Journal: American family physician
Acute pancreatitis is most commonly caused by gallstones or chronic alcohol use, and accounts for more than 200,000 hospital admissions annually. Using the Atlanta criteria, acute pancreatitis is diagnosed when a patient presents with two of three findings, including abdominal pain suggestive of pancreatitis, serum amylase and/or lipase levels at least three times the normal level, and characteristic findings on imaging. It is important to distinguish mild from severe disease because severe pancreatitis has a mortality rate of up to 30%. Contrast-enhanced computed tomography is considered the diagnostic standard for radiologic evaluation of acute pancreatitis because of its success in predicting disease severity and prognosis. The BALI and computed tomography severity index scores also can aid in determining disease severity and predicting the likelihood of complications. Treatment begins with pain control, hydration, and bowel rest. In the first 48 to 72 hours of treatment, monitoring is required to prevent morbidity and mortality associated with worsening pancreatitis. When prolonged bowel rest is indicated, enteral nutrition is associated with lower rates of complications, including death, multiorgan failure, local complications, and systemic infections, than parenteral nutrition. In severe cases involving greater than 30% necrosis, antibiotic prophylaxis with imipenem/cilastatin decreases the risk of pancreatic infection. In gallstone-associated pancreatitis, early cholecystectomy and endoscopic retrograde cholangiopancreatography with sphincterotomy can decrease length of hospital stay and complication rates. A multidisciplinary approach to care is essential in cases involving pancreatic necrosis.
Bell palsy is an acute affliction of the facial nerve, resulting in sudden paralysis or weakness of the muscles on one side of the face. Testing patients with unilateral facial paralysis for diabetes mellitus or Lyme disease is not routinely recommended. Patients with Lyme disease typically present with additional manifestations, such as arthritis, rash, or facial swelling. Diabetes may be a comorbidity of Bell palsy, but testing is not needed in the absence of other indications, such as hypertension. In patients with atypical symptoms, magnetic resonance imaging with contrast enhancement can be used to rule out cranial mass effect and to add prognostic value. Steroids improve resolution of symptoms in patients with Bell palsy and remain the preferred treatment. Antiviral agents have a limited role, and may improve outcomes when combined with steroids in patients with severe symptoms. When facial paralysis is prolonged, surgery may be indicated to prevent ocular desiccation secondary to incomplete eyelid closure. Facial nerve decompression is rarely indicated or performed. Physical therapy modalities, including electrostimulation, exercise, and massage, are neither beneficial nor harmful.
Lacerations, abrasions, burns, and puncture wounds are common in the outpatient setting. Because wounds can quickly become infected, the most important aspect of treating a minor wound is irrigation and cleaning. There is no evidence that antiseptic irrigation is superior to sterile saline or tap water. Occlusion of the wound is key to preventing contamination. Suturing, if required, can be completed up to 24 hours after the trauma occurs, depending on the wound site. Tissue adhesives are equally effective for low-tension wounds with linear edges that can be evenly approximated. Although patients are often instructed to keep their wounds covered and dry after suturing, they can get wet within the first 24 to 48 hours without increasing the risk of infection. There is no evidence that prophylactic antibiotics improve outcomes for most simple wounds. Tetanus toxoid should be administered as soon as possible to patients who have not received a booster in the past 10 years. Superficial mild wound infections can be treated with topical agents, whereas deeper mild and moderate infections should be treated with oral antibiotics. Most severe infections, and moderate infections in high-risk patients, require initial parenteral antibiotics. Severe burns and wounds that cover large areas of the body or involve the face, joints, bone, tendons, or nerves should generally be referred to wound care specialists.
Tinea infections are caused by dermatophytes and are classified by the involved site. The most common infections in prepubertal children are tinea corporis and tinea capitis, whereas adolescents and adults are more likely to develop tinea cruris, tinea pedis, and tinea unguium (onychomycosis). The clinical diagnosis can be unreliable because tinea infections have many mimics, which can manifest identical lesions. For example, tinea corporis can be confused with eczema, tinea capitis can be confused with alopecia areata, and onychomycosis can be confused with dystrophic toenails from repeated low-level trauma. Physicians should confirm suspected onychomycosis and tinea capitis with a potassium hydroxide preparation or culture. Tinea corporis, tinea cruris, and tinea pedis generally respond to inexpensive topical agents such as terbinafine cream or butenafine cream, but oral antifungal agents may be indicated for extensive disease, failed topical treatment, immunocompromised patients, or severe moccasin-type tinea pedis. Oral terbinafine is first-line therapy for tinea capitis and onychomycosis because of its tolerability, high cure rate, and low cost. However, kerion should be treated with griseofulvin unless Trichophyton has been documented as the pathogen. Failure to treat kerion promptly can lead to scarring and permanent hair loss.
Low back pain is usually nonspecific or mechanical. Mechanical low back pain arises intrinsically from the spine, intervertebral disks, or surrounding soft tissues. Clinical clues, or red flags, may help identify cases of nonmechanical low back pain and prompt further evaluation or imaging. Red flags include progressive motor or sensory loss, new urinary retention or overflow incontinence, history of cancer, recent invasive spinal procedure, and significant trauma relative to age. Imaging on initial presentation should be reserved for when there is suspicion for cauda equina syndrome, malignancy, fracture, or infection. Plain radiography of the lumbar spine is appropriate to assess for fracture and bony abnormality, whereas magnetic resonance imaging is better for identifying the source of neurologic or soft tissue abnormalities. There are multiple treatment modalities for mechanical low back pain, but strong evidence of benefit is often lacking. Moderate evidence supports the use of nonsteroidal anti-inflammatory drugs, opioids, and topiramate in the short-term treatment of mechanical low back pain. There is little or no evidence of benefit for acetaminophen, antidepressants (except duloxetine), skeletal muscle relaxants, lidocaine patches, and transcutaneous electrical nerve stimulation in the treatment of chronic low back pain. There is strong evidence for short-term effectiveness and moderate-quality evidence for long-term effectiveness of yoga in the treatment of chronic low back pain. Various spinal manipulative techniques (osteopathic manipulative treatment, spinal manipulative therapy) have shown mixed benefits in the acute and chronic setting. Physical therapy modalities such as the McKenzie method may decrease the recurrence of low back pain and health care expenditures. Physical therapy modalities such as the McKenzie method may decrease the recurrence of low back pain and use of health care. Educating patients on prognosis and incorporating psychosocial components of care such as identifying comorbid psychological problems and barriers to treatment are essential components of long-term management.
Evidence supports the use of opioids for treating acute pain. However, the evidence is limited for the use of chronic opioid therapy for chronic pain. Furthermore, the risks of chronic therapy are significant and may outweigh any potential benefits. When considering chronic opioid therapy, physicians should weigh the risks against any possible benefits throughout the therapy, including assessing for the risks of opioid misuse, opioid use disorder, and overdose. When initiating opioid therapy, physicians should consider buprenorphine for patients at risk of opioid misuse, opioid use disorder, and overdose. If and when opioid misuse is detected, opioids do not necessarily need to be discontinued, but misuse should be noted on the problem list and interventions should be performed to change the patient’s behavior. If aberrant behavior continues, opioid use disorder should be diagnosed and treated accordingly. When patients are discontinuing opioid therapy, the dosage should be decreased slowly, especially in those who have intolerable withdrawal. It is not unreasonable for discontinuation of chronic opioid therapy to take many months. Benzodiazepines should not be coprescribed during chronic opioid therapy or when tapering, because some patients may develop cross-dependence. For patients at risk of overdose, naloxone should be offered to the patient and to others who may be in a position to witness and reverse opioid overdose.
Infantile colic is a benign process in which an infant has paroxysms of inconsolable crying for more than three hours per day, more than three days per week, for longer than three weeks. It affects approximately 10% to 40% of infants worldwide and peaks at around six weeks of age, with symptoms resolving by three to six months of age. The incidence is equal between sexes, and there is no correlation with type of feeding (breast vs. bottle), gestational age, or socioeconomic status. The cause of infantile colic is not known; proposed causes include alterations in fecal microflora, intolerance to cow’s milk protein or lactose, gastrointestinal immaturity or inflammation, increased serotonin secretion, poor feeding technique, and maternal smoking or nicotine replacement therapy. Colic is a diagnosis of exclusion after a detailed history and physical examination have ruled out concerning causes. Parental support and reassurance are key components of the management of colic. Simethicone and proton pump inhibitors are ineffective for the treatment of colic, and dicyclomine is contraindicated. Treatment options for breastfed infants include the probiotic Lactobacillus reuteri (strain DSM 17938) and reducing maternal dietary allergen intake. Switching to a hydrolyzed formula is an option for formula-fed infants. Evidence does not support chiropractic or osteopathic manipulation, infant massage, swaddling, acupuncture, or herbal supplements.
Apophysitis and osteochondrosis are common causes of pain in growing bones but have differing etiologies and required management. Apophysitis results from a traction injury to the cartilage and bony attachment of tendons in children and adolescents. Most often it is an overuse injury in children who are growing and have tight or inflexible muscle tendon units. Although apophysitis occurs in upper and lower extremities, it occurs more often in the lower extremities, with common locations including the patellar tendon attachment at the patella or tibia (i.e., Larsen-Johansson and Osgood-Schlatter diseases), the calcaneus (i.e., Sever disease), and multiple locations around the hip, including the anterior inferior iliac spine. Other locations include the medial epicondyle, which is common in patients who throw or participate in racket sports, and more rarely at the base of the fifth metatarsal (i.e., Iselin disease). Radiography can be helpful in evaluating for other pathologies but is usually not necessary. Treatment includes stretching the affected muscle groups, relative rest, offloading the affected tendon, icing after activity, and limited use of nonsteroidal anti-inflammatory drugs. Osteochondrosis presents less commonly and refers to degenerative changes in the epiphyseal ossification centers of growing bones. Unlike apophysitis, the etiology of osteochondrosis is unknown. Multiple possible etiologies have been explored, including genetic causes, hormonal imbalances, mechanical factors, repetitive trauma, and vascular abnormalities. Other locations of osteochondrosis include the second metatarsal head (i.e., Freiberg disease), the navicular bone (i.e., Köhler bone disease), the femoral head (i.e., Legg-Calvé-Perthes disease), and the capitellum (i.e., Panner disease). Radiography results may be normal initially; magnetic resonance imaging is more sensitive to early changes. Osteochondrosis generally resolves with relative rest, but close monitoring is needed to ensure resolution. Surgery is rarely needed for either apophysitis or osteochondrosis.
Many people with depression or anxiety turn to nonpharmacologic and nonconventional interventions, including exercise, yoga, meditation, tai chi, or qi gong. Meta-analyses and systematic reviews have shown that these interventions can improve symptoms of depression and anxiety disorders. As an adjunctive treatment, exercise seems most helpful for treatment-resistant depression, unipolar depression, and posttraumatic stress disorder. Yoga as monotherapy or adjunctive therapy shows positive effects, particularly for depression. As an adjunctive therapy, it facilitates treatment of anxiety disorders, particularly panic disorder. Tai chi and qi gong may be helpful as adjunctive therapies for depression, but effects are inconsistent. As monotherapy or an adjunctive therapy, mindfulness-based meditation has positive effects on depression, and its effects can last for six months or more. Although positive findings are less common in people with anxiety disorders, the evidence supports adjunctive use. There are no apparent negative effects of mindfulness-based interventions, and their general health benefits justify their use as adjunctive therapy for patients with depression and anxiety disorders.
Pediculosis and scabies are caused by ectoparasites. Pruritus is the most common presenting symptom. Head and pubic lice infestations are diagnosed with visualization of live lice. Nits (lice eggs or egg casings) alone are not sufficient to diagnose a current infestation. A “no-nit” policy for return to school is not recommended because nits can remain even after successful treatment. First-line pharmacologic treatment for pediculosis is permethrin 1% lotion or shampoo. Newer treatments are available but costly, and resistance patterns are generally unknown. Noninsecticidal agents, including dimethicone and isopropyl myristate, show promise in the treatment of pediculosis. Extensive environmental decontamination is not necessary after pediculosis is diagnosed. In adults, the presence of pubic lice should prompt an evaluation for sexually transmitted infections. Body lice infestation should be suspected in patients with pruritus who live in crowded conditions or have poor hygiene. Scabies in adults presents as a pruritic, papular rash in a typical distribution pattern. In infants, the rash can also be vesicular, pustular, or nodular. First-line treatment for scabies is permethrin 5% cream. Clothing and bedding of persons with scabies should be washed in hot water and dried in a hot dryer. Counseling regarding appropriate diagnosis and correct use of effective therapies is key to reducing the burden of lice and scabies.