Primary Care -- AAFP

Terms in this set (1276)

E. Intravenous labetalol (Normodyne, Trandate). Patients with thoracic aneurysms often present without symptoms. With dissecting aneurysms, however, the presenting symptom depends on the location of the aneurysm. Aneurysms can compress or distort nearby structures, resulting in branch vessel compression or embolization of peripheral arteries from a thrombus within the aneurysm. Leakage of the aneurysm will cause pain, and rupture can occur with catastrophic results, including severe pain, hypotension, shock, and death. Aneurysms in the ascending aorta may present with acute heart failure brought about by aortic regurgitation from aortic root dilatation and distortion of the annulus. Other presenting findings may include hoarseness, myocardial ischemia, paralysis of a hemidiaphragm, wheezing, coughing, hemoptysis, dyspnea, dysphagia, or superior vena cava syndrome. This diagnosis should be suspected in individuals in their sixties and seventies with the same risk factors as those for coronary artery disease, particularly smokers. A chest radiograph may show widening of the mediastinum, enlargement of the aortic knob, or tracheal displacement. Transesophageal echocardiography can be very useful when dissection is suspected. CT with intravenous contrast is very accurate for showing the size, extent of disease, pressure of leakage, and nearby pathology. Angiography is the preferred method for evaluation and is best for evaluation of branch vessel pathology. MR angiography provides noninvasive multiplanar image reconstruction, but does have limited availability and lower resolution than traditional contrast angiography. Acute dissection of the ascending aorta is a surgical emergency, but dissections confined to the descending aorta are managed medically unless the patient demonstrates progression or continued hemorrhage into the retroperitoneal space or pleura. Initial management should reduce the systolic blood pressure to 100-120 mm Hg or to the lowest level tolerated. The use of a β-blocker such as propranolol or labetalol to get the heart rate below 60 beats/min should be first-line therapy. If the systolic blood pressure remains over 100 mm Hg, intravenous nitroprusside should be added. Without prior beta-blocade, vasodilation from the nitroprusside will induce reflex activation of the sympathetic nervous system, causing increased ventricular contraction and increased shear stress on the aorta. For descending dissections, surgery is indicated only for complications such as occlusion of a major aortic branch, continued extension or expansion of the dissection, or rupture (which may be manifested by persistent or recurrent pain).
E. Midgut volvulus. Volvulus may present in one of three ways: as a sudden onset of bilious vomiting and abdominal pain in a neonate; as a history of feeding problems with bilious vomiting that appears to be a bowel obstruction; or less commonly, as failure to thrive with severe feeding intolerance. The classic finding on abdominal plain films is the double bubble sign, which shows a paucity of gas (airless abdomen) with two air bubbles, one in the stomach and one in the duodenum. However, the plain film can be entirely normal. The upper gastrointestinal contrast study is considered the gold standard for diagnosing volvulus. Infantile colic usually begins during the second week of life and typically occurs in the evening. It is characterized by screaming episodes and a distended or tight abdomen. Its etiology has yet to be determined. There are no abnormalities on physical examination and ancillary studies, and symptoms usually resolve spontaneously around 12 weeks of age. Necrotizing enterocolitis is typically seen in the distressed neonate in the intensive-care nursery, but it may occasionally be seen in the healthy neonate within the first 2 weeks of life. The child will appear ill, with symptoms including irritability, poor feeding, a distended abdomen, and bloody stools. Abdominal plain films will show pneumatosis intestinalis, caused by gas in the intestinal wall, which is diagnostic of the condition. Hypertrophic pyloric stenosis is a narrowing of the pyloric canal caused by hypertrophy of the musculature. It usually presents during the third to fifth weeks of life. Projectile vomiting after feeding, weight loss, and dehydration are common. The vomitus is always nonbilious, because the obstruction is proximal to the duodenum. If a small olive-size mass cannot be felt in the right upper or middle quadrant, ultrasonography will confirm the diagnosis. Intussusception is seen most frequently between the ages of 3 months and 5 years, with 60% of cases occurring in the first year and a peak incidence at 6-11 months of age. The disorder occurs predominantly in males. The classic triad of intermittent colicky abdominal pain, vomiting, and bloody, mucous stools is encountered in only 20%-40% of cases. At least two of these findings will be present in approximately 60% of patients. The abdomen may be distended and tender, and there may be an elongated mass in the right upper or lower quadrants. Rectal examination may reveal either occult blood or frankly bloody, foul-smelling stool, classically described as currant jelly. An air enema using fluoroscopic guidance is useful for both diagnosis and treatment.
B. Over-the-counter heel inserts. Plantar fasciitis is a common cause of heel pain. It may be unilateral or bilateral, and the etiology is unknown, although it is thought to be due to cumulative overload stress. While it may be associated with obesity or overuse, it may also occur in active or inactive patients of all ages. Typically the pain is located in the plantar surface of the heel and is worst when the patient first stands up when getting out of bed in the morning (first step phenomenon) or after prolonged sitting. The pain may then improve after the patient walks around, only to worsen after prolonged walking. The diagnosis is made by history and physical examination. Typical findings include point tenderness to palpation on the plantar surface of the heel at the medial calcaneal tuberosity where the calcaneal aponeurosis inserts. Radiographs are not necessary unless there is a history of trauma or if the diagnosis is unclear.

The condition may last for months or years, and resolves in most patients over time with or without specific therapy. One long-term follow-up study showed that 80% of patients had complete resolution of their pain after 4 years. Treatments with limited (level 2) evidence of effectiveness include off-the-shelf insoles, custom-made insoles, stretching of the plantar fascia, corticosteroid iontophoresis, custom-made night splints, and surgery (for those who have failed conservative therapy). NSAIDs and ice, although not independently studied for plantar fasciitis, are included in most studies of other treatments, and are reasonable adjuncts to first-line therapy. Magnetic insoles and extracorporeal shockwave therapy are ineffective in treating plantar fasciitis.

Due to their expense, custom-made insoles, custom-made night splints, and corticosteroid iontophoresis should be reserved as second-line treatments for patients who fail first-line treatment. Surgery may be offered if more conservative therapies fail. Corticosteroid injection may have a short-term benefit at 1 month, but is no better than other treatments at 6 months and carries a risk of plantar fascia rupture.
C. Morphine identified in an employee taking a prescribed cough medicine containing codeine. Results of urine drug test panels obtained in the workplace are reported by a Medical Review Officer (MRO) as positive, negative, dilute, refusal to test, or test canceled; the drug/metabolite for which the test is positive or the reason for refusal (e.g., the presence of an adulterant) or cancellation is also included in the final report. The MRO interpretation is based on consideration of many factors, including the confirmed patient medical history, specimen collection process, acceptability of the specimen submitted, and qualified laboratory measurement of drugs or metabolites in excess of the accepted thresholds. These thresholds are set to preclude the possibility that secondary contact with smoke, ingestion of poppy seeds, or similar exposures will result in an undeserved positive urine drug screen report. Other findings, such as the presence of behavioral or physical evidence of unauthorized use of opiates, may also factor into the final report.

When a properly collected, acceptable specimen is found to contain drugs or metabolites that would be expected based on a review of confirmed prescribed use of medications, the test is reported as negative. Morphine is a metabolite of codeine that may be found in the urine of someone taking a codeine-containing medication; morphine is not a metabolite of methadone. Oxazepam is a metabolite of diazepam but the reverse is not true. Tetrahydrocannabinol would not be found in the urine as a result of tramadol use.
E. Avoidance of contact sports. Infectious mononucleosis presents most commonly with a sore throat, fatigue, myalgias, and lymphadenopathy, and is most prevalent between 10 and 30 years of age. Both an atypical lymphocytosis and a positive heterophil antibody test support the diagnosis, although false-negative heterophil testing is common early in the disease course. The cornerstone of treatment for mononucleosis is supportive, including hydration, NSAIDs, and throat sprays or lozenges.

In general, corticosteroids do not have a significant effect on the clinical course of infectious mononucleosis, and they should not be used routinely unless the patient has evidence of acute airway obstruction. Antihistamines are also not recommended as routine treatment for mononucleosis. The use of acyclovir has shown no consistent or significant benefit, and antiviral drugs are not recommended.

There is also no evidence to support bed rest as an effective management strategy for mononucleosis. Given the evidence from other disease states, bed rest may actually be harmful.

Although most patients will not have a palpably enlarged spleen on examination, it is likely that all, or nearly all, patients with mononucleosis have splenomegaly. This was demonstrated in a small study in which 100% of patients hospitalized for mononucleosis had an enlarged spleen by ultrasound examination, whereas only 17% of patients with splenomegaly have a palpable spleen. Patients should be advised to avoid contact- or collision-type activities for 3-4 weeks because of the increased risk of rupture.
A. on the basis of clinical symptoms alone. Influenza is a highly contagious viral illness spread by airborne droplets. This patient's symptoms are highly suggestive of typical influenza: a sudden onset of malaise, myalgia, headache, fever, rhinitis, sore throat, and cough. While influenza is typically uncomplicated and self-limited, it can result in severe complications, including encephalitis, pneumonia, respiratory failure, and death.

The effectiveness of treatment for influenza is dependent on how early in the course of the illness it is given. Because of the recent global H1N1 influenza outbreak that resulted in demand potentially outstripping the supply of antiviral medication, the Centers for Disease Control and Prevention has modified its recommendation as follows:
Antiviral treatment is recommended as soon as possible for patients with confirmed or suspected influenza who have severe, complicated, or progressive illness or who require hospitalization.
Antiviral treatment is recommended as soon as possible for outpatients with confirmed or suspected influenza who are at higher risk for influenza complications based on their age or underlying medical conditions. Clinical judgment should be an important component of outpatient treatment decisions.
Antiviral treatment also may be considered on the basis of clinical judgment for any outpatient with confirmed or suspected influenza who does not have known risk factors for severe illness, if treatment can be initiated within 48 hours of illness onset.
Many rapid influenza tests produce false-negative results, and more accurate assays can take more than 24 hours. Thus, treatment of patients with a clinical picture suggesting influenza is recommended, even if a rapid test is negative. Delaying treatment until further test results are available is not recommended.
B. A 72-year-old female with no chronic medical conditions. The U.S. Preventive Services Task Force (USPSTF) has summarized the evidence for the use of aspirin in the primary prevention of cardiovascular disease as follows:
The USPSTF recommends the use of aspirin for men 45-79 years of age when the potential benefit from a reduction in myocardial infarctions outweighs the potential harm from an increase in gastrointestinal hemorrhage (Grade A recommendation)
The USPSTF recommends the use of aspirin for women 55-79 years of age when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage (Grade A recommendation)
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years of age or older (Grade I statement)
The USPSTF recommends against the use of aspirin for stroke prevention in women younger than 55 and for myocardial infarction prevention in men younger than 45 (Grade D recommendation)
In summary, consistent evidence from randomized clinical trials indicates that aspirin use reduces the risk for cardiovascular disease events in adults without a history of cardiovascular disease. It reduces the risk for myocardial infarction in men, and ischemic stroke in women. Consistent evidence shows that aspirin use increases the risk for gastrointestinal bleeding, and limited evidence shows that aspirin use increases the risk for hemorrhagic strokes. The overall benefit in the reduction of cardiovascular disease events with aspirin use depends on baseline risk and the risk for gastrointestinal bleeding.
D. A dipyridamole-thallium scan. Family physicians are often asked to perform a preoperative evaluation prior to noncardiac surgery. This requires an assessment of the perioperative cardiovascular risk of the procedure involved, the functional status of the patient, and clinical factors that can increase the risk, such as diabetes mellitus, stroke, renal insufficiency, compensated or prior heart failure, mild angina, or previous myocardial infarction.

This patient is not undergoing emergency surgery, nor does she have an active cardiac condition; however, she is undergoing a high-risk procedure (>5% risk of perioperative myocardial infarction) with vascular surgery. As she cannot climb a flight of stairs or do heavy housework, her functional status is <4 METs, and she should be considered for further evaluation. The patient's diabetes is an additional clinical risk factor.

With vascular surgery being planned, appropriate recommendations include proceeding with the surgery with heart rate control, or performing noninvasive testing if it will change the management of the patient. Coronary angiography is indicated if the noninvasive testing is abnormal. Pulmonary function studies are most useful in patients with underlying lung disease or those undergoing pulmonary resection. Hemoglobin A1c is a measure of long-term diabetic control and is not particularly useful perioperatively. Carotid angiography is not indicated in asymptomatic patients being considered for lower-extremity vascular procedures.
B. vocal cord dysfunction. Vocal cord dysfunction is an idiopathic disorder commonly seen in patients in their twenties and thirties in which the vocal cords partially collapse or close on inspiration. It mimics, and is commonly mistaken for, asthma. Symptoms include episodic tightness of the throat, a choking sensation, shortness of breath, and coughing. A careful history and examination reveal that the symptoms are worse with inspiration than with exhalation, and inspiratory stridor during the episode may be mistaken for the wheezing of asthma. The sensation of throat tightening or choking also helps to differentiate it from asthma.

Pulmonary function tests (PFTs) are normal, with the exception of flattening of the inspiratory loop, which is diagnostic of extra-thoracic airway compression. Fiberoptic laryngoscopy shows paradoxical inspiratory and/or expiratory partial closure of the vocal cords. Vocal cord dysfunction is treated with speech therapy, breathing techniques, reassurance, and breathing a helium-oxygen mixture (heliox).

PFTs in patients with asthma are normal between exacerbations, but when symptoms are present the FEV1 /FVC ratio is reduced, as with COPD. With anaphylaxis, there will typically be itching or urticaria and signs of angioedema, such as lip or tongue swelling, in response to a trigger such as food or medication; PFTs are normal when anaphylaxis symptoms are absent. Globus hystericus is a type of conversion disorder in which emotional stress causes a subjective sensation of pain or tightness in the throat, and/or dysphagia; diagnostic tests such as spirometry and laryngoscopy are normal.
D. Fomepizole (Antizol). Ethylene glycol poisoning should be suspected in patients with metabolic acidosis of unknown cause and subsequent renal failure, as rapid diagnosis and treatment will limit the toxicity and decrease both morbidity and mortality. This diagnosis should be considered in a patient who appears intoxicated but does not have an odor of alcohol, and has anion gap acidosis, hypocalcemia, urinary crystals, and nontoxic blood alcohol levels. Ethylene glycol is found in products such as engine coolant, de-icing solution, and carpet and fabric cleaners. Ingestion of 100 mL of ethylene glycol by an adult can result in toxicity.

The American Academy of Clinical Toxicology criteria for treatment of ethylene glycol poisoning with an antidote include a plasma ethylene glycol concentration >20 mg/dL, a history of ingesting toxic amounts of ethylene glycol in the past few hours with an osmolal gap >10 mOsm/kg H O2 (N 5-10), and strong clinical suspicion of ethylene glycol poisoning, plus at least two of the following: arterial pH <7.3, serum bicarbonate <20 mmol/L, or urinary oxalate crystals.

Until recently, ethylene glycol poisoning was treated with sodium bicarbonate, ethanol, and hemodialysis. Treatment with fomepizole (Antizol) has this specific indication, however, and should be initiated immediately when ethylene glycol poisoning is suspected. If ethylene glycol poisoning is treated early, hemodialysis may be avoided, but once severe acidosis and renal failure have occurred hemodialysis is necessary. Ethylene glycol is rapidly absorbed, and use of ipecac or gastric lavage is therefore not effective. Large amounts of activated charcoal will only bind to relatively small amounts of ethylene glycol, and the therapeutic window for accomplishing this is less than 1 hour.
D. Pasteurella multocida. Pasteurella species are isolated from up to 50% of dog bite wounds and up to 75% of cat bite wounds, and the hand is considered a high-risk area for infection (SOR A). Although much more rare, Capnocytophaga canimorsus, a fastidious gram-negative rod, can cause bacteremia and fatal sepsis after animal bites, especially in asplenic patients or those with underlying hepatic disease. Anaerobes isolated from dog and cat bite wounds include Bacteroides, Fusobacterium, Porphyromonas, Prevotella, Propionibacterium and Peptostreptococcus.

In addition to animal oral flora, human skin flora are also important pathogens, but are less commonly isolated. These can include streptococci and staphylococci, including methicillin-resistant Staphylococcus aureus (MRSA). Coverage for MRSA may be especially important if the patient has risk factors for colonization with community-acquired MRSA. Pets can also become colonized with MRSA and transmit it via bites and scratches.

Cat bites that become infected with Pasteurella multocida can be complicated by cellulitis, which may form around the wound within 24 hours and is often accompanied by redness, tenderness, and warmth. The use of prophylactic antibiotics is associated with a statistically significant reduction in the rate of infection in hand bites (SOR A). If infection develops and is left untreated, the most common complications are tenosynovitis and abscess formation; however, local complications can include septic arthritis and osteomyelitis. Fever, regional adenopathy, and lymphangitis are also seen.
C. Oral fluoride supplementation is recommended if the primary drinking water source is low in fluoride. The current (2004) recommendation of the U.S. Preventive Services Task Force (USPSTF) is that children over the age of 6 months receive oral fluoride supplementation if the primary drinking water source is deficient in fluoride. The USPSTF cites "fair" evidence (B recommendation) that such supplementation reduces the incidence of dental caries and concludes that the overall benefit outweighs the potential harm from dental fluorosis.

Dental fluorosis is chiefly a cosmetic staining of the teeth, is uncommon with currently recommended fluoride intake, and has no other functional or physiologic consequences. Fluoridated toothpaste can cause fluorosis in children younger than 2 years of age, and is therefore not recommended in this age group. Fluoridated toothpaste by itself does not reliably prevent tooth decay.

Fluoride varnish, applied by a dental or medical professional, is another treatment option to prevent caries. It provides longer-lasting protection than fluoride rinses, but since it is less concentrated, it may carry a lower risk of fluorosis than other forms of supplementation.

Oral fluoride supplementation for children over the age of 6 months is based not only on age but on the concentration of fluoride in the primary source of drinking water, whether it be tap water or bottled water. Most municipal water supplies in the United States are adequately fluoridated, but concentrations vary. Fluoride concentrations in bottled water vary widely. If the concentration is >0.6 ppm no supplementation is needed, and may result in fluorosis if given. Lower concentrations of fluoride may indicate the need for partial or full-dose supplementation.
D. familial adenomatous polyposis. People with familial adenomatous polyposis typically develop hundreds or thousands of polyps in their colon and rectum, usually in their teens or early adulthood. Cancer usually develops in one or more of these polyps as early as age 20. By age 40, almost all people with this disorder will have developed cancer if preventive colectomy is not performed.

The approximate lifetime risk of colon cancer in the general population of the United States is 6%. Most case-control studies of cigarette exposure and adenomas have found an elevated risk for smokers. Tobacco use raises the risk of colon cancer by approximately 50%.

Patients with ulcerative colitis are at increased risk for colon cancer. The anatomic extent and duration of the disease correlate with the degree of risk. In one meta-analysis, investigators found that the risk of colon cancer was 2% in the first 10 years after ulcerative colitis develops, 8% during the first 20 years, and 18% during the first 30 years.

The evidence is still evolving regarding the level of future risk of colon cancer associated with having had an adenomatous polyp removed in the past, but it may approach a doubling of the baseline risk of colon cancer. Studies suggest a clear association with a history of multiple polyps or a single large (>1 cm) polyp. The data is less clear for single small adenomas. Of the three types of adenomas (tubular, tubulovillous, and villous), villous adenomas are most likely to develop into adenocarcinomas.

Having a family history of a first degree relative with colon cancer raises the risk approximately two-to threefold. If that relative was younger than age 50 at the time of diagnosis the risk is three-to fourfold higher.
A. Exclusive breastfeeding until the infant is 4 months of age. Atopic dermatitis is a pruritic, inflammatory skin disorder affecting nearly 1 in 5 children residing in developed countries. The vast majority of those eventually afflicted experience the onset of symptoms by the age of 5 years, and more than half will present before the age of 1 year. The etiology is not fully understood, but it seems clear that environmental, immune, genetic, metabolic, infectious, and neuroendocrine factors all play a role. Environmental factors that may be involved include harsh detergents, abrasive clothing, Staphylococcus aureus skin infection, food allergens (cow's milk, eggs, peanuts, tree nuts, etc.), overheating, and psychological stress. Aeroallergens that are problematic for asthmatics, such as animal dander, dust mites, and pollen, have not been clearly linked to atopic dermatitis.

Large, well-designed studies have found no evidence that delaying the introduction of solid foods until after 6 months of age reduces the likelihood of atopic dermatitis. Ingestion of probiotic agents during pregnancy has also not been shown to have any effect, and studies of probiotic use in breastfeeding mothers and their infants have yielded conflicting results. Exclusive breastfeeding for the first 4 months of life has been shown to reduce the cumulative incidence of atopic dermatitis in the first 2 years of life for infants at high risk of developing atopic disease; doing so beyond 4 months does not appear to provide additional benefit. Maternal dietary restriction during pregnancy and lactation has not been associated with significant benefit. Limited studies have demonstrated that emollients and moisturizers can reduce associated xerosis and are thought to be helpful treatments, but the data is not convincing.
A. separation anxiety disorder. This patient suffers from separation anxiety disorder, which is unique to pediatric patients and is characterized by excessive anxiety regarding separation from the home or from people the child is attached to, such as family members or other caregivers. The anxiety is beyond what is developmentally appropriate for the child's age. Patients may even suffer distress from anticipation of the separation. Other characteristics include persistent worry about harm occurring to major attachment figures, worry about an event that may separate the patient from caregivers, reluctance to attend school due to the separation it implies, fear of being alone, recurring nightmares with themes of separation, and physical complaints when faced with separation. Children diagnosed with separation anxiety disorder must be under 18 years of age and have had symptoms for at least 4 weeks.

Social phobia is a persistent fear of a specific object or situation. Exposure to the object provokes an immediate anxiety response such as a panic attack. To meet the criteria for social phobia, patients must suffer symptoms for at least 6 months. Generalized anxiety disorder is characterized as excessive anxiety and worry regarding a number of events or activities. Physical symptoms include restlessness, irritability, or sleep disturbance. Symptoms must be present for at least 6 months.

Acute stress disorder occurs after a traumatic event that the individual considers life threatening. Patients experience dissociative symptoms, flashbacks, and increased arousal. Symptoms are present for at least 2 days, with a maximum of 4 weeks. Beyond 4 weeks, a diagnosis of posttraumatic stress disorder is made. Panic disorder with agoraphobia is characterized by recurrent panic attacks with a fear of being in situations in which the patient cannot escape or may be embarrassed by doing so. Symptoms must be present for 1 month for the diagnosis to be made (SOR C).
E. Pityriasis rosea. This presentation is typical of pityriasis rosea. There was a mild prodrome, thought to be jet lag by this patient, followed by the development of an ovoid salmon-colored, slightly raised herald patch, most commonly seen on the trunk. This was followed by an outbreak of multiple smaller, similar lesions that trend along Langer's lines. In this case, clear evidence of the herald patch remains visible in the left interscapular region, which is helpful in confirming the diagnosis.

Guttate psoriasis shares some features with pityriasis rosea in that it can appear suddenly and often follows a triggering incident such as a streptococcal infection, which could be confused with a prodromal phase; however, the absence of a herald patch and the smaller but thicker erythematous lesions differentiate psoriasis from pityriasis rosea. Tinea versicolor often involves the upper trunk and may appear as a lightly erythematous, scaling rash, but the onset is more gradual than in this case. Although this patient may be exposed to low levels of radiation in her job, radiation dermatitis requires doses such as those administered in cancer treatment protocols and would generally be limited to the field of exposure. Cutaneous T-cell lymphoma usually presents as a nonspecific dermatitis, most commonly in men over the age of 50.

An infectious etiology for pityriasis rosea is strongly suspected, although none has been identified. There is some evidence that the agent may be human herpesvirus 6. The illness generally resolves within 2 months, leaving no residual signs other than postinflammatory hyperpigmentation.
D. video-electroencephalography (vEEG) monitoring. Inpatient video-electroencephalography (vEEG) monitoring is the preferred test for the diagnosis of psychogenic nonepileptic seizures (PNES), and is considered the gold standard (SOR B). Video-EEG monitoring combines extended EEG monitoring with time-locked video acquisition that allows for analysis of clinical and electrographic features during a captured event. Many other types of evidence have been used, including the presence or absence of self-injury and incontinence, the ability to induce seizures by suggestion, psychologic tests, and ambulatory EEG. While useful in some cases, these alternatives have been found to be insufficient for the diagnosis of PNES.
Elevated postictal prolactin levels (at least two times the upper limit of normal) have been used to differentiate generalized and complex partial seizures from PNES, but are not reliable (SOR B). While prolactin levels are often elevated after an epileptic seizure, they do not always rise, and the timing of measurement is crucial, making this a less sensitive test than was previously believed. Other serum markers have also been used to help distinguish PNES from epileptic seizures, including creatine phosphokinase, cortisol, WBC counts, lactate dehydrogenase, pCO2 , and neuron-specific enolase. These also are not reliable, as threshold levels for abnormality, sensitivity, and specificity have not been determined.
MRI is not reliable because abnormal brain MRIs have been documented in as many as one-third of patients with PNES. In addition, patients with epileptic seizures often have normal brain MRIs.
D. Placental abruption. Late pregnancy bleeding may cause fetal morbidity and/or mortality as a result of uteroplacental insufficiency and/or premature birth. The condition described here is placental abruption (separation of the placenta from the uterine wall before delivery).

There are several causes of vaginal bleeding that can occur in late pregnancy that might have consequences for the mother, but not necessarily for the fetus, such as cervicitis, cervical polyps, or cervical cancer. Even advanced cervical cancer would be unlikely to cause the syndrome described here. The other conditions listed may bring harm to the fetus and/or the mother.

Uterine rupture usually occurs during active labor in women with a history of a previous cesarean section or with other predisposing factors, such as trauma or obstructed labor. Vaginal bleeding is an unreliable sign of uterine rupture and is present in only about 10% of cases. Fetal distress or demise is the most reliable presenting clinical symptom. Vasa previa (the velamentous insertion of the umbilical cord into the membranes in the lower uterine segment) is typically manifested by the onset of hemorrhage at the time of amniotomy or by spontaneous rupture of the membranes. There are no prior maternal symptoms of distress. The hemorrhage is actually fetal blood, and exsanguination can occur rapidly. Placenta previa (placental implantation that overlies or is within 2 cm of the internal cervical os) is clinically manifested as vaginal bleeding in the late second or third trimester, often after sexual intercourse. The bleeding is typically painless, unless labor or placental abruption occurs.
E. Taking patient compliance into account when performing the evaluation. Pay-for-performance programs are becoming a critical part of the health care reform debate, and when the discussion began in 2005, over 100 such programs were in existence. The objective is to reward physicians for achieving goals that should lead to improved patient outcomes. In addition to evaluating clinical performance, many programs now also evaluate efficiency and information technology. However, many programs are not based on outcomes data, and have less desirable aspects such as inadequate incentive levels, withholding of payment, limited clinical focus, or unequal or unfair distribution of incentives. Plans that exclude patient compliance as a factor can lead to withholding of physician incentives because of patient nonadherence, or to physicians selectively removing such patients from their panels.

As the exact process is still being defined, all family physicians should be actively engaged in learning more about these programs, and in negotiating for appropriate measures to be included. The AAFP has seven main principles in its support for pay-for-performance programs: (1) the focus should be on improved quality of care; (2) physician-patient relationships should be supported; (3) evidence-based clinical guidelines should be utilized; (4) practicing physicians should be involved with the program design; (5) reliable, accurate, and scientifically valid data should be used; (6) physicians should be provided with positive incentives; and (7) physician participation should be voluntary. Ensuring that patient adherence is included helps prevent conflicts between patients and their physicians.
A pay-for-performance program should not result in a reduction of fees paid to the physician as a result of implementing a program. Negative results should not penalize the physician with regard to health plan credentialing, verification, or licensure.
E. Order CT of the abdomen. Perinephric abscess is an elusive diagnostic problem that is defined as a collection of pus in the tissue surrounding the kidney, generally in the space enclosed by Gerota's fascia. Mortality rates as high as 50% have been reported, usually from failure to diagnose the problem in a timely fashion. The difficulty in making the diagnosis can be attributed to the variable constellation of symptoms and the sometimes indolent course of this disease. The diagnosis should be considered when a patient has fever and persistence of flank pain.

Most perinephric infections occur as an extension of an ascending urinary tract infection, commonly in association with renal calculi or urinary tract obstruction. Patients with anatomic urinary tract abnormalities or diabetes mellitus have an increased risk. Clinical features may be quite variable, and the most useful predictive factor in distinguishing uncomplicated pyelonephritis from perinephric abscess is persistence of fever for more than 4 days after initiation of antibiotic therapy. The radiologic study of choice is CT. This can detect perirenal fluid, enlargement of the psoas muscle (both are highly suggestive of the diagnosis), and perirenal gas (which is diagnostic). The sensitivity and specificity of CT is significantly greater than that of either ultrasonography or intravenous pyelography.

Drainage, either percutaneously or surgically, along with appropriate antibiotic coverage reduces both morbidity and mortality from this condition.
E. A history of a stress fracture resulting from minimal trauma. The initial definition of the female athlete triad was amenorrhea, osteoporosis, and disordered eating. The American College of Sports Medicine modified this in 2007, emphasizing that the triad components occur on a continuum rather than as individual pathologic conditions. The definitions have therefore expanded. Disordered eating is no longer defined as the formal diagnosis of an eating disorder. Energy availability,defined as dietary energy intake minus exercise energy expenditures, is now considered a risk factor for the triad, as dietary restrictions and substantial energy expenditures disrupt pituitary and ovarian function.

Primary amenorrhea is defined as lack of menstruation by age 15 in females with secondary sex characteristics. Secondary amenorrhea is the absence of three or more menstrual cycles in a young woman previously experiencing menses. For those with secondary amenorrhea, a pregnancy test should be performed. If this is not conclusive, a progesterone challenge test may be performed. If there is withdrawal bleeding, the cause would be anovulation. Those who do not experience withdrawal bleeding have hypothalamic amenorrhea, and fit one criterion for the triad.

Athletes who have amenorrhea for 6 months, disordered eating, and/or a history of a stress fracture resulting from minimal trauma should have a bone density test. Low bone mineral density for age is the term used to describe at-risk female athletes with a Z-score of -1 to -2. Osteoporosis is defined as having clinical risk factors for experiencing a fracture, along with a Z-score <-2.
E. Lisinopril (Prinivil, Zestril). ACE inhibitors such as lisinopril are indicated for all patients with heart failure due to systolic dysfunction, regardless of severity. ACE inhibitors have been shown to reduce both morbidity and mortality, in both asymptomatic and symptomatic patients, in randomized, controlled trials. Unless absolutely contraindicated, ACE inhibitors should be used in all heart failure patients. No ACE inhibitor has been shown to be superior to another, and no study has failed to show benefit from an ACE inhibitor (SOR A).

Direct-acting vasodilators such as isosorbide dinitrate also could be used in this patient, but ACE inhibitors have been shown to be superior in randomized, controlled trials (SOR B). β-Blockers are also recommended in heart failure patients with systolic dysfunction (SOR A), except those who have dyspnea at rest or who are hemodynamically unstable. These agents have been shown to reduce mortality from heart failure.

A diuretic such as furosemide may be indicated to relieve congestion in symptomatic patients. Aldosterone antagonists such as spironolactone are also indicated in patients with symptomatic heart failure. In addition, they can be used in patients with a recent myocardial infarction who develop symptomatic systolic dysfunction and in those with diabetes mellitus (SOR B). Digoxin currently is recommended for patients with heart failure and atrial fibrillation, and can be considered in patients who continue to have symptoms despite maximal therapy with other agents.
C. Pelvic inflammatory disease. The promise of a reduction in the incidence and prevalence of sexually transmitted diseases through partner notification and treatment programs remains elusive, as evidence supporting this effect is scarce and inconclusive. What is clear is that treating sexual partners does reduce reinfection of the index patient. Programs such as contact notification, counseling and scheduling of appointments for evaluation of the partner, and expedited partner therapy (EPT), in which sexual contacts of infected patients are provided antibiotics delivered by the index patient without evaluation or counseling, have demonstrated only limited effectiveness; in the case of EPT this limited benefit has been shown only with trichomoniasis. Because currently available evidence fails to demonstrate benefit from treating the male sexual contacts of women with vaginal candidiasis, vaginal warts, or bacterial vaginosis, the Centers for Disease Control and Prevention (CDC) states that treating the male partner is not indicated with these infections.

In the case of pelvic inflammatory disease (PID), evaluation and treatment of males with a history of sexual contact with the patient during the 60 days preceding the onset of symptoms is imperative because of the high risk of reinfection. Current CDC guidelines recommend empiric treatment of these male contacts with antibiotic regimens effective against both chlamydial and gonococcal infection, regardless of the presumed etiology of the PID.