ITEMS IN AFP WITH MESH TERM:
ABSTRACT: Effective pain management in the terminally ill patient requires an understanding of pain control strategies. Ongoing assessment of pain is crucial and can be accomplished using various forms and scales. It is also important to determine if the pain is nociceptive (somatic or visceral pain) or neuropathic (continuous dysesthesias or chronic lancinating or paroxysmal pain). Nociceptive pain can usually be controlled with nonsteroidal antiinflammatory drugs or corticosteroids, whereas neuropathic pain responds to tricyclic antidepressants or anticonvulsants. Relief of breakthrough pain requires the administration of an immediate-release analgesic medication. If a significant amount of medication for breakthrough pain is already being given, the baseline dose of sustained-release analgesic medication should be increased. If pain does not respond to one analgesic medication, physicians should use an equianalgesic dose chart when changing the medication or route of administration. Opioid rotation can be used if pain can no longer be controlled on a specific regimen. The impact of unresolved psychosocial or spiritual issues on pain management may need to be addressed.
ABSTRACT: A detailed history alone may lead to a specific diagnosis in approximately 70 percent of patients who have wrist pain. Patients who present with spontaneous onset of wrist pain, who have a vague or distant history of trauma, or whose activities consist of repetitive loading could be suffering from a carpal bone nonunion or from avascular necrosis. The hand and wrist can be palpated to localize tenderness to a specific anatomic structure. Special tests can help support specific diagnoses (e.g., Finkelstein's test, the grind test, the lunotriquetral shear test, McMurray's test, the supination lift test, Watson's test). When radiography is indicated, the posterior-anterior and lateral views are essential to evaluate the bony architecture and alignment, the width and symmetry of the joint spaces, and the soft tissues. When the diagnosis remains unclear, or when the clinical course does not improve with conservative measures, further imaging modalities are indicated, including ultrasonography, technetium bone scan, computed tomography, and magnetic resonance imaging. If all studies are negative and clinically significant wrist pain continues, the patient may need to be referred to a specialist for further evaluation, which may include cineroentgenography, diagnostic arthrography, or arthroscopy.
ABSTRACT: Musculoskeletal pain can be difficult for children to characterize. Primary care physicians must determine whether the pain may be caused by a systemic disease. Change in activity, constitutional symptoms such as fevers and fatigue, or abnormal examination findings without obvious etiology should raise suspicion for rheumatic disease. A complete physical examination should be performed to look for extra-articular signs of rheumatic disease, focusing on but not limited to the affected areas. A logical and consistent approach to diagnosis is recommended, with judicious use of laboratory and radiologic testing. Complete blood count and erythrocyte sedimentation rate measurement are useful if rheumatic disease is suspected. Other rheumatologic tests (e.g., antinuclear antibody) have a low pretest probability in the primary care setting and must be interpreted cautiously. Plain radiography can exclude fractures or malignancy; computed tomography and magnetic resonance imaging are more sensitive in detecting joint inflammation. Family physicians should refer children to a subspecialist when the diagnosis is in question or subspecialty treatment is required. Part II of this series discusses rheumatic diseases that present primarily with musculoskeletal pain in children, including juvenile arthritis, the spondyloarthropathies, acute rheumatic fever, Henoch-SchÃ¶nlein purpura, and systemic lupus erythematosus.
ABSTRACT: The incidence of hip fracture is expected to increase as the population ages. One in five persons dies in the first year after sustaining a hip fracture, and those who survive past one year may have significant functional limitation. Although surgery is the main treatment for hip fracture, family physicians play a key role as patients' medical consultants. Surgical repair is recommended for stable patients within 24 to 48 hours of hospitalization. Antibiotic prophylaxis is indicated to prevent infection after surgery. Thromboprophylaxis has become the standard of care for management of hip fracture. Effective agents include unfractionated heparin, low-molecular-weight heparin, fondaparinux, and warfarin. Optimal pain control, usually with narcotic analgesics, is essential to ensure patient comfort and to facilitate rehabilitation. Rehabilitation after hip fracture surgery ideally should start on the first postoperative day with progression to ambulation as tolerated. Indwelling urinary catheters should be removed within 24 hours of surgery. Prevention, early recognition, and treatment of contributing factors for delirium also are crucial. Interventions to help prevent future falls, exercise and balance training in ambulatory patients, and the treatment of osteoporosis are important strategies for the secondary prevention of hip fracture.
ABSTRACT: Primary care physicians should have a working knowledge of rheumatic diseases of childhood that manifest primarily as musculoskeletal pain. Children with juvenile rheumatoid arthritis can present with painless joint inflammation and may have normal results on rheumatologic tests. Significant morbidity may result from associated painless uveitis, and children with juvenile rheumatoid arthritis should be screened by an ophthalmologist. The spondyloarthropathies (including juvenile ankylosing spondylitis and reactive arthritis) often cause enthesitis, and patients typically have positive results on a human leukocyte antigen B27 test and negative results on an antinuclear antibody test. Patients with acute rheumatic fever present with migratory arthritis two to three weeks after having untreated group A beta-hemolytic streptococcal pharyngitis. Henoch-Schbnlein purpura may manifest as arthritis before the classic purpuric rash appears. Systemic lupus erythematosus is rare in childhood but may cause significant morbidity and mortality if not treated early. Nonsteroidal anti-inflammatory drugs and physical therapy may be useful early interventions if a rheumatic illness is suspected. Family physicians should refer children when the diagnosis is in question or subspecialty treatment is required. Part I of this series discusses an approach to diagnosis with judicious use of laboratory and radiologic testing.
Fibromyalgia - Article
ABSTRACT: Fibromyalgia is an idiopathic, chronic, nonarticular pain syndrome with generalized tender points. It is a multisystem disease characterized by sleep disturbance, fatigue, headache, morning stiffness, paresthesias, and anxiety. Nearly 2 percent of the general population in the United States suffers from fibromyalgia, with females of middle age being at increased risk. The diagnosis is primarily based on the presence of widespread pain for a period of at least three months and the presence of 11 tender points among 18 specific anatomic sites. There are certain comorbid conditions that overlap with, and also may be confused with, fibromyalgia. Recently there has been improved recognition and understanding of fibromyalgia. Although there are no guidelines for treatment, there is evidence that a multidimensional approach with patient education, cognitive behavior therapy, exercise, physical therapy, and pharmacologic therapy can be effective.
Diagnosis of Ear Pain - Article
ABSTRACT: Many patients in primary care present with ear pain (otalgia). When the ear is the source of the pain (primary otalgia), the ear examination is usually abnormal. When the ear is not the source of the pain (secondary otalgia), the ear examination is typically normal. The cause of primary otalgia is usually apparent on examination; the most common causes are otitis media and otitis externa. The cause of secondary otalgia is often difficult to determine because the innervation of the ear is complex and there are many potential sources of referred pain. The most common causes are temporomandibular joint syndrome, pharyngitis, dental disease, and cervical spine arthritis. If the diagnosis is not clear from the history and physical examination, options include a trial of symptomatic treatment without a clear diagnosis; imaging studies; and consultation with an otolaryngologist. Patients who smoke, drink alcohol, are older than 50 years, or have diabetes are at higher risk of a cause of ear pain that needs further evaluation. Patients whose history or physical examination increases suspicion for a serious occult cause of ear pain or whose symptoms persist after symptomatic treatment should be considered for further evaluation, such as magnetic resonance imaging, fiberoptic nasolaryngoscopy, or an erythrocyte sedimentation rate measurement.
Managing Pain in the Dying Patient - Article
ABSTRACT: End-of-life care can be a challenge requiring the full range of a family physician's skills. Significant pain is common but is often undertreated despite available medications and technology. Starting with an appropriate assessment and following recommended guidelines on the use of analgesics, family physicians can achieve successful pain relief in nearly 90 percent of dying patients. Physicians must overcome their own fears about using narcotics and allay similar fears in patients, families and communities. Drugs such as corticosteroids, antidepressants and anticonvulsants can also help to alleviate pain. Anticonvulsants can be especially useful in relieving neuropathic pain. Side effects of pain medications should be anticipated and treated promptly, but good pain control should be maintained. The physical, psychologic, social and spiritual needs of dying patients are best managed with a team approach. Home visits can provide comfort and facilitate the doctor-patient relationship at the end of life.
When a Patient's Chronic Pain Gets Worse - Curbside Consultation
ABSTRACT: A systematic approach to chronic nonmalignant pain includes a comprehensive evaluation; a treatment plan determined by the diagnosis and mechanisms underlying the pain; patient education; and realistic goal setting. The main goal of treatment is to improve quality of life while decreasing pain. An initial comprehensive pain assessment is essential in developing a treatment plan that addresses the physical, social, functional, and psychological needs of the patient. One obstacle to appropriate pain management is managing the adverse effects of medication. Opioids pose challenges with abuse, addiction, diversion, lack of knowledge, concerns about adverse effects, and fears of regulatory scrutiny. These challenges may be overcome by adherence to the Federation of State Medical Boards guidelines, use of random urine drug screening, monitoring for aberrant behaviors, and anticipating adverse effects. When psychiatric comorbidities are present, risk of substance abuse is high and pain management may require specialized treatment or consultation. Referral to a pain management specialist can be helpful.