American family physician
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Chronic constipation has significant quality-of-life implications. Modifiable risk factors include insufficient physical activity, depression, decreased caloric intake, and aggravating medication use. Chronic constipation is classified as primary (normal transit, slow transit, defecatory disorders, or a combination) or secondary (due to medications, chronic diseases, or anatomic abnormalities). ⋯ If the initial treatment approach is ineffective, patients should be referred to gastroenterology for more specialized testing, such as anorectal manometry and a balloon expulsion test. Patients with refractory constipation may be considered for surgery. Those in whom pelvic floor dysfunction is identified early should be referred for pelvic floor therapy with biofeedback while first-line medications, such as bulk or osmotic laxatives, are initiated.
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A detailed history and physical examination can distinguish between key features of a benign primary headache and concerning symptoms that warrant further evaluation for a secondary headache. Most headaches that are diagnosed in the primary care setting are benign. Among primary headache disorders, tension-type headache is the most common, although a migraine headache is more debilitating and likely to present in the primary care setting. ⋯ A lumbar puncture is also needed to rule out subarachnoid hemorrhage if the scan result is normal. For less urgent cases, magnetic resonance imaging of the brain is preferred for evaluating headaches with concerning features. Primary headache disorders without red flags or abnormal examination findings do not need neuroimaging.
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Thrombocytopenia is a platelet count of less than 150 × 103 per μL and can occur from decreased platelet production, increased destruction, splenic sequestration, or dilution or clumping. Patients with a platelet count greater than 50 × 103 per μL are generally asymptomatic. Patients with platelet counts between 20 and 50 × 103 per μL may have mild skin manifestations such as petechiae, purpura, or ecchymosis. ⋯ Transfusion of platelets is recommended when patients have active hemorrhage or when platelet counts are less than 10 × 103 per μL, in addition to treatment (when possible) of underlying causative conditions. It is important to ensure adequate platelet counts to decrease bleeding risk before invasive procedures; this may also require a platelet transfusion. Patients with platelet counts of less than 50 × 103 per μL should adhere to activity restrictions to avoid trauma-associated bleeding.
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Each year, malaria causes an estimated 500,000 deaths worldwide. Most of these deaths occur in Africa and disproportionally affect children younger than five years worldwide. Human malarial disease is caused by protozoan parasites of the genus Plasmodium. ⋯ Severe malaria is mainly caused by Plasmodium falciparum. Children, pregnant patients, and people who are not from endemic regions are at highest risk of severe malaria. Intravenous artesunate is the treatment of choice for severe malaria.