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Each of these branch to form the bronchi which lead into the main lobes of the lungs discount zithromax 250mg treatment for dogs kidney failure. The airways continue to divide separating the lung into smaller and smaller units purchase zithromax 500 mg on line antibiotics and alcohol. As the airways divide they can be grouped into several distinct categories based on structure zithromax 250 mg free shipping bacteria reproduce asexually. The bronchi are the larger airways and are distinguished by the presence of cartilage in the wall and glands just below the mucosal surface zithromax 250mg on line virus 4 free. Distal to the terminal bronchiole is the respiratory unit of the lung or acinus, the site of gas exchange. The airway walls of the respiratory unit are very thin, the width of a single cell, to facilitate the transfer of gases. The airways to the level of the terminal bronchiole are surrounded by a layer of smooth muscle that is able to control the diameter of the airways by contracting and relaxing. The smooth muscle cells are controlled by the autonomic nervous system and also by chemical signals released from near by cells. Alveoli The alveoli and respiratory bronchioles warrant further discussion given the essential role they play in supplying the body with oxygen. As discussed above the walls of the alveoli are thin and designed to allow for efficient transfer of gas with the blood. There are also alveolar macrophages (involved with defense) found in the alveoli or attached to the wall. Because the alveoli are designed to easily ex- pand when we breathe in and collapse when breathing out there is a risk that the thin walls would stick together. To prevent this there is a layer of a protein called surfactant coating the alveolar membranes. Surrounding the alveoli is a complex network of capillaries that carry the blood and red blood cells through the lungs to pick up oxygen and discard the carbon dioxide. Between the capillaries and the alveoli cells is a layer of protein called the basement membrane and the pulmonary interstitium. The latter contains a variety of cells, collagen and elastic fibers that facilitate the expanse of the lungs. Parenchyma The definition of parenchyma is: The tissue characteristic of an organ, as distinguished from associated connective or supporting tissues. The majority of the lung tissue consists of the airways and gas exchange membranes as discussed above. There is some interstitial tissue between the alveolar cells and the capillary wall. Cell Morphology and Function There are many different types of cells found in the airways of the lung. For example some cells are present for physical support, some produce secretions and others defend the body against infection. Type I pneumocyte: These are the flat epithelial cells of the alveolar wall that have the appearance of a fried egg with long processes extending out when seen under a microscope. They enter the alveoli from the blood through small holes in the wall called the pores of Kohn. Smooth muscle cells: As discussed above the airways down through the level of the terminal bronchioles contain bands of smooth muscle. The muscle cells are controlled by the autonomic nervous system and chemical or hor- mones released from other cells such as mast or neuroendocrine cells. Ciliated epithelia cells: The lining of the majority of the airways is com- posed of pseudostratified, tall, columnar, ciliated epithelial cells. The cilia are hair-like projections on the surface of these cells that beat in rhythmic waves, allowing the movement of mucus and particles out of the lungs. Goblet cells: This cell type is found interspersed with the ciliated epithelial cells. Basal cells: These are small epithelia cells that are found along the basement membrane of the epithelium. Lymphocytes and mast cells: These cells are part of the immune defense of the body. They make, store and secrete a variety of substances including lipids and proteins. They can also develop into other cell types as needed to replace the loss of cells. This is accomplished by the exchange of air in the lungs with the ambient air through the process of pulmonary ventilation. This is initiated when the diaphragm contracts causing it to descend into the abdomen. When this occurs the volume of the lungs increases and by the laws of physics the pres- sure within the lungs decreases leading to a rush of air into the lungs. When the diaphragm relaxes and the lung tissues naturally recoil, the pressure in the lungs increases pushing air out of the lungs. Respiration is controlled by a number of factors including the autonomic nervous system, the voluntary muscles of respiration, the levels of carbon dioxide and oxygen in the blood, and the level of acid in the blood. During normal respiration between 400 and 1000 ml of air is moved into and out of the lungs; however, all of this volume is not available for gas exchange. The airways proximal to these are referred to as the conducting airways or ana- tomic dead space. This is the amount or volume of air breathed each minute and is a function of the tidal volume (see table of lung volume definitions) and the breathing rate. During exercise this can increased as a result of increasing the rate breathing and volume of each breath to as much as 150 L. These are useful for the diagnosis and discussion of disease processes affecting the lungs. Through the upper airways and to the level of the terminal bronchioles, airflow occurs by bulk movement or convection. Because of the vast increase in cross-sectional area after the ter- minal bronchioles airflow slows and the gas molecules move by diffusion. The velocity of airflow is dependent on both airway resistance related to the size of the airway and lung compliance (stiffness) that results from the mechanical constraints of the chest wall. The base of the lung receives more ventilation per volume of lung than does the top or apex. An understanding of normal lung function and physiology provides impor- tant clues to the mechanisms underlying diseases of the lung. For example, the abrupt change in flow from convective to diffusion at the level of the terminal bronchioles causes some inhaled particulates to get deposited here, making this area susceptible to damage. Diseases which primarily affect the apex of the lung will impact breathing differently than those diseases that affect the base. In the following chapters, specific diseases of the pulmonary system will be discussed; a basic understanding of the normal structure and function of the lungs will allow for a more complete understanding. The products of combustion formed during any given fire are dependent on the materials consumed within the fire, the amount of oxygen present and the temperature at which the fire burns. When considering the risk of chest disease in fire fighters exposed to the products of combustion it is helpful to break these down into acute effects (those happening at or shortly following exposure and which tend to resolve), and chronic effects (those changes in health that occur following multiple or long-term exposures).
The higher rates in women everywhere (2 3 times those in men) are hormonally driven discount 500 mg zithromax visa antibiotic 127. It may be stress related or associated with musculo- skeletal problems in the neck buy discount zithromax 100mg online antibiotic kennel cough. As experienced by very large numbers of people discount zithromax 500 mg with amex infection urinaire, episodic tension-type headache occurs zithromax 250mg low cost virus 56, like migraine, in attack-like episodes. Chronic tension-type headache, one of the chronic daily headache syndromes, is less common than episodic tension-type headache but is present most of the time: it can be unremitting over long periods. Headache in either case is usually mild or moderate and generalized, though it can be one- sided. It is described as pressure or tightness, like a band around the head, sometimes spreading into or from the neck. Tension-type headache pursues a highly variable course, often beginning during the teenage years and reaching peak levels around the age of 30 40 years. Episodic tension-type headache is the most common headache disorder, reported by over 70% of some populations (12), though its prevalence appears to vary greatly worldwide (3). Lack of reporting and under- diagnosis were thought to be factors here, and it may be that cultural attitudes to reporting a relatively minor complaint explain at least part of the variation elsewhere. Cluster headache Cluster headache is one of a group of primary headache disorders (trigeminal autonomic cepha- lalgias) of uncertain mechanism that are characterized by frequently recurring, short-lasting but extremely severe headache (1). Episodic cluster headache occurs in bouts (clusters), typically of 6 12 weeks duration once a year or two years and at the same time of year. Strictly one-sided intense pain develops around the eye once or more daily, mostly at night. Unable to stay in bed, the affected person agitatedly paces the room, even going outdoors, until the pain diminishes after 30 60 minutes. The eye is red and watery, the nose runs or is blocked on the affected side and the eyelid may droop. In the less common chronic cluster headache there are no remissions between clusters. Though relatively uncommon, probably affecting no more than 3 per 1000 adults, cluster head- ache is clearly highly recognizable. It is unusual among primary headache disorders in affecting six men to each woman. Most people developing cluster headache are 20 30 years of age or older; once present, the condition may persist intermittently for 40 years or more. Medication-overuse headache Chronic excessive use of medication to treat headache is the cause of medication-overuse head- ache (15), another of the chronic daily headache syndromes. Medication-overuse headache is oppressive, persistent and often at its worst on awakening in the morning. A typical history begins with episodic headache migraine or tension-type headache. In the end-stage, which not all patients reach, headache persists all day, uctuating with medication use repeated every few hours. A common and 74 Neurological disorders: public health challenges probably key factor at some stage in the development of medication-overuse headache is a switch to pre-emptive use of medication, in anticipation of the headache. All medications for the acute or symptomatic treatment of headache, in overuse, are associ- ated with this problem, but what constitutes overuse is not clear in individual cases. Suggested limits are the regular intake of simple analgesics on 15 or more days per month or of codeine- or barbiturate-containing combination analgesics, ergotamine or triptans on more than 10 days a month (1). Frequency of use is important: even when the total quantities are similar, low daily doses carry greater risk than larger weekly doses. In terms of prevalence, medication-overuse headache far outweighs all other secondary headaches (16). It affects more than 1% of some populations (17 ), women more than men, and children also. In others for whom there are no published data, in Saudi Arabia for example, clini- cal experience suggests this disorder is not uncommon, with a tendency to be more evident in afuent communities. Serious secondary headaches Some headaches signal serious underlying disorders that may demand immediate intervention (see Box 3. Although they are relatively uncommon, such headaches worry nonspecialists because they are in the differential diagnosis of primary headache disorders. The reality is that intracranial lesions give rise to histories and physical signs that should bring them to mind. Over-diagnosed headaches Headache should not be attributed to sinus disease in the absence of other symptoms indicative of it. Many patients with headache visit an optician, but errors of refraction are overestimated as a cause of headache. In developed countries, tension- type headache alone affects two thirds of adult males and over 80% of females (12). Extrapolation from gures for migraine prevalence and attack incidence suggests that 3 000 migraine attacks occur every day for each million of the general population (6). Less well recognized is the toll of chronic daily headache: up to one adult in 20 has headache on more days than not (17, 18). In other cases headache mours, brain scanning is not justied as a routine investi- or eye pain may be episodic and mild. Idiopathic intracranial hypertension is a rare cause of Meningitis, and its associated headache, occur in an obvi- headache not readily diagnosed on the history alone. The signs of fever and neck stiffness, later illoedema indicates the diagnosis in adults, but is not seen accompanied by nausea and disturbed consciousness, re- invariably in children with the condition. These Unless there is a clear history of similar uncomplicated epi- infections need to be recognized wherever they are likely sodes, these characteristics demand urgent investigation. New headache in any patient over 50 years of age should Other disorders seen more in the tropics that may pres- raise the suspicion of giant cell (temporal) arteritis. These are often diagnosed only on imaging or Jaw claudication is highly suggestive. No signicant mortality is associated with headache disorders, which is one reason why they are so poorly acknowledged. Nevertheless, among the recognizable burdens imposed on people affected by headache disorders are pain and personal suffering, which may be substantial, im- paired quality of life and nancial cost. Collectively, all headache disorders probably account for double this burden (3), which would put them among the top ten causes of disability. Repeated headache attacks, and often the constant fear of the next, damage family life, social life and employment (21). For example, social activ- ity and work capacity are reduced in almost all people with migraine and in 60% of those with tension-type headache. Headache often results in the cancellation of social activities while, at work, people who suffer frequent attacks are likely to be seen as unreliable which they may be or unable to cope.
Syndromes
- Vaginal hysterectomy: 3 to 4 weeks
- Croup
- Remove any sources of standing water (such as old tires, cans, gutters, and wading pools).
- Alopecia totalis -- complete loss of scalp hair
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- Talk to your doctor about the risk of birth control pills. Birth control pills can increase the chance of blood clots, which can lead to stroke. Clots are more likely in women who also smoke and who are older than 35.
- Kidney damage
Pseudomonas infection is suspected piperacillin or r Identication and management of underlying causes ciprooxacin are effective cheap zithromax 100mg antibiotics for sinus infection how long. Septicaemia originating in skin and soft tis- sue infections requires ucloxacillin and benzylpeni- Prognosis cillin 500 mg zithromax with amex antibiotics on birth control. Chest pain can arise from the cardiovascular system buy 100 mg zithromax with amex antibiotics effective against strep throat, the r Angina that occurs at rest or is provoked more easily respiratory system generic 250 mg zithromax visa antimicrobial wood, the oesophagus or the musculoskele- than usual for the patient is due to acute coronary syn- tal system. Some patients describe a feeling r Alleviating factors of impending doom (angor animi). It is a ret- r Exacerbating factors rosternal or epigastric pain that radiates to the neck, r Symptoms associated with the pain back or upper abdomen. The pain of pericarditis may last days or even 2 3 (particularly the left) and jaw. Its onset is abrupt and of greatest intensity at the and may hang their legs over the side of the bed or go time of onset. Chest pain associated with tenderness is suggestive of r Cheyne Stokes respiration is alternate cyclical hy- musculoskeletal pain. Oesophageal pain is a ret- failure, in some normal individuals (often elderly), in rosternal sensation often related to eating and may be patients with cerebrovascular disease and patients re- associated with dysphagia. It is thought that this pattern retrosternal burning pain, often exacerbated by bending of breathing results from depression of the respiratory forwards. Equally,painarisingfromstructures r Patients with severe acute left ventricular failure often in the chest may present as abdominal pain, e. Dyspnoea However, the major causes of frank haemoptysis are from the respiratory system. In general dyspnoea arises from either the respiratory or cardio- vascular system and it is often difcult to distinguish Palpitations between them. The patient may notice it on strenuous a missed beat, or their heart beating irregularly. In severe failure, patients are breath- rate and rhythm (ask the patient to tap out the beat with less at rest. Associated symptoms may include breath- pnoea an underlying cause should be sought, such as lessness, dizziness, syncope and/or chest pain. This symptom normally arises when a patient s exer- r Palpitations lasting just a few seconds are often due cise tolerance is already reduced. The patient becomes aware of the mechanisms are responsible for this phenomenon: a pause that occurs in the normal rhythm after a prema- redistribution of uid through gravity in the lungs ture beat and may sense the following stronger beat. Some patients may know how to terminate propping themselves up on pillows at night, or, in se- their rapid palpitations with manoeuvres such as vere cases, sleeping in a chair. Orthopnoea is highly squatting, straining or splashing ice-cold water on the suggestive of a cardiac cause of dyspnoea, although it face. These features are very suggestive of a distinct may also occur in severe respiratory disease due to the tachyarrhythmia rather than general anxiety or pre- second mechanism. It is thought to occur by a simi- Syncope lar mechanism to orthopnoea coupled to a decreased sensory response whilst asleep. Patients awake breath- Syncope is dened as a transient loss of conscious- less and anxious, they often describe having to sit up ness due to inadequate cerebral blood ow. There may be no warning, or patients may describe feel- The distance a patient can usually walk on the at be- ing faint, cold and clammy prior to the onset. Asthenarrowing tend to be ushed and sweaty but not confused (unless ofthearteriesbecomesmoresignicant,theclaudication prolonged hypoxia leads to a tonic-clonic seizure). Eventually rest pain may occur, this r Vasovagal syncope is very common and occurs in the often precedes ischaemia and gangrene of the affected absence of cardiac pathology. The heart contracts force- fully, which may lead to a reex bradycardia via vagal Oedema stimulation and hence a loss of consciousness. A number of mechanisms tion, hypovolaemia or due to certain drugs especially arethoughttobeinvolvedinthedevelopmentofoedema. Normally tissue uid is formed by a balance of hydro- r Cardiac arrhythmias may result in syncope if there is a static and osmotic pressure. This may oc- Hydrostatic pressure is the pressure within the blood cur in bradycardias or tachycardias (inadequate ven- vessel (high in arteries, low in veins). The loss of consciousness occurs produced by the large molecules within the blood (albu- irrespective of the patient s posture. A Stokes Adams min, haemoglobin) and draws water osmotically back attack is a loss of consciousness related to a sudden into the vessel. The hydrostatic pressure is high at the loss of ventricular contraction particularly seen dur- arterial end of a capillary bed hence uid is forced out of ing the progression from second to third degree heart the vasculature (see Fig. The colloid osmotic pressure then draws uid back in r Carotid sinus syncope is a rare condition mainly seen at the venous end of the capillary bed as the hydrostatic in the elderly. As a result of hypersensitivity of the carotid sinus, light pressure, such as that exerted by atight collar, causes a severe reex bradycardia and hence syncope. The syncope results from an inability of the heart to increase cardiac output in response to in- Hydrostatic Oncotic 0ncotic Hydrostatic creased demand. Intermittent claudication Artery Vein Claudication describes a cramp-like pain felt in one or both calves, thighs or buttocks on exertion. This may be a result of blood bypassing uid is then returned to the circulation via the lymphatic the lungs (right to left shunting) or due to severe lung system. Mechanismsofcardiovascularoedemaincludethefol- lowing: r The arterial pulse Raised venous pressure raising the hydrostatic pres- sure at the venous end of the capillary bed (right ven- The pulse should be palpated at the radial and carotid tricularfailure,pericardialconstriction,venacavalob- artery looking for the following features: struction). The normal pulse is dened as a rate be- which increases the circulating blood volume with tween 60 and 100 beats per minute. Outside this range pooling on the venous side again raising the hydro- it is described as either a bradycardia or a tachycardia. Albumin is the major factor respon- r The character and volume of the pulse are normally sible for the generation of the colloid osmotic pressure assessedatthebrachialorcarotidartery. A drop volume felt at the carotid may be described according in albumin therefore results in an accumulation of to the waveform palpated (see Fig. Radio-femoral delay is suggestive of coarcta- is left after pressing with a thumb for several seconds) tion of the aorta, the lesion being just distal to the or nonpitting. Cardiac oedema is pitting unless long origin of the subclavian artery (at the point where the standing when secondary changes in the lymphatics may ductus arteriosus joined the aorta). Distribution is dependent lay suggests arterial occlusion due to an aneurysm or on the patient. Pleural effusions and Jugular venous pressure ascites may develop in severe failure. The internal jugular vein is most easily seen with the pa- tient reclining (usually at 45), with the head supported Cyanosis and the neck muscles relaxed and in good lighting con- Cyanosis is a blue discolouration of the skin and mu- ditions. It is due to the presence of desaturated toid muscle in the upper third of the neck, behind it haemoglobin and becomes visible when levels rise above in the middle third and between the two heads of ster- 5 g/dL. Cyanosis is not present in very anaemic patients nocleidomastoid in the lower third. Cyanosis is divided from the carotid pulse by its double waveform, it is non- into two categories: palpable, it is occluded by pressure and pressure on the r Peripheral cyanosis, which is seen in the ngertips and liver causes a rise in the level of the pulsation (hepato- peripheries.
Follow up in one week to check glycemia If on insulin and taking appropriately buy zithromax 250mg fast delivery antibiotics by class, increase dose as needed zithromax 500mg otc virus locked computer. Must check renal function (Cr) and/or make sure patient is making urine (reason for Foley catheter) before giving entire fluid bolus buy zithromax 100 mg line virus model. Therefore order 500 mg zithromax antibiotics for a sinus infection, must check potassium and supplement during insulin infusion If K > 6 mEq/L, do not give potassium If 4. Start with 2L bolus, but make sure patient urinating and check renal function before proceeding with remainder of fluid bolus. Give plenty of fluids in each case, monitor urine output, electrolytes, and do glycemia checks every 2hr while on insulin therapy. Even when lab potassium is near normal, patients are actually hypokalemic and need repletion. Transfer early- typically any patient who continues to have tachycardia, hypotension, tachypnea, or confusion after 24hr of aggressive treatment. There are three goals of treatment with different types of medications working for varying reasons. The goals of treatment are to 1) stabilize cardiac membrane, 2) cause an intercellular shift of K+, and 3) remove K+ from the body. Transfer to referral center for dialysis consideration any patient with hyperkalemia and renal failure. Recommendations All patients with acute hypernatremia should be admitted to the hospital. Those equations are beyond the scope of these introductory guidelines and osmolalities are not often available. Recognize that correcting the sodium too fast will lead to severe brain damage and irreversible neurological deficits. Causes Thermal Chemicals Radiation Electrical Current Signs and symptoms History o Important features include time since burn (hours, days? Regular dressing changes are necessary, but are extremely painful and require either conscious sedation with Ketamine (extensive burns) or opiate pain control (small burn area) o After initial presentation, remove any burned clothing and cover patient in clean sheet until burns can be dressed appropriately o Wash burn area thoroughly with sterile water or normal saline If blister is intact, do not break open blister If blister is open, de-roof blister and clean area of skin underneath o Cover clean burn area with light coat of honey (if antibiotic ointment unavailable) or Flamazine or other topical antibiotic Donotcoverburnareawithdrydressing! A paper from 2008 estimated between 1300-2400 snake bites per year in Rwanda with between 43-328 deaths as a result. Mark the border of the edema/erythema and reassess both measurements every 30minutes. Drowning Definition: A process resulting in a primary respiratory impairment from submersion/immersion in a liquid medium. Causes Accidental submersion Suicide attempt Forced submersion Signs and symptoms History o Ask about timing of event (how many hours ago did it occur? If saturation does not improve, transfer to referral center for intubation and positive pressure ventilation. If they remain asymptomatic, with a normal physical exam and saturation >95%, they can be discharged home. Identification of the specific substance(s) involved in a poisoning can frequently assist clinical management, but is not always possible in actual practice. Recognizing symptom patterns, known as toxidromes, may help direct general management of the patient even when the exact agent responsible for poisoning remains unknown. Specific antidotes for some toxins exist, but their availability is often limited. Good supportive care is critical to managing many toxic exposures Causes Exposure to a sufficient amount of any substance is toxic, even those substances required for survival. Toxidromes include: anti-cholinergic, cholinergic, opiod, sympathomimetic and sedative-hypnotic. Ideally have the container of the involved substance brought immediately for inspection. Management: Varies depending on substance that was ingested, but as this is often unknown or unverified, focus on stabilizing the patient and offering supportive care. Monitor serum potassium and blood glucose every 30 minutes (if possible) until stabilized. If unknown amount of ingestion, start with 5 g and repeat until seizures controlled. Delerium Tremens is the most severe manifestation of alcohol withdrawal syndrome and can be fatal. Intoxication may include extreme happiness (euphoria) or agitation and combativeness. Central nervous system depression often occurs including slurred speech, ataxia, and nystagmus and can eventually lead to coma and respiratory depression. Signs and symptoms If pregnant, patients are at high risk of hypovolemic shock, severe anemia, or sepsis. Ask about sexual assault, recent trauma, and history of irregular bleeding from other parts of the body. Management of the Sexual Assault Patient Definition: Sexual violence is the verbal, physical, or emotional abuse of a person. In your notes, put the date and time of the assault, number of assailants, type of assault. Ask about physical injuries, date of last menstrual cycle, and if patient is on contraception. Definition: Pain/discomfort in the lumbar and sacral region; a common condition affecting up to 90% of adults. Loss of rectal tone is a serious red flag that should alert you to do imaging Urinary retention is the most consistent finding in cauda equina. Differential diagnosis Cellulitis Ruptured Baker cyst Acute occlusion of an artery Lymph obstruction Investigations Labs o If going to Warfarin or Lovenox, need renal function (Cr, urea) to ensure no kidney failure. Recommendations Remember to feel the swollen extremity for warmth, good capillary refill, and good distal pulses. An arterial clot presents very similarly to venous clot, but will result in amputation of limb if not recognized and treated aggressively. Contraindications Procedure requires general anesthesia Patient has significant co-morbid illness where the risk of procedural sedation in the emergency room outweighs the benefits of the procedure (severe lung disease, hypoxic on room air, problems with sedation medication in the past, etc. Note: it is very important that you do not remove your finger before the tube goes in. If you remove your finger, you will lose the "track" and risk placing tube into a space other than the lung! If this is not available, connect chest tube to Heimlich valve and/or create a water seal using a sterile saline bottle. Men: Hold penis with your non-dominant hand upright, away from scrotum Hold catheter firmly with your dominant hand and gently pass well lubricated catheter through external urethral meatus.
