American family physician
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American family physician · Jul 2009
ReviewHelping patients who drink too much: an evidence-based guide for primary care clinicians.
Excessive alcohol consumption is a leading cause of preventable morbidity and mortality, but few heavy drinkers receive treatment. Primary care physicians are in a position to address heavy drinking and alcohol use disorders with patients, and can do so quickly and effectively. The National Institute on Alcohol Abuse and Alcoholism has published a guide for physicians that offers an evidence-based approach to screening, assessing, and treating alcohol use disorders in general health care settings. ⋯ Patients who are not alcohol-dependent may opt to reduce drinking to lower risk levels. Patients with alcohol dependence should receive pharmacotherapy and brief behavioral support, as well as disease management for chronic relapsing dependence. All patients with alcohol dependence should be encouraged to participate in community support groups
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As death approaches, a gradual shift in emphasis from curative and life prolonging therapies toward palliative therapies can relieve significant medical burdens and maintain a patient's dignity and comfort. Pain and dyspnea are treated based on severity, with stepped interventions, primarily opioids. Common adverse effects of opioids, such as constipation, must be treated proactively; other adverse effects, such as nausea and mental status changes, usually dissipate with time. ⋯ Delirium should be prevented with normalization of environment or managed medically. Excessive respiratory secretions can be treated with reassurance and, if necessary, drying of secretions to prevent the phenomenon called the "death rattle." There is always something more that can be done for comfort, no matter how dire a situation appears to be. Good management of physical symptoms allows patients and loved ones the space to work out unfinished emotional, psychological, and spiritual issues, and, thereby, the opportunity to find affirmation at life's end.
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Chronic low back pain is a common problem in primary care. A history and physical examination should place patients into one of several categories: (1) nonspecific low back pain; (2) back pain associated with radiculopathy or spinal stenosis; (3) back pain referred from a nonspinal source; or (4) back pain associated with another specific spinal cause. For patients who have back pain associated with radiculopathy, spinal stenosis, or another specific spinal cause, magnetic resonance imaging or computed tomography may establish the diagnosis and guide management. ⋯ Patients with radicular symptoms may benefit from epidural steroid injections, but studies have produced mixed results. Most patients with chronic low back pain will not benefit from surgery. A surgical evaluation may be considered for select patients with functional disabilities or refractory pain despite multiple nonsurgical treatments.