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Health studies over the last 30 years have consistently shown excesses of non-malignant respiratory disease in fire service members order advair diskus 500mcg visa asthma treatment guidelines aap. First advair diskus 500mcg online asthma treatment in 1940s, there is a general lack of detailed historic smoking information among fire fighters order advair diskus 100mcg overnight delivery asthma definition wikipedia. Second, because lung cancer can take many decades to develop, insufficient years of observation can result in under identification of deaths. The onset of lung cancer relatively late in life, long after fire service retirement would then elude researchers trying to link the diagnosis to work which ended several decades earlier. Some prevention strategies applicable to fire service members will also be described. Based on reports from cases between 2001-2005, the median age at diagnosis is 74 years and the number of new cases increases with age. For example, people with a history of chronic obstructive pulmonary disease also have an increased risk of developing lung cancer. About 90% of all lung cancer in the United States is estimated to be attributable to cigarette smoking20 which is thought to increase the risk of lung cancer development by 20-fold, compared to those who never smoked. In addition, secondhand smoke, or smoke from other people s cigarettes, increases the risk of lung cancer in non-smokers. Public health experts state that current lung cancer statistics describe an "epidemic" that can be traced to the 1930s and reflect the increase in cigarette smoking at that time and which continued rise into the 1980s for men and which still continues to rise in women. In fact, lung cancer has been the most thoroughly studied of cancers regarding environmental causes, perhaps because of the obvious inhalation exposure route making deposition of cancer- causing agents directly into the lung, a plausible scenario for initiating a cancer. Other chemicals including some metals are known lung carcinogens as is asbestos and diesel exhaust, which, as mentioned above are encountered in the fire service. Studies of cancer risk by occupational group tend to reinforce these observations about agents which increase lung cancer risk, as seen in Table 2-9. Each has different sub- classes within the main categories that are based on the cell type in the lung that is growing abnormally. It tends to arise more centrally in the lung; therefore on presentation, there may be obstruction of bronchi with post-obstructive pneumonia. Other symptoms that may be present at the time of diagnosis include: dyspnea (shortness of breath), chest pain, bloody sputum (phlegm), and pneumonia. Some patients will present with a change in the shape of their nail beds called clubbing. Symptoms resulting from compression of major blood vessels such as facial or upper body swelling (superior vena cava syndrome) and lightheadedness may sometimes occur. Symptoms may occur from spread of the tumor to outside the chest (metastasis) to other organs. Examples include: bone pain from bone involvement; fatigue from brain and/or liver involvement, headaches and/or seizures from brain involvement and paralysis from spinal cord involvement. The history focuses on risk factors for cancer including cigarette smoking, environmental or occupational exposure to carcinogens and family history of lung cancer. A normal chest x-ray can rule out this diagnosis in many instances: however, in some cases cancer can be missed. For example, a review of primary care records in England revealed that 10% of patients diagnosed with lung cancer had a chest x-ray interpreted as normal within the year prior to their diagnosis. Tissue Biopsy Once a mass has been identified, diagnosis is made by tissue biopsy or aspirate of the abnormal tissue. Local anesthesia and mild sedation is provided, so that the bronchoscopy is only mildly uncomfortable. Rather, a needle is passed through the chest and then with X-ray guidance is directed into the nodule or mass to obtain the tissue sample. In this procedure a small incision (about 2 inches) is made at the base of the neck and a scope is passed into the middle of the chest. Biopsy samples can be obtained from these centrally located lymph nodes but not from the airway or lungs. This procedure is done under general anesthesia and typically does not require an overnight hospital stay. This procedure is done under general anesthesia and will require a hospital stay for several days or longer. This includes how large the tumor is and whether there is evidence for metastasis (cancer spread) to other areas including lymph nodes within the chest or to distal organs outside the chest. One of the best indicators of the extent of cancer is involvement of the lymph nodes. Lymph nodes are tiny glands that help the body fight infection but are often the first areas for tumor metastasis. The prognosis and treatment will depend on the stage or extent of disease at the time of diagnosis. An A and B subgroup is applied to stages to separate those within a stage who have certain findings associated with a better or worse prognosis. When diagnostic techniques and/or treatments are developed and impact on survival, the staging system is revised. Although there are complexities in the staging system that are beyond the scope of this chapter, the basic criteria for classification are as follows: Stage 0 also known as carcinoma in situ is a very early stage of cancer where the cells are not yet invading. Rarely, if ever do we make the diagnosis of lung cancer at Stage 0, but it is our hope that newer screening techniques will be developed to achieve this. Prognosis The higher the stage, the more advanced the cancer and poorer the prognosis. The percentage of patients who live at least five years after being diagnosed is termed the five-year survival rate. For patients diagnosed with stage I lung cancer, the five-year survival rate is 56%, though rates are higher for the A subgroup (73%). This relatively favorable survival substantially decreases as the disease spreads. Good prognostic factors at the time of diagnosis include early staging at the time of diagnosis, the patient s good general functional ability called performance status which includes daily activities as well as function assessed by pulmonary and cardiac tests and either no weight loss or weight loss of less than 5% at the onset of disease. The treatment of cancer has become a field involving multiple modalities, or types of interventions. Based on the type and extent of disease, a therapeutic plan is designed by a pulmonologist, thoracic surgeon, medical oncologist who may administer chemotherapy and a radiation oncologist who may administer radiation therapy. In latter stages of disease, pain or palliative physicians are an important addition to this process. Depending on location and size of the tumor, the surgical approach can be performed by video assisted thoracoscopic surgery or by open lung thoracotomy.

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She has had the occasional episode of acute cystitis order 500mcg advair diskus with mastercard asthmatic bronchitis medicine, approximately on a 2-yearly basis buy 500 mcg advair diskus free shipping asthma score definition. Acute appendicitis classically presents with a short his- tory of central abdominal pain which rapidly localizes to the right iliac fossa purchase advair diskus 100mcg on-line asthma 2. There is guard- ing and board-like rigidity and rebound tenderness in the right iliac fossa. Untreated, some cases will resolve spontaneously, whereas others will perforate leading to localized or gener- alized peritonitis. Rarely a delayed diagnosis may result in acute appendicitis progressing to an appendix mass consisting of a haemorrhagic oedematous mass in the ileocaecal region. The symptoms of loin pain and presence of blood and protein in the urine mimicking a urinary tract infection suggest the appen- dix may be retrocaecal. Patients with retro-ileal appendicitis often have little abdominal pain, but irritation of the ileum can lead to severe diarrhoea and vomiting. Patients may also present with subacute intestinal obstruction due to intestinal ileus, or urinary reten- tion due to pelvic peritonitis. The treatment is appendicectomy as soon as urinary tract infection has been excluded. A 62-year-old lady had been admitted 10 days previously to have a right hemicolectomy performed for a cae- cal carcinoma. This was discovered on colonoscopy which was performed to investigate an iron-deficiency anaemia and change in bowel habit. The initial surgery was uneventful, and she was given cefuroxime and metronidazole as routine antibiotic prophy- laxis. Over the next 5 days the patient remained persistently febrile, with negative blood cultures. In the last 24 h, she has also become relatively hypotensive with her systolic blood pressure being about 95 mmHg despite intravenous colloids. Her pulse rate is 110/min regular, blood pressure 95/60 mmHg and jugular venous pressure is not raised. Her sepsis is due to an anastomotic leak with a localized peritonitis which has been partially controlled with antibiotics. The low sodium and high potassium are common in this condition as cell membrane function becomes less effective. The elevated white count is a marker for bacterial infection and the low platelet count is part of the picture of disseminated intravas- cular coagulation. Jaundice and abnormal liver function tests are common features of intra- abdominal sepsis. Aminoglycosides (gentamicin, streptomycin, amikacin) cause auditory and vestibular dysfunction, as well as acute renal failure. Risk factors for aminoglycoside nephro- toxicity are higher doses and duration of treatment, increased age, pre-existing renal insuffi- ciency, hepatic failure and volume depletion. Monitoring of trough levels is important although an increase in the trough level generally indicates decreased excretion of the drug caused by a fall in the glomerular flow rate. She requires transfer to the intensive care unit where she will need invasive circulatory monitoring with an arterial line and central venous pres- sure line to allow accurate assessment of her colloid and inotrope requirements. She also needs urgent renal replacement therapy to correct her acidosis and hyperkalaemia. In a haemo- dynamically unstable patient like this, continuous haemofiltration is the preferred method. Once haemodynamically stable, the patient should have a laparotomy to drain any collection and form a temporary colostomy. Over this time her appetite has gone down a little and she thinks that she has lost around 5 kg in weight. The intensity of the pain has become slightly worse over this time and it is now present on most days. She has developed a dif- ferent sort of cramping abdominal pain located mainly in the right iliac fossa. This pain has been associated with a feeling of the need to pass her motions and often with some diarrhoea. During these episodes her husband has commented that she looked red in the face but she has associated this with the abdominal discomfort and the embarrassment from the urgent need to have her bowels open. She has smoked 15 cigarettes daily for the last 45 years and she drinks around 7 units of alcohol each week. She has noticed a little breathlessness on occasions over the last few months and has heard herself wheeze on sev- eral occasions. She has never had any problems with asthma and there is no family history of asthma or other atopic conditions. She worked as a school secretary for 30 years and has never been involved in a job involv- ing any industrial exposure. The typical clinical features of the carcinoid syndrome are facial flush- ing, abdominal cramps and diarrhoea. The symptoms are characteristically intermittent and may come at times of increased release on activity. Carcinoids do not generally produce their symptoms until they have metastasized to the liver from their original site, which is usu- ally in the small bowel. In the small bowel the tumours may produce local symptoms of obstruction or bleeding. The tumour can be reduced in size with consequent lessening of symptoms by embolization of its arterial supply using interventional radiology techniques. When odd symptoms such as those described here occur, the diagnosis of carcinoid tumour should always be remembered and investigated. In real life, most of the investigations for suspected carcinoid turn out to be negative. Carcinoid tumours can occur in the lung when they act as slowly growing malignant tumours. No history was available from the patient, but her partner volun- teered the information that they are both intravenous heroin addicts. She is unemployed, smokes 25 cigarettes per day, drinks 40 units of alcohol per week and has used heroin for the past 4 years.

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Have elevated concern for abuse if the child is not yet ambulatory and has a femur fracture or if the history is not consistent with the type of fracture buy advair diskus 100mcg with amex asthma symptoms 6 month old. Knee Injuries Definition: Knee injuries are common and can be accompanied by significant vascular or neurologic injuries order 100 mcg advair diskus mastercard asthma symptoms for weeks. For instance discount advair diskus 100mcg asthma 70, popliteal artery injuries occur in approximately 35% of knee dislocations. Always check for distal pulses o Failure to re-vascularize the popliteal artery within 6-8 hours leads to approximately 90% amputation rate. Ankle Injuries Definition: Injuries can include ligament injuries, tendon injuries, dislocation or fracture of the tibia, fibula and/or talus. Partial or complete ligament tears are the most common ankle injuries (ankle sprain). Associated proximal tibial and fibular fractures are often seen; therefore careful inspection of the entire leg distal to the knee is very important. The plaster is changed in series, decreasing the plantar flexion and eventually moving toward short-leg casts in a neutral ankle position. Respiratory failure (patient is not able to maintain adequate oxygenation or ventilation) is also a very common cause of death in Rwanda. Start oxygen with non-rebreather mask (bag reservoir) and consider intubation if possible. Is the patient posturing (sitting upright, uncomfortable, with increased work of breathing)? Consider early intubation if the equipment is available in your hospital and the physician is trained on the procedure. More importantly however, is stabilizing the patient until they reach a referral center. Pneumonia Definition: Infection in the lung space that can be caused by a virus, bacteria, and less often a fungus. Consider a Foley catheter in any patient who is ill appearing and be sure urine output is atleastO. Antibiotics: Treatment regimens are typically based on local sensitivities for pathogens. Large studies do not exist for pathogens specific to Rwanda therefore we must use other guidelines to direct our care. If you do transfer to referral hospital, record what antibiotics were given and for how many days so referral specialists know how to guide treatment upon arrival. Results in mediastinal displacement and kinking of the great vessels, which compromises preload and cardiac output and can cause cardiac collapse/death Open pneumothorax (sucking chest wound): due to a direct communication between the pleural space and surrounding atmospheric pressure Signs and symptoms Clinical status and stability of patient is related to size of pneumothorax. Air between the visceral pleural line and chest wall seen as area of black without vascular or lung markings. Pulmonary Edema Definition: The presence of excess fluid in the alveoli, leading to impaired oxygen exchange. Pulmonary edema can result from either high pulmonary capillary pressure from heart failure (cardiogenic) or from non-cardiogenic causes, such as increased capillary leak from inflammation. Many patients with acute hypertensive pulmonary edema may not be fluid overloaded! Studies have shown that it is an inferior vasopressor compared to others (such as norepinephrine) in cardiogenic shock (Debacker, et al), but it is the best option to temporarily increase blood pressure. Counsel family and patient early to decide when appropriate to switch goals of care towards palliation. Transfer to referral center only after discussion with family and consideration of whether there is possibility of recovery. While the two are different and often unrelated processes, their clinical symptoms and treatments are similar. Can present anxious (because of inability to breathe), tachypneic, tachycardic, and with wheezing. Massive hemoptysis is rare but frequently fatal; definitions vary from 100-600 ml of blood over 24 hours. Only consider if prognosis is reasonable and referral facility will be able to obtain useful tests (i. Effusions can be either transudative (caused by changes in the hydrostatic and or osmotic gradient) or exudative (caused by pleural inflammation and increased permeability). If unable to sit, lie patient on affected side with ipsilateral arm above head Use ultrasound to find the largest pocket of fluid and measure distance from skin to fluid. Stop once fluid is aspirated and inject some Lidocaine to anesthetize the parietal pleura. Make sure to turn the stopcock to the off position when removing the syringe to prevent air from entering the pleural space. Can range from occult and insignificant to massive, causing obstructive shock and death. It may originate from an organ located in the chest or be referred from another part of the body. Signs and symptoms History: Ask about the following factors o Duration: Constant (likely not cardiac) vs. Causes Low contractility o Cardiomyopathy o Myocarditis Poor heart filling o Arrhythmias o Mitral stenosis o Pericardial tamponade Other valvular heart disease o Examples include acute mitral regurgitation or aortic regurgitation from acute rheumatic fever or endocarditis Signs and symptoms History o Depends on etiology; may have slowly progressing or acute symptoms o Dyspnea, syncope, weakness, confusion/coma Exam o Low blood pressure alone should not make the diagnosis. These patients are in shock because their heart is not squeezing well (contractility problem). This may need to be reduced with Captopril or nitroglycerin once above pressors have been started and blood pressure is raised. Be aware that this may further lower their blood pressure, therefore, may need to start pressors prior to or just after intubation. Cardiogenic shock secondary to mitral stenosis and rapid heart rate o These patients are in shock because their left ventricle is unable to fill adequately during diastole (preload problem). If they are in rapid atrial fibrillation, defibrillate o If defibrillation does not work, give Amiodarone or Digoxin Amiodarone 150 mg over 10 minutes Digoxin 0. Ischemic heart disease as a cause of heart failure is thought to remain relatively uncommon in Rwanda, particularly in more rural settings. If anything other normal or cardiomyopathy, should be referred for formal echocardiogram (possible candidates for cardiac surgery) Management: Initial approaches to heart failure the same in all patients.