American family physician最新文献

Jaundice is an indication of hyperbilirubinemia and is caused by derangements in bilirubin metabolism. It is typically apparent when serum bilirubin levels exceed 3 mg/dL and can indicate serious underlying disease of the liver or biliary tract. A comprehensive medical history, review of systems, and physical examination are essential for differentiating potential causes such as alcoholic liver disease, biliary strictures, choledocholithiasis, drug-induced liver injury, hemolysis, or hepatitis. Initial laboratory evaluation should include assays for bilirubin (total and fractionated), a complete blood cell count, aspartate transaminase, alanine transaminase, gamma-glutamyltransferase, alkaline phosphatase, albumin, prothrombin time, and international normalized ratio. Measuring fractionated bilirubin allows for determination of whether the hyperbilirubinemia is conjugated or unconjugated. Ultrasonography of the abdomen, computed tomography with intravenous contrast media, and magnetic resonance cholangiopancreatography are first-line options for patients presenting with jaundice, depending on the suspected underlying etiology. If the etiology of jaundice is unclear despite laboratory testing and imaging, liver biopsy may be required to establish the diagnosis, prognosis, and management of the disease.

Gastroesophageal reflux is a common physiologic event in infants in which gastric contents pass from the stomach into the esophagus. Gastroesophageal reflux may be asymptomatic or cause regurgitation or "spit up." This occurs daily in approximately 40% of infants. Symptoms often begin before 8 weeks of life, peak at approximately 4 months of age, and usually resolve by 1 year. The prevalence of gastroesophageal reflux is 2% to 8% in children and adolescents. Family physicians should reassure parents that gastroesophageal reflux is self-limited, not pathologic, and does not warrant routine testing or pharmacologic treatment. Gastroesophageal reflux may progress to gastroesophageal reflux disease when the reflux leads to troublesome symptoms (eg, recurrent postprandial expressions of distress or pain, coughing, choking) or causes complications, such as esophageal stricture or reflux esophagitis. Diagnostic tests, such as endoscopy, barium study, multichannel intraluminal impedance, and pH monitoring, may be used when there is diagnostic uncertainty or alarm symptoms are present (eg, bilious or projectile vomiting, hematemesis). Conservative treatments for gastroesophageal reflux disease in infants include the use of thickening agents or extensively hydrolyzed or amino acid-based formulas in formula-fed infants or maternal elimination of dairy for infants who are fed breast milk. Infants and children who do not improve with conservative measures may require pharmacologic treatment, including an empiric trial of acid-suppression therapy for 4 to 8 weeks.

Dysuria, a feeling of pain or discomfort during urination, is often caused by urinary tract infection but can also be due to sexually transmitted infection, bladder irritants, skin lesions, and some chronic pain conditions. History is most often useful for finding signs of sexually transmitted infection, complicated infections, lower urinary symptoms in males, and noninfectious causes. Most patients presenting with dysuria should have a urinalysis performed. Urine culture should be performed for infection to guide appropriate antibiotic use, especially for recurrent or suspected complicated urinary tract infection. Vaginal discharge decreases the likelihood of urinary tract infection, and other causes of dysuria, including cervicitis, should be investigated. If a patient has persistent urethritis or cervicitis with negative initial testing, Mycoplasma genitalium testing is recommended. Clinical decision rules may increase the accuracy of diagnosis with and without laboratory analysis. Evaluation and treatment of dysuria through a virtual encounter without laboratory testing may increase recurrent symptoms and antibiotic courses. Persistent symptoms after initial evaluation and treatment require further workup for infectious and noninfectious causes.