Constipation is typically classified as having fewer than 3 bowel movements per week. Symptoms of constipation include painful, hard, or incomplete bowel movements and/orstraining.

Things you can do to help reduce constipation:

Check Your Fluid Intake

If you don’t consume enough fluid it may make your symptoms worse. You may also want to cut down on liquids that can be dehydrating, like alcohol.

 Note: If you are taking fiber supplements, you will also need additional fluid. Fiber absorbs water and can swell, potentially causing a blockage in your digestive tract.

Tip: Check the color of your urine. If it is dark yellow, you are probably not drinking enough fluid

Increase the Fiber in Your Diet (found in whole grains, fruits, vegetables, nuts and beans)

Fiber adds bulk and can soften bowel movements, making them easier to pass. Most people need between 25-35 grams of fiber per day.

Switching to whole grains is an easy way to increase your fiber intake, e.g. eating whole wheat pasta instead of white pasta.

Tip: Look for foods with 3 grams of fiber or more per serving

 ▶Soluble fiber(found naturally in apples, bananas, pears, plums, artichokes, carrots, peas, potatoes, squash, barley, oats and beans)

Soluble fiber acts like a gel and can help regulate bowel movements, especially if you alternate between constipation and diarrhea (this is common with irritable bowel syndrome).

Try to include a source of soluble fiber in your diet every day.

Tip: In addition to containing soluble fiber, prunes (dried plums) are a natural source of sorbitol, which can act like a laxative. Apples, cherries, dates, pears and peaches also contain sorbitol

▶Insoluble fiber (found naturally in whole grains, e.g. whole wheat bread and brown rice, bran, and the edible skins of fruits andvegetables)

 Insoluble fiber helps to move food through your digestive tract, thus increasing your bowel movements. It also adds bulk to movements, making them easier to pass.

Tip: If you normally peel the edible skins of vegetables, e.g. cucumbers and potatoes, leave them on to increase your intake of insoluble fiber

Get Active

Exercise may increase muscular contractions in your intestines, thus aiding bowel movements.

Most healthy adults need at least 150 minutes of moderate physical activity per week, such as brisk walking or riding a bike.

Tip: Try to spread your activity throughout the week. If you need to increase your activity, aim for small increases (i.e. 10 minutes at a time). Consult your doctor if you are unsure if you should increase your activity

Limit/Avoid the Use of Laxatives

Long-term use of certain laxatives can reduce your body's natural ability to have regular bowel movements and can cause laxative dependence.

    •  Fiber is nature's natural laxative. If you simply aren’t able to consume enough fiber through food, you could try taking a fiber-containing laxative, like Metamucil or Citracel. However, be aware that fiber supplements can interfere with the absorption of certain medications

    •  Your doctor may also suggest taking a stimulant laxative (such as Senokot or Dulcolax), an osmotic laxative (such as Miralax), or a stool softener (such as Colace). Be sure to check with your doctor before buying over-the-counter versions of these laxatives, as they can affect electrolyte levels (such as potassium) in the body

Check Your Supplements and Medications

Calcium and iron supplements can contribute to constipation. Antacids can also cause constipation, as can long-term use of certain pain medications, like opiates. Certain antidepressants (such as amytriptline), diuretics (such as furosemide), and blood pressure medications may also affect bowel regularity.

   •  A dietitian can review your diet to see if a nutrition supplement is necessary. A dietitian may also advise you on how to reduce heartburn to decrease reliance on antacids

   •  If you are concerned that medication may be contributing to your constipation, talk to your doctor

Note: While research does not support taking probiotic supplements to relieve constipation, consuming healthy probiotic-containing foods (like yogurt, kefir, miso and kimchi) may offer benefits and should not worsen constipation if consumed as part of a regular diet.

Practice Regularity

Do not resist the urge to have a bowel movement, as this may worsen constipation symptoms. You may even want to set aside time each day to have a bowel movement, such as after breakfast.

Eating regular meals also helps your colon work properly. Try to avoid skipping meals and be sure you are consuming adequate calories to support normal bowel function.

This document is intended to provide health related information so that you may be better informed. It is not a substitute for your care team's medical advice and should not be relied upon for treatment for specific medical conditions.

© 2017 The General HospitalCorporation.

Primary Care OfficelnSite

developed by the MGH Laboratory of Computer Science and Division of General Internal Medicine

What is hand, foot, and mouth disease? 

Hand, foot, and mouth disease (HFMD) is an infection caused by a virus. HFMD is easily spread from person to person through direct contact. Anyone can get HFMD, but it is most common in children younger than 10 years.

What are the signs and symptoms of hand, foot, and mouth disease? 

The following signs and symptoms of HFMD normally go away within 7 to 10 days:

•      Fever 

•      Sore throat

•      Lack of appetite

•      Sores or blisters on your tongue, gums, and inside your cheeks that appear 1 to 2 days after a fever starts

•      Rash on the palms of your hands and bottoms of your feet

•      Painful blisters on your hands or feet

How is hand, foot, and mouth disease diagnosed?

 Your healthcare provider will ask how long you have had symptoms and if you have been near anyone who has HFMD. You may also need the following tests:

•      Throat culture: This test may help healthcare providers learn which type of germ is causing your illness. Your healthcare provider will rub a cotton swab against the back of your throat. He will send the swab to a lab for tests

•      Bowel movement sample: A sample of your bowel movement is sent to a lab for tests. The test may show what germ is causing your illness

How is hand, foot, and mouth disease treated? 

HFMD usually goes away on its own without treatment. You may need to drink extra fluids to avoid dehydration. You may also need medicine to decrease a fever or pain. You may need a medical mouthwash to help decrease pain caused by mouth sores.

How do I prevent the spread of hand, foot, and mouth disease? 

You can spread the virus for weeks after your symptoms have gone away. The following can help prevent the spread of HFMD:

•      Wash your hands often. Use soap and water. Wash your hands after you use the bathroom, change a child's diapers, or sneeze. Wash your hands before you prepare or eat food

•      Avoid close contact with others.Do not kiss, hug, or share food or drinks. Ask your child's school or daycare if you need to keep your child home while he has symptoms of HFMD 

•      Clean surfaces well: Wash all items and surfaces with diluted bleach. This includes toys, tables, counter tops, and door knobs

What are the risks of hand, foot, and mouth disease? 

You may get HFMD again. You may not want to eat or drink because of the pain in your mouth and throat. If you do not drink enough fluids, you may become dehydrated. You may lose a fingernail or toenail about 4 weeks after you get sick. The virus may spread and cause meningitis or encephalitis. Meningitis is an infection and swelling of the covering of the brain and spinal cord. Encephalitis is an infection that causes the brain to swell. Encephalitis is rare but can be life-threatening.

When should I contact my healthcare provider? 

•      Your mouth or throat are so sore you cannot eat or drink

•      Your fever, sore throat, mouth sores, or rash do not go away after 10 days

•      You have questions or concerns about your condition or care

When should I seek immediate care? 

•      You urinate less than normal or not at all

•      You have a severe headache, stiff neck, and back pain

•      You have trouble moving, or cannot move part of your body

•      You become confused and sleepy

•      You have trouble breathing, are breathing very fast, or you cough up pink, foamy spit

•      You have a seizure

•      You have a high fever and your heart is beating much faster than it normally does

CARE AGREEMENT:

You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment.

© 2017 Truven Health Analytics LLC All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or Truven Health Analytics.

What are tension headaches?

Almost everyone has a headache from time to time. Tension headaches are by far the most common kind. People generally describe tension headaches as causing a dull pain in the forehead or at the sides and back of the head. Many people describe a tight feeling, as if a too-small hatband is squeezing the head. Some people also notice tenderness around the head, neck and shoulders. Tension headaches come on gradually and can last for as little as 30 minutes or as long as several hours or even days. The pain is usually mild to moderate. However, tension headaches can lead to other problems such as insomnia, fatigue, irritability, loss of appetite and difficulty concentrating.

What causes tension headache?

The exact cause of tension headache is unknown. In the past, doctors thought that tension headaches were connected to muscle contractions in the face, neck and scalp. They believed that these contractions were caused by tension or stress, thus the name ’tension headache.’ Although stress and lack of sleep are the most frequent triggers of tension headaches, doctors now believe that this kind of headache actually develops from changes in certain brain chemicals such as serotonin and endorphins.

Migraine may trigger tension headaches in people who have both kinds of headaches. Because women are somewhat more likely than men to develop tension headaches, some doctors suspect that there could also be a link with fluctuating estrogen levels. The formal medical name for tension headache is now tension-type headache to show that the connection between tension and these headaches is no longer considered direct.

What can I expect my doctor or nurse to do?

Your doctor or nurse will ask questions about your general health and your family’s health history. Sometimes headaches happen because of other medical problems and your doctor will want to rule out that possibility. You may have a physical exam.

You will also be asked questions about your symptoms - how often you have headaches and what the pain is like. There are three types of tension headaches based on how frequently they occur:

•       Infrequent episodic tension headaches occur one day a month or less and the pain is usually mild

•       Frequent episodic tension headaches occur at least once but no more than 14 days a month and the pain can be mild to moderate

•       Chronic tension headaches occur 15 days or more each month and have been recurring for at least 6 months. The pain may be mild to severe

There are no medical tests to tell you are having tension headaches. The doctor will rely on the physical exam and your description of your symptoms for a diagnosis.

What is the treatment for tension headaches?

The treatment your doctor recommends for you will depend on how severe your headaches are and how often you have them. In most cases, over-the-counter (OTC) medicines are the first thing the doctor suggests. You may find fast, effective relief by taking OTC pain relievers such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin, Advil), acetaminophen (Tylenol) and naproxen (Naprosyn, Aleve). In some cases, people find more relief with combination medicines such as aspirin or acetaminophen combined with caffeine. People with stomach problems, kidney disease and bleeding conditions should not use aspirin or NSAIDs. 

People with severe chronic tension headaches may require stronger painkillers or preventive medicines to reduce the frequency and severity of headache pain. These include prescription medicines such as isometheptene combinations (Midrin, Duradrin) or butalbital combinations(Fiorinal, Fioricet). In a few cases, the doctor may recommend a group of medicines called triptans, medicines that act on serotonin, one of the chemicals that may be involved in triggering tension headaches.

Doctors sometimes prescribe antidepressants to prevent tension headache, especially the chronic form. These medicines are not painkillers and the doctor is not prescribing them because you are depressed. Instead, certain antidepressants work on headache by stabilizing the levels of brain chemicals such as serotonin, which may be involved in the development of your headaches.

It is important to know that frequent use of some prescription pain relievers could lead to dependency. Using any pain reliever too often may cause a ‘rebound effect’ in which the medicine interferes with the body’s natural painkilling mechanism, causing the pain to return, even stronger than before, once the medicine wears off. Also, some painkillers, prescription and OTC, can interact with other prescription or OTC medicines, so it's a good idea to check with your doctor about the benefits and risks of taking any medicine. Ask your doctor if you are not sure what medicine is right for you.

What can I do to help take care of myself?

Learning a stress management technique, such as meditation or yoga, often helps. Regular exercise is also beneficial. It’s also important to get enough sleep and maintain a healthy diet. Some people find that good posture helps them avoid headaches. Try to avoid sitting, standing or working in one position for long periods of time. Alternative therapies such as biofeedback, relaxation therapy, massage, and acupuncture may also help prevent and/or relieve tension headaches.

When should I call the doctor or nurse?

Seek medical care quickly for a headache that comes on rapidly, is unusually severe, or is far different from other headaches that you have had. Headaches that waken you from a sound sleep, are worse when lying down or worsen over time, come with fever or a stiff neck, follow a head injury, come with disturbed speech, numbness, weakness, blackouts or difficulty remembering things are not typical for a tension headache. Discuss these problems with your doctor promptly.

This document is intended to provide health related information so that you may be better informed. It is not a substitute for your care team’s medical advice and should not be relied upon for treatment for specific medical conditions.

© 2017 The General HospitalCorporation.

Primary Care OfficelnSite

developed by the MGH Laboratory of Computer Science and Division of General Internal Medicine

What is a fever?

A fever is an increase in your body temperature. Normal body temperature is 98.6°F (37°C). Fever is generally defined as greater than 100.4°F (38°C).

What are common causes of a fever? 

The cause of your fever may not be known. This is called fever of unknown origin. It occurs when you have a fever above 100.9˚F (38.3°C) for 3 weeks or more. The following are common causes of fever:

•  An infection caused by a virus or bacteria

•  An inflammatory disorder, such as arthritis

•  A brain infection or injury

•  Alcohol or illegal drug use, or withdrawal

What other signs and symptoms may I have?

•  Chills and shivers

•  Muscle stiffness

•  Weight loss

•  Night sweats

•  Fever that comes and goes

•  Fever that is higher in the morning

How is the cause of a fever diagnosed? 

Your healthcare provider will ask when your fever began and how high it was. He or she will ask about other symptoms and examine you for signs of infection. He or she will feel your neck for lumps and listen to your heart and lungs. Tell your provider if you recently had surgery or an infection. Tell him or her if you have any medical conditions, such as diabetes or arthritis. You may also need blood or urine tests to check for infection. Ask about other tests you may need if blood and urine tests do not explain the cause of your fever.

How is a fever treated? 

You may need any of the following, depending on the cause of your fever:

•  NSAIDs, such as ibuprofen, help decrease swelling, pain, and fever. This medicine is available with or without a doctor's order. NSAIDs can cause stomach bleeding or kidney problems in certain people. If you take blood thinner medicine, always ask if NSAIDs are safe for you. Always read the medicine label and follow directions. Do not give these medicines to children under 6 months of age without direction from your child's healthcare provider

•  Acetaminophen decreases pain and fever. It is available without a doctor's order. Ask how much to take and how often to take it. Follow directions. Read the labels of all other medicines you are using to see if they also contain acetaminophen, or ask your doctor or pharmacist. Acetaminophen can cause liver damage if not taken correctly. Do not use more than 4 grams (4,000 milligrams) total of acetaminophen in one day

•  Antibiotics may be given if you have an infection caused by bacteria

What can I do to be more comfortable while I have a fever?

What is shingles? 

Shingles is a painful rash. Shingles is caused by the same virus that causes chickenpox (varicella-zoster). After you get chickenpox, the virus stays in your body for several years without causing any symptoms. Shingles occurs when the virus becomes active again. Once active, the virus will travel along a nerve to your skin and cause a rash.

What are the signs and symptoms of shingles? 

Shingles often starts with pain in the back, chest, neck, or face. A rash then develops in the same area. The rash is usually found on only one side of the body. The rash may feel itchy or painful. It starts as red dots that become blisters filled with fluid. The blisters usually grow bigger, become filled with pus, and then crust over after a few days. You may also have any of the following:

•     Fatigue and muscle weakness

•     Pain when your skin is lightly touched

•     Headache

•     Fever

•     Eye pain when exposed to light

What increases my risk for shingles? 

•     Age older than 50

•     Exposure to the virus while your mother was pregnant with you

•     A medical condition such as cancer, AIDS, or Hodgkin disease 

•     Treatment for cancer that decreases your immune system

•     Stressful life events that weaken your immune system

•     An organ or stem cell transplant

How is shingles diagnosed? 

Your doctor will ask about your symptoms. Tell him if you have had chickenpox. Tell him if you have recently been around anyone who has chickenpox or shingles. The appearance of your rash will usually be enough for your doctor to know you have shingles. He may also send skin scrapingsor fluid from your blisters for tests. 

How is shingles treated? 

•     Antiviral medicine helps decrease symptoms and healing time. It may also decrease your risk for nerve pain. You will need to start taking this medicine within 3 days of the start of symptoms to prevent nerve pain

•     Pain medicine may be prescribed or suggested by your doctor. You may need NSAIDs, acetaminophen, or opioid medicine depending on how much pain you are in

•     Topical anesthetics are used to numb the skin and decrease pain. They can be a cream, gel, spray, or patch

•     Anticonvulsants decrease nerve pain and may help you sleep at night

•     Antidepressants may be used to decrease nerve pain

•     Epidural medicine is put into your spine to block pain. This medicine treats severe pain that does not get better with other pain medicines. Epidural medicine includes numbing medicine and steroids

Can I infect others?

The virus can be passed to a person who has never had chickenpox. This person may get chickenpox, but not shingles. You may pass the virus to others as long as you have a rash. The virus is spread by direct contact with the fluid from the blisters. Usually, you cannot spread the virus once the blisters dry up.

What are the risks of shingles? 

If left untreated, shingles may cause eye problems, such as a drooping eyelid or blindness. It may lead to a brain infection or stroke. Shingles can also cause nerve damage and lead to twitching, dizziness, or loss of taste and hearing. The blisters may leave scars or changes in skin color. Shingles may cause pain even after the rash is gone. It may also lead to trouble moving parts of your body. 

How can I care for myself? 

Keep your rash clean and dry. Cover your rash with a bandage or clothing. Do not use bandages with adhesive. These may irritate your skin and make your rash last longer. 

What can I do to help prevent shingles or a shingles outbreak? 

A vaccine may be given to help prevent shingles. Ask for more information about this vaccine. 

When should I seek immediate care? 

•     You have painful, red, warm skin around the blisters, or the blisters drain pus

•     Your neck is stiff or you have trouble moving it

•     You have trouble moving your arms, legs, or face

•     You have a seizure

•     You have weakness in an arm or leg

•     You become confused, or have difficulty speaking

•     You have dizziness, a severe headache, or hearing or vision loss

When should I contact my doctor? 

•     You feel weak or have a headache

•     You have a cough, chills, or a fever

•     You have abdominal pain or nausea, or you are vomiting

•     Your rash becomes more itchy or painful

•     Your rash spreads to other parts of your body

•     Your pain worsens and does not go away even after you take medicine

•     You have questions or concerns about your condition or care

CARE AGREEMENT:

You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment. 

© 2017 Truven Health Analytics LLC All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or Truven Health Analytics. 

不是在患者放弃治疗之后延长生命的选择，不是在没有其它治疗方案后的选择，更不是放弃患者，舒缓治疗是为了更好的支持患者与家属。

对许多人来说，看病的时间是非常宝贵的。因此，在治疗的过程，大部分患者都会将每次和医生面对面的有限时间，更多地花在探讨治疗方案和专业问题上。
并且不自觉地会避免用“小事”、“小问题”去麻烦医生，一方面是担心自己想太多，也怕是自己太“娇气”，想着撑一撑就好......殊不知有时候“撑一撑”甚至可能是致命的，特别是在重症治疗中。
因为，面对重症，身体“小事”不只是小事。

像是晚期肿瘤患者，可能在很早期化疗期间，因为副作用产生了便秘和疝气，以至于后续的疼痛一直控制不好，恶心、呕吐、腹胀等，导致化疗不能很好地坚持下去，肿瘤很快进展。

又或是，正在接受抗肿瘤治疗的患者，忽视了牙疼问题，导致吃得少、营养跟不上，化疗耐受性变差，还潜藏了并发严重感染的可能性。

还有一些如心衰、慢性病晚期患者，有时候会以为自己只是小小的不舒服对它视而不见，导致后续引发的大小不一并发症。

这些宛如地雷的“小问题”，患者往往不会主动向医生报告。美国麻省总院舒缓治疗科副主任Kamdar医生来嘉会时曾经特意提到过这个现象：患者在医生面前，会努力表现为一个“good patient”（好患者）。
但我们深知重症无“小事”，对于重症患者来说，“小事”的影响，可能是巨大的，不只是身体健康，还有陪伴在身边的陪护者们。
因此，为了更好地照顾患者以及患者家庭，此时就需要舒缓治疗（Palliative care）团队发挥作用了。