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Treatment is to stop the alcohol and replace thiamine (Vit B-1) although painful symptoms frequently persist medications that interact with grapefruit carbidopa 300mg cheap. It presents as an acute progressive usually ascending faccid paralysis that reaches its peak usually around 10-14 days but always by defnition in less than 4 weeks treatment 4 autism generic carbidopa 300 mg. This is followed by a plateau phase and eventual recovery for most patients after 3-6 months symptoms congestive heart failure carbidopa 300 mg otc. Two thirds of cases are associated with a history of preceding febrile illness symptoms stiff neck order 125mg carbidopa free shipping, diarrhoea medicine 027 purchase carbidopa online pills, immunization or surgery during the previous 2-3 weeks medicine on airplane discount 110 mg carbidopa otc. Clinical features The presenting complaint is that of a rapidly developing motor weakness occurring over days and sometimes hours. Sensory symptoms, mainly paraesthesiae, often painful may accompany the weakness but these are usually mild. Lower motor neurone type facial weakness occurs in about half the patients but may be mild and is frequently bilateral. Tese include transverse myelitis, organophosphorous poisoning, diphtheria, polio, botulinum and lead poisoning. If available, nerve conduction studies will show marked slowing of motor conduction velocities characteristic of a demyelinating polyneuropathy. Nursing care is directed at checking for signs of increasing weakness, respiratory failure and the prevention of bedsores and contractures. The vital signs and in particular the vital capacity should be measured 4 hourly for the frst few days of the illness. The heart should be monitored for arrhythmias and any surges in blood pressure treated with beta blockers. Compression stockings and low dose heparin are used to prevent deep vein thrombosis and pulmonary emboli. Disease progression, respiratory failure and signifcant disability are all indications for their use and they should be administered within the frst 2 weeks of onset of the illness, as they are not of value after that time. Teir main role is to halve the average period of hospital stay from about 12 to 6 weeks. However, these treatments are mostly unavailable because of their high cost and limited resources. Recovery in the remaining 90% is good but some (10-20%) remain partially disabled at 12 months. The clinical features are characterized by a mixed motor sensory peripheral neuropathy usually with proximal as well as distal weakness. Treatment is with high dose steroids prednisolone initially 60 mg/od for 4-6 weeks, reducing slowly over months until on a minimum maintenance dose of 5-20 mg on alternate days. Response to immunosuppression is good but may have to be continued in the longer term. Neuropathy in Ethiopian diabetics: a correlation of clinical and nerve conduction studies. Guillain-Barre syndrome in northern Tanzania: a comparison of epidemiological and clinical fndings with western Norway. Increased incidence of symptomatic peripheral neuropathy among adults receiving stavudine versus zidovudine based antiretroviral regimens in Kenya. A clinical, epidemiological and genetic study of hereditary motor neuropathies in Benghazi, Libya. The clinical skills needed to examine the individual cranial nerves are presented in chapter 1. The overall aim of this chapter is to present the main cranial nerve disorders and to integrate examination and localization in their diagnosis. After reading the chapter the student should be able to localize and diagnose main disorders afecting pupils, vision, eye movements, facial sensation and movements, hearing, speech and swallowing. During a routine neurological examination it is sufcient to ask the patient if there is a loss or decrease in the sense of smell (anosmia). Frequently patients are unaware of a loss of smell or may only complain of losing their sense of taste. This is because both smell and taste are used together to appreciate the favors of food and drink. If there is a loss or deterioration in smell, then each nostril should be tested separately as outlined in chapter 1. The most common cause of transient loss of smell is mucosal swelling in the nose or sinuses as a result of local infection. Anosmia may occur after a head injury when there is a shearing injury to the olfactory bulb and its central connections through the cribriform plate. Optic nerve Disorders afecting the optic nerve are common and clinical assessment involves a history and examination. The history involves asking about a loss or decrease in vision, double vision, pain and headache and their mode of onset, progression and time course. The examination of the optic nerve includes testing the pupillary responses, visual acuity, visual felds and fundoscopy. Details concerning the technique of examination have already been set out in chapter 1. It does this by means of two groups of muscle fbres supplied by William Howlett Neurology in Africa 287 Chapter 12 Cranial nerve disorders the autonomic nervous system. The sphincter pupillae is a circular constrictor smooth muscle supplied by the parasympathetic and the dilator pupillae is a radial smooth muscle supplied by the sympathetic nervous system. The light in one eye sends an aferent impulse along the optic nerve to the midbrain. The aferent anatomical pathway to the midbrain involves the retina, optic nerve, chiasm and optic tract. From the midbrain, a second order neurone travels to the Edinger Westphal nucleus on both the same and opposite side of the midbrain. From there, eferent parasympathetic fbres travel back to the eyes, via the outside of the oculomotor nerve to the ciliary ganglion and to the constrictor sphincter pupillae. If all pathways are working normally, then the pupils in both eyes constrict equally and at the same time in response to light shone in one eye (Fig 12. This represents the normal light refex in the light stimulated eye and the consensual refex (response) in the other eye. A lesion anywhere along that pathway results in a dilated pupil (mydriasis) on the afected side. The resulting defect is called an aferent pupil defect if it afects the optic pathway (Fig 12. A B A normal: both pupils constricted B eferent defect: shine torch in afected eye (dilated pupil): light is perceived but afected pupil is unable to react because of a defect in the eferent pathway Because the aferent pathway is unafected, there is a normal consensual response in the C other eye C aferent defect: shine torch in afected eye (dilated pupil); light is not perceived and afected pupil in unable to react because of a defect in the aferent pathway Because the aferent pathway is afected, there is no consensual response in the other eye Figure 12. Because sympathetic nerves also supply fbres to the ipsilateral eyelid (levator palpebrae superioris), the orbit and adjacent skin, a lesion in the sympathetic chain also results in ptosis, enopthalmos and anhydrosis. Swinging torch test A relative aferent pupil defect is a sign of optic neuritis in the eye being examined. It can be demonstrated by the swinging torch test, during which light is repeatedly shone alternatively into the good eye and the afected eye. When light is shone on the non afected good eye, both pupils constrict normally, however, when the light is transferred briskly to the afected or bad eye both pupils dilate (Fig. The explanation for this is that the weak direct efect on the bad eye is counterbalanced by the withdrawal of the stimulus from the good eye and the loss of the consensual response. This is a sign of incomplete optic neuropathy and is most commonly seen in optic neuritis. A Both pupils constrict on shining light in unafected left eye B Both pupils dilate on shining light in afected right eye (relative aferent pupillary defect) Figure 12. The aferent component of the accommodation refex is conveyed in the optic nerve and the eferent pathway is less certain but does involve the visual cortex and some of the same pathways as the eferent light refex. Testing for the presence of the accommodation refex has become less useful in clinical practice especially with the decrease in the frequency of neurosyphilis worldwide (Chapter 6). Neurological disorders afecting the aferent pathway are relatively common in Africa. Tese are termed optic neuropathies and result in loss of vision and aferent pupil defects (Fig 12. If the oculomotor (3rd nerve) is compressed on its path from the brain stem to the eye, then damage to the parasympathetic William Howlett Neurology in Africa 289 Chapter 12 Cranial nerve disorders fbres which travel on the outside will result in a fxed, dilated pupil on that side. Tere may also be features of 3rd nerve palsy depending on the extent of the compression. Important neurological causes include raised intracranial pressure above the tentorium and an aneurysm compressing the nerve. Neurological causes are uncommon and mainly involve lesions in its central pathway. Primary lung cancer involving the apex of the lung is an important cause, although this disorder is still relatively uncommon in Africa. Other disorders afecting pupils include the Holmes Adie pupil which is a benign condition usually afecting one side which is found in women in their 20-40s. The afected pupil is dilated with an impaired response to light but also accommodates slowly. It may be or becomes bilateral and is also associated with absent ankle refexes (Table 12. The Argyll-Robertson pupil is a small and irregular pupil that accommodates to near vision but has a reduced or absent light refex (Table 12. It was a well known sign of neurosyphilis but is very uncommon in clinical practice nowadays. Illustrative charts are available for illiterate patients and hand held reading charts can be used to formally test near vision. Tese include refractive errors in the lens, cataracts and retinal diseases, particularly of the macula. Tese consist of a series of plates of coloured dots arranged so that persons with normal colour vision can see and identify correctly, a hidden set of numbers or trails arranged in diferent colours on each plate of dots. The patient must be able to read the frst (control) plate before proceeding and each eye should be tested separately. Defective colour vision may be inherited and is a feature of diseases involving the optic nerve in particular optic neuritis. The confrontation method is useful for detecting large visual feld defects in the visual pathway. In order to interpret and localize the main fndings correctly it is important to remember the following three points. The nasal side of each eye picks up the opposite or temporal half of the visual feld whilst the temporal side of the eye picks up the opposite or nasal half of the visual feld (Fig. The optic nerve fbres serving the nasal sides of the retina decussate to the opposite side at the level of the optic chiasm (Fig. The main visual defects, their sites of origin and causes are outlined below (Table 12. In summary, it is important to look at and inspect the optic disc, blood vessels and retinal background. Disorders afecting the optic nerves may result in swelling of the optic disc, called papilloedema or wasting of the optic nerve called optic atrophy. Both of these disorders can be easily seen and identifed by fundoscopy and are illustrated below (Figs 12. Examples of retinopathy in hypertension and diabetes are included for comparison (Fig 12. Papilloedema Papilloedema is swelling of the optic disc sometimes with surrounding retinal haemorrhages and exudates. It is nearly always caused by raised intracranial pressure but it may also be due to infammation of the optic nerves when it is termed optic neuritis or papillitis. Papilloedema is nearly always bilateral and occurs mostly without visual symptoms. Fundoscopy confrms features of papilloedema, a swollen and sometimes haemorrhagic disc (Fig. The main disorders causing optic neuritis are infammatory, toxic, nutritional and infections (Table 12. William Howlett Neurology in Africa 293 Chapter 12 Cranial nerve disorders Fundoscopy fndings in papilloedema Normal fundus Loss of optic cup, disc swelling, indistinct & elevated disc margins, haemorrhages & exudates around the disc Fundoscopy fndings in chronic papilloedema Pallor, loss of optic cup & disc swelling Figure 12. The nerve which was swollen acutely in infammatory optic neuritis and in cases of long standing papilloedema later when chronic becomes pale and atrophic. Optic atrophy is characterized clinically by a loss of visual acuity coupled with a clearly visible pale/white optic disc with clear margins on fundoscopy (Fig 12. It is important to exclude chronic glaucoma which may present with optic atrophy and painless loss of vision, however it is usually monocular. The third, fourth and sixth nerves working together are responsible for normal eye movements. A lesion in any one of these nerves results in a loss of movement in the direction of action of the paralyzed muscles and double vision (diplopia), which is most marked when looking in the direction of action of the paralysed muscles. Eye movements are controlled by two mechanisms: tracking and by voluntary saccades (jumps). Tracking or pursuit occurs when we look at and follow a moving object without thinking.

Many medical cen where they can be easily retrieved by family or friends should ters administer this service as well as local Council on Aging the need arise symptoms yellow eyes discount carbidopa 125 mg amex. With this munication issues so that emergency personnel can respond document medicine ketoconazole cream discount 125mg carbidopa mastercard, a patient either chooses the treatment or not medications used to treat anxiety generic carbidopa 110mg with visa. Patients with myasthenia gravis should also consider purchasing a MedicAlert (or similar) bracelet the Health Care Power of Attorney is very confusing to many ( A Health Care Power of Attorney of consideration for any patient with a chronic disease and a is for health care only; however treatment centers for depression discount 300mg carbidopa free shipping, a Durable Power of Attorney patient with myasthenia gravis is no exception to this rule medicine search purchase carbidopa once a day. These documents are quite useful should a neys not by the patient or their designee medications list a-z cheap carbidopa 110 mg free shipping. Health Care Power patient not be able to communicate their wishes during a time of Attorney documents can be obtained from local medical in of crisis. A Living Will allows a patient to document wishes re stitutions and must be witnessed by two individuals unrelated garding the use of mechanical ventilation or artificial feeding to the patient and share no common interests so that there should a patient be in a non-communicative state, terminally can be no secondary gain from executing this document. Local hospitals usually have these Health care personnel are not allowed to witness these docu documents available for patients to complete. The note, completion of these documents requires a witnessed and document must be notarized. Copies of these documents should be Power of Attorney, the order for decision making on behalf of Psychosocial Issues: From 105 the patient goes to the spouse and if the patient has no 6. A common issue that One of the perplexities for a patient with myasthenia gravis is arises in these situations is with a patient who may be sepa judging the degree of muscle strength and not overtaxing the rated from a spouse. It is a good practice often remind us when we have overtaxed ourselves but for the to complete both a Living Will and a Health Care Power of At myasthenic patient, it is important to avoid this altogether. What may seem to be a simple walk from a should a situation arise that requires intervention. Common parking lot, may prove to be overtaxing for the myasthenia pa mistakes that patients make with these documents are: tient who has overly exerted themselves on a given day. Handicapped parking applications may be obtained from the Division of Motor Vehicles for tem 3. The Division of Motor Vehicles charges A patient should always make sure that a copy of these docu a nominal fee for this special parking permit. Of course, one of ments is given to all treating physicians and medical institu the issues with this is that muscle weakness cannot be out tions and a copy accompanies the patient when traveling. Educating files and make certain that family members or any health care the public about the disease will be a lifelong endeavor for agent has a copy. Many states have Legal Aid services avail those who have the disease and for healthcare providers. Psychosocial Issues: From 106 Managing muscle weakness may evoke a major change in life dependent Living or Vocational Rehabilitation may be re style for the patient with myasthenia gravis. Frustration arises as the patient is forced to make lifestyle changes centered on the disease Body image and muscle weakness may have a profound effect process and may foster greater losses such as giving up old on sexual expression of the patient with myasthenia. Due to roles, finding new interests that are less physically taxing, or the sensitive nature of this topic, patients may not feel com establishing shortcuts in daily routines. It is help change in lifestyle will vary from individual to individual ful for the health care provider to affirm that in some cases, pa based on personality types, where they are in the grief cycle tients may experience functional limitations and decreased en and the degree of support available to them. This affirmation alone walking or adaptive equipment for activities of daily living may encourage open communication about any issues that the throughout the course of the disease. Couples should be encouraged to tional therapists can be instrumental in assessing these needs talk openly with each other. In the event to consider planning intimacy during peak strength times, us that home modifications are needed, therapists can be helpful ing techniques that require minimal energy and developing in determining the needed modifications. Agencies such as In other frequent expressions of love and affection to strengthen Psychosocial Issues: From 107 and reinforce sexuality in the relationship. Even in a healthy person, emotional and physical responses to stress can compromise health. For a myasthenic Most individuals with a chronic illness have to plan special patient, stress is one of the factors that may exacerbate the ill events, such as traveling, very carefully and the patient with ness and have harmful affects on overall management of the myasthenia gravis is no exception to this rule. There is virtually impossible, we as health care providers must pro are some web based programs for purchase that will allow pa mote the use of stress management techniques and encourage tient access to their medical information but whatever modal patients to explore activities that lower stress levels. Patients ity the patient pursues for obtaining this information, timeli may benefit from counseling services offered through local ness is of the utmost importance. Patients should be encour mental health centers or through the private sector in the com aged to discuss this issue with medical information adminis munity. Many states have local myas extra medication when traveling to avoid any complications thenia gravis chapters that promote patient services, research, that may occur in the event of lost or misplaced medication. Meeting other individuals with myas the MedicAlert bracelet would be especially helpful to wear thenia gravis through these local chapters can be an invalu during travel times and anyone traveling with the patient able resource for patients as well as afford them an opportu should at least be made aware of the illness in case a crisis nity to become involved with activities of the organization. The Myasthenia Gravis Foundation of America offers support the patient should always have pertinent information such as and education and is a resource for information about local re a list of medications and those that are contraindicated, as sources available to patients. The web site for obtaining this Psychosocial Issues: From 108 well as a copy of their Advanced Directive. In some instances, pharmaceutical companies may offer assistance programs for patients who meet criteria for fi 6. The Medicare Part D program, which is ef fective beginning January 1, 2006, is a prescription drug pro Management of the disease with medication is also an impor gram offered to Medicare recipients. Medicare Part D offers tant component when treating the myasthenia gravis patient. Plan designs It is important to closely monitor the patient for side effects as vary; therefore, patients should be cautious in choosing a plan adverse effects may discourage a patient from taking the medi that meets their coverage needs. Encourage patients to talk freely about medications so tions for the treatment of myasthenia. Once a patient has cho that adjustments can be made if medications are found to be sen a plan, the patient is not allowed to make a change in unsuitable. Some medications are with the Medicare D program by completing an application taken on a fixed schedule that may require that a patient and submitting it to the Social Security Administration. Some patients may require assistance from family mem ents who did not choose a plan by the open enrollment dead bers to awaken them or patients may need to set alarm clocks line of May 15, 2006. Penalties may also be applied to those to coincide with medication administration. Regardless, this future Medicare eligible patients if they do not choose a plan all equates to another lifestyle change as it is imperative that within a certain period of time after becoming Medicare eligi medications be taken timely and in proper dose. For assistance in choosing a plan, pa Psychosocial Issues: From 109 tients may visit Patients with access to the One of the difficulties with myasthenia is that diagnosis may internet may visit Local agencies such as take some time and many remain uneducated about the dis Council on Aging; Elder Care; or Senior Centers may have rep ease. Symptom management may be inconsistent throughout resentatives available to assist elders in choosing a plan. It is the course of the disease such that a patient, who is capable of most important for the health care provider to address with working one week, may not have the same capabilities the fol the patient a plan for obtaining medications since medication lowing week. Extreme absenteeism from work may present a management of the disease is a crucial part of the treatment. Decisions regarding the financial burdens associated with the disease can be over vocational issues can be difficult to make since symptom pres whelming for a patient with myasthenia gravis. The patient is entation varies and it is often a fine line between consistently faced with the costs of medications, hospitalizations and peri performing job duties and being disabled as a result of the dis odic visits to physicians and other health care providers for ease. A major variable in this decision is, of course, the type of maintenance of the disease. Patients should be encouraged to work that an individual with myasthenia does as it is impor speak with financial counselors in the treating institutions to tant to factor in the amount of exertion required. The Ameri determine if payment plans can be established to reduce cans with Disabilities Act of 1990 was instrumental in requir stress associated with payment for services rendered that are ing employers to accommodate disabled workers and out not covered by insurance. As discussed earlier, stress can have lawed discrimination based on hiring, firing, or pay. Making an adverse affect on the outcome of treatment and should be reasonable accommodations for a disabled employee in no monitored in all aspects of disease management. Beginning in the early stages of most risk for having difficulties performing job duties since Psychosocial Issues: From 110 myasthenia gravis weakens muscles and manifestation of this nate work because of the increasing manifestations of the dis muscle weakness is unpredictable. Social Security Disability may be available for patients abilities Act, which applies to all state and local government who are not expected to be able to maintain gainful employ employers and private employers with 15 or more employees, ment for a period no less than a year. If an employer does not have a istration to inquire about these benefits or visit transferable position, the patient may have to seek other alter These patients may wish to consider a referral to Voca lack of education and the unpredictability of myasthenia gra tional Rehabilitation Services that provides skills assessment, vis, disability is often difficult to obtain. Disability determina job search and training for individuals with limitations due to tion personnel may request that a patient visit one of their phy a disability who may need to pursue another employment sicians for screening. Vocational Rehabilitation Agencies are generally located knowledge about the disease thus leading to disability denial. This will help higher education for purposes of obtaining a new skill set for clarify work limitations and alleviate any misunderstandings employment. Pa There certainly exists the category of patients who absolutely tients who are employed may be vested with an employer who cannot participate in gainful employment of any nature or provides insurance even if a patient becomes disabled. Some who work for a period of time and eventually have to termi Psychosocial Issues: From 111 patients, who are employed, but are unable to continue with pervision for the patient 24 hours a day. Skilled Nursing facili employment, may have the option of cobra coverage for at ties are covered, in part, by Medicare, Medicaid and some com least a year once employment is terminated. The patient is re mercial insurances and can provide a higher intensity of care quired to pay a monthly fee to continue this coverage. Others such as 24 hour nursing services and skilled services such as may be eligible for Medicare two years after becoming dis physical, occupational and speech therapy. Obviously, a huge abled and others may qualify for Medicaid for the disabled concern of patients with myasthenia going into Assisted or based on income eligibility. The Social Security Administra skilled facilities is the degree to which staff are familiar with tion administers Medicare benefits and the County Depart the intricacies the disease. Medication administration is of ut ments of Social Services administer Medicaid benefits. It is important for the staff to understand the disease and know warning signs of crisis. Facilities are governed and licensed by State facilities services and patients should be en 6. Now we must turn to the group of patients who are considered a very Assisted Living facilities can offer therapy services through brittle myasthenic and cannot effectively care for themselves Home Health agencies and these services are covered by Medi at home and lack family who can assist with their care. These services can also be provided in a tions such as Assisted Living or Skilled Nursing facilities that home setting as well. Counties generally have numerous agen can provide the level of care needed and the choice is largely cies that can provide these services. Assisted cies are licensed to provide therapy services but, as mentioned Living facilities are not funded by Medicare but can offer assis previously, the degree of education about myasthenia gravis tance such as medication administration, meals and assis varies from agency to agency as well as professional to profes tance with activities of daily living. Home Health services require a physician order prior more independently functioning patient and can provide su Psychosocial Issues: From 112 to arranging. The health care professional who is arranging words and the impressions we instill in our patients can have these services should be cognizant of the degree to which the a lasting impact. Just as it is important to know about myasthenia gravis and the psychosocial aspects of the disease, it is equally important Sorting through issues and feelings about the disease is a life to know how to care for ourselves as caregivers. I would argue that a healthier approach to patient Part of our goal as health care providers is to help every pa care would be to focus on caring for both ourselves as well as tient see that they are a person who just happens to have myas our patients. We are there to provide the support and re sistently and effectively manage patients is to consistently and sources needed to make sure that every patient discovers that effectively manage ourselves first. Just as the patient with my yes, there is life after a diagnosis of myasthenia gravis and asthenia must recognize triggers to an exacerbation of illness, while it may seem like a roller coaster ride, we are on that the health care provider must recognize when it is time to nur roller coaster together.

If the frequency is weekly or greater or the attacks are disabling medications zovirax buy cheap carbidopa 125 mg, then those patients may beneft from daily prophylaxis medicine daughter discount carbidopa online. Medications used in prophylaxis and their dosages and main side efects are outlined below medications during labor generic 300 mg carbidopa with amex, and the initial treatment duration is for 3-6 months medicine reminder effective 125mg carbidopa. The most commonly used options include amitriptyline 85 medications that interact with grapefruit buy carbidopa 300 mg overnight delivery, beta-blockers and sodium valproate medicine wheel teachings order generic carbidopa canada. The anticonvulsant topiramate can also be very efective in cases resistant to other medications, but it is more expensive. William Howlett Neurology in Africa 355 Chapter 15 headaChe and faCial pain Table 15. Tese are usually cases of transformed migraine or chronic tension headaches and may afect over 2% of the population in high income countries, most commonly females. Patients typically complain of daily throbbing bilateral headaches which are only transiently and incompletely relieved by increasing doses of medications. Management The management aim is to decrease the frequency, severity and duration of the headaches by complete withdrawal of medication. The patient will need to be encouraged to have a regular life style and avoid cafeine and be specifcally educated about the overuse of analgesics. In particular they will need to understand that there will be persisting symptoms including headaches, nausea, agitation and insomnia, particularly during the frst two weeks after stopping. Withdrawal for ordinary analgesics, ergotamine and triptans should be carried out abruptly over a period of 24-48 hours. It has its onset mostly in the 3rd and 4th decade and the male female ratio is about 5:1. It receives its name from its tendency to cluster usually 1-3 times daily (can be up to 8 times) for periods of 3-6 weeks or longer at a time with long intervals, sometimes years completely free of attacks. The attacks are brief, lasting between 30-120 minutes, in contrast to migraine which persists for 4-72 hours. Cluster headaches typically occur at the same time in the 24 hour cycle often waking the patient from sleep. Tese can be well controlled by inhalation via a mask of 100% oxygen @ 7-10 litres/min for 15-20 minutes. They can be repeated once in 24 hours but should be avoided in patients with multiple attacks because of the danger of overuse. Concomitant use of ergot drugs is absolutely contraindicated because of the danger of a stroke. Prophylaxis during a cluster can be helpful with high dose steroids, prednisolone 60 mg/po/daily for 5 days decreasing by 10 mg every 3 days. This includes verapamil 80 mg bd for 2 weeks increasing by 80 mg every 2 weeks to a maximum of 320 mg bd or tds. Other causes to be considered include hypertension, arterial dissection, head injury, brain abscess, subdural haematoma and medications. Secondary headaches may lead to serious consequences if the underlying cause is not identifed and treated. William Howlett Neurology in Africa 357 Chapter 15 headaChe and faCial pain Table 15. The headache of an expanding intracranial tumour is produced by raised intracranial pressure and is often described as bursting and severe in nature. Characteristically it is present on waking in the morning or may wake the patient at night and improves during the day. It is aggravated by measures that increase intracranial pressure; these include lifting, bending, lying down, coughing, sneezing and straining. The distribution of the pain is either generalized or referred to the fronto/ temporal area, or vertex/occipital area depending on the site of origin of the tumour. The presence of nausea, vomiting, visual disturbances, altered level of consciousness all suggest raised intracranial pressure. Neurological examination should check carefully for papilloedema (Chapter 12) and focal neurological fndings. Details on brain tumours, abscess, subdural haematoma and other space occupying lesions are presented elsewhere in this textbook (Chapters 6, 7, 16 & 19). The arteritis causes a new onset, severe, throbbing, mostly bilateral headache and exquisite local scalp tenderness. On palpation, the superfcial temporal artery may be hot, tender, swollen and non pulsatile. Other arteries may be similarly afected and blockage of the ophthalmic artery may result in transient blindness which can become permanent in about 25% of cases. Females are afected more frequently than males and temporal arteritis is associated with polymyalgia rheumatica. Diagnosis is confrmed by a temporal artery biopsy which ideally should be performed early on but this may not always be practical. Management is with immediate high dose steroids as soon as the diagnosis is suspected without waiting for investigation results. Prednisolone 60 mg/po/daily is prescribed for a total of 2-3 months and then tapering to a maintenance dose of 5-10 mg on alternate days. Patients typically present with a severe morning throbbing type headache often associated with nausea, vomiting and sometimes visual disturbances. Visual disturbances include transient often postural episodes of loss of vision lasting seconds, as well as more sustained William Howlett Neurology in Africa 359 Chapter 15 headaChe and faCial pain blurring and sometimes permanent loss of vision. Neurological examination is otherwise normal apart from occasional isolated 6th nerve palsy and a mild gait ataxia. The diferential diagnosis includes the other causes of medically serious headaches including cerebral venous sinus thrombosis. Management Acute treatment measures include repeated lumbar punctures in combination with high dose steroids used over 3-5 days. The main long term management includes weight loss, stopping the contraceptive pill and a diuretic, acetazolamide tablets 250 mg tid. Many of the neurological disorders which cause headache may also cause facial pain; these include cluster headache, temporal arteritis and occasionally migraine. However there are some neurological disorders where the pain is restricted to the face, these include trigeminal neuralgia, post herpetic neuralgia and atypical facial pain. The local causes of facial pain are usually determined clinically by their site and associated clinical fndings. Previously no cause was found in most patients with trigeminal neuralgia and these were termed idiopathic. Secondary causes include herpetic infection and a cerebellopontine angle tumour compressing the trigeminal nerve during its intracranial course. Clinical features Patients with trigeminal neuralgia typically present with unilateral facial pain in the distribution of one or more divisions of the trigeminal nerve. The pains are characteristically sudden, severe, brief, shooting, electric shock like, lancinating or knife like stabs in the distribution of one or more branches of the trigeminal nerve. The attack lasts less than a second usually afecting only one side of the face, typically the corner of the mouth or nose. Tere are frequently trigger areas on the face where any stimulus however gentle may produce pain. The pain may be triggered by touching, talking, eating, drinking cold or hot liquids or cleaning teeth. Between the stabs there may be a lingering continuous background pain but it is usually much less severe. The natural history is one of remission but only after weeks or months of facial pain and the neuralgia typically recurs again after a few months. The diferential diagnosis includes local causes of facial pain including dental infections, sinusitis, disease of the temporomandibular joint and other atypical forms of facial pain Management The pain does not respond to simple analgesics and requires adequate doses of anticonvulsants for control. The standard starting dose is 100 mg/po/bd increased as needed over the next few days or weeks. A usual therapeutic and maintenance dose of carbamazepine is 200 to 400 mg twice or three times daily. If the pain becomes intractable or intolerable and an adequate trial of drug treatment fails then the nerve can be considered for interruption either temporarily with an injection of alcohol or more permanently with phenol, glycerol or a destructive procedure. Migraine attack frequency, duration, and pain intensity: disease burden derived from a community-based survey in northern Tanzania. Manji Hadi, Connolly Sean, Dorward Neil, Kitchen Neil, Metha Amrish, & Wills Adrian. Oxford William Howlett Neurology in Africa 361 Chapter 15 headaChe and faCial pain Handbook of Neurology. Prevalence and impact of headache and migraine among secondary school students in Nigeria. Prevalence and clinical characteristics of headache in medical students of the University of Lagos, Nigeria. Prevalence and burden of primary headache in Akaki textile mill workers, Ethiopia. The prevalence of headache with emphasis on tension-type headache in rural Tanzania: a community-based study. Prevalence of migraine headache in a rural area of northern Tanzania: a community-based door-to-door survey. Other classifcations include tissue type, grade of malignancy and the main site afected. Primary intracranial tumours originate mostly from brain or meninges whereas secondary or metastatic tumours originate mostly elsewhere in the body. The most common primary tumours are gliomas accounting for between 30-50% of all adult intracranial tumours. Gliomas are malignant tumours which arise from glial support cells rather than neuronal cells and are termed astrocytoma, oligodendroglioma, ependymoma and pinealoma. Tese arise from the meninges covering the brain and cranial nerves accounting for 20-30% of all adult intracranial tumours. Other benign intracranial tumours are pituitary adenoma, craniopharyngioma, colloid cyst and acoustic neuroma. The aim of this chapter is to present an overview of the main intracranial tumours. The student should aim to know the main types of tumour, their clinical presentation, diagnosis and management. The incidence in Africa is not known but some studies suggest they may be less frequent there. The cause of most brain tumours is not known but some are related to genetic factors, radiation exposure and possibly environment. Primary intracranial tumours account for the majority, 70-80% of all intracranial tumours, with metastatic tumours accounting for the remaining 20-30% (Table 16. The frequency of intracranial tumour increases with age and metastatic tumours are most common in older age groups. They can exist for long periods with no or few symptoms and when symptoms do occur the tumours may be advanced. Pain is variable, ranging from being dull, low grade and intermittent to being severe, continuous, deep, nocturnal, present on waking and often associated with vomiting. Intracranial tumours have three recognizable main modes of clinical presentation (Table 16. Tese can occur either alone or together depending on type, stage and site of tumour. Highly malignant or fast growing tumours tend to present with combinations of all three main modes of presentation occurring over weeks or months whereas low grade or slow growing tumours tend to present with isolated seizures and/or neurological defcits occurring over months or years. The age of the patient, speed of onset of symptoms and neurological fndings all help to determine the site and the probable type of tumour. Tese include hemiparesis, dysphasia, visual loss, feld defects, cognitive impairment, personality change, cranial nerve palsies and ataxia. The combination of ataxia and cranial nerve palsies occurs more frequently with tumours arising in the posterior fossa. Seizures Seizures are the presenting complaint in approximately a quarter of patients and occur as a complication in about another quarter (Chapter 4). Seizures arise mostly from tumours afecting the temporal lobes and occur most commonly in association with malignant tumours. The seizures are mostly generalised tonic clonic-type seizures with a focal origin. Headache is the most common symptom being typically severe in advanced tumours, often waking the person from sleep during the night or early morning and frequently associated with vomiting (Chapter 15). The site of the headache is mostly frontal in supratentorial tumours and occipital in posterior fossa tumours, however the site may not necessarily be localising. The most common neurological defcits include hemiparesis and 3rd, 4th and 6th nerve palsies. A history of visual disturbances and the presence of papilloedema are usually late clinical fndings. Eventually, the expanding tumour results in herniation either through the tentorium or foramen magnum leading to death. Frontal lobe Tumours involving the frontal lobe typically present late because the frontal lobe has a large silent area.

Having more than one preceptor has the potential to disrupt continuity for the student but also offers advantages of sharing preceptorship duties as well as exposing students to variations in practice styles treatment of scabies order 300mg carbidopa free shipping. Students are not to substitute for paid clinicians medicine 7253 pill order carbidopa 125mg on-line, clerical staff treatment spinal stenosis order generic carbidopa canada, or other workers at the clinical sites medications similar to abilify order 110mg carbidopa visa. However medications every 8 hours buy carbidopa mastercard, every patient must be seen and every procedure evaluated prior to patient discharge symptoms yeast infection men buy generic carbidopa 110mg online. The preceptor must also specifically document that the student was supervised during the entirety of the patient visit. This may be done through standardized forms at admission or on a person-by-person basis. Preceptors should clearly understand how different payers view student notes as related to documentation of services provided for reimbursement purposes. This information is required as a means to evaluate the breadth and depth of clinical experiences as well as determine if the student has met Program benchmark encounters in order to graduate. Students are allowed to document only aspects of the history that include the past medical history, family history, social history, and review of systems. Needle Stick / Blood Exposure Protocol Health professions students may be at a higher risk of exposure due to their inexperience. The student should follow these initial steps immediately following exposure: 1) Immediately and thoroughly wash and/or irrigate the exposure site. As the year continues, they should progress in development of their clinical acumen with an increasing ability to effectively develop assessment and treatment plans. If the preceptor deems it necessary, students initially may observe patient encounters. We also suggest a sit-down conversation with the student at the mid-point of the rotation. The Preceptor Evaluation of the Student (Appendix C) and Preceptor Evaluation of Clinical Skill Proficiency (Appendix D) may be used as a starting point for this conversation. A delay in completing the student evaluation may result in delayed feedback to students, inability to submit grades to the University, and thus, potentially delayed graduation. Your evaluation and evaluation score should reflect student knowledge and skills as well as their improvement throughout the rotation. Scores should assess student progress in comparison to other students at the same level. Additionally, staff feedback may enhance the student experience from one rotation to another and can help to improve efficiency and flow while also maximizing educational opportunities. If you feel a student is not performing at an expected level after appropriate feedback, please contact the Director of Clinical Education as soon as the deficiencies are identified. A mean score is calculated from the preceptor responses on the student evaluation. The preceptor assessment is not calculated into the course grade for an individual rotation; however, preceptors are asked to assess their performance at the end of each rotation to ensure that they are making adequate progress. The student will initiate a request to the preceptor for assessment in each of the specialties throughout the year during the rotation where the specialty experience occurs. The rubric for each specialty is based on detailed clinical rotation learning outcomes and instructional objectives (Appendix B). In addition, open communication and early problem solving may help to avoid a diminution in the educational experience. Agreements are also required for any facility in which the student will be participating in patient care with the supervising preceptor. The Director of Clinical Education creates a clinical rotation schedule by matching student required rotation needs and preceptor availability. The Program cannot guarantee student appointments on a continuous, year round basis. Once the schedule is established, each site will receive a list of scheduled students with start/end dates of the rotations. Likewise, if we have to change a student schedule or cancel a rotation at your site, we will notify you as soon as possible. Students must not assume responsibilities of an employee until after Program completion. Even more critical is the occasional opportunity, or suggestion, from a potential employer to participate in patient-care activities outside of the formal rotation assignment prior to graduation. While these opportunities may be attractive and seemingly benign, they must be avoided. Preceptor Development Tools Appendix I provides links and descriptions of the following helpful tips and teaching tools. Mastery of clinical knowledge and skills is gradual and does not occur with any single exam, course, or rotation. The primary goal of the Instructional Objectives is to guide students in their studies by describing what the learner will be able to do after completing a unit of instruction. Independent, life-long learning is required of all healthcare providers and is essential for success in the clinical year. During the rotation, the student must review applicable learning outcomes and instructional objectives for the appropriate specialty. During the clinical rotation, the student must review the applicable learning outcomes and instructional objectives for the specialty. Apply knowledge of anatomy, pathophysiology, epidemiology, etiology, & risk factors 2. Identify signs/symptoms of medical conditions and differentiate between normal and abnormal findings 3. Follow instructions, accept responsibility, take initiative, is dependable, and modifies behavior following criticism 18. Recognize personal limitations in knowledge/ability and exhibit appropriate level of self-confidence 21. This student is performing at a level appropriate for his/her current stage of Yes No professional education. Was the preceptor (or designee) available on a daily basis to Yes No direct/supervise your activitiesfi Were you ever asked to evaluate and dismiss a patient without the patient being seen by a licensed providerfi The preceptor provided timely feedback regarding my performance as needed throughout the rotation. Learning objectives for this rotation (as stated in the student handbook) were adequately met. Please provide additional comments here: 59 the following questions will help us categorize and quantify the types of patient encounters and experiences obtained at this rotation site. Please comment on additional, unique opportunities for patient encounters at this rotation site 60 Appendix G Clinical Site Visit Evaluation Form Clinical Site Visit Evaluation Form Name of Faculty Reviewer: Date of Eval: Name of Clinical Site: Rotation Type: Related to facilities, resources, and learning opportunities:C4. Vincent Road Kochi 682 018, Kerala Phones: +91-484-4036109, +91-484-2395739, +91-484-2395740 e-mail: kochi@jaypeebrothers. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher. In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only. My positive reaction to the previous Edition probably gives some clues on why I accepted the second invitation, this time to introduce the Sixth Edition to new students of Pathology and other potential readers. Up to now, it has been used by thousands of students and I am sure that it will continue to be read and cherished in the new Edition as well. For the Sixth Edition, Dr Mohan has partially restructured the book, substantially revised it, and updated the text wherever it was necessary. Following the advances of basic sciences and clinical pathology, the revisions and addition are most evident in portions pertaining to molecular biology and genetics. Other aspects of modern pathology have not been neglected either and contain numerous novelties; even the seasoned specialists will learn something new from each and every chapter. Furthermore, the author has dramatically increased the number of illustrations, which are so essential for understanding Pathology. The distribution of illustrations has also been changed so that they are now much closer to the text to which they relate. For the new generation of modern students who have grown up next to the computers, the author has placed all the images and tables on the website with facility for downloading them. These images will serve the twin purpose of quick review and self-assessment for students and will appeal to Pathology teachers who could use them for their lectures, being assured that their students will have access to the same material for review and study. The Quick Review Book, the ever popular companion to the previous two Editions, was also updated, succinctly supplementing the main text. It will provide a helpful study material to many a student and help them review the subject for examinations. In summary, it is my distinct pleasure and honour to most enthusiastically endorse the new edition of an established textbook and salute its publication. Dr Mohan deserves kudos for the job well done and for providing the medical students with such an attractive, modern, up-to-date and useful Textbook of Pathology. These books are sent to my office from publishers, with a standard request for a potential review in the Journal. I acknowledged the receipt of the books by email, and also congratulated the Publisher on a job well done. A brief electronic exchange between Kansas City and New Delhi ensued, whereupon Mr Vij asked me to write a foreword for the Reprint of 5th Edition of the Textbook. Even though there were no specific instructions attached to the request, I assumed that I should address my notes primarily to undergraduate and graduate students of Pathology. Furthermore, I decided to write the Foreword in the form of answers to the questions that I would have had if I were a medical student entering the field of Pathology. I hope that these hypothetical questions and answers of mine will be of interest to the readers of this Textbook. This is a modern Textbook written by an expert who knows his pathology; an experienced teacher who knows what is important and what is not, and who has obviously taught pathology for many years; a well informed academician who is au courant with modern trends in medical education, and knows how to present pathology as a preparatory step for future clinical education of medical students. This Indian Textbook covers more or less the same topics as the equivalent Textbooks currently used in the Western Hemisphere. Like the Western textbooks it covers the traditional fields of General and Systemic Pathology: one-third of the book viii is devoted to General Pathology, whereas the remaining two-thirds cover Systemic Pathology. In that respect the Indian textbook resembles more the European than the American textbooks, which have become more clinically-oriented. In my opinion this approach gives excellent results, but only if the students have enough time to devote to Pathology. Histopathology has been deleted from most curricula, and most American medical students do not know to use efficiently the microscope, which is unfortunate. Answer: the material is presented in a systematic manner in the best tradition of classical British textbooks, a tradition that can be traced to the classical writers of ancient Greece and Rome. This time tested teaching will be most appreciated by students who are methodical and do not take shortcuts in their effort to acquire encyclopedic knowledge of pathology. As we all know clear writing reflects clear thinking, and clear thinking in my opinion, is an absolute prerequisite for good teaching. Judging from the book at hand, Professor Mohan (whom I do not know personally) is not only a clear thinker, but he must be also an exceptionally talented teacher. Each chapter is subdivided into smaller entities, which are further divided into paragraphs, ideally suited for easy reading. Color coded headings and the added emphasis in form of words printed in bold or capital letters are additional attractions that facilitate learning. Unique to this Textbook are the numerous hand-drawn color illustrations, including many renditions of histopathologic slides. Students will most likely understand them much easier than the relatively impersonal original microphotographs of the same histopathologic lesions. Flow-charts are most efficiently used to explicate the pathogenesis of various lesions or the pathophysiology of disease processes. The tables are good for classifications and comparative listings of closely related diseases and their pathologic features. I always recommend to my students to buy a major textbook and a smaller review book containing a digest of the most important concepts; or a book of questions and answers, so that the student could test his/her knowledge of pathology and the understanding of the material in the main textbook.

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