FATIGUE Fatigue, loss of energy, and lassitude are common complaints hat bring patients to the family physician.

Fatigue consistently ranks among the ten most commonly described symptoms in primary care practice. Women complain of fatigue to the physician 1.5-3.9 times more often than men. Fatigued patients see their physician more often than nonfatigued patients and more diagnosis on their medical records. (1 . 1) Clinical diagnosis and evaluation a. Acute fatigue! "cute fatigue most commonly presents as an incidental symptom of common illnesses. #his problem can occur after stressful life e$periences, because of sleep depri%ation, or as a symptom of common %iral illnesses, pregnancy, medication side effects. #he e%aluation of acute fatigue is best considered in the conte$t of the patient&s other symptoms. 'n most situations, the etiology of acute fatigue (uickly becomes e%ident to both the patient and the physician )ith a basic office history and physical history and physical e$amination. b. Chronic fatigue! *atients )ith chronic fatigue ha%e often seen other physicians pre%iously and may be frustrated by the lack of specific information regarding the cause of their symptoms. "s many as 5+, of patients )ith chronic fatigue )ill continue to be fatigued 1 year after their initial presentation to the physician (1 . " detailed history and physical e$amination are re(uired, including careful re%ie) of pre%ious medical records. #argeted laboratory e%aluation may be useful. 'n most cases, the physicians )ill be unable to identify a specific diagnostic cause of the chronic fatigue, and a fle$ible and systematic management plan )ill be necessary. (i History. -istory at the time of initial %isit should include information regarding the de%elopment of the fatigue and associated symptoms, family history, occupational history, and medication history. .pecial attention should be gi%en to the patient&s sleeping habits, symptoms of depression, history of blood loss, thyroid disorders, e$ercise habits, cardio%ascular fitness, se$ual history and risks factors of human immunodeficiency %irus infection. *atients should be encouraged to share their past e$periences )ith medical e%aluations of the fatigue and any frustrations they may ha%e e$perienced in this area. " history of alcohol or drug abuse should be elicited and a family genogram or other method of family assessment should be considered. (ii Physical exa ination. " complete physical e$amination should be performed. #his )ill impro%e the doctor-patient relationship and establish that the physician takes the complain of chronic fatigue seriously. /e%ertheless, it is unlikely that findings on the physical e$amination )ill be particularly helpful in establishing a definiti%e diagnosis. (iii !a"oratory evaluations. 0aboratory e%aluations are only helpful to the management of the patient in a small percentage of cases (1 . /o tests should be ordered until the old medical records are re%ie)ed in the patient )ho has undergone prior medical e%aluations for fatigue. "dditional tests should be ordered only if indicated by the history or physical e$amination. #he basic laboratory e%aluation includes a 232 and a serum chemistry profile, )hich includes blood glucose, renal function, li%er en4ymes, urinalysis, and sedimentation rate. #hyroid function studies should be considered in patients )ho may ha%e associated symptoms of thyroid disorders. #ests of immune function, 5pstein-3arr %irus titers and lymphocyte subpopulation analysis are of no established benefit in e%aluating these patients

(3 . /either is it helpful to do rheumatologic or serologic e%aluation of these patients in the absence of associated symptoms suggesting these disorders. c #ifferential diagnosis. #he differential diagnosis can best be remembered in broad categories, such as infectious diseases (including %iral syndromes , mononucleosis, hepatitis, endocarditis , to$in and drug effects (such as medication side effects alcohol and drug abuse , endocrine and metabolic problems (such as electrolyte disorders, hypothyroidism, diabetes and malnutrition , neoplasmic conditions (such as leukemia, lymphoma and occult malignancy , %ascular disorders (such as congesti%e heart failure, %al%ular heart disease and cardiomyopathies , pulmonary conditions (such as chronic obstructi%e pulmonary disease or restricti%e lung diseases , miscellaneous conditions (such as anaemia, pregnancy, connecti%e tissue disease , and psychological problems ( such as depression, an$iety, ad6ustment reactions, situational life stress, se$ual dysfunction, spouse abuse, occupational stress and professional burnout .

a. Chronic fatigue syndro e. 'n 1977, the 2enters for 8isease 2ontrol (282 appro%ed diagnostic criteria for chronic fatigue syndrome. "lthough this disorder has engendered considerable contro%ersy, much research has taken place to characteri4e the chronic fatigue patient more effecti%ely. Follo)ing the establishment of the 282 criteria, criteria )ere also described in the 3ritish and "ustralian literature that considerably o%erlap but ha%e some differences. Fe)er than 5, +f patients )ith chronic fatigue in a family practice meet the diagnostic criteria for chronic fatigue syndrome. #hus, although patients ha%e also read about this disorder, the ma6ority of patients )ith chronic fatigue do not (ualify for this diagnosis. #his has caused some researchers to ad%ocate liberali4ing the diagnosis criteria9 the 282&s case-defining criteria are as follo)s! 1. $a%or criteria for chronic fatigue syndro e a. /e)-onset persistent or relapsing fatigue that impairs daily acti%ity belo) 5+, usual acti%ity le%el in a patient )ho has no pre%ious history of similar symptoms. b. :ther conditions that produce similar symptoms must be e$cluded. 1. $inor criteria for chronic fatigue syndro e. #he minor criteria are separate into symptom criteria and physical e$amination criteria. a. The sy &to criteria. " symptom must ha%e begun at or after the time of the onset of the fatigue and ha%e persisted for at least ; months. #hee symptoms are as follo)s! i Fe%er or chills ii .ore throat iii *ainful lymph nodes in the anterior, posterior, cer%ical, or a$illary distribution i% <ne$plained generali4ed muscle )eakness % =uscle discomfort and myalgia %i *rolonged generali4ed fatigue at le%els of e$ercise that )ould ha%e been easily tolerated before %ii >enerali4ed headaches %iii =igratory arthralgia )ith or )ithout 6oint s)elling i$ /europhysiologic or neuropsychological complaints (such as photophobia, transient %isual scotomas, forgetfulness and e$cessi%e irritability $ .leep disturbance $i #he main symptom comple$ initially de%eloping o%er a fe) hours to days b. Physical exa ination criteria

#hese criteria must be documented by a physician on at least t)o occasions, 1 month apart. 1. 0o)-grade fe%er 1. /one$udati%e pharyngitis 3. *alpable or tender anterior cer%ical or a$illary lymph nodes ''. $anage ent of the fatigued &erson .uccessful management of patients )ith chronic fatigue re(uires empathy and trust in the doctor-patient relationship. #he follo)ing principles of management are suggested! ". 3e as interested and concerned about the effects of the patient&s fatigue as you are about its cause. 'n many cases, no diagnosis is forthcoming after the initial e%aluation. 't is therefore also necessary to focus on the effect he symptom is ha%ing on the patient&s life and occupation and the li%es of family members. #his )illingness to address both cause and effect broadens the patient&s problems e%en )hile the diagnostic )orkup is under)ay. 3. 5$plain to patients that the most common cause of fatigue in family practice are depression and psychosocial problems. =any times it )ill take se%eral office %isits for the patient to become sufficiently comfortable to pro%ide additional history to the physician. *roblems such as family %iolence, se$ual abuse, ma6or depression and substance abuse all commonly present )ith the initial complaint of fatigue. 8iscussing these issues early and repeatedly in the course of the e%aluation rather than after physical disorders ha%e been ruled out is beneficial. 2. 5licit the patient&s and family&s thoughts about the most likely e$planations for the fatigue. " symptom diary can be completed by the patient and used by both physician and patient to identify patterns in the symptoms. 8. 2onsider con%ening the patient&s family to e$plore health beliefs and to pro%ide education. 5. 2onsider pro%iding articles about chronic fatigue syndrome and professional burnout to patients. F. <se consultants to support and reinforce the care plan. 2ommunicate clearly )ith consultants about the purpose of the referral. "lthough consultants rarely pro%ide startling ne) insight into the etiology of the patient&s fatigue, they can be helpful as part of a team approach to help the patient understand and cope )ith this problem more effecti%ely. >. " targeted e$ercise program is more effecti%e in helping patients )ith chronic fatigue than is prolonged test. '''. Prognosis Whereas patients )ho are acutely fatigued are most commonly e$hibiting a self-limiting condition that )ill resol%e on its o)n, chronic fatigue is more likely to be refractory to medical management. 'n one study, 5?, of patients )ith chronic fatigue in a family practice setting continued to be fatigued 1 year after their initial e%aluation. *articularly in patients )ho ha%e long-standing histories of chronic fatigue, a palliati%e rather than curati%e approach to management is appropriate. <sing this approach, most patients are e%entually able to return to )ork or school and to li%e producti%e li%es. #I''I(E)) 8i44iness is one of the most challenging diagnostic and therapeutic problems in primary care medicine. .e%eral features make di44iness a particularly perple$ing problem.

=ost patients ha%e a problem that is not life threatening. #here is no measure of di44iness se%erity! it is a sub6ecti%e sensation. #he differential diagnosis is e$tremely long. #hus, diagnostic algorithms are of little %alue. 'nstead, clinicians must use hypothesis testing and pattern recognition. #he diagnosis usually hinges on the clinical history " %ariety of speciali4ed tests are a%ailable (e.g. 1@-hour cardiac monitoring, brain imaging , but they rarely make the diagnosis. =any common diagnoses ha%e therapies that are ineffecti%e or only partially effecti%e. AWait and seeB is often the best approach if serious problems are ruled out.

1. Ta*ing a history ". 8i44iness is a sub6ecti%e sensation of mo%ement or disorientation in space. 't can be a AheadB sensation, a body AsensationB or both. 2ommon terms include spinning, light-headedness, giddiness, %ertigo, imbalance, and a falling sensation. 3. .ubtypes of di44iness. #ry to define the problem as one of these symptom categories! %ertigo, presyncopal light-headedness, imbalance (dise(uilibrium , ocular or other. #he ma6ority of di44iness complains in young and middle-aged adults can be fit into one of these categories. =ost older adults complain of multiple sensations, so this categori4ation is less useful in the elderly. (i +ertigo! Certigo is a sensation of mo%ement, often of rotation, sometimes of tilting. 't is generally associated )ith disorders of the %estibular system, although some psychological diagnoses (e.g., panic disorder are accompanied by %ertigo. 2ommon diagnoses include benign positional %ertigo, acute labyrinthitis, serious otitis media, %ertebrobasilar distribution transient ischemic attack of stroke (15, of brain stem strokes present initially as isolated %ertigo , =eniere&s disease, atypical migraine, cer%ical %ertigo and recurrent %estibulopathy (ii Presynco&al light,headedness! #his is the sensation that one is about to faint, caused by inade(uate circulation to the cerebral corte$. 2ardio%ascular causes, postural hypotension, many medications, %iral illnesses, hypo%olemia and %aso%agal attacks are common causes. (iii I "alance -dise.uili"riu )! this is the sensation of unsteadiness. 'mbalance is al)ays )orse )hen the patient is standing or )alking. 't usually indicates a neurological disease )hen present as an isolated di44iness symptom9 the lesion may be cerebellar (e.g., cerebellar degeneration due to alcoholism , a$onal (e.g. multiple sclerosis , or peripheral (e.g. peripheral neuropathies from %itamin 311 deficiency or diabetes mellitus . (i% /cular di00iness! using the eyes brings on a light-headed, disoriented feeling. 2ommon causes included recent refraction changes, cataract surgery, hyperglycemia, and recent reduction in %ision due to disease (often )ith a concomitant problem in the %estibular or propriocepti%e system for )hich the eyes )ere compensating . (% /ther! >enerally, di44iness that cannot be typed presents )ith %ague light-headed feelings. 't is commonly associated )ith psychological disease such as an$iety and depression. 2. E&isodic versus continuous di00iness ! clarifying the temporal pattern of the di44iness often helps establish the diagnosis. (i 2ontinuous di44iness tends to be due to chronic conditions or psychological disorders or both. (ii 5pisodic di44iness often has a pattern that is uni(ue to certain diagnoses a 3enign paro$ysmal positional %ertigo. #his is episodic %ertigo lasting less than a minute, usually precipitated by rapid head mo%ement such as rolling o%er in bed or bending o%er and sitting up.

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#ransient ischemic attacks. #hese present as episodic di44iness (usually %ertigo lasing 1+ mins to 1 hours in a high-risk patient. 8i44iness need not be accompanied by other neurological symptoms. =eniere&s disease. #his disease presents as episodic %ertigo lasting 1 hours to 1 days, accompanied by tinnitus and often preceded ear stuffiness, )ith gradual de%elopment of permanent lo)fre(uency hearing loss. Decurrent %estibulopathy. 'nfre(uent attacks, usually lasting a day, consist of %ertigo )ithout hearing symptoms. #he course is generally benign9 a fe) e%ol%e into =eniere&s disease.

2. "ssociated symptoms can sometimes help establish the diagnosis. (i -istory of rhinitis, snee4ing, stuffiness can indicate sinusitis or serous otitis media. (ii 8i44iness brought on by hand mo%ement can indicate subcla%ian steal syndrome. (iii /umbness or tingling around the mouth or hands can indicate an$iety or hyper%entilation. (i% 0oss of consciousness can indicate arrhythmia, %aso%agal episode or sei4ure. (% /eck pain mo%ement may indicate cer%ical osteoarthritis. (%i <nilateral hearing loss and tinnitus can indicate =eniere&s disease, acoustic neuroma or middle-ear disease. 1. Physical exa ination and la"oratory testing ". *hysical e$amination should be focused, depending on the history. When the history is unclear, concentrate on %ital signs and cardio%ascular, otologic and neurological e$aminations (i 'f benign paro$ysmal positional %ertigo is suspected, perform the -allpike (also called 3aranyaaa+ maneu%er. 'n this test, the patient is rapidly mo%ed from a sitting to a head hanging (3+ degrees to left or right position! a positi%e result in%ol%es %ertigo, rotatory nystagmus, latency of onset (3 E 1+ seconds , and fatigability )ith recurrent testing. (ii Forced hyper%entilation )ill usually precipitate psychological di44iness. 3. 0aboratory testing should be 6udicious. (i -ead imaging. =D' is preferable to 2#, because most causes to be ruled out are small in the posterior fossa. (ii 2auses of di44iness that can be detected on biochemical testing include hypothyroidism, anaemia, uremia, and %itamin 311 deficiency. (iii 5lectronystagmography helps to identify )hether a %estibular problem is present. 't is useful in a fe) elderly patients. (i% 8oppler ultrasound e$amination of the %ertebrobasilar system. 't is useful in cer%ical %ertigo to rule out subcla%ian steal and it may help differentiate bet)een %ascular and arthritic causes of cer%ical %ertigo. (% -olter monitoring. <se only if history suggests arrhythmia. 3. $anage ent Princi&les a. =ake a diagnosis, if possible. b. <se medications sparingly (i 8rugs cause or )orsen di44iness more often than they help it. (ii =ecli4ine (3onine is useful during acute labyrinthitis, =eniere&s disease or recurrent %estibulopathy! other)ise it generally is not useful. (iii 8ia4epam (Calium suppresses central responses to %estibular stimuli9 it is useful in some chronic di44iness problems.

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"ntidepressants often help panic disorder and an$iety 'f migraine is suspected, appropriate medication can help.

*hysical #herapy is useful for most older persons )ith chronic di44iness, because physical deconditioning is generally present and )orsens the symptoms9 specific physical therapy modalities e$ist to help benign positional %ertigo, bilateral or se%ere unilateral %estibular loss, cer%ical %ertigo due to arthritis and cerebellar ata$ias.

C/UGH 2ough is a mechanism to clear the air)ays of secretions and inhaled particles and is caused by a %ariety of diseases that! a #hat alters mucus (uantity or (uality (e.g. bronchitis b 'ncrease sensiti%ity of cough receptors (e.g asthma c 8irectly stimulate the receptors (e.g. foreign bodies, aspiration d 'ndirectly stimulates the receptors (e.g. reflu$ e "ffect psychological health 2ough is the chief complaint for 3.;, of office %isits to <... physicians E about 15 million annually. "t any time, about 17, of people ha%e a cough. 1. Clinical &resentation ". $edical history. #he differential diagnosis of chronic cough is e$tensi%e but a diagnosis can be made by history alone 7+, of the time. 'mportant issues to clarify includes! (i Ti ing. 's there a history of a recent respiratory infection (a cough can continue for 1 months or longer follo)ing %iral respiratory infection F 's there a similar patternF 8oes it occur )ith hobbies or )orkF 's it more prominent at night (more likely to be from asthma, gastroesophageal reflu$ disease (>5D8 , or congesti%e heart failure (2-F F 's it related to meals or positingF 's it made )orse by e$ercise or e$posure to cold air (e.g. asthma F (iii 1uality and .uantity. 's the cough producti%e (e.g. bronchitis or dry (e.g. asthma is it more like throat clearing (e.g. postnasal is it AbrassyB (e.g. tracheal causes G. (i% Associated sy &to s. 's there dyspnea (e.g. 2-F or intestinal lung disease , hemoptysis (most fre(uently seen in bronchitis but can be the presenting symptom of lung cancer and tuberculosis , )hee4ing, hoarseness (e.g. postnasal or reflu$ , heartburn, fe%er, rthinitis or chest painF (% Past edical history. 's there a history of pneumonia (suggesting bronchiectasis or respiratory allergiesF (%i Health,related "ehaviours. What is the patient&s occupationF 's the patient e$posed to dust or irritantsF 8oes the patient smoke cigarettes or mari6uanaF (%ii $edications. 's the patient taking angiotensin-con%erting en4yme ("25 inhibitors, beta-blockers ()hich may precipitate asthma or nitrofurantoin ()hich may cause interstitial fibrosis F 3. Physical exa ination. 2oncentrate on the follo)ing areas! 1. 5ars! 2heck for cerumen or hairs impinging on the tympanic membrane ("rnold&s refle$ . 1. /ose! 0ook for discharge, edema, or polyps. 2heck for sinus tenderness. 3. #hroat! 0ook for cobblestoning of the oropharyn$ (suggesting postnasal drip . @. /eck! 2heck for masses. 5. 2hest! "sk the patient to repoduce the cough if you ha%e not heard it. 0isten for crackles (rales , rubs and locali4ed and general )hee4es (musical sounds . 'nspiratory )hee4es can be caused by masses or foreign bodies, )hereas, e$piratory )hee4es are commonly heard in bronchospasm. " normal e$amination does not e$clude lung disease.

''. #ifferential diagnosis. "cute cough is usually from a lo)er respiratory tract infection, but it may be caused by any of the chronic cough. #he etiology of chronic cough includes the follo)ing, in order of appro$imate fre(uency.

a. Postnasal dri&. #his is not a )ell-defined entity, but is common and is usually associated )ith allergic or %asomotor rthinitis, less fre(uency )ith sinusitis. #here often s a sensation of tickle or li(uid in the back of the throat. b. Postinfectious. " person may couch for more than 7 )eeks after a respiratory infection has other)ise resol%ed, probably because of bronchial hypereacti%ity. -o)e%er, in some patients, asthma starts )ith a mycoplasmal or other respiratory infection. c. Asth a. 2ough %ariant asthma presents )ith dry cough alone and like may be )orse in e$ercise or cold air. Whee4ing is usually absent in cough %ariant asthma. d. >astroesophageal reflu$. <p to ?5, of patients )ith cough due to >5D8 ha%e minimal or no >' symptoms. #he cough is probably due to the stimulation of the distal esophagus rather than to microaspiration. e. #rug induced. 2ough occurs in more than 1+, or more of patients taking "25 inhibitors. f. Chronic "ronchitis. Forty to ;+, of people )ho smoke one pack a day or more ha%e cough. ' is defined as chronic bronchitis if the cough if the cough has been producti%e for at least 3 months during 1 consecuti%e years. g. /ccu&ational and environ ental irritants. 2igarette or mari6uana smoke, secondhand smoke, air pollution, dust and industrial pollutants may be causes of cough. h. !ess co on causes include (not in fre(uency order tumor (especially broncogenic or mediastinal , aortic aneurysm, pulmonary embolism, 2-F, aspiration, lung abscess, bronchienctasis, petussis, tuberculosis, pneumocystis, sarcoidosis, interstitial lung disease, cystic fibrosis, esophageal disorders, auditory canal stimulation ("rnold&s refle$ , foreign body, any abdominal process that irritates the diaphragm and psychogenic. i. 'n children, the differential for chronic cough includes (roughly in order of descending fre(uency post infection, asthma, postnasal drip and irritants. <ncommon causes include other respiratory infections such as tuberculosis or fungus, pertusis, foreign body, cystic fibrosis, congenital abnormalities and psychogenic. " psychogenic cough occurs primarily in children and adolescents. 't is loud, barklike and ceases during sleep. '''. Ancillary tests. #hese should be ordered 6udiciously. #he etiology is determined most often from the treatment trial. a. I aging 1. 2hest radiography. :rder if there are signs or symptoms suggesti%e of pneumonia, if symptoms are prolonged or se%ere, or if there are une$pected physical findings. 1. )inus fil s. #hese may be helpful in patients )ith cough and suspected postnasal drip. 3. !ung CT scan or $2I. :rder to better define endobronchial, parenchymal or mediastinal masses. 2# scan has replaced bronchrography or diagnosing bronchiectasis. b. 3lood tests 1. " W32 count is sometimes helpful in determining the presence of a significant bacterial infection (leukocytosis, not left shift . 1. "n ele%ated or increasing pertussis to$in or filamentous hemagglutinin titer is the best )ay to diagnose Bordetella pertussis. 3. Fungal serology. #iters for coccidioidomycosis, histoplasmosis and aspergillosis can be checked if a fungal infection is suspected.

c. )*in tests. "n intradermal =antou$ tuberculin skin test is still the best screening test for the presence of current or past tuberculosis infection. " positi%e test result should be follo)ed up by a chest film.

d. )&utu tests and icro"iology 1. >ram&s stain, not bacterial culture, is the best )ay to determine the likely organism causing bronchitis or pneumonia. 1. .putum or nasal smear for eosinophils can help confirm an allergic basis for cough 3. 2ytology can be ordered in the cigarette smoker )ith persistent cough and a normal chest film. @. /asopharryngeal cultures for group ". streptococcus and 3. pertussis should be done if this etiology is under consideration. 5. #uberculosis or fungal smear and culture )ill diagnose acti%e disease. e. Pul onary function tests 1. .pirometry is helpful in the diagnosis of obstructi%e lung disease e.g. chronic bronchitis, asthma and restricti%e lung disease (e.g. sarcoid . *atients )ith post infectious or cough %ariant asthma maysho) mild obstruction but often ha%e normal spirometry. 1. 3ronchopro%ocation test )ith methacholine or other aerosol challenge is not )idely a%ailable but sometimes is the best )ay to diagnose cough %ariant asthma. 'f normal, it rules out asthma, but there are false positi%e results. f. 8irect nasopharyngoscopy directly %isuali4es abnormalities of the nose, pharnyn$ and laryn$. g. bronchoscopy is occasionally necessary to diagnose une$plained hematosis, endobronchial lesions or foreign bodies. h. <pper gastrointestinal endoscopy and barium esophagrams are often normal in patients )ith reflu$. 5sophageal p- monitoring is the best test, )ith a sensiti%ity of 91,, for >5D8. 'C. $anage ent. 2oughing is a symptom, and )here possible, therapy is directed to its etiology. a. "l)ays try to get patients to stop smoking, especially those )ith chronic bronchitis or irritant cough. 5%en after smoking cessation, ho)e%er, it can take a year or longer to for the cough o resol%e. b. 'nhaled beta-agonists, such as metaproterenol or albuterol )ith a spacer, 1-1 inhalations e%ery @-; hours, are the bronchodilators of choice for asthma, but they do not suppress bronchial hyperacti%ity. #herefore, other types of medication may be more effecti%e in cough %ariant asthma and postinfectious cough. 'nstead beta-agonists )ork as )ell as antibiotics for the treatment of acute bronchitis. 'pratropium aerosol("tro%ent 1 inhalations (id is often effecti%e in the treatment of chronic bronchitis. c. 'nhaled medications that are recommended for cough %ariant asthma and postinfectious cough are cromolyn and steroids, such as beclomethasone. #he usual stating dose for either is 1 inhalations (id. d. 8econgestant antihistamine combinations are the first-line treatment of postnasal drip. 'ntranasal steroid sprays or aerosols such as beclomethasone or de$amethasone 1-1 sprays bid to (id, should be tried for postnatal drip caused by %asomotor or allergic rthinitis that does not respond to he oral combinations. e. "ntitussi%es ha%e a limited role. 'n acute respiratory infections )here cough disrupts sleep, de$tromomethorplan, 1+-3+mg, or codeine, 15-3+mg, taken e%ery 3-@ hrs may suppress cough. -o)e%er, randomi4ed controlled trials in children and adults sho) neither to be more effecti%e in than placebo or guaifenesin. f. 5$pectorants may decrease sputum %iscosity, but there is little e%idence for their effecti%eness. >uaifenesin is the most prescribed e$pectorant and is also used to loosen mucus in sinusitis. g. 'n "25 inhibitor-induced cough, it is best to stop the drug. .ubstituting another "25 inhibitor doe usually help. 'f the medication must be continued, use of a cromolyn inhaler may suppress the cough. h. :ther non-specific cough ailments that may help, but are not )ell e%aluated, include hydration, humidification, postural drainage, topical nebuli4ed @, lidocaine, and oral ben4onatate, 1++mg tid.

i. "ntifeflu$ therapy includes -1 antagonists for acid suppression, ranitidine (Hantac , 15+mg bid, or promotility agents such as cisapride (propulsid , 1+-1+ (id or both. :ther non-drug measures include bed ele%ation, a%oiding alcohol and caffeine and diet change. 'f there are heartburns symptoms and they respond to treatment, the cough )ill likely also impro%e. 6. 3eha%ioural therapy, rather than insight-oriented psychotherapy, has been used to treat psychogenic cough. k. 2omplications of coughing include chest )all pain, (e%en rib fracture , abdominal )all pain, insomnia, hemoptysis, urinary incontinence, syncope, sub6uncti%al hemorrhage, pneumothora$, headache, and most importantly, social isolation.

CHE)T PAI( 2hest pain is a clinical syndrome that may be caused by almost any c%ondition affecting the thora$, abdomen or internal organs. 't is critically important to distinguish the t)o ma6or presentations of chest pain, emergent and nonemergent, as their clinical epidemiology is %ery different. E ergent chest pain is usually defined as the type of pain that cannot be ignores and that prompts most indi%iduals to seek immediate medical attention usually in the emergency room. =ost of the medical literature on the sub6ect of chest pain describes the type of pain, for )hich the probability of acute cardiac ischemia or unstable coronary artery disease (2"8 is (uite high. (one ergent chest pain is less compelling and patients usually choose to seek medical care during routine office hours. 't is a common complaint in the primary care setting, representing 1-1, of office %isits. "lthough fe) studies ha%e described these patients, it is clear that the probability of acute cardiac ischemia or unstable 2"8 in this setting is significantly lo)er than is seen in the emergent setting! the most fre(uently recorded diagnoses are musculoskeletal chest pain and gastrointestinal tract conditions. " significant proportion of cases remain undiagnosed or labeled atypical or noncardiac chest pain. #his chapter presents a suggested approach to the diagnosis of nonemergent chest pain as seen in routine office practice, follo)ed by common clinical presentations of the most fre(uently seen conditions, and laboratory and ancillary studies helpful in establishing a diagnosis. .pecific management recommendations are left for the chapters describing each condition in more detail. 14 General a&&roach to the evaluation of chest &ain a. *erform se%erity and acuity assessment. 'f the patient has emergently sought care at the office for acute onset of se%ere pain or pain associated )ith diaphoresis or difficulty breathing, e%aluate as for emergent chest pain. 8iagnostic e%aluation should focus on the e$clusion of se%ere cardiac disease. b. Use &ro"a"ilities to focus attention on the ost li*ely diagnostic &ossi"ilities . 3egin )ith the pre%alence data supplied in section '' as a crude estimate of the prior probability of possible diagnoses, then ad6ust these probabilities up or do)n, based on e$perience and the fi%e key clinical features i.e. predisposing factors, onset, duration and character of pain, and things pro%iding relief of pain. 8o not begin by attempting to rule out specific conditions. *remature use of e$amination findings, laboratory studies, and ancillary testing to e$clude specific diagnoses leads to e$cessi%e use of medical resources.

=ore important, the use of some ancillary tests e.g. graded e$ercise tests on populations )ith a lo) probability of the disease in (uestion results in a high rate of false-positi%e errors in test interpretation. c. Perfor directed &hysical exa ination and la"oratory assess ent. " complete physical e$amination is often not necessary )hen history alone strongly suggests a specific cause. For e$ample, in patients )ith costochondritis, reproducibility of pain on palpation can confirm the diagnosis )ithout need for further e$amination or laboratory studies. d. Use follo5,u& visits to reassess chest &ain 5hen diagnosis is uncertain . #ime can be both a diagnostic and therapeutic agent in the primary care setting. 2linical clues to the diagnosis may only appear o%er time, and pain may resol%e spontaneously. .pecific diagnosis and inter%ention is not al)ays necessary at the initial %isit. e. Consider e &iric thera&y. When a specific diagnosis is likely but not yet pro%ed, consider a trial of empiric therapy based on the tentati%e diagnosis. 'f therapy is successful, confirmation of the diagnosis is through laboratory studies or ancillary testing may no longer be necessary. ''. Co on clinical conditions causing none ergent chest &ain6 including their &revalence6 characteristic clinical features6 and hel&ful tests4 a. $usculos*eletal conditions (3;, 1. $uscular chest &ain6 chest 5all uscle &ain6 &ectoralis strain (1+, . #his condition is most commonly seen in acti%e young men and )omen. .uggesti%e history includes sharp pain of recent onset, associated )ith minor trauma or repeated use of arms and shoulders, and pain )ith mo%ement, radiating to shoulder, back or arm, )ithout associated systemic symptoms. 2haracteristic physical e$amination findings include tenderness on musculoskeletal palpation or e$acerbated by mo%ement. 'n this clinical setting, laboratory studies are not necessary. 1. Costochondritis -Tiet0e7s synro e) 1894 #his condition is often seen in young )omen, particularly black )omen. .uggesti%e history includes pain )ith the use of the chest )all muscles and sometimes chest ache at rest or pain )ith deep inspiration, )ithout history or trauma. 'f tried, o%er-the Ecounter anti-inflammatory agents ha%e often pro%ided relief. #he characteristic physical e$amination finding is tenderness to palpitation o%er the costochondral margins, often )orse o%er the left third or fourth margin. 0aboratory studies are not helpful in establishing the diagnosis. 3. "nother musculoskeletal condition causing chest pain is ri" fracture (1, . "4 Gastrointestinal conditions -1:9)4 1. Gastroeo&hageal reflux disease -GE2#)6 reflux eso&hagitis6 dys&e&sia6 gastritis -189) . #his condition affects al ages and both se$es. 2linical history may %ary considerably, but suggesti%e findings include late postrandial discomfort (half an hour or more after food intake , pain on an empty stomach, night or morning cough or both. "ssociated abdominal or epigastric discomfort, sharp retrosternal pain or pressure, dysphagia or odynophagia, hoarse %oice, )ater brash and presence of significant e$ternal stressors. *atients may e$press relief )ith antacids or food intake. #here are fe) characteristic physical e$amination findings! epigastric tenderness is a common but nonspecific finding. 0aboratory studies helpful in establishing the diagnosis include upper gastrointestinal radiography (<>' , esophagogastroduodenoscopy (5>8 , esophageal manometry and p- measurement, and 3ernsteins test. 1. Eso&hageal s&as (@, . #his condition may be more common in patients )ith >5D8. 2linical history is (uite %ariable is (uite %ariable but may include the follo)ing! sudden onset of none$ertional s(uee4ing substernal pain or pressure, sharp susbsternal pain that can atimes be locali4ed by the patient )ith one

finger, often relie%ed by antacids or eructation, positional ()orst )hen recumbent but not affected by mo%ement. #he pain can last from moments to hours and can be associated )ith dysphagia. #here are no characteristic physical e$amination findings. 0aboratory studies are often necessary to establish the diagnosis! barium s)allo) (nutcracker esophagus or esophageal manometry (markedly ele%ated muscle tone are especially useful, and <>', 5>8 or esophageal p- measurement may confirm associated gastroesophageal p- measurement may confirm associated gastroesophageal reflu$. 8ifferential diagnosis for these patients may include angina pectoris. #he similarities of symptoms make it e$tremely difficult to distinguish esophageal spasm from angina )ithout confirmatory laboratory testing. 84 /ther GI conditions causing chest &ain; Pe&tic ulcer disease -19)6 choletothiasis and cholecystitis -19)6 eso&hageal uscle and otility disorders -<19) 2. Cardiac conditions -1=9) 1. >Ty&ical cardiac ische ia; angina &ectoris -1?9)6 unsta"le -crescendo) angina -14@9) . #his condition is most commonly seen in middle-aged to elderly men and pos menopausal )omen. .uggesti%e history includes diffuse susternal chest tightness and discomfort )ith consistent le%el of physical e$ertion, sometimes )ith emotional e$ertion, often associated to radiation to 6a), left arm or back and sometimes accompanied by respiration and not relie%ed by dyspnea, nausea, diaphoresis or sudden fatigue. *ain is not affected by respiration and not relie%ed by antacids or position changes but is usually relie%ed by antacids or position changes but is usually relie%ed by rest of sublingual nitates. 3et)een episodes there are no characteristics physical e$amination findings. 8uring episodes, patients may ha%e hypertension or hypotension, palpably displaced point of ma$imal cardiac impulse, systolic murmur of mitral insufficiency, transient third or fourth sound (.3 or .@ , or other signs suggesti%e congesti%e heart failure. -elpful laboratory studies include 52> (.#-segment depression during episode , graded e$ercise testing (>I# , stress thallium scan, stress echocardiography and cardiac catheteri4ation. .erum creatine phosphokinase isoen4yme measurement (2*J should only be performed in the inpatient setting. 'f clinical suspicion of (=' is sufficiently high to )arrant 2*J measurement, the patient should be admitted for cardiac monitoring and consideration of thrombolytic therapy. #he clinician must differentiate bet)een stable and unstable angina. 'f patient has no pre%ious diagnosis of angina (all ne)-onset angina is by definition unstable until symptom pattern established or if there is an increase in fre(uency, intensity or other change from established pattern of angina episodes, the diagnosis is unstable angina and aggressi%e management is indicated. 1. >Aty&icalA angina &ectoris -vasos&astic angina6 variant angina) -<19) .#his condition primarily affects young to middle-aged )omen suggesti%e history includes diffuse substernal chest tightness or discomfort occurring at rest, sometimes radiating to the 6a), left arm, or back, occasionally accompanied )ith dyspnea, nausea, diaphoresis or sudden fatigue. #he pain is not associated )ith inspiration or e$piration and is not relie%ed by antacids or position changes. 3et)een episodes, there are usually no specific physical e$amination findings. 8uring an episode, patients may ha%e he e$amination findings listed. -elpful laboratory studies include 52> (.#-segment depression during episode , >I#, stress thallium, stress achocardiography and cardiac catheteri4ation )ith ergono%ine challenge testing. 3. $ital valve &rola&se syndro e -14@9)4 #his condition is almost e$clusi%ely seen in young to middleaged )omen. *atients often report substernal chest pain of %ariable duration, sharp or dull, often accompanied by palpitations that may be )orse )ith e$ertion or in the presence of e$ternal stressors. #he characteristic physical e$amination finding is a mdsystolic click follo)ed by systolic murmur on cardiac auscultation (click-murmur . #)o-dimensional echocardiography )ill confirm this diagnosis. 'f

echocardiographyis normal, the clinician should consider alternati%e, diagnoses, such as an$iety-related chest pain, panic disorder or %ariant angina. @. :ther cardiac conditions causing chest pain! 2ardiac dysrththmias (1, and acute and subacute pericarditis (K1, . 8. Psychosocial conditions -:9) 1. Anxiety or stress related chest &ain4-B9). #his condition is usually seen in healthy young men and )omen. 2haracteristic symptoms include chest tightness associated )ith dyspnea, difficulty in taking a deep breath, or hyper%entilation, often associated )ith other stress-related symptoms (headache, >' symptoms or the presence of significant e$ternal stressors9 usual duration might be hours to days. :n physical e$amination, patients often e$hibit distress out of proportion to ob6ecti%e findings. 0aboratory studies are usually not helpful, but a brief mental health screening instruments such as *D'=5-=8 (? , may assist in establishing a diagnosis of an$iety disorder, depression and stomati4ation disorder. 1. Panic attac*s or &anic disorder -<19). #hese conditions are most commonly in seen in young )omen, )ho usually presents )ith episodes of chest tightness accompanied by some of the follo)ing autonomic symptoms! dyspnea, AsmotheringB sensation, di44iness, palpitations, trembling, s)eating, nausea, parenthesias, hot flashes, depersonali4ation, and fear of dying or going cra4y. 3et)een episodes, physical e$amination is non-specific, sometimes characteri4ed by an$iety. 8uring episodes, patients may ha%e a rapid respiratory rate, tachycardia, and increased tremulousness. 0aboratory studies are usually not helpful, but a brief mental health screening instrument or re%ie) of the diagnostic criteria for panic disorder )ith the patient may assist in establishing the diagnostic criteria for panic disorder )ith the patient may assist in establishing the diagnosis. 8ifferential diagnosis should include mirtral %al%e prolapse and generali4ed an$iety disorder. f4 Pul onary conditions -@9) 1. 3ronchitis -C9). #his condition is more likely to occur in smokers. .uggesti%e history includes dull chest ache often accompanied by a producti%e cough, )ith occasional sharp pain )ith cough. *hysical e$amination may re%eal upper air)ay congestion, rhonchi clearing )ith cough, or diffuse )hee4ing on pulmonary auscultation. 0aboratory studies are not necessary, unless chest radiography is performed to rule out pneumonia. 1. Pleurisy6 &leurodynia -1,C9). #his condition often accompanies %iral or bacterial respiratory infections or inflammatory conditions. .uggesti%e history includes acute onset of sharp pain associated )ith breathing or mo%ement sometimes by other symptoms of inflammation (e.g. 6oint stiffness or pain or rash . *hysical e$amination may re%eal a pleural friction rub laboratory studies such as serum rheumatoid factor, antinuclear antibody screen and erythrocyte sedimentation rate may be useful to e$clude underlying rheumatologic or connecti%e tissue disease. 2hest radiography may be helpful to e$clude pneumonia. 3. Pneu onia -19). #his condition affects all ages and both se$es. .uggesti%e history includes sharp or Ara)B pain e$acerbated by inspiration and cough accompanied by systemic symptoms of se%ere cough, fe%er, and dyspnea. 2haracteristic physical e$amination findings include to$ic appearance, rapid respiratory rat, fe%er and consolidation or locali4ed )hee4ing on pulmonary auscultation. <seful laboratory studies include chest radiograph and sputum culture. @. /ther ul onary conditions causing chest &ain; Pul onary e "olis -<19)6 &ne othorax -<19). F. /ther conditions -189)! /onspecific or atypical chest pain (13, . #his ill-defined diagnostic label refers to the absence of an identifiable cause for chest pain, but most descriptions of this entity refer to relati%ely young

patients )ith %aguely defined pain occurring )ith a specific pattern. *ain is often described as As(uee4ingB and not )ell locali4ed. *atients are usually alarmed by these symptoms9 attribute them to cardiac disease and present for reassurance. #his diagnosis is often reached only after an e$tensi%e and negati%e e%aluation for cardiac disease has been completed.

C/()TIPATI/( 2onstipation can be defined as ha%ing fe)er than three spontaneous episodes of defecation per )eek. =ore than @.5 million "mericans are affected and at least L3;7 million is spent each year on o%er-the-counter (:#2 la$ati%es. 1. Etiology. #he causes of constipation include the follo)ing! #o$ins and drugs (e.g. anticholinergics, opiates, calcium and iron supplements %erapamil and aluminum and bismuth containing antacids . =etabolic (e.g. diabetes mellitus, hypercalcemia, hypothyroidism, hypokalemia, pregnancy, uremia /europathic (e.g. -irshsprung&s disease, multiple sclerosis, *arkinson&s disease =yopathic (e.g. amyloidoisis, scleroderma .tructural e.g. colorectal carcinoma, rectal strictures, hemorrhoids, di%erticulosis. 8ietary (e.g. decreased fecal )ater due to dehydration, decreased fiber intake *sychosocial (e.g. fecal retention, hectic lifestyle ''. Evaluation and 5or*u& a. -istory. 2onstipation means different things to different people, so the specific pattern of defecation should be ascertained )ith (uestions! -o) many stools per )eekF "re stools hard or pelletlikeF 8o you strain or e$perience incontinenceF 'nclude the duration of symptoms, onset, description of medications used, temporal relationship to symptoms, abdominal surgery and family history. b. Physical exa ination. 0ook for the dry skin, delayed deep tendon refle$es, and other signs of hypothyroidism and the facies, gait, rigidity and tremor that characteri4e *arkinson&s disease. *alpate the thyroid for masses or enlargement. 5$amine for abdominal distention, tenderness, bo)el sounds and masses. Dectal e$amination may re%eal a stricture or mass. "bnormal sphincter tone or absent anal )ink may indicate a spinal cord disorder. -emorrhoids or fissures may be apparent.

c. #iagnostic studies should be guided by the data obtained from the history and physical e$amination, tailored by specific risk forces and the clinical presentation. "n abrupt change in the defecation pattern of a middle-aged or older patient must be e%aluated for colorectal cancer. #he acute onset of constipation and abdominal pain and %omiting should be e%aluated for obstruction. #he child )ith lifelong constipation may suggest -irshsprung&s disease. 2hronic constipation not impro%ed after a 1 to @ )eek trial of fiber and fluid merits further e%aluation. 1. !a"oratory tests may include stool occult blood, serum potassium, calcium, creatinine, glucose and thyroid stimulating hormone. 1. 3ariu ene a is performed to e$clude a structural lesion, such as colon. 3. Flexi"le sig oidosco&y or colonosco&y may be used to e$clude structural lesions. *atients o%er ;+ years old and selected younger patients )ith risk factors may )arrant colorectal cancer screening. @. Didney6 ureter6 and "ladder and u&right radiogra&hs can confirm the presence of stool in the colon. 8ilated pro$imal bo)el loops , air-fluid le%els, and a paucity of distal bo)el gas are e%idence of obstruction. 5. Anorectal ano etry is helpful in delineating outlet obstruction. 0ack of refle$ rela$ation of the internal anal sphincter is diagnostic of -irschprung&s disease. ;. 2adio&a.ue ar*er studies document transit through the ascending colon. -is study is indicated in the patient&s refractory to treatment )ith normal anorectal manomatry, distinguishing colonic inertia from imaginary constipation. ?. Tissue "io&sy may be performed in the e%aluation for -irschsrung&s disease or colorectal cacinoma. '''. Prevention a. #ietary fi"er su&&le entation is an effective eans for reducing consti&ation and de&endence on laxatives. .oluble fiber, such as that found in grains bran, nuts and beans, as )ell as ra) fruits and %egetables in con6unction )ith ade(uate fluids (e.g. )ater, 6uices, caffeine-free soda produce, larger, softer, more easily passed stools. 2onsumption of highly refined foods is to be reduced b. $edications, la$ati%es and supplements kno)n to precipitate or e$acerbate constipation should be a%oided, reduced or eliminated if possible. c. Education. 2ounsel the patient that there is )ide %ariation in normal patterns of defecation and that daily ApurgingB is not necessary. 'nstruct patients to set aside time for bo)el training, to take ad%antage of the peristalsis that usually occurs mornings and after meals and to respond to the refle$ defecation urge that it stimulates. =inimi4e %oluntary suppression of the defecation refle$. Dela$ the e$ternal sphincter by sitting on the toilet on a regular basis for 1+ minutes )ithout straining. Degular e$ercise may be beneficial.

'C. $anage ent. :b6ecti%es of treatment include relief of impaction, if present9 minimi4ing of aggra%ating factors e.g. drugs, diet identifying and correcting the primary disease process e.g. colon cancer, rectal pathology, and restoring responsi%eness to normal bo)el refle$es. -a%ing reasonably e$cluded organic causes, short-term la$ati%e therapy is institutes )hen pre%ention fails. >eneral measures are detailed belo)! a. 3ul* agents are recommended as a first-line treatment. #hey are effecti%e and ine$pensi%e, and they produce results in 7-1@ hrs but may take up to 3 days. .ide effects include bloating, gas, and impaction. "dminister at least 7 glasses of li(uid )ith each adult dose.

1. $ethgycellulose! (citrucil . "dult dosage is 1-@ tablespoonfuls daily *:. 2hildren older than 3 yrs can take M tablespoonful (d-tid *:. 1. Calciu &olycar"o&hil (fiberall, Fiber2on #ablets . "dult dosage is 1 tablet (d-(id *:. 2hildren aged ;11 yrs can take half the adult dose. 3. Psylliu (=etamucil, Jonsyl . "dult dosage is 1 tablespoon (appro$imately 3.@g (d-tid *:. @. 3arley alt extract (=altsupe$ . "dult dosage is 11-31g *: bid. 'nfants older than 1 month can take @-7 g in 1-@ o4 of fluid or formula bid as needed. b. !u"ricants, such as, mineral oil, coat the stool, allo)ing it to pass more easily. #hey are mild yet effecti%e for short-term use. Desults are produced )ithin 7 hours. #here is a risk of lipoid pneumonia if aspirated, and they impair absorption of fat-soluble %itamins. 0ubricants can be used in impaction or before instituting pre%enti%e measures. "dult dosage is 1-1 tablespoons bid *:9 for children 1+-15 ml (hs to bid *:. c. /s otic oral preparations )ork in ;-1@ hrs, and suppositories in15-3+ minutes. Fre(uent la$ation may still be re(uired in an occasional patient. .orbitol ?+, or lactulose is recommended. 1. )or"itol ?+,. .orbitol is ass effecti%e as lactulose at a much lo)er cost. "dult dosage is 3+-;+ ml (hs *:. 1. !actulose (2hronulac . "dult dosage is 3+-;+ml (hs *:. <se )ith caution in diabetics. 3. Polythelene glycol,electrolyte solution (>o0N#50N is indicated in preparation of bo)el studies. 't may e a useful ad6unctin the se%erely constipated patient. "dult dosage is 15+ ml e%ery 15 minutes *: or by nasogastric tube for a total of 1.5-3.5 liters after a @ to 5 hours fast. @. Glycerin (Fleet . >lycerine lubricates and spftens hard stool and stimulates the rectal refle$. "dult dosage is one 1-3g suppository *D9 for children less than ; years old, gi%e a 1 to 1.?g suppository *D. C. /ther easures a. Pro*inetic agents increase apontaneous stool fre)uency and diminish la$ati%e dependence in chronically constipated patients. adult dosage of cisapride (*ropulsid is 1+ mg bid *:. b. )ti ulants and irritants. #hese are not recommended for chronic use. .ide effects include chronic camping, fluid and electrolyte disturbances, .te%ens-Oohnson syndrome and abuse potential. #hese agents include phenolphthalein (5$-la$ , the anthra(uinone deri%ati%e senna (.enokot , and bisacodyl (8ulcola$ . c. )aline laxatives are indicated for acute bo)el e%acuation, not for long-term use. Watery diarrhea is produced )ithin +.5-; hours. =agnesium hydro$ide 7, suspension (=ilk of =agnesia 1+ o4 *: is used in this setting. d. Ene as are to be used sparingly and administered carefully per rectum due to risk of perforation. #hese agents include sodium phosphate (Fleet , 117 ml *D, and sorbitol 15-3+, solution (11+ ml *D . #hey may be useful in relief of impaction. #ap )ater enemas are not indicated for use in infants or children. e. )urfactants soften stools but ha%e not been sho)n to ha%e a significant la$ati%e effect in fi%e randomi4ed trials. 8ocusate sodium (2olace , 5+-5++ mg (d *:, is the adult dosage. f. )urgery is rarely re(uired (as it is in -irschsprung&s disease or colorectal carcinoma . g. Consultation should be obtained from the appropriate specialist )hen the diagnosis remains obscure, if management is in doubt o%er an e$tended period, or )hen speciali4ed procedures are indicated.

3ACD PAI( 3ack pain, particularly lo) back pain affects %irtually e%eryone at some time. #he etiology is often obscure but once a series medical problem is eliminated, the management is usually straightfor)ard. 1. !o5 "ac* &ain ". Etiology. 2auses include musculoligamentous in6uries, disk herniation )ith ner%e impingement, sacroiliac (.' 6oint derangements, degenerati%e changes of the bone, disk, or facet 6oint, spinal stenosis, such as cancer, infection, rheumatologic disease and %isceral diseases, such as aortic aneurysms or kidney disease. #he first task for the clinician is to rule out a serious non-orthopedic problem. #hereafter, defining a specific lesion is less important. 3. #iagnosis 1. History. .erious conditions are found more fre(uently in patients older than ;+years. #o rule out a potentially serious condition, ask about a history of trauma, cancer, une$plained )eight loss or fe%er, failure of pain relief )ith bed rest, saddle anesthesia, bladder or bo)el dysfunction, or a history that indicate a risk for infection (e.g. -'C-positi%e status, 'C drug use, and immune suppression . 'n(uire about the onset of pain. 8isk problems tend to occur suddenly, )hereas other mechanical pain often comes gradually. 'nformation about the duration of the pain, prior episodes of back pain, and identification of precipitating situations at )ork or during e$ercise can be helpful. *ain belo) the knee, paresthesias, and )eakness of the lo)er legs are consistent )ith a ner%e compression, usually due to a disk derangement! protrusion or herniation. *atients )ith unilateral lo) back and buttock pain that gets )orse )ith standing in one position may be suffering from an .' 6oint derangement. " history in older patients of e$acerbation of pain )ith )alking that is relie%ed by leaning for)ard is suggesti%e of neural claudication due to spinal stenosis. 't is important to assess current functional limitations, employment history and psychosocial situation in order to plan a course of treatment. 1. Physical exa ination. :bser%ation of the person&s posture and demeanor as you )alk in the room helps to assess the se%erity of pain. 5$amine the spine for acute de%iation, )hich is a sign of disk derangement. #esting the range of motion of the spine looking for asymmetric motion can also help identifying disk problems. #he )alk test is performed by the e$aminer positioning his or he thumbs o%er the patient&s posterior superior iliac spines )hile the patient ' standing, then )atching to see if the thumbs mo%e symmetrically )hen the patient&s hips are fle$ed. "symmetry of mo%ement indicates an .' problem. .traight leg raising and e$tension of the knee )hile sitting (flip test are tests for dural impingement9 these tests are considered positi%e )hen pain is produced in the back or leg as the leg is e$tended. *ain on the contralateral side is a strongly positi%e test result. 5%ery back e$amination should include a neurological e$amination that includes muscle testing, sensory e$amination and testing of deep tendon refle$es, especially in the 0-@ to .-1, distribution, because 95, of lumbar disk herniations occur at 0-@ to 0-5 to .-1. *alpation for tenderness o%er he lumbar spinous processes and bet)een 0-@ and the iliac crest o%er the ileolumbar ligament completes the e$amination. 3. !a"oratory and radiogra&hic studies. 'n the e%aluation of nontraumatic lo) back pain, laboratory or radiographic studies are not usually necessary )ithin the first @ )eeks of the onset of the back pain unless there are signs of a serious condition. 2# scans and =D's can be misleading

because of their high false positi%e rate. ;@, of asymptomatic people ha%e either a bulge or a protrusion of a disk on =D'. 5%en after @ )eeks, these tests should be reser%ed for the case in )hich the surgery is contemplated. 3lood tests are not indicated for the first @ )eeks unless there is a fe%er or other sign of systemic illness. 2. $anage ent 1. Patient education. 3ecause 9+, of patients reco%er )ithin @ )eeks despite method of treatment, patient education regarding the natural history of lo) back pain is an important aspect of a successful outcome. #aking time to discuss successful specific e$ercises and pre%ention by impro%ing general fitness is also important. *atients should be sent back to )ork, in a modified capacity if necessary, as soon as possible to pre%ent deconditioning and to increase mo%ement. #his also ser%es to a%oid de%eloping a disability mindset. 2ontemporary management, as e$pressed in the "gency for -ealth 2are *olicy and Desearch ("-2*D #ask Force report, mo%es beyond e$clusi%ely addressing pain control and bed rest to emphasi4e on impro%ed acti%ity tolerance and an early return to )ork. 1. Activity level. 3ed rest should be a%oided e$cept in the e$treme cases, and e%en then patients should be put on bed rest for only 1 or 1 day. "ll lifting and bending should be a%oided temporarily. "fter 1 )eeks, conditioning e$ercises should be instituted. =ild aerobic and postural e$ercises, such as strengthening e$ercises are used as impro%ement progresses. 3. $edication. :ne )ell-designed study has sho)n that patients treated )ith fe)er pain medications and less bed rest than other therapies ha%e lo)er cost and e(ual functional impro%ement after 1 and 1)1 months. /on-steroidal anti-inflammatory drugs (/."'8s and acetaminophen should be used as first-line agents. =uscle rela$ants are fre(uently used but ha%e not sho)n to be any more effecti%e than mild analgesics. "-2*D guidelines suggest that opiod used for more than 1 )eeks, oral steroids, and colchicines should be a%oided all together. .ome specialists, ho)e%er, find %alue in these treatments for the occasional patient )ith se%ere pain. @. Physical treat ent ethods. =anipulation by physical therapists, physicians, or chiropractors can be helpful during the first month of symptoms. 't can also be used for .' 6oint problems that are common in pregnancy. =cJen4ie e$ercises are helpful for disk derangement. #raction, biofeedback, and physical modalities, such as heat and cold packs and corsets, ha%e not been sho)n to be helpful. 5. In%ections. 5pidural in6ections can be helpful in radicular pain. #rigger point in6ections are also used but ha%e not been )ell studied. ;. )urgery. 2auda e(uina syndrome re(uires immediate surgery9 other)ise only 5-1+, of symptomatic disk herniations re(uire surgery. 'n fact, sciatica e%idence of ner%e root compromise after a month of conser%ati%e care. ?. Psychosocial factors. " poor social situation can alter a patient&s reaction to pain, especially if there is 6ob dissatisfaction. :ther factors, such as pending litigation can complicate can complicate or prolong the treatment. "ssessment by a psychiatrist or other mental health professional may be helpful if the psychological issues are comple$. ''. Chronic lo5 "ac* &ain. 0o) back pain lasting more than ? )eeks is considered chronic and carries )ith it a )orse prognosis. #he longer the pain endures, the less the likelihood of reco%ery. #he goal of treatment should be to impro%e functional capacity despite the pain. *assi%e modality treatment should be a%oided. =echanical assessment, such as that done by a =cJen4ie program and acti%e e$ercise reconditioning programs )ith e$perienced therapists, can be helpful. :ngoing psychosocial support is also crucial. 0igament in6ections are ad%ocated by some physicians. .urgery is best a%oided unless there is a pro%en source of pain.

=any alternati%e therapies are a%ailable to these patients9 unfortunately fe) ha%e been studied scientifically. =ost do not cause harm and may be )orth trying for selected patients. '''. Cervical &ain. ". #iagnosis 1. History. " history of trauma, particularly that related to motor %ehicle accidents, should be obtained. *ain do)n the arm )ith paresthesias in the distribution of 2-@ to 2-5 or belo) indicates ner%e compression, often caused by disk protrusion. " story of )aking up )ith a painful, de%iated neck is consistent )ith an acute torticollis. 1. Physical exa ination. Dange-of-motion testing of the neck should be performed, including side fle$ion, rotation, for)ard fle$ion, and e$tension. " complete neurological e$amination of both upper e$tremities should be performed, including motor, sensory and refle$ testing. 3. !a"oratory and radiogra&hical studies. <nless there is a reason to suspect a systemic illness causing the pain or there is history of a trauma, no radiographs or other radiological studies are necessary on initial e%aluation. 3. $anage ent. When needed, immobili4ation )ith a hard or soft cer%ical collar should be limited to 6ust a fe) days. #he patient should start gentle range-of-motion e$ercises immediately. 'f the pain persists for more than 1 )eek, the patient should be referred for physical therapy. =edications should be limited to a mild analgesic, and a muscle rela$ant should be added only if there is no response to the analgesic alone. .urgery is reser%ed for fractures or radiculopathy )ith disabling pain. EEIGHT !/)) -unger, appetite, caloric balance, and )eight are carefully controlled at numerous sites. #he hypothalamus influences hunger and satiety9 the amygdala affects olfaction and feeding control. .hort-term and long-term control factors include body fat percentage, glucose stores, protein balance, gastrointestinal stimulation and en%ironment. 8uring the initial phases or calorie malnutrition, the body acti%ates numerous compensatory mechanisms to protect protein stores and control )eight loss (W0 . 8eficits of less than 1 )eek&s duration cause mostly fluid-based W0, decreases in serum albumin and transferring le%els, lymphocyte counts belo) 11++G ul, and anergic skin testing. #hose e$periencing in%oluntary W0 often ha%e a fear of malignancy and may re(uest e$pensi%e, e%asi%e or unnecessary diagnostic tests. " )ell-organi4ed plan of assessment may assist the clinician and the patient in properly e%aluating the presentation. 1. 3ac*ground; Adults ". General 1. 5ight percent of ambulatory adults claim W09 only 5+, of those actually ha%e documentable loss! clothing si4e, serial )eights, and family report. 1. .e%enty percent of true W0 patients ha%e a definable cause after completion of a thorough history and physical e$amination )ith limited laboratory assessment9 15, remain idiopathic, )ith rare cases of unrecogni4ed malignancy presenting during close follo)-up. 3 $alignancy (only 15-3+, of W0 patients 1. Historic ar*ers. #hese include older age, se%erity of presentation, smoking history )ith respiratory change, nausea or %omiting, bo)el change and )eakness. 1. Physical ar*ers. #)enty-fi%e percent of those )ith neoplasia ha%e a palpable mass or hepatomegaly at presentation. 3. 5 to 1+, W0 in 3-; months should trigger )orkup.

''. 3ac*ground; Infants ". General 1. "ny )eight or height loss needs e%aluation. 1. Weight for age reflects past and present nutrition. 3. -eight for age reflects more chronic nutrition. @. Weight for height reflects recent nutrition. 3. Evaluation &ara eters 1. 'f an infant is at ?5-9+, )eight for age, or )eight for height, his or her gro)th parameters should be obser%ed. 1. 'f an infant is at ;+-?5, )eight for age, he or she should be in%estigated fore a treatable cause. 3. if an infant is found to be less than ;+, )eight for age consider hospitali4ation for e%aluation. '''. #ifferential diagnosis. <nintentional )eight loss may occur secondary to numerous causes. " thorough history and physical e$amination )ith limited laboratory assessment )ill determine he ma6ority of patients. Nou may organi4e your e%aluation based on the mnemonic E4E4I4G4T4!4/4)4)4 ". E F Eorry or neuro&sychiatric causes 1. 1+-1+, of W0 cases are psychiatric in origin. 1. =a6or depression is the most common cause and is often missed, )ith symptoms blamed on aging changes. 3. Nou may assess )ith the Nesa%age >eriatric 8epression scale. @. 'f W0 e$ceeds 1+,, consider other etiologies. 5. 2onsider recurrence of psychiatric cause in patients )ith past psychiatric history or eating disorder history. ;. /euro%ascular diseases (cardio%ascular accident, dementia, parkinsonism cause 5-7, of W0 cases. 3. E F Eating and endocrine 1. 1;-17,of homebound patients and 3+-5+, of in-patients are calorie deficient. 1. 'ntake should be 17++ kcalGday for )omen, 1@++ kcalGday for men 3. 15, of hyperthyroid cases occur in seniors9 atrial fibrillation is a common manifestation of hyperthyroidism in this population. :nly 3-9, of W0 cases in seniors endocrine disease are due to and often reflect uncontrolled diabetes mellitus. 2. I F Infections 1. Demember to rule out coccidiomycosis, tuberculosis, subacute bacterial endocarditis, and gastrointestinal and urinary tract infections. 1. 5+, of -'C-infected patients ha%e palpable nodes before W0. 8. G F Gastrointestinal and getting older 1. 11, of W0 cases are gastrointestinal in origin. 1. 2onsider the absorption, feeding and sensory changes of aging. 5. H F Hu oral factors, such as cachectin, interleukins and bombesin, may unpredictably contribute to W0. F. T F Tu ors and thera&eutics

2ancers cause 15-3+, of W0 cases9 thorough history, physical and limited laboratory tests clarify most cases. 1. >astrointestinal (3-9, , lung (@-1+, , lymphatic system (@, and genitourinary (3-9, are the most common tumor sites9 pancreatic cancer is often found late. 3. Doutine laboratory tests should include 232, urinalysis, thyroid studies, chemistry profile, stool guaiac and chest radiography. 0o) albumin or high alkaline phosphatase le%els are markers for cancer. @. #herapeutics that may cause W0 include digo$in, chemotherapy, angiotensin-con%erting en4yme inhibitors, diuretics, antidepressants, cathartics and macrolides. >. ! F !ittle ones 1. 1-1+,of children ha%e W09 ?5, are due to non-organic causes. 1. organic causes are usually found )ith good history and physical e$amination. 2onsider lead le%el, 232, urinalysis, chemistry profile, tuberculosis test and s)eat test -. / F /rganic disease of heart, lungs gastrointestinal tract and renal, hepatic, and most organ systems may cause W0. '. ) F )elf inflicted 1. 1-5, of people )ith a prior history of an eating disorder ha%e recurrence in their life. 1. =anipulati%e dieting and chemical abuse may be present. O. ) F )ocioecono ic factors affect the ability to buy groceries, tra%el to stores and o)n appliances to prepare food. 'C. Prevention. =any cases of W0 may be pre%ented by in-home and predischarge multidiscipline analysis of atrisk patients. 5arly inter%ention and in%ol%ement of family and community resources may pro%e %aluable.

1.

#-5 F"='0N ". #-5 </'# :F 2"D5 "s early as 1931, an official publication of the /ational :rgani4ation of *ublic -ealth /ursing stated! A The cardinal principle of public health nursing must permeate all condideration of %isit content is that family health )ork is the basis upon )hich all factors restB. #he concept of the family as a unit of ser%ice )as acceped )ell before the publication of that document and has been reiterated fre(uently since that time . the importance of the family in community health nursing )as again emphasi4ed in a recent World -ealth aorganisation committee report. Net despite such )idespread acceptance, there are many indications that practice does not al)ays follo) precept. 'n community health or home care ser%ices, those pro%iding care usually think in terms of the family as the basic unit, and records are aggregated in family groups. -o)e%er, the concept of the family as an interacting sysem )ith its o)n problems of maintenance and action is changing, or becoming elusi%e. :ne must, therefore determine )hether the idea of the family as a unit of ser%ice is as %alid today as it has been in the past. #he family remains a natural unit of ser%ice #here are cogent arguments for considering the family as the unit of ser%ice in community health nursing! 1. the ma6ority of people continue to li%e in, and belie%e in the importance of, a family or a family-like structure. #he concept of the family is undergoing great change. #he ideal of marriage as a permanent institution and the %alidity of rigid roles for family members are being challenged. #he father is no longer seen as the sole bread)inner of the family, although in many countries he is most often the principal )age earner. =arital fidelity is no longer assumed to be compulsory E or e%en, for many, desirable. "t the same time, ne) configurations appear attesting to the %itality of the family as a basichuman organi4ation. Whether )e speak of traditional families, tribal families, e$tended families, open marriages, single se$ marriages, or communes, these structures all pro%ide the familial characteristics of intimacy, affectional interchange, mutual responsibility and reasonable stability. For e$ample, 0aucks )rites! A#he idea of family e$tension in purely blood tie terms has e$hausted itself,B and goes on to describe a type of e$tended family based on Ahomogenous ideals and purposes.B =ead points out that )hile children must go beyond their parents& orbit in order to de%elop and gro), )ithout adult care they )ill die, )ithout affection and stability they )ill ne%er learn to trust. #here is ne) interest in the e$tended family, )hether in a natural or contri%ed form. Jonrad 0oren4, the great student of animal beha%ior, is con%inced that in the human family the traditional frame)ork of the father, mother and siblings is not enough to pro%ide for ade(uate human de%elopment. -e stresses the need for larger, stable family group for the sur%i%al of human society. *erharps the most elo(uent defense of the family comes from *auline *aolucci! AFrom the home and family radiate the )armth and concern that keep people human. -ome represents the safe harbor from the stress of e%ery day li%ing. 't is the harbor )here each person can feel he is of %alue to himself and others. #he society of the future )ill ha%e need for richer, more supporti%e tiesB. "bo%e all, the family pro%ides an opportunity for e$pression of deeply human attributes E of lo%e, commitment, compassion and understanding E that are, in the long run, basic to human sur%i%al. #he general le%el of family functioning E the degree to )hich the family can )ork as a unit in dealing )ith its problems and can ma$imi4e the potential of each of its members E )ill profoundly influence its capability in handling health matters. #he (uality of family functioning is, therefore, a central concern of the community health nurse.

1. #he family as a group generates, pre%ents, tolerates or corrects health matters in its membership. -ealth problems may be caused by many factors! genetic fault (such as #ay-.achs disease , alcoholism, beha%ioral irregularities of catastrophic illnesses. Families can cause ad%erse health conditions! disease may be transmitted from parent to child9 or prolonged stress in a family may produce emotional illness in one or more of its members. 2on%ersely, the skill and confidence of a family operating unison not only may facilitate treatment and pro%ide physical support but also may lend emotional strength to an afflicted member and contribute to the social psychological de%elopment of the total group. 't is usually the family, rather than the indi%idual that must e$ert the energy necessary to achie%e health goals. 3. the health problems of families are interlocking. 't is %ery likely thast the health of any member of the family )ill affect the )ell-being of others. #he child )ith a de%elopmental disability may affect the health of his siblings because he re(uires an inordinate amount of parental time and energy, or the terminal illness of a parent cared for at home may impair the health of the daughter )ho is home nurse as )ell as )ife and mother. Whate%er happens to one member of the family has some effect upon the family collecti%ely and re(uires a )hole series of accommodations on the part of the other family members. 5motional problems, in particular, appear to be reinforced by family interaction. @. the family pro%ides a crucial en%ironmental force. 5ach indi%idual member constantly interacts )ith the physical, social and interpersonal milieu created by his family. #he indi%idual responds in his o)n )ay to the particular ambiance of his o)n family! to slo%enly housekeeping or to compulsi%e conformity to rigid norms, to positi%e family attitudes of social responsibility or to a sense of social alienation. 'n turn, each indi%idual affects the family en%ironment by his o)n beha%ior. #hat is, each person ser%e either to reinforce or to contest the %alues or attitudes held by the others, to preser%e or to modify the e$isting physical en%ironment, and to strengthen or )eaken the cohesi%eness of the family as an operating unit. #his continual interaction, )hich e$ists for the most part )ithin a closed system, influences and molds the indi%idual in myriad )ays. 5. the family is most fre(uently the source of decisions about health and personal care. 'n the long run, it is most often the family unit, not the indi%idual or the health professional, that decides )hether or not to seek or use health care. 2hildren, of course, must rely on parental action for their health needs. :ften there is one strong character )ithin the family )ho, through force of personality or traditional position, e$erts more influence. " husband&s desires may ha%e much to do )ith his )ife&s decision to seek care early in pregnancy or to see that the child recei%e proper immuni4ation9 a grand mother may influence child rearing practices9 a mother may ad%ocate home remedies or homeopathic medicines. #he family is the most usual source of health care. 2are for minor ills, long-term illnesses, or disability and prehospital and posthospital care during acute illness are generally pro%ided for at home by family members. 'n many instances, no care other than family care is re(uired or sought. "lpert asked ?7 lo)-income families (selected at random from a case pool of 5++ families to record on a calendar the day-by-day health of their members !they )ere to note any indisposition and the manner in )hich it )as remedied. #his study re%ealed that these lo)-income families sought professional medical help in only @.?, of the episodes of illnesses9 the remaining 95.3, illnesses (most often described as respiratory or gastrointestinal ailments, fe%er, headache, or accidental in6ury )ere presumably treated by the families themsel%es. -ence, the ability of the family to pro%ide nursing care for its members is an important factor in health care. ;. the family is an effecti%e and a%ailable channel for much of community health nursing. #he community health nurse has the ability to de%elop sustained and close relationships )ith the families she ser%es. #he relationship in turns enables her to established communication (uickly )hen it is needed9 she can elicit appropriate self-reporting on the part of the family and she can bring them rapidly into the larger health care ser%ice9 she can help them in time of crisis, and prepare them for possible future stress. Furthermore,

he number of indi%iduals )ho are reached by care is greater )hen the family is the unit of ser%ice. #he family itself becomes the means of e$tending a nurse&s influence to those members she cannot personally see. 3y )orking )ith the family as a )hole, she is more likely to fulfill her obligations to reach the entire community. ?. the family, through its interaction )ith the larger social system, %alidates and infuences health efforts. 3y merely refusing to use an a%ailable health ser%ice, the family can precipitate a re-e%aluation of the usefulness and acceptability of that ser%ice. #he rural family, faced )ith erosion of the rural )ay of life, may e%ol%e ne) perspecti%e E or, alternati%ely, may fail to ad6ust and create or contribute to ne) tensions. /e) industries, factories, strip mining, po)er plants E all )ill alter the en%ironment and ha%e a profound effect upon the economic and emotional stability of local families. #he effects of change in the larger system upon the indi%idual family are nomous. " population control policy and program, opportunities for employment of )omen, and increased educational facilitiesmay lead to smaller families, more )orking mothers, and changes in family roles E all of )hich can be either re)arding or threathening. #he successful family system must interact internally in a contructi%e )ay, but must interact as )ell )ith the larger social system )ith )isdom and foresight. #here )ill, of course, be instances )hen the indi%idual, rather than the family, is the logical unit of ser%ice. #he increasing comple$ity of care may re(uire the use of clinical specialists in nursing )ho are not trained to treat the broad spectrum of problems found in family care. Whereas the community health nurse may consider the indi%idual as her patient, thinking of the family only as a tangential influence. #he specialist, ho)e%er, can and should )ork )ithin the conte$t of the family9 that is, she should take into account family concerns that affect the treatment of her patient and try to modify them )hen they are inimical to the patient&s care. "lso, there are cash programs directed at limited phases of health care )hich tend to focus on the indi%idual, not the family. #o be consistent, the community health nurse must, in this setting, focus primarily on the indi%idual. #his method of deli%ering health care sets some constraints on the relationship bet)een nurse and family9 ho)e%er, on the other hand, it may possibly lead to a greater depth in the nurse-patient relationship. #-5 F"='0N ". 20'5/# #he family consist of a group of indi%iduals in close and continuing association, constantly interacting )ith one another as indi%iduals and, indi%idually and collecti%ely, )ith others in their orbit and the community as a )hole. 'ts functioning affects and is affected by the physical, social and psychological milieu in )hich it e$ists. #hrough this interaction, the family clarifies its goals, %alues and purposes, crates its interpersonal style, accommodates to the needs of its members, and determines and implements action on its o)n behalf. 2hanges in any single part of the system affect the total. #he health professional must be a)are that such changes may greatly affect the health decisions and capability of the family. #hus, if a couple decides that the father of the family shall become the homemaker )hile the )ife )orks outside the home, the capability )ithin that family for continuing health obser%ation may be reduced. " sharp change in economic status or en%ironment (sudden unemployment, a mo%e from suburb to high rise apartment )ill re(uire many adaptations by the family as a )hole to accommodate to the ne) circumstances. Family Calues and :rientations 'nfluence 2hoice 5ach family acts as in accordance )ith its o)n sets of %alues and orirentations to life. #he concept of family obligation )ill defer E ranging from a central demanding concern to analmost casual interest.one family )ill feel personally responsible for looking afer a second cousin li%ing in a distant state and needing help in illness or economic ad%ersity9 another family )ill feel that care of their elderly ailing parents should be the responsibility

of the community. AFamily may be seen as the parents and children still at home, or as the entire net)ork of relations, 8ifferent families )ill assign different %alues to traits such as honesty, industriousness, independence and selfreliance9 conformity to religious tenets, community norms9 or tangible e%idence of economic AsuccessB. #-5 F"='0N 85C50:*. '#. :W/ 0'F5.#N05 5ach family de%elops its o)n pattern of beha%ior and its o)n style of life. 'n some families, there is little or no communication bet)een husband and )ife and bet)een parents and children. 5ach member li%es locked up in a pri%ate thought and feeling, e%en though the physical aspect of group life goes on, in other families, there may be much %oluble interchange E )here shouts, tears recriminations are balanced by o%er tenderness, respect and sharing. 'n still other families, undemonstrati%e out)ard beha%ior may conceal a depth of undestandingand affection not (uickly apparent to the obser%er. Families also de%elop their o)n po)er systems, )hich may either be balanced ()herein the father, mother and children ha%e their o)n areas of decision and control or strongly biased ()herein one member gains dominance o%er the others . 'n some instances po)er distribution is related to role! the mother may make all decisions regarding management of the home and care of the children, )hile the father makes decisions regarding economic aspects of the family life. *o)er struggles )ithin the family are not uncommon, ripples from such conflicts may reach e%ery member of the family. :rientation regarding time may also %ary. For some, the focus is only on the present, and problems that may arise in the future ha%e little meaning. 'f the family has been li%ing precariously, future considerations may ha%e little significance in comparison to the immediate problems of securing food or paying the rent. 'n the times of crisis or confusion, some families cope )ell, dealing as a matter of course )ith problems as they arise. #he poor mountain family may manage to sur%i%e despite a year of poor crops and little outside )ork, to find a )ay to get to the health center)hen no transportation is readily a%ailable, or to impro%ise a bed for a sick child )ho ordinarily shares a bed )ith ordinary children. :ther families simply gi%e up )hen ttrouble strikes, and )ait helplessly for something or someone to come and help. #-5 F"='0N "22:==:8"#5. "22:D8'/> #: #-5 /558. :F #-5 '/8'C'8<"0 Within each family, the indi%idual functions not only as a member of the group but also as a uni(ue humam being )ith its o)n destiny to fulfill. 5ach member must assert himself in a )ay that allo)s him to gro) and de%elop. .ometimes, indi%idual needs and group needs seem to find a natural balance9 the need for self-e$pression does not o%ershado) consideration for thers, po)er is e(uitably distributed, and independence is permitted to flourish. "t other times, indi%idual needs and family needs are not so easily reconciled, and conflict may ensue. #he adolescent&s need for social acceptance, and the result could be a continuing battle. #-5 F"='0N D50"#5. #: #-5 2:==</'#N #he family de%elops a characteristic stance )ith respect to the community. For some, this relationship is )holesome and reciprocal9 the family utili4es its community and its institutions and, in turn, contributes )hate%er it can to impro%e the community. 'n some cases there is a firmly rooted sense of family responsibility, often stemming from a tradition of charitable endea%or. :ther families feel a sense of isolation from the community. #hey may maintain a proud A)e keep to oursel%esB attitude9 or they may be entirely passi%e, taking the benefits that are offered by the community )ithout either contributing to it or demanding changes in it.

#he family gro)th cycle Families, like indi%iduals, ha%e their o)n gro)th cycles. 'n the foreseeable future the dominant pattern of the family is e$pected to be fairly traditional, )ith most couples married and remaining married, electing to ha%e t)o or three children. #he husband )ill continue to be the principal bread)inner, although many )i%es )ill be employed as )ell. 'n this general pattern, a typical cycle may be identified. For about t)o years, the a%erage couple )ill be childless9 for the ne$t t)enty tears or so, child bearing and child rearing )ill be central concerns, follo)ed by about si$ years )hen children are lea%ing home for college, marriage or carriers. For appro$imately 13 years the old couple )ill be li%ing alone once more, and for the final 1;P years, the family )ill be reduced to a )ido) or )ido)er. #his pattern is by no means characteristic of all families. "typical families )ill face different cycles. For e$ample, the childless couple )ill miss the child rearing and separation phases9 the contract of marriage of limited duration may ne%er reach the )ido) or )ido)er stage because of early termination of the relationship. A:penB marriages create altogether ne) patterns. #here are also many single-member families, or households containing only one person )ho may be part of a larger family unit li%ing else)here e.g. the career girl, college student, bachelor and )ido). #he commune AfamilyB may ha%e a groupGchildren pattern, and se%eral phases (child rearing, separating, )ido)hood, couple alone may co-e$ist )ithin the group at a gi%en time. #he concept of cycles is useful since each step in the AtypicalB cycle makes is o)n demands on care. #he sharp transitions bet)een phases that used to e$ist ha%e been greatly modified. #he smaller a%erage number of children has reduced the dependent period, pro%iding more time for the indi%idual to us at his or o)n discretion. 'ncreased technology, impro%ed domestic appliances and day-care centers permit homemakers to take part-time 6obs or engage in ci%ic acti%ities. 'n sum, the family is the unit to )hich the community health nurse is most often addressed. 't is a functioning group composed by indi%iduals held together by bonds of kinship or strong emotional ties9 a unit in )hich the action of any member may set off a )hole series of reactions )ithin the groups9 and entity )hose inner strengh may be its greatest single supporti%e factor )hen one of its members is stricken )ith illness or death. -5"0#- #".J :F #-5 F"='0N #he health tasks of the family are a primary concern of the nurse. 5ach family cares for its heath in a manner consistent )ith its o)n uni(ue set of %alues, capabilities, resources and life styles. #hese tasks include the follo)ing! 1. Decogni4ing interruptions of health or de%elopment! such as illness or a child&s failure to thri%e. Families differ in their concepts of illness and health! for e$ample, backache may constitute an illness in one family but is an e$pected normal occurrence in another9 pre%enti%e care may be considered important by some, unimportant by others. 1. seeking health care! the family must decide )hether to see a physician, to ask a druggist&s ad%ice, to institute home remedies or to A6ust )ait and seeB each time family member is indisposed. <sually the family is the first to recogni4e any de%iation from normal health9 and )hen necessary, it must take the first step to)ard getting into getting into the health care system. /o amount of professional outreach can compensate for family lethargy or resistance to care. 3. =anaging health and non-health crises. .ooner or later, e%ery family )ill face a crisis. .e%ere or incapacitating illness, death, childbirth and hospitalisation affect all families at some time. /on-health crises (une$pected unemployment, military ser%ice, mo%ing into an unfamiliar community also ha%e effect on health since, if poorly met, these episodes place great emotional strain on the family as a group as )ell as its indi%idual members.

@. *ro%iding nursing care to the sick, disabled, or dependent members of the family. :nly a small fraction of illnesses are cared for in hospitals or other institutions. #reating minor ills and minor care of the %ery young or the %ery old, tending the sick before or after hospitalisation or caring for ambulatory patients )ho re(uire special treatment E all represent health care demands commonly placed upon the family. -ome care may range in comple$ity from pro%iding dialysis to caring for a child )ith a head cold. 5. maintenaing a home en%ironment conduci%e to good health and personal de%elopment. #he home should be physically safe, a place in )hich elderly members are protected from falls by sturdy railings and to )hich young children are not e$posed to rate bites or tempted by accessible s)itches on the gas sto%e. 't should also pro%ide a stable, emotional and social en%ironment, an atmosphere of confidence and mutual concern, a modicum of beauty and comfort, and room in )hich to rela$ and gro). ;. =aintaining a reciprocal relationship )ith the community and its health institutions. -ealth care of the family re(uires inter%ention from a %ariety of indi%iduals and groups ranging from neighbours )ho baby sit to the sophisticated teaching hospital. 'n relating to the community or its institutions, the family must arri%e at some realistic basis of e$pectations. #hey must learn to appreciate their rightsas indi%iduals and at the same time to understand the limits inherent in the community or institutional situation. #he family has a right, for e$ample, to e$pect that those )ho pro%ide care should be (ualified and that health ser%ices should be run efficiently. :n the hand, the family should e$pect to assume responsibility for sending children to school on time, for putting garbage in a co%ered container, for securing immunisation at the proper time, for keeping clinic appointments as scheduled, and for not making unreasonable demands on ser%ices that may be unbderstaffed amnd o%er)orked. 2ommunity de%elopment is one step to)ard social health. <nfortunately, opportunities for e%eryone to contribute to decisions about community programs are not al)ays made a%ailable to all segments of the population. #hese family tasks are ob%iously of great importance, and the community health nurse must be deeply concerned )ith increasing the capability of each family. #o perform them. 't is not enough to impro%e the family&s ability to care for aan elderly and incapacitated patient at home ehile ignoring the need for changing a home en%ironment that is upsetting the physical or emotional health of its other members. /or is it enough to deal only )ith that often chance-selected portion of the populationthat recei%es nursing care. #his problems calls for special multiagency planning and action, calculated to reach a substantial portion of the families in the community. #-5 2:==</'#N -5"0#- /<D.5&. D:05 '/ F"='0N F</2#':/'/> #he e$traordinary impact of family organisation and functioning upon indi%idual, family and community health makes it a mandatory concern of community health nursing. #he nurse&s responsibility is not limited to using the family as a resource for health care9 it also includes the pro%ision of general support for family de%elopment. "s she builds nursing care on the family&s o)n abilities and supplements their action )hen the problem is too much for them to manage alone, the nurse is constantly a)are of the opportunity of strengthening the family, better e(uipping it to deal )ith future problemsof health care and family management. =oral and technical limits restrict actions to change family beha%iour. First, the family&s right to freedom and choice must be abrogated9 e%ery family has the right to establish its o)n %alues. 0ifestyle and patterns of health care, pro%ided they do not harm others. For e$ample, refusal by parents of certain medical treatments for a child may be tolerated as long as the child is not endangered! refusal of routine health e$aminations may be )ell )ithin parental rights, )hereas, on the hand, refusal to permit surgery that )ould pre%ent blindness in a child may re(uire legal action on the child&s behalf to ensure that the re(uired care is pro%ided. "n adult deciding for himself to refuse such care )ould be )ithin his rights. 5fforts to con%ert families to the nurse&s o)n concept of desirable family beha%iour should be suppressed in fa%our of pro%ing the family )ith the information they need in order to decide for themsel%es.

'n some instances, problems of se%ere family pathology may be beyond the nurse&s competence, re(uiring inter%ention by a social )orker or psychiatrist. Within these ca%eats, ho)e%er, the community health nurse can do much to support and encourage general family de%elopment as a basis for family health care. 3y supplying prompt and responsi%e help or careful referral, she can strengthen the family&s confidence in, and its ability to use community institutions. 'n planning her ser%ice to families, the community health nurse must )ork )ithin the frame)ork of the )hole structure of the family health tasks. .he must also understand that the resolution of many health problems )ill depend upon a family&s skills in areas other than health. #he family that utili4es health-car ser%ices too late or too infre(uently may be reflecting a general failureto relate to the community. #hrough her efforts to sol%e a particular health problem, the community health nurse can help ameliorate other negati%e factors. #he family may be helped to disco%er alternati%es to some present patterns and to apply problem-sol%ing approaches in making decisions. #hey may be helped to disco%er alternati%es to some present patterns and to apply problem-sol%ing approaches in making decisions. #hey may be helped to see the relationship bet)een health beha%iour of their goals and %alues. For e$ample, a family that sees material possessions as an inde$ of success may feel that the child entering school must ha%e a ne) outfit for each day of the first )eek of classes. 'n the case of a lo)-income family, the nurse may be tempted to argue that education, not a competiti%e fashion sho), is the ob6ect of going to school. 't )ould be )iser to encourage an early start on sa%ings for this foreseeable financial crises, or to urge in%estigation of thrift shops or of se)ing classes. #he shift from the concept of care for the indi%idual to the concept of the family as patient is not an easy one. =uch of the clinical education of health professionals is carried out in large medical centers that are primarily concerned )ith serious and acute illness or disability and )ith the indi%idual as the natural ser%ice unit. #hus, the habit of basing treatment on the indi%idual is apt to be established. Furthermore, the community health nurse is likely to come from a middle class background and to ha%e %alues and )ays of dealing )ith family problems that differ from those of the families for )hom she cares. .he may e$pect other to hold %alues similar to her o)n9 for e$ample, in a prosperous population, she may not reali4e the social problems placed upon the )ife of an e$ecuti%e and may feel that too much of the mother&s child-rearing responsibility is being assigned to employees. "t times, the nurse may not be able to separate herself from her o)n family e$periences. 'f she has been caring for a disabled mother )hile )orking full-time, she may pro6ect her o)n resentments or frustrations into he obser%ations she makes in the course of her )ork. .he may ha%e stereotyped ideas of )hat make a AgoodB mother or a Acooperati%eB family, )hich )ill hamper her effecti%eness. "lso, in many cases, the nurse )ill be younger and less e$perienced in handlingfamily situations than in the group she ser%es.. if the nurse has 6ust graduated from student status,shemay feel inade(uate to the demands made upon her for understanding or for decision-making. " sense of inade(uacy could also arise from the feeling that she herself could not muster a much strengh and )isdom as the family has done.she may be o%er)helmed b their problems and by a lack of self confidence in her capacity to help. "t times, she may feel helpless in the face of seemingly hopeless situations, e%en to the degree that 6udgement is clouded. Furthermore, in many cases, she )ill not see any tangible resultsof her labours. .he )il obser%e that in the hospital the patient looks more comfortable, that his treatment is producing the desired result, and that all tat has been prescribed has been dispatched )ith efficacy. -elping a family in the home, ho)e%er, is often much less %isibly re)arding. :ne is confronted )ith problems that seems to ha%e no solution! ho) can one help rduce the an$iety of a moher )hosehusband is out of )ork and )ho has ne%er e$perienced the AindignityB of making a )elfare applicationF -o) can one help the o%er)orked young mother )ho also has the responsibility of caring for a senile parent )ho )andersaround and needs constant sur%eillanceF When the nurse feels she cannot possibly pro%ide help, she can feel bitterly frustrated E )hich )ill make it difficult for her to )ork producti%ely )ith the family.

"t moments like these, the nurse should remember that %ery fe)families are truly helpless or hopeless, and that ad%ersity ios part of the learning e$perience. #here )ill ine%itably be setbacks and bleak patches, but the community health nurse ne%er functions alone. .he has colleagues )ithin the agency and a host of other professionals to turn to for assistance and ad%ice, plus a broad range of health and )elfare resources at her disposal. With time, her o)n e$periences )ill accumulate and pro%ide a solid base for future assurance and confidence. /ursing has al)ays been a challenging profession, and challenges do not gro) from single con(uests to easy solutions.

-'>--D'.J F"='0'5. -ealth care of the gro)ing family must be %ie)ed as more than maternal and infant care. #he health challenge implicit in childbearing and child rearing affects e%ery member of the family as )ell as the community at large. #he addition of a child to the family may create problems of emotional security for the siblings, economic concern for the father, and physical and management problems for the mother. #he addicti%e effect of family si4e may create serious economic de%elopmental problems for a community or for a country. -igh-risk families include! 1. Families more %ulnerable due to socio-economic risks a 0o)-income groups and those li%ing in po%erty b 'mmature families c 'ncomplete families d Families )ith an ad%erse genetic history e Families )ith a history of emotional stress and inability to cope f Families in )hich the baby is un)anted or in )hich the pregnancy has been undertaken for secondary reasons. 1. Families more %ulnerable due to obstetrical risk of the mother. a Women under 1; or o%er @+ years of age. b Women ha%ing nutritional problems and poor nutritional habits, particularly )ho ha%e anaemia, or are substantially under)eight or o%er)eight c Women )ith pre-e$isting disease such as hypertension, cardiac, or metabolic disorders, infectious disease or gynaecologic abnormalities d Women )ith a pre%ious history of obstetrical abnormalities e Women )ho are hea%y smokers or alcoholGdrug abusers 3. Families more %ulnerable due to special risk of the infant a 'nfants )ith lo) birth )eight (under 15++ gm and infants )ith high birth )eight (o%er @+++ gm b 'nfants )ith a lo) "pgar score or those )hose mothers ha%e undergone prolonged or difficult labour c 'nfants )ith congenital malformations or birth in6ury d 'nfants )hose parents are immature or inade(uate )ith a history of addiction to drugs or alcohol, a history of child neglect, or a history of mental illness.