Acute low back pain falls into two causal categories: specific and nonspecific. Specific causes can be intrinsic to the spine, from systemic disease, or referred pain from other organs. However, acute low back pain typically is nonspecific. Aside from recent trauma, most patients with acute low back pain do not require imaging unless history reveals red flag findings. Those with red flag findings require immediate evaluation and treatment, including imaging and specialty referral or consultation. For patients with nonspecific low back pain, first-line treatment involves maintaining activity, use of heat therapy, and other nonpharmacologic treatments (eg, dry needling, transcutaneous electrical nerve stimulation, acupuncture). Pharmacotherapy options include nonsteroidal anti-inflammatory drugs, trigger point injections, and possibly systemic corticosteroids for radicular low back pain. Drugs that should not routinely be used include benzodiazepines, gabapentin, pregabalin, opioids, and acetaminophen. Physicians should address comorbid conditions that increase the risk of acute low back pain becoming chronic. Patients with pain persisting beyond 8 weeks despite appropriate therapy should be considered for imaging and laboratory evaluation to identify specific causes.

Clinicians often need to differentiate between benign, self-limited variations of pubertal development and more serious underlying causes. Precocious puberty should be considered when thelarche occurs in female patients before 8 years of age or when testicular enlargement occurs in male patients before 9 years of age. Delayed puberty should be considered in female patients who lack breast development by 13 years of age or do not experience menarche by age 15 and in male patients who lack testicular growth by age 14. Assessment should focus on clinical and family history, growth, and pubertal examination to rule out benign pubertal variations. Further laboratory and radiographic workup may include early morning testing of luteinizing hormone, follicle-stimulating hormone, thyroid-stimulating hormone (thyrotropin), total testosterone (in male patients), and estradiol (in female patients), as well as left-hand bone age radiography. Neuroimaging with contrast-enhanced magnetic resonance imaging of the brain should be obtained in all patients with central precocious puberty who have neurologic signs or symptoms; are female and younger than 6 years; or are male and younger than 9 years. Specialist evaluation by pediatric endocrinology is often indicated when examination results are not consistent with a benign variation of puberty.

Developmental dysplasia of the hip (DDH) is the most common joint condition in infants, encompassing a complex spectrum of pathologic states that can result in hip instability and dislocation. The most significant risk factors for DDH are breech positioning in the third trimester and family history of hip dysplasia. The condition is more common in females. Diagnosis is based on age-specific physical examination maneuvers and imaging studies. The Ortolani and Barlow maneuvers are the recommended physical examination techniques used to screen infants up to 3 months of age. Ultrasonography is the preferred imaging modality to evaluate younger infants, whereas plain radiography is preferred after 4 months of age. If DDH is identified, abduction bracing is the first-line treatment in infants younger than 6 months. Operative management is reserved for infants older than 6 months or if abduction bracing fails. Early diagnosis may prevent the need for invasive surgical procedures and reduce the risk of early degenerative changes of the hip in adulthood.

Iron deficiency anemia is common worldwide. In adult patients without inflammation, a ferritin level of less than 45 ng/mL or ferritin level of 46 to 99 ng/mL plus a transferrin saturation of less than 20% is diagnostic of iron deficiency. In patients with inflammation, a ferritin level of less than 100 ng/mL is diagnostic. Risk factors for iron deficiency anemia include low socioeconomic status, female sex, age younger than 5 years, and chronic inflammation. Underlying causes should be investigated. Recurrent blood loss is responsible for 94% of cases. In younger patients with a plausible cause of iron deficiency anemia (eg, heavy menstrual bleeding), a reasonable approach is to treat the bleeding and provide iron supplementation. In men and postmenopausal women, bidirectional endoscopy should be performed. Noninvasive testing for Helicobacter pylori infection and celiac disease is recommended because both are common causes of iron deficiency anemia. Oral iron replacement is the first-line treatment for most patients. However, intravenous iron is recommended in patients with heart failure to increase exercise capacity. Every-other-day dosing of oral iron improves absorption. Approximately 50% of patients have decreased adherence due to adverse effects. Patients taking oral iron therapy should be evaluated for response in 2 to 4 weeks. Patients who cannot tolerate oral iron or do not have adequate response should receive intravenous iron. Hypersensitivity to newer formulations of intravenous iron is rare (less than 1%).

Vaginitis is a general term for inflammation of the vagina with symptoms such as vulvovaginal itching, burning, irritation, dyspareunia, odor, or abnormal vaginal discharge. It is a common condition that results in 5 million to 10 million office visits annually. The leading infectious causes of vaginitis are bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis. Noninfectious causes include atrophic, irritant, and inflammatory vaginitis. Bacterial vaginosis usually presents with a thin, homogenous vaginal discharge and a fishy odor. Vulvovaginal candidiasis often manifests with a white, thick, curd-like discharge, pruritus, and vulvar erythema. Trichomoniasis usually presents with a green or yellow frothy discharge, and speculum examination may reveal cervical erythema with petechiae. Noninfectious vaginitis can present with clear or purulent discharge and can be pruritic depending on the etiology. Bacterial vaginosis can be diagnosed using Amsel criteria, Gram stain, or a nucleic acid amplification test (NAAT). Vulvovaginal candidiasis can be diagnosed by visualization of yeast hyphae or budding yeast on microscopy, vaginal fungal culture, polymerase chain reaction testing, or NAAT. Trichomoniasis can be diagnosed with visualization of motile, flagellated protozoa on saline microscopy, NAAT, or DNA probe test. Bacterial vaginosis is treated with oral or intravaginal metronidazole or intravaginal clindamycin. Vulvovaginal candidiasis is managed with topical or oral antifungals. Trichomoniasis is treated with oral metronidazole or tinidazole. When treating trichomoniasis, testing for reinfection, as well as other sexually transmitted infections, is recommended. Treatments for noninfectious vaginitis include vaginal lubricants and moisturizers, topical hormones, and topical steroids, depending on the cause.

To care for patients at the end of life, family physicians should be able to evaluate the causes of symptoms, differentiate between distressing symptoms and common end-of-life changes, and balance treatment effectiveness with potential adverse effects, while ensuring alignment with the patient's values and wishes. For severe pain and dyspnea, opioids are the mainstay of treatment. Palliation of pain with adjuvant medications and nonpharmacologic measures may delay or decrease the need for opioids. Nausea can be treated by reducing exacerbating factors and choosing agents that target the specific receptor site affected. Constipation should be prevented or treated quickly with osmotic and stimulant laxatives. Severe opioid-induced constipation may require enemas, prokinetics, or mu-opioid antagonists. Anorexia is extremely common at the end of life and may not warrant specific treatment in the absence of distress. Appetite stimulants can be considered after dysphagia, dyspepsia, nausea, and constipation are addressed. Early recognition of delirium, reduction of offending medications, and frequent reorientation may reduce the need for psychotropic medications. Mood disturbances should be distinguished from grief and cognitive loss, and treatment should consider prognosis and time to benefit.