Electrodiagnostic studies can help determine whether the neuropathy is the result of damage to the axons (axonal neuropathy) or the myelin (demyelinating neuropathy), or both (mixed). Hyperreflexia is seen with pre-eclampsia It can be confused with heartburn, gallbladder problems, flu, indigestion or pain from the baby kicking. The former is usually achieved by eliminating offending agents, such as toxins or medications; correcting a nutritional deficiency; or treating the underlying disease (e.g., corticosteroid therapy for immune-mediated neuropathy).8 These steps are important to halt the progression of neuropathy, and they may improve symptoms. 2022 Sep 12. The rooting reflex is present if stroking the lateral upper lip causes movement of the mouth toward the stimulus. What happens to the patellar tendon reflex after running on the spot and why does this happen? When the reflexes are absent try eliciting it after re-enforcing (Jendrassik maneuver0, by asking the patient to interlock and pull flexed fingers. Deep tendon reflexes are increased in many women prior to seizures, but seizures can also occur without hyperreflexia. (2016). Unexplained pain. Is a change in your deep tendon reflex history an ominous sign? Nerve damage can have a lot of causes, including illnesses and injuries. Edema monitoring (watch for and educate mother about this): Calcium gluconate: antidote for magnesium sulfate toxicitybe sure to have it handy, Left side-lying position (helps prevent placenta ischemia and increases blood flow to baby), bed rest/limit stimulation, fetal heart rate monitoring (report decrease in fetal activity), Assess for seizure activity eclampsia: there is a risk during and after labor (up to 48 hours), Magnesium sulfate administered to prevent seizures during and after labor (risk for seizures up to 48 hours after delivery), Protein-rich diet (remember there may be low protein in blood due to proteinuriaprotein leaks into the urine and leaves blood), I & Os: strict monitoring (may need Foley catheter), abnormal sign: low urinary output less than 30 cc/hr (kidneys arent being perfused very well), Antihypertensives (labetalol, hydralazine), Test your knowledge: Preeclampsia NCLEX Questions, Gestational Hypertension and Preeclampsia. Many patients have a history of malaise or nonspecific symptoms suggesting an acute viral syndrome.33 Any patient with these symptoms or signs of preeclampsia should be evaluated with complete blood count, platelet count, and liver enzyme determinations.34. After the convulsion has ended and the patient is stabilized, plans should be made for prompt delivery. Hyperreflexia refers to hyperactive or repeating (clonic) reflexes. For potential or actual medical emergencies, immediately call 911 or your local emergency service. All of these pain symptoms may be a sign of HELLP Syndrome or a related problem in the liver. A physical examination may be performed, as well as a test of the deep tendon reflexes. That means using your smart phone camera or just a reg A new study recently published by the New England Journal of Medicine found that women at high risk for preterm preeclampsia who took aspirin were less likely to develop the condition than women who w What is AFLP? During late pregnancy, you may be advised to lie on your left side to prevent restriction on certain veins which could also contribute to elevated blood pressure. Deep tendon reflexes. The presence of neuropathic symptoms, decreased ankle reflexes, and decreased distal sensations, regardless of distal muscle weakness and atrophy, makes the diagnosis of peripheral neuropathy likely.4 The isolated presence of neuropathic symptoms or decreased ankle reflexes is less valuable for diagnosis. The disease is sometimes referred to as a silent killer because most people cant feel their blood pressure going up. Treasure Island (FL): StatPearls Publishing; 2022 Jan. A simple dipstick test of your urine at each prenatal check-up can screen for proteinuria, though other methods may be used in clinics and medical offices such as a Protein:Creatinine Ratio (PCR) or a timed urine collection. All Rights Reserved. Copyright 2023 American Academy of Family Physicians. Call your health professional immediately. Common vision changes include sensations of flashing lights, auras, light sensitivity, or blurry vision or spots. Please note, we cannot prescribe controlled substances, diet pills, antipsychotics, or other abusable medications. This limits their sensitivity in detecting neuropathies of the small nerve fibers (i.e., those with pain, temperature, and autonomic functions). Enter your email address below and hit "Submit" to receive free email updates and nursing tips. Retrieved 19 March 2020, from https://www.preeclampsia.org/the-news/1-latest-news/299-new-guidelines-in-preeclampsia-diagnosis-and-care-include-revised-definition-of-preeclampsia, Phipps, E., Prasanna, D., Brima, W., & Jim, B. La preeclampsia, en todas sus formas, puede requerir muchos anlisis, tanto durante como despus del embarazo. Biceps Reflex Muscle involved: biceps brachii Nerve supply: musculocutaneous Segmental innervation: C5-C6 Brachioradialis Reflex Muscle involved: brachioradialis Nerve supply: radial Segmental innervation: C5-C6 Triceps Reflex A 24-hour determination is most accurate because urine dipsticks can be affected by variable excretion, maternal dehydration, and bacteriuria.7 A random urine protein/creatinine ratio of less than 0.21 indicates that significant proteinuria is unlikely with a negative predictive value of 83 percent; however, confirmatory 24-hour urine protein determination is recommended.30 Generalized edema (affecting the face and hands) is often present in patients with preeclampsia but is not a diagnostic criterion.1, Severe Preeclampsia. your healthcare . However, sometimes it may indicate a problem with the liver, especially if it accompanies other symptoms of preeclampsia. The clonus test is a type of reflex test. Alguna vez se pregunt por qu el proveedor de atencin mdica le solicita tantos anlis El parto NO es la cura para la preeclampsia. In non-pregnant normotensive women the patellar reflex was recorded once. Clipboard, Search History, and several other advanced features are temporarily unavailable. Home readings should never replace prenatal visits, nor should a "normal" reading mean you can ignore other symptoms of preeclampsia. Peripheral nerves serve different motor, sensory, and autonomic functions. Introduction to the Reflex Exam Do not be afraid to question your caregiver if any of these tests are omitted. +2= Normal reflex Damaged blood vessels allow more water to leak into and stay in your body's tissue and not to pass through the kidneys to be excreted. A total of 8 g of magnesium sulfate should not be exceeded over a short period of time.43,53. Patients with treatment-resistant severe hypertension or other signs of maternal or fetal deterioration should be delivered within 24 hours, irrespective of gestational age or fetal lung maturity. Safe Maternity Care During the COVID-19 Pandemic, What Were Learning, Low-Dose Aspirin Continues to Prove Effective in Reducing Onset of Preeclampsia, Acute Fatty Liver of Pregnancy Can Be Confused with Preeclampsia and HELLP Syndrome. sharing sensitive information, make sure youre on a federal Not limited to obstetric conditions Inappropriate coagulation occurs in the microcirculation 1+ = a slight but definitely present response; may or may not be normal. You can buy your own blood pressure monitor at most pharmacies, and some of these stores have a monitor available for your use, though they aren't always reliable. Loss of sensation (including vibration, proprioception, temperature, and pinprick sensations) in distal extremities suggests peripheral neuropathy, as does a distal-to-proximal gradient of reflex elicitation. Initial management of an eclamptic seizure includes protecting the airway and minimizing the risk of aspiration by placing the woman on her left side, suctioning her mouth, and administering oxygen. Pharmacologic treatment is needed to prevent maternal end-organ damage from severely elevated blood pressure (150 to 180/100 to 110 mm Hg); treatment of mild to moderate chronic hypertension does not improve neonatal outcomes or prevent superimposed preeclampsia. If unresponsive: administer anticonvulsants insidious onset, visible bleeding, bright red blood, painless, soft contender uterus, normal FHR, normal vitals, decreased urine output Findings of Abruptio placentae sudden onset, concealed or visible, dark red blood, constant sharp, firm rigid uterus, fetal distress, contractions with hypertonicity, clinical findings of hypovolemic shock RECAP: Youre assessing for new onset of hypertension (>140/90most likely to start occurring at 20 weeks and onward), protein in the urine proteinuria, signs and symptoms of organ injury. Urine output should be greater than 30 mL per hour44 and intravenous fluids limited to 100 mL per hour.35,44, Delivery Decisions in Severe Preeclampsia. A postictal phase may follow with confusion, agitation, and combativeness. Copyright 2010 by the American Academy of Family Physicians. Low-dose aspirin (75 to 81 mg daily) has small to moderate benefits for the prevention of preeclampsia (NNT = 72), preterm delivery (NNT = 74), and fetal death (NNT = 243). A certain amount of swelling is normal during pregnancy. Know your blood pressure prior to pregnancy, especially if it's normally considered low. Reflex Exam (Deep Tendon Reflexes) The reflex exam is fundamental to the neurological exam and important to locating upper versus lower motor neuron lesions. Electrodiagnostic studies are recommended if the diagnosis remains unclear after initial diagnostic testing and a careful history and physical examination.4,5 There are two primary types of electrodiagnostic studies: nerve conduction studies and electromyography (EMG). The goals of treatment are to prevent seizures, lower blood pressure to avoid maternal end-organ damage, and expedite delivery. Preeclampsia and eclampsia nursing maternity NCLEX review for students! A serum potassium level higher than 5 mEq/L (5 mmol/L) indicates hyperkalemia. Hemolysis, Elevated Liver enzymes, Low Platelets The grasp reflex is present if gently stroking the palm of the patient's hand causes the fingers to flex and grasp the examiner's . Deep Tendon Reflexes In a normal person, when a muscle tendon is tapped briskly, the muscle immediately contracts due to a two-neuron reflex arc involving the spinal or brainstem segment that innervates the muscle. Edema (eyes, face, extremities, pulmonary edema, increase weight gain, cerebral edema): the increase in permeability of the endothelial cells causes protein to escape the vessel. The fetal heart rate was 132 beats per minute. The cerebral cortex and a number of brainstem nuclei exert influence over the sensory input of the muscle spindles by means of the gamma motoneurons that are located in the anterior horn; these neurons supply a set of muscle fibers that control the length of the muscle spindle itself. Classification Of Hypertensive Disorders Of Pregnancy Nursing Management 1. A brain tumor that makes a DTR brisker will always (no exceptions) do s Not feasible to interpret your reflexes in absence of clinically correlative symptoms. At 15 mEq/L, signs of abnormal conductivity surface as SA/AV node block. Normal nerve conduction studies and needle EMG significantly decrease the likelihood of peripheral neuropathy, whereas abnormal nerve conduction findings confirm the diagnosis. In non-pregnant normotensive women this was recorded once. In: StatPearls [Internet]. Preeclampsia is characterized as mild or severe based on the degree of hypertension and proteinuria, and the presence of symptoms resulting from involvement of the kidneys, brain, liver, and cardiovascular system (Table 2).12 Severe headache, visual disturbances, and hyperreflexia may signal impending eclampsia. . Speak with your health care professional before taking any nutritional supplement herbal or otherwise. Laboratory tests are used to diagnose HELLP syndrome (Table 33335); a decreasing platelet count and an increasing l-lactate dehydrogenase level (indicative of both hemolysis and liver dysfunction) reflect disease severity.33,35 When the platelet count is less than 50,000 per mm3 (50 109 per L) or active bleeding occurs, coagulation studies (i.e., prothrombin time, partial thromboplastin time, and fibrinogen level) should be performed to rule out superimposed disseminated intravascular coagulation. Eclampsia. The Preeclampsia Foundation recognizes the importance of a good diet, however we do not recommend any particular diet or juice product. Signs of shock with progression: Rapid shallow respirations, rapid pulse, fall in BP, skin pale and cool, decreased urinary output, changes in level of consciousness, laboratory signs-decreased platelets, prolonged prothrombin time, bleeding time prolonged, increased fibrin split products, decreased fibrinogen, Life threatening defect in coagulation that may occur w/ severe preeclampsia or eclampsia Preeclampsia: Updates in Pathogenesis, Definitions, and Guidelines. If you have tried taking over-the-counter medication without relief, if the headache is very painful, you have light sensitivity, or if your headache is accompanied by vision changes (please read the section below on "Changes in Vision") call your provider immediately and ask to see him/her that day. As the nurse it is important youre aware of how this condition is diagnosed. Delivery like going from 2+ to 4+ on a scale that goes to 5+. Copyright 1990, Butterworth Publishers, a division of Reed Publishing. Injection Gone Wrong: Can You Spot The Mistakes? ASSESSMENT OF THE ECLAMPTIC MOTHER'S DEEP TENDON REFLEXES OVERVIEW Pregnancy-Induced Hypertension Hypertensive disorders induced by pregnancy or complicated rank among the leading causes of maternal mortality and make a significant contribution to perinatal mortality. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Mechanical ventilation should be considered in patients whose forced vital capacity is less than 20 mL per kg or is reduced by more than 30 percent of baseline, or if maximal inspiratory pressure is less than 30 cm of water.11. If you are under treatment with magnesium sulfate to prevent seizures, your healthcare provider may also test your reflexes to monitor for the need to start, adjust or stop the magnesium treatment. It is important to help patients control troublesome symptoms of peripheral neuropathy, such as severe numbness and pain, as well as to alleviate disability resulting from weakness.12 Several pharmacologic options exist to treat neuropathic pain, including some antiseizure medications (e.g., gabapentin [Neurontin], topiramate [Topamax], carbamazepine [Tegretol], pregabalin [Lyrica])13,14 and antidepressants (e.g., amitriptyline).1517 Topical patches and sprays containing lidocaine (Lidoderm) or capsaicin (Zostrix) also may relieve pain in some patients.18 Other supportive measures, such as foot care, weight reduction, and shoe selection, may also be helpful.2 Narcotics may have a role in the treatment of chronic neuropathic pain in selected patients19; candidates initially should be evaluated for their risk of substance abuse and addiction, and several nonnarcotic regimens should be tried first. The benefit of aspirin is greatest (NNT = 19) for prevention of preeclampsia in women at highest risk (previous severe preeclampsia, diabetes, chronic hypertension, renal disease, or autoimmune disease). And even if it's not a symptom of preeclampsia, it can still be a sign of a problem. Antidote for MgSo4 toxicity is calcium gluconate: should be available at bedside: 1gm IV given over 3 minutes In normotensive pregnant women the patellar reex was cross-sectionally recorded using surface electro-myography at four time points during pregnancy and six to eight weeks post-partum. Normally during pregnancy, the spiral arteries within the uterus widen in diameter to help increase blood flow to the placenta, which is very vital as the pregnancy progresses and baby requires more nutrients and oxygen. Many women suffering from preeclampsia dont feel sick, and may be surprised or become frustrated when they are admitted to the hospital or prescribed bed rest since they still feel well. A potential limitation of electrodiagnostic studies is that they are able to test only the large, myelinated nerve fibers. Maintain a safe environment: padded side rails In the early stages of peripheral neuropathy, patients typically present with progressive symptoms, including sensory loss, numbness, and pain or burning sensations in distal limbs in a stocking and glove distribution. What is the definition or description of: hyperactive deep tendon reflexes? To learn more, please visit our. Let's raise up our voices so more women know about preeclampsia and HELLP syndrome and less women have adverse outcomes! ), Lungs: fluid can start to accumulate in the lungs leading to difficulty breathing, Brain: due to brain swelling and decreased perfusion the woman may experience headache, vision changes, hyperreflexia, clonus (if this is present there is a HIGH risk for seizures due to central nervous system irritability), >1+ dipstick test (if hypertension is present along with protein in the urine the physician may order the woman to complete a 24-hour urine), Watch for exaggerated reflexes called hyperreflexia like 4+. It is very important every pregnant patient is monitored for preeclampsia so it can be managed, which can help with the prevention of eclampsia in most cases. Hyperreflexia is when your reflexes are so strong that when your knee is tapped by a rubber hammer, your leg bounces back hard. The optimal level of blood pressure control in pregnancies complicated by hypertension is unknown.2,6 Less tight control may decrease the risk that the infant will be small for gestational age, but it may increase the risk of respiratory distress syndrome of the newborn, severe hypertension, and antenatal hospitalization.2,5 Although traditional recommendations are based on diastolic blood pressure, a retrospective review of 28 women with severe preeclampsia who experienced a cerebrovascular accident demonstrated that more than 90 percent had systolic blood pressure over 160 mm Hg, but only 12.5 percent had diastolic blood pressure over 110 mm Hg.45, Intravenous labetalol and hydralazine are commonly used for the acute management of preeclampsia.1,46 A Cochrane review showed no evidence that one parenteral agent had superior effectiveness.46 For women with severe preeclampsia undergoing expectant management remote from term, oral labetalol and nifedipine are acceptable options.7, Fluid Management. Proteinuria, another sign of preeclampsia, is the result of proteins, normally confined to the blood by the filtering role of your kidney, spilling into your urine. 2-12 % severe pre-eclamptic women will develop With preeclampsia, the blood pressure is usually normal at the beginning of the pregnancy, but around 20 weeks gestation it starts to elevate. Theyre both considered hypertensive disorders BUT gestational hypertension doesnt cause injury to organs in the body or proteinuria, and this leads us to the next criteria. HHS Vulnerability Disclosure, Help Absent reflexes are seen when a patient develops magnesium toxicity, 0= Reflexes absent Bethesda, MD 20894, Web Policies In a 24 hour collection, proteinuria is diagnosed when there is at least 300 mg/24h though an amount close to that might be equally concerning. Patients with severe preeclampsia are admitted to the hospital, placed on bed rest, and carefully monitored (Figure 27 and Table 51,7,12 ). The damaged cells of the glomerulus start to leak protein from the blood into the urine causing proteinuria. Use as a tocolytic for up to 48 hours for short-term prolongation of pregnancy for the administration of antenatal corticosteroids in women . Clonus reflex is a set of rhythmic, involuntary muscle movements. The peripheral nerves consist of bundles of long neuronal axons as they exit the central nervous system (CNS). Complications-abruption, acute renal failure, hepatic hematoma or rupture, pulmonary edema, preterm birth, fetal or maternal death. In a normal person, when a muscle tendon is tapped briskly, the muscle immediately contracts due to a two-neuron reflex arc involving the spinal or brainstem segment that innervates the muscle. Unauthorized use of these marks is strictly prohibited. Graded to +2. Keep a log of your blood pressure, taken at the same time each day and in the same position. These usually indicate an interruption of corticospinal and other descending pathways that influence the reflex arc due to a suprasegmental lesion, that is, a lesion above the level of the spinal reflex pathways. Normal pregnancy: vascular volume and cardiac output increase significantly . When a patient presents with symptoms of distal numbness, tingling and pain, or weakness, the first step is to determine whether the symptoms are the result of peripheral neuropathy or of a lesion in the CNS, and whether a single nerve root, multiple nerve roots, or a peripheral nerve plexus is involved. Decisions regarding the timing and mode of delivery are based on a combination of maternal and fetal factors. Monitor presence of headache, epigastric pain, edema The aroused receptors initiate the reflex arc, causing the muscle to move. Methods. Please note that home monitors are not always as accurate as those used in clinics or hospitals. Morning sickness should disappear after the first trimester and the sudden appearance of nausea and vomiting after mid pregnancy may be linked to preeclampsia. So, there is less blood volume being used to perfusion the organs and this cause further organ injury. Pre means before and eclampsia means a convulsive state, according to Merriam-Websters Dictionary (Eclampsia Merriam-Webster, n.d.). The evaluation of a patient with peripheral neuropathy starts with simple blood tests, including a complete blood count, comprehensive metabolic profile, and measurement of erythrocyte sedimentation rate and fasting blood glucose, vitamin B12, and thyroid-stimulating hormone levels5 (Figure 1). +2 Marked edema of lower extremities A maternal blood pressure measurement of 140/90 mm Hg or greater on two occasions before 20 weeks of gestation indicates chronic hypertension. At 10 mEq/L, there will be a loss of deep tendon reflexes and muscle weakness. [7] [8] [9] [10] Go to: History and Physical Additional tests, if clinically indicated, may include a paraneoplastic panel to evaluate for occult malignancy; antimyelin-associated glycoprotein antibodies to evaluate for sensorimotor neuropathies; antiganglioside antibodies; cryoglobulins; cerebrospinal fluid (CSF) analysis to evaluate for chronic inflammatory demyelinating neuropathy; antisulfatide antibodies to evaluate for auto-immune polyneuropathy; and genetic testing if hereditary peripheral neuropathy is suspected (Table 3). Tendon reflex response demonstrates a balance of signals between the cerebral cortex and the spinal cord Hyperreflexia is seen with pre-eclampsia Brisk reflexes are the result of an irritable cortex and indicate central nervous system . There is a fine line that has to be followed when using blood pressure medication on a pregnant woman because blood flow must be maintained to the placenta and baby. Your healthcare provider will let you know if he/she is concerned and whether it is an indication, along with other signs and symptoms, that you should go to the hospital. A symptom is something you may experience and recognize, such as a headache or loss of vision. The motor unit action potential on voluntary muscle contraction also is assessed. Assessment prior to initiation: Vital signs, deep tendon reflexes/clonus, level of consciousness, symptoms such . Preeclampsia can stress fetus. I need your help please? Proper technique of reflexes examination and experience play a major role in eliciting and categorizing deep tendon reflexes. Magnesium sulfate Would you like email updates of new search results? When these reflexes are disrupted, hyperreflexia (disease induced) or. Call your care provider. A common regimen for expectant management of mild preeclampsia is outlined in Table 4.1,7 Nonstress tests, amniotic fluid index measurements, and biophysical profiles are used to monitor patients for uteroplacental insufficiency.1,7 Umbilical artery systolic/diastolic ratios measured by Doppler ultrasonography may detect early uteroplacental insufficiency.36,37 The decision to deliver involves balancing the risks of worsening preeclampsia against those of prematurity. EKG Rhythms | ECG Heart Rhythms Explained - Comprehensive NCLEX Review, Simple Anatomy Quiz Most Nurses Get WRONG! government site. official website and that any information you provide is encrypted There are five primary deep tendon reflexes: biceps, brachioradialis, triceps, patellar, and ankle. The most common treatable causes are diabetes, hypothyroidism, and nutritional deficiencies. His height and weight are both between the 25 to 50th percentiles and his head circumference is within 2 standard deviations of the mean. This is because preeclampsia temporarily damages this filter. Albumin, as well as many other proteins, are lost this way. When endothelial cells are exposed to the toxic substances by the placenta they become damaged and do not work properly. The use of magnesium sulfate for seizure prophylaxis in women with mild preeclampsia is controversial because of the low incidence of seizures in this population. Eliminating alcohol and any medication not prescribed by a physician is essential. However, we urge caution when considering diets designed for weight-loss or claiming to prevent preeclampsia that encourage large amounts of protein. Serum indicators can serve as a crude estimate of what is happening in the tissues, but it is the tissue response that is more important to determine. On palpation, the abdomen is rigid and board-like and no vaginal bleeding is evident. Peripheral neuropathy can be caused by a variety of systemic diseases, toxic exposures, medications, infections, and hereditary disorders (Table 1). Its a type of hypertensive disorder that occurs during pregnancy. This website provides entertainment value only, not medical advice or nursing protocols. Boston: Butterworths; 1990. (Learn how to take your blood pressure.). The most common treatable causes include diabetes mellitus, hypothyroidism, and nutritional deficiencies. This further complicates things because it decreases blood volume. Main outcome measures. Preeclampsia is the development of new-onset hypertension with proteinuria after 20 weeks of gestation. +1= Reflexes present, hypoactive The site is secure. In neuropathic conditions, reinnervation changes are recorded, the details of which are beyond the scope of this article. Monitor respirations closely: concerned if <12/minute There are five primary deep tendon reflexes: biceps, brachioradialis, triceps, patellar, and ankle. In these cases, a specialized test directed at autonomic functions, and other non-electrodiagnostic tests (e.g., epidermal skin biopsy) may yield the diagnosis. It is our collective voice that reduces isolation for others, raises awareness and improves healthcare practices. 2002;19(4):286-95. doi: 10.1080/0899022021000037755. Also, watch for Stomach and Right Shoulder Pain (above) and mention this symptom to your health care provider. Shoulder pain can feel like someone is deeply pinching you along the bra strap or on your neck, or it can be painful to lie on your right side. Once the lesion has been localized to peripheral nerves, the next step is to find the etiology and exclude potentially treatable causes, such as acquired toxic, nutritional, inflammatory, or immune-mediated demyelinating disorders. A more recent article on hypertensive disorders of pregnancy is available. What is normal for deep tendon reflexes? During each prenatal visit, ask your health care provider for the results of your urine test. By using our website, you consent to our use of cookies. Initial blood tests should include a complete blood count, comprehensive metabolic profile, and measurement of erythrocyte sedimentation rate and fasting blood glucose, vitamin B12, and thyroid-stimulating hormone levels; specialized tests should be ordered if clinically indicated. (deep tendon reflexespatellar and bicep) Watch for exaggerated reflexes called "hyperreflexia" like 4+ At 37 weeks' gestation, a woman presents to labor and delivery complaining of intense, knife-like abdominal pain that started suddenly about 1 hour ago and has not subsided. In disorders that cause acute peripheral neuropathy, such as those produced by toxic exposures, patients may present with similar but more fulminant symptoms, and pain predominates; symptoms also typically have a faster progression.
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