Abdominal Pain DYK's (Did You Know)

In medical school I was taught that anorexia was a sign of appendicitis, but apparently that is no longer true.[1]
Patients with peritonitis will sit still and patients with colic will move around a lot. [1]
There was also a cochrane  study that said that you can give patients with acute abdominal pain opioids without fearing that it will interfere with an accurate diagnosis [2]

1 Evaluation of Acute Abdominal Pain in Adults
SARAH L. CARTWRIGHT, MD, and MARK P. KNUDSON, MD, MSPH, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Am Fam Physician. 2008 Apr 1;77(7):971-978.

2 Cochrane Briefs :Opioid Analgesia During Evaluation of Acute Abdominal Pain 
Am Fam Physician. 2007 Oct 1;76(7):971.

OA= Often Asymmetrical; A Synopsis of AFP's "Osteoarthritis: Diagnosis and Treatment" by Keith Sinusas

This is a review of the January 1, 2012 American Family Physician, volume 85 number 1.


OA is a common disorder, but there are other joint disorders that look similar. OA worsens with activity, especially after rest. Morning stiffness usually lasts LESS THAN 30 minutes ( RA is usually longer). Any joint can be involved, but it usually occurs asymmetrically. Heberden and bouchard nodes can be seen. Lab work and imaging isn't that helpful in the diagnosis of OA.
So there is a "stepped care approach" to treatment which is clearly described on table 5 of this article. Basically it's says this: first start with diet and exercise ( water exercises are apparently not at good as land based programs). You can also start the patient off with some acetaminophen or try an NSAID. The next step is to try ibuprofen or naproxen and a different NSAID. If that doesn't work try glucosamine and chondroitin for 3 months. If the patient is still in pain you can move on to opioids. At this point if the patient has severe OA it may be time to consider corticosteroid injections, hyaluronic acid injections and lastly, a joint replacement. Capsaicin cream and SAM-e have also shown some benefit.

Florence Nightingale’s Notes on Nursing Which Apply to the Art of Caring

http://www.consultant360.com/blog/florence-nightingale?utm_source=dlvr.it&utm_medium=twitter

Consultant posted a nice article about Florence Nightingale and how she shaped the foundation of the modern hospital . See the link above for the story. Below is a summary of her basic principles which I took directly from the article.

Florence Nightingale’s Notes on Nursing Which Apply to the Art of Caring

Observe the sick.
Never let a patient be waked out of his sleep.
Avoid unnecessary noise: Whisper outside the room.
View and sunlight are matters of first importance to the sick.
Leading questions are useless or misleading.
Obtain accurate information.*
Be confidential.
Children are much more susceptible than grown people to noxious Influences.†

SYNOPSIS of AFP's Article "Subacute to Chronic Mild traumatic Brain Injury" by Timothy Mott MD, Michael McConnon MD, and Brian Rieger PhD

This is a review of the article in American Family Physician December 1, 2012 pages 1045-1050.


Mild TBI is loosely defined as a transient loss of consciousness, amnesia, change in mental status, focal neurological deficits, and a GCS of 13-15, after a closed head injury. Most patients recover within hours to days, but some symptoms could last 4 weeks or longer. Typical symptoms are headache, nausea, blurred vision, fatigue, irritability, mood, and sleep disturbances. Most of these symptoms should be treated individually, such as antiemetics for nausea, analgesics for headaches, and SSRI's for behavioral problems.
The physical exam should focus on a proper neurological exam, including ALL cranial nerves, reflexes, strength, sensation, and posture. Cognitive and mental exams should also be completed. Imagining is not typically necessary. Patients must be rigorously reassessed and referral or alternative diagnosis must be considered if the condition persists or worsens.
There is not much for treatment in TBI. It is important to manage the specific symptoms and prevent complications. Early education is critical in care as it gives the patient a realistic expectation and reduces anxiety. Patients are urged to rest both physically and cognitively, and to return to normal activities gradually.

SYNOPSIS of AFP's "Weight Loss Maintenance" by SAMUEL N. GRIEF, MD, and ROSITA L.F. MIRANDA, M

Losing weight can be hard, but often the real challenge is keeping it off. Some strategies for maintaining weight loss: http://bit.ly/VQsvk9 


Weight Loss Maintenance SAMUEL N. GRIEF, MD, University of Illinois at Chicago, Chicago, Illinois  ROSITA L.F. MIRANDA, MD, MS, Clay County Hospital, Flora, Illinois
Am Fam Physician. 2010 Sep 15;82(6):630-634.

     So after seeing this tweet from AFP and looking down at my belly I figured this would be a good article to read and review. Lets start with the facts and the stats. We are fat and we all want to be thin. It is killing us.Losing weight is hard and not fun. I can't remember which journal that was from.
     The best way to lose and maintain weight is by diet and exercise. The National Weight Loss Control Registry (NWCR) has found that the three most common factors in success are restricting certain foods, limiting quantity, and counting calories. Decreasing variety of food and not pigging out on weekends and holidays are also common traits of successful weight loss. Other common factors in successful patients are watching less TV, eating breakfast every day, exercising an hour a day, and monitoring their weight with a scale. 
     There is also a concept of "diet disinhibition" which is composed of three things; cognitive restraint, uncontrolled eating, and emotional eating. This refers to binge eating, common to those on overly restricted diets. This doesn't help.
     The two approved medications for weight loss (at the time of this publication) are Orlistat and Sibutramine. These have been shown to be effective in weight loss. Patients need to have a BMI over 30 or a BMI over 27 with medical comorbidities. Some of thee medications have side affects, like oily stool or heart valve problems, which is something to consider when choosing this route.
     Surgery is another option. There are several varieties , from bariatric to full on surgery. Patients have had, not only weight loss, but also remission of comorbid conditions from the procedure. Patients should have a BMI greater than 40 or greater than 35 with comorbid conditions. They also need to attempt a weight loss program, and dieting, for a set amount of time, and be unsuccessful. There is limited RCT's on these procedures and some studies even suggest that pharmacology is as effective as surgery.

SYNOPSYS of American Family Physicians article "Seasonal Affective Disorder, by STUART L. KURLANSIK, PhD, and ANNAMARIE D. IBAY, MD,

This is a review of the article from AFP called Seasonal Affective Disorder, by

STUART L. KURLANSIK, PhD, and ANNAMARIE D. IBAY, MD,

found at Am Fam Physician. 2012 Dec 1;86(11):1037-1041.

     This article on SAD was a good review, and all the research pretty much confirmed what we already know. SAD is basically depression that occurs in the fall and winter months and resolves in the spring and summer. This doesn't mean that every patient who walks into your office with depression around the holidays has SAD. It needs to occur for two seasons in a row.  The amount of depression episodes in the fall/winter must outnumber the number of episodes in the spring summer.  It is more common in women during childbearing years. One interesting factor is that patients have a tendency to have carbohydrate cravings and hyperphagia. This will cause the patients to gain weight. I could see how these patients could be under treated if a young lady comes into your office upset because she gained some extra weight over the holidays. There are some depression tools to help determine if the patient is depressed  Beck Depression Inventory  and Hamilton Rating Scale for Depression)

    Treatment has not changed much recently. The three types of therapy are light therapy, antidepressants, and CBT. Light therapy is done for 30 minutes a day with a specific lux and spectrum.It takes bout 1-2 weeks to kick in. The medications used are typically second generation antidepressants (SSRI's and SNRI's) most commonly Prozac. CBT is not typically done by everyone and more often referred out, do to the expertise needed and time restraints. Combinations of these therapies have been shown to be more effective than any one therapy alone.      

     Prevention has been shown to be effective as well. Patients can begin light therapy or take Wellbutryn prophylactically  n the early autumn. CBT can be done prophylactically as well. Exercise and relaxation techniques can also help.

Cheesecake Factory Medicine

I'm reading an article from the New Yorker By Atul gawande- google Cheesecake Factory medicine and enjoy!

SYNOPSIS of "Hepatitis A", by Samuel Mattheny MD in AFP

This is a review of the article " Hepatitis A, SAMUEL C. MATHENY, MD, MPH, and JOE E. KINGERY, DO, University of Kentucky College of Medicine, Lexington, Kentucky"

Am Fam Physician. 2012 Dec 1;86(11):1027-1034.

     Hepatitis A is an RNA virus, specifically the picornavirus. It is transmitted through the fecal-oral route. It is spread through contaminated water, in day care centers, on raw vegetables, and through "sexual contact that promotes fecal-oral transmission".  The incubation period is about 28 days, at which time onset is abrupt. Signs and symptoms include jaundice, nausea, vomiting, diarrhea, dark urine, fever,  hepato/splenomegaly, headache, and abdominal pain.
     Laboratory tests will show elevated serum transaminase, bilirubin (total and direct) AP, ALT and AST (ALT will be higher). Diagnosis can be made through detection of IgM anti-HAV antibodies. It will become positive within 5-10 days, but will no longer be detectable after 4-6 months. IgG anti-HAV will increase at this time. The virus is shed in the stool during the time after the increase in ALT and before Igm is detectable (pearl or the day!)
     Hepatitis A is self limiting. There is a small chance of relapse, but it wont become chronic. Treatment consists of bed rest, not going to school or work until the fever and jaundice has resolved and avoiding alcohol.
     All children should be immunized between 1 and 2 years old. Immunoglobulin can be used as pre or post-exposure prophylaxis.  High risk populations (illicit drug users, men who have sex with men, health care workers, those with adopted children from endemic areas, with liver disease or clotting factor disorders) should also be vaccinated. Vaccination should be given to travelers going to countries other than Australia, New Zealand, Canada, Europe, or Japan at least 2 weeks prior. If the patient is over 40 years old, immunocompromised, or is leaving before 2 weeks, you can also give immunoglobulin. If the patient does not want the vaccine,  you can give them the Ig, but you would triple the dose to 0.06mL/Kg if they are going to travel for more than two months.
    For post exposure prophylaxis, you can give the patient the vaccine (or Ig) within two weeks of exposure.

Rate vs Rhythm- The Hatfields and Mccoy's of Atrial Fibrillation

So I was listening to the Medscape Family Medicine Podcast on my way to work and there was a three part episode on atrial fibrillation. The guest was talking about treatment and she said that if the patient is symptomatic, then she would consider rhythm control. she also said that she would try an convert almost anyone at least once because rhythm control gives the patient a better quality of life. Rhythm control can be use for younger patients without co morbid conditions. I felt like that was different than what I had had previously learned. It decide to use my new iPhone app "AFP by topic" and read all the articles on treatment for AFIB. Ill discuss anti-coagulation next time.
      Rate control is preferred for patients who are asymptomatic or mildly symptomatic "AFIBers". It improves diastolic filling, coronary  perfusion, and decreases myocardial energy demands. So for rate control, we have beta blockers, calcium channel blockers (diltiazem and verapamil) and digoxin. The calcium channel blockers are contraindicated in patients with structural disease. As a side note, these two calcium channel blockersdo have an effect in the glomerulus, similar to ACEI's and ARB's in patients with CKD. Digoxin is not preferred because it is not effective for rate control during exercise. It can have a synergistic effect when used in conjugation with beta blockers. 
     It is true that rhythm control should be tried at least once because the patient could cardiovert and stay in sinus rhythm for several years without needing medications.  This may also be considered if the patient is young, first time AFIBers. The four main antiarrhythmic drugs are dronadarone, flecanide, propafenone and sotolol. Those patients with structural heart disease my need a different therapy [2].I failed to mention amiodarone. This medication is the strongest antiarrhythmic, but there are many bad side effects (lung damage, liver damage, and pulmonary toxicity), thus it is not considered a first line medication for rhythm control. There have been studies that recommend amiodarone in patients with low injection fraction.
     There have been several studies comparing rate vs. rhythm in atrial fibrillation. The PIAF (2000) study compared therapy with symptoms (palpitations, dyspnea, and dizziness) and showed no difference between the two therapies. It also showed better exercise tolerance and mor frequent need for hospitalization in the rhythm group. The more hospitalizations were do to the more frequent need to recardiovert patients. The PIAF QOL (2003) study showed no difference in quality of life in either group.
The STAF (2003) study compared the to therapies against "primary endpoint" (The primary endpoint was the combination of death, cardiopulmonary resuscitation, cerebrovascular event, and systemic embolism). Again there was no difference.
The RACE (2002) study compared the two therapies against a primary endpoint of a "composite of death from cardiovascular causes, heart failure, thromboembolic complications, bleeding, implantation of a pacemaker, and severe adverse drug effects [3]". Again there was no difference.
The AFFIRM (2002) trial which again showed "no clinical advantage for rhythm control over rate control".  It did however, show that amiodarone was the most effective antiarrhythmic drug. Also, the study reinforced the importance of anticoagulation. 
     SO what does all this mean? Rate control is safer and cheaper. If you put a gun to my head, then I would treat with rate control measures. But it is really a case by case process, especially in those who are highly symptomatic.



1.Am Fam Physician. 2002 Jul 15;66(2):249-257
2.Can J Cardiol. 2011 May-Jun;27(3):388.
3.Pharmacologic Management of Atrial Fibrillation: Where Do We Currently Stand? , by John Camm, MD
Medscape Cardiology, 2005-02-28

SYNOPSIS of "The Hospital Medicine Podcast: Immune thrombocytopenia Purpura" by Dr Gil Porat MD

This podcast was recorded on July 2, 2012 and can be found here: https://itunes.apple.com/us/podcast/hospital-medicine-podcast/id541752791


   This was a very interesting podcast, as are all of Dr. Porat's lectures. So lets start of by saying that platelets are non-nucleated cells that clot to prevent bleeding. Thrombin forms when coagulation proteins bind to the platelet surface. Platelets also secrete factors for platelet repair. They live for about 10 days and 30% of them are sequestered in the spleen.
     Thrombocytopenia is when the platelet count is below 150k. ITP is normally a chronic benign condition. Spontaneous remission is seen in 9% of adults and is even more common in children. The two ways that ITP occurs is through decreasing production of platelets  (by drugs and bone marrow diseases  and decreasing the survival of platelets ( by ITP, TTP sepsis, hypersplenism, etc).
    The type of ITP that Dr. Porat discusses in this podcast is autoimmune induced thrombocytopenia. It is commonly a diagnosis of exclusion after systemic illnesses and medication reactions are ruled out. ITP is commonly an incidental finding on a lab results, but petechiae, purpura, menstrual  mucosal and cutaneous bleeding my be seen.
     Treatment goals are hemostasis and to increase the platelet count to above 30k. If there is no bleeding and the platelet count is already above 30k, then treatment is typically not needed. Otherwise, the first line of therapy is corticosteroids. Improvement should be noted within one to two weeks, although re-occurrence will often be seen after the steroids are discontinued  Splenectomy is considered second line treatment. Patients should have the appropriate vaccinations prior to surgery (pneumovax, H. influenza, and meningococcal . This therapy is associated with a 60% remission rated although physicians should be diligent to watch for inherent side affect of this surgery (i.e, sepsis). Anabolic steroids have also been used for treatment, but may not be appropriate for female patients.
     Rituximab is a monoclonal antibody that decreases the production of B cells. It decreases the antibodies that are destroying the platelets. It has been shown to be effective, but immune suppressants such as this one have several restrictions and warnings as well.
     The newer medications affect thrombopoietin  Thrombopoietin is made in the liver and sent to the bone marrow to tell the megakaryocytes to increase production of platelets. Two thrombopoietin agonists (Romiplostim and Eltrombopag)  have shown to increase platelet counts to greater than 50K in 94% and 87%, respectively. These medications are very expensive, and continual use is needed for them to work. Some of the side effects are elevated LFT's, thromboembolism, and bone marrow fibrosis.
     Lastly , platelet transfusion in emergency situations, although the effect, is temporary. IVIG can be given along side the transfusion to help the effects.

Review of "Diagnosis and Treatment of Acute Low Back Pain" by Dr. Brian Cassazza

this is a review/synopsis of the article "Diagnosis and Treatment of Acute Low Back Pain by BRIAN A. CASAZZA, MD"


Am Fam Physician. 2012 Feb 15;85(4):343-350



     Since my back pain is only slightly better I figured that this would be  an appropriate time to reread and review an article on Low back pain. First off , acute low back pain is pain for 6-12 weeks , between the area of your back from your "lower costal angle to your gluteal fold". I  have never heard that geographic description so I thought I would mention it . So the most common causes are compression fractures, herniated discs,  lumbar strain/ sprain, stenosis, and sponylo's (-losis, lysis, and listhesis). There are also connective tissue diseases, osteomyelitis, aortic aneurysms  and a lot more so you may want to check out this article to see the complete differential. I'm pretty sure I have a lumbar sprain/strain. 
     When you take your history it is important to pay attention to red flags that MAY OCCASIONALLY be associated with a serious pathology. Bowel or bladder incontinence or saddle anesthesia may be a sign of cauda equina syndrome. Vertebral tenderness and weight loss may be a sign of malignancy. Trauma in the elderly could be a fracture.
     Spine pain rarely radiates below the knee. Sacro-iliac pain radiates often to the thigh and below the knee. Nerve root irritation often manifests as leg pain over back pain. L1-L3 radiates to the hip and though whereas L4-S1 radiates below the knee.
Imaging is often not needed (unless in trauma). It may be considered if pain persists beyond 4-6 weeks and you are considering a serious pathology.
For medications, NSAID's or acetaminophen can often relieve low back pain. They all have shown to be squally effective and can be changed at will. Opioiods are commonly prescribed but have shown little evidence of benefit. Epidural spinal injections have recently come under fire do to the fungal meningitis outbreak due to contaminated product. They don't really have any long term benefit although it may provide some temporary pain relief of radiating pain(if you don't mind the meningitis).
     So if you have a patient who wants to get well and isn't just going to pout until you give him/her a percocet script, you can tell him/her this: stay active. Avoid twisting and turning while bending forward. Try to get back to your normal level of activity as soon as possible. Heat packs can help.
     Some things that don't really work err... I mean haven't been shown to be effective are back braces, acupuncture  massage, traction,  or oral steroids. Just think bed rest = Bad rest!