Medical Toxicology Fellow, Division of Medical Toxicology, Department
of Emergency Medicine, University of Virginia School of Medicine,
Charlottesville, VA, USA
It should also enable the service providers to decide on the assessment of patient menopause 35 symptoms buy premarin 0.625 mg free shipping, treatment options menstrual kits purchase premarin 0.625mg with amex, managing special situation (like co-infections) menstrual smell purchase premarin 0.625 mg overnight delivery, parameters for timely referrals and quality service delivery women's health clinic spruce grove 0.625mg premarin sale. I hope, these guidelines will offer the needed guidance for delivering quality treatment and services in a public health approach. Various etiological agents (Hepatitis A, B, C, D and E viruses) have been implicated that can lead to acute, chronic or sequel of chronic infection. Viral hepatitis is increasingly being recognized as a public health problem in India. The study documented the pooled prevalence of Hepatitis C amongst various sub populations. This meta-analysis concluded that based on the above studies, it can be estimated that India (current population = ~1. Estimating the problem statement There are a few estimates that are available from global publications. However, it is assumed that these estimates are likely to change, as data sets and evidence increase across India. Liver cancer secondary to hepatitis B Liver cancer secondary to hepatitis C Acute hepatitis A Acute hepatitis B Acute hepatitis C Acute hepatitis E Numbers in thousands Total (in thousands) 5. Cirrhosis due to hepatitis B Cirrhosis due to hepatitis C Numbers in thousands 141. The National Health Profile 2016 identified viral hepatitis to contribute to 3% of all deaths related to communicable diseases in India in 2015. Inactivated attenuated vaccine, which is safe, immunogenic and effective, is available. Constitutional symptoms of low grade fever, anorexia, nausea and vomiting, 16 National Guidelines for Diagnosis & Management of Viral Hepatitis fatigue, malaise, arthralgias, myalgias, headache, photophobia, pharyngitis, cough and coryza may precede onset of jaundice by 1-2 weeks. Dark urine and clay colored stools may be noticed by the patient from 1-5 days before the onset of clinical jaundice. With the onset of clinical jaundice, the constitutional prodromal symptoms usually diminish. The liver becomes enlarged and tender and may be associated with right upper quadrant pain and discomfort. During recovery phase the constitutional symptoms disappear, but usually some liver enlargement and abnormalities in liver biochemical tests are still evident. Its replication is limited to the liver, but the virus is present in liver, bile, stools and blood during late incubation period and acute pre-icteric / pre-symptomatic phase of illness. Yellowish discoloration of sclera (jaundice) and skin is usually visible when serum bilirubin value is >2. Virtually all previously healthy patients with hepatitis A recover completely with no clinical sequelae. Infection in the community is best prevented by improving social conditions especially overcrowding and poor sanitation. Perinatal transmission and occasionally horizontal transmission early in life are most common in high prevalence areas. During the acute phase, manifestations range from subclinical or anicteric hepatitis to icteric hepatitis and, in some cases, fulminant hepatitis. Extra-hepatic manifestations can also occur with both acute and chronic infection. The disease may be more severe in patients co-infected with other hepatitis viruses or with underlying liver disease. A serum sickness-like syndrome may develop during the prodromal period, followed by constitutional symptoms, anorexia, nausea, jaundice, and right upper quadrant discomfort. The symptoms and jaundice generally disappear after one to three months, but some patients have prolonged fatigue even after normalization of serum aminotransferase concentrations. The rate of progression from acute to chronic hepatitis B in immunocompetent persons is determined primarily by the age at infection. The rate is approximately 90 percent for a perinatally acquired infection, 20 to 50 percent for infections between the age of one and five years, and less than 5 percent for an adult-acquired infection. In addition, appropriate measures should be taken to prevent infection in exposed contacts. Patients, who have a coagulopathy, are deeply jaundiced, or encephalopathy should generally be hospitalized. Hospitalization might also be considered in patients who are older, have significant comorbidities, cannot tolerate oral intake, or have poor social support systems. In acute cases, the patients who have fulminant hepatitis or hepatitis B with underlying cirrhosis should be considered for antiviral treatment. Some patients experience exacerbations of the infection which may be asymptomatic, mimic acute hepatitis, or manifest as hepatic failure. Physical examination may be normal, or there may be stigmata of chronic liver disease. Jaundice, splenomegaly, ascites, peripheral edema, upper gastrointestinal bleed and encephalopathy may be present in patients with decompensated cirrhosis. As mentioned above, acute hepatitis may be heralded by a serum sickness-like syndrome manifested as fever, skin rashes, arthralgia, and arthritis, which usually subsides with the onset of jaundice. Exacerbations are believed to be due to a sudden increase in immune-mediated lysis of infected hepatocytes. The serum bilirubin concentration may be normal in patients with anicteric hepatitis. In patients who recover, the normalization of serum aminotransferases usually occurs within one to four months. The same assay should be used in the same patient to evaluate the efficacy of antiviral therapy. Please refer to Annexure 1 for details on assessing severity of liver disease (fibrosis and cirrhosis) Please refer to Annexure 2 for the algorithm for laboratory diagnosis of Viral hepatitis Management Whom To Treat It is critical to evaluate the patient carefully as treatment of hepatitis B is life-long in most cases. The clinical spectrum and phases of the chronic hepatitis B pose difficulty in deciding on whom to treat. The section below deals with these drugs and their dosages in adults and children. Key points in counseling and preparing the patient prior to initiation of therapy Preparing to start treatment: Patients should be counseled about the indications for treatment, including the likely benefits and side-effects, willingness to commit to long-term treatment, and need to attend for follow-up monitoring both on and off therapy; the importance of full adherence for treatment to be both effective and reduce the risk of drug resistance; and cost implications. The discontinuation of treatment of Hepatitis B is usually not recommended and should be done at specialized centers under the guidance of the necessary expertise Decision to discontinue therapy requires careful consideration on the risk of virological relapse, decompensation and death on discontinuation versus the financial implication of continued cost of medications and monitoring. All patients with cirrhosis should not discontinue antiviral therapy because of the risk of reactivation which may potentially lead to decompensation and death. Monitoring for tenofovir and entecavir toxicity Measurement of baseline renal function and assessment of baseline risk for renal dysfunction should be considered in all persons prior to initiation of antiviral therapy. Renal function should be monitored annually in persons on long-term tenofovir or entecavir therapy, and growth monitored carefully in children. Only a proportion of those with hepatitis B virus infection (pregnant or otherwise) need treatment. Hepatitis B in a pregnant woman is not a reason for considering termination of pregnancy. If, for some reason, the birth dose is not administered within 24 hours, it should still be administered as soon as it is possible and not omitted. This birth dose must be followed by timely administration of 3-doses of hepatitis B-containing vaccine [e. The hepatitis B vaccine birth dose followed by these three doses is the most effective method for prevention of mother-to-child transmission of hepatitis B. However, additional benefit provided by it, over properly-administered hepatitis B vaccine (as described above) is small. Data on benefit and risks of administering anti-hepatitis B drugs to the pregnant women for prevention of mother-to-child transmission are unclear. Breast feeding A mother who has hepatitis B may breast feed her baby, unless there is an exuding injury or disease of the nipple or surrounding skin. The advantages of breast feeding far outweigh the risk, if any, of transmission of hepatitis B to a baby who has received hepatitis B vaccine.
Nursing-sensitive outcome measures for the acute care setting include pediatric I pregnancy lingerie cheap premarin 0.625 mg free shipping. Standards as Domains of Organizational Structure Quality of health care is also viewed in domains of structure menopause emotions discount 0.625 mg premarin mastercard. Sierchio (2010) identifies three domains: the organizational leadership women's health issues in thrombosis and haemostasis 2013 premarin 0.625 mg generic, the healthcare professional menopause estrogen levels purchase premarin 0.625 mg with mastercard, and the patient/consumer of health care. Standards of Care the recipient of care, the patient, is the focus of standards of care. Standards of care can be voluntary, such as those promulgated by professional groups, or they may be mandated legislatively. Standards of care describe the results or outcomes of care and focus on the patient. An example of a nursing standard of care is: "The patient is free of infection related to infusion therapy" (Sierchio, 2010, p. Standards of Practice Standards of practice focus on the provider of care and represent acceptable levels of practice in patient care delivery. Like the standards of care, practice standards address the clinical aspects of patient care services and imply patient outcomes. Standards of nursing practice define nursing accountability and provide a framework for evaluating professional competency. Standards of practice are consistent with research findings, national norms, and legal guidelines, and they complement the expectations of regulatory agencies. These standards reflect commitment to quality patient care and include generic and specialty standards of practice (Sierchio, 2010). A correlating standard of practice to the standard of care stated above is: "The peripheral insertion site is aseptically cleansed with antimicrobial solution before catheter insertion" (Sierchio, 2010, p. Internal standards are those developed within the profession of nursing for the purpose of establishing the minimum level of nursing care. These documents guide nursing care and can be used as a yardstick to measure the practice of individual nurses. External standards are guides for nursing developed by non-nurses, the government, or institutions. These standards describe the specific expectations of agencies or groups that utilize the services of nurses. Staying Current with Standards of Care for Infusion Therapy Whenever nurses administer infusion therapy, they must know and conform to acceptable nursing standards established by the facility, by the infusion specialty, and by state and federal guidelines. The following list presents guidelines for safeguarding practice: Collect assessment data before beginning infusion therapy. Apply knowledge of venous anatomy and physiology in selecting appropriate vein sites. Clarify unclear orders and refuse to follow orders you know are not within the scope of safe nursing practice. Administer the medications or infusions at the proper or prescribed rate and within the ordered intervals. Monitor the patient receiving an infusion for complications and implement interventions appropriate for those complications. Additional Strategies in Quality Management Benchmarking Benchmarking is the process of measuring and comparing the results of processes with those of the best performers. For example, the patient fall rate is expected to be higher in a rehabilitation unit versus an ambulatory care unit. The goal of benchmarking is to identify the best practices so that an organization can improve its performance. Problem-based benchmarking targets efforts toward improving specific concerns, such as lowering medication error rates or decreasing patient waiting times. More recently, facilities are turning to processbased benchmarking, which entails targeting continuous improvement of key processes. Managers can benchmark to help decide a variety of factors, such as where to allocate resources more efficiently, when to seek outside assistance, how to quickly improve current operations, and whether customer requirements are being adequately met. The 2013 National Patient Safety Goals for hospitals include: Identify patients correctly. Prevent infection; this specifically includes infections related to central lines. Publicly Reported Outcomes A variety of health-care outcomes can be accessed by the public and may be used by health-care customers in choosing an organization. The organizations with better outcomes will receive higher reimbursements, whereas those with poor performance will face financial penalties. The purpose of this data collection is to encourage organizations to improve quality. Examples of publicly reported hospital outcomes include timely treatment of certain conditions. Examples of publicly reported home care measures include hospitalization rates for home care patients, improvement in the symptom of dyspnea, improvement in pain, and patient satisfaction. Examples of publicly reported outcomes for long-term care facilities include health inspection results and deficiencies, and quality of care measures such as percentage of patients with pressure ulcers. The ability to compare or benchmark patient satisfaction data with data from other organizations can be helpful in improving quality. Organizations may also choose to perform other methods of patient data collection beyond standardized surveys, such as making follow-up phone calls after patient discharge or obtaining patient satisfaction information via a focus group or postcare interview. P4P has become a reality in part because of persistent deficiencies in quality in the U. Beginning in October 2012, hospitals will be rewarded financially for both achievement and improvement in care. It will affect 1% of payments beginning in 2012 for all admissions and will increase to 2% in October 2017. S107) Standards of Practice define risk management as "a process that centers on identification, analysis, treatment, and evaluation of real and potential hazards. Risk management concepts include the concerns that organizations face with exposure to losses. Organizations handle the chances of losses or risks by financing, purchasing insurance, or practicing loss control. Loss control consists of preventive and protective activities that are performed before, during, and after losses are incurred. It provides for the review and analysis of risk and liability sources involving patients, visitors, staff, and facility property. Risk management consists of the following components: Identification and management of clinical areas of actual and high risk Identification and management of nonclinical. Risk management strategies combine the elements of both loss reduction and loss prevention. The purpose of informed consent is to provide patients with the information they need to make a rational and knowledgeable decision regarding whether to undergo treatment. The right of self-determination provides the basis for informed consent and is grounded in the bioethical principles of autonomy. A competent adult (competence to consent) is aware of the consequences of a decision and has the ability to make reasonable choices about health care, including the right to refuse health care. There are categories of necessary elements for informed consent and informed refusal. Generally, this disclosure must include benefits and risks of the procedure, alternative procedures, benefits and risks of the alternatives, and qualifications of the provider. The patient must know that options and risks exist, even if he/she does not want to know what they are. Other limits to consent include verbal limits; for example, the patient may tell the infusion nurse, "Okay, I will let you try to restart my I. The duty to obtain informed consent belongs to the person who will perform the procedure, but it also may belong to the licensed person who is aware that the patient has not been informed, does not understand, or did not consent (Table 1-4). Consent shall be obtained by the health-care provider who will provide the procedure. Unusual Occurrence Reports Unusual occurrence reports, also called incident reports, are documented when there is a deviation in care.
Separation anxiety is best dealt with by keeping the child and parent together as much as possible during evaluation and involving the parent in the treatment if appropriate; if possible buy women's health big book of exercises purchase 0.625 mg premarin fast delivery, interact first with the parent to build trust with infant iv breast cancer 86 year old woman purchase premarin 0.625mg line. Allow a child to hold objects of importance to them like a blanket women's health department rockford il discount premarin 0.625mg without prescription, stuffed animal or doll Page 333 of 385 With the head beginning to grow at a slower rate than the body women's health clinic in ottawa purchase premarin 0.625mg without prescription, children begin no longer requiring shoulder rolls limiting flexion of the neck when bag-valve-mask ventilating or intubating ix. As children begin to relate cause and effect, painful procedures make lasting impressions; be considerate by limiting painful procedures and adequately treating pain 3. The rapid increase in language means they will understand much of what you say if simple terms are used iii. Do not waste time trying to use logic to convince preschoolers; they are concrete thinkers,; avoid frightening or misleading comments vii. Children with chronic illness or disabilities begin to be very self-conscious iii. With patients loosing baby teeth and getting adult teeth, one must be particularly careful when intubating ii. School aged children can understand simple explanations for illness and treatments iii. Reassure children that everything is going to be all right, if appropriate, and that they are not going to die vi. Relationships generally transition from mostly same sex ones to those with the opposite sex d. History (age, preceding symptoms, choking episode, underlying disease, sick contacts, prematurity) b. Physical findings (mental status, respiratory rate, pulse oximetry, capnometry, work of breathing, color, heart rate, degree of aeration, presence of stridor or wheeze) 4. Chronic lung disease that usually occurs in infants form born prematurely and treated with positive pressure ventilation and high oxygen concentrations b. Recurrent respiratory infections and exercise induced bronchospasm are complications c. Inhaled medicationsbronchodilators (albuterol, ipratropium, racemic epinephrine) v. Oral and intramuscular medications (prednisolone, dexamethasone)Corticosteroids vi. History (fever, vomiting, diarrhea, urine output, fluid intake, blood loss, allergic symptoms, burns, accidental ingestion) b. Physical findings (heart rate, blood pressure, capillary refill, color, petechiae, mental status, mucous membranes, skin turgor, face/lip/tongue swelling) 4. Anaphylactic: subcutaneous epinephrine, intravenous antihistamines (diphenhydramine, ranitidine), and intravenous steroids d. History (age, sweating while feeding, cyanotic episodes, difficulty breathing, syncope, prior cardiac surgery, poor weight gain) a. Physical findings (heart rate, blood pressure, capillary refill, color, mental status, cardiac murmurs/rubs/gallops, pulse oximetry, 4 extremity blood pressures) c. Causes of altered mental status in children (trauma, toxins, infection, electrolyte or glycemic imbalance, intussusception, seizure, uremia, intracranial bleed, intracranial mass) b. History (age, fever, vomiting, photophobia, headache, prior seizures, extremity shaking, staring episodes, trauma, ataxia, ingestions, oral intake, bloody stool, urine output, baseline developmental level) b. Medications for intubation (thiopental, etomidate, lidocaine, non-depolarizing muscle relaxants) Page 339 of 385 ii. History (polyuria, polydipsia, weight loss, visual changes, poor feeding, abnormal odors, growth delays) b. Physical findings (heart rate, blood pressure, mucous membranes, mental status, virilization, frontal bossing, blindness) c. Administration of stress dose steroids for cortisol deficiency Hematologic/Oncologic/Immunoloic 1. History (chest pain, weakness, abdominal pain, extremity pain, trauma, bleeding, swollen joints, swollen glands, fever, bruising) Page 340 of 385 G. Physical findings (all vital signs, lung sounds, extremity tenderness, signs of active bleeding, bruises, joint swelling, lympadenopathy, capillary refill) c. History (blood or bile in emesis, diarrhea, age, gender, constipation, fever, medications, tolerance of gastrostomy tube feeds, prematurity, blood type incompatibility, epistaxis, liver disease) b. Physical findings (heart rate, blood pressure, mucous membranes, icterus, capillary refill, blood in nares, abdominal distention or mass, hepatomegaly, pallor, anal fissure) c. School age (infectious enteritis, juvenile polyps, hemolytic uremic syndrome, Henoch Schonlein purpura) iii. History (time of ingestion/exposure, amount ingested, abnormal symptoms, bottles/containers available) b. Specific toxidromes (anticholinergics, cholinergics, opiates, benzodiazepines, sympathomimetics, beta-blockers, calcium channel blockers, salicylate, tricyclic antidepressants) b. Page 343 of 385 Special Patient Population Geriatrics Paramedic Education Standard Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment/disposition plan for patients with special needs. Normal changes associated with aging primarily occur due to deterioration of organ systems; B. Pathological changes in the elderly are sometimes difficult to discern from normal aging changes. Temperature Sensory perception including audio, visual, olfactory, touch and pain 3. Liver function decreases with increased potential for drug toxicity Genitourinary 1. Reduction in renal function due to decreased blood flow and tubule degeneration 2. Pain Perception - inability to differentiate hot from cold Pharmacokinetic change A. Consider polypharmacy as a reason for problems Psychosocial and economic aspects A. May present with only dyspnea, acute confusion (delirium), syncope, weakness or nausea and vomiting B. Peripheral edema is frequently present in elderly patients with or without failure and may signify a variety of conditions 4. Transient reduction in blood flow to the brain due to cardiac output drop for any reason d. Presentation can include dyspnea, congestion, altered mental status, or abdominal pain. Anxiety and fear of treatment of current medical problems Delirium- a sudden change in behavior, consciousness, or cognitive processes generally due to a reversible physical ailment. Evaluation of pathophysiology through history, possible risk factors, and current medications a. Evaluation of pathophysiology through history, possible risk factors, and current medications. Alcohol/ Cirrhosis of the Liver Medications in use: nonsteroidal anti-inflammatory drugs, warfarin i. Venous access- care should be taken to avoid use of indwelling fistulas or shunt unless necessary in cardiac events. Diffuse tenderness on palpation of abdomen, with distention, guarding, or masses; upon auscultation high pitched noises k. Blood pressures, lying, sitting, and standing noting any change of 10 mm/Hg or more lower as the patient moves to an upright position d. Pulses, lying, sitting, and standing noting any change of 10 beats per minute more higher as the patient moves to an upright position. Evaluation of patient treatment through reassessment Biliary disease is disorders of the liver and gallbladder. Evaluation of patient treatment through reassessment Chronic Renal Failure- is the inability of the kidneys to excrete waste, concentrate urine, or control electrolyte balance in the body. Medications that damage the kidneys: antibiotics, nonsteroidal anti-inflammatory drugs, anticancer drugs 2. Diabetes Mellitus- an inability of the pancreas to produce a sufficient amount of insulin causing hyperglycemia. Hyperglycemia: plasma levels greater than 200 mg/dl, fasting levels of greater than 126 mg/dl iii.
Essential Features Pain without adequate organic or pathophysiological explanation pregnancy gingivitis order premarin 0.625 mg with mastercard. Proof of the presence of psychological factors in addition by virtue of both of the following: (1) an appropriate and important relationship in time exists between the onset or exacerbation of the pain and an emotional conflict or need women's health recipe finder purchase premarin 0.625mg with visa, and (2) the pain enables the individual to avoid some activity that is unwelcome to him or her or to obtain support from the environment that otherwise might not be forthcoming women's health center rome ga cheap 0.625 mg premarin with mastercard. The condition must not be attributable to any psychiatric disorder other than the following menstrual symptoms after hysterectomy cheap premarin 0.625 mg mastercard, and it should conform to the requirements for the diagnoses of Dissociative [conversion] Disorders (F44) or Somatoform Disorder (F45) in the International Classification of Diseases, 10th edition, or to those for somatization disorder (300. The differential diagnosis from tension headache usually will be based on one or more of the following: (a) the level of observed anxiety is not sufficient to account for tension which might produce the symptom; (b) the personality conforms to the hysterical or hypochondriacal pattern and the complaint to an acute conflict situation or to a pattern of multiple symptoms; and (c) relaxation exercises and sedation do not provide relief. Differential Diagnosis Muscle tension pain with depression, delusional, or hallucinatory pain; in depression or with schizophrenia, muscle spasm provoked by local disease; and other causes of dysfunction in particular regions. It is important not to confuse the situation of depression causing pain as a secondary phenomenon with depression which commonly occurs when chronic pain arising for physical reasons is troublesome. If the patient has a depressive illness with delusions, the pain should be classified under Pain of Psychological Origin: Delusional or Hallucinatory. If muscle contraction predominates and can be demonstrated as a cause for the pain, that diagnosis may be preferred. Patients with anxiety and depression who do not have evident muscle contraction may have pain in this category. Previously, depressive pain was distributed between other types of pain of psychological origin, including delusional and tension pain groups and hysterical and hypochondriacal pains. The response to psychological treatments or antidepressants is better than to analgesics. A Note on Factitious Illness and Malingering (1-17) Factitious illness is of concern to psychiatrists because both it and malingering are frequently associated with personality disorder. No coding is given for pain in these circumstances because it will be either induced by physical change or counterfeit. In the second case, the complaint of pain does not represent the presence of pain. X8e Signs Extremity weakness and areflexia are essential features of the neuropathy. Back and leg pain are commonly exacerbated by nerve root traction maneuvers such as straight-leg raising. Relief Acetaminophen or nonsteroidal anti-inflammatory drugs for mild to moderate pain. Beyond the first month, burning tingling extremity pain occurs in about 25% of patients. Note: While in the Guillain-Barre syndrome weakness typically occurs first in the feet and the legs and then later in the arms, the worst pain is in the low back, buttocks, thighs, and calves. Site Strictly limited to the distribution of the Vth nerve; unilateral in about 95% of the cases. The second, third, and first branches of the Vth cranial nerve are involved in the foregoing order of frequency. In patients with multiple sclerosis, there is also an increased incidence of tic douloureux. Age of Onset: after fourth decade, with peak onset in fifth to seventh decades; earlier onset does occur, but onset before age 30 is uncommon. Associated Symptoms and Signs Occasionally, a mild flush may be noted during paroxysms. Pathology When present, always involves the peripheral trigeminal (primary afferent) neuron. Essential Features Unilateral, sudden, transient, intense paroxysms of superficially located pain, strictly confined to the distribution of one or more branches of the trigeminal nerve, usually precipitated by light mechanical activation of a trigger point. Sensory and reflex deficits in the face may be detected in a significant proportion of such cases. Essential Features Paroxysmal neuralgia in the trigeminal innervation zone, with one or more atypical features such as hyperesthesia or depression of corneal reflex, or longer-lasting paroxysms. Secondary Neuralgia (Trigeminal) from Central Nervous System Lesions (11-2) Definition Sudden, severe, brief, stabbing recurrent pains in the distribution of one or more branches of the Vth cranial nerve, attributable to a recognized lesion such as tumor or aneurysm. Pain Quality: paroxysmal pain may be indistinguishable from "true" tic douloureux. Attack pattern may be less typical with longer-lasting paroxysms or nonparoxysmal pain. Tumor Aneurysm Arnold-Chiari syndrome: congenital; Secondary Trigeminal Neuralgia from Facial Trauma (11-3) Definition Chronic throbbing or burning pain with paroxysmal exacerbations in the distribution of a peripheral trigeminal nerve subsequent to injury. Pain Quality: biphasic with sharp, triggered paroxysms and dull throbbing or burning background pain. Page 61 Signs Tender palpable nodules over peripheral nerves; neurotrophic effects. Usual Course Progressive for six months, then stable until treated with microsurgery, graft-repair reanastomosis; transcutaneous stimulation and anticonvulsant pharmacotherapy. Complications Acute glaucoma and corneal ulceration due to vesicles have been reported. Time Pattern: pain usually precedes the onset of herpetic eruption by one or two days (preherpetic neuralgia); may develop coincident with or after eruption. Signs and Laboratory Findings Cutaneous scarring, loss of normal pigmentation in area of earlier herpetic eruption. Hypoesthesia to touch, hypoalgesia, hyperesthesia to touch, and hyperpathia may occur. Summary of Essential Features and Diagnostic Criteria Chronic burning, dysesthesias, paresthesias, and intractable cutaneous pain in distribution of the ophthalmic division of the trigeminal associated with cutaneous scarring and history of herpetic eruption in an elderly patient. Pain Quality: sharp, lancinating, shocklike pains felt deeply in external auditory canal. Signs and Laboratory Findings Usually follows an eruption of herpetic vesicles which appear in the concha and over the mastoid. Summary of Essential Features and Diagnostic Criteria Onset of lancinating pain in external meatus several days to a week or so after herpetic eruption on concha. X2 Neuralgia of the Nervus Intermedius (11-7) Note: this condition is admittedly very rare and is presented as a tentative category about which there is still some controversy. Pain Quality: sharp agonizing electric shock-like stabs of pain felt in the ear canal, middle ear, or posterior pharynx, usually of brief duration, often with a refractory period after multiple jabs of pain. Page 63 Periodicity is characteristic, with episodes occurring for weeks or months, and then months or years without any pain. Pathology Most patients have impingement on the nervus intermedius at its root entry zone. Essential Features Unilateral, sudden, transient, intense paroxysms of electric shock-like pain in the ear or posterior pharynx. Radiation to external auditory canal (otic variety) or to neck (cervical variety). Time Pattern: episodic bouts occurring spontaneously several times daily or triggered by any of above mentioned stimuli. Associated Symptoms Cardiac arrhythmia and syncope may occur during paroxysms in some cases. Usual Course Fluctuating; bouts of pain interspersed by prolonged asymptomatic periods. Summary of Essential Features and Diagnostic Criteria Paroxysmal bursts of sharp, lancinating pain, spontaneous or evoked by mechanical stimulation of tonsillar area, often with radiation to external ear or to angle of jaw and adjacent neck. Page 64 Neuralgia of the Superior Laryngeal Nerve (Vagus Nerve Neuralgia) (11-9) Definition Paroxysms of unilateral lancinating pain radiating from the side of the thyroid cartilage or pyriform sinus to the angle of the jaw and occasionally to the ear. Combined ratio of vagoglossopharyngeal neuralgia to trigeminal neuralgia is about 1:80. Pain Quality: usually severe, lancinating pain often precipitated by talking, swallowing, coughing, yawning, or stimulation of the nerve at its point of entrance into the larynx. Main Features Prevalence: quite common; no epidemiological data; most often follows acceleration-deceleration injuries. Age of Onset: from second decade to old age; more common in third to fifth decades.
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