American family physician最新文献

Nail abnormalities occur in all age groups but are more prevalent in older adults. Nail disorders account for 10% of dermatologic disorders. Nail abnormalities can be categorized as surface texture irregularities, color changes, defects of nail plate attachment/nail shedding, tumors, or a combination of these. Brittle nails affect up to 20% of the population but are most prominent in older women and on fingernails. Different patterns of brittle nails can be seen in the same patient or can coexist in the same nail. Beau lines are transverse grooves caused by decreased keratinocyte activity in the proximal nail matrix. Nail pitting is due to abnormal keratinization in the proximal nail matrix. More than one-half of patients with psoriasis will have some nail involvement, and pitted nails are just one manifestation of nail psoriasis. Color changes may appear in the nail plate, nail bed, or nail matrix. In the nail unit, melanocytes are located only in the nail matrix. Brown-black nail changes are known as melanonychia and are caused by melanocyte activation or proliferation. Melanoma typically presents as longitudinal brown-black nail lines, but in approximately 30% of cases, it may present as a nail mass. Abnormal growth in the nail unit should raise concern for benign or malignant tumors, including the most common malignant tumor, squamous cell carcinoma. Nail clippings, ultrasonography, dermoscopy, and biopsy are useful for the diagnosis of nail abnormalities. Dermoscopy can assist in triaging lesions and differentiating those that can be safely observed from those that should be biopsied.

Slipped capital femoral epiphysis occurs in childhood and adolescence and is associated with potentially serious lifelong complications and sequelae. The incidence of slipped capital femoral epiphysis appears to be increasing as rates of childhood obesity increase. Patients may have a noted limp and present with poorly localized pain in the hip, groin, thigh, buttock, low back, or knee. Pain increases with activities that require hip flexion, such as squatting, prolonged sitting, and riding a bicycle. Inspection may reveal an antalgic walking pattern with a Trendelenburg gait and external rotation of the leg. Passive flexion of the hip may induce an obligatory external rotation and abduction (Drehmann sign), and internal rotation of the hip may be limited. Slipped capital femoral epiphysis is typically diagnosed from anteroposterior pelvis and frog-leg radiographs. Initial management focuses on decreasing complications and long-term sequelae by halting further slippage. To limit progression, patients should be immediately placed into non-weight-bearing status and urgently referred to an orthopedic surgeon for surgical fixation. Return to activity or sport depends on a gradual increase in activity that normally lasts approximately 6 months after surgery.

Venous thromboembolism (VTE) presents as deep venous thrombosis (DVT) or pulmonary embolism (PE). VTE is the third most common fatal cardiovascular condition in the United States. Clinical prediction rules such as the Wells' Criteria for DVT, Wells' Criteria for PE, and Pulmonary Embolism Rule-Out Criteria should be used to determine the pretest probability of DVT or PE. The D-dimer assay is used in low-risk patients to rule out DVT and in moderate-risk patients to rule out PE. Compression ultrasonography is the preferred imaging modality to diagnose DVT. PE typically is diagnosed with computed tomographic pulmonary angiography or with ventilation-perfusion scintigraphy if the patient has contraindications to computed tomographic pulmonary angiography. Preferred outpatient therapy for VTE is a direct-acting oral anticoagulant rather than a vitamin K antagonist or low-molecular-weight heparin. Most patients with acute uncomplicated DVT can be treated as outpatients. The Simplified PE Severity Index can guide treatment decisions for patients with PE. Apixaban or rivaroxaban can be used for initial management without the need to bridge with parenteral therapy. Treatment is recommended for 3 to 6 months after initial VTE. Patients with chronic risk factors, a recurrent VTE after primary treatment, or a first unprovoked VTE should be considered for secondary prevention with a direct-acting oral anticoagulant or warfarin after a bleeding-risk assessment.

Heart failure is a complex clinical syndrome in which impaired ventricular filling and ejection of blood into circulation causes decreased stroke volume and cardiac output. Heart failure with preserved ejection fraction (50% or more) is the most common type of heart failure, and up to 1 in 10 adults will be affected in their lifetime. Clinical symptoms such as peripheral edema, dyspnea, and orthopnea, with clinical findings including jugular venous distention, third heart sound, and laterally displaced apical impulse should prompt consideration of heart failure. Laboratory values (eg, elevated N-terminal fragment of the prohormone brain natriuretic peptide) can also aid in diagnosis, which can then be confirmed with specific echocardiographic findings. Once heart failure with preserved ejection fraction is diagnosed, medications should be initiated to manage comorbid symptoms and conditions such as hypertension, obesity, and obstructive sleep apnea. Sodium-glucose cotransporter-2 inhibitors have been shown to reduce hospitalizations related to heart failure and cardiovascular-related mortality in patients with symptomatic heart failure, elevated natriuretic peptide levels, and an ejection fraction more than 40%; therefore, they should be considered in all patients with heart failure with preserved ejection fraction. Additionally, loop diuretics, mineralocorticoid receptor antagonists, and angiotensin receptor blocker/neprilysin inhibitors can be used. In patients with end-organ dysfunction or signs of refractory treatment, consultation with a heart failure specialist should be considered.

Uterine fibroids are the most common benign tumor in women. Most fibroids are asymptomatic, but presenting symptoms include those associated with increased uterine size (eg, abdominal distension, urinary frequency or urgency, constipation), abnormal uterine bleeding, pelvic pain, and infertility. The initial evaluation of fibroids should include a full gynecologic history with abdominal, speculum, and bimanual pelvic examinations. Initial imaging of choice is the combination of transvaginal and transabdominal ultrasonography. Pelvic magnetic resonance imaging with contrast may further characterize the extent of disease and guide treatment. Treatment choices are determined by fibroid size and location with preferences for uterine and fertility preservation. Pharmacotherapy is used to control heavy or abnormal uterine bleeding and includes combined and progestin-only oral contraceptives; 52-mg levonorgestrel-releasing intrauterine devices; nonsteroidal anti-inflammatory drugs; tranexamic acid; and hormonal therapies, such as gonadotropin-releasing hormone antagonists and gonadotropin-releasing hormone agonists. Surgical and interventional options reduce bulk symptoms, reduce bleeding, and may preserve or improve fertility. Surgical and interventional radiologic options include hysterectomy, myomectomy, uterine artery embolization, radiofrequency ablation, and high-intensity focused ultrasonography. Treating vitamin D deficiency may reduce fibroid tumor size or halt progression.