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Common Physical Symptoms    Website: http://ivmsicm.blogspot.com/                                            1
Common Physical          Symptoms          Marc Imhotep Cray, M.D.           Companion Online Folder:IVMS-Physical Diagnos...
Objectives• Know general guidelines for managing  nonpain symptoms• Understand how the principles of intended /  unintende...
General management guidelines             ...• History, physical examination• Conceptualize likely causes• Discuss treatme...
Breathlessness (dyspnea) . . .• May be described as  – shortness of breath  – a smothering feeling  – inability to get eno...
. . . Breathlessness (dyspnea)• The only reliable measure is patient self-report• Respiratory rate, pO2, blood gas  determ...
Causes of breathlessness•   Anxiety              •   Pulmonary embolism•   Airway obstruction   •   Thick secretions•   Br...
Management           of breathlessness• Treat the underlying cause• Symptomatic management  – oxygen  – opioids  – anxioly...
Oxygen•   Pulse oximetry not helpful•   Potent symbol of medical care•   Expensive•   Fan may do just as well             ...
Opioids•   Relief not related to respiratory rate•   No ethical or professional barriers•   Small doses•   Central and per...
Anxiolytics• Safe in combination with opioids  – lorazepam     • 0.5-2 mg po q 1 h prn until settled     • then dose routi...
Nonpharmacologic interventions            ...• Reassure, work to manage anxiety• Behavioral approaches, eg, relaxation,  d...
Nonpharmacologic interventions            ...•   Eliminate environmental irritants•   Keep line of sight clear to outside•...
. . . Nonpharmacologic              interventions• Introduce humidity• Reposition  – elevate the head of the bed  – move p...
Nausea / vomiting• Nausea  – subjective sensation  – stimulation     • gastrointestinal lining, CTZ, vestibular apparatus,...
Causes           of nausea / vomiting•   Metastases                            Mechanical•   Meningeal irritation     obs...
Pathophysiology        of nausea / vomiting  ChemoreceptorTrigger Zone (CTZ)     Vomiting centerNeurotransmitters Seroton...
Management             of nausea / vomiting•   Dopamine antagonists    •   Prokinetic agents•   Antihistamines          • ...
Dopamine antagonists•   Haloperidol•   Prochlorperazine•   Droperidol•   Thiethylperazine•   Promethazine•   Perphenazine•...
Histamine antagonists           (antihistamines)• Diphenhydramine• Meclizine• Hydroxyzine                              20
Acetylcholine antagonists                (anticholinergics)• Scopolamine                                     21
Serotonin antagonists• Ondansetron• Granisetron                             22
Prokinetic agents• Metoclopramide• Cisapride                            23
Antacids• Antacids• H2 receptor antagonists  – cimetidine  – famotidine  – ranitidine• Proton pump inhibitors  – omeprazol...
Cytoprotective agents• Misoprostol• Proton pump inhibitors (omeprazole,  lansoprazole)                                    ...
Other medications•   Dexamethasone•   Tetrahydrocannabinol•   Lorazepam•   Octreotide                           26
Constipation• Medications           • Metabolic    – opioids             abnormalities    – calcium-channel               ...
Management            of constipation• General measures       • Specific measures   –establish what is       – stimulants ...
Stimulant laxatives•   Prune juice•   Senna•   Casanthranol•   Bisacodyl                                29
Osmotic laxatives• Lactulose or sorbitol• Milk of magnesia (other Mg salts)• Magnesium citrate                            ...
Detergent laxatives           (stool softeners)• Sodium docusate• Calcium docusate• Phosphosoda enema prn                 ...
Prokinetic agents• Metoclopramide• Cisapride                            32
Lubricant stimulants• Glycerin suppositories• Oils  – mineral  – peanut                              33
Large-volume enemas• Warm water• Soap suds                           34
Constipation            from opioids . . .• Occurs with all opioids• Pharmacologic tolerance developed slowly, or  not at ...
. . . Constipation               from opioids• Combination stimulant / softeners are useful  first-line medications  – cas...
Causes of diarrhea•   Infections•   GI bleeding•   Malabsorption•   Medications•   Obstruction•   Overflow incontinence•  ...
Management of diarrhea•   Establish normal bowel pattern•   Avoid gas-forming foods•   Increase bulk•   Transient, mild di...
Management          of persistent diarrhea•   Loperamide•   Diphenoxylate / atropine•   Tincture of opium•   Octreotide   ...
Anorexia / cachexia• Loss of appetite• Loss of weight                              40
Management     of anorexia / cachexia . . .• Assess, manage comorbid conditions• Educate, support• Favorite foods / nutrit...
. . . Management         of anorexia / cachexia•   Alcohol•   Dexamethasone•   Megestrol acetate•   Tetrahydrocannabinol (...
Management        of fatigue / weakness . . .•   Promote energy conservation•   Evaluate medications•   Optimize fluid, el...
. . . Management         of fatigue / weakness• Dexamethasone  – feeling of well-being, increased energy  – effect may wan...
Fluid balance / edema . . .• Frequently associated with advanced illness• Hypoalbuminemia  decreased oncotic  pressure• V...
. . . Fluid balance / edema•   Limit or avoid IV fluids•   Urine output will be low•   Drink some fluids with salt•   Frag...
Skin• Hygiene• Protection• Support                      47
Pressure (decubitus) ulcers•   Prolonged pressure•   Inactivity•   Closely associated with mortality•   Easier to prevent ...
Odors• Topical and / or systemic antibiotics    – metronidazole    – silver sulfadiazine•   Kitty litter•   Activated char...
Insomnia• Assessment of sleep• Other unrelieved symptoms• Use family to help assess                              50
Management               of insomnia . . .•   Regular sleep schedule, avoid staying in bed•   Avoid caffeine, assess alcoh...
. . . Management                  of insomnia•   Antihistamines•   Benzodiazepines•   Neuroleptics•   Sedating antidepress...
Reference Resource Folder:IVMS-Medical Teacher Articles
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IVMS -ICM COMMON SIGNS AND SYMPTOMS

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IVMS -ICM COMMON SIGNS AND SYMPTOMS

  1. 1. Common Physical Symptoms Website: http://ivmsicm.blogspot.com/ 1
  2. 2. Common Physical Symptoms Marc Imhotep Cray, M.D. Companion Online Folder:IVMS-Physical Diagnosis Notes and Reference Resources
  3. 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. 4. General management guidelines ...• History, physical examination• Conceptualize likely causes• Discuss treatment options, assist with decision making 4
  5. 5. Breathlessness (dyspnea) . . .• May be described as – shortness of breath – a smothering feeling – inability to get enough air – suffocation 5
  6. 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. 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. 8. Management of breathlessness• Treat the underlying cause• Symptomatic management – oxygen – opioids – anxiolytics – nonpharmacologic interventions 8
  9. 9. Oxygen• Pulse oximetry not helpful• Potent symbol of medical care• Expensive• Fan may do just as well 9
  10. 10. Opioids• Relief not related to respiratory rate• No ethical or professional barriers• Small doses• Central and peripheral action 10
  11. 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. 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. 13. Nonpharmacologic interventions ...• Eliminate environmental irritants• Keep line of sight clear to outside• Reduce the room temperature• Avoid chilling the patient 13
  14. 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. 15. Nausea / vomiting• Nausea – subjective sensation – stimulation • gastrointestinal lining, CTZ, vestibular apparatus, cerebral cortex• Vomiting – neuromuscular reflex 15
  16. 16. Causes of nausea / vomiting• Metastases  Mechanical• Meningeal irritation obstruction• Movement  Motility• Mental anxiety  Metabolic• Medications  Microbes• Mucosal irritation  Myocardial 16
  17. 17. Pathophysiology of nausea / vomiting ChemoreceptorTrigger Zone (CTZ) Vomiting centerNeurotransmitters Serotonin Dopamine Acetylcholine Histamine 17
  18. 18. Management of nausea / vomiting• Dopamine antagonists • Prokinetic agents• Antihistamines • Antacids• Anticholinergics • Cytoprotective agents• Serotonin antagonists • Other medications 18
  19. 19. Dopamine antagonists• Haloperidol• Prochlorperazine• Droperidol• Thiethylperazine• Promethazine• Perphenazine• Trimethobenzamide• Metoclopramide 19
  20. 20. Histamine antagonists (antihistamines)• Diphenhydramine• Meclizine• Hydroxyzine 20
  21. 21. Acetylcholine antagonists (anticholinergics)• Scopolamine 21
  22. 22. Serotonin antagonists• Ondansetron• Granisetron 22
  23. 23. Prokinetic agents• Metoclopramide• Cisapride 23
  24. 24. Antacids• Antacids• H2 receptor antagonists – cimetidine – famotidine – ranitidine• Proton pump inhibitors – omeprazole – lansoprazole 24
  25. 25. Cytoprotective agents• Misoprostol• Proton pump inhibitors (omeprazole, lansoprazole) 25
  26. 26. Other medications• Dexamethasone• Tetrahydrocannabinol• Lorazepam• Octreotide 26
  27. 27. Constipation• Medications • Metabolic – opioids abnormalities – calcium-channel • Spinal cord blockers – anticholinergic compression• Decreased motility • Dehydration• Ileus • Autonomic dysfunction• Mechanical obstruction • Malignancy 27
  28. 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. 29. Stimulant laxatives• Prune juice• Senna• Casanthranol• Bisacodyl 29
  30. 30. Osmotic laxatives• Lactulose or sorbitol• Milk of magnesia (other Mg salts)• Magnesium citrate 30
  31. 31. Detergent laxatives (stool softeners)• Sodium docusate• Calcium docusate• Phosphosoda enema prn 31
  32. 32. Prokinetic agents• Metoclopramide• Cisapride 32
  33. 33. Lubricant stimulants• Glycerin suppositories• Oils – mineral – peanut 33
  34. 34. Large-volume enemas• Warm water• Soap suds 34
  35. 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. 36. . . . Constipation from opioids• Combination stimulant / softeners are useful first-line medications – casanthranol + docusate sodium – senna + docusate sodium• Prokinetic agents 36
  37. 37. Causes of diarrhea• Infections• GI bleeding• Malabsorption• Medications• Obstruction• Overflow incontinence• Stress 37
  38. 38. Management of diarrhea• Establish normal bowel pattern• Avoid gas-forming foods• Increase bulk• Transient, mild diarrhea – attapulgite – bismuth salts 38
  39. 39. Management of persistent diarrhea• Loperamide• Diphenoxylate / atropine• Tincture of opium• Octreotide 39
  40. 40. Anorexia / cachexia• Loss of appetite• Loss of weight 40
  41. 41. Management of anorexia / cachexia . . .• Assess, manage comorbid conditions• Educate, support• Favorite foods / nutritional supplements 41
  42. 42. . . . Management of anorexia / cachexia• Alcohol• Dexamethasone• Megestrol acetate• Tetrahydrocannabinol (THC)• Androgens 42
  43. 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. 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. 45. Fluid balance / edema . . .• Frequently associated with advanced illness• Hypoalbuminemia  decreased oncotic pressure• Venous or lymphatic obstruction may contribute 45
  46. 46. . . . Fluid balance / edema• Limit or avoid IV fluids• Urine output will be low• Drink some fluids with salt• Fragile skin 46
  47. 47. Skin• Hygiene• Protection• Support 47
  48. 48. Pressure (decubitus) ulcers• Prolonged pressure• Inactivity• Closely associated with mortality• Easier to prevent than treat 48
  49. 49. Odors• Topical and / or systemic antibiotics – metronidazole – silver sulfadiazine• Kitty litter• Activated charcoal• Vinegar• Burning candles 49
  50. 50. Insomnia• Assessment of sleep• Other unrelieved symptoms• Use family to help assess 50
  51. 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. 52. . . . Management of insomnia• Antihistamines• Benzodiazepines• Neuroleptics• Sedating antidepressant (trazodone)• Careful titration• Attention to adverse effects 52
  53. 53. Reference Resource Folder:IVMS-Medical Teacher Articles

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