FP essentials最新文献

Acute stress disorder and posttraumatic stress disorder (PTSD) are debilitating psychiatric conditions that may occur following traumatic events or severe stressors. Generally, these two conditions have similar diagnostic criteria, with acute stress disorder marked by symptoms for less than 1 month and PTSD with symptoms lasting 1 month or more. The exact mechanism by which PTSD develops in the brain is not known. Groups at risk for developing PTSD include women, people with low socioeconomic status, previously married people, and people younger than 65 years. Symptoms must include exposure to a stressor, intrusive thoughts or perceptions, avoidance, negative cognitions or emotions, and marked arousal and reactivity. Early treatment of acute stress disorder may prevent progression to PTSD. Treatment is primarily trauma-based psychotherapy, although medications may be used for symptom management and treating comorbid psychiatric conditions such as depression or panic attacks. Patients with PTSD should not be treated with benzodiazepines due to worsening morbidity. Treatment of PTSD limits the course of the condition and reduces comorbidities.

Acute psychosis is characterized by symptoms such as hallucinations and delusions, although catatonia and disorganized thought may also be present. Distinguishing an underlying cause from a primary disorder is a focus of initial evaluation. Secondary causes of psychosis include some mood disorders such as major depressive disorder, exposure to certain substances, and many medical conditions. Legal medications and illicit substances can cause hallucinations and delusions. Medical conditions include central nervous system infection or primary neurologic causes such as dementia or traumatic brain injury. When found, secondary causes should be treated. Psychosis associated with substance use, such as cannabis or methamphetamine, will usually resolve within 30 days of abstinence from the substance. Primary psychosis is typically treated with a second-generation antipsychotic medication, and the specific choice of medication depends on the patient's symptoms, desired outcomes, and adverse effect profile of the medication. Antipsychotic medications should be used with caution in older adults and patients with dementia-related psychosis due to the associated risk of mortality. Clozapine is an effective antipsychotic medication with severe adverse effects that requires close monitoring.

Personality disorders describe enduring, pervasive, pathologic patterns of behavior and inner experiences that deviate from a patient's culture. Personality disorders are divided into three clusters depending on core features. Diagnosis of a personality disorder is generally made based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, although other diagnostic modalities exist. The most common disorders in primary care settings include obsessive-compulsive personality, narcissistic personality, and borderline personality disorders. Obsessive-compulsive personality disorder is associated with pathologic perfectionism and intense rigidity. Treatment is primarily psychotherapy, although there is some evidence for using selective serotonin reuptake inhibitors. Narcissistic personality disorder is marked by grandiosity, need for admiration, and a lack of empathy. Psychotherapy is the primary treatment. Borderline personality disorder is associated with instability and intense reactivity, and the primary treatment is typically psychotherapy. Dialectical behavior therapy was developed specifically for borderline personality disorder, although evidence suggests other behavior therapies may be as beneficial.

Attention-deficit/hyperactivity disorder (ADHD) is characterized by the inability to regulate attention and/or symptoms of hyperactivity that interfere with some level of daily functioning. Although this disorder is well-recognized in children, it is less frequently diagnosed and treated in adults. The pathogenesis of ADHD is not well understood, but norepinephrine and dopamine appear to play roles in the disorder because they modulate the area of the brain involved in attention and behavior regulation. ADHD has a high comorbidity rate, particularly with substance use disorder. Screening for ADHD can be performed in the primary care setting with tools such as the Adult ADHD Self-Report Scale. Diagnosis should be made based on the Diagnostic and Statistical Manual of Mental Disorders criteria, which lists symptoms of inattention and hyperactivity-impulsivity separately. For adults, diagnosis requires patients to have at least five of the symptoms in either category for more than 6 months. Symptoms must have been present before age 12 and must have occurred in at least two independent settings. Treatment is generally a combination of cognitive behavior therapy and stimulant medications, usually amphetamines, although exceptions exist based on comorbid conditions.

Adolescents Well-child visits in adolescence (ages 13-17 years) are intended to assess growth and development, promote emotional well-being, and counsel patients and their families on safe behaviors at a time when youth are increasingly making independent choices that affect their health. All adolescents should be offered time alone with their physician for discussion of confidential health concerns, including but not limited to sexual health, mental health, substance use, and peer relationships. Minor consent laws vary by state. Adolescents who are sexually active should be provided with behavioral counseling on sexually transmitted infection prevention as well as offered screening for sexually transmitted infections. Sexually active adolescents who could become pregnant should be counseled on the range of contraceptive options, including long-acting reversible contraception. Vaccines should be offered and completed on time. Adolescents should be screened for depression and anxiety and offered treatment, including cognitive behavior therapy and pharmacotherapy. Adolescents should be counseled on getting 1 hour/day of physical activity and 8 to 12 hours/night of sleep, and setting goals for healthy media use, including having media-free times and spaces, including the bedroom.

Well-child care for newborns and infants (birth to 12 months) allows clinicians to identify any abnormalities in growth and development, administer vaccinations, and provide anticipatory guidance. History should focus on feeding, stooling, and sleeping. Trends in infant growth over time should be observed. Infants require a comprehensive physical examination to assess for normal development. Caregivers should be counseled on vaccination practices and their importance for disease prevention with adherence to standard schedules. Vaccine hesitancy should be addressed. Clinicians should review or perform routine newborn screenings for critical congenital heart disease, genetic conditions, hearing, hyperbilirubinemia, and neonatal opioid withdrawal syndrome. The birthing person should be screened for perinatal mood disorders through the infant's first 6 months of life. Families should be screened for social determinants of health and offered community resources to help with identified areas of need. Caregivers should be educated on infant nutrition, including breastfeeding and introduction of solid foods. Many infants may benefit from vitamin D and iron supplementation. Safety should be discussed with caregivers, including rear-facing car seats, water safety, and avoiding infant walkers. Caregivers should be counseled on normal infant sleep patterns and safe sleep.

The goals of the well-child visit for school-aged children (ages 6-12 years) are health promotion, disease prevention, disease detection, and anticipatory guidance. Critical components include the physical examination and developmental surveillance. Vaccines remain a cornerstone of disease prevention and should be administered on time. Screening for dental care, dyslipidemia, hearing, hypertension, mental health, overweight and obesity, scoliosis, social determinants of health, and vision should be considered or performed, and is often dictated by risk factors. Healthy lifestyle should be discussed at every well-child visit, including recommending 60 minutes/day of physical activity, adequate nutritional intake, 9 to 12 hours/night of sleep without disturbance, and routine dental care, including fluoride supplementation if not in the primary water supply. Social history should be reviewed, including media use and substance use and exposure. Children and families should be counseled on safety, including the leading cause of death in this age group: unintentional injury.

The well-child examination is a crucial time for health promotion and disease prevention in toddlers and preschool-aged children (ages 1-5 years). Critical components are the physical examination and developmental screening because they provide the opportunity to intervene on developmental delays. Children should be assessed for healthy growth; obesity or growth faltering should be addressed with a stepwise and interdisciplinary approach. Vaccinations are critical for disease prevention and should be administered on time. Screening for anemia, autism spectrum disorder, dental health, hypertension, lead, tuberculosis, and vision should be considered or performed, often dictated by the risk factors of the child. Physicians should provide counseling on behavioral concerns, such as temper tantrums or breath-holding spells, with guidance on planned-ignoring, time-ins or time-outs, and referrals where indicated. Physicians should provide counseling on minimizing screen time and injury prevention. Reassurance and injury prevention strategies should be provided for common sleep disorders, such as night terrors and sleepwalking. Physicians should provide counseling on bathroom training and common issues such as constipation and enuresis. Constipation should be managed via bowel disimpaction and maintenance regimens after excluding red flag features, such as weight loss, hematochezia, bilious vomiting, or inconsolable abdominal pain. First-line therapy for enuresis includes bed alarms and desmopressin.