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!