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C. Auscultate 1. Auscultate the heart and lungs. 2. Auscultate the abdomen for bowel sounds. D. Palpate abdomen. 1. Evaluate for the presence of tenderness. 2. Evaluate for masses. E. Neurologic examination 1. Perform neurologic examination, including checking deep tendon reflexes (DTRs), sense of smell, and Babinski reflex (vitamin B12 deficiency). Diagnostic Tests A. Annual recommended laboratory testing for all procedures 1. Complete blood count (CBC) with differential 2. Liver function tests 3. Glucose 4. Creatinine 5. Electrolytes B. Annual laboratory testing suggested for LAGB, recommended for all other procedures 1. Iron/ferritin 2. Vitamin B12 3. Folate 4. Calcium 5. Intact parathyroid hormone (PTH) 6. 25-hydroxy vitamin D 7. Albumin/prealbumin C. Optional labs that may be required based on symptoms 1. Zinc 2. Copper 3. Vitamin B1 4. Vitamin B6 5. Vitamin A D. Other labs as appropriate for condition and prevention 1. Monitor Hg A1c and blood glucose closely in patients with diabetes. 66 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Diabetes has resolved after bariatric surgery in some patients. 2. Lipid profile E. Abdominal ultrasound F. CT scan abdomen G. Doppler ultrasound of limb for suspected deep vein thrombosis (DVT) H. Pulmonary ventilation/perfusion scan for suspected pulmonary embolus I. Bone mineral density (dual-energy x-ray absorptiometry [DEXA]) scan: Recommended annually until stable after malabsorptive procedures J. Endoscopy as needed for abdominal complaints Differential Diagnoses A. Postoperative surgical complication(s) B. Infection C. Abdominal pain D. Fascial dehiscence E. DVT F. Bowel obstruction G. Band slippage H. Anastomosis leakage I. Stomal stenosis/stricture J. Cholecystitis K. Dumping syndrome L. Food intolerance M. Gastric ulcer N. Gastroenteritis O. Vitamin deficiency P. Malnutrition/protein deficiency Q. Incisional hernia R. Osteoporosis Plan A. General interventions 1. Lifelong follow-up is required after bariatric surgery. Ideally, patients should follow up with their surgical group, but many do not. Primary care providers are well positioned to capture those lost to follow-up. Continuous reinforcement of good nutritional habits is important. 67 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
B. Patient teaching: Many complications can be prevented by adhering to diet and lifestyle recommendations. 1. Supplements are required lifelong; strict adherence will prevent deficiencies. 2. Dumping syndrome can be prevented by avoiding foods that trigger it such as high sugar and/or high-fat foods. Patients can keep food diaries to identify triggers. 3. Hypoglycemia can usually be prevented by careful monitoring of carbohydrate intake. 4. Surgery does not replace the need for a balanced diet or exercise. Approximately 150 minutes of moderate activity each week is recommended, though safety and tolerance differs so exercise recommendations should be individualized. Any activity is better than none. 5. Food should be chewed thoroughly and consumed slowly. Liquids should be avoided 30 minutes before and after meals. Avoid eating and drinking liquids simultaneously. 6. Protein is important for maintaining muscle mass during rapid weight loss and avoiding hunger during maintenance. Between 60 and 100 g of protein daily is recommended. Limit carbohydrate intake to 50 g per day or less. Limiting carbohydrate intake reduces risk of weight regain by preventing rebound hunger. 7. To prevent dehydration, as well as reduce the risk of kidney stones and constipation, encourage 64 ounces of fluids daily. 8. Stress, boredom, and emotions often affect eating habits. Identifying problems and seeking help early are important. 9. Support groups can be a vital source of education and social support, both of which are key to weight loss and maintenance. 10. Weight plateaus are common and normal. This is the body's way of trying to establish a new set point. Do not be discouraged by plateaus. Consistency is key to overcoming them. 11. Adequate sleep and successful stress management are also key to successful weight loss and maintenance. C. Pharmaceutical therapy 1. Medication absorption can be altered after bariatric surgery. Evaluate need for adjustments of medication dosing, especially diabetic, 68 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
psychiatric, and antihypertensive medications as well as any medication with a narrow therapeutic window. 2. Patients may require alternate formulations of medications, including crushed, chewable, liquid, patches, intramuscular, or subcutaneous. Long-acting, extended-release, or enteric coated medications may not be absorbed as well and may need to be switched to immediate release. 3. Refer to Table 2. 5. 4. Recommended supplementations: a. Multivitamin plus mineral i. LAGB: One daily ii. All other procedures: Two daily b. Calcium: (all procedures) 1,200 to 1,500 mg daily from food and calcium citrate in divided doses c. Vitamin D: (all procedures) 3,000 IU daily, titrate to therapeutic level d. Iron i. LAGB: Not usually necessary ii. All other procedures: 45 to 60 mg daily from multivitamin plus additional supplementation e. Vitamin B12 i. LAGB: Not usually necessary ii. All other procedures: As needed to maintain levels in the form best tolerated f. Long-term anticoagulation may be needed for DVT/pulmonary embolism (PE) prophylaxis. g. Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids should be avoided to reduce the risk of marginal ulcers. D. Psychosocial changes: Bariatric surgery often results in dramatic lifestyle and body changes and may require significant psychosocial adjustments for the patient as well as his or her friends and family. 1. Monitor for depression/anxiety, body image concerns, and social support. 2. Alcoholism can be a concern after bariatric surgery. Less alcohol is needed to elevate blood alcohol levels and blood alcohol levels are sustained longer after bariatric surgery. 69 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
TABLE 2. 5 Routine Supplementation Based on Type of Gastric Bypass Surgery TABLE 2. 6 Recommended Annual Laboratory Monitoring for Bypass Patients 70 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Follow-Up A. Bariatric surgery requires lifelong follow-up, ideally by a multidisciplinary team of health care providers. Initial follow-up schedules are set by the surgeon. Long-term follow-up (after the first 2 years) is usually provided for by the bariatric surgery program, but research has shown that follow-up is often poor, which leads to poor outcomes and substandard patient care. B. Laboratory and diagnostic testing is required as listed in Table 2. 6. Early recognition of nutritional deficiencies can prevent permanent damage and even death. C. Chronic disease management (particularly diabetes, lipids, and bone disease) can be simpler or more complex after bariatric surgery, depending on the patient's adherence to lifestyle and nutritional recommendations. Consultation/Referral A. Bariatric surgeon for surgical complications, revisions B. Surgeon for cholecystectomy (preferably bariatric surgeon or general/GI surgeon experienced in the care of bariatric patients) 71 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
C. Gastroenterology consult D. Nutrition consultation and/or counseling E. Psychologist consultation F. Physical therapy/exercise specialist G. Support group Individual Considerations A. Women a. All women of childbearing age should receive adequate folate supplementation and be given contraception and preconception counseling. b. Oral contraceptives (OCPs) may not be as effective after bariatric surgery because of changes in absorption. B. Pregnancy a. Pregnancy should be delayed for 12 to 18 months after bariatric surgery or however long it takes for weight loss to stabilize. b. Bariatric surgeon consult may be required. c. Increased folic acid may be needed preconception to reduce risk of neural tube defects. d. Increased vitamin supplementation may be necessary during pregnancy. Vitamin A should be limited to 5,000 IU daily. e. Gastric band may need to be adjusted during pregnancy. f. Serial ultrasounds may need to be done to follow fetal growth. Substance Use Disorders Moya Cook and Robertson Nash Definition With the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013), there has been a significant shift in the classification of substance use disorders and their categorization. Previously, the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV ; APA, 1994) provided distinct groups of substance use, listed as follows: 72 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Substance abuse: A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) specific symptoms, occurring within a 12-month period. B. Substance intoxication: The development of a reversible substance-specific syndrome caused by recent ingestion of (or exposure to) a substance. C. Substance dependence: A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) specific symptoms, occurring at any time in the same 12-month period. D. Substance withdrawal: The development of a substance-specific syndrome caused by the cessation of (or reduction in) substance use that has been heavy and prolonged. The DSM-5 states that diagnosis of a substance use disorder should be based on a pathologic pattern of behaviors related to the use of the substance. The DSM-5 notes that an underlying characteristic of substance use disorders is changes in brain circuitry that may persist beyond detoxification. Manifestations of those changes include intense drug craving and relapse. Those patterns of behavior have been categorized into four groups, listed in the following: E. Impaired control 1. Use of a substance in larger amounts or for a longer time than originally intended 2. Repeated unsuccessful attempts to cut down use of substance 3. A great deal of time spent obtaining, using, and recovering from the substance 4. Intense desire for the substance, especially in an environment in which it was previously used. F. Social impairment 1. Recurrent substance use leading to a failure to meet personal and social obligations 2. Continued substance use, in spite of significant, ongoing social problems caused or exacerbated by the substance 3. Abandoning important personal and social goals because of substance use G. Risky use 1. Recurrent substance use in environments in which it is dangerous to use the substance 73 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2. Continued substance use in spite of knowledge of persistent/recurrent physical/psychological problems caused by the substance. H. Pharmacological criteria 1. Requirement for a markedly increased dose to achieve desired effect or markedly reduced effect at standard dose 2. Desire to consume the substance as a means to mitigate withdrawal symptoms As a modifier, use severity is assessed across three categories, listed as follows. It is important to note that the word addiction has been removed from the DSM-5 because of its vague definition and possible negative connotation. A. Mild—two or three of the symptoms listed as follows are present; B. Moderate—four to five symptoms listed as follows are present; C. Severe—six or more symptoms listed as follows are present. Incidence A. Statistics indicate that the most commonly used legal substances are caffeine, alcohol, and nicotine. According to the National Institute on Drug Abuse (NIDA), tobacco use is the leading preventable cause of disease, disability, and death in the United States. According to the Centers for Disease Control and Prevention (CDC), approximately one in five premature deaths in the United States every year is the result of cigarette smoking. B. The most commonly used illicit drugs are marijuana and cocaine. In 2013, an estimated 24. 6 million Americans aged 12 years or older had used an illicit substance in the past 30 days. NIDA reports usage for the most commonly abused drugs (see Table 2. 7). C. NIDA notes that in 2013 approximately 6. 5 million Americans (aged 12 years or older) used prescription drugs for a nonmedical reason in the past 30 days (see Table 2. 8). Opioids, central nervous system (CNS) depressants, and stimulants are the most abused prescription drugs. D. Studies indicate that 8% of adults in the United States had a substance use disorder in the past 12 months. Approximately 40% of hospital admissions are related to substance abuse or related to the effects of using substances. E. Approximately 88% of the American population consumes some alcohol (at one time or another). In 2009, the Drug Abuse Warning Network (DAWN) reported 4. 6 million drug-related emergency department 74 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
encounters, 32% of which involved alcohol alone or in combination with another substance; 5% to 7% of Americans have alcoholism in a given year, and 13% will have it sometime during their lifetime. Prevalence rates of alcoholism are 5% to 6% for men and 1% to 2% for women. Alcoholism is highest in men aged 18 to 64 years and women aged 18 to 24 years. F. Approximately 21% of Americans use tobacco products. One study states that there is a link between early nicotine use and alcohol abuse and depression. Smoking before the age of 13 years significantly increases the risk of drug dependence. G. It is estimated that 37% of the population aged 12 years or older has used an illicit psychoactive drug at least once. A substance abuse problem is recognized in as few as 1 in 20 substance-abusing patients seeking medical attention. Pathogenesis A. No single gene has been identified as the culprit in the predisposition to substance dependence. Certain biological features seem to be inherited by first-degree relatives (particularly males) of alcoholics, for example, a resistance to intoxication, a subnormal cortisol rise after drinking, and a subnormal epinephrine release following stress. B. Some theories postulate alterations in metabolism of alcohol and drugs in people who are dependent. Studies pertaining to alcohol have included research into genetic heritability, flawed metabolism of alcohol by alcoholics, insensitivity to alcohol inherited by alcoholics (thus tending to increase tolerance or ability to know when to stop), and alterations in brain waves in alcoholics. C. Although much of the research is specific to only one drug, much of what we know about the research can be applied to other drugs. There appears to be a higher rate of substance dependence, not limited to alcohol, in children of alcoholics. Predisposing Factors Factors vary among individuals, and no one factor can account entirely for 75 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
the risk of substance abuse. Studies indicate a high correlation between substance use and the presence of psychiatric disorders, especially anxiety disorders, depression, schizophrenia, and, in women, eating disorders. A. Genetic B. Familial C. Environmental D. Occupational E. Socioeconomic F. Cultural G. Personality H. Life stress I. Psychiatric comorbidity J. Biological K. Social learning and behavioral conditioning Common Complaints Patients' complaints will be focused on the symptoms of the problem rather than the substance dependence. The problem itself will be avoided through the use of denial, minimization, blaming, and projection (all signs of the disease of substance dependence). A. Chronic anxiety and tension B. Insomnia C. Chronic depression D. Headaches and/or back pain Consider patients who present frequently with somatic complaints, such as back pain or headache, as “drug seeking,” especially when the patient knows what drugs work best or asks for specific narcotic analgesics. E. Blackouts F. Gastrointestinal problems G. Tachycardia/palpitations H. Frequent falls or minor injuries 76 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Substance abuse should be suspected in all patients who present with accidents or signs of repeated trauma, especially to the head. I. Problems with a loved one, problems at work, or with friends Other Signs and Symptoms A. Defensiveness about alcohol/drug use or vagueness with answers B. History of problems with family life, marital relationships, work, finances, and physical health C. Change in spiritual beliefs (stops attending religious services) D. Unexplained job changes and multiple traffic accidents E. History of impulsive behavior, fighting, or unexplained falls F. Arrest for public drunkenness, driving under the influence, or illegal activity when alcohol/drugs were involved G. Tremors (shakes) TABLE 2. 7 Commonly Abused Drugs 77 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
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TABLE 2. 8 Commonly Abused Prescription Drugs 80 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
H. Delirium tremens (DTs) I. Seizures related to drugs J. Hallucinations K. History of chronic family chaos and instability L. Physical indications of chronic alcohol/drug use include spider angiomas, ruddy nose and face, nasal lesions, bruxism, swollen features, bruises, needle 81 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
marks/tracks, cutaneous abscesses, malnourishment, anemia, jaundice, and severe dental problems such as “meth mouth. ” M. Active withdrawal symptoms include nausea and vomiting, malaise, weakness, tachycardia, diaphoresis, tremors, lightheadedness or dizziness, insomnia, irritability, confusion, perceptual abnormalities or hallucinations (auditory, visual, or tactile), paresthesia, blurred vision, diarrhea, anorexia, abdominal cramps, severe depression, severe anxiety, piloerection, fasciculation (muscle twitching), rhinorrhea, fever, elevated blood pressure and pulse, tinnitus, nystagmus, delirium, or seizures. N. Overdose symptoms related to drug(s) include seizures, cardiovascular depression/collapse, and respiratory depression/collapse. Be prepared to provide cardiovascular and respiratory support and supportive care until transport. Subjective Data A. Review the onset, duration, and course of presenting complaints. B. The U. S. Preventive Services Task Force (USPSTF) recommends that all adults be screened in primary care for alcohol and drug use. C. Question the patient regarding relatives with a history of alcohol, tobacco, or drug use or problems pertaining to use. D. When questioning the patient, assume some use, for example, “At what age did you first start drinking?” Start with the least invasive questions first: Cigarettes, over-the-counter (OTC) medications, prescription medications, then alcohol, marijuana, stimulants, opiates, sedatives, hypnotics, benzodiazepines, barbiturates, hallucinogens, inhalants, steroids, and other drugs. E. Review use of the following drugs concerning quantity and type (if cigarettes, brand smoked; if alcohol, type of alcohol: Beer, wine, hard liquor), and age at initiation. Query regarding previous attempts to stop use. F. Start with the past and proceed to the present with use; include first use of the mood-altering substance, amounts, and the last use of the particular substance and amount. G. Follow the CAGE test. The CAGE (two out of four) is highly predictive of addiction. 1. Have you ever tried to cut down on your alcohol/drug use? 2. Do you get annoyed if someone mentions your use is a problem? 82 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
3. Do you ever feel guilty about your use? 4. Do you ever have an “eye-opener” first thing in the morning after you've been drinking or using the night before? H. If patient admits drinking or drug use, ascertain specific amounts and last use of each substance. I. Establish usual weight and recent loss and in what length of time. J. Determine whether patient experiences suicidal ideation and whether there is a history of past attempts (see Chapter 22, Psychiatric Guidelines, Suicide). Physical Examination A. Check temperature, pulse, respirations, blood pressure, and weight. B. Inspect 1. Observe general appearance, dress, grooming, breath odor, wasted appearance, attitude, sad affect, psychomotor retardation, or tremors. 2. Conduct a dermal examination for spider angiomas, bruises, track marks, color, pallor, rash, jaundice, petechiae, and gynecomastia in men (hallucinogens). 3. Examine the eyes for sclera color and features, pupil size, and reactivity. 4. Inspect the nasal mucosa for erythema, edema, spider telangiectasis, and discharge; look for septal lesions or perforation, deviation, and polyps. 5. Inspect the mouth/pharynx: Oral lesions, poor dental hygiene, erythema, and teeth for uneven surfaces, tooth decay, and gum erosion. C. Palpate 1. Palpate the neck and thyroid. 2. Palpate the axilla and groin for lymphadenopathy. 3. Palpate the abdomen; note hepatomegaly/tenderness. D. Percuss 1. Percuss the chest; note pulmonary consolidation. 2. Percuss the abdomen for hepatosplenomegaly. E. Auscultate 1. Auscultate the heart for murmur, new S4 gallop, single S2, and arrhythmias. 2. Auscultate the lungs for rales, effusion, and consolidation. F. Perform neurologic examination/mental status. 83 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Diagnostic Tests A. Blood alcohol level B. Cotinine level (nicotine); (where available) C. Urine drug screen D. Complete blood count (CBC) with differential E. Platelet count F. HIV or hepatitis Intravenous drug use contributes strongly to the spread of AIDS, hepatitis B and hepatitis C, and other infectious diseases. Consider evaluation for sexually transmitted infections. G. Antinuclear antibody, erythrocyte sedimentation rate, and rheumatoid factor H. Electrolytes I. Liver panel 1. Elevated liver enzymes can also be attributed to overuse of acetaminophen (Tylenol), found in combination with opiates. J. Blood cultures (fever) K. Bone density studies 1. Patients who have been drinking for years should have bone density studies done because alcohol increases the risk for osteoporosis. Differential Diagnoses A. Substance use disorder B. Chronic pain syndrome C. Anxiety D. Depression Plan A. General interventions 1. Discuss your concerns about alcohol, nicotine, or drug use and discuss addiction treatment with the patient (refer to the NIDA Principles of Drug Addiction Treatment mentioned earlier in the chapter). 84 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2. At each office visit, provide support to help prevent relapse. If relapse occurs, encourage the patient to try again immediately. 3. Consider signing a contract with the patient to stop smoking, drinking, or using drugs. 4. Assess potential for suicide with every office visit. 5. If possible, obtain confirmation of the patient's abstinence from a family member. 6. Stress the importance of 12-step meetings such as Alcoholics Anonymous (AA), Cocaine Anonymous (CA), and Narcotics Anonymous (NA). 7. Have the patient sign a written release of information so that you can speak with a rehabilitation counselor. If the patient is willing, refer to an alcohol and drug treatment facility or smoking-cessation program, after initial assessment and differential diagnosis is made. 8. Treat physical/laboratory findings as indicated. 9. Identify potential withdrawal symptoms from the cessation of stimulants, such as caffeine intake reduction, alcohol, and drug use. 10. If malnourished, discuss dietary needs and treatment. B. Patient teaching; See Section III: Patient Teaching Guide for this chapter, “Alcohol and Drug Dependence. ” 1. Educate the patient about the impact of alcohol, tobacco, and drugs on physical/emotional health. Provide information for the patient to read at home. C. Pharmaceutical therapy 1. Consider nicotine replacement for those who smoke more than one pack of cigarettes per day or who smoke their first cigarette within 30 minutes of waking. Stress that there is no smoking while using the nicotine patch. The FDA has changed this warning www. fda. gov/For Consumers/Consumer Updates/ucm345087. htm 2. Nicoderm (dosing based on more than 10 cigarettes/d habit) a. 21 mg/q D for 6 weeks (14 mg q D × 6 weeks for less than 10 cigarettes/d) then b. 14 mg/q D for 2 weeks (7 mg q D × 6 weeks for less than 10 cigarettes/d) then c. 7 mg/q D for 2 weeks (only for more than 10 cigarettes/d habit) 3. Nonnicotine therapy: Adults—Bupropion (Zyban, Wellbutrin) 150 85 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
extended release (ER) mg daily for 3 days, then increase to 150 mg ER twice daily. Treat for 7 to 12 weeks. The patient may continue to smoke during the first 2 weeks of starting medication. This medication should not be given to patients with seizure disorders. 4. Varenicline (Chantix): Start at 0. 5 mg/d for the first 3 days, then for the next 4 days, 0. 5 mg twice daily. After the first 7 days the dose is 1 mg twice daily × 11 weeks. a. Encourage the patient to choose a stop date for smoking and start the Chantix 1 to 2 weeks before this stop date. b. Patients should be encouraged to quit even if they have relapses. c. Instruct patients that the most common side effects of Chantix are insomnia, vivid or strange dreams, and nausea. Advise that side effects are usually transient. d. Warn the patient regarding potential side effects of mood swings, aggression, homicidal thoughts, psychosis, anxiety, and panic disorder, which may occur on rare occasions. e. See package inserts or the Physicians' Desk Reference for detailed instructions. 5. Detoxification and methadone maintenance: Should be performed by specially licensed and trained professionals. 6. Disulfiram (Antabuse) therapy is not recommended. Patients who consume alcohol after taking Antabuse can become extremely ill. 7. Refer the patient to a physician or specialist if the patient is experiencing withdrawal; consider admission to rehabilitation center for detoxification and treatment. Follow-Up A. Make a follow-up appointment weekly. Make contact with the referral source (smoking cessation program, alcohol/drug rehabilitation program) before the next follow-up visit to check on the patient's progress. At the weekly visit, question the patient regarding compliance. B. Order blood alcohol, urine drug screen, or nicotine level (as appropriate) with every office visit while in outpatient treatment and throughout the year following treatment. C. Once positive change is seen, the patient can be seen monthly. Discuss changes the patient has made, past relapses, circumstances under which they 86 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
occurred, and any special concerns. D. Refer to the medical diagnosis for other applicable follow-up recommendations. Consultation/Referral A. Refer patients with drug and/or alcohol dependence to a community mental health center that has an outpatient alcohol/drug rehabilitation program or to a specialist in the community who deals frequently with substance abuse/dependence. B. Planning a family meeting to confront the patient is best done with the help of an experienced mental health professional. C. Have referral numbers at close hand, so that the patient's moment of motivation is not lost. Individual Considerations A. Pregnancy 1. Substance-dependent pregnant women frequently avoid early prenatal care for fear of identification and reprisal. 2. Cocaine use is associated with abruptio placenta and preterm labor. Consider drug screen for emergent admissions for patients in preterm labor and abruption. 3. Notify the hospital nursery personnel/neonatologist before delivery to closely monitor the newborn for withdrawal and seizure precautions. 4. Nicotine/smoking use is associated with intrauterine growth restriction, preterm delivery, and bleeding in pregnancy. 5. Nicotine-dependent pregnant women should be encouraged to stop smoking without pharmacological treatment. The nicotine patch should be used during pregnancy only if the increased likelihood of smoking cessation, with its potential benefits, outweighs the risk of nicotine replacement and potential concomitant smoking. Similar factors should be considered in lactating women. 6. Pregnant women who use alcohol, tobacco, or drugs should always be classified as substance dependent rather than substance abusive. B. Pediatrics 1. Infants of smokers have increased risk of sudden infant death syndrome (SIDS). 87 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2. The diagnosis of substance dependence is more difficult to make in children younger than 18 years. If there is any indication of substance dependence, children should be referred to a pediatrician who deals specifically with this problem. 3. Consider drug use when alienation of friends and family, falling grades, and isolation occur. 4. “Huffing” is common with gasoline, glues, aerosol sprays, and spray paints. 5. The use of synthetic cannabinoid products is on the rise in the adolescent population. K2, Spice, and bath salts and others are available in tobacco stores, gas stations, over the Internet, and in other small shops. These products can be very harmful. They are not detected on routine toxicology drug screens. Be aware of illicit drug use if patients present with change in behavior, depression, paranoid delusion, and aggressive behaviors. Educate the patient and family regarding the toxic use of these OTC substances. Stress to the patient that these are abusive substances that can potentially be fatal. Stress cessation of use and refer to specialist. C. Adults 1. With women, tolerance can be established by asking the question, “How many drinks does it take to make you high?” More than two drinks indicates some tolerance. 2. In considering a diagnosis of alcohol dependence, consider the following diagnostic findings: Hypertension; nonspecific EKG changes; cardiomyopathy; palpitations; increased mean cell volume; decreased red blood cell count; low platelet count; increased alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactic dehydrogenase, gamma-glutamyl transpeptidase, alkaline phosphatase; type IV hyperlipoproteinemia; gout; and adult-onset diabetes mellitus. D. Geriatrics 1. In this population, consumption of as little as 1 oz/d can indicate a problem. 2. Pain medications and benzodiazepines, along with multiple medications for health problems, may create a substance abuse problem. E. Partners/family members 1. For fear of retribution, the family may remain silent about the problem, even if accompanying the patient to the health care visit. 88 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2. Some studies by corporate business show that, per capita, business spends more money on the care of family members of substance-dependent patients than on the employee. 3. Refer family members of alcoholics/drug addicts to Al-Anon, Nar-Anon, Co-dependents Anonymous, or Adult Children of Alcoholics (ACOA) meetings. Resources American Society of Metabolic and Bariatric Surgery: www. info@asmbs. org National Institute on Drug Abuse (NIDA): www. drugabuse. gov; NIDA for Teens: https://teens. drugabuse. gov Substance Abuse and Mental Health Services Administration (SAMSHA): http://www. samsha. gov References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed. ). Washington, DC: American Psychiatric Press. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed. ). Arlington, VA: American Psychiatric Publishing. Violence Moya Cook and Robertson Nash Children Definition The definitions of sexual abuse, childhood abuse, and the age of children included in statistics changes with each state in the United States. Any family member, friend, or stranger can perpetrate abuse; however, fathers, mothers' boyfriends, female babysitters, and mothers are the most common perpetrators of abuse. Nonaccidental injury/abuse may result in serious physical or emotional harm and may result in failure to thrive (FTT), delayed developmental progress, or death. A. Physical abuse: Infliction of pain/harm producing injuries, including skeletal fractures, skin (i. e., burns), and CNS injuries (i. e., abusive head trauma [AHT] and shaken baby syndrome [SBS]/shaking-impact syndrome) B. Sexual abuse: Inappropriate exposure; fondling; sexual stimulation; 89 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
coercion; oral, genital, buttock, breast contact; anal or vaginal penetration; foreign-body insertion; and making use of child pornography C. Emotional abuse: Rejection, lack of affection or stimulation, ignoring, dominating, intimidating, describing the child negatively, blaming the child, and verbal abuse (belittle, yell, threats of severe punishment) abuse, resulting in impaired psychological growth and development D. Child neglect: Isolation; starvation; lack of medical care; inadequate supervision; failure to provide love, affection, and emotional support; and failure to enroll/attend school Incidence A. Childhood abuse occurs worldwide; the exact incidence is not known. It occurs across all cultures and at all racial, socioeconomic, and educational levels. B. Approximately one million cases of child abuse and/or neglect are reported annually by child protective services (CPS). C. Sexual abuse is underreported, underrecognized, and undertreated. D. Approximately one in six boys is sexually abused before the age of 16 years. E. Greater than 15 million children live with families in which partner violence occurs at least once a year. Seven million children live in families in which severe partner violence occurs. Witnessing domestic violence is associated with experiencing physical abuse and witnessing physical abuse of a sibling. Pathogenesis A. Society, lack of parenting skills, the home environment substance abuse, and untreated mental illness are all factors that contribute to abuse. Predisposing Factors A. Child victims 1. Minority children 2. Disabled or medically fragile children a. Congenital anomalies b. Mental retardation c. Handicapped 90 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
d. Chronic medical illness e. Hyperactive f. Adopted children/stepchildren g. Poor bonding 3. Age of children (physical abuse) a. Younger than 1 year (67%) b. Children younger than 3 years (80%) B. Parental factors 1. Young or single parents 2. Distant or absent extended family 3. Low educational level of parents 4. Few role boundaries 5. Acute or chronic instability and stress in the family a. Loss of employment b. Divorce/death c. Drug/alcohol abuse d. Parents with a history of abuse/neglect as a child (learned behavior) e. Presence of psychiatric illness f. Poverty g. Criminal history C. Sexual abuse risk factors 1. Male a. Younger than 13 years b. Non-White c. Low socioeconomic status d. Not living with the biological father e. Disabled 2. Female a. Young age between 7 and 14 years b. Absence of a parent c. Appearance of isolation, depression, or loneliness Common Complaints A. Oral/facial injuries 1. Oropharyngeal sexually transmitted infections: Sexual abuse 2. Black eyes 91 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
3. Nasal perforation/septal deviation 4. Skull fracture 5. Traumatic alopecia 6. Retinal hemorrhage 7. Hearing loss/tympanic injury B. Burns (6%-20% of injuries) 1. Cigarette burns (pathognomonic for child abuse) 2. Scalding/immersion 3. Caustic exposure 4. Branding 5. Microwave burns 6. Stun-gun burns C. Fractures (second most common injury) D. Bruises (most common type of injury) E. Lacerations F. Bites G. Force feeding “bottle jamming”/forced ingestion (water, salt, pepper, poisons) H. Starvation I. Sexual abuse 1. Difficulty with bowel movements 2. Urinary tract infections 3. Vaginal infections, itching, or discharge 4. Complains of stomachaches 5. Headaches 6. Vaginal or rectal bleeding 7. Difficulty walking or sitting J. Behavioral signs 1. Loss of appetite/eating disorder 2. Clinging, withdrawn, or aggressive 3. Nightmares, disturbed sleep pattern, and fear of the dark 4. Regression (i. e., bedwetting, thumb sucking, crying) 5. Poor grades/school attendance 6. Expression of interest or affection inappropriate for the child's age 7. Intercourse or masturbation or other sexual acting out 8. Self-injurious behavior (i. e., cutting, biting, pulling out hair) 92 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Other Signs and Symptoms A. A caregiver's refusal to allow an interview of the child alone in the examination room is considered a “red flag” for abuse. B. The history is inconsistent, changes with repeated questioning, conflicts with other family members/caregivers who are interviewed, is implausible, or there is a total lack of history (i. e., “I don't know how it happened”). C. History is inconsistent with the child's developmental ability/stage. D. Caregiver behaviors that may indicate abuse include delay in seeking care, argumentativeness, lack of emotional response, inappropriateness, or violence. E. Radiographs should be obtained for a history of “soft,” easily broken bones. F. The child exhibits inappropriate behavior for his or her developmental age. Subjective Data A. Use open-ended questions during the history to evaluate how injuries were sustained. As the interview continues, ask specific questions related to responses. If the child can talk, direct questions to him or her before the caregiver. B. If this is the first clinic visit, ask whether the child had routine health care, including immunizations. Physical Examination The physical examination should be performed with the child totally unclothed; however, clothing can be removed as the physical progresses from head to toe (i. e., upper body, torso, lower body, lastly perineum/rectum). Detailed documentation of history is essential. A. Check blood pressure, pulse, and respirations, and temperature if indicated. B. A forensic examination requires thorough documentation of injuries. 1. Use color photographs before any treatment is started. 2. Photograph damaged clothing. 3. Take at least one full-body photograph and a facial photograph. 4. Take close-up photographs of all injuries. 93 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
5. Use a ruler to identify/document the size of injuries. 6. Documentation on the back of the photographs should include the patient's name, date, photographer's name, as well as any witnesses to the examination. The photographer should also sign each photograph. C. General observation 1. Observe the interactions between the caregiver and the child. Is the child fearful or reluctant to have the examination? Are there signs of discomfort during the examination with movement such as range of motion (ROM)? 2. Evaluate the child's overall appearance: Is the child clean and are his or her clothes appropriate for the season? Observe for poor hygiene, body odor, malnourishment, dehydration, depression, violence, withdrawn, behavioral compliance even during a painful examination of the rectum/genitalia, and level of consciousness. 3. Dermal examination: Evaluate from head to toe, including the palms, soles of the feet, and between toes; observe for injuries in different stages of healing and new trauma, including burns, lesions, swelling, bruises, and signs of pinching. Evaluate the corner of the mouth for signs of being gagged. Examine the head for alopecia from hair pulling. Evaluate bruises and burns for the characteristics of shapes (i. e., iron, handprints, long belt marks, loops, bite marks, ligature marks). 4. Eye examination: Observe for retinal hemorrhages, black eyes, periorbital edema, and papilledema (indicates increased intracranial pressure). 5. Ear examination: Evaluate hearing, hemotympanum or possible laceration to the external canal, and insertion of foreign objects. 6. Nasal examination: Evaluate the presence of blood, swelling, and foreign objects. 7. Mouth and throat: Evaluate the presence of caustic ingestion; observe for ligature marks and cry/voice quality. D. Auscultate 1. Heart 2. Lungs 3. Abdomen in all four quadrants 4. Over the globes of the eyes if warranted (bruit may indicate traumatic carotid cavernous fistula) 94 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
5. The carotid arteries bilaterally if warranted (bruit may indicate carotid dissection) E. Palpate 1. Examine for facial fractures; palpate for instability of the facial bones, including the zygomatic arch. 2. Palpate abdomen in all four quadrants for guarding, tenderness, and masses (hematoma). 3. Examine for any trauma to the spine. F. Neurologic examination 1. Assess mental status and memory: Determine whether the patient is awake, alert, cooperative, and oriented (to person, place, time, and situation). Temporary impairment of memory is one of the most common deficits after a head injury. 2. Assess cranial nerve function. a. Opthalmoscopic/visual examination (cranial nerve II) b. Pupillary response (cranial nerve III) c. Extraocular movements (cranial nerves III, IV, VI) d. Facial sensation and muscles of mastication (cranial nerve V) e. Facial expression and taste (cranial nerve VII) 3. Perform a motor examination on all four extremities. 4. Perform a sensory examination on all four extremities. G. Genital/rectal examination 1. Evaluate genitals/anal area for redness, swelling, bruising, hematomas, abrasions, or lacerations. 2. Evaluate for evidence of sperm. 3. Evaluate for presence of condyloma. 4. Evaluate for presence of foreign bodies. Diagnostic Tests Diagnostic tests and x-rays are ordered dependent on the type of presenting complaints and physical examination. A. Complete blood count (CBC) with differential and peripheral smear; bleeding evaluation, including prothrombin time/partial thromboplastin time (PT/PTT), alanine aminotransferase (ALT), and aspartate aminotransferase (AST), to evaluate injury to the liver, serum amylase, or lipase to rule out pancreatic injury 95 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
B. Urinalysis C. Drug screen/toxicology (urine and serum) D. Obtain forensic DNA samples from the skin, under nails, vagina, rectum, and saliva from bite marks using sterile cotton-tipped applicators that have been moistened with sterile saline. These should be sent to a crime laboratory as soon as possible. E. Test for sexually transmitted infections/HIV. F. Pregnancy test (age appropriate) G. Radiographs: Facial injury, anteroposterior (AP) and lateral radiograph for any areas of bone tenderness, swelling, deformity, or limited ROM H. Neuroimaging CT/MRI for any suspected nonaccidental head injury (i. e., head trauma, history of shaking, and scalp hematoma) Differential Diagnoses A. Child abuse (physical, sexual, emotional, and/or neglect) B. Congenital syphilis C. Rickets D. Osteogenesis imperfecta (OI) E. Mongolian spots F. Impetigo G. Dermatitis herpetiformis H. Folk-healing practices I. Immune thrombocytopenia (ITP) J. Malignancy K. Meningitis: Neurologic signs Plan A. General interventions 1. Each state may have a requirement for parental permission before taking any photographs. B. Safety planning is the first priority. Contact (states differ on reporting). C. Increase public awareness. D. Failure to report a suspected case of sexual abuse may incur criminal charges. Patient Teaching 96 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Reinforce that abuse/neglect is not the victim's fault. B. Help is available. Pharmaceutical Therapy A. Prescribe antibiotics to treat sexually transmitted infections or wounds. B. Antidepressant therapy may be appropriate. Follow-Up A. Each state mandates reporting of child abuse. Refer to your state requirements or laws. CPS is responsible for investigations. Depending on your locality, police involvement may be mandatory. The Child Abuse Prevention Services (CAPS) website lists individual state abuse hotlines: www. capsli. org/reporting-abuse/individual-state-hotlines B. Hospitalization may be required, depending on physical findings, child safety, and parental observation. C. Child victims are at high risk of depression, anxiety, eating disorders, discipline problems, drug/alcohol use, runaway tendencies, and low self-esteem. Therapy and follow-up vary for each individual child. Family participation in a recommended treatment program is helpful. The goal of treatment is to help the child regain his or her prior state of mental and psychological health. Neglect is the major reason that children are removed from a home, especially when the parents have drug/alcohol problems. Consultation/Referral A. Consult with other health care providers who have greater experience with abuse (i. e., CPS, physician, psychiatrist or psychologist, social worker). B. Refer for a nurse in-home assessment if available/indicated. C. Specialty consultations 1. Genetic consultation: OI 2. Orthopedic consultation 3. Plastic surgeon 4. Child psychiatrist 5. Ophthalmology Resources Childhelp Prevention and Treatment of Child Abuse: www. childhelp. org 97 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
National Child Abuse Hotline: 1-800-422-4453 Rape, Abuse & Incest National Network (RAINN): 1-800-656-HOPE Stop It Now:1-888-PREVENT (1-888-773-8368) Intimate Partner Violence Definition A. Intimate partner violence (IPV) is defined as intentional control or victimization of a person with whom the abuser has had or is currently in an intimate, romantic, or spousal relationship. Domestic IPV crosses all cultures and economic boundaries; it encompasses violence between both genders, including gay and lesbian relationships. Abusive behaviors can occur in a single event, sporadically, or continually. The following is a list of the many forms through which IPV may manifest itself: B. Physical abuse, sexual assault, coercion, social isolation, emotional abuse, economic control, and deprivation are associated with IPV. There is no typical abuser, although all abusers tend to be violent in the home setting and their behavior at work is normal. C. Forms of physical violence include threatening or assaulting with weapons, pushing, shoving, slapping, punching, choking, kicking, holding, throwing objects, and binding. D. Psychological abuse includes threats of physical harm to the victim or others, humiliations, intimidation, degradation, ridicule, false accusation, isolation, and deprivation of food, money, access to health care, and transportation. E. Psychological abuse in lesbian, gay, bisexual, and transgender (LGBT) relationships includes the threat to “out” their partner as well as threats related to custody of coparent children. F. Cyberstalking is psychological abuse via the Internet or texting. Intimate partner stalking can occur during a relationship or after the relationship ends. 1. Monitoring cell phone and Internet activity 2. Posting photographs or other types of humiliation on social media G. Sexual abuse is nonconsensual (unwanted kissing or touching) or painful sexual acts. H. Reproductive coercion is another form of IPV. 1. Partner sabotage of safe-sex practices (i. e., refusal to use condoms, 98 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
exposing the patient to sexually transmitted infections) 2. Refusal/control of contraception 3. Forcing the woman to have an abortion, or utilizing physical violence to endanger a pregnancy 4. Controlling access to health care Incidence The exact incidence of IPV is unknown because of the lack of reporting. The United Nations estimates that more than 600 million women live in countries where domestic violence is not considered a crime. The most significant reason for missing the diagnosis of IPV is failure to ask the patient. A. Domestic violence is the leading cause of homicide in women globally. B. Up to 75% of domestic assaults occur after separation; women are most likely to be murdered when reporting abuse or attempting to leave an abusive relationship. C. An estimated 81% of women stalked by an intimate partner also suffer physical assault. Stalking by an intimate partner is estimated at 1 million women and 317,000 men per year. D. An estimated 4% to 15% of women presenting in emergency rooms have situations related to domestic violence. E. Women who separate have a risk of violence approximately three times that of divorced women. 1. More than half of the children who witness domestic violence intervene in some way, including yelling to the abuser to stop, calling for help, and trying to get away. F. The incidence of abused men is estimated as one in three. Men are also victims of attempted or complete rape, at approximately 3% during their lifetime. G. Pregnancy has an increased incidence of violence. 1. One in five young women and 35% of women overall have experienced pregnancy coercion. 99 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2. 53% of young women have experienced birth control sabotage. 3. It is estimated that 5% to 20% of intimate partner abuse occurs against pregnant women. H. Sexual violence, rape, physical assault, or stalking by an intimate partner occurs in 11% of lesbians and in 15% of men with male partners. I. Among college women, 20% to 30% report violence during a date. J. Physical, emotional, or verbal abuse is estimated in one in three adolescent girls from a dating partner in the United States. 1. The tween population (ages 11 to 14 years) reports that half of their friends have experienced dating violence. 2. Tween population reports that their friends are victims of verbal abuse. 3. Teen victims are more likely to smoke, use drugs, and have other risky behaviors. K. Women in the military are recognized as a vulnerable population susceptible to abuse because of geographical location away from family and friends and the social isolation within the military culture. 1. In 2012, the Department of Defense (Do D) estimated that 26,000 instances of unwanted sexual contact occurred in the U. S. military. a. Only 2,949 (approximately 7%) were reported. 2. One in three convicted military sex offenders remain in the military. 3. The highest rates of abuse occur in the Army, followed by the Marines and then the Navy; the Air Force has the lowest rate of abuse of the branches of the service. Pathogenesis Intrapartner violence is not associated with an underlying medical condition. The cycle of abuse has three phases. A. Tension building, in which the victim tries to avoid violence and is described as “walking on eggs,” unsure what will trigger an abusive incident B. Explosion and acute battering occur C. “Honeymoon phase,” noted for the absence of tension and reconciliation D. Victims stay with their partners for multiple reasons, including fear, shame, denial, religious reasons, lack of resources, custody issues and other legal issues, fear of being “outed,” and family pressures. Predisposing Factors 100 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Gender: Victims are predominantly female. B. Race: African American, American Indians, Hispanic women, and Alaskan Natives C. Higher incidence in interracial couples D. Pregnancy E. History of violence 1. Violence present in family of origin 2. Abuse as a child:50% report abuse as an adult F. History of drug use G. Posttraumatic stress disorder (PTSD) H. Lack of social support systems I. Impulse control disorders J. Poor economic status K. Lesbian, gay, bisexual, and transgender (LGBT) Common Complaints A. Vague complaints B. Sexual problems C. Depression D. Chronic pain inconsistent with organic disease E. Chronic headaches/migraines F. Stress 1. Anxiety 2. Panic attacks G. Alcohol or drug abuse (the batterer, victim, or both) H. Current or past self-mutilation I. Gynecologic and obstetric complaints 1. Dyspareunia 2. Frequent vaginal or urinary tract infections 3. Pelvic pain/infection 4. Recurrent sexually transmitted infections 5. Unintended pregnancy 6. Late prenatal care 7. Miscarriage 8. Preterm bleeding/delivery J. Complaints of falls and other recurrent accidents 101 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
K. Eating disorders L. Gastrointestinal complaints/irritable bowel syndrome M. Musculoskeletal complaints Other Signs and Symptoms A. Multiple prior visits to the emergency room for traumatic and nontraumatic complaints B. A delay between injury and office visits (may result from lack of transportation or the inability to leave the house) C. Noncompliance with the treatment or missed appointments (lack of access to money or telephones) D. Suicide attempt (25% higher in women with IPV) E. A partner who accompanies the patient at all visits Subjective Data The “gold standard” research method to document the prevalence of women's exposure to violence includes conducting the interview one on one, in private, and asking specific direct questions. A. The batterer often refuses to leave the patient alone and may answer questions for the patient. Translators should not be a member of the patient's or suspected abuser's family. B. Use direct questions: Women-validated Partner Violence Screen (PVS). 1. Have you been hit, punched, kicked, or otherwise hurt by someone in the past year? If yes, by whom and were you injured? 2. Do you feel safe in your current relationship? 3. Is a partner from a previous relationship making you feel unsafe now? 4. Are you here today because of injuries from a partner? 5. Are you here today because of illness or stress related to threats, violent behavior, or fears of a partner? C. Assess whether the patient has ever told family or friends, called hotlines, or attempted to leave the abuser. D. Has the patient sought help with law enforcement or legal help, that is, filed a criminal complaint or got an order of protection? E. Are there any weapons in the home? 1. Has the abuser ever threatened or tried to kill you? 2. Are you thinking of suicide? Have you ever considered or attempted to 102 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
commit suicide because of problems in your relationship? 3. Have you ever considered or attempted killing your batterer? 4. Do you have a plan? Physical Examination A. Enforce the need to interview and conduct physical examinations in private. Do a full-body examination, including the head/scalp. 1. Most injuries are to the central (breast, chest, and abdomen) area, which is easily concealed by clothing. 2. Other frequent sites of injury include the head, face, throat, and genitals. 3. Explain the physical examination and touch with permission. 4. Forensic examinations need thorough documentation of injuries. a. Use color photographs before any treatment is started. b. Photograph damaged clothing. c. Take at least one full-body photograph and a facial photograph. d. Take close-up photographs of all injuries. e. Use a ruler to identify/document the size of injuries. f. Documentation on the back of the photographs should include the patient's name, date, and photographer's name, as well as any witnesses to the examination. The photographer should also sign each photograph. g. Use direct quotes of the patient's history of the violence. B. Check blood pressure, pulse, and respirations. C. General observation: Observe for depression/withdrawn, or flat affect, anxiousness, fearfulness, evasiveness, poor eye contact, and wearing heavy makeup or clothing to conceal signs of abuse. Evaluate voice changes: Dysphonia and aphonia. Observe for difficulty breathing. D. Inspect 1. Dermal examination for the presence of cigarette burns, impression marks, rope burns, welts, abrasions, scratch marks, claw marks, bite marks, ligature marks, petechiae, and contusions at multiple sites (e. g., back, legs, buttocks). 2. Eye examination a. Observe subconjunctival hemorrhages from strangulation/struggle. b. Perform a funduscopic examination (if indicated secondary to 103 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
trauma). 3. Evaluate the genitals for lacerations and hematomas of the vagina or labia. E. Auscultate 1. All lung fields. 2. The bowel sounds in all four quadrants of the abdomen. F. Palpate 1. Evaluate skull/facial trauma to the maxillofacial area, eye orbits, mandible, and nasal bones. Facial injuries are reported in 94% of victims. 2. Evaluate for dislocations, fractures (including spiral fractures), sprains, and contusions to the wrists and forearms, and shoulders. G. Percuss abdomen, chest, and areas of injury (if indicated secondary to trauma). H. Perform a neurologic examination (if indicated secondary to trauma). I. Genital/rectal examination 1. Evaluate genitals/anus area for redness, swelling, bruising, hematomas, abrasions, or lacerations. 2. Perform bimanual examination (females). 3. Order an anoscopy (if indicated). 4. Evaluate for evidence of sperm (recto/vaginal). 5. Evaluate for the presence of condyloma (perineum, rectum, vagina). 6. Evaluate for the presence of foreign bodies (recto/vaginal). Diagnostic Tests Diagnostic tests and x-rays are ordered dependent on the type of presenting complaints and physical examination. A. Administer a domestic abuse assessment screening tool and have the victim mark a body map of injuries (see Figure 2. 4). B. CBC with differential and peripheral smear, bleeding evaluation, including PT/PTT, ALT, and AST, to evaluate injury to the liver, serum amylase, or lipase to rule out pancreatic injury. C. Urinalysis D. Drug/toxicology screen (urine and blood) E. Obtain forensic DNA samples from the skin, under nails, vagina, rectum, and saliva from bite marks using sterile cotton-tipped applicators that have been moistened with sterile saline. These should be sent to a crime laboratory 104 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
as soon as possible. F. Test for sexually transmitted infections/HIV. G. Pregnancy test (if indicated) H. Radiographs: Facial injury, AP, and lateral radiograph for any areas of bone tenderness, swelling, deformity, or limited ROM I. Ultrasounds as indicated J. Neuroimaging CT/MRI may be used for any suspected nonaccidental head injury (i. e., head trauma, or scalp hematoma) Differential Diagnoses A. Domestic violence 1. Intimate partner abuse 2. Elder abuse 3. Child abuse B. Rape C. Other: Related to presenting symptoms 105 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
FIGURE 2. 4 Abuse assessment screening tool with body map. Source: Reprinted with permission from Futures Without Violence: www. futureswithoutviolence. org Plan A. Provide a safe environment. Assess for immediate danger. B. Clearly document the history, physical findings, and interventions. C. Determine the risk to the victim and any children. D. Evaluate the need for emergency room/hospital admission. E. Battery is a crime; assess the victim's readiness for police intervention and need for a court order of protection. F. Help develop a safety plan. G. Assess readiness to leave: Signs include collection important papers (e. g., 106 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
birth certificates, custody papers, divorce papers, and legal agreements, address book, copies of restraining orders), access to money/credit cards, and telling family and friends. H. Provide contact numbers for shelters. Have the patient hide information in her shoes. I. Counsel that violence may escalate. Patient Teaching A. Reinforce that the violence is not the victim's fault. IPV is very common and the victims do not deserve to be abused. Discuss the cycle of abuse. B. Violence increases in frequency and severity. C. Help is available. D. The Do D has a self-help phone app created by the Rape, Abuse, & Incest National Network (RAINN) for sexual assault survivors to create a customized self-care plan. This app is available through the i Tunes store. The app is a resource for Active Duty, National Guard, and Reserve service members. Pharmaceutical Therapy A. Prescriptions are related to physical injuries. B. Provide treatment may be offered for sexually transmitted infections in the oral anal genital areas. C. Tranquilizers may impair the victim's ability to flee or defend herself/himself and should not be prescribed. Follow-Up A. Develop a follow-up plan. 1. What type of help does the patient want? 2. Does the patient have a plan for returning? Is the batterer home? Does she think it is safe? 3. Does she have a place to stay with family or friends; or does she want to go to a shelter? 4. Give the telephone numbers for shelters and crises hotlines. B. Screen the patient for abuse at all subsequent visits. C. Mandatory reporting 1. States require reporting when domestic violence involves a child 107 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
younger than 18 years and abuse or neglect of the child is suspected. 2. Abuse of a disabled person must be reported to the Disabled Persons Protection Commission. 3. Reporting elder abuse may be mandatory in your state. D. Your state may mandate reporting and intervention with law enforcement. Refer to the Domestic Violence, Sexual Assault, and Stalking Data Resource Center. www. jrsa. org/dvsa-drc/st-summary. shtml E. The 2013 National Protocol for Sexual Assault Medical Forensic Examination for Adults and Adolescents is available at https://ncjrs. gov/pdffiles1/ovw/241903. pdf Consultation/Referral A. Facilitate referrals to a shelter, counseling, and legal services. B. Contact a Sexual Assault Nurse Examiner (SANE)-qualified health care provider if indicated. C. Refer to community or private support groups and agencies. D. Refer for a consultation with a psychiatrist if the victim is homicidal or suicidal. E. Refer for a neurologic or neurosurgical consultation for intracranial injuries or focal neurologic findings. F. Refer for an orthopedic consultation for fractures. Individual Considerations A. Pregnancy is a known period of increased risk of violence. 1. The genitals, breast, and abdomen are common sites targeted for trauma. 2. Women may present with a miscarriage or premature labor. 3. Blunt trauma is a common injury in pregnancy. 4. Perform universal screening at each trimester and postpartum as abuse often begins during pregnancy. Resources Dating Abuse Stops Here: www. datingabusestopshere. com Domestic Violence, Sexual Assault and Stalking Data Resource Center: http://www. jrsa. org/dvsa-drc/st-summary. shtml Futures Without Violence ( Formerly Family Violence Prevention Fund): www. futureswithoutviolence. org 108 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
National Domestic Violence Hotline: 1-800-799-7233 National TEEN Dating Abuse Helpline: 1-866-311-9474 Rape Abuse & Incest National Network (RAINN) Hotline: 1-800-656-4673: www. domesticviolence. org Older Adults Definition Abuse in older individuals, defined as older than age 65, is associated with loss of functional capacity, depression, cognitive impairment, and increased morbidity and mortality. Perpetrators include partners, and family members (of all ages), as well as strangers. There are several types of maltreatment in this population. A. Physical abuse: Willful unnecessary restraint, the infliction of physical pain, or injury B. Sexual abuse: Nonconsensual sexual contact C. Psychological abuse: Infliction of emotional harm, bullying, ridicule, verbal abuse, and terrorizing D. Neglect: Failing to provide for needs and protection of a vulnerable adult E. Self-neglect: FTT of the elder as a subset of neglect F. Abandonment: Desertion G. Financial exploitation: Misappropriation of resources H. Health care fraud and abuse: Not providing care, but charging for services, overmedicating or undermedicating Incidence A. In 2011, the population of those aged 65 years and older was estimated to be 41. 4 million. It is estimated that one in every eight people in the United States is an older person (65+ years). By 2040, the population of 85+ years is projected to be 14. 1 million. B. The exact incidence of elder abuse, neglect, exploitation, and self-neglect is unknown; however, it is believed to be common. The incidence is underreported because of the reluctance to report abuse, fear of implicating family members, and fear of being removed from the home. C. Abuse is not uncommon in the institutional setting. D. The highest rate of abuse is among elderly women older than age 80, with the abuser being the spouse or adult child. In the case of cognitive 109 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
impairment, the victim may not remember or recognize abuse. Pathogenesis Maltreatment of vulnerable adults occurs by people who have an ongoing relationship with the older person when there is an expectation of responsibility: these include sons/daughters, spouses/intimate partners, other family members such as grandchildren, and others, including paid and unpaid caregivers. There have been several identifying psychopathologies in the abuser. A. Physical frailty and mental impairment of the victim plays an indirect role. The victim may have a decreased ability to defend or escape. B. Caregiver stressors from caring for the elderly patient, including the patient's physical and verbal demands. Psychosocial factors of the caregiver, mental illness, and alcohol or drug abuse contribute. C. The child who was once abused may continue the cycle of violence transferred to the parent. Predisposing Factors A. Age: 65 years and older (some studies indicate age 60 years) B. Institutionalized C. Cognitive impairment/diminished capacity D. Decreased capacity for performing activities of daily living (ADLs) 1. Difficulty feeding themselves 2. Difficulty bathing and dressing themselves 3. Difficulty going to the toilet and performing personal hygiene E. Decreased capacity performing instrumental activities of daily living (IADLs) 1. Ability to prepare meals 2. Ability to do household chores 3. Ability to use the telephone 4. Ability to manage personal finances F. Females have a higher incidence of physical/sexual abuse. G. Male gender is associated with self-neglect associated with impaired ADLs and IADLs. H. Family stressors involving the caretaker 110 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Common Complaints A. Depression B. Falls C. History of hip fracture D. Pressure ulcers E. Bruises, lacerations, and burns Other Signs and Symptoms A. Indications of healing spiral fractures on x-ray B. Poor nutrition: Lack of resources/transportation to obtain food; caregiver not providing adequate nutrition/withholding food C. Multiple hospitalizations D. Recurrent urinary tract infections E. Noncompliance: May not be able to pay for medications; medications may be withheld, or even given in excess by the caregiver. F. Complaints of sexual abuse 1. Pain or soreness in the genital area 2. Bruises or lacerations on the perineum/rectum 3. Vaginal or rectal bleeding G. Traumatic tooth and/or hair loss H. Sedation from overmedicating I. Changes in personality Subjective Data A. The caregiver often refuses to leave the patient alone and may answer questions for the patient. B. The caregiver has a different explanation of the injury. C. Ask the patient directly about abuse, neglect, or exploitation. 1. Has anyone at home threatened or ever hurt you? 2. Are you afraid of anyone at home? 3. Are you left alone for long periods of time? 4. Who cooks your meals? How often and what amounts of food do you eat? 5. Who handles your financial business? Have you signed any documents that you did not understand? 111 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
D. Assess the patient's living arrangements. Has the patient ever told family or friends of his or her concerns, called hotlines, or attempted to leave the caregiver? Physical Examination A. Assessment 1. Observation: If abuse is suspected, enforce the need to do the physical examination in private. Do a full-body examination. a. Forensic examinations need thorough documentation of injuries. i. Use color photographs before any treatment is started. ii. Take at least one full-body photograph and a facial photograph. iii. Take close-up photographs of all injuries. iv. Use a ruler to identify/document the size of the injuries. v. Documentation on the back of the photographs should include the patient's name, date, and photographer's name, as well as any witness to the examination. The photographer should also sign each photograph. vi. Use direct quotes of the victim's history. 2. Check blood pressure, pulse, respirations, and weight. 3. General observation: Observe for depression, withdrawal demeanor, flat affect, fearfulness, poor eye contact, inappropriate dress, and signs of malnutrition. 4. Observe for poor hygiene, presence of urine and feces, matted or lice-infected hair, odors, dirty nails and skin, and soiled clothing. 5. Assess cognitive abilities, depression, and functional ability of ADLs and IADLs. B. Inspect 1. Dermal examination for signs of burns, tears, lacerations, impression marks, and bruises in different stages of healing. Frequent areas of the body involved are the neck, arms, and/or legs. Evaluate for the presence of decubitus/pressure ulcers. Signs of dehydration include dry fragile skin, dry sore mouth, and mental confusion. 2. Oral examination for poor oral hygiene, absence of dentures, and dry mucous membranes. 3. Evaluate breasts and genitals for lacerations, and hematomas of the 112 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
vagina or labia. C. Auscultate 1. All lung fields 2. Bowel sounds in all four quadrants of the abdomen D. Palpate: Evaluate for dislocation, fractures, sprains, and contusions to the wrists, forearms, and shoulders. E. Percuss abdomen and chest (if indicated). F. Genital/rectal examination 1. Evaluate genitals/anus for redness, swelling, bruising, hematomas, abrasions, or lacerations. 2. Evaluate for evidence of sperm. 3. Evaluate for the presence of foreign bodies. Diagnostic Tests A. Diagnostic tests and x-rays are ordered dependent on the type of presenting complaints. B. Obtain a CT for evaluation of injuries to the head and assault to the face, neck, or head. A CT or Doppler ultrasound may be ordered for abdominal injuries. C. Order laboratory testing to evaluate dehydration, malnutrition, electrolyte imbalance, and medication/substance abuse. 1. CBC 2. Chemistry-7 3. Urinalysis 4. Calcium, magnesium, and phosphorus 5. Drug/alcohol screen 6. Serum levels for relevant medications D. Obtain DNA samples if sexual abuse is present. Differential Diagnoses A. Elder abuse B. Depression C. Abdominal trauma D. Sexual assault E. Gait disturbance/fall F. Pathologic fracture 113 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
G. Epidural/subdural hematoma Plan A. Provide a safe environment. B. Clearly document the history, physical findings, and interventions. C. Determine the perpetrator(s). D. Evaluate the need for emergency room/hospital admission. Patient Teaching A. Reinforce that abuse/neglect is not the victim's fault. Elder abuse is very common. B. Help is available. Pharmaceutical Therapy A. Ensure prescriptions are related to physical injuries. B. Recommend treatment for sexually transmitted infections in the oral anal genital areas. Follow-Up A. Develop a follow-up plan. All states have legislation protecting against abuse, neglect, and exploitation of the older population. B. Know whether your state has mandatory requirements to report any suspicion of elder mistreatment. C. Abuse of a disabled person must be reported to the Disabled Person Protection Commission. D. Know whether your state has additional regulations related to self-neglect. Contact adult protective services or law enforcement agencies. E. At the present time, there is no recommendation for universal screening of all older adult patients except in nursing facilities. Consultation/Referral A. Schedule a social Order a social work consultation to coordinate an in-home geriatric assessment visit. B. Facilitate referrals to a shelter, counseling, and legal services. C. Contact a SANE qualified health care provider if indicated. D. Refer to the community Area Agency on Aging for assistance. 114 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
E. Refer for a psychiatric consultation if indicated. F. Refer for a neurologic or neurosurgical consultation for intracranial injuries or focal neurologic findings. G. Refer for an orthopedic consultation for fractures. Resources American Association of Retired Persons (AARP): www. aarp. org Clearinghouse on Abuse and Neglect of the Elderly (CANE): www. cane. udel. edu Help Hotline for suspected elder abuse, neglect, or exploitation: 1-800-677-1116 National Adult Protective Services Association (NAPSA): www. napsa-now. org National Center on Elder Abuse Administration on Aging (NCEA): www. ncea. aoa. gov Bibliography Administration on Aging Administration for Community Living, U. S. Department of Health and Human Services. (2015). A profile of older Americans:2015. Retrieved from https://aoa. acl. gov/Aging_Statistics/Profile/2015/docs/2015-Profile. pdf American College of Obstetricians and Gynecologists. (2012, February). Intimate partner violence. Committee Opinion, 518, 1-5. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed. ). Arlington, VA: American Psychiatric Publishing. American Society for Metabolic and Bariatric Surgery. (2014). Approved procedures. Retrieved from https://asmbs. org Angstman, K. B., Pietruszewski, P., Rasmussen, N. H., Wilkinson, J. M., & Katzelnick, D. J. (2012). Depression remission after six months of collaborative care management: Role of initial severity of depression in outcome. Mental Health in Family Medicine, 9(2), 99-106. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. Becker, D. A., Balcer, L. J., & Galetta, S. L. (2012). The neurological complications of nutritional deficiency following bariatric surgery. Journal of Obesity, 2012. doi:10. 1155/2012/608534 Cahoo, C. G. (2012). Depression in older adults. American Journal of Nursing, 112 (11),22-31. Centers for Disease Control and Prevention. (2014). Adult obesity facts. Retrieved from https://www. cdc. gov/obesity/data/adult. html Centers for Disease Control and Prevention. (2015). Overweight & obesity. Retrieved from https://www. cdc. gov/obesity/index. html Dating Abuse Stops Here. (n. d. ). Create a safety plan. Retrieved from www. datingabusestopshere. com/create-a-safety-plan/ Dating Abuse Stops Here. (n. d. ). Warning signs in depth. Retrieved from www. datingabusestopshere. com/warning-signs/warning-signs-in-depth Devries, K. M., Mak, J. Y. T., Garcia-Moreno, C., Petzold, M., Child, J. C., Falder, G.,... Watts, C. H. (2013, June 30). The global prevalence of intimate partner violence against women. Sciencexpress. Retrieved from http://www. sciencemag. org/content/early/recent Domestic Abuse Intervention Project. (n. d. ). Abuse of children wheel. Retrieved from www. theduluthmodel. org/pdf/Abuse%20of%20Children. pdf 115 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Domestic Abuse Intervention Project. (n. d. ). Power and control wheel. Retrieved from www. theduluthmodel. org/pdf/powerandcontrol. pdf Domestic Violence, Sexual Assault and Stalking Data Resource Center. (n. d. ). State summaries. Retrieved from http://www. jrsa. org/dvsa-drc/state-summaries. shtml domesticviolence. org. Personalized safety plan-domestic violence. (n. d. ). Retrieved from www. dynamed. com/topics/dmp~AN~T115009/Obesity-in-adults Dyna Med Plus. (2016, March 8). Obesity in adults. Ipswich, MA: EBSCO Information Services. Retrieved from https://www. dynamed. com/topics/dmp~AN~T115009/Obesity-in-adults Ewing, J. A. (1984). Detecting alcoholism. The CAGE questionnaire. The Journal of the American Medical Association, 252(14), 1905-1907. Futures Without Violence, Formerly Family Violence Prevention Fund. (n. d. ). The facts on children's exposure to intimate partner violence. Retrieved from https://www. futureswithoutviolence. org/the-facts-on-childrens-exposure-to-intimate-partner-violence Futures Without Violence, Formerly Family Violence Prevention Fund. (n. d. ). The facts on the military and violence against women. Retrieved from https://www. futureswithoutviolence. org/userfiles/file/Children_and_Families/Military. pdf Giardino, A. P. (2013, April 1). Physical child abuse. Medscape. Retrieved from http://emedicine. medscape. com/article/915664-overview Gupta, A. K. (2016, February 19). Obesity and weight loss (adult). Essentials Evidence Plus. Retrieved from www. essentialevidenceplus. com Handzlik-Orlik, G., Holecki, M., Orlik, B., Wylezol, M., & Dulawa, J. (2015). Nutrition management of the post-bariatric surgery patient. Nutrition in Clinical Practice: Official Publication of the American Society for Parenteral and Enteral Nutrition, 30(3), 383-392. Hamdan, K., Somers, S., & Chand, M. (2011). Management of late postoperative complications of bariatric surgery. British Journal of Surgery, 98(10), 1345-1355. Hardy, S. (2013). Prevention and management of depression in primary care. Nursing Standard (Royal College of Nursing (Great Britain):1987), 27(26), 51-56; quiz 58. Healthy Place America's Mental Health Channel. (n. d. ). Abuse test: Woman abuse screening tool. Retrieved from http://www. healthyplace. com/psychological-tests/woman-abuse-screening-tool Heber, D., Greenway, F. L., Kaplan, L. M., Livingston, E., Salvador, J., & Still, C. ; Endocrine Society. (2010). Endocrine and nutritional management of the post-bariatric surgery patient: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology and Metabolism, 95(11), 4823-4843. Help Guide. org. (n. d. ). Child abuse and neglect: Recognizing, preventing, and reporting child abuse. Retrieved from www. helpguide. org/mental_abuse_physical_emoional_sexual_neglect. htm Help Guide. org. (n. d. ). Domestic violence and abuse: Signs of abuse and abusive relationships. Retrieved from www. helpguide. org/mental/domestic_violence_abuse_types_signs_causes_effects. htm Help Guide. org. (n. d. ). Elder abuse and neglect: Warning signs, risk factors, prevention, help. Retrieved from www. helpguide. org/mental/elder_abuse_physical_emotional_sexual_neglect. htm Help Guide. org. (n. d. ). Help for abused men: Escaping domestic violence by women or domestic partners. Retrieved from www. helpguide. org/mental/domestic-violence-men-abused-by-women. htm Henry, M., Cortes, A., & Morris, S. (2013). The 2013 Annual Homeless Assessment Report (AHAR) to Congress. Washington, DC: U. S. Department of Housing and Urban Development. Jensen, M. D., Ryan, D. H., Donato, K. A., Apovian, C. M., Ard, J. D., Comuzzie A. G.,... Yanovski, S. Z. (2014). Special issue: Guidelines (2013) for managing overweight and obesity in adults. Obesity, 22 (S2), i-xvi, S1-S410. 116 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Kerner, J. (2014). Nutrition support after bariatric surgery. Support Line, 36(3),9-20. Liraglutide. (2016). Retrieved from www. drugs. com/cdi/liraglutide. html Merrill, S. (2009). Introducing syndemics: A critical systems approach to public and community health. San Francisco, CA: Jossey-Bass. Moyer, V. A. ; U. S. Preventive Services Task Force. (2013). Screening for intimate partner violence and abuse of elderly and vulnerable adults: U. S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 158(6), 478-486. National Committee for the Prevention of Elder Abuse. (2008). Elder abuse. Retrieved from www. preventelderabuse. org/elderabuse National Committee for the Prevention of Elder Abuse. (n. d. ). Domestic violence. Retrieved from http://www. preventelderabuse. org/elderabuse/domestic. html National Committee for the Prevention of Elder Abuse. (n. d. ). Financial abuse. Retrieved from http://www. preventelderabuse. org/elderabuse/fin_abuse. html National Committee for the Prevention of Elder Abuse. (n. d. ). Neglect. Retrieved from http://www. preventelderabuse. org/elderabuse/neglect. html National Committee for the Prevention of Elder Abuse. (n. d. ). Physical abuse. Retrieved from http://www. preventelderabuse. org/elderabuse/physical. html National Committee for the Prevention of Elder Abuse. (n. d. ). Psychological abuse. Retrieved from http://www. preventelderabuse. org/elderabuse/psychological. html National Committee for the Prevention of Elder Abuse. (n. d. ). Sexual abuse. Retrieved from http://www. preventelderabuse. org/elderabuse/s_abuse. html National Institute on Drug Abuse. (2011, March). Commonly abused drugs chart. Retrieved from www. drugabuse. gov/drugs-abuse/commonly-abused-drugs/commonly-abused-drugs-chart National Institute on Drug Abuse. (2016, January). Commonly abused prescription drug chart. Retrieved from www. drugabuse. gov/drugs-abuse/commonly-abused-drugs-charts O'Malley, P. A. (2012). Baby boomers and substance abuse: The curse of youth again in old age: Implications for the clinical nurse specialist. Clinical Nurse Specialist, 26(6), 305-307. Pounds, B. P. (2015). Improving primary care provider knowledge regarding malabsorptive nutritional deficiencies after bariatric surgery. Unpublished manuscript, Frontier Nursing University, Hyden, KY. Prevent Child Abuse America. (n. d. ). Fact sheet: Sexual abuse of boys. Retrieved from www. preventchildabuse. org/images/docs/sexualabuseofboys. pdf Prevent Child Abuse America. (n. d. ). Fact sheet: The relationship between parental alcohol or other drug problems and child maltreatment. Retrieved from www. preventchildabuse. org/Images/docs/therelationshipbetweenparentalalcoholandotherdrugproblemsandchildmaltreatment. pdf Prevent Child Abuse America. (2016, February). Fact sheet: Emotional child-abuse. Retrieved from www. preventchildabuse. org/Images/docs/emotionalchildabuse. pdf Prevent Child Abuse America. (2016, February). Fact sheet: Maltreatment of children with disabilities. Retrieved from http://www. preventchildabuse. org/Images/docs/maltreatmentofchildrenwithdisabilities. pdf Prevent Child Abuse America. (2016, February). Fact sheet: Sexual abuse of children. Retrieved from www. preventchildabuse. org/resource/sexual-abuse-of-children-fact-sheet Prevent Child Abuse America. (2016, February). Recognizing child abuse: What parents should know. Retrieved from www. preventchildabuse. org/Images/docs/recognizingchildabuse-whatparentsshouldknow. pdf Rape, Abuse & Incest National Network. (n. d. ). State resources. Retrieved from https://www. rainn. org/state-resources Rape, Abuse & Incest Rational Network. (n. d. ). Victims of sexual violence: Statistics Retrieved from 117 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
http://www. rainn. org/get-information/statistics/sexual-assault-victims Richardson, L., & Puskar, K. (2012, June). Screening assessment for anxiety and depression in primary care. Journal for Nurse Practitioners, 8(6), 475-481. Ross, R., Roller, C., Rusk, T., Martsolf, D., & Draucker, C. (2009). The SATELLITE sexual violence assessment and care guide for perinatal patients. Women's Health Care: A Practical Journal for Nurse Practitioners, 8(11),25-31. Saha, S., Deanne Wilson, J., & Adger, R. J. (2012). K2, spice, and bath salts drugs of abuse commercially available. Contemporary Pediatrics, 29(10),22-28. Shannon, C., Gervasoni, A., & Williams, T. (2013). The bariatric surgery patient-nutrition considerations. Australian Family Physician, 42(8), 547-552. Smith, M. (2013). Care of adolescents who have mental health and substance misuse problems. Mental Health Practice, 1(5), 32-36. U. S. Department of Defense. (2012, September 17). New DOD safe helpline mobile app now available [News release]. Retrieved from www. 115fw. ang. af. mil/shared/media/document/AFD-121013-016. pdf U. S. Department of Health and Human Services, National Institute of Diabetes and Digestive and Kidney Diseases. (2012). Overweight and obesity statistics (NIH Publication No. 04-4158). Retrieved from win. niddk. nih. gov/statistics U. S. Department of Housing and Urban Development. (2011). Homeless emergency assistance and rapid transition to housing. Retrieved from https://www. hudexchange. info/homelessness-assistance/hearth-act U. S. Department of Justice, Office on Violence Against Women. (2013). A national protocol for sexual assault medical forensic examinations: Adults/adolescents (2nd ed. ). Washington, D. C. : Author. Retrieved from https://www. ncjrs. gov/pdffiles1/ovw/241903. pdf U. S. Food and Drug Administration. (2016). Find information about a drug. Retrieved from www. fda. gov/Drugs/Resources For You/Consumers/ucm450624. htm Wendell, A. D. (2013). Overview and epidemiology of substance abuse in pregnancy. Clinical Obstetrics and Gynecology, 56(1),91-96. World Health Organization. (2011). Intimate partner violence during pregnancy. Retrieved from http://apps. who. int/iris/bitstream/10665/70764/1/WHO_RHR_11. 35_eng. pdf World Health Organization. (2013). Gender and women's mental health. Retrieved from www. who. int/mental_health/prevention/genderwomen/en 118 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
3Pain Management Guidelines Acute Pain Moya Cook Definition A. Acute pain is defined as pain of a short, limited duration, usually the result of an injury, surgery, or medical illness that generally results from tissue injury; however, it may be experienced even with no identifiable cause. Acute pain usually resolves when the tissue injury improves with the healing process. Most acute pain resolves in less than 6 weeks. Incidence A. Acute pain is the most common reason for self-medication and presentation for treatment in the health care system. Acute pain is very individual, and if not treated properly it can have devastating physiological and psychological effects. Because pain is very subjective, the patient care plan needs to be individualized to meet the patient's needs. Proper treatment of acute pain could prevent the development of some types of chronic pain syndromes. Pathogenesis A. Acute pain is usually the result of stimulation of the sympathetic nervous system. Common Complaints A. Pain at the specific site B. Increased heart rate 119 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
C. Increased respiratory rate D. Elevated blood pressure (B/P) E. Sweating F. Nausea Other Signs and Symptoms A. Urinary retention B. Dilated pupils C. Pallor Subjective Data A. Elicit location of pain. B. Note effects of pain on activities of daily living (ADLs). C. Note intensity of pain at rest and during activity. D. List precipitating factors. E. Identify alleviating factors. F. Note the quality of pain. G. Is there radiation of pain? H. Rate pain on a pain scale (usually on the 1-10 scale, with 1 being the least and 10 being the worst). Adaptations need to be made to the assessment tool using the Faces scale in children. Incapacitated or cognitively impaired patients may also need special consideration to evaluate their pain. Physical Examination A. Check temperature, pulse, respiration, and blood pressure. B. Inspect 1. Observe overall appearance. 2. Note affect and ability to express self and pain. 3. Note facial grimaces with movement. 4. Note gait, stance, and movements. 5. Inspect area at pain site. C. Auscultate 120 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
1. Auscultate heart and lungs. 2. Auscultate neck and abdomen. D. Palpate: Palpate affected area of pain. E. Percuss 1. Percuss chest. 2. Percuss abdomen. F. Perform musculoskeletal examination. When performing a musculoskeletal examination, identify the location of pain, presence of trigger points, evidence of injury or trauma, edema, erythema, warmth, heat, lesions, petechiae, tenderness, decreased range of motion, pain with movement, crepitus, laxity of ligaments or cords, spasms, or guarding. 1. Perform complete musculoskeletal examination, concentrating on the area of pain. 2. Assess deep tendon reflexes (DTRs). G. Neurologic examination 1. Perform complete neurologic examination. 2. Identify change in sensory function, skin tenderness, weakness, muscle atrophy, and/or loss of DTRs. Diagnostic Tests A. No diagnostic testing is required unless clearly indicated to rule out organic cause of pain. If organic disease is suspected, diagnostic testing may include: 1. CT imaging 2. MRI 3. Blood chemistries 4. Radiographic x-ray 5. Lumbar puncture 6. Ultrasound 7. Electrocardiogram (EKG)/echocardiogram 121 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Differential Diagnoses The differential diagnoses depend on the location of the acute pain. A. Head 1. Migraine 2. Cluster headache/migraine headache 3. Temporal arteritis 4. Intracranial bleeding or stroke 5. Sinusitis 6. Dental abscess B. Neck 1. Meningitis 2. Muscle strain/sprain 3. Whiplash injury 4. Thyroiditis C. Chest 1. Pulmonary emboli 2. Myocardial infarction 3. Pneumonia 4. Costochondritis 5. Angina 6. Gastroesophageal reflux disease/esophagitis D. Abdomen 1. Peritonitis 2. Appendicitis 3. Ectopic pregnancy/uterine pregnancy 4. Endometriosis 5. Pelvic inflammatory disease 6. Peptic ulcer 7. Cholelithiasis 8. Colitis/diverticulitis 9. Constipation 10. Gastroenteritis 11. Irritable bowel syndrome 12. Urinary tract infection, kidney stone, pyelonephritis 13. Prostatitis 122 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
14. Malignancies E. Musculoskeletal 1. Muscle sprain/strain/tear 2. Skeletal fracture 3. Viral infection 4. Gout 5. Vitamin D deficiency Plan A. General interventions 1. Acute pain is a symptom, not a diagnosis. 2. Identify the cause or source of the acute pain depending on the location. If the pain is organic in nature, make the appropriate referral. 3. Overall goal is to treat the acute pain appropriately. B. Patient teaching 1. The pain management plan must include patient and family education regarding preventing and controlling pain, potential medication side effects, and how to prevent the side effects. 2. Discussion must include addiction concerns. 3. The newest recommendation from the Centers for Disease Control and Prevention (CDC) is the lowest possible dose of narcotics for pain for no longer than 3 to 5 days before reevaluation. Explain that risk of addiction is low when medication is used as directed for a short duration. Explain that complete pain relief may not be achievable initially, but the overall goal is to decrease the pain, thus allowing some daily activities at home to begin recovery. C. Pharmaceutical therapy 1. Visceral pain: Treatment of choice is corticosteroids, intraspinal local anesthetics, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids. 2. Somatic pain: Acetaminophen, cold packs, corticosteroids, localized anesthetics, NSAIDs, opioids, and tactile stimulation. 3. Neuropathic pain: Tricyclic antidepressants (TCAs), using amitriptyline are the first-line treatment for neuropathic pain. Anticonvulsants like carbamazepine (Tegretol), phenytoin (Dilantin), and valproic acid (Depakene) can be useful in treating neuropathic pain. Other treatments include local anesthetics, tramadol (Ultram), and 123 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
glucocorticoids. Know each medication's mechanism of action, potential adverse side effects, half-life, and drug-drug interaction potential. Always document that you have advised on the potential for sedation, suggested no driving/machinery use, or no alcohol while taking medication with these potential adverse side effects. The Food and Drug Administration (FDA) advises extreme caution when using NSAIDs with patients with cardiovascular disease due to the increased risk of heart attack and stroke. Follow-Up A. Once organic cause of pain has been ruled out, initial follow-up is 48 to 72 hours after onset. B. Ensure that the patient has access to care on a regular schedule. Consultation/Referral A. If the acute pain is organic, make the appropriate referral to a specialist. Individual Considerations A. Geriatrics 1. Physiologic changes that occur in the elderly, such as decreased body mass, hepatic dysfunction, and renal dysfunction may cause increased serum drug concentrations of pain medication. Use caution when prescribing pain medication to this population. 2. Antiinflammatories are not recommended for the elderly as a general rule due to the effects of the medication on the kidneys. Chronic Pain Moya Cook Definition 124 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Chronic pain is defined as an alteration in comfort that persists longer than 6 weeks (or longer than the anticipated healing time). The pain may be continuous or recurrent and of sufficient duration and intensity. Legitimate chronic pain interferes with a patient's ability to function with normal daily activities and decreases quality of life. Incidence Pain syndromes are commonly seen in clinical practice and are the third most widespread health problem in the United States. Chronic pain costs the American people about $65 billion a year in health care expenses, disability costs, and lost productivity. The Centers for Disease Control and Prevention (CDC) found that 11. 2% of adults state that they have pain daily. Chronic pain patients have a better than 50% chance of becoming addicted to prescription pain medications. As the U. S. population continues to age and the average life expectancy is increasing, the primary care provider will be providing care for more chronic diseases and handling more chronic pain patients. A. Women are affected more than men by two to one. B. Onset is usually in the fourth, fifth, or sixth decades and is often associated with marked functional disability. Pathogenesis A. Skeletal muscle pain occurs in the soft tissue involving the neck, shoulders, trunk, arms, low back, hips, and lower extremities. Myofascial pain syndrome relates to the fascia surrounding the muscle tissue. B. Inflammatory pain is caused by chemicals, such as prostaglandins, leading to the stimulation of the pain receptors. Examples include arthritis, infection, tissue injury, and postoperative pain. C. Mechanical/compressive pain is the direct result of the muscle, ligament, and tendon causing strain, leading to the stimulation of the pain receptors. Diagnosis may be based on diagnostic imaging results, which may include fracture, obstruction, dislocation, or compression of tissue by a tumor, cyst, or bony structure. D. Neuropathic pain involves dysfunction of the somatosensory system. The most common types are diabetic neuropathy, sciatica from nerve root compression, trigeminal neuralgia, and postherpetic neuralgia. 125 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
E. Nociceptive pain is caused by nociceptors, a type of sensory neuron that receives the pain signal. Mechanical/compressive pain and inflammatory pain are examples of this type of pain. They both respond well to opioids, with the exception of arthritis. Predisposing Factors A. Age 30 to 50 years B. Female gender C. History of having seen many physicians D. Frequent use of several nonspecific medications E. Depression F. Personality, including moods, fears, expectations, coping efforts, and resources Common Complaints A. Specific to site of pain B. Emotional distress related to fear, maladaptive or inadequate support systems, and other coping resources C. Treatment-induced complications D. Overuse of drugs E. Inability to work F. Financial complications G. Disruption of usual activities H. Sleep disturbances I. Pain becomes primary life focus Other Signs and Symptoms A. Pain lasts longer than 6 months. B. There may be anger and loss of faith or trust in the health care system. This type of patient frequently takes too many medications, spends a great deal of time in bed, sees many physicians, and experiences little joy in either work or play. Subjective Data A. Elicit a clear description of the onset, location, quality, intensity, and time course of pain and any factors that aggravate or relieve it. Use the acronym 126 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
OLD CARTS-U. O = onset, L = location, D = duration, C = characteristics, A = aggravating triggers, R = relieving triggers, T = timing, S = severity, U = YOU. What do YOU think is going on? What have YOU done to relieve it? B. Self-reporting pain assessment tools should be used early in the process of patient evaluation. Use the tool at each office visit to see progression or regression. Lack of pain assessment is a barrier to good pain control. Consider the age of the patient; his or her physical, emotional, and cognitive status; and preference when choosing the self-reporting pain assessment tool. 1. Verbal rating scales rate pain as mild, moderate, or severe. 2. Numeric rating scales rate pain intensity from 0 to 10. They are patient friendly and quick to complete. 3. The Faces scale is useful for pediatric and cognitively impaired patients. Multicultural translations may be downloaded at www. wongbakerfaces. org C. Determine the extent to which the patient is suffering, disabled, and unable to enjoy usual activity. It is important to inquire about activities of daily living (ADLs) and functional limitations. D. Obtain a complete review of systems, including nausea, numbness, weakness, insomnia, loss of appetite, dysphoria, malaise, fatigue, or depression signs and symptoms. E. Obtain a complete family and social history. Address spiritual and cultural issues. History of chemical dependency is of interest in this patient population. F. Obtain the patient's medical history relevant to the pain, including diagnosis, testing, treatments, and outcomes. G. Obtain a pain history to identify the patient's attitudes, beliefs, level of knowledge, and previous experiences with pain. Are previously used methods for pain control helpful? What is the patient's attitude toward the use of certain pain medications? Often, the patient discusses certain adverse side effects or allergies from undesired pain medication. Physical Examination A. Check temperature, pulse, respirations, and blood pressure. B. Inspect 1. Observe overall appearance. 2. Note affect and ability to express self and pain. 127 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
3. Note facial grimaces with movement. 4. Note gait, stance, and movements. 5. Inspect area at pain site. C. Auscultate 1. Heart and lungs 2. Neck and abdomen D. Palpate the affected area of pain. E. Percuss 1. Chest 2. Abdomen F. Perform musculoskeletal examination. When performing musculoskeletal examination, identify the location of pain, presence of trigger points, evidence of injury or trauma, edema, erythema, warmth, heat, lesions, petechiae, tenderness, decreased range of motion, pain with movement, crepitus, laxity of ligaments or cords, spasms, or guarding. 1. Perform a complete musculoskeletal examination, concentrating on the area of pain. 2. Note limitations in range of motion. G. Neurologic examination 1. Perform complete neurologic examination. 2. Note the patient's affect and mood. Is the patient cooperative during examination? 3. Identify change in sensory function, skin tenderness, weakness, muscle atrophy, and/or loss of deep tendon reflexes (DTRs). H. Functional assessment 1. The baseline functional assessment provides objective measurable data on a patient's physical abilities and limitations. It can be used to determine if the patient's efforts are valid and complaints are reliable. 2. The information may be used to identify areas of impairment, establish specific functional goals, and measure the effectiveness of treatment interventions. 128 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
3. These objective data may be used in worker compensation cases, returning-to-work status, federal disability, and motor vehicle accident lawsuits. 4. Know the resources in your area that are trained to perform functional assessments. Physical therapists and occupational therapists are the best qualified to perform the assessments. Diagnostic Tests A. None is required unless clearly indicated to rule out the organic cause of pain. 1. Remember that pain previously diagnosed as chronic pain syndrome can be organic and vice versa. Organic causes must always be evaluated and excluded. 2. Plain radiography should be ordered first for muscle, inflammatory, or skeletal pain. Plain radiography will diagnose a fracture. Additional studies may be recommended by the radiologist if a lesion/abnormality is seen on plain radiography. 3. MRI and CT are ordered if the plain radiograph is negative and the patient continues to complain of pain. 4. Electromyography and nerve conduction studies are used to evaluate neuropathic pain. Numerous serum and urine studies should also be considered if the neuropathic pain is undiagnosed. B. Depression screening tool: Consider using a depression assessment tool such as the Beck Depression Inventory or Patient Health Questionnaire 9 (PHQ9). These tools can be administered at a subsequent appointment to follow the patient's symptoms. Differential Diagnosies A. Pain disorder B. Pain related to a disease with no cure/malignancy C. Somatization disorder D. Conversion disorder E. Hypochondriasis F. Depression G. Chemical dependency H. Fibromyalgia 129 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Plan A. General interventions 1. Treatment is multidimensional and should not be focused on pharmacological treatment alone. 2. Offer hope and potential for improvement of pain control and improvement of function but not cure. 3. The pain is real to the patient, and acceptance of the problem must occur before a mutually agreed-on treatment plan can be initiated. 4. Depression is a common emotional disturbance in chronic pain patients and is treatable. 5. Identify specific and realistic goals for therapy such as having a good night's sleep, going shopping, or returning to work. Patient discussion needs to include the idea that the goal may be decreasing pain intensity, not eliminating pain. 6. Carefully assess the level of pain using available tools such as a daily pain diary or other pain assessment scales. 7. Avoid pain reinforcement such as sympathy and attention to pain. Provide positive response to productive activities. Improving activity tolerance assists in desensitizing the patient to pain. 8. Shift the focus from the pain to accomplishing daily assigned self-help tasks. The accomplishment of these tasks functions as positive reinforcement. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Chronic Pain. ” C. Pharmaceutical interventions 1. Skeletal muscle pain: Treatment should focus on physical rehabilitation and behavioral management. Tricyclic antidepressants (TCAs) and muscle relaxants (cyclobenzaprine) may be used. Research is lacking regarding the need for opioids. 2. Inflammatory pain: Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are first-line pharmaceutical interventions. Topical creams and solutions have been used in treating arthritis pain. 3. Mechanical/compressive pain: Opioids may be used to manage these symptoms while other measures are being taken. 4. Neuropathic pain 130 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
a. Gabapentin (Neurontin) and pregabalin (Lyrica) have become first-choice treatments in recent years for diabetic neuropathy and postherpetic neuralgia. b. TCAs are extremely useful. Patients who are not depressed obtain excellent pain relief with TCAs such as amitriptyline and doxepin. c. Selective serotonin reuptake inhibitors (SSRIs) are also effective for chronic pain control. Duloxetine (Cymbalta) has been approved for chronic pain as monotherapy or in conjunction with TCAs. d. Anticonvulsants are useful in controlling some neuropathic pain: Carbamazepine (Tegretol), phenytoin (Dilantin), and valproic acid (Depakene). Patients need to be monitored monthly for hepatic dysfunction and hematopoietic suppression. e. Topical agents: Capsaicin applied three to four times per day can reduce pain without significant systemic effects. Topical lidocaine 5% patches are approved for postherpetic neuralgia. f. Carbamazepine is used as the first-line treatment for trigeminal neuralgia. g. Opioids: Tramadol is considered to be a good choice if an opioid is indicated. In addition to pain control, tramadol also causes serotonin reuptake inhibition similar to that seen with the TCAs. 5. All therapies need a 2-to 3-week trial period to adequately evaluate therapy. Some medications take longer than that to evaluate. 6. NSAIDs should be used for flare-ups of mild to moderate inflammatory or nonneuropathic pain. 7. Opioids require careful patient selection, titration, and monitoring. Avoid long-term, daily treatment with short-acting opioids (Vicodin, Norco, and Percocet). For as-needed use, prescribe small quantities. 8. Smiths Medical received Food and Drug Administration (FDA) approval in February 2013 to market ambulatory infusion pumps in the United States. These pumps can be programmed to administer pain management medication continuously, intermittently, tapered, or patient controlled. 9. Benzodiazepines and barbiturates are not advised for treatment of chronic pain due to the high risk of substance abuse. 10. Addiction risk interventions when considering opioids: A checklist for prescribing opioids can be found at 131 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
www. cdc. gov/drugoverdose/pdf/PDO_Checklist-a. pdf a. Check your state's prescription monitoring program (PMP) before prescribing controlled substances, as needed, and at least annually. PMPs are state-run electronic databases that track dispensing of controlled substances. PMPs provide clinicians with critical information about patient narcotic prescription history and identify drug-seeking behavior patterns. b. Contact the patient's pharmacy for a list of current medications. The PMP is not in real time, and all current patient prescriptions are available from the pharmacy. c. Perform urine drug screen before prescribing controlled substances initially, as needed, and annually. National guidelines recommend the enzyme immunoassay (EIA) and gas chromatography/mass spectroscopy urine screen. Depending on the results of urine drug screening, the provider may seek additional consultation, change medication therapy, refer for substance abuse, or discharge the patient. d. A written controlled substance treatment agreement among patient, provider, and clinic is recommended. Include expectations of the patient: No other controlled substances will be prescribed by any other provider. One pharmacy only should be used. Medication must be taken as prescribed. These are no early refills on controlled substances. The patient must agree to random drug screens and may be called to report to the clinic for random drug screens and/or pill counts. e. Utilize tools such as the Addiction Behavior Checklist, Diagnosis, Intractability, Risk, Efficacy (DIRE) score, or CAGE (have you ever tried to cut down on your alcohol/drug use? Do you get annoyed if someone mentions your use is a problem? Do you ever feel guilty about your use? Do you ever have an “eye-opener” first thing in the morning after you have been drinking or using the night before?) assessment. f. Red flags for misuse, abuse, addiction, and diversion with opioids include: i. Psychiatric illness ii. Personal history of alcohol or drug abuse iii. Family history of alcohol or drug abuse 132 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
D. Alternative interventions 1. Cognitive behavioral training: Examples of cognitive behavioral training include problem solving, guided imagery, hypnosis, controlled breathing exercises, attention diversion, meditation, and yoga exercises; progressive muscle relaxation (PMR) is recommended to help relax major muscle groups. Randomized controlled trials showed significant reduction in pain with alternative interventions such as music, relaxation, distraction, and massage use. 2. Exercise: Examples of exercise include yoga exercises and PMR. PMR is recommended to help relax major muscle groups. Research indicates that yoga decreases bothersome pain after 12 weeks of regular exercise. The benefits of yoga exercise include improved strength, balance, coordination, range of motion, and reduced anxiety. Yoga instruction by a qualified teacher is a low-cost intervention. Yoga is an effective form of self-care and is an affordable way to alleviate pain. Always advise patients to start slowly and be prepared for an approach to pain management that may take several weeks of therapy. 3. Alternative therapies: Randomized controlled trials showed significant reduction in pain with alternative interventions such as music, relaxation, distraction, acupuncture, myofascial release treatments, and massage use. 4. Occupational therapy 5. Vocational therapy 6. Physical therapy such as noninvasive techniques, transcutaneous electrical nerve stimulation, hot or cold therapy, hydrotherapy, traction, massage, bracing, and exercise 7. Individual and family therapy or counseling 8. Aesthetic or neurosurgical procedures 9. Patients will inquire about the use of herbal products to treat chronic pain. Advise patients that these products are not regulated by the FDA. Advise them that these herbal products may interact with current medications and cause complications. Advise them to research all herbal products on reputable medically based websites, not blogs or chat rooms. Caution patients regarding devil's claw, feverfew, willow bark, glucosamine, and chondroitin. Discourage any use of dimethylsulfoxide. Follow-Up 133 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. See patients every 4 to 6 weeks for evaluation. B. Ensure that the patient has access to care on a regular schedule. C. These brief visits should be regular so that care is not perceived to be dependent on escalation of symptoms. Consultation/Referral A. Consider patient referral to a pain management clinic if pain control is not adequate. Interventions commonly performed at the specialty clinic include facet joint injections, percutaneous radiofrequency neurotomy, epidural corticosteroid injections, transforaminal epidural injections, and sacroiliac joint injections. B. Consult with a physician if referral is needed for psychological counseling or if substance abuse is suspected. C. Refer to a certified pain specialist physician if the patient is taking high doses of opioids and detoxification is indicated. Buprenorphine (Suboxone) is the most common medication prescribed by a certified pain specialist physician. D. Consider rheumatology consult if indicated. Lower Back Pain Moya Cook Definition Painful conditions of the lower back may be categorized as follows: A. Potentially serious disorders: Acute fractures, tumor, progressive neurologic deficit, nerve root compression, and cauda equina syndrome B. Degenerative disorders: Aging or repetitive use, degenerative disease, and osteoarthritis C. Nonspecific disorders: Benign and self-limiting with unclear etiology Incidence A. Lower back pain is commonly seen in patients from ages 20 to 40 years. B. Approximately 70% to 80% of people experience back pain at one point in their lifetime. 134 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Pathogenesis A. Pain arises from fracture, tumor, nerve root compression, a degenerative disc, osteoarthritis, and strain of the ligaments and musculature of the lumbosacral area. Predisposing Factors A. Trauma causing ligament tearing; stretching of vertebra, muscles, tendons, ligaments, or fascia B. Repetitive mechanical stress C. Tumor D. Exaggerated lumbar lordosis E. Abnormal, forward-tipped pelvis F. Uneven leg length G. Chronic poor posture due to inadequate conditioning of muscle strength and flexibility, improper lifting techniques causing excessive strain, and poor body mechanics H. Inadequate rest I. Emotional depression Common Complaint A. Pain in the lower back area may range from discomfort to severe back pain, with or without radiation. Other Signs and Symptoms A. Ambulating with a limp B. Limited range of motion C. Posture normal to guarded Subjective Data A. Ask the patient to discuss the origin of pain. How has the pain progressed or changed since the initial injury? B. Ask the patient to point to an area where pain is felt. C. Have the patient describe the pain. Is it radiating, with sharp, shooting pain down to the lower leg and feet? D. Ask: What makes the pain worse or better? Does activity make the pain 135 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
worse or better? Have the patient list current medications or therapies used for pain, noting results of treatment. E. Investigate occurrence of systemic symptoms such as fever and weight loss. F. Explore the patient's past medical history. Note previous trauma or overuse, tuberculosis, arthritis, cancer, and osteoporosis. G. Inquire about symptoms such as dysuria, bowel or bladder incontinence, muscle weakness, paresthesia, and loss of sensation. Bowel or bladder dysfunction, bilateral sciatica, and saddle compression may be symptoms of severe compression of the cauda equina that necessitate an urgent workup and referral. H. Ask the patient about precipitating factors such as athletics, heavy lifting, driving, yard work, occupation, sleep habits, or systemic disease. I. Use a pain scale to describe the worst pain and the best pain levels. Physical Examination A. Check temperature, pulse, blood pressure, and respiration. B. Inspect 1. Observe general appearance; note discomfort and grimacing on movement and/or examination. 2. Distraction may distinguish pain behavior from actual pathology. 3. Note evidence of trauma with bruises, cuts, and fractures. 4. Note posture and gait. C. Palpate 1. Palpate spine and paravertebral structures, noting point tenderness and muscle spasm. Palpation elicits paravertebral tenderness and generalized tenderness over the lower back to upper buttocks. 2. Examine abdomen for masses. 3. Extremities: Palpate peripheral pulses. D. Perform neurologic examination 1. Identify sensation and pain distribution. 2. Determine motor strength and evaluate whether muscle strength is symmetrical: Upper extremity resistance is equal bilaterally. 3. Test deep tendon reflexes (DTRs) and dorsiflexion of the big toes. E. Check sensation of perineum to rule out cauda equina syndrome. F. Perform traction tests: Straight leg raises, crossed leg raises, Yeoman 136 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Guying, Patrick's test. Musculoskeletal findings include the following: 1. Straight leg raising and dorsiflexion of foot on the affected side may reduce lower back discomfort. 2. Elevate each leg passively with flexion at the hip and extension of the knee. Positive straight leg raise gives radicular pain when the leg is raised 30° to 60°. 3. Crossed leg raises: Test is positive when pain occurs in the leg not being raised. 4. Yeoman Guying: Unilateral hyperextension in prone position identifies lumbosacral mechanical disorder. 5. Patrick's test: Place heel on opposite knee and apply lateral force; check for hip or sacroiliac disease. 6. Range of motion: Increased pain with extension often indicates osteoarthritis. Increased pain with flexion often indicates strain or injured disk. G. Pelvic examination: Consider pelvic and rectal examination, if indicated. If the patient has fallen on the coccyx, a rectal examination is needed to check for stability. Diagnostic Tests A. Laboratory: Complete blood count, erythrocyte sedimentation rate, serum calcium, alkaline phosphatase, urinalysis, and serum immunoelectrophoresis when inflammatory, neoplastic, diffuse bone disease, or renal disease is suspected B. Radiography of spine C. Consider the following tests 1. MRI to rule out disk disease and tumors 2. Bone scan to rule out cancer Differential Diagnoses A. Back pain secondary to musculoskeletal pain B. Herniated intervertebral disease C. Sciatica D. Fracture E. Ankylosing spondylitis F. Malignancy/tumor 137 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
G. Abdominal aneurysm H. Pyelonephritis I. Metabolic bone disease J. Gynecologic disease K. Peripheral neuropathy L. Depression M. Prostatitis N. Spinal stenosis O. Osteoarthritis P. Osteoporosis Plan A. General interventions 1. The patient should continue physical activity as tolerated. 2. For acute muscle strain, have the patient apply local cold packs 20 to 30 minutes several times a day for the first 24 hours. Heat packs are recommended after the initial 24 hours of injury. 3. Chronic or recurrent pain may be treated with either ice or heat applications, whichever gives relief. B. Patient teaching 1. Give accurate information on the prognosis for quick recovery such as continuing light physical activity, performing back-strengthening exercises, and avoiding overuse of medications. 2. Improvement occurs in most cases in a few weeks, although mild symptoms may persist. 3. Joint guidelines by the American College of Physicians and the American Pain Society recommend rehabilitative therapies for patients who do not improve after medications and self-care recommendations. Rehabilitative therapies include exercise therapy, acupuncture, massage therapy, spinal manipulation, cognitive behavioral therapy, and yoga. 4. Provide educational handouts on back exercises; see Section III: Patient Teaching Guide for this chapter, “Back Stretches. ” 5. After intense pain abates, the patient may perform low-back exercises for range of motion and strengthening, and isometric tightening exercises of abdominal and gluteal muscles. 6. Teach patient knee-chest exercises. Recommend to the patient to 138 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
place his or her back against the wall and contract abdominal and gluteal muscles with 5 to 10 repetitions four to six times per day. 7. Research indicates that yoga is beneficial for many types of back pain. Types of back pain benefited by yoga include musculoskeletal injury, herniated disc, spinal stenosis, spondylolisthesis, piriformis syndrome, arthritis, and sacroiliac joint derangement. 8. Encourage the patient to perform walking exercise daily. 9. Teach relaxation techniques. 10. Encourage the patient to modify work hours and job tasks. 11. Refer the patient for therapeutic massage or physical therapy as needed. 12. Obesity is often related to decreased exercise and poor physical fitness with reduced trunk muscle strength and endurance. Obese patients may experience back pain with normal activity. C. Pharmaceutical therapy 1. Analgesics: Acetaminophen 350 to 650 mg every 4 to 6 hours. Maximum dose is 4,000 mg a day. Inquire of any other current medications and/or over-the-counter preparations containing acetaminophen. 2. Nonsteroidal anti-inflammatory drugs (NSAIDs): Unless contraindicated due to gastrointestinal symptoms or cardiovascular disease a. Aspirin:325 to 650 mg every 4 to 6 hours b. Ibuprofen:200 to 800 mg every 6 to 8 hours; maximum dose is 3. 2 g a day under the care of the provider, otherwise 1. 2 g a day c. Naproxen:500 mg initially, followed by 250 mg every 6 to 8 hours d. Piroxicam (Feldene):20 mg every day e. Meloxicam (Mobic):7. 5 to 15 mg daily f. Celebrex:100 to 200 mg twice a day 3. Muscle relaxants a. Cyclobenzaprine Hcl (Flexeril):10 mg three times daily b. Carisoprodol (Soma):350 mg four times daily—use with extreme caution due to risk of addiction c. Methocarbamol (Robaxin):1. 5 g every day initially, and then 750 to 1,000 mg every day d. Orphenadrine citrate (Norflex):100 mg twice a day 139 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
e. Metaxalone (Skelaxin):800 mg three to four times a day Follow-Up A. If pain is severe or unimproved, follow up in 24 hours. B. If pain is moderate, reevaluate the patient in 7 to 10 days. C. See the patient in 2 to 4 weeks to reevaluate his or her condition and behavioral changes. D. Recurrences are not uncommon but do not indicate a chronic or worsening case. Consultation/Referral A. Consult with a physician when considering red-flag diagnoses such as cauda equina syndrome, herniated disk, widespread neurologic involvement, carcinoma, or significant trauma. B. Referral to a physician is needed for patients who note significant morning stiffness with a gradual onset prior to age 40 years, with continuing spinal movements in all directions, and involving some peripheral joints, iritis, skin rashes indicating inflammatory disorders such as ankylosing spondylitis and related disorders. Individual Considerations A. Pregnancy: Pregnancy is often associated with low-back discomfort. This is due to the redistribution of body weight. As weight increases in the abdominal area with the growing fetus, patients tend to compensate by changing posture and tilting the spine back. B. Adults 1. For patients older than 50 years presenting with no prior history of backache, consider a differential diagnosis of neoplasm. The most common metastasis seen is secondary to the primary site of breast cancer, prostate cancer, or multiple myeloma. Pain most prominent in a recumbent position rarely radiates into the buttock or leg. 2. Men and women in their early adulthood (ages 20-45 years) who present with chronic back pain that improves with activity should be further evaluated for ankylosing spondylitis. 140 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Bibliography Centers for Disease Control and Prevention. (2016, March 15). CDC guidelines for prescribing opioids for chronic pain—United States, 2016. Morbidity and Mortality Weekly Reports. Retrieved from https://www. cdc. gov/mmwr/volumes/65/rr/rr6501e1. htm Centers for Disease Control and Prevention. (2016, March 22). Checklist for prescribing opioids for chronic pain. Retrieved from https://www. cdc. gov/drugoverdose/pdf/PDO_Checklist-a. pdf Chronic Pain Perspectives. (2013). Ambulatory infusion system gets FDA clearance. Retrieved from https://www. google. com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=Ambulatory+infusion+system+gets+FDA+clearance Costead, L., & Banasik, J. (2012). Pathophysiology (5th ed. ). St. Louis, MO: Elsevier Saunders. Dunphy, L., Brown, J., Porter, B., & Thomas, D. (2015). Primary care: The art and science of advanced practice nursing (4th ed. ). Philadelphia, PA: F. A. Davis. Fishman, L. (2012). Efficacy and application of yoga for back pain. Chronic Pain Perspectives. Retrieved from http://chronicpainperspectives. com/articles/feature-article/article/efficacy-and-application-of-yoga-for-back-pain/8c51fc8df7a517da1a5e8baa1f28d7e8. html Goertz, M., Thorson, D., Bonsell, J., Bonte, B., Campbell, R., Haake, B.,... Timming, R. (2012). Health care guideline: Adult acute and subacute low back pain (15th ed. ). Bloomington, MN: Institute for Clinical Systems Improvement. Retrieved from https://www. icsi. org/_asset/bjvqrj/LBP. pdf Hooten, W. M., Timming, R., Belgrade, M., Gaul, J., Goertz, M., Haake, B.,... Walker, N. (2013). Health care guideline: Assessment and management of chronic pain (6th ed. ). Bloomington, MN: Institute for Clinical Systems Improvement. Retrieved from https://pdfs. semanticscholar. org/e1f7/c26a36d83686607ad89ee835daa3c9db3f4c. pdf Michigan Quality Improvement Consortium. (n. d. ). Management of acute low back pain. Retrieved from https://www. guidelines. gov National Guideline Clearinghouse. (2011a). Guideline summary: Guideline for the evidence-informed primary care management of low back pain. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from https://www. guideline. gov/content. aspx? id=37954&search=chronic+low+back+pain+and+acute+low+back+pain+and+assessment+and+management+of+pain National Guideline Clearinghouse. (2011b). Guideline summary: Managing chronic non-terminal pain in adults including prescribing controlled substances. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from https://www. guideline. gov/summaries/summary/25657/managing-chronic-nonterminal-pain-in-adults-including-prescribing-controlled-substances? q=Managing+chronic+nonterminal+pain+including+prescribing+controlled+substances National Guideline Clearinghouse. (2013, November). Guideline summary: Assessment and management of chronic pain. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from https://www. guideline. gov/summaries/summary/47646 Rosenquist, E. (2016). Evaluation of chronic pain in adults. In T. W. Post & M. Aronson (Eds. ), Up To Date. Retrieved from https://www. uptodate. com/contents/evaluation-of-chronic-pain-in-adults?source=search_result&search=chronic+pain&selected Title=3%7E150 141 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
4Dermatology Guidelines Acne Rosacea Jill C. Cash and Amy C. Bruggemann Definition A. A multifactorial vascular skin disorder, acne rosacea is characterized by chronic inflammatory processes in which flushing and dilation of the blood vessels occur on the face. It is manifested in four stages of pathologic events. Incidence A. Acne rosacea affects approximately 13 million people in the United States. Pathogenesis A. Rosacea is a functional vascular anomaly with a tendency toward recurrent dilation and flushing of the face. This results in inflammatory mediator release, extravasation of inflammatory cells, and the formation of inflammatory papules and pustules. Predisposing Factors A. Tendency to flush frequently B. Exposure to heat, cold, or sunlight C. Consumption of hot or spicy foods and alcoholic beverages D. Some topical medications, astringents, or toners Common Complaints A. Papules, pustules, and nodules. Hallmarks for diagnosis are the small 142 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
papules and papulopustules. Many presenting erythematous papules have a tiny pustule at the crest. No comedones are present. B. Periodic reddening or flushing of face C. Increase in skin temperature of face D. Face flushing in response to heat stimuli (hot liquids) in mouth Other Signs and Symptoms A. Periorbital erythema B. Telangiectasia, paranasally and on cheeks C. Rhinophyma D. Blepharoconjunctivitis with erythematous eyelid margins E. Conjunctivitis: Diffuse hyperemic type or nodular F. Keratitis: Lower portion of cornea, associated with pain, photophobia, and foreign-body sensation Subjective Data A. Ask the patient to describe the location and the onset. Was the onset sudden or gradual? How have the symptoms continued to develop? B. Assess if the skin is itchy or painful. C. Assess for any associated discharge (blood or pus). D. Complete a drug history. Has the patient recently taken any antibiotics or other medications? E. Determine whether the patient has used any topical medications, astringents, toners, or new skin-care products. F. Rule out any possible exposure to industrial or domestic toxins, insect bites, and possible contact with venereal disease or HIV. G. Ask the patient about close contact with others with skin disorders. H. Identify whether exposure to heat, cold, or sunlight provokes the symptoms. I. Ask whether eating or drinking hot or spicy foods or consumption of alcoholic beverages provokes the symptoms. Physical Examination A. Check temperature, pulse, and blood pressure. B. Inspect 1. Skin, focusing on face and scalp 143 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2. Nose and paranasal structures 3. Eyes, eyelids, conjunctiva, and cornea. An ocular manifestation, rosacea keratitis, may cause corneal ulcers to develop. Diagnostic Tests A. Consider skin biopsy to rule out lupus, sarcoidosis, or other possible causes if history and physical exam findings warrant further testing. Differential Diagnoses A. Acne rosacea B. Acne vulgaris C. Steroid-induced acne D. Perioral dermatitis E. Seborrheic dermatitis F. Lupus erythematosus G. Cutaneous sarcoidosis Plan A. General interventions: Identify any causative or provocative factors— heat, cold, hot or spicy foods, alcoholic beverages, sunlight. 1. Advise washing face with a mild cleanser such as Cetaphil or Cerave in the morning and at night. 2. Avoid direct sunlight exposure by wearing protective clothing/hats when outdoors. Suggest using a sunscreen of sun protection factor (SPF)-30 when exposed to sunlight. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Acne Rosacea. ” C. Pharmaceutical therapy 1. Drug of choice: Tetracycline 500 to 1,000 mg twice to four times daily for 2 to 4 weeks. 2. Others: Erythromycin 500 mg twice daily until clear, minocycline (Minocin), 50 to 200 mg daily divided into two doses, doxycycline (Vibramycin) 100 mg daily, Amoxil, and metronidazole (Flagyl, Protostat). Start at a higher dose and taper to the maintenance dose. a. Topical antibiotics. Apply topical Metrogel twice daily after cleansing skin. 144 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
b. Do not use topical steroids. Topical steroids may worsen irritation. c. Other topical antibiotics: Clindamycin (Cleocin T), erythromycin twice daily. 3. Refractory cases may respond to isotretinoin (Accutane). Follow-Up A. Follow up in 2 weeks to evaluate therapy. B. See patients monthly for evaluation until maintenance is reached. C. Relapses are common following discontinuance of antibiotics; repeat treatment. Consultation/Referral A. Consult or refer the patient to a dermatologist if there is no improvement, or if the patient is unable to reach maintenance. B. Provide an immediate referral to an ophthalmologist for treatment and follow up if the eye is involved. Individual Consideration A. Adults: Tinted sulfacetamide (Sulfacet-R) lotion may be used by fair-skinned patients to cover erythema. Acne Vulgaris Jill C. Cash and Amy C. Bruggemann Definition A. Acne vulgaris is a disorder of the sebaceous glands and hair follicles of the skin that are most numerous on the face, back, and chest. The sebaceous glands become inflamed and form papules, pustules, cysts, open or closed comedones, and/or nodules on an erythemic base. In severe cases, scarring can result. Incidence A. Acne is the most common skin disorder in the United States, affecting 40 to 50 million persons of all ages and races. Nearly 80% to 90% of all adults 145 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
experience acne during their lifetime. Acne vulgaris, commonly seen in adolescence, may even extend into the third or fourth decade of life. Pathogenesis A. Sebum is overproduced and collects in the sebaceous gland. Sebum, keratinized cells, and hair collect in the follicle. With Propionibacterium acnes present, the duct becomes clogged, and lesions (noninflammatory and/or inflammatory) evolve. Predisposing Factors A. Age (adolescence) B. External irritants to skin (makeup, oils, equipment contact on skin) C. Hormones (oral contraceptives with high progestin content) D. Medications (lithium, halides, hydantoin derivatives, rifampin) E. Hot, humid weather Common Complaints A. Outbreak of pimples on face, chest, shoulders, and back that do not resolve with over-the-counter (OTC) treatment. B. Acne rosacea: Telangiectasia, flushing, and rhinophyma present Other Signs and Symptoms A. Mild: Comedones open (blackhead) and closed (whitehead) B. Moderate: Comedones with papules and pustules C. Severe: Nodules, cysts, and scars Subjective Data A. Elicit the age of onset of outbreak, duration, and course of symptoms. B. Determine what makes the lesions worse or better. C. Ask whether there are certain times of the month or year when lesions are better or worse. D. Identify the patient's current method of cleanser or moisturizer treatment. E. Ask if the patient has ever been treated by a provider for this problem. If so, determine the treatment and results of the treatment. F. Assess whether other family members have this same problem. G. Ask the patient for a description of his or her environment and 146 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
occupation. H. Explore with the patient any current stress factors in his or her life. Physical Examination A. Inspect 1. Observe skin for location and severity of lesions. 2. Rate severity of lesions as mild, moderate, or severe. a. Mild: Few papules/pustules, no nodules b. Moderate: Several papules/pustules, rare nodules c. Severe: Many papules/pustules with many nodules 3. Take a picture of areas of affected skin for chart and document date. Use this for future appointments as a reference to compare results for follow-up visits. Diagnostic Tests A. No tests are generally required. B. Culture lesions to rule out gram-negative folliculitis with patients on antibiotics. C. Consider hormone testing if other primary causes of acne are taken into account (follicle-stimulating hormone, luteinizing hormone, testosterone levels). Differential Diagnoses A. Acne vulgaris B. Acne rosacea C. Steroid rosacea D. Folliculitis E. Perioral acne F. Drug-induced acne Plan A. General interventions 1. Document location and severity of lesions. Assess quality of improvement at each office visit. 2. The primary goal of treatment is prevention of scarring. Good control of lesions during puberty and early adulthood is required for best results. 147 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Anticipate ups and downs during the normal course of treatment. B. Patient teaching 1. See Section III: Patient Teaching Guide for this chapter: “Acne Vulgaris. ” 2. Instruct the patient on proper cleansing routine. The patient should wash affected areas with a mild soap (Purpose, Cetaphil) twice a day and apply medications as directed. 3. Warn the patient that washing the face more than two to three times a day can decrease oil production and cause drying. 4. Discuss current stressors in the patient's life and discuss treatment options. 5. Recommend an exercise routine 3 to 5 days a week. 6. Recommend oil-free sunscreens. C. Pharmaceutical therapy: It may take 1 to 3 months before results are visible when using these medications. 1. Mild: Treatment of choice is topical. Use one of the following: a. Benzoyl peroxide, 2. 5%, 5%, 10%; begin with 2. 5% at bedtime. May graduate to 5% or 10% twice daily, if needed, as tolerated. b. T-Stat: Apply to dried areas twice daily. Avoid eyes, nose, and mouth creases. c. Topical tretinoin 0. 1% (Retin-A Micro); use at bedtime. i. With Retin-A use, the patient may see rapid turnover of keratin plugs. ii. Instruct the patient to avoid abrasive soaps. iii. Warn the patient regarding photosensitivity. iv. Warn the patient regarding increased dryness. May apply a moisturizer such as Cerave or Cetaphil if needed. d. Desquam E: Use at bedtime. Wash face with soap and then apply Desquam E. 2. Moderate: Use one of the aforementioned topical medications in addition to one of the following oral medications: a. Tetracycline 500 mg twice daily for 3 to 6 weeks, for adolescents older than 14 years. As condition improves, begin tapering medication to 250 mg twice daily for 6 weeks, then to daily or to every other day. i. Instruct the patient to take tetracycline on an empty stomach and to avoid dairy products, antacids, and iron. 148 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
ii. Warn the patient about photosensitivity. This medication may be used as a maintenance dose at 250 mg daily or every other day for those patients who break out after discontinuing antibiotic therapy. No drug resistance is seen with tetracycline. b. Erythromycin 250 mg four times per day after meals or topical erythromycin 2%, solution or gel, twice daily, or clindamycin (Cleocin T) solution, pads, or gel, twice daily. Erythromycin resistance has been seen. c. Minocycline 100 mg twice daily. When this is effective, taper to 50 mg twice daily. i. Have the patient drink plenty of fluids. ii. Central nervous system (CNS) side effects (headaches) have been seen. d. Bactrim single strength twice daily, if the aforementioned regimens do not work well. Bactrim works well if others fail because it is effective for Gram-negative folliculitis. e. Oral contraceptives with higher doses of estrogen have also been effective for girls. f. Doxycycline g. Spironolactone 3. Severe: Medications as prescribed by the dermatologist. Follow-Up See patients every 6 to 8 weeks for evaluation. A. Mild: Adjust dose depending on local irritation. B. Moderate (oral and topical medications) 1. Adjust dose according to irritation. 2. Taper oral antibiotics with discretion and/or continue topical medications. 3. Oral antibiotics may be tapered and discontinued when inflammatory lesions have resolved. C. Severe: Recommend referral to dermatology and follow-up with the specialty. Consultation/Referral A. Consult with a physician if treatment is unsuccessful after 10 to 12 weeks 149 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
of therapy or if acne is severe. B. The patient may need dermatology consultation. Individual Considerations A. Pregnancy 1. Acne may flare up or improve during pregnancy. 2. Medications preferred during pregnancy are topical agents. 3. Teratogens include tretinoin, tetracycline, and minocycline. a. When using teratogenic medications, contraception must be practiced to avoid pregnancy to prevent severe fetal malformations. b. Begin contraception 1 month before starting the medication and continue contraception 1 month after finishing the medication. Animal Bites, Mammalian Jill C. Cash and Amy C. Bruggemann Definition A. Bites of any mammalian animal to the human can be potentially dangerous. Human bites are included. Incidence A. Account for 1 to 3. 5 million emergency room (ER) visits each year. B. About 80% to 90% of bites are dog bites. C. About 6% of bites are cat bites. D. From 1% to 15% are human bites. E. Children and the elderly are especially prone. Pathogenesis A. Mechanical trauma and break to skin and/or underlying structures B. Infection from transmission of bacteria 1. Pasteurella multocida is primarily associated with cat bites but may also be associated with dog bites. 150 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2. Staphylococcus aureus, Staphylococcus epidermis, and Enterobacter species can be transmitted by dog and cat bites. 3. Streptobacillus moniliformis can be transmitted by rat and mice bites. 4. Streptococcus, Staphylococcus, and Eikenella can be transmitted by human bites. 5. Human bites can transmit diseases: Actinomycosis, syphilis, tuberculosis, hepatitis B, and potentially HIV. C. Rabies, an acute viral infection, may be transmitted by means of infected saliva or by an infected animal licking mucosa of an open wound. It is rarely contracted by means of airborne transmission, but this has been reported to occur in bat-infested caves. Predisposing Factors A. Entering an animal's territorial space and/or surprising an animal Common Complaints A. Bitten B. Pain C. Redness D. Swelling Other Signs and Symptoms A. Normal: Mild redness and swelling, sero-sanguinous oozing, discomfort B. Abnormal: Erythema, fever, pus, red streaks, pain, loss of sensation Subjective Data A. What person or type of animal bit the patient? B. Was this a provoked or an unprovoked attack? C. Did the patient identify and contact the owner of the animal? D. What was the behavior of the animal: Unusual, strange, or ill appearing? E. How much time elapsed from being bitten to seeking treatment? F. Did the patient start any self-treatment? G. What is the patient's tetanus immunization status? H. Review history for any prior rabies immunizations. I. Does the patient know if the animal was a domestic animal? Is the animal's vaccination status known? 151 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
J. If the bite is of human origin, determine if it is a closed-fist injury or plain bite. Physical Examination A. Check blood pressure, pulse, and respirations, and observe overall respiratory status. B. See Table 4. 1. Diagnostic Test A. Refer to Table 4. 1. Differential Diagnoses A. Animal bite: Dog, cat, human, and so forth 1. Cat bites more frequently become infected. 2. Bites on the hand have the highest infection rates. Bites on the face have the lowest infection rates. B. Cellulitis and abscesses C. High-risk potential for rabies from the following: 1. Skunks, foxes, raccoons, and bats are primary carriers. 2. Rabbits, squirrels, chipmunks, rats, and mice are seldom infective for rabies. 3. Properly vaccinated animals seldom are infective. Plan A. General interventions 1. Control bleeding. 2. Perform wound care. a. Immediately wash wound copiously with soap and water. b. Irrigate wound with saline using a 20-gauge or larger catheter. c. Use 150 to 1,000 m L of solution. d. Direct saline stream on the entire wound surface. e. Scrub entire surrounding area. f. Debride all wounds. g. Trim any jagged edges to prevent cosmetic and/or functional complications. h. Cover with dry dressing. 152 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
3. Do not suture wounds with high risk of infection: a. Hand bites, closed-fist injuries b. Bites older than 6 hours TABLE 4. 1 Bites c. Deep or puncture wounds d. Bites with extensive injury of surface or underlying structures 4. Rabies control measures: a. Consult with the local health department regarding the risk of rabies in the area. b. The domestic animal should be identified, caught, and confined for 10 days of observation. If the animal develops any signs of rabies, it should be destroyed and its brain tissue analyzed. No treatment is necessary if results are negative. c. The wild animal should be caught and destroyed for brain tissue analysis. No treatment is necessary if results are negative. 153 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
d. If the bat or wild carnivore cannot be found, rabies prophylaxis is instituted. B. Patient teaching 1. Stress the importance of keeping the site free from infection. Instruct the patient on how to keep the site free from infection such as teaching cleaning techniques, good handwashing, and using medications as prescribed. 2. Discuss symptoms to report to the provider if signs of infection begin (erythema, swelling, drainage, and tenderness). C. Pharmaceutical therapy 1. Antibiotic prophylaxis is controversial, but it is generally recommended for wounds involving subcutaneous tissues and deeper structures. a. Amoxicillin/clavulanic acid (Augmentin) 875 mg every 12 hours; for children, prescribe 25 to 45 mg/kg/dose in two divided doses for 3 to 7 days. Available as 200 mg/5 m L and 400 mg/5 m L liquid. b. Alternatively, prescribe doxycycline 100 mg twice per day for 3 to 7 days; for children, prescribe clindamycin 10 to 25 mg per kg divided every 6 to 8 hours plus trimethoprim/sulfamethoxazole 8 to 10 mg per kg (trimethoprim component) divided every 12 hours for 3 to 7 days. 2. Tetanus prophylaxis 3. Rabies prophylaxis a. Active immunization: Human diploid cell vaccine (HDCV), 1 m L, is given intramuscularly (IM) on the first day of treatment, and repeat doses are administered on days 3, 7, 14, and 28. b. Passive immunization: Rabies immunoglobulin; (human) should be used simultaneously with the first dose of HDCV; the recommended dose of RIG is 20 IU/kg. Approximately one half of RIG is infiltrated into the wound, and the remainder is given IM. Follow-Up A. Evaluate wound and change dressing in 24 to 48 hours. B. Reevaluate as indicated. If the patient is on immunoprophylaxis and has no signs of infection, see the patient in 1 week. C. Instruct the patient to return immediately in case of any signs of infection. 154 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Consultation/Referral A. Refer all patients with bites of the ears, face, genitalia, hands, and feet. B. Consult with a doctor if suspicion of rabies is involved. C. Contact the local health department. D. Wounds involving tendon, joint, or bone require hospitalization and surgical consultation. Individual Consideration A. Pregnancy: Use appropriate antibiotic management. B. Pediatrics: Children are more prone to animal bites. C. Geriatrics: The elderly population is more prone to animal bites. Benign Skin Lesions Jill C. Cash and Amy C. Bruggemann Definition A benign skin lesion is a cutaneous growth with no harmful effects to the body. Benign lesions must be distinguished from the following: A. Basal cell carcinoma (BCC): Nodular tumor with pearly surface, telangiectasia on surface, and depressed center or rolled edge B. Squamous cell carcinoma (SCC): Irregular papule, with scaly, friable, bleeding surface C. Malignant melanoma: Asymmetric papule, with irregular border, of two or more colors, and size varies Incidence A. Benign lesions are common to all races, and they are seen primarily in the adult and elderly populations. Pathogenesis A. The course varies, depending on the specific type of lesion. Predisposing Factors A. Sun exposure in the adult and elderly populations 155 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
B. Dermatosis papulosa nigra: Common in African Americans and Asians Common Complaint A. New lesion of the skin Other Signs and Symptoms A. Seborrheic keratosis: Waxy papule with a stuck-on appearance is seen in adults; they appear symmetric, 0. 2 to 3. 0 cm in size, with a well-demarcated border and a variety of colors (tan, black, and brown). B. Dermatosis papulosa nigra: Hyperpigmented mole located on face or neck; a pedunculated papule that is symmetric, 1 to 3 mm in diameter. C. Cherry angioma: Vascular papule, red to purple, located on trunk in adults; begins in early adulthood; 1-to 3-mm diameter papules that do not blanch. D. Solar lentigines (liver spots): Tan maculae on sun-exposed areas in elders, especially on face and hands; border is irregular, and the size varies. E. Sebaceous hyperplasia: Enlarged sebaceous glands that appear as yellow papules on sun-exposed areas, especially on the face in elders; papules have central umbilication, and their size varies. F. Actinic keratoses: Rough, scaly patch on your skin that develops from years of exposure to the sun. They are most commonly found on your face, lips, ears, back of your hands, forearms, scalp, or neck. These areas should be monitored closely as they can become cancerous. Subjective Data A. Identify when the patient first discovered the lesion. B. Determine whether the lesion has changed in size, shape, or color. C. Ask if the patient has discovered more lesions. D. Elicit information regarding a family history of skin lesions or cancer. Physical Examination A. Inspect 1. Observe skin; note all lesions and evaluate each for asymmetry, border, color, diameter, evolving changes, and/or elevation change. 2. Note the patient's skin type. 156 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Diagnostic Tests A. Benign lesions do not require any tests. B. If unsure regarding possible malignancy, a biopsy is recommended. Differential Diagnoses A. Benign skin lesion 1. Seborrheic keratosis 2. Dermatosis papulosa nigra 3. Cherry angioma 4. Solar lentigines 5. Senile sebaceous hyperplasia 6. Keratoacanthoma Plan A. General interventions 1. Reassure the patient that lesions are benign. No treatment is required unless the patient chooses to have the lesion removed for cosmetic purposes. 2. Benign skin lesions may be removed using cryotherapy if they are bothersome for the patient. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Skin Care Assessment. ” C. Pharmaceutical therapy 1. Medications are not recommended for treatment. Follow-Up A. Routine skin examinations should be performed yearly. Consultation/Referral A. Immediately refer the patient to a dermatologist if malignancy is suspected or confirmed by biopsy. Individual Considerations A. Adults: Skin lesions begin to appear in early adulthood. Encourage patients to monitor lesions over time. 157 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
B. Geriatrics: Benign lesions are commonly seen in the elderly population. Candidiasis Jill C. Cash and Amy C. Bruggemann Definition A. A fungal infection of the mucous membranes and/or skin, candidiasis is caused by the Candida albicans fungus. Incidence A. It occurs frequently in women, children, and the elderly population. Pathogenesis A. An overgrowth of C. albicans occurs when mucous membranes and/or skin are exposed to moisture, warmth, and an alteration in the membrane barrier. Predisposing Factors A. Immunosuppression B. Use of antibiotics C. Hyperglycemia D. Chronic use of steroid E. Frequent douching by women F. Adults wearing dentures Common Complaints A. Oral: A persistent white patch on the tongue or roof of mouth may be slightly reddened with or without crevices on the tongue B. Vaginal: Thick, white, “cottage-cheese-like” vaginal discharge with or without vaginal itching C. Genital: Bright red rash with well-demarcated satellite lesions advancing to pustules or erosions in genital or diaper area D. Males: Erythemic rash that may advance to erosions seen on male genitalia; scrotum is perhaps involved 158 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Subjective Data A. Question the patient about onset, duration, and location of lesions. B. Determine whether the patient has a history of previous infections. C. Inquire into medical history and current medications. D. Rule out the presence of any other current medical conditions. Physical Examination A. Inspect 1. Assess skin and mucous membranes for discharge and lesions. 2. Observe location and severity of lesions. B. Palpate: Palpate lymph nodes in neck and groin. Diagnostic Tests A. Vaginal and genital infections need to be evaluated for sexually transmitted infections (STIs), especially if the patient is sexually active with multiple partners. Vaginal/genital culture specimen should be sent for gonorrhea/chlamydia testing. B. Other specimens to consider include wet prep/potassium hydroxide (KOH) 10% solution, Gram stain vaginal culture for Candida. Differential Diagnoses A. Oral candidiasis 1. Leukoplakia 2. Stomatitis 3. Formula (for newborns) B. Diaper area 1. Candidiasis 2. Contact dermatitis 3. Bacterial infection C. Genital area 1. Candidiasis 2. Bacterial infection 3. Bacterial vaginosis 4. Chlamydia 5. Gonorrhea 159 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
6. Trichomoniasis Plan A. General interventions 1. Treatment can be successful with good hygiene and medications. 2. Stress to the patient to keep the affected area cool and dry. Frequent changes of clothing may be necessary to keep the area cool and dry to avoid damp conditions. 3. Diaper area will need to be changed more frequently; suggest using cloth diapers and allowing skin to be exposed to air for short periods. B. Patient teaching 1. Use medication on the skin to help with symptoms. 2. Do not scratch. Keep fingernails short. C. Pharmaceutical therapy: Choose one of the following pharmaceutical therapies: 1. Oral a. Nystatin (Mycostatin) oral suspension 100,000 U/m L, 2 m L for infants and 4 to 6 m L for older children and adults, four times daily for 7 to 10 days b. Gentian violet aqueous solution, 1% for infants and 2% for adults, one to two times per day c. Lotrimin buccal troches, five times per day for 2 weeks, only for adults 2. Diaper a. Nystatin cream, three to four times per day for 7 to 10 days b. Mycolog II; apply sparingly to skin twice daily until resolved 3. Vaginal a. Clotrimazole 1% cream, 5 g intravaginally for 7 to 14 days b. Miconazole 2% cream, 5 g intravaginally for 7 days (over the counter [OTC]) c. Terconazole 0. 8% cream, 5 g intravaginally for 3 days d. Terconazole 80 mg vaginal suppository, at bedtime for 3 days e. Fluconazole (Diflucan) 150 mg, oral tablet one time f. Other preparations available in stronger or weaker doses Follow-Up 160 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. None indicated unless not resolved or complications arise. Consultation/Referral A. Consult a physician if not resolved within 2 weeks. Individual Considerations A. Pregnancy 1. Most effective medications for pregnant women are clotrimazole, miconazole, and terconazole. 2. Recommend a full 7-day course of treatment during pregnancy. B. Adults 1. Consider immunosuppression in all adults with oral candidiasis (HIV, diabetes, chemotherapy, leukemia). 2. Adults with oral lesions need to be assessed for leukoplakia, especially if the patient has a history of smoking or chewing tobacco. Contact Dermatitis Jill C. Cash and Amy C. Bruggemann Definition A. Contact dermatitis is a cutaneous response to direct exposure of the skin to irritants (irritant contact dermatitis) or allergens (allergic contact dermatitis). 1. Irritant contact dermatitis is a nonimmunologic response of the epidermis. 2. Allergic contact dermatitis is an immunologic response after one or more exposures to a particular agent. Incidence A. Occurs in all ages. People who work with chemicals daily and wash their hands numerous times a day have a higher incidence of irritant dermatitis. Irritant contact dermatitis is seen in the elderly because of dry skin. Pathogenesis 161 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Irritant contact dermatitis is caused by an alteration of the outer layer of the dermis caused by exposure to chemicals; lotions; cold, dry air; soaps; detergents; or organic solvents. B. Allergic contact dermatitis is caused by an alteration in the epidermis when, after exposure to an allergen, the immune system responds by producing inflammation of the cutaneous tissue. Common allergens include poison ivy, poison oak, sumac, nickel jewelry, hair dye, rubber and leather chemicals (latex gloves), cleaning supplies, harsh soaps, detergents, and topical medicines. Predisposing Factors A. Occupation (hairdresser, nurse, housecleaner, etc. ) B. Jewelry C. Activities in yard or woods Common Complaints A. Irritation of the skin, ranging from redness to pruritic inflammation, with possible progression of blisters. 1. Poison oak, ivy, and sumac induce classic presentation: Lesions (vesicles) and papules on an erythemic base presenting in a linear fashion with sharp margins. 2. Diffuse pattern with erythema may be seen when oleoresin is contacted from pets or smoke from burning fire. B. Exposure to some type of irritant known to the patient. Round or annular lesions may have an internal cause such as a drug reaction. Other Signs and Symptoms A. Chronic 1. Erythema with thickening 2. Scaling 3. Fissures 4. Inflammation; with chronic dermatitis, lichenification may occur with scales and fissures. B. Diaper dermatitis: Prominent red, shiny rash on buttocks and genitalia C. Candidiasis diaper rash 1. Bright red rash with satellite lesions at margins 162 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2. Inflammation and excoriations present 3. Creases may be involved. Subjective Data A. Ask the patient when irritation began and how it has progressed. B. Elicit history of exposure to allergens. C. Question the patient regarding activity and skin contact with irritants before outbreak (cleaning agents, walking in woods, hobbies, change in soap/laundry detergent, shaving cream, lotions, etc. ). D. List occupation and family history of allergens. E. Review medication list, including prescription, over-the-counter (OTC), and herbal medicines, to evaluate an interaction. F. List medications used to relieve symptoms and results. Physical Examination A. Check temperature (if indicated). B. Inspect 1. Inspect skin, noting types of lesions and location of lesions. Note the pattern of inflammation. The shape of irritation may mimic the shape of the irritant, such as the skin under a ring or watch, for example. 2. Determine progression of lesions. 3. Differentiate between primary and secondary lesions. Diagnostic Tests A. Consider none if source is known. B. Wet mount (potassium hydroxide [KOH], saline) to rule out fungal infection if candida is suspected C. Culture/sensitivity of pustules D. Patch test to rule out allergic contact dermatitis Differential Diagnoses A. Irritant contact dermatitis B. Allergic contact dermatitis C. Diaper dermatitis D. Candida E. Tinea pedis, corporis, cruris 163 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
F. Drug reactions G. Pityriasis rosea H. Scabies Plan A. General interventions 1. Irritant contact dermatitis: Removal of irritating agent a. Use topical soaks with saline or Burow's solution (1:40 dilution) for weeping areas. b. Suggest lukewarm baths (not hot); or oatmeal (Aveeno) baths, as needed. c. For dry erythematous skin, use recommend Eucerin or Aquaphor ointments to rehydrate skin. d. Remind the patient to avoid scratching skin and to keep nails short. e. Suggest use of mild soaps and cleansers. 2. Allergic contact dermatitis a. Instruct the patient to avoid contact with the causative agent. b. Have the patient wash the affected area with cool water immediately after exposure. c. Recommend lukewarm baths with oatmeal (Aveeno) three to four times per day. d. Tell the patient to apply calamine lotion after baths. 3. Diaper dermatitis a. Instruct the caretaker to change the patient's diaper frequently, cleaning with water only, and allow skin to air dry 15 to 30 minutes four times a day. Tell the parent not to use lotions or powders, but to apply zinc oxide (Desitin ointment or powder, or Happy Hiney) with each diaper change. b. If candidiasis diaper rash presents, for treatment refer to the “Candidiasis” section in this chapter. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Dermatitis. ” C. Pharmaceutical therapy 1. Irritant contact dermatitis: Hydrocortisone 2. 5% ointment three to four times per day for 2 weeks 2. Allergic contact dermatitis 164 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
a. Low-dose topical steroids: Hydrocortisone 2. 5% ointment three to four times per day for 1 to 2 weeks after blistering stage. Triamcinolone acetonide 0. 025% (Kenalog) ointment/cream twice daily. b. Intermediate-dose topical steroids: Triamcinolone acetonide 0. 1% (Kenalog) cream twice daily. Cream/ointment should not be used longer than 2 weeks at a time. c. High-potent topical steroids: Fluocinonide 0. 05% (Lidex) ointment three to four times per day; not to be used on face or skin folds. Cream/ointment should not be used longer than 2 weeks at a time. d. Hydroxyzine 25 to 50 mg four times daily, diphenhydramine Hcl (Benadryl) 25 to 50 mg four times daily. For children, 0. 5 mg/kg/dose three times daily as needed. e. If the rash is severe (face, eyes, genitalia, mucous membranes), consider prednisone 60 to 80 mg/d to start and taper over 10 to 14 days. f. Triamcinolone acetonide (Kenalog) 40 to 60 mg by intramuscular (IM) injection 3. Secondary bacterial infections: Erythromycin 250 mg four times daily or amoxicillin/clavulanic acid (Augmentin) 875 mg twice daily for 10 days 4. Candidiasis a. Use miconazole nitrate 2% cream, miconazole powder, or nystatin cream. b. Use clotrimazole (Lotrimin) or ketoconazole (Nizoral) cream three to four times per day for 10 days. c. If inflammation is present along with yeast, use Mycolog II. d. If secondary bacterial infection is present, use mupirocin (Bactroban) ointment three times daily for 7 to 10 days. Follow-Up A. None required if case is mild. B. See the patient again in 2 to 3 days for severe cases, or phone to assess progress. Consultation/Referral 165 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |