Neuro-Ophthalmology for Internists
This article discusses neuro-ophthalmic complaints that frequently present to the internist, including acute vision loss, double vision, and unequal pupils. It focuses on pertinent clinical features of the most common causes of these chief complaints and additionally highlights salient points of history, diagnosis, examination, and management with special emphasis on the signs and symptoms that should prompt expedited evaluation. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - April 27, 2021 Category: Primary Care Authors: Neena R. Cherayil, Madhura A. Tamhankar Source Type: research

Ocular Side Effects of Common Systemic Medications and Systemic Side Effects of Ocular Medications
When prescribing medications, it is important to consider the ocular side effects of common systemic therapy as well as potential systemic side effects of ocular medications. Although not an exhaustive list of medications/classes of medications, this article does include many commonly used drugs and also provides information on some topical therapies commonly used by ophthalmologists. These ocular medications may result in systemic effects and/or alter patients ’ management of systemic conditions. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - April 27, 2021 Category: Primary Care Authors: Misha F. Syed, Ahmad Rehmani, Matthew Yang Source Type: research

CME Accreditation Page
(Source: Medical Clinics of North America)
Source: Medical Clinics of North America - April 27, 2021 Category: Primary Care Source Type: research

Eye Care for the Internist
As a consequence of limited time devoted to eye disease in medical school, highly technical, not readily available, and unfamiliar instruments used to examine the eye, and ophthalmic progress notes that are often indecipherable to the internist, many nonophthalmologist physicians view ocular complaints and disease as impossible to evaluate meaningfully and something to refer to an eye care provider. One may think that the main goal of this issue is to unravel the mystery and shed light on an organ that is difficult to examine and has diseases they rarely encounter. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - April 27, 2021 Category: Primary Care Authors: Paul J. Bryar, Nicholas J. Volpe Tags: Preface Source Type: research

Ophthalmology
MEDICAL CLINICS OF NORTH AMERICA (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - April 27, 2021 Category: Primary Care Authors: Paul J. Bryar, Nicholas J. Volpe Source Type: research

Copyright
ELSEVIER (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - April 27, 2021 Category: Primary Care Source Type: research

Forthcoming Issues
Update in Endocrinology (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - April 27, 2021 Category: Primary Care Source Type: research

Contributors
JACK ENDE, MD, MACP (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - April 27, 2021 Category: Primary Care Source Type: research

Contents
Jack Ende (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - April 27, 2021 Category: Primary Care Source Type: research

Vision Restoration
Cataract surgery is one of the most common surgical procedures performed in the United States. The decision to remove a cataract is determined by the patient ’s ability to perform activities of daily living, such as reading, driving, and watching television. Cataract surgery also offers the potential of spectacle independence with a wide array of premium intraocular lens options. In addition, with the continuing advances in ophthalmology, patients now also have the option of selecting between traditional approaches and femtosecond laser–assisted procedures. Cataract surgery continues to be an effective and ever...
Source: Medical Clinics of North America - April 2, 2021 Category: Primary Care Authors: Sonia H. Yoo, Mike Zein Source Type: research

Age-Related Macular Degeneration
Age-related macular degeneration (AMD) is a leading cause of blindness. The main risk factor is advancing age, with the severity of vision loss ranging from mild to severe. There is a 25% risk of early AMD and 8% risk of late AMD in patients over the age of 75, with the number of cases expected to increase because of the aging population. Diagnosis of the disease requires a dilated fundus examination. Physicians should be aware of the symptoms, risk factors, and treatment options for AMD to refer appropriately for ophthalmologic evaluation. Early detection can be helpful to prevent disease progression. (Source: Medical Cli...
Source: Medical Clinics of North America - April 2, 2021 Category: Primary Care Authors: Catherine J. Thomas, Rukhsana G. Mirza, Manjot K. Gill Source Type: research

Glaucoma
This article reviews the pathophysiology, classification, clinical manifestations, diagnosis, and management of glaucoma. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - April 2, 2021 Category: Primary Care Authors: Jessica Minjy Kang, Angelo P. Tanna Source Type: research

Eye Disease in Medical Practice
Incidence of cataract, diabetic retinopathy, macular degeneration, and glaucoma will significantly increase by 2050. Visual impairment can increase morbidity and mortality in nonocular disease. There are different patterns of vision loss in cataract, diabetic retinopathy, age-related macular degeneration, and glaucoma. Internists and medical subspecialists play an important role in prevention, detection, and early treatment of eye disease. Awareness of screening guidelines for eye disease as well as a basic ocular history and simple penlight examination can decrease incidence of vision loss and its impact. Visual impairmen...
Source: Medical Clinics of North America - April 2, 2021 Category: Primary Care Authors: Carol H. Schmidt, Nicholas J. Volpe, Paul J. Bryar Source Type: research

Ocular Complaints, Disease, and Emergencies in the General Medical Setting
Primary care physicians see nearly half of all clinical visits, and 2% to 3% of those are for eye complaints. Taking a good ocular history is essential to establishing the diagnosis. Patient complaints fall into several categories including visual change, redness, and pain. Primary care physicians can screen for patients at risk of vision loss from glaucoma, diabetes, and toxic medication and ensure that patients have appropriate eye evaluations. Examination techniques such as direct ophthalmoscopy, evaluation of the red reflex, eversion of the upper lid, checking pupillary response, and using fluorescein to stain the corn...
Source: Medical Clinics of North America - April 2, 2021 Category: Primary Care Authors: Cynthia A. Bradford, Andrew T. Melson Source Type: research

Diabetic and Retinal Vascular Eye Disease
The retinal vasculature is the only neurovascular system directly visible to the human eye, easily evaluated by fundoscopy and many imaging modalities. This window allows physicians to diagnose and treat retinal pathologies and detect systemic diseases including diabetes, hypertension, hypercoagulable/hyperviscosity syndromes, and vasculitis. Diabetic retinopathy is the most common retinal vascular disease, followed by retinal vein and artery occlusion. Patients with these conditions require medical optimization to prevent further damage to the eyes and to the other organs. Both the internists and medical subspecialists pl...
Source: Medical Clinics of North America - April 2, 2021 Category: Primary Care Authors: Hong-Gam Le, Akbar Shakoor Source Type: research

Ocular Oncology —Primary and Metastatic Malignancies
Several neoplastic processes can involve the eye, either primarily or secondary to a systemic malignancy. The most common primary tumors of the eye include conjunctival and uveal melanoma, retinoblastoma, conjunctival and intraocular lymphoma, and ocular surface squamous neoplasia. Metastatic spread from systemic malignancies, especially of the breast and lung, also can involve the eye. A combination of ophthalmologic examination, ancillary testing, and cytologic/histopathologic evaluation leads to accurate diagnosis. Management consists of surgery, radiotherapy, chemotherapy, and immunotherapy delivered in various forms. ...
Source: Medical Clinics of North America - April 2, 2021 Category: Primary Care Authors: Basil K. Williams, Maura Di Nicola Source Type: research

Inpatient Ophthalmology Consultations
Comprehensive patient care requires an integrated approach that often includes different specialties. Of these specialties, Ophthalmology stands out with its variable pathologic conditions, unique tools, and special examination techniques, which are not part of the standard training of internal medicine or other specialties. The authors review prior studies focused on inpatient ophthalmology consultations, common reasons for inpatient ophthalmology consultation, and the recommended approach to the most common ocular complaints that could present to the inpatient provider. They also shed light on the basic ocular history an...
Source: Medical Clinics of North America - April 2, 2021 Category: Primary Care Authors: Dilraj S. Grewal, Hesham Gabr Source Type: research

Diseases of the Eyelids and Orbit
This article provides a foundational overview of eyelid and orbital anatomy, as well as common and key disorders that may confront internists and medical subspecialists. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - April 2, 2021 Category: Primary Care Authors: Emily Li, Christopher B. Chambers Source Type: research

When to Refer
Of all the challenges faced by general internists and other primary care providers, When to Refer is among the most important. Patients present with problems that may be outside their providers ’ area of expertise, both diagnostically and therapeutically, and so referral to an appropriate specialty colleague is required. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - April 2, 2021 Category: Primary Care Authors: Jack Ende Tags: Foreword Source Type: research

Rheumatic Complications of Immune Checkpoint Inhibitors
This article reviews rheumatic irAEs that may be encountered in the general medicine practice and provides guidance to support prompt recognition, referral, and treatment of these patients. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 13, 2021 Category: Primary Care Authors: Nilasha Ghosh, Anne R. Bass Source Type: research

Fibromyalgia
is a chronic pain condition manifested by chronic generalized pain, fatigue, disordered sleep, and cognitive difficulties, persistent for at least 3  months. Other common complaints/conditions include symptoms of irritable bowel syndrome, headaches, intermittent paresthesias, and various mood disorders. Women are more commonly affected than men. The treatment approach should be individualized and focused on associated mood disorders, sleep, exe rcise, correction of maladaptive responses to pain, and coping with stress. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 13, 2021 Category: Primary Care Authors: Carmen E. Gota Source Type: research

Pregnancy and Management in Women with Rheumatoid Arthritis, Systemic Lupus Erythematosus, and Obstetric Antiphospholipid Syndrome
Management of women with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and obstetric antiphospholipid syndrome (APS) during pregnancy presents unique clinical challenges. Women with both RA and SLE can have disease flares during pregnancy, leading to pregnancy complications, such as preeclampsia, small-for-gestational-age infants, and preterm delivery. Disease should be under control prior to conception. Women with obstetric APS need to be anticoagulated during pregnancy. Many but not all antirheumatic medications can be used during pregnancy and lactation. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 13, 2021 Category: Primary Care Authors: Adela Castro-Gutierrez, Kristen Young, Bonnie L. Bermas Source Type: research

Management of Knee Osteoarthritis
Knee osteoarthritis (OA) is a common and morbid condition. No disease-modifying therapies exist; hence the goals of current treatment are to palliate pain and to retain function. OA is significantly influenced by the placebo effect. Nonpharmacologic interventions are essential and have been shown to improve outcomes. Canes, unloading braces, and therapeutic heating/cooling may be valuable. Pharmacotherapy options include topical and oral nonsteroidal anti-inflammatory drugs, duloxetine, and periodic intra-articular glucocorticoids and hyaluronans. Opioids, intra-articular stem cells, and platelet-rich plasma are not recomm...
Source: Medical Clinics of North America - February 13, 2021 Category: Primary Care Authors: Joel A. Block, Dmitriy Cherny Source Type: research

Rheumatoid Arthritis
Rheumatoid arthritis (RA) is a chronic, progressive inflammatory disorder that manifests as a symmetric polyarthritis of small and large joints that may lead to joint and periarticular structural damage and the consequences of systemic inflammation. This overview of early RA examines the unmet needs and challenges in RA, how to best diagnose RA, and pitfalls in early diagnosis and treatment. The rules for referral to a rheumatologist are reviewed. Primary care physicians are at the front line of early diagnosis and need to start disease-modifying therapy as soon as a diagnosis of RA is established. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 13, 2021 Category: Primary Care Authors: John J. Cush Source Type: research

CME Accreditation Page
(Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 13, 2021 Category: Primary Care Source Type: research

Rheumatology: Modifying Disease, Changing Medical Practice
Medical practice these days is hardly without its hassles. Tedious administrative burdens, overly complicated electronic medical records, and onerous systems for reimbursement vex physicians at every turn. But one criticism that cannot be leveled at medical practice is that it is stagnant. Hardly. In fact, medical practice, including diagnosis and treatment, has evolved dramatically over the past decades. We can treat patients and prevent or forestall complications of chronic illness that in the past seemed inexorable. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 13, 2021 Category: Primary Care Authors: Jack Ende Tags: Foreword Source Type: research

Rheumatology
MEDICAL CLINICS OF NORTH AMERICA (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 13, 2021 Category: Primary Care Authors: Brian F. Mandell Source Type: research

Copyright
ELSEVIER (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 13, 2021 Category: Primary Care Source Type: research

Forthcoming Issues
Ophthalmology (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 13, 2021 Category: Primary Care Source Type: research

Contributors
JACK ENDE, MD, MACP (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 13, 2021 Category: Primary Care Source Type: research

Contents
Jack Ende (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 13, 2021 Category: Primary Care Source Type: research

Vaccinations in Patients with Rheumatic Disease
This article reviews the impact of immunosuppressive therapies and rheumatic disease on vaccine efficacy in this vulnerable patient population as well as discusses best practices. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - January 13, 2021 Category: Primary Care Authors: Cassandra Calabrese Source Type: research

Managing Cardiovascular Risk in Patients with Rheumatic Disease
Individuals with rheumatoid arthritis, systemic lupus erythematosus, or gout have increased risk of cardiovascular disease (CVD) compared with the general population. This risk relates to a combination of traditional cardiovascular risk factors and disease-specific factors. Screening for CVD is important because CVD contributes to significant morbidity and mortality. Management includes tight control of disease activity to reduce inflammation, but with care to minimize use of nonsteroidal anti-inflammatory drugs and prolonged courses of high-dose corticosteroids. Traditional cardiovascular risk factors should be managed wi...
Source: Medical Clinics of North America - January 13, 2021 Category: Primary Care Authors: Lyn D. Ferguson, Naveed Sattar, Iain B. McInnes Source Type: research

Perioperative Management of Rheumatic Disease and Therapies
Patients with rheumatic disease, including those with systemic lupus erythematous, rheumatoid arthritis, and spondyloarthritis, use total hip and knee arthroplasties at high rates. They represent a particularly vulnerable population in the perioperative setting because of their diseases and the immunosuppressant therapies used to treat them. Careful planning among internists, medical specialists, and the surgical team must therefore occur preoperatively to minimize risks in the postoperative period, particularly infection. Management of immunosuppressant medications, such as conventional synthetic disease-modifying antirhe...
Source: Medical Clinics of North America - January 13, 2021 Category: Primary Care Authors: Diane Zisa, Susan M. Goodman Source Type: research

Management and Cure of Gouty Arthritis
Gout is the most common inflammatory arthritis in the United States. Gouty arthritis is associated with significant morbidity and mortality and is caused by hyperuricemia. Gout is effectively managed and potentially cured by decreasing the overall urate burden with serum urate-lowering therapy. When serum urate is maintained at less than 6.0  mg/dL urate deposition is resolved and gout can be cured. Unfortunately, owing to a lack of physician monitoring and dose escalation the majority of patients do not achieve these urate levels. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - January 13, 2021 Category: Primary Care Authors: Sarah F. Keller, Brian F. Mandell Source Type: research

Update on the Treatment of Giant Cell Arteritis and Polymyalgia Rheumatica
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are considered 2 diseases on the same spectrum due to their many underlying similarities. In recent years, both diseases have witnessed both diagnostic and treatment advances, which shaped the way we manage them. In this article, the authors focus on different diagnostic modalities in GCA as well as the presence of different clinical phenotypes and the role of screening for aortic involvement. The authors also discuss traditional treatments and the role of evolving steroid-sparing agents in the management of both GCA and PMR. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - January 13, 2021 Category: Primary Care Authors: Sarah El Chami, Jason M. Springer Source Type: research

Suspecting and Diagnosing the Patient with Spondyloarthritis and What to Expect from Therapy
This article provides an updated understanding of disease classification and practical advice about diagnosis to aid in the determination of which patients should be referred to rheumatology. It is important to provide patients the opportunity to have early and effective therapy. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - January 13, 2021 Category: Primary Care Authors: Philip J. Mease Source Type: research

Antinuclear Antibody Testing for the Diagnosis of Systemic Lupus Erythematosus
Systemic lupus erythematosus (SLE) is an autoimmune inflammatory condition that may involve multiple organ systems. Although the antinuclear antibody (ANA) test is positive in nearly every case of SLE, it is not specific for this disease and must be interpreted in the appropriate clinical context. Key features that warrant ANA testing include unexplained multisystem inflammatory disease, symmetric joint pain with inflammatory features, photosensitive rash, and cytopenias. ANA staining patterns and more specific autoantibody testing may be helpful in diagnosis of suspected SLE or ANA-associated disease. For patients with no...
Source: Medical Clinics of North America - January 13, 2021 Category: Primary Care Authors: Rand A. Nashi, Robert H. Shmerling Source Type: research

Providing Rheum with a View
Providing care for the population of patients with rheumatic and musculoskeletal diseases in the United States is problematic and likely to become even more so over the next decade. Approximately a third of hospital discharges and 20% of office visits include a musculoskeletal diagnosis. These are common disorders, common yet with enormous heterogeneity and varied complexity. The breadth of rheumatic disease and related symptoms of patients wandering into an internist ’s office is staggering. Rheumatic diseases do not afford physicians the common courtesy of targeting a single organ. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - January 13, 2021 Category: Primary Care Authors: Brian F. Mandell Tags: Preface Source Type: research

Statin-Associated Myalgias and Muscle Injury —Recognizing and Managing Both While Still Lowering the Low-Density Lipoprotein
Although statins are generally safe and well tolerated, some patients experience muscle complaints that can be attributed to their use. Those with muscle discomfort but no demonstrable muscle weakness or creatine kinase (CK) elevations may have statin-associated muscle symptoms. Individuals with elevated CK levels, with or without muscle discomfort or weakness, may have statin-associated myotoxicity. Rare patients have statin-associated autoimmune myopathy, a disease characterized by proximal muscle weakness, elevated CK levels, and autoantibodies recognizing hydroxy-methyl-glutaryl coenzyme A reductase. In this review, th...
Source: Medical Clinics of North America - December 22, 2020 Category: Primary Care Authors: Andrew L. Mammen Source Type: research

Approach to the Patient with Cough
Cough is a common presenting symptom for patients in a primary care setting. Chronic cough is defined as a cough lasting for more than 8  weeks. The most common causes of chronic cough are upper airway cough syndrome, asthma, and gastroesophageal reflux disease. Detailed history and physical examination are critical in identifying potential etiologies of cough. When there is no prevailing diagnosis, step-wise empiric trial of medica tion is a strategic and cost-effective approach. Certain features of chronic cough should provoke an expedited and invasive diagnostic strategy. Effectively treating patients with chronic ...
Source: Medical Clinics of North America - November 25, 2020 Category: Primary Care Authors: Joshua A. Davis, Kirana Gudi Source Type: research

CME Accreditation Page
(Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 25, 2020 Category: Primary Care Source Type: research

Evidence-Based Approach to Palpitations
This article reviews current data and guidelines on how to evaluate palpitations in the primary care setting. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 25, 2020 Category: Primary Care Authors: Clara Weinstock, Hilary Wagner, Meghan Snuckel, Marilyn Katz Source Type: research

Headaches in Adults in Primary Care
Headaches are common in primary care. The diagnosis is made by a careful history and physical examination. Imaging is generally not warranted. Several general principles underlie the acute treatment of headache: early initiation of therapy and adequate dosing at first dose. Careful attention to avoiding too frequent administration of acute therapy is important to avoid medication overuse headaches. Opioids should always be avoided. Preventive treatment is indicated for frequent headaches. Successful treatment entails low-dose medication with careful titration and monitoring of headache frequency. Behavioral strategies are ...
Source: Medical Clinics of North America - November 25, 2020 Category: Primary Care Authors: Melissa McNeil Source Type: research

Solving the Problem of Insomnia in Clinical Practice
Insomnia is a common condition affecting approximately 50% of people at some point. Physicians must be equipped to diagnose and treat it as part of outpatient practice. Chronic insomnia is a common complaint that has potentially dangerous short-term and long-term effects, but effective treatments are available. The 2 methods of treatment are psychological, which is preferred, and pharmacologic, for when behavioral therapies are not effective. It is important to understand the various behavioral interventions and risks and benefits of the medications available to engage patients in a shared decision-making model to find the...
Source: Medical Clinics of North America - November 25, 2020 Category: Primary Care Authors: Adrienne F. Willard, Allison H. Ferris Source Type: research

Approach to Fatigue
Owing to the broad differential diagnoses that can present as fatigue, a rational approach to diagnosis is paramount. Performance of a battery of diagnostic tests is unlikely to assist with diagnosis, highlighting the importance of a thorough history and physical examination. Fatigue can be a sequela of an underlying medical disease or exists as a primary condition. Management of secondary fatigue largely depends on treatment of the underlying condition. There are no FDA-approved medications for primary fatigue, now known as system exertion intolerance disease. Treatment is focused on individualized exercise therapy and co...
Source: Medical Clinics of North America - November 25, 2020 Category: Primary Care Authors: Jason C. Dukes, Matthew Chakan, Aaron Mills, Maurice Marcaurd Source Type: research

Common Symptoms in Outpatient Practice
Welcome to this issue of Medical Clinics of North America focused on Common Symptoms in Outpatient Practice. We hope you find this a valuable resource to the most common complaints seen in your practice. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 25, 2020 Category: Primary Care Authors: Lia S. Logio Tags: Preface Source Type: research

Common Symptoms in Outpatient Practice
MEDICAL CLINICS OF NORTH AMERICA (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 25, 2020 Category: Primary Care Authors: Lia S. Logio Source Type: research

Copyright
ELSEVIER (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 25, 2020 Category: Primary Care Source Type: research

Forthcoming Issues
Rheumatology (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - November 25, 2020 Category: Primary Care Source Type: research