FP essentials
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Review Case Reports
Cardiac risk factors: noninvasive testing to detect coronary heart disease.
Patients with acute chest pain should be assessed first for the likelihood of acute coronary syndrome using the Thrombolysis in Myocardial Infarction score or the Agency for Health Care Policy and Research criteria. If assessment indicates high risk, the patient should be admitted to the hospital. Low- and intermediate-risk patients whose chest pain has ceased and who have normal or unchanged electrocardiograms and troponin levels can be monitored for 6 to 8 hours. ⋯ Coronary computed tomographic angiography and magnetic resonance angiography currently are not standard tools for this testing. Testing also is sometimes obtained for asymptomatic outpatients with intermediate risk of coronary heart disease, with the goal of reclassifying them in low- or high-risk categories. Carotid intima-media thickness, ankle-brachial index, coronary artery calcium scores, stress tests, coronary computed tomographic angiography, and magnetic resonance angiography have been suggested for this purpose, but they only result in reclassification of small percentages of patients and are not recommended routinely.
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The diagnosis of irritable bowel syndrome (IBS) should be considered when patients have had abdominal pain/discomfort, bloating, and change in bowel habits for 6 months. Patients may experience variation between periods of constipation and diarrhea. When evaluating patients with IBS, physicians should be alert for red flag symptoms, such as rectal bleeding, anemia, nighttime pain, and weight loss. ⋯ Constipation-dominant IBS can be managed with antispasmodics, lubiprostone, or linaclotide, whereas diarrhea-dominant IBS can be managed with loperamide or alosetron, though the latter drug can cause ischemic colitis. For long-term therapy, tricyclic antidepressants or selective serotonin reuptake inhibitors have good efficacy. Peppermint oil and probiotics also may provide benefit.
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Nationally, the rates of intimate partner violence (IPV) among lesbian, gay, bisexual, or transgender (LGBT) individuals are similar to or greater than rates for heterosexuals. Many have experienced psychological and physical abuse as sexual minorities, making it difficult for them to seek help for IPV. Physician behavior, such as not assuming that all patients are heterosexual, being nonjudgmental, and using inclusive language, can empower LGBT patients to disclose IPV. ⋯ As sexual minorities experiencing IPV, LGBT individuals are at greater risk of depression and substance abuse than are non-LGBT individuals. Minority stress, resulting from stigmatization and discrimination, can be exacerbated by IPV. Physicians should learn about legal issues for LGBT individuals and the availability of community or advocacy programs for LGBT perpetrators or victims of IPV.
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Dyspnea is a subjective experience of breathing discomfort; patients experience qualitatively distinct sensations that vary in intensity. Acute dyspnea might be secondary to an acute problem, or it might be an exacerbation of an existing disease (eg, asthma, chronic obstructive pulmonary disease, heart failure). It also accompanies a variety of illnesses at the end of life. ⋯ For patients with intermediate or high probability, obtain computed tomography pulmonary angiography for a definitive diagnosis. Patients who have dyspnea from a chronic obstructive pulmonary disease exacerbation can experience hypercapnic failure. As an adjunct to usual medical treatment, noninvasive positive pressure ventilation decreases the need for mechanical ventilation and is particularly useful in patients who have chosen not to be resuscitated with intubation.
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The etiology of chronic obstructive pulmonary disease (COPD) is chronic lung inflammation. In the United States, this inflammation most commonly is caused by smoking. COPD is diagnosed when an at-risk patient presents with respiratory symptoms and has irreversible airway obstruction indicated by a forced expiratory volume in 1 second/forced vital capacity ratio of less than 0.7. ⋯ Pulmonary rehabilitation after an acute exacerbation reduces hospitalizations and mortality, and improves quality of life and exercise capacity. Smoking cessation is the most effective management strategy for reducing morbidity and mortality in patients with COPD. Lung volume reduction surgery, bullectomy, and lung transplantation are surgical interventions that are appropriate for some patients with COPD.