American family physician
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American family physician · Jun 2022
Metabolic Surgery for Adult Obesity: Common Questions and Answers.
In 2019, approximately 256,000 metabolic surgery procedures were performed in the United States, a 32% increase since 2014. The most common procedures are the laparoscopic sleeve gastrectomy and the Roux-en-Y gastric bypass. Choice of procedure depends on concurrent medical conditions, patient preference, and expertise of the surgeon. ⋯ Persistent changes in diet, such as consuming protein first at every meal, regular physical activity, and ongoing attention to behavior change are critical for the success of the patient after metabolic surgery. Common adverse outcomes include surgical complications, nutritional deficiencies, bone density loss, dumping syndrome, gastroesophageal reflux disease, and loose skin. The family physician is well positioned to counsel patients about metabolic surgical options and the risks and benefits of surgery and to provide long-term support and medical management for postsurgery patients.
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Soft tissue masses are a common presentation in family physician offices. Although most lesions, including lipomas, fibromas, and epidermal and ganglion cysts, are benign, rare lesions such as soft tissue sarcomas may have serious consequences. Masses that are deep to the fascia, are 5 cm in diameter or larger, grow rapidly, or present suddenly without explanation should prompt further workup. ⋯ Incisional biopsy of a concerning soft tissue mass can also be useful for establishing a diagnosis. Lipomas and epidermal cysts may be excised if they are painful or if there is concern for malignancy. Because of the high mortality rate of soft tissue sarcomas, evaluation of high-risk masses with magnetic resonance imaging with contrast should be expedited with a referral to orthopedic oncology.
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Finger fractures and dislocations are commonly seen in the primary care setting. Patients typically present with a deformity, swelling, and bruising with loss of function. Anteroposterior, lateral, and oblique radiography should be performed to identify fractures and distinguish uncomplicated injuries from those requiring referral. ⋯ Distal interphalangeal joint dislocations require reduction and splinting in full extension (for volar dislocations) or 15 to 30 degrees of flexion (for dorsal dislocations) for two to three weeks. Dorsal metacarpophalangeal joint dislocations are managed with reduction and splitting, but referral to an orthopedic specialist is required if the dislocation is not easily reduced. Volar metacarpophalangeal dislocations are rare and warrant referral.
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Stroke accounts for significant morbidity and mortality and is the fifth leading cause of death in the United States, with direct and indirect costs of more than $100 billion annually. Expedient recognition of acute neurologic deficits with appropriate history, physical examination, and glucose testing will help diagnose stroke and rule out mimicking presentations. The National Institutes of Health Stroke Scale should be used to determine stroke severity and to monitor for evolving changes in clinical presentation. ⋯ Patients with cerebellar symptoms should be evaluated with a HINTS (head-impulse, nystagmus, test of skew) examination because it is more sensitive for cerebellar stroke than early magnetic resonance imaging. Additional cerebrovascular imaging should be considered in patients with large vessel occlusions presenting within 24 hours of last known well to assess benefits of endovascular interventions. Once initial interventions have been implemented, poststroke evaluations such as telemetry, echocardiography, and carotid imaging should be performed as clinically indicated to determine the etiology of the stroke.
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Community-acquired pneumonia (CAP) is a common condition with a hospitalization rate of about 2% in people 65 years or older and is associated with a 30-day mortality rate of 6% in hospitalized patients. In studies conducted before the COVID-19 pandemic, a bacterial pathogen was identified in 11% of patients, a viral pathogen in 23% of patients, and no organism in 62% of patients. Certain signs and symptoms can be helpful in diagnosing CAP and selecting imaging studies. ⋯ All adults 65 years or older or those 19 to 64 with underlying conditions should receive the 20-valent pneumococcal conjugate vaccine alone or the 15-valent pneumococcal conjugate vaccine followed by 23-valent pneumococcal polysaccharide vaccine one year later. The 13-valent pneumococcal conjugate vaccine is no longer recommended for routine administration. The Centers for Disease Control and Prevention recommends vaccination against influenza and SARS-CoV-2 viruses for all adults.