Dr neil jaddou m. D board certified and professor of family medicine



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Constipation quiz answers
1. Which describes constipation?

  1. Irregular motions

  1. Less than one stool per day

  2. Less than three bowel movements per week or difficult and painful defecation with incomplete evacuation

  3. Blood in stool

2. Which lifestyle causes of constipation?

A. Lack of fiber in diet

B. Lack of exercise

C. Lack of fluids in diet

D. All of the above


3. Which disease has constipation as its clinical feature?



  1. Interstitial nephritis

  2. Rheumatic fever

  3. Irritable bowel syndrome (bowel dysfunction with abdominal pain with characterized by disturbed bowel movement such as diarrhea, alone or alternating)

  4. Onchocercosis

4. Which drug causes constipation as a side effect?



  1. Antidepressants

  2. Aluminum containing antacids

  3. Diuretics

  4. All of the above

5. Which metabolic disease leads to secondary constipation?



  1. Rickets and Osteomalacia

  2. Hypothyroidism

  3. Hyperthyroidism

  4. Hyperparathyroidism

6. True or false, prolonged laxative use may predispose towards constipation?



True (due to degeneration of mesenteric plexus of colon. Increase constipation in spite of taking larger doses of laxatives.

False

7. Constipation is a clinical feature in which of the following diseases?


  1. Systemic Scleroderma (due to number of GI signs & symptoms such as nausea, vomiting, gaseous distention)

  2. Q fever

  3. Scarlet fever

  4. Chickenpox

8. Which of the following neurological disorders has constipation as its clinical feature?

A. Parkinson’s disease

B. Chagas disease

C. Multiple sclerosis

D. All of the above

9. Stool bulking agents may be beneficial in the treatment of constipation in irritable bowel disorder.

True

False

10. Which of the following is useful in the diagnosis of constipation?


  1. Barium enema

  2. Sigmoidoscopy

  3. Thyroid function test

  4. All of the above


Somerset Family Medicine Clinical Module

Bread & Butter of Family Medicine:

Smoking Cessation
Smoking cessation is a leading preventable cause of mortality. Tobacco use can lead to tobacco/nicotine dependence and serious health problems. Nicotine dependence is the most common form of chemical dependence in the United States. Quitting smoking is difficult and may require several attempts.
Assessment of use and exposure: The United States Preventive Health Services guidelines recommend that tobacco use status of every patient treated in a healthcare setting be assessed and documented at every visit. This practice has been shown to increase the likelihood of smoking-related discussions between patients and physicians and to increase the smoking cessation rates.
Nicotine withdrawal syndrome : Nicotine is a potent psychoactive drug that can cause physical dependence and tolerance. In the absence of nicotine, a smoker develops cravings for cigarettes and symptoms of nicotine withdrawal syndrome. These symptoms include:
1. Dysphoric or depressed mood

2. Insomnia

3. Irritability,frustration or anger

4. Anxiety

5. Difficulty concentration

6. Restlessness

7. Increased appetite or weight gain
Clinical trials have found that behavioural therapy along with pharmacotherapy has the best results for smoking cessation.
Choice of treatment
In general, clinicians should offer patients both behavioural and pharmacologic therapy as these treatments in combination have been found to have higher abstinence rates.
Types of treatment:

Behavioural counselling: Behavioural counselling can be provided in a variety of formats, including direct parent-physician encounters, via telephone, computer programs, text messaging, or group based therapy. A simple five step program called the 5 A’s (ask,advise,assess,assist,arrange) that operationalizes the elements of brief counselling programs for office practice are effective for increasing the abstinence rates.


Five "A's" for assessing for tobacco use and addressing smoking cessation

Intervention

Technique

Ask

Implement an officewide system that ensures that, for every patient at every clinic visit, tobacco-use status is queried and documented. Repeated assessment is not necessary in the case of the adult who has never used tobacco or has not used tobacco for many years, and for whom this information is clearly documented in the medical record.

Advise

Strongly urge all tobacco users to quit in a clear, strong, personalized manner.




Advice should be:




Clear - "I think it is important for you to quit smoking now and I can help you." "Cutting down while you are ill is not enough."




Strong - "As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you."




Personalized - Tie tobacco use to current health/illness, and/or its social and economic costs, motivation level/readiness to quit, and/or the impact of tobacco use on children and others in the household.

Assess

Determine the patient's willingness to quit smoking within the next 30 days:




If the patient is willing to make a quit attempt at this time, provide assistance.




If the patient will participate in an intensive treatment, deliver such a treatment or refer to an intensive intervention.




If the patient clearly states he or she is unwilling to make a quit attempt at this time, provide a motivational intervention.




If the patient is a member of a special population (eg, adolescent, pregnant smoker), provide additional information specific to that population.

Assist

Provide aid for the patient to quit. These actions are summarized in the accompanying table.

Arrange

Schedule follow-up contact, either in person or by telephone. Follow-up contact should occur soon after the quit date, preferably during the first week. A second follow-up contact is recommended within the first month. Schedule further follow-up contacts as indicated.




Congratulate success during each follow-up. If tobacco use has occurred, review circumstances and elicit recommitment to total abstinence. Remind the patient that a lapse can be used as a learning experience. Identify problems already encountered and anticipate challenges in the immediate future. Assess pharmacotherapy use and problems. Consider use or referral to more intensive treatment.

Adapted from: Fiore MC, Jaen C, Baker T, et al. Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services. Public Health Service. 2008.

Graphic 74402 Version 7.0



Five "R's" to motivate smokers unwilling to quit

Intervention

Technique

Relevance

Encourage the patient to indicate why quitting is personally relevant, being as specific as possible. Motivational information has the greatest impact if it is relevant to a patient's disease status or risk, family or social situation (eg, having children in the home), health concerns, age, gender, and other important patient characteristics (eg, prior quitting experience, personal barriers to cessation).

Risks

Ask the patient to identify potential negative consequences of tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient. The clinician should emphasize that smoking low-tar/low-nicotine cigarettes or use of other forms of tobacco (eg, smokeless tobacco, cigars, and pipes) will not eliminate these risks.




Examples of risks are:




Acute risks - Shortness of breath, exacerbation of asthma, harm to pregnancy, impotence, infertility, and increased serum carbon monoxide.




Long-term risks - Heart attacks and strokes, lung and other cancers (larynx, oral cavity, pharynx, esophagus, pancreas, bladder, cervix), chronic obstructive pulmonary diseases (chronic bronchitis and emphysema), long-term disability, and need for extended care.




Environmental risks - Increased risk of lung cancer and heart disease in spouses; higher rates of smoking in children of tobacco users; increased risk for low birth weight, Sudden Infant Death Syndrome, asthma, middle ear disease, and respiratory infections in children of smokers.

Rewards

Ask the patient to identify potential benefits of stopping tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient.




Examples of rewards include:




Improved health




Food will taste better




Improved sense of smell




Save money




Feel better about yourself




Home, car, clothing, breath will smell better




Can stop worrying about quitting




Set a good example for and have healthier babies and children




Not worry about exposing others to smoke




Feel better physically and perform better in physical activities




Reduced wrinkling/aging of skin

Roadblocks

Ask the patient to identify barriers or impediments to quitting and note elements of treatment (problemsolving, pharmacotherapy) that could address barriers.




Typical barriers might include:




Withdrawal symptoms




Fear of failure




Weight gain




Lack of support




Depression




Enjoyment of tobacco

Repetition

The motivational intervention should be repeated every time an unmotivated patient visits the clinic setting. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.

Adapted from: Fiore MC, Jaen C, Baker T, et al. Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services. Public Health Service. 2008.

Graphic 70628 Version 5.0

Pharmacologic therapy: Aims at reducing the symptoms of nicotine withdrawal, thereby making it easier for the smoker to stop the habitual use of smokers.




Drug-

nicotine replacement therapy



dose and duration

efficacy and safety and side effects

Nicotine transdermal patch

Smokers > 10 cigarettes per day


smokers<45 kgs or <10 cigarettes per day

21 mg/day for 6 weeks, followed by 14 mg/day for two weeks, finishing with 7 mg/day for two weeks.


14 mg/kg per 14 days followed by 7 mg/day for two weeks

Insomnia and vivid dreams are reported as side effects when the patch is left overnight.

Nicotine Gum
Smokers >25 cigarettes
lighter smoker

4 mg per day

2 mg per day


Nausea, vomiting,abdominal pain, headache,sore jaw

Nicotine Lozenge
Smokers who smoke within 30 min after awakening

lighter smokers



4 mg per day

2 mg per day


Mouth irritation, ulcers

Nicotine sublingual tablet

4 or 2 mg depending on nicotine dependence




Nicotine inhaler

6 to 16 cartridges per day for the first 6-12 weeks, followed by gradual reduction of dose over the next 6 to 12 weeks.

Irritation of mouth and gums.

Nicotine nasal spray

1-2 sprays for recommended for maximum of 3 months




Nicotine mouth spray

1-2 sprays when the cravings occur




Bupropion

Started 1 week before the start of the quit date.

150 mg/day for 3 days, followed by 150 mg/day twice a day thereafter for 7-12 weeks.



Insomnia, agitation,dry mouth and headache.

Varenicline

0.5 mg for 3 days,followed by 0.5 mg for twice daily for four days, and then 1 mg daily for 12 weeks

suicidal ideation,depression,

increase in cardiovascular events in patients with CVD



Combined nicotine therapy

Nicotine patch + short acting-NRT product (gum,spray or inhaler)

more efficacious than single agent

Finally, for the patients who are not ready to quit smoking, it is the duty of the clinicians to assess the patient’s perspective (the risks and benefits of continuing to smoke) in order to help the smoker to begin to think about quitting.


REFERENCES
http://wwwuptodate.com.

www.webmd.com

END

OF

CLINICAL

MODULE
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