Chronic Disease
Key Feature 2: Regularly reassess adherence (compliance) to the treatment plan (including medications). Skill: Clinical Reasoning Phase: History, Follow-up Ischemic Heart Disease Key Feature 4: In a patient with stable ischemic heart disease manage changes in symptoms with self-initiated adjustment of medication (ex: nitroglycerin) and appropriate physician contact (ex: office visits, phone calls, emergency department visits), depending on the nature an severity of symptoms. Skill: Clinical Reasoning Phase: Treatment Key Feature 5: In the regular follow-up care of patients with established ischemic heart disease, specifically verify the following to detect complications and suboptimal control:
Phase: History, Diagnosis Once a patient has been diagnosed with ischemic heart disease, they have a chronic symptomatic disease that warrants ongoing treatment of the main symptom: angina. Many patients will be started on a daily beta-blocker because they work by decreasing the heart's effort and its subsequent oxygen requirement and associated angina when it is oxygen starved. Calcium channel blockers would be second-line if a beta-blocker is contraindicated or not sufficient for additional therapy. Despite daily medications to help prevent cardiac ischemia, patients may still develop acute episode of cardiac ischemia pain or angina. For these, the patient needs to be advised to take a nitrate medication (usually a tab of sublingual nitroglycerin under the tongue, every 5 min as needed up to 3 doses) for relief of the acute symptoms. Alternatively, the patient can be advised to take a prophylactic dose before exertion to prevent the onset of angina. Beyond having an understanding of how to take medications as indicated, another major component of patient education involves counselling about when and where to receive followup medical care. For the patient with stable ischemic heart disease, UpToDate suggests follow-up every 6 to 12 months for ischemic heart disease, which should include a review of:
For the patient experiencing acute angina that is either not responding to nitroglycerin or that is much more severe than typical episodes of angina for them, they should be advised to call an ambulance for emergency medical care of what could be a heart attack. Patients may also choose to attempt to call their clinician(s) or a medical information line if they have any uncertainty about what they ought to be doing should their symptoms change, but this should only be for situations that do not involve ongoing chest pain. Any acute episode of angina that is not going away despite abortive therapy warrants emergent medical attention in an emergency care setting.
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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 5: Given a non-compliant patient, explore the reasons why, with a view to improving future adherence to the treatment plan. Skill: Patient Centered Phase: History All patients should be screened for substance use, be it during a new consultation or periodically from time-to-time as substance use patterns naturally can change over time. Patients who screen positive for a potential substance use disorder deserve a dedicated comprehensive substance use assessment. The following is my approach to gathering an addiction focused history and physical examination. This assessment helps to identify the presence, severity, and complications of substance use disorders. History
Physical Examination
Investigations Patients who have risk factors for infectious diseases should be screened accordingly (not to mention they deserve to be screened for cardiovascular diseases and cancers much like the general population as well). Specific risk factors that go along with substance use include intravenous drug use, intranasal drug use, and any sort of shared drug paraphernalia. Such patients warrant screening as frequently as every 3-6 months and at least once a year for HIV, HBV, and HCV. Also consider screening for anemia with a CBC and ferritin, for liver disease with liver function testing, and pulmonary function testing if they have a significant smoking history and chronic respiratory symptoms. While I will address the treatment of the substance use disorders proper in a separate post, what I will do here is just briefly touch on the management of comorbidities that may be detected in the workup of a substance use disorder.
*When learning about what social supports a person may or may not have, it is important to have a high index of suspicion for domestic or intimate partner violence, as well as for the possibility of codependence, which may appear at first as a very loving and supportive relationship. As defined by Wikipedia, "Codependency is a type of dysfunctional helping relationship where one person supports or enables another person's drug addiction, alcoholism, gambling addiction, poor mental health, immaturity, irresponsibility, or under-achievement." Wikipedia goes on to explain that the concept arose from Alcoholics Anonymous and that "...the term 'codependent' was first used to describe how family members of individuals with substance abuse issues might actually interfere with recovery by overhelping." It may be important to involve a patient's partner or main support(s) in the patient's clinical care so as to communicate ways in which helping behaviours may actually be causing more harm than good. Counselling to address these issues both as individual and as couples therapy may be helpful. Key Feature 3a: In patients with chronic disease: Actively inquire about pain. Skill: Clinical Reasoning Phase: History Key Feature 3b: In patients with chronic disease: Treat appropriately by:
Phase: Treatment, Hypothesis generation Palliative Care Key Feature 4: In patients with pain, manage it (ex: adjust dosages, change analgesics) proactively through frequent reassessments and monitoring of drug side effects (ex: nausea, constipation, cognitive impairment). Skill: Clinical Reasoning Phase: Treatment, Follow-up The standard general approach to pain control is based on the World Health Organization's Pain Ladder, with the diagram and information below coming from "Palliative medicine: A case-based manual" by Doreen Oneschuk, Neil Hagen, and Neil MacDonald. The "ladder" was designed with cancer pain in mind, but it tends to provide the framework for pain management for people with all sorts of acute and chronic sources of pain. The basic idea is that for mild pain you start with non-opioid medications, with specific choice depending on the type of pain and patient characteristics. It is important to actively inquire not just about the presence of pain, but also about the quality of the pain in patients in order to treat it most effectively. Not illustrated as part of the pain ladder but equally important are also nonpharmacological interventions that can be useful in alleviating pain. As pain increases in severity, the choice of pain medication and/or dose ought to increase accordingly. Adjuvants (medications originally developed for reasons other than to improve pain, but that can also alleviate pain as a secondary effect, depending on the type of pain) can also be very useful when indicated. Poor pain control can have a significant negative impact on quality of life, and we have lots of tools in the box to work to mitigate this source of distress. It is important to continue to reassess patients experiencing pain or receiving therapy for it, to ensure that pain is in fact controlled, as well as to monitor for side and adverse effects. Nonpharmacological therapies to consider starting, in the context of mild pain and patients who are motivated to try them, or to consider adding on to pharmacological treatments for added pain relief, could include:
Common non-opioid medications for mild pain include acetaminophen and NSAIDs (ex: naproxen, ibuprofen, diclofenac, ketorolac).
For pain that is sufficiently severe and that cannot otherwise be controlled (with non-opioids, adjuncts, and nonpharmacological modalities), treatment with an opioid may be indicated. Opioids exert their analgesic effect mostly by agonising mu opioid receptors in the brain. Commonly prescribed weak opioids include codeine and tramadol, and commonly prescribed strong opioids include morphine, hydromorphone, oxycodone, fentanyl, and methadone. General principles of opioid initiation and titration include having a regular dosing schedule (initially starting with a short-acting preparation until the baseline pain is controlled) with a prescribed breakthrough dose for pain to be taken as needed for acute exacerbations (generally prescribed to be taken as much as every 1 hour, or in the setting of opioids with a very rapid half life, up to every 30 minutes or so). The degree of pain control as reported by the patient along with the number of needed breakthrough doses in a given 24 hour period indicates whether or not there is a need to adjust the baseline opioid dose. As a general rule of thumb, if greater than 3 breakthrough doses in a 24 hour period are needed, unless this is attributed to being incident pain (aggravated by a specific event such as movement that would not otherwise be present at baseline), then an increase in the baseline opioid dose is warranted. The amount to up-titrate can be calculated by adding up the total quantity of opioid needed in the last 24 hour period (baseline and amount of breakthrough used), calculating the conversion to the new choice of opioid based on number of morphine equivalents, and dividing this quantity so that it is given over the next 24 hour period as the scheduled dose. And then a new quantity of breakthrough pain medication is prescribed, and a rule of thumb for this is dosing it at about 10% of the total daily scheduled amount of opioid to be given over the next 24 hour period. On the flip side, when patients report good pain control, with minimal to no use of doses required for breakthrough pain, the patient can be gradually weaned down as tolerated. Side effects of all opioids are generally the same (though they may occur to different degrees depending on the formulation, dose, and patient factors), and they most commonly include transient nausea, transient drowsiness, and constipation that is not transient and that lasts as long as the opioid is being taken. If they are given in a high dose too quickly, they can cause respiratory depression, but when prescribed responsibly in small doses with gradual up-titration, this concern is mitigated. For the nausea, an antiemetic can be prescribed either to be taken routinely or as needed, and for the constipation the patient will likely need to be on a regular dose of laxative medication. See my next post for more detail on these options. Besides the above side effects that can occur when any opioid is used, there is also the phenomenon of opioid neurotoxicity that can occur. Briefly, this is a situation in which patients can develop altered mental status (ex: delirium, agitation, somnolence), vivid or unpleasant dreams, delusions/hallucinations (usually visual), and increased pain perception (ex: allodynia or hyperalgesia). Myoclonic jerks and seizures can also occur. In the setting of suspected opioid neurotoxicity, rotating to a different opioid is warranted (other options include simply changing the route by which the current opioid is delivered, decreasing the dose of the current opioid and adding an adjuvant, or just treating the toxic symptoms themselves; rotating the opioid is generally the preferred option). This is done by adding up the total number of morphine equivalents a patient has on board in a given 24 hour period, calculating the equivalent dose in the opioid to which the patient is being rotated to, reducing this dose by 25%, and dividing the dose to be scheduled throughout the day as the half-life of the new opioid indicates. Opioid options include:
Some adjuvants that may be useful in pain management, particularly in the palliative care setting:
Abdominal Pain
Key Feature 2: In a patient with diagnosed abdominal pain (ex: gastroesophageal reflux disease, peptic ulcer disease, ulcerative colitis, Crohn’s disease), manage specific pathology appropriately (ex: with. medication, lifestyle modifications). Skill: Clinical Reasoning Phase: Treatment Key Feature 8: Given a patient with a diagnosis of inflammatory bowel disease (IBD) recognize an extra intestinal manifestation. Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Chronic Disease Key Feature 1: In a patient with a diagnosed chronic disease who presents with acute symptoms, diagnose:
Phase: Diagnosis When I was on rotation on the Family Practice Teaching Service at St Paul's Hospital I was managing a 27 year old female inpatient admitted with abdominal pain NYD (not yet diagnosed). Her past medical history was significant for ulcerative colitis, intravenous drug use now on opioid agonist therapy, pelvic inflammatory disease, and a ruptured ovarian cyst. Prior to the onset of the pain that brought her into the emergency department, she had not been taking any medications for the ulcerative colitis (the disease had been in remission) and she was on opioid agonist therapy to help manage her opioid use disorder. When she presented to the ED with acute abdominal pain she did not have a clear etiology to blame, and she was certainly unwell, so she was admitted to our service so we could manage her pain and figure out what was going on to resolve the underlying issue. After a couple of days into her admission and many investigations later, the team surmised that her pain was likely secondary to a flare up of the ulcerative colitis compounded with the pain of acute opioid withdrawal - the opioid agonist therapy she was taking was in the form of ingested slow-release oral morphine, which was likely not getting absorbed in her gut given its disposition. She was started back up on her antiinflammatory medication, her pain was temporarily managed with hydromorphone, and soon she was feeling back to her baseline. The list of possible aetiologies for abdominal pain is - as I've highlighted in previous blog posts - extensive. I will outline here the general management of selected aetiologies of abdominal pain that I must be familiar with as a family doctor. My information was gathered from Bugs & Drugs and the following UpToDate articles:
Overview of the management of gastroesophageal reflux disease (GERD) For uncomplicated GERD without alarm features*
Overview of the management of peptic ulcer disease (PUD) The patient will have already been seen by a gastroenterologist, as endoscopy would've been done to detect the presence of ulceration. Although this means the gastroenterologist almost certainly will have developed a treatment plan for the patient to follow, it is important for family doctors to understand what needs to be done so they can ensure patient compliance.
Overview of the management of inflammatory bowel disease [IBD] (ulcerative colitis [UC] or Crohn's disease [CD]) As with patients diagnosed with PUD, patients diagnosed with IBD will be seen and likely will continue to be seen by a gastroenterologist. It is important for family doctors to understand the management of IBD because they will be actively involved in helping patients manage the disease as well as their overall health, which can be impacted in numerous ways by IBD.
*Interestingly, the patient I was managing who had ulcerative colitis had an outbreak of lesions on her arms and legs, which she said started only a few days before she went in to the ED with abdominal pain. The two common types of extraintestinal skin manifestations associated with IBD are erythema nodosum and pyoderma gangrenosum. According to the UpToDate article, Dermatologic and ocular manifestations of inflammatory bowel disease, "Erythema nodosum typically appears as raised, tender, red or violet subcutaneous nodules on the extensor surfaces of extremities. As erythema nodosum usually parallels intestinal disease activity, treatment is directed at the underlying IBD. If skin nodules precede any bowel symptoms or occur during quiescent phases of IBD, therapy with other medications, including prednisone, may be required." I looked up pictures of erythema nodosum, and the lesions the patient had certainly fit the look, along with the fact that they were nodular and tender to palpation, and were located on the extensor surfaces of her arms and legs. How interesting that they erupted at the same time or possibly right before the concomitant flare-up in her bowel disease! In summary, this has been another long but not even very detailed post that provides an overview of important elements in the management of common and occasionally serious causes of abdominal pain. By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Chronic Disease Key Feature 4: In patients with chronic disease, actively inquire about:
Phase: History Difficult Patient Key Feature 3: In a patient with chronic illness, expect difficult interactions from time to time. Be especially compassionate and sensitive at those times. Skill: Patient Centered, Professionalism Phase: Treatment, Follow-up Key Feature 4: With difficult patients remain vigilant for new symptoms and physical findings to be sure they receive adequate attention (ex: psychiatric patients, patients with chronic pain). Skill: Selectivity Phase: Hypothesis generation, Diagnosis Disability Key Feature 3: In patients with chronic physical problems (ex: arthritis, multiple sclerosis) or mental problems (ex: depression), assess for and diagnose disability when it is present. Skill: Clinical Reasoning, Patient Centered Phase: Diagnosis, Hypothesis generation Key Feature 4: In a disabled patient, assess all spheres of function (emotional, physical, and social, the last of which includes finances, employment, and family). Skill: Patient Centered Phase: History Key Feature 5: For disabled patients, offer a multi-faceted approach (ex: orthotics, lifestyle modification, time off work, community support) to minimize the impact of the disability and prevent further functional deterioration. Skill: Patient Centered, Professionalism Phase: Treatment Multiple Medical Problems Key Feature 4: Given a patient with multiple defined medical conditions, periodically assess for secondary depression, as they are particularly at risk for it. Skill: Clinical Reasoning Phase: Hypothesis generation, History Key Feature 5: Periodically re-address and re-evaluate the management of patients with multiple medical problems in order to:
Phase: Treatment, Follow-up Stress Key Feature 1: In a patient presenting with a symptom that could be attributed to stress (ex: headache, fatigue, pain) consider and ask about stress as a cause or contributing factor. Skill: Clinical Reasoning, Communication Phase: Hypothesis generation, History Key Feature 2: In a patient in whom stress is identified, assess the impact of the stress on their function (i.e., coping vs. not coping, stress vs. distress). Skill: Patient Centered Phase: History, Diagnosis Key Feature 3: In patients not coping with stress, look for and diagnose, if present, mental illness (ex: depression, anxiety disorder). Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 4a: In patients not coping with the stress in their lives: Clarify and acknowledge the factors contributing to the stress. Skill: Patient Centered, Clinical Reasoning Phase: History The first patient I saw in clinic today was the first patient I saw in clinic at the same time last week, a 47 year old female who had an extensive relationship with chronic pain. Over the years, she had trialed a significant number of medications and alternative therapies to alleviate her pain, but her pain was tenacious. During my first visit with her last week, after confirming that her pain was indeed unchanged over the last many years, and after confirming for myself there weren't any "red flags" in her presentation suggestive of more ominous disease, I reviewed her current pain management strategies, including whether or not she was using any non-prescribed substances to cope. Her approach was as chaotic as the shopping bag she brought with the countless concoctions of over-the-counter supplements and herbal remedies, including some that appeared to not be sold on Canadian pharmaceutical shelves. She was speaking very quickly, wanting to tell me so very much about everything, and I think she was probably in anxious distress and having a hard time trying to cope. At the first visit, we reviewed the past history of her chronic pain - all of the previous investigations that were done and all of the specialists she had seen - and what the conclusions were. We then proceeded to clean up her pain medications and reduce them to the ones she felt confident were making a real difference in her pain. And then our time was well up. We ended this visit with an organized regimen of pain medications and a followup appointment to reassess how things were going in one week. And now here we were. She sat down in front of me and after a polite exchange of hellos she gently asked what we should do this week to modify her pain medications. There is so much about chronic pain we have yet to understand. The pathophysiology is still highly theoretical. We are aware of its association with mood disorders and psychosocial stressors, but we do not understand at a level of utilitarian specificity as to why this is the case. Chicken, egg, or both? In any case, no matter how we arrive at chronic pain, we do know that it worsens mood and aggravates social stress, just as mood and psychosocial stress negatively modulate perception of pain. By extension, if I can do anything to improve mood and psychosocial stress, I may alleviate suffering, and the corollary argument also holds that if I alleviate pain I may improve mood and attenuate psychosocial stress, thereby enhancing quality of life. Knowing the connection between chronic pain, mood, and stress, and now that I had the medical facts straight, during this follow-up appointment I decided to explore what was going on in this patient's personal life. As for mood, although she did not think she was clinically depressed and denied active suicidal ideation, it was certainly suboptimal, compounded not only by her pain but by her debt of sleep secondary to her pain. As it turned out, she attributed her low mood to the stresses in her life: her father living overseas was currently admitted to hospital for life-threatening cardiac disease, and her husband was riddled with aneurysms from his aorta to his renal arteries and was awaiting urgent surgery to prevent sudden rupture and possible death. Wow. Suddenly her pain had context, and was only a part of what I felt was infringing on her quality of life. The focus of our conversation shifted entirely away from her pain at this point, and she opened up about her fears of living life without her most significant others as well as her concerns regarding return to work as she felt she needed to prepare for a future with less financial stability, which was already troublesome. I did not have any advice for her anymore, and instead I just sat there listening to her experience with ache in my heart. After she shared the most salient aspects of her personal life stressors and the impact they were having on her ability to function or create disability, we rerouted the conversation to some practical takeaways to manage things for now, with planned follow-up again in one week. We decided that what was best right now was probably not to make any significant changes to medications, and rather to first have follow-up counselling later this week with her psychologist whom she endorsed having a strong relationship with. At this time she was not interested in any support groups or other community supports, but she said she would consider it in the future depending on how things progressed. She had come to the clinic today asking what we should do to modify her pain medications, and she left saying she was happy we weren't making changes to her current medications and that we were instead focusing on other ways of modulating her pain (I think this must have been partly because she had so many futile experiences with inconsequential medication changes over the years and didn't have much faith that yet another medication change would be her solution). As she was getting up to leave the examining room she said, "I'm now leaving here with more hope, and it's what I really need right now." When I first encounter patients with very complicated medical histories, either because of the number or significance (ex: cancer) of the comorbidities, I find myself feeling stunned by the complexity, oftentimes not knowing where to begin or to what depth I should delve under the pressure of time constraints. Indeed, this is how I felt when I first met this patient. In vain, I have felt personally overwhelmed by patients with multiple somatic complaints, serving only to increase my stress without making any difference in quality of patient care. Instead, these feelings ought to serve as internal cues to the fact that if I am feeling overwhelmed, it almost certainly means the patient is feeling this too, and likely with greater whelm. In that midst of overwhelming complexity, taking time to move beyond exploration of the disease process to exploring the illness experience, can, as this patient taught me, be the basis for a restoration of hope, alleviation of suffering, and improved quality of life. |
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