ITEMS IN FPM WITH MESH TERM:
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.
Evaluation of Dysuria in Men - Article
ABSTRACT: Men with pain or a burning sensation on urination should be evaluated with a thorough history, a focused physical examination and urinalysis (both urine dipstick and microscopic examination of the urine specimen). Although dysuria may be caused by anything that leads to inflammation of the urethal mucosa, it is most often the result of urinary tract infection. In younger patients, the infectious agent is usually a sexually transmitted organism such as Chlamydia trachomatis. In patients over 35 years of age, coliform bacteria predominate. Infection in older men most often occurs as a result of urinary stasis secondary to benign prostatic hyperplasia. Other conditions that may cause dysuria include renal calculus, genitourinary malignancy, spondyloarthropathy and medications. Successful treatment of dysuria depends on correct identification of its cause.
Hip Pain in Athletes - Article
ABSTRACT: Hip pain in athletes involves a wide differential diagnosis. Adolescents and young adults are at particular risk for various apophyseal and epiphyseal injuries due to lack of ossification of these cartilaginous growth plates. Older athletes are more likely to present with tendinitis in these areas because their growth plates have closed. Several bursae in the hip area are prone to inflammation. The trochanteric bursa is the most commonly injured, and the lesion is easily identified by palpation of the area. Iliotibial band syndrome presents with similar lateral hip pain and may be identified by provocative testing (Ober's test). A methodical physical examination that specifically tests the various muscle groups that move the hip joint can help determine a more specific diagnosis for the often vague complaint of hip pain. A number of hip conditions are more prevalent in athletes of certain ages. Transient synovitis is a common diagnosis in the very young, Legg-CalvÃ©-Perthes disease causes bony disruption of the femoral head in prepubescents, and slipped capital femoral epiphysis is seen most commonly in obese adolescent males. Femoral neck stress fractures are seen in adult athletes, especially those involved in endurance sports, and can progress to necrosis of the femoral head if not found early. Older athletes may be limited by degenerative joint disease but nonetheless should be encouraged to stay active.
Anterior Hip Pain - Article
ABSTRACT: Anterior hip pain is a common complaint with many possible causes. Apophyseal avulsion and slipped capital femoral epiphysis should not be overlooked in adolescents. Muscle and tendon strains are common in adults. Subsequent to accurate diagnosis, strains should improve with rest and directed conservative treatment. Osteoarthritis, which is diagnosed radiographically, generally occurs in middle-aged and older adults. Arthritis in younger adults should prompt consideration of an inflammatory cause. A possible femoral neck stress fracture should be evaluated urgently to prevent the potentially significant complications associated with displacement. Patients with osteitis pubis should be educated about the natural history of the condition and should undergo physical therapy to correct abnormal pelvic mechanics. "Sports hernias," nerve entrapments and labral pathologic conditions should be considered in athletic adults with characteristic presentations and chronic symptoms. Surgical intervention may allow resumption of pain-free athletic activity.
The Evaluation of Common Breast Problems - Article
ABSTRACT: The most common breast problems for which women consult a physician are breast pain, nipple discharge and a palpable mass. Most women with these complaints have benign breast disease. Breast pain alone is rarely a presenting symptom of cancer, and imaging studies should be reserved for use in women who fall within usual screening guidelines. A nipple discharge can be characterized as physiologic or pathologic based on the findings of the history and physical examination. A pathologic discharge is an indication for terminal duct excision. A dominant breast mass requires histologic diagnosis. A breast cyst can be diagnosed and treated by aspiration. The management of a solid mass depends on the degree of clinical suspicion and the patient's age.
Treatment of Nonmalignant Chronic Pain - Article
ABSTRACT: Nonmalignant, chronic pain is associated with physical, emotional and financial disability. Recent animal studies have shown that remodeling within the central nervous system causes the physical pathogenesis of chronic pain. This central neural plasticity results in persistent pain after correction of pathology, hyperalgesia, allodynia, and the spread of pain to areas other than those involved with the initial pathology. Patient evaluation and management focus on pain symptoms, functional disabilities, contributory comorbid illnesses, and medication use or overuse. Treatment of chronic pain involves a comprehensive approach using medication and functional rehabilitation. Functional rehabilitation includes patient education, the identification and management of contributing illnesses, the determination of reachable treatment goals and regular reassessment.
ABSTRACT: Procedures performed by an interventional radiology specialist are becoming increasingly important in the management of patients with cancer. Although general interventional radiology procedures such as angiography and angioplasty are used in patients with and without cancer, certain procedures are reserved for the diagnosis and treatment of cancer or cancer-related complications. Interventional radiology procedures include imaging-guided biopsies to obtain samples for cytologic or pathologic testing without affecting adjacent structures. Transjugular liver biopsy is used to diagnose hepatic parenchymal abnormalities without traversing Glisson's capsule. This biopsy procedure is particularly useful in patients with coagulopathies. Because the transjugular liver biopsy obtains random samples, it is not recommended for biopsy of discrete hepatic masses. Fluid collections can also be sampled or drained using interventional radiology techniques. Transcatheter chemoembolization is a procedure that delivers a chemotherapeutic agent to a tumor along with sponge particles that have an ischemic effect on the mass. Tumor ablation, gene therapy and access of central veins for treatment are performed effectively under radiographic guidance. Cancer complications can also be treated with interventional radiology techniques. Examples include pain control procedures, vertebroplasty and drainage of obstructed organs. Interventional radiology techniques typically represent the least invasive definitive diagnostic or therapeutic options available for patients with cancer. They can often be performed at a lower cost and with less associated morbidity than other interventions.
ABSTRACT: Multiple myeloma, the most common bone malignancy, is occurring with increasing frequency in older persons. Typical symptoms are bone pain, malaise, anemia, renal insufficiency, and hypercalcemia. Incidental discovery on comprehensive laboratory panels is common. The disease is diagnosed with serum or urine protein electrophoresis or immunofixation and bone marrow aspirate analysis. Skeletal radiographs are important in staging multiple myeloma and revealing lytic lesions, vertebral compression fractures, and osteoporosis. Magnetic resonance imaging and positron emission tomography or computed tomography are emerging as useful tools in the evaluation of patients with myeloma; magnetic resonance imaging is preferred for evaluating acute spinal compression. Nuclear bone scans and dual energy x-ray absorptiometry have no role in the diagnosis and staging of myeloma. The differential diagnosis of monoclonal gammopathies includes monoclonal gammopathy of uncertain significance, smoldering (asymptomatic) and symptomatic multiple myeloma, amyloidosis, B-cell non-Hodgkin lymphoma, WaldenstrÃ¶m macroglobulinemia, and rare plasma cell leukemia and heavy chain diseases. Patients with monoclonal gammopathy of uncertain significance or smoldering multiple myeloma should be followed closely, but not treated. Symptomatic multiple myeloma is treated with chemotherapy followed by autologous stem cell transplantation, if possible. Melphalan, prednisolone, dexamethasone, vincristine, doxorubicin, bortezomib, and thalidomide and its analogue lenalidomide have been used successfully. It is important that family physicians recognize and appropriately treat multiple myeloma complications. Bone pain is treated with opiates, bisphosphonates, radiotherapy, vertebroplasty, or kyphoplasty; nephrotoxic nonsteroidal anti-inflammatory drugs should be avoided. Hypercalcemia is treated with isotonic saline infusions, steroids, furosemide, or bisphosphonates. Because of susceptibility to infections, patients require broad-spectrum antibiotics for febrile illness and immunization against influenza, pneumococcus, and Haemophilus influenzae B. Five-year survival rates approach 33 percent, and the median survival rate is 33 months.
Nonmalignant Chronic Pain: Taking the Time to Treat - 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.