Managing Selected Chronic Conditions in Hospitalized Patients.

The management of chronic illnesses should continue during hospitalization. Some chronic conditions require immediate intervention, whereas intensification of therapy for other conditions may be delayed until after discharge. Factors such as pain, anxiety, poor sleep hygiene, and concurrent illness can result in a transient elevation of blood pressure. Acute lowering of blood pressure in hospitalized patients who do not have target-organ damage is not recommended and may lead to harm. If treatment is needed, intravenous antihypertensive agents should be avoided. Patients with diabetes mellitus require continued management of their blood glucose while hospitalized. Noninsulin agents are typically discontinued. Blood glucose levels should be managed using basal, prandial, and/or correction insulin. During hospitalization, conservative blood glucose targets (140 to 180 mg per dL) are preferred vs. lower targets to reduce length of stay, mortality, and the risk of hypoglycemic events in critically ill patients. Alcohol use disorder is common and hospitalization for other conditions necessitates identification and management of alcohol withdrawal syndrome. The mainstay of therapy for alcohol withdrawal syndrome is benzodiazepines; however, phenobarbital is an alternative treatment option. The risk of venous thromboembolic disease is significantly increased for hospitalized patients. Venous thromboprophylaxis is recommended for all but low-risk patients. Pharmacologic prophylaxis with subcutaneous low-molecular-weight heparin is preferred; mechanical prophylaxis is an alternative for patients who are at high risk of bleeding or have contraindications to anticoagulation.

Cardiovascular Disease: Other Common Arrhythmias.

Premature atrial contractions (PACs) occur in nearly all individuals. Although typically asymptomatic, they can cause palpitations. PACs previously were considered benign, but there is increasing recognition that frequent PACs are associated with developing atrial fibrillation. After potentially reversible causes (eg, electrolyte abnormalities, hyperthyroidism) are eliminated, symptomatic PACs can be treated with beta blockers; some patients are candidates for ablation. Premature ventricular contractions (PVCs) also are common, occurring in more than two-thirds of the population. They typically are asymptomatic, but some patients experience palpitations and dizziness. Persistent PVCs are associated with underlying heart disease; an echocardiogram can help detect this disease. Reversible causes (eg, electrolyte abnormalities, hyperthyroidism, stimulant drug use) should be excluded. Patients with PVCs and left ventricular dysfunction are candidates for ablation. Others may be treated with beta blockers, nondihydropyridine calcium channel blockers, or antiarrhythmics. Supraventricular tachycardia also is common. Hemodynamically unstable patients are treated with cardioversion. Stable symptomatic patients can be considered for catheter ablation or medical antiarrhythmics. Finally, sinus node dysfunction, previously called sick sinus syndrome, causes a variety of rhythm disturbances, including bradycardia, sinus arrest, bradycardia-tachycardia syndrome, and others. Unstable patients are treated with atropine to increase heart rate. Stable patients should discontinue bradycardia-causing drugs, if possible. Some may require a pacemaker.

Cardiovascular Disease: Inflammatory and Infectious Heart Conditions.

Acute pericarditis, the most common inflammatory heart condition, typically is caused by viral infections. Patients have sharp chest pain that improves when leaning forward. Electrocardiogram typically shows widespread ST-segment elevation; echocardiogram may show pericardial effusion; and levels of inflammatory markers may be elevated. Colchicine plus nonsteroidal anti-inflammatory drugs are first-line treatment. Patients with fever, elevated inflammatory marker levels, or pericardial effusion should be hospitalized. Myocarditis also commonly is caused by viruses, although some cases are due to autoimmune or other conditions. Symptoms include chest pain, dyspnea, and fever. Although endomyocardial biopsy is the definitive diagnostic test, most cases are diagnosed based on clinical symptoms, electrocardiogram, echocardiogram, and cardiac markers, plus excluding other conditions. Patients with heart failure should receive guideline-recommended therapy, plus treatment of underlying conditions (eg, autoimmune conditions). Infective endocarditis is caused by infection of cardiac valves, chambers, or intracardiac devices. There are many causative organisms, but Staphylococcus aureus is most common. Fever is the most frequent symptom, although some patients have systemic emboli or heart failure. The modified Duke criteria can aid in diagnosis, which is confirmed by positive blood cultures. Antibiotics are started immediately after obtaining blood cultures, modified based on culture results, and continued for 4 to 6 weeks after first negative culture.

Cardiovascular Disease: Atrial Fibrillation and Atrial Flutter.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in adults, with lifetime rates of 21% to 33%. There are numerous risk factors, including older age, hypertension, coronary disease, obstructive sleep apnea, diabetes, and others. Patients engaging in lifelong high-endurance exercise also have increased risk. Some organizations recommend screening; others do not. However, many patients identify AF themselves using mobile cardiac monitoring devices, some of which accurately detect the arrhythmia. Patients with AF with hemodynamic instability are treated with immediate synchronized cardioversion. Treatment options for stable patients include scheduled cardioversion, rhythm control with pharmacotherapy, catheter ablation, and rate control with pharmacotherapy. Catheter ablation is increasingly used as first-line therapy, with up to 80% of patients remaining AF-free after one or two ablation treatments, an outcome superior to that with pharmacotherapy. Patients with AF should receive anticoagulation based on the CHA2DS2-VASc (Congestive heart failure, Hypertension, Age 75 years or older [doubled], Diabetes, prior Stroke or transient ischemic attack or thromboembolism [doubled], Vascular disease, Age 65 to 74 years, Sex category) score, and also before and immediately after ablation or cardioversion. It is uncertain whether long-term anticoagulation is needed after successful ablation. Atrial flutter (AFL) is the second most common sustained supraventricular arrhythmia. Patients with AFL are at risk of developing AF, and many recommendations for managing AFL are similar to those for AF. The preferred management for AFL is catheter ablation, with success rates exceeding 90%.

Cardiovascular Disease: Anticoagulation Therapy for Atrial Fibrillation.

Patients with atrial fibrillation (AF) should receive anticoagulation with warfarin or direct oral anticoagulants (DOACs) if the CHA2DS2-VASc (Congestive heart failure, Hypertension, Age 75 years or older [doubled], Diabetes, prior Stroke or transient ischemic attack or thromboembolism [doubled], Vascular disease, Age 65 to 74 years, Sex category) score is at least 2 in men or 3 in women. Antiplatelet therapy is not recommended. DOACs typically are the first-line therapy. Anticoagulation requires special consideration in some patient groups (eg, patients with bleeding problems should be considered for left atrial appendage occlusion devices, rather than anticoagulation). Atrial high-rate episodes detected on electronic devices confer higher AF risk; however, there currently are no clearly defined thresholds to determine who benefits from anticoagulation. Patients with AF with valvular heart disease should receive anticoagulation based on CHA2DS2-VASc score; those with mechanical heart valves or moderate to severe stenosis of a native mitral valve should receive warfarin, not DOACs. Chronic kidney disease requires dose reduction. Patients with AF taking antiplatelet therapy for acute coronary syndrome or percutaneous coronary intervention require special consideration because of the bleeding risk. The risk-benefit profile favors anticoagulation in older adults. Patients undergoing surgical procedures with high bleeding risk often need temporary anticoagulant discontinuation. Patients receiving anticoagulation who develop life-threatening bleeding should receive reversal therapy.

Thrombocytopenia: Evaluation and Management.

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. Patients with platelet counts of less than 10 × 103 per µL have a high risk of serious bleeding. Although thrombocytopenia is classically associated with bleeding, there are conditions in which bleeding and thrombosis can occur, such as antiphospholipid syndrome, heparin-induced thrombocytopenia, and thrombotic microangiopathies. Patients with isolated thrombocytopenia in the absence of systemic illness most likely have immune thrombocytopenia or drug-induced thrombocytopenia. In stable patients being evaluated as outpatients, the first step is to exclude pseudothrombocytopenia by collecting blood in a tube containing heparin or sodium citrate and repeating the platelet count. If thrombocytopenia is confirmed, the next step is to distinguish acute from chronic thrombocytopenia by obtaining or reviewing previous platelet counts. Patients with acute thrombocytopenia may require hospitalization. Common causes that require emergency hospitalization are heparin-induced thrombocytopenia, thrombotic microangiopathies, and the hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Common nonemergency causes of thrombocytopenia include drug-induced thrombocytopenia, immune thrombocytopenia, and hepatic disease. 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.

Otolaryngeal and Oropharyngeal Conditions: Dysphonia.

Dysphonia is any alteration of voice quality or vocal effort that impairs communication and affects quality of life. In patients with dysphonia, voice qualities often are described as tremulous, hoarse, strained, or raspy, with altered pitch, breathiness, or vocal fatigue. Dysphonia is a sign of an underlying disease process. Up to one-third of individuals will experience dysphonia in their lifetime. The evaluation includes a history, physical examination, and, in some cases, laryngoscopy. The most common cause of dysphonia is acute laryngitis, with the majority of cases lasting fewer than 3 weeks. Longer duration of symptoms occurs with chronic laryngitis, laryngopharyngeal reflux, muscle tension dysphonia, benign vocal fold lesions, vocal fold paresis or paralysis, and spasmodic dysphonia. Laryngeal malignancy is uncommon; the major risk factors are smoking and concurrent alcohol use. Laryngoscopy should be performed in all patients with dysphonia that does not resolve or improve within 4 weeks or of any duration if a serious underlying etiology is suspected. Management is directed at the underlying etiology. Empiric treatment with antibiotics, corticosteroids, and antireflux drugs should be avoided in the absence of a clear indication. In patients with a definitive diagnosis, management includes vocal hygiene, voice therapy, pharmacotherapy, and surgery.

Otolaryngeal and Oropharyngeal Conditions: Temporomandibular Disorders.

Temporomandibular disorders (TMDs) is a collective term for a group of heterogeneous musculoskeletal and neuromuscular conditions involving the temporomandibular joint (TMJ) complex, masticatory muscles, and surrounding osseous structures. TMDs affect 5% to 12% of the US population, with a peak incidence at ages 45 to 65 years. Common clinical manifestations include facial pain, ear pain, headache, TMJ discomfort, and adventitious sounds. The etiologies of TMDs are multifactorial and include behavioral, social, emotional, and occlusive factors. Common causes of TMDs are myofascial pain and dysfunction, articular disk displacement, and degenerative joint conditions. In most cases, the diagnosis can be made based on the history and physical examination. In the absence of trauma, imaging typically is reserved for patients with chronic TMDs. Initial management includes education, self-management, behavioral therapy, and physical therapy. Occlusal devices are recommended for management of sleep bruxism or diurnal clenching. Adjunctive pharmacotherapies include nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, antidepressants, and anticonvulsants. (This is an off-label use of some NSAIDs and an off-label use of benzodiazepines, antidepressants, and anticonvulsants.) Intra-articular injections have been used alone or with arthrocentesis. Patients who do not benefit from these therapies should be referred to an oral and maxillofacial surgeon.

Otolaryngeal and Oropharyngeal Conditions: Common Nontraumatic Dental Conditions.

Dental and oral health conditions are widespread in the US population. Among children and teenagers, 46% have dental cavities; among adults, more than 90% have cavities and 46% have periodontal disease. In 2015, more than $117 billion was spent on dental care in the United States, with a significant share delivered in emergency departments (EDs). Common nontraumatic dental conditions seen in EDs include dental pain and infection. Less than one-third of patients seek follow-up dental care. The mildest form of oral disease is dental cavities. Gingivitis is inflammation of the gums. Left unmanaged, it can lead to necrotizing ulcerative gingivitis, periodontitis, and periodontal abscesses. Acute periodontal abscess can be managed by a nondental physician with simple incision and drainage. Rarely, patients will develop orofacial space infections from unrecognized or unmanaged dental infections. These medical emergencies require immediate surgical consultation. Initial management of postextraction bleeding consists of application of constant pressure for more than 30 min at the bleeding site. Dental conditions and their complications are preventable. Family physicians play a role in providing oral health education. The primary areas of needed intervention are continuity of dental care, healthy nutritional habits, oral hygiene education, systemic disease management, and smoking cessation.

Otolaryngeal and Oropharyngeal Conditions: Common Ear Conditions.

Ear pain (otalgia) is a common reason for visits to family physician offices and emergency departments. Otalgia is primary when the pathology originates from the ear, and is secondary for disease processes associated with otalgia and an ear examination with normal findings. The most common diagnosis related to otalgia in children and adults is acute otitis media (AOM). It is characterized by an erythematous, bulging, and cloudy tympanic membrane. Otitis media with effusion is the presence of fluid behind the tympanic membrane without signs of inflammation. Chronic middle ear effusion is managed definitively with myringotomy and tympanostomy tube placement. Tympanic membrane rupture is a common complication after AOM or trauma. Tympanic membranes that do not heal develop chronic infection, leading to chronic suppurative otitis media. Initial management is cleaning and drying of the ear and application of topical antibiotics. Otitis externa is a painful cellulitis of the external auditory canal associated with erythema, edema, and occasional drainage. Cerumen impaction is managed with cerumenolytics, irrigation, or manual extraction. Foreign bodies in the ear are common in children younger than 6 years. Many foreign bodies can be removed with irrigation or forceps.

Syncope: Evaluation and Differential Diagnosis.

Syncope is an abrupt and transient loss of consciousness caused by cerebral hypoperfusion. It accounts for 1% to 1.5% of emergency department visits, resulting in high hospital admission rates and significant medical costs. Syncope is classified as neurally mediated, cardiac, and orthostatic hypotension. Neurally mediated syncope is the most common type and has a benign course, whereas cardiac syncope is associated with increased morbidity and mortality. Patients with presyncope have similar prognoses to those with syncope and should undergo a similar evaluation. A standardized approach to syncope evaluation reduces hospital admissions and medical costs, and increases diagnostic accuracy. The initial assessment for all patients presenting with syncope includes a detailed history, physical examination, and electrocardiography. The initial evaluation may diagnose up to 50% of patients and allows immediate short-term risk stratification. Laboratory testing and neuroimaging have a low diagnostic yield and should be ordered only if clinically indicated. Several comparable clinical decision rules can be used to assess the short-term risk of death and the need for hospital admission. Low-risk patients with a single episode of syncope can often be reassured with no further investigation. High-risk patients with cardiovascular or structural heart disease, history concerning for arrhythmia, abnormal electrocardiographic findings, or severe comorbidities should be admitted to the hospital for further evaluation. In cases of unexplained syncope, provocative testing and prolonged electrocardiographic monitoring strategies can be diagnostic. The treatment of neurally mediated and orthostatic hypotension syncope is largely supportive, although severe cases may require pharmacotherapy. Cardiac syncope may require cardiac device placement or ablation.

Diagnosis and treatment of temporomandibular disorders.

Temporomandibular disorders (TMD) are a heterogeneous group of musculoskeletal and neuromuscular conditions involving the temporomandibular joint complex, and surrounding musculature and osseous components. TMD affects up to 15% of adults, with a peak incidence at 20 to 40 years of age. TMD is classified as intra-articular or extra-articular. Common symptoms include jaw pain or dysfunction, earache, headache, and facial pain. The etiology of TMD is multifactorial and includes biologic, environmental, social, emotional, and cognitive triggers. Diagnosis is most often based on history and physical examination. Diagnostic imaging may be beneficial when malocclusion or intra-articular abnormalities are suspected. Most patients improve with a combination of noninvasive therapies, including patient education, self-care, cognitive behavior therapy, pharmacotherapy, physical therapy, and occlusal devices. Nonsteroidal anti-inflammatory drugs and muscle relaxants are recommended initially, and benzodiazepines or antidepressants may be added for chronic cases. Referral to an oral and maxillofacial surgeon is indicated for refractory cases.

Common questions about outpatient care of premature infants.

Preterm births (deliveries before 37 weeks' gestation) comprise 12% of all U.S. births and are responsible for onethird of all infant deaths. Neonatal medical advances have increased survival, and primary care physicians often care for infants who were in the neonatal intensive care unit after birth. Functions of the primary care physician include coordination of medical and social services, nutritional surveillance, and managing conditions associated with prematurity. Parental guidance and encouragement are often necessary to ensure appropriate feeding and infant weight gain. Enriched formula and nutrient fortifiers are used for infants with extrauterine growth restriction. Iron supplementation is recommended for breastfed infants, and iron-fortified formula for formula-fed infants. Screening for iron deficiency anemia in preterm infants should occur at four months of age and at nine to 12 months of age. Gastroesophageal reflux is best treated with nonpharmacologic options because medications provide no long-term benefits. Neurodevelopmental delay occurs in up to 50% of preterm infants. Developmental screening should be performed at every well-child visit. If developmental delay is suspected, more formalized testing may be required with appropriate referral. To prevent complications from respiratory syncytial virus infection, palivizumab is recommended in the first year of life during the respiratory syncytial virus season for all infants born before 29 weeks' gestation and for infants born between 29 and 32 weeks' gestation who have chronic lung disease. Most preterm infants have minimal longterm sequelae.

Early recognition and management of sepsis in adults: the first six hours.

Sepsis is a complication of severe infection characterized by a systemic inflammatory response. Mortality rates from sepsis range between 25% to 30% for severe sepsis and 40% to 70% for septic shock. The clinical presentation of sepsis is highly variable depending on the etiology. The most common sites of infection are the respiratory, genitourinary, and gastrointestinal systems, as well as the skin and soft tissue. Fever is often the first manifestation of sepsis, with pneumonia being the most common presentation leading to sepsis. Early goal-directed therapy completed within the first six hours of sepsis recognition significantly decreases in-hospital mortality. Initial management includes respiratory stabilization followed by aggressive fluid resuscitation. Vasopressor therapy is indicated when fluid resuscitation fails to restore adequate mean arterial pressure and organ perfusion. Early antibiotic therapy can improve clinical outcomes, and should be given within one hour of suspected sepsis. Blood product therapy may be required in some cases to correct coagulopathy and anemia, and to improve the central venous oxygen saturation. Insulin therapy may be required to maintain serum glucose levels less than 180 mg per dL. Initiation of low-dose corticosteroids may further improve survival in patients with septic shock that does not respond to vasopressor therapy. Timely initiation of evidence-based protocols should improve sepsis outcomes.

Thrombocytopenia.

Thrombocytopenia is defined as a platelet count of less than 150 × 10(3) per µL. It is often discovered incidentally when obtaining a complete blood count during an office visit. The etiology usually is not obvious, and additional investigation is required. Patients with platelet counts greater than 50 × 10(3) per µL rarely have symptoms. A platelet count from 30 to 50 × 10(3) per µL rarely manifests as purpura. A count from 10 to 30 × 10(3) per µL may cause bleeding with minimal trauma. A platelet count less than 5 × 10(3) per µL may cause spontaneous bleeding and constitutes a hematologic emergency. Patients who present with thrombocytopenia as part of a multisystem disorder usually are ill and require urgent evaluation and treatment. These patients most likely have an acute infection, heparin-induced thrombocytopenia, liver disease, thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, disseminated intravascular coagulation, or a hematologic disorder. During pregnancy, preeclampsia and the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome are associated with thrombocytopenia. Patients with isolated thrombocytopenia commonly have drug-induced thrombocytopenia, immune thrombocytopenic purpura, pseudothrombocytopenia, or if pregnant, gestational thrombocytopenia. A history, physical examination, and laboratory studies can differentiate patients who require immediate intervention from those who can be treated in the outpatient setting. Treatment is based on the etiology and, in some cases, treating the secondary cause results in normalization of platelet counts. Consultation with a hematologist should be considered if patients require hospitalization, if there is evidence of systemic disease, or if thrombocytopenia worsens despite initial treatment.

Evaluation of syncope.

Syncope is a transient and abrupt loss of consciousness with complete return to preexisting neurologic function. It is classified as neurally mediated (i.e., carotid sinus hypersensitivity, situational, or vasovagal), cardiac, orthostatic, or neurogenic. Older adults are more likely to have orthostatic, carotid sinus hypersensitivity, or cardiac syncope, whereas younger adults are more likely to have vasovagal syncope. Common nonsyncopal syndromes with similar presentations include seizures, metabolic and psychogenic disorders, and acute intoxication. Patients presenting with syncope (other than neurally mediated and orthostatic syncope) are at increased risk of death from any cause. Useful clinical rules to assess the short-term risk of death and the need for immediate hospitalization include the San Francisco Syncope Rule and the Risk Stratification of Syncope in the Emergency Department rule. Guidelines suggest an algorithmic approach to the evaluation of syncope that begins with the history and physical examination. All patients presenting with syncope require electrocardiography, orthostatic vital signs, and QT interval monitoring. Patients with cardiovascular disease, abnormal electrocardiography, or family history of sudden death, and those presenting with unexplained syncope should be hospitalized for further diagnostic evaluation. Patients with neurally mediated or orthostatic syncope usually require no additional testing. In cases of unexplained syncope, further testing such as echocardiography, grade exercise testing, electrocardiographic monitoring, and electrophysiologic studies may be required. Although a subset of patients will have unexplained syncope despite undergoing a comprehensive evaluation, those with multiple episodes compared with an isolated event are more likely to have a serious underlying disorder.