GENERAL APPROACH TO THE PATIENT

• Case history

• Patient Compliance

• pertinent physical examination

The medical interview should accomplish three important

functions• to collect information

• to respond appropriately to the patient's emotional state

• to educate the patient and beneficially influence patient behavior

Patient Compliance

• For many illnesses, treatment depends on fundamental behavioral changes

• alterations in diet

• Exercise

• Smoking

• drinking

COMMON SYMPTOMS

• PAIN

• Pain is the most common symptom causing patients to seek medical attention. Information about the nature, location, timing, severity, and radiation of pain is crucial for proper treatment; the same is true for aggravating or alleviating factors.

Recommended clinical approach to pain management

• Ask about pain regularly. Assess pain systematically (quality, description, location, intensity or severity, aggravating and ameliorating factors, cognitive responses). Ask about goals for pain control, management preferences

• Believe the patient and family in their reports of pain and what relieves it.

• Choose pain control options appropriate for the patient, family, and setting. Consider drug type, dosage, route, contraindications, side effects. Consider nonpharmacologic adjunctive measures.

• Deliver interventions in a timely, logical, coordinated manner.

• Empower patients and their families. Enable patients to control their course to the greatest extent possible.

• Follow up to reassess persistence of pain, changes in pain pattern, development of new pain.

Drug Therapy

• The proper treatment of any patient's pain depends upon a careful diagnosis of its cause, selection of appropriate and cost-effective treatment, and ongoing evaluation of treatment results

Drugs for Mild to Moderate Pain

• aspirin, acetaminophen

• ibuprofen or naproxen in the 200 mg dosage formulation.

• For moderate pain, salicylates, NSAIDs, or acetaminophen in higher doses often suffice; if not, the clinician can prescribe drugs such as codeine or oxycodone.

Drugs for Moderate to Severe Pain:

• Opioids

• Opioids can be classified as full opioid agonists, partial agonists, or mixed agonist-antagonists

• Full agonists include morphine, hydromorphone, codeine, oxycodone, methadone, levorphanol, and fentany

Contraindications to Opioids

• In patients with acute abdominal pain

• Patients with hypothyroidism, adrenal insufficiency, hypopituitarism, acute intermittent porphyria, reduced blood volume, and severe debility are particularly apt to suffer adverse effects from opioid analgesics

Adverse Effects of Opioids

• Respiratory Depression

• Central Nervous System Effects

• Gastrointestinal Side Effects

• Urinary Retention

• Pruritus

• Hypersensitivity

• Allergic Response

Respiratory Depression

• Respiratory depression is commonly feared as a hazard of parenteral morphine administration. Morphine acts to depress the respiratory center in the brainstem. The respiratory rate decreases gradually; abrupt cessation of breathing does not occur. Severe respiratory depression is uncommon, occurring in 0.05–0.9% of treated patients

Central Nervous System Effects

• Central nervous system effects include euphoria, mental clouding, and sedation. Antidepressants, antihistamines, phenothiazines, sedative-hypnotics, and alcohol can potentiate these effects.

Gastrointestinal Side Effects

• Gastrointestinal side effects are chiefly decreased bowel motility and constipation and nausea and vomiting. Because constipation is an inevitable side effect of opioid administration, the physician should attempt to prevent it by prescribing dietary fiber and regularly scheduled doses of a laxative

Urinary Retention

• Urinary retention sometimes occurs because morphine inhibits parasympathetic outflow from the spinal cord, causing bladder spasm. It is more common following spinal (epidural) than parenteral or oral administration and more often a problem in older men with benign prostatic hyperplasia

Pruritus

• Pruritus occurs commonly when morphine is administered via the epidural or intrathecal routes, less frequently with intravenous or intramuscular administration, and uncommonly following oral dosing

Hypersensitivity

• Enhanced sensitivity to the opioid drugs occurs in patients with hepatic impairment; biliary spasm may cause severe biliary colic.

Allergic Response

• Allergic manifestations also occur, but rarely

FEVER & HYPERTHERMIA

• The average normal oral body temperature is 36.7 °C (range 36–37.4 °C)

• The normal rectal or vaginal temperature is 0.5 °C higher than the oral temperature, and the normal axillary temperature is correspondingly lower. Rectal temperature is more reliable than oral temperature, particularly in the case of patients who are mouth-breathers or who are tachypneic.

• The normal diurnal temperature variation may be as much as 1 °C, being lowest in the early morning and highest in the late afternoon

• Fever is a regulated rise to a new "set point" of body temperature. When proper stimuli act on appropriate monocyte-macrophages, these cells elaborate one of several pyrogenic cytokines, which causes elevation of the set point through effects in the hypothalamus. These cytokines include interleukin-1 (IL-1), tumor necrosis factor (TNF), interferon-gamma, and interleukin-6 (IL-6). The elevation in temperature may result from either increased heat production (eg, shivering) or decreased heat loss (eg, peripheral vasoconstriction). Body temperature in interleukin-1-induced fever seldom exceeds 41.1 °C unless there is structural damage in the hypothalamus.

Important Causes of Fever & Hyperthermia

• Infections:Bacterial, viral, rickettsial, fungal, parasitic.

• Autoimmune Diseases• Central Nervous System Disease• Malignant Neoplastic Disease• Hematologic Disease:Lymphomas, leukemias,

hemolytic anemias.• Cardiovascular Disease:Myocardial infarction,

thrombophlebitis, pulmonary embolism

• Gastrointestinal Disease:Inflammatory bowel disease, liver abscess, alcoholic hepatitis, granulomatous hepatitis.

• Endocrine Disease:Hyperthyroidism, pheochromocytoma may raise temperature because of altered thermoregulation.

• Diseases Due to Chemical Agents: Drug reactions (including serum sickness), neuroleptic malignant syndrome, malignant hyperthermia of anesthesia, serotonergic syndrome

• Factitious fever

Treatment

• Temperature over 41 °C is a medical emergency

• Measures for Removal of Heat:Alcohol sponges, cold sponges, ice bags, ice-water enemas, and ice baths will lower body temperature and provide physical comfort for patients who complain of feeling hot

Antipyretic Drugs

• In most instances, antipyretic therapy by itself is not needed except for reasons of comfort or in patients with marginal hemodynamic status. Aspirin or acetaminophen, 325–650 mg every 4 hours, is quite effective in reducing fever

Fluid Replacement

• Oral or parenteral fluids must be administered to compensate for increased insensible fluid and electrolyte losses as well as those from perspiration

• Antibiotic Therapy

Dyspnea

• Dyspnea is the subjective experience of difficulty in breathing and may be characterized by patients as tightness, shortness of breath, or a feeling of suffocation

• Treatment of dyspnea is usually first directed at the underlying cause

Nausea & Vomiting

• Nausea and vomiting are common and distressing symptoms

• Vomiting may be due to stimulation of peripheral afferent nerves

Constipation

• Given the frequent use of opioids, poor dietary intake, and physical inactivity

DIAGNOSIS OF SKIN DISORDERS

• Morphology

• History

• Physical ExaminationPhysical Examination

Morphologic categorization of skin lesions and diseases.

• Pigmented – Freckle, lentigo, seborrheic keratosis, nevus, blue nevus, halo nevus, dysplastic nevus, melanoma

• Scaly - Psoriasis, dermatitis (atopic, stasis, seborrheic, chronic allergic contact or irritant contact), xerosis (dry skin), lichen simplexchronicus, tinea, tinea versicolor, secondary syphilis, pityriasis rosea, discoid lupus erythematosus, exfoliative dermatitis

Vesicular

• Herpes simplex, varicella, herpes zoster, dyshidrosis (vesicular dermatitis of palms and soles), vesicular tinea, dermatophytid,

dermatitis herpetiformis, miliaria, scabies, photosensitivity

Weepy or encrusted

• Impetigo, acute contact allergic dermatitis, any vesicular dermatitis

Pustular

• Acne vulgaris, acne rosacea, folliculitis, candidiasis, miliaria, any vesicular dermatitis

Figurate (-shaped) erythema

• Urticaria, erythema multiforme, erythema migrans, cellulitis, erysipelas, erysipeloid, arthropod bites

Bullous

• Impetigo, blistering dactylitis, pemphigus, pemphigoid, porphyria cutanea tarda, drug eruptions, erythema multiforme,

toxic epidermal necrolysis

Papular

• Hyperkeratotic: warts, corns, seborrheic keratosPurple-violet: lichen planus, drug eruptions, Kaposi's sarcoma Flesh-colored, umbilicated: molluscum contagiosum Pearly: basal cell carcinoma, intradermal nevi Small, red, inflammatory: acne, miliaria, candidiasis, scabies,folliculitis

Pruritus

• Xerosis, scabies, pediculosis, bites, systemic causes,anogenital pruritus

Nodular, cystic

• Erythema nodosum, furuncle, cystic acne, follicular (epidermal)inclusion cyst

Photodermatitis (photodistributed rashes)

• Drug, polymorphic light eruption, lupus erythematosus

Morbilliform

• Drug, viral infection, secondary syphilis

Erosive

• Any vesicular dermatitis, impetigo, aphthae, lichen planus, erythema multiforme

Ulcerated

• Decubiti, herpes simplex, skin cancers, parasitic infections, syphilis (chancre), chancroid, vasculitis, stasis, arterial disease

Respiratory system

• PHYSIOLOGY OF RESPIRATION The medulla (located in the brain stem just above the

spinal cord) is the respiratory center. It is stimulated by the increased concentration of carbon dioxide and increased hydrogen ions.The lungs and circulation act together to bring gases to body tissues for gas exchange. Movement of oxygen into the lungs (inspiration) and removing carbon dioxide (exhalation) is called ventilation. Respiration occurs in the alveoli capillary system where there is an actual exchange of gases between the air and blood.

Normal respiratory functioning-Depends on four

essential factors• The integrity of the airway system• Properly functioning alveolar system • Properly functioning cardiovascular system • Muscle movements which provide the force for

ventilation• The diaphragm and the intercostal muscles are

responsible for normal breathing.

SYMPTOMS OF ACUTE HYPOXIA

• Dyspnea

• Elevated blood pressure with a small pulse pressure

• Increased respiratory and pulse rates

• Paleness

• Cyanosis

• Anxiety and restlessness

SYMPTOMS OF CHRONIC HYPOXIA

• Altered thought processes • Headaches • Chest pain • Enlarged heart • Polycythemia -clubbed fingers - secondary to

polycythemia • Anorexia • Constipation • Decreased urinary output • Weakness of extremity muscles

FACTORS AFFECTING RESPIRATORY FUNCTIONING

• HEALTH -Persons with renal or cardiac problems often have respiratory problems related to fluid overload.

• DEVELOPMENT- Scoliosis- Obesity and pregnancy • NARCOTICS AND ANALGESICS • Versed and Valium can cause respiratory arrest particularly if given IV push at too fast a

rate. • LIFE-STYLE • Smoking decreases lung ciliary action, decreases production of surfactant, and

increases blood pressure due to nicotine absorption. • Smoking is measured in pack-years. To calculate, take how many packs a day the

person smokes, times the number of years the person has smoked. • ENVIRONMENT • Smoke, and irritating fumes (butane, paint thinner, glue) can lead to upper respiratory

irritation such as laryngitis. • PSYCHOLOGIC HEALTH • Stress can lead to excessive sighing or hyperventilation. • Anxiety has be linked to bronchospasm and bronchial asthma.

Hyperventilation

• SUDDEN anxiety or "panic attacks" can be accompanied by hyperventilation.

• Common symptoms of anxiety attacks with hyperventilation include: nervousness, palpitations, increased respiratory rate, numbness, and tingling around mouth, tip of nose, and finger tips.

• Continued hyperventilation will result in respiratory alkalosis, nausea, lightheadedness, fainting, and cramping of the hands.

ASSESSING RESPIRATORY FUNCTIONING

• INSPECTION

• PALPATION

• PERCUSSION

• AUSCULTATION

INSPECTION

• The anterior-posterior diameter should be less than the transverse diameter

• Movement of the chest should be symmetrical • Skin should be warm and dry • No cyanosis or pallor • Respiratory rate 16 to 24 per min for adult • Flaring nostrils, intercostal retractions,

tachypena, or bradypnea needs evaluation.

PALPATION

• Trachea equidistant from each clavicle • Vocal fremitus - bilateral equal mild fremitus • Increased fremitus is seen with pneumonia. • Decreased or absent fremitus is noted in

COPD. • The presence or absence of crepitations,

masses, edema, or tenderness should be noted

PERCUSSION

• Resonance is heard over the normal lung • Emphysematous lungs have loud low, booming

sound (hyperresonance). • Dull sound over liver is normal. Dullness over the

lung field occurs when fluid or solid tissue replaces normal lung tissue and requires investigation.

• Dullness over the lung field is indicative of the following conditions: pneumonia, hemothorax, and lung tumors

AUSCULTATION

• The client should breath through his open mouth slowly.

• If abnormal sound is heard, have the client cough and listen again.

• Location, change in breath sounds after coughing, and heard of inspiration or expiration should be noted

Adventitious Breath Sounds

• Crackles (Rales)

• Crackling sounds caused by air passing through moisture in the alveoli or bronchioles

• Heard in Bronchitis, Pneumonia, Pulmonary edema, CHF, Interstitial fibrosis

• Rattles (Rhonchi)

• Coarse rattling/bubbling sounds from fluid or obstructions in large airways. Sounds tend to change with coughing

• Heard in Chronic bronchitis, Tumors, Pneumonia and COPD

• Squeaks or Wheezes

• Squeaky, musical sounds associated with air squeezing through narrowed airways

• Bronchospasm (asthma) Edema, Tumors, RSV

• Rubs (Pleural friction rubs)

• Rough, grating, scratching sounds caused by inflamed surfaces of the pleura rubbing together. Usually associated with pain on deep inspirations.

• Pleurisy, TB, Pneumonia, and Lung Cancer

PROBLEMS ASSOCIATED WITH THE

UPPER RESPIRATORY TRACT • Epistaxis -Most caused by injury• Irritation, dryness, Inhalation of drugs High blood pressure and blood

clotting abnormalities • Most nosebleeds occur in the front part of the nasal septum • In most cases, nasal bleeding can be controlled easily by tilting the

head forward and using a firm 15 minute nose pinch (include the soft bulb of the nose)

• If the patient is currently taking anticoagulants be sure to notify the MD. • It is important not to pick, rub, or blow after bleeding has stopped. • Avoid hot liquids. Aspirin and smoking can also promote bleeding. • If the bleeding cannot be controlled, the clots may need removed and a

nasal packing inserted to stop the bleeding. • The nasal pack may be left in for 1-2 days before removal

Allergic Rhinitis

• Inflammation and irritation of the nasal mucosa in response to allergic stimuli: pollen, dust, dander, fungus, molds, foods, grasses

• Symptoms: clear nasal discharge, itchy nose, sneezing, watery and itchy eyes.

• The nasal mucosa may appear pale, engorged, and bluish grey in client with allergic rhinitis.

• To exam-tilt the clients head back and use a pen-light. • Evaluation will involve physical exam of the nasopharanax for

signs of pale edematous mucosa and nasal polyps, which are a frequent complication of allergic rhinitis.

• May involve allergy testing with conventional skin testing, or blood testing.

• Sinus x-rays may be performed to rule out sinus infection.

Upper Respiratory Infections or Colds

• The "common cold" is the most common infectious upper respiratory illness (URI).

• Viral infection transmitted by inhalation or self-innoculation • Frequent hand washing prevents spread • Usually lasts 3-7 days • Symptoms are congestion, runny nose with clear to white mucous,

sneezing, watery eyes, sore throat and dry cough. • Dark yellow or green nasal drainage could indicate a bacterial infection

such as sinusitis. • Treatment - Good nutrition, vitamins, plenty of fluids, and rest.

Decongestants and antihistamines, and cough suppressants can help with the symptoms

• Persistent symptoms, high fevers, chills, dark colored nasal drainage, productive cough, shortness of breath, or chest pains on coughing could indicate a more serious infection

Sinusitis or Sinus Infection• Viral or bacterial infection of the sinuses • Pt with allergic rhinitis have greater incidence of Sinusitis. • Common symptoms of sinusitis • runny nose, posterior nasal drip, yellowish or greenish nasal

discharge, dull facial pain or headache in the area of the sinuses is common. Cough can develop secondarily post-nasal drip .

• Sinus headaches frequently become worse with position changes

• Evaluation • History and physical examination • Palpation will increase pain. • X-rays - Sinus Series • Culture and Sensitivity • CT scan if indicated

Sinusitis or Sinus Infection-Treatment

• Decongestants, Antihistamines - when allergies are involved.

• Antibiotics when fever, colored nasal discharge, or x-ray findings of sinusitis are present .

• Antibiotic therapy is often necessary for 3-4 weeks duration to reduce the likelihood of recurrence.

• Patients will be encouraged to rest, and drink plenty of fluids.

• A cool steam vaporizer at the bedside can help liquefy secretions and promote drainage

Tonsillitis and Pharyngitis• Inflammation of the pharynx and/or tonsils from a viral or

bacterial infection • Often coexist and are treated in the same manner • Majority of cases are viral -But a culture needs done to

rule out strep throat • antibiotics will have no effect on viral pharyngitis • Symptoms of viral pharyngitis • Red painful throat, hoarse voice, but usually no great

difficulty with swallowing, and no difficulty opening the mouth

• Treatment of viral pharyngitis • Rest, fluids, Tylenol, anesthetic lozenges and gargling

with warm saline