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.