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


Somerset Family Medicine Clinical Module



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Somerset Family Medicine Clinical Module

Bread & Butter of Family Medicine:
Pain Management

Introduction

Pain is one of the most common patient complaints in family medicine. It is very difficult to control effectively because it is highly subjective and multidimensional. The different types of pain are:



  • Nociceptive/somatic Pain: linked to tissue damage and the resulting inflammation.

  • Neuropathic Pain: results from a lesion or disease of the somatosensory system. It can persist even after healing, and is lancinating, shock-like, and burning.

  • Central Sensitization: alteration to the CNS processing of sensation, leading to amplification of pain signals (mechanisms poorly understood)

  • Psychogenic Pain: compounded by mental states of anxiety, depression, maladaptive coping mechanisms, excessive stress, and influence of social support systems.

  • Idiopathic Pain: no identifiable etiology.

Unfortunately, a patient’s complaint of pain is likely a combination of all of the above factors.

History

The history is the most valuable tool for evaluation because the patient’s self report has been proven to be the most reliable indicator of pain. Be sure to ask thorough questions regarding onset, provoking/palliating factors, quality, radiation, severity, timing, and associated symptoms. Severity can be difficult to gauge, as all patients handle and interpret pain differently. There are three common scales:

1. Visual Analog Scale 2. Numeric Rating Scale: Either ask to rate from 1-10, 10 being worst pain you can imagine, or if they would say their pain is mild, moderate, or severe. 3. Wong-Baker FACES Pain Rating Scale


An important clinical distinction to be made is if the pain is acute or chronic. Chronic pain is pain not associated with cancer or other medical conditions that persists more than 3-6 months, pain lasting 1 month longer than the acute illness or injury, or pain recurring in intervals of months to years [1]. Acute pain could require more investigation to rule out injuries, while chronic pain often requires more consideration of compounding factors (especially psychiatric issues).
Physical Examination

Observation: There are nonverbal cues for pain such as jaw clenching, pacing/restlessness, immobility, guarding, and wincing.

Vital Signs: Patients may be hypertensive, tachycardic, and tachypneic.

Examination: Evaluate for warmth, tenderness to palpation, range of motion restriction, and misalignment in the area of the pain. Pay close attention to changes in sensation, asymmetric reflexes, or poor motor function. Perform any special tests indicated [straight leg raise for low back pain, Anterior Drawer Test for ACL, McMurray’s for meniscus, Tinel’s/Phalen’s for carpal tunnel, etc.]


Diagnostic Studies

X-ray: Least expensive imaging study, can rule out fractures and evaluate joint space changes associated with arthritis.

MRI: Ordered with high suspicion of ligament/tendon tear, intervertebral disc damage, radiculopathy; or in the case of pain refractory to treatment attempts. (CT if MRI is contraindicated)
Conservative Therapies

There are various non-pharmacologic ways of relieving pain. Patients should attempt these instead of or in conjunction with their medications.



  1. PRICE- Protect, Rest, Ice, Compress (tape, ACE bandages), Elevate.

  2. Stretching/Exercise/Weight Loss **No complete bed rest with back pain!**

  3. Physical Therapy 4. Massage 5. Psychiatric eval.

  1. Thermo-therapies: Alternating hot and cold patches, warm baths, hot tubs.

  2. Chiropractors, Osteopathic Manipulative Medicine Specialists




Patches

Caspaicin, Lidoderm, Salonpa, IcyHot

Creams

Caspaicin, Volteran gel, BenGay

Joint Supplements

Help preserve cartilage. Glucosamine Chondroitin, Osteo Bi-Flex



Pharmacologic Management

Pain medication is a slippery slope, and prescribers need to be extremely cautious with regard to max doses of harmful medications and their risk of dependence/addiction. A rule of thumb is to start with low initial doses and increase slowly, perpetually offering conservative options for pain relief.


The World Health Organization developed a ladder for the management of pain. Their steps are:

  1. Start with non-opioid +/- adjuvant medication (anti-anxiety or muscle relaxers).

  1. If pain persists or increases, use weak opioid (hydrocodone) +/- non-opioid, +/- adjuvant.

  1. If pain still worsening, use stronger opioid (morphine), +/- non-opioid, +/- adjuvant.



Medication

Mechanism of Action

Dosing Info

Adverse Effects

Use with Caution

Steroids

[Medrol Dosepak]

Decreases transcription of inflammatory mediators

6-4mg pills day 1, 5 on day 2, 4 on day 3, 3 on day 4, 2 on day 5, and 1 on day 6.

Acne, adrenal suppression, hyperglycemia, osteoporosis

Side effects likely occur with long-term use

NSAIDs

[Ibuprofen, Naproxen, Motrin, Advil]

Reversible inhibition of COX 1 and 2

Adult: 10mg/kg dose, max dose 800mg, q 6-8 hr. max 2,400mg/day

PED: 4-10 mg/kg/dose q 6-8 hours.

GI discomfort/bleeds, cardiovascular thrombotic events

Renal impairment, GERD/PUD/history of GI bleeds, atherosclerotic disease

Aspirin (NSAID)

Irreversible Inhibition of COX 1 and 2

325-1,000mg q4-6hrs with max of 4g/day

Same as above, Contraindicated in children [Reye’s Syndrome], except in Kawasaki’s Dz.

Celebrex

[Celecoxib]

Selective COX-2 inhibition

200mg/day

Less GI issues but higher cardiovascular risk (stroke/MI)

Atherosclerotic disease, afib, hypercoagulable state

Tylenol

[Acetaminophen]

Decreases CNS production of prostaglandins, anti-pyretic effects on hypothalamus

ADULT: 325-650mg q 4-6hrs with max of 4,000mg [FDA].

PED: 10-15mg/kg/dose with max 2,600mg.



Hepatotoxicity

Drinkers, liver disease. If a patient drinks, decrease max dose to 3,000mg/day.




Tramadol

[Ultram]

Antagonizes opioid receptors and blocks serotonin and NE reuptake

50-100mg q4-6 hours, 400mg max/day.

Flushing, dizziness, HA, constipation, nausea

Contraindicated with acute alcohol or opioid intoxication

Flexeril

[Cyclobenzaprine]

Muscle Relaxant related to tricyclic antidepressants

5mg-10mg up to t.i.d.

Drowsiness, dry mouth

CHF, arrhythmias, hyperthyroidism

Valium

[Diazepam]

Muscle Relaxant, binds to GABA receptors to increase release

2-10mg b.i.d.-q.i.d.

Dependence, withdrawal seizures, respiratory dpn.

Depression, substance abuse, respiratory disorders

Opioids

[Norco]

Antagonizes opioid receptors in CNS to decrease synaptic transmission of pain signals

5-10mg of hydrocodone with 325 acetaminophen q4-6hrs (max 4,000mg acetaminophen)

Constipation, nausea/vomiting, itching, respiratory depression, DEPENDENCE.

Liver disease/drinkers, substance abuse, hypoventilated states.

INJECTIONS

Toradol [Ketorolac]

NSAID; IM 60mg single dose

C/I epidural or intrathecal

Kenalog [Triamcinolone]

Steroid; Intra-articular. 40mg large joint, 30mg medium, 10mg small.

Long-term and frequent injections can result in osteonecrosis.




Headache Management

Medication

Mechanism

Dosing

Adverse Effects

Caution

NSAIDs

[Ibuprofen, Naproxen, Motrin, Advil]

Reversible inhibition of COX 1 and 2

Adult: 10mg/kg dose, max dose 800mg, q 6-8 hr. max 2,400mg/day

PED: 4-10 mg/kg/dose q 6-8 hours.

GI discomfort/bleeds, cardiovascular thrombotic events

Renal impairment, GERD/PUD/history of GI bleeds, atherosclerotic disease

Excedrin Migraine

Anti-inflammatory and vasoconstrictor

250mg Acetaminophen, 250mg Aspirin, 65mg Caffeine per tablet.

GI discomfort/bleeds, hepatotoxicity

Renal impairment, GERD/PUD/history of GI bleeds, atherosclerotic disease

Imitrex

[Sumatriptan]

Serotonin receptor agonist, cause vasoconstriction in cranial arteries

25, 50, or 100mg tablet at onset of headache. No relief in 2 hours, take a second tablet.

Chest pain/tightness, coronary artery spasm, nausea

Uncontrolled HTN, CAD

Inderal

[Propranolol]

Migraine prophylaxis. Nonselective B blockade

80mg/day and increase q three weeks to 160-240mg/day divided q 6-8hr.

Bradycardia, hypotension, masks hypoglycemia, depression

Heart block, diabetics (especially on insulin), depression



Medical Marijuana: Uses- Chronic and severe pain, anti-nausea, appetite stimulant. Most often used for late stage cancer. THC binds to cannabinoid receptors to alter signaling with neurotransmitters. Physicians apply for licensure through their state’s program. In Michigan, it is the Medical Marijuana Program at [http://www.michigan.gov/lara/0,4601,7-154-35299_63294_63303_51869---,00.html]. Patients undergo full evaluation by licensed physician and then apply for their registration cards.

References

  1. Bickley, L., & Szilagyi, P. (2013). Bates' guide to physical examination and history-taking (11th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 2. uptodate.com 3. http://www.who.int/cancer/palliative/painladder/en/,


Somerset Family Medicine Clinical Module

Bread & Butter of Family Medicine:

CONSTIPATION
- Less than 3 bowel movements a week or hard, dry, or small, difficult to pass stool

Causes

  • Diet low in fiber, and not enough liquids

  • Lack of physical activity

  • Medications

  • Neurological (spinal cord injury, Parkinson’s etc) and metabolic disorders

  • GI tract (adhesions, tumors, celiac, diverticulosis, colon polyps)

Management

Medication categories of treatment:



  • Bulking laxatives (psyllium=Metamucil, methylcellulose=Citrucel, polycarbophil=FiberCon)

  • Osmotic laxatives (magnesium hydroxide=Exlax, Milk of Magnesium, polyethylene glycol= Miralax, Peg for bowel prep, and Lactulose)

  • Stimulant laxatives (sennosides= Senokot, Senexon, and bisacodyl=Dulcolax, Correctol)

  • Surfactant laxatives (docusate sodium=Colace, Philips, docusate calcium, mineral oil, and fleets oil enema)

  • Chloride channel activator (lubiprostone or Amitiza)

Medication mechanism of action include:

Bulking laxatives: Metamucil, Citrucel (First-line therapy)

Bulk laxatives bind to fecal content and pull water to the stool. Bulk forming holds water in the stool. (not useful when patients on opioids, avoid if patient has celiac disease or gluten intolerance due to wheat dextrin products). More bloating occurs. May take up to 3 days to work.



Osmotic laxatives: Miralax and Lactulose. (Second-line therapy)

Increased concentration of solutes creates osmotic pressure by drawing fluid from a less concentrated gradient to a more concentrated gradient, thus increases osmotic pressure to stimulate intestinal motility.

Research shows Miralax more effective than lactulose. Osmotic laxatives have less bloating

Stimulant laxatives: Senokot, Dulcolax (Third-line therapy)

Increase peristalsis through direct effects on the smooth muscle and simultaneously promote fluid accumulation in the colon. Avoid for long-term use as they have short-term usefulness.



Surfactant laxatives: (stool softener) Colace, Philips, and mineral oil (Third-line therapy)

Reduces surface tension of the liquid contents of the bowel, therefore allowing water and fat to enter and soften. Only prevents constipation, but do not treat it.



Chloride channel activator: Amitiza

Derived from prostaglandin. Works by enhancing chloride-rich intestinal fluid without altering serum sodium and potassium concentration. The activation of chloride in the intestines pulls water into the lumen of intestine.

The drug is poorly absorbed systemically and appears to act locally on the intestines, improving stool consistency and motility. No studies to compare efficacy of Amitiza to other medications.

Lifestyle modifications

Diet and nutrition management

20-35 grams of fiber a day (no refined or processed foods)



Drinking plenty of liquids (water, vegetable juice, & fruit juice)

Examples of Foods That Have Fiber

Beans, cereals, and breads

Fiber

½ cup of beans (navy, pinto, kidney, etc.), cooked

6.2–9.6 grams

½ cup of shredded wheat, ready-to-eat cereal

2.7–3.8 grams

⅓ cup of 100% bran, ready-to-eat cereal

9.1 grams

1 small oat bran muffin

3.0 grams

1 whole-wheat English muffin

4.4 grams

Fruits

1 small apple, with skin

3.6 grams

1 medium pear, with skin

5.5 grams

½ cup of raspberries

4.0 grams

½ cup of stewed prunes

3.8 grams

Vegetables

½ cup of winter squash, cooked

2.9 grams

1 medium sweet potato, baked in skin

3.8 grams

½ cup of green peas, cooked

3.5–4.4 grams

1 small potato, baked, with skin

3.0 grams

½ cup of mixed vegetables, cooked

4.0 grams

½ cup of broccoli, cooked

2.6–2.8 grams

½ cup of greens (spinach, collards, turnip greens), cooked

2.5–3.5 grams







Physical activity

“Physical activity appears to be unrelated to the risk of constipation in employed adults, but higher physical activity was associated with improved quality of life. Recommendations to increase physical activity may not alter symptoms of constipation but may improve overall well-being.” (American Journal of Gastroenterology, 2005)



Constipation quiz

1. Which describes constipation?



  1. Irregular motions

  2. Less than one stool per day

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

  4. 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

  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

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



  1. Systemic Scleroderma

  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





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