Monday, June 23, 2014

Acute Complaints: 3 of The 2013 Top 20 AFP articles

- Jennifer Middleton, MD, MPH

AFP recently posted its 20 most-read articles from last year here. The topics run through much of the full spectrum of Family Medicine, from health maintenance to acute complaints, from initial work-up to chronic management. Here are three articles that explore acute complaints:

1. Approach to Acute Headache in Adults (5/15/2013)
This article provides a practical approach to differentiating benign headaches (age <30, "features typical of primary headaches," prior similar headaches, normal neurologic exam, no high-risk comorbidities) from dangerous headaches (worst headache ever, headache triggered by exertion, mental status change, age > 50, papilledema, sudden onset, systemic illness, temporal artery tenderness). The authors review the classic "primary" headache syndromes (tension, migraine, cluster) and include a helpful table regarding choice of radiographic testing should 1 or more dangerous headache signs be present.

2. Diagnosis and Management of Acute Diverticulitis (5/1/2013)
This article provides likelihood ratios for common physical exam findings that can help to rule in or rule out diverticulitis (LLQ tenderness + absence of vomiting + CRP >50 = LR+ of 18). The authors review guidelines for laboratory and radiographic evaluation as well as recent evidence arguing against antibiotic use in patients with mild, uncomplicated diverticulitis. Weight loss, smoking cessation, fiber, and exercise help to prevent recurrences but avoidance of seeds, nuts, etc. does not.

3. Outpatient Diagnosis of Acute Chest Pain in Adults (2/1/2013)
Only 1.5% of patients presenting to a primary care office with chest pain have unstable angina or acute coronary syndrome, but identifying who these patients are can be challenging. The authors review likelihood ratios of clinical symptoms more likely to be associated with serious cardiac disease (among others, radiating pain and use of a term other than "pain" - such as "tightness" or "squeezing" increase the pre-test probability). Pleuritic chest pain and "sharp" or "stabbing" chest pain, on the other hand, are less likely to be due to acute coronary syndrome. The authors also present a validated clinical decision rule to assist with diagnosis (Table 2). They review the more common, and typically less serious, diagnoses of chest wall pain, GERD, and anxiety along with the less common, but more serious, possibilities of pericarditis, pneumonia, CHF, or pulmonary embolism.

By my count, half of the Top 20 articles from 2013 dealt with evaluation of new and/or acute complaints. Given how much of 21st century Family Medicine is chronic disease care, it's interesting that acute complaints caught so much of the attention of AFP readers, though certainly family doctors experience both on a daily basis.

What AFP articles dealing with acute issues have changed your practice lately?