, ptosis, or miosis), migraine, and tension (occipital or bandlike).
     Treatment includes nonpharmacologic therapies including cessation of tobacco/caffeine, biofeedback, relaxation techniques, good sleep hygiene, diet, and regular mealtimes. Abortive therapies include acetaminophen, NSAIDs, tramadol, and triptans. Prophylactic therapies include amitriptyline, fluoxetine, gabapentin, onabotulinumtoxinA, propranolol, tizanidine, and valproate/ topiramate. Adverse affects from medications are common in these patients, especially due to overuse.

A Synopsis of AFP's "Diagnostic Approach to Pleural Effusion in Adults"

A synopsis of:
Diagnostic Approach to Pleural Effusion in Adults
JOSÉ M. PORCEL, M.D., Arnau de Vilanova University Hospital, Lleida, Spain RICHARD W. LIGHT, M.D., Saint Thomas Hospital, Nashville, Tennessee Am Fam Physician. 2006 Apr 1;73(7):1211-1220.

     Pleural effusion is just fluid accumulation between the pleural and parietal membranes of the thoracic cavity. Effusion caused by pressure differences is typically transudative effusion. Inflammatory and malignancy typically cause exudative effusion. Light's criteria is used to differentiate them. Exudative effusion has a
pleural to serum protein ratio above 0.5,
a pleural to serum LDH ratio above 0.6, and
a pleural LDH level greater than 2/3 the upper limit of normal.
     Patients may present with dyspnea, cough, or pleuritic chest pain. Physical examination will show dullness to percussion and reduced tactile fremitus. A thoracentesis can be performed when effusion is found on chest x ray (or CT or US if the x ray is inconclusive). PA chest films can detect as little as 200 ml and a lateral film can pick up as little as 50 ml. The thoracocentesis is done for diagnostic and therapeutic benefit. Removal of large amounts of fluid can help alleviate dyspnea.The diagnostic fluid is sent for inspection, protein, LDH, gram stain, TB, pH, and cytology. Neutrophil predominant fluid may be due to an acute process. Lymphocytic predominant fluid may be due to chronic heart failure, TB, malignancy, or thoracic duct injury. A low Ph may reveal malignancy or a connective tissue disorder. Milky appearing fluid may be chylothorax. If food particles are found, it may be due to an esophageal perforation. If the fluid is transudative, treat the cause (if known) or check TSH for hypothyroidism, urine protein for nephrotic syndrome, transaminases for cirrhosis, or pro-BNP for heart failure.  If the fluid is exudative, a pulmonary consult may be in order. These patients will need a more intense workup if the underlying cause is not apparent. This may result in a pleural biopsy, thoracoscopy, or bronchoscopy.

   

A Synopsis of AFP's "Care of the Homeless: An Overview"

A synopsis of:
Care of the Homeless: An Overview
DAVID L. MANESS, DO, MSS, and MUNEEZA KHAN, MD, University of Tennessee Health Science Center, Memphis, Tennessee Am Fam Physician. 2014 Apr 15;89(8):634-640.

     Homeless people are more likely to become ill, become hospitalized, or die at an early age. Homeless children have higher rates of asthma, iron deficiency, lead poisoning, ear infections, respiratory problems, GI issues, and emotional/behavioral issues. These patients may often present initially with advanced forms of common illnesses. It is critical to identify these people so that they can receive care tailored to their situation. Confidence, trust, and empathy must be developed with these relationships. Setting up referrals, follow ups, and monitoring lab results may be challenging. A case manager or patient advocate may help with logistics.
     Common diseases in the homeless include hypertension, diabetes, CHF, PVD, high cholesterol and CAD. Poor diet, excessive mental stress, alcohol/ drug abuse, and poor coping mechanisms can exacerbate these conditions. Lifestyle modification is especially tough in this group of individuals. Patients are also susceptible to acts or violence, rape, sexual abuse, and physical abuse. Mental illness and traumatic brain injury are other illnesses that are found in high rates in the homeless. Stable housing, cognitive rehabilitation, support services, and access to therapy are critical for an optimal outcome.
     Prevention, immunizations and periodic evaluations are as important in this population as they are in the general public. Tdap vaccinations should be offered if its been longer than 10 years. Influenza vaccination should be offered annually. Pneumococcal vaccinations should be offered appropriately. These patients should also be tested for HIV, hepatitis B and hepatitis C.  Tuberculosis should always be considered as part of a differential in a sick homeless patient.
     Foot and skin care are also important. These patients endure long periods of standing and walking, often times in old or poor fitting shoes, with unclean or wet socks. This is a great nidus for ulcerations, cellulitis, edema, and stasis. Education, early detection, proper fitting shoes, clean socks, and sanitary living conditions are helpful measures of prevention.
     The best way to provide services to these people is through a multidisciplinary PCMH style approach with outreach services and community programs. Having multiple services at one spot is an effective approach.
   
   

A Synopsis of AFP's "Diagnosis and Management of Ectopic Pregnancy"

A Synopsis of :
"Diagnosis and Management of Ectopic Pregnancy"
JOSHUA H. BARASH, MD; EDWARD M. BUCHANAN, MD; and CHRISTINA HILLSON, MD, Thomas Jefferson University, Philadelphia, Pennsylvania
Am Fam Physician. 2014 Jul 1;90(1):34-40.

     An ectopic pregnancy is when a fertilized egg implants anywhere in the womans body, other than the uterus. It occurs in 1-2% of all pregnancies, and is a top cause or pregnancy-related deaths. Risk factors include sterilization, advanced maternal age, history of PID, cigarette smoking, previous tubal surgery, and previous ectopic pregnancy. Symptoms include first-trimester bleeding, peritoneal signs, and abdominal pain. A transvaginal ultrasound can be done after 5.5 weeks gestation to see if there is an intrauterine pregnancy, which will rule out an ectopic (unless there are two fetuses). If not found, it is prudent to image the areas of the pelvis where an ectopic pregnancy may likely be found. 
    An important lab value to look at is the bHCG discriminatory level. When the bHCG increases to 1500-2000 mlU/mL, an intrauterine pregnancy should be seen with ultrasound (about 5.5 weeks). Laparoscopy is another option if the location cannot be found. The bHCG level should also increase by 50% every two days in intrauterine pregnancies. The bHCG will typically not increase this fast in ectopics (although 20% of the time it does!) A sudden drop in serial bHCG may signify a nonviable or a ruptured ectopic. Falling levels need to be monitored until they are undetectable, to confirm resolution of pregnancy. 
     Women with suspected ectopic pregnancy need to have their Rh status determined to decide if RhoGam immunoglobulin should be given.
     Once it is determined that that an ectopic pregnancy is present, treatment can be decided upon. Patients with extensive bleeding or intravascular compromise will benefit from a salpingectomy. If fertility is to be preserved, a salpingostomy is preferred. Otherwise a patient can  be prescribed methotrexate, which inhibits cell replication and DNA synthesis. In order to prescribe methotrexate, the gestational sac should be smaller than 3.5cm. Factors that increase treatment failure include cardiac activity in the embryo, free blood in the abdomen, high progesterone, or high bHCG (>2000 mlU/mL).  Methotrexate is contraindicated in immune compromise, liver or kidney damage, asthma, or PUD.  Following treatment, the bHCG decreases at least 15% within 7 days. It takes 5-7 weeks for the bHCG to be undetectable. 

     

A synopsis of AFPs "Prevention and Treatment of Motion Sickness"

A synopsis of
Prevention and Treatment of Motion Sickness
ANDREW BRAINARD, MD, MPH, and CHIP GRESHAM, MD, Middlemore Hospital, Auckland, New Zealand 
Am Fam Physician. 2014 Jul 1;90(1):41-46.
http://www.aafp.org/afp/2014/0701/p41.html

     Motion sickness is caused by...um.... motion. Symptoms include nausea, drowsiness, malaise and irritability.  Signs include burping, yawning, heartburn, flushing and hyperventilation. It is more effective to treat prophylactically before the symptoms occur.  With many things, the best protection is abstinence! If you must travel, try and do so in calm weather or light terrain. It is helpful to have a view of the horizon. Patients with motion sickness in planes do better when their seat is over a wing. Patients with motion sickness in cars do better in the front seat. These spots will have the least motion. Other behavioral strategies include avoiding reading, wearing sunglasses, closing eyes, avoiding alcohol, avoiding an empty stomach, and staying hydrated.
     Medication can be quite helpful to minimize signs and symptoms. Transdermal scopalamine is the most effective route for relief. Anticholinergic side affects may occur. First generation antihistamines (promethazine) are moderately effective. Diphenhydramine and meclizine are less effective but can be used.  Other medications include benzodiazepines and rizatriptan. 
    Other treatments that are commonly used include ginger root and the P6 acupressure point (on the anterior wrist). Data is limited and may be strictly placebo.