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Low Back Pain

I.        Overview
Your patient will complain of low back pain. This is an extremely common complaint; in
fact, it is estimated that 70% of the population will develop back pain at some time
during their lives. The most common cause is “lumbosacral sprain syndrome”, thought to
be caused by trauma, lifting, prolonged standing, abnormal posture, and probably by
psychological stress. The source of the pain may be avulsion of tendinous attachments,
rupture or spasm of muscle fibers, stress upon ligaments, chronic degeneration or the
facet joints, or even early herniation of the disc. Some of the conditions to be
differentiated are herniation of the disc versus back pain “referred” from intra-abdominal
sources such as kidney stones, tumors of the prostate, gynecological organs, or colon.
(By “referred pain” we mean that pain from organs which share the same nervous system
tracts as the low back, may present as pain in the low back only.)

II.    Chief characteristics:
The chief characteristics which differentiate types of back pain are its association with
movement and the presence or absence of specific patterns of radiation.
       A. Pain which originates in the musculoskeletal system (sprain or slipped disc)
           will cause limitation of motion and will be exacerbated by movement.
           Typically these patients feel better lying flat on their backs, and worse when
           they turn, bend or walk.
       B. Pain unrelated to movement suggests that it is referred from an intra-
           abdominal source. In addition, pain of an intra-abdominal source will usually
           have other symptoms of intra-abdominal disease, such as urinary, bowel, or
           gynecological problems.
       C. The radiation of the pain into the legs or feet suggests nerve root irritation,
           more typical of a slipped disc.

III.   Physician Tasks:
       A. Psychosocial Issues – Above all, though, remember that this is an individual
          who was functioning in his or her world prior to the onset of this pain.
          Indeed, often the disruption in the patient’s life brought on by the changes
          required is more catastrophic than the pain itself. Indeed, this disease process
          or injury may have forced changes in the patient’s family, professional, and/or
          social life, which in turn may have affected his or her financial status, career
          path, personal relationships, and even self-esteem, especially when
          accompanied by a loss of independence. These issues become especially
          important when the rehabilitative process begins, since the patient is the key
          contributor to his/her rehabilitative process. The motivation of the patient to
          tackle the disability depends on many factors, which include self-image as
          well as the patient’s own psychological, social, and financial resources.

           Begin to address these issues by asking what the patient’s understanding of
           the pain is. How has the pain affected the patient? What are the patient’s

   thoughts and concerns? How has the patient’s family reacted to the changes
   in the patient’s well-being? Has it affected the patient’s professional life?

B. Clinical Issues – Try to elicit from your patient a description of the pain, its
   radiation pattern, and its relation to position movement. Find out how it
   began. Find out if there is evidence of intra-abdominal organ problems.

C. Treatment Issues – Investigate and develop a rational for recommending a
   muscle relaxant medication for the patient to take in addition to ibuprofen as
   initial drug treatment. Also, find out what physical therapy can do to ease
   back pain and promote back health. List at least two modalities.


 I.        Overview
   About 18 million Americans, 1 in 15, suffer from some degree of depression each year.
   The lifetime expectancy is about 10% for men and 20% for women. Depression is a
   medical disorder that can be treated with medication and/or psychotherapy. Your task in
   this encounter is to explore whether your patient is suffering from depression. You will
   not be expected to decide a treatment plan. A patient will complain of chronic fatigue.
   As part of your history-taking, you should explore the symptoms of depression, as well as
   other issues that emerge during the session.
   Depression is more than “feeling blue” or grieving a loss for a short period of time.
   Instead depression includes a disruption of normal daily activities. As you talk with the
   patient, you will want to explore the patient’s daily activities and feelings and how they
   might have changed since s/he began experiencing chronic fatigue.

II.         Chief characteristics:
    The symptoms include loss of energy (found in 97% of depressed patients), a loss of
   interest in activities that patients used to enjoy, acting agitated/angry/restless, feeling
   slow or lethargic, feelings of worthlessness or guilt, changes in appetite, gaining or losing
   weight, feeling sad or “blue”, concentration problems, sleeping too much or not enough,
   inability to fall or stay asleep, chronic fatigue. Individuals who are depressed might also
   have thoughts of suicide or simply recurrent thoughts of death, but no suicidal ideas.
   Individuals who are depressed experience some of these symptoms nearly every day for
   at least two weeks. The more of the symptoms the patient experiences, the more severe
   the depression.

   Individuals experiencing mild depression may experience a few of the above symptoms,
   or just in a milder form. They might find their daily activities difficult to continue, but
   they are still able to perform what is necessary to their work and home lives. Those who
   suffer from moderate depression have many symptoms and may not be able to complete
   tasks necessary to perform their jobs or sustain their households. Individuals with severe
   depression have nearly all the symptoms. Severely depressed individuals almost always
   fail to perform their routine daily tasks.

III.        Physician Tasks:
    A. Causes:
    Depression can be caused by chemical imbalances in the brain. It can also be caused by
    certain medicines, recreational drugs, or alcohol. As a result, you will need to explore
    these in your interview. About 10-15% of all depressions are caused by other medical
    conditions: thyroid disease, cancer, or neurological problems or medications. As part of
    your history taking you will want to explore the patient’s medical history, you will want
    to ask about present illnesses and medications.

   Depression can also be situational. Extreme grief, loss, or stress can cause depression.
   Often, when the stressful event passes or grief lessens, the depression diminishes as well.

If the symptoms don’t go away, they should be treated. You will want to explore
stressors or major changes in the patient’s life that might have preceded the fatigue and
other symptoms you discover in your interview.

B. Treatments
1. Treatments for depression include antidepressant medication, psychotherapy, or both.
   Medication includes drugs such as Prozac, Paxil, Elavil, Desyrel, and many others.
   All these medications have similar efficacy (but different side effects) and will work
   to relieve symptoms of depression in about 75% of the patients who take them. The
   medications restore the balance of chemicals in the brain. When these are effective,
   patients begin to feel better within a few weeks. All antidepressants include differing
   side effects ranging from dry mouth, dizziness, nausea, rash, constipation,
   drowsiness, weight gain or loss, or restlessness. These usually disappear within a few
   weeks of taking the medication. More serious side effects include seizures, fainting,
   sexual dysfunction, or heart problems.

2. Psychotherapy (cognitive or behavioral therapy) is another treatment option. This
   treatment is effective in about half of the cases of mild or moderate depression.
   Individual therapy, group therapy, and family therapy have all proven to be helpful.
   Usually psychotherapy for depression is time limited. Physicians often assist patients
   in finding an effective therapist. Psychotherapy is often combined with
   antidepressants, especially for severe cases of depression.
   Modified from “Depression: ACOG Patient Education” 1994, and other sources

   Upper Respiratory Infection or Influenza?

 I.       Overview

   It’s “flu” season. A patient will present with symptoms of an upper respiratory infection.
   S/he will complain of typical symptoms associated with the common cold: cough, stuffy
   nose, headache, and feeling unwell. S/he is concerned that s/he might have something
   more serious, such as influenza.

II.       Physician Tasks:

   The common cold shares many common symptoms with influenza, which can be serious,
   One of your task includes exploring the chief complaint and its relationship to more
   serious associations with influenza.

   Influenza, "the flu," is caused by viruses that infect the respiratory tract. Usual symptoms
   include fever: typically between 100F to 103 in adults. This can be even higher in
   children. Other symptoms include severe coughing, profound fatigue, headache, diffuse
   muscle aches, sore throat, and a runny or stuffy nose. To determine the seriousness of the
   patients problem you will need to do a complete exploration of the patient’s chief
   complaint. Additionally, influenza typically comes on very suddenly, whereas a “cold”
   will come on gradually over a couple of days.

   You will also need to explore associated symptoms. Patients may fear that the common
   cold is influenza, if they are also experiencing some gastrointestinal illness. Many
   patients refer to nausea or diarrhea as “stomach flu.” These problem are caused by other
   microorganisms, not associated with upper respiratory infection.

   A. Prognosis.
   You will want to explore the duration of symptoms, as well as their severity. The typical
   recovery period for influenza is 1-2 weeks. In serious cases the flu can turn into severe
   medical complications, including pneumonia. Be alert to the seriousness of the
   symptoms. In an average year, 20,000 people die of influenza. Many more are
   hospitalized. Most at risk are the elderly and people with chronic health problems.

   B. Types of Influenza Viruses
   Generally influenza viruses are divided into three types, designated A, B, and C.
   Types A and B emerge almost every winter and are more serious than C. Type C causes
   only very mild illness, less infectious than types A & B. Patients may wonder why they
   come down with the flu every year. You might need to explain that influenza viruses
   continually change by mutation. This process enables the virus to overcome the body’s
   immune system. As a result, patients are vulnerable to influenza infection throughout
   life. When a person is infected with influenza the body develops antibodies to fight that
   particular strain of virus. But as viruses change, the previously developed antibody
   doesn’t recognize the new form. As a result, reinfection can occur.


I.      Overview:
Headache is the most common neurologic symptom. It has been estimated that over 35
million individuals in the United States suffer from recurrent headaches. Most of these
patients have headaches that are related to migraine, muscle contraction or to tension.
The overwhelming majority of headaches which doctors treat are not caused by any
demonstrable or treatable organic diseases.

II.    Chief Characteristics:
While there are a number of different types of headaches, the three most common types
of headaches are:

        MIGRAINE – A throbbing, pounding, unilateral headache. It is often
accompanies by nausea, vomiting or anorexia, diarrhea, fever, chills, and possible
neurologic deficits. Migraine headaches are three times more likely to occur in women
than in men. Young adults often suffer from migraine headaches. This is an inheritable
condition, with a positive family history obtained in 70-75% of patients.

        CLUSTER – Severe pain occurs several times a day. The pain is located around
the eye and is always unilateral. These headaches occur almost exclusively in men,
especially adolescent males. Cluster patients tend to be heavy smokers and drinkers.
Signs and symptoms include unilateral nasal congestion and watering of the eyes.

       TENSION – Tension headaches typically involve the entire head. The neck and
should muscles are often tight and tense as well. People who have poor posture, who
perform jobs which involve stationary repetitive task, or who perform jobs which involve
much motion of the neck and shoulders are at particularly high risk for tension
headaches. Emotional tension is frequently a factor, either primary or secondary.

         OTHER POSSIBLE CAUSES OF HEADACHES – The usual causes of tension
headaches are anxiety and stress; however, headaches may also be the result of referred
pain from sinus infections, ocular disease, and dental disease. In chronic forms,
depression may also be a contributing factor. (A headache is said to be chronic if it
persists for 15 days a month for a period of at least 6 months.). Viral infections, chronic
obstructive pulmonary disease, and poisoning may also produce headaches. In addition,
it is vital to determine whether the patient is taking any medications that may be
producing the head pain.

III.   Physical Tasks:
       A. Psychosocial Issues – How have these headaches been affecting the patient’s
          life, both family and work life? Is his/her family aware of the occurrence of
          these headaches? What kinds of concerns does the patient have? Does the
          patient have any fears which need to be addressed? A headache may
          symbolize many different things to patients; thus it is important to assess how
          the patient has explained its presence to him or herself.

B. Clinical Issues – It is important for the doctor to determine the following:
   1. Is there a pattern to these headaches? (When do they occur? Where do
      they hurt? How severe? etc.)
   2. Is the patient in any of the high risk categories above? (Consider gender,
      work history, family, and psychosocial histories.)
   3. Is the patient experiencing stress, anxiety or depression?
   4. How has the patient been treating the headaches? (People who have
      chronic headaches may also become dependent on medications.)
   5. Are there other neurologic symptoms?

C. Educational Issues – Identification of some of the stresses in the patient’s life
   may suggest ways to control or reduce stress. Other triggers may be identified
   and strategies developed to avoid or counteract such stimuli.

D. Treatment Issues – Limiting caffeine intake (coffee, tea, cola) may provide
   relief, although it may cause severe withdrawal symptoms for a few days.
   Additional treatments include simple analgesics, hot packs, relaxation, stress
   reduction exercises, and physical therapy to loosen muscles. Look up and
   develop a therapeutic rationale for recommending at least two OTC pain
   relievers and at least two prescription treatments for headaches.

   In one interesting study the best predictor of patient’s being pain free one year
   after presenting with tension, cluster or migraine headaches was whether
   patient felt that they had a chance to explain their problems and be listened to
   sympathetically by the doctor during the first visit. Listening well is an
   important treatment.

Weight Reduction

I.      Overview:
Genetic, behavioral and psychological factors are involved in weight problems. Research
on the role of genetics in obesity suggests there may be a limit to the amount of weight a
person can lose. Fortunately, the interview can bring to light factors your patient can

II.    Chief Characteristics:        not applicable

III.   Physician Tasks:
       A. Psychosocial Issues – Some people with weight problems have already been
          on one or many diets. For these people, frustration and feelings of
          hopelessness concerning their ability to lose weight may be a problem.
          Helping the patient to find the reasons for overeating is critical. Eating may
          be triggered by emotional cues such as anxiety, depression, boredom,
          loneliness and anger. Your patient may eat continuously after fork to relax or
          binge after an upsetting situation. Often these individuals are very
          knowledgeable about proper nutrition, but they just can’t seem to eat
          consistently. Inquiring about family relationships, work and social life and
          stressors can aid you in determining if referral to counseling or a support
          group can be helpful.

           Try to get as much information as you can in a supportive, non-threatening
           way. How has being overweight affected your patient’s life? How does the
           individual feel about his or her weight? These insights can help you and your
           patient select the best approach to dieting.

       B. Clinical Issues – Before giving a patient instructions about weight loss, the
          doctor should try to identify the patient’s present eating habits and attitudes.
          Common habits you may see are skipping meals and compensating with high
          calorie snacks, favoring calorically dense foods, and on again – off again
          dieting. Inquiring about food choices in restaurants is necessary when your
          patient frequently eats out. The patient may not realize their double burger,
          fries and coke total 930 calories. Instructions to eat less might be meaningless
          to a patient who already sees himself or herself as “eating like a bird.” A
          more productive means of identifying a patient’s eating problems might be to
          ask the patient to keep a diary of all foods consumed, including snacks and

       C./D. Educational/Treatment Issues – A patient who needs help in managing
          his/her weight may be referred to a nutrition counselor. Some insurance
          companies provide 50% reimbursement for such expenses, depending upon
          the medical reason for such counseling and the nutrition counselor’s
          credentials. Other insurance policies do no provide any reimbursement.
          Patients should be instructed to consult their insurance provider before

selecting a counselor. There are also low cost and no cost programs available
in the community. The Weight Watchers program can be successful it the
patient appears to need more nutrition information and direction in diet
planning. This program is affordable for most people. Patients can call for
information. Overeaters Anonymous is a non-profit organization. Members
pay a voluntary contribution at meetings. This organization is a better choice
for patients who appear to be compulsive over-eaters, or suffer from what may
be called “food addiction.”

Patients can find the phone numbers of a Weight Watchers or an Overeaters
Anonymous chapter in the white pages of the phone book. Look up and
have at least these two numbers available for your patient.

The doctor may help the patient select an exercise plan that is appropriate.
This may be as simple as finding a sport which the patient enjoys playing,
such as golf or tennis. However, exercise can be a problem, particularly for
older patients who may also be suffering from arthritis. For many of these
patients, swimming or walking may be an effective, less strenuous form of
exercise. Doctors should work with patients over 45 years old, an exercise
tolerance test is often recommended before starting an exercise program.

                           Video Taping Exercise Protocol
Abdominal Pain

I.     Overview:
A patient has come to you complaining of heartburn and indigestion.

II.    Chief Characteristics – not applicable
“Indigestion” or “heartburn” are terms frequently used by patients to describe a multitude of
symptoms generally indicating distress associated with eating.

III.   Physical Tasks:
       A.             Psychosocial Issues – Listen carefully for, and directly elicit, the
          potential impact of psycho-social issues on this patient’s symptoms. Stress can
          have a significant relationship with abdominal pain, and it is important to
          investigate the stress in the patient’s life and the methods they use to handle it.
          (Refer to the Stress Protocol for additional information on stress and stress
          management.) Remember that the patient may have fears about the pain he/she is
          feeling. What does it mean to him/her? How has it affected his/her personal
          and/or professional life?

       B.               Clinical Issues – You will want to find out what the patient means by
            “indigestion” and “heartburn,” and identify whether or not the patient has been
            self-medicating. How successful have these efforts been? Ask the patient to
            describe the nature of the pain, its location, frequency and time of occurrence, its
            relationship to meals, and the special circumstances, which lead to its
            exacerbation or relief. Associated physical symptoms such as nausea and
            vomiting, abnormal bowel habits, steatorrhea, diarrhea, and melena should also
            be sought.

            The working diagnosis in this case is undifferentiated peptic disease of the upper
            gastrointestinal system (dyspepsia). This category of disease includes gastric and
            duodenal ulcer, gastritis, duodenitis, and esophagitis, each of which exists on a
            continuum that ranges from mild to severe. In order to make a distinction it is
            important to learn whether the symptoms are: 1. constant, i.e., continually present
            over extended periods of time. 2. intermittent, as in acute gastritis following an
            alcoholic binge or associated with the use of certain drugs (NSAIDS, ASA). 3.
            have a diurnal pattern, for example, pain seen in esophagitis. 4. seasonal (which
            may occur in peptic ulcer disease, in which some patients experience more
            discomfort in the spring and autumn.)

            Another important and often diagnostic feature is the relation of pain or
            indigestion to eating. This relationship is especially significant if symptoms
            occur either during or minutes after the meals (esophagitis, gastric ulcer) or if
            they occur several hours (2 or more) after eating. Indigestion occurring several
            hours after eating may reflect failure of the stomach to empty adequately, as in
            pyloric stenosis or gastric atony. It may also be a symptom of duodenal ulcer, in
            which case it classically occurs several hours after the meal when the ulcerated

     mucosa is exposed to acid secretions of the stomach unbuffered by food.
     Conversely, the relief of pain following food ingestion is also seen in patients
     with peptic ulcer and is presumably due to the neutralization of the acid by
     ingested food.

C.                Educational Issues – One of the primary education tasks is to assist
     the patient in understanding the relationship between his or her abdominal pain
     and its cause. This lays the foundation for the co-development of an effective
     treatment plan.

D.                Treatment Issues – Often the changes, which will be necessary, will
     require significant effort from patients. What have they been doing to treat their
     pain? Has it been successful? Listening carefully to the patient’s understanding
     of their disease and their description of their situations at home and at work.
     Their motivations and health beliefs will assist you in developing with a
     treatment plan which the patient will feel comfortable with.

     Abdominal pain relief associated with food ingestion is typically alleviated
     quickly by oral antacids, but over time if the ulcer worsens the antacids may lose
     their effectiveness. Ulcer pain may be worsened by caffeine in coffee or other
     drinks, by smoking, and by alcoholic beverages. It may be brought on by
     especially stressful situations.

     An outpatient treatment plan for peptic ulcer disease can include prescribing
     antacids such as Mylanta, H2 blockers (e.g. Cimetidine), changes in diet to
     eliminate foods that trigger discomfort (food that cause the patient difficulty),
     behavior change to reduce the use of tobacco, caffeinated beverages, and ethanol,
     and possibly stress management. These behavior changes may require substantial
     changes in patient habits. It is, therefore, important to arrive at the plan jointly
     with the patient. It may not be possible for the patient to make all these changes
     at one time. The physician should become the ally of the patient positively
     reinforcing the steps taken toward healthier patterns.

     If the above treatment plan is unsuccessful in a week or so, it suggests the
     diagnosis is incorrect or that the ulcer disease is complicated. This would
     indicate that an upper G.I. barium x-ray or upper endoscopy should be done.


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