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By: E. Kurt, M.B. B.CH. B.A.O., M.B.B.Ch., Ph.D.
Associate Professor, Stanford University School of Medicine
Failure of health care providers to account for the developmental level of a child as they assess pain can lead to a critical undertreatment of pain among infants hypertension jnc 8 guidelines buy furosemide australia, children enrique iglesias heart attack discount furosemide uk, and adolescents throughout the world blood pressure juice generic furosemide 40 mg mastercard. Pain is a complex process involving both physiologic and nonphysiologic factors unique to each individual blood pressure medication and adderall discount 40mg furosemide with amex. Self-report is the best way to assess pain, but there are other ways to elicit pain cues from patients. Pain relief should begin with a straightforward, developmentally appropriate explanation to the patient about the causes of pain. Symptom management at the end-of-life stage is complex and requires ongoing assessment and intervention. Many factors beyond the physical experience of pain affect how pain is perceived (Figure 1). Newborns circumcised without analgesia showed more distress during later routine immunizations than uncircumcised infants or those circumcised with local anesthesia. Also, pediatric cancer patients given inadequate analgesia during an invasive procedure showed more severe distress during later procedures than those who received a potent opioid during the first procedure. Emotional states such as depression also play a key role in the experience of pain. Sometimes the fear of pain, injury, or loss of physical ability may be more disabling than the pain itself. People dealing with chronic illness often experience feelings of depression and helplessness. Because approximately half of depressed patients express pain as a symptom of their illness, pain control must address the accompanying symptoms of depression and anxiety. This latter group of children may not receive appropriate analgesia because they might not report their pain to the same degree. Children with naturally good coping mechanisms such as information seeking or focusing attention away from the painful stimuli can better handle pain. Those who accept their illness as a challenge to overcome usually fare better than those who do not accept their illness or who see their illness as a sign that they are "damaged. For example, a preschooler may not understand or gain comfort from a cause-and-effect explanation for a painful procedure (e. Parents and caregivers can model both positive and negative ways to tolerate and express pain. Caregivers can listen, comfort, and counsel children on dealing with pain appropriately, but caregivers can also inadvertently encourage children to stay in the "sick role" even if no longer necessary. A family overwhelmed by financial stress, unemployment, a housing crisis, or other major life stressors may not have the resources to properly attend to the pain of a child in their midst. Self-Report If a child is of sufficient age and developmental level, eliciting a full qualitative description of his or her pain is helpful. Females tend to be more vocal about pain, whereas males may feel Scale uses a straight line with end points identified as "no pain" and "worst pain": divisions along the line are marked in units from 0 to 5 (high number may vary). Scale that they need to be "tough" and therefore may be used horizontally or vertically. Some cultures conceive of pain as 0 1 2 3 4 5 punishment for wrongdoing, and children No Pain Worst Pain can incorporate and embody these same Figure 2. Health care providers should be attuned to the spiritual needs of 0 1 2 3 4 5 No Hurt Hurts Hurts Hurts Hurts Hurts their patients in their efforts to holistically Little Bit Little More Even More Whole Lot Worst address pain. Selfreport is the "gold standard" of pain assessment, but this is obviously challenging in infants, nonverbal children, and children too critically ill to communicate verbally. In these situations, a therapeutic trial of comfort measures and analgesic medications may be helpful in interpreting distressed behavior. A health care provider should assess and document pain at regular intervals-with each new report of pain, as well as after a pharmacologic or nonpharmacologic intervention has been provided to offer the best possible pain management. Children aged 8 or more years can generally use a simple linear scale (Figure 2) to rate the intensity of their pain, giving a quantitative measure to pain. This linear scale helps patients describe their pain better and can provide important information about whether pain management techniques are effective.
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Canaliculitis (Lacrimal apparatus) Etiology: Actinomyces blood pressure 80 over 60 order cheap furosemide line, Staphylococci blood pressure medication overdose 100 mg furosemide sale, Streptococci; fusobacterium arrhythmia on ultrasound generic 100mg furosemide amex, Nocardia sp heart attack kurt generic furosemide 40mg on-line. Referral to ophthalmologist for removal of granules and local irrigation with an antibiotic solution. Topical Gentamicin, Ciprofloxacin 6-8x/d Comments: Hyperpurulent discharge is observed. Viral Conjunctivitis (Pink eye) Etiology: Adenovirus 3 & 7 in children Preferred Regimen: No antibiotic Consider short course topical antibiotic-steroid drops one to two drops every 3 to 4 hours for 7 to 14 days in cases with severe inflammation, membranes or epithelial defects. Although adenoviral conjunctivitis is self-limiting, topical antibiotic-steroid is given to those with severe symptoms. Comments: Ophthalmology consult recommended because it can progress to corneal perforation. For those aged 12y and older with recurrent infections (>2x a year), Aciclovir 400 mg bid for 12 months may be given to prevent recurrences. Comments: Obtain specimen for Gram stain and culture studies and adjust treatment accordingly. Bacterial keratitis can be a vision-threatening disease: prompt consultation with an ophthalmologist is essential. Consider systemic antibiotic for large (>6 mm) corneal ulcer, corneal perforation or scleritis due to Pseudomonas aeruginosa and other Gram-negative enteric bacteria. Fungal keratitis Etiology: Aspergillus, Fusarium, Candida Preferred Regimen: Refer to ophthalmologist Comments: Obtain specimen for fungal wet mount and cultures. Preferred Regimen: Refer to ophthalmologist Comments: Corneal infection usually associated with trauma or soft contact lens use. Topical cycloplegic (atropine sulfate 1%) one drop 3 times a day until free of pain. Keratitis, Non-tuberculous Mycobacterial (Post-Lasik surgery) Etiology: Mycobacterium chelonae, M. Treatment regimen is as for extrapulmonary tuberculosis (see National Antibiotic Guidelines on Tuberculosis). Vitrectomy should be considered to decrease the burden of organisms and to allow the removal of fungal abscesses that are inaccessible to systemic antifungal agents. Consider prophylactic administration of systemic + intravitreal antibiotics in high risk injuries (soil contamination, >24h delay in wound closure, intraocular foreign body). Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children. In throat infections caused by Epstein Barr virus (infectious mononucleosis), Amoxicillin or ampicillin produces a non-allergic maculopapular rash, which does not preclude the future use of penicillins. Because penicillin does not effectively penetrate epithelial cells, this internalization may contribute to persistence despite antibiotic therapy. In cases of persistent pharyngitis, antibiotic options include cephalosporins, Co-amoxiclav, macrolides including azalides (azithromycin), and clindamycin. These cases have a predominance of superficial infections, including subcutaneous abscesses, cellulitis, and recurrent skin infections. Vaccine containing diphtheria toxoid is available in combination with tetanus and pertussis. Routine pediatric immunization should include 5 doses given on ages 6 weeks, 10 weeks, 14 weeks, 12 months (provided there is a minimum interval of 6 months from dose 3) and 4-6 years before school entry. Eradication of the organism should be documented 24 hours after completing treatment by 2 consecutive negative cultures from pharyngeal specimens taken 24 hours apart. If follow-up cultures are positive, erythromycin should be given for an additional 10 days.
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Diagnosis Acute peritonitis is usually characterized by acute abdominal pain and tenderness blood pressure 75 over 55 order furosemide with mastercard, dehydration pulse pressure pediatrics generic furosemide 40 mg fast delivery, fever arteria iliaca cheap furosemide line, hypotension blood pressure medication classifications discount 40mg furosemide overnight delivery, nausea and vomiting and tachycardia. Bacterial translocation, bacteraemia and impaired antimicrobial activity contribute to its development. Antimicrobial therapy is adjunctive to surgical correction of underlying lesion or process and treatment will depend on causative agent. Referral Patient needs referral to centers where surgical intervention is adequate (i. Contributory factors may include inactivity, low fiber diet and inadequate water intake. Diagnosis Fewer than three bowel movements per week, small, hard, dry stools that is difficult or painful to pass, need to strain excessively to have a bowel movement, frequent use of enemas, laxatives or suppositories are characteristic. Other features may include; abdominal bloating, rectal bleeding, spurious diarrhea, low back pain, feeling of incomplete evacuation, and tenesmus. Referral the following signs and symptoms, if present, are grounds for urgent evaluation or referral: Rectal bleeding Abdominal pain Inability to pass flatus Vomiting Unexplained weight loss. Diagnostic guides: An extensive work up of the constipated patient is performed on an outpatient basis and usually occurs after approximately 3-6 months of failed medical management. Imaging studies are used to rule out acute processes that may be causing colonic ileus or to evaluate causes of chronic constipation. In the acute situation with a patient at low risk who usually is not constipated, no further evaluation is necessary. Consider sigmoidoscopy, colonoscopy, or barium enema for colorectal cancer screening in patients older than 50 years. The internal hemorrhoids are graded into four groups: Bleeding with defecation Prolapses with defecation but return naturally to their normal position Prolapses any time especially with defecation and can be replaced manually Permanently prolapsed. Diagnosis the most common presentation of hemorrhoids is rectal bleeding, pain, pruritus, or prolapse. However, these symptoms are nonspecific and may be seen in a number of anorectal diseases. A thorough history is needed to help narrow the differential diagnosis and adequate physical examination to confirm the diagnosis. V internal hemorrhoids or any incarcerated or gangrenous tissue requires prompt surgical consultation External hemorrhoid symptoms are generally divided into problems with acute thrombosis and hygiene/skin tag complaints. The former respond well to office excision (not enucleation), while operative resection is reserved for the latter. Drugs of choice Steroids and local anesthetics aims to reduce inflammation and provide relief during painful defication. Diagnosis the hall mark is severe sharp pain during and after defecation with/out bright red bleeding. Diagnostic consideration Perform digital rectal examination or protoscopy, which must be done with topical anesthesia. Treatment Guide Stools must be made soft and easy to pass; ensure high fluid intake, use osmotic laxatives such as Lactulose 20 mls 12 hrly (O) Topical anesthetics (Lidocaine jelly 2% - applied 12 to 8 hrly anal area with frequent seat baths reduces sphincter spasm. Vasodilator treatment with topical isosorbide mononitrate 1% or diltiazem 2% - applied 12 hrly anal area, is effective at increasing fissure healing rate and it is the first line of management. At worst, anal itching causes intolerable discomfort that often is accompanied by burning and soreness. Causes include: Benign anorectal condition such as hemorrhoids or anal fissure Neoplasia such as anal cancer, pagets disease Dermatological disease e. Hepatitis may occur with limited or no symptoms, but often leads to jaundice, anorexia and malaise. Hepatitis is acute when it lasts less than six months and chronic when it persists longer. A group of hepatotropic viruses cause most cases of hepatitis worldwide, but it can also be due to other viral infections( e. Diagnosis Acute infection with a hepatitis virus may result in conditions ranging from subclinical disease to self-limited symptomatic disease to fulminant hepatic failure.
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