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IVMS -ICM COMMON SIGNS AND SYMPTOMS
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IVMS -ICM COMMON SIGNS AND SYMPTOMS

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IVMS -ICM COMMON SIGNS AND SYMPTOMS Presentation Transcript

  • 1. Common Physical Symptoms Website: http://ivmsicm.blogspot.com/ 1
  • 2. Common Physical Symptoms Marc Imhotep Cray, M.D. Companion Online Folder:IVMS-Physical Diagnosis Notes and Reference Resources
  • 3. Objectives• Know general guidelines for managing nonpain symptoms• Understand how the principles of intended / unintended consequences and double effect apply to symptom management• Know the assessment, management of common physical symptoms 3
  • 4. General management guidelines ...• History, physical examination• Conceptualize likely causes• Discuss treatment options, assist with decision making 4
  • 5. Breathlessness (dyspnea) . . .• May be described as – shortness of breath – a smothering feeling – inability to get enough air – suffocation 5
  • 6. . . . Breathlessness (dyspnea)• The only reliable measure is patient self-report• Respiratory rate, pO2, blood gas determinations DO NOT correlate with the feeling of breathlessness• Prevalence in the life-threateningly ill: 12 – 74% 6
  • 7. Causes of breathlessness• Anxiety • Pulmonary embolism• Airway obstruction • Thick secretions• Bronchospasm • Anemia• Hypoxemia • Metabolic• Pleural effusion • Family / financial / legal• Pneumonia / spiritual / practical• Pulmonary edema issues 7
  • 8. Management of breathlessness• Treat the underlying cause• Symptomatic management – oxygen – opioids – anxiolytics – nonpharmacologic interventions 8
  • 9. Oxygen• Pulse oximetry not helpful• Potent symbol of medical care• Expensive• Fan may do just as well 9
  • 10. Opioids• Relief not related to respiratory rate• No ethical or professional barriers• Small doses• Central and peripheral action 10
  • 11. Anxiolytics• Safe in combination with opioids – lorazepam • 0.5-2 mg po q 1 h prn until settled • then dose routinely q 4–6 h to keep settled 11
  • 12. Nonpharmacologic interventions ...• Reassure, work to manage anxiety• Behavioral approaches, eg, relaxation, distraction, hypnosis• Limit the number of people in the room• Open window 12
  • 13. Nonpharmacologic interventions ...• Eliminate environmental irritants• Keep line of sight clear to outside• Reduce the room temperature• Avoid chilling the patient 13
  • 14. . . . Nonpharmacologic interventions• Introduce humidity• Reposition – elevate the head of the bed – move patient to one side or other• Educate, support the family 14
  • 15. Nausea / vomiting• Nausea – subjective sensation – stimulation • gastrointestinal lining, CTZ, vestibular apparatus, cerebral cortex• Vomiting – neuromuscular reflex 15
  • 16. Causes of nausea / vomiting• Metastases  Mechanical• Meningeal irritation obstruction• Movement  Motility• Mental anxiety  Metabolic• Medications  Microbes• Mucosal irritation  Myocardial 16
  • 17. Pathophysiology of nausea / vomiting ChemoreceptorTrigger Zone (CTZ) Vomiting centerNeurotransmitters Serotonin Dopamine Acetylcholine Histamine 17
  • 18. Management of nausea / vomiting• Dopamine antagonists • Prokinetic agents• Antihistamines • Antacids• Anticholinergics • Cytoprotective agents• Serotonin antagonists • Other medications 18
  • 19. Dopamine antagonists• Haloperidol• Prochlorperazine• Droperidol• Thiethylperazine• Promethazine• Perphenazine• Trimethobenzamide• Metoclopramide 19
  • 20. Histamine antagonists (antihistamines)• Diphenhydramine• Meclizine• Hydroxyzine 20
  • 21. Acetylcholine antagonists (anticholinergics)• Scopolamine 21
  • 22. Serotonin antagonists• Ondansetron• Granisetron 22
  • 23. Prokinetic agents• Metoclopramide• Cisapride 23
  • 24. Antacids• Antacids• H2 receptor antagonists – cimetidine – famotidine – ranitidine• Proton pump inhibitors – omeprazole – lansoprazole 24
  • 25. Cytoprotective agents• Misoprostol• Proton pump inhibitors (omeprazole, lansoprazole) 25
  • 26. Other medications• Dexamethasone• Tetrahydrocannabinol• Lorazepam• Octreotide 26
  • 27. Constipation• Medications • Metabolic – opioids abnormalities – calcium-channel • Spinal cord blockers – anticholinergic compression• Decreased motility • Dehydration• Ileus • Autonomic dysfunction• Mechanical obstruction • Malignancy 27
  • 28. Management of constipation• General measures • Specific measures –establish what is – stimulants “normal” – osmotics –regular toileting – detergents –gastrocolic reflex – lubricants – large volume enemas 28
  • 29. Stimulant laxatives• Prune juice• Senna• Casanthranol• Bisacodyl 29
  • 30. Osmotic laxatives• Lactulose or sorbitol• Milk of magnesia (other Mg salts)• Magnesium citrate 30
  • 31. Detergent laxatives (stool softeners)• Sodium docusate• Calcium docusate• Phosphosoda enema prn 31
  • 32. Prokinetic agents• Metoclopramide• Cisapride 32
  • 33. Lubricant stimulants• Glycerin suppositories• Oils – mineral – peanut 33
  • 34. Large-volume enemas• Warm water• Soap suds 34
  • 35. Constipation from opioids . . .• Occurs with all opioids• Pharmacologic tolerance developed slowly, or not at all• Dietary interventions alone usually not sufficient• Avoid bulk-forming agents in debilitated patients 35
  • 36. . . . Constipation from opioids• Combination stimulant / softeners are useful first-line medications – casanthranol + docusate sodium – senna + docusate sodium• Prokinetic agents 36
  • 37. Causes of diarrhea• Infections• GI bleeding• Malabsorption• Medications• Obstruction• Overflow incontinence• Stress 37
  • 38. Management of diarrhea• Establish normal bowel pattern• Avoid gas-forming foods• Increase bulk• Transient, mild diarrhea – attapulgite – bismuth salts 38
  • 39. Management of persistent diarrhea• Loperamide• Diphenoxylate / atropine• Tincture of opium• Octreotide 39
  • 40. Anorexia / cachexia• Loss of appetite• Loss of weight 40
  • 41. Management of anorexia / cachexia . . .• Assess, manage comorbid conditions• Educate, support• Favorite foods / nutritional supplements 41
  • 42. . . . Management of anorexia / cachexia• Alcohol• Dexamethasone• Megestrol acetate• Tetrahydrocannabinol (THC)• Androgens 42
  • 43. Management of fatigue / weakness . . .• Promote energy conservation• Evaluate medications• Optimize fluid, electrolyte intake• Permission to rest• Clarify role of underlying illness• Educate, support patient, family• Include other disciplines 43
  • 44. . . . Management of fatigue / weakness• Dexamethasone – feeling of well-being, increased energy – effect may wane after 4-6 weeks – continue until death• Methylphenidate 44
  • 45. Fluid balance / edema . . .• Frequently associated with advanced illness• Hypoalbuminemia  decreased oncotic pressure• Venous or lymphatic obstruction may contribute 45
  • 46. . . . Fluid balance / edema• Limit or avoid IV fluids• Urine output will be low• Drink some fluids with salt• Fragile skin 46
  • 47. Skin• Hygiene• Protection• Support 47
  • 48. Pressure (decubitus) ulcers• Prolonged pressure• Inactivity• Closely associated with mortality• Easier to prevent than treat 48
  • 49. Odors• Topical and / or systemic antibiotics – metronidazole – silver sulfadiazine• Kitty litter• Activated charcoal• Vinegar• Burning candles 49
  • 50. Insomnia• Assessment of sleep• Other unrelieved symptoms• Use family to help assess 50
  • 51. Management of insomnia . . .• Regular sleep schedule, avoid staying in bed• Avoid caffeine, assess alcohol intake• Cognitive / physical stimulation• Avoid overstimulation• Control pain during the night• Relaxation, imagery 51
  • 52. . . . Management of insomnia• Antihistamines• Benzodiazepines• Neuroleptics• Sedating antidepressant (trazodone)• Careful titration• Attention to adverse effects 52
  • 53. Reference Resource Folder:IVMS-Medical Teacher Articles