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The occurrence of a single seizure does not always require initiation of antiepileptic drugs. Risk of recurrent seizures should guide their use. In adults, key risk factors for recurrence are two unprovoked seizures occurring more than 24 hours apart, epileptiform abnormalities on electroencephalography, abnormal brain imaging, nocturnal seizures, or an epileptic syndrome associated with seizures. In children, key risk factors are abnormal electroencephalography results, an epileptic syndrome associated with seizures, severe head trauma, and cerebral palsy. The risk of adverse effects from antiepileptic drugs is considerable and includes potential cognitive and behavioral effects. In the absence of risk factors, and because many patients do not experience recurrence of a seizure, physicians should consider delaying use of antiepileptic drugs until a second seizure occurs. Delaying therapy until a second seizure does not affect one- to two-year remission rates. Treatment should begin with monotherapy. The appropriate choice of medication varies depending on seizure type. Routine monitoring of drug levels is not correlated with reduction in adverse effects or improvement in effectiveness and is not recommended. When patients have been seizure free for two to five years, discontinuation of antiepileptic drugs may be considered. For patients with seizures that are not controlled with these agents, alternative treatments include surgical resection of the seizure focus, ketogenic diets, vagus nerve stimulators, and implantable brain neurostimulators. Patients who have had a recent seizure within the past three months or whose seizures are poorly controlled should refrain from driving and certain high-risk physical activities. Patients planning for pregnancy should know that antiepileptic drugs are possibly teratogenic. [ABSTRACT FROM AUTHOR]

Illness after recreational water activities can be caused by a variety of agents, including bacteria, viruses, parasites, algae, and even chlorine gas. These illnesses are more common in summer. Waterborne illnesses are underreported because most recreational activity occurs in unsupervised venues or on private property, and participants tend to disperse before illness occurs. Symptoms of waterborne illness are primarily gastrointestinal, but upper respiratory and skin manifestations also occur. Gastrointestinal symptoms are usually self-limited, and supportive treatment may be all that is necessary. However, some infections can cause significant morbidity and mortality. Cryptosporidium and Giardia intestinalis are the most common cause of gastrointestinal illness and have partial chlorine resistance. Respiratory infections are typically mild and self-limited. However, if legionnaires' disease develops and is unrecognized, mortality may be as high as 10%. Cellulitis caused by Vibrio vulnificus can result in serious illness, amputation, and death. Early and appropriate antibiotic treatment is important. Chronically ill and immunocompromised persons are at high risk of infection and should be counseled accordingly. [ABSTRACT FROM AUTHOR]

Primary intracranial tumors of the brain structures, including meninges, are rare with an overall five-year survival rate of 33.4%; they are collectively called primary brain tumors. Proven risk factors for these tumors include certain genetic syndromes and exposure to high-dose ionizing radiation. Primary brain tumors are classified by histopathologic criteria and immunohistochemical data. The most common symptoms of these tumors are headache and seizures. Diagnosis of a suspected brain tumor is dependent on appropriate brain imaging and histopathology. The imaging modality of choice is gadolinium-enhanced magnetic resonance imaging. There is no specific pathognomonic feature on imaging that differentiates between primary brain tumors and metastatic or nonneoplastic disease. In cases of suspected or pathologically proven metastatic disease, chest and abdomen computed tomography may be helpful, although determining the site of the primary tumor is often difficult, especially if there are no clinical clues from the history and physical examination. Using fluorodeoxyglucose positron emission tomography to search for a primary lesion is not recommended because of low specificity for differentiating a neoplasm from benign or inflammatory lesions. Treatment decisions are individualized by a multidisciplinary team based on tumor type and location, malignancy potential, and the patient's age and physical condition. Treatment often includes a combination of surgery, radiotherapy, and chemotherapy. After craniotomy, patients should be followed closely for complications, including deep venous thrombosis, pulmonary embolism, intracranial bleeding, wound infection, systemic infection, seizure, depression, worsening neurologic status, and adverse drug reaction. Hospice and palliative care should be offered when appropriate throughout treatment. [ABSTRACT FROM AUTHOR]

Polymyalgia rheumatica affects proximal muscles and joints, causing disability in older adults. Giant cell arteritis affects medium and large arteries and can result in blindness. These conditions overlap significantly, often occurring together. Despite the similarities, each has distinct symptoms, corticosteroid dosing requirements, and prognosis. The hallmark of both conditions is inflammation. Polymyalgia rheumatica primarily affects the shoulders, neck, and hips with prominent bilateral pain. Systemic findings such as fatigue and weight loss are common, and there is no definitive diagnostic test. Moderate-dose corticosteroid therapy with a slow taper rapidly resolves symptoms. Management of patients responding to treatment can occur in the primary care setting, if there is no concomitant giant cell arteritis. The clinical presentation of giant cell arteritis varies widely, from new-onset headache and constitutional symptoms, to jaw claudication, to less common isolated visual changes and upper extremity claudication. Treatment requires higher dosages of corticosteroids and urgent referral to a rheumatologist. Relapse is common in both diseases. Sur­veillance is important, as is monitoring for long-term complications of corticosteroid use. Osteoporosis management and gastrointestinal ulcer prophylaxis should be initiated. The primary care physician's coordination of care with a rheumatologist and with other subspecialists, if needed, is essential in the management of giant cell arteritis. [ABSTRACT FROM AUTHOR]

Focuses on the diagnosing and treatment of the acute sore throat. Serious illnesses that may present themselves with a complaint of sore throat; Symptoms associated with group A beta-hemolytic streptococcal (GABHS) pharyngitis; When efforts to identify and treat patients with GABHS should be carried out; Laboratory tests commonly ordered in evaluating patients with acute sore throat; Patient information for sore throat.

Family physicians may be the first point of contact for adults with new-onset seizure. There are many etiologies of seizures in adults. Etiologies of provoked seizures include temporary metabolic disturbances, central nervous system infections, cerebrovascular disease, drug withdrawal, and traumatic brain injury. Stable or evolving cerebral conditions can cause unprovoked seizures. Nonorganic etiologies include nonepileptiform convulsions, such as a pseudoseizure, which are psychogenic. In the emergency department setting, computed tomography scan of the head should be considered for all patients with new-onset seizure. An electroencephalogram and magnetic resonance imaging study are recommended as further evaluation for an adult with a new-onset seizure unrelated to trauma, alcohol, or drugs. The occurrence of a single seizure does not always necessitate initiation of an antiepileptic drug. The risk of recurrent seizure should dictate the need for drug initiation. Patients should be counseled against driving until they have been seizure free for at least 3 months. Patients who are planning for pregnancy should be informed that antiepileptic drugs are potentially teratogenic., (Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.)

Parkinson disease (PD) is a complex neurologic disorder that involves motor and nonmotor brain functions. PD is the second most common neurodegenerative disease after Alzheimer disease. Motor symptoms include resting tremor, cogwheel rigidity, extreme slowness of movement, shuffling gait, and impaired balance. Swallowing and speaking difficulties also are common. Nonmotor symptoms include depression, hallucinations, and sleep disturbances that seriously affect quality of life. There is no cure for PD but management of motor and nonmotor symptoms can improve quality of life. Carbidopa-levodopa is an effective initial treatment for motor symptoms of rigidity and resting tremors. Treatments for nonmotor symptoms include antidepressants, antipsychotics, and drugs for dementia. (This is an off-label use of some antidepressants, antipsychotics, and drugs for dementia.) A multidisciplinary approach to optimizing care can include physical and occupational therapy, speech therapy, and psychological therapy., (Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.)

Dizziness is seen frequently in patients in the family medicine and emergency department settings. The differential diagnosis of dizziness can be expansive but with a targeted history and physical examination, a correct diagnosis often can be established and appropriate treatment offered. Common etiologies of dizziness include hypotension, benign paroxysmal positional vertigo (BPPV), and Meniere disease. Strokes and malignancies also can cause this symptom. Imaging is indicated if intracranial pathology is suspected. BPPV typically is self-limited but maneuvers such as the Epley maneuver can be used for more rapid resolution. Meniere disease can be difficult to manage. First-line treatments are lifestyle and diet modification. Avoidance of triggers is important for patients with vestibular migraine. Some vestibular-suppressive drugs and anticonvulsants may be useful in the prevention and management of vestibular migraine. (This is an off-label use of some anticonvulsants.)., (Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.)

Peripheral neuropathies (PNs) are a group of conditions caused by damage to the peripheral nervous system. PN is a condition commonly seen in the family medicine setting and can lead to reduced quality of life due to pain, ulceration, and falls. More than 100 etiologies of PN have been identified; the most common are metabolic, drug-related, and systemic etiologies. Common treatable etiologies include diabetes and other medical conditions. Screening is recommended only for patients with suspected diabetic PN. The diagnosis of neuropathies is made primarily using the clinical history and physical examination results. Laboratory and electrodiagnostic tests can be used to identify the etiology of PN, and should be considered in atypical cases or if the diagnosis is uncertain. In some cases, management of the underlying cause of the neuropathy is indicated. Management includes adequate control of the blood glucose level in patients with diabetes and correction of vitamin deficiencies. Symptom control often is achieved with use of drugs., (Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.)