Empyema Necessitans is a rare complication of Empyema Thoracis that is caused by a longstanding pleural infection such as persistent pleural effusion. It is caused by an extension of pus to nearby structures including the chest wall and is usually caused by Mycobacterium tuberculosis infection. It is difficult to diagnose since its features are similar to those of other disease entities such as malignancies; therefore, imaging tests such as a chest CT scan are helpful in establishing the diagnosis. In addition, other diagnostic tests such as acid-fast stain and GeneXpert may be falsely negative due to inadequate or incorrect sampling location. One such case is this 30-year-old female with chronic cough and recurrent pleural effusion that progressed to Empyema Necessitans presenting as an abdominal mass where sputum GeneXpert was negative, but aspirate of the abdominal mass showedMycobacterium tuberculosis. Prompt initiation of anti-tuberculosis treatment once diagnosis is confirmed as well as emphasizing its completion is imperative for definitive treatment. As such, family physicians have a vital role in navigating patients for further workup and necessary referrals for a multidisciplinary management especially in persistent disease processes as well as screening and treatment of the family for holistic care.

Human ; Female ; Adult: 25-44 Yrs Old ; Mycobacterium Tuberculosis

Dementia is an acquired loss of cognitive ability and is found to have a significant physical, psychological, social, and economic impact on patients, families, and communities. Diagnosis of dementia should be based on history and physical examination, together with cognitive, functional, and behavioral assessment. Validated tools such as the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MOCA) should be used to screen for cognitive impairment. Functionality or Activities of Daily Living (ADL) should be assessed using the Katz and Lawton Index. Work-up of patients with dementia includes ruling out dementia-mimicking conditions, including routine hematology (full blood count and ESR), biochemistry (electrolytes, calcium, glucose, renal and liver function), Thyroid function tests, and Serum B12 and folate levels. Neuroimaging is performed to detect reversible causes of cognitive impairment and to determine the subtype of dementia. Family-based and community-based interventions should be offered to patients with dementia.

Dementia ; Primary Health Care ; Primary Care ; Mini Mental Status Examination (mmse) ; Mental Status And Dementia Tests ; Cognitive Decline ; Cognitive Dysfunction

Depression is a mental health condition that affects more than 3.3 million Filipinos. Screening of adults and elderly patients is recommended with the use of validated tools like the Patient Health Questionnaire (PHQ-2 or PHQ-9) or the Geriatric Depression Scale-15 (GDS-15). The two-step approach can be followed for adults by using the PHQ-2 first, followed by the PHQ-9 if the PHQ-2 tests positive. Geriatric patients may be screened using the GDS-15 tool or PHQ-9. Diagnostic work-up should be done to rule out metabolic or organic conditions that can mimic or cause depression. Diagnosis of depression should be confirmed using the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria. Referral to a specialist should be done in cases of severe depression, psychosis, high suicide risk, severe malnutrition, pregnant adults, or non-response to initial treatment.

Human ; Depression ; Physicians, Primary Care

Background: Dizziness is a commonly encountered symptom in the primary care which can be caused, most of the time by benign condition and rarely due to serious conditions needing higher level of care. Objective: To develop a clinical guideline and pathway that will serve as guide in the diagnosis and management of adult patients with dizziness in primary care and outpatient setting Methods: A guideline development team was formed which is composed of family and community medicine specialists from different institutions. Searching, selection and assessment of the latest evidence on dizziness diagnosis and management was done using the search terms: “dizziness”, “diagnosis”, “management”, and “primary care”. Formulation of the recommendation was done using Grade approach and graded with modified GRADEPro and expert panel consensus. External review was also done by an expert in otorhinolaryngology. Recommendations: Clinical Assessment •Recommendation1.Askforthepatient’sdescriptionofdizzinessandclassifythepatientintooneofthefourtypes: vertigo, presyncope, disequilibrium, and lightheadedness and classify as acute/episodic or chronic/sustained. (Strong Recommendation, Low Quality Evidence) •Recommendation2.Obtainamedicalhistoryfocusingonthetiming,triggers,associatedsymptoms,riskfactorsfor atherosclerotic vascular disease, and functional status or quality of life. (Strong Recommendation, High Quality Evidence) •Recommendation3.Performaphysicalexaminationfocusingonvitalsigns,HEENT(includingotoscopy),cardiovascular and neurologic examination. (Strong Recommendation, High Quality Evidence) •Recommendation4.PerformspecialphysicalexaminationslikeDix-Hallpikemaneuverforacuteepisodictriggeredvertigo to check for BPPV (most common cause of peripheral vertigo), HINTS plus test for spontaneous episodic vertigo to check for stroke and hyperventilation provocation test for patients suspected of anxiety (Strong Recommendation, High Quality Evidence) •Recommendation5.Elicitredflagsthatshouldwarrantreferrallikeseveredizzinessandassociated,alteredmentalstatus, loss of consciousness and abnormal vital signs. Other symptoms like chest pain, palpitations, dyspnea, neurologic deficit may warrant referral for evaluation and management. (Strong Recommendation, High Quality Evidence) •Recommendation6.Forpatientsconsultingviatelemedicine,obtainamedicalhistoryfocusingonthetiming,triggers, associated symptoms, risk factors for atherosclerotic vascular disease, and functional status or quality of life, and observe and conduct self-physical examination (vital signs, mental status, ocular and facial nerve) (Strong Recommendation, Low Quality Evidence) Diagnostic •Recommendation7.Laboratorytestingisnotroutinelyrecommendedamongpatientswithdizziness.However,testingmay be requested if there is a need to identify a definite etiology to guide treatment and should be guided by the classification of dizziness, possible etiology, and the medical history and physical examination. (Strong Recommendation, High Quality Evidence).Recommendation8.Forpatientswithvertigoandwithauditorysymptoms(i.e.,hearingloss,tinnitusandauralfullness, etc.), pure tone audiometry speech test may be requested if available. (Strong Recommendation, High Quality Evidence) •Recommendation9.Forpatientswithpresyncope/syncopeandachronicmedicalconditionisbeingconsidered,complete blood count may be requested for those with probable blood dyscrasia, serum blood glucose may be requested for those with diabetes, electrocardiogram and lipid profile may be requested for those with cardiovascular disease. (Strong Recommendation, High Quality Evidence) •Recommendation10.Forpatientswithdisequilibriumandwithanabnormalneurologicphysicalexaminationfinding,CT scan may be requested. (Strong Recommendation, High Quality Evidence) Pharmacologic •Recommendation11.Empirictrialofshortcourse(7days)pharmacologictreatmentforsymptomreliefshouldbeoffered. Referral should be considered if the dizziness become more severe or it did not improve in 7 days. (Strong Recommendation, High Quality Evidence) •Recommendation12.Forpatientswithmildtomoderatevertigo,offerhistamineanalogue(betahistine)orantihistamine (meclizine, diphenhydramine, dimenhydrinate or cinnarizine) for symptom relief. (Strong Recommendation, High Quality Evidence) •Recommendation13.Forpatientswithmildtomoderatevertigoassociatedwithmigraine(vestibularmigraine),aside from symptom relief, offer any of the triptans as preventive medication. (Strong Recommendation, High Quality Evidence) •Recommendation14.Forpatientswhosedizzinessisdescribedasdisequilibrium(gaitimbalance)orpresyncope(near faintness) or dizziness with anxiety attack, offer symptomatic treatment and intervention based on the underlying cause or consider referral to appropriate specialist. (Strong Recommendation, High Quality Evidence) Non-pharmacologic •Recommendation15.Allpatientsshouldbeprovidedwithhealtheducationoncauses,triggersandfollowup.(Strong Recommendation, Low Quality Evidence) •Recommendation16.Allpatientsshouldbeadvisedonappropriatedietandlifestylemodification.(StrongRecommendation, Low Quality Evidence) •Recommendation17.Dependingonthenatureofvertigo,educateandtrainthepatientoncanalrepositioningmaneuver and vestibular rehabilitation. Referral to rehabilitation medicine may be considered. (Strong Recommendation, High Quality Evidence) •Recommendation18.Thepatient’sfamilymustalsobeprovidedwithhealtheducationandidentifyacaregivertoassist and promote compliance to management. (Strong Recommendation, Low Quality Evidence) •Recommendation19.Encouragecommunity-basedvestibularrehabilitationactivitiessuchasgroupbalancetraining exercise. (Strong Recommendation, Low Quality Evidence) Patient Outcomes •Recommendation20.Thepatientshouldknowthenatureofdizziness,causesandpotentialcomplicationsanddevelop skills in postural exercises. (Strong Recommendation, Moderate Quality Evidence) •Recommendation21.Decreaseinfrequencyandseverityshouldexpectedwithin48hoursandresolutionisexpectedwithin a month. (Strong Recommendation, Moderate Quality Evidence) •Recommendation22.Improvedqualityoflifeshouldalsobeelicited.(StrongRecommendation,ModerateQualityEvidence) •Recommendation23.Referraltoappropriatespecialtyshouldbedoneifnoresolutionorprogressionofsymptomsor impaired quality of life for more than a month. (Strong Recommendation, Expert Opinion) Implementation The committee shall disseminate the guidelines through presentations and via journal publications. The QA committee shall be in charge of implementation of the guideline and pathway.
Community Health Services ; Dizziness ; Partnership Practice