American family physician最新文献

Cancer screening guidelines for older adults are increasingly recommending individualized decision-making rather than relying on age cutoffs. This is in large part due to the individual complexity of aging, such as functional differences, risks of diagnostic procedures, remaining life expectancy, perceived quality of life, and goals of care. The US Preventive Services Task Force (USPSTF) recommends screening for breast cancer until 74 years of age, whereas the American Cancer Society suggests screening as long as the patient is in good health or has a life expectancy of at least 10 years. The USPSTF recommends that men 55 to 69 years of age discuss the potential benefits and harms of prostate-specific antigen screening with their doctor before making an individual decision; for men 70 years and older, the USPSTF and the American Urological Association do not recommend routine screening. Most guidelines recommend that cervical cancer screening should stop at 65 years of age in patients who have adequate prior screening results and do not have high risk. The USPSTF and the American Cancer Society recommend routine colorectal cancer screening until 75 years of age, after which individualized screening can occur based on shared decision-making until 85 years of age. Guidelines recommend lung cancer screening for patients who are 50 to 80 years of age, have at least a 20-pack-year smoking history, and are able and willing to have curative surgery.

Heel pain accounts for 2 million office visits annually and is associated with higher body mass index, manual jobs, and a sedentary lifestyle. Retrocalcaneal bursitis is more common in women 40 to 60 years of age with Haglund deformity and a thickened Achilles tendon. Calcaneal apophysitis (Sever disease) is the most common cause of heel pain in active children and adolescents; in the outpatient setting, it accounts for up to 16% of musculoskeletal conditions in children. In os trigonum syndrome, athletes such as soccer players, gymnasts, and dancers who are engaged in repetitive plantar flexion commonly present with worsening posterior ankle pain and an antalgic gait. Risk factors for peroneal tendon injuries include corticosteroid injections into the peroneal sheath, use of fluoroquinolones, rheumatoid arthritis, hyperparathyroidism, and diabetes. Magnetic resonance imaging is the most accurate test for the diagnosis of most causes of heel pain, but ultrasonography is being used more often as it becomes more readily available at the point of care. Most patients with heel pain improve with conservative treatment, and surgical management should be reserved for recalcitrant cases. Pain catastrophizing and kinesiophobia are associated with diminished foot function and poorer prognosis.

Vaginitis is a general term for inflammation of the vagina with symptoms such as vulvovaginal itching, burning, irritation, dyspareunia, odor, or abnormal vaginal discharge. It is a common condition that results in 5 million to 10 million office visits annually. The leading infectious causes of vaginitis are bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis. Noninfectious causes include atrophic, irritant, and inflammatory vaginitis. Bacterial vaginosis usually presents with a thin, homogenous vaginal discharge and a fishy odor. Vulvovaginal candidiasis often manifests with a white, thick, curd-like discharge, pruritus, and vulvar erythema. Trichomoniasis usually presents with a green or yellow frothy discharge, and speculum examination may reveal cervical erythema with petechiae. Noninfectious vaginitis can present with clear or purulent discharge and can be pruritic depending on the etiology. Bacterial vaginosis can be diagnosed using Amsel criteria, Gram stain, or a nucleic acid amplification test (NAAT). Vulvovaginal candidiasis can be diagnosed by visualization of yeast hyphae or budding yeast on microscopy, vaginal fungal culture, polymerase chain reaction testing, or NAAT. Trichomoniasis can be diagnosed with visualization of motile, flagellated protozoa on saline microscopy, NAAT, or DNA probe test. Bacterial vaginosis is treated with oral or intravaginal metronidazole or intravaginal clindamycin. Vulvovaginal candidiasis is managed with topical or oral antifungals. Trichomoniasis is treated with oral metronidazole or tinidazole. When treating trichomoniasis, testing for reinfection, as well as other sexually transmitted infections, is recommended. Treatments for noninfectious vaginitis include vaginal lubricants and moisturizers, topical hormones, and topical steroids, depending on the cause.