A concepção crítica dos direitos humanos refletida no campo contratual
2. Contratos e Governança Corporativa em Direitos Humanos
• Never extends outside the Vth nerve territory
• Mouth-ear zone and naso-orbit zone are commonly affected;
ophthalmic division is involved rarely (5%)
• F:M = 3:1; middle-aged or elderly
• Strictly unilateral
• Sudden, severe, stabbing/shooting/lancinating pain, for seconds which may be repetitive. Precipitated by touching the ‘trigger zones’ in face or by eating; usually no neurological sign present
• Remit and relapse
• May be related to disseminated sclerosis or posterior fossa tumour
4. Post-herpetic neuralgia
↓
• Very elderly females > males, over 70 years
• Over ophthalmic division of Vth nerve (forehead)→ most severe over eyebrows and may mimic headache of temporal arteritis
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Facial Pain
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• Very severe; often non-stopping type
• Post-herpetic scars are anaesthetic; normal skin between scars are tender
• High suicidal tendency
5. Trauma/post-traumatic neur algia 6. Facial migraine syndrome
↓
• Males > females; any age
• Deep eye pain; often a feeling as if the mastoid is swollen
• Throbbing type with lacrymation and conjunctival injection
• Alcohol aggravates the pain
• Probably a variety of ‘clusture headache’; previously called ciliary neuralgia, vidian neuralgia, petrosal neuralgia, spheno-palatine neuralgia or geniculate neuralgia are probably variants of facial migraine
• ‘Sluder’s lower-half headache’ (rare)
• Bursting; near base of the nose, near mastoid, behind the eye with nasal congestion
7. Atypical facial pain
↓
• F > M; 30-50 years
• Continual, unbearable, deep bruning type pain; over either or both maxillary region; the patient clutches his face in pain
• May be associated with delusional overtones
8. Temporo-mandibular osteoarthritis (Costen’s syndrome)
↓
• Usually in elderly females
• The site of pain is over the joint or just anterior to it
• May be mistaken with temoporal arteritis
• Aggravates on chewing or yawning
• Severe aching type; only present on eating 9. Carotidynia
↓
• Episodic throbbing type pain in neck
• Associated with swelling and tenderness of the carotid artery
• A little presure over carotid → pain ↑
• A firm presure over carotid → pain ↓
Facial Pain 95 10. Temporal arteritis
↓
• Intermittent claudication of jaw muscles and tongue; headache
• Elderly; F > M = 4:1
• Associated with scalp tenderness, fever, malaise, visual problems (from diplopia to permanent visual loss) or ptosis
• Thickened and tender temporal arteries 11. Anginal pain
↓
• Along with central, stabbing chest pain with radiation to arms (left > right), there may be radiation of pain to neck and lower jaw
• Sublingual isosorbide dinitrate relieves the pain 12. Somatisation syndrome/anxiety
• Aggravating and relieving factors
** There is no such specia l invest igation which may pin-poin t the diagnosis.
PAIN IN THE EYES PAIN IN THE EYES
• Trauma • Periorbital cellulitis
• Conjunctivitis, blepharitis • Xerophthalmia
• Iritis, iridocyclitis, uveitis • Entropion
• Foreign body • Retrobulbar neuritis
• Glaucoma • Cerebral tumour/aneurysm
• Clusture headache • Irritation from eye drops
• Tic douloureux • Ultraviolet light
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LUMP IN THE FACE LUMP IN THE FACE
1. Parotid swelling (mumps, mixed parotid tumour)
2. Preauricular lymphadenititis (tender lymph nodes in front of ea r) 3. Subcutaneous abscess (a tender and fluctuant swelling)
4. Dental abscess (tenderness of under lying tooth on gen tle tapping) 5. Preauricular lymphoma (non-tender lymph nodes in front of ear) 6. Melanoma (painless swelling with pigmented lesion), sebaceous cyst
(swelling with punctum)
7. Basal cell carcinoma (painless ulcer)
8. Nasopha ryngeal carcinoma (swelling at root of nose, ophthal-moplegia)
9. Angioneurotic oedema (so lid asymmetrical oedema involving lips, eyelids)
10. Facial haematoma (from trauma)
11. Neurof ibrom a (singl e or multip le painl ess rubb ery cuta neous tumour).
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Chapter 97
DEFINITION DEFINITION
It is the excessive tiredness on exertion, and occurs in organic or functional ill-health. The severe form of fatigue is known as ‘exhaustion’. Fatigue literally means that the patient is ‘tired all the time’. It is one of the most distressing symptom to the patient.
COMMON CAUSES COMMON CAUSES
1. Physiological–overwork, insomnia, boredom.
2. Pathological–
a. Nutritional deficiency, dyselectrolytaemia
b. Congestive cardiac failure (CCF), hepatic failure, uraemia, malignancy, immunocompromised states (e.g. AIDS), sleep-apnoea syndrome
c. Myxoedema, diabetes mellitus, Addison’s disease, thyrotoxicosis d. Tuberculosis, brucellosis, post-viral infectious states (e.g. influenza or infectious mononucleosis), collagen vascular diseases (e.g. SLE) e. Anaemia, lymphoma and leukaemias, terminally-ill patients f. Multiple sclerosis, myasthenia gravis, myopathies, poliomyelitis g. Functional–anxiety, sleep dis orders, depression, chronic fatigue
syndrome (CFS)
h. Drugs—beta-blockers, sedatives, corticosteroids, α-methyldopa, antihistaminics, anti-epileptic drugs
i. Terminally ill patients—disseminated carcinomatosis.
* At least in 50% cases the cause is functional, i.e. depression, anxiety or somatoform disorders
UNDERLYING MECHANISM UNDERLYING MECHANISM
1. Accumulation of lactic acid in muscles and circulation
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C H A P T E R C H A P T E R
Fatigue
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2. Deficiency of oxygen
3. Creatinine depletion form muscles 4. Tumour necrosis factor and cytokines.
FATIGUE IN CCF FATIGUE IN CCF
1. Inadequate systemic perfusion
2. Sleep d isturba nce (d ue to parox ysmal noctur nal dy spnoea , orthopnoea, decubitus angina, nocturia)
3. Side-effects of beta-blockers
4. Dyselectrolytaemia due to diur etic therapy 5. Systemic manifestations of SBE.
CLUE TO DIAGNOSIS CLUE TO DIAGNOSIS
1. Functional–more at rest, dis appears on activ ity, clin ically WN L, investigations NAD (WNL = within normal limit, NAD = no abnor-mality detected).
2. Cachexi a with loss of weight– tuberculo sis, h aematolo gical o r systemic malignancy.
3. Tremor + muscle cramps → dyselectrolytaemia.
4. Females in their 20-50 years of age → fatigue after minimal exertion–
chronic fatigue syndrome (vide chapter on ‘Diffuse aches and pains’).
5. Hypotension + hyperpigmentation–Addison’s disease.
6. ↑ Appetite + weight loss → thyrotoxicosis.
7. Polyuria + polyphagia + polydipsia→ diabetes mellitus (fatigue may be presenting complaint).
8. Frequent awakening at night + snoring + pa uses in bre athing during sleep + day-time sleepiness → sleep-apnoea syndrome.
9. Recent H/O viral illness + tiredness goes away after few weeks or month → post-viral.
10. Early morning wake-up + tiredness maximum in the morning which persists all along the day + anorexia → depression.
ASSESSMENT ASSESSMENT
Fatigue is a subjective symptom, and even objective changes like loss of body weight may be absent. So, clinically assessment should rely on self-reporting by the patient. Scales which measure fatigue, for example, Edmonton Functiona l Assessment tool, the Fatigue Self-Report scales are useful in research rather than clinical purposes. The ‘Karnofsky
Fatigue 99 Performance Status’ is a simple performance assessment clinical scale with questions like–“how much of the day does the patient spend in bed?”
such a scale having grading, and allows assessment over time by third parties.
TREATMENT TREATMENT
1. Graded exercise programme 2. Treatment of underlying aetiology 3. Psychotherapy (e.g. CFS)
4. Antidepressants (e.g. SSR I), tra nquilizers, anti-a nxiety drugs (e .g.
clonazepam, buspirone), vitamins and electrolytes powder as and when necessary.
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DEFINITION DEFINITION
It is a slowly spreading erythema of the skin of face (often accompanied by neck and upper anterior chest) due to temporary capillary dilatation.
Sometimes, it may be associated with light-headedness, tinnitus, tremulousness, nausea and a sense of suffocation. Flushing is common in females in comparison to males.
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