American family physician
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American family physician · Nov 2024
ReviewRheumatoid Arthritis: Diagnosis and Management for the Family Physician.
Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that causes joint inflammation, erosion, and deformity. The prevalence of RA in North America is 0.5% to 1%. RA is associated with significant morbidity and disability and an increased mortality rate. ⋯ Although RA remains incurable, patient quality of life has improved dramatically with biologic disease-modifying antirheumatic drugs (DMARDs) and targeted synthetic DMARDs. All DMARDs increase the risk of infection; therefore, routine vaccinations should be up to date in patients taking these drugs. Because patients with RA have increased risk of cardiovascular disease, addressing other cardiovascular risk factors may reduce morbidity and mortality.
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Genital herpes is a sexually transmitted infection caused by herpes simplex virus (HSV) type 1 or 2. It affects at least 500 million people worldwide and is a lifelong condition involving initial infection and periodic reactivation with variable viral shedding. There are no vaccinations for the prevention of HSV, and routine serologic screening is not recommended in asymptomatic individuals. ⋯ Complications of genital herpes include encephalitis, meningitis, and urinary retention. During pregnancy, antiviral suppression is recommended starting at 36 weeks of gestation in patients with a known history of genital herpes. Elective cesarean delivery should be offered to patients with active lesions to reduce neonatal exposure to HSV.
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Tongue conditions occur in 15.5% of the US population. The most common tongue conditions are geographic tongue, fissured tongue, and black hairy tongue; these conditions do not require treatment. Median rhomboid glossitis can be associated with a candidal infection; symptomatic lesions usually improve with use of antifungals. ⋯ Burning mouth syndrome often involves the tongue, and if it does not resolve spontaneously, studies have shown improvement with gabapentin, topical clonazepam, capsaicin, and cognitive behavior therapy. Oral lichen planus is a chronic inflammatory disorder that can affect the tongue and is best treated with topical or systemic corticosteroids and calcineurin inhibitors. There is a lack of consensus on the definition and treatment of ankyloglossia (tongue-tie); however, some evidence supports that frenotomy can improve breastfeeding and decrease lactation-associated nipple pain.
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Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 and type 2 diabetes resulting from an absolute or relative insulin deficiency. It can occur in patients of all ages and can be the initial presentation of diabetes, especially in young children. Polyuria and polydipsia are the most common symptoms, followed by nausea, vomiting, abdominal pain, weight loss, severe fatigue, dyspnea, and preceding febrile illness. ⋯ Amylase, lipase, hepatic transaminase levels, troponin, creatine kinase, blood and urine cultures, and chest radiography are additional tests to consider. Treatment involves fluid and electrolyte replacement, insulin, treatment of precipitating causes, and close monitoring to adjust therapy and identify complications. Prevention strategies include identifying diabetes before DKA develops, educating patients to manage high-risk situations, and ensuring uninterrupted access to therapies for diabetes.
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Prostate cancer is the most diagnosed noncutaneous malignancy and the second most common cause of cancer death among men in the United States. Risk factors include older age, family history of prostate cancer, and Black race. Screening via prostate-specific antigen testing may lead to a small reduction in prostate cancer-specific mortality, with no reduction in all-cause mortality, but it can cause significant harms related to false-positive test results, unnecessary biopsies, overdiagnosis, and overtreatment. ⋯ If the prostate-specific antigen level is still elevated, next steps include multiparametric magnetic resonance imaging, assessment of urine or blood biomarkers, and referral to urology. Active surveillance is increasingly accepted as the preferred standard of care for patients with newly diagnosed low-risk prostate cancer, because it is associated with similar long-term survival and better quality of life than curative treatment. The primary intent of screening is to identify patients with clinically significant prostate cancer who may benefit from curative treatment while minimizing the detection of clinically insignificant cancer.