By R. Dennis. Daniel Webster College.

Patients should be asked about their beliefs and expectations about the future of their pain problem diovan 80 mg discount. Are they convinced that they will not be cured unless they have a surgery? These questions are meant not only to assess the patient’s thoughts (beliefs buy generic diovan 80 mg line, ex- pectations, attitudes) surrounding their pain problem but also to assess whether the patient has considered that rehabilitation is possible. It is important to note that the categories are listed as if they are independent. Actually they are interre- lated and, ultimately, will allow the evaluators to identify specific areas for rehabilitation. Observation of patients’ behaviors (ambulation, body pos- tures, facial expressions) can occur while they are being escorted to inter- view, during the interview, and when exiting interview (observation check- lists are available to assist in assessing pain behaviors; Keefe, Williams, & Smith, 2001; Richards, Nepomuceno, Riles, & Suer, 1982). Observation of sig- nificant others’ responses to patients can occur at the same time. Is there evidence of deactivation and avoidance of activity due to fear of pain or exacerbation of injury? Does patient view himself or herself as having any role in symptom management? Alcohol and Substance Use · History and current use of alcohol (quantity, frequency) · History and current use of illicit psychoactive drugs · History and current use of prescribed psychoactive medications · Consider the CAGE questions as a quick screen for alcohol dependence (Mayfield, McLeod, & Hall, 1987). Depending on response consider other instruments for alcohol and substance abuse (Allen & Litten, 1998). Psychological Dysfunction · Current psychological symptoms/diagnosis (depression including suicidal ideation, anxiety dis- orders, somatization, posttraumatic stress disorder).

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If the patient points at the first metatarsophalangeal joint 160 mg diovan amex, then the patient probably has hallux rigidus caused purchase 40 mg diovan overnight delivery, in part, by ill-fitting shoes. If the patient points at the first metatarsocuneiform joint, the patient proba- bly has hallux valgus (bunions) that are usually caused by a small toe- box in the shoe. If the patient points to the second or third interdigital From: Pocket Guide to Musculoskeletal Diagnosis By: G. Pain in the metatarsals (particu- larly the second metatarsal) may be metatarsalgia. If the patient points to the bottom of the foot, the patient may have a stress frac- ture, tarsal tunnel syndrome, plantar fasciitis, calcaneal bursitis, or retrocalcaneal bursitis. Pain at the ball of the foot may be a contusion or stress fracture of one of the sesamoid bones. If the patient has plantar fasciitis, the patient will give a history of insidious onset of medial plantar heel pain that begins on taking the first step of the morning. Classically, the pain alleviates after a few steps but tends to return later in the evening. Patients with sesamoiditis complain of pain that began or became more pronounced during jumping or pushing off to run. Patients with calcaneal or retrocalcaneal bursitis may complain of pain with running. Patients with stress fractures complain of pro- gressively worsening pain that usually is precipitated by an increase in activity intensity. For example, if the patient begins training for a marathon and is running more than usual, the patient may develop a stress fracture. Patients with an interdigital neuroma, metatar- salgia, hallux valgus, or hallux rigidus may complain of pain that began with a change in footwear. An insidious onset of intractable heel pain is indicative of tarsal tunnel syndrome. Patients with tarsal tunnel syndrome will complain of numbness and burning in addition to pain behind the medial malleolus and at the sole of the foot. Other important questions to ask include: What makes the pain better or worse?

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