AFP's Top Articles
View the top 20 articles published in American Family Physician each year based on web views.
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The following lists are the 20 most popular articles from each year according to page views on the website. The articles are listed in order of most views.

2023

Hypertension in Adults: Initial Evaluation and Management

S. Lindsey Clarke

Hypertension is a leading modifiable risk factor for cardiovascular disease and the most common chronic condition seen by family physicians. Treatment reduces morbidity and mortality due to coronary artery disease, myocardial infarction, heart failure, stroke, and chronic kidney disease. October 2023

Syncope: Evaluation and Differential Diagnosis

Max Bayard, Fereshteh Gerayli, and James Holt

Syncope is an abrupt, transient, and complete loss of consciousness caused by cerebral hypoperfusion. The condition is common, and evaluation focuses on history, physical examination (including orthostatic blood pressure measurements), and electrocardiographic results. November 2023

Fibromyalgia: Diagnosis and Management

Bradford T. Winslow, Carmen Vandal, and Laurel Dang

Fibromyalgia is characterized by diffuse musculoskeletal pain, fatigue, poor sleep, and other somatic symptoms. It can occur in children and adults and is found worldwide and across cultures. Changes in the diagnostic criteria over the past decade have resulted in more patients with chronic pain meeting the criteria for fibromyalgia. February 2023

Managing Menopausal Symptoms: Common Questions and Answers

Jennifer G. Chang, Meghan N. Lewis, and Maggie C. Wertz

Menopause can cause bothersome vasomotor and genitourinary symptoms, including hot flashes and vulvovaginal dryness. Treatment includes hormonal and nonhormonal options. The choice of formulation depends on patient preference and consideration of individual risks and benefits. July 2023

Osteoporosis: Common Questions and Answers

Kira Harris, Christopher A. Zagar, and Kelley V. Lawrence

Osteoporosis affects 10.2% of adults older than 50 years and is expected to increase to 13.6% by 2030. Osteoporotic fractures, specifically hip fractures, have significant impacts on morbidity, mortality, and quality of life. March 2023

Chronic Asthma Treatment: Common Questions and Answers

Tyler J. Raymond, Thomas A. Peterson, and Jessica Coulter

This article reviews common questions about outpatient asthma treatment and provides evidence-based answers. April 2023

Common Dermatologic Conditions in Skin of Color

Winfred Taylor Frazier, Sanketh Proddutur, and Kayley Swope

This article focuses on five diagnoses that disproportionately affect people with skin of color and can substantially impact mental health and quality of life. January 2023

Acute Abdominal Pain in Adults: Evaluation and Diagnosis

Ken S. Yew, Mary K. George, and Heidi Allred

The most common causes of acute abdominal pain are gastroenteritis and nonspecific abdominal pain. The location of pain, history, examination findings, and imaging in selected patients help guide the workup. June 2023

Prenatal Care: An Evidence-Based Approach

Sarah Inés Ramírez

Well-coordinated prenatal care that follows an evidence-based, informed process results in fewer hospital admissions, improved education, greater patient satisfaction, and lower pregnancy-associated morbidity and mortality. August 2023

Allergic Rhinitis: Rapid Evidence Review

Jackie Weaver-Agostoni, Zachary Kosak, and Stacy Bartlett

This rapid evidence review article outlines the most current evidence for the diagnosis and treatment of allergic rhinitis. May 2023

Smell and Taste Disorders in Primary Care

Dillon J. Savard, Francesca G. Ursua, and Heidi L. Gaddey

Disorders of smell and taste are common, especially among older people. Smell and taste disorders affect quality of life and the ability to identify smoke and toxins. These disorders can be an early sign of dementia or Parkinson disease and are associated with increased mortality. September 2023

Chronic Kidney Disease: Prevention, Diagnosis, and Treatment

Andrew J. Goodbred and Robert C. Langan

Chronic kidney disease affects approximately 15% of the U.S. population; however, 9 out of 10 people do not know they have impaired renal function. The most common causes of chronic kidney disease are diabetes mellitus (38%) and hypertension (26%). More advanced disease is associated with an increased risk of cardiovascular disease and death. December 2023

Childhood and Adolescent Sports-Related Overuse Injuries

Laura J. Lintner, Jeremy Swisher, and Zachary E. Sitton

With early sports specialization, overuse injuries are becoming more common. Proper technique, resistance training, protective equipment, and avoiding early sports specialization are necessary for injury prevention in adolescents. December 2023

Diagnosis and Management of Sodium Disorders: Hyponatremia and Hypernatremia

Nathaniel E. Miller, David Rushlow, and Stephen K. Stacey

Sodium abnormalities are electrolyte disorders associated with significant morbidity and mortality. An understanding of the pathophysiologic basis of these conditions can be helpful in diagnosis and treatment. November 2023

Joint and Soft Tissue Injections

Julie A. Creech-Organ, Sarah E. Szybist, and Jacqueline L. Yurgil

Musculoskeletal conditions are reported by 48% of the population and are a significant component of primary care visits. A patient’s understanding of risks, benefits, and alternatives to injection promotes patient-oriented outcomes. August 2023

Fatigue in Adults: Evaluation and Management

Kelly M. Latimer, Althea Gunther, and Michael Kopec

Fatigue is among the top 10 reasons patients visit primary care offices, and it significantly affects patients’ well-being and occupational safety. Myalgic encephalomyelitis/chronic fatigue syndrome is a chronic, severe, and potentially debilitating disorder. July 2023

Tonsillitis and Tonsilloliths: Diagnosis and Management

Kelly Lacy Smith, Rachel Hughes, and Palee Myrex

Tonsillitis is most commonly caused by viruses. Treatment is focused on supportive care; however, if tonsillitis is caused by group A beta-hemolytic streptococcus, it should be treated with antibiotics to prevent complications. Tonsillar stones may be associated with recurrent tonsillitis and are managed expectantly. January 2023

Psoriasis: Recognition and Management Strategies

Kathryn K. Garner, Kattie D. S. Hoy, and Adriana M. Carpenter

Psoriasis is an inflammatory skin and systemic disorder that affects 3.2% of the U.S. population, including 1% of children. It presents in various forms; treatment strategies are similar for most forms of psoriasis and based on body surface area involved. Special consideration is needed for treatment of children and patients who are pregnant, breastfeeding, or trying to conceive. December 2023

Over-the-Counter Medications in Pregnancy

Elizabeth Allison Powers, Ryan Tewell, and Max Bayard

This article reviews the safety and effectiveness of over-the-counter medications for common conditions of pregnancy. October 2023

Pleural Effusion: Diagnostic Approach in Adults

Joy Shen-Wagner, Christine Gamble, and Phyllis MacGilvray

Evaluation of pleural effusion focuses on differentiating exudates from transudates, analyzing fluids, and determining the need for thoracentesis or specialty consultation. Accurate and early diagnosis is critical, with delays potentially causing complications and increased mortality. November 2023

2022

Office-Based Urinalysis: A Comprehensive Review

Nathan Hitzeman, Dineen Greer, and Erik Carpio

Urinalysis is a simple, inexpensive means of detecting urologic and systemic conditions such as infection, urolithiasis, malignancy, and metabolic diseases. Visual inspection of the urine, familiarity with dipstick testing, and point-of-care micros-copy are important diagnostic skills for family physicians. Urine dipstick test kits are widely available and easy to use. Results may be interpreted visually off the dipstick or by an automated machine. July 2022

Antibiotic Use in Acute Upper Respiratory Tract Infections

Denise K. C. Sur and Monica L. Plesa

Studies show that many upper respiratory tract infections are treated unnecessarily with antibiotics. Antibiotics should not be used for the common cold, influenza, COVID-19, or laryngitis. Evidence supports antibiotic use in most cases of acute otitis media, group A beta-hemolytic streptococcal pharyngitis, and epiglottitis, and in a limited percentage of acute rhinosinusitis cases. December 2022

Sacroiliac Joint Dysfunction: Diagnosis and Treatment

David P. Newman and Adam T. Soto

Sacroiliac joint dysfunction is a common cause of low back pain. A set of provocation tests that together have high sensitivity and specificity can help differentiate sacroiliac joint dysfunction from other causes of back and lower extremity pain. Manipulation combined with exercise can be an effective first-line treatment. March 2022

Evidence-Based Contraception: Common Questions and Answers

Scott L. Paradise, Corinne A. Landis, and David A. Klein

Primary care clinicians are uniquely situated to provide holistic contraceptive care. This article addresses emergency contraception, fertility awareness methods of contraception, long-acting reversible contraception, and contraception options for transgender people with a uterus. September 2022

Arthropod Bites and Stings

Joel Herness, Matthew J. Snyder, and Raquelle Suzanne Newman

Insect and arachnid bites and stings account for up to 1 million emergency department visits annually in the United States. Arthropods' most significant effects on humans are as vectors for infectious diseases, and direct effects of their bites and stings are typically only a self-limited nuisance. August 2022

Common Oral Lesions

David A. Randall, N. Lyn Wilson Westmark, and Brad W. Neville

Patients with oral disease may present to their family physician before a dentist. Some lesions are purely localized to the mouth, and others have systemic manifestations. Common conditions include aphthous stomatitis, candidiasis, herpetic stomatitis, leukoplakia, erythroplakia, and oral lichen planus. April 2022

Fever of Unknown Origin in Adults

Aïsha David and Jeffrey D. Quinlan

Fever of unknown origin is defined as a clinically documented temperature of 101°F or higher on several occasions, coupled with an unrevealing diagnostic workup. The possible causes are typically categorized as infection, malignancy, noninfectious inflammatory disease, or miscellaneous. February 2022

Cluster Headache: Rapid Evidence Review

Omojo Odihi Malu, Jonathan Bailey, and Matthew Kendall Hawks

Patients with cluster headache experience severe unilateral pain located in the orbital, supraorbital, and/or temporal region that occurs from every other day up to eight times per day and lasts from 15 to 180 minutes. Attacks occur in clusters, are episodic or chronic, and are associated with ipsilateral autonomic symptoms and a sense of agitation or restlessness. January 2022

Long COVID: Rapid Evidence Review

Eric Herman, Elizabeth Shih, and Anthony Cheng

Postacute sequelae of COVID-19, or long COVID, has affected millions of people, with a broad range of symptoms such as fatigue, postexertional malaise, and cognitive dysfunction. Symptoms usually resolve over time. However, there are varying rates of recovery and outcomes, and the long-term prognosis is unclear. This article summarizes the best available evidence for the diagnosis and management of long COVID. November 2022

Metabolic Surgery for Adult Obesity: Common Questions and Answers

Elaine Seaton Banerjee, Robin Schroeder, and T. Daniel Harrison

Metabolic surgery reduces all-cause mortality by 30% to 40% at two to 15 years compared with patients with obesity who did not have surgery. Remission of type 2 diabetes mellitus occurs in as many as 70% of patients two years after surgery and is maintained at 10 years in about 30% of patients; other obesity-related conditions are also greatly reduced, and quality of life improves. June 2022

Generalized Anxiety Disorder and Panic Disorder in Adults

Katharine C. DeGeorge, Molly Grover, and Gregory S. Streeter

Generalized anxiety disorder and panic disorder are common mental health conditions often seen in primary care. Evaluation should be considered in patients who express recurrent, pervasive worry or present with multiple somatic symptoms not attributed to underlying medical conditions. Effective treatments include cognitive behavior therapy and antidepressants. August 2022

Heart Murmurs in Children: Evaluation and Management

Brian Ford, Sebastian Lara, and James Park

The lifetime incidence of murmurs in children is high. The presence of a murmur can indicate conditions ranging from no discernable pathology to acquired or congenital heart disease. All infants, with or without a murmur, should have pulse oximetry screening to detect underlying critical congenital heart disease. March 2022

Pruritus: Diagnosis and Management

Jedda Rupert and James David Honeycutt

The etiology of pruritus is complex and can include histamine, serotonin, and neuropeptide release, and neuronal itch signal transmission. General management includes trigger avoidance, liberal emollient use, limiting water exposure, and administration of oral antihistamines and topical corticosteroids. January 2022

Smoking Cessation Interventions

Heidi L. Gaddey, MaryAnn Dakkak, and Nicole Marie Jackson

Cigarette smoking is the leading cause of preventable disease and death in the United States despite its known health effects. Although nearly one-half of people who smoke try to quit each year, only up to 1 in 20 who quit without support achieve abstinence for at least six months. November 2022

Barrett Esophagus: Rapid Evidence Review

Carl Bryce, Merima Bucaj, and Renee Gazda

Barrett esophagus is estimated to affect up to 5.6% of the U.S. population. Risk factors for Barrett esophagus include gastroesophageal reflux disease, obesity, age older than 50 years, male sex, tobacco use, and a family history of Barrett esophagus or esophageal carcinoma. October 2022

Acute Headache in Adults: A Diagnostic Approach

Anthony J. Viera and Brian Antono

A detailed history and physical examination can distinguish between key features of benign primary headaches and concerning symptoms that warrant further evaluation for a secondary headache. Among primary headache disorders, tension-type is the most common, although migraine headache is more debilitating. September 2022

Orthostatic Hypotension: A Practical Approach

Michael J. Kim and Jennifer Farrell

Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or more, or a decrease in diastolic blood pressure of 10 mm Hg or more within three minutes of standing from the supine position. Goals of treatment are reducing symptoms and improving quality of life. January 2022

Diverticular Disease: Rapid Evidence Review

Justin Bailey, Sheev Dattani, and Ann Jennings

This rapid evidence review briefly summarizes signs and symptoms of and tests and clinical prediction rules for diagnosing acute diverticulitis. Management is guided by symptom severity, development of complicated disease, and patient response to treatment. August 2022

Celiac Disease: Common Questions and Answers

Pamela M. Williams, Lisa M. Harris, and Michael R. Odom

Celiac disease may present with a variety of manifestations and develop at any age. This article presents evidence-based answers to common questions about the evaluation and management of celiac disease. July 2022

Acute Diarrhea in Adults

Erica S. Meisenheimer, Carly Epstein, and Derrick Thiel In the United States, diarrhea accounts for an estimated 179 million outpatient visits, 500,000 hospitalizations, and more than 5,000 deaths annually, resulting in approximately one episode of acute diarrheal illness per person per year. Infectious noninflammatory diarrhea is typically viral in etiology and is the most frequent presentation; however, bacterial causes are also common and may be related to travel or foodborne illness. July 2022

2021

Hip Pain in Adults: Evaluation and Differential Diagnosis

Rachel Chamberlain

Hip pain usually localizes anteriorly, laterally, or posteriorly. A focused history and physical examination can help differentiate the causes of hip pain, which is important for prescribing effective therapy. The history should include personal history of hip problems, sports activities, and injuries; family history of hip problems; and the location and quality of pain, aggravating and alleviating factors, and mechanical symptoms. Physical examination should include evaluation of gait, range of motion, and muscle strength; palpation of the painful area; and special tests as indicated. If imaging is needed, standing radiography of the hip and pelvis should be the initial test. January 15, 2021

Onychomycosis: Rapid Evidence Review

Winfred Taylor Frazier, Zuleica M. Santiago-Delgado, and Kenneth C. Stupka II

Onychomycosis is a chronic fungal infection of the fingernail or toenail bed, causing brittle, discolored, and thickened nails. Confirming the diagnosis with a potassium hydroxide preparation is recommended before initiating treatment, which can include oral or topical therapies. Treatment choice should be based on shared decision-making. October 2021

Irritable Bowel Syndrome: Questions and Answers for Effective Care

John M. Wilkinson and Margaret C. Gill

Irritable bowel syndrome (IBS) is a heterogeneous group of conditions related to specific biologic and cellular abnormalities that are not fully understood. Psychological factors do not cause IBS, but many people with IBS also have an anxious or depressed mood, prior adverse life events, or psychosocial stressors. Physicians should understand the concerns and expectations of patients and the models that patients use to explain their illness and should empathetically respond to psychosocial cues. Anxiety related to the unpredictability of symptoms may have a greater effect on quality of life than the symptoms themselves. Patients who meet symptom-based criteria and have no alarm features may be confidently diagnosed with few tests. Treatments should focus on symptom relief and improved quality of life. June 15, 2021

Home Blood Pressure Monitoring

Jeffrey M. Weinfeld, Kathryn M. Hart, and Jose D. Vargas

Home blood pressure monitoring can confirm the diagnosis of hypertension after an elevated in-office blood pressure measurement. Although ambulatory blood pressure monitoring is the diagnostic standard for measurement, home blood pressure monitoring is more practical and accessible to patients. September 2021

Topical Corticosteroids: Choice and Application

Stephen K. Stacey and Mark McEleney

Topical corticosteroids are an essential tool for treating inflammatory skin conditions. These medications are classified by strength and the risk of adverse effects such as atrophy, striae, rosacea, telangiectasias, purpura, and other cutaneous and systemic reactions. The quantity prescribed depends on the duration of treatment, the frequency of application, the skin location, and the total surface area treated. March 15, 2021

Hypothyroidism: Diagnosis and Treatment

Stephen A. Wilson, Leah A. Stem, and Richard D. Bruehlman

Clinical hypothyroidism is present in one in 300 people in the United States, with a higher prevalence in female and older patients. Symptoms range from minimal to life-threatening. More common symptoms include cold intolerance, fatigue, weight gain, dry skin, constipation, and voice changes. The signs and symptoms that suggest thyroid dysfunction are nonspecific and nondiagnostic. A diagnosis is based on blood levels of thyroid-stimulating hormone and free thyroxine. There is no evidence that population screening is beneficial. Symptom relief and normalized thyroid-stimulating hormone levels are achieved with levothyroxine replacement therapy. May 15, 2021

Tinnitus: Diagnosis and Management

Sarah N. Dalrymple, Sarah H. Lewis, and Samantha Philman

Tinnitus is the perception of sound in the absence of an objective internal or external source. Tinnitus is a symptom, not a disease, and although it is typically not associated with a dangerous condition, it can significantly affect an individual’s quality of life. Guidelines recommend a standard approach to history and physical examination to determine the etiology, followed by audiometric testing and imaging, laboratory studies, and other testing as appropriate. Cognitive behavior therapy is the only treatment that has been shown to improve quality of life in patients with tinnitus. Avoidance of noise exposure may help prevent the development or progression of tinnitus. June 1, 2021

Recent-Onset Altered Mental Status: Evaluation and Management

Brian Veauthier, Jaime R. Hornecker, and Tabitha Thrasher

Potential precipitating factors for the recent onset of altered mental status can be multifactorial and include central nervous system insults, systemic infections, metabolic disturbances, toxin exposure, medications, chronic systemic diseases, and psychiatric conditions. Clinicians must quickly identify and treat reversible causes to avoid poor patient outcomes. November 2021

Care of the College Student

Brian K. Unwin, Jeffrey Goodie, Brian V. Reamy, and Jeffrey D. Quinlan

Although generally healthy, about 20% of students who attend college have special health care needs, including asthma, diabetes mellitus, and learning, mental health, and substance use disorders. Physicians can facilitate the transition of a youth to an adult model of health care by using structured processes to orient the youth to self-care. August 2021

Eating Disorders in Primary Care: Diagnosis and Management

David A. Klein, Jillian E. Sylvester, and Natasha A. Schvey

Eating disorders are potentially life-threatening conditions characterized by disordered eating and weight-control behaviors that impair physical health and psychosocial functioning. Up to 8% of females and 2% of males are affected during their lifetimes. At least one-third of persons with disordered eating develop persistent symptoms that remain 20 years postdiagnosis. Co-occurring mood, anxiety, substance use, personality, or somatic disorders are identified in more than two-thirds of persons with eating disorders. Early intervention with symptom improvement decreases the risk of a protracted course and long-term pathology. January 1, 2021

Unintentional Weight Loss in Older Adults

Heidi L. Gaddey and Kathryn K. Holder

Unintentional weight loss in people older than 65 years is associated with increased morbidity and mortality. Treatment should focus on feeding assistance, addressing contributing medications, providing appealing foods, and social support. July 2021

The Preparticipation Physical Evaluation

James MacDonald, Marie Schaefer, and Justin Stumph

The preparticipation physical evaluation (PPE) is a common primary care medical visit for young athletes. In 2019, the American Academy of Pediatrics published updated PPE recommendations. The general goals outlined in these guidelines include determining general physical and psychological health; evaluating for life-threatening or disabling conditions; and serving as an entry point into the health care system for those without a medical home or primary care physician. The PPE should include a structured physical examination with focus on the cardiovascular, musculoskeletal, and neurologic systems. Screening for depression, anxiety disorders, and attention-deficit/hyperactivity disorder is also recommended. Consideration should be taken to address the needs and concerns of transgender athletes and athletes with physical and intellectual disabilities. May 1, 2021

Interpreting SARS-CoV-2 Diagnostic Tests: Common Questions and Answers

William D. Nettleton

The spectrum of asymptomatic, presymptomatic, and symptomatic SARS-CoV-2 transmission presents challenges for evaluating SARS-CoV-2 test performance for diagnostic or screening purposes and for interpreting test results. Molecular and antigen SARS-CoV-2 tests both have high specificity. However, antigen tests generally have lower sensitivity and thus greater potential for false-negative results, especially when performed more than five days after the onset of symptoms. This article addresses common questions about SARS-CoV-2 testing and presents an approach to interpreting diagnostic test results. April 15, 2021

Health Maintenance for Women of Reproductive Age

Heather L. Paladine, Himabindu Ekanadham, and Daniela C. Diaz

This article focuses on screening and counseling for health conditions that are more prevalent in, or have a unique impact on, women, transgender men, and nonbinary individuals of reproductive age. Health issues including cardiovascular risk factors, obesity, hypertension, cancer, depression, intimate partner violence, sexually transmitted infections, and unhealthy drug and alcohol use should be considered. To have the greatest impact on health, physicians should focus on U.S. Preventive Services Task Force grade A and B recommendations with patients. February 15, 2021

Bipolar Disorders: Evaluation and Treatment

Gabrielle Marzani and Amy Price Neff

Bipolar disorders are common mental health conditions of variable severity that are difficult to diagnose. New diagnostic criteria and specifiers with attention on mixed features and anxious distress aid the physician in recognizing episode severity and prognosis. Early recognition and treatment of bipolar disorders improve outcomes. Physicians should consider bipolar disorder in any patient presenting with depression. Pharmacotherapy with mood stabilizers is a first-line treatment that should be continued indefinitely because of the risk of patient relapse. Active lifestyle approaches include good nutrition, exercise, and sleep hygiene. Monotherapy with antidepressants is contraindicated during episodes with mixed features, manic episodes, and in bipolar I disorder. Psychotherapy is a useful adjunct to pharmacotherapy. Patients and their support systems should be educated about the chronic nature of the illness, possible relapse, suicidality, environmental triggers, and the effectiveness of early intervention. February 15, 2021

Peripheral Nerve Entrapment and Injury in the Upper Extremity

Sabrina Silver, Christopher C. Ledford, Kendall J. Vogel, and James J. Arnold

Peripheral nerves in the upper extremities are at risk of injury and entrapment because of their superficial nature and length. Injury can result from trauma, anatomic abnormalities, systemic disease, and entrapment. Most peripheral nerve injuries seen by family physicians will involve neurapraxia, resulting from entrapment along the anatomic course of the nerve. History and physical examination alone are often enough to identify the injury or entrapment; advanced diagnostic testing with magnetic resonance imaging, ultrasonography, or electrodiagnostic studies helps to confirm the clinical diagnosis and is indicated if conservative management is ineffective. Initial treatment is conservative, with surgical options available for refractory injuries or entrapment caused by anatomic abnormalities. March 1, 2021

Nutrition Support Therapy

Mary N. R. Lesser and Lenard I. Lesser

Nutrition support therapy is the delivery of formulated enteral or parenteral nutrients to maintain or restore nutrition status. Family physicians can provide nutrition support therapy to patients at risk of malnutrition when it would improve clinical outcomes or quality of life. Physicians should initiate a thorough nutrition screening and assessment to determine an individual’s nutrition status and the potential need for nutrition support therapy. December 2021

Alcohol Withdrawal Syndrome: Outpatient Management

Samuel M. Tiglao, Erica S. Meisenheimer, and Robert C. Oh

Approximately one-half of patients with alcohol use disorder who abruptly stop or reduce their alcohol use will develop signs or symptoms of alcohol withdrawal syndrome. Alcohol withdrawal syndrome can lead to tremors, insomnia, nausea and vomiting, hallucinations, anxiety, and agitation. September 2021

Telemedicine Management of Musculoskeletal Issues

Nicole T. Yedlinsky and Rebecca L. Peebles

Telemedicine has become a valuable tool during the coronavirus disease 2019 pandemic. Musculoskeletal issues are a common reason for primary care visits and can often be managed using telemedicine, especially if a standardized approach is used. This article discusses telemedicine methods and techniques, including visit preparation, virtual history collection and physical examination, and initial treatment options. Findings from the virtual history and physical examination usually suggest a likely diagnosis. However, physicians should have a low threshold for proceeding with further evaluation, including in-person visits, if the diagnosis or initial management is unclear. February 1, 2021

Initiating Hormonal Contraception

Ruth Lesnewski

Most patients can safely begin using hormonal contraception at any point during their menstrual cycle. A flexible, patient-centered approach to initiating contraception promotes health and enhances patients’ reproductive autonomy. A recent Papanicolaou test is not necessary before prescribing hormonal contraception. Most patients can begin using progestin-only contraceptives immediately after childbirth. Delaying contraception to wait for the next menses or for an appointment creates unnecessary barriers for patients. Clinicians can facilitate the use of hormonal contraception by providing anticipatory guidance about common side effects, giving comprehensive information about available contraceptive choices, honoring patients’ preferences, and eliminating office-related barriers. March 1, 2021

2020

Outpatient Management of Covid-19: Rapid Evidence Review

Anthony Cheng, Dominic Caruso, and Craig McDougall

When possible, patients with suspected coronavirus disease 2019 should be triaged via telehealth before they receive in-person care. There are no evidence-based treatments appropriate for use in the outpatient setting; management is supportive and should include education about isolation. In hospitalized patients, remdesivir should be considered to reduce time to recovery, and low-dose dexamethasone should be considered in patients who require supplemental oxygen. October 15, 2020 [Updated March 1, 2021]

Managing Hypertension Using Combination Therapy

Dustin K. Smith, Robert P. Lennon, and Peter B. Carlsgaard

Most adults with primary hypertension will eventually require treatment with at least two antihypertensive agents. This article focuses on combination therapy—when to initiate it, choice of agents, and special populations whose comorbid conditions influence those choices. March 15, 2020

Acute Chest Pain in Adults: Outpatient Evaluation

John R. McConaghy, Malvika Sharma, and Hiten Patel

Approximately 1% of primary care office visits are for chest pain. Initial evaluation is based on determining whether the patient needs to be referred to a higher level of care to rule out acute coronary syndrome (ACS). Age, sex, and type of chest pain can predict the likelihood of coronary artery disease. Patients with suspicion of ACS should be transported to the emergency department. Those with low or intermediate risk can undergo outpatient testing. In those with low suspicion for ACS, consider costochondritis, gastroesophageal reflux disease, and anxiety states. Other less common considerations include acute pericarditis, pneumonia, and heart failure. December 15, 2020

Functional Dyspepsia: Evaluation and Management

Anne Mounsey, Amir Barzin, and Ashley Reitz

Dyspepsia affects up to 30% of the general population in the United States, Canada, and the United Kingdom, with 70% of patients having functional dyspepsia. Symptoms include postprandial fullness, early satiety, and epigastric pain or burning. Perform a dyspepsia endoscopy for patients 60 years or older. For patients younger than 60 years, a test and treat strategy for Helicobacter pylori is recommended before acid suppression therapy. All patients should be advised to limit foods associated with increased symptoms of dyspepsia. January 15, 2020

Management of Hypertriglyceridemia: Common Questions and Answers

Robert C. Oh, Evan T. Trivette, and Katie L. Westerfield

Hypertriglyceridemia is associated with increased risk of cardiovascular disease, and severely elevated triglyceride levels increase the risk of pancreatitis. Common risk factors for hypertriglyceridemia include obesity, metabolic syndrome, and type 2 diabetes mellitus. Management starts with lifestyle modifications such as diet and exercise. Statins can be considered for patients with high triglyceride levels who have borderline or intermediate 10-year risk of atherosclerotic cardiovascular disease. Icosapent can be added in patients at high cardiovascular risk if triglyceride levels remain high despite statin use. Fibrates, omega-3 fatty acids, or niacin may be considered in patients with severe hypertriglyceridemia to reduce the risk of pancreatitis. September 15, 2020

Neck Pain: Initial Evaluation and Management

Marc A. Childress and Samantha Jayne Stuek

The broad differential diagnosis for neck pain requires an efficient but global assessment. Emphasis is typically placed on red flags that can assist in the early recognition and treatment of more concerning diagnoses, such as traumatic injuries, infection, malignancy, vascular emergencies, and other inflammatory conditions. August 1, 2020

Atopic Dermatitis: Diagnosis and Treatment

Winfred Frazier and Namita Bhardwaj

Atopic dermatitis is a chronic relapsing and remitting inflammatory skin disease that causes intensely pruritic skin lesions. Maintenance therapy consists of liberal use of emollients and daily bathing with soap-free cleansers. Use of topical corticosteroids is the first-line treatment for flare-ups, with or without the addition of a calcineurin inhibitor. Ultraviolet phototherapy is a safe and effective second-line treatment for moderate to severe atopic dermatitis. March 15, 2020

Urinary Tract Infections in Young Children and Infants: Common Questions and Answers

Brian Veauthier and Michael V. Miller

The decision to test for urinary tract infection should be based on risk factors and the child’s age. Urinalysis can help rule out infection and inform decisions about when to start antibiotics. However, urine culture is needed for definitive diagnosis. Antibiotic selection should be based on local sensitivity patterns and adjusted once culture results are available. September 1, 2020

Tickborne Diseases: Diagnosis and Management

Emma J. Pace and Matthew O'Reilly

The incidence of tickborne disease is increasing in the United States. Patients presenting with flulike symptoms during the spring and summer months should be evaluated for a tickborne disease. Treatment based on experience and observation is recommended for tickborne diseases that fit the clinical presentation and geographic distribution of the disease. Early treatment with doxycycline has been shown to improve morbidity and mortality. Prophylactic treatment after tick exposure in patients without symptoms is generally not recommended. May 1, 2020

Management of Fever in Infants and Young Children

Jennifer L. Hamilton, Susanna G. Evans, and Munish Bakshi

Febrile illness in children younger than 36 months is a concern with potentially serious consequences. Factors include poor arousability and increased respiratory effort. Urinary tract infections are the most common serious bacterial infections in these children. Antibiotic choice should reflect local patterns of microbial resistance. June 15, 2020

Short-Term Systemic Corticosteroids: Appropriate Use in Primary Care

Evan L. Dvorin and Mark H. Ebell

Short-term systemic corticosteroids are frequently prescribed for adults by primary care physicians; however, short courses of the steroids are associated with adverse effects, including hyperglycemia, elevated blood pressure, mood disturbance, sepsis, and fracture. There is evidence against corticosteroid use in patients with acute bronchitis, acute sinusitis, carpal tunnel, and allergic rhinitis and for its use in patients with Bell palsy and acute gout. There is insufficient evidence supporting its use for patients with pharyngitis, lumbar radiculopathy, and herpes zoster. January 15, 2020

Frequent Headaches: Evaluation and Management

Anne Walling

Repeated headaches can induce central sensitization and transformation to chronic headaches that are intractable and difficult to treat. Learn which red flag features to watch for that could signal serious underlying pathology. April 1, 2020

Gout: Rapid Evidence Review

Karl T. Clebak, Ashley Morrison, and Jason R. Croad

Risk factors of gout include male sex; obesity; hypertension; alcohol intake; and a diet rich in meat, seafood, and fructose-rich food and beverages. Gout is characterized by swelling, pain, or tenderness in a peripheral joint or bursa. Diagnosis is made using several validated clinical prediction rules. Arthrocentesis should be performed when suspicion for an underlying septic joint is present; synovial fluid or tophus analysis should be performed if the diagnosis is uncertain. Colchicine, nonsteroidal anti-inflammatory drugs, and corticosteroids all relieve pain in acute episodes. Indications for chronic urate-lowering therapy include chronic kidney disease, two or more flares per year, urolithiasis, the presence of tophus, chronic gouty arthritis, and joint damage. November 1, 2020

Chronic Diarrhea in Adults: Evaluation and Differential Diagnosis

Kristina Burgers, Briana Lindberg, and Zachary J. Bevis

Common causes of chronic diarrhea include irritable bowel syndrome, inflammatory bowel disease, celiac disease, and microscopic colitis. The differential diagnosis for chronic diarrhea is broad; however, a thorough history and physical examination can narrow the diagnostic evaluation. April 15, 2020

Basal Cell and Cutaneous Squamous Cell Carcinomas: Diagnosis and Treatment

Jonathon M. Firnhaber

Keratinocyte carcinoma is the most common skin cancer malignancy found in humans. It is comprised of basal cell carcinoma and cutaneous squamous cell carcinoma. The increasing incidence of cutaneous squamous cell carcinoma is primarily in older patients and is attributed to cumulative ultraviolet light exposure. September 15, 2020

Outpatient Burn Care: Prevention and Treatment

Jason S. Lanham, Nicole K. Nelson, Bryan Hendren, and Teneisha S. Jordan

For all types of minor burn injuries, the goal of initial treatment is to minimize the extent of the burn, clean the wound, and address pain. The burn surface should be cooled with running tap water. Although superficial burns do not require dressings, advanced dressings should be used for partial-thickness burns to promote reepithelization and protect the wound. Patients with full-thickness burns should be immediately referred to a burn center. April 15, 2020

Peripheral Neuropathy: Evaluation and Differential Diagnosis

Gregory Castelli, Krishna M. Desai, and Rebecca E. Cantone

Peripheral neuropathy is one of the most common neurologic problems encountered by family physicians. Common identifiable causes include diabetes mellitus, nerve compression or injury, alcohol use, toxin exposure, hereditary diseases, and nutritional deficiencies, although many cases are idiopathic. Diagnosis requires a comprehensive history, physical examination, and judicious laboratory testing. December 15, 2020

Point-of-Care Ultrasonography

Michael J. Arnold, Christopher E. Jonas, and Rachel E. Carter

Point-of-care ultrasonography (POCUS) reduces cost, radiation exposure, and imaging delays, and increases patient satisfaction. POCUS is useful in resource-limited settings, and the use of POCUS in primary care is increasing. March 1, 2020

Sepsis: Diagnosis and Management

Robert Gauer, Damon Forbes, and Nathan Boyer

To improve sepsis diagnosis, which can be challenging, clinicians must obtain historical, clinical, laboratory, and radiographic data supportive of infection and organ dysfunction. After initial airway and respiratory stabilization, the sepsis bundle should be initiated (fluid resuscitation, antibiotics, lactate measurement, and cultures) within three hours of presentation. Vasopressor therapy is needed if fluid resuscitation is ineffective. April 1, 2020

Chronic Musculoskeletal Pain: Nonpharmacologic, Noninvasive Treatments