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Family Medicine
Counseling
www.sawa2006.com
[email protected]

 Diabetes Mellitus
 Diabetic Foot
 Hypertension
 Family History of IHD
 Low Back Pain
 Migraine
 Statin
 Metformin
 Antithyroid drugs
 Radioactive Iodine
 IBS
 Thalassemia Carrier
 Iron deficiency anemia
 G6PD
 Obesity

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www.sawa2006.com
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1. DM
1- It is a chronic disease so it will last forever because it is not curable but it is manageable ,
and if you could control it well , you would avoid most of its complications.
2- Mention the complications of the disease ( not in details) , it is enough to say that it has
complications on your eyes, kidneys , heart and foot.
3- Management:
A. Life style modification ;
Diet: tell him that his diet is the healthy diet so even normal people should follow his diet 
 increase fibers , vegetables , fruits as much as u can (fruits : one type/day)
 decrease fat mainly saturated & trans fat .. depend more on the poly/mono saturated fat.
make it hypo caloric diet ( less than normal people by 500 kcal.)
 Whole grain wheat bread

Exercise: half hour daily of either brisk walking , gardening or swimming ….. choose what
is appropriate for you.
Reduce your weight.
Stop smoking and alcohol.
Avoid stress.
B. drugs … Metformin ( mentioned later )
C. follow up;
daily: - take your medications as prescribed on time.
- daily gluco- check
\ - visit your doctor regularly.
- daily care for your feet .
 every 3-6 months : - HBA1c and lipid profile.
yearly: - eye ( visit your ophthalmologist)
- kidneys ( KFT)
- dental care.

2. Diabetic Foot
.‫غسم انقدييٍ يىيياً تانًاء و انصاتىٌ و انرُشيف جيدًا خاصح تيٍ األصاتع‬ .i
.‫اسرعًال انكزيًاخ انًزطثح نرهييٍ انًُاطق انصهثح و انًرشققح‬ .ii
.‫جىارب قطُيح َظيفح يُاسثح انذجى‬ .iii
www.sawa2006.com
.‫أدذيح طزيح و يقاسها يُاسة و يزيخ‬ .iv
.‫ذجُة انًشي دافي‬ .v
.‫فذص و ذفقد انقدييٍ يىيياً تادثاً عٍ خدوش أو جزوح أو ذشققاخ‬ .vi
.‫قص األظافز تانًقص طىنياً وعدو ذزك دىاف دادج‬ .vii
.‫عدو انعثث تانجهد انًيد أو األظافز انُاييح‬ .viii
.ٍ‫ايقاف انردخي‬ .ix
.ً‫ذجُة ذعزيض انقدييٍ نألياكٍ انساخُح أو انًدفأج يثال‬ .x
.‫انرذكى انجيد تًسرىي انسكز تاندو‬ .xi

3. Hypertension
1-It is a chronic disease so it will last forever because it is not curable but it is manageable , and
if you could control it well , you would avoid most of its complications .
2- Mention the complications of the disease ( not in details) , it is enough to say that it has
complications and that is the cause why It is important to treat this disease … and the
complications are;
 ATH. brain . heart. kidney.
3-Management:
A. life style modification.
Diet:
 decrease your salt intake;
- tab5ah 3’er mal7ah.
- No salt on the table
- No mokasarat , mo5alalt, mo3alabat.
 decrease fat ( less saturated and trans , more poly/mono saturated fat) and decrease
cholesterol .
decrease caffeine ( 1-2 cups/day)
Exercise: half hour daily of either brisk walking , gardening or swimming ….. choose what
is appropriate for you.
Reduce your weight.
Stop smoking and alcohol.
Avoid stress.
B. Drugs
age < 55 age>55
Step 1 ACE (A) or  blocker (B) CCB (C) or thiazide diuretics (D)
Step 2 A or B + C or D A or B + C or D
Step 3 A+C+D A +C +D
Step 4 A + C + D and ADD  blocker or A + C + D and ADD  blocker or
spirinolactone. spirinolactone.
 www.sawa2006.com
C. Follow up:
 take your medications as prescribed on time
monthly (in each visit) - check BP
- ask about the risk factors.
- ask about any new complication.
- ask about smoking..
yearly: - check FBS , KFT ,creatinine .

4. Family History of IHD

(( the question is : a totally healthy young male came to your clinic afraid because he has a strong
family history of ischemic heart disease , and asking you what should he do ??? )

1- Explain the disease ; ( tell him that the disease is caused by fatty deposits that accumulate in
the walls of the coronary arteries leading to the narrowing of these arteries causing ischemia
to the heart muscle …. And if it became complete narrowing , it would cause myocardial
infarction –heart attack-)

2- Talk about the symptoms : -chest pain / tightness.

-SOB.
-nausea + vomiting.
-intermittent claudication.

3- Talk about the risk factors:

 non modifiable : age ( male > 55 , female > 65 ) , male , family history of ( HTN ,
hyperlipidemia, DM , premature death ( male <55 , female <65)
modifiable : smoking / alcohol , obesity / exercise , HTN / hyperlipidemia/DM …

4- Life style modification :

Diet:
 increase fibers , vegetables , fruits as much as u can (fruits : one type/day)
 decrease fat mainly saturated and trans fat … depend more on the poly/ mono saturated
fat
Exercise: half hour daily of either brisk walking , gardening or swimming ….. choose
what is appropriate for you.
Reduce your weight.
Stop smoking and alcohol.
Avoid stress.
5- Regular investigations :
BP , FBS, lipid profile .
www.sawa2006.com

5. Low Back Pain Due to Muscle Strain & Sprain

1- It is a benign condition and self limiting
2- we can give you analgesics to relieve the pain ( and the best is paracetamol) and muscle
relaxants
and we advice you with bed rest for 2-3 days …. But you have to do minimal physical activity
because absolute rest may aggravate the problem.

Note : Patient’s question : should I take one week (2ejazeh) from my work?
The answer : no , 2 days are enough.

3- MRI is done only when there is RED FLAG.

Mention all the red flags

age <20 , >50

pain that is increasing in severity , not relieved by analgesics (for>6weeks) , increases at night
and at rest.
progressive sensory or motor deficit.
numbness (over buttocks and groin) , numbness and weakness( in one or both legs)
 urinary or fecal incontinence.
associated with fever , unexplained weight loss , systemic infections.
history of cancer , alcohol/drug abuse , significant trauma.

4- You have to tell the patient that > 90% of all MRI scans show some abnormalities so even
normal people ‘s MRI may show problems.
5- Tips for preventing back pain :
 don’t try to lift objects too heavy for you.
 don’t lift by bending over , lift any object by bending your knees and squatting to pick up
the object. Keep your back straight and the object close to your body , avoid twisting your
body while lifting.
push rather than pull when you must move heavy objects.
if you must sit at your disk or at the wheel of a car or truck for long hours , break up the
time with stops to stretch.
wear flat shoes or shoes with low heals.
exercise regularly .
maintain healthy diet to reduce or prevent excessive weight gain.
if you smoke , quit.

6- What is the best way to sit ?

Sit in chairs with straight backs or low back support. Keep your knees a little higher than your
hips. Turn by moving your whole body rather than by twisting at your waist.

7- What is the best position for standing?

If you must stand for long periods , rest one foot on a low (stool) and switch the foot every 5-
15 mins .

8- What is the best position for sleeping?

Sleep on one side with your knees bent . put a pillow under your head to support your neck ,
you may also put a pillow between your knees.
Note: if you sleep on your back , put pillows under your knees and a small pillow under your
lower back.
Don’t sleep on your stomach unless you put a pillow under your hips.
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6. Migraine
1- It is a chronic disease , not curable , but it is manageable .
2- Management :
A- Life style modification:
 avoid triggering factors . mention them :
1- fatigue
2- Sleep excess or deprivation.
3- Diet ( fasting , caffeine withdrawal, trymine in cheese , nitrites in bacon and salami ,
chocolate, alcohol mainly red wine )
4- Bright light and weather.
5- Stress
6- Hormonal factors ( menstruation , ovulation, exogenous estrogen,pregnancy,menopause)

 get enough sleep.

eat regularly
stress management.

B- Symptomatic treatment
Analgesics ( acetaminophen, NSAIDS , ergotamine derivatives)
Antiemetic (IV meteclopromide)
Others ( benzodiazepines , barbiturates, opiods)

C- Prophylactic treatment in case of frequent and severe headaches:

 blockers.
Ca channel blockers.
D- ADMIT if severe headache persists for longer than two days.

3- MRI is done only when there is RED FLAG.

RED FLAGS :
1. Significant trauma
2. Sudden onset .
3. Worsening pattern.
4. Headache with fever , stiff neck or rash (meningitis)
5. Headache with BP > 200 / 130
6. Trigger with cough , exertion , valsalva.
7. Focal neurological signs , seizures , loss of consciousness , change in mental or functional
status and papilledema.
8. Pregnancy /postpartum.
9. New headache in patients with serious illness:
cancer (mets)
lyme disease : (meningitis)
HIV : opportunistic infection , tumor.

7. Statin
1- Given once daily , in the evening ( it works on the endogenous cholesterol )
2- Follow up :
every 3 months
 www.sawa2006.com
 in each visit :-LFT , - CK , -ask about muscle pain.
Note; the first visit must be after 6 weeks … the same investigations .

3- Side effects :
 GI disturbance
elevated liver enzymes.
3 grades of myopathy :  muscle pain and ache . myositis rhabdomyolysis.

4- When should you stop the drug ?

LFT ( increase by 3X )
 CK ( increase by 10X)
new onset of muscle pain .

5- What do you have to do after stopping the drug ?

stop the drug for one month.
then you have three options ;
- Continue with the same drug .
- Choose another type of statins
- Or choose another type of ante lipid ( niacin , fibrates , bile sequestrants )

6- Drug – drug interaction ?

 macrolides ( arthromycin ).
antimalarial.
cyclosporine.
chloramphinicol.
fibrates.
grapefruit.

8. Metformin
1- It is a drug to control your sugar level in the blood
2- You have to take it for life.
3- Must be taken before the meal. Note : the first week ; one pill/ day
The second week ; 2pills/day
Then … increased gradually..
4- It is a good drug because it doesn’t cause hypoglycemia or increase in the body weight.

5- Side effects:
nausea and vomiting
 diarrhea
Note : these effects are only experienced in the beginning ..

6- When should you stop the drug ?

unexplained abdominal
 two days before using IV contrast.
overt nephropathy ( creatinine >200 )
Other drugs for diabetes :
1-Basal insulin (lantos) …doesn’t cause hypoglycemia.
2- sulphunyl urea ( glipiclemide , glipizide ) …
S/E : - increase the heart rate
 www.sawa2006.com
-hypoglycemia
-skin rash
-hematologic complications
3- glitazone … S/E : heart failure , hepatic impairment .

9. Antithyroid drugs : carbimazole , propylthiouracil

1- It must be taken for 18 months … with monthly follow up.
2 -At the end of the 18 months …50% will have complete remission And 50% will end with life
long disease.
3- Side effects :
 hypothyroidism ( the patient will be on thyroxin for life
severe skin rash ( it occurs in 50% of the patients , 40% will discontinue the drug, the
rash is temporary it disappears when the drug is stopped )
granulocytosis ( 0.5% of the patients.)
Note: ask the patient to come back if he/ she develops fever or sorethroat.

10. Radioactive Iodine (RAI)

1- Risk of hypothyroidism (10 % in the first year , 3-5% accumulative risk each year)
2- No risk of malignancy.
3- The cure rate .
75% from the 1st dose , 20 % from the 2nd dose , 5% multiple doses
4- Contraindicated in pregnancy and breastfeeding.

11. IBS
- It’s a common disease.
- It’s not curable but manageable.
- There’s a recurrence, but your disease isn’t getting worse and will not convert to a cancer.
And you will not need any surgical intervention.
- Diet:
-drink plenty of water.
-eat small meals but more frequent.
- eat food rich in fiber.
- avoid food that makes you feel worse.

- Life style:
-regular exercise (and walking after dinner).
-avoid stress.
-stop smoking.

- Avoid laxatives because they worsen your condition.

- You’ve not alarming symptoms, so no need for endoscopy until u start to develop some of
the alarming symptoms.
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12. Thalassemia / Carrier

- Common, 10% of the population (in Jordan).
- Asymptomatic.
- Not serious. (will not decrease your life span, will not affect your activity, will not cause
disability, no need for blood transfusion).
- No treatment is needed, and you don’t need iron supplement because your iron level is
normal.
- But we can give you folic acid to improve the anemia.
- Before marriage: do pre-marital test (Hb, MCV, electrophoresis).
- If you married a carrier, the chance to have a thalasemic baby is 25% .

13. Iron deficiency anemia (IDA)

- Anemia is common, 30% of the population are anemic, and half of those IDA.
- Iron needed for RBC formation.
- Now you need DIET + iron supplement to replenish the deficiency.
- Diet rich in iron: sabane5 o awra8 5a9’ra + red meat + kebdeh + sardeen. And
decrease tea and milk.
- Iron supplement:
- I’ll give you ferrous sulfate, because it’s the elementary iron, and cheap/
- 3 times per day.
- On empty stomach.
- Take it with lemon juice (Vit C).
- For 3-6 months duration.
- Side effects:
-nausea & vomiting.
-black stool & constipation.
-metallic taste.
- can be decreased by taking it with food, or change it to ferrous gluconate.
- if still not tolerated take IV iron (S/E : anaphylaxis).
- Follow up:
After 10 days to check the retics count, but it’s practical.
After 1 month to check Hb, supposed to be elevated 2- 3 g/dl.

14. G6PD
- what do you know about the disease ?? did you have jaundice during neonate ?
- your disease is G6PD deficiency; is deficiency in enzyme that its imp to make the RBCs
membrane and RBCs will be affected by this deficient in some situation that may lead to
destruction in this cell cause bleeding or anemia.
 www.sawa2006.com
- this disease is X-linked recessive related to your family.
- Its common 10% of population and its most common haemolytic in Jordan
- Its chronic, not treatable as its related to family and gene as you see. BUT dont worry its
manageable.
- management mostly depend in avoiding the factors that preciptate the acute hemolysis :
A: Drugs :
Aspirin
antimalaria
sulfa drugss
ulfonamind
chloramphenical (even the eye drop )
methylen blue
B: food
fava been .
C: Infection or acute illness
just away from sick people.
D:Naphthalene
- if you notice any of these plz call your doctor
a. jaundice b. pallor c. change in the urine color ( dark or red )

- blood transfusion, only in sever acute hemolysis as a life saving.

- No need for treatment now, but we may give you Iron supplement it will improve the
anemia .

15. Obesity
- Common.
- There are a genetic causes, and environmental causes ( which you can control).
- The environmental causes are:
-Diet.
- Physical inactivity.
- Diseases (mainly: endocrine disorders).
- Drugs: (anti-depressant, anti-convulsant, steroid, oral contraceptive, DM medication
like insulin & sulphnyluria).

- Central obesity more dangerous than generalized obesity.

- Obesity increase the risk of:
-IHD.
-HTN.
-DM type 2.
-Hyper-lipidemia.
-Obstructive sleep apnea.
-Fatty liver.
-Gallstone.
-Psychological impact: (decrease physical activity, depression, poor self-esteem).
 www.sawa2006.com
- Management:
1. Diet :
-Reduce the calories to (800-1500) Kcal.
-Decrease the fat.
-Decrease the simple sugar.
-Decrease the amount of meals but eat more frequent.

2. Exercise: ½ hr daily.
3. Drugs:
-Reduct: which decrease the appetite, act on hypothalamus, S/E: headache, HTN,
Insomnia, Dry mouth, and constipation.
-Orlistat: GI lipase inhibitor. S/E: oily stool, fecal incontinence, diarrhea, and
decrease the absorption of Vit (K,E,D,A).

4. Surgery:
- Gastric band.
-Gastric bypass
* Indicated if :
BMI >40, Or BMI >35 + DM

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