FP essentials最新文献

Small bowel obstruction and ileus are common surgical concerns that family physicians may encounter in a consultative role with surgical specialties. The most common cause of small bowel obstruction in adults and children is adhesions, followed by internal and external hernias. Postoperative ileus is a common complication that can occur after any abdominal surgery; however, with the implementation of enhanced recovery after surgery protocols, the incidence is decreasing. For small bowel obstruction, treatment focuses on gastric decompression, fluid resuscitation, electrolyte replacement, and pain control, which may include opioid therapy initially. Use of oral contrast medium studies for small bowel obstructions managed nonoperatively is now considered the standard of care after appropriate decompression and fluid resuscitation in the low-risk patient. Operative management is recommended for patients with hemodynamic instability, surgery in the previous 6 weeks, or signs of peritonitis, and for those in whom the condition does not resolve with an initial nonoperative approach. Treatment of postoperative ileus is largely supportive, entailing electrolyte correction, intravenous fluids as needed, and pain control.

Acute appendicitis is one of the most common causes of emergency abdominal surgery in adults and children. Although tenderness at the McBurney point is the most specific symptom, diagnosing appendicitis clinically is challenging. Diagnosis should include the use of laboratory testing, including white blood cell count with differential, C-reactive protein level, and neutrophil-to-lymphocyte ratio, in addition to use of clinical prediction tools such as the Appendicitis Inflammatory Response score and diagnostic imaging. Although ultrasonography is a reasonable first-line imaging modality, its outcomes are user-dependent and studies are often nondiagnostic (ie, unable to rule out appendicitis). Computed tomography is commonly used in the United States to diagnose acute appendicitis and has the additional benefit of being able to evaluate for multiple etiologies of abdominal pain. Based on imaging findings, acute appendicitis can be subcategorized as uncomplicated (ie, inflammatory changes without signs of necrosis or abscess) or complicated (ie, signs of necrosis with perforation or abscess formation). Patients with appendicolith on imaging and pregnant patients should be managed surgically. The standard of care for uncomplicated acute appendicitis remains laparoscopic appendectomy, whereas complicated appendicitis in stable patients may initially be managed nonoperatively with antibiotic therapy and percutaneous abscess drainage before consideration of interval appendectomy.

Cholelithiasis, characterized by the presence of gallstones, is a common condition in the United States, with 80% of affected individuals having no symptoms. Symptomatic gallstone disease encompasses symptomatic cholelithiasis, biliary dyskinesia, acute cholecystitis, choledocholithiasis, gallstone pancreatitis, and acute cholangitis. It often manifests as sharp, stabbing right upper quadrant or epigastric pain as well as nausea and vomiting. History, physical examination, and laboratory evaluation alone are insufficient to make an accurate diagnosis. Ultrasonography should be the first-line imaging modality for evaluating right upper quadrant pain. Symptomatic cholelithiasis is diagnosed with the confirmation of gallstones on imaging in patients presenting with classic symptoms. Clinical prediction tools such as the 2018 Tokyo guidelines for acute cholecystitis or pretest probability calculation for choledocholithiasis should be used to aid diagnosis and determine the need for further imaging. Laparoscopic cholecystectomy is the standard treatment for most forms of symptomatic gallstone disease. In cases of choledocholithiasis, intraoperative common bile duct exploration at the time of cholecystectomy or endoscopic retrograde cholangiopancreatography performed before, during, or after cholecystectomy is needed.

Diverticular disease is a common finding in Western countries, with a prevalence of up to 70% among individuals at 60 years of age. The term diverticular disease includes the historically recognized conditions of diverticulosis, uncomplcated diverticulitis, complicated diverticulitis, and diverticular bleeding; it also includes the increasingly recognized condition of symptomatic uncomplicated diverticular disease. The diagnosis of symptomatic diverticular disease requires a history and physical examination, laboratory evaluation, and imaging. In uncomplicated diverticulitis, antibiotic therapy and hospital admission may not be required. In complicated diverticulitis and diverticular bleeding, consultation with a gastroenterologist or surgeon for endoscopy may be required to rule out malignancy and control diverticular bleeding. In addition, surgical consultation may be needed for those who have abscesses, fistula formation, or perforation and for those patients who are unstable.

Obesity-hypoventilation syndrome is characterized by daytime hypercapnia (arterial partial pressure of carbon dioxide of 45 mm Hg or more) in a patient with a body mass index of 30 kg/m2 or more, in the absence of alternative causes of hypoventilation. It should be suspected in patients with obesity who have daytime somnolence, dyspnea, fatigue, snoring, apnea, and sleep-related and daytime hypoxemia. The diagnosis is confirmed with overnight polysomnography. Additional tests such as measurement of arterial blood gases, serum bicarbonate, and arterial oxygen saturation can further support the diagnosis. Patients with obesity-hypoventilation syndrome have higher rates of intensive care unit admission and health risks; therefore, early diagnosis and specialist referral are crucial to reduce morbidity and mortality. Management includes weight loss (eg, through a comprehensive weight loss pro-gram or bariatric surgery) and positive airway pressure therapy (eg, continuous or bilevel positive airway pressure) to address hypercapnia and concurrent sleep-disordered breathing, if present.

Pulmonary hypertension is a complex progressive disorder characterized by elevated pulmonary artery pressure. Diagnosis requires early clinical suspicion based on symptoms such as exertional dyspnea, fatigue, syncope, and chest discomfort, with echocardiography as a first-line diagnostic study. Diagnosis is confirmed using right heart catheterization, with a mean pulmonary artery pressure of 20 mm Hg or more and pulmonary vascular resistance greater than 2 Wood units. Strategies for primary and secondary prevention include regular physical activity, tobacco cessation, weight management, immunizations, and family planning to minimize risks associated with pregnancy. Prevention and evidence-based control of hypertension, diabetes, and dyslipidemia are essential. Occupational and environmental exposures, including poor indoor and outdoor air quality, should be addressed. Advances in pharmacotherapy for pulmonary arterial hypertension that target the endothelin, prostacyclin, and nitric oxide pathways and activin receptor inhibition have improved outcomes. Endothelin receptor antagonists, prostacyclin analogues, and phosphodiesterase 5 inhibitors are key treatment options. Combination therapy is recommended for patients with moderate to severe disease, whereas parenteral prostanoids are indicated for advanced pulmonary arterial hypertension. Right-sided heart failure, a major complication, is managed with fluid manage-ment and diuretics, with lung transplant evaluation and palliative shunt procedures considered for refractory cases. Addressing nutrition and iron deficiency are important supportive measures.

Noninfectious pleural effusions arise from an imbalance between fluid entering and leaving the pleural space. Effusions are classified as transudative or exudative, based on protein and lactate dehydrogenase levels. Common symptoms are dyspnea, cough, and chest pain. Physical examination findings may include dullness to percussion and decreased breath sounds. Transudates are associated with conditions such as congestive heart failure and cirrhosis, whereas exudates are linked to pneumonia, malignancy, pulmonary embolism, and gastrointestinal disorders. Diagnosis relies on chest imaging and image-guided thoracentesis for pleural fluid analysis. The differentiation between transudative and exudative effusions is primarily based on Light criteria, which include ratios of effusion to serum concentrations of protein and lactate dehydrogenase. Additional testing (eg, cytology, glucose level, microbiological studies) may be necessary for indeterminate cases. Management focuses on treating the underlying condition. Interventions such as therapeutic thoracentesis, pleurodesis, or surgical procedures may be needed, depending on the etiology of the effusion. Accurate classification and targeted treatment are key for optimizing patient outcomes.

Pulmonary nodules are commonly detected during routine lung cancer screening on low-dose chest computed tomography (CT) or incidentally on other imaging. Approximately 1.6 million people in the United States are diagnosed with pulmonary nodules annually, with most being asymptomatic. The etiology of pulmonary nodules ranges from benign to malignant, necessitating a structured approach to evaluation. The US Preventive Services Task Force recommends lung cancer screening for high-risk individuals because it reduces lung cancer mortality. Management of pulmonary nodules relies on statistical models to estimate malignancy risk by incorporating radio-graphic features and clinical history. The Fleischner Society provides guidelines for managing incidentally detected nodules, whereas the Lung CT Screening Reporting and Data System offers a framework for risk stratification and surveillance. Radiographic characteristics suggestive of malignancy include part-solid or ground-glass appearance, large nodule size, spiculated margins, vascular convergence, and pleural retraction. Risk factors such as smoking history, older age, chronic obstructive pulmonary disease, cancer history, and environmental or occupational expo-sure to toxins further increase the probability of malignancy. Management strategies are dependent on malignancy risk and may include serial imaging for low-risk nodules and invasive procedures such as biopsy or surgical resection for high-risk lesions. Referral to a specialist is warranted for nodules with a high likelihood of malignancy or if tissue diagnosis is required.