Principles of office anesthesia: part II. Topical anesthesia

The development of topical anesthetics has provided the family physician with multiple options in anesthetizing open and intact skin. The combination of tetracaine, adrenaline (epinephrine), and cocaine, better known as TAC, was the first topical agent available for analgesia of lacerations to the face and scalp. Cocaine has been replaced with lidocaine in a newer formulation called LET (lidocaine, epinephrine, and tetracaine). For analgesia to nonintact skin, LET gel is generally preferred over TAC because of its superior safety record and cost-effectiveness. EMLA (eutectic mixture of local anesthetics) is perhaps the most well-known topical anesthetic for use on intact skin. EMLA can be used to anesthetize the skin before intramuscular injections, venipuncture, and simple skin procedures such as curettage or biopsy. To be fully effective, EMLA should be applied at least 90 minutes before the procedure. ELA-Max is a new, rapidly acting topical agent for intact skin that works by way of a liposomal delivery system and is available over the counter. Other delivery vehicles for topical anesthesia currently in development, including iontophoresis and anesthetic patches, may one day give patients and physicians even more flexibility.     

Regional anesthesia for office procedures: part I. Head and neck surgeries

Although local anesthesia usually is used in surgical procedures, field or nerve blocks can provide more effective anesthesia in some situations. In a field block, local anesthetic is infiltrated around the border of the surgical field, leaving the operative area undisturbed. In field blocks, epinephrine may be added to the anesthetic to enhance vasoconstriction and prolong the duration of anesthesia. In a nerve block, anesthetic is injected directly adjacent to the nerve supplying the surgical field. A review of regional anatomy and the location of nerves and other important structures is essential before administering the injection. Systemic toxicity is rare with regional anesthesia and can be prevented by using the smallest dose possible and aspirating before the injection. Supraorbital, supratrochlear, infraorbital, and mental nerve blocks can provide adequate anesthesia in procedures on parts of the face. Field block also may be considered when operating on the ear or lips.     

Osteoporosis: part I. Evaluation and assessment

Osteoporosis afflicts 75 million persons in the United States, Europe and Japan and results in more than 1.3 million fractures annually in the United States. Because osteoporosis is usually asymptomatic until a fracture occurs, family physicians must identify the appropriate timing and methods for screening those at risk. Prevention is the most important step, and women of all ages should be encouraged to take 1,000 to 1,500 mg of supplemental calcium daily, participate in regular weight-bearing exercise, avoid medications known to compromise bone density, institute hormone replacement therapy at menopause unless contraindicated and avoid tobacco and excessive alcohol intake. All postmenopausal women who present with fractures as well as younger women who have risk factors should be evaluated for the disease. Physicians should recommend bone mineral density testing to younger women at risk and postmenopausal women younger than 65 years who have risk factors for osteoporosis other than being postmenopausal. Bone mineral density testing should be recommended to all women 65 years and older regardless of additional risk factors. Bone mineral density screening should be used as an adjunct to clinical judgment only if the results would influence the choice of therapy or convince the patient to take appropriate preventive measures.     

Regional anesthesia for office procedures: Part II. Extremity and inguinal area surgeries

The hand can be anesthetized effectively with blocks of the median, ulnar, or radial nerve. Each digit is supplied by four digital nerves, which can be blocked with injections on each side of the digit. Anterior or posterior ankle blocks can be used for regional anesthesia for the foot. The anterior ankle block, which is used for procedures on the dorsum of the foot, involves blocking the saphenous nerve, and superficial and deep peroneal nerves. The posterior ankle block, which is used to anesthetize the sole of the foot, involves blocking the sural and posterior tibial nerves. Paracervical block is used for procedures on the cervix, such as loop electrocauterization or conization. Dorsal penile block has been the most commonly recommended anesthetic technique for neonatal circumcision. A safe and effective alternative is the application of anesthetic cream over the skin to be circumcised.     

The painful shoulder: part I. Clinical evaluation

Family physicians need to understand diagnostic and treatment strategies for common causes of shoulder pain. We review key elements of the history and physical examination and describe maneuvers that can be used to reach an appropriate diagnosis. Examination of the shoulder should include inspection, palpation, evaluation of range of motion and provocative testing. In addition, a thorough sensorimotor examination of the upper extremity should be performed, and the neck and elbow should be evaluated.     

Contemporary management of angina: part I. Risk assessment

Ischemic heart disease is one of the most common disorders managed by family physicians. Stratifying patients according to risk is important early in the course of the disease to identify patients who require invasive (percutaneous or surgical) treatment. Physical examination, clinical history, noninvasive tests and angiography are all helpful in determining who will benefit most from medical therapy, percutaneous revascularization or coronary artery bypass surgery. Surgery improves morbidity and mortality in a well-defined group of patients with left ventricular dysfunction and left main coronary artery disease or triple-vessel disease. Patients with proximal left anterior descending artery disease and moderate or severe ischemia benefit from surgery as well. In all other patients, definitive treatment includes aspirin, beta-adrenergic blockers and lipid-lowering agents. Percutaneous revascularization should be considered primarily a palliative measure, because it has never been shown to improve mortality more than medical therapy.     

Chronic shoulder pain: part I. Evaluation and diagnosis

Shoulder pain is defined as chronic when it has been present for longer than six months. Common conditions that can result in chronic shoulder pain include rotator cuff disorders, adhesive capsulitis, shoulder instability, and shoulder arthritis. Rotator cuff disorders include tendinopathy, partial tears, and complete tears. A clinical decision rule that is helpful in the diagnosis of rotator cuff tears includes pain with overhead activity, weakness on empty can and external rotation tests, and a positive impingement sign. Adhesive capsulitis can be associated with diabetes and thyroid disorders. Clinical presentation includes diffuse shoulder pain with restricted passive range of motion on examination. Acromioclavicular osteoarthritis presents with superior shoulder pain, acromioclavicular joint tenderness, and a painful cross-body adduction test. In patients who are older than 50 years, glenohumeral osteoarthritis usually presents as gradual pain and loss of motion. In patients younger than 40 years, glenohumeral instability generally presents with a history of dislocation or subluxation events. Positive apprehension and relocation are consistent with the diagnosis. Imaging studies, indicated when diagnosis remains unclear or management would be altered, include plain radiographs, magnetic resonance imaging, ultrasonography, and computed tomography scans. Plain radiographs may help diagnose massive rotator cuff tears, shoulder instability, and shoulder arthritis. Magnetic resonance imaging and ultrasonography are preferred for rotator cuff disorders. For shoulder instability, magnetic resonance imaging arthrogram is preferred over magnetic resonance imaging.     

Acute finger injuries: part I. Tendons and ligaments

Improper diagnosis and treatment of finger injuries can cause deformity and dysfunction over time. A basic understanding of the complex anatomy of the finger and of common tendon and ligament injury mechanisms can help physicians properly diagnose and treat finger injuries. Evaluation includes a general musculoskeletal examination as well as radiography (oblique, anteroposterior, and true lateral views). Splinting and taping are effective treatments for tendon and ligament injuries. Treatment should restrict the motion of injured structures while allowing uninjured joints to remain mobile. Although family physicians are usually the first to evaluate patients with finger injuries, it is important to recognize when a referral is needed to ensure optimal outcomes.     

Guidelines for managing Alzheimer's disease: part I. Assessment

Family physicians play a key role in assessing and managing patients with Alzheimer's disease and in linking the families of these patients to supportive services within the community. As part of comprehensive management, the family physician may be responsible for coordinating assessments of patient function, cognition, comorbid medical conditions, disorders of mood and emotion, and caregiver status. Suggestions for easily administered and scored assessment tools are provided, and practical tips are given for supporting primary caregivers, thereby increasing efficiency and quality of care for patients with Alzheimer's disease.