Final objectives Flashcards

Question

Compare the prevalence of acute bronchitis, flu, and pneumonia in different populations.

Answer 1

Old and young people are most likely to be susceptible, or those with compromised immune systems. Pneumonia more likely in old ppl or people who have a lot of hospital/ health care setting exposure. Flu: old peeps Bronchitis: Patients with COPD have it a lot.

Answer 2

Flu: Viral. Transmitted through particle droplets; contaminated surfaces. Most often in winter Bronchitis: Most often due to virus; occasionally bacterial. Most often in Winter. Pneumonia: bacterial more often than viral – most treated as bacterial.

Answer 3

Bronch-a-donk: COPD, smoking, prev exposure to flu or URI | Flu: >65 yo,

Answer 4

Bronch: persists more than 5 days (1-3 wks), inflamed bronchi, productive cough, wheezing, NOT Fever, chills, nausea Flu: fever, nonproductive cough, myalgia, malaise, headache, sore throat, rhinitis possible, usually lasts 3-7 days Pneumonia: productive mucopurulent/rust colored cough mucus, fever, chills, dyspnea, chest pain, malaise, headache, confusion, lung buildup, consolidation (no sound from lung due to build up, popping sound).

Answer 5

Honk-a-bronch-a-losis: worsening of chronic conditions Flu: Can lead to bronchitis, pneumonia, sinusitis, ear infections, worsening of chronic conditions Pneumonia: death

Answer 6

BRONCHITIS: [symptomatic]warsh yo hands, expectorants, cough suppressants, beta-2 agonists if wheezing, possible high dose inhaled corticosteroid, echinacea for prevention? pelargonium for cough suppressant/reduce duration? Honey? FLU: [antivirals]vaccination. antivirals (tamiflu), avoid sick ppl, warsh yo damn hands!, avoid touching mucous membranes (eyes, nose, mouth), cover face orifices when sneezing/coughing PNEUMONIA: [antibiotics] vaccination for the elderly and children. Anti-bacterials - macrolides (azithromycin). viral, self limiting: flu, bronchitis bac: pneumonia vaccine, fever: flu, pneumonia

Answer 7

Asthma: bronchoconstriction, excess mucus production, periodic shortness of breath; inflammation of lung; narrowing or airflow way. Childhood onset: more likely to be allergy based (possible genetic predisposition to IgE mediated response to aeroallergens). Adult onset: more often nonallergic; negative family history; possibly due to environ exposures - tobacco exposure COPD: airflow limitation and obstruction; progressive; assoc with chronic inflammatory responses in airways and lungs to noxious particles or gases. Smoking #1 risk factor

Answer 8

Asthma:7.3% of population (1 in 13 Americans); ~3600 annual deaths (trending down); most common chronic disease in children COPD: smoking #1 risk factor, ppl over 40

Answer 9

Asthma: aspirin, NSAIDS, exposure to environ pollutants, allergies, genetic predisposition to IgE mediated response to aeroallergens COPD: Having the Flu, recurrent URI, smoking, exposure to environ pollutants, genetic antitrypsin-1 deficiency, having chronic asthma

Answer 10

Asthma: coughing, wheezing, chest tightness, shortness of breath, emotions COPD: decreased expiratory ability, wheezing, cough, (antibiotics should only be given to someone with COPD if they have the three cardinal symptoms of increased dyspnea, increased sputum volume, increased sputum purulence).

Answer 11

xacerbations, death. More death. Breathing = not good, exercise intolerance.

Answer 12

Short acting - SABA (albuterol, levalbuterol, isoetharine; inhaled anticholinergic (has longer onset of action, may not be best for rescue) - ipratropium. Controller drugs - Inhaled corticosteroids (ICS), mast stabilizers, leukotriene modifiers, Long acting bronchodialators (LABA) - inhaled beta agonist (salmeterol) - often used in combination with inhaled corticosteroids.

Answer 13

Spacers allow for more of the active drug to be appropriately inhaled deep into the lung without getting stuck in the mouth. Nebulizers: Nebulizer – vaporize meds, breathe in. Often for breathing treatments for people who don’t respond as well to other treatments (inhalers). Takes several minutes to breathe it all in. Slow process. Breathe normally. May take 5-10 minutes to get all drug. Can be better for elderly, ppl with COPD. There are handheld portable nebulizers.

Answer 14

Self-Treatment OK: symptoms mild, intermittent, short duration OR prior diagnosis of intermittent asthma AND individ knows warning signs and symptoms indicating need for urgent care AND individ does not have any concurrent diseases that impair oxygen intake or breathing (COPD, CAD) AND patient is older than 5yo AND not pregnant AND current asthma symptoms are consistent with previous symptoms AND nonRx meds are for short-term (

Answer 15

Breathe in and out fully, then breathe in a deep breath, and exhale into the PFM with as much force as you can; do this three times. The highest number reached is the patient’s “personal best” - use this number to determine if they’re in the green zone (within 80% of personal best - lung function is ok); if they’re in the yellow zone (50-79% of personal best - lung function is decreasing, may need to reevaluate treatments, how they’re being used); If they’re in the red zone (below 50% of personal best - they need to seek medical help). Can be a useful tool in tracking lung function

Answer 16

Frequent heartburn for more than 3 months Heartburn while taking recommended dosages of nonRx H2RA or PPI Heartburn/dyspepsia that continues after 2 wks of treatment with a nonRx H2RA or PPI Heartburn and dyspepsia that occur while taking a Rx H2RA or PPI Severe heartburn/dyspepsia Nocturnal heartburn difficulty/pain on swallowing solid foods Vomiting blood or black material or passing black/tarry stools Chronic hoarseness, wheezing, cough, choking Unexplained weightloss Continous nausea, vomiting, diarrhea Chest pain accompanied by sweating, pain radiating to shoulder, arm, neck, jaw, shortness of breath Children 45 with new-onset dyspepsia

Answer 17

Heart Burn Usually w/in 1 hour of eating Especially after over eating/drinking Regurgitation with bitter/acidic fluid Occuring 2+ times a week may = GERD (gastresophageal reflux disease) Dyspepsia Postprandial fullness (still unusually full feeling long after a meal) → persistance of food in stomach Early satiation → feeling full after not eating much Epigastric pain → unpleasant feeling under the sternum Epigastric burning → feels like an unpleasant sensation by the heart Bloating, nausea, vomiting, belching Alarm symptoms: sudden weight loss, anemia, blood loss, dysphagia (trouble swallowing)

Answer 18

Nonpharmacological Dietary and lifestyle modifications; move exercise/physical activity and less heavy/greasy/fatty foods Keep diary of “triggers” and avoid them Weight loss Elevating head at bed time 6-8” Eat smaller meals Refrain from eating within 3 hrs of laying down Evaluate Rx and nonRx meds for their likelihood to cause heartburn/dyspepsia Discourage tobacco use Limit alcohol/caffeine intake Pharmacological Antacids Neutralize gastric acid Contain Mg, Ca, Al, Na Act as buffering agent in lower esophagus → cations react with chloride and form water compounds Most minimally absorbed systemically Take at onset of symptoms and 1-2 hrs later if they persist Should NOT take regularly for more than 2 wks Aluminum containing compounds assoc with constipation Ca++ Carbonate ma → belching and flatulence (same with Na+ bicarbonate) H2RA (Histamine Type 2 Receptor Antagonist) Cimetidine, ranitidine, famotidine, nizatidine → considered interchangable at low dose Decrease fasting and food stimulated gastric acid secretion and gastric volume by inhibiting H2Rs BA not affected by food; reduced a little by antacids Tolerance builds when taken daily Preferred to take on as-needed basis For mild-moderate infrequent/episodic heartburn and for heartburn prevention (prevention = take 30 min to 1 hr before meal) Most common SEs = HA, dizziness, diarrhea, constipation, drowsiness Rare thrombotic events, impotence, gynocomastia PPIs Antisecretory drugs Relieve heartburn/dyspepsia by decreasing gastric acid secretion Inhibit H+/K+ ATPase, irreversibly blocking final step in gastric acid secretion Relative BA increases with regular dosing Symptom onset relief may take 2-3 hours, but FULL EFFECT may not be seen for 1-4 days Ex: omeprazole Most common SEs = dizziness, HA, diarrhea, constipation Chronic use may increase risk of infection. INCREASED RISK FOR OSTEOPOROSIS IN ELDERLY Risk of rebound acid secretion once stopped Bismuth Subsalicylate Believed to have topical effect on stomach mucosa Not recommended for children Should be avoided in those with renal failure Dont use in those with aspirin allergy Dark tongue and black stools ok

Answer 19

If worsens, or continues after two weeks of treatment, go see PCP If radiating pain or sweating, shortness of breath with pain, go see PCP Try to limit use Chronic use of PPI could = rebound acid secretion

Answer 20

Common disorders: motion sickness, pregnancy, acute viral gastroenteritis, overeating, indigestion Involves CNS and GI tract CTZ = chemotrigger zone; outside blood-brain barrier; responds to stimuli from bloodstream or cerebrospinal fluid VC = vomiting center; in brain stem (medulla oblongata) Mechanical obstruction (small intestine obstruction) Motility disorders (gastroparesis) Infections Topical GI irritants (Alcohol, NSAIDS, antibiotics) Vestibular Disorders (motion sickness) Increased Intracranial pressure (CNS tumor) Psychogenic (anticipatory vomiting, anxiety) CNS Disorders (migraine) Irritation of CTZ (medication induced → chemotherapy, opioids, drug withdrawl)

Answer 21

General Treatment Approach most cases self-limiting and will spontaneously resolve. ORS

Answer 22

Exclusions for Self Treatment urine ketones/ high BG in DM patients suspected food poisoning that doesnt clear after 24 hrs n/v with fever and/or diarrhea (infectious disease?) severe upper R quadrant pain, especially after eating fatty foods (pancreatitis?) blood in vomit yellow skin/eye discoloration/dark urine (hepatitis?) stiff neck, no HA, light sensitivity (meningitis?) Head injury with n/v, blurred vision/ numbness, tingling ppl with glaucoma, BPH, chronic bronchitis, emphysema, asthma (may have bad reaction to OTC antiemetics) preggo (severe symptoms)/ breastfeeding drug induced n/v (opioids, NSAIDS, antibiotics, estrogens, digoxin, theophylline, lithiuim) psychgenic induced: AN, BN chronic disease induced : gastroparesis with DM, DKA or HHS with DM, GERD

Answer 23

Nausea and Vomiting in Preggos Motion Sickness Overeating

Answer 24

Motion Sickness Does it occur while they’re traveling? In a car, reading while moving, on boats, riding carnival rides? Overindulgence Does it occur after eating or drinking too much? Especially if it is a lot of sugary foods Pregnancy Morning sickness; are they pregnant? How far along? (mostly seen in first trimester). Is anyone around them sick? Viral/Bacterial illness Is anyone around them sick? Accompanied by fever, body aches, diarrhea, other signs of viral or bacterial infection?

Answer 25

``` NonPharmacologic Therapy ORS for rehydration Sports drink avoid reading during travel avoid XS food/alcohol, especially during/before travel ``` Avoid N/V in Pregnancy: fresh air where you sleep eat some dry crackers before getting out of bed get out of bed very slowly eat more, smaller meals throughout day; donot overeat at meals drink small sips of liquids btwn meals; dont drink a lot at meals or soup if nauseated, sip carbonated beverage avoid greasy/fatty foods eat chilled rather than warm or hot foods eat high protein, bland foods Pharmacologic Therapy Motion Sickness amtihistamines: Meclizine (may be less sedating), doxylamine, diphenhydramine (use with caution with opiates, psychiatric meds, B-blockers, antiarrhythmics) may thicken brochial mucus (anticholenergics) → use with caution in asthmatics, COPD, angle-closure glaucoma dizziness Food or Beverage overindulgence, comsumption of disagreeable foods, indigestion antacid and histamine type 2-receptor agonist (H2RA) Bismuth subsalicylate Phosphorated carbohydrate solution (PCS) (theory is that it slows stomach down, like eating something to help nausea) may cause stomach pain and diarrhea caution in patients with diabetes first generation antihistamines are anticholinergic; so second generations like Allegra dont work bc not anticholinergics. (effects on inner ear fluids) Food Poisoning Throw it up! Get it out of the system. Stay hydrated. Self-limiting Medications May need Risk/Benefit assessment. Can lessen or pull patient off drug/ change meds. May also have patient take med with meals to lessen stomach upset.

Answer 26

``` Cyclizine Anticholinergic/antihistamine; may cause sedation, dry mouth, dry eyes Dont use in those under 6 Meclizine Antihistamine; avoid with alcohol, not as sedating Dont use in those under 6 Dimenhydrinate May cause drowsiness/ paradoxical CNS stimulation, anticholinergic effects, tinnitus, hypotension Can use in 2-6 yos Diphenhydramine Marked drowsiness Can use in 2-6 yos ```

Answer 27

Stay hydrated with ORS. If it does not clear up after 24 hrs, go see PCP. If symptoms change or get worse, see PCP. If due to overeating, change your eating habits. If medication related, consult with PCP before changing meds.

Answer 28

Exclusions for Self-Treatment (Intestinal Gas) intestinal gas symptoms that persist more than several months or occur several times a month severe debilitating symptoms sudden change in location of abdominal pain, significant increase in the frequency or severity of symptoms, or an onset of symptoms in individuals > 40yo symptoms accompanied by significant abdominal discomfort or a sudden change in bowel function (diarrhea/constipation) presence of severe/persistent diarrhea/constipation, GI bleeding, fatigue, unintentional weight loss, frequent nocturnal symptoms ``` Exclusions for Self-Treatment (Diarrhea) or = 6 mo with persistent fever >102.2 F blood, mucus, pus in stool protracted vomiting orthostatic hypotension severe abdominal pain risk for significant complications DM, severe CVD, renal disease; multiple chronic conditions; immunosuppressed patients (AIDS, organ transplant, chemo) Pregnancy chronic/ persistent diarrhea inability of caregiver to administer ORS suboptimal response to ORS ```

Answer 29

Nonpharmacological Treatments: (Intestinal Gas) changes in eating habits and diet reduce consumption of gas producing foods CAM (Intestinal Gas) probiotics Carminatives (mint, peppermint, spearmint, fennel) fennel = contraindicated in pregnancy; may cause photosensitivity, cleates with ciprofloxacin lessening its activity ``` NonPharmacologic Therapy (Diarrhea) rehydration using ORS ```

Answer 30

Intestinal gas Pharmacologic Therapy: Simethicone and activated charcoal = relieve symptoms after intestinal gas has formed. simethicone: mix of inert silicon polymers defoaming agent to relieve gas→ reduces surface tension of gas bubbles embedded in mucus of GI tract FDA approved Contraindicated in those with simethicone sensitivity or GI perforation and obstruction Simethicone and loperamide: treatment of nonspecific diarrhea = quick relief Antacids:many contain antacid and simethicone → efficacy of combo not well founded Activated Charcoal → purported to eliminate malodorous sulfur-based gases lactase and alpha-galactosidase may prevent gas formation/ diarrhea oligosaccharides alpha-galactosidase: hydrolyzes (high fiber foods) safety remains to be determined *** should not be used in patients with galactosemia *** beware mold allergies *** beware those with diabetes *** haven’t been evaluated for safety in peds Lactase: break down lactose no known adverse effects Special Populations Peds ped formulations of simethicone available (40 mg simethicone / 0.6 mL) → used with gas from colic Not absorbed by GI, considered dafe Preggos No reports of congenital defects Preg Category C Safe for Nursing moms Diarrhea Pharmacologic Therapy loperamide: synthetic opioid agonist that lacks CNS effects antidiarrheal effects: stimulates peripheral micro-opioid rececptors on intestinal circular muscles to slow intestinal motility and allow absorption of water and electrolytes symptomatic relief of acute, nonspecific diarrhea can use in 6 yo and greater, provides directions for as young as 2 yo SE: constipation, dizziness; infrequent: abdominal pain, N/V, dry mouth, fatigue not recommended for invasive bacterial caused diarrhea Bismuth Subsalicylate antimicrobial effects and antisecretory effects (reduce fluid and electrolyte loss) 12 yo and older also for indigestion may cause black tongue/ stool tinnitus could = toxicity (from salicylates) contraindicated in those recovering from chickenpox or flu (Reye’s Syndrome); asthmatics (bronchospasms), dont use with aspirin CAM probiotics daily zinc supplement Special Populations children under 5 = self-limiting treatment; ORS; antidiarrheals not recommended elderly (>65yo) strongly caution against antidiarrheals; diarrhea can be fatal Preggos = refer

Answer 31

Appropriate for preventing and treating mild acute, uncomplicated diarrhea, especially rotavirus diarrhea in children. Probiotics produce acids that lower stomach pH and inhibit growth of harmful bacteria, enhance immune responses, and compete with pathogenic bacteria for binding sites

Answer 32

If Diarrhea gets more severe or is still an issue after 48 hrs, go see PCP. If it is bloody at all, go see PCP. Stay hydrated!!!!

Answer 33

Exclusions for Self - Treatment marked abdominal pain, significant distension or cramping marked or unexplained flatulence fever N/V presence of chronic medical condition that may preclud selfcare laxative treatment (paraplegia or quadriplegia, inflammatory bowel disease, colostomy) daily laxative use (excluding fiber therapy) unexplained changes in bowel habits, especially if accompanied by weight loss blood in stool or dark, tarry stool marked change in stool character (becomes pencil thin) any bowel symptoms that last for greater than 2 weeks or recur over at least 3 months any bowel symptoms that recur after dietary or lifestyle changes or laxative use inflammatory bowel disease anorexia age 2 or less

Answer 34

``` Clinical Presentation decreased frequency or difficulty passing anorexia dull HA Lassitude low back pain abdominal discomfort bloating/flatulence psychosocial distress ```

Answer 35

Nonpharmacologic therapy prevent eat a balanced diet, increase fruit intake, vegetable intake, half of grains consumed should be whole grain, 14 g dietary fiber per 1000kcal consumed (25 g for women, 38 g for men) Fiber adds weight and tends to normalize bowel movements gradually increase intake of insoluble fiber; limit foods with no fiber (cheese, meat, processed foods) supplement diet with fiber supplement (inulin); bulk forming (psyllium and methylcellulose) Benefits of adding fiber to diet may not be seen for 3-5 days or longer significantly increasing dietary fiber in any form may lead to erratic bowel movements, flatulence, and abdominal discomfort for first few weeks gradually increase fiber intake over 1-2 weeks to improve tolerance Behavior modification (bowel training) when you have to go, go! can try to go first thing in morning and 30 mins after meals when gastrocolic reflexes are strongest Exercise → low activity levels associated with more constipation Pharmacologic therapy Ideal laxative: nonirritating and nontoxic, would act only on descending colon and sigmoid colons, produce normal stool within a few hours bulk forming agents things with methylcellulose, polycarbophil, psyllium recommended for most constipation bc most closely approximate physiologic mechanism in promoting evacuation dissolve/swell in intestines, forming emollient gels that stimulate peristalsis and facilitate passage dosage forms = tablets, capsules, powders to be mixed with drinks, fiber chews, wafers, or gummies NOT systemically absorbed Action onset 12-24 hours, may be up to 72 hours Useful for patients on low fiber diets postpartum women older adults patients with colostemies, irritable bowel syndrome, diverticular disease prophylactically for patients who should avoid straining in bowel movements too much could = obstruction if not enough fluid intake or increased flatulence most common SE = abdominal cramping and flatulence if not taken with enough fluid, can swell in throat or esophagus and cause choking AVOID IN THOSE WITH SWALLOWING ISSUES and those with hypersensitivities, and those with intestinal ulcerations, stenosis, disabling adhesions palliative care patients and opioid induced constipation patient issues can interfere with medication absorption; should space bulking agents and medications by at least two hours assess before giving to diabetic patients for sugar content sugar free ones contain aspartame and should be avoided in those with phenylketonuria Hyperosmotic agents polyethylene glycol 3350; glycerin ions that draw fluid into the colon or rectum to stimulate bowel movement PEG recommended only for those 17 and older powder for oral administration (17 g of powder/day mixed in 4-8 oz water) not realy absorbed or degraded by GI tract → well tolerated Glycerin suppositoties usually produce a bowel movement in 15-30 minutes of administration safe and effective, may cause anal irritation if over used no concern for drug interactions

Answer 36

Bulking agents → adds more bulk/weight, helps push things through your system. Good for those with straining and little bowel movement Onset = 12-72 hours Fibers psyllium Hyperosmotics → draw liquid into the gut/intestines and helps get things moving Onset = 15-30 minutes for suppository; Oral PEG = 12-72 hrs PEG glycerin Stimulants → works directly on cilia in the gut, gets them moving faster so things move faster through GI track Onset = 6-10 hrs, may require up to 24 hrs Senna compounds Bicacodyl Emollients → soften the stool, makes it easier to pass Onset = 12-72 hours (usually 48 hours) docusate Lubricants→ what it says, lubes it up so stool can pass quicker Onset = oral 6-8 hrs; rectal 5-15 minutes Mineral oil Saline solutions → uses ions to pull water from GI track and gets things flushed out Onset = 30 mins to 6 hrs (oral); 2-15 mins (rectal) Magnesium sulfate

Answer 37

Staying hydrated can help keep stools soft. Depending on cause of constipation, may want to add fiber (slowly) to the diet. If opioid induced, will want to stay on a regimen of stimulant and emollient (like senna and docusate)

Answer 38

OA → gradual softening and destruction of cartilage between bones OA pain does not directly correlate to degree of joint damage proximal muscles may be involved if a person with OA guards the affected joint to reduce discomfort pain often limits patient’s activities of daily living (ADL) Aka “degenerative joint disease” Slowly progressive Characterized by: Loss of cartilage Bone remodeling Inflammation Bone-on-bone friction pain, stiffness and reduced range of motion in affected joints •Normal cartilidge is smooth and relatively thick; arthritis gets fibrous, thinner cartlidge, bone on bone rubbing à initiates bone remodeling; but unregulated = additional growths (ostephyte) = inflammation of synovial cap •Synovium membrane surrounds the joint cavity •Contains synovial fluid •Smooth articular cartilage •Regulated chondrocyte activity •Compared to OA: •Inflamed synovium membrane •Degenerated cartilage from excessive chondrocyte activity •Growth of osteophytes/ bony spurs •Pain from activation of nociceptive nerve endings •Cells found in cartilage – produce and maintain the cartilage matrix •The more chondrocytes in the cartilage, the more elastic it is: •Elastic cartilage •Hyaline cartilage •Fibro-cartilage •These cells are able to regenerate to a certain extent, but the process is slow and unable to effectively counteract repetitive stress or injury •At this point, damage is first seen in the cartilage via imbalance of chondrocytes that eventually affects all other tissues in the joint •Progression from cartilage à whole joint disease

Answer 39

Most common type of arthritis Age of onset = 45yo; 45 is dividing line ppl with symptoms b4 45 are likely male, after 45 more women than men F ≥45yo: OA is seen in F>M Incidence increases with age, most often in elderly Most common cause of disability among the elderly Symptoms get worse with age; reduce range of motion Men are at a greater risk of developing OA early on because they are more likely to have jobs or participate in activities that involve a lot of lifting or repetitive movement Women on the other hand are more likely to develop OA than men when they are 45 or older

Answer 40

Obesity – preventable, risk associated with weight-bearing joints Occupation – prolonged activities and repetitive movements Sports – activity that is done on a pre-existing injury History of joint trauma Genetic – still being studied, less likely compared to other factors

Answer 41

Affected joints = hands, knees, hips and spine weight bearing joints Distal joints > medial joints Unilateral bilateral with progression; keeping weight off one knee = over compensation on other knee pain in both Typical symptoms: Morning stiffness lasting

Answer 42

Pain, stiffness, reduced range of motion. May affect ability to work

Answer 43

May be genetic predispositions that are influenced by the environment 2-3x more women affected than men Pain, stiffness, and swelling in the morning lasting greater than 1hour Predominantly, but not exclusively, affects smaller joints (as opposed to weight bearing) Hands, wrists, feet, ankles Characteristically affects the first and second joints on the hands. (opposed to OA, which has something to do with distal joints) proximal interphalangeal (PIP) metacarpophalangeal (MCP) Usually poly-articular This wont just hurt in the morning, will hurt all the time Symmetrical ``` Muscle Weakness and Joint Deformity Reduced grip strength Osteopenia (not osteoarthritis) Systemic and focal Sjogren’s Syndrome Oral and ocular dryness Carpal Tunnel Syndrome (inflammation around nerve that causes pain) 1-5% prevalence in RA patients Organ Involvement Skin, lung, heart, eyes ``` Yeah, NSAIDS help with pain, but doesn’t slow down disease progression. Glucocorticoids make you feel better, but complications with long-term therapy à suppresses adrenal system, so if you were to suddenly stop using them you might die (also fat redistribution = round face and buffalo hump)

Answer 44

NonPharmacological options Weight loss Exercise Physical and occupational therapy OT learning how to do certain activities, tips/tricks to do daily activities with range of motion you have; PT focused on healing affected joint, getting back range of motion Thermal treatment Assistive devices Acupuncture Manual therapy - chiropractic Surgical procedures Pharmacological Therapy Topical/ Transdermal Agents Salicylates – provide topical counter-irritation to distract from symptoms of the affected joint Ex. Methyl salicylates (IcyHot, Bengay), trolamine salicylate (Arthricream) Capsaicin – isolated from hot peppers, releases and depletes substance P from afferent nociceptive nerve fibers Apply 2-4x/day, may take up to 2 weeks for full effect NSAIDs (Rx) – only topical agent on the market is COX-2 selective Ex. Diclofenac gel/ solution MAX total body dose for GEL = 32g/day Oral Agents APAP – inhibits prostaglandin synthesis Scheduled for chronic OA = 352-650mg Q4-6hr NSAIDs (OTC)– block prostaglandin synthesis via inhibition of COX 1 & 2 enzymes Remember standard counseling for NSAIDs: adverse effects, toxicities, etc Tramadol – opioid with weak inhibition of norepinephrine and serotonin reuptake Possible monotherapy for pain: schedule IV Rx Opioids – reduce pain perception by binding to & blocking opioid receptors Typically 3rd line due to side effects, reserve for chronic OA only Oxycodone most studied Duloxetine – SNRI, also indicated for depression and diabetic neuropathy Takes up to 4 weeks to see effect No clear recommendation for use, off-label Reserved as last line/ adjunct for chronic pain Dietary Supplements Glucosamine & Chondroitin Sulfate: stimulate anabolic process in cartilage and thought to have anti-inflammatory activity Possible supplement or adjunct to prevent/ slow progression of OA Glu/CS shown to prevent 1.2% cartilage volume loss in the knee May help reduce symptoms long-term for patients; not recommended as first line or monotherapy Vitamin D: deficiency associated with poor bone health No correlation between vitamin D serum levels and incidence of OA Intra-articular Injections Corticosteroids & Hyaluronic acid

Answer 45

Myalgia - muscle pain; can result from systemic infections (flu), chronic disorders (fibromyalgia), and meds (statins). Can also be result of alcohol abuse or vit D deficiency Strains - result of injury to muscle or tendon. Can be caused by acute injury, pro-longed over use; can become a chronic condition. caused by eccentric contraction of muscle while muscle is lengthening Tendonitis - inflammation of tendon. Results from acute injury or chronic repetitive movements. Ex: carpal tunnel (nerve sheaths inflammed and squeeze the nerve) tennis/golfer’s elbow swimmer’s shoulder jumper’s knee ****Medication: fluoroquinolone antimicrobials may cause tendon rupture/tendonitis Bursitis - common cause of localized pain, tenderness, and swelling worsened by movement of the joint (bursa). results from acute injury/ repetitive action. Sprains - most common problem with ligaments. → inversion ankle injury Grade I - result from excessive stretching Grade II - result from partial tear Grade III - result from complete tear of tissue Grades II & III usually = moderate to severe pain, loss of function of affected limb, and inability to bear weight Tears and ruptures more common in ligaments than tendons Strain- tendon or muscle; over exertion Sprains and strains generally treated the same Low Back Pain - common cause = sedentary life style, poor posture, improper shoes, poor mattress/sleeping posture, excessive body weight, improper technique when heavy lifting most recover in a few days to a few weeks without needed treatment if lasts > 3 mo = chronic lower back pain other causes → congenital abnormalities, OA, vertebral fractures and compressions, spinal TB, pain from kidneys, liver, pancreas, prostate OA → gradual softening and destruction of cartlidge btwn bones Clinical Presentation of Musculoskeletal Injuries and Disorders pain varying degrees of joint function → limited joint function from a sprain may = (partial) tear → req’s proper workup to rule out fracture or tear carpal tunnel patients diminished sense of heat/cold sense hands are swollen when they’re not weakness in hands → tendency to drop things symptoms persist during sleep and when hands not being used → distinguishing factor OA pain does not directly correlate to degree of joint damage proximal muscles may be involved if a person with OA guards the affected joint to reduce discomfort pain often limits patient’s activities of daily living (ADL) Low Back Pain can be neuropathic, involving sciatic nerve → sharp, referred pain in one or both legs can limit ability to stand, bend, move, sit walk Untreated pain/injuries may involve further tissue damage Bone/cartilage remodeling disability work loss physical impairments (insomnia)

Answer 46

Nonpharmacological RICE rest, ice (not applied for more than 15-20 mins at a time), compression, elevation promotes healing, helps reduce inflammation Can prevent sports/exercise injuries by warming up/ stretching muscles before activity, ensuring proper hydration, and wearing appropriate footwear Muscle cramps → stretch and massage, then immediately rest electrolyte depletion → oral supplement of electrolytes; fluids containing potassium, sodium, and magnesium Heat and cold therapy heat → for noninflammatory in nature injuries; good for acute back pain; hot water bottle, warm wet compress, heating pad should NOT be used with topical analgesics or over broken skin; should be avoided with inflamed areas; dont use on areas with decreased sensation Products → (ThermaCare - dont place in knee pit or elbow pit, Precise, generics) can be worn for up to 8-12 hrs Heat wraps should not be worn during sleep, and should be worn over a towel/article of clothing for those 55yo and up Cold → 15-20 mins 3-4 times a day TENS → transcutaneous electrical nerve stimulation FDA approved Class II medical device For sore, aching muscles/joints/chronic intractable pain (may provide temp relief, but wont necessarily take care of problem itself) SOURCE OF PAIN RELIEF → alteration of pain transmission and release of natural endorphins used 15-30 mins, up to TID electrode pad placement is product dependent AVOID USING ON CHEST, NECK, HEAD, CAROTID ARTERY AVOID PLACE ON wounds, sores, inflamed areas, sensitive/sensitized areas, cancerous lesions, over topical analgesics AVOID in ppl with internal or attached devices (pacemakers, insulin pumps, respirators, cardiograms) AVOID IN PREGGOS For home use Proper posture and use of ergonomic controls (seats with back support) Better fitting shoes mobilization with PT or exercise chiropractic manipulation acupuncture

Answer 47

Exclusions for Self-Treatment severe pain (pain score >6) pain that lasts >10days Pain that continues >7 days after treatment with a topical analgesic increased intensity or change in character of pain Pelvic or abdominal pain (other than dysmenorrhea) Accompanying nausea, vomiting, fever, other signs of systemic infection or disorder Visually deformed joint, abnormal movement, weakness in any limb, numbness, or suspected fracture pregnancy

Answer 48

Topical Products local analgesic, anesthetic, antipruritic, anti-irritant effects nonRx topical analgesics are approved specifically for topical treatment of minor-moderate aches and pains of muscles and joints (arthritis, sprains, bruises, strains) recommened as adjunct to pharmacologic and nonRx therapy of musculoskeletal injuries and disorders counterirritants → applied to skin to relieve pain. Produce a less severe pain to counter a more intense one → relief more from nerve stimulation than suppression produce mild, local inflammatory rx → relieves site underlying skin where applied → detract from deep-seated pain in muscles, joints, and tendons Pain is only as intense as it’s percieved to be. Cannot be used on those under 2yo Have been chemical burn reports products with higher [ ] of menthol: greater than 3% menthol and 10% methyl salicylate Methyl Salicylate: occurs naturally as winter green oil, etc. Usually combined with other ingredients (menthol, camphor) rubefacient → causes vasodilation thereby producing hyperemia; supposed to increase temp of skin and produce a counterirritant effect. Responsible for “hot” aciton in many topical products inhibit central and peripheral prostaglandin synthesis direct tissue penetration Camphor: occurs naturally, but about ¾ available = synthetically made [ ] of 0.1-3.0% = depresses cutaneous receptors and is used as a topical analgesic, anesthetic, and antipruritic [ ] > 3.0% , when combined with other counterirritants, induces pain relief by masking moderate-severe deeper visceral pain, with a milder pain when applied vigorously, acts as rubefacient Higher [ ]s can cause serious SE and toxicity CNS toxicity → seizures, can occur w/i 10 mins following ingestion can cause nausea, vomiting, delirium, convulsion, coma, death dangerous for kids Menthol: synthetic or prepped from peppermint oil can be used in small qty as flavoring agent [ ] at 1.25% = stimulates cutaneous receptor resonse (acts as counterirritant) topical menthol activates TRPM8 menthol receptor, triggering sensation of cold, followed by sensation of warmth Methyl Nicotinate: nicotinic acid is inactive topically, readily penetrates cutaneous barrier. vasodilation and elevation of skin temp result from low [ ]s with indomethacin, ibuprofen, aspirin significantly depress skin’s vascular response to methyl nicotinate → vasodilator response affected bc prostaglandin synthesis disrupted Due to vasodilation effect, may cause drop in BP/pulse rate if applied to large area Capsicum Preparations: capsaicin, capsicum, capsicum oleoresin → derived from fruits of nightshade family. contains ~1.5% irritant oleoresin → capsaicin = major component major pungent ingredient of chili peppers when applied to normal skin, elicits feeling of warmth through stimulation of TRPV1 receptor. MOA → depletes substance P (found in slow-conducting, unmyelinated type C neurons that innervate dermis and epidermis) pain and pruritic stimuli passed along type C neurons depletion occurs peripherally and centrally when substance P released = burning sensation compares with counterirritants USED TO REDUCE PAIN BUT NOT INFLAMMATION of RA/OA optimal dose varies btwn patients pain relief not immediate. USually takes 14 days; may take 4-6 weeks must use 3-4x/day wash hands after application has been assoc with cough, runny nose, sneezing Additional counterirritants allyl isothiocyanate, ammonia water, turpentine oil → Category I rubefaciants Pharmaceutical Efficacy and Recommendations for Counterirritants topical rubefascients not supported to be used for acute or chronic pain; compare poorly with NSAIDs methyl salicylate and menthol patch for moderate-mild muscle strain = effective; only FDA approved analgesic patch Other Topical Analgesics Trolamine Salicylate category III, but several nonRx contain it as primary ingredient. Not supported by evidence Topical NSAIDs not available nonRx in US Rx example → diclofenac benefits of oral NSAIDs with minial SEs Product Selection Guidelines Special Populations not significant response variability btwn age groups or races Preggos should be eval-ed by pcp capsaicin = category B; some list it as C camphor, menthol, methyl salicylate not categorized suggested that topical camphor compatible with pregnancy Patient factors nonpharm and oral drug therapy often used consider patient’s history, other meds, allergies Patient Preferences dosage forms

Answer 49

Mobility Aids - Cane o Reduce weight or assist with balance o Opposite hand of affected limb o Want the handle about wrist height, don’t want them to have to have unusual posture when using it à prevent other injuries § A lot are adjustable - Crutch o Usually not for older patients o Usually want an inch or two below arm pit (posture); hand grip should be about wrist height à slight bend in elbow o Are a lot of problems that can occur with long-term use - Walker o Many diff types; assess specific needs § Balance issues? § Pain/injury issues? - Wheelchair o Many different types; assess specific needs o Foot rests are often a fall hazard o Prolonged use hazards § Pressure sores/ bed sores § Loss of circulation § Make sure brakes are used § Communication issues § When they come up to the pharm counter and you cant see them bc they are low and pharmacy counter is really high - Joint Protection: Splints and Braces o Immobilize or limit mobility § May help with inflammatory conditions § Wrist brace for carpal tunnel syndrome § Semi-restrictive ankle brace to avoid injury § A lot of times people will come in having already been diagnosed with something - Support Stockings o Who can support from them? § People with edema (CHF) · With severe edema, size might go down over time § Varicose veins § People who stand for long periods of time/ sit for long periods of time (lower pressure gradients) § Ppl who are likely to develop DBTs (higher gradients) § Pregnancy § Come in a lot of diff patient gradients; highest at lowest point (near foot); less pressure as you get up § NOT for arterial insufficiency § Chronic venous insufficiency (higher gradients) o Should be worn as much as possible (safe to wear all day) o Some can be machine washed, some have to be hand washed o Some pharmacies carry, some have to order, some sock stores carry, some athletic stores carry o Be careful to latex allergies/ components of stockings o Watch for rashes and reactions o Don’t use for people who have lesions that might be oozing or weeping