Management of Urgent Medical Conditions at the End of Life
Medical emergencies at the end of life require recognition of patients at risk, so that a comprehensive assessment and plan of care can be put in place. Frequently, the interventions depend on the patient ’s underlying prognosis, location of care, and goals of care. The mere presence of a medical emergency often rapidly changes an estimated prognosis. Education of the patient and family may help empower them to adequately handle many situations when clinicians are not available. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 14, 2020 Category: Primary Care Authors: Benjamin M. Skoch, Christian T. Sinclair Source Type: research

Management of Gastrointestinal Symptoms (Nausea, Anorexia and Cachexia, Constipation) in Advanced Illness
Anorexia and cachexia, nausea and vomiting, and constipation are gastrointestinal symptoms that commonly accompany serious illness. Basic science and clinical research continue to improve the understanding of their pathophysiology. Thorough assessment necessitates history, physical examination, and laboratory and diagnostic testing. Pharmacologic management attempts to counteract or reverse the underlying pathophysiologic mechanisms that accompany each symptom, which may benefit from a multimodal approach to achieve adequate control. Future improvements in management require investments in clinical research to determine th...
Source: Medical Clinics of North America - February 13, 2020 Category: Primary Care Authors: Monica Malec, Joseph W. Shega Source Type: research

Recognizing and Managing Polypharmacy in Advanced Illness
Older adults, particularly those late in life, are at higher risk for medication misadventure, yet bear the burden of increasing polypharmacy. It is incumbent on practitioners who care for this vulnerable population to use one or more approaches to deprescribe medications that impose a greater burden than benefit, including medically futile medications. It is essential that health care providers use compassionate communication skills when explaining these interventions with patients and families, pointing out that this is a positive, patient-centric intervention. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 10, 2020 Category: Primary Care Authors: Shaida Talebreza, Mary Lynn McPherson Source Type: research

Traumatic Brain Injury
Traumatic brain injury (TBI) is an acquired insult to the brain from an external mechanical force that may result in temporary or permanent impairment. The goal of this article is to provide a general review of the epidemiology, pathophysiology and medical management of adult patients with TBI for providers practicing outside the field of physical medicine and rehabilitation. The medical and rehabilitation management of moderate to severe TBI is the focus of this article, with a brief discussion of the management of mild injuries. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 6, 2020 Category: Primary Care Authors: Allison Capizzi, Jean Woo, Monica Verduzco-Gutierrez Source Type: research

Updated Approach to Stroke Rehabilitation
This article summarizes stroke rehabilitation, with a particular focus on rehabilitation from acute diagnosis to chronic impairments of stroke. The emphasis is on both pharmacologic and nonpharmacologic intervention and interdisciplinary collaboration. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 6, 2020 Category: Primary Care Authors: Leroy R. Lindsay, Diane A. Thompson, Michael W. O ’Dell Source Type: research

CME Accreditation Page
(Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 6, 2020 Category: Primary Care Source Type: research

Physical Medicine and Rehabilitation: An Update for Internists
MEDICAL CLINICS OF NORTH AMERICA (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 6, 2020 Category: Primary Care Authors: David A. Lenrow Source Type: research

Copyright
ELSEVIER (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 6, 2020 Category: Primary Care Source Type: research

Forthcoming Issues
Palliative Care (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 6, 2020 Category: Primary Care Source Type: research

Contributors
JACK ENDE, MD, MACP (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 6, 2020 Category: Primary Care Source Type: research

Contents
Jack Ende (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 6, 2020 Category: Primary Care Source Type: research

Neck Pain and Lower Back Pain
Neck pain is the fourth leading cause of disability. Acute neck pain largely resolves within 2  months. History and physical examination play a key role in ruling out some of the more serious causes for neck pain. The evidence for pharmacologic interventions for acute and chronic musculoskeletal neck pain is limited. Lower back pain is the leading cause of disability and productivity loss. C onsultation with a physical medicine and rehabilitation spine specialist within 48 hours for acute pain and within 10 days for all patients with lower back pain may significantly decrease rate of surgical interventions a...
Source: Medical Clinics of North America - December 20, 2019 Category: Primary Care Authors: Adrian Popescu, Haewon Lee Source Type: research

Therapeutic Exercise
Physicians often overlook exercise as a treatment or prophylactic measure for many common diseases and ailments. It can be used to treat comorbidities including obesity, cardiovascular disease, chronic obstructive pulmonary disease, diabetes mellitus, osteoporosis, osteoarthritis, cancer, and low back pain. Education on the general physical activity guidelines as well as easy exercise prescription methods can improve the ability of physicians to prescribe exercise as a therapeutic option. In addition, identifying barriers to compliance with exercise and ways to overcome these barriers is also necessary in order to use ther...
Source: Medical Clinics of North America - December 19, 2019 Category: Primary Care Authors: Kim Barker, Sarah Eickmeyer Source Type: research

Cancer Rehabilitation:
This article reviews the functional impairments frequently encountered in breast, head and neck, brain, and spinal cord tumors. The authors also discuss management and treatment options incorporated in comprehensive cancer rehabilitation to address these impairments to maximize and maintain function and quality of life. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - December 19, 2019 Category: Primary Care Authors: Phalgun Nori, Cristina Kline-Quiroz, Michael D. Stubblefield Source Type: research

Management of the Patient with Chronic Spinal Cord Injury
This article provides a framework to help PCPs understand how these changes impact their patient’s physiologic function and subsequent risks for health complications with guidance for initial treatment approaches. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - December 19, 2019 Category: Primary Care Authors: Binnan Ong, James R. Wilson, M. Kristi Henzel Source Type: research

Determination of Postacute Hospitalization Level of Care
In the United States, we are blessed with many options for postacute care: inpatient rehabilitation facilities, long-term acute care hospitals, skilled nursing facilities, home health agencies, and outpatient rehabilitation. However, choosing the appropriate level of care can be a daunting task. It requires interdisciplinary input and involvement of all stakeholders. The decision should be informed by outcomes data specific to the patient ’s diagnosis, impairments, and psychosocial supports. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - December 19, 2019 Category: Primary Care Authors: Robert Samuel Mayer, Amira Noles, Dominique Vinh Source Type: research

Geriatric Rehabilitation
Aging-associated anatomic and physiologic decline begins during the fourth decade of life and progresses over the ensuing decades sometimes to a state of frailty, with the decline amplified when there is deconditioning. Aging-related gait and balance disorders leading to an increased risk of falling can be compensated for with the use of exercise interventions, durable medical equipment, and environmental modifications. Caregiver training is an essential component of geriatric rehabilitation. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - December 19, 2019 Category: Primary Care Authors: Randel Swanson, Keith M. Robinson Source Type: research

Osteoarthritis
This article reviews the pathology, symptoms, diagnosis, and various conservative, surgical, and novel treatments of OA. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - December 18, 2019 Category: Primary Care Authors: Benjamin Abramoff, Franklin E. Caldera Source Type: research

Medical Care That Matters
Medicine is a team sport. Internists, other primary care providers, subspecialists, radiologists, nurses, therapists, and so many others work together and, it is hoped, provide care that is as coordinated as it is comprehensive. But this care must also extend beyond the episode of the acute illness. Consider, for example, the patient in the hospital. Suppose the patient is ready for discharge. Then what happens? Ideally, the patient has improved and returns to his or her previous level of function. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - December 10, 2019 Category: Primary Care Authors: Jack Ende Tags: Foreword Source Type: research

Physical Medicine and Rehabilitation: An Update for Internists
Research and clinical care in the field of Physical Medicine and Rehabilitation (PM&R) have made tremendous advances since the field ’s early days of treatments predominantly with exercise and modalities. The focus of PM&R on patient function with a holistic approach has now spread to other specialties in medicine. The growth of the field has increased the presence of PM&R physicians in communities and hospitals providing treatment for patients with restrictions in function due to injury, illness, or disabling conditions. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - December 9, 2019 Category: Primary Care Authors: David A. Lenrow Tags: Preface Source Type: research

Cancer Rehabilitation
This article covers the common functional impairments experienced by cancer survivors and the treatment strategies used in cancer rehabilitation. Application of these services can enhance the ongoing care for cancer survivors. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 23, 2019 Category: Primary Care Authors: Cristina Kline-Quiroz, Phalgun Nori, Michael D. Stubblefield Source Type: research

Common Injuries of the Weekend Athlete
Each year increasing numbers of people participate in a wider variety of athletic endeavors. Unlike previous generations, many patients remain in these activities later into their lives, some well beyond retirement. As the population ages and their activities continue, they are subject to injury of various forms affecting all aspects of their bodies. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 23, 2019 Category: Primary Care Authors: Mark I. Ellen, Christina Lin Source Type: research

Approach to Patients with Eosinophilia
Physicians may encounter blood or tissue eosinophilia through a routine complete blood count with differential or a tissue pathology report. In this article, the basic biology of eosinophils is reviewed and definitions of blood eosinophilia, as well as the challenges of defining tissue eosinophilia, are discussed. Conditions associated with eosinophilia are briefly discussed as well as a general approach to evaluating eosinophilia. Future challenges include determining which eosinophil-associated diseases benefit from eosinophil-targeted therapy and identifying biomarkers for disease activity and diagnosis. (Source: Medica...
Source: Medical Clinics of North America - November 20, 2019 Category: Primary Care Authors: Fei Li Kuang Source Type: research

Anaphylaxis for Internists
This article reviews the definition, classification, evaluation, differential diagnosis, prognosis, complications, and management of anaphylaxis. Tailored for internists, the article focuses on anaphylactic medication allergies. It provides a guide to optimally evaluate and manage patients with antibiotic allergy using a simple, rapid risk stratification technique, graded antibiotic challenge (test dose), and/or allergist-guided drug desensitization. It also reviews other causes of anaphylaxis that internists are likely to encounter, and an approach to their management. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 20, 2019 Category: Primary Care Authors: Derek K. Chu, David J. McCullagh, Susan Waserman Source Type: research

Approach to Patients with Allergic Rhinitis
This article evaluates the role of allergen immunotherapy (AIT) in the treatment of allergic rhinitis (AR). AIT has been shown to be effective in treating AR symptoms with resultant improvements in overall quality of life, comorbid illnesses, and medication requirements. Persistent clinical benefits have been shown years after AIT treatment discontinuation. AIT may prevent the progression of AR to asthma. AIT may more cost-effective than pharmacotherapy. Multiple individual studies and systematic reviews provide strong evidence for the clinical effectiveness of AIT in the treatment of AR. Cost-effectiveness and disease mod...
Source: Medical Clinics of North America - November 20, 2019 Category: Primary Care Authors: Linda Cox Source Type: research

Mast Cell Activation
Mast cell activation syndrome (MCAS) is a heterogeneous and rare disorder with episodic and severe activation of mast cells. Because symptoms of mast cell activation are nonspecific, it is important to base the diagnosis on best available clinical and scientific evidence, and not make it one of exclusion. MCAS, much like the mast cell itself, as a whole is greater than the sum of its proposed diagnostic criteria. When each component is considered in isolation, criteria can seem nonspecific, and thus, a broad constellation of symptoms can be attributed to MCAS when they may be due to other disease processes. (Source: Medica...
Source: Medical Clinics of North America - November 20, 2019 Category: Primary Care Authors: Dilawar Khokhar, Cem Akin Source Type: research

Drug Hypersensitivity Reactions
This article discusses special considerations about antibiotics, angiotensin-converting enzyme inhibitors, anesthetic agents, aspirin and nonsteroidal antiinflammatory drugs, radiocontrast media, and chemotherapeutic agents. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 20, 2019 Category: Primary Care Authors: Mark S. Dykewicz, Jason K. Lam Source Type: research

Allergy: The “Whole” Story
A subspecialist friend of mine once told me, in jest, “get an organ” as we were debating over which of us should manage a disease that overlapped in both of our specialties. However, to do so is impossible in the field of allergy. As allergist-immunologists, we quickly came to understand that allergic diseases are immunologic, and by definition, in volve the entire body. It is true that many allergic diseases manifest predominantly in 1 organ, such as asthma involving the lung or atopic dermatitis involving the skin, yet all allergic diseases are systemic. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 20, 2019 Category: Primary Care Authors: Anne Marie Ditto Tags: Preface Source Type: research

Overreactions
Charles Harrison Blackley was a mid-1800s English physician who was committed to finding out why he repeatedly suffered from “summer colds.” Earlier theories had suggested the possibility that the trigger for such “colds” could be odors, dust, ozone, benzoic acid, or just the heat itself. Dr Blackley believed that pollens were the stimulant for these symptoms. In order to prove this, he applied serial dilutions of pollen to his own eyes and nose. He showed that just 2 μg of pollen could elicit symptoms of hay fever. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 20, 2019 Category: Primary Care Authors: Bimal H. Ashar Tags: Foreword Source Type: research

CME Accreditation Page
(Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 20, 2019 Category: Primary Care Source Type: research

Dedication
I would like to dedicate this issue to my mother. Without her love, sacrifice, support, and encouragement, I would not have had the opportunity to specialize in Allergy-Immunology. Thank you, Mom! (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 20, 2019 Category: Primary Care Source Type: research

Allergy and Immunology for the Internist
MEDICAL CLINICS OF NORTH AMERICA (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 20, 2019 Category: Primary Care Authors: Anne Marie Ditto Source Type: research

Copyright
ELSEVIER (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 20, 2019 Category: Primary Care Source Type: research

Forthcoming Issues
Physical Medicine and Rehabilitation: An Update for Internists (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 20, 2019 Category: Primary Care Source Type: research

Contributors
BIMAL H. ASHAR, MD, MBA, FACP (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 20, 2019 Category: Primary Care Source Type: research

Contents
Bimal H. Ashar (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 20, 2019 Category: Primary Care Source Type: research

Approach to Patients with Stinging Insect Allergy
Stinging insect allergy is uncommon but can be life threatening. Diagnosis requires clinical history and confirmative skin or blood testing by an allergist. Baseline serum tryptase level can be used to stratify risk. Treatment is supportive for all reactions except for anaphylaxis, which is treated with intramuscular epinephrine, recumbent posture, and adjunct measures such as IV fluids, and oxygen. Venom immunotherapy is most effective for long-term management in patients with a history of anaphylaxis. Venom immunotherapy rapidly reduces the risk of sting anaphylaxis by up to 98% and maintenance treatment can be stopped a...
Source: Medical Clinics of North America - October 28, 2019 Category: Primary Care Authors: Elissa M. Abrams, David B.K. Golden Source Type: research

Approach to the Patient with Hives
Urticaria is a common presenting problem to the primary care provider. Acute urticaria lasting less than 6 weeks may be associated with a drug or food allergens. Chronic urticaria lasting more than 6  weeks is often associated without a known underlying cause. Inducible stimuli causing hives should be excluded using specific provocation testing. Treatment follows a standardized algorithmic approach as outlined by the Joint Task Force Practice Parameter and/or International Urticaria guidelines. Patients not responsive to steps 1 or 2 should be referred to an urticaria specialist for further evaluation and treatment. T...
Source: Medical Clinics of North America - October 28, 2019 Category: Primary Care Authors: Justin Greiwe, Jonathan A. Bernstein Source Type: research

Cough
This article provides a practical approach to treatment and management of cough, emphasizing causes and potentiators. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - October 28, 2019 Category: Primary Care Authors: Baotran B. Tran, Anne Marie Ditto Source Type: research

Allergic Contact Dermatitis
Allergic contact dermatitis is common, resulting in considerable morbidity. Diagnosis is based on a thorough history, physical examination, and patch testing. Several commercially available panels of patch testing are currently used. Allergens are found in a wide variety of daily products, occupational exposures, and foods. The mainstay of treatment is avoidance of the allergen, and databases like Contact Allergen Management Program and Contact Allergen Replacement Database help patients to select products that do not contain allergens to which they are sensitized. Topical corticosteroids can be used to treat exacerbations...
Source: Medical Clinics of North America - October 28, 2019 Category: Primary Care Authors: Stacy Nassau, Luz Fonacier Source Type: research

Asthma in Adults
Asthma affects approximately 300 million people worldwide and approximately 7.5% of adults in the United States. Asthma is characterized by inflammation of the airways, variable airflow obstruction, and bronchial hyperresponsiveness. The diagnosis of asthma is a clinical one with the history and physical examination being significant, but objective measures, such as pulmonary function testing, can be used to aid in the diagnosis. There are multiple associated comorbidities with asthma, including rhinitis, sinusitis, gastroesophageal reflux disease, obstructive sleep apnea, and depression. There is often an allergic compone...
Source: Medical Clinics of North America - October 28, 2019 Category: Primary Care Authors: Anil Nanda, Anita N. Wasan Source Type: research

Atopic Dermatitis in Adults
This article examines the pathophysiology, epidemiology, heterogeneous clinical presentation, burden, diagnosis, and treatment of adult AD. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - October 25, 2019 Category: Primary Care Authors: Jonathan I. Silverberg Source Type: research

Food Allergy in Adults
Food allergy presents in all ages and has a significant impact on an individual ’s quality of life. Some of the food allergies that start in childhood remain into adulthood and new-onset allergies can occur at any point of life. Health care providers caring for adult patients should be aware of various food allergy presentations and syndromes. In this article, the authors co ver recent literature on food allergies in adults and discuss the epidemiology of adult food allergy as well as common clinical scenarios and presentations of various types of food allergies. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - October 23, 2019 Category: Primary Care Authors: Mahboobeh Mahdavinia Source Type: research

Genetic Causes of Liver Disease
This article describes hereditary hemochromatosis, Gilbert syndrome, alpha-1 antitrypsin deficiency, Wilson disease, PFIC, BRIC, and LAL-D. The most common cause of hereditary hemochromatosis is a C282Y mutation in the HFE gene. Gilbert syndrome is a benign cause of indirect hyperbilirubinemia. Alpha-1 antitrypsin deficiency causes both lung and liver disease. Wilson disease can cause neurologic disease and liver disease. Progressive familial intrahepatic cholestasis and benign recurrent intrahepatic cholestasis are rare causes of cholestasis. LAL-D is a rare disease that can appear similar to NAFLD in adults. (Source: Med...
Source: Medical Clinics of North America - October 1, 2019 Category: Primary Care Authors: Emily A. Schonfeld, Robert S. Brown Source Type: research

The Diagnosis and Management of Neurofibromatosis Type 1
This article summarizes the clinical features, diagnostic work-up, and management of NF1. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - October 1, 2019 Category: Primary Care Authors: K. Ina Ly, Jaishri O. Blakeley Source Type: research

Symptomatic Joint Hypermobility
Joint hypermobility may be syndromic or nonsyndromic, asymptomatic or symptomatic. However, asymptomatic joint hypermobility can cause repetitive use injury, alter biomechanics, or become symptomatic later in life. Symptomatic joint hypermobility can result from soft tissue injury or muscular strain caused by muscular imbalance. Treatment is straightforward once joint hypermobility is recognized. Generalized joint hypermobility can be assessed using a standardized in-office examination. Generalized joint hypermobility may also be a feature of a heritable connective tissue disorder with other systemic findings. Therefore, a...
Source: Medical Clinics of North America - October 1, 2019 Category: Primary Care Authors: Brad T. Tinkle, Howard P. Levy Source Type: research

Population Whole Exome Screening
Compared to clinicians previously surveyed, primary care providers employed in a health system known for clinical genomics were more likely to have ordered or referred a patient for genetic testing, but had only modestly more genetics training and reported similarly low levels of comfort answering patient questions about genetic risk. Most supported population genomic screening, reported willingness to get screened themselves, and judged a hypothetical patient ’s decision to be screened favorably relative to a similar patient’s decision to decline screening. Stakeholder perceptions of the ethical appropriatenes...
Source: Medical Clinics of North America - October 1, 2019 Category: Primary Care Authors: Patrick R. Heck, Michelle N. Meyer Source Type: research

CME Accreditation Page
(Source: Medical Clinics of North America)
Source: Medical Clinics of North America - October 1, 2019 Category: Primary Care Source Type: research

Genetics and Precision Medicine
MEDICAL CLINICS OF NORTH AMERICA (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - October 1, 2019 Category: Primary Care Authors: Howard P. Levy Source Type: research

Copyright
ELSEVIER (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - October 1, 2019 Category: Primary Care Source Type: research