Responding to Symptoms Summary PDF

Preview

Summary

an overview of each R2S lecture, includes pharma and non pharma treatment, red flags and symptoms...

Description

General Pain Management

Pain

Symptoms/Causes

Non-Pharma Advice Use the ‘ladder’: Step 1 – Non-Pharma Step 2 – Step 1 + NSAID or oral opioid Step 3 – Step 2 + increase dose

Pharma Advice • ANALGESICS: Non-opioids: Paracetamol + NSAIDS non-steroidal antiinflammatory drugs) Opioids: Morphine Derivatives + Codeine, Tramadol, Oxycodone) Other: Ice + Heat Rubs, Capsaicin, Antidepressants, Muscle Relaxants • Panadol/Paracetamol Children – 60mg/kg/day (in 4 doses) *NOTE: babies Panadol is 100mg/mL → much smaller dose (0.15mL/kg/dose) Adults – 4g/day (8 x 500mg tablets) Pregnancy – recommended painkiller if it is necessary • NSAIDs Aspirin – Mild to Moderate Pain + Inflammation Dose = 300mg – 900mg every 4-6 hours. Max 4g daily Ibuprofen – Mild to Moderate Pain + Inflammation Dose = 200mg – 400mg every 6-8 hours. Max 2.4g daily CHILDREN UNDER 3 MONTHS: 5-10mg/kg every 6-8 hours *Take with or after food Diclofenac – Mild to moderate pain + inflammation Dose = 75-150mg daily in divided doses Take with (or after) food

Red Flags Notes (Other) Questions to ask: • Paracetamol: 1. LOCATES Overdose → Liver Toxicity Early symptoms incl. vomiting, anorexia and nausea Location of the pain – does it travel? There are MANY products with paracetamol – be careful Other associated symptoms (e.g. to avoid overdose nausea) Character of the pain (throbbing, • Aspirin sharp, dull, burning) NOT to be given in children under 16 – Reye’s syndrome Aggravating and alleviating factors NOT safe in pregnancy Caution: bleeding disorders, asthma, renal impairment + (what makes it better or worse?) allergies Timing of the pain; constant or not? Environment (when/triggers) • Ibuprofen Severity (1-10 scale) NOT suitable with pregnancy (esp. third trimester) 2. Minimising NSAID risk: Use minimal effective dose for • NSAIDs (General) shortest time possible GI adverse effects (may cause ulceration: coffee coloured Fish Oil + Paracetamol as vomit, black + tarry stools alternative Renal adverse effects (worsen hypertension or heart Topic use where appropriate failure) Bronchospasm: check asthma status + if yes – history of NSAID (caution) Antiplatelet Activity: is there a history of bleeding?? Irreversible w/ aspirin not with others Do NOT use more than one NSAID at a time – combine with paracetamol instead Acute symptom relief ONLY • Diclofenac NOT for children under 14 Pregnancy – use alternatives… NOT RECOMMENDED in third trimester

Back Pain

Musculoskeletal

Headaches Note: symptom – NOT disease

Diagnosis based on clinical evaluation + review of current and historical symptoms + investigations to rule out red flags 1. Tension Front of head (bilateral) Low intensity & short duration Related to tight muscles in head and neck Often associated with environmental stresses – like this practical 2. Migraine Moderate to severe intensity Throbbing/Pulsating pain Made worse by movement Unilateral – can swap sides Duration: 4-72hrs Associated Symptoms = nausea + vomiting + photophobia 3. Cluster – RED FLAG Severe Pain + short duration (15min – 3hrs) Occurs in ‘clusters’ (1-8 attacks per day for 2-12 weeks) Unilateral pain; droopy eyelid, constricted pupil, teary, rhinorrhoea* + restless behaviour 4. Medication Overuse – REFER (to get meds changed) Headache more than 15days/month Regular overuse of medication (10-15 days/month, for 3 months) Caused by use of analgesics in anticipation of headache 5. Sinus 6. Cervicogenic Acute & Self-Limiting Sporting Injuries Minor Work Accidents Pain, swelling, bruising • Soft Tissue Injury Caused by local impact → Pain • Swelling Caused by over-rotation of the joint → inflammation • Sprains Caused by overstretching of ligament (fall, twist or blow) → reduced movement • Strains Caused by uncontrolled movement (twisting or pulling muscle or tendon) → tenderness • • • • •

Poor Posture Weak Muscles Heavy Lifting/Bending Obesity Pregnancy

• Identify and Avoid Triggers e.g. stress, alcohol, chocolate, sleep, missing meals, dehydration • Rest in quiet + dark place (esp. migraines) • Relaxation exercises (esp. tension) Massage, stretching, postural correction • Establish regular eating & sleeping patterns Sleep hygiene advice: -sleep and wake at same time every day -don’t ignore tiredness -don’t go to bed if you don’t feel tired -get enough early morning sun exposure -good sleeping environment (e.g. mattress) -dark enough room + right temperature -use bed only for sleeping -daily exercise, relax hour before bed, avoid electronics Reduction in caffeine

• Tension-Type Headaches Simple analgesics (paracetamol/NSAIDs) • Migraines Aspirin: 600-900mg, repeat at 4h if needed (soluble is useful) Ibuprofen: 200-400g, repeat at 6h if needed Diclofenac: 50-100mg, repeat at 6h if needed (orally) Naproxen Sodium: 550-825mg, repeat at 6h if needed Paracetamol (may be less effective): 1g soluble, repeat at 4h if needed Simple analgesics → Add Antiemetic* → Increase Dose → Prophylaxis (Refer: schedule 4) • Caffeine (65-200mg) may increase effectiveness of paracetamol • Opioids – AVOID UNLESS OTHER TREATMENT FAILS Aggravate gastrointestinal symptoms of migraines Only use under specialist advice Reduce pain & promote sleep (sleep terminates migraine attack)

• • • • • • • •

Sudden onset Recent onset/first experience – esp. 50+ years old Child under 5 years old Neurological Symptoms outside the norm Worsening or recent change in patterns Signs of meningitis – fever, neck stiffness, rash Signs of giant cell arteritis – temple pain, jaw pain Recent head trauma

CLUSTER HEADACHES!

Causative Medications: MOH • High: Opioids, Caffeine, Ergotamine • Moderate: Triptans, Tramadol • Low: Aspirin, Paracetamol, short-acting NSAIDs • Negligible: long-acting NSAIDs, dihydroergotamine

• • Medication Overuse Headaches Education of patients Withdraw overused drugs Initiate prophylaxis Plan regular follow up visits (relapse rate is high)

• • •

Initial first aid (RICER + no HARM) Simple analgesics (topical preparations) REMEMBER: pain is there for a reason – inflammation limits damage… prevention of further damage is more important than pain relief

Questions to Ask: • Onset of headache? • Frequency of headache? • Triggers and attack pattern? • Duration of attacks? • Severity? • Description of pain? (incl location) • Loss of function? • Other symptoms? • Changes in pattern? • Medication Use? • Response w/ treatments? • Discussed with GP?

• • • • •

If pain is severe or not improving after 24 hours When patient cannot bear weight Numbness or obvious deformity Severe pain and swelling Any doubt about severity of injury

RICER Protocol: Rest Ice (covered by damp cloth, 20min every 2 hours for 48-72 hours) Compression (firm, elastic nonadhesive bandage… compression over the top of ice pack, release for sleep) Elevation (above level of heart) Referral (after 48hrs) NO HARM PROTOCOL For the first 48 hours avoid: Heat Alcohol Re-injury Massage

• • • • • •

Severe or reoccurring pain Associated with fall or injury Patient completely immobile Pain is interfering with sleep Other symptoms – e.g. numbness Need continual pain relief for more than few days

Arthritis Menstrual Pain Dental Pain Children’ s Pain & Fever

1. Osteoarthritis (OA) Wear and tear of cartilage – common in the elderly and sports 2. Rheumatoid arthritis (RA)

•

OA – minimise use of affected joints

Caused by changes in prostaglandin levels during menstrual cycle Diagnosis based on timing of symptoms Physical Symptoms: • Fluid Retention • Swollen, painful breasts • Joint + muscle pain • Headaches • Tiredness Emotional Symptoms • Irritability • Difficulty in concentration Tooth Decay is a Major Cause of Dental Common Causes Pain • Pulpitis: inflammation of dental • Advice regarding good oral hygiene pulp Reversible: stabbing or shooting pain • Brushing with fluorine toothpaste & triggered by hot, cold or sweetness flossing twice a day Irreversible: dull and throbbing after • Rinsing with antiseptics mouth watch stimuli removed • Regular dental check-ups & • Dental Cracks: pain triggered professional cleaning from biting – relieved by pressure release • Dentin sensitivity: pain is short and sharp, caused by changes in temp. or osmotic pressure • Mucositis (mouth ulcers) • Facial nerve issues • Crying • Cuddles and attention • Holding area that is sore • Eating & Sleeping less • Increased irritability or unusually quiet • Pale, sweating, fast pulse

•

OA – simple OTC pain relief

• •

• •

NSAID pain relivers are good – ibuprofen, mfenamic acid (Ponstan), naproxen Can take with paracetamol for more relief

• • • • •

• • •

Simple analgesics (esp. NSAIDs) Topical analgesics Oils of Cloves popular (antiseptic and anaesthetic effects)

• • •

Kenalog 5g (triamcinolone 1mg/g paste) SM-33 Gel (lignocaine HCl 2.5%w/w paint) Difflam Gel (Benzydamine HCl 1%, certylpyridinium Cl0.1% gel)

•

Paracetamol and/or ibuprofen

RA – complex autoimmune disease; needs specialist and aggressive treatment to prevent permanent disease Small Joints; worsened by rest; unrelated to age First occurrence over 25 years Abnormal, severe or prolonged pain Abnormal vaginal discharge or irregular/heavy bleeding Pain during sex Presence of fever

• Good practice to send to dentist anyway for review URGENT: • Severe pain • Pain interfering with sleep • Pain lasted more than 48 hours • Difficulty swallowing or eating • Signs of infection – fever or chills • Pain due to face/head trauma • Excessive bleeding • Jaw pain associated with chest pain (or other heartissue related symptoms)

• • • • • • •

Under 3 months old – temp is 38oC+ Between 3-6 months old – temp is 39oC+ Pain or fever lasting 2+ days Repeated fever Drowsier than usual + constant or unusual crying Changes in breathing, seizures, mottled rash, stiff neck, sensitivity to light Poor oral intake + signs of dehydration

Reflux

Gastro-Intestinal Disorders

Oral Health

Symptoms/Causes • Dry Mouth: changes in saliva quantity or quality Sore cracked lips Difficulty Swallowing Increased infections/bad breath • Mouth Ulcers: minor → common; major → rare •

Non-Pharma Advice Clean gums morning and night (use a small, soft toothbrush and age appropriate fluorine toothpaste) • Visit dentist every 6-12 months • Quit smoking (if applicable) • Limit intake of sugary food/drink Dry Mouth • Treat underlying cause: alcohol, dehydration, snoring, medicines Modification of diet Causes • Failure of lower oesophageal sphincter • Less fatty meals to close properly • Reduce alcohol and • Inflammation of lower oesophageal caffeine tract • Small meals more • Most common causes = overeating + frequently medicines Weight Loss Drug Review Symptoms • Heartburn: burning feeling rising from • Verapamil stomach • Anticholergics • Regurgitation: backward flow and return Moderate Exercise of swallowed food into the mouth – may Minimise Stress be mistaken for vomiting Stop Smoking Avoid Lying Down After • Sudden salivation Eating • Avoid eating too close to bedtime • Extra pillows/elevate bedhead •

Pharma Advice Dry Mouth • Biotene Mouthwash

Red Flags/Referral • Tooth, gum or jaw pain • Swollen or Bleeding Gums • Bad Breath with an unknown cause • Pus around teeth or gums

Mouth Ulcers Local anaesthetics: lignocaine gel, lozenge, pastes (Kenalog in orbase S3) • • Rinse mouth with salt water (PAINFUL!) • •

• • • • • • • • • • • •

Antacids: combination of metal salts with low and high solubility Neutralise Gastric Acid (to raise pH) Reduce irritability of stomach acid Generally, well tolerated Magnesium Salts = diarrhoea Aluminium Salts = constipation Sodium Salts = increased risk in people with heart failure Rapid onset for effect Enteric coated – do not swallow whole Space other drugs out by 2hrs Dose: After or in between meals; max duration 2 weeks Products Available: Liquids/Suspensions, Tablets E.g. Mylanta, Rennie, Gaviscon

Alginates: forms raft when reacts with stomach acid • Forms physical protective layer over stomach contents • Dose: 10-20mL after meals… Also are tablets available Histamine H2 Receptor Antagonists: block activity of partial cells for decreased acid secretion • Ranitidine (e.g. Zantac) • More expensive than antacids + used when it is predictable • Unscheduled: 14 x 150mg tablets • S2: 28 x 150mg tablets, or 14 x 300mg tablets • Dose: Up to 150mg twice daily Proton Pump Inhibitors (PPI’s): irreversible inhibition of the H+/K+-ATPase (proton) pump • S2: up to 7 tablets (e.g. Nexium) • 23: up to 14 tablets (e.g. Heartburn Relief) • Dose: daily dosing; highly effective when use right dose • Well-tolerated for short term use • Recommended for frequent episodes (slower onset of action but more sustained effect) • Ensure adequate follow up after 2 weeks

• • • • • •

Dry Mouth – Sjogren’s Syndrome* Mouth Ulcers – If major; larger than 1cm + persistent for 14+ days … other symptoms such as fever/sore throat

Cardiac-type chest pain Non-specific abdominal pain/discomfort + nausea Hoarseness + sore throat Coughing After adequate trail of OTC options (consider dose, duration & escalation of treatment) Recurrent episodes with no clear trigger, or not previously investigated

ALARM Symptoms • Anaemia • Loss of weight (unintentional) • Anorexia • Recent onset and progressive • Melaena (black, tarry stools) or Haematemesis (vomiting blood) •

Notes (Other) Mouth Ulcers • History is required: number, location, size, shape & age (U10 rare), painful?

Proton Pump Inhibitors – if no affect after 2 weeks!!

Special Population → BABIES • True reflux = referral • Refusal to feed • Weight loss or concerning percentiles • Vomiting blood (Haematemesis) • Chronic cough/wheeze

Also Known As: • Acid Reflex • Indigestion • Heartburn • Dyspepsia*

BABIES • Vomiting and regurgitation is very common • Peaks at 4 months • Prevalence decreases at 12 months

Peptic Ulcers

Classified by location • Oesophageal • Gastric (stomach) Pain when eating – 30 minutes after • Duodenal Pain 2-3 hours after eating

•

Blood Loss • Bright red – in vomit • Coffee ground vomit – partly digested food • Black, tarry stools Anaemia • Lethargy, decreased energy • Pale appearance + shortness of breath • Increased in bowel movements, or • watery stools, compared to what is usual • for that person • Causal mechanisms: increased fluid secretion, decreased fluid absorption • Simple Gastric Irritation • Drug Induced (antibiotics) • Infectious gastroenteritis Bacterial → contaminated food or water Viral → norovirus and rotavirus Vomiting resolves faster than diarrhoea

Mostly self-limiting Best to let it ‘run its course’

• • •

• Loperamide (e.g. Gastro-stop) First Dose = 4mg (2 capsules, orally) Then, 2mg (1 tablet) after each unformed stool Max. 16mg per day (8 tablets/day) • Schedule 3 – Diphenoxylate/Atropine (e.g. Lomotil) Initially → 5+0.05mg (2 tablets) orally, 3-4 times a day CNS effects = drowsiness Reduce dose as soon as symptoms improve Maximum 20mg (8 tablets) per day • Treatment to manage dehydration Oral Rehydration Solutions (ORS) that are isotonic May be taken with or without food Do not dilute; sip slowly

Recent Overseas Travel? Chronic or recurrent diarrhoea (14+ days) Swaps between diarrhoea and constipation Change in bowel habits 50+ years old Significant dehydration risk (unable to tolerate adequate oral intake or extremely large volume) • Not responding to ORS treatment • Blood or mucus n bowel motions Severe antibiotic related diarrhoea Crohn’s disease Ulcerative disease

Examples: Hydralyte Gastrolyte

Diarrhoea

Suspected Peptic Ulcers is a red flag Increased risk in NSAID users GORD treatment may mask symptoms

•

• Special Population: babies Use in addition to breastfeeding Can be used to substitute for formula in first 12 years

• • • • •

Children with Diarrhoea • Not drinking + still vomiting/diarrhoea • High volume/persistent (8-10 watery motions) • Continue after 10 days • Dehydration – not passing urine, pale and has lost weight, sunken eyes, cold hands/feet, hard to wake up • Very bad stomach pain • Blood in faeces • Green vomit

Presentation is highly variable • Straining and/or pain and/or discomfort with defecation • Change in stool consistency • Decreased frequency of bowel movements • Abdominal discomfort • Sense of incompleteness

• • •

Constipation

• • •

Remove/reverse underlying cause Check drug interactions (e.g. Anticholergics, antacid metal salts) Diet modification (gradual increase of fibre intake + increase fruit) Increase Exercise Increase fluid Respond to urges

Laxatives: considerations • • •

Oral – most convenient, prevention + treatment appropriate; effect through entire colon Suppositories – need to be able to retain in rectum; relatively local effect – limited to colon and rectum… good for treatment, not for prevention Enemas – as above but for larger volume

Laxatives: types of… Bulk-forming Oral: 2-3 days for onset of action Mechanism: Increases stool volume → stimulates bowel movements Adverse Effects: flatulence, bloating, ab discomfort Ensure adequate fluid intake • Osmotic e.g. Glycerol, Lactulose, Sorbitol; Oral: 1-3 days, Rectal: 5-30 minutes Mechanism: draws water into faeces via osmotic gradient to stimulate peristalsis Adverse Effects: flatulence, abdominal discomfort, cramping Taste is sweet (20-30mL per dose); can mix with water, juice or milk Macrogol; Oral: 1-3 days Mechanism: large polymers with osmotic activity. Combine with electrolytes to minimise fluid loss Adverse Effect: nausea, bloating, fluid + electrolyte disturbance, rectal irritation Discard any solution after 6 hours Saline; Oral: 0.5-3 hours, Rectal: 2-30 minutes Mechanism: contains poorly absorbed ions to retain fluid in rectum Adverse Effects: nausea, bloating, fluid + electrolyte disturbance, rectal irritation Care needed in heart failure • Stool softeners Oral: 1-3 days Mechanism: increases water mixture into faeces, increases intestinal fluid Adverse Effects: abdominal discomfort Ensure adequate fluid intake • Stimulant Oral: 6-12 hours, Rectal: 5-60 minutes Examples: Dulcolax, senokat. Coloxyl Mechanism: direct stimulation of nerve endings Adverse Effects: ab discomfort, cramping, nausea May be used for long term in people who take opioids Most often associated with misuse • Lubricants Mechanism: lubricates faecal material to facilitate passage Adverse Effects: anal leakage and rectal irritation Glycerine Suppositories and Liquid Paraffin Onset of action → 30min (suppository) *NEED CORRECT SIZE* Liquid Paraffin only short term + avoid lying down 2hrs after

•

• • • • • • • • • •

Anorexia Unintentional weight loss Obstipation* Children under 1 year old Rectal loss of blood, melaena or mucus Fever/signs of infection Rectal pain Alternating diarrhoea and constipation → steatorrhea Over 50 years old Family history of IBD or colorectal cancer

INSERTING SUPPOSITORIES 1. In warmer weather – run under cool water 2. Wash hands and put on gloves (if desired) 3. Remove from individual wrapper 4. Insert pointed end first 5. Remain lying on side for about 5 minutes after inserting

USING ENEMAS 1. Clean hands 2. Remove orange protective shield 3. Lie of left side with knee bent; or knee then lower head and chest forward until left side of face is resting on surface 4. With steady pressure insert tip into rectum with a slight side to side movement 5. Have the t...