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1.
Am Fam Physician ; 103(2): 97-106, 2021 01 15.
Artigo em Inglês | MEDLINE | ID: mdl-33448766

RESUMO

Dysphagia is common but may be underreported. Specific symptoms, rather than their perceived location, should guide the initial evaluation and imaging. Obstructive symptoms that seem to originate in the throat or neck may actually be caused by distal esophageal lesions. Oropharyngeal dysphagia manifests as difficulty initiating swallowing, coughing, choking, or aspiration, and it is most commonly caused by chronic neurologic conditions such as stroke, Parkinson disease, or dementia. Symptoms should be thoroughly evaluated because of the risk of aspiration. Patients with esophageal dysphagia may report a sensation of food getting stuck after swallowing. This condition is most commonly caused by gastroesophageal reflux disease and functional esophageal disorders. Eosinophilic esophagitis is triggered by food allergens and is increasingly prevalent; esophageal biopsies should be performed to make the diagnosis. Esophageal motility disorders such as achalasia are relatively rare and may be overdiagnosed. Opioid-induced esophageal dysfunction is becoming more common. Esophagogastroduodenoscopy is recommended for the initial evaluation of esophageal dysphagia, with barium esophagography as an adjunct. Esophageal cancer and other serious conditions have a low prevalence, and testing in low-risk patients may be deferred while a four-week trial of acid-suppressing therapy is undertaken. Many frail older adults with progressive neurologic disease have significant but unrecognized dysphagia, which significantly increases their risk of aspiration pneumonia and malnourishment. In these patients, the diagnosis of dysphagia should prompt a discussion about goals of care before potentially harmful interventions are considered. Speech-language pathologists and other specialists, in collaboration with family physicians, can provide structured assessments and make appropriate recommendations for safe swallowing, palliative care, or rehabilitation.


Assuntos
Transtornos de Deglutição/etiologia , Deglutição/fisiologia , Medicina de Família e Comunidade/métodos , Transtornos de Deglutição/diagnóstico , Transtornos de Deglutição/terapia , Esôfago/patologia , Feminino , Humanos , Masculino , Faringe/anatomia & histologia , Exame Físico/métodos
2.
Am Fam Physician ; 103(2): 81-89, 2021 01 15.
Artigo em Inglês | MEDLINE | ID: mdl-33448767

RESUMO

Adults commonly present to their family physicians with hip pain, and diagnosing the cause is important for prescribing effective therapy. Hip pain is usually located anteriorly, laterally, or posteriorly. Anterior hip pain includes referred pain from intra-abdominal or intrapelvic causes; extra-articular etiologies, such as hip flexor injuries; and intra-articular etiologies. Intra-articular pain is often caused by a labral tear or femoroacetabular impingement in younger adults or osteoarthritis in older adults. Lateral hip pain is most commonly caused by greater trochanteric pain syndrome, which includes gluteus medius tendinopathy or tear, bursitis, and iliotibial band friction. Posterior hip pain includes referred pain such as lumbar spinal pathology, deep gluteal syndrome with sciatic nerve entrapment, ischiofemoral impingement, and hamstring tendinopathy. In addition to the history and physical examination, radiography, ultrasonography, or magnetic resonance imaging may be needed for a definitive diagnosis. Radiography of the hip and pelvis should be the initial imaging test. Ultrasound-guided anesthetic injections can aid in the diagnosis of an intra-articular cause of pain. Because femoroacetabular impingement, labral tears, and gluteus medius tendon tears typically have good surgical outcomes, advanced imaging and/or early referral may improve patient outcomes.


Assuntos
Lesões do Quadril/diagnóstico , Doenças Musculoesqueléticas/diagnóstico , Dor/etiologia , Adulto , Nádegas , Diagnóstico Diferencial , Medicina de Família e Comunidade/métodos , Feminino , Quadril , Articulação do Quadril , Humanos , Masculino , Dor/diagnóstico
6.
Eur J Gen Pract ; 26(1): 182-188, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33337939

RESUMO

COVID-19 outbreak has significantly changed all aspects of general practice in Europe. This article focuses on the academic challenges for the discipline, mainly in the field of education, research, and quality assurance. The efforts of the European Region of the World Organisation of National Colleges, Academies, and Academic Associations of General Practitioners/Family Physicians (WONCA Europe) to support academic sustainability of the discipline in the time of pandemic are presented. Medical education was affected by the pandemic, threatening both its productivity and quality. Emerging new educational methods might be promising, but the results of their rapid implementation remain uncertain. A relatively small number of publications related to COVID-19 and general practice is available in the medical literature. There is a shortage of original data from general practice settings. This contrasts with the crucial role of GPs in fighting a pandemic. COVID-19 outbreak has opened widely new research areas, which should be explored by GPs. Maintaining the quality of care and safety of all patients during the COVID-19 pandemic is the utmost priority. Many of them suffer from poor access or inadequate management of their problems. Rapid implementation of telemedicine brought both threats and opportunities. The COVID-19 pandemic also challenged doctors' safety and well-being. These aspects will require discussion and remedy to prevent deterioration of the quality of primary care. WONCA Europe is making a multi-faceted effort to support GPs in difficult times of the pandemic. It is ready to support future efforts to uphold the integrity of family medicine as an academic discipline.


Assuntos
Pesquisa Biomédica , Educação Médica , Medicina de Família e Comunidade/métodos , Educação a Distância , Europa (Continente) , Medicina de Família e Comunidade/educação , Medicina de Família e Comunidade/normas , Medicina Geral/educação , Medicina Geral/métodos , Medicina Geral/normas , Humanos , Qualidade da Assistência à Saúde , Telemedicina
7.
Am Fam Physician ; 102(12): 740-750, 2020 12 15.
Artigo em Inglês | MEDLINE | ID: mdl-33320508

RESUMO

Degenerative cervical myelopathy encompasses a collection of pathologic conditions that result in progressive spinal cord dysfunction secondary to cord compression. Patients are typically male (3: 1 male-to-female ratio), and the average age of presentation is 64 years. The exact incidence is unclear because of differences in terminology and because radiographic findings can be present in asymptomatic individuals. Common examination findings include neck pain or stiffness, a wide-based ataxic gait, ascending paresthesia in the upper or lower extremities, lower extremity weakness, decreased hand dexterity, hyperreflexia, clonus, Babinski sign, and bowel or bladder dysfunction in severe disease. Definitive diagnosis requires correlation of physical examination findings with imaging findings. Magnetic resonance imaging of the cervical spine with and without contrast media is the preferred imaging modality. Cervical spine computed tomography, computed tomography myelography, and plain radiography are helpful in certain situations. Treatment depends on the presence and severity of symptoms. Surgery is recommended for patients with moderate to severe symptoms or rapidly progressive disease. Conservative treatments with monitoring for progression may be considered in patients with mild to moderate disease. The evidence for the effectiveness of conservative treatments is scarce and of low quality, and outcomes can vary with individual patients. Primary care physicians play a vital role in recognizing the typical presentation of degenerative cervical myelopathy, coordinating treatment as indicated, and managing comorbidities.


Assuntos
Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/patologia , Medicina de Família e Comunidade/métodos , Compressão da Medula Espinal/diagnóstico , Doenças da Medula Espinal/diagnóstico , Espondilose/diagnóstico , Diagnóstico Diferencial , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Cervicalgia/etiologia , Compressão da Medula Espinal/diagnóstico por imagem , Doenças da Medula Espinal/diagnóstico por imagem , Espondilose/diagnóstico por imagem
9.
Am Fam Physician ; 102(12): 732-739, 2020 12 15.
Artigo em Inglês | MEDLINE | ID: mdl-33320513

RESUMO

Peripheral neuropathy, a common neurologic problem encountered by family physicians, can be classified clinically by the anatomic pattern of presenting symptoms and, if indicated, by results of electrodiagnostic studies for axonal and demyelinating disease. The prevalence of peripheral neuropathy in the general population ranges from 1% to 7%, with higher rates among those older than 50 years. Common identifiable causes include diabetes mellitus, nerve compression or injury, alcohol use, toxin exposure, hereditary diseases, and nutritional deficiencies. Peripheral neuropathy is idiopathic in 25% to 46% of cases. Diagnosis requires a comprehensive history, physical examination, and judicious laboratory testing. Early peripheral neuropathy may present as sensory alterations that are often progressive, including sensory loss, numbness, pain, or burning sensations in a "stocking and glove" distribution of the extremities. Later stages may involve proximal numbness, distal weakness, or atrophy. Physical examination should include a comprehensive neurologic and musculoskeletal evaluation. If the peripheral nervous system is identified as the likely source of the patient's symptoms, evaluation for potential underlying etiologies should initially focus on treatable causes. Initial laboratory evaluation includes a complete blood count; a comprehensive metabolic profile; fasting blood glucose, vitamin B12, and thyroid-stimulating hormone levels; and serum protein electrophoresis with immunofixation. If the initial evaluation is inconclusive, referral to a neurologist for additional testing (e.g., electrodiagnostic studies, specific antibody assays, nerve biopsy) should be considered. Treatment of peripheral neuropathy focuses on managing the underlying etiology. Several classes of medications, including gabapentinoids and antidepressants, can help alleviate neuropathic pain.


Assuntos
Medicina de Família e Comunidade/métodos , Anamnese/métodos , Doenças do Sistema Nervoso Periférico/diagnóstico , Exame Físico/métodos , Neuropatias Diabéticas/diagnóstico , Diagnóstico Diferencial , Humanos , Doenças do Sistema Nervoso Periférico/prevenção & controle
11.
Semergen ; 46(7): 479-486, 2020 Oct.
Artigo em Espanhol | MEDLINE | ID: mdl-33046353

RESUMO

The new coronavirus (SARS-CoV-2) is responsible for a severe acute respiratory syndrome. Among its manifestations, it can develop a thrombotic disease, both venous and arterial, due to excessive inflammation that affects the vascular system, with platelet activation and endothelial dysfunction, among other mechanisms. Thrombosis is associated with SARS-CoV-2 infection, increasing its severity and conferring a worse prognosis. Our performance as Family Physicians can contribute important actions in the management and control of this severe complication. Considering that many of our patients already receive antithrombotic or anticoagulant therapy, the fact that they may develop a COVID-19 infection will have implications for the choice, dosage and control of their treatment. In this document we review, with the information currently available, the relationship between disease caused by SARS-CoV-2 and thrombosis, as well as its management with a focus on Primary Care.


Assuntos
Anticoagulantes/administração & dosagem , Infecções por Coronavirus/complicações , Infecções por Coronavirus/terapia , Medicina de Família e Comunidade/métodos , Pneumonia Viral/complicações , Pneumonia Viral/terapia , Atenção Primária à Saúde/métodos , Trombose/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Anticoagulantes/uso terapêutico , Betacoronavirus , Infecções por Coronavirus/diagnóstico , Humanos , Pandemias , Pneumonia Viral/diagnóstico , Medição de Risco , Trombose/virologia , Tromboembolia Venosa/virologia
15.
Rev Med Suisse ; 16(694): 1022-1025, 2020 May 20.
Artigo em Francês | MEDLINE | ID: mdl-32432418

RESUMO

New technologic devices are presented: insulin pumps and continuous glucose monitoring (CGM) devices as well as morphine pumps to help general practitioners to deal different intensive situations. Insulin pumps and CGM devices are revolutionary for the management of diabetes. However, their use requires strong patient involvement, the opposite of automated diabetes management. Morphine pumps are a great help when patients in end-of-life stage cannot swallow oral morphine anymore. This article summarizes the main principles of use of these technological devices, common problems and situations at risk primary care practice.


Assuntos
Automonitorização da Glicemia/métodos , Glicemia/análise , Medicina de Família e Comunidade/métodos , Morfina/administração & dosagem , Glicemia/metabolismo , Automonitorização da Glicemia/instrumentação , Diabetes Mellitus/metabolismo , Diabetes Mellitus/terapia , Humanos , Morfina/uso terapêutico
16.
Rev Med Suisse ; 16(694): 1039-1043, 2020 May 20.
Artigo em Francês | MEDLINE | ID: mdl-32432421

RESUMO

Interprofessional collaboration (IPC) in primary care is widely encouraged, however, while medical students have a favourable attitude towards IPC, this attitude is less favourable when they reach the post-graduate level. A review of the literature on the characteristics of interprofessional primary care teams shows that while the positive effects of IPC are relatively clear on the care processes, they are much less clear with respect to patient health outcomes. A third paper studies the annual rate of family medicine visits and shows no association with mortality or hospital admissions rates. A final article, from China, looks at the idea of changing patients' perceptions of expected waiting times in order to improve their satisfaction with the health care system. The results could be extrapolated to our Western systems!


Assuntos
Medicina de Família e Comunidade , Assistência ao Paciente , Atenção Primária à Saúde , Medicina de Família e Comunidade/métodos , Medicina de Família e Comunidade/organização & administração , Medicina de Família e Comunidade/normas , Humanos , Internacionalidade , Assistência ao Paciente/métodos , Assistência ao Paciente/normas , Atenção Primária à Saúde/métodos , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/normas
17.
Am Fam Physician ; 101(7): 399-406, 2020 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-32227823

RESUMO

Cryosurgery is the application of freezing temperatures to achieve the destruction of tissue. Cutaneous cryosurgery has become a commonly performed outpatient procedure because of the combination of its safety, effectiveness, low cost, ease of use, lack of need for injectable anesthetic, and good cosmetic results. Cryosurgery may be performed in the outpatient setting using dipstick, spray, or cryoprobe techniques to treat a variety of benign, premalignant, and malignant skin lesions with high cure rates. Benign lesions such as common and plantar warts, anogenital condylomas, molluscum contagiosum, and seborrheic keratoses can be treated with cryotherapy. Basal and squamous cell carcinomas with low-risk features may be treated with cryosurgery. Contraindications to cryosurgery include neoplasms with indefinite margins or when pathology is desired, basal cell or squamous cell carcinomas with high-risk features, and prior adverse local reaction or hypersensitivity to cryosurgery. Potential adverse effects include bleeding, blistering, edema, paresthesia, and pain and less commonly include tendon rupture, scarring, alopecia, atrophy, and hypopigmentation.


Assuntos
Criocirurgia/métodos , Medicina de Família e Comunidade/métodos , Dermatopatias/cirurgia , Criocirurgia/efeitos adversos , Crioterapia/métodos , Humanos , Ceratose Seborreica/cirurgia , Molusco Contagioso/cirurgia , Verrugas/cirurgia
18.
Am Fam Physician ; 101(7): 419-428, 2020 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-32227826

RESUMO

Most frequent headaches are typically migraine or tension-type headaches and are often exacerbated by medication overuse. Repeated headaches can induce central sensitization and transformation to chronic headaches that are intractable, are difficult to treat, and cause significant morbidity and costs. A complete history is essential to identify the most likely headache type, indications of serious secondary headaches, and significant comorbidities. A headache diary can document headache frequency, symptoms, initiating and exacerbating conditions, and treatment response over time. Neurologic assessment and physical examination focused on the head and neck are indicated in all patients. Although rare, serious underlying conditions must be excluded by the patient history, screening tools such as SNNOOP10, neurologic and physical examinations, and targeted imaging and other assessments. Medication overuse headache should be suspected in patients with frequent headaches. Medication history should include nonprescription analgesics and substances, including opiates, that may be obtained from others. Patients who overuse opiates, barbiturates, or benzodiazepines require slow tapering and possibly inpatient treatment to prevent acute withdrawal. Patients who overuse other agents can usually withdraw more quickly. Evidence is mixed on the role of medications such as topiramate for patients with medication overuse headache. For the underlying headache, an individualized evidence-based management plan incorporating pharmacologic and nonpharmacologic strategies is necessary. Patients with frequent migraine, tension-type, and cluster headaches should be offered prophylactic therapy. A complete management plan includes addressing risk factors, headache triggers, and common comorbid conditions such as depression, anxiety, substance abuse, and chronic musculoskeletal pain syndromes that can impair treatment effectiveness. Regular scheduled follow-up is important to monitor progress.


Assuntos
Analgésicos/uso terapêutico , Medicina de Família e Comunidade/métodos , Transtornos da Cefaleia/diagnóstico , Transtornos da Cefaleia/terapia , Ansiedade/complicações , Depressão/complicações , Fibromialgia/complicações , Transtornos da Cefaleia/tratamento farmacológico , Humanos , Transtornos de Enxaqueca/diagnóstico , Transtornos de Enxaqueca/terapia , Dor Musculoesquelética/complicações , Exame Neurológico , Transtornos Relacionados ao Uso de Substâncias/complicações
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